osteopathic Manipulation


What is Osteopathic Manipulation?

    OSTEOPATHIC MANIPULATIVE TREATMENT or OMT is the unique hands-on manual medicine utilized by DOs. There are over thirty different Osteopathic techniques that make up the collected work of DOs. Each DO resonates with several of these techniques and then applies them holistically in an individualized way for each patient. Some of the techniques are very subtle and utilize gentle pressure while other techniques are more physical and engage the tissues in a more assertive way.

Andrew Taylor Still, the founder of Osteopathy, did not separate his technique into different categories. He generically called his hands-on approach “Osteopathy.” His closest students looked carefully at his methods and subsequently named many of his unique clinical procedures. Later generations of DOs expanded upon his ideas and created new techniques that were in agreement with his principles of Osteopathy.

I classify the Osteopathic manipulative approach into three major categories and give a few key examples in each group. This classification scheme is not officially utilized by American or international Osteopathic organizations. It is my way of sorting Osteopathic Manipulation into practical categories that make it easier for me to explain and teach.

INDIRECT ACTION TECHNIQUES work at the balance point away from the barrier of motion or away from the restriction. These techniques include: Indirect Technique, Functional Method, Indirect Myofascial Release, Strain/Counterstrain, Facilitated Positional Release, Balanced Ligamentous Tension, Balanced Membranous Tension, Manual Percussion and Vibration, Articulatory Technique, and this is the predominant approach used in Cranial Osteopathy.

DIRECT ACTION TECHNIQUES work up against, or through the barrier to motion or the restriction. These techniques include: Muscle Energy Technique, Recoil Technique, Joint Translation of Accessory Motion, Direct Myofascial Release, Manual Percussion and Vibration, Articulatory Technique, the High Velocity Low Amplitude thrusting techniques, and some applications of Cranial Osteopathy.

NON-DIRECT/NON-INDIRECT TECHNIQUES do not work at all with barriers to motion as a reference point but instead utilize non-material elements as the orientation to treatment. These very sophisticated treatments require a high degree of perceptual skill and do not have formal names. They are taught to Osteopaths via the oral tradition and go back to original approaches utilized by the founder of Osteopathy, Andrew Taylor Still. This form of treatment is handed down from teacher-to-student by a hand-to-hand transmission through four generations of Osteopaths.

All of Osteopathic Manipulation can be classified into these three categories. In my Osteopathic office practice, I mix these approaches to create an intricate combined method of treatment. I seamlessly move back and forth between INDIRECT and DIRECT ACTION approaches with that of a NON-DIRECT/NON-INDIRECT perspective. In reality, my entire Osteopathic approach is an integrated method of combining techniques in ways that uniquely help individual patients.

It is important for me to emphasize that Osteopathy is not just a technique or even a collection of techniques. Osteopathy is a philosophy. More specifically it is a practical clinical philosophy. Osteopathy is also a hands-on healing science and art. DOs apply their healing art by using intelligent and compassionate hands. We don’t just employ a technique like a drug or like a physical medicine modality, such as ultrasound, electrical stimulation, cold laser, diathermy, heat, ice, or traction.

Osteopathic Treatment: My Unique Style

I have a very eclectic Osteopathic style. I use a wide variety of methods to help patients achieve a greater expression of health and holism. I don’t have a cookbook approach and do not utilize the same treatment plan for every patient.

Sometimes my treatment approach is very subtle. At other times it can be more physical. Osteopathic Manipulative Treatment is not painful. My goal is not to find the painful areas and push on them or make them worse. The goal of an Osteopathic Treatment is not to “pound down the high spots.”

Several features determine my way of treating, the amount of physical pressure that is necessary, or the category of touch that is required. The age of the patient, the size of the individual, their gender, their overall medical condition, and the complexity of the dysfunction that is being addressed all weigh into the complex decision process that determines a holistic Osteopathic Manipulative Treatment.

Often the style that I utilize is created in the moment for an individual patient with a unique problem. By using Osteopathic philosophy in a patient-specific way, I am able to be present with that person and help them distinctively. Each of the many directions that I can utilize is flexible enough to allow for great creativity.

What does Osteopathic Manipulation Treat?

Sometimes Osteopathic Manipulation is used as the primary form of treatment. In other situations it is used to complement other interventions and it part of a team approach to the overall care of a patient.

In general, Osteopathic Manipulation can be used to treat restore harmonious function and normal structure to any part or any tissue in the body. Osteopathy Treatment can re-establish normal arterial, venous, and lymphatic flow by relieving obstructions; resolve fascial and connective tissue strains; helps coordinate the normal functioning of the nervous system; directly treats dysfunctions relating to the organs or viscera; and stimulate the function of the immune system.

Osteopathic Manipulation also connects with the those indefinable subtle inherent forces of healing. These NON-DIRECT/NON-INDIRECT approaches access the non-material fields that A. T. Still called “the unnamed forces of healing” that provide the real holistic link in an Osteopathic Treatment.

Key Techniques Used in My Holistic Osteopathic Approach:

I have taken the time to become proficient in some key Osteopathic styles and I utilize these tools selectively for specific situations. Some approaches can be used more globally to address most problems, others are useful in just a few selected types of tissues dysfunctions. By having many different tools, I have a greater ability to help a higher percentage of patients with a greater variety of medical issues. In a typical office visit I may at some point utilize each of these distinct approaches in a seamless and elegant therapeutic dance.

I have listed the ten Osteopathic styles that I employ in numerical order based upon how frequently I utilize that particular approach.

CRANIAL OSTEOPATHY: I utilize Cranial Osteopathy (a.k.a. Osteopathy in the Cranial Field) both as a type of treatment and as a method of assessment. Cranial Osteopathy is a gentle anatomically specific Osteopathic technique that uses a detailed contact to elicit changes in the bone, membranes and fluid primarily of the cranium, spine, and sacrum. The cranium is a powerful window that allows a view of the entire body from this key anatomic perspective. To utilize Cranial Osteopathy effectively, one must have excellent knowledge of neuroanatomy and cranial bone structure and function. Effective Cranial Osteopathy accesses the intricate relationships between cranial bones, dural membranes, cerebrospinal fluid, and the subtle inherent forces of healing. The technique of Cranial Osteopathy is simply the application of clinical Osteopathic philosophy to the unique interconnected anatomy of the cranium, spine, and sacrum. Every patient in my practice receives Cranial Osteopathy to some degree. For some problems the entire treatment is an intricate and finely tuned cranial clinical anatomic “operation.” For other issues, Cranial Osteopathy complements other approaches.

FACILITATED POSITIONAL RELEASE (FPR): This INDIRECT ACTION technique works with the muscular system to find the balance point of release that occurs away from the barrier of motion or restriction. It is a gentle approach that positions specific muscles in a way that initiates a reflex neuro-muscular relaxation alleviating muscle tightness and spasm that may be causing abnormal function of bones, muscle, nerves, blood vessels, or lymphatic circulation.


BALANCED LIGAMENTOUS/MEMBRANOUS TENSION: This INDIRECT ACTION technique differs from FPR by consciously engaging the various connective tissues (ligaments, tendons, joint capsule, fascia, and membranes) rather than the muscles. The goal is to also find the balance point of release away from the barrier of motion or restriction. The motive force of release is initiated by the inherent forces of healing (tides or rhythmic power, the Health, or other non-material vital elements). This gentle approach is like using Cranial Osteopathy on areas outside of the head.

DIRECT MYOFASCIAL TECHNIQUE: This DIRECT ACTION technique is a gentle or assertive approach to treating muscular and connective tissue restrictions by intelligently pushing up against the barrier of motion. By attempting to directly go just beyond the restriction, the tissue can soften, release, and give up its hold on dysfunction.

MUSCLE ENERGY: This DIRECT ACTION technique is a physical way to go up against the barrier of motion to help increase joint and muscular action. This technique uses voluntary patient cooperation. The Osteopath positions a specific anatomic region while the patient pushes against a precise resistance with an isometric muscular contraction. The result is increased joint range of motion, an enhanced flexibility of muscles, and the freeing of restrictions that limit normal nerve function or the free flow of material fluids.

ARTICULATORY TECHNIQUE: This technique can be either DIRECT or INDIRECT ACTION. A joint is carried through its range of motion either against the barrier of motion or away from it within a narrow range of balance. This technique may lead to fascial unwinding of the tissues. The ultimate therapeutic goal is to increase joint range of motion.

JOINT TRANSLATION OF ACCESSORY MOTION TECHNIQUE: Accessory motion is defined as movement at a joint that cannot be performed voluntarily but can be performed passively with an external force applied by an Osteopath. Joint translation is the act of engaging these accessory motions. By treating limitations in accessory motion we can restore greater voluntary motions of a joint. In other words, by Osteopathically using this deliberate and physical DIRECT ACTION technique we can restore greater motion to a restricted joint by affecting releasing the constricted connective tissues surrounding a joint.

MANUAL PERCUSSION AND VIBRATION: This approach can be used as either a DIRECT or INDIRECT ACTION technique. It is an old Osteopathic technique that has recently been revitalized. It is a gentle form of rhythmic vibration or percussion that helps to restore motion to joints, encourage greater circulation, a remove localized restrictions in the tissues. I also utilize the vibrational component of this technique as a diagnostic tool.

RECOIL TECHNIQUE: This method is a DIRECT ACTION technique that goes up against the restriction or engages the tightness of specific tissues and then rapidly releases the built-up elastic force causing a recoil that reflexively releases the dysfunction. It is also an old Osteopathic technique that has recently been revitalized. It a gentle technique that is used with anatomic precision to treat dysfunctions in muscle, bone, arteries, veins, nerves, and the various connective tissues.

HIGH VELOCITY LOW AMPLITUDE (HVLA): This DIRECT ACTION technique uses a very fast but extremely short, thrusting force that precisely pushes just beyond the restricted anatomic barrier to motion. This technique can elicit a pop or cracking noise, but the sound does not mean that the technique was successful. It is not necessary to hear a sound when using this approach; it is more important that the Osteopath feels the motion under one’s fingers. I rarely utilize this technique in my practice. However, there are special situations where this method can be selectively helpful for a specific dysfunction.

I offer these detailed descriptions of my work as an Osteopath because many patients want a more in depth explanation of my unique hands-on approach. However, I would prefer to be more vague, like Dr. Still, and tell people that I am simply an Osteopath who does Osteopathy.

It is important form me to restate that Osteopathy is not a technique it is an applied clinical philosophy. Osteopathic philosophy informs the technique. The technique does not define Osteopathy.

                Steve Paulus, DO, MS