Osteopathy addresses the patient as a whole system and it refers to a set of techniques used by Osteopaths for the treatment of musculoskeletal, myofascial, cranial and visceral dysfunctions. It is the combination of three different “approaches” - Structural, Visceral and Cranial Osteopathy - and the use of one or the other specific technique depends on the patient's needs and not on the “style” that the Osteopath prefers.
This means that not only structural techniques can improve musculoskeletal issues, but also visceral and/or cranial techniques can contribute to alleviating musculoskeletal symptoms if any relationship has been found between the two parts. Similarly, structural techniques can help to manage symptoms of visceral conditions (e.g. Irritable bowel syndrome - IBS).
Why is there a tendency among Osteopaths to divide their practice between different styles?
Nowadays, the lack of scientific evidence within Osteopathy has unfortunately led to polarizing the views of the profession. The evidence-based medicine (EBM) culture has regrettably divided the osteopathic profession into two opposite categories compromising the profession itself. On one hand, there are white-coated technicians robotically performing set treatment protocols for specific symptom pictures based on scientific evidence. On the other extreme are those who use patient-centred techniques (such as Cranial Osteopathy), for which there is no plausible biological model and an absence of scientific evidence of effects, despite positive clinical experience and patient feedback.
From my humble point of view, I try to stand in the middle of the debate! In my practice, I try to integrate approaches based on scientific evidence and techniques based on positive clinical experience and unequivocal feedback/reactions of patients, even though the research has not yet explained the causal mechanism behind their effectiveness.
WHAT IS STRUCTURAL OSTEOPATHY?
Structural Osteopathy is the most commonly used approach and is the foundation upon which modern osteopathic training is based. it is directed toward the treatment of the musculoskeletal system for the relief of pain and improvement of motion. Joints are moved, muscles are massaged and stretched, exercises are prescribed and in so doing the treatment effect can help the nervous system, the blood supply or organs function.
The main actor of Structural Osteopathy is joint manipulation, which is mainly performed on the spinal column but also on the rest of the body’s joints.
What are joint manipulations?
Manipulations, also commonly known by the name ‘adjustments’, consist of a quick thrust to a joint over a very short amplitude, thus the name ‘high-velocity thrust’ (HVT). They are often also associated with an audible ‘crack’ or ‘click’ (which often feels very satisfying) and they can be applied to various joints in the body.
Contrary to old false myths, the click is not produced by bone rubbing on bone and there is no evidence to suggest that this technique can cause arthritis. The pop sound occurs within the synovial fluid of a joint (a lubricant within the joint capsule that reduces friction) and it consists of the dissipation of nitrogen gas bubbles due to the change in fluid pressure from the thrust.
When done safely and skillfully, Manipulations/HVTs provide several beneficial effects. They help to:
Improve joint movement and synovial fluid dynamic
Relieve nerve/joint impingement
Reduce the swelling of a joint capsule.
Reduce muscle tension.
Release endorphins (which modulate inflammatory processes and promote analgesia).
Increase the range of movement.
Relieve back pain, when performed on the spinal column.
Even though manipulations can be very beneficial, it is important to understand they do not realign the bones. The common belief that manipulations are used to put bones back in place is just another wrong old theory.
Finally, evidence shows that audible pop is not necessary for successful HVT manipulation and to achieve its benefits. It does not represent a successful manipulation procedure and it should not be the focus of the clinician or the patient during spinal manipulation. It has been highlighted symptoms markedly improve even though the HVTs are not accompanied by the cavitation sound.
If you are wondering what to expect from a general Osteopathic appointment click here.
WHAT IS VISCERAL OSTEOPATHY?
Visceral Osteopathy is a technique used within the osteopathic practice. It is not a separate profession. By contrast, it is part of the expertise Osteopaths have to address the patient’s needs.
It looks at the relationship between the physical structures of the body and the organs, such as the digestive tract, respiratory system or genitourinary tract.
The link between the visceral and musculoskeletal system is made by the attachments of the organs and structures involved: the organs are not merely contained within the body compartments of the throat, thorax, abdomen and pelvis and many of them are fixed relatively solidly and uniformly to the surrounding framework. However, they are not immobile!
Organs naturally move (for example during the diaphragmatic excursion with respiration) and this mobility could be disturbed in the same way that articular mobility can be altered. From a physiopathological point of view, these disturbances can trigger, increase or maintain musculoskeletal (e.g., low back pain) or gastrointestinal complaints (e.g., irritable bowel disorders).
Consequently, to better address the patient complaints from a holistic point of view, Visceral Osteopathy proposes that these visceral mobility disturbances should be detected by palpation and treated by manipulations as well as any other musculoskeletal dysfunction of the body.
Any strain in the connective tissue of the viscera resulting from surgical scars, adhesions, illness, posture or injury can create tensional patterns form through the fascial network deep within the body and consequentially generate a cascade of effects far from their sources for which the body will have to compensate.
As I mentioned before, Visceral Osteopathy is another tool in Osteopaths’ hands for approaching a patient’s issues. Therefore, the Osteopathic visit will remain the same.
Firstly, an initial consultation will take place before any active treatment or management begins. Questions about your problem will be asked, as well as your general health and medical conditions will be investigated. All the information you will share is confidential, they will be recorded in your case notes.
Then, the consultation will be followed by a physical examination: you will be requested to do some movements in order to observe your posture and mobility, as well as passive tests and orthopaedic evaluation, which will also be executed. During the assessment, the Osteopath will perform some visceral osteopathic tests, which consist of gentle palpation of the abdominal area and the thorax to detect any tenderness or visceral mobility disturbance.
After the assessment, a unique treatment plan will be proposed to meet your needs. This will include a discussion about what the treatment will consist of, the number of sessions you are likely to need (this number may change and it depends on the patient’s response to treatment) and some lifestyle adjustment and/or home exercises program you will be advised to do to recover faster.
If your condition requires further medical investigations or if Osteopathy is not the most accurate therapy for your problem you will be referred to your GP or another medical specialist. Most patients are likely to receive treatment during the first initial appointment.
During the treatment, if some visceral techniques are needed, the Osteopath will explain to you their aim and execution. Any technique will be performed without having previously gained your consent. At any time, if you do not feel comfortable with any approach proposed, you will be free to express your disappointment and the Osteopath will find alternatives.
When Visceral techniques are received, some people are likely to experience different sensations, while others might not experience anything and feel the benefits afterwards. Common sensations are visceral gurglings and sounds, mild tension, aching or sensitivity that gradually disappears, feelings of warmth and abdominal relaxation.
Evidence shows Visceral Osteopathy can help to reduce lower back pain and it can be beneficial for some digestive problems.
Overall, despite huge positive clinical experiences and patients’ feedback none of the theoretical aspects of Visceral Osteopathy has received wide empirical and scientific support yet. This is the reason why some Osteopaths may not use Visceral Osteopathy in their practice.
** Be aware Osteopaths who use visceral manipulations usually do NOT perform internal pelvic techniques. Mistrust practitioners who claim to use them unless they are not qualified under another title. **
WHAT IS CRANIAL OSTEOPATHY?
Cranial Osteopathy, as well as Visceral Osteopathy, is part of the osteopathic practice and it is not a separate profession. It is another technique/approach that can be used during the osteopathic visit, according to the patient's needs.
Its focus is the study of the mechanisms in the cranium and their interrelationship with the body as a whole. Even though the name can create some misunderstandings, Cranial Osteopathy approaches and treats somatic dysfunctions of the head and also other parts of the body.
It is a gentle type of approach and treatment designed for all age groups, from babies and children to adults. It is an alternative to physical manipulation, stretching and massage.
Nowadays, the principles and effectiveness of Cranial Osteopathy are still debated and evidence is still limited. However, its origin dates back to 1930, when its founder William G. Sutherland, DO observed and claimed that:
the bones of the skull are mobile
there is 'inherent' motility of the brain and spinal cord
there is the motility of the meninges (layers of membranes that protect the brain and spinal cord)
there is involuntary motion between the sacrum and the ilia, which is synchronised with the cranial motion by the spinal dural meninge.
This rhythmic motion, called Primary Respiratory Mechanism (PRM) is also transmitted by fluids or fascia throughout the body and it can be palpated simultaneously at any place.
The fascia is a connective tissue that wraps bones, muscles and organs and connects all the different parts of the body. It has a fundamental role in Cranial Osteopathy: it represents where alterations of the PRM and somatic dysfunctions can be appreciated, palpated and treated.
The aim of Cranial Osteopathy is to remove these fascial dysfunctions, improve the patient wellbeing and boost the recovery process.
Sometimes just working on the muscles and the bones might not be 100% resolutive because some further tensions can be contained and transmitted through the fascia. Cranial Osteopathy can integrate, support and boost even more the musculoskeletal approach of Osteopathy.
Cranial Osteopathy is a very gentle and relaxing approach. Even though it might seem very passive (from outside no much appears!), the practitioner aims to release and re-balance areas of dysfunction (sometimes even not too close to the location of complaint but deeply related to it through the fascial connection).
Overall, the Osteopathic visit will not significantly change.
Firstly, an initial consultation will take place before any active treatment or management begins. Questions about your problem will be asked, as well as your general health and medical conditions will be investigated. All the information you will share is confidential, they will be recorded in your case notes.
Then, the consultation will be followed by a physical examination: you will be requested to do some movements in order to observe your posture and mobility, as well as passive tests and orthopaedic evaluation, which will also be executed. During the assessment, the Osteopath will perform some cranial osteopathic tests, which consist of gentle palpation of specific areas of the head and the body in order to check any alteration in the fascial system.
After the assessment, a unique treatment plan will be proposed to meet your needs. This will include a discussion about what the treatment will consist of, the number of sessions you are likely to need (this number may change and it depends on the patient’s response to treatment) and some lifestyle adjustment and/or home exercises program you will be advised to do to recover faster.
If your condition requires further medical investigations or if Osteopathy is not the most accurate therapy for your problem you will be referred to your GP or another medical specialist. Most patients are likely to receive treatment during the first initial appointment.
During the treatment, if some cranial techniques are needed, the Osteopath will explain to you their aim and execution. Any technique will be performed without having previously gained your consent. At any time, if you do not feel comfortable with any approach proposed, you will be free to express your disappointment and the Osteopath will find alternatives.
When Cranial techniques are received, some people are likely to experience different sensations, while others might not experience anything and feel the benefits afterwards. Common sensations are mild tension, aching or sensitivity that gradually disappears, and feelings of warmth, relaxation or emotional relief. Regarding the latter, the fascial system is deeply connected with emotions and somatic dysfunctions can relate to stress, anxiety and emotional distress.
Some studies show that Cranial Osteopathy can be beneficial for:
managing symptoms of chronic conditions such as fibromyalgia and chronic fatigue
headaches (especially tension-type headaches)
improving sleeping patterns, global health and quality of life
reducing anxiety and stress
treating babies (Paediatric Osteopathy)
Overall, even though some studies show the clinical benefits of Cranial Osteopathy, there is still heterogeneous and insufficient evidence to scientifically support it. For this reason, some Osteopaths may not use Cranial Osteopathy in their practice.
Bibliography:
Anne Jäkel, MSc, DPhil et al (2011). Therapeutic Effects of Cranial Osteopathic Manipulative Medicine: A systematic review. The Journal of the American Osteopathic Association.
Axel Müller DO MSc et al (2014). Effectiveness of Osteopathic Manipulative Therapy for Managing Symptoms of Irritable Bowel Syndrome: A Systematic Review. The Journal of the American Osteopathic Association.
Eileen L. DiGiovanna, DO FAAO et al (2005). An Osteopathic Approach to Diagnosis and Treatment (THIRD EDITION).
Florance BM et al (2012). Osteopathy improves the severity of irritable bowel syndrome: a pilot randomized sham-controlled study. European Journal of Gastroenterology & Hepatology.
Guillaud et al (2018). Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review. BMC Complementary and Alternative Medicine.
Janine Leach (2008). Towards an osteopathic understanding of evidence. International Journal of Osteopathic Medicine.
Jon Parsons DO PGCE MSC Ost et al (2008). Osteopathy Models for Diagnosis, Treatment and Practice.
Timothy W. Flynn, PT, PhD et al (2003). The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. The American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.
