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OSTEOPATHY
A) BASIC PRINCIPLES
a) The unity of being
b) The body has in itself the means to fight
disease
c) The structure governs function and vice versa
d)
The rule of the artery
e) The importance of the musculoskeletal system
B) MAJOR CURRENTS OF CONTEMPORARY OSTEOPATHY
C) STRUCTURAL OSTEOPATHY
a) Neurophysiological Theory
b) What do we call osteopathic diagnosis?
c) What is the structural osteopathic treatment?
A) THE
BONE: BASIC PRINCIPLES
a) The unity of being
Dr
Still considers the whole person. For him one part of the body affected mean an imbalance in the harmony of the whole body.
Treatment should therefore apply to regain not only the function of the affected part but also balance the whole body. The
man being a whole, but also an element of all, Dr Still considered in its diagnosis and its treatment of the patient's
environment, including living conditions and hygiene.
b) The body has in itself
the means to fight disease
For Still, the body's natural tendency is a return to equilibrium. The body must have in it the means
to find this balance, supported by an environment and adequate food. If the tendency of the body is in balance, why do we
fall ill? Why at some point, the body does not react to the imbalance? What happened to its defence system? Treatment should
not directly attack the evil in question, but reactivate the functions of the body's defence?
c) The structure governs function and vice versa Dr Still wrote: "The structure governs function." But he added
that they were interdependent. A defect in one reflects in on another. What does he mean by structure? The term structure
applies to bones, muscles, ligaments, tendons, supporting tissues, organs and even cells. The
role of the structure corresponds to its function that is explained by the particular physiology. The structure of striated
muscle cell for example is related to its function which is essentially the movement. Indeed, it is a long and slender cell
(muscle cell of the sartorius muscle for example ranging from the ilium to the tibia). It has multiple nuclei and structures
that are highly specific, the myofibrils.These myofibrils play a role in the contraction of striated muscle cell and thus
its primary function is movement.Striated muscle cell is also involved in the production of heat. In fact, during
its contraction it transforms its chemical potential energy into mechanical work producing much heat.
Given the large number of striated muscle cells in the body, they produce so much heat from the body and
are involved in maintaining the homeostasis of body temperature. One could cite the same way other body structures in relation
to their function.
d) The rule of the artery
"The rule of the artery is
supreme" (Still).
Dr Still thought the blood was able to produce substances
needed to maintain natural immunity against disease. Remember once again to underscore its merit, at that time very little
was known about immunity and physiological functions of blood. The circulatory system (blood and lymph) is distributing in
all territories of the human body, as well as the nervous system, the integrity of these systems was for Dr. Still a prerequisite
to good health.
e) The importance of the musculoskeletal system
This system is called the "Neuro
Musculo Skeletal System. Why this structure is so important for a healthy body? This system is more than a frame, it allows
movement, so life. It is also the system of our body the widest area. Its dysfunction can have an effect on the physiology
of the whole body. Striated muscles are the biggest consumers of energy and largest producers of waste.
Life is not only related to the function of our bodies. We could not live
solely in digesting, secreting, breathing, etc.We run, we walk, we eat, we write,
we build, etc. Everything we do is expressed by our "Neuro-musculoskeletal. In 1959, Dr. BD Wyke, a great English
neurologist, said: "It is through movement that man has developed a social life. His muscles are the instrument by which
he communicates his thoughts and feelings to his neighbour.”And he adds:
"It is through the neuro-musculo-skeletal system that the brain expresses its activity and personality. The brain uses
as tools striated muscles of millions of receivers equipped to understand and explore the world outside." For this reason,
the great American physiologist, Dr. Irvin Korr, consider the skeleton, the muscles that move and the nerves that control
them as: "the primary machinery of life" (Korr, 1970).Primary must be taken in this context,
the fundamental meaning. He calls the other systems: "the secondary machinery of life"-because their role is mainly
to feed and serve the neuro-musculo-skeletal system allowing us to adapt to our environment and live normally.
In summery, osteopathy is a diagnostic and therapeutic system based on the quality of movement in the body,
whose treatment is exclusively manual, considering the whole person in his or her environment.
It
deals firstly some acute or chronic conditions of the neuro-musculo-skeletal, but also those of the individual state, situated
between the normal and pathological states which we call "subnormal." In this it joins the concepts of "functional
medicine, medicine field of Claude Bernard, and preventive medicine.
B) MAJOR CURRENTS
OF CONTEMPORARY OSTEOPATHY
Osteopathy has evolved considerably since its founding
by Dr. Still, in 1874. Although the basic concepts mentioned previously remain the foundation, the manipulative techniques
of treatment have greatly evolved and have mostly been codified in a more rational fashion. On the other hand, new trends
have emerged, including osteopathy craniosacral developed by William Garner Sutherland, who was himself
a student of Dr. Still early in the century.
Thus, osteopathy contemporary consists
of three main lines and the rest can be complementary:
- Structural osteopathy;
- Osteopathy craniosacral;
- Visceral osteopathy.
C) STRUCTURAL OSTEOPATHY
a) Neurophysiological Theory.
Structural Osteopathy today is the continuation of osteopathy original performed by Dr. Still.
It seeks to manually
process certain chronic or acute conditions in the neuro musculoskeletal system. We hear use sub-normal, the state located
between the boundaries of normal and pathological boundaries.
We have seen, the neuro-musculo-skeletal for Dr.
Irvin Korr: "the primary machinery of life". All other systems in its service.
The purpose of this system
vary between moments. For example, when we sit and then suddenly we wake up and we run to take a bus. Our metabolism speeds
up, the heart, lungs, muscles and glands increase their activity. All these changes are controlled at every turn by the autonomic
system whose centers are located in the spinal cord, brainstem and brain. At different spinal segments, the fibres of this
system emerge through foramina of the spine prior to distribution to various organs. On their way, they rub the different
structures of the intervertebral joint (meninges, disc, capsule, ligaments, articular processes, costo-vertebral joints).
According to Professor Irvin Korr, an injury to one of these structures in relation to nerve fibres, can cause a reflex
reaction locally or remotely causing not only discomfort or pain, but also changes in the activity of autonomic nervous system
and thereby changes in the organs it innervates. This affects not only the fibres of the autonomic nervous system, but also
all other fibres (sensory and motor) of the spinal segment involved. Through the pair of spinal nerves that emerges is ultimately
an entire metamere who will be affected (dermatome viscerotome, sclerotome, myotome). Writes to this subject, Professor Irvin
Korr in his theory of segmental facilitation:
1. Normally, the efferent neurons do not discharge in response to
every impulse that stimulates them. A neuron efferent discharge, if not its membrane potential was brought to a sub-threshold
value by other afferents that articulate with him. In other words, it must be facilitated prior to discharge. This need represents
a kind of "insulation" to our nervous system. "
2. "In the medullar segment in injury, this"
insulation "no longer works. A large number of efferent neurons are kept near their unloading is facilitated even at
rest by a bombardment from related chronic metameric structures in connection with neurons: dermatome viscerotome, sclerotome,
myotome "
3. "The proprioceptors are, undoubtedly, an important source of such afferents, but any structure
can be metameric origin. An organ pathology, trigger point, or any other structure may be inflamed or irritated a chronic
source of afferents to the spinal and be responsible for facilitating a more or less tonic (a trigger point is a point of
tension. Its tenderness is very useful for the diagnostic and therapeutic ) "
4 "Any influx of additional
quota can bring these facilities to unload efferent neurons, the origin of these impulses is the cerebral cortex, the center
of balance and posture, the bulbar centers, the skin receptors or more. If this bombing is related sufficiently large and
persistent, neurons facilities and the organs they innervate can be continually lying in state of excessive activity.
5 "The state of facilitation can extend to all the neurons and their cell bodies in the spinal segment that innervates
the joint, lesion, which includes the anterior horn cells, the pre-ganglionic fibres of the nervous sympathetic system.
6. "Given that a structural disorder (an osteopathic lesion) sensitizes spinal segment to influx from all sources
quoted above, the lesion in spinal segment should not be considered a center of irritation, but rather as a lens which converge
to irritations. Since the barriers of "insulation" is impaired in the lesion segment, any excitation is channelled
to the motor nerve pathways that start from this segment. A stream of air, a slight shock, lead to response, preferably at
the segment level facilities, and thus pain, cramp or a skin reaction in tissues innervated by these segments. "
"We can therefore conclude that osteopathic lesion corresponds to a spinal segment facility, maintained in this state
by 'the influx of endogenous origin which reach the medulla, the dorsal root corresponding structures that are under the
control fibres efferent this segment are potentially exposed to an excitation or inhibition excessive. " (Korr, 1947,
1976, 1978).
And Professor Irvin Korr also adds: "If one accepts the importance of proprioceptors in the mechanism
of the osteopathic lesion, do not neglect the fact that any metameric structure compared with the affected spinal segment,
can the same way, create or maintain a state lesion. In fact, any source of afferents, whether related or not metameric, can
exert influence through the network of neurons of association. "
"It is therefore very important to remember
that the efferent neurons represent final common pathways, these pathways · are themselves the culmination of a lot
of influx of all kinds in addition to the influx from the Musculoskeletal. Therefore we can deduce that the disorders or joint-related
injuries, osteopathic, cannot be considered an ultimate cause of disease; rather, they represent one of many causal factors
that operate simultaneously in the establishment of a pathological process. "In fact, one wonders if there ever was one
cause for every effect, and if ever there was a causal factor for any single clinical entity. Each factor is acting in the
context of many other factors and causes certain effects only in a combination of factors. The osteopathic lesion is one of
the most important factors. It is a sensitizing factor, predisposing, locating and channeling. The osteopathic lesion sensitizes
a segment of the spinal cord weakens its protective barriers and facilitates. It does not necessarily cause symptoms, and
even when it is silent on the symptomatic level, one can discover it. This is not to downplay the osteopathic lesion, rather,
is to broaden the concept. First, it proves that the osteopathic diagnosis and therapy can contribute to preventive medicine.
"
Thus, for example, increased activity of a receptor due to nerve irritation in his one element of the articular
segment is transmitted to corresponding spinal segment. If the initial irritation persists, the spinal segment will permanently
biased. Corresponding efferent neurons, even at rest will be bombarded by afferent impulses. Their response threshold lowered,
these neurons will therefore be facilitated. Any additional information bring these effector neurons to discharge, now the
different areas of their corresponding metamere excessive activity.
Information thus flows from the receiver to
spinal segment, segment medullary metamere and thereby the initial receiver. It therefore creates a system of feedback, a
real "loop overstimulation." Thus, pain or discomfort felt by the functional segmental patient muscle indurated
cords or reductions in mobility of a vertebral segment relative to the segments above and underlying palpated by the osteopath,
are somehow the result of this facilitation segmental these structures now in a state sub-normal excitation.
This
theory is attractive and could partly explain the results obtained by osteopaths. It is the result of long years of studies
on scientific grounds by Professor Irvin Korr and his team.
Can it shed light on the action of manual therapy?
Here again what we said about Professor Irvin Korr: "Here we can only guess, but at least our estimates are based on
sound assumptions and demonstrated experimentally"
"The methods that osteopathic manipulative apply,
generally intended to muscles remained in a permanent state of contraction, unable to relax spontaneously even if the stimulus
is removed (state of contracture)."
"A relaxation of these muscles leads to a passive increase in the
length of their fibres, which implies a reduction in the tension on the muscle proprioceptors and tendons, reducing the voltage
reduces the number of impulses sent to the spinal by receivers and therefore the level of facilitation spinal segment in question.
Since excessive tension of muscles and tendons, eg due to some bone displacement, tends to produce more power handling by
reducing the overall voltage.
'Another vicious circle can occur that can be broken by manual therapy: we said
that the facilitation of a spinal segment included the facilitation of sympathetic pathways. This facilitation of sympathetic
pathways can lead to a state of sympathicotonia likely to cause visceral disease. The latter, once constituted, will behave
as an additional source of bombardment to the segment facility, aggravating the injury somatic, which in turn will lead to
more intense irritation of the organ. The relaxation of muscles by handling can break this vicious cycle by decreasing the
firing rate of proprioceptors. Even if the irritation cannot be removed except for a short time, the action of natural healing
process it is still favoured. "
"Thanks to a rebalancing of the skeleton and manipulative with a readjustment
of posture, the original cause of stress, that is to say excessive tension of muscles, tendons and ligaments, can be eliminated,
making it more sustainable results ".
"This is undoubtedly a very simplified version of the fundamental
consequences of manipulation, but it can serve as hypothesis and a guide for further experimental research."
In other words, when osteopath restores the mobility of a joint segment of the spine (mobility being a very relative concept),
it would have a dual action of local and remote. Such manual processing lavished at the right time and properly, may prevent
further deterioration and greater evils since break the vicious circle of this loop facilitator who keeps the local structures
and distance in a state of sub-normal excitement.
In conclusion, this neurophysiological theory of segmental facilitation,
is now accepted by all schools of osteopathic structural, including the BSO. It also helps to give a scientific explanation
to the notion of states "subnormal" resulting from this continuous overstimulation may eventually become either
degenerate and pathological, is being standardized by the hands of the osteopath.
b) What do we call a osteopathic
diagnosis?
It is a vast subject that is the foundation of any osteopathic treatment and it is difficult to treat
in a few lines. To talk, I will refer mainly to the writings of Miss Audrey Smith, especially her book titled "Osteopathic
Diagnosis."
Miss Audrey Smith, whom I had the chance to meet, is a great personality of osteopathy English
past thirty years. She has developed in the mid 50 in England, diagnosis and treatment by soft tissue (soft tissue). The term
applies to soft tissue, muscle fascia, tendons, capsules, ligaments and other soft tissues of the body. We saw one of the
major principles of osteopathy is the unity of being. In other words, osteopathy does not treat a disease, but a whole person.
The diagnosis is the same approach.
Say for example that the scope of osteopathic medicine intersects
with that of orthopedic developed in England by Cyriax and his pupil Troisier in France, this is true but limits the osteopathic
concept. This does not mean that osteopathy should not know the ontology. Quite the contrary, it must have a strong medical
background and be capable of differential diagnoses in order to further eliminate the disease outside its scope, indicating
any manual therapy.
But as Miss Audrey Smith said: "Although knowledge and use of osteopathic diagnosis and medical
terminology, all of its review is not at first to label a particular syndrome, but rather to establish all the structural
and functional changes that led a particular body part to suffer. " And she also added: "The osteopathic diagnosis
is a process of identification of structural disturbances of the body associated with their functional disturbances, now subnormal
activity in tissues and eventually leads to their degeneration. In this, Miss Smith joined Professor Irvin Korr on his theory
of segmental facilitation (the Facilitated spinal segment), cited above. This theory greatly expands the scope of structural
osteopathy, because through the metamere involved in facilitating segmental, it is not only the muscles, tendons, ligaments
and joints that are affected, but also all other tissue corresponding to metamere. We thus find once again one of the basic
principles of osteopathy which defines the structure at large as being a bone, muscle, ligament, but also by extension, an
organ or a cell itself. On the other hand, this theory sheds light on another better principle of osteopathy, which is the
unity of being. The states which we speak subnormal tissue Miss Smith and Prof. Irvin Korr, are in fact, what some call the
"osteopathic lesion". It is palpable for hands knowledgeable, and reducible by manual techniques. There is great
confusion about the concept of "injury osteopathy."
Miss Smith told us about it: "The concept of
vertebral sublimation or displacement is wrong. What we call a spinal injury in flexion for example, is
the result of muscular spasm which, if it continues, will turn into a permanent contracture now the vertebra in the direction
of bending, but always within the physiological limits of the joint. "treat this lesion by manipulation in flexion extension,
cannot drown the muscle and therefore increase their suffering, prompting him to return to its original position or even aggravating
the injury .
In fact what's going on?
We are back once more to the neurophysiological theory of Professor
Irvin Korr. Achieving one of the innervated segment vertebral joints, capsular ligaments stretching, irritation or degeneration
of the posterior portion of the annulus, for example, causes a reflex response involving all metamere which if it continues
will lead this change in tissue consistency that some call the "osteopathic lesion". As appropriate, this reflex
reaction thus maintains the particular segment in the direction of flexion, extension, rotation or lateral flexion, giving
the impression of movement.
This "osteopathic lesion" can remain silent.
When it speaks, it
causes discomfort or pain acute, or chronic, resulting in restriction of movement in the segment. It ss
indeed the main reason for consultation, having discomfort or pain during movement.
The osteopath is trained to
observe but also to feel, writes again Miss Smith's "Osteopathic Diagnosis". "The osteopath must develop
his/her observation and palpation of soft tissues. He/she must be able to recognize any changes in their condition. He/she
must be able to assess the quality of a segment that it is controlled by soft tissue atrophy, hypotonic, normal, hypertonic
spasms, contractures, etc."
We note once again the importance of soft tissue in structural osteopathy. They
are the main guide to the osteopath.
Particularly innervated, they provide information in accordance with changes
in their surface texture, on changes in deeper structures of the body. Through them, the neuro-musculo-skeletal system is
a real book that osteopathic see’s with his/her eyes and feel with his/her hands.
The exercise is difficult
and requires a good knowledge of medicine, the disruption of the neuromusculoskeletal system may hide the disease from another
system, the practitioner must know the differential diagnosis. And back pain may be due to a disc problem or capsular ligament,
but may also reveal ankylosing spondylitis, a bone tumor or Pott's disease. We know some other pain radiating to the original
bladder shoulder or shoulder blade straight and some radiating pain of pancreatic origin in the back. Be wary of even some
atypical chest pain (intercostal or back) may be related to coronary artery disease or lung cancer.
On the other
hand, an "osteopathic lesion" may be locally remain silent but speak in other remote parts of the body. It will
be said in this case a primary lesion led to remote secondary lesions. The role of the osteopath, will find the silent primary
lesion and normalization.
Shoulder pain for example, may be due either a local problem of tendinitis of the supraspinatus,
a chronic sub acromial bursitis or pathology microtrauma of acromioclavicular joint, or a restriction of mobility lower cervical
intervertebral segment (C5 C6) or upper back (D2 D3). The two problems, locally and remotely, can of course coexist.
Joining the above, what the English call "The referred pain" is an important component of osteopathic structural
diagnosis. It is an atypical pain of neurological origin which is not really rooted in its expression, but which is within
the territories innervated by the nerve root. That's the difference between on the one hand, the sciatic nerve root pain
with his true characteristic.
Indeed, the muscle that goes from the front of the sacrum to the upper end of the
femur, is innervated by branches from the sacral plexus. The pain in the buttocks, may radiate to the posterior
thigh and possibly in the calf or foot. The sign of SLR is negative and neurologic examination was otherwise normal.
Techniques generally known as "inhibition" relax the muscle and thus act on the pain, and it disappears.
To complete this diagnostic approach in osteopathy, structural remains sadly incomplete as there are still a lot to say,
note that if palpation is an essential part of diagnosis, it must be accompanied by careful observation and a precise examination.
In fact palpation should punctuate every time of clinical examination as a thread. Finally, if necessary, the osteopath can
help with exams, additional (CBC, ESR, radios, etc ...) to confirm the diagnosis.
In total we can say the osteopathic
structural diagnosis:
- It is different in its approach to conventional medical diagnosis.
- It is mainly based
on palpation and observation of changes in tissue (soft tissue) and the quality movement in the body.
- There is no movement
regarding the spine. The spinal segment is attached by a knee-jerk reaction due to a disturbance of one aspect of this complex
segment (capsule, ligament, muscle, disc). Thus this segment is set in the direction of flexion, extension, rotation or lateral
flexion, but still within the physiology of articular segment.
- The concept of fixation reflex is valid for any segment
of the joints in the body.
- It is very well explained in the vertebral theory of segmental facilitation of Professor
Irvin Korr.
- This theory expands the scope of structural osteopathy because an entire metamere which is involved in
facilitating segmental (dermatome, myotome, cisclerotome, sclerotome).
- Facilitating segmental gives a good explanation
of most states subnormal tissue commonly called "osteopathic lesions".
- The osteopath is trained to feel the
subnormal tissue and normalize them before they escalate.
c) What is the structural osteopathic treatment?
The treatment is to relieve pain and restore the quality of movement in the body. For this, the practitioner uses
a variety of manual techniques including not only the manipulations themselves, but also techniques of joint mobilization,
soft tissue techniques, muscle energy techniques, effleurage, etc. ....
- The manipulations are not of course never
done with force.
They mainly use techniques leverage (short, long and compound leverage) softer than direct techniques.
Thus, the osteopath who first diagnosed the process, will put a pressure, this pressure should not cause
pain. It is, we repeat, a movement of high velocity and low amplitude. As for the crack it simply means that the degree of
mobilization was sufficient to overcome resistance and allow a sharp separation of joint surfaces. It is by no means evidence
of successful treatment, it is that evidence of manipulation. Indeed, any trained therapist is able to crack any joint structure
of the human body, even if it requires no treatment. And without going so far, any newcomer is able to crack his fingers.
Manipulation therefore has value only if an accurate diagnosis is focused in advance on the articular segment to treat because
of osteopathy as medical therapy is nothing without the diagnosis.
- Joint mobilization techniques, as these manipulations,
also use tension. But, once the power is obtained, the therapist releases the pressure slowly and leaves the articular segment
back to its resting position. Then he starts again the same movement. It will do so several sets of joint mobilization. These
gentle techniques, allow the repetition of their movements, increase range of motion of a segment. - The soft
tissue, therapeutic techniques are both superficial and deep planes. Given their role in osteopathic diagnosis, they have
an important part in the first treatment. They can be used either before or after handling or independently handling.
Dr. Paul Elie Cohen, "Report of an internship in Internal Medicine General (IMG) at the British School of Osteopathy
(BSO)" - UNIVERSITE PIERRE ET MARIE CURIE (PARIS 6) - Faculty of Medicine Pitie-Salpetriere, 1989. pp 24-53
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