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
Friday, April 1, 2011
Saturday, February 19, 2011
Understanding the shoulder joint and the rotator cuff - an osteopathexplains
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.
Video: Combined techniques for the shoulder
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
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.
Video: Combined techniques for the shoulder
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
Monday, January 31, 2011
Hip examination from the perspective of an osteopath
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
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
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.
(For more info about studying manual medicine)
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.
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