6 Principles of Osteopathic Manipulative TechniquesOsteopath ic manipulat ive techniques (OMT) are numerous. Some techniques have been known by more than one name, many new techniques have been developed, and some have seen resurgence af ter years of neglect . They have gone through a metamorphosis in descr ip t ion, and f inal ly , wi th the advent o f the Educat ional Counci l on Osteopathic Pr inciples (ECOP) and i ts Glossary of Osteopath ic Terminology (www.aacom.org/om/ Glossary.doc) , have been s tandard ized into the s ty les descr ibed in th is text .

Direct and Indirect TechniqueI t is somet imes eas ier to understand the pr inciples of OMT according to which barr ier and anatomic area the technique pr imari ly a f fects . The f i rst pr inc ip le rela tes to the nature and di rect ion of the rest r ict ive barr ier . Us ing th is pr inciple, most techniques can be categor ized as d irect or indi rect . Thus, a technique engaging the most rest r ict ive barr ier (b ind, t ight) is c lassi f ied as d irect and a technique engaging the least restr ic t ive barr ier (ease, loose) is c lassi f ied as ind irect .The second pr incip le is associated wi th which anatomic manifestat ion of the dysfunct ion is pr imary (e .g. , muscle versus jo int ) . To determine that a muscle dysfunct ion is pr imary, the second pr inciple d irects the physic ian to use techniques such as sof t t issue or muscle energy rather than h igh-ve loc i ty, low-ampl i tude (HVLA) technique or osteopathy in the crania l f ie ld .General ly , d i rect techniques engage the most restr ic t ive barr ier , and ind irect techniques engage the least restr ic t ive barr ier , which most commonly is descr ibed as the edge of the phys io log ic barr ier (Fig. 6 .1 ) . Frequent ly , however , a dysfunct ional s ta te causes restr ic t ive barr iers to each side of the normal rest ing neut ra l po int . These bi la tera l restr ic t ive barr iers are most commonly asymmetr ic in re ference to thei r d istance from neutral but may be

equal ly and symmetr ica l ly distant ( Figs. 6.2 and 6.3 ).

Figure 6.1. Asymmetric range of motion with a normal physiologic barrier (Pb) opposite the side on which a restricted barrier (Rb) is present.

Examinat ion of the barr iers de l ineated in Figures 6.2 and 6.3 shows that i t is possible to t reat a restr ic t ive barr ier a t e i ther the ease or b ind qual i ty e l ic i ted on the palpatory examinat ion.Many have descr ibed phys io log ic pr inc ip les of mot ion of the sp ine, and most f requent ly the pr incip les stated by Harr ison Fryette, DO, are those pr imar i ly taught in osteopathic medical schools ( f i rs t and second pr inciples of physiolog ic mot ion). These ru les are speci f ic to the thoracic and lumbar sp ine regions, but they have tangent ia l re lat ion to how the mechanics of the cerv ical spine are perceived. Our non-Amer ican manual medicine associates have added other caveats to Fryet te , yet they agree with the basis o f these f ind ings, which have been dupl icated by others (e .g. , White & Panjabi , coupled mot ions) ( 1 ) .Paraphras ing C. R. Nelson (whose pr inciple of mot ion is cons idered the th ird of the three phys io log ic pr inc ip les of mot ion), we see that the in i t iat ion of spinal

P.76vertebral mot ion in one plane wi l l af fect mot ion in al l other planes ( 2 ) . Osteopathic texts have descr ibed th is pr inciple, but always within the context o f a s ingle rest r ict ive barr ier caus ing asymmetr ica l ly rest r icted f ind ings of mot ion potent ia l in an ar t icu la t ion. Expanding th is s ta tement to what we have observed c l in ica l ly would therefore correlate wi th Figures

6.2 and 6.3 . This would also make it feasible to orient classically described direct techniques, such as HVLA, in an indirect manner (which we have seen taught and performed internationally). The most important criteria to understand, whether performing direct or indirect techniques, are the normal physiologic motions of the specific area being examined and/or treated and the compliance of the tissues involved (e.g., acute versus chronic dysfunction).

Figure 6.2. Two restrictive barriers ( Rb ) asymmetrically restricted.

Figure 6.3. Two restrictive barriers (Rb) symmetrically restricted.

Somatic DysfunctionAs stated ear l ier , somat ic dysfunct ion is the d iagnost ic cr i ter ion that ca l ls for OMT. The var ious qual i t ies e l ic i ted on the physica l examinat ion of a pat ient may lead the physic ian to understand that the nature of a dysfunct ion in one region is di f ferent f rom that o f another dysfunct ion in a di f ferent reg ion. Thus, the physic ian may choose to use one technique for one dysfunct ion and another technique for the other . I f a pat ient exhibi ts reg ional mot ion disturbance but in tersegmenta l mot ion is normal, a technique or iented to the art icular aspects of the anatomy may not be ind icated. Or a pat ient might present for neck ache that on examinat ion exhib i ts paraver tebral muscle hyper tonic i ty and genera l tenderness but no speci f ic tender points . Th is pat ient may benef i t f rom a myofascial technique but not counterst ra in , as no counterst ra in tender po ints are present.Some pat ients exhib i t somat ic components of v iscera l d isease, and the t reatment of th is component may have only a l imi ted ef fect , whereas a pat ient wi th a pr imary somat ic dysfunct ion and a secondary v iscera l component may react wel l (somat ica l ly and viscera l ly) to a speci f ic OMT. Other factors in the presentat ion somat ic dysfunct ion may change the thought process in develop ing the t reatment plan. Other v iscera l and autonomic ef fects, lymphat ic congest ion, and gross edema wi l l a l l cause the physic ian to reevaluate the poss ib i l i t ies for OMT and the potent ia l for a number of techniques that may be ind icated in that case.

ContraindicationsContra ind icat ions to OMT have changed dramat ical ly dur ing our years of c l in ica l pract ice because of the development of new and/or modif ied techniques and bet ter understanding of disease processes. The abi l i ty to per form OMT in a range of extremely gent le to more forcefu l manner , combined wi th a d i rect or indi rect approach, has caused us to look di f ferent ly a t the appl icat ion of OMT, genera l ly making the decis ion on a case-by-case basis o f c l in ical presentat ion. This case-by-case or ientat ion may of ten change only the choice of the pat ient 's posi t ion for a technique and not be considered a cont ra indicat ion for

an ent i re technique category. Cer ta in condi t ions, such as f racture, d is locat ion, tumor, in fect ion, and osteomyel i t is , are contraind icat ions for OMT di rect ly over that s i te . However, i t does not preclude OMT to re la ted somat ic dysfunct ion in areas that are proximal or distal to the problem.Other condi t ions that may al ter the physic ian 's op in ion concern ing the appropr ia teness of OMT are Down syndrome, rheumatoid arthr i t is , Kl ippel-Fei l syndrome,

P.77achondroplast ic dwar f ism, pregnancy, st ra ins and sprains, acute herniated in terver tebra l d isc, acute inf lammatory s i tuat ions, anatomic instabi l i ty , hypermobi l i ty , jo in t prosthesis, and severe mani festat ions of v iscera l d isorders. These condi t ions may contraind icate OMT in to ta l or may cont ra ind icate on ly a speci f ic technique in a speci f ic reg ion. The phys ic ian's c l in ical judgment and a complete understanding of the technique are paramount in the f inal decis ion as to whether OMT is appropr ia te.

The Osteopathic Manipulative Treatment PrescriptionThe se lect ion of the technique to be used is pr imari ly founded in the nature of the somat ic dysfunct ion and i ts most prominent mani festat ions. This at las presents 12 osteopathic manipulat ive technique sect ions. Each sect ion has an explanatory preface for the speci f ic technique and the pr inciples of i ts use and appl icat ion. The prev iously stated areas of dysfunct ion (ar t icu lar, myo- fasc ia l , v iscera l , vascular , lymphat ic, and so on) that can be considered dur ing se lect ion of the t reatment p lan may af fect the decis ion to use a speci f ic technique at one dysfunct ional leve l or another, depending on the phys ica l f ind ings ( i .e. , HVLA versus muscle energy versus fac i l i tated posi t ional re lease versus myofascial release or a combinat ion) . Th is wi l l be discussed fur ther and more speci f ica l ly in each of the technique sect ions.The OMT prescr ipt ion is s imi lar to that of the pharmacologic prescr ipt ion: the type of technique is comparable to the category of the pharmacologic agent chosen; the method and/or posi t ion chosen for the OMT technique is comparable to the route of admin is trat ion of the pharmacologic agent ; the forces invo lved in the OMT and whether they are di rect ly or indi rect ly appl ied are comparable to the st rength or dose of the medicat ion; and the repet i t ions, t iming, and durat ion of the OMT are comparable to the amount of medicat ion dispensed and the f requency of i ts administ ra t ion.For example, a 70-year-o ld pat ient who compla ins of chronic low back pain secondary to lumbar discogenic spondylosis, lumbar spina l stenosis, and lumbar somat ic dysfunct ion may be t reated wi th art icu la tory and myofascial sof t t issue techniques weekly over weeks to months. However , a 16-year-o ld pat ient who complains of acute low back pain secondary to a spra in dur ing footbal l pract ice may be treated with a combinat ion of ind irect myofascial re lease, muscle energy, and counterst ra in techniques every 2 to 3 days for 2 to 4 weeks.Simple ru les to guide the implementat ion of OMT are best seen in the dose guidel ines out l ined in the Foundat ions for Osteopathic Medic ine (2 ) . In general , one must understand the nature of the dysfunct ion and the other c l in ical manifestat ions being presented, the sever i ty and energy-deplet ing ef fects of the condi t ion, the age of the pat ient , and whether the condi t ion is acute or chronic. Common medical sense combined wi th a wel l -grounded r isk-benef i t ra t ionale should be the guid ing pr inc ip les.

References1. White A, Panjabi M. Cl in ica l Biomechanics of the Spine. 2nd ed. Phi ladelphia: L ipp incott Wi l l iams & Wilk ins, 1990.2. Ward R (ed) . Foundat ions for Osteopathic Medicine. Phi ladelphia: Lipp incott Wi l l iams & Wi lk ins, 2003.