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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A brief review of the history and philosophy of osteopathy

The Common Cold - An Osteopathic Approach

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

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

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

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

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

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

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

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

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

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

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

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

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

John Martin Littlejohn - Triangles of Force Made simple

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

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


Anterior- Posterior and Posterior-Anterior Gravity Lines:

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

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

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

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

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

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

Some new tension lines – Anterior and Posterior Central Lines:

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

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

Low back pain during pregnancy - an osteopathic approach

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

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

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

Spondylosis: Disease or Natural Response to Stress

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

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

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

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

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

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