Osteopathy for Osteopaths

Wrist fractures and osteopathy

2011-11-14T05:29:00.000-08:00

An osteopath needs to be aware of the consequences of a patient's fractured bones. A Colle's fracture, fracture of the distal end of the radius, is one of the commonest fractures and so it is likely to present at an osteopathic clinic.

Colle's fractures are normally the result of a fall on the outstretched arm. If the wrist is strong the impact of the fall is likely to reach the shoulder and may dislocate it. However, if the wrist is weak such as in people with osteoporosis then it can result in a fracture. For this reason it commonly occurs in women above the age of 40.

The fracture occurs transversely roughly 2 cm across the distal end of the radius. The fractured segment is displaced posteriorly and laterally resulting in the classic “dinner-fork” deformity. Colle's fractures usually recover rapidly but the functional results are often dissapointing. This suggests that the extent of the soft-tissue injury in Colle's fractures are an important consideration to acheiving a positive functional outcome.

The tendon of extensor-pollicis-longus curves around the dorsal radial tubercle and over the radial wrist extensors to the thumb so it is naturally a place of abrasion and wear and tear. Rupture of extensor-pollicus-longus can occur naturally but occurs more frequently between 4-8 weeks after a fracture of the radius. Rupture of extensor-pollicis-longus leads to the inability to extend the distal joint of the thumb.

Osteopathic treatment may be able to improve the recovery by helping to restore flexibility to the wrist and tendons which are likely to have scar tissue and tension after the fracture. Osteopathic soft tissue massage to the wrist extensors and flexors combined with articulation of the carpel and radio-ulnar joints could improve the blood supply, facilitate recovery of the soft tissues and help to restore good function and reduce abrasion.

For more information:
http://www.osteopath.co.il/home-eng.php
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Pancoast tumor - what an osteopath should remember

2011-09-21T07:48:00.000-07:00

An osteopath always needs to be aware of medical conditions that mimic musculo-skeletal ones so as not to miss a problem that requires a referral to another discipline. Most osteopaths are familiar with treating musculo-skeletal pain conditions that cause pain starting in the lower cervical or upper dorsal spine with pain that radiates into the shoulder, scapula, down the arm and into the hand. These kind of symptoms could very easily be justified as compression of the lower cervical nerve roots C7-C8 due to narrowing of the zygo-apophyseal joints at the relative level. It could also be justified as thoracic outlet syndrome or a another shoulder condition.

It may however be worth the osteopath considering the possibility of a Pancoast tumor when faced with such a symptom picture. A Pancoast tumor is an extrathoracic tumor of the lung, plaquelike, located in the upper apex of either lung usually found in smokers. It is the location of the tumor and not the pathophysiological changes in the lung tissue that result in the symptom picture, and so one rarely sees lung symptoms in this condition. Rather, the symptoms are the result of the tumor invading adjoining tissue in the confines of the thoracic inlet such as the intercostal nerves, the lower roots of the brachial plexus, the stellate ganglion and the sympathetic chain.

The patient will most likely complain to the osteopath about pain felt locally in the shoulder and down the medial border of the scapula, not an uncommon complaint in any osteopathic clinic! Due to the invasion of the tumor into the lower roots of the brachial plexus (C8) and upper thoracic trunk (T1, T2), the patient may also complain of pain radiating down the ulnar distribution of arm to the elbow (T1) and ultimately to the ulnar surface of the forearm and to the small and ring fingers of the hand (C8). The osteopath should examine the patient's hand muscles checking for weakness and atrophy, reflexes may show a reduced or absent triceps reflex on the affected side. Since the tumor may also involve the cervical sympathetic ganglion and stellate ganglion, sympathetic involvement leads to ispilateral Horner's syndrome (hemianhydrosis, enophthalmos, ptosis and miosis) on the affected side of the face. If the tumor invades the recurrent laryngeal nerve there may be hoarsness and a bovine cough associated with the symptoms.

The patient is often in extreme pain with postural change creating little relief. The patient may tell the osteopath that other than supporting the elbow of the painful arm with the unaffected hand in order to take the tension off the painful area there are not many postural positions that help. The patient will most likely be taking narcotics for relief.
After reading this the osteopath should begin to see the overlap between a Pancoast tumor and any musculo-skeletal condition causing similar symtoms. However, unlike an ordinary neck-shoulder condition or nerve root irritation the osteopath may discover on questioning that the patient also experiences malaise, fever, weight loss and fatigue emphasising the importance of a comprehensive osteopathic case history.

A Pancoast tumor is just one example of a life-threatening pathalogical condition that mimics a musculo-skeletal one. The osteopath needs to be fully aware of these conditions in order not to make the mistake of treating the condition and potentially delaying the appropriate treatment
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The shoulder complex through the eyes of an osteoapth

2011-09-06T00:08:00.000-07:00

A unique quality of being an osteopath is the approach to biomechanics and the shoulder is no exception. The function of the shoulder is to guide the arm through space and hence it requires a considerable range of movement, in fact the shoulder is the joint with the largest range of movement in the body. It achieves the range of movement in a number of ways. The main factor is the incongruity between the head of the humerus and the glenoid fossa which allows the joint a massive range of movement due to its reduced bony apposition. This does however make the joint vulnerable due to lack of support. The shoulder compensates for this with a complex network of muscles and secondary joints and most importantly a tightly bound capsule that keeps the head of the humerus in apposition with the glenoid fossa.

The secondary joints are the acromioclavicular joint, the sternoclavicular joint and the scapulothoracic joint. The acromioclavicular joint keeps the scapula suspended away from the body and allows for changes in the position of the scapula and therefore the axis of movement of the glenohumeral joint. The scapulothoracic joint allows for a large degree of play by sweeping around the thorax and allowing the scapula a large degree of movement. The sternoclavicular joint attaches the scapula to the axial skeleton keep in the shoulder complex firmly attached to the body.

Finally the muscles involved in shoulder function can be divided in to three groups. The suspensory muscles, that is, the muscles from which the scapula and glenohumeral joint are suspended. The suspensory muscles are latisimus dorsi, trapezius, rhomdoid major and minor posteriorly and anteriorly, pectoralis major and minor. The extra-conal muscles or prime-movers of the shoulder joint are middle fibres of trapezius, deltoid, teres major, biceps and triceps whose job it is to move the shoulder in its anatomical directions. The final group is the periarticular muscles, the rotator cuff muscles, supraspinatus, infraspinatus, teres minor and subscapularis.

As osteopaths it is important that our examination and treatment incorporate the role of each of these areas to the patient's shoulder condition. Any alteration due to postural change or trauma can affect the different categories of muscle or joints listed above. As osteopaths it is our duty to view the all the structures and treat them accordingly. The osteopath needs to integrate his knowledge of biomechanics and apply them to the structure of the shoulder and of the body as a whole and treatment should be given accordingly.
For more information on osteopathy and the shoulder:
http://www.osteopath.co.il/sports-injuries-heb.php
http://www.osteopath.co.il/sports-injuries.php

How an osteopath views knee mechanics.

2011-04-01T06:12:00.000-07:00

A well known osteopathic principle developed by the founder of osteopathy Andrew Tailor Still is “structure governs function” and so as an osteopath my starting point is always the function of the joint. Evolution has adapted body structure according to its function and therefore once the osteopath understands the joint's function, structure is simply an adaption to meet the demands of the environment. Furthermore, as an osteopath I consider how the patient uses his body, that is, what kind of environment do the joints have to cope with and how pathophysiology may be developing under the circumstances. The knee joint is one of the most interesting joints in the body since it has two mutually exclusive functions which it has to perform; motility and stability. Unlike the shoulder, the king of joint mobility, the knee is a weight bearing joint. Unlike the hip, the king of stability, the knee needs to be highly mobile. Therefore there are structures unique to these 2 joints that we do not see in the knee. However, the knee is similar to the shoulder in that it requires a degree of mobility and it is similar to the hip in that it requires stability and it shares some of the structural features common to both. The knee like the shoulder lacks congruity and so has muscle and ligamentous strength to support it. Just like the hip the knee propels the body forward and therefore has structures that increase its congruity providing stability with mobility.

So, the knee has multiple function, but probably the most obvious one is that of propelling the foot forward in order to make contact with the ground to allow the leg to propel the body forward.

If the knee were a regular hinge joint like the elbow, one can imagine how much trouble the leg would run into. Therefore unlike the elbow the knee allows for a degree of rotation in order to allow for uneven surfaces and pivoting.

If we appreciate for a moment the weight bearing function of the knee we will see that if all the ligaments and the muscles were removed from the knee joint it would essentially collapse in a medial direction. The reason for this is the q-angle. The femur which attaches to the pelvis extends laterally from the body in order to increase the range of movement of the hip. However, in order for the feet to face forwards the femoral condyles are more medial than the hip joint. The result of this is that most of the body weight is transferred to the medial aspect of the knee and therefore this has to be more stable than the lateral side.

The knee is split up into two compartments essentially. One compartment is designed for stability, that is the medial side of the bit – fem joint. It has a much wider surface area, it is much larger than the lateral side of the tibial plateau. The medial meniscus is much less mobile, it is deeper and the medial side is stabilised by the medial collateral ligaments, a structure which holds the medial side of the tib fem joint tightly together allowing only a small degree of valgus to occur. Furthermore, the medial meniscus is attached to the medial collateral ligament reducing its mobility further. The horns of the medial meniscus are attached further apart from one another resulting in a lot less mobility of the meniscus itself which in effect limits the mobility of the femoral condyle on the tibial plateau.

The stability of the knee joint is mainly contained on the medial aspect of the knee as mentioned above. The knee joint compared to the hip and to the shoulder has a complex latticework of ligaments which stabilize the knee in more than one direction and which support one another. In addition to the ligamentous support the muscles act as flexible elasticated ligaments with semitendinosis, gracilis and sartorius acting to support the medial collateral ligament and tensor fascia lata, biceps femoris and popliteus acting to support the weak lateral collateral ligament.
The bony structure of the lateral tibial side of the knee on the other hand is much smaller as is the femoral condyle. This smaller contact point does however have a greater range of movement than the medial femoral condyle. It not only flexes and extends but pivots and rocks around the tibial plateau under the guidance of the ligaments and meniscus.

So there we have it a medial condyle which is stable and a lateral one which is mobile. This allows the knee to perform its function of propelling the knee forward but at the same time supporting the body weight.

Before we move on to the menisci let us take a look at the centrally fixed cruciate ligaments which have the function of controlling the axis of movement of the knee. Most people are aware of the functions of the cruciate ligaments – preventing anterior and posterior shift but they are less aware of their function in limiting internal rotation of the tibia on the femur and guiding the femoral condyles smoothly into position on the tibial plateau during extension.

If we look at a graph of the tensility of the ligaments we tend to see that all the ligaments are at their most tensile during extension. Due to their origins and insertion around the femur and tibia all ligaments tend to become more taut the further into extension the knee goes. This results in a “tight-packing” of the knee which allows for no rotation of the tib-fem joint at all when locked in full extension. Therefore the knee is most stable, least mobile, during extension and least stable when the knee is flexed. The close packing is due to the increased tensility of ligaments and the squashing of the menisci whose job it is at this stage to increase the congruity of the knee joint.

The menisci have the primary task of providing increased congruity to the unstable tibial plateau. The differences between the 2 menisci related to the functions that we mentioned above, which is that the medial compartment maintains the stability whilst the lateral compartment creates mobility. The menisci are made of fibrocartilage which allows them to stretch and be squashed. The medial meniscus is less mobile than the lateral meniscus due to its shape, it is a C shape and less able to swing back and forth. It is tightly bound to the tibial plateau and reinforced by coronary ligaments and the medial collateral ligament. The lateral meniscus is O shaped, highly mobile, unrestrained due to loose coronary ligaments, unattached to the lateral collateral ligament and attached to the popliteus muscle which actively pulls it posteriorly out of danger when it contracts. This allows for a much more mobile surface on which the lateral femoral condyle can rest.

Finally we consider the patella femoral joint which is a sesamoid bone designed to improve the efficiency of the quadriceps. It slides between the femoral condyles creating a much stronger force during flexion and extension. It is reinforced by retinacula tissue from medial and lateral muscles, a lateral femoral buttress and finally a thick layer of cartilage posteriorly to protect it from friction on the femur.

As osteopaths we are trained to build up a detailed picture of the way the patient uses the knees. What stresses does the patient's environment put on the various structures listed above? As osteopaths we must not be hasty to rush into the examination and treatment. The more information an osteopath gets from the patient the more focused will be the osteopathic examination and the better the treatment. The patient's work may influence the knee structure. Prolonged standing with a strong need for the illio-tibial band to contract causing an imbalance of the quadriceps, a history of a congenital hip displacement or Perthes that may influence the position of the hip and thus the q-angle, prolonged kneeling, repetative strains caused by regular rotatory forces.

In short, since ligaments are designed to support, most ligamentous injuries occur when the they are at their least flexible, in extension and the result is normally a force that stretches them beyond their physiological norm resulting in a partial tear. Menisci on the other hand are designed for movement and most meniscal injuries occur during movement, slightly out of sync with the movement of the femoral condyles becoming caught in between the femoral condyle and the tibial plateau and tearing partially.

To conclude, the knee is a classic case of function governing structure and for an osteopath to treat the joint effectively a deep understanding of the biomechanics makes the life of an osteopath much easier and more enjoyable. The osteopath can develop a clearer osteopathic diagnosis, a clearer osteopathic treatment plan and a more effective treatment.

For more info on knee pain: http://www.osteopath.co.il/knee-pain.php
More info in Hebrew: http://www.osteopath.co.il/knee-pain-heb.php

Understanding the shoulder joint and the rotator cuff - an osteopath explains

2011-02-19T12:00:00.000-08:00

The function of the shoulder joint is reflected in its unique structure in much the same way as the hip joint and as the founder of osteopathy Andrew Tailor Still believed, once the anatomy is understood, the osteopath can figure out the pathophysiology.

Let us consider the function of the shoulder joint. It is to guide the upper limb through space in order that we can use the hand to perform our daily activities. Circumduction of the shoulder joint allows a massive range of movement, much more so than the hip is capable of achieving. The hip's strong ligaments and tight capsule play a crucial role in stabilizing the joint but it is primarily the bone which limits hip movement. The deep acetabulaum provides a snug home for the femoral head stabilized by the congruence of the two articular surface. The end result is a tight-fitting stable joint whose range of movement increases only as a result of features unique to the hip that have evolved with time such as the femoral neck and various angles of anteversion to improve the range of movement.

The stability of the shoulder however is compromised for the sake of mobility. Unlike the femoral head which can remain attached to the acetabulum even after ligaments and muscles have been removed, the humerus which lacks congruence with the shallow glenoid cavity would fall away completely if not for the muscles, ligaments and capsule surrounding it.

What the glenohumeral joint lacks in bony congruity it makes up for in a complex arrangement of muscles which act as joint movers and tensile ligaments to provide added support. Furthermore, stability of the gleno-humeral joint is reenforced by no-less than 4 other joints: the scapulothoracic joint, the acromioclavicular joint, the acromioclavicular joint and the sternoclavicular joint.

The muscles that control movement of the shoulder can be divided into 2 groups, much the same way as the hip; long muscles and short muscles. The long muscles such as biceps brachii, coracobrachialis, deltoid as well as secondary muscles like triceps, pectoralis major, teres major, latissimus dorsi and trapezius. The short muscles are supraspinatus, infraspinatus, teres minor and subscapularis and are commonly referred to as the rotator cuff. Whilst working together synergistically these two groups of muscles have a different role in controlling the movement of the glenohumeral joint and any dysfunction in one group is likely to be reflected in problems in the second group.
The long group of muscles have the role of moving the shoulder joint since they have a greater mechanical advantage over a larger range of movement. Due to the glenohumeral joint's lack of congruity the axis of movement is constantly changing as it slides around the glenoid fossa. Therefore the short muscles have the job of finely controlling the movement of the head of the humerus as it ducks underneath the coracoacromial joint. They have the job of orienting the head of the humerus for the movement of the humerus and so the short muscles, the rotator cuff muscles, can be defined as the “fixers” whilst the long muscles can be defined as the “movers”. The supraspinatus muscle pulls the head into the glenoid and slightly rotates the humerus into abduction. The infaspinatus muscle rotates and slightly pulls it down,. The teres minor muscle pulls the head of the humerus down in a slightly different direction and the subscapularis muscle pulls the head into the glenoid but it is has mainly a rotatory action, internally rotating the humerus along its longitudinal action.
Having explained the unique structure of the glenohumeral joint and its dependence on muscluar support the osteopath can start to understand the unique pathophysiology of the joint. Unlike the hip which suffers mainly from osteoarthritis, the shoulder is prone to soft-tissue injuries; capsulitis (frozen shoulder), tendonitis, rotator cuff tears, bursitis and shoulder dislocation. The osteopath therefore needs to put a strong emphasis on understanding the patient's unique way of using the shoulder joint and how the day to day use may be disturbing the fine balance between the long and short muscles. First the osteopath must decide what may be disturbing the fine movement of the rotatotor cuff thus causing friction, compression or ischemia of the surrounding soft tissues and then it is the osteopath's job to try to reintegrate the structures of the shoulder joint using careful osteopathic techniques and a fine osteopathic hand.

For more information on shoulder problems and sports injuries: http://www.osteopath.co.il/sports-injuries.php

For more information on shoulder prolems in Hebrew: http://www.osteopath.co.il/sports-injuries-heb.php

Hip examination from the perspective of an osteopath

2011-01-31T05:58:00.000-08:00

In order to diagnose back pain the osteopath needs to be aware of the contribution of the hip joint. The hip has a unique structure carefully designed to fulfill its functions in the body.

The hip has two main functions; mobility, propelling the leg forward, and stability, linking the lower limb to the torsoe. Unlike other bones in the body, the head of the femur is attached to its shaft via a neck. This system of levers allows increased range of movement and less muscular effort, however, it also increases the joint's vulnerability.

Hip stability is the result a multitude of structures such as the head of the femur sitting in a deep pelvic acetabulum reenforced by the acetabular labrum and strong ligaments (pubo, ischio and illio-femoral ligaments). It has a good nerve supply, the obturator nerve (L2, L3, L4), which supplies the hip capsule and serves to convey proprioceptive information to the brain about hip position. Multiple arteries, the circumflex artery and ligamentum teres provide the necessary nutrients. However, disturbence of the blood supply ultimately results in avascular necrosis of the bone, degeneration and osteoarthritis. Ironically it is the strong ligaments that surround the neck of the femur that can compromise the security of the hip by compressing its blood supply.

Conditions that affect the hip joint as a result of poor blood supply are Perthes disease and slipped femoral ephiphysis. Patients with a history of these conditions or congenital hip displacement may turn up at an osteopthic clinic many years later complaining of low back pain.

A fixed flexion deformity of the hip due to osteoarthritis is the result of contraction of the muscles surrounding the hip joint (the strong external rotators and adductor magnus), in an attempt to stabilize the joint. The body compensates for reduced hip extension by extending the lumber spine beyond its normal range leading to stress on the soft tissues of the lumber spine or compression of the facet joints leading to back pain. Other causes of back pain may be the result of referred pain from the hip's nerve supply (obturator nerve). Finally, contraction of the muscles around the hip joint such as gluteus minimus or medius may be mistaken for back pain.

The osteopath should be aware of hip invlovement when assessing back pain. As well as using the standard orthopedic tests, Trendelenberg's sign and Thomas's test the osteopath has the added skill of palpation of the hip joint to assess quality of movement and decide whether there is any shortening of the soft tissues or arthritic changes.

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TMJ problems - an osteopathic guide.

2010-06-09T02:44:00.000-07:00

How many times have you arrived at the end of a case history for a patient suffering with either headaches or neck pain and they say, there is one other thing, I also have a “clicky jaw” whenever I eat or open my mouth.

The jaw is an exciting joint to treat. Unlike treating patients suffering with a slipped disc or low back pain, the tempero-mandibular-joint (TMJ) is one which the osteopath can really get hold of and treat the soft tissue structures that support it.

The jaw is quite a complex joint with some unique features. Take for example the articular disc of the TMJ. The TMJ has an inter-articular disc which separates the joint cavity into two. Not only is the disc's structure special being both concavo-convex superiorly whilst inferiorly it is only concave (thus fitting its joint surfaces exactly), it also is made of fibrocartilage allowing a certain degree of trauma and regeneration. The tempero mandibular joint functions for so many of our daily activities, the most significant of which is eating which requires tremendous leverage and strength

It is the disc that is often the bane of most peoples problems suffering with TMJ pain. It is the structure most likely to be giving the clicking sound that patients hear when chewing. This occurs as a result of disc displacement. The disc can be be displaced at various places along its length and this can interfere with the smooth gliding of the mandible on the articular surface of the temporal bone. The most common problem is for the disc to be displaced medially as a result of the action of the masseter muscle straining and lengthening the lateral TMJ ligaments and allowing excessive medial movement

The TMJ can move in 6 directions:
1)Up and down – the main movement used in biting and chewing
2)Protrusion and retraction – mainly used for tongue movements, talking and swallowing
3)Left and right – for grinding the food when chewing

The muscles that control these movements are:
1)Masseter – this muscle is the main chewing muscle and often becomes tight from emotional stress. It extends from the zygomatic arch to the outer surface of the ramus of the mandible
2)Temporalis muscle – supports the masseter muscle aiding it in chewing and it stabilizes the bite of the TMJ. It is a fan shaped muscle and extends from the surface of the temporal fossa, deep to the zygomatic arch and inserts on to the ramus of the mandible.
3)Lateral and Medial Pterygoid - these 2 muscles are found deep to the ramus of the mandible and they elevate and protrude the mandible.

Observation:
When assessing a patient with TMJ problems the osteopath begins with a standing postural assessment observing head-neck-spine relationships. The osteopath paying special attention to the position of the TMJ in relation to the skull, anterior and posterior cervical soft tissues and shoulder girdles all of which make up the closed kinetic chain of the gnathic system. The osteopath should observe areas of stress in around the TMJ itself including the scalenes, sternocleidomastoid and platysma. Obvious signs of tension or stretching should be noted by the osteopath as they will indicate a stress and potential imbalance of the TMJ and will need to be reassessed during the passive examination.

Active examination should focus on asking the patient to perform movements of the spine specifically the cervical spine noting restricting in movement in any direction which could be related either directly or indirectly to the TMJ via the cervical fascia, infra-hyoid muscles, anterior cervical muscles and posterior cervical muscles.

Active examination should also include examination of the gleno-humeral joints which have a soft-tissue connection to the somato-gnathic system.

Finally one can ask the patient to open the mouth in all directions paying attention to any adventitious movements.

Passive examination:
Palpation by the osteopath of all the structures previously mentioned, however this time the osteopath is able to put his hands directly on the TMJ and ask the patient to open her mouth. This allows the osteopath direct contact with the dysfunctional joint. The osteopath should simultaneously palpate the muscles around the TMJ gathering information about the hypertonia of the soft tissues and any inequality on either side that may be creating an imbalance of movement.

Gentle palpation along the anterior and posterior structures of the cervical spine should include articulation of the hyoid bone, glenoumeral joints, clavicles, menubrio-sternal joints and ribs, all of which have a role to play in the stability of the TMJ function.

Treatment
After a full assessment of the patient's condition the osteopath can start to design a treatment plan. Osteopathically I like to begin treatment distal to the area of pain. After doing a general osteopathic examination and treatment (where necessary) including working as far afield as the feet, ankles, knees and hips I eventually start to focus on structures directly related to the jaw.

Osteopathic treatment will most likely start with the dorsal spine removing any somatic dysfunction that may be reflecting in the cervical spine. Treatment may involve balancing the glenohumeral joints by treating the rotator cuff muscles and muscles of the scapulo-thoracic complex. Any tension in the scapula will be reflected in the cervical spine, anteriorly and posteriorly creating unilateral tension in the TMJ.

Osteopathic treatment of the cervical spine focuses strongly on the sub-occipital muscles and occipito-atalantal articulation onto which many TMJ-related muscles attach indirectly due to their close proximity.

The osteopathic work around the TMJ needs to address the local muscles directly using soft tissue massage to masseter and temporalis and indirectly to the pterygoids using articulation of the jaw or muscle energy.

The osteopath must try to be as clear as possible in which direction the jaw is being pulled so as to treat the appropriate muscles. The theory is that if during opening the mouth the jaw shifts to the right thereis tension in the muscles on that same side. It is important therefore treat the muscles on that side to allow some relaxation of the soft-tissues and for the TMJ to sit equally well in the condyles of both sides. Treatment to masseter can be quite painful so it it good to use gentle inhibition assessing the patients response and not working too aggressively.

The osteopath will most likely need to address the TMJ itself using techniques that temporarily “gap” or separate the two joint surfaces between the the condyle of the mandible and the base of the skull. This gapping allows the joint to reset itself comfortably and also may induce some movement that may have been lost due to excess tension on the restricted side.

At the end of treatment the osteopath should reassess how the movement in the TMJ has changed and whether there is any improved function. This is done by asking the patient to open her mouth and observing any adventitious movement. Often observation is done best when standing at the head of the table with the patient lying supine. Furthermore the osteopath can slide his finger over the joint with his little finger tucked in the joint under the ear lobe. This allows direct contact with the the TMJ as it opens and closes and dysfunction can be easily palpated.

Often patients go back to bad habits of chewing gum or experiencing emotional stress that influences the masseter but awareness of these factors as well as a management plan and gentle stretches can prevent the problem from reoccurring.

Cranial Osteopathy - The five fundamental principles of the cranio sacral mechanism

2010-01-16T12:00:00.000-08:00

The cranial concept is a system of therapy that is being used widely throughout the world and I will try to explain the fundamental principles that apply to it. The cranial concept was first developed by an osteopath called William Garner Sutherland in the early 20th century and he was the first to coin the phrase cranial-osteopathy. Since Sutherland, there have been practitioners like Upledger who have further developed the theory and other branches have developed such as cranio-sacral therapy (craniosacral). The system of cranial osteopathy and cranio-sacral therapy is becoming more and more popular in Israel and in Jerusalem specifically patients are beginning to benefit from it due to greater awareness.

Whether an osteopath uses cranial osteopathy, structural osteopathy, classical, visceral or functional osteopathy, the same principles of diagnosis are used which are based on a system that applies anatomy and physiology in order to prevent disease. The osteopath considers the whole body as a unit all of whose parts need to be properly nourished by its internal fluid environment in order to function, heal itself and thus combat disease.

When the osteopath considers the body as a whole, inevitably this includes the cranium and all of it components; it's bone, cartilage, membranes and internal environment that is nourished by blood-vessels and nerves.

5 fundamental principles exist in cranial osteopathy:

1) That an inherent mobility exists within the brain and spinal cord.
The neural tube develops in the embryo with 2 anterior sections that invaginate and curl up like a ram's horn to form the cerebral cortex. Since it is believed that there is inherent motility within the brain, the pulsating motility responds by curling and uncurling in the way it was developed.

2) Fluctuation of the cerebro-spinal fluid.
There are a number of theories as to how the CSF fluctuates and what the basis of its movement is. For the osteopath however, the important factor is that changes in pressure can be palpated along the route of the CSF and any existing restrictions may alter the CSF fluctuation and have consequences on the body.

3) Motility of intracranial and spinal membranes.
The spinal membranes that form the structures of the intracranial membranes are the falx cerebri and the 2 tentorium cerebelli. These sickle-shaped structures arise from a common origin at the straight sinus known as "The Sutherland fulcrum". The insertions of these membranes are along various points around the cranium. The falx cerebri originates at the internal occipital protuberance, travels upward and forward and eventually insert into the crista galli of the ethmoid bone. The 2 tentoria cerebelli pass along the transverse ridges and the two converge on the body of the sphenoid and insert onto the anterior clinoid process. Together, these membranes constitute the reciprocal tension membranes linking the cranium to the sacrum, functioning as a unit around a common fulcum - the Sutherland fulcrum.

4) Mobility of the bones of the skull.
Whilst the skull may appear to be a solid structure in fact it has zigzag edges which grow together to form movable sutures. These joints evolve from smooth-edged plates of membrane in the newborn and eventually evolve into articulations with slight movement according to the contours of the two surfaces.

5) The involuntary mobility of the sacrum between the ilia.
Not to be confused with movement of nutation and counter-nutation of the sacrum between the ilia, the cranial-osteopathic concept considers the sacrum having an involuntary, respiratory mobility. We have already mentioned the mobility of the intracranial and spinal membranes and it is the lower attachment of these membranes to the sacrum that results in the direction and containment of the sacrum's movement. The movement is a physical extension of the primary respiratory mechanism and allows the sacrum to flex an extend at the level of the second sacral vertebra.

It is with the comprehension of these five fundamental concepts that the cranial osteopath starts to understand the craniosacral mechanism. With a knowledge of the anatomy of the cranium, the physiology of the respiratory mechanism and the cranio-sacral rhythm the osteopath embarks upon a path of therapeutics that are applicable to all kinds of ailments experienced by patients.

Click, for more information on cranio-sacral therapy in Jerusalem

Why wry neck? An osteopathic assessment and treatment of torticollis

2009-09-10T02:27:00.000-07:00

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

2009-07-27T04:07:00.000-07:00

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

2009-05-17T14:04:00.000-07:00

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

2009-02-05T12:37:00.000-08:00

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

2009-01-18T23:22:00.000-08:00

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

2009-01-15T11:56:00.001-08:00

The Common Cold - An Osteopathic Approach

2009-01-07T12:32:00.000-08:00

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.

John Martin Littlejohn - Triangles of Force Made simple

2008-11-23T06:44:00.000-08:00

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

2008-11-08T23:42:00.000-08:00

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

2008-11-03T10:07:00.000-08:00

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

2008-08-24T04:29:00.001-07:00

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

2008-06-16T23:50:00.001-07:00

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

2008-05-31T23:31:00.000-07:00

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

2008-05-15T10:11:00.001-07:00

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

2008-05-11T11:13:00.000-07:00

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

2008-05-09T03:31:00.001-07:00

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 internal rotation (ask patient to touch their dorsal lumber junction), then abduction and then flexion. 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)

2008-05-05T00:10:00.000-07:00

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

2008-04-07T08:13:00.000-07:00

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

2008-03-28T06:49:00.000-07:00

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.