Biomechanical Osteopathy

with Janine Talty, D.O., M.P.H.

Biomechanical Osteopathy is a specialized branch of osteopathic medicine. This area of specialty was developed at the Michigan State University College of Osteopathic Medicine some three decades ago, although many of the principles have been in practice by physicians through the centuries of physical medicine. Today less than 2% of practicing D.O.s (Doctor of Osteopathy) are trained in this specialty. Over the years this biomechanical approach has been refined with specialized therapies and nomenclature to allow the biomechanically-based osteopathic physician to not only perform successful unique non-invasive therapeutic methods, but also be able to communicate complex three-dimensional structural diagnostics and procedures to the rest of the medical establishment.

Contents:

Overview

The Interview

The Exam

Self-Guided Correctional Therapies

Post Biomechanical Therapy

Other Correcting Therapies

Some Special Nomenclature

Summary

Overview

The basic underlying objective of the biomechanically-based osteopathic physician is to first establish the underlying physical causal relationships between movement or injury and the resulting disorder. The osteopath will determine whether and where there are causal structural imbalances within the patient’s body, and then work to re-establish the balance using non-invasive and gentle guided self-adjustment motion. The biomechanically-based osteopath will carefully assess the patient’s subjective description of their disorder, then proceed with a thorough exam of the various components of the structural disorder, starting first with a thorough neurological exam, then a specialized mechanical assessment of the pelvis, including an assessment of the pelvis, spine, sacrum, cranium shoulder girdle, rib cage, muscle firing patterns, and the various other structures that might be related to the disorder, i.e., feet, hands, wrists, hips, etc. Once the cause of the damage or disorder has been established structurally, the biomechanically-based osteopath works with the patient to guide an isometric self-correction process to realign structural imbalance that result in pain and/or motion restriction.

The Interview

The biomechanically-based osteopathic physician’s first course is to interview the patient to discover the background of the ailment, and the history and possible causations and interactions that might precipitate the complaint. The patient will first fill out a comprehensive form that initiates some of this discussion, including locations of pain using a pain diagram and other clinical history. During the interview the osteopath will ask, if pain is involved, what is the quality and level of the pain. Usually a 1-10 scoring system is used, with 10 being the worst pain and 1 being the least, and 0 being no pain. A number of qualifying questions such as the type of pain felt (dull, aching, piercing, sharp, throbbing, etc.) with the precise location, the timing of the pain and the length of time that pain continues, are all asked. The patient will be asked to describe what factors (sitting, standing, walking, running, etc.) make the pain start or worsen, and what factors reduce the pain.

Also during the interview the osteopath will determine some of the patient’s common tasks, postures, stresses, and tendencies during this assessment. If a particular injury is seen as a cause, then that accident will be thoroughly examined by the osteopath during this interview, including how the patient was moved or jarred during the injury, where they met with unmovable objects, etc. Any pictures, diagrams or other visual tools can assist the osteopath to understand, from a biomechanical perspective, exactly how the particular forces and/or vectors of force would have resulted in the injury. The osteopathic physician will also observe the patient’s posture and physical, nonverbal behaviors during the interview phase of the exam. This information adds the tremendously to the clinical assessment.

The Exam

The physical exam, or “vet exam”, as osteopaths sometimes refer to it as, is extremely critical to the osteopath. Rather than an assessment of pain, it consists of a formal methodical evaluation of the entire structural system and how it behaves in standing, seating, and laying in supine and prone positions. From these positions the biomechanically-based osteopathic physician will carefully assess the structural positions of the joints, bones and associated tendons, ligaments and muscles in relationship to each other and against standard biomechanical function.

Since many structural injuries are associated with, or exasperated by structural imbalances that exist at the pelvic girdle, spinal region or cranium, this is a central focus of the osteopath’s exam following a review of the specific areas of pain or inflammation. There are a number of reasons for this. One is that the pelvis and spine and their adjoining tendons and musculature structurally support the body’s basic movements of walking, reaching, lifting, twisting or bending. Another is that both the body’s motor and autonomic nervous systems are connected to the spinal column by neurons that carry impulses from receptors to the spinal cord and brain.

Imbalances can exist structurally in the lumbarsacral region, for example, that can directly affect a person in a number of ways far removed from the sacral area or spine. One may be experiencing numbness or pain down the legs, or feet, or be experiencing cervical or shoulder pain, all possibly caused by a structural imbalance in the lumbarsacral region. One may have hip dysfunction that might be caused by the sacroiliac motion restriction during the walking cycle, or a true leg length discrepency,  for example.

In the standing position, the pelvis and lumbarsacral region is one of the first spinal regions for the biomechanically-based osteopathic physician to review in the spinal region. Typically the osteopath performs a standing flexion test, where the patient bends (into flexion) at the hip while the osteopath monitors the posterior superior iliac spine of the illium in order to understand the balance and movement at the sacrum and the pelvic girdle. Then a measurement of the posterior superior iliac spine is done during movement by the patient bending each knee to 90 degrees at the hip. The region is then tested for side-bending movement for standing and then sitting. During these movements the osteopath measures the alignment and subsequent movement of the pelvic surface from the coccyx through to the upper lumbar vertebra. Since the sacral spinal nerves are traveling through the sacrum, any imbalance, be it sheer or torsion, or side-bending, can cause pain and numbness up and down the legs.

In the supine position (laying on back) the osteopath will assess the pubic tubrical and relationship between the left and right sides of the pelvic inlet and outlet by palpating the pubic tubercles, iliac crest and the anterior superior iliac spine while the patient is supine. This assessment will tell the osteopath whether there is any structural imbalances that may be throwing off one’s structure through the mid-region, legs and spinal column.

In the prone position (lying on the stomach) the osteopath will assess the lumbar vertebra. This assessment requires a high level of experience in the understanding of the proper positioning and movement of the vertebra, as well as their alignment not only amongst the other vertebra, but also together with the sacrum, and of course the associated tendons, ligaments and muscles in the surrounding area.

Here the osteopath must carefully assess whether each vertebra is positioned correctly, calling for a three-dimensional approach to movement and anatomy. Since the spinal column and its surrounding vertebra can move in a three-dimensional manner, each vertebra must be assessed with respect to whether they are allowing for full intrasegmental movement. A vertebra may be flexed or extended (anterior to posterior), side-bent (lateral to medial), or rotated (torsion), or any combination of these three. For example a vertebra might be stuck in flexion, which may cause pain or difficulty bending backward or sitting up. A vertebra might be side-bent, causing difficulty or pain bending from side to side. Or a vertebra might be rotated, or turned on its axis (like a spinning globe), or as is often the case a combination of all three, stuck in flexion or extension, side-bent and rotated. All motion in the spine is coupled due to the complexity of the anatomy of the vertebra and its joint surfaces. The misalignment of one or more of the vertebra can cause referred pain in a variety of locations throughout the body. This can depend upon a number of factors, including the location of nerve pathways between the associated vertebra, and how those vertebra might be maligned in position. Maligned vertebra can compress nerves causing numbness, or irritate nerves causing pain. A maligned vertebra may cause a pouching or even leakage of disc fluid outside of the vertebra body region. A leaking of disc fluid onto nerves can cause pain such as sciatica, or generalized low back region pain, for example.

The osteopath measures the vertebra alignment in all three directions, running well-educated hands up and down the spinous and transverse processes (the bony ridges of the spine) while measuring alignment as the osteopath directs the patient to either sit, stand, bend or lie prone. This assessment will be made from the lumbar (lower) region to the thoracic (mid-back) region, through the cervical (upper back and neck) region, then up through the cranial region. At the neck (cervical) region, the focus of movement made by the osteopath during the assessment will be made with a gentle rotation and side-bending of the head and neck. During this movement, the osteopath will understand where there may be vertebra stuck in a flexed, extended, side-bent or rotated manner. Typically vertebra will be stuck in a combination or “coupled” movement.

Should the biomechanically-based osteopathic physician suspect movement or posture irregularities, they will have the patient illustrate the suspecting movements or postures. Should the offending source be a particular movement, the patient will describe and show a description of the movement. Should walking or lifting styles be suspected, the osteopath will have the patient perform those movements in order for the osteopath to exam for disrupting irregularities. Often, for example, an osteopath will have the patient walk down the hall, or pretend to pick up a baby to show possible movement irregularities. Surprisingly often, pain and discomfort can be caused by a particular unsuspecting postural or moving habit, that once corrected, can remove the pain.

Guided Self-Correction Therapies

Once the biomechanically-based osteopathic physician determines the nature of the pain, with its contributing or causational factors, a guided self-correction process is usually embarked on between the patient and the doctor. This process is particularly nurturing, as it assumes first, before any invasive therapies are considered, that irregularities and pain may be removed by either adjusting ones repetitive movement, or in the case of structural malignment, by a gently-guided structural realignment, often done immediately on the first visit.

The biomechanically-based osteopathic physician does not perform forced manipulation. The osteopath, rather than pushing or forcing movement among the articulations, will work to guide the patient with slow and gradual isometric pressure. The osteopath will assist the patient into a position and, using the patient’s own musculature, will guide specific corrections, causing the tissues around the offending joints to reset the muscle tone around the joint. This will allow the structures and surrounding tissues to regain normal healthy natural alignment that existed previous to the injury or cause of pain.

For example if a biomechanically-based osteopathic physician finds that there is an alignment issue in the lumbarsacral area, i.e. a maligned vertebra or sacrum, (i.e., side-bent, extended or flexed and/or rotated), the osteopath will position the patient’s body, arms and/or legs in such a way that allows for an isolation of one side of the torsion, and then will monitor the motion with light fingertip pressure while asking the patient to push against that pressure with resistance of either the trunk or extremities, depending on the segment being treated. The patient will thus be guided into repositioning and correcting the malignment by applying the precise motion internally while the osteopath positions, isolates and guides the path for this self-correction. The osteopath may position a patient on their back (supine), and their abdomen (prone), on one side or another, or just sitting up or standing in order to isolate the precise area while allowing movement into just the right location with the patient’s own motor systems.

There are several common maligned areas, and thus common corrective self-guided strategies:

A patient may have a pubic restriction that is slightly out of proper alignment. This is important because the axis of rotation in the anterior portion of the pelvis happens at the pubic symphysis. The osteopath will adjust this by guiding the adductors and abductors through isolated pressure, so that the patient will push and “gap” the pubic symphysis to reposition this region.

A patient might have a flexion or extension and possible rotation at the sacral base. This would result in the biomechanically-based osteopathic physician isolating the area of torsion while gently positioning the patient to perform a very specific muscle contraction against resistance to correct the sacral mechanical restriction.

A patient might have a side-bent, rotated, and extended or flexed lumbar vertebra in such a way that puts that vertebra at odds with the normal curves of a healthy spine. This vertebra will likely cause pain or difficulty with movement in the pelvis, hips or buttocks. It also may lead to a lumbar disc that is squished to one side, possibly leaking or putting pressure upon the spinal column. The biomechanically-based osteopathic physician can often balance out the malignment by positioning the patient, either in a sitting or side-lying position, while isolating the “neutral” area (aligned), while guiding the patient to reposition movement away or toward the motion restriction (malignment). This will allow the supporting muscle tissues on the opposite side to relax. The opposing relaxation produces muscular tone balance and allows the spinal segment to achieve natural alignment.

As the osteopath travels up the bony processes of the spine, he or she will assess the alignment throughout the column. It is likely that a repositioning of a person’s vertebra back into alignment may cause another vertebra elsewhere to neurologically respond through complex inter-neuron mechanisms in the central nervous system and move slightly out of alignment. This can appear several vertebrae apart. The osteopath assesses these areas and takes the patient through the appropriately guided movements to enable the patient to continue to apply his or her own strength to align the various structures of the spine into their natural positions. As the osteopath travels up the spine, more upper-body muscles can be put in play by the patient to self-align. In doing this, elbows, shoulders, legs, chest region and head are all gently guided by the osteopath to assist the patient in their own structural realignment and balancing.

By the nature of these guided self-correction measures, post-therapy pain or straining of muscles, tendons, etc. it typically avoided. This is because the patient used their own tendons and musculature rather than being structurally being forced.

Cerebrospinal Fluid Flow

After working up and down the spine with guided self-adjustment, the biomechanically-based osteopathic physician may turn focus to the circulation of the cerebral spinal fluid. This is an important factor, as the continuous and unrestricted flow of cerebrospinal fluid is essential for health and the proper functioning of the nervous system.

Cerebrospinal fluid (CSF) is watery, much like blood plasma. It circulates and envelopes the brain and spinal column and extensions into the peripheral nervous system with the existing spinal nerves. CSF allows the brain and central nervous system to “float” in this aqueous layer traveling through the subdural layer, allowing for the protection and cushioning of the delicate nervous system and brain structures. CSF travels through these regions and is secreted through and pumped much like a bellows due to pressure gradients created by the four CSF diaphragms in the body (tentonum cereberii in the occipital base of the head, fascia in the base of the neck and surrounding the great vessels, the thoracoabdominal diaphragm in the mid-section, and the pelvic diaphragm). With the rising and falling of the chest during respiration together with the cardiac rhythm and its pressure gradients, the complementary but separate CSF pulse circulates the CSF throughout the spinal column and cranial region, eventually being absorbed back into the bloodstream through the arachnoid villi positioned in the subdural layer throughout the brain.

Should there be any restrictions due to pressures exerted from any of the bones in the head or spinal column, the CSF will not properly circulate. Restrictions can also be intersegmental motion restrictions caused by infection and inflammation. The biomechanically-based osteopath can palpate the bones of the cranium to measure and assess the pulse of the CSF. Should this pulse seem restricted or abnormal, the osteopath may gently work around the head to open up the restricted areas of CSF flow. This may be done by gently separating the sutures between the bones in the head, combined with gentle pressure at the ventricles with the objective of gently allowing for a fuller, unrestricted CSF flow. One typical release of the osteopath is called the venus sinus drainage release, releasing CSF flow at the base of the neck and occipital bones of the skull.

Post Biomechanical Therapy

Following osteopathic biomechanical therapy with self-guided adjustment, a patient might have some post-therapy stiffness or pain due to their history of chronic restriction, with some sensitivity from hypertonic (stressed) surrounding muscles. Also, postural problems and repetitive motion can work some of the restrictions back into place, requiring additional and follow-up treatment. In some cases periodic realignment or physical therapy are necessary to assist the patient to complete recovery.

Other Correcting Therapies

The biomechanically-based osteopathic physician may apply a number of other therapies to guide the patient back to structural or less-painful health. For example the osteopath may discover that one leg is significantly longer than the other, causing the patient imbalances throughout their body while walking or other movement. In this case the osteopath might supply the precise lift for the patient to insert into their shoes to correct the imbalance.

A biomechanically-based osteopathic physician may also prescribe specific physical therapies in order to correct an area of difficulty. They may also prescribe other special therapeutic devices including special chairs, braces, or other posture-correction measures. In some cases pain medication and/or other biochemical methods might be prescribed. The biomechanically-based osteopathic physician may also use a number of other therapies in the treatment of pain, including trigger point injections, prolotherapy injections or epidural injections.

Some Special Nomenclature

The biomechanically-based osteopathic physician will utilize specially-developed nomenclature to communicate the diagnosis, alignment issues and resulting treatment.

Some key words are:

• Flexed=a joint or region pushed away (forward bent) from its normal axis of movement
• Extended=a joint or region pulled too tight (backward bent) into its normal axis of movement
• Side-bent=a joint or region bent either to the right or left of the normal axis of movement. A joint or vertebra may be side-bent to the right or left.
• Rotated=a joint or region may be twisted around the axis of normal movement. A joint or vertebra might be rotated right or rotated left.

For example, the biomechanically-based osteopathic physician might reference something like L5 FRSLT, which would communicate that the patient’s L5 vertebra is Flexed, Rotated, and Side-Bent to the Left.

Summary

The biomechanically-based osteopathic physician utilizes methods of examination and treatment that are uncommon even among osteopath doctors, with an estimated only 1.2% of D.O.s being trained in these methods. This specialized science requires advanced training and practice and many years of clinical training. The biomechanically-based orthopedic physician will carefully assess a patient’s injury and accident with a keen eye towards the mechanics of the trauma, in order to illicit the causal connections. Then a precise exam will follow, with particular attention placed upon the areas that might cause referred pain or limitations of movement. After the exam, (and oftentimes during the exam) the osteopath will use a well-established therapeutic course by guiding the patient to use their own internal strength to realign structural systems back into place, without the jerking, popping, or forcing that might typically be envisioned with structural manipulation.

Dr. Janine Talty, D.O., M.P.H. holds a Doctor of Osteopathic Medicine and Masters in Public Health, with a BS in Sports Medicine, with Residency and Fellowship at Michigan State University College of Osteopathic Medicine, with certifications in Manual Medicine, Muscle Energy Techniques, Myofascial Release, Strain-Counter Strain, Function Indirect Technique, Craniosacral Techniques, Direction Action Thrust, and Exercise Prescription. She is board certified by the American Osteopathic Board of Family Physicians, holds a California State Medical License, is a member of the American Osteopathic Association, the American College of Osteopathic Family Physicians, the American Back Society, the International Spinal Injection Society and a Board Member of the American Association of Orthopedic Medicine. Dr. Talty is a Clinical Assistant Professor at Michigan State University College of Osteopathic Medicine and is the Medical Director of the Wellness & Rehabilitation Medical Center.