Tuesday, July 10, 2007

How Scars influence your posture

(You can find a French translation of this article Here)

Surgeries are not always useful or needed but they do save millions of lives every year.

While allopathic medecine "saves" your life, it brings little attention to the consequence of such a procedure. I don't talk here about the risk inherent to a surgery but about the "post traumatic adaptation" of your body.

My first clinical experience with such a case was when I was an Osteopathic student at the ESO teaching clinic. I was treating Mr G., 67yrs old, for some chronic low back pain. Mr G. couldn't stand for more than 30 minutes without experiencing pain in both thighs. This was a good excuse to avoid the boring food shopping with his wife. He was playing golf twice a week, while the walking and the swing were more supportable than standing still, at the end of the game and for the following few days his back was particularly stiff.
The treatment that I was providing were mostly based on deep massages, mobilisation of the spine, hips, knees... Mr G. was feeling some relief from it and was coming back every 3 weeks for a maintenance treatment.
One day, my Osteopathic tutor (Miss Celine Meneteau) entered the treatment room and asked me : "What is the scar your patient does have on the front ? Did you ever stretch it ?" Effectively the patient had a peritonitis 20 years ago and a subsequent 20 cm scar on his abdominal wall, and "no" I never worked on it, and never thought that it could be of any significance regarding my patient symptoms.
I did indeed stretch this scar as well as providing the usual treatment.
3 weeks later, Mr G. reported that he could not escape any more the shopping with his wife because he could stand more than 2hrs and half without any pain. His swing improved of 60 yards (obviously with the same club !).

"Post traumatic adaptation" :
Obviously an open wound is an experience a bit painful. The following weeks after the surgery, the patients will tend to protect their scar adopting an antalgic posture. The aim of this antalgic posture is to decrease the tension around the painful area.
In the case of a Csection, for example, the patient will bend forward and avoid to straighten up or to arch backward. Slowly the patient recovers from her surgery and can sraighten up a bit more, but compare to her initial posture she is now leaning forward. Why is this ? because there are some scar adhesions !
When an abdomen is cut open, you cut different layers of skin, muscles, fasciae... when the healing process takes place, scarring tissues create adherences between these different layers. What was once upon the time smooth, sliding, elastic healthy tissues are now fix, congested, non-elastic ones. This is the beginning of a long chain of problems...

Let's continue with our new mother who just had a Csection :
The first symptoms will be a sensation of heavyness on the lower abdomen, increase frequency of urination, bloating sensation.
Few months later low back pain starts being an issue and can be associated with pain/cramps in the calves. Of course carrying a child is not helping, but the tension of the scar obliges the mother to constantly lean forward. To compensate this imbalance, the extensors muscles of the spine constantly contract to prevent her from falling forward. At the same time when she leans forward, her gravity centre moves forward as well. This increases the pressure at the distal end of her feet. More tension by the calves muscles is needed to bring back the gravity centre. Guess what ! it gives pain/cramp/stiffness in the calves !

Exercise Time, let's have a try :
Please stand up, flat feet on the floor, bend forward a bit then grab an inch of skin underneath your belly button. Now straighten up (gently) stop as soon as you feel uncomfortable in your lower abdomen. As you cannot straighten up completely, you should be able to feel some contraction in your low back muscles. Slowly you will feel your posture shifting forward, and an urge to push down with your toes, now you feel more tension in your calves . Well done ! if you are a man you just discover the post traumatic adaptation of a Csection!
If you continue this little exercise, You will notice that if you want to look straight you have to extend a bit more your neck. On the long term it increases the compression on the facets of the cervical spine which leads to neck pain, spondylosis, headaches...

In this case, if you just manipulate the spine or massage the back you cannot expect any improvement but a symptomatic short term relief. As soon as you will start working on this scar as well as opening the anterior fascial chain, the change in the posture will be tremendous and this will lead to a great improvement of the symtoms.

Patients who had a masectomy and suffer from shoulder pain on the same side few years later, Patients who had an appendicectomy as a child and now you suffer from some sacro-iliac pain on the right side, patients who had a Csection or a hysteretomy and complain from low back pain or neck pain, did you ever think it could come from this old scar ? If it sounds familiar don't hesitate to contact your nearest osteopath or another competent therapist.

Friday, July 6, 2007

Different Osteopathic approaches of diagnosis and treatment :

In this post I'll try to explain different modalities of Osteopathic treatment.

The two extreme ways of treatment are the minimalist approach and the other one is the maximalist approach. The minimalists will tend to push the diagnosis at the extreme and the treatment at its minimum, while the maximalists will tend to treat and diagnose at the same. The ratio in % I give is purely indicative.

Mechanical link (95% diagnosis, 5% treatment) :

Paul Chauffour and Eric Prat developed this approach in which they are looking for the Primary lesion and treat it, hoping for a decompensation of all Secondary restrictions.
They divide the body in 8 different unities :

-the spine and pelvis
-the anterior thorax
-the limbs (arms and legs)
-the cranium
-the viscerae (organs)
-the cardio-vascular system
-the intra-osseus lines of force
-the skin

Each of these unities will reveal one or two major restrictions. So which one is the one to treat ? Paul and Eric use the "inhibitory balance" to find out : if you apply a gentle pressure on two dominant restrictions the adaptation will soften under your fingers while the predominant lesion will still be dense. After finding the major restriction, the "Primary Lesion", you treat it with a "recoil" technique ( a swift flick of your thumb). The major restrictions found earlier should have soften, if not, then treat again the most dominant one. Each treatment comprises of around 350 to 400 tests and only 1 to 3 recoils !!!

This example of treatment has been reported to me by 3 of my colleagues who where watching a "mechanical link" demonstration :
The patient was having some pain in the right shoulder if he abducted his shoulder to more than 90 degrees. The Primary lesion was a spasm of the right femoral artery ! After correction of this spasm with a recoil, the patient could lift his shoulder without any pain or restriction.
This sounds incredible ? this is just one example. Even chronic cases seem to respond as well from this type of treatment.

This approach fits perfectly with A.T. Still statement : "find it, fix it, leave it alone..."

Gilette's approach (80% diagnosis, 20% treatment) :

This protocol of treatment has been developed by a Chiropractor (Gilette) but been presented to us during our osteopathic course by an Osteopath Mr Desjardins. Even if I am not so keen on chiropractic in general, I must say that I find this approach quite interesting.

The "philosophy" of this approach is that the pelvis is the major area of compensation between the descending forces of the upper body and the ascending forces coming from the legs. Therefore if the pelvis is not able to compensate then problems occur.

The diagnosis is fairly straight forward :
specific diagnosis of the pelvis pattern
-gross mobility testing of the thoracic spine
-testing of the occiput-atlas joint

The treatment is fairly straight forward :
-specific stretches of the pelvic ligaments
-mobilisation of the major group in restriction of the thoracic spine (HVT/Staircase)
-the occiput-atlas is seen as a barometer of the spine ; if after the previous corrections it is still restricted then manipulation of this level will be needed.

The pelvis and the thoracic spine is then reassessed.

With this methods you can treat a patient in less than 20 minutes. Mr Desjardins told us that it was the most effective type of treatment he ever practiced. Some of my colleagues use it and are convinced of its effectiveness.

Personally I still hope that I am a bit more than just a pelvis and a spine... But if you want to keep your practice simple and be able to see more than 80 patients a week this is certainly the way !

The Three Unities (75% diagnosis, 25% treatment) :

I have learned this approach from David McGinn at the CIDO. But I am still confused about who was the original author of this approach (dear colleagues please help me out with this one).

The aim of this method of diagnosis is to divide the body in three unities :

-Unity 1 : this is the locomotion unity, involving the lumbar spine from L3, the pelvis and the legs
-Unity 2 : this is the action and balance unity, involving the arms, the head and the cervical spine down to T4
-Unity 3 : this is the vital unity as well as the junction between the two other unities. It comprises the thoracic spine, upper lumbars as well as all the ribs.

Global tests permit to know quickly if a unity is involved or not. If a unity is involved then specific testing will reveal the predominant Osteopathic lesions.
As a general rule the Primary lesion should be found in all positions (standing, sitting, prone, supine, sidelying) and its correction should result in an increase of mobility of the other secondary restrictions.

I find this method of diagnosis really interesting and relatively minimalist. From your findings you can use the type of treatment you want. The major reproach I can think of is that the visceral and the cranial systems are not really integrated. A few other tests are needed for the diagnosis to be a bit more precise.

My Osteopathic Approach (40% diagnosis, 60% treatment):

I generally spend a good 15 min of the treatment (out of 40 mins) to test and diagnose a chain of tension to work on. The method of practice will change according to the body morphology. The fitter the patient is, the more precise the diagnosis will be and the more minimalist the treatment will be. If the patient is not as fit as he could be, the treatment will tend towards a maximalist approach (GOT approach, see below).

My assessment is based on the "Three Unities" (see above) while integrating fully the visceral system.

The treatment will generally be focused first on the visceral system, which removes the major part of the musculo-skeletal restrictions. After a reassessment I treat the remaining Osteopathic lesions from bottom to top.

I generally keep the cranial approach towards the end of the treatment unless I have found that area to be the main focus of my treatment (eg :TMJ, stressed patient, emotional trauma...).

The General Osteopathic Treatment (10% diagnosis, 90% treatment) :

Also known as Total Body Adjustment, the GOT, as practiced in the UK, has been introduced by John Martin Littlejohn and his student John Wernham. GOT is the British classical Osteopathy.

It is a routine of treatment based on 10 different principles :

  • routine
  • rhythm
  • rotation
  • mobility
  • motility
  • articular integrity
  • coordination
  • correlation
  • stabilization
  • mechanical law

The aim of the treatment is to literally "shake" your body by mobilizing every one of your joints from head to toe. It may be associated with some HVT ("cracking" techniques) through the spine. By mobilizing the whole body, an harmonization of all structures takes place. It improves the plasticity and elasticity of the tissues therefore enhances the adaptability of the body to its surrounding environment.

One may argue that the diagnosis is 100% part of the treatment, as the GOT practitioner diagnoses and treats at the same time. This is true, but this is the case for any type of techniques, because 90% of the treatment is spent in treating the patient, GOT is the most maximalist Osteopathic approach.

Of course these are not the only way to treat a patient, but the most well-known, or interesting that I have met during my Osteopathic Journey. Every Osteopathic practitioners evolve between a more minimalist or maximalist approach depending on the patient they treat.