Anda di halaman 1dari 353

For Elsevier:

Senior Commissioning Editor: Sarena Wolfaard


Project Development Manager: Mairi McCubbin
Project Manager: Gail Wright
Senior Designer: Judith Wright
Illustrations Manager: Bruce Hogarth
Osteopathy
Models for Diagnosis, Treatment
and Practice

Jon Parsons D O PGCE MSC Ost


Osteopathy Practitioner, Maidstone, Kent;
Senior Lecturer and Senior Clinical Tutor, European School of Osteopathy, UK

Nicholas Marcer DO MSC Ost


Osteopathy Practitioner and Teacher, Fribourg, Switzerland and Ischia, Italy
International Lecturer and Examiner

Forewords by

Simon Fielding OBE DO


Founding Chairman, General Osteopathic Council, London;
Director, Prince of Wales's Foundation for Integrated Health, London, UK
and

Renzo Molinari DO
Principal, European School of Osteopathy, Boxley, UK

Illustrations by
Amanda Williams

ELSEVIER
CHURCHILL
LIVINGSTONE

D1NBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2005
ELSEVIER
CHURCHILL
LIVINGSTONE

© 2006, Elsevier Limited. All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or


transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without either the prior permission of the publishers or a
licence permitting restricted copying in the United Kingdom issued by the
Copyright Licensing Agency, 90 Tottenham Court Road, London WIT 4LP.
Permissions may be sought directly from Elsevier's Health Sciences Rights
Department in Philadelphia, USA: phone: (+1) 215 239 3804, Fax: (+1) 215 239 3805,
e-mail: healthpermissions@elsevier.com. You may also complete your request on-
line via the Elsevier homepage (http://www.elsevier.com), by selecting 'Support
and contact' and then 'Copyright and Permission'.

Cover photographs © Kampfner Photography

First published 2006


Reprinted 2008

ISBN 978 0 443 07395 3

British Library Cataloguing in Publication Data


A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data


A catalog record for this book is available from the Library of Congress

Notice
Knowledge and best practice in this field are constantly changing. As new
research and experience" broaden our knowledge, changes in practice, treatment
and drug therapy may become necessary or appropriate. Readers are advised to
check the most current information provided (i) on procedures featured or (ii) by
the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindica-
tions. It is the responsibility of the practitioner, relying on their own experience
and knowledge of the patient, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety pre-
cautions. To the fullest extent of the law, neither the publisher nor the authors
assumes any liability for any injury and/or damage.

Working together to grow


libraries in developing countries
www.elsevier.com | www.bookaid.org | www.sabre.org

The
Publisher's
policy is to use
paper manufactured
www.elsevierhealth.com from sustainable forests

Printed in China
V

Contents

Forewords vii 14. Balanced ligamentous tension techniques 219


Preface ix
15. Visceral osteopathy 223
Acknowledgements xi
Abbreviations xiii 16. Indirect approach technique: myofascial 233
17. Functional technique 241
SECTION 1 Osteopathy and the osteopathic
18. Jones technique 245
lesion - a developing concept 1
19. Trigger points 249
1. W h a t is osteopathy? Towards a definition 3 20. Chapman's reflexes 251
2. The osteopathic lesion or somatic dysfunction 17 21. Soft tissue techniques 253

SECTION 2 Osteopathic conceptual


SECTION 4 Clinical conditions 257
(perceptual) models 41
22. Dysmenorrhoea 259
3. Structural concepts 43
23. Irritable bowel syndrome 265
4. Tensegrity 71
24. Asthma 271
5. Biotypology 83
25. Low back pain 275
6. The nervous system 107
26. Headache 285
7. Psychological considerations 137
27. Pregnancy 289
8. The respiratory-circulatory model of osteopathic
care 159 28. Otitis media in the infant 295

9. The total osteopathic lesion 165 29. Sports injuries 299


30. Blood pressure 305
SECTION 3 Introduction to models of
31. Whiplash 313
diagnosis and treatment 177
32. Geriatrics 317
10. General osteopathic treatment 181 33. Treatment planning 323
11. Specific adjusting technique 189 34. Specialisms in osteopathy 331
12. Muscle energy technique 193
13. Cranial osteopathy 201 Index 333
vii

Forewords

Having known both the authors as students it is a significant contribution to that much-needed body
great privilege to be asked to write a brief foreword of knowledge, charting, as it does, the historical
to this, their first book. Sadly, in spite of their both perspectives of osteopathy and its evolution into a
having been my students, I can make no claim healthcare profession that has a rational evidence
whatsoever for any of the wisdom contained base for its concepts and clinical practice.
within these pages. As the chapters progress the reader is given an
In the late 1970s I became aware that if osteopa- overview of the major concepts in osteopathic
thy was to fulfill its potential in healthcare and thinking. The book traces these concepts from their
achieve any form of recognition from conventional historical roots too and describes how these are rel-
medicine there needed to be universal and credible evant to current osteopathic practice and its
standards of undergraduate training underpinned emphasis on integration with emerging orthodox
by the principles of conventional anatomy, physiol- concepts such as psycho-neuroimmunology. The
ogy and pathology. At that time anyone, irrespec- book also describes how concepts such as tenseg-
tive of their level of training, could set up and rity can be applied to the science of osteopathy and
practise as an osteopath. Training courses ranged are relevant to clinical practice.
from 4-year full-time programmes to merely a few The book manages throughout to achieve a sense
weekends' instruction in manipulation. This situa- of holism and consistency of thought, bringing
tion meant that neither patients nor conventional together the different concepts and models of
medical practitioners could rely upon the safety osteopathic healthcare that have arisen within the
and competence of all members of the osteopathic worldwide osteopathic community. What emerges
profession. is a total concept of osteopathy, not only in terms of
Throughout the 1980s and early 1990s I was for- somatic dysfunction but also integrating areas such
tunate to be able to assist the profession in coming as tensegrity and psychology. While destined to be
together to form a consensus on the needs of under- a set text for all osteopathic students, this book also
graduate training and proper regulation, which has much to offer all practitioners of the
resulted in the passing of the Osteopaths Act 1993. mind/body therapies. I look forward with eager
The establishment of osteopathy as a statutory reg- anticipation to the next offering from these two
ulated profession along the same lines as medicine innovative osteopathic thinkers.
and dentistry is, however, only the beginning of the
story. The profession now has a firm foundation Simon Fielding OBE DO
from which to realize its full therapeutic potential Founder Chairman of the General Osteopathic
and establish the coherent body of osteopathic Council and Trustee of The Prince of Wales's
knowledge and research essential for its future Foundation for Integrated Health
development. This book by Parsons and Marcer is a
viii FOREWORDS

This book is written at a crucial point in the still In the last decade, osteopathy has spread irre-
young history of osteopathy and for this reason it sistibly around Europe, not only as a discrete
will remain as a milestone. approach to health and medicine for the benefit of
Osteopathy developed in the USA and was inte- patients but also academically. A number of differ-
grated progressively into the medical culture of ent groups have been active in this growth and the
that country. In its early infancy, JM Littlejohn European School of Osteopathy is considered to be
brought this young and fragile approach to health one of the main protagonists.
and medicine to Europe, where it has developed From its inception, the School has had a
and expanded independently. Today we have a European outlook, having a French, English and
duality in approach and understanding around very quickly a Belgian branch. From 1994 the net-
Europe, but we must work together to create a work expanded and academic links developed pro-
forum in which the successes of our osteopathic gressively so that new schools were helped to
efforts can be shared. structure themselves. 1998 saw the foundation of
The dynamic growth of our profession in Europe the Osteopathic European Academic Network
and throughout the world can be summarized by a (OSEAN), which aims to link these institutions.
discussion that took place between Viola Frymann The two authors of this book, Jon Parsons and
and myself in Colorado Springs, USA. She was Nicholas Marcer, have been active internationally
arguing that when the "osteopathic seed' is planted during the last decade and it is now a great privi-
in one country, there are always two trees that grow lege to see their ideas coming to light.
and fight for life. To my mind, when the osteo- The real internationalization of osteopathy is just
pathic seed is planted in one country, the roots beginning and the next step will take place through
spread in different directions; it is only when these cross-fertilization between the two sides of the
roots are able to accumulate enough energy that the Atlantic. Research will be the medium to expand
trunk can grow. this dialogue, as the research basis of our science
We are at exactly this moment in the develop- needs to be developed.
ment of osteopathy. In every country various edu-
cational groups have formed and strengthened; on Renzo Molinari DO
different continents diverse groups have structured Principal of the European School of Osteopathy
the professional and educational aspect of our art
and science. It is now time to work together on
developing the core of our profession.
ix

Preface

The aim of this book is to attempt to explore some of case that many of the fundamental concepts that
the fundamental concepts to which an undergrad- are expressed within this book are rooted in
uate student of osteopathy, or other manual therapeu- 'English' or perhaps even 'Maidstone' osteopathy;
tic approach, will be exposed. We are relating these however, between the two of us, we have worked
concepts to the treatment and support of human extensively in Europe and the USA, and have been
beings. This creates certain difficulties, as the rich exposed to many other osteopathic paradigms.
complexities of the human form and function are not Wherever possible, we have tried to incorporate
easily pinned down and so the attempts to interpret or explain these varying views. We have also
these complexities for a therapeutic purpose are sought the advice of osteopaths throughout the
often numerous and varied. osteopathic world. Any shortcomings are our own,
Within the osteopathic world specifically there are however, and are apologised for.
a multitude of varied interpretations and percep- The book has been structured in four sections:
tions, and though it is a relatively young profession,
Section 1 looks at the development of osteopathy,
over time osteopathic concepts have been subject to
how we may define it, and then explores the idea of
the interpretation and reinterpretation of many great
the osteopathic lesion (somatic dysfunction), as an
tlunkers, and some less great! Each has added then-
entity itself and within a more holistic perspective.
own perspective.
Section 2 addresses some of the conceptual mod-
Different countries have also developed their
els that have been used, in an attempt to under-
understanding in subtly different ways. Within
stand how functional or pathological problems
Europe there are shades of differences that occa-
may be explained from an osteopathic perspective.
sionally appear so opaque that they severely limit
Section 3 discusses some of the models of diag-
communication: one simple example of this is the
nosis and treatment, how they have arisen and
nomenclature utilized to classify somatic dysfunc-
(where known) their underlying physiological
tion. In the USA, the allopathic/osteopathic combi-
rationale.
nation has further modified their contribution.
Section 4 consists of several case histories that
As a result of the above considerations, there are
attempt to integrate the first three sections by
many differing perceptual and practical approaches
demonstrating the processes involved in analysing
utilized, often with tension arising between the
several conditions from an osteopathic perspective.
apparently differing schools of thought. It is with this
situation in mind that we draw in this book on Though there was a combined input in all sec-
founding principles in an attempt to facilitate under- tions logistics dictated that Sections 1 and 2 were
standing in a relative newcomer to osteopathy. predominantly written by Jon Parsons and Sections
We were both trained at the European School 3 and 4 by Nick Marcer. It is hoped that the slight
of Osteopathy in Maidstone, England. As we are difference in writing styles is not too off-putting,
all influenced by the osteopathic paradigm in but it does allow us as individuals to express the
which we developed, it is almost certainly the concepts that are most important to each of us.
x PREFACE

Throughout this book we have made much use with the advances in science, perhaps appear to be
of conceptual models. Many may feel that this is naive or lacking in scientific gravitas or simply
inappropriate, criticizing the fact that people are incorrect. We have done this as we feel that it is
too varied to conform to models; or that a particu- important to understand the concepts that underpin
lar model is too reductionist in its conception with the foundation of osteopathy and that have been
regard to the whole that is a person. Both these and the springboard for development of the more recent
the many other arguments that could be put for- interpretations, to gain a more complete under-
ward have validity; however, it must be understood standing of osteopathy.
that these, as with all principles, are not to be fol- Though we have attempted to offer much infor-
lowed slavishly but are there rather as a support mation, as is so often the case with osteopathy the
designed to facilitate the comprehension of the answers are not always obvious and it may be that
complexities of the human form and its function for in some sections you will come away with more
the neophyte body worker. Through application, questions than answers. That being said, we hope
the inherent strengths and weaknesses of each that you find this book helps you take the first steps
model will become apparent, and clinical experi- on the exciting, confusing and rewarding osteo-
ence will then remodel each individual's under- pathic path.
standing.
We have also discussed models originated by Maidstone and Fribourg Jon Parsons
some of the early osteopathic innovators which, Nicholas Marcer
xi

Acknowledgements

Our greatest thanks must go to my wife, Alison, for Francais, Paris; College of Osteopaths, London;
her patience, support and understanding (JP), and The Academy of Children's Development, St
to Holly my daughter (NM). Petersburg; Skandinaviska Osteopatskolen,
Others who have contributed greatly, some both Gothenburg; Norwegian Osteopathic School, Oslo;
intellectually and emotionally, are Phil Austin, Instituto Superiore d'Osteopatia, Milano; Russian
Christian Fossum, Celine Meneteau, Renzo Academy of Osteopathic Medicine, St Petersburg;
Molinari, Lizzie Spring, Caroline Stone, Frank Wiener Schule fur Osteopathic, Vienna;
Willard, Jane Carreiro and Margaret Gamble. Osteopathic Schule Deutschland, Hamburg,
For those brave souls who read the early drafts, Stuttgart, Bremen and Kassel; University of New
Lynne Pruce, Hedi Kersten, Rob Thomas and England, College of Osteopathic Medicine, Maine,
Steven Bettles. USA.
And all of the students and faculty and staff at Heidi Harrison of Butterworth-Heinemann for
the European School of Osteopathy for the last 20 commissioning us originally and with Elsevier,
years, who have nurtured us as individuals, as Mary Law and Mairi McCubbin for their patience
osteopaths and as teachers. Similarly, the students and Gail Wright for quietly and efficiently making
and faculty of all of the schools in which we have order out of the chaos.
taught and learnt, notably College International Finally, we would like to thank Ewan Halley for
d'Osteopathie, St Etienne; College Osteopathique jumping in at the eleventh hour and saving the day!
xiii

Abbreviations

AACOM American Association of Colleges of GIT gastrointestinal tract


Osteopathic Medicine GOT general osteopathic treatment
AC anterocentral (anterior central) GST general systems theory
ACTH adrenocorticotropin hormone HPA hypothalamic-pituitary-adrenal
ANS autonomic nervous system HVLA high velocity low amplitude
AP anteroposterior HVT high velocity thrust
ASIS anterior superior iliac spine IBS irritable bowel syndrome
ASO American School of Osteopathy IL mterleukin
BLT balanced ligamentous tension IVM involuntary mechanism
C cervical L lumbar
BMT balanced membranous tension LC locus ceruleus
CAT computer assisted tomography L/S lumbosacral
CCP common compensatory pattern LVHA low velocity high amplitude
CNS central nervous system MET muscle energy technique
CRF corticotropin-releasing factor MRI magnetic resonance imaging
CRH corticotropin-releasing hormone NIM neuroimmunomodulation
CPJ cranial rhythmic impulse NMDA N-methyl-d-aspartate
CSF cerebrospinal fluid NMT neuromuscular technique
D dorsalsyn thoracic NO nitric oxide
D/L dorsolumbar NSAIDs non-steroidal anti-inflammatory
ECM extracellular matrix drugs
EEO Ecole Europeenne d'Osteopathie NRS easy normal rotation sidebending
EFO Ecole Francaise d'Osteopathie lesion
ESO European School of Osteopathy PA posteroanterior
ERS extension rotation sidebending PC posterocentral (posterior central)
lesion PGI paragigantocellularis
ESR electrical skin resistance PMS premenstrual syndrome
FRS flexion rotation sidebending lesion PNI psychoneuroimmunology
GOsC General Osteopathic Council of PNS peripheral nervous system
Great Britain PSIS posterior superior iliac spine
GAR general adaptive response PSNS parasympathetic nervous system
GAS general adaptation syndrome PRM primary respiratory mechanism
GAT general articulatory treatment PRT progressive relaxation training
GHRH growth hormone-releasing PVN paraventricular nucleus of the
hormone hypothalamus
xiv ABBREVIATIONS

RTM reciprocal tension membrane SRR stress resistance resource


S sacral T thoracic
SAM sympathetic adrenal axis TBA total body adjustment
SAT specific adjusting technique T/L thoracolumbar
SBS sphenobasilar symphysis TMJ temporomandibular joint
SCS strain counterstrain TOL total osteopathic lesion
SI sacroiliac TRH thyroid-releasing hormone
SNA sympathetic neural axis WDR wide dynamic range (neurone)
SNS sympathetic nervous system
Parasympathetic Sympathetic

The autonomic nervous system: (left) parasympathetic outflow; (right) sympathetic outflow. The basis of osteopathic medicine lies in
an understanding of the autonomic nervous system. All practitioners of osteopathy should have their own image of the autonomic
nervous system firmly imprinted in their own central nervous system to refer to during every treatment. This converts the lay bone-
setter into the osteopath.
SECTION 1

Osteopathy and the


osteopathic lesion - a
developing concept
SECTION CONTENTS This section introduces the term osteopathy
and reviews some of the numerous attempts
1. W h a t is osteopathy? Towards a
definition 3
at the difficult task of defining what it
actually is. It explores the precepts originally
2. The osteopathic lesion or somatic
conceived by Andrew Taylor Still, the founder
dysfunction 17
of osteopathy, and their role in underpinning
and informing the practice of osteopathy. It
also reflects briefly on the historical
development of osteopathy itself.
The osteopathic lesion, or somatic dysfunction,
is used as a vehicle to explore the variety of
ways of perceiving osteopathy. This section
also includes an attempt to draw some
parallels between the varieties of models used,
to minimize the confusion that can arise when
communicating with osteopaths grounded in
differing conceptual models.
3

Chapter 1

What is osteopathy?
Towards a definition

INTRODUCTION
CHAPTER CONTENTS

Introduction 3 The concept of osteopathy came to Andrew Taylor


A brief history of the origins of osteopathy 6 Still, the founder of osteopathy, at 10 o'clock on
Andrew Taylor Still (1828-1917) 7 22 June, 1874. He describes it as a revelation; it is
1

Subsequent developments 7 not uncommon for innovators or inventors to


describe the moment of comprehension in this way
Still's founding principles 9
and this is often referred to as the 'eureka princi-
Still's political platform 13
ple'. After years of study and background work, the
Summary 13
ideas suddenly coalesce at a particular point in
References 14 time, a revelation so significant that the individual
can recall the actual time that it occurred. Another
interpretation is that it was more a 'point of deci-
sion' than a revelation. At this point, Still's cumula-
tive experience enabled him to decide that he
would 'reform' current medical practice by intro-
ducing a system of therapeutics which would utilise
'natural forces' in the process of healing, rather than
'poisonous chemical agents'.
Whether it was a eureka 'experience', or a point
of decision, Still certainly possessed an appropriate
background. He is reported to have had an interest
in anatomy from his childhood, and he worked as a
Frontier doctor during the American Civil War.
This experience, combined with a deep dissatisfac-
tion with the current practice of medicine, would
have contributed to the development of his ideas.
His original conception was founded on the
importance of anatomy and its relationship to
the 'flow of natural forces' in the body. As he
became more pragmatic, these 'natural forces' even-
tually developed into his ideas on 'the rule of the
artery', 'venous liberty' and later 'nerve force'. The
anatomical relationship matured into the theory
4 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

that the normal workings of the body could be dis- the musculoskeletal system. This is a subtle dis-
4

turbed by anatomical abnormalities or displace- tinction for the layperson to appreciate, and the
ments. concept that osteopathy is just related to bones is
However, it was not until 1885 that he chose one that generations have tried hard to escape. One
to name this new approach 'osteopathy'. In the such attempt is:
intervening time, he experimented with several
approaches. He continued to use his skill as a med- Osteopathy, or osteopathic medicine, is a philosophy,
ical doctor (at the standards of his time), in combina- a science and an art. Its philosophy embraces the
tion with 'magnetic healing' (in 1865 he advertised concept of the unity of body structure and function
himself as a 'magnetic healer' in Missouri) and bone in health and disease. Its science includes the chemi-
setting (which he might have learned from the cal, physical and biological sciences related to the
Shawnee Indians whilst working at Wakarusa maintenance of health and the prevention, cure and
Mission in Kansas in the 1850s). He gradually real- alleviation of disease. Its art is the application of the
philosophy and the science in the practice of osteo-
ized that, of all of these approaches, manipulative
pathic medicine. 6

techniques were the most effective in working on


'anatomical abnormalities'. He therefore started to This tries to demonstrate that osteopathy refers
refine these techniques, so that they could be applied to a complex interplay of concepts and bodies of
in disorders beyond the purely rheumatological and knowledge, not just a bone out of place.
orthopaedic cases where the natural bonesetters did In the time since its conception 130 years ago
most of their work. In the early 1880s, manipulative many people have attempted to define osteopathy,
techniques were the a priori of his practice, and, though not without difficulty. Wolf stated, 'On
around 1882, he started advertising himself as a many occasions members of our profession have
'Lightening Bone-setter'. 2
tried to define the term 'osteopathy', but I doubt
Thus in 1885 Still coined the term 'osteopathy'. It anyone has produced a definition which satisfies'. 7

derives from two Greek words: 'osteon' meaning Each attempt will have a validity, but as with any
'bone', and 'pathos' meaning 'suffering'. However, healthy areas of pursuit, osteopathy is continually
within medical literature 'pathos' is taken to mean advancing. As new developments arise, and
'disease', as in 'myopathy', a disease of the muscles. thought processes change, the understanding and
For this reason the name osteopathy has, in the therefore the definition of osteopathy will subtly
past, and to this day, created some confusion, often change.
being taken to mean 'bone disease' or more simply It is of benefit to look at some of the definitions of
'something to do with bones'. Early osteopathic osteopathy that have been utilized in the past: in so
writers - explain that this was not Still's intention,
3,4 5
doing, it is possible to observe the range of interpre-
most notably Wilson and Tucker, who consulted tations. It is logical to start with two of Still's own
with a Classical Greek scholar to find a true etymo- definitions. The simplest was given in response to
logical root. He directed them to the root derivation the question, 'What is osteopathy?'. Still replied: 'It
of 'pathos' and the similar term, 'ethos'. The origi- is anatomy first, last, and all the time'. A more com-
8

nal meaning of 'pathos' was 'sensitive to' or plete attempt, cited in his autobiography, is:
'responding to' incoming impressions, in contrast
to 'ethos' which describes the same impressions, but Osteopathy is that science which consists of such
their outgoing effects. exact, exhaustive and verifiable knowledge of the
structure and function of the human mechanism,
The name was created to contrast with allopathy
anatomical, physiological and psychological, includ-
and homeopathy. These terms arise, respectively,
ing the chemistry and physics of its known elements,
from 'alios' meaning 'another' or 'opposite', and as has made discoverable certain organic laws and
'homoios' or 'homeo' meaning 'the same' or 'simi- remedial resources, within the body itself, by which
lar'. Thus, allopathy involves responding to or nature under the scientific treatment peculiar to
being influenced by opposites, and homeopathy osteopathic practice, apart from all ordinary methods
means responding to similars. Osteopathy involves of extraneous artificial or medicinal stimulation, and
sensitivity or responsiveness to bones, reflecting the in harmonious accord with its own mechanical prin-
concept that derangements of the musculoskeletal ciples, molecular activities and metabolic processes,
system can, via the various systems, lead to disease, may recover from displacements, disorganisations,
and that disease can be diagnosed and treated via derangements, and consequent disease, and regain
W h a t is o s t e o p a t h y ? T o w a r d s a d e f i n i t i o n 5

its normal equilibrium of form and function in health Progressing to 1991, William and Michael
and strength. Kuchera employed a description of the founding
9
13

principles of osteopathy in their definition:


This is written in somewhat archaic language and is
typical of Still's manner of writing, which can deter Osteopathy is a total system of healthcare which
people from attempting to read his original texts. It professes and teaches the osteopathic philosophy:
is perhaps necessary to look beyond the words for 1. The body is a unit.
the meaning within. However, the key element is 2. It has its own self-protecting and regulating
the breadth of the description. mechanisms.
3. Structure and function are reciprocally
This broad ranging version contrasts with a some-
interrelated.
what later definition given by Edythe Ashmore. 10

Treatment considers the preceding three principles.


Once the Professor of Osteopathic Technique at the
Osteopathy also encompasses all recognized tools of
American School of Osteopathy (ASO) in Kirksville,
diagnosis and healing including osteopathic
she wrote in 1915 that osteopathy is 'based upon the
palpatory and manipulative treatment methods.
sciences of anatomy, chemistry and physiology' and
that the 'central thought of the science of osteopathy Osteopathy has developed so many facets in the
is the lesion'. This focus on the lesion as central to mtervening years since its creation that there is now
osteopathy is reinforced by Jocelyn Proby, a 11
a trend for many current authors to not even
graduate of the ASO who wrote in 1937: 'It is by the attempt to define it, as to encompass all of the
bony 'lesion', and particularly the vertebral lesion that potential aspects would make a lengthy and some-
osteopathy as a school of practice must stand or fall.' what complicated essay; rather, there is a tendency
In essence there are similarities with Still's defi- to state the key principles in a manner similar to
nitions, but it is possible to perceive the rationaliza- Kuchera's above. If a definition is attempted, the
tion of the osteopathic concept and its reduction to result is generally kept very simple, as illustrated
the lesion and to a structural cause and effect. This by the following two examples.
continued throughout the 1930s and 1940s. Dr Leon One of the most recent definitions, and the one
Page wrote in the introduction to his book, The that the British osteopaths practise under, is that of
Principles of Osteopathy, in 1952: 12
the General Osteopathic Council of Great Britain
(GOsC) which states that:
The practice of osteopathy consists of various
prophylactic, diagnostic and therapeutic measures Osteopathy is an established recognised system of
designed to maintain or restore structural integrity diagnosis and treatment, which lays its main empha-
and thus ensure physiological function. The rational sis on the structural and functional integrity of the
application of therapy requires a comprehensive body. It is distinctive by the fact that it recognises
knowledge of normal structure and function and that much of the pain and disability which we suffer
familiarity with those structural and functional stems from abnormalities in the function of the body
perversions that constitute disease. structure as well as damage caused to it by disease."

It is interesting for contemporary osteopaths to note The American equivalent, compiled by the American
that neither the person nor the body is mentioned Association of Colleges of Osteopathic Medicine
(AACOM), defines osteopathy as:
and, as for the environment and psyche (discussed
below), he tends to refer to these as complications A complete system of medical care with a philosophy
that will be encountered and that will need to be that combines the needs of the patient with current
dealt with in the clinic, but not as part of the aetio- practice of medicine, surgery and obstetrics; that
logical whole: emphasizes the interrelationship between structure
and function and that has an appreciation of the
Therapy itself is an art and reflects the ability of the body's ability to heal itself.' 5

practitioner to utilize the combined experience of


himself and others in dealing with the intricate clini- The latter attempt demonstrates the incorpora-
cal problems which are complicated by such intangi- tion of osteopathy into the allopathic system of
ble elements as human personality, unusual healthcare in America, which contrasts with the
environmental circumstances, and many physical European approach, where it is still a distinct
and psychic aspects which are, as yet, unknown to entity, working with, but not within, the allopathic
factual science. system.
6 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

Over the last few decades there has been a grad-


A BRIEF H I S T O R Y OF T H E O R I G I N S
ual return to a more holistic approach to health, and OF OSTEOPATHY
more attention has been paid to the interdepend-
ence of the mind, the body and the spirit. The next
Manual medicine, in its broadest conception, is as
definition is a recent reinterpretation by Philip
old as mankind itself; it has developed in a multi-
Latey of Still's quote cited earlier. It demonstrates
plicity of ways of which osteopathy is one. Many of
the subtle shifts in conceptualization that have
these approaches have been passed down through
occurred since Still's time, but also the relevance, to
the generations with little recorded rationale.
this day, of the originating concepts:
Conceptualization of disease was originally rudi-
mentary and often incorporated a supernatural
The goal of osteopathy is the regaining of the normal
element.
equilibrium of form and function that typifies good
health. The osteopath helps achieve this by treatment Modern Western medicine has its deepest roots
methods that are in harmonious accord with the in Mesopotamia and Egypt, but the critical site of
human organism's own biological constitution and development of the science of medicine is thought
organisation. The treatment methods are aimed to by many to be Ancient Greece, notably on the two
enable or help the organism recover from displace- neighbouring islands of Cos and Cnidos where two
ments, derangements and disorganisations. We do of the earliest medical schools exist. It was from
this without using or introducing any extraneous, these schools, whilst medicine was still in its
artificial or medicinal intervention. So: we rely only infancy, that a perceptual schism arose as to how
on those remedial resources contained within the to view patients and their disease processes.
organism. We are able to do this through our knowl- The ethos of the school on Cos from around 400 BC
edge and discovery of organic laws; through careful was developed by Hippocrates; often cited as the
and exacting scientific research into the anatomical,
father of medicine, his principal achievement at that
physiological and psychological structure and func-
time was to develop a rational approach based on
tion of the human being.'"
observation of medical factors.
Fundamental to Hippocratic teaching was that:
Wolf is perhaps correct, in that there are no perfect
definitions. This appears to frustrate some individ- » effect must have a cause, and this cause may be in
uals, particularly since osteopathy is considered to the internal or external environment;
be a profession and, as such, we should to be able • whether that cause is an internal or external fac-
to define our practice precisely. However, it is also tor, it could be explained by natural phenomena,
possible to consider this as one of the great fea- (thus dispelling the mystical concepts of medi-
tures of our profession: it has many facets, and cine, such as possession by evil spirits).
refraining from the imposition of a rigid definition
allows space for each individual to create their But perhaps more critically significant, and the root
own. One of the aims of this book is to assist you cause of the philosophical schism, are the concepts
in creating your own uniquely personal definition that:17

of osteopathy based on the sum of all your experi-


ences, belief systems and contemporary and past « the medical art has three terms: the sickness, the
paradigms of osteopathy specifically, and science sick person, and the doctor. The doctor is the ser-
and knowledge generally. This definition will vant of the art, and, with the doctor, the sick per-
inform your whole approach to the practice of son must combat the sickness; and
osteopathy and, as we have seen with the above • the body will heal itself, and it is the role of the
definitions, it will change as your experience and practitioner to assist the patient's body in achiev-
knowledge grow. ing this.

In this brief discussion it can be seen that these have However, these views were not shared by his con-
been, and continue to be, major conceptual shifts temporaries at the neighbouring school at Cnidos,
within the practice and philosophy of osteopathy and where the opinions held were notably divergent.
it is perhaps useful to look at the development of Here they concentrated on the internal structures of
osteopathy to get a clearer picture of what osteopa- the body, dividing the contents into systems, and
thy is, and how we have arrived at our current rather than believing that disease processes fol-
understanding of it. lowed general 'rules', considered that each body
W h a t is o s t e o p a t h y ? T o w a r d s a d e f i n i t i o n 7

system and disease required a separate philosophy great importance of the blood supply in human
and method of treatment. Treatment should, then, function or dysfunction, as well as the concept of
be aimed directly at that specific disease process natural immunity, or the body's inherent capacity
rather than at assisting the patient in the resolution to self-regulate and cure itself.
of the problem. As we have seen, it was not until 1885 that he
It is from this that the conceptual differences coined the term osteopathy, and it was not until
arose. Stated somewhat simplistically, allopathic 1889 that he actually called himself an osteopath.
medicine has tended to follow the Cnidian philoso- Prior to that, he called himself a 'magnetic healer' or
phy of the practitioner intervening in the disease Tightening bone-setter'. It is possible that the
20

process. This has become especially apparent over reason for this delay was that Still did not realize
the last century with the discovery of the germ for some time that he had invented something dif-
theory. Treatment has become more symptom spe- ferent from healing and bone-setting. 21

cific and research is looking ever more microscopi- By 1892 he had founded the American School of
cally for the specific pathogen or biochemical Osteopathy (ASO) in Kirksville, where he taught phi-
imbalance. Thus the disease process itself has losophy and osteopathic treatment. Still was aware
become the principle. The individual is less and less of the need to distinguish osteopathy as a separate
the one who expresses health or ill health, but entity from medicine, and though the charter of the
instead one who is afflicted by disease in the form school permitted the award of an MD degree, he
of noxious pathogenic agents or phenomena and insisted on awarding the distinctive DO, Diplomate
requires antidotal treatment (though it should be of Osteopathy. He continued to work as an osteopath
noted that, recently, allopathic medicine is shifting and teacher all his life and observed the gradual
away from this reductionist approach). 18
flowering of osteopathy until his death in 1917.
The Cos school, imbued by Hippocrates' ideas
promulgating a more global concept of disease,
acknowledging the body's ability to resolve prob- SUBSEQUENT DEVELOPMENTS
lems, and seeing the role of the practitioner as sup-
portive rather than interventionalist, has been POLITICAL AND A C A D E M I C
pursued by the more holistic complementary
approaches, and as such it is of no surprise that the The first graduating year from the ASO consisted
legacy of Hippocrates was picked up by Still. of just 14 students; included within this group were
three of Still's sons and one daughter. The course
was less than a year long for the first alumni. John
A N D R E W TAYLOR STILL ( 1 8 2 8 - 1 9 1 7 ) Martin Littlejohn enrolled as a student in 1898 and
graduated in 1900. At the same time as being a
Still was born in 1828 in Lee County, Virginia. He student he held the post of Professor in Physiology
was reportedly interested in anatomy from an early and later became Dean. There was an amazingly
age and, as a teenager, was known to dissect ani- rapid growth in osteopathy. By the turn of the
mals that had been shot. Through a process of century, 12 other osteopathic schools had already
apprenticeship, some tuition and self-motivation he been formed, and collectively they had some 700
became a frontier doctor. During the Civil War, he students.
was a captain in the Union Army. He used his med- Osteopathy, as a subject, was introduced in the
ical skills to help the wounded and, by so doing, UK in 1898 through a lecture at the Society for
continued to develop his anatomical knowledge. Science, Letters and Arts in London by Littlejohn.
In 1864, after witnessing the death of his chil- These lectures were repeated in 1899 and again in
dren from meningitis and being impotent to help 1900. The first osteopaths settled to practise in the
them, he began searching for an alternative UK in 1902: they were FJ Horn, Lillard Walker,
approach to healthcare. He experimented with Harvey Foote and Jay Dunham. The influx of
magnetism and Mesmerism but the final result of
19 American-trained osteopaths was so numerous that
this search was the creation of osteopathy. On 22 in 1910 the British Osteopathic Society was
June 1874 he proposed a different model of treat- founded. In 1911 they changed their name to the
ment and diagnosis that was mediated principally British Osteopathic Association. The first school in
by the musculoskeletal system but recognized the Europe, the British School of Osteopathy in London,
8 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

was founded in 1915 by Littlejohn, and incorpo- Concurrent with the spread of osteopathy
rated in 1917. Migration of osteopaths continued throughout the world was a gradual shift in the
into the rest of Europe. In 1923 Dr Stirling intro- conceptual principles and means of applying
duced osteopathy to a group of medical doctors in osteopathy. Dummer describes four evolutionary
22

France, one of whom was Paul Geny, who went on stages of the development of osteopathy. (These
to found the Ecole Francaise d'Osteopathie (EFO) stages are an oversimplification, but have a use in
in Paris in 1951. This later moved, under the direc- describing trends, particularly in the material being
torship of Tom Dummer, to Maidstone in England taught within the osteopathic schools at the various
to become the Ecole Europeenne d'Osteopathie stages.)
(EEO), later the European School of Osteopathy The first stage is essentially formative and devel-
(ESO). Many of the first graduates of the EFO went opmental, starting with the origin in 1874 and pass-
on to found schools in other parts of Europe. ing through to 1900/1910. There is little clear idea of
Osteopaths trained in America moved to Australia the true nature of Still's treatment approach as he
in the early 20th century, and in 1909 several wrote no books on technique, but it would appear
osteopaths were listed as practitioners in the that though he describes both maximal and minimal
Melbourne area. Canada and New Zealand fol- approaches, essentially it was based on a minimal
lowed a similar pattern of development. structural approach and was rather intuitive and
subjective. It is also clear that he was difficult to
CONCEPTUAL learn from; he demonstrated on actual patients and
rarely repeated any particular treatment or tech-
Statutory recognition has not been straightforward. nique. He felt that 'common sense applied in a
In America, Vermont became the first state to mechanical way was the fundamental principle
license DOs in 1896 but it was not until 1989 that underlying the successful treatment of all disease of
Nebraska finally passed an unlimited practice law the human family'. His students tried to imitate his
23

for DOs (the last of the states to do so). treatment but, lacking his experience and under-
In the UK, after several failed attempts at get- standing, ended up using a 'shot gun' type method
ting a Bill passed through Government, it was rec- of treatment, cracking every joint in the body to
ommended that a voluntary register be set up. This ensure that nothing was missed. This marked the
start of the second stage of development.
was legally constituted in 1936 under the title,
The General Council and Register of Osteopaths Occurring between the years of 1900/1910 to
Ltd (GCRO). The GCRO, and particularly Simon 1950/1960, this was a structural-mechanical period.
Fielding, continued to pursue recognition but it There was a tendency to objectivity and rational
was not until 1993 that they finally succeeded and approaches. The osteopathic lesion became the
The Osteopaths Act was passed to regulate the focus of attention (as seen in the definitions of
osteopathic profession in England, granting osteo- Ashmore and others; see p. 5). The treatment style
paths a status equivalent to doctors of medicine was more maximal than that of the earlier 'find it,
and dentists. The wording of the Act is as follows: fix it' minimal approach. Much treatment was
based on thrust techniques reversing the dysfunc-
An Act to establish a body to be known as the tion of the osteopathic lesion. Littlejohn and Fryette
General Osteopathic Council; to provide for the were prime influences in this era, and it was
regulation of the profession of osteopathy, including Littlejohn that kept alive the early more maximal
making provision as to the registration of osteopaths general treatment approaches by developing the
and as to their professional education and conduct; to 'general osteopathic treatment' (GOT), also now
make provision in connection with the development known as 'total body adjustment' (TBA).
and promotion of the profession; and for connected
purposes.24 It should be remembered that though these
approaches dominated, other systems were devel-
In 1994, the practice of osteopathy and osteopathic oping concurrently. In 1915, FP Millard's approach
training became federally regulated in Finland. was based on mobilization of the body fluids and
Belgium and France have draft propositions in place particularly the lymph, and in the 1920s Sutherland
and Norway is poised to grant recognition. By the and Weaver developed the concepts of cranial
time this book has been published, other countries motion and the approaches later to be known as
will almost certainly have followed suit. balanced ligamentous or membranous tension
W h a t is o s t e o p a t h y ? T o w a r d s a d e f i n i t i o n 9

(BLT and BMT). This reached fruition in the next redefined. Thus in 1953 the Osteopathic Committee
era. at Kirksville restated the above as:
25

By the 1950s a new paradigm began evolving, 9 The body is a unit.


further developing the cranial approach of • Structure governs function.
Sutherland and spawning the emergence of the so- • The body possesses self-regulatory mechanisms.
called 'indirect techniques'. CH Bowles and HV • The body has the inherent capacity to defend
Hoover were responsible for developing the con- itself and repair itself.
cept of functional technique, while TJ Ruddy and F
Mitchell concentrated on muscle energy techniques, And later these four were supplemented by the 26

and LH Jones focused on counterstrain. This, the following:


third stage of development, from 1950 to 1975, » When the normal adaptability is disrupted, or
could be termed the cranial-functional phase. when environmental changes overcome the body's
Development has continued apace with each capacity for self-maintenance, disease may ensue.
approach leading to further subtle developments, » The movement of the body fluids is essential to
so that today we have a rich and varied armamen- the maintenance of health.
tarium enabling us to modify conceptual and prac- • Nerves play a crucial part in controlling the fluids
tical approaches to the needs of each individual, of the body.
leading us to the fourth and present stage. This is • There are somatic components to disease that are
described as the 'holistic return-to-the-source which not only manifestations of disease but also are
gives (apparently in keeping with Still's original factors that contribute to maintenance of the dis-
conception), equal emphasis to the dynamic struc- eased state.
tural/ functional-functional/structural aspects both
in diagnosis and technique'. 22 These simple precepts require some explanation to
Even though, as the above demonstrates, there appreciate the depth of thought behind these few
have been marked changes in conceptualization words.
and we now possess a great variety of approaches
within osteopathy, it is possible to trace nearly all of THE BODY IS A UNIT
these approaches back to the original principles
espoused by Still. The following section will return Still was a devout man who believed that the body
to the roots of osteopathy and explore some of these was designed by God (whom he often described as
principles. 'the Architect'). Being divine, the design should be
perfectly suited to its function, with each element
contributing to the whole. In Research and Practice,
STILL'S F O U N D I N G P R I N C I P L E S he utilized the analogy of man as a city. 'Let us say
that each person is a well organised city and rea-
Like Hippocrates, Still developed a 'person-specific' son by comparison that the city makes all the work-
rather than disease-specific approach. His philoso- shops necessary to produce such machinery as
phy was based on the integrity of the individual as required for the health and comfort of its inhabi-
a unified whole, rather than a review of physiologi- tants. Each organ is a labourer of skill and belongs
cal processes occurring in individual and separate to the union of Perfect Work.' All parts of the body
1

systems. are integrated. On an anatomical level, it can be


The earliest interpretation of Still's writings observed that the entire body and its systems are
resulted in the formation of the four precepts of united by means of the fascia. It is continuous
osteopathy, which can be stated as follows: throughout the body, uniting system to system and
cell to cell, and by supporting and maintaining
• The body is a unit.
these structures enables them to work in harmony.
• Structure governs function.
This phenomenon is also observed on a func-
• The rule of the artery is supreme.
tional level. Each part of the body has its own spe-
• The body possesses self-regulatory and seK-healing
cific function to achieve (e.g. temperature regulation
mechanisms.
or pH balance); however, each of these separate
These are still utilized as guiding rules, but as is the elements works as part of a 'team' to support the
case with most concepts, they have been gradually overall functioning of the individual. These are all
10 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

regulated by the nervous system, the central nerv- Furthermore he discovered that by addressing the
ous system controlling the musculoskeletal system somatic structure he could beneficially affect the
whilst the autonomic nervous system oversees the function of the local tissue/organ, and the general
visceral function; the endocrine system controlling health of that individual.
hormonal balance; and the immune system defend-
We say disease when we should say effect; for disease
ing the body. Once described as separate entities, it
is the effect of a change in the parts of the physical
is now known that these work together in a com-
body. Disease in an abnormal body is just as natural
plex harmony, termed the neuroendocrine-immune
as is health when all parts are in place)
system.
Compensation and adaptation are also high- This concept of structure functional dependency is
lighted in this notion of unity. Change in one sys- one of the fundamental tenets of osteopathic medi-
tem will be accompanied by adaptation in another, cine; implicit within it are predictive or diagnostic
always trying to maintain an integrated and func- possibilities. Thus by understanding in detail the
tioning (homeostatic) system. Taken beyond the anatomy of the body and the relation of one struc-
anatomical level, the concept of unity can incorpo- ture to another, it should be possible to predict the
rate the elements of the mind, the body and the consequences that would arise when one structure
spirit; this removes the locus of evaluation from the is moved from its normal position, and what effects
body alone and places it within the environment, this would be likely to have on its contiguous and
expanding the osteopathic concept into a truly continuous structures. For example, with an aber-
holistic arena. Thus a change in any one of the rant position of a rib, there will be consequent dis-
body's systems, whether caused by an internal or ruption of the attached intercostal muscles. This
external agent, will have an effect on other areas, will in turn have an effect on the structures passing
be they in the body, the mind or the spirit, and within them, i.e. on the fluid exchange of the artery,
affecting one will affect all of the others. vein and lymphatic system, and on the nerve con-
duction of impulses, both peripheral and centrally
STRUCTURE GOVERNS FUNCTION to its spinal segment, and on its neurotrophic func-
tion, having deleterious consequences on both
This statement appears to be immediately under- somatic and visceral structures supplied. The inap-
standable and on the simple level it is possible to propriate position of the rib will result in a compen-
conceive that if anything is designed for a purpose, satory pattern developing in other areas of the
change in that design will obviously affect the thorax or spine, which themselves will then create a
achievement of the purpose. For centuries, practi- similar disturbance.
tioners have been aware that if there is a pathologi- As osteopaths we have access principally, and
cal change in a structure, this naturally affects the most obviously, to the body's structure, and it is by
way that the structure functions. So, for example, a observing and palpating the structure of an indi-
ruptured ligament would lead to instability in the vidual that we can conceive the possible effects on
relevant articulation and thus affect its ability to function. By treating these structural problems we
function normally. Similarly, cirrhosis of the liver hope to improve both the local and global function-
will have an effect on every function that the liver is ing of the individual, supporting the body in its
expected to perform, such as detoxification of the homeostatic role.
blood, anticoagulant formation and so on.
With a correct knowledge of the form and function of
Still's strength was taking these concepts into the
the body and all its parts, we are then prepared to
non-pathological realm and looking at both local
know what is meant by a variation in a bone, muscle,
and distal consequences of such a disturbance. (It ligament, or fibre or any part of the body, from the
should be noted that in Still's original concept, least atom to the greatest bone or muscle. By our
because 'the rule of the artery is supreme', the func- mechanical skill, preceded by our intelligence in
tion disturbed is that of circulation of the body flu- anatomy, we can detect and adjust both hard and soft
ids; either directly, or indirectly via the autonomic substances of the system. By our knowledge of
nervous system reflexes controlling vasomotor tone; physiology we can comprehend the requirements of
this then affects all of the other tissues. ) As a doc-
22
the circulation of the fluids of the body as to time,
tor, Still had realized that certain disease processes speed, and quantity, in harmony with the demands of
had consistent reflection in the somatic structure. normal life.27
W h a t is o s t e o p a t h y ? T o w a r d s a d e f i n i t i o n 11

The intimate and inseparable relationship of mechanisms are in constant interaction, thus
structure and function has been recognized by sub- enabling the body to achieve a constant state of bal-
sequent authors, and this precept is more com- ance (e.g. blood pressure control, acid secretion in
monly stated as: 'Structure and function are the stomach). However, when dysfunction occurs,
reciprocally related'. Dr Viola Frymann is said to the body will have to work harder to maintain its
have taken this one step further when she stated balance; this additional work is referred to as the
that 'structure is solidified function'. Tom Dummer allostatic load (see Ch. 7). If great or sustained, this
responded that 'function (motion) is de-solidified would lead to possible specific effects on the body
structure' and stated: as well as general fatigue or malaise. By removing
the dysfunction, the allostatic load would be
Structure and function are indivisible and are simply reduced, the body returning to 'normal homeosta-
two aspects of the one expressed bioenergy. There is sis', and there would be both a local and a general
no 'starting-point' -function and structure are in improvement in the person's health.
this sense continuous and relative in their expression
Note that the practitioner's role is to remove
of the life-process.
22

the dysfunction: the body is then able to restore


So far in this discussion, we have focused on the function.
larger tissue systems; however, 'one function of This ability has, in the past, been ascribed to the life
anatomy is the supplying of a framework, even to force, but more recently has been thought to be due to
the remotest cell structure'. The structural func-
28
the body working as a tensegrous system. Implicit
tional reciprocity process is easy to imagine when with tensegrity structures is the ability to self-stabilize
dealing with large organs or tissue structures, but once any opposing force has been removed.
envisaging the effects at the cellular level is perhaps
more difficult. The system that best illustrates the THE BODY HAS THE INHERENT CAPACITY
micro-macroscopic relationship is the fascial sys- TO DEFEND ITSELF A N D REPAIR
tem. This system is continuous throughout the
body, creating an internal 'soft tissue skeleton' com- This could be seen, to an extent, as an extension of
posed of connective tissue ranging from the dense the previous precept. In Still's words, 'the brain of
tissue layers separating the body systems, down to man was God's drugstore, and had in it all liquids,
the microfibrils uniting the internal structures of the drugs, lubricating oils, opiates, acids, antacids, and
cells. Affecting any part of this system will have a every quality of drugs that the wisdom of God
cascade effect on the continuous structures from thought necessary for human happiness and
macroscopic to microscopic, influencing the struc- health'.29

tures invested by the connective tissue and thus The body has several levels of defence against
affecting the function of these structures, be they potential external or internal aggressors (the skin,
systems, organs or cells. The particular relevance of and the various tissues and cells of the immune sys-
this system will be discussed further in Chapter 4 tem and their relationships with the nervous and
on tensegrity. endocrine systems) and therefore is able to main-
tain health within the body. If damage does occur,
THE BODY POSSESSES SELF-REGULATORY the body has the capacity to repair itself.
MECHANISMS Still's conception of disease is not focused on the
invading pathogen, but rather on the body's
Still believed that as well as possessing self-regulating attempts to resist it. This is in contrast to the allo-
mechanisms, the body also possesses self-healing pathic concept which is based on Pasteur's Germ
mechanisms, often described as 'vis medicatrix natu- Theory which, stated simply, believes that the pri-
rae'. What Still ascribed to 'nature', we would now mary causal agent of a disease is an external
refer to as the homeostatic mechanisms. pathogen which has gained access to the body.
The body always works towards homeostasis, Disease can therefore strike anybody. To prevent
and possesses mechanisms to control the function disease, we have to build defences. Still's under-
of the body, e.g. through hormonal mediation standing is more akin to that of the Cellular Theory
(hypothalamic-pituitary axis controlling the of Antoine Bechamp (1816-1908) and Claude
endocrine glands) and nervous mediation (barore- Bernard (1813-1878) which states that pathogens
ceptors, receptors to salt in the kidneys, etc.). These are nearly always present in the body, and therefore
12 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

the body's tissues, 'the terrain', are constantly including immunity, nutrition and detoxification,
exposed to them, but the body's inherent systems all of which are essential to the maintenance of
have a capacity to resist them. They only become health. Thus, any disturbance of this flow, directly
pathogenic as the health of the individual deterio- or indirectly, will have an effect on well-being. The
rates; this could be due to stressors such as somatic flow of bioenergy could also be included within this
dysfunction, psychological or social problems, poor section.
diet, other pathology, etc. Therefore disease or ill-
ness occurs when in unhealthy conditions the inher- NERVES PLAY A CRUCIAL PART IN
ent systems are caused to fail and the terrain CONTROLLING THE FLUIDS OF THE BODY
becomes vulnerable. The implication is that if the
cause of the excessive demand is found and This is perhaps aimed at removing the apparent pri-
resolved, the body will be able once again to resist macy of the fluid systems in the earlier precepts. It
the effects of the pathogens. Thus, to prevent dis- addresses both mechanical or direct impingement,
ease we have to create health; to create health, the and that produced reflexively via vasomotor control.
body structure must be as near normal as feasible. The mechanical aspects are largely dictated by
the somatic nervous system, which controls muscle
W H E N THE N O R M A L ADAPTABILITY IS tone and thereby the gross posture of an individ-
ual. Changes in muscle tone will have possible con-
DISRUPTED, OR W H E N E N V I R O N M E N T A L
sequences locally, i.e. if the muscles become
CHANGES OVERCOME THE BODY'S CAPACITY hypertonic this could possibly affect contiguous
FOR S E L F - M A I N T E N A N C E , DISEASE MAY fluid systems. Contraction of muscle can create a
ENSUE relative pressure barrier, impeding fluid flow; hence
if the pelvic diaphragm is hypertonic there will be
This is essentially an extrapolation of the latter two impaired fluid return from the lower extremities.
precepts. Its relevance is to perhaps make more More systemic or global changes can occur as a
explicit the holistic nature of the stressor, and the result of muscle tone changes leading to a modifica-
inherent capacity of the body to deal with most tion of the body posture and thus of the way that
pathogenic agents, as long as its capacity is not the body cavities relate to each other, affecting their
overwhelmed. The term 'environmental' can be function as a whole, including fluid exchange.
interpreted broadly so that stressors that could (These are discussed more fully in Section 2.)
overcome the body's defences may be from any The reflex control of vasomotion is mediated by
source, somatic, functional or pathological, psy- the autonomic nervous system (ANS), with many of
chosocial or spiritual. Stress is also accumulative, the fluid systems having direct relationships with the
thus several small stresses, perhaps from differing ANS. Thus changes in the ANS will affect body flu-
sources, can have the same effect as one large stress. ids and therefore its general health. The ANS itself is
The effects of a stressor may also have long-term subject to stressors of any source, be they physical or
consequences such as unresolved grief or anger, or psychological. This offers one mechanism through
deformity resulting from poor union of a fracture; which problems within any aspect of the total osteo-
both could be significant components of an individ- pathic lesion, whether arising in the mind, body or
ual's 'environmental changes', decades after their spirit, may have global systemic effects. This is dis-
original occurrence. cussed more fully in Chapters 6, 7 and 9.

THE M O V E M E N T OF THE BODY FLUIDS IS


ESSENTIAL TO THE M A I N T E N A N C E OF HEALTH THERE ARE SOMATIC COMPONENTS TO
DISEASE THAT ARE NOT ONLY MANIFESTA-
This precept is a clarification of the often cited prin- TIONS OF DISEASE BUT ALSO CONTRIBUTE
ciple that 'the rule of the artery is supreme'. The TO THE M A I N T E N A N C E OF THE DISEASED STATE
clarification ensures that one is concerned not only
with arterial flow, but rather with the flow of any This precept attempts to address the concept of
body fluid, including arterial, venous, lymphatic reflex relationships that will arise when structures
and cerebrospinal fluids. It is through these fluid are subject to somatic dysfunction or become dis-
systems that physiological processes are mediated, eased, and the reciprocal relationship that arises
W h a t is o s t e o p a t h y ? T o w a r d s a d e f i n i t i o n 13

between them. The clearest example is perhaps • Sixth: The osteopath does not rely on electricity,
that of a visceral disease and its somatic manifes- X-radiance, hydrotherapy or other adjuncts, but
tation. relies on osteopathic measures in the treatment of
If, for the sake of this discussion, a viscera is in a disease.
diseased state, neural information will convey this • Seventh: We have a friendly feeling for other non-
information to the appropriate spinal segment, drug, natural methods of healing, but we do not
where it will synapse with visceral efferents in an incorporate any other methods into our system.
attempt to rectify the problem. It will also synapse We are all opposed to drugs; in that respect at
with alpha and gamma motor efferents which will least, all natural unharmful methods occupy the
cause aberrant muscle tone, perhaps around the same ground. The fundamental principles of
vertebral segment, and result in somatic dysfunc- osteopathy are different from those of any other
tion in the 'soma' or body. Thus, a viscerosomatic system and the cause of disease is considered
reflex has been instated. Osteopathic terminology from one standpoint, viz: disease is the result
distinguishes hierarchically between the first dys- of anatomical abnormalities followed by physio-
functioning structures, in this case the viscera, logical discord. To cure disease the abnormal
which would be called the primary lesion, and the parts must be adjusted to the normal; therefore
dysfunction that arises as a consequence of this pri- other methods that are entirely different in princi-
mary lesion, in this example the somatic problem, ple have no place in the osteopathic system.
which would be termed the secondary lesion. Thus • Eighth: Osteopathy is an independent system and
the secondary lesion is the somatic manifestation of can be applied to all conditions of disease, includ-
a disease. ing purely surgical cases, and in these cases is but
However, the precept indicates that this is not a a branch of osteopathy.
one-way relationship, primary to secondary; as the • Ninth: We believe that our therapeutic house is
secondary lesion begins to become dysfunctional just large enough for osteopathy and that when
itself, it will have a deleterious affect on the primary other methods are brought in just that much
lesion, thus setting up a vicious cycle. Clinically, osteopathy must move out.
this is pertinent as in order to achieve resolution of
a problem both elements will need to be addressed.
This example is a simplification. There may be SUMMARY
multiple somatic secondaries; there may also be the
possibility of visceral secondaries. The precepts offer an insight into Still's perception
Having addressed the precepts it is of interest to of the body. He stressed the unity of the body, from
look at the 'political platform' that Still originally the macroscopic level (mind, body and spirit within
envisaged for osteopathy. a given environment), through the continuity and
interdependence of the human body on an organic,
tissue and cellular level. There is a synergy between
all of these elements, enabling the body to regulate
STILL'S P O L I T I C A L P L A T F O R M and defend itself, to achieve homeostasis and when
problems arise, to repair itself. It is nourished by
This is stated in his Research and Practice: 30
the fluid system and overseen by the neurological
• First: We believe in sanitation and hygiene. system.
• Second: We are opposed to the use of drugs as In stating this, Still makes explicit some of the sig-
remedial agencies. nificant features of the body and its function. These
• Third: We are opposed to vaccination. concepts are not unique to osteopathy, and would
• Fourth: We are opposed to the use of serums in have been understood even by Hippocrates.
the treatment of disease. Nature furnishes its own Perhaps, however, what is fundamental to osteo-
serum if we know how to deliver them. pathic practice (and to that of other holistic body
• Fifth: We realize that many cases require surgical workers) is the structure-function reciprocity. With
treatment and therefore advocate it as a last a deep understanding of the structure of the human
resort. We believe many surgical operations are body, differences from the norm can be perceived
unnecessarily performed and that many opera- and an understanding of the functional changes that
tions can be avoided by osteopathic treatment. may arise can be derived. With this understanding
14 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

and an ability to differentiate subtle changes in the A separate point that has current value is that
affected tissues, it is possible to discover problems with an armamentarium practically bursting the
and resolve them before they have become frank doors of the 'osteopathic therapeutic house', it is
pathology. An allopathic diagnosis would generally perhaps pertinent to reflect on the ninth statement
be made by noting the collection of signs and symp- and, by thorough critical reflection and appropriate
toms of a disease process; but these will only mani- research, begin to dispense with some of the more
fest themselves when frank pathophysiological redundant methods.
changes have occurred. Thus, it is by applying the Finally, Still saw the body as a whole. He never
above precepts that osteopathy can work with the demonstrated techniques, but rather whole treat-
subclinical, prepathological states and, as well as ments. He did not talk about lesions in the sense
resolving complaints that a patient is aware of, it can that the term 'osteopathic lesion' is used today, but
also function as a preventive medicine. rather used terms such as 'strains', 'sprains',
However, if disease has arisen, osteopathy has 'twisted vertebrae', 'bony lesions', and even in a
the tools to remove elements that may have been few cases 'hypermobility'. He promoted a very
precipitating or may be maintaining factors of the holistic approach. It has been said earlier that his
diseased state, and to help the body activate its own students found it difficult to assimilate all that Still
defence and repair systems to restore itself, elimi- tried to convey. In their attempt to understand, and
nating or reducing the need for medication. Thus, later to convey Still's ideas to their own students,
osteopathy can be a complete therapeutic system. they attempted to dissect his approach with rational
This having been said, when Still originated his thought and analysed the parts independently. This
osteopathic political platform, medication was hap- hailed the second stage, the structural-mechanical
hazard, passing from the useless through to the era. Of great importance in this period was the con-
extreme of poison and with every shade between. cept of the osteopathic lesion and its role in disease.
Current pharmaceuticals have advanced from those This will be explored in the following chapter; how-
days and many have the ability to save lives. There ever, before passing to that, it is germane to reflect
are not many osteopaths who would argue against that though the reason for the dissection of Still's
the use of antibiotics in the management of bacterial concepts is understandable, and educationally it
meningitis (and Still's children might have survived may be perceived that such disection does facilitate
had these been available in his time). the learning of otherwise complex concepts, it
carries with it an inherent danger. The danger is
Although osteopathy is a complete system and
that the concepts, having been deconstructed, may
an osteopathic rationale could be devised for treat-
later not be reconstructed, thus losing that which is
ing almost any disease state, one should not hesitate
arguably the most important principle of osteo-
from recommending another approach should this
pathy, that the body is a whole and that the whole
appear to be the most effective treatment for any
is greater than the sum of the parts.
particular condition.

References
1. Still AT. Osteopathy research and practice. Kirskville: 7. Wolf AH. Osteopathy - A state of mind. Colorado Scott
Journal Printing; 1910. memorial lecture - 1965. AAO; 1966:42-46.
2. Fossum C. Lecture notes. Maidstone: Unpublished; 2003. 8. Hoover MA. Some studies in osteopathy. AAO;
3. Tucker EE. The word 'osteopathy'. Osteopath 1904; 1951:55-72.
May:194-196. 9. Still AT. Autobiography. Kirksville: Journal Printing;
4. Tucker EE, Wilson PT. The theory of osteopathy. 1897.
Kirskville: Journal Printing; 1936. 10. Ashmore EF. Osteopathic mechanics. Kirksville: Journal
5. Chila AG. Exposition of Still's thought: the word Printing; 1915; 2.
'osteopathy'. J Am Acad Osteopath 2003; 13(2):2. 11. Proby JC. Essay on osteopathy. Oxford: private printing;
6. Warner MD et al. The osteopathic concept. Tentative for- 1937:13.
mulation of a teaching guide for faculty, hospital staff 12. Page LE. The principles of osteopathy. Kansas City:
and student body prepared by the special committee on AAO; 1952:31-32.
osteopathic principles and osteopathic technic. AAO; 13. Kuchera WA, Kuchera ML. Osteopathic principles in
1954:57-59. practice, 2nd edn. Columbus: Original Works; 1992; 2.
W h a t is o s t e o p a t h y ? T o w a r d s a d e f i n i t i o n 15

14. General Osteopathic Council. Online. Available: 23. Webster Jones S. Osteopathy as revealed in the writings
http://www.osteopathy.org.uk 3 Aug 2003. of A T Still, Martin Littlejohn Memorial lecture 1954.
15. Educational Council on Osteopathic Principles. Glossary London: The Osteopathic Publishing Company; 1954.
of osteopathic terminology. Chicago: American 24. GOsC. Osteopathy in the United Kingdom. Online.
Association of Colleges of Osteopathic Medicine; 2002. Available: http://www.osteopathy.org.uk/goc/law/
16. Latey P. Still and osteopathy before 1900. Aust J index.shtml 6 Sept 2003.
Osteopath 1990; Dec:2-17. 25. Special committee on Osteopathic Principles and
17. Littre E. Oeuvres completes d'Hippocrates. Vol 1:1839. In: Osteopathic Technic. An interpretation of osteopathic
Kulungian H. On the moral obligation of the medical pro- concept. Tentative formulation of a teaching guide for
fession according to Hippocrates. 1999. Online. Available: faculty, hospital staff and student body. Journal of
http: / / www.macrodiet.com/ Contributors / Kulungian- Osteopathy 1953; 60 (October):8-10.
Hippocrates.shtml 24 Aug 2003. 26. DiGiovanna EL, Schiowitz R, eds. An osteopathic
18. Lever R. An osteopathic orientation within a social con- approach to diagnosis and treatment. Philadelphia: JB
text. I Soc Osteopath 1981; 10. Lippincott; 1991.
19. Abehsera A. Concepts of bo ne setting mesmerism. 27. Still AT. Philosophy and mechanical principles of
Israel: Unpublished lecture notes; 2002. osteopathy. Kirksville: Journal Printing; 1902: 22-23.
20. Trowbridge C. Andrew Taylor Still, 1828-1917. 28. Jordan T, Schuster R, eds. Selected writings of Carl
Kirksville: Thomas Jefferson University Press; 1991. Philip McConnell, D.O. Columbus: Squirrel's Tail Press;
21. Abehsera A. The roots of osteopathic technique: healers 1994:34.
and bone-setters. Israel: Unpublished lecture notes; 29. Still AT. Autobiography, 2nd edn. Kirksville: Journal
2002. Printing; 1908.
22. Dummer T. A textbook of osteopathy, vol 1. Hadlow 30. Still AT. Osteopathy research and practice. Kirksville:
Down: JoTom Publications; 1999. Journal Printing; 1910: 14-15.
Page Intentionally Left Blank
17

Chapter 2

The osteopathic lesion


or somatic dysfunction

INTRODUCTION A N D DEFINITION
CHAPTER CONTENTS

Introduction and definition 17 Defining the osteopathic lesion, like defining


Anatomical findings in joint dysfunction 18 osteopathy itself, is difficult. In a recent lecture, the
Introduction to concepts of lesions 26 author stated that one of the General Osteopathic
Council's (GOsC) working definitions of osteopa-
Hierarchical considerations 29
thy was 'Osteopathy is what osteopaths do'. When
Fryette spinal mechanics 32
he later asked the students to define an osteopathic
Convergent and divergent lesions 36
lesion one wit replied, 'That which osteopaths
A historical perspective 37
find!'
References 39
There is in fact much truth in this statement, as
the definition appears to be dependent on one's
perception or understanding of osteopathy. This
chapter will attempt to discuss the commonly used
models and underlying principles of the osteopathic
lesion.
The expression 'osteopathic lesion' has tended to
be superseded in more recent years by the term
'somatic dysfunction'. This was defined as 'an
1

impaired or altered function of related components


of the somatic framework; skeletal, arthroidal,
myofascial and related vascular, lymphatic and
neural elements'. 2

The principal reason for this change was the


confusion that arose from the word lesion. Lesion
has different meanings within the osteopathic
and allopathic paradigms. In allopathic terms,
lesion indicates a pathological entity or process.
Osteopathically, it is indicative of a functional
rather than a pathological problem, hence the more
recent use of 'dysfunction'. Additionally, the 'osteo-
pathic' descriptor tends to indicate exclusivity in
diagnosis and treatment to osteopaths. This is rele-
vant as, with the growing interest in manual medi-
cine, these concepts are being shared and anything
18 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

that permits ease of communication and breaks Osteopathically, it is necessary to be aware of the
down barriers between the various disciplines is 'ideal' or expected range and planes of movement
beneficial. of each articulation, and then to have the flexibility
In this text, the terms have tended to be used to superimpose any of the above individual differ-
interchangeably, the reason being that when dis- ences noted in the person being assessed and, by
cussing some of the early osteopathic concepts the applying this, to arrive at some concept of what
word lesion is an integral part of the terminology their actual norm is likely to be.
(e.g. first degree lesion). It is felt that it would not be This process is an excellent exercise in under-
appropriate to retrospectively modify this to 'first standing the musculoskeletal system and develop-
degree dysfunction', and the same applies to other ing the concept of an individual's norm as opposed
similar terms. to the textual norm. In a clinical situation, it is also
Thus, in this book, any usage of 'lesion' will helpful to compare an articulation with its paired
mean a functional rather than pathological entity, or similar articulation, though when differences in
unless clearly stated otherwise. range of movement are found it is important to
In an attempt to define what is meant by know whether the relative hypomobile or hyper-
the term 'somatic dysfunction' the following chap- mobile range is the norm for that individual.
ter will offer several different perspectives and This approach is objective, permitting one to uti-
also trace some of the concepts from a historical lize apparatus, such as a goniometer, to record the
perspective. actual differences in range of movement. Usually,
however, it is the palpatory and visual sense of dif-
ference in range of movement that is used in daily
A N A T O M I C A L FINDINGS I N J O I N T practice.
DYSFUNCTION The qualitative approach is a subjective perspective
that is utilized in somatic dysfunction analysis. It
When attempting to understand joint dysfunction assesses the quality of movement, assessing whether
it is possible to analyse it from two major perspec- movement is free flowing or whether there is a dis-
tives: quantitative and qualitative. turbance in the quality of the movement. If there is
A quantitative approach addresses the range of disturbance, it is important to assess whether it is
movement that each structure is subject to. This throughout the entire range of movement, or if it
applies to visceral and cranial structures as well occurs at a specific point of movement. The nature
as the musculoskeletal articulations discussed of the disturbance is also relevant, be it fine or
below. coarse, hard or soft, as well as the nature of the asso-
Each articulation has a normal range of move- ciated soft tissues: elastic, indurated, boggy, hot,
ment that, in the ideal situation, it is able to move cold, etc. The sensations noticed by the individual
through. This is governed by local articular factors, also contribute to the qualitative assessment of dys-
such as the type and shape of the joint itself and function, such as whether it feels tender or painful.
the nature of the supporting myofascial structures. Being subjective, this approach is not verifiable
It is possible to find the specific direction and by conventional analytical methods and utilizes
expected ranges of movement of each articulation terms that may sound naive and unscientific, such
in relevant text books. However, there are often dif- as 'boggy' or 'sticky'. However, this qualitative pal-
ferences in the values cited by these texts. This may patory sense is as critical to the understanding of
possibly be due to differing research methods somatic dysfunction as the quantitative, the two
employed or perhaps to the more individual or per- together combining to give the necessary informa-
son-specific factors such as the gender, age, biotype tion to make an initial diagnosis of that dysfunc-
and health state of the individuals assessed. For tion. By the nature of its subjectivity, it is the
example women's articulations are generally responsibility of each individual practitioner to
slightly more mobile than those of men. Articular develop their own 'palpatory reference library' and
flexibility and range of movement usually reduces to make the links to the underlying functional or
as age increases. The biotype of the person will pathophysiological changes that have caused the
have an effect, as will their state of general health symptoms to occur.
and the degree to which they have exercised, or These two perspectives will now be addressed
even overused, an articulation. more fully.
T h e o s t e o p a t h i c l e s i o n or s o m a t i c d y s f u n c t i o n 19

QUANTITATIVE CONSIDERATIONS IN When somatic dysfunction occurs (for the sake of


ARTICULAR SOMATIC DYSFUNCTION this discussion in the absence of any underlying
or secondary problems) there will be a restriction of
Hach articulation has an active and passive range of movement before the physiological barrier in one
movement. 'Active' means that the movement can or more of the possible planes of movement. In each
be achieved by voluntary contraction of the muscles affected plane of movement there will be one direc-
acting on the articulation. There is possible move- tion away from the neutral where the range of
ment beyond this range, but this can only be movement is less than full, whilst the range of
achieved passively; that is, movement introduced by movement in the other direction remains full. This is
someone other than the individual being assessed, a useful finding to differentiate between a patholog-
and this is therefore not under voluntary control. The ical problem and somatic dysfunction, as with
end-points of these movements are termed 'barriers'. pathological problems movement is generally lim-
Active movement is said to stop at the 'physio- ited in all directions, whereas with somatic dysfunc-
logical barrier'. This is determined by the tension tion, as just stated, one direction of movement is
in the soft tissues around the joint (e.g. muscles, lig- limited but the other full.
aments, joint capsule). The normal range of move- Thus, to consider a vertebra that has a dysfunc-
ment of a joint occurs within the physiological tion in rotation, it would be possible to find, for
barriers of this joint. This range can be slightly example, that on passive testing, rotation to the
increased if the individual regularly exercises, par- right from neutral to the physiological barrier is
ticularly with stretching type exercises, and gener- found to be full, but when left rotation is attempted,
ally decreases with age. restriction to this movement is found before the left
However, movement can be introduced pas- physiological barrier is attained. The point of limi-
sively beyond the physiological barrier, stretching tation is the restriction barrier (R). This would be
the supporting soft tissues until the limit of tension termed a right rotated somatic dysfunction and is
in these tissues is reached. This is the 'anatomical shown in Figure 2.2.
barrier' (Fig. 2.1). If a movement is applied beyond The naming of lesions is bound by certain con-
the anatomical barrier, it will damage the surround- ventions, to ensure that there is some accord
ing soft tissues and disrupt the joint structure, and amongst the profession. In Figure 2.2 there are two
the resulting damage would be considered within pertinent conventions:
the realms of pathology. The anatomical barrier can
not be altered by exercise. 1. The direction in which a vertebra moves is always
named by the direction in which the vertebral body
Somatic dysfunction occurs when there is a
moves. In Figure 2.2, the body moves fully to the
restriction of motion occurring within the normal
right but not fully to the left, so right rotation is
range of movement. This restriction of movement is
greater than left. (This can occasionally create con-
sometimes termed a 'restriction barrier'. Most osteo-
fusion, as, when performing passive vertebral
pathic experts believe that true osteopathic dysfunc-
movement testing, the spinous process of the verte-
tion can only occur within the physiological barriers.
brae is the structure contacted, and it is possible to
This will certainly be the case with compensatory
dysfunction, but in the case of traumatically induced become focused on its movement, the findings of
problems it is felt that they can occur beyond the which would be opposite to that of the body; how-
physiological barrier up to the anatomical barrier, ever, the body is always the point of reference.)
and still be non-pathological and reversible. In the 2. The lesion is always named by the direction of
following discussion a somatic dysfunction will be the ease of movement rather than the direction of
considered to occur within the normal range of bind. Thus, in Figure 2.2, this would be termed a
motion, i.e. within the physiological barriers. right rotated (or rotating) lesion. The same logic
will apply to any of the planes of movement in
In the case of pathological change in an arti-
which the joint is capable of moving, and any or
culation (such as osteoarthritis, fracture, cancer,
all of which may be affected depending upon the
oedema, etc.) there will be a 'pathological barrier'.
complexity of the lesion.
As with the osteopathic lesion this can also occur
within the physiological barrier, and generally there This concept often appears to be counter-intuitive
will be a limitation in all ranges of movement of the to students. An oversimplified concept that may
affected articulation. help with visualization of this convention is to
20 OSTEOPATHY A N D THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

Figure 2.1 Anatomical (A) and physiological (P) barriers. Active movement occurs between the physiological barriers, the passive
range of motion occurs between the anatomical barriers. Movement beyond the anatomical barriers will result in physical damage of
the articulation and its supporting structures. (A) Schematic; (B) rotation; (C) flexion extension; (D) side-bending.

imagine a muscle, attached to the transverse pro- shortened right-sided muscle, limiting the range
cess, as the initiating and maintaining factor in the of movement in that direction. If, however, one
dysfunction. To rotate the vertebra to the right, the attempted to rotate it to the right, the shortened
muscle on the right transverse process would have muscle would further shorten and not impede
to actively shorten, and to remain actively short- rotation, thus moving more easily into the direc-
ened to perpetuate it. If one attempted to rotate tion of the lesion. This is shown schematically in
that vertebra to the left it would pull against the Figure 2.3.
T h e o s t e o p a t h i c l e s i o n or s o m a t i c d y s f u n c t i o n 21

connective tissue (as has been described above with


the articular structures). This tissue is divided into
ligaments, capsules and tendons for ease of anatom-
ical description, but osteopathically it is perhaps
better to consider it as a connective tissue matrix
(see Ch. 4 on tensegrity). Thus, in the ideal situa-
tion, there will be a range of movement that is per-
mitted within this soft tissue matrix, within the
equivalent of the physiological barrier, and if move-
ment is encouraged beyond this point, stretching
the supporting soft tissues, it will be possible to feel
the point equivalent to the anatomical barrier.
Dysfunction can be assessed on a quantitative level
by palpating the permissible ranges of movement
of any structure; where premature restriction of a
movement occurs, dysfunction has been located.
When the normal range of movement of that struc-
ture has been restored, then quantitatively that
Figure 2.2 Passive segmental motion findings in rotation for a
structure has been corrected. (Reflecting on the fact
vertebra with a right rotated somatic dysfunction. Passively
rotating the vertebra to the right results in a full range of that the range of movement of any bodily structure
movement terminating at the anatomical barrier (A). Passive is dictated by the supporting connective tissue
rotation to the left is found to be limited, stopping before the matrix, it is perhaps possible to understand why
physiological barrier has been reached. The point where this there is such a wide variety of normal, as this
movement is limited by somatic dysfunction is termed the matrix is as unique to an individual as their finger-
restriction barrier (R).
prints and is an expression of all of the processes
that are occurring within any individual at any
time.)
Please note that this is not a complete explana- The situation can become slightly more compli-
tion of how lesions are maintained, but a simple cated when addressing the involuntary aspect of
illustration aimed to try to demonstrate how it is cranial, visceral or fascial osteopathic practice. In
possible for the ease of movement to be in the direc- the above description it is the mobility of the struc-
tion of the lesion. tures that is being assessed. Within the involuntary
The principal active movements that joints are field, one is assessing the motility as opposed to the
capable of are rotation, side-bending (lateroflexion), mobility of the structures.
and flexion or extension. There are other often
• 'Mobile' refers to an object's ability to have free-
smaller accessory movements that can occur pas-
dom of movement, to be moveable.
sively or as a consequence of, or coupled with, the
• 'Motile' refers to the inherent and spontaneous
greater movements. The most important of these is
movement of a structure.
known as translation (gliding or shearing), which is
movement of two contiguous parts of an articula- This is an important distinction to make; thus,
tion sliding relative to each other in a direction rather than introducing a movement to assess
parallel to their plane of contact. This can occur in mobility, the practitioner 'listens' to the inherent
a lateral, anterior/posterior, or superior/inferior motility using a passive receptive hand.
plane. Motility is usually described in terms of respira-
The above movements relate to dysfunction tory flexion and extension (as in primary respiration
within the musculoskeletal system. Earlier it was or cranial respiration, not the respiration of breath-
stated that these concepts apply equally to the other ing which is termed secondary respiration). During
structures in the body. The principles are the same, respiratory flexion, the skull and body reduce in
though it is not currently possible to look up the anterior posterior diameter and superior inferior
expected range of movement of a liver or a tempo- diameter whilst increasing bilaterally laterally. This
ral bone! Every structure within the body is main- causes the midline unpaired structures to flex and
tained in its position by the complex interplay of the peripheral (paired) structures, which includes
22 OSTEOPATHY A N D THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

Figure 2.3 A schematic demonstration


to illustrate how it may be possible for a Rotation
vertebra to move more freely into the right
direction of the lesion. (A) Rotation of
the vertebra to the left will be resisted
by the active contraction of the muscle
on the right side. (B) Rotation to the
right will further approximate the origin
in insertion of the actively contracted
right muscle, which will therefore offer
no resistance to the movement. The left
muscle will be stretched but as it is not
actively contracting, it will offer limited
resistance to movement. Thus, movement
is easier into the direction of the lesion.

Passively elongated
in response to the
change in position Actively shortened,
initiated and maintained origin approximating
by the contralateral insertion, causing and
muscle contraction maintaining right rotation
of the vertebra

QUALITATIVE CONSIDERATIONS IN ARTICULAR


the body extremities and viscera, to externally SOMATIC DYSFUNCTION
rotate. Respiratory extension is the reverse of this.
Thus, unlike structural flexion or extension which Qualitative assessment of articular movement is an
describes movement of all structures with regard to important diagnostic tool for assessing both patho-
the anatomical position, or approximation and sepa- logical and functional problems. Fluent movement
ration of an articulation, respiratory flexion is more is dependent on many elements, including articular
complicated and relates to the separate interactions integrity, 'correct' physiological processes and even
of the articulations. More specific information on the phenomenally complex interplay between the
these movements will be dealt with in the relevant soft tissues and the neuroendocrine immune sys-
chapters in Section 3. tem. Absence of this fluency may lead one to sus-
From a quantitative perspective, the basic criteria pect an underlying dysfunction.
for assessing motile structures are amplitude and This may be a minor disturbance, such as move-
rate. Amplitude is the full range of movement from ment not feeling 'quite as free' as its paired arti-
respiratory flexion to respiratory extension and the culation, perhaps indicating general soft tissue
rate is generally described as the number of these changes due to a local inflammatory response or,
cycles that occur in a minute. at the other end of the spectrum, the gross findings
The osteopathic lesion or somatic d y s f u n c t i o n 23

of coarse crepitus associated with articular degener- • A springy block at the extreme range of move-
ation from osteoarthritis, or cog wheel rigidity due ment would be suggestive of an intraarticular dis-
to the neurological disturbance associated with placement, such as a meniscal tear.
Parkinson's disease. • Fibrosis associated with the more chronic restric-
There are numerous medical texts that discuss tions has a very rapid build-up in tension occur-
pathological qualitative findings, therefore the fol- ring close to the limiting barrier and with a firmer
lowing discussion will focus principally on the non- elasticity than felt with a hypertonic muscle or
pathological situation. Also as with the previous ligamentous problem.
section, the concepts will first be explored with • An abrupt stop to the movement short of the nor-
regard to a musculoskeletal dysfunction, and will mal range of motion that is hard and inelastic
then be applied to other systems. would suggest a bony limitation.
Dysfunction in the supporting connective tissue
matrix, as well as causing problems within the range Dysfunction may result in hypermobility as well as
of movement, will also have an effect on the quality the hypomobility discussed so far. Hypermobility
of this movement. This will obviously be subject to is difficult to appreciate by palpation: there is often
the individual variation cited earlier, but it will also a sensation of increased elasticity of the joint com-
be subject to the changes that occur in the soft tis- plex and increased range of motion, with a rapid
sues over time. Initially, the body tries to resolve build-up of tension and hardness as one reaches the
and repair any problems; if it is unable so to do, it end of the range of motion.
will adapt. As time passes, the soft tissues progres- Additionally oedema is associated with an end
sively change and these changes are discernable feel that is 'boggy'. Pain often causes a sudden,
through palpation. Thus the qualitative 'feel' of a jerky and at times inconsistent ratchet-like sensa-
dysfunctioning area can give information regarding tion, often due to guarding behaviour of the mus-
both the nature of the underlying problem and an cles associated with the joint. The relationship
indication of how long the problem has been pres- between the onset of pain and the resistance is also
ent. The range of qualitative changes are described very useful diagnostically.
in a variety of ways. These will be discussed below. The onset of pain before any resistance is felt is
indicative of possible pathology or extraarticular
End feel
lesion, such as acute bursitis, abscess or neoplasia.
The quality at the end range of the movement is The lack of resistance is due to the fact that pain has
termed the 'end feel'. In a non-lesioned articulation limited the movement before the articulation has
it describes the quality of the movement between been engaged (this is sometimes termed an 'empty'
the physiological and anatomical barriers. As previ- end feel).
ously stated the physiological barrier is the end- If the resistance and pain are synchronous this
point of active movement, where the articulations' would indicate an active dysfunction, and the
periarticular soft tissues are engaged. Passively tak- nature of the end feel would reflect the degree of
ing the joint beyond that range will stretch these tis- acuteness. Thus a hard, muscular end feel would
sues, thus in a normally functioning joint an elastic indicate a more acute dysfunction, and a firm, elas-
and progressive tissue tension should be felt tic feel would be less acute.
towards the end-range of motion. If the resistance to the movement is felt before
When an articulation is in lesion, it is observed that the onset of pain, this would be indicative of a more
end feel is felt before the physiological range of move- chronic dysfunction.
ment. The end feel varies according to the articula-
Tissue t e x t u r e changes
tion and on the tissues limiting the movement. ' 3 4

The quality of the tissue surrounding a joint is per-


• Muscles can cause a range of end feel, from soft haps one of the principal indicators of somatic dys-
and elastic to a relatively hard 'twangy' sensation, function of that articulation. These tissues include
depending on the degree of protective spasm the skin, muscles, ligaments, joint capsules and sub-
present. cutaneous fat. Palpation of these tissues not only
• Ligaments or capsule limiting the movement indicates the presence of dysfunction but can also
create a firm and elastic end feel, as if stretching give an indication of the age of the lesion, i.e.
thick rubber. whether it is acute, subacute or chronic. These
24 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

tissue changes are often referred to as 'tissue tex- If the problem is not resolved, the fibrosing
ture abnormalities'. process continues and may lead to marked fibrosis
The changes are mainly driven by the action of of the muscle. There will also be associated atrophy
the local tissue or humoral response and its interac- of the muscle.
tion with the sympathetic nervous system. Louisa Burns researched the changes that occur
5

In the initial acute stage of injury, the affected tis- over time in somatic dysfunction. She identified at
sues release vasodilator substances (e.g. bradykinin). least eight stages:
This leads to an inflammatory response and local
1. Hyperaemia in the capillary bed, which will be
oedema. The area will become hot, red, swollen and
evident in the first few minutes.
tender.
2. Congestion of blood in the precapillary arteri-
There is a simultaneous increase in sympathetic
oles, occurring in less than 10 minutes.
autonomic nervous system activity. The sympa-
3. Oedema or the accumulation of fluid in the tis-
thetic system controls blood vessels, sweat gland
sue space will be seen in 30 to 40 minutes.
activity and the erector pilae muscles. In the acute
4. In several hours, minute haemorrhages or
stage, the sympathetic action on the local blood sup-
petechiae will appear in the oedematous fluid.
ply is to cause vasoconstriction and therefore rela-
tive decrease in perfusion; however, in the early 5. In 3 to 7 days, organization of the petechiae will
stages of dysfunction the action of bradykinin over- be seen.
powers the sympathetic activity, thus there is a 6. Organization, which is the canaliculization of
resultant vasodilatation and consequently local the petechiae by the infiltration of fibrocytes,
oedema is present. There will also be increased local will result in one of two changes: absorption
sweat gland activity, and possibly raised hairs, of the petechiae, or continuing fibrocytic inva-
where present. sion with early fibrotic changes in the ground
substance.
As time passes the local tissue response decreases
7. If fibrosis continues, it will shut off the capillary
and the vasoconstrictive effects of the sympathetic
circulation and result in ischaemia over the next
system become more apparent. The area concerned
several months.
consequently receives a reduction in blood flow.
8. Ischaemia will eventually lead to atrophy of the
With greater time the reduction in perfusion
periarticular tissues.
becomes more apparent and in very chronic states
the signs of relative hypoxia become marked. The Part of these tissue changes will be mirrored in any
area concerned will become cold and pale, the skin tissues or organs that are segmentally related to
quality becomes poor with signs such as local skin the area of dysfunction via the embryological
dryness and flaking, increase in skill pore size, and metameric divisions, i.e. that segment of the spinal
spots. Sweat gland activity also decreases due to cord supplied by one pair (right and left) of motor
progressive fatigue of the sweat glands, further and one pair of sensory nerves including the:
exacerbating the skin dryness.
Whilst the above relates particularly to the effects • Myotome: all of the muscles supplied by the
observed within the connective tissue, these paired nerves exiting that spinal segment. (This
changes are also observable within the muscle tis- will also involve the complex reflex balance
sue. On a muscular level, what is first observed is a between agonist and antagonists.)
reactive muscle spasm (this being a protective • Dermatome: leading to areas of tenderness or
mechanism). After about a week, this reactive dysthesia and nutritional changes on the skin due
spasm decreases but a hypertrophy of the muscle to impaired sympathetic supply to the superficial
is observed, due to the continued neural output capillary beds, sweat glands and sebaceous
maintaining the muscle contraction, and the lesion glands of that dermatome.
pattern. • Sclerotome: leading to periarticular, ligamentous
Later, the muscle begins to fatigue leading to or periostial pain.
progressive hypotrophy. As the muscle is still being • Viscerotome (enterotome): causing disturbed vis-
required to contract, connective tissue starts to be ceral dysfunction (somaticovisceral reflex) as well
deposited in the muscle fibres to maintain the mus- as 'tender points' such as Chapman's reflexes or
cle shortening with minimal energy expenditure to Jarricot's dermalgie reflexe (viscerocutaneous
the body. reflex).
The osteopathic lesion or somatic dysfunction 25

This is summarized in Table 2.1. ous process is anomalous. Therefore it is always


Though the terms boggy, ropey and stringy important to first observe the body for asymmetry,
sound rather unscientific, they are useful descrip- then to test it.
tors and have been defined in the Glossary of Not all asymmetry is significant or needs to be
Osteopathic Terminology as follows:
2
'corrected'. There are numerous genetic or postural
asymmetries, such as those arising from right or left
• Bogginess: A tissue texture abnormality charac-
handedness, which one needs to be aware of but
terized principally by a palpable sense of spongi-
not necessarily attempt to resolve.
ness in the tissue, interpreted as resulting from
congestion due to increased fluid content. Tenderness
• Ropiness: A tissue texture abnormality character-
This is due to the humoral or inflarnmatory response,
ized by a cord-like feeling.
and the neurological response to the dysfunction.
• Stringiness: A palpable tissue texture abnormality
Generally, the more recent the dysfunction, the
characterized by fine or string-like myofascial
greater the tenderness. As the lesion becomes more
structures.
chronic in nature the tenderness decreases and may
disappear totally. Thus pain and tenderness is only
Asymmetry
useful in mdicating the presence of an acute lesion.
Due to the asymmetrical muscle tonicity associated Tenderness appears to be becoming progressively
with somatic dysfunction, asymmetry may be more used as an indication of the significance of a
observable and palpable in comparison with its lesion. This is incorrect; it is not possible through
opposite if paired, or other similar joints if not. This pain or tenderness alone to intuit any primacy or
is noticeable in the articulation itself and its associ- particular osteopathic significance to any underlying
ated soft tissues. There may also be consequent dysfunction.
asymmetry in the whole body, as it attempts to
Temperature
adapt to the local dysfunction. This asymmetry
may be noticed through positional change, changes In the acute stage of dysfunction it is often possible to
in function or, as is more usual, both position and palpate a slight increase in temperature, either at the
function. Static or observed asymmetry alone is not skin surface or by running your hand about 15 cm
a reliable indicator of dysfunction as there are above the area (this is generally termed 'thermal diag-
many bony and soft tissue anomalies that can occur nosis'). Again, this is caused by the initial humoral
in the absence of somatic dysfunction; a common effect. As the lesion becomes older the temperature
example of this is the spinous processes of the tho- difference will become less pronounced. In very
racic vertebrae. They are often not straight, and the chronic lesions, where the blood supply has become
resulting deviation to one side could be interpreted reduced, the area may feel slightly colder. Thermal
as a rotation to the opposite side; however, when diagnosis is used by some osteopaths to indicate the
passively segmentally tested, it may be found to relative state of the viscera as part of the somaticovis-
have an equal movement bilaterally thus indicat- ceral or viscerotomal relationship, the interpretation
ing that there is no dysfunction and that the spin-
of the findings being based on the above logic.

Table 2.1 A comparison of tissue changes in an acute and chronic somatic dysfunction

Acute Chronic

Skin Inflammatory response: oedema, vasodilatation, Skin is pale, cold, dry with signs of trophic changes
hot, red, increased sweat gland activity such as spots, increased skin pore size
Subcutaneous tissues 'Boggy' feel Indurated and atrophied
Muscles Acute reactive muscle spasm, contraction, Atrophy ± fibrotic insertions, leading to fibrosis
leading to hypertrophy 'Ropey' or 'stringy' feel
Neural reflexes Initially may not be apparent Somaticosomatic and somaticovisceral reflexes
Pain Tenderness or acute pain Slight or absent tenderness
26 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

With regard to non-articular structures and the These offer the main diagnostic criteria for a somatic
qualitative assessment, mention has already been dysfunction, most particularly an acute dysfunction.
made concerning the soft tissue changes that There is insufficient mention of the end feel of an
occur. In addition, as they guide all movement articulation; however, if that can be incorporated,
in the body, the qualitative changes in mobility can they are reasonably complete.
be deduced. Regarding the qualitative changes The term 'restricted movement' is often used in
expected within the motile structures, rhythmicity the mnemonics TART and STAR. The reason that
is an important factor (i.e. how the structure is mov- range of motion and abnormality (from PRATT) has
ing with regard to its axes of movement and with been utilized in this text is because the dysfunction
regard to its contiguous structures). Rate, rhythm may have hypermobility associated with it, rather
and amplitude are the basic criteria for assessing than hypomobility.
motility in any structure. Beyond rhythm there is a STAR has the advantage of including sensibility
phenomenal and confusing range of qualitative changes rather than pain or tenderness, allowing
terms used to describe the state of tissues. These are for the full range of sensation changes that can
often idiosyncratic and often only truly meaningful accompany any dysfunction.
to particular individuals or small groups of people
who have worked together and have established a
communicable palpatory language. But they are no I N T R O D U C T I O N T O CONCEPTS O F
less important for this. The different tissues all have LESIONS
a particular feel and this will change depending on
their particular state; this cannot be learnt from a There are several different ways to conceptualize
book but will require coaching with an experienced somatic dysfunction or the osteopathic lesion. Many
teacher and practitioner, and an ability for you, were devised early in the genesis of osteopathy, and
yourself, to accept and analyse what you feel to
have been modified by subsequent generations, and
enable you to make these links for yourself.
none is without its detractors. The main models will
be presented to enable you to obtain an overview of
SUMMARY the various concepts, to help you to challenge them
yourself. Inherent within these models are concepts
It is through the summation of both quantitative related to:
and qualitative findings that one obtains an indica-
tion of the nature and age of the underlying dys- • causation of the lesion - traumatic, postural or
function. Several mnemonics have appeared over compensatory;
recent years that attempt to summarize the findings • temporal considerations - reflecting the changes
in somatic dysfunction; none of these is complete, that may have occurred in the lesion with time;
but they are useful as aides-memoire. • hierarchical concepts - which is the first or most
significant lesion, which are compensatory; and
TART
• physiological aspects - proposed models of spinal
2

Tissue t e x t u r e abnormality movement and aspects of the distal effects medi-


Asymmetry
ated largely via the nervous system.
Range of motion abnormality
Tenderness. The term lesion is being used in this discussion as the
models are early and predate the use of dysfunction.
STAR
Conceptualization and the description of lesions is
6

Sensibility changes
an area where much confusion exists. Paradoxically,
Tissue t e x t u r e abnormality
it appears generally that what is being said is the
Asymmetry
same, but it is being said in differing ways. Where
Restricted range of m o t i o n .
possible this section will draw parallels between
PRATT these apparentlv differing concepts.
Pain
Range of m o v e m e n t abnormality FIRST AND SECOND DEGREE LESIONS
Asymmetry
Tissue changes One of the means of classifying somatic dysfunction
Temperature. in the UK is by utilizing the terms first or second
The osteopathic lesion or somatic d y s f u n c t i o n 27

degree lesions. Inherent within these terms are the principles of first and second degree lesion and
possible causative factors, and the response of the knowing the direction of the rotation, the direction
segments over time. The causative factors in fact of side-bending should be understood. The appro-
relate to Fryette's theories of spinal motion, though priate flexion or extension component is then added
this aspect is often lost in the UK. As Fryette's at the end.
nomenclature is used widely in Europe, included at It can be seen that in this system of nomencla-
the end of each section is the equivalent Fryette ture the lesions are named by the rotation.
nomenclature for ease of cross reference. A fuller For example, a first degree right lesion (abbrevi-
explanation of Fryette's nomenclature is presented ated to 1°R or 1st °R) is:
later in this chapter.
• First degree - this would mean that rotation and
Causative factors side-bending will occur ipsilaterally.
• The right relates to the rotation, in this case being
A first degree lesion is considered primarily to be
to the right.
due to a traumatic event, usually affecting a single
• As it is in first degree and rotation and side-
vertebra at one of the pivotal areas of the spine,
bending are ipsilateral, the side-bending will also
occurring whilst the spine is out of neutral position.
be to the right.
The subsequent coupled movements of rotation and
• Flexion means that the lesion is also in flexion.
side-bending occur to the same side (ipsilateral), i.e.
if rotation is to the right, side-bending will also be A second degree left flexion would mean left rota-
to the right. (In early osteopathic texts this lesion is tion and right side-bending in flexion.
known as a 'Still lesion'.) As will be seen later, this is a somewhat flexible
In Fryette's terms it would be described as an interpretation of Fryette's principles.
extension, rotation, side-bending lesion, abbreviated As well as the causal element inherent within
to an ERS lesion. these terms there are also considerations relating to
A second degree lesion is thought to be princi- anticipated changes with the passage of time.
pally adaptive or postural, thus tending to occur
T e m p o r a l considerations
when the spine is in neutral. These lesions tend to
occur as group lesions, which are several vertebral As stated, a first degree lesion generally arises as a
segments moving as one complex in the direction of result of a traumatic event, thus it is an acute episode
the lesion. The rotation and side-bending occur in with all of the consequent local tissue changes (see
opposite directions (contralaterally). Thus, if rota- the discussion on tissue changes in acute lesions
tion is to the right, side-bending will occur to the earlier in this chapter). At this stage the effects are
left. Occasionally this pattern of contralateral rota- purely local and functional.
tion and side-bending may not occur, due to the If the body is unable to resolve the resulting
direction of the forces applied by the faulty repeti- lesion and the individual does not seek treatment,
tive postural or occupational changes overriding the the lesion then tries to 'stabilize' itself. It can do
anatomical 'logic'. this by creating compensations with other vertebrae
In Fryette's terminology the second degree in the spine, and/or by adapting at the lesioned
lesion is termed a flexion, rotation, side-bending segment itself.
lesion, the flexion referring to the 'easy normal flex- Other vertebrae, either local to the site or distal
ion', Fryette's term for the neutral position of the to it, will begin to compensate, and this can often
spine. This is abbreviated to an FSR or sometimes involve a group of vertebrae adapting to the ori-
NSR (the F and N representing the easy normal ginal dysfunction. These compensating lesions
flexion). will be second degree lesions with rotation and
Where UK nomenclature differs from much of side-bending occurring in opposite directions. This
the rest of Europe is that both first and second may be sufficient to create adequate balance within
degree lesions can occur in either flexion or exten- the spine. The whole process of establishing a com-
sion. This is in contrast to 'pure' application of pensatory pattern that results in postural balance
Fryettian concepts of ERS and FRS. may take weeks or months. This will have an effect
To name these lesions, the convention is to state on the tissues local to both the initial area of dys-
whether it is first or second degree, and then to cite function and those areas compensating for it, thus
the direction of the rotation. By understanding the the joint capsule, overlying muscles, associated
28 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

nerves and blood vessels, all tending to a chronic As a consequence, the body may overcompensate
state. It will also begin to have an effect on those and a subsequent imbalance occurs on the con-
associated distal structures, such as segmentally tralateral side of the body. This may potentially
supplied viscera, via the somaticovisceral reflex. evoke the next level of adaptation, whereby the
The longer the dysfunction has been present body as a whole compensates. The pelvis reverse
the more marked the tissue changes will be, tilts in an attempt to shift the entire spine and
both locally and distally, resulting in progressively body back into the midline, resulting in a third
greater functional or even pathological tissue degree lesion. Dummer states that this is obvious
7

changes; and proportionately the longer the to the naked eye, as with first and second degree
expected prognosis and duration of treatment. lesions the high side of the pelvis is ipsilateral to
Also, there will be changes occurring at the site the concavity in the lumbar spine, but in third
of the original lesion, starting usually within a few degree lesions it is on the opposite side. This is, by
days. The process often involves a counter rota- its very nature, a long-standing and slowly evolv-
tion from the original position, heading towards ing process. The functional element progressively
a slightly more stable position. As the vertebra is diminishes and the consequences become more
in lesion and by definition is not able to resolve structural and pathological, resulting in long-term
itself fully, the counter rotation may be slight, and and profound physiological and tissue changes
the resulting lesion positionally will still appear both locally and distally.
to be a first degree lesion, but if the segment is The above is the definition with which many
motion tested there will be limitation in both direc- osteopaths in the UK will be familiar; however,
tions of rotation. This is because the initial rota- there are several other interpretations of the third
tion, say for example to the right, would by degree lesion. The features that they have in com-
definition result in left rotation being limited. mon are the profound and chronic nature of the
However, as the vertebra attempts to rotate to the lesion and its inherent complexity. Other versions
left, right rotation will be limited, hence the bilat- include:8

eral limitation. This is often quite difficult to diag-


nose, as the rotation may be approximately equal • a counter rotating first degree can be described
(but limited) at the segment, therefore it will be as a segmental third degree lesion
picked up by comparison with its adjacent verte- • a first degree superimposed on a second degree,
bral segments. There will also be chronic tissue or more simply, one lesion superimposed on
changes at the affected segment which will also another
be indicative. • a lesion that does not 'obey' the osteopathic con-
ventions (described by Fryette as an 'off the rails'
9

Another feature of this lesion is that as it is


lesion)
'actively' counter rotating, when assessing the ver-
•a 'complicated lesion' as described by Hoover, 10

tebrae functionally it will be positionally rotated


being the total summation of two or more simple
one way, but functionally rotating in the opposite
lesions
direction, going in the direction of the lesion.
• in Europe it is often described as a side-shift
(Note on terminology: Because of the dynamic
lesion, this occurring as it tries to 'escape' from
nature of this process the terms rotating or
the coupled rotation side-bending
side-bending as opposed to rotated or side-bent
• a hyper mechanical and hyper physiological
are preferred, thus differentiating the dynamic
lesion.
adapting/compensating situation that is occur-
ring in this physiological model from that of the Table 2.2 summarizes the key features of this
static non-adapting situation that is inherent in model.
the positional model where the term 'rotated' is Many osteopaths have made the conceptual
sufficient.) link between the temporal aspect of this model
and the gradual but progressive tendency towards
THIRD DEGREE LESIONS chronic tissue changes, hypofunction and ulti-
mately pathology, and the physiological triphasic
There are occasionally situations that are slightly stages of Hans Selye's General Adaptation
more complex, where even the adaptations des- Syndrome. Table 2.3 indicates this proposed
11

cribed above fail to achieve satisfactory balance. relationship.


The osteopathic lesion or somatic d y s f u n c t i o n 29

T a b l e 2.2 A s u m m a r y o f t h e key f e a t u r e s o f t h e first, s e c o n d and t h i r d d e g r e e lesions

Onset Affecting Rot/SB State

First degree Traumatic Single vertebrae Ipsilateral Acute


Second degree Compensation Group vertebrae Contralateral Chronic
Third degree Compensation Whole body (+/- single vertebrae) Side shift/complex Very chronic

T a b l e 2.3 A proposed relationship b e t w e e n the


BANCES OF STRUCTURE'. THUS, ESSENTIALLY, THE PRIMARY
stages of d y s f u n c t i o n and the General A d a p t a t i o n
LESION LEADS TO A SECONDARY LESION. THIS DOES NOT
Syndrome
JUST APPLY TO PROBLEMS OCCURRING WITHIN THE BODY.
Dysfunction General Adaptation Syndrome IF ONE IS THINKING HOLISTICALLY, IT IS POSSIBLE TO IMAG-
INE THE PRIMARY LESION BEING out of the body, SUCH AS
First degree lesion Alarm phase A MAJOR PSYCHOLOGICAL STRESS WHICH WILL RESULT IN A
Second degree lesion Resistance phase CASCADE OF SECONDARY CONSEQUENCES; SIMILARLY THE
Third degree lesion Exhaustion phase SECONDARY LESIONS MAY BE SOMATIC, VISCERAL OR
PSYCHIC.
THESE TERMS ARE OFTEN CONFUSED WITH FIRST AND
FRYETTE'S TYPE I AND TYPE II LESIONS SECOND degree. THIS IS NOT ALTOGETHER SURPRISING AS
THERE IS SOME OVERLAP. IN THE RECENT OR ACUTE SITUA-
IT WOULD BE LOGICAL TO DISCUSS THESE AT THIS POINT; TION THE PRIMARY LESION IS OFTEN ALSO A FIRST DEGREE
HOWEVER, AS THEY FORM AN INTEGRAL PART OF A COM- LESION, BUT WITH TIME THE FIRST DEGREE LESION MAY
PLEX BIOMECHANICAL PRINCIPLE, THEY ARE DISCUSSED PROGRESS TO A SECOND OR THIRD DEGREE LESION, BUT STILL
AS PART OF FRYETTE'S SPINAL MECHANICS LATER IN THIS BE PRIMARY. WHATEVER SIMILARITIES THEY HAVE IT IS
CHAPTER. HAVING READ THAT SECTION IT WOULD BE OF IMPORTANT TO REALIZE THAT THEY ARE BASED ON DIFFERENT
BENEFIT TO REREAD THE FIRST AND SECOND DEGREE LESION PREMISES, AND TO AVOID CONFUSION IT IS BETTER TO TREAT
SECTION ( P . 2 6 ) AND CONTRAST THESE WITH T Y P E I AND THE TWO CONCEPTS AS SEPARATE ENTITIES.
T Y P E II LESIONS ( P . 3 2 ) . IMPLICIT WITHIN THIS CONCEPT IS THE PREMISE THAT IF
ONE TREATS THE PRIMARY LESION THEN THE SECONDARY
COMPENSATIONS SHOULD RESOLVE. THIS IS POSSIBLY THE
HIERARCHICAL CONSIDERATIONS CASE WITH SHORT-STANDING PATTERNS THAT HAVE NOT
BECOME SUBJECT TO CHRONIC TISSUE CHANGES, BUT WITH
PRIMARY AND SECONDARY LESIONS LONGER-STANDING PROBLEMS THIS WILL OFTEN NOT BE THE
CASE, AS WITH TIME THE ASSOCIATED TISSUES BECOME
ANY ATTEMPT TO UNRAVEL THE COMPLEX PATTERNS OF PROGRESSIVELY FIBROSED, PREVENTING SPONTANEOUS
DYSFUNCTION FOUND IN THE AVERAGE PERSON MERITS A RECOVERY.
RELATED ATTEMPT TO ESTABLISH WHAT HAS INITIATED THE FOR EXAMPLE, IF A TRAUMA HAD INDUCED A LESION
PROBLEM, AND THEN WHAT AREAS HAVE COMPENSATED OR AT C 2 / C 3 APPROXIMATELY 2 YEARS PREVIOUSLY, THERE
ARE SECONDARY TO THIS. THE TERMS PRIMARY AND SEC- WOULD HAVE BEEN AN ATTEMPT TO STABILIZE THE SITUA-
ONDARY LESION ARE USED TO DESCRIBE THIS HIERARCHY. TION LOCALLY BY THE C2 COUNTER ROTATING. IF THIS WAS
THE PRIMARY LESION IS DEFINED BY MITCHELL AS 12 INSUFFICIENT TO STABILIZE THE BODY IT WOULD THEN BE
'ONE THAT CAUSES AN ADAPTIVE OR COMPENSATORY REQUIRED TO INVOLVE ANOTHER AREA OR AREAS OF THE
CHANGE TO OCCUR IN THE BODY OR DIRECTLY CAUSES SPINE TO FULLY COMPENSATE. THIS WOULD BE A SECOND-
SOME OTHER PART OF THE BODY TO MALFUNCTION OR ARY LESION AND, FOR THE SAKE OF THIS DISCUSSION, LET US
UNDERGO TROPHIC CHANGES'. D U M M E R IS MORE SUC- 7 SAY THIS OCCURRED AT T 4 . THIS PROCESS MAY OCCUR
CINCT, DEFINING PRIMARY LESIONS AS 'THOSE BASIC DIS- ALMOST IMMEDIATELY OR TAKE WEEKS TO OCCUR. AFTER
TURBANCES OF STRUCTURE WHICH EVENTUALLY CAUSE THE ACUTE STAGE HAS PASSED, BOTH AREAS WILL BE
SECONDARY AND COMPENSATORY DISTURBANCES OF OTHER SUBJECT TO THE PROCESS OF STABILIZING: THE FIBROSIS,
RELATED STRUCTURES' AND SECONDARY LESIONS AS 'THE HYPOPERFUSION, MUSCLE HYPERTROPHY THEN HYPOTRO-
SECONDARY AND COMPENSATORY DISTURBANCES OF PHY AND GENERALIZED REDUCTION IN MOBILITY. THIS
STRUCTURE WHICH EVENTUALLY ARISE FROM BASIC DISTUR- WILL BECOME PROGRESSIVELY MORE MARKED IN THE
30 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

intervening time between the onset of the lesion anterior and medially positioned. The positional
and the time when treatment is to be attempted. findings do not have to be incorporated into the
The concept of treating the primary lesion and the models of first and second degree or Fryette's Type I
secondary resolving itself is clearly unlikely to and II lesions, and as these models are used for
occur in this situation; in fact if the primary alone describing articulation, they do not apply to viscera -
were treated, the 'old secondary' could potentially which therefore will utilize just the stated positional
become the 'primary' and reinstate the 'old pri- findings for a positional diagnosis (functional find-
mary' as a secondary! ings are also used to describe the functional aspects
This process can be continued throughout the of these lesions). Inherent within these statements of
body via reflex connections. Continuing the above position are implications of expected relative ease or
situation, T4 will have had an effect via the somatico- bind of movement. As noted earlier in a simple
visceral reflex on its segmentally related viscera and osteopathic lesion, for each plane of movement
their supporting structures, creating possible distur- where there is restriction, there will be relative ease
bances in the viscera's mobility, motility and inter- of movement in the opposite direction of that plane
nal physiology, with all the consequent problems. of movement. Convention decrees that the lesion is
As the T4 is now relatively chronic the structures named according to the direction of ease of the
likewise will be in a chronic state. This may set up a movement. The same logic applies to any structure,
self-perpetuating somaticovisceral-viscerosomatic including visceral, fascial and cranial.
reflex loop. Thus there are cascading levels of pri- The positional findings are thought by many
mary and secondary lesions which may themselves osteopaths to be essential for accurate correction of
be interchangeable. the lesion, as it is believed that to effectively correct a
There is thought, by some, to be a sole primary lesion it is necessary to reverse all of the components
lesion within an individual's pattern, resolution of of that lesion. This, however, is not the case with all
which will lead to resolution of the whole pattern practitioners; many feel that it is sufficient to note
of compensations. Whilst this may theoretically be that an articulation is restricted, and will mobilize it
the case, it fails to acknowledge the temporal ele- successfully without previously assessing the specific
ments discussed above - should the pattern of dys- positional findings. In this situation they are guided
function and compensation have been present for more by the feel or function of the articulation. Both
any more than a few weeks, the subsequent tissue approaches have merit, though there does currently
changes will prevent the 'unravelling' of the entire appear to be a trend to move away from the posi-
pattern. Perhaps more significantly, no person is tional findings model. Being able to understand and
without layers of dysfunction; this starts as a fetus apply both models is perhaps the ideal.
with possible birth trauma and then is overlaid by
every subsequent unresolved insult to the body,
creating a complex pattern of compensation not OSTEOPATHIC LESION W I T H REGARD TO
easily unravelled. THE UNDERLYING PHYSIOLOGICAL
The term 'most significant dysfunction' is used MECHANISMS
by many osteopaths to indicate the key dysfunction
within a particular pattern, in a particular person at The previous models give us useful tools for diag-
a particular time, and to an extent obviates the need nosing and naming positional lesions, but perhaps
for primary or secondary terminology. This having do not pay much attention to the maintaining
been said, it is still of great benefit (some would say factors, i.e. the neuromusculoskeletal, and fascial
essential) to attempt to analyse the complex super- elements, or their more distal consequences.
position of lesion patterns in each individual to be The earliest osteopaths were well aware that it
treated. was not the facet lock alone that maintained the
restriction of movement within somatic dysfunc-
THE OSTEOPATHIC LESION ACCORDING TO tion. At its simplest they were aware of the role of
POSITIONAL FINDINGS the muscles in perpetuating the lesion and, obvi-
ously, linked with that, the role of the reflex arc.
Osteopathic lesions are often described by their posi- These tentative steps into the understanding of the
tion, e.g. T4 right rotated, left side-bent flexed; exten- neuromusculoskeletal basis of the osteopathic lesion
sion of the sphenobasilar symphysis; or the liver is were supported by the findings of John Hilton.
T h e o s t e o p a t h i c l e s i o n or s o m a t i c d y s f u n c t i o n 31

John Hilton's findings in the early 1860s were of length and degree of contraction and thereby con-
great significance to the early osteopaths. These were trolling the articular position and function.
summarized in what became known as Hilton's Somatic afferents also synapse with the nuclei of
Law, and although it is stated in various forms, in the autonomic nervous system (ANS). This system
essence it is: 'A nerve trunk which supplies any has an effect on local blood supply, sweat gland
given joint, also supplies the muscles which move activity, smooth muscle and visceral function. Much
the joint and the skin over the insertion of such mus- of this was thought to be organized at a spinal seg-
cles'. The importance to the early osteopaths was the mental level, though it is now known to be ulti-
implication of an accurate and physiological har- mately under the control of the higher centres of
mony in the various cooperating structures, intra- the central nervous system (CNS).
articular, periarticular and the skin. It seems naive
7
As much of this activity is organized at a spinal
now to invest much significance in such a finding as segmental level, Korr proposed that where there is
this is now tacit knowledge, but it enabled the early somatic dysfunction there will be an increase in
practitioners to start to construct a rational basis for neurological activity at the appropriate spinal seg-
their practice. mental level and therefore 'facilitation' at that level.
Head's studies in the early 1890s are summarized The facilitation of that segment makes it more 'reac-
as Head's Law, which states: 'when a painful stim- tive' in response to both local or distal neurological
ulus is applied to a body part of low sensitivity (e.g. input, causing a preferentially greater effect on all
viscus) that is in close central connection with a those structures supplied by that segment, via the
point of higher sensitivity (e.g. soma), the pain is somatic and autonomic nervous systems (be they
felt at the point of higher sensitivity rather than at muscle, viscera or blood vessel) than the non-facili-
the point where the stimulus was applied'. 2 tated segments.
TTus means that sympathetic nerves which supply The spread of excitation from the vertebral lesion
internal organs have, via their central connections to a viscus by the above mechanism, known to the
(reflex arc), a relationship with spinal nerves which early osteopaths as a primary reflex lesion, would
supply certain muscles and areas of skin. By apply- currently be described as a somaticovisceral reflex.
ing Head's Law, as viscera are relatively insensitive The reverse, where a problem arising in a viscus
to pain, sensation created by a noxious stimulus in would be conveyed to the relevant spinal segment
the viscus is transferred to the area of greater sensi- leading to local spinal facilitation, would be termed a
tivity, i.e. the related muscles and skin. Through this, viscerosomatic reflex (Fig. 6.5), or in earlier terms, a
early practitioners established a relationship secondary reflex lesion. Korr's theories offered a
between a somatic problem and its related viscera. coherent rationale for these various types of dysfunc-
Of particular note was J.M. Littlejohn, who created a tion that had been noted by osteopaths.
table of 'osteopathic centers' relating vertebrae to Korr's concepts are explored more completely in
their physiological and visceral function. Early Chapter 6.
osteopathic texts refer to dysfunction created by this More recent models have expanded on Korr's
process as a reflex lesion; a primary reflex lesion if concepts and on the functional consequences of
the origin of the dysfunction is in the soma reflexly somatic dysfunction, most notably the role of noci-
affecting a viscus, and a secondary reflex lesion ception and centralized sensitization (see Ch. 6).
when the reverse is true, with a dysfunction in a vis- The role of the psyche in this process cannot be
cus affecting a somatic structure. overstressed; it is the overseer of all aspects of life,
These early concepts continued to be developed consciously and unconsciously. It is possible for the
but it was not until the late 1950s that a relatively psyche to be 'facilitated', in a similar way as the
complete and rational model of the neurophys- spinal segment, by the stresses of the underlying
iological mechanism of the osteopathic lesion was condition, especially if the problem is chronic in
proposed. Professor Irvin Korr, a physiologist work- nature, causing a somaticopsychic reflex. The con-
ing in the field of osteopathy proposed that the verse may also occur, where general stresses (to
articular dysfunction, arising from either trauma or which we are all subject, to a greater or lesser
postural adaptation, is maintained by the complex extent) may facilitate the higher centres, causing
interplay of the motor system via the afferent input inappropriate responses in the body via psychoso-
from the muscle spindles and Golgi tendon organs matic reflexes. This will perhaps lower the overall
and the sensory efferents controlling the muscle resistance of that individual and facilitate more
32 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

somatic disturbance (as in Bechamp's Cellular pile of bricks would behave. The posterior column
Theory of disease). See Chapters 6 and 7 for more was unable to side-bend until it had first rotated to
detail. some degree; his analogy in this case was that 'they
behaved like a flexible ruler or a blade of grass'.
9

The difference in the manner in which these two


FRYETTE SPINAL MECHANICS columns behaved underpins Fryette's concepts.
Essentially, these concepts are based on whether the
HH Fryette, DO (1878-1960) wrote widely on spine is in easy normal flexion (neutral), at which
osteopathy in general but is now perhaps best time the spine will be supported by the discs and
known for his work on spinal motion published in vertebral bodies, the facets being free to move in
1918 in a paper, 'Physiological Movements of the their permissible ranges of movement and thus act-
Spine'. This was the first organized approach to
13
ing as the anterior section of the spine in Lovett's
the investigation of spinal motion that involved the experiment; or whether the spine is out of the neutral
three axes of motion. It has been condensed into in either flexion or extension, and thereby the facets
Fryette's three laws of spinal motion and the associ- are engaged and as such are responsible for guiding
ated lesion patterns. Fryette's other major contribu- the movement and acting as the posterior section,
tion is that of expanding Dr AD Becker's 'total requiring rotation before side-bending can occur.
structural lesion' into the Total Osteopathic Lesion, Fryette's conclusions from the analysis of this at
thereby reintroducing holism at a time when the a segmental level have now become known as his
approach had a reductionist tendency (the 'total Taws of spinal motion', or perhaps more correctly
osteopathic lesion' will be explored in Ch. 9). Fryette's principles of spinal motion.
This chapter will look at the laws of spinal There are three major principles of physiological
motion, which more correctly are now termed motion, being: 15

Fryette's principles. It will also address the concepts


and nomenclature of the somatic dysfunction • First principle: When the thoracic and lumbar
related to these principles. The lesion nomenclature spine is in a neutral position (easy normal), the
devised by Fryette is widely used in Europe and coupled motions of side-bending and rotation for
America, but less so in the UK, so an attempt has a group of vertebrae are such that side-bending
been made to look at the various systems of lesion and rotation occur in opposite directions (with
nomenclature and, where possible, draw equiva- rotation occurring toward the convexity).
lents in an attempt to ease communication. • Second principle: When the thoracic and lumbar
spine is sufficiently forward or backward bent
THE PRINCIPLES OF PHYSIOLOGICAL MOTION (non-neutral), the coupled motions of side-bend-
ing and rotation in a single vertebral unit occur in
Fryette expanded on the work of Dr Robert A the same direction (with rotation occurring
Lovett published in Lateral Curvatures of the Spine and
14 toward or into the concavity).
Round Shoulders (1907). Lovett based his studies on • Third principle: Initiating motion of a vertebral
the movement of the whole spine, whereas Fryette segment in any plane of motion will modify the
applied these findings to individual vertebrae. movement of that segment in other planes of
It would appear that, for Fryette, the critical fea- motion. (This is also sometimes stated as 'intro-
ture of Lovett's work was an experiment in which duction of motion to a vertebral joint in one plane
he divided a human spine into two by sawing automatically reduces its mobility in the other
through the pedicles. This resulted in one column two planes', sometimes called Beckwith's law or
consisting of the anterior structures, the vertebral Nelson's law.)
bodies and the intervertebral discs, and another
consisting of the posterior elements, the articular The first and second principles are summarized in
facets and the posterior arch. Table 2.4.
On experimenting with these two columns he It will be seen that the first two principles are
found that in attempting to side-bend them under written only in regard to the vertebrae of the tho-
load they behaved differently. The anterior column racic and lumbar spine. Due to the shape and orien-
tended to collapse toward the convexity. He tation of the articular facets and the modified
described this as occurring in the same way that a vertebral body shape (the uncinate processes) of the
The osteopathic lesion or somatic d y s f u n c t i o n 33

Table 2.4 A summary of Fryette's first and second normal movement. According to the first principle,
principles. (After Simmons SL. The cram pages. Online: when the spine is in neutral and a compound move-
http://pages.prodigy.net/stn1 /Cram°/o20Pages.pdf ment of rotation and side-bending is initiated, the
19 Sept 2003) side-bending will occur first, followed by rotation to
the opposite side. Hence, when naming lesions
Spinal position Direction
obeying the first principle, the side-bending com-
Neutral first principle S R orS R
x Y Y x
ponent is stated first, i.e. NSR.
Non-neutral second principle R S orR S
x x Y Y It is also possible to make some generalizations
about Type I dysfunctions. They occur only when
the spine is in the neutral position or, more impor-
typical vertebrae of the cervical spine, side-bending tantly, when the articular facets are unable to guide
and rotation will occur in the same direction regard- the movement of the vertebral unit. There is a range
less of whether the vertebral unit is in easy normal of movement in which this can occur (which
flexion, flexion or extension, behaving in accor- accounts for the rather bewildering number of
dance with the second principle of motion. names relating to Fryette's neutral position, see the
The atypical vertebrae are also exceptions to the note below), but this range is very small. It is rare
above principles, most notably the C1 and C2, these for the spine to be within this range during activity,
having their own particular motions and lesion clas- but not uncommon when the body is at rest. Thus
sification. This will be discussed later in this chapter. Type I lesions are more commonly lesions of com-
The principles can be applied to somatic dys- pensation or adaptation than of traumatic origin.
function that may arise. The lesions are named They also more frequently occur in groups rather
according to the principle that describes their than individually.
motion, thus the first principle will result in a Possible causes of a of Type I dysfunction
Type I somatic dysfunction. include: 16

Type I somatic dysfunction • as a compensation to Type II dysfunction (non-


neutral): either ERS or FRS
The first principle applies when the thoracic or
• cranial and/or upper cervical spine dysfunctions
lumbar spine are in the neutral position. Thus, for
• rib cage dysfunction (structural or functional)
a Type I somatic dysfunction to occur, the spine
• visceral and fascial dysfunctions in abdominal or
must be in the easy normal position at the time of
thoracic cavities
the induction of the somatic dysfunction. That
being the case, the side-bending and rotation • three-dimensional asymmetrical tightness -
will occur in opposite directions (S R or S R in
X Y Y X
looseness in the myofascia
Table 2.4). • viscerosomatic reflexes
• idiopathic scoliosis
So, if the spine is in neutral and side-bending
• sacral base unlevel (sacroiliac or iliosacral dys-
occurs to the right at the T9 vertebra, it will then
functions)
rotate to the left. This example would be written as
• anatomical or functional short leg syndrome
T9NS R , or T9NSR , meaning:
R L L
• uncoordinated and faulty movement patterns
and muscular imbalances.
T9 - the T9 vertebra in relation to the T10
N - neutral, or easy normal Notes on nomenclature of the neutral position: 'Easy
S - side-bending right
R normal flexion' is the term used by Fryette to indi-
R - rotating left.
L cate that the spinal curve is in its normal resting
position or neutral position. It is often abbreviated
In the second, more paraphrased, example the 'N' to 'easy normal', 'easy flexion' or simply 'normal'
indicates that the spine is in the neutral position (hence the N in NSR).
and therefore the first law applies. Thus by naming In some texts the term 'easy normal extension' is
the direction of rotation, and applying the first law, also used. This is often coupled with 'easy normal
the side-bending will be assumed to be opposite to flexion' to indicate the neutral range of movement
that of the rotation. of the spine, within which range the facets will not
The naming of the lesion gives an indication as to be engaged and thus the vertebrae will respond
the sequence of movement that is likely to occur in according to Fryette's first principle.
34 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

with rotation and side-bending occurring to the


Type II somatic dysfunction
same side. Possibly as a consequence of the cervical
The second principle applies when the thoracic mobility, there is a tendency for the vertebrae to
or lumbar spine are sufficiently out of the neutral side-shift (translate) to the opposite side.
position for the articular facets to direct the move- Thus if the vertebra is in extension with right
ment, i.e. in flexion or extension. Thus for a Type II rotation there will be an associated right side-
somatic dysfunction to occur the spine must simi- bending and left side-shift.
larly be out of neutral at the time of the induction of Many utilize this side-shifting tendency to clas-
the somatic dysfunction. That being the case, the sify typical cervical lesions.
side-bending and rotation will occur in the same Thus if the vertebra side-shifts more easily to the
direction, R S or R S .
X X Y y
left, the vertebra will be in right side-bending rota-
So if the spine is in (for example) flexion and side- tion, and if more easily to the right it will be in left
bending occurs to the right, the vertebra will rotate side-bending rotation. All that remains to complete
to the right. Shorthand for this example would be the diagnosis is to assess for flexion or extension.
FR S or FRS . In this case the initial F, flexion (or E,
R R R

extension) indicates that this is to obey Fryette's sec- Atypical cervical vertebrae
ond principle, hence in the later, shorthand, example The anatomical structure of the upper two cervical
only the direction of the side-bending is supplied, vertebrae is sufficiently different from that of the
the ipsilateral rotation being implied. The vertebral rest of the cervicals to necessitate a separate method
level would precede the description. of classifying lesions of this area.
The second principle derives from the observa- This can be done in two ways, with regard to
tion Lovett made of the posterior column, described Fryette's Principles of Physiological Motion or by
by Fryette as behaving like a flexible ruler or a blade the possible positional findings.
of grass in that before it could side-bend it had to According to Fryette, whereas the typical cervical
rotate. This is the sequence of movements that are vertebrae respond to the second principle of physi-
thought to occur. Thus when naming lesions obey- ological motion (ERS, FRS), the C0-C1 follows only
ing the second principle the rotation is stated first, the first principle (NSR), and the C1-C2 exhibits
i.e. FRS and ERS. primarily rotation (with a very small amount of
Type II dysfunction is thought often to be due to side-bending).
trauma rather than postural adaptations or compen- The possible positional findings or the potential
sation, as the spine must necessarily be out of neu- lesion patterns anticipated are: -7 17,18

tral at the time of the induction of the dysfunction.


• posterior or anterior occiput, left or right
They are also thought to occur quite commonly
• bilateral anterior or posterior occiput
as individual rather than group lesions.
• occiput side-shift right or left
• posterior or anterior atlas, left or right
THE CERVICAL SPINE
• side-shift of the atlas, left or right
• right or left rotation of the axis.
The cervical spine, as previously stated, is an excep-
tion to the first and and second principles, due to
the nature of the facet orientation and body shape. COMPLICATED OR 'DERAILED' LESIONS
The cervicals are divided into the typical vertebrae,
C3 to C7, and the atypical vertebrae, CI and C2. Fryette utilized the term complicated or 'derailed'
These will be discussed separately. lesions for those lesions that have gone beyond his
principles, or perhaps more precisely, lesions that
Typical cervical vertebrae
have a non-physiological movement complicating
The cervical spine is the most mobile area of the the dysfunction. The clearest example that he states
spine. This is due to the particular structure of the is that of the inclusion of side-shift or translation in
typical cervical vertebrae, the intervertebral discs an articulation where it is not within its normal
and the facet orientation. As a result of this they act physiological range of movement, the main possible
in accordance with Fryette's second principle sites for this being the L5, the T i l and C2 to C6 ver-
regardless of whether they are in easy normal, flex- tebrae. Before one can address the dysfunction, the
ion or extension. Thus cervical lesions tend to exist non-physiological movement must be resolved, to
The osteopathic lesion or somatic d y s f u n c t i o n 35

put the vertebra 'back on the physiological track, 9


occurring at each of the three spinal curves as the
and then treatment can occur as normal. This whole body progressively bends forwards or back-
approximately equates to the complicated lesion or wards.
third degree lesion. As often mentioned, it must be appreciated that
the principles of physiological motion are in fact only
A NOTE ON FRYETTE'S NOMENCLATURE intended as guidelines to give an indication as to
RELATING TO FLEXION AND EXTENSION what may happen in the perfect situation. There will
be exceptions. An obvious example would be that of
Those of you wanting to read Fryette in the original trauma, with either macro- or microtrauma creating
will need to be aware of his occasionally confusing the lesion; should the force be sufficiently large or
nomenclature around flexion and extension. sufficiently constant then the anatomical principles
For Fryette, the terms flexion or extension have can be overcome. Or, in osteoarthritis, as the disc
different meanings depending on whether one is degenerates, the role of the facets changes, thereby
discussing spinal curves or individual vertebrae. modifying the expectations inherent in the first prin-
ciple. It also becomes more complex when lesions
Spinal curves become layered, such as when an existing lesion is
When referring to the spinal curves Fryette utilizes subject to another lesion-inducing force; again, the
the mechanical or anatomical definition for the rules will no longer be obviously applicable.
movements. Thus, flexion is defined as an increase Fryette's principles also have been questioned by
in the normal existing curve, or the approximation more recent researchers. Since Fryette proposed the
of the two ends of a curve. Extension is the reduc- principles of physiological motion they have been
tion, straightening or even reversal of the curve so subject to some further research to assess their
the ends of the curves become more distant; this is veracity. In summary ' Stoddard demonstrated
19 20

sometimes referred to as 'flattening' of the curve. radiologically that side-bending in the cervical
As the individual curves differ in their anteroposte- spine is always accompanied by rotation to the same
rior orientation they will be described as moving in side regardless of cervical posture. His observations
different ways. Therefore, if applying Fryette's in relation to the cervical spine are consistent with
nomenclature, when an individual forward bends Lovett's findings and Fryette's laws. These findings
fully, the cervical and lumbar curves will have are further supported by research undertaken by
extended and the thoracic spine flexed. Mimura et al. However, no consistent pattern of
21

coupling behaviour has been demonstrated in the


Vertebral segments lumbar or thoracic spine. Therefore in the cervi-
22-25

When discussing individual vertebral movement cal spine, Fryette's second principle is consistent
the position of the vertebral body is always used as and verified by research, but in the lumbar and
the reference point. Therefore in spinal flexion the thoracic spine, the coupled motions are inconsistent
vertebral body approximates that of the vertebra and Fryette's second principle may or may not
below (forward bending), and vice versa for verte- apply here. So, as with all models, it offers a
bral extension. hypothesis and it is then up to the practitioner to
test whether that hypothesis is consistent with the
Table 2.5 summarizes the above and includes
findings in a patient.
what would be described, according to Fryette, as

T a b l e 2.5 A s u m m a r y of Fryette's n o m e n c l a t u r e f o r s e g m e n t a l and spinal m o v e m e n t . ( A f t e r D u m m e r T. A t e x t -


book of o s t e o p a t h y , v o l 1. H a d l o w D o w n : J o T o m P u b l i c a t i o n s ; 1999:129)

Movement Individual vertebrae Spinal curve Fryette's description

Flexion Forward bending Ends of the curve approximate Cervical extension. Thoracic flexion. Lumbar
increasing the curve extension

Extension Backward bending Ends of the curve separate reducing Cervical flexion. Thoracic extension. Lumbar
the curve flexion
36 OSTEOPATHY AND THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

Flexion
CONVERGENT AND DIVERGENT LESIONS

This is another model of somatic dysfunction used by


many manual therapists. It is based on Fryette's con-
cepts but relates only to Type IT dysfunctions which
are described as being convergent or divergent. It
helps with the creation of a 'mental picture' of P
the articulation following the somatic dysfunction,
thereby clarifying the methods and directions used
to correct the dysfunction. The convergence and
divergence relate to the state of the facets as to
whether they are 'open' or 'closed': convergence
means closing of the facet joints or extension, diver-
gence means opening of the facet joints or flexion.
This is illustrated by the following examples 26

with regard to Type II lesions to the right in first


extension, rotation, side-bending lesion (ERS) and
then flexion, rotation, side-bending lesion (FRS).

Figure 2.4 ERS dysfunction (Type II) ERS right or right conver-
ERS RIGHT DYSFUNCTION (TYPE II)
gent. In an ERS dysfunction the facet joint in trouble is on the
same side as mentioned in the dysfunction, e.g. in ERS right, the
The superior vertebra is in extension, rotation and right facet will not go into flexion or divergence. If the spine
side-bending to the right, causing the right facets to moves into flexion, the right transverse process will not move
approximate, and thus this facet will be convergent anteriorly and the right transverse process will be more promi-
or will not open (or go into flexion or diverge). If nent to palpation in flexion. In extension the movement will be
the vertebra is moved into extension the dysfunc- symmetrical.
tion will neutralize and if it is moved into flexion
the dysfunction will become more prominent and
asymmetrical, as the right facet will remain 'fixed'
while the left opens. See Figure 2.4.

FRS RIGHT DYSFUNCTION (TYPE II) P

For an FRS dysfunction it is essentially the opposite:


the superior vertebra is in flexion, rotation and side-
bending to the right causing the left facet to separate,
thus this facet will be divergent or will not close (or go
into extension or converge). If the vertebra is moved
into flexion the dysfunction will neutralize and if it is
moved into extension the dysfunction will become
more prominent and asymmetrical. See Figure 2.5.

SUMMARY

In an ERS dysfunction the facet joint in trouble is on Figure 2.5 FRS dysfunction (Type II) FRS right dysfunction or
the same side as mentioned in the dysfunction, e.g. left divergent: In an FRS dysfunction the facet joint in trouble is
opposite to the side mentioned in the dysfunction, e.g. in FRS
in ERS right, the right facet will not go in flexion or
right, the left facet will not go into extension or convergence. If
divergence. In an FRS dysfunction the facet joint in the spine moves into extension the left facet joint will not close
trouble is opposite to the side mentioned in the dys- which means that the right transverse process will be more
function, e.g. in FRS right, the left facet will not go prominent by palpation when the patient is in extension.
into extension or convergence. In flexion movement will be symmetrical.
The osteopathic lesion or somatic d y s f u n c t i o n 37

This can be utilized as a diagnostic tool. When a Table 2.6 Common classifications and their
patient with an ERS right dysfunction moves into equivalents
extension, both transverse processes will become sym-
Type 1 Type II
metrical with respect to the frontal plane; they will
become 'even'. If this patient then moves into flexion, NSR FRS
the right transverse process will not move anteriorly Second degree First degree
as it should in flexion under normal circumstances. Contralateral rotation Ipsilateral rotation
This means that the right transverse process will be side-bending side-bending
more prominent to palpation in flexion. Convergent/divergent
Similarly, when a patient with an FRS right Usually group dysfunction Usually segmental dysfunction
moves into flexion, both transverse processes will
become symmetrical. But in extension, the right
transverse process will not move anteriorly (in
this case the left facet joint will not close, and the Additionally, for the cervical spine there is also a
right transverse process becomes prominent when model that utilizes the side-shift element to name
moved into extension). This means that the right the lesion. The side-shift results from the ipsilateral
transverse process will be more prominent by pal- rotation and side-bending and occurs in the oppo-
pation (when the patient is in extension). site direction to these movements. Thus a side-shift
right dysfunction would be the equivalent of left
COMPARISON W I T H OTHER MODELS Type II or possibly a 'derailed' Type II, or a first
OF DYSFUNCTION degree left dysfunction!
The array of different classification of somatic
The nomenclature and method of classifying lesions dysfunction is somewhat baffling; Table 2.6 illus-
differs from country to country, creating much con- trates some of the common classifications and their
fusion. In fact, a large portion of all of the classifica- equivalents.
tions derive from the same source (i.e. Fryette), with There appears to be a myriad of ways to qualify
slight differences in interpretation creating the con- and quantify somatic dysfunction. Each has a par-
fusion. In much of mainland Europe Fryette's prin- ticular relevance to certain conceptual approaches,
ciples are applied more stringently and, as such, e.g. defining a dysfunction by its positional find-
could correctly be called rules. This has some signif- ings is essential to the Specific Adjusting Technique
icance. If one is to be true to Fryette's principles, the (SAT) approach. The models of dysfunction are not
rules apply only to the thoracic and lumbar spine; necessarily interchangeable between treatment
the cervical spine is only able to exhibit Type II approaches, so that the positional findings neces-
lesions. It is interesting to note that within the sary for SAT are not helpful in conceptualization of
degree type classification (first, second and third dysfunction within a functional approach. In this
degree) no distinction is made between the three approach the critical factor is movement and not
spinal curves, each being able to demonstrate lesions position, the ease or bind of the articulation.
of all three degrees, thus the equivalent of a Type I Many osteopaths do not even feel the need to
could exist in the cervical spine according to this make specific diagnoses of dysfunction, diagnosis
model (though this opposes recent research < ). 20 21
in the sense that is utilized in both Fryette's Type I
Another aspect of Fryette's principles that creates and II lesions and the first and second degree
some confusion is that Type I (NSR) dysfunctions lesions, believing that it is unnecessary to reverse
are always compensations and do not involve the the components and impossible to get a positional
articular facets. As the facets are not restricted they change, and simply aim to improve the function.
do not need to be adjusted on an articular level, but
rather are treated by addressing the causative dys-
functions and then the soft tissues mamtaining the A HISTORICAL PERSPECTIVE
compensation. Thus, the only true vertebral dys-
functions are the Type II (FRS and ERS). One can chart the history of osteopathy by its
The Type II dysfunctions are sometimes, for approach to the osteopathic lesion. Still did not talk
descriptive purposes, also described as convergent about lesions but more about adjusting the abnor-
or divergent, as discussed above. malities which interfered with the normal activities
38 OSTEOPATHY A N D THE OSTEOPATHIC LESION: A DEVELOPING CONCEPT

and function of the patient. Of prime importance was they will contribute to the aetiology and maintenance
the relationship between structure and function, and of disease. By treating those elements amenable to
though there have been attempts to base treatment osteopathic treatment, the total load will be reduced,
rationale and approach on Still's practice, too little is along with the tendency to disease.
known of the manner in which he treated to make At approximately the same time, WG Sutherland
supportable statements. However, this concept is began applying Still's concepts to the cranium. He
perhaps in keeping with many of the current schools addressed its function rather than the positional
of thought that are interested in the harmony of changes. This reestablished the idea of exaggerat-
structure and therefore function in contrast to the ing the lesion rather than reversing the components.
more mechanistic approach that followed. From this arose the approaches later known as 'bal-
As time passed, a rational approach was imple- anced ligamentous tension' or 'ligamentous articu-
mented and a search for the scientific basis of lar strain'. Hoover and Bowles further developed
osteopathy caused the emphasis to pass to the this approach to establish 'functional technique'.
structural cause of disease, which became known Within these models, the aim is not to oppose and
as the 'osteopathic lesion'. The focus was on its impose on a static site of dysfunction, but rather to
effect on local and distant tissues, to the extent of move in the direction of ease, working with the
analysing the histopathological changes induced by body's inherent self-healing abilities, permitting it
artificially producing lesions in animals. Lovett to resolve the problem. The combination of a more
developed the 'physiological' movements of the holistic approach, a more dynamic concept of
spine resulting in positional findings for lesions. somatic dysfunction, and the aim of working with
The 'whole patient' became somewhat forgotten. the body rather than doing something to it, repre-
This was a period where the aim of treatment was sented a radical conceptual shift from the earlier
to reverse the components of the lesion, to 'retrace approaches. As such, the positional concepts of dys-
the vectors of force' and thus reinstate the normal function are not applicable within these models.
neuromusculoskeletal harmony. Allied with this The 1950s saw the arrival of approaches that
was the tacit assumption that, in so doing, the were less spinally focused, taking the concept of
pathophysiological process that had been observed dysfunction further into the body as a whole.
in experimental situations to be associated with the Carl Kettler and Thomas J Ruddy utilized the
lesion would also be reversed. muscles as a corrective force, inspiring Fred L
This slightly linear interpretation of the lesion as Mitchell Senior to develop 'muscle energy tech-
a focus of disturbance which, via various reflexes, niques'. William Neidner and George A Laughlin
creates local and remote effects, caused the osteo- directed their attention towards the fascia and manip-
pathic approach to be rather reductionist. The lesion ulative procedures designed to normalize it (Neidner
became the single target for osteopathic technicians, used 'fascial twist techniques' of a more direct char-
and an array of structural techniques were refined acter, and Laughlin integrated Sutherland's 'involun-
to address the lesion specifically and produce the tary mechanism' to release the fascia). Frank P
desired clinical results. Millard had since the 1920s emphasized a routine for
In the 1920s, the trend began to change. Arthur evaluating and working on the lymphatic system of
Becker introduced the idea of the 'total osteopathic the body, possibly influencing Gordon Zink in his
lesion', which was later expanded upon by Fryette. development of the 'respiratory-circulatory model of
This is described as being 'the composite of all the disease'.
various separate individual lesions or factors, Each of these approaches will have borrowed
mechanical or otherwise, which cause or predispose concepts of dysfunction from earlier models, but
to cause disease from which the patient may be suf- will understandably have had to create new con-
fering at the moment. These factors may vary from cepts where these were lacking. It is for this reason
corns to cholera, from "nervousness to insanity'". 9
that there is a rather bewildering array of concepts
This reintroduced the holism that had been tem- and models relating to somatic dysfunction or osteo-
porarily lost. Somatic dysfunction was included as pathic lesion. An awareness of the principles behind
one of the many stressors to which a person may be each of these should enable you to be able to apply a
subject. Stressors from both internal and external wide range of treatment approaches, selecting the
sources summate and detract from the individual's most appropriate one for each individual patient
well-being. Depending on the extent of the stressors rather than making the patient fit an approach.
The osteopathic lesion or somatic d y s f u n c t i o n 39

Many students have asked why the earlier Having explored the idea of the somatic dys-
approaches are still taught, as they believe that the function in such depth, it is perhaps pertinent to
more recent approaches have superseded them. clarify one point.
This is a very pertinent question; the answer ulti- 'The contemporary definition of the somatic
mately rests with each individual. The authors feel dysfunction is not exclusive to the osteopathic pro-
that no model has truly superseded any other; fession, but used in manual medicine and physio-
they all have a relevance to clinical practice, therapy as well. We, as osteopaths, can not claim its
though the older concepts will require tempering ownership but trace its historical development to the
in light of current research. It is possible for an profession, and chart the progression of the profes-
osteopath to employ direct and indirect sion by it. The osteopathic identity, however, does
approaches, use positional and functional findings not rest upon the somatic dysfunction as an identi-
and work with structural, fascial, cranial, visceral fying feature, but rests upon our ability to identify
and functional approaches. To do this as effec- with the original philosophy of Still, Littlejohn and
tively as possible it is necessary to have some level others, and to express this clinically through our
of understanding of all of the concepts discussed evaluation and management of the patient. The
in this section. If the practitioner's desire is to prac- somatic dysfunction didactically has a value, but
tise within just one area (such as structural, cra- philosophically only as part of the whole.' 8

nial or visceral) only those concepts related to that The next section will address the more global
area need to be known, but it is difficult to under- models that take the somatic dysfunction, in its
stand why anyone would want to limit themselves abstract sense, and place it within its physical, men-
in this manner. tal and emotional context.

References
1. Rumney IC. The history of the developmental term 14. Lovett RA. Lateral curvatures of the spine and round
'somatic dysfunction'. Osteopathic Annals 1979; shoulders. London: Rebman; 1907.
7(l):26-30. 15. Mitchell FL. The muscle energy manual, vol n. East
2. Educational Council on Osteopathic Principles. Glossary Lansing: MET press; 1998.
of Osteopathic Terminology. Chicago: American 16. Fossum C. Lecture notes. Maidstone: Unpublished; 2003
Association of Colleges of Osteopathic Medicine; 2002. 17. Stone C. Science in the art of osteopathy. Cheltenham:
Online. Available: http://www.aoa-net.org/ Stanley Thornes; 1999:155.
Publications/glossary202.pdf. 18. Littlejohn J. The occipito-atlantal articulation. Maidstone:
3. Cyriax J. Textbook of orthopaedic medicine, vol I. Maidstone College of Osteopathy.
London: Bailliere Tindall; 1978. 19. Gibbons P, Teheran P. Spinal manipulation: indications,
4. Isaacs ER, Bookhout MR. Bourdillon's spinal manipula- risks and benefits. IBMT 2001; 5(2):110-119.
tion, 6th edn. Boston: Butterworth Heinemann; 2002. 20. Stoddard A. Manual of osteopathic practise. London:
5. Mitchell FL. The muscle energy manual, vol I. East Hutchinson; 1969.
Lansing: MET Press; 1995. 21. Mimura M, Moriya H, Watanabe K et al. Three-
6. Dowling D. S.T.A.R.: A more viable alternative descrip- dimensional motion analysis of the cervical spine with
tor system of somatic dysfunction. AAO fournal 1998; special reference to the axial rotation. Spine 1989;14:
8(2):34-37. 1135-1139.
7. Dummer T. A textbook of osteopathy, vol 1. Hadlow 22. Pearcy M, Tibrewal S. Axial rotation and lumbar
Down: JoTom Publications; 1999: 97. sidebending in the normal lumbar spine measured by
8. Fossum C. Personal communication. 2003. three-dimensional radiography. Spine 1984; 9:582-587.
9. Fryette HH. Principles of osteopathic technic. Carmel, CA: 23. Plamondon A, Gagnon M, Maurais G. Application of a
Academy of Applied Osteopathy; 1980: 37. stereoradiographic method for the study of intervertebral
10. Hoover HV. Complicated lesions. In: Barnes MW, ed. motion. Spine 1988:13(9):1027-1032.
1950 Academy Yearbook. Michigan: Academy of Applied 24. Panjabi MM, Yamamoto I, Oxland T et al. How does pos-
Osteopathy; 1950: 67-69. ture affect coupling in the lumbar spine? Spine 1989;
11. Selye H. The stress of life. New York: McGraw-Hill; 14(9):1002-1011.
1976. 25. Vicenzino G, Twomey L. Sideflexion and induced lumbar
12. Mitchell FL. Towards a definition of 'somatic dysfunc- spine conjunct rotation and its influencing factors. Aust J
tion'. Osteopathic Annals 1979; 7(l):12-25. Physiother 1993; 39:299-306.
13. Fryette HH. Physiological movements of the spine. ] Am 26. Fossum C. An introduction to spinal mechanics.
Osteopath Assoc 1918;XVIII (1). Maidstone: unpublished; 2003.
Page Intentionally Left Blank
41

SECTION 2

Osteopathic conceptual
(perceptual) models

SECTION CONTENTS 2. Tensegrity


3. Biotypology
3. Structural concepts    43 
4. Neurological models
4. Tensegrity    71 
5. Psychological considerations
5. Biotypology    83 
6. Fluid model
6. The nervous system      107  7. The total osteopathic lesion
7. Psychological considerations    137  This reductionist approach of selecting certain
8. The respiratory‐circulatory model  aspects with which to analyse the human is
of osteopathic care    159  anathema to the holistic concept of osteopathy. It is
important to remember that in the reality of
9. The total osteopathic lesion      165 
osteopathic practice, the total understanding is by
This section will look at some of the ways the application of a mixture of these models. The
that osteopaths have attempted to perceive reason that they have been separated out here is for
the human body and how it functions. For ease of understanding.
the purpose of this discussion certain
It is also important to realize that while these
elements of the body have been selected as
models are useful to begin to understand a person,
the basis of conceptualization. The
they are only concepts and are not prescriptive. No
paradigms selected are:
model is able to fully describe the rich variety that
1. The structural or musculoskeletal model exists in humankind.
43

Chapter 3

Structural concepts

INTRODUCTION
CHAPTER CONTENTS

Introduction 43 This section will look at some of the concepts that


Development of the spine 43 relate to an understanding of how the structure of
Some considerations on the functions the body generally, and the spine specifically, have
of the spine 45 been interpreted osteopathically. It begins with
some general concepts and concludes with a review
Littlejohn's biomechanics 51
of certain of the key elements of the biomechanics of
Conclusion 68
JM Littlejohn. Nearly all of this material is founded
References 70
purely in empiricism. From the fact that these con-
Recommended reading 70 cepts have survived, and are used daily in osteo-
pathic practices throughout the world, it could be
said that they have been thoroughly tested clini-
cally. This does not of course prove their veracity;
however, that is not the task of this book. They are
presented here as possible interpretations that may
enable you to develop your own way of seeing and
understanding the body. Some of the models are
purely conceptual or 'visual' and do not even
attempt to have a rational scientific basis. An exam-
ple of this is the section on 'areas under a curve',
and how balance is achieved. Mathematically and
biomechanically, there is no truth to it. However, if
it is taken, as it is intended, as a visual comparison,
with the numerical formulae there only to illustrate
the point, it offers a useful tool to aid the initial
interpretation of spinal curves.
Initially, the segmental relationships between the
spinal curves will be explored and then the bio-
mechanical concepts of JM Littlejohn.

D E V E L O P M E N T O F T H E SPINE

It is of interest to reflect on how spinal curves


develop from fetus to maturity. In utero the baby is
44 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

floating in amniotic fluid. Its spinal curve is to lift it against gravity. However, by about week
kyphotic, convex posteriorly, from occiput to eight, it has begun to raise its head. In doing so, the
sacrum. Its similarity in shape to the letter 'C has baby has begun to create the neurological circuitry
led to this shape being termed the 'primary C to the cervical erector spinae muscles, initiating
curve' (Fig. 3.1). movement and muscle strengthening. The cervical
At birth this fluid support is lost; it is at this erector spinae muscles become strong and intro-
point that the human starts its long and arduous duce the first lordotic curve in the cervical region.
battle against gravity. At birth the baby should be This curve is often termed a secondary curve, to dis-
developed to the point of independent function. tinguish it from the primary C curve. This further
Naturally, it still relies on its mother for its nutri- develops as the baby sits and later crawls. See
tional needs, but anatomically the organ systems Figure 3.2.
are fully functional. The nervous system has to The crawling position still limits one's interac-
begin the process of learning and the laying down tion with the world, so the baby then tries to stand
of neural connections to complete its circuitry. From up. This means balancing on two potentially mobile
a structure/function viewpoint, the baby's move- ball and socket joints, the hips. To enable this to
ments of arms and legs are haining the muscles and occur there needs to be some degree of dynamic fix-
making connections that will allow the child to later ation of the pelvis to permit the spine to rest stably
perform coordinated tasks. Even at birth, the baby on it. This is achieved by a complex interaction of
has a number of 'preloaded' reflexes present that the iliopsoas, pelvic floor, hip extensors and erec-
allow it to survive, e.g. the rooting reflex in order to tor spinae muscles. For the baby to stand up it is
search for the nipple and gain sustenance, and the also necessary for the hip to extend further than it
neck righting reflex which allows the baby to lift ever has before. This will oppose the action of the
and turn its head from side to side in the prone hip flexors, the iliopsoas muscles. As these are
position, preventing suffocation. attached to the anterior aspect of the lumbar spine,
The natural progression from this stage is for the stretching the iliopsoas will cause a pull on their
baby to lift its head and begin to interact with its attachments on the lumbar spine. This and the
new world, and thereby increase its visual knowl- strengthening of the lumbar erector spinae muscles
edge of its whereabouts. This is not an easy task, cause the lumbar spine to be drawn anteriorly, cre-
considering the relative size of a baby's head and its ating the second secondary curve. See Figure 3.3.
body, compared with those of an adult. It also has As with the cervical spine this curve is largely
maintained by the erector spinae muscles perform-
ing an 'antigravity' role, but from the above it can
be understood also to be dependent on the inter-
play between the iliopsoas, pelvic floor, hip exten-
sor and abdominal muscles, or in fact by anything
else that could affect the degree of pelvic tilt.

Figure 3.2 The development of the cervical lordosis as the


Figure 3.1 The primary C curve of the baby in utero. baby crawls.
Structural concepts 45

tain the vital organs, the brain, the heart and lungs;
and our means of reproduction. They are protected
in stable bony cages, therefore mobility has to come
from other areas of the spine. The thorax is a perfect
example of function affecting structure: the ribs
create a bony box and to an extent these limit the
mobility of the thorax, but their arrangement is such
that they permit the box to expand and contract in
response to respiration, whilst at no time leaving
the vital centres within vulnerable.
The balance between the roles of protection and
mobility is also demonstrated within the spine itself
as a whole. The vertebrae may be considered to be
comprised of two major components: an anterior
part, which consists of the vertebral bodies and inter-
vertebral discs, and a posterior part comprised of the
bony vertebral arch and its superiorly and inferiorly
projecting articular pillars. Thus the spine as a whole
can be seen to consist of three pillars: a massive one
anteriorly, designed for weight-bearing, and two
much smaller ones, created by the articular pillars,
designed to permit movement. The posterior arches,
with the ligaments passing between, then create the
spinal canal, designed to protect the spinal cord. It is
this combination of the three bony columns that pro-
vides an intricate balance of stability and mobility
Figure 3.3 The erect posture. whilst at the same time still achieving protection of
the delicate central nervous system.

SOME CONSIDERATIONS ON THE


FUNCTIONS OF THE SPINE THE ROLE OF THE CURVES IN THE RESISTANCE
TO AXIAL PRESSURE AND THEIR ROLE
Bv looking at the spinal curves with regard to the IN MOBILITY
developmental primary C curve, it is possible to see
that the vestiges of this kyphotic curve are still pres- Another important function of the spine is that of
ent in the sacrum, thoracic curve and the cranium resisting axial compression forces. The resistance of
(the occiput can be considered to be a modified ver- a curved column has been shown to be directly pro-
tebra ). Intervening between these are the second-
1
portional to the square of the number of curves plus
ary curves. These are lordotic and are the areas one, or R = N + 1 (where R is the resistance and N
2

where the body has adapted to enable upright pos- is the number of curves). 2

ture, thus they are sites of adaptation. This ability to


adapt may in part account for the finding that often For a straight spine, or no curves, N = 0
individual segmental lesions are found within the R = 0 + 1
2

secondary curves, whereas in the thorax this is rare, Therefore R = 1


with most lesions occurring as group lesions.
Looking at their mobility it can be noted that the For three curves, N = 3
two lordotic curves represent areas that are mobile R = 3 + 1 = 10
2

transitions between relatively hypomobile areas. R = 10


(Lumbar mobility is greater than that of the thoracic
in all planes except for rotation. ) This arrangement
2
Thus the introduction of three dynamic curves
can, to some extent, be explained by the body's increases the resistance to ten times greater than that
functional requirements. The hypomobile areas con- of a straight column.
46 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Figure 3.4 The Delmas index. This Increased 'Normal' Decreased


is defined as the extended length of curves curves
the spine divided by its actual
height. Thus for the three spines
illustrated this will give a low
Delmas index for the increased
spinal curves and a high index for
the decreased curves. The index has
a relation to the function of the
spine, thus the greater the A/P cur-
vature, the lower the Delmas index
and the more dynamic the spine. A
reduction in the A/P curvature leads
to a higher Delmas index and there-
fore a more static spine. (After
Kapandji IA. The physiology of the
joints, vol 3: the trunk and vertebral
column. Edinburgh: Churchill
Livingstone; 1974.)

Low Delmas High Delmas


index index
Function of curve Dynamic Intermediate Static

The nature of the curves has also been shown to how frequently are they also rigid in body, with a
have an effect on their function in terms of mobility, marked upright, straight spine appearance? This is
see Figure 3.4. This is quantifiable by applying the verging on the point of stereotypical, but perhaps the
Delmas index. This is established by dividing the
2
body and mind are just different expressions of the
height of the spinal curves in the upright individual same thing.)
by the length of the spine were it to be fully extended
or straightened. Thus a spine with increased curves THE ROLE OF THE SOFT TISSUES
will be slightly shorter than one with 'normal' curves
in the upright posture. If both had the same potential We have talked about the functions of the bony
length when fully extended, the Delmas index would structures, but of equal significance are the soft tis-
be lower for the increased curve spine. He concluded sues. In the diagrams of the mature upright posture
that the spinal column with augmented curves (and (such as Fig. 3.3) the extensor or antigravity muscles
therefore a lower Delmas index) is more that of a are generally illustrated by thick lines; this is to
dynamic type, whilst reduced AP curvature (and a indicate their strength. Working against gravity has
higher Delmas index) leads to a more static type. caused them to become strong. The flexor muscles
(Perhaps it is fanciful to extrapolate from this con- in the anterior throat and abdomen are illustrated
cept to personality types, but reflect on your acquain- with thin lines, indicating their relative weakness.
tances and think of the mentally inflexible people: There is a tendency for osteopaths to be more
Structural concepts 47

focused on hypertonia of the strong'antigravity They act synergistically, that is, they work interde-
muscles, and therefore the posterior aspect of their pendently; dysfunction in one element will be con-
patient. However, it is important to remember that veyed to all elements. This concept is perhaps better
upright posture is achieved by a balance between explained by tensegrity mechanics rather than those
the flexors and the extensors, and that though the based on Newtonian concepts and this will be dis-
extensors appear to be able to exert a greater effect, cussed in Chapter 4.
weakness or hypotonia of the flexor groups can
have dramatic effects on posture. THE BALANCE OF THE CURVES
For example Hides et al have demonstrated that
3

the abdominal container also has a role in the stabi- In Figure 3.3 the relationship between the spinal
lization of the trunk on the pelvis. They defined this curves is that which one would expect to find in the
container or cylinder as being comprised of the 'ideal' posture. Looking at people in general it is easy
pelvic diaphragm, the transversus abdominis mus- to see that this is not always the 'normal' posture.
cle, the thoracolumbar fascia and the respiratory There are a great many variations from this ideal.
diaphragm. If someone has lost tone in any of these Osteopaths and others have spent much time
muscles, the consequence is that the lumbar lordosis trying to look for trends that would aid general
increases. In Newtonian terms the flexor and exten- understanding. Some of the commonly used models
sor muscles can be imagined as opposing but bal-
anced pulley systems: if the flexor pull is reduced
there will be a dominance of the extensor pull, hence
the increase in the lumbar curve.
Another way of perceiving this is based on
the knowledge that the body cavities are an impor-
tant part of the body's support structure. The
abdominopelvic cavity is filled with viscera and
fluid. They are constrained by a muscular 'con-
tainer'. If the container is firm, the whole structure is
relatively rigid, and can therefore offer support.
When the container becomes lax, as in this example, Leverage
with the abdominal muscles becoming hypotonic, balanced
the fluids are no longer compressed and the support
offered is reduced. The viscera then ptose anteriorly,
pulling on their posterior fascial attachments and
causing an increase in the lumbar curve. (Another
way of looking at this is to note that an increase in
the lumbar curve may relax the peritoneum, to
which organs are attached, and because they lose
support they ptose.)
In each situation the hypotonic state of the weak
anterior muscles is the cause. The consequent lumbar
curve change, and any other compensations that may
occur as a result of this, are secondary. It is possible
that symptoms may arise as a result of the secondary
problems, for example the L5 becoming symptomatic
because of hyperextension. Treatment applied to the
L5 or the lumbar curve will at best offer only tempo-
A
rary relief. True resolution will occur only when the
Figure 3.5 (A) A stable dynamically balanced situation. The
primary problem of the weak abdominal muscles has
'container' (thoracic and pelvic diaphragms, transversus abdo-
been addressed (see Figs 3.5 A and B). minis, thoracolumbar fascia and the erector spinae) is gently
In actuality, upright posture and correct body compressing the viscera creating a stable structure (like a foot-
functioning is maintained by a complex interplay ball when fully inflated). The muscles are tonic, but generally
of all of the elements of the body, bony and soft. are just fine-tuning the balance.
48 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

The lumbar curve increases

The leverage on the


lumbar spine increases The longer lever requires greater
muscle contraction posteriorly to
maintain balance

The sacrum and therefore


Visceroptosis pelvis globally nutates

B
Figure 3.5 cont'd (B) The abdominal muscles have become weak, creating a less stable container for the viscera, which then ptose
anteroinferiorly. This increases the leverage on the lumbar spine causing it to move anteriorly and the pelvis to nutate. The posterior
muscles contract to resist the forward pulls spine.

will be discussed below. (Please note that the fol- AREA UNDER A CURVE
lowing concepts are not 'mathematically' accurate:
they are conceptual models to aid in the visualiza- A slightly simplistic view of why this occurs can be
tion of the changes in the balance of the spinal demonstrated by considering the area under a
curve.) curve. If you were to draw the three mobile spinal
curves and take a line through the length of the
THE INTERDEPENDENCE OF THE CURVES spine at the midline position, you would arrive at
two small curves anterior to the line, the cervical
Stated simply, there is a constant relationship and lumbar, and one longer curve posterior to the
between the three dynamic curves. If one curve is line, the thoracic (see Fig. 3.7A).
changed, the others change to maintain this rela- If the area anterior to the line was to be thought
tionship. Figure 3.6 represents this principle. In this of as positive and the area posterior as negative,
illustration the change in the curves is due to a in order to achieve balance the summation of the
change in the lumbosacral angle, causing an ascend- anterior and posterior curves should equal zero.
ing pattern change. If the cervical curve was Reflecting on the interdependence of the curves,
increased for any reason, this would theoretically if one curve is increased the area under the curve
also cause an increase in the other two curves; this would be similarly increased. This would disturb
would be a descending pattern of change. The tho- the balance until the other two curves were equally
racic curve, obviously, is able to affect the other two increased (Fig. 3.7B). Thus it would be possible to
curves as well. say that we achieve a sense of balance throughout
This is one possible model or pattern of spinal the spine by maintaining the balance underneath
adaptation. the curves.
Structural concepts 49

opposite forces acting on a central point, the key-


stone. Looking at the lumbar spine the keystone
would be the L3 vertebra. As there are equal num-
bers of similar sized vertebrae either side of this
keystone it seems a fair assumption to say that the
LI and L5 vertebrae are performing equal and
opposite tasks, as are the L2 and L4. See Figure 3.8.
The significance, osteopathically, of this, is that if
there is a specific dysfunction that occurs in a par-
ticular vertebra of a curve, to maintain balance, one
of the (many possible) ways to adapt would be to
have the equal and opposite vertebra perform the
counter movement.
An example would be that if the L2 vertebra
were to be rotated left, to maintain balance the L4
vertebra might rotate to an equal degree in the
opposite direction (Fig. 3.9A).
Another very common adaptation is for the
immediately neighbouring vertebra to counter the
imbalance (Fig. 3.9B).
This would be one method of resolving problems
within a curve, without requiring any adaptation
from the other superimposing curves, as the area
under the curve (in this case lumbar) has been
maintained.
Figure 3.6 The interdependence of curves. If the lumbosacral
Resolution within a curve does not always occur,
angle is increased from the normal all three curves will be
similarly augmented. The reverse will occur with reduction of and the compensation therefore may occur across
the lumbosacral angle. This demonstrates the interdependence the curves. This is best explained diagrammatically
of the curves. (Figs. 3.9C and D).
The discussion so far has only indicated single
vertebrae adapting to single vertebral dysfunction.
The interdependence is certainly not the only way This does not have to be the case: as long as the
that the spine can adapt. As long as the net result is laws of equal and opposite are considered to apply,
zero, it is possible for the curves to behave dissimi- there is a seemingly infinite number of possible
larly. Figure 3.7C demonstrates one example of this. ways to ultimately achieve balance. Some basic con-
It would, however, have been equally effective for cepts should help you in deconstructing compensa-
the cervical curve to have remained unchanged and tion patterns in your patient.
the thoracic curve to have increased sufficiently to If a vertebra has rotated 4° to the right (the fig-
balance the increase in the lumbar curve. ures are purely to illustrate a point), it may be
adapted for by one vertebra rotating 4° to the left.
BALANCE WITHIN THE CURVES Equally it may be by two vertebrae rotating 2° each
to the left. Or four rotating 1° each; or one rotating
Still thinking of spinal curves and how they achieve 2° and two rotating 1° etc. This applies similarly to
balance, we can look at balance achieved within the all planes of movement.
curves, as opposed to the previous example of bal- It is also possible to utilize the 'area under a curve'
ance between the curves. analogy to look at the possible adaptation patterns as
Let us take just one curve, for example the lum- just discussed, but from a visual perspective. This is
bar, and imagine that for the moment it is without best illustrated diagrammatically (Fig. 3.10).
its neuromuscular ligamentous support system. It So far, the discussion has principally been with
does not take too much imagination to compare its regard to the anteroposterior (AP) balance of the
structure, in a supine position, to that of a bridge. curves. The previous concepts are equally applicable
The bridge maintains its integrity by equal and in the lateral plane, with the balance tending to occur
50 OSTEOPATHIC CONCEPTUAL (PbRCFPTUAL) MODELS

- 0 + - 0 + - 0 +

A = +0.5 units 2

A = +1 unit 2

A = +1.5 units 2

B = -2 units 2
B = -3 units 2
B = -2 units 2

C = +1.5 units 2

C = +1 unit 2

C = +1.5 units 2

A+B+C=0 A+B+C=0 A+B+C=0


(+1) + (-2) + (+1) = 0 (+1.5) + (-3) + (+1.5) = 0 (+0.5) + (-2) +(+1.5) = 0

A B C
Figure 3.7 (A) Area under a curve. A, B, and C correspond to the areas described by each curve. To achieve balance A+B+C must be
equal to zero. (B) This demonstrates the interdependence of the curves. An increase in one curve will lead to a similar increase in the
other two, so that A+B+C still equals zero. (C) As long as the total equals zero, balance can be achieved in various ways.

across the same pivotal areas as in the AP examples. complex ones, some of which will be discussed later
The same visual analogy of the areas also applies, in this chapter. However, with these tools it is possi-
the curves being in the lateral plane rather than AP. ble to start analysing superimposed spinal adaptation
The preceding concepts create what is perhaps one patterns and to begin to establish what is related to
of the most basic of models with which to interpret what. The key point within this model is to look for
patterns within a spine. There are numerous more similars. The concept of 'similars' is frequently uti-
lized in osteopathy, and as the word implies, similars
are entities that are nearly or sometimes exactly the
Keystone same. When analysing adaptation patterns the similar
L3 may be an opposite pattern but similar in its degree
or extent. For example, there may be a shallow right
side-bending group passing over three vertebrae. Its
similar would be a shallow left side-bending group
passing over three vertebrae, or, bearing in mind the
previous material, a slightly deeper left side-bending
group passing over two vertebrae, etc.
Figure 3.8 It can be seen that the vertebrae are acting around Many dysfunctions will have a major component
the central keystone of L3. As such, the L5 and L I , and the L2 to them, be it rotation, side-bending or flexion/
and L4 can be hypothesized as performing an equal and oppo- extension. By looking for its 'similar but opposite'
site role around the keystone. and making an assessment as to whether it is suffi-
Structural concepts 51

function has been present. As compensation to


dysfunction occurs relatively rapidly, the initiating
problem, and any compensations to it, will have the
same tissue feel. Other patterns in the body, which
Cervical
may be older or more recent, will have different tis-
sue feels. Thus tissue feel can assist in identifying the
relationships between specific dysfunction and its
compensatory pattern. This all appears to be very
simple; however, lesion patterns will often overlie
each other, somewhat obscuring the patterns. But,
with experience, and the will and interest to explore
these ideas practically, their interpretation becomes
progressively more easy. The advantage of under-
Thoracic standing the layers of patterns is that it should be
possible to remove a pattern with the minimum of
disturbance to the rest. This is critical when treating
someone who is about to do something important
shortly after the treatment (take part in an athletic
competition, get married, go on holiday), when they
will not thank you for leaving them unbalanced and
possibly suffering worse symptoms than before.
This approach has many detractors: osteopaths
Lumbar who feel that such ideas are unnecessary at best and
fallacious at worst. However, it is often better to
explore ideas first and then, if they do not work,
discard them, rather than discarding them from a
point of ignorance.
Figure 3.11 is a schematic attempt at illustrating
these concepts within the whole spine.
The preceding information offers some insight
into certain features of the spinal structure
and function. However, for a truly complete struc-
Figure 3.9 Several possible areas of compensation for a
somatic dysfunction (SD). (A) Is equal and opposite within its tural system one has to look at the work of JM
curve. (Bi and ii) Either of its immediately neighbouring verte- Littleiohn.
brae. (C) Across the transition between the curves. The section
is drawn out to reveal the similars across the central point. (D)
With its reflection across the mid axis of the spine (T9). LITTLEJOHN'S B I O M E C H A N I C S

John Martin Littlejohn (1865-1947) was one of the


great early osteopathic thinkers. He refined and
developed systems that encompass both segmental
and global biomechanical analysis, and he was
instrumental in bringing a sound physiological
cient to balance the original problem, you will have basis (based on contemporary knowledge) to the
established a relationship hypothesis. This hypothe- prevailing osteopathic concepts. He approached
sis will be repeatedly tested by the subsequent the spine as an articulated whole, looking at the
physical examination before it is acted on, but it is osteokinematics, or its position in space in relation-
the starting point of a diagnosis. ship to its different parts. He then approached
Tissue feel is an extremely useful tool in helping the arthrokinematic level, the movement of the
you analyse these problems. As mentioned in zygapophyseal joints, using the tripod concept
Chapter 2, tissue changes associated with somatic outlined by George Webster and himself. The tri-
dysfunction are proportional to the time that the dys- pod theory has been superseded by Fryette's
52 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

A B C

D E F
Figure 3.10 A selection of examples illustrating how balance may be achieved utilizing the 'area under a curve' analogy. The spine
has been represented as a straight line to facilitate its interpretation. Note that the example F fails to achieve balance.
Structural concepts 53

Figure 3.11 An example of the analysis of complex


patterns of dysfunction. (A) Posterior view; (B)
Lateral view. Note on the lateral view the dotted line
is the theoretical 'normal'. A possible hypothesis of
the relationships between the areas of dysfunction is:
1. The right side-bending sacrum leads to a scoliotic
pattern arising in all three curves, demonstrating the
interdependence of the curves. 2. The increase in the
lumbar curve is compensated for by a decrease in the
cervical curve, maintaining a balance with regard to
the total spinal area under a curve. 3. Segmental bal-
ance of rotational dysfunction, one vertebra (3A)
being compensated for by two lesser rotated verte-
brae (3Bi and 3Bii). 4. A simple group flexion lesion
compensated for by an equal extension group lesion.
5. A side-bending lesion being compensated for
across the transition point of one curve and the next.
6. A side-bending curve or vertebra compensating
with its immediately neighbouring vertebra within the
same curve. Associated with this is a flexion and
extension pattern (seen on lateral view). Note how
patterns are superimposed on each other i.e. the lat-
eral curve in (1) is overlain with the side-bending pat-
tern of both (5) and (6). This makes interpretation less
obvious; however, palpation of the associated soft tis-
sues to 'age' the lesion will aid in repeating the vari-
ous layers.

A B

arthrokinematic observations, stated in his pre- almost synonymous with 'classical osteopathy', it
cepts. For this reason, the tripods will not be dis- can be demonstrated that his principles also under-
cussed here. Littlejohn's biomechanical principles pin many of the more recent approaches.
underpin many of the osteopathic models that are The systems that Littlejohn developed in fact
in use throughout Europe, and though his ideas are appear rather intimidating in their complexity and,
54 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

perhaps for this reason (and perhaps their relative to its mechanics and the central gravity line and
antiquity), have lost favour in certain osteopathic not necessarily the point of maximum curvature. 4

quarters. Those that do utilize the concepts gener- He excluded the CI vertebra as he considered it
ally fall into two camps: the traditionalists, who to be little more than a connecting ring between
attempt to interpret the material as Littlejohn the occiput and the cervical arch. He, and later
intended it, and those who utilize the concepts as a Wernham, have drawn an analogy between its role
foundation and attempt to integrate them with new and that of the L5, particularly in the 'functional
concepts as they arise. arches', and as such it could be thought of as a pivot
There appears to have been a trend over the last between the occiput and the C2.
few years to dismiss Littlejohn's work as non- Littlejohn described four types of arches:
scientific and inaccurate. A prime example that has
• the structural arches
given rise to this opinion is that he cites the L3
vertebra as the centre of gravity for the body, • the functional arches
whereas most contemporary studies demonstrate • the central or double arch, and
that it is anterior to the body of the S2 vertebra. It • the physiological arches.
is, however, perhaps worth reflecting on the source Each classification is based on a particular role or
of his theories. They arose from close observa- criteria, as implied by their names. A brief descrip-
tion of individuals in a clinical setting and were tion of each follows.
tested in the treatment of these individuals. The
construct of lines and pivots he created was his T h e structural arches
attempt to define what he saw. By contrast, the S2 This is essentially the manner in which the spine
level was discovered utilizing complex analytical has been described by anatomists, based on
equipment. Most osteopaths utilize the same assess- regional anatomy. Thus the neck passes from the
ment tools that Littlejohn used: our eyes, hands and skull to the thorax, therefore the spine in that region
intellect. Perhaps the models that he inspired still is the cervical spine, and similarly for the other
have a relevance to the practising osteopath. curves. Though it is possible to distinguish which
Ultimately, each individual practitioner must come group most of the vertebrae belong to by looking
to their own conclusions on this matter. at their structure, it is not based principally on the
In this chapter, no attempt has been made to morphology of the vertebrae. The arches are illus-
encompass Littlejohn's whole oenvre, due to the con- trated in Figure 3.12.
fines of space, but the key elements are introduced
as well as their more contemporary interpretations. The arches The keystones
For those interested in Littlejohn's original concepts C2-T2 C2/3
there is a list of recommended reading at the end of T2-T12 T5/6
this chapter. T12-L5 L3
L5-Coccyx
THE ARCHES
T h e f u n c t i o n a l arches
Littlejohn analysed the spinal curves in a series of
different ways. He based these interpretations on a As the name implies, this classification is based on
wide range of criteria, including the morphology of the way the curves function as units. Function is dic-
the vertebra such as their facet orientation and body tated by structure, in this case the structure of the
shape, the origins and insertions of muscles attach- vertebrae and their supporting muscle groups.
ing to the spine, sites where the perceived lines of Morphologically there is a gradual transition as the
force (AP, PA, AC, PC and central gravity line) sec- spine is descended. Some of these changes dictate
tion the spine, the centre of the arc of individual the movements that are possible, such as the orien-
vertebral movement (oscillatory centre), the embry- tation of the articular facets of the vertebrae. The
ological development of the spine, and observable attachments of the spinal musculature can be inter-
function - to mention a few. This resulted in a series preted as dividing the spine into functional units.
of 'arches and keystones' for each analysis. The Thus it is possible by observing the manner in which
term 'keystone' was used by Littlejohn to mean the spine functions and by analysing the nature and
the most important vertebra in the arch, in relation position of the above structures, to create a series of
Structural concepts 55

Arches

C2-C4
Cervical

C6-T8

Thoracic

T10-L4

Lumbar

Sacrococcygeal

Coccyx
Figure 3.12 The structural arches. Figure 3.13 The functional arches.

arches defined by the function (and structure) of the


Thus these points - C5, T9, L5 (CI) - represent the
spine. This does not comply with the regional
pivots between the arches. One type of movement is
approach utilized conventionally in anatomical
permitted above and another type is permitted
descriptions, such as that described above in the
below. It is clear that these pivots will be subject to
structural arches. The arches so defined are termed
a lot of strain.
the functional arches. The key features are:
Complex analysis of the origins, insertions and
• The C5 and the T9 are cited as points of transition directions of action of the surrounding spinal
of facet orientation and therefore represent transi- musculature reveals that though working as an
tional points for movement. integrated unit, it is possible to observe a functional
• The L5 is envisaged as the linkage point between division into groups, the position of which further
the lumbar spine and the sacrum, in an analogous supports the structural observations leading to the
role to that of the CI. functional curves. See Figure 3.13.
56 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

The arches The interarch pivots Keystone


C2-C4 C5
C6-T8 T9
T10-L4 L5
Sacrum-Coccyx

The central (double) arch


The key element of analysis in this arch is that of
support of the spine and body. The central arch is
thought to represent the strongest unit of the spine.
This is based on several concepts:
• The thorax is a primary curve; it has retained its
embryological kyphotic curve into adulthood and
is therefore stable and strong. The cervical and
lumbar curves are secondary, and therefore
almost by definition are areas of compensation T9
rather than support, adapting to both the primary The central arch
curve and to gravity. T5-L2
• The T4 represents the point where the compres-
sive forces of the head and neck are supported by
the primary curve.
• The L3 represents the centre of gravity of the
body with everything below being suspended
from this point.
• Both of the above points are also major pivotal
areas. The T4 is the point of articulation between
the upper and lower triangles and the L3 is the
apex of the little triangle (see p.64). These repre-
sent points of mobility either side of a relatively
hypomobile stable thoracic group.
Thus the central arch supports the spine: the cepha-
lad end of the arch is a foundation for the compres-
sion originating from the head and neck, and the
caudad end is also the point of suspension from L3
and below for the pelvis and lower extremities.
Thus the central arch runs from T5 to L2. It is some-
times referred to as the double arch as it is com- Figure 3.14 The central or double arch
prised of both a kyphotic arch and a lordotic arch
(Fig. 3.14).
The key points are that C7 and T9 are the oscilla-
The arches The keystone tion centres for the cervical and thoracic and the
C2-T4 thoracic and lumbar regions respectively and it is
T5-L2 The central arch T9 these that define the cephalad pivot of the two
L3 below curves. Analysis of the osteopathic and autonomic
centres within each region would enable one to
The physiological arches
predict the type of physiological dysfunction that
This is based on a rather complex analysis of the might occur. See Figure 3.15.
lines of force, the osteopathic centres, autonomic
nervous system control, and centres of oscillation The arches The keystone
(the central point of a circle described by the orien- C7-T8 T9
tation of the facets). T10-Coccyx
Structural concepts 57

Keystone •occiput/Cl
• C5
• T4
•T9
• T12/L1 (thoracolumbar junction)
• L3
• L5/S1.
C7-
The C5, T9 and L3 are sometimes referred to as mid-
arch pivots and the others are termed interarch piv-
ots. This is not consistent with Littlejohn's usage of
C7-T8 these terms, but has a practical use.
The spinal curves are thus described as follows:
• The cervical curve passes from CI to T4 (often cited
as C2 to T4 due to Littlejohn's ideas on the CI).
• The thoracic curve passes from the T4 to the T12.
T9- • The lumbar curve passes from LI to L5. See
Figure 3.16.
Variations on this are often seen, the most common
of whch are:
• Rather than occiput/Cl, the occiput/C3 is used.
This is based on Fryette's logic that the upper cer-
vical complex should be perceived as one unit
functioning as a universal joint, permitting all
planes of movement within the group, enabling it
to adapt to any postural changes in the body and
T10-coccyx still maintain the correct alignment of the head.
• The thoracolumbar junction is sometimes not
included as a pivot.
• The L5/S1 junction is sometimes stated as the
sacrum, presumably to allow for consideration
of the sacroiliac articulations as well as the
lumbosacral.
This reductionist interpretation of the arches and
pivots has created a very useful model that can be
used to underpin methods of diagnosis and treat-
Figure 3.15 The physiological arches.
ment, e.g. the treatment models of specific adjusting
technique (SAT) and general osteopathic treatment
Analysis of each of these arches and their pivots (GOT) (see Section 3) are discussed in the next two
enabled osteopaths to understand the patterns of chapters. Below are two examples of how this model
dysfunction that might arise and how to treat them, may be applied as a diagnostic tool. Though they
but with passing time it became progressively could not be described as originating directly from
simplified to what is nowadays sometimes referred Littlejohn, they have arisen from an interpretation
to as a 'pivotal model', this being a synthesis of all of his concepts. On returning to the more classical
four of the 'arches'. views of Littlejohn, more uses of this model will
become apparent.
THE PIVOTAL MODEL
'Functional' pivots
This contemporary interpretation cites the pivots as It must be appreciated that the pivots and curves
being: are cited for the 'ideal' posture. In reality the
58 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Midarch pivot Interarch pivots Spinal curves This is clinically useful if one accepts this pivotal
model, and has an understanding of the interplay
between the pivots, because by analysing an indi-
vidual's pattern, one can interpret what areas of the
spine are fulfilling each role. At the simplest level
of treatment rationale, should the patient be rela-
C5
Cervical tively healthy and, with treatment, be able to adapt
C0-T4 fully, the patient's pattern as analysed in relation to
the functional pivotal model is the starting point and
the 'ideal' model can be used as the ultimate aim of
the treatment (Fig. 3.17B). It may only be possible to
get the person to a certain point along the contin-
uum from their current posture to the 'ideal', but it
serves as a guide. A simple treatment rationale for
Figure 3.17 may be that the lower thoracics are
extended, causing the elongation of the lumbar lor-
T9
Thoracic dosis and the shortened but deeper thoracic and cer-
T4-T12 vical curves. If the low thoracics were the primary in
this pattern, mobilization into flexion of this group
would allow the thoracic spine to 'drop down' to its
more ideal position. Similarly, the lumbar spine
would be normalized, as would the cervical spine
(assuming that the problem was relatively recent
and no chronic tissue changes were present to pre-
vent it from reestablishing balance). The pivots
Lumbar would thus pass to their more appropriate situations
L3
L1-L5 and the 'ideal' would have been achieved. Note. We
as osteopaths are not always aiming for the perfect
posture. In some individuals this may, for many rea-
sons, not be possible, but a concept of where one
would ideally 'go' with treatment is of benefit.
This is a very simple example of how one might
apply this concept.

The application of the concepts of balance within


a curve and across the curves to the pivotal model
Earlier in this section the means by which balance
may be achieved within the curves and across the
Figure 3.16 The pivotal model. Please note that the terms
midarch pivot and interarch pivot used in this diagram are not whole curves/spine was discussed. These concepts
consistent with Littlejohn's usage of these terms. can be applied to the dynamic and functional pat-
terns that are modelled using Littlejohn's pivotal
model. Again, it should be pointed out that these
positions will vary, often markedly from that stated. are oversimplifications and therefore open to criti-
Where there is this difference from the ideal the cism; however, they do create a simple model with
name of the pivot can be utilized as a functional which to attempt to understand the complex inter-
descriptor. Thus if someone has a long lumbar play of spinal mechanics and thence the functioning
curve extending up to the T10, the actual T9/T10 of the body. From this level of understanding it is
vertebrae will be acting as the transition between possible to pass to the next level of understanding.
the thoracic and lumbar curves and it could be One of the most important elements in the under-
termed the 'functional T / L pivot'. The functional standing is that the pivots will move, they are not
L3 pivot may be the actual LI or L2 vertebra. See static. However, the role of the pivot is still the same
Figure 3.17A. regardless of the vertebra acting as one. Littlejohn
Structural concepts 59

Actual vertebral Functional pivotal role


level being performed

Functional C5
C5

Functional T4

T4

Functional T9

T9
Functional T/L

T12(T/L)

Functional L3

L3

Figure 3.17 (A) The long lumbar curve has caused the pivots to be 'shifted' up, therefore vertebrae not designed to be junctional
are forced into the role (and a greater chance to dysfunction). These new pivots are sometimes termed 'functional pivots' (in the
sense that they are functioning as a pivot). Thus for example the T10 vertebra is the functional T/L. (B) This shows the theoretical
'ideal'. If the patient is fit and has the ability to adapt, this may be the end result of treatment. If structural changes have occurred it
may be possible to go only so far along this route; it is then necessary to balance them around that pattern.

used the analogy of a keystone from architecture, be taken by L2. The lumbar spine from Figure 3.17
this being the point where the forces are acting is shown schematically in Figure 3.18. From this it
equally and in opposition, maintaining the integrity is possible to see that the T10 is the functional
of the curve. Thus for the lumbar curve it could be cephalad end of the lumbar curve, and the L5 the
supposed that the L3 is the logical keystone (Fig. caudad end. Thus if dysfunction occurs at the L4,
3.8). However, as shown in Figure 3.17 the role can one of the places to expect compensation would be
60 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

lumbar curve is L3. These three vertebrae serve the


same function in their respective curves. As they
'Functional' (T/L)
have the same function, it is possible to imagine
that dysfunction in one may be compensated for by
one or both of the other keystones. This is equally
true regardless of what actual vertebra is acting as
each of the pivots. It is the role performed by the
structure that is important, not its actual name.
With this understood, it is possible to apply the
simple concepts of balance within the curves and
across the curves and establish hypothetical pat-
terns of interdependence in any spine. Then, by uti-
lizing palpation skills to assess tissue changes (the
primary lesion and its compensation, after the acute
period has passed, will have very similar tis-
sue changes), and applying an understanding of the
causative factors and how the particular indi-
vidual's body will respond to these forces, further
confirm or refute that hypothesis. The resulting
hypothesis will then be further tested in the gross
and segmental examination of the whole spine.

T h e significance o f T 9
Osteopathically, the T9 is of great significance, with
many experienced osteopaths recommending cau-
tion when addressing it. Some of its significance can
be understood when it is realized that the T9 can
be perceived as being the keystone of all three curves;
this is possible to envisage if the spinal curves are
drawn as the person is prone (Fig. 3.19). This does
not mean, however, that it should not be mobilized,
but an awareness of its possible mechanical role in
the entire spine is advantageous.
Figure 3.18 Balance is still achieved within the curve in the
same manner, even though the pivots have moved. This exam- Now we return to the more 'classical' concepts of
ple demonstrates that the areas of balance may include more Littlejohn.
than just one vertebra; in this instance either may adapt,
or both.
THE LINES OF FORCE, CENTRAL GRAVITY LINE,
T11/T12. Balance within the curve is achieved in the AND THE CENTRE OF GRAVITY
usual way.
In the ideal situation, the keystone of the cervical Littlejohn wanted to establish some means of dis-
curve is C5, of the thoracic curve is T9 and of the covering the central gravity line and the centre of

Figure 3.19 T9 can be thought of as


the keystone of the whole spine, hence
its great significance osteopathically.
Structural concepts 61

It also helps to take some of the emphasis off one


of the apparently major stumbling blocks for the
acceptance of this work, namely the L3 being cited
as the centre of gravity. However, in the orthograde
position, the model that Littlejohn originated has
helped numerous generations of osteopaths gain
some understanding of the biomechanical relation-
ships of the body, and what may be anticipated if
the central gravity line shifts from the ideal.
Undeterred by the complexity of the human
form, Littlejohn adapted the model in Figure 3.20
to the human body. He devised the anteroposterior
(AP) and posteroanterior (PA) lines as mirrors of
the lines crossing to give the centre of gravity of the
piece of wood. He also, however, complicated this
slightly by attributing a particular role to each line.
He describes the AP line as a line of force rmiting
the spinal curves and the PA as a line to balance the
cavity pressures.

The anteroposterior line


The AP line begins at the anterior-most point of the
superior part of the spine, variously described as
the anterior margin of the foramen magnum at the
base of the skull, or the anterior tubercle of CI. It
Figure 3.20 The method used to find the centre of gravity of a then passes inferiorly and posteriorly through the
square, and the central gravity line, by resolving the two oblique bodies of T i l and T12, to the posterior junction of
lines. L4/5 and then through the body of SI to arrive at
its most distal posterior point, the tip of the coccyx.
The stated role of this line is that it is a Tine unit-
gravity of the body. This is a relatively straightfor- ing the entire spine into one articulated mechanism
ward process if working with a square piece of ... and is the chief point of mechanical resistance to
wood, as shown in Figure 3.20. the loss of the normal arches of the spine'. 5

However, applying this to the human body is not Another way of looking at it is that it resolves the
as straightforward. The human body is a dynamic forces in the spine. Again, a simple analogy may help
structure, and the centre of gravity is constantly explain this, that of the bow, as in a bow and arrow.
shifting. As well as the musculoskeletal element The bow's arch is maintained by the string rurvning
being dynamic, there is a constant change in the from tip to tip. It is in a state of balance, thus it is
internal physiological and fluid dynamics which possible to say that the forces in the bow are bal-
will have an effect on the whole body. On this, anced, equally and in opposition, by the tension in
Campbell succinctly states:
4
the string; or that the vector represented by the string
resolves, or opposes and balances, the forces within
given these considerations the importance of the the bow. This logic could be extended to systems that
centre of gravity as the centre of mass of body tissue consist of more than one arc, as seen in Figure 3.21.
ceases itself to be of vital importance and gives way
To balance this, Littlejohn described the pos-
to the idea of a centre of balance between the internal
teroanterior line.
forces, gravity and environmental factors. In the
balanced and integrated body there will be a unique The posteroanterior (PA) line
relationship between this 'centre of balance' and the
centre of gravity. This begins at the posterior-most point of the supe-
rior part of the spine, generally taken to be the mid-
This makes explicit those concepts that are so often point of the posterior margin of the foramen
lost when discussing this aspect of Littlejohn's work. magnum. It then passes anteroinferiorly to the
62 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

The AP line is
analagous to the
string and the
spinal curves
the bow in part A

Bow String

A B C

Figure 3.21 The bow and string analogy to illustrate how the AP line may unite the entire spine into one articulated mechanism.
(A) The string can be perceived as resolving the forces present in the bow, or as the force maintaining the bow in its stable position.
(B,C) This analogy can be taken further to address more than one curve. Thus the AP line represents the string and can be seen as
resolving the forces in the spine or binding the curves into 'one articulated mechanism'. (B = lateral view; C = posterior view.) (After
Campbell C. A brief review of the mechanics of the spine. Maidstone: Maidstone College of Osteopathy.)

anterior margin of the articulation of L2/3 where it are not mutually independent, thus while a par-
bifurcates and passes to the most anterolateral part ticular function may be attributed to each line, the
of the spine and pelvis, the acetabulae. (In some other line will have a component of force in that
texts it is shown as continuing anteriorly around direction also' ) 4

the pubic ramus, encompassing the pelvic cavity, to • represents a line of pressure binding the poste-
meet at the symphysis pubis.) rior occipitoatlantal articulation to T2 and the sec-
This is a much more complicated line, with sev- ond rib to maintain the integrity of neck tension
eral functions. Figure 3.22 shows the areas of the PA (see 1 on Fig. 3.22)
line which particularly serve the functions stated. • strengthens the line of abdominopelvic support
Wernham states that the functions are that it: 5
(see 2 on Fig. 3.22)
• directs tension from the articulation of L 2 / 3 to
• is complementary to the AP line. (Though it is the femoral heads (via the psoas muscle and the
complementary, Campbell warns that 'the lines deep abdominopelvic fascia, which are repre-
Structural concepts 63

Sections of the upper


pole of the thorax

Passes anterior to
the crura of the
diaphragm Bifurcates at-
L2/L3

S y m p h y s i s pubis-

Surrounds the-
pelvic cavity
Figure 3.22 The role of the PA line. The figures refer to the stated functions of the PA line, please refer to the text for the details.
This Figure shows that the line traverses key points of each of the cavities and its role in coordinating the pressures in the internal
cavities of the body is more easily understood. (A) Lateral view. (B) Posterior view. (After Campbell C. A brief review of the mechanics
of the spine. Maidstone: Maidstone College of Osteopathy.)

sented by the lines as they bifurcate at the L2/3 environmental factors. Its role in balancing the cavity
and pass laterally to the acetabulae; see 3 on pressures can be understood by being aware that the
Fig. 3.22) PA line passes through the upper pole of the tho-
• maintains tension of neck, trunk and legs coordi- racic cavity at the level of Tl. It then passes interiorly
nate with the pressures in the internal cavities through the junction of the abdominal and thoracic
of the body via the T / L ligaments which oppose cavities and anterior to the crural attachments of the
the hip and leg movements in relation to the diaphragm at the level of the L2/3 vertebrae. There
abdominal muscles and pelvic organs (see 4 on it bifurcates, passing anteriorly, laterally and interi-
Fig. 3.22). orly through the abdominal cavity to the acetabulae
bilaterally. It finally passes around the pubic ramus
It can be seen that this line serves more of the ele- to reunite at the symphysis. Thus it is present at key
ments balancing the internal forces, gravity and points throughout each of the cavities.
64 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

continuing to the acetabulae opposite to their side


The central gravity line
of origin. (See Fig. 3.24.)
As with our original piece of wood in Figure 3.20, if Resolution of the AC and PC lines will also give
a line is drawn between the two oblique lines, the the central gravity line.
AP and PA, the resultant line should be the central With these two sets of lines it is now possible
gravity line. to see how certain concepts have arisen.
This passes 'between the two condyles of
The three triangles of force and the three unities
the occiput, at the odontoid process', inferiorly to
pass through the centre of the body of the L3, If the two PC lines and the PA line are superimposed
'through the anterior promontory of the sacrum, on each other, three triangles appear. These are
medially to the centre of the hip, knee and ankle, termed, rather descriptively, the little, lower and
thence anteriorly to the metatarsal head and poste- upper triangles. See Figure 3.25.
riorly to the tuberosity of the calcaneus'. 5
The little triangle has its base at the femoral artic-
ulations of the acetabulae, and its apex anterior to
The centre of gravity of the body
the body of the L3 vertebra. The lower triangle
As the central gravity line passes through the body shares the same base as the little triangle, but the
of the L3 vertebra, this is cited by Littlejohn as the apex passes up to the anterior aspect of the T4. The
centre of gravity of the body. Thus the body above upper triangle has its small base at the posterior
L3 is supported on it, whilst the spine, pelvis and margins of the foramen magnum, and its apex at
lower extremities are 'suspended' from it. the level of the T4, meeting the apex of the lower
This process has so far assessed the human triangle.
body as if it were a two-dimensional object, resolv- For Littlejohn these triangles were another way of
ing it only in the sagittal plane. To assess it in three observing the interrelationships of the body. The L3
dimensions it is necessary to perform the same being the centre of gravity of the body and the T4
procedures in the coronal plane. The lines used to arguably the second most important pivot in the
do this are termed the anterior and posterior cen- body (possibly in contest with the T9 for this posi-
tral lines. tion), this allows one to observe how the body may
function around these significant pivots. A simple
The anterior central (AC) and posterior central example of this is the 'gossip' or drop knee test. The
(PC) lines knees are alternately bent and the effects observed.
The same major role is apportioned to the AC as the As the base of both the lower triangles is affected
AP line (much to the confusion of students), that is, there should be movement noted at both the L3 and
mamtaining articular tension; and similarly with the the T4. There also should be a smooth transition of
PC being assigned the same major role as the PA, side-bending curves throughout the spine; failure in
namely integrating cavity pressures. This creates a any of these will indicate dysfunction. To find out
slight problem in that as articular tension has only 1° where this dysfunction is occurring would involve
of freedom, it can be represented in three dimensions further tests. In fact, there is a whole diagnostic rou-
as a single line - therefore there is only one AC line, tine based on these three triangles to establish the
but as cavity pressure is a volumetric concern, it can- sites of various dysfunctions, which is termed 'unity
not be represented in three dimensions by one line, so testing'.
two PC lines are used. This is not a critical point but
can sometimes further confuse students. The three unities and unity testing
Thus the AC line passes from the anterior mid- Unity testing is a complete series of tests based on
point of the spine in the coronal plane and passes the three triangles, which examines the whole body
inferiorly and posteriorly to the coccyx. In fact, it is osteopathically. It was devised by Tom Dummer 6

exactly the same as the AP line. See Figure 3.23. 'based on an original concept of Still, i.e. that the body
The PC lines attempt to encompass as much of is made up of a triad of pelvis and lower extremities;
the coronal aspect of the spine and torso as possi- cranium, neck, shoulder girdles and upper extremi-
ble. They therefore originate one from either side of ties; both articulating with the thorax and trunk,
the lateral-most aspect of the posterior border and all three being functionally independent'. The
of the foramen magnum, passing medially across unities are just as described in the above section on
the body, crossing anterior to the T4 level and then the three triangles, though the unities also include
Structural concepts 65

Figure 3.23 The AC line when viewed


from the sagittal plane can be seen to be
identical to the AP line. (A) Posterior view.
(B) Lateral view.

the limbs (this is implicit in the triangles but often was chosen as the first unity because of the prime
not stated). As the body is an integrated structure importance placed on pelvic balance within 'clas-
there will be an overlap anatomically and function- sical' osteopathy.)
ally, and therefore some overlap when assessing the • Unity 2 is the same as the upper triangle, passing
unities; however, essentially the boundaries of each from and including the cranium to the T4. It also
unity are as for the triangles, thus: includes the shoulder girdles and the upper
extremities. (The shoulder girdles and the upper
• Unity 1 relates to the small triangle, thus it passes extremities are functionally and anatomically
from the L3 and includes the pelvis and the related to both Unities 2 and 3. Generally, con-
lower extremities. Anatomically the whole lum- ceptually, they are related to Unity 2, but for the
bar spine is generally included and thus also in convenience of testing they are included in the
the assessment routine. (It is possible that this testing routine of Unity 3.)
66 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Figure 3.24 Superior origins of the PC line. X indicates the cephalad origin of the PC lines.

• Unity 3 includes the thorax and the vital organs The upper polygon has a triangular base sur-
and extends from the T4 to the L3. The shoulder rounding the foramen magnum of the skull, pro-
girdle is also included. viding a base for the support of the cranium (Fig.
3.26Ai). The apex is found at the T4 and rib 3 which
The details of the diagnostic routine are be- is the point through which the compressive and tor-
yond the scope of this book. For a detailed des- sional forces of the head and neck act.
cription, refer to Tom Dummer's Textbook of The lower polygon has its base in the bony pelvis
Osteopathy (see recommended reading at the end (Fig. 3.26Aii). When correctly aligned this acts as a
of the chapter). solid base for the support of the abdominal and
The triangles of force and unities are two-dimen- pelvic organs and is instrumental in maintaining
sional interpretations. The polygons of force offer a abdominal tension. The soft tissues are of great
three-dimensional interpretation. importance in mamtaining the integrity of this poly-
gon, as its relatively large lateral margins are formed
The polygons of force in the abdomen and the lower two-thirds of the tho-
The polygons are created by combining the AP, AC rax. Loss of soft tissue tone or balance will lead to
and PC lines, as in Figure 3.26. a collapse of this polygon, with a consequent
Structural concepts 67

and pathological changes that may arise as a result of


this shift.
As well as modelling the changes with gross
anterior and posterior shifts, the polygons offer a
means of interpreting the vectors of force that may
be acting on the individual in a three-dimensional
manner. To illustrate this, take the example of a
functional unilateral short leg (Fig. 3.27).
The pelvis will be lower on the side of the short
leg; this will result in a lowering of the base of
the lower triangle with a resultant increase in the
vector of force represented by the ipsilateral PC
line passing obliquely inferiorly and laterally from
its contralateral origin at the occiput to the acetabu-
lae (Fig. 3.27A). Generally associated with the low-
ering of the pelvis there will also be a movement in
the anteroposterior plane. For the purpose of this
discussion we will say that the acetabula has
moved slightly anteriorly. This will cause the line
of tension to have an additional vector of force
acting anteriorly. This results in a torsional vector
of force acting through the body (Fig. 3.27B).
Applying this concept (where appropriate) will
Figure 3.25 Combining the PA and PC lines gives rise to the model the probable passage of this vector of force.
three triangles and the three unities.
Any structure lying within this vector of force will
be subject to that force, be it articular, visceral, neu-
rological, vascular, etc. Analysis of the vectors of
deleterious effect on the viscera within. The apex force and an understanding of the underlying
articulates with the apex of the upper polygon ante- structures will enable one to anticipate the effects
rior to T4 at the point where they both cross the cen- this will have on those structures. In the diagram
tral gravity line. The two polygons thus pivot an organ is positioned with its rotational axis lat-
around this point, hence its great mechanical signifi- eral to the descending vector, thus it will be caused
cance. Problems in either polygon may reflect, and to rotate medially. The anterior vector of the
thus possibly cause symptoms, at this pivot and/or descending force will cause it also to rotate anteri-
its related structures. orly. When palpating this structure, its mobility
will be greater on medial rotation and anterior
Combined, the polygons represent the support of
rotation, as it will move preferentially into the
the spine and the viscera, and how the relative pres-
direction of the lesion. If that is what is found, it
sure differentials between thoracic, abdominal and
would be reasonable to hypothesize that this pat-
pelvic cavities are maintained. They also represent
tern is as a result of the short leg, and as such
the articular tensions (particularly spinal) as they
would only resolve fully when the leg length dis-
oscillate around the central gravity line. Many of the
crepancy is resolved. However, if the findings on
effects of this will be addressed more fully in
the organ differed from this it may indicate that it
Chapter 5, where Littlejohn's anterior and posterior
is not part of the global pattern, and therefore may
body types are analysed. In brief, the anterior and
itself be in dysfunction, requiring specific local
posterior weight-bearing types describe the changes
treatment. The polygons can therefore help model
that occur in the body when the centre of gravity line
global patterns that will be visible on observation
shifts either forwards or backwards from the neutral
and palpable as fascial patterns and via the tissues
position, with a consequent deformation of the poly-
and organ mobility.
gons. It is possible, by analysing the effects that it has
on the lines of force, and therefore spinal integrity (Please read the conclusion with regard to the
and cavity pressure balance, to hypothesize on the Newtonian concepts of pulleys and lever inherent
gross positional changes and possible physiological with the above.)
68 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Figure 3.26 The polygons of force. (Ai, ii) Points of attachment of the lines of force. By uniting the points of the lines of force at
the foramen magnum, and similarly at the pelvic bowl, two triangles appear: an upper one with its apex facing anteriorly, and a lower
one where the apex faces posteriorly. By drawing in the lines of force passing between their points of origin on the two triangles, the
polygons of force appear. (B) The polygons of force.

assist in the understanding of the unities and the


CONCLUSION polygons, and you are therefore directed to Tom
Dummer's own writings on the subject in the
This chapter has offered numerous different inter- Textbook of Osteopathy. However, the key point of this
pretations of how the spine and the body may be chapter is that you start truly looking at the body.
modelled utilizing structural conceptual models. As This ability to look and actually see is one of the most
stated in the introduction, they are all empirical. important skills, and sadly one of the ones most often
A relatively wide range of concepts has been dis- neglected. The looking is not to impose any of
cussed, from patterns of individual dysfunction com- these particular models on a patient, but to see inside
pensation, to the planar model of patterning of the the body, to see what pattern it is expressing.
triangles or unities, to the more global view offered Michelangelo, when commissioned to create a sculp-
by the polygons. At this point in time these ideas will ture, would go to the marble mines to look at the
still appear to you as rather strange abstractions. This blocks of marble. He would look deep within them
is partly due to the relatively wide range of to see what sculptures the blocks themselves
approaches, which are necessary because of the infi- expressed. He did not impose the form; he revealed
nite variety of patterns a patient can express. Also, what was already within. This may sound flowery,
this results from the confines of this book limiting but that is exactly what osteopaths aim to do.
further explanation of the diagnostic routines of the All of the concepts above are based on a New-
unities. An understanding of these procedures will tonian conception of mechanics which utilizes the
Structural concepts 69

The vector of force passing


obliquely interiorly passes medial
to the AP axis of the organ,
causinq it to medially rotate

The vector also has a force acting


PC line anteriorly which will cause the
organ to anteriorize around its
horizontal axis
AP/AC line

PC line
ncrease in the vector
of force acting around
the left lateral PC line,
the direction being
inferior and lateral An organ here will be
caused to rotate
anteriorly and medially
(see above expanded
image)

nferior and Anterior vector


lateral vector Inferior and lateral
vector

Short left
leg

Anterior rotation of
the iliac 'torsions'
the tension line so
it now acts laterally,
inferiorly and anteriorly.
This effect will
be transmitted to all
of the structures
through which
it passes

B
Figure 3.27 Modelling the effects on the polygons of force that will occur in the presence of a functional unilateral short leg.

compressive force of gravity to support structures tantly, over the last few decades a new model has
that are comprised of columns, beams, levers and been emerging that appears to be able to explain
fulcra, such as in a conventional building. Most of some of these anomalies - in fact, the more this
our biomechanical concepts are based on these model is tested the better the results. That model
Newtonian principles. These concepts are being is tensegrity. Technically it should be discussed
questioned, as there are too many features of the within this chapter, but because of the possible
human form and function that cannot be great importance of it, it will be 'honoured' with a
explained by this model. Perhaps more impor- chapter of its own, Chapter 4.
70 OSTEOPATHIC CONCEPTUAL. (PERCEPTUAL) MODELS

References
1. Weaver C. The cranial vertebrae. JAOA 1936; March. 4. Campbell C. A brief review of the mechanics of the spine.
2. Kapandji LA. The physiology of the joints, vol 3: the trunk Maidstone: Maidstone College of Osteopathy; 22.
and vertebral column. Edinburgh: Churchill Livingstone; 5. Wernham J, Hall TE. The mechanics of the spine and
1974. pelvis. Maidstone: Maidstone College of Osteopathy;
3. Hides JA, Stokes MJ, Saide M et al. Evidence of lumbar 1960.
multifidus muscle wasting ipsilateral to symptoms in 6. Dummer T. A textbook of osteopathy, vol 1. Hadlow
patients with acute/subacute low back pain. Spine 1994; Down: JoTom Publications; 1999:175-200.
19(2):165-177.

Recommended reading
There are few books that address the spinal lesion patterns. Most of Campbell C. A brief review of the mechanics of the spine.
the early part of this chapter consists of the author's own thoughts Maidstone: Maidstone College of Osteopathy.
derived from the collective teachings of Tom Dummer, Harold Klug Dummer T. A textbook of osteopathy, vol 1. Hadlow Down:
and Robert Lever, and the indirect teachings of Michelangelo, foTom Publications; 1999:116-126,166-203.
Picasso and the natural beauty of nature. Only Tom Dummer has a Littlejohn IM. The fundamentals of osteopathic technique.
widely available text. Maidstone: Maidstone College of Osteopathy.
Original Littlejohn texts are rare, and those interpreted by John Stone C. Science in the art of osteopathy. Cheltenham: Stanley
Wernham are somewhat opaque in nature, but are worth the effort. Thornes; 1999:122-165.
An excellent introductory text is that of Chris Campbell. The Wernham }, Hall TE. The mechanics of the spine and pelvis.
Maidstone College of Osteopathy prints several of the following Maidstone: Maidstone College of Osteopathy; 1960.
books; however, it rarely includes the date of publication. Those
dates shown are the collective opinions, but are not guaranteed.
71

Chapter 4

Tensegrity

INTRODUCTION
CHAPTER CONTENTS

Introduction 71 One of the fundamental concepts within osteo-


Tensegrity 72 pathic philosophy is the concept of vis medicatrix
The application of the tensegrity model to the naturae, or the self-healing nature of the body. The
human form 75 role of a practitioner is to aid the body in this
attempt. For AT Still, a devout man, this ability
The hierarchical structure of tensegrity 76
could be accounted for by God's perfect design of
Conclusion and practical applications 80
the human body, a theological vitalistic philosophy.
References 81
Many subsequent osteopaths share this faith and
Recommended reading 81 thereby, to varying degrees, the rationale. For those
that could be termed non-theological vitalists, the
self-healing ability may be due to the vital force
within the body, a non-physical inner force or
energy that gives the body the property of life (chi,
prana, ki, elan vital or variations on these). Another
vitalistic term that is often used is 'the body's inher-
ent wisdom'. However, for the many students and
practitioners who do not have these beliefs, it is an
exceptionally difficult concept to accept. Even
though in practice it can be observed to be the case,
a rational explanation for it is lacking. There have
been attempts at creating mechanistic models
(many of which are included in this book) to
explain this idea, and though useful, none appear to
be able to account for the truly holistic affects that
osteopathy is capable of eliciting from the body.
However, more recently there has been a grow-
ing interesting concept that challenges the accepted
paradigm of biomechanics. It offers a logical ration-
ale for vis medicatrix naturae, as well as many other
of the tenets of osteopathy such as that:

• structure and function are reciprocally related


• changes applied in one area will also have effects
distally.
72 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

It may also offer routes leading to a greater 'the whole building', which contracts symmetrically
understanding of the h u m a n b o d y beyond a purely w h e n the b e a m is l o a d e d distributing the forces
4

somatic level. This concept is based on principles of throughout the structure.


tensegrity. This section will explore some of the Fuller considered all structures, from the atom to
ways that tensegrity may offer novel interpretations the solar system, to be tensegrity structures. (It is
of well observed phenomena and possibly result in worth noting the similarities between Fuller ideas
a shift in the osteopathic conceptual paradigm. and those of B e r t a l a n f t y and General S y s t e m
Theory in Chapter 9). It is not always obvious w h y
or h o w certain structures are tensegrities, so some
TENSEGRITY examples will be briefly discussed before looking at
the application of tensegrity to the h u m a n body.
Tensegrity is, in itself, not a recent concept. The
architect Richard Buckminster Fuller (1895-1983), A S I M P L E 'STICK A N D S T R I N G ' M O D E L
more familiarly k n o w n as B u c k y , began thinking
and writing about coexistent tension and compres- A simple example of a tensegrity structure is shown
sion in the 1920s. In 1948 Kenneth Snelson, a stu-
1
in Figure 4 . 1 . It can be seen that the compression
dent of Fuller's, built the first tensegrity structure. elements are acting as struts that push into the con¬
Both men developed the concept of tensegrity in tinuous cable. As the system functions as a whole,
differing w a y s , with Fuller's concepts p e r h a p s whatever occurs at one point of the structure will
being more o b v i o u s l y applicable to the h u m a n occur equally at all of the other points. So if you
body. 'tighten one point in a tensegrity system, all the
The w o r d itself is a contraction of 'tensional other parts of it tighten evenly. If you 'twang' any
integrity'. A simple definition of tensegrity is that it tension member anywhere in the structure, it will
is a structural system composed of discontinuous give the same resonant note as the others'. 4

compression elements connected by continuous ten¬ All tensegrity structures have the property that
sion cables, which, due to the w a y in w h i c h the even before the application of any external load,
tensional and compressive forces are distributed members of the structures are already in compres¬
within the structure, is a self-stabilizing structure, sion or tension. This is k n o w n as 'prestress'. The
i.e. stable but able to interact in a dynamic w a y . 23
stiffness of the structure depends on the degree of
Fuller offers a more complete definition, describing prestress within it; this will be determined by the
it as 'a structural-relationship principle in which position of the struts and the degree of contractility
structural shape is guaranteed by the finitely closed, or elasticity in the tensional cable. Thus in the sim¬
comprehensively continuous, tensional behaviours of ple structure shown in Figure 4 . 1 , either lengthen-
the system and not by the discontinuous and exclu¬
sively local compressional member behaviours'. 4

The discontinuous local compressional m o d e l


referred to is that of conventional or 'classical' archi¬
tecture based on Newtonian mechanics, which uti¬
lizes the compressive force of gravity to maintain
structures based on columns, b e a m s , levers and ful-
crums. It is from this compressional model that our
current thinking of the biomechanics of the b o d y
arises. All of the concepts discussed in the previous
chapters are based on Newtonian principles.
T e n s e g r i t y structures b e h a v e very differently
from structures b a s e d on the classical c o m p r e s -
sional architectural model, most notably in their
ability to act as 'whole systems'. If a beam is loaded
within a structure based on the classical model, the
forces will be distributed locally. Within a tenseg-
Figure 4.1 A simple 'stick and string' tensegrity structure. It
rity structure the tensegrity beam does not act inde¬ consists of discontinuous compression elements maintained in
pendently, or locally, but acts only in concert with their particular relationship by the continuous tension cable.
Tensegrity 73

ing the struts or using a stronger elastic band will


increase the degree of prestress. Increasing the
degree of prestress will reduce its inherent move-
ment (without friction) and also increase its
mechanical responsiveness. 5

The combination of tensional and compressional


elements is called 'synergy'. They are mutually
dependent. Synergy is defined by Fuller as 'the
behaviour of integral, aggregate whole systems
unpredicted by behaviours of any of their compo-
nents or subassemblies of their components taken
Figure 4.2 A simple tent demonstrates many of the key fea-
separately from the whole'. Levin illustrates this
4

tures of tensegrity structures. It is: light; flexible; external


clearly by stating that one would not examine the forces, when applied, are distributed throughout the whole
properties of the metal sodium, and the gas chlo- structure and when that force is removed the tent returns to its
rine, and predict the properties of the combination, original shape, thus it is self-stabilizing.
salt.
6

A common example of this basic model is that of sion of the stick and string model. The tension-bearing
the more recent design of the dome-shaped tent, members in these [tensegrity] structures map out the
which at its simplest consists of two flexible rods shortest paths between adjacent members (and are
that insert into the fabric of the tent. therefore, by definition, arranged geodesically).
Such a tent demonstrates many of the features of Tensional forces naturally transmit themselves over the
tensegrities. The structure is extremely light and shortest distance between two points, so the members
though it appears to be frail, it is in fact very strong. of a tensegrity structure are precisely positioned to best
Much of its strength is derived from the rapid withstand stress. For this reason, tensegrity structures
omnidirectional distribution of applied forces. Thus offer a maximum amount of strength. The name geo-
3

if an external force is applied to the tent it will be desic dome is somewhat misleading in that it tends
dispersed throughout the fabric of the tent and to make one visualize the well-known examples such
poles, causing it to deform as a whole. By sharing as the Geosphere at Disneyworld in Florida and the
the force throughout the whole structure it is able to Biosphere in Montreal. However, they do not have to
withstand forces far greater than could be predicted be symmetrically spherical, as in the examples above,
by engineering analysis of the separate components but can be asymmetrically spherical, like pears, cater-
(synergy). This is perhaps more easily envisaged pillars, or elephants, not to mention human beings.
4

with the geodesic domes and will be discussed By looking at Figure 4.3 it is possible to see that
again below. the geodesic dome is comprised of numerous trian-
The fact that tensegrity structures work as 'whole gles. Structures that are completely comprised of
systems', mamtaining a constant relativity between triangles are termed 'fully triangulated' structures.
the elements of the structure, can be demonstrated These are inherently stable structures and though
in the tent by pushing or pulling on opposite sides the joints within them are flexible, they are not sub-
of it: the entire tent will then expand or contract ject to the torque or bending movements that other
symmetrically. structures are prone to, such as structures based on
Another unique and markedly significant feature squares (imagine the torque that you can induce on
of this structure is that when the external force is a cardboard box by just compressing it obliquely). 7

removed the tent will return to its original shape - it The triangulation therefore contributes to the
is self-stabilizing. strength and rigidity of the structure. Fully geodesic
structures differ from the stick and string model in
THE GEODESIC DOME that they appear to be constructed solely of rigid
elements or struts; however, each strut is able to
Geodesic is a mathematical phenomenon, being the resist either tension or compression depending on
most economical relationship between two events, the particular requirement. Thus they are able to act
i.e. a straight line between two points. A geodesic as either the tensile or the compressional elements
dome is a structure based on that principle. It could required in a tensegrity. It is interesting to note that
they do not require direct contact between all
be considered essentially to be a more complex ver-
74 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

In a wagon wheel the load is transferred through


the structure by loading of directly connected
compression elements. The weight of the wagon
presses on the axle which presses on the wheel hub
which compresses the underlying spoke which, in
turn, compresses the rim of the wheel. In bicycle wheel
mechanics the weight of the frame transfers to the hub
of the ivheel which is hung in a tension network of
wire spokes. There is continuous tension of the spokes,
which are pre stressed, but the compression elements
are discontinuous and do not compress one another.
The hub remains suspended in its tension network.
Compression loads are distributed around the
rim. The compression elements behave in a
A counterintuitive way, not loading one another as in
Newtonian construct but loaded by the tension
elements. The rim of the wheel is compressed by the
distributed tension of the spokes. The hub hangs from
the spokes, which are always under tension, and the
spoke under the hub is never compressed.

The planets of the solar system are maintained in


their orbits in a similar manner. The spokes of the
wheel, the constant tensional elements, are replaced
by the attraction of the planets to the sun. The sun
acts as the hub of the wheel. Passing from one
extreme to the other, it is also possible to utilize this
analogy in regard to an atom, with the electrons
being maintained in their orbits by their attraction
to the nucleus. It is interesting to reflect on the rela-
Site of external force
acting on the structure
tively vast distances over which this power to
B attract electrons occurs. If the nucleus was consid-
Figure 4.3 (A) The Geosphere: a geodesic dome is comprised ered to be 1 cm across, the outer electrons would
of numerous triangles. (B) Any external force will be transmit- be 1 km away.
ted omnidirectionally to all parts of the structure.

THE BALLOON
compressional elements for stability. By observing
5

the patterns of triangulation it is possible to con- The final example for discussion is that of a bal-
ceive how an external force would be distributed loon. To understand this it is useful to apply a
from its point of contact omnidirectionally, spread- slightly different terminology. Rather than using
ing progressively to the whole structure. (See the terms 'compression' and 'tension' it is possible
Fig. 4.3B.) to replace them with 'push' and 'pull', where
'push' is synonymous with discontinuous com-
A BICYCLE WHEEL pression and 'pull' with continuous tension. The
balloon, when analysed as a tensegrity, can be
A bicycle wheel is another commonly used example seen as consisting of a continuously pulling rub-
of a tensegrity structure. The spokes are the tension ber skin being discontinuously pushed by the
elements that suspend the hub, and they transmit individual air molecules contained within the bal-
the forces from both the ground and the frame of loon, thereby keeping it inflated. Any external
the bicycle to the entire rim of the wheel. Levin 8 force acting on the balloon will be dissipated by
illustrates the differences between Newtonian and all of the enclosed air molecules to all of the skin.
tensegrity mechanics by comparing the mechanics The same effect would be achieved by filling the
of a wagon wheel with that of a bicycle wheel. balloon with water.
Tensegrity 75

SUMMARY is changed it will become unstable: if a house is


tilted it will fall down.
To summarize the key features of tensegrity and The tensegrity model shifts the emphasis, and
tensegrities: views the bones of the skeleton as being discontinu-
ous compression components suspended, or 'float-
• Many structures, from the solar system to the
ing', within a continuous soft tissue tension network.
atom, are tensegrity structures.
It should be remembered that the fascial system is
• Tensegrity is a structural system composed of
continuous throughout the whole body. From this it
discontinuous compression elements connected
is possible to see that it complies with the definition
by continuous tension cables, with the balance
of a tensegrity.
between tensional and compressive (or push and
Caroline Stone attempts to illustrate this concep-
9

pull) forces creating the stability.


tual shift in the role of the skeleton by imagining a
• They act as 'whole systems' so that any external
'rubber tent man' (see Fig. 4.4). This makes use of
forces acting on them are transmitted to all ele-
the example of the tent as a tensegrity structure but
ments of the structure equally, causing it to
relates it to man! The skin acts as the tent fabric,
deform symmetrically rather than to collapse.
and the bones of the skeleton as the tent poles.
• Vibration in one part of the structure will be Without the poles it will be flat, but as the poles are
passed to all other parts. inserted they push out the skin, causing it to become
• They have the property of synergy, meaning that taut and to gradually take on the shape of a man.
it is not possible to deduce the function of the She later uses the concept of the balloon tensegrity
whole by analysis of the parts. model to inflate the body cavities, thereby offering
• The structure is efficient, requiring fewer materi- greater structural support to the tent man. In draw-
als than an equivalent constructed in the classical ing this analogy she is trying to illustrate the inter-
model, and though the structures may be light dependence of the structures: neither the rigid
they are in fact very strong. structures nor the elastic structures have primacy.
• They are setf-stabilizing structures; once the exter-
As well as fulfilling the initial continuous tension
nal force is removed they will return to their orig-
and local compression definition of tensegrity, the
inal shape.
body exhibits other features of tensegrity mechanics:
• They can be either symmetrically spherical or
asymmetrically spherical (a dome or an elephant). T h e body demonstrates prestress
• The continuous tensional elements do not have to
The muscles of the body have a physiological resting
be visible, as in the solar system and atoms.
length, meaning that they are always in slight ten-
• Prestress and /or triangulation are essential ele-
sion. The ligaments of the spine have been shown to
ments in tensegrities.
also be held in a degree of tension, ' and it can be
10 11,12

• Pneumatic and hydrostatic systems can be tenseg-


conceived that other ligaments will behave similarly.
rities, e.g. a balloon or a football.
This can be interpreted as prestress.

T h e body cavities and their c o n t e n t s act


THE APPLICATION OF THE TENSEGRITY
as 'balloon' tensegrities
MODEL TO THE HUMAN FORM
The biomechanical principles of JM Littlejohn stress
The current model of the human body is based on the importance of the body cavities, notably the tho-
classical Newtonian mechanical principles. Within racic and abdominopelvic, in the maintenance of
this model the skeleton is perceived as being the upright posture. Reflecting on this from a tensegrity
primary support, held together by compression, perspective, they can be interpreted as functioning in
with the soft tissues and viscera hanging off it or the manner of the balloon tensegrity model. The cavi-
acting as local tensioners. This model has been criti- ties, being filled with viscera and fluid, exert an effect
cized on many grounds, most notably that the on the internal fascial compartments of the body,
mechanical laws of leverage that operate in the keeping them 'inflated' and contributing to the over-
compressional system would create forces that far all stability of the body (as used in the 'tent man').
outstrip any strength of biologic materials. Another
6
The fact that tensegrities are self-stabilizing
criticism of the Newtonian model is that it is uni- structures may also begin to offer the beginnings of
directional, so that if the orientation of the structure a rationale for vis medicatrix naturae.
76 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Figure 4.4 The rubber tent man. (A) Imagine a deflated rubber man lying flat on the ground. (B) Now imagine a series of rods being
inserted within the rubber skin of the man. These rods push out the skin so that the man begins to stand. Instead of being filled by
air, the shape of the man is formed by the rubber membrane being pushed taut by the internal rods. (C) Inside the trunk, limbs and
head a series of horizontal membranes within the rubber skin of the man help to divide him into compartments. These are expanded
by the insertion of the rods that help the man to stand upright. Further support is then offered by filling the compartments with
uncompressible fluid and viscera. (Reproduced with the permission of Nelson Thornes Ltd from Science in the art of osteopathy
0 7487 3328 0, first published in 1999.)

If the evidence is beginning to become sufficient the same principles applying at each level of decreas-
to make this hypothesis appear viable, it is interest- ing or increasing complexity, so that the macroscopic
ing to reflect on the role of synergy as an important principles just discussed should be reflected in the
feature of tensegrities. Synergy in this context microscopic levels. We will now explore some of the
means that it is not possible to deduce the function smaller levels of organization of the body.
of the whole by analysis of the parts; this concept
has always been stressed within the holistic THE ARTICULAR LEVEL
approach, in the tenet 'the whole is greater than the
sum of the parts'. Passing down to an articular level, Levin persua-
sively argues that both the sacroiliac and shoulder
8

girdle articulations are clear examples of tenseg-


13

THE HIERARCHICAL STRUCTURE rity mechanics. He utilizes the bicycle wheel anal-
OF TENSEGRITY ogy as the underlying model. Thus, for the pelvis,
the pelvic ring would represent the rim of the wheel
One of the principles that has not been mentioned yet and the sacrum the hub. These represent the dis-
is that there is a hierarchical structure to tensegrities, continuous compressive elements of the model. The
Tensegrity 77

sacrum is suspended between the ilia by the com- entifically that by addressing the gross structure it
plex arrangement of ligaments and muscles; these is possible to have an effect at the deepest levels of
represent the spokes of the wheel or the tensile ele- the body, including at that of the cellular physio-
ments. This offers omnidirectional stability and is logical level. The cytologists Ingber, Wang and their
independent of the position of the body, or the team have largely been responsible for pushing this
direction of any external forces that may be applied research to these new levels of understanding. (As it
to it. Any forces acting on the sacrum can be dis- is only possible to discuss the findings briefly here,
persed around the pelvic bowl. As with the hub of a list of their articles is included in Recommended
the wheel, assuming that there is no structural dam- reading at the end of the chapter.)
age to the spokes, the hub stays in the same position The conventional image of the cell, with which
relative to the rim; so too will the sacrum. In order most of us are familiar, looks something like a fried
to do this, though, the movement must be in tan- egg, with the nucleus sitting in the middle, sur-
dem with the other pelvic bones, giving rise to ten- rounded by the organelles, all floating in a viscous
sion coupled movement patterns. gel (see Fig. 4.5A). This flattened appearance is in
It is perhaps interesting to reflect on this com- fact an artefact due to the cell membrane adhering to
plex pattern of supporting soft tissues and try to the underlying plate; in vivo they take up a different
envisage what effects may arise in the presence of shape depending on the cell type. How cells achieve
dysfunction in any one of these supporting soft tis- and maintain their shape was poorly understood.
sues, particularly considering the numerous and They were known to contain a cytoskeleton com-
varied functions of the pelvis. prised of microtubules, microfilaments and interme-
The shoulder has been similarly envisaged with diate filaments, but an understanding of the precise
the scapula being the hub and the radiating muscles roles of these elements was lacking. Ingber, having
and connective tissue being the spokes. an interest in both the tensegrity sculptural work of
Kenneth Snelson, and the actual concept of tenseg-
Reciprocal t e n s i o n membranes rity, attempted to model the cell from a tensegrity
Another example of tension coupled movements was perspective, and eventually succeeded in so doing.
first described by WG Sutherland in 1939. He stated
14 The processes that he went through to achieve this
that the intracranial and spinal dural membranes bal- are detailed in the article "The Architecture of Life'. 3

ance and maintain the relationship between the To summarise Ingber described a 'hard wired'
bones of the cranium, and also synchronously main- network-like structure comprised of three types of
tain their relationship with the sacrum. He termed filaments: microtubules and microfilaments which
this phenomenon 'reciprocal tension', and the dura act as the compression elements, and actin microfil-
the 'reciprocal tension membrane'. This would now aments which offer the continuous tension. This net-
be described as a tensegrity arrangement, the dura work occurs throughout the cell, including passing
being envisaged as the continuous tensional element continuously into the nucleus of the cell. The struc-
mamtaining a dynamic equilibrium between the cra- ture of the cell is thus maintained by the contractile
nial bones and the sacrum. The concepts of balanced actin microfilaments creating tension, pulling
membranous and balanced ligamentous tension towards the nucleus. This in turn is resisted by the
(BMT and BLT) that have arisen from his work are compression elements, the microtubules and large
also easily explained in tensegrity terms. bundles of cross-linked microfilaments. The whole
In Chapter 2 much attention was directed towards network is integrated by the intermediate filaments
the coupled movement of the vertebrae. Perhaps in making connections between these elements and the
the future, tensegrity will offer a more convincing cell membrane. The integrins within the cell mem-
answer to this complicated problem. If so, the axial brane connect with fibres of the extracellular matrix
compression gravity based models that are depend- (ECM), anchoring it externally and further resisting
ent on keystones and pivots will need to be revised. the inward pull of the microfilaments. The hard
wiring of the cell has been demonstrated by pulling
on the cell membrane, which caused the cytoskele-
THE CELLULAR LEVEL
ton filaments and the nucleus to line up in the direc-
tion of the pull. This also demonstrates that by
This, arguably, is the area in which some of the
affecting the cell membrane it is possible to affect
most exciting research has occurred. It also offers
structures deep within the cell. 15

manual therapists the opportunity to appreciate sci-


78 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Continuing on from this research, and of a most cellular matrix within a connective tissue matrix. In
fundamental significance, was the finding that by essence when you touch a human body you are touch-
changing the shape of a cell it was possible to cause ing a continuously interconnected system, composed
cells to switch between different genetic pro- of virtually all of the molecules of the body linked
grammes. ' Experiments were set up that enabled
16 17 together in an intricate webioork. The living matrix
the shape of the cells to be varied, from flat to has no fundamental unit or central aspect, no part
spherical and even square. that is primary or most basic. The properties of the
whole net depend upon the integrated activities of all
By simply modifying the shape of the cell, they could of the components. Effects of one part of the system
switch cells between different genetic programs. can, and do spread to others.
Cells that spread flat became more likely to divide,
The shape, form, mechanical, energetic, and
whereas round cells that were prevented from
spreading activated a death program known as functional characteristics of every cell, tissue or
apoptosis. When cells were neither too extended nor organ arise because of local variations in the
too retracted, they neither divided nor died. Instead properties of the matrix.18

they differentiated themselves in a tissue-specific


manner: capillary cells formed hollow capillary As well as creating the structure of the body, the
tubes; liver cells secreted proteins that the liver living matrix performs many functions, and the full
normally supplies to the blood; and so on. impact of some of these has yet to be fully under-
stood. It acts as a dynamic conduit for the fluid in
Thus, mechanical restructuring of the cell and which it is bathed and, consequently, oversees all
cytoskeleton apparently tells the cell what to do. of the humoral based communication. It can con-
Very flat cells, with their cytoskeletons stretched, vey vibration, and tissue harmonics have been
sense that more cells are needed to cover the
explored as possible indicators of carcinogenic tis-
surrounding substrate, as in wound repair, and that
sue. Chemical, mechanical and visual stimuli can
19

cell division is needed. Rounding indicates that too


all be transduced into vibration which can be con-
many cells are competing for space on the matrix and
that cells are proliferating too much; some must die veyed throughout the matrix to the nucleus of the
to prevent tumour formation. In between these two
extremes, normal tissue function is established and
maintained. 3

The other key realization was that the cell membrane


has globular proteins that span it, having receptor
sites both internally and externally. Many of these
are chemoreceptors, but some are mechanoreceptors.
The mechanoreceptors are called integrins, and are
connected internally to the intracellular fibrous
cytoskeleton, and extracellularly to the ECM fibrous
network. By these connections it is possible to convey
tension and compression from the extracellular fibre
matrix to the cell, and even to the nucleus: they act as
mechonotransducers. The cell can now be seen as a
part of a much greater structure: it is physically
bound into the ECM which will then be bound to
another cell and so on. The ECM and its continuity
with the cell membrane and contents is the cellular A
expression of the fascial continuity. This entire inter-
connected system is variously known as the tissue-
tensegrity matrix or the living matrix (see Fig. 4.5B).

The living matrix is a continuous and dynamic B


'supramolecular' webwork, extending into every nook Figure 4.5 (A,B) The conventional view of a cell, demonstrat-
and cranny of the body: a nuclear matrix within a ing no particular organization (B = lateral view).
Tensegrity 79

C
Figure 4.5 cont'd (C) The tensegrity view of the ceil. The cell is 'hard wired'. Note that the fibres are continuous from the cell
membrane to the nucleus itself, and that it is continuous via the integrins with the extracellular matrix.

cells. The matrix as a whole can be looked at as a is able to convey bioelectronic signals throughout
crystalline matrix which is piezoelectric, so that the body, creating another method of communi-
when it is deformed in any way it will generate cation. The possibilities yet to be explored are
18

bioenergetic signals. As it is a semiconductor it endless.


80 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL] MODELS

From a manual therapist's perspective these con- 'inflated', contributing to the overall stability of
cepts enable us to touch the body and know that the body.
we are in contact with the entire network of the living On a cellular level, the cells are hard wired intra-
matrix, and that changing the relationship of one cellularly, but also connected, via the transmembra-
part of the body to another part will have an effect nous integrins, to the ECM, the whole forming the
throughout the tensegrity matrix, with possible con- massive living matrix that permeates every part of
sequences at a cellular level. the body.
It is possible to take this concept to an even This chapter started with the premise that
smaller scale. The tensegrity hierarchy is continu- tensegrity may offer some explanation of vis med-
ous; atoms are tensegrity structures, they combine icatrix naturae. As the whole of the body is perme-
with other atoms which obey the physical laws of ated by the living matrix, which is in essence a
triangulation and close packing and therefore
11
human-shaped geodesic dome, it should theoreti-
are by definition geodesic. These then combine to cally have the ability to self-stabilize. This is similar
form more complex molecules, e.g. proteins, which to stating that if one can correct the primary lesion
combine to form organelles, then cells, tissues, of the body it will resolve all the other problems
organs, systems, the whole body (known as self- therein. There is truth in both statements, but the
assembly). The body acts as a complete system. reality is a lot more complex. Tensegrity structures
The synergetic concepts also apply on the ever will transmit forces throughout their structure
increasing scale; we work within a family unit, when they are functioning well. When one element
within a community, in a country, being part of a is dysfunctioning it will distort the whole structure,
species living on a planet which itself is part of the but by adding a focus (i.e. the dysfunctional or rigid
universe ... element) in a system that should by rights not have
The hypothetical applications of this concept any, it is as if a Newtonian lever has been intro-
are almost limitless, but unfortunately will not be duced into the body, destabilizing the tensegrity.
debated here. However they should provide you Where many of these occur it may be possible for
hours of creative debate. tensegrity and Newtonian biomechanical patterns
to be present simultaneously.
This model offers excellent examples of structure
CONCLUSION AND PRACTICAL functional reciprocity and reveals a coherent ration-
APPLICATIONS ale for how changes applied in one area will also
have effects distally. Perhaps most significantly it
The tensegrity model of biomechanics challenges enables us to realize changes in the gross structures
the Newtonian compressive model from which our will have an effect, via the living matrix, on the
current concepts of the biomechanics of the body most fundamental levels of organization (molecu-
arise. It is a system composed of discontinuous lar, cellular structure and physiology).
compression elements connected by a continuous From a more practical osteopathic perspective it
tension cable that are arranged in such a way as to removes the primacy from the bony structures and
distribute forces omnidirectionally throughout the highlights the very great importance of the soft tis-
structure. It focuses on the structure's ability to sues. This does not make the bony concepts redun-
work as an integrated whole unit. dant, but will cause one to analyse how these
All structures can potentially be viewed as models achieve their results (as they certainly have
tensegrities. To help understand the way the body for over 100 years) from a slightly different perspec-
might achieve support from these structures it is tive. It should be remembered that continuous ten-
possible to utilize some basic examples: A simple sion and local compression are interdependent.
stick and string model, the geodesic dome, a bicycle It also reveals the true genius of WG Sutherland
wheel and a balloon. (and the many others who have promulgated simi-
The bones of the skeleton may be considered lar theories) with regard to his concepts of 'recipro-
as discontinuous compression components sus- cal tension', and the treatment models that have
pended within a continuous soft tissue tension arisen from it BLT and BMT (see Section 3).
network. The muscles and ligaments exhibit pre- The full expression of all components of the
stress, and the body cavities and their contents body is manifest in the living matrix, both in
act on the fascial compartments keeping them function and in dysfunction. Careful assessment
Tensegrity 81

of the matrix will inform the practitioner of where nial - as long as normal function is reinstated the
ihey should direct their efforts. The choice of self-stabilizing effects of the human geodesic dome
treatment approach is not important from a tenseg- will restore the structural, physiological and possi-
rity perspective - it may be structural, fascial or era- bly psychological homeostasis.

References
1. Fuller KB. 4D time lock. Online. http://www.cjfearnley. 10. Nachemson A, Evans J. Some mechanical properties of
com/fuller-faq-5.html. the third lumbar mter-laminar ligaments. J Biomechanics
2. Lee P. Tensegrity. The Cranial Letter 2000; 53(3):10-13. 1968; 1:211.
3. Ingber DE. The architecture of life. Scientific American 11. Tzaczuk H. Tensile properties of the human lumbar longi-
1998; 278(l):48~-57. tudinal ligaments. Acta Orthop Scand; 1968; Suppl. 115.
4. Fuller RB, Applewhite EJ. Synergetics: explorations in the 12. Kazarian LE. Creep characteristics of the human spinal
geometry of thinking. New York: Macmillan; 1975. column. Orthop Clinics of North America; 1975; Ian:6.
Online, http://www.bfi.org/synergetics/index.html. 13. Levin SM. Putting the shoulder to the wheel: a new bio-
5. Chen CS, Ingber DE. Tensegrity and mechanoregulation: mechanical model for the shoulder girdle. Online.
from skeleton to cytoskeleton. Osteoarthritis and Available: http://www.biotensegrity.com/.
Cartilage 1999; 7(l):81-94. 14. Sutherland WG. The cranial bowl. Mankato: Free Press
6. Levin SM. Continuous tension, discontinuous Company; 1939.
compression: a model for biomechanical support of the 15. Maniotis A, Chen C, Ingber DE. Demonstration of
body. The Bulletin of Structural Integration 1982; 8 (1): mechanical connections between integrins, cytoskeletal
31-33. filaments and nucleoplasm that stabilize nuclear
7. Levin SM. A different approach to the mechanics of the structure. Proc Natl Acad Sci USA 1997; 94:849-854.
human pelvis: tensegrity. In: Vleeming A, Mooney V, 16. Chen CS, Mrksich M, Huang S et al. Geometric control of
Snijders C et al, eds. Movement, stability and low back cell life and death. Science 1997; 276:1425-1428.
pain: the essential role of the pelvis. Edinburgh: Churchill 17. Singhvi R, Kumar A, Lopez G et al. Engineering cell shape
Livingstone; 1997:162. and function. Science 1994; 264:696-698.
8. Levin SM. The tensegrity system and pelvic pain syn- 18. Oschman TL. Energy medicine. Edinburgh: Churchill
drome. Online. Available: http://www.biotensegrity. Livingstone; 2000: 48.
com/. 19. Pienta Kf, Coffey DS. Cellular harmonic information
9. Stone C. Science in the art of osteopathy. Cheltenham: transfer through a tissue tensegrity matrix system. Med
Stanley Thornes; 1999:102. Hypotheses 1991; 34:88-95.

Recommended reading
The best introduction is Ingber's 'Architecture of Life'; it is easily Levin SM. A different approach to the mechanics of the
read and is inspirational. Fuller's Synergetics z's heavy on the math- human pelvis: tensegrity. In: Vleeming A, Mooney V,
ematics side. Levin has an excellent website where he posts all of his Snijders C et al, eds. Movement, stability and low back
articles. But for sheer beauty, visit Snellson's website. pain: the essential role of the pelvis. Edinburgh: Churchill
Livingstone; 1997.
Fuller RB, Applewhite EJ. Synergetics: explorations in the Levin SM. Online at: http://www.biotensegrity.com/.
geometry of thinking. New York: Macmillan; 1975. Online. Oschman TL. Energy medicine. Edinburgh: Churchill
http://www.bfi.org/synergetics/index.hrml (if that fails, Livingstone; 2000:48.
try: http://www.rwgrayprojects.com/synergetics/ SnelsonK. Online, http://www.kennethsnelson.net/.
synergetics .html).
Ingber DE. The architecture of life. Scientific American 1998;
278(l):48-57.
Page Intentionally Left Blank
83

Chapter 5

Biotypology

INTRODUCTION
CHAPTER CONTENTS

Introduction 83 Biotypology is the study and classification of the


Historical perspective 87 human race with regard to elements of people's
Recent models of biotypology 87 physical appearance or morphology. From this it is
possible to make generalizations about their
Summary and applications 103
anatomical structure, physiological processes and
References 105
psychological attitudes. It also aids in predicting
Recommended reading 105
potential pathological problems to which each bio-
type may be prone.
This attempt at introducing some order to the
infinite variation within the human race has its for-
mal roots in the Orient, notably in Ayurvedic and
Traditional Chinese Medicine. The Western world
was thought to be introduced to this concept via the
writings of Empedocles and Hippocrates. Every
subsequent generation has then added its own
interpretations.
In fact, if one reflects, we, as individuals, perform
a similar process of classification every day. In our
dealings with people we consciously or uncon-
sciously assess them from their appearance and
demeanour. We may be able to know instantly
whether we could get on with someone or not, often
even before they have spoken; or understand how
to engage someone and what topics of conversation
may interest them. Of course, this initial opinion may
subsequently change, but more often than not we are
quite astute at assessing people's interests and atti-
tudes from their physical appearance. We can utilize
these same observations in a more formalized, objec-
tive and clinical way to enable us to make hypothe-
ses concerning health from similar observations.
Perhaps not thought by all osteopaths to be truly
'osteopathic', it is largely through the work of Tom
84 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Dummer that biotyping has been incorporated into by Sheldon, or 'constitution' by Vannier; and 'that
the body of osteopathic study. He integrated the which can be', which is mutable and dependent on
work of several of the foremost exponents of biotyp- all of the environmental and psychosocial elements,
ing to develop a model of osteopathic significance. It defined by both as 'temperament'. Dummer extracted
is not difficult to see why he became interested in elements from all of these models and compiled an
this field when you consider that WH Sheldon, cre- osteopathic interpretation, enabling these useful con-
ator of one of the most widely used biotypical mod- cepts to be applied clinically.
els stated that 'physique and temperament are Each of these interpretations is a complete and
clearly two aspects of the same thing ... it is the old thorough entity, and it is not possible, within the con-
notion that structure must somehow determine fines of this book, to do them justice. Rather, an
function' - a reiteration of Still's famous principle. attempt is made to introduce some of the key concepts
There are numerous models of classification or of each, especially those that have the most obvious
biotypology. For this discussion we will principally application osteopathically. Examples are discussed
be discussing those of WH Sheldon, JE Goldthwait, in an attempt to explore the underlying concepts.
E Kretschmer, L Vannier and T Dummer. These These concepts should then be applicable in other
have been chosen as they are generally well known, areas of the body, or across the body types. For a more
utilize terminology that is easily understood, and complete understanding of these models it will be
their application to osteopathy, or in fact to any necessary to refer to the original texts (listed in the
holistic therapy, is very apparent. Most other mod- Recommended reading at the end of the chapter).
els could be applied equally well, and those of you It is interesting to note that although Goldthwait
who have grounding in Eastern philosophy or med- (orthopaedic surgeon), Sheldon (psychologist),
icine will find much to interest them by exploring Kretschmer (clinical psychologist) and Vannier (doc-
the Oriental 'biotypes'. tor and homeopath) had different conceptual back-
Goldthwait, an orthopaedic surgeon as would be grounds, and pursued their observations from
expected, considers the overall structure of the body, different perspectives, there is a notable concordance
how this may differ from one biotype to the next and between their biotype definitions. The criteria uti-
the effects that will arise from disturbance of the lized by the above authors for including individuals
overall posture. There is a large overlap with the lat- in a particular group, though not identical, have
ter element and the anterior and posterior biotypes sufficient similarities to make useful comparisons
derived from Littlejohn and described by TE Hall between the classifications; this is shown in Table 5.1.
and later by J Wernham (this will be discussed within This area of study is often criticized. The two
this chapter). Kretschmer's work is principally based major concerns are:
on the psychological tendencies relating to certain
types. Sheldon's classification is perhaps one of the • The types stated never appear in reality and are
models most commonly utilized in all forms of thera- just hypothetical concepts.
peutic intervention. It is a thorough and integrated • These are stereotypical models that, at best, are
analysis of biotype from both a structural and a psy- prescriptive and, at worst, lead to judgemental
chological perspective. It does suffer somewhat in behaviour and, in extremis, fascism or racism.
that the research was done purely on males, and In response to the first criticism, each of the
though many believe it can be applied equally well to researchers take great pains to state that they have
women, this cannot be supported by the original utilized the extreme, or 'perfect' example, as the
research. Vannier's model is based on a homeopathic
interpretation of the three calcareous constitutions. Table 5.1 A c o m p a r i s o n between the biotypical
This results in a somewhat complicated analysis, classifications
enabling predictions to be made on morphology,
intellect, character, possible diseases to which they Author Biotype classification
may be prone, and what their constitutional reme-
Sheldon Ectomorph Mesomorph Endomorph
dies may be. Both Sheldon's and Vannier's models
Kretschmer Asthenic Athletic Pyknic
use a two-level classification addressing the 'struc-
Goldthwait Slender Intermediate Stocky
tural' consequences and the psychological effects. Put
Vannier Phosphoric Carbonic Fluoric
another way, 'that which is', the immutable elements
Dummer Functional Structural Functional
that are genetic or atavistic, termed 'physical traits'
Biotypology 85

defining descriptor for each group (Fig. 5.1). about racial differences. This is not a fault of the
They also state that these extreme types will model, but rather the fault of those people applying
occur very infrequently in reality. More usually, an it. This material is not intended to be prescriptive,
individual will have a mixture of characteristics but rather indicative of a potential relationship
from two or more of the classifications within their between structure, function/dysfunction and psy-
model, and the traits expressed will reflect the rela- chological attitudes. It is there to help us towards a
tive proportions of these characteristics. The pure first level of hypothesis about an individual, which
examples are often explained as being points on a will then be 'tested' throughout the rest of the clini-
continuum, with a gradual shift in dominance from cal interaction, from case history to treatment.
one type to the next as the cycle progresses. This is Another point sometimes raised is that the rela-
shown figuratively in Figure 5.2. tionship between body type and personality are
The second criticism has some validity, in that not direct, as is implied, but possibly indirect.
individuals have utilized these models inappropri- People with different body types do differ in per-
ately, most notably in eugenics. Kretschmer's work sonality, but they may do so because of the different
was subverted and used to justify the Nazi logic treatment to which they are exposed. Currently in

Figure 5.1 The three biotypical extremes.


86 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Figure 5.2 Biotypical extremes can be seen as points on the continuum, with a gradual shift from one type to the next. The individ-
ual will demonstrate characteristics from both, dependent on their relative proportions.

the Western world the slender (ectomorph) type is An awareness of this possibility should help to dis-
considered to be the most desirable, the stocky tance the practitioner from the possible stereotypi-
(endomorph) type less so. Is it the difference in cal 'labelling' application of these models.
treatment between the types that contributes to the A list of recommended reading is to be found at
development of their personalities? This is a more the end of this chapter. The original texts will give a
complicated point, and in all probability there are much more complete understanding of the concepts.
elements that are direct and some that are indirect.
Biotypology 87

Before exploring these models we will briefly therefore define the constitution of that individual.
consider the early history of biotypical models Inherent with this concept is that each constitution
which has influenced subsequent models. will demonstrate particular characteristics in the sense
of anatomy, i.e. body shape, dominance of body sys-
tems and physiology, with each type having a greater
HISTORICAL PERSPECTIVE susceptibility or mclination to particular diseases. This
relationship between certain characteristics and the
From ancient times, the principal medical cultures tendency to certain disease is referred to as diathesis.
tried to classify individuals according to their Similarly, an individual's temperament will
morpho-functional characteristics in order to study depend on the relative predominance of the humors
and understand their tendencies in terms of health in the individual:
and sickness. Ayurveda, India's traditional medicine,
• Sanguine (sanguis - Latin - blood): warm, pleas-
is thought to have been in existence for 5000 years
ant, active and enthusiastic.
and is considered the world's oldest and most com-
plete medical system. Ayurveda regards the human • Phlegmatic (phlegma - Latin - lymph): slow mov-
being as consisting of body, mind and spirit. These ing, apathetic and sluggish.
respond to the vital forces known as doshas, classified • Choleric (khole - Greek - bile): changeable, quick
as Vata, Pitta and Kapha, which together control all to react and irritable.
bodily functions. The full range of physiological, psy- • Melancholic (melas khole - Greek - black bile):
chological and behavioural characteristics is based on depressed, sad and brooding.
the balance between these forces. Other relationships within the humoral concept are
Chinese medicine is nearly as old as Ayurveda, summarized in Table 5.2.
and has similar holistic roots. Two principal con- These terms have passed into general usage - a
cepts are that of the duality Yin and Yang, and the few phrases that have their origins in the humoral
Five Elements Theory, which proposes that all concept are:
things, including the human body, are comprised
• humourless
of five basic elements: fire, earth, metal, water and
• in good/bad humour
wood. Our physical tendencies and personality type
are dependent on the relevant proportions of Yin • melancholic
and Yang and the Five Elements. • jaundiced
• sanguine
It seems probable that these Oriental philoso-
• bitter or sour attitudes
phies will have significantly influenced Western
• seeing red when angry
medicine. In Ancient Greece, Empedocles (495-435
• feeling black when depressed.
BC), a Pythagorean philosopher, scientist and healer,
stated that all matter is comprised of four 'root ele- This was further developed by Galen and was
ments': earth, air, fire and water. These could be used as recently as 1764 by Kant in his typology of
combined in an indefinite number of variations and temperament in Observations on the Feeling of the
proportions to create all matter. He supported this Beautiful and Sublime.
rather bold statement by drawing an analogy to the Temperament and constitution together form the
great variety that painters can produce with only so-called biotype.
four pigments.
Hippocrates (c 460-c 377 BC) based his system of
constitution and temperament on the Pythagorean RECENT MODELS OF BIOTYPOLOGY
system and the teachings of Empedocles. Hippocrates
based his system on four bodily fluids or humors. Fire JOEL E G O L D T H W A I T : SLENDER, INTERMEDIATE
is akin to blood, earth to phlegm (lymph), air to yel- AND STOCKY TYPES
low bile, and water to black bile. According to his
humoral theory, just as with the Oriental models, the Goldthwait (1866-1961), an American orthopaedic
general health or constitution of man entirely depends surgeon, observed the variation within anatomical
on an appropriate balance among the four bodily structures and their positions. He attempted to
humors. Though there is a balance of the humors, in describe two aspects of this, firstly the differences
most individuals one will predominate, and that will that will be found in the three classifications:
88 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

T a b l e 5.2 A s u m m a r y o f c e r t a i n key f e a t u r e s o f t h e h u m o r s

Humor Temperament Nature Taste Temperament in action


Red blood Sanguine Hot and moist Salty Active, enthusiastic and pleasant in nature
Phlegm Phlegmatic Cold and moist Sweet Sluggish, dull, or apathetic coldness or indifference
Yellow bile Choleric Hot and dry Bitter Easily moved to unreasonable or excessive anger
Black bile Melancholic Cold and dry Sour Marked by depression of mind and spirit

• the slender type In discussing the biotypes, the features men-


• the intermediate (or normal) tioned are variations from the intermediate type;
• the stocky type. the intermediate type can be conceived as 'ideal' (to
use Goldthwait's preferred term) and will not there-
The intermediate type is seen as being the ideal or
fore be discussed. The descriptions below are taken
normal, and variations from this are classified
from Goldthwait and Spring. Please note that all
1 2

within the other two types.


of the descriptions are of the 'classical' example of
Secondly, he described the anatomical and phys-
each type, and though the terms 'usually' and 'nor-
iological changes that will occur as a result of poor
mally' are used sporadically throughout, even-
posture.
statement could be qualified by these and similar
By analysing the gross changes in the anatomy words: nothing is 'written in stone'.
that occur as a result of these differences from the
norm, he and his fellow researchers proposed that it The slender type
is possible to predict the likely problems, both func-
This type is generally small and delicate, or tall and
tional and pathological, that may arise as a conse-
slender, with a narrow face, soft, thin skin and
quence. In his own words:
abundant hair. The limbs vary greatly, but are often
not all human beings are made alike, and a study of proportionately long, with the hands and feet being
these anatomical differences is helpful in the small, with long and tapering toes and fingers. The
understanding and treatment of disease. The muscles are delicate, lacking bulk and rather strap-
recognition of structural differences is also of great like in nature, further exaggerating the slender
value in the maintenance of health and physical well appearance. Similarly, the ligaments (and connec-
being, for differences within the organs accompany tive tissue generally) are delicate and therefore lax,
those changes seen externally. This leads to a leading to a relative articular hypermobility.
somewhat different normal function and a different
reaction to the environment. Individuals of different The stocky type
body types show different susceptibility to various
This is essentially the opposite of the slender type.
diseases. The pattern of the body is inherited and
They are generally much more heavily built, with a
depends upon the body type of ancestors. However
while the body type cannot be changed, the manner proportionately much greater width in relation to
in which it is used can be modified greatly. The the height. The head is rounded, sitting on a short
health of the individual depends largely on this, as and thick neck. The face is broad with a square jaw
well as whether he will succumb to one of the and closely set eyes. The skin is relatively thick and
diseases of which he is a potential victim.l the hair sparse. The limbs are stocky and short, as
are the hands, feet and digits. The muscles are large
This is based on the premise that structure gov- and rounded with coarse fibres; they may be well
erns function, and its relevance to osteopathy can delineated but are often covered with a layer of
immediately be understood. fatty tissue, softening their appearance. The liga-
The findings of Goldthwait and his colleagues were ments are tight and strong, leading to a relative
published in 1945 in The Essentials of Body Mechanics in hypomobility.
Health and Disease. Unfortunately at that time the med- An overview of some of the key defining features
ical paradigm was shifting to a more specific, 'invad- of the types is shown in Table 5.3.
ing pathogen'-led approach and so the work was By extrapolating from these basic observations,
largely overlooked by bis allopath colleagues. one can begin to be able to understand why and
Biotypology 89

Table 5.3 S o m e of t h e key f e a t u r e s of G o l d t h w a i t ' s t h r e e types. ( W i t h permission f r o m Spring L. B o d y


m o r p h o l o g y . U n p u b l i s h e d dissertation. M a i d s t o n e : E u r o p e a n School o f O s t e o p a t h y ; 1998.)

Intermediate Slender Stocky

Torso Moderate length Tall and slender Short torso and neck
and breadth

Subcostal angle 70-90° Less than 70° Greater than 90°

Ligaments Ideal' Lax with an average 15-30° increased Tight and strong with an average
ROM from norm 10-20° decreased ROM from norm

Visceral Optimal Ptosed Tightly bound

Spinal curves 'Ideal' Increased lumbar lordosis and thoracic kyphosis Normal

how many of the changes in the body may occur, less obviously. As well as the intrinsic soft tissues
and the consequences that arise as a result of these. mamtaining the shape of the organs they are also sup-
For example, Goldthwait describes the slender type ported externally by connective tissue, which holds
as having weak or lax ligaments. This will apply to all them in the 'correct' position and is partly responsible
of the connective tissues, mcluding the muscles. Static for mamtaining the shape of the organ.
support of the spine and body generally is achieved in The position of an organ and the effects of lax
the ideal situation by the person leaning' on his liga- connective tissue of a slender individual are well
ments, notably the iliofemoral ligament (the "Y" liga- illustrated by the large intestine. The transverse
ment of Bigelow), the anterior longitudinal ligament, colon is essentially supported by its connective tis-
and the posterior knee ligaments. The ankle cannot be sue attachments at the hepatic and splenic flexures.
"locked", but by leaning forward only a few degrees Laxity of these will result in the large intestine
the gastrocnemius must contract to support the entire dropping into the lower abdominal and even pelvic
body. Relaxed erect posture is principally ligamentous cavity; see Figure 5.3. This will affect its ability to
with only the gastrocsoleus muscle group active'. 3
function effectively on a physiological level as well
The Y ligament prevents hyperextension of the as possibly causing pain.
hip; it also limits the anterior movement of the pelvis Another example of this is the stomach in the slen-
and body, as the person leans into it. It is supported der type. Having a fine muscular wall it is unable to
in this role by the anterior longitudinal ligament. In maintain its inherent shape easily, and lacking any
the slender type these ligaments are lax and therefore firm connective tissue support, the stomach changes
allow the body to glide further anteriorly, causing from its 'normal shape' into that described as a 'fish
the lumbopelvic angle to increase and a consequent hook' stomach, as seen in Figure 5.4. In the stocky
increase in the lumbar lordosis. As the body attempts individual the stomach is 'normal'. The structure is
to maintain its centre of gravity there also will be an appropriate to its function. The curve of the stomach is
increase in the thoracic and cervical curves, hence the designed to allow some pooling of the contents, per-
finding stated above for the slender individual of mitting the process of digestion to occur. Contraction
increased lumbar and thoracic spinal curves. As there of the strong muscular walls then causes the partially
is such a great overlap between this model and the digested food to pass over the slight incline of the
posterior type of Littlejohn the global and physiologi- pylorus of the stomach, through the pyloric sphincter
cal effects will be discussed with the posterior biotype and into the duodenum. In the slender individual's
later in this section. stomach, as can be seen in Figure 5.4, there is a large
Another example that can be extrapolated is curve in the lower part of the stomach. This acts rather
related to the viscera. Goldthwait states that the skele- like the 'U' bend of a toilet, pooling the contents of the
tal muscle of the slender type is much finer and less stomach in the deep curve. The muscle wall is thin
bulky than that of the stocky type. This also holds and relatively weak and the incline that needs to be
true for the smooth muscle found in the walls of overcome before the contents can be conveyed to the
many of the viscera. As such the viscera in the slender small intestines is great. The combination of these two
type are much less well defined, and hold their shape factors means that the contents remain in the stomach
90 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

A B
Figure 5.3 A comparison of the position of the large intestine in a stocky and a slender individual. (A) Slender individual's colon. (B)
Stocky individual's colon.

for too long, resulting in poor digestion, flatus and anterior type, and backward the posterior type. The
possible ulceration from the prolonged presence of the central gravity line is found by resolution of the
gastric secretions. This may appear to be a somewhat anteroposterior (AP) and the posteroanterior (PA)
naive rationale, but, empirically, slender types are lines, and the anterocentral (AC) and posterocentral
prone to gastrointestinal problems, and stocky types, (PC) lines (see Ch. 3). For Littlejohn, the 'ideal' posi-
due to the efficiency of their gastrointestinal system, tion of the central gravity line has it passing between
tend to put on excessive weight. the occipital condyles, then inferiorly to pass
Tables 5.4, 5.5 and 5.6 summarize Goldthwait's through the centre of the body of the L 3 , through
findings within the viscera, the physiological func- the anterior promontory of the sacrum, and medial
tion and the susceptibility to disease. to the centre of the hip, knee and ankle, where it
The postural changes that predominate in bifurcates and passes anteriorly to the metatarsal
Goldthwait's The Essentials of Body Mechanics in heads and posteriorly to the calcaneum. When the
Health and Disease relate largely to those of a pos- gravity line shifts from this position a series of
tural slump. The findings are very similar to those changes in the structure of the body and therefore its
of Littlejohn's posterior type. function will occur. Littlejohn modelled these
changes, and they are conveyed via J Wernham and
TE Hall in The Mechanics of the Spine and Pelvis. 4

JM LITTLEJOHN'S ANTERIOR AND As already mentioned, the types that will be


POSTERIOR W E I G H T - B E A R I N G TYPES discussed represent perfect examples or the extremes
of their type, although this in fact rarely exists.
The anterior or posterior types relate to the shifting, However, once the underlying principles are under-
either forward or backward, of the central gravity stood, it is an easy task to moderate them or apply
line from its ideal position, forward leading to the them to individuals with a mixed presentation.
Biotypology 91

A B
Figure 5.4 (A) The 'fish hook' stomach of a slender individual. (B) The more 'usual' shape of the stomach in a stocky individual.

When attempting to analyse these models the this, the thoracic spine will extend, 'flattening' the
author has found it useful to attempt to put his own spine to the upper lumbar spine. This is com-
body into a similar position to that being analysed: pounded by the whole extensor apparatus of the
it is then possible to work a large part of the find- posterior thorax contracting, as if trying to prevent
ings by assessing the information coming from the person from falling anteriorly. This will also
one's own body. This is useful in clinical practice cause the scapulae to retract, resulting in external
with any complicated postural patterns, but do rotation of the upper extremities (try getting into
beware of mirrors! the posture!). The suboccipital muscles also contract
The anterior type generally appears more easy to to extend the upper cervical spine to keep the eye
envisage, making it easier to interpret the possible line horizontal.
anatomical and physiological consequences. For As a consequence of this, the thorax is in a posi-
this reason, the discussion will start with the ante- tion of relatively full inspiration, causing the
rior type and then draw conclusions from that to diaphragm to be similarly in inspiration, its posi-
the posterior type. tion being lower than its 'normal' resting position.
The lower diaphragmatic position will compress the
The anterior type
abdominal viscera inferiorly into the
In this type, the central gravity line has shifted abdominopelvic cavity.
forward. Their posture is similar to that of a ski The anterior position causes the pelvis as a
jumper in flight, though obviously less marked. whole to rotate anteriorly and the hip extensors
The key features can be seen in Figure 5.5. The contract in an attempt to limit this. The abdominal
following text explores a selection of these key fea- muscles, the rectus abdominis and the internal and
tures. The head is held forward and the chest is external obliques take origin from the ribs and
held in a position of relative inspiration. To achieve insert at the inguinal ligament and the pubic
92 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Table 5.4 Viscera. (With permission from Sprinig L. Body morphology. Unpublished dissertation. Maidstone:
European School of Osteopathy, 1998.)

Intermediate Slender Stocky

Abdomen Upper abdomen firm, rounded Peculiarities in shape and Cavities and internal organs
and of equal circumference at attachments of viscera larger than that of the
the mammary line; no marked Intermediate type
depression below subcostal margin

Fat Plenty Of firm perivisceral fat for Less, especially retroperitoneal of Plenty excess retroperitoneal,
support and protection fat for the kidneys perivisceral and abdominal fat

Stomach Pear-shaped, easily emptying into Long and tubular with longer Roughly oval. The transverse
the duodenum attachments; the downward diameter is greater. It is firmly
displacement increases on standing attached with consequent
decreased downward
displacement

Liver Lower edge level with subcostal Small, often sags down and to the Firmly attached beneath
border, it should not be felt inferior right. The right lobe can even rest diaphragm
to that on right iliac crest

Kidney At lower margin, reaches the upper Reaches lower than Intermediate,
edge of L3 very mobile

Small intestine About 20 ft long 10-15 ft long, thin walled and 25-35 ft, thick walls and
small lumen; long mesentery leads relatively large lumen
to sag into pelvic cavity on standing

Large intestine 5/6 ft long; adheres to posterior 3-5 ft long; the attachments are 5-8.5 ft long, with short, firm
abdominal wall on right; only slight long leading to increased mobility. retroperitoneal attachments,
downward and forward sagging The whole colon may be below reducing the sag
as it crosses to the splenic flexure; the iliac crests. The transverse
it then reattaches posteriorly down colon may have an entirely free
to sigmoid colon mesentery

Appendix Long and well developed

Pelvic organs Differences (unspecified)

ramus. As the thorax is lifted superiorly and anteri- tially a flexible box that can be opened and closed;
orly, and the pelvis is rotated anteriorly and inferi- the viscera are constant. Opening the box reduces the
orly, there will be a distancing of origin and pressure exerted on them, and closing it increases it.
insertion of the abdominal muscles, putting them In this case, the thorax is in relative inspiration and
under tension. This will cause the viscera to be the diaphragm descended, thus there is 'greater
compressed posteriorly into the abdominopelvic space' within the thoracic cavity and, therefore, a
cavity. relative decrease in pressure within the thorax.
The knees will be hyperextended and the Conversely, below the diaphragm the abdomino-
gastrocnemii under tension. pelvic cavity is being compressed from above by the
One of the principal roles of the polygons of force diaphragm, anteriorly by the abdominal muscles,
and the PA and PC lines is to maintain the pressure and possibly posteriorly with the extension of the
differentials in the cavities. Looking at the above it is thoracic and upper lumbar spine taking the vertebral
clear to see that an imbalance between the pressures bodies anterior to their norm. Thus there is a relative
must occur in the anterior type. The thorax is essen- increase in pressure below the diaphragm.
Biotypology 93

T a b l e 5.5 T h e p h y s i o l o g i c a l f u n c t i o n . ( W i t h p e r m i s s i o n f r o m Spring L. Body m o r p h o l o g y . U n p u b l i s h e d d i s s e r t a -


t i o n . M a i d s t o n e : E u r o p e a n S c h o o l o f O s t e o p a t h y , 1998.)

Intermediate Slender Stocky

Physiological Because this type is the norm Generally everything is rapid. However, Stomach empties easily
function with optimum gut length, easy stomach empties with difficulty against and long GIT leads to good
emptying of stomach and little gravity. Due to GIT shortness, this type nutrition and tendency to f a t
sag of the transverse colon, it is needs a more concentrated diet, to Because increased function,
most efficient and least prevent problems of poor assimilation. process slightly slower
susceptible to disturbance Increased length of attachments can
lead to visceral ptosis and constipation

Circulation Good venous and pulmonary Is more rapid (BP is lower) but Usually adequate; a tendency to
function poorly adapted to long sustained high BP. Face 'ruddy and
effort. Slowing/partial stagnation plethoric'. There is greater
of the pulmonary and venous development of left side of heart
systems due to postural sag; with
cold, clammy extremities and
venous varicosities; also a
tendency to 'eye-strain' with
increased AP eye diameter

Puberty No comment Comes early for both sexes; the Tends to be later; basal metabolism
female tends to dysmenorrhoea often less than the norm

Psychologica il No comment Tendency to learn fast and Easy-going socially and in


tendencies impatience with slower heavier temper; good sense of humour;
types. Often dogmatic and tolerant. Make poor reformers.
fanatical, quick to anger, limited Slow but greater endurance;
endurance, but quick recovery slow recovery from fatigue.
from fatigue. Adjusts rapidly to Extrovert, not self-conscious.
changes in environment Does not adjust easily to changes
in the environment

T a b l e 5.6 T h e s u s c e p t i b i l i t y to disease. ( W i t h p e r m i s s i o n f r o m Spring L. Body m o r p h o l o g y . U n p u b l i s h e d d i s s e r t a -


t i o n . M a i d s t o n e : E u r o p e a n S c h o o l o f O s t e o p a t h y , 1998.)

Intermediate Slender Stocky

Susceptibility This type is least susceptible Rapidity of response in this type can Less susceptible to acute infections
to disease to disease. (Beyond that, lead to problems of reaction in the but chronic disease common: chronic
Goldthwait makes no immune system. Greater tendency to bronchitis, emphysema, hypertension
comment) contract influenza, bronchitis, TB and and arteriosclerosis, myocardial
acute infectious diseases. Fevers are degeneration, chronic nephritis,
common, as is hypotension. Inadequate gallstones and gallbladder disease.
gastric secretion, gastric and duodenal Gout and osteoarthritis. Hypertrophy
ulcer and spastic colon common. Also , of prostate more common. Also
common: hyperglandular disturbances hyposecretion of endocrine glands,
and rheumatoid arthritis early hair loss and baldness

Cephalic and Melancholia, depression and acute Cerebral haemorrhage.


psychiatric nervous and mental disorders Degenerative and chronic
nervous and mental disorders
94 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

The whole thorax is pulled superiorly and


Shoulders retracted and externally rotated anteriorly
The thorax is therefore in relative inspiration,
with the diaphragm being lower and more
The whole extensor apparatus of the spine is tense flattened at rest
On inspiration, the thoracic cage moves
en masse anteriorly and superiorly
The abdominal pressure is increased
The anterior thorax leads to a decrease in the by the combined effects of:
thoracic kyphosis
1 The lowering of the thoracic diaphragm
The lateral expansion of the lower ribs
2 The increased tension in abdominal
is decreased
muscles due to the anteriorization
of the ilia causing an increased distance
between the abdominal muscles' origin
and insertion
Dorsoabdominal junction 'opened out , therefore
1

respiration is more efficient than the posterior type 3 The anteriorization of the lower
lumbar vertebrae

The centre of gravity line is anterior to the — Symptoms:


lumbosacral junction, causing an anteriorization Due to increased tension below the
of the pelvis diaphragm and relative stasis above,
the anterior viscera below the diaphragm
are theoretically preferentially irritated as
the centre of gravity line has shifted forward

Centre of gravity line has moved Anteriorly

Knee hyperextended

Figure 5.5 The anterior biotype.


Biotypology 95

Global fluid exchange will be disturbed as the pres- dysmenorrhoea, and could possibly be a contribut-
sure gradients that are present in the ideal state are ing factor to difficulty conceiving.
modified. Thus in the anterior type there is an increase Above the diaphragm, the relative decrease in
in pressure in the abdomen and pelvis. Blood return- pressure leads to a tendency for stasis and hypo-
ing from the lower extremities now has to overcome a function. Respiration is slightly impaired as the rel-
greater pressure to enter the cavity as the pressure ative fixity of the thorax in inspiration limits the full
gradient has increased. Clinically the result is that range of thoracic movement.
there will be congestion in the lower extremities. The
T h e posterior t y p e
suboccipital muscle tension will have a similar effect
at the cranium, possibly affecting the supply via the The posterior type, as with the majority of these
vertebral arteries and/or the drainage via the internal models, is the converse of the above, see Figure 5.6.
jugular vein, resulting in headaches of differing nature The thorax is held in relative expiration, causing
- more of a migrainous, hemicranial type headache the ribs to be more sharply inclined inferiorly,
with arterial compression, and more congestive, thereby reducing the anteroposterior diameter of
whole head type headache with venous congestion. the thoracic cavity and the intercostal spaces, but
Compression tends to cause an irritative state in also slightly increasing the lateral expansion of the
the tissues subject to it, whereas a decrease in pressure ribs. The diaphragm will be held high in the expira-
tends to lead to a hypofunctioning state and stasis. tion position, approximating its origin and insertion
All of the viscera below the diaphragm are subject on the central tendon, thereby reducing its ability to
to an increase in pressure. As the gravity line has contract efficiently. The heart is attached firmly to
shifted anteriorly, the body and the structures within the central tendon of the diaphragm, and relies
are tractioned forward. The clinical changes are partly on the traction and relaxing effects of the
noticed more in the anterior structures than in the diaphragmatic excursion to aid its own perfusion.
posterior ones. To illustrate the changes that can As the diaphragm passes inferiorly it tractions the
occur below the diaphragm we will look at the rela- heart, creating a relative increase in pressure within
tionship between the bladder and uterus. In the ideal the coronary arteries and the myocardium itself,
position they are both supported in place by their and the reverse as it passes superiorly. This posi-
fascial attachments supporting them over the pelvic tive effect will be reduced as the diaphragmatic
diaphragm. As the person walks, the foot plant will excursion is also reduced in this type. It is possible
cause a downward movement of the viscera, which, that this action aids cardiac contraction and there-
as they are supported above, will cause them to frac- fore disturbance of this movement may even affect
tionally elongate and will cause a relative increase in the body's perfusion generally.
pressure within the viscera. As the viscera returns to Additionally, as the potential space within the tho-
its normal position and normal shape the pressure racic cavity is effectively reduced by the position of the
will drop again: this has the effect of acting as a local ribs and diaphragm, there will be a relative increase in
pump promoting fluid exchange. This movement is intrathoracic pressure, further compromising perfusion
limited and softened by the pelvic floor. of any intrathoracic structures. There will be a ten-
In the anterior type, the pelvis rotates anteriorly, dency to cardiac hypertrophy, as the heart is having to
so that the bladder, rather than resting on the pelvic contract against a greater resistance. Venous return
floor, is now resting on the posterior aspect of the from other areas of the body will be diminished as the
pubic ramus. The uterus will tend to antevert, com- pressure gradient entering the thorax has been
pressing the bladder more firmly against the ramus. increased. The changes in the abdominopelvic cavity
When walking occurs in this situation, the bladder are essentially the reverse of those in the thorax. Thus
is unable to stretch freely as before, but is squashed there is a relative decrease in pressure within these cav-
against the pubic ramus. The stretching effect will ities. Stasis occurs due to the increased pressure in the
be reduced, impairing local perfusion and, there- thorax. Symptomatically, the posterior weight-bearing
fore, its physiological function, and the compressive type is characterized by irritability in the structures in
element will, with time, make it painful and tender. the thorax and congestion of the abdominopelvic cav-
This could be a rationale for the presence of cystitis ity contents being most prevalent in the posterior struc-
of a non-infective nature. The anteversion and rela- tures, e.g. haemorrhoids, constipation, retroversion of
tive compression of the uterus will possibly lead to the uterus, menorrhagia.
96 OSTEOPATHIC CONCEPTUAI (PERCEPTUAL) MODELS

The centre of gravity line has


moved posteriorly
Depressed upper thorax leading to
a decrease in movement of the
upper ribs, decreased excursion
of the thoracic cage and therefore
impaired upper lung function

Ribs are held in relative expiration


so that the diaphragm is held
relatively high

The high dome of the diaphragm — The above two factors lead to a
puts it at a mechanical disadvantage relative increase in the thoracic
resulting in decreased excursion cavity pressure

Most rib movement occurs at the — Posterior rotation of the pelvis


lower ribs (bucket handle) approximates the origin and insertion
of the anterior abdominal muscles,
There is a marked extension of the - reducing their tone and permitting
spine usually at the level of L3/4. visceroptosis
The lumbar erector spinae in this
area shorten and there is an increase The high diaphragmatic position and
in tone of the iliopsoas to prevent the the poor abdominal tone result in a
lumbar spine from 'collapsing' relative decrease in the intrabdominal
and pelvic cavity pressures
The ilia rotate posteriorly and the
posterior viscera become congested, Abdominal venous return is largely
e.g. the uterus, rectum, etc. dependent on the compression
created on the veins by visceral
In conclusion, there is a general peristalsis. This action is enhanced
decrease in cardiac and respiratory by the rigidity of the 'abdominal
function resulting in congestion and container'. In this situation the abdominal
stasis below the diaphragm muscles are weak, reducing venous
return, and the increase in intrathoracic
pressure increases the pressure
gradient between abdominal and thoracic
cavities resulting in stasis below
the diaphragm

Figure 5.6 The posterior biotype.


Biotypology 97

W H S H E L D O N : ENDOMORPH, ECTOMORPH by three numerals. The first digit relates to the


A N D MESOMORPH degree of endomorphy, the second to mesomorphy
and the third to ectomorphy. Subjects were rated
Sheldon's classification is perhaps one of the most thor- on a on a 1-7 scale. Thus a 117 would be an extreme
oughly researched and perhaps one of the most widely ectomorph, whereas 711 would be an extreme
used. It is a simple model, easily applicable in the clini- endomorph and an extreme mesomorph would
cal situation, offering an interesting insight into the score 171. Very rarely, though, does any individual
relationship between the body structure and an indi- belong to a single, extreme somatotype. People
vidual's psychological predispositions. His studies are often have the features of two or even three of the
divisible into two distinct but interrelating areas. Those types. An average person who has some ectomor-
relating to the morphology of man are published in phic tendencies would score 446, whereas 444 is a
the book The Varieties of Human Physique: An mixture of all three types. Sheldon referred to the
Introduction to Constitutional Psychology (1940), and5
analysis of the physical traits as the 'statics' of
those relating to the psychological correlates are pub- psychology (remember, he was trying to classify
lished in The Varieties of Temperament: A Psychology of psychological predispositions via morphology). He
Constitutional Differences (1942). 6
believed that these characteristics define the indi-
Sheldon's interest was that of a psychologist vidual and that they are immutable.
attempting to find morphological and psychological However, the classical definitions are:
correlates. He was critical of the difficulty of clinical Endomorphy: this means a relative predominance
application of the earlier biotypological classifica- of soft roundness throughout the various regions
tions based solely on anthropometric criteria. He of the body. When endomorphy is dominant the
and his team wanted to produce an easily applicable digestive viscera are massive and tend relatively
useful morphological taxonomy. In order to do this to dominate the body economy. The digestive vis-
they carefully examined thousands of photographs cera are derived principally from the endodermal
of young men, and experimented in organizing embryonic layer.
them in several different ways. Initially they were Mesomorphy: this means a relative predominance
aware that there were no specific types, but that of muscle, bone and connective tissue. The meso-
there were obvious variations. By selecting the most morph physique is normally heavy, hard and rec-
extreme of these variations they eventually arrived tangular in outline. Bone and muscle are prominent
at three main components of morphological varia- and the skin is made thick by heavy underlying
tion, termed endomorphy, mesomorphy and ecto- connective tissue. The entire body economy is dom-
morphy. They then selected a small number of inated, relatively, by tissues derived from the meso-
anthropometric criteria to enable objective assess- dermal embryonic layer.
ment of these features, and subsequent classification Ectomorphy: this means a relative predominance
utilizing these components. Sheldon's research has of linearity and fragility. In proportion to his mass,
received criticism from certain quarters in that it the ectomorph has the greatest surface area and
did not include any women. The reason Sheldon hence relatively the greatest sensory exposure to the
gave for this omission was that he could find no outside world. Relative to his mass he also has the
true female ectomorphs. It is the authors' experience largest brain and central nervous system. In a sense,
that though no women were included within the therefore, his bodily economy is relatively domi-
research, the findings are equally applicable in nated by tissues derived from the ectodermal
the clinical situation to both men and women. embryonic layer. See Figure 5.7.
There is sufficient overlap between the physical
T h e physical correlates or s o m a t o t y p e
characteristics expressed by Sheldon and Goldthwait
Sheldon arrived at the threefold classification based that this will be only briefly discussed here. Sheldon
on the predominant embryological tissue, the endo- assessed the physical performance of each body
derm giving rise to the viscera; the mesoderm the type in five categories: strength, power, endurance,
musculoskeletal system; and the ectoderm the neu- body support and agility. The endomorphic type is
ral tissue and skin. The physical correlates derive low in all categories, the mesomorphic type is high
from this. 5 in all categories, and the ectomorphic type is high in
Sheldon called the pattern of the morphological endurance, bodily support and agility but low in
components the 'somatotype'. This was expressed strength and power.
98 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Figure 5.7 The endomorph,


mesomorph and ectomorph.

Endomorph Mesomorph Ectomorph

T h e psychological correlates or t e m p e r a m e n t and for affection. The Viscerotonic extremes are


-people who 'suck hard at the breast of mother earth'
The second element of his classification was to and love physical proximity with others. The
assess the psychological correlates of the somato- motivational organization is dominated by the gut
type. This he termed 'temperament'. Unlike the and by the function of anabolism. The personality
physical traits, which are immutable, the tempera- seems to centre around the viscera. The digestive
ment is influenced by the environment. He tried to tract is king and its welfare appears to define the
explain this by using the term 'statics of psychol- primary purpose of life
ogy', and 'the balance among the components [Somatotonia is] roughly predominance of muscu-
comprising the morphology of man at rest' as lar activity and of vigorous bodily assertiveness.
descriptors of the immutable physical traits. To com- The motivational organization seems dominated
plement this he utilized the term 'dynamics' for the by the soma. These people have vigour and push.
mutable temperament or psychological component. The executive department of their internal econ-
He described this as 'the science of man in motion. omy is strongly vested in their somatic muscular
When man gets up and moves around, expressing systems. Action and power define life's primary
his desires and motivations and interacting with his purpose.
fellows'.
[Cerebrotonia is] roughly a predominance of the
Sheldon used 60 traits to devise three categories element of restraint, inhibition, and of the desire
of temperament: 6
for concealment. Cerebrotonic people shrink away
from sociality as from too strong a light. They
• Viscerotonia
'repress' somatic and visceral expression, are
• Somatotonia, and hyperattentional, and sedulously avoid attracting
• Cerebrotonia. attention to themselves. Their behaviour seems
Sheldon's full definitions are included here, as dominated by the inhibitory and attentional
their language is well suited to the description of functions of the cerebrum, and their motivational
these types. Table 5.7 also presents the typical hierarchy appears to define an antithesis to both of
the other extremes.
characteristics of each type.
[Viscerotonia] in its extreme manifestation is The genius of Sheldon's classification lies in his
characterised by general relaxation, love of comfort, use of the primitive germ layers of the embryo as
sociability, conviviality, gluttony for food, for people the foundation of his system.
Biotypology 99

Figure 5.8 The viscerotonic individua Figure 5.9 The somatotonic individua

have a tendency to enjoy food, and as they have


perhaps the most efficient digestive systems of the
somatotypes they have a tendency to easily put
weight on. However, it is not just food they like;
they take pleasure in elegant and sumptuous sur-
roundings, good friends to dine with, and the pres-
entation and smells of the food. This is an
expression of the sensual and sensitive side of the
viscera (see also Table 5.7).
The mesodermal layer gives rise, essentially, to
the musculoskeletal system. As these tissues pre-
dominate in the mesomorph they achieve expres-
sion through activity of the somatic muscular
system, somatotonia. Somatotonic individuals
enjoy physical activity and perform well at it. They
have a tendency to be aggressive, not in a physi-
cally violent way (though that is possible) but
working hard at what they do; they are competi-
tive and can be dominating. Their pursuits simi-
larly reflect these attitudes - they enjoy physical
Figure 5.10 The cerebrotonic individual. team sports.
The ectodermal layer gives rise to the nervous
Thus the endodermal layer gives rise to the vis- system and the skin, the ectomorph therefore ex-
cera, particularly the gastrointestinal system and pressing itself through the central nervous system,
liver, pancreas, thymus, thyroid and parathyroids. cerebrotonia. These are sensitive individuals, some
In the endomorph these tissues predominate and would say hypersensitive. They have a tendency
they therefore seek to express themselves via to intellectual over-stimulation and introspection.
this system - hence viscerotonia. Endomorphs All senses are acute; they dislike noise, and (with
100 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

T a b l e 5.7 F e a t u r e s o f t e m p e r a m e n t f r o m Sheldon's c l a s s i f i c a t i o n

Viscerotonia Somatotonia Cerebrotonia

Personality type Sociable, loving, secure Physical, assertive, adventurous, Intellectual, restrained,
a risk taker self-conscious, artistic

Wants Have a want of affection Desire power and dominance Need of privacy, peace and quiet

Lifestyle Love of food and comfort Need of enjoyment and physical Mentally and emotionally over
activity intense

Relations with others Relaxed, easy-going Competitive, active and noisy Inhibited, quiet, introverted

Social tendencies Tolerant, sociophilic, Indifference to what others think Socially anxious, sociophobic
indiscriminate amiability or want

When troubled seek out People Action Solitude

Orientation towards Childhood and family Goals and activities of youth Later periods of life
relationships

Sporting pursuits Not greatly interested Team sports, aggressive, i.e. rugby, Solitary pursuits often including
fast burst activities such as sprinting endurance, cycling, long-distance
running, mountaineering

regard to the skin as a sense organ) tend to emotional or strong person. They are easily
be 'thin skinned' and therefore to avoid social fatigued and need regular sleep.
interaction.
Mesoblastic constitution
Thus Sheldon's classification unites the mind
and the body. These people are stocky to fat, with good
musculoskeletal development and muscle tone.
MARTINY'S ENDOBLASTIC, MESOBLASTIC AND Their faces are generally oval with a ruddy
ECTOBLASTIC TYPES complexion. Being both active and powerful, this
results in a strong and self-confident person,
M Martiny created a system of biotypology who needs to expand and communicate. It is
utilizing the same concept of embryological because of this that they do not consider sleep very
tissues as the basis for the classification. There important.
follows a very brief review of his biotypological
Ectoblastic constitution
classifications, primarily for the sake of compari-
son and interest. It is not certain whether These people are tall, thin, pale, and look weak,
Sheldon and Martiny communicated with each but have a good muscular tone. Their tempera-
other, but the similarities between the two ment is nervous because of the dominance of the
classifications are great. Martiny utilized the sympathetic system. A poor vitality, but high
terms endoblastic, mesoblastic, ectoblastic and nervousness explains their tendency to catch
chordoblastic constitutions to distinguish his everything going, but also to a remarkable sensi-
types. - 7 8 tivity. Ectoblastics are complicated people, closed
in their own inner world, and consider the
Endoblastic constitution environment to be an external reality which con-
These people are generally short in height, fat, trasts with their own somewhat idealized
pale and flaccid with a round and relaxed perception of it. This results in the individual dis-
face. The parasympathetic system prevails, with playing an apparently strong personality,
the individual being a slow, passive, not very generally indifferent to popular opinions.
Biotypology 101

Chordoblastic constitution LEON V A N N I E R


This person is an equal combination of the three
Leon Vannier (1880-1963), during his practice as
other types, and is therefore perfect!
a homeopath, observed that there was a correla-
tion between the constitution of individuals and
ERNST KRETSCHMER: PYKNIC ATHLETIC A N D
the characteristics of three homeopathic reme-
A S T H E N I C TYPES dies: Calcera Carbonica, Calcera Phosphorica and
Calcera Fluorica. He felt he could roughly divide
Ernst Kretschmer (1888-1964) is only discussed
the human species into three distinct types which
briefly here, due to the strong similarities he described as Carbonic, Phosphoric and
between his and Sheldon's findings. A German Fluoric.
psychiatrist, he proposed the classification of
Like Sheldon, he stated that the biotype was
three basic constitutional types: pyknic, athletic
comprised of two levels, and termed these 'consti-
and asthenic. Also sometimes included within
tution' and 'temperament'.
this classification is 'dysplastic', a combination
'Constitution' is 'the unchangeable structure out
of the three types. He suggested that asthenics
of which the body develops' arising from heredity,
10

and, to a lesser degree, the athletic types were


being observable in the structure of the musculo-
more prone to schizophrenia, while the pyknic
skeletal system and its relations.
types were more likely to develop manic-depres-
'Temperament' is a mutable element, described
sive disorders. He has received much criticism as
as 'that which becomes'. It is affected by the envi-
his work was used by the Nazis for eugenics pur-
ronment and may also be influenced, to good or ill
poses; however, the classifications are still valid.
effect, by the individual.
He modified his terminology throughout his
Vannier's is an exceptionally rich and highly
research; the terms in parenthesis are the earlier
complex interpretation of biotypes. By reducing
terms.9

it to the elements shown in Table 5.9, we are


Pyknic (cyclothyme) doing it some injustice. See Recommended read-
ing at the end of the chapter for the original
This derives from the Greek word puknos meaning texts.
'thick'. These are plump, rotund, macrosplanchnic
types. Kretschmer proposed that these people
were more likely than others to develop manic- TOM DUMMER'S CONTRIBUTION
depressive disorders.
Tom Dummer was an eclectic individual with an
Asthenic (leptosomic or schizothyme) avid interest in people and philosophy. In his
These are the tall, thin, microsplanchnic types, Textbook of Osteopathy (1999) he commented on a
who were said to be more prone to schizo- broad range of biotypology approaches from the
phrenia. East and the West, psychological, physiological
and structural. He created an empirical bipolar
Athletic
These are the more muscular, athletic types. T a b l e 5.8 A brief comparison between the key
This type is less inclined to any psycho- temperament findings of Kretschmer and Sheldon
logical disturbance. When present it is more
likely to be schizophrenic than manic- Kretschmer Athletic Asthenic Pyknic
Competitive Serious Social
depressive.
Quiet Friendly
Dysplastic Solitary Lively
Introvert Extrovert
This is a combination of the first three basic
types. This is not always used within the general Sheldon Mesomorph Ectomorph Endomorph
classification. Vigorous Introverted Jovial
Table 5.8 compares Kretschmer's classification Aggressive Inhibited Pleasure-
with that proposed by Sheldon. loving
102 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

T a b l e 5.9 A summary of key e l e m e n t s of Vannier's classification of constitution and temperament. (With


permission from Spring L. Body morphology. Unpublished dissertation. Maidstone: European School of Osteopathy;
1998)

Carbonic Phosphoric Fluoric

Structure Rigid and straight Elegant and shapely, expressive Unstable and flexible
and variable in appearance

U/E limb angle When standing, forearm projects Hyperextension shows forearm Forearm forms reflex angle with
slightly forward, and in forced forms straight line with humerus humerus, more so when in forced
hyperextension still forms small hyperextension
angle with upper arm

L/E limb angle Thigh and leg not precisely aligned, Thigh and leg in perfect alignment Thigh and leg show an angular deformity,
but show no angular deformities a forward-facing obtuse angle

Orthodontic Lower and upper rows of teeth Upper and lower rows of teeth in Undershot jaw is normal. Upper
are in perfect occlusion. Teeth perfect contact at all points. and lower rows of teeth do not
very white, central incisors Palatine arch ogival (gothic arch). meet correctly
almost square Teeth long and yellow, central
incisors' transverse diameter less
than vertical

Function No comment Fragile with low resistance Irregular

Psychological/ Basic and fundamental: is Aesthetic considerations rule his Unstable in attitude. Uncertain and
social resistant and stubborn. Directing spirit and dictate his smallest irresolute, takes decisions on spur
principle is order, reasons actions. He loves beauty and of moment; his plans are often
logically. Likes to establish, to seeks to express it contradictory, always sudden and
organize, to construct and in unpremeditated. Gifted with
whatever situation, has strong extraordinary mimicry, variety of
sense of responsibility brilliant performances

Heredity No comment Tubercular Syphilitic

model of typology based on a synthesis of these was to refer to the physiological processes within
many sources, modified specifically to help the the body, the Structural approach in treatment
osteopath in the clinical situation. He included a would be a direct appeal to the musculoskeletal
third classification, which was a mixture of the structures leading to an effect of the local tissues
two. upon the physiology via circulation and nervous
He based this classification on Still's concept tissues; a Functional approach in treatment would
be a direct appeal to the physiology, via intracellular
of structure and function, classifying the types
behaviour, leading to effects upon the musculoskele-
as either 'Structural' or 'Functional' or a mix-
tal structures. 2

ture of the two types which he called 'Mixed'.


Table 5.10 draws on some of the key elements of Both structural and functional approaches
this model, but yet again you are referred to the achieve similar results; it is just the methods
original texts for a more complete under- of application that differ. This statement does
standing. - 11 12
not perhaps emphasize the more psychological
Dummer's basic premise was that structure aspects, but these would be considered within
governs function. Spring succinctly states the the approach to the patient.
concept underpinning this: Dummer makes clear that there are numerous
If Structure was to refer to the musculoskeletal factors, other than just biotype, that will play a part
body, the body's literal structures and Function in dictating the mode of treatment most suitable for
Biotypology 103

T a b l e 5.10 T h e s t r u c t u r a l f u n c t i o n a l classification o f T o m D u m m e r , including f e a t u r e s o f level o f d y s f u n c t i o n and


preferred t r e a t m e n t a p p r o a c h . (Modified after D u m m e r T . Specific adjusting t e c h n i q u e . H o v e : J o T o m Publications;
1995, and Spring L. Body m o r p h o l o g y . M a i d s t o n e : U n p u b l i s h e d dissertation. European School of O s t e o p a t h y ; 1998)

Structural Functional Mixed

Solid frame, big muscles with strong Either: 1. Short with decreased muscle Combination of aspects of both
tonus, hypomobile joints, tendency to tonus and hypermobile joints, under-reactive. structural and functional
put on fat Or: 2. Tall with slightly more muscle tonus ,
mediate joints, mobility, over-reactive

Any activity that allows them to utilize .1. Tending to the caring professions Dependent on the proportions of the
their physical abilities, or express their 2. Activity that allows them to express structural or functional components
competitiveness and aggression, such their artistic tendencies
as a 'hard-headed businessman'

Level: physical level, i.e. anatomical, Level: vital energy. The energy matrix Dependent on the proportions of the
physiological, biochemical structural or functional components

Depth: superficial, involving Depth: profound on a bioenergetic level; Dependent on the proportions of the
structure more than function. Often involving the dysfunction of all tissues structural or functional components
at the musculoskeletal level, or with emphasis on the viscera, and also
structure of organs and vessels the psyche and particularly the emotional
level and subconscious mind

Treatment approach: most open to Treatment approach: most open to change Treatment approach: care required to
appeal in the musculoskeletal field. in fascial or fluid fields. Cranial and assess the relative balance of mix of
Structural mechanical: General indirect (functional*) structure/function
osteopathic treatment (GOT), general
articulator/ treatment (GAT)

*lt should be noted that the term 'functional' is used by Dummer to mean both the treatment approach developed by Bowles and Hoover, and
as a term for a group of approaches more widely termed indirect. In this incidence it is intended to mean indirect approaches.

a patient. He also states that the intention or mode those features listed are numerous and are presented
of application of any treatment can make it structural in tabular form. You are not expected to memorize
or functional. However, this classification does give all of the traits specific to each classification; in fact,
some indicators that will assist in making the final I would actively encourage you not to do that.
treatment plan. Rather, it is the intention that you read the words
and from them build a picture in your head of each
of the three major types. This will be a condensation
SUMMARY AND APPLICATIONS of the work of some of the foremost biotypologists,
each coming from differing scientific and philosoph-
This chapter has covered what is perhaps one of the ical backgrounds. As you observe more people and
more 'difficult' concepts in the book. As mentioned think about them as whole and unique individuals,
previously, there is an inherent disquiet amongst you will develop your own interpretation of these
many individuals about the application of labels or models and will be able to place each patient some-
stereotypes to people, and this is right, to an extent. where on the continuum of typology. (This is not a
However, there are differences between people, and situation of 'once placed, never moved'; this is a
these differences are not so great that people cannot dynamic process, to be reviewed at each consulta-
be grouped together in some manageable and use- tion. As you learn more about the person, their posi-
ful form. tion on the continuum will subtly change.)
The other relatively difficult aspect of this chapter Most importantly, do not forget that you are a
is that the models are radically summarised and human being too, with an ability to empathize
104 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

and understand fellow human beings. You can initially, to engage the patient. Later the subtleties
see when an individual is sad or happy. It is writ- of the mixed biotypes can be explored.
ten in the body, gestures, face, eyes and voice. Functional and pathophysiological changes are
So often in teaching clinics the authors have varied, depending on the biotype. This is due to a
observed students who have these abilities to combination of the differing structure and support
'read people', but the moment they put on their of the organs, and the nature of their overriding
white coat and shut the treatment room door, fail motivations (visceral, musculoskeletal or cerebral).
to recognize or utilize these inherent skills, The examination can confirm or refute the consti-
becoming a practitioner rather than a person. This tutional elements. It is equally important for the
is obviously partly due to the stress and relative hypothesis to be proven right or wrong. If it is
novelty of the situation, but a practitioner must wrong, this gives you the opportunity to re-exam-
be a person too. ine why you thought it was so in the first place, to
The benefit of applying these models is enor- reassess, rethink and create a new hypothesis. This
mous. The moment you see your patients you can serves two purposes: firstly, it prevents you from
start the process of getting to understand them as a going down investigative cul-de-sacs, and secondly,
whole. Firstly, the gender and estimated age of it is by reflecting on such aspects of your practice
patients will immediately narrow down the differ- that you will continue to develop your skills as an
ential diagnostic possibilities. (These, too, are another osteopath.
form of biotype; male/female, child, youth, middle- Analysis of all of the above leads you to the point
aged, elderly.) Then, a rough assessment of biotype of deciding what treatment to apply. Dummer's
will begin to permit you to create hypotheses on classification of the structural and functional will
their body structure, organ position, problems that assist in this, but as stressed in his writings, the
they may be predisposed to, as well as the way they model should not be followed blindly. There are
may think and communicate. numerous other factors that need to be considered
These early hypotheses are then progressively such as patients' vitality, and the environmental
tested. While taking a history, it will be possible to moulding to which their temperaments have been
explore patients' mental approach and attitudes to subjected, which may override those qualities you
lif e, and their views of themselves and of the prob- would have expected, based on their biotypes.
lem that they have consulted you about. Within this modelling, those individuals that are
With regard to communication, and utilizing the paradoxical are perhaps of greatest interest to the
extreme examples of their type, ectomorphs will be practitioner. That is, those people who have, for
detailed in the explanation of their problem, and whatever reason, attempted to achieve something
will expect a similarly detailed reply. They will want to which their biotype is not particularly suited. An
to know the intricate details of what the problem is, example would be an ectomorph attempting to
how it could have been caused, whether it is likely compete at a high level in sprinting, the normal
to occur again, what can be done to prevent this, domain of mesomorphs. Such a person will be
and what the long-term consequences may be ... be aware that they have to work harder than others
prepared to explain all. that they come across. Being naturally introspective
Mesomorphs, in comparison, generally will not they will question why. This will range from a logi-
want to know much about the process. They are cal analysis to the extreme of self doubt. Discussion
more pragmatic, and if you were to start explaining around the particular strengths of a biotype may
the underlying causes and what you intend to do, lead to either an acceptance of the problem from an
you would probably be interrupted and told that informed perspective, leading to the person adopt-
they are not interested in what you do, and that ing realistic coping strategies, both mental and
they simply want you to do what is necessary to physical; or to the realization this may not be their
permit them to continue their sport or life free of particular area of expertise - perhaps this person
pain as quickly as possible. should attempt a different form of running more
appropriate to their biotype.
Endomorphs will be more interested in engag-
ing you in conversation about life in general. Patients may find it reassuring if it is explained
Obviously these are the extremes of the types, that what they are feeling or experiencing is within
but they often appear to be reasonably accurate and the normal realms of their biotype. More often than
give an indication to the practitioner on what level, not we feel that we are the only ones that are
Biotypology 105

experiencing such problems, and it can be a great thought underlying these bare statements may have
relief to know that it is nothing unusual and that been sacrificed, despite constant reiterations of the
the feelings or problems have been experienced by continuum of the classifications, and warnings
many before, allowing a degree of connecting with about not dogmatically following the models. The
one's fellows. Often 'problems' do not need to be most important point to take away from this subject
resolved, but just understood for what they are; this is that a natural curiosity and interest in people will
in itself can lighten the 'load'. The real problem may enable you to more effectively communicate with
be fear of the unknown. your patient and help you find the most effective
This is a vast area of study, and the above approach to enable your patient to achieve better
discussion has just skimmed the surface of it. It is a health. The models are there just to provide some
matter of concern that, in so doing, the depth of structure for your thoughts.

References
1. Goldthwait JE, Lloyd T, Loring T et al. Essentials of body 7. Martiny M. Essai de biotypologie humaine. Paris:
mechanics in health and disease, 5th edn. Philadelphia: I Peyronnet; 1948.
JB Lippincott; 1952. 8. Notes on Martiny. Online. http://www.giuseppeparisi.
2. Spring L. Body morphology. Maidstone: Unpublished com/framesetipiumanx.htm.
dissertation. European School of Osteopathy; 9. Kretschmer E. Physique and character: an investiga-
1998. tion of the nature of constitution and of the theory
3. Caillet R. Low back pain syndrome, 3rd edn. of temperament. New York: Harcourt Brace;
Philadelphia: F.A. Davis Company; 1986: 34. 1925.
4. Wernham J, Hall TE. The mechanics of the spine and 10. Vannier L. La doctrine de l'homeopathie Francaise.
pelvis. Maidstone: Maidstone College of Osteopathy; 1960. Paris: G Doin; 1931.
5. Sheldon WH, Stevens SS, Tucker MD. The varieties of 11. Dummer T. A textbook of osteopathy, vol 1. Hadlow
human physique: an introduction to constitutional Down: JoTom Publications; 1999:133-154.
psychology. New York: Harper; 1940. 12. Dummer T. Specific adjusting technique. Hove: loTom
6. Sheldon WH, Stevens SS. The varieties of temperament: Publications; 1995: 36-43.
a psychology of constitutional differences. New York:
Harper; 1942.

Recommended reading
Unfortunately nearly all of these books are out of print, Kretschmer, E. Physique and character: an investigation
and devilishly difficult to get hold of. The British Library of the nature of constitution and of the theory of
can get them for you, but be prepared for a long wait. temperament. New York: Harcourt Brace; 1925.
If you are going to use them for a final project, ordering Martiny M. Essai de biotypologie humaine. Paris:
them should be your first priority. It is only by reading I Peyronnet; 1948.
these original texts that you will get a true feel for each Sheldon WH, Stevens SS, Tucker MD. The varieties of human
particular model. Lizzie Spring's excellent physique: an introduction to constitutional psychology.
(unpublished) undergraduate project, from which most New York: Harper; 1940.
of the tables came, is available at the ESO library in Sheldon WH, Stevens SS. The varieties of temperament: a
Maidstone. psychology of constitutional differences. New York:
Harper; 1942.
Dummer T. A textbook of osteopathy, vol 1. Hadlow Down: Spring L. Body morphology. Maidstone: Unpublished
loTom Publications; 1999:133-154. dissertation. European School of Osteopathy; 1998: 53.
Goldthwait IE, Lloyd T, Loring T et al. Essentials of body Vannier L. Typology in homoeopathy. Beaconsfield:
mechanics in health and disease, 5th edn. Philadelphia: Beaconsfield Publishers; 1992, or
IB Lippincott; 1952. Vannier L. La typologie et ses applications therapeutiques: les
Keuls K. Osteopathic medicine: Part 1 osteopathic principles. temperaments, prototypes et metatypes. Paris: Doin
Brighton: Keuls; 1988. Editeurs; 1976.
Page Intentionally Left Blank
107

Chapter 6

The nervous system

INTRODUCTION
CHAPTER CONTENTS

Introduction 107 The nervous system has always been perceived as


The basic organization of the nervous having a fundamental role in the coordination of the
system 108 body. Classically the somatic nervous system was
Neural reflexes 108 thought to be responsible for the musculoskeletal
system, and the autonomic nervous system (ANS)
The spinal reflex 108
regulates the visceral function. The understanding
The reflex in a simple model of somatic
of the nervous system has advanced dramatically
dysfunction 112
over the last few decades; the old concept of it being
A brief review of the anatomy of the autonomic an independent and discrete 'hard wired' system
nervous system 113 has now been replaced by the concept of it as a com-
Viscerosomatic and somaticovisceral plex integrated system, cornmurricating bidirection-
reflexes 115 ally with the endocrine and immune system
Psychosomatic and somaticopsychic (neuroendocrine immune system) and being
reflexes 118 affected by changes in the psyche as well as the
The nociceptive model of somatic soma (giving rise to the new area of study psy-
dysfunction 123 choneuroimmunology [PNI]). Information is con-
The neuroendocrine-immune system 124 veyed by a multiplicity of possible pathways which
Central sensitization 130 are neuroplastic in nature, i.e. capable of being con-
Summary and conclusion 133 ditioned or learning in response to particular
References 134 requirements or environmental factors.
Recommended reading 135 The nervous system has always been understood
to be involved in the causation and maintenance of
the osteopathic lesion. The understanding of its
actual role has been modified in relation to the
prevalent knowledge of neuroanatomy and neuro-
physiology. Much of the early work in this area
was performed by Professor Irvin Korr and his co-
workers, notably Dr JS Denslow. The results of this
research have given several decades of osteopaths a
scientific rationale for the practice of osteopathy.
This research is now slowly beginning to show
signs of age and new models are appearing that,
in light of the advancing knowledge, offer slightly
108 0STEOPATHIC CONCEPIUAl (PERCEPTUAL) MODELS

differing interpretations. This reevaluation will excellent texts that contain more specific informa-
continue as long as these sciences continue to tion regarding the nervous system and its function;
advance. This chapter will review the key concepts, elements that have a specific relevance osteopathi-
offering a historical perspective and examining the cally will be discussed in this text.
current proposed models of the neural basis of We will begin by looking at the basic level of
osteopathic medicine. neurological organization, the neural reflex, and
what role this has in creating and maintaining
somatic dysfunction in the musculoskeletal and
T H E BASIC O R G A N I Z A T I O N O F T H E other systems. The concept of the facilitated seg-
NERVOUS SYSTEM ment will also be addressed.

The function of the nervous system is to control and


regulate various activities of the body and to enable NEURAL REFLEXES
the body to react to the continuous changes of its
internal and external environments. It is the nerv- The neural reflex is an involuntary response of an
ous system that mediates most of the inputs made effector to a stimulus from a receptor. This simple
during an osteopathic treatment, and thus a sound statement belies the complexity of even the simplest
knowledge of neuroanatomy and neurophysiology of reflexes. Much of the early research in this area
is essential. Anatomy texts will often divide the was done by Sir Charles Scott Sherrington (1857-
nervous system structurally into the central and 1952) and published in 1906 in his classic text, The
peripheral nervous systems, and functionally into Integrative Action of the Nervous System.1

the somatic and autonomic nervous systems. It is By working with decerebrate animals, he explored
the interaction of these divisions that underpins the spinal reflexes and demonstrated that they did
osteopathic medicine and hence treatment. not function as a series of isolated processes, as was
The central nervous system (CNS) consists of the then currently accepted, but rather that they work as
brain and spinal cord and it receives, interprets and an integrated part of the total organism's activities.
creates responses to all of the information passed to The truth of this integration was supported by his
it. The information is passed to it via the peripheral discovery in the late 1890s of the 'reciprocal inner-
nervous system (PNS) which is comprised of the vation' of muscles, also known as Sherrington's sec-
peripheral nerves and ganglia. The PNS is divided ond law: when a muscle receives a nerve impulse
into afferent (sensory) and efferent (motor) systems, causing it to contract, its antagonist receives, simul-
the afferent system gathering the sensory infor- taneously, an impulse causing it to relax. His signifi-
2

mation and the efferent system transmitting the cance in the early genesis of neurophysiology is
responses to the effector muscles or organs. Broadly, revealed by the fact that he was responsible for coin-
the somatic system organizes information related to ing such terms as neurone, synapse, interoceptor,
the musculoskeletal system and the ANS coordinates exteroceptor and proprioceptor.
the visceral system (cardiac muscle, smooth muscle The research in this area has advanced rapidly,
and glands). The ANS is divided into a sympathetic with the phenomenal complexity of the nervous
branch (sympathetic nervous system, SNS) or thora- system being progressively revealed. Even so, there
columbar outflow, and a parasympathetic branch are still innumerable questions yet to answer. In
(parasympathetic nervous system, PSNS) or cran- order to appreciate how reflexes work we will begin
iosacral outflow. The SNS essentially prepares the by looking at one of the so-called simple reflexes,
body systems for action whereas the PSNS has a the spinal reflex.
more vegetative calming role.
The nervous system does not work in isolation
but via a complex interaction with other body sys- THE SPINAL REFLEX
tems, perhaps most significantly in an osteopathic
context with the endocrine and immune systems, Figure 6.1 shows the simple monosynaptic spinal
the whole generally being known as the neuro- reflex consisting of an afferent limb comprised of a
endocrine-immune system. This system is largely peripheral receptor, that when stimulated, passes
responsible for maintaining homeostasis and will an action potential via the afferent fibres to enter
be addressed later in this chapter. There are many the spinal cord at the posterior horn. The spinal
The nervous system 109

Posterior Posterior The receptor in this stretch reflex is the muscle


horn root Afferent limb spindle (Fig. 6.2). Muscle spindles are small struc-
Central limb tures (3-12 mm) lying within and attached by
Afferent fibre fibrous connections to the muscle itself. They lie par-
allel to the fibres of the overlying muscle. As they
are an integral part of the whole muscle, the spin-
dle's length is directly related to the muscle length of
the muscle that they are within, i.e. when the muscle
Anterior Efferent shortens or lengthens, so does the spindle.
(motor) fibre
horn The spindle consists of a fibrous outer sheath
encapsulating several small muscle fibres which are
Efferent Stretch of golgi referred to as intrafusal fibres ('intra' is Latin for
limb tendon organ 'inside', 'fusus' is Latin for 'spindle') to differentiate
Muscle them from the larger extrafusal fibres of the sur-
contraction rounding muscle. There are two types of intrafusal
fibres and each has different stretch characteristics.
Attached to these are the sensory receptors of which
there are also two types. One reports on the static
Figure 6.1 The monosynaptic stretch reflex. length of the intrafusal fibre, increasing the output
proportionate to the increase in length, and both
report on the change in length of the fibres. This
combination permits the spindle to have both a
cord is part of the central nervous system, so is static and a dynamic response. Impulses are con-
sometimes referred to as the 'central limb' of the stantly passing to the cord from these endings.
reflex. The fibres, having entered the posterior horn The sensory fibres from the receptors connect,
of the cord, pass via the grey matter to the anterior some monosynaptically, with the same alpha motor
horn where they synapse with the nuclei of the neurones that supply the surrounding extrafusal
motor neurones. Passing out of the cord by the fibres. The afferent input from these receptors is
anterior root, the motor fibres form the efferent limb excitatory to the alpha neurones with which they
of the reflex arc, conducting the impulses to the synapse. Thus when the muscle is stretched the
effector muscle, causing it to contract. In fact this spindle via the reflex causes the muscle to contract,
type of reflex exists only in the myotatic (stretch) thus opposing the stretch. Conversely when the
reflex - in reality reflexes are far more complex, but muscle shortens there is a diminution of spindle
this simple example serves well to give a basic output leading to less stimulation of the alpha neu-
understanding on which to build. rone, resulting in relaxation or lengthening of the
muscle. Thus they oppose change of length in both
THE M O N O S Y N A P T I C MYOTATIC OR STRETCH directions.
REFLEX
THE G A M M A EFFERENT SYSTEM
The monosynaptic stretch reflex contains two neu-
rones with one synapse linking them together. The motor supply to the spindles consists of gamma
Stretching a muscle will stimulate sensory endings efferent fibres. Their full function appears to be rel-
of the receptor, the muscle spindle, to pass an action atively poorly understood, but their significance is
potential to the spinal cord by way of a primary evidenced by the fact that they appear to make up
afferent fibre. This will then synapse with an alpha almost a third of the efferent ventral root fibres.
motor neurone at spinal cord level, the impulse Collectively this is termed the gamma efferent sys-
then passing along the axon and subsequently caus- tem. Of those aspects of its role that are understood
ing contraction of the effector muscle. It is this reflex it appears that its principal action is to cause con-
that forms the basis of the deep tendon reflexes that traction of the intrafusal fibres. When the motor cor-
are used as part of the clinical testing of the nervous tex initiates a movement, a barrage of impulses are
system. Its role in the body is that of an important passed to the alpha motor system to cause the
postural reflex. appropriate muscles to contract. At the same time
110 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Fibroblasts in capsule

Motor end plate on nuclear


chain muscle fibre

Fusimotor fibres.

1b fibre -

1a fibre- Flower spray


nerve endings

Annulospiral
nerve endings
Nuclear chain -

Fusimotor fibres

Motor end plate on nuclear


bag muscle fibre

Intrafusal fibre

Extrafusal fibre

Figure 6.2 The muscle spindle.


The nervous system 111

there is a similar barrage passing to the gamma sys- of tension is exceeded the receptor inhibits the
tem with the intention of causing the intrafusal related muscle. As with the spindle it has both a
fibres to contract in a similar proportion to that of dynamic and static response, but whereas the spin-
the alpha fibres, thus mamtaining the same length dle detects length and rate of change of length, the
and tension relationship between the two sets of Golgi tendon organ detects degree and rate of
fibres. Thus the same degree of tension is main- change of tension. Both are constantly feeding infor-
tained within the extrafusal fibres, permitting a mation into the spinal cord and to the higher cen-
'damping' of the movement and a constant respon- tres and have significant roles in maintaining
siveness of the muscle. If the intrafusal fibres were posture and in controlling movement. These are just
to lag, they would be stretched, causing tensioning two of a large range of proprioceptors present in
of the extrafusal fibres. It is thought that the regis- the muscles, tendons, skin and labyrinth apparatus
tering and balancing of the length of the spindle that are responsible for this control.
with regard to the surrounding muscle fibres, and
hence the ultimate length of the muscle, is con- POLYSYNAPTIC REFLEXES
trolled via a system termed the gamma loop (the
reflex spinal loop between the spindle afferents and The myotatic or monosynaptic reflex as described
the gamma efferents). above is suitable for producing a simple response,
As well as this role, it is thought to have a function such as a withdrawal response from a painful stim-
in preparing the body for anticipated work. For ulus. However, to obtain coordinated movements
example, when one is about to lift a box, the higher necessitates the uniting of the contraction or relax-
centres make an assessment as to how heavy it is and ation of numerous independent muscles simultane-
what will be required of the muscles. This informa- ously and this requires much more complicated
tion is passed to the spindles via the gamma effer- processes. To this end the primary afferents that
ents, 'warming up' the relevant muscles via the project to the spinal cord not only synapse with the
spindle afferents and the alpha motor neurones loop. motor neurones of the stretched muscle but also to
Another proposed role is almost that of an ampli- muscles having a synergistic function to comple-
fier. When a muscle is contracted and static the ment the action of the prime mover.
extrafusal fibres are notably shorter than their nor- In addition, as demonstrated by Sherrington,
mal resting lengths; similarly, as the intrafusal stretching a particular muscle or group of muscles
fibres are in parallel with the extrafusal fibres, they will cause a relaxation response in the antagonist
too will be shortened. This will result in a decreased muscles; this is termed reciprocal inhibition. The
sensory afferent output from the intrafusal fibres, mechanism for this was found to be that the
and so there will be a lack of information as to the primary afferents, in addition to synapsing with
mechanical state of the muscle. If the muscle has the alpha motor neurones of the prime mover and
shortened to balance the stretching of its antagonist its synergists, also synapse with inhibitory inter-
there will be reciprocal inhibition from the stretched neurones that pass to the alpha motor neurones of
muscle to the shortened muscle, further reducing the antagonist muscles.
its afferent output. The body is dependent on the By using a simple example it is possible to demon-
gamma afferent output to 'know' where that part strate how these reflexes work and to introduce
of the body is. So it is thought that the gamma effer- another, the crossed extensor reflex. If we step onto a
ent system fine-tunes the spindle to amplify any nail, free nerve endings, acting as pain receptors in
feedback that exists. As an analogy it is rather like the skin, will send impulses to the spinal cord which
turning up the volume control of a hi-fi to full, in will synapse with the alpha motor neurones passing
order to listen to a quiet passage of music. to the flexor muscle of the leg, causing a reflex with-
drawal of the limb from the painful stimulus. In fact,
THE GOLGI T E N D O N ORGAN the afferent fibres will also synapse with interneu-
rones in the dorsal horn of the spinal cord, which
The muscle spindle works in tandem, but almost then in turn act upon the motor neurones of several
antagonistically, with the Golgi tendon organ, a spinal cord segments in order to activate a number of
sensory receptor in the muscle tendons. This works muscle groups. In addition to activating the flexor
in a similar manner to the spindle but responds to response, the interneurones will inhibit the actions
levels of tension in the tendon. Once a particular level of the extensor muscles in the same limb, perimtting
112 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

the flexion to take place. Furthermore, there will be From the above it is possible to see that there is a
commissural interneurones that cross to the con- constant feedback from the muscles to the spinal
tralateral side of the spinal cord that create an exten- cord as to their state of mechanical tension. This
sor contraction and flexor relaxation in the opposite allows the body to regulate the state of contraction
limb. This so-called crossed extensor reflex serves to and relaxation wittifn individual muscles and within
prepare the opposite limb to support the change in muscle groups and therefore the position of the
weight-bearing due to the raising of the flexed limb. underlying articulation. This mechanism is equally
Once again, this whole process is a spinal cord reflex, true for the limb muscle groups and for the axial
but has now become a polysynaptic reflex. It is by muscles; the complex interplay between these per-
employing these simple spinal cord reflex circuits mits postural control and coordinated movement.
that the higher centres of the nervous system are able
to control the more complex coordinated movements
with relatively simple input. T H E R E F L E X IN A S I M P L E M O D E L OF
The higher centres can modify these reflex arcs. SOMATIC DYSFUNCTION
An example of this has already been mentioned,
whereby there is an increased output of the gamma By simplifying the model of somatic dysfunction
efferent system causing the spindles to shorten and analysing it from the perspective of a single
slightly and therefore increase the tone of the extra- muscle or group of muscles at a spinal segmental
fusal fibres of the muscles in anticipation of lifting a level, it is possible to examine what processes occur
heavy load. Overall, the higher centres have an in normal postural functioning, and, from that, to
inhibitory effect on the reflex arcs. This is demon- extrapolate to what would occur under abnormal
strated by upper motor neurone problems in which conditions, such as a somatic dysfunction of the
the central control is lost and the deep tendon articulation. See Figure 6.3.
reflexes become brisk; however, it appears to have a It is possible to see from the diagram that an
limitless overriding role responding to circum- intersegmental muscle is part of the erector spinae
stances as they arise. group of the paravertebral muscles and joins the

Spindle efferents stimulated by stretch


in the extrafusal and intrafusal fibres
as a result of the somatic dysfunction

Efferent fibre attempts to contract the -


stretched muscle and resolve the
problem. As the dysfunction is
unable to be resolved, the efferent
fibres continue to fire and the afferent
fibres continue to contract the effector
muscle but to no effect

Figure 6.3 A simple model of somatic dysfunction.


The nervous system 113

two vertebrae. The structure of this muscle is simi- trolling the musculoskeletal system unconsciously.
lar to any other skeletal muscle; it comprises a belly The nervous system is such an inherent part of this
and two tendons of attachment. Within the muscle process that most people refer to the neuromuscu-
itself are the muscle spindles and within the ten- loskeletal system.
dons are the Golgi tendon organs, i.e. the structures The visceral systems, logically, have a similar
that are responsible for monitoring the muscle feedback system, e.g. the presence of food in the
length and tone. These structures, as we have seen, stomach will be noted by receptors on the stomach
are linked to the respective spinal cord segments by lining which will then feed this information via the
afferent fibres and the responses are mediated back afferent limb of the reflex arc to the appropriate
to the muscle by way of the efferent motor neurones. spinal segment, which will cause the effector glands
If an excessive tension is applied to a muscle, by, to increase secretion. Thus it is the same process
for example, making a side-bending movement to and would be termed a viscerovisceral reflex. There
the opposite side, there will be an increase in the is one major difference, in that the part of the nerv-
rate of firing in the muscle spindles of the muscle ous system mediating the visceral reflex is the auto-
on the lengthened side. This will then be relayed to nomic nervous system rather than the somatic
the spinal cord to produce a contraction of the mus- nervous system of the somatic reflex.
cle in an attempt to restore its normal length and
tension, and hence the position of the vertebra. In
effect a simple spinal reflex is being used to restore A BRIEF R E V I E W O F T H E A N A T O M Y O F
the segment to the normal position and tension. If THE AUTONOMIC NERVOUS SYSTEM
for some reason the position cannot be restored, it
will then set up a constant barrage of impulses into The autonomic nervous system (ANS) is primarily
the spinal cord at this level and the segment will involved with the day-to-day automatic functions
become, in Irvin Korr's terms 'facilitated' (the 'facil- of the visceral processes of the body. It is ultimately
itated segment' will be further explored below). controlled by the brain and brain stem structures,
This abnormal positioning of the vertebra and the but as with the somatic nervous system, it has a
increased neural activity would be termed a somatic peripheral system that functions at a spinal level.
dysfunction. It may be the result of a trauma, or In fact, much of the time the peripheral autonomic
repetitive strain, which in the case of postural mus- fibres 'hitch a lift' in the somatic nerves. This dis-
cles could be as a result of a compensatory pattern cussion will concentrate on the peripheral aspects of
(as we have seen earlier when we looked at the the ANS. See Figure 6.4.
biomechanics of the spine) or many other sources,
The sympathetic part of the ANS is also known
visceral, psychic, etc. This explains some of the
as the thoracolumbar outflow, as the nuclei of the
local', purely mechanical features of dysfunction
sympathetic outflow arise from an extra horn of the
(muscle hypertonicity, asymmetry of position and
grey matter of the spinal cord section termed the lat-
movement). However, there are many more
eral horn or intermediolateral cell column. This is
aspects, both local and distant, that are involved
present only from the first thoracic segment to the
within somatic dysfunction. These are not depend-
second or third lumbar segments. The axons of
ent on just the nervous system, but on the complex
the sympathetic neurones pass from the spinal cord
bidirectional interplay between the nervous,
to the sympathetic ganglionic chain and hence
endocrine and immune systems. These aspects will
are termed preganglionic nerves. They pass from the
be discussed more fully later in this chapter.
spinal cord to the ganglionic chain by way of the
white rami communicantes, so called because the
SOMATIC AND VISCERAL REFLEXES axons are group B myelinated fibres and appear
whiter due to the presence of the myelin. WitMn the
Thus far, in the reflexes discussed, both the sensory ganglionic chain, there are four options open to them:
receptor and the motor effector have been within the
somatic or musculoskeletal system. Osteopathically, • They may synapse at that level with a post-
this reflex would be termed a 'somaticosomatic ganglionic fibre that will then pass on to its
reflex', the first word indicating where the sensory target viscus.
part has arisen from and the second word where its • They may pass through the ganglion without
efferent effect will be felt. It is the body's way of con- synapsing and pass to a sympathetic ganglion
114 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

CR III Occulomotor

VII Facial
IX Glossopharyngeal
X Vagus

S 2,3,4

Inferior
mesenteric
ganglion Bladder

Hypogastric
plexus

Sympathetic Parasympathetic
Figure 6.4 A schematic representation of the autonomic nervous system.

closer to their target viscus where they will pass to a sympathetic ganglion closer to their tar-
synapse. get viscus where they will synapse.
• They may ascend or descend within the gan-
glionic chain and synapse at a level different to It is by ascending and descending that the pregan-
their exit level. glionic fibres reach the ganglia to which there are
• They may ascend or descend within the gan- no white rami communicantes, i.e. those areas
glionic chain without synapsing and then exit to where there are no sympathetic nuclei in the lateral
The nervous system 115

horn - the cervical, lower lumbar and sacral regions. An awareness of the position of the various ele-
Axons leaving the ganglia pass in the grey rami com- ments of the ANS will help in understanding why
municantes that is made up almost exclusively of dysfunction in a certain area may result in more
unmyelinated group C postganglionic fibres then complex effects than anticipated. For example,
pass into the spinal nerve to be carried to their ulti- somatic dysfunction at the cervicothoracic region
mate destination. will possibly affect the motor and sensory supply to
The sympathetic ganglionic chain extends from the the upper extremity via the somatic nervous sys-
upper cervical region down to the coccyx. At most tem, leading to any combination of weakness, pain
levels there exists a pair of ganglia, one either side of and paraesthesia; but it could also have an effect on
the vertebral column. In the cervical region the gan- the blood supply to the cranium via disturbance of
glia lie on the anterior aspect of the transverse the sympathetic fibres ascending from their Tl lat-
processes just posterior to the carotid sheath. In the eral horn nuclei, possibly resulting in migrainous
thoracic region the ganglia lie on the anterior aspects or vascular type headaches.
of the costovertebral joints, whilst in the lumbar Much osteopathic treatment is directed at affect-
region they lie on the lateral aspect of the bodies of ing the peripheral, and thereby the central, aspects
the lumbar vertebrae. In the pelvis, they are to be of the ANS. There are numerous examples of how
found on the anterior aspect of the sacrum just medial this can be achieved. Simple rib raising/articulation
to the anterior sacral foramina. Finally, the sympa- techniques will have a major effect on the sympa-
thetic chains from either side join together to form a thetic chain; how this can occur can be understood
single ganglion at the coccyx, known as the ganglion by observing the close proximity of the rib heads
impar. In the upper cervical region the ganglia are and the ganglionic chain. Releasing tension in the
normally coalesced to form a series of three ganglia, cervical muscles and fascia will affect the autonomic
the superior, middle and inferior cervical ganglia. In supply to the head, as a sacral toggle will affect the
addition, the inferior cervical ganglion may be joined parasympathetic supply to the pelvis. These are
to the first thoracic ganglion to form the so-called stel- obvious examples, but by understanding the organ-
late ganglion. Above the cervical region, the sympa- ization of the ANS, and where it may be disturbed,
thetic nerves pass into the interior of the skull you will be able to treat systemic complaints much
with the internal carotid artery. There may be a single more effectively.
ganglion which arises from the joining of the two
sides that is known as the ganglion of Ribes. In this
manner, although there are 31 paired spinal nerves,
VISCEROSOMATIC AND
the number of paired ganglia will normally be fewer.
SOMATICOVISCERAL REFLEXES
Many of the preganglionic fibres that pass out
of the ganglionic chain continue into the body From the earliest days of osteopathy, the osteo-
where they form ganglia. This is most pronounced pathic lesion has been known to have both local
in the abdomen and the pelvis where they form effects and distal effects. The relationship between
the paraaortic ganglia, the coeliac, mesenteric and visceral dysfunction and spinal tenderness and the
hypogastric ganglia. mechanism through which this was mediated had
The parasympathetic part of the ANS is also been proposed well before the founding of osteopa-
known as the craniosacral outflow as the nuclei of thy. As early as 1836, Professor Jean Cruveilhier
the outflow arise in the cranial nuclei of cranial (1791-1874) observed points of tenderness on the
nerves III the occulomotor nerve, VII the fascial spine related to certain pathological problems, and
nerve, IX the glossopharyngeal and X the vagus, these occurred at specific levels of the thoracic spine
and the lateral horn of the sacral segments S2, 3 and dependent on the site of the pathology. He termed
4. They pass as preganglionic fibres in their respec- these points 'dorsal points'. Moreover, if treatment
tive nerves to ganglia either in or very near to the was applied at these sites rather than to the tissue
target organ where they synapse and the short overlying the affected organ, the effect was greater
postganglionic fibres pass to the organ. The fibres and longer lasting.
are also found in the sympathetic ganglia. The mechanisms mediating this were established
It can be appreciated that though the nuclei arise by numerous researchers, though perhaps the most
in only parts of the CNS, all visceral structures significant were Sir Charles Sherrington and Sir
receive an autonomic supply. Henry Head (1861,1940). Both were pioneers in the
116 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

area of spinal reflexes and they were in regular com- ondary reflex lesion.) If the viscera can have an
munication, pooling their respective findings. effect on the somatic structures it is logical that the
In 1893, Head coined the term 'referred pain' to reverse can occur. This is described as a somatico-
describe visceral pain that is felt in regions of the visceral reflex or, in the early osteopathic texts, as a
body other than in the organ that has the pathol- primary reflex lesion.
ogy. He discovered reproducible zones of tender-
3
A simple representation of these reflexes is
ness and hyperalgesia of skin, associated with shown in Figure 6.5.
visceral disease; these became known as Head's It has now been shown that there are numerous
zones. For example, a patient with hepatic disor- synaptic connections between the somatic and auto-
ders may feel pain or dysthesia in the skin on the nomic systems. The earlier representations of clear,
right side of the thoracic cage and the right shoul- well-divided somatic and autonomic reflex arcs dra-
der. As well as the sensation changes, there were matically oversimplify the reality. In fact there
also trophic changes noted in the somatic area of appears to be a marked overlap between these two
referral. The trophic changes include changes in the systems. This is well demonstrated by looking at
blood flow, in the texture and structure of the skin, the organization of the grey matter of the spinal
thickening of the subcutaneous connective tissue cord. This has been divided into 10 zones termed
structures and muscle atrophy. The reflex zones do Rexed layers. Nociceptive afferents from both vis-
not form as soon as a clinical picture of original dis- ceral and somatic structures enter the spinal cord
order is established: certain elements such as blood and pass into Lissauer's tract, passing superiorly
supply changes and sudomotor changes may be and inferiorly in this tract and sending branches to
present very soon, but the more chronic tissue synapse in Rexed layers I, II, V and X. There they
5

changes such as skin texture change can take 2-3 synapse with interneurones, many of which are wide
months after the onset of the visceral disturbance dynamic range (WDR) neurones. These interneu-
to manifest in the somatic zones. rones are multireceptive, receiving inputs from both
Head also demonstrated the mechanism respon- visceral and somatic afferents, thus they are common
sible for this phenomena, revealing that a sympa- to both. The interneurones then stimulate both the
thetic nerve supplying an internal organ has a visceral efferents and motor efferents, including both
corresponding nerve which supplies particular alpha and gamma motor neurones. To date there do
areas of skin, and perhaps most importantly, that not appear to be any ascending tracts that are solely
these two nerves are linked by a reflex in a spinal for the transmission of visceral sensation, so all trans-
cord segment. He also realized that the viscera were mission of sensory information to the higher centres
poor at registering pain and that in the case of a is via shared tracts. Thus the systems act in an
6

noxious stimulus affecting a viscera there may be integrated and mutually dependent manner.
diffuse poorly localized minor pain felt in the vis-
cera, while the pain was generally felt more THE RELATIONSHIP BETWEEN SOMATIC
strongly at its associated referral area of the skin, A N D VISCERAL STRUCTURES
or Head's zone. Many early osteopathic texts quote
an interpretation of this as Head's law: 'When a The patterns of the relationships between the
painful stimulus is applied to a part of low sensibil- somatic structures and the viscera have been stud-
ity in close central connection with a part of much ied by numerous individuals and there have been
greater sensibility, the pain produced is felt in the many charts drawn of these relationships. They can
part of higher sensibility rather than in the part of be divided broadly into two general classifications,
lower sensibility to which the stimulus was actu- those related to the spinal segmental supply, and
ally applied'. This law will appear particularly per-
4
those concerned with viscerosomatic tender points.
tinent with regard to the neurological lens concept
within the discussion on segmental facilitation T h e segmental supply model
below.
The distribution of nerve fibres is more or less seg-
The reflex mediating the production of changes mental throughout the body. This is the result of
in the somatic structures, the skin and its associated the preservation by the sensory levels of the nerv-
connective tissue, as a consequence of a primary ous system of the original embryologic division of
visceral problem, is termed the viscerosomatic the body into metameres. A metamere consists of
reflex. (Early osteopathic texts refer to it as a sec- the spinal segment that provides sensory and motor
The nervous system 117

Articulation
Somatic
Skin
receptors
Posterior root

Muscle

Posterior primary
ramus

Anterior primary
ramus

Sympathetic
ganglion
Anterior root
(Paravertebral
root)

Somaticovisceral
Viscus Viscerosomatic

Figure 6.5 The viscerosomatic and somaticovisceral reflexes.

innervation to one embryologic division. It is 7 The autonomic spinal segmental supply of each
composed of: viscera is known. For the heart it is from Tl to T6. As
there is a direct relationship between the autonomic
• A dermatome, which is the cutaneous area sup-
and somatic nervous systems, the skin changes
plied by a single pair of posterior (sensory) roots
would be expected to be found in the dermatomal
and their ganglia.
areas of Tl to T6. There may also be referral to the rel-
• A sclerotome, which is the area of bones supplied
evant myotomal or sclerotomal levels, causing muscle
by the unit.
or bone pain predominantly in the upper left thorax.
• A myotome, which is the area of skeletal muscle
The converse is obviously the case where areas of
supplied by the anterior (motor) roots of the
spinal dysfunction will have an effect on the viscera.
segment.
It is possible to predict what viscera are going to be
• A viscerotome, which is the area of viscera sup-
affected by the same means as above, but in reverse.
plied by the same unit.
Littlejohn attempted to model these relationships
• It also includes all the vessels, arteries, veins and
in his work on the 'osteopathic centres'; these gener-
lymphatics at each level.
ally mirror the autonomic supply though there are
Thus it is probable that when a particular spinal seg- notable exceptions. For example, the uterus has an
ment is disturbed, changes will occur in any or all of osteopathic centre at C2/3, which is far away from
those structures supplied by that spinal segment. its autonomic supply.
118 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

V i s c e r o s o m a t i c tender points model


PSYCHOSOMATIC AND SOMATICO-
In this model, there are points that are reproducible PSYCHIC REFLEXES
but not obviously related to the segmental spinal
supply. Head's zones are an example of this type In our hectic and stressful society the psychosomatic
of referral, as are the dorsal points described by reflex and its effects are now well known, for exam-
Cruveilhier. Other examples are Chapman's ple, the effects of stress in the pathogenesis of car-
reflexes, Jones' tender points, myofascial trigger diovascular disease. Similarly there is now a much
points and Jarricot's Dermalgies reflexes. These are greater awareness of the psychological effects of
discussed in more detail in Section 3. somatic dysfunction. Reflecting on the integration of
Awareness of these models has great advantages the nervous system it is possible to extend this reflex
clinically. They offer an objective means, other than to psycho visceral and visceropsychic. The mecha-
assessing the viscera locally, of confirming diagnos- nism of this is essentially similar to the reflexes
tically the presence of an underlying visceral dys- already discussed, but will be addressed in greater
function, and, after treatment, a means of assessing depth in the next chapter, on psychology.
whether there has been full resolution. By observing
the autonomic changes present at the skin it is pos- Much of the work of relating these reflexes to
sible to relate those to the associated viscera; thus if osteopathy and researching their validity has fallen
the skin has chronic changes with atrophy, hypo- to Professor Irvin Korr, an American physiologist
perfusion and coarsening, it would be possible to who has dedicated his life to these studies.
hypothesize that the related viscera will similarly
have undergone chronic changes. The converse will PROFESSOR KORR'S CONTRIBUTION
be the case for an acute presentation with oedema,
heat sweat and tenderness at the skin and a related In his work entitled 'The Neural Basis of the
recent problem at the viscera. Osteopathic Lesion', Korr stated:
Conceptually they enable one to hypothesize
Within the nervous system, in the phenomena of exci-
where a particular problem, in the somatic or vis-
tation and inhibition of nerve cells, and in synaptic and
ceral systems, may have a related dysfunction via
myoneural transmission, lie the answers to some of the
these reflex links. This is particularly important in most important theoretical and practical osteopathic
that they are branches of a reflex arc. If only one problems. The existence of a neural basis for the lesion
aspect of the arc is corrected it is possible for the has been known, of course, for a long time. The seg-
untreated aspect to reinstate the one previously mental relation of the osteopathic lesion to its somatic
resolved. With regard to treatment they offer an and visceral effects is explicable in no other way.
additional 'way in' to a problem: either end of the
reflex can be treated to give some relief. This is par- The activity and condition of the tissues and organs
ticularly useful in the case of an especially acute are directly influenced, through excitation and
problem where it is too tender to address the prob- inhibition, by the efferent nerves which emerge from
lem locally, or where there is some underlying con- the central nervous system and which conduct
dition that precludes a direct approach; treatment impulses to these tissues and organs. 8

applied distally at the tender points may have a pal- His aim was to explain how various effects of the
liative effect. osteopathic lesion, both local and distant, were pro-
It is important to be aware of the individual dif- duced. The effects included hyperaesthesia, hyper-
ferences present in people; we are not anatomically irritability, tissue texture changes of the skin, muscle
identical, and the relationships are not always and connective tissue, local circulatory changes and
exactly as they are stated in the charts or texts. altered visceral and other autonomic functions. (See
These are only conceptual models - they serve to Qualitative considerations in articular somatic dys-
create hypotheses that need to be tested against the function on p.22.)
case history and other examination findings before
one can act on them. EARLY STUDIES
There is another very important reflex that needs
to be mentioned - the psychosomatic, and its reverse, Professor Korr worked with Dr JS Denslow to inves-
the somaticopsychic. tigate the relationship between the osteopathic
The nervous system 119

lesion and the control of efferent activity. One study Information passing into
involved the application of a certain amount of pres- a spinal segment will have
sure via a calibrated pressure meter to the spinous an affect locally at that
segment, but also it will
processes of the thoracic spine and measurement of pass both cephalad and
the resulting muscular activity electromyographi- caudally to neighbouring
cally at the corresponding levels. Essentially this spinal segments
was measuring the activity in a simple spinal reflex
arc. The pressure at each segment was gradually
increased in order to initiate muscular activity
at each particular level, thus the researchers deter-
mined the 'reflex threshold' that needed to be
exceeded to cause a motor response. By comparing
lesioned segments', which they determined by pal-
pation, with the non-lesioned reflex thresholds, it
was found that thresholds were lower in lesioned
segments. In addition, it was found that the more
severe the lesion, the lower the threshold.

The spread of excitation

Next, they explored the manner in which neural


activity may spread from its original site through-
out the spine, and the possible consequences of this.
Four vertebral levels in the thoracic spine (T4, 6, 8
and 10) were selected, and using the above methods
the reflex thresholds for each level ascertained. The
muscle activity was monitored at every level in
response to pressure applied to each of the separate
spinous processes, i.e. 16 readings were taken.
Their principal findings were that there was a far
Figure 6.6 The reflex spread of excitation. See the section on
greater spread of excitation towards a lesioned seg-
spread of excitation for an explanation. (After Korr IM. The neu-
ment than away from it. So that if, for example, T6 ral basis of the osteopathic lesion. In: Peterson B ed., The col-
was a severely lesioned segment (i.e. it had a low lected papers of Irvin M Korr. Colorado: American Academy of
reflex threshold), only very slight pressure at T6 Osteopathy; 1979.)
was required to elicit an EMG response at T6. But
even a very high pressure at T6 did not evoke
much greater sensibility, the pain produced is felt in
responses in T4, 8 or 10. Whereas, at T4, 8 or 10
the part of higher sensibility rather than in the part
application of a low pressure would produce no
of lower sensibility to which the stimulus was actu-
response at the level where the stimulus was
ally applied.'
applied, but elicit a response at T6. See Figure 6.6.
Korr expressed this in a simple analogy: The facilitated segment: a simple explanation

The anterior horn cell of a lesioned segment Many students find this concept difficult to grasp.
represents a bell easily rung from a number of push The author has found that a simple analogy some-
buttons, while the spinous process or push button of times helps. The premise is based on the true concept
the lesioned segment does not easily ring bells other that for a nerve to pass an action potential it has to
than its own.8 receive a stimulus that exceeds the threshold poten-
tial of that nerve - anything below that will fail to
The hyperexcitable segment they termed a 'facili- illicit a response. This is termed the threshold stimu-
tated segment' from the Latin word 'facilis' mean- lus, being the difference between the resting potential
ing 'easy' - it is more easy to elicit a response at and the threshold potential. See Figures 6.7A and B.
that particular segment. This reflects Head's law: Where there is somatic dysfunction there will be
'When a painful stimulus is applied to a part of low a barrage of afferent information from the recep-
sensibility in close central connection with a part of tors, relaying information about the aberrant
120 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

position of the lesioned structures to the cord, in aims to pictorially represent how the facilitated seg-
an attempt to get the efferent system to contract ment can act as a 'neurological lens'.
the effector muscles and to resolve the problem as
The neurological lens
in Figure 6.3. Inherent in the concept of somatic dys-
function is the principle that the body is not able to Korr's team used this term to describe the effects that
resolve the problem itself, and so the above process a facilitated segment will have (see Fig. 6.7D). The
continues unabated. This will cause the affected seg- term is an analogy based on the action of a magnify-
ment to have a higher level of neural activity than ing glass. A magnifying glass will focus a wide range
before. Thus this could be perceived as having raised of light rays to one point, concentrating them suffi-
the resting potential of that particular segment, so ciently to be able to burn paper, as all children know.
that a lesser threshold stimulus is required to elicit a The facilitated segment acts like the magnifying glass,
response from that segment. See Figure 6.7C. taking any neural inputs passing up or down the
Due to the metameric organization of the spinal spinal cord and focusing them on that segment and
cord this means that the resulting facilitation will its associated structures, hence the neurological lens.
affect the segmentally supplied muscles, viscera
and associated tissues via both the somatic and vis-
ceral efferents. Tissue texture changes
Figure 6.7D is a schematic representation of In the discussions above, mention has been made
Korr's experiment on the spread of excitation. This of the possible autonomically mediated visceral

A 10 Threshold potential (TP)

The threshold stimulus required to elicit


a response is 10 or more units. Anything
less will elicit no response.This would
be the situation for a normally functioning
segment

0 Resting potential (RP)

Figure 6.7 A schematic view of the facilitated segment. (A) Basic premise: the
B Stimulation of
all or nothing principle. Stimulation of the spinous process of the vertebra, if
sensory receptors
able to overcome the threshold potential of the segment, will cause the anonci-
at spinous process
ated paraspinal muscles to contract. (B) No segmental lesion. This concept will
be applied to the spinal segments and for the purpose of this exercise the actual
figures are not going to be used, but rather it is proposed that the resting poten-
tial of the segment is 0 units and the threshold is 10 units, thus the threshold
stimulus has to exceed 10 units.
The nervous system 121

c
10 Threshold -
potential (TP)

The threshold stimulus


required to elicit a response
now only 6 + units. Thus at
this segment it is 'facilitated'

4 New resting -
potential (RP)
Neural activity generated by
somatic dysfunction raises
the resting potential
0

D Information passing into


the spinal segment will
affect the local segment,
TP but will also be passed
cephalad and caudally
several spinal segments

TP

This markedly facilitated segment


requires only 2 units to create a
response in the segmental
muscle response in the other
(T4, T8 or T10) segments.
However, relatively light pressure
TP
(more than 2 units) when applied
to the other segments will elicit
no response at these segments,
but will elicit a response here (T6).
Thus it is acting as a 'neurological
lens' (see below) focusing the
passing neural stimulation on
this segment.
TP i

T10 requires about 6 units to elicit


a response locally, but as well as
the local affect the T6 will also
be affected

Figure 6.7 cont'd (C) Segmental dysfunction. Pressure on T8 (unlesioned and resting potential of zero). No local response will be
elicited until a large force equivalent to 10 units is applied. However, before this occurs there will be a spread of the neural stimulus
to distal segments. If the stimulus transmitted exceeds 2 units a response will be elicited at T6, and if it exceeds 6 units then T10 will
also have a motor response. Thus neural stimuli are passed superiorly and inferiorly through the spinal cord, eliciting responses prefer-
entially in areas of increased neural activity (such as that associated with somatic dysfunction). The dysfunctioning segment is
thought of as being facilitated and acting as a neural lens, preferentially focusing neural activity at the facilitated and lesioned seg-
ments. (D) Where lesioned segments occur, they may act as foci to neural activity within the spinal cord.
122 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

or systemic effects that may accompany the mus- In their summary, they state:
culoskeletal consequences of somatic dysfunction.
However, the above experiments only demonstrate These studies suggest that the patterns of aberrant
the musculoskeletal effects. So Korr and his co- areas of sudomotor and vasomotor activity, which we
have previously described in apparently normal
workers formulated a series of experiments to
subjects, may reflect subclinical and asymptomatic
attempt to demonstrate the relationships between
sources of afferent bombardment, over selected dorsal
the osteopathic lesion and sympathetic activity.
roots, or of direct irritation of nerve fibres or
They focused their attention on the tissue texture ganglion cells. That is, the altered patterns of
changes that occur in the region of an osteopathic sympathetic activity appear to be either reflex
lesion: localized oedema, temperature changes and manifestation of changes in sensory input arising in
fibrous alterations of the muscles, which appear to nerve endings and receptors in the musculoskeletal
be mediated by the sympathetic nervous system tissue or the effects of direct insults to nerve fibres
causing altered vasomotor activity, fluid balance, (or ganglion cells) or a combination of both.
capillary permeability and trophic factors. They
monitored the tissue changes that occurred with Observation of the organization of the peripheral
changes in autonomic supply. nervous system allows one to take this hypothesis
Initially they utilized electrical skin resistance as a one step further. The anterior and posterior rami
possible index of changes in vasomotor and sweat arise from the same spinal segment and therefore
gland activity. They found that reducing the flow of will be subject to the same influences with regard to
impulses over a sympathetic pathway to a given area the degree of facilitation. The posterior ramus car-
of skin caused marked elevation of resistance in that ries the sympathetic fibres to the posterior blood
area (due to a decrease in vasomotor and sweat gland vessels and sweat glands, the action of which was
activity), and the converse, that stimulation of sym- assessed in the previous experiment. The anterior
pathetic pathways either locally or systemically low- ramus, as already stated, is subject to the same
ered the skin resistance. They utilized the electrical
9
degree of facilitation as the posterior; therefore the
skin resistance (ESR) and skin temperature as an indi- sympathetic changes occurring in the skin should
cation of the degree of local sympathetic activity. The be the same as those occurring in the structures
backs of numerous subjects were assessed, and each supplied by the sympathetic fibres carried in the
individual exhibited a unique pattern of resistance, anterior ramus. Thus it is possible to theorize on the
and, by implication, facilitation. Interestingly, these state of the deep visceral function of the body by
individual patterns remained relatively constant in just observing the tissue changes overlying the der-
some subjects for time spans that ran into years. matomal region of the relevant spinal segments.
The researchers then attempted to see the effects By observing these changes it is possible to corre-
that could be induced by introducing a factor that late them to actual or possible disease states. It also
would cause a change in the mechanical balance of has a preventive function in that subclinical and
the individual, thus reflecting the changes that might asymptomatic disease states will have this superfi-
arise consequent to the presence of a somatic dysfunc- cial representation before the patient shows any
tion. One way that this was done was by using a heel outward symptoms of frank disease. They are on
lift under one foot only. Changing the postural the first stage of the continuum from the normal
mechanics of patients caused an exaggeration of the physiological state, about to pass to the pathophysi-
existing sudomotor patterns, and additional regions ological change. This stage is still reversible with
of sudomotor activity appeared which related to the treatment, but if it were to continue further it would
new areas of postural adaptation and consequent dys- pass into possibly irreversible pathology.
function and discomfort. This was interpreted as a
10

direct correlation to areas of dysfunction and changes A S U M M A R Y OF KORR'S CONCEPTS


in superficial segmental sympathetic activity.
The segmental relationship of soft tissue changes Korr demonstrated that a spinal osteopathic lesion,
and segmental facilitation was reinforced when as well as having the musculoskeletal component of
later the researchers demonstrated that there was aberrant position and muscle tone, has a neurophys-
often lowered skin resistance in the areas of referred iological component. The prime coordinator of this is
pain and in the dermatomes related to the muscu- the muscle spindle and its gamma loop. The spindle
loskeletal disturbances. 11
is disturbed by the change in position, and bombards
The nervous system 123

the cord via the afferent branch of the reflex, in an Typically, they have many peripheral branches
attempt to stimulate the efferent branch and its effec- that innervate adjacent areas of the same structure.
tor muscle to normalize the position of the vertebrae. When one branch of the neurone is stimulated suffi-
As it is unable to do this, the increase in neural activ- ciently to pass an action potential, it passes both
ity continues. This activity 'warms up' the segment, centrally to the spine and the CNS (referred to as
making it easier for it to respond, thus it becomes a the centripetal action) and peripherally to its other
facilitated segment. The facilitation causes that seg- branches (the centrifugal action). To transmit the
ment to respond to passing neural activity which action potential there will be a release both centrally
may otherwise fail to illicit a response in less facili- and peripherally of neurotransmitters including
tated segments. Thus it acts as a neurological lens. substance P and somatostatin.
By assessing the sympathetic activity at the skin
T h e c e n t r i f u g a l actions
surface, Korr and his colleagues demonstrated that
somatic dysfunction does have an effect on it, result- Neurotransmitters will be released from the nerve
ing in the palpable tissue texture changes noted endings of the neurone branches directly affected
around somatic dysfunction. The distribution of by the noxious stimulus. It will also cause its
nerve fibres is more or less segmental throughout peripheral branches (that have not been directly
the body, therefore the dermatomal area of skin that affected) to similarly release neurotransmitters from
is affected will be related to a myotome, viscero- their nerve endings into the surrounding tissues.
tome, sclerotome and all the vessels, arteries, veins The effect of these neurotransmitters in the periph-
and lymphatics at that level. Korr's work poses the ery is to act as vasodilators and chemical attractors
hypothesis that all of these structures will be simi- for tissue macrophages and lymphocytes. They also
larly affected, so if the skin is demonstrating features have an action which will both stimulate the release
that would indicate hypersympatheticotonia then all of, and act as synergists to, the inflammatory chem-
of those elements supplied by that segment will be icals (cytoWnins) such as histamine from mast cells
subject to the same degree of sympathetic activity. If and mterleukin-1 (IL-1), and tumour necrosis factor
this disturbance is sustained it will be deleterious to (TNF) from leucocytes and complement activators
the target tissues, possibly leading to clinical rather whose role is to stimulate vasodilatation, phagocy-
than subclinical conditions, the nature of which will tosis and inflammatory chemotaxis. In doing this
be determined by the particular response of the tis- the nervous system is having a direct influence on
sue or organs to the atypical stimulation. 12
the immune system, something that only a few
years ago was not understood.
The local effect of this response is to irritate the
THE NOCICEPTIVE MODEL OF SOMATIC surrounding nociceptors so that the threshold is
DYSFUNCTION decreased, leading to a greater sensitivity locally,
and to create local oedema. Both of these are signs of
The work of Korr and Denslow focused on the acute somatic dysfunction. What also is now known
muscle spindle as the mediating factor of somatic to occur is that the locally produced cytokinins, IL-1
dysfunction. Van Buskirk offers another model for and TNF, are able to cross the blood brain barrier
somatic dysfunction, based on the concept of the to have a wide variety of effects on CNS functions,
nociceptive input. The following discussion is based one of which is activating the hypothalamic pitu-
on his paper, 'The Nociceptive Reflex and the itary axis. They also lead to behavioural changes
Somatic Dysfunction: A Model'. 13 designed to limit activity and therefore aid healing,
Nociceptors belong to the myelinated type III such as fatigue, fever, malaise, and reduced interest
and unmyelinated type IV peripheral neurones. in feeding, drinking and socializing. 14

They have sensory receptors that respond to pain in Having looked at the effects of peripheral
all its forms. The receptors are free nerve endings branches of the fibres it is now necessary to follow
that originate in great numbers in most tissues, them as they pass to the spinal cord.
including the 'dermis, sub dermis, joint capsules,
T h e centripetal action
ligaments, tendons, muscle fascia, periosteum, all
blood vessel stroma except that of the capillaries, in The afferent nociceptive fibres from both visceral
the meninges, and in the stroma of all internal (nociautonomic) and somatic (nocifensive) structures
organs'. 13
travel with the somatic and autonomic fibres in the
124 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

peripheral nerves. The nociceptive afferents enter the nociceptive model proposed by Van Buskirk and
spinal cord at the dorsal horn and pass into that proposed by Korr is the receptor that provokes
Lissauer's tract. The majority of these fibres pass the response, the nociceptors in Van Buskirk's
straight to their relevant spinal segment, while a por- model and the muscle spindle in Korr's. The cen-
tion remain in Lissauer's tract to pass either cephalad trifugal effects of the nociceptive impulse and the
or caudad for approximately five segments before local release of substance P does also offer a slightly
sending branches into the grey matter to synapse. better explanation for the local tissue changes that
The synapses occur in relaxed layers I, II, V and X. occur at the site of dysfunction. While the circulat-
There they connect with WDR interneurones that ing cytokinins and the central action on the HPA
receive inputs from both visceral and somatic affer- (see below) explain some of the systemic effects, in
ents, thus they are common to both. The interneu- all probability both processes (those described by
rones then stimulate both the visceral efferents and Korr and Van Buskirk) occur simultaneously in
motor efferents, the alpha and gamma motor neu- most somatic dysfunction. See Figure 6.8.
rones. As mentioned earlier this complex and con- In summary, Van Buskirk proposed a hypotheti-
vergent arrangement of fibres from mixed origins cal model of somatic dysfunction based on these
synapsing with non-specific neurones is the probable observations:
explanation of the observed reflex relationships
(somaticovisceral, viscerosomatic, viscerovisceral • A somatic insult of any type will lead to the stim-
and somaticosomatic). An example of this conver- ulation of the local nociceptors. They will pass
gence is that when there is visceral dysfunction, there the action potential centrifugally to its periphera I
will be contraction of the abdominal muscles that are branches where release of substance P leads to
related segmentally to the affected viscus. the local irritation of the nerve endings and local
inflammation aided by its synergistic action on
Some of the axons pass into the spinothalamic
the local humoral/inflammatory response.
and spinocervicalthalamic tracts, to pass to the
• The action will be sent simultaneously cen-
higher centres, to give an appreciation of pain,
tripetally to its central connections. There it will
while the others remain at a segmental level.
either pass to the higher centres to be recognized
Those that remain at the segmental level are
as pain; or remain at a spinal reflex level where it
responsible for such nocifensive reflexes as the
will potentially create changes in the visceral sys-
withdrawal reflex, whereby if a painful or noxious
tem via the autonomic nervous system or
stimulus is touched, the reflex causes the hand to be
changes in the somatic system via the somatic
withdrawn. This is a simple example, equivalent to
motor system.
the myotatic stretch reflex discussed earlier. The
withdrawal and myotatic reflexes are the most sim- • The combination of these effects could account
ple examples present in the body. The majority of for the local tissue changes associated with
the other reflexes are phenomenally more complex somatic dysfunction, including all of those fea-
than those examples, with the nocifensive and noci- tures typified by the mnemonic TART, and possi-
autonomic reflexes creating complex and wide- ble segmentally related changes in both the
ranging connections throughout the somatic and somatic and visceral systems.
autonomic systems. Van Buskirk also briefly mentions the effects, direct
If there is sufficient nociceptive input this may and indirect, that the nervous system may have on
lead to facilitation within the relevant spinal seg- the immune system as a result of the dysfunction.
ments). If sustained, this may lead to a shift from The relation to the nervous system and the immune
physiological pain, which is the normal response to system will be explored below.
injury, to clinical pain, where there may be hyperal-
gesia or allodynia, and perpetuation of the somatic
dysfunction causing the original problem. If sus- THE NEUROENDOCRINE-IMMUNE
tained, this may be accompanied by metabolic and SYSTEM
anatomical changes and possibly central sensitiza-
tion (see p. 130) and chronic pain. It was demonstrated in the earlier discussion on the
The rationale for the maintenance of somatic dys- peripheral effects of the centrifugal action potential
function is essentially no different from that pro- of the nociceptors, that secretion of the neurotrans-
posed by Korr. The prime difference between the mitters substance P and somatostatin could have a
The nervous system 125

Descending pathways: hypothalamic pituitary adrenal (HPA)


and sympathetic medulla (SAM)

Higher centres Connective tissue


reorganization

Static Chronic
Pain
changes
perception

Muscle shortening
(dynamic)
Centripetal
Spinal cord
circuit Acute
reflex

Any stretch
reinforces pattern

Somatic N/S
(centripetal)
Autonomic nervous system
(centripetal)

Noxious Actuation of
Nociceptor
stimulus sympathetic N/S +
endocrine system

Centrifugal Visceral effects Immune effects


Centrifugal
circuit

Substance P Vasodilatation and local


Free nerve endings
Somatostatin tissue oedema

Release of cytokinins Greater tissue


(IL-1.TNF) sensitivity

Figure 6.8 A schematic summary of the nociceptive model of somatic dysfunction.

direct influence on the immune system. Thus, the Recent research has revealed that the centripetal
nervous system is directly affecting the immune action potentials have a major effect on the immune
system. Similar interactions also occur centrally. response. The ascending fibres pass into the spino-
The complex interplay between these systems offers reticular and spinothalamic pathways. The spino-
a rationale for the systemic effects that have been reticular tract is of particular importance as it
noted in the presence of chronic somatic dysfunc- blends with the reticular network in the brain stem.
tion, but until now have not been adequately This area plays a major role in the control of the
explained. general adaptive response (GAR). The GAR is the
126 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

response that occurs in the presence of a stressful The PGi receives sensory information from many
stimulus of any origin. (This concept was first sources. It is responsible for activating the sympa-
discussed by Hans Selye in what he termed the
15
thetic nervous system and can be considered the
general adaptation syndrome (GAS). Selye's work final common pathway for initiating the sympa-
and the GAS are explored in the next section; how- thetic component of the GAR. The PGi is also able
16

ever, the material about to be discussed and the to stimulate the locus ceruleus (LC) in the midbrain,
GAS are intimately related and thus would benefit a key sympathetic nervous system control centre
from being studied at the same time.) responsible for vigilance and arousal. The LC itself
To date there do not appear to be any ascending communicates with the PVN causing it to release
tracts that are solely for the transmission of any dis- corticotropin-releasing hormone (CRH). The PVN
crete source of sensation, thus the transmission of receives input from many sources including the
sensory information, regardless of its origin, somatic, limbic system. The PVN modulates both the auto-
nociceptive or autonomic passes to the higher cen- nomic system via descending neural pathways, and
tres in shared tracts. Thus it can be perceived that
6 the endocrine system via its relationship with the
the systems act in an integrated manner. pituitary gland. Stimulation of the LC-PVN axis
The ascending nociceptive information passes to leads to an increase in sympathetic activity and an
the brain stem where it synapses, most notably with increased output of the hypothalamic-pituitary-
two nuclei that are involved with the GAR, the adrenal (HPA) axis.
nucleus paragigantocellularis (PGi) in the medulla, Before this becomes too confusing, let us break it
and the paraventricular nucleus of the hypothala- down into its major constituent parts: the hypo-
mus (PVN). thalamus, the HPA, the sympathetic neural axis

Limbic system

Noradrenaline
LC
CRH

Hypothalamus
PGi
HPA CRH
Hypothalamic
pituitary —| Anterior Posterior
axis (HPA) pituitary
pituitary
Sympathetic neural
axis (SNA)
HPA
ACTH
Adrenal
cortex
Adrenal
medulla
Sympathetic adrenal Thoracolumbar
Cortisol medulla axis (SAM) outflow (T1-L2)

Sympathetic supply
Metabolic actions Adrenalin + to the whole body
in the body Noradrenaline
secreted

Figure 6.9 A schematic representation of the hypothalamic-pituitary-adrenal axis (HPA), the sympathetic neural axis (SNA) and the
sympathetic adrenal axis (SAM). ACTH - adrenocorticotropin hormone; CRH - corticotropin-releasing hormone; LC - locus ceruleus;
PGi - paragigantocellularis nucleus.
The nervous system 127

(SNA) and the sympathetic adrenal axis (SAM) mus can directly control many functions such as the
(Fig- 6.9). heart rate, digestive function, and vasoconstriction.
The body's response to a stressor or noxious To support this action, the SAM is also activated
stimulus has two components: the rapid acting simultaneously. The adrenal medulla receives a
'fight or flight' response mediated by the SAM direct sympathetic preganglionic innervation from
and SNA and the slower onset Cortisol response, the spinal cord, and when stimulated will cause the
mediated by the HPA, which creates favourable adrenal medulla to secrete adrenaline and nora-
conditions for wound healing and makes extensive drenaline directly into the bloodstream, which fur-
metabolic adjustments designed to enable the body ther support those changes listed above.
to face the stressor. Therefore activation of the SAM and SNA in
The key point of this discussion is that somatic response to a noxious stimulus or stressor will
dysfunction could be the origin of the noxious stim- result in:
ulus resulting in activation of these processes.
• increased heart rate and force of beat
Fundamental to all of these responses is the hypo-
• constriction of blood vessels to viscera and the
thalamus.
skin
• dilation of the blood vessels to the heart and the
THE HYPOTHALAMUS
skeletal muscle
• contraction of the spleen
The hypothalamus is the major link between the
• conversion of glycogen to glucose in the liver
nervous and endocrine systems. The hypothalamus
• sweating
is also the centre of all vegetative function in the
• dilation of bronchial tubes
body. It controls the function of the autonomic nerv-
• decrease in enzyme production by digestive
ous system, and has a role in sleep, sexual behav-
organs
iour and temperature regulation. To perform this,
• decreased urine output.
the hypothalamus has extensive connections with
other areas of the nervous system. These are bidi- These responses are rapid and short-lived, and are
rectional, meaning that any of these connections can designed to counteract an immediate danger by
have an effect on its action. It also has direct effects mobilizing the body's resources for immediate
on the autonomic nervous system via its descend- physical activity (fight or flight).
ing projections (SNA and SAM). It coordinates the These descending autonomic pathways also have
endocrine system via its vascular relationship with a direct immunomodulatory action. The production
the anterior pituitary gland. This secretes numerous sites of immune cells, the bone marrow and thymus
hormones that control the body's metabolism; of are richly supplied with autonomic fibres; these
particular interest to this discussion is the release of fibres also supply all of the lymphoid organs and
adrenocorticotropin hormone (ACTH). lymphoid tissues of the respiratory tract and
gastrointestinal system. Their exact function is not
THE SYMPATHETIC NEURAL AXIS A N D THE yet fully understood, but they appear to have a role
SYMPATHETIC ADRENAL AXIS in the maturation and activation of the immune
cells and therefore the immune response, and
It has already been mentioned that the LC, PGi and would appear to be able to regulate all of the cells
the hypothalamus are key coordinators of the auto- involved with inflammation. 14

nomic nervous system. It has also been stated that


there is a close relationship between the LC, the PGi THE H Y P O T H A L A M U S AND THE H Y P O T H A L A M I C
and the PVN, and that they are susceptible to any PITUITARY A D R E N A L (HPA) AXIS
nociceptive input. The response to this input is
mediated largely via the SNA and SAM. The HPA is the communication link between the
The SNA is the direct neural link from the hypo- nervous system and the immune system. In
thalamus to the ANS. Fibres project from the hypo- response to a stressor, the PVN of the hypothala-
thalamus to the medulla where they synapse with a mus produces CRH which passes via the hypophy-
group of cells that descend to the sympathetic system seal portal system to the anterior pituitary. This
in the spinal cord. Predominant within these are the stimulates the pituitary to secrete ACTH into the
cells within the PGi. Via this system the hypothala- bloodstream. The ACTH passes to the adrenal
128 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

glands where it causes the adrenal cortex to release It was also demonstrated that the LC can be sensi-
Cortisol. tized by nociceptive input, possibly indicating that
The Cortisol levels are controlled by two nega- the nociceptive input from a somatic dysfunction
tive feedback loops that function to stop further may provoke the GAR. 16

production of CRH by the hypothalamus: one that


T h e H P A and i m m u n o r e g u l a t i o n
passes to both the hypothalamus and limbic sys-
tem (this is a long-term loop taking minutes to As briefly mentioned earlier in this chapter, the
hours); and another short-term quick-acting loop cytokinins released locally at the site of dysfunction,
passing to the anterior pituitary, where it is directly such as IL-1 and TNF, can pass via the humoral sys-
inhibited by the Cortisol. tem across the blood-brain barrier to have numer-
Thus, activation of the PVN by a stressor from ous effects on CNS function, including activation of
any source will lead to an increase in the activity of the HPA.
the HPA axis and therefore a consequent increase Several hormones released by the pituitary gland
in Cortisol levels. It should be remembered that the in response to the hypothalamus also appear to have
hypothalamus can be affected by any of its numer- an immunoregulatory effect, including growth hor-
ous relations. Within this discussion we will be mone, thyrotropin-releasing hormone, thyroid-
particularly interested in the excitation of the PVN stimulating hormone, human chorionic gonadotropin,
via the numerous ascending nociceptive fibres; via arginine vasopressin, gonadotropin-releasing hor-
stimulation from the PGi-LC (which is itself stimu- mone, androgens and prolactin. 14

lated by the ascending nociceptive fibres); and


through its links with the limbic system which DISCUSSION
mediates emotion.
Cortisol, a glucocorticoid, readies the body to The above pathways are present to combat poten-
face the stressor. It aims to ensure that energy is tially harmful situations, mobilizing the body for
available, by breakdown of proteins and amino immediate (SAM and SNA) and short-term (HPA)
acids in the liver, leading to gluconeogenesis. The responses to these situations. This represents a coor-
increase in glucose makes the body more alert, and dinated effort on the part of the nervous, endocrine
assures sufficient energy availability should rapid and immune systems. Recent research has modified
activity be required. Cortisol causes vasoconstric- the interactions of these systems. Perhaps one of the
tion and therefore leads to an increase in blood most important revelations is with regard to the 'mes-
pressure. It also attempts to moderate the inflam- senger' molecules of the three systems. In the past
matory response by decreasing the production they were thought to be system specific: neuroregu-
and release of proinflammatory regulators, such as lators, hormones and immunoregulators. It is now
the interleukins (IL), interferon and tumour necro- understood that they communicate freely between
sis factor; decreases capillary permeability; and the systems via a receptor-mediated mechanism.
decreases phagocytosis by monocytes. Thus the communication is bidirectional, uniting the
As it is an fmmunoregulator, long-term high levels neuroendocrine and immune systems into one
of Cortisol will decrease antibody formation and lead incredibly complex network responsible for control-
to atrophy of the thymus gland, spleen and lymph ling and mamtaining homeostasis. Figure 6.10 is an
nodes leading to a decrease in immune response. It attempt to represent the various levels of integration
also retards connective tissue regeneration. within the neuroendocrme-immune system.
From this, it should be possible to deduce the Reactions discussed are thus a short-term coordi-
effects that this would have if a dysfunction, either nated response of the neuroendocrine-immune sys-
physical or psychological, were to chronically facili- tem to a noxious stimulus. However, there are
tate the HPA axis. The effects in extremis are situations in which the noxious stimulus persists,
demonstrated by someone suffering from Cushing's causing the short-term responses to continue longer
syndrome. Excessive action of the HPA has also than intended. This results in pathophysiological
been implicated in melancholic depression, atypi- changes and possibly pathology.
cal depression, rheumatoid arthritis and chronic It is of great interest to osteopaths, and to any
fatigue syndrome. Excessive and long-term stimu-
17
other body workers, that it is possible to demon-
lation of the LC (and by implication the LC-PVN strate that nociceptive information from somatic
axis) has been shown to be associated with depres- dysfunction will have an effect on this system. The
sion and chronic maladaptive physiological states. range of possible disease states that may be
The nervous system 129

Cortisol
Limbic forebrain

Nociception
Noradrenaline
Cortisol
Hypothalamus
LC
CRH (PVN)
CRH

Cortisol
Posterior Anterior
pituitary pituitary
Medulla
(PGi)

ACTH

Nociception
SNA

Adrenal SAM
cortex and
medulla Sympathetic supply
to lymphoid tissue

Cortisol

Cytokinins
Centripetal
Thoracolumbar
Somatic and outflow
Centrifugal
visceral Sympathelic
substance P nociception supply to the
Adrenalin + whole body
Noradrenaline

Lymphoid Visceral
organs, tissues mechanical/chemical
and cells stressor
(somatic dysfunction)

Figure 6.10 A schematic representation of the neuroendocrine-immune system.

involved with a shift in this homeostatic system is perspective, it is of interest to reflect on the anatom-
potentially great, including chronic fatigue, depres- ical position of the hypothalamus and the
sion, feelings of malaise, fibromyalgia and RA. pituitary gland. The pituitary is suspended by the
Knowing that this is the case, we have a concep- infundibulum in the sella turcica of the sphenoid.
tual model of possible aetiological, contributing and The hypothalamus forms the floor of the third ven-
maintaining factors that will form the basis of a tricle, overlying the clivus, being the posterior part
rational management plan for individuals suffering of the sphenoid, the sphenobasilar symphysis (SBS),
from such conditions. Also, from a practical and the basilar part of the occipital bone. The SBS is
130 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

very often prone to somatic dysfunction. The possi- Pain itself has an important function in alerting
ble consequences of this can be imagined, such as us to possible damage, and encouraging us to avoid
torsioning the infundibulum, or loss of the regular actions that might increase the damage. This 'physi-
'pumping' action resulting from the flexion exten- ological pain' resolves over a period of time, under
sion movements of the cranial rhythmic impulse normal conditions and with appropriate manage-
that occur at the SBS. These would affect the com- ment. Most conditions or complaints, allowing for
munication between the hypothalamus and the individual differences such as age, health state and
pituitary. It is also possible to imagine the positive environment, have a reasonably predictable dura-
benefits of techniques, such as the CV4, that aim to tion. However, with certain individuals the pain
affect the ventricular systems. does not resolve within the anticipated time, and in
The hypothalamus has numerous connections fact it may worsen. They have made the transition
with the limbic forebrain and its 'emotional' nuclei to a chronic pain state. In this state they may pres-
such as the hippocampus and the amygdala. It is ent with one or more of the following:
possible to conceive that emotional states could 9
pain in the absence of a noxious stimulus (spon-
have an effect on the hypothalamus and activate the
taneous pain)
above systems. However, this discussion will be
• increased duration of response to brief stimula-
saved for the next chapter.
tion (ongoing pain or hyperpathia)
• reduced pain threshold (allodynia)
• increased responsiveness to suprathreshold stim-
CENTRAL SENSITIZATION
ulation (hyperalgesia)
• spread of pain and hyperalgesia to uninjured tis-
In clinical practice you will always find a minority
sue (referred pain and secondary hyperalgesia). 19

of patients who do not present with clinically con-


sistent signs and symptoms: patients who complain This situation has long been recognized, but the
of pain wherever you touch them on their body, underlying mechanisms have been debated for
even with a very light touch, but physical findings more than a century. The principal argument has
do not match the reported symptoms; and others been over the role of peripheral and central neural
who will not respond as expected with their pain mechanisms in the initiation and maintenance of
perhaps lasting longer than expected, or who may these pathological conditions. It is now generally
become worse, with the pain spreading to other accepted that both have a role. 20

areas. Also, there will be numerous individuals The peripheral and central nervous systems
with chronic pain syndromes often diagnosed as become sensitized, peripheral sensitization being an
fibromyalgia, postwhiplash syndrome, chronic increase of sensitivity of nociceptive primary affer-
fatigue syndrome or similar, or perhaps they have ent neurones. Central sensitization is hyperexcitabil-
been written off as 'fat file syndrome' or malinger- ity of nociceptive neurones in the CNS.
ers. All of these individuals are very difficult to Peripheral sensitization is thought to be pro-
treat, and attempting to find a clinical rationale for duced by the action of inflammatory mediators
their management is almost impossible. such as bradykinin, prostaglandins, neuropeptides
It is possible to explain these problems in terms of and cytokines which activate corresponding recep-
central sensitization. Stated simply, this is an tors of nerve fibres. This works synergistically
21

increased excitability and responsiveness in the cen- with the action of the neurotransmitters such as
tral nociceptive pathways. It is the situation that substance P and somatostatin secreted from the
arises in states of chronic pain. An important part nerve endings, which will stimulate the release of
of the pain manifestation (e.g. tenderness and cytoldnins. 13

referred pain) related to chronic musculoskeletal dis- The mechanism behind central sensitization is
orders may result from peripheral and central sensi- not so clearly understood. Some of the currently
tization. As with any concept it is almost certainly
18
accepted theories are briefly discussed below.
only part of the answer; however, an understanding
of central sensitization will enable you to develop a PROLONGED OPENING OF N M D A RECEPTORS
management plan based on rational theory, and
through more effective treatment, give some relief The significant role of N-methyl-d-aspartate (NMDA)
to these long-suffering individuals. receptors and the production of nitric oxide (NO) in
The nervous system 131

central sensitization, hyperalgesia and chronic pain patterns of pain presentation that differ from those
has often been demonstrated. Blockade of the
22
expected from the standard dermatomal or
NMDA receptors prevents and reduces central sensi- myotomal distributions. The potential for such
tization. It is thought that an abnormally high trans-
21
neural plasticity is demonstrated at both the
mission of C fibre inputs leads to high levels of peripheral and central elements of the nervous
glutamate in the synaptic cleft. These eventually system. 23

cause the postsynaptic NMDA receptors to open,


permitting an influx of calcium into the neurone. This CORTICAL MODULATION
is further exacerbated by NO stimulating more trans-
mitter release. This will have a progressive effect on Nociceptive input into the CNS is not simply pas-
other neurones in the dorsal horn locally and via the sively received but rather is subject to modulation
numerous synaptic interconnections, and sensitiza- through spinal cord neuroplasticity and descend-
tion has begun. 23
ing influences from supraspinal sites activated by a
variety of environmental signals, including the
CYTOKINE A C T I O N ON THE CNS acute or persistent nociceptive input itself and
behavioural and emotional stimuli. 22

The action of the cytokines, particularly the inter- Cortical modulation has a significant effect on
leukins and tumour necrosis factor, on the CNS is the way that pain is perceived, and it is known that
another possibility. As mentioned earlier, they the effects created by this modulation can lead to
are produced at the site of tissue damage, and the same type of changes as those found in central-
appear, in certain situations, to be able to cross the ized sensitization. Often called 'gating', the corti-
blood-brain barrier where they have a part to play cal control has both facilitatory and inhibitory
in centralized sensitization. They are also responsi- influences from supraspinal sites. The descending
ble for producing the 'malaise' type symptoms facilitatory influences possibly account for second-
associated with disease and injury that are often ary hyperalgesia, the hyperalgesia observed in
part of the chronic pain pattern. A review of recent uninjured tissue, distant from the site of insult. The
research in this area is to be found in LR Watkins inhibitory effect may be used to block certain areas
and SF Maier's article 'The pain of being sick: of receptivity, thus making those not blocked pro-
implications of immune-to-brain communication portionately more reactive - thus, in effect, having
for understanding pain'. 24
an excitatory effect on those not blocked. An
extreme example of a purely inhibitory effect on
NEURAL PLASTICITY the ascending information is illustrated by stories
of farmers having cut their arm off, calmly heaving
Another area possibly involved in centralized sen- it onto their shoulders and walking to the hospital
sitization is the concept of neural plasticity. The to have it sewn back on. This type of inhibitory
nervous system has an ability to change in pain gating can also be provoked consciously in
response to its environment; without this we methods such as biofeedback techniques of pain
control.
would not be able to learn. Pain perception has tra-
ditionally been perceived as a 'hard wired' system Research is rapidly progressing and will 'firm
in which a receptor is stimulated by a noxious trig- up' our understanding of the underlying processes
ger, causing an impulse to pass into the CNS of sensitization. Perhaps most importantly, from an
where it may elicit a spinal response (reflex arc), or osteopathic viewpoint, it is necessary to be able to
be passed via specific ascending tracts to the rele- observe the signs in your patients that will lead
vant area of the cortex for interpretation. It is now you to suspect that this process is happening, i.e.
being realized that this is not the case, and that the that the patient is passing from acute to chronic
structures of these pain pathways are very diffuse pain presentation. It goes without saying that it is
and changeable. It has also been demonstrated that better to prevent this occurring, than to attempt to
the receptive field (i.e. those areas of the brain that treat the chronic problem. David Butler details
23

are the receiving areas for the afferent information) some of the key features that would make a practi-
will change in response to even relatively small tioner suspect that this process may be occurring;
changes in the afferent input. This will lead to
25 as it is difficult to improve on his descriptions,
new ways of the CNS perceiving pain, resulting in these will be quoted at length:
132 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Area and description • It could be that every movement hurts, yet there
may be no great range of movement loss. These
The following pain areas, descriptions and clinical patients are often labelled as 'irritable' or
scenarios may relate to central sensitivity: 'unstable'. I believe that it is more likely that
• Symptoms are often not within neat anatomical or patients present with instability of symptoms
dermatomal boundaries. rather than instability of structure. In routine
• Any original pain may have spread. physical examination, such as a straight leg raise,
• In the case of multiple area symptoms, pains may a patient may complain of pain, yet you, the
be linked, in that they either occur together, or the therapist, may feel no resistance. It is as though
patient has one pain or the other pain. the movement has touched a memory rather than
• The contralateral side to the initial pain may be a damaged tissue.
painful, though rarely as much as the initially • Patients may say 'it hurts when I think about it'.
injured side. There can be mirror pains, which
are hard to explain in terms of primary Other features
hyperalgesia.
• Clinicians may 'chase the pain'. This is a common There are other features which could be a part of a
practice in manual therapy. For example, back central sensitivity pattern:
pains may ease but then the patient complains of • These pains can be cyclical, with perhaps more in
thoracic pains. It is almost as though the pain winter, and perhaps at anniversaries or reminders
processing networks need to include a somatic of traumatic times in life.
component. • With the CNS dysregulation, changes in response
• There could be unexpected sudden stabs of pain. and background homeostatic systems such as the
• Patients may say 'it has a mind of its own'. The autonomic, endocrine, motor and immune systems
pain is called 'it', suggesting that it has lost the neat are likely. Sometimes these responses may be overt
stimulus-response relationships of familiar, and to in some systems, for example, focal dystonias of the
the patient, understandable tissue-based pains. hand in musicians, central contributions to
complex regional pain syndromes (CRTS), or
Behaviour sickness responses in the case of the immune
system.
The behaviour of the pain state may provide clues to
• There may be links to traumatic and multiple
a central mechanism. For example:
traumatic events in life. These events could be
• The perception of pain is ongoing. If pain persists during childhood or around the injury time.
past known healing times of tissues and a • This state may be associated ivith anxiety and
comprehensive subjective evaluation reveals no depression.
occupational provocation, disease or other reason ' 'Miracle cures' are possible. Every clinician has
for pain maintenance, then a central mechanism hopefully had a 'miracle' in the clinic. If there is
could be suspected. sudden, dramatic and apparently miraculous relief
• Summation. A number of repeated similar of severe and long-lasting symptoms from little
activities evoke pain, for example, using a input, then the pathobiological mechanisms are
computer, an exercise bike, or interpreters using unlikely to be from local tissues. Miracles are
sign language. great, but they are even better if you have some
' The stimulus/response relationship is distorted. idea of why they happened. It is more likely a
The pain state worsens or is evoked at variable central change involving some alteration in
times after the input. This could be after 10 sec- cognitions and emotions.
onds or even after a day or so. Most clinicians are • Central sensitivity is likely to be involved in
familiar with the often uncomfortable situation syndromes such as fibromyalgia, myofascial
where they examine a patient and then pain starts syndrome, reflex sympathetic dystrophy, chronic
a short time after the examination. low back pain and post-whiplash pain syndromes,
• Responses to treatment and input are unpre- in fact anywhere pain persists or the word
dictable. What may appear a successful treatment 'syndrome' is paired with a part of the anatomy.
technique one day may not be successful the next. • The cortical modulation, or put another way,
There is a pattern though, where traditional psycho-emotional and psychosocial factors, have
manual therapy may help for a day or two, but been shown to have a correlation with the develop-
then symptoms invariably return. ment of chronic pain patterns. The New Zealand
The nervous system 133

government have published a list of psychosocial segments or the various 'tender points'. These have
factors that have been shown to be involved in this a role in both diagnosis and treatment. Once again
process. They termed these factors 'yellow flags' (to it is necessary to remember that they are in fact
contrast with the pathological 'red flags'). Put sim- branches of a reflex arc, and as such are mutually
ply, the more yellow flags present, the greater the dependent. Should a somaticovisceral problem
chance of that individual developing chronic pain. have been present for more than a few weeks, and
only the somatic element be resolved with treat-
These 'yellow flags' are covered in the next chapter. ment, it is probable that the visceral branch will
From this it is possible to see that the clinical reinstate the original dysfunction but now as a
presentation can be varied, complex and above all viscerosomatic reflex.
confusing. In the past these patients may have been Korr's concept of the neurophysiological basis of
termed malingerers, or worse. It is also clear that the osteopathic lesion is essentially based on the
individuals suffering from this condition will aberrant bombardment of the spinal segment from
require an holistic approach, possibly involving the proprioceptors disturbed by the somatic dys-
appropriate referral to other practitioners. From a function. This increase in neural input causes facili-
patient's perspective, just the reassurance that they tation at the affected spinal segment, making it
are not going mad and that there is a scientific proportionately more easily excitable. As such it
rationale for the problems that they are experienc- acts as a 'neurological lens', focusing passing neural
ing can go a long way towards resolving them. activity onto that segment, causing it to respond
where other less facilitated segments are unaffected.
All elements supplied by that segment, be they
SUMMARY AND CONCLUSION somatic or visceral, myotome, sclerotome, viscero-
tome or associated connective tissues, will be sub-
This chapter has attempted to explore some of the ject to the same degree of change in their levels of
more fundamental neurological concepts that under- activity. It is possible to anticipate the changes that
pin our understanding of osteopathy. The discussion may be occurring in a viscus by assessing its related
started by looking at the most simple of the reflex dermatome. If the dermatome is showing signs of
arcs, and attempted to model somatic dysfunction chronic changes it would be logical to assume that
on a monosynaptic reflex. It is clear that no dysfunc- the associated viscera will similarly exhibit chronic
tion is really that simple; however, the principle of changes.
this simple model does hold true, and it almost acts Van Buskirk proposed a nociceptive mechanism
as a foundation upon which can be loaded the pro- rather than a proprioceptive one for the generation
gressively more sophisticated models. The polysy- of the aberrant input. He additionally incorporates
naptic models, that involve complex harmonious the interplay of the nervous system and immune
function, requiring simultaneous inhibition of cer- system in the generation of local tissue changes. The
tain areas and excitation of others, are in effect just more recent research on the neuroendocrine-
more complicated versions of the basic model. An immune system reveals that what previously were
awareness of how they function will enable you to thought to be three independent systems are in fact
manipulate them to achieve the desired effect. For one complex interacting system communicating
example, if an individual had a very contracted and bidirectionally at all levels of organization. This fur-
acutely painful biceps, which was in fact too painful ther supports Van Buskirk's model of somatic dys-
to address directly, it would be possible to address function by demonstrating that a nociceptive input
its antagonist, the triceps, and by stimulating it to can have a role in activating the various systems
contract, cause an inhibitory reflex to pass to the responsible for maintaining homeostasis, particu-
biceps and cause some degree of relaxation. larly the HPA, SNA and SAM. This can supply a
The visceral and somatic systems were shown to rationale for the more complex systemic presenta-
work in a coordinated manner, with the afferent tions that appear to arise as a result of dysfunction.
information from both sources synapsing with mul- Central sensitization, without wanting to belittle
tireceptive WDR neurones, with problems arising it, is essentially central facilitation, a concept that is
in one system causing reflections in the other. It is not difficult for an osteopath to grasp. Though the
through this that we can read visceral dysfunction determining physiology is very complex, from a
in the soma, via either the metamerically organized practical sense, there are psychosocial features and
134 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

physical features that may indicate the possibility plan addressing the physical and emotional ele-
that a patient is passing to a more chronic pain ments of the problem with respect to that particular
state. Awareness of these factors will enable you to individual.
try and assist the patient, with the aim of prevent- The role of the psyche in many of the more
ing them from moving from the reversible acute recent concepts is very apparent. This area of study
state to the much more fixed chronic condition. is vast, and even if dealt with in a most superficial
Little attempt has been made to discuss specific way demands a separate chapter. This is purely an
osteopathic rationale for addressing these problems. attempt to keep the material as unambiguous and
They could be approached in an infinitely varied understandable as possible. In reality they are
number of ways, and it is thought that with a thor- inseparable, as in fact are most elements discussed
ough knowledge of both the concepts discussed within this book, and you are strongly urged to
above, and neuroanatomy and physiology, it would reunite them in a manner that enables you to apply
be possible to devise an appropriate management them as a whole within the clinical environment.

References
1. Sherrington CS. The integrative action of the nervous sys- 12. Korr IM. Sustained sympatheticotonia as a factor in dis-
tem. London: Constable; 1911. ease. In: Korr IM, ed. The neurobiology mechanisms in
2. Educational Council on Osteopathic Principles. Glossary manipulative therapy. New York: Pleniun Press; 1978:
of osteopathic terminology. Chicago: American 229-268.
Association of Colleges of Osteopathic Medicine; 2002. 13. Van Buskirk RL. Nociceptive reflexes and the somatic
3. Head H. On disturbances of sensation with especial refer- dysfunction: a model. JAOA 1990; 90(9):792-809
ence to the pain of visceral disease. Brain 1893; 16:1-13. 14. Watkins A, ed. Mind body medicine. New York:
4. Downing CH. Principles and practice of osteopathy. Churchill Livingstone; 1997: 6.
London: Tamor Pierston; 1981. 15. Selye H. The Stress of Life. New York: McGraw-Hill; 1976.
5. DeGroat WC. Spinal cord processing of visceral and 16. AstonTones G, Valentino RJ, Van Bockstaele E et al. Brain
somatic nociceptive input. In: Willard F H, Patterson MM, noradrenergic neurons, nociception and stress: Basic
eds. Nocioception and the neuroendocrine-immune con- mechanisms and clinical applications. In: Willard FH,
nection. Indianapolis: American Academy of Osteopathy; Patterson MM, eds. Nocioception and the neuro-
1994: 47-72. endocrine-immune connection. Athens: University
6. Patterson MM, Wurster RD. Neurophysiologic system: Classics; 1994:107-147.
integration and disintegration. In: Ward RC, ed. 17. Gold P. Neurobiology of stress. In: Willard FH, Patterson
Foundations for osteopathic medicine. Baltimore: MM, eds. Nocioception and the neuroendocrine-immune
Williams and Wilkins; 1997. connection. Athens: University Classics; 1994: 4-17.
7. Loeser JD, Butler SH, Chapman R et al, eds. Bonica's man- 18. Arendt-Nielsen L, Graven-Nielsen T. Central sensitization
agement of pain, 3rd edn. Baltimore: Lippincott, Williams in fibromyalgia and other musculoskeletal disorders. Curr
and Wilkins; 2001. Pain Headache Rep 2003; 7(5):355-361.
8. Korr EVI. The neural basis of the osteopathic lesion. In: 19. Coderre 17, Katz J. Peripheral and central hyperexcitabil-
Peterson B, ed. The collected papers of Irvin M. Korr. ity: Differential signs and symptoms in persistent pain.
Newark: American Academy of Osteopathy; 1979: Behav and Brain Sci 1997; 20(3):404-419.
120-127. 20. Urban MO, Gebhart GF. Supraspinal contributions to
9. Korr TM, Thomas PE, Wright HM. Patterns of electrical hyperalgesia. Proc Natl Acad Sci USA 1999;
skin resistance in man. In: Peterson B, ed. The coDected 96(14):7687-7692.
papers of Irvin M. Korr. Newark: American Academy of 21. Schaible HG, Ebersberger A, Von Banchet GS.
Osteopathy; 1979: 33-40. Mechanisms of pain in arthritis. Ann N Y Acad Sci 2002;
10. Korr IM, Wright HM,Thomas PE. Effects of experimental 966:343-354.
myofascial insults on cutaneous patterns of sympathetic 22. Urban MO, Gebhart GF. Central mechanisms in pain.
activity in man. In: Peterson B, ed. The collected papers of Med Clin North Am 1999; 83(3)585-596.
Irvin M. Korr. Newark: American Academy of 23. Butler DS. The sensitive nervous system.Australia:
Osteopathy; 1979: 54-65. Noigroup Publications; 2000.
11. Korr IM, Wright HM, Chace JA. Cutaneous patterns of 24. Watkins LR, Maier SF. The pain of being sick: implica-
sympathetic activity in clinical abnormalities of the mus- tions of immune-to-brain communication for understand-
culoskeletal system. In: Peterson B, ed. The collected ing pain. Annu Rev Psychol 2000;51:29-57.
papers of Irvin M. Korr. Newark: American Academy of 25. Harman K. Neuroplasticity and the development of per-
Osteopathy; 1979: 66-72. sistent pain. Physiotherapy Canada 2000; Winter:64-71.
The nervous system 135

Recommended reading Irvin M Korr, vol 1. Newark: American Academy of 


Osteopathy; 1979. 
Butler DS. The sensitive nervous system. Australia: 
Noigroup Publications; 2000. 
This is a superb book, taking you through some of the more recent  King HH, ed. The collected papers of Irvin M Korr, vol 2. 
advances in neurology and neurophysiology in an immediately  Colorado: American Academy of Osteopathy; 1997. 
understandable way. It is also written for manual therapists. This  Korrʹs collected works cover some of the most significant 
is a must to read. Peterson B, ed. The collected papers of  studies in the neural basis of osteopathic medicine. These are 
still very relevant. 
 
Page Intentionally Left Blank
137

Chapter 7

Psychological considerations

INTRODUCTION
CHAPTER CONTENTS

Introduction 137 The mind is known to have quite dramatic effects


Psychosomatic concepts 138 on the body. Reflect on someone that is suddenly
Psychoanalysis and the roots of psychodynamics very frightened: they become pale in the face, their
hands sweat and body hair is raised. A depressed
and mind-body work 139
person is often noticeable by their habitus. They
Homeostasis, the effect of the environment,
have a stooped posture with rounded shoulders,
and stress 141
lowered head, and even their physiological pro-
Psychosocial factors helping to identify risk cesses are slowed. Anxiety gives one 'butterflies in
factors that increase the probability of the stomach', and if sustained is contributory to
long-term disability 147 gastric ulceration. These are all examples of psycho-
The osteopathic consequences 149 somatic problems. In our current society the emo-
Psychoneuroimmunology 150 tional demands are great, and it is rare to meet
The physical expression of emotion in the someone unaffected by these stresses and, logically,
body 153 the somatic consequences. It is interesting to note
Emotional anatomy 154 how many emotions we describe in terms of somatic
Some osteopathic empirical mind-body sensations ('gut reaction', 'butterflies', 'visceral'
concepts 155 response, 'in the pit of my stomach').
Conclusion 156 We are aware of many of these responses intu-
References 157 itively. We can recognize them within ourselves,
Recommended reading 158 and, perhaps more importantly, observe them in
others. These easily observable features have inter-
ested philosophers and scientists alike since ancient
times, for example Hippocrates (460-355 BC) and his
followers based their understanding on the balance
or predominance of the four 'humors': black bile,
yellow bile, phlegm and blood. Excess of any would
lead to emotional changes hence:

• Melancholic (melas khole is Greek for black bile) -


depressed, sad and brooding.
• Choleric (khole is Greek for bile) - changeable,
quick to react and irritable.
• Phlegmatic (phlegma is Latin for lymph) - slow
moving, apathetic and sluggish.
138 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

• Sanguine (sanguis is Latin for blood) - warm, will conclude with a look at some of the mind-body
pleasant, active and enthusiastic. approaches and their interpretation of disease.
Juvenal (60-140 AD), the Roman satirist, coined the
phrase 'mens sana in corpore sano', a sound mind in a
PSYCHOSOMATIC CONCEPTS
sound body. Littlejohn had similar views:
we realise the fact that [the] mind is the ascendant Within this discussion the term psychosomatic will
power and that in a healthy physiological life nothing be used in its broadest sense (and almost certainly
less than a healthy mind can secure that vigorous with opprobrium from certain quarters) for the
condition of body which is so much desired by all, relationship between the mind and body. The term
health and happiness. We must realise that while we psychosomatic was first utilized in 1818 by the
treat what seems to be purely body diseases, we must German psychiatrist Heinroth, but it was not until
2

not overlook the fact that psychopathy opens up the


1935 that it was used in its now generally accepted
field of mental disease and reveals certain mind
form, appearing in HF Dunbar's publication Bodily
conditions without the removal of which it is
impossible to cure bodily diseases.
1
Changes: A Survey of Literature on Psychosomatic
Interrelationships: 1910-1933?
However, with the progress of science, there has Taber's Medical Dictionary defines psychosomatic
been a trend to separate the mind from the body. as: 'Pertaining to the relationship of the mind and
Descartes (1596-1650) is the individual usually cited body'. It continues with a brief discussion on one of
as being responsible for separating the mind from the key problems within this area of study:
the body. He envisaged the body as a mechanical
structure able to function in a manner similar to Disorders that have a physiological component but are
some large mechanical manikins that he had thought to originate in the emotional state of the patient
observed, independent of the mind. This division is are termed psychosomatic. When so used the impres-
termed 'Cartesian dualism' and has exerted a pro- sion is created that the mind and body are separate enti-
found influence on the understanding and practice ties and that a disease may be purely somatic in its
effect or entirely emotional. This partitioning of the
of healthcare until very recent times.
human being is not possible; thus no disease is limited
However, it would appear that recently, health- to only the mind or the body. A complex interaction is
care generally has been undergoing a slow but always present even though in specific instances a dis-
steady revolution. The Cartesian reductionist ease might on superficial examination appear to involve
approach is being challenged, and the body systems only the body or the mind.
are being 'put back together again'; hence the adop-
tion of such terms as the neuromusculoskeletal sys- All of the concepts discussed below could be con-
tem, and the neuroendocrine-immune system. ceived as elements of psychosomatic medicine, or
Interest in the role of the psyche has persisted, perhaps more importantly the psychological mod-
even during the apparently reductionist and dualist elling of the holistic continuum that defines health
period of history. As one can imagine there are as and disease.
many theories as there are interested people. In this There is a vast array of psychological concepts
chapter, the role that the psyche plays in these that have a relevance to psychosomatic medicine.
processes will be addressed. We will initially look at In an attempt to simplify this, three major concep-
some of the earlier and often more empirical mod- tual shifts have been recognized, each having appli-
els, then explore some of the key concepts of the cations within the osteopathic paradigm:
emerging science of psychoneuroimmunology. This
study is beginning to find rational explanations for 1. The psychoanalytic and psychodynamic models
those long observed phenomena relating stress to that originated in the work of Sigmund Freud
illness. The physiological processes behind it are from 1895, and which were later modified and
understandably horrendously complicated and as related directly to the body by the somewhat
yet not fully understood, but the results so far offer eccentric Wilhelm Reich. These have continued
very tempting insights into the human condition. to be developed and variations of these concepts
Osteopathy, as one of the many holistic approaches are applied currently.
to health, is ideally suited to finding an application 2. From the 1950s onwards there was a shift to
for these new and exciting discoveries. This chapter more holistic models, looking at the changes the
Psychological considerations 139

body makes in response to its environment. This be of interest and possible benefit to an osteopath -
was rooted in the earlier work of Walter Cannon however, there are also numerous excellent texts
on homeostasis, and the then current work of available on his work so this chapter will briefly
Hans Selye and the General Adaptation look at Freud's view on personality as his terms are
Syndrome (GAS). External/environmental fea- used regularly within many of the mind/body
tures became more important, leading to a more approaches.
psychosocial concept of health.
3. The most recent shift has occurred in the last THE P S Y C H O D Y N A M I C MODEL OF
20 years. It has been supported by the rapid PERSONALITY
advances in technology permitting a more accu-
rate assessment of the brain and its physiological Freud's view of personality was that it was com-
responses. This has led to new areas of study: prised of three interacting parts: the id, the super-
psychoneuroimmunology (PNI) and neuroim- ego and the ego.
munomodulation (NIM). Even though this is
delving ever deeper into the brain, far from T h e id
being a reductionist approach, it is reuniting the This is the totally subconscious element. It is present
mind and body and offering physiological find- from birth and strives for immediate gratification of
ings to account for the previously inexplicable. basic drives, such as thirst, hunger and desire for
The model has returned to a more holistic per- sex. It cannot distinguish reality from fantasy.
spective and a biopsychosocial outlook.
T h e superego
The aim of this is chapter not to encourage you to
This is often viewed as the opposite to the id. This is
become psychologists, but just by touching the sur-
the moralist attempting to curb the 'gratification at
face of psychosomatic medicine to expose you to a
all costs' id. Part conscious and part subconscious, it
few different perspectives on health and disease that
tries to enforce the moral dictates of society, social
may have a relevance to you in your clinical practice.
grouping or family. It is often in conflict with the id.

T h e ego
PSYCHOANALYSIS AND THE ROOTS OF This is the part that has to mediate between the con-
PSYCHODYNAMICS AND MIND-BODY flicting id and superego, and function on a con-
WORK scious level in the actual world. It provides the
sense of self, it is the integrator of personality. Due
Sigmund Freud (1856-1939), the Austrian psychia- to the conflict within the ego's role, Freud's model
trist, is the founding father of psychoanalysis. The of personality accepts that conflict is a fact of life in
foundations were laid in 1895 with the publication personality.
by Freud and Breuer of Studies on Hysteria. This
4
The different roles are well illustrated by the fol-
theorized that the symptoms of hysteria derive from lowing example:
the suppression and repression of painful or other-
a teenage boy sees an exotic sports car sitting parked,
wise emotionally disturbing memories, often of
with the keys visible 'within. Id will see an opportunity
events that had occurred in early childhood. These
to race around in a fast and powerful vehicle. Superego
have subsequently manifested themselves in the
will insist that such behaviour would be stealing, and
soma, a process they called 'conversion'. is morally wrong. Ego may note that people are walk-
From these roots, psychoanalysis developed, ing on the street, and therefore the chances of getting
analysing many somatic problems from an uncon- caught are very high. Tims, in this case, the outcome
scious emotional level, thus laying the groundwork would probably be not to steal the car.5

for psychosomatic medicine. The broader applica-


tion of these concepts became known as psycho- We will see later that the biodynamic model
dynamics, and can be defined as a study of the applies these three elements of personality to the
interrelationship and actions of the various parts of body.
the mind, personality and motivations. Another significant individual at this time was
There are so many aspects of Freud's work, and Wilhelm Reich (1897-1957), also Austrian, who is
the later Neo Freudian psychodynamics, that would said to have worked with Freud. He made a radical
140 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

departure from the basic principles of classical itself in chronically tense muscles. The 'muscular
7

psychoanalysis; he attempted to relate significant armouring' or chronic muscular tension impedes


psychological events to patterns of responses within the flow of body fluids and energy.
the body, addressing them with actual physical con- Reich's work has fostered numerous mind-body
tact with the patient. In view of his obvious signifi- practices:
cance in the field of mind-body work we will look
at his earlier concepts in some depth. • Gerda Boyesen (Biodynamic)
• David Boadella (Biosynthesis)
• Alexander Lowen and John Pierrakos (Bioener-
W I L H E L M REICH (1897-1957)
getics)
• Stanley Kelman (Emotional Anatomy)
Wilhelm Reich, a psychiatrist and a sexologist, is
• Ron Kurtz (Hakomi)
often cited as the founder of mind-body work. In
• Ida Rolf (Rolfing)
his early years he worked closely with Sigmund
Freud, and he was undoubtedly influenced by • Jack Rosenberg (Gestalt Body Psychotherapy)
Freud's theories but he developed them in a radi- • Mosche Feldenkrais (Feldenkrais method)
cally different way. He developed an approach that ... to mention just a few of the more well-known
incorporated somatic, neuromuscular aspects and ones. 8

psychoanalysis; this eventually was termed Orgone The biodynamic model has some interesting
Therapy. Fundamental to this approach was the osteopathic parallels in its modelling of the body.
idea that a natural energy flowed through the body. Amongst other concepts it utilizes Freud's id, ego
He called this energy Orgone (this may have a par- and superego and relates them to the body. The
allel in chi, the CRI, prana, etc.). Orgone could be 'motoric ego' acts almost as the structural aspect of
blocked at various points, often as a response to the ego, which is the regulator of the antisocial id. It
some trauma or suppressed impulse or emotion. is horizontally organized and it is related to the
A typical example could be a child's habitual inhi- ability to translate ideas into action, to interacting in
bition of impulses and expressions of feeling that and with the world. The muscles can function to
arise from being in a difficult or unpleasant situa- act, to hold back, to express, to repress. In them we
tion, such as when exposed to the disapproval of can interject parental models, prohibitions and cul-
its parents. The child learns to tense the muscles to tural styles as unconscious identifications with the
hold back the movement or feeling. When this is body attitudes and postures of others. Where we
done repeatedly, the muscular holding pattern are in harmony with ourselves, the muscles can
becomes chronic and unconscious. This would then embody grace, physical skills and vitality. When we
become part of the child's character and structure. 6
are in conflict, this is directly reflected in patterns of
Within this structure there would be palpable muscular tension as the different impulses and inhi-
changes, often hypertonic, but also hypotonic. The bitions pull against each other. Chronic conflict
areas of muscle rigidity became known as muscular reduces blood flow and creates the hardening and
'armour'. This is the somatic equivalent of the ego's fixedness of muscle tension we call armour. Also 6

binding of unacceptable impulses. Release of these recognized in the biodynamic model is the alimen-
restrictions by bodywork, which for Reich would tary canal or 'id-canal'; vertically organized, it is the
involve working with the somatic and the psycho- instinctual force of feeling and impulse. This repre-
logical systems simultaneously, would release this sents our visceral sensation; much emotion is
energy and result in a greater structural and emo- expressed or repressed in the viscera, a point that is
tional harmony. worth being aware of when addressing the viscera
with any body work.
Reich recognized the importance of the ANS act-
ing as an interface for bodily and emotional There are some osteopathic models that, though
processes. It is directly involved with the functions not perhaps directly influenced by Reich, echo some
of the internal organs, but it also serves as a mes- of his concepts. However, many individuals do not
senger for emotional perception via blood and like having their approaches likened to Reich's work.
plasma streams, and is linked to the cerebral areas His methods of application were often fairly strong
which represent emotion through connections in and imposing. With most of the patient-centred
the CNS. Impaired function of the ANS, via the cen- practices, including the indirect and biodynamic
tral connections with the WDR neurones, manifests approaches in osteopathy, they are non-imposing,
Psychological considerations 141

perrmtting space for the vital force, breath of life, etc. immobility and lack of flexibility. It mirrors an inner
to create the change. Also it is principally his early state of mind which requires 'backbone'.
work that the approaches are based on, not the Aggressions, especially kicking impulses, are
whole oeuvre. However, the caveat having been frequently suppressed in the lower back. Moreover,
stated, there are areas of similarity between these the back stands for support in life: a lack of necessary
early Reichian concepts and the biodynamic work of 'backing' results in back pain. Fear of softness and
Jim Jealous and Rollin Becker, and the work of surrender lead to tension in the lumbar region: the
Robert Fulford, and from the muscular guarding hollow back lessens the pelvis' mobility, and with it
aspect, Philip Latey (see the recommended reading the experiencing of sexual pleasure. 10

at the end of this chapter for references). When confronted with material like this many
students either laugh at it or disregard it. This is
A P S Y C H O D Y N A M I C A N D A BIOENERGETIC very easy to understand, as both descriptions are
INTERPRETATION OF LOW BACK ACHE couched in unfamiliar terminology, and discuss
concepts that may at first appear strange, such as a
To illustrate the way that these models may be child offering his 'gift of faeces'. Also there is a ten-
applied to something that is commonly seen in dency now to think that Freudian concepts are no
osteopathic practice, there follow two examples of longer valid, especially as there is a discussion
the possible interpretations of low back pain, firstly about the possibility of his falsifying some of his
from a psychodynamic perspective and then a research. This, however, is throwing the baby out
bioenergetic view. with the bath water; his research methods may have
Dave Heath, an osteopath, explains lower back- been dubious but his concepts are still strikingly
ache from a psychodynamic perspective: original and have been applied for a century to
good effect. We also have a tendency to analyse
Examination of these patients usually identifies tense things from an adult perspective (not surprisingly),
muscles in the region of the lower back, pelvis, and so the 'gift of faeces' appears laughable. However,
thighs. Additionally, many of them have concomitant
that child is offering something of himself, and it
bowel dysfunction such as constipation or irritable
has been rejected, and sometimes with apparent
bowel syndrome. A common pattern with many of
revulsion. Imagine the hurt.
these patients is that they give a lot of themselves
sometimes to the point of feeling resentful, their It is interesting to reflect on where frustrations
problem being a difficulty in striking a balance and emotional hurt do 'go'. Most people are aware
between pleasing themselves versus pleasing others. of tension going to their shoulder muscles when
Looked at in Psychodynamic terms the production of they are stressed, or can tell by the set of someone's
muscular tensions in the lumbo-pelvic area can relate jaw that they are angry. But we often do not
to the anal stage of development; much of the dynam- look beyond these obvious areas. Philip Latey - 10 11

ics of this stage being about battles of wills. This stage explores the role of muscles as sensory organs from
is typified by toilet training when the child can offer a very pragmatic and jargon-free perspective. He
his gift of faeces of which he may be proud or ashamed, considers the changes that may occur within mus-
dependent on the parent's reaction to it. He can also cles as a result of trauma, both physical and emo-
learn that he can not only exercise self-control but
tional, and offers an insight to how to approach
control over the parent by withholding of his product
them. His work is briefly discussed later in the
through the tensing of anal sphincter and pelvic
chapter. These concepts do, however, permit one to
muscles. I think with some of this patient group an
look at the interplay of suppressed emotions, often
eruption of pain results from an archaic protest of
withholding leading to increased tonus in already taut from the early stages of life, and the possible
muscles and a likely explanation for bowel symptoms somatic concepts that may arise from this.
that sometimes coincide with lower back pain?

Contrast that with Heike Buhl's bioenergetic HOMEOSTASIS, THE EFFECT OF THE
interpretation. E N V I R O N M E N T , A N D STRESS
The expression 'holding back' demonstrates the
correlation between a muscular 'holding of the back' By the 1950s attitudes began to shift away from the
and the restraint on the emotional level. An somewhat introspective position of the psychoana-
immobile spinal column can be a sign for mental lytic or psychodynamic models, toward more out-
142 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

ward looking approaches, emphasizing objective • vasoconstriction in the skin and certain visceral
observation and experiments. It is possible to trace blood vessels
the ideas of keeping physiological processes within • increased activity in the liver
normal limits back to the 19th century when Claude • decreased salivary production
Bernard spoke of 'The ability of living beings to • decreased enzymatic activity in the gut
maintain the constancy of their internal milieu'. In 12
• contraction of the spleen.
the early 20th century, Walter B Cannon (1871-1945)
This series of actions flows into the resistance phase
proposed the idea of 'homeostasis' and described the
which is an adaptation to the stressor, where, in
'fight or flight response' initiated by the sympathetic
addition, the following processes begin:
nervous system mobilizing the body, preparing it to
respond to any real or perceived threat. He also 13
• Increased nervous activity in the hypothalamus
apparently coined the much less used phrase 'rest leads to an increase in the output of various hor-
and digest' as the opposite process overseen by the mones within the body, e.g. corticotropin-releas-
parasympathetic nervous system, replenishing its ing factor (CRF), adrenocorticotropin hormone
stores of energy when no threat is present. 14
(ACTH), growth hormone-releasing hormone
Then in 1936 a Viennese physiologist named (GHRH), and thyroid-releasing hormone (TRH).
Hans Selye coined the term 'stress' and eventually • This may lead to diseases of adaptation in the
became known as the 'father of stress'. Selye noted form of hypertension, ulcers, impaired immune
that the stressors, as he called them, may be bio- function and asthma.
chemical, physical or psychological in origin and he Finally, the exhaustion phase may occur, in which
proposed the General Adaptation Syndrome (GAS) the body's resources become further compromised
as the body's way of reacting to the stressor, irre- and the ability to resist further may collapse, result-
spective of its origin. 15
ing in disease or death. Symptoms include:
The GAS was described as consisting of three
phases (alarm, resistance/adaptive and exhaustion) • decreased potassium in the blood: aldosterone
that formed a continuum, which to a certain extent, retains sodium in exchange for potassium and
at least in the first two stages, is reversible. See hydrogen ions;
Figure 7.1. • depletion of glucocorticoids;
According to Selye, during the alarm phase, the • over-activity of the cardiac vasculature and of the
body is mobilized in order to defend itself against adrenal cortex;
the stressor and there is high arousal. The physio- • immunosupression and poor wound healing.
logical processes include: If the end result is death, it would at first glance
appear that this is not a very useful defensive action
• increased cardiac rate and output
to utilize! However, this is essentially a short-to-
• increased respiratory rate
medium term process enabling the body to resist or
avoid threats. The alarm phase responds to imme-
diate threats and when these have passed, allows
the body to return to its natural harmony. The
Resistance resistance phase attempts to moderate the effects of
longer-lasting threats, a sort of 'damage limitation'
stage which, if successful, as with the alarm phase,
will then permit the body to return to its normal
Alarm Exhaustion balance. The exhaustion stage occurs when the
body has been unable to resolve the threat and
Normal resistance therefore represents the end stage and failure of this
level homeostatic mechanism.
At this point it would be of benefit to reflect
back on the general adaptive response (GAR) and
its mediating elements, the hypothalamic-pitu-
Figure 7.1 A schematic representation of Selye's General itary-adrenal (HPA), sympathetic adrenal axis
Adaptation Syndrome. (Modified after Selye H. The stress of life. (SAM) and sympathetic neural axis (SNA), which
New York: McGraw-Hill; 1976.) were discussed in the previous chapter. It can be
Psychological considerations 143

seen that the alarm stage of the GAS is, in essence, body itself will then perhaps be able be restore
the fight and flight response governed principally homeostasis and enable the patient to pass back to
by SAM and SNA. In the resistance stage the HPA normal healthy function, whereas without this
axis becomes the primary system. The GAS is thus Tightening' the sheer load would make that an
a model of the effects that may arise as a result of impossibility.
protracted stressors affecting the hypothalamus via Tom Dummer related the GAS concept to possi-
its many and varied connections, and its actions in ble findings in the body that would perhaps be
activating and perpetuating the action of the HPA, more immediately observable in the musculoskele-
SAM and SNA. tal system (Table 7.1).
This triphasic general adaptation syndrome can It should perhaps be pointed out at this stage
also be perceived as representing the continuum that not all stress is detrimental. Selye used the term
of normal physiology, through pathophysiology 'eustress' for stressors that are of benefit. Without
and on to abnormal pathology (see Fig. 7.2). In the some level of stress it is unlikely that many of us
right circumstances, whether by the body's intrin- would achieve as much as we do. Our experience of
sic self-healing factors or some form of external stress is also a very personal thing. The stress of a
treatment, pathophysiological changes are able to big competition or a major event will be beneficial
revert to normal physiological function. The phys- to some individuals, enabling them to perform at
iological and pathophysiological changes occur in their best (i.e. eustress), but to others it can be dis-
the alarm and resistance phases respectively. abling and decidedly not eustress. This is perhaps
Exhaustion represents the onset of irreversible well illustrated by sportsmen: many of the top level
pathological changes. Recognition and appropri- competitors 'on paper' are performing at the same
ate management of an individual who is in one of high level, and in qualifying rounds perform
the first two stages will prevent their continuation equally well. However, often it is the manner in
to the pathological stage. The theory of the total which they deal with the emotional stress of the
osteopathic lesion (TOL) explores the concept of final competition that determines who ultimately
summation and compound action of multiple wins, and not just their physical prowess.
stressors of varied origins (see Ch. 9). Applying The fact that sustained stress or the summative
the TOL within this context would enable one to action of numerous stressors is detrimental to health
obtain an holistic view of the contributing factors, is illustrated by the Social Readjustment Rating Scale
and help the practitioner realize that to achieve developed in the 1960s by Holmes and Rahe which16

good results they have to help lighten the body's relatively accurately correlated the potential illnesses
summative load. In a patient who is subject to someone may suffer proportionate to the amount of
numerous stressors, it is not always necessary to stress to which they have been exposed.
remove all of them (not that that would be possible
anyway), but by addressing some of them, the
SOCIAL READJUSTMENT RATING SCALE

Holmes and Rahe were able to correlate, with con-


siderable accuracy, the number of stress points a
Pathophysiology person accumulated in any 2-year period, with the
degree of seriousness of the disorder which that
person was then likely to suffer. From this they cre-
ated the Social Readjustment Rating Scale (SRRS)
Physiology Pathology
which gave numerical values to many different
types of stressful situations. The ratings for some of
the common life stressors are shown in Table 7.2.
The number of points is calculated over a 2-year
period; the results are variously described as:

• less than 150 life change units: 30% chance of


Figure 7.2 An adaptation of the GAS to demonstrate the developing a stress-related illness;
physiology, pathophysiology, pathology continuum. (Modified • 150-299 life change units: 50% chance of illness;
after Selye H. The stress of life. New York: McGraw-Hill; 1976.) • over 300 life change units: 80% chance of illness;
144 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Table 7.1 The possible consequences on t h e musculoskeletal system related to Selye's three stages of the g e n -
eral adaptation syndrome. (After Dummer T. A textbook of osteopathy, vol 1. Hadlow Down: JoTom Publications;
1999: 171)

Stage Possible consequences

Alarm stage
Acute state of reaction and defence Muscular hypertonicity resulting from an exaggerated nervous stimulus, and local
tissue changes in reaction to trauma, voluntary physiological contracture (CNS),
involuntary (ANS) visceral origins, or psychological stress. This leading to
decreased range of movement (ROM) due to spasms and contractures
Resistance stage
+/- adequate adaptation, compensation Muscular hypertrophy, fibrosis, limitation of ROM due to fibrous tissue
(subacute on top of chronic symptomatology, accumulation with diminution of muscular fibres due to long-term adaptation
but not uncommonly asymptomatic) to stress
Decreased local circulation
Acidic and toxic deposits
Beginning of osteoarthritis
Exhaustion stage
Lack of adaptation and compensation Fibrosis and muscular atrophy, which is the result of atonia and replacement of
Disease the muscular fibres by fibrous tissue, coming generally from:
Degeneration • acidic saturation, circulatory and nutritive deficiency
• under adaptation to chronic stress
• osteoarthritis

Table 7.2 Selected examples of t h e life change units Or:


attributed to stressful situations from the Social • more than 250 points is likely to be followed by a
Readjustment Rating Scale. (Modified from Holmes T H ,
life-threatening illness;
Rahe RH. The social readjustment rating scale. Journal
• 150 points by an illness which may be serious,
of Psychosomatic Research 1967; 11: 213-218)
but not life-threatening;
Stressful situation Units • 20-50 points, recurrent bronchitis, headaches,
cold sores or other illnesses may result.
Death of a spouse 100
Divorce 73 Though this scale is not without its detractors it
Marital separation 63 would appear that stress is cumulative and that it
Death of a close family member 63 can have a predictable effect on various systems in
Marriage 50 the body and therefore homeostasis. This has a
Marital reconciliation 45 reflection in the concept of the total osteopathic
Retirement 45 lesion, segmental facihtation and central sensitiza-
Change to a different line of work 36 tion. The Social Readjustment Scale is still occasion-
Sexual difficulties 39 ally used, but it has been noted that it does not take
Trouble with your boss 23 into account certain pertinent factors such as peo-
Change in residence 20 ple's appraisal of the stressor, nor their mechanisms
Taking out a mortgage or loan for a lesser or resources available to cope with the stressors,
purchase (e.g. for a car, TV, freezer) 17 and so other tools are now more frequently used. It
Major change in sleeping habits (significant is however an excellent example of its kind. 17

increase/decrease, or change in pattern) 16 Concomitant with tire publication of Selye's find-


Vacation 13 ings and other similar research, a plethora of self-
Christmas 12 help books appeared, all addressing methods of
stress reduction. Practitioners, both allopathic and
Psychological considerations 145

other, developed and incorporated relaxation tech- to describe 'maintaining stability or homeostasis
niques within their patient management. An exam- through change' (Fig. 7.3). They proposed that
ple of this is biofeedback, a process where there were three possible outcomes to a cycle of
information concerning the individual's own physi- allostasis:
ological responses is conveyed to them (via some
1. Normal equilibrium is restored after the stress
sort of recording device, depending on the res-
has passed.
ponses being monitored) to enable them, with prac-
2. The body becomes 'stuck' in an overactive state.
tice, to alter their ANS responses through conscious
techniques and therefore minimize the deleterious 3. The body becomes 'stuck' in an underactive state.
effects. Another example is progressive relaxation Since the body is constantly exposed to numer-
training (PRT) involving selective muscle contrac- ous forms of stressors throughout every day, these
tion and relaxation, allowing people to become repeated cycles of allostasis may go in any of the
aware of focal muscle tension in their bodies as a above directions. Furthermore, since the body is not
possible indicator of stress. This differs from the indestructible, there is a price to pay for the overuse
often used relaxation system of progressively con- of these systems and that has been termed 'allostatic
tracting and relaxing the muscles throughout the load'.
body: with PRT the focus is on the small muscles to Thus allostasis relates to the short-term, protec-
create a specific awareness. It is more difficult to tive effects and allostatic load relates to the longer-
learn but ultimately more likely to achieve the term changes and the resulting damaging effects. It
desired effect. Yoga, transcendental meditation, and appears that these changes occur in all systems of
other mind-body approaches also became more the body.
widely practised. Thus the clinical emphasis had Professor Bruce McEwen has offered four pos-
19

shifted from the introspective psychodynamic sible causes of allostatic load:


approach to a more outward looking one which
attempted to try and control the environmental con- 1. Repeated hits from multiple novel stressors.
tributory factors. Associated with this was a greater 2. Lack of adaptation.
tendency for the individual patient to be involved 3. Prolonged response due to delayed shutdown.
with their own therapeutic management. 4. Inadequate response that leads to compensatory
hyperactivity of other mediators.
MODERN PERSPECTIVES: ALLOSTASIS See Figure 7.4. (A) represents the normal allostatic
response. In the case of (B) an example could be a
Due to the possibility of normal physiology passing 'normal' working day: the car will not start; when it
eventually to pathology, numerous researchers does the petrol tank is on the low mark; there is a
have looked more closely at the effects of stress and traffic jam so you are late for a meeting with the
what occurs when the body does not fully recover. boss ... and so on throughout the day. It represents
Sterling and Eyer studied the effects on the car-
18
a series of different and relatively minor hindrances
diovascular system in its change from resting to which each create a stress response.
active states. They proposed a new term, 'allostasis'

Figure 7.3 Cycle of allostasis.


Stressor
Cycles of allostasis may go one
of three different ways. All
create allostatic load but
under- or overactive responses
increase the load.
Cycle of allostasis

Body remains in an Restoration of normal Body remains in an


overactive state equilibrium underactive state
146 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Physiological response

A
Time
Physiological response

Physiological response

Allostatic load
Normal adaption

B Time C Time
Physiological response

Physiological response

D Time E Time
Figure 7.4 (A) A normal allostatic response. (B) Repeated hits from multiple novel stressors. (C) Lack of adaptation. (D) Prolonged
response due to delayed shutdown. (E) Inadequate response that leads to compensatory hyperactivity of other mediators. (Reproduced
with permission from McEwen BS. Three types of allostatic load. New Eng J Med 1998; 338(3) :171-179. Copyright© 1998
Massachusetts Medical Society. All rights reserved.)
Psychological considerations 147

In the second case (C), it could be that every PSYCHOSOCIAL FACTORS HELPING TO
morning the car will not start and normally the I D E N T I F Y RISK F A C T O R S T H A T I N C R E A S E
body should dampen its response to a repeated THE PROBABILITY OF L O N G - T E R M
stress, but for some reason, every morning pro- DISABILITY
vokes the same stress response.
In the third case (D), the normal response should In this discussion it has been mentioned that the
be followed by a relatively rapid return to the nor- individual response to the GAS and the allostatic
mal resting state, but for some reason the response cost of stressors is dependent on the psychoemo-
takes longer to return to normal. tional makeup of that individual and their environ-
Finally, in case four, the body does not produce ment. The New Zealand government commissioned
an adequate response and so there may be insuf- research into the psychosocial factors that are likely
ficient levels of glucocorticoids which normally to increase the risk of an individual with acute low
counter regulate the cytokines, resulting in increased back pain developing prolonged pain and disability
levels of the latter. causing work loss, and associated loss of quality of
McEwen states: life. Published under the title of 'Guide to Assessing
Psychosocial Yellow Flags in Acute Low Back Pain',
When the brain perceives an experience as stressful,
it is freely available on the internet ( see ref. 26). The
physiologic and behavioural responses are initiated
following is taken from Table 2: 'Clinical assess-
leading to allostasis and adaptation. Over time,
ment of psychosocial yellow flags', from this paper.
allostatic load can accumulate, and the overexposure
They defined acute low back problems as activity
to neural endocrine and immune stress mediators can
have adverse effects on various organ systems leading intolerance due to lower back or back and leg
to disease.
10 symptoms lasting less than 3 months, and chronic
low back problems as activity intolerance due to
It is the persistent exposure to over-secretion of lower back or back and leg symptoms lasting more
naturally produced stress hormones and other than 3 months.
endogenous factors that may result in a number They utilized the term 'Yellow Flags' for these
of pathological states such as atherosclerosis, coro- psychosocial risk factors in contrast to 'Red Flags',
nary heart disease and type II diabetes as well as which are physical risk factors. 26

pain, inflammation and reduced mobility. 21-25


A person may be at risk if:
Although stress seems to be taking the blame for
a wide number of disease states, a large number of • there is a cluster of a few very salient factors, or
individuals are exposed to it and a certain number • there is a group of several less important factors
of individuals seem to emerge unscathed. It is how that combine cumulatively.
the body reacts that determines an individual's sus-
ceptibility to the different possible outcomes. It The risk factors are discussed under the headings:
could be argued that there is a certain genetic pre- attitudes and beliefs about back pain, behaviours,
disposition to the effects of stress resulting in dis- compensation issues, emotions, family and work.
ease state, but studies of asthma in identical twins
reveal low levels of concordance so it appears not to
Attitudes and beliefs about back pain
be the complete answer.
Furthermore, it could be argued that personality, • Belief that pain is harmful or disabling resulting in
as in the classic type A or B, would predispose the fear-avoidance behaviour, eg, the development of
type A person to a greater damaging effect, since guarding and fear of movement
their volatile behaviour is creating a risk of greater • Belief that all pain must be abolished before attempting
allostatic load. However, a type B person could also to return to work or normal activity
run a risk by falling into the 'inadequate response' • Expectation of increased pain with activity or work,
group of McEwen's four types of allostatic load. All lack of ability to predict capability
these points are in need of further investigation. It is • Catastrophising, thinking the worst, misinterpreting
also very probable that the way one perceives bodily symptoms
stress, or in fact perceives life, will have a great • Belief that pain is uncontrollable
influence on this system. • Passive attitude to rehabilitation
148 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Behaviours Emotions
• Use of extended rest, disproportionate 'downtime' • Fear of increased pain with activity or work
• Reduced activity level with significant withdrawal • Depression (especially long-term low mood), loss of
from activities of daily living sense of enjoyment
• Irregular participation or poor compliance with physical • More irritable than usual
exercise, tendency for activities to be in a 'boom-bust' • Anxiety about and heightened awareness of body sen-
cycle sations (includes sympathetic nervous system arousal)
• Avoidance of normal activity and progressive • Feeling under stress and unable to maintain sense of
substitution of lifestyle away from productive control
activity • Presence of social anxiety or disinterest in social activ-
• Report of extremely high intensity of pain, eg, above ity
10, on a 0-10 Visual Analogue Scale
• Feeling useless and not needed
• Excessive reliance on use of aids or appliances
• Sleep quality reduced since onset of back pain Family
• High intake of alcohol or other substances (possibly as
self-medication), with an increase since onset of back pain • Over-protective partner/spouse, emphasising fear of
• Smoking harm or encouraging catastrophising (usually well-
intentioned)
• Solicitous behaviour from spouse (eg, taking over
Compensation issues tasks)
• Socially punitive responses from spouse (eg, ignoring,
• Lack of financial incentive to return to work
express ing frustration)
• Delay in accessing income support and treatment cost,
• Extent to which family members support any attempt
disputes over eligibility
to return to work
• History of claim/s due to other injuries or pain prob-
• Lack of support person to talk to about problems
lems
• History of extended time off work due to injury or Work
other pain problem (eg., more than 12 weeks)
• History of previous back pain, with a previous claim/s • History of manual work, notably from the following
and time off work occupational groups:
• Previous experience of ineffective case management - Fishing, forestry and farming workers
(eg, absence of interest, perception of being treated - Construction, including carpenters and builders
punitively) - Nurses
- Truck drivers
- Labourers
Diagnosis and treatment
• Work history, including patterns of frequent job
• Health professional sanctioning disability, not providing changes, experiencing stress at work, job dissatisfac-
interventions that will improve function tion, poor relationships with peers or supervisors, lack
• Experience of conflicting diagnoses or explanations for of vocational direction
back pain, resulting in confusion • Belief that work is harmful; that it will do damage or
• Diagnostic language leading to catastrophising and be dangerous
fear (eg, fear of ending up in a wheelchair) • Unsupportive or unhappy current work environment
• Dramatisation of back pain by health professional pro- • Low educational background, low socioeconomic status
ducing dependency on treatments, and continuation • job involves significant bio-mechanical demands, such
of passive treatment as lifting, manual handling heavy items, extended sit-
• Number of times visited health professional in last year ting, extended standing, driving, vibration, mainte-
(excluding the present episode of back pain) nance of constrained or sustained postures, inflexible
• Expectation of a 'techno-fix', eg, requests to treat as if work schedule preventing appropriate breaks
body were a machine • Job involves shift work or working unsociable hours
• Lack of satisfaction with previous treatment for back • Minimal availability of selected duties and graduated
pain return to work pathways, with unsatisfactory imple-
• Advice to withdraw from job mentation of these
Psychological considerations 149

• Negative experience of workplace management of back • Material: money and all the things it can buy -
pain (eg, absence of a reporting system, discourage- food, shelter, etc.
ment to report, punitive response from supervisors and • Physical: strength, health and attractiveness.
managers) • Intrapersonal: inner strength, based largely on
• Absence of interest from employer self-esteem.
• Informational and educational.
It is not intended that you learn this verbatim, but it • Cultural: the sense of coherence or of belonging
is included to give a general overview of the possi- to a community or race. 17

ble psychosocial contributory factors. This research


was based on factors contributing to chronic low Many of these elements will be interrelated.
back pain; however, it seems reasonable that similar It is now possible to create a management plan
factors will be contributory to most musculoskeletal that can be patient specific, addressing as many of
problems, and a large element of them to any their stressors as possible. Where necessary, con-
chronic painful condition. sider referral to other practitioners better suited to
deal with particular aspects of the whole.
When presenting this material in lectures it tends
THE OSTEOPATHIC CONSEQUENCES to make osteopaths appear to be omniscient,
omnipotent and to possess infinite reserves of
The model offered by the GAS and the more recent energy. This is obviously not the case. However,
concepts of allostasis have a great relevance to the many of these elements can be addressed at a very
osteopathic practitioner. The key stage of the GAS is basic level and have a surprisingly good effect. Let
the adaptive stage. This is where the body is show- us look very briefly at some of the levels where we
ing signs of pathophysiological change, but is not may be able to help.
yet pathological. The body is working hard and it is From a material perspective, if someone is
drawing heavily on its reserves: drawing an anal- unable to work because of long-standing pain, they
ogy to a battery, there is not a lot of charge left. The will generally be less financially stable, and if
individual will be facilitated emotionally, physio- unemployed perhaps have low self-esteem. Chronic
logically and somatically. The concept of the total pain will lead to suppression of the immune sys-
osteopathic lesion is discussed in Chapter 9. Simply tem and thus a greater susceptibility to disease. The
stated, it is a concept of summation of stressors. high Cortisol levels that will occur as a result of
Each stressor, regardless of its origin, will have an over-action of the HPA have been implicated in the
effect on the individual across all aspects of their aetiology of depressive disorders. Resolving their
27

being, however you choose to describe them: mind, pain will allow them to return to work and will
body, spirit, or emotion, physiology, soma. The ameliorate all of the above elements. Perhaps more
majority of the patients that are treated within the importantly, by resolving problems before the pain
osteopathic clinics in Europe are either at the passes from physiological to chronic, these compli-
alarm or adaptation stage, and though they may be cations will not arise. Hence the need to recognize
presenting complaining of a somatic problem, all the signs and symptoms of someone teetering on
other systems will be similarly under strain. By the cusp between the adaptive and exhaustion
thoroughly exploring their health and psychosocial stages of the GAS, and by addressing the multiple
situations it should be possible to gain an under- factors that have brought them to that point, bring
standing of the stressors to which they are exposed. them back from the brink. The psychosocial factors,
These may be cataclysmic (affecting several people or 'yellow flags' that may help predict the likeli-
or whole communities at the same time), personal hood of someone passing to a chronic pain state
(small and large), or background (the daily hassles have been discussed above. Selye offers the follow-
of life, bearing in mind the cumulative effect this ing list of many of the physical features that he
ni.iy have allostatically). Also it is important to considers are possible signs of the adaptive phase: 28

assess the individual's coping strategies and their


stress resistance resources (SRRs). SRRs are all
of the factors that we have available to us that • General irritability, hyperexcitation or depression
enable us to cope with life's stresses. They include • Pounding of the heart
resources of different types: • Dryness of the throat and mouth
• Impulsive behaviour, emotional instability
150 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

• The overpowering urge to cry or run away and Someone who is well educated and articulate
hide will have the ability to explore problems and
• Inability to concentrate, flights of thoughts and obtain information about their condition easily.
general disorientation However, not everyone is that fortunate. Not
• Predilection to become fatigued, and loss of 'joie de knowing the cause of something, or how to go
vivre' about discovering what it is, is remarkably stress-
• 'Floating anxiety', that is to say we are afraid but ful. Explaining to an individual what is occurring
not exactly sure ivhat of
in lay terms and being able to offer advice around
• Emotional tension and alertness, 'keyed up'
systems and procedures (especially medical) will
• Trembling, nervous ticks
allay the fear of the unknown.
• Tendency to be easily startled
An awareness of the compound aspects of all
• High pitched, nervous laughter
• Stuttering and other speech difficulties frequently problems will lead to a quicker and more effective
stress induced recovery and, perhaps most importantly, prevent
• Bruxism them from getting to the irreversible exhaustion
• Insomnia, often as a consequence of being 'keyed stage.
up'
• Hyper motility, or hyperkinesia. The inability to be
relaxed and rest quietly PSYCHON EURO I M M U N O L O G Y
• Sweating more in stressful situations
• The frequent need to urinate Research has been directed at trying to understand
• Diarrhoea, indigestion, queasiness in the stomach, the physiological basis for the effects of stress on
and sometimes vomiting the immune system, as it has been observed that
• IBS stress, and particularly psychoemotional stress,
• Migraine headaches influences the state of health of an individual.
• Premenstrual tension, or missed menstrual cycles Empirically, this phenomenon has been known
• Pain in the neck or low back for years, but the complexity of the human body,
• Loss of, or excessive appetite and particularly of its brain, make a full under-
• Increased smoking standing of this difficult. Any stress affects the psy-
• Increased use of legally prescribed drugs chological state of an individual, and at the same
• Alcohol and drug addiction time the psychological state influences the body
• Nightmares function.
• Neurotic behaviour
Research has in the past concentrated on the
• Psychoses
immune system, as it is this system that is princi-
• Accident proneness? 1

pally responsible for the health of an individual.


A combined awareness of both the physical signs Studies revealed that depression, loneliness, unhap-
and symptoms and the psychosocial predictive fac- piness, anxiety and hostility all have the effect of
tors should alert the practitioner to this possibility. lowering the function of the immune system, result-
The practitioner's interpersonal skills are often ing in the development of minor diseases such as
highly significant, such as when communicating herpes labialis.
with an individual who is overweight. These indi- The effects of bereavement and marital disrup-
viduals often have a poor self-image: telling them tion have been shown to have a similar action on
that they are obese or that the problem is due to the immune system: they are known to increase
their being overweight will reinforce this negative morbidity and mortality. However, these results are
image. The term 'obese', though medically correct, more difficult to analyse, as in such situations there
to the lay person is pejorative; a more thoughtful is a possibility of other factors mtervening, such as
use of language can lessen this impact. Obesity does loss of appetite, increase in alcohol consumption or
contribute to many aspects of poor health, but is decrease in sleep, which are also factors that can
usually one of many aetiological factors: why not influence the immune system.
address these other factors first rather than putting More recent research is revealing a much greater
everything down to obesity? This is not advocating interdependence between the psyche, nervous sys-
avoiding the issue but presenting it in a construc- tem and immune system than was previously appre-
tive rather than destructive manner. ciated. They are so interrelated that it seems that it is
Psychological considerations 151

not possible to disentangle them. In the last 20 years, encourage the release of cytokinins such as IL-1
largely due to advances in technology and imaging and TNF; these in turn pass to the CNS and acti-
techniques, the emphasis has passed to the neuro- vate the HPA.
physiological processes of the CNS. Concomitant Key to the function of all of this is the hypo-
with this research was the emergence of the new thalamus.
field of research known as psychoneuroimmunol- To relate this to emotions it is necessary to briefly
ogy (PNI), (the term neuroimmunomodulation discuss the emotional areas of the brain with refer-
(NIM) is sometimes used in place of PNI or some- ence to the above. The emotions appear to be repre-
times refers to a slightly different branch of the same sented in the limbic system of the brain. Of
study). Of fundamental significance to this area of particular importance are the limbic forebrain struc-
study is the realization that the immune and neu- tures, the amygdala and the hippocampus. The
roendocrine systems are in fact in close bidirectional hypothalamus has direct connections with the lim-
communication and, indeed, 'talk' to each other all bic forebrain-limbic midbrain circuitry. It is via
29

the time, ensuring a coordinated defence of the body these connections that the emotions will be able to
and maintenance of homeostasis. Interruption of this affect the hypothalamus and therefore influence all
communication, whether genetic, surgical or phar- of the elements of the neuroendocrine-immune sys-
macological, has led to an increased susceptibility to tem discussed. Thus an emotion or psychological
disease. stressor can, via the limbic-hypothalamic-brain stem
The demonstration of 'cross-talk' between the circuitry, activate the HPA and the SAM, resulting
immune and neuroendocrine systems provides a in increased Cortisol release and sympathetic activ-
scientific basis for understanding how emotions can ity, and stimulating the physiological changes
influence the onset, course and remission of disease. already discussed. See Figure 7.5.
The physiological basis is exceedingly complex; However, it is even more complex than this.
however, most of the processes behind this have Previous experience, cultural attitudes, individual
already been discussed. coping strategies and a near infinite number of ele-
ments of personality, conscious and unconscious,
DEEPER EXPLORATION OF PNI will modulate the limbic-hypothalamic-brain stem
circuitry. Consider the case of a person who has had
We will start by reviewing some of the key points an emotionally traumatic childhood. This person
so far discussed. will have developed a heightened vigilance and
The neuroendocrine-immune system has been preparedness for flight. This will possibly result in
described as a complex interwoven series of pro- an increase in unconscious emotional response to a
cesses that behave in a coordinated manner. There stressor. This in turn will lead to an increased phys-
is bidirectional communication between the systems iological response to stress and an increase in pro-
via a receptor-mediated mechanism, with neuroreg- duction of immunosuppressive neuropeptides and
ulators, hormones and immunoregulators acting hormones, and submissive behaviour. The con-30

not just on 'their own' system, but also on the other verse can also work, where a 'positive' mind state
two. At the centre of this is the hypothalamus and will moderate the response to a stressor.
its numerous afferent and efferent connections with Melzack and Wall, in analysing pain percep-
31

other areas of the nervous system. tion, illustrate the complex interplay of psychoso-
The physiological changes that occur in response cial concepts that may influence the interpretation
to noxious stimuli are mediated via the HPA, SAM of a noxious stimulus. They state that cultural
and SNA axes and have been discussed elsewhere. expectations surrounding the meaning of pain
The descending autonomic pathways supply reflect differences in pain tolerance. Certain cul-
all of the lymphoid tissue and therefore have an tures or ethnic groupings demonstrate a more stoic
immunomodulatory effect, as do certain hormones attitude to pain, while others demonstrate less tol-
secreted by the neuroendocrine system. erance and allow greater expression of their emo-
The nervous system, in response to a noxious tions. Additionally, the quality and intensity of
stimulus, has been shown to secrete neurotrans- pain is determined by a number of other factors
mitters such as somatostatin and substance P such as an individual's early experiences, their
which act as vasodilators and chemical attractors level of anxiety, and the attention that is focused
for tissue macrophages and lymphocytes and on the pain.
152 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

Emotion/stress

Cortisol
Limbic forebrain

Nociception
Noradrenaline
Cortisol
Hypothalamus
LC
CRH (PVN)
CRH

Cortisol
Posterior Anterior
pituitary pituitary
Medulla
(PGi)

ACTH

Nociception
SNA

Adrenal SAM
cortex and
medulla Sympathetic supply
to lymphoid tissue

Cortisol

Cytokinins
Centripetal
Thoracolumbar
outflow
Somatic and Sympathetic
Centrifugal
visceral supply to the
substance P nociception whole body
Adrenalin +
Noradrenaline

Lymphoid Visceral
organs, tissues mechanical/chemical
and cells stressor
(somatic dysfunction)

Figure 7.5 A schematic representation of the PNI process.


Psychological considerations 153

From this it is possible to comprehend the com- • The history of our present emotional state, includ-
plexity of both the physiological processes under- ing the effects of our most recent experiences. 32

pinning the PNI process and the enormous range of


psychosocial factors that will modulate their effects. The muscular system carries our ego identity in the
The task for the practitioner of trying to synthesize broadest sense. How we use our muscle, our charac-
all of this complexity appears to be insurmountable. teristic posture, gait, gesture reflects and communi-
It is easy to get buried under the constant deluge of cates a great deal about our gender, class, race,
current research, but it is important not to lose sight culture, and lifestyle, as well as our developmental
of fundamental concepts such as effective and empa- history. Embedded in our muscles are all the skills,
habits, expressions and defences we have acquired.
thetic communication with patients and concepts
The range of our learning includes normal develop-
such as 'structure governs function' and vis medica-
ment skills, such as feeding, and walking; specific
trix naturae. These go a long way to addressing
skills - such as weaving, carpentry, juggling, driv-
elements of this complexity, and the intellectual
ing; character attitudes, such as defiance or deference;
concepts should be there to inform our actions, not patterns stemming from trauma, including birth
dictate them. trauma; and identifications made loith others. 6

THE PHYSICAL EXPRESSION OF EMOTION PHILIP LATEY'S PATTERNS OF POSTURAL


IN T H E BODY LAYERING, REGIONAL TENSION

So far the discussion has largely been concerned The osteopath Philip Latey has spent many years
with the physiology behind the psychoemotional looking at the sensory functions of the musculature,
contribution to ill health. This section will address and exploring the relationship between the emo-
some of the total body concepts, the physical mani- tions and the patterns of postural layering and
festation of the emotions within the body. regional tensions that are observable within various
Being able to assess people's emotional state is different layers within the body. The following has
an innate skill that is present in all of us. It is possi- been compiled from his work published in the
ble to see anger, fear, sorrow, love, hate, in fact all of Journal of Bodywork and Movement Therapies f ^ 1

the emotions, in people's faces. Emotions are also He describes four layers of posture: the image,
visible within the body as a whole. Some are obvi- slump, residual and inner tube postures. 11

ous: consider the upright, open body of the happy


T h e image posture
and confident individual, and the bowed head,
closed body posture of someone who is depressed. This is the social posture, the one that is utilized
There are also more subtle, complex patterns of when one is aware of being observed. The body is
emotions present within the body which are more held in an overtly 'correct' posture by the generally
difficult to read. We can all recognize many of these overtense large superficial muscles. This will give
patterns but, paradoxically, it often seems that the an indication of the persona that the patient
moment many practitioners enter their clinics, these expresses socially. As the patient begins to be more
exceptionally useful skills are disregarded. Good comfortable they begin to relax into the second pos-
observation of an individual will give an enormous ture, the slump posture.
amount of information. The way an individual
T h e s l u m p posture
stands and moves gives a detailed history of their
physical and emotional life: This represents the individual's more habitual pos-
ture, the way that it functions in response to grav-
Body shape and patterns of movement simultaneously ity. This is maintained by the action of the key
tell three stories, each relating to the way we experi- postural muscles including the popliteus, tensor
ence gravity: fascia lata, adductors and deep external rotators of
• An evolutionary history, representing the millions the hip, lumbosacral muscles, serratus posterior
of years that our ancestors adapted to life in the inferior and superior, suboccipital muscles, ster-
gravity field of our planet nomastiod, temporalis and the pterygoids. The
• A shorter history of personal traumas and adapta- third posture will be revealed when the patient is
tions during our lifetime lying down, relaxed on the couch.
154 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

T h e residual posture
and shoulder girdle. When these are subject to ten-
This is the pattern of residual tone and activity left sion, the fist analogy can be utilized with these
after minimizing the effects of the social interaction areas being termed the lower, middle and upper
and gravity. Some of the postural muscles may fists respectively. Contraction of each of these fists
remain hypertonic, particularly the deep erector in response to any of the emotions listed above
spinae muscles. There will also be a background will result in a series of changes that may lead to
tone and activity that is present in all of the muscu- musculoskeletal and/or systemic dysfunction.
lature, this is the resting state of muscles maintained The lower fist may lead to problems with the low
by the unconscious control of the higher centres. As back, pelvis and lower extremities, creating mechan-
such Latey considers that it is closer to the involun- ical imbalances and musculoskeletal pain. Changes
tary processes of the body than would be usually in the control of the pelvic musculature and per-
expected of skeletal muscle, and therefore very sig- ineum may initially lead to the generation of sensa-
nificant in a psychophysical context. In health tion and, if sustained, its eventual obliteration. The
the tissues should exhibit a relatively rhythmical chronic state will lead to stasis, inflammation or con-
motion; this can be affected by, and therefore indica- gestion of the bowel, bladder and genitalia, with
tive of, different emotions or physical influences. In innumerable possible clinical consequences.
chronic exhaustion or illness the movements become The middle fist will have an effect on the muscles
generally feeble and flaccid. In areas subject to of respiration. This area is important in the expres-
extreme physical or emotional shock the tissues can sion (or suppression) of emotion, e.g. laughing, cry-
feel static, lifeless, rigid, stringy or numb. ing, sighing. Chronic contraction of the middle fist
This has strong similarities to the psychodynamic compresses the thoracolumbar region of the spine,
concepts and the more recent interpretations of it, possibly having an aetiological role in juvenile
such as Reich's body armouring and the suppres- osteochondrosis. Mechanically this is a significant
sion or repression of emotions. area, disturbance of which will have numerous
musculoskeletal consequences. On a visceral level
T h e inner t u b e it may affect respiration, contributing to such con-
This consists broadly of the involuntary visceral and ditions as asthma, recurrent chest infections or
vascular smooth muscle. The gastrointestinal system digestive system problems such as gastric reflux,
lies at its centre, combined with the respiratory sys- ulcers and hiatus hernia.
tem. It is closely linked to emotional processes, and The upper fist is involved with the perception,
it is here that Latey places the senses concerned with response and restraint of response to the outer
the generation and perception of bodily and cere- world. Tightening of the upper fist muscles can con-
bral emotion, depth of meaning and mood. 33
tribute to such complaints as tension and migraine
To describe the effects that can occur within headaches, temporomandibular problems, sinusitis,
these muscles he utilizes the analogy of a clenched and ear, nose or throat problems.
fist: This is a very brief overview of the foundations
of Latey's concepts. He has developed a broad
A clenched fist represents the closing down of open approach which encompasses aetiological, diagnos-
interaction and engagement; it may be rage, fear, tic and therapeutic elements, all based on the inter-
defiance or defensiveness; it might be a recoil in shock dependence of the mind and the body. It is not
and denial when something awful has happened. The possible to do his work full justice within the con-
clenching may be enclosing something very precious; fines of this text; for a more complete understand-
could be simply expressing tenacity and determina- ing you are referred to the references cited in the
tion or enforcing stillness. recommended reading at the end of this chapter.
Unclenching of an area of the body, after an initial
stage of weakness, vulnerability, ache and unsteadi-
ness, should bring physiological relaxation. Warmth, EMOTIONAL ANATOMY
breathing and involuntary motions are restored. 11

Another whole body psychoemotional approach that


He describes three main areas on which the ten- has a particular resonance for many osteopaths is
sions of the body focus: the pelvic girdle; the lower that devised by Stanley Kelman, termed Emotional
ribs and the upper abdomen; and the head, neck Anatomy. One of the strengths of his approach is
34
Psychological considerations 155

that his book, of the same name, conveys the con- physical self. This involves correct breathing, nutri-
cepts in a very visual manner. It is possibly this tion and 'mindful' living. The parallels between this
which perhaps makes it more obviously understand- model and many of the osteopathic principles are
able in clinical terms. This benefit will be lost to an clear.
extent in this discussion - however, a brief overview
follows.
As with the psychodynamic model, Kelman SOME OSTEOPATHIC EMPIRICAL
divides the body into three layers: MIND-BODY CONCEPTS
• The outer layer consists of the nervous system
There are many osteopathic concepts that have been
and the skin and represents our interaction with
tacitly accepted. One of these is the emotional
the world.
release. Simply stated, this is the application of an
• The middle layer encompasses the muscles,
osteopathic technique with the specific intention of
bones and connective tissues.
resolving the stress patterns manifest in the body.
• The inner layer consists of the internal organs of
Resolution of the pattern is often associated with
digestion, assimilation, respiration and distribu- some form of emotional release, ranging from cry-
tion. ing or laughing to a complete recall of all the ele-
(The biodynamic equivalents of these would be the ments of the situation that caused the pattern.
skin ego, the motoric ego and the id canal respec- As has been discussed, the model of a rigid 'hard
tively.) wired' central neurological pathway is being ques-
He also divides the body into three compart- tioned.
ments, the head, chest and abdomen. For health Memory is a complex phenomenon. Though not
there must be balance between the layers and fully understood, it is probable that sensory infor-
pouches and good fluid exchange throughout. mation is passed to the higher centres as bundles
This harmony, and therefore the posture, are of information and despite the fact that different
affected by stress or 'insults'. Depending on the types of information pass to separate sections of the
intensity, duration and frequency of the stresses cortex for interpretation, in some manner the infor-
the body will pass through a series of postural mation is still united. An example of this, that most
changes. Initially they become larger and expand people have experienced, is that of catching a waft
outwards, passing progressively from a rigid cau- of a particular scent and suddenly recalling a par-
tionary stance to a threatened bracing one and then ticular time, place or situation. Your memory is
finally to a turning pose as if getting ready to run complete - as well as the olfactory component, it
away. The next three postures involve getting will often include the visual surroundings, an
smaller, shorter and becoming fixed. These repre- impression of sounds or recall of words, and associ-
sent a freezing type response. The postures evolve ated emotions.
through the stages of a contracted bracing, to a Thus, when a trauma occurs, be it physical or
withdrawal, submission and finally a downward emotional, it is possible to hypothesize that it will
collapse in defeat. create a pattern of somatic changes in the tissues of
With time the tissues become thickened, the com- the body, including the neuromusculoskeletal and
partments shift and the fluid exchange is perturbed. visceral systems, but at the same time the visual,
Kelman describes the end result of the changes by auditory, olfactory and emotional sensations will be
using four types: 'bundled' with it. Just as in the above example,
stimulating one aspect of that bundle will have the
• Rigid and controlled possibility of evoking complete recall.
• Dense and shamed
Patterns of dysfunction can occur as a result of
• Swollen and manipulative
purely emotional stimuli, in the absence of physical
• Collapsed compliant.
trauma. The somatic patterns may be created
Each type has its own possible sequelae physically, preferentially in certain areas of the body. Fulford 35

socially and psychologically. describes 'shock' held in the diaphragm and solar
Kelman believes that because of the reciprocity plexus. Structures like the diaphragm are easy to
between emotive states and physical well-being it is conceive as an area where emotion can be 'fixed';
possible to reverse the processes, strengthening the just recall a situation where you have been suddenly
156 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

frightened and how the diaphragm was felt to con- when it would respond more effectively to an indi-
tract. Some other common somatic sites where this rect approach.
may occur are the upper fibres of trapezius, the From a diagnostic perspective, it is thought to
masseter muscles and the pelvic floor. The actual be possible to distinguish the feel of tissue affected
distribution depends on the causative nature of the by emotional shock as opposed to physical trauma.
stress - any area of muscle has the potential to be If this is the case then it may be appropriate to
emotionally charged. gently enquire about possible traumatic occasions
The viscera are also affected by emotion. Though that may have precipitated it. Uniting the emotion
not as physically obvious as the above examples, with its physical manifestation in the body,
most of us will have experienced the sense of cer- prior to treating the somatic element, is thought by
tain viscera being affected emotionally. Many will many to be more powerful in resolving it com-
know that 'gut wrenching' feeling associated with pletely.
emotions of loss or jealousy, or the hollow, empty We, as osteopaths, do not need to know specific
feeling that accompanies the death of someone very information on what has caused the particular psy-
dear. These are acute manifestations of the emotion chological disturbance; as long as the patient is
felt within the deep visceral structures (Latey's aware of it, that is sufficient. Should the patient
inner tube, Kelman's inner layer, the biodynamic id wish to discuss it, that is their choice, and it is up to
canal). Chronic emotional disturbances will have you as a practitioner to establish your own bound-
similar effects though these effects will not neces- aries around this. A note of caution should be intro-
sarily be felt on a conscious level. Empirical osteo- duced at this point. Most osteopaths are not
pathic anecdotes also describe emotional reaction psychologists, and there are times when appropri-
to treatment at the umbilical area, the liver, gall- ate referral to someone more qualified in this field
bladder, lungs and uterus. may be more beneficial for the patient and for you,
The fascia as a whole appears to have the ability the practitioner, too.
to retain a memory of both the physical and emo-
tional aspects of a trauma, both possibly being re-
experienced as the fascial pattern is treated. CONCLUSION
As well as the neurological explanation for the
emotional charge of particular areas, some concepts This chapter was intended to reinforce the concept
appear to be rooted in a blend of Eastern and ener- that the mind and body are inextricably related. It
getic concepts. The sternum, the fourth thoracic ver- aims to build on some of the elements brought up
tebra and the cardiac plexus are often considered to in the earlier section on biotypology, most notably
be emotional centres, possibly due to their relation to the work of Sheldon and Kretschmer. These biotyp-
the heart chakra, also in this area. Another example ical models attempt to express the potential or pre-
is the relationship between shoulder dysfunction and disposition of an individual both somatically and
parental disagreements, or home or work conflict. emotionally. They analyse the whole body mor-
Whatever the underpinning mechanism, empiri- phology, rather than responses to particular events.
cally there is a relatively high incidence of emo- This potential is then moulded by the environment
tional releases occurring when working in areas and situations to which they are exposed to create a
such as these. An awareness of this will allow you unique combination of mind and body.
to appreciate the subtle interplay between the mind It is the outcome of effects of the moulding from
and the body. It will enable you to be prepared for other sources that is explored here. Some of the con-
the possible emotional release that may occur when cepts that have been utilized over the last century to
treating someone with emotional or shock patterns. rationalize this relationship were introduced. The
This will help you establish an appropriate time to chapter has focused most particularly on the mech-
effect the release; it will not be appreciated if it is anisms through which this relationship occurs, as
performed when the patient is unprepared, or not opposed to the manner in which one would treat
strong enough to cope with it at that time, or just such situations, because the approach of this book is
prior to an important occasion without leaving suf- primarily conceptual rather than practical. The link
ficient time for the effects to wear off. between the concepts and their application is some-
It will also prevent you from further traumatiz- thing that will have to be experienced clinically
ing an area by attempting to release it directly, with the supervision of a tutor.
Psychological considerations 157

The theories explored were discussed with regard In the author's opinion (JSP) the most important
to their chronology. However, just because one skill that can be learned within this field is that of
approach has been superseded by another does not listening. This is not just hearing the words, and
mean that the earlier one is now redundant. Most then jumping in with your ideas of how any prob-
conceptual models can be kept 'current' by incorpo- lems can be solved, but listening with the intent of
rating the new levels of understanding as they arise. understanding. You need to create an environment
In the practice of medicine in its broadest sense, there in which the patient feels comfortable in express-
are very few absolutes, and this appears to be partic- ing what they want to express, and thereby allow
ularly true in the approach to the psyche. Currently them to create their own associations and answers.
there is an enormous range of different therapeutic Where they are having difficulties in doing this,
psychological approaches, each having a degree of rather than telling them what they need to do, ask
success. It has been the aim of the author to scratch them a question that will start their minds think-
the surface of some of the major approaches, in the ing again.
hope that you will find one that resonates with you Whatever way you choose to apply this knowl-
as a person and as a practitioner, and which will edge, helping someone to evolve emotionally as
enable you to formulate some ideas behind the psy- well as physically is perhaps one of the most
choemotional contribution to the whole. rewarding aspects of our job.

References
1. Littlejohn JM. Psychology and osteopathy. J Osteopath 16. Holmes TH, Rahe RH. The social readjustment rating
1898;Iuly:67-72. scale. I Psychosom Res 1967; 11:213-218.
2. Lipowski ZJ. What does the word 'psychosomatic' really 17. Sheridan CL, Radmacher SA. Health psychology, chal-
mean? A historical and semantic inquiry. Psychosom Med lenging the biomedical model. New York: Wiley; 1992.
1984;46(2):153-171. 18. Sterling P, Eyer J. Allostasis: A new paradigm to explain
3. Dunbar HF. Bodily changes: a survey of literature on psy- arousal pathology. In: Fisher S, Reason J, eds. Handbook
chosomatic interrelationships:1910-1933. New York: of life stress, cognition and health. New York: lohn Wiley;
Colombia University Press; 1935. 1988.
4. Breuer J, Freud S. Studies on hysteria. In: Strachey J, ed. 19. McEwen BS. Protective and damaging effects of stress
The standard edition of the complete psychological works mediators. New Engl I Med 1998; 338:171-179.
of Sigmund Freud, vol 2. London: Hogarth Press; 1955. 20. McEwen BS, Stellar E. Stress and the individual mecha-
5. Classman WE. Approaches to psychology. Buckingham: nisms leading to disease. Arch Intern Med 1993;
Open University Press; 2001. 153:2093-2101.
6. Carroll R. The motoric ego, thinking through the body. 21. Akerstedt T, Gillberg M, Hjemdahl P et al. Comparison of
1999. Online, http://www.thinkbody.co.uk/papers/ urinary and plasma catecholamine responses to mental
motoricego.htm 13 July 2003. stress. Acta Physiol Scand 1983; 117:19-26.
7. Buhl HS. Autonomic nervous system and energetic medi- 22. Karasek RA, Russell RS, Theorell T. Physiology of stress
cine: bioenergetic and psychosomatic causes for health and regeneration in job related cardiovascular illness.
and illness. Online, http://www.orgone.org/articles/ I Human Stress 1982; 8:29-42.
ax2001buhl-a.htm 5 July 2003. 23. Manuck SB, Kaplan JR, Adams MR et al. Studies of psy-
8. Eiden B. The use of touch in psychotherapy. Self & chosocial influences on coronary artery atherosclerosis in
Society Magazine 1998; 26(2):3-8. Online. http://www. cynomolgus monkeys. Health Psychol 1995; 7:113-124.
chironcentre.freeserve.co.uk/articles/useoftouch.html 24. Rozanski A, Bairey CN, Krantz DS et al. Mental stress and
7 July 2003. the induction of silent myocardial ischaemia in patients
9. Heath D. Bodywork and the psyche, psychotherapy and with coronary artery disease. New Engl} Med 1988;
the body. Online. Available: http://www.uktherapists. 318:1005-1011.
com/articles/lifestieam/1998/7/03.htm 5 July 2003. 25. Seeman TE, McEwen BS, Singer BH et al. Price of adapta-
10. Latey P. The muscular manifesto, 2nd edn. London: Philip tion - Allostatic load and its health consequences.
Latey; 1979. MacArthur Studies of Successful Ageing. Arch Intern
11. Latey P. Feelings, muscles and movement. Journal of Med 1997; 157:2259-2268.
Bodywork and Movement Therapies 1996; l(l):44-52. 26. Kendall N, Linton S, Main C. Guide to assessing psy-
12. Bernard C. Les phenomenes de la vie, vol 1. Paris: I-B chosocial yellow flags in acute low back pain: Risk factors
Bailliere; 1878. for long-term disability and work loss. Wellington: ACC
13. Cannon WB. The wisdom of the body. New York: Norton; and National Health Committee; 1997. Online.
1932. http:// www.acc.co.nz/injury-prevention/
14. Butler DS. The sensitive nervous system. Australia: back-injury-prevention/treatment-provider-guides or
Noigroup Publications; 2000. http://www.nzgg.org.nz/library/gl_complete/
15. Selye H. The stress of life. New York: McGraw-Hill; 1976. backpain2/purpose.cfm#contents 16 Sept 2003.
158 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL] MODELS

27. Gold P. Neurobiology of stress. In: Willard FH, 31. Melzack R, Wall P. The challenge of pain, 2nd edn.
Patterson MM, eds. Nocioception and the London: Penguin Books; 1988.
Neuroendorine-Immune Connection. Athens: 32. Oschman TL. Energy medicine. Edinburgh: Churchill
University Classics; 1994. Livingstone; 2000.
28. Selye H. The stress of life. Revised edn. New York: 33. Latey P. Maturation - the evolution of psychosomatic
McGraw-Hill; 1978. problems: migraine and asthma. loumal of Bodywork
29. Willard FH, Mokler DJ, Morgane PJ. Neuroendocrine- and Movement Therapies 1997; 1(2):107-116.
immune system and homeostasis. In: Ward RC, ed. 34. Keleman S. Emotional anatomy. Berkeley: Center Press;
Foundations for Osteopathic Medicine. Baltimore: 1985.
Williams and Wilkins; 1997. 35. Comeaux Z. Robert Fulford DO and the philosopher
30. Watkins A, ed. Mind body medicine. New York: physician. Seattle: Eastland Press; 2002.
Churchill Livingstone; 1997.

Recommended reading
Brooks RE, ed. Life in motion: the osteopathic vision of Latey P. Maturation - the evolution of psychosomatic
Rollin E. Becker, DO. Portland: Rudra Press; 1997. problems: migraine and asthma. lournal of
Brooks RE, ed. The stillness of life: the osteopathic philoso- Bodywork and Movement Therapies 1997;
phy of Rollin E. Becker, DO. Portland: Stillness Press; 1(2):107-116.
2000. Latey P. Basic clinical tactics. Journal of Bodywork and
Comeaux Z. Robert Fulford DO and the philosopher physi- Movement Therapies 1997; 1(3):163-172.
cian. Seattle: Eastland Press; 2002. Latey P. The balance of practice. lournal of Bodywork and
Glassman WE. Approaches to Psychology, 3rd edn. Movement Therapies 1997; l(4):223-230.
Buckingham: Open University Press; 2000. Latey P. Complexity and the changing individual.
A good basic introduction to the various theories in psychol- Journal of Bodywork and Movement Therapies 1997;
ogy, very readable. l(5):270-279.
Kline N. Time to think, listening to ignite the human mind. Latey P. The pressures of the group. lournal of Bodywork
London: Cassell Illustrated; 1999. and Movement Therapies 1998; 2(2):115-124.
An excellent book that explores how to listen effectively, very Latey P. Curable migraines: part 1. lournal of Bodywork and
strongly recommended. Movement Therapies 2000; 4(3):202-215.
Latey P. The muscular manifesto, 2nd edn. London: Philip Latey P. Curable migraines: part 2, upper body technique.
Latey; 1979. Journal of Bodywork and Movement Therapies 2000;
Almost impossible to obtain, hence all of the journal references 4(4):251-260
below. Watkins A, ed. Mind body medicine. New York: Churchill
Latey P. Feelings, muscles and movement. lournal of Livingstone; 1997.
Bodywork and Movement Therapies 1996; l(l):44-52. A good introduction to PNI.
159

Chapter 8

T h e respiratory-circulatory model
of osteopathic care

INTRODUCTION
CHAPTER CONTENTS

Introduction 159 'The rule of the artery is supreme' is one of Still's


Movement of fluids 160 most often cited principles. It was later modified to
The respiratory-circulatory model of osteopathic the more globally inclusive 'The movement of the
care 161 body fluids is essential to the maintenance of
health'. Fluid bathes our whole body. Many of us
Conclusion 163
tend to think initially of the blood in the arterial
References 164
and venous system as the major fluid system in
Recommended reading 164
the body. This, however, accounts for only 8% of
the total body fluid. Body fluid accounts for 60% of
the total body weight of a human, which is 42 L of
fluid. Of this, 40%, or 28 L, is intracellular fluid and
20%, or 14 L, extracellular fluid. The blood repre-
sents just 5 L.1

The fluids serve a multiplicity of tasks. They


carry the nutritional requirements such as oxygen
and glucose to all of the tissues of the body, and
then bear away the waste products such as lactic
acid and carbon dioxide.
They can be seen as the mediator of the humoral
communication systems that are essential for
the defence of the body and the maintenance of
homeostasis. The cellular elements of the immune
system are conveyed within the vascular system
and can pass into the extracellular fluid when
required. The humoral communication messengers
of the neuroendocrine immune system, the hor-
mones, neurotransmitters, cytokinins, etc., are all
transmitted via the fluid systems.
The lymphatic system, though often seen as a sep-
arate entity, is also a part of the total fluid system. It
has two major roles. It transmits the fatty fluids from
the gastrointestinal tract (GIT), and the interstitial
fluid that escapes from the capillaries, back into the
160 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

cardiovascular system. It also has a major role in the lar, is dependent on pressure gradients. Where the
defence of the body, with mobile 'surveillance' ele- appropriate pressure gradient is disturbed there
ments, such as the lymphocytes, circulating the body will be a disturbance in the flow of fluids, resulting
and destroying or producing antibodies to any for- in a relative decrease in perfusion in areas of high
eign substances; and static organs through which the pressure, and stasis in areas of low pressure. Thus
fluids have to pass and through which medium for- an increase in the pressure of the abdominopelvic
eign substances are removed. cavity will result in a relative hypoperfusion in the
It also has a role in support and protection. Fluid organs and tissue contained therein, but as the pres-
fills the fascial cavities, 'inflating' them, and thereby sure gradient between the lower extremities and the
offering structural support to the area both locally pelvis has increased, there may be insufficient pres-
and to the body globally. These fluid-filled cavities sure within the lower extremity return mechanisms
act as tensegrity structures, offering protection by to overcome this gradient. Consequently, fluids will
causing any forces acting on them to pass equally to tend to pool in the lower extremities, both in the
the entire surrounding structure, diminishing the venous system and in the tissues and extracellular
overall effect. It can also be seen as a hydraulic sup- spaces, and stasis will ensue. With decrease in per-
port system which can buffer the supported struc- fusion there will also be a reduction in all of the
tures from any external forces, such as the physiological effects of the fluid: nutrition, commu-
cerebrospinal fluid (CSF) protecting the central nication, elimination, etc.
nervous system. Other mechanisms of aiding the return of fluids
are the contraction and relaxation of striated mus-
cles and of the smooth muscle of the alimentary
M O V E M E N T OF FLUIDS canal in peristalsis. As they are contained in a fas-
cial envelope, this will cause an alternating pressure
Fluid passes to every cell, even when there are no within the envelope, moving the fluids along. There
vessels or obvious passageways for it to get there. will also be an effect on the neighbouring soft tissue
The only obvious pump for the circulation of the structures in their envelopes, creating similar
fluids is the heart, which acts on the arterial sys- changes in the fluids. The movement of fluid is
tem. Circulation of the extra- and intracellular assisted by the valves in the lymphatic system and
fluids, lymph, venous blood and CSF depend on parts of the venous system. When the pressure is
a complex interplay of the soft tissues and the increased in a cavity, fluid will be pushed along the
resulting pressure changes in the body. On a vessel, but it will be prevented from dropping back
gross scale the contraction and relaxation of the with the following decrease in pressure, by the
thoracic diaphragm in respiration creates a con- action of the valves.
stant cycle of pressure changes throughout the The inherent motility of cells, tissues and organs
body. As the diaphragm moves inferiorly on inspi- will also have an effect on the fluid dynamics.
ration there will be a relative increase in pressure The various diaphragms are also thought to have
below the diaphragm and a relative decrease a great influence on the circulation of fluids. The
above. Increase in pressure tends to 'squeeze' flu- thoracic diaphragm has already been mentioned.
ids out of tissues; as the pressure is decreased it The plantar fascia is thought by some to act as a
will cause fluids to be 'sucked' into the tissues. This gentle pump, being active when walking. The
helps the perfusion of these tissues. Similarly any remaining diaphragms, the pelvic floor, the thoracic
movement of the body will be transmitted through inlet (Sibson's fascia), and the tentorium cerebellae
the extracellular tissue matrix, torsioning and with or without the diaphragma sella, are more
shearing the planes of the tissues, creating 'wring- generally seen as possible areas of restriction to
ing out' effects on the tissues right down to a cellu- fluid flow if dysfunctioning.
lar and intracellular level.
It will be noted that fluid movement is depend-
To aid these two actions the body is organized ent on pressure and movement of tissues. If a local
into a series of fascial compartments on both a local somatic dysfunction occurs, it will often result in
level, creating multiple small spaces, and a global local hypomobility and an increase in tension in the
level with the cranial, thoracic and abdominopelvic associated soft tissues. This will automatically result
cavities. Transmission between these fascial com- in a local decrease in tissue perfusion which will
partments, or even from extracellular to intracellu- result in relative hypoxia and decrease in all of the
T h e r e s p i r a t o r y - c i r c u l a t o r y m o d e l o f o s t e o p a t h i c care 161

physiological functions mediated by the con- It would appear that he was influenced by the
stituents carried in the fluid. strong emphasis that AT Still placed on the role of
Gross disturbances of the body, such as postural the body fluids and particularly the lymphatics:
problems, will disturb the balance of pressure 'your patient had better save his life and money by
between the cavities and will therefore have a dra- passing you by as a failure, until you are by knowl-
matic effect on the circulation of all of the fluids of edge qualified to deal with the lymphatics'. 6

the body, and consequently a global physiological Another great influence was FP Millard who devel-
effect. This is described by Littlejohn in the anterior oped a systematic approach to evaluate and treat
and posterior weight types, Goldthwait in Body the lymphatic system. Zink's respiratory and cir-
7

Mechanics and Kelman in Emotional Anatomy. - < 2 3 4 culatory model can be seen as an expansion of
Pressure and mobility are not the only factors Millard's work. The other major influence was WG
affecting fluid exchange. Others include osmolar Sutherland, most notably his work on the primary
gradients and the electrical potential of particles, to 5 respiratory mechanism and fluid fluctuations.
mention just two; however, the obvious importance The key feature of Zink's model is that for health
of the factors discussed earlier and their accessibility (or homeostasis) there must be good circulation of
to manual therapists make them predominantly all of the body fluids; this will ensure that there is
important. proper nutrition and drainage of the tissues right
Inherent in many treatment approaches is the down to a cellular level. This represents the circula-
concept of restoring mobility and thereby restoring tory part of the name.
fluid exchange. The general osteopathic treatment In order to achieve this, the respiratory processes
(GOT) is an approach that cites this as one of its key must be working efficiently. Of prime importance is
aims, and this is discussed in the next section. Some the 'respiratory suction pump', by which he means
of the approaches within the involuntary mecha- the action in respiration of the thoracic diaphragm,
nism are based on fluid movement, such as the CV4 the thorax and the lungs. He describes it as a 'three
which is thought of as a compression of the fourth way' suction pump; air, venous blood and lymph
ventricle which encourages CSF exchange, amongst being aspirated by it. This pump is therefore work-
8

other stated benefits. The osseous structures them- ing synergistically with the 'pressure pump' of the
selves may be visualized as being composed of a heart to ensure the circulation of the body fluids.
sea of molecules rather than as a rigid structure, This is the respiratory aspect of the title.
permitting work on an intraosseous level; again the The concept as a whole is best described in
rationale behind involuntary approaches is dis- Zink's own words.
cussed in Section 3.
Another approach that is perhaps more con- Respiration and circulation are unifiable functions.
ceptual than practical is that of Gordon Zink's The need for establishing 'normal respiration', which
is diaphragmatic when the patient is resting in the
Respiratory-Circulatory Model of Osteopathic Care.
supine position, is obvious when we consider the fact
The practical application of this draws on a series of
that most of the volume of blood is found in the
approaches including articulation, high velocity
venous reservoir. This low pressure system is
thrust (HVT) and indirect work such as fascial dependent on pressure differentials in the body
unwinding, or cranial techniques. It can be seen as a cavities for effective flow, because there is no
conceptual model, the application of which can be assistance from the muscles, which are aptly called
adapted by the practitioner depending on the 'peripheral pumps'. The cardiogenic aspect of
patient's needs, biotype, state of health and the circulation depends on the respirogenic aspect of
practitioner's abilities. circulation to complete the circuit. But that is not all;
the most important feature is the fact that the
'terminal' lymphatic drainage into the venous system
THE RESPIRATORY-CIRCULATORY MODEL is also dependent on the effective diaphragmatic
OF OSTEOPATHIC CARE respiration when the patient is resting. 9

J Gordon Zink was an American osteopath and Another element that was thought by Zink to be
educator based at the Des Moines College of essential to the body's physiological respiratory
Osteopathic Medicine and Surgery in Iowa (until he mechanisms was the primary respiration described
died in 1982). by Sutherland. Particular attention was paid to the
162 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

freedom of movement of the cranial and pelvic Thus any fascial torsion will affect the fluid circula-
diaphragms, and their relationship with the thoracic tion of the body and therefore compromise its
diaphragm, and articular mobility of the sacrum health. The common compensatory pattern (CCP)
between the ilia. The primary respiration is there- represents a series of myofascial torsions that are
fore supporting the secondary respiration and its compatible with physiological function. Simply
thoracoabdominal pelvic pump, these two working stated, if the diaphragms are rotated in alternating
in synergy with the heart. directions it indicates compensated physiological
function (Fig. 8.1).
THE C O M M O N COMPENSATORY PATTERN (CCP) Zink also described another physiological pat-
tern which is a series of myofascial torsions that are
The pattern as described by Zink and BA TePoorten 10 rotated in alternating directions but opposite to that
is based on the junctional areas between the three of the CCP; it is also compatible with physiological
body parts, the cranium, thorax and pelvis. These function. As it is relatively rare it is termed the
junctions are the upper cervical complex, the thoracic uncommon compensatory pattern (Fig. 8.2).
inlet, the thoracic outlet or thoracolumbar junction, If the fascial torsions are found on testing not to be
and the lumbosacral complex. These areas are mobile rotated in alternately opposite directions it indicates
and vulnerable to dysfunction and they each have a a non-compensatory pattern. This is not physiolo-
diaphragm associated with them and a relationship gical and therefore compromises the respiratory-
with the ANS. This is shown in Table 8.1. circulatory integrity of the body and its normal
The four diaphragms are, as already mentioned, function, predisposing the individual to disease. This
important in the movement of both body fluids and should be resolved to restore a physiological com-
air by producing pressure differentials within the pensatory pattern. This can be achieved by address-
body cavities. They are considered the main rota- ing the osseous attachments of the diaphragm
tional/torsional components in the body's com- utilizing a direct approach, or by addressing the
pensatory pattern. Besides being connected to the fascia by an indirect approach, or by a combination
junctional areas of the spine, the diaphragms are of the two.
also linked with the longitudinal connective tissue
continuity of the body. Distortion of the diaphragms
would introduce a myofascial torsioning of the lon-
gitudinal fascial continuity, and their function as a
vascular pathway of the body would be disturbed. Right Left

Table 8.1 The relationship between the junctions


in the common compensatory pattern in Zink's
respiratory-circulatory model

Spinal Related Autonomic


Junction level diaphragm action

The upper C0-C3 The tentorium cerebellae PSNS


cervical and the falx cerebri (also
complex part of the RTIVT)
The thoracic C7-T1 The thoracic inlet SNS
inlet diaphragm {Sibson's
fascia)
The thoracic T12-L1 The thoracoabdominal SNS
outlet diaphragm Figure 8.1 The common compensatory pattern (CCP), the spe-
cific finding of alternating fascial motion at the diaphragms of
Lumbosacral I5-S1 The urogenital or pelvic PSNS the junctional areas of the body as described by Zink. (Modified
complex diaphragm after Glossary of osteopathic terminology. Chicago: American
Association of Colleges of Osteopathic Medicine; 2002.)
The r e s p i r a t o r y - c i r c u l a t o r y model of o s t e o p a t h i c care 163

A BRIEF DISCUSSION OF THIS MODEL


Right Left
Using Zink's (and TePoorten's) compensatory and
non-compensatory patterns in evaluation and
management of patients has many advantages.
First of all, it is inclusive, which means that your
approach to the patient is global, not focal. It is rel-
atively descriptive: the sequencing allows you to
approach patients who are acutely ill or hospital-
ized. Where, after your examination, you do not
understand the chaos of findings, following the
descriptors will take care of approximately 80% of
the body's dysfunction. The model focuses on res-
piration and circulation, crucial factors in restor-
ing and maintaining health. It acts as a sort of
American GOT. 11

Within Europe many would find this prescriptive


treatment approach anathema. However, that does
not invalidate the fascial torsion patterns and the con-
Figure 8.2 The uncommon compensatory pattern: the specific
finding of alternating fascial motion at the diaphragms of the sequences that this will have on the fluid exchange.
junctional areas of the body opposite to that of the CCP. Perhaps a more flexible treatment approach will
(Modified after Glossary of osteopathic terminology. Chicago: enable this useful conceptual model to be applied
American Association of Colleges of Osteopathic Medicine; more widely.
2002.)

CONCLUSION
BA TePoorten describes the structural pattern
of dysfunction that is to be found in the CCP. 10

This is a very short section, in essence dealing purely


Me advocates that these dysfunctions should be
with Zink's Respiratory-Circulatory Model of
resolved and suggests that, once this is achieved,
Osteopathic Care. This is included here as the model
most of the associated problems should be
has at its roots a very simple concept, that of correct
resolved.
breathing being of great importance in completing
1. Pelvic torsion with the left mominate being pos- the cardiac cycle and thus ensuring the optimum
terior and the right anterior with a consequent perfusion of the body's tissues. At first glance
left elevated pubic tubercle. it appears to be somewhat naive and, with
2. The sacrum is in a left on left torsion. TePoorten's model, prescriptive. However, if you
3. Right rotation and left side-bending of the lum- take on board the concept uriderpirtning the model,
bosacral articulation. and then incorporate it into the conceptual models
4. The thoracolumbar junction is left rotated and that you already have, it becomes an interesting and
side-bent. important and perhaps different perspective that
5. The tenth rib is held in inspiration, being infe- will add to the efficacy of your treatment. An imme-
rior and posterior. diate example that is cited about Zink's treatment is
6. Rib five is in inspiration and anterior to its left that he utilizes a HVT to ring the fluid out of the tis-
equivalent. The fifth thoracic vertebra is in sues, not a thought that would immediately have
extension and right rotation. sprung to mind.
7. The third thoracic vertebra is right rotated caus- Little has been said here about CSF circulation
ing the left rib to be anterior. and cranial treatment. It is addressed slightly in
8. The first rib is elevated on the left. Section 3, but as there is a plethora of articles cur-
9. The first and second thoracic vertebrae are rently available on this subject, and the concepts are
rotated to the right. changing very rapidly, a search on the web for the
10. The upper cervical complex (C2) is in side- most recent concepts would be more appropriate
bending right and left rotation. than anything written here.
164 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

References
1. Guyton AC, Hall JE. Textbook of medical physiology. In: 6. Still AT. Philosophy and mechanical principles of
Royder JO. Fluid hydraulics in human physiology. J Am osteopathy. Kirksville: lournal Press; 1902: 105.
Acad Osteopath 1997; 7(2):11-16. 7. Millard FP. Applied anatomy of the lymphatics.
2. Wernham J, Hall TE. The mechanics of the spine and Kirksville: lournal Printing; 1922.
pelvis. Maidstone: Maidstone College of Osteopathy; 8. Zink IG. Applications of the holistic approach to home-
1960. ostasis. AAO Yearbook; 1973.
3. Goldthwait JE, Lloyd T, Loring T et al. Essentials of 9. ZinklG. Respiratory and circulatory care: The
body mechanics in health and disease, 5th edn. conceptual model. Osteopathic Annals 1997; March:
Philadelphia: JB Lippincott; 1952. 108-112.
4. Keleman S. Emotional anatomy. Berkeley: Center Press; 10. TePoorten BA. The common compensatory pattern. The
1985. lournal of the New Zealand Register of Osteopaths 1988;
5. Royder JO. Fluid hydraulics in human physiology. J Am 2:17-19.
Acad Osteopath 1997; 7(2):11-16. 11. Fossum C. Personal communication; 2003.

Recommended reading
Little is written on Zink's model other than the articles referenced Millard FP. Applied anatomy of the lymphatics. Kirksville:
here; these are of interest. For an historical perspective Millard's Journal Printing; 1922.
book makes interesting reading.
165

Chapter 9

The total osteopathic lesion

INTRODUCTION
CHAPTER CONTENTS

Introduction 165 The total osteopathic lesion is a concept that under-


Historical perspective/origins 165 pins the entire practice of osteopathy. It is founded
The total osteopathic lesion 166 on the humanist perception of care, looking at the
Comparisons with other concepts and models patient as a whole person, the sum of their mind,
body and spirit, and being aware of all of the influ-
169
ences, both internal and environmental, to which
The practitioner as part of the total osteopathic
they are subject in everyday life. Then by assessing
lesion 171
their import and impact on the patient, trying to
Practical application of the total osteopathic determine how these factors may be contributing to
lesion 173 the specific complaint that the individual has con-
Concluding thoughts 174 sulted you about and their response to these influ-
References 175 ences generally.
Recommended reading 175

HISTORICAL PERSPECTIVE/ORIGINS

It is possible to see in the writings of AT Still that he


saw humankind from more than just a somatic per-
spective. He stated that 'man is a triune when com-
plete', a triune being an integration of the mind,
1

body and spirit, and that the duality of the mind


and body was an intellectual fabrication. 2

We know from his students that Littlejohn's


teaching was based on this more global perspective
from as early as 1905. He taught that 'adjustment
was the fundamental principle of osteopathy, [and]
that its application embraced every conceivable
form of structural, functional or environmental mal-
adjustment that might affect the human organism'. 3

The structural element included all of 'the skeletal


and articular problems, and also to include the soft
tissues, the intercellular and intracellular structures
in an attempt to affect the tissues on an atomic
166 OSTEOPATHIC CONCEPTUAL (PERCEPTUAL) MODELS

level'. Functional was the 'chemical change in the • Emotional, physical, chemical
structures', and as these structures are made up of • Neural, mechanical, chemical.
biochemical elements there must be adequate nutri-
tion. The environment included the 'air, sunshine As can be seen from Figure 9.1, the terms psycho-
and psychic stimuli'. He believed that 'biochemistry logical, mechanical and physiological have been
or nutrition, psychology and environment [were] used, with some degree of subdivision. The central
equally important links of the chain of osteopathic area, where all three circles overlap, represents the
theraperutics'. It is fascinating to reflect on the
3
combined influence of these three factors to which
breadth of his conception and how advanced his the individual is subject.The circles can be perceived
ideas were. as the internal expression of these groupings. The
The total lesion concept was reified by HH Fryette whole of this is surrounded by the environment.
in 1954. He studied at the Littlejohn College in
4 This exerts an overruling influence, which can affect
Chicago, and was therefore exposed to Litlejohn's the individual via any or all of the three groupings.
ideas. He also drew on the concept that Dr AD We will now look at each of these aspects in greater
Becker had originated in the late 1920s which he depth.
termed the 'total structural lesion'. This consisted of
'the primary structural lesion plus all of the resulting THE E N V I R O N M E N T
mechanical complications and compensations, and
that all of these related mechanical factors should be The environment is perhaps one of the most influen-
thought of as one mechanical lesion and should be tial elements. Reflecting on the concepts expressed
considered en masse'. This definition is very much
4
in biotypology, there are certain characteristics of a
rooted in the slxucturomechanistic approach that was biotype that are immutable, referred to as the 'con-
current at that time. stitution' or 'somatotype'. However, the 'tempera-
Fryette expanded on Becker's total structural ment' defines those aspects that can change. Vannier
lesion, mcorporaring a broader range of factors. He states that it is the dynamic state of an individual
dropped the word structural from the name, being 'which represents the sum of all the possibilities of
content just to use 'total lesion'. The total lesion is the subject - physical, biological, psychological, psy-
'the composite of all the various separate individual chic and dynamic. During the life of the human
lesions or factors, mechanical or otherwise, which being their temperament alters, either getting better
cause or predispose to cause disease from which the and better, or, thwarted by environment or illness,
patient may be suffering at the moment. These fac- becoming progressively weaker until the character-
tors may vary from corns to cholera, from "nervous- istic signs of disease appear whether physical, bio-
ness" to insanity'. This clear statement reiterated
4 logical, mental or psychological'. It can be seen
5

those concepts that are tacit in the writings of Still, from this that Vannier shared the holistic approach
and placed osteopathy firmly in the realms of that underpins the total osteopathic lesion and
holism. understood the key role that the environment
performs in sculpting the individual in health and
disease.
THE T O T A L OSTEOPATHIC LESION Our interaction with the environment occurs on
several different levels. On the physical level, this
The word osteopathic became incorporated some includes the manner in which the body is used at
time later, so that now it is generally referred to as work or recreationally, and what traumata, micro
the total osteopathic lesion. It is often represented and macro, acute and chronic, it is exposed to
schematically by a Venn diagram (Fig. 9.1). through these and other sources.
The terms utilized in such a Venn diagram vary Psychosocially, we all exist in a collection of
from author to author. A selection of commonly settings, i.e. family, work, racial, religious and
occurring ones are listed below; however, whatever recreational settings. Each of these will shape our
terms are used, the principle of the triune is the psychoemotional attitude, and will be overlain by
same. the influence of the current Zeitgeist. Elements of
these will be constructive, such as an excellent
• Mind, body, spirit support network of friends and family, and others
• Psychology, biomechanics, physiology destructive: divorce, trouble with the boss. Early
The total osteopathic lesion 167

Environment

Work

Family Current situation


Psychological
Emotional
Mental health
Spiritual

Us
Mechanical Physiological
Micro- and macrotrauma Diet, substance usage
Acute/chronic