General osteopathic principles

Osteopathy conceives of the individual as a unity of mind, body, and spirit and believes that all bodies have the capacity for self-regulation, self-healing, and health maintenance through the reciprocal relationship between anatomy and function. Somatic dysfunction is the impairment or altered function of musculoskeletal structures and their associated lymphatic, neural, and vascular elements. Diagnosis includes structural examination to identify tissue texture changes, asymmetry, restricted movement, and tenderness. Diagnostic tools include the application of Fryette laws, which describe the principles of physiological motion of the spine, and the observation of viscerosomatic reflexes, which are somatic responses to localized visceral stimuli (e.g., irritation). Osteopathic manipulative treatment is a set of techniques (e.g., muscle energy, myofascial release) involving the manipulation of bodily structures (e.g., joints, soft tissues) to treat somatic dysfunctions, thereby alleviating pain and restoring function. Direct treatments (e.g., muscle energy) engage the restrictive barrier while indirect treatments (e.g., counterstrain) involve positioning the dysfunctional region in its direction of ease. In active treatments, the patient voluntarily contracts their muscles; in passive treatments, the patient relaxes while the physician moves the body.

Principles of osteopathic philosophy

1. Osteopathy conceives of the body as a unit. An individual is composed of a mind, a body, and a spirit that are all connected.
2. All bodies have the capacity for self-regulation, self-healing, and health maintenance.
3. Anatomical structures and physiological functions are reciprocally interrelated.
4. Rational osteopathic treatment is founded on these basic principles.

Five models of osteopathic care

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

Definition

• An impairment or altered function of musculoskeletal structures and their associated lymphatic, neural, and vascular elements

Predisposing factors

• Trauma (e.g., due to occupational or athletic overuse or overstretch)
• Obesity, pregnancy
• Anomalies (e.g., abnormal vertebral size or shape, spina bifida)
• Irregularities in transitional areas of the spine (occipitoatlantal joint, C7–T1, T12–L1, L5–S1)
• Emotional stress
• Infection
• Viscerosomatic reflexes

Diagnostic criteria

• Tissue texture changes
  • Acute: edematous, tender, boggy, and/or red
  • Chronic: rigid, ropy, and/or atrophic
• Asymmetry: lack of normal symmetry in the position or motion of corresponding bones, muscles, joints, and/or soft tissues
• Restriction of motion: decreased range of motion or restrictive barrier
• Tenderness: pain upon palpatory examination

Somatic dysfunctions are characterized by “TART”: Tissue texture changes, Asymmetry, Restriction, Tenderness.

Barriers to motion

Normally functioning joints have two barriers to motion: physiological and anatomical.

• Physiological barrier
  • The range of motion of a joint that can be achieved by the patient's active movement
  • Functional limit within the anatomical range of motion
• Anatomical barrier
  • The range of motion of a joint that can be achieved by passive movement of the patient by the physician
  • Restrictions are caused by tendons, ligaments, and bones.
• Restrictive barrier
  • A pathological barrier to motion that restricts a joint's symmetrical movement within the normal physiological range of motion
  • Restrictive barriers are caused by trauma or disease (e.g., inflammation, joint effusion).

Acute and chronic somatic dysfunction

Superior facet orientation and spinal motion

• Superior facet orientation determines the motion of vertebral segments.
• For more information, see “Vertebral column” article.

Fryette laws of spinal motion

Fryette laws describe the principles of physiological motion of the spine and its segments and are used to diagnose dysfunctions.

Fryette first law of spinal motion

• The first law states that when the thoracic and lumbar spine is in a neutral position (i.e., neither flexed nor extended), sidebending precedes rotation, and they occur to opposite sides, e.g., T6 neutral, sidebent left, rotated right (T6 NS_LR_R).
• Type 1 somatic dysfunction
  • A group dysfunction of adjacent thoracic and lumbar vertebrae (typically ≥ 3) that follows Fryette's first law
  • In a type 1 somatic dysfunction, the spine is in a neutral position, and the rotated and sidebent segment does not realign with flexion or extension.
  • Somatic dysfunctions of the spine are always named for their freedom of motion.
  • The name of a somatic dysfunction identifies the following elements in order:
    • The affected segment or segments
    • The position of the spine (always neutral in type 1 dysfunctions)
    • The direction of ease of sidebending and the direction of ease of rotation e.g., T7 neutral, sidebent right, rotated left (T7 NS_RR_L).
• See “Examination of thoracic spine dysfunction.”

Fryette second law of spinal motion

• The second law states that when the thoracic and lumbar spine is in a nonneutral position (i.e., flexed or extended), rotation precedes sidebending, and they occur to the same side, e.g., T6 flexed, sidebent right, rotated right (T6 FS_RR_R).
• Type 2 somatic dysfunction
  • A dysfunction affecting an individual segment of the thoracic or lumbar spine that follows Fryette's second law
  • In a type 2 somatic dysfunction, the spine is flexed or extended, and flexion or extension will either intensify or resolve asymmetry (e.g., if flexion intensifies the dysfunction, extension will improve it).
  • Somatic dysfunctions of the spine are always named for their freedom of motion.
  • The name of a somatic dysfunction identifies the following elements in order:
    • The affected segment or segments
    • The position of the spine (flexed or extended in type 2 dysfunctions)
    • The direction of ease of sidebending, and the direction of ease of rotation, e.g., T7 extended, rotated right, sidebent right (T7 ER_RS_R).
• See “Examination of thoracic spine dysfunction.”

Fryette third law of spinal motion

• The third law applies to the entire spine and states that the movement of any vertebral segment of the spine in a plane of motion alters its movement in other planes (e.g., dysfunction in one plane reduces motion in the other planes).
• Applies to the cervical, thoracic, and lumbar spine

Fryette's first and second laws only apply to the thoracic and lumbar spine.

This section covers the techniques commonly used by osteopathic physicians to alleviate pain and restore function.

Overview

Types

Treatment is either direct or indirect and either active or passive. Some techniques combine direct with indirect (e.g., Still technique) and active with passive (e.g., muscle energy) approaches.

• Direct treatment: : The tissue and/or joints are moved to engage the restrictive barrier (e.g., HVLA, articulatory techniques).
• Indirect treatment: : The tissue and/or joints are moved in the direction of ease (e.g., counterstrain, FPR).
• Active treatment: : The patient voluntarily contracts the muscle or muscles (i.e., isometric, isotonic, or isolytic contraction).
• Passive treatment: : The patient relaxes while the physician moves the body.

Muscle contraction

• Isometric contraction
  • A muscle contraction in which the muscle does not change length
  • The physician's and the patient's force are equal.
• Isotonic contraction: a muscle contraction in which the muscle's length changes while its strength remains constant
  • Concentric contraction: a muscle contraction in which the muscle shortens while generating force
  • Eccentric contraction: a muscle contraction in which the muscle lengthens due to an external force
• Isolytic contraction
  • A muscle contraction in which the muscle contracts against resistance while the muscle is forced to lengthen
  • The physician's force is stronger than the patient’s force.
• For more information, see “Muscle tissue” article.

Description

• Definition: : an osteopathic technique to treat joint restrictions, hypertonicity, and muscle weakness by using voluntary muscle contraction in a controlled position against an equal counterforce. Postisometric relaxation and reciprocal inhibition are the most commonly used muscle energy techniques.
• Description: active treatment that can be direct or indirect
• Indications
  • Muscle contracture
  • Lymphatic congestion
  • Muscle weakness
  • To increase the range of motion of a restricted joint
• Contraindications
  • Severe osteoporosis
  • Severe illness
  • Severe muscle strains
  • Fracture or severe joint instability
  • Unresponsive or uncooperative patient

Types

Postisometric relaxation

• Definition: : a direct muscle energy technique in which the patient contracts the affected muscle for 3–5 seconds in the direction of ease against equal counterforce applied by the physician
• Description
  • This isometric contraction causes a reflex relaxation of the affected muscle, which is followed by passive lengthening of the muscle by the physician.
  • The physician uses light force (approx. 10–20 lbs).
• Indication: : typically used to treat chronic somatic dysfunctions, especially those involving muscle hypertonicity and restricted joint range of motion
• Procedure
  • Position the joint to engage the restrictive barrier.
  • Ask the patient to move the joint in the direction of ease.
  • Apply an equal and opposite counterforce to induce an isometric contraction and hold for 3–5 seconds.
  • Relax for 5 seconds.
  • Position the joint to engage the new restrictive barrier and repeat.
  • Reassess.

Reciprocal inhibition

• Definition: : a direct or indirect muscle energy technique in which the antagonist muscles are contracted, causing reflexive relaxation of the agonist muscles
• Description
  • Direct or indirect active technique
  • The physician uses gentle force (< 1 lb).
• Indication: : typically used to treat acute somatic dysfunctions
• Procedure
  • Example: Contraction of the biceps is accompanied by antagonistic relaxation of the ipsilateral triceps.
  • Direct
    • Fully extend the elbow into the restrictive barrier.
    • The patient contracts their triceps against equal counterforce applied by the physician.
  • Indirect (rarely used)
    • Fully flex the elbow in the direction of ease.
    • The patient contracts their triceps against equal counterforce applied by the physician.

The stretch reflex stimulates a muscle while inhibiting the antagonist muscle via the muscle spindle.

Joint mobilization

• Definition: a muscle energy technique that utilizes the patient's voluntary muscle contraction to restore normal range of motion
• Description: The physician uses approx. 30–50 lbs of force.

Oculocephalogyric reflex

• Definition: a muscle energy technique that utilizes extraocular muscle contraction to reflexively affect the muscles of the neck and trunk
• Indications: severe, acute cervical and upper thoracic conditions
• Procedure: The patient turns their head toward (reciprocal inhibition effect) or away from the restriction (postisometric effect) while the physician applies gentle force.

Respiratory assistance

• Definition: a muscle energy technique that uses the patient's voluntary exaggerated breathing to restore normal motion
• Indications: inhalation rib dysfunctions and exhalation rib dysfunctions

Crossed extensor reflex

• Definition: a muscle energy technique used if direct manipulation of the extremities is not possible (e.g., due to fractures or burns).
• Description
  • Based on the principle that contracting a flexor muscle in the unaffected limb can induce relaxation in the flexor muscle and contraction of the extensor muscle in the affected limb
  • Example: Contracting the left biceps results in relaxation of the right biceps and contraction of the right triceps.

Description

• Technique
  • Direct or indirect
  • Active or passive
  • Loosens restricted musculature and fascia
• Types
  • Counterstrain
  • Facilitated positional release (FPR)
  • Balanced ligamentous tension (BLT)
  • Still technique
  • Cranial osteopathy
  • Direct fascial release
  • Functional fascial release
  • Unwinding
  • Visceral manipulations
  • Progressive inhibition of neuromuscular structures
• Procedure
  • Direct: Apply direct force to stretch the tissues.
    • Engage the tissues with pressure.
    • Move the tissues into the restrictive barrier and hold or engage in a rhythmic stretch.
  • Indirect: Apply indirect force to promote inherent tissue relaxation.
    • Engage the tissues with pressure.
    • Tissues are moved in the direction of ease and held until there is a release.
• Indications
  • Improve circulation and lymphatic drainage
  • Relieve edema
  • Improve range of motion
  • Relieve pain
  • Hospitalized patients with acute illness
  • Older individuals
• Contraindications
  • No absolute contraindications
  • Pain with treatment

Direct and indirect MFR techniques are often used in combination to achieve maximum release.

Facilitated positional release (FPR)

• Definition: : an indirect, passive MFR technique in which the spine is placed in a neutral position and a facilitating force (e.g., compression) is applied while moving the dysfunctional region into its direction of ease
• Description
  • Modeled after the counterstrain technique
  • Uses a facilitating force (e.g., compression) to reduce the time needed for tissue release
• Indications: to reduce tissue tension and improve joint function in superficial musculature and deep intervertebral muscles
• Procedure
  1. Place the patient's spine in a neutral position.
  2. Apply a facilitating force (e.g., compression) while placing the dysfunctional region in the direction of ease.
  3. Hold for 3–5 seconds.
  4. Relax.
  5. Reassess.

The treatment sequence of FPR can be remembered as “neutral, compress, ease.”

Balanced ligamentous tension (BLT)

• Definition
  • An indirect, passive MFR technique that applies very light force (approx. 1–3 lbs) to balance tension in the affected ligaments across all planes of motion
  • Practiced by disengaging the articulatory point, exaggerating the initial position of injury (i.e., moving the joint further into its freedom of motion), and holding the position until a balance point (i.e., minimal ligamentous tension) is achieved
• Indications: : treat somatic dysfunctions and enhance musculoskeletal flexibility
• Procedure
  • Identify restriction in movement at a joint.
  • Apply a disengaging force to the joint (usually, compression or traction, if applicable).
  • Move the joint into its position of ease.
  • Hold the dysfunctional region in position until there is a release. The area of dysfunction should shift back to its physiological neutral.
  • Reassess.

Counterstrain

• Description: indirect, passive technique
• Indications: treat tender points
• For more information, see “Strain-counterstrain” article.

Still technique

• Definition: a passive MFR technique that combines direct and indirect approaches and involves the application of an axial force while engaging the restrictive barrier
• Description
  • Modeled after FPR technique
  • Allows for gentle movement of a joint back into its neutral position
• Procedure
  1. Move the dysfunctional region back to neutral position by placing the patient in the direction of ease.
  2. Apply an axial force (e.g., compression) and gently move the dysfunctional region to engage the restrictive barrier.
  3. Hold for 3–5 seconds.
  4. Relax.
  5. Reassess.

Progressive inhibition of neuromusculoskeletal structures (PINS)

• Definition: an MFR technique that involves the gradual application of inhibitory pressure to the most tender point (primary point) and the insertion site of the affected muscle (end point)
• Procedure
  1. Isolate and palpate the most tender point (primary point).
  2. Locate the insertion site of the affected muscle (end point).
  3. Apply inhibitory pressure to both points for ∼ 30 seconds.
  4. Locate the nearest point along the affected muscle that is more tender than the existing primary point. This is the new primary point.
  5. Repeat steps 3–5.
  6. Continue along the affected muscle until the end point is reached.

• Definition: : a direct, passive osteopathic manipulative treatment that involves the brief application of a rapid force over a short distance to move a joint past its restrictive barrier
• Procedure
  1. Position the joint to engage the restrictive barrier.
  2. Apply a high velocity, low amplitude thrust to move it past its restrictive barrier.
  3. Relax.
  4. Reassess joint mobility for symmetry.
• Contraindications
  • Absolute
    • Osteoporosis
    • Metastatic bone disease
    • Joint instability
    • Bone fractures
    • Osteomyelitis
    • Joint ankylosis
    • Traumatic muscle contracture
    • Vertebrobasilar insufficiency
  • Relative
    • Pregnancy
    • Postsurgical conditions
    • Osteoarthritis with moderate loss of motion
    • Mild to moderate strain in the area
    • Mild to moderate herniated nucleus pulposus with radiculopathy
    • Patients on anticoagulation therapy

• Definition: a direct passive, osteopathic manipulative technique that uses either gentle rhythmic motions or concentric repetitive movements to increase the range of motion of a restricted joint
• Types
  • Rib raising
  • Spencer technique
  • Thoracic lymphatic pump
• Description: Typically performed before muscle energy
• Indications
  • Children and adolescents
  • Older individuals
  • Postoperative patients
• For more information, see “Lymphatic techniques.”

Spinal facilitation (osteopathy)

• Definition: a state of partial excitation in a pool of spinal neurons (due to recurrent stimulation or irritation) leading to a lower threshold for firing
• Characteristics
  • Less afferent stimulation is required to stimulate the nerve.
  • Higher resting membrane potential
  • Hyperexcitable neural state
• Description
  • Persistent hyperexcitation of the spinal segment can lead to hypertonicity of the associated structures and abnormal pain responses (allodynia, hyperalgesia, and hyperpathia).
  • Facilitation may also lead to referred pain.
    • Visceral afferent sensory fibers coincide with preganglionic sympathetic somatic nerves on the same spinal segment.
    • Example: In myocardial infarction, the sensory afferents from the heart and sympathetic preganglionic somatic nerves to the chest and arm arise from T1–T4.
  • Often seen in somatic dysfunctions

Reflexes

• Somatic structures and visceral organs are interrelated, and reflex interactions occur between them.
  • Viscerosomatic reflex: a somatic response to localized visceral stimuli (e.g., irritation) that can manifest as a somatic dysfunction or imbalance of the sympathetic or parasympathetic nervous system (e.g., myocardial infarction causing left-sided arm and jaw pain)
  • Somatovisceral reflex: a visceral response to localized somatic stimuli that can manifest with altered function of visceral organs (e.g., tissue injury at T2 worsening preexisting lung conditions)
  • Viscerovisceral reflex: a visceral pathology that causes a visceral response (e.g., gastric distention increases lower GI motility)
  • Somatosomatic reflex: a somatic pathology (or stimuli) that causes a somatic response (e.g., torn biceps muscle causes pain in the arm)
• In these reflexes, the original stimuli can either have an excitatory or inhibitory influence on the corresponding structure.
• Observation of these reflexes is an important diagnostic tool that can guide targeted manipulative techniques.

Overview of autonomic levels

For more information, see “Autonomic nervous system overview” in "Autonomic nervous system."

Zink patterns

Common compensatory pattern

• Definition: : the alternating pattern of preferred directions of fascial rotation at four transitional areas of the spine, observed in approx. 80% of individuals without an underlying condition
• Occipitoatlantal (OA) junction: : rotated left
• Cervicothoracic junction: : rotated right
• Thoracolumbar junction: : rotated left
• Lumbosacral junction: : rotated right

Uncommon compensatory pattern

• Definition: the alternating pattern opposite to the common compensatory pattern, observed in approx. 20% of individuals without an underlying condition
• Occipitoatlantal (OA) junction: rotated right
• Cervicothoracic junction: rotated left
• Thoracolumbar junction: rotated right
• Lumbosacral junction: rotated left

Uncompensated pattern

• Definition: the absence of an alternating pattern of preferred directions of fascial rotation of the spine, mainly observed in individuals with somatic dysfunctions and/or recent stress or trauma

Description

• First described by Travell and Simons
• Hypersensitive, painful taut bands found within skeletal musculature that give rise to characteristic patterns of referred pain when compressed
• Develop due to sensitization from constant direct stimuli (e.g., muscle strains) or visceral dysfunctions

Diagnostic criteria

• Palpation of a taut band within a muscle
• Pain at the site of the band when compressed
• Referred pain when the band is compressed
• The referred pain is reproducible and specific to certain muscles
• Local twitch response with palpation (not necessarily present in all trigger points)

Pathophysiology

• The underlying pathophysiology for referred pain patterns associated with trigger points is currently unknown.
• Trigger points are mediated by a reflex arc whereby:
  • An acute injury or strain, or chronic overuse or poor posture → overstretched muscle spindle → sensitized corresponding spinal interneurons → a taut band in the originating muscle fibers
  • Visceral dysfunctions → facilitation of the spinal cord → trigger point (e.g. as a viscero-somatic reflex)

Approach

• Myofascial release
• Spray and Stretch technique
• Trigger point injection with local anesthetic
• Dry needling