sacroiliac mechanics revisited - doctors of osteopathy...

Sacroiliac Mechanics Revisitedpages 11-17

Forum for Osteopathic Thought

Tradition Shapes the Future Volume 16 Number 2 June 2006

�/The AAO Journal June�006

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TheAmericanAcademy of Osteopathy®(AAO)Journalisapeer-reviewedpublicationfordisseminatinginformationonthescienceandartofosteopathicmanipulativemedicine.Itisdirectedtowardosteopathicphysicians,students,internsandresidentsandparticularlytowardthosephysicianswithaspecialinterestinosteopathicmanipulativetreatment.

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In this Issue:AAOCalendarofCourses...................................................................................4Contributors.........................................................................................................6ComponentSocieties’CMECalendar...............................................................��

Editorial

ViewfromthePyramids:Anthony G. Chila, DO, FAAO ..............................5

Regular Features DigOn............................................................................................................7 MyronC.Beal,DO,FAAO FromtheArchives..........................................................................................9 BookReviews......................................................................................... �9-30 ElsewhereinPrint.........................................................................................31

Original ContributionConceptual and Treatment Models in Osteopathy II: Sacroiliac Mechanics Revisited..................................................................... 11TheodoreR.Jordan,DO,CSPOMM

Osteopathic Medical EducationPost Operative Osteopathic Manipulative Protocol for Delivery by Students in an Allopathic Environment....................................................19RobertC.Clark,DO,CSPOMMandThomasM.McCombs,DO,C-NMM/OMM

The Student Physician Crohn’s Disease: A Case Report including the most recent Theories and Treatment Principles...............................................................�� DeanaMitchell,OMS-III(TCOM)andJerryL.Dickey,DO,FAAO

Manipulation of Adhesive Capsulitis under Anesthesia................................�7 JenniferHurrell,OMS-III(TCOM),ArthurJ.Speece,DO,and StuartF.Williams,DO,C-NMM/OMM

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Tradition Shapes the Future • Volume 16 Number 2 June 2006Official Publication of the American Academy of Osteopathy®

4/The AAO Journal June�006

American Academy of Osteopathy®

Calendar of Events2006Jul 1 AOBNMMapplicationdeadlineJul 14-16 Visceral Manipulation: Urogenital inSanFranciscoAug 18-20 The Still Technique (Applications of a Redis-

covered Technique of Andrew Taylor Still, MD) atSouthpointHospitalinCleveland,OH

Sep 15-17 Advanced Clinical Jones Strain-Counterstrain: Emphasis on Extremities atUniversity

ofIndianapolisOct 15 One-daycourse–Introduction to Osteopathic Medicine for the Non-physician

Licensed Health Care ProviderinLasVegasOct 16-20 AOA ConventioninLasVegasNov 3-5 Prolotherapy: Below the Diaphragm atUNECOMDec 1 AOBNMMapplicationdeadlineDec 1-3 Visceral Manipulation: Membranes inSanFrancisco

2007 Course CalendarDates and locations tentative –

pending confirmation in August 2006

Jan18-�1 Contemporary OMT at the Contemporary;AnnL.Habenicht,DO,FAAO,ProgramChairperson,WaltDisneyWorld®,BuenaVista,FL

Feb16-18 Diagnosis of Muscle Imbalance and Exercise Prescription; The Greenman Protocol;PhilipGreenman,DO,FAAO,FeaturedSpeakerandBradS.Sandler,DO,ProgramChairperson.AZCOM,Glendale,AZ

Mar19-�1 Visceral Manipulation: GI-Abdominal;KennethJ.Lossing,DO,ProgramChairperson,ColoradoSprings,CO

Mar�1-�5 AAO Convocation, Neuromusculoskeletal Medicine: An Osteopathic Evolution,GeorgeJ.Pasquarello,DO,FAAO,ProgramChair-person,ColoradoSprings,CO

AprilTBD Osteopathic Treatment of Headache;DennisJ.Dowling,DO,FAAO,ProgramChairper-son,SiteTBD

May4-6 Prolotherapy: Above the Diaphragm;MarkS.Cantieri,DO,FAAO,ProgramChairper-son,SiteTBD

June8-10 Muscle Energy-Counterstrain; Walter C.Ehrenfeuchter, DO, FAAO and EdwardK. Goering, DO, Program Chairpersons,PCOM/GeorgiaCampus,Suwanee,GA

July14-16 Master Series: Title TBD;StephanieWaecker,DO,ProgramChairperson,CCOM,Chicago,IL

Aug�0-�� Visceral Manipulation: Manual Thermal;KennethJ.Lossing,DO,ProgramChairper-son,SanFrancisco,CA

SepTBD Advanced Clinical Jones Strain-Counter-strain:The Extremities;EdwardK.Goering,DO, Program Chairperson, Indianapolis,IN

Sepr�9 One-day course: OMT without an OMT Table;AnnL.Habenicht,DO,FAAO,Pro-gramChairperson,SanDiego,CA

Sep30-Oct4 AOA Convention;JohnE.Balmer,DO,AAOProgramChairperson,SanDiego,CA

Nov16-18 Prolotherapy: Below the Diaphragm;MarkS.Cantieri,DO,FAAO,ProgramChairper-son,SiteTBD

Nov30-Dec�Visceral Manipulation: Colon; Kenneth J.Lossing,DO,ProgramChairperson,

SanFrancisco,CA


View from the Pyramids

Anthony G. Chila

The�004ThomasL.NorthupMemorialLecturewasdeliveredbyJohnC.Glover,DO,FAAO.1 DoctorGloveraddressedthedevelopmentandimplementationofaCORECOMPETENCYCOMPLIANCEPROGRAMresultingfromtheworkdedicatedtoosteopathicgraduatemedicaleducation(OGME).Heofferedsuggestionstostrengthenthosepropos-als.Thecompetenciesaregivenas:

1. OsteopathicPhilosophyandOsteopathicManipulativeCare�. MedicalKnowledge3. PatientCare4. InterpersonalandCommunicationSkills5. Professionalism6. Practice-basedLearningImprovement7. System-basedPracticeCompetencies

RobertC.ClarkandThomasM.McCombs(p.�6)ad-dresstheprobabilitythatosteopathicmedicalstudentswillspendsomeoralloftheirclinicalrotationsinallopathicinsti-tutions.Theirproposalforaprotocolofosteopathicmanipu-lativetreatment(OMT)techniquesforpostoperativepatientsisdesignedtoaddressthisconsideration.Asaprotocol,thetechniquesrepresentfundamentalskillslevelsamenabletoadministrationbyanystudentorphysician.Asacontribu-tiontoalargerpicture,theproposalrepresentsaresponsetothequestionposedinthe�004ThomasL.NorthupMemorialLecture.

ClarkandMcCombsdirecttheirconcernstoYears3and4oftheosteopathictrainingprogram.Inhissummaryrecom-mendationsforthisperiodoftraining,Gloversuggested:

1. StandardizedsetofprotocolstailoredtospecificpatientpopulationsthatserveasabaselineofOMMcareandexpandknowledgeandimproveefficiency.

�. StressOMMintegrationwithpharmacologic,surgical,nutritional,andbehavioraltreatment.

3. StresstheroleofOMMinoptimizingsystemsfunctions,notjustforalleviationofmotion,restrictionorpain.

4. RequiredOMMrotationthatrequiresdeliveryofOMTbythestudents,butallrotationsshouldencourage,allowandfostertheintegrationofOPPandOMTintopatientmanagement.

5. DesignatedOMMfacultyonstaffinthehospitalswhoconsultonhospitalpatientsandworkwithstudents.

6. Requirementthatstudentsevaluate,treat,anddocumentintheprogressnotesaminimumof100supervisedtreat-mentstograduate.

7. RequireOMMcompetency/proficiencyexamtograduate.

Emergingleadershipisacategoryofrecognitionad-dressedannuallybytheAmerican Osteopathic Foundation throughitsCommittee on Educational Grants. TheWY-ETH Emerging Leader Award seekstorecognizeandhonorosteopathicphysicianswhoexhibitexemplarycharacteristicsofemergingleaderswithintheosteopathicprofession.ThisawardconsidersosteopathicphysiciansengagedinAOA-approvedinternshiporresidency,orinpracticelessthan5years.Specificcharacteristicsandskillsinclude:

1. Commitmenttoosteopathicphilosophyandtheprofession.�. Strongleadershipskillsanddemonstrateduseofthese

skills.3. Noteworthyaccomplishmentsdemonstratinghis/herrole

asaleader.4. Outstandingcharacterandthedrivetobealeader.5. Demonstratedcontributionsinosteopathicorganizations,

suchasteaching,committeework,andnationalassocia-tions.

6. MembershipintheAOAandtheindividual’sspecialty college.

ThetimelinefortheimplementationoftheCORECOMPETENCYCOMPLIANCEPROGRAMbeganinJuly�004.Atthattime,(1.)OsteopathicPhilosophyandOsteo-pathicManipulativeCareand(�.)MedicalKnowledgewerethespecifiedcompetencies.AssessmentbeganinJanuary�005.Introductionoftheremainingcompetenciesandtheirassessmentwillrequireaperiodofthreeyears.Takenindi-viduallyandasawhole,thequestionposedbyGlover,theresponseofferedbyClarkandMcCombs,andtheauspicesofWyethPharmaceuticalsappeartocontributesignificantlytotheAmericanOsteopathicFoundationgoalof“Ensuringtheidealsofosteopathicmedicinebyinitiatingandsupportingprogramsthatenhancetheprofession,advancethequalityofpeopleshealth,andrecognizeexcellenceintheareasofeducationandresearch”.

1.Where Do We Go From Here? AAOJ: Volume15,Number1;March�005,11-14.r

Emerging Leadership


Contributors Regular Features

Theodore R. Jordan. Sacroiliac Mechanics Revisited. TheauthorcontinuesthestudyofConceptual and Treatment Models in Osteopathy. Hisfirstpublication(AAOJ. Vol-ume13,Number1;Spring�003)addressedtheevolutionoftreatmentofhipdislocation.Thispaperaddressessacroiliacmechanics.Inbothpapers,thenecessitytodistinguishbe-tweentreatment andconceptual modelsisemphasized.Thecontentionismadethat“theosteopathicprofessionusesav-erysuccessfultreatment modelfortreatingSIJdysfunction,butmaintainsaflawedconceptual modelofSIJmechanics.”(p. 11).

Deanna Mitchell and Jerry L. Dickey. Crohn’s Dis-ease: A Case Report Including Theories And Principles Of Treatment. Theauthorsreviewtheoccurrenceandman-agementofthisidiopathic,chronicandrecurrentinflamma-toryboweldisease.Thesubjectisa30-yearsoldfemale.ThepathogenesisofCrohn’sdiseaseremainsunclear.Dysregula-tionoftheimmuneresponseoftheguthasbeenproposedtobethereasonforoccurrenceofinflammatoryprocesses.Whenviewedasageneticdisorderwithanimmunologicalbasis,theosteopathictreatmentofsomaticdysfunctionsisanappropriateandrationalintervention.(p. 22).

Robert C. Clark and Thomas M. McCombs. Postop-erative Osteopathic Manipulative Protocol For Delivery By Students In An Allopathic Environment. Inthe�004ThomasL.NorthupLecture,JohnC.Glover,DO,FAAOdiscussedthedevelopmentofaCoreCompetencyCompli-anceProgramforosteopathicgraduatemedicaleducation(OGME).TheauthorsrespondtothechallengeofCoreCom-petenciesbyofferingaprotocolofosteopathicmanipulativetreatmenttechniquesfortheimmediatepostoperativeperiod.Theproceduresdescribedrepresentfundamentalskillslevels,andstrategiesforimplementationareoffered.(p. 19).

Jennifer Hurrell, Arthur J. Speece and Stuart F. Williams. Manipulation Of Adhesive Capsulitis Under Anesthesia. Aprimary(idiopathic)formandasecondary(traumaticorillness)formofadhesivecapsulitiscanbecat-egorizedinthreestages.Whiletheutilizationofmanipula-tionunderanesthesiaforthisproblemremainscontroversial,theauthorsdescribethesuccessfuloutcomeinthecaseofa47-yearsoldmalepatient.Thediscussionincludesconsider-ationofvariousreportedseriesshouldermobilizationunderanesthesia.(p. 27).

DIG ON. MyronC.Beal,DO,FAAOservedasEditor,American Academy of Osteopathy ® ,1988-�004.DoctorBealhasbeenProfessorEmeritus,MichiganStateUniversitysince1989.Sciatic Neuritis—A Research Study waswrittenduringhisyearsofprivatepracticeinRochester,NewYork(1951-1974).Presentationhereisafittingcomplementtohisrecentlypub-lishedvolumeContributions to Osteopathic Literature. (p. 7)

FROM THE ARCHIVES. The Practice of Osteopathy (CarlPhilipMcConnellandCharlesClaytonTeall,1906)describestreatmentofthesacruminwaysthatmayhavebe-comelostinthemultilayeringoftermsandapproacheswhichseemtocharacterizecontemporaryteachingandpractice.Readacenturylater,theauthorsappeartofavoraminimalnumberofadjustiveconsiderations.(p. 9).

BOOK REVIEW. Thereleaseoftwovolumesin�005effectivelyspansosteopathicthoughtinthe�0thcenturyandleadsintotheearlyyearsofthe�1stcentury.The Collected Writings of Robert G. Thorpe, DO, FAAO (1917-1999)andContributions to Osteopathic Literature—Myron C. Beal, DO, FAAO willofferthereaderanunusualopportunitytoappreciatetheoryandresearchappliedtopracticebytwoofNewYork’sfinestgentlemen.(p. 29). THIEME Atlas of Anatomy (�006)istheaccomplishmentofagoal“tofindoutwhatthe‘ideal’atlasofanatomyshouldbe”.InadditiontoseekingopinionsandneedsofstudentsandlecturersintheUnitedStatesandEurope,thepublishersdevoted8yearstothedevelopmentofanap-proachandpreparationofnewillustrations.Theresultisanatlaswhichsetsanewpublishingstandard.(p. 29-30).

ELSEWHERE IN PRINT. Asrecentlyastenyearsago,therewaslittleoptimismabouttheprospectsforultimatelydefeatingAlzheimer’s disease.ThebiologyofAlzheimer’swaslittleunderstood.Itsoriginsandcourseweregenerallythoughttobesocomplexastobehopeless.Recenttremen-dousstrideshavebeenmadeintheunderstandingofmolecu-lartriggeringevents.Underexplorationnowareavarietyofstrategiesforslowingorhaltingdestructiveprocesses.Pain hasavarietyofdescriptors:throbbing,itching,aching,stab-bing,stinging,pounding,piercing.Thecommondenomina-tor:allthosewhoendureitwantittostop.RenéDescartes’17thcenturytheoryof“fastmovingparticlesoffirecreateadisturbancethatpassesalongthenervefilamentuntilitreach-esthebrain”isessentiallybeingutilizedincontemporaryre-searcheffort.Betterunderstandingofcellularandmoleculartransmissionofpainsignalsisprovidingnewtargetsfordrugscapableofrelievingvariouskindsofpain.(p. 31).

CME CREDIT. Inresponsetoreaderrequests,AAOJ willofferCMECredittoreaderscompletingtheenclosedquiz.Atthistime,1HourII-BCreditwillbeoffered,withrequestforupgradeasAAOJ qualificationsarereviewedbytheAmerican Osteopathic Association. (p. 18).


Dig On

Clinicalresearchstudiesofosteopathicpracticehavebeenadvocatedtoexaminetheroleofmanipulationinhealthcare.Fewstudieshavebeenconductedinaprivatepracticesetting.Thereasonscitedarethepaucityoftrainedpersonal,thetimeinvolved,thedifficultyinestablishinganacceptablediagnosis,and theproblem inobtaininganadequatenumberof relatedcases.

Thefollowingstudywasconductedtodeterminethefeasibil-ityofconductingaclinicalresearchprojectinaprivatepractice.Sixty-onecasehistoriesofsciaticneuritiswereselectedfrommypatientfilescoveringaperiodof10years.

HistoryEachpatientinthisseriespresentedwithahistoryoflow

backpainwithinvolvementofthesciaticnerve.Fifty-fivepa-tientsgaveahistoryofstrainortraumaprecedingtheonsetofsymptoms.Forty-sevenhadpriorhistoriesoflowbackinjuryorstrain.Sixhadpreviousinvolvementofthesciaticnerveandonehadhaddiscsurgery.Thestudyconsistedof18womenand43men.Theyrangedinagefrom�4to76yearsofage.

DiagnosisThediagnosisconsistedofahistoryandphysicalexamination

withspecialattentiontothemusculoskeletalsystem.Palpatoryexaminationwasusedtoevaluateareasofmusclecontractionandtenderpointsthatelicitedanaggravationofthepatient’spainpattern.Particularattentionwaspaidtothelumbarspineandpelvis.Thestraightlegraisingtest,achillesandpatellareflexeswereaconsistentpartofthephysicalexamination.X-rayswereorderedifthephysicalfindingswarranted.Theywereroutinely

Sciatic Neuritis: A Research StudyMyron C. Beal

ordered1)incasesoftraumawherebonedamagewaslikely,�)incasesofunremittingpainparticularlywherethephysicalfindingsdidnotcorrelatewiththesymptoms,3)wherethepa-tienthadhadtheproblemforseveralmonthspriortohisvisitandhadhadnox-rays,4)ifthepatientdidnotmakeadequateprogresswithinatwoweekintervaloftreatment.

TreatmentEachpatientwasgivenmanipulativetreatmenttoidentified

areasofmusculoskeletalsomaticdysfunction.Thedurationoftreatmentwasfromafewdaystoseveralmonths.(Figure1)Othermeasureswereutilizedwhereappropriatesuchasheat,backsupports,lifttherapy,andmedication.Fourpatientshadtwoepisodesofsciaticneuritis,onepatienthadthreeepisodes.Approximately �0 percent of the patients were under treat-ment longer than four months. Eight of these patients wereWorkman’sCompensationcases.Theirdurationof treatmentwaswellaboveaverage.

Theacutesymptomperiodwithpainintheleglastedfromafewdaystothreemonths.Theacutesymptomshadsubsidedinthemajorityofpatientswithinfourweekstime.Thirty-sevenpatientsmadearecoverywithnorecurrenceoftheirproblem.Sixofthesepatientsmadeagoodrecoverybutstillhadsomebackorminorlegsymptoms.Onepatientwithacongenitalhipstillhadsomesymptomsinherback.Onepatienthadoccasionalsymptomsinherlegandanotherhadlow-gradesymptomsintheback.Onepatienthadosteoarthritisandanotherpatienthadhadpreviousdiscsurgery.Onepatienthadsensitivityinherbackandlegrelatedtothreeoperationsforatumoronherfootandtheresultantscartissue.

➝

PATIENTS

DURATION OF TREATMENT

Figure 1


Fifteenoftheremainingpatientshadrecoveredfromtheirsymptomswhentheyweredischarged.Nofurthercontacthadoccurredwiththem.

Sevenpatientshadsurgery.Onepatienthadaneuromaofthespine.Sixpatientshaddiscsurgery.Onepatientwent tothehospitalafteroneweekoftreatment.Anothertransferredtoanotherphysicianaftertwoweeksoftreatment.

Ofthesixpatientshavingdiscsurgery,onehadrecoveredfromanattackofacutesciaticneuritisandthenfivemonthslaterre-aggravatedtheconditionandfailedtorespondtotreatment.Asecondpatientwasundertreatmentfortwomonthsandseemedtobemakingprogressexceptwhenhesquattedhegotasharppaininhis leg.Hewasanelectricianandcouldnotwork.Athirdpatientwasundertreatmentfortwoweekswithoutmakingsubstantialprogress.Hehadalreadyseenaneurosurgeonandwaswaitingforadatetoenterthehospital.Afourthpatientwasundertreatmentforfourmonths.Hewasimprovingafterthefirsttwomonthsoftreatmentwhenhesuddenlyaggravatedhisproblematworkandfinallywenttosurgery.Afifthpatientwasseenfortwoweeksinacutepain.Hecouldnottoleratethepainandwasadvisedtohavesurgery.Thelastpatientwastreatedforfourweekswithoutimprovement.Shehadalreadyhadherproblemforfivemonths.Shefinallywenttosurgery.

SummaryIhavepresentedastudyof61patientswithahistoryofsci-

aticneuritisandtheirresponsetomanipulativetreatmentasaclinicalresearchstudyconductedinaprivatepractice.Patientsweretreatedforaperiodoffrom3daysto10months.Fifty-tworespondedwithclinicalimprovement.Ninefailedtorespondtotreatment.r

Address Correspondence to:MyronC.Beal,DO,FAAO110FerrisHillsCanandaigua,NY144�4

The ColleCTed WriTings of roberT g. Thorpe, do, fAAo

Edited by:John D. Capobianco, DO, FAAO and

Sonia Rivera-Martinez, DO

From the Preface:Whetheryourealizeitornot,bypickingup

thisbookyouhaveenteredintotheworldofDr.Thorpe’smuscu-

loskeletalorgan.Inhisworld,themusculoskeletalsystemholds

acentralpositionthatdefinesman.Hereferstothissystemasthe

organofbehaviorandaction,forwithit,ourbrainandmindbe-

comeaperson.Inthiscapacity,themusculoskeletalorganiscen-

traltoconceptualthoughtbetweenourverybeingandourinternal

andexternalenvironments.Italsobecomestheprotectorinfight

orflight.Further,heexpandsontheroleofthemusculoskeletal

organinrelationtoendocrinedisease,stress,autonomicnervous

system,infectionandchronicdisease.Hefittinglydescribesthe

significanceofthemusculoskeletalorgan,aswithoutit,allother

organsystems“coulddonothingbutlieinagelatinousheapand

pulsateandquiver.”

SoniaRivera-Martinez,DO

Mineola,NY

r Collected Writings of Robert G. Thorpe, DO, FAAO @$30.00+$7S/H inU.S. Pleaseadd$1.00 for eachadditionalbookordered.

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Did You Miss the Audioconference on Coding?IfyoudidnothaveachancetoparticipateintheMay�4

live,one-hourcontinuingmedicaleducationprogramviaaudio-conference,youcanstillorderanaudioCDoraudiocassettetapeoftheprogramfor$1�5.Douglas J. Jorgensen,DOdelivereda presentation on Osteopathic Documentation and Coding: Managing Patients with Ongoing Problems. Dr. JorgensencurrentlyservesaschairpersonoftheAcademy’sOsteopathicMedicalEconomicsCommitteeandisafrequentpresenteroncoding and reimbursement topics atAAO Convocation. Logontohttp://registration.glyphics.com/php/sem-online/semSelect.php?cmpId=35andclickontheMay�4course,whichwillleadyoutodirectionsonhowtoplaceyourorder.

Thisprogramhadthefollowingobjectives:(1)properdocu-mentationoftheosteopathicevaluationintheobjectivesectionoftheSOAPnote;(�)properdocumentationofthediagnosesofsomaticdysfunction(s)intheassessmentsectionoftheSOAPnote;(3)properdocumentationofOMTprocedure(s)intheplansectionoftheSOAPnote;and(4)basicunderstandingofthecodingfor theevaluationandmanagementcomponentof thepatientencounterandtheOMTprocedure.


From the Archives

The SacrumThe Practice of Osteopathy.CarlPhilipMcConnellandCharlesClaytonTeallCopyright1906.pgs60,90-9�

Examinationofthesacrumisbestmadewiththepatientlyingontheside,withtheosteopathstand-inginfrontandwiththehandpalpateitsposterior

surface.Inthesittingpostureitsrelationwithbothin-nominatescanbedetermined.Itisdisplacedposteriorlybutseldom,themostfrequentbeinganterior,downward,andacombinationofthetwo.Intheanteriorconditionstendernessatthesacroiliacarticulationsisagoodpoint,butitmustnotbeconfoundedwithaninnominatelesion.Thedownwarddisplacementisshownbycomparisonwiththelowerlum-barvertebrae.Observetherelationbetweenthesacrumandfifthlumbarandcarefullydifferentiatebetweenthetwo,asachangeincontourofthespinewillalsochangetheangleofthesacrumandviceversa.

The sacrum.–Adjustmentsofthesacrum,asdistin-guishedfromtheiliuminstrictlyinnominatelesions,arenotmany.Whenposteriorwiththepatientonastool,thekneeoftheosteopathcoveredbyapillowandplacedagainstthesacrum,andbothhandsgraspingtheanteriorbordersoftheilia,strongtractionwillmoveitintoposition.Inadownwarddisplacementwiththeaidofanassistantfrombehindholdingthecrestsoftheiliafirmlyasthepatientsitsonthetable,theosteopathinfrontclaspingbotharmsaboutthepatientandwitharockingmotionfromside,disengagesthesacrumandatthesametimeliftsitintoposition.

Foranteriordisplacementsusethetechniquedescribedinreplacingupwardandbackwardinnominatedislocationfirstrightsideandthenleft,whichwillresultincorrectingthelesion.

Theprecedingosteopathictechniqueincludesthemajorityoftreatmentsgivenbytheosteopath.Althoughmanyosteo-pathsusemethodsnotgivenhere,theyhavebeenleftout,assomearedangeroustreatmentsandshouldbeexcludedfromosteopathictherapeutics,andbesidesthoseoutlinedaresufficientfortreatmentsinallpracticalworkandwillbefoundextensiveenoughforallillustrativepurposes.Apointwhichcannotbetoothoroughlyimpresseduponthestudentisthatosteopathictreatmentisinrealityconstructivework,thatis,re-adjustive,notonlyindetail,butinviewingthebodystructureasawhole.Detailedreadjustmentisanessential,stilldonotlosesightoftherelationoftheparttothewhole.Inourdistinctiveworkanatomicalconstructionisthebasisofphysi-ologicalfunction,althoughphysiologicalstimulusisessentialtoanatomicaldevelopment.

How often to treat.–Howoftentotreatacasedependsentirelyuponthenatureofthediseasefromwhichthepatient

issuffering.Justasingivingdrugsthefrequencyoftreat-mentisentirelydependentupontheseatofthediseaseanditsseverity.Acutecasesrequireathoroughtreatmentatleastoncedaily,andmanytimesinseverecasesthetreatmenthastoberepeatedseveraltimesdaily.Insubacuteandchroniccases,asarule,treatmentshouldnotbegivenasoftenasinacutecases;possibilityonceaday,butusuallyalternatedaysisbetter.Inofficepracticecasesarecommonlytreatedtwoorthreetimesweekly.Stillitisbetternottotreatsomecasesoftenerthenonceperweek.

Thereismoredangerintreatingtoooftenthaninnottreatingoftenenough.Thedistinctiveworkofanosteopathistocorrectdisorderedanatomicalstructures;andwhenacertainderangementhasbeencorrectedthetissuesshouldhaverestandplentyoftimeforrepair.Whentreatmentsaregivenoften,itsimplykeepsthetissuesinanirritatedstateandnaturedoesnothavetimetohealthediseasedtissues.Alwaysmakeitapointateachtreatmenttocorrectsomedefinitelesion,andwhentheworkisaccomplishedletthepartsaloneuntilthetissueshaverecoveredasmuchaspossiblefromtheeffectsoftheprevioustreatmentbeforeanothertreatmentisattempted.Thereasonwhysomecasesdonotgetcuredunderosteopathictreatmentissimplybecausetheosteopathkeepsthediseasedtissuesinanaggravatedstatebytheconstanttreatmentsothattheydonothavetheleastchancetoheal;thephysicianisthusaddingirritationtothedisease.

Itisonlybyexperiencethatonecantellhowoftentotreat.Eachcaseisaspecialstudy;whatwouldbequitesufficientforacertainindividualwithagivendiseasewouldnotbeallsuitableforasecondindividualwiththesamedisease.Asindrugswhatissuitableforonepersonwouldnotbeadaptedtoanother,becausethemake-upofeachindividualisentirelydifferentfromothers;butheretheparallelismdiverges,forindrugsthereisaforeignagentintroducedintothesystem,whileinosteopathictreatmentthecurativeagentisentirelyharmoniouswiththeidiosyncrasiesoftheindividual.Itisforthisreasonthatexperienceinpracticeissoessential.

Mostcasesshouldnotbetreated,asarule,afteramealun-lessthepatientissufferingfromsomedigestivedisturbance;forintreatingotherregionsofthebodyoutsideofthediges-tivetractcausesmoreorlessstimulationofthepartstreatedandtherebydrawsbloodawayfromtheorgansofdigestion.Casesofdisorderedbraincirculation,wherethepatientisun-abletorestorsleepatnight,shouldbetreatedatabouttheirretiringtimesothatthecirculationofthebodymaybeequal-ized,thusgivingthepatientundisturbedrest.r


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June�006 The AAO Journal/11➝

IntroductionOsteopathshaveunderstoodforoveracenturythatthesac-

roiliacjoint(SIJ)moves.Furthermore,theSIJmaybeasourceofpainanddysfunctionandcanbesuccessfullytreatedbyusingmanipulation.However,ourexplanationofhowthesetreatmentsworkisoutdated.Inotherwords,theosteopathicprofessionusesaverysuccessfultreatmentmodelfortreatingSIJdysfunction,but maintains a flawed conceptual model of SIJ mechanics.Thedifferencebetweenourtreatmentandconceptualmodelsmustnotonlybedefined,butwemusttakespecialcarenottoconfusethetwo.

Forexample,Dr.AndrewTaylorStillbecamefamous fortreating what he called “displaced hips”. He taught that inmanypatientswithhiporlegpain,oralteredgait,theheadofthefemurhadactuallyslippedoutoftheacetabulum(completeandpartialsubluxationsoftheacetabularjoint)andcouldbereplaced with manipulation. Dr Still became famous for histreatmentofthehipdysfunctionsbecausehehelpedsomanypeoplebymanipulatingtheirhips.Whenx-raysweredevelopedandusedtoimagethese“partiallydislocatedhips”,theyfailedtoshowtheroutineexistenceofhipdislocations.Withhistech-nique,A.T.Stillwasundoubtedlyalteringthemechanicsofthepelvisandlowerextremitieswithgreatclinicalsuccess,buthewasnotreplacingpartiallydislocatedhips.Althoughtreating“displacedhips”wasasuccessfultreatmentmodelinthehandsofA.T.Still,itwasshowntobeaninvalidconceptualmodelofacetabularmechanics.�

Therefore,avalidtreatment modelmustfulfillthreecriteria:(1)Provideaframeworktointerpretphysicalfindings,(�)pre-scribeatreatmenttocorrectthefindings,and(3)givepredictableresultswiththeprescribedtreatment.Forexample,themuscleenergymodelofsacraldysfunctionisanelegantandsuccessfultreatmentmodelinthatitfulfillsallthreecriteria.

Ontheotherhand,thevalidityofconceptualmodeliswhollydependantuponoutsideknowledge.Aconceptualmodelmustprovidethemostaccuratedescriptionandunderstandingpos-sible;itmustcloselyrepresentreality,(althoughamodelmayidealizeawayextraneousfactsforsimplification).Asscientificadvancesincreaseourknowledgeandnewerbetterunderstand-ingbecomesavailable,ourconceptualmodelsmustchangetostaycurrent.

Thepurposeofthispaperistoreviewtheosteopathicconcep-tualmodelofSIJmechanicsinlightofrecentscientificstudies.Inordertodothis,wewillstartwithanhistoricaloverviewofhowourconceptsdeveloped.

Evolution of osteopathic sacral diagnosis and treatment

“The anatomy text that you are studying (Gray’s) is one of the standard anatomies of the world and it states that the sacro-iliac joint is an immovable joint and l stand here and expect you to support me that the sacro -iliac joint is a movable joint and that all the anatomies will be changed before many years… I may not live to see it but some of you will.”3–A.T.Still

Dr.A.T.StillwasaheadofhistimeinteachingthattheSIJ

movesandthatlesionsoftheSIJcanbetreatedwithmanipula-tion.Dr.Stillconsideredthatthewedgeshapedsacrumcouldbecomejammeddownwardbetweenthe twoilia.Oneofhisfavorite techniques involved holding one ilium of a seatedpatientfirmlydownonachairwithonehand,whilepullingupwardtractiononthetrunkandlaterallyshiftingandslightlyrotatingthetrunktoworkthesacrumloose.4

Reviewofearlyosteopathicliteratureshowsmanyattemptstounderstandthemechanicsofthiscomplexregion.Thisearlyperiodgaverisetonumeroustechniqueapproaches;includingavarietyoneandtwooperatortechniquesandtheadjunctuseofstraps,slings,andwedges.Manyofthesewerereasonabletechniques,otherswereratherbrutal.TobringsomelightonthemattersofSIJmechanicsandtreatment,the“InternationalSocietyofSacroiliacTechnicians”wasformed in the1930s.But,untilthe1940s,therewasnosingleacceptedconceptofsacroiliacdysfunction,despitemanyattempts.

Inthe1940s,oneseesthebeginningofourcurrentconceptsofsacraldysfunction.Dr.H.Magounwaslecturingonsacraldysfunctionsin194�andemphasizedthatsacral lesionsthatoccuronanobliqueaxisarethemostprevalent.5In1945,Drs.KennethLittleandH.V.Hooverwroteofthreeacceptedtypesofsacraldysfunction:flexion,extension,androtation,andaddedthedescriptionsoffivemorepatternsofdysfunction. In thispaper,theygivedirectionstodiagnosesacralmal-positionbynotingtherelativedepthofthesacralsulci.6

In1954,HarrisonFryettewroteextensivelyonthesacroiliacjoint,itsanatomy,dysfunctions,diagnosisandtreatmentinhis“PrinciplesofOsteopathicTechnic”ratherthanemphasizeaxesofrotation,torsion,etc.

Dr.Fryetterecognizedthecomplexityofthisjointandstatedthat“thereissuchagreatvarietyofsacroiliaclesionsthatalmostanymethodofdiagnosisandtreatmentmightbemorerightthanwrong,occasionally.”7

Conceptual and Treatment Models in Osteopathy II:

Sacroiliac Mechanics RevisitedTheodore R. Jordan

An up-to-date osteopath must have a masterful knowledge of anatomy and physiology.1 -A. T. Still

1�/The AAO Journal June�006

Finally,in1958,theosteopathicconceptofsacralandsacro-iliacdysfunctionreachedmaturityintheinfluentialpaper“Struc-turalPelvicFunction”byFredMitchellSr. In thispaper,heacknowledgedtheworkofDrs.H.V.Halladay,C.G.Beckwith,andHaroldMagounascontributingtohismodel.ThispaperbyDr.Mitchellwassocompleteandelegantofamodel,andleadtosomuchreliableclinicalsuccess,thatitovershadowedfurtherattemptstodescribeSIJdysfunction.Suddenly,afterover70yearsofosteopathicresearchandthought,aclinicallysuccessfulmodelwasproposedandadopted.Sincethattime,Mitchell’smuscleenergymodelofsacraldysfunctionhasbecomestandard,notonlyforthemajorityoftheosteopathicprofession,butalsoformanualmedicinepractitionersthroughouttheworld.Thisspeakswelloftheutilityandexcellentclinicalresultsthatthismodelprovides.

Despitethesuccessofthismodel,fornearlyahalf-century,anyadvancementofourknowledgeofsacraldysfunctionhasstopped.Theconceptsbeing taught innearly all osteopathictextbookstoday,reflectthoseputforthbyFredMitchellSr.in1958.Newscientific studiesdemonstrate theneed toupdatethisconceptualmodel.

Current concept of sacral dysfunctionTheosteopathic conceptof sacroiliac joint dysfunction is

thattheSIJsubluxes.Asubluxationisdefinedasapartialorincomplete dislocation of a joint. In this model, the sacrumchanges itsposition in relation to the iliuminanydirection,rotating about a vertical, horizontal, or oblique axis.Thesechangesresultindiagnosesdefinedassacralflexion,extension,shear,ortorsion.

Figure 1. Axes of sacral rotation from AOA glossary of osteo-pathic terminolgy.

Diagnosis of sacroiliac dysfunctionAlthoughmanyphysicalfindingsareused,twomajorcom-

ponentsofsacraldiagnosisrelyonthecomparativedepthofthetwosacralsulciindifferentpositionsandtherelativepositionoftheinferiorlateralangles(ILA).Palpatorydiagnosisofthestaticpositionofthesacrumisusuallyperformedwiththepa-

tientproneandbypressingbilaterally,medialtotheposteriorsuperioriliacspines(PSIS)onthesacrum.Positionaldiagnosisofasacraldysfunctionreliesheavilyonasymmetryofthedepthofthesacralsulci,asymmetryoftheapexofthesacrum,therelative tensions of attached ligaments, and both active andpassivemotiontests.

Figure 2. Landmarks for Sacral Testing from the AOA glos-sary of osteopathic terminology.

Scientific evidence of sacroiliac joint motionAseriesofexperimentshaveconfirmedthattheSIJdoesin

factmove.Astudyusingfreshcadaversdemonstratedsacroiliacmotion with extremes of physiological motion, even thoughthecadaversusedwerefromelderlypersons,whereonewouldexpectlessSIJmotion.8Moreimportantarestudiesutilizingtheroentgenstereophotogrammetricanalysis(RSA)techniqueasdescribedbelow.Thistechniquehasallowedmeasurementofexactamountsofsacroiliacmotioninlivehumanvolunteers,9,10andhasdocumentedsacroiliacmotionbothduringthestandinghipflexiontest11andinthereciprocalstraddleposition.1�

Role of surrounding ligaments and musclesThe SIJ is a synovial joint and is surrounded by thick

ligaments.Asmentioned,theSIJmoves,butthesurroundingligamentsacttocheckmotion.Forceappliedtoinducesacralnutationstressesthesacrotuberousligamentandcounternutationstressesthelongdorsalsacroiliacligaments.13Manyoftheseligaments are also linked to muscles, therefore surroundingmuscletensionmodifiesSIJmechanics.Tensionappliedtothetendonofthebicepsfemorisistransmittedtothesacrotuberousligament,14 therefore biceps femoris tension can presumably


help to limit sacral nutation.Moreover, deep and superficiallayersoffascialaponeurosisoverlaythethoracolumbarregionandsacrum.Muscles thatconnect to thisfascialsystem,andtherefore influence the mechanics of the lumbar spine andpelvisincludethetrapezius,latissimusdorsi,externalandin-ternalobliques,gluteusmaximus,andgluteusmedius.15Thesemusclesrepresentthe“global”systemofmusclesthatmodifysacroiliacjointmechanics.Morecentraltothesemusclesarethe“core”muscles.

Figure 3. Posterior Pelvic Anatomy. Permission to reprint received from Primal Pictures Ltd., Copyright 2001

Core muscles as stabilizersThecoremusclesacttogethertocreatearigidcylinderof

theabdominalcavity,therebyprotectingthelumbarspineandSIJsfrommechanicalstressandtransferringmechanicalload-ingfromthetrunktothepelvisandlowerextremities.Thecoremuscles include the transversus abdominus, obliques, rectusabdominus,multifidus,respiratoryandpelvicdiaphragms.Theyarealsoessentialtopullthethreebonesofthepelvissnuglytogether,thereforestabilizingthesacrumbetweentheilia.Thismechanicalactionistermed,force closure of the pelvis,andiscentraltounderstandingpelvicmechanics.

Themultifidusspecificallyhasbeenfoundtobealumbarandlumbo-sacralstabilizerthatcanalsoacttostiffenindividualsegments.16Themultifidus,withthetransverses,appearstoplaya crucial role in stabilizationof the lumbar spine and trunk.Thisco-contractionoccursina“feed-forward”manner,sothatelectromyographyshowstransversusabdominusandmultifidusmusclescontractingseveralmillisecondsbeforeothermotorac-tivityactuallyoccurs,orbeforeananticipatedmechanicalchal-lengeoccurs(suchascatchingaball,orbeforemovinganarm).Thismechanism,combinedwiththeactionoftherespiratoryandpelvicdiaphragms,workinthisfeed-forwardmechanismtoincreaseintra-abdominalpressureandthereforestabilizethelumbarspineandpelvisbyformingasemi-rigidcylinder.Inlowbackpainpatients,analysishasshownthatthis“feed-forward”contraction is lost; thecoremuscles either contract after the

mechanicalchallengeorfailtocontractatall.Likewise,failureofthepelvicdiaphragmtocontractwithmechanicalchallengehasbeendocumentedinlowbackpainpatients.17,18,19Inthesepersons,thejointsandtissuesofthelumbarspineandpelvisaresubjecttogreaterinjuryfromanymechanicalchallenge,evenfromsimplemotions.Recentadvancesinlowbackrehabilitationhavefocusedonrestoringthisessentialfunctionofthesecoremuscles.�0SIJmotionandstabilityisthereforedependentontheproperfunctionofboththe“core”and“global”neuromuscularandfascialnetworks.

Position of sacroiliac joint before and after manipulation

In1998,TychoTullberg,MD,PhD,StephanBlomberg,MD,PhD,BjörnBranth,MD,andRagnarJohnsson,MD,PhD,pub-lishedastudyinSpinetitled“ManipulationDoesNotAlterthePositionoftheSacroiliacJoint:ARoentgenStereophotogram-metricAnalysis.”�1ThisexperimentwasdesignedtoaccuratelymeasuretheamountofmovementthatresultsfrommanipulationofdysfunctionalSIJ’sinhumans.

In this study, ten persons with significant sacroiliac dys-functionwere studied.Threepairs of radio-opaque tantalummarkerswereembeddedintheboneofthesacrumandiliumofthedysfunctionalsacroiliacjointinthesesubjectsabout�daysbeforetheexperiment.WithRoentgenStereophotogrammetricalAnalysis(RSA),theprecisethree-dimensionalpositionofeachmarkercouldbeidentifiedwithanaccuracyofroughly0.1mm.Thisinvolvedshootingtwosimultaneouscrossfirex-rayswiththeradio-opaquemarkersinplace.BycomparingtheRSAfilmsbefore and after manipulation, any change in the translationandrotationofthesacrumandiliumcouldbemoreaccuratelycalculatedthaneverbeforepossible.

Onthedayoftheexperiment,thesubjectswereexaminedbyamanualmedicinepractitionerandwerefoundtohaveamajorityofpositivesacroiliactests(stronglyindicatingsacro-iliacdysfunction).ThefirstRSAfilmswerethenobtained.Themanual medicine practitioner immediately treated the sacro-iliacdysfunction.Followingmanipulation, the subjectsweremanuallyretestedandfoundtohavenormalizedsacroiliactests,indicatingthattheirsacroiliacdysfunctionhadbeenresolvedwithtreatment.AsecondsetofRSAfilmswerethenimmedi-atelyperformed.TheRSAfilmsbeforeandaftermanipulationwerelateranalyzed.

Surprisingly, no significant change in sacral position wasfound before and after manipulation in any of the subjects,despite theapparent resolutionof thedysfunctionswithma-nipulation.Toquotetheauthors:“Innoneofthetenpatientsdidmanipulationalterthepositionalrelation,definedbyRSA,betweenthesacrumandtheilium.Positionaltestresultschangedfrompositivebeforemanipulationtonormalaftermanipulationwithout corresponding alteration in skeletal position.Thus,positional testsdidnotprovideavaliddescriptionof thesa-crum-ilium position.�� Subsequently, the model of sacroiliacmechanicsmustbere-examinedandredefined.

From this study, our concept of sacral subluxation ap-pears to be an incorrect conceptual model, even thoughour treatments fulfill the criteria for a valid treatment

➝


Thequestionsuddenlypresents:doespalpationofthesacrallandmarksactuallyrepresentsacralposition?

Problems with palpatory diagnostic methods

In theclinicalsettingweonlyhaveaccess to thesurfaceofthebody.Usingvisionandpalpation,onlydiscreetlandmarksandtheirrelativepositioninspacecanbenoted.Theentirepelvisandsacrumcannotbefullyvisualized,onlyasymmetrybetweenlandmarksofthetwosidesofthebody.Conceptualmodelshavebeenconstructedtoexplainthesefindingsintermsofskeletalmal-position,suchassacraltorsions,flexions,extensions,iliacrotations,out-flares,etc.Justbecausethesemodelshavebeenwidelyaccepteddoesnotmakethematruerepresentationofunderlyinganatomy.

Palpationofthedeeperskeletalstructuresnecessitatespress-ing through skin, fat, fascia, and muscle. Particularly whenpalpatingforsacralsulcusdepth,theroleofunderlyingmuscleisignoredandsacralpositionismisinterpreted.Althoughthemultifidusisonlyoneofmanyanatomicalstructuresthatinflu-enceourdiagnosisoftheSIJ,itwillbeemphasizedbecauseofits important role in thediagnosisofsacraldysfunction,andnewunderstandingofitsfunction.

Multifidus anatomyThemultifidusmuscle isattached to theposteriorsurface

ofthesacrum,medialposteriorsuperioriliacspine,posteriorsacroiliacligaments,sacrotuberousligament,aponeurosisoftheerectorspinaemuscleandmammillaryprocessesofthelumbarvertebrae.ThemusclethenrunsmedialandsuperiortoattachtothespinousprocessesofthelumbarvertebraeL1-L5.Themultifidussendsfibersoverthesacrumtounitewiththesacro-tuberousligament.�3,�4Thereismoremusclemassnearthebaseofthesacrumthantheapex,especiallyfillingthespacebetweentheposteriorsuperioriliacspines(PSIS),thanneartheinferiorlateralangles(ILA).Itiseasytooverlookhowprominentofa muscle the multifidus is in the lumbar and sacral region.Transverseplaneimagingshowsasignificantcrosssectionalarea.Itisdirectlyintothismusclemassthatpalpationoccurstodiagnose sacraldysfunction (seefigure�).Themultifidusreceivesitsinnervationsegmentallyfromthemedialbranchofthelumbardorsalrami.Dissectionsindicatethateachmedialbranchinnervatesonlyonesegmentallevel.�5

Whenonepalpatesdownintothesacralsulciandchecksforrelativesacralsulcusdepth,therelativedepthdoesnotreflectsacralposition,butratherreflectsmultifidusthickness.EveninthepetitefemaleillustratedinFigure4,themultifidusisnearly�.5cmthickatthelevelofthePSIS.Inaddition,overlyingthemultifidusisthelumbo-sacralfascia,averythicklayerofcollag-enousconnectivetissue.Thisthicklayeroffasciacanfeelquitesolidandbemistakenforbone.Asymmetryintherelativesacralsulcusdepthsisthenmistakenasrepresentinganunevensacralbase.Instead,thisasymmetryshouldbeinterpretedasasymmetryintherelativethicknessofthemultifidusatthatlevel.

Documented asymmetry of multifidusThecross-sectionalareaofamuscle,asseenonultrasound,

CT or MRI, represents either the relative contraction of amuscle,ormusclehypertrophyoratrophyasmayoccurovertime.Whenimaged,healthysubjectsexhibitsymmetriccrosssectionalmeasurementsofthemultifidi.Conversely,lowbackpainpatientscommonlydemonstratesignificantasymmetryofthecrosssectionalareaofthemultifidimuscles.Thisasymmetryoftenoccursinadiscreetsegmentalmanner.�6,�7,�8,�9Inthelumbarregion,ifthereissignificantdysfunctionofasinglesegment,thesmallermusclesegmentisfoundonlyatthatsymptomaticsegmentandonthesamesideasthesymptoms.30

Therearetwomajortheoriesastowhythissegmentalasym-metryinmultifiduscross-sectionaldiametermightoccur.Thefirsttheoryisthatonemusclesegmentatrophies.Muscleatrophyoccursovertimeandisoftenvisualizedonscanswithincreasedfattyinfiltrationofthemultifidus.However,inastudybyHides,etal.,onepatientdevelopedsegmentalmultifidusasymmetrywithin�4hoursafteranacutebackinjury,whichleadthemtoconcludethatthemechanismofmultifidusasymmetryinbackpainismostprobablyreflexinhibition.31

Theimportanceinsacraldiagnosisisthatifonemul-tifidusatthesacralbaseismorecontractedthantheoppositemuscle, it produces a greater cross sectional area, and thatsulcuswillthenappearshallower.Palpationofthesacralsul-cus,then,isprimarilyevaluatingrelativesegmentalmultifiduscontraction,notsacralbaseposition.Theasymmetryrepresentsdysfunction,notinthepositionofthesacrum,butinthefunc-tionofthemuscleoverlyingthesacrum;amuscleintimatelyresponsibleforstabilizationofprotectionofthemechanicsofthisregion.Afterosteopathicmanipulation,symmetryismostoftenreestablished,painalleviatedandfunctionrestored.Thisrepresentsanormalizationofneuromuscularfunctionmechan-ics,notareplacementofadisplacedbone.

Figure 4. MRI cross-section. Sacrum of 32 year-old female showing multifidi muscles overlaying the sacrum between the ilia. Even in this petite female the multifidi are nearly 2.5 cm in A-P dimension. (The MRI has been inverted as if the patient was laying prone, to correspond to the following illustrations.)


Figure 5. Diagram of transverse cross section of pelvis through the PSIS, illustrating concept of deep sacral sulcus as a result of an anteriorly displaced sacral base. This concept of sacral subluxation has been thrown into question with recent Roentgen Stereophotogrammetrical Analysis studies.

Sacroiliac stiffnessFromtheserecentstudies,theconceptemergesthattheSIJ

worksmoreasaspringthanasajointthatcanbesubluxed.TheSIJiscapableofbeingdeformedwithforce,butitreturnstoneutralaftertheforceisremoved.The“spring”ofthisjointislikelydependentonsurroundingmuscularandligamentousten-sionaswellaslocalligamentintegrityandoverallbodyposture.Certainly, this “spring” function is essential forgait.Duringheelstrike,theSIJabsorbsmechanicalenergyandtransformitintopotentialenergy,thenreleasestheenergyasmechanicalenergyat thepushoffphaseofgait; thusconservingenergy

Figure 6. Diagram of transverse cross ection of pelvis through PSIS, illustrating deep sacral slcus as result of multifidus asymmetry.

Figure 7. MRI cross-section of pelvis through PSIS of a 29y/0 female who developed severe low back pain following childbirth. Note the asymmetric cross sectional area of the multifidi. (The image has been inverted to correspond to the previous illustrations.)

andfacilitatinglocomotion.Moreover,recentstudiessuggestthatrelativeasymmetryofthe“stiffness”ofthese“springs”iscorrelatedwithSIJpain.

AresearchgroupintheNetherlandshasdevisedanoninva-sivewayofmeasuringthisSIJstiffness.ThismethodinvolveslayingasubjectpronewithoneASISuponavibratingtrans-ducer.ADopplerultrasoundisthenheldovertheSIJ.Whenthetransducerisvibrating,thevibrationscanbeseenviatheDopplerultrasoundinthePSISastheyaretransmitteddirectlythroughtheilium.Ifthejointisstiff,transmissionofvibrationoccursacrosstheSIJandvibrationisseenonboththesacrumandiliumastheyvibrateasoneunit.WhentheSIJis“loose,”theiliumisobservedvibrating,butatthesameenergylevel,vibration is not seen in the sacrum. By then turning up theenergy(or“volume”)ofthetransducer,eventuallythevibra-tionsareobservedtransferringacrosstheSIJtothesacrum.Bydetermininghowmuchenergyittakestotransmitvibrationalenergyfromtheiliumacrosstothesacrum,aroughestimatecanbemadeastotherelativestiffnessoftheSIJ.

ThismethodoftestingSIJstiffnesswasfirstvalidatedoncadavers.3�Thenagroupofnormalwomenwithoutbackpainwastested.33ThenormalsubjectsshowedsymmetricSIJstiff-nesswiththesemeasurements.AfurtherstudyofperipartumwomenwithpelvicpaindemonstratedsignificantasymmetryintheSIJstiffness,righttoleft.TheauthorscouldnotconcludethatSIJassociatedpainwasduetoalooserortighterjoint,onlythatasymmetryintightnesswasassociatedwithpain.34

ThisrelativestiffnessoftheSIJscanbeobservedinseveralexaminationprocedures,suchastheiliacspringandthesacralspring tests.The relative stiffness may actually represent amechanicalcharacteristicof theSIJ,butmayalsoreflect thefunctionofthesurroundingcoreandglobalmuscleandfascialsystems.Clinicalexperiencesuggeststhatmanipulativetech-niquescannormalizeasymmetricalSIJstiffness.

➝


Discussion“The great tragedy of science-the slaying of a beautiful hy-pothesis by an ugly fact.”-Aldous Huxley

Clearly,itappearsthatourlongheldconceptsofsacralme-chanicsneedrevision,yetourtreatmentsarequitesuccessful.Iproposethatthetreatmentmodelforsacraldysfunctionisvalidbasedonitsclinicalefficacy,butthattheconceptualmodelofsacralsubluxationisinvalidbasedonrecentscientificstudies.Osteopathic treatment techniques arenot replacing subluxedSIJs, but actually modifying the complex interaction of themyofascialnetworksthatcontrolsacralmechanics.

Onapersonalnote,whenIfirstconsideredthis,itwasadauntingrevelation.Then,asIthoughtaboutit,manyprevi-ouslymysteriousobservationssuddenlymadesense.WhenIwasastudent,IrememberwatchingKennethDye,DOtreataverymarkedsacraltorsionbyusingJones’strain-counterstrainof threeanterior tenderpoints.Nowhere inhis treatmentdidIseeanymechanicalforcethatwouldhavereplacedatorsedsacrum, yet the dysfunction completely resolved. Likewise,atanAAOconvocationIsawDr.WynneSteinsnyderpresentthe“F.A.K.S.S.” technique topelvicdysfunction thatsimplyinvolved applying cross fiber pressure for a few seconds tobilateralmusclegroupsinasequentialprocess.Itwasobviousthat this technique did not directly alter SIJ mechanics, yetthis treatmentwas also successful.Additionally, I have seengentleindirecttechniquesandcraniosacraltechniquesofsacralbalancing. Innoneof thesementioned techniquesdid I everseethetypeofmechanicalforcethatwasnecessarytomoveasacroiliacjoint.Eventhemuscleenergytechniquefortreatingaforward(orbackward)sacraltorsionnevermadesenseasfaras themechanicsof replacingadisplacedsacrum.Yetallofthesetechniquesseemtoworkunderthehandsofacompetentosteopath.

Moreover,Ihavetreatedseveralunfortunatepatientswithtruesacralinstabilityaftertrauma.Onesuchpatient’ssacrumwouldaudiblycrackaspressureappliedtothesacralapexcausedthesacralapextoshiftanteriorlynearlyacentimeter.Anotherpa-tientwithtotallossofcoremuscleintegritywouldlaysupineandhersacrumwouldcounter-nutateinsmallcreakingincrements,resemblingthefeelingoftwowetpiecesofrubberrubbingandcreakingastheymovedinajerkingmotion.Inthesepatients,thesacrumrotatedaboutahorizontalaxis.Becauseofgravity,thesepatientswithSIJinstabilitytendtohavehyper-nutationofthesacrumandresultantincreasedlumbarlordosis.Inthesecasesofgrosssacralinstability,thesacrumisclearlymovingbetweentheilia.Onedoesnotgetthesamedramaticsenseofmotion when using osteopathic techniques to treat commonsacraldysfunctions.

Imustconcludethatosteopathictechniquesworkbymodify-ingtherelativetensionofthemanytissuesthatcontroltheme-chanicsoftheSIJ,andnotsimplybyreplacingadisplacedjoint,exceptincasesofgrosssacralinstability.Thisisamuchmoredynamicconceptthanthatsimplyoftwomal-positionedbonesthatneedtobemanipulatedbackintoplace.Thelivingtissuesofthebodywillassisttheoperatoroncorrectingadysfunction,andunder trainedhands,minimalforceisrequired.Adevel-

opedsenseoftouchistheprimarytoolneededtosuccessfullyassistinthecorrection.Thisiswhatsomanygreatosteopathsintuitivelyknowandpracticedaily.Yetourconceptualmodellagsbehindourpracticeandournomenclatureislikewiseout-dated.Newconceptualmodelsneedtobeintroducedtomorecloselydescribethedynamiccomplexityofthemechanicsofthesacroiliacjoint.35

Summary1.ThesubluxationmodeloftheSIJisavalidtreatmentmodel:

Itgivesatheoreticalexplanationofpalpatoryfindings,pre-scribestreatment,andgivespredictableresults.

�.ThesubluxationmodeloftheSIJisnotavalidconceptualmodel:Recent researchhas failed toshowanychange inpositionoftheSIJbeforeandaftermanipulation.

3.TheSIJdoesnotsublux,asdescribedinosteopathictexts.Thistheorywasdevelopedduetomisinterpretationofpalpa-toryobservations.

4.Palpation of anatomic landmarks used to diagnose sacraldysfunctiondonotaccuratelyreflectskeletalposition,butratherreflectunderlyingmuscularandfascialtension.

5.ThehealthySIJmoves.Itdeformswithforcebutreturnstoitsneutralposition.Mechanicallyitactsasaspringtotrans-formmechanicalenergyintopotentialenergyandbackintomechanicalenergy,especiallyimportantfornormalgait.

6.SIJ mechanics are under the influence of surroundingmuscles,ligaments,andskeletalposture.AlteredsymmetryofthesurroundingmuscularandfascialnetworkwillreflectasalteredSIJmechanics.

7.AsymmetricalstiffnessoftheSIJ’shasbeenassociatedwithpain.

8.Grosssacroiliacinstabilityoccursrarely,andonlywithtrau-maticdisruptionofSIJligamentousintegrity,and/orlossofcoremusclecompetency.

9.TotreatSIJdysfunction,thesurroundingmuscularandfas-cialdysfunctionsmustbecorrected.Successfulosteopathictechniquesworkprimarilyonnormalizingmuscular,fascialandligamentousfunctionthatinfluenceSIJmechanics,notonrepositioningamal-positionedjoint.

References1. StillAT.The Philosophy and Mechanical Principles of Oste-

opathy.Hudson-KimberlyPub,.KansasCity,MO.190�,.p18.�. JordanT.ConceptualandtreatmentmodelsinOsteopathyI:

Settinghips.AAO Journal.�003.Springissue.pp31-38.3. TruhiarRE.DoctorA.T.StillintheLiving.ChagrinFalls:

Privatelypublished:1950,p16.4. “HulettGD.A textbook of the Principles of Osteopathy,4thed.

Kirksville:JournalPrintingCompany:1906,p351-�.5. MagounHI,NorthupGW.LecturesgivenbyH.I.Magoun,

D.O.ReportedbyG.W.Northup,D.O.AcademyofAppliedOsteopathyYearbook.194�;p105.

6 LjleK,Hoover,HV.Respiratorymobilizationandmoldingofthesacrum.Academy of Applied Osteopathy Yearbook,1945;pp67-68.

7. FryetteHH.Principles of Osteopathic Technic.AcademyofAppliedOsteopathy,CarmelCA;1954.

8. SmidtGL,Shun-HwaW,McQuadeK,BarakattMA,TianshengS,StanfordW.Sacroiliacmotionforextremehipposition.Afreshcadaverstudy.Spine.1997.��(18):�073-8�.


9. EgundN,OlssonTH,SchnmidH,andSelvikG.Movementsinthesacroiliacjointsdemonstratedwithroentgenstereophoto-grammetry.Acta Radiol Diagn(Stockh)1978;19(5):833-46.

10. SturessonB,SelvikG,UdenA.Movementsofthesacroiliacjoints.Aroentgenstereophotogrammetricanalysis.Spine.1989.14(�):16�-5.

11. SturessonB,UdenA,andVleemingA.Aradiostereometricanalysisofmovementsofthesacroiliacjointsduringthestand-inghipflexiontest.Spine.�000.�5(3):364-8.

1�. SturessonB,UdenA,andVleemingA.Aradiostereometricanalysisofthemovementsofthesacroiliacjointsintherecipro-calstraddleposition.Spine.�000.�5(�):�14-7.

13. VleemingA,Pool-GoudzwaardAL,HammudoghluD,Stoeck-artR,SnijdersCJ,andMensJMA.Thefunctionofthelongdorsalsacroiliacligament. Spine.1996.�1(5):556-6�.

14. VleemingA,MooneyV,DormanT,SnijdersC,andStoeckartR.MovementStability&LowBackPain:Theessentialroleofthepelvis.NewYork:ChurchillLivingston;1997:63.

15. VleemingA,Pool-GoudzwaardAL,StoeckartR,WingerdenJ,andSnijdersCJ.Theposteriorlayerofthethoracolumbarfas-cia.Itsfunctioninloadtransferfromspinetolegs. Spine.1995.�0(7):753-58.

16. KayA.Anextensiveliteraturereviewofthelumbarmultifidus:Biomechanics.J Manual Manipulative Ther.�001.9(1):1739.

17. O’SullivanPB,BealesDJ,etal.Alteredmotorcontrolstrate-giesinsubjectswithsacroiliacjointpainduringtheactivestraight-leglraisetest.Spine.�00�.�7(l):1-8.

18. AveryA,O’SullivanP,andMacCallumM.Evidenceofpelvicfloormuscledysfunctioninsubjectswithchronicsacro-iliacjointpainsyndrome.Proceedingsofthe7thScientificConfer-enceoftheIFOMT.Nov�000.

19. ThompsonJandO’SullivanP.Levitorplatemovementdur-ingvoluntarypelvicfloormusclecontractioninsubjectswithincontinenceandprolapse:acrosssectionalstudyandreview.Int Urogynecol Journal.�003.1�(4);84-88.

�0. RichardsonC,etal.Therapeutic exercise for spinal segmental stabilization in low back pain, scientific basis and clinical ap-proach.NewYork.ChurchillLivingstone.1999.

�1. TullbergT,BlombergS,BranthB,andJohnssonR.Manipula-tiondoesnotalterthepositionofthesacroiliacjoint:aroentgenstereophotogrammetricanalysis.Spine.1998.�3(10):11�4-11�9.

��. TullbergT,BlombergS,BranthB,andJohnssonR.Manipula-tiondoesnotalterthepositionofthesacroiliacjoint:aroentgenstereophotogrammetricanalysis.Spine.1998.�3(10):11�6.

�3. PorterfieldJandDeRosa,C.Mechanical low back pain, perspectives in functional anatomy.�nded.Philadelphia.WBSaunders.1991:75-76.

�4. KayA.Anextensiveliteraturereviewofthelumbarmultifidus:Anatomy.J Manual Manipulative Ther.�000.8(3):10�114.

�5. BogdukN,WilsonA,andTynanW.Thehumandorsalrami.J Anat.198�.134:383-397.

�6. LaasonenEM.Atrophyofsacrospinalmusclegroupsinpatientswithchronic,diffuselyradiatinglumbarbackpain.Neuroradi-ology.1984:�6(l):9-13.

�7. CooperRG,StClairForbesW,andJaysonMI.Radiographicdemonstrationofparaspinalmusclewastinginpatientswithchroniclowbackpain.Br J Rheumatology.199�.Jun31.(6):

389-94.�8. HidesJA,StokesMJ,SaideM,JullGA,andCooperDH.

Evidenceoflumbarmultifidusmusclewastingipsilateraltosymptomswithacute/subacutelowbackpain. Spine.1994.Jan15.19(�):165-7�.

�9. RamsbacherJ,etal.Ultrastructuralchangesinparavertebral

musclesassociatedwithdegenerativespondylolisthesis.Spine.�001.�6(�0):�180-�185.

30. RichardsonC,etal.Therapeutic exercise for spinal segmental stabilization in low back pain, scientific basis and clinical ap-proach.NewYork.ChurchillLivingstone.1999.p71-73.

31. RichardsonC,etal.Therapeutic exercise for spinal segmental stabilization in low back pain, scientific basis and clinical ap-proach.NewYork.ChurchillLivingstone.1999.p74.

3�. BuyrukHM,StamHJ,SnijdersCJ,VleemingA,LamerisJS,andHollandWP.TheuseofcolorDopplerimagingfortheassessmentofsacroiliacjointstiffness:astudyonembalmedhumanpelvises.Eur J Radiol.1995.�1(�):11�-116.

33. BuyrukHM,SnijdersCJ,VleemingA,LamerisJS,HollandWP,andStamHJ.ThemeasurementofsacroiliacjointstiffnesswithcolourDopplerimaging:astudyonhealthysubjects.Eur J Radiol.1995.�1(�):117-1�1.

34. BurukHM,StamHJ,SnijdersCJ,LamerisJS,HollandWP,andStijnenTH.Measurementofsacroiliacjointstiffnessinperi-partumpelvicpainpatientswithDopplerimagingofvibrations(Div).Eur J Obstet Reprod Biol.1999.Apr.83(�):159-63

35. Ofcoursethisbegsthequestion:Iftheconceptualmodelofsacralmechanicsisnotvalid,whatwillweaskaboutonosteo-pathicboardexams?r

Accepted for Publication:March�006

Address Correspondence to:

TheodoreR.Jordan,DO5100W.BroadSt.,Suite107Columbus,OH43��8Fax:614/878-8031

CME QUIZ Thepurposeofthequizfoundonthenextpageistoprovideaconvenientmeansofself-assessmentforyourreadingofthescientificcontentinthe“ConcepturalandTreatmentModelsinOsteopathyinOsteopathyII:Sacro-iliacMechanicsRevisited”byTheodoreR.JordanANDin“PostOperativeOsteopathicManipulativeProtocolforDeliverybyStudentsinanAllopathicEnvironment”byRobertC.ClarkandThomasM.McCombs.Foreachofthequestions,placeacheckmarkinthespaceprovidednext toyouranswerso thatyoucaneasilyverifyyouranswersagainstthecorrectanswersthatwillbepublishedintheSeptember�006issueoftheAAOJ. ToapplyforCategory�-BCMEcredit,transferyouranswerstotheAAOJCMEQuizApplicationFormanswersheetonthenextpage.TheAAOwillrecordthefactthatyousubmittedtheformforCategory�-BCMEcreditandwillforwardyourtestresultstotheAOADivisionofCMEfordocumentation.


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Questions 4-6: Name of Article: Post Operative Osteopathic Manipulative Protocol for Delivery by Students in an Allopathic EnvironmentAuthors: Robert C. Clark, DO & Thomas M. McCombs, DOPublication: Journal of the American Academy of Osteopathy,Volume16,No.�,June�006,pp19-�1

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1.Whenpalpatingoverthesacralbase,justmedialtothePSISbilater-ally,therelativedepthofthesacralsulcimostdirectlyrepresents:

a.Psoasmuscletoneorcontraction b.Biceptsfemorismuscletoneorcontractionviatension transmittedthroughthesacrotuberousligament c.Relativepositionofthesacruminrelationtotheilia(innominates) d.Multifidusmuscletoneorcontraction e.Ipsilateralexternalobliquemuscletoneorcontractionvia tensiontransmittedthroughthethoracolumbarfascia

�. WhenusingavibrationtransducerovertheASIStoobservethetransmissionofvibrationacrossthesacroiliacjoint,researchershaveconcludedthat:

a.Asymmetryofstiffnessbetweenthetwosacroiliacjointsisonly observedincadaverstudies b.Asymmetryofstiffnessbetweenthetwosacroiliacjointsis associatedwithpain,butthepainfulsidecannotbeconcluded

tobeeitherthe“stiffer”,orthe“looser”side c.Whenthereisasymmetryinthestiffnessofthesacroiliacjoints, thepainfulsideismostcommonlythe“stiffer”sacroiliacjoint d.Asymmetryofstiffnessbetweenthetwosacroiliacjointsisonly observedpregnantfemales e.Whenthereisasymmetryinthestiffnessofthesacroiliacjoints, thepainfulsideismostcommonlythe“looser”sacroiliacjoint

3.Recentscientificstudieshaveconcludedthat: a.Thesacroiliacjointdeformswhenexternalforcesareappliedtoit b.Thereisnochangeinthepositionalrelationbetweenthesacrum

andtheiliabeforeandaftermanipulationofthesacroiliacjoint c.Asymmetryinthecrosssectionaldiameterofthemultifiduscan occur,andisoftenseenafterinjury,andinlowbackpainpatients d.Relativestiffnessesofthesacroiliacjointsisinfluencedbythetone

ofthesurroundingmuscles(gluteus,hamstrings,latissmus,etc.) e.Alloftheabove

4.CondylarDecompressionnotonlycounteractsthemechanicalef-fectsofintubation,butservestooptimizethephysiologyof:

a.ThePhrenicNerves b.TheTrigeminalNerves c.TheVagusNerves d.TheSplanchnicNerves e.TheSympatheticNerves

5.Treatmentofthemid-cervicalspineisadvocatedforPostOperativeOMT,tocounteractthemechanicaleffectsofintubationandtoopti-mizethephysiologyof:

a.ThePhrenicNerves b.TheBrachialPlexus c.TheVagusNerves d.TheSplanchnicNerves e.TheRecurrentLaryngealNerves

6.TheRespiratoryDiaphragmventilatesthelungbases,andwhenrobust,itsmotion(duringinhalation)willalso:

a.Displacetheabdominalwallposteriorly b.Narrowallbronchiallumens c.Slowvenousreturntothethorax d.Relaxtheloweresophagealsphincter e.Stimulateperistalsis


Tradition Shapes the Future • Volume 16 Number 2 June 2006Official Publication of the American Academy of Osteopathy®


AbstractToday’sstudentsarefacedwiththe

probabilitythatsomeoralloftheirthirdyearclinicalrotationswillbeinallopathichospitals.Thisaffordsthemlittleifanyopportunitytopracticetheirosteopathicmanipulativeskillsasthereare:a.no0MMcredentialsofferedbythe

hospitalb.noopportunitiesinthebusyschedulec.no permission from theAttending

Physicians,andd.rarelyqualifiedsupervisorspresent.

Theauthorshavedevisedaprotocolof osteopathic manipulative treatmenttechniquesforuseonpatientswhoareintheimmediatepost-operativeperiod.Thisprotocol canbeadministeredbyquali-fiedthirdyearorfourthyearosteopathicstudentswithoutsupervision.Thetech-niques selected represent fundamentalskilllevelsthatanyosteopathicstudentorphysicianshouldbeabletoadminister.

(KeyWords:LymphaticPumpTechnique,Osteopathic Manipulative Treatment[OMT],PostoperativePain,SoftTissueTechnique,RibRaisingTechnique)

IntroductionStudiesbyStiles,1Radjieski,�Can-

tieri,3 No.114 and others show thatosteopathicmanipulative treatmenthasapositive impacton lengthof stay forhospitalizedpatientsinavarietyofdiag-noses-ordiagnosticrelatedgroupsalsoknownasDRGs.

Stiles’workfrom1974showsthatpatients lengthof staywas reducedbyroughlyoneday.Radjieski’s�workshowsthat in the case of pancreatitis, lengthofstaywasreducedbyaboutonehalf.Cantieri’sstudy3fromtheAAOJournal

Post Operative OsteopathicManipulative Protocolfor Delivery by Studentsin an Allopathic EnvironmentRobert C. Clark and Thomas M. McCombs

Winter 1997 showed that for a varietyofDRGs,OMTcombinedwithnormalmedicalcarereducedthelengthofstayby an average of 1/� day compared tonormalmedicalcarealone.TherewerealargenumberofDRG’sandinseveralcasesnocomparisoncanbemadei.e.nopatient did not receive OMT. Cantieriposedanumberofexcellentquestionsforfurtheranalysis.No114examinedtheroleofOMTinhospitalizedelderlypatientswith pneumonia and evaluated severalparameters. Inhisstudy, lengthofstayinthehospitalwasreducedfromameanof8.6dayswithoutOMTto6.6daywithOMT.Additionally,thelengthofuseofintravenousantibioticswasreduced.

Sleszynski and Kelso5 comparedthoracicpumptechniquetoincentivespi-rometrytechniquesinthepreventionofpost-operativeatelectasis.Thoracicpumpwas used twice daily while spirometrywasusedthreetofourtimesaday.Bothtreatmentswereeffectiveinreducingatel-ectasisfroma50percentoccurrenceratetoafivepercentoccurrencerate;howevertheOMTachievedtheresultwithhalfthenumberoftreatmentsandpatients’recov-ery,asmeasuredbypulmonaryfunctiontestsoccurredmorequickly.

However, they did not observelengthofstayintheirstudy.

Withthiscollectionofdatainmind,theauthorslookedatTUCOM-CAanditsheavyrelianceuponallopathichospitaltraining environments for its students.In these environments, it is extremelydifficultforstudentstoperformOMTastheirattendingsareunabletoprovidesu-pervision.Oneoftheauthors(McCombs)provides weekly instruction in each ofthree San Francisco bay area hospitalswhichparticipate in theTUCOM thirdyear training program; however, he is

astaffmemberinonlyoneofthethreeinstitutions and in that institution seespatientsonalimitedbasis.

Informalconversationwithstudentswhorotate,atbothlocalaswellasdistantinstitutions,revealsanextremevariabil-ity in the opportunities for students togiveOMT.Somestudentspresenttotheirattendingphysiciansarationalbasisforgivingatreatmentandattendingsgranttheirpermissionforstudentstoperformtreatments. Others have, on occasion,resorted to deception saying that theywerenotgivingosteopathicmanipulativetreatmentbut theyaregivingtreatment,whichis“massage-likeinnature.”Sadly,thisdeceptivestrategymayproveeffectiveinallowingthestudenttotreat;however,withinthedeceptionliesafunctionalab-senceofinformedconsentbyboththepa-tientandtheattendingbecausethestudenthasnotfullydisclosedaccurateandpre-ciseinformationastowhatisbeingdone.Students,therefore,areworkingwithoutthe benefit of experienced supervision,riskingpatientsafety,lackingbackupformanagementoftreatmentreactions,andloweringthestatureofosteopathicmedi-cine.Farmorehospitalstrainosteopathicstudentsthanhaveadequatesupervisionavailable forOMM.Tomeet theneedsofstudentswhohavepermissionbutnotsupervision toapplyOMM, theauthorshaveformulatedaprotocoloftreatmenttechniquessuitableforstudentstoadmin-isterwithoutsupervisiontopatientsinthepost-operativeperiod.

The techniques chosen are basictechniquesdesigned to support respira-tion, circulation,ventilation, andperfu-sion thereby augmenting the healingprocessfollowingasurgicalprocedure.The techniques selected are those that

➝

�0/The AAO Journal June�006

arenowtaughtinthefirsttwoyearsofOMM training atTUCOM-CA.Thesetechniquesareeasytoadministerandareverysafe.ModificationsfordeliveryinthehospitalenvironmentweredevelopedbyauthorMcCombs.

Someof the impactsofsurgeryonthepatientsphysiologyincludeacentralnervoussystemthathasbeenstunnedbytheanestheticagents.TheauthorsobserveaweakenedCranialRhythmic Impulse,which is typicallynotedashavingbotha slower rate anda lesser amplitude. Ithas also been observed that prolongedintubationslowsandrestrictsmotionofthesphenobasilarsynchondrosis.Theauto-nomicnervoussystemexperiencessimilareffects.Oneofthecommoneffectsofsur-geryispost-operativeileus.Additionally,thepatientwhoisintubatedaspartofageneralanestheticprocedureexperiencesmarkedextensionoftheoccipitalatlantaljoints and midcervical spine.This canhaveadverseeffectsuponthevagusandthephrenicnerves,causingsuboptimalenervationtotherespiratorydiaphragm,heart,lungs,andgastrointestinalsystem.Additionally,ithasbeenobservedthattheuseofventilatingmachineryhasaneffectofreducingthevenousandlymphaticflowreturns. Lastly, the patient experiencesincisional pain, which often manifestswithguardedshallowrespiration,whichincreases the riskof atelectasis, venousstasisandileus.Additionally,earlypost-operativecareoftenutilizesopiatepaincontrol medications which candepressrespiratorydriveanddepressgastrointes-tinalfunction-specificallyperistalsis.

Thenaturalsequelaeofthesecumula-tiveinsultstophysiologyareseendailyineveryhospitalinAmerica:atelectasis,il-eusandvenousstasis(edema,deepvenousthrombosis,skinulcerations).Allopathicmedicine offers incentive spirometry,early ambulation, continuous passivemotionequipment,anticoagulationdrugs,andskillednursingpracticestocounteracttheeffectsdescribed.Theauthorssubmitthat early interventionwithosteopathicmanipulativetreatment(OMT)willavertorminimizesuchadverseoutcomes.In-deed,wehopethatbysendingosteopathicstudentswhoarecompetentwiththispro-tocolintotheallopathicworld,thatworldwilldevelopincreasedawarenessofandrespectforosteopathy.

Thetherapeuticgoalsofpostopera-

tiveOMTare:1)Restorethecranialrhythmicimpulse

toitsfullrateandexcursion.�)Restoreventilationtofullcapacity.3)Maintainand/orrestoreperistalsis.4)Restorethethirdspacefluidtocircula-

tion.Anumberoftechniquescanbeused

foreachoneofthesefourgoalsandsomeofthesetechniqueswilloverlapandmeetmultiplegoals.

ProtocolThe protocol we recommend is a

seven-stepsequenceofosteopathicma-nipulativetechniques:1.Condylar decompression (using a

lateralapproachiftheheadofthebedisinaccessible).

�.Sphenobasilardecompression(usingalateralapproachiftheheadofthebedisinaccessible).

3.Correctionofcervicalspinedysfunc-tions utilizing soft tissue techniqueandifappropriate,highvelocitylowamplitudetechnique.

4.Rib-raising.5.Redomeingofthediaphragm6.Lumbosacral decompression and

balancingofthepelvicdiaphragmasindicated.

7.Lymphatic pump, such as the pedalpump, can be used to complete theprotocol.

Thisprotocolwasindependentlyde-rivedbytheauthors.Duringtheliteraturereview,theNo.114protocolwasdiscov-ered.Althoughtechniqueselectionsandoursequenceareslightlydifferent,manyofthesametechniquesareused.NicholasandOleski7practicedafour-stepprotocolcomposedofribraising,treatmentofthethoracicinlet,respiratorydiaphragmandpelvic diaphragm.The overlap of thethreeprotocolsisnotable.

Rationale for Selection of Tech-niques in this Protocol

Techniques were chosen becausetheyareeasilyadministeredbystudentswithverylowrisktothepatientsandahighprobabilityofsuccessfuloutcome.The No.114 protocol was administeredby second year students who receivedspecific training in the protocol.Thisexperiencesupportsthecontentionthatthe techniques can be safely adminis-

teredbystudents.Theauthorsviewtheirprotocolasasetofrecommendationsorguidelinesfortreatmenttechniquestobeadministered to postoperative patients.It is recognized thata spectrumofcir-cumstances,whichcannotbepredictedin this article, may be encountered bythe student or physician. Therefore,appropriateclinicaldecisionmaking toexclude a particular technique due tospecial patient circumstances must beexercised.For example,pedalpump isnotanappropriatetechniquetobeusedifthepatienthasdeepveinthrombosis,central venous lines, is intubated, or ifthelegisimmobilizedinacastorotherfixationdevice.

TheCondylardecompressiontech-niquewasselectedtooffsetthehyperex-tensionnecessitatedbyintubation.Thistechniquealsohasbeneficialeffectsofremovingcompressionandirritationofthe vagus nerve pathway through thejugular foramen, minimizing the prob-ability of onset of postoperative ileus.The technique is easily administered.Patientsreportthatitfeelsgood.

The sphenobasilar synchondrosis(SBS)decompression techniquealso isbeneficialinreducingthepostoperativeeffectsofanesthesiaandintubation.Alat-eralapproachtobothcondylarandSBSdecompressionisrecommendedbecauseofthecommonproblemofhospitalbedsbeing against walls with the head endinaccessible. It isbest tonotmove thebed and disturb the various supportivehardwareandmonitoringequipment.

Treatment to the cervical spine isbeneficialbecausethephrenicnerveorig-inatesatC3,4,and5providesinnervationtothediaphragm.Intheextensionoftheneckforintubationthisareaisstressed.Anecdotally, many patients with post-operativesingultushavedysfunctionsofC3,4,or5.Treatmenttothisareacanhelpnormalizenervesupplytothediaphragmandeliminatethesingultus.

Rib-raisingtechniquesareselectedfor the protocol because they are easyto administer and have a long historyof success dating from the 1890s. Ribraisingenhancestheinhalationphaseofrespiration,helpsbalancetheautonomicnervous system, enhances lymphaticdrainagethroughthethoracicduct,andcan be beneficial in maintaining andrestoringperistalsis!

June�006 The AAO Journal/�1

Redomingthediaphragmisa tech-niquebeneficial inrestoringventilation,stimulatingperistalsis,andrestoringthirdspace fluid to circulation.As a conse-quenceofinhaledanesthesiatechniquesrequiringparalyticagents,thediaphragmceases to functionandspontaneous res-toration of function postoperatively isveryslow.Ribraisingtechniquescanbesupportiveascanthediaphragmredomingordiaphragmreleasetechniques.Thedia-phragmhasbeenfoundinrecentresearch6tohave significant lymphatic collectionstructuresonitsinferiorsurface.Theriseandfallofthediaphragmwithrespirationhelpsaccelerate thecollectionofasciticaccumulationsintheabdomenandreturnthemtolymphaticcirculation.

Thisdiaphragmreleaseorredomingisaveryvaluableandclinicallypowerfultechnique.

Lumbosacral decompression andbalancingofthepelvicfloor,dependinguponthesurgery,canbeverybeneficialinassistinginthemaintenanceandrestora-tionofperistalsisandurinaryfunction.

Pedalpumpwaschosenbecauseitisconsideredbymanytobeoneofthegen-tlestlymphaticpumptechniques.Sincethepatientsintheearlyphasespostop-eratively are not ambulatory, there isaccumulationoffluidsinthelegs.Pedalpumptechniquecouldbebeneficialinthepreventionofdeep-veinthrombosisandperipheraledemabothofwhichcanberestrictivefactorsinambulatoryefforts.

Strategies for Implementation of these procedures

Implementationofthisprotocolfirstrequires training students via lectureandlabwithsupervisedpracticeof theprotocol.Eachtechniqueislearnedindi-viduallyoverthecourseofthefirsttwoyearsoftraininginOMM.StudentshavefurtherskillspracticeopportunitiesintheLongTermTUCOM-CAOMMPatientcare/Patient-Partnerprogram.TechniquesarepresentedintheprotocolformatinthelastOMM labof the secondyear.Theprotocolisrevisitedwhenthethirdyearstudentsarecalledbacktocampus.

Discussionwithphysiciansat sev-eral allopathic hospitals affiliated withTUCOMleadsustothefollowingrec-ommendations:

The medical staff should receiveexposure to these procedures. Grand

Roundspresentationswouldbeanidealmechanism.Thestaffshouldbeinformedthatthecollege(s)considerthestudentsqualifiedtoadministertheseprocedureswithout direct supervision.An OMMspecialistbackupshouldbeavailableinthe unlikely event complications arise,ideally provided by a member of thehospital’smedicalstaff.

Appropriate rationale should begivenfortheprocedureandappropriatedocumentation prepared.These shouldbepresentedformedicalstaffapprovaljustasanyotherproceduredoneinthehospital.Oncesuchapprovalisobtained,students could then be directed byAt-tendingPhysicianstoadministerOMT,and document this by using progressnotesorpre-approvedforms.Inconjunc-tionwiththeattendingphysiciansandtheinstitutions; length of stay and patientoutcomeevaluationscouldbeperformedtocreateadatabaseofclinicalexperienceandevidencetovalidatetheeffectivenessofthisprotocolandthesetechniques.

IfallOMTiscodedusingCPTcodes989�5-989�9,utilizationreviewcanmoni-torpatientoutcomesthatcontainOMTforcomparison with non-OMT “controls.”Lengthofstay,timetoambulation,useofpainmedication,andultimatelycostsav-ingscanbetracked.Thisprotocoltreats5-6regions:head,neck,ribs,lumbarspine,sacrum, and lower extremities and theOMTCode:989�7isapplicable.

ConclusionThe techniques in this protocol

are easily administered by osteopathicstudents during their third and fourthyearrotations.Asthemajorityofthesetechniques in one form or another aretaught in most colleges of osteopathicmedicineitshouldbeeasytoexpandtheapplicationtoinvolveallstudentsfromall schools inanyclinicalenvironmentwhere appropriate approval has beengranted for the administration of suchprocedures.Theseproceduresareconsid-eredquitesafe,withverylowrisktothepatientandcanbeadministeredwithoutexpert supervision. Clinical judgmentis always indicated in determining theappropriatenessofanygiventechniquewithin theprotocolandthedurationofanygiventreatmentsession.Appropriatedocumentation of these procedures inboththeD.O.andM.D.institutionswill

servetoexpandanexperientialdatabaseforclinicaloutcomestudies.Also,withtheappropriatesupportoftheinstitutions,studentswhochoosetoadministerOMTonasurreptitiousbasiscanbeconvertedtostudentsadministeringOMTonapub-lic,open,andacceptedbasis.Thisservestoenhancetheimageandeffectivenessoftheprofessionnowandinthefuture.

References:1. StilesEG.Somaticdysfunctionin

hospitalpractice.Osteopathic Annals. 1979.Jan;7(1)35-8,quiz39-40.41b(56)

�. RadjieskiJM,LumleyMA,andCant-ieriMS.Effectofosteopathicmanipu-lativetreatmentonlengthofstayforpancreatitis:arandomizedpilotstudy.JAOA.1998.May.98:(5):�64-�7�.

3. CantieriMS.Inpatientosteopathicmanipulativetreatment;impactonlengthofstay. The AAO Journal.APublicationoftheAmericanAcademyofOsteopathy1997Win;7(4):�5-�9.

4. NollDR,ShoresJH,GamberRG,etal.Benefitsofosteopathicmanipula-tivetreatmentsforhospitalizedelderlypatientswithpneumonia.JAOA.�000.December.100(1�):776-78�.

5. SleszynskiSLandKelsoAF.Com-parisonofthoracicmanipulationwithincentivespirometryinpreventingpostoperativeAtelectasis.JAOA.1993August.93:(8):834-838,843-845.

6. WillardF.AnatomyoftheLymphaticsAAO.1998Convocationpresentation.

7. NicholasAS.andOleskiSL.JAOA. �00�.SeptemberSupplement.3:10�(9):S5-S8.r

Accepted for Publication: March�006


RobertC.Clark,DO3�43ClaytonRd.Concord,CA94519Email:[email protected]

or

ThomasM.McCombs,DOTUCOM,DeptofOMM1310JohnsonLaneVallejo,CA9459�Email:[email protected]

��/The AAO Journal June�006

IntroductionCrohn’sDiseaseisaninflammatoryboweldiseasethatis

idiopathic,chronic,andrecurrent.Itcanaffectanypartofthegastrointestinaltract,butit isclassicallyknownforaffectingthe terminal ileum. It is characterized by an insidious onsetof low-grade fever,diarrhea, cramping, right lowerquadrantmassortenderness.Oftenitcanbeconfirmedwithradiologicverificationofulceration,structuring,orfistulas.(Sartor,�004).AstronggeneticcomponenthasbeenlinkedtoCrohn’sdisease,whichmaycausetheimmunesystemtoworkimproperlyinthegut.Currenttherapyinvolvescorticosteroids,buttheyhaveonlybeeneffectiveininitiatingremissionforanattack.However,newtherapiesinvolvingbiologicaltherapyhavebeenpromis-ing,andwilllikelysoonbecomethenewstandardoftreatmentforinflammatoryboweldisease.Thepeakonsetofthediseaseisaround�0to40years,andalthoughresearchdemonstratesageneticcomponenttothisdisease,thepatternisnonmendelianandcomplex.

Althoughthediseaseoccursequallyinmenandwomen,itcanhaveaprofoundimpactonwomen’shealthcare.Women’sissuesinvolvingCrohn’sdiseaseincludebodyimage,fertility,managementduringpregnancy,andosteoporosis(Sarathchan-dra,�001).ThepatientinthecasehistorybelowinvolvesMs.EN,whowillhavetodealwiththeseunfortunateissuesinherlifetime,andwholikelyalreadyhasinher10yearsofstrugglingwithCrohn’s.Carteret.al(�004)reportsthat,“TheimpactofIBDonsocietyisdisproportionablyhigh,aspresentationoftenoccursatayoungageandhasthepotentialtocauselifelongillhealth”(p.vi).ThisreportwilldetailthecasehistoryofMs.EN,explainthediseaseprocess,aswellasreviewthecurrentliteratureregardingthistopic.

Case ReportMs.ENisa30-year-oldheterosexualCaucasianfemalewith

achiefcomplaintofmusclesorenessandfatigueduetoarecentflairofCrohn’sdiseasewithapreviousepisodeofcrampinganddiarrhea.ThepatientpresentswithanextensivehistoryofchronicandremittingCrohn’sDisease.Sheisafulltimenanny,single,livinginDallas,Texas.ThisisherfirstevaluationbyaUNTHSCthirdyearmedicalstudent,DeanaMitchell.Noothersourceswereavailable.Thepatientappearedtobecooperative,reliable,andrational.

History of the Present IllnessMs.ENpresentedwithcrampinganddiarrheathatstarted

acutelytwonightsago.Shedescribesintensepaindiffuselyin

Crohn’s Disease: A Case Reportincluding the most recent Theories and Treatment PrinciplesDeana Mitchell and Jerry L. Dickey

herabdominalarea,characterizedas10/10,aswellasnauseaandvomitingx3duringthecourseofthenight.Thepatientstatesthathermouthbegantodryout,withalternatingfeelingsofbe-inghotandcold.Thepatientdescribesbecomingdiaphoreticbeforethesymptomsofcrampingoccurred.Thecrampinganddiarrheawasconstant,andlastedforabout1�hours.Fortreat-mentthepatienttookaspirin,butthisdidnothelptoalleviatethe pain. Recently she has experienced several stressful lifeevents,suchasbeingterminatedfromherfull-timejob,lossofinsurance,andotherfinancialworries.Shewasnotabletomakeherpainbetter.Ms.ENproceededtotheER,whereshewasgivenIVsteroidsofhydrocortisone,aswellaspainmedicationofwhichshedoesnotrememberthename.Shenowpresentswithmuscletightnessandsoreness,especiallyinherthoracic,lumbar,andpelvicregionthatischaracterizedbyan8/10,whichbegantooccurafterherCrohn’sattack.

Past Medical HistoryThepatientisallergictopenicillin.Theonlymedications,

which she is taking regularly includeYasmin,Tegretol, andPentasa1grampoqid.Herpastmedicalhistoryissignificantfordepressionandaseizuredisorder.Pastsurgeriesincludealumpectomyintheleftbreastin�003.SheisaG1POO1OwithahistoryofabnormalpapsmearsdescribedasASCUS.Thepa-tienthasaprevioushistoryofHPV,butdenieshavinganyotherSTD’s.Herperiodsareregularwitha�8-day-cycle.HerfamilyhistoryissignificantforIrritableBowelSyndrome,whichhasbeendiagnosedinhergrandmother,father,mother,andsister.Thepatientdoesnotsmoke,andhasapproximately�-5drinksperweek.Thepatientdeniesanyuseofillegalsubstances.

Review of Systems

GeneralConstitutionalSymptoms:No fever, chills, malaise.

Skin:No rashes or other changes.

HeadandNeck:No history of head injury. History of periodic headaches, approximately one time per month, relieved by resting and aspirin.

Eyes:Wears contacts daily with a prescription of -6 and sees optometrist yearly.

Ears:No dizziness, discharge, or pain present.

Nose:Occasional respiratory infection, 1-2x a year with post-nasal drip. There is no problem reported with sense of smell.


➝

MouthandThroat:No soreness, change in voice, no difficulty eating or chewing food.

Breasts: No pain, discharge, nipple tenderness. Patient has had a lumpectomy in 2003, which showed benign fibrocystic changes.

Cardiovascular:No shortness of breath, chest pain, or difficulty performing activities, no pain, tenderness, discoloration, tem-perature change, or swelling in extremities.

ChestandLungs:No history of asthma, bronchitis, or pneumo-nia. Patient has no breathing difficulties, cough, or pain.

Endocrine:No history of changes in thyroid, skin, hair, or tem-perature preference. No polyuria or polydipsia, and no history of diabetes.

Lymphatic:No known lymph node enlargement.

Gastrointestinal: 10-year history of recurrent and remitting Crohn’s Disease with cramping, diarrhea, and intense pain. Triggers to attacks include stressful life events, or spicy and irritating food. Past treatments have included pentasa, cortico steroids, B12 shots, and colestipol. The patient’s last colonos-copy was conducted 6 years previously, which showed intense ulcerations and structuring of the terminal ileum. Neurologic: Patient has history of seizure disorder, which occur 1-2x a year. No history of motor or sensory symptoms. This is being controlled with Tegretol.

Psychiatric: Patient has a history of depression, which was controlled with Prozac for two years. The patient is not taking any antidepressants currently.

Physical ExaminationGeneralAppearance:Alert, oriented, cooperative, well groomed, communicates well

Skin,Hair,Nails:no lesions, tenderness, edema, erythema, no clubbing, brisk capillary refill, thick hair texture

HEENT:head normocephic, pupils are equal round, and reactive to light and accommodation, no AV nicking, exudates, Erythema, normal pearly gray tympanic membranes without exudates, no tenderness present over frontal or maxillary sinuses, trachea midline, thyroid not enlarged.

Heart: regular rate and rhythm without heaves, lifts, thrills, murmurs

Lungs:normal bronchio, bronchiovesicular, vesicular sounds, clear to auscultation bilaterally, no wheezes, normal anterio-posterior diameter

Abdomen:flat abdomen, no masses, tenderness, no guarding or rigidity, normal bowel sounds heard in all four quadrants.

Lymphatic: cervical, supraclavicular lymph nodes not pal-pated

Neuro:+2DTR’s in lower and upper extremity, cranial nerves II-XII intact, gross sensory and motor function normal, nega-tive Romberg sign

Musculoskeletal:Restriction sidebending and rotating to the right, OA SRRL. C2-C7 RLSL. Ropy and tight over thoracics, especially the right side of T5-7. T1-T5 SRRL. T6-T7 SLRR. L1-L5 SRRL. Patient lateralized right with a left sacral shear and a right rotation on a right oblique axis with a negative spring test. Right anterior innominate.

Therapy and Clinical CourseMS.ENhadherfirstactivediseaseofCrohn’sin1995.Her

grandmotherhadjustpassedaway,andthestressinherlifewasbecomingintolerable.OnherinitialvisittotheER,thedoctorsentherhomewithadiagnosisof“normalcramps.”Onsub-sequentvisitstotheER,andwithaconfirmatorycolonoscopy,thedoctorwasthenabletomakethediagnosisofCrohn’s.ThepatientwasthenplacedonsteroidsandwasaprescribedPentasa,andoralmesalamineagent.Ms.ENwasslowlytaperedoffofsteroids.Shealsochangedherdietsothatshedidnoteatspicyorfriedfoods,whichirritatedhercondition.

SinceherinitialERvisitin1995,Ms.ENhashadapproxi-mately10attackswheresheneededtoberushedtotheERduetointensepain,cramping,anddiarrhea.Herlastcolonoscopywassixyearsagoin1998.Ms.ENhaselectednottotakemedicationforherCrohn’s,andtotakecareofacuteattacksastheyhap-penwithsteroids.Shehasnothadinsuranceforthepastthreeyears,whichiscontributingtoherdecisiontonotmanageherCrohn’swithmedication.

Osteopathic Considerations and TreatmentAlthoughCrohn’sisageneticdisorderwithanimmunologi-

calbasis,somaticdysfunctionscanbetreated,thesympatheticand parasympathetic nervous systems addressed, along withlymphaticsystem.Thegoalofosteopathictreatmentistobalancetheautonomicnervoussystem,relievelymphaticandvenouscongestion,andremovesomaticdysfunctionsforthepatient.Kuchera(1994)describesthesympatheticinnervationstotheintestines:“SympatheticinnervationtotheGItracthasitsoriginincordsegmentsT5-L�adinnervatestheintestinesbywayofthecollateralsympatheticgangliaintheabdomen”(p.11�).Ms.ENdidnothaveanon-neutraloverthisarea,butitfeltropyandtightoverherthoracics,especiallytherightsideofT5-7.Inordertobalancethesympatheticnervoussystem,ribraisingalongwithHVLA,softtissue,andmuscleenergywasusedtotreatthethoracolumbararea.Also,inhibitoryventralabdominaltechniqueswereutilized,alongwithmesentericliftexercises.Parasympatheticinnervationissuppliedtotheintestinesviathevagusnerve.ThelefthalfofthecolonandpelvisissuppliedbythepelvicsplanchnicnervesS�-S4(Kuchera,1994).ForMs.EN,theOAwastreated,alongwithHVLAforhersacralshearandfloatingofthesacrum.Therightanteriorinnominatewastreatedwithmuscleenergy.Lymphatictechniquesthatwereusedincludingreleasingthethoracicinletanddomingthediaphragm.Duringthecourseofonemonth, twoOMMtreatmentsweregiventoMs.ENwithsatisfactoryprogressmade.DuringthistimeshehasnothadaflareupofherCrohn’s,andherthoracicsomaticdysfunctionshavegonefroma7/10toa3/10.


Review of LiteratureCrohn’sDisease,aspreviouslydiscussed,isanidiopathic

inflammatorydiseasethatcaninvolvetheentiregastrointestinaltract.FourfactorshavebeendescribedregardingthediagnosisofCrohn’s,whichincludeclinicalsymptoms,radiological,endo-scopic,andhistologicalsigns.Atpresenttwoofthefourfactorsmustberecognizedbeforeadiagnosiscanberendered.Itisadifficultdiagnosisbecauseeachpatientcanpresentdifferently,anditcanbemistakenformanyotherdiseaseprocesses(Sartor,�004).Thedifferentialdiagnosisincludesinfectiousprocesses,medicationcomplications,endocrinedisorders,malabsorptionsyndromes,endometriosis,colonicischemia,andirritablebowelsyndrome(Sarathchandra,�001).

Ithasbeen shown that70%ofpatientshaveabdominalpainanddiarrheauponpresentation.Othersymptomsarefever,weightloss,andbleeding.Extraintestinalmanifestationsoftenincludediseaseassociatedwithjoints,suchasarthralgiasandar-thritis.Erythemanodosum,iredocyclitis,uveitis,andprimarysl-cerosingcolangitishavealsobeenassociatedwithinflammatoryboweldisease.Complicationsofthediseaseinvolveobstruction,abscesses, fistulas, perianal disease, carcinoma, hemorrhage,leucopenia,lymphoma,andmalabsorptionsyndromes,whichcanleadtoanemiaandosteoporosis(Sartor,�004).

Thediseaseprocessmostcommonlyinvolvestheterminalileum,butinhalfofthecasesthecolonisalsoinvolved.Itisdescribed as a transmural process that can involve mucosalinflammationandaphthoidulceration.The transmural repre-sentationinvolvesaggregatesoflymphoidhyperplasia,whichcanthenleadtotheformationofgranulomas.Onceinremis-sion,thescarringandfibrosiscanleadtostrictures.Thediseaseprocessisusuallymultifocal,whichcanleadto“skiplesions”andcobblestoning(Sartor,�004,p.409).

ThepathogenesisofCrohn’sDiseaseisstillunclear,butmanytheorieshavebeenproposed.Dysregulationof theim-mune response of the gut has long been proposed to be thereasonwhy inflammatoryboweldiseaseoccurs.GordanandMacDonald(�003)believethatthisdysregulation,“resultsinastronglypolarizedmucosalCD4+Thelpercell1(Th1)response,characterizedbyincreasedproductionofthepro-inflammatorycytokinesinterleukin(IL)-�interferon(INF)andtumornecrosisfactor(TNF)-á.”Theseauthorsfurtherproposethatinnormalmucosaltissue,whentheseCD4synthesizedcellsmigratetothelaminapropina,theyusuallyundergoapoptosis.InCrohn’showever,theydonotdieandthuscontinuetosecreteinflamma-torycytokines.Furthermore,thetextstatesthat,“ItappearsthatthenormalnegativeregulatoryfunctionofTGFß1inthegutisinoperativeinCrohn’sDisease(Gordan,�003,p.708).

TheroleofCD4cellsinCrohn’swasfirstnoticedwhenpatientsstartedtoenterremissionfollowingthedevelopmentofAIDSorafterhavingabonemarrowtransplant(Gordan,�003).Theintroductionofharmfulpathogenswouldneedtooccurtodiscoveradysfunctional immunesystem.Franchimontetal.(�004)statesthat,“Mountingevidencesuggestsapivitolroleoftheentericbacteriaflorainthepathogenesisofinflammatorybowel disease” (p. 987).This suggests, of course, that thereseemstobeadisturbedhost-bacterialreactionfollowedbyanirregularanddebilitatingimmunologicalresponse.

Manygeneshavebeenidentifiedtosuggestthatvariantsare

associatedwithCrohn’s.Environmentaltriggers,suchasinfec-tionordrugs,couldbethecauseofthediseaseingeneticallysus-ceptiblepeople,butthesetriggershavenotyetbeenidentified.However,itdoesstateintheliteraturethatsmokingisatrigger,asitincreasesone’sriskofdevelopingCrohn’s.Onesuchgenethatcouldbetheculpritcodesforapatternrecognitionreceptorthatcanrecognizeandbindtolipopolysacchairdes(LPS)andpeptidoglycans(PGN)fromgramnegativeandgram-positivebacteria.Avariantofthisgene,NOD�/CARD15,ishighlyas-sociatedwithCrohn’sdisease,anddisrupttherecognitionofLPSandPGNfrombacteria.Franchimontetal.(�004)reportsthat,“ThusdefectsinLPSand/orPGNsignalingseemtorepairtheinnatemucosalimmuneresponse,essentialtocounteractearlybacterialinvasion,thisleadingtomucosaltissuedestructionandchronicintestinalinflammation”(p.987).ThesamearticlealsofoundaconnectionbetweeninflammatoryboweldiseaseandapolymorphisminaLPSreceptorTLR4,Asp�99Gly.Thisrecep-torisimportantinrecognizingLPSingramnegativebacteria,and has recently also found to be associated with decreasedbronchialresponsestobacteria(Franchimontet.al,�004).

Therehavebeenmanyconventional,mainstaytreatmentsfor Crohns. These include nutritional therapy, antibiotics(metronidazole andciprofloxin), probiotics, thiopurines suchasazathioprine(AZA),and6-mercaptopurine(6-MP),and5-aminosalicyclicacidproductssuchasPentaseandSulfasalazine.Corticosteroidshavebeenthemainstayoftreatmentforremis-sion.However,accordingtoGordon,et.al (�003),“theyarenoteffectiveinmaintainingremission,donotpromotemucosalhealingorinfluencethenaturalhistoryofCrohn’sdisease,andhavesignificantsideeffects.Furthermore,approximately30%ofpatientsbecomesteroiddependentwithinoneyearwithafurther15%beingsteroidrefractory”(p.708).

AbreakthroughtherapyforpatientswithCrohn’sisbiologi-caltherapy.Thepremiseofthisistouseanagentthattargetsa specific immune pathway, by using monocolonal antibod-ies or small molecules.The targeted cytokine by biologicaltherapyhasbeenTNFαandthishasbeenverysuccessful.ItismarkedlyelevatedinCrohn’sDiseaseandhasavarietyofimmunologicaleffects,suchasactivatingmacrophages,activat-ingothercytokines,increasingadhesionmoleculeexpression,andstimulatingtheactivationofenzymeswhicharecapableofmucosaldestructionandulcerformation.ThedrugnameisIrifliximab,anditisanIgGantibody,whichhasthecapabilityofbindingtoTNFα.Itiscapableofinducingremissionofactivedisease,aswellaspromotingshort-termhealingofthemucosaandfistulatingdisease.Itisnowreservedforthosewithseveredisease,orthosewhosediseaseisrefractorytomedicationandothertreatments(Gordon,�003)

ThepopularbeliefthatsurgeryiscurativeforCrohn’sisamyth.Mostoftenpatientshavetoundergomultiplesurgeriesintheirlifetime.Gordon,et.al(�003)hasproclaimedthat,“Over60%ofpatientsrequiresurgeryatsomestage,followingwhich,over70%ofpatientshave endoscopic evidenceof recurrentdiseaseatoneyear”(p.708).Carteret.al(�004)statesthat,“InCDsurgeryisnotcurativeandmanagementisdirectedtominimizing the impact of disease” (p. v3). It further reportsthatwithin10yearsofhavingthedisease50%ofpatientswillrequiresurgeryand70-80%willneeditwithintheirlifetime.


Apatientwouldmostlikelyproceedtosurgeryforobstructionandpain.OnewouldreceiveemergencysurgeryforCrohn’sforfailuretoimprovewithinfivedaysoftreatment,hemorrhage,toxicmegacolon,obstruction,perforation,andperitonitis.Elec-tivesurgerywouldtakeplaceduetofistulas,abscesses,failuretreatment, the inability to tolerate medication, dysplasia, ormalignancy(Timothy,�003).

Discussion and SummaryMuchmoreresearchneedstogointothesubjectofCrohn’s

Disease.ThisincludeshowosteopathicOMTcanaffecttheout-comeofCrohn’s,especiallyininducingandretainingremission.SuchasinthecaseofMs.EN,sincesheisnottakingsteroidsor other medication to increase the probability of staying inremission,osteopathicOMTcouldprovetobebeneficialinthiscause.ThediscoveryofbiologicaltherapyisverybeneficialtopatientswithCrohn’sbecausenotonlydoesithelpsuppresstheimmunologicalresponse,butitalsoseemstoinducehealinginthemucosa.Perhapsinthefutureitcanbeutilizedinmanymorepatients,andnotjusttheoneswithsevereactivediseases.Nowthatweareidentifyingspecificgenes,whichtranscribeaberrantreceptorproteins,thisconditionmayonedaybetreatedwithgene therapy, or with biological therapy which targets thosespecificreceptorswhichseemstobeawryinCrohn’s.

RightnowMs.ENisinremission,andisnotexperiencingactivedisease.Untilshecanacquireinsurance,shewilltreateachacuteattackwithemergencydoctorvisitsandsteroids.Inthefutureshedesirestotakeanothercolonoscopytoseehowherdiseasehasprogressed,aswellastakedailymedicationthatmayworktosuppressherimmuneresponse.Untilthen,shewillcontinuetocontrolherdiseasewithdietandOMTtreatments.Ms.ENdoesnothaveaseverecaseofCrohn’s,andthusfarshehasnotrequiredsurgerytotreatherillness.Unfortunately,thismaychangeinthefuturebecauseweknowthatCrohn’sisachronicandrecurrentdiseasewithnon-curativetherapies,whichonlyservetodelayandrepressthediseaseprocess.

ReferencesBullenTandHershmanMJ.(�003)SurgeryForInflammatoryBowelDisease.Hospital Medicine64(1�)719-7�3.

CarterMJ,LoboAJ,andTravisSPL.(�004).Guidelinesforthemanagementofinflammatoryboweldiseaseinadults.Gut 53.(SupplV),v1v16.

FranchimontD,VermeireS,HousniHEl,PierikM,VanSteenK,GustotT,QuertinmontB,AbramowiczM,VanGossumA,DeviereJ,andRutgeertsP.(�004).Deficienthost-bacteriainteractionsininflammatoryboweldisease?Thetoll-likereceptor(TLR)-4Asp�99glypolymorphismisassociatedwithCrohn’sDiseaseandulcerativecolitis.Gut 53.987-99�.

GordanJNandMacDonaldTT.(�003).BiologicalTherapyinCrohn’sDisease.Hospital Medicine.64(1�)708-71�.

KucheraMLandKucheraWA.(1994).Osteopathic Considerations in Systemic Dysfunction.Ohio.GreydenPress.

ReddySJ.MD,MPHandWolfJL,MD.(�001).ManagementIssuesinWomenWithInflammatoryBowelDisease.JAOA.101(1�):517-5��.

SartorBandSandbornW.(�004).Kirsner’s Inflammatory Bowel Diseases.USA.Elsevier.

Thuraisingam,A.,&Leiper,Keith.(�003).MedicalManagementofCrohn’sDisease.Hospital Medicine.64(1�):713-718.

TierneyLM,McPheeSJ,andPapadakisMA.(Eds.).(�004).Current

Medical Diagnosis & Treatment.(forty-thirded.).USA.McGraw-Hill.r

Accepted for Publication: March�006


DeanaMitchell,OMS-III4813DexterAve.FortWorth,TX76107E-mail:[email protected]

or

JerryL.Dickey,DO,FAAOUNTHSC/TCOMDept.ofOMM3500CampBowieBlvd.FortWorth,TX76107Fax:817/735-�480

OMM / FunctiOnal Medicine

Practice FOr Sale

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For more information, call

207/985-1806or email

[email protected]


September 15-17, 2006Intermediate Course: Crash Recovery, The Long Road Home: Treating Victims of Motor Vehicle Accidents and Brain InjuryTheCranialAcademyBayClubCorteMadrea,CACME:17Category1A(anticipated)

September 15-17, 2006Functional Methods in Osteopataic Pal-patory Diagnosis and Treatment, Part 1HarryFriedman,DO,FAAOWesternUniversity(COMP)Pomona,CAToregistergotowww.Biodo.comorwww.sfimms.com

September 23-24, 2006Annual Fall SeminarChapman’s Reflexes: Past, Present and Future (An Osteopathic “Think Tank” Retreat and Seminar)ArizonaAcademyofOsteopathyMWU/AZCOMOMMLaboratoryGlendale,AZCME:13Category1A(anticipated)Contacts: AmyHeadyorSharonCarey [email protected] [email protected] 6�3/57�-3350

October 27-28, 2006OMT & Body Core Tender PointsPaulRennie,DO,FAAOSouthPointHospitalWarrensvilleHeights,OHCME:14Category1A(anticipated)Contact: MaureenKendel [email protected] �16/491-7�35

Component Societies’CME Calendar and other

OsteopathicAffiliated Organizations

October 27-29, 2006Energetically Integrated Osteopathic Medicine (A Fulford Course)ZacharyComeaux,DO,FAAOArizonaAcademyofOsteopathyMWU/AZCOMOMMLaboratoryGlendale,AZCME:13Category1A(anticipated)Contacts: LauraJones [email protected] 6�3/57�-3351

December 1-3, 20062006 Winter UpdateIndianaOsteopathicAssociationMarriottDowntownIndianapolis,INContact: MichaelClaphan,CAE 317/9�6/3009

2007

April 12-15, 2007Functional Methods in Osteopataic Pal-patory Diagnosis and Treatment, Part 1HarryFriedman,DO,FAAOVailMarriott,COToregistergotowww.Biodo.comorwww.sfimms.com

May 18-20, 2007Functional Methods in Osteopataic Pal-patory Diagnosis and Treatment, Part 2HarryFriedman,DO,FAAOWesternUniversity(COMP)Pomona,CAToregistergotowww.Biodo.comorwww.sfimms.com

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Manipulation of Adhesive Capsulitis under AnesthesiaJennifer Hurrell, Arthur J. Speece, and Stuart F. Williams

IntroductionAdhesive capsulitis is a syndrome

ofpainfulrestrictionofshouldermove-mentthatresultsinglobalrestrictionoftheglenohumeraljointoftenleadingtoprolongedpainanddisability.Althoughmanyothertermshavebeenappliedtothis condition such as frozen shoulder,periarthritis and adherent subacromialbursitis, adhesive capsulitis is consid-ered the least misleading term, as it isderivedfromsurgicalfindingsofactualadherenceofthecapsuletothehumeralhead.Adhesive capsulitis can occur aseitheraprimaryorsecondarydisorder.The primary form is idiopathic, whilethe secondary form can be linked to aprecipitatingtraumaticeventor illness.The differential diagnosis for adhesivecapsulitis is ratherextensive, includingarthritis,metastaticdisease,referredpainfrom viscera, inflammatory disorders,rotatorcuffpathologyandfracture.Keyhistoryandphysical examfindingsaidthe physician in making the diagnosis.The cardinal feature of adhesive cap-sulitis is a marked limitation in activeandpassive rangeofmotion.Thepainisgenerallyunilateral,ofsubacuteonsetif it isprimaryandfrequentlyworseatnight.Whentestingrangeofmotiontheendpointofpassivemotionfeelsfirm,butnotasmuchsoasananatomicbarriersuchasbone.

The natural history of adhesivecapsulitis has been divided into threestages; the painful stage, the adhesivestage and the recovery stage.The firststage,thepainfulstage,consistsofpainwith movement, general ache, musclespasm,nightandrestpain.Thesecondphase, the adhesive stage, involves adecreaseinpain,butincreasedstiffnessand restriction of movement with dis-comfortatextremerangesofmovement.Finally,intherecoverystageweseeeven

less pain and marked restriction withgradualincreaseinrangeofmotionandspontaneousrecovery.Thelengthofeachphasevarieswidely,however,generallythepainfulstagelastsabout3-8months,theadhesivestagemayrangefrom4-1�monthsandtherecoverystagelastsabout1-3months.Althoughapproximately7-15%ofpatientspermanentlylosetheirfullrangeofmotion,onlyafewhaveatrue functional disability and many donotnoticethelimitationatall.

Manytreatmentoptionsareavailableandinwidespreaduseforpatientswithadhesive capsulitis although few havebeen proven effective in randomizedcontrolledtrials.Giventhenaturalhistoryofthediseasemosttreatmentsareaimedatspeedingrecovery, limitingpainandimproving motion outcomes.Therapyoptions include rest, analgesia, simplerange-of-motion exercises, home exer-cises,physicaltherapywithmobilization;oralcorticosteroids,corticosteroidinjec-tion, osteopathic manipulative therapy,capsulardistention,manipulationunderanesthesia, and arthroscopic capsularrelease.Manipulationunderanesthesiaisanadvantageouswaytoperformmanipu-lationtechniquesasthepatientisrelaxedandnotguardedbypain.It iseasiertofeelandidentifysomaticdysfunctionandloosenrestrictions.

CaseA 47-year-old white male was in-

jured three months ago while at workataconstructionjob.Heisreferredbyanotherphysicianwhouptothispointhasbeenmanagingthepatientwithconserva-tive treatmentsuchasphysical therapyandmedication.Intheinitialincidentthepatientwasattemptingtomoveaheavycheckoutcounterwithafellowworker.Astheyweremovingtheheavy,awkwardobjecttheotherworkerdroppedhisend

andthepatientfeltanimmediatepopinhisshoulder,neckandlowback.Hispainbegan soon after the incident and waslocalized inhis left shoulder,neckandlowbackwithradiationandparasthesiasfromthelowbackdowntherightlegandfromtheneckdowntheleftarm.Thepainthatwasmostdebilitatingtohimatthetimeofhisfirstvisitwas the lowbackpain.Palpationdemonstratedastraightleg raise thatwaspositiveon the rightat40degreesandpositiveontheleftat50degrees.Pressureontopofhisheadincreasestheleftarmpain.Considerationofepiduralsteroidinjectionsduetohisfailure to improve with conservativetreatmentwastherecommendationathisfirstvisit.Thepatientagreedtoconsiderthisoptionandfollowupsoon.Patientreturned3weekslaterwiththeworstpainnowlocatedinhisleftshoulderespeciallywithmovement.Hehadverylittleactiveorpassivemotiononphysicalexam.Theleftshoulderpainhadbecomedebilitat-ing, disturbing his sleep and makingwork impossible.The physician’s planfor thepatientwasadjusteddue to thedevelopmentofseverelimitationoftheleft shoulder overshadowing his backandneckpain.Asteroidinjectionoftheleft shoulder with manipulation underanesthesiawasrecommended.Oneweeklater the patient returned for his firststeroidinjectioninaseriesofthreewithmanipulationoftheteresminor,anteriorandmiddlescalenes,firstribandarticula-tionoftheshoulderthroughafullrangeofmotionunderanesthesia.5ccof

0.5% bupivacaine with 40mg ofmethylprednisolone was injected intotheareaoftheleftshoulder.Theanteriorand middle scalene and first rib weretreatedwithligamentousarticularstrainand inhibition, teresminorwas treatedwith inhibition and the shoulder was


articulatedthroughafullrangeofmotionwithsomedifficulty.Thepatientreturnedforthesametreatmenttwicemoreatonemonthintervals,thenafourthtreatmenttwomonthslater.Aftereachtreatment,thepatientreporteddecreasedpainandimproved range of motion.After thefourthtreatment,hisconditionwasnearlyresolvedbuthewillbegintreatmentonhislowback,whichremainspainful.

DiscussionThe use of shoulder manipulation

under anesthesia in the treatment ofadhesive capsulitis remainscontrover-sial.Somecitetheriskofinjurytotheshoulder such as dislocation, fracture,nerve palsy, or rotator cuff tear as adeterrenttomanipulation.A1999studybyJPReichmisterfromtheDepartmentofOrthopedicSurgeryatSinaiHospitalevaluated38shouldermanipulationsin3� patients over 58 months and foundthat 97% of patients received relief ofpainwithoutinjury.

Most studies have found that ma-nipulationunderanesthesiadoes speedrecoveryintheshorttermalthoughthereis no significant long-term differencewhen compared to the natural course.Duetotheprotractedcourseofadhesivecapsulitis,anydecreaseindisabilityevenin theshort termwillallowpatients toresumeasmuchoftheirdailyactivitiesaspossibleandspendlesstimeawayfromworkandinpain.Othman’s�00�studyof74adhesivecapsulitispatientsfoundthatmanipulation under general anesthesiaimprovestherangeofmorerapidly.

Sourcesdifferastowhethersteroidinjectionsareeffective.Bulgen,forex-ample,hasfoundthatthereisshort-termbenefit from injections into the joint,whileKivimakicomparedmanipulationunderanesthesiawithandwithoutsteroidinjectionandfoundthatsteroidinjectiondidnotproduceanadditionaltreatmenteffect.Inotherwords,injectionsdidnotenhancetheeffectofmanipulation.

Unfortunatelythereislittleinforma-tion on the use of specific osteopathictechniquesunderanesthesiaasanadjuncttoarticulationoftheshoulderthroughafullrangeofmotiontoloosenorbreakadhesions.Astudyof�9elderlypatientsin�00�didshowthattheuseoftheSpen-cer technique on non-sedated patientsimprovedrangeofmotionanddecreased

pain.Nostudiesofspecificosteopathictechniques for the shoulder under an-esthesia were found. Many physicaltherapyandothertechniqueshavebeenstudied, no high-grade evidence hasbeenproducedtosuggestonetechniqueissuperiortoanother.Thelimitationsofthestudiesareoftenpoormethodologyandsmallsamplesizes.

Manipulationoftheshouldercanbeoffered to reducepainand the levelofdisabilityinpatientswhofailconserva-tivetreatment.Morestudiesareneededto produce a treatment algorithim forpatientsindifferentstagesofthedisease.Studies with larger populations and ofspecific osteopathic techniques wouldbeextremelyinteresting.TheadditionofOMTtoareassuchastheteresminor,firstribandscalenes,whichfrequentlyhavesomaticdysfunctionduetocompensationforthelimitationoftheshoulder,islikelytoprovideaddedbenefitwith littlead-ditionalrisk.Ourpatientwasfunctionalwith only slightly reduced motion andlittleshoulderpainateightmonths.

ReferencesBulgenDY,BinderAT,HaziemanBL,Dut-tonJ,Roberts5,FrozenShoulder:prospec-tiveclinicalstudywithanevaluationofthreetreatmentregimens.AnnRheuDis1984;43:353-60.

Guler-UysalF,KozanogluE,Comparisonoftheearlyresponsetotwomethodsofrehabilitationinadhesivecapsulitis.SwissMedicalWeekly�004;134:353-358.

Kimberly,PaulE.,OutlineofOsteopathicManipulativeProcedures.WalsworthPub-lishingCompany,millenniumedition,�000.

KivimakiJ,PohjolainenT.,Manipulationunderanesthesiaforfrozenshoulderwithandwithoutsteroidinjection.ArchivesofPhysicalMedicineandRehabilitation�001Sep;8�(9):1188-1190

KnebiJA,ShoresJH,GamberRG,GrayWT,HerronKM.,ImprovingfunctionalabilityintheelderlyviatheSpencertech-nique,anosteopathicmanipulativetreat-ment:arandomized,controlledtrial.JAOA�00�Jul;10�(7):387-396

MassoudS.,Operativemanagementofthefrozenshoulderinpatientswithdiabetes.JournalofShoulderandElbowSurgery11(6)609-613

OthmanA,TaylorG.,Manipulationunderanaesthesiaforfrozenshoulder.Internation-alOrthopaedics�00�Mar;�6(5):�68-70.

Sandor,RickMD,AdhesiveCapsulitis:OptimalTreatmentof‘FrozenShoulder’.ThePhysicianandSportsMedicine�000Sep;�9(9).

SiegelLoriB.MD,Cohen,NormanJ.MD,Gall,EricP.MD,AdhesiveCapsulitis:AStickyIssue.AmericanFamilyPhysician1999Apr;59(7).

ReichmisterJP,FriedmanSL.Long-termfunctionalresultsaftermanipulationofthefrozenshoulder.MdMedJ1999;48:7-11.r

AcceptedforPublication:March�006

AddressCorrespondenceto:

JenniferHurrell,OMS-IIIUNTHSC/TCOM3500CampBowieBlvd.FortWorth,TX76107

or

ArthurJ.Speece,DO381�CR530-BBurleson,TX760�7Email:[email protected]

or

StuartF.Willliams,DOUNTHSC/TCOMDept.ofOMM3500CampBowieBlvd.FortWorth,TX76107Email:[email protected]


Capobianco, John D. and Rivera-Martinez, Sonia (Editors): The Collected Writings of Robert G. Thorpe, DO, FAAO. Published by the American Academy of Osteopathy® , 2005. pp. 118, including Appendix and Index. Price: $35.00 plus s/h. Order on-line: www.academyofosteopathy.org/pub/cfm

King, Hollis H. (Editor): Contributions to Osteopathic Literature—Myron C. Beal, DO, FAAO. Pub-lished by the American Academy of Osteopathy®, 2006. 2005 AAO Yearbook: pp. 176. Price: $20.00 plus s/h. Order on-line: www.academyofosteopathy.org/pub/cfm

ThestateofNewYorkhasadistinguishedhistoryinthedevelopmentoftheosteopathicmedicalprofession.Thelegislativebattlesofthelate19thandearly�0thcenturiesarefullofthedeterminationtosucceedintheestablishmentofrightsforthenewphilosophyofpractice.Throughouttheyearsofthe�0thcentury,fociofprofessionalactivityincludedtheNewYorkOsteopathicClinic,thePostgraduateInstituteofOsteopathicMedicineandSurgery,editorialsupervisionoftheformerjournalOsteopathic Annals andthepresentprogramsoftheNewYorkCollegeofOsteopathicMedicine/NYIT.Theseinclusionsadmittedlydonotevenscratchthesurfaceofthevalueofnumerousindividualcontributors.

Inpart,thelatterconsiderationisaddressedintherecentpublicationofthecontributionsofRobertG.Thorpe,DO,FAAO(1917-1999)andMyronC.Beal,DO,FAAO.Thesignificanceofeachindividualisperhapsbestrecognizedbytheeditorsoftherespectivevolumes.

Robert G. Thorpe

“Theyear1917sawnotonlythepassingonofthefounderofthescienceofosteopathy,AndrewTaylorStill,butalsothebirthofoneofthetwentiethcentury’sfewosteopathicmasters,RobertGrantThorpe.Dr.Thorpe’sinspirationandmentorwasRolandCoryell,DO,astudentofA.T.StillandgraduateoftheAmericanSchoolofOsteopathyin1907.Dr.CoryelltreatedThorpe’sbrotherstrickenwithrheumaticfeverwhowasabandonedandleftfordeadbythemedi-calestablishmentoftheday.Dr.Coryellsavedhisbrother.Coryell’sphilosophyandmethodsastaughtbythefounderofosteopathywouldalsoprovideabridgebetweenStillandthetwentiethcentury,leavinganindelibleimpressiononyoungThorpe.

Whetheryourealizeitornot,bypickingupthisbookyouhaveenteredintotheworldofDr.Thorpe’smusculoskeletalorgan.Inhisworld,themusculoskeletalsystemholdsacentralpositionthatdefinesman.Hereferstothissystemastheorganofbehaviorandaction,forwithit,ourbrainandmindbecomeaperson.Inthiscapacity,themusculoskeletalorganiscentraltoconceptualthoughtbetweenourverybe-ingandourinternalandexternalenvironments.Italsobecomestheprotectorinfightorflight.Further,heexpandsontheroleofthemuscu-loskeletalorganinrelationtoendocrinedisease,stress,autonomicnervoussystem,infectionandchronicdisease.Hefittinglydescribesthesignificanceofthemusculoskeletalorgan,aswithoutit,allotherorgansystems‘coulddonothingbutlieinagelatinousheapandpulsateandquiver’.”

Myron C. Beal

“Forthoseofuswhohaveobservedthedevelopmentoftheosteopathicmedicalprofessionfromtheperspectiveofteachers,practitioners,andresearchersoftraditionalosteopathicprinciplesandpractice,thenameMyronC.Beal,DO,FAAOiswellknownandevokesfeelingsofrespectandadmiration.Hisosteopathiccareerhasspannedthesecondhalfofthe�0thCenturyandhiscontributionshaveservedtopropeltheprofessiontothebrinkof�1stCenturyhealthcareleadership.

IndividuallyandincollaborationwithothersDr.Bealwasapioneerinresearchrelatedtovalidityandreliabilityissuesparticularlyinpalpatorydiagnosticprocedures.Hispublicationsonviscero-somaticreflexesareclassicsinthis

areacentraltooneofthemajorcontributionsosteopathicmedicalpracticeiscontinuingtomakeintheunderstandingofthehealingarts.Evertheproponentofsolidresearchdesign,Dr.Bealappreciatedthefullnessofosteopathicphilosophyinactionbyemphasizingpalpatoryskillintheosteopathicexaminationasaninteractionbetweenthepatientandexaminer.Heappreciatedthedifferencebetweensensingandperception,recognizingthemindbodyintegrationeverpresentinosteopathicphilosophyandactualizedinosteopathiceducation.”

Read,savorandbenefitinyourpracticeandteachingfromstandingontheshouldersofthesegiants.


Reviewer: Anthony G. Chila

Ross, Lawrence M. and Lamperti, Edward D. (Consulting Editors): THIEME Atlas of Anat-omy. ©2006 Georg Thieme Verlag. Thieme New York, 333 Seventh Avenue, New York, NY 10001 USA. Pp. 541; 1694 Illustrations; 100 Tables. Price: $64.95 paperback; $119.95 hardback; order on-line: www.thieme.com or phone: 212/760-0888.

“……itwasourintentiontocreateanatlasthatwouldguidestudentsintheirinitialstudyofanatomy,stimulatetheirenthusiasmforthisintriguingandvitallyimportantsubject,andprovideareliablereferenceforexperiencedstudentsandprofessionalsalike.”Inordertomeetthisgoal,thecreationofanentirelynew

setofillustrationsbeganataskwhichrequired8yearsforcompletion.Intheprocess,opinionsandneedsofstudentsandlectur-ersweresoughtinEuropeandtheUnitedStates.TheworkoftheoriginalEuropeanauthors(MichaelSchünke,ErikSchulte,UdoSchumacher,MarkusVoll,KarlWesker)wasreviewedbytheUnitedStatesconsultingeditors(RossandLamperti).Thisledtothenextstep,cooperationwiththeeditorsatThieme,inmakingthisresourceavailabletoNorthAmericanstudentsandprofessionals.Intheirwords,thetaskforRossandLampertiwas:

“….toreview,foraccuracy,theEnglisheditionoftheTHIEME Atlas of Anatomy. Ourworkinvolvedaconversionofnomen-claturetotermsincommonusageandsomeorganizationalchangestoreflectpedagogicalapproachesinanatomyprogramsinNorthAmerica.Thistaskwaseasedgreatlybytheclearorganizationoftheoriginaltext.Inallofthis,wehavetrieddiligentlytoremainfaithfultotheintentionsandinsightsoftheoriginalauthors.”

ThisatlasconcernsitselfwithGeneral Anatomy andMusculoskeletal System. TheContentsconsistof:General Anatomy; Trunk Wall; Upper Limb; Lower Limb; Appendix (References, Index). Anyoftheseareascanbeutilizedasastudyuntoitself.Theconceptualandorganizationalpresentationofextensiveinformationiscoupledwiththesoundpresentationofthecontem-poraryknowledgebase.Theresultisinfactacomprehensiveeducationalresource.Thesuperlativequalityofillustrationssetsthisatlaswellapartfromsimilareffortsinthisgenre.Anatomicalconceptsarepresentedinalogicalandprogressivesequence.Theliberalintroductionofclinicalconceptsisfacilitatedthroughillustration,explanatorytextandtabularsummarization.Thisiswhatprovideseaseforintegrationbysystemandtopography.Detailandaestheticsarenotsacrificed.

Anygivenpresentationinthisatlasisdisplayedin�well-organizedandvisuallypleasingpages.Thisiswhatfacilitateseasyaccesstoandcomprehensionofthepresentation.Thisalsopermitstheincorporationofanumberingsystemwhichhelpstoguideprogressionthroughagivenregion.Twoexamplescanbetakenfromthevarioussectionstodemonstrate:

GeneralAnatomy---------8.GeneralNeuroanatomy5.5 StructureofaSpinalCordSegmentA. StructureofaspinalcordsegmentwithitsspinalnerveB. SpinalcordsegmentC. Topographicalandfunctionalorganizationofaspinalcordsegment

TheTrunkWall-----------�.Musculature:FunctionalGroups1.1 TheMusclesoftheTrunkWall,TheirOriginandFunctionA. TrunkwallmusclesinthestrictsenseB. TrunkwallmusclesinthebroadsenseC. MusclesthatmigratedsecondarilytothetrunkwallD. Somitesinafive-week-oldhumanembryoE. Transversesectionsthroughasix-week-oldhumanembryoF. Diagramoftheprincipalmusclegroupsinaneight-week-oldhumanembryo

Thisatlasmeetsandexceedsalloftheexpectationsoftheoriginalauthorsandthesupportingeffortsoftheconsultingedi-tors.ItisasuperbproductofpublicationfromGeorg Thieme Verlag. Itsetsanewstandardforthedisciplineofanatomy.Fortheneedsofeducators,studentsandpractitionersintheosteopathicmedicalprofession,thetraditionalconceptsoftheprofessionandthebasisfortheartandpracticeofmanipulativeinterventionaremadeclear:asclearasAndrewTaylorStill’sinsistenceonretainingthe“pictureofnormalanatomyinordertounderstandthepresentationoftheabnormal.”


Shutting Down Alzheimer’sMichael S. Wolfe

TheauthorisassociateprofessorofneurologyatBrighamandWomen’sHospitalandHarvardMedicalSchool.HisresearchactivityfocusesonunderstandingthemolecularbasisofAlzheimer’sdiseaseandidentifyingeffectivetherapeuticstrategies.HehasrecentlyfoundedtheLaboratory for Experimental Alzheimer Drugs atHarvardMedicalSchool.TheefforthereistowarddevelopmentofpromisingmoleculesintodrugsforAlzheimer’sdisease.

“Thehumanbrainisaremarkablycomplexorganiccomputer,takinginawidevarietyofsensoryexperiences,processingandstoringthisinformation,andrecallingandintegratingselectedbitsattherightmoments.ThedestructioncausedbyAlzheimer’sdiseasehasbeenlikenedtotheerasureofaharddrive,beginningwiththemostrecentfilesandworkingbackward.Aninitialsignofthediseaseisoftenthefailuretorecalleventsofthepastfewdays—aphoneconversationwithafriend,arepairman’svisittothehouse—whilerecollectionsfromlongagoremainintact.Astheillnessprogresses,however,theoldaswellasthenewmemoriesgraduallydisappearuntilevenlovedonesarenolongerrecognized.ThefearofAlzheimer’sstemsnotsomuchfromanticipatedphysicalpainandsufferingbutratherfromtheinexorablelossofalifetimeofmemoriesthatmakeupaperson’sveryidentity.

Unfortunately,thecomputeranalogybreaksdown:onecannotsimplyrebootthehumanbrainandreloadthefilesandpro-grams.”

Researchfocusiscurrentlyonthehypothesisthatthepeptideamyloid-beta(A-beta)isresponsiblefortriggeringthedisruptionanddeathofbraincellsinAlzheimer’sdisease.OnestrategyistoseekclearanceoftoxicaggregatesofA-betafromthebrain.Anapproachinvolvesinducingthepatient’sproductionofantibodiesthatrecognizeA-beta.

Scientific American. Volume 294, Number 5; May 2006, 72-79.

Toward Better Pain ControlAllan I. Basbaum and David Julius

BasbaumisprofessorandchairofthedepartmentofanatomyattheUniversityofCalifornia,SanFrancisco.Juliusisprofes-sorofcellularandmolecularpharmacologyatUCSF.Theauthorsareoftencollaboratorsonstudyingthecellularandmolecularmechanismsthatunderliepain.

“Yetthemostwidelyusedanalgesicstodayareessentiallyfolkremediesthathaveservedforcenturies:morphineandotheropiatesderivefromtheopiumpoppy,andaspirincomesfromwillowbark.Althoughthesetreatmentscangiverelief,eachhasitslimitations.Aspirinandothernonsteroidalanti-inflammatorydrugs(NSAIDs),suchaibuprofen,cannoteasethemostseveretypesofdiscomfort.Andevenopiates,generallythestrongestmedicines,donotworkforeveryone.Moreover,theycanhaveserioussideeffects,andpatientstendtobecometoleranttothem,requiringescalatingdosestogetanyreliefatall.”

Betterunderstandingofthetransmissionofpainsignalsfromcellsandmoleculesisprovidingnewtargetsfordrugsunderdevelopment.Peripheral Targets. CapsaicinreceptorandASIC(reductionofpainaccompanyinginflammation);TTX-resistantsodiumchannels(silencingofnociceptorsignaling);Bradykininreceptor(easingofpain-relatedinflammation);Prostaglandin-producingenzymes(reductionofsideeffects;aspirin,ibuprofen,COX-�inhibitors).Spinal Cord Targets. Calciumchannelsonnoceptors(buildoneffectsofexistingdrugssuchasNeurontinandPrialt);NMDAreceptors(impedetransmissionofpainsignalsbydorsalhornnervecells;combathypersensitivityofthosecells);NK-1receptors(usesubstancePtotransportatoxinintodorsalhorncells).

Scientific American. Volume 294, Number 6; June 2006, 60-67.

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Excerpts from the book’s ForewordFor those of us who have observed the development of the osteopathic medical profession from the perspective of teachers, practitioners, and researchers of traditional osteopathic principles and practice, the name Myron C. Beal, DO, FAAO is well known and evokes feelings of re-spect and admiration. His osteopathic career has spanned the second half of the 20th Century and his contributions have served to propel the profession to the brink of 21st Century healthcare leadership. Ever the proponent of solid research design, Dr. Beal appreciated the fullness of osteopathic philosophy in action by emphasizing palpatory skill in the osteopathic examination as an interaction between the patient and examiner. He appreciated the difference between sensing and perception, recognizing the mind body integration ever present in osteopathic philosophy and actualized in osteopathic education.

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