osteopathic concepts

respiration and involuntary motion

Osteopaths identify and treat a number of interrelated respiratory processes, structures and motions. We situate healthy respiration and unerring involuntary motion of the entire body at the core of health. Breath disengages structure and promotes physiological space. Altered respiration influences health. Suboptimal respiration can be caused by anxiety, trauma or asthma. Breathing patterns emerge early in life and can reflect the influences of behavioral modeling, chronic and recurrent respiratory illness and early childhood stress and trauma. These patterns often persist into adulthood, eventually they can become redundant and dysfunctional. Respiratory dysfunctions frequently contribute to and perpetuate musculoskeletal problems. Breathing pattern disorders (hyperventilation) shift the autonomic nervous system towards sympathetic dominance and physiology into alkalosis – this has far reaching long term health implications.

From a local and anatomical perspective the respiratory diaphragm has extensive connections to the liver, heart, stomach, spine and much of the lower rib cage. Merely restoring diaphragm function can have unanticipated positive effects because breathing is a systemic process.

Involuntary motion refers to indwelling motion that is both an expression of health and the polyrhythms of interacting physiological systems and processes. Examples of processes that produce palpable rhythms include cardiac pressure waves, lymphatic movement, gastrointestinal peristalsis, vascular dilation-contraction and the circulation of cerebrospinal fluid. Treatment of involuntary motion promotes synchronisation of these processes and a sense of stillness and relaxation. Patients often express amazement at the deep local and systemic effects of working with involuntary motion.

pain and dysfunction

Pain is a complex phenomenon and a common symptom of dysfunction. Pain perception is influenced by emotional, psychological, cultural and physiological factors. Thresholds to pain and tolerance to tissue injury vary enormously. It is therefore unwise and insensitive to dismiss another persons pain or suffering by pejoratively situating it ‘in their head.’

When working with patients in acute or chronic pain it is helpful to build their basic understanding of tissue injury, pain processing and inflammation. In many situations I discuss with patients cognitive, emotional, respiratory and if necessary pharmacologic approaches to reducing pain and its sequelae. Sequelae include whole body responses that effect movement, posture, respiration, mental state, sleep and energy levels. Persistent pain can modify the way we process and experience pain – this change in pain processing is called sensitisation. In such instances the patient may experience pain and debility even after resolution of tissue injury.

In manual medicine, provocation and reproduction of pain and other neurological phenomena can assist in tissue specific diagnosis. Reduction in pain is usually associated with improved function, both are invaluable outcome measures. The therapeutic relationship in manual medicine is informed and influenced by changes in pain and function – they are parameters that can be quantified and form the basis of a transparent, outcome-based approach that is patient focused.

Pain that roams reflects the ongoing work, adaptation and perpetual reorganisation of the body. Fixed and persistently localised pain may reflect an impasse where these processes and solutions have become exhausted. Once serious pathological causes of persistent localised pain have been excluded or factored into treatment, osteopaths can assist adaptive and homeostatic responses.

structure and function

The interdependence of structure and function is a canonical osteopathic notion. The relationship is not linear or simple because the body has deep adaptive capacities (homeostatic reserve) that protect structure against altered function. Imaging studies illustrate the complexity of the structure-function relationship. Myelography, CT and even MRI reveals evidence of lumbar disc herniation in 28-50% of asymptomatic people. The duration, severity and debility of low back pain is not associated with the extent of anatomical abnormality. The rate of false positive findings in the neck appears to be as high as 75% in asymptomatic populations. The presence of structural signs in diagnostic imaging does not predict future problems. Similar patterns have emerged in the imaging of the rotator cuff muscles in asymptomatic populations. In spite of these observations, diagnostic imaging is often used to justify invasive procedures like cortisone injection, arthroscopy and spinal surgery. The article by Eyal Lederman explores this topic in more detail.

biomechanics and energy conservation

Injury can alter biomechanics and undermine smooth integrated movement. Clunky movement is less efficient and alters loading patterns throughout the body. Anyone who has had a debilitating injury is able to describe the changes in movement quality and associated muscular tensions that reflect the cost of adapting to altered biomechanics. Restoring function and reducing the metabolic cost of movement is central to the osteopathic treatment.

Functional limitations of the lower limbs and pelvis, undermine smooth transfer of momentum. In movement there is a coupled spiraling relationship between the shoulder girdles, spine, pelvis and lower limbs – they are connected through extensive fascial networks and coordinated through by precise motor control patterns. Restoring these relationship is essential to relaxed and free movement.

fascia and biotensegrity

Fascia (connective tissue) permeates the entire musculoskeletal system and has a number of distinct regional functions that are relevant to osteopathic practice. Fascia is now regarded as a ‘body wide mechanosensitive signaling system with an integrating function analogous to that of the nervous system’.

Fascia is involved in functions as diverse as:

  • creating distinct compartments for muscles as well as facilitating their interconnection and coordinated function
  • acting as an ectoskeleton for muscular attachment and augmented contraction
  • circulatory-support function (the so-called muscle pump phenomenon)
  • protection of underlying vascular and neurological structures

Fascia is made up of collagen, elastin and lots of ‘bound’ water. It contains specific types of cells that synthesise collagen and mediate immune function. The palpable density of fascia varies enormously between individuals suggesting that patients might benefit from quite different therapeutic approaches.

Muscles, tendons and ligaments are composed of increasing proportions of dense connective tissue – it is richly innervated and displays contractile properties. Connective tissue is therefore integral to and affected by biomechanical and proprioceptive function, trauma and postural load. Its mechanical properties can be defined in complex material engineering terms – however biological materials behave quite differently when exposed to force.

Under balanced loading conditions, connective tissue resists, stretches and recoils. Sudden, repetitive or persistent abnormal loading can cause creep, micro tearing or even rupture. These processes are associated with inflammation. Osteopathic treatment of traumatic injury extends beyond the local injury into the related and interdependent fascial network. We often refer to this approach as ‘tracking a lesion field’ – these fields typically consist of connected and interrelated tissues (including fascia) that on assessment reveal altered physiology and function. Tracking such fields means that osteopaths shift from local into more systemic treatment.

Biotensegrity refers to the role of compression and tension relationships in biological systems. Fascia forms an integral part of this system. Analysis and modeling of loading patterns and capacities as well as other biomechanical properties in human systems has been enriched through biotensegrity.

neuroimmunoendocrine integration

‘The rule of the artery is supreme’ is a phase coined A.T. Still, the founder of osteopathic medicine. The depth of this insight is reflected in our current understanding that neurological, biochemical, hormonal and immunological systems are regulated through interdependent networks. The previously artificial distinctions between these systems have gradually dissolved as neuroimmunoendocrine integration has emerged. Complex processes like stress, non alcoholic fatty liver disease and metabolic syndrome exemplify the benefits of an integrated approach to understanding normal and altered physiology.

working upstream

This term is a treatment principle and has at least two meanings.

Firstly, it relates to the diagnostic and therapeutic necessity of paddling beyond a patients superficial and obvious symptoms and compensations, towards cause.

The second meaning refers to therapeutic locality, agency and potency. Downstream treatment focuses on reducing autonomic chatter, resolving tissue strain and fluid issues. These responses are mediated by a vectorial involuntary motion with moderate potency. Upstream treatment ulilises slow, fluid and deep involuntary motion with remarkable systemic intelligence and potency. This type of motion is a gateway into stillness.

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