Osteopathy Manipulative Treatment Within Manual Therapy
Consider Manual Therapy and Complementary and Alternative Medicine for Optimal Health
Integrative Manual Therapy (IMT) and Osteopathic Manipulative Treatment (OMT)
Integrative Manual Therapy has in common with osteopathic medicine that it promotes the application of osteopathic philosophies and concepts focus on total body healing.
Integrative Manual practitioners follow many of the accepted methods of physical diagnosis and treatment found within osteopathic medicine.
They are trained to expertly evaluate their clients from a total body perspective, looking at all systems including cranial, visceral and neuromusculoskeletal tissues.
They seek to achieve normal body mechanic through the use of various direct and indirect manual manipulative medicine.
Integrative Manual Therapy practitioners recognize the body’s ability to regulate itself and bring about facilitation and strengthening of the body’s defenses against most somatic and pathologic conditions.
Integrative Manual therapy thus recognizes the cranial, visceral, and neuromusculoskeletal systems as crucially important to the full expression of life.
“The viscera and fluid systems serve the neuromusculoskeletal system by providing nourishment to it and by removing its wastes.
The neuromusculo skeletal system often functions as a mirror of both health and disease, responding to inflammation and pain in other body systems as well.”
Northup, G. W. (1965). “Osteopathic Medicine: A Medical Reformation.” J Am Osteopath Assoc 64: 787–94.
The Integrative Manual Therapist considers the body as an integrated unit comprising multiple complex functions that are interrelated.
Another important principle IMT shares with osteopathic medicine is the philosophy that structure and function are intimately interrelated structures. An abnormality in the structure of any body part can lead to abnormal function, whether expressed locally or distantly from the deranged structure. To correct a deranged structure, the Integrative Manual Practitioner use a hands-on approach. It is gentle and controlled; it may be directed toward joint mobility or directed toward the muscles of fascia, viscera or the nervous system. Integrative Manual therapy is also used to affect circulation, breathing and movement of body fluids and the gastrointestinal tract.
Self-Regulation
At the core of Integrative Manual Therapy lies a recognition of the body’s ability to regulate itself, and its inherent capacity to protect and repair itself. If there is an injury or disease process, the person may needs some external help which can be provided by a manual therapist, nutritional supplementation, exercises and other means.
IMT practitioners are trained to recognize somatic components to disease that are not only manifestations of disease but also factors that contribute to maintenance of a disability or disturbance of the body. The somatic component can be caused by a direct bodily injury or by the response of viscera to pathology via the viscero-somatic Reflex. In many instances, illness is an imbalance between the neuromuscular system and the visceral systems. Sometimes there are emotional or social issues contributing to dysfunction. All the issues need to be addressed so the body can heal itself.
Integrative Systems Approach
Integrative Manual Therapy practitioners use a wide variety of manual therapy techniques. Some were developed by osteopaths (Muscle Energy Technique [Fred Mitchell Sr.], Strain and Counterstrain [Lawrence Jones], CranioSacral Therapy [John Upledger], Visceral Manipulation [Jean-Pierre Baral]), while others introduced by the developers of Integrative Manual Therapy, Sharon W. Giammatteo, P.T., PhD and her husband, Thomas Giammatteo, D.C. Some techniques used by IMT practitioners were originally based on the Giammatteo’s studies of osteopathic approaches. (Muscle Energy and Beyond for the extremity joints, Advanced Strain and Counterstrain (Weiselfish,1997) and (Wheeler,2004) for autonomically innervated muscles such as blood vessels, Cranial Therapy, Visceral Mobilization, Bone Bruise Technique and more).
Giammatteo, T. and S. Weiselfish-Giammatteo (1997). Integrative manual therapy for the autonomic nervous system and related disorders : utilizing advanced strain and counterstrain technique. Berkeley, Calif., North Atlantic Books.
Wheeler, L. (2004). “Advanced Strain Counterstrain.” Massage Therapy Journal 43 Winter(4).
There are also a whole range of techniques within the field of Integrative Manual Therapy, which were developed by Sharon W. Giammatteo in a unique manner. These techniques have names like Recovery Motilities, Physical Functional Medicine (PFM), Compression Syndromes to decompress the tissue, Integrative Diagnostics Applied Psychosynthesis (IDAP) for whole body and emotional wellbeing, Templates for Autonomic Nervous System dysfunctions, Energetic phenomenon such as Synchronizers, Hypothalamus Regulation Mechanisms, Reference Points, etc.
Hands-On Therapy
In Osteopathic Manipulative Treatment (OMT), use of the hands to diagnosis and treatment patients, is an integral part of the overall treatment plan for many types of injuries and disability processes. Supportive modalities such as exercise, nutritional counseling, and lifestyle counseling are also included.
Like Osteopathic Manual Practitioners, IMT practitioners consider, postural, structural, and biomechanical dysfunctions in their assessment and treatment planning to help increase the clients function and decrease signs and symptoms.
Integrative Manual Therapy uses both direct (Muscle Energy Technique) and indirect (Strain and Counterstrain) techniques. Some IMT techniques such as the Bone Bruise technique for facilitating bone healing is a combination of both direct and indirect components.
Integrative Manual Therapy practitioners use techniques which address the ability of the nerves to move (Neural Tissue Tension Technique) as well as contacting reflex points (Synchronizer, Hypothalamus Regulation Mechanisms and Reference Points) to facilitate healing within the nervous system thereby improving the way the nervous system interacts with all other systems in the body.
They also look at the “container” around the nervous system to ensure that the cranial bone / spinal vertebral movement and Cranial Rhythmic Impulse (CRI) is functioning well. Integrative Manual Therapy practitioners work with children with autism, cerebral palsy as well as neurodegenerative diseases such as Parkinson’s and Alzheimer’s disease and chronic pain syndromes.
Burnham, K. (2006). The effect of Integrative Manual Therapy on the symptoms of Parkinson’s disease abstract, PhD Dissertation in Integrative Medicine (August 2006) Westbrook University.
Consideration is given to the respiratory system including the lungs, diaphragm and rib cage but IMT practitioners also look at respiration on a cellular level and try to ensure that oxygen is brought efficiently into the lungs but also treat to ensure there are no blockages of the circulatory system, which would interfere with oxygen reaching the cells.
Many IMT practitioners have studied Visceral Manipulation with Jean-Pierre Baral, DO and palpate the motilities of the organs and use both direct and indirect techniques to improve the movement and function of the soft tissue. In addition there are other motilities/ rhythms palpated by IMT practitioners which are thought to be reflective of how the organ is functioning. One way to describe this form of manual therapy is to think of someone who’s heart has stopped. The person doing CPR is using a specific amount of pressure in a specific location to normalize a rhythm in the body. Within IMT practitioners use a specific amount of pressure (typically less than used with CPR) in specific locations (ie) over organs, to normalize function within the organs.
Burnham, K. (2005). “A way to consider Integrative Manual Therapy.” Health & Recovery, The Newsletter About Integrative Manual Therapy — The Science of Whole Body Health(1).
There is a case study article by an IMT practitioner, which brings together the importance of the lymphatic system to decrease pain and increase healing. Crowell explains how using the Bone Bruise technique and Neurofascial Process and lymphatic techniques from IMT as well as a functional exercise program enabled bone healing and a decrease in lymphedema.
Crowell, T. (2005). “The relationship between bone bruises and lymphedema after fracture: a case study.” The Townsend Letters.
In Integrative Manual Therapy (IMT) emphasis is given to the treatment of the unique imbalances of each client. Most clients usually require a mixture of modalities. It is always imperative to “listen” to the feedback from the patient’s tissues to determine when and where and in which combination a particular type of technique will be used.
Osteopathy and IMT both look at systemic treatment considerations, the individual/ unique client, exercise and self-care programs and how the dysfunction has affected the person’s posture, gait and tissue. They use case history taking, hands on evaluation, observation, anatomic considerations and a substantial knowledge base to develop effective efficient treatment plans.
Both Osteopathic Manual Practice/ Osteopathic Manipulative Treatment and Integrative Manual Therapy take a systemic approach to treatment and assessment.
a) Address the fascial tissue and soft tissue dysfunctions (Myofascial Release, Ligamentous Articular Strain Technique, Balanced Ligamentous Tension Technique, Ligament Fiber Therapy, Tendon Therapy);
b) Biomechanical approaches for joints (Muscle Energy Techniques, Adjustment Therapy, Percussional Therapy, Thrusting Techniques);
c) Treatment for muscle spasms (Strain and Counterstrain, Advanced Strain and Counterstrain, Facilitated Positional Release, PINS techniques [progressive inhibition of neuromuscular structures: steady pressure to soft tissues to effect relaxation and normalize reflex activity]);
d) Techniques focused on facilitating movement of the cranial bones and proper flow of fluid within the cranium (Cranial Rhythmic Impulse, CranioSacral Therapy, Cranial Therapy, Cranial Osteopathy)
e) Functional Techniques (AT Still, Harold Hoover, Harrison Freyette, Irvin Korr, etc) which include passively placing a segment into its 3 planes of motion with one hand + palpatory listening with other hand — using breathing increasing the segmental motion in the direction of ease, removing restrictions — repeated until full ease of motion is established)
f) Ways to work with reflexes within the body (Chapman’s reflex points, Synchronizers, Hypothalamus Regulation Mechanisms, Reference Points) as well as an awareness of acupuncture points.
g) An awareness and approaches for the lymphatic system
h) An appreciation and techniques to improve the integration of the Autonomic Nervous System (AdvStrain Counterstrain, Thoracic Pumping, ANS Templates)
i) Visceral manipulation, including pulmonary, cardiac, gastrointestinal, renal & urological, and gynecologic considerations.
j) Neurological consideration: motor, sensory, autonomic (sympathetic and parasympathetic).
Osteopathic Medicine
“The uniqueness of osteopathic medicine lies in the application of osteopathic philosophy and concepts. Osteopathic medical practitioners follow accepted methods of physical (and surgical) diagnosis and treatment; they are also trained to expertly evaluate the neuromusculoskeleton system and seek to achieve normal body mechanisms through the use of manual manipulative medicine. Osteopathic (physicians) recognize the body’s ability to regulate itself and mount its own defenses against most pathologic conditions.”
DiGiovanna, E. L. and S. Schiowitz (1997). An osteopathic approach to diagnosis and treatment. Philadelphia, Lippincott-Raven. pg 3–5.
“Osteopathic medicine thus recognizes the neuromusculoskeletal system as crucially important to the full expression of life. The viscera subserve the neuromuscoloskeletal system by providing nourishment to it and by removing its wastes.”
Northup, G. W. (1965). “Osteopathic Medicine: A Medical Reformation.” J Am Osteopath Assoc 64: 787–94.
Musculoskeletal Approaches
The musculoskeletal system is intimately connected with all other systems of the body through both the voluntary and the involuntary nervous system. Thus, indications are that the musculoskeletal system is a mirror of both health and disease, responding as it does to inflammation and pain from disorder in other body systems.
Therefore, when assessing the patient, the osteopathic (physician) considers the body as an integrated unit comprising multiple complex functions and interrelated structures.
DiGiovanna, E. L. and S. Schiowitz (1997). An osteopathic approach to diagnosis and treatment. Philadelphia, Lippincott-Raven. pg 10.
Structure and Function
Another important principle in osteopathic medicine is that structure and function are intimately interrelated structures. An abnormality in the structure of any body part can lead to abnormal function, whether expressed locally or distantly from the deranged structure. To correct the mechanical disorders, the osteopathic (physician) undertakes therapeutic osteopathic manipulation. This hands-on approach is gentle and controlled; it may be directed toward joint motion or directed toward the muscles of fascia. It is also used to affect circulation, body fluids, and nervous impulses.
DiGiovanna, E. L. and S. Schiowitz (1997). An osteopathic approach to diagnosis and treatment. Philadelphia, Lippincott-Raven. pg 11.
The heart of osteopathy is the recognition of the body’s ability to cure itself, with some external help, of many pathological. This tenet echoes the belief enunciated by Hippocrates more than 2,000 years ago: “Our natures are the physician for our diseases.”
DiGiovanna, E. L. and S. Schiowitz (1997). An osteopathic approach to diagnosis and treatment. Philadelphia, Lippincott-Raven. pg 11.
Fluid Movement
Movement of body fluids is essential to the maintenance of health. The nervous system plays a crucial part in controlling the body. There are somatic components to disease that are not only manifestations of disease but are also factors that contribute to maintenance of the diseased state. The somatic component can be caused by a direct bodily injury or may represent the response of viscera to pathology via the viscerosomatic reflex. The nervous system is the most important system connecting and integrating the visceral and skeletal organs. In many instances, illness is an imbalance between the neuromuscular system and the visceral systems. This must be mitigated before the body can heal itself.
DiGiovanna, E. L. and S. Schiowitz (1997). An osteopathic approach to diagnosis and treatment. Philadelphia, Lippincott-Raven. pg 14–15.
Osteopathic medicine considers the person as an integral unit. Chapter 11 talks about OMT defined as osteopathic manipulative treatment “which includes a variety of techniques using the hands in the diagnosis and treatment of patients. It is part of the overall treatment plan for many types of injuries and disease processes. This plan may include (pharmacological agents), exercise, nutritional counseling, modalities, (surgical procedures), and lifestyle counseling. OMT is directed specifically at the treatment of somatic dysfunction, which involve the body framework — joint, muscles, fascia, tendons, and ligaments, as well as the blood vessels and nerves that are involved with these structures.
DiGiovanna, E. L. and S. Schiowitz (1997). An osteopathic approach to diagnosis and treatment. Philadelphia, Lippincott-Raven. pg 77–79.
Osteopathic Physicians
“The growth and acceptance of osteopathic physicians as conventional medical practitioners in the United States has also raised questions about the distinctive aspects of osteopathic medicine. Although the use of osteopathic manipulative treatment (OMT) and a focus on primary care are most often cited as rationales for the uniqueness of osteopathic medicine, an osteopathic professional identity remains enigmatic.
There is presently a scarcity of basic mechanistic and translational research that can be considered to be uniquely osteopathic.
To be sure, there have been advances in osteopathic clinical trials, particularly those involving OMT for low back pain. Meta-analysis of these low back pain trials has provided evidence that: (1) OMT affords greater pain reduction than active or placebo control treatments; (2) the effects of OMT are comparable regardless of whether treatment is provided by fully-licensed osteopathic physicians in the United States or by osteopaths in the United Kingdom; and (3) the effects of OMT increase over time.
The intersection of these fundamental aspects of osteopathic medicine suggests that the profession may successfully adopt a generic strategy of “focused differentiation” to attain a competitive advantage in the health care arena. While there are both requisite demands and risks for the osteopathic profession in adopting such a strategy, these are reasonable in relation to the potential rewards to be attained.
The osteopathic profession should adopt a coherent strategy for developing and promoting its identity. Failure to do so will likely ensure that osteopathic medicine remains “stuck in the middle.”
Licciardone, J. C. (2007). “Osteopathic research: elephants, enigmas, and evidence.” Osteopath Med Prim Care 1: 7.
Originally published in The Burnham Review on February 1, 2006.
