1. Osteopathic Manipulation
Peter D. Muench, D.O.
NCC PCSM Fellow

2. Outline History Principles of Osteopathy Basic Terminology Techniques
Workshop
A. T. Still, M.D., D.O.

3. Dr. Andrew Taylor Still
Mid 19th Century frontier physician and Civil War surgeon
Dissatisfied with conventional “heroic” medicine
Devised new system of disease prevention and treatment through mechanical manipulation
Wanted to treat cause instead of effect
Founded first school of Osteopathy in Kirksville, MO in 1894

4. Osteopathic History 20th century struggle for recognition
Unrestricted Medical License in all 50 states ( )
Federal recognition 1966: entry into DoD Medical Corps
AMA recognition 1969
LTG Ronald Blanck, DO

5. Core Principles
1. The body is a unit, and the person represents a combination of body, mind, and spirit.
2. The body is capable of self-regulation, self-healing, and health maintenance.
3. Structure and function are reciprocally interrelated.
4. Rational treatment is based on correct understanding of the above principles.

6. Somatic Dysfunction
Impaired or altered function of ANY part of the soma: skeletal, myofascial, and related vascular, lymphatic and neural elements
Diagnosed via PALPATION
Freedom of motion vs. Restricted motion
Findings
T – tenderness
A – asymmetry
R – restricted range of motion
T – tissue texture changes

7. Tissue Texture Changes
Acute
Immediate
Vasodilation
Edema/swelling
Increased moisture
Heat/redness
Rough texture
“Boggy” tissue
Chronic
Longstanding
Fibrosis
Pruritic
Cool
Ropy or stringy tissues
Dryness
Thin texture

8. Barriers to Motion Physiologic Barrier Physiologic Barrier Restrictive
Anatomic
Barrier
Anatomic
Barrier
Tissue Damage N
Active ROM
Passive ROM

9. Manipulative Techniques
Direct
Soft Tissue
Muscle Energy
HVLA
Myofascial Release
Indirect
Counterstrain
Facilitated Positional Release
Myofascial Release

10. Soft Tissue Techniques
Relax hypertonic muscles
Stretch passive fascial structures
Enhance local circulation, improving local tissue nutrition, oxygenation, etc
Identify somatic dysfunction
Provide general state of relaxation

11. Muscle Energy Technique
Direct technique
Precisely controlled position
Patient actives muscles on request
Examiner provides a distinctly executed counterforce

12. High Velocity Low Amplitude
Specific joint mobilization
Corrects loss of normal ROM
Not “putting back” something that is “out of place”
Short, quick thrust through restricted barrier
Does not require a “pop” for success
Advanced technique that requires knowledge, practice, and experience

13. Strain / Counterstrain
Spontaneous release by positioning
Find tenderpoint
Find position of comfort with patient relaxed
Hold for 90 seconds
Passive return to neutral position
Recheck tenderpoint
Safe, simple to perform, well tolerated

14. Myofascial Release Direct and Indirect technique
Fascia is a seamless web of connective tissue surrounding and connecting muscles, organs, and skeletal structures
Fascia can tighten in any plane of motion as a response to illness or injury – there is also a corresponding looseness
Treatment uses varieties of traction, twist, shear, and compression forces applied three-dimensionally
Integrated technique – requires experience

15. Questions?

16. Workshop – Soft Tissue Suboccipital Inhibition Patient supine
Pads of examiners fingers in suboccipital tissues just inferior to nuchal line
Lift and support patient’s head, gravity pulls down to table
Repeat as necessary

17. Workshop – Soft Tissue Cervical stretching Patient supine
Examiner crosses arms under patients heads with fingers on anterior shoulders of patient
Can stretch in flexion, roatation, and sidebending
Can combine with Muscle Energy Technique

18. Workshop – Soft Tissue Over/Under Thoracic
Patient seated, examiner facing patient
Patient crosses arms, examiner reaches under patient’s arms and over shoulders to t-spine soft tissues
Examiner leans back drawing patient towards you while exerting downward and anterior pressure on soft tissue with pads of fingers
Can combine with deep articulatory technique

19. Workshop – Soft Tissue Supine Lumbar Rotation with Counterleverage
Patient supine with flexed knees and hips
Pull patients knees toward you with caudad hand, reach under lumbar soft tissues with cephalad hand
Pull up on lumbar soft tissues, push knees away from you
Repeat, bilaterally if necessary

20. Workshop – Soft Tissue Prone Lumbar Pressure with Counterleverage
Patient prone, stand at patient’s hip level
Contact lumbar soft tissues on opposite side of patient with cephalad hand, grasp ASIS with caudad hand
Pull up on ASIS, kneed down on lumbar soft tissues
Repeat, bilaterally if necessary

21. Workshop – Soft Tissue Rhomboids
Patient lateral recumbent, treatment side up
Grasp superior shoulder with cephalad hand, reach under patients arm and grasp medial scapula with caudad hand
Time stretching with patient inhaling
Repeat as necessary
Be sure to maintain positive control of shoulder girdle

22. Workshop – Muscle Energy
Technique:
Position bone, joint, body part at position of resistance (Restrictive Barrier)
Instruct patient to lightly resist – away from the barrier with 20% to 30% of strength, while examiner provides equal counterforce (no movement)
Hold for 3 to 5 seconds, then patient relaxes
Take up slack, move to new barrier
Repeat 2 to 4 times as necessary
Reevaluate

23. Workshop – Muscle Energy
Application:
C-spine planes of motion
T-spine planes of motion
L-spine planes of motion
Hip Flexors/Extensors
Knee Flexors/Extensors
Hip AB/Adductors
Hip Internal and External Rotators

24. Workshop - Counterstrain
Technique
Find tenderpoint / triggerpoint
Remember T.A.R.T.
Find position of comfort with patient relaxed
Attempt to find 75% to 100% relief in position
Usually requires shorteneing of local musculature
Hold for 90 seconds while lightly palpating/monitoring tenderpoint
Passive return to neutral (patient relaxed)
Recheck

25. Workshop - Counterstrain
Application:
C-spine tenderpoints
T-spine tenderpoints
L-spine tenderpoints
Ribs
Iliosacral points

26. Workshop - HVLA Thoracic Multiple Plane Seated, “Shotgun”
Patient seated, stand behind patient
Place small pillow between patient’s back and your epigastrum
Patient’s fingers interlaced behind head
Place your hands under patient’s axillae and contact dorsum of wrists
Patient takes deep breath and exhales while bringing elbows together
Examiner simultaneously exerts anterior-superior HVLA thrust through epigastrum and arms
Retest range of motion

27. Workshop – HVLA Prone, Crossed Hand Thoracic, “Texas Twist”
Patient prone, stand of symptomatic side of patient (side of prominent posterior thoracic process)
Patient turns head towards you, arms at sides
Cross your arms, near hand points towards patient’s head, hypothenar eminance over area of dysfunction
Your oppostite hand contacts transverse process of segment below on contralateral side of spine, fingers point towards patient’s feet
Patient takes deep breath, on exhalation apply gradual downward and torsional force to barrier, then quick HVLA thrust using momentary drop of body weight
Recheck range of motion