1. Process Approach in Osteopathy: Beyond the tructural Model
Dr. Eyal Lederman DO PhD

2. A premise in osteopathy
The body (person) has self-healing / self recovery capacity*
* Most of the time

3. Process Approach
Co-create with the patient environments in which their recovery processes can be optimised

4. The three recovery processes
Repair
Adaptation
Alleviation of symptoms
Lederman E 2013 Therapeutic stretching: towards a functional approach. Elsevier

5. Alleviation of symptoms
Recovery environments
Physical, behavioural, psychological, social
Physical, behavioural, psychological, social
Repair
Adaptation
RECOVERY
Alleviation of symptoms
Physical, behavioural, psychological, social

6. Recovery environments
Process
Condition
Specific management
Shared management
Repair
All acute conditions, max 8 weeks:
All tissue damage,
Joint & muscle sprains, post surgery, blunt trauma, first phase of frozen shoulder,
Moderate cyclical and repetitive loading
Applied locally to affected area
Gradual loading
Pain-free / tolerable movement
Can be either active or passive
Any movement pattern but preferably functional. Extra-functional is OK
Psychological
Ease movement pain related anxieties, catastrophising, support, reassure, comfort,
Sooth and calm
Therapeutic relationship - trust, non-judgmental, empathic..
Contextual factors
Cognitive
Inform
Plan
Set goals
Provide choice
Behavioural
Support recovery behaviour
Raise awareness to avoidance behaviour
Physical
Functional movement
Frequent exposure to activity
Adaptation
All chronic conditions:
Post immobilisation contracture, ROM rehab, postural and movement re-education/rehab, CNS damage/rehab, structural/biomechanical change, enhance/recover human performance
Active
Task specific
whole and goal movement
Functional
Repetition
Overloading
Discomfort likely and generally OK
Alleviation of symptoms
Acute/Chronic pain/discomfort
Acute/chronic stiffness
Depending on patient expectations..
Physiologically:
Active may be better than passive movement
Cyclical movement may be better than static approaches
Functional or extra-functional

7. Alleviation of symptoms
Treatment strategy acute injuries
Repair
Adaptation
Alleviation of symptoms
Acute phase
Long term 7

8. Recovery environments
Process
Condition
Specific management
Shared management
Repair
All acute conditions, max 8 weeks:
All tissue damage,
Joint & muscle sprains, post surgery, blunt trauma, first phase of frozen shoulder,
Moderate cyclical and repetitive loading
Applied locally to affected area
Gradual loading
Pain-free / tolerable movement
Can be either active or passive
Any movement pattern but preferably functional. Extra-functional is OK
Psychological
Ease movement pain related anxieties, catastrophising, support, reassure, comfort,
Sooth and calm
Therapeutic relationship - trust, non-judgmental, empathic..
Contextual factors
Cognitive
Inform
Plan
Set goals
Provide choice
Behavioural
Support recovery behaviour
Raise awareness to avoidance behaviour
Physical
Functional movement
Frequent exposure to activity
Adaptation
Alleviation of symptoms

9. Alleviation of symptoms
Post immobilisation / contractures
Adaptation
Repair
Alleviation of symptoms
Reduced ROM 9

10. Recovery environments
Process
Condition
Specific management
Shared management
Repair
Psychological
Ease movement pain related anxieties, catastrophising, support, reassure, comfort,
Sooth and calm
Therapeutic relationship - trust, non-judgmental, empathic..
Contextual factors
Cognitive
Inform
Plan
Set goals
Provide choice
Behavioural
Support recovery behaviour
Raise awareness to avoidance behaviour
Physical
Functional movement
Frequent exposure to activity
Adaptation
All chronic conditions:
Post immobilisation contracture, ROM rehab, postural and movement re-education/rehab, CNS damage/rehab, structural/biomechanical change, enhance/recover human performance
Active
Task specific
whole and goal movement
Functional
Repetition
Overloading
Discomfort likely and generally OK
Alleviation of symptoms

11. Alleviation of symptoms
Chronic pain conditions
Adaptation
Alleviation of symptoms
Repair?
Acute phase
Chronic state 11

12. Recovery environments
Process
Condition
Specific management
Shared management
Repair
Psychological
Ease movement pain related anxieties, catastrophising, support, reassure, comfort,
Sooth and calm
Therapeutic relationship - trust, non-judgmental, empathic..
Contextual factors
Cognitive
Inform
Plan
Set goals
Provide choice
Behavioural
Support recovery behaviour
Raise awareness to avoidance behaviour
Physical
Functional movement
Frequent exposure to activity
Adaptation
Alleviation of symptoms
Acute/Chronic pain/discomfort
Acute/chronic stiffness
Depending on patient expectations..
Physiologically:
Active may be better than passive movement
Cyclical movement may be better than static approaches
Functional or extra-functional

13. Alleviation of symptoms
Treatment strategy acute injuries & post surgery
Repair
Adaptation
Adaptation
Repair
A of symptoms
Alleviation of symptoms
Acute phase
Long term 13

14. Alleviation of symptoms
Frozen shoulder
Repair
Adaptation
Adaptation
Repair
Alleviation of symptoms
A of symptoms
Painful phase
Stiff phase 14

15. Why do we need a new model?
Lack of correlation between structure/biomechanics and development of conditions or symptoms
Structural change is not possible by manual means

16. No association between structure, biomechanics and LBP
Trunk asymmetry, thoracic kyphosis and lumbar lordosis in teenagers and developing LBP in adulthood (Poussa MS 2005)
Elevation of one shoulder, elevation of one hip, and deviation of the spine from the midline of the body to LBP & neck pain (Dieck GS, 1985)
Low muscle strength, low muscle endurance, or reduced spinal mobility and erector spinea pairs imbalances during extension
(Hamberg-van Reenen HH 2007 & Reeves PN 2006)
Lumbar lordosis (Norton BJ 2004).
Spinal scoliosis (Christensen ST 2008 syst. rev.)
Increased lumbar lordosis and sagittal pelvic tilt on back pain during pregnancy (Franklin ME 1998)
Differences in regional lumbar spine angles or range of motion (Mitchell T, 2008)
Pelvic obliquity and the lateral sacral base angle pelvic asymmetry
(Fann AV 2002 & Levangie PK 1999)
Inflexibility of the lower extremities or leg length discrepancy (Nadler SF 1998)
Hamstrings and psoas tightness (Hellsing, 1988)
Correcting foot mechanics have no effect on preventing back pain (Sahar T, et al, 2007)
Lederman E 2010 Fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by LBP. CPDO online journal.

17. The feet in 100 symptom free participants
Static (postural) biomechanical assessment bears no relation to the position that healthy feet adopt during gait
Large numbers of symptom free feet exhibit the so-called ‘structural deformities, ’.
These deformities are not associated with differences in foot kinematics.
They are normal and irrelevant variations in foot alignment.
Jarvis HL et al 2017 Challenging the foundations of the clinical model of foot function: further evidence that the root model assessments fail to appropriately classify foot function. Journal of Foot and Ankle Research
Garbalosa JC et al 1994 The frontal plane relationship of the forefoot to the rearfoot in an asymptomatic population. J Orthop Sports Phys Ther.20:200–6. 43.
Keenan AM et al 1996 Video assessment of rearfoot movements during walking: a reliability study. Arch Phys Med Rehabil. 1996;77:651–5.

18. Are manual forces sufficient for overloading?

19. Co-creating a multidimensional environment for recovery
Engage in social/occupational recreational situations that provide exposure to challenges
Person
Alleviate fears
Inform
Encourage
Motivate
Set goals
Support
Psychological factors, cognitions, needs and drives
Amplify recovery behavior
Identify activities that challenge movement loss
Develop with the patient their scheduling of movement challenges
Behavior
Recovery
Process
Be all inclusive, psychological neurological and tissue dimension, but prioritise management
Lederman E 2013 Therapeutic stretching: towards a functional approach. Elsevier

20. Functioncise: functional approach to self-care
Functional movement - the unique movement repertoire of an individual.
Functional rehabilitation - the process of helping a person recover their movement capacity by using their own movement repertoire (whenever possible).
Extra-functional – a movement pattern outside the individual’s movement repertoire
Lederman E Neuromuscular Rehabilitation in manual and physical therapies. Elsevier

21. Process vs. Structural Structural Process
Self healing / recovery premise
Management focuses on creating ideal biomechanical conditions for recovery
Management focuses directly on recovery processes
Manual techniques or physical activities aim to correct structure or biomechanics
Manual techniques or physical activities support recovery processes
Medical diagnosis + biomechanical and anatomical considerations
Medical diagnosis + by which process will the individual improve
Tissue causing symptoms
Identifying underlying recovery processes. Tissue identification not essential for management
Therapist or clinically determined management goals
Patient determined management goals
Structural change as therapeutic target
Patient determined functionality as therapeutic target
Management in the biomechanical dimension
Multidimensional management
Therapist dependent / external locus of health
Emphasis on self-care / independence / autonomy internal locus of health
Pathologising normality (postural deviations, asymmetries, imbalances, etc.)
Focus on pathways/opportunities to recovery. Positive messages and empowerment
Recovery occurs during the clinical sessions
Recovery occurs in individual’s environment
Exercise dissimilar to human movement (extra-functional)
Functional – management created from the patient’s own movement repertoire
Education – anatomy rules
Education – processes rule

22. Alleviation of symptoms
Clinically
A. By which process will this person recover?
RECOVERY
Repair
Adaptation
Alleviation of symptoms
B. Consider this management
Process
Condition
Specific management
Shared management
Repair
All acute conditions, max 8 weeks:
All tissue damage,
Joint & muscle sprains, post surgery, blunt trauma, first phase of frozen shoulder,
Moderate cyclical and repetitive loading
Applied locally to affected area
Gradual loading
Pain-free / tolerable movement
Can be either active or passive
Any movement pattern but preferably functional. Extra-functional is OK
Psychological
Ease movement pain related anxieties, catastrophising, support, reassure, comfort,
Sooth and calm
Therapeutic relationship - trust, non-judgmental, empathic..
Contextual factors
Cognitive
Inform
Plan
Set goals
Provide choice
Behavioural
Support recovery behaviour
Raise awareness to avoidance behaviour
Physical
Functional movement
Frequent exposure to activity
Adaptation
All chronic conditions:
Post immobilisation contracture, ROM rehab, postural and movement re-education/rehab, CNS damage/rehab, structural/biomechanical change, enhance/recover human performance
Active
Task specific
whole and goal movement
Functional
Repetition
Overloading
Discomfort likely and generally OK
Alleviation of symptoms
Acute/Chronic pain/discomfort
Acute/chronic stiffness
Depending on patient expectations..
Physiologically:
Active may be better than passive movement
Cyclical movement may be better than static approaches
Functional or extra-functional

23. Find out more www.cpdo.net
Lederman E 2010 The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. CPDO Online Journal.
Lederman E 2011 The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. Journal of Bodywork and Movement Therapies.
Lederman E 2015 A process approach in physical therapies: beyond the structural model.
Lederman E 2017 A process approach in osteopathy: beyond the structural model. Int. J. Ost Med.
Lederman E 2017 Prozessorientierung in der Osteopathie: ein Ansatz jensiets des Structurmodells. Osteopathische Medizin 18. Jahrg 3/2017, S 23

24. Find out more: Read the article + workshops: www.cpdo.net
Online workshops:
and Skype group supervision
Contact: 24