Part 1

Osteopathic Principles in Diagnosis

IntroductionOsteopath ic d iagnosis invo lves a l l c lassica l methods of phys ical examinat ion (e.g. , observat ion, pa lpat ion, auscul tat ion) . In addi t ion, some d ist inct techniques are most common to osteopathic medicine and are less commonly used in al lopath ic medicine. These techniques have to do wi th f ine methods of t issue texture evaluat ion and epicr i t ic in tersegmenta l evaluat ion of the card inal axes (x- , y- , and z-axes) o f sp inal mot ion. Evaluat ing the pat ient using both observat ion and palpat ion of speci f ic landmarks in these axes to assess symmetry , asymmetry, and so on may be referred to as three-p lane mot ion d iagnosis in la ter chapters.

1 Principles of the Osteopathic ExaminationOsteopathic Principles (Philosophy)The pr imary goal of the Educat ional Counci l on Osteopath ic Pr inciples (ECOP) of the Amer ican Associat ion of Col leges of Osteopath ic Medic ine is to evaluate the most current knowledge base in the f ie lds of b iomechanics, neuroscience, and osteopathic pr inc ip les and pract ice. By constant ly s tudying the most current t rends in osteopath ic pr inc ip les and pract ice, as wel l as the bas ic science database, th is commit tee produces a glossary of osteopath ic terminology that is the language standard for teaching this subject . I t was or ig ina l ly created to develop a s ingle, uni f ied osteopath ic terminology to be used in a l l Amer ican osteopath ic medical schools. One of the reasons Nicholas S. Nicholas, DO, FAAO, publ ished h is or ig inal At las of Osteopathic Techniques was to help in th is endeavor. He and his associate, David Hei l ig , DO, FAAO, were two of the or ig inal members of th is commit tee as representat ives of one of the or ig ina l sponsors, the Phi ladelph ia Col lege of Osteopath ic Medic ine (PCOM). Over t ime, wi th i ts g lossary rev iew commit tee, the ECOP has produced frequent updates of the Glossary of Osteopath ic Terminology , issued each year in the American Osteopath ic Associat ion Yearbook and Di rectory of Osteopath ic Phys ic ians (1 ) . I t is now pr in ted in each edi t ion of Foundat ions for Osteopathic Medic ine (2 ) .The ECOP glossary def ines osteopath ic phi losophy as “a concept of heal th care suppor ted by expanding sc ient i f ic knowledge that embraces the concept o f the uni ty o f the l iv ing organism's st ructure (anatomy) and funct ion (physiology) . Osteopath ic phi losophy emphasizes the fo l lowing pr inc ip les: ( a) The human being is a dynamic un i t o f funct ion. ( b ) The body possesses sel f - regulatory mechanisms that are sel f -heal ing in nature. ( c ) St ructure and funct ion are inter re lated at al l levels. ( d ) Rat ional t reatment is based on these pr inc ip les. ” (1 ) The uses of the d iagnost ic and therapeut ic maneuvers i l lust ra ted in th is a t las are al l based upon these pr inc ip les.

Structural ComponentsStructure and FunctionStructure and funct ion concepts of the myofascial and ar t icu lar por t ions of the musculoskeletal system are inherent to understanding osteopathic diagnost ic and therapeut ic techniques. For example, knowledge of the or ig in and inser t ion of muscles ( funct ional anatomy) is imperat ive in the per formance of muscle energy technique. Understanding the st ructure of the sp inal jo in ts helps in the evaluat ion of sp inal mechanics and in the di rect ion of appl ied forces in techniques such as high-veloci ty , low-ampl i tude (HVLA) manipulat ions, such as when i t is necessary to consider obl ique cerv ical facets and coupled jo int mot ion.

Barrier ConceptsBarr iers are also an impor tant concept in the understanding and appl icat ion of osteopathic techniques. In osteopath ic medicine, var ious barr iers to mot ion have been classica l ly descr ibed within the f ramework of normal phys io log ic mot ion.The greatest range of mot ion in a speci f ied region is the anatomic range, and i ts pass ive l imi t is descr ibed as the anatomic barr ier (1 ) . This barr ier may be the most important to understand, as movement beyond th is point can disrupt the t issues and may resul t in subluxat ion or dis locat ion. Osteopath ic techniques should never involve movement past th is barr ier !

The physio log ic range of mot ion is the l imi t of act ive mot ion given normal anatomic st ructures and the art icular , myofascial , and osseous components ( 1 ) . The point at which the physiolog ic mot ion ends is the physio log ic barr ier . The term elast ic barr ier is used to descr ibe the mot ion between the physiolog ic and anatomic barr iers , which is avai lable secondary to pass ive myofasc ia l and l igamentous st re tching ( 1 ) .

P.6When a dysfunct ional s ta te exists, reduced mot ion or funct ion occurs, and a rest r ict ive barr ier between the physiolog ic barr iers may be demonstrated ( 1 ) . The rest r ict ive barr ier , the major aspect of the overal l dysfunct ional pat tern, can be e l iminated or minimized wi th osteopath ic t reatment. Manipulat ive techniques incorporate act ivat ing forces in the at tempt to remove the restr ic t ive barr ier , but these forces should be kept wi th in the bounds of the phys io log ic barr iers whenever possible. A pathologic barr ier is more permanent; i t may be re la ted to cont ractures wi th in the sof t t issues, osteophyt ic development, and other degenerat ive changes (e.g. , osteoar thr i t is) .

To avoid further in jur ing the pat ient wi th diagnost ic or therapeut ic techniques, the pract i t ioner must understand the normal compl iance of t issues and the l imits they mainta in . These d i f ferent barr iers must be understood complete ly , as they may cause the phys ic ian to al ter the technique chosen ( i .e . , ind irect versus d i rect ) , or may l imi t the mot ion di rected in to the t issues and or jo ints dur ing t reatment.In osteopathic pr inc ip les the present system of descr ib ing the card inal mot ion dynamics in sp ina l mechanics is based on the posi t ional and/or mot ion asymmetry related to the f reedom of mot ion (1 ) . Previous ly , there have been other ways to descr ibe these asymmetr ies. The di rect ion in which the mot ion was rest r icted was the most common ear ly method. Other past descr ip t ions included whether the jo int was open or c losed. These were also based on the mechanica l f ind ings revealed on palpat ion. Today, the governing system in use names the b iomechanica l f ind ings based on mot ion restr ic t ion and/or asymmetry and the d irect ions in which mot ion is most f ree. This mot ion f reedom is also cal led ease, f ree, and loose. In myofascial d iagnost ic f indings, i t is common to see both the f reedom and the l imi ta t ion used ( i .e. , loose, t ight ; ease, bind; and f ree, restr ic ted) . Yet the use of these descr ip t ions does not al low for problems in which mot ion is symmetr ica l ly and/or un iversa l ly rest r icted, as seen in some pat ients .One of the most impor tant pr inciples in d iagnosis and treatment is to control the t issue, jo in t , or o ther s tructure wi th in i ts normal ly adapt ive mot ion l imi ts . Thus, the mot ion in a t reatment technique should be within normal phys io logic l imi ts . Cer ta in ly , the mot ion used should always be wi th in anatomic l imits. I t is our ph i losophy that contro l l ing mot ion with in the physiolog ic l imits ensures greater safety margins whi le st i l l keeping ef f icacy high, whereas moving closer to the anatomic l imits increases r isk wi th l i t t le increase in e f f icacy.For example, in an HVLA technique, the rest r ict ive barr ier should be engaged i f engagement is to lerated. The movement necessary to af fect th is barr ier , however, should be only 1 to 2 degrees of mot ion (s t i l l w i th in the physiolog ic l imits) , whereas the actual phys io log ic barr ier o f normal mot ion may be 5 to 6 degrees further.

Somatic DysfunctionSomatic dysfunct ion is the d iagnost ic cr i ter ion for which osteopathic manipulat ion is indicated. The ECOP def in i t ion of somat ic dysfunct ion is as fo l lows:Impaired or a l tered funct ion of re lated components of the somat ic (body f ramework) system: skeleta l , ar throdia l , and myofascial s tructures, and re lated vascular , lymphat ic, and neural e lements. Somat ic dysfunct ion is t reatable us ing osteopath ic manipulat ive t reatment. The posi t ional and mot ion aspects of somat ic dysfunct ion are best descr ibed using at least one of three parameters: (a ) the pos i t ion of a body par t as determined by palpat ion and

re ferenced to i ts ad jacent def ined st ructure; ( b ) the d irect ions in which mot ion is f reer; and (c ) the d irect ions in which mot ion is rest r icted ( 1 ) .

Associated cr i ter ia for somat ic dysfunct ion are related to t issue texture abnormal i ty , asymmetry, rest r ict ion of mot ion , and tenderness (mnemonic: TART ) . The g lossary of osteopath ic terminology states that any one of these must be present for the d iagnosis. The pr imary f indings we use for the diagnosis o f somat ic dysfunct ion are mot ion restr ic t ion (and re la ted mot ion asymmetry , i f present) and t issue texture changes. Tenderness (some prefer sens i t iv i ty) can be one of the great pretenders in the c l in ica l presentat ion of a problem. Tenderness may be el ic i ted on palpat ion due to pressure or because the pat ient wants the phys ic ian to be l ieve there is pa in. Pain may be present in one area but the pr imary dysfunct ion or problem d is tant . Therefore, we bel ieve tenderness (sensi t iv i ty or pain) to be the weakest o f the aforement ioned cr i ter ia, and in our pract ice i t is used in a l imi ted fashion, most ly when implement ing counterst ra in techniques.Certain qual i t ies of these cr i ter ia are par t icu lar ly common in speci f ic types of dysfunct ions ar is ing f rom acute and chronic s ta tes. Increased heat, moisture, hyperton ic i ty, and so on are common wi th acute processes. Decreased heat, dryness, at rophy, and st r ing iness of t issues are more common wi th chronic problems.

Myofascial-Articular ComponentsAs the presence of somat ic dysfunct ion by def in i t ion may inc lude myofascial and ar t icu lar components, the palpatory examinat ion is an important par t of the evaluat ion. Palpat ion wi l l determine whether there is a pr imary myofascial or ar t icu lar component or both and P.7lead to the development of the most appropr iate t reatment p lan. Speci f ic types of dysfunct ions are best t reated by certain techniques. For example, a pr imary t issue texture abnormal i ty in the fascia is best t reated by a technique that most af fects change at that leve l (e .g. , myofascial release) , whereas another technique may have no real e f fect on the speci f ic t issue involved (e.g. , HVLA). Art icular dysfunct ions, on the other hand, are best t reated with an art icu lar technique, such as HVLA, and myofasc ia l re lease would be less appropr ia te.

Visceral-Autonomic ComponentsSome dysfunct ions may d i rect ly a f fect an area (e.g. , smal l in test ines wi th adhesions) , whi le other dysfunct ions may be more ref lex ively important ( i .e . , card iac ar rhythmia–somatov iscera l re f lex). Somatic dysfunct ion may cause react ions wi th in the autonomic nervous system and resul t in many cl in ica l presentat ions or v isceral d isorders present wi th a number of somat ic components ( 3 ) .

Order of ExaminationThe order o f the osteopath ic phys ical examinat ion is best based on the pat ient 's history and cl in ical presentat ion. In genera l , i t is best to begin the examinat ion by performing the s teps that have the least impact on the pat ient phys ical ly and that lead to the least t issue react iv i ty and least secondary ref lex st imulat ion.

General ObservationI t is recommended the phys ic ian begin with general observat ion of the s tat ic posture and then dynamic posture (ga i t and regional range of mot ion). For safety, i t is best to begin by

observing funct ion and range of mot ion wi th act ive reg ional mot ion test ing. Af ter examin ing the pat ient in th is manner , the physic ian may decide to observe the pat ient 's l imi ts by pass ive range of mot ion (ROM) test ing. The pass ive ranges should typica l ly be s l ight ly greater than those e l ic i ted dur ing act ive mot ion assessment. Af ter ident i fy ing any asymmetr ies or abnormal i t ies at th is point , i t is reasonable to proceed to the palpatory examinat ion.

Layer-by-Layer PalpationThe palpatory examinat ion is a lso best star ted by observ ing the area of in terest for any vasomotor , dermatologic, or developmental abnormal i t ies. The examinat ion may then proceed to temperature evaluat ion. The physic ian may now make contact wi th the pat ient fo l lowing a layer-by- layer approach to the examinat ion to evaluate the t issue texture. This approach permits the examiner to dist inct ly monitor each anatomic layer f rom a super f ic ia l to deep perspect ive to best determine the magnitude of and speci f ic t issues invo lved in the dysfunct ional s ta te. The t issues are progress ively evaluated through each ensuing layer and depth by adding a sl ight ly greater pressure wi th the palpat ing f ingers or hand. The phys ic ian should a lso at tempt to moni tor the t issue texture qual i ty and any dynamic f lu id movement or change in t issue compl iance. During palpat ion over a v iscera, the mobi l i ty o f that organ may be evaluated a long with any inherent mot i l i ty present wi th in that organ.Another method that we commonly use is a screening evaluat ion using percussion over the paraspina l musculature, wi th pat ient seated or prone, to determine di f ferences in muscle tone at var ious spinal levels. In the thoracic and lumbar areas, a hypertympanic react ion to percuss ion appears to be associated with the s ide of the rotat ional component.These s teps in the examinat ion evaluate the postural and regional movement ramif icat ions invo lved in the pat ient 's problem, in addi t ion to el ic i t ing any gross and f ine t issue texture changes. The f ina l s tep in the examinat ion is to determine whether there is a re la ted ar t icu lar component to the pat ient 's problem. This involves control l ing a jo in t and put t ing i t through very f ine smal l mot ion arcs in a l l phases of i ts normal capabi l i t ies ( intersegmental mot ion test ing) . The physic ian at tempts with a three-p lane mot ion examinat ion to determine whether the mot ion is normal and symmetr ic or whether pathology is rest r ict ing mot ion, wi th or wi thout asymmetry in the card inal axes. For example, the C1 segment may be restr ic ted wi th in i ts normal physiologic range of ro tat ion and exhibi t e i ther a bi la tera l ly symmetr ic rest r ict ion in ro tat ion (e.g. , 30 degrees r ight and le f t ) or an asymmetry of mot ion with greater f reedom in one d irect ion than the other (e .g. , 30 degrees r ight , 40 degrees lef t ) . As stated prev ious ly , most descr ipt ions of somat ic dysfunct ion re la te to the asymmetr ic rest r ict ions, but symmetr ic restr ic t ions are seen cl in ica l ly.In performing the s tepwise layer-by- layer palpatory examinat ion and f in ishing wi th the in tersegmenta l mot ion evaluat ion, the physic ian can determine the speci f ic t issues involved in the dysfunct ion (e.g. , muscle, l igament, capsular) , the extent to which i t is present (e .g. , s ing le segment, reg ional ) , and whether the process is acute, subacute, or chronic. These determinat ions prepare the phys ic ian to develop the most appropr ia te t reatment p lan for the somat ic dysfunct ion or dysfunct ions.

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References1. G lossary Review Commi t tee , Educat iona l Counc i l on Os teopath ic Pr inc ip les o f the Amer ican Assoc ia t ion o f Co l leges o f Osteopath ic Medic ine . G lossary o f Osteopath ic Termino logy . www.aacom.org .2 . Ward R (ed) . Foundat ions fo r Osteopath ic Medic ine . Ph i lade lph ia : L ipp incot t Wi l l iams & Wi lk ins , 2003.

3. N icho las AS, DeBias DA, Ehrenfeuchter W, e t a l . A Somat ic Component to Myocard ia l In fa rc t ion . Br Med J 1985;291:13–17.