Although the teaching at most osteopathic training establishments world-wide has been predominantly structural in approach, there is a considerable interest, and validity, in many of the more newly developed methods. Indirect methods are generally less invasive in application, although they may be no less effective in action. They require just as long to perfect as direct methods, but give the student or practitioner who is not experienced in direct technique an ability to treat the patient immediately in a generally safe and comfortable way.
Indirect methods should not be an excuse for inefficiency in technique. They should be a supplement and complement to primary methods, and add a dimension to treatment that cannot be gained as easily with structural approaches. There are some cases that will only respond to some of the indirect techniques, but these are rare, and conventional structural technique remains the mainstay of osteopathic practice for most practitioners.
Increasingly, as knowledge of these methods spreads, they are being integrated with the more common structural methods as adjuncts, as supplements, or as a substitute in some situations. Most experienced practitioners unconsciously use a combination of approaches. No single method has all the answers to all mechanical dysfunction problems in the neuro-musculo-skeletal system.
The reasons for the development of indirect technique are interesting and varied according to location. In some countries it has been due to a backlash against the powerful manipulative methods in common usage, and is seen to be more holistic and cooperative rather than being confrontational. In some quarters it has been due to the ever increasing fears of litigation when 'manipulation' is performed and an articular sound is heard. This can lead to accusations of possible harm and wrong results. That a well-constructed treatment based on good technique using structural methods should not be painful or traumatic is clearly not considered by individuals who use powerful and uncomfortable methods. There may be many reasons why practitioners continue to use such approaches. They may not have been trained sufficiently in gentle and effective technique, or have not been able to acquire the skills adequately. They may feel that firm force is an essential requirement, or that it is what the patient expects. In my view, excessively high force is generally a sign of weakness in approach. Force conceals weakness. This is not to say that force is not necessary, but simply to state that the minimum force capable of producing the required result should be the aim of the thinking, caring practitioner.
The various categories of indirect technique therefore have many uses and possible advantages. In this section the description of these methods is not designed to be a full exposition, but simply an introduction. Experienced practitioners of these various methods may be somewhat irritated by my attempts to simplify and abbreviate the systems, but this simplification is the whole purpose of this section. The reader is referred to the bibliography for more details of literature relating to each of the various types of technique and treatment. There are many other methods in use, and this list is not as comprehensive as some might like; however, I have tried to include the main methods in wide use by osteopathic practitioners. Although no method 'belongs' to any system, some approaches are more commonly practised by other manual therapists such as chiropractors and physiotherapists. I have tried to remain essentially osteopathic and to try to reflect the main methods in use in Great Britain rather than that in world-wide. From my travels and observation elsewhere, I suspect that the British situation closely resembles most other countries. There may be regional and national differences that are due largely to the lack of availability of technique teachers.
I have tried not to be judgemental in my comments, but only to speak as a structural osteopath who has eclectically incorporated many other methods into my armamentarium as I have found them useful. There are some methods that I rarely use, but I may incorporate some of their principles, if not the techniques themselves. The various methods are listed alphabetically.
Cranio-sacral technique was first described by William Garner Sutherland DO. He was a student of Andrew Taylor Still, so clearly got some of his knowledge from the fountainhead of osteopathy. He postulated the possibility of movement between the cranial sutures and bones and that they could become dysfunctional. He put forward the idea that these dysfunctions were amenable to manual manipulative methods. The technique rapidly grew to include some basic concepts. These were:
1. The existence of an inherent motility of the central nervous system.
2. An inherent motility and pulsatile nature of the cerebro-spinal fluid.
3. The existence of reciprocal tension membranes, namely the meninges, particularly the falx cerebelli and the tentorium.
4. The mobility of the cranial bones around articular axes.
With the combination of these principles, and a range of holds and techniques, the cranio-sacral system and dysfunctions in movement patterns can be addressed. The head is held in a variety of predetermined holds, and the practitioner 'tunes in' to the cranial rhythmic impulse (CRI). This rhythmic impulse is described as being an ebb and flow of approximately 10-12 cycles per minute. He may find disturbed movement or flow. If this is the case he can apply gentle forces to stimulate the potency of the system and the fluid drive to perform any correction deemed necessary. The sacrum can similarly be treated with holds that allow it to float on the fluid drive and free itself, guided by the practitioner. The dural attachments to the sacrum can be freed to allow better function at the upper end of the system in the cranium. As time has passed, the concept has been developed to make it applicable to most structures of the body via the CRI. The impulse is best located in the cranium, but can be felt to a greater or lesser extent all over the body. Treatment using this principle can be applied to many structures remote from the head. For this reason, many practitioners now like to refer to treatment of the involuntary mechanism, rather than cranial osteopathy.
Although cranio-sacral techniques were at one time the exclusive province of osteopaths, they are now (like most techniques) being used increasingly by other manual therapists. However, the fuller implications of cranial work with whole body health seem only to have been considered in detail by osteopaths. Osteopaths using cranio-sacral techniques often treat many conditions other than local head symptoms and many good results are produced. There is substantial interest, and increasing evidence of the particular benefits in neonates and small children, although the techniques can be used with efficacy in all age groups. Of all the systems of indirect technique, cranio-sacral methods are probably the one approach used by some practitioners as an exclusive treatment tech nique. This shows the effective nature of the approach. If it did not produce good results, they would not be able to sustain a private practice with its sole usage.
Functional technique was evolved by Bowles and Hoover, DOs in the USA in the first half of the twentieth century. It has been extensively developed by Professor William Johnson DO, in Michigan. It is a system of osteopathic technique based on the premise that segmental dysfunction is palpable as an increasing resistance to motion demand in certain directions in a lesioned segment. This has been called the bind sensation. Any dysfunction will have certain pathways of 'ease', where resistance to movement is felt to progressively collapse. The 'bind' states can be treated by finding a pathway of least resistance in the segment. If all directions and pathways of 'ease' can be found this should allow 'quietening' of proprioceptive feedback and 're-setting' of Gamma gain in tendon and joint receptors.
The dysfunction can be detected by a variety of methods including palpatory awareness of limitation of movement quality rather than range of motion. He then assesses the responses to find which ones bind, and which ones ease. Whereas conventional manipulation challenges barriers to 'break' them down, functional technique eases the segment into a multiple movement pathway of accumulating ease. This aims to aid relaxation of the adnexial tissues and produce more harmonious mobility. It is based on the concept that afferent feedback to the spinal cord is disturbed in a dysfunctional segment. The proprioceptive mechanisms are maintaining this disturbance, and by passing the segment into a pathway of ease, the afferents will quieten. This should lead to a reduction of efferent firing. The sum effect of this is to cause a new setting of the afferent to efferent balance, and a more harmonious movement pattern. Although the physiological explanation is open to ques tion considering more up-to-date thinking, the validity and effectiveness of the method is not in doubt.
Holds have been developed for treatment of most articular structures. Although the principles of moving away from a barrier are opposite to conventional structural technique, they can be integrated with other treatment techniques very easily to form a combined system. The system is guided purely by palpatory feedback from the tissues and is, therefore, dependent on good palpatory skill. Conventional manipulative skill gives the practitioner the ability to perceive accumulating barriers. Functional technique requires the skill to palpate disintegrating barriers. This may take some conversion of thinking and awareness, but most can acquire it fairly quickly with suitable instruction.
Gentle therapeutic manipulation (GTM) is a system of active patient movement guided by the practitioner in specific directions and in specific order. The active movement of the patient is monitored by gentle pressure in particular directions over the dysfunctional area by the operators' fingertips. It was first demonstrated in Great Britain by John Spence DO, in 1994. The system originated in New Zealand, and like many of these indirect approaches, evolved from a combination of other methods.
Immediate change in perceived muscle tension and fascial irritability is apparent after successful treatment using this method. Relatively little is known of this method in Europe so far, but interest is growing as results are seen. It is commonly combined with specific advice as to ice packs and specific exercise as a follow-up to treatment. Although it employs hardly any applied force, there may be tissue reaction due to the changes produced. The rationale is thought to be of joint and tissue release by way of guided pathways of active movement pro ducing a return to more normal harmonious patterns.
Harmonic technique is a system of approach that uses a harmonic pressure against different areas of the body, and allows a natural recoil to take place. It is a re-discovery of some of osteopathy's oldest methods. The early pioneers of osteopathic technique used harmonic oscillating movement as part of their treatment. It became less used as time went by and more linear methods became popular. Although most schools of osteopathy taught some form of rhythmic technique, it was not generally taught as a system in itself. E. Lederman DO re-discovered, classified and re-introduced harmonic methods, and has extensively researched the physiological effects of this, and other methods of manipulative approach.
The patient allows the part being worked to be pushed, pulled or moved in a specific direction, and the natural recoil and rebound of the tissues return it to neutral. This action is repeated in a harmonic fashion until an oscillation is taking place where the operator is acting as a catalyst. The best balanced harmonic rhythm is when the effort on the behalf of the practitioner becomes least. The operator starts the oscillation and changes speed until this dynamic balance is found. The rate of oscillation will vary according to which part of the body is being worked and length of the lever. The technique is continued until a sense of relaxation is perceived in the area being worked. Holds have been developed for most body areas, and the technique can be used as a treatment in itself, or as a preliminary to other categories of technique if desired. It is seen as most useful where the rhythmic pattern of movement of a part has been lost. An example might be as in a severe arthrosis of the hip. Conventional stretching will clearly make some change, but a gentle rolling of the thigh, allowing the natural recoil to return the thigh to neutral, would be a typical harmonic technique. The range of movement might change only slightly, but the quality of movement should improve markedly if the correct harmonic has been found. There will also be circulatory changes stimulated by better relaxation and fluid interchange.
The technique is not merely an oscillation back and forth. There are certain directions that are essential for the system to produce the best results, and amplitude is also important.
There are several possible explanations for the effect of harmonic technique. There are evidently neurological, hydraulic, mechanical and psychological reasons why it works.
Muscle energy technique (MET) was first described by Fred Mitchell Sr. DO, in Michigan USA in 1958, and was developed extensively by his son Fred Mitchell Jr. Much further development has taken place under Ed Stiles DO, also of Michigan. It is a system of therapeutic approach that relies on diagnosis of a mechanical dysfunction, and treatment with active patient resistance in certain directions against the resistance applied by the operator. The barrier to joint motion or muscle function is found and the operator holds the part against this barrier. He then gets the patient to push either away or toward the barrier depending on the required result and effect. After a few seconds, the patient is instructed to relax, and the barrier should have been found to have moved. The new motion barrier is found, and the activity repeated several times. The mechanism is perceived to be a re-balancing of the afferent to efferent feedback from the spinal cord. There are four main methods of approach: isotonic; isometric; isokinetic; isolytic.
Isotonic muscle energy technique is where the operator resists the patienf s active muscle contraction and allows slight movement in the direction of muscle contraction to maintain the muscle in the same tension. The 'retraining' of muscle is perceived to change the tone and body awareness of the muscle so that it can learn a new pattern of useful contraction.
Isometric muscle energy technique is where the operator resists the patienf s active muscle contraction and does not allow movement. This causes the muscle to remain at the same length throughout. This is used to either strengthen the muscle, or to allow the practitioner to use the reflex relaxation after contraction to apply a stretch. It will also produce a reflex relaxation in the antagonist muscle which can then be stretched more easily.
Isokinetic muscle energy technique is where the operator resists contraction of a muscle or group of muscles in the patient and allows a gradual lengthening of the muscle during the resistance. This is perceived to act as a re-education to the muscle to normal movement and contraction patterns.
Isolytic muscle energy technique is where the operator resists the contraction of a muscle or group of muscles in the patient and overcomes the resistance to 'breakdown' the muscle. The patient must resist with enough effort to cause the muscle to contract, but at the same time must allow the operator to overcome the resistance to the effort. The effect of this is for the muscle or muscle group being affected to lengthen under the stretch while it is contracting. This is designed to have the effect of breaking down resistance to movement caused by muscle protection and allowing greater freedom of function.
Each one is designed to have a different action on muscle and can be performed against or with a barrier. Although this concept may now be found wanting physiologically, results of recent research show that the method is in wide-spread and effective use.
Myofascial technique has developed relatively recently as a conglomerate of several different approaches. It has some similarity in approach to some of the cranio-sacral approaches. However, it can be applied to all areas of the body as it works on the muscle to fascia and fascia to bone and viscera interface. It may use some of the principles of muscle energy technique in that resistance is utilized. It uses perception of fascial plane tension in diagnosis and treatment procedures. There are various common methods of application.
The technique is often applied by the operator finding an area of perceived dysfunction and gently guiding it toward more harmonious working with adjacent areas. The pressure will vary, and the time taken will depend on the speed of release perceived by the operator's palpating hand. This is generally a very slow and gentle method that is perceived as relating to the neurological control of the muscle and fascial attachments. This concept relies on accurate feedback from the fascia and muscle state as to the optimum relaxation phase of the area. Control of the phase of breathing is also emphasized.
Some myofascial technique approaches use quite strong stretch along the fascial planes with either single or multiple, slowly applied stretches. Some approaches use diagonal transfascial stretches. One of the chief critical elements of myo-fascial technique success is the use of sufficient time in the hold position to allow adequate fluid interchange and soft tissue 'creep' to take place. Muscles are essentially fluid in life, and as fluid is non-compressible, some of the action is probably produced by sustained pressure allowing fluid to change its position within the fascial tubes.
The two models of approach may seem at variance, but like many other approaches will depend on many factors as to their applicability in any given case. As in most systems of approach, practitioners usually polarize to a particular method. Some may find one method easier; some may prefer the rationale of one method; some may feel one is more effective.
Neuro-muscular technique was developed by Stanley Lieff DO and Boris Chaitow DO, English osteopaths. It employs a system of progressively searching sliding pressure designed to find dysfunctional areas and then treats them with varied directions of deeper pressures. It attempts to 'normalize' these areas by allowing improved circulation and 're-setting' of the neural control of tendons and muscles. Its main action is on connective tissues, fascia and muscle attachments. In the spinal area the practitioner uses thumb pressure on the para-vertebral gutters, directly over the facet joints and using the fingers as a fulcrum, oscillates over each level until the lesion is detected. He then sometimes uses a lubricant such as a massage oil to apply mostly longitudinal pressure repeatedly over the segment in question and one or two adjacent segments.
Neuro-muscular technique can also be applied along the whole length of the spine, concentrating on areas of dysfunction with firmer pressure. It is also sometimes used on the abdomen and limbs. There is a complete system of approach that has been documented to apply it to a wide range of conditions. Although this technique is not as widely used now as it was in the first half of the twentieth century, it has a certain following. It is now not taught in many osteopathic schools. There are some similarities with Rolf-ing and some other deep massage techniques. Practitioners using this method feel that it can produce longer-lasting results than some of the articular-directed techniques.
SPECIFIC ADJUSTING TECHNIQUE
Specific adjusting technique was evolved mostly by the late Parnell Bradbury DO DC
who was a chiropractor and osteopath. He combined the current thinking of the two professions at the time to introduce a system of osteopathic manipulative methods that used chiropractic thinking on malpositioning and replacement. The technique is mostly a thrust approach using extremely rapid yet gentle force that is often performed just short of a facet gapping. It is designed to replace or retrace the pathway of lesioning position, and relies on specific positional diagnosis and specific directions of adjustment. The system was little known or taught for some years until being re-introduced to osteopathic education by Tom Dummer DO at the European School of Osteopathy in Maidstone. It is now being carried on by some of his pupils.
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