Diagnosis

Diagnosis of somatic dysfunction (impaired or altered function of related components of the body framework) is a relatively simple procedure when the degree of deviation from normal is marked. When, however, there is only a slight deviation, then the diagnostic exercise is more difficult. There are a variety of diagnostic methods used in assessing somatic dysfunction, and diagnostic indications fall into the following three categories:

Changes in symmetry.
Restrictions in mobility.
Tissue texture changes.

The tests used to assess these changes usually fall into five classes.

General impression. This is a screening, either visual or by palpation (feeling by hand of the whole body or parts of it) for general asymmetries and any obvious abnormalities in structure or function. Other disciplines (physical medicine, orthopaedics etc.) use similar tests. Osteopaths tend to use their palpatory skills to focus on possible problem areas before further consideration.
Motion testing. A variety of tests to elicit motion, or lack of it, in regions of joint activity (e.g. low back) are utilized. These methods are not confined to osteopaths but are used in general medicine as well. Such factors as ease of movement, range of movement, continuity of movement, degree of discomfort or pain brought about by movement, are all assessed using active (the patient moves himself), passive (the practitioner moves the patient), or resisted movements, whilst the area is palpated and ‘visualized’. Restrictions in motion are noted precisely. These might include flexion, extension, sidebending or rotation limitations, for example.
Positional changes. The practitioner palpates for specific bony landmarks and visually judges these for asymmetry or malposition. Pairs of landmarks (shoulder blades, pelvic bones etc. ) are compared and their relative positions noted. Such tests may be combined with motion tests so that position and motion can be compared simultaneously.
Soft tissue changes. These are assessed by inspection and palpation. Osteopathic practitioners have developed these methods to a fine art. Tissues such as muscles., ligaments and tendons are assessed for changes in temperature and consistency. The practitioner will quite likely run his hands lightly over the area being checked, seeking changes in the skin and the tissue below it. Having localized any changes in this way he will assess the deeper tissue structure by using greater pressure. He will be looking for a number of specific changes, including:
1. Skin changes. Over an area of acute dysfunction the skin will feel tense and will be difficult to move, or glide, over the underlying structures.
2. Induration (hardening). A slight increase in diagnostic pressure will ascertain whether or not the superficial musculature has a hardened feeling. When chronic dysfunction exists the skin and superficial musculature will demonstrate a tension and immobility, indicating fibrotic changes within and below these structures.
3. Temperature changes. In acute dysfunction a localized increase in temperature may be evident. In chronic lesion conditions there may, because of relative arterial narrowing, be a reduced temperature of the skin. This usually indicates the formation of fibrous tissue in the underlying structures.
4. Tenderness. Tenderness can be misleading as it may indicate local or reflex problems in acute or chronic dysfunction. The practitioner will note its presence, but not necessarily consider it as important. In acute joint dysfunction the superficial musculature and skin usually palpate as tender.
5. Oedema (excessive fluid). An impression of fullness and congestion is apparent in the overlying tissues in acute dysfunction. In chronic dysfunction this has usually been replaced by fibrotic changes.
These diagnostic methods are used almost exclusively by osteopathic practitioners.
Local motion testing. As distinct from the testing of a region, this method attempts to assess the local response to a motion demand. The motion might be introduced by the practitioner, or the joint or area might be palpated whilst motion is introduced by the patient. Continuity of motion, tension, resistance and local tissue response are all judged. This class of tests helps to specifically identify areas of resistance to motion, and this leads to the normalizing manipulative procedures used in treatment. This is a purely osteopathic diagnostic procedure.

What Are These Tests Locating?

In the main the problems that affect general health lie in the spinal and cranial regions, as do most of the areas of dysfunction dealt with by those osteopaths whose work is confined to the aches and pains of the musculo-skeletal system. Spinal lesions display limitations of mobility, spasms of the related musculature with ligament involvement, swelling and congestion, sensitivity to pressure, and usually some degree of asymmetry. If such a state is prolonged, then chronic inflammation, fibrotic changes contractures and arthritic changes (calcium deposits), will show themselves. Whether acute or chronic, and regardless of which of the above mentioned changes have taken place, nerve impulses will be transmitted to the central nervous system from such a lesion. These will influence other segments of the spine and affect the organs or tissues supplied from the level of the lesion. There may also, of course, be local discomfort, pain and disability.

Spinal dysfunction may also result in reflex activity from an organ to the spinal segment that supplies it. As Paul Isaacson, D.O., says:

From a purely anatomic viewpoint, it would seem clear that a stress or strain applied to any one spinal articulation, regardless of cause, would involve several others to some degree. It would manifest itself by varying degrees of disturbance to the body mechanics, affecting posture, muscular tone, circulation, reactions to the nervous system and visceral function. At first these disturbances would be physiological, or functional, and reversible, but if allowed to persist might in time produce organic or irreversible changes in the tissues and viscera. Conversely, a primary lesion in a viscus (organ) may predispose the musculature and ligaments, innervated by the respective segments, to lesioning. [1]

Fundamental to the successful application of any osteopathic diagnostic methods, is a highly developed tactile sense coupled with a sound knowledge of human anatomy, physiology and pathology. The ability to diagnose changes in tissue texture, symmetry and the quality and range of joint movement, presupposes a knowledge of what is normal and healthy. The experienced osteopath is able to detect changes in texture, temperature, contour and relative moisture on the surface of the skin. By palpating he can assess deeper tissue changes such as increased tension and fluid content. He can readily tell the difference between the state and quality of superficial and deeper muscles. By feeling and looking he can assess imbalance in structure and asymmetry and can then detect gross and subtle changes in joint mobility. This is sometimes the earliest sign of joint dysfunction.

The development of the skills required for such work involves persistent effort and practice. The osteopath must be able to receive, through the hands, the messages that are present in the tissue. These must be correctly assessed and interpreted before therapy can be meaningful or successful. Correct diagnosis is essential to successful treatment.

Dr Viola Fryman has written as follows regarding what may be discovered via palpation. [2]

A very light touch, even passing the hand a quarter inch above the skin, provides information on the surface temperature. An acute lesion area will be unusually warm, an area of long standing, chronic lesion may be unusually cold as compared to the skin in other areas.

Light touch will also reveal the cutaneous humidity, the sudorific (perspiration) or sebaceous (oily secretion) activity of the skin.

The tone, the elasticity, the turgor of the skin may be noted by light pressure.

A slightly firmer approach brings the examiner into communication with the superficial muscles to determine their tone, their fullness, their metabolic state.

Penetrating more deeply, similar study of the deeper muscle layers is possible.

The state of the fascial sheaths (fibrous tissue enveloping the muscles).

In the abdomen similar palpation will provide information about the state of the organs within.

On deeper penetration, firm yet gentle, contact is reached with bone.

Viola Fryman adds these general thoughts on palpation.

Palpation cannot be learned by reading or listening; it can only be learned by palpation. But in order to learn let us develop a perceptive, exploratory palpation; let us look to find what is under our hands, rather than seek what the text advises us should be there. Every patient, on every visit, is a new territory to be explored. A history at best incomplete. Frequently patients forget, or do not choose, to remember traumatic events. But the human body bears a record of significant injuries for the physician to read if he understands the language of the tissues. The scars of disease also remain to distort and obstruct, if the disease was supressed rather than cured. These scars must be recognized and understood. Profound emotional shock, grief and anger also leave their imprints within. The sensitive, perceptive hands can find and change these effects with lasting benefit to the patient. This is the art and science of osteopathy.[3]

Osteopathic diagnosis incorporates all that is useful and valid in standard medical diagnosis including the use of x-rays and other standard tests and procedures. These are all used as well as the unique and distinguishing measures and skills discussed above. This enables the osteopathic practitioner to read the signs that others might miss.

Knowledge of the many reflex pathways and activities in, and between, the body systems, is a further aid to accurate osteopathic diagnosis. A system which combines diagnosis and treatment is the use of what are known as neurolymphatic reflexes. These were first described by an osteopath. Dr. Frank Chapman, in the 1930’s. These comprise areas of ‘stringy’, sensitive tissue, in precise areas of the body. When present they indicate dysfunction or pathology of associated areas or organs. Treatment of these areas, by pressure techniques, is a useful method of promoting recovery, as well as being a means of ascertaining the degree of severity of the problem. There are other reflex patterns in the body such as the so called ‘trigger’ points (myofascial triggers) which produce pain in predictable target areas when irritated. Via knowledge of these and other reflexes, osteopaths are able to assess the patient’s symptoms and can often diagnose potential problems before they have shown themselves.

1. ‘Anatomic Basis of Osteopathic Concept’. Journal American Osteopathy Association, Vol 79, No. 12, page 759.

2. ‘Palpation’, Academy of Applied Osteopathy Yearbook 1963, page 17.

3 ’Palpation’, Academy of Applied Osteopathy Yearbook 1963, page 31.