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Prof. David López Sánchez
Kinesiologyst; Chiropractor D.C.
Director of the Chiropractic Program
Central University of Chile
Director of Manual Therapy Diplomats
Saint Thomas University, Chile
The Spinal Osteopathic Manipulative
Therapy (OMTh): revisited by other
Manual Therapist
XX edition of International Disabled People’s Day.
International Scientific Symposium
20-23 March 2014. Zgorzelec, Poland.
Osteopathy: Art,
Science & Philosophy
 Mind – Body – Spirit are a single unity
 OMT is Hands-On Medicine
 Structure and Function are reciprocally
related: Localized visceral stimulation
produces patterns of reflex response in
spinal segments related with somatic
structures (1,2)
 The body is a system who heals itself and
capable of self regulation
1.- Beal, M.C.: “Viscerosomatic Reflexes: A Review.” Journal of the A.O.A.. 85, (12): 786-801, 1983.
2.-Louisa Burns, Viscero-Somatic and Somato-Visceral Spinal Reflexes. The Journal of The American Osteopathic
Association. 2000; 100(4);249-258. 2David Lopez Sánchez DC, PT
Asymmetry
Restricted Range of Motion
Tissue Texture Changes
Position of Elements
Restricted Motion Direction
Free Motion Direction
Skeletal structures
Myofascial structures (Tozzi, 2012)
Tissues: Vascular, Lymphatic and
Neural related elements (Langevin,
2006)
Somatic Dysfunction:
Diagnosis
Impairment
Disorder
Paolo Tozzi, Selected fascial aspects of osteopathic practice, Journal of Bodywork & Movement Therapies. 2012;16, 503-519.
Helene M. Langevin, Karen J. Sherman, Pathophysiological model for chronic low back pain integrating connective tissue and
nervous system mechanisms, Medical Hypotheses, 2006; 68,74-80.
3David Lopez Sánchez DC, PT
Spinal Osteopathic Manipulation:
Forces
Extrinsic
Forces
Adjusting
Springing
Traction
Gravity
Mechanical
Systems
Intrinsic
Forces
Muscle
Contraction-
Relaxation
Respiration
Homeostatic
4David Lopez Sánchez DC, PT
Manipulation:
Homeostatic Effects
•Free Nerve Ending
•Mechanoreceptors
Receptors
•Brain
•Dorsal Corn
Integrator •Muscle
•Vessels walls
•Glands
Efectors
Homeostasis & OMT:
Stable operating conditions in the internal inviroment
to maintain the physiological equilibrium
The response to the manipulative stimulus leads the changes.
ResponseOMT
5David Lopez Sánchez DC, PT
Intervertebral Somatic
Dysfunction
Fryer, Gary (2003) Intervertebral Somatic Dysfunction: A Discussion of the Manipulable Spinal Lesion. Journal of Osteopathic
Medicine, 6 (2). pp. 64-73. ISSN 1443-8461
The facilitated segment: There is
evidence of spontaneous
electromyographic (EMG) activity
and increased sympathetic output
at spinal levels associated with
clinically detected segmental
dysfunctions (Denslow 1947 & Korr,
1958).
A vertebral segment or spinal cord
level exhibits a pool of related
neurons that maintain a state of
partial excitation; then less afferent
stimulation is required to trigger
the discharge of impulses.
Muscle Inhibition;
Compensatory
Shortened and
Overactive muscles
Joint ROM restriction
Asymmetry
Increased Sympathetic
Output
Tissue Texture Changes
(Edema & fibrosis);
Circulatory Changes
(ischemia)
Increased Nociception
(Pain);
Altered gamma and
Alfa Activity
(Mechanoreceptors
hyperactivity)
Facilitated
Spinal Cord
Neurons
6David Lopez Sánchez DC, PT
The Pathokinesiological
Dysfunction produces
neurophysiological
Dysfunction
The Neurophysiological
Dysfunction produces
Pathokinesiological
Dysfunction
Intervertebral Somatic
Dysfunction: Cause or Effect?
7David Lopez Sánchez DC, PT
Joint Dysfunction:
Deafferentation
• The loss of motor control in a joint
it can become restricted or
unstable.
• The Joint Dysfunction can alter the
mechanoreceptors Type I & II
discharge and limit their role on
the pain modulation, which results
in an increased nociceptor
feedback.
• This has effects at the segmental
level and the cortex. The
manipulation could reverse these
effects acting at GDR’s level.
1.- Terrett and Terret, “Referred Posterior Thoracic Pain,” Chiropr J of Australia 2002; 32: 44
2.- Seaman DR, Winterstein JF. Dysafferentation, a novel term to describe the neuropathophysiological effects of joint
complex dysfunction: A look at likely mechanisms of symptom generation. J Manip Physiol Ther 1998;21(4):267-80
8David Lopez Sánchez DC, PT
David Lopez Sánchez DC, PT 9
Osteopathy & Tensegrity:
The Body as full integrated Unit
The body is a unit…with a architectural
network of omnidirectional viscoelastic
forces and rigid components distributed
an tied through a tensegrity system.
Thus the cranium content could be
affected by tensions transferred from the
related structures through the connective
and soft tissues. Under this model
secondary stresses can be the result of
the posture of the spine and any distant
change of tension within the
musculoskeletal system.
Graham Scarr. Helical tensegrity as a structural mechanism in human anatomy. International Journal of Osteopathic Medicine. March
2011 (Vol. 14, Issue 1, Pages 24-32.
Dentate Ligament Theory:
Cord Traction
10David Lopez Sánchez DC, PT
The Dentate Ligament connect the spinal cord and brain stem with dura
mater. Any misalignmet at level Occipito-Atlanto-Axial could be a factor of
direct traction on the spinal cord.
1) J Neurol Neurosurg Psiquiatría v.47 (4); 04 1984
2) The Origins of the Grostic Procedures. Jhon Grostic DC. ICA, 1978.
David Lopez Sánchez DC, PT 11
Dentate Ligament :
Role in Mielopathy
• In presence of a spondylotic bar, tensile forces acts over the spinal
cord from the dentate ligament causing traction and neural tissue
stress, this produces narrowing of small vessels and decreased local
microcirculation, thus consequentelly mielopathy.
David N Levine. Pathogenesis of cervical spondylotic myelopathy. Journal of
Neurology, Neurosurgery, and Psychiatry 1997;62:334-340
Dentate Ligament Theory:
Cord Traction
12David Lopez Sánchez DC, PT
Journal of Clinical Neuroscience 19 (2012) 1150–1153
 Dentate Ligament before & after a meningiom of spinal cord resection.
 The spinocerebellar tracts (proprioception) are located at the site of maximal
mechanical irritation, their irritation may cause hypertonicity and spasticity in
the muscles of the pelvic girdle and lower extremities
Somatic Dysfunction:
Cord & Neural Traction
13David Lopez Sánchez DC, PT
Atlas Dysfunction
Fernandez Noda et al. ‘Neck
and brain transitory vascular
compression causing
neurological complications’, J.
Cardiovasc Surg 1996; 37 (suppl.
1 to no. 6): 155-66).
The trigeminal nerve spinal
nucleus may be tractioned by a
lateral deviation and rotation of
the atlas.
Osteopathic Cavitation:
Joint Space Separation?
14David Lopez Sánchez DC, PT
• The separation of the zygapophyseal joints after manipulation has been
demonstrated with MRI.
• The observed gapping increases significantly over a tension of 8 kgs., the
facetary surfaces separates 4,7 mms with an audible cavitation. (Cramer G.,
2013, 2012, 2000).
Cramer Gregory DC. J Manipulative Physiol Ther. 2013 May; 36(4):203-17
15
David Lopez Sánchez DC, PT
1.- Johnson, Gillian M. The sensory and sympathetic nerve supply within the cervical spine: review of recent observations. Manual
Therapy Volume: 9, Issue: 2, May, 2004, pp. 71-76.
2.- Spine. 15 January 2007 - Volume 32 - Issue 2 - pp 244-248. Friedrich, Klaus M. MD et als. High-Field Magnetic Resonance Imaging
of Meniscoids in the Zygapophyseal Joints of the Human Cervical Spine. Spine. 15 January 2007 - Volume 32 - Issue 2 - pp 244-
248.
3.- Engel R. & Bodguk N. The menisci of the lumbar zygapophysial joints. J. Anat. (1982) 135, 4, pp. 795-809 795.
 The cervical zygapophysial joints and
their richly innervated meniscoids have
been well documented as source of neck
pain (1).
 The High-Field MR image sequence is
best for the evaluation of the meniscoid
anatomy and pathology (2).
 Meniscoids may become entrapped
between the articular cartilages of the
facet joints and OMT could release them.
OMT: Entrapped
Zygoapophysial Meniscoid
Spinal Manipulation:
ROM and Neurophysiological
Effects
16David Lopez Sánchez DC, PT
• K. Rodrigues DC. Active range of motion in the cervical spine increases after
spinal manipulation (J Manipulative Physiol Ther 2001;24:552-5).
• Fernández-de-las-Peñas, César et als. Immediate changes in radiographically
determined lateral flexion range of motion following a single cervical HVLA
manipulation in patients presenting with mechanical neck pain. Journal of
Osteopathic Medicine Volume: 8, Issue: 4, December, 2005, pp. 139-145.
• Herzog, PhD et al. Electromyographic responses of back & limb muscles
associated with spinal manipulative therapy. Spine 1999; 24(2): 146-153.
b. Peak load
d. Duration of the impulse
(relates to resonant frequency)
c. Rate of rise of applied load
a. Pre load
• Prolonged or repetitive activity of
dorsal horn neurons caused by
sustained noxious stimulation may
subsequently produces central
sensitization and may be involved in
the generation of referred pain and
hyperalgesia across multiple spinal
segments (Mira M, 2007).
• The systematic critical review of the
literature confirms an hypoalgesic
effect of spinal manipulative therapy
(SMT) on experimentally induced
pain provoked by pressure (Millan,
2012, Bronfort, 2010)
David Lopez Sánchez DC, PT 17
1.- Mira Meeus & Jo Nijs. Clin Rheumatol (2007) 26:465–473
2.- Millan et al.Chiropractic & ManualTherapies 2012, 20:26
3.-Bronfort, G. Chiropractic & Osteopathy 2010, 18:3
Osteopathic Manipulation (SMT):
Hypoalgesic
Effects
The OMT could not been seen only as an useful technique to restore the
segmental mobility. It can also intend to restore the vascular and neural and
homeosthatic functions of the tissues according the age, gender, lifestyles,
health and current somatic dysfunction of the patient.
David Lopez Sánchez DC, PT 18
Osteopathic Vision:
Health & Disease
From IAO:
Modern Principles of Osteopathy
2011.
David Lopez Sánchez DC, PT 19
Spinal
Osteopathic Manipulative Therapy:
Where are we now?
 Osteopathy is a system of diagnosis and
treatment with a well differentiated philosophy
that practice a “whole person” approach in
healthcare (1).
 Osteopathy does not declare to treat diseases or
illness, it optimizes patient health to stimulate
self-regulating processes (repair, anti-
inflammatory, immunity and defense
mechanisms, homeosthasis) (2).
1.- Glossary of Osteopathic Terminology. Prepared by (ECOP/AACOM). Revised April 2009
2.- International Academy of Osteopathy. Modern Principles of Osteopathy, 2011
David Lopez Sánchez DC, PT 20
Spinal Osteopathic Manipulative Therapy:
Summary
 The manipulative therapy is essential for
osteopaths to restore and correct the
human biomechanical function.
 Basic medical sciences, scientific research
and a clinical osteopathic reasoning are
used to explain and understand the
interaction between biomechanics and the
neural, musculoskeletal, circulatory and all
physiological system in a somatic
dysfunction.
Glossary of Osteopathic Terminology. Prepared by (ECOP/AACOM). Revised April 2009
WHO. Benchmarks for training in traditional / complementary and alternative medicine: benchmarks for training in osteopathy. 2010
David López Sánchez
Kinesiologyst; Chiropractor DC
E mail: consultas@dolordeespalda.cl
www.dolordeespalda.cl
Conference: “The Spinal Osteopathic Manipulative Therapy (OMTh): revisited by
other Manual Therapist” Poland, 2014
Conference: “Osteopathic Manipulative Therapy (OMTh) of Extremities: revisited
by other Manual Therapist”, Poland, 2014
XX edition of International Disabled People’s Day.
International Scientifique Symposium
20-23 March 2014. Zgorzelec, Poland.

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Spinal Osteopathic Manipulative Therapy (OMTh) Revisited by Manual Therapists 2014

  • 1. Prof. David López Sánchez Kinesiologyst; Chiropractor D.C. Director of the Chiropractic Program Central University of Chile Director of Manual Therapy Diplomats Saint Thomas University, Chile The Spinal Osteopathic Manipulative Therapy (OMTh): revisited by other Manual Therapist XX edition of International Disabled People’s Day. International Scientific Symposium 20-23 March 2014. Zgorzelec, Poland.
  • 2. Osteopathy: Art, Science & Philosophy  Mind – Body – Spirit are a single unity  OMT is Hands-On Medicine  Structure and Function are reciprocally related: Localized visceral stimulation produces patterns of reflex response in spinal segments related with somatic structures (1,2)  The body is a system who heals itself and capable of self regulation 1.- Beal, M.C.: “Viscerosomatic Reflexes: A Review.” Journal of the A.O.A.. 85, (12): 786-801, 1983. 2.-Louisa Burns, Viscero-Somatic and Somato-Visceral Spinal Reflexes. The Journal of The American Osteopathic Association. 2000; 100(4);249-258. 2David Lopez Sánchez DC, PT
  • 3. Asymmetry Restricted Range of Motion Tissue Texture Changes Position of Elements Restricted Motion Direction Free Motion Direction Skeletal structures Myofascial structures (Tozzi, 2012) Tissues: Vascular, Lymphatic and Neural related elements (Langevin, 2006) Somatic Dysfunction: Diagnosis Impairment Disorder Paolo Tozzi, Selected fascial aspects of osteopathic practice, Journal of Bodywork & Movement Therapies. 2012;16, 503-519. Helene M. Langevin, Karen J. Sherman, Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms, Medical Hypotheses, 2006; 68,74-80. 3David Lopez Sánchez DC, PT
  • 5. Manipulation: Homeostatic Effects •Free Nerve Ending •Mechanoreceptors Receptors •Brain •Dorsal Corn Integrator •Muscle •Vessels walls •Glands Efectors Homeostasis & OMT: Stable operating conditions in the internal inviroment to maintain the physiological equilibrium The response to the manipulative stimulus leads the changes. ResponseOMT 5David Lopez Sánchez DC, PT
  • 6. Intervertebral Somatic Dysfunction Fryer, Gary (2003) Intervertebral Somatic Dysfunction: A Discussion of the Manipulable Spinal Lesion. Journal of Osteopathic Medicine, 6 (2). pp. 64-73. ISSN 1443-8461 The facilitated segment: There is evidence of spontaneous electromyographic (EMG) activity and increased sympathetic output at spinal levels associated with clinically detected segmental dysfunctions (Denslow 1947 & Korr, 1958). A vertebral segment or spinal cord level exhibits a pool of related neurons that maintain a state of partial excitation; then less afferent stimulation is required to trigger the discharge of impulses. Muscle Inhibition; Compensatory Shortened and Overactive muscles Joint ROM restriction Asymmetry Increased Sympathetic Output Tissue Texture Changes (Edema & fibrosis); Circulatory Changes (ischemia) Increased Nociception (Pain); Altered gamma and Alfa Activity (Mechanoreceptors hyperactivity) Facilitated Spinal Cord Neurons 6David Lopez Sánchez DC, PT
  • 7. The Pathokinesiological Dysfunction produces neurophysiological Dysfunction The Neurophysiological Dysfunction produces Pathokinesiological Dysfunction Intervertebral Somatic Dysfunction: Cause or Effect? 7David Lopez Sánchez DC, PT
  • 8. Joint Dysfunction: Deafferentation • The loss of motor control in a joint it can become restricted or unstable. • The Joint Dysfunction can alter the mechanoreceptors Type I & II discharge and limit their role on the pain modulation, which results in an increased nociceptor feedback. • This has effects at the segmental level and the cortex. The manipulation could reverse these effects acting at GDR’s level. 1.- Terrett and Terret, “Referred Posterior Thoracic Pain,” Chiropr J of Australia 2002; 32: 44 2.- Seaman DR, Winterstein JF. Dysafferentation, a novel term to describe the neuropathophysiological effects of joint complex dysfunction: A look at likely mechanisms of symptom generation. J Manip Physiol Ther 1998;21(4):267-80 8David Lopez Sánchez DC, PT
  • 9. David Lopez Sánchez DC, PT 9 Osteopathy & Tensegrity: The Body as full integrated Unit The body is a unit…with a architectural network of omnidirectional viscoelastic forces and rigid components distributed an tied through a tensegrity system. Thus the cranium content could be affected by tensions transferred from the related structures through the connective and soft tissues. Under this model secondary stresses can be the result of the posture of the spine and any distant change of tension within the musculoskeletal system. Graham Scarr. Helical tensegrity as a structural mechanism in human anatomy. International Journal of Osteopathic Medicine. March 2011 (Vol. 14, Issue 1, Pages 24-32.
  • 10. Dentate Ligament Theory: Cord Traction 10David Lopez Sánchez DC, PT The Dentate Ligament connect the spinal cord and brain stem with dura mater. Any misalignmet at level Occipito-Atlanto-Axial could be a factor of direct traction on the spinal cord. 1) J Neurol Neurosurg Psiquiatría v.47 (4); 04 1984 2) The Origins of the Grostic Procedures. Jhon Grostic DC. ICA, 1978.
  • 11. David Lopez Sánchez DC, PT 11 Dentate Ligament : Role in Mielopathy • In presence of a spondylotic bar, tensile forces acts over the spinal cord from the dentate ligament causing traction and neural tissue stress, this produces narrowing of small vessels and decreased local microcirculation, thus consequentelly mielopathy. David N Levine. Pathogenesis of cervical spondylotic myelopathy. Journal of Neurology, Neurosurgery, and Psychiatry 1997;62:334-340
  • 12. Dentate Ligament Theory: Cord Traction 12David Lopez Sánchez DC, PT Journal of Clinical Neuroscience 19 (2012) 1150–1153  Dentate Ligament before & after a meningiom of spinal cord resection.  The spinocerebellar tracts (proprioception) are located at the site of maximal mechanical irritation, their irritation may cause hypertonicity and spasticity in the muscles of the pelvic girdle and lower extremities
  • 13. Somatic Dysfunction: Cord & Neural Traction 13David Lopez Sánchez DC, PT Atlas Dysfunction Fernandez Noda et al. ‘Neck and brain transitory vascular compression causing neurological complications’, J. Cardiovasc Surg 1996; 37 (suppl. 1 to no. 6): 155-66). The trigeminal nerve spinal nucleus may be tractioned by a lateral deviation and rotation of the atlas.
  • 14. Osteopathic Cavitation: Joint Space Separation? 14David Lopez Sánchez DC, PT • The separation of the zygapophyseal joints after manipulation has been demonstrated with MRI. • The observed gapping increases significantly over a tension of 8 kgs., the facetary surfaces separates 4,7 mms with an audible cavitation. (Cramer G., 2013, 2012, 2000). Cramer Gregory DC. J Manipulative Physiol Ther. 2013 May; 36(4):203-17
  • 15. 15 David Lopez Sánchez DC, PT 1.- Johnson, Gillian M. The sensory and sympathetic nerve supply within the cervical spine: review of recent observations. Manual Therapy Volume: 9, Issue: 2, May, 2004, pp. 71-76. 2.- Spine. 15 January 2007 - Volume 32 - Issue 2 - pp 244-248. Friedrich, Klaus M. MD et als. High-Field Magnetic Resonance Imaging of Meniscoids in the Zygapophyseal Joints of the Human Cervical Spine. Spine. 15 January 2007 - Volume 32 - Issue 2 - pp 244- 248. 3.- Engel R. & Bodguk N. The menisci of the lumbar zygapophysial joints. J. Anat. (1982) 135, 4, pp. 795-809 795.  The cervical zygapophysial joints and their richly innervated meniscoids have been well documented as source of neck pain (1).  The High-Field MR image sequence is best for the evaluation of the meniscoid anatomy and pathology (2).  Meniscoids may become entrapped between the articular cartilages of the facet joints and OMT could release them. OMT: Entrapped Zygoapophysial Meniscoid
  • 16. Spinal Manipulation: ROM and Neurophysiological Effects 16David Lopez Sánchez DC, PT • K. Rodrigues DC. Active range of motion in the cervical spine increases after spinal manipulation (J Manipulative Physiol Ther 2001;24:552-5). • Fernández-de-las-Peñas, César et als. Immediate changes in radiographically determined lateral flexion range of motion following a single cervical HVLA manipulation in patients presenting with mechanical neck pain. Journal of Osteopathic Medicine Volume: 8, Issue: 4, December, 2005, pp. 139-145. • Herzog, PhD et al. Electromyographic responses of back & limb muscles associated with spinal manipulative therapy. Spine 1999; 24(2): 146-153. b. Peak load d. Duration of the impulse (relates to resonant frequency) c. Rate of rise of applied load a. Pre load
  • 17. • Prolonged or repetitive activity of dorsal horn neurons caused by sustained noxious stimulation may subsequently produces central sensitization and may be involved in the generation of referred pain and hyperalgesia across multiple spinal segments (Mira M, 2007). • The systematic critical review of the literature confirms an hypoalgesic effect of spinal manipulative therapy (SMT) on experimentally induced pain provoked by pressure (Millan, 2012, Bronfort, 2010) David Lopez Sánchez DC, PT 17 1.- Mira Meeus & Jo Nijs. Clin Rheumatol (2007) 26:465–473 2.- Millan et al.Chiropractic & ManualTherapies 2012, 20:26 3.-Bronfort, G. Chiropractic & Osteopathy 2010, 18:3 Osteopathic Manipulation (SMT): Hypoalgesic Effects
  • 18. The OMT could not been seen only as an useful technique to restore the segmental mobility. It can also intend to restore the vascular and neural and homeosthatic functions of the tissues according the age, gender, lifestyles, health and current somatic dysfunction of the patient. David Lopez Sánchez DC, PT 18 Osteopathic Vision: Health & Disease From IAO: Modern Principles of Osteopathy 2011.
  • 19. David Lopez Sánchez DC, PT 19 Spinal Osteopathic Manipulative Therapy: Where are we now?  Osteopathy is a system of diagnosis and treatment with a well differentiated philosophy that practice a “whole person” approach in healthcare (1).  Osteopathy does not declare to treat diseases or illness, it optimizes patient health to stimulate self-regulating processes (repair, anti- inflammatory, immunity and defense mechanisms, homeosthasis) (2). 1.- Glossary of Osteopathic Terminology. Prepared by (ECOP/AACOM). Revised April 2009 2.- International Academy of Osteopathy. Modern Principles of Osteopathy, 2011
  • 20. David Lopez Sánchez DC, PT 20 Spinal Osteopathic Manipulative Therapy: Summary  The manipulative therapy is essential for osteopaths to restore and correct the human biomechanical function.  Basic medical sciences, scientific research and a clinical osteopathic reasoning are used to explain and understand the interaction between biomechanics and the neural, musculoskeletal, circulatory and all physiological system in a somatic dysfunction. Glossary of Osteopathic Terminology. Prepared by (ECOP/AACOM). Revised April 2009 WHO. Benchmarks for training in traditional / complementary and alternative medicine: benchmarks for training in osteopathy. 2010
  • 21. David López Sánchez Kinesiologyst; Chiropractor DC E mail: consultas@dolordeespalda.cl www.dolordeespalda.cl Conference: “The Spinal Osteopathic Manipulative Therapy (OMTh): revisited by other Manual Therapist” Poland, 2014 Conference: “Osteopathic Manipulative Therapy (OMTh) of Extremities: revisited by other Manual Therapist”, Poland, 2014 XX edition of International Disabled People’s Day. International Scientifique Symposium 20-23 March 2014. Zgorzelec, Poland.