The World Authority
on Orthopaedic Medicine
AAOM 30th Anniversary Year
From The Editor
By Anette Mnabhi, DO, RN, MSN, ABONMM, ABOFP, CAAOM

Anette MnabhiThe beginning of wisdom is to call things by their right names. (Unknown)

As the AAOM moves on to it's 31st year we face many challenges. The world of medicine is changing, new techniques emerge and are developed, new understanding of disease processes are uncovered. In this changing dynamic world of medicine, we have had little structure for naming things, compared to some of the other sciences.

Science has guidelines in the biologic world for naming plants and animals, a taxonomy that is very descriptive. The field for naming newly developed medical techniques and procedures has lagged behind. Traditionally procedures were named after the person developing the technique or procedure–just consider all the names of various tests in the process of physical and musculoskeletal examination. This has moved to more descriptive naming approaches but there are no absolute rules on how to name a new medical procedure.

Does it really matter how we name things? How important are labels and names? Doctor, Physician, Provider, Clinician, Professor, Teacher, Lecturer; Orthopedic Medicine, Orthopaedic Medicine; Adviser, Counselor; Agreement, Contract; Law, Rule, Regulation, Policy, Guideline; Partner, Spouse, Mate; Adjustment, Manipulation, Manual Therapy, Osteopathic Treatment, Chiropractic Treatment; Prolotherapy, Ligament Reconstruction Therapy, Regenerative Injection Therapy; Treatment, Therapy; Procedure, Technique; Educate, Train; Neural Therapy, Neural Prolotherapy; Joint Injection, Intra–articular Injection.......and the list goes on and on. Each word creates a different or similar mental image, varying flavors and nuances.

In the medical world the name of a procedure linked with a number, that in turn is associated with words that identify or name certain conditions or symptoms, is how insurance companies determine payment. Patients search for Doctors who perform certain procedures or who treat certain conditions using key words. Web rankings and search results of key word specific. Names are important.

Thus, it is important to create a language and nomeclature of new procedures that we can use consistently within our professional community and in discussions with our patients.

Thanks to Andrew, Dean and Brad, our nomenclature committee from the Board of Directors for their intensive efforts on putting together the document on nomenclature. Please read it carefully and send back your comments. Outcomes from this discussion are already in evidence as Dr. Lyftogt's next scheduled course is titled "Perineural Injection Technique Conference".

From the President
By Paul Lieber

Paul Lieber

Greetings,

This will not be my usual monthly addition to the Newsletter. I have planned a bunch of different articles, but they will have to wait. As a part of my plan to help advance the organization and to get you, its members more involved, I will outline the committees which have been proposed and the purpose of each committee. Ideally, each committee will have about 6 members which will participate in advancing the organization as a whole. If you see a place that you fit in or just want to get involved, please get in touch with either myself or Maelu and we will make it happen. The AAOM appreciates you expertise and willingness to pitch in.

All for Now.

AAOM Committees

Marketing Committee
Purpose: The Marketing Committee develops marketing programs for the AAOM and the AAOM programs.
Tasks: To find appropriate venues to expose and educate the public, media and professional associations about the programs, mission and benefits of the AAOM.

Fundraising (Development) Committee and Bachrach Lecture Fund
Purpose: The Development Committee leads the AAOM in development and fundraising.
Tasks: The committee develops policies, plans, procedures, and schedules for fund raising. It helps educate members about the organization's program plans and the resources needed to realize those plans.

Membership Committee
Purpose: The Membership committee looks at AAOM membership classifications per the Bylaws, evaluates and recommends membership pricing, membership benefits and programs and approves membership in questionable situations.
Tasks: The committee develops policies, plans, procedures, and schedules for membership, membership benefits and programs.

Certification Committee
Purpose: The Certification committee provides oversight for the AAOM Certification program.
Tasks: The Certification committee looks at the AAOM Certification Program evaluates and recommends needed content changes. The Certification committee looks at the AAOM Certification Program applications and recommends approval according to the existing criteria.

Newsletter Committee
Purpose: The Newsletter committee provides oversight for the AAOM e–newsletter.
Tasks: To develop 10 E–newsletters per year. To encourage content contributors, To expand the newsletter content and section areas.

Website Committee
Purpose: The Website committee provides oversight for the AAOM Website.
Tasks: The Website committee looks at the AAOM Website and evaluates and recommends needed content changes.

Educational Program Committee
Purpose: The Educational Program committee evaluates current programming design to ensure it remains relevant, provides speaker, content, cme and timeline oversight to assure the AAOM Annual Conference and Workshop are on time, on budget and have appropriate and timely content.
Tasks: The committee meets regularly to provide feedback to the Conference and Workshop Chairs.

Workshop Protocols and Standards of Practice Committee
Purpose: The Workshop Protocols and Standards of Practice Committee develop Regenerative Injection Therapy Protocols and Standards of Practice to be incorporated in the curriculums of AAOM educational programs.
Tasks: The International Workshop Protocols and Curriculum Committee develop Regenerative Injection Therapy Protocols and Standards of Practice.

From the Board:
AAOM Nomenclature and Terminology Recommendations

Andrew Kochan MD, K. Dean Reeves MD, Brad D. Fullerton MD

Emerging Procedures and Techniques has led to a need to clarify how we name what we do.

Rationale for recommendations on terminology.
Proper nomenclature is necessary and desirable for a number of reasons.

  1. It promotes clear communication in the scientific literature to evaluate efficacy of a particular technique.
  2. It facilitates better understanding by the public and those receiving progress notes of treatment given.
  3. It allows for development of reimbursement guidelines based on the work involved in each procedure.
  4. It may help prevent improper bundling of techniques performed at one visit (i.e. If an insurer covers prolotherapy someday, everything else that has prolotherapy in the title will be denied by the insurer because of bundling guidelines and cannot be billed for separately– even if it is a different procedure).

The Nomenclature Committee has examined the issue and we are recommending adoption of the following guidelines for naming of procedures and techniques. This system is descriptive for maximum clarity and accuracy with corresponding proposed acronyms that are easy to remember.

Name and
Proposed
Acronym


Target

Substance
Used
Proposed
Primary
Mechanism
Prolotherapy Ligament
Tendon
Joint
Myo–Fascia
Dextrose
Na Morrhuate
P2G
Pumice
Ozone
other
Regeneration of tissue
Bioregenerative Injection
BRI
Myo–Fascia
Ligament
Tendon
Joint
Whole blood Platelets
Stem Cells
Regeneration of tissue
Perineural Subcutaneous Injection
PSI
Subcutaneous sensory nerves (i.e. nerves in the superficial fascia/fat) Dextrose
Mannitol
Other
Reduction of neurogenic inflammation
Perineural Deep Injection
PDI
Nerves deep to the superficial fascia/fat Dextrose
Mannitol
Other
Reduction of neurogenic inflammation
Percutaneous neuroplasty
PCNP
Entrapped nerves deep to the superficial fascia/fat Dextrose
Mannitol
Normal Saline
Steroid
other
Mechanical hydrodissection around nerve (ultrasound guided procedure)
Perineural Deep injection in Caudal Space
PDI Caudal
Sacral Hiatus Dextrose
Mannitol
other
Reduction in neurogenic inflammation
Epidural Steroid Caudal
Intra–laminar
Intra–foraminal
Corticosteroid Reduction in prostaglandin based inflammation
Mesotherapy Mesoderm Homeopathic
Substance or Tincture
Dependent upon mixture injected
Neural Therapy Scars
Interference fields
Sympathetic
ganglia
Procaine Neurogenic, via normalizing autonomic neuron signaling
Acupuncture Acupuncture points
Tender points
Osteopuncture points
Acupuncture needle Neurogenic, via activation of autonomic NS pathways
Trigger Point Injections
TPI
Muscle Trigger points Lidocaine
Dextrose
Dry Needling
other
Neurogenic, via mechanical disruption of abnormal neuromuscular junction
Apitherapy Acupuncture points
Tender points
Bee Venom
Live or Apitoxin
Neurogenic via modulation of CNS adrenergic pathways
Perineural Topical Application
PTA
Subcutanous and cutaneous nerves Dextrose gel
Capsaicin ointment
Xylocaine gel
other
Reduction in neurogenic inflammation

We propose that in official AAOM documents, advertising and meetings the suggested names or a reasonable facsimile be used. The name can be expanded to include more specificity if the mechanism for a procedure becomes known. We suggest that, at a minimum, the suggested names be used. During the transition to this nomenclature, colloquial names could be referred to with quotations.

Of course, any colloquial name can be used in private and unofficial communication between orthopedic medicine specialists. However, the use of accepted nomenclature will facilitate communication and prevent the confusion caused by several different procedures having the same name or one procedure having several different names.

Discussion Regarding Nomenclature Generated From the Web Edition
From Dr. Cantieri

"After reviewing this document I would like to make several observations. I hope you will share this with the authors.

  1. Ozone. The best published research on it indicates it probably functions as an analgesic. I am not aware of any documentation of it having a proliferative effect.
  2. Phenol. Phenol has an analgesic effect. That is why it is used in some forms of Chapstick and Chloroseptic throat spray at 1.25–1.3%. When combined with glycerin it prevents the glycerine from diffusing. Banks 1994 article is good in theory but does not have supporting evidence.
  3. Myo Fascia. Never seen that term in anatomical literature. I am familiar with myofascial though. Is that what is being addressed here?
  4. Epidural steroid. The term I am familiar with is transforaminal. Are we using the same terms as the CPT? We should be consistent with CPT where possible.
  5. Should PTA include Vit D and ultrasound.
Hope this is positive input."

Dr. Reeves Response: "Thanks Mark. Appreciate your feedback very much.

Because ozone is being promoted as prolozone and combined with dextrose, we included it in the proliferative category. I certainly agree the mechanism of ozone alone is unclear. Lack of clarity in mechanism is why we are looking at generic descriptions of interventions.

Phenol become destructive to nerves at about 2.5%. Reeves KD. Mixed Somatic Peripheral Nerve Block for Painful or Intractable Spasticity: A Review of 30 Years of Use. Am Jnl Pain Mgmnt 1992; 2:205–210. Below that its effects are somewhat unclear. I don't dispute the analgesia but I note that with nerve destruction with phenol you have work and work with phenol to kill all nerve fascicles and there is never an analgesia that keeps the motor nerves from conducting. Including any anesthetic with phenol renders the nerve non stimulatable.

Myofascial seems to be a typo.

PTA would included vitamin D with similar proposed effect. I don't know what you mean by ultrasound? There are certainly a number of skin applictions such a magnets, etc, that may have an effect on the subcu nerves."

Professional Dialogue is essential as medicine faces multiple challenges ahead. Be part of the dialogue!

In The Literature

Fascia is a significant organ system of interest in the practice of Orthopaedic Medicine.

Be sure to read the July issue of the Journal of Bodywork and Movement Therapies, vol. 17 issue 3 fascia section for Dr. Thomas Findley's article:

FASCIA SCIENCE AND CLINICAL APPLICATIONS: HISTORICAL PERSPECTIVE Fascia Research Congress Evidence from the 100 year perspective of Andrew Taylor Still

Thomas W. Findley, MD PhD, Mona Shalwala, MS–IV

Summary: More than 100 years ago AT Still MD founded osteopathic medicine, and specifically described fascia as a covering, with common origins of layers of the fascial system despite diverse names for individual parts. Fascia assists gliding and fluid flow and is highly innervated. Fascia is intimately involved with respiration and with nourishment of all cells of the body, including those of disease and cancer. This paper reviews information presented at the first three International Fascia Research Congresses in 2007, 2009 and 2012 from the perspective of Dr Still, that fascia is vital for organism's growth and support, and it is where disease is sown.

Published by Elsevier Ltd.

Read more: http://download.journals.elsevierhealth.com/pdfs/journals/1360-8592/PIIS136085921300082X.pdf

Dextrose–What's Happening?
By Anette Mnabhi, DO

Dextrose, a key component of prolotherapy solutions is hard to find in our core concentration of 50%.

A survey of the board members led to the following resources and information in finding dextrose and coping with the shortage. The shortage is directly related to FDA inspections and changes that needed to be made to the manufacturing process, pulling multiple products out of production. Any of the pharmacy sources were called on 7/1/2013 to verify the availability. Here are some options:

1. Some have been using 5% dextrose in their prolo solutions from IV bags available still from most medical suppliers.

2. Some have used plain lidocaine.

3. Torrance Company has bags of 30% Dextrose in 500ml bags (verified on 07/01/2013) 800 Lenox Ave., Portage, Michigan 49024
Nationwide: (800) 327-0722, International: (269) 327-0722, FAX: (269)327-0763

4. College pharmacy compounds D50 and is able to do it now. (verified on 7/1/2013)
3505 Austin Bluffs Parkway, Suite 101
Colorado Springs, CO 80918
Tel: (800) 888-9358/(719) 262-0022
Fax: (800) 556-5893/(719) 262-0035
Patient Email: inforequest@collegepharmacy.com
Practitioner Email: info@collegepharmacy.com

5. Bjorn offered that he can still get 50% dextrose from Park Pharmacy in Orange County California – 949 551 7195.

6. Dean: 50% dextrose in 500 ml bags has been available for use from some time. However, even these are in short supply and if they are used, they can't be stored and used intraarticularly unless not only a hood is available but also a proper class entry room due to compounding regulations. With governmental issues as they are, compounding has become an issue, something perhaps worth talking about to AAOM members. So, I am not sure that this information will help anyone.

a. However, here is what I know from the manufacturer as of today, verbatim. (Manufacturer is Hospira):
*The shortage is due to increased demand and a manufacturing delay. *Amphastar has a shortage of dextrose 50% syringes due to increased demand for the product.
*The Amphastar shortage has resulted in increased demand for Hospira's dextrose 50% syringe presentations.
*The increased demand from the Amphastar shortage has created a shortage of Hospira's dextrose 50% syringe presentations.
*The shortage of dextrose 50% syringe presentations has now forced usage to the dextrose 50% and 70% IV flexible container.
*The increased demand of the dextrose 50% and dextrose 70% flexible IV container presentations has created a shortage in those presentations.
*The increase in demand coupled with a manufacturing delay is creating a short term backorder for the dextrose 50% IV flexible container.
*The next delivery for this product is the week of August 5th and this item is expected to fully recover the week of August 19th."

In addition: Estimated Resupply Dates

Hospira has dextrose injection 50% Ansyr II Luer–lock syringes, 50 mL Lifeshield syringes, and 50 mL vials on back order and the company estimates a release date of mid–June 2013 for the Lifeshield syringes and early–July 2013 for the 50 mL vials and Ansyr II syringes.
Amphastar (IMS) has dextrose injection 50% 50 mL Luer–Jet syringes on intermittent back order and the company is releasing product regularly.

b. Bottom line, is this appears to NOT be permanent issue. For placing orders it is probably good to "get in line" via whatever intermediary you use.

7. The same supplier (Hospira) makes the D50 bottles. Here is their response when asked specifically about the 50 ml flip top D50 bottles that come 25 to a case: "6648–02 is manufactured on a line that carries several critical products. For this line, Hospira worked closely with the FDA to prioritize the molecules made on this line and it the FDA requested that we prioritize the micronutrients. We're expecting the next delivery of 6648–02 in mid July. We just received a very small delivery and hospitals received partial orders."

Enhance Your Orthopaedic Medicine Skills – Upcoming Educational Opportunities

AAOM Workshop
Friday, August 9 – Saturday, August 10, 2013
SERI (Scientific, Education, Research Institute)

9005 Grant Street, Thornton, CO 80229

The AAOM continues to raise the bar in education in Regenerative Orthopaedic Medicine:

Learn from world–renowned experts–
•Cutting–edge research and best practices in PRP, Prolotherapy, Regenerative Therapies, Bone Marrow, Adipose, Manual Medicine, Nutrition and Hormones, and more
•Observe live patient treatments and injections
•Clinical product demonstrations
•Connect with vendors for the latest products in Orthopaedic Medicine
  • Topographic Anatomy for Needle placement
  • Using Ultrasound for Diagnosis
  • Understand Blood Tests for improved patient care
  • Using Nutrition and Hormones for improved pain treatments
•Experience Cadaver Lab for Hands–on needle guided injections
  • Inject cadavers with ultrasound–guidance
  • Inject cadavers with fluoroscopic – guidance
1:4 faculty &anp; attendee Ratio.

Learn and Network with experts about the latest research, procedures and protocols in Orthopaedic Medicine. This 2–day event will include lectures and labs on regenerative orthopaedic medicine, PRP, Prolotherapy, Stem Cells, Soft Tissue Pain Injections for Pain, Manual Medicine, MRI, Ultrasound and Topographic Anatomy for diagnosis.

Register Now at www.aaomed.org



AAOM One Week Mexico Prolotherapy Workshops
Preliminery Announcement for Guadalajara and Cancun.

Many of you, who are reading this newsletter, are aware of the tremendous success of the AAOM Prolotherapy Workshops offered in Mexico. The opportunity to learn and sharpen injection therapy skills is abundant. Every student physician was grateful for the learning opportunity and many said it was the best course they had ever attended. We are pleased to announce the scheduled dates for both Guadalajara and Cancun. Each week–long workshop will have a Faculty of just five teachers allowing us to have only 20 student spots at each venue. If you have interest in making this trip to either Guadalajara or Cancun, I urge you to sign up immediately as we are 50% full for Guadalajara and only 12 spots out of a total 20 remain available for Cancun. Once the spots are filled, the course will be closed to further applicants and you will miss this unusual and wonderful opportunity to learn while providing a service to inhabitants of the Mexican towns of Guadalajara and Cancun.

39.5 CME category I credits are being offered for participants who sign–up for either trip. So, don't delay if you have an interest in this trip. Make sure you have all of the prerequisites in order.

  1. Participation in either AAOM Annual Conference or AAOM Annual Workshop
  2. AAOM Membership – MD or DO
  3. Current Medical License
  4. Current CV
DATES: Guadalajara – November 2 – 9, 2013
TUITION for GUADALAJARA is $2895.00

  • 7 nights lodging AAOM Host Hotel Guadalajara
  • All Meals (Breakfast/Lunch/Dinner daily)
  • 39.5 Category 1 AMA Credit
  • Experienced Faculty
  • Medical Supplies
Participant Expenses:
  • Airfare to/from Guadalajara is at participant;s expense
  • Transfers to/from Airport
DATES: Cancun – February 1 – 8, 2014
TUITION for CANCUN is $3495.00

  • 7 nights lodging AAOM Host Hotel Cancun
  • All Meals (Breakfast/Lunch/Dinner daily)39.5 Category 1 AMA CreditExperienced FacultyMedical Supplies
Participant Expenses:
  • Airfare to/from Cancun is at participant's expense
  • Transfers to/from Airport

Mark your calendar for November 2 – 9, 2013 and February 1 – 8, 2014.
Remember, the AAOM Mexico Workshops fill up fast so if you want to go to Mexico, call ASAP 888.687.1920 or 970 626 4441 (outside of the USA).

© 2013 American Association of Orthopaedic Medicine. All Rights Reserved.