John Martin Littlejohn - Triangles of Force Made simple

THIS ARTICLE IS A WORK IN PROGRESS - IT WILL BE FINISHED IN THE COMING WEEKS

John Martin Littlejohn developed a theory on the mechanics of the spine and in the 1985 Yearbook of the Maidstone College of Osteopathy John Wernham explains the theory. This article is not meant as a substitute for the original text. The original contains a more detailed explanation of the theory and also provides very useful diagrams. I have tried to simplify the article which can be complicated and confusing as a springboard for others to go and return to the original.


Anterior- Posterior and Posterior-Anterior Gravity Lines:

John Wernham, for the sake of this study divides the "body" in to 2 parts - the vertebral column and the pelvis and finds the centre of gravity within them. To find the centre of gravity he draws 2 lines – the anterior-posterior gravity line and the posterior-anterior gravity line.

Anterior-Posterior Gravity line:
The anterior- posterior line is a line drawn from the upper to the lower limits of the body; that is, from the anterior margin of the foramen magnum to the end point of the coccyx. On its journey it crosses the posterior junction of L4/L5 and the body of S1 to get to the point of the coccyx.

Posterior Anterior Gravity line:
The second line is drawn from the posterior margin of the foramen margnum to the anterior most part of the spine – L2/L3 at which point the line splits to both femoral articulation in the acetabulae.

For reasons that are explained in the original article, the resultant ( a term used in physics) of these two lines passes through the body of L3 vertebrae and it marks the centre of gravity. The importance of this is that it means that the entire body above is supported on L3 and the remainder of the body is supported from L3. Therefore in standing or walking all movement passes through L3 and it is therefore it is most vulnerable to lesion.

The anterior-posterior line, which begins at the anterior foramen magnum and ends at the coccyx, is the foundation of spinal movement. The line crosses D11 and D12 which is the central point of the line. Therefore D11 and D12 are of great importance in lateral curvatures of the spine, postural conditions and of blood circulatory conditions involving the blood supply to the abdomen. Whilst being the strongest vertebra in the column D11 and D12 also have the weakest mechanical rib position as they are floating ribs.

As was mentioned earlier, the posterior-anterior line is a line of pressure (complimentary to the atlas-coccyx line) that begins at the posterior margin of the foramen magnum and splits at L2/L3 to both femoral acetabulae. It crosses rib 2 and D2 and therefore binds the occipito-atlantal joint with them (maintaining the integrity of the neck) and maintains the tension in the trunk and legs.

Some new tension lines – Anterior and Posterior Central Lines:

The anterior-posterior central line follows the same course as the anterior-posterior gravity lines. The anterior-posterior central line is balanced against the 2 posterior-anterior central lines that are drawn from the posterior margin of the posterior margin of the foramen magnum through the centre of the body D4 and on to the centre of femoral pressure on the acetabula. The anterior-posterior crosses posterior-anterior line in front of D4 and therefore form triangles above and below D4 and are associated with rib 3. Therefore, any torsion movements of the trunk tend to focus at the rib 3 and D3 and D4 (see original text for view of triangles).

Therefore, the articulation of the head sits on the base of the upper triangle (the foramen magnum) and is poised on the apex of the triangle (D4). Any alteration in the position of the triangle essentially is the alteration of the head in relation to the trunk and leads to strain at the apex of the triangle creating strain at D4 and rib 3 bilaterally. It is therefore logical to conclude that treatment of problems relating to headaches must include treatment of the base of the occiput and D4.

Low back pain during pregnancy - an osteopathic approach

As has been mentioned earlier posts (coccyx pain and gastric reflux) pregnancy puts a great demand on the body as the increased weight leads to mechanical changes in the body and especially the spine. Areas which the osteopath may be unfamiliar with addressing in patients that are not pregnant are the uterosacral ligaments. As pregnancy develops and the size of the uterus increases the uterosacral ligaments have to adjust and become taught. Due to their mechanical attachments to the sacrum and the sacrum's mechanical attachments, the coccyx, pubic symphysis lumber spine and sacrum, all have to adjust accordingly. In some cases the mother may not be able to adapt well due to mechanical restrictions elsewhere in the body and this can put excess strain on the uterosacral ligaments causing back pain. A method for the osteopath to determine the role of the uterosacral ligaments is to ask the mother to stand whilst the osteopath gently lifts and supports the uterus. If the mother describes a relief from pain and ease of movement then the osteopath can start to build up a diagnosis.

As the pregnancy develops the weight of the mother increases anteriorly, the pelvis rotates and lumber spine gets pulled into extension. Ideally the extension should occur throughout the lumber spine, however if the upper lumber spine does not adapt well and most of the extension occurs at the lumbo-sacral junction then most of the weight bearing will occur on one set of facet joints (zygo-apophyseal joints) that are not designed for such a task. Eventually the facet joints will become irritated and inflammation and muscle spasm will develop leading to pain. The osteopath, by improving the function of the other lumber vertebrae can help to spread the weight bearing load that is now required of the back. The osteopath must of course pay due attention to the illiolumber ligaments which will be under strain due to the nutation and counter-nutation of the sacrum throughout pregnancy.

Disc herniations are also common due to the increases leverage applied to the back due to the increase in anterior weight. This can obviously be most uncomfortable for the mother who has to adapt to the regular pregnancy-related changes. The osteopath can significantly aid the pregnant mother by applying techniques to help the body accommodate the physical changes in her body. Soft-tissue massage to the muscles of the spine, articulation to the appropriate areas – especially the junctional vertebra – dorso-lumber junction, cervical-dorsal junction and the lumber sacral junction. Regular osteopathic treatment in this fashion can be very helpful in allowing the mother to adapt to the changes and hopefully to stop pain occurring.

Spondylosis: Disease or Natural Response to Stress

Structural changes in the vertebrae may be considered as features which are related to disease. Changes which occur in the intervertebral disc are described as spondylosis. Changes in the facet joints are described as osteoarthritis.

When an osteopath examines an X-ray of a neck that has spondylosis the osteopath will notice osteophytes or bony spurs along the perimeter of the vertebral body i.e. at the junction between the two vertebral bodies and the disc. The osteopath could be forgiven for perceiving these osteophytic changes as part of an aggressive disease attacking the body, however, on closer examination the osteopath begins to understand that it is in fact part of the body's natural response to the mechanical stresses that are applied to the spine throughout life. In other words, it is an active purposeful process in the body, used to compensate for the natural, physiological changes occurring with age.

In a young healthy adult the vertebral disc in between each vertebrae adapts according to the stresses placed on the spine. It is able to do this due to its high water content. With age the disc loses water and hence flexibility – essentially it dries out, becomes less flexible and as a result the surrounding cartilage, the annulus, bears most of the weight.

Eventually, in cases of excess compression along the annulus, ossification starts to develop and can occur around the entire margin of a vertebral body. This can be viewed as if the vertebral body is trying to expand the surface area for articulation in order to distribute the load.

The osteopath must remember that spondylosis and osteoarthritis are not necessarily associated with pain; in fact spondylosis is just as common with people who have symptoms as those who do not have symptoms. Similarly, patients with pain may not have a single trace of spondylosis.

We could therefore conclude that there must be another cause for the pain in people with spondylosis and osteoarthritis and not necessarily the bony changes. As osteopaths this fact supports much of the work that we do. Osteopathy claims to help the body accommodate to changes. Osteopaths are regularly asked whether they treat arthritis. Well, osteopaths don't so much as treat arthritis as they do the patient's whole body – helping it to compensate for any changes that may put stress on the soft tissues.

Colic - Osteopathic Approach

Colic is a common disorder in infants. It is defined as distress or crying in infants that lasts more than 3 hours a day, for more than 3 days a week for at least 3 weeks in an infant which is otherwise healthy.

Many infants "grow-out" of their colic after about 4 months of age but it is the infants whose discomfort continues beyond this period are the ones that often find their way into osteopathic clinics. Colic affects between 15-40 % of infants, a somewhat confusing statistic considering its wide range but 40 % being the more mild cases and 15 % the more severe cases.

Crying is a common criterion of colic and more likely to occur in the evenings with observation of discomfort, restlessness and flatulence. In an infant the digestive system is still immature and so gut motility and transit time is slow relative to an adult. This may lead to the production of intestinal gases and antigen build up causing discomfort and possible inflammation of the gut.

After the case history has been completed by the osteopath it is time for the physical examination. The osteopath may discover a feeling of tension in the soft tissues. Colic can be associated with a number of different causes.

Osteopathic theory suggests that one of the causes of colic in infants is difficulty during labor. The osteopathic theory is that compression at the base of the skull due to the pressure from passing through the birth canal may compress the bones of the cranium specifically the hypoglossal canal and jugular foramina. The central nervous system and its meningeal coverings are particularly sensitive to mechanical pressure. It is an interesting coincidence that colic often starts between the second and fourth week of life – just around the time of the beginning of the development of the voluntary control of the posterior cervical muscles. It is at this age that infants start to lift the head when placed in the prone position. Osteopaths believe that irritation of the vagal nerve, which exits the cranial base and supplies the gut may contribute to colic and the sudden engaging of the posterior cervical muscles of the neck may irritate an already susceptible vagal nerve.

As with most osteopathic treatments, the approach is to integrate the body. In addition to examining the cranial base, the osteopath will need to examine the musculo-skeletal system checking for tension in the rest of the body with a focus on the gut, thorax and the nerve supply of these areas. It is important that the osteopath considers the possibility that gastric reflux may be associated with colic. For this reason the osteopath must pay attention to the mechanics of the diaphragm and ribs (please see post on gastric reflux for more information).

Sinusitis - Rhinitis

In the skull there are 4 sinuses – the maxillary, ethmoid, frontal and sphenoid sinus. The sinuses are air-filled cavities which have a number of functions. The sinuses humidify/warm the air before it enters the lungs for gaseous exchange. They also have an immune function – the sinuses are lined with lymphoid tissue that produces large amounts of mucous to filter air by trapping bacteria and other unwanted material. The sinuses which are lined with cilia waft this unwanted material out of the sinuses and towards either the nasopharynx where it is swallowed or towards the nasal cavity where it is blown out.

Sinusitis is the inflammation of the mucous membranes that line the sinuses. In cases where the mucoid material drains poorly then there is a risk that infection will develop. Therefore, in order to reduce the chances of sinusitis the osteopath needs to improve drainage of the sinuses.

The osteopathic perspective is to address the problem mechanically. Osteopaths are interested in the anatomical relationships between the bones that make up the sinuses and the other structures around the face. The osteopath should start by observing facial relationships, looking for signs of squashed eyes, nose, cheeks and mouth. This may be more obvious in infants who may have had pressure through the face on exiting the birth canal. The osteopath should observe the relationship of the skull to the neck, throat, thorax and shoulders where compression and torsion may lead to compromised draining.

In addition to the direct anatomical relationships, the osteopath must address function the autonomic nervous system (parasympathetic and sympathetic nervous system) and its contribution to the function of the sinuses. The autonomic nervous system regulates the activity of the mucosa. The sympathetic nerve supply originates from C8-T2 and travels via the superior ganglion until it reaches the pterygopalatine ganglion which is lodged in the pterygopalatine fossa and which can be irritated following impingement of the palatine bone.

The parasympathetic nervous system has the function of enhancing secretion and has a vasodilatory effect on the mucosa of the sinuses. The parasympathetic nervous system travels via the facial nerve and eventually also arrive at the pterygopalatine ganglion.

It is normally possible for the osteopath to achieve a change in the function of the nasal mucosa within 5-7 treatments.

The osteopath should also explore the possibility that the sinusitis may be affected by diet and exposure to environmental irritants. Once all factors have been addressed the body is normally able to recover.

Carpal Tunnel Syndrome

Carpal tunnel syndrome results in a feeling of numbness and/or pain in the hands and arms caused by compression of the median nerve. It is more common post-pregnancy when hormonal changes may cause fluid retention in the arms.

Osteopathic examination of the patient:
During the case history the osteopath should try and discover the factors contributing to the problem. Posture at work or whilst feeding the baby may be putting pressure on the wrist, shoulders, ribs and neck all of which may reduce the bodies ability to drain the fluid back to the heart from the arm. Questions about the patient's endocrine function are important especially thyroid gland as many cases of hypothyroidism have been known to cause carpal tunnel syndrome.


The osteopath observes the patient standing paying attention to spinal curves, neck and shoulders looking for areas of compression or tension. Active movements will include movements of the neck, shoulder, elbow and wrists – again looking for areas of tension and reduced movement.

Check for goiter.

A full examination including neurological examination (reflexes, power and sensation) as well as checking the pulses.

The osteopath carefully palpates the ribs, cervical spine, pectoral girdle, clavicle, shoulder, elbow, wrist and fingers noting areas of tension.

Osteopathic treatment:

I prefer to work distally, beginning at the neck and shoulder girdle – releasing any soft-tissue tension around the cervical spine, ribs, pectoral girdle and shoulder. This is particularly important not just to relieve any brachial tension around the neck but drainage into the thoracic duct that may be compressed by the clavicle. The osteopath relieves tension distal to the area of pain in order to make room for the fluid to drain (see post on glue ear).

From the shoulder girdle the osteopath examines and treats the soft tissues of the arm, elbow and forearm. When the osteopath treats the wrist he aims to relieve restriction of the soft-tissues around the carpel bones, phalanges and the palmer aponeurosis. The osteopath should try and be gentle and accurate in this area and as usual, knowledge of the anatomy especially the nerves and the carpal bones is invaluable.

Finally the osteopath can introduce efflerrage in the direction away from the wrist to encourage a return of fluid to heart.

Gentle work to the throat, scalenes, oesophagus and hyoid bone to improve thyroid function can be included when appropriate.

The patient should be given advice on posture whilst breast-feeding or work environment to avoid flexing the wrist for too long and also reducing any local pressure on the wrist. The patient should be encouraged to have a blood test if hypothyroidism is suspected.

Radiculopathy and Radicular Pain - its relevance to the Osteopath

There is a subtle difference between radiculopathy and radicular pain and understanding the pathophysiology of both can help improve the osteopath's diagnosis, prognosis and treatment.

Radiculopathy is the term that describes the neurological state of blocked axon conduction in a nerve or a nerve root. If a sensory axon is blocked then it results in numbness. If a motor axon is blocked then it results in muscle weakness. A blocked axon normally occurs as a result of compression or ischemia of the affected axon. The most common causes of radiculopathy are vertical subluxation of a vertebrae and osteophytes from a disc.

The osteopath must realise that radiculopathy is a STATE OF NEUROLOGICAL LOSS and it does NOT cause pain neither in the back nor in the limbs.

If the osteopath finds that the patient describes pain as well as radiculopathy (neurological loss) then the osteopath should be aware that the mechanism of radiculopathy may not necessarily be the same as the mechanism of pain.

Radicular pain on the other hand is pain that arises out of IRRITATION of a spinal nerve or a nerve root.

So, at the risk of sounding repetitive:

Radiculopathy – neurological state (weakness or numbness) caused by conduction of the axon being blocked.

Radicular Pain – Pain caused by nerve irritation.

Radicular pain may or may not occur with radiculopathy.

Radicular pain is sharp and shooting in quality and it travels down the limb along a band of no more than 2 inches. This is different from somatic referred pain which is more constant in nature, poorly localised and aching. It is important that the osteopath be aware of the differences.

A good example of radicular pain is sciatica. Sciatica is caused by the irritation of the sciatic nerve or one of its roots. However the term sciatica should only be used to describe a case when the pain is indeed sharp, shooting and is of 2 inches in width down the leg. The osteopath should clearly make a distinction between this and somatic referred pain which, as mentioned above is broad, achey and poorly localised.

The single most common cause of radicular pain is a disc herniation. The pathophysiology of this is still unclear - whether the nerve irritation is caused by an autoimmune inflammatory response from the nucleus pulposis or from ischemia.

Thus the osteopath should use the above information to make a diagnosis and treatment plan. The osteopath must be direct in questioning and in examination of the patient in order to be able to distinguish between a state of neurological loss and between pain. Once the osteopath has distinguished between these he should further examine the parameters and quality of the pain to distinguish between radicular and somatic pain. This way his diagnosis will lean more towards foraminal stenosis - vertical subluxation of the vertebrae or osteophytes if radiculopathy is suspected and towards a disc herniation if radicular pain is suspected.

Piriformis Syndrome

I have treated at least 3 cases of piriformis syndrome in the past 18 months that had been misdiagnosed as disc-herniations and were due to have spinal surgery. The key to diagnosing piriformis syndrome is using a basic osteopathic tenant – listening to the patient.

The osteopaths questions need to be focused and gleaning of information. The basic osteopathic case-history questions are sufficient. The most revealing questions are; cause of onset and aggravating and relieving factors. Together with a good osteopathic active and passive examination the osteopath can save a patient from taking increased doses of medication, cortisone injections and at the very least the surgeon's knife.

A point that may be important to the new graduate of osteopathy is that indeed in each case that I saw with piriformis syndrome either a disc herniation was present on MRI or there was a case of disc thinning on X-ray. Whilst imaging has a vital use in today's medical world there is always the danger that it will be a sunbstitute for good case history. The osteopath must never rely on someone else's diagnosis.

The main diagnosis between which piriformis syndrome needs to be differentiated is sciatica caused by nerve root compression as both have similar symptoms of radiation down the back of the leg. In pirifomis syndrome the sciatic nerve is compressed by the piriformis muscle as the nerve passes through it on its journey into the leg.

My treatment plan is to first approach the problem globally. I start at the feet and work my way up the body to the cranium paying particular attention to the function of the sacro-illiac joints bilaterally and their relationship to the lumber spine, pelvis and surrounding muscles. Don't be afraid to give due attention to the neck, dorsal spine, ribs and dorso-lumbar junction. Remember that these all exert strong forces through the sacrum and pelvis and may call upon pirifomis to secure the stability of the area.

The osteopath can cause significant changes by applying sustained inhibition to the piriformis attachments either by the sacrum or the hip, with or without muscle-energy resisted movement. The osteopath must of course pay due care and attention not to aggravate the sciatic nerve further by watching the patient and using his ostoepathic palpatory skills.

Frozen Shoulder - Adhesive Capsulitis

Frozen shoulder can make an osteopath feel "disarmed" in terms of what treatment approach to take. However, a thorough knowledge of anatomy, a careful examination of the shoulder and reasonable expectations regarding prognosis are the key to helping the patient.

The diagnosis "Frozen shoulder" is often banded about as a diagnosis whenever there is shoulder limitation avoiding an accurate diagnosis. Much information is available on the internet for the diagnostic pointers of frozen shoulder but the most significant ones are reduced range of movement in external rotation, abduction, flexion and finally internal rotation in that order. Reduction in movement may not be associated with pain and there may not even have been a precipitating trauma.

Frozen shoulder is also known as adhesive capsulitis because the two surfaces of the capsule of the shoulder stick to one another. Instead of relying on the traditional diagnosis, for osteopaths it can be more helpful to develop a broader picture of the dysfunction of the shoulder and its associated joints and muscles and build a diagnostic story - whilst keeping the conventional diagnosis in mind.

The patient is observed standing and the relative positioning of both gleno-humeral joints is noted. The osteopath should analyse whether the problematic shoulder is retracted or protracted, superior or inferior relative to the healthy shoulder? Observation includes active movements - observing the ranges of movement in all direction and paying particular attention to the scapulothoracic rhythm - the relationship between movement of the scapula relative to the humerus.

Osteopaths emphasise the importance of the body's function as a unit and so osteopathic examination must extend to observation of the pelvis and of course beyond. At the risk of stating the obvious, the shoulder is attached to the dorsal spine via the dorsal erector spine and ribs, the dorsal spine sits on the lumber spine and the lumber spine rests on the sacral base which is firmly lodged in the pelvis. Furthermore, latisimus dorsi attaches from the pelvic rim onto the medial inferior border of the scapula and therefore the pelvis and spine must be examined and treated in order to treat the frozen shoulder comprehensively.

In my opinion, when treating frozen shoulder the osteopath approaches the treatment in 3 ways. Firstly, treatment of the local musculature of the shoulder to improve the scapulothoracic rhythm with special emphasis on teres minor. Next I like to work on the more distal areas; that is, treatment of the dorsal spine, lumber spine, neck, ribs and pelvis. Finally, once I feel I have prepared the body, I like to work directly into the capsule using a form of muscle-energy. I find this an especially affective technique assuming the patient is not so acute so as to be unable to tolerate it. With the patient side-lying and the osteopath standing at the head of the table the osteopath brings the patient's uppermost shoulder into flexion passively (sometimes the osteopath can add a little adduction by asking the patient to fully relax the shoulder – this increases the tension in the capsule and the arm drops towards the table slightly). At the end of range the osteopath asks the patient to try and bring the arm back to neutral (in the direction of extension in other words). The osteopath resists this movement until the osteopath requests that the patient gradually relax the shoulder (after about 5-10 seconds). The osteopath increases the stretch gently and repeats 2-3 times. The osteopath can apply this muscle-energy technique to any of the directions in which the patient is restricted.


The body's natural response to most shoulder injuries is for the surrounding muscles to contract in a protective manner. This is useful in terms of splinting the joint for protection but can interfere with the healing process by reducing the blood supply as the head of the humerus is pulled up into the glenoid fossa. Contraction of the rotator-cuff especially supraspinatus leads to the head of the humerus moving superiorly and buttressing the acromiom process of the scapula instead of sliding smoothly under it which can lead to further soft-tissue irritation. The osteopath should therefore encourage the head of the humerus to move inferiorly using techniques such as traction and distraction in concert with soft tissue massage to the rotator-cuff muscles. Any form of soft tissue contraction around the shoulder, clavicle, pectoral muscles and scapula may equally restrict lymphatic drainage from the shoulder into the thoracic duct as a result of compression between the clavicle and first rib, so due attention should be paid by the astute osteopath to these areas.

It is important for the osteopath explain 2 things from the outset. Firstly, frozen shoulder takes time, maybe even a few months but a better prognosis is expected than without treatment. Secondly, the patient may not see a change for the first 3-5 treatments and so should not be disheartened by this. It is worth using a gomiometer to show the patient the increased range of movement as the restricted shoulder is often forgotten once an improvement is achieved.

Glue Ear (Chronic Seromucinous Otitis)

Glue ear is a condition that worries many parents as it can lead to a temporary hearing loss in infants. It is a condition characterized by a build up of fluid in the middle ear which drains poorly.

The condition usually starts with an infection in the throat leading to an obstruction at the point where the nasopharynx meets the auditory canal. For the auditory canal to function efficiently it must be well ventilated. When poorly ventilated as in the case of obstruction caused by the infection, the cilia (the hairs that help drain fluid out of the ear) become paralysed and there is fluid build up. The fluid becomes increasingly thick and sticky – hence the name "glue-ear".

The osteopath must start by observing the infant – the face, the relationship of the mouth, nose and ears. Do they seem squashed together and is there anything in the case-history that may indicate trauma to this area during birth? The osteopath gently palpates the chest, upper ribs and neck as well as getting a comprehensive picture of the health of the tissues throughout the body. Whenever dealing with drainage the osteopath always begins by treating the more distal areas first in order to make a space in which to drain. There is little point in draining the auditory canal if the neck and chest are congested.

Once the osteopath has attended to restrictions in the hips, spine and chest, the osteopath gently approaches the neck observing any restrictions at the cranial base. The osteopath pays particular attention to the function of the temporal bone in which sits the auditory canal. The osteopath checks the relationship of the temporal bone to the frontal bone and the occiput. Gently the osteopath introduces a pumping action bilaterally to the glabella (frontal bone) and the mastoid process (temporal bone). The osteopath can also introduce a gentle springing action to the manubrium under which lies the thymus gland to stimulate the infant's immune system.

Remember that infants respond quicker than adults and one should be aware of over-treating. It is a gentle approach with a light but accurate touch.
"Find it, fix it and leave it alone"

Gastric Reflux / Heartburn

Gastric reflux is the regurgitation of the contents of the stomach back up into the oesophagus. All adults suffer with reflux to a degree but problems occur when the regurgitation becomes chronic and the oesophageal mucosa becomes inflamed. Normal physiology is for food to pass down through the oespohagus which punctures the diaphragm via the oesophageal aperture and enters the stomach. Pressure in the stomach exceeds pressure in the oesophagus so regurgitation would occur naturally were it not for the high pressure zone (HPZ) at the lower end of the oesophagus created by a lower eosophageal sphincter and contraction of the diaphragmatic crura.
The HPZ acts as a sphincter between the lower end of the oesophagus and the stomach. It is surrounded by the diaphragm muscle which helps to create this functional sphincter.

Osteopathic treatment of the gastric reflux must include the treatment of the diaphragm due to its close relationship with the oesophagus. There are local osteopathic techniques designed to stretch the diaphragm such as clasping the muscle underneath the costal margin and splaying the ribs. However, local muscular work to the diaphragm alone in an attempt to reduce symptoms will bear little success without observing global posture and tissue status throughout the body.

A comprehensive observation of the spinal curves is vital, with emphasis on thoraco-lumber junction and upper 2-3 lumber vertebra to which the diaphragmatic crura attach. Any restriction in movement of these vertebrae may be reflected in the crura. Since the body of the diaphragm can function independently of the crura dysfunction of the diaphragm is more perceptible in relation to its oesophageal relationship at the crura.

Quality of movement of the ribs especially the 11th and12th rib which is used by the diaphragm as a pivot on which to move provides information. The operator should apply gentle pressure to the lower ribs in order to see whether they are restricted in movement and if so in which direction. With the patient lying supine feel to see whether the 12th rib is raised off the table or not.

The xiphoid process is the diaphragm's anterior attachment. Any restriction in the function of the sternum may affect the diaphragm. Take for example poor abdominal tone resulting in the abdominal muscles dragging the sternum inferiorly and anteriorly further altering the diaphragm-rib cage relationship.

An osteopathic approach would be incomplete without examination of the cervical spine. The vagus nerve, which sits beneath the cranial base has the function of affecting gastric emptying time and acid secretion. Any irritation of the phrenic nerve at the level of C3, C4 and C5 could affect the function of the diaphragm which it innervates and receives sensory input.

Coccyx Pain

From time to time osteopaths are confronted with a case of coccygeal pain. A vestigial joint exists between the sacrum and the coccyx and it is at this location that strain can occur. Most commonly it exists after pregnancy after a difficult labour. However it can also occur after a fall on one's bottom.

During pregnancy the mother's body undergoes drastic changes in a very short period of time. Not only is there a sudden weight gain due to the increase of the weight of the foetus, amniotic fluid and breast tissue but there are drastic hormonal changes occurring to prepare the mother's body for the upcoming birth. Let us not ignore the emotional changes that must be taking place too and the effect on the body tissues of perhaps anxiety or depression.

As the weight changes so does the posture. There are a variety of changes that occur through the lumber spine with an initial increase in the lordosis followed by a flattening of the lumber spine as the foetus grows and pushes out the ribs.

To accommodate the changes in the lumber spine the pelvis has to change it relative position by rotating either anteriorly or posteriorly depending on the stage of the pregnancy. The result is an increased tension in the sacroiliac joints as they attempt to accommodate the changes in the spine, illium and increased weight from above. The alteration would of course not be complete without making mention of the changes that have to occur in the femoral joints.

All ligaments connected to these areas will be under significant strain and it is no surprise that the sacroiliac, ischiosaral and coxxgeal ligaments will take much of the brunt.

During labour, the head of the baby passes through the pelvis and slides along the sacrum and coccyx to make its exit. These ligaments come up against enormous pressure as the contractions of the uterus force the head of the baby up against them.