Osteopathy is a hands-on healthcare modality that relies on the mechanical skill of the practitioner to diagnose and treat dysfunction. Since its was founded by Andrew Taylor Still in 1874, it has centered on the concept of the body’s innate intelligence, that ability to self-regulate and self-protect (1902). By using manual methods aimed at optimizing the relationship between structure and function, rather than implementing surgical and pharmacological methods, this field was set apart from the trend of western medicine. This separation remains today. Training with Still’s concept of “anatomy first, last, and all the time” (Hoover, 1951), osteopaths learn the subtle feel of the body, and how to interpret the message of health or dysfunction without the use of tools and machines. In the same way, treatments can be applied with the hands, without reliance on medications, surgery, and medical devices.
Being based in anatomy, a key concept of osteopathy is the primary relationship between structure and function. I agree with Tom Dummer’s theory that these two concepts are “indivisible and are simply two aspects of the one expressed bioenergy” (Marcer and Parsons, 2006). Through this inextricable link, they function more like opposite ends of the same continuum, rather than individual components. Therefore osteopaths can obtain information about function by examining structure, and alternately, by studying function can deduced information about structure. Any change in one aspect will result in a change of the other. From this relationship, the state of dis-ease can be defined as that point when “environmental changes overcome the body’s capacity for self-maintenance” (DiGiovanna and Schiowitz 1991). The role of the osteopath then is to apply input that will help the body return to normal, in a more suitable structure and function. This idea can be found in many texts, however my personal views differ slightly. Rather than trying to make the body look like some version of normal, or attempting to maximize mobility without regard to the components, our aim as osteopaths should be to strike a balance between the two aspects that allows the individual body the ability to again self-govern to return to optimal health.
It then follows that a holistic approach is a necessary component to osteopathy, as the structure and function will affect the patient physically, emotionally, and spiritually. Within our patients, these parts can never be entirely separated, thus a comprehensive treatment approach will be necessary to take them all into account. To me, Still’s founding premise of examining “the body as a unit” (Kuchera and Kuchera 1992) gives consideration to these biopsychosocial aspects in diagnosis and treatment. I believe that through manual therapy we can influence all of these.
Andrew Taylor Still founded the discipline on the American frontier in a very different medical climate than that which exists today, and while many of his principles remain quite valuable, like sanitation and hygiene, some are up for debate. Still (1910) was opposed to an osteopath using any form of intervention aside from manual therapy, whether in assessment, diagnosis, or treatment. His position was firm, not only against the use of vaccines and drugs, but also against non-drug remedies, x-ray, electrotherapy, and hydrotherapy. While I am in agreement that none of these are or should be required to perform quality osteopathic treatment, I do find that herbs and homeopathic remedies can often be beneficial. Even if they are only valuable for a placebo effect as some argue, that is still an effect, sometimes a quite powerful one. More tools in the proverbial toolbox may increase the osteopath’s ability to help their patients in the variety of conditions that they experience. A well-placed ice pack can be soothing to an acute strain, a well-timed arnica remedy limiting to the severity of an inflammatory reaction. Eliminating all things adjunct is reductionist and limiting to the scope of practice. I think many methods can be used in combination to achieve peak wellness, and any therapy that sets out to heal everything on its own is doomed to fail. Our patients are as varied as our techniques, so the same tool cannot equally be applied to each.
Stemming from a time when the scientific approach to medicine was on the rise, it is profound that Still taught surgery as a last resort (1910). While so many were working to discover how to intervene to help repair the human body in many invasive ways, he developed a method that avoided surgery at all costs. While surgical techniques and technology have drastically improved over the past century, statistics still show that in many cases patients get little or no improvement, and can sometime have new or increased in symptoms (Surg Neuro 1998). Therefore I agree with Still’s concept of surgical treatment as a last resort.
Within the field there are a variety of techniques used to assess and treat, and as many explanations to go along with them. One prevailing concept is that the focus of the practitioner should be on identifying the bony lesion, and particularly a vertebral lesion (Proby 1937). This has led to osteopaths being widely knows as spine manipulators. I believe this is a valuable concept, but certainly not the whole story, and drastically minimalistic. While spinal manipulation can be used to affect a great number of symptoms and body parts, I believe the same is true in reverse: treating any body part will have a ripple effect throughout the body. Therefore I feel it is inappropriate to go about one’s practice primarily focused on spinal evaluation, rather the entire person should be taken into consideration, with no bias or preference shown for any section over another.
This leads to another conundrum within osteopathy: what is a primary lesion? This has been described as the chronologically oldest lesion, the most restrictive lesion, the central lesion which “by treating it, everything else will be corrected” (Chauffour and Prat 2002), and probably other definitions as well. This idea is widely debated, and some practitioners even consider it unimportant. Personally I follow the Mechanical Link theory of the primary lesion being the central lesion. I believe this concept to be extremely important, and that by treating a person in a careful sequence, more change can be made in a single visit, and fewer follow-up treatments will be required. This in turn saves the patient time and money, as well as offering permanent results faster. Easier said than done, as assessment is one of the most variable and subjective steps of osteopathic care. Add to that the years required to hone the subtle skills of palpation while learning to listen and interpret the messages of the body all via the hands, and you seem to have your own Everest to climb. However, there are practitioners of this method that treat with 1-5 moves per session that are widely successful, demonstrating to me that meticulous assessment can lead an observant practitioner to the very root of the dysfunction. A goal in this type of practice is to be more efficient in treatment, and that by following the sequence shown to you by the patient’s body, you will incur fewer side effects and flare-ups after treatment.
For my own practice, I am especially drawn to Jean-Pierre Barral’s functional and visceral techniques and John Upledger’s cranio-sacral therapy. The subtlety of these methods appeals to my desire to provide treatment that is gentle and non-invasive, while still being versatile and immediately effective. I hope to create a practice that is gentle not only for the patient, but on my own body, minimizing repetitive stress. While high velocity techniques became the discipline standard, they cannot be directly linked to Andrew Taylor Still’s work, and are only a facet of what osteopathic medicine entails. Like any discipline, new ideas and discoveries have led to a progression and changes within the field. In the words of Sue Turner (2010):
“I don’t know what for each individual is the truth of their portion of the divine nature, but something in them knows… we’re working with a patient towards a common goal, which is their well-being, so if I see myself in that situation as working towards that persons well-being, whatever that may be for them, making myself available to cooperate with the truth of their own, the truth of their health, the truth of the way the divine nature seeks to manifest itself in them as an individual, my place is simply to make myself available to cooperating with what is intending to happen within them for their fulfillment and the fulfillment of their potential. I don’t need to know what that is.”
Much of what draws me to osteopathy is this expansion into the subtler, esoteric realms that link the budding medical frontier with ancient internal wisdom.
Chauffour, P. and Prat, E. Mechanical Link. Berkeley, CA, North Atlantic Books 28-29
DiGiovanna EL, Schiowitz R, eds. (1991) An osteopathic approach to diagnosis and treatment. Philadelphia, PA, JB Lippincott
Hoover M. A. (1951) Some studies in osteopathy. AAO 55-72
Kuchera W.A. and Kuchera M.L. (1992) Osteopathic principles in practice. 2nd ed. Columbus, Original Works 2
Marcer, N. and Parsons, J. (2006) Osteopathy: Models for Diagnosis, Treatment, and Practice. London, Elsevier Churchill Livingstone 30
Proby J.C. (1937) Essay on osteopathy. Oxford, private printing 13
Still A.T. (1902) The Philosophy and Mechanical Principles of Osteopathy Kansas City, MO, Hudson-Kimberly Publication Co. 58
Still A.T. (1910) Osteopathy research and practice. Kirskville 27
Surg Neurol 1998 Mar. 49(3):263-7; discussion 267-8
Turner, S. (2010) 1000 years of osteopathy: video interviews. available at http://1000yearsinterviews.com/sue_turner/turner.swf (accessed: 12.12.2011)