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.

1 comment:

Anonymous said...

a very good description of the major treatment in osteopathy.
the 3 unit approach is based on the biomechanical research of J Littlejohn but only for the concept not for the testing.
too bad for gilette to treat only compensatory pattern why not treating the primary lesion in the leg as well?...
all the best pierre for the rest.....