Why wry neck? An osteopathic assessment and treatment of torticollis

Children with infant torticollis present with a tilt of the head to one side and rotation of the chin in the opposite direction. There are various causes of childhood torticollis ranging from the least serious, functional torticollis to the more serious, structural torticollis. Both conditions usually involve the sternocleidomastoid muscle which has the function of flexing and rotating the neck.

Various theories have been proposed for each of these conditions. It has been suggested that functional torticollis occurs as aresult of an unusual lie in the uterus, weakening sternocleidomastoid and resulting in other changes such as a altered shape of the cranium. Structural scoliosis is a change in the structure of the sternocleidomastoid muscle either due to a congenital shortening of the muscle or due to a fibrosis of the muscle belly due to the trauma of birth.

Tension in the sternocleidomastoid muscle may affect the structures to which it attaches; the occiput, the mastoid process, the cervical spine, the clavicle and the sternum. Left untreated there is the danger that the tension will result in asymmetry of the neck, basocranium and viscerocranium as the body continues to grow. Using knowledge of applied anatomy, osteopaths are able to relieve tension in and around the sternoceidomastoid.

The osteopath should begin by observing the position of the infant and how the child tends to hold the head observing which side the infant favours and where in the cervical spine the most torque occurs. Observation by the osteopath includes assessing the shape of the cranium to see whether tension in the sternocleidomastoid has effected the symmetry of the bones. Particular attention should be paid by the osteopath to the occiput to which the sternocleidomastoid attaches. observing any changes to the shape of the bone and its articulation.

All possible somatic dysfunction should be explored by the osteopath but specifically the upper dorsal spine, upper ribs, scapulae, pectoral muscles, clavicles and sternum. Sutherland felt that the osteopath must consider cranial nerve XI, the accessory nerve, for possible entrapment neuropathy due to its passage through the jugular foramen and the jugular foramen's close association with the sternocleidomastoid muscle.

Once the osteopath has made an evaluation of the infant, both direct and indirect osteopathic techniques can be applied. Needless to say these techniques are gentle and specific. Direct techniques in the form of gentle articulation to the cervical spine as well as sub-occipital inhibition to "disengage" the occipito-atlantal joint. Gentle springing using the thumbs and finger tips can be applied to the upper ribs and pectoral region releasing the upper ribs, pectoral muscles. With the child's anterior held against the shoulder of the parent, the osteopath can apply gentle pressure with the thenar emmenence to the exposed vertebrae articulating them into extension to reduce restriction in the spine, sacrum and hips.

Indirectly, the osteopath can use cranial techniques applied to the occiput and temporal bones with special attention to the quality of movement of the occipitomastoid suture which may be restricted due to its close association with the sternocleidomastoid muscle. Additionally the osteopath should evaluate the quality of the membranes in the upper thorax, mediastinum and gut, assessing facial strains occurring from the neck and causing strains distally.

Scoliosis - A living curve - an osteopathic approach

To give a prescriptive list of areas to treat when faced with a patient with scoliosis is to do an injustice to both osteopathy and the scoliosis. After all, a scoliosis is a general term for a lateral curvature of the spine but a variety of scolioses exist, all of which have unique characteristics that are necessary for the osteopath to consider when assessing, diagnosing and treating.

Idiopathic scoliosis is a scoliosis that has no known pathological cause. Of all the scolioses it is the most worrisome due to its potential compression of the viscera; the lungs and pericardium. The scoliosis begins normally during childhood or adolescence and stops once spinal growth ceases. The scoliosis can be either thoracic, thoraco-lumbar or lumber. It is normally thoracic and is identified by the involvement of the ribs which which produce a so-called "high-side", a phenomena in which the ribs are thrust backwards on the side of the convexity.

Compensatory scoliosis is one where there is nothing intrinsically wrong with the spine per se but rather external forces affect the spine, such as a tilted pelvis from shortened adductor or abductor muscles, a leg-length difference or a fixed abduction or adduction deformity of the hip. Usually, once the cause has been removed, the scoliosis dissappears unless the scoliosis has been left untreated for many years and resulted in tissue shortening around the spine.

Secondary scoliosis is normally secondary to an underlying pathology such as poliomyelitis or cerebral palsy where unequal muscular contracture as a result of the pathology results in extreme angulation of the spine.

Sciatic scoliosis is a temporary form of scoliosis which is normally a person's attempt to protect oneself by reducing pressure on an irritated nerve. Once the acute phase is over the scoliosis normally disappears.

Examination guide for the osteopath:

The osteopathic examination should focus on assessing the movement of the axial skeleton. The osteopath should try and determine to what extent the axial skeleton, that is, the sacrum, the spine, the ribs, the sternum and the cranium are being dragged away from the mid line. The osteopath needs to examine these areas both passively and actively in order to assess which of these areas show most restriction of mobility. It is often the case that the thoraco-lumber area and the cervico-occipital junction display most restriction.

Once the osteopath has observed the axial skeleton, the peripheral areas should be observed. For example, observation of the foot-arches, knees, hips, the pectoral girdles. Osteopathic examination should involve comparing the shoulders and the pelvic girdles, assessing inequality. The osteopath should be aware of the Adam's test, a test which involves flexing the spine forward as if to touch the toes. This test exaggerates the high-side and shows the extent of the scoliosis.

Factors for the osteopath to consider:

The pelvis - The osteopaths needs to observe the pelvis for tilting. A tilted pelvis will result in a lateral curvature of the lumber spine. Therefore the osteopath needs to decide what is causing the imbalance in the pelvis and if necessary to treat the muscles that connect to the pelvis such as the hip adductors and abductors. Similarly the osteopath should check for a leg-length difference.

Pelvic and Shoulder girdles - The osteopath can develop a good understanding of how the body is adapting to the scoliosis by observing the pelvic and shoulder girdles. Any raised shoulder could well be coming from a lateral curvature in the spine. So too a raised posterior superior iliac spine could be causing an imbalance in the spine and shoulders.

Occipital protuberance - The occipital protuberance should be directly above the gluteal crease. Any deviation from the line indicates a lateral curve in the spine.

The diaphragm - The diaphragm should be observed both passively and actively as the patient breaths. The osteopath should check the lower 6 ribs and the upper lumber spine where the crura of the diaphragm attach. A lateral curvature of the spine that involves rotation through the thoracic spine will inevitably affect the ribs and the diaphragm.

From a cranial-osteopathy view much emphasis is placed on a few areas:
The spheno-basilar-symphisis - the body's attempt to overcome the scoliotic changes in the spine results in the cranium shifting in order to keep the vestibular and optic senses balanced. This may mean that the cranium is tilted slightly, causing alteration in the natural position of the occipital condyles. This will then be reflected in the movement of the spheno-basilar-symphisis. The osteopath needs to assess each person individually to check to what degree and in which direction the occipital condyles have adapted and so too, what type of strain is reflected through the spheno-basilar-symphisis.

The abdominal muscles are a doorway to palpating the viscera. So often the lateral curvature of the scoliosis results in compression and compensation of the visceral contents. Using cranial and visceral osteopathic techniques in particular, the abdominal muscles give a good indicator as to the internal changes occurring from the change in weight bearing.

Treatment guide for the osteopath:

The osteopath should mainly focus on the somatic dysfunction that occurs as a result of the scoliosis, paying particular attention to the postural decompensation that occurs. The treatment should then be aimed at focusing as much as possible on restoring the biomechanical changes and helping them do compensate. The osteopath should try to reverse the postural decompensation and try and strengthen any areas that will help strengthen the curve and prevent it from collapsing. Similarly, the osteopath will do well to pay attention to balancing the sacrum and pelvis and as much as possible restoring symmetry. Finally, the osteopath should include work around the neck and cranium in order to remove any possible dysfunction in the proprioceptive units within the cranium.

An Osteopathic Perspective on Down Syndrome

Osteopaths who deal with the treatment of infants are likely at some point to receive a phone call from a parent exploring the benefits of osteopathy for children with Down syndrome. In this article I will try to outline some of the more relevant areas around which an osteopath can build a treatment plan.

Downs syndrome is a chromosomal abnormality that results in a variety of changes in the structure of the face, head, eyes, ears, internal organs, muscles and central nervous system. A theory proposed by Nicholas J.R. Handoll D.O. (1) is that the altered developmental processes experienced by people with Down syndrome are not an inherent result of the chromosomal abnormality. Instead, they are the result of hypoxia of the central nervous system caused by compressed sinuses and regular respiratory infections that children with Down syndrome suffer from.

Children with Down syndrome present typically with a flat occiput and face, the maxilla and the mandible are often small, the mouth is open and the tongue protrudes giving the impression that the tongue is longer than usual. A high palate often affects speech and a tendency towards respiratory infections.

Sinus development is affected, particularly the frontal, ethmoid, maxillary and sinus bones which compress and compromise the airways and the respiratory tract function. An important consideration for the osteopath is the cranial base which is shorter antero-posteriorly due to the underdevelopment of the sphenoid. Furthermore, the nasopharynx is narrowed further reducing the capacity of the respiratory airways and oxygen saturation.

It should start to become clearer now how a child with Down syndrome is more vulnerable to upper respiratory and sinus infections. The facial and cranial changes are so profound that they are bound to lead to sinus and respiratory infections in the majority of children with Down syndrome. The osteopath should therefore pay special attention to the cranium and thorax in order to improve blood and lymph drainage in order to reduce infection in the respiratory airways.

Many children with Down syndrome need to have operations early on in life to correct visceral problems of the heart or the gut. The consequence of this is that scar tissue and secondary problems develop in the musculo-skeletal system. Children with Down syndrome also tend to be hypotonic affecting posture and gait.

Treatment should begin as soon as possible after birth when the tissues are still flexible and before growth spurts begin. At the beginning treatment may need to be concentrated and coordinated with growth spurts and seasonal changes.

In summary, based on the theory that much of the developmental dysfunction of Down syndrome is due to the postnatal hypoxia from airway obstruction, osteopaths are able to improve the development of the basocranium and viscerocrnium and function of the airways, reduce the chances of infection and improve oxygenation of the central nervous system and hence aid the natural development of the body.

1) http://www.cranial.org.uk/res/handoll/downs/index.htm

Kissing - the risks involved - an osteopathic approach to Infectious Mononeucliosis / Glandular Fever

Infectious mononeucleosis or Glandular Fever, otherwise known as Pfeiffer's disease or "kissing disease" is a viral infection (Epstein-Barr) that occurs commonly in adolescents and young adults. It is usually passed person to person, saliva being the primary method of transmission. It is characterized by a sore throat due to lymphadenopathy, fever and fatigue which explains why the cause of the problem is so commonly overlooked due to it's similarity with other illnesses. These symptoms may be accompanied by splenomegaly or hepatitis.

The aim of the osteopathic treatment for this condition is, as with all conditions that osteopaths treat, to aid the body's recovery. Patients often recover slowly from mononeucliosis, and even when the primary symptoms have disappeared the patient may continue to suffer from fatigue, aching, digestive problems, depression and a reduced immune system making them prone to infection.

From my own experience in treating viral infections the osteopathic approach is usually to address the patient's systems accordingly:

1) The lymphatic system
2) The respiratory system
3) The autonomic nervous system

The osteopath begins as usual with a medical case-history gathering as much information about the patient's symptom picture as possible – each patient will be affected by the virus individually and so it is important that the osteopath gears the treatment to the systems that have been affected.

The osteopath should find out if there was any liver or splenic involvement and if so how long the symptoms lasted for. It is also prudent that the osteopath check to find out when the patient's last blood test was to be sure that there is no liver or splenic inflammation of which the patient may be unaware.

For the postural examination the osteopath should focus on specific areas:
The thoracic inlet is a crucial part of any treatment when dealing with infection. Between the clavicle and the first rib lie the sub-clavian veins into which the body's lymph drains thus the osteopath should note any postural tension in the anterior and posterior cervical fascia.

Spinal mechanics are important, paying attention to any viscero-somatic changes throughout the spine.

Respiratory mechanics – diaphragm, ribs, and secondary respiratory muscles – all involved in lymphatic drainage.

Tests:
Abdominal examination: Testing for any liver or splenic tenderness
Lymphatic: All lymph nodes – especially cervical and axilla
Observe nail beds, mucous membranes and sclera for any discolouration that may be caused by anemia or jaundice.

Treatment:
Once the examination has been done the osteopath starts on the treatment. The following is simply a guide for the osteopath as every osteopath will gear the treatment according to the individual patient. I have tried to incorporate into the osteopathic treatment some of the main osteopathic areas of importance.

I generally approach treatment using general-osteopathic-treatment beginning at the feet and working my way up to the cranium checking each and every joint for any restriction.

Lymphatic drainage:
The areas related to the lymphatic-system are widespread. The osteopath can begin with gentle work around the thoracic inlet, articulating the cervico-dorsal junction, clavicle, first rib and scapulo-thoracic articulations. Gentle soft tissue/ muscle energy/ stretching techniques can be applied to subclavius, pectoralis major, scalenes, and cervical fascia. All this is aimed at improving lymphatic drainage through the left and right subclavian veins that lie between the first rib and clavicle and through which all of the lymph drains.

Next the osteopath can move on to diaphragmatic work. It is unclear whether the lymphatic system has any inherent motility (see below) so the diaphragm is considered to be crucial to the flow of lymphatic fluid around the body. The contraction and relaxation of the diaphragm causes a constant change in pressure between thorax and abdomen. During inspiration the thorax increases in size the diaphragm descends the negative pressure in the thorax increases. Since fluid moves from an area of high pressure to low pressure fluid moves up the body from the lower limbs and abdomen into the thorax. Any restriction of the patient's diaphragm will inhibit this process making lymphatic drainage sluggish.

Technically the osteopath can use a variety of techniques to stretch the diaphragm including local inhibition under the costal margin, rib articulation of the lower 6 ribs, L1-3 articulation to affect the crura, or a technique called "doming" where the osteopath puts his hands around the both sides of the rib cage anteriorly and asks the patient to inspire. The osteopath's pressure on the ribs inhibits them from flaring and indirectly stretches the diaphragm.

Since mononucleosis causes lymphadenopathy the osteopath should do work around the face and throat (see post on pharyngitis for hyoid articulation).

To further improve lymphatic drainage the osteopath can use the thoracic lymphatic pump technique or pedal pump.

Assuming the osteopath has checked that there has been no liver or splenic damage the osteopath may wish to include liver or splenic massage into the treatment as these organs are often affected by mononucleosis.

I would like to spend some time on the treatment of the autonomic nervous system for viral infections but the scope of this article is insufficient. Dr Raymond Perrin in his book The Perrin Technique explains how the treatment of the autonomic nervous system is important in chronic fatigue syndrome/ME and he goes to great lengths to explain the importance of treatment of the autonomic nervous system treatment and recovery. In summary though, harmony must exist between the autonomic nervous system and the demands placed on the body otherwise it can lead to systemic, arterial or muscular dysfunction all of which will inevitably cause ill health. It is up to the osteopath to check for somatic dysfunction of the vertebrae with an emphasis on the thoracic spine and vagus nerve all of which can be treated by HVT or articulation as examples.

Treatment can be concluded with side-lying soft-tissue massage to the lumber erector spinae moving up the dorsal erector spinae aiding not only lymph return to the heart but also somatic restrictions around the spinal column.

Advice to the patient:
Diet: Reduce artificial substances, white-flour, sugar and caffeine. Relaxed meals and not sleeping on a full stomach. Increase fruit and veg, healthy balance of protein and carbs. Reduce fried foods.
Exercise: Start gently and build up. Preferably walking and increase as feels healthy.

In conclusion, the osteopath needs to guide the patient back to good health. There are neither quick-fixes nor one single approach. Treatment is about the osteopath aiding the systems most affected by the particular virus (in this case Barr-Epstein). Treatment needs to be gentle and accurate with the osteopath focusing on the areas that physiology and anatomy indicate are vital to restoring homeostasis.

"I did not exhale!" - The osteopathic approach to asthma

Before attempting to treat asthma it is important that the osteopath understands the pathophysiology of the disease and the biomechanics.

Asthma is a disease triggered by factors such as dust, anxiety, cold air and animal-hair, defined as the chronic hyperactivity of lung tissue resulting in constriction of the bronchial tree. The constriction of the bronchial tree causes dysponea (difficulty breathing), wheezing and coughing. It results in excess production of mucous, bronchospasm and oedema. Since the airways are narrowed, the asthmatic finds it difficult to exhale, the exhalation phase is prolonged leading to hyperinflated lungs and the osteopath may observe "barrel-chest".

Exposed to the allergen, the acute asthmatic responds with the production of inflammatory cells and mast cells which initiate mucous production and bronchospasm. However when asthma becomes chronic it results in the hypertrophy of the smooth muscle, fibrosis and an increase in the number of blood vessels in the bronchiole mucosa. This is why it is so important to treat the asthmatic from an early age.

Observation:
Observation of the patient by the osteopath is focused mainly on the respiratory mechanics – the relationship between the thoracic spine, ribs, sternum, clavicle, scapulae, cervical spine, cervical fascia and diaphragm. The osteopath should palpate for somatic dysfunction in all of these areas, observing compliance and flexibility. The osteopath should check to what extent each area is able to accommodate inhalation and exhalation and to what degree the lower 6 ribs are compliant to allow the diaphragm to descend. The secondary respiratory muscles are often hypertonic in the asthmatic patient and the osteopath should check to what extent this is the case and whether there is any asymmetry of hypertonicity in the body. The osteopath should observe the face and the relationship of the mouth, nose, eyes, forehead, ears and palate noting any asymmetry and compression that may cause obstruction in the sinuses and airways.

A common cause of asthma in children is gastric reflux so the osteopath should take into consideration the overlapping areas of the respiration and digestion, in other words, the diaphragm, the upper lumber spine, the lower ribs and the sternum.

Examination:
When examining the asthmatic patient the osteopath needs to pay due attention to the areas directly related to breathing:
Upper thoracic vertebrae and ribs.
Sympathetic nerve supply to the lungs (T1-5).
Vagus nerve (cranial nerve X) which innervates the smooth muscle of the bronchioles.
Anterior cervical musculature
Diaphragm locally – the lower 6 ribs, the attachments of the crura – L1 and 2 and its nerve supply C3,4,5 – phrenic nerve.
Accessory muscles of respiration –sternocleidomastoid, scalene muscles and the intercostal muscles.

Treatment:
There are a few objectives to the osteopathic treatment:
a) To improve the breathing mechanics.
b) To balance the sympathetic and parasympathic nervous system.
c) To encourage lymphatic drainage.

The order of treatment should obviously be what the osteopath deems appropriate but a simple guide after checking for somatic dysfunction could be to first treat any dysfunction observed in the primary breathing mechanics that is the ribs, thoracic spine, sternum and diaphragm. Next the osteopath moves on to the more peripheral areas such as the scapulae, the secondary respiratory mechanics, that is the cervical muscles and fascia.

Next the osteopath can address the sympathetic nerve supply to the bronchioles – T1-6 as well as paying due attention to vagus nerve specifically as it exits the occipito-atlantal joint and the phrenic nerve which innervates the diaphragm.

The osteopath can end off with a gentle lymphatic pump either thoracic or pedal.

Treatment of the asthmatic patient by the osteopath really does require a holistic approach and the osteopath should remember to address more than just the patient's musculo-skeletal system. The approach needs to be multifactorial, combining environmental advice, dietary advice, exercises and relaxation techniques.

A brief review of the history and philosophy of osteopathy

The Common Cold - An Osteopathic Approach

It is that time of the year when many of us have patients presenting at our clinics with the common cold. Although they may arrive for a different matter, with the patient's permission, it is a chance for the osteopath to treat some of the less-known conditions that osteopathy addresses.

At the back of the throat sits a ring of lymphoid tissue – the pharynx, the adenoids and the tonsils. They serve as the first line of defense against infections of the mouth and throat. The main virus that causes the common cold is the rhinovirus.

On examining the patient with a cold, the osteopath may find that the posterior pharyngeal muscles are inflamed, the hyoid bone is restricted in movement on one side, the cervical lymph nodes are enlarged, there is restriction in movement of the cervical vertebrae and there is hypertonic cervical-erector-spinae.

The aim of osteopathic treatment is two-fold:
a) To improve fluid drainage to and from the problem area.
b) To boost the immune system.

In conjunction with a general osteopathic treatment, the osteopath should focus on a number of relevant areas. The clavicle and first rib, between which lie the left and right thoracic ducts, must move freely so that drainage from the head and neck is not restricted. The same applies to the thoracic outlet. The diaphragm is also important in intrathoracic pressure and fluid dynamics. Furthermore the osteopath should address sternocleidomastoid (SCM) making sure that it is relaxed and not restricting sound fluid drainage from the throat by either local hypertonia or pinching the thoracic ducts between clavicle and first rib.

To boost the immune system the osteopath can apply the lymphatic pump, splenic and pedal pump.

Local soft tissue work to SCM and articulation with gentle muscle-energy to the pharangeal muscle can be executed in the following way:

With the patient lying supine, the osteopath stands to the side of the patient and clasps the hyoid between two fingers (it is worth explaining to the patient the procedure in advance). Gently, the osteopath articulates the hyoid bone laterally and asks the patient to swallow. The osteopath will feel a gentle tension increase around the hyoid and this produces an effective accurate stretch to the surrounding musculature.

Gentle inhibition can be applied to the sub-occipital muscles and cervical-erector-spinae.

The osteopath can finish with some gentle effleurage around the ears, eyes nose and throat.

The order in which these techniques are used is up for debate but there is some logic in beginning with the peripheral areas first to create pools for the fluid to drain into.

The osteopath may wish to advise the patient to rest and to reduce complex and artificial foods, sticking mainly to boiled vegetables in the first 24 hours.

In conclusion, the osteopath applies skilled hands to knowledge of anatomy and physiology, creating an optimum environment for the body to combat the virus, bringing symptomatic relief, reducing pain and hopefully speeding the recovery.