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.
Video demonstrating passive hip examination.
Click here for more info on arthritis and osteopathy
or here for more info in Hebrew
Monday, January 31, 2011
Wednesday, June 9, 2010
TMJ problems - an osteopathic guide.
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.
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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.
Saturday, January 16, 2010
Cranial Osteopathy - The five fundamental principles of the cranio sacral mechanism
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.
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
Thursday, September 10, 2009
Why wry neck? An osteopathic assessment and treatment of torticollis
Children with infant torticollis present with a tilt of the head to one side and rotation of the chin in the opposite direction. There are various causes of childhood torticollis ranging from the least serious, functional torticollis to the more serious, structural torticollis. Both conditions usually involve the sternocleidomastoid muscle which has the function of flexing and rotating the neck.
Various theories have been proposed for each of these conditions. It has been suggested that functional torticollis occurs as aresult of an unusual lie in the uterus, weakening sternocleidomastoid and resulting in other changes such as a altered shape of the cranium. Structural scoliosis is a change in the structure of the sternocleidomastoid muscle either due to a congenital shortening of the muscle or due to a fibrosis of the muscle belly due to the trauma of birth.
Tension in the sternocleidomastoid muscle may affect the structures to which it attaches; the occiput, the mastoid process, the cervical spine, the clavicle and the sternum. Left untreated there is the danger that the tension will result in asymmetry of the neck, basocranium and viscerocranium as the body continues to grow. Using knowledge of applied anatomy, osteopaths are able to relieve tension in and around the sternoceidomastoid.
The osteopath should begin by observing the position of the infant and how the child tends to hold the head observing which side the infant favours and where in the cervical spine the most torque occurs. Observation by the osteopath includes assessing the shape of the cranium to see whether tension in the sternocleidomastoid has effected the symmetry of the bones. Particular attention should be paid by the osteopath to the occiput to which the sternocleidomastoid attaches. observing any changes to the shape of the bone and its articulation.
All possible somatic dysfunction should be explored by the osteopath but specifically the upper dorsal spine, upper ribs, scapulae, pectoral muscles, clavicles and sternum. Sutherland felt that the osteopath must consider cranial nerve XI, the accessory nerve, for possible entrapment neuropathy due to its passage through the jugular foramen and the jugular foramen's close association with the sternocleidomastoid muscle.
Once the osteopath has made an evaluation of the infant, both direct and indirect osteopathic techniques can be applied. Needless to say these techniques are gentle and specific. Direct techniques in the form of gentle articulation to the cervical spine as well as sub-occipital inhibition to "disengage" the occipito-atlantal joint. Gentle springing using the thumbs and finger tips can be applied to the upper ribs and pectoral region releasing the upper ribs, pectoral muscles. With the child's anterior held against the shoulder of the parent, the osteopath can apply gentle pressure with the thenar emmenence to the exposed vertebrae articulating them into extension to reduce restriction in the spine, sacrum and hips.
Indirectly, the osteopath can use cranial techniques applied to the occiput and temporal bones with special attention to the quality of movement of the occipitomastoid suture which may be restricted due to its close association with the sternocleidomastoid muscle. Additionally the osteopath should evaluate the quality of the membranes in the upper thorax, mediastinum and gut, assessing facial strains occurring from the neck and causing strains distally.
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.
Monday, July 27, 2009
Scoliosis - A living curve - an osteopathic approach
To give a prescriptive list of areas to treat when faced with a patient with scoliosis is to do an injustice to both osteopathy and the scoliosis. After all, a scoliosis is a general term for a lateral curvature of the spine but a variety of scolioses exist, all of which have unique characteristics that are necessary for the osteopath to consider when assessing, diagnosing and treating.
Idiopathic scoliosis is a scoliosis that has no known pathological cause. Of all the scolioses it is the most worrisome due to its potential compression of the viscera; the lungs and pericardium. The scoliosis begins normally during childhood or adolescence and stops once spinal growth ceases. The scoliosis can be either thoracic, thoraco-lumbar or lumber. It is normally thoracic and is identified by the involvement of the ribs which which produce a so-called "high-side", a phenomena in which the ribs are thrust backwards on the side of the convexity.
Compensatory scoliosis is one where there is nothing intrinsically wrong with the spine per se but rather external forces affect the spine, such as a tilted pelvis from shortened adductor or abductor muscles, a leg-length difference or a fixed abduction or adduction deformity of the hip. Usually, once the cause has been removed, the scoliosis dissappears unless the scoliosis has been left untreated for many years and resulted in tissue shortening around the spine.
Secondary scoliosis is normally secondary to an underlying pathology such as poliomyelitis or cerebral palsy where unequal muscular contracture as a result of the pathology results in extreme angulation of the spine.
Sciatic scoliosis is a temporary form of scoliosis which is normally a person's attempt to protect oneself by reducing pressure on an irritated nerve. Once the acute phase is over the scoliosis normally disappears.
Examination guide for the osteopath:
The osteopathic examination should focus on assessing the movement of the axial skeleton. The osteopath should try and determine to what extent the axial skeleton, that is, the sacrum, the spine, the ribs, the sternum and the cranium are being dragged away from the mid line. The osteopath needs to examine these areas both passively and actively in order to assess which of these areas show most restriction of mobility. It is often the case that the thoraco-lumber area and the cervico-occipital junction display most restriction.
Once the osteopath has observed the axial skeleton, the peripheral areas should be observed. For example, observation of the foot-arches, knees, hips, the pectoral girdles. Osteopathic examination should involve comparing the shoulders and the pelvic girdles, assessing inequality. The osteopath should be aware of the Adam's test, a test which involves flexing the spine forward as if to touch the toes. This test exaggerates the high-side and shows the extent of the scoliosis.
Factors for the osteopath to consider:
The pelvis - The osteopaths needs to observe the pelvis for tilting. A tilted pelvis will result in a lateral curvature of the lumber spine. Therefore the osteopath needs to decide what is causing the imbalance in the pelvis and if necessary to treat the muscles that connect to the pelvis such as the hip adductors and abductors. Similarly the osteopath should check for a leg-length difference.
Pelvic and Shoulder girdles - The osteopath can develop a good understanding of how the body is adapting to the scoliosis by observing the pelvic and shoulder girdles. Any raised shoulder could well be coming from a lateral curvature in the spine. So too a raised posterior superior iliac spine could be causing an imbalance in the spine and shoulders.
Occipital protuberance - The occipital protuberance should be directly above the gluteal crease. Any deviation from the line indicates a lateral curve in the spine.
The diaphragm - The diaphragm should be observed both passively and actively as the patient breaths. The osteopath should check the lower 6 ribs and the upper lumber spine where the crura of the diaphragm attach. A lateral curvature of the spine that involves rotation through the thoracic spine will inevitably affect the ribs and the diaphragm.
From a cranial-osteopathy view much emphasis is placed on a few areas:
The spheno-basilar-symphisis - the body's attempt to overcome the scoliotic changes in the spine results in the cranium shifting in order to keep the vestibular and optic senses balanced. This may mean that the cranium is tilted slightly, causing alteration in the natural position of the occipital condyles. This will then be reflected in the movement of the spheno-basilar-symphisis. The osteopath needs to assess each person individually to check to what degree and in which direction the occipital condyles have adapted and so too, what type of strain is reflected through the spheno-basilar-symphisis.
The abdominal muscles are a doorway to palpating the viscera. So often the lateral curvature of the scoliosis results in compression and compensation of the visceral contents. Using cranial and visceral osteopathic techniques in particular, the abdominal muscles give a good indicator as to the internal changes occurring from the change in weight bearing.
Treatment guide for the osteopath:
The osteopath should mainly focus on the somatic dysfunction that occurs as a result of the scoliosis, paying particular attention to the postural decompensation that occurs. The treatment should then be aimed at focusing as much as possible on restoring the biomechanical changes and helping them do compensate. The osteopath should try to reverse the postural decompensation and try and strengthen any areas that will help strengthen the curve and prevent it from collapsing. Similarly, the osteopath will do well to pay attention to balancing the sacrum and pelvis and as much as possible restoring symmetry. Finally, the osteopath should include work around the neck and cranium in order to remove any possible dysfunction in the proprioceptive units within the cranium.
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.
Sunday, May 17, 2009
An Osteopathic Perspective on Down Syndrome
Osteopaths who deal with the treatment of infants are likely at some point to receive a phone call from a parent exploring the benefits of osteopathy for children with Down syndrome. In this article I will try to outline some of the more relevant areas around which an osteopath can build a treatment plan.
Downs syndrome is a chromosomal abnormality that results in a variety of changes in the structure of the face, head, eyes, ears, internal organs, muscles and central nervous system. A theory proposed by Nicholas J.R. Handoll D.O. (1) is that the altered developmental processes experienced by people with Down syndrome are not an inherent result of the chromosomal abnormality. Instead, they are the result of hypoxia of the central nervous system caused by compressed sinuses and regular respiratory infections that children with Down syndrome suffer from.
Children with Down syndrome present typically with a flat occiput and face, the maxilla and the mandible are often small, the mouth is open and the tongue protrudes giving the impression that the tongue is longer than usual. A high palate often affects speech and a tendency towards respiratory infections.
Sinus development is affected, particularly the frontal, ethmoid, maxillary and sinus bones which compress and compromise the airways and the respiratory tract function. An important consideration for the osteopath is the cranial base which is shorter antero-posteriorly due to the underdevelopment of the sphenoid. Furthermore, the nasopharynx is narrowed further reducing the capacity of the respiratory airways and oxygen saturation.
It should start to become clearer now how a child with Down syndrome is more vulnerable to upper respiratory and sinus infections. The facial and cranial changes are so profound that they are bound to lead to sinus and respiratory infections in the majority of children with Down syndrome. The osteopath should therefore pay special attention to the cranium and thorax in order to improve blood and lymph drainage in order to reduce infection in the respiratory airways.
Many children with Down syndrome need to have operations early on in life to correct visceral problems of the heart or the gut. The consequence of this is that scar tissue and secondary problems develop in the musculo-skeletal system. Children with Down syndrome also tend to be hypotonic affecting posture and gait.
Treatment should begin as soon as possible after birth when the tissues are still flexible and before growth spurts begin. At the beginning treatment may need to be concentrated and coordinated with growth spurts and seasonal changes.
In summary, based on the theory that much of the developmental dysfunction of Down syndrome is due to the postnatal hypoxia from airway obstruction, osteopaths are able to improve the development of the basocranium and viscerocrnium and function of the airways, reduce the chances of infection and improve oxygenation of the central nervous system and hence aid the natural development of the body.
1) http://www.cranial.org.uk/res/handoll/downs/index.htm
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
Thursday, February 5, 2009
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.
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.
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