Osteopathic Manipulative Medicine/Treatment Models

Chapter 2: Treatment Models

Objectives:

Identify the six major treatment techniques utilized in osteopathic manipulative treatment
Describe the mechanism of the six major treatment techniques
Discuss the absolute and relative contraindications of each treatment model

Major Treatment Techniques

Osteopathic treatment is a therapeutic modality that serves as an adjunctive therapy to medical management. The goals of osteopathic manipulation are to relieve or reduce pain, improve function, increase blood flow, increase venous and lymphatic flow, and to restore natural neural transmission.

Osteopathic treatment techniques can be classified as active or passive and as direct or indirect:

Direct technique: movement into the restrictive barrier
Indirect technique: movement into the ease of motion
Active technique: patient is actively involved in the treatment
Passive technique: physician performs treatment without patient input

The classes of techniques which we will consider from the Educational Council on Osteopathic Principles (ECOP):

Soft tissue (ST)
Myofascial release (often used interchangeably with soft tissue; MFR)
Counterstrain (CS)
Muscle energy (ME)
High-velocity low-amplitude (HVLA)
Lymphatic techniques
Osteopathic cranial manipulative medicine (OCMM)

Technique	Direct or indirect	Active or passive	Mechanism of action	Absolute contraindications	Relative contraindications
Soft tissue	Direct	Passive	Deep pressure, kneading, stretching, inhibition and/or traction; separation of muscle origins and insertion while monitoring tissue response and motion changes by palpation Stretch the skin, fascia, and the muscle tissues	Treatment directly over fracture or dislocation Serious vascular compromise Local malignancy or infection Patient refusal Lack of somatic dysfunction	Fracture or dislocation Vascular compromise Malignancy or infection Severe osteoporosis Acutely injured muscles Patient tolerance
Myofascial release (MFR)	Direct or indirect	Passive	Term often used interchangeably with “soft tissue”; light, moderate or heavy force which engages fascia versus deeper tissue with constant pressure; piezoelectric changes relax and release restricted tissues (direct) Guiding fascia along the path of least resistance until free movement is achieved (indirect)	Treatment directly over fracture or dislocation Serious vascular compromise Local malignancy or infection Patient refusal Lack of somatic dysfunction	Fracture or dislocation Vascular compromise Malignancy or infection Severe osteoporosis Acutely injured muscles Patient tolerance
Counterstrain (CS) - first described by Lawrence Jones DO	Indirect	Passive	Positions tenderpoint to position of significantly decreased or eliminated pain for 90 seconds Somatic dysfunction is due to a neuromuscular dysfunction involving muscle spindle receptors and inappropriate proprioception (sense motion/position) For tenderpoints involving a hypertonic muscle (common in upper and lower extremity somatic dysfunctions), tenderpoints can be found anywhere along the length of the muscle	Severe illness in which strict positional restrictions preclude treatment Traumatized tissue that would be negatively affected by repositioning	Any disease which predisposes increased pain with repositioning
Muscle energy (ME) - first described by Fred Mitchell DO	Direct	Active	Post isometric relaxation: During the patient’s contraction, increased pressure is placed on the Golgi tendon organ proprioceptors within the muscle tendon leading to reflex inhibition and subsequent muscle lengthening (patient pushes into their ease); chronic somatic dysfunctions Reciprocal inhibition: Utilizes the agonist/antagonist relationship of inverse relaxation with contraction (patient pushes into their barrier); acute somatic dysfunctions Respiratory assistance: Utilizes patient respirations to move soma through a barrier Joint mobilization: Use of muscular attachments and physician hands as fulcrums to mobilize joints with limited mobility Techniques are repeated 3-5 times for 3-5 seconds each; each time the physician is moving further into the restrictive barrier.	Fracture/dislocation Moderate to severe joint instability	Moderate to severe muscle strains Severe osteoporosis Severe illness with cardio-pulmonary compromise (ICU, post-surgical)
High-velocity low-amplitude (HVLA)	Direct	Passive	Release of entrapped synovial folds and disruptions of periarticular or articular adhesions	Joint instability Severe osteoporosis Severe herniated nucleus pulposus with radiculopathy at area of treatment. Metastatic disease in local area Infection in the local area Vertebrobasilar insufficiency Congenital abnormalities: Down’s syndrome, Chiari malformation	Osteoarthritis with moderate motion loss Osteopenia Mild to moderate sprain/strain
Lymphatic (an extension of MFR)	Direct	Passive	Mechanical compression via physician’s force leads to mobilization of lymphatic fluid	Necrotizing Fasciitis	Acute hepatitis Mononucleosis Malignancy Deep venous thrombosis Severe heart failure
Osteopathic cranial manipulative medicine (OCMM) - first described by William Sutherland DO	Direct or indirect	Passive	Engages the PRM to improve ANS function Mobilizes soma to reduce dysfunction Five principles of the PRM (Chapter 10): Inherent motility of the brain and spinal cord Fluctuation of cerebrospinal fluid Mobility of membranes Articular mobility of the cranial bones Involuntary mobility of the sacrum between the ilia	Intracranial hemorrhage Acute skull fracture Increased intracranial pressure	Space-occupying lesion Coagulopathies Seizure disorders

There are other treatment models that are used but not part of the ECOP classes detailed above:

Balanced ligamentous tension (Ligamentous articular strain) (BLT/LAS)
Facilitated positional release (FPR)
Still's technique

Technique	Direct or indirect	Active or passive	Mechanism of action	Absolute contraindications	Relative contraindications
Balanced Ligamentous Tension (Ligamentous Articular Strain)	Direct or indirect	Passive	Disengagement: compression or traction of tissues allows the most motion to occur without resistance Exaggeration: moving the joint toward the original position of injury (indirect) or barrier (direct) Balance: balancing the tension until a release is felt results in an ebb and flow	Treatment directly over fracture or dislocation Serious vascular compromise Local malignancy or infection Patient refusal Lack of somatic dysfunction	Fracture or dislocation Vascular compromise Malignancy or infection Severe osteoporosis Acutely injured muscles Patient tolerance
Facilitated Positional Release	Indirect	Passive	Muscle spindle fibers return to normal length decreasing tension in muscle activity fibers	Moderate-to-severe joint instability Severe vertebral herniated nucleus pulposus with radiculopathy at area of treatment Intervertebral foraminal stenosis Severe spains and strains Congenital abnormalities: Down’s syndrome, Chiari malformation Vertebrobasilar insufficiency	Fracture or dislocation Vascular compromise Malignancy or infection Severe osteoporosis Acutely injured muscles Patient tolerance
Still's Technique	Indirect	Passive	Indirect positioning toward the ease of somatic dysfunction in which pressure is applied followed by another part of the body being used as a long-levered force vector to move the segment through the least resistant path toward the barrier causing relaxation of hypertonic musculature	Moderate-to-severe joint instability Severe vertebral herniated nucleus pulposus with radiculopathy at area of treatment Intervertebral foraminal stenosis Severe spains and strains Congenital abnormalities: Down’s syndrome, Chiari malformation Vertebrobasilar insufficiency	Fracture or dislocation Vascular compromise Malignancy or infection Severe osteoporosis Acutely injured muscles Patient tolerance

There are three joint capsule receptors which are utilized:

Proprioceptors are receptors which sense motion and position of the body
Mechanoreceptors are receptors excited by mechanical pressures or distortions such as those responding to touch and muscular contractions
Nociceptors are peripheral nerve organs or mechanisms for the appreciation and transmission of painful or injurious stimuli

Much less voltage is required to stimulate the mechanoreceptor input to proprioception than that required to stimulate the nociceptors. For example, when considering low back pain, nociceptors are present in the structures of the lumbar spine. (Refer to [Chapter 6 - Lumbar Spine] for additional information.) The relationship between somatic dysfunction and the sympathetic nervous system can result in the altered neurologic relationship called a facilitated segment.

Facilitated segments exist in a state whereby the maintenance of a pool of neurons is at full or partial sub-threshold excitation. Facilitation occurs when a segment of the nervous system has been subject to injury via trauma or chronic disease, causing the segment to become hyperactive. Strain on facilitated segments are often compensated until mechanical failure is reached. This may be manifest as group dysfunctions on opposite sides of the spine. Single vertebrae dysfunctions often form first, with group dysfunctions occurring as a result of compensation. Nociceptive input can lead to increased muscle tension and chronic irritation as well as compensatory structures changes i.e. facilitated segments. This is usually in response to actual tissue damage or toxic stimuli and can be activated either mechanically or chemically.

Two mechanisms of muscle control include muscle spindle fibers and Golgi tendon organs:

Muscle spindle fibers are very sensitive to changes in length. When stretched sufficiently, it will induce reflex contraction of the muscle. Muscle spindle fibers monitor stretch and rates of change. In somatic dysfunction, the muscle spindle fibers have a strong influence on changes in postural muscles.
Golgi tendon organs are safeguards of anatomic integrity of joint structure and serve as a “relief reflex” which produced marked reduction of muscular activity when there is a severe stretch. Golgi tendon organs measure muscle tension and are more sensitive to stretch during contraction of a muscle that it is associated with. Golgi tendon organs are located in the musculotendinous area of the distal ends of muscles. Sufficient impulses from Golgi tendon organs will result in inhibition of the muscle it occupies and its synergists (and facilitate antagonists).

Review Questions

1. A patient presents with significantly hypertonic paraspinal muscles. Which treatment technique is the most appropriate initial treatment on this patient?

A. Counterstrain
B. Muscle energy
C. HVLA
D. Myofascial release/Soft tissue
E. Lymphatic techniques

Questions 2-5: Match the following descriptions with the listed treatment technique.

2. Myofascial release/Soft tissue
3. Counterstrain
4. Muscle energy
5. HVLA

A. Passive, direct
B. Passive, indirect
C. Active, direct
D. Active, indirect
E. Can be either direct or indirect

Questions 6-10: Match the mechanism with the treatment technique.

6. Post-isometric muscle energy
7. Counterstrain
8. HVLA
9. Reciprocal inhibition muscle energy
10. Myofascial release/Soft tissue

A. Deep pressure, kneading, stretching, inhibition and/or traction of the skin, fascia, and muscle tissues with separation of muscle origins and insertion while monitoring tissue response and motion changes by palpation
B. Positioning of a tenderpoint to a position of significantly decreased or eliminated pain (typically for 90 seconds)
C. Increased pressure is placed on the Golgi tendon organ proprioceptors within the muscle tendon leading to reflex inhibition and subsequent muscle lengthening
D. Utilization of agonist/antagonist muscle relationships of inverse relaxation with contraction used primarily in the treatment of acute somatic dysfunctions
E. Rupture of entrapped synovial folds and disruptions of periarticular or articular adhesions

11. Which of the following correctly describes a direct and active technique?
A. A technique in which the patient is taken to the barrier of the somatic dysfunction and the patient performs an action as directed by the physician.
B. A technique in which the patient is taken into the ease of motion and the patient performs an action as directed by the physician.
C. A technique in which the patient is taken into the barrier of the somatic dysfunction and the physician performs all of the action without assistance from the patient.
D. A technique in which the patient is taken into the ease of motion and the physician performs all of the action without assistance from the patient.

Answers to Review Questions

D
E
B
C
A
C
B
E
D
A
A

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