Osteopathic Treatment Approaches.

DIRECT TECHNIQUES
Thrust, or high-velocity, low-amplitude (HVLA) technique is an example of direct technique; HVLA technique has been a mainstay of osteopathic treatment since inception of the profession. The patient is placed in a position so that the joint is brought into its physiological restricted barrier to motion. The physician applies a small amount of force quickly, just enough to go beyond the restrictive barrier. Then, motion is reassessed. The expected result is improved function (i.e., motion). This is a passive treatment because the physician provides the force.
An example of thrust technique is a patient who presents with anterior chest wall pain. The most common etiology of this complaint is somatic dysfunction of the ribs. Assuming this is the diagnosis, the physician determines the barrier to rib head motion and after positioning the patient, gently and swiftly overcomes the barrier to motion. Besides improved motion, one expects immediate alleviation of pain.

Muscle energy technique is another example of direct treatment. This form, unlike thrust, is an active technique in that the patient helps provide the corrective force. An example is a patient who presents with acute lumbar pain. On examination, the practitioner finds that the L-5 vertebra rotates easier to the right than the left (i.e., rotated right) and sidebends easier to the left than the right (i.e., sidebent left). The patient is positioned, and the physician has the patient rotate to the right and sidebend to the left in the lumbar region against resistance applied by the doctor.

Cranial manipulation may also involve direct treatment. For example, if a neonate refuses to suckle, this problem may be caused by suboccipital compression secondary to labor and compressive forces of the birth canal. This in turn puts pressure on the involved cranial nerves, which decompression may relieve. The expected result is immediate improvement in suckling.

INDIRECT TECHNIQUES
Indirect techniques of manipulation involve taking the dysfunctional unit in a direction away from the restricted motion barrier until a state of balanced tension is obtained. Functional and indirect ligamentous balance technique uses these principles. For example, an athlete suffers a sprained ankle on the soccer field. Before any other intervention is done the physician cradles the proximal aspects of the tibia and fibula in one hand and grasps both malleolae in the other. He or she holds them in a state of balanced, ligamentous tension, feeling the release of the strain-sprain take place. When the tissues feel palpably normalized the physician retests motion. The usual result is immediate: alleviation of dysfunctional symptoms. In many cases, depending on severity, the athlete can immediately return to the game.

Strain-counterstrain is another form of indirect manipulation. A tenderpoint related to a specific somatic dysfunction is located. The ends of the muscle or muscles in which it occurs are approximated and held for about 90 seconds, at which point they are slowly released. At this point the muscle contraction and tenderpoint will be gone, and retesting of the joint motion reveals less dysfunction. An example is a patient with acute torticollis. The physician palpates the most tenderpoint along the anterior or posterior articular pillars in the cervical paraspinal musculature. Then the physician presses the point and asks the patient to quantify the pain (e.g., the most pain is equivalent to $1.00) Then he or she repositions the spine so that when he or she presses on the point again the patient tells the physician that 25¢ or less of the pain remains. The physician then holds the patient in this position for 90 seconds and then, without any help from the patient, brings the patient to a neutral position and firmly presses the point. Reevaluation of the specific joint dysfunction will reveal an improved range of motion and the patient will report significantly less pain. This form of manipulation is one of the best for the neophyte to begin with when starting to learn osteopathic manipulation because it involves only the most elementary type of palpation, is easily grasped, and produces excellent, longlasting results.

OTHER TYPES OF OMT
There are many other types of osteopathic manipulation: Chapman's reflex points, fascial unwinding, fluid techniques, such as V-spread, energetic treatments, percussion hammer work of Robert Fulford, DO, embryologically based treatment of James Jealous, DO, indirect forms of cranial manipulation and the work of Rollin Becker, DO, John Upledger, DO, and others, to name but a few options.