Diagnostic Principles

Because osteopathic manipulative treatment is aimed at restoration of function, the diagnosis of dysfunction within the somatic system is a crucial starting point. As Dr. Still’s writing was ripe with concepts and barren with practice, the clarification and development of these topics is ongoing within the osteopathic profession.

The primary structural diagnosis in osteopathic manipulative medicine is “somatic dysfunction.” This is defined by the AOA glossary of terms as “impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements.”⁵ This broad definition is important for two reasons: (1) it creates a definitive concept around a palpatory experience and (2) it extends the scope of dysfunction to a zone greater than that of the neuromusculoskeletal system, that of the visceral and cellular functioning of the human organism.

This diagnosis is based on palpatory findings within the musculoskeletal system. The classic acronym for establishing a diagnosis of somatic dysfunction is STAR, which stands for sensitivity, tissue texture change, asymmetry of palpatory landmarks, and restriction of motion. Sensitivity may be identified as the patient’s experience of nociception to palpation, that is, tenderness, although sensitivity could be identified as hypalgesia, dysesthesia, or paresthesia. Tissue texture change is the appreciation of a palpatory difference of resilience of the examined tissue when compared to the surrounding area or an area of mirror image tissue; zones superior, inferior, or contralateral to those examined. Descriptors such as “boggy”, “ropy”, “banded” are commonly used to document alterations from the patient’s individual baseline reference. Asymmetry of palpatory landmarks is easily appreciated by the beginner at shoulder heights, iliac crest heights, or relative lengths of the lower extremities at the medial malleoli. Less obvious are discrepancies between the heights of the occipital condyles, anterior and posterior superior iliac spines, or pubic tubercles. More difficult to appreciate are prominences of rib angles, transverse processes of the vertebral segments, and the relative depths of the sacral sulci. Restriction of motion is the final examination criteria for the diagnosis of somatic dysfunction. This restriction of motion is generally very small and limited to one segment or joint but can extend to surrounding segments. Through the process of segmental definition, a practitioner evaluates a patient with greater and greater tissue specificity until a segmental diagnosis such as T3 flexed, rotated right, and side-bent right is determined. These diagnoses are based upon the normal motions of the regions being examined and are named according to their respective motions of ease rather than restriction. Therefore, in the example, examination would have found the third thoracic vertebrae was relatively restricted in its motion of extension, rotation to the left, and side-bending left when compared to the segments T2 and T4.

Diagnostic Process

In addition to conventional medical diagnostic procedures, palpatory examination leading to segmental diagnosis of somatic dysfunction is essential to the practice of osteopathic manipulative medicine. Typically, the process of coming to a diagnosis usually involves some measure of palpatory screen, scan, and finally, segmental definition. Screening is the process of palpation and movement designed to answer the question, “Is there a problem?” Scanning answers the question, “Where is the problem?” and segmental definition answers the question, “What is the problem?”⁶

The screening structural examination is a rapid assessment of tissue texture and motion asymmetries throughout the body, evaluating the differences in tissue texture and motion in the major regions of the body: head, cervical, thoracic, ribs, lumbar, sacropelvis, upper extremities, and lower extremities. This is accomplished by broad-based palpation using an open, flat hand to assess tissue tension in two of each of these regions and determine if there is a differential tension at any of them. For instance, screening examination of the lumbar spine consists of a flat hand placement over the upper lumbar region and lower lumbar region. If there is a difference in tension between those two regions, that difference is noted. Similarly, palpation of the upper extremity checks the tension bilaterally in the upper (humeral) arm and separately at the lower (radio-ulnar) arm. Regional motion is assessed by testing for the relative extent of passive (practitioner-directed) motion capacity in two planes and noting the presence of asymmetry. For example, the cervical spine is tested by slowly rotating the head on the cervical spine passively to the right and left and noting differences in the endpoint of motion. If the spine is capable of rotating more to the left than the right, that difference is noted. Typically, two separate motions are used to screen any region just as two areas are palpated in any region. Again, in the cervical spine, rotation and side-bending are typically tested. A presence of asymmetry in tissue tension and motion in any of the regions is considered prima facie evidence of somatic dysfunction and demands a scanning evaluation.

The scanning examination is one that narrows the finding of somatic dysfunction to a segment, rib, or joint. This is accomplished by a more focused palpation over the region assessing changes in tissue texture that are more specific to the region involved. For instance in the thoracic spine, palpation along the zone of the transverse processes, segment by segment, will help to identify the segment that is dysfunctional, usually by noting a firmness of the surrounding tissue as compared to the segmental transverse process above and below it. This finding is then confirmed through motion testing by initiating passive side-bending or rotation in the thoracic spine and then observing the tissue response to that motion and comparing that response to motion in the segments above and below it. For example, after screening the thoracic spine and finding it to be dysfunctional, a scan is performed and the 5th thoracic segment displays increased tissue tension at the region of the transverse process when compared to the transverse processes above and below it. With the patient’s arms crossed (to eliminate unconscious external stabilization), the trunk is side-bent to the left and an assessment of ease or bind at the 5th thoracic segment is identified as compared to the segments above and below. If restriction to motion is identified with left side-bending, there will be ease to right side-bending of the thoracic spine. Typically, a restriction to motion is more easily appreciated on palpation, but conventionally, the segment is always described in its direction of ease; therefore, the 5th thoracic segment with restriction to side-bending to the left is described as “side-bent right.” The choice of side-bending as a test is completely arbitrary here and passive rotation could just as easily have been demonstrated. The findings of segmental tissue texture change and motion asymmetry determine a positive scan and the next step, segmental definition, must be accomplished if any treatment is to be considered (Fig. 18-1).

Figure 18-1 Scanning the thoracic region. This figure demonstrates the position for determining segmental response to regional rotation of the thoracic spine.

Segmental definition is the process of finely tuning one’s scan and focusing palpation and motion testing to account for all possible motion characteristics that occur at the particular segment or joint. To continue our example of the 5th thoracic vertebrae, we identified that motion ease is palpated in lateral side-bending to the right.³ Additionally, we must further check rotation right and left, flexion and extension, anterior or posterior translation, cephalad or caudad translation, or ease in response to the respiratory cycle of inhalation or exhalation. Again, this testing is done passively with the operator moving the patient in all of the aforementioned planes of motion with a palpating hand checking for tissue response to that movement. This provides the most accurate and detailed type of definition for a vertebral segment. Segmental definition of joints of the extremities is a natural extension of the scan for that region. Because motion restriction is detected asymmetrically in the extremities, that motion is more definitively described according to the major motions, but also the minor or secondary motions, such as glide and translation. While these secondary motions are significant in the vertebral column, these subtler motions in the extremities often hold the key to defining dysfunction and, hence, treating it.

This style of diagnosing somatic dysfunction is but one method of approach to this problem. It is a simple, yet comprehensive approach to the entire body. There are as many approaches to defining somatic dysfunction as there are practitioners of osteopathic manipulative medicine, but they each contain some portion of the steps elucidated herein. What is simple is not always easy. Palpating for these tissue texture changes and motion characteristics seems simple when described, but the psychomotor skill of applying these techniques is extremely difficult to begin to appreciate and takes many years to master. As in many other aspects of medicine, the learning process continues until death. Osteopathy has the unique attribute of revealing itself through its patients to the practitioner, if he or she approaches it with open eyes, an open heart, and thinking fingers. My patients teach me every day, and new clues to a greater appreciation of osteopathy are revealed to me, unexpectedly, enriching my experience and my ability to help them.

Muscle Energy Treatment: Lumbar

Muscle energy treatment was developed by Fred Mitchell, Sr., DO, as a way to approach problems directly without high-velocity, low-amplitude thrusting.⁷ This is a direct technique in which the operator moves the dysfunctional segment toward its restrictive barrier and then stabilizes it while the patient applies an isometric contraction away from the barrier. This contraction is held for 3 to 5 seconds and the patient is instructed to discontinue the contraction. At that point, the operator readjusts the position of the segment to accommodate for the muscle relaxation and lengthening that has occurred, and moves the segment into a new barrier. This sequence is repeated until maximum improvement in the segmental findings is achieved. The advantage of this technique is that the force that is applied is generated by the patient and monitored by the physician. Dr. Fred Mitchell, Jr, DO, who wrote extensively about his father’s technique, explained that the anatomy in a patient’s own (body) was more precisely and intimately known to the patient’s muscles than they could be to any examiner. For this reason he said, his father chose to use the energy of the patient’s muscles instead of his own for the corrective forces.⁷ This alleviates the danger or unnecessarily overzealous application of an externally applied force. Difficulties with this procedure usually surround the localization of force by the practitioner, lack of stabilization against the isometric contraction on the part of the physician, and too great a force applied by the patient. The force applied need only be great enough to engage the tissues at the level of the localized, treated segment. Too great a force can become too diffuse and difficult to localize around the segment, it may also be too strong to oppose by the physician. The treated segment must be stabilized in its position against the barrier and if that stabilization is compromised because the physician is trembling against the force of the patient, it will be impossible to maintain a stable position at the barrier. Muscle energy technique, when properly applied, should not look like a wrestling match.

The lumbar spine is identified as the lower five vertebrae resting on the sacrum. These are large vertebrae with no rib attachments. Primary motions at these segments include flexion, extension, side-bending, and rotation. The intervertebral discs support the vertebrae, providing both a cushion for shock absorption and a stable, yet flexible interface between the segments, allowing for movement. The remainder of the vertebrae include a pedicle and spinous process creating the spinal canal; transverse processes bilaterally and articular processes above and below the transverse process that create functional joints with the spinal segments superior and inferior to it. These processes form the zygapophyseal or facet joints, true synovial joints in the lumbar spine. Between the pedicles of each of the vertebral segments course the peripheral spinal nerve roots.⁸

Pain in the lumbar spine is common and multifactorial.⁹ It is beyond the scope of this chapter to discuss all of the possible causes of back pain; more importantly, there is much speculation about the true etiologies of any of these types of pain. Common pathologies occurring in the lumbar spine that can easily affect the function of the region include: osteoarthritis, herniated nucleus pulposus, inflammatory arthropathy, spondylolisthesis, spondylosis, and ligamentous strain. Although each of these problems has its unique presentation, they each have the capacity to express themselves as a functional limitation of that region, exhibiting signs of somatic dysfunction. Disruption of the normal integrity of the musculoligamentous structures of the axial spine in any location can result in muscular hypertonicity. Because this hypertonicity is usually asymmetrical and is generally restrictive in motion of the spine, diagnosis of tissue texture differences and resultant motion asymmetry is quickly identified. Important in the diagnosis of somatic dysfunction at any location is the appreciation of the anatomic and subsequent physiologic influences any dysfunction can have at local, adjacent regions or distal regions, whether by myofascial continuity or neural irritability.

Important influences that extend from lumbar dysfunction include regional influences. Lumbar dysfunction with its requisite biomechanical changes can affect segments locally adjacent. Because of the physiologic differences between the regions of the axial spine, dysfunction in the lumbar region can influence the appearance of dysfunction in the thoracic spine and sacropelvis and vice versa. As a result of normal physiologic relationships within the viscera and their relationship to the lumbar region anatomically, functions of those viscera can be affected, especially the viscera of the lower pelvis including the large intestine, sigmoid colon, rectum, and pelvic organs. Although this is partly due to the direct effect that a change in normal biomechanics can have on involuntary motions such as those associated with respiration, some of the effect is due to a reflex influence of the somatic system on the autonomic nervous system in the levels of the spine that are affected. In this case, T12 to L2 are most closely associated with the sympathetic cell bodies that provide autonomic influence to the colon below splenic flexure and other pelvic organs. In this way, osteopathic manipulative medicine extends beyond the realm of musculoskeletal pain management and becomes part of a complete system of medicine in which its application begins to influence the visceral function and ultimately the metabolic health of the organism.¹⁰ At this point the encompassing definition of “somatic dysfunction” becomes actualized in its application of treatment.

Beginning with muscle energy treatment of the lumbar spine, let us assume that the practitioner has previously performed a structural screening examination, scanning examination, and obtained a segmental definition of L4 flexed, rotated, and side-bent to the right. According to the previous discussion this implies ease in the direction of diagnosis and restriction in the opposite directions. Therefore, its motions are restricted at L4 in extension, rotation, and side-bending to the left. Any manner of positioning designed to activate that segment at its points of restriction is appropriate, but for the purpose of this description of treatment, the seated position will be used. Because the nature of this treatment is to provide resistance against the patient’s activating force in an isometric contraction, it is important to consider how one will stabilize the body of the patient while monitoring tissue changes at the dysfunctional segment. Proper body mechanics and choice of positioning allows for the use of as many core trunk muscles of the physician for stabilization and fewer of the muscles of the appendicular skeleton that tend to be shorter and quicker to fatigue. In this case, the patient is seated on the table and the physician is standing behind her on the side of her side-bending restriction. The height of the table or chair is selected to maximize the physician’s ability to apply an adequate counterforce in side-bending by bringing his axilla as close to the superior aspect of his patient’s shoulder on the side of side-bending restriction. The opposite hand is used to palpate the tissue at the dysfunctional segment and monitor for specific localization of forces into that segmental region.

The physician grasps the opposite shoulder by placing his arm across the anterior cervical thoracic junction of the patient and holds the patient snugly. He moves the patient’s trunk passively until the position of restriction is palpated at the previously identified segmental level, which in this case means rotating her trunk to the left and side-bending to the left with lumbar extension until the force of these motions is palpated at L4. The accuracy of the localization of these forces is crucial to the effective application of these techniques (Fig. 18-3). Too little motion and the forces will be localized superior to the segmental region, too much motion and the forces will be directed at a level inferior to the dysfunctional segment. When localization is achieved, the patient is asked to attempt to side-bend and rotate away from the position that she has been put into by the physician. In this case, the patient is directed to, “gently turn to the right.” Generally, only one direction of motion is necessary to activate the force sufficiently to achieve an effect at the dysfunctional segment. Because of normal spinal mechanics, motion in one of the cardinal directions of the spine will affect motion in all the other planes where motion is engaged, so by asking the patient only to rotate, side-bending and flexion are normally engaged. The force of the isometric contraction must be palpated at the level of the dysfunctional segment. The localized isometric contraction is held for 3 to 5 seconds and then the patient is asked to stop turning, or to relax. A moment is given to appreciate the relaxation in the tissues and then the segment is moved into its next restrictive barrier, in this case, slightly further rotated left, side-bent left, and extended. This sequence is repeated as many times as it is needed to effect maximal change, but generally this occurs within five repetitions. At that point, the patient is slowly and gently returned to physiologic neutral, and the dysfunctional segment is checked again for improvement in tissue texture and motion.

Figure 18-3 Position for seated muscle energy procedure in the lumbar spine.

Impediments to the successful application of any of these techniques usually stem from an inaccuracy in the diagnosis or inappropriately applied technique. Whereas an inaccuracy in diagnosis may result from a mistake in interpretation of palpatory findings, more commonly there is a lack of appreciation for the complexity of dysfunctional findings and a missed diagnosis of dysfunction in a seemingly unrelated region that is critical in maintaining the dysfunction that is erroneously being treated as primary. For example, the lumbar dysfunction may be a secondary result of a primary dysfunction in the sacrum. Unless that sacral dysfunction is recognized and treated, the lumbar segment may resolve incompletely or return quickly after treatment. Other common mistakes in muscle energy treatment resulting in lack of complete resolution include, isometric forces too strong or too weak, lack of accurate stabilization resulting in irregular movements during isometric contraction, or returning the patient to a neutral position too quickly.

Muscle energy treatment is easy to apply to all regions of the body although the lumbar region is demonstrated here. Wherever one can identify a structural diagnosis in which one or more planes of motion are restricted, the patient can always be moved into the edge of that restriction and with a series of isometric contractions, change the presence of that barrier. This includes all of the axial skeleton and appendicular skeleton. The physiology of muscle energy treatment is suspected to be an activation of intramuscular proprioceptive fibers called Golgi tendon organs.¹¹ These sensory units are found at the musculotendinous junctions and, when activated, will reflexively cause the motor units to temporarily shut down and relax the muscle tissue. They are thought to have a protective function against overstretching the muscle. By placing the muscle in a position of restriction and then having the patient isometrically contract, these fibers are thought to be activated and then reflexively allow for muscle relaxation. After the next point of restriction or barrier is achieved, the process is repeated until the dysfunction is resolved. Muscle energy treatment is very effective in conditions where an obvious muscular hypertonicity is palpated. It may be too vigorous treatment in an acute injury, although there are no contraindications for its use in that situation. In general, muscle energy treatment is well tolerated by patients and extremely effective in its treatment of somatic dysfunction.

Strain Counterstrain Treatment: Cervical Region

Strain counterstrain treatment, or spontaneous release by positioning, was developed by Lawrence Jones, DO, and first described in the literature in 1964. The initial discovery of this technique is derived from a patient encounter wherein Dr. Jones was having difficulty treating his patient’s low back pain. After treating him several times unsuccessfully, he asked his patient if there was any position that could be comfortable for him. As the patient assumed that position on the treatment table, Dr. Jones began to prop his extremities and support his spine. After achieving that position of comfort, Dr. Jones left the room and went about treating other patients. When he returned to the treatment room, his patient was asleep. He quietly woke him to find that he was pain free. After slowly removing his supports and helping him sit up from the treatment table, the patient exclaimed that he felt better than he had been in months. Shocked at the dramatic improvement, Dr. Jones began to experiment with this type of “spontaneous release by positioning.” His discovery led him to find that dysfunction generally exhibited itself through tender points, discrete areas of tenderness to palpation. As he found these points, he also began to develop treatment positions for them. His initial explorations were on the posterior surface of the body, but later he discovered the importance of treating points on the anterior body that related to those on the posterior surface.¹²

The principle of this style of treatment involves understanding the pattern of trauma, its dysfunctional stabilization, and its eventual resolution. The original trauma is described in the context of a segmental strain. This described scenario creates an overstretch of an agonist muscle and a reflexive contraction of the antagonist muscle. Immediately after the moment of strain, there is a recoil where the agonist muscle attempts to return to its original level of stretch. The speed at which this occurs, however, results in the reflexively contracted antagonist being unable to relax, resulting in a secondary persistent counterstrain of the antagonist muscle. The treatment for this problem involves shortening the antagonist to a point in which spontaneous relaxation occurs followed by a slow return to neutral, eliminating the dysfunction.¹³

The physiology of this treatment is thought to revolve around the activity of the muscle spindle fiber. This intrafusal proprioceptive fiber responds to relative length of muscle. In contrast to the stretch receptors of the Golgi tendon organ, these muscle spindles seem to respond to increasing length by increasing tone as opposed to decrease. Muscle spindles are thought to be related to a reflexive protective mechanism and increasing the resistance to the muscle becoming overstretched. This is modulated by the gamma motoneuron, one of the types of neural fibers responsible for maintenance of muscle tone. By shortening these fibers during strain counterstrain treatment, this is thought to reduce the afferent stimulus to the spinal cord and subsequent down-regulation of the gamma efferent back to the muscle itself.¹⁴ Howell and colleagues demonstrated that osteopathic treatment with strain-counterstrain in Achilles tendinitis resulted in a reduction in stretch reflex amplitude but without changing H-reflex amplitude, suggesting a reset of the intrafusal mechanism without changing the spinal reflex.¹⁵

The principles of treatment are straightforward in their description, but again, the correct execution of this treatment is one that requires practice and patience on the part of the physician. The first step in treatment of dysfunction using strain counterstrain treatment is the identification of the “tender point.” This is usually a discrete, nonradiating area found within the belly of the muscle or at the muscular attachment at a body prominence. Multiple tender points may be found in a regionally related group of muscles and, in that case, the most tender point should be taken and treated first. These tender points are differentiated from myofascial trigger points in that there is not the characteristic radiation of pain that is typical of a trigger point.¹⁶ In order to quantify the amount of tenderness at the beginning of treatment, the patient is instructed that whatever tenderness is being elicited with palpation should be considered a 10/10 in intensity to begin.

Next, the patient is positioned according to her comfort and the position is finely tuned until the pain is considered a 3 or less. Alternatively, the physician may initially suggest that the tenderness is worth one dollar, and query the patient as to when the tenderness is worth a quarter or less. This is the most unique aspect of any of the osteopathic treatments. As previously mentioned, osteopathic treatment is one that focuses on dysfunction and restoration of function and movement. Pain is considered to be a result of dysfunction and not treated per se. Counterstrain treatment is the only treatment in osteopathic manipulative medicine in which the level of tenderness is used as a guide to treatment and as an assessment as to the efficacy of the treatment after it is completed.

While the position of greatest comfort is unique to every patient, there are general rules by which one can easily begin to see what positions will treat what problems. Texts on counterstrain are full with diagrams documenting treatment positions for tender points of all regions of the body, but all practitioners operate with the admonition to watch for “maverick” points that may not follow the typical patterns. Classically, points on the anterior aspect of the body respond to flexion where tender points on the posterior aspect respond more effectively to extension. Tender points that are lateral to the spine generally require some side-bending and rotation away from the tender point. Tender points along the posterior rib angles tend to be relieved by rotation and side-bending toward the side of the tender point with the addition of compression or distraction if the rib is in greater ease with exhalation or inhalation.

Approaching the tender point is a step-wise process. Contact is maintained on the tender point with the palpating finger tip, preferably not the thumb to eliminate the practitioner’s appreciation of his own pulse. Additionally, the finger tips are more sensitive than the thumb to palpation. As the patient’s body position is adjusted to approximate the desired location, the patient is asked, “is this less tender?” If the answer is, “yes,” then a quantification of the improvement is obtained. If improvement is 70% or better, then that position is held for 90 seconds. If, however, the improvement is present but less than 70%, the position is fine-tuned to get closer to the point at which the counterstrained muscle fibers are shortened and afferent barrage from the muscle spindle subsides.

When a position of comfort is obtained, the position is held for 90 seconds. This time length is optimal for allowing a neurologic reset of the gamma efferent barrage and releasing the underlying hypertonicity of the counterstrained muscle. At this time, the tender point continues to be monitored, but no pressure and no activity is taking place. The therapeutic action is based solely on the passive positioning of the patient and the time he or she is in that position. During the 90 seconds that the patient remains in that position, special attention should be given to the comfort of the physician and patient. The physician must hold the patient securely to allow for the patient to completely relax and facilitate the release of the tender point. For that to occur, the physician must be in a position that is supported and comfortable to limit fatigue of tonically held muscles and subsequent tensing of the patient because he or she no longer feels secure.

After 90 seconds of positioning, the patient is slowly returned to the neutral position. This slow return is thought to minimize any secondary reflexive spasm of the treated tissue, re-initiating a tender point and dysfunction. The first 10 degrees of motion are the most crucial and should be accomplished very slowly, following those 10 degrees the return to neutral may be a little faster, but should remain smooth and gentle. Also important is the patient’s complete lack of effort in the return to neutral. At the beginning of the return, the patient is instructed: “I am going to bring you back to neutral and I don’t want you to help me at all. I want you to totally relax and let me do all the work.” This can be difficult for patients as they try to be helpful, particularly if they perceive that their weight is putting an undue strain on the physician’s body. It is incumbent on the physician to communicate firm control to the patient nonverbally by the amount of steady contact, grip, and smooth, controlled motion that the physician exhibits at this point in the treatment.

When the patient is returned to neutral, the tender point is rechecked. At this time, the tenderness should be 70% improved or more. If improvement did not attain that level, then the treatment is repeated; the diagnosis is reevaluated; or the physician should look for another tender point, perhaps in a similar region, but also on the opposite side of the body, anterior or posterior. If suitable improvement is obtained, then other tender points can be treated, or the treatment session may be ended.

As with other osteopathic treatments, the patient is instructed to limit daily activities to only those that are performed on a daily basis for the next 24 hours. This is to limit overuse while the neuromusculoskeletal system is integrating the effects of the treatment and accommodating to the relief of any biomechanical imbalance that may have been present as a result of the diagnosed dysfunction.

Strain counterstrain treatment is an indirect technique. In contrast to muscle energy technique where the functional barrier is approached, an activating force is applied, and then the segment is moved through the barrier, this technique moves the segment away from its resistance into its ease. This movement away from the barrier, combined with 90 seconds of elapsed time, gives the neuromusculoskeletal system a chance to reset its aberrant firing pattern, and is an example of using an intrinsic activating force. This intrinsic force is usually breath or ease of positioning and allows for spontaneous correction. The advantage of using an indirect technique is that the process of release is internally regulated and the potential to cause any harm to the patient through use of external force is minimized. This wide margin of safety and gentleness of technique allows for easy use in acute injury and when significant pain might be present. Therapeutic movements are generally slow in indirect techniques and the goal is generally toward palpable objective ease within the tissue. Treatment with strain counterstrain is specific toward alleviation of discomfort, making it even more attractive when applied to painful situations.

The cervical spine region is unique because it articulates with the cranium superiorly and the thoracic cage inferiorly. Rotation, side-bending, flexion, and extension are all movements of the spine that are integral to the function of the cervical region and important to the organism. As the final common biomechanical pathway from the appendicular and axial skeleton toward the cranium, the cervical spine fulfills an important function for the organism, primarily by directing its sense organs—vision, hearing, smell, and taste—toward the external environment. Its remarkable freedom of movement provides a suspensory function during gait and a stabilizer to the cranium during rapid changes in directional movement. It serves to keep the gaze level and uses remarkable proprioceptive influences to sustain that during normal motion of the body. Closely associated with the cervical spine are the vertebral arteries and carotid arteries, which are crucial in creating the cerebral circulation. Venous drainage of the head through the jugular veins is through the region of the cervical spine. The two halves of the autonomic nervous system are in close proximity in the cervical spine with the cell bodies of the vagus nerve emerging from the jugular foramen of the cranium, providing parasympathetic function extending inferiorly from the brainstem to the level of C2 and the sympathetic cervical ganglia providing afferent stimulation to the head, neck, and cardiac regions. The viscera of the esophagus and trachea have their origins in the cervical spine. The importance of considering the anterior and posterior musculature in stabilization of a particular region is easiest to appreciate in the cervical spine. Posteriorly, the erector spinae group of muscles along with the upper splenius capitis and cervicis muscles interface at the cranial base with the rectus capitis muscles along with the obliquus capitis muscles. Anteriorly, the sternocleidomastoid provides a significant support against rapid extension of the head on the cervical spine, and longus colli and capitis provide support and aid in flexion of the neck. The uppermost two cervical vertebrae are the atlas and axis, both of which are considered atypical cervical vertebrae. The axis, C1, articulates with the cranial base and C2. It lacks a vertebral body or transverse processes. The articulation with the occiput is primarily designed to allow for flexion and extension of the head on the cervical spine, whereas the articulation between C1 and C2 allows for the primary rotation of the head to the right and left. This is because the atlas and axis behave as one segment providing two distinct motion functions. The contact between C1 and C2, the dens and its surrounding ligaments and cartilage is actually a modification of a vertebral body and intervertebral disk. The remaining cervical vertebrae from C3 to C7 are the typical vertebrae with a round vertebral body and intervertebral disc. Unique to these vertebrae are their nearly horizontal articular facets in the superior segments that become progressively more oblique in their presentation as they move inferiorly, but still oriented in an anterior to posterior plane. Additionally, the transverse processes of the cervical vertebrae from C2 to C7 have foramen that allow the passage of the vertebral arteries bilaterally and vertically. These converge over the atlas and enter the foramen magnum where they produce the posterior arch of the circle of Willis at the brainstem.⁸

Because of the anatomy of the articulations within the cervical spine, the dysfunctions tend to occur with rotation and side-bending to the same side. This may or may not occur with an accompanying flexion or extension component because the neutral position of the cervical spine tends to rest in extension with a cervical lordosis. As a result of this neutral extension, any dysfunction that is found and diagnosed with rotation and side-bending to opposite sides is thought to be a result of significant trauma that has created a constellation of forces that impose nonphysiologic motion and function.

When electing to use strain counterstrain, scanning not only includes motion testing but also palpation for tender points in the region where dysfunction has been identified. Again, this necessary palpation for tenderness is a unique feature of preparation of treatment with counterstrain. Identification of tender points can be approached by two methods. In one, a previous knowledge of the typical locations of tender points in the region are known and the practitioner scans for likely locations in the region of the dysfunctional segment. In another, palpable change in the tissue tension, such as ropiness, bogginess, or bands are palpated, the specific tender point is localized, and then the practitioner uses that information to further focus the scan and segmentally define a dysfunction. In either method, identification of a tender point is an extension of, or palpatory evidence of, segmental somatic dysfunction. Importantly, it is not sufficient to simply find a tender point without further investigation as to the defining characteristics of the dysfunction, tempting though it might be.

Treatment positions for tender points in the cervical spine fall into three broad categories. Specific exceptions to these generalizations occur but are beyond the focus of this chapter and necessitate further study. Typically, the two types of tender points are posterior and anterior. The posterior points fall directly over the spinous processes of the cervical spine and generally require passive extension as a position of comfort. An alternative location for the posterior points is just on the lateral and inferior edge of the spinous process (Fig. 18-4). Treatment of these points requires extension, side-bending, and rotation away from the side of the tender point for resolution. The anterior tender points are found along the anterior surface of the transverse processes of the cervical spine and require side-bending toward and rotation away from the side of the tender point combined with flexion of the cervical spine to obtain resolution of the tender point (Fig. 18-5).¹⁴

Figure 18-4 Positioning for treatment of posterior C2 on the right (PC1).

Figure 18-5 Positioning for treatment of anterior C5 tender point (AC5).

Specifically, in the subsequent examples, the positions for treatment of posterior C2 (PC2), posterior lateral C3 (PLC3), and anterior C5 (AC5) are shown. For each of these positions, the previous principles of treatment apply: (1) identify the tender point; (2) find a position of at least 30% improvement; (3) hold the position 90 seconds; (4) slowly return the patient to a neutral position; and (5) recheck the tender point for resolution.

High Velocity Low Amplitude: Thoracic Spine

High velocity low amplitude (HVLA) is a direct technique in which a segment or joint is brought to its restrictive barrier and a short thrust is applied, forcing the segment or joint through the barrier and resolving the dysfunction. This style of manipulation is usually the most recognizable form of manual medicine because it is the most dramatic. This is typically what a patient incorrectly describes when she says, “The doctor cracked my back.” The diagnosis that precedes this treatment is commonly described as “my back being out.” Each of these colloquialisms is inaccurate, in part, and presents misconceptions and oversimplifications, but describes an easily recognizable and memorable treatment experience.

HVLA was the dominant form of osteopathic manipulation taught in the United States for the first half of the 20th century until the advent of muscle energy treatment. Interestingly, although this was so widely taught in the early days of osteopathy, this treatment was probably not what Dr. Still practiced. Through limited descriptions of his treatments in his writings and one short film clip that shows him treating a shoulder, along with writings of some of his students, Still probably did not treat with HVLA, but more likely treated from the myofascial and articulatory perspective, some of which will be described later in this chapter. Dr. Ray English wrote of Dr. Still’s technique “I have seen [Dr. Still] adjust lesions but I have never heard him adjust a lesion.”¹⁷ It is reported that D.D. Palmer, the founder of chiropractic in 1895, visited Dr. Still in 1893, was treated by him, and had numerous meetings with him. After the “discovery” of chiropractic, “the Palmer method” was demonstrated by Dr. C.E. Achorn at the American Osteopathic Association convention in 1900. Although this was described as “a very crude and very poor imitation of the kind of manipulative therapy Dr. Still practiced,⁴” it is thought that Palmer’s influence may have been reabsorbed into the osteopathic profession and elaborated as osteopathic HVLA treatment. The ease of the description of this treatment seems to belie its pervasiveness as the dominant style of treatment taught in the osteopathic colleges until newer methods were developed—eventually leading to the elaboration of Still Technique⁵ (a more developed description of some of the articulatory techniques thought to represent Still’s original style) in the 1990s. Because of its universality of application and simplicity of execution, HVLA continues to be the most popular style of manipulation in osteopathic practice.¹⁸

The skill of execution of HVLA technique lies in the localization of the barrier and the quality of the thrust. In HVLA, the barrier is palpated by movement of regional treatment zones, typically in opposite directions in an effort to “lock out” the barrier. In the axial spine, the zygapophyseal joints are those that are most commonly treated with HVLA. Generally, the anatomy of those joints and their direction of articulation define the motion that is undertaken by the physician to engage the barrier and later, the application of thrust. The name, “high velocity low amplitude”, is an apt descriptor for the type of force applied. Classically, a short 1⁄8-inch thrust is quickly applied to the barrier and then the region is rechecked. This can be a difficult concept for a beginning student to grasp. This thrust quickly moves the articulations apart and often results in an audible pop or crack. No definitive explanation for the therapeutic benefit of this procedure has been agreed on, although neural mechanisms along with alteration in cross-link connective tissue adhesions has been proposed.⁵

This technique is particularly indicated for dysfunctions of a chronic nature in otherwise healthy adolescents or adults. Of all manipulative medicine techniques, those of the high velocity style are fraught with the highest morbidity. Of the regions that can be treated with high velocity manipulation, the cervical spine carries with it the highest morbidity and potential mortality. The American Osteopathic Association published a position paper in 2004 after reviewing the reported adverse events associated with cervical HVLA treatment as well as its benefits and concluded that osteopathic manipulative treatment of the cervical spine with HVLA treatment is effective for neck pain and is relatively safe, especially in comparison to other common treatments.¹⁹ Because of these risks, relative contraindications to use of HVLA procedures include rheumatoid arthritis, Down’s syndrome, bony carcinoma, osteoporosis, and osteomyelitis. The benefit of the application of this technique, in skilled hands, generally outweighs the risk in most situations and provides rapid relief of dysfunction and allows for great patient satisfaction.

Thoracic HVLA Treatment 1: Flexed Dysfunction

As a direct technique, HVLA demands segmental definition diagnosis of somatic dysfunction so an appropriate position into the restrictive barrier can be introduced before thrusting. In this technique, the patient is placed in the prone position and the diagnosed segment is identified. The physician stands to the side of the patient that exhibits thoracic rotation dysfunction and places his hands on the thoracic region with hypothenar eminences on opposite sides of the diagnosed segment (Fig. 18-6). The hands are placed in opposite directions so that the fingers are pointing cephalad on the side of the thoracic side-bending and caudad on the side opposite the side of thoracic side-bending. For example, in the diagnosis of “T5 flexed, rotated, and side-bent right,” the physician stands on the right side of the prone patient and places the hypothenar eminences on the region of the transverse processes with the fingers on the left side of the spine pointing cephalad and those on the right side pointing caudad. This provides a position for creating tissue tension that encourages leftward side-bending. The tissue tension and motion restriction is tested in that position, moving the tissue into the barrier by slightly increasing the side-bending to the left through opposite motions of the cephalad and caudad hands. The patient is instructed to take a deep breath and exhale. Contact with the tissue is maintained through inspiration and followed through exhalation as the barrier is more significantly engaged through slightly greater increases in pressure. At the end of exhalation, the barrier is completely engaged and a slight ⅛-inch thrust toward the table and with both cephalad and caudad pointing hands quickly moving in opposite directions, in a twisting manner.

Figure 18-6 Prone cross-arm HVLA treatment for mid-thoracic dysfunction.

Thoracic Treatment 2: Extended Dysfunction

Treatment of this type of dysfunction is performed with the patient in the supine position. A diagnosis is made of the dysfunctional thoracic segment. For this example, the diagnosis is T5 extended, rotated, and side-bent right. The physician stands on the side of the supine patient that is opposite that of the rotation. In this example, the physician would stand on the left side of the supine patient. The patient is asked to cross both arms across the chest snugly and grasp the shoulders. This provides the elbows as a point of contact for the physician’s sternum, draws the scapulae laterally for better contact with the thoracic spine, and tightens the fascia of the thoracic cage, allowing for a more specific direction of force into the segmental barrier. The cervical-occipital junction is supported with the right hand of the physician, whereas the left hand reaches around and behind the patient to make contact with the dysfunctional thoracic segment. An open-handed fist is used to localize the dysfunctional segment by making contact with the thenar eminence on the rotated transverse process (Fig. 18-7). The patient’s torso is brought anterior into flexion and then relaxed over the open-fist fulcrum balance force between the physician’s sternum, the fulcrum, and the supporting hand on the occipital-cervical junction. When forces are balanced and the barrier is engaged, the patient is asked to inhale and exhale. On the exhaling breath, the physician follows the thoracic cage as it collapses in anterior-posterior diameter and at the end of exhalation, applies a short 1⁄8-inch thrust through the sternum, patient’s elbows, and through the dysfunctional articulation. The direction of this thrust has a slightly cephalad orientation as the motion is intended to create a relative flexion of the thoracic segments that are restricted in extension (Fig. 18-8).

Figure 18-7 Correct placement of thenar eminence on posterior transverse process in preparation for supine HVLA.

Figure 18-8 Positioning for supine HVLA technique in the thoracic region.

Two significant points of refinement in the successful approach to HVLA in clinical practice are accuracy of engagement of the functional barrier and appropriate application of force. The application of force is sometimes described as that amount of force necessary to squash a grape under one finger without sullying your finger with the juice. This is an excellent image of the accuracy, the speed, the type of force, and the slight recoil that occurs in a thrust technique. There is no wind-up and no follow-through. This is a specific and directed application of rapid compression intended only to move the intended segment past the barrier and no more. This force may be accompanied by a sound of pop or click but this is not necessary for the treatment to be effective. Effectiveness of treatment is measured by reevaluation of the diagnosed segment after the treatment is performed.

Localization of the barrier is essential to the appropriate execution of the thrust in HVLA. These treatments often use regional leverage as a way to minimize the amount of overall force applied to a given segment. For example, in the supine application of HVLA to the thoracic spine in the example just mentioned, rotation, side-bending, and the balance of flexion and extension are maximized to localize all forces exactly at the segmental articulations that are dysfunctional. Too much of any of these motions will disturb the focus of applied force either localizing it to an unintended segment or diffusing the force too broadly across multiple segments resulting in an ineffective thrust.

High velocity, low amplitude osteopathic manipulation can be a rapid and effective approach to dysfunction of the thoracic region but can also be applied to any dysfunctional region of the body. Further training allows for discovery of different positions to treat dysfunction of different regions, but the principles of treatment will remain the same. This treatment requires specificity of application of force to be effective and any variation from that specificity increases the likelihood that the treatment will not be effective or potentially harmful.

Myofascial Release: The Extremities

The origin of myofascial release technique in osteopathy dates to the time of A. T. Still. In Principles of Osteopathy he writes: “we think we prove conception, growth, and cause of all diseases to be in the fascia.”³ Given the importance that he attaches to the fascia, it is likely that within his style of technique, treatment of the fascia was given significant consideration. Considering the ubiquity of fascia within the body it is easy to overemphasize or casually ignore its presence. Treatment of the fascia can be superficial or deep and may be applied from a perspective of direct or indirect technique or a combination of the two.

Conventional anatomic approaches to fascia tend to overlook its presence as an obstruction to the study of more exciting tissue, muscles, nerves, vessels, glands, bones, and viscera. The very extent of its presence in the human body belies its importance. Embryologically, this connective tissue network provides the matrix for all of the differentiated organs and tissue to develop and so provides support and guidance as these tissues form. Following ontogenetic development, the fascia supports the entire structure of the human organism and extends its influence from the loose connective subdermal connective tissue inward through muscle septa, perineural tissue, perivascular support, forming visceral and parietal peritoneum, and extending its influence even further to the interstitial connective tissue network between cells. Because of its universal influence, fascia is said to be both continuous and contiguous throughout the whole body. It provides a matrix for the interstitial fluids and the extracellular aspects of the immune system. Functional freedom within the fascial network is essential to the proper functioning of all aspects of the human organism.

Although it is true that this connective tissue network is necessarily influenced by any manipulative technique because of its universal presence, specific myofascial release technique is different in its focused palpatory attention to that tissue. Treatment can be focal such as a superficial connective tissue release over the knee by articulating the relative torsional motion at the fascia of the femur and tibia, or it can be remarkably remote such as treatment of the upper extremity as a long lever in relation to the thoracolumbar fascia and its influence on the pelvis and lower extremity. The diversity of approaches is akin to the phenomena of smoothing out a wrinkle in a tablecloth. One can choose to address the wrinkle directly, smoothing it out with one’s hands; alternatively, one can choose to stand at the end of the table and tug along the length of the cloth until the tension reaches the region of buckling and the slack is balanced again.

Most conventional approaches to fascia and naming of fascia create artificial distinctions between types and locations of fascia: Scarpa fascia, Colles fascia, Buck fascia, Sibson fascia, and so on. The naming of fascia in this manner detracts from its interconnectedness when, in an example of functional anatomic reality, the distinction between the fascia of the humeral and radioulnar joint is indistinguishable in its continuation as the fascia of the biceps and brachialis muscles. Treatment with myofascial release technique becomes first a matter of perspective on the totality of the connective tissue network with its presence and functional importance everywhere in the body.

Myofascial technique often makes use of motion stacking when addressing dysfunctioning from the position of the extremities. Motion stacking occurs when one part of the extremity is moved into a chosen position according to one’s intention and then begins to move another portion of the extremity into another position with the intention of holding the first position. For example, in addressing the upper extremity from a distal to proximal approach using direct fascial technique, first the hand and wrist is moved into a position that engages resistance in as many fascial planes as possible. Next, while maintaining that position with the wrist, the forearm is secondarily engaged in resistance in as many fascial planes as possible. This process is continued proximally along the upper extremity until the motions are stacked into the axilla or proximally. At that point, the phenomena of hysteresis or creep occurs and the fascia will release spontaneously while held in tension. Attention to the different regions of an extremity can be engaged separately also, by first treating the wrist, returning to neutral, treating the forearm, returning to neutral, and so on.

Palpation Exercise

As an introduction to the fascial concept, this exercise in palpation can help to hone one’s palpatory focus to the relative tensions or looseness in the fascia. Start with your patient in the supine position standing at the patient’s right side, just caudad to the wrist. Pick up the wrist and slowly maintain some light tension through the arm and shoulder. Your attention should be tuned to the tension in the connective tissue with the intention of palpating the different levels of tension throughout the different levels of the extremity. Next, turn the wrist into pronation slowly until you feel the engagement of the humerus. Continue to internally rotate the humerus until you begin to feel and endpoint of the connective tissue near the glenohumeral region. When you have found that endpoint, ask your patient to turn his or her head to the right slowly. Observe the changes in tension that occur along the upper extremity during the rotation and after, when at rest in right cervical rotation. After a moment, ask the patient to turn his or her head to the left slowly and feel the differences in tension that occur as there is movement through that rotational arc. Ask the patient to bring the neck into a neutral position again, and again maintain your tension in the upper extremity. When you have regained your palpatory focus, have the patient inhale deeply and hold the breath for a moment. Feel for any changes in the upper extremity with that phase of respiration. Have the patient relax in breathing for a few moments and then, while you maintain your tension, have him or her to inhale deeply, exhale, and hold the exhale for a few moments. Feel for any differences in the tension pattern of the upper extremity while the patient is in that phase of respiration. This exercise begins to increase an awareness of the palpation necessary to perform myofascial release along with an appreciation of the interrelationship of motion at disparate areas of the body and an appreciation of the influence of respiration on the fascial network.

Myofascial Release

Assessment and diagnosis of the extremities is similar to the axial spine in that identification of tissue texture change and restriction in motion are identified and the identified joint motion is named in its motion of ease. The preponderance of dysfunctions in the upper and lower extremity occurs not in the major motions of the joint but in the secondary, often involuntary, motions. These are often gliding or translatory motions that provide an important adaptive role but are generally not under direct voluntary control of the musculature. For example elbow pain can be traced, many times, to a restriction in the medial and lateral translatory glide that is present at the humeral and ulnar joint. This must be tested passively by the physician for a structural diagnosis to be obtained. With the significant number of joints that may possibly be dysfunctional in each of the extremities, a detailed description for testing will not be discussed here but is instead a subject for further study.

Upper Extremity

In this example, treatment of the upper extremity begins with the patient in the lateral recumbent position with the extremity to be treated, off the table. Treatment begins proximally by engaging the fascial tissue surrounding the scapula. The physician’s hand surrounds the posterior portion of the scapula and passively moves it cephalad, caudad, medial, and lateral. When a barrier is reached, the tissue is permitted to release spontaneously or with respiratory assistance as in the palpatory exercise example. Next, the deep fascia of the extremity is addressed by abducting the arm while the fascia of the anterior axilla and then the posterior axilla is stabilized. The fascia of the elbow is next addressed by stabilizing the elbow while slowing supination and then pronating the forearm to the endpoints of motion in each direction. The fascia of the wrist is addressed through slow articular stretching of the radiocarpal joint; the metacarpals are individually articulated with attention to the connective tissue; and the fascia of the phalanges is mobilized as well. Finally, the entire upper extremity is brought into abduction and external rotation, engaging the pectoralis fascia along with the myofascial network of the upper extremity. Next internal rotation and adduction of the upper extremity is performed, engaging the myofascial tissue of the upper extremity along with the posterior trapezius, latissimus dorsi, and other axial fascial connections, superficial and deep (Fig. 18-9).

Figure 18-9 Upper extremity fascial release opening axillary fascia.

The Lower Extremity

Treatment of the lower extremity with myofascial release technique begins by placing the patient in the supine position. This treatment technique makes use of the joints of the lower extremity as anchors for the fascial components of the interarticular soft tissue and the connection of the lower extremity to the pelvis as it engages the myofascial connections in the pelvis, abdomen, and axial skeleton. With the patient in the supine position, one leg is flexed creating an equilateral triangle with the distance between the femur, tibia, and the space between the hip and foot on the table being roughly equivalent. The foot is internally rotated to its fascial barrier, and the caudad hand is placed over the tibial-talar region to stabilize the internal rotation. The cephalad hand is placed on the knee and by moving the knee in a medial direction, the hip is internally rotated to its fascial endpoint. This endpoint is held while the patient is asked to inhale deeply, exhale, and hold the exhale as long as possible. At the end of the exhale, typically just before the patient takes the next breath, the tissue will relax and a new fascial barrier will be reached. This can be repeated until a maximum amount of motion is obtained through the lower extremity fascia. The lower extremity is then returned to the neutral position and the foot is taken out of internal rotation and placed in the neutral position. Next, the foot is externally rotated to its fascial barrier and held with the caudad hand over the tibial talar region. The cephalad hand is now placed on the medial aspect of the flexed knee and the hip is externally rotated to its fascial barrier, the patient is asked to inhale deeply and hold the inhalation until unable to hold it any longer. Again, at the point of exhalation, the tissue will relax and a new fascial barrier is reached. This treatment is repeated until no further release is appreciated. The lower extremity is then returned to a neutral position and the identified dysfunction is rechecked for resolution.

This treatment efficiently addresses dysfunction at multiple levels of the lower extremity and engages the fascia of the anterior and posterior pelvis. Internal rotation of the lower extremity with the knee in flexion and the ankle stabilized creates a relative inversion of the talocalcaneal joint, internal rotation of the tibia, posterior lateral glide of the tibia at the femur, posterior glide of the proximal fibula, internal rotation of the femur at the acetabulum, and associated fascial engagement of the posterior pelvis including the gluteal and piriformis regions. Internal rotation of the lower extremity largely creates the opposite motions and tensional engagement of the anterior pelvis and internal rotators of the hip including the anterior fibers of the gluteus medius and minimus, the adductor longus and brevis, the pectineus, the medial hamstrings (semitendinosus and semimembranosus) and the tensor fascia latae (Fig. 18-10). Myofascial technique can be applied to any area of the body effectively with focused palpation and knowledge of the musculoskeletal anatomy. Although both treatment techniques described here are direct techniques, application of indirect myofascial technique methods is also appropriate by combining palpation and regional motion to find the greatest ease or path of least resistance as the dysfunctional region is moved away from the barrier and an allowance of spontaneous resolution through intrinsic movement toward health and functional homeostasis occurs.

Figure 18-10 Lower extremity fascial release position.

Osteopathy in the Cranial Field

Treatment of the cranium fundamentally applies the principles of osteopathic manipulative treatment for the rest of the body, but involves a greater sensitivity to palpatory cues and appreciation of the subtle motion in the region of the head. Central to the practice of osteopathy in the cranial field is the understanding of the mechanics of the cranium and how that motion is reflected in the rest of the body. A respect for the potentially negative impact of treatment of the cranial region is also necessary and extensive treatment should not be undertaken by the beginner, but should only be attempted after sufficient introductory training by an instructor-led course. To that end, this chapter will cover only principles of cranial technique with an example of treatment that is effective and safe to apply by relatively inexperienced hands.

The origin of cranial osteopathy as an extension of other types of osteopathic manipulative treatment is credited to William G. Sutherland, DO, a student of Dr. Still. The moment of its origination was when young Dr. Sutherland, walked past a model of a disarticulated skull in 1899 at the American School of Osteopathy, and “like a blinding flash of light came the thought—beveled like the gills of a fish and indicating articular mobility for a respiratory mechanism.”²³

This began his study and development of cranial osteopathy. He later wrote that he was merely following Dr. Still’s advice to dig on as Dr. Still earlier wrote, “the cerebrospinal fluid is the highest known element that is contained in the human body, and unless the brain furnishes the fluid in abundance a disabled condition of the body will remain,” and mandated that, “this great river of life must be tapped and the withering field irrigated at once, or the harvest of health be forever lost.”³ Dr. Sutherland devised mechanisms to create dysfunction in his own cranium, studied the effects it would have, and then developed treatments to resolve them. He wrote The Cranial Bowl in 1939 and taught the cranial concept to interested physicians from 1940 to 1953.²⁴

The cranial concept was a development of the mechanical principles of the cranial motion combined with the motion of the cerebrospinal fluid and the relationship of both to respiration. The combination of all three of these aspects he combined as the primary respiratory mechanism. Dr. Sutherland elucidated five fundamental principles of the cranial concept: (1) the fluctuation of the cerebrospinal fluid, (2) the function of the reciprocal tension membrane, (3) the motility of the neural tube, (4) the articular mobility of the cranial bones, and (5) the involuntary mobility of the sacrum between the ilia. Fundamentally, this concept states that primary respiration, the fundamental metabolic cellular process of existence, is driven first intrinsically through the related components of the central nervous system including the cerebrospinal fluid. Although each aspect of the components of the primary respiratory mechanism have been studied in anatomic and physiologic detail,²⁵ this overriding concept of the function of the primary respiratory mechanism remains elusive and falls somewhere between the domains of physiology and phenomenologic epistemology.

While detailed explanations about the palpatory diagnostic findings are well beyond the purposes of this chapter, a cursory illustration of some of the aspects of this concept will be attempted here. The bones of the cranium develop embryologically as either membranous bone or cartilaginous bone depending on their location. In general, the bones of the base of the cranium, the basiocciput and the sphenoid and petrous temporal arise out of cartilage, whereas the temporal squamous, occipital squamous, parietal, early frontal bones arise out of membrane. These slowly approximate each other as development continues after birth until they interdigitate during late ossification and become sutures. These sutures are not fused, but are largely patent with dissectible connective tissue fibers, lymphatics, and occasional nerve fibers present. The patency of the sutures allows for motion and this has been recorded and documented. The motion that occurs at these sutures is reflective of a deeper motion that drives them, and the development of the articulations is a result of that motion. With fine palpation, it is possible to appreciate a subtle cyclical expansion and contraction of the cranium with a rate of 6 to 12 oscillations per minute and with a variable amplitude.²⁶ This motion is first appreciated as a flexion and extension that occurs at the cranial base in the synchondrosis of the sphenoid and base of the occiput. Motion is distributed to the paired cranial bones of the temporal and parietal that articulate the cranial base, and flexion and extension then becomes internal and external rotation. This combination of motions—flexion, extension, internal and external rotation—translates into a palpatory experience of a rhythmic expansion and contraction of the cranium. This motion is intrinsic and primary, but is also associated with respiration and extends its influence to all the tissues of the body as inspiration is linked with external rotation of all the paired bones of the body and exhalation is linked with internal rotation of all the paired bones of the body.

Diagnosis of the cranial region involves a detailed appreciation of the motion of the primary respiratory mechanism including the different movements of the cranial bones and appreciation of the ways in which they can become dysfunctional. As in any other joint of the body, certain common patterns exist and are readily palpated by trained hands. Treatment of the cranial region follows principles that apply to osteopathic treatment of the rest of the body, namely treatments that are direct or indirect in their approach. Direct treatments gently engage the functional barriers to motion of the cranial bones and use respiration or voluntary muscular contraction, including respiration, as activating forces to restore normal function. Indirect treatments move the affected portion of the cranium away from the barrier and allow for intrinsic homeostatic balancing mechanisms, including respiration, to allow for spontaneous correction and restoration of normal function. Again, because the cranium is the home to the brain and brainstem, this action must be performed carefully and with great respect for the impact that treatment can have, not only on the cranium but also on the functioning of the entire organism.

Palpation Exercise

If one is to appreciate the palpatory experience of osteopathic treatment within the cranial field, the following exercise is presented. Treatment of the cranium is usually applied with the patient in the supine position. The physician sits at the head of the table on a chair that is at a height such that the elbows can rest comfortably without disturbing the erect seated posture of the practitioner. One of Dr. Sutherland’s students, Rollin E. Becker, DO wrote about establishing a treating fulcrum in a region other than the hands to allow for the greatest palpatory sensitivity.²⁷ This fulcrum is usually the forearm or elbow and this portion of the upper extremity makes firm contact with the treatment table to allow for less distracting proprioceptive input in the hands and fingers. The hands are lightly placed on the vault of the cranium, thumbs touching and off the cranium to prevent over compression (Fig. 18-11). The index finger rests in the region of the greater wing of the sphenoid posterior to the lateral canthus of the eye. The middle finger rests just superior to the auricle. The fourth digit rests just inferior to the auricle and the fifth digit is posterior and inferior to the mastoid process in the region of the squamous portion of the occiput. When this position is achieved, the physician must take account of the amount of pressure that he is imposing on his patient. The amount of pressure must be enough to make light contact, but no more, because undue pressure can negatively affect the quality of the intrinsic motion present within the cranial vault. The physician checks his posture and relaxes as much as possible, again to reduce the amount of extraneous proprioceptive input, allowing for the greatest sensitivity to subtle motion. Next, the physician focuses on the space occupied between his palpating hands rather than what is happening at the surface under his fingers. Focusing on that space allows for the appreciation of the rhythmic alteration of the shape of the volume under his palpating hands. Commonly, he might first appreciate the rhythmic oscillations of respiration as it is transmitted up to the cranium or the cardiac pulse as it resonates into the cranium, but the cranial rhythm is a movement that is independent from that. With continued practice and refocus it is possible to palpate the cranial rhythm with its 6 to 12 cycles per minute periodicity and variable amplitude. This is the starting point for appreciation of the normal functional movement of the cranium, all cranial diagnosis, and subsequent intervention or treatment.

Figure 18-11 Vault hold.

Treatment: Release of the Cranial Base and Atlas

One of the significant portions of cranial anatomy is reflected in the articulation between the base of the occiput and the atlas. This area is rich with neural, vascular, and fascial structures. The base of the occiput near the atlas is the location of the jugular venous foramen in the articulation between the occiput and the temporal bone. This foramen provides venous drainage from the cranial vault along with the exit of cranial nerves IX, X, and XI. In addition, the cell bodies of the vagal nucleus descend in the upper spinal cord to the level of C2. At the cranial base, the dura still has some freedom of motion before it becomes attached at C2. A small fascial connection between the suboccipital muscles called the nuchal ligament is found in this region also.²⁸ This is the final common pathway for all forces rising from the lower extremities, trunk, and upper extremities as the transition is made from the relatively mobile spine to the relatively immobile cranium. For this reason, release of this region is considered vital to maintaining homeostasis in the organism. Although this is a common location to begin to treat headaches, it is also useful in treatment of visceral problems because of its potential influence on the vagus nerve. If this area is addressed with skill, deep relaxation of the patient is quickly achieved. This parasympathetic “relaxation response” is considered to be a healthy and healing alternative to the hypersympathetic overdrive that we tend to exist in as a culture. The origin of this technique dates to the early days of A.T. Still, when he rested his head on a loop of plough rope, fell asleep and awoke to find his headache had been relieved.¹

This treatment is performed with the patient in the supine position with the physician at the head of the table as previously described. The fingers of the treating hand make contact with the tissue just under occiput in the tissue of the region of the atlas because the atlas has no definitive landmark as a spinous process. The tips of the fingers are gently extended anteriorly into the muscles of the suboccipital tissue, allowing a normal relaxation as the pressure is increased. Importantly, only enough pressure necessary to engage the tissue is needed here (Fig. 18-12). Too much pressure can cause undue discomfort for the patient and becomes fatiguing to the hands of a new practitioner. Too little pressure and the technique is simply ineffective. Once the initial release of positioning is obtained, the practitioner can appreciate an asymmetry of tension within the tissue. Increasing the pressure on the side that is less tight, attempting to balance the tension between the two sides allows for a release of the tissue on the more restricted side. This is an indirect approach as we are moving into the ease of the tissue and allowing for a spontaneous correction. This anteriorly directed contact in the suboccipital region continues until no further release of the tissue is appreciated by the practitioner, usually within a few minutes.

Figure 18-12 Hand position for suboccipital release.

To fully appreciate the effect of this procedure, the fingers of the treating hands increase in their extension, supporting the suboccipital region by themselves with little support from the palms of the hands. This approximates the extension at the cranial base that Dr. Still experienced with his nap on the plough rope. When completed the patient is slowly returned to neutral and the tension of the tissue at the base of the cranium is rechecked. This simple treatment can have dramatic impact on diverse regions of the body, from the neurocranium and viscerocranium, to the thoracic and abdominal viscera, to general responses to pain along with other functional medical problems.