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COMAT Osteopathic Principles

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TABLE OF CONTENTS Preface........................................................................................................ 1 About the COMAT OPP Examination ........................................................... 4 Chapter One: Osteopathic Philosophy ......................................................... 6 History of Osteopathy ...................................................................................................... 6 Basic Osteopathic Principles ........................................................................................... 8 Five Models ..................................................................................................................... 11 Using Osteopathic Principles in Practice ...................................................................... 14 Barrier Concepts ............................................................................................................ 18 Somatic Dysfunction ...................................................................................................... 22 Fryette’s Principles ........................................................................................................ 23 Key Takeaways ............................................................................................................... 25 Chapter Questions ......................................................................................................... 26 Chapter Two: Skeletal Structure and Function .......................................... 30 Axial Skeleton ................................................................................................................ 30 The Skull Bones.............................................................................................................. 31 Facial Bones ................................................................................................................... 42 Vertebral Column ........................................................................................................... 46 Thoracic Cavity .............................................................................................................. 52 Appendicular Skeleton ................................................................................................... 54 Pectoral Girdle ............................................................................................................... 54 Arm and Forearm........................................................................................................... 57 Wrist and Hand .............................................................................................................. 60

Pelvic Girdle ................................................................................................................... 62 Thigh and Leg ................................................................................................................ 64 Foot and Ankle ............................................................................................................... 68 Joint Anatomy and Physiology ...................................................................................... 68 Evaluating Skeletal Disorders........................................................................................ 73 Evaluating Specific Joints .............................................................................................. 75 Common Skeletal Disorders ..........................................................................................80 Bursitis ...........................................................................................................................80 Tendonitis ...................................................................................................................... 82 Carpal Tunnel Syndrome ............................................................................................... 83 Hand Osteoarthritis ....................................................................................................... 85 Atlantoaxial Subluxation ............................................................................................... 85 Herniated Discs.............................................................................................................. 86 Lumbar Spinal Stenosis ................................................................................................. 87 Sciatica ...........................................................................................................................88 Spondylolisthesis ........................................................................................................... 89 Osteoporosis................................................................................................................... 90 Evaluation of Joint Pain ................................................................................................ 92 Key Takeaways ............................................................................................................... 96 Chapter Questions ......................................................................................................... 97 Chapter Three: Muscular Structure and Function .................................... 101 Muscle Basics ................................................................................................................101 Head and Neck Muscles ............................................................................................... 102 Back Muscles ................................................................................................................ 108

Abdominal Muscles....................................................................................................... 111 Thoracic Cage Muscles .................................................................................................. 115 Upper Extremity Muscles ............................................................................................. 115 Pelvic Floor Muscles .................................................................................................... 124 Leg Muscles .................................................................................................................. 125 Muscular Disorders...................................................................................................... 138 Myopathy ..................................................................................................................... 138 Myositis ........................................................................................................................ 138 Myasthenia Gravis ....................................................................................................... 139 Key Takeaways ............................................................................................................. 142 Chapter Questions ....................................................................................................... 143 Chapter Four: Vascular Structure and Function....................................... 147 General Blood Vessel Information .............................................................................. 147 Head and Neck Vessels ................................................................................................ 149 Thoracic Vessels ............................................................................................................155 Upper Extremity Vessels.............................................................................................. 158 Abdominal Vessels ........................................................................................................ 161 Pelvic Blood Vessels ..................................................................................................... 166 Lower Extremity Vessels .............................................................................................. 167 Blood Vessel Disorders ................................................................................................. 171 Abdominal aortic Aneurysm ......................................................................................... 171 Thoracic Aortic Aneurysm ............................................................................................172 Atherosclerosis ..............................................................................................................173 Vasculitis .......................................................................................................................175

Key Takeaways .............................................................................................................. 177 Chapter Questions ....................................................................................................... 178 Chapter Five: Lymphatic System ............................................................. 182 Lymphatic Basics ......................................................................................................... 182 Head and Neck Lymphatics ......................................................................................... 185 Upper Limb Lymphatics .............................................................................................. 187 Lower Limb Lymphatics .............................................................................................. 188 Lymph Node Physiology .............................................................................................. 189 Lymph Node Examination ............................................................................................ 191 Disorders of the Lymphatics ........................................................................................ 192 Lymphedema ............................................................................................................... 194 Hodgkin Lymphoma .................................................................................................... 196 Non-Hodgkin Lymphoma............................................................................................ 198 Lymph Mobilization ..................................................................................................... 199 Key Takeaways ............................................................................................................. 203 Chapter Question .........................................................................................................204 Chapter Six: Neurological System ........................................................... 207 Central Nervous System .............................................................................................. 207 Cerebrum ..................................................................................................................... 207 Cerebellum ................................................................................................................... 210 Basal Ganglia................................................................................................................. 211 Midbrain....................................................................................................................... 213 Pons .............................................................................................................................. 214 Medulla Oblongata....................................................................................................... 215

Spinal Cord................................................................................................................... 216 Cranial Nerves .............................................................................................................. 219 Cervical Nerves ............................................................................................................ 221 Peripheral Nerves of the Upper Body .......................................................................... 223 Peripheral Nerves of the Lower Body .......................................................................... 225 Autonomic Nervous System ........................................................................................ 230 Autonomic Dysfunction ............................................................................................... 234 Autonomic Neuropathies ............................................................................................. 235 Pure Autonomic Failure ............................................................................................... 235 Peripheral Nerve Disorders ......................................................................................... 235 Neuromuscular Junction Disorders ............................................................................ 237 Key Takeaways .............................................................................................................240 Chapter Questions ....................................................................................................... 241 Chapter Seven: Viscerosomatic Reflexes and OPP ................................... 245 Viscerosomatic Reflexes .............................................................................................. 245 Chapman Reflexes ....................................................................................................... 248 Key Takeaways ............................................................................................................. 255 Chapter Questions ....................................................................................................... 256 Chapter Eight: Osteopathic Diagnoses of the Body .................................. 259 Cranial Diagnoses ........................................................................................................ 259 Craniosacral Techniques.............................................................................................. 264 HEENT Diagnoses ....................................................................................................... 267 Pulmonary Diagnoses .................................................................................................. 268 Rib Diagnoses .............................................................................................................. 269

Diaphragm Diagnoses .................................................................................................. 270 Osteopathy in Pregnancy ..............................................................................................271 Osteopathy in Hospitalized Patients ........................................................................... 272 Key Takeaways ............................................................................................................. 273 Chapter Questions ....................................................................................................... 274 Chapter Nine: Osteopathic Diagnoses of the Spine, Pelvis, and Extremities .......................................................................................... 278 Thoracic and Lumbar Diagnoses ................................................................................. 279 Pelvis and Sacral Diagnoses......................................................................................... 281 Upper Extremity Diagnoses ......................................................................................... 284 Lower Extremity Diagnoses ......................................................................................... 285 Key Takeaways ............................................................................................................. 287 Chapter Questions .......................................................................................................288 Chapter Ten: Osteopathic Treatments ..................................................... 292 Articulation .................................................................................................................. 292 Facilitated Positional Release ...................................................................................... 294 Still Technique ............................................................................................................. 295 Balanced Ligamentous Technique ............................................................................... 295 Functional Technique .................................................................................................. 296 Myofascial Release ....................................................................................................... 297 Muscle Energy .............................................................................................................. 297 HVLA ............................................................................................................................ 298 Strain and Counterstrain ............................................................................................. 299 Key Takeaways ............................................................................................................ 300 Chapter Questions ....................................................................................................... 301

Summary ................................................................................................ 304 Course Questions .................................................................................... 307 Answers to Questions............................................................................... 371 Chapter One ..................................................................................................................371 Chapter Two ................................................................................................................. 373 Chapter Three .............................................................................................................. 374 Chapter Four ................................................................................................................ 375 Chapter Five ................................................................................................................. 376 Chapter Six ................................................................................................................... 377 Chapter Seven .............................................................................................................. 379 Chapter Eight ...............................................................................................................380 Chapter Nine ................................................................................................................ 381 Chapter Ten .................................................................................................................. 382 Course Questions ......................................................................................................... 384

PREFACE The purpose of this course is to prepare you for the COMAT Clinical Osteopathic Principles and Practice examination, which you should be taking after you have completed your clinical coursework in these areas. While there are other COMAT examinations that assess your knowledge in the fields of primary care medicine, emergency medicine, and pediatrics, among others, this particular course covers the Osteopathic Principles and Practice field, which helps you to apply the specific things you have learned about osteopathy as a field of medicine in its own right. You will learn about some of the history and philosophy of osteopathy as background information on osteopathy as it is practiced in the US today. You will also study the different bones, muscles, lymphatics, and nerves in the human body and will use these things and your knowledge of diseases of these areas in order to apply them to clinical practice. You will also learn about osteopathic diagnoses and treatment strategies. There are numerous osteopathic manual techniques used in all areas of osteopathic medicine that you should know when to apply in different clinical situations and how to perform. These things are included in some of the latter aspects of the course. In chapter one of this course, you will learn some of the basic tenets of osteopathic philosophy, including how it began and how it evolved since the inception of this field of medicine. Part of understanding these things is to see how history has shaped osteopathy so you can better understand the basic osteopathic principles and five models of osteopathic medicine. Barrier concepts are important to understand as they apply to osteopathy as is an understanding of somatic dysfunction, which are also discussed. Things like TART and Fryette’s principles are basic things you need to know as you begin your assessment and treatment of the different patient presentations, so these are covered in this chapter. In chapter two, the focus is on the human skeleton, including the axial skeleton, the appendicular skeleton, and the joints, which include the tendons and ligaments. These

structures are covered completely in the chapter as well as how to examine the different musculoskeletal areas of the body. Common disorders of the skeletal system are also discussed. This chapter focuses specifically on the general evaluation and management of the skeletal system and its abnormalities. The osteopathic diagnoses and treatments of these areas are discussed in a later chapter. Chapter three in the course is about the human muscular system, its structure, and its function. This ties well into the skeletal system as these two types of tissues are intricately connected, with the muscles having a major influence on the relative positions of the bones. Also covered in this chapter are diseases affecting muscles. There are various muscle disorders, both common and rare, that can affect some of the patients you will see in clinical practice. The main topic of chapter four is the vascular supply to the body as well as the different blood vessel disorders you might encounter. Blood vessels are mainly divided into arteries, capillaries, and veins but, for the purposes of this course, you need only to know the arterial supply and venous return with regard to the various body areas. Some blood vessel diseases, such as atherosclerosis, are very common, while vasculitis is uncommon. Both of these and others are covered in this chapter. Chapter five in the course introduces the lymphatic system. In this part of the course, we will talk about the anatomy of the lymphatic system in all parts of the body, lymph node physiology, and the lymph node examination. Also discussed in this chapter are the different lymphatic diseases, such as lymphadenopathy, lymphedema, and the different lymphomas. How the doctor of osteopathy performs lymphatic mobilization is also covered in this chapter. Chapter six is about the neurological system and its various disorders. The central nervous system, which includes the brain and spinal cord, are covered in this chapter as are the cranial nerves, the autonomic nervous system, and the different peripheral nerves involved in the upper and lower extremity motor and sensory functions. Disorders of the autonomic nervous system are discussed as part of this chapter along with disorders of the peripheral nerves and how these are often treated.

Chapter seven in the course covers some of the basic reflexes related to the viscera and somatic nervous systems, which lead to an understanding of the origin of things like Chapman reflexes and viscerosomatic reflexes. These interrelated things can be crucial to making a complex diagnostic process simpler using osteopathic principles and practice. The majority of this chapter relates specifically to how these reflexes can be used for the osteopath trying to make an accurate visceral diagnosis. As part of chapter eight, we will begin to talk about some of the osteopathic somatic diagnoses you will have to learn as part of the COMAT examination. This chapter talks about cranial diagnosis, as well as diagnoses related to non-spinal areas of the body, such as the ribs, the diaphragm, and the different diagnoses you will encounter in the pregnant and postoperative or hospitalized patient. These can be difficult concepts but will be those you will frequently see on the examination, apart from how these areas are treated. The focus of chapter nine in the course is primarily on the osteopathic diagnoses related to the spinal column, pelvic and sacral structures, and the extremities. Many patients will have primary issues related to these body areas, leading to somatic dysfunctions that can be directly or indirectly treated. As you will soon discover, there are differences in the spine all along its levels and specific dysfunctions you should be able to diagnose manually and treat accordingly. These are covered as part of this chapter. Chapter ten talks about some of the common osteopathic techniques used to treat somatic dysfunctions and other illnesses using what you know about osteopathy. While true knowledge of these techniques is best understood through practice and gaining skill, there will be questions on the COMAT OPP examination that will also test what you know about the different techniques and where they belong in your osteopathic practice.

ABOUT THE COMAT OPP EXAMINATION COMAT examinations are given by each osteopathic school in different ways in order to assess the osteopathic student’s knowledge of what they have learned. The COMAT Clinical Examination on Osteopathic Principles and Practice represents the things you should know after taking your basic and clinical coursework. The test not only examines your knowledge in the various clinical areas but they indirectly test the effectiveness of the osteopathic college you attend as well. The COMAT exam scores are collected for every student from a particular college and are compared to the scores of students from other osteopathic colleges. This helps the colleges identify areas where they need to be more successful in teaching the students as a whole. Each COMAT examination consists of a total of 125 multiple choice questions that must be completed within two hours and thirty minutes. You will receive a brief tutorial on how the examination is set up but, if you are listening to this audio-course, you should already be familiar with what is expected of you. The test questions will be different every time you take or repeat the examination and will be different, depending on what college you attend. Some questions will be more difficult than others. A COMAT exam is generally offered several times per year. When you take an examination, the scoring will be standardized so that the mean score will be 100 and the standard deviation will be 10. You can use a conversion table on the National Board of Osteopathic Medical Examiners website in order to find out your percentile rank among your peers. Reporting scores this way helps understand the test in the context of scores gotten from similar tests throughout the country. In this examination, the focus is on osteopathic principles and practice or OPP. There are three separate parts that have different weights on the exam. About 11 to 35 percent of the test is on osteopathic concept and philosophy. These include your clinical skills based on a knowledge of musculoskeletal structure and function, vascular and lymphatic structure and function, and neurological structure and function.

CHAPTER ONE: OSTEOPATHIC PHILOSOPHY In this chapter, you will learn some of the basic tenets of osteopathic philosophy, including how it began and how it evolved since the inception of this field of medicine. Part of understanding these things is to see how history has shaped osteopathy so you can better understand the basic osteopathic principles and five models of osteopathic medicine. Barrier concepts are important to understand as they apply to osteopathy as is an understanding of somatic dysfunction, which are also discussed. Things like TART and Fryette’s principles are basic things you need to know as you begin your assessment and treatment of the different patient presentations, so these are covered in this chapter.

HISTORY OF OSTEOPATHY While the idea of using manual therapy as part of the treatment of disease states existed from the time of Hippocrates, osteopathy as it exists today is most commonly thought to have originated because of the life and works of Andrew Taylor Still, who was born in Virginia in 1828 and ultimately raised in Tennessee. He came from a medical background as his father was both a traveling preacher and a physician himself. Andrew Still studied medicine in Missouri, primarily by reading medical textbooks and training with an existing physician, who happened to be his own father, so he could set up his own practice as a country doctor. He served in the American Civil War as a surgeon. His life was greatly impacted by headaches he had as a child and by the death of three of his children in 1864 from acute meningitis. These things led Still to believe that the medicine of the era was inadequate in treating some diseases and began to study ways he thought would be better at treating diseases. Sill came to believe through research and observation that the musculoskeletal system was crucially important in the manifestations and treatment of disease. He believed the body was able to self-heal, especially if it was stimulated in the right ways. From this, he determined that, through correcting the structure of the body with manual techniques—

techniques he called osteopathic manipulative medicine or OMM—the body could ultimately heal itself. The concepts of disease prevention and the “whole patient” were developed as ways to see how to promote health. Dr. Still opened the first-ever school of osteopathic medicine in Kirksville, Missouri, in 1892, in order to transform his philosophy of health into broader practice. Part of the reason this was done was to protest the ways people were treated through conventional medicine at the time, in ways he felt were morally corrupt and caused more harm than good to the patient. Remember that this was a time during which there was little access to antiseptics, no antibiotics, and harsh medical treatments for disease states. The idea behind what he ultimately called osteopathy is that manual manipulation of the musculoskeletal system and surgery, with little use of medications, is the preferred method of managing a patient’s health. This was because of his belief that many physiological dysfunctions were based on a disordered musculoskeletal system. Through understanding the interaction between the musculoskeletal system and other body areas, a variety of disease states can be managed without side-effects. Certainly, the early years of osteopathy were times of contention between this clinical practice and conventional medicine. Many medical organizations, including the American Medical Association, denounced osteopathy as a “cult”. Osteopathy was primarily a practice of manual medicine until 1950, when it expanded to include family practice. From 1971 to the present time, the scope of osteopathy further expanded to become a multi-specialty option and one where full service care could be given to patients of all ages. This isn’t to say the road toward recognition as a medical specialty hasn’t been a rocky one. It wasn’t until 1966 that osteopaths were allowed to serve as physicians or surgeons in the US military. In 1962, the American Medical Association took great pains to eliminate the practice of osteopathy in the state of California. Doctors of Osteopathy were given an MD degree and a ban was placed on licensing DOs. This practice was reversed in 1974.

Throughout the Twentieth Century, various states enacted laws granting licenses to Doctors of Osteopathy so they could have the same privileges in practicing medicine as MDs. It wasn’t until 1989 that the last state enacted these types of laws. Currently, the training of osteopathic students is nearly indistinguishable from traditional medical students, with the same lengths of training in medical school and residency. Some differences include those of emphasis on osteopathic principles in osteopathic colleges and the reliance of clinical rotations in private practices, which is more often done in osteopathy training than it is in traditional medical training. Some osteopathic schools do not do this, however, and focus on hospital-based rotations in the same way as medical schools.

BASIC OSTEOPATHIC PRINCIPLES The basis for the approach of the osteopath is called osteopathic philosophy. Knowledge of a patient’s health involves all aspects of health, such as mental, physical, spiritual, and emotional health. The focus is patient-centered and involves a whole body approach with the addition of manual diagnosis and patient management to both prevent and treat disease states. It is both the attitude and viewpoint of the osteopath practicing basic osteopathic principles that provide the template for solving clinical problems, restoring heath, maintaining optimal health, and educate the patient. These things become extremely important as medicine in general comes face to face with problems that have been found to involve the complexities of social, psychological, physical, ethical, and spiritual issues, in addition to basic physical and anatomic dysfunction. Nowadays, osteopathic principles are coordinated through the efforts of the Education Council on Osteopathic Principles or the ECOP. Those who lead this organization are the same people who are responsible for developing and promoting osteopathic principles and philosophy in the world today. They are also responsible for maintaining an up to date glossary of osteopathic terminology, which is published annually by the organization.

According to this glossary, osteopathic philosophy can be defined as a concept of healthcare that is supported by the expansion of scientific knowledge, which is based on the complex interactions between the anatomy and physiology of the human body. The core principles of osteopathic philosophy include these: 1.

The body of a human being is a dynamic unit of function.

Within the body are self-regulatory mechanisms that support self-healing as a natural process.

There is a strong interrelationship between structure and function of the body at all levels.

Osteopathy involves rational treatment that is based on these principles.

This places an increased focus in osteopathy toward a patient-centered, health-oriented approach to each patient situation that involves the enhancement, restoration, and maintenance of the body’s normal physiologic processes. For this reason, it is important to focus on more than the dysfunctional part of the patient and instead to understand the physiological and adaptive response patterns that can be used to help the patient restore or maintain their own optimal health. According to most physiology textbooks, there are tend different bodily functions that are coordinated in each patient. These include circulation, respiration, fluid and electrolyte balance, postural and body movement control, digestive processes, metabolism and energy balance, sensations, protective mechanisms, reproduction, and conscious or behavioral processes. The ECOP has combined these bodily functions into five integrated and coordinated bodily functions that together help a person adapt to the different circumstances of life. These include the following: 1.

Posture and motion together, which include the fundamentals of biomechanical and structural reliability.

Macroscopic and cellular respiratory and cellular factors operating together.

Metabolic processes of all kinds, including the biochemical processes involved in nutritional, endocrine, and immune system regulation.

Neurologic integration at all levels, including the CNS, peripheral and autonomic nervous systems, neuroendocrine factors, neurocirculatory factors, and the reflex relationships between each of these.

The collection of spiritual, cultural, psychosocial, and behavioral elements.

As you well know, osteopathy is more than just manual therapy. There are several physician roles, including addressing the major causes of disease using the available evidence-based practices in all of medicine, enhancing the patient’s own healing capacity, individualizing the patient’s management plan that integrates health restoration and disease prevention, and using manipulative therapies in order to maximize mechanical, structural, and physiological functioning. We will talk more about somatic dysfunction but, when it comes to osteopathic principles and practice, part of the goal is identifying these. A somatic dysfunction can be described as an impairment or alteration of function of related components of the body framework, which includes the skeletal, myofascial and arthrodial structures along with their interconnected lymphatic, vascular, and neural elements. When a dysfunction happens, there are noticeable changes, primarily in the area of motion. There can be disturbances in structure and function based on postural, behavioral, or traumatic issues underlying the problem. The diagnostic criteria for a somatic dysfunction are few. These include increased sensitivity, tissue texture change, asymmetry or positional change, and restriction of movement. These things can easily be detected if you know to look for them. Any impairment of the viscera can be reflected in the musculoskeletal system in what’s known as a viscerosomatic reflex. The reverse is true so that musculoskeletal dysfunction can be seen as a visceral impairment in what’s called a somatovisceral reflex. Interactions between these symptoms can contribute to a sort of vicious cycle that is self-perpetuating. OMT treatment can help to break this cycle. With OMT, somatic dysfunction can be managed by removing the myofascial and musculoskeletal blockages to what would otherwise be normal physiological processes. The direct techniques we will later talk about engage the restrictive barrier, while

indirect techniques involve positioning away from the barrier in order to follow the sense of tissue ease. It is the activating force that is used to affect change. This force can be initiated by the physician using things like compression, traction, or deep pressure. The force can also be initiated by the patient using voluntary muscle contraction or deep breathing activities as directed by the physician. The tissue targeted can be the neuromyofascial elements, the viscera, or the joints. We will discuss these later in the course.

FIVE MODELS There are the five coordinated body functions we just talked about, which can be referred to as five models, which can be used as ways to approach the patient. These allow the physician to have several different avenues for the diagnosis, treatment, or management of the patient’s presenting concerns, including using palpation as a method of diagnosis and osteopathic manual treatment for intervening on the concerns. These five models represent the different physiological functions that help us to maintain health and to adapt to stressors, through repair and recovery from disease states and illness. The musculoskeletal system is that which links the different coordinated body functions. This concept of the five models has been used in the study of osteopathy for more than 35 years. This has been since recognized by the World Health Organization as one of the main contributions of osteopathy to world health care. These five models are recognized simply as the biomechanical, respiratory-circulatory, neurological model, metabolicenergy, and behavioral models. Dr. Still introduced the various regional anatomical approaches used in osteopathy today. According to this model, assessing the patient’s joints and muscles, including posture and motion, involves the biomechanical model, while looking at the ribcage and diaphragm involves assessing the respiratory-circular model. The abdominopelvic examination and treatment of disorders of this area involve the metabolic-energy model. The head and spinal examination involves looking at the neurological model and

directing attention to stressors, values, and lifestyle choices represents a look at the behavioral model. In the biomechanical model, the patient’s concern is seen from a mechanical or structural perspective. One looks for connective tissue compliance, motion, and postural mechanisms, regardless of their initial etiology. These will generally interfere with the lymphatic, vascular, and neurological functions. The musculoskeletal system, however, interferes with each of the other systems in the body and, while it is a dysfunction in the joints, muscles, bones, or connective tissue, these things can impair the neurological and vascular structures as well, which can further interfere with metabolism and even behavior. Various other bodily functions can be disrupted, including mental functioning and the body’s homeostatic mechanisms. There will often be an inability to recover from or adapt to the different stresses placed on the body as well as the inability to halt further tissue and functional breakdown. In searching for a solution, the osteopath will often look for some type of structural impediment to healing and will attempt to correct this. This further corrects the other areas of dysfunction, such as the vascular, behavioral, structural, and metabolic areas. The body can then be allowed to repair itself. In the respiratory-circulatory model, the focus is on these interrelated components of physiology and pathophysiology. There are central and peripheral processes involved with this system, including arterial supply, venous or lymphatic drainage, lung and heart function, central neural control, and cerebral spinal fluid flow. This system also interacts with the other models in achieving homeostasis. The main function of this system is to have no impediment to the delivery of nutrients and oxygen to the tissues as well as the removal of waste products from the cells and tissues. Both the extracellular and intracellular fluid components are involved in this model. Any type of stress on the body that interferes with the function of this system will affect overall health. OMT, in particular, places a focus on the mechanics of respiration, circulation, and the flow of other bodily fluids. Because the osteopath deals with each of these models and how they interact with one another, the osteopathic doctor will treat illnesses such as pneumonia with a variety of

modalities, such as antibiotics, rehydration, and restoring the function and mobility of the diaphragm, rib cage, and both the thoracic and cervical spine. The neurological model looks at impairment of the different neural elements of the body. These too will affect other bodily systems, including the respiratory-circulatory functions, structural components, metabolic processes, and even behavioral processes. Because of the interaction between the nervous system and endocrine systems, an aberrancy in one of these will lead to problems with the other area. In treating the patient using this model, the goal is to reestablish optimal neural function. This will secondarily help to provide gains in each of these other areas, such as behavioral, metabolic, structural, and vascular areas. An example is the postop patient with ileus from anesthesia with spasm of the neck and back muscles because of neural reflexes. This leads to gaseous expansion of the gut, lack of appetite, nausea and vomiting, lack of adequate ambulation, and poor lung excursion. This is an example of how the CNS affects several other components of the body. By using OMT to relieve the muscle spasm, the patient can begin to heal themselves. The metabolic-energy model places a focus on how the body gains energy and uses it to provide nutrients to the rest of the body. Again, the musculoskeletal system plays a role in this process. It takes normal posture, good arterial supply and venous return, balanced emotions, and normal neurological mechanisms in order to have the metabolic-energy system work properly. By improving any one of these areas, the metabolic-energy system can function at a more efficient rate. Remember that the human body will always try to seek a balance between the intake of energy, energy distribution, and energy expenditure. When this is balanced, the patient is better able to adapt to different stressors, including psychological, immunological, and nutritional stressors. If the musculoskeletal system is dysfunctional, there is a burden on the rest of the body, including that of the ability to have an efficient metabolic-energy system. OMT can address the somatic dysfunctions that dysregulates the other body systems. In the behavioral model, the osteopathic physician focuses on the patients, emotional, mental, and spiritual state as they apply to lifestyle choices that will, in turn, affect the

other body systems. There are many factors that affect behavior, including hereditary, cultural, environmental, and socioeconomic factors. For example, the person who does not eat well, uses addictive substances, cannot exercise, or is involved with environmental toxicities can have subsequent issues with their thoughts, emotions, or behaviors. Often, the musculoskeletal system will participate in the expression of emotions and feelings, usually through increased neuromuscular tension. The function of OMT is to interfere with the cycle of emotions and muscle tension by addressing both of these things at the same time. The whole individual is considered with any patient concern so as to avoid missing the behavioral system as playing a role. As part of this, the physician helps the patient by making recommendation regarding lifestyle choices that will improve mental outlook, compliance with treatment, and the ability to participate in preventive care. The behavioral model recognizes that this aspect of the patient is most influential in preventive care strategies. An example of this might be the emphysema patient who has their disease from tobacco use. This particular behavior causes pathological changes in the lungs, which causes vascular compromise due to lack of oxygenation. This environment also affects neurological function of the CNS as well as the shape of the ribcage and its musculoskeletal connections. Shortness of breath leads to anxiety over breathing dysfunction as well as sleep disturbances. To help each of these things, the osteopath may use a variety of modalities, including medications to help tobacco addiction, to affect a behavioral change that may cascade down to affect all of the other body systems.

USING OSTEOPATHIC PRINCIPLES IN PRACTICE Because of the contributions of early osteopathic medical professionals, it becomes clear to the practitioner that the patient is of primary importance. As part of attempting to find solutions to the person’s complaint, it is necessary to get a thorough differential diagnosis that includes all aspects of the individual—from mind, body, and spirit. The solution to the patient’s complaints involves implementing things that are realistic and that have measurable outcomes. Lastly, the practitioner uses patient-oriented

educational practices that address as many concerns as possible. The major things that need to be emphasized include the restoration of health and the prevention of disease. In order to provide excellent and comprehensive patient care management, the emphasis is on restoring the patient’s well-being. This means many different possible addressable options, such as personal safety measures, adequate rest, reasonable nutrition, exercise to include strengthening, having solid social relationships, avoiding frequently-abused substances, reducing abusive interpersonal relationships, and avoiding environmental exposures. When the focus of health is within the patient, the person participates in their own diagnoses and the body provides its own prescriptions that are given in the proper doses and without the side effects seen when intervention happens from outside the patient. In that sense, the patient gets themselves well rather than the provider. This process of healing often goes beyond looking at the presenting complaint and beyond the relief of symptoms or the identification of a disease process. While the goal is to treat the impairment from a physical sense, it is also to identify and allow for the contribution of the whole patient’s body systems, including the behavioral system, in both the causation and management of the disease process. Of course, some of the most destructive factors that play a role in disease may be impossible to manage or eliminate, such as genetics and certain pathogens. Some things are changeable but difficult to change, such as societal involvement and lifelong habits. There are aspects, too, that involve the activities of the community or government. Because of these limitations, the main focus is on those adverse factors that can be modified through some type of professional or personal action and those that will modify the effect of those factors that cannot be changed. This is seen when the provider uses OMT in order to make a difference in body mechanics in order to affect health changes. It is also seen when the patient himself makes positive lifestyle changes to modify disease outcomes. This leads us to an understanding of the proposed osteopathic principles for the care of patients as proposed in 2002 by an interdisciplinary task force. These include the following: 15

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The focus in all of healthcare is the patient as an individual. This means that the relationship between the provider and patient is one where both are engaged in the healing process, with the provider as the patient’s advocate.

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The patient has the main responsibility for their own health. The provider’s job is to guide the patient in achieving their optimal health. Even so, the provider’s responsibilities in this process are still considerable, particularly when it comes to education.

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Effective treatment of the patient involves using these two tenets in order to provide an accurate diagnosis and use evidence-based guidelines for treatment that serves to optimize the patient’s overall health and wellness. Osteopathy as a whole embraces the idea that evidence-based care is what should guide the treatment strategy.

Still’s initial understanding of health and the osteopath’s role in it is often referred to as classic osteopathic philosophy. According to this philosophy, health involves a natural state of harmony within a human being. The emphasis is on the person’s structural and mechanical integrity so that, to Dr. Still, osteopathy involves the laws of matter, mind, and motion. Still studied movement in humans from the fetal period to old age. Still argued that health involves a completely natural state of harmony and that the body is itself a perfect machine for both health and activity. As long as the body fluids and nerves flow optimally, a healthy state can be achieved. Disease, on the other hand, is generally multifactorial. It is generally caused by some type of mechanical impediment to the normal flow of either nerve activity or bodily fluids. Once these are removed, heath can be restored. There also needs to be the inclusion of behavioral, mental, social, environmental, and cultural factors in health promotion, with goals that are realistic and achievable. Still further argued that lack of motion is not good for one’s life or overall health. So, what is involved in normal nerve activity and in the flow of bodily fluids? Still argued that the flow of bodily fluids meant the flow through arteries, veins, the lymph system, and nerves. These things need to progress unimpeded in order to gain nutrients to the various bodily areas and to eliminate wastes from these areas. The brain was

identified as the power source for the body machine, sending nerves that ultimately drive the flow of bodily fluids. Dr. Still’s classic philosophy of disease from an osteopathic perspective was that it was multifactorial. He recognized that pathogens were opportunistic to a poor host defense mechanism rather than as the primary causes of disease by themselves. In addition, some disease processes were from a buildup of fluids, leading to both congestion and inflammation. There was a recognition of the environment as being partially causative of disease. Ischemia itself could be caused by congestion, which might be traumatically induced. He taught that blood flow was under the control ultimately by the nervous system. Arterial blood flow was felt to be essential but so is the flow of the lymphatics. Other contributing factors to disease are substance abuse, poor personal hygiene, poor dietary choices, lack of exercise, and poor sanitation. Classic osteopathic philosophy also involves the idea that the body is its own pharmacy so that some people are more resistant to disease than others but that good blood flow is a necessity for healing. Drugs and medications are believed to be beneficial in some cases but, because they can also be harmful, they should be used judiciously. Vaccinations were once felt to be riskier than they were beneficial but this was revised in 1910. Still also believed that diseases mostly had mechanical causes, which meant that treatment had to be directed in this area. Manipulation is designed to relieve soft tissue and bony barriers to adequate blood and nervous system functions. Even in infectious diseases, the tension in the paraspinal muscles and related fascia were felt to impede healing. The treatment of patients also involved highlighting moderation things like diet and exposure to the environment. Substance abuse was also to be avoided and mental or emotional support by the physician was part of the healing process. As for the patient, he or she is to be considered as a whole, mostly because of the interdependence of the different aspects of the whole on each other. The collection of these interdependent factors leads to homeostasis within the body; dysfunction of any factor often leads to dysfunction of each of the other factors to varying degrees. Patients are more than just their body but have a mind and are affected by heredity and the

The total range of motion of a given joint will be limited by the structural integrity of the different physical components. There will be external forces that, if they move a joint beyond its anatomical barriers, there will be soft tissue damage, dislocation, or fracture. Midline is described as being between the extremes of the different anatomical barriers. The total range of motion of a joint or spinal segment can be divided into a passive range of motion and an active range of motion. The passive range of motion is determined by an elastic barrier, which is the normal barrier to motion that results when all of the tension has been taken up within the joint and its surround soft tissues. The difference between the elastic barrier and the anatomical barrier is called the “para-physiological space”. It is within this space that HVLA or high velocity, low amplitude thrust appears to cause its typical popping sound. The active range of motion, on the other hand, is determined by the physiological barrier. This will be less than the passive range of motion. The physiological barrier happens because of increased tension in the muscle and myofascial components. Myofascial shortening is often the cause of a reduction in the active range of motion. Any active movement of the musculoskeletal system is a result of voluntary muscle contractions generated by the patient. Passive movement of this system results from some type of application of forces on the part of the osteopathic physician. There are different types of muscle contractions that cause an increase in the tension of a muscle. These include the following: •

Concentric contraction—when any muscle develops enough tension to overcome an external resistance and visibly shortens to move a body part, this involves concentric contraction

•

Eccentric contraction—when an externally applied force becomes greater than the internal tension of a muscle resulting in lengthening of the muscle, this is called eccentric contraction.

•

Isotonic contraction—this is muscle contraction where the internal muscle forces are constant. If the externally applied forces are less than those generated internally, this is an isotonic contraction.

•

Isometric contraction—this is contraction of a muscle that does move any joint. There are equal and opposite internal and external forces from inside the muscle or from an external source in isometric contractions.

If a healthy muscle is passively stretched past its resting length, there is increased tension in the series and parallel elastic components. There is little tension in the muscles if the length difference between the applied stretch and the resting length. As the muscle is stretched near its elastic limit, however, tension in the muscle is dramatically increased. Any stretching beyond the elastic limit will tear the muscle and damage the muscle tissue. The sensation of elasticity and the absence of an identifiable hard barrier defines a normal joint. There can be pathological barriers to motion that can be found within skin, muscles, ligaments, fascia, and joints. There can be barriers associated with a spinal segment or a single joint. It may also cross over more than one spinal segment or joint. This leads to pathological changes within nearby tissues that results in certain end-feel sensations and loss of motion. When a restrictive barrier is present, it can be due to compromise of the active range of motion or to the inability to have passive range of motion beyond the active range of motion. When there is this restrictive barrier, the range of active motion can be defined by both the normal physiologic barrier and the restrictive barriers present. The treatment goal is to move the restrictive barrier as far as possible into the direction of motion loss. When you make a structural diagnosis, you are looking for abnormalities in the range, symmetry, and quality of joint motion in order to look for areas of dysfunction. Your treatment focus is to restore the maximum degree of pain-free movement of the entire musculoskeletal system. As part of this, you should ask if the range of motion is symmetric, if there is a reduction in the total range of motion, what the quality of the motion is like, and what does it feel like at the end point of motion. There are different feelings you might notice when evaluation a restrictive barrier. Look for these things: •

Normal tissue—this will be smooth and elastic, like a spring 20

•

Hypertonic tissue—this will appear tight

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Hypermobile joint or tissue—the resistance will be minor until then end, when it feels hard

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Fibrotic tissue—there will be an abrupt and hard end-feel to the tissues

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Spasm—there will be guarding that is jerky due to pain

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Edema of the tissues—it will feel spongy and boggy

One of the phenomena associated with any restrictive barrier is a shift of the neutral resting position in some direction away from the midline neutral. This creates what is called the pathological neutral, which is often at the midpoint of the available range of the joint or muscle’s active range of motion. The definition of the neutral resting point depends on the region being discussed. As part of your evaluation and treatment of a body area, you will be asked to identify whether the movement you are evaluating is free and easy or binding and difficult. As you move away from neutral, the greater will be the degree of binding and resistance to movement. The opposite is true as you get close to neutral. A joint at maximum ease is called “loose-packed”. When you understand this concept, you will understand best what happens when you participate in indirect osteopathic techniques. In a situation of hypertonicity of a muscle, for example, there is a high degree of muscle tone that reduces the range of motion, even in the passive stretching of the muscle. There will be the perception of a barrier to this passive motion. You should be able to tell the difference between the experience of testing passive range of motion in a normal muscle and in a hypertonic muscle. If there is this type of resistance or barrier, this is dysfunctional and your job will be to treat this in order to remove this type of restrictive barrier. In the case of hypertonicity of a part of the paracervical muscles, you will experience different displacements of cervical spinal rotation or sidebending from side to side with the same forces applied to each side. If you found a restrictive barrier to right rotation, for example, you would diagnose left C1 rotation or right rotation restriction of the cervical segment.

In the lumbar spine, you recognize that flexion and extension involves opening or closing of the paired facet joints. It is like an accordion that pulls outward or inward. With regard to the muscles, hypertonicity affects the opening of this accordion. This is called a positional diagnosis of extension of the lumbar segment because it is defined as where the segment is able to go and not where it is unable to go. If instead you are making a motion restriction diagnosis, you say that the segment resists flexion. If just one side of the lumbar spine is hypertonic, affecting the right transverse processes only, you will see that there is a restrictive barrier to flexion, left rotation as well as left sidebending. The positional diagnosis is extended, right rotated and right sidebent because this motion is possible. The motion restriction diagnosis is the opposite of that, called resistance to flexion, left rotation, and left sidebending.

SOMATIC DYSFUNCTION Somatic dysfunction of any type involves an alteration of function or impairment of a musculoskeletal structure plus their associated neural, vascular, and lymphatic elements. You can help to define this by assessing the TART of the tissues. TART is an acronym that refers to the following tissue changes: •

Tissue texture changes. In acute situations, the tissue may be red, tender, boggy, or edematous. In chronic situations, the tissue is atrophic, ropey, and rigid.

•

Asymmetry—the patient’s posture or joint function will be asymmetric when comparing both sides of the body.

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Restriction of motion—this can include the physiological barrier restriction, which involves the patient’s active movement of the joint or an anatomical barrier restriction, which involves inability to achieve adequate passive range of motion.

•

Tenderness—the patient experiences soreness upon palpation.

Somatic dysfunction is generally named by the area where it has freedom of motion rather than a restriction of motion. In further evaluating acute and chronic changes in the tissues, you will note differences depending on whether it is acute or chronic. In acute changes, the temperature of the tissue is increased, there is increased drag on a skin drag test, rigid tension, higher levels 22

of moisture, redness, boggy or rough texture, edema, and venous congestion. In chronic tissue dysfunction, the temperature is usually decreased, with decreased skin drag, ropey or stringy tension, mild tenderness, dryness, minimal redness, smooth or atrophic texture, neovascularization, and absence of edema. As you evaluate the patient for somatic dysfunction, you can follow Greenman’s modified ten-step examination to screen for this. These are the ten steps: •

Posture screening observed from several viewpoints and including assessment of the spine for curvatures and symmetry of the anatomic landmarks.

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Gait analysis, which is done through walking and squatting maneuvers.

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Sidebending maneuver to assess active sidebending ability.

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Standing flexion test.

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Stork test to assess the sacral and ilium movement.

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Seated flexion test, which assesses the sacroiliac motion together.

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Upper extremity screening of all the joints’ ranges of motions.

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Seated sidebending and rotation test, involving active and passive maneuvers

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Head and neck mobility

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Total body scan of the major landmarks while the patient is supine to include the ribs and a straight leg raising test.

FRYETTE’S PRINCIPLES In any assessment of the movement of the spine, you will apply the different Fryette’s laws, which apply mainly to the thoracic and lumbar spine. The exception is the third law, which applies to the entire spinal column. These were initially developed by Dr. Harrison Fryette in 1918, except for the third law, which came later. Fryette’s first principle applies only to the neutral spine. It states that, when the spine is neutral, any sidebending to one side involves horizontal rotation to the opposite side. It is applied in a type I somatic dysfunction, when more than one vertebra is not in alignment. This opposite nature of sidebending and rotation cannot be normalized by extending or flexing the vertebrae. Each vertebra of the group has the same dysfunction. 23

The second Fryette’s principle involves the flexed or extended spinal position. In such situations, sidebending and rotation happen in the same direction. This is seen in type II somatic dysfunction and involves just one vertebral segment. If the spine is placed into a non-neutral way, either flexion or extension, the misaligned segment will realign. In Fryette’s third principle, when there is motion in one plane, it will reduce the motion in the other two planes. In other words, any dysfunction in a single plane will affect all other planes. As an example, if you engage flexion, you also engage the sidebending and rotational aspects of the dysfunction.

Figure 2.

The sphenoid bone is butterfly-shaped and located between the frontal and temporal bones in the middle of the skull. There is a central body that surrounds the pituitary gland, and two sets of wing-like structures, called the lesser and greater wings. Some of the swallowing and chewing muscles attach to the inferior pterygoid processes. Figure 3 is a closeup view of the sphenoid bone and its location in the cranium:

Figure 3.

The lesser wings come up from the sides of the central body as do the greater wings, which are larger extensions that also come up from the sides of the body. The orbital surface of the greater wing could be seen behind the orbits and form part of the orbital cavity. Through the lesser wing is the optic canal, where the optic nerve and the ophthalmic artery pass through. Between the lesser and greater wings is the superior orbital fissure, through which the oculomotor, abducens, trigeminal, and trochlear

nerves pass. Figure 4 shows a skull through which this fissure can be seen in the orbit itself:

Figure 4.

The small hole in the greater wing, also at the base of the skull, is called the foramen rotundum, through which the maxillary branch of the trigeminal nerve passes. Also on the greater wing more posteriorly is the foramen ovale, through which the mandibular branch of the trigeminal nerve, the accessory meningeal artery, the emissary veins, and the lesser petrosal nerve pass. Finally, also in the greater wing is the foramen spinosum, through which the middle meningeal artery and a branch of the mandibular nerve pass. In the body of the sphenoid bone at the base of the skull is the chiasmatic groove. This is the exact place where the optic nerves in the brain partially cross over or decussate in what’s called the optic chiasm. On either side of this is the anterior clinoid process where the dura mater attaches and where the pituitary gland is protected. The two

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