"Energy Based Osteopathy, EBO - a new look at the art of Osteopathy"
Author: Piotr Godek, M.D.
Society of Polish Osteopaths
The purpose of the work is to study a new conception of therapy, based on manual treatment performed in accordance with osteopathic philosophy and applicable to the fascial system perceived as a three - dimensional, multi - level network. These manual interventions are introduced to the fascial system in order to release energetic overloads of the network produced by mechanical overloads.
- Human body as a three-dimensional web, is built as a system of tensegrity, where traction forces are balanced by compression forces. The web is like multilevel system of bridges spanning on nearly-stiff bone pillars, where myofascial system acts as suspended bridges over it and where osseous attachment points fix points of the web. It seems that according to the rule of integrated tensions ( tensegrity) - the basic movement of the balanced web would be - vibration. There is no isolated point in the web. Each stimulus causing the web vibration induces co-vibrations of all elements proportionaly to the distance from the source of the stimuli. In vivo the web is a dynamic construction. It alters its function and structure in presence of mechanical load. It makes itself more stiffer or differently shaped as the stimuli differ their power and directions. The web is an intelligent structure. It possesses shape memory and even after shape adaptations satisfying user's demands. It is able to correct itself to the previous state of balance. The fascial web is a multi-level structure, formed in Russian-doll manner. We can distinguish several levels of web organization. First level, the macroscopic one - seen during surgery or autopsy, the second as a microscopic organization of the tissue where the muscles fascicles, nerves and vessels branches build tree-shaped macro structures, the third web level observed in the intracellular organization ( microfilaments, microtubular system).
- The basic condition to sustain living tissue is a supply of energy. Beyond an energy of chemical links of nutrition, breathing gases etc., the tissue is exposed to inevitable energy intake in form of mechanical stimuli. To resist gravitation forces and activity of musculosceletal system ventilation, circulation, digestive system activity and even hearing and balance control system are dependent on mechanical stimuli and produce mechanical derived energy intake proportional to the force of stimulus. It is impossible to prevent a tissue from mechanical inducement. Each mechanical stimulus directing elastic tissue produces tension in it, leading to increased potential energy just as the stretched sling becomes energy-charged.
- Life processes are connected with energy processing. A part of energy uptake is stored in form of glycogen or ATP, another must be dissipated as heat wastes but the crucial part through musculosceletal system activity and other, above mentioned life functions, is dissipated in form of fascial web vibrations. The web vibrations may then be perceived as a form of energy processing. Every single breath, heart beat, muscle cramp, liquid flow, peristaltics, etc. causes this kind of energy waste. Any limitation of network elasticity or disfunction in transmission of tensions can lead to limitation of vibration-related dissipation of energy in any anatomical region. Can we say about increased energy in this area? According to the principle of energy preservation - yes, we can.
- Dynamic balance between energy intake and dissipation is necessary to obtain and to preserve physiological state of homeosthasis. A living tissue can not be isolated from kinetic ( mechanical) energy intake because any physiological process produces web vibration ranged from lazy peristaltics of monk's digestive system in a state of meditation to the "muscles orchestra" during sprinter run. Any disfunction in the dynamic balance between energy supply and release caused, for example, by decreasing ability of the web vibration promotes homeosthasis disorders.
- Web vibrations as information. Transmitting vibrations, the web presents features of a certain continuum - it transmits a piece of information about actual state of any particular web region. Amplitude of vibration, direction of force vector and frequency of cyclic repetitions or period of network differentiation are important data collected not only by nervous system but also by the web itself to monitor a way of energy dissipating. The web receives a feedback about a structure and function of itself and is able to correct itself immediately. Then the web is - to certain extend - intelligent - that is, it is aware of the tasks to perform and of its self-correction values.
- There are optimal conditions for energy dissipation in the web. Mobility of structures being in balanced, reciprocal tensions, spans resilence, distance between pillars and junctions configuration, length of spans, neurologic control or blood supply are essential to reach optimal Energy Dissipation Potential (EDP) of the network. In a state of balance the web upset by stimulus receives a certain amount of potential energy which can be given away as vibrations and a quality of this vibration decides how much energy is released. The term EDP refers to ability of the tissue to express maximal dose of energy after being exposed to mechanical tensions. EDP depends on a structural and functional state of the tissue which manifests itself by quality of vibration - first of all, its amplitude and period of duration. It assesses, then, a certain effectiveness of the web to get rid of an excessive energy intake.
- Pathology of dissipation. Mechanical overstimulation or ineffectiveness of dissipation results in energetic overload of the tissue. As a result, the areas of energy storing come into being called High Potential Area (HPA). These areas in form of spots pose "contaminated by energy"can exist in any organ because of universal presence of connective tissue. Simply, the tissue which is unable to get rid of a certain amount of energy, must store it until EDP improvement or until the stimulus providing is ceased. In clinical practice these are enthesopathy, chronic muscle spasms, compartments syndroms, etc. Some of HPA are emotionally-related and can be seen as spots where the web stored traumatical events of emmotional and psychological origin. We call them Emotional Charged Areas (ECA) and we believe that anatomical localisation of these regions is chosen by the web in order to prevent further traumatisation. Dissipation patology refers to each level of the network. Sometimes an amount of energy supplied by stimuli is so great or so rapidly loaded that the web puts its dissipation off and an adaptation to it doesn't consist in an increased dissipation but in surrounding the area by a certain kind of sanitary cordon. So the -so called - Energetic Cysts (EC) come itno being. The sudden availability for vibrations in sublevels of the web seems to be an deciding factor of EC promotion. In clinic practice there are areas with pulsating heat release during manual treatment with indirect technics such as unwinding.
- Adaptation resposes of the fascial web (understood in wide meaning) is possible thanks proprieties of collagen which is an universal component of connective tissue. It stands to reason that it is not only fascia of musculosceletal system, but also pleura, peritoneum, nerves and vesels sheets, etc. Therefore a human body can be compared with vegetable soup where organs (vegetables) are plunged in collagen consomme. Collagen as a set of microcrystals presenting piezoelectric features makes fascial system similar to piezoelectric condensator device where the resilient deformation of connective tissue due to mechanical stimuli is conversed in an electrical potential and stored. For exaple deformed bone generates negative charges on the squeezing side and positive charges on the stretched side. In case of completely dissipated mechanical energy of deforming stimulus - through a return to the original shape by the process of vibration - a piezoelectrical gives off electrical charge to the environment. When, as a result of an excessive or sistematically repeating overload vibration - related emision of energy doesn't occur - the cristal of collagen remains charged. It behaves itself like a magnet in ionized environment - it attracts calcium and incrustations over the collagen web come soon. It results in web stiffening and restriction of resilient deformation ability. If so, web subjected to constant mechanical overload will become more and more "contaminated" by the amount of energy lingering and more stiffened mechanically, as well. The process goes from phase of functional ( reversible) disfunction to structural ( irreversible) disorder as the web becomes totally frozen. At this stage the web is not able to absorb energy because of its inability to deform and because of this the energy aiming the tissue must be transferred to another region/ level in the interrelated kinematic chain. Areas of energetic lingering such as HPA, ECA, EC in adjacent organs/tissues are the results of such disordered energetic distribution. Accordingly, to its stiffness and local conditions in the web, these areas still can absorb energy or - if totally stiffened or separated from the rest of the web by a cordon ( like in case of EC) - they don't absorb it inside the zone but with greater intensity on the brims of the stiffened area.
A tissue that doesn't fully dissipate the energy produced by mechanical stimuli must inevitably absorb it until state of full stiffness.
State 0 - is characterized with maximum currently avaible EDP, maximal vibration amplitude, minimal stiffness, clinical example - Achilles tendon of normal lenght, tension, diameter, normal blood supply and normal range of motion ( ROM ) of the ankle joint makes that segment EDP abundant
State +1 - ( state F) - decreased EDP, but the state is reversible ( functional disorder), because when the force aiming the tissue stops its effect the tissue converges back to its primary configuration fully returning the charge to the environment, clinical exaple - an overtrained tendon
State +2 - (state F/S) - beyond functional alterations, temporary decreased EDP, structural alterations appear due to longlasting mechanical overload, simply some collagen fibers had been involved in calcification process and deposits restrict return of fibers to their normal length so the EDP sinks, clinical example - tendon with degenerative alterations and deposits
State 3+ ( state S) - alterations went too far to find returning way, the tissue cummulated potentials as a result of overstimulations lasting for years. As a consequence, it stiffens to such a degree that it cannot receive any further amounts of mechanical energy because it can't deform out of nearly total stiffness, so it becomes a conglomerate in web construction. EDP reaches the minimal amount when the stiffness meets the apogeum. Clinical example - calcaneal spur.
Of course in clinical practice we meet mosaic of above mentioned states in every particular organ and tissue.
Clinical proves confirming the theory that overstiffness is a consequence of mechanical overstimulation
According to Delpech - Wolf theory - osseous rebuilding follows lines of mechanical loads. Radiologic findings confirm theory, for example, in region of femoral neck where the medial part of it posseses more condensed lines in bone architecture. Joints degenerative alterations observed in regions of overpressure appear as a osteophytes and condensated trabeculi made in order to increase surface for epiphyseal contact but in regions of overtension we meet more oftly spurs and calcifications of soft tissue atachments ( enthesopathies).
Estimation of energetical load in mechanical overstimulated areas - preliminary test
A proof was carried out on 15th December 2005 at the Department of Mechatronics of Warsaw Polytechnics. It was a preliminary experiment whose purpose was to assess usefullness of termovision in observation of heat realase during the osteopathic treatment. The camera with sensivity about 0,1 C deg was used. It recorded the heat emission from overstimulated areas previous tested by clinical or sonography tests. The experiment was carried out on 3 patients whose clinical problems had been known known and treated for several weeks. So it was quite easy to locate precisely spots where the energy use to release during the previous osteopathic sessions. During the measurement therapist was applied the undirect osteopathic technic in a safe distance in order to eliminate influence of his own hands temperature to camera display.
The first test was performed after putting the patient on the table made of heat nonconducting material ( wooden), after a several minute phase of total rest with no access to any additional heat sources. Then, a therapist experienced in osteopatic functional techniques introduced unwinding techniques in order to dismantle web tensions but acting possibly far from point of camera observation to avoid any influence of his hand's temperature. The areas of observation were chosen on the basis of patient's complaints and ultrasound images confirming alterations of mechanical overload character. A functional technique called here unwinding consists in searching for movement vectors of the slightest resistance. These vectors are presented by the web dynamically as a fascial floating which expresses its struggle to return to the right shape restricted by any kind of obstacle (trauma, overload, etc.). Practitioner thanks sensitive palpation just listen to this inner movement and tries to enforce tendences of the web in direction to state of balance. This is a kind of dance which is performed by duo web and therapist.The technic of unwinding doesn't evoke temperature increase through tension or tissue pressing as it happens in massage or muscle energy technics. In the possible most delicate way the therapist only thru positining gives the tissue access to new movement vectors and the tissue does the rest. According to theoretical assumptions the above behaviour should improve balancing in fascial tensegrity system, indirectly improve EDP of the tissue and of course release energy load gathered as a consequence of an upset balance between supply and dissipation procesess.
Patient A.G. - suffers from chronic pain of lateral elbow compartment classified after ultrasound examination as a tennis elbow. A beginning measurement in the area of lateral epicondyle (area marked by cross on the picture) was the temperature 30,4 deg C. Above mentioned technique was performed from subboccipital area - next measurement shows 0,5 deg increase , then decrease to the primary temperature.
Patient T.B. - suffers from chronic tensions in area of TMJ, denies any skull trauma. A beginning temperature of mandibule angle area - 33,5 deg C , after introducing unwinding from the sacral area preserving supine position of the patient temperature measurment shows 1,0 deg C increase lasting till the end of the tretment.
Patient K.T. - suffers from chronic anterior knee pain classified after ultrasound check as a rectus femoris patellar atachment entesopathy. A beginning measurement in the patellar region was 32,5 deg C , during the therapy performed from suboccipital region temperature increased by 1,5 deg C lasting till the end of the treatment.
The method of fascial modeling by functional unwinding applied in EBO is a delicate technique, friendly to the patient and thoroughly safe. It results from a fact of directing the therapeutic session course by the tissue not by the therapist himself. It occurs thanks to a web shape memory and always present in web tendency to minimize sum of tensions. Acting coherently with the web intentions the therapist follows the shortest and safest way to get position of energy release. During the session the therapist uses such elements of manual therapies as compression and traction, rotation and lateral shift in order to achieve a zero tension position known in other therapies as stillpoint in which state tension balance gives opportunity to release cumulated energy in a form of heat emision, vibration, muscle fibrillation or even sudden limb shrug. At the moment of finding a right vector direction the therapist feels a "suspicious ease" in further movement then sudden stop and still phase when the tissue is ready to get rid of energetical overload. Then follows heat emmision in the region of pain or stiffness which gives relief and specific inner calm. Such release can start from any point of body when the therapist is experienced enough to listen to intentions of the body. Of course, there are some regions particular important for web functional integrity as subboccipital area, thoracic outlet, diaphragm or pelvic outlet. These areas are important during the therapy as well, because an access to above mentioned areas makes therapy very effective and technically simple. Through delicate, regardful palpation and three dimentional modeling we can obtain magnification of therapist force input and evoke self-cleaning mode of activity in multilevel web overwhelming much broader area.
The experiment shows that the method of termovision is useful in imaging and objectiving changes in tissue energetics derived from mechanical overload. EBO dealing with fascial web remodelling is a valuable therapeutic tool in cases of myofascial disorders.
EBO and Classical Osteopathy - common points and differences
Classical Osteopathy (C.O.) - created by A.T. Still at the turn of the XIX century aims at treating disorders ( not only of musculosceletal system) by "searching health in the body". It means that accent is put on inner vital forces of the body and its adaptation possibilities. In the times of its origin C.O. used musculosceletal system as a convenient lever to affect selfregulating systems. Alongside with the development of C.O.a techniques was introduced possible to apply in other systems - nervous, vascular, cranial, however a purpose remained the same - optimize mobility of the tissue as a postulate of its right functional state. C.O. searches for disfunctions in the body perceived as a restricted tissue mobility. It is to be stressed - C.O. is the method of diagnosing, treating and philosophy of medical care based on tissue mobility analysis, method of restoring this moblility when restricted by applying manual treatment with the hope in mind that the body as a whole does the rest.
Therapeutic techniques can be divided into- direct such as mobilisations, manipulations, muscle energy techniques, neuromuscular release and indirect as unwinding.
- whole body treatment
- searching for health - through a stimulation of selfregulation features of the body
- high effectiveness and low risk in comparison with non-specific ( symptomatic) pharmacology
- low aggressiveness of the method compared with surgery
- oftly lack of direct link between mobility restriction and specific desease
- incidence of restrictions without clinical effects
- theoretically possible worsening of symptoms if treated restriction was the last line of defence in the patogenesis chain
Energy Based Osteopathy (EBO) - assesing the tissue in categories of energetic balance other features as blood supply, neurologic control and ROM are only derivative of energetical state. EBO searches then for an incorrect energy balance of the tissue produced by mechanical ( HPA) or emmotional (ECA) overstimulation. It should be stressed that tissue can be traumatized by lack or excess of non -mechanical stimuli. It means that deprivation of desired stimuli can be as dengerous for the web as overstimulation like stress generated when a man is drowning in deep water or is deprived of water in the desert. So the freezing of tissue motion comes along in the presence of inducement. Belief in body wisdom and its tendency to selfregulation is common to both C.O and EBO.
Clinical observations let us draw conclusions that using manual techniques, particulary direct ones, we can solve a lot of problems of mechanical origin in musculosceletal system. Sometimes however, we are helpless coming up against problems caused by disordered energy balance. Besides, there a is risk of another traumatization by introducing mechanical stimulus in form of manipulation if not coherent with the body intentions and body actual need. HPA regions may be found not only in muscles, fascia, around joins but inside trabecular architecture of bone as well. It is difficult to detect such a disorder by common osteopathic examination as the particular shape or ROM of bone in adjacent joint can be theoretically normal. Despite it, the tissue is in a state of patological inducement and its matabolism and interrelationship with neighbouring structures can be disturbed.
It may be compared with matter concentration, increased inertia of certain element, as if inner knotting or curling of matter comes along by not always distorted outer shape or objectively confirmed restricted motion. The phenomenon of tissue remodeling lasts until it is alive.
Let's indentify a "dogmatic" differences between C.O. and EBO on an example of sacral bone. According to Wolf thesis - calcification and bone remodeling comes along the direction of forces to which they are exposed. Analyzing bone architecture of sacrum we find the regularity of trabecular formation along the vectors of compression and along potential telescopic movement of compressed and squeezed sacrum. This assures motility of sacrum not only in presence of compressing forces but also in the state of relaxation.
There is a difference between mobility of sacrum known from biomechanical basis as movement on transverse, oblique and vertical axes and the motility understood as inner phasic movement not dependent on muscle work or any conscious control. What happens when sacral bone subjected to trauma accepts significant amount of energy written in its internal architecture. Its trabecular system shrinks internally under a weight of machanical load gaining a huge potential because of piezoelectric phenomenon. Such a bone stiffens not only functionally ( freezed motility) but also with time its archtecture will build another map without respect for physiological vectors of load.
Technical differences between C.O. and EBO are possible to be ilustrated by the following example.
In cranial osteopathy a restricted motion in sphenobasal joint ( SBJ ) is analyzed and described with relation to certain axis of rotation between sphenoid and occipital bone. It implies a proper therapist's hands positioning allowing to regain proper motion of SBJ. Theoretically the process of ordering should be controlled by therapist's intentional manoeuvres and the result ( while fulfilling the above conditions) possible to predict. In EBO it is skull that decides how to touch and where to start from. It is similar to a slow spacecraft landing on an unknown planet. The process of ordering SBJ ( itself) is not at all similar to a steered movement between bones. It is more a process of sistematic "defrost" of each area, which has any meaning for SBJ integrity ( in practice - the whole skull).
It is improbable for HPA topography to respect anatomicallly borders of each bone. It is impossible that an area of injury refers exactly a certain bone or exactly a certain membran or muscle. It is similar more to a situation in which a subjected to trauma part of skull has been put in glue whose marks cover areas in a randomized way along the traumatic vector and without respecting colourful anatomical charts. Of course, consequences of restriction of normally movable skull parts by"glue" is far broader than the marked area because the skull behaves as a Rubic cube - there is no isolated restriction of movement, one restricted plan has influence on another one. It seems, then, that pedantic searching of proper touch points and fine tunning to described classical axes of rotation have minor meaning.
Perhaps, it's better to clean the "glue" ( area of inducement) and let the joint move spontaneously sooner or later out of its inner, physiological power to keep moving not by the mechanical and immediate intervention. The body is able with an elaborate precision to defrost one - seemingly unimportant muscle or a structure even hard to define like a thin fascial strap. It may be, for instance, a vessel which is in a state of torsional disfunction as a main obstacle of a muscle blood supply, which in turn is a culprit of joint restriction or a nerve being repressed by overtensioned muscle of which presence the therapist is even unaware. It's no use repeating on a stiffy blocked joint elaborated manipulations, this joint is a following segment of "domino" game. The organism waits for somebody to help it to regain control over the first segment.
In the case of SBJ, it's sometimes one little, " forgotten" muscle that can derail this, fundamental for the skull, mechanics joint. Even the most sophisticated biomechanical study, which we owe to Sutherland - a founder of cranial osteopathy - is merely coming-up to reality, a certain project of thoughts, a hypothesis which tries to explain what a therapist feels examining the skull. Let's imagine a maltreted ( an exhausted by overstimulation) temporal muscle which has been stimulated for years by a man, who hated his father and could never let himself for eruption of the emotions even deep inside. If the generated for years energy which led to frozen tissue of this muscle could be used, fascial web of this muscle would be safe - but instead of it this frozen energy poses only toxic effect as unbearable load.
This muscle, until it doesn't get rid of the energy, will pose an effective obstacle for reposition of SBJ becoming the main culprit of wedging between temporal, sphenoid and occipital bone. Of course, C.O. is aware of such condition, recommending relaxation techniques of temporal muscle simmultaneously with SBJ decompression. The problem is, though, that the exhausted temporal muscle oftly "doesn't wish" to be treated by an engaged therapist using a set of merely right exercises described in an osteopathic textbooks in a rate of - let's say -three sets repeated five times every two days. The muscle simply wants to tell its story to a compassionate hand oftly in a odd way, far beyond of even experienced therapist expectations. But it is its own rate, time and performance.
EBO respects the right of such muscle to do it. It merely assists in the process of energy dissipation or alternatively if such a will only appears to encourage the beginning of process and then to help it last but always accordingly to scenario written in the muscle. Working in EBO concept therapist's hand only approximates to the topography of muscle close enough to listen its pulsation. Then, if the muscle allows, it presents a vector of past traumatisation and oposite vector - how to dismantle energy load stored in the multilevel web of the muscle ( fascial, intramuscular compartments). When right vector has been found, the tissue starts to unwind inner restrictions, heat emmision takes place, oftly by patient reffered false to the therapist hand as a source of it. After release the muscle loses its tension and chances for spontaneuos mobilisation of SBJ grow up.
Then, a question appears- why does the process not come into being spontaneously without participation of practitioner if the therapy plan is just ready and written in the tissue. And that is the greatest mystery of osteopathy and at the same time a beautiful methafor of evangelical advice " together carry your burdens". Let's sum up the most important features of EBO. It is a method of diagnosing, treating and philosophy of medical care based on analysis of an energetic state of the tissue perceived as a three-dimentional web in an aspect of its potential to dissipate energy provided by environment. Therapeutic techniques to help the tisue to restore maximal EDP through indirect techiques ( unwinding) dedicated to HPA, ECA and EC areas or direct techniques known in osteopathic treatment as mobilisations, manipulations, fascial release, muscle energy techniques, etc. applied to provide enforcement of dissipation ( mobile structure dissipates energy better than stiff one).
Suggested tactics of EBO
- to discover where HPA is present
- to discover where a center of alteration is
- define possible areas of receiving and transmissing vibrations
- regulating web tension in direction of EDP increase
- control test according to tension, mobility, energy storage, etc.
Advantages of EBO
- the work takes place precisely in an area of energy excess or in areas associated as routes of transmission
- theoretically minimal risk of adaptation process deterioration
- chronology of work - from areas most overloaded to least overloaded, from primary affected to secondary affected, from archaic wounds to fresh ones
Disadvantages of EBO
- area of overload may contain doses of energy which are archaic in relation to current ailments - then even if there is a connection between a cause and a certain patology there is a lack of spectacular therapeutic effect and longlasting unwinding discourages both - the patient and practitioner.
Likewise C.O. concept of EBO is not only therapeutic technique, is not only a tool in treating of sufferings, it is rather a philosophy in action. Working in a conception of EBO - anatomy, biomechanics and physiology in classical meaning are its basis. However EBO goes deeper. It analizes the tissue not only from the anatomical, histological or embryological point of view.
It is important also "historical past " of the tissue in the form of its energetic and emmotional load. EBO adress its investigation to the inner tendency of tissue to return to normal which - as it stated W.G. Sutherland - doesn't ever pass and is stronger than any blind force brought from outside. Although EBO's practitioner manipulates the tissue using strongly recommended functional techniques it is possible to apply any other "trick", because the technique is not most important but keeping in mind that every intervention which improves EDP of the tissue leads to desired results in terms of its energetical balance. When the balance is secured, other symptoms of normal functional state as: range of movement, strength or lenght of muscles, blood supply, neural control, etc. are secondary restored.