General osteopathic principles

Principles of osteopathic philosophy

1. The body is a unit; mind, body, and spirit connect to make the whole person.
2. The body is capable of self-regulation, self-healing, and health maintenance.
3. Structure and function are reciprocally interrelated.
4. Rational treatment is based upon the understanding of these basic principles.

Five models of osteopathic care

1. Biomechanical
2. Respiratory–circulatory
3. Neurological
4. Metabolic–energy
5. Behavioral

Palpation

• Function
  • Touch: human interaction; conveys empathy and professionalism; must always be appropriate
  • Palpation: diagnostic touch; therapeutic; differentiate shape, size, consistency, position, and health of underlying tissues
• Approach: layer by layer, superficial to deep; use finger pads, not fingertips; ample communication
• Layers (from superficial to deep): skin → subcutaneous tissue → vessels → deep fascia → muscle → ligament → bone
  • Skin: Note color, temperature, skin drag, texture, and turgor.
  • Subcutaneous tissue: normally spongy; edematous with acute changes
  • Vessels: Look for congestion or vascular formation.
  • Deep fascia: normally smooth, firm
  • Muscle: Follow muscle fibers. Observe tension or hypertonicity.
  • Ligaments: Note tenderness.
  • Bone: Follow contours, landmarks, structure, and symmetry.

Somatic dysfunction

• An impairment or altered function of musculoskeletal structures and their associated lymphatic, neural and vascular elements
• Characterized by TART
  • Tissue texture changes
    • Acute: Tissue may be edematous, tender, boggy, and/or red.
    • Chronic: Tissue may be rigid, ropy, and/or atrophic.
  • Asymmetry: Posture or joint function lacks symmetry compared to the complementary side.
  • Restriction of motion
    • Physiologic barrier: range of motion of a joint that can be achieved by active movement of the patient
    • Anatomical barrier: range of motion of a joint achieved by passive movement (i.e., examiner moving the patient)
    • Restrictive barrier: range of motion of a joint that can be achieved by active movement of the patient that is a functional limit of the physiologic barrier
  • Tenderness: pain felt upon palpatory examination
• Named after the freedom of motion rather than the restricted motion (e.g., rib 3–5 inhalation dysfunction → ease during inhalation → restriction during exhalation)

Acute versus chronic changes

Step 1: posture screening

• Assess overall posture from anterior, posterior, and lateral view points.
• Assess symmetry by comparing major anatomical landmarks.
• Evaluate the spine for appropriate lordosis and kyphosis as well as scoliotic curves.

Step 2: gait analysis

• Assess gait by observing the patient walk.
• Assess lower extremity weakness by having the patient squat, walk, and stand back up (duck walk).

Step 3: active trunk side bending

• Assess lateral spinal curvature by having the patient side bend to each side.

Step 4: standing flexion test

• Assess iliosacral motion by performing a standing flexion test.

Step 5: stork test

• Assess motion of the ilium and sacrum in relation to each other by performing a stork test.

Step 6: seated flexion test

• Assess sacroiliac motion by performing a seated flexion test.

Step 7: screening of the upper extremities

• Assess range of motion of the upper extremities.
  • Have the patient abduct their arms until the backs of the hands are touching (∼ 180° if possible).
  • Have the patient cross their arms and hold onto their elbows.
  • Have the patient flex their arms to ∼ 90°, interlock their fingers from opposite sides, and bring their hands through the arms.

Step 8: trunk mobility testing (side bending and rotation)

• Assess side bending and rotation of the trunk while in a seated position (active and passive).

Step 9: head and neck mobility

• Assess range of motion of the head and neck.

Step 10: quick total body screen

• Assess major landmarks while patient is supine.
• Perform the ASIS compression test, FABERE test, and straight leg raise test.
• Assess rib motion with respiration.

Fryette's first law of spinal motion

• The spine exhibits a neutral mechanic.
  • Side bending and rotation of the segment occur in opposite directions (e.g., the thoracic segment is side bent left and rotated right).
  • The rotated and side bent segment does not realign when placed into flexion or extension.
• Present in type 1 somatic dysfunctions
  • Dysfunction is present in a group of adjacent segments of ≥ 3 vertebrae.
  • Each vertebra of the same group exhibits the same dysfunction.
  • A type 2 dysfunction may be present between two different type 1 dysfunctions.

Fryette's second law of spinal motion

• The spine exhibits a non-neutral mechanic.
  • Side bending and rotation of the segment occur toward the same side (e.g., lumbar segment is side bent and rotated right).
  • The rotated and side bent segment realigns when placed into either flexion or extension (non-neutral mechanics).
• Present in type 2 somatic dysfunctions
  • Dysfunction is limited to one segment.

Fryette's third law of spinal motion

• Motion of an isolated segment in one plane engages the motion of the segment in the other planes (e.g., engaging flexion also engages the rotational and side bending component of the dysfunction).

This section covers the techniques commonly used by osteopathic physicians with the goal of alleviating pain and enhancing function.

Articulatory techniques

• Active direct techniques
• Increase range of motion of restricted joints
• Utilize gentle rhythmic spinning motions or concentric movements of a joint
• Typically performed prior to advanced musculoskeletal manual techniques (i.e., muscle energy)

Myofascial techniques

• Description
  • Active or passive
  • Direct or indirect
  • Loosen restricted musculature and fascia
  • Can be performed prior to advanced manual musculoskeletal techniques (i.e., muscle energy, high-velocity low-amplitude)
• Types of myofascial techniques
  • Strain-counterstrain
  • Facilitated positional release
  • Balanced ligamentous tension
  • Cranial osteopathy
  • Direct fascial release
  • Functional fascial release

Muscle energy

• Description
  • Developed by Dr. Fred L. Mitchell, Sr.
  • Active direct technique
  • Clinical uses
    • Muscle contracture
    • Congestion
    • Muscle weakness
    • Increase range of motion of a restricted joint
  • Utilizes voluntary muscle contraction against equal and opposite resistance from the examiner
  • Contraction of the opposing muscle or muscle group causes a reflexive relaxation of the contracted muscle.
• Procedure
  1. Perform soft tissue techniques.
  2. Place patient's joint into restrictive barrier (e.g., flexion of the hip joint).
  3. Ask patient to move joint toward its freedom of motion (e.g., extension of the hip joint).
  4. Apply an equal and opposite counterforce to induce an isometric contraction for 3–5 seconds.
  5. Relax for 5 seconds.
  6. Place joint further into its restrictive barrier and repeat.
  7. Reassess joint mobility for symmetry.

Facilitated positional release

• Description
  • Developed by Dr. Stanley Schiowitz and Dr. Eileen L. DiGiovanna
  • Modeled after the strain-counterstrain system
  • Indirect functional technique
  • Improves joint function and reduces tissue tension
• Procedure
  1. Perform soft tissue techniques.
  2. From a neutral position, add a compressive force on the joint.
  3. Place the patient's joint into its freedom of motion (e.g., flexion, right rotation, and left side bending of a thoracic segment).
  4. Hold for 3–5 seconds.
  5. Relax.
  6. Reassess.

Still technique

• Description
  • Developed by Dr. Richard van Buskirk
  • Modeled after the high-velocity low-amplitude technique
  • Allows for gentle movement of a joint back into its neutral position
• Procedure
  1. Place dysfunction into its freedom of motion (e.g., flexion, right rotation, and right side bending of a cervical segment).
  2. Add a compressive force for 3–5 seconds.
  3. While maintaining a compressive force, place the dysfunction into its barriers (e.g., extension, left rotation, and left side bending of a cervical segment).
  4. Relax.
  5. Reassess.

Strain-counterstrain

• See the article on strain-counterstrain.

High-velocity low-amplitude

• Description
  • Also known as the thrust technique
  • Passive direct technique
  • Utilizes a rapid (high-velocity) and short (low-amplitude) force on a joint to move it past its restrictive barrier in one or more planes of motion
• Procedure
  1. Perform soft tissue technique.
  2. Place joint into its restrictive barrier (e.g., anterior rotation of the innominate).
  3. Apply a high-velocity low-amplitude thrust past the restrictive barrier.
  4. Relax.
  5. Reassess joint mobility for symmetry.

Progressive inhibition of neuromusculoskeletal structures (PINS)

• Position: seated, supine, or prone
• Procedure
  1. Palpate and isolate the most tender point (primary point).
  2. Locate the insertion site of the affected muscle (endpoint).
  3. Apply inhibitory pressure to both points for ∼ 30 seconds.
  4. Locate a new point along the affected muscle near the previous primary point.
  5. Determine if new point is more or less tender.
     • If the second point is more tender, then this will be the new primary point.
  6. Repeat steps 3–5.
  7. Continue along the affected muscle until the endpoint is reached.

Viscerosomatic and somatovisceral reflexes

• The neurophysiological basis for reflex interactions refers to the relationship between somatic structures and visceral organs.
  • Viscerosomatic reflex: Specific visceral pathology (e.g., myocardial infarction) has the potential to manifest as a somatic dysfunction (e.g., tissue texture changes between T1–T5).
  • Somatovisceral reflex: Somatic dysfunction alters the activity of a visceral structure.
• In both of these reflexes, the original stimuli can either have an excitatory or inhibitory influence on the corresponding structure.
• This influence is primarily facilitated by the sympathetic and parasympathetic nervous systems. Understanding their effects and the segmental innervation of these individual visceral structures is an important diagnostic tool, which can be used to employ targeted manipulative techniques to attenuate the autonomic nervous system activity and any associated visceral dysfunction.

Zink Patterns (common compensatory patterns)

• Patterns
  • Common compensatory pattern
    • OA: rotated left
    • Thoracic inlet: rotated right
    • 12^th rib: rotated left
    • Innominate: right anteriorly rotated
  • Uncommon compensatory pattern
    • OA: rotated right
    • Thoracic inlet: rotated left
    • 12^th rib: rotated right
    • Innominate: left anteriorly rotated
  • Uncompensated pattern: a pattern that does not alternate
• Description
  • Assess the following four junctions:
    • Atlanto-occipital joint: OA dysfunction
    • Cervico-thoracic junction: thoracic inlet dysfunction
    • Thoraco-lumbar junction: 12^th rib dysfunction
    • Lumbo-sacral junction: pelvic dysfunction
  • The manner in which the four junctions are rotated characterizes each pattern

Muscle imbalance syndromes

• First described by Dr. Vladimir Janda
• A predictable crisscross configuration of overlapping overactive (hypertonic and shortened) and underactive (weak and lengthened) muscle groups
• Causes acute and, if left untreated, chronic muscle pain, joint degeneration (e.g., glenohumeral, sacroiliac), and pronounced postural changes
• Divided into upper and lower cross syndromes
• A combination of both upper and lower cross syndromes is called Layer syndrome (or stratification syndrome).
• May be associated with various somatic dysfunctions
• Treatment consists of strengthening the weak muscles and stretching the tight ones.

Upper cross syndrome

• Has become a common condition in the 21^st century.
• Typically caused by poor posture
• Involves muscles of the neck, shoulder, and chest
• The posterior cervical and anterior thoracic muscles become hypertonic and shortened, while the deep cervical flexors and mid-back muscles become weak and lengthened.
  • Muscles prone to tightness
    • Anterior thoracic muscles
      • Pectoralis major
      • Pectoralis minor
      • Scalenes
    • Posterior cervical muscles
      • Cervical erector spinae
      • Suboccipital
      • Sternocleidomastoid
      • Upper trapezius
      • Levator scapulae
  • Muscles prone to weakness
    • Anterior cervical muscles
      • Deep cervical flexor muscles (longus capitis, longus coli, etc.)
    • Posterior mid-back muscles
      • Rhomboids
      • Mid-lower trapezius
      • Serratus anterior
• Overall postural change places increased pressure on specific joints, putting the patient at increased risk for joint degeneration.
  • OA joint
  • C4/C5 junction
  • C7/T1 junction
  • T4/T5 junction
  • Glenohumeral joint

Lower cross syndrome (anterior pelvic tilt)

• Characterized by a forward tilted hip and exaggerated lumbar lordosis
• Typically caused by physical inactivity, prolonged sitting, or poor exercise technique
• Involves muscles of the lower back, hip, and thighs
• Posterior lumbar, thigh, and leg with anterior hip and thigh muscles become hypertonic, while the anterior abdominal and thigh with posterior hip and thigh muscles become weak and stretched.
  • Muscles prone to tightness
    • Anterior hip and thigh muscles
      • Iliopsoas
      • Rectus femoris
      • Adductor brevis
    • Posterior lumbar, hip, and leg muscles
      • Thoracolumbar erector spinae
      • Hamstrings
      • Piriformis
      • Tensor fascia lata
      • Quadratus lumborum
      • Gastroc-soleus complex
  • Muscles prone to weakness
    • Anterior abdominal and thigh muscles
      • Rectus abdominis
      • Transversus abdominis
      • Obliques
      • Vastus group
      • Tibialis anterior
      • Fibularis longus
    • Posterior hip and thigh muscles
      • Gluteus maximus
      • Gluteus medius
      • Gluteus minimus
      • Tibialis posterior
• Diminishes functional capacity, including curling up and sitting up from supine and forward-bent positions
• Overall postural change places increased pressure on specific joints, putting the patient at increased risk for joint degeneration.
  • L4/L5 junction
  • L5/S1 junction
  • Sacroiliac joint
  • Acetabulofemoral joint