The osteopathic viewpoint

Sandier

The osteopathic viewpoint S. E. Sandier A prime tenet of good osteopathic practice is the structure-function relationship. This applies to the viscera as well as the more obvious somatic dysfunction. With this in mind the osteopath begins by taking a detailed case history, looking to find the tissue at fault and then the fault in the tissue. The case begins with standard sociological data regarding Ms Smith and her age, marital status and occupations, both professional and social. Stress does not start just at home; it can be work-related and sport-related too. Changes in circumstances and lifestyle can impose new stresses to an already overburdened system. Different individuals react to stress in different ways. It is important to look at Ms Smith as an individual and not a collection of symptoms. One person copes with divorce; another does not (Jerome 1997). The description of her problem as detailed as possible tells the practitioner what sort of pain she is suffering from and its location (Fig. 1). A specific pinpoint pain or a pain that relates to a specific dermatome or nerve root indicates one structure, whilst a more generalized ache or referred pain can indicate another. The important

word here is 'indicate'. It will not be possible to make any accurate diagnoses on the basis of where it hurts. The description of the pain is also important. Sometimes patients describe their pain in very descriptive or florid language, which can give an indication of how well or not they cope with the problem. The history of the problem, who has seen it before, what tests or examinations have been performed and the results of those tests reveal how Ms Smith has been seen by other health-care workers, be they allopathic or complementary. She would be asked about her former therapists and how successful or not they have been with her. It is easier sometimes coming into the therapeutic relationship late on in the scheme of things. Perhaps your viewpoint is successful only in

the light of other people's failures, or to put it another way, if their diagnosis and treatment had been correct the patient would not be here to see me today! Obviously, their interpretation of the case should not be ignored out of hand just because my discipline is trained to think along different lines. The aggravating, relieving and non-affecting factors will then guide the practitioner along certain lines of thought. The patient should be asked for some description (in her own language) of what makes things better or worse. Ms Smith would be asked if there is anything she has had to give up or stop doing as a result of the pain, i.e. sport or hobbies. The severity of the pain is often revealed in just how much people are prepared to endure. The structure-function relationship is paramount at this point of the

Nature of pathology or dysfunction

Related to systems

• Infection • Inflammation • Degeneration

• • • • •

• Trauma • Neoplasm

Gynaecological Gastrointestinal tract Urinary Liver and biliary Skeletal system with specific Q/A for each

t

Abdominal pain

Stephen E. Sandier DO MRO FECert British Schoolof Osteopathy, 275 Borough High Street, London SE1 1JE, UK Correspondence to: S. E. Sandler Tel: +44 131 407 0222; Fax: +44 171 839 1098 Received November 1997 Accepted December 1997

Does the pain change in relation to function?

Other factors predisposing to ill health

+/+/+/+/-

• • • •

menstruation defecation urination fatty foods

• Psyche Social Stressors Family Expectations

+ / - locomotion Journal of Bodywork and Movement Therapies (1998) 2(2), 78-81 © Harcourt Brace & Co. Ltd 1998

Fig. 1

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The osteopathic viewpoint consultation. It is important to know how tissues react in order to question the patient about them. For example, if the pain is worse with movement what tissue does this implicate? Muscles produce movement but joints are where the movement takes place. If Ms Smith gets the pain on the initiation of motion this might indicate a muscle in spasm that is protecting a joint and not allowing motion. However, if she is stiff on the initiation of the motion and then easier as the motion progresses it might mean that the motion eases the build-up of metabolites in the muscle belly and thus relieves the pain (Lederman 1997). If practitioners knew nothing of neuromuscular joint physiology they could not make sense out of the answer and would just be asking the question by rote. In other words it is useful to know the answer to a question before you ask it! The same is said of the stressrelated factors. It is not enough to think simply 'bone, muscle, disc, etc', as this falls into the allopathic trap of relating everything to histopathology and not the person that contains the problem. We know that Ms Smith is stressed because of the divorce, but how is she coping with that stress? I would ask her just how she feels about her life at this point: does she regard herself as being depressed or just simply uptight about things? Osteopaths are not trained as psychotherapists and so it is not usual to use this information therapeutically. Instead, it relates to the way we think about our patients and how they are coping with their problems (Latey 1996). Why is it that some people will get musculoskeletal aches and others not? Perhaps it is because some people's immune systems are compromised by their previous stress and stress-related problems. The stress might be physiological or psychological. Think of a sports player who is constantly breaking down and producing injury after injury: it may be because of the

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psychological stress of performing at the top that they do not cope with their performances and thus present with muscular problems (Kuland 1982). The visceral links come with the general medical quiz or they may come with the presenting factors if this is how the patient perceives osteopathy and the things that osteopaths treat. Certainly, her general health is vital to the diagnosis. I always ask my patients a simple question: 'when was the last time you visited the doctor for anything at all apart from the present complaint?' If she has a list of problems of varying nature is it because she is immune suppressed or simply has a history of low-grade inflammation? Has she had any virus infections in the recent past, because chronic fatigue syndrome is something that will affect patients' ability to cope with pain (Willard et al 1997). Many factors in her endocrine history, for example, might show in her pain history. If the tissue part of the history revealed a muscular-ache type of problem, fairly non-specific but with acute flare-ups, I would want to know why she presented with these symptoms at this time. It may be stress-related as mentioned before, but if she has an underactive thyroid it might mean that the muscular aches are part of a general background of non-specific aches. Her general medical quiz will include questions relating to every system of the body because her thyroid gland relates to every system of the body. A patient with an underactive thyroid will tend to be constipated, tired, have dry skin or may be losing hair, be suffering from amenorrhoea, etc. (Macleod et al 1988). So we can see that it is necessary to have a detailed knowledge not only of neuromuscular pathology but of general clinical medicine as well. Histopathology is relevant in so much as it provides the osteopath with an understanding of the presenting symptoms, but clinical pathology shows the cases that we can or cannot

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try to help. The same red flags are applicable in all therapeutic settings (Box 1). These might include weight loss, bilaterality of symptoms and known malignant disease that supersedes the previous episode. Red flags are stop lights that should never be crossed without extreme caution and then only if the risk is weighed and taken into account. The next part of the examination is the physical examination, which usually begins with a standing examination to look at the anterio-posterior and lateral plane postures (Box 2). The organs live within the skeletal framework, and a kypholordotic posture or a scoliosis will mean additional stress on the organs attached to the skeletal framework (Rolf 1977). Every organ has a blood supply, venous drainage and afferent and efferent nerve supplies. The descending diaphragm is resisted by the tone of the abdominal muscles and the pelvic floor. Every inspiration and expiration uses the massaging effect of this diaphragm on the abdomen and pelvic organs. It moves them and encourages this blood flow (Scariati 1991). If the skeletal framework is compromised by mechanical strains and pains so will be the motion of the organs. If this is chronic it will lead on to chronic dysfunction (Barral & Mercier 1988). One only has to look at patients with gross degeneration of the hip joints confined to chairs for hours on end by the pain of movement and it comes as no surprise that invariably they are also chronically constipated because they have lost their verticality, which is so essential to normal organ function. The passive motion of the parts assessing how each spinal segment moves in relation to its neighbour and how this movement fits in with the pre-existing expectation as governed by the age, weight and build of the patient dictates just how successful the body is at coping with its lifestyle and just how much it is failing.

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Sandier

Thus, at the end of the first session a competent practitioner should have an idea of the tissue at fault, the fault in the tissue, and which local and general pathology are playing their part in the case in front of them. They can then choose the correct treatment modality, be it osteopathic or otherwise, that is best for the patient. In the case in point, Ms Smith might be suffering from anything from muscular backpain that is stress related, to irritable bowel syndrome. Both would fit the picture given, but it is obvious from the previous paragraphs that the evaluative route taken to arrive at a diagnosis is quite different. Only by using a detailed

knowledge of the structure-function relationship can the final diagnosis come to light, if at all.

Some practitioners use craniosacral evaluation at this point; others use specialized approaches such as an evaluation of the visceral mobility and motility (Barral & Mercier 1988). To some extent the treatment modalities favoured by a practitioner will shape how they frame up the diagnosis. Some practitioners use only structural techniques such as high velocity thrust (HVT) or muscle

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energy technique (MET); others use only craniosacral techniques. Most practitioners use a variety of technical approaches with the same patient depending on their findings (Hartman 1997). At this point standard orthopaedic, neurological or other tests such as blood tests and X-rays come in to play, not to make a diagnosis, but to confirm or deny the previous thought processes.

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The results of the initial encounter can and do change as the patient changes with treatment. The assessment process starts with the first interview and then as the practitioner gets to know the patient better so more can be included in the final evaluation. It never ceases to surprise me just how much my thought processes can change in the course of time. Part of this change is the patients themselves and their perception of the problem. I try to discuss my findings in words that are appropriate to patients so that they have some perception of their problem and the part that they have to play in their recovery. It is not so much that we work on patients as that they lend us their bodies while we try to improve their suffering. At the end we have to give them back and the patients have to go their way in the world whatever we have managed to do for them. Hopefully they will feel better for the process.

REFERENCES Barral JP, Mercier P 1988 Visceral Manipulation. Eastland Press, Seattle, WA Hartman L 1997 Handbook of Osteopathic Technique, 3rd edn. Chapman & Hall, London

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The osteopathic viewpoint/Case study Kuland D 1982 The Injured Athelete, 2nd edn. JB Lippincott, Philadelphia, PA Latey P 1996 Feelings, muscles and movement. Journal of Bodywork & Movement Therapies 1, 44-52 Lederman E 1997 Fundamental of Manual Therapy: Physiology Neurology and Psychology. Churchill Livingstone, Edinburgh

Jerome J 1997 Stress management in primary care. In: Ward R (ed.) Foundations for Osteopathic Medicine. Williams & Wilkins, London Macleod J, Edwards C, Bouchier I 1988 Davidson's Principles & Practice of Medicine, 15th edn. Churchill Livingstone, Edinburgh Rolf I 1977 Rolfing: The Integration of Human Structures. Harper & Row, New York, NY

Scariati P 1991 The diaphragm. In: DiGiovanna E, Schiowitz S (eds) An Osteopathic Approach to Diagnosis and Treatment. JB Lipincott, Philadelphia, PA Willard F, Monler D, Morgane P 1997 Neuroedocrine-Immune System and Homoeostasis. In Ward R (ed.) Foundations for Osteopathic Medicine. Williams & Wilkins, London.

Introduction

General health history

Mary M, a 35-year-old mother of two children, presented to the author complaining of chronic pain in her right iliac fossa. The patient explained that this pelvic pain had persisted for almost 2 years and had recently begun to interfere with her daily activities. The patient also explained that a week before the initial consultation with the author she had 'collapsed' in a shopping centre: a sharp sudden onset of pain in the right pelvic region had resulted in a giving way of her right leg. Mary was an international representative long-distance runner; the pelvic pain had led to her giving up all competitive running.

This patient did not readily disclose her health history and eventually revealed that she had suffered a serious eating disorder during the peak of her running career, dropping her body weight to under 45 kg whilst still running at a high competitive level. She possessed photographs that revealed a considerably thin woman straining to run up a hill during an intemafional event. She explained that she had competed in this particular race some 4 months after the birth of her second child. She stated that her eating disorder was presently under control. Mary reported that she had felt breathless running up hills shortly before the onset of her pelvic pain; she believed that these hills should not have been a problem to her, as she had performed step aerobics every day for some years to strengthen her ability to tackle hills in such a race. The remainder of her general health history was unremarkable.

slightly to the right side (Fig. 1). She stated that the pain had then slowly spread to include most of her right lower abdominal region, before extending to her fight groin and inside thigh. She also stated that she had noted a recent onset of pain over the region of her right buttock. She reported that at first the pain was of a constant, 'niggling' nature that had increased in intensity over a period of 6 months prior to the initial consultation. At the time of the initial consultation she explained that the pain was of a constant deep nature; she was experiencing difficulty in walking upstairs and rising from any seated position. At these times the pain could suddenly become sharp and severe, relieved only when Mary lay supine for up to 10 minutes. After first noticing the pain, Mary reported that she consulted a number of medical specialists. These included her general practitioner, a gynaecologist, a gastrointestinal specialist, a consultant physician, an orthopaedic surgeon and a sports injuries specialist. Mary reported that the only notable finding to emerge from these examinations was that of decreased bone density over the region of the lesser trochanter of the right femur following a bone scan. She was then referred to a specialist sports physician, who injected cortisone in the region of the

Case study P. Noone

Paul Noone BAppSc (Chiro) DipAc

17 Belgrave Square, Monkstown, Co Dublin, Republic of Ireland Correspondence to: Paul Noone Tel: +353 1 2875944; Fax: +353 1 2875944; e-mail: (Paul Noone) chirores@iol,ie Received November 1997 Accepted December 1997

Journal of Bodywork and Movement Therapies (1998) 2(2), 81-87 © Harcourt Brace & Co, Ltd 1998

Chief complaint Mary reported that the onset of her pain had occurred some 2 years earlier; she had first suffered her pelvic pain after a competitive race over a course that had included two steep hills. Mary indicated that her pain was firstly located above her pubic region,

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