It is becoming increasingly apparent that different OMTs can be applied to enhance patients’ rehabilitation, both alone and in combination with targeted therapies used in holistic regimens. Therefore, it may be beneficial to inform the general community and educate the public and those associated with the healthcare sector about the benefits of using OMT as a treatment modality. OMT is low cost, non-invasive and highly effective in promoting whole body healing by targeting the nervous, lymphatic, immune and vascular systems. There is a growing body of literature related to osteopathic research and the potential molecular pathways involved in the healing process, and this growing field is expected to increase in value in healthcare. This review explains the commonly used OMT methods and their recognized therapeutic benefits, which underscore the need to understand the potential molecular mechanisms and circulating biomarkers associated with the systemic benefits of osteopathy.

The use of many osteopathic techniques is also becoming more common in some areas of healthcare, particularly primary care abroad. Therefore, the aim of this review article is to educate the public about osteopathy , what it is and how it is used.

Osteopathic principles describe the body as a single, functional unit. The goal of osteopathy is to facilitate and support self-healing, which is encompassed by the four osteopathic principles. These four principles of osteopathy are: (i). The body is a single unit that includes body, mind and spirit. (ii). The body is capable of self-regulation, self-healing and health maintenance. (iii). Structure and function are interrelated. and (iv). Rational treatment is based on understanding and applying principles one to three. Much of the osteopathic approach involves listening to both the patient and the patient’s body. “Listening” to the patient’s body requires knowledge of physical dysfunction and the ability to physically assess it, which is the additional training offered in osteopathic schools. In this respect, osteopathic education creates a practitioner with increased dynamic active listening skills at the start of practice. While osteopaths are trained in additional learning elements known as Osteopathic Manual Therapy Techniques (OMTs) and the use of compassion and care to treat the patient as a whole and not just the affected organ. There are many techniques in osteopathy that address specific dysfunctions and diseases.

An osteopath indicates the use of specific OMT techniques based on an assessment of body dysfunctions, such as tenderness, asymmetry, restriction of movement or changes in tissue texture. These physical dysfunctions may occur due to impaired functions of the skeletal, neuroarticular and myofascial structures and their associated vascular, lymphatic and nervous components. Dysfunctions can also occur in the spinal vertebrae and autonomic nervous system and can start anywhere in the body, causing chronic pain and increased morbidity. The mechanisms underlying the beneficial actions of the different OMTs are mainly based on the interconnection of the body’s systems and the inherent capacity for self-healing. An abnormality in the musculoskeletal system can manifest itself in the organs (somato-physical reflex) and the pathology of the visceral organs can manifest itself either as reduced range of motion or as changes in tissue texture in the musculoskeletal system (visceral-physical reflex). OMT administration not only addresses these dysfunctions, but also reduces pain, increases range of motion, increases the ability to move with ease, and improves neurovascular and lymphatic flow to facilitate the resulting benefits.

The osteopathic approach to patient care was intended to be a “complete system”. This means that the OMT prescription can be directed and modified for each type and severity of illness. In this perspective, OMT is usually considered for use as an adjunct to medical interventions. The versatility of OMT offers it in the treatment of multiple types and severity of diseases. Osteopathic techniques are tailored based on the patient’s condition, age, weight and other characteristics, delivering personalized, holistic therapy. Techniques include lymphatic manipulation, rib elevation, diaphragmatic manipulation, short range high speed, myoperitoneal release, balanced ligamentous tension, muscle energy, visceral therapy, and cranial osteopathic therapy which is a unique and central method of technique belonging to osteopathy.

Diaphragm dome
Relaxing the respiratory diaphragm by applying pressure under the chest bilaterally. Improves the diaphragmatic movement.
Secondary uses: reduction of cervical, thoracic and lumbar pain due to multiple adductions and improvement of circulation.

Indirect diaphragm release
Relaxation of the respiratory diaphragm by placing the hands on the anterolateral cage of the ribs and moving the tissues. Reduces cervical, thoracic and lumbar pain due to multiple adhesions and improves circulation.

High Velocity Low Amplitude (HVLA)
Application of rapid force at a short range directed at a joint, which engages the restraining barrier and releases the restraint. Reduces joint pain, improves mobility and improves range of motion.

Lymph Pump
Clearing obstructions in the lymphatic channels and using pumping techniques usually performed on the legs, abdomen and chest. It is used in infections of the gastrointestinal tract, respiratory infections and swelling.
Secondary uses : Improving immune function and vaccination efficacy.

Rib Raising
A method of “lifting” the ribs forward in order to affect the function of the ganglia of the sympathetic chain located in front of the ribs. It reduces the activity of the sympathetic nervous system, increases respiratory function, increases the mobility of the chest wall and lymphatic flow.
Cranial Osteopathy. Improving both central and peripheral brain functions by balancing the flow of CSF and improving the movement of the sacrum and skull. It promotes the function of the primary respiratory mechanism, treats physical dysfunction of the bones of the skull, tissues, dura mater and overlying fascia, reducing the burden of symptoms associated with concussion.

Osteopathy includes many treatment methods for targeting assessments. An individual assessment can be treated in a variety of ways, depending on many factors such as the patient’s age, severity, size of the patient and/or therapist, environment, etc. A popular treatment option method of choice is the muscle energy technique. This approach is both direct and active , where the patient actively participates in the treatment and is placed in the obstacle or restrictive movement . The muscle energy technique was invented in 1948 by Fred Mitchell Sr., DO. This therapy is used primarily to increase range of motion of restricted areas, stretch tight muscles, reduce pain, and improve circulation and lymphatic flow throughout the body.

For post-isometric relaxation, the DO will place the muscle at the barrier (the point where tension is initially felt) and instruct the patient to contract his/her muscle in the direction of ease (away from the barrier). The patient will contract again for five seconds against the counteracting force generated by the DO The procedure is repeated three to five times or until the desired range of motion is achieved.

While the goal of reciprocal suspension is the same as post-equilibrium relaxation, the mechanism is different. Using this method, the D.O would instruct the patient to contract the antagonist muscle to cause relaxation and stretching of the agonist muscle. Think of a hypertonic biceps. The D.O will place the patient on the restraining bar just as one would for post-isometric relaxation, but the D.O will have the patient contract the triceps muscle against his/her strength instead of contracting the biceps muscle (as would be done during post-isometric relaxation). The D.O. will then place the patient in the new restrictive barrier and continue treatment as previously described. The difference between the subtypes is which muscle is used to give results – the agonist or the competitor.

The underlying mechanism of post-isometric relaxation involves the Golgi tendons of the muscle being treated. When the muscle is contracted during the treatment, the Golgi tendon is stimulated. The stimulation sends a signal through afferent neurons 1b to the inhibitory interneurons of the spinal cord. This signal creates a sustained period after muscle contraction and initiates a reflex relaxation in the target muscle, so the D.O. can place the patient in a new barrier. The mutual suspension mode is not based on the Golgi tendon organ like post-isometric relaxation. Instead, it activates the fibers of the muscle spindle through Tension. Stretching stimulates the muscle spindle, which in turn activates 1a afferent motor neurons. The key difference between post-isometric relaxation and reciprocal suspension is that the former is the ability of a muscle to relax when experiencing tension or increased tension, while reciprocal suspension is the relaxation of muscles on one side of a joint to accommodate contraction on the other side of that joint. The result is an inhibition of the alpha motor neurons that send information to the agonist muscle, leading to muscle relaxation. Therefore, the doctor can indirectly treat the hypertonic muscle by contracting the antagonist muscle, leading to relaxation of the agonist muscle.

To initiate spinal muscle energy, the D.O. must find a physical dysfunction. The assessment is practically done by locating the area of greatest restriction and identifying the vertebral segment or group of vertebrae causing the restriction. Once the most constrained area is identified, local evaluation of the location preference in 3 dimensions/planes is the next step. This will help determine the setting of the technique by identifying the location of the restriction. First, the D.O. will place his or her thumbs on each transverse process of the vertebra and determine which transverse process is more posterior compared to the other. The posterior transverse process determines the direction of rotation of the vertebral segment. If the right transverse process is more posterior, the vertebra turns to the right. The D.O. will then evaluate the symmetry of the transverse in neutral, bending and extension. Whichever position provides the greatest symmetry between the processes is considered an evaluation. For example, if symmetry improves when the patient bends his/her back, the patient has a bending dysfunction-named after the direction of ease. If symmetry is improved by bending or extension, the lateral flexion component of the vertebra will be the same as the rotational component and the dysfunction is most likely to be located in a single segment. If symmetry remains unchanged, the lateral bending component is the opposite of the rotation component and the assessment is a neutral malfunction, which is more likely to present as a combined malfunction.

Once a physical dysfunction is found, the D.O. can then set the patient up for OMT. If post-isometric muscle energy therapy is used, the patient will be placed on his restrictive block and then apply contraction in the direction of ease against an opposing force applied by the doctor for about five seconds, relax and repeat. In the case of the spine, the restrictive barrier will have three elements: flexion/extension/neutral, rotation and lateral flexion.

The muscle energy technique can be used to treat many dysfunctions. One of the most common presentations targeted is back pain. Low back pain has been identified as the leading cause of disability in the US Treating this pain with muscle energy reduces the prescription of drugs, specifically opioids, as well as invasive (and often unnecessary) surgeries and costly imaging, and allows the patient to maintain a better quality of life. Indeed, a number of studies have shown that chronic pain is associated with more than just physical symptoms, but also with mental symptoms such as anxiety and depression disorders. Therefore, using OMT as a treatment modality allows for easier access and more affordable care options.

Due to the prevalence of low back pain in the US, the effectiveness of the muscle energy technique has been investigated in a series of trials to determine appropriate treatment. Back pain can occur due to spinal dysfunctions or a number of other dysfunctions, such as those of the ribs, sacrum, pelvis and lower limbs. Fortunately, muscle energy can be used to treat all of these dysfunctions. Numerous case studies have been conducted to determine its effectiveness. A pilot clinical trial investigated the impact of muscle energy for the treatment of low back pain in a population of 19 participants, divided equally into a control group and an experimental group. At the end of the study, the data showed a statistically significant difference between the groups, with the treatment group showing a greater reduction in pain. A systemic review also showed the success of muscle energy therapy in acute and chronic back pain and other musculoskeletal dysfunctions. In 2016, a randomized controlled trial found the muscle energy technique to be effective in treating non-specific low back pain before moving on to more expensive, invasive methods of relief. A recent study in 2018 compared the effectiveness of treating patients with a muscle energy technique versus a strain-counter strain technique and found that both are successful treatment methods for relieving back pain. Another case study recorded the progress of treatment of a patient with back pain. the patient was treated using a muscle energy technique at the sacroiliac joint rather than the lumbar spine itself and the study reported a realignment of the patient’s pelvis after a series of treatments and, consequently, a reduction in back pain. The latest case study clearly demonstrated one of the basic principles of osteopathy : treating the body as a single, connected unit.

Treatment of the deficit caused by dysfunction in the sacroiliac region is critical to the patient’s rapid recovery from pain and long-term well-being. Think about the sacroiliac joint – the anatomical structure responsible for holding the body upright and moving the lower limbs. The method of treating back pain with sacroiliac muscle energy techniques is demonstrated in a study comparing OMT to conventional treatments and the study supported the use of muscle energy technique over conventional treatments. A study by Patel et al. (2018) showed that the muscle energy technique can be used to correct anonymous (pelvic bone) rotation. During anonymous rehabilitation, the sacroiliac joint was relieved of tension and back pain was also relieved as a result.

The muscle energy technique can also be used to treat visceral conditions/diseases. In an eloquent study in 2019, the effectiveness of the muscle energy technique in the treatment of chronic obstructive pulmonary disease (COPD) was evaluated. The study results do not indicate muscle energy therapy as an effective treatment method, but like other published studies involving muscle energy technique, the researchers attribute these results to the small sample size of the study. The researchers ultimately found the study inconclusive, as a larger sample size is necessary to access the statistical significance of the treatment method in COPD patients. Although muscle energy techniques can be applied to any area of the body, unfortunately, there are very few published case studies investigating the effectiveness of muscle energy techniques due to its recent emergence as a therapeutic modality. However, almost all studies conducted to date show statistically significant results that support the use of muscle energy therapy as an effective course of treatment. In this respect, the few inconclusive studies are likely to be due to small sample sizes and, consequently, asymmetric data and insufficient evidence of its effectiveness. Therefore, confirmation of the benefits and efficacy of OMT needs to be properly addressed through large multicentre clinical trials so that these therapeutic approaches can be regularly implemented in the hospital setting.

The advantages of the muscle energy technique are enormous. It is more affordable and provides easier access to healthcare, reduced prevalence of painkiller use and avoidance of costly and unnecessary scans and procedures. Η οστεοπαθητική προσέγγιση λαμβάνει υπόψη το σώμα ως μια ενιαία, λειτουργική μονάδα, που προσεγγίζει τη θεραπεία από μια προσέγγιση νου, σώματος και πνεύματος [ . Although the available research at this time is limited, there is hope among the osteopathic community that this treatment method, as well as various other osteopathic treatment manipulations, will become a new area of research and use. Osteopathy is emerging and becoming increasingly popular, with evidence of its success in clinical practice settings.

Myofascial release technique (MFR) is a passive technique, either direct or indirect, that uses the body’s fascia to release the binding tissues and stimulate the body’s focus on healing and health. One of the main conditions of MFR use is chronic back pain. However, other pathologies such as disorders of the musculoskeletal system, peripheral nerves and tendons have also been treated. The MFR approach targets the myoperitoneum, which is continuous with connective tissue throughout the body and surrounds and supports bones, muscles, tendons, organs, vessels, nerves and lymphatic systems. Collagen tissue stretches throughout the body to create stability, but is also elastic enough to ensure tissue flexibility. Fascia can be thought of as a continuous sheet of tissue that connects the different parts of the body. A malfunction somewhere in the fascia can be detrimental to other components of the body’s internal systems.

The identification of myoperitoneal dysfunction requires a complete patient history and physical assessment based on the presenting symptoms. The goal is to improve restriction, restore function and reduce patient discomfort. Dysfunction is still determined based on TART findings, as discussed earlier in this review. The body is assessed on a holistic basis, looking at how each component of the body connects to the next to determine the origin of the problem and not just the presenting symptom. Contraindications for MFR may include patient refusal, recent fractures, open wounds, deep vein thrombosis and aortic aneurysm.

MFR requires engaging the fascia with gentle and constant pressure at either the direct barrier or indirect easement position, taking into account the rotation, extension/flexion and lateral bending of the tissue being treated. The D.O. should be able to feel the tissue under his hands release and soften as the changes occur. Once the release is felt, the D.O. should take care to slowly move the tissues back to normal rather than allowing an immediate return. Too rapid a return of the tissues could cause re-binding of the tissues and treatment would be futile. With tissue response, the results should be immediate. However, it may take a few days for a full response to the treatment to occur as the patient’s body readjusts to the new location of the fascia.

Some research has been completed on the biomechanical and chemical effects of MFR, which provided evidence of reduced inflammation as well as increased immune response. At the cellular level, MFR treatment can alter the function of fibroblasts, which are specialized cells that are an integral part of the function of fascia within the body. If the fibroblasts in the body are compromised, then the healing and function of the fascia is compromised, which leads to the assessment of physical dysfunction. There is limited research on the effectiveness of MFR. However, the evidence-based research that has been completed shows significant positive results. A recognized study of MFR showed statistical significance in a randomized trial with improvement in both pain and disability compared to those who did not receive myoperitoneal release therapy. Other studies have shown that MFR has been successful with temporomandibular joint (TMJ) disorders as it relates to the musculoskeletal system in the skull region, where fascia tissues can be remobilized by improving pathological blocks. MFR, as a non-drug and practical clinical technique, is an affordable treatment and rehabilitation option for all patients, especially to reduce the need and use of pharmaceuticals in the population.

Balanced ligamentous tension (BLT) is an indirect, passive technique used for ligamentous joints such as the pelvis, hip, shoulder, knee, elbows, etc. After a complete patient history and physical evaluation, BLT indications are based on at least two TART findings, just as any other osteopathic technique requires. Contraindications of BLT are fractures, malignancies and patient refusals. In addition, BLT administration skills depend on the physician’s palpation skills to sense changes in the tissues.

In short, the BLT technique requires either a short or long lever to compress the joints. A short lever applies compression at a shorter distance, while a long lever applies compression at a longer distance. For example, a short lever for the shoulder may use the elbow, while a long lever will use the entire upper limb. In addition, causing a vertebra to turn through contact with the spinous process is an example of a short lever, while causing that vertebra to turn by grasping an arm or leg and moving the body into a turn is an example of a long lever. Based on the constraint found, the peripheral hand monitors the joint while the proximal hand places the lever. First compression should be added and then rotation, extension/bending and lateral bending should be used to place the joint in the position of convenience for indirect treatment. As the name implies, a point of balanced tension is achieved by adjusting the direction of pressure and movement induced by the provider’s hand. The point of finding the balanced stress in the links is the key component that separates this technique from MFR.

The connective or myoperitoneal tissues in the case of MFR are brought to a point of ease and directional balance or equilibrium, as the name of the technique suggests. Balanced tension is a point at which the joint feels as if it has equal tension in all directions from the ligaments attached to it. The feeling of release should be warmth, unwinding of tissues and increased movement where less restriction is felt. The procedure may be repeated after the completion of the re-evaluation. When moving the joint back to neutral, the movements should be done slowly to ensure that the joint does not return to a state of restriction. Ultimately, however, being such a safe, tolerable treatment, BLT is one that can be used in many cases. One study used BLT in whole body case management for ACL injury and another used BLT involving the TMJ ,in both cases, osteopathic therapy helped reduce recovery time and improve both function and healing abilities of the body.

Humans have five connective tissue structures that are arranged in a transverse pattern throughout the body and these structures are our diaphragms. These five diaphragms include: the cerebellar spine, the tongue, the upper thoracic diaphragm, the respiratory diaphragm and the pelvic diaphragm. These structures play an integral role in our body to maintain homeostasis and proper function. Therefore, the diaphragms help us to control and synchronise our pressures within the cavity. The diaphragms also help to control the circulation between the different cavities and the interstitial space of the visceral parenchyma.

The diaphragm is the main muscle of breathing, so restrictions in this muscle can cause difficulty in breathing. Diaphragm therapy should be considered in patients with COPD, emphysema, asthma, pneumonia and other respiratory diseases that may be associated with breathlessness, in addition to general osteopathic therapy aimed at supporting and improving homeostasis. Contraindications to the diaphragm technique include patient refusal or intolerance, open wounds and recent fractures. The respiratory diaphragm is the main muscle involved in breathing and acts as a passageway for many vessels, nerves and organs. The vena cava, oesophagus, aorta, spouse, lymphatic vessels and sympathetic nerves pass through the respiratory diaphragm, so malfunctions can potentially affect these important structures. The respiratory diaphragm has attachments on the lower ribs, the vertebral column and the xiphoid process, as well as numerous attachments of the fascia. These attachments are important as septal dysfunction can cause biomechanical problems elsewhere in the body as tension is transferred through the fascia. There are multiple approaches to osteopathic treatment of the muscular diaphragm. The following section describes the dome and indirect aperture release techniques along with their uses.

One of the most common and effective approaches is called a diaphragmatic vault and this technique involves locating the xiphoid process and the lateral arch in the anterior chest. Once identified, the D.O. places the thumbs about 2 to 3 inches below the ribs, emphasizing contact to the lower surface of the diaphragm on exhalation. The patient will take deep breaths and as the patient exhales, the doctor will follow the head of the diaphragm and magnify the movement with additional pressure. The patient and the D.O. will repeat this cycle three to five times, with the D.O. maintaining a constant head pressure on inhalation and increasing the pressure on exhalation.

With regard to the diaphragm and its associated structures, this technique has been shown to help reduce the prolonged pain that can occur in the cervical spine, as the diaphragm is innervated by the phrenic nerve (C3-C5). A study was published in 2016 in which the authors aimed to demonstrate the effect of treating peripheral tissues that are neurologically related to the proximal parts of the spine. In this study, pain pressure thresholds were measured bilaterally in the C4 paraspinal musculature, at the lateral end of the clavicle, before and after diaphragm release therapy. After treatment, the results showed a statistically significant hypoalgesia in the vertebral part of C4 bilaterally. This result demonstrates that diaphragm therapy can cause a direct effect on C4 due to its relationship with the phrenic nerve.

Another commonly used treatment for the respiratory septum is an indirect treatment that involves removing the tissues from their restrictive barrier. The treatment requires the D.O. to place his hands on a patient’s anterior surface in a supine position and move the rib and overlying tissues to a position of ease, balancing him in the three planes of motion that present the least resistance. The patient will then take a series of deep breaths while this position is held by the D.O. who may make small changes as the diaphragm is released after each breath. A study by Mancini et al. (2019) suggested that the indirect diaphragm release technique may improve diaphragm mobility by performing this technique as well as treating diaphragmatic pillars in healthy participants and then assessing diaphragm motion and thickness using ultrasound assessments. The results of this study showed a statistically significant increase in diaphragmatic motion after osteopathic treatments and therefore recommended further studies to be done to confirm the findings as well as to identify clinical conditions that may benefit.

The diaphragm appeals to the thoracolumbar junction of the spine, thoracic cage, and posterior psoas and quadriceps muscles. In front, the diaphragm appeals to the core muscles. Physical dysfunctions in the respiratory diaphragm can translate into these other connections and cause pain that is relieved by treating the diaphragm. Martí-Salvador et al. (2018) worked to show this relationship using an OMT protocol involving diaphragm interventions in patients with non-specific chronic low back pain and the results of this study showed that there was a statistically significant reduction in pain reporting in the experimental group compared to the sham group. This study demonstrated the benefit of septal interventions in patients with non-specific chronic low back pain.

Each diaphragm plays an integral role in the overall function of the human body and the goal of osteopathy is to achieve balance in the human body so that it can function to its full potential. Although not discussed individually in this article, the other diaphragms in the body should also be considered during the two treatments mentioned above. Overall, the respiratory diaphragm has many functions in the human body and the possibility of treating it with osteopathic manipulation has proven to be very beneficial in many cases. A variety of benefits can result from the multitude of connections that the respiratory diaphragm has to the body, from nervous system relationships to musculoskeletal and structural relationships.

Another commonly used treatment for the respiratory septum is an indirect treatment that involves removing the tissues from their restrictive barrier. The treatment requires the D.O. to place his hands on a patient’s anterior surface in a supine position and move the rib and overlying tissues to a position of ease, balancing him in the three planes of motion that present the least resistance. The patient will then take a series of deep breaths while this position is held by the D.O. who may make small changes as the diaphragm is released after each breath. A study by Mancini et al. (2019) suggested that the indirect diaphragm release technique may improve diaphragm mobility by performing this technique as well as treating diaphragmatic pillars in healthy participants and then assessing diaphragm motion and thickness using ultrasound assessments. The results of this study showed a statistically significant increase in diaphragmatic motion after osteopathic treatments and therefore recommended further studies to be done to confirm the findings as well as to identify clinical conditions that may benefit.

The diaphragm appeals to the thoracolumbar junction of the spine, thoracic cage, and posterior psoas and quadriceps muscles. In front, the diaphragm appeals to the core muscles. Physical dysfunctions in the respiratory diaphragm can translate into these other connections and cause pain that is relieved by treating the diaphragm. Martí-Salvador et al. (2018) worked to show this relationship using an OMT protocol involving diaphragm interventions in patients with non-specific chronic low back pain and the results of this study showed that there was a statistically significant reduction in pain reporting in the experimental group compared to the sham group. This study demonstrated the benefit of septal interventions in patients with non-specific chronic low back pain.

Each diaphragm plays an integral role in the overall function of the human body and the goal of osteopathy is to achieve balance in the human body so that it can function to its full potential. Although not discussed individually in this article, the other diaphragms in the body should also be considered during the two treatments mentioned above. Overall, the respiratory diaphragm has many functions in the human body and the possibility of treating it with osteopathic manipulation has proven to be very beneficial in many cases. A variety of benefits can result from the multitude of connections that the respiratory diaphragm has to the body, from nervous system relationships to musculoskeletal and structural relationships.

High velocity, low range manual manipulation (HVLA) is a technique commonly used by many osteopaths and Ackermann chiropractors to treat pain or loss of motion in a joint. This method involves more caution due to the nature of a rapid thrust applied to the body. Contraindications may include rheumatoid arthritis, other inflammatory arthritis, Down’s syndrome, Chiari malformation, fractures, dislocations, joint instability, , joint infection, myelopathy, bone malignancy, recent trauma, hypermobility, spondylolisthesis and implanted devices. This technique involves a manipulation in which a D.O. provides a fast (high-speed), therapeutic force that travels a short distance (low range) within a range of motion in a joint, and this force will engage the restrictive barrier to release the restriction in the joint and restore the range of motion. One of the hypotheses explaining why HVLA is effective involves the idea that movement stretches a contracted muscle and this stretch can produce enough afferent impulses from the muscle spindles to travel to the central nervous system. Muscle spindles are much more responsive to shorter spacing and this makes them an ideal target for HVLA techniques. The central nervous system will then send an inhibitory signal to the muscle spindle to relax this contracted muscle. Therefore, the HVLA technique can be used on virtually any joint of the body, but this section will focus on the uses and applications associated with HVLA performed on the cervical spine, thoracic spine, lumbar spine and lumbar spinal junction.

One of the most common ways of performing HVLA on the thoracic and lumbar spine is for the patient to lie in lateral recumbency on their non-dysfunctional side, with the therapist standing on the side of the table facing the patient. While assessing the dysfunctional processes, the D.O. flexes the patient’s upper leg at the knee and hip until flexion is felt in the palpation arm. The practitioner uses the forearms to cause opposite rotation of the shoulder and pelvis. Each time the patient exhales, there is more rotational “relaxation” until an endpoint is felt. During the final exhalation, when the patient relaxes, a final push is applied. There are other HVLA techniques that can be used on a patient if they are not receptive to this technique or if it is contraindicated. It is important to familiarise yourself with the different variations of HVLA techniques used in the spine.

HVLA has significant benefits in increasing the range of motion (ROM) in a joint. Griffiths et al. (2019) showed the direct effects of HVLA on the thoracolumbar convolution compared to ROM. This study included a group of participants who received HVLA, a sham group who received light touch, and a control group who lay supine for the designated time. After measuring ROM with a digital instrument before and after treatment, there were significant increases in ROM in the HVLA-treated group of participants. Another notable study on the care of patients using HVLA was published in 2013, which compared the effectiveness of HVLA with diclofenac, a non-steroidal anti-inflammatory drug. This 2013 study by von Heymann et al. was performed in patients with acute low back pain for less than 48 hours and the results showed that the group of participants who received the HVLA manipulation had significantly improved Roland-Morris disability scores. Although this study was unable to use a control group to strengthen the study for ethical reasons due to non-viable pain, the results show promise for the use of HVLA for the relief of acute low back pain from structural dysfunction as a superior alternative to diclofenac.

However, it is also noted that some of the absolute contraindications to be aware of before HVLA treatment in the thoracic/lumbar spine are bone risk (trauma, tumour, infection), neurological problems (spinal cord compression, cauda equina syndrome, etc. etc.) , vascular (spinal insufficiency, cervical artery abnormalities, aortic aneurysm, acute abdominal pain).

HVLA techniques will be optimally successful if the patient is fully relaxed, therefore performing soft tissue mobilisation and/or myoperitoneal release on the area prior to treatment can help build confidence and relax the patient. For treatment, patients lie in a supine position with the D.O. sitting at the head of the table. While supporting the head and monitoring the cervical spine at the level of dysfunction, the osteopath will engage the restricted barrier at the three levels of motion. Once the patient relaxes, they will start to take deep breaths. During each exhalation, the osteopath further engages the barrier until an endpoint is felt. On the final exhalation, a short push is applied to move the section through this final restrictive barrier. Cervical HVLA can also be performed in the sitting position using similar conceptual and local movements to the supine treatment position to achieve the same effect. However, the supine position is used more often.

Applying HVLA to the cervical spine has been shown to have many benefits as well as contraindications. Many of these benefits are listed, along with relevant absolute contraindications to the technique. Achilles pain is associated with disability and significant health costs, and is also ranked as one of the top two causes of disability caused by musculoskeletal pain conditions by the Global Burden of Disease studies. It has been shown that Cervical HVLA can be effective in resolving neck, shoulder and head pain (including cervical headaches) as well. A notable benefit of HVLA in the cervical region involves manipulation of the atlanto-occipital joint, with the patient experiencing an immediate increase in the pain threshold of the trigger points in the masseter muscle and temporalis muscle. This atlanto-occipital manipulation also showed an increase in the degree of active mouth opening. Overall, HVLA has been shown to be an effective tool used by osteopaths to treat pain and increase ROM in patients. As more thorough studies on this technique are completed, there will be more knowledge as to the exact mechanisms of benefit from this treatment. With informed consent, proper patient preparation, confirmed lack of contraindications and correct technique, this treatment has been shown to reduce pain, increase ROM and improve the quality of life of patients with joint immobility.

Rib elevation is an osteopathic technique that can be used in many patients, especially those with disorders involving the sympathetic nerves. Contraindications for rib elevation may include recent fractures, patient refusal or lack of consent, bony malignancy or infection and any relevant clinical scenario data considerations. The rib raising technique focuses on the sympathetic chain ganglia that run parallel to the thoracic spine and stimulation of this chain is thought to help bring the autonomic nervous system into a balanced state.

Ganglionic sympathetic chain pathway. The bilateral symmetrical sympathetic chain ganglia are located just ventral and lateral to the spinal cord and extend parallel to the thoracic spine. The ganglionic pathway of the sympathetic chain extends from the upper neck to the coccyx, forming the cervical, thoracic, lumbar or sacral ganglia. The postganglionic fibre extends into the thoracic cavity, abdominal cavity or pelvic cavity and dysfunctions in many organs can be treated with different variations of rib elevation techniques. Adapted from Karemaker et al. (2017). The eighth and ninth thoracic vertebrae are defined as T8 and T9, respectively. The eighth and ninth thoracic spinal nerves run under these vertebrae.

The rib lift technique is performed with the patient in a supine or sitting position and the Osteopath sits at the patient’s side with his/her fingers in contact with the unilateral corners of the ribs.The Osteopath will use a slow and gentle rocking motion to lift the corners of the ribs forward and then release the tension. The Osteopath will work along the rib cage until the technique is done on each rib corner several times, ensuring that this technique is done bilaterally as well . Indeed, a variety of modifications have been made to this technique. The Osteopath will usually feel the muscle tension and restrictions of movement lessen as the technique is performed on the patient. Rocha et al. (2020) conducted a pilot study to measure the effects of rib mobilization and diaphragm release on cardiac autonomic control in patients with COPD. It was documented that the majority of patients reported significant improvement in symptoms.

In a 2010 study, Henderson et al. biomarkers such as salivary α-amylase are monitored to measure the effects of the autonomic nervous system of rib raising. Salivary α-amylase is known to increase during situations of physical or psychological stress in humans, so this study involved measuring α-amylase levels in participants before, immediately after treatment and 10 minutes after treatment. The study noted that saliva flow rate, which is mainly dependent on parasympathetic stimulation, showed no significant changes with the technique. The study showed that there was a significant reduction in saliva alpha-amylase in the treatment group that received rib elevation compared to the placebo group that received only light touch. The results of this study support the idea that rib elevation may reduce the activity of the sympathetic nervous system, which may prove beneficial in many conditions.

The reduction in sympathetic activity from rib elevation may be beneficial in patients suffering from pneumonia. The technique can increase lymph flow by increasing respiratory function. Excessive sympathetic stimulation can reduce chest wall mobility by creating hypertonicity of the chest muscles and increasing intra-abdominal pressure, and lymph flow depends on this pressure gradient to flow properly. Elevating the ribs can reduce sympathetic activity and this causes increased chest wall mobility and improved lymph flow. Therefore, this technique could be used alone or with other OMT techniques to benefit patients with pneumonia. In general, it has often been observed that the use of osteopathic techniques in a hospital setting is valuable as many patients cannot move properly, which limits the patient’s ability to receive other beneficial treatments such as physiotherapy. In these patients, osteopathic techniques can be used to treat restrictions directly or indirectly and can be modified to allow effective treatment for patients who cannot actively participate in treatment. The rib lift is an excellent example of this passive but effective treatment technique.

In a recent study, conducted in eighty-seven inpatients in the non-ICU to determine the tolerance of rib elevation in this population, Chin et al. (2019) clearly documented that rib elevation is well tolerated. They treated patients with rib elevation and then asked them to rate the treatment on a scale of 0 to 10, where 0 is no discomfort and 10 is maximum discomfort. The results showed that the treatment is well tolerated, with 92.0% of patients scoring between 0 and 3, 6.9% scoring between 4 and 6 and 1.1% scoring between 7 and 10 on the tolerance scale. Rib elevation can also be used in coordination with many other osteopathic techniques and can enhance the effects of other treatments. Interestingly, Martingano et al. (2019) used a range of treatments such as rib elevation, lymphatic drainage, posterior decompression, paraspinal suspension and sacral suspension as part of labour management for pregnant patients to determine whether OMT had beneficial effects. The group receiving the OMT combination had a significantly shorter duration of delivery than the control group.

The lymphatic pumping technique (LPT) is the most well-studied of the OMTs and has shown significant promise in enhancing immune defenses against microbial infections. Indeed, the lymphatic system is a vital component of homeostasis and immune responses in the body . Briefly, the lymphatic system includes lymphatic vessels, capillaries and lymph nodes/organs that work together to absorb interstitial fluid, transport lymph and accelerate immune function. When lymphatic capillaries absorb excess interstitial fluid for transport, they also transport osmotically active proteins, parenchymal cell products, inflammation mediators, immune cells, proteins, apoptotic cells, antigens and infectious organisms to the lymph nodes for processing. Lymph fluid is transported through the vessels by exogenous and intrinsic forces. At rest, about 1/3 of the lymph fluid transport to the lower limbs is due to compression of the lymphatic vessels by skeletal muscle contractions (extrinsic) and 2/3 is from active smooth muscle pumping into the lymphatic vessels (intrinsic) . Lymph fluid moves through the body at about 125 mL/h at rest and can increase by a factor of 10 during physical activity. There are many problems that can occur with this system that can disrupt the body’s homeostasis, such as: valve failure (valves usually block the reverse flow of lymph), fluid overload, muscle contraction weakness, lymphatic vessel/node damage from surgery or radiation, etc. When lymphatic system dysfunction occurs, it can lead to swelling, accumulation of inflammatory mediators, tissue injury, poor immune system function and a variety of other disease states. Contraindications for lymphatic therapy may include anuria and/or renal failure, advanced heart failure, acute asthma, unstable heart disease and acute fractures in the treatment area.

The importance of the lymphatic system has been the focus of osteopathic physicians from the beginning and many techniques have been designed to improve lymphatic circulation. Indeed, LPT has been used by osteopaths in the management of congestive heart failure, upper and lower gastrointestinal tract dysfunctions, respiratory diseases, infections and oedema. There are LPTs used for different areas of the body and osteopaths often use a combination of techniques to achieve optimal lymphatic circulation. Rand et al. (2015) [showed positive evidence for integrating osteopathy into primary care using “pedal pump” and “chest pump” approaches to treat patients. The pedal pump involves standing on a patient’s feet in a supine position and gently applying dorsiflexion . The gentle force of dorsiflexion causes a fluid wave to move cephalad into the patient and then the fluid wave will bounce and move caudally. The osteopath maintains this oscillation of fluid within the patient to promote fluid circulation throughout the body within the patient. The chest pump is another common technique with a similar principle. The patient is placed in a supine position as the osteopath stands at the head of the bed with his or her hands on the patient’s chest wall. It begins a gentle rhythmic pumping motion that promotes lymphatic movement within the chest pores and sternum. In addition to “pedal pump” and “chest pump” techniques, there are many other LPT techniques that focus on releasing tension in the diaphragms in order to reduce lymphatic flow restrictions that have shown promising results in both human and animal models.

Studies have been done in rodents and dogs to show that there is an increase in lymph flow as well as increases in leukocyte concentrations in lymph fluid during and after lymph pump treatments. In a 2013 study involving lymphatic duct samples taken from dogs before, during and after two rounds of LPT, there were significant increases in leukocyte counts within 1 minute of starting treatment. This suggests that the lymph pump was helping to mobilise leukocytes into circulation. These numbers remained elevated at 10 minutes after treatment. This increase in immune support cells within the lymph fluid could benefit the health of patients who are unable to effectively circulate their own lymph.

One of the most important effects of LPT is its effectiveness against microbial infections. Studies have documented that lymphatic pumping is an effective procedure for removing bacteria, particularly in patients with pneumonia. A study supporting this claim was done by inoculating rats with Streptococcus pneumoniae and measuring the total number of bacteria and leukocytes found in the lungs 8 days after inoculation. They compared a group of rats treated with a daily lymphatic pump technique with a sham group and a control group. The sham group was lightly touched daily and no compressions were performed. After 8 days, the group of treated pups had significantly less bacteria in their lungs than the sham or control groups. The treated rats also had a reduced number of leukocytes in their lungs. It was suggested that lymphatic therapy helped to mobilise immune cells by rapidly transferring antigens to the lymph nodes, which helped activate the immune system to fight bacteria.

LPTs are also related to the impact of vaccines. A study was completed in 1998 in which subjects received the hepatitis B vaccine and one group received OMT in the form of lymphatic and splenic pumps while the other group received only light touch. The results of this study showed that by week 6 after vaccination, the treatment group had higher mean hepatitis B titres than the control group. This research supports the idea that this lymphatic pump technique may enhance the immune system response and could be a useful adjunct to enhance vaccine responses in the future. Indeed, several recent reviews have highlighted the advantage of using OMT as an adjunct to current allopathic treatments against infections and emerging pandemics. In this regard, promising evidence on the beneficial effects of LPT in patients with progressive pneumonia COVID-19 have initiated several multicentre clinical trials. Therefore, it is imperative that more research is conducted in the future to confirm these findings and to elucidate the molecular mechanisms associated with the significant beneficial effects.

Cranial Osteopathy is widely known for treating babies but is equally effective for children, adults and the elderly. This OMM technique includes different treatment methods that improve the primary respiratory mechanism by balancing cerebrospinal fluid (CSF) flow, somatic dysfunction, parasympathetic regulation and intrinsic CNS mobility. Cranial Osteopathy is a subtle and refined approach to osteopathy that follows all the principles of osteopathy and takes into account both the anatomy and physiology of the head. There are several cranial __cpLocations that can affect parasympathetic supply, such as the vagus nerve affecting other associated processes that can cause physical dysfunction. Movement within these cranial bases can help the practitioner to identify the pathology of the normal stress pattern and properly address the problem. Importantly, the sacrum moves involuntarily between the iliac sleeves due to its attachments through the spine to the skull. The meninges maintain the structural integrity of the bony skull. Therefore, if one end is affected, the problem spreads everywhere. Osteopaths are well trained to provide balance to the entire system through cranial OMT. Contraindications for the skull technique include patient refusal, intracranial bleeding and skull fracture, as well as any other relevant considerations given the clinical scenario.

Cranial techniques can also be applied in the treatment of residual concussion symptoms. Cases have been reported showing cranial techniques after concussion have helped patients return to their daily activities. While over 90% of patients will have resolution of concussion symptoms, the remaining 10% should experience symptoms for a long time. The benefit of Osteopathic Cranial Osteopathy is not only supported by evidence. Alzheimer’s disease is a debilitating and devastating disease not only for the patient but also for their support system. Surgical medicine of the skull has been shown in an elderly rat model to increase the effects of aging and account for Alzheimer’s disease. This was shown by performing OMM in a rat for 7 days and then performing PET scans, learning and memory analyses and immunohistochemical studies. Western blot studies showed an increase in neurofilament acidic protein (GFAP), aquaporin 4 (AQP4) and lymphatic vessel endothelial hyaluronan receptor 1 (LYVE1). Compared to the control, the skull manipulation group showed improved spatial memory and increased fluid circulation, which improved the removal of metabolic waste. Interest in non-traditional medicine and alternative techniques to relieve symptoms is not a new interest. Dating back to the 20th century, Abraham Flexner wrote about the addition of osteopathy to scientific education and research.

Osteopathic manipulation therapy involves a variety of techniques aimed at strengthening the body and its homeostatic function as a holistic unit. It is incredible to see the ability of the human body to heal itself, given the right conditions. As mentioned earlier, Osteopathy is more affordable and much less invasive than other practices. It also promotes complete healing of the body, as it views the body as a single, functional unit. However, even with the promise of harnessing the body’s vast healing capacity, the use of OMT can be severely limited due to a variety of factors. First and foremost is consent. Whether or not a patient wants or wishes to be treated with OMT dictates its use. The second is the clinical scenario and the prioritisation of the patient’s immediate, urgent and emergency needs. Third, many patients hang in the balance of a dysfunctional condition that may be prone to further contraction if treated too aggressively with OMT. In light of these restrictions, it is recommended to be careful and do no harm first.

While research determining the success of OMT in various symptomatologies is limited, there is new evidence that will emerge in the coming years as its popularity grows along with awareness of this field. When Osteopaths incorporate OMT into each patient encounter as part of the physical exam, it allows the D.O. to get a whole body view and better understand the patient’s history and the details of the current disease/symptom the patient may be experiencing. As research, techniques and interest in Osteopathic treatments grow, the data will continue to show their effectiveness and safety. Modern healthcare has shifted to evidence-based medicine, which benefits patient care, and this review helps summarize current knowledge of OMT. With limited contraindications and many indications, the use of OMT for various diseases will increase. OMT continues to grow and flourish and it is the hope of osteopaths that it will become a common component of physical examinations and management in all areas of healthcare due to its many benefits and successful outcomes.”

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