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Preface
Thistextisacomposite ofinformationdrawnfrommany immunesystem, the respiratory/circulatory system, and
and varied sources. It is the culmination of research, the bioenergetic model. Although a discussion of these
study and practice in the science and art of osteopathy models isintegratedthroughoutthetext,ashortsynopsis
and its application to children. Along the way I have isprovidedhere.
learned much frommycolleagues andteachers,butmost One ofthe primarydiagnostic clues garnered from an
ofwhatIhave learnedhas been from my patients. From osteopathic examination is the spinal facilitation. This is
the tiniest seventeen-week gestation newborn to the a localized area of palpatory change in the muscles and
eldest in her ninth decade, their bodies and minds and fasciaadjacent to the spine. Thesechanges include tissue
spirits have taught me how to be still and listen. In my swelling or edema, increased or decreased temperature,
somewhat naive opinion, much of the art of osteopathy and stiffnessorlossoftone. Thesetissue texture changes
isthe ability tointegrate the indescribable,perhaps even represent localized areas of inflammation that occur in
incomprehensiblebutpalpable,informationthepatient's response to direct local insult. They may also arise in
body isprovidingwith whatis scientificallyknown and responsetodamageorirritationtodistal tissues through
understood. One type ofinformation does not negate or visceral-somatic reflexes. Visceral-somatic reflexes were
diminish the value ofthe other.They dovetailtoprovide first describedby osteopathsin the early partofthis cen
amorecomplete,amoreunified pictureoftheindividual. tury. Recent scientific investigation into the mechanism
Thisbook ismy attempttodojustthat. and effectsoftheseinteractionshas shednew lightonthe
Thebook is arranged in two parts. The first discusses intimate relationship between the musculoskeletal sys
basic concepts of physiology from the perspective of an temand theviscerathroughthesympatheticnervoussys
osteopathic clinician. The second describes the more tem. Chapman's reflexes are superficial areas of tissue
common pathophysiological processes seen in children. texture change thathave a high correlation with visceral
Severalrecurring themes are woventhroughoutthe text: pathology. These pea-sized areas of fibrosous are found
the mechanisms by which pathophysiological processes on the anterior and posterior torso. The site of location
influenceeachother;thenormalchanges and adaptations and presence of both anterior and posterior findings
instructureand function thatoccurthroughoutchildhood suggests a visceral problem (Owen 1963). Chapman's
and how the changes can be affectedby these processes; reflexeswere first discussed in the early part of the 20th
andarationaleforosteopathictreatment.Acommonbelief centurybyFrankChapman,D.O.Theyareveryeasilyinte
inUSosteopathicpracticeisthat'theindicationforosteo gratedin the general physical exam and provideanother
pathic manipulation is somatic dysfunction'. While that tool in developing a differential diagnosis. A general
may be true, different pathophysiological processes understandingofthevisceral-somaticmap andChapman's
often require different osteopathic approaches especially reflexes can give the clinician clues about what may be
in the very young, the very old and the very sick.With causingthe patient's symptoms andcan provide a path
that in mind, somatic dysfunction is discussed from the way fortherapeuticapproach.
perspective of the findings in different tissues, i.e.fluid, Theneuroendocrine-immuneconnection isa term that
membranous, articular, osseous, and neural findings. has been coined to refer to the complicatedinterdepend
Osteopathic treatmentis discussed within the context of ency between the nervous system, hormone balance
physiological models: somato-visceral interactions, pos and immune function. Basically speaking, the human
tural or biomechanical influences, the neuroendocrine- bodymaintainsinternalbalance orhomeostasis, through
viii PREFACE
rhythmicchemical secretions from thebrain(neurotrans of the muscles of the back, thorax, neck and upper
mitters),immuneorgans (immunoregulators),andglands extremities playa role in respiratory mechanics. Altered
(hormones). The chemicals that are secreted interact to respiratorymechanics cancontributetotissue congestion
stimulate and suppresseach other, thus coordinatingthe and decreased clearance;alteredventilationandincreased
internal chemistry ofthe body. Potentiallyharmfulstim energy expenditure; and altered lymphatic and venous
ulifromboth external andinternalsources canalter these return pressures. Factors that can affect respiratory
rhythmical patterns,thusaffectingthehomeostasisofthe mechanics include, butare not limited to, respiratory ill
internal body chemistry and creating a general adaptive nesses, scoliosis, thoracic or abdominal surgery, obesity,
response. Normally, once the stress is removed the adap andposturalchanges.
tive response resolves and homeostasis isre-established. The human body requires a balance between energy
Howeverunderlong-termorseverestress,theentirephys expenditureandenergysupplytomaintainhomeostasis.
iology of the neuroendocrine-immune system can alter, Efficient operation of internal body systems conserves
creating a permanent condition of adaptive response. energythatcanbeused toadapttoexternalstressorssuch
Brain chemistry, immune system function and hormone asnutritional deficiencies,trauma, infection, nociceptive
balance will alter. Not only is this person more suscep stimulation and others. When several stressors occur
tible to disease, he or she will have a much harder time simultaneously, their influence may become cumulative
adapting to any new stress. Many studies have demon orsynergistic, furthercompromisingthe body'sability to
stratedchangesinimmunecells,hormonelevelsandnerv maintain homeostasis. Changes in the musculoskeletal
oussystem function understress (McEwan1987,Ganong systemmay increase the body's energy requirement. For
1988,Gold & Goodwin 1988a,1988b,Keicolt Glaser & example, restriction in joint motion because of somatic
Glaser 1991,Esterly 1992,Sternberg1992).Stressful stim dysfunctionwillalterbiomechanicsandreduce efficiency
uli may include psychological and physiological influ ofmotion. Itwillrequiremore worktouse thejoint- this
ences.Pain, ornociceptivestimuli, isconsideredapotent increasesthemetabolicdemandsplaceduponthepatient.
stressor. From an osteopathic perspective, somatic dys Now imagine there are many restricted joints, all in the
function or other strains in the patient's body may thorax, and the patient is a four-month-old infant with
adverselyinfluence the neuroendocrineimmunesystem. respiratorysyncitialvirus.Anyprocessthatinterfereswith
The postural/biomechanicalmodel views the body as localorsystemichomeostasishas thepotentialtoincrease
an integration ofsomatic components. Stresses or imbal thebody'senergyrequirements.
ances between these components result in increased Inmy view these fivephysiologicalmodelsinterweave
energy expenditure, changes in joint structure, impedi to form the fabric of the osteopathic approach. There is
ment ofneurovascular function and altered metabolism. one other component that, when added, turns osteo
Inveryyoungchildrenbiomechanicalorposturalstresses pathic approach into osteopathic treatment. That is the
may influence the developmentofmotorskills, and per relationshipbetweenthe osteopathicpractitionerand the
haps even cognitive processes. Furthermore,altered pos patient. Bythis I do not mean the personalities - most
turalmechanicswillinfluenceconnectivetissueand fascia, two-week olds don't have much personality! I refer to
potentially affecting vascular and lymphatic drainage. an acknowledgement that must take place between
These changes can contribute to the accumulation of the practitionerandthe patient. Though perhaps lacking
cellular waste products, altered tissue pH, changes in in conversational skills, even the youngest patient is an
osmotic pressure, and impediment of oxygen and nutri individual, a complete human being, with no less or no
ent delivery. This is important in cases of infection, car greater bearing in Life than the physician. Osteopathic
diopulmonary problems, and metabolic diseases such treatmentrequirestwothings tobesuccessful-thepatient
asdiabetes. Posturalimbalancesmay alsocauseirritation andthepractitioner.Osteopathsarenot abjecthealers. We
to paraspinal tissues, including the articular tissues of are facilitators. The patientprovides the clues thatallow
the vertebrae. Irritation to these tissues will stimulate us touseour knowledgeandskilltofacilitatechange. But
somatosympathetic fibers, resulting in sympathetically the patient'sbody, the patient's mechanism has to make
mediated changes in the involved tissues and potential that change. The osteopathic practitioner must have a
changes inassociatedviscera. human relationship with the child. You cannot come
The respiratory/circulatory model concerns itselfwith along andjust do thingstothe tissues.
themaintenanceofextracellularandintracellularenviron Throughout this book I have tried to incorporate the
ments through the unimpeded delivery of oxygen and most commonly practiced techniques and approaches
nutrientsand theremovalofwasteproducts.Theintegrity used by the osteopathic profession. However, because
oftherespiratory/circulatorysystem isinfluencedbypos much of the book deals with very young children, the
tural changes on a microscopiclevelthroughtissue stress teachingsofWilliamSutherland,D.O.figure prominently
and macroscopicallythroughrespiratorymechanics.Most inthetext.Itisimportanttorememberthat DrSutherland
PREFACE ix
always maintained that his teachings were not his con me know whenthe information isunclear,incomplete or
cept, but his understanding of Dr Still's principles of (heavenforbidit)justplainwrong.Itgoeswithoutsaying
osteopathy.Likewise,whatis written withinthese pages thatpats onthebackarealways welcome.
arenot my ideas, myinventionsormy discoveries.They DrAnneWalesisfondofsaying, 'Weosteopathsareon
arebutan attempt toexplain mystillfeebleunderstand afrontier'- Ilookforward tojourneyingwith you.
ing of the principles of osteopathy in the treatment of
children.Withthatinmind, Iencourage eachreader tolet Je,2003
REFERENCES
Esterling B1992Stress-associatedmodulationofcellularimmunity. Keicolt-GlaserJK,GlaserR1991Stressand immunefunctionin
In:Willard FH,PattersonM(eds)Nociceptionand the humans.In:AderR,Felton DL,CohenN (eds)
neuroendocrine-immuneconnection.AmericanAcademyof Psychoneuroimmunology,2nd edn. AcademicPress,SanDiego, CA,
Osteopathy:275-294 pp 849-895
GanongW1988Thestress response- adynamicoverview. McEwan B1987Glucocorticoid-biogenicamineinteractionsin relation
HospPrac23:155-171 tomoodandbehavior. BiochemPharm36:1755-1763
Gold P,GoodwinF1988aClinical andbiochemicalmanifestationsof OwenC1963AnendocrineinterpretationofChapman'sreflexes,
stress:Part I.New EnglandJournalofMedicine319:348-353 2nd edn.AmericanAcademyofOsteopathy,Colorado
Gold P,GoodwinF1988bClinical and biochemicalmanifestationsof SternbergE,ChrousosG1992Thestress responseandtheregulation
depression:PartII.New EnglandJournalofMedicine319:41~20 ofinflammatorydisease.AnnInternMed 117:854-866
Acknowledgements
Thisbookwouldnever have cometofruition ifitweren't friends and teachers who eachhelped me open adoor to
for the support, patience and encouragement of Mary my vocationandheart'sdelight. Iwould alsoliketo pay
Law, Katrina Mather and Derek Robertson of Elsevier myhighestrespect toViolaFrymann,D.O.and Edna Lay,
Science.Tothem loweadebtofgratitude.Alsogenerous D.O.Although they may not know it, each has been an
intheirsupportand encouragementwereSteveShannon, inspiration and force in my professional development.
D.O.and BoydBuser,D.O.,Dean andAssociate Dean of IwouldliketothankJayneAlexander,D.O.,MaryBayno,
the CollegeofOsteopathic Medicine at the Universityof D.O., Michael Burraunno, D.O., Hugh Ettlinger, D.O.,
New England. Andrew Goldman, D.O., Sabine Schmidt, D.O., and
Iwould like to thank the members ofmy department, Lynette Bassett, D.O. for critical reading and discussion
Ann Nielsen and Nancy Goulet; George Pasquarello, throughoutthe productionofthe text.Inaddition, Susan
D.O.,CharlieCarr,D.O.,and RalphThieme,D.O.;and the Winer graciously provided edititorial advice in the early
residents and fellows for supporting me and putting up stages forwhich Iamvery grateful. Icannotend without
with my frequent periods of pre-occupation with this acknowledgingmy respectedfriend and colleague Frank
endeavor. Likewise,Iwouldliketoacknowledgethestu H. Willard,PhD.Formanyyears Ihave been very fortu
dentsatthe RoyalMelbourneInstituteofTechnology,the natetoworkwithhim.Thedissectionphotographsinthis
Winer Schule fur Osteopathie, the European School of textarepartofacollectionthat wehave evolvedover the
Osteopathyand especiallytheUniversityofNewEngland pastdecade. Dr Willard isa gifted anatomist and photo
College of Osteopathic Medicine for their infectious grapher.
enthusiasm, probing questions and insistence on clarity. Last and most importantly I would like to thank my
Youhave taughtmemuch. family,especially FrancisandJessewho have supported,
However,even moreimportantly,Iamindebtedinper encouraged, cajoled, bribed and fed me through this
petuitytoAnne Wales,D.O.andJamesJealous,D.O.,two process.
1
CHAPTERCONTENTS
Introduction 1
Embryologicaldevelopmentofthenervoussystem The nervous
Myelination 3
Spinalreflexes 3
system - a
Spinalsegmentation 4
Primaryafferentfibres 5
Neurogenicinflammation 5 clinician's
Convergence 6
Spinalfacilitation 6
Viscera-somaticintegration 7 perspective
Viscera-somaticreflexes 10
Facilitationandemotions 10
Conclusion 11
INTRODUCTION
Thephysiologyanddevelopmentofthe nervoussystem is
avastand complicatedsubject,which Icannotdojusticeto
inthespaceofthischapterorthedepthofmymind. Rather,
Ihopetoprovidethereaderwith aclinician's viewofsome
fundamental processes in the nervous system and their
potential rolein osteopathic evaluation and management.
Formore information,readersare directed totheexcellent
textsandessays referenced attheendofthischapter.
EMBRYOLOGICAL DEVELOPMENT OF
THE NERVOUS SYSTEM
The cellular development of the nervous system can be
divided into sevenstages: proliferation,migration, aggre
gation, differentiation, synaptogenesis, remodelling, and
myelination (Moore & Persaud 1993,Kandel et al 2000).
The first three, proliferation, migration and aggregation,
happen early in embryological development. They are
completedby birth. The latter four are not finished at the
time of birth; in fact, some of them are just starting and
will continuethroughoutlife.Early ingestation,neuronal
cellsmigrate and arrange themselves into groups, which
share a common function. In the primitive brainstem,
neuronal cells cluster into nuclei. In the spinal cord,
theyorganizethemselvesinto elongatedcolumns.Wecan
thinkofthe earlyembryoasasegmented columnwith an
opening at the most anterior aspect: the anterior neural
pore. The most anterior aspect will grow, elongate and
tumposteriorly, inferiorlyandanteriorlylikearam'shom
toform the cortical hemispheres (Fig.1.1).The remaining
segmentedcolumnwillform the spinalcord. Thiscolumn
is surrounded by the somites of the body. Each somite
will cluster a group ofaxons from the adjacent neural
cells.Thesomites giverise toallthe somatic tissues ofthe
body; skin, muscle, periosteum, fascia,etc.As the somite
developsintothese tissues, itusuallydragsitsinnervation
2 ANOSTEOPATHICAPPROACHTOCHILDREN
Figure1.1 (A)Lateralviewoftheexternalsurface ofthebrain.Thearachnoid hasbeenremoved fromthesurface oftherighthemisphere.but
isstillinplace(arrows)ontheleft.(B)Sagittalsectionthrough midlineofbrain.CC.corpus callosum; M.midbrain; Pit,pituitary stalk. Usedwith
permission oftheWillard&CarreiroCollection.
C8
L4
Figure 1.2 Mapofdermatomes.
fromthe adjacent spinalsegment. Within the thorax, this C3-C5 could present as pain in the area of the scapula
arrangement ofstacked segmented innervationis readily (sclerotome)orinthetrapezius(myotome).
evident in the dermatomalpattern (Fig.1.2).However, in Dermatomes, myotomes and sclerotomes are areas of
the extremities, where the somatic tissue was dragged sensory innervation associated with a common nerve
out along the axis of the appendage, the organization is root. These areas were first described at the tum of the
distorted. Thestacked arrangementislostand in itsplace centuryby Dr Head and are called the 'zones ofHead'.
is left a hodgepodge of overlapping tissues such that A zone of Head represents the summation of the der
the motor innervation from C3-C4-C5 is found in the matome, myotome and sclerotome patterns which have
diaphragmbutthesensoryinnervationfrommusculartis thesameembryological origin,i.e.patternofinnervation.
sue (themyotome) isfound in the trapezius, the sensory Nociceptivestimulationtotissueinanyoftheseareaswill
innervation from skin (thedermatome) is found over the activatecellsinthedorsalhomofthespinalcord.Inmany
top ofthe shoulderandforearm,and the sensoryinnerv situations,the same neuralcellsmay receiveinformation
ation from bone (the sclerotome) is found in the scapula fromthree different kinds oftissue: skin, bone, and mus
(Fig. 1.3).Irritationofnerve cellsinthespinal cordareaof cle.Thisinformationwillbe relayed tothe brain. Cellsin
THENERVOUSSYSTEM- ACLINICIAN'SPERSPECTIVE 3
people, the brainis initially exposed to pain signals from
somatic rather than visceral tissue. The brain learns to
interpretnociceptivesignals from most areas ofthe spinal
cordascomingfromsomatictissue.Thussymptomsofvis
ceralpathologyarereferred tothemusculoskeletalsystem.
However,whenchildrensufferearlyvisceral diseasesuch
asreflux,intussusceptionorsurgical correctionofcongen
ital heartdisease, the brainlearnsto interpretnociceptive
inputfrom those areas ofthe spinalcord as visceral rather
thansomatic irritation. Later,whensomatic irritationdoes
develop, the child may complain of symptoms similar to
those associatedwiththeearly visceral pathology.
MYELINATION
The embryological processes of proliferation, migration
and aggregation can be thought of as laying down the
paths.Youcan drive on a road thatisnotpaved,butyou
havetodriveslowly.Pavingthe roadcan becomparedto
myelinatingthe nerves. Myelination allows the signal to
travelveryquickly.However,anervedoes notneed tobe
myelinated in order to function. In a fully functioning
nervous system, the pain system is unmyelinated, yet it
functions appropriately. But, as would be expected, the
conduction time is slower than in other systems. The
amountofmyelinationdetermineshowquicklycommu
Figure1.3 Schematicdiagramdepictingthedermatome(Derm),
sclerotome(Seier),myotome(Myo),andmotorinnervationfrom nication will occur. For example, the large-calibre fibres
C3-C5. involved in proprioceptive input are heavily myelinated
and have rapid conduction times. Myelination initially
the cortex learn to interpret signals from the spinal cord startsin peripheralnerves, the spinalcordand the brain
as comingfrom specific tissues,baseduponthe qualities stem. Consequently, spinal reflexes are established very
of the signal and location of the activated cell. Cortical early and are present at birth. Later, maturation of the
cells learn to distinguish between nociceptive, proprio cortical spinalconnectionswill dampenthese reflexes.
ceptive and discriminative touch stimuli. Cells in the
cortex learn to associate activity in a certain level of the
SPINAL REFLEXES
spinalcord withirritationto aspecifictissue. However,if
theincitingspinalcord cellreceives inputfrommorethan Reflexescanbedividedinto twocategories: spinalreflexes
one kind oftissue, the cortex maynotbe able todifferen and supraspinal reflexes. Spinal reflexes are segmental
tiate between them. This is one of the mechanisms of andmonosynaptic.Forexample,tappingapatellatendon
referredpain.Anirritationorinjurytooneareaofthebody withareflexhammercausesthe tendontostretchrapidly,
is interpreted as coming from a different tissue because exciting muscle spindles within the quadratus muscle
the two havea commoninnervation. Clinically,we often (Fig.1.4).Thesignalfrom the musclespindleiscarriedto
associate this processwithvisceralpathology. thespinalcord, whereitisrelayedthroughinterneurones
Most sensory cells in the spinal cord receiving input to the alpha motor neurones of the ventral hom. The
from somatic tissue will also receive input from viscera. alphamotorneuronessignalextrafusalmusclefibres that
Whenthebrainreceivesasignalfromthatareaofthespinal causethe quadratusmuscletocontract.Thisisaspinalor
cord,itcannotdistinguishbetweenthevisceralandsomatic stretchreflex.
tissue. If, during life, the cortex has learned to interpret Thestretchreflexcanbebrokendownintotwocompon
pain stimulation from the T4 area as arm or shoulder ents: a dynamicstretchreflex,whichrespondsquicklyto
injury, thenwhenT4becomes stimulatedby myocardial rapid changes in muscle length, and a weaker static
injury, the brain maycontinue to interpretthat signal as stretchreflex,whichcontinuesto maintaincontractionof
shoulder pain. Many incidents of referred pain, such as the muscleaslongas the stretchforcepersists.Theentire
shoulder irritation with gallbladder disease, and back circuitisrunwithinthespinalcord.Theinterneuronemay
painwithurinarytractinfections,canbeaccountedforby alsosendasignaltothe braintoletitknowwhathas hap
the convergencepatternsofthe zonesofHead. For most pened,butthe reflex isnotdependenton inputfrom the
