Still Review

Andrew Taylor Still
founded an overall healthcare philosophy.
A.T. Still University Review Fall 2006
Contents
The articles in this edition were first published in the Journal DO Deutsche Zeitschrift
fr Osteopathie, 1 and 2/2006, Hippokrates Verlag in Germany in 2006. Professor Rene
McGovern, Ph.D., was the invited editor of that edition.
On the Cover:
An oil painting of Andrew Taylor Still
by George Burroughs Torrey, who also
painted portraits of Theodore Roosevelt,
King George of Greece, and President
William Howard Taft.
James J. McGovern, Ph.D.

President
Adrian Anast, Ph.D.
Vice President of
Communications and Marketing
Hector Contreras
Senior Editor
Bill Beard, JK Creative Printers

Graphic Art Design
JK Creative Printers, Quincy, Ill.

Printing
The A.T. Still University Review is

published by the Communications and
Marketing office of A.T. Still University,
800 West Jefferson St., Kirksville, MO
63501
A.T. Still University is an equal
employment/affirmative action institution.
3
5
7
10
14
20
Thoughts on Healthy Aging

from Dr. Andrew Taylor Still
Osteopathically
Caring for the Old
Osteopathic Medicine
and Research in America
Aging and Osteopathy:

The Role of Evidence
Osteopathic Manipulation
in the Elderly and Current
Clinical Research
What Osteopathy has
to offer Golden Girls
Still university review
Fall 2006
Thoughts on Healthy Aging

from Dr. Andrew Taylor Still
Jason Haxton, M.A.

Director, Still National Osteopathic Museum
ndrew Taylor Still, M.D.,

D.O., spent 20 years
learning and perfecting
osteopathic medicine before
founding the American School
of Osteopathy. He was 65 years
old when he first opened the
doors to his medical school. The
plan to build this school was
strongly encouraged by Kirksville
leaders and businessmen who
feared that because of his age,
Dr. Still might die at any time
without trained followers. The
loss of Dr. Stills unique healing
skills would jeopardize the newly
gained revenue coming from
thousands of patients coming
to the town for osteopathic
treatments. Initially, Kirksvilles
citizens were considering their
own self-interest because they did
not really understand this doctor
who practiced medicine without
relying on drugs and healing
crippled bodies with his hands.
Dr. Still advocated awareness of
healthy activities for the body,
mind, and spirit as a solid defense
against disease. This insight by
Dr. Still is confirmed today in
several recent studies. In one
study of centenarians conducted
by Evercare, spirituality was cited
most frequently as the driver of
their longevity.1
United States Life Expectancy3

Approx. Date
1800
1900
1950
2000
Fall 2006
Old Age
40
52
65
77
In books written during the

1800s, there are references to men
in their 40s as dear old men.
People typically died young. The
average life expectancy in the
United States did not reach 65
years until about 50 years ago
(see chart below). With this in
mind, one can see that Dr. Still
was considered old by the time he
opened his school for students.2
Because reaching a ripe old age
was enough of a struggle, devoting
time to studying the needs of the
elderly was not much of a concern
in this period of history. Even Dr.
Still seemed to have his doubts
about his future prospects. On
Aug. 8, 1897, in an address before
his fellow townsmen, Dr. Still said,
I am now 69 years old. Next year
makes 70. I do not expect to have
many more such celebrations.
My father died at 71, my mother
at 89. As long as I live, I will be
an uncompromising defender
of osteopathy.4 Dr. Still lived
another 19 healthy years after
making this speech.
For both the young and the
elderly, Dr. Still viewed the human
body as a machine in which needs
for health and longevity were
the same. His concept embraced
the physical, the chemical, and
the psychic factors involved in
any given condition. His simple
statement of the principles
formulated from his studies and
experiments was I knew I had
the truth and that the truth was
immortal and that some day the
principles of osteopathy would be
hailed with gladness throughout
the Earth. The principles are in
harmony with the great laws of
God as seen in nature. Osteopathy
deals with the body as a perfect
machine, which if kept in proper
adjustment, nourished and
cared for, will run smoothly
into ripe and useful old age. As
long as the human machine is
in order, like the locomotive or
any other mechanical product, it
will perform the function that it
should.5 Dr. Still further argued
that to be an osteopath you
must study and know the exact
construction of the human body;
the exact location of every bone,
nerve, fiber, muscle and organ;
the origin, the course and flow
of all the fluids of the body; the
relation of each to the other; and
the functions it is to perform in
perpetuating life and health.6
Dr. Still also advocated that
Dr. A.T. Still with staff age 83

Museum Collection [PH 2000.34.05]
He also commented
on food and aging in his
books, indicating that as
one grows older and slows
in activity, food intake
should be less. Using
nature as his guide, he
advised, All long-lived
birds and animals that
live on but a few kinds of
food should be a lesson
for man not to eat and
drink until the body is so
full that no blood vessel
can pass in any part of
the chest and abdomen.
Our great dinners are
only slaughter pens of
show and stupidity. Let
me eat quick and trot,
and . . . have health and
strength.8
Comparing the body
to architecture and noting
that the end result or
later years of life reflect
the early years, he said,
Dr. A.T. Still upon his 82nd birthday climbing a tree
With us the foundation
to show off his vigor and good health.
of life must be solidly
Museum Collection [PH STAT- 18]
constructed of stones of
the highest grades of purity, or
through healthy eating, exercise,
your house will lean toward the
proper alignment and positive
imperfect stones in the foundation;
thoughts, the human brain was
your building will bulge, crack,
capable of creating the necessary
decay and fall down, and become
medicines needed for the bodys
simply a heap of ruins that will
health throughout ones life. He
write the history of ignorance
said, Turn the waters of life loose
on the part of the architect and
at the brain, remove all hindrances
builder.9
and the work will be done, and
give us the eternal legacy
LONGEVITY.7
Further, he had such a solid
interest in healthy eating that
Dr. Still had strong words about
excessive eating at all stages of
life. He once said, Eat three
conservative meals a day. Do not
be a glutton! You can poison your
system with too much food too
often and of the wrong kind.

Following his own advice to

seek proper alignment, Dr. Still
regularly gave himself adjustments
using a wooden ball on a stick
and took treatment from others
as needed. Of this area of healthy
aging, he stressed, When all parts
of the human body are in line, we
have perfect health. When they are
not, the effect is disease. When the
parts are readjusted, disease gives
place to health.10
In addition to his focus on
healthy living, he wrote a good
bit on his belief that death
was a natural part of the cycle.
Death is the completed work of
development of the sum total of
effort to a finished work of nature.
Thus, immortality is the design
or object of natures God in its
production of man.11
Just before his 80th birthday,
Dr. Andrew Taylor Still was
recognized for his achievements
for helping others achieve
healthier lives. On this occasion,
Dr. Still said, I do not know how
long I will live. That doesnt make
any difference with me. Nature to
me has good horse sense like
God.12
Dr. Still lived to be 89 years old. n
Bibliography
1 Minneapolis PRNewswire (2006).
Evercare leading provider
of health plans for elderly,
disabled and chronically ill in
the USA. http://money.cnn.
com/services/tickerheadlines/prn/
200608100800PR_NEWS_USPR__
___NYTH008.htm
2 Lifespan and Aging. http://www.
baptistonline.org/health/library/
agin3385.asp
3 Fertility and Mortality in the U.S,
1800-2000. http://www.eh.net/
encyclopedia/?article=haines.
demography
4 Booth, E.R. (1924) History of
Osteopathy. Cincinnati, OH. pp.
435.
5 Webster, G. (1935) Sage Sayings of
Still. Los Angeles, CA. pp. 25.
6 Still, A.T. (1908) Autobiography
of Andrew T. Still. Kirksville, MO.
pp. 358.
7 Still, A.T. (1899) Philosophy of
Osteopathy. Kirksville MO. pp. 79.
8 Still, A.T. (1908) Autobiography
of Andrew T. Still. Kirksville, MO.
pp. 369.
9 Andrew Taylor Still Papers. 2.5:56.
10 Still, A.T. (1910) Research and
Practice. Kirksville, MO. pp. 25.
11 Andrew Taylor Still Papers. 2.2:46.
12 Journal of the American
Osteopathic Association. (1908)
September 8(1):3.
Fall 2006
Osteopathically Caring for the Old

President, A.T. Still University
r. Michael Merzenick,
professor of neurosciences
at the University of
California at San Francisco, says
one thing worth learning by old
people is that if they dont keep
learning, they will lose their
minds. Dr. Merzenicks research
indicates senility develops in old
people unless they continue to
learn. The key is keeping up the
brains machinery for learning,
he says. What happens . . . is
you stop learning and you stop
the machinery, so it starts dying.
(Deutschman, p. 62)
Most people think they are
learning when they just do what
they have been doing with only
modest changes or adjustments.
That is not enough. Learning
requires changes in the mental
framework we have constructed to
guide our functioning. Changing
our minds is good for us and is
also a good definition of learning.
Dr. George Lakoff, professor of
cognitive science and linguistics
at the University of California at
Berkley, defines frames as mental
structures of the mind or spirit
that shape the way we see the
world. He claims frames cannot
easily be changed. For instance,
when we are presented with facts,
they have to fit what is already
structured in the synapses of
the brain, or they seem crazy or
unintelligent to us (Deutschman,
p. 59).
According to neuroscientists,
our structures are actually wellworn neural pathways in the
brain. Therefore, just as the
Fall 2006
osteopathic principle of StructureFunction Interdependencies is

useful in explaining interactions of
physical structures and functions,
this same principle explains
mental and spiritual structures
since they too have a physical
presence in the brain.
Because of the various uses of the
words mind and spirit, we need to
clearly distinguish between them.
We define spirit as representing
drives having unconscious
origins that are
related to the bodys
autonomic systems,
while the mind
relates to conscious
thoughts controlling
the nonautonomic
systems.
Sigmund Freud
believed movement
toward mental health
involved interpreting
defense mechanisms
(structures) of the
spirit to reveal
unconscious motivations for
behavior (functioning). We also
have conscious structures like
language, models, and rules to
aid our conscious functioning.
In general, structure-function
interactions occur in the mind and
spirit, as well, as the body.
Another osteopathic principle
is that a Self-Healing Mechanism
exists in the body. This principle
may be considered a part of
the ongoing natural selection
of evolutionary processes, and
has been expanded to involve
the mind and the spirit as well
as the body. What this means

is that there are self-healing
mechanisms helping the minds
and spirits of old people to heal.
For instance, people tend to forget
bad experiences and recover their
good spirits after a sound sleep.
Depression slows down thinking,
and within limits, may be as
helpful as the rise in temperature
the body uses as part of its selfhealing when confronted by a viral
or bacterial invasion.
Another osteopathic principle

is Interactive Unity of the parts
of the body. This principle has
also been expanded to include
the interactive unity of the mind
and spirit as well as the body.
For instance, depression of
the spirit can cause decreased
mental functioning and decreased
bodily resistance to diseases. The
principle of Interactive Unity also
can be used in a good way to
help a problem in one sector, e.g.
the body, by further developing a
related aspect in another sector,
e.g. the spirit. For instance,
Table I
Applications of Types of Causes

Principle
1. Interactive Unity
2. Structure-Function
3. Self-Healing Mechanism
4. Meaning-Expectancy
Perspectives
Plans
Flow Charts
Organizational Charts
Objectives
good spirits or laughter can help

depression, which has bodily and
mental aspects.
In general, the three
osteopathic principles of
Interactive Unity, StructureFunction Interdependency and
Self-Healing Mechanisms can be
used within and among the mind,
body and spirit of human beings.
These three osteopathic
principles relate to the first three
principles of perceiving reality
(causality) of Aristotle, but there
was no osteopathic principle
relates to his fourth principle
of a final cause. We proposed a
Meaning-Expectancy Response
to summarizing the osteopathic
practice of explaining to patients
what seems to be happening
thereby giving them meaning, and
hence, stress relieving expectancy
(McGovern, pp. 76-79).
This principle, along with the
three main osteopathic principles,
can be used to understand the
interactions of the mind, body and
spirit. For instance, when a health
professional explains how a bodily
or mental interaction works, an
elderly person can expect what
will happen next. This brings a
degree of control or peace of mind
to the patient.
As delineated in Table I, these
four principles of osteopathy or
health care correspond to the
perspectives used by a manager
Detection
Plot
Scene
Culprit
Motive
running a company or a detective

solving a crime:
In detective work, one starts
with what is known. Using that
knowledge, one investigates what
remains unknown to reveal the
full picture. So, too, in treating
senior citizens, we first investigate
what we know, but invariably
need to understand the other
underlying causes.
Andrew Weil, M.D., of the
University of Arizona, suggests
that cures rely on our inner
healing mechanisms:
the final common cause of
all cures is the healing system,
whether or not treatment is
applied. When treatments work,
they do so by activating innate
healing mechanisms. Treatments
including drugs and surgery
can facilitate healing and remove
obstacles to it, but treatments
are not the same as healing.
Treatments originate outside you;
healing comes from within. (Weil,
p. 110).
Healing has been defined as
a sense of personal wholeness
involving the physical, mental,
and emotional aspects of being
human (Egnew, p. 4). Healing is
seen as overall care, bringing a
sense of harmony or wholeness
among the mind, body, and spirit
of an individual.
Patients must trust
professionals enough to tell them
their story, structure, or sense

of reality. Unless patients feel
that professionals truly heard
their story, they cannot gain
new meaning and restructure
themselves (Egnew, p. 4).
Patients activate their healing
mechanism when professionals
see them as other selves
as people like themselves,
and therefore likeable. When,
and only when, patients feel
this liking will they respond
and change. In turn, the
patients own activation of inner,
parasympathetic mechanisms
requires liking themselves,
shortcomings included
(McGovern, p. 130).
In summary, elder care can be
greatly improved by employing the
overarching osteopathic principles
as a format to study and treat the
interactions within and among
the mind, body and spirit. If we
are to help patients activate their
internal, healing mechanisms, we
must reach patients. We can
do that to the extent we can see
ourselves in them. n
Bibliography
Deutschman, Alan. Making Change,
Fast Company, May 2005.
Egnew, Thomas R. The Meaning of
Healing: Transcending Suffering,
Annals of Family Medicine, Vol. 3,
May/June 2005.
Greenspan, Stanley I. and Stuart
G. Shanker. The First Idea:
How Symbols, Language and
Intelligence Evolved from Our
Primitive Ancestors. Cambridge,
Massachusetts: Da Capo Press
(Perseus Books), 2004.
McGovern, James J. and Rene J.
McGovern. Your Healer Within,
Tucson, Arizona: Fenestra Books,
2003.
Fall 2006
Osteopathic Medicine
and Research in America
John Heard, Ph.D.,
Vice President, Research, Grant and Information Systems
The Problem
Since its founding in 1892 by
Andrew Taylor Still, M.D., D.O.,
the osteopathic profession has
been one mainly of health-care
provision and not one of research.
Quick to provide the relief that
was perceived as needed by its
recipients, the profession was
slow in taking the steps necessary
to establish a firm basis for its
multiple therapies. Anecdotal
evidence sufficed, and there was
always the thought that some day
the needed research would be
performed. Some day has arrived,
and in this age governed by the
scientific method, anecdotes no
longer suffice osteopathic
medicine must be supported by
high-quality and rigorous scientific
inquiry.
Because it is mainly a
profession involved in the delivery
of health care and medical
education, osteopathic medicine
is relegated to a position of notquite alternative/complementary,
yet not completely mainstream.
Osteopathic medicine is the
interface between completely
accepted medical practice and the
unproven techniques of manual
medicine. This position actually
is a very powerful one to be in,
for it allows the profession to
define itself as an integrative
entity, equally comfortable in both
conventional and complementary
worlds.
Today, our country struggles
with increasing costs of traditional
Fall 2006
medical care, triggered by the

increasing duration of antibiotic
use and length of hospital
stay.1,2,3 Additionally, the growing
mistrust by a large segment of the
population of traditional medicine
with its pharmaco-centric view
has produced a climate where
alternative forms of therapy are
enjoying a resurgence.4,5,6
The need for research into
the philosophy and practices
of osteopathic medicine has
existed for many years.7,8 Studies
demonstrating the efficacy of
osteopathic medicine are more
urgently needed today because
a large number of individuals
throughout the world are placing
an increased emphasis on the use
of alternative medical practices.
The advent of evidence-based
medical practice also spawns the
need for osteopathic medicine
efficacy studies. It is incumbent
upon the osteopathic profession
to demonstrate the effects of its
philosophy in a manner that can
be transferred to a wider audience.
However, research related to
osteopathic medicine and all of
its implications has, until very
recently, been a low priority of the
profession.9,10,11,12,13
Of the many principles
espoused by osteopathic medicine,
the ones most clearly visible
to the public and which
accord this profession access to
complementary medicine are
those manual medicine techniques
used by its practitioners. Patients
continue to request the use of

manual medicine when traditional
and more costly methods of
treatment offer only temporary
relief. The need to scientifically
demonstrate the efficacy of the
professions multiple treatments
is clear. However, a sound
scientific basis for any procedure
places an especially burdensome
requirement on the field of
osteopathic medicine because
its practitioners are untrained
in the techniques of rigorous
scientific inquiry. With modern
medicine rapidly moving toward
a system based on the provision
of care backed by a strong base
of evidence, and with the need
for appropriate reimbursement
for its treatments, it is incumbent
upon the osteopathic profession
to develop a strong evidence base
if it intends to compete in todays
health-care environment. The
evidence required is acceptable
only if it is produced through
rigorous scientific processes
demonstrating the efficacy of
particular procedures.
The Coming Storm
Recent census figures indicate
the post-war baby boom will soon
swell the ranks of the geriatric
population. As an indication of
this trend, of the total population
in Germany in 1975, individuals
65 years and older accounted for
14.8 percent and individuals over
the age of 80 accounted for 2.2
percent; by 2000 these figures
increased to 16.2 percent and 3.5
percent, respectively During the

same time in the United States
these numbers increased from 10.5
percent (65+) and 2.1 percent
(80+) in 1975 to 12.6 percent
(65+) and 3.3 percent (80+) in
2000.14 In addition, due to the
advances of modern healthcare,
the current geriatric population
lives to an older age. These two
phenomena will place increased
demands on an already stressed
healthcare system. An increasing
elderly population guarantees an
increasing level of chronic disease,
which will have to be managed.
The current level of chronic
disease already places a heavy
burden on the healthcare system.
As the population ages, the
appearance of chronic conditions
will increase, leading to a situation
where the healthcare system may
not be able to provide all of the
required services. Given the rapid
increase in the aging population
of the world, it is incumbent
upon the healthcare industry to
develop preventive methods rather
than waiting to deal with myriad
of chronic conditions in the
future. These preventive methods

must be grounded in irrefutable

scientific evidence in order to gain
widespread acceptance.
Within the set of chronic
conditions afflicting an aging
population, conditions relating
to the musculoskeletal system
abound. Muscle/skeletal-related
problems such as low back pain,
osteoporosis, arthritis, and falls
are but a few of the conditions
afflicting this population. Manual
medicine as practiced by the
osteopathic profession in the
past is accepted as efficacious for
many of these conditions based
on anecdotal evidence from
patients who personally relate
the relief of symptoms through
application of this medical
modality. No longer does it suffice
to have patients relate their
positive response to osteopathic
manipulative treatments. Evidence
scientifically demonstrated
evidence is required.
The Road to Success
Beginning in the mid 1960s and
continuing for the next decade or
so, a large body of data relating
to osteopathic manual medicine
was gathered in Kirksville, Mo.
Irvin Korr, Ph.D., and J. Stedman

Denslow, D.O., working at the
Kirksville College of Osteopathic
Medicine, now part of the A.T.
Still University, developed
techniques allowing them to build
a strong foundation on which
future osteopathic researchers
would expand. Unfortunately,
their promising work languished,
known only to the few who had
developed an interest in studying
the concepts of manual medicine
embodied in the techniques of
osteopathic medicine.
In 1998 this situation changed.
James J. McGovern, Ph.D.,
became the ninth president of the
Medicine (KCOM). He came to
KCOM as a strong supporter of
research and early in his tenure
presented his belief of an organized
research program to demonstrate
the uniqueness of osteopathic
manual medicine. He promised
to support the development of
a clinical research program at
KCOM. One of his first actions
was to establish a true universitylevel division for the support
of the research endeavor. This
division includes grants and
program development to seek
funding for projects, research
support to provide biostatistical
and other necessary assistance,
and information technology
and services to provide data
and information management
capabilities.
Subsequent to this, the
Interdisciplinary Research
Committee (IRC) composed of
basic scientists, clinical scientists,
nursing and support staff from
the division was established.
This group sets priorities for the
research direction as well as advises
clinical researchers on the direction
Fall 2006
of individual projects. In order to

support the early development
of these new research activities, a
Strategic Research Initiative fund
was developed to provide seed
money for pilot projects in the
specific area of osteopathic manual
medicine. These funds are awarded
specifically with the expectation
of securing external funding from
the results they generate. The IRC
reviews all proposals and makes
funding recommendations based
on an objective peer review of each
proposal.
Finally, all of these activities
were formally organized into
the Still Research Institute
(SRI). The SRI is managed by an
administrative team composed
of basic and clinical scientists
working together with input from
various members of the Division of
Research, Grants and Information
Systems. Additionally, an External
Board of Scientific Counselors
leading scientists from across
the nation help guide the overall
direction of the Institute. The
SRI has become the focal point
for clinical research development
within the University.
Realizing that the University
is not large enough to support all
needed research, the SRI sought
interested external individuals to
become members of the Institute.
In return, members gain access
to research design, biostatistical
analyses, technical writing and
research grant-seeking support.
Individuals seeking this affiliation
are provided an agreement
spelling out the resources to
which they will have access. They
also are given titles within the
Institute consisting of Research
Professorship appointments. As
affiliates they compete for funding
from the Strategic Research
Fall 2006
Initiative to develop pilot data. In

return, they acknowledge their
affiliation with the Institute. In this
way, the strength of the Institute
is expanded by incorporating
excellent individuals with research
interests in manual medicine
without requiring their physical
presence at the University.
Achievements to Date and the
Future
Is there evidence these activities
have influenced the potential for
clinical research at the University?
Since its inception, there have
been more than 51 proposals
submitted to the Strategic Research
Initiative. Of these, 32 have been
funded, accounting for $700,000
in internal funds. Data from some
of these grants have led to the
securing of external funding as
well. In fact, seven external grants
have been funded for more than
$1.8 million, including the first
two known National Institutes of
Health awards for clinical research
in osteopathic manual medicine.
The majority of these grants focus
on elderly individuals or chronic
diseases.
An osteopathic manual
medicine researcher has been
named to be both the director of
the Still Research Institute as well
as the Assistant Vice President
for Osteopathic Research. Five
clinicians are involved in clinical
research together, and five
individuals have signed affiliation
agreements with the Institute.
Negotiations are underway to hire
an assistant director for research
as well as expand the capacity
of resident researchers and those
affiliated with the Institute.
The future of osteopathic
manual medicine research appears
very promising for the Institute
and its various researchers.
Progress to date has been

significant. The promise to support
the development of a clinical
research program at the University
has been implemented and is
leading to a promising future for
the field of osteopathic manual
medicine. n
Bibliography
1 Fitzgerald, M. (1984) Osteopathic
hospitals solution to DRGs may
be OMT. The D.O. (Convention
Report). pp. 97-101.
2 Kline, C.A. (1965) Osteopathic
Manipulative Therapy, antibiotics,
and supportive therapy in respiratory
infections in children: Comparative
Study. The Journal of the American
Osteopathic Association. 63(3): pp.
278-281.
3 Crosby, J. (2001). The Road to
be Taken: AOA Leadership on
Complementary and Alternative
Medicine. The D.O., June. pp. 11-12.
4 Hortos, K.A. (2000) Revised structural
exam form catches on in Michigan.
The D.O. March. p. 39.
5 Glover, S.H. and Rivers, P.A. (2003)
Strategic Choices for a Primary
Care Advantage: Re-engineering
Osteopathic Medicine for the 21st
Century. Journal of the American
156-163.
6 Dyer, M. and Wood, D. (2001)
Collaboration on Research Picks
up Steam. Journal of the American
13-14.
7 Crosby, J. (2001) Launching an
Aggressive Research Agenda: Why
Not? The D.O., May. pp. 10-11.
8 Major, J. (2001) More Research
Imperative to Advance Profession.
The D.O. January. pp.67-68.
9 Guillory, V.J. and Sharp, G. (2003)
Research at US Colleges of
Osteopathic Medicine: A decade of
Growth. Journal of the American
Osteopathic Association. 103(10):
pp. 458-459.
10 Goetz, J. (2002) Rekindling Research.
The D.O. April. pp.22-25.
11 Goetz, J. (2002) Research Progress.
The D.O. April. pp.26-27.
12 Goetz, J. (2002) Getting off the
Ground. The D.O. April. pp.28-30.
13 Crosby, J. (2001) Research and Public
Health: New Day Dawns at AOA.
The D.O. December. pp. 11-12.
14 Kinsella, Kevin and Victoria A.
Velkoff, (2001) U.S. Census Bureau,
Series P95/01-1, An Aging World:
2001, U.S. Government Printing
Office, Washington, DC.
Aging and Osteopathy:

The Role of Evidence
lthough well suited to meet

the demands of an aging
society, osteopathy may be
limited in the ability to respond
to the challenge of evidence-based
medicine to demonstrate efficacy.
This article describes the models
of health care evolving to meet the
needs of the elderly, the process of
establishing practice guidelines,
and makes the case for defining
osteopathic outcomes based on
the philosophy of our founder,
A.T. Still. Areas where promising
outcomes for osteopathy have been
identified will be reviewed, along
with recommendations to the
osteopathic profession to: 1. Value
the osteopathic interactive and
integrative approach to healthcare,
2. Consider establishing an
international collaborative to
generate osteopathic clinical
practice guidelines, 3. Attempt
to participate as a field with
other health professionals in the
development of interdisciplinary
clinical guidelines, and 4. Become
adept at utilizing the many
resources available to explore the
evidence on osteopathy.
Developed before the twentieth
century by A.T. Still, osteopathy
is currently sought by people
around the world as an approach
to particular health problems and
to improve their overall health
and well-being. With its handson and integrative style of care,
one could make the case that
osteopathy is well positioned to
assist with what is being called
the aging crisis. In the current
10
culture of medical technology and

the rapidly increasing knowledge
of new health treatments from
research endeavors, osteopathy,
with its varying levels of
provider training and paucity of
qualified researchers, may be at
a disadvantage in demonstrating
evidence of positive outcomes for
patients.
Worldwide, the profession
needs to respond to the call for
accountability in ways that are on
par with medicine, if not in the
ability to generate research, then
in the sophistication of identifying
critical osteopathic outcomes
and literacy in navigating health
outcomes research.
The transition of mainstream
medicine from the biomedical
to the biopsychosocial model
with its emphasis on health
and prevention, whole-person
treatment, respect for the bodys
capacity for self-healing, and the
collaborative partnership with
the health provider (Millenson,
1995), all recall the wisdom of our
founder, A.T. Still.
First the material body, second
the spiritual being, third a being of
mind which is far superior to all
vital motions and material forms,
whose duty is to wisely manage this
great engine of life.
A.T. Still,
Philosophy of Osteopathy
Over the past 25 years, this
transition has incorporated the
principles at the root of the
Rene J. McGovern, Ph.D.

Professor of Neurobehavioral Sciences
osteopathic profession, namely
the integrative treatment of mind,
body, and spirit. The biomedical
focus has been on curing disease
through human intervention and
the search for a magic bullet.
On the heels of the evidencebased medicine movement, there
has been a call for a new model
of medicine called translational
medicine (Liebman, 2005) that
would ask the physician/healer to
be a collaborative problem solver
rather than a hypothesis generator
diagnosing illnesses.
Disease would be thought
of as a life process instead of a
diseased state, where whole person
consideration of the interaction
of genes, environment, and
lifestyle are taken into account as
solutions are sought. Translational
medicine would give us the
kind of communication links
needed to optimize the input of
different healing disciplines for
the overall benefit of the patient.
The difficulty with the transition
to translational medicine, with
its focus on scientific evidence, is
that most health care providers
were not trained in the application
of the scientific method or how
to evaluate the merit of scientific
studies. Despite this, all providers
are expected to be able to manage
the massive research evidence
being generated and translate it
into their clinical practice.
According to the Institute
of Medicine (2001), evidencebased medicine is defined as
The integration of the best
Fall 2006
research evidence with our

clinical expertise and our patients
unique values and circumstances.
Although not trained scientists,
osteopathic practitioners, as
well as other interactive clinical
care providers, will remain the
experts on the unique values and
circumstances of their patients.
Osteopathic practitioners may
be at an advantage due to their
hands on approach to care. The
balanced emphasis on scientific
evidence, unique patient values
and circumstances are critical for
the proper analysis of risks versus
gain in making clinical decisions.
The basic building blocks
of evidence-based medicine
include diagnostic criteria, which
are typically created by expert
consensus; the identification
and measurement of outcomes;
levels of evidence, which involve
research design and population
samples; meta-analyses, which are
statistical methods of summarizing
the outcomes of multiple studies;
and finally, practice guidelines,
which should synthesize all of
the above (Strauss et al., 2005).
What I believe we are being told
by the evidence-based movement
is that clinical intuition, in order to
become evidence, needs to move
through a rigorous process of being
applied systematically with clearly
defined, measurable outcomes and
the capacity for reproducibility
before it may be called a truth.
There are several types of
clinical study designs, each with
their unique limitations.
For example, randomized
controlled trials (RCT), which are
considered the gold standard
of the medical research industry,
often measure outcomes more
discrete and less clinically relevant
to the patients quality of life in a
Fall 2006
real world setting. Longitudinal

studies, which follow a large
sample of individuals over time,
can be cumbersome and expensive,
with the potential of losing
subjects due to attrition.
Cross sectional studies, which
take only a one-time snapshot of
individuals, have a greater risk of
chance findings unique to the time
of evaluation. Single-case design,
which observe only one individual
over time and can be done in
clinical settings, are limited in
the generalizability of results
with other people or populations.
Quasi-experimental studies,
without randomization to control
for all the variables that could be
contributing to the outcomes being
measured, can lead to distortions
in the evaluation of outcomes and
tempt us to find the outcomes we
hope for.
One must never underestimate
the difficulty of defining and
measuring outcomes. Sometimes
this is akin to the story of the
drunk under the lamp post
looking for his keys, not because
they were lost there, but because
the light is better. We always must
ask, Are we measuring the right

outcomes? (Bradley, et al., 2000).
Methods are currently being
used in the United States to
assist health professionals to
navigate the onslaught of health
information and to make sound
clinical decisions based on the best
synthesis of the current evidence.
The U.S. Preventive Services Task
Force (USPSTF, Calonge, 2005,
www.preventiveservices.ahrq.gov)
was established as an independent
panel of nationally recognized nonfederal researchers experienced
in primary care, prevention,
evidence-based medicine, and
research methods. Other member
disciplines included family
medicine, pediatrics/adolescent
medicine, Ob/GYN, nursing,
counseling/behavioral medicine,
public health, and health policy
experts. The task force was charged
by the U.S. Congress to review
the scientific evidence for clinical
preventive services and develop
evidence-based recommendations
for the health care community.
These recommendations are
considered by many to be the gold
standard for clinical preventive
11
services in the United States.

An important consideration
when reviewing recommendations
is to remember that intervention
studies often do not look at longterm health outcomes or longterm behavior change. This can
have significant implications on
the clinical relevance of the study
outcomes. Also, there are few
studies that provide evidence on
the best application in clinical
settings, and there is very little data
on potential harms of intervention.
A useful example to assist in
developing an understanding of
the limitations of the guidelines is
the recommendation for behavioral
dietary counseling in primary care.
The USPSTF (Calonge, 2005)
found fair evidence that brief, lowto medium-intensity behavioral
dietary counseling in the primary
care setting can produce small-to-
he following process
is used to create the
recommendations (Calonge,
2005): define the question and
outcomes of interest within
an analytic framework, define
and retrieve relevant evidence,
evaluate the quality of individual
studies, synthesize and judge the
strength of available evidence,
determine the balance of benefits
and harms, link recommendation
to judgments about net benefits.
The grading scheme of
the recommendations utilizes
evaluation of the strength
of the research evidence for
effectiveness and the estimate
of net benefit, which equals
potential benefit minus risk
of harm. Once the research
evidence, benefits, and risks have
been assessed, a recommendation
is graded. The wording
12
medium changes in average daily

intake of core components of an
overall healthy diet (especially
saturated fat, fruit, and vegetables)
in unselected patients. The
strength of the evidence, however,
was limited by the use of selfreported diet outcomes, a limited
use of measures corroborating
reported changes in diet, limited
follow-up data beyond 6 to 12
months, and enrollment of study
participants who may not be fully
representative of primary care
patients. In addition, there was
limited evidence to assess possible
harms of nutritional counseling.
As a result, the USPSTF concluded
that there is insufficient evidence
to determine the significance and
magnitude of the benefit of routine
counseling to promote a healthy
diet in adults.
In summary, we need to
of recommendations is as
follows: Strongly recommend,
with benefits substantially
outweighing harms, Recommend,
with benefits outweigh
harms, USPSTF makes no
recommendation, with benefits
and harms closely balanced,
Recommend against routine use,
with ineffective interventions
or harms outweighing potential
benefits, Insufficient evidence
to recommend for or against the
intervention.
It is important to remember
that the meaning of the I
rating is insufficient evidence to
recommend for or against the
intervention. Common reasons
for an I are lack of evidence on
clinical outcomes, poor quality
of existing studies, good quality
studies with conflicting results,
and the possibility of clinically
remember the following: Its

difficult to justify a positive
recommendation when you
cannot join all the links in the
chain of evidence; Clinical trials
are essential to the evidence;
and an I insufficient evidence
recommendation is a call for
research, not a conclusion that the
intervention is not effective.
So what does this mean for
osteopathy? The above example
demonstrates the complexity
of the process involved in
interpreting evidence and making
recommendations for practice
guidelines, even when a significant
number of studies have been done
in a particular area. Consideration
of outcomes is key. A recent article
in JAMA (Califf, 2005) regarding
critical health outcomes reminds
us to focus on the Big 4 when
evaluating clinical studies:1.
important benefits but more
research is needed to show the
benefits.
It is also important to
understand the possible reasons
for conflicting recommendations,
which may include: An evidencebased versus consensus process
for the decision; Clinical
versus intermediate outcomes
having been used for the
conclusion; Differing degrees of
consideration of possible harms
taken into account; The issue of
effectiveness versus efficacy with
ideal setting vs. real world having
been the site for data collection;
Primary care guidelines may
have a differing perspective
from specialty providers;
Finally, differing groups may
have differing approaches to
uncertainty and the call to Do no
harm.
Fall 2006
Length of life; 2. Quality of life; 3.

Discrete negative events; 4. Cost.
Some helpful guides (Davidson
et al., 2004) for assistance in
navigating the evidence-based
medicine literature, many of
which can be found on the
internet, include The Center
for Evidence-Based Medicine
(www.cebm.utoronto.ca, select
Practicing EBBM), The EvidenceBased Medicine Tool Kit, The
Cochran Library (www.cochrane.
org), CONSORT (Consolidated
Standards for Reporting Trials),
and individual discipline practice
guidelines (www.guideline.gov).
In addition, a future reference that
will be helpful is the World Health
Organization (WHO) guidelines
on basic training and safety in
osteopathy that are currently being
drafted.
There are growing areas of
evidence for the effectiveness of
osteopathic treatments, several of
which can directly assist in the
aging function. Recent reviews
of the literature give supporting
evidence for the following
applications of osteopathy
(Licciardone et al., 2003;
Anderson et al., 2000; Biomed
Central, 2005; Natural Standards,
2005): back pain; ankle injury;
asthma; tennis elbow; knee or
hip joint replacement; Others:
COPD & emphysema, depression,
fibromyalgia, menstrual pain, neck
pain, pneumonia & thoracic outlet
syndrome, postoperative care, and
overall QOL.
Evidence-based osteopathic
research specific to the elderly
includes benefits for the treatment
of acute pneumonia, vaccine
enhancement, gait disturbance,
Parkinsons Disease, and frozen
shoulder (see Noll article included
Fall 2006
in this journal issue).

We must remember that our
Founder was well read in the
sciences and philosophies of his
day and used them to develop
further insights and interactive
principles. Our fundamental
legacy calls for continued research
on the efficacy of osteopathy and
a creative integration with what is
best in current health practices.
I would like to suggest the
osteopathic profession consider
the following recommendations
worldwide. First and foremost,
we need to value our integrative
approach to healthcare and
interactive style of patient care.
It makes us well equipped
to manage healthy aging and
chronic disease. Next, consider
establishing an international
collaborative to generate clinical
guidelines for osteopathy. This
would be a worthwhile investment
in the future development of
osteopathy.
Through professional
organizations, we should try
to gain access to the current
evidence-based medicine networks
to participate as a field in the
development of interdisciplinary
guidelines. This is something that
my profession, health psychology,
is attempting to do. It is critical
that we be part of the team
to contribute to patient care.
We need to join with partner
disciplines.
Finally, as individual clinical
scientists, we each need to make
the effort to develop the skills
necessary to become literate
in evidence-based research by
utilizing and mastering the many
resources available to explore
the evidence on osteopathy and
related healthcare. n
Bibliography
Anderson, G.B.J., Lucente, T., Davis,
A.M., Kappler, R.E., Lipton, J.A. &
Leurgans, S. (1999). A comparison of
osteopathic spinal manipulation with
standard care for patients with low
back pain. The New England Journal
of Medicine, 341(19): 1426-1431.
Bradley, E.H., Bogardus, S.T., Jr., van
Doorn, C., Williams, C.S., Cherlin,
E. & Inouye, S.K. (2000). Goals
in geriatric assessment: are we
measuring the right outcomes? The
Gerontologist, 40(2): 191-196.
Califf, R.M. (2005). Simple principles of
clinical trials remain powerful. JAMA,
Vol.293, No.4, 489-491.
Calonge, N. (2005). Recommendations
from the U.S. Preventive Services
Task Force: a roadmap for behavioral
medicine and public health
(and some missing landmarks).
Presentation at the Annual Meeting
of the Society of Behavioral Medicine,
Boston, MA.
Davidson, K.W., Trudeau, K.J., Ockene,
J.K., Orleans, C.T. & Kaplan,
R.M. (2004). A primer on current
evidence-based review systems and
their implications for behavioral
medicine. Annals of Behavioral
Medicine, 28(3): 226-238.
Licciardone, J.C., Stoll, S.T., Fulda, K.G.,
Risso, D.P., Siu, J. & Swift, W., Jr.
(2003). Osteopathic manipulative
treatment for chronic low back pain,
a randomized controlled trial, Spine
28(13): 1355-1362.
Licciardone, J.C., Brimhall, A.K. &
King, L.N. (2005). Osteopathic
manipulative treatment for low back
pain: a systematic review and metaanalysis of randomized controlled
trials. BioMed Central (BMC)
Musculoskeletal Disorders, 6:43,
DOI: 10.1186/1471-2474-6-43.
Liebman, M.N. (2005). An engineering
approach to translational medicine.
The American Scientist, 93:296-298.
Millenson, J.R. (1995). Mind Matters,
Psychological Medicine in Holistic
Practice. Seattle, WA: Eastland Press.
Natural Standard and the Faculty of
the Harvard Medical School (2005).
Osteopathy. Retrieved August 30,
2005, from http://www.intelehealth.
com.
Straus, S., Richardson, W. S., Glasziou,
P. & Haynes, R. B, (2005). EvidenceBased Medicine, How to Practice
and Teach EBM. Edinburgh: Elsveier,
Churchill, Livingstone.
13
Osteopathic Manipulation in the

Elderly and Current Clinical Research
Donald R. Noll, D.O., Professor of Internal Medicine
he elderly are a significant

segment of the population
likely to benefit from
a wide variety of applications
of osteopathic manipulation.
While the number of clinical
research trials testing the efficacy
of osteopathic manipulative
treatment, or OMT, remains too
few, there is a growing body of
research exploring the use of
OMT in the elderly. This article
highlights the current literature on
various applications of OMT in the
elderly.
Practical aspects of using
OMT in the elderly have been
reviewed.1,2 These review articles
emphasiz the role of dosing
the manipulative treatment to fit
individual anatomic, physiologic
and psychological conditions.
For example, the amount of force
used in a technique for a frail
elder is less than what would
be used in a muscular, healthy
young adult with a similar
problem. Kimberly reviews in
detail the concept of dosing and
the osteopathic prescription.3
Likewise, the types of techniques
recommended in the elderly
are gentle direct techniques and
indirect techniques rather than
high-velocity and low amplitude
(HVLA) thrusting techniques.1,2
The HVLA techniques have many
contraindications for problems
common in the elderly, which
include a history of pathologic
fractures, advanced osteoporosis
and advanced osteoarthritis.
However, Dodson points out that
14
if an HVLA technique is correctly

dosed and applied, then it is still
appropriate in selected elders.1
Atchison and English describe a
diversity of non-thrust osteopathic
manipulative techniques they
recommend for the elderly,
which are useful for treating
musculoskeletal restrictions of the
shoulder, wrist, hip, knee, foot,
spine, ribs and sacroiliac joints.4
Unfortunately, the applications
and characteristics of OMT in
actual practice in the elderly have
not been well studied, at least
within the United States. However,
an observational, practice-based
study of chiropractic treatment
has been done, characterizing
805 patients in the United State
and Canada who are 55 years and
older.5 The overwhelming majority
sought chiropractic treatment for
musculoskeletal problems like
back pain; 7.5 percent visited
for health maintenance and
only 0.8 percent were there for
nonmusculoskeletal complaints.
Chiropractic physicians
overwhelmingly used direct
high-velocity type manipulation
techniques when treating the
elderly. One study providing
information on applications of
osteopathic manipulation is a
survey reporting the results from
955 osteopathic physicians in
the United States on their use
of OMT in their practices, with
patients of all ages included.6
The use of OMT by body
systems was: musculoskeletal,
51.5 percent; injuries or trauma,
17.5 percent; neurologic,

10.9 percent; respiratory, 8.8
percent; genitourinary, 2 percent;
medical conditions, 1.9 percent;
gastrointestinal, 1.7 percent;
rheumatology, 1.6 percent;
other/general, 1.5 percent;
cardiovascular or circulatory, 1
percent; behavior, 0.8 percent;
and pediatric, 0.7 percent. No
information was reported on
the types of techniques used for
these conditions. However, the
osteopathic literature suggests
a diversity of techniques and
applications for manipulation
in the elderly, although
systematic, practice-based studies
characterizing actual use of OMT
in the elderly need to be done.
The idea of treating the
musculoskeletal system with
OMT to benefit a primarily
visceral organ system or systemic
disorder remains a novel idea
to conventional allopathic
medicine and a rich aspect of
our osteopathic heritage. When
the osteopathic profession was
founded more than a hundred
years ago, most people died
suddenly from acute illness,
often from infectious diseases.
Many osteopathic manipulative
techniques in use today were
originally developed to combat
acute infectious disease by
boosting host defense. Today, with
the advent of effective antibiotic
therapies, time demands, and
the scarcity of clinical research,
the use of OMT to treat acute
nonmusculoskeletal problems has
Fall 2006
greatly declined. Lynch reported

the use of OMT in acute-care
hospitals in the United States
between 1990 and 1999 averaged
only 30.4 individuals per 100,000
discharges and that the use of
OMT declined throughout the
decade.7 Osteopathic manipulative
treatment was used predominantly
in small hospitals in the
Midwestern United States and
most commonly for individuals
hospitalized for musculoskeletal
problems, childbirth, and
respiratory tract infections.
The osteopathic profession
has long cited pneumonia as an
infectious disease that responds
to osteopathic manipulation.8,9
Despite modern antibiotic therapy,
pneumonia remains a major
cause of death and morbidity for
the elderly. The elderly have a
higher incidence of pneumonia,
a higher hospitalization rate,
longer hospital stays, and greater
mortality from pneumonia than
the general adult population.10,11
Noll et al. conducted a small
pilot study of 18 elderly subjects
Fall 2006
hospitalized with pneumonia.

The study demonstrated a shorter
mean length of hospital stay
and duration of IV antibiotics in
the OMT group, although the
difference was not statistically
significant. The mean duration
of oral antibiotic therapy during
hospitalization was longer in the
OMT group, indirectly suggesting
faster recovery.12
Based on these encouraging
results, a larger, more refined
study was conducted to see if
the elderly would benefit from
osteopathic manipulation in
addition to conventional care for
pneumonia.13 Subjects, age 60
and over, hospitalized with acute
pneumonia were recruited for the
study. All patients had to have a
new pulmonary infiltrate, as well
as several signs and symptoms of
pneumonia to participate. The end
points for the study were death,
respiratory failure, or discharge
from the acute-care hospital.
Subjects entered the study within
24 hours of admission and were
randomized to either a treatment
or a sham control group. The

treatment group received a
standardized OMT protocol twice
daily, seven days a week by a
student doctor trained in the
protocol until a study end point
was reached. All subjects in the
treatment group also had at least
one nonstandardized treatment
session with a physician specialist
in osteopathic manipulative
medicine during their hospital
stay. The standardized treatment
sessions were approximately 15
minutes in duration and consisted
of seven techniques: bilateral
paraspinal inhibition, bilateral rib
raising, diaphragmatic myofascial
release, condylar decompression,
soft tissue to the cervical muscles,
myofascial release to the anterior
thoracic inlet, and the thoracic
lymphatic pump. Kimberly has
described these techniques.14 The
sham treatment group received
light touch to the same areas for
the same duration and frequency
as in the treatment group.
Fifty-eight subjects completed
the study, 28 in the treatment
15
group and 30 in the sham

group. There were no significant
demographic differences between
the two groups. Both groups had
similar severity of illness scores
at baseline. The study found
statistically significant reduction
in both the mean duration of
intravenous (IV) antibiotic therapy
and the length of hospital stay in
the treatment group. The mean
duration of IV antibiotic therapy
was 7.3 days for the sham group
and 5.3 days for the treatment
group. The mean length of hospital
stay was 8.6 days for the sham
group and 6.6 for the treatment
group. Thus, OMT reduced use of
IV antibiotics and the length of the
hospital stay by an average of two
days.
The study also provided some
evidence suggesting OMT alters
the immune response to infection.
Temperatures tended to run higher
16
in the group receiving OMT, with

the difference reaching statistical
significance on days two and five
of the hospital stay. Also, the mean
white blood cell counts fell slower
in the treatment group, with the
difference reaching statistical
significance on day three of the
hospital stay, when the sham
groups white blood counts had
a mean decrease of 5,945 cells
and the OMT group had a mean
decrease of only 2,341 cells, relative
to each groups mean baseline white
blood counts on admission.
Currently, the Multi-center
Osteopathic Pneumonia Study in
the Elderly (MOPSE) is underway.
This much larger study involves
five hospital sites around the
United States and builds upon the
experience gained from the two
previous pneumonia studies. The
MOPSE study design randomizes
elderly subjects hospitalized with
pneumonia into one of three

groups: a conventional care-only
group, a light touch control group,
and an OMT group. Major outcome
measures for MOPSE include length
of hospital stay, time to clinical
stability, and rate of symptomatic
and functional recovery. When
MOPSE is completed in late 2007,
more than 288 subjects likely
will have finished the study, and
the results will provide the most
definitive evidence to date on the
benefits of OMT in the elderly with
hospitalized pneumonia.
Osteopathic manipulation may
work to improve clinical outcomes
for infectious diseases by enhancing
the bodys immune response to
infection. In a small clinical study,
Jackson et al. showed an increased
rise in mean antibody titers to the
Hepatitis B vaccine when using the
thoracic lymphatic pump (TLP)
with activation combined with
Fall 2006
the splenic pump technique.15

The term activation indicates a
version of the TLP technique where
pressure is built up on the chest
wall through three or four cycles
of the technique, then the pressure
is suddenly released by removal
of the hands to create negative
intrathoracic pressure, causing
air to rush into the airways. The
mean hepatitis antibody titers were
consistently higher in the OMT
group, a difference that reached
statistical significance on week 25,
but was not significant at weeks
five, six, seven, 13, 18, 31 or 34 of
the study. The authors of this article
speculate OMT might enhance the
immune response to the influenza
vaccine in the elderly, since the
elderly are at greatest risk from
influenza and tend to mount an
incomplete immune response to the
influenza vaccine. This suggestion
spawned three separate clinical
trials testing the hypothesis that
OMT can be used to boost the
vaccine in the elderly.
Noll et al. studied the effect of a
multi-technique OMT protocol on
the influenza vaccine response in
elderly nursing home residents.18
A total of 22 randomized subjects
received either a standardized OMT
protocol or a sham protocol. Mean
age was 84.8 for the OMT group
and 85.2 years for the sham group.
The OMT study protocol consisted
of a structural exam and treatment
of specific somatic dysfunction
followed by a standardized protocol
consisting of paraspinal muscle
inhibition, myofascial release to the
thoracic inlet, myofascial release
to the abdominal diaphragm,
thoracic lymphatic pump with
activation and splenic pump
technique. The sham protocol
consisted of a structural exam
Fall 2006
with careful auscultation of the

heart and lungs followed by light
touch to the same anatomic areas
addressed in the OMT protocol.
The duration of both protocol
treatments was approximately 15
minutes. The treatment sessions
started the day of vaccination and
continued three times a week for
the first two weeks and twice a
week for weeks three and four.
A post-study survey indicated
the sham protocol was highly
successful in blinding subjects to
group assignment.19 IgM and IgG
antibody titers were measured at
baseline and on post-vaccination
for the first four weeks. Analysis
showed no statistically significant
difference between groups in the
rise in antibody titers for any of the
post-vaccination measures, taking
into account the baseline measures.
However, the mean number of
days on antibiotic therapy for the
October 1999 through March 2000
influenza season was significantly
lower in the group receiving the
OMT protocol. The mean number
of days on antibiotics was 10.7
days for OMT group and 25 days
for the sham group, October
through March. The difference
was most dramatic and reached
statistical significance for the
month of January when the OMT
group was on antibiotics a mean
of 0.9 days while the sham group
was on antibiotics a mean of 5.5
days. This difference in January is
interesting because the last OMT
protocol treatment was given at the
end of October, suggesting OMT
may have some lasting effect on
host defense that is not measured
by the influenza antibody titers.
The treatment group also scored
lower on the Geriatric Depression
Scale at week 16 of the study.
Because of the small sample
size and the many confounding

variables that might influence the
outcomes, these results should be
interpreted with caution. All three
small studies testing the hypothesis
that manipulation can boost the
vaccine in the elderly showed
no significant improvement in
antibody titers.
Wells et al. studied the
immediate effects that a singlesession standardized OMT protocol
had on gait in people with
Parkinsons disease.20 Parkinsons
disease is the second most common
neurodegenerative disease in the
world and a disorder primarily
affecting the elderly. Twenty
subjects with Parkinsons disease
enrolled in the study, with 10
randomized to an OMT group and
10 to a sham control group. Eight
normal subjects, free of Parkinsons
disease, also participated. All
subjects with Parkinsons disease
had their medications held for 12
hours before starting gait analysis.
The OMT group and eight normal
subjects received one standardized
14-technique treatment session
lasting approximately 30 minutes,
with student doctors trained
in the protocol conducting the
treatments. The techniques used in
the study were direct articulatory,
muscle energy and myofascial
techniques targeting the spine,
shoulder and joints of the external
limbs, including the ankles and
wrists. The sham group received
examination of the voluntary range
of motion of each joint manipulated
in the OMT protocol. Pre- and
post-treatment gait analysis was
performed. Subjects receiving the
OMT protocol had a significant
increase in gait parameters relating
to stride length and limb velocity
for both upper and lower limbs,
17
while those in the sham control

group and the normal subjects did
not. The study showed that OMT
does improve gait parameters in
people with Parkinsons disease and
demonstrated the utility of using
gait analysis to study OMT. More
research is needed to investigate
the longer-term effects of OMT and
which techniques or combinations
of techniques work best for
improving gait in Parkinsons
disease.
Cavalieri et al. conducted a small
study on the effectiveness of OMT
for reducing the frequency of falls,
the fear of falling and to improve
gait and balance in the elderly.21
Twenty-eight subjects over the
age of 65, each with a history of
falling twice in the previous nine
months, were recruited for the
study. All subjects were entered
into a falls prevention program,
but half received additional OMT
18
once every six weeks for up to six

months. While there was overall
mean improvement in gait and fall
outcomes relative to baseline for all
subjects participating in the study,
there was no significant difference
between groups for any of the
outcome measures. Limitations of
this study are that it was probably
underpowered for the types of
outcomes measured, and the
OMT intervention may not have
been frequent enough to change
outcomes.
Restricted shoulder range of
motion is a common problem in
the elderly hindering functional
independence. Recently, it has been
reported manipulative therapy to
the cervical, thoracic spine and
adjacent ribs, when added to the
usual medical care of patients with
shoulder dysfunction, produced
subjective benefits in adults.22 In
1916, Spencer reported a series
of manipulative techniques useful

for treating baseball players and
others who suffered trauma to
the shoulder.23 Patriquin detailed
the evolution of the Spencer
technique series over the decades,
including the recent addition of
a muscle energy component to
the techniques.24 The series uses
seven techniques to stretch the
tissues surrounding the shoulder
and improve range of motion in a
variety of planes.
Knebl et al. conducted a
randomized controlled clinical
trial testing the effectiveness of
the Spenser technique series for
treating chronic shoulder restriction
and pain in the elderly.25 Elderly
subjects with limited shoulder
range of motion were recruited
for the study. Subjects were
randomized to receive either
the Spenser technique series or
a placebo treatment during five
Fall 2006
treatment sessions over 14 weeks.

Measures were taken one week
after each treatment session. The
placebo treatment consisted of
the Spenser techniques without
administration of the actual
corrective forces (isometric
muscle contraction). Twenty-nine
subjects completed the study, with
both groups showing significant
improvement in shoulder range
of motion and reduced pain.
However, when the subjects
returned on week 19 of the study,
the treatment group maintained
significant improvement in range
of motion while the placebo group
Bibliography
1. Dodson D. Manipulative therapy for the
geriatric patient. Annals of Osteopathic
Medicine March 1979; 7(3):114-119.
2. Hoefner VC. Osteopathic manipulative
treatment in gerontology. Annals of
Osteopathic Medicine December 1982;
10(12):546 549.
3. Kimberly PE. Formulating a prescription
for osteopathic manipulative treatment.
JAOA April 1980; 79(8):506 513.
4. Atchison JW, English WR. Manipulative
techniques for geriatric patients. Manual
Medicine November 1996; 7(4):825842.
5. Hawk C, Long CR, Boulanger KT,
Morschhauser E, and Fuhr AW.
Chiropractic care for patients aged 55
years and older: report from a practicebased research program. JAGS May
2000; 48:534-545.
6. Johnson SM, Kurtz ME. Conditions
and diagnosis for which osteopathic
primary care physicians and specialists
use osteopathic manipulative treatment.
JAOA October 2002; 102(10):527-540.
7. Lynch JK. Osteopathic Manipulation
Treatment in United States Hospitals:
Review of the National Hospital
Discharge Survey, 1991-1999. 2000
(abstract).
8. Chila AG. Pneumonia: helping our
bodies help themselves. Consultant
March 1982; p. 174-188.
9. Kuchera M, Kuchera AW. Osteopathic
considerations in systemic dysfunction.
Medicine Press; 1990. p. 33-52.
10. Feldman C. Pneumonia in the elderly.
Clinics in chest medicine 1999;
20(3):563-573.
Fall 2006
did not. One limitation of the

study is that the sham protocol
used resembles the Spenser
technique series as practiced
before the incorporation of the
muscle energy technique, although
joint stretching was probably
minimal in the sham protocol. The
Spenser technique series remains
a promising treatment and merits
further investigation.
The elderly have a variety
of physical disorders and
conditions that may benefit
from osteopathic manipulation.
More investigation is needed to
determine which conditions best
11. Marrie JT. Bronchitis and pneumonia.
In: Yoshikawa TT, and Norman DC.
Infectious disease in the aging: a clinical
handbook. Totowa, NJ: Humana Press;
2001. p. 53-65.
12. Noll DR, Shores J, Bryman PN, and
Masterson EV. Adjunctive osteopathic
manipulative treatment in the elderly
hospitalized with pneumonia: a pilot
study. JAOA March 1999; 99(3):143151.
13. Noll DR. Benefits of osteopathic
manipulative treatment for hospitalized
elderly patients with pneumonia. JAOA
December 2000; 100(12):776-782.
14. Kimberly PE. Somatic dysfunction
principles of manipulative treatment and
illustrative procedures for specific joint
mobilization. Kirksville, Mo. Kirksville
College of Osteopathic Medicine: 1980.
15. Jackson KM, Steele TF, Dugan EP,
Kukulka G, Blue W, and Roberts A.
Effect of lymphatic and splenic pump
techniques on the antibody response to
hepatitis B vaccine: a pilot study. JAOA
March 1998; 98(3):155-160.
16. Dugan EP, Lemley WW, Roberts CA,
Wagner W, and Jackson KM. Effect of
lymphatic pump techniques on the
immune response to influenza vaccine.
JAOA August 2001; 101(8):472
(abstract).
17. Breithaupt T, Harris K, Ellis J, Purcell
E, Weir J, Clothier M, and Boesler D.
Thoracic lymphatic pumping and the
efficacy of influenza vaccination in
healthy young and elderly populations.
JAOA January 2001; 101(1):21-25.
18. Noll DR, Degenhardt BF, Stuart
MK, Werden S, McGovern RJ, and
Johnson JC. The effect of osteopathic
manipulative treatment on immune
response to the influenza vaccine in
nursing home residents: a pilot study.
Alternative Therapies in Health and
respond to manipulation and

which techniques work best.
Likewise, the mechanisms by
which manipulation works need
further investigation. If clinical
research shows clear benefit, then
osteopathic manipulation will be
used more often for conditions
such as acute pneumonia, vaccine
enhancement, gait disturbance,
Parkinsons disease and frozen
shoulder, all common problems
seen in the elderly. The osteopathic
profession has much to offer the
world of healthcare, and its full
potential is just now being explored
through clinical research. n
Medicine. July/August 2004; 10(4):7476.
19. DR Noll, BF Degenhardt, M Stuart,
R McGovern, and M Matteson. The
effectiveness of a sham protocol and
adverse events in a clinical trial of
osteopathic manipulation in a nursing
home. JAOA March 2004; 104(3):107113.
20. Wells MR, Giantinoto S, DAgate,
Areman R, Fazzini EA, Dowling D,
and Bosak A. Standard osteopathic
manipulative treatment acutely improves
gait performance in patients with
Parkinsons disease. JAOA February
1999; 99(2):92-98.
21. Cavalieri TA, Miceli DL, Goldis M,
Masterson EV, Forman L, and Pomerantz
SC. Osteopathic manipulative therapy:
impact on fall prevention in the elderly.
JAOA July1998; 98(7):391 (abstract).
22. Bergman GJD, Winters JC, Groenier
KH, Pool JM, Jung BM, Postema K,
and van der Heijden G. Manipulative
therapy in addition to usual medical
care for patients with shoulder
dysfunction and pain. Annals of Internal
Medicine September 2004; 141(6):432440.
23. Spencer H. Shoulder technique. JAOA
1916; 15:218-220.
24. Patriquin DA. The evolution of
osteopathic manipulative technique: the
Spencer technique. JAOA September
1992; 92:1134-1146.
25. Knebl JA, Shores JH, Gamber RG,
Gray WT, and Herron KM. Improving
functional ability in the elderly via
the Spenser technique, an osteopathic
manipulative treatment: a randomized,
clinical trial. JAOA July 2002; 102:347396.
19
What Osteopathy
Has To Offer Golden Girls
steopathic physicians
have been trained to
appreciate the role of
the musculoskeletal system in
the maintenance of health. The
understanding of the reciprocal
relationship of structure and
function in mature womens
health may provide opportunities
for healthy aging. For instance,
female health care consumers have
been receiving education about
menopause, osteoporosis, cancer,
and chronic disease processes
that affect women through
support groups, magazines,
radio, the internet, and other
telecommunication media. They
have been bombarded with
information about exercise,
nutrition, pharmacotherapy, and
other activity therapies. During
well-woman visits, physicians can
offer additional counseling about
healthy aging, cancer screening, or
laboratory evaluation. However,
osteopathic physicians can further
utilize clinical diagnostic skills
of observation and palpation of
the musculoskeletal system (in
addition to breast and pelvic
exams) to positively influence total
body function.
At the present time, many
women are still concerned about
whether they should consider
hormone therapy. Further, some
suitable candidates independently
decide to stop appropriate
treatment. They may also be
concerned about sexuality as
they become widowed, retired,
and/or empty nesters; develop
20
Melicien Tettambel, D.O., Professor, Maternal and Child Health

incontinence; or have increased
arthritic pain which interferes with
satisfying intimacy. Medications
used to treat some of these issues
may be too expensive or have
unpleasant side effects. Some
patients may be too depressed to
discuss any of these problems.
While it is true that women are
twice as likely to be depressed,
it is also true that there are
many more mature women
than men living past 70 years of
age. These women may fear that
depression is a sign of senility
or part of the aging process
which is incorrect! Fear of the
consequences of aging, pain, and
depression can create a circuit for
women. Health care providers
can recommend counseling,
medication, and some kinds of
physical therapies. Physicians who
provide osteopathic treatments
can stabilize body structure to
facilitate physiological function.
Therapists may then complement
the treatments with counseling
or physical therapies to maintain
activity.
Posture is the result of
ones continuing ordeal with
locomotion and gravity. With
advancing age, there may be spinal
changes affecting spinal curves
and gait. Weight gain or loss as
results of nutrition or activity
patterns can also affect posture.
Women lose height and develop
increased thoracic kyphosis with
osteoporosis. Arthritic diseases
also can cause structural and
gait deformities. Soft tissue,
functional, or indirect treatment

techniques can increase joint range
of motion and mobilize tissue
fluids to reduce inflammation
and edema. The patient may be
inclined to initiate other concerns
about herself during the course
of a treatment. This could be an
opportunity to cultivate rapport
in developing a treatment plan for
other or non-gynecologic issues.
In addition to evaluating
posture (structural health), the
osteopathic physician can read
a patients emotional status
by observing her respiration.
Unusually slowed or rapid
breathing may convey anxiety
or depression. During the
gynecologic visit, a woman may
express her concerns about
diagnosis of cancer. She may
also be confronting the difficult
acceptance of the complexity of
chronic disease management.
By focusing on the patients
breathing, a physician may note
how the respiratory system
might be engaged to maintain
general health. Manual treatment
of the thorax can influence
its contents to fight infection,
metabolize medicines, and reduce
inflammation.
The most recent data published
by the United States Public Health
Service Office of Womens Health
(April, 1995) lists the 5 most
common fatal diseases (percentage
of occurrence) in women aged 65
and older. They are heart disease
(30.8%), cancer (20.3%), stroke
(8.4%), pneumonia/influenza
Fall 2006
(4.4%), lung
disease (4.2%),
and diabetes
(2.7%). It is
interesting that
breathing may
be affected by
any or all of
these diseases.
Treatment of the
thoracic spine
may influence
the sympathetic
nervous systems
effect on cardiac
function.
Mobilization of
the rib cage may
reduce strain
of inhalation
or exhalation
while fighting
lung infections.
Improved
breathing as
a result of rib
raising techniques
or lymphatic
drainage can aid
in dissipating
infection. Altered
respiration to
encourage slow,
deep breathing
can help relieve
pain and breathe
away toxins or drug metabolites.
Treatment of the thoracic inlet
can decompress tensions on the
vascular and neural contents of the
upper thorax to relieve edema. In
addition to addressing restrictions
of the rib cage, release of
respiratory diaphragmatic tension
can also facilitate motion of body
fluids and lymphatic drainage.
Women with breast cancer may
be treated by lymphatic massage
Fall 2006
therapists to reduce incidence of

post-mastectomy lymphedema.
These patients will derive greater
benefit from their therapists if
they also receive osteopathic
treatment to the thorax, spine,
and diaphragm. Common sites
of gynecologic cancer metastasis
are the lungs, bones, liver, and
brain. Treatment of the thorax
may reduce the stress of breathing,
congestion, and also relieve pain.
The American
Lung Association
promotes the
slogan, If you cant
breathe, nothing
else matters.
Treatment utilizing
gentle techniques
that provide patient
comfort are also
beneficial in assisting
respiration and
general metabolism.
The patient may be
treated frequently
and not become
exhausted or
stressed by vigorous
handling of body
tissues. Whether in
the office or in the
hospital, osteopathic
treatments to the
thorax need not take
more than 5 or 10
minutes.
Osteopathy
offers golden
girls pain relief,
increased physical
mobility, improved
metabolism, and
anti-depressant
relief through
manual treatment.
It may also
reduce the need to add more
pharmaceuticals to a treatment
regimen to achieve similar goals of
improved circulation, nerve, and
joint function as well as reduced
pain and inflammation. Osteopathic
treatments have few side effects or
cross-reactivity with medication.
They may aid in the promotion of
longevity and independent living! n
21
A.T. Still University

University Officers & Administration
Gaylah Sublette, M.B.A.
President
Associate Vice President for Grants and Program

Development
Adrian Anast, Ph.D.
Barbara Wood
Vice President for Communications and Marketing
Assistant Vice President for Communications and Marketing
Robert L. Basham, CFRE
KCOM
Philip C. Slocum, D.O., FACOI, FCCM, FCCP, 76
Vice President for Institutional Advancement
Randy Danielsen, Ph.D., PA-C
Dean, Arizona School of Health Sciences (ASHS)
Jack Dillenberg, D.D.S., M.P.H.
Dean, Arizona School of Dentistry and Oral Health (ASDOH)
Ronald R. Gaber, Ed.S., CT
Vice President and Dean of Students
Monica L. Harrison, CPA

Treasurer
John T. Heard Jr., Ph.D.
Vice President for Research, Grants, and Information Systems
Tracey J. Lantz, M.B.A.
Assistant to the President and Secretary to the Board
Jon Persavich, Ph.D.
Dean, School of Health Management (SHM)
Craig M. Phelps, D.O., FAOASM, 84

Provost Mesa Campus
Henry R. Setser, J.D., LL.M.
Vice President and General Counsel
Philip C. Slocum, D.O., FACOI, FCCM, FCCP, 76
Vice President for Medical Affairs and Dean, Kirksville College

of Osteopathic Medicine (KCOM)
O.T. Wendel, Ph.D.
Associate Provost Mesa Campus
Douglas L. Wood, D.O., Ph.D.
Dean, College of Osteopathic Medicine Mesa Campus
University Associate/Assistant Vice Presidents

Gretchen E. Buhlig
Vice President for Medical Affairs and Dean
Stephen D. Laird, D.O., M.H.P.E., FACOS

Associate Dean for Academic Affairs
Jeffrey A. Suzewits, D.O., M.P.H., FAAFP, 88

Associate Dean for Clinical Educational Affairs
Lloyd J. Cleaver, D.O., FAOCD, 76
Assistant Dean, Continuing Medical Education
Tammy Kriegshauser, M.B.A.
Assistant Dean, Clinical Educational Affairs
Clinical Chairs
Michael D. Lockwood, D.O., 81
Assistant Vice President for Information Technology and

Services
Edward Phillips, M.B.A.
Assistant Vice President for Institutional Advancement

Mesa Campus
Beth Poppre, M.Ed.
Assistant Vice President for Student Services Mesa Campus
Randy R. Rogers, CFP
Associate Vice President for Institutional Advancement

Kirksville Campus
22
Eric L. Sauers, Ph.D., ATC, CSCS
Interdisciplinary Health Sciences/Athletic Training Program
Albert F. Simon, DHSc., PA-C

Physician Assistant Studies
ASDOH
Jack Dillenberg, D.D.S., M.P.H.
Dean
L. James Bell, D.D.S.

Vice Dean
Robert A. Cederberg, D.D.S.
Associate Dean for Clinical Activities
Wayne Cottam, D.M.D., M.S.
Associate Dean for Community Partnerships
Kneka P. Smith, M.P.H., R.D.H.

Janet Woldt, Ph.D., M.S.
Internal Medicine
Associate Dean for Academic Assessment
G. Barry Robbins Jr., D.O., FACN, 70
George Blue Spruce Jr., D.D.S., M.P.H.
Neurobehavioral Sciences
Assistant Dean, American Indian Affairs
Toni R. Smith, D.O., FAOCA, 79
College of Osteopathic Medicine

Douglas L. Wood, D.O., Ph.D.
Surgery
Margaret A. Wilson, D.O., 82
Family Medicine and Community Health
Dean
Nehad El-Sawi, Ph.D.

Associate Dean
Basic Science Chairs

Charles Fleschner, Ph.D. (Interim Chairperson)
Thomas E. McWilliams, D.O.
D. Fred Peterson, Ph.D.
SHM
Jon Persavich, Ph.D.
Biochemistry
Physiology
Neil Sargentini, Ph.D.
Pharmacology
Bryan Krusniak, M.B.A.
Audiology
Donald R. Noll, D.O., FACOI, 87
Brian Degenhardt, D.O.
Associate Vice President for Admissions & Alumni Services
Tabitha Parent-Buck, Au.D.
Associate Dean for Curriculum Management and Integration
Microbiology/Immunology
Lori A. Haxton, M.A.
Occupational Therapy
Osteopathic Manipulative Medicine
Associate Vice President for Institutional Advancement

Mesa Campus
Assistant Vice President for Osteopathic Research and
Director, A.T. Still Research Institute
Bernadette Mineo, Ph.D., OTR/L
Robert J. Theobald Jr., Ph.D.

Lex C. Towns, Ph.D.
Anatomy
Mesa Campus Administration

Craig M. Phelps, D.O., FAOASM, 84
Provost
O.T. Wendel, Ph.D.

Associate Provost
ASHS
Randy Danielsen, Ph.D., PA-C
Associate Dean
Dean
Elsie Gaber, Ph.D.

Associate Dean
Keith Nordmann, M.S.

Associate Dean
Kimberly R. OReilly, M.S.W.

Associate Dean
Program Chairs
Michael A. Creedon, D.S.W.
Geriatric Health Management
Michael E. Samuels, Dr.P.H.
Public Health and Health Administration
Dean
Department Chairs
Suzanne R. Brown, M.P.H., PT
Physical Therapy
Fall 2006
Kirksville College of Osteopathic Medicine

Office of Continuing Medical Education
2006-2007 CME Programs

Primary Care Update
November 30-December 2, 2006
Big Cedar Lodge
Branson (Ridgedale), Missouri
18 hours category 1-A credit, AOA
Primary Care Update

February 22-24, 2007
Monte Carlo Resort
Las Vegas, Nevada
Biodynamics Phase 1 Course

January 5-8, 2007
ATSU Mesa, AZ Campus
22.25 hours category 1-A, AOA
Primary Care Update

March 12-16, 2007
Hilton Hawaiian Village
Honolulu, Hawaii
Primary Care Update

January 21-28, 2007
Freedom of the Seas
Western Caribbean
Tropical Medicine
March 26-30, 2007
Placencia, Belize
International Tropical Medicine

February 8-10, 2007
Diria Beach & Golf Resort
Tamarindo, Costa Rica
For more information, contact

Rita Harlow, Director, CME
660.626.2232
Toll free 866.626.2878, ext. 2232
Fax 660.626.2931
Email: cme@atsu.edu
Web: www.atsu.edu
Fall 2006
23

800 W. Jefferson St.
Kirksville, MO 63501
660.626.2272
School of Health Management

210A S. Osteopathy St.
660.626.2272
Arizona School of Dentistry & Oral Health

Arizona School of Health Sciences
College of Osteopathic Medicine - Mesa
5850 E. Still Circle
Mesa, AZ 85206
480.219.6000
www.atsu.edu
800 W. Jefferson St.

660.626.2272
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Andrew Taylor Still

founded an overall healthcare philosophy.

A.T. Still University Review Fall 2006

James J. McGovern, Ph.D.

Adrian Anast, Ph.D.

Bill Beard, JK Creative Printers

JK Creative Printers, Quincy, Ill.

The A.T. Still University Review is

Thoughts on Healthy Aging

Aging and Osteopathy:

Still university review

Thoughts on Healthy Aging

Jason Haxton, M.A.

ndrew Taylor Still, M.D.,

United States Life Expectancy3

In books written during the

Still university review

Dr. A.T. Still with staff age 83

Following his own advice to

Osteopathically Caring for the Old

osteopathic principle of StructureFunction Interdependencies is

as the body. What this means

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Another osteopathic principle

Applications of Types of Causes

good spirits or laughter can help

running a company or a detective

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their story, structure, or sense

medical care, triggered by the

continue to request the use of

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percent, respectively During the

must be grounded in irrefutable

Irvin Korr, Ph.D., and J. Stedman

of individual projects. In order to

Initiative to develop pilot data. In

Progress to date has been

Still university review

Aging and Osteopathy:

lthough well suited to meet

culture of medical technology and

Rene J. McGovern, Ph.D.

research evidence with our

real world setting. Longitudinal

ask, Are we measuring the right

Still university review

services in the United States.

medium changes in average daily

remember the following: Its

Length of life; 2. Quality of life; 3.

in this journal issue).

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Osteopathic Manipulation in the

he elderly are a significant

if an HVLA technique is correctly

17.5 percent; neurologic,

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greatly declined. Lynch reported

hospitalized with pneumonia.

or a sham control group. The

Still university review

group and 30 in the sham

in the group receiving OMT, with