CONCEPTS OF
OSTEOPATHIC MEDICINE
William C. Scott, D.O.
Jennifer E. Marks, D.O.
Agenda




The history of
manipulation
The history of Osteopathy
Physiologic and anatomic
principles behind
Osteopathic rationale
“Its not just cracking
backs”
– Lymphatics
– Autonomic reflexes


Specific techniques
Research in Osteopathy
Ancient manipulation

The oldest known record of spinal
manipulation are prehistoric cave paintings
found in modern-day France that date back
to 17,000 B.C.

Greeks treating low back pain – 1500 BC
Ancient manipulation

Chinese – used it as
far back as 2650 BC
Socrates 469-399 B.C.

“If you would seek
health look first at
the spine”
Hippocrates

Wrote a 200 page
manuscript on
manipulative therapy,
Corpus Hippocrateum
 “Get knowledge of the
spine, for this is
requisite for many
diseases”
Andrew Taylor Still
Who was Andrew Taylor Still?

The founder of
Osteopathy
 Born in 1828 in Virginia,
of Scots-Irish descent
 His father was a circuitriding minister in the
Methodist church, a
physician, and a farmer.
 An avid hunter, Still
would skin the animals he
killed and developed a
lifelong fascination with
their muscles, bones and
joints.

He acquired his formal education as his father
moved west, and followed him on rounds to the
farms and small communities.

Still became a Civil War soldier, abolitionist, and
suffragist.

He earned his M.D. degree in Kansas City
In the 1850’s and 1860’s doctor’s had little
understanding of the causes of disease.
 Common treatments included: purgatives, heroin,
bloodletting, mercury, alcohol.


An epidemic of meningitis took the lives of three
of Still’s children; orthodox medicine was unable
to save them. He was disheartened and
dissatisfied with the results of medicine at his
time.

“Like Columbus,” he declared, “I trimmed my
sail and launched my craft as an explorer”

Still broke from Allopathy in 1874 to establish his
Osteopathic practice.
Tenets of Osteopathy

He expanded on many of the guiding principles of
Hippocrates and identified the musculoskeletal
system as a key element of health.
The body is a unit – consisting of mind, body, and
spirit.
 The body’s individual systems are mechanically
linked by fascia, uniting the body from head to
foot.


Structure and function are reciprocally related

The body possesses self regulatory mechanisms
Ex: Neuronal reflex mechanisms, carotid
sinus/baroreceptors

The body has the inherent capacity to defend and
repair itself.

When normal adaptability is disrupted or
environmental changes overcome the body’s
capacity for self maintenance, disease may ensue.

Rational treatment is based on the previous
principles.
Still’s perception of the
musculoskeletal system

Still realized that most of the body is made
of muscles and bones.

He was puzzled why physicians only paid
attention to this system when there was a
tumor in it, a fracture, cut, strain, or bruise.

1892 – Still purchased a two room building and
started the American School of Osteopathy in
Kirksville Missouri. The school’s original charter ,
granted on May 10, 1892, gave it the right to
confer the degree of M.D., but the school’s
governing body chose to award the D.O. degree.

By 1913, 39 states passed osteopathic practice
laws. By 1923, 46 states.
Still’s first class graduated in 1893 and included five
women.
 “ I opened wide the doors of my first school for
ladies….Why not elevate our sister’s mentality, qualify
her to fill all places of trust and honor, place her hand
and head with the skilled arts?”

• Andrew Taylor Still
History of Osteopathy

He trained his brothers, children, patients, and
other M.D.’s in his new profession.

A few years after Still established ASO, he
announced he wished his graduates to be general
practitioners, treating medical issues and being
able to perform common surgical procedures and
deliver babies. He sanctioned the use of 3 classes
of drugs –anesthetics, antidotes, and antiseptics.
“The body in normal structural relationship,
and with adequate nutrition, is capable of
mounting its own defenses”, A.T. Still

1902 Anatomy Class
Andrew Taylor Still

Still died in 1917 at
the age of 89, leaving
the fate of Osteopathy
in the hands of those
he taught.
Daniel David Palmer
(1845-1913)

Briefly studied with
A.T. Still.
 Left osteopathy to
found the field of
chiropractic care.
 Believed spinal
manipulation was the
key to all diseases.
Osteopathy vs. Chiropractic

Differ in the manner of manipulation, and in some
of the theory
 Osteopaths have understood the complementary
role of traditional medicine, including medications
and surgery.
 Chiropractic manipulation relies primarily on a
high velocity, low amplitude action which is
supposed to act as a stimulus to the body to selfcorrect.
Osteopathy vs. Chiropractic
“Chiropractors have generally remained focused
on spinal manipulation for a limited set of
conditions, particularly those that are often
resistant to allopathic therapy, such as back pain.
 Osteopaths, on the other hand, have worked hard
to employ the entire therapeutic armamentarium of
the modern physician, and in so doing they have
moved closer to allopathy.” J.D. Howell, M.D.
Ph.D.
 The New England Journal of Medicine. Nov 4,
1999

1918 Spanish Flu Epidemic


Spanish Flu pandemic of 1918. In terms of
sheer virulence, it far outstripped the Black
Death, claiming at least 25 million victims in
just one year. In the United States alone, one
in four Americans were stricken with the
disease, and some 600,000 died.

The Spanish Flu first surfaced in the U.S. on
March 11, 1918 at Ft. Riley, Kansas, when an
Army private reported for sick call
complaining of a fever, sore throat and
headache. Within a few hours, the number of
soldiers reporting in with similar symptoms
rose to over 100. Within a week, more than
500 were down with the flu.
Spanish Flu Epidemic

It was not just the U.S.
that was affected. Troop
ships going to Europe
often served as
incubators for infection.
Indeed, on World War I
battlefields,
commanders
sometimes lost as many
troops to the flu as to
enemy fire.
Spanish Flu Epidemic
20-40% of the world’s
population became ill
 25 million people died
worldwide
 ¼ of the American
population fell sick
 500,000 deaths in the U.S.
between Sept. 1918-April
1919
 “Nationwide casket
shortage”, NY Times 1919

Spanish Flu Research

DOs had considerable success in using OMT to
treat the Spanish Flu.
 The following data was reported by an Insurance
company at the time of the Spanish Influenza
Epidemic
 43,500 of their insured were treated by D.O.s in
the U.S.



Only 160 deaths
0.37% mortality for patients being treated by DO’s vs. 2.5%.
At the allopathic rate one would expect 2,175 deaths
Spanish Influenza Research






L.K. Tuttle M.D., D.O., NY
Journal of the American Academy of Osteopathy,
January 1919
62 cases with Spanish Influenza
9 cases with concurrent pneumonia
Only 2 cases terminal
“When rib mobility is re-established in
pneumonia, your case has progressed far
towards recovery.”
Spanish Influenza Research

“One-hundred
thousand cases of
influenza with a death
rate one fortieth of that
officially reported
under conventional
medical treatment”
– R.K. Smith M.D.,
D.O.
– JAAO 1920
More research on Pneumonia

“Pneumonia research in children at Los
Angeles County Osteopathic Hospital vs.
NYC municipal hospitals” JAAO 1939
– Bronchopneumonia
– 10.66% versus 29.6% mortality
The Road to Acceptance
The Surgeon General and government regulators
blocked acceptance of Osteopathy by the federal
government despite active support by such
prominent supporters as former president
Theodore Roosevelt.
 During WWII, DOs could not obtain commissions
in the military and DOs were deferred rather than
drafted, waiting for an opportunity to serve that
never came.
 Ironically, the DOs left behind became family
physicians to thousands of patients left by the
MDs serving in the military.
The California Saga

In the early 1960s an agreement was reached
between the California Osteopathic Association
and the California Medical Association

With the blessing of the American Medical
Association, 2000 of the states 2300 DOs agreed
to accept a new M.D. degree for a nominal fee,
good for purpose of licensure in California.

One of six DO colleges, and 1/5 of the profession
was lost.

DO’s in other states became involved in advocacy
and fought for more rights, denying the AMA’s
offer to switch to an M.D. degree.

The Federal government agreed in 1966 to admit
DOs into the armed services medical corps and the
Public Health Service. Recently Ronald R. Blank,
D.O. was appointed Surgeon General of the U.S.
Army.
The Louisiana Saga

Louisiana was the last state to allow D.O.s to
obtain licensure
 The most recent amendment allowed a D.O. to
obtain LA licensure only if they were board
certified, or had passed all 3 steps of the MD and
DO Boards
 LSBME announced as of June 2005, a D.O. who
has passed all 3 steps of the COMLEX will be
permitted licensure!
History of Osteopathy

Today there are two distinct schools of
Medicine recognized in the United States
and much of the world.

The number of Osteopathic schools in the
U.S. will approach 30 in the near future.
By 2020 there will be an estimated 100,000
osteopathic physicians in the U.S.
History of Osteopathy

The training of an Osteopathic physician involves
similar entrance requirements and coverage of the
basic sciences and clinical applications with an
additional emphasis on osteopathic principles, the
neuromusculoskeletal system and its relationship
to the viscera.

Today, DOs practice in all fields and
subspecialties and train in both Allopathic and
Osteopathic residencies.
Physiological Basis for
Osteopathy

Focus:
– Neurophysiology of Reflexes
– Autonomic Nervous System
– Fascia
– Lymphatic System
Neurophysiology of Reflexes

In Osteopathy, for both palpation and treatment,
an understanding of reflex function is critical.

The reflex has been found to be anything but a
static unit of input-output relationships, but rather
an active and ever-changing mosaic.
The Simple Reflex

The patella tendon
reflex is a vast
oversimplification of
the interactions that
occur when a stimulus
causes a response. It is
the most simple reflex
structure – a
monosynaptic reflex

The usual concept of the knee reflex suggests that
the reflex limbs are well defined and limited
primarily to one input and output channel, with
little interaction with other reflex networks.

Almost all reflex networks can be influenced by a
wide variety of other excitatory and inhibitory
signals from higher or lower levels of the CNS.
Somato-Somatic Reflex

Are named from the origin
of the information and the
location of action, both
somatic.

The simple somatosomatic reflex is
exemplified by the
defensive withdrawal
action when touching
something hot.
–
Sensory afferent activity flows into
the interneurons of the spinal cord
central gray, and finally into the
ventral horn of motor neurons
which then cause muscle
contraction.
Viscero-Visceral Reflex

Sensory inputs from a visceral structure
cause activity in a visceral organ.

Ex: Distension of the gut results in a
increased contraction of the gut muscle.
Reflexes

We might expect to find that afferent inputs from
somatic structures have some influence on visceral
organs and that inputs from visceral organs have
some effect on somatic structures.

Somato-Visceral and Viscero-Somatic reflexes
have been known for many years but until recently
have received little attention from the research and
medical community.
Visceral-Somatic Reflex

Ex: A person feeling pain and muscle tightness in
the left shoulder with the onset of an MI.

The nociceptive inputs from the compromised
myocardium (visceral) are exciting not only the
pathways interpreted as pain in the shoulder
(somatic), but are causing motoneurons in the
shoulder to become active.
Visceral-Somatic reflexes

Eble, JN. Patterns of response of the
paravertebral musculature to visceral
stimuli. AM L Physiology 1960;198:429433
 Stimulated visceral structures and recorded
somatic muscle activity. He demonstrated
that stimulation of visceral structures would
produce somatic muscle activity.
Viscero-Somatic Reflex
Somato-Visceral Reflexes

It was found in the following study that somatic
nerve stimulation can affect cardiovascular,
vesicular, and GI tract etc depending on which
area is stimulated and the strength of stimulation.

Sato A. Reflex modulation of visceral functions by
somatic afferent activity. In Patterson MM,
Howell JN, eds The central connection
somatovisceral/Viscerosomatic Interaction.
Indianapolis, Ind American Academy of
Osteopathy; 1992;53-73
Somato-Visceral Reflexes

Somatovisceral response following osteopathic
HVLAT: a pilot study on the effect of unilateral
lumbosacral high-velocity low-amplitude thrust
technique on the cutaneous blood flow in the lower
limb.

J Manipulative Physiol Ther. 2003 May;26(4):220-5.

20 healthy male subjects

Laser Doppler flowmetry was used to measure relative changes
in the cutaneous blood flow over the L5 dermatome

Twelve subjects, who received a successful HVLAT
manipulation, showed a significant increase (P <.001) in blood
perfusion, both ipsilaterally and contralaterally.
Somato-visceral reflex


Some of these reflex interactions occur directly in
the spinal cord. With others the activity travels up
the spinal cord to the brainstem, resulting in a
cascade of activity from the brainstem back down
to the spinal autonomic motoneurons.
The activity resulting from the stimulation of a
structure can be either inhibitory or excitatory.
 EX: stimulating the belly skin results in inhibition
of gut activity (a somato-visceral reflex), but
increased heart rate.
Somatosympathetic reflexes

J Neurophysiol. 2003 Oct;90(4):2548-59. Epub
2003 Jun 11.

Somatosympathetic reflexes from the low back in the
anesthetized cat.
Kang YM, Kenney MJ, Spratt KF, Pickar JG.

The study determined if mechanical loading of the lumbar
spine and lumbar paraspinal muscle irritation reflexively
affects postganglionic sympathetic nerve discharge (SND) to
the spleen and kidney.
Somatosympathetic reflexes

The L2-4 multifidus muscles were injected with the
inflammatory irritant mustard oil (20%, 60 microl total) and a
vertebral load was applied at the L3 spinous process.

The results indicate that inflammatory stimulation of
multifidus muscle in the low back evokes a somatosympathetic
reflex

The reflex's afferent arm travels in the medial branch of the
dorsal ramus, and its efferent arm can affect sympathetic
outflow to the spleen and the kidney as well as affect HR and
BP
Somatosympathetic reflexes

Magnitude of abdominal incision affects the
duration of postoperative ileus in rats.
Surg Endosc. 2004 Apr;18(4):606-10. Epub
2004 Feb 02.
What is the significance of
these reflex interactions?

Research indicates a communication exists
between the somatic structures (muscles,
fascia) and visceral organs.

This communication is mediated by
autonomic reflex mechanisms.
Why are these reflex interactions so
critical to the Osteopathic physician?

When using palpatory diagnosis to detect subtle
problems in function, whether it be tissue texture
changes, motion characteristics, or temperature
variations, the physician is sensing clues from the
musculoskeletal system – the skin, muscles and
fascias. These clues reflect functional
characteristics of the underlying visceral function
through the viscero-somatic reflex.
 When the physician uses manipulative treatment
to correct somatic dysfunctions, underlying
visceral function is also affected through the
somato-visceral and somatosympathetic reflex
networks.
Research by Michael
Patterson, PhD.

A reflex neurophysiologist with a special interest
in sensitization of interneurons in the spinal cord.

Persistent musculoskeletal dysfunction affecting a
certain spinal level can affect the function of an
internal organ related to that same spinal cord
segment for its innervation

Removal of the irritation of dysfunction allows the
related internal organ to return to its normal
function.
Parasympathetic

Innervation to visceral organs, glands, and smooth
muscles – has little to do with innervation of
muscles or blood vessels.

Cranial outflow – Via cranial nerves III, VII, IX,
X (oculomotor, fascial, glossopharyngeal, vagus)

Sacral outflow – Originates in cell bodies in
segments S2,3,4
– parasympathetics to the left colon and the pelvic organs
Effects of Prolonged
Hypersympathetic activity

Sympathetic activity is beneficial for acute
responses (fight/flight), beyond that prolonged
hypersympathetic activity can be detrimental.

Corneal ulceration can be produced in the eye of a
cat through lesioning of the cats trigeminal nerve
and these ulcerations can be healed by
stellatectomy.

Baker, George Proc. Staff meeting Mayo Clinic; Vol 34 1959
Effects of Prolonged
Hypersympathetic activity

The removal of the lower sympathetic
ganglion in young puppies caused the bones
on that side to grow larger and longer. In
another group of puppies, researchers
produced chronic sympathetic stimulation
on one side of the body and found that the
growth of the bones was stunted.
Gullickson, Glenn Jr, 1951
Effects of Prolonged
Hypersympathetic activity

Children who had paralytic Polio and one leg that
was destined to be underdeveloped, withered and
deformed.
 That leg was found to have hypersympathetic
activity; so, the physicians disrupted the
sympathetic neurons on that side and found that
the paralyzed leg would then grow to the same
size and length as the non-paralyzed leg.

Kottke, F.G. Arch of Physic. Med. And Rehab; Vol 39 1958
Thoracolumbar Outflow –
The Sympathetic Division.

Innervation to all parts of the body originates in
cell bodies in the interomediolateral columns of
the SC at T1-L2 levels.

Efferent sympathetic impulses travel out the
ventral nerve roots at those levels, branch off
through ventral white ramus communicantes and
then enter the paraspinal chain ganglia next to
each vertebra.
Thoracolumbar Outflow –
The Sympathetic Division.

In the thoracic area, a
paraspinal ganglion
lies in the fascia
directly over each rib
head.

Dysfunction of rib
motion/alignment can
cause alterations in
sympathetic output.
Thoracolumbar Outflow –
The Sympathetic Division.

Rib Raising – An Osteopathic manipulative
treatment that involves lifting the rib heads while
the patient is supine.

Due to the location of ganglia and the fascial
attachments, this causes movement of the
paraspinal ganglion and initially produces a shortlived stimulation of sympathetic activity. This is
followed by long lasting sympathetic reflex
inhibition via the medulla.
Thoracolumbar Outflow –
The Sympathetic Division.

- “Treatment and prevention of post-op ileus”

Inhibitory pressure to T10-T12 area of the spine
resulted in reduction in sympathetic tone to the
bowel. Patients had a decreased incidence of postop ileus (0.3% compared to 7.6%). In patients that
had post op ileus already it encouraged a faster
resolution. Herman E., The DO, Oct 1965: 163-4
I.M. Korr, Ph.D

Contributed major findings to explain the
autonomic nervous system’s involvement in
osteopathic philosophy and treatment.
Definition -The facilitated
segment

The spinal segment receives exaggerated input
from either a somatic or visceral structure
 Afferent motor and autonomic components are
maintained in a state of excitement
 The segment is hyperirritable and has a decreased
threshold to stimuli
 Can result in increased efferent somatic (muscle
contraction) and autonomic (sweating) activity.
Facilitated segment continued

Korr’s studies indicate there is spinal segmental
patterning from the visceral organs i.e. pressure in
a balloon in the duodenum produced referral to the
area of T5-T9.
Korr’s findings indicate that there are not only
facilitated segments in the spinal cord but also
segmental viscero-somatic reflex patterns.
“Palpatory Testing for Somatic
Dysfunction in Patients with
Cardiovascular Disease”
Palpation of Sympathetically
Mediated Facilitated
Segments

Palpatory changes in the skin correlate with
instrumentation (thermography, electrical skin
resistance, sweat gland activity).
 Facilitated segments often cause contraction of the
paraspinal muscles (especially in the rotators) on
the side of predominate input.
 Motion often prefers sidebending and rotation to
the side of the predominant afferent input.
 Thus, asymmetry and restricted motion are present
with increased sympathetic activity.
Fascia

A freshman student in anatomy often perceives
that the fascia and loose connective tissues are
what has to be disposed of in order to see the
“real” anatomy.
 Fascia is around every cell, muscle fiber, every
organ and it anchors itself to bony structures.
 Fascia is continuous (can follow the fascia from
one area of the body to another area) and
contiguous (they touch all)
Fascia

If all the other tissue could be dissolved and
the fascia left intact, the person would still
be identifiable.

Looking at the fascia, we can see the
interrelationship of one part of the body
with another.
The Functions of Fascia

The four “P’s”




Packaging
Protection
Posture
Passageways
The Functions of Fascia

Packaging – Superficial fascia is segmented into small
fibrils which are usually vertical to the skin and attach to
the deep fascia, forming small compartments through
which pass nerves vessels and lymphatic.

This arrangement allows the physician to determine deep
fascial preferences called “ease” or “drag”.

Torsion of fascial tissues can encumber the flow of blood,
lymph, and neural impulses through the tissues.
Normal Functioning Tissue
Tissue Reflecting Dysfunction
Functions of Fascia

Protection
– Establishes limits of joint motion
 The end point of the physiologic barrier is
established by fascia.
– Stabilizes joints and body tissues.
Functions of Fascia

Posturing
– The Proprioceptors for sensing body
movements are present in the fascias; therefore
the fascial environment influences posture.
Asymmetry of posture may be a sign of fascial
dysfunction.
Functions of Fascia

Passageways:
– Fascia forms the passageways for somatic and
autonomic nerves, venous, arterial, and
lymphatic vessels. Also wraps around organs.
– These passageways may be altered by fascial
dysfunction (torsions) and therefore be a factor
in body function and the state of health or
disease.
Fascial Dysfunction

Connective tissue and fascia show changes in the
function of the cell and interstitial tissues in states
of disease.

It is revealed by:
– 1) Regional motion preference in the soft tissues.
– 2) Regional congestion via restricting lymphatic
drainage.
– 3) Poor circulation
– 4) Myofascial tender points
– 5) Faulty posture etc..
Terminal Lymphatic Drainage
Sites

Fascial dysfunction is
also revealed as tissue
congestion which may
be a clue to a
dysfunction in the
related area of the
body.
 Regional congestion
can be palpated at
specific terminal
lymphatic drainage
sites.
The Role of the Diaphragm in
Lymphatic Movement

Primary muscle of respiration
 Causes pressure gradients to help return
lymph and venous blood back to the thorax.
The Role of the Diaphragm in
Lymphatic Movement

Diaphragmatic contractions increase the relative
negative pressure of the thoracic cage and
increases the relative positive pressure in the
abdomen. This produces a pressure gradient
favorable for “pulling” lymphatic and venous
fluids into the thorax.
 As the diaphragm relaxes there is a relative
increase in the thoracic and a relative decrease in
the abdominal pressure. During this phase, back
flow does not occur because the vessels contain
one way valves.
The Role of the Diaphragm in
Lymphatic Movement

It is not sufficient to just have contraction and
relaxation of the diaphragm. Diaphragmatic
movement must displace effective volumes in
order to provide a good lymphatic pump effect.
 In order to do this it must be well domed (relaxed)
and its nerve supply from the mid-cervical area
must be free from somatic dysfunction to allow
even effective diaphragmatic movement.
 Goal is to maximize the movement of an
unrestricted diaphragm in order to maximize
displaced volume  Optimizes the pumping
action maximizes lymphatic system to help
fight disease and circulate fluid.
Effect of Diaphragm
Redoming
The Role of the Diaphragm in
Lymphatic Movement

Attachments ;




Xiphoid process
Ribs 6—12 b/l
Body/intervertebral discs of L1-L3
Restriction of motion of these attachments
will exert restriction on the motion of the
Diaphragm and thus, decrease the
effectiveness of the diaphragm as the
primary lymphatic pump.
The Role of the Diaphragm in
Lymphatic Movement

The osteopath utilizes techniques to increase
diaphragmatic excursion by:
– Redoming the diaphragm (relaxing).
– Treating somatic dysfunction of the cervical vertebrae
to improve neural flow via somtatovisceral reflexes.
- Treat Diaphragm attachments of xiphoid, ribs, and L1-3
in order to maximize their movement, and to impart
greater freedom of diaphragmatic movement.
Comparison of thoracic manipulation
with incentive spirometry in preventing
postoperative atelectasis.

J Am Osteopath Assoc. 1993 Aug;93(8):834-8, 843-5.

1-year randomized, researcher-blinded trial, low-risk
cholecystectomy patients were subjected to either the
thoracic lymphatic pump (n = 21) or incentive
spirometry (n = 21) to prevent atelectasis

Study patients treated with the thoracic lymphatic pump
technique had an earlier recovery and quicker return
toward preoperative values for FVC and FEV1 than
patients treated with incentive spirometry.
Reference for Osteopathic
literature regarding lymphaitc
pump
 Update
on osteopathic manipulaion and the
effects on the lymphatic system.
J Am Osteopath Assoc. 1996 Feb;96(2):97-100.
Osteopathic Definitions and
Diagnosis

Somatic Dysfunction – An impairment or
altered function of related components of
the somatic system. i.e.: skeletal,
myofascial, arthroidal, and related vascular,
lymphatic, and neural elements. May
present itself as “TART”.
Why try to find a somatic
dysfunction?

To confirm a diagnosis (structural and/or
visceral)

Treat the structural component of the
patients problems.

“It is more important
to know the patient
who has the disease
than to know the
disease that your
patient has” - Osler

John S. Billings recruited
William Osler to be the first
physician-in-chief of Johns
Hopkins Hospital
TART- A mnemonic for helping
to find somatic dysfunction
T –Tissue texture changes
 A – Asymmetry
 R - Restriction
 T – Tenderness

Palpation

With experience one
learns to appreciate,
believe, and know
what is being palpated.
TART - Tissue Texture
Changes
Related to the degree of hypersympathetic
activity.
Helps classify somatic dysfunction as being
acute or chronic.
Tissue Texture Changes
Acute somatic dysfunctions: Chronic somatic dysfunctions:
Blood vessels injured, release of
endogenous peptides = chemical
vasodilatation overides
sympathetic activity
Warm skin
Moisture
Boggy tissues
Skin – (moist skin) no trophic
changes
Erythema test- area stays red longer
Chronic hypersympathetic tone with
vasoconstriction
Dry skin
Cooler
Ropy muscles
Skin – pimples, scaly, dry, folliculitis,
pigmentation (trophic changes)
Erythema test-blanching quickly
occurs
TART - Asymmetry

Of the body in general – Posture
- comparing right to left
Of a body region –
- Observing and palpating for
hypertrophy of a region of muscle
mass.
- A short leg or uneven horizontal
planes (the occipital or mastoid plane,
the shoulder plane, the scapular plane,
the iliac plane, the PSIS plane and
Trochanteric plane).
Asymmetry - cont.
Asymmetry of a body segment- One joint with the same joint on
to other side.
- One transverse process with the
other at the same spinal segment.
TART - Restricted Motion

General restriction




Walking
Sitting
Gets up from a seated position
Watching the spine and pelvis work as the patient
bends over to touch the floor.
Restricted Motion - cont.

Regional restricted fascia

Is determined by testing the “drag or ease” of fascial
motion
There are four major fascial junctions of the body
–
–
–
–
Occipito-atlantal area
Thoracic inlet or cervicothoracic area
Thoracolumbar area
Lumbrosacral area
Restricted Motion – cont.

Segmental Motion testing – could be of any
joint

Each Joint has a:
– Physiologic barrier
– Pathologic Barrier
– Restrictive Barrier
Physiologic Barrier
Within the anatomic ROM.

Has soft tissue tension accumulation which limits
the voluntary motion of an articulation.

The point at which a patient can actively move any
given joint.

Further motion toward the anatomic barrier can still
be induced passively.
Pathologic Barrier

Is a limit within the anatomic range of
motion, which abnormally diminishes the
normal physiologic range.

May be associated with somatic
dysfunction

Aka restrictive barrier.
Anatomic Barrier
The limit of motion imposed by anatomic structure.
The point at which a physician can passively move
any given joint.
ANY movement beyond the anatomical barrier will
cause ligament, tendon, or skeletal injury.
Barriers
Barriers – Depicted in
Vertebral Movement
TART - Tenderness

Acute

Chronic

Sharp or severe

Dull ache, tenderness,
or paresthesias such as
burning, crawling,
itching.
Spinal Motion – Fryettes
principles.

1918- Harrison Fryette , D.O., presented a paper to
the A.O.A, regarding his observations regarding
physiologic movements of the spine.

Principle I and II describe biomechanical motion
of the T and L Spine.

He utilized palpation of the transverse processes to
determine rotation of the vertebrae.
Fryette’s Principle I

Principle I- If the spine is in neutral position (no
flexion or extension) , and if sidebending is
introduced, rotation would then occur to the
opposite side.

Ex. – Person SB to the left so L2 can no longer SB
on L3 (facets are locked), then L2 will rotate to
the right to facilitate further SB.
Fryette’s Principle II

If the spine is nonneutral (flexed or
extended), and
rotation is introduced,
the SB will occur to
the same side.
Evaluating lumbar and
thoracic spine dysfunctions

1. Assess rotation by placing the thumbs
over the transverse processes of each
segment. If the right thumb is more
posterior than the left, then the segment is
rotated right.
Evaluating the cervical spine

Cervical spine mechanics do not follow
Fryette’s principles I and II!
Evaluating the cervical spine
Segment
Main motion
Rotation and
sidebending
Opposite sides
OA
AA
Flexion &
Extension
Rotation
Upper cervical
Rotation
Same sides
Lower cervical
Sidebending
Same sides
Opposite sides
To summarize thus far…

Studies demonstrate, communication exists
between visceral and somatic structures via
neurological reflex mechanisms and mechanical
forces.

Physiologic and biomechanical principles are
utilized to diagnose somatic dysfunctions

Palpation of somatic structures may be useful to
discern the meaning of this communication and
thereby aid with clinical diagnosis of both somatic
and visceral pathology
Goals of Osteopathic
Manipulative Treatment (OMT)








Normal Body mechanics
Remove restrictions to motion
Achieve homeostasis
Remove impedance to normal nerve conduction
Treat somatic dysfunction
Reduce symptoms- improve quality of life
Maximize patients innate abilities to heal itself
Facilitate functioning
Classification of Techniques;
Patient Participation

Passive: The patient takes no role - is passive
while the operator performs the technique on the
patient.

Active: The patient is guided by the operator to
assist in the treatment process. May involve a
muscle contraction (Isometric or Isotonic, or
respiratory effort, etc).
Contractions utilized in OMT

Isometric – Results in increased resistance without
an approximation of origin and insertion. In such
cases the
operators force=patient force

Isotonic – results in the approximation of the
muscle’s origin and insertion without a change in
its tension . In such cases the
operators force<patients force
Classification of Motion

Direct: a direct technique is one in which
the joint is placed “against the barrier”, that
is, in the direction in which the joint
motion is restricted. The goal of a direct
technique is to use the force in such a way
that motion will be created through and
beyond the restrictive barrier.
Classification of Motion

Indirect: A technique is indirect when the
joint is positioned into its freedom of
motion. The goal is then to allow the
body’s inherent neurological or intrinsic
forces to free up the restriction of motion so
that the joint will regain its ability to move
freely through the barrier.
Osteopathic Treatment
Techniques

Myofascial release
 Counterstrain
 Facilitated Positional release
 Muscle energy
 High Velocity Low Amplitude
 Balanced Ligamentous tension
 Cranial sacral manipulation
 Lymphatic pump
 Rib raising
 Doming of the diaphragm …and many more.
Muscle Energy

An Active and Direct Technique.

Utilizes the Golgi tendon organ
– GTO prevent too much pull from excessive muscle
tension by continually monitoring muscle force
– They lie within the muscle tendons
– They are in series with the extrafusal muscle fibers so
they will be pulled when the muscle contracts
– They respond to changes in force, not changes in length
Muscle Energy-How Does It
Work?

A patient provides a contraction in a already tight
muscle, acting against equal resistance provided
by the physician, results in pulling on the Golgi
tendon receptors producing a reflex relaxation of
that muscle’s extrafusal muscle mass through the
Golgi tendon reflex mechanism.

When the patient is completely relaxed, the
operator advances the joint to the new restrictive
barrier. At each new length, the Golgi receptor is
stretched again and the muscle’s length is again
increased.
Muscle Energy Schematic
Muscle Energy - Goals

Treatment of individual joints

For stretching the muscle – increasing ROM

For preparation to manipulate somatic
dysfunction by some other method.
Principles of Muscle Energy
High Velocity Low Amplitude
Thrust

A passive and Direct technique

Used to reestablish normal ROM and treat
somatic dysfunction

The Osteopath may draw from many
techniques available to accomplish this
same goal, in patients where HVLA is
contraindicated.

High Velocity Low Amplitude
Thrust
This technique often produces an auditory ‘Pop”
Why?
– One theory involves the CO2 and other gases
that are dissolved in the synovial fluid;
– If you change the volume in an enclosed space
the body has to change gas in solution to a free
gas to maintain pressure volume relationships.
– In order to hear the pop again , the gas must go
into solution again and this takes time.
– This could explain why a joint cannot be repopped immediately.
High Velocity Low Amplitude
Thrust

Do we need to hear a
pop when we thrust a
joint?

NO – Motion can
be re-established
without an audible
sound!
High Velocity Low Amplitude
Thrust

Does popping joints cause arthritis?
– Somatic dysfunction affecting a joint is more
likely to encourage future arthritis than is the
manipulation which reestablishes the normal
joint motion.
High Velocity Low Amplitude
Thrust

Absolute Contraindications:
– Fracture in the area of the thrust
– Neurological symptoms while you are setting
up the procedure or pain increase at the barrier
– Severe rheumatoid arthritis
– Potential vertebral artery dissection, considered
in patients who report vertigo, ataxia, or CNS
symptoms after previous manipulation
– Metastatic CA
High Velocity Low Amplitude
Thrust

Relative Contraindications
– If the main complaints related to the area are
progressive neurological complaints
– If bruits are heard over the carotid vessels –
may dislodge a plaque and cause a CVA
– Hemophiliacs, coagulation disorders,
anticoagulation
– Osteoporosis
– Medicolegal situations
– Acute strains i.e. whiplash, sprains
Treatment Plan

Absolute rules for dosing and frequency do not
exist.
 Typical guidelines:
– The sicker the patient the less the dose
– Allow time for the patient to respond to the treatment
– Chronic disease requires chronic treatment
– Pediatric patients can be treated more frequently;
geriatric patients need a longer interval to respond to
the treatment
– Acute cases should have a shorter interval between
treatments; as they respond the interval is increased.
Some of the difficulties with
research in Osteopathy



Can the rigors of a randomized double blind, placebocontrolled, prospective study be applied to a hands on
therapy?
Double blinding is problematic.
What constitutes a manipulation placebo?
– Sham manipulation is intended to overcome this
– However, in the process of providing the sham, some therapeutic
benefit may occur, thereby reducing the observed efficacy of OMT
– This placebo effect has been estimated to be the equivalent of one
third of the effect of NSAIDs.
 J Clin Epidemiol.1990; 43:1313 -1318


Should only one OMT technique be tested, or should the
entire spectrum of OMT techniques be available for use?
What’s the payback to funding research with
manipulation?
Research in Manipulation

BMJ. 2004 Nov 29
United Kingdom back pain exercise and manipulation (UK BEAM)
randomized trial: cost effectiveness of physical treatments for back
pain in primary care.

PARTICIPANTS: 1287

MAIN OUTCOME MEASURES: Healthcare costs,
quality adjusted life years (QALYs), and cost per QALY
over 12 months.

CONCLUSIONS: Spinal manipulation is a cost effective
addition to "best care" for back pain in general practice.
Manipulation alone probably gives better value for money
than manipulation followed by exercise
Research in Osteopathy

A Comparison of Osteopathic Spinal Manipulation
with Standard care for patients with Low Back
Pain
–
Anderson, M.D., Ph.D., New England Journal of Medicine, Nov. 1999

Randomized controlled trial that involved patients who
were 20-69 years of age had back pain for at least three
weeks but less than six months.

Results:
– Patients in both groups improved during the twelve weeks
– The Osteopathic treatment group required significantly less
medication (analgesics, anti-inflammatory, and muscle relaxants)
and less physical therapy.
Research in Osteopathy

Clinical Practice Guideline on Acute Low Back
Problems in Adults
– Agency for Health Care Policy and Research
– (now known as the Agency for Healthcare Research and Quality)

Recommended that spinal manipulation can be
helpful for patients with acute low back problems
without radiculopathy when used within the first
month of symptoms
Research in Osteopathy

OMT appears to decrease the use of other
cotreatment modalities such as medications
– Anderson GB, Lucente T, Davis AM, Kappler RE, Lipton JA,
Leurgans S. A comparison of osteopathic spinal manipulation with
standard care for patients with low back pain. N Engl J Med.1999;
341:1426 -1431.
– Williams NH, Wilkinson C, Russell I, et al. Randomized osteopathic
manipulation study (ROMANS): pragmatic trial for spinal pain in
primary care. Fam Pract.2003; 20:662 -669.
– Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, WinnW, et al.
Osteopathic manipulative treatment for chronic low back pain: a
randomized controlled trial. Spine.2003; 28:1355 -1362
Research in Osteopathy

Safety of manipulative treatment: review of
the literature from 1925 to 1993
– Vick DA, McKay C, Zengerle CR. The safety of manipulative
treatment: review of the literature from 1925 to 1993. J Am
Osteopath Assoc. 1996;96:113 -115.

185 incidents attributed to manipulation during a span
of six decades

Most involved forceful, high-velocity techniques or
manipulation done with the patient anesthetized. No
injuries were attributed to muscle energy, indirect, or
fascial techniques.
Research in Osteopathy

OMT improved short-term physical and
longer-term psychological outcomes in
patients with neck or back pain, at little
extra cost.
– Williams NH, Wilkinson C, Russell I, et al. Randomized osteopathic
manipulation study (ROMANS): pragmatic trial for spinal pain in
primary care. Fam Pract.2003; 20:662 -669
Research in Osteopathy
 Improving
functional ability in the elderly via
the Spencer technique, an osteopathic
manipulative treatment: a randomized,
controlled trial.
 J Am Osteopath Assoc. 2002 Jul;102(7):387-96.

Examined the efficacy of the Spencer technique in
patients with decreased ROM of the shoulder

Treatment groups had significantly increased ROM (P <
.01) and decreased perceived pain (P < .01).

After treatment, OMT group demonstrated continued
improvement in their ROM, while ROM in the placebo
Research in Osteopathy

Single-blind randomized controlled trial of
chemonucleolysis and manipulation in the treatment
of symptomatic lumbar disc herniation.
Eur Spine J. 2000 Jun;9(3):202-7.

This single-blind randomized clinical trial compared
osteopathic manipulative treatment with chemonucleolysis
(used as a control of known efficacy) for symptomatic lumbar
disc herniation.

Because osteopathic manipulation produced a 12-month
outcome that was equivalent to chemonucleolysis, it can be
considered as an option for the treatment of symptomatic
lumbar disc herniation, at least in the absence of clear
indications for surgery.
Research in Osteopathy

Standard osteopathic manipulative treatment
acutely improves gait performance in patients with
Parkinson's disease.
–
J Am Osteopath Assoc. 1999 Feb;99(2):92-8.

Ten patients with idiopathic Parkinson's disease and a
group of eight age-matched normal control subjects
were subjected to an analysis of gait before and after a
single session of an OMT protocol. A separate group of
10 patients with Parkinson's disease was given a shamcontrol procedure

Statistically significant increases were observed in
stride length, cadence, and the maximum velocities of
upper and lower extremities after osteopathic treatment
group

no significant differences observed in the control groups
Research in Osteopathy

Effects of OMT on Pediatric Patients with Asthma
–
Study by Peter A. Guiney, D.O., Rick Chou, D.O., Andrea Vianna, MD, Jay
Lovenheim, D.O. JAOA January 2005

Single-blind randomized placebo controlled trial

140 subjects, 90 placed in OMT group, 50 placed in
control group (who received a “sham” OMT treatment).

Statistical analysis looked at differences in Peak expiratory
flow measurements before and after OMT treatments
Effects of OMT on pediatric
asthma, continued…..

Analysis of data showed a 95% probability that PEF
improved between 7L per minute and 19 L per minute.

T-test data showed a mean increase of 4.8% in PEFs for
patients in the OMT group versus a mean increase of 1.4%
in PEFs for patients in the control group

Statistically significant therapeutic effect of OMT amongst
pediatric asthmatic patients in this study population
Research in Osteopathy

The Graduate School of Biomedical
Sciences (GSBS) is collaborating with the
Texas College of Osteopathic Medicine
(TCOM) at UNTHSC, and the Arizona
College of Osteopathic Medicine (AZCOM)
to propose a Developmental Center for
Research on Osteopathic Manipulative
Medicine (DCR-OMM).
How could manipulation add to the
treatment of pneumonia?

1) Maximize diaphragmatic excursion to maximize the
lymphatic pump mechanism and help prevent atelectasis
– Treat somatic dysfunctions of diaphragm attachments
(ribs, l-spine)
– Redome the diaphragm

Remove fascial torsions at terminal lymphatic drainage
sites

Provide mechanical stimulation of lymphatic flow with
thoracic and pedal pump techniques

Treat somatic dysfunction in b/l T2-T7 to decrease
somatosympathetic input to the respiratory system.
In Summary

Based on anatomical and physiological principles,
there are a variety of diagnostic and therapeutic
interventions available to treat a range of
pathology.

Osteopathic manipulative medicine can be an
effective adjunct to current medical practice

Optimal research design is very difficult to
achieve, but will be necessary to fully prove to
skeptics 19000 years of anecdotal evidence and
results thus far, from sub-optimal research
designs.