Physiological Regulation Through Manual Therapy
ERIC A. MEIN, MD
DOUGLAS G. RICHARDS, PhD
DAVID L. McMILLIN, MA
JOHN M. McPARTLAND, DO, MS
CARL D. NELSON, DC
From the Meridian Institute Virginia Beach, Virginia (EAM, DGR,DLM,CDN)
Department of Osteopathic Manipulative Medicine
Michigan State University College of Osteopathic Medicine East Lansing,
[NOTE: This book chapter was published in Physical Medicine and Rehabilitation:
State of the Art Reviews, Vol. 14, No. 1, February, 2000. Philadelphia,
Hanley & Belfus, Inc.; see
below for continuing
education credit for this material.]
CORRECTION AND REGULATION
Manual therapy can be divided into two distinct conceptual
approaches to treatment: specific adjustments for correction of anatomic
issues (structure) and adjustments for physiologic regulation (function).
In recent years, the primary emphasis of most practitioners has been on
finding structural problems associated with musculoskeletal issues and
correcting anatomic findings ("lesions" and "subluxations"). Less
emphasized has been the capability for manual therapy to regulate physiology,
reestablishing equilibrium and balance among the various systems and
processes of the body. Historically, however, the origins of both
osteopathy and chiropractic can be traced to positive outcomes in the treatment
of systemic dysfunction. A. T. Still, founder of osteopathy, used
an "inhibition" technique (lying with his head in a sling) to relieve his
own headaches; D. D. Palmer,
founder of chiropractic, first treated a patient with a hearing impairment.
Recognition of the structure versus function choices
within manual therapy dates to the early days of osteopathy. For
example, Hazzard (1899), a prominent early osteopathic physician, acknowledges
both of these approaches in his textbook Principles of Osteopathy:
In our treatment of a spine there are two points which we may
take into consideration; two objects which we may have in view. In
the first place, we may wish to TREAT THE SPINE ITSELF [anatomical correction.
In the second place, we may wish to REACH, BY TREATING THE CENTERS ALONG
THE SPINE, THE VISCERA TO WHICH THESE NERVES RUN [physiologic regulation].
It is not always possible to disassociate these in your practice.23
The textbooks of the early 1900s emphasized regulation,
yet by 1991, Kuchera and Kuchera state: "The majority of DOs do not use
manipulation. Many of those physicians who do so use it primarily
for treating musculoskeletal complaints. They do not use manipulation
for its homeostatic benefits [regulation] to the body's physiology."30
Johnston points out that there are aspects of osteopathic
manipulation in which spinal segment dysfunction is not necessarily the
focus for diagnosis and treatment.25 These include direct manipulation
of the visceral organs themselves, influencing cerebrospinal fluid flow,
and adjustment of postural influences on visceral support systems.
All of these are interventions that regulate physiology.
The general lack of awareness of regulatory techniques
and effects can complicate the interpretation of research. For example,
Balon et al. compared active and simulated chiropractic manipulations as
an adjunctive treatment for childhood asthma.4 They concluded
that, because there were no significant differences in response to the
active and simulated treatments, chiropractic spinal manipulation provides
no benefit. However, the so-called simulated or sham treatment involved
"soft tissue manipulation and gentle palpation to the spine, paraspinal
muscles, and shoulders." Additional manipulations were applied to the head,
ankles and feet, gluteal region, and occipital protuberance. "Low-amplitude,
low-velocity impulses were applied in all these nontherapeutic contacts,"
in contrast to the standard high-velocity chiropractic manipulation.
Unfortunately, this simulated treatment resembles a traditional general
osteopathic regulatory treatment.5,17,23 The Early American
Manual Therapy website provides easy access to several such examples from
the traditional manual therapy literatures.32
1, which dates back to 1909, demonstrates such a technique. In
the Balon study, both treatments produced positive effects. The authors
note, "We are unaware of published evidence that suggests that positioning,
palpation, gentle soft-tissue therapy, or impulses to the
musculature adjacent to the spine influence the course of asthma."4
Richards et al. and Nelson et al. have, however, shown that there is substantial
published evidence that such techniques are effective in regulating a large
number of physiologic parameters.41,50
Despite the low level of awareness, there is a substantial
body of regulatory technique in historical materials, and there are osteopaths
still very much concerned with this aspect of manual therapy.30
There is also a strong linkage between this broader approach to manual
medicine and the growing interest in complementary and alternative medicine.
Edgar Cayce, to whom the Journal of the American Medical Association
traced the roots of modem day holism,10 strongly advocated osteopathy
as a very helpful treatment system, especially for maintaining coordination
of the nervous system. Cayce indicated the osteopathy is "not merely
the punching in a certain segment or the cracking of the bones, but is
the keeping of a balanceby the touch-between the sympathetic and the cerebrospinal
system! That is real osteopathy!"36
One approach, used by the Kucheras, groups systems
of the body by their common autonomic and lymphatic elements.30
It explores selected structural and functional considerations in osteopathic
medicine, with an emphasis on physiology and reflexes. The goal is
to enhance the body's homeostatic mechanisms. Their book discusses
a variety of techniques and clinical experience of effectiveness, for each
system of the body. The Kucheras provide techniques to enhance circulation
and drainages. Each section discusses (1) sympathetic and parasympathetic
innervation and relevant reflexes, (2) lymphatic drainage patterns, and
(3) manipulative treatment for influencing sympathetic, parasympathetic,
and lymphatic drainage to augment homeostasis.
In this chapter, we address four key concepts affecting
regulation: coordination, centers, reflexes, and drainage. We draw
on the historical osteopathic and chiropractic literature for techniques
and examples and review research that demonstrates the effectiveness and
explores the mechanisms of these techniques.
FOUR KEY CONCEPTS: REFLEXES, COORDINATION, CENTERS, AND DRAINAGE
To go beyond diagnosing and treating musculoskeletal
complaints and to treat the entire person, manual medicine requires the
existence of physiologic linkages between the surface/somatic areas and
the deeper viscera. These reflex connections exist in the form of
viscerosomatic reflexes, in which dysfunction in the viscera is expressed
as somatic dysfunction, and somatovisceral reflexes, in which dysfunction
or treatment at the surface of the body is reflexively conveyed to the
viscera.54 Furthermore, the spinal
cord behaves as a "neurologic lens" for a variety of stressors and acts
as an "organizer" of disease and dysfunctional processes that initiates
both somatic and visceral Symptoms.28 This is illustrated
in Figure 2.
Although the locations of many of the centers are
obviously correlated with the segmental anatomy of the body, there also
exist reflexes that may cut across segmental boundaries and affect areas
far removed from the point of manipulation. "Referred pain" is one
obvious form of a viscerosomatic reflex. For example, gallbladder
dysfunction is often experienced as muscle pain in the right shoulder.
There is a direct relationship between certain segments of the spine and
various internal organs (Table 1). Diagnosis
in osteopathy can rely heavily on viscerosomatic reflexes. While
the primary focus here is on physiologic regulation through somatovisceral
reflexes, it is worth noting the evidence for viscerosomatic reflexes,
because it provides a feedback mechanism for the practitioner, and diagnosis
and treatment are often carried out simultaneously. Beal reviews
the clinical and
experimental evidence related to this and provides a detailed table
of the findings of a large number of studies, including double-blind studies
of palpation in diagnosis.6 Viscerosomatic reflexes also
have been demonstrated experimentally in several studies in animals54
and have been shown to be clinically relevant in humans since Korr's work
in 1947.27 Measuring surface temperature reflexes has
emerged as a way to track visceral function.53
Somatovisceral reflexes have received little attention
yet are significant for physiologic regulation. Among the more important
reflexes for regulation of physiology are Chapman's reflexes. In
the late 1930s, Frank Chapman, D.O., first published his findings identifying
specific neurolymphatic reflex points that correspond to particular organs
and glands. There is a discussion of the diagnostic and therapeutic
application of Chapman's reflexes in the text An Endocrine Interpretation
of Chapman's Reflexes.43 Most of these points are
located on the front of the body between the ribs next to the sternum and
on the back along the spine between the spinous processes and the tips
of the transverse processes. Palpation of Chapman's points can be
used for assessment of lymphatic function with correlation to specific
organs. Stimulation of Chapman's points can influence the
motion of the lymph and can also influence visceral functions through
nervous system reflexes. Stimulation of Chapman's points is performed
by firm pressure in a gentle circular motion on the point. Owen thought
that Chapman's reflexes exerted a particularly profound influence on the
glandular system.43 Kuchera and Kuchera interpret palpatory
changes in Chapman's points as indicating functional involvement of the
sympathetic nervous system.30
Patriquin gives practical guidelines for diagnosis
and treatment using Chapman's reflexes.45 For example,
for irritable bowel syndrome, Chapman's reflexes for the colon are found
along the anterior aspect of the iliotibial bands, a 2inch strip on the
lateral side of each thigh. The anatomic location of the reflex ganglioform
masses found can be correlated with specific portions of the colon.
These can be treated with soft tissue kneading, a mechanical percussion
hammer, or other types of vibration to
produce a somatovisceral influence on the sympathetic innervation to
Some of the Chapman's points bear an obvious segmental
relationship to the target organ. For example, the anterior point
for bronchitis is the intercostal space between the second and third rib
close to the sternum. The posterior point is located at the second
dorsal (thoracic) vertebra, midway between the spinous process and the
tip of the transverse process.43 On the other hand, some
of the Chapman's points bear little obvious relation to the target organ.
For example, the anterior points for the eye problems of retinitis and
conjunctivitis are located on the front of the humerus.43
It is not clear how Chapman's reflexes actually work
physiologically. Some have a segmental relationship, but some are
aberrant (e.g., the eye-humerus reflex cited above). Patriquin is
uncomfortable relating Chapman's reflexes to autonomic responses, because
in his view, the autonomics, by the time they reach the surface, tend to
be quite diffuse (the thermodiagnosis
movement, which relies on surface temperature findings to make specific
diagnoses, would tend to counter this).45 Chapman's reflexes,
on the other hand, are very localized, small, distinct areas. Patriquin
also notes that Chapman himself saw the reflexes as neurolymphatic, but
this could not be confirmed by biopsy. Patriquin admits, "I think
we're trying to influence the visceral disturbance by treating some part
of a reflex arc, even though we haven't the foggiest notion what reflex
arc it is."44
Despite the unclear anatomic justification for Chapman's
reflexes, there is a solid experimental physiologic basis for regulation
of visceral function by manual surface stimulation and inhibition.
Sato explored somatic-autonomic reflexes in animals.54
Sato and his colleagues, working with anesthetized animals, traced reflexes
from various types of mechanical, thermal, and chemical
stimulation of the skin to visceral effector organs including the heart,
stomach, sweat glands, bladder, and adrenal medulla. For example,
heart rate can be increased in anesthetized cats by stimulation of any
one of a variety of skin areas. This reflex is produced mainly by
an augmentation of cardiac sympathetic efferent nerve activity. Similarly,
in the anesthetized rat, Sato demonstrated inhibition of gastric contractions
by stimulating the abdominal skin. Conversely, noxious stimulation
of a hind paw
sometimes augments gastric motility, mediated by reflex facilitation
of gastric vagal efferent nerve activity.
The body's physiologic processes normally operate
in a coordinated manner, and the goal of manual therapy is to restore coordination.
For example, Gregory (1922) equated coordination with health and incoordination
with disease: "It is the existence and continuation of the normal equilibrium,
and of perfect coordination and reflex action, which maintain perfect health,
and it is the existence of some variation and loss of the perfect equilibrium
of nerve action which engenders derangement
of function, and the resulting incoordination, and their consequences,
which is disease."19
Modern systems theory, when combined with the concept
of energy, leads to the prediction that the various parts of the body may
interact not only physiologically, but also energetically and therefore
informationally.57 This interaction can reach the level
of harmonic integration, which has been termed entrainment.33
How, then, does manual therapy accomplish coordination?
Two techniques bear mentioning. First, physiologic regulation and
coordination are accomplished through stimulation and inhibition of centers
along the spine and at other locations on the surface of the body.
Goetz defines the two types of manipulation that regulate physiology: stimulation
and inhibition.17 To stimulate is to manipulate the parts
thoroughly. To inhibit is to desensitize or hold the part for 1-3
minutes. According to Ashmore, "Stimulation usually consists of a
quick stroking or rotary massage. Inhibition consists of slow, steady
pressures, often applied with stretching of the underlying or adjacent
tissues."2 Sato demonstrated this phenomenon with somato-endocrine
Pinching stimulation of the lower chest of the anesthetized
rat increases the rate of secretion of adrenaline and noradrenaline by
the adrenal medulla. In contrast, innocuous brushing of the same
surface area decreases the rate of secretion. Barber indicated that
"with a thorough knowledge of the various nervecenters, and the innervation
of the different tissues and organs, the osteopath is able to coordinate
the nerve-force of the body. He can increase the nerve-current to
almost any part of the being, and can quiet an excessive one as well."5
A second technique to accomplish coordination, which
needs further researching, may date to the influence of what historically
has been called "magnetic healing" in the practice of osteopathy.
It involves holding the practitioner's hands over certain spinal centers
at the completion of treatment to coordinate them rhythmically. The
harmonizing of coupled oscillators into a single, dominant frequency is
frequency-selective entrainment. Skilled practitioners may enhance
this transfer with the use of empathetic, meditative, centered states.33
Control theory may help us better understand coordination
within the body. A control system is a connection of elements that
communicate with each other to produce a specific effect. Control
systems with negative feedback regulate; those with a positive feedback
system do not regulate but can disrupt the status quo.31
An example of the former are the muscle spindles that control postural
balance, and an example of the latter is the tickle in one's throat that
can produce reflexive coughing.
Systems with both types of feedback, such as the body, can be influenced
by nonlinear dynamics, or chaos as it is commonly called. This can
be helpful in understanding how small perturbations, such as a facilitated
spinal segment, can impact the system exponentially. It can also
help explain how manual therapies can alter the dynamics of the larger
The concept of centers is inherent in the osteopathic
model of treatment. From the beginning of the profession, osteopathy
recognized the significance of certain nerve ganglia as important centers
that influence and regulate the vital processes of the body such as circulation,
assimilation, and elimination. Barber (1898) states:
We all agree upon the one great point, that man is a machine,
and that nerve-centers have been discovered upon which a pressure of the
hand will cause the heart to slow or quicken its action, from which we
can regulate the action of the stomach, bowels, liver, pancreas, kidneys,
and the diaphragm. The thousands of people snatched from the grave
by an application of these never-failing principles are proof positive
that at last the keynote has been struck; and a school [osteopathy] established
that can explain intelligently why certain manipulations produce certain
The early osteopaths found a number of locations along
the spine whereby the physiology of specific viscera could be affected
by stimulation or inhibition of the center. According to Tasker (1903):
An osteopathic center is that point on the surface of the body
which has been demonstrated to be in closest central connection with a
physiological center, or over the course of a governing nerve bundle.
No portion of the nervous system ever functions absolutely independently.
The action of every portion affects all other portions, but certain areas
in the brain and spinal cord seem to be somewhat set apart to govern or
coordinate the physiological activity of certain organs. Physiology
has demonstrated a large number of these centers.60
Many centers correspond to locations on the chain of
sympathetic ganglia, from which nerves go to the viscera. Different
books give different numbers of centers. For example, Ashmore identified
primary and secondary centers.2 Korr diagrams the centers
along the spine, with connections to the viscera.28 There
are areas in the cervical, upper thoracic, mid-thoracic, and lumbar regions
where the ganglia are fused: C2-3, T4, T9, and L4. Cayce indicated
that these may be especially important regulatory centers in the coordination
between sympathetic and central nervous systems.36
An example of treating one of the centers, using
an inhibitory technique as discussed in the coordination section above,
is shown in Figure 3.
Drainage and Circulation
Like the concepts of centers and reflexes, the concept of drainage dates
back to the early days of osteopathy. Riggs (1901), in a textbook
section entitled "Brain Troubles," states:
The osteopath's work is directed toward toward two primary
objects: First. The equalizing of the general circulation of the
blood. Second. The continued control of the blood supply to
the brain and correlative drainage. To accomplish these ends the
circulatory centers are first thoroughly treated; the muscles, ligaments
and tissues which surround them are relaxed by movements which will stretch
the tissues. The next treatment is a stimulation put upon the deeper
structures so as to secure the action of the heart and arteries.51
Numerous techniques are given in osteopathic texts for
controlling circulation and drainage. Chapman's reflexes are one
example that has already been mentioned. Kuchera also gives ideas
for detailed treatment of lymphatic system dysfunction. The three
basic goals are:
Treatment techniques include manipulation of the thoracic
inlet, stretching the abdominal diaphragm, fascial releases, thoracic lymphatic
pump, liver pump, and splenic pump, among others. Kuchera and Kuchera
have this to say regarding lymphatic drainage and the lungs:
To promote the free flow of lymph through its lymphatic vessels and fascial
To improve function of the abdominal diaphragm, the extrinsic pump for
the lymphatic system
To reduce sympathetic outflow30
There is no argument about the importance of maintaining lymphatic
flow from the lungs in disease or in health. Basic research, as well
as medical and osteopathic research, has proven that chronic lymphatic
congestion with resultant poor oxygenation of the cells is associated with
increased infection, increased mortality, increased healing time, and increased
fibrosis and scarring if healing does occur. Studies have shown that
tissue congestion decreases the effectiveness of medical therapy.
Respiratory therapy, pulmonary toilet and osteopathic manipulative treatment
all have substantial effect on the prognosis of a patient with a respiratory
infection when their inclusion is applied to enhance homeostasis.30
Thoracic lymphatic and splenic pump techniques have
proven especially useful, as discussed in the research section below.
Similarly, in glaucoma, the buildup of pressure has been linked to poor
lymphatic drainage of the eye. "Where the sclera, cornea, iris and
ligamentum pectinatum meet is defined as the angle of the anterior chamber
of the eye. 'Upon the integrity of this angle depends the proper
circulation of lymph to nourish the anterior portion of the eye;' glaucomatous
frequently been linked to poor lymphatic drainage of the eye."62
The four key concepts can be used for specific therapeutic
purposes or as part of a general treatment. A description of a general
treatment described by Barber in 1898 is provided in Table
2. A good general treatment has been considered a tonic to the
overall system, stimulating the nervous and circulatory systems.
It requires about 20 minutes.17
RESEARCH ON PHYSIOLOGIC REGULATION
Research on physiologic regulation is scattered through
the osteopathic, chiropractic, and massage literature. Selected studies
demonstrating regulation of a variety of body systems are included here.
The studies vary from clinical case reports to double-blind, controlled
Much research has been done on the thoracic lymphatic
pump, a technique that regulates circulation and drainage. The use
of lymphatic pump techniques goes back to the early days of osteopathy.38
The thoracic lymphatic pump has been shown to modify immune function24,34,35,46
and to improve respiratory function.7,56 Wallace et al.
provide a good overview of the lymphatic pump.61a
Measel cites several studies from 1910 to 1934 demonstrating
an effect of osteopathic stimulation of the spleen on immune function.34
Measel investigated the effect of the lymphatic pump on the immune response
of normal male medical students. He used two serologic tests to assess
immune response to pneumococcal polysaccharide as an antigen. The
lymphatic pump group had a statistically greater immune response than the
control group, which received no treatment. In a later, double-blind
study, Measel and Kafity demonstrated a significant change in bone marrow
(B) and thymic (T) derived cells in peripheral blood, with the lymphatic
Jackson et al. explored the effect of lymphatic and
splenic pump techniques on the antibody response to hepatitis B vaccine.24
The experimental subjects (n = 20) received the lymphatic and splenic
pump procedures three times per week for 2 weeks after each vaccination.
The control subjects (n = 19) received vaccine but no osteopathic manipulative
therapy (OMT). Fifty percent of the subjects in the treatment group
achieved protective antibody titers on the 13th week; only 16% of the control
subjects had positive antibody responses. This is further evidence
that the lymphatic and splenic pumps enhance immune response.
Sleszynski and Kelso explored the value of the lymphatic
pump in alleviating respiratory distress following abdominal surgery.56
They compared two 21-patient groups of postoperative cholecystectomy patients
in a 1-year, randomized, researcher-blinded trial. Patients treated
with the thoracic lymphatic pump (TLP) technique had an earlier recovery
and quicker return to preoperative values of two respiratory parameters
than patients treated with incentive spirometry, a
mechanical respiratory aid. The authors believe that the TLP
treatment enhances three mechanisms: lymphatic drainage, deep inspirations,
and stimulation of a physiologic reflex controlling the respiratory center.
A particularly interesting historical study cited
by Kuchera and Kuchera looked at the outcomes from conventional medical
therapy compared with OMT in the flu epidemic of 1918:
The effectiveness of osteopathic manipulative support for patients
who were not receiving effective medications was clinically tested during
the flu epidemic of 1918. Antibiotics had not yet been discovered
to help patients fight bacterial complications. Even today, antibiotics
are ineffective against viral infections. In this study of 100,000
people with influenza, Smith reported that patients who received osteopathic
manipulation had a 0.25% overall mortality and a 10% mortality rate if
they developed pneumonia. The mortality rates for patients who only
received medical care and no osteopathic manipulation were 5% overall and
30-60% if they developed pneumonia.30
A number of studies have shown the effectiveness of
manual therapy in modifying respiratory physiology. Stiles, for example,
looked at chronic obstructive pulmonary disease.59 Jackson
and Steele reviewed the literature on the osteopathic manipulative treatment
of asthma.23a They found studies dating back to the 1920s
in which OMT was effective in producing physiologic changes in asthma patients.
Manipulations included cranial flexion, the thoracic lymphatic pump, and
spinal manipulation. Some recent articles on the physiology of asthma
lead us to suggest that historical osteopathic techniques for influencing
both the sympathetic and parasympathetic nervous systems may be useful
in treating asthma.10a,24a,25a,25b,30b,55a
In another study involving the respiratory system,
Belcastro et al. explored the use of OMT in treating wheezing due to bronchiolitis
in infants.7 The OMT included scapular release, rib raising,
intercostal fascial release, diaphragm release, and cranial fascial release.
Because of the small number of subjects (12) and the absence of a control
group, it was not possible to determine the efficacy of the treatment.
Nevertheless, the authors are optimistic that, with transcutaneous oxygen
measurements, the value of this form of OMT on respiratory physiology could
Radjieski et al. conducted a study of the effects
of osteopathic manipulative treatment on patients with pancreatitis.48
The study was randomized with a control group and with the attending physicians
blind to group assignment. The treatment involved 10-20 minutes daily
of a standardized protocol using myofascial release, soft tissue, and strain-counterstrain
techniques. Patients who received OMT averaged significantly fewer
days in the hospital before discharge (mean reduction,
3.5 days) than control subjects, although there were no significant
differences in time to food intake or in use of pain medications.
The early osteopaths made much of the ability of
manual therapy to affect the cardiovascular system. In modern research,
Rogers and Rogers have reported that osteopathic manipulative therapy is
of significant value in some patients with coronary insufficiency.52
Burchett et al. found that manual therapy in the form of generalized paraspinal
inhibition is useful in decreasing
total peripheral resistance and cardiac workload.9
Fitzgerald reports that osteopathic manipulative treatment has been demonstrated
to significantly lower the incidence of arrhythmias and mortality in post-myocardial
Hypertension is also amenable to manual therapy and
is a condition for which there are reports going back to the early days
of osteopathy.12 Mannino3l and Northrup42
have shown substantial drops in blood pressure with osteopathic manipulative
therapy. In the Mannino study of hypertensive patients, treatment
of Chapman's posterior points to the adrenals resulted in a
blood pressure drop of 15 mmHg systolic and 8 mmHg diastolic.
In the Northrup study, there was an average drop of 33 mmHg systolic (from
199 to 166 mmHg) and 9 mm diastolic (from 123 to 114 mmHg).
Mannino looked at both systemic blood pressure and
serum aldosterone levels in hypertensive patients.31 It
is possible that abnormal function of the angiotensin-aldosterone system
may be involved in some forms of hypertension. No significant alterations
of systemic blood pressure were demonstrated, but there was a significant,
reproducible decrease in serum aldosterone levels after osteopathic manipulative
therapy. Mannino speculated that insufficient time was allowed for
the hormonal change to affect blood pressure.
Morgan et al. also attempted to use spinal manipulation
to influence hypertension.40 They employed a different
manipulative technique than Mannino did (a spinal manipulation/soft tissue
massage) to lower blood pressure on the principle that major autonomic
outflows are present at the chosen locations. They did not find evidence
of effectiveness of their technique but noted
that future studies should identify techniques that are effective in
lowering blood pressure and specific types of patients for whom the techniques
Regulatory techniques in the head and neck area have
also been studied. Purdy et al. demonstrated that gentle, soft tissue
manipulation in the suboccipital region can result in significant changes
in blood flow in the fingers, mediated by the sympathetic nervous system.47
Their result is particularly interesting because it demonstrates measurable
changes in the autonomic periphery during manipulation of a dermatome unrelated
to the area being measured. This shows the complexity of reflexes
that may be used in physiologic regulation.
Craniosacral technique focuses primarily on the head.
The goals of craniosacral technique include improving circulation and venous
drainage. Central to craniosacral therapy is the concept of the articular
mobility of the bones of the cranium. The relationship between craniosacral
dysfunction and symptoms has not been established firmly in controlled
studies.18 Nevertheless, Greenman et al. cite several
clinical studies suggesting a relationship. Of particular interest
is an efficacy study of
craniosacral therapy by Frymann in which there was a statistically
significant improvement in the sensory performance of children with neurologic
Kaluza and Sherbin performed a controlled study of
the physiologic response of the nose, utilizing osteopathic manipulative
treatments They took a systen-fic and historical approach to the importance
of the nose in general body physiology, stating: "If a therapeutic modality
is capable of improving nasal function, it is then implied that the body
as a functioning unit is also improved."26 They noted
that there are a number of reflexes involving the nose, including both
parasympathetic influences. The reflexes range from a nasal-pulmonary
reflex to sexual responses from olfactory stimulation. They used
the treatment protocol of Bailey, which included (1) manipulative stimulation
of the supraorbital nerve, the superior aspect of the orbit, and the infraorbital
nerve; (2) alternating pressure over the medial canthus of the eyes and
over the lower third of the nose; (3) deep pressure over the maxiuary and
frontal sinuses; and (4) massage of the temporal regions.3
Using rhinomanometry, they found a significant improvement in nasal function
following treatment, including removal of physiologic congesfion of the
nose (one form of drainage).
Misischia39 and Feely et al.13
have shown that osteopathic manipulation can be effective in reducing intraocular
pressure in glaucoma. The Feely study was a double-blind, randomized
study that reported significant pressure changes after osteopathic manipulative
In a placebo-controlled study, Guthrie and Martin
demonstrated that inhibitory pressure in the lumbar area was effective
in relieving pain during labor, whereas thoracic pressure was not.21
The Continuum of Manual Therapy for Regulation
Specific adjustments have been, and will likely continue
to be, the province of specialists, e.g., osteopaths and chiropractors.
For regulation, on the other hand, there is a continuum of manual therapy.
The early osteopaths did both, and some felt that this distinguished them
from chiropractors, who focused on specific adjustments. Few modem
osteopaths concern themselves with regulation, although it is of great
importance to some.30 But regulation is not limited to
osteopaths. There is a continuum related to the degree of training
in regulation. Manual therapists who employ techniques of regulation
include physical therapists, massage therapists, nurses, and some chiropractors.
Acupressure, acupuncture, and manual lymph drainage would also fall in
the area of regulation.
For example, the protocol followed by Kaluza and
Sherbin for improving nasal drainage did not involve any form of spinal
manipulation or adjustments. It consisted of soft tissue work around
the face, including massage. Similarly, the soft tissue work used
as simulated chiropractic manipulation in the Balon et al. study enhanced
peak expiratory flow in asthmatic children.4
Guthrie notes that his technique of lumbar pressure
to relieve pain during childbirth does not require an osteopath; it may
be administered easily by a husband or other nonprofessional.20
Similarly, Sleszynski and Kelso state that the thoracic lymphatic pump
technique (used in this case for postsurgical respiratory problems) can
be taught to and administered by a respiratory
therapist, at a cost savings over an osteopath.56
Of particular interest is the physiotherapist Harold
Reilly, who originally was trained as a chiropractor but later developed
many regulatory techniques.49 Reilly integrated massage
with chiropractic and osteopathic concepts to yield a broad-based system
of manual therapy. For more than 30 years, the Reilly Health Institute
in Rockefeller Center in New York City was a health mecca for prominent
people. Reilly combined traditional massage with "rotations," the
manipulation of the long bones of the body, with a variety of drainage
techniques, and with hydrotherapies such as fume baths, sitz baths, and
colonic irrigations, all to affect the physiology of the patient.
Reilly's approach continues to be taught at the Reilly School of Massotherapy
in Virginia Beach. There are also other specialties of manual therapies
that are no longer practiced, such as neuropathy and spondylotherapy, which
employed regulatory techniques.
DIRECTIONS FOR THE FUTURE
Research on Regulatory Techniques
There is a wealth of regulatory techniques in the
works of such authors as Barber and Hazzard that are not in common use
today and have never been scientifically studied. Basic research
into the anatomy and physiology of manual therapy effects is needed to
explain the relationship among structure and function, specific techniques,
and biologic effects. For example, there is a need for a systematic
investigation of both centers and reflexes (e.g., Chapman's reflexes).
There is also a need for clinical demonstration of the effectiveness or
ineffectiveness and under which conditions techniques such as Barber's
can be effective.
To accomplish these goals, several considerations
might be helpful. First, it is necessary to acknowledge the full
spectrum of manual therapies. This will help with developing research
methodology that addresses the problem of active control treatments that
distort findings and can compromise conclusions. Second, whenever
possible, the political turf battles within manual
therapies should be avoided. Cooperation and the respect of the
diversity of practices with manual medicine will help accomplish these
goals more quickly and completely.
Many feel that we are in the midst of a medical revolution. There
is currently a window of opportunity to legitimize these techniques and
educate the medical establishment of their efficacy.
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|FIGURE 1. Manipulation of the muscles in the
back, in general treatment of the spine from A Manual of Osteopathy
by Eduard W. Goetz, D.O., published in 1909. Soft tissue manipulation
was often used by the early osteopaths for a wide range of systemic disorders.
Typically, paraspinal massage and manipulation were included in the osteopathic
general treatment format to improve nervous system coordination and drainages
throughtout the system. This type of soft tissue technique is similar
to the "simulated" (control) treatments given in a study for childhood
asthma.4 (From Goetz EW: A Manual of Osteopathy with the
Application of Physical Culture, Baths and Diet. Cincinnati,
Nature's Cure Company, 1909.)
|FIGURE 2. Spinal cord as "neurologic lens" for
a variety of stressors to initiate somatic and/or visceral symptoms. (From
Ward RC (ed): Foundations for Osteopathic Medicine. Baltimore, Williams
& Wilkins, 1997, p 916; with permission.)
|FIGURE 3. Headache - holding the vaso-motor
from Osteopathy Complete by E. D. Barber, D.O., published in 1898.
In addition to its use for relieving headaches, this treatment was valued
as a means of regulating physiology. "It is impossible for the osteopath
to reach directly the center in the medulla oblongata. The same results
are attained, however, by a pressure through so-called "reflex action,"
by a pressure upon the upper cervicals - where is situated the most important
subsidiary center - at the same instant tipping the head backward, thus
bringing the neck into such a position as to throw a pressure upon the
nerves over the cervical vaso-motor center. A steady pressure at
this point for a few moments - reduces the general blood pressure, slows
the action of the heart, and will reduce the temperature of the body in
one-half the time required by any other known method." (From Barber
ED: Osteopathy Complete. Kansas City, MO, Hudson-Kimberly Publishing,
TABLE 1. Relationship between Spine Segments and
Lungs and Airways
Cecum and appendix
T6-T 12 (mainly T11-12)
TABLE 2. General Osteopathic Treatment
1 . Place the patient on the side; beginning at the upper cervicals,
move the muscles upward and outward, gently but very deep, the entire length
of the spinal column, being very particular in all regions which appear
tender to the touch, have an abnormal temperature, or where the muscles
seem to be in a knotty, cord-like, or contracted condition. Treat
the opposite side in a similar manner.
2. With the patient on the back, place the hand lightly over the following
organs, vibrating each two minutes, respectively: lungs, stomach, liver,
pancreas, and kidneys.
3. Flex the lower limbs, one at a time, against the abdomen, abducting
the knee, and abducting the foot, strongly as the limb is extended with
a light jerk.
4. Grasping the limb around the thigh with both hands, move the muscles
very deeply from side to side the entire length of the limb. Treat
the opposite limb in a similar manner.
5. Place one hand upon the patient's shoulder, pressing the muscles
down toward the point of the acromion process; with the disengaged hand
grasp the patient's elbow, rotating the arm around the head.
6. Holding the arm firmly with one hand, with the other rotate the muscles
very deep the entire length of the arm; also grasp the hand, placing the
disengaged hand under the axilla, and give strong extension. Treat
the opposite arm in a similar manner.
7. Place one hand under the chin, the other under the occipital, and
give gentle but strong extension.
8. Place one hand under the chin, drawing the head backward and to the
side; with the disengaged hand manipulate the muscles which are thrown
upon a strain. Treat the opposite side in a similar manner.
Also manipulate, thoroughly and deep, the muscles in front of the neck.
9. Place the patient upon a stool; the operator placing the thumbs upon
the angles of the second fibs, an assistant rising the arms slowly but
strongly above the head as the patient inhales; press hard with the thumbs
as the arms are lowered with a backward motion, patient relaxing all muscles
and permitting elbows to bend; move the thumbs downward to the next lower
ribs; raise the
arms as before; and repeat, until the fifth pair of ribs have been
treated in a similar manner.
From Barber ED: Osteopathy Complete. Kansas City, MO, Hudson-Kimberly
Publishing, 1898, pp 306-307.
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