Osteopathic philosophy, practice and technique

2 Osteopathic philosophy, practice and technique



Osteopathy, or osteopathic medicine, is a philosophy, a science and an art. Its philosophy embraces the concept of the unity of body structure and function in health and disease. Its science includes the chemical, physical and biological sciences related to the maintenance of health and the prevention, cure and alleviation of disease. Its art is the application of the philosophy and the science in the practice of osteopathic medicine and surgery in all its branches and specialties.


Health is based on the natural capacity of the human organism to resist and combat noxious influences in the environment and to compensate for their effects; to meet, with adequate reserve, the usual stresses of daily life and the occasional severe stresses imposed by extremes of environment and activity.


Disease begins when this natural capacity is reduced, or when it is exceeded or overcome by noxious influences.


Osteopathic medicine recognizes that many factors impair this capacity and the natural tendency towards recovery and that among the most important of these factors are the local disturbances or lesions of the musculoskeletal system. Osteopathic medicine is therefore concerned with liberating and developing all the resources that constitute the capacity for resistance and recovery, thus recognizing the validity of the ancient observation that the physician deals with a patient as well as a disease.1


The philosophy underpinning the osteopathic approach to patient care can be enunciated as shown in Box 2.1.



Box 2.1 Philosophy underpinning osteopathic approach




• The body is an integrated unit


• The body is self-regulating with inherent capacity for healing


• Structure and function are inter-dependent


• Somatic component to disease


• Neuromusculoskeletal dysfunction impacts on overall health status


• Neuromusculoskeletal dysfunction impacts on recovery from injury and disease


• Unhindered fluid interchange necessary for maintenance of health



Osteopathic Treatment Models


Scientific validation for the use of manual and manipulative approaches, including high-velocity low-amplitude (HVLA) thrust techniques, is limited. Consequently, practitioners must rely upon theoretical and clinical models to justify the use of HVLA thrust techniques in clinical practice.


Osteopaths use five treatment and clinical-reasoning models:2



1. Biomechanical


2. Neurological


a. autonomic nervous system

b. pain

c. neuroendocrine

3. Respiratory / circulatory


4. Bioenergy


5. Psychobehavioural.



Biomechanical (postural / structural)


This model is based upon the concept that mechanical and structural dysfunction can result from single incidences of trauma or from microtrauma occurring over time and as a result of postural imbalance or occupational and environmental stresses. Cumulative microtrauma can lead to a breakdown of the body’s normal compensatory mechanisms with resultant development of dysfunction and pain.


The biomechanical model requires the practitioner to restore maximum function to the neuromusculoskeletal system with enhancement of the body’s ability to compensate for external mechanical stresses and any primary or secondary postural imbalance. Therapy is directed towards restoring near-normal motion and / or function to joints, ligaments, muscles and fascia. The aim is to regain optimal function within the musculoskeletal system.



Neurological


This model is based upon the concept that neural mechanisms may be influenced by the use of manual medicine approaches. The neurological models provide a framework for treatment that is based upon postulated mechanisms of interaction between the somatic and neurological systems. These mechanisms are complex and beyond the scope of this manual. It is suggested that manual intervention may influence:



• the two divisions of the autonomic nervous system


• the integration of function between the central and peripheral nervous systems for modulation of pain


• the neuroendocrine–immune connection, resulting in both local and systemic effects.



Respiratory / circulatory


This model is based upon the concept that normal fluid exchange is essential for the continued health of tissues at both the ‘micro’ and ‘macro’ level. Manual treatment is directed towards improving blood and lymph flow and aiding intracellular fluid exchange by enhancing musculoskeletal function. Treatment is directed towards restoring the capacity of the musculoskeletal system to assist venous and lymphatic return.



Bioenergy


This model is based upon the body’s inherent energy fields that can be utilized for diagnosis and treatment. Internal and external environmental factors may influence the vitality and quality of energy flow within the human body. The aim of treatment is to restore balance and harmony to these fields of energy.



Psychobehavioural


This model recognizes that many internal and external factors influence a patient’s response to pain and dysfunction. Social, economic and cultural factors all impact upon the way in which a patient deals with pain, dysfunction and disability. An understanding of the factors that can influence a patient’s coping mechanisms is pivotal to this model, as is knowledge of the psychosocial interventions that may assist the patient to deal with pain and disability.


These five models provide a conceptual framework upon which decisions relating to patient management can be made. It must be understood that these are simply conceptual models with various amounts of evidence to support their use.


These osteopathic models provide a framework for choosing a treatment approach and selecting osteopathic manipulative techniques. However, the treatment models do not clearly establish a rationale for the use of HVLA thrust techniques as distinct from other osteopathic manipulative techniques.



Diagnosis Of Somatic Dysfunction


Osteopaths diagnose somatic dysfunction by searching for abnormal function within the somatic system.


Palpation is fundamental to structural and functional diagnosis.3


The accepted definition for somatic dysfunction in the ‘Glossary of osteopathic terminology’ is as follows:



Somatic dysfunction is an impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and related vascular, lymphatic, and neural elements.4


Research has explored both inter- and intra-examiner reliability of various diagnostic palpatory procedures. Inter-examiner reliability consists of one assessment of all subjects by each of two or more raters, blinded to each other’s observations, and allows assessment of rater agreement. Intra-examiner reliability is determined by repeated measurements of single individuals to evaluate rater self-consistency.


Osteopaths have shown reasonable levels of inter-examiner agreement for passive gross motion testing on selected subjects with consistent findings of regional motion asymmetry.5,6 One osteopathic study demonstrated low agreement of findings for patients with acute spinal complaints when practitioners used their own diagnostic procedures.7 Level of agreement can be improved by negotiating and selecting specific tests for detecting patient improvement.8 Standardization of testing procedures can improve both inter- and intra-examiner reliability.9


In asymptomatic somatic dysfunction, high levels of inter- and intra-observer agreement for palpatory findings have yet to be demonstrated. Many studies and systematic reviews indicate that inter- and intra-examiner reliability for palpatory motion testing without pain provocation is poor.10–21


Poor reliability of clinical tests involving palpation may be partially explained by error in location of bony landmarks22 and differences in palpation technique.23 Consensus training has been demonstrated to improve inter-observer reliability in the palpatory tests of lumbar spine tissue texture and tenderness.24 Palpation as a diagnostic tool has been reported to demonstrate high levels of sensitivity and specificity in detecting symptomatic intervertebral segments.25,26 A further study refuted some of these findings demonstrating that manual examination had high sensitivity but poor specificity for identifying cervical zygapophysial joint pain.27


A systematic review of manual examination of the spine identified that reproducibility of palpation for pain response was consistently better than for motion palpation.28 Increasing evidence is emerging that clusters of provocation and motion palpation tests have better reliability than single tests for assessing the sacroiliac joints.21,29,30


Traditionally, diagnosis of somatic dysfunction was made on the basis of a number of positive findings. Specific criteria in identifying areas of dysfunction were developed and related to the observational and palpatory findings of asymmetry, altered range of motion, tissue texture changes and tenderness. This was represented as the acronym TART (tissue tenderness, asymmetry, range of motion and tissue texture changes).2,4,31


Pain provocation and reproduction of familiar symptoms should also be used to localize somatic dysfunction. The presence of somatic dysfunction and / or pathology should be determined not only by physical examination but also by information gained from a thorough patient history and patient feedback during assessment. This depth of diagnostic deliberation is essential if one is to select which case may or may not be amenable to treatment and which treatment approach might be the most effective while offering the patient a reasoned prognosis. We would advocate that the convention for the diagnosis of somatic dysfunction – TART – should be expanded to include patient feedback relating to pain provocation and the reproduction of familiar symptoms.



Somatic dysfunction is identified by the S-T-A-R-T of diagnosis (Box 2.2)



S relates to symptom reproduction


Although somatic dysfunction can be asymptomatic, it commonly exists within the context of a patient presenting with symptoms. Pain provocation and the reporting of reproduction of familiar symptoms are therefore essential components of the physical examination.



Box 2.2 Diagnosis of somatic dysfunction

























• S relates to symptom reproduction
• T relates to tissue tenderness
• A relates to asymmetry
• R relates to range of motion
• T relates to tissue texture changes

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Sep 3, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Osteopathic philosophy, practice and technique

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