Principles and Practice

Part 1

• The Four Osteopathic Principles
• The Osteopathic Lesion (Somatic Dysfunction)
• The Commonest Osteopathic Presentation - Low Back Pain

Part 2

• Osteopathic palpation
• An overview of osteopathic techniques
• Common Osteopathic presentations
• Neck Pain
• Headaches

Part 3

• The Fascial Influence
• The Lymphatic Influence
• Postural Influences
• Common Osteopathic Presentations
• Repetitive Strain Injuries of the Wrist and Hand
• Achilles Tendonitis

Part 4

• Osteopathy and Arthritis
• Osteoarthritis
• Rheumatoid Arthritis
• Osteopathy and Irritable Bowel Disease
• Osteopathy and Dysmenorrhoea
• Osteopathy and Pulmonary Dysfunction

Part 1

The Four Osteopathic Principles

The body is a unit

• Each body part works for the optimum efficiency of the whole organism.
• The health of the physical body interacts with the mental and spiritual well-being.

The body has self-regulating mechanisms

• The body is dynamic and will attempt to maintain homeostasis or form compensations to external and internal stresses.
• Our environment, air, water, food, heat, light, protection, rest all influence health.
• Over-compensation may eventually lead to dysfunction - 'the final straw'.

Structure and function are reciprocally interrelated

• An individual's structure will determine that person's ability to perform certain tasks. 
• Functional demands on the body invoke structural changes in an attempt to meet these challenges.

Rational treatment to meet the other three principles

• Osteopathic manipulation of the thoracolumbar region aims to improve: 
• E.g.1: local mobility and support and so aid mobility & posture of the whole body.
• E.g.2: posture and so relieve stresses on the diaphragm and epigastric region and improve the self-regulating mechanisms of he body.
• E.g.3: the structural balance and therefore the function.

The Osteopathic Lesion (or Somatic Dysfunction)

Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthroidal, myofascial structures and related vascular, neural and lymphatic elements.

Finding the somatic dysfunction enables the osteopath to:

• Confirm the structural (or visceral) diagnosis.
• Treat the structural component of the patient's problem.
• Diagnosis and treatment of areas to support the body's self-protecting and self-regulating mechanisms.

Osteopaths practice the skills of observation and palpation to find the somatic dysfunction

• Tissue texture change
• Asymmetry
• Restriction of motion
• Tenderness

The Commonest Osteopathic Presentation - Low Back Pain

Most low back pain is described by patients as originating from an area dubbed 'the multifidus triangle' with its base level with L4 and its apex at the coccyx. 

Pain producing structures in this area include:

• The posterior muscles of the back
• Superficial layer of latissimus
• Intermediate layer of erector spinae group
• Deep layer of multifidi and rotators
• The anterior muscles of the back and abdomen
• Quadratus lumborum, iliopsoas, transverses abdominis, obliques
• The anterior, posterior longitudinal ligaments, ligamentum flava, supra- and interspinous 
• ligaments
• The posterior longitudinal ligament is narrow at the lumbar level leaving weak unsupported areas at the posterolateral part of each lumbar disc.
• The joint capsule and capsular ligaments
• A fairly rare cause of sudden, relatively non-traumatic lumbar spasm is due to 'facet joint lock' caused by pinching of the joint capsule. These can be released by manipulation of that joint and are the so called 'miracle cures' of osteopathy.
• The bone
• Fractures, pars articularis defects
• Cysts, carcinoma, Paget's disease or infection of bone.
• The spinal nerves in their intervertebral foramen may be impinged and inflamed by pressure from a posterolateral prolapse of the intervertebral disc, by spondylosis of the apophyseal facet joints or by spondylolisthesis.
• Sacroiliac and sacral shear problems.

Because of muscular and ligamentous attachments, body unity and reflex phenomena, lumbar somatic dysfunction may be associated with pain and dysfunction in other areas:

• Headaches, neck pain, balance problems
• Thoracic and rib girdle 
• Upper extremity, arm, shoulder pain or dysaethesia (primarily due to attachment of L. dorsi muscle)
• Gluteus, hip and groin (e.g. iliolumbar ligament syndrome has similar symptoms to inguinal hernia)
• Lower extremity pain or dysaethesia (most commonly posterior sciatic n. pain, anterior femoral n. pain), hamstring and calf tension
• Viscerosomatic reflexes and direct contiguous tissue irritation from kidney, ureter, uterine, bowels, metastatic disease, epigastric, GIT, abdominal.

However many causes of pain in the structures of the multifidus triangle are due to functional compensations:



a) Postural compensation patterns of the thoracolumbar region.

Postural weakness due to prolonged sitting causing:

• non-structural kyphosis of the thoracolumbar area
• protraction of the shoulder girdle
• hyperlordosis of the mid cervical region

This produces:

• lengthening, weakening and subsequent fibrosis of the posterior spinal muscles
• shortening, weakening of the psoas muscles
• weakening and prolapse of the abdominal musculature and contents
• tension and impairment of diaphragmatic function
• tension in latissimus dorsi fixing the internal rotation and protraction of the shoulder girdle and creating tension in the thoracolumbar fascia
• tension in the mid lumbar attachments of psoas and the diaphragmatic crura resulting in local lordosis and reduced mobility

A relatively minor trauma can then cause a significant spasm in the posterior spinal muscles, which, if the underlying causes are not addressed, can cause significant long-lasting disruption to normal activities and life.

b) Sacral shear dysfunction and compensations

The patient may present complaining of:

sacroiliac pain on the side opposite the sacral shear (due to compensatory overuse); in the back or neck; chronic rib problems; chronic headaches; extremity dysfunction or even temperomandibular or sinus problems. There may or may not be a short leg syndrome. 

The initial injury may have been forgotten or not painful. Compensations usually occur throughout the spine to the cranium. If the sacral shear is not removed any treatment of other painful areas will tend to be short-lived; of course the chronic compensatory patterns must also be addressed to obtain full relief. 

The sacral shear is produced by opposite forces across the sacroiliac joint through the innominate bone from the ischial tuberosity or through the leg and acetabulum meeting a downward force through the spine and sacrum:

• A fall on the buttocks
• A surprise step of a kerb, missed step, slipping on ice 
• A lifted load that shifts causing a sudden force on one leg
• A runner with a short leg repeatedly overloading that side
• A farmer getting of his tractor on the same side on to the same leg 
• Digging the garden using the same foot on the spade each time
• Carrying a heavy load on one shoulder 

The sacral ligaments are normally loose enough to allow the non-physiologic shear to occur without tearing the ligaments. There is usually little or no movement allowed on the side of the shear.

In chronic shears, there is often more pain over the contralateral sacroiliac joint because the ligaments are stressed by compensatory over-work.

Because of the ring like nature of the pelvic girdle, a strain in one part is likely to cause a strain in another, commonly the pubic symphysis.

E.g. a pubic strain causes tension in the adductors and can irritate osteoarthritic changes in the knee.

Part 3

The Fascial Influence

Fascia is a special form of connective tissue found in sheet form, which covers organs, bones, muscles and joints and produces fascial sheaths and pathways through the body.

• Packaging
• Protection
• Posture
• Passageways 

Through these fascial pathways pass vessels for nutrition and waste removal and lymphatic vessels for protection and tissue fluid drainage. These fascial sheets also provide pathways for somatic nerves (voluntary musculoskeletal control) and visceral afferent and autonomic nerves for visceral sensation as well as visceral, glandular and vascular regulation. 

Compensations in the somatic function result in myofascial compensation patterns. 

The Lymphatic Influence

The lymphatic system is essential in health and good lymphatic flow also increases the body's immune response. There is increased demand for its most efficient function during disease, tissue dysfunction, physiologic stress, infection and any other condition, which increases the formation of interstitial fluids.

Congestion occurs when production outstrips removal of fluids in an area. Therefore it arises when there is any obstruction to the lymphatic pathways and/or dysfunction of the abdominal diaphragmatic action (the primary lymph pump).

Congestion promotes the accumulation of waste products and other metabolites in the interstitial tissues; it is associated with poor circulation and nutrition of the cells and can impair the distribution of medication in the body tissues.

Osteopathic manipulation can improve the efficiency of the lymphatic system by

• Freeing the fascias of the thoracic inlet
• The functional thoracic inlet of vertebral units T1-4, ribs 1-2 and the manubrium
• Relaxing the thoracolumbar attachments and improving bilateral diaphragmatic mobility
• Ensuring good pressure gradients
• Freeing peripheral fascial pathways of the extremities
• Freeing fascial torsions of the abdominal mesenteries
• Promoting lymphatic flow using osteopathic manipulative and pumping techniques.