A.T. Still’s principle “the body is a unit”, also sometimes noted as “the person is a unit” is the holistic approach where the human body does not function as a collection of separate parts but rather as an integral whole whose parts all work together to benefit the organism in totality.
A problem in any of the parts will compromise health or it may be expressed through dysfunction in another part. So osteopathic treatment needs to be broad, in order to address all components to function. For this it is necessary to appreciate different aetiologies for imbalances in health of the patient. This allows different courses of treatment and management to emerge for a patient.
During the GOE (general osteopathic observation) we can identify expressions of compensatory patterns – the best path the body could take with the current stressors/influences. As a practitioner we can open up different paths for the body to choose instead (by working on specific areas of tension or lesion), that may bring more balance in the whole.
Because circumstances (stressors) are variable by nature, we need to constantly adapt our healthcare to the needs of the individual. Therefore each application of osteopathy is different.
Aetiology is something I found we know very little about (much less than we would like to!), so rather than focusing on that, I find it important during assessment and treatment to just be present with the current state of the body, combining knowledge and intuition to find a way “in”, to make an informed decision which part of the whole to treat first, in order to affect the whole. So in other words, to find the language to offer change, that the body understands. If this fulcrum, is offered in a way the body can work with it, it allows a change in the current compensatory path to restore the self-healing mechanism and the body’s ability to maintain homeostasis. The osteopath then monitors the change, which leads to the decision for a next step.
The five models of osteopathic care provide different doors into the person, from which to view the patient, and/or treat. They provide different perspectives. However, it is obvious that the different components of human beings, even if organized into models, overlap, and they are all intimately related to each other. These holistic principles can be quite overwhelming when it comes to practical situations. Therefore it is useful to have a reductionist view within the holistic view, in order to organize the management for treatment. The five models for osteopathic care can be very useful for this.
Biomechanical model
Considering the interrelationship of structure and function, or body, mind and spirit, we find that everything will affect the musculoskeletal system. Patients that come into clinic with musculoskeletal pain, injuries or dysfuncton, postural imbalances or gait abnormality, could benefit from treatment in the biomechanical model: during our GOE we can detect compensatory patterns manifesting as areas of restriction (for example an osteopathic lesion of L3 vertebra, or a group lesion in the thoracic spine). Structural restriction can cause or be caused by dysfunction of muscles, joints, and/or connective tissue (bones and soft tissue are closely related). This can compromise vascular or neurological structures and therefore affect associated metabolic processes and/or behaviours which is closely related to pain). Depending on a person’s adaptive capabilities, this can result in increased energy expenditure (for example by muscles, to maintain balance.
As a result, the person’s ability to adapt to stressors becomes further compromised, having a larger effect on social activity and habits for example.
This shows how closely related the different models are; they encompass the totality of components and functions of the patient. When treating the biomechanical model, the osteopath wants to improve function (posture and motion) and therefore health, by removing restrictive forces in the musculoskeletal system.
Musculoskeletal pain is often associated with poor posture (influenced by physical as well as psychosocial elements). For example, an increased lumbar lordosis will cause traction in the ligaments (iliolumbar), and to prevent persistent strain on the ligaments, muscles contract slightly (long term strain will unable structures from returning to their original shape → tensegrity. But then long term muscle contraction also changes structure and function of connective tissue and therefore causes dysfunction of the bone.
These patterns will cause further compensation of other structures. On the long term these patterns are more difficult to reverse. An example is someone with a bad posture due to long term depression. When they come out of their depression their posture is still bad because the tissues have adapted.
Herein an osteopath considers the fascial tensegrity of the body; the continuity that makes us understand how muscle chains are linked together, and don’t only act as locomotive elements but also as functional tensional elements which maintain, adapt and compensate in postural and structural alignment. This means that injury or dysfunction is not necessarily due to direct local impact. It can begin as a long-term strain in other parts of the body. The actual manifestation could be due to inherent weakness or previous injury of the area.
So as osteopaths we try to not just treat the manifestation or symptoms, but the underlying patterns and causes, as far as we can trace them.
(There are many techniques to use for treating this model, for example High Velocity Thrusts, Muscle Energy Techniques, articulations, soft tissue techniques.)
The treatment will help to decrease pain, improve quality of joint motion, joint function, toning of muscles, and overall health of the musculoskeletal system – all factors that have an effect on other models and vice versa. For example: Visceral disorders could cause myofascial pain syndromes, which can on their turn also mimic visceral diseases, and therefore have to be considered in the diagnosis of regional myofascial pain syndromes.
Educating the patient about posture is important (psychosocial elements), as well as treating the compensatory mechanisms that occurred due to prolongued bad posture, causing the patient to use more energy than necessary to maintain it. The changes in length and tone of either abdominal or erector spinae muscles can change the line of gravity and the way the body is weightbearing. (“research demonstrates that patients with low back pain show a significantly increased body sway pattern”) This also affects (or can be affected by) the pressure between the thoracic and abdominal cavity. The diaphragm muscles play an important role here. This leads us to the Respiratory/circulatory model.
Respiratory-circulatory model
One of A.T. Still’s principles is “the rule of the artery is supreme” This could be interpreted as stressing the importance of movement of fluids, leading to proper nutrition and drainage of the tissues at macro and microscopic levels, essential to maintenance of health.
The respiratory model therefore focuses on the dynamic interaction between central neural control, cerebral spinal fluid flow, arterial supply, venous and lymphatic drainage, as well as pulmonary and cardiovascular function. To maintain homeostasis. Osteopathic treatment within this model addresses dysfunction in respiratory mechanics, circulation, and the flow of fluids. It also considers the interaction with the functions of other models.
An osteopath would address the different diaphragms (cranial, thoracic, pelvic) as well as lungs and thorax, and even plantar fascia (active as gentle pump while walking). They act as transverse restrictors of motion, working as a pump affecting blood (oxygen and nutrients), lymph (therefore supply of oxygen and nutrients and removal of waste products) and CSF and are very dependent on the heart for pressure to allow the circulation. Examples of techniques are thoracic outlet resctircion removal followed by lymph drainage of the face. Mobilising the ribs or treating thoracic outlet syndrome also improves the function of the respiratory system.
“if we were allowed to treat only one muscle in every patient it would be the diaphragm”. A restricted diaphragm will reduce respiratory pumping action, therefore reduce venous return, lymphatic drainage and diaphragmatic respiration causing increased accessory respiration which can trigger the sympathetic nervous system, which has many effects that I will discuss later. A restricted diaphragm can have many causes/origins, for example postural, visceral (inflammation leading to somatic dysfunction caused by neural referral), neural (root or pathways), mechanical (for example from psoas, or via fascia after surgery), or vascular.
Metabolic-energy model
When treating the metabolic-energy model, the aim is homeostasis to facilitate recovery; to help the body deal with internal and external stressors that affect the physiology during adaptation (for example through the fight/flight response of the sympathetic adrenomedullary system).
This is done by removing structural restrictions: On an organ-system level you can influence the neuroendocrine immune system (hypothalamic, pituitary, adrenal axis), visceral system and joint structures. On a tissue level you affect innervation, nutrition, drainage (see also respiratory circulatory model). On a cellular level you affect the tensegrity. You can palpate physiology in the tissues (sympathetic state, parasympathetic state), whose structure governs the function.
Removing somatic dysfunction will facilitate efficiency of motion and decrease energy expenditure. Specific visceral techniques are used, or more general treatment, directed towards improving physiological function. Osteopthic treatments have been reported to help support a patient’s recovery and increase the potency of medication, thus reducing drug dosage and is potential side-effects.
Techniques to free up the diaphragms are also used in this model.
Reduced diaphragmatic circulation can cause reduced bloodflow to gastrointestinal tract, leading to digestion problems. Stress (fight or flight mode) also reduces blood flow to organs of digestion. The lack of nutritients can lead to further problems such as anxiety and depression, which are linked to irritable bowel syndrome (gut-brain axis), however this disorder’s aetiology is poorly understood. Anxiety and other negative emotions have been suggested to play a major role in gut function.
Nutritional and exercise counseling also play an important role, as well as stress management, breathing techniques and mindfulness training. (see also behavioural model)
Neurological model
The effects of the stimulation of the SNS (Sympathetic Nervous System) are widespread (because the sympathetic chain allows one preganglionic fiber to synapse with many postganglionic neurons) and enhanced and prolonged by the adrenal medulla. The body goes into fight/flight mode .
The PSNS (Parasympathetic Nervous System) on the other hand prepares the body for rest and relaxation. Homeostasis is a balance of the two; most organs receive a dual innervation, one of wich increases excitation and one of which inhibits activities, for example heart rate or stomach mobility. The aim of treatment of this model is – again
– homeostasis; to relax and remove restrictions in structures or tissues that may cause herniated discs, pinched nerves, or spinal degeneration.
Mobilisation (raising) of the ribs – affecting the sympathetic chain, to attain autonomic balance. Releasing tension in muscles and fascia of the neck will affect the autonomic supply to the head whereas As a sacral toggle will affect the parasympathetic supply to the pelvis.
Treatment may also relief pain (or paraesthesia); remove facilitated segments, decrease afferent nerve signals, using techniques such as MET, HVT, Chapman reflex points, Soft tissue inhibition, and any technique that treats spinal dysfunction. And as mentioned before, the superior thoracic aperture.
Osteopaths often balance the osteopathic centres (C2-3 (superior cervical ganglion) T4 (UEX) T9 (Coeliac plexus) L4 (LEX) Coccyx). The connections to the viscera are very important to consider. Patients complaining of constipation, abdominal cramps could have a hyperactive SNS. This is related to stress. The release of stress hormones as a compensation to improve certain body functions (for example due to poor posture), without having to actually fight or flee (so not having to engage in muscular exercise) can cause memory to be impaired, surpression of immune function and energy to be stored as fat.
Behavioural/psychosocial model
This model is based on the idea that physical, emotional and social health are inseperable, therefore in the management of the patient, the whole person is considered. In this model osteopaths will address the patient’s lifestyle and environmental factors, because they can contain stressors. To identify them the practitioner can apply the theory of the total osteopathic lesion.
It is not necessary to remove all the stressors, but rather to restore homeostasis and encourage the self-healing mechanisms for optimal physiological function. Within this model this is done by improving biopsychosocial components of the patient’s health, including emotional balancing and compensatory mechanisms, reproductive processes and behavioral adaption.
The psychosocial approach considers pain and disability as a complex and dynamic interaction among physiological, psychological and social factors, which can maintain and aggravate the presenting complaint.
Examples of the psychosocial model as a primary approach: a patient that comes in with pain caused by chronic bronchitis who also is a heavy smoker, or a ballerina with low blood pressure due to eating habits caused by social pressure.
To identify potential reasons for the persistence of a problem, it is important for the treatment management to consider psychosocial risk factors, that include certain beliefs, behaviours and moods, that have been associated with the risk of development of chronic pain. It’s about the patient’s experience of pain and the meaning they may attach to such pain. Identifying the individuals belief concerning their pain is key. For example the belief that pain is harmful or disabling can result in fear-avoidance behavior, eg, the development of muscle guarding and fear of movement, further affecting the patient (muscle wasting, depression, etc). Moreover, the individual’s perception about work can also affect disability. Low expectations of return to work or recovery from symptoms could affect the prognosis.
Depression showed the strongest evidence as a predictor for increased risk of chronicity. However, standard measures are difficult to apply in practice.
Research stuff
Lederman (1997, p183) talks about the effects of physical touch during treatment that may enhance the self-healing mechanism, for example changed autonomic and visceral activity, general alterations in muscle tone, or altered pain perception (Liem et al. 2012), controlled in the limbic system of the brain. For example, Campbell et all (2006) emphasizes the physiology of how physical touch triggers a variety of reactions such as feelings of trust, confidence and security, calm and wellbeing, which can make pain more bearable. Besides, the tactile stimuli also increase oxytocin concentration (Okabe et al. 2015), which reduces stress responses (Churchland & Winkielman 2012), accelerates the healing of wounds (Liem et al. 2012). , and may have a part in prosocial influence on behaviour, benefits on social reasoning, emotion perception, empathy and social memory (Bartz et al. 2011; Dodhia et al. 2014).
Consedine et al. (2016) debated that touch communicates not only an osteopath’s care and devotion but also expertise and proficiency, hence, forming the foundation of an effective patient-practitioner relationship.
Within this relationship, speech has been shown to affect the patient’s biology by improving the efficacy of medication, alleviate pain and change brain function (Rüegg 2011).
CONCLUSION BIT (take some stuff from the beginning to the end maybe)
Because the body is a unit with a fascial continuity, different kinds of treatment will affect the person as a whole, not only locally, and physical aspects will affect psychological aspects and vice versa. Within this holistic view, osteopaths use reductionist approaches and models in order to organize treatment management and decision making. The 5 models of osteopathic care provide different perspectives on all aspects of a person, and treatment within the models aims to restore the body’s natural homeostatic balance.