Mark. S. Cantieri, DO, FAAO Receives 2006 Thomas L. Northup...

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tradItIon shapes the Future Volume 17 number 1 march 2007

Mark. S. Cantieri, DO, FAAO Receives 2006 Thomas L. Northup Award

�/The AAO Journal March�007

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

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In thIs Issue:AAOCalendarofCourses...................................................................................4Contributors.........................................................................................................6ComponentSocieties’CMECalendar...............................................................11

edItorIal

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

regular Features DigOn............................................................................................................7 FromtheArchives........................................................................................10 BookReview.................................................................................................30 ElsewhereinPrint.........................................................................................31

2006 thomas l. northup lectureTeaching Osteopathic Principles in an Allopathic Environment:Osteopathic Guerrilla Warfare..........................................................................1�

MarkS.Cantieri,DO,FAAO

scIentIFIc paper/thesIs (Faao)Counterstrain Tender Points as Indicators of Sustained Abnormal Metabolism: Advancing the Counterstrain Mechanism of Action Theory..............................16PaulR.Rennie,DO,FAAO

InternatIonal communIcatIonAtributetoJohnWernham,DO,FICO,FCO....................................................�5AnthonyG.Chila,DO,FAAO

student physIcIanManagementofPepticUlcerDiseaseUsingOsteopathicManipulation......... �6HeatherDanielleMorris,OMSIVandJerryL.Dickey,DO,FAAO

tradItIon shapes the Future • Volume 17 number 1 march 2007

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, emphasizing the integration of osteopathic principles, practices and manipulative treatment in patient care.

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4/The AAO Journal March�007

American Academy of Osteopathy®

Calendar of Events• March19-�1 Visceral/Manual-ThermalinColoradoSprings KennethE.Lossing,DO,ProgramChair

• March�1 Facilitated Positional ReleaseinColoradoSprings StanleySchiowitz,DO,FAAO,ProgramChair NEW 6-Hour Course

• March�1-�5 AAO ConvocationinColoradoSprings GeorgePasquarello,DO,FAAO,ProgramChair

• April�7-�9 Osteopathic Treatment of Headache atPCOM DennisJ.Dowling,DO,FAAO,ProgramChair

• June(daysTBD) Muscle Energy-Counterstrain atPCOM/GeorgiaCampus WalterC.Ehrenfeuchter,DO,FAAOandEdwardK.Goering,DO

• July13-15 The Golden Opportunity: Three Masters of Osteopathy in the Cranial FieldatCCOM StephanieWaecker,DO

• August/September(exactdatetobedetermined) Still Technique: A Rediscovered Technique of A.T. Still, MD (placetobedetermined) RichardL.VanBuskirk,DO,FAAO

• September�9 One-daycourse:OMT without an OMT Table inSanDiego AnnL.Habenicht,DO,FAAO

• September30–October4 AOA Convention: AAO program: Adjuncts to OMT in the Treatment

of Chronic PaininSanDiego JohnE.Balmer,DO,ProgramChair

• November(datestobedetermined) Prolotherapy Weekend for ALL Levels and ExperienceatUNECOM MarkS.Cantieri,DO,FAAO

• December1-3 Visceral Manipulation: Colon inSanFrancisco KennethLossing,DO

the brentwood center oF excellence

presents

The BrentwoodOMT Skills Series

Muscle Energy Technique (MET)Faculty:

FredL.Mitchell,Jr.,DO,FAAOJaySandweiss,DO,C-NMM/OMM

KaiMitchell,CMT

Part II:Thoracic & RibsMay 19-20, 2007

Part III:Lumbar, Sacrum/Pelvis

October 6-7, 2007

Part IV:Extremities

November 10-11, 2007

Location:SouthPointeHospital

WarrensvilleHeights,OH

Course Objectives:•Todefineandintroducefoundational conceptsandmechanismsofMET.•To understand the scope in practice of

theMETparadigmandhowitrelatestoothermanualtherapymodalities.

•Toreviewtheanatomyandbiomechan-icsofmultiplebodyregionswithspecialemphasisonthoseelementsastheyper-taintotheapplicationofMET.

•To describe how the tonic and phasicmusclesof thebodyareorganizedana-tomicallyandphysiologically.

•Todefinesomaticdysfunctionrelativetothespecificbodyregions,andtoelu-cidatethedynamicrelationshipbetweenthosesomaticdysfunctionsandotherregionsofthebody.

•Todescribeatleasttwowaystotestandtwowaystotreateachsomaticdysfunc-tion.

•TodemonstratenewapplicationsofMuscleEnergyTechnique.

For more informationcontact the course coordinator:

Dr. Jay Sandweiss at (734) 995-1880


View from the Pyramids

Anthony G. Chila

Asreadersofthisjournalarebynowaware,changeineditorialleadershipisforthcoming.OnDecember�0,�006,Isubmit-tedmyletterofresignationasEditor-in-Chief,theAmerican Academy of Osteopathy JOURNAL (AAOJ) toPresidentKennethH.Johnson,DO,FAAO.TheresignationfollowedmyacceptanceofthepositionofExecutiveEditor,Foundations for Osteopathic Medicine, 3rd Edition. Inothercommunicationandpublications,interestedindividualshavebeenencouragedtosubmitapplica-tionforconsiderationtocontinueservicetotheAAOJ.

Myservicebeganintheyear�000(Volume10,Number1,Spring�000).ConsecutiveyearsofserviceinthiscapacitywillconcludewithVolume17,Number�,June�007.AshasbeennegotiatedwiththeAmericanAcademyofOsteopathyBoardofTrustees,serviceinthispositionisdefinedasatermof3years,reappointmentsubjecttoapprovaloftheBoardofTrustees.Mytenure,then,representstwocompletedterms(�000-�00�,�003-�005)andone-halfofathirdterm(January�006-June�007).AccordingtopreviousactionoftheBoardofTrustees,mysuccessor,afterselectionandappointment,wouldinitiallyservethebalanceofmyincompletethirdterm.

Duringmytermsofservice,thefollowingrequirementshavebeenfulfilled:•Servicewithoutcompensation•Acceptanceofthree-yeartermsofoffice•Publicationofaquarterlyjournalwithintheannualbudgetappropriation•Solicitationofcontributions•Peerreviewofsubmissions•Selectingandeditingfinalmaterialforpublication•WorkingwithAAOstaffregardingcolumns,proofingandpublicationdeadlines

Throughmyinitiatives,thefollowinghavebeenaccomplished:•ReorganizationoftheAAOJMasthead•ImplementationofanEditorialAdvisoryBoard•ImplementationofCMECredit(1HourII-B)•Implementationofcategoriesofpublication:

•ScientificPaper/Thesis(FAAO)•OriginalContribution•ClinicalPractice•TheStudentPhysician• InternationalCommunication

Implementationofeditorialcolumns:•ViewfromthePyramids•Contributors•DigOn•BookReview•ElsewhereinPrint

Retentionofeditorialcolumns:•FromtheArchives

AssignmentofcopyrightformaterialspublishedintheAAOJ

Duringmyyearsofservice,supportfromthestaffoftheAmericanAcademyofOsteopathyhasbeengenerousandunlimited.IamcertainthenextEditor-in-Chiefwillfindthistobetrue.Asthepageturns,allofuswhoareinvolvedinthefunctionsoftheAmericanAcademyofOsteopathywill,hopefully,continuetobesupportiveofthisvehicleofcommunication.Inatimewhenpublicationsareexperiencinggreatcompetitiveandfinancialdemands,definingandsustainingapublicationbecomesamatterofgreatorganizationalpriority.

Ithasbeenaprivilegetoserve.

Turning the Page


Contributors Regular FeaturesMark S. Cantieri. Teaching Osteopathic Principles in

an Allopathic Environment: Osteopathic Guerrilla War-fare. The34thThomasL.NorthupLecture(�006)addressesamajorchangeincontemporaryosteopathiceducation.Theproblemanalyzedbytheauthoristheincreasinglyfrequentconductofosteopathiceducationininstitutionshavinglittleornoexperiencewithsuch.FollowingtheadmonitionsofSunTzu(The Art of War) ,astrategyisproposedforthechang-ingeducationalenvironmentwhichconfrontstheosteopathicprofession. (p. 12).

Paul R. Rennie. Counterstrain Tender Points as Indicators of Sustained Abnormal Metabolism: Advancing the Counterstrain Mechanism of Action Theory. ThisScientificPaper/ThesiswassubmittedinpartialfulfillmentofrequirementsforFellowshipintheAmericanAcademyofOs-teopathy.TheauthorwasconferredstatusasFellowin�006.ThetraditionaltheoryoftheCounterstrainModelassertsthatabnormaltoneismaintainedbythemusclespindle.Theauthorenlargesconsiderationstorevieweffectsonmusclemetabolismfrominjury,andtheresultantforcesplacedonallstructuresassociatedwithmuscle.Theanatomicalconsistencyoftenderpointsandmotorpointlocationsarealsoexplored.(p. 16).

International Communication: John Wernham, DO, FICO, FCO (1907-2007). Thisiconicindividualwaschar-acterizedbyhisadherenceto“ClassicalOsteopathy”.ThetouchstoneforhislifelongcommitmentwasgroundedintheteachingofJohnMartinLittlejohn.Wernham’slife,teach-ingandpracticeprovidedacontinuityofthoughtreferabletonearlyacenturyofosteopathicexistence.(p. 25).

Heather Danielle Morris and Jerry L. Dickey. Manage-ment of Peptic Ulcer Disease Using Osteopathic Manipula-tion. Case Report. Theauthorspresentanoverviewofpepticulcerdiseasewithconsiderationgiventogeneralmedicalandosteopathicmedicalviews.DetailedconsiderationofstructuralinfluencesanddietaryinfluencesguidedtheuseofOsteopathicManipulativeTreatment.(p. 26).

DIG ON. Criticismofthelackofosteopathicresearchinsupportofitspremisesseemsnotconfinedonlytotheprofes-sionintheUnitedStates.IntheUnitedKingdom,“Asystem-aticreviewofsystematicreviewsofspinalmanipulation”hasbeenpublishedinJ R Soc Med �006;99; 19�-6.Theauthors,ErnstandCanter,concludedthatspinalmanipulationisnoteffectiveforanycondition,andthat“spinal manipulation is not a recommendable treatment”. WidepublicitywasgivenintheUK.TheresponsegivenbyNicholasP.LucasandRobertW.Moran(Editorial/International Journal of Osteopathic Medicine 9 (2006) 75-76) meritstheattentionoftheAmericanaudience.(p. 7)

FROM THE ARCHIVES. A Personal Note waswrittenbyJohnWernham.FortheAmericanaudience,thisisarareportraitofoneoftheosteopathicprofession’sverysignificantearlyfigures,JohnMartinLittlejohn.FortheEuropeanandAmericanaudiences,thisnoteservesasareminderoftheWernhamlegacyinperpetuatingthememoryofhismentor.Wernham’sdedicationindoingso,untilhispassingonFebru-ary9,�007,hasgivenusalltheopportunitytoberemindedoftheearliesteffortsofStillandLittlejohninevolvingthephi-losophyandteachingoftheosteopathiccurriculum.(p. 10).

CME CREDIT. Inresponsetoreaderrequests,AAOJ willofferCMECredittoreaderscompletingtheenclosedquiz.Atthistime,1HourII-BCreditwillbeoffered,withrequestforupgradeasAAOJ qualificationsarereviewedbytheAmerican Osteopathic Association. (p. 23).

BOOK REVIEW. Tworecenttextshavebearingonthetreatmentofsomaticdysfunction.Neural Therapy: Applied Neurophysiology and Other Topics (RFKidd)elaboratesanapproachtoaddressingfociofelectrophysiologicalinsta-bility.Somatic Dysfunction in Osteopathic Family Medicine (KENelson,TGlonek)offersacontemporaryunderstandingofosteopathicphilosophy,applieddiagnosisandtreatment.(p. 30).

ELSEWHERE IN PRINT. Inthissurvey,readerscan:ExploreThe Cutting Edge (Where Practice, Science and Con-sciousness Merge);AppreciatethenotionthatantisenseRNAorDNAcouldblockmRNAtranslationintoprotein;Becomeawareofpotentialcontemporaryusesforasubstancehavingamedicinalhistoryatleast5,000yearsold. (p. 31).


Dig On

➝

Asaprofessionworkinginanenvironmentwherehealth-carepolicyisdeterminedbyacuriousblandofscienceandpolitics,wecan’tescapenumbersrappedupinstatistics.Manyindividualpractitionersmightbeabletoavoidstatisticsentirely,however,thisisaluxurynotaffordedtothosewhorepresenttheprofessiontothirdpartiessuchasresearchers,university,healthinsurancecompanies,governmentagencies,andimportantly,themedia.Oneofthereasonwecan’tescapenumbersisbecausetheyhelpsummarisetheeffectivenessofourinterventions.Effectivenessisimportantbecause,withfewexceptions,consumersdon’tenjoypayingforhealthcareservicesthatfailto‘workasadvertised’.

ArecentandprominentexampleoftheimportanceofeffectivenessdatawasthepublicationinAprilbyErnstandCanterofasystematicreviewofsystematicreviewsforspinalmanipulationintheJournal of the Royal Society of Medicine,1andtheensuingflurryofmediaattentionthearticleattracted.Theconclusionofthepaperwasthatspinalmanipulationisnoteffectiveforanycondition,andthat“spinalmanipulationisnotarecommendabletreatment”.Themainmessageofthemediareleasewassimilarlyblunt,andwaswidelypublicisedinUKpress.

VariouscritiquesofErnstandCanter’sarticle,havebeenforthcomingandessentiallyhighlightproblemsrelatedtothemethodologytheyemployedtoconducttheirstudy;thelimitedoperationaldefinitionsofmanipulation;andsourcesofbias.�-5Oneofthespecificcriticismslevelledatthepaperisthatthereviewwasfocussedsolelyonstudiesofspinalmanipulation,andthattrialsincorporatingcomplextreatmentpackageswereexcluded.�Theargumentisthereforedevelopedthatosteopathsrarelyeverusespinalmanipulationinisolationandsothisreviewisnotrepresentativeofosteopathictreatmentandthereforedoesnotrepresentachallengetotherelevanceofosteopathy.Regardlessofwhetherthispointistrue,somedam-agemayhavealreadybeendone.Thereviewhasalreadybeenpublished,anditsconclusionshavebeenwidelypublicized.

Whilethereareproblemswithusingsystematicreviewstosummarisetreatmenteffectiveness,itmayheprudentto

Is Osteopathy research relevant?A challenge has been madeNicholas P. Lucas and Robert W. Moran“International Journal of Osteopathic Medicine” 9 (2006) 75-76

considerthefollowing:wherearetheresearchdatafromtheosteopathicprofessionthatdemonstratestheeffectivenessoftheinterventionscommonlyadministered,someofwhichhavebeeninuseformorethanacentury?Iftheevidencewasthereinaformatconsistentwithcurrentstandardsinresearchreportingandbiomedicalpublishing,thenthatevidencewouldheincludedinsystematicreviews.Iftheresearchisthere,butsuffersfrommethodologicalweaknesses(suchaspoorop-erationaldefinitionsofthemanipulativeprotocol),orflawsinreportingthedata(suchasfailingtoreportdropouts)thenwemustresolvetoimproveresearchprotocoldesignandreport-inginordertoensurethatitisnotexcludedfromsystematicreviews.Ifwedon’tenjoybeinginthefiringline,thenwemayalsoneedtoexaminetheunwittingcontributionwehavecollectivelymadetotheammunitionofcritics(suchasErnstandCanter)byfailingtoadequatelyinvestigateanddocumenttheeffectivenessofourtreatment.

Thiscallforclinicalresearchmaybedownplayedonthebasisthatosteopathy“can’tbesummedupinatesttubeorinalaboratory”,or“thatareductionistresearchparadigmcannotinvestigateaholisticpatientcentredtreatmentap-proach”.However,clinicalresearchiscapableofmeasuringmanydifferentfacetsofhealthviathenumerousoutcomesoftheclinicalencounter:frompatientsatisfaction,moodstate,mentalhealth,quality-of-life,andpositiveoutlook,tophysi-calfunction,disability,painintensity,andrecurrence.Itisunlikelythatthiswiderangeofoutcomesisassessedduringthenormalcourseofdailypractice,andifpatientsareonlyaskedhowtheyfeel,or“istheirpainbetter?”,thenperhapsthisisamorereductionistapproachtomeasuretheimpactofosteopathictreatmentonanindividualthantheapproachwelldesignedclinicalresearchemploys.

Thisiswherethenumberscomeintoplay,becausechangesthatmayfollowosteopathictreatmentinthiswiderangeofpatientdomainsaresummarisedbynumbersintermsofstatisti-calsignificance,confidenceintervals,andimportantly,theeffectsize(ameasureofclinicalrelevance)ofthetreatmentoverandaboveothertreatmentapproachesornaturalhistory.Itisalso


fromthesenumbersthatsystematicreviewers,likeErnstandCanter,obtainthedatafromwhichsystematicreviewsandmeta-analysisareprepared.Duetotheirpositionatthetopoftheevidencehierarchy,suchsystematicreviewshavethepoten-tialtoheavilyinfluencehealthcarepolicyandmaythereforebeconsideredoneofthedeterminantsorthefutureshapeofthehealthcareenvironmentinwhichweallpractice.RegardlessofthemethodologicalcriticismsthatcanbeaimedattheErnstandCanterstudy,theoverwhelminglessonisthatwereallymustprovidebetternumbersforsystematicreviewerstoworkwith.

ThereviewbyErnstandCanterraisesmanyissues,butperhapsthemostimportantoftheseisthatinordertoanswersuchchallenges,theprofessionwillneedtocontinuetak-ingstepstowardsdemonstratingtheclinicaleffectivenessofosteopathictreatmentusinggoodqualityclinicalstudies.Al-most10yearsago,GibbonsandTehan6wrotethattherespon-sibilityforthescientificcredibilityofosteopathicmedicinerestssolelywiththeosteopathicprofession.Theystatedthat:

“It is imperative that the osteopathic profession under-take research to validate clinical practice. A priority in research should be outcome studies to measure the im-pact of osteopathic treatment upon pain and disability.”

Itiswidelyacknowledgedthatconductingstudiestoinves-tigateclinicaleffectivenessisnosimpleundertaking.Orga-nisingtheresourcesandexpertisetoundertakesuchstudiesusuallyrequirestheassemblyofmultidisciplinaryteams.Adecentclinicaltrialwillrequireexperiencedandcompetentinvestigatorswhocanpreparerobustexperimentaldesigns,orchestrategrantwritingtosecurefunding,gainethicalap-provals,securesuitableclinicalfacilities,recruit,andbriefpractitioners,andliaisewithadministrators,inadditiontotheactualrecruitment,enrollmentandongoingmanagementofpatients.Thenofcourse,thereisdataanalysis,manuscriptpreparationandpublication.

It’seasytoreflectonGibbonsandTehan’scallandwonderwhatprogresstherehasbeentowardssatisfyingthegoalofhavingourown‘osteopathic’datatosupporttheanecdotalsuccesswecollectivelyclaim.Oneofthemajordifficultiesisthattherearen’tenoughexperiencedandavailablepersonnelwithintheprofessiontoundertakehighqualityeffectivenessstudies.Therehavebeenveryfewmajorclinicaloutcomestudiesinvestigatingosteopathypublishedoverthelast10years,andreadersmayskimthroughthisjournalwonderinghowmanyofthestudiespublishedinIJOMarerelevanttoclinicalpractice.It’seasytobenonchalantabouttheimpor-tanceofresearch,andit’seasytodismissasirrelevantthesmall-scaleinvestigationsinto“howxtechniquechangesyrangeofmovement”,or“thenumberofconsultationsforxconditioninyclinicalpractice”.Inadditiontothepublishedresults,alessobviousbutimportantoutcomefromthesestud-iesisthehardwonexperiencegainedthroughwranglingwithanethicscommittee,orgrapplingwithafundingproposal,orgainingmoresophisticateddataanalysisskillsthroughdeter-

minationandstrongespresso.Theseareamongtheskillsthatareneededtoevendrawneartothestartinglineforconduct-ingagoodqualityeffectivenesstrial.Fundingbodieswon’tgrantmoneytoresearcherswholacka“trackrecord”–andthereisonlyonewaytodevelopatrackrecord–wehavetostartwithsmallsteps.

So,fornowtheprofessionwillstruggletorespondtocallsforeffectivenessdata,andfortheinterimitmaybetheap-parentlylessimportantstudiesthatwillpopulatethesepages.However,theprofessionisincrementallybuildingexpertiseandexperienceinplanningandconductinggoodscience–exactlytheskillsneededtomoveintotheclinicaleffective-nessarena.

References1. ErnstEandCanterPH.Asystemicreviewofsystematicre-

viewsofspinalmanipulation.J R Soc. Med.�006.99:19�6.�. BreenA,VogelS,PincusT,FosterN,UnderwoodM.Sys-

tematicreviewofspinalmanipulation:abalancedreviewofevidence?J R Soc Med.�006.99:�77.

3. ByfiedD,McCarthyP.Systematicreviewofspinalmanipula-tion:abiasedreport. J R Soc Med.�006.�77-8.

4. LewisBJ,CarruthersG.Systematicreviewofspinalmanipula-tion:abiasedreport. J R Soc Med.�006.99:�78

5. MooreAnn.NationalCouncilforOsteopathicResearch.systematicreviewofspinalmanipulation:includingdifferenttechniques. J R Soc Med.�006.99:�779.

6. GibbonsP.TehanP.Osteopathicmedicine:validationofclinicalpracticebyresearch.J Osteopath Educ Clin Res.1997.7:10:8

NicholasP.Lucas*SchoolofBiomedical

&HealthSciences,UnviersityofWesternSydneySydney,Australia*CorrespondingauthorE-mail:[email protected]

RobertW.MoranSchoolofHealthScience,UnitecNewZealandAuckland,NewZealandE-mail:[email protected]

Reprinted International Journal of Osteopathic Medicine, Vol 9, pp 65-76 (2006) with permission from Elsevier.


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From the Archives

Iwas introduced to John Martin Littlejohn (J.M.L.) in thegardenofhishomeatBadgerHallinthesummerof1915.Imusthavebeenverysmallbecausehewasshortofstature

and I remember studying his waistcoat buttons atsomelengthtocovermyconfusion.TherewasteaonthelawnandacricketmatchinwhichtheDeantookhisstandatthewicketandI,beingademonbowler,tookasilentvow to get his wicket at all costs.ItmustbesaidthatIfailedinmyobjective and the Dean retiredunhurt.Iwaseightyearsold.

There were many suchvisitsforteaandcricketdur-ing thewar years andmanya tough match was playedonthe‘backmeadow’attherear of the house. BadgerHall was a commodiouslateVictorian structure at-tached to a late eighteenthcenturyfarmhouseinaboutforty-five acres of a ratherunproductivesoil,scrubandwoodland, overlooking themarshesandtheThamesestu-ary.Itwasanattractivesettingand a splendid playground forhisfamily,nowgrowingup.Builtin 1895, the foundations werefoundtobepoor,andtheoldhouseisnomoreafterarelativelyshortlife.

J.M.L.wasasoftlyspoken,gentle,kindlyman,muchgiventohisowncom-panyandwanttowithdraw,intohimself.Hedidnotengageinargument,hedidnotrelishdebate,raisehisvoiceinanger,orquarrelwithhisneighbour.Yetunderneaththatcalmexteriortherewasamindthatneverceasedinthequestforknowledgewithabreadthofscholarshipthatwasalmostunbelievableinsofrailabody.Hishealthwasnevergoodbuttheindomitablespiritovercameeveryobstacleofthefleshfromthebeginningtotheendofhislife.

IremembertalkingwithhiminhisstudyoneSundayafter-noonandInotedaGreekTestamentlyingonhisdesk;apparentlyhewaspreparingasermonfortheeveningservice.Hesaid“Itranslateformyself’.Thiswastypicalofhim.Hewentintothe

studyofosteopathywithanalmostfuriousintensitythatmusthavestartledhiscontemporariesandhascertainlypuzzledtheirdescendants.Intheearlydayshemadehisowndissectionof

thenervoussystemandheoncesaidtome“IwouldnothavetheknowledgethatIhave,ifIhadnot

donethat.”AndrewTaylorStillgaveusosteopa-

thybutitwasLittlejohnwhounraveledthesciencethatwasthenhidden,and

unknown to thepractitioners of hisdayandwhichremainsso,toalargeextent,uptothepresenttime.Fewmen have studied so deeply, orworkedsohardasthisdourScot.Traveling40mileseachday,hetookhisfirstpatientat9inthemorning and the last patientat�.30 in theafternoon, thenwalked across Green Park totakehislecturefor3o’clock,arrivinga regular10minuteslate.At6o’clockthelectureswereover for thedaybut theDean was busy in his officeuntilthefinalclinicsessionwas

closedat8o’clock.Another40miles, a light meal at 10 and a

sleepuntilmidnight followedbythepreparationoftomorrow’slec-

turesuntil�a.m.OnSaturdayworkforthedaywascompleteby6o’clock

insteadof8.Sundaywasadayofrest,unlesshewaspreachingortakingtheChair

atameetingoftheMen’sBrotherhoodintheafternoon.HealsoservedontheParishCouncil.

Hisphysicalandmentaloutputwasenormous. Hewasamanofimmensecourageandtohisstudentsa

toughbutkindlyteacher.HeoncewrotealettertomewhenhethoughtIwasnotworkinghardenough,thecontentsofwhichIhaveforgotten,exceptthatitwasprettyforthright.Atalatertimewhendifficultiesarose,aswassometimesthecaseinthoseearlydays,Irememberthathegrippedmebythehand,lookedmestraightintheeyeandsaidnothing.Thegripandthelookremaintothisday.Stilllater,hecametomyconsultingroomsmuchconcernedregardingthewellbeingofastudentandclinicassistantsolatelydischargedandwithaviewtofuturepractice

A Personal Note (written by John Wernham)

A LITTLEJOHN COMPANION (compiled by T. Norminton, DO, MRO; copyright IPR 1998). Pages 7-10 reprinted by permission.


inassociationwithmyself.Yes,hewasacaring and far-seeingman. Inmy saladdayshefixedmewithamorepenetratinglook than usual and reminded me that“In osteopathy we need spade workers-thereistimelateronforthebrilliant-“.‘Whether he meant that I should beginasaspadeworkerandfinishupbrilliant,orbeginasaspadeworkerandstaythatway,leavingthebrilliancetosomebodyelse,areproblemsasyetunresolved. Anumberofanecdotescometomind:a student who had spent some time inIndiawastalkinginHindustanitoapa-tientandwasoverheardbytheDeanwhopromptlyenteredthecubicleandjoinedin the conversation, in that language!Thesamestudentmadeseveralattemptsto persuade J.M.L. to demonstrate spe-cifictechnique,arequestthatwasgrantedonlythreetimes,andthenunderprotest.Hewouldnot employandnever taughtspecific technique, as it is understoodtoday.J.M.L.didnotmixwithhispeers;he lived inaplebeianpartofEssex,anarea without history, or development atthat time.Hepractised in theWestEndofLondonbutnotintheacceptedareaswheredoctorscommonlyaretobefound.Heonceremarked,havingevidentlybeenincontactwithmedicaldoctors,“Ifyouleavemealone,I’llleaveyoualone.”Hewas a ‘loner’ by choice and inclinationandhepioneeredhisowninterpretationofA.T.Still’sgreatdiscoverywithoutlet,orhindrance,fromanyman.

Infact,thelifeofLittlejohnexempli-fiestherealvalueofthesolitaryworkerinhumanactivity.A.T.StilllabouredinAmerica and Littlejohn in the UnitedKingdom, neither of who were popularwith the medical opinion of their time.J.M.L. used to say that osteopathy isincompatible with medicine, not in acriticalsense,butthatosteopathyhasitsown voice, its own philosophy, and itsowndestiny.Hepossessedeverytextonphysiologypublishedforoverhalfacen-turyandpublishedtwovolumesonthatsubject.‘Whenstudentscomplainedthathislecturesweredifficulttounderstand,he merely reminded them that they didnotknowthephysiology.Ithasbeenre-marked,morerecently,“YoudonotreadLittlejohn,youstudyhim.”Ihavebeendoingjustthatforhalfalifetimeandheisstill“wayahead”,ashewouldsay.r

Component Societies’ CME Calendar andother Osteopathic Affiliated Organizations

March 24-25, 2007Weekend Midyear ConferenceBreast Imaging Update 2007AmericanOsteopathicCollegeofRadiologyChicago,ILRegisteronlineat:www.aocr.org

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

May 3-6, 2007Where Excellence and Elegance Meet110th Annual ConventionIndianaOsteopathicAssociationMerriville,INContact: IOA 317/9�6-3009or 800/94�-0501

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

May 19-20, 2007The Brentwood OMT Skills SeriesMuscle Energy Technique-Part IIThoracic & RibsFredL.Mitchell,Jr.,DO,FAAOSouthPointeHositalWarrensvilleHeights,OHContact: JaySandweiss,DO 734/995-1880

June 16-20 , 2007June Basic CourseTheCranialAcademyTucson,AZCME:40HoursCategory1AContact: TheCranialAcademy 317/594-0411 www.cranialacademy.org

June 21-24, 2007Annual Conference “And, I Do Mean All”TheCranialAcademyTucson,AZCME:40HoursCategory1AContact: TheCranialAcademy 317/594-0411 www.cranialacademy.org

June 27-30, 2007AACOM’s Annual MeetingCollaboration: The Keystone to SuccessBaltimore,MDRegisteronline:www.aacom.org

September 24-28, 2007Annual ConventionEmergency and Trauma RadiologyRocaRaton,FLAmericanOsteopathicCollegeofRadiologyChicago,ILContact: AOCR 660/�65-4011or 800/�58-AOCR

October 6-7, 2007The Brentwood OMT Skills SeriesMuscle Energy Technique-Part IIILumbar, Sacrum/PelvisFredL.Mitchell,Jr.,DO,FAAOSouthPointeHositalWarrensvilleHeights,OHContact: JaySandweiss,DO 734/995-1880

November 10-11, 2007The Brentwood OMT Skills SeriesMuscle Energy Technique-Part IVExtremitiesFredL.Mitchell,Jr.,DO,FAAOSouthPointeHositalWarrensvilleHeights,OHContact: JaySandweiss,DO 734/995-1880

December 7-9, 200726th Annual Winter UpdateIndianaOsteopathicAssociationIndianapolis,INContact: IOA 317/9�6-3009or 800/94�-0501

1�/The AAO Journal March�007

SunTzuwasaphilosopherwhowroteThe Art of War�500yearsago.1Heoutlinedthefundamentalprinciplesofstrategy.Hedescribedstrategyasdoingtherightthingandtacticsasdo-ingthingsright.Whatfollowsaremythoughtsforastrategyforourprofessioninachangingeducationalenvironment.

Osteopathiceducationinthethirdandfourthyearsofmedicalschoolismorefrequentlyoccurringininstitutionswithlittleornoexperienceinosteopath-iceducation.Asclasssizesincreaseandmorenewschoolsopen,theneedfornewteachingsiteshasgrown.Thishasresultedinourdeansatestablishedcol-legesofosteopathicmedicines(COMs)havingtofindrotationsatallopathicinstitutionsinthecommunitieswhereDOshavetrainedforyearsandthoseatnewschoolshavingtofindclinicalrota-tionsathospitalswithnoexperienceinclinicaleducationoronlyhavingexpe-rienceinallopathictraining.ManyhaveregardedthisscenarioasamajorreasonfortheprofessionlosingourgraduatestoAmericanCollegeGraduateMedicalEducation(ACGME)residencies.

Therehasbeenamajorshiftinosteopathicpostgraduateeducation.Over50%ofDOgraduatesnowchooseACGMEresidencies.MarkCummings,PhDnotedthattheyarebeing,byandlarge,onlyacceptedintoprimarycareprogramsandnotintospecialtypro-grams,particularlysurgicalresidencies.�ThishasresultedinamarkedlossofDOsintheAmericanOsteopathicAs-sociation(AOA)approvedprimarycareprogramswhilespecialistsarelargelycomingoutofourAOAapproved

2006 Northup Lecture

Teaching Osteopathic Principlesin an Allopathic Environment:Osteopathic Guerrilla WarfareMark S. Cantieri

programs.Osteopathicmedicine,longknownasemphasizingprimarycaretraining,isnowseeingthattrainingisbeinglargelyperformedinACGMEprogramswherethereisnomandatefortheinclusionofosteopathicprinciples.

Asaclinicalinspectorforosteo-pathiccollegeaccreditation,Ihavehadtheopportunitytoseehowourcollegesareaddressing(andnotaddressing)theteachingofosteopathicprinciplesinthethirdandfourthyears.Averylastingimpressionwasmadeonmeatonelong-standingcollege.IfirstwenttoahospitalthathadbeeninvolvedinteachingDOsformanyyears.TheDi-rectorofMedicalEducation(DME),anosteopathicphysician,hadbeenatthisinstitutionfor3�years.WhenIinquiredabouttheutilizationofOMMintheinpatientsetting,herespondedthattheydidnotdoitandtherewasnotenoughtimeforit,buttheydiddosomeatnear-byambulatoryclinics.

ThenexthospitalIwenttowasasmallolderinnercityhospitalthathadjustrecentlybecomeateachingsitefortheCOM.TheCOM’sfacultywasresponsibleforteachingandpatientcare.WhenIinquiredabouttheutilizationofOMMthere,thestudentsenthusiasticallyspokeaboutpatientstheyweretreatingandresearchtheyhopedtoconductafterexperiencingpositivepatientoutcomes.Theyspokehighlyoftherolemodelsthattheirclinicalprofessorswere.

Thefinalhospitalwevisitedwasarelativelynewsitefortraining.Theverylargeandstate-of-the-arthospitalhadanexcellentreputationfortrainingintheallopathiccommunity.TherewasaDO

DMEfortheAOAprogramsandaMD DMEfortheACGMEprograms.Bothwereinattendancefortheinspection.TheDODMEwasinhissecondyearofpractice.HeindicatedthathedidnotreallyknowhowtoincorporateOMMintothecurriculumandthatchartre-viewrelativetotheutilizationofOMMwasperformedeverythreetofourmonths,longafterthestudentsweregoneorthecaseslongforgotten.TheCOMhadnotprovidedhimwithanyteachingtoolsforOMM.TheelderlyandexperiencedMDDMErespondedthatifgivenaprogrambytheCOM,theywouldseethatitwasimplementedandproperlyoperated.HewasenthusedabouthavingDOstudentsandresidentsintheinstitutionandwantedtoseethemfullytrainedasDOs.

Withintheprofessionweappeartohaveperceivedthatosteopathiccon-ceptswillbeviewedasbackwardorarchaicbytheallopathicworldandtendtooperatedefensively.Asanaccredita-tioninspector,Ihavenotfoundthistobetrue.IhaveaskedMDprogramdirectorsatlargeuniversityallopathicprogramsiftheyhaveanyconcernabouttheutilizationofosteopathicmanipula-tionbythird-andfourth-yearmedicalstudents.Theirreplyisthattheywouldwelcomeitespeciallywithappropriatesupervision.

Iseetheexpansionofourtrain-ingprogramsintothesenon-traditionalsitesasanopportunity,althoughonenotwithoutrisks.BythewhimofallopathicprogramsnotselectingDOsandtakingtheirown,wewillfindourselvesattheirmercyandcontrol.Allopathicprograms


➝

haveopenedafewnewschoolsandtherehasbeenageneralcallforthemtoincreaseclasssize.3WiththemajorityofourpostgraduatetrainingoccurringoutsideofAOAprograms,weplaceourselvesinavulnerableposition.Howdowecontinueinthisfashionandyetgrowtheosteopathicprofession,notjustintotalnumbersbutproducedis-tinctlyosteopathicphysicians?HowdoweproduceDOswhoareproudoftheirheritageandwanttosupportitsorgani-zationsandfuture?

SunTzustated:“YouraimmustbetotakeAll-under-Heavenintact.Thus,yourtroopsarenotwornoutandyourgainswillbecomplete.”4Forourprofession,thistranslatesintocaptur-ingourmarketplace.Wehavebyreasonofsimplenumbersandanill-definedmissionremainedfairlyunknowninthemedicalmarketplace.Inordertocapturemarketplace,wemusthavenumbers.WeneedtohavenumbersthatarecomparabletotheMDnumbers.Doyouthinkthatisimpossible?IamsureFordandGeneralMotorsthoughtthatthesmallJapaneseautomakersofthe1970swouldnevercompetewiththem.ButtheJapanesewithacom-mittedlong-rangeplantoproduceaqualityproducthavegraduallycometodominationintheindustry.Wecanaswell,ifwemakethissamecommitmenttoquality.Ifthequalityexists,thereisnoreasonnottogrowmoreschools.

Weneedtohavemoreschoolsinordertohavemoregraduates.Weneedmoregraduatesinordertocapturemar-ketplace.Morenumbersmeansmoreattendingphysicians,morepatientsandgreaterinfluenceathospitalsites.Thiscreatesgreaterleverageinpostgraduateeducation.

Sohowdoweproducequalityos-teopathicgraduates?OurprofessionandinparticularourCOMsneedtoclearlyprojecttothestudentsthemissionoftheprofession,reflectingamoralinfluenceorspiritofthatmission.TheyneedtorallyafirestormofcommitmentandafightingspiritinthebeliefthatbeingaDOmeansonehasbeeneducatedtoprovideasuperiorformofpatientcare.Withthisattitudeinstilledinourgradu-ates,theircommitmenttotheprofes-sioniscemented.AsSunTzusaid,“Hewhoseranksareunitedinpurposewill

bevictorious.”4

TheprofessionneedstostopbeingdefensivewithitsstudentsandtaketheattitudeDaleDodson,DOdidwithme.Iwasafirst-yearstudentwhenhewaspresidentoftheAOAandcametovisitDesMoinesUniversityCollegeofOsteopathicMedicine.Iaskedhimthetypicalstudentquestion:“WhatwastheAOAdoingtomakethepublicknowwhataDOis”?Hechallengedmebyresponding,“Whatareyoudoingtopromotetheprofession”?Hisresponsehelpedpropelmetobecomeactiveintheprofession.NolongerwasitjusttheAOAthatwasaccountable.Iwasac-countableaswell.

Ourschoolsmustadequatelyarmourstudentsforthisbattle.Thatmeansfirstmarshalingadequateresources.NormanGevitz,PhDpointedoutthatourschool’sadministratorsmustfinan-ciallydevoteadequateportionsoftheirbudgetstodistinctosteopathicmedicaltraining,meaningadequatewell-paidfull-timefacultyforallfouryears,firstclassfacilities,indepthandcontinu-ousfacultydevelopment,coordinationofinstructionwiththebasicsciencedepartmentsandongoingresearchinosteopathicprinciplesthatincludesstudents.5

Iwouldaddtothat,thatstudentsneedtolearnphysicalexaminationskills,utilizeosteopathicmanipulativetreatment(OMT)andfollowpatientslongitudinallybeginningearlyintheirfirstyearofmedicalschool.CurrentlytheAccreditation of Colleges of Osteo-pathic Medicine: COM Accreditation and Standards and Procedures,standard1.5requiresthateachCOMhaveonornearcampusafacilitywhereosteopath-icmedicineispracticed.6Thisstandardneedstobebroadenedtorequireafacil-ityofadequatespacesothatstudentscouldsee,treat,andlongitudinallyfol-lowpatientsduringtheirfirsttwoyearsoncampus.EvaluatingandtreatingfellowstudentsintheOMMlabora-toryisnocomparisontoputtingone’shandsonpatientswithrealpathology.Indoingthis,wearmourstudentswiththephysicalskillsandconfidencetoundertakethenextstepinourmission.

Ourstudentsneedtoseethesci-encebehindosteopathicconcepts.Asastudent,IhadOMMprofessorswho

eachhadparticularlystrengths.Dr.Ber-nardTePoortenhadtheabilitytoteachmetechniqueandanatomy,whileDr.GordonZinkshowedmetheanatomyandphysiologicalrationaleforosteo-pathicmanipulation.IgravitatedtowardDr.Zinkandteachresidentstodayinasimilarmanner.OurstudentsneedtoknowthatthebasicsciencestheylearnhavepracticalapplicationintheOMMtheyutilizeforittohavecredibility.WeneedtoteachthatDr.StillutilizedOMTtooptimizephysiology,nottojusttreatmechanicaldysfunctionandpain.

Thescienceofosteopathythatweteachinthefirsttwoyearsneedstoexpandsothatwhenourstudentsentertheirclinicalyears,theycanexplaintheirrationaleforutilizingOMM,notonlytopatientsbuttocolleaguesandat-tendingphysicians.Asoundtacticistoarmthemwithabetterdepthofunder-standingofthescienceofosteopathy.Newareasofscienceneedtobeaddedtoourcurriculumstofurthershowthedepthofthescienceofosteopathy.Os-teopathiceducationandresearchshouldlookdeeperintohowanalterationofnormalstructureandfunctionaffectsusatthecellularlevel.DonaldIngber,MD,PhDwrote:

Inbiologyandmedicine,wetendtofocusontheimportanceofgenesandchemicalfactorsforcontroloftissuephysiologyandthedevelopmentofdisease,whereaswecommonlyignorephysicalfactors.Thisisinterestingbe-causeitwascommonknowledgeattheturnofthelastcenturythatmechanicalforcesarecriticalregulatorsinbiology.7Wolff’slawdescribingthatboneremod-elsalonglinesofstresswaspublishedin189�.8However,theadventofmorereductionistapproachesinthebasicsciences,andthedemonstrationoftheirpowertoadvanceunderstandingofthemolecularbasisofdisease,ledtoalossofinterestinmechanics.9

Theconceptofcellularmechano-transductionisaperfectfit:themolecu-larmechanismbywhichcellssenseandrespondtomechanicalstress.Thisistheosteopathicconceptofstructureandfunctionatthecellularlevel.

EdwardStiles,DO,FAAOhasbeentoutingtensegrityforanumberofyears.Itwasreceivedenthusiasticallybythe


professionwhenhepresenteditaspartofhisA.T.StillMemorialLectureattheAOAHouseofDelegates.Tensegri-tytheorycanpredictcomplexmechani-calbehaviorsatboththecellularandbiomechanicallevels.10Thisshouldbeastandardpartofourosteopathiceduca-tionandisanareaofresearchperfectlysuitedtoourprofession.

Ifourstudentsareproperlyarmed,theyarereadytogointotheirthirdandfourthyears.But,theyneedthehelpofmentorsatthatpoint,whocanproperlyutilizeandspeakintelligentlyaboutos-teopathicprinciplesandpractice.ThisiswherewemusthavepracticingDMEsandclinicalfacultywhowillserveasrolemodelsandinstructorswhowillholdthestudentsaccountablefortheutilizationofOMM.Thison-siteteamwouldberesponsibleforconductingregularchartreviewsoncurrentinpa-tientsandseeingthatOMMwasbeingproperlyutilized.Studentswouldalsoberequiredtoperformanddocument1�0osteopathictreatmentsperyear.TheDMEandclinicaladjunctfacultywouldsignoffonthestudentonceproficiencyhadbeenproven.ThisisarequirementforanyproceduralskillinthehospitalandOMMshouldbenodifferent.

EachcoresiteshouldberequiredtohaveadesignatedDOclinicaladjunctfacultymemberanditsDMEinvolvedwithcontinuousfacultydevelopment.ThisfacultydevelopmentwouldincludetheaffiliatedCOM’sOMMdepartmentordivision.ItsresponsibilitywouldbetotrainthesetwofacultymembersinassessingtheutilizationofOMMandteachingOMMtostudentsandresidents.Semi-annually,thetwocorefacultymemberswouldgototheCOM

forCME.TheOMMdepartmentcouldthenvideostreamtothesedistantclini-calsitesanOMMtrainingmodulefortheresidentsandstudents.Theon-siteteamwouldberesponsiblefortheclini-caltraining.

AmericanAssociationofCollegesofOsteopathicMedicine(AACOM)andExecutiveCouncilofOsteopathicPostdoctoralTraining(ECOP)needtocollaborateinthetodevelopmentandimplementationofOMMteachingmodules.Theseneedtohaveathree-yearformat.Theyalsoneedtoincludemodulesonclinicalresearch.TheseresearchmoduleswouldneedtobecoordinatedwiththeBureauofClinicalEducationandResearch(BOCER).TheresearchdepartmentattheCOMwouldberesponsibleforcoordinatingresearchatthesecoresites.

Eachofushasaresponsibilitytothisprocess.“And,therefore,thegener-alwhoinadvancingdoesnotseekper-sonalfame,andinwithdrawingisnotconcernedwithavoidingpunishment,butwhoseonlypurposeistoprotectthepeopleandpromotethebestinterestsofhissovereign,isthepreciousjewelofthestate.”4Thisistheattitudeweneedtoexhibitasleadersinourprofession.Eachofusisageneralrelativetoourpatientsandthestudentswementor.Wemustbewillingtoservehumblyandforthegreatergoodoftheprofession.Weeachneedtobewillingtotakestudentsandtoteachthem.Weneedtokeepcur-rentwiththeresearchandbelife-longlearners.Weneedtosupportourlocal,state,andnationalorganizationsandpro-motetheprofessionbyservingaseduca-torsandambassadorstoourpatientsfortheprofession.Inwar,victorycomesby

holdingthehigherground.Thatishowwe,too,shallbevictorious.

References1. MichaelsonGA.SunTzu.The Art of

War for Managers, 50 Strategic Rules.�001.AdamsMediaCorporation.Avon,MA0�3��.USA.

�. CummingsMandDobbsK.TheIronyofOsteopathicMedicineandPrimaryCare.Acad Med. �005.80:70�-705.

3. MullanF.TheCaseforMoreU.S.MedicalStudents.MassachusettsMedicalSociety.Vol.343(3).�0July�000.pp�13-�17.

4. McNeillyM.Sun Tzu and the Art of Business, Six Strategic Principles for Managers.OxfordUniversityPress,Inc.NewYork,NY.1996.

5. GevitzN.CenterorPeriphery?TheFutureofOsteopathicPrinciplesandPractice. JAOA.Vol106:3:1�1-1�9.March�006.

6. Accreditation of Colleges of Osteo-pathic Medicine: COM Accreditation and Standards and Procedures.

7. ThompsonDW.On Growth and Form.�nded.London:CambridgeUniversityPress.195�.

8. WolffY.DasGeserzderTransforma-tionderKnochen.Berlin.184�.

9. IngberDE.MechanobiologyandDiseasesofMechanotransduction.Ann Med. 35:564-577.�003

10. IngberDE.Thearchitectureoflife.Scientific American.�78:48-57.1998.

Accepted for Publication:November�006

Address correspondence to:MarkS.Cantieri,DO,FAAOCorrectiveCare,PC3555ParkPlaceWest,Suite�00Mishawaka,IN46545E-mail:mscantieri.pol.netr


Osteopathic Manipulative MedicineFaculty Position Opening

Touro University-CaliforniaCollege of Osteopathic Medicine

The Department of Osteopathic Manipulative Medicine (OMM) has a full time position available. The applicant should have interest and experience in clinical practice and teaching 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• Work with OMM Fellows program• 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 will continue until a suitable candidate is hired. The position will begin July 1, 2007. Information 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


Proposed TheoryPrevious explanations for the mechanism of action in

counterstraintheoryhavecenteredprominentlyontheroleofthemusclespindleapparatus triggered fromasudden“paniclengthening”ofthemusclefibersduringinjury.8,�5Thistheoryassertsthatthemusclespindlemaintainstheabnormaltone.

Thisarticlewillreviewthevariouseffectsonmuscleme-tabolismthatresultfrominjuryandtheresultantforcesplacedonallstructuresassociatedwiththemuscle.Keytothisprocessisthecriticalbalanceofoxygendelivery,bloodflow,sympa-thetictone,andintramuscularpressureonmetabolicrecoveryaftermuscleeffort.5,10Theresultantalterationinmuscleeffortmay exert a traction/compression effect on the nerve fibers,bloodvessels,andlymphaticchannelsastheycoursethroughthemyofascialtissues.38,41,43,46

Anatomicalconsistencyofmanyof the tenderpointandmotorpointlocationsthroughoutthebodywillalsobeexplored.Viewedinrelationtothemetabolicalterationsfoundwithinin-juredmuscles,thefollowingdiscussionwillprovideadditionalinsightintothetremendousoverlapinphysiologicalandana-tomicalprocessesleadingtowardapossibleexplanationforthesharedphenomenonoftendernessandtreatmentapproaches.

Therefore,sustainedalteredmetabolismisatthecenteroftheestablishmentoftenderpointmanifestations.Properposi-tioningofthetissuesduringcounterstraintreatmentreducesthetenderpointmanifestationwhileenhancingcirculatorymove-mentand,therefore,normalizationwithinthesetissues.

Postural IntegrityPosturalintegrityisavitalfunctionofthemusculoskeletal

system.Ideally,thebodyisnotoverlychallenged,andthesystemiskeptatequilibrium.However,whentissuesbecomeinjuredordeconditioned,anadaptationmusttakeplaceinordertoattempttomaintainposturalorientation.Alterationinmusclecoordina-tionwithresultantreorchestrationofthemuscleeffortsbecomesevident,andthesefindingsofferaroadmaptotherehabilitationneedsofthepatient.4,36,40,46

Anexplorationofwhatunderliesposturalintegrityrequiresanunderstandingofhowthesystemsofthebodyfunctionallyrelate.Theosteopathicphilosophystressestheconceptofunityofthelivingorganism’sstructure(anatomy)andfunction(physi-ology).7�Osteopathicprinciplesarefoundedontheprinciplesthatthehumanbodyisadynamicunitoffunction,possesses

Counterstrain Tender Pointsas Indicators of SustainedAbnormal Metabolism:Advancing the Counterstrain Mechanism of Action TheoryPaul R. Rennie

self-regulatorymechanismsthatareself-healinginnature,thatstructure and function are interrelated at all levels, and thatrationaltreatmentisbasedontheseprinciples.

Somaticdysfunctionisdefinedastheimpairedoralteredfunctionofrelatedcomponentsofthesomatic(bodyframework)system: skeletal, arthrodial, and myofascial structures, andrelatedvascular, lymphatic,andneuralelements.7�Therefore,thediagnosisofsomaticdysfunctionconfirmsthatosteopathicneuromusculoskeletaltreatmentisindicatedandappropriateaspartofthetreatmentplan.Abetterunderstandingoftheana-tomicalandphysiologicalmatrixofthebodyrevealshowthesesystemscanbeinfluencedinamannerthatwillcontributetotheposturalintegrityofthebody.

Effect of Reduced Blood Flow and Increased Nociceptive Activity

Properbalanceinbloodflowisrequiredfornormalmeta-bolicactivityforalltissues,includingthemusculoskeletalsys-tem.Reducedbloodflowleadstoreducedoxygenandmetabolicsupport, along with reduced waste by-product removal andreducedoverallforcegenerationfromthemuscles.

Capillariescoursebetweenthemusclefibersthroughspacessosmallthattheredbloodcelldiscsmusttravelinahorizontalorientationtotraversethesechannels.13Anyfurthercompressionorreductioninmusclepumpingeffortreducesthemovementof these cells. Ischemia is a local anemiadue tomechanicalobstruction(mainlyarterialnarrowing)of thebloodsupply.14Theischemiathatresultsfromthisreductioninbloodflowcanstimulatethenociceptivereceptorsandtriggerapainresponse,especiallywiththereleaseofacidichydrogenionsandbradyki-nin.�9,44Alteredbloodflowthereforetriggersaneuralresponsesignalingthataproblemexistswithinthetissuesandthatthereisastateoflow-energyformationinthemuscles.

Bloodflowisonenecessarycomponentformusclecontrac-tion.Theotherisacoordinatedandeffectiveneuralstimulus.Therefore,musclecontractionrequiresbothachemicalandanelectricalreaction.Theneural(electrical)processinvolvessen-soryandmotoractivityconductedbetweenthecentralnervoussystemandtheperiphery.Bloodflowismediatedthroughthearterial,capillary,andvenousconduitsconnectedwithvariousorgansystems,particularlytheheart,lungs,gastrointestinal,andgenitourinarysystems.


Sufficientbloodflowmustbemaintainedinordertoregen-eratetheATPnecessarytobreaktheactin-myosincross-linkssothatmusclefibermovementmaybecontinued.�,71Therefore,evenwithoutconsideringtheelectricaleffects,reducedbloodflowwillalterthemetabolicsupportnecessaryfornormalmusclemovement.ThisprocessdemonstratestheobservationofAndrewTaylorStill,MD,DOthat“theruleofthearteryissupreme”.Withoutappropriatebloodflow,suboptimalfunctionalactivityremainsandlikelymaintainsthesomaticdysfunction.

Theneuraltissuesalsodependonproperbalancewithinthecirculatorysystem.Nociceptorsarefoundincloseproximitytothearteriolesandprovideforearlywarningofdysfunctionwithinthetissues.Onceactivated,thenociceptiveinputtriggersanaxonreflexthatactivatesadaptivemechanismsinordertoprotectthebodyfromfurtherinjuryandtogeneratethereparativeresponseneededintissuesthatbecomedamaged.Thisresponsecanaug-mentthevascularresponseandrequiresadequatebloodflow.Nociceptorsareactiveinreleasingthechemicalenvironmentbywhichtissueedemaisgeneratedfromincreasedtissuepermi-abilityandvasodilation.Ifmaintained,thisleadstocongestionandreducedbloodflow.1�

Nociceptiveinputisalsotransmittedtothespinalcordandbrainstem.Normally,nociceptivethresholdresponse,andthere-foreneuralsignalpropagation,shouldbeabletodiscriminateaneventthatistissuethreateningandtherefore,notactivateinthepresenceofweaklocalappliedpressures,normalphysiologiccontractions,andnormaljointrangesofmotion.However,someinputthroughthespinalcordandbrainstemmayinducelong-termchangesinsynapticprocessesindorsalhornneurons.

This afferent input is maintained in the central nervoussystemandremainsdespiteapparentresolutionattheoriginaltissueinjurysite.8Experimentshaveshownthatamorphologi-calchangeoccursintheCNSthatproducesafixedfunctionalchange.48Itisthoughtthatthisprocessmaybethemechanismbe-hindhyperalgesia(increasedsensitivitytonociceptivestimuli).Therefore,centralsensitizationincreasesthetendernessoftheperipheralstructuresduetospinalrewiringwithnon-nociceptiveinputsstimulatingnociceptivepathways.1�Thiscentralfixationmaybeonereasonwhyittakesmoretimeforpaintodiminishinchronicpainpatients.

Intramuscular PressureMuscletoneisthedegreeofmuscletautnessatrest.Itis

measured by the degree of stiffness or resistance to passivemovement.9Thistoneisestablishedbytheviscoelasticproper-tieswithin themusclefibersandfasciaandby thedegreeofactivationofthecontractileelements.17

Intramuscular pressure (IMP) is that pressure containedwithinthemuscle.IMPbecomeselevatedifincreasedexternalorinternalcompressionisappliedtothemuscletissues.Causesofthisincludeinternaltissuedamage(compartmentsyndromeas an extreme example), sustained muscle contraction andoverusesyndromes,andpressureplacedonthemuscletissuesviatautfascialcompartmentsandboneyelementsthatsurroundthemuscletissues.39

Each muscle, due to its morphologic arrangement, mayattainadifferentmaximalintramuscularpressureduringcon-tractioneffortascomparedtoothermusclesinthebody.Asan

example, maximal intramuscular pressures measured in onestudyofshoulderabductionrevealedthetrapeziustoaverage86mmHg,deltoid146mmHg,infraspinatus439mmHg,andthesupraspinatus5�4mmHg.6Additionally,whenthesupraspinatusmusclewasmeasuredduring shoulderflexion at 30degrees,theIMPaveragewas58mmHg.Therefore,morphologicandpositionalfactorsareinvolvedintheIMPgenerated.

SustainedmusclecontractionsmaintainahigherIMP.Ifthemusclecontractsat30%ormoreofitsmaximalcontractionforce(MCF),itwillcompressitsownbloodvessels.1�Ifsustained,suchaswithoveruse syndromes, repetitive strain injury, andchroniccompartmentsyndrome,thiswillreducenutrientandoxygen delivery necessary for the mitochondria to regener-ateATPviaoxydativephosphorylationfor theuncouplingofactin-myosincross-bridges.49,50Thissets-upaviciouscycleofvenousandlymphaticcongestion,ischemia,furtherreleaseofvasoactiveandnociceptivesensitizingchemicaledemaandthus,aperpetuationofthedysfunction.Andsotheprocessbegunasametabolicabnormalityresultsinacycleinwhichthenocicep-tiveafferentsystemelicitsalterationsinthemotorresponsetoeitherincreaseordecreaseaparticularmuscleeffortsecondarytoactualorperceivedtissuedamage,andthenociceptiveresponsefurtheraltersmetabolism.

Increasedandsustainedsympathetic tonewith increasedexerciseorlaboractivitieswillalsoaffectbloodflow.Intracel-lularphisreducedwithresultantreductioninbloodflowandmitochondrialrespiration.51Despitethecompensatorymetabolicvasodilatoryeffect,thesympatheticvasoconstrictiveeffectonthebloodvesselsisnotovercome.Therefore,oxygensupportdoesnotadjustforthemetabolicneedsinthemuscletissues.Phosphocreatinine and oxydativeATP recovery is dependentprimarilyontheoxydativecapacityinthemuscletissues.Higherlevelsofexercisecanresultinaworseningoftheimbalanceinoxygendelivery64andbloodflow.55This,coupledwithalimita-tionofoxygenattheonsetofexercise,leadstoagreaterrelianceonanaerobicATPturnover.49

Increased IMP has been found to be associated with anincreasedfluidcontentafterrepeatedmaximalisokineticcontrac-tions.IMPisaffectedbythefascialcomplianceandfluidcontentinthemusclecompartment.53IncreasedIMPmayaffectbloodflow particularly in the low-pressure venous system, therebyreducingwasteproductremovalfromthetissues.Ontheotherhand,increasedIMPduringrepetitivecontractionsdoesassistinvenousflowreturntotheheart.54Theemphasishereiswithaproperbalanceofmusclecontractionstoaugmentlow-pres-surefluidflow.StaticworkandinactivityaggravatetheeffectofsustainedelevatedIMP.However,withthedevelopmentoffatigue, adrop in IMP towardmeanarterialpressure (MAP)may allow for maintenance of muscle perfusion and oxygendelivery.Again,themetabolicenvironmentisparamountandnormallydictatesaresponseinbloodflowthatsignalstotheindividualtoadjusttheiractivityleveltosupportrecoverytothemetabolicenvironment.

Metabolic RecoveryMetabolic recovery within themuscle requires that IMP

returntoproperrestinglevels.Theselevelsvarywithindiffer-entmusclesandhavenotbeenfullyresearchedforeachmuscle.


ProlongedelevatedIMPandstaticmusclepositioningleadtoimpairmentofintramuscularbloodflowtothemuscleandten-dons.EMGstudiesonthebicepsmusclehavefoundthatIMPhadtoreturntobelow�0mmHgbeforemetabolicrecoverywaspossible.10IthasalsobeenfoundthatIMPaslowas15mmHgcandecreasemicrocirculationtothemarginsofaninjuredandedematoussiteandtomorefragilesitessuchasthetendons.5Removalofinterstitialfluidwithultrafiltrationhasbeenshowntoreducetheriskofdevelopingacutecompartmentsyndromeinpatientspronetothiscondition.56Theidealistoofferaconserva-tivemeanstomaintainproperrestingIMPlevelsinallpeoplebeforefurthermetaboliccompromiseorongoingdegenerationbecomesestablished.

Otherinfluencesalsoplayaroleonbloodflowtothetis-sues.Inonestudyinvolvingpaintothetrapeziusmuscle,IMPmeasurements indicated the muscle had no significant bloodflow impairment. However, laser doppler flowmetry (LDF)revealedaloweredlocalbloodflowduetoimpairedregulationofthemicrocirculation.57Thiseffectwasthoughttobecreatedthroughadefectinthereleaseofvasodilatorysubstancesthatareexcretedaxonally.

Therefore,muscleanditsbloodvesselspossessthecapac-ityto“squeeze-out”theirbloodsupply,themuscle’smetabolicsupport.The resultant loss of mechanical effort from thesefibersmustbetaken-upbyotherhealthymusclefibers.44Thisincreasestheworkloadonthesefibers,possiblyincreasingtheIMPinthesemusclegroups.Thisprocesshasthepotentialofspreadingtoyetotherregionsofthebodyinordertoadapttothemechanicalneedsofthebody.39Ifsustained,moremusclefiberswillsuffermetabolicexhaustionduetosustainedelevatedIMPandlossofmetabolicsupport.

Skeletal muscle fibers can be categorized into slow andfasttwitchtypes.Thesetypesdistinguishmetabolicandfunc-tionaldifferencesbetweenthemusclefibers.Slowtwitch(tonic)musclefibersaresmallerthanfasttwitchfibersbuthavemoremitochondriaandbloodcapillaries thandofast twitchfibers.Thesarcoplasmalsohasahighcontentofmyoglobinthatcarriesadditionaloxygenforusebythemitochondria.Thesefeaturesaccountfortheredcolorationofthesefibersasopposedtothepale-coloredfasttwitchmusclefibers.

Fast twitch (phasic) muscle fibers are metabolically andfunctionally designed for more ballistic activities requiringpowermovementperformedoverashortdurationoftime.Inordertoaccomplishthis,thefasttwitchfibersutilizetheglyco-lyticpathwaywithamoreextensivesarcoplasmicreticulumtoallowfastermovementofcalciumiontransport.However,thesefibersaremoreeasilysubjecttofatiguethantheslowtwitchtype.Yet, if thereisadisturbanceinthebloodflowcharacteristicstotheseslowtwitchfibers,theremaybetheincreaseduseofthemorefatiguingfasttwitchfibersleadingtopotentialearlyfatigue.Also,sincetheslowtwitchfiberstendtohavehigherproprioceptive input, this may have an influence on the bal-anceeffortsfromthemusclesresultinginmoreuncoordinatedmovement.Thisleadstotheconditionofmuscleimbalance,tobediscussedasfollows.

Altered Joint FunctionJoint inflammation or increased joint fluid pressure will

stimulate jointafferentneurons in the sameway that injuredmuscle fibers and elevated intramuscular pressure stimulatesintramuscularnociceptiveafferentreceptors.Thecommonendresultisinhibitionofmuscleandjointmovementtotheinjuredsites, with protective spasm from other healthy, non-injuredmusclegroups.

Thedifferingmetabolicprofilesofspecificmuscleandtheaffect they have on joint arrangements are associated with apatternofrecognizablemuscleinhibitionandjointrestriction.Forinstance,thegluteusmaximusmuscleappearstobecomeinhibitedwithipsilateralsacroiliacrestriction,thegluteusmediuswithacetabularrestriction,themultifidiwithzygapophysialre-striction,andtherectusfemoriswithkneejointrestriction.1,3,11,15Knowing theseassociationsallows for focused treatmentap-proaches.

Correlation between Motor Points and Tender Points

Counterstrain tenderpoints arehyperalgesic areas foundat consistent anatomical locations throughout thebody.7,8,18,19,

�0,�1,�3,45,47Onfurtherreviewofmanyoftheknownandreliabletenderpointsites,aclearcorrelationbetweenthesesitesandmo-torpointsitesmaybefound.Themajorityoftenderpointsitesappeartobeconsistentwithneuraltissuelocationswhetheritbemotorpoints46,61,6�,63,64,65,66,67,68ormoredeeplyinvestedneuralfibersintotheligamentousstructuressuchasthecollateralliga-mentsattheknee.70

Thisprovocativeassociationsuggests that theaccessibleneuralcomponentsfoundattheseregionsrevealthefacilitatedstatusoftheconnectedstructures.Thesesitesdonot,intheirentirety,indicatethattheproblemisexclusivetothissitebutmaybepartofachainattachedtodeeperandmoreelaboratestruc-turaldysfunction.Maintainedmuscletightness,elevatedIMP,ischemia,andsustainednociceptiveactivation,eitherthroughanactivatedaxonalreflexand/orsustainedneuroplasticresponsemaytriggerthenecessaryenvironmenttocreatethemanifesta-tionsencounteredonpalpatingcounterstraintenderpoints.

Manyoftheneuralandcirculatoryconduitsfollowsimilarcoursesthroughthebody.The“ruleoftheartery”alsoappliestotheneuralsystem.Itisnocoincidencethatthesetwovitalconduitscommonlywindtogetherthroughvariousconnectivetissueelementstoreachthetissuestheyserve.4�Functionalin-tegrityrequiresthisintimateconnectioninordertoprovidefororganizedmovementandresponsivenessofthebodysystems.Thisviewdiffersfromthe“boney”modelwhereinwemayviewthatavertebralmisalignmentmaybethesolecauseofourso-maticdysfunction.Theviewshouldratherbethatofacontiguousmechanismthatrequiresallelementsofthesomaticframeworkandvisceralsystemtomaintainhomeostasis.

Various methodologies also view the presence of tenderareasonthebodythatareassociatedwithsomaticandvisceraldysfunction. In addition to the current discussion regardingcounterstraintenderpoints,therehasbeenmuchdebateaboutthenatureandqualitiesoftriggerpoints,fibromyalgiatenderpoints,andacupuncturepoints.However, therehasbeenless


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debateovermotorpointsites,andthismaybeduetoanatomicalconsistencyanddiagnosticmethodslargelycorrelatedtoEMGstudies.Dr.AngusCathiestatedin1960that“manysocalled‘triggerpoints’ correspond to thepointswherenervespiercefascialinvestments”.58Othershavesitedtheconnectionbetweenneuralpositionsinrelationtothemusclesandfasciaandapos-sibleroleinpainandfunctionalalterations.

In“Muscles,TestingandFunction,”HenryO.Kendallsug-geststhatnervescouldbeirritatedfromthemusclesbeingdrawntautandfirm,thusexertingacompressiveorfrictionforceonthesenerves.46Musclesthatarepiercedbyaperipheralnervemaybecomesymptomaticifthemuscledevelopsadaptiveshorteningmovingthroughashorterrangeofmotionandbecomingtightbeforereachingitsfulllength.Examplesinclude:• Radialnervewiththesupinatorandlateralheadofthetri-

ceps• Mediannervewiththepronatorteres• Ulnarnervewiththeflexorcarpiulnaris• Greateroccipitalnervewiththetrapeziusandsemispinalis

capitis• C5&C6rootoftheplexusandthelongthoracicnervewith

thescalenusmedius• Musculocutaneousnervewiththecoracobrachialis• Lumbarplexusnerveswiththepsoas• Iliohypogastricnervewiththetransversusabdominis• Obturatornervewiththeexternaloblique• Fibularnerveviththebicepsfemorisandgastrocnemius

In the JAOA article, “Nerve compression syndromes asmodels for research on osteopathic manipulative treatment”(Luchenbill-Edds,Bechill),aquestionpresentedbyDr. IrvinKorrasked“Howmanycompression,angulation,orotherde-formationsofnervesandnerverootsbysurroundingstructuresinfluenceneuralchemistryandmetabolismand thesynthesisandaxonaltransportofmacromoleculesandsubcellularstruc-tures”?59Furtherreviewindicatedthattheeffectofcompressiononthenervescanproduceischemiaatpressuresof30mmHg,affectingthevesselsofthesubperineuralregionandleadingtodecreasedvenularoutflow.Additionally,theeffectofischemiaincreases the permeability of the endothelial linings of thecapillaries,which increases edema.Compression alsoblocksanterogradeandretrogradeaxonaltransportnecessaryfornu-trientsupport. Itwasalsosuggestedthatneurapraxia(axonalconductionand transportcompromisebutnoaxondegenera-tionresultingfromchronicoracutenervecompression)mayberelievedwithOMTwithcounterstrainlistedasoneof thepossibletreatmentmethods.

Chronicmyofascialtendernesshasnotbeenfoundtobeas-sociateddirectlywithongoinginflammation.�Localtendernessiscommonlyfoundovernervetrunksatsitesofentrapmentormetabolicinsult.Thishasbeenattributedtothesensitizationoffreenerveendingswithinneuralconnectivetissues,thenervinervorum.6�Additionally,itappearsthatunmyelinatedsensoryfibersaretheafferentlimboftriggerpoints.60Triggerpointscanbereducedbylidocaineinfiltrationorbytransectionofthemo-tornerveinnervatingthetriggerpoint.60However,transectionofthespinalcordabovetheleveltotheinnervationsitetothemusclehasbeenshowntofailtoabolishthetwitchresponseof

thetriggerpoint.Thisinterestingstudythereforedemonstratedthatthelocaltwitchresponseisaspinalreflexandnotmediatedinthecortex.

Acupuncturepointshavenotonlybeenassociatedwithtrig-gerpointsbutalsowithmotorpoints.60,61,63,64,65,66,67,68Therehasalsobeenthesuggestionthatacupuncturelocibecategorizedinto types that involve motor points, superficial nerves, andnerveplexi.63Clearly,incommonisthepresenceoftendernessatthesesites.Tendernessatmotorpointslocatedinthemyotomeshas been correlated to segmental spinal injury.67 Further, thedegreeoftendernesshasbeenfoundtocorrelatewiththesever-ityofsymptomswithgreaterinvolvementtoboththeanteriorandposteriorprimaryrami.Muscletendernessisfoundtobemaximalatthemotorpointlocation(neurovascularhilus).ThistendernesshasalsobeenassociatedwithpositiveEMGchangesthatmayormaynotbepresentinthemildestformoftendernessbutbecomemoreclearlysignificantwithgreaterneuropathicfindings.68Therefore,earlyneuropathicchangesthatmaynotbe detected by EMG could be best elicited by palpating fortendermotorpoints.

Concept of Neurocirculatory Integration (Fascial Release)

Itisevidentthattheaforementionedphysiologicchangesplayaroleintheassociatedmanifestationsofthecounterstraintenderpoint.Sustainedalterationwithinthemusclefibersthathavebecomeinhibitedandtautcanbeexpectedtodemonstratepoormetabolicactivityandsustainednociceptive input.��,30,33Tenderpointsfoundlongaftertheinjuryoccurreddemonstratesamemoryeffectlocallywithinthetissuesandthroughthecentralnervoussystem.

It is interesting to note the correlation of counterstraintreatmentpositionswith thepositionof thepatient’sbodyatthetimeofinjury.8Howisitthatosteopathicphysiciansremedythesomaticdysfunctionbyreturningthebodytothepositionofinjury?Howisitthattreatmentdecreasesthesensitivityandimprovesthequalityoffunctionofthesetissues?

Particularlyinterestingistheadditionalmanifestationofapalpablepulsationresponsefeltatthetenderpointsiteastreat-mentisdelivered.�3,45,47Itiscommonlythecasethatwhenthepatientreportsthemostsignificantreductionintenderness,thuswhenthenociceptiveinputisterminated,thepulsationamplitudeisfoundtobeatitsgreatestintensity.

Because neural and circulatory conduits tend to followtogether,andtenderpointsandmotorpointsareoftenfoundinclose proximity, the anatomical explanation why osteopathicphysicians are able to perceive this pulsation phenomenonbecomesmoreevident.Thisrepresentsanobjectivemanifesta-tionofimprovedmetabolicrecoverywithinthemuscletissues.Thisphenomenonsuggestsimprovedintramuscularperfusionnecessaryforthemuscletissuestorecovermetabolically,thusreversingtheeffectsfromaninjuryprocess.

Muscleimbalanceisdefinedastheexistenceofinequalityinthestrengthofopposingmusclegroupswhereinonemusclegroupisweakanditsopposinggroupisstrong(tight).Thisim-balanceleadstoinefficientandpotentiallyinjuriousmovements,particularlytothejoints.4,46Bothweakandtightmusclesreflect

�0/The AAO Journal March�007

abnormalmetabolicactivity.Counterstraintreatmentrequiresareductioninthetension(and,secondarily,ashortening)ofaparticularmuscleorgroupofmusclesalongwiththeassociatedmyofascialstructuresandjointsinordertoreducethenociceptiveafferentstimulusfoundatthetenderpointsite.7,8,�3,45,47

Muscles that are tight (with limited range of motion)anddonotpossesstenderpointstypicallyrequiretherapeuticlengthening,whichcanbeperformedwithvariousmanipulativetechniquessuchaswithmuscleenergytechnique.Musclesthatcontaintenderpointsmaynotbeasaccommodatingtoaggres-sivelengtheningwithoutaddeddiscomfort.Thus,counterstrainmethodologyhasprovidedamore“indirect”meansofreducingdiscomfortandassistingintheproperlengtheningoftheaffectedmyofascialtissues.

Typically,injuredmuscletissuesareprotectedfromfurthermovement through a spastic neural response generated frommuscletissues,themusclespindlesthatarecapableofprovid-ing this adaptation.1� Counterstrain treatment can be appliedconcurrentwiththeapplicationofpost-isometricrelaxationtotheantagonistmusclestoallowfurtherunloadingoftensiontothemyofascialgroupcontainingthetenderpoint.Thisprocesstransforms“classical”counterstrainapproachthatrequiresthepatienttobetotallypassivetoamoreintegratedprocessthatincorporatesgroupIainhibitoryinterneuronsthatnotonlyfunc-tionlocallyontheantagonistmusclesbutalsoathighercentersofcontrolopposingmusclesatthejointinreciprocalfashion.9

Togetherwiththereestablishmentofimprovedcirculatoryflowandreducednociceptiveinput,thisneurocirculatoryinte-grationfascialreleaseapproachincorporatesaneffectiveandefficient means of addressing the integrated neurocirculatoryneedsofthemusculoskeletalsystem.Thisintegrationofmeth-odsprovides for thecorrectionof the structural andposturalresponsesthebodyhasmanifestedwiththeoriginalinjury.Thisallowsforimprovedmusclebalancethroughtheactionontheagonists,antagonists,andsynergists.

Integrative Thinking – The ChallengeWearethereforeatthepointlonghopedforintheosteo-

pathicprofessionwherethemanifestationswehaveattemptedto describe receive support from dynamic technologies thatbringtolifetheanatomicalandphysiologicalmanifestationsofsomaticdysfunction.

Wehaveestablishedthecentralrolethatalteredmetabolicprocessescontributeintheinitiationandmaintenanceoftenderpoints,amanifestationofthepresenceofsomaticdysfunction.Thecoupledroleoftheneuralandcirculatorysystemsnowhavetobeviewedasaunitinordertomorecompletelyunderstandthepathophysiologyofsomaticdysfunctionandthemethodologiesrequiredtotreatthesedysfunctions.Toneglecttheimportanceof either system leads to a suboptimal understanding of theunderlyingphysiology.

The primary goal in the provision of medical servicesshouldbetooffer,throughbetterunderstandingofthebody’sresponsetoinjury,aconservativemeanstorestoreandmaintainproperrestingIMPlevels,circulatoryflow,andreducenocicep-tivestimulusbeforefurthermetaboliccompromiseorongoingdegenerationandmuscleimbalancebecomesestablished.Thisconservative emphasis should be encouraged throughout the

healthcaresystem.Neurocirculatory integration fascial release that utilizes

counterstrainalongwithotherosteopathicmanipulativeprin-ciplesenhancesneuralandcirculatorynormalizationwithinthetissues,providingaconservativeapproachthatisbothdiagnosticandtherapeutic.Theconceptsexploredhereofferawindowintoabetterunderstandingofthecomplexityandyettheopportunityto evolve with a greater appreciation for what we can do toaddresstheneedsourpatients.Thisunderstandingcanleadtoimproveddiagnosticassessmentsandtreatmentoutcomesthatimpactthehealthcaresystemand,mostimportantly,thetreat-mentofourpatients.

__________________________________________

SpecialthankstoClaudioCarvalho,DO,MS.AdditionalthankstotheFellowshipCommitteeoftheAmericanAcademyofOsteopathyandtoDennisJ.Dowling,DO,FAAO,RichardL.VanBuskirk,DO,PhD,FAAO,RobertKessler,DO,andtoGabrieleRenniefortheireditorialassistance.

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41. KukowskiB.SuprascupularNerveLesionasanOccupationalNeuropathyinaSemiprofessionalDancer.ArchivesofPhysicalMedicineandRehabilitation.Jul1993;74(7):768-769.

4�. RingelSP,TreihaftM,CarryM,FisherR,JacobsP.Supra-scapularNeuropathyinPitchers.AmericanJournalofSportsMedicine.Jan-Feb1990;18(1):80-86..43

43. FerrettiA,CerulloG,RussoG.SuprascapularNeuropathyinVolleyballPlayers.JournalofBoneandJointSurgery,Ameri-canVolume.Feb1987;69(�):�60-�63.

44. HerbertsP,KadeforsR,HogforsC,SigholmG.ShoulderPainandHeavyManualLabor.ClinicalOrthopaedicsandRelatedResearch.Dec1984;(191):166-174.

45. RenniePR,GloverJ,CarvalhoC,KeyLS.CounterstrainandExercise:AnIntegratedApproach.�ded.Williamston,Mi:RennieMatrix;�004.

46. KendallFP,McCrearyEK,ProvancePG:Muscles,Testing,andFunction.ed.Philadelphia,Pa:Lippincott,WilliamsandWilkins;1993.

47. GloverJ.RenniePR.StrainandCounterstrainTechniques,In:FoundationsforOsteopathicMedicine,Baltimore,Md:Lip-pincott,WilliamsandWilkins;�00�.

48. SperryMA,GoshgarianHG.Ultrastructuralchangesintheratphrenicnucleusdevelopingwithin�haftercervicalspinalcordhemisection.ExperimentalNeurology.-1993;1�0:�33-�44.

49. HughsonRL,Shoemaker3K,TschakovskyME,&Kowalchuk3M.DependenceofmuscleVo�(oxygenuptake)onbloodflowdynamicsatonsetofforearmexercise.JournalofAppliedPhysiology,1996;81(4):1619-16�6.

50. JanssonE,DudleyGA,NormanB,TeschPA.Relationshipofrecoveryfromintensiveexercisetotheoxidativepotentialofskeletalmuscle.ActaPhysiologicaScandinavica.May1990;139(1):147-15�.

51. Shoemaker3K,PandeyP,HerrMD,SilberDH,YangQX,SmithMB,GrayK,SinowayLI.Augmentedsympathetictonealtersmusclemetabolismwithexercise:lackofevidenceforfunctionalsympatholysis.JournalofAppliedPhysiology,1997;8�(6):193�-1938.

5�. KagayaA,HommaS.BrachialarterialbloodflowduringstatichandgripexerciseofshortdurationatvaryingintensitiesstudiedbyaDopplerultrasoundmethod.ActaPhysiologicaScandinavica.Jul1997;160(3):�57-�65.

��/The AAO Journal March�007

53. GSjogaard,BRJensen,ARHargens,KSogaard.IntramuscularpressureandEMGrelateduringstaticcontractionsbutdissoci-atewithmovementandfatigue.JournalofAppliedPhysiology.�004;96:15��-15�9.

54. AmeredesBT,ProvenzanoMA.Regionalintramuscularpressuredevelopmentandfatigueinthecaninegastrocne-miusmuscleinsitu.JournalofAppliedPhysiology.Dec1997;83(6):1867-1876.

55. SaltinB,RadegranG,KoskolouMD,RoachRC.Skeletalmusclebloodflowinhumansanditsregulationduringexercise.ActaPhysiologicaScandinavica.Mar1998;16�(3):4�1-436.

56. OdlandR,SchmidtAH,HunterB,KidderL,BechtoldJE,LinzieBM,PedowitzRA,HargensAR.Useoftissueultrafil-trationfortreatmentofcompartmentsyndrome:apilotstudyusingporcinehindlimbs.JournalofOrthopaedicTrauma.Apr�005;19(4):�67-�75.

57. LarssonR,ObergPA,LarssonSE.Changesoftrapeziusmusclebloodflowandelectromyographyinchronicneckpainduetotrapeziusmyalgia.Pain.Jan1999;79(l):45-50.

58. CathieAG.Thefasciaofthebodyinrelationtofunctionandmanipulativetherapy.In:1974YearbookofPapersSelectedfromtheWritingsandLecturesofAngusG.Cathie,D.0.,M.Sc.(Anatomy),F.A.A.O.ColoradoSprings,Co:AmericanAcademyofOsteopathy;1974:81.

59. Luckenbill-EddsL,BechillGB.Nervecompressionsyn-dromesasmodelsforresearchonosteopathicmanipulativetreatment.JournaloftheAmericanOsteopathicAssociation.1995;95(5)319-3�6.

60. RivnerMH.Theneurophysiologyofmyofascialpainsyndrome.CurrentPainandHeadacheReports.Oct�001;5(5):43�-440.

61. MelzackR.Myofascialtriggerpoints:relationtoacupunctureandmechanismsofpain.ArchivesofPhysicalMedicineandRehabilitation.1981;6�:114-117.

6�. QuintnerJL,CohenML.Referredpainofperipheralnerveorigin:analternativetothe“myofascialpain”construct.ClinicalJournalofPain.Sep1994;10(3):�43-51.

63 GunnCC,DitchburnFG,KingMH,RenwickGJ.Acupunc-tureloci:aproposalfortheirclassificationaccordingtotheirrelationshiptoknownneuralstructures.AmericanJournalofChineseMedicine.1976;4:183-195.

64. GunnCC,MilbrandtMD,LittleAS,MasonKE.Dryneedlingofmusclemotorpointsforchroniclow-backpain.Spine.May1980;5(6)�79-�91.

65. LiaoSJ.Acupuncturepoints:Coincidencewithmotorpointsofskeletalmuscles.ArchivesofPhysicalMedicineandRehabili-tation.1975;56:550.

66. LiuYK,VarelaM,OswaldR.Thecorrespondencebetweensomemotorpointsandacupunctueloci.AmericanJournalofChineseMedicine.1975;3:347-358.

67. GunnCC,MilbrandtWE.Tendernessatmotorpoints.Adiag-nosticandprognosticaidforlow-backinjury.JournalofBoneandJointSurgery(Am].Sep1976;58(6):815-8�5.

68. GunnCC,MilbrandtWE.Tendernessatmotorpoints:Anaidinthediagnosisofpainintheshoulderreferredfromthecervicalspine.JournaloftheAmericanOsteopathicAssociation.Nov1977;77:196-�1�.

69. WalkoEJ,JanouschekC.Effectsofosteopathicmanipulativetreatmentinpatientswithcervicothoracicpain:pilotstudyusingthermography.JournaloftheAmericanOsteopathicAs-sociation.Feb1994;94(�):135-141.

70. McDougallJJ,BrayRC,SharkeyKA.Morphologicalandimmunohistochemicalexaminationofnervesinnormalandin-juredcollateralligamentsofrat,rabbit,andhumankneejoints.TheAnatomicalRecord.May1997;�48(1):�9-39.

71. BoronWF,BoulpaepEL.MedicalPhysiology,Philadelphia,Pa:Saunders;�003:�39,1��0,1�45.

7�. TheGlossaryReviewCommitteeoftheEducationalCouncilonOsteopathicPrinciples.Glossaryofosteopathicterminology.In:WardR.FoundationsforOsteopathicMedicine.Baltimore,Md:Lippincott,WilliamsandWilkins;�00�:1�4�,1�49.

71. BoronWF,BoulpaepEL.MedicalPhysiology,Philadelphia,Pa:Saunders;�003:�39,1��0,1�45.

7�. TheGlossaryReviewCommitteeoftheEducationalCouncilonOsteopathicPrinciples.Glossaryofosteopathicterminology.In:WardR.FoundationsforOsteopathicMedicine.Baltimore,MD:Lippincott,WilliamsandWilkins;�00�:1�4�,1�49.

Accepted for publication:March�006

Address correspondence to:PaulR.Rennie,DO,FAAOCAOBNMM,CAOBFP,DAAPMAssociateProfessorTUCOM/NV874AmericanPacificDriveHenderson,NV89014E-mail:[email protected]

CME QUIZ Thepurposeofthequizfoundonthenextpageistoprovideaconvenientmeansof self-assessment foryourreading of the scientific content in the “Counterstrain Tender Points as Indicators of Sustained Abnormal Metabo-lism – Advancing the Counterstrain Mechanism of Action Theory”byPaulR.Rennie,DO,FAAO.Foreachofthequestions,placeacheckmarkinthespaceprovidednexttoyouranswersothatyoucaneasilyverifyyouranswersagainst thecorrectanswersthatwillbepublishedintheJune�007issueoftheAAOJ. ToapplyforCategory�-BCMEcredit,transferyouranswerstotheAAOJCMEQuizApplicationFormanswersheetonthenextpage.TheAAOwillrecordthefactthatyousubmittedtheformforCategory�-BCMEcreditandwillforwardyourtestresultstotheAOADivisionofCMEfordocumentation.

mIchIgan

Medicalofficebuildingforsale.BetweenLakeErieandI-75.�0minutesfromhospitalsinMonroe,MIandToledo,OH.Floorareaspace1,�74sq.ft.3examrooms,office,�restrooms,library/kitchen,largewaitingroomandlargestorageroom.Pavedcarportandamplefrontparking.Naturalgas,citywaterandcitysewer.ContactIsabelleChapelloafter�:00pm.Phone734/848-5565.Buildinglocation:10643Val-leywoodDrive,LunaPier,MI.


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Name of Article:Counterstrain Tender Points as Indicators of Sustained Abnormal Metabolism – Advancing the Coun-terstrain Mechanism of Action Theory

Author: PaulR.Rennie,DO,FAAO

Publication: Journal of the American Academy ofOsteopathy,Volume17,No.1,March�007,pp16-��

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December�006AAOJCMEquizanswers:1.C�.A3.B4.C5.A6.D

1.Itisexpectedthatweaklocalappliedpressurewillstimulateanociceptiveresponse.

A.True B.False

�.Fromwhatpercentageofamuscle’smaximalcontractionforcewillitcompressitsownbloodvessels?

A.10% B.�0% C.30% D.50% E.80%

3.Increasedintramuscularpressure(IMP): A. isassociatedwithreducedfluidcontentafter

repeatedmaximalisokineticcontractions B. isunaffectedbythefascialcomplianceinthemuscle

compartment C. isaggravatedbystaticworkandinactivity D. hasnoeffectonthelow-pressurevenoussystem E. increaseswasteproductremovalfromthetissues

4.Incontrasttofasttwitchmusclefibers,slowtwitchmusclefibers:

A. havelessmitochondriaandbloodcapillaries B. arelessinvolvedwithproprioceptiveinput C. aremorepaleincolor D. aredesignedmoreforballisticactivities E. arelesssubjecttofatigue

5.Whichofthefollowingistrueregardingintramuscularpressure?

A. Allofthemusclesinthebodygeneratethesameintramuscularpressuresduringnormalactivities.

B. Eachindividualmusclegeneratesthesameintramuscularpressureinalldirectionsofmotion(positions)forthatparticularmuscle.

C. Pressuresaslowas15mmHgreducemicrocirculatorysupporttofragilesitessuchasthetendons.

D. Enhancesnutrientandoxygendeliveryatpressuresgreaterthan30mmHg.

E. Reducesnociceptivestimulationatpressuresgreaterthan30mmHg.

6.Tendernessfoundatmotorpointscorrelatestosegmentalspinalinjuryandthedegreeoftendernesstotheseverityofsymptoms

A. True B. False

FORUM FOR OSTEOPATHIC THOUGHT


John Wernham, DO, FICO, FCO

JOHN WERNHAMDO FICO FCO

Osteopath

2nd May 1907 – 9th February 2007

JohnWernham,DO,FICO,FCO,passedawayonFebruary9,�007.Hehadenteredhis100thyear,aged99yearsand3months.Hislifeandimpactontheteachingandpracticeof“ClassicalOsteopathy”intheUnitedKingdomwasgreat,indeed.

Froman early age, this iconic individualwasprofoundlydedicated to his friend and mentor, John Martin Littlejohn.HavingmetLittlejohnwhenhewasayoungchild,timewouldprovehisdevotiontothethoughtofthiscontemporaryofAn-drewTaylorStill.ThemajorsourceofinspirationforWernham’sworkappearstohavederivedfromLittlejohn’sworkwiththeBritishSchoolofOsteopathyduringthedecadesofthe19�0sand1930s.

FollowingLittlejohn’sdeath in1947,JohnWernhamem-barkedonanumberofactivitieswhichreflectedhisdesiretopreserve traditionalosteopathicphilosophyandprinciples inteachingandpractice.HeorganizedtheMaidstoneOsteopathicClinicin1949.WithT.E.Hall,anotherinfluenceonhisprofes-sionallife,hewasafoundermemberoftheInstituteofAppliedTechniquein1954.ThisorganizationservedasaforumformanyoftheUnitedKingdom’searlyosteopathicpioneers,andsoughttoperpetuatetheirteaching.Today,thatorganizationisknownasTheInstituteofClassicalOsteopathy.AnotheravenueofJohnWernham’seducationalinfluencewashisassistanceofThomasDummer,DOintheestablishmentoftheEuropeanSchoolofOsteopathyintheearly1970s.Organizationalskillsinsupportof commitment to purpose were supplemented by abundantjournalisticandphotographicskills.Itwasthroughtheseactivi-tiesthatthepublicationofmanytextsandarticlesdealingwithosteopathicprinciplesandpracticewasaccomplished.

RecognitionofJohnWernham’steachingwasextendedbymanycountriesoftheworldasidefromtheUnitedKingdom.ApartiallistincludesFrance,Belgium,Sweden,Finland,Italy,Canada,Japan,Ireland,Spain,Australia,NewZealand.Itmay

International Communications

A Tribute to John Wernham, DO, FICO, FCOAnthony G. Chila

bethattheUnitedStatesisonecountrywheretheteachingofthisosteopathisrelativelyunknown.Ifthatisso,itisanunfor-tunatecircumstance.

InFebruary�001,throughtheintercessionofmyfriendPaulMasters,DO,IhadtheopportunitytomeetandinterviewJohnWernham.Ontheoccasionofhis95thbirthday,May�,�00�,Iextendedbestwishestohim,recognizinghisstatureandnumer-ouscontributionstoOsteopathy.1Hisreplywas:

June5,�00�

DearDr.Chila:Thankyouforyourkindthoughts.Wemustremember,

however,thatstatureatthispresenttimehasbeenbuiltonthefoundationsofourpastandifwearetoremainintothefuturethenthefoundationsmustremain,firmandsecure.

WitheverygoodwishJohnWernham

Inthissameexchange,IexpressedthehopethatImighthavetheopportunitytowishhimaHappyBirthdayagaininfivemoreyears.Byamerethreemonths,thishasprovennottobeso.Duringthisinterval,anduntilhisrecentpass-ing,JohnWernhamremainedunyieldinginhiscommitmenttotraditionalosteopathicthought,teaching,andpracticeasunderstoodbyhim.

1. The American Academy of Osteopathy Journal. Volume1�,Number�,Summer�00�.p8.


IntroductionPepticulcerdisease(PUD)isvery

common,affectingapproximatelyfourmillionpeopleintheUnitedStates.Thelifetimeriskofdevelopingapepticulceris10%formalesand4%forfemales.Althoughitmayfirstappearinyoungadulthood,itismostcommonlydiagnosedinmiddle-agedtoolderadults.Somepatientswillhavecomplicationsfromthedisease.Thesecomplicationsincludebleedingin15-�0%ofpatients,a5%chanceofperforation,anda�%chanceofobstructionfromedemaorscarring.7

Althoughthecomplicationsofulcerscanbelife-threatening,pepticulcerdiseasetendstoimpairqualityofliferatherthanshortenlife-expectancy.Pepticulcerdiseaseiscommonlytreatedwithacidanti-secretoryagents,mucosalprotectiveagents,andmedicationstoeradicateHelicobactor pylori.Alternativetreatmentssuchasosteopathicmanipulativetreatment(OMT)canbehighlyadvantageousandeffectiveasanadjuncttherapyinreducingpatient’spainsymptomsandimprovingtheirqualityoflife.Thecasepresentedinthispaperandstudiespublishedintheliteraturefurthersupportsthistheory.

Definition:Apepticulcerisabreakinthemucosaofthegastrointestinal(GI)tractarisingwhenaggressivefactors,suchasacidproduction,overwhelmthemucosaldefensesystem.13Pepticulcersaremostoftenchronic,solitarylesions,andaremostprevalentwithintheduodenumorstomach.

Management of Peptic UlcerDisease Using OsteopathicManipulationHeather Danielle Morris and Jerry L. Dickey

Epidemiology:PepticulcersaremorecommoninpatientswhochronicallyuseNSAIDsorsmoke.Theredoesnotseemtobeevidenceindicatingalcoholasacontributoryforce.Theroleofstressisalsouncertain.13Theprevalenceofulcerstendstobehigherinmen.However,womenareatincreasedriskofdevelopinganulceraftermenopause.7

Etiology:Pepticulcersarisewhenthereisanimbalancebetweenthedamagecausedbyacidsecretionandtheprotectionmediatedbythemucosalbarrier.Therearethreemajorproblemsthatresultinthistypeofimbalance:chronicH. pyloriinfection,NSAIDs,andhypersecretorystates.BothH. pylori andNSAIDsresultindecreasedmucosalbarrierprotection.H. pyloricausesachronicintenseinflammatoryreactionthatoverwhelmsthemucosa.WhenH. pyloriiseradicated,ulcerrecurrenceratesaredramaticallyreduced.13NSAIDsdecreasemucosalprotectionbysuppressingtheproductionofprostaglandinsandalsoactingasadirectirritant.Theysignificantlyincreasetheriskofgastriculcers,butonlyslightlyincreasetheriskofduodenalulcers.TheriskofNSAIDscausinganulcerisincreasedwithhigherdoses,advancedage,andconcomitantcorticosteroidadministration.13Hypersecretorystatescauseanimbalancebecauseofanoverabundantproductionofacid;examplesincludeaZollinger-Ellisontumor,increasedbasalacidsecretorydrive,orimpairedinhibitionofacidproduction.7

Clinical Features:Themajorityofpepticulcerscauseepigastricgnawing,burning,orachingpain.Thepaintendstobeworseatnightandisclassicallyrelievedbyalkalisorfood.Nausea,vomiting,bloating,belching,andsignificantweightlossareadditionalmanifestations.7

Case PresentationIdentification:C.A.isa43-year-

oldwhitefemale.

Vital Signs:BP118/78,HR70/reg,Resp14,Wt9�.5lbs

Chief Complaint:Thepatientpresentstotheofficewithacomplaintofneck,shoulder,andupperbackpainpresentformanyyears.Patientalsostatesshehasheadachesthatworsenwithstress.

History of Present Illness:Thepainisrateda�onascaleof1-10,butissometimesahigherintensity.Patientdeniesradiationofpainorinjuryduetotrauma.

Past Medical History:Shehasbeentreatedwithanti-inflammatorymedication,musclerelaxants,andphysicaltherapy,noneofwhichproducedlong-termreliefofpain.ShehashadaMRIthatshowedslightbulgingatthecervicaldisc,butwastoldthiswasnotthecauseofherpainbyherfamilypractitioner.

Past Surgical/Trauma History: Positivefortworear-endandtwofront-endmotorvehicleaccidents.Shehas


alsohadtwonormalvaginaldeliveries,199�and1994.

Social History:ThepatientisabanddirectorwithintheDallasschooldistrict.Sheisnegativefortobaccoanddrinksalcoholsocially(onedrinkpermonth).

Allergies:Patientisallergictokeflexandpenicillin.Shedeniesseasonalallergies.

Medications:ThepatientiscurrentlybeingtreatedwithZoloft5mgfordepressionandsleeplessness.

Family History:Patient’sfatherdiedofemphysemaattheageof79.Hermotherdiedattheageof44ofalcoholismandsuicide.

Physical Exam:Thepatientwasexaminedinthewalking,standing,sitting,supine,andpronepositions.Thegaitisabnormalwithslappingoftherightfoot.Stanceappearsnormal.Whenviewedfromanteriortherightshoulderislowerthantheleftshoulder,althoughthepatientisleft-handdominant.Thereisnoheadtiltandotherwisegoodsymmetry.Onprofile,theweight-bearinglinefallsfromshouldertomalleolusclosetoideal.ThereisalossofdorsalkyphosisfromT4toT8,withthevertebradirectlyaboveandbelowcorrespondingtoherpainfulareas.Thereisalsoreducedlumbarandcervicallordosis.

Viewedfromposterior,therightshoulderislowerthantheleftshoulder.Thereisnoheadtilt.Thereisnoevidenceofscoliosisorhiphumpprovoked.Thereisevidenceofashortrightlegbasedontrochantericheight,poplitealtension,andAchillestendontension.

Thereisapositiveseatedandstandingflexiontestontheleftside.Whenassessedinthesupineposition,thepatientisfoundtohavealeftanteriorinnominate.Thepatientwasthenplacedinthepronepositionandthebonyelementsofthepelviswereassessed.Nosacralsomaticdysfunctionisfound.

ThereismotionrestrictionatL5inanon-neutralpattern,sidebent

rightandrotatedright.Also,thereisinhalationrestrictionofribs7-10.T1throughT4arerestrictedinsidebendingtotherightandrotationtotheleft.T8andT9arerestrictedinsidebendingtotheleftandrotationtotheright.Thereisalsoastrikingnon-neutralatT6,restrictedrotationandsidebendingtotheleft.ThecervicalspinehasosteoarthriticchangesfromC3toC6.Therewasalackofmotionofthefirstribbilaterally.

Theabdomenwaspalpated.Itissoftandscaphoid.Tendernessispresentovertheduodenalcap.

Initial Assessment: Leglengthsunequal,gastritis/duodenitis,cervicalspondylosis,andsomaticdysfunctionofthecervical,thoracic,lumbarspine,pelvisandribcage.

Treatment Plan:Itwasdecidedthatosteopathicmanipulativetreatment(OMT)wouldbeadministeredforaninitialthreevisits.Shewouldbereevaluatedatoneweekandthreeweekspostinitialvisit.

Course of Treatment: Attheinitialvisit,OMTwasdoneafteracompleteexamofthepatient.Theleftanteriorinnominatewascorrectedwithmuscleenergy.However,thiswasactuallyacompensationduetotheprobableleftshortleg,whichwillbefurtherassessedbyathreeviewposturalx-rayseries.Thenon-neutralL5wastreatedwithaseatedHVLAtechnique.TheribsandupperthoracicsweremobilizedusingaproneHVLAtechnique.ThelowerthoracicspinewasmobilizedbyasupineHVLAprocedure.ThecervicalspinewassuccessfullymobilizedwithHVLAandthefirstribdysfunctionwastreatedwithmuscleenergy.

Thenon-neutralfoundatT6wastreatedwithsupineHVLA.BecauseitisthereferencezonefortheGIsystem,thepatientwasquestionedforanddeniesheartburn.However,patientdoesadmittosuboccipitalheadacheswithretro-orbitalradiation.

Uponfurtherquestioning,thepatientalsostatedshedoesnoteatbreakfast.Patientwasinstructedtoeatahigh-proteinbreakfast,consistingof

aneggormeatsource.Shewasalsotoldtotakepeanut-buttertoschooltohelpneutralizethestomachacid.PatientwasgivenaprescriptionforAxid150mg,#60,tabs1bidwithmeals,x�refills.

Followingtreatment,patientcouldarisecomfortablyfromtheseatedpositionwithoutthecharacteristicpain.Thepatientwaswarnedthatshemightexperiencesoreness,especiallyinthecervicalspine.PatientwasdirectedtotheMedicalSurgicalHospitalforposturalstudy.

Atthesecondvisitapproximatelyoneweeklater,patientstatesherneckandbackpainareapproximatelythesameintensityaslastweek.PatientwasinformeditisstilltooearlytoseemarkedimprovementofGIsymptoms.Theposturalx-rayswerereviewedandthepatienthadadeclinationof4mmofrightfemoralheadand6mmdeclinationofthesacralbase.PatientwasgivenaV4inchheellift.Patient’scervicals,thoracics,andpelviswerealsotreatedwithHVLA.

Thethirdvisitwasscheduledforapproximatelythreeweeksaftertheinitialvisit.However,thepatientcalledandcanceledthisappointment.Thepatientwascontactedathomeforquestioningonhowshefelt.Shestatedthatherneckandbackpainwereintermittent,butstillthesameintensity.Shewasalsostillhavingoccasionalsuboccipitalheadaches.However,shestatedshewasnothavingabdominalpain.ThepatientadmittedthatshehadforgottentouseherprescribedheelliftandthatsheoccasionallyforgottotakeherAxid.Shealsostatedshewasinconsistentwitheatingahighproteinbreakfast.

Review of LiteratureAstudybyPikalovandKharin

evaluatedtheeffectivenessofspinalmanipulativemedicineinthetreatmentofduodenalulcers.Thereweretwogroupscompared:thecontrolgrouphadtraditionalmedicaltreatmentandtheinterventiongrouphadmanipulativetherapyrangingfrom5-��days.ThestudyshowedtherewasabenefitofOMTforrecurrentPUD,withtheinterventiongrouphavingpainreliefafter1-9daysandclinicalremission


anaverageoftendaysearlierthantraditionalcare.9

Severalstudiesintheliteraturedemonstratedthesignificanceofthoraciclesionsonthegastrointestinaltract.Tweednotedhyperchlorhydria,sometimeswitherosions,inanimalswithupperthoraciclesions.�Magounrealizedtheimpactofthoraciclesionswriting,“Animalswhichhavelesionsofthefifthandsixthvertebraeshowedulcerationareas;animalswhichhavenolesiondonotshowulceratedareas.Thefifththoraciclesioniscertainlyanimportant,ifnotchief,causeofgastriculcer.”8

Burnsalsodemonstratedtheimportanceoftheselesionsinastudyusingrabbits.Sheshowedthatalesionofmorethansixmonthsdurationwithinthethoracicvertebrae,particularlythefifthandsixth,causedgastriculcers.Shealsofoundthatfifth,sixth,andsevenththoracicnervelesionsresultsinhyperchiorhydria.4AnotherfacetofherstudywasdeterminingtheeffectsGIlesionshadonthemusculature.Shedidthisbymakingartificiallesionsinanimalsandnotinganychangesthatfollowed.Shefoundthatwithintwenty-fourhoursedemaandmusculartensionwerepalpated.Shealsonotedanincreaseinskintemperatureandmoisture.Lesionsovertwoyearsresultedinanincreaseinfibrosisduetomusclecontracture.Thesemuscleswerefoundtobehard,tense,andhypersensitivetopalpation.4

Throughouttheliterature,excessivevagalstimulationwasanimportantaspectinpepticulcerformation.AstudybyDeckerfoundthatchildrenwithvagusirritation,especiallytheuppercervicals,presentedwithpyloricspasms.6Pritchardalsostressedtheimportanceoflesionsintheuppercervicalareaandtheireffectsonthevagusascausativefactorsinpepticulcers.11Bondiesstated,“Cervicalandclavicularlesions,actingthroughthevaguscausedhypermotilityandhypersecretion”.�

Bruerestablishedthatthediaphragmanditseffectonthelymphaticsystemplayedamajorroleinformationandmaintenanceofulcers.Hestated,“...imperfectlymphaticdrainage,eitherlymphaticorvenous,

cannothelpbutproducepathologicalstates...theactionofthediaphragmisthegreatestsinglefactorinfluencinglymphaticandvenousdrainage.”3Also,experimentalinterferencewiththegastriccirculationwasshowntoincreasethesizeanddepthofgastriculcers.�

AcasestudybyUssher,foundthatagroupofpatientsthatpresentedwithabdominalpainalsohadposturaldefects,themajoritybeingshortlegsyndrome.ReliefofbackandGIpainwasobtainedbycorrectingthismisalignmentwithaheellift.15Magoun’sresearchsupportedthisandhestated,“Thefirststepistoeliminatetheunevenfoundation,foronlythiswaycouldwehopetosuccessfullyapproachthoselesionsmorecloselyrelatedtothegastroduodenalarea”.8

DiscussionTherearetwomainsourcesof

innervationtotheuppergastrointestinaltract.ThesympatheticinnervationtothestomacharisesfromT5-T9viatheceliacganglionandthesplanchnicnerves.Stimulationofthesympatheticsinhibitstheactivityoftheparasympathetic,whichresultsindecreasedacidsecretion.Italsoslowsperistalsisandmotility.Theparasympatheticinnervationisderivedfromthevagusnerve.Cholinergicstimulationincreasesacidsecretionandperistalticactivity.16

Alexanderstates,“…themotorcellsareinadelicatedynamicbalance.Thisbalancecanbelostbyexcessivestimulationfromanyoneormorenumeroussourceswhichbombardthecord.”1Whenthisbalanceischronicallylost,asinPUB,alterationsofthevisceracanresultindysfunctionofsegmentallyrelatedsomaticstructures.16Thisconceptisknownastheviscero-somaticreflex.Midthoracicpain,acommoncomplaintinpatientswithPUB,isanexampleofthisreflex.Themidthoracicareaisthesiteofthesympatheticoutflow.Thesympatheticgangliaarelocatedalongsidethevertebrae,anteriortotheribheads.Chronicgastricdiseaseresultsinirritationofthesympatheticnerves,whichisthentransmittedtothemidthoracicareaviathesplanchnic

nervescausingmusclespasmandpain.14

Thesomato-visceralresponseisanotherosteopathicconcept.Thisisdefinedassomaticinputproducingareflexresponseinsegmentallyrelatedvisceralstructures.16Thoracicsomaticdysfunctionpredisposingpatientstopepticulcerdiseaseexemplifiesthisreflex.Somaticdysfunctionofthemidthoracicareainhibitstheneurologicaloutputofthesympatheticganglia.Thiscouldconceivablycauseanimbalancebetweenthesympatheticandparasympathicnervoussystem,resultinginapredominanceofparasympatheticinput.Asdiscussedearlier,theparasympatheticstimulationcausesincreasedacidsecretionandthereforecouldpredisposepatientstopepticulcersformation.ThisisfurtherbackedupbyConleywhostates,“...pepticulceristheresultofcontinuedactionofthegastricjuiceonanareaofloweredresistanceinthestomachwall”.5

Althoughvertebrallesionsareconsideredthekeyareaofdysfunction,thereareotherproblemsthatcoexistinPUDpatients.Onesuchproblemisexcessivevagalstimulation.Pepticulcerpatientsshouldbeevaluatedforuppercervicalsomaticdysfunctionduetothelocationofthesuperiorandinferiorvagalgangliaattheoccipitalatlantalandatlantal-axialjoint.1�Chronicgastricirritationcausesanincreasedparasympatheticactivity,whichisthenreferredtotheseareasresultingincervicalsomaticdysfunction.Also,thevagushasconnectionswiththefirsttwosomaticnerves.1�Theseprovidepathwaysforfiberscarryingpainsensationtotheposteriorhead.Thisprovidesapossibleexplanationfortheoccipitalheadachessufferedinsomepatients.

AnothercoexistingprobleminpatientswithPUDisinhalationorexhalationthoracicribcagesomaticdysfunction.Thisshouldbeassessedbecausearibexcursionproblemcouldresultindiaphragmmotionrestrictionsincethediaphragmattachestoribs6-1�.Thediaphragmisresponsibleforthepressuregradientthathelpstoreturnlymphandvenousbloodbacktothethorax.11Finally,tocomplete


thewholebodyosteopathictreatment,patientsshouldbeevaluatedforanunequalposture(forexample,shortlegsyndrome)andifpresent,treatedwithaheellift.

Summary/ ConclusionOsteopathicphysicianscantreat

ahostoffactorsthatincreasethepatient’ssusceptibilityofdevelopingapepticulcer.However,itisimportanttounderstandthattreatmentofthedyspepticsymptomsalonedoesnotresultincompletecureofpepticulcerdisease.Aproperdiet,antacids,acidanti-secretoryagents,andantibiotics(ifH.pyloriispresent)areimportantandshouldbeusedifthephysiciansuspectsapepticulcer.Nevertheless,patientsshouldbeassessedtomakesureallaspectsoftheirbodiesareworkingatoptimallevels.Thisallowsthebodytohavethecapacitytohealitselfandpossiblypreventcircumstancesthatcouldleadtosubsequentulcerformation.

Thepatient’spresentingproblemwasslightlyimproveduponusingosteopathicmanipulation.Thelackofsubstantialimprovementwaslikelyduetopoorpatientcooperationandfailuretocompletetherequiredtreatmentprotocol.However,evenintheabsenceoffullcompliance,therewasadecreaseinthepatient’sabdominalpain.Ithinkthisandtheprecedingliteraturejustifiestheeffectivenessof

manipulativetreatmentandshowsthatbytreatingthewholebodymanyissuescanberesolvedthatmightleadtofuturemedicalproblemsandexpenses.Osteopathictreatment,asanadjunctivetherapytomedication,hasbeenproventoreducethepainandshortenthehealingtimeinpatientswithpepticulcers.OMTisthereforeatherapeuticoption,anditdefinitelyservesabeneficialpurposeinthetreatmentofthiscommonproblem.

References1. AlexanderClaudC.TheRoleof

OsteopathicLesionsinFunctionalandOrganicGastrointestinalPathology.JAOA. 1950.50:�5-�7.

�. BondiesOIandStillmanCJ.BasicPa-thologyofUlcerativeGastritis,JAOA.1936.35:5�5-5�9.

3. BruerWP.TheOsteopathicConceptofPepticUlcer. JAOA.1950.49:343-345.

4. BurnsL.VertebralLesionsandGastricUlcers,JAOA.19�8.187-189.

5. ConleyGJ.OsteopathicLesionasanEtiologicFactorinsomeCommonSur-gicalDisorders,JAOA.�001.101:467-470.

6. DeckerCEPathologyoftheStomach.JAOA.19�9.�9:15�-153.

7. KumarV,etal.RobbinsPathologicBasisofDisease.7thedition.Philadel-phia,PA.Saunders.�005.

8. MagounHI.GastroduodentalUlcersfromanOsteopathicViewpoint.Yearbook of the Academy of Applied Osteopathy. pp117-1�0.

9. PikalovAandKharinV.UseofManip-ulativeTherapyinTreatingDuodenal

VIOLA M. FRYMANN DO, FAAO, FCA AWARDED NEW HONORS“Docteur Honoris Causa” by L’Universite Europeenne D’Osteopathie, Paris, France and

FIRST “Professeure Emerite” by Faculty, College D’Etudes Osteopathiques, Montreal, Canada

DR FRYMANN WILL DIRECT CRANIAL COURSESMay 7-11 & July 30 - August 3, 2007

At Osteopathic Center for Children San Diego, California

Brochure, Registration and Forms available at www.osteopathiccenter.orgInquiry: [email protected] (T) 619.583.7611 (F) 619.583.0296

Sponsored by:OSTEOPATHY’S PROMISE TO CHILDREN

4135 54TH Place, San Diego, CA 92105

Ulcer:APilotStudy.J Manipulative and Physiologic Therapeutics.1994.5:310-313.

10. PritchardW.AnatomicalandPhysiol-gicalConsiderationsoftheStomachandDuodenum.JAOA.19�9.�9:15�-153.

11. SavareseRG,et.al.OMTReview.3rdedition.USA.�003.

1�. SimmonsSL.Osteopathic Manipula-tive Medicine.1stedition.USA:�00�.

13. TierneyLM,etal.Current Medical Diagnosis and Treatment.44thedition.McGraw-Hill.�005.pp568-574.

14. TumenHJandYaskinJC.Backacheduetointra-abdominaldisease.Gas-troenterolgy.1946.7:�94-305.

15. UssherNT.Viscerosomaticsyndrome:NewConceptofVisceromotorandSensoryChangesinRelationtoDe-rangedSpinalStructures.Ann Int Med. 1940.13:�057-�090.

16. WardRC,et.al.Foundations for Os-teopathic Medicine.Philadelphia,PA.LippincottWilliams&Wilkins.�003.

Accepted for publication:September�006

Address correspondence to:HeatherDanielleMorris,OMS-IV�501OakHillCircle,Apt.�14FortWorth,TX76109Email:[email protected],DO,FAAOUNTHSCatFortWorth/TCOM3500CampBowieBlvd.FortWorth,TX76107Fax:817/735-�480


Book ReviewAnthony G. Chila, Reviewer

Neural Therapy: Applied Neurophysiology and Other Topics. Robert F. Kidd, MD, CMpp. 203, incl. Index. Copyright © 2005. ISBN 0-9737800-0-2. $79.95 USTelephone: 1-800-575-1968. Fax: 613-432-7184. www.neuraltherapybook.com

Thefieldofneuraltherapybeganwiththerealizationthattherapeuticeffectsofprocainemightbeexpectedtosignificantlyoutlastusualexpectationsforlocalanesthesia.Theclinicalexperienceofpracticingneuraltherapyenhancesrespectfortheautonomicnervoussystem’simportanceinregulat-ingthebody’sprocesses.Thesuccessofthisapproachrestsonfindingandtreatinginterference fields, thefociofelectrophysiologicalinstability.Thistextoffersanintroductiontoneuraltherapyfortheaveragegeneralphysicianhavingnopreviousknowledgeofthesubject.

Theauthorhaspracticedneuraltherapysince1987,andtaughtintheUSandCanadasince1995.HisworkoffersthefirstEnglish-languagetextbookonneuraltherapyinmorethan�0years.HehasgivenhisAmericanaudienceofosteopathicphysiciansOsteopathic treatment by injection: a comparison of osteopathic manipulative treatment and neural therapy. AmAcadOsteopathyJ�001;11(3):�9-33.Thethreesectionsofthetextexplore:neurophysiologicalprinciples;practicalapplicationofgeneralprinciplestointerferencefields;systemicfactorsinhibitingneuraltherapy.

Thecasualreaderwillbenefitfromreadingthescholarlypresentationofthehistoricaldevelopmentofthisapproachinordertoconsideritsrelevancetoosteopathictheory,methodsandpractice.Themotivatedreaderwillbenefitfromexploringthepotentialforintegrationofthismethodintohis/herpracticeofosteopathicmedicine.

Somatic Dysfunction in Osteopathic Family Medicine.Editor, Kenneth E. Nelson; Associate Editor, Thomas Glonekpp. 532, incl. Index. Copyright © 2007 Lippincott Williams & WilkinsIllustrations Copyright © 2007 American College of Osteopathic Family PhysiciansISBN-10: 1-4051-0475-9 and ISBN-13: 978-1-4051-0475-3 $42.95 USTelephone: 1-800-638-3030. www.lww.com

Atextisnowavailablewhich“presentsacontemporaryunderstandingofthefundamentalsofosteo-pathicphilosophyandtheapplieddiagnosisandtreatmentofsomaticdysfunctionthroughoutthepracticeoffamilymedicine”.ThetextwasinitiatedattherequestofAndreV.Gibaldi,DO,FACOFP,formerChair,DepartmentofFamilyMedicine,ChicagoCollegeofOsteopathicMedicine.Fromaproposedseriesof

postdoctoraleducationlectures,thegradualdevelopmentofatextbookofclinicalpracticetookplace.

Thetextisdividedintoareasof:Philosophyandprinciplesofpatientcare;Categoriesofpatientsencountered;Categoriesofclinicalconditionsencountered;Practiceissues.Itisemphasizedthatthetextisneitherareviewofgeneralmedicalpracticenoramanualofosteopathicmanipulativetreatment(OMT)procedures.Rather,focusisgiventopatientempowermentintheestablish-mentandmaintenanceofhealth.Inseekingtoaccomplishthisgoal,thediagnosisandtreatmentofsomaticdysfunctionfostersthepatient-oriented,holisticapproachtohealthcare.Theeffect(s)ofsomaticdysfunctiononhealthstatusisgivenprominentattention,aswellasthelogicforclinicaluseofOMTinpatientcare.Selectedexamplesofproceduralchoicesisprovided.Althoughfrustrat-ingtopractitionersofdisease-focusedmedicine,thispatient-focusedparadigmlendsitselfquitenaturallytothebroadcategoryoffunctionalillnessessofrequentlyencounteredinfamilypractice.

Thetextisenhancedbythecontributionsofmultipleauthors,andtheextensivelistofreviewershelpstoinsurethatthetextadherestoitspurposes.Theresultisavaluableresourceforthefamilypractitioner.


Elsewhere in PrintPhilosophy, Science, Art

The Cutting Edge: Where Practice, Science & Consciousness Merge

Fourinternationallyrespectedpioneersparticipatedonapanelatthe�006ISSSEEMConference.Theparticipantswere:HarryOldfield,D.Hom.(Med.);BeverlyRubik,PhD;JohnVeltheim,DC,BAc;NormShealy,MD,PhD.Someoftheirpersonalanddeeplyheldbeliefswerearticulated:

Oldfield:“Theintentistodowell,tobringsomeonebackfromdiseaseintoease,whichmeansbalance.”Shealy:“...scienceisthefocusofconsciousness.Atruesciencecan’texistwithoutconsciousness.”Veitheim:“Ihaveseentopstudentswhostillcan’tmakealivingbecausetheyhadnotlearnedhowtoeffectivelygetthepatient’sconsciousnessworkingwiththem.”Rubik:“Ithinkitisimportantthatpractitionersbefullypresentandnotbeunderstress.Ithinkthattheymustbeinaplaceofhigh-levelwellness.”

BRIDGES: Summer 2006 17 No 2Schachter, B. The Explosive Silence of RNAi

A Brief History of the Basic and Applied Science of Antisense Oligonucleotides.“ThenotionthatantisenseRNAorDNAcouldsilencegenespost-transcriptionally(i.e.,blockmRNAtranslationintoprotein)camefrom1978reportsbyPaul ZamecnikandMary Stephenson(Harvard).TheirworkshowedthatsmallantisenseDNA,whenaddedtoacellextract,boundspecificallytoitscomplementonmRNAintheextractandselectivelyinhibitedtranslationofthatmRNA.Extendingthatfinding,researchersshowedthatantisenseoligodeoxynucleotides(ASOs)couldsometimesblockmRNAfunctioninlivingcellsandeveninintactorganisms.Duringthe1980s,ASOscapturedtheimaginationofmanyscientists:SomeaimedtousethesyntheticASOsastoolsforknockingdownexpressionoftheirgenesofchoice,tostudytheirfunctions.OtherinvestigatorstriedtodesignanddevelopASOdrugs.Indeed,therecentRNAi“applicationsrevolution”haditsconceptualoriginsinASOresearch.AmajorhurdlehasbeenthatASOsrarelyworkedwell.AsRNAiresearchersliketomention,RNAistrategiesarerobustandspecificpreciselybecauseappliedRNAiexploitsanendogenouscellularmechanism,somethingASOsdonotdo.

Update. The New York Academy of Sciences Magazine, January-February 2007: 6-9Stix, G. Spice Healer

“KnownasHaldiinHindi,jiang huanginChinese,manjalinTamil,turmerichasamedicinalhistorythatdatesback5,000years.Atthattimeitwasakeymedicamentforwoundhealing,bloodcleansingandstomachailmentsinIndia’sAyurvedicsystemofmedicine.ThefirstrecordinPubMedofresearchonthebiologicalactivityofcurcumindatesbackto1970,whenagroupofIndianresearchersreportedtheeffectsofthecompoundoncholesterollevelsinrats.Thepaceofstudiespickedupinthe1990s;oneoftheleaderswasBharatAggarwal,aformerscientistatGenentechwho,beforeturningtocurcumin,hadtakenanotherapproachtoseek-ingcancertreatments.Thatworkledhimcircuitouslytothecompound.Inthe1980s,AggarwalandhisteamatGenentechwerethefirsttopurifytwoimportantimmunemolecules–tumornecrosisfactor(TNF)alphaandbeta–thathavebeenidentifiedaspotentialanticancercompounds.Thesemoleculescan,infact,killcancercellswhendeployedinlocalizedareas,butwhencirculatedwidelyinthebloodstream,theytakeondifferentproperties,actingaspotenttumorpromoters.TheTNFsactivateanimportantprotein,nuclearfactorkappaB(NFkappaB),whichcanthenturnonahostofgenesinvolvedininflammationandcellproliferation.”

“AggarwalhasgoneontopublishstudiesshowingthatblockingtheNFkappaBpathwaywithcurcumininhibitsthereplicationandspreadofvarioustypesofcancercells.Thisworkhasservedasajumping-offpointforearly,smallclinicaltrialsatM.D.An-dersonusingcurcuminasanadjuncttherapytotreatpancreaticcancerandmultiplemyeloma.TrialsarebeginningorunderwayelsewhereforpreventionofcoloncancerandAlzheimer’sdisease,amongothers.”

3�/The AAO Journal March�007

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