+ A. Cranial osteopathy is a sub-specialty of osteopathic manipulative
+ medicine performed by a physician. This sub-specialty deals with subtle
+ motions of the body through the cranial sacral mechanism. It is a gentle
+ and powerful system, part of osteopathic medicine, that uses the
+ patient’s own inherent forces to overcome membranous, articular,
+ ligamentous strains in the body. It is a diagnostic and treatment method
+ for soft tissue injuries and especially cranial and sacral structures.
+
+
+
+ Q. What is the cranial rhythm?
+
+
+ A. It is a cyclic expansion and contraction of the membranous tissues of
+ the body that occur 8 to 14 times per minute. It is distinct from other
+ known pulses of the body, i.e., the heart and respiratory. It can be
+ felt at all parts of the body by a skilled cranial osteopath.
+
+
+
+ Q. Who performs cranial osteopathy?
+
+
+ A. Cranial osteopathy is an osteopathic technique devised by William
+ Garner Sutherland, D.O., originating in 1899 and popularized in the
+ 1940s to this day. It is a technique performed by osteopathic
+ physicians.
+
+
+
+ Q. What is cranial sacral therapy?
+
+
+ A. Cranial sacral therapy is the use of manual techniques performed by
+ therapists to unwind membranous articular strains of the cranial sacral
+ mechanism. Originally developed by William Garner Sutherland, D.O.,
+ popularized by John Upledger, D.O., and may be performed by any
+ therapist trained in this manner.
+
+
+
+ Q. Who would benefit from cranial osteopathy?
+
+
+ A. Many patients with a variety of conditions would benefit from cranial
+ osteopathy, primarily persons with soft tissue injuries with membranous
+ articular strains to the head, torso and extremities. It is a part of
+ the osteopathic manipulative medicine physician’s armamentarium in
+ treating the whole body from a biomechanical perspective, therefore, a
+ patient suffering from biomechanical dysfunction causing disease such as
+ asthma, sinusitis, ear-nose-throat problems, cerebral palsy, cranial
+ synestosis, plageocephalgy and muscle tension headache would benefit
+ from the use of cranial osteopathy.
+
+
+ Cranial osteopathy works on the basis of unwinding the membranous
+ articular strains that are present in the body thus removing the
+ biomechanical restrictions that prohibit fluid flow, improve circulation
+ and restore normal homeostasis to the body part and structure.
+
+
+
+
+ Q. What are the contraindications to cranial osteopathy?
+
+
+
+ A. Patients with no biomechanical problems and patients with an aversion
+ to being treated or touched.
+
+
+
+ Q. How does it feel while being treated?
+
+
+ A. The physician places a very light touch on your head, spine and
+ sacrum examining the cranial rhythmic impulse and verifying the areas of
+ the body where the impulse is restricted. The physician gently unwinds
+ the membranous articular strains with his/her hands. When that happens,
+ the patient may feel a slight sensation where the physician’s hands are
+ placed, otherwise, there is no sensation of pain or any other activities
+ while he/she is performing these maneuvers on your body.
+
+
+
+ Q. What is cranial manipulation?
+
+
+ A. Cranial manipulation is the application of an osteopathic physician’s
+ hands to the body, palpating the cranial rhythmic impulse—also known as
+ the primary respiratory mechanism, or third pulse of the body. The
+ physician determines the rate and amplitude of the cranial rhythmic
+ impulse, or lack thereof. Then, subtle pressure is applied to the body
+ part to enhance the movement of fluid and energy to that area. After the
+ connective tissue and the fascia (a web-like covering over all muscle
+ and tissue) are released from tension, the cranial rhythmic impulse will
+ have free rein and health will be restored to that body part.
+
+
+
+ Q. How does cranial manipulation work?
+
+
+ A. The body produces cerebrospinal fluid, which fluctuates 10 to 14
+ times a minute within the dura mater—the covering of the brain and
+ spinal cord. The billions of brain cells expand and contract, which
+ electrically and biochemically and hemodynamically cause a perceived
+ pulse—the cranial rhythmic impulse.
+
+
+ Because of the articular design of the 22 bones of the skull, motion is
+ permitted. The articular design of the sacrum (at the base of the spine)
+ between the ilea or hip bones permits motion down the spine. Because the
+ membranes covering the brain and spinal cord have elastin tissue and are
+ allowed to expand and relax, the cranial rhythmic impulse can be felt.
+ The amount of movement can be measured in millimeters and can be felt in
+ all parts of the body by a skilled cranial osteopath.
+
+
+
+
+ Q. What can I expect to feel during and after a treatment?
+
+
+
+ A. During a treatment, you can expect to feel subtle pressures on the
+ head, spinal column and tailbone. You may also feel a slight pounding of
+ fluid under the doctor’s hand. After a treatment, you may expect to feel
+ overall general well-being, as well as relief of some or all pain.
+
+
+
+
+ Q. Do some patients feel cranial manipulation more strongly than
+ others?
+
+
+
+ A. Yes. Generally speaking, the more out of balance a patient is, the
+ more he or she will feel the cranial manipulation. Some people are also
+ more sensitive than others.
+
+
+
+ Q. How long are the treatments?
+
+
A. Cranial manipulative treatments typically take 10 to 30 minutes.
+
+
+ Q. How frequently should I get a treatment?
+
+
+ A. Depending on your condition, treatment may be recommended once or
+ twice a week on an outpatient basis. As your condition improves,
+ treatments should taper to twice a month, then once a month, and finally
+ to three or four times a year for preventive maintenance.
+
+
+
+ Q. Are there any after-treatment restrictions?
+
+
+ A. It is not good to do heavy exercise, consume alcohol, eat a heavy
+ meal or engage in sexual activity within 12 hours after a treatment.
+
+
+
+
+ Q. What is the duration of the relief? Can it be permanent?
+
+
+
+ A. The duration of relief can be from hours to days, and generally
+ increases with successive treatments. Pain relief can be permanent.
+
+
+
+ Q. What should I bring with me to my first appointment?
+
+
+ A. You should bring any x-rays, MRIs, MRAs, CT scans and PET scans with
+ you on your first cranial manipulation visit. Also remember to bring any
+ laboratory and neurodiagnostic studies, such as EEGs, EMGs and
+ NCV-SSEPs.
+
+
+
+
+ Q. What age range benefits most from cranial manipulation?
+
+
+
+ A. The younger the patient, the more benefits he or she receives from
+ cranial manipulation. The best results are found in patients in the
+ first six months of life, followed by age six months to two years, age
+ two to six, and age seven to 18. With each successive decade, a patient
+ will usually need longer and more frequent treatments to achieve the
+ desired results.
+
+
+
+
+ Q. Which illnesses respond best to cranial manipulation?
+
+
+
+ A. Cranial manipulation is very effective in treating any mechanical
+ trauma to the head or tailbone. Birth trauma responds the quickest and
+ most completely to this form of treatment.
+
+
+
+
+ Q. What is Dr. Feely’s success rate with cranial manipulation?
+
+
+
+ A. Most patients are greatly improved or cured within six to eight
+ visits.
+
+
+
+
+ Q. Is there a clearinghouse for osteopaths who practice cranial
+ manipulation?
+
+
+
+ A. Yes. The Cranial Academy can give you a list of competency-tested
+ cranial osteopaths in your area. For physician referrals, send a
+ self-addressed, stamped business-size envelope ($0.55 postage) to:
+
+
+ The Cranial Academy
+
+ Referrals
+
+ 8202 Clearvista Parkway, #9-D
+
+ Indianapolis, IN 46256
+
+
+ Please include the city and state for which you are requesting
+ referrals.
+
+
+ The Cranial Academy will also fulfill requests for physician referrals
+ by e-mail or fax for a $10 charge; Visa and MasterCard are accepted.
+ Requests are fulfilled within 24 hours.
+
+
+ To request a referral by e-mail, contact:{" "}
+ cranacad@aol.com
+
+ Fax referral requests to: 317/594-9299
+
+
+
+ Q. Can any osteopath perform cranial manipulation?
+
+
+ A. Yes. Any licensed osteopath is able to perform manipulation,
+ including cranial osteopathic manipulation. But all osteopaths are not
+ highly skilled in this specialized form of treatment. Contact the
+ Cranial Academy at the address above for a referral to an osteopath who
+ is skilled in cranial manipulation.
+
+
+
+ Q. Are there specialists within osteopathic medicine?
+
+
+ A. Yes, there are osteopathic specialists in all recognized medical
+ specialties, from obstetrics, neurosurgery and cardiology to family
+ practice. Most DOs are family practitioners. A few, like Dr. Feely,
+ specialize in osteopathic manipulation.
+
+
+
+
+ Q. Can there be a change in the body’s reaction to prescription drugs
+ while undergoing this treatment?
+
+
+
+ A. Yes. When a person is under the influence of a narcotic, cranial
+ osteopathic manipulation often takes longer, more frequent treatments.
+
+
+
+
+ Q. Does Dr. Feely work in conjunction with MDs to balance a patient’s
+ prescription drugs and overall treatment?
+
+
+
+ A. Yes. Dr. Feely recognizes the importance of all of your health care
+ providers understanding your treatment regimen, as well as being aware
+ of any and all prescription medications you may be taking. If you need
+ additional medication or changes in your medication, Dr. Feely will be
+ happy to speak with your physician or prescribe it himself.
+
+
+
+
+ Q. Is it realistic to expect to be prescription drug-free after
+ successful treatment?
+
+
+
+ A. Not all patients will have total relief with osteopathic
+ manipulation. Some patients may need to continue a few prescription
+ drugs. However, most patients will decrease their amount of medicine
+ dependency, as well as the need for painkillers and other frequently
+ used drugs such as migraine medications.
+
+
+
+
+ Q. What is the price range for cranial osteopathic manipulation
+ treatments?
+
+
+
+ A. Dr. Feely normally performs cranial osteopathic manipulation in
+ conjunction with total body osteopathic manipulation treatments. For
+ price information, please contact our office manager, Farida Charania,
+ at 312-266-8565.
+
+
+
+
+ Q. Is a referral from an MD necessary for cranial osteopathic
+ manipulation?
+
+
+
A. No.
+
+
+
+ Q. Does medical insurance cover osteopathic manipulation?
+
+
+
+ A. Yes, most medical insurance covers osteopathic manipulative treatment
+ when the claim form is properly coded and the insurance company applies
+ the proper definition to those codes, and does not self-impose any
+ restrictions on manipulation. Some insurance plans allow only about
+ $1,000 of treatment per calendar year; other plans do not pay for an
+ office visit and osteopathic manipulation performed on the same day.
+
+ Cranial osteopathy, also known as osteopathy in the cranial field, was
+ developed as a natural extension of Dr. Andrew Taylor Still’s – the
+ founder of the osteopathic profession – philosophical and therapeutic
+ approaches to health through manipulation. William Gardner Sutherland
+ D.O. was the founder of cranial osteopathy, utilizing the body’s
+ inherent forces to overcome membranous articular restrictions
+ principally in the head and spine with secondary effects throughout the
+ rest of the body.
+
+
+
+ A cranial osteopath is an osteopathic physician and surgeon in the
+ United States. In other countries, the osteopathic physician has a
+ limited license. He or she diagnoses the patient holistically, body,
+ mind and spirit with particular detail to the musculoskeletal system and
+ the cranial sacral mechanism in particular. The cranial sacral mechanism
+ is a dynamic force within the living human body. It is the Qi or energy
+ of the central nervous system and is reflected throughout the rest of
+ the body.
+
+
+
+ Cranial osteopathy is a sub-specialty within osteopathic manipulative
+ medicine. It has a unique defined body of knowledge, educational
+ requirements and specific diagnostic treatment procedures that are part
+ and parcel of a complete osteopathic manipulative medicine specialist
+ practice. Diligent study of anatomy, physiology and pathology is
+ required to become a cranial osteopath. True system of preventive
+ medicine, treating the whole person, not just the disease.
+
+
+
+ Osteopathic medical schools teach courses in all branches of medicine
+ and surgery in the United States and various manipulative techniques. It
+ takes four years of training in osteopathic medical schools in the
+ United States. Most D.O.’s seek additional training in cranial
+ osteopathy after graduation. Most osteopathic medical schools in the
+ United States involve two hundred to three hundred hours of osteopathic
+ manipulative diagnostic and treatment education
+
+
+
The Cranial Academy
+
+
+ The professional organization representing D.O.’s who practice cranial
+ osteopathy, The Cranial Academy, requires a 40 hours basic course just
+ for membership and after that most osteopathic physicians have an
+ additional 100 to 200 hours of training in osteopathic manipulative
+ medicine related to the cranial field. In addition, The Cranial Academy
+ offers competency testing and fellowship certification for D.O’s
+ receiving national prominence.
+
+
+
+ Cranial osteopaths were originally labeled as quacks for identifying
+ that the bones of the skull were slightly mobile and that this mobility
+ allowed for membranous articular strains that could cause dysfunction
+ and pain. Today, scientist and many M.D’s through the use of high-tech
+ diagnostic equipment agree that there is a motion present in the
+ cranium.
+
+
+
+ There are many other therapies and therapist out there that claim to be
+ cranial osteopaths. But only physicians (M.D’s. D.O.’s and dentists) can
+ be trained by The Cranial Academy, the national organization recognized
+ by the American Academy of Osteopathy and the American Osteopathic
+ Association (AOA) as the professional organization in this field.
+
+
+
+ Cranial osteopathy cannot be effectively learned via the Internet or
+ reading books. It is a psychomotor skill be best taught with hands on
+ guidance. It must be practiced on living human heads with a skilled
+ trained practitioners providing guidance, experience, knowledge, skill
+ and information to the student.
+
+
+
The Rhythmic Impulse
+
+
+ The body has a self healing mechanisms. One of these mechanisms is the
+ third pulse of the body that emanates from the central nervous system.
+ This inherent motility of the brain and spinal cord occurs with the
+ initial inspiration of the breath of life at birth. This primary
+ respiratory mechanism called the cranial rhythmic impulse which is
+ associated with a very slight coiling and uncoiling of the spinal cord
+ and the central nervous system. The bones of the head and the central
+ nervous system become slightly wider and shorter from front to back in
+ the inspiration or flexion phase of the sphenobasilar synchondrosis. In
+ the exhalation phase, the primary phase, the primary respiratory
+ mechanism moves in just opposite direction. The head and central nervous
+ system becomes longer and slightly wider. This amount of movement is in
+ the millimeter range. One measurement placed it within hundredths of an
+ inch. But this varies according to where one measures the motion, at
+ which suture.
+
+
+
+ The fluctuation of the cerebral spinal fluid occurs with the motion of
+ the billions of glial cells in the central nervous system and this
+ movement occurs in the relatively closed container of the cranium. As
+ the brain and spinal cord change shape and go through the cycle of
+ inhalation and exhalation/flexion and extension, the cerebral spinal
+ fluid fluctuates back and forth within the spaces of the brain and
+ spinal cord. This helps push the cerebral spinal fluid through the small
+ channels around the nerved down the spinal cord and exiting the central
+ nervous system into the peripheral nervous system. The motion of the
+ membranes of the head called the dura mater that surround the bones and
+ house the vessels in the skull. The dura membranes appear as the three
+ attached sickle shaped membranes forming a tripod to support the brain
+ and skull.
+
+
+
+ They are called the falx cerebri and the tentorum cerebelli with a small
+ slip dividing the left and right half of the cerebellum. They limit and
+ control the slight motion of the bones of the head effecting the whole
+ fasat mechanism involving the cranium to the sacrum. The dura membranes
+ are firmly attached at the foramen magnum, second and third cervical
+ vertebra and the sacral segment. The 26 bones of the head are in slight
+ rhythmic motion along with the cerebral spinal fluid, the central
+ nervous system, the dural membranes and the sacrum. These cranial bones
+ are architecturally designed to fit together with various grooves and
+ gear-like articulation with each other. The sutures are comprised on
+ connective tissues, membranes and blood vessels with elastic tissue
+ identified microscopically. Since the dura is firmly attached at the
+ base of the skull and the sacrum, motion of the cranial mechanism is
+ transmitted into the sacrum. The cranium and the sacrum work together in
+ a flexion and extension phases. This constant rhythmic motion moves the
+ sacrum into nutation and antinutation.
+
+ Today, only one branch of mainstream medicine follows the Hippocratic
+ philosophy of medical care that centers on the patient, not the disease.
+ It is Osteopathic Medicine and, currently, some 36,233 osteopathic
+ physicians and surgeons offer this dimension in medical care.
+
+
+ Doctors of Osteopathic Medicine (D.O.’s) are fully licensed and
+ recognized physicians and surgeons who stress the unity of all body
+ systems. They emphasize holistic medicine-awareness of proper nutrition
+ and environmental factors; a hands-on approach to medicine; and a unique
+ aid to the diagnosis and treatment of various illnesses known as
+ Osteopathic Manipulative Treatment.
+
+
+ One of the Osteopathic concepts of good medicine is that the body’s
+ musculoskeletal system is central to the patient’s well-being.
+
+
+ The system includes the bones, muscles, tendons, tissues, nerves and
+ spinal column–about 60 percent of the body mass. This framework works
+ with all the body’s organs. It responds–properly or improperly—every
+ time a breath is drawn or any other body movement occurs. Besides being
+ prone to mechanical disorders, the musculoskeletal system reflects many
+ internal illnesses and may aggravate or accelerate the disease process
+ throughout the body. The osteopathic physician takes advantage of this
+ fact in management not only of problems of the musculoskeletal system
+ itself, but also in managing disorders affecting the rest of the body as
+ well.
+
+
+ Osteopathic physicians utilize all of the recognized procedures and
+ modern technologies for prevention, diagnosis and treatment of disease,
+ including drugs, radiation and surgery. In addition, the D.O. assesses
+ the musculoskeletal system by the use of a finely trained sense of touch
+ with the hands in a process called palpatory diagnosis. Disorders found
+ there are treated by the introduction of carefully applied manual
+ forces, directed to the bones, muscles and joints, in a type of
+ treatment called Osteopathic Manipulative Treatment (OMT), or simply
+ “manipulation.” Osteopathic manipulation of the musculoskeletal system
+ is a proven technique for many diagnoses and treatments. Often, it can
+ provide an alternative to therapies involving drugs or surgery.
+
+
+ Because musculoskeletal dysfunction can mimic many diseases, osteopathic
+ manipulation is an important component in diagnosis, as well as a means
+ of correcting structural problems.
+
+
+ For example, it has been well-documented that diseases of specific
+ organs can produce pain in other parts of the body. Stomach ulcers
+ consistently cause area of spinal pain and irritation just below the
+ shoulders in the back. The radiation of pain to the loin is the
+ reflection of pain and disability to the left shoulder following heart
+ disease. In diagnosing such diseases, D.O.’s recognize that symptoms can
+ be produced without actual disorder in organs to which pain has been
+ referred.
+
+
+ Also, disturbances affecting the musculoskeletal system can cause
+ symptoms that stimulate other illnesses. Among the most common causes of
+ recurrent headaches, for example, is disorder of the cervical (upper)
+ portion of the spinal column. Properly applied manipulative treatment,
+ particularly directed to the head and neck, can often relieve headache
+ symptoms when other remedies have failed.
+
+
+ Osteopathic Manipulative Treatment is often part of the medical
+ treatment for stress headaches, sinus problems and pulmonary distress.
+ Obstetricians often use manipulation to relieve low back pain during
+ pregnancy or as additional medical treatment for menstrual cramps.
+
+
+ Studies indicate that Osteopathic Manipulative Treatment, as part of the
+ total patient treatment, actually accelerates the rate of recovery from
+ illness or injury, keeping hospital or home stays to a minimum.
+
+
+ By combining unique osteopathic principles with traditional diagnostic
+ and therapeutic procedures, D.O.’s offer a balanced system of health
+ care to both prevent and cure disease. The osteopathic approach is a
+ true system of preventive medicine, treating the whole person, not just
+ the disease.
+
+
+
Section B | What is the Difference?
+
+ American osteopathic physicians are fully licensed physicians and
+ surgeons. To become fully licensed, they must graduate from one of 16
+ osteopathic medical schools accredited by the Bureau of Professional
+ Education of the American Osteopathic Association. After completing
+ osteopathic medical school, D.O.s serve a one-year internship. During
+ that year, they gain hands-on experience in internal medicine,
+ obstetrics/gynecology, family practice, pediatrics and surgery. Often a
+ D.O. will opt to continue their education by entering a two to six year
+ residency program in a specialty area such as cardiology, neurology or
+ thoracic surgery.
+
+
+ There are currently 35,000 D.O.s in the United States, with 60 percent
+ of them in primary care areas of family practice, internal medicine,
+ obstetrics/gynecology and pediatrics. D.O.s comprise 5.5 percent of the
+ total physician population and 18 percent of all physicians in the
+ military. By the year 2000, there will be 45,000 osteopathic physicians
+ in practice in the United States. Each year, 100 million patient visits
+ are made to D.O.s.
+
+
+ Unlike in England, in the USA an osteopathic doctor is a fully licensed
+ and trained physician and surgeon like an MD but with the addition of
+ osteopathic manipulation. Each DO is licensed by each individual state
+ to practice Osteopathic Medicine and Surgery. An English DO to practice
+ in the US would have to take 4 years of Osteopathic Medicine at a US
+ college plus 3 years of residency/internship, then pass a national or
+ state board exam. He would then be able to apply and receive a state
+ license.
+
+
DOs and MDs are Similar
+
+
+ All must have four years of undergraduate training with an emphasis on
+ science courses.
+
+
All must complete four years of basic medical education.
+
+ All may choose a medical specialty after completing medical school.
+
+
+ All must pass an unlimited physician and surgeon state licensing
+ examination.
+
+
+ All may practice in fully accredited, licensed hospitals and medical
+ centers.
+
+
+
DOs and MDs are Different
+
+
+ D.O.s focus on preventive health care.
+
+
+
+ D.O.s receive additional training in the musculoskeletal system,
+ gaining a therapeutic and diagnostic advantage.
+
+
+
+
+ D.O.s do not treat specific illnesses or symptoms, but instead
+ practice a whole person approach to medicine.
+
+
+
+
+ D.O.s incorporate osteopathic manipulative treatment (OMT) into
+ their practice which allows them to use their hands to diagnose and
+ treat soft tissue injury or illness, thereby encouraging the body’s
+ natural tendency toward health.
+
+
+
+
+
DOs, MDs and DCs
+
+ While health care practitioners are very familiar with the similarities
+ and differences between their particular treatment approaches, many
+ times the public is not. The following table is provided to help give a
+ general overview of the training and root philosophies of these three
+ professional disciplines.
+
+
+
+
+
Osteopathic Physicians (DO)
+
Allopathic Physicians (MD’s)
+
Chiropractors (DC’s)
+
+
+
+ Undergraduate Training Required
+
+
4 years
+
4 years
+
4 years
+
+
+
+ Postgraduate Training Required
+
+
5-8 years
+
5-8 years
+
3-4 years
+
+
+
+ Hospital Residency Required
+
+
Yes
+
Yes
+
No
+
+
+
+ Able to Prescribe Drugs
+
+
Yes
+
Yes
+
No
+
+
+
+ Able to Perform Surgery
+
+
Yes
+
Yes
+
No
+
+
+
+ Training in Bodily Manipulation
+
+
+ Receives 300-500 hours extensive training in bodily manipulation
+ including cranial, extremity, spinal joints, and connective tissue
+
+
+ Receives no formal training in manipulation, spinal or otherwise
+
+
Receive up to 600 hours in the use of spinal manipulation
+
+
+
+ Founders
+
+
+ A.T. Still, physician whose philosophy is a “whole person” approach
+ and whose emphasis was on disease prevention as well as cure. A.T.
+ Still was an American original.
+
+
+ German trained physicians who viewed the body as being comprised
+ primarily of parts and who emphasized treating symptoms through
+ drugs and surgery.
+
+
+ D. D. Palmer who felt that spinal manipulation could effectively
+ address 95% of all illness. Briefly studied with A. T. Still, then
+ developed his own techniques.
+
+
+
+
+
Section C | Principles
+
+ Osteopathy is the knowledge of the structure, relations and functions of
+ each part and tissue of the human body applied to the adjustment in the
+ correction in whatever may be interfering with the harmonious operation.
+ Doctors of osteopathy conceive of man as a biomechanism, an organic
+ machine which, as long as the cells, tissues, organs, muscles, ligaments
+ and bones are normal in themselves in their reciprocal relationships,
+ they will function normally. They maintain that structural integrity and
+ physiological adjustment of the tissues and fluid tensions of the
+ organism which form the most important factors in maintaining health.
+ Life essentials-food, water, light, air, heat, exercise, protection and
+ rest-are necessary also environmental and psychological harmony. In an
+ organism structurally perfect, these constitute the requirements of man
+ for maintaining health. The principles of osteopathy follow the logic of
+ an applied knowledge of anatomy, physiology and pathology.
+
+
The principles of Osteopathy are as follow:
+
+
that the body is a unit
+
structure and function are reciprocally interrelated
+
the body possesses self regulating mechanisms
+
+ the body rationale therapy is based upon knowledge and use of the
+ above three principles.
+
+
+
+ The osteopathic concept includes surgery which osteopathic physicians
+ practice and recommend as indicated. Osteopathy is not drug-less
+ profession in the strict sense of the word. It uses drugs which have
+ specific scientific value and proven effectiveness. The osteopathic
+ physician is a skilled engineer of the vital human mechanism influencing
+ by manipulation and other osteopathic measures the activity of the nerve
+ cells, glands and organs and the distribution and the distribution of
+ fluids and the discharge of nerve impulses therefore, normalizing tissue
+ fluid and function.
+
+ Receives 300-500 hours extensive training in bodily manipulation
+ including cranial, extremity, spinal joints, and connective tissue
+
+
+ Receives no formal training in manipulation, spinal or otherwise
+
+
Receive up to 600 hours in the use of spinal manipulation
+
+
+
+ Founders
+
+
+ A.T. Still, physician whose philosophy is a “whole person” approach
+ and whose emphasis was on disease prevention as well as cure. A.T.
+ Still was an American original.
+
+
+ German trained physicians who viewed the body as being comprised
+ primarily of parts and who emphasized treating symptoms through
+ drugs and surgery.
+
+
+ D. D. Palmer who felt that spinal manipulation could effectively
+ address 95% of all illness. Briefly studied with A. T. Still, then
+ developed his own techniques.
+
+ During pregnancy, a woman’s body undergoes many anatomic (structural),
+ circulatory (fluid), and hormonal changes that may lead to various
+ musculoskeletal complaints, increase her risk of injury, or alter the
+ course of pre-existing conditions. Some of the more common complaints
+ include low back and pelvic pain, carpal tunnel syndrome, headache,
+ nausea, vomiting, and edema. Approximately 2/3 of women with rheumatoid
+ arthritis will have improvement in their symptoms during pregnancy but
+ may suffer a flare-up in the post partum period. Many women with
+ ankylosing spondylitis may have an exacerbation of symptoms. Women with
+ scoliosis have no increased risk over non pregnant women for
+ progression. [1,2]
+
+
+
+ Most of the symptoms encountered can be attributed to the development
+ and growth of the fetus and are often specific to the different
+ trimesters of the pregnancy. Osteopathic manipulation can play an
+ important role in providing relief for the common complaints throughout
+ the various stages of pregnancy, delivery, and the post partum period.
+
+
+
First Trimester
+
+ Common conditions in the first trimester include heartburn as well as
+ nausea and vomiting (“morning sickness”). Structural dysfunction is
+ often found at the spinal levels related to the nervous system supply to
+ the organs involved. Osteopathic manipulation to the cervical and
+ thoracic spine can be used to influence these nervous system inputs,
+ providing relief for gastrointestinal complaints. [3]
+
+
+
Second Trimester
+
+ As the uterus increases in size, pain may be felt through the round
+ ligaments and the pubic symphysis. Once it expands from the pelvis in to
+ the abdomen, the diaphragm becomes elevated affecting breathing. Fascial
+ release through the abdomen, ribcage, and diaphragms may improve
+ respiration and prevent or alleviate backache, sciatica, cramps or
+ posterior pelvic pain. The second most common complaint in the second
+ trimester is hand and wrist pain resulting from localized swelling.
+ Anywhere from 1% -25% of all pregnant women may exhibit the classic
+ carpal tunnel syndrome symptoms of numbness, tingling, and night-time
+ pain. Since it almost always resolves after delivery, conservative
+ treatment is recommended. This would include night time splinting and
+ manipulative treatment aimed at improving lymphatic flow and releasing
+ tension at the wrist. [1,3]
+
+
+
Third Trimester
+
+ Mechanical and structural changes are at their greatest in the third
+ trimester. These result in changes in gait, loss of balance, and low
+ back pain. Gravitational effects from the uterus in the abdomen and
+ pelvis cause pressure that decreases lymphatic and venous return from
+ the lower extremities leading to edema and hemorrhoids. Constipation and
+ reflux are also common. Osteopathic manipulation to the pelvic floor and
+ mid thoracic and lumbar spine helps to mobilize fluid and relieve these
+ complaints.
+
+
+
Labor & Delivery
+
+ During labor, Osteopathic manipulation focused at the lower thoracic and
+ lumbar areas can influence the nerves that supply the pelvic organs.
+ Soft tissue and myofascial treatment of the pelvis and sacrum can help
+ to maintain good mobility of the sacrum, allow for proper rotation and
+ descent of the fetal head, and influence cervical dilation. Osteopathy
+ in the Cranial Field has been shown in studies to influence uterine
+ contractility and help to overcome uterine inertia by its effect on the
+ pituitary secretion of oxytocin. [4, 5]
+
+
+
Post Partum
+
+ Throughout pregnancy, a woman’s body produces the hormone relaxin. This
+ allows the joints of the pelvis to become flexible for the fetus to
+ pass. It is also responsible for the increased joint laxity that can
+ lead to the dysfunctions that occur during pregnancy and delivery. Since
+ the serum levels of relaxin return to near normal three days post
+ partum, treatment immediately after delivery can help to re-align the
+ sacropelvic structures that have just undergone the stress of pushing
+ and positioning in stirrups. Later follow-up with osteopathic
+ manipulation is useful for the treatment of any persistent pain in the
+ low back or pelvis.
+
+
+
Contraindications
+
+ In most cases, the use of Osteopathic manipulation in pregnancy is both
+ safe and effective. Conditions where it should not be used include:
+ premature labor, abruption placentae, rupture of membranes without
+ labor, incompetent cervix, eclampsia, and ectopic pregnancy. 5
+
+
+
Summary
+
+ Pregnancy is a time where a women’s body undergoes many changes-often
+ resulting in some form of musculoskeletal complaint. Osteopathic
+ manipulation can serve as a valuable adjuvant therapy in the normal
+ obstetrical care. By providing relief from pain, maintaining homeostasis
+ and circulation, and supporting labor and delivery, pregnancy can be a
+ more comfortable and enjoyable experience.
+
+
+
References
+
+ 1. Ireland M, Ott S. The Effects of Pregnancy on the Musculoskeletal
+ System. Clinical Orthopaedics and Related Research. 2000. 372:169-179.
+
+
+ 2. Jones A, Lockwood M. Osteopathic Manipulative Treatment in Pregnancy
+ and Augmentation of Labor: A Case Report. AAO Journal. 18:1 March 2008:
+ 27-29.
+
+
+ 3. Ward R. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia,
+ PA: Lippincott Williams & Wilkins; 2003: 450-461.
+
+
+ 4. McAfee S, Chila A. Occipital Compression and its Potential Uses in
+ Obstetrics. AAO Journal. 17:3 September 2007: 27-29.
+
+
+ 5. DiGiovanna E, Schiowitz S, Dowling D. An Osteopathic Approach to
+ Diagnosis and Treatment 3rd ed. Philadelphia, PA: Lippincott Williams
+ & Wilkins; 2005: 651-659.
+
+ In an era marked by medical advances, from state-of-the-art surgery to
+ the newest prescription medication, what unique tool will osteopathic
+ physicians use? Their hands.
+
+
+
+ Osteopathic physicians (D.O.s) provide you with all the best that
+ medicine has to offer. They can specialize in any recognized area of
+ medicine, from pediatrics to neurosurgery. However, their knowledge and
+ use of the latest medical technology is complemented by their
+ application of a hands-on treatment tool known as osteopathic
+ manipulative treatment, or OMT.
+
+
+
+ Using OMT, D.O.s bring an added dimension to healthcare, in the form of
+ a non-invasive treatment. D.O.s use OMT to diagnose, treat and even
+ prevent illness or injury. When appropriate it can be used in
+ conjunction with, or in place of, medication or surgery.
+
+
+
Unique Philosophy
+
+
+ D.O.s are widely recognized for their incorporation of manipulative
+ medicine into their spectrum of care. OMT is just one element of the
+ unique philosophy of osteopathic medicine.
+
+
+
The Big Picture
+
+
+ By taking the whole person approach to care, D.O.s don’t just focus on
+ the disease or injury. They look for the underlying causes of disease
+ instead of simply treating the symptoms. Not only do they consider your
+ physical condition, but also they take other factors into account like
+ home, work and family life when making a diagnosis.
+
+
+
Patient, Heal Thyself
+
+
+ D.O.s recognize that the body is inherently capable of healing itself,
+ though it must constantly fight physical, emotional and nutritional
+ “stressors” to maintain a state of wellness. D.O.s believe in educating
+ you about good health and prevention of disease.
+
+
+
The Musculoskeletal System
+
+
+ D.O.s place particular emphasis on the musculoskeletal system, which
+ comprises two-thirds of the body’s mass. D.O.s believe that all of the
+ body’s systems, including the musculoskeletal system, work together and
+ that disturbances in one system may impact function elsewhere in the
+ body. This understanding of body structure and function provides the
+ foundation for the osteopathic approach to medicine.
+
+
+
The ABC’s of OMT and How It Can Work for You
+
+
+ OMT is predicated upon your D.O.’s knowledge of medicine. Once your D.O.
+ has ruled out mechanical causes for your illness or injury (through
+ blood and urine testing, X-rays, etc.), and based upon physical and
+ mechanical findings, your D.O. may decide to utilize OMT. While it is
+ commonly associated with physical ailments such as low back pain, this
+ modality can also be used to relieve the discomfort or musculoskeletal
+ abnormality associated with a number of disorders, including: asthma,
+ sinus disorder, carpal tunnel, migraines and menstrual pain.
+
+
+
+ The osteopathic approach to treating many diseases includes medication
+ and/or surgical intervention, plus OMT. OMT can relieve muscle pain
+ associated with a disease and can hasten your recovery from illness by
+ promoting blood flow through tissues.
+
+
+
Diagnosis
+
+
+ Your structural exam will begin with an assessment of your posture,
+ spine and balance. Your D.O. will then use his fingers to palpate your
+ back and extremities. Your D.O. will then use his fingers to palpate
+ your back and extremities. He will also check your joints for
+ restriction and/or pain during motion as well as check your muscles,
+ tendons and ligaments where tenderness can signal a problem. Through
+ extensive osteopathic training in manipulative medicine, D.O.s can
+ detect changes in tissue, however small, that signal injury or
+ impairment.
+
+
+
+ Once the structural exam is complete, your D.O. will integrate this
+ information with your medical history and a complete physical exam.
+ After that point, a treatment plan can be established.
+
+
+
Treatment
+
+
+ Using a variety of OMT techniques, your D.O. will apply manual forces to
+ your body’s affected areas to treat structural abnormalities and will
+ then apply specific corrective forces to relieve joint restrictions and
+ misalignments. Based upon the severity of your problem, you may require
+ more than one treatment.
+
+
+
Case 1
+
+
+ Mary visited her D.O. complaining of a sharp pain in her side. The
+ physician asked a series of questions about her pain: its intensity,
+ onset and duration. They also discussed her medical history. The
+ physician then ordered a series of tests to determine whether the pain
+ was caused by disease (i.e. gallbladder or appendix). Tests revealed
+ that it was not. Since the patient indicated that she worked in an
+ office with a “surround style” desk, the D.O. considered that Mary might
+ be suffering from postural/mechanical strain. Based upon his
+ examination, interview with the patient and negative test results, the
+ physician decided to employ OMT to relieve motion restrictions and
+ muscle strain caused by improper sitting and movement. He also
+ recommended changes in the set-up of her workstation to alleviate
+ further pain.
+
+
+
Case 2
+
+
+ Michael’s symptoms included cough, congestion, fever and headache.
+ Suspecting chronic sinusitis, his D.O. conducted an exam and ordered
+ appropriate tests. When results confirmed the diagnosis, the physician
+ prescribed an antibiotic to treat the infection. She also employed a
+ variety of OMT techniques to promote sinus drainage and relieve pain
+ related to the infection. Michael’s congestion was markedly reduced
+ after just one OMT session. Upon completion of his antibiotic therapy
+ two weeks later, his infection was eliminated.
+
+
+
Who Can Benefit
+
+
+ People of all ages and backgrounds have found relief from pain and
+ dysfunction as well as improved mobility through OMT. D.O.s incorporate
+ this modality into their treatment plans for top athletes and
+ performance artists, workers with on-the-job injuries and thousands of
+ people, just like you.
+
+
+
Proof Positive
+
+
+ A study published in the November 4, 1999 issue of the New England
+ Journal of Medicine confirms what D.O.s have known for years’ that OMT
+ works. In this case, researchers examined the effectiveness of OMT for
+ treating low back pain.
+
+
+
+ Patients were divided into two groups’ one treated with standard options
+ like hot/cold packs, physical therapy and anti-inflammatory medication
+ while the other group received OMT and standard care. After a
+ twelve-week period, patients in both groups showed improvement. However,
+ researchers learned that the patients receiving OMT required less
+ medication and physical therapy, resulting in less side effects and
+ lower health care costs.
+
+
+
+ Another study released on OMT revealed its effectiveness in reducing
+ pain after a hysterectomy. Researchers measured the amount of morphine
+ to treat patients’ pain as well as their perception of their pain
+ levels. Upon the study’s completion, it was determined that
+ administering OMT significantly reduced patients’ needs for pain
+ medication.
+
+
+
+ By incorporating OMT into their practice of complete medicine, D.O.s are
+ providing the most comprehensive care available today.
+
+
+
History
+
+
+ The earliest medical writings from centuries past describe the efficacy
+ of manual medicine. In 1874, osteopathic medicine’s founder, Dr. A.T.
+ Still, recognized the power of hands-on care and incorporated it into
+ his philosophy of medicine. Dr. Still identified the musculoskeletal
+ system as a key element of health; he recognized the body’s self-healing
+ capacity; he emphasized prevention, exercise and keeping fit; and he
+ identified palpation and human touch as vital and less intrusive
+ elements of diagnosis and treatment. As the impressive growth of
+ osteopathic medicine demonstrates, Dr. Still’s founding tenets have
+ withstood the test of time and scientific scrutiny.
+
+
+
Education
+
+
+ D.O.s complete four years of medical training at one of the nation’s
+ fully accredited colleges of osteopathic medicine. The osteopathic
+ curriculum is intensive and broad-based. It includes comprehensive
+ training in the musculoskeletal system and the use of OMT. Manipulation
+ combined with the osteopathic principles of holistic care, prevention
+ and primary care makes osteopathic medicine unique.
+
+
+
+ Upon graduation from medical school, D.O.s complete a one-year rotating
+ internship through all the areas of primary care. Afterwards, they may
+ complete a residency in any of more than 120 specialty and subspecialty
+ areas of medicine. However, sixty-four percent of all D.O.s remain in
+ primary care practices.
+
+ A. Osteopathy is a complete school of medicine in the United States. It
+ is a separate and distinct medical profession with unlimited practice
+ rights in the field of medicine and surgery. It is a medical art and
+ science with a unifying holistic philosophy of body, mind and spirit.
+
+
+
+ Q. What is an osteopathic doctor in the USA?
+
+
+ A. In the USA, an osteopathic doctor is a fully licensed and trained
+ physician and surgeon like an MD but with the addition of osteopathic
+ manipulation. Each DO is licensed by each individual state to practice
+ Osteopathic Medicine and Surgery. An English DO to practice in the US
+ would have to take 4 years of Osteopathic Medicine at a US college plus
+ 3 years of residency/internship, then pass a national or state board
+ exam. He would then be able to apply and receive a state license.
+
+
+
+ Q. What is Osteopathic Manipulation?
+
+
+ A. Osteopathic manipulation is a manual medical procedure that the
+ physician applies to a patient. This manual hands-on technique involves
+ putting joints and tissues through a range of motion, releasing
+ membranous articular strain, muscle spasm and tight joint capsules and
+ ligaments. Osteopathic manipulation alleviates somatic dysfunction.
+
+
+
+ Q. What is Somatic Dysfunction?
+
+
+ A. Somatic dysfunction is impaired or altered function of related
+ components of the somatic (body framework) system. This includes
+ skeletal, arthrodial, myofascial structures, and their related vascular,
+ lymphatic, and neural elements.
+
+
+
+ Q. What is the Osteopathic profession like?
+
+
+ A. The osteopathic profession is a group of over 36,000 physicians and
+ surgeons throughout the United States that are involved in unlimited
+ medical practice providing diagnosis and treatment in all standard
+ medical specialties including family practice, internal medicine,
+ neurosurgery, cardiovascular surgery, obstetrics and gynecology, general
+ surgery, cardiology, neurology, internal medicine, etc.
+
+
+
+ Q. What is Osteopathic Manipulative Medicine?
+
+
+ A. It is a primary care specialty emphasizing in-depth application of
+ the osteopathic philosophy and special proficiency in osteopathic
+ diagnosis and treatment.
+
+
+ Q. What is Osteopathic manipulative treatment?
+
+
+ A. It is a diagnosis followed by therapeutic application of manually
+ guided forces by an osteopathic physician to alleviate somatic
+ dysfunction. This is accomplished by a variety of techniques.
+
+
+
+
+ Q. What are some techniques used in Osteopathic manipulative
+ treatment?
+
+
+
A. Some techniques include:
+
+
+ 1. Articulatory treatment - low velocity, moderate to high amplitude
+ technique that carries a joint through a full range of motion to
+ increase freedom of movement.
+
+
+ 2. Counterstrain - inhibits inappropriate strain reflex by applying mild
+ strain opposite to the reflex.
+
+
+ 3. Cranial treatment - diagnosis and treatment using the primary
+ respiratory mechanism.
+
+
+ 4. Directed treatment - engages the restrictive barrier and carries the
+ dysfunctional component towards the restricted barrier.
+
+
+ 5. Exaggeration treatment - moves the dysfunctional component away from
+ the restricted barrier through and beyond the range of motion.
+
+
+ 6. Facilitated positional release - myofascial release treatment
+ involving activating force compression or torsion.
+
+
+ 7. Muscle energy treatment - patient moves as directed by the physician
+ against defined resistance.
+
+
+ 10. Myofascial treatment - continuous palpatory feedback to achieve
+ release of myofascial tissues.
+
+ 12. Traction treatment - stretching or separating parts along the
+ longitudinal axis.
+
+
13. Visceral manipulation - positioning viscera to fascial balance.
+
+ Q. What is the Osteopathic philosophy?
+
+
+ A. Osteopathic medicine is a philosophy of healthcare and a distinctive
+ art supported by expanding scientific knowledge. Its philosophy embraces
+ the concept of the unity of the living organism's structure and
+ function. It applies science and art to establish and maintain health,
+ prevent and alleviate disease. Osteopathic concepts emphasize principles
+ like the body's self-regulatory mechanisms, interrelation of structure
+ and function, and rational treatment based on these principles.
+
+
+ Q. What is an Osteopathic structural examination?
+
+
+ A. An examination of the patient by an osteopathic physician with an
+ emphasis on the neuromuscular skeletal system. It includes palpatory
+ diagnosis of somatic dysfunction in the context of total patient care.
+
+
+ Q. What is palpatory diagnosis?
+
+
+ A. It is the process of palpating the patient to evaluate the
+ neuromuscular skeletal and visceral systems.
+
+
+ Q. What is the primary respiratory mechanism?
+
+
+ A. It refers to the interdependent function among five body components:
+ brain and spinal cord motility, cerebral spinal fluid fluctuation,
+ intracranial and intraspinal spinal membrane mobility, articular
+ mobility of cranial bones, and sacral mobility between ilia or pelvic
+ bones.
+
+
+ Q. What is postural decompensation?
+
+
+ A. It's the distribution of body mass away from the ideal when postural
+ homeostatic mechanisms are overwhelmed, resulting in changes like
+ scoliotic, rotational, kyphotic, or lordotic changes.
+
+
+ Q. What is the somato visceral reflex?
+
+
+ A. It's an involuntary nervous system response to sensory input that
+ produces reflex responses in segmentally related visceral structures.
+
+
+ Q. What is a visceral somatic reflex?
+
+
+ A. It's a localized visceral stimuli producing patterns of reflex
+ response in segmentally related somatic structures.
+
+
+ Q. What is the cranial sacral mechanism?
+
+
+ A. It refers to the connection between the occiput and sacrum by the
+ spinal dura mater as described by William G. Sutherland D.O.
+
+
+ Q. What is spinal facilitation?
+
+
+ A. It's the maintenance of a pool of neurons, motor neurons, or
+ preganglionic sympathetic neurons in a state of partial or subthreshold
+ excitation in the spinal cord, requiring less afferent or presynaptic
+ stimulation to trigger impulse discharge.
+
+ If you’re like most people, you’ve been going to a doctor ever since you
+ were born, and perhaps were not aware whether you were seeing a D.O.
+ (osteopathic physician) or an M.D. (allopathic physician). You may not
+ even be aware that there are two types of complete physicians in the
+ United States.
+
+
+ The fact is, that both D.O.s and M.D.s are fully qualified physicians
+ licensed to perform surgery and prescribe medication in all 50 states.
+ Is there any difference between these two kinds of doctors? Yes. And no.
+
+
DOs and MDs
+
+
+ Applicants to both D.O. and M.D. colleges typically have a four-year
+ undergraduate degree with an emphasis on scientific courses.
+
+
+ Both D.O.s and M.D.s complete four years of basic medical education.
+
+
+ After medical school, both D.O.s and M.D.s can choose to practice in a
+ specialty area of medicine–such as psychiatry, surgery or
+ obstetrics–after completing a residency program which requires an
+ additional two to six years of training.
+
+
+ Both D.O.s and M.D.s must pass comparable state licensing
+ examinations.
+
+
+ D.O.s and M.D.s both practice in fully accredited and licensed health
+ care facilities.
+
+
+ D.O.s comprise a separate, yet equal branch of American medical care.
+ Together, D.O.s and M.D.s enhance the state of care available in
+ America.
+
+
+
Something Extra
+
+
+ Osteopathic medical schools emphasize training students to be primary
+ care physicians.
+
+
Osteopathic physicians focus on preventive health care.
+
+ D.O.s receive extra training in the musculoskeletal system — your
+ body’s interconnected system of nerves, muscles and bones that make up
+ two-thirds of its body mass. This training provides osteopathic
+ physicians with a better understanding of the ways that an injury or
+ illness in one part of your body can affect another.
+
+
+
+ Osteopathic manipulative treatment (OMT) is incorporated in the training
+ and practice of osteopathic physicians. With OMT, osteopathic physicians
+ use their hands to diagnose injury and illness and to encourage your
+ body’s natural tendency toward good health. By combining all other
+ medical procedures with OMT, D.O.s offer their patients the most
+ comprehensive care available in medicine today.
+
+
More than a Century of Care
+
+ Osteopathic medicine is a unique form of American medical care that was
+ developed in 1874 by Dr. Andrew Taylor Still. Dr. Still was dissatisfied
+ with the effectiveness of 19th Century medicine. He believed that many
+ of the medications of his day were useless or even harmful. Dr. Still
+ was one of the first in his time to study the attributes of good health
+ so that he could better understand the process of disease.
+
+
+ In response, Dr. Still founded a philosophy of medicine based on ideas
+ that date back to Hippocrates, the father of medicine. The philosophy
+ focuses on the unity of all body parts. He identified the
+ musculoskeletal system as a key element of health. He recognized the
+ body’s ability to heal itself and stressed preventive medicine, eating
+ properly and keeping fit.
+
+
+ Dr. Still pioneered the concept of “wellness” more than 125 years ago.
+ In today’s terms, personal health risks–such as smoking, high blood
+ pressure, excessive cholesterol levels, stress and other lifestyle
+ factors–are evaluated for each individual. In coordination with
+ appropriate medical treatment, the osteopathic physician acts as a
+ teacher to help patients take more responsibility for their own
+ well-being and change unhealthy patterns.
+
+
+ For more about the history of the profession, visit The History of
+ Osteopathic Medicine Virtual Museum.
+
+
+ Just as Dr. Still pioneered osteopathic medicine on the Missouri
+ frontier in 1874, today osteopathic physicians serve as modern day
+ medical pioneers.
+
+
+
+ Over half of all osteopathic physicians practice in primary care areas
+ such as pediatrics, family practice, obstetrics/gynecology and
+ internal medicine.
+
+
+ Many D.O.s fill a critical need for doctors by practicing in rural and
+ medically underserved areas.
+
+
+
+ Today osteopathic physicians continue to be on the cutting edge of
+ modern medicine. D.O.s are able to combine today’s medical technology
+ with their ears, to listen compassionately to their patients; their
+ eyes, to see their patients as whole persons; and their hands, to
+ diagnose and treat injury as well as illness.
+
+
+ “As an osteopathic physician, I believe in prevention. I am committed to
+ educating my patients so they can take the necessary steps to live and
+ maintain healthier lifestyles.”
+
+
Tyler C. Cymet, D.O., Internal medicine, Baltimore