“Osteo” Related Musculoskeletal Conditions and Osteopathic Treatment
For: National Academy of Osteopathy, Toronto
Submitted By: Renata Adamczyk
Introduction
The majority of people are unaware of the principles of Osteopathy. When people
hear the word Osteopathy they often ask, ‘what is that’? Most tend to relate the root word
‘osteo’ to bones or think that is mainly to treat osteoporosis. Then relations between
chiropractors or massage therapists are brought into context to give a comparative
reference. People that initially have no idea of what an osteopath does; now conjure up a
vague representation of what the profession is about. They think along the lines of it
treating those with bone deformities, back pain or osteoporosis. However osteopathy is
much more then that, the found Andrew Taylor Still, MD, DO writes:
“Your duty as a master mechanic is to know that the engine is kept in so perfect a
condition that there will be no functional disturbance to any nerve vein or artery that
supplies and governs the skin, the fascia, the muscle, the blood or any fluid that should
freely circulate to sustain life and renovate the system from deposits that would cause
what we call disease”1 .
This quotation from the founder reveals the inner beauty that the profession is capable of.
Thus explaining this definition to individuals unaware of what osteopathy treatment is
will leave them enlightened on what is available to them for their health and well being.
This paper will cover common musculoskeletal conditions that people suffer
from. An overview of the condition will be presented along with how osteopathy
treatment should be administered or in some cases not. There are many indications and
contraindications that are to be known before treating certain conditions. The aim of this
paper is to give a clear explanation of which conditions are most suitable for treatment.
Conditions containing the prefix ‘osteo’ will be focused on as many people relate them
with osteopaths. The prefix, ‘osteo’ is of Greek origin and is defined as, “combining form
denoting relationship to bone or the bones.’ 2 To begin we will give a brief overview of
the anatomy and physiology of bone.
A Bone to Pick
Bones are synthesized before birth and continue until death. Each bone constantly
undergoes modeling during life to help it adapt to changing biomechanical forces, as well
as remodeling to remove old, microdamaged bone and replace it with new, mechanically
stronger bone to help preserve bone strength. 3 This is carried out by the remodeling cycle
of 4 sequential steps as follows; activation, resorption, reversal and formation. The bone
remodeling unit is composed of a tightly coupled group of osteoclasts (bone breaking)
and osteoblasts (bone forming) that sequentially carry out resorption of old bone and
formation of new bone. Osteocytes are matured osteoblasts and may live for decades in
the body. The figure below illustrates the remodeling cycle.
Figure 1
The bone remodeling cycle.
The four general categories of bones are long bones, short bones, flat bones, and
irregular bones. Bones have 4 layers, from outer to inner they are; periosteum, cortical
(hard bone), cancellus (spongy bone), and bone marrow. The bone marrow is where
white and red blood cells are synthesized. The following diagram of a long bone shows
the aforementioned layers as well as the epiphysis (end o f a bone) and diaphysis (shaft of
a bone). The ephiphyseal line and articular cartilage will be discussed in later sections as
their dysfunction are linked to some common disorders.
Figure 2
Anatomy of a long bone
The human body is very complex, as justified by the remodeling cycle and how
bones can regenerate. In relation to the osteopathic profession, bones are helpful for
orientating the body and palpating landmarks. Bones form joints in which osteopaths can
move through different ranges of motion and perform techniques on. The goal of
treatment is not to ‘crack some bones’. Treatment rather is to create ease in the body and
allow the nutrients in the body to flow to the best of their capability.
Osteoporosis
As we have glimpsed at the anatomy and physiology of bone structure we can
further discuss one of many bone related disorders. One which is becoming more
prevalent in Canada is osteoporosis. It is described as a systemic metabolic disease
resulting in low bone mass, which increases the risk for fracture. Referring back to the
remodeling cycle there is more osteoclast activity then osteoblast activity. It can often go
under diagnosed and undertreated in people. The best way to know if you have this
condition is through a DXA scan which measures the density of your bones.
“Osteopathic physicians (DOs) are in a unique position to improve diagnosis and
management of this clinical condition when they implement a holistic and multifactoral
approach”4 . It is also stated, an effective multifactoral treatment plan should include
instructions for fall-risk reduction, nutrition guidance and dietary supplementation,
physical exercise, and osteopathic manipulative treatment (OMT). 5 Referring back to one
of the principles of osteopathy is the concept that structure and function are reciprocally
interrelated. Thus an osteopathic approach to osteoporosis must begin with prevention. It
is well known through studies that performing weight-bearing exercises can help to
prevent the onset of osteoporosis. As populations age, it is important to employ
osteopathic principles and techniques to maximize the patients’ ability to perform normal
weight-bearing exercises such as walking, climbing stairs or resistance training.
Examples of appropriate OMT paradigms for the maximization of function
include muscle energy, myofascial release, strain/counterstrain, Still technique,
craniosacral manipulation, and several other direct and indirect manipulative
approaches. 6 These treatments seek to normalize joint motion, balance soft tissue tension,
support the body’s inherent motion, improve circulatory and lymphatic function, and
maximize the patient’s feeling of well-being. Improved bone physiology should result,
thus slowing the rate of osteoporosis and improving active daily living through better
range of motion, increased confidence in physical activity, and reduce overall body pain. 7
Other advice for prevention offered by osteopaths should include the importance
of vitamin D and calcium intake. These two minerals are important for bone structure and
health. Exposure to sunlight for 10 to 15 minutes a day can provide vitamin D.
Consumption of good quality dairy products such as yogurt and milk contain calcium to
help build strong bones. Those who abstain from smoking and drinking excessive
amounts of alcohol are also at a lower risk of developing osteoporosis. Things that you
can not control that are a risk factor include age and family history. Those who have
family members with the condition are more at risk. As you age your chances increase. It
is more prevalent in women compared to men and often starts post- menopause.
There are two general categorizations you can make with osteoporosis. One
category being severe onset of disease, current or past fractures. The other category is
being without a fracture or early on set of the disease. Osteopaths should never treat a
fracture directly. However, strain-counterstrain techniques are safe to perform indirectly
on those who have a fracture. To invoke pain is not the aim during a treatment. If the
patient is experiencing any pain then that mobilization should not be administered.
Special caution when working on elderly with osteoporosis should be used. Treatment
should be gentle and not cause acute pain.
Osteoarthrits
A different ‘osteo’ condition with a high prevalence rate in Canada is
Osteoarthritis. It affects one in ten Canadian adults, and is witnessed more in those o ver
the age of 60. 8 Joint pain is the common symptom of osteoarthritis, caused by
inflammation. Pain, stiffness, redness and swelling compose this inflammation. It occurs
when articular cartilage (refer to figure 2), the tough elastic material that covers and
protects the ends of bones begins to wear away. Cartilage is an essential part of the joint;
it acts as a shock absorber and enables the joint to move smoothly. With osteoarthritis the
cartilage erodes, eventually resulting in pain, stiffness, swelling and bone-on-bone
movement in the affected joint.
The general signs and symptoms include pain in the joint after use. During late
stages of osteoarthritis, pain in the morning can be severe, and pain after daily activities
is also experienced. Resting the body seems to relieve the associated pain. There are no
tests to identify this condition but an x-ray can help diagnose it.
The osteopath’s role in regards to this condition to help prevent the onset of
osteoarthritis is to advise people to maintain a healthy weight. Even ten pounds can cause
strain on your joints if they have to carry more weight then they should. 9 Educating
people on proper posture and joint movements such as squatting will also help to lessen
the load placed on joints. In regards to hands on treatment for someone who already has
osteoarthritis, the main goals are to control pain and improve overall ability to function.
This can be done by using techniques that increase range of motion such as muscle
energy techniques and joint mobilizations. These techniques will help the joints to
function better and allow more nutrients to flow to the area. One contraindicatio n to
perform direct treatment would be if there was a bony prominence. This could cause
further damage or pain and should be avoided.
Osteochondritis Dissecans
Another joint condition similar to osteoarthritis is osteochondritis dissecans. It a
condition whereby a variable amount of bone and its adjacent cartilage loses its blood
supplies. With this conidition a piece of bone that has become avascular may also
separate from underlying bone. It can affect any joint in the body but most often presents
itself in the knee or elbow. Usually, only a small portion of the affected cartilage is
involved. Most at risk of developing this condition are boys aged 9-18. The cause of
osteochondritis dissecans is uncertain but theories suggest mild recurrent injuries or
growth disturbances to be the reason.
Symptoms of osteochondritis dissecans are a direct result of the irregularity of the
cartilage within the affected joint. The symptoms experienced are joint pain, stiffness,
and uniquely, locking of the joint so that its range of motion is significantly limited to the
point that it cannot be moved beyond a limited range. For example, when osteochondritis
dissecans affects the elbow, the joint may not move beyond 90 degrees of extension
instead of being able to fully extend straight to 180 degrees. 10 Osteochondritis dissecans
can be suggested clinically by observing this lack of full range of motion with "locking"
of the joint at a certain angle. 11 It is at this angle that the loosened cartilage and bone is
being "pinched" as the joint is attempting to move.
As an osteopath you must screen your patients and see if they are suitable for
treatment. In assessing patients range of motion and if they demonstrate the sign of a
locked out joint, osteochondritis dissecans could be present. In this scenario it is best to
refer to them to a doctor as diagnosing is not within your scope of practice. It is best
diagnosed with imaging studies, such as magnetic resonance imaging scan (MRIscan) or
an arthrogram. 12 There is no cure, but the condition can be treated different ways
depending on the size and location of the lesion as well as the age of the patient and the
degree of symptoms. Arthroscopic surgery is a procedure that is frequently used as a
treatment to remove the loose cartilage and bone tissue from the joint.
13
Thus osteopaths
should not treat patients with this condition as it may worsen the affected joint with free
body substances floating around. If surgery is not needed then activity modification and
immobilization is suitable.
Osteochondroma
A different bone condition not suitable for treatment is osteochondroma. It results
in a bone tumor. “An osteochondroma may grow in a child or adolescent and usually
stops at maturity”.
14
It is thought to arise during skeletal growth when bone grows away
from the growth plate instead of in line with it. 15 The cause is unknown and physicians
have been unable to find a suitable prevention. Thus as an osteopath there are no
preventive measures that can be taken to help patients from this condition. One can
recognize the signs and symptoms, however, the most common being a painless bump
near the joints (often the knee or shoulder). 16 The tumor can also be situated under a
tendon which affects the overlying tissues. Rarely seen but possible, it can also be near a
nerve or blood vessel causing disruption in feelings or blood circulation. To diagnose an
X-ray will show the bony growth. Treatment involves surgery if there is causing pain or
growing.
Osteomyelitis
Osteomyelitis is another bone condition but refers to an infection in the bone. The
infection is usually caused by bacteria or in rare cases fungi. Risk factors include;
diabetes, drug use, bone surgery, trauma or poor blood supply. 17 If a patient seeks out an
osteopath and upon screening them they fine bone pain, fever, local swelling and general
discomfort they can suspect osteomyelitis as the cause, as these are the root signs and
symptoms. Osteopaths should not treat areas where inflammation is present as further
damage may be caused. Tests to diagnose this condition include bone scan, bone x-ray,
and blood sample. Treatment is in the form of antibiotics to destroy the bacteria and rid
the bone of infection. Surgery may be needed in severe cases where dead bone tissue with
an infection that doesn’t subside.
Osteopenia
The last ‘osteo’ related condition we will cover is osteopenia. It is defined as
having a lower bone mineral density (BMD) then normal. However the BMD is not low
enough to be classified as osteoporosis. Consequently if you have this condition you are
at risk of having osteoporosis when your BMD drops to the associated levels. There are
no symptoms but pain might by present as bones thin and you increase your chances of
getting a fracture. To diagnose it a dual-energy X-ray absorptiometry (DEXA) scan will
detect bone density. Osteopaths can treat this condition similarly to osteoporosis. The
prevention strategies as previously mentioned would be employed as well as techniques
listed in the osteoporosis section. Osteopenia is a less severe form of osteoporosis thus
caution with pain should still be considered.
Conclusion
Covering a full circle of osteo related terms from osteopenia which is the precondition of osteoporosis and everything in between from; osteoarthritis, osteochondritis
dissecans, osteochondroma and osteomyelitis, osteopathy has it’s place for treatment or
in same cases not. What people should take away from the notion of osteopathic
treatment is its benefits of primary preventative care. It seeks to restore balance in the
human body through different techniques and mobilizations. Treatment will enhance the
body’s mechanisms to perform optimally. This will reduce the likelihood of improper
functioning of cells and tissues that over time can lead to more serious and chronic issues.
The founder, Still states the four principles of osteopathy as follows;
“The body is a unit, the body possess self-regulatory mechanisms, structure and function
are reciprocally interrelated; and rational therapy is based on an understanding of body
unity, self- regulatory mechanisms, and the interrelationship of structure and function”.
Osteopathy doesn’t cure or treat all ‘osteo’ related conditions. It can help relieve
symptoms associated with osteoporosis, osteoarthritis, and osteopenia. However, with
osteochondritis dissecans, osteochonroma and osteomyelitis, treatment is not
recommended.
1
Still Andew. Philosophy and Manual of Osteopathy, 1902
2
Neurotrauma Law Nexus. “Neuroglossary”. Accessed: 06 May 2012.
<http://www.neurolaw.com/neuroglossary.php>.2012.
3
Clark, Bart. “Normal Bone Anatomy and Physiology”. Division of Endocrinology,
Diabetes, Metabolism, and Nutrition. Mayo Clinic. Minnesota, 2008.
4
Gronholz, J. M. “Prevention, Diagnosis, and Management of Osteoporosis-Related
Fracture: A Multifactoral Osteopathic Approach”. J Am Osteopath Association. October
1, 2008 vol. 108 no. 10 575-585.
5
Gronholz, J. M. “Prevention, Diagnosis, and Management of Osteoporosis-Related
Fracture: A Multifactoral Osteopathic Approach”. J Am Osteopath Association. October
1, 2008 vol. 108 no. 10 575-585.
6
Devine, H.W. & Ross, S.J. “Osteopathis Medicine’s Approach to Managing
Osteoporosis” 2004.
7
Devine, H.W. & Ross, S.J. “Osteopathis Medicine’s Approach to Managing
Osteoporosis” 2004.
8
“Osteoarthritis.” Site created by the Arthritis Society. 30 Nov. 2011
<http://www.arthritis.ca/types%20of%20arthritis/osteoarthritis/default.asp?s=1&province
=ns>.
9
“Osteoarthritis.” Site created by the Arthritis Society. 30 Nov. 2011
<http://www.arthritis.ca/types%20of%20arthritis/osteoarthritis/default.asp?s=1&province
=ns>.
10
“Osteochondritis Dissecans.” Site created by Medicine Net. Accessed: 4 May 2012.
<http://www.medicinenet.com/osteochondritis_dissecans/article.htm>.
11
“Osteochondritis Dissecans.” Site created by Medicine Net. Accessed: 4 May 2012.
<http://www.medicinenet.com/osteochondritis_dissecans/article.htm>.
12
“Osteochondritis Dissecans.” Site created by Med icine Net. Accessed: 4 May 2012.
<http://www.medicinenet.com/osteochondritis_dissecans/article.htm>.
13
“Osteochondritis Dissecans.” Site created by Medicine Net. Accessed: 4 May 2012.
<http://www.medicinenet.com/osteochondritis_dissecans/article.htm>.
14
“Osteochondroma.” Site created by American Academy of Orthopaedic Surgeons.
Accessed: 6 May 2012. <http://orthoinfo.aaos.org/topic.cfm?topic=A00079>.
15
“Osteochondroma.” Site created by American Academy of Orthopaedic Surgeons.
Accessed: 6 May 2012. <http://orthoinfo.aaos.org/topic.cfm?topic=A00079>.
16
“Osteochondroma.” Site created by American Academy of Orthopaedic Surgeons.
Accessed: 6 May 2012. <http://orthoinfo.aaos.org/topic.cfm?topic=A00079>.
17
“Osteomyelitis”. A.D.A.M. Medical Encyclopedia. Site Created by U.S National
Library of Medicine on 25 May 2010.
<http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001473/>.
Figure 1 <http://humupd.oxfordjournals.org/content/early/2010/04/28/humupd.full>.
Figure 2 <http://en.wikipedia.org/wiki/Long_bone>.