One purpose of osteopathic manipulative therapy (OMT) is to restore physiological motion to areas in which there is restriction or dysfunction. By restoring or improving function in the musculo-skeletal system, it is anticipated that all connected parts will benefit, whether these are other parts of the musculo-skeletal system or areas influenced via nerve or circulatory pathways. OMT is not aimed at specific disease processes but rather at normalizing the musculo-skeletal structures with a view to benefiting overall function and thereby maximizing the body’s homeostatic, self-regulating and healing activities.
There are a great variety of osteopathic manipulative methods. It is just as ridiculous to talk of manipulation, as though it is a specific entity, as it is to talk of medicine or surgery in the same terms. Just as the allopathic doctor, or surgeon, has a wide range of choice regarding medication or surgical procedure, so does the osteopathic practitioner have a wide range of choices regarding techniques and methods of manipulation.
Among the aims of manipulation are the restoration to normal of the supporting tissues such as muscle, ligaments, fascia etc. Then there is the normalization of movement and articulation, there is the use of reflex, mechanical, influence on the body as a whole.
Techniques can, roughly speaking, be divided into three groups:
|Shows a soft tissue stretching technique in which the shoulder girdle muscles are lifted and stretched. It also simultaneously allows articulation of the shoulder joint.|
Soft-tissue techniques. These are varied and involve any method that is directed towards tissue other than bone. Frequently soft-tissue techniques are used diagnostically, as well as therapeutically. Soft-tissue techniques may involve stretching movements across or along the lines of the muscular fibres and deep pressure techniques, as well as stretching and separation of muscle and other soft-tissue fibres, especially where muscles originate or insert into bony structures. Much soft-tissue manipulation involves working on fascia or connective tissues. These methods usually precede manipulation of the bony structures but can frequently achieve mobilization and normalization of joint structures on their own. This can result from the improvement of rigid or tense tissues, allowing a previously restricted joint to achieve a free range of motion.
A uniquely British contribution to this end was developed by the late Stanley Lief D.O., and it is in the use of this and other soft-tissue methods that attention is usually paid to the reflex areas that might influence the patient’s condition. These might range from simple trigger points to more complex reflexes, involving internal function (Chapman’s reflexes etc.). With soft-tissue techniques, diagnosis and treatment are often simultaneous. As the practitioner is palpating and assessing the tissue for signs of dysfunction, so is he treating and attempting to normalize what he finds.
A direct action method, very similar to those employed by chiropractors. It involves high velocity and low amplitude in its execution. The supporting couch may have a sprung section to allow for a rebound effect.
Direct Techniques. In these methods the practitioner attempts to overcome limitations to normal movement by taking the joint involved towards, or through, the restrictive barrier that is preventing normal motion. This might involve thrust techniques in which, after careful positioning of the hands in relation to the joint, a high velocity, low amplitude thrusting movement forces the bony articulation to move. There would be very little movement of the hands, or of the joint in question, in such a manipulation. A matter of only a centimetre or less of actual movement might take place, but at very high speed. This might be compared to trying to move a drawer that is jammed. Pushing slowly on it, however hard, will often fail to shift it, whereas a sharp tap at the appropriate angle releases it instantaneously.
This direct action, high velocity, low amplitude manipulation involves the precise localization of the forces required to allow correction of the particular dysfunction. This is achieved by means of rotation and sidebending of the patient’s spine, followed by the adjustment.
This direct action manipulation positions the patient so that by extending, side-bending and rotating the neck a locking of joint facets is obtained which localizes the forces preparatory to the high velocity, low amplitude thrust being delivered to the appropriate vertebrae (in this case the second thoracic vertebrae. )
A different direct method of OMT is known as articulatory technique. In this the restricted joint may be repeatedly taken through its free range, up to the point of restriction, in an attempt to gradually force a greater range of mobility, with more freedom of movement. This type of manipulation often employs leverage to achieve its aims, and, as always, the longer the lever the greater the force that can be applied. A knee joint, for example, may be mobilized by the joint itself being stabilized, whilst the lower leg is grasped at the ankle and taken through a range of movements. The lower leg thus becomes a lever, and depending upon the skill with which the leverage is applied around the fulcrum (the knee joint) a great deal of controlled force can be brought to bear on the motion barriers, or on restricted tissues and surfaces. This is essentially a low velocity (slow moving), high amplitude, type of manipulation.
This direct action technique enables the practitioner to use leverage to force into its correct anatomical position a posterior subluxation of the head of the fibula.
Muscle Energy Technique (MET) is a further method of applying direct action to a restricted area. With MET, however, it is the patient’s own forces which produce the manipulative effort. By placing a joint in a precise position, and calling on the patient to use a muscular effort in a particular direction, against a distinctly executed counter-force from the practitioner, it is frequently possible to achieve dramatic improvements in joint mobility. The skill in such a manouevre is in creating a balance of forces which can operate precisely on the restriction. In general terms MET involves placing the joint in question at the limit of its possible motion, in the direction in which it is most restricted. This position is maintained (not exaggerated) by pressure from the practitioner and, in a controlled manner, the patient then attempts to move the joint, by sustained effort, against the practitioner’s counterforce. No movement should take place during repeated short or long efforts of this type. After each such effort the joint should be reassessed, and if the range of movement has increased then the joint should be taken to this new limit before the next attempt. This method is virtually painless, and is suitable for self-use in many areas of the body (fingers or elbow, for example).
Indirect Techniques. These methods, rather than engaging and attempting (by whatever means) to overcome resistance, do the opposite. In counterstrain technique, for example, the part in question is moved by the practitioner away from the planes of restricted motion towards the planes of easier, unrestricted motion. There is a constant seeking for the position of greatest ease. At this point a mild degree of strain is introduced by the operator. This results in a reflex release of previously restricted tissues. The essence of this slowly performed technique is the introduction of the mild strain, whilst the joint is held in a position opposite to the direction in which there is a limitation of movement. It is essential that all movements are directed and controlled by the practitioner, as he eases the joint along the path of least resistance.
A further type of indirect technique is called functional technique. This also uses practitioner induced movement, whilst the area of dysfunction is constantly palpated. The joint is taken in all directions of ease (as opposed to directions of bind, which indicate irritation of tissues) gradually guiding towards the point of maximum ease. The palpating hand informs the practitioner when the affected area is least in distress. There is no further treatment at this point. The feedback from the distressed joint whilst in its state of ease is enough to begin normalization.
Shows the spontaneous release technique in which the affected part (in this case the low back) is carefully positioned in an exaggerated degree of the distortion already existing. This is maintained until there is a reflex release of spasm. No active manipulation is used at this usually acute stage.
Spontaneous release technique is a method ideally used when an area or joint is in lesion and is distorting its normal anatomical position. Often in low back problems, or neck conditions, there will be an obvious distortion. The individual might be in a stooped position or tilted to one side, or be unable to straighten a sidebent neck. This technique gently guides the affected part further into the direction of distortion. By exaggerating the lesion and holding the area in this position for several minutes, there is often a reflex release of muscular spasm and a resolution of the problem. This is a painless method.
Many techniques employ the assistance of the respiratory movements of the patient. It is a fascinating fact that as we breathe in and out, every part of the body moves. Perhaps some of the movement is very slight indeed, but it is palpable to the trained hand. For example, as we breathe in, the arms and legs rotate slightly outwards, and all the spinal joints move. The opposite (i.e. a return to the neutral position) takes place as we breathe out. Using this knowledge an osteopath will often synchronize attempts to move a joint with the phase or the respiratory cycle that will most aid the movement.
Combinations of direct and indirect techniques, sometimes preceded or followed by soft tissue methods, are often employed. Whether one method or another or a combination is needed, will be dictated by the individual case. The wide range of techniques available (and those described are by no means all) gives the osteopathic practitioner the ability to deal with musculo-skeletal problems and their ramifications.
A further area of manipulative effort is the use of cranial technique. This will be considered more closely in Chapter 11, but it is worth mentioning, in passing, that there does exist this specialized form of treatment which incorporates the cranial structures into the overall consideration of body mechanics. Cranial osteopathy attempts to normalize the bones of the head as well as influencing the circulation and fluid movements (cerebro-spinal fluid etc.) to, from and within the cranium. It attempts to balance what is known as the cranio-sacral mechanism. What this is and what its effects are will be dealt with in the appropriate chapter. The cranial concept and the techniques employed in correcting dysfunction in this area, have opened new vistas to the osteopathic profession. Birth injuries and many previously untreatable conditions have responded to cranial methods.
All osteopathic manipulation is aimed at accomplishing specific ends. Not only must the physiology of the area being treated be understood but the overall inter-relationship between it and the body as a whole needs to be considered. At the same time the manipulative techniques being employed must take into account the individual needs of the patient. When selecting the appropriate technique the practitioner visualizes the desired end result and the way in which this is most likely to be achieved. The choice will differ from patient to patient, and even in the same patient, from one visit to another.
The oldest maxim in osteopathy is ‘Find it, fix it, and leave it alone’. These are golden words.