2004 northup memorial lecture where do we go from here? · 2018-08-10 · 1. type all text,...

2004 Northup Memorial LectureWhere Do We Go From Here?

John C. Glover, DO, FAAO

Forum for Osteopathic Thought

Tradition Shapes the Future Volume 15 Number 1 March 2005

2/The AAO Journal March 2005

Instructions to Authors

The American Academy of Osteopathy®

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

The AAO Journal welcomes contributions inthe following categories:

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

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

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

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

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

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

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

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

Editorial ReviewPapers submitted to The AAO Journal maybe submitted for review by the EditorialBoard. Notification of acceptance or rejectionusually is given within three months after re-

ceipt of the paper; publication follows as soonas possible thereafter, depending upon thebacklog of papers. Some papers may be re-jected because of duplication of subject mat-ter or the need to establish priorities on theuse of limited space.

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

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

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

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

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

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PermissionsObtain written permission from the publisherand author to use previously published illus-trations and submit these letters with themanuscript. You also must obtain writtenpermission from patients to use their photosif there is a possibility that they might beidentified. In the case of children, permis-sion must be obtained from a parent or guard-ian.

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

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

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

March 2005 The AAO Journal/3

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IN THIS ISSUE:AAO Calendar of Courses ................................................................................. 4Contributors ....................................................................................................... 6Component Societies’ CME Calendar ............................................................... 7

EDITORIAL

View from the Pyramids: Anthony G. Chila, DO, FAAO ................................. 5

REGULAR FEATURES

Dig On: WOHO’s First Congress ................................................................. 8From the Archives: Ohio Recognizes Osteopathy ...................................... 10Book Review .............................................................................................. 34Elsewhere in Print ....................................................................................... 35

2004 THOMAS L. NORTHUP LECTURE

Where Do We Go From Here? ................................................................... 11John C. Glover, DO, FAAO

ORIGINAL CONTRIBUTION

Medical Coverage for the American Teamat the World 24-hour Champion Race in Brno Czech Republic ................. 15Andrew Lovy, DO, FACN

CLINICAL PRACTICE

The Case of a Patient with Persistent Urinary Urgency ............................. 20Robert C. Clark, DO, MS

Expanded Spinal Flexion Test: A new palpatory toolfor LBP Analysis or an old test revisited? .................................................. 24Paul T. McTurk, DO and Halina H. Harding, DO

THE STUDENT PHYSICIAN

Acute Intermittent Porphyria Mimic of Guillain-Barré Syndrome: A CaseReport with the Use of Osteopathic Manipulation Management of Pain ... 29E. Ryann McClennen, OMS-III and Russell G. Gamber, DO

FORUM FOR OSTEOPATHIC THOUGHT

TRADITION SHAPES THE FUTURE • VOLUME 15 NUMBER 1 MARCH 2005

A PEER-REVIEWED JOURNAL

The Mission of the American Academy of Osteopathy® is to teach, advocate,and research the science, art and philosophy of osteopathic medicine, emphasiz-ing the integration of osteopathic principles, practices and manipulative treat-ment in patient care.

AMERICAN ACADEMY OF OSTEOPATHY®

Stephen D. Blood, DO, FAAO ............. PresidentKaren M. Steele, DO, FAAO ....... President ElectStephen J. Noone, CAE ......... Executive Director

AAO PUBLICATIONS COMMITTEE

Raymond J. Hruby, DO, FAAO ........ ChairpersonDenise K. Burns, DOStephen M. Davidson, DOEileen L. DiGiovanna, DO, FAAOEric J. Dolgin, DOStefan L.J. Hagopian, DOHollis H. King, DO, PhD, FAAOJohn McPartland, DOPaul R. Rennie, DOMark E. Rosen, DO

Ex-officio Members:Myron C. Beal, DO, FAAO ....... Yearbook EditorAnthony G. Chila, DO, FAAO ...... Journal Editor

THE AAO JOURNAL

Anthony G. Chila, DO, FAAO .... Editor-in-ChiefStephen J. Noone, CAE ......... Supervising EditorDiana L. Finley, CMP ............... Managing Editor

The AAO Journal is the official publication of theAmerican Academy of Osteopathy®. Issues are pub-lished in March, June, September, and Decembereach year.

Third-class postage paid at Carmel, IN. Postmas-ter: Send address changes to: American Academyof Osteopathy®, 3500 DePauw Blvd., Suite 1080,Indianapolis, IN., 46268. Phone: 317-879-1881;FAX: (317) 879-0563; e-mail [email protected]; AAO Website: http.//www.academyofosteopathy.org

The AAO Journal is not itself responsible for state-ments made by any contributor. Although all ad-vertising is expected to conform to ethical medicalstandards, acceptance does not imply endorsementby this journal.

Opinions expressed in The AAO Journal are thoseof authors or speakers and do not necessarily re-flect viewpoints of the editors or official policy ofthe American Academy of Osteopathy® or the in-stitutions with which the authors are affiliated, un-less specified.

Official Publication of the American Academy of Osteopathy®


2005 AAO Calendar of Courses1APRIL

9-10 Dr. Fulford’s Basic Percussion: A SystematicApproach to the Whole BodyMidwestern University/CCOM; Chicago, IL

MAY

13-15 Prolotherapy: Above the DiaphragmUNECOM; Biddeford, ME

JUNE

17-19 Visceral Approachto Cardiopulmonary DysfunctionUNECOM; Biddeford, ME

JULY

29-31 Muscle Energy: Three VisionsMidwestern University/CCOM; Chicago, IL

AUGUST

19-22 15th Annual OMT Update: Application ofOsteopathic Concepts in Clinical Medicineplus Preparation for Certifying BoardsThe Contemporary at Walt Disney World®

Buena Vista, FL

SEPTEMBER

16-18 Clinical Application of Principles ofLigamentous Articular Strain in Primary CareUMDNJ-SOM; Stratford, NJ

OCTOBER

22 Rapid OMT: Increase Your Reimbursementin an Ambulatory SettingOrlando, FL

23-27 AOA Unified Convention:AAO Program: Osteopathy in the Specialties:A Hands-on ApproachKenneth E. Lossing, DO, Program ChairOrlando, FL

NOVEMBER

11-13 Prolotherapy: Below the DiaphragmUNECOM; Biddeford, ME

DECEMBER

2-4 Lymphatic Approach to the VisceraAZCOM; Glendale, AZ

June 9-13, 2005Osteopathy in the Cranial Field

Course Director: Hugh M. Ettlinger, DO, FAAONYCOM

Old Westbury, NY

40 Category 1-A CME Hours

Contact: Judy Staser @ Phone: 817/926-7705or Fax: 817/924-9990

These programs anticipate being approved for AOA Category1-A CME credit pending approval by the AOA CCME

Visit our website at: www.sctf.com

Energy Medicinein the 21st Century

You are invited to participate in a seminar and workshopthat addresses the role of Proprioception and Low LevelLasers as healing modalities for many of the health issuesfaced by your patients.

Who Should Attend?Doctors of Osteopathy, Dentistry, and Medicine

Dates: February 25-27, 2005; Phoenix, AZApril 29-May 1, 2005; Philadelphia, PAJune 24-26, 2005; Chicago, IL

Cost: $395/person ($345/person for 2 or more/office)

Continuing Education:15 Hours Category 1A-AOA approved (February and April courses are co-sponsored by AAO) (June course co-sponsorship by the AAO is pending)15 Hours CDE (pending approval)

Course Leader:Melicien A. Tettambel, DO, FACOOG, FAAO

Contact:Integrative Health Resources

Tel: (800) 715-5937 Fax: (617) 969-4325Email: [email protected]


View from the Pyramids

Anthony G. Chila

In little more than nine months, the practice pathway forcertification in Neuromusculoskeletal Medicine and Osteo-pathic Manipulative Medicine (NMM/OMM) will close. (SeeMessage from the Executive Director; AAO Newsletter,January 2005, 15). The detailed explanation provided byStephen J. Noone, CAE, brings out important points whichcan provide perspective for the viewing of change.

Certification in disciplines of practice presently expectsthe prerequisite of residency training in virtually all medicalcertifying boards, and this trend has been in progression inthe osteopathic profession since the mid-1990s.

Prior to 1972, there was no board certification status forosteopathic physicians engaged in what was then described asgeneral practice. The movement toward establishment of sucha board was initially met with the question: “How can ageneralist become a specialist?” Just a few years later, interestbegan to develop for the establishment of a cadre of educa-tional leaders in all disciplines of board certification withinthe osteopathic profession. The vehicle through which thiswas to be accomplished was the status of Fellow of theAmerican Academy of Osteopathy. That momentum has led tothe establishment of American Osteopathic Certifying Boardsfor Special Proficiency in Osteopathic Manipulative Medicineand, now, Neuromusculoskeletal Medicine. Over time, theacceptance and maturation of what is now known as theAmerican Osteopathic Board of Family Physicians offerscertification in family practice and osteopathic manipulativetreatment.

The growth in numbers and expansion of programs incolleges of osteopathic medicine recognized the need forqualified teachers in osteopathic principles and practice(OPP), now generally known as osteopathic manipulativemedicine (OMM). Osteopathic physicians who possessedcredentials described above were regularly recruited for suchteaching. Much of curricular teaching as it was applied toareas of specialty disciplines was presented from the practiceexperiences of board certified generalists. This was viewed asbeing necessary because of the relatively rare participation ofboard certified specialists in the teaching of OPP/OMM. Intime, these faculty members became regarded as “special-ists” in OPP/OMT/OMM. In time, also, most graduallyaccepted the erosion and loss of their previous identities asgeneral practitioners.

In addition to increasing numbers of colleges, enlargementof student bodies in the colleges has strained the teachingstrength of a what has long been recognized as a small pool offaculty. Now that residency training programs are becoming

Specialist or Generalist?the norm for board certification in any practice disciplinewithin the osteopathic profession, it may be appropriate toask: “How can a specialist become a generalist?”

It has been noted that in the years since July 1, 1999,residency training in NMM/OMM has shown significantgrowth. Sixteen institutions are currently sponsoring 21programs. Two new programs were recommended forapproval in January 2005 and other institutions are planningto submit applications for new programs to begin in 2006.Superficially, this appears to reflect strength in anticipatingthe need for future faculty for numerous present and futurecolleges of osteopathic medicine. Given that a total of 37residents were enrolled in these programs, 2003-2004, is thisreally so? How many of the estimated 500-600 currentlyboard certified osteopathic physicians are serving in collegefaculty positions? Will the expanding numbers of institutionalNMM/OMM residency programs become the new pool forrecruitment and retention of faculty for the general teachingeffort of osteopathic medical education? What is the planningdocument for needs assessment, implementation of training,recruitment and retention of specialists who may well befaced with the need to serve as generalists in portraying thebroad applicability of osteopathic philosophy, principles,theory, methods and practice?

What will be the nature of the sunrise following the sunseton December 31, 2005?

Are you interested in becomingBOARD CERTIFIED

in Neuromusculoskeletal Medicine andOMM?

PRACTICE TRACK CLOSES

December 31, 2005May 1, 2005 – Application Deadline

for the November 2005 Exam

Contact:Dee Kieffaber, certification coordinator

AOBNMM3500 DePauw Blvd., Suite 1080

Indianapolis, IN 46268Phone: (317) 879-1881Fax: (317) 879-0563

E-mail: [email protected]


Contributors

John C. Glover. Where Do We Go From Here. The 2004Thomas L. Northup Lecture addresses the improvement ofthe quality and uniqueness of osteopathic medical education.The components of a Core Competency Compliance Programarising from Osteopathic Graduate Medical Education(OGME) meetings are reviewed. The Compliance programbegan in July 2004 and the seven components of the programwill be introduced and assessed over the next three years.Suggestions are offered which may contribute to moresubstantive meaning. (p. 11)

Andrew Lovy. Medical Coverage for the AmericanTeam at the World 24 hour championship race in Brno,Czech Republic. The author had the privilege of serving asthe Doctor for the American Team in this World GamesEvent. This was his second appearance in this capacity,previously in Holland. It is clear from this communicationthat the addition of a physician with osteopathic medicalskills was a welcome addition to the team’s effort. The teamsuccesses reflect the value of good will ambassadors, com-petitive spirit and professionalism amply supported by thephysician’s skills. (p. 15)

Robert C. Clark. The Case of a Patient with PersistentUrinary Urgency. “Think osteopathically”. How many timesthis admonition asserts itself in the presence of persistent ordifficult clinical circumstances. The author presents a thor-ough evaluation of a common clinical problem. Persistence ofsymptoms following successful conventional treatment led to areassessment (osteopathic) of nerve supply and adjacent tissuecharacteristics. Resolution followed a revised treatment planfor manipulative intervention. (p. 20)

Paul T. McTurk and Halina H. Harding. ExpandedSpinal Flexion Test: A new palpatory tool for LBP Analy-sis or an old test revisited? The authors view their contribu-tion as an incidentally discovered new test or a new applica-tion of an old test. In carefully stating their premise, theydemonstrate the following: the determination of type dysfunc-tion (Fryette classification); increased objectivity for evalua-tion of apex and vertex segments. The authors encouragemore discussion and study of their proposal. (p. 24)

E. Ryann McClennen and Russell G. Gamber. AcuteIntermittent Porphyria, Mimic of Guillain-Barre´ Syn-drome: A Case Report with the use of OsteopathicManipulation for management of pain. The authors presenta most interesting consideration of motor neuropathiesthrough the mimic effect of these entities. Physicians gener-ally recognize that standard modalities of treatment oftenprovide little relief of pain in complicated situations. Theauthors meet this challenge through their demonstration of thevalue of osteopathic manipulative intervention and encour-agement of patient involvement. (p. 29)

DIG ON. WOHO’s First Congress. The first congress ofthe World Osteopathic Health Organization took place atParis, France on January 8, 2005. The location was the Palaisdu Luxembourg, seat of the French Senate. One hundred andsixty-seven participants from 16 different countries demon-strated their willingness to unite for the the purpose ofachieving international recognition for the value of Osteopa-thy. It is appropriate that this column recognize the contribu-tion of Bruno Ducoux, DO, MRO(F) (p. 8)

FROM THE ARCHIVES. From January 1, 1900 throughthe spring of that year, Arthur G. Hildreth,DO was activelyinvolved in seeking legal recognition for the practice ofOsteopathy in the State of Ohio. Based on his efforts inMissouri in 1895 and 1897, his account serves to remindtoday’s practitioners of the early years of struggle. (p. 10)

BOOK REVIEW. The complexities of Billing andCoding for medical practice in today’s environment aresuccinctly given explanation in A Physician’s Guide toBilling and Coding (Jorgensen and Jorgensen). The mannerof presentation provides a useful service for implementationin individual practices. A Second Voice (Miller) is a centen-nial contribution recognizing the development of osteopathicmedicine in Ohio. The story of this state is certainly mirroredin the early legislative battles of other states. In an age ofprofessional affluence and recognition, occasional remindersof the early struggles are not remiss. (p. 34)

ELSEWHERE IN PRINT. Skin Resistance vs. BodyConductivity. Chang-Li Zhang discusses critical problems ofelectronic measurements on the acupuncture system. Hiseffort seeks to offer a new understanding of the backgroundof acupuncture as well as other branches of holistic medicine.(p. 35)

CME CREDIT. In response to reader requests, AAOJ willoffer CME Credit to readers completing the enclosed quiz. Atthis time, 1 Hour II-B Credit will be offered, with request forupgrade as AAOJ qualifications are reviewed by the Ameri-can Osteopathic Association. (p. 22)

Regular Features


Component Societies’CME Calendarand other Osteopathic Affiliated Organizations

April 1-4, 2005Biodynamics Phase IV:The MidlineTopanga, CACME: 23 Category 1A (anticipated)Contact: Stefan Hagopian, DO

207/778-9847

April 2-5, 2005Biodynamics Phase II: The Fluid BodyFranconia, NHCME: 23 Category 1A (anticipated)Contact: Donald Hankinson, DO

207/778-9847

April 9-10, 2005Advanced NeuroFascial ReleaseCourse: The ExtremitiesArizona Academy of OsteopathyCME: 16 Category 1A (anticipated)Contact: Stephen Davidson, DO

602/957-3525 (AZ)800/359-7772 (USA)

website: www.healthabounds2.com

April 15-17, 2005Neurofascial Release Conference WestArizona Academy of OsteopathyCME: 24 Category 1A (anticipated)Contact: Stephen Davidson, DO

602/246-8977 (AZ)800/359-7772 (USA)


April 17-20, 2005Biodynamics Phase III:The Long Tide and the DuraFranconia, NHCME: 22.5 Category 1A (anticipated)Contact: James Jealous, DO

207/778-9847

April 21-24, 200550th Annual ConferenceFlorida Academy of OsteopathyGrosvenor ResortLake Buena Vista, FLCME: 20 Category 1A (anticipated)Contact: FAO

727/581-9069

May 8-11, 2005Biodynamics Phase VI:The Embryological HealthFranconia, NHCME: 24.75 Category 1A (anticipated)Contact: James Jealous, DO

207/778-9847

May 12-15, 2005108th Annual ConventionIndiana Osteopathic AssociationIndianapolis, INCME: 30+ Category 1A (anticipated)Contact: IOA

800/942-0501 or317/926-3009

May 15-18, 2005Biodynamics Phase VII:The Health AloneCME: 22 Category 1A (anticipated)Franconia, NHContact: James Jealous, DO

207/778-9847

May 20-22, 2005Crash Recovery, the Long Road Home:Treating Victims of Motor VehicleAccidents and Brain InjuriesThe Cranial AcademyUMDNJ/SOMStratford, NJCME: 17 Category 1A (anticipated)Contact: The Cranial Academy

317/594-0411

May 22-25, 2005Biodynamics Phase V: TheEmbryological FaceFranconia, NHCME: 21.5 Category 1A (anticipated)Contact: James Jealous, DO

207/778-9847

June 5-8, 2005Biodynamics Phase VI:The Embroyological HealthFranconia, NHCME: 24.75 Category 1A (anticipated)Contact: James Jealous, DO

207/778-9847

June 9-13, 2005SCTF 40-hour Basic CourseOsteopathy in the Cranial FieldNYCOMWestbury, NYDirector: Hugh Ettlinger, DO, FAAOContact: Judy Staser

817/926-7705

June 18-22, 2005June Basic CourseThe Cranial AcademyIndian Lakes ResortBloomingdale, ILCME: 40 Category 1A (anticipated)Contact: The Cranial Academy

317/594-0411

June 23-25, 20053rd Annual MeetingAmerican Association of Colleges ofOsteopathic Medicine (AACOM)Bethesda, MDFurther details will be published on theWebsite as it becomes available: http://www.aacom.org.events/annualmtg

continued on page 22


Dig OnAnthony G. Chila

World Osteopathic Health OrganisationWOHO’s First Congress

Palais du Luxembourg, ParisJanuary 8, 2005

Editor’s Note: The text in this document are excerpts fromthe narrative by Guy Roulier, DO (France). For a completecopy of his article as well as an interview with Bruno Ducoux,DO(France), please visit the website:

www.osteopathie-france.net/Osteo-pratique/congres_WOHO1.htm

“The first congress of the World organisation, WOHO, tookplace in Paris on the January 8, 2005 in the prestigious Palaisdu Luxembourg, the seat of the French Senate. One hundredand sixty-seven participants took part in this historical meetingcoming from 16 different countries: Europe Australia, UnitedStates and Canada. They are came individually to show theirwill to unite in the objective of creating a worldwide movementin favour of our marvellous branch of therapy. In his openingspeech, our friend and organiser Bruno Ducoux, stressed thefact that this world congress of WOHO, the first ever, was tak-ing place in a highly symbolic place, the seat of the FrenchSenate, where a decisive law recognising the qualification ofosteopaths in France was voted with near unanimity on the 4thof March 2002. The climax came with Viola Frymann’s contri-bution. Her professionalism, kindess, serenity, charisma andopen mind offer an example to be followed by all osteopaths.For me, the main impression of this day on top of the quality ofthe contributions was the true harmony and the feeling of belong-ing to the same family, of communication.”

Guy Roulier, DO (France)

Members of the bureau of WOHO : Left to right (front row):President Michael Mulholland-Licht, vice-presidents Jane Carreiroand Simon Fielding, and Renzo Molinari. Left to right (back row):Bruno Ducoux, Michael Patterson, Raimond Engel and ZacharyComeaux.


Family Practice/Emergency Medicine in “Great Northwoods of New Hampshire: Replace an EM physician who has taken onsome of the administrative duties at the Hospital. Join 3 other EM physicians. Full time is considered 85/24 hour shifts a yearwith the support of tenured, certified EM nurses. This busy ER sees about 10,000 visits a year with LifeFlight to Dartmouth-Hitchcock Medical Center. This is a “critical access” hospital. Excellent salary and benefits; easy access to Portland, ME;Burlington, VT; as well as Boston and Montreal. This community offers a qualty educational system, affordable housing anda great place to raise a family.

Internal Medicine in South Central Pennsylvania: Join 2 other physicians in a very lucrative practice with an excellentreferral base. Employed position with a 2-year track to partnership. Excellent compensation package with benefits. Sharedcall coverage. Associated with 150-bed community teaching hospital. South-Central metropolitan community of 381,000 iswithin 1 hour of Baltimore, Washington, and Harrisburg.

Orthopedic Surgeon Group in picturesque St. Albans, VT: Looking for a partner who is interested in general orthopedics (aplus would be someone interested in any sub-specialty). Attractive income with partnership track, incentive, and a fullcomplement of benefits. Single office and single hospital responsibility with a state-of-the-art spacious office across thestreet from the hospital. Located on Lake Champlain, 30 minutes from Burlington and Smugglers Notch Ski Resort. Onehour to Montreal and three hours to Boston.

General Surgery in New Hampshire: Replace a retiring general surgeon on the medical staff of this “Award Winning” newhospital. Be part of an outstanding, respected and established surgical team with 1:3 call coverage. The hospital will providea 2-year employment contract for you as you build your practice and reputation. Your office will be staffed by an experiencedgroup and is in the medical offices attached to the hospital. Located at the northern edge of the White Mountains and an easydrive to Boston, Montreal, and Manchester.

OBG in coastal Rhode Island: Join a premier group of two OB/GYNs and one nurse practitioner who are looking to expand.Call rotation is 1:5. Office is located on the next block to the hospital. Approximately 60% of the practice is GYN and 40%is OB with a good population mix. Malpractice is very low due to an indemnity insurance program provided to the groupthrough Women and Infants. Located just 11 miles south of Providence; 60 miles from Boston and Cape Cod.

Orthopedic Surgery in Suburban Philadelphia (Bala Cynwyd, PA): Opportunity for a young orthopedic surgeon to join a SSGof 2 BC ORS. Chance to grow a practice with the strong support of a quality group and the backing of an experienced MSO.This medical practice also partners in a Management Services Organization, which is a “super center” with ambulatory back-up at Lankenau Hospital. Tremendous first-year compensation and benefits. This suburban community is located only 10minutes from Center City, Philadelphia.

General Surgery in Philadelphia, PA: Excellent opportunity to be in on the ground floor and build a GS group, which will besupported by the hospital. Any sub-specialty training would be a plus. The hospital has 350 beds and is located in NortheastPhiladelphia. The hospital has invested millions of dollars in surgical upgrades in the past year. Located about 1/2 hour tocenter city Philadelphia.

OBG in Central New Jersey: Outstanding opportunity to be employed with a well-respected and established group offering a1:5 call. Practice also has 5 mid-wives. This state-of-the-art office is 2 miles from the hospital. Mammograms on site; Lab;Ultrasound; and Bone Density as well as a procedure room. Excellent compensation and benefits provided for you and yourfamily. The hospital, Community Medical Center (Toms River) is a 596 bed facility and is part of The St. Barnabas HealthCare System. Located just 1 hour from Philadelphia and 1 hour from New York City. Great place to raise a family.

Contact:

Margie QuinlanLawlor and AssociatesPhone: 800/238-7150

Fax your CV: 610/431-4092Email: [email protected]

Practice Opportunities Available


From the Archives

During the early part of 1900, it wasdecided that I should go to Ohio to se-cure recognition for our profession in thatstate. At that time there were between tento fifteen osteopathic physicians practic-ing in Ohio. Among them were Dr. M. F.Huiett of Columbus, and Dr. H. H.Gravett of Piqua, who assisted me veryably in the legislative work. We madesome very wonderful friends in both theHouse and the Senate. Former UnitedStates Senator Willis of Delaware, O.,who at that time was a young member ofthe House, proved to be one of the mostloyal supporters of osteopathy from thebeginning of our acquaintance until hisuntimely death. He spoke before osteo-pathic gatherings at many places andmade one of the graduation addresses atKirksville. He also spoke at the Ameri-can Osteopathic Association conventionheld in Kirksville in August, 1924, cel-ebrating the fiftieth anniversary of the dis-covery of osteopathy. NicholasLongworth, of Cincinnati, afterwardsSpeaker of the House of Representativesin Congress, was also a member of thatSenate, as was the late President WarrenG. Harding.

Using the same tactics as in the legis-lative campaigns in Missouri, in 1895 and1897, I attempted to contact every mem-ber of the House and of the Senate andlay before them the fact that people whowished to have osteopathic treatment inOhio could not do so unless there wereat hand osteopathic physicians who hada legal right to practice. It was necessaryfor the citizens who wanted osteopathicphysicians, as well as for the professionitself, to have a law that would enablethese doctors to practice.

I was in Ohio from January 1 until late

in the spring. The session did not adjournuntil the very last of May and everythingseemed to be going our way. The billpassed the House. The opposition by themedical people, however, was so verystrong that at the time the bill was broughtup for action in the House a number ofphysicians from cities around Columbuswere present and endeavored to defeat it.Many of these were family physiciansand were seated by the sides of memberson the floor of the House when the billcame up for final action. Notwithstand-ing this obvious influence, a number ofthe members voted for our bill, eventhough their family physicians, seated attheir sides, opposed it.

About that time, or just as the excite-ment was at its height, and it looked as ifthe bill would become a law, the leaderof the medical opposition wired SenatorForaker in Washington, DC, as follows:

“Eight thousand physicians in theState of Ohio will hold you responsible ifthe osteopathic bill, to be voted upon bythe State Senate at ten o’clock Saturdaymorning, becomes a law.”

Senator Foraker promptly wired that hewas not aware that such legislation waspending in Ohio, and that if he had been,he would have used his best efforts to seethat the measure became a law. Thus yousee the type of friend osteopathy had inSenator Foraker. We had not troubled himwith the fact that such a measure was in-troduced; he was a busy man, and we feltthat we could win the battle upon the mer-its of the measure alone.

Our bill was passed in the House andit was sent over to the Senate, where thesame earnest effort was put forth. Wewould have had enough friends to pass itthere, had it not been interfered with. A

senator who professed to be our friendsecured the floor when the bill was calledup and offered an amendment. Heclaimed that he had discussed the matterwith me and that both the allopathic phy-sicians and I had agreed. That was abso-lutely untrue. I had never even heard ofthe amendment until after it had becomea part of that bill. The amendment he of-fered was about as follows: A provisionpermitting an osteopathic physician, whois a graduate of a recognized college re-quiring a course of study of four years offive months in four separate years, to takean examination under the State MedicalBoard in anatomy, physiology, diagno-sis and chemistry. The Senate passed thebill with the amendment.

In Ohio it was not necessary for theGovernor to attach his signature for ameasure to become law; therefore, nochance for a Governor’s veto was pos-sible. There were no colleges of osteop-athy at that time giving a course of fouryears; neither was there a medical col-lege devoting that much time to the studyof medicine; thus, when the osteopathicphysicians in the state fought the law theSupreme Court ruled it was unconstitu-tional because the law demanded qualifi-cations of osteopathic physicians not re-quired of the graduates of other schools ofmedicine. I might mention that previousto the presentation of this amendment themedically controlled members of the leg-islature offered a substitute bill. That billprovided that all osteopathic physicianswho wished to practice in Ohio should takean examination under the medical boardin anatomy, physiology, diagnosis, andchemistry. We were able to defeat that bill,but were tricked by an amendment to theoriginal osteopathic bill.

The Lengthening Shadow of A. T. StillSecond Edition, Copyright 1942, Chapter XII

Ohio Recognizes Osteopathy


2004 Thomas L. Northup Lecture

Where Do We Go From Here?John C. Glover

Attending an AOA Convention pro-vides a wonderful opportunity to attenda wide variety of educational programs,professional meetings, and run into col-leagues you have not seen in a numberof years. Personally, I have always lookedforward to hearing the Northup lecture.It was a chance to hear a personal per-spective on osteopathy. Sometimes it washistorical, sometimes philosophical,sometimes thought provoking, but al-ways worth the time to listen. I had thepleasure of talking with Dr. GeorgeNorthup, Thomas Northup’s son. He al-ways made it a point to come to this lec-ture. I am honored to have been chosento present this year’s Thomas L. NorthupLecture.

Late one night when I was working atmy computer, I heard a Great HornedOwl calling nearby. I looked out the win-dow and saw the owl’s silhouette on adead branch, high in a tree. The bird’scall started me thinking about our pro-fession. I do not know how many of youhave are familiar with the Great HornedOwl. It is a powerful bird, capable of tak-ing prey much larger than other birds ofprey its size and possessing sight consid-erably greater than our own, which en-ables it to see through the darkness. Owlshave also been a symbol of wisdom.

Andrew Taylor Still demonstratedwisdom about patient care far beyondothers of his time. He was a powerfulvoice who spoke about healing at a timeof relative darkness in the medical pro-fession. During his life, he took on somevery powerful prey and remained strongand focused, despite many challenges.Today, osteopathy has remained a sepa-rate form of medicine, despite many chal-lenges. We remain separate, but do weremain true to the teachings of Dr. Still?

My desire to become an osteopathicphysician was firmly rooted in Dr. Still’s

teachings, but as soon as I matriculated,I realized my reasons for choosing os-teopathic medicine represented a minor-ity opinion within my class and in the os-teopathic profession as a whole. It wasin the Undergraduate American Academyof Osteopathy and the members of theAcademy that I found people of likethought and motivation. My associationwith the Academy has both nurtured andchallenged my perspective on health care.

Before entering osteopathic medicalschool, I taught at the college level forseven years. Education has always beenimportant to me. I have even been ac-cused of trying to teach at all the osteo-pathic medical schools. Although theAcademy has been a major resource forfostering Dr. Still’s approach to patientcare, it is not the sole voice in the profes-sion. Some potentially important changesin osteopathic medical education beganthis past July.

These ideas came from work done atthe osteopathic graduate medical educa-tion (OGME) meetings. The people whoattend the OGME meetings are constantlyworking to improve the quality anduniqueness of osteopathic medical edu-cation. A Core Competency ComplianceProgram has been developed that has thepotential to refocus osteopathic medicaleducation and incorporate Dr. Still’s ideasmore fully into the educational process.Let me remind you of the seven core com-petencies.

1. Osteopathic Philosophy and Osteo-pathic Manipulative Care

2. Medical Knowledge3. Patient Care4. Interpersonal and Communication

Skills5. Professionalism6. Practice-based Learning Improvement7. System-based Practice Competencies

The timeline to implement the com-petencies began this July with the firsttwo and the beginning of their assessmentwill begin this January. Over the courseof the next three years all seven will beintroduced and assessment begun. I ap-plaud the work of the OGME, but I thinkmore detail is needed to give the propos-als more meaning. I would like to makesome suggestions toward this end.

Years 1 and 2The major challenge of the first two

years is that the colleges start with stu-dents who typically have limited palpa-tory skills and little or no clinical experi-ence. We have to develop their palpatoryskills as they learn a wide spectrum ofosteopathic manipulative techniques andtry to understand when to use them andhow they integrate into patient care, butwithout a clinical reference to apply them.That job is difficult enough, given the toooften limited resources and overextendedOMM faculty, but we try to do it at thesame time they are being challenged tolearn the basic science foundation theyalso need. No undergraduate advisorwould allow a student to take the stan-dard first or second year medical schoolcurriculum.

Curricula in the osteopathic medicalschool have undergone constant revisionsince the first school opened in 1892. Thegroup who delivers a large part of theOPP/OMT education are the members ofthe Educational Council on OsteopathicPrinciples or ECOP. Members of ECOPcome from each of the osteopathic medi-cal schools. They have the difficult taskof balancing budgets, contact hours, andstaff. This takes place in an educationalenvironment where the overall knowl-edge base is constantly growing and

➻


where every department is asking formore time in the teaching schedule. TheOMM faculty at each school typically hasa greater teaching load than other clini-cal faculty and is also expected to be ac-tive in college committees, clinical prac-tice, and scholarly activities includingresearch.

The OMM curriculum is not standard-ized between the schools any more thanthe overall curriculum. Standardizationapplies to content, not process. Everydepartment of OMM is unique and willpresent the material to fit departmentaland college philosophy. The EducationalCouncil on Osteopathic Principles(ECOP) has been working toward thisend and with the support of the Board ofDeans will be able to set a basic gold stan-dard. A gold standard implies high qual-ity, not “dummed down” to the lowestcommon denominator. ECOP developeda core curriculum over several years thatled to the production of the Foundationsfor Osteopathic Medicine textbook. Se-lection of the executive editor for the thirdedition is being discussed at this meetingand the selection is critical to the form ittakes and its potential use by the schools.

Students need a firm grounding in theart and science of palpation. Withoutgood palpatory skills, students will notbe able to make accurate diagnoses. With-out an accurate diagnosis, the manipula-tive techniques taught will not result in afavorable outcome. Poor outcomes pro-duce low self confidence and question theusefulness of OMT. The end result is thatOMT will rarely if ever be used in prac-tice. The major factor that determinessuccess in developing OMT skills is aquality learning environment. That envi-ronment includes the curriculum, the in-structors, and the physical environment.

It is critical that the OMM faculty andtable trainer skill standards are high. Thatstandard should be the AOBOMM certi-fication. Every physician who teachesOMM in our schools should be OMMcertified. After the fall of 2005, the onlypeople who will be eligible to be certi-fied will be those who have done aneuromusculoskeletal medicine resi-dency, plus one NMM year or an FP/NMM combined residency. The numberwho complete training in one of thesethree programs is currently less than tena year. After 2005, the practice tract op-

tion will be closed. The closing of thepractice tract was necessary to bring thestandards for certification up to currentstandards. The problem is that there aremany people who would like to be ableto sit for the certification, but who arenot able to take the extra 1-3 years oftraining to qualify. My hope is that indi-viduals who have been certified in anyother area of medicine would be eligibleto become certified after completing anestablished set of CME criteria. Withoutgreater access to certification, there will notbe enough qualified faculty to teach in thecolleges, let alone be active in practice.

Another and more important challengeis the faculty-to-student ratio. There areguidelines in the literature that suggestlearning is hampered when the faculty:student ratio is less than 1:10. Most ofour schools meet that standard, but howthey meet it is questionable. Manyschools use adjunct faculty from the com-munity to supplement the OMM faculty.Some of those individuals are well quali-fied and NMM certified. Others have aninterest in OMM, but are not certified andmay not possess a high level of OMMskills. The administrations of the newosteopathic colleges are aware of thisfact. In still other cases, a good ratio ismet only by including predoctoral OMMTeaching Fellows, whose skills varywidely. The worst situation is when theratio is met by using students in a classahead to replace faculty. It may be betterthan nothing or cost effective, but it doesnot set an acceptable quality standard.Everyone who teaches in the OMM labshould be NMM certified or working to-ward certification.

The facility where instruction takesplace is another factor that effects theoutcome of osteopathic training. A labo-ratory must have enough space to oper-ate in, closed circuit monitors that allowall students to see demonstrations, a qual-ity text, and the most important part ofthe physical environment is an adjustabletable. Very few of the schools meet thesestandards. Fixed tables are a major chal-lenge to students who vary tremendouslyin height and weight. Even when a stu-dent is matched with a table of adequateheight for a given procedure, differentmanipulative techniques require differenttable heights for the same individual.Most schools try to adapt by using steps

for the vertically challenged, but it doesnot solve the problem. Hydraulic or elec-tric adjustable tables should be the stan-dard in all of the schools and a require-ment for accreditation. Few students whodo not have access to an adjustable tabledevelop good OMM skills and the confi-dence to use them that goes with that con-fidence. The difference in cost is far out-weighed by the benefit to the students’learning.

The more students see a separationbetween OMM faculty and curriculum,the easier it is for them to separate themin practice. Separation all too often meanselimination of OMM into clinical think-ing and utilization. Clinical faculty outsidethe OMM department should be encour-aged to participate in OMM labs, but notat a lowering of OMM skills. Conversely,OMM should also help in other clinicallabs. One way to help this process wouldbe to develop a physical diagnosis coursethat integrates the osteopathic structuralexam into the basic physical exam. Thisintegration ideally should also be incorpo-rated into specialized clinical exams andtailored for different specialties. Basic sci-ence lectures can also incorporate OMMdidactic material. Consideration of OMMintegration as part of promotion and ten-ure encourages all faculty to work towardbetter integration of OMM into all aspectsof osteopathic medical education.

Years 3 and 4During the clerkship years a student’s

clinical knowledge base is expected to in-crease by review of material presented inthe first two years and increasing experi-ence in patient management. This does nothappen with OMM for a variety of rea-sons. Most students do not know where orhow to apply much of the OMM theylearned and the clinicians they rotate withare typically at a loss to help fill this void.One method to help would be the devel-opment of OMM protocols that are spe-cific for different patient populations andcan be used by different specialties. ManyOMM specialists reel at the thought of anOMM protocol because they feel one pro-tocol cannot address the uniqueness of eachpatient. To an extent that is true, but a goodprotocol addresses the most important as-pects of management and more impor-tantly gives a student a place to start. With


experience a protocol can be adapted bythe student to fit them and the patients intheir care. Understanding the protocols willimprove efficiency and provide experienceto modify the protocols.

Again, the key is integration. Whenthe OMM information is integrated intopatient care it becomes part of the differ-ential diagnosis and the role of OMM ineach patient’s management is better un-derstood. OMM should be considered anoption on equal ground with pharmacol-ogy, nutrition, surgery, exercise and be-havioral management. Students need tounderstand OMM involves optimizingthe function of all systems of the body,not just improving joint motion or reliev-ing pain.

Every student should be required todemonstrate knowledge of how to inte-grate OMM into the management of ev-ery patient, provide treatment tailored toeach patient and document it in the pa-tient record. This is not being done cur-rently for a variety of didactic, political,and practical reasons. One way to helpwith the problem is to have a full timeOMM hospitalist on staff at each teach-ing hospital. Currently, a student mayreceive some OMM instruction an houra month or a week, if they are lucky, be-cause few hospitals have an OMM spe-cialist on staff or even available for con-sultation. Each student should be requiredto give at least one OMT under supervi-sion per week and document it in thechart. That would mean each studentwould have given about 100 treatmentsduring their clerkship years. Experiencetranslates into confidence and compe-tence. That competence should be evalu-ated by the student’s OMM faculty andbe a requirement for graduation.

Postgraduate YearsOnce the student has graduated and

starts postgraduate training the work ofintegrating OMM into patient care shouldcontinue. Each patient population has itsown unique set of problems and theOMM didactic information taught to resi-dents and the treatment given should meetthe needs of those patients. Collaborationbetween members of the AAO and eachspecialty college can produce specialtyspecific information. This informationshould be put to the test and refined withresearch. Residents should also be ex-

pected to provide OMT and mentor stu-dents. A requirement of 100 treatmentsdocumented per year by each residentwill continue to build confidence andcompetence. The specialty specific didac-tic OMM information needs to be part ofthe written test and the practice require-ments need to include demonstration ofcompetence in OMT for residents to be-come certified.

Once a resident has completed train-ing the OMM information should continueto be presented in continuing medical edu-cation programs. An AOA requirement of20 OMM specific 1A credits per cycle isneeded. This would include both didac-tic and hands on information. The AOAand specialty colleges working with eachstate licensing board should require dem-onstration of OMT skills and OMM in-tegration in patient care. There needs tobe a change in the requirements for eli-gibility to become certified in NMM sothat any certified physician can becomecertified in OMM with additional train-ing in OMM. Beyond quality of patientcare is the need to be paid for OMT. Theissue of payment is being addressed bythe AAO and the AOA. These effortsneed to be supported by individual os-teopathic physicians and state societiesas well and the AOA, so both effort andmoney can be focused on the problem.

As I bring my thoughts to a close, Iam reminded of the Great Horned Owl’scall, “Whooo, who, who”. Who will of-fer their skills to teach, who will offertheir time to help in whatever way isneeded by the profession, and who willcontinue to fight for osteopathy by an-swering the call of Dr. Still to “Dig On”?Quality, distinctive osteopathic educationis the key to the vitality and growth ofour profession! Thank you again for theopportunity to share my thoughts.

Recommendationsin Summary

Years 1 and 21. All OMM faculty NMM certified and

a faculty to student ratio of 1:10 orbetter in OMM labs

2. Adjustable height tables in OMM labs3. Develop and utilize Gold Standard

OMM Curriculum4. Integrate OMM into basic science and

all clinical lectures5. Integrate structural exam into physi-

cal exam from the beginning6. Promotion and tenure in part based on

OMM integration for all faculty7. Use non OMM faculty to help in

OMM labs and vice versa, but theyneed to have a high level of OMM skill

Years 3 and 41. Standardized set of protocols tailored

to specific patient populations thatserve as a base line of OMM care andexpand knowledge and improve effi-ciency.

2. Stress OMM integration with pharma-cologic, surgical, nutritional, and be-havioral treatment.

3. Stress the role of OMM in optimizingsystems functions, not just for allevia-tion of motion restriction or pain.

4. Required OMM rotation that requiresdelivery of OMT by the students, butall rotations should encourage, allowand foster the integration of OPP andOMT into patient management.

5. Designated OMM faculty on staff inthe hospitals who consult on hospitalpatients and work with students.

6. Requirement that students evaluate,treat, and document in the progressnotes a minimum of 100 supervisedtreatments to graduate.

7. Require OMM competency/profi-ciency exam to graduate.

Postgraduate Years1. Collaboration between AAO and each

specialty college to develop standards.2. Establish specialty specific didactic

OMM information integrated intoresidency training.

3. Establish specialty specific OMT pro-cedures and protocols.

4. Require that interns and residentsevaluate, treat, and document in theprogress notes a minimum of 100 su-pervised treatments per year.

5. Testing of OMM didactic informationon all board certification exams.

6. Demonstration of specialty specificOMM skills as a component of allboard certification exams.

7. Provide option for any physicianboard certified in any specialty, to beable to sit for NMM certification af-ter additional CME training, includ-ing MDs. ➻


CME1. Requirement of 20 OMM didactic and

hands on CME credits per cycle forall physicians.

2. Incorporate OMM questions and dem-onstration of skills into recertificationexams.

3. OMM CME should mirror real prac-tice and focus on practice perfor-mance.

4. Requirement to demonstrate OMMskills for state licensure.

5. Allow any physician already certi-fied to be eligible to certify in OMMwith the addition of additional CMEtraining.

6. AOA, working with the state societ-ies, need to devote considerable timeand energy toward reimbursement forOMT.

7. Encourage all osteopathic physiciansto mentor students in OMM.

Address Correspondence to:John C. Glover, DO, FAAOChairperson, Dept of OMMTouro University / California1310 John LaneVallejo, CA 94592

The Arizona Academy of Osteopathypresents two upcoming hands-on courses:

Advanced NeuroFascial Release: The ExtremitiesApril 9-10, 2005

Phoenix, AZ(16) Category 1A – AOA CME Approved

Neurofasical Release Conference WestApril 15-17, 2005

Phoenix, AZ(24) Category 1A – AOA CME Approved

Instructor:Stephen M. Davidson, DO, C-SPOMM

For further information, please call:AZ Residents: 602/957-35225USA Toll Free 800/359-7772

Email: [email protected] the website at http://www.Healthabounds2.com

Counterstrain and Exercise:An Integrated Approach

Paul R. Rennie, DOwith John C. Glover, DO, FAAOClaudio Carvalho, DOand Larry S. Key, DO

These works will enhance quick and effective learning of this osteopathic neuromusculoskeletaltreatment method. Educators will find the CD version especially helpful for presentations. A point andclick tender point locator map provides immediate referrence to detailed information including theassociated anatomical considerations, clinical correlation, treatment position, and exercise link. Addi-tionally, these exercise routines can be printed for patient use.

The hardcover version is a milderly updated version of the CD. This work includes full-color imaging8 1/2 by 11 inch format. It contains 256 illustrations in 186 pages and contains a more detailed index.

Order Form: Name: ______________________________________________________________

Shipping Address: ________________________________________________________________

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Daytime Phone: ______________________________ AAO Accepts MasterCard or Visa

Credit Card #: _______________________________ (Below price includes shipping/handling)

Expiration Date: _____________________________ CD ___ x $77.95 Book ___ x $98.95

Check Attached: ____________ Total Amount of Order: $___________

CD (Windows® only) is $69.95 + $8.00 S/HHardcover version is $89.95 + $9.00 S/H

American Academy of Osteopathy¤

3500 DePauw Blvd., Suite 1080, Indianapolis, IN 46268Phone: 317/879-1881 ¥ Fax: 317/879-0563

Website: http//www.academyofosteopathy.org


The task of appropriatecoverage for the Worldgames began when I wasasked to once again be theDoctor for the AmericanTeam. I had participated inthe event the previous year,when the team went toHolland, and they did quitewell; and it appeared clearto the members that the ad-dition of a physician withosteopathic medical skillswas a welcome addition.

Upon notification, Icorresponded with theteam Co-Captain, RoyPirrung, and gave him themost recent set of drugsanctions and a list of nonapproved drugs, with theproviso that if any of therunners were taking any ofthe medication on the list,they contact me, or theirprescribing doctor to en-sure that there would be nocomplications in the event of drug test-ing. I then contacted each runner to learnof any medical or structural issues theyhad prior to the race and if there was any-thing we could do to enhance their abili-ties prior to the race. I had an advantagein that I had worked before with all buttwo of the runners, Peter Ebret and AlexSwenson. Prior to the race itself, I did astructural evaluation of each runner andsome soft tissue and stretching to estab-lish a base line to compare against dur-ing the competition. The race began af-ter the appropriate ceremonies introduc-ing the athletes.

There are many events that are greaterthan the sum of its parts. The 24-hourworld championships were a wonderfulexample of that. From the moments ofits inception until the final gun went offthe team faced many challenges. KevinSetnes, a premier American runner him-self and one of the main supporters andsponsors, sent an e-mail to the entire teamand stressed that this was a team efforteven though each individual runner runshis or her race. And it is that team effortthat really counts. As the event unfoldedhis comments showed exceptional wis-dom.

The women’s teamconsisted of StephanieEbret, Pam Reed, andSandy Powell, all sea-soned individual champi-ons in their own right. Themen’s team consisted ofScott Eppleman, JohnGeesler. Roy Pirrung, andAlex Swenson. Again, apremier group of indi-vidual runners all ofwhom had participated inthe team event the previ-ous year, except for Alexwho was a new and wel-come addition to the team.Peter Ehret, ran as an opendivision runner for theUSA as well.

The course as well asthe site had been changedseveral times due to manyconsiderations, havingbeen moved from Hollandto Brno. Even there thecourse was changed from

a 2.5 K to a .867 K with up and downgrades, as well as 7 left and 3 right turns.Portions of the course were run oncobblestone surfaces making footing apossible issue.

Except for the extraordinary efforts ofTomas Rusak, who hosted the event, theevent may not have taken place at all. Hemanaged to mobilize the entire CzechRepublic to make this a premier event(there even was a commemorative stampput out, regarding the event).

After the gun went off and the racerswent on their way, the American men’s

Medical Coverage for theAmerican Team at theWorld 24-hour Championship Racein Brno Czech RepublicAndrew Lovy

➻


team started in 9th place. Over the courseof the event, the team moved its way upsteadily and gradually to 4th and then heldthat position for the last 5 hours, a trulyremarkable achievement considering whatwas happening to the individual runnersthemselves. The women’s team also startedstrongly, moved from 7th to 5th to 4th, andin the last 4 hours, moved into 3rd place,which they tenaciously held on to finish-ing as a medalist team. It required not onlyexceptional individual performances but ateam spirit and concept as well, the run-ners encouraging each other during thecourse to keep going, to not give up, etc.

The runners were noted by other teamsand officials as one of the few teams who,for the last three hours, had all the runnersout on the course and ran well. (See Roy’scomments.)

Tomas assigned two Czech ladies towork with us and one Maria (?) stayed withthe team for the entire 24 hours, getting usall the food and supplies needed to main-tain the performance, as well as act as trans-lator when the occasion called for that. Thehandlers themselves, in addition to han-dling their runner, handled every memberof the team. It appeared to an outside ob-server that the effort was seamless, all run-ners getting full attention as they went byfrom whomever was available at the time.As the runners came by they were giveneverything they asked for, wanted orneeded and may not have known theyneeded, unaware that, when they left thearea there was a major scramble to beready for the next lap.

From the medical perspective, all of therunners were seen and tuned up withmuscle energy, myofascial release prior tothe race and at intervals during the racechosen by either the handlers or the run-ner to enhance their performance. The run-ners felt that this was a part of their suc-cess, being stretched out and ensured thattheir medical issues were addressed as theyoccurred.

The story is less than half told if onedoes not mention the individual perfor-mances and their contribution to the teameffort.

John Geesler began steadily but verysoon into the race began to have seriousgastrointestinal problems. He reported tome that he was making a pit stop literallyat every loop, which obviously sloweddown his time. However, while he was

running, he did maintain form and speed.We had several attempts to slow the prob-lem down and ultimately I went to the of-ficial medical tent, manned by Dr. LubosHrazdira and his medical team, who pro-vided us medical assistance and Imodium.Within 3-5 laps, the problem abated andhe was able to run for a period of time with-out further problems. However, the gas-trointestinal issues continued to plague himthroughout the race and reached the pointwhere it was difficult to maintain fluids andnourishment. Anything that worked onlydid so for a short time, and then became aproblem again. Sparing most of the detailsand another bout of gastrointestinal dis-tress, John finished the race with far fewermiles than his anticipated mileage. How-ever, a lesser man would have found manygood reasons, not excuses to slow downor to stop entirely. By not doing so, he in-sured a very high position for the team.OMM was applied to the appropriate spi-nal segments. Soft tissue massage andstretching helped, but with Jon’s contin-ued push, each adjustment would last onlyfor a period of time and required furtheradjusting, taking time from his speed anda bit of loss of ability to maintain.

Roy Pirrung started smoothly, learn-ing from his experiences from the previ-ous year, and having periodic tune ups, ransteadily, moved his way up the course andthe field, and within the last two hours hadbroken another national record.

Scott Eppleman ran a steady wellmodulated and paced race, being almostself contained, coming in periodically tothe tent, asking for what he needed, andthen moving on. He had a strong steadyperformance, and during his last threehours he closely approached the speed ofhis first three hours.

Alex Swenson ran a wonderful pacedrace. He seemed to be unflappable. Regard-less of the situation or how he felt, hemarched on with few complaints and agood sense of humor. He mentioned thatone of his few complaints was that one ofthe handlers (the doctor) kept calling himEric instead of Alex, but he even overcamethat misidentification. He was in the topthree American runners and if anyonewould have faltered, his mileage alonewould have insured a very high place inthe standings.

On the women’s side, Pam Reed ran amarvelously steady pace. She came in afew times, had a few muscular issues todeal with because of the track conditions,but maintained a championship race forthe entire event. At no time did hermuscles indicate a fatigue level and herrunning was very powerful at the end, asit was at the beginning.

Sandy Powell ran steadily andstrongly, also sustained some gastrointes-tinal issues later in the race, but overcamethat with a change in electrolytes, fluids,and Imodium. In the last 4 hours basi-cally she did not let any female runneron the teams behind the Americans passher. She stated later that she wanted thethird place for the team and she wouldhave maintain pace at all costs, even if shehad to crawl. Competence without cour-age leads to decent performance. Couragewithout competence leads to a great indi-vidual effort. But when you have both, suchas Sandy did, you exceed all expectations.

Stephanie Ebret, the new addition tothe team, ran a steady paced race early.In the middle phases she had an addi-tional gear and ran with the leaders forseveral hours. She then slowed downbriefly, paced herself well, then ran thelast 4 hours strong and hard, and on a verychallenging course, set a PR by 10 miles.(I had mentioned, after viewing thecourse conditions and layout, that it wasnot a PR course, but one that would bevery challenging. I did not fully take intoaccount the strong will and desire that therunners had to excel beyond their indi-vidual capabilities.)

We also had Peter Ehret, running forthe United States, but in the open divi-sion. He ran well enough to have brokenhis personal best up to 100 miles. He thensat down for a few minutes, rehydrated,gathered his thoughts, then got up. Hecollapsed a few yards later with what Dr.Roger Bannister coined “Runners Neu-rogenic Shock”. His blood pressuredropped, (70/40), his pulse becamethready and it looked as if his race wasover. However, after rehydrating and set-tling his system down, blood pressure re-turned, pulse became regular and steady,and he continued onward. Rather thanslow down, however, within a few lapshe was again running well, and when therace had ended, he was in first place inthe open division.


It was a very proud moment forAmerica and American sports to have ourwomen stand up on the podium as med-alists. They ran with extreme compe-tency, fierce determination and grace. Therules were explained to all runners andteams prior to the race starting; and therewere some very innovative interpreta-tions that some of the teams applied, butour runners stuck strictly to the letter andintent of those rules. At all times theyshowed courtesy to other runners as wellas handlers. We were very politely ap-plauded at the start, but much more wildlyat the finish, as the runners proved them-selves worthy competitors and a team tobe reckoned with. From the medical per-spective, the shifting electrolyte, food andwater needs were a constant challenge;and the needs shifted during the event.Then the addition of the gastrointestinalcomplications kept us constantly tryingto work out new and different ways tokeep energy levels and hydration up, inthe face of reluctant gastrointestinaltracts. Attention to Chapman’s reflexes,massage, soft tissue manipulation, myo-fascial release, cross fibering, muscleenergy techniques all blended together asthe runners came in for the few minuteswhile they were making equipmentchanges. The runners stated they felt itwas very useful in maintaining their pacethroughout the race.

As an additional honor, when thewomen’s team went up to receive theirmedal, I was asked to join them as a ma-jor support. I have several hundred med-als, medallions and trophies for partici-pation in runs throughout the years formy running persistence, but this is thefirst time I have received a medal formedical coverage. I felt this to be a greathonor to be on that podium withAmerica’s finest. It was a very proudmoment when Tomas mentioned my par-ticipation, being available for all the run-ners, being a psychiatrist, sports medi-cine specialist and Osteopathic Doctor.The international reputation of Osteo-pathic Physicians as being at the forefrontof those called on for athletic events ismoving forward at a rapid pace.

The Olympiad of this year was a re-flection of the finest each nation was tofield for the various events. There was agood deal of well deserved publicity forthe athleticism shown. This event was the

Olympics for the ultra distance athlete;and for our teams to do that well, it onlyattests to the great potential that we haveif given the support. All our runners workfull time and do their training after hoursand when and as they can. Individualslike Kevin Setnes, Roy Pirrung, and amyriad of other giants are making it pos-sible to reach this level and additionalsupport would be more than welcome. Ienvision some day when some of ourteams and athletes will be hearing ournational anthem played as they are on thepodium.

One cannot close without mentioningthe support system. Within the first fewhours it became obvious that we had ateam of handlers, as well as a team outon the track. Most of us put on 14 -20miles chasing down food, chasing downrunners, chasing down medications to as-sist our runners. We all stayed up the en-tire 24 hours as support. The young ladyfrom the Czech Republic is especially tobe commended. Rather than leave at 6:00PM for a night on the town, she stayedwith the team for the full 24 hours as welland was adopted by the entire team.

Dr. Hrazdira was more than graciousduring the entire event. He is one of veryfew doctors who had his medical teamand himself there at the event for the full24 hours, giving expert aid and assistanceto the runners, never leaving his post, andallowing me the courtesy of using hisfacility to work on our runners.

After the awards ceremony, the topthree runners in each category were askedto go to the medical tent for drug testing.It was an appropriate, but also quite chal-lenging, situation. After viewing the pro-cedure, I was very sure that the testingitself was fair and very thorough in theirhandling the situation to ensure that norunner has an unfair advantage by usingillegal drugs.

This event should be publicized na-tionwide. The performance of our athletesrepresenting our country is worthy of in-ternational recognition and fame. Theyhave that internationally and hopefullythat will also occur in the USA. They aremarvelous examples of good will ambas-sadors, superior athletes and good rolemodels for our youth on professionalismand competitiveness. The role of the phy-sician as part of the support team hasproven itself time and time again.

October 30, 2004

Dear Doctor Lovy,Once again, I offer my sincere thanks for

your professionalism during our 24-hourWorld Cup event held in Brno, Czech Repub-lic on October 23rd and 24th, 2004.

I was pleased when you responded affir-matively to my request to accompany the teamfor the second consecutive year. Many of theathletes were returning as well and the firstquestion I heard from them was if you wouldbe making the trip again.

Last year, we placed sixth in the men’scompetition and fourth in the women’s divi-sion. Our goal was to move up at least oneplace for each team.

Without your assistance prior to, and dur-ing the race, we would not have been able toaccomplish that goal.

The men moved up two places to takefourth and the women, with your proven os-teopathic methods, were able to move to themedal stand!

I was also very pleased that the race di-rector recognized you during the awards cer-emony as assisting the team and enablingthem to keep running while others were side-lined.

In fact, I have received a number of e-mailsfrom other team coaches mentioning the factthat ALL U.S. runners were still running overthe final hours of the event. I know it wasbecause of your talents and skills that we wereable to do that.

We have worked together on many otherof my American record performances so itcame as no surprise to me that with you thereI broke my own 24-hour 55-59 age groupnational record on a course that was unusu-ally tough for an international event with theWorld Cup designation.

On behalf of the American 24-hour team,I thank you for your service and making thisrace a rewarding experience. We look forwardto you being a part of our team in Worschach,Austria on July 23-24, 2004.

See you in a few miles ....

roy plrRUNgWorld Champion, U.S. Champion

American Record HolderU.S. 24-hour Team Captain Manager

Accepted for Publication:January 2005

Address Correspondence to:Andrew Lovy, DO, FACNKCOM800 W. Jefferson StreetKirksville, MO 63501


The Case of a Patientwith Persistent Urinary UrgencyRobert C. Clark

Chief Complaint:Urinary Urgency

History of Chief Complaint:Patient presents to office with a chief

complaint of Urinary Urgency that hasbeen present frequently for the past 5weeks. She initially observed the urgencyaccompanied by frequency and burningon urination, an unpleasant odor andblood in her urine. She self-medicatedwith amoxicillin 500 milligrams TID) fortwo days. Her physician prescribedAugmentin 1000 milligrams 2 tabletsdaily in a single daily dose for 10 days.Urinary symptoms of burning and fre-quency resolved over the course of treat-ment. The urgency diminished. At the endof treatment the patient’s frequency hadreturned to normal. The burning, odor,and blood were absent. The urgency waspersistent yet less severe. Approximatelyone week into the course of the treatment,the patient presented with vaginal dis-charge characteristic of candidiasis. Thepatient received a single dose treatment offluconazole and had complete resolutionof the symptoms of the yeast infection.

Review of Systems:Head, Ear, Nose, and Throat:

Patient has recurrent neck pain andheadache from an automobile accidentapproximately five years previous. Sheis presently under treatment with an os-teopathic physician for this and doingwell.

Respiratory:Patient has a history of asthma and is

on a regimen of prophylactic medicationsof Serevent and Flovent.

Cardiovascular:Patient has a four-year history hyper-

tension controlled with nifedipine 20milligrams once daily.

Gastrointestinal:Patient reports no symptoms.

Genitourinary:In addition to the chief complaint the

patient has had one pregnancy deliveredby emergency C-section 20 years prior.

Musculoskeletal:Thoracolumbar pain, lumbosacral

pain, sacroiliac pain, neck pain, and head-ache all of which the patient attributes tothe sequelae of the aforementioned auto-mobile accident and several prior inju-ries. The patient receives monthly OMTand this controls the symptoms quitewell.

Neurologic:Patient has prism correction for diplo-

pia secondary to the automobile accident.

Physical Examination:Patient is a 52-year-old Caucasian fe-

male in no apparent distress. Patient ismoderately overweight. Blood pressureis normotensive. Heart rate approxi-mately 72 beats per minute. Respirationroughly 14 breaths per minute. The pa-tient shows moderate somatic dysfunc-tion in the thoracolumbar area and in the11th and l2th ribs – showing an inhala-tion pattern of the ribs more so on theright side. Pubic bones are level. Sacrumlevel. The ilia show no rotation and arelevel.

LaboratoryExamination:

Urine is clear. No blood cells or bac-teria are present.

Impression:Recurrent urinary tract urgency sec-

ondary to a viscerosomatic reflex andfacilitated segment involving the thora-columbar junctional area. Additionallythe previously diagnosed urinary tractinfection and vaginitis are filly resolved.

Treatment:Patient was treated in the thoracolum-

bar area and good mobilization occurredusing a combination of muscle energytechniques and ligamentous articulatoryrelease techniques. Patient reported im-provement.

First Follow-up:Five days later on follow-up the pa-

tient reported some improvement hadoccurred; however, the urgency was sig-nificant enough that it caused her incon-venience as well as discomfort.

Reexamination:The thoracolumbar area was substan-

tially better than on previous visit - itagain was treated. Sacrum and pelviswere in normal alignment The patient’spelvic diaphragm showed marked asym-metry - extremely tender to palpation onboth sides. Right side appears inferior toleft side. Indirect myofascial treatment ofthe pelvic diaphragm resulted in signifi-cant improvement in the patient’s symp-toms at that time, however in view of thepatient’s long-standing symptoms, shefelt this level of improvement was inad-equate and inquired as to what additional


The purpose of the quiz found onthe next page is to provide a conve-nient means of self-assessment foryour reading of the scientific contentin the case study, The Case of a Pa-tient with Persistent Urinary Urgencyby Robert C. Clark, DO, MS.

For each of the questions, place acheck mark in the space provided nextto your answer so that you can easilyverify your answers against the cor-rect answers that will be published inthe June 2005 issue of the AAOJ.

To apply for Category 2-B CMEcredit, transfer your answers to theAAOJ CME Quiz Application Formanswer sheet on the next page, thenmail the bottom half of the form withyour AOA number ONLY to the AAOas indicated. The top half of the formshould be sent to the American Os-teopathic Association in Chicago. TheAAO will record the fact that yousubmitted the form for Category 2-BCME credit and will forward your testresults to the AOA Division of CMEfor documentation.

CME QUIZ

June 23-26, 2005Annual Conference:The Osteopathic MindThe Cranial AcademyIndian Lakes ResortBloomingdale, ILContact: The Cranial Academy

317/594-0411

September 2-5, 2005Biodynamics Phase III:The Long Tide and the DuraTopanga, CACME: 22.5 Category 1A (anticipated)Contact: Stefan Hagopian, DO

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October 14-16, 2005Neurofascial Release Conference WestArizona Academy of OsteopathyCME: 24 Category 1A (anticipated)Contact: Stephen Davidson, DO

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continued from page 7treatment could be given. Evaluation ofthe suprapubic area for visceral strain in-volving bladder and uterus was per-formed and no dysfunctions were de-tected. Evaluation of the urethral arearevealed a significant myofascial strainof the periurethral soft tissues with a sig-nificant pull to the patient’s right side andsuperiorly. This was treated utilizing amyofascial release technique indirectmethod with an immediate and significantrelief such as the patient noted her symp-toms were now almost imperceptible.

Second Follow-up:Three days later the patient reported

that symptoms had improved no less than95% and examination of the pelvic dia-phragm and thoracolumbar area revealednormal structures. The patient felt addi-tional treatment to the urethra was nec-essary. Myofascial strain pattern of theperiurethral tissues was found and treatedagain with indirect myofascial releasetechnique.

Discussion:This case presents a diagnostic chal-

lenge. Why did urgency persist despitecomplete resolution of all other symp-toms? Thinking osteopathically mandatesconsideration of nerve supply, blood sup-ply, venous, and lymphatic drainage. Aviscerosomatic reflex can set up a facili-tated segment that can cause persistentphysical symptoms via a somatovisceralreflex.

As the autonomic innervation to theurinary systems is from the thoracolum-bar area and the sacral area, the firstthought was to examine these two areas.The thoracolumbar area and 11th and l2thribs were dysfunctional in this patient.Empirical proof of the reflexes was seenwith the success of the treatment.

However, the persistence of the symp-toms suggested an additional etiologywas operating. After the circulation andnervous system were treated, osteopathicthinking suggests evaluating the adjacentstructures. In this case the, pelvic dia-phragm, the bladder, urethra, and the pe-riurethral tissues are the adjacent struc-tures. In this case, the pelvic diaphragmand periurethral tissue proved to be thefinal pieces of the diagnostic puzzle andtreatment resolved the problem.

The patient wondered what her fatewould have been had she not had a DOas her doctor? More importantly, she hada DO who thought osteopathically andlooked to the host when there was no dis-ease to attribute her illness.

Would she have gotten better in time?Five weeks of symptoms suggests not.Her next step was urologic consultation.Would she eventually be diagnosed asinterstitial cystitis? Did we prevent thatoutcome with OMT? We will never knowwhat we prevent!

Accepted for Publication:September 2004

Address Correspondence to:Robert C. Clark, DO, MSDepartment of OMMTouro University / California1310 John LaneVallejo, CA 94592


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Name of Article: The Case of a Patient with PersistentUrinary Urgency

Authors: Robert C. Clark, DO, MS.

Publication: Journal of the American Academy ofOsteopathy, Volume 15, No. 1, March 2005, pp 20-22

Catebory 2-B credit may be granted for this article.

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Answer sheet toMarch 2005AAOJ CME

quiz will appearin the June2005 issue.

December 2004AAOJ CME quiz

answers:1. C2. D3. B4. D5. B

1. For patients with persistent urinary ur-gency after the infection is resolved, theosteopathic physician should consider:

____A. nerve supply.____B. blood supply.____C. venous and lymphatic drainage.____D. all of the above.

2. The continued presence of symptomsafter effective treatment of facilitated seg-ments and supporting circulation, suggestthe osteopathic physician should:

____A. refer the patient for appropriatespecialty care.

____B. evaluate the adjacent anatomicalstructures.

____C. repeat the antibiotic treatment.____D. perform a follow-up culture and

sensitivity of the urine.

3. In the patient with persistent urinary ur-gency after effective treatment of the in-fection, what was the initial proposed ex-planation of the urgency?

____A. Incomplete antibiotic regimen____B. Uncontrolled hypertension____C. Sequellae of injury____D. Facilitated Segment of the thoraco-

lumbar area

4. Sympathetic autonomic innervation tothe urinary system is from the:

____A. mid thoracic area.____B. thoraco-lumbar area.____C. lumbo-sacral area.____D. sacral plexus.

5. What structures are adjacent to thebladder?

____A. Urethra____B. Pelvic diaphragm____C. Periurethral soft tissues____D. All of the above


The Department of Osteopathic Manipulative Medicine (OMM) has a full time positionavailable. The applicant should have interest and experience in clinical practice and teach-ing osteopathic manipulative medicine in a variety of settings.

Qualifications:¥ Board certified in OMM/NMM or eligible to sit for certification¥ Clinical practice experience¥ Licensed or ability to be licensed in the State of California¥ Unrestricted DEA licensure¥ Graduate of an AOA-approved osteopathic college¥ Residency training and teaching experience desirable

Responsibilities:¥ Participate in the delivery of the Department of Osteopathic Manipulative Medicine

(OMM) educational programs¥ Work/teach with other university departments to integrate OMM throughout the

curriculum¥ Participate in other departmental programs, including pre and post doctoral training,

research, and other scholarly activities¥ Patient care in the Touro University Health Care Center

Rank, Salary, and Benefits:¥ Assistant or Associate Professor¥ Salary based on experience and credentials¥ Touro University faculty benefit package

Letters of interest and current curriculum vitae are being accepted at this time and willcontinue until a suitable candidate is hired. The position will begin July 1, 2005. Informa-tion and inquiries should be sent to:

John C. Glover, DO, FAAOChairman, Department of Osteopathic Manipulative Medicine

Touro University-California1310 Johnson LaneVallejo, CA 94592

(707) 638-5219, Fax (707) 638-5255, e-mail: [email protected]

Touro University is an Equal Opportunity/Affirmative Action Employer

Osteopathic Manipulative MedicineFaculty Position Opening

Touro University-CaliforniaCollege of Osteopathic Medicine


Expanded Spinal Flexion Test:A New Palpatory Tool for LBPAnalysis or an Old Test Revisited?Paul T. McTurk and Halina H. Harding

AbstractExpanded spinal flexion test (ESFT), in its simplest defini-

tion, involves the application of the classical sacral test for sac-ral unleveling test1 (or simply sacral flexion test - SFT) to thelumbar and lower thoracic vertebrae. This incidentally discov-ered new test or a new application of an old test, does not ap-pear to be documented or used elsewhere in the literature. Ac-cording to the spinal motion laws documented first by Fryette2

in the osteopathic literature, Law #3 states that a motion or dys-function in any plane of motion of a single vertebrae will causea restriction for further motion of the same vertebrae in the re-maining plane(s) of motion. Currently, the clinical palpationtests and observations regarding the dysfunction of lumbar ver-tebrae are geared towards side bending and rotational move-ments,3,4 even though the major motion of the lumbar spine isflexion and extension, and even though a dysfunction in coro-nal and transverse planes could significantly affect the furthermotion of lumbar vertebrae in their dominant motion that isflexion and extension, i.e. on the sagittal plane. In our view, itshould be intuitive that any dysfunction in this group of verte-brae may be more easily and directly observed by paying atten-tion to the dynamic motion of the lumbar vertebrae (and itscomponents) in the sagittal plane. Indeed, it was found that adysfunction in the lumbar vertebrae could be clinically detectedand diagnosed by applying the sacral flexion test on the lumbarand lower thoracic vertebrae. Therefore, this study aims to docu-ment this finding and explain its theoretical basis and conform-ance with the existing and well accepted spinal motion laws. Itis hoped that an interest leading to a myriad of studies regard-ing its use, applicability, specificity, sensitivity may be fueledin this area.

DefinitionIn sacral flexion testing, clinicians use their hands and thumbs

to palpate a discrepancy or asymmetry on one dysfunctionalside of the sacroiliac junction upon active lumbosacral flexionby the patient. When it is done with the patient in sitting posi-tion a positive result indicates a sacroiliac dysfunction and apositive result with patient in standing position is said to indi-cate an iliosacral dysfunction, i.e. a dysfunction in the lowerextremities.

ESFT is performed in a similar fashion to the classical sacral

flexion test. Instead of the lower portion of the PSIS’s, eachthumb is lightly placed laterally next to the transfer processesbilaterally while grabbing the patients torso with the remainingfingers and palms on either side. Then, the patient is asked tobend over from the waist up without bending his/her hips, kneesor ankles. If one of the thumbs moves upward then the test isconsidered positive on the side of the upward moving thumb.

Literature SearchA Medline research covering up to July 21, 2004, was per-

formed. In addition, using various internet search engines thekey words thoracic flexion, lumbar flexion, sacral flexion, ceph-alad, and thumb were searched. Osteopathic literature wassearched via the American Academy of Osteopathy indexes forthe years 1938 through 2004. It was noticed that in addition toosteopathic physicians, physical therapists, manual medicinephysicians, chiropractors, etc. used the sacral flexion tests, andhad even written papers and discussions on the sacral flexiontest in the USA and the world.5,6,7,8,9 However, none of the re-trieved articles had any reference to a test or clinical observa-tion comparable to the one declared in this study. There are avariety of studies in the literature regarding the palpation oflumbar and thoracic vertebrae in the past but efforts were in thedirection of evaluating the patient either in rotation or insidebending to accentuate the effectiveness of palpation, butnever while-in-active flexion using the thumbs as discussedabove.10,11,12 On the other hand in a recent discussion, it wasnoted that there may be several practitioners who may be usingthe expanded spinal test on a regular basis, although no addi-tional written records of such use have been suggested.13

PurposeLBP is caused by various etiologies, and, therefore, treat-

ment options may differ. Currently, TART is employed in clini-cal judgement and diagnosis of LBP. It is often difficult to pal-pate the dysfunctional vertebral rotations and easy to miss themduring the exam unless the clinician has a special interest onthe subject with years of palpation experience. It is also diffi-cult to come to a consensus regarding the examination find-ings, thus leading to misdiagnosis of underlying mechanismsof back pain, particularly in the lower back. A more objectivemethod that can be measured and is visual with more obvious


findings would greatly reduce the efforts to diagnose, to easethe index of suspicion, and result in effective treatment.

Selection CriteriaInclusion criterion: Any adult or adolescent patient who

allowed the palpation test, with or without declared back pain.Exclusion criterion: Any patient with spinal abnormalities

documented with visual records such a X-rays, MRI, CT Scans,or surgical exploratory studies. Also, anyone with a history ofspinal surgery, vertebral fusion and other heroic interventionsexcept patients who receive pain management and injections tothe nerve roots.

We have examined many patients. Most patients had some sortof LBP or have experienced LBP in their life. Because this studyis a pilot for documentation of the test itself, no statistical evalua-tions were done. We have reported two cases for the purposes ofshowing the application of the expanded spinal flexion test.

DiscussionStanding or sitting sacral flexion test is probably one of the

more exciting clinical tests in osteopathic medicine and one ofthe more widely accepted and used tests among a spectrum ofmedical professionals around the world. This excitatory natureof the test is probably due to its visual presentation, observability,reproducability and, perhaps even measurability, if desired.

In the sacral flexion test, physician places their thumbs onthe lower portion of the PSIS’s of the patient and grabs thepatient’s ilia with their palms and asks the patient to bend for-ward gently without bending his knees. If one of the thumbsmoves cephalad during the test then the test is positive indicat-ing a dysfunction on the side of the cephalad thumb, as seen inFigures 1a and lb.

Figure 1a shows the standard sacral flexion test with patientstanding. Figure lb shows the movement of the thumb as patientis instructed to bend forward. In classical definition, the side withthe cephalad thumb motion is assumed to be the dysfunctionalside, i.e. the TART changes secondary to somatic dysfunction force

➻

the more superficial tissue to be dragged in the direction of ease ofmotion. Although the underlying mechanics of a positive SETsign have not been fully understood,14 it is apparent that one canactually document a motion as well as measuring the distancetravelled by the thumb on the positive side.

If the same test is applied to lumbar and lower thoracic ver-tebrae, similar results are found if there is a dysfunctional seg-ment or a dysfunctional group. Again, Figure 2a shows the hold-ing position for either lumbar or thoracic vertebral segment,and Figure 2b shows the cephalad movement of the thumb onthe dysfunctional side.

A question now arises. Does this definition go along withthe Fryette’s15 laws for vertebral motion dysfunctions? The an-swer is “Yes” and the finding is in conformance with Fryette’slaws. As a minimum, a positive sign indicates a dysfunction inaccordance with the third law of Fryette, i.e. a motion (or dis-placement) of a vertebra in one axis (or plane) will restrict themotion of the vertebra in other axes or planes. Now, let us look


at Fryette’s first and second laws of vertebral motion.According to the Fryette’s first law, if the spine is in neutral

position sidebending intoduces rotation of a group of vertabraein the opposite direction, and that side bending occurs first.Fryette’s second law states that if the spine is in non-neutralposition (i.e. in flexion or extension), rotation and side bendingare on the same side and the rotation occurs first.

Here we appear to have a dilemma: the upward motion ofthe thumb alone is clearly on the coronal plane and cannot pos-sibly tell us which type of dysfunction we are faced with. Or,can it?

We believe this test can tell us the type of dysfunction as it isrelated to the rotational and sidebending dysfunctions, as well.The key is to repeat the ESFT at several different levels, se-quentially. This test can be reproduced by asking the patient toflex several times while the physician is marching from lowerlumbar segments in cephalad direction. It may be seen that, simi-lar cephalad thumb movements on the side of rotation may bepalpated and visually observed, and even measured. Thus, se-quentially repeated positive signs on one side should indicate aType I dysfunction and a positive sign at only only one segmentalone should indicate a Type 2 dysfunction. Consequently, in-terpretation of the test results become intuitive.

The cephalad movement of the thumb follows the freer mo-tion of the vertebral facet and/or transverse processes. Thus,having a positive sign on the right should indicate a sidebendingto left.

If we summarize the above, a repeated positive sign on theright, for example, means Type I dysfunction with sidebendingleft and rotated right, where a single isolated positive sign onthe right would mean Type 2 dysfunction with sidebending androtation to left.

Therefore, it is probably incorrect to talk about a distinctlydysfunctional side as is the case in the classical sacral flexiontest where we equate a positive sign with the dysfunctional side.

ResultsPatients were shown the Figures 1a through 2b and it was ex-

plained that the physician will be doing an additional exam onthem, regardless of their current complaint. Patients were also toldthat this examination may or may not lead to a treatment.

The two cases below were presented as it is related to theuse and the positive findings of the ESFT.

In Case #1, Patient was a 45-year-old white male truck driverwho was complaining of LBP for two years since he starteddriving cement trucks. Patient had a spinal CT done that re-sulted essentially negative. He could not find another job andwas on pain killer narcotics. However, patient complained thatno amount of pain killer was making his pain better, despite arecent dose increase in his pain medications. During the examit was found that this was a classical case of left psoas contrac-ture with a non-neutral dysfunction of L5. Patient’s L5 was ro-tated left and sidebent left with standing sacral flexion test posi-tive on left. Patient’s left psoas was tight and hip extension waslimited compared to the right side. Muscle Energy was pro-vided to the left side. Indirect facilitated positional relaxationmethod16 was used on L5, which did not help the dysfunctionmuch. Then patient was given HVLA with lumbar on the sidemethod17 and this corrected both the sacrum and L5. What isworth mentioning here was that ESFT (as applied to the sacrum)was applied to the L5 level and left thumb moved in cephaladdirection. More over, the same test was negative at L4 and up-per spinal levels, indicating a single vertebral dysfunction withL5 SB and rotated to left. Patient complained of a new type ofpain for two days following the manipulation. Patient was alsoinstructed psoas and LBP specific exercises as well as daily walk-ing. In subsequent visits patient was happy with the dose of hisexisting pain medication and felt like he was almost painfree. Hecontinues to drive the cement truck on a daily basis.

Case #2, patient was a 44-year-old white male who works asa forklift operator. His work, with recent addition of new re-sponsibilities, required him to push carts and heavy items on arailway. Patient also complained of LBP for years and admitedthat he had some before his current job. Patient stated that hewas more aware of his pain while standing up, and the pain isslightly on left of his mid-lower back. Eyeballing the hipunlevelling, trochanters, ASIS’s were not conclusive to make adecision. Lateral malelolar comparison with patient in supineposition suggested possible short left syndrome on left. Stand-ing flexion test was positive on left. Palpation of paraspinalmusculature and tissue was inconclusive. However, ESFT ap-plied to lumbar levels was positive on left L5T12. That is, thethumb monitoring showed cephalad motion of left thumb indi-cating a group curve dysfunction and thus defaulting insidebending right and rotation left (Fryette’s Law #1), whichappears to be a compensatory response to a shortleg syndromeon left. Patient was recommended left heel lift, exercises tostrengthen his lower back and paraspinal musculature, as wellas trying to use a rolled up towel when he is resting on his leftside to counter-act convexity of the curve on his left.


Why would one need this sign?First of all, it is more visual and measurable, therefore more

objective and less subjective, compared to existing palpationmethods. It may be used alone or as a supplementary test to theexisting methods.

What is even nicer is that if the dysfunction is on a singlevertebra, the physician gets the information about not only therotation, but also the side bending component of the dysfunc-tion. For example, if one vertebra is sidebent and rotated to thesame side, then it is a neutral dysfunction. Conversely, in a groupcurve, sidebending and rotation will be to opposite sides indi-cating a non-neutral component.

So this could actually speed up diagnostic logic and supportthe proper treatment for the diagnosis.

It is an additional tool for confirmation of visual and palpa-tory exam.

The sign confirms and is in line with the known behavior ofspinal motion, i.e. Fryette principles. Therefore, it also is a use-ful tool in teaching manipulation theory and practice. With thistechnique, it is probably easier to identi0fy group curves as wellas single vertebral dysfunctions along lumbar and lower tho-racic vertebrae. This technique coud be used in the lower tho-racic vertebrae because of the fact that lower thoracic segmentsare more likely to behave like lumbar vertebrae as opposed toupper thoracic segments and that the ribs attached to these seg-ments are floating ribs.

It appears to be vertebra specific but not pain specific. Inother words patient may have a pain in the neck around C4-5but may still have positive lumbar ESFT.

This test may also be one of the most sensitive test to clini-cally diagnose any scoliotic changes, although this needs to beproven.

ConclusionThe movement of the thumb in ESFT can indicate both the

rotation of the vertebrae and the side of sidebending in a verte-bral dysfunction. Depending on how many segments involvedone can also determine the type of dysfunction as classified byFryette. In addition, in a group dysfunction, the apex and vertexsegments can also be more objectively evaluated based on theamount of cephalad movement of the thumb.

The ESFT may be used for investigation of various patholo-gies such as tight psoas on one side, short leg syndrome, trauma,scoliosis, sacroiliac dysfunction, possibly vicerosomatic dys-functions and other compensatory pathologies that involve lum-bar, thoracic and cervical vertebrae.

Naturally a thorough research with more patients is neededto investigate the validity, sensitivity and specificity of this newmethod. As a matter of fact, a myriad of research topics may bedesigned to scrutinize and possibly utilize this technique. Asstated in the beginning of this paper, the goal of this study wasto draw attention to ESFT, create discussion and fuel interestfor further research on the subject, because the use of this methodcan provide more direct and accurate clinical diagnoses as wellas increase the speed of clinical decision making.

References

1 Foundations for Osteopathic Medicine. p 1136. American Osteo-pathic Association. 1997.

2 Nelson, CR. “Postural Analysis and its relation to systemic dis-ease (1948)” pp. 16-19. Postural Balance and Imbalance. EditorBarbara Peterson. AAO. Ohio. 1983.

3. Greenman M. The Principles of Manual Medicine. pp 65-71.221-230. 3rd Edition. 2003.

4. Sutton SE. “Postural imbalance: Examination and treatment uti-lizing flexion tests,” AAO. 1983. Archives. pp. 102-108.

5. Cibulka MT and Koldehoff R. Clinical usefulness of a cluster ofsacroiliac joint tests in patients with and without low back pain. JOrthop Sports Phys Ther. 1999. 29(2):83-89.

6. Karel Lewit and Alois Rosina “Why yet another diagnostic signof sacroiliac movement restriction?” Journal of Manipulative andPhysiological Therapeutics. March/April 1999. 22:3.

7. Sacroiliac joint diagnostics in the Hamburg construction work-ers’ study. R Toussaint, Christian Gawlik, Uwe Rehder andWolfgang Ruther. Journal of Manipulative and PhysiologicalTherapeutics. March/April 1999. 22:3.

8. Ren Toussaint, Christian Gawlik, Uwe Rehder and WolfgangRuther. “Sacroiliac dysfunction in construction workers.” Jour-nal of Manipulative and PhysiologicalTherapeutics. March/April1999. 22:3.

9. Mousavi, SJ. “Interexaminer and intraexaminer reliability of eightsacroiliac joint static and dynamic tests,” Department of physicaltherapy, School of Rehabilitation Sciences, Isfahan University ofMedical Sciences, Isfahan, Iran. Proceedings from PT 2003: TheAnnual Conference and Exposition of the APTA. June 18-22, 2003(Paper No. PL-RR-174-F).

10. Sutton, SE. “Postural imbalance: Examination and treatment uti-lizing flexion tests,” AAO. 1983. Archives. pp 102-108.

11. Greenman, M. The Principles of Manual Medicine. pp. 65-71,221-230. 3rd Edition. 2003.

12. Kimberly, PE. “Outline of Osteopathic Manipulative Procedures.The Kimberly Manual. Chapter 3, pp. 17-35, 63-80, 159-182, 1stprinting. Walsworth Publishing Co. Marceline, Missouri. August2000.

13. Discussion section at 2004 Annual Seminar of American Acad-emy of Osteopathy. Indianapolis, Indiana. August 13-15, 2004.

14. Ren Toussaint, Christian Gawlik, Uwe Rehder and WolfgangRuther. “Sacroiliac dysfunction in construction workers.” Jour-nal of Manipulative and Physiological Therapeutics. March/April1999. 22:3.

15. Nelson, CR. “Postural Analysis and its relation to systemic dis-ease (1948)” pp 16-19, Postural Balance and Imbalance. EditorBarbara Peterson. AAO. Ohio. 1983.

16. Foundations for Osteopathic Medicine. pp 831-841. AmericanOsteopathic Association. 1997.

17. Foundations for Osteopathic Medicine. pp. 679-683. AmericanOsteopathic Association. 1997.

Accepted for publication:January 2005

Address correspondence to:Paul T. McTurk, DOHalina H. Harding, DOWestview Osteopathic HospitalFamily Medicine Residency Program3630 Guion RoadIndianapolis, IN 46222


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(Special emphasis on Cervical and thoracic spines, ribcage,shoulder, elbow, wrist and hand.


IntroductionMotor neuropathies include a wide

spectrum of clinical presentations and anextensive differential diagnosis. Muscleweakness commonly occurs in patientswith an attack of Acute Intermittent Por-phyria (AlP) and clinical presentation canmimic Guillain-Barré Syndrome.1 BothAlP and Guillain-Barré Syndrome (GBS)can be preceded by abdominal symptomsthat are followed by a progressive motorparalysis with or without sensory distur-bance and including some respiratoryparalysis.2 The pathologic changes havebeen described as either peripheral de-myelination (GBS) or axonal degenera-tion (AIP).2 Cohen et al. describes a pa-tient with AlP that presented with severebilateral leg pain and weakness, whichprogressively worsened3; however thereis little in the literature to discuss the re-habilitation procedure necessary for man-agement of long term weakness or painfollowing attacks of AIP.

The following case represents an in-teresting incorporation of both the diag-noses of GBS and AIP. Refractory to theprimary treatment for GBS and positiveurine analysis for porphyria, it is stillunclear the exact cause of his symptoms.None the less, the patient possesses a pro-found debilitating pain that remains fol-lowing initial acute peripheral motor neu-ropathy presentation five years ago. Lit-erature is lacking with regards to the re-habilitation benefits of osteopathic ma-nipulative medicine in such complicatedcases where standard modalities of treat-ment provide little relief of pain.

Case ReportA 40-year-old Caucasian male and

former boxer, reports to the OsteopathicManipulative Medicine Clinic in a wheel-chair with a chief complaint of bilateralpain in the hips, thighs, lower legs withsome radiation to low back. He describesa progressive, constant, debilitating,burning (sometimes sharp) pain that be-gan in April 1999, following gastrointes-tinal illness and pain. At that time, he hada sudden onset of sharp pain in his rightcalf followed by a loss of sensation ofboth feet over 4-5 days, which then pro-gressively spread proximally. He wassubsequently admitted to the hospital forfive days observation, following progres-sive paralyzation including respiratorydifficulty without subsequent intubation.During this hospitalization, he was diag-nosed as having Guillain-Barré Syn-drome, although cerebral spinal fluid(CSF) failed to demonstrate elevation inprotein without accompanying pleocyto-sis. Following discharge, patient subse-quently failed intravenous immunoglob-ulin therapy in an outpatient setting withcomplaints of fever, diaphoresis, and dif-fuse body aches. Patient also receivedgabapentin (Neurontin) without any re-lief. Three months following initial pre-sentation, the patient received carisopro-dol (Soma) and amitriptyline (Elavil)which lead to a profound regression inhis condition. After stopping all medica-tions, he was found to be porphobilino-gen positive on urine analysis and wasdiagnosed with Porphyria. The patient’scurrent medications include buproprion

(Wellbutrin) and ibuprofen (Motrin).Electromylogram (EMG) studies weredone at the onset of disease and werefound to show abnormal neuromuscularactivity. Repeat studies done in 2002,three years following initial presentation,showed restoration of neuromuscularfunction. The patient currently, five yearspost initial presentation, describes a re-turn of sensation and motor function witha decrease in strength; however he de-scribes a profound debilitating pain thatmakes daily functions difficult. Formerlyemployed as a technician for Motorola,he is currently drawing disability follow-ing the onset of his current diagnosedmedical conditions. He reports the painis unrelenting and is worse with pro-longed standing or sitting. As a result ofhis pain, he has remained wheelchairbound even though he is able to walk withthe assistance of a cane. The use of thecane is complicated by bilateral carpaltunnel syndrome which limits his toler-ance. The patient further reports that herecently was given bilateral lidocaine in-jections by a physiatrist in his trochant-eric bursa five days prior to his initial con-sultation at the OMM clinic. The patientclaims that the injections have given hima fair amount of relief in his hips andthighs. He denies any other treatment thatgives him any significant relief, and dueto his porphyria he is very limited in ac-ceptable pain medications. The patientfurther claims sensitivity to sunlight ifexposed for prolonged periods of time.Past medical history is significant forfractures to the right wrist and humerus.

Acute Intermittent Porphyria Mimicof Guillain-Barré Syndrome:A Case Report with the Useof Osteopathic Manipulationfor Management of PainE. Ryann McClennen and Russell Gamber

➻


Additionally, due to his history of being aboxer, the patient has bilaterally fracturednearly all bones in his hands. He sufferedhead and left arm trauma following a mo-tor vehicle accident in 1995. The patientfurther claims being hit by a car as a childwhile riding his bike and being thrown intothe windshield. He also has a history ofright knee and lumbar trauma and gall-bladder surgery in 2002. The patientstopped smoking in 1997 and currentlydenies any use of alcohol or any knowndrug allergies. He is currently under thecooperative care of his primary care phy-sician, pain management specialist, neu-rologist, and physiatrist.

Physical Examand Treatment

The patient had significant difficultytolerating the initial exam due to increas-ing discomfort during the exam. Reflexeswere intact bilaterally in both the upperand lower extremities. Muscle strengthwas diminished to one out of five bilater-ally in the lower extremities and four outof five bilaterally in the upper extremities.Fine touch and pin-prick sensation to theupper and lower extremity were intact bi-laterally. On his initial visit, his pain wasa four out of ten; however this was fivedays post lidocaine injections to his tro-chanteric bursa. His cervical spine, C3 wasrotated left, side bent left (R1S1) and thethoracic spine, T3 and T4 was side bentright, rotated left (SrR1). There were bi-lateral tenderpoints at the sacrotuberousligament, sacroiliac joint and iliolumbarligament (particularly on the right). Addi-tionally, there was a tender point at L5-S1.There were also bilateral tender points atthe piriformis muscle. In the upper ex-tremities there was bilateral carpal tunneltightness and in the lower extremities theleft leg malleolus is 1/4" longer than theright. Myofascial release and strain/counterstrain OMT were performed on theabove dysfunctions and somatic dysfunc-tions improved following treatment. Thepatient was also educated in self-treatmentof tender points and stretches to dothroughout the day. On the following re-turn to clinic, the patient reported signifi-cant pain for the five days (eight out often) following treatment, however he didnotice some increase in mobility and im-provement in overall pain. During this visit

he was again noted to be R1S1 at C3-4and side bent left, rotated right (S1Rr) atT6-8. The patient had bilateral tenderpoints at iliolumbar ligament, sacrotuber-ous ligament, sacroiliac joint and pirifor-mis muscles. Additionally, there was againa tender point at L5-S1. Furthermore, hehas bilateral carpal tunnel tenderness, calfmuscle, Achilles tendon and arch of hisfoot tender points. Again myofascial re-lease and strain-counterstrain OMT wereperformed with relief of somatic dysfunc-tion. On a third subsequent visit, the pa-tient states that he felt there has been smalloverall improvement since the start oftreatment. He feels he has “good days” and“bad days”. He continues to stretch andwas again reminded of the importance ofregularly releasing his own tender points.During this visit his cervical C3-4 are RlSl

and thoracic vertebrae T3-5 are SrRl. Thepatient again presents with a tender pointsat his right sacroiliac joint, piriformismuscle and calf muscle. Overall, his bodyappears to have less somatic dysfunctionthan his initial presentation less than onemonth prior. The same therapeutic regimewas again followed during this visit andthe patient was instructed to follow-up inthe clinic in three weeks.

DiscussionAlthough the above case presentation

was initially diagnosed with GBS, it ispossible that his current manifestations areactually remnants of an acute intermittentporphyric attack. Millward et al. reportsthat many porphyria patients have an av-erage time of six years from the onset ofsymptoms to diagnosis.8 Additionally,there is currently no reliable serologicalmarker for GBS and disorders that mimicGBS include various neurotoxins, heavymetals, chemical toxins, drugs, vasculitis,hereditary disorders (AIP), infections,critical illness, and myelopathy.5

Acute Intermittent Porphyria (AIP),the most common of the inherited dis-eases of porphyrin metabolism, is anautosomal dominant condition causedby a defective allele for porphobilino-gen (PBG) deaminase, a componentnecessary for heme biosynthesis. Mostheterozygotes remain asymptomaticunless exposed to factors that increasethe demand for hepatic heme. Alcoholingestion, low-calorie diets, endog-enous and exogenous steroids, and a va-

riety of drugs can be precipitating fac-tors (Table I).

The major manifestations of the hepaticporphyrias include neuropathic abdomi-nal pain, neuropathy, and mental distur-bances, although the pathogenesis forthese problems is poorly understood.2

Abdominal symptoms are often the firstcomplaint and may include nausea, vom-iting, constipation or poorly localizedcolicky pain.4 Abdominal symptoms areneurologic rather than inflammatory andabdominal tenderness, fever, and leuko-cytosis are usually absent or mild.2 Periph-eral neuropathy is due to axonal degen-eration and primarily affects motor neu-rons.5 Often the first symptoms occur inthe arms, motor neuropathy affecting theproximal muscles first2; although distallower extremity presentation does not ex-clude diagnosis. Although the majority ofneuropathies associated with metabolicprocesses are categorized as diffuse sym-metrical axonal damage with most severedamage usually being associated with thelongest and most distal axons.11

Electrodiagnostic findings usually showactive denervation with profuse fibrilla-tion potentials.12 AIP can have a diffusepresentation of symptoms. Andersson etal. describes a patient who presented withprogressive paresis in arms and hands; shedropped things, could not extend her fin-gers and could not write.6 Cohen et al.describes another porphyria patient whopresented with recurrent severe leg painand weakness. Additionally, progressivemuscle weakness can lead to respiratorydifficulties.2 AIP is commonly seen in as-sociation with dysautonomia, chiefly au-tonomic over-activity. These symptomsfrequently include: abdominal colic, hy-pertension, and tachycardia.7 Neuropsy-chiatric manifestations of AIP can includeanxiety, insomnia, depression, disorienta-tion, hallucinations, and paranoia duringacute attacks.2 After an attack resolves, ab-dominal pain may disappear within hours,and paresis begins to improve within daysand may continue to improve over sev-eral years.2 Severe porphyrias have had re-current attacks with differing degrees ofseverity over a long period of time. Addi-tionally, according to Millward et al., qual-ity of life is lower in AIP. Patients surveyedhad major life consequences including afailure to secure or loss of employment.8

Furthermore, indescribable, severe physi-


cal pain was discussed in Wikberg et al.,in association in women with recurrentAIP attacks.9

Pain is a common and difficult prob-lem to treat in peripheral neuropathies.Analgesics are often ineffective againstperipheral neuropathic pain; therefore,the first line of treatment includes tricy-clic antidepressants or trazodone. Secondline treatment can include carbamazepineor gabapentin.10

Table I. Drug recommendations for patients with acute porphyric disorders

Contraindicated (Unsafe) Indicated (Safe)

Alcohol AcetaminophenAmitriptyline Acetylsalicylic acidAmphetamine AcyclovirBarbiturates AmphotericinCarbamazepine Ascorbic acidChloroform HCL AtropineClonazepam AzathioprineClonidine BeclomethasoneDapsone BupivacineErythromycin CephalosporinsEstrogen Chloral hydrateEtidocaine CholpromazineFlurazepam CodeineHydantoin DexamethasoneGlutethimide DiazepamImipramine DiflunisalLidocaine DiphenhydramineMepivacaine FentanylMeprobamate Folic acidMethyldopa GentamicinMetoclopramide GuanethidineMiconazole IbuprofenOral Contraceptives (some) IronOxazepam LithiumOxycodone MeperidinePentazocine MorphinePhenacetin NeostigminePhenobarbital Nitrous OxidePhenytoin Sodium (Dilantin) NortriptylineSulfonamides PenicillinsThiopental Sodium PhenothiazinesTranylcypromine ProcaineTrazodone HCL PropanololValproate Reserpine

StreptomycinSuccinylcholineTetracaineTrifluoperazine

Moore et al. Acute Porphyric Disorders. Oral Surgery, Oral Medicine, Oral Pathology.September 2000. 90:3:257-62.

Traditionally, treatment for neuro-pathic pain becomes extremely compli-cated in the case of AIP patients. The firstand second line treatments are contrain-dicated with a porphyric condition andcan perpetuate or exacerbate a currentattack.4 This then becomes an excellentopportunity for Osteopathic ManipulativeTherapies to profoundly benefit patientsin AIP.

OMT techniques are based on treat-

ing the articular, circulatory, immuno-logic, myofascial, neurologic and visceralramifications of somatic dysfunction.Somatic dysfunction is defined as im-paired or altered function of related com-ponents of the somatic system. Directtreatments (i.e. high-velocity-low- ampli-tude (HVLA), muscle energy, myofascialrelease, and cranial) engage a restrictionbarrier while indirect treatments (i.e.strain-counterstrain, facilitated positionalrelease, myofascial release, and cranial)take the patient away from a barrier in anattempt to reduce tension to a minimum.The patient presentation delegates whichtreatments or combinations of techniquesare used. Typically, for patients with se-vere, intense pain, indirect techniques arepreferred.13

It has been postulated that the hyper-tonicity of acute somatic dysfunction isdue to the increased rate of firing of sym-pathetic fibers as a result of increasedvisceral pain, maintaining the muscletone at the level of the segment involved.The strain-counterstrain approach allowsfor major dysfunction areas relating to thepain complaint to be discovered, i.e.tenderpoints. The treatment also worksto overcome the abnormal flow of affer-ent impulses in the involved musculaturewhich have fixated joint motion main-taining the dysfunction. The mechanismof action is believed to be that of reset-ting abnormal efferent and afferent ap-paratus: the alpha-gamma fiber loop.With pain reduction, exercise and rangeof motion techniques can be introducedwhich further increase the patient’s re-habilitation.14

Fascia, the connective tissue through-out the body, increases proportionatelywith tension force or mechanical require-ments; sustained tension can lead to fas-cial thickening and shortening. Entrap-ment of venous blood and lymph vesselsin the fascial restrictions, due to changesin muscle activity and fascial tension,leads to chronic passive congestion,edema, pain and eventual fibrosis. Myo-fascial release techniques produce a bal-ancing of various proprioceptors, Golgitendon organ apparatus and musclespindle, to lengthen muscles through re-lease of fascial restrictions. With releaseof restrictions in addition to local tem-perature increases, lymph flow and

➻


venous return of blood is enhanced whichfurther perpetuates the natural healing ofthe body in the areas of dysfunction. In theAlP patients, myofascial release of restric-tions would promote axonal regenerationand aid in relieving pain. Additionalstretching exercises and strengtheningroutines promote healing and encouragecontinued range of motion improvementto facilitate a shorter recovery time. Allin all, OMT provides a variety of addi-tional modalities for treatment in the AlPpatient when pharmacological manage-ment becomes difficult. The above pa-tient continues to improve with eachtreatment and hopefully will continue toprogress towards his goals of regainingstrength and pain management.

References1. King PH, et al. Porphyria presenting with

bilateral radial motor neuropathy: Evi-dence of a novel gene mutation. Neurol-ogy. 2002. 58:1118-1121.

2. Desnick R. The Porphyrias. In D.Kasper, et al. (Ed.), Harrison’s Prin-ciples of Internal Medicine. 2005: 16th

ed. New York. McGraw-Hill.

3. Cohen PL, et al. Acute intermittent por-phyria presenting as acute muscle pain,fever, and weakness. Arthritis and Rheu-matism. 1997. 40(3):586-7.

4. Moore AW, et al. Acute porphric disor-ders. Oral Surgery, Oral Medicine, OralPathology. 2000. 90:257-62.

5. Levin K. Variants and Mimics ofGuillain-Barré Syndrome. Neurologist.2004. 10:61-74.

6. Andersson C, et al. Atypical attack ofacute intermittent porphyria-paresis butno abdominal pain. J of Internal Medi-cine 2002. 252:265-70.

7. McDougall AJ, McLeod, JG. Autonomicneuropathy, II: Specific peripheral neu-ropathies. J of Neurological Sciences1996. 138:1-13.

8. Millward, LM, et al. Self-rated psycho-social consequences and quality of lifein the acute porphyrias. J Inherit. Metab.Dis. 2001. 24:733-47.

9. Wikberg A, et al. Women’s experienceof suffering repeated severe attacks ofacute intermittent porphyria. J of Ad-vanced Nursing. 2000. 32(6):1348-55.

10. Bushbacher L. Rehabilitation of patientswith peripheral neuropathies. In R.Braddom et al. (Ed.), Physical MedicineandRehabilitation. 2000: 2nd ed.; Phila-delphia: W.B. Saunders Co.

11. McDeavitt JT. Evaluation of

Nonentrapment Neuropathies. InGrabois et al. Physical Medicine andRehabilitation: The Complete Ap-proach. 2000. Massachusetts.Blackwell Sciences, Inc.

12. Léger, JM and Salachas F. Diagnosisof motor neuropathy. European Jour-nal of Neurology. 2001. 8:201-8.

13. Nicholas A, et al. Osteopathic Manipu-lation for management of pain. JAOA.1999. 99(6):S5-10.

14. Jones LH, et al. Jones Strain-Counterstrain 1995: Boise: JonesStrain-Counterstrain, Inc.

15. Cooper G. Some Clinical Consider-ations on Fascia in Diagnosis and Treat-ment. JAOA. 1979. 78:336-47.

Accepted for publication:September 2004

Address Correspondence to:E. Ryann McClennen, OMS-IIIRussell G. Gamber, DO, MPHDept. of OMMUNTHSC at Fort Worth/TCOM3500 Camp Bowie Blvd.Fort Worth, TX 76107

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Faculty PositionsKirksville College of Osteopathic Medicine,the founding college of osteopathic medi-cine, seeks physicians to fill clinical facultyvacancies for the department of Osteopathic

Manipulative Medicine. Faculty responsibilities includecourse development, instruction, research, and student ad-visement. Qualified candidates will be board certified or boardeligible, with teaching experience preferred. On the cuttingedge of osteopathic medical education, there is a wealth ofopportunity for faculty to grow professionally while usingthe latest instructional technology. In addition, faculty mem-bers participate in a wide variety of clinical activities, whichmay include hospital consultation and treatment, specialty,outpatient care, nursing home and senior care, and mentoringof residents and osteopathic medical students. This personwill have a faculty appointment in the department of OMMfor A. T. Still University of Health Sciences at its KirksvilleCollege of Osteopathic Medicine.

Academic rank and salary will be commensurate with cre-dentials and experience. Application review continues untilpositions are filled. Please send letter of interest, curriculumvitae, and 3 references to:

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[email protected]

Equal Employment Opportunity Employer


Book ReviewReviewer: Anthony G. Chila

A Physician’s Guide to Billing and CodingDouglas J. Jorgensen, DO, CPCRaymond T. Jorgensen, MS, CPCpp. 165, incl. Index. (c) 2004 by Douglas J. Jorgensen, DO, CPC and Raymond T. Jorgensen,MS, CPC. ( www.academyofosteopathy.org) $25.00

The authors provide guidelines, recommendations and interpretations to be used as a guide forimplementation in individual practice(s). The approach utilized offers the best evaluation and man-agement (E&M) recommendations to date, conservatively presented and remaining within federalguidelines. Emphasis is placed on the fact that correct coding can arise from observing a few simplerules and is not difficult to accomplish. Eight chapters cover the following topics: Current ProceduralTerminology (CPT); International Classification of Diseases (ICD); Evaluation and ManagementServices and the Federal Documentation Guidelines; The History; The Physical Examination; MedicalDecision Making; E&M Code Selection; Charge Setting.

In addition to very readable explanations of the significance of the various topics, historical reviewsare often provided, as well as discussions about the progression of thought associated with each. Theconciseness with which all of this is accomplished makes this volume a small but very powerful aid tothe successful management of today’s complex health care provider environment. Strongly recom-mended for a happier and more successful practice.

A Second VoiceA Century of Osteopathic Medicine in OhioCarol Poh Millerpp. 161, incl. Index. (c)2004 by Ohio University Press (www.ohio.edu/oupress). Cloth, $49.95;Paper, $24.95.

The rapid growth and expansion of the osteopathic profession during the last quarter of the 20thcentury is occasion for pause and reflection. This volume offers that opportunity. For many years, thestate of Ohio has been among the top 3 states in relative strength of osteopathic medicine. As is trueof other states, the profession’s history in Ohio has been characterized by unity, leadership, the passingof leaders and the contemporary economic change in the landscape. Through an extensive search andselection process, the charge to the author was “to write a scholarly, objective history that would bethoroughly documented, factually accurate, and readable-a work written to appeal not only to D.O.’s,their employees, and their patients, but also to the educated general reader.” As acknowledged by theauthor, “Writing this history required substantial self-education.”

Six chapters describe: Pioneers; The Struggle for Recognition and Equal Practice Rights; MovingForward; Postwar Strides and Setbacks; An Ohio College of Osteopathic Medicine; A Second Voice.Appendices provide: Timeline of Osteopathic Medicine in Ohio; Presidents of the Ohio Osteopathic


Elsewhere in Print

SKIN RESISTANCE vs. BODY CONDUCTIVITY:On the Background of Electronic Measurement on SkinSubtle Energies & Energy Medicine: Volume Fourteen, Number Two; 151-174Chang-Li Zhang: College of Life Science, Zhejiang University, Hangzhou 310028, China or: Facbbereich 4, SiegenUniversity, D-57086 Siegen, Germany

Electronic measurement of the acupuncture system is discussed by the author. Initial acknowledgment of the continuingstubborn challenge to established scientific knowledge is coupled with the absence of anatomic evidence. The author suggeststhat if acu-meridian and Qi really exist, then revision of modern scientific views of body-mind is clearly in order. The clinicalsuccess of the acupuncture system requires research for better understanding of the old medical model as well as the develop-ment of modern science itself.

Various critical problems of electronic measurements on the acupuncture system are discussed: Size, shape, location andstability of acu-points and acu-meridians; violent fluctuation of measurement data; transmission and speed of signal alongmeridians; parallel distributions between higher-conductivity and higher sound intensity points; mathematical background oflog-normal distribution of measurement data.

Ten experiments are described which were involved with questioning the terminology “Skin Resistance”. An example isExperiment 3, which considered the movement of acu-meridian and acu-point on a large scale. Consideration is given to theobservation that landscape conductivity on skin having some correlation with the acupuncture system is dynamic and not fixed;great change may be noted in some special pathological, physiological or psychological conditions. It has been observed that“sensation propagation” usually coincidental to acu-meridians can have large variations in special pathological states. Thisphenomenon can be objectively electronically measured. Rapid changes in “skin resistance” can occur during a needlingoperation. The summary of Experiment 3 indicates that “The large scale movement of acu-meridians and acu-points tells us thatthe acupuncture system is not some fixed network like the blood vessel network or nerve fiber network, but something which isa dynamic structure. In the normal state of a body-mind system, the structure is relatively stable. The outline of the relativelystable structure was somehow discovered by ancient people and roughly described in the theories of acupuncture and ayurvedaas an acu-meridian network and chakras.

Further analysis of measurements considered: Skin layers and the reading of electronic measurement; Conductivity vs.Resistance; Acupuncture System and Heterogeneous Distribution of the Electromagnetic Field; The Source of the Heteroge-neous Distribution of the Electromagnetic Field Inside a Body; The Relationship Between the Inner Electronic Field and OutsideRadiation; Mathematical Background of the Statistical Behavior of Measurement Data; The Rough Picture of the InvisibleDissipative Structure.

Emerging conclusions of this extensive effort suggest that the invisible dissipative structure of electromagnetic fields arechiefly composed of an interference pattern of standing waves in the resonance cavity of the human body under condition ofpermanent support of energy in an open system. To some extent, this corresponds to the acupuncture system and carries closerelationship to many energetic medicine systems. This in turn offers a new understanding of the background of acupuncture aswell as other branches of holistic medicine. Not least, a scientific and quantitative way to evaluate the degree of coherence(harmony) of a body-mind system.

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Clinical Specialist in the Department of Osteopathic Manipulative Medicine

The University of New England College of Osteopathic Medicine (UNECOM) invites applications for Clinical Specialist in Osteopathic Manipulative Medicine. This individual will hold the appointment in the Department of Osteopathic Manipulative Medicine, and at Maine Spine and Rehabilitation, a multi-discipline practice including neurosurgery, orthopedics, physiatristy and osteopathic medicine. This position involves patient care, precepting residents, and teaching medical students.

The successful applicant will have a D.O. degree and profi ciency in OMM/NMM, particularly in the management of neuro-musculoskeletal problems. Board Certifi cation or eligibility by the AOBNMM or AOBSPOMM is required.

The University of New England has a competitive salary and benefi ts program that includes immediate vesting in a pro-gressive 403B retirement program, well funded insurance benefi ts, and free tuition for dependants at over 250 consortium colleges/universities.

Salary for this position will be commensurate with experience and qualifi cations. To inquire further about the position, please contact:

Jane Carreiro, D.O.Department Osteopathic Manipulative Medicine

University of New England11 Hills Beach Road

Biddeford, ME [email protected]

University of New England is an equal opportunity/affi rmative action employer and welcomes minority candidates. Please visit our website at www.une.edu

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