the three links

8/14/2019 The Three Links

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ISCO Principles and Practice of Connective Osteopathy

The Three Links I

The structure, tools and scope

of osteopathic treatment / Alain Abraham Abehsera Do Md

Early in my career as a practicing and teaching osteopath, I formulated a general

theory of osteopathic diagnosis and therapeutics, a theory named "the Three Links",

namely, the circulatory, the neurologicaland the mechanicallink.

This theory offers a useful, rigorous and exhaustive framework for the osteopathic

physician.

I owe its development to two of the main thinkers of osteopathy in the XXth

century: J.M. Littlejohn DO and Irwin K. Korr PhD. As a student, I was exposed to

the writings of JM Littlejohn through the teaching of my master, SJG Wernham

D.O. John Wernham used to read in class pages upon pages of Littlejohns writings,

and we were exposed to an osteopathy which applied to all of medicine, something

very refreshing in view of the English osteopathy we had known, i.e., a techniqueaimed at relieving pains and aches in the musculo-skeletal system. With Littlejohn,

we were introduced, for the very first time, to the osteopathic treatment of

pneumonia, of typhoid fever, of appendicitis, of goiter or of angina pectoris. To

understand what he actually meant in his descriptions of physiology, pathology and

osteopathic treatment was another question. This author has written abundantly but

in a very obscure style. We suspected that his writings and ideas were all very

precious, but could not understand what this was all about. One day, looking

through the library of our teacher, SGJ Wernham, I fell, by accident, on the second

determining author in my career: I.K. Korr, a physiologist who spent his career

doing research in osteopathic institutions and whose work was mentioned briefly in

my preceding lecture.

Unlike Littlejohn, Korr writes extremely well. Although not a clinician himself, he

has formulated the first "scientifically expressed", coherent and systematic model of

osteopathy. His system of thought provides the osteopath with the basic framework

needed by any therapist: diagnosis, therapy and prevention. However, and I came to

realize this early on, the model he proposed was somehow restrictive. It is almost

entirely centered on neurological disturbances and deals with other systems only in

so far as they are governed by the nervous system, and, more restrictively even, by

disturbances of the sympathetic branch of the nervous system. Circulatory

disturbances, for instance, are considered as secondary to sympathetic hyperactivity.

The laboratory evidence brought by Korr in favor of his "facilitation" model israther limited, as limited as the means that were at his disposal. His review and his

commentary on the deleterious effects of chronic sympathetic stimulation (which

results, in his model, from segmental facilitation) is exhaustive and of excellent

quality. It does leave out, however, major aspects of osteopathic principles and

standard physiology, two fields which cannot be reduced to neurological function.

It became clear to me that the aspects left out by Korr could be classified into two,

and only two, other categories: Solid Mechanics and Fluid Circulation. There are

very many reasons for such a classification. It appears clearly (although

unconsciously) in the writings of AT Still and in the entire osteopathic literature.


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ISCO Course in Connective Osteopathy 2

Israel School of Connective Osteopathy - www.connective.org

In the present lecture, I will demonstrate the necessity of this wider model through a

logical, step by step definition of the scope, possibilities and limitations of

osteopathy.

With one hand in my pocket.

Indeed, what can an osteopath hope to achieve with his hands when he makes

contact with his patient? We are not talking here about complex effects such as

"increase the level of immunity", "raise the level of cortisolemia" etc. The osteopath

cannot do these things with his hands; he takes, possibly, manipulative measures

which will lead to such effects, but these are brought about indirectly. What the

osteopath can actually achieve directly with his hands is rather modest: he can only

modify neurological, mechanical, circulatory relationships between organs or

tissues.

In simple terms, the act of laying one's hands on the patient will lead to three

fundamental effects, immediately measurable by the patient and the operator: the operator will displace solid tissues (skin, artery, bones, nerves, muscles,

viscera) through pushing or pulling

he will also displace fluids (blood, lymph, intra-ocular fluid etc.) he will set into play the nervous system (sensitive, motor and autonomic nerves)The simple fact of laying one's hands on a patient will necessary lead to these three

effects, each one to a varying degree (very gentle touch will lead mainly to nervous

stimulation, whereas strong massage will produce marked circulatory, mechanical

and neurological changes).

It can thus be said that osteopathic touch

mobilizes solid masses displaces fluids and stimulates nerves

That is a priori all that can be claimed. The osteopath with his hands does not cause

a secretion of hormones, does not selectively stimulate B lymphocytes and does not

increase the rate of bilirubin conjugation. The precise purpose of the science of

osteopathy is to achieve, through the three basic effects described above, all kinds of

complex physiologic effects.

For instance, an osteopathic treatment aimed at improving endocrine or

gynecological functions, will always resort to neurological, solid and fluidmechanics. It cannot do otherwise since the skin always separates the operator from

the innards of the patient and shrouds every body function in secrecy. We do know

that massage and manipulation lead to the secretion of very many chemical

molecules behind the curtain of the skin, but this cannot be known by our hands.

Indeed, our hands cannot "feel" the differences between histamine, vasoactive

substance, endothelin or bradykinin. The osteopath can only feel solid and liquid

masses being moved, he can feel or see the patient feel that something is being done,

but no more than that.


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From this viewpoint, and temporarily at least, I am being a staunch defender of

Still's idea that the chemistry of the body tissues is none of our business. It is far too

complex for us to apprehend and we should only concentrate on bringing to tissues

the blood and nervous fluid they need; the chemistry will follow.

I propose to summarize the above with the following axiom:

The osteopath, with his hands, can only cause three effects: neurological

(stimulation of nerves), fluidic (displacement of fluids) and mechanical

(displacement of solids)1.

The slightest laying on of hands will cause some nervous stimulation, some minimal

displacement of cutaneous and sub-cutaneous tissues, some minor displacement of

blood, interstitial fluid, lymph etc. The secretion of neuromediators or other

chemicals will be a response of the body to the above basic "manipulations".

The axiom above seems the minimal definition of the osteopathic act, one thatseems of universal value. I propose it as the "cogito ergo sum" of osteopathic

practice.

Very much like Descartes then, we may proceed to build on this first axiom, and

follow with this other axiom:

The osteopath, with his hands, claims a therapeutic effect in most spheres of

human pathology. To achieve such a therapeutic effect, he must consider the

totality of body tissues as being exclusively made of three elements: neurological2,

solids and fluidic.

As a first, starting point for osteopathic principles of technique, I have suggestedthat the only immediate, measurable and perceptible consequences of osteopathic

touch are neurological, fluidic and mechanic. On the other hand, osteopathy claims

that it can treat all organs and tissues of the body, i.e., osteopathy is not just skin or

muscular massage. This manipulative therapy believes it has an effect on all

structures, however deep. Osteopathy is thus very limited in its practice (it can only

move solids, fluids and stimulate) but very wide in its principles and claims. We can

make one clear deduction from the above: the osteopath, in order to treat any part or

organ of the body, must consider it as being made of neurological, mechanic and

fluidic elements.

If the osteopath can only move solids, liquids and stimulate nerves, he must

transform any tissue he intends to deal with into a solid, a liquidand an irritable

whole.

1The distinction made here between mechanical and fluidic is rather improper from the semantic

point of view. Indeed, mechanics includes fluid dynamics, and these two should not be

distinguished as two separate entities. . A better choice would have been hydrodynamic, a word

which, although it still belongs to the vocabulary of mechanics, conveys the idea that we are

interested in the property of fluids and not of blood vessels as mechanical structures. Hydrodynamic

is too long a word and sounds rather inappropriate in an osteopathic text. We have thus created the

neologism fluidic (instead of fluid).2

The same remark goes for neurological. Nerves are solids and contain fluids. As such they are

part of the mechanic and fluidic mobility discussed above. By neurological, I wish to designatewhat is specific to nerves, i.e., theirconduction of impulses.


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In other words, before he deals with any organ, the osteopath must transform it into

a substance that his hands can affect. This reduction distinguishes osteopathy from

all other therapies. This transformation of all organs into a fluid, solid or irritable

mass is thefundamental abstraction made by all osteopaths (see our lectures on

abstractions in CTh).

For example, I wish to treat some endocrine imbalance through some work on thehypophysis. I cannot consider the hypophysis as a gland that secretes prolactine,

ACTH, FSH, ADH etc. This information is meaningless for my hands: they cannot

identify these elements and distinguish between them. Their distinction is certainly

useful for the endocrinologist, for the herbal therapist or the naturopath, but not for

the osteopath. His visualization of the hypophysis is unique and shared - partly

only with surgeons. For both, the hypophysis is a tissular mass

surrounded by, anchored to several solid tissues (mechanics) such as themeninges, the brain etc.

which possesses a specific blood supply (fluid) which is innervated by specific neural pathways(neurological)My diagnostic and therapeutic approach will be directed towards an evaluation and a

balancing of these three aspects. Tissues become full of meaningful information for

my hands when they are turned into pure solid, fluid or irritable substances. Indeed,

hands can modify mechanical relationships, displace fluids or stimulate neural

pathways. The body of the patient, after the osteopathic manipulation, will "decide"

if the level of such and such hormone should be raised or lowered. In other words,

chemical effects are responses of the patients body to the osteopaths coaxing of the

mechanics, the fluids and the irritability of the tissues.

Another example: the osteopathic liver is a tissular mass that is attached in

specific mechanicalways, vascularized (blood, bile, lymph etc.) and innervated.

The liver cannot be, for my hands, a mass that synthesizes albumin or glycogen.

This would be meaningless.

My osteopathic treatment of the liver will have to be directed only at the three

aspects discussed above, and I do not know if that treatment will lead to an increase

in parasympathetic tone, or a decrease in glycogen or albumin synthesis.

I wish to insist on this point: an osteopath must visualize, must translate the

structures he wants to affect, into structures he can affect.

Johnsons Miracle Cure

Leon Page, an early osteopath, gave an interesting image about the fascia. I will

resort to that image, in a somewhat modified way, to illustrate the point I have made

above.

Suppose one of the major companies that makes chemical solvents comes out with a

strange product designed for a strange market. This company has invented a solvent

specifically active on human or animal flesh. Its particularity: when you dip a

cadaver into it, it dissolves everything but connective tissue. The indications on the

bottle state that when the cadaver is left to macerate into the product for about an

hour, all of the tissues melt away except for connective tissue, i.e., tendons, fascia,

aponeuroses, the mesenchyme around all cells etc


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The marketing claim about this product: it allows bereft families to keep a lighter

form of their dear ones.

Suppose a client has bought it and proceeded to macerate his recently and naturally

(?) deceased mother-in-law.

Question: how much resemblance is there between the macerated subject before andafterthe maceration ? We are left with a connective tissue woman. How close to

the complete (i.e., the initial) woman is that creature?

The answer is unequivocal: there would be no difference, to our eyes, between the

two persons. Provided the lost substance was replaced with air or wax, the

connective tissue woman would be identical to the complete woman. Indeed,

connective fibers surround every single cell in the body as well as condense into

sheet and covers which surround every tissue. Consider that the body is made of

individual, framed pictures, grouped into bigger framed pictures. The small pictures

are the cells of the body, the larger ones, the organs. Connective tissue can be

considered as theframe of every single part - from the smallest to the largest - of thebody.

Should you remove all the pictures, the general shape will be preserved.

I propose to designate the substance of this connective tissue subject, the

mechanicallink.

I suggest that the osteopath who wishes to work on the mechanical aspect of any

tissue or limb must resort to a visualization of the tissue similar to that obtained

with the solvent above. The osteopath must resort to an abstraction of his patient

equivalent to a mental dissolving of everything but the connective tissue. I shall

designate this mental dissolving, the mechanical reduction of the tissue. Indeed,

what is left is not irritable (the nervous system has been removed) and is notfluid (the circulation has been removed). What is left is a tissue with purelysolid

mechanics properties (stretch, torsion etc.).

I suggest that the osteopath must visualize, within his patient, a human being

entirely made of connective tissue, a kind of body frame that contains all the other

tissues and substances; the fact that all other tissues have melted away did not cause

any significant morphological difference.

A succession story

The commercial success of this solvent has led our chemical company to search foralternative products. A new product is marketed. After two hours of maceration, it is

able to dissolve everything in the body, except nervous tissue. Owing to the

dissolution of the connective tissue, the resulting cadaver loses all rigidity. It

becomes a nervous blob, hardly recognizable for the family. In addition to the

solvent, the company decides to supply a special wax, one able to hold all nerves

into their original place3.

3These distinctions hold only broadly speaking. It is obvious that nerves are made of connective

tissue, that the connective tissue is innervated etc. With respect to our hands, however, this distinctionholds.


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After the prescribed two hours of maceration, we are left with a purely neuronal

woman. Question: how resembling is that neuronal woman to her previous,

complete self? If some resemblance is obvious, is this neuronal woman a better or a

worse reproduction of the connective version?

Answer: the neuronal woman will be a faithful and exact reproduction of the

complete woman, as if nothing was missing. It will also be about as faithful areproduction as the connective woman. Nervous fibers are present everywhere,

reach almost every cell of the body. Indeed, our neuronal woman, to our eyes, will

look exactly the same as before.The shape of his nose, the swell of her cheeks, her

wrinkles will all be there. Some features may be lost, such as hair, but this will

happen with all our solvents.

Very much like we did for the connective tissue man, we can choose to see this

neuronal man as the essence of the human being, all our tissues being there only to

give it support.

We thus have found already two faithful copies of ourselves within our anatomy, aneuronal and connective one, and each one can be considered as central.

Get yourself together

Our chemical company has found a flourishing market: people are interested in

keeping their dear ones in a state that respects entirely their form, but using as little

of their original substance as possible. In other words, they are looking for the

lightest possible versions of their deceased.

A member of the marketing division, obviously a man of considerable medical

culture, thinks of a third solvent. This product is able to melt every tissue except for

the endothelial linings of all vessels and their fluid content. Nerves, connectivetissue etc. disappear leaving a purely vascular man. This is, again, a rather

difficult feat since blood vessels are surrounded by connective tissue and our

vascular man would also need some deep-freezing or wax to hold its shape. This

technical feat is achieved.

Question as above: how faithful a reproduction is our vascular man? Would he be

recognized by his close ones? Without a shadow of a doubt, yes, this vascular man

will constitute an exact copy of the person, with all his folds, valleys, elevations,

asymmetries. A microscope would certainly and immediately reveal the weirdness

of this creature, but his family looks at him with their eyes and not with a

microscope.Indeed, blood vessels, lymphatic vessels and many other types of vessels reach and

surround every cell of the body, perfuse all tissues. Again, we can see this vascular

network as the true skeleton of the body, the rest having been created to support it.

The three mes

So far, we have found three exact copies of ourselves, side by side, in our body. All

are equally faithful copies. Their only differences lie in the amount of stiffness, the

color etc. I have designated these three copies as the neuronal, the vascular and

the connective human.


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This holds for the body as a whole or for its parts: the liver, for instance, includes a

neuronal, a vascular, a connective liver.

Fig 1. The three internal copies of the liver.

The liver contains three copies of itself, which have an internal and external shape

identical to the original organ.

In Stills writings, we can certainly find these three essences, these three readings of

the human body and its organs. He mentions them in a confused way, but it is clear

to me that osteopathy was a three-stage discovery for Still: he first had the intuition

of this art whilst considering the vascular system and its rule over the body. He

later realized the importance of the nervous system and had it rule over all other

tissues. In his later years, he became attached to the connective tissue (the fascia

in his terminology) and consecrated it as the House of God in the body. I believethat Stills recurrent notion of ruling over other tissues attributed in succession to

the vascular, the nervous or connective tissue system is a reflection of the model

proposed here.

The reader may protest that there are other ubiquitous cellular or molecular systems

in the body, systems that could, should we dissolve everything but those cells or

molecules, leave a conform copy. Take, for instance, the immune or endocrine

systems. They indeed are everywhere. And we certainly could imagine a

lymphocyte man or an insulin man, since there are lymphocytes everywhere and

receptors to insulin on every cell. These are not, however, continuous anatomicsystems. They are discontinuous. Only the connective tissue, the vascular and

nervous system offer a continuous copy of the animal body. We shall see that

other systems, such as the immune or endocrine one, can be included, but not at this

stage of our development. The only ubiquitousandcontinuous systems of the body

are the nervous, vascular and connective tissues.

These three possible readings of the body have another interesting and common

characteristic. Each of them possesses a centraland aperipheralpart:

the vascular system (blood and lymph) is centered by the heart. At theperiphery are found all the vessels.

the nervous system is centered by the brain, spinal cord and plexuses. Fromthese centers, nerves densely branch out to the periphery


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the center of the connective system is the skeleton, with connective fibersirradiating to all the body from our bones.

I shall summarize the above with the following axiom:

Within each and every tissue mass of the body, three anatomical networks of

equivalent importance may be found: a vascular network, a neurological network,a connective (or mechanic) network. Each network reproduces the exact external

and internal shape of that organ and can be said to contain that organ

(including the other two networks).

These networks are normal anatomical features of our organs. They are, however, of

great pathological significance. Indeed, each of these networks can be said to

contain the rest of the organ like a womb. In other words, each network marks the

internal and external limits of each organ. But just like a womb can become a tomb

or prison, these networks can become three traps that threaten the cellular tissue

they surround. For instance, the cells of the liver are normally surrounded by aconnective, neurological and vascular network. As pathology sets in, each of these

can become a trap for liver cells.

When the osteopath restores mobility to a tissue, he is actually freeing it from these

three possible traps. Remember, the osteopath does not deal directly with the

chemistry inside the cell - something done by conventional physicians or

homeopaths - he can only deal with the effects of these three extra- cellular

skeletons on tissue function. Having increased total tissue mobility, having freed

the tissue from these three possible entrapments, body chemistry will proceed as it

sees fit, away from our eyes.

We may now return to our first axiom, the one which stated that the osteopath, with

his hands, can only move solids, liquids and stimulate nerves. From the discussion

above, we may see that the three fundamental skeletons found in every tissue are

made of the very substances that the osteopath can have an effect upon (nerves,

solids and liquids). There is thus conformity between what the osteopath can do and

what all of the tissues of the body -however deep - are made of.

This systematization applies to all parts of the body.

All tissues are accessible to osteopathic treatment - however distant they may be

from our hands - so long as the osteopath seeks the skeleton of the tissue and not itschemical functions4. Below, we shall see that the osteopath may also have an

intracellular effect. We have drawn this conclusion from the simplest possible

anatomo-physiological laws.

I will summarize the above in the following axiom:

All the tissues of the body may be accessible to osteopathic treatment provided

they are reduced to their triple component skeletons: neurological, mechanical

and vascular.

4Below, we will see that the osteopath can also have an intracellular effect.


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The Three Links II

Definition of the Osteopathic Lesion

In my preceding lecture, I dealt mainly with the normalstructure of tissues. I

mentioned the three static skeletons that build any tissue. These are part of the

structure of the tissue.

The osteopath, however, has to deal with tissues in a dynamic state. They can either

be freely mobile or in osteopathic lesion, i.e., a state of disturbed mobility. I

propose to travelinside a tissue in lesion and see what happens to the cells and

networks I have described above.

Imagine you are in a dissecting room. In front of you, on a lab table, lies a (dead)

animal and you are asked to dissect it so as to expose the anterior aspect of the

vertebral column (or posterior abdominal wall). To achieve that, you must firstremove all the contents of the abdominal cavity: large and small intestine, stomach,

pancreas etc. You do not need to be too delicate with the viscera you have to remove

since you are only interested in exposing the vertebral column. You just need to

introduce one hand under the diaphragm and another hand, above the pubis, both as

deep as possible, and then pull all the viscera away.

Obviously, several structures will prevent us from separating the content of the

abdominal cavity from the posterior abdominal wall. The stomach, for instance is

prolonged by the esophagus and the latter will have to be cut. The same goes for the

rectum which ends in the anus. After having cut these verticalconnections, you are

left with the intra-abdominal connections.

First and foremost, you will have to cut all the connective tissue bands, ligaments,aponeurosis, fascia etc. which attach the viscera to each other and to the abdominal

walls: e.g. the fascia of Treitz, the fascia of Toldt, the omenta, the mesocolon or

mesentery, the falciform ligament, the urachus etc. These are powerful structures

which will offer considerable resistance.

This strong mechanical link is made of a dense network of connective tissue bands,

attaching the content of the abdominal cavity to the surrounding walls. This

particular link exists, in fact, between all articulated tissues of the body. In the figure

below, I have illustrated the link between a muscle and a bone as well as between a

bone and a viscera. We shall call this type of articulation, this restraining factor

between tissues, the mechanical link.


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Fig. Two sets of tissue in the body: a muscle and a bone, a viscus (here the colon,

and a neighboring bone)

Fig. We see the mechanical link between the bone and the muscle, the colon and the

pelvis. This is highly schematic. The mechanical link of the muscle, for instance, attaches

along the bone but only at the two ends of the muscle, to allow shortening and lengthening.

Likewise, the colon is attached through its peritoneal sheath to the iliac bone.

Fig. Parts of the mechanical link in the abdominal cavity. The various peritoneal

folds that envelop and anchor the intestines may be seen.


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The nerves are the second type of tissue that will prevent you from tearing easily the

content of the abdomen away from its supporting walls. Indeed, nerves run

everywhere, come out of the brain of the spinal cord to spread to the muscles, the

viscera, the glands etc. When I try to pull on some structure in the body to separate

from some other, I will always end up stretching or tearing some nerve trunks.

Nerves are thus also restraining ropes that hold all tissues together. We shallconsider that, as such, they act as links and call this type of articulation, the

neurological link. Obviously, as mentioned at the beginning of this lecture, the

neurological link is basically made of mechanical tissue (i.e., the connective tissue

that holds nerve fibers together). We discussed this issue before and have proposed

to see in the neurological system a network and a link which cannot be reduced

to its connective tissue or vascular envelopes. In other words, there is something

unique to the neurological link between tissues, different to the mechanical one.

This uniqueness is due to the irritability of the nervous tissue, one that is mobile

and connective, i.e., through the nerves, the irritability of one tissue is linked to the

irritability of another one (in fact of any other one, through the central nervoussystem). This linked irritability is the essence of the neurological link.

Fig. The neurological link between two contiguous tissues and articulated tissues.

The third type of tissue that will resist my efforts at pulling away the contents of the

abdomen will be the blood and lymphatic vessels that vascularize and drain the

abdomen and its musculo-skeletal casing. This constitutes our third link, the fluidic

link.

Blood vessels act as ropes because they contain connective tissue (i.e., the

mechanical link). Here again, however, we propose to see the vascular link as

having an essence different from the mechanical one. Liquids have a mobility and

carry an information that is different from the mobility and information

characteristic of the other two links. They are able to relate organs through their

unique mobility and information.


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Fig. The vascular link between adjacent tissues.

These three types of ropes that connect tissues together, each one in its own

unique way, form what I have proposed to call the three links.

Fig. Composite drawing of the three links between a muscle and a bone, or between

a viscus and a bone.

We shall posit that all tissues of the body are connected through these three links.

As we mentioned earlier, there are other possible links between tissues, but the three

links discussed here are the only anatomically ubiquitous and continuous links

between all tissues of the body. It can be said that these three links articulate or bind

contiguous tissues such as the ones drawn in our figures, but it can also be said, in a

more inclusive way, that any tissue is connected to any other tissue through the threelinks. For instance, there is a mechanical connection between the colon and the

bones of the foot (through the fascia), but there is also a neurological connection

(through the CNS), and a vascular (blood/lymph) connection.

We shall summarize the above with the help of the following axiom:

All tissues of the body - both contiguous and non-contiguous - are connected

through three links: mechanical, neurological, fluidic.

It must be emphatically stated again that although these three links are themselves

linked to each other, each one is irreducible to the other two. There is something


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lesion that causes a permanent stretch5 of some link will have repercussions right

through the involved tissues.

Fig. Between these two stylized tissues, one may distinguish the three links. Within

each of the two tissues, one may see the three networks. One may also see that the

links and the networks are strictly continuous with each other.

From the above, we may infer, that the osteopathic lesion is not a lesion of the

inter-articular tissues (i.e., ligaments, muscles etc) but a phenomenon that penetrates

right through the tissues. Indeed, a tension of the mechanical link between any two

tissues will be prolonged, through the mechanical web of both tissues, to all parts of

the two involved tissue (to a degree and amplitude that will depend on the amount

of stretch). We shall see how important this notion is in terms of visualization. We

must not forget that, generally, in structural osteopathic technique, the operatortends to think of the osteopathic lesion as a phenomenon that pulls on , strains

the ligaments that join bones. The pain is generally felt on the area of insertion of

the ligament,

e.g., the internal collateral ligament of the knee, a frequent victim of sprain. He

would not tend to think it important to consider the prolongation of this ligamentous

tension right through the tibia. This would be even meaningless to him since

structural osteopathy cannot manipulate the mass of the tibia, it can only manipulate

the tibia with relation to another bone (femur, fibula, talus). This prolongation of the

links right through the linked tissues is, however, fundamental to our technique

since we believe that we can act on the mass of the tibia itself. It is thus veryimportant, in any lesion, to have a visualization of the involved tensions as complete

as possible. The tension of the articulatory tissues (ligaments) is only part of the

picture; how this tension involves the femur, the foot, the muscles etc. is no less

important.

5I use the term stretch all three links although it should be applied only to the mechanical link andthe mechanical part of the neurological and vascular tissue. The vascular and neurological links are

brought into play in their own typical way. For thesake of brevity, however, I use the word stretch

to designate the implication of all three links.


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The osteopathic lesion, as I understand it, must therefore not be understood as an

articulatory problem, it is also a tissular problem.

We will include this notion in the following axiom:

The osteopathic lesion is both articular and tissular. In other words, in ones

visualization, one must not stop the effects of the lesion at the surface of the boneor the viscus. In the operators mental image, the effects of the osteopathic lesion

must be prolonged well into the articulating organs or tissues.

Fig. The continuity of the three links between and three webs inside two schematic tissues.

During a mobilization of the two articulated tissues, the three links are stretched and this

stretch runs deep into the tissues. This fig. shows also one possible kind of osteopathic

lesion and its deep tissue effects. Again, one aspect of the three links is emphasized, the

mechanical one. Indeed, what is stretched in the three figures above is the mechanical

component of nerves and blood vessels. We must understand however that stretch has

distinct neurological, mechanical and hydrodynamic effects (see below).

We remember that in our chapter on the three facilitations, we had proposed a

wider definition of the term mobility in osteopathy.

We had proposed that this notion had to include:

mechanical mobility, i.e., the classical understanding of the word mobility.This defines the ability of tissue masses to change their relationship in space: for

instance, mobility of the liver in relationship to the diaphragm, mobility of the

anterior tibial artery in relation to the interosseous membrane.

neurological mobility, the variability of the membrane potential of neurons(individuals or groups). From the fig. above, and our discussion of the three

links, it could have been understood that we have discussed so far the mobility

of nerve trunks as a mechanical structure. Although a very important element, the


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stretching of a nerve trunk belongs to the mechanical link, i.e., here, the

mechanical aspect of the nervous system. This would be a restrictive

understanding of the theory of the three links. By neurological link, we imply the

actual neurological articulation between the liver and the heart, i.e., the

mobility of one tissue mass in relation to the other (both organs are innervated by

the vagus making their articulation rather obvious. We can discuss also theneurological articulation between the flexor and extensor muscles of the spine.

All these articulations are largely in the CNS and have a certain mobility, i.e.,

flexor tonus can exceed extensor tonus and vice-versa according to the needs of

the moment. The two tissue masses symbolized above can thus represent

extensive muscle complexes, two distant organs (heart and kidney) etc.

vascular mobility, i.e., the variability of fluid pressure and flow in a tissue or incontiguous tissues, or in tissues who, although distant, have correlated rates of

flow according to metabolic or thermal needs. Vascular mobility includes alltypes of fluids in the body: blood, lymph, bile, intra-ocular fluid etc. The same

remark holds for vascular mobility and neurological mobility. Indeed, from the

figures used above, one may think that in an osteopathic lesion, the blood vessels

and nerve trunks are mechanically stretched leading to electrical and

hydrodynamic disturbances. This indeed occurs and is an important part of the

lesion syndrome. This effect is however due to the mechanical aspect of blood

vessels and nerves (since both contain connective tissue). The vascular link and

its vascular mobility has its own, additional role, i.e. the variability of flow

between contiguous and distant beds.

All tissues of the body possess this triple mobility within themselves and between

them.In health, this triple mobility is maximal, in disease, it is disturbed.

We shall summarize the above through the following axiom:

An osteopathic lesion between two contiguous or distant but related tissues always

presents itself as the disturbance of mechanical, neurological and vascular

mobility between and within these tissues.

As we shall see below, in any osteopathic lesion, one the mobilities is

predominantly disturbed depending on the etiology. Whenever one is affected,

however, the other two will automatically be affected due to the extremeconnectivity of structures and functions in the human body. We remember that

blood vessels are innervated and are made of connective tissue, that connective

tissue is vascularized and innervated, that nerves are vascularized and made also of

connective tissue. In acute lesions, one of the mobilities is predominantly affected.

In chronic lesions, with time, this predominance decreases. A systematic

osteopathic treatment of any given tissue or group of tissues will thus have to deal

with all three mobilities.

This will allow us to formulate the following axiom, one that summarizes all the

preceding ones:


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The human body is made of countless tissues articulated through the three links,

endowed with a mobility characteristic of each link. As a result of some

pathological input, this mobility can be affected, leading to an osteopathic lesion.

The number of osteopathic lesions is thus equal to that of articulations. These

lesions always affect the three links. The strict anatomo-physiological continuity

between those three links and the three webs that make up each of the bodystissues, extend the effects of osteopathic lesions deep within the tissues. A

thorough osteopathic treatment is one that bears upon the three links. It will

normalize not only the articulation between the affected tissues but also their

structural fabric.

We shall see below that each link possesses its own corrective techniques, hence the

importance of their systematic separation.

Etiology of Osteopathic Lesions

We have tried so far to determine a common denominator between the abilities of

the hand of the osteopath and the characteristics of the osteopathic lesion. Our hand

can only have three effects: it can displace solids, fluids or stimulate. Body tissues

have three distinct forms of articulations: solid with solid, fluid with fluid, neuronal

input to input (or output). Osteopathic lesions always imply those three types of

articulation. We may then conclude that the hand of the osteopath and the object on

which it is applied (the osteopathic lesioned tissue) are made of the same substance,

are homogeneous. Our hand can affect the lesion complex.

We may now deal with the origin of the osteopathic lesions, i.e., what has disturbed

the mobility of the three links in the first place? In other words, what is the etiology

of the osteopathic lesion? A detailed answer to this question is way beyond the

limits of these lectures. Indeed, the state of a tissue at any moment is conditioned by

so many factors, chemical, biochemical, genetic, physical etc. that to reduce a given

pathology to a single cause would be very preposterous. But our text here is not a

textbook of pathology. We are interested in defining principles that may lead to

general frameworks for our therapeutic techniques. In the case of pathology and

etiology, we are interested in finding the classification of etiologic factors accordingto how tissues are made and what our hands can do about it. Since our hands cannot

remove directly chemicals or genes by pinching them between thumb and fingers,

the chemical or genetic etiologic factor cannot be included in an osteopathic

discussion. They can be modified in an indirect way, as a result ofour work on the

three links. We have already seen that to affect directly the chemical and genetic

factor, a major change is needed in osteopathic thinking and its conditions will be

described at a later stage. At present, we are concerned with acquiring an

understanding of the etiopathology of the osteopathic lesion that is homogeneous to

what my hands can achieve. A therapist who uses osteopathy for the treatment of

lumbago and homeopathy for the relief of gastro-duodenal ulcer has clearly

renounced to have a unified vision of his work. He has two distinct etiologic


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understandings of the body. Although it can be useful and effective clinically, I

believe that the eclectic approach is very destructive for each profession. Ideally, as

patients ourselves, we would wish that the practitioner we go to for treatment, has

gone as far as possible in exploiting the possibilities of his approach. We suppose

here that every approach, such as Acupuncture, Homeopathy, Naturopathy etc.

represents an essentially original reading of human pathology, irreducible to theothers. The fact that some - many - practitioners resort to acupuncture needles,

manipulation and herbal/homeopathic prescriptions on the same patient, in the same

session, should not be condemned only for the sake of purity of principles. One must

teach, however, to students a given therapeutic method as if no other method exists.

Even if within a given school, several therapeutic approaches are taught, it is of the

highest importance that each approach should be taught as isolated. Not only will

that lead to the formation of highly skilled practitioners but also to highly creative

ones, i.e., to original syntheses between distinct techniques within the same

approach or distinct approaches.

This discussion is most critical when dealing with the subject of etiology. Indeed,my visualization of the causative factor of disease (a particular one, a set of diseases

etc.) will largely determine my technique. Do I think that all problems are psycho-

somatic? Due to poor or adulterated nutrition? Bad posture? Often, practitioners

have strong beliefs about the psycho-emotional origin of that type of problem and

the nutritional cause of that other type of problem etc. We are not interested in that

eclectic approach. We are interested in finding the widest application of the notion

of etiology to the principles of osteopathy, as if no other approach existed.

Repetitive clinical failure using such principles would then possibly indicate that

another approach is needed, that what is occurring in this patient is not

homogeneous to what I can achieve with my hands and my osteopathic principles,

that the etiology, the source of the problem the patient came for, is beyond myapprehension.

We therefore propose to define which minimal statements can be made about

etiology so far as an osteopath, practicing only manipulative medicine, is concerned.

Osteopathy sees the body as a complex of articulated masses. We have defined this

articulation as being of a triple nature. From the choice of the word osteopathy, it

is clear that Still favored the mechanical link. Indeed, that link is the most obvious

to the eye: everything in the body seems to be made of parts articulated by

ligaments. We can compare the body to one of those mobiles made of little piecesof wood that are linked by strings to some central piece. The solid pieces move in all

sorts directions, dangling from their string, when the mobile is shaked.

Let us now give a blow to that mobile. All the pieces will move wildly. The parts of

the mobile that will take up most of the force of the blow are the little strings. They

may even tear. For the pieces of wood to break we would need a very considerable

force.

In other words, in a connected mechanism, external strains are first absorbed by

the links between the parts. In mechanical models, they are the first to stretch.

The human body is also a mechanical mobile, it is full of parts that are held by

strings. All external strains are first and foremost absorbed by these mechanical


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links. Forces that exceed the absorbing ability of those strings will break and destroy

the parts themselves

I suggest that this simple observation, obvious in the case of the mechanical system,

should be extended to the vascular and neurological links. We would then be able to

describe three possible mobiles, which are made of pools of fluid (vascular

link), pools of irritability (neurological link), pools of inertia (mechanical link).The various pools have their own type of strings that unite them to some central

piece or to each other. Obviously only in the case of the mechanical link, do these

connections look like actual strings. In the other two links, they have a form that

cannot be drawn as a link (for instance, strings of information in the neurological

link, strings of trophicity in the vascular link)

From the example of the mechanical mobile, we have seen that when a strain is

applied to a mobile - i.e. a complex of mobile masses linked by strings -, the strain

is absorbed and buffered by the strings or links. We suggest the same applies to a

complex made of neurological parts or vascular parts. Any strain applied to

these mobiles will first and foremost be absorbed by the links. Beyond, they willtear and parts will begin to break down, leading to permanent loss of information

(neurological) or fluid (vascular). We can thus say that in any given articulated

structure, links are generally the point through which strains are absorbed and

buffered. We can qualify our last axiom: links do not transmit integrally the forces

they receive to the internal tissue networks with which they are continuous. Links

have a protective role towards the tissue.

Our model of the three links will allow us to define three categories of strains which

will penetrate the body through their specific link These strains constitute the

etiologies specific to each link and therefore of each of the networks that make up

the tissues of the body.

Mechanical Etiology

All physical forces, all mechanical strains, trauma are absorbed by the mechanical

link between all tissues. A given shock will move one structure with relation to the

other and the tissue that suffers most is the linking tissue. Only when the strain is

important, repeated or constant, will the tissues that are linked be affected in their

own structure (see preceding axiom). Most probably, links absorb minor strains

almost completely, leaving tissues undisturbed.

Neurological Etiology

One of the main types of strain here is obviously psycho-emotional strain. Anxietyis able to literally move neurological relationships (as well as mechanical and

vascular ones, obviously). Another type is metabolic strain which will be recorded

in the nervous system and, through its own links, lead to manifestations at a distance

(for instance, referred pain, osteopathic reflexes etc.)

Fluidic Etiology

A vascular strain will also penetrate through the vascular link. The stress to which

fluids are extremely sensitive - much more than the solids - isgravity. Gravity

determines largely the distribution of fluid masses in the body. Factors that amplify

these tendencies are markedly pathogenic.


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We have thus defined, for the three links, the existence of specific etiologies,

although the connectivity between the three links forbids the drawing of clear lines.

We can only say that the fluid system is more immediately sensitive to gravity than

some bone or some group of well supported neurons. Likewise neurons are more

directly sensitive to emotional difficulties than fluids of the knee. Clearly, however,

any strain will affect all other links with severity or time. Initially only, it can be saidthat specific strains will penetrate in our mobile through the links that are

homogeneous to them.

We will formulate the above in the following axiom:

The body absorbs stresses and strains through the three links, each of the link

absorbing those stresses that are homogeneous to it. Osteopathic lesions occur

when this absorbing and buffering ability is permanently disturbed. Except for

major destructive processes (trauma, infection), the link is always affected

primarily, before the linked structures.

How can we use these notions clinically?

When a patient comes to our consultation with a given symptom, one of the most

crucial questions for the osteopath is: what shall I treat? Practitioners, with time,

acquire diagnostic skills and acumen; they are often able to recognize a given

problem before they examine the patient, from sheer experience.

Such wizzards know that for this type of sciatic pain in this type of patient, the

second cervical vertebral vertebra will have to be adjusted, something that baffles

the young student that may happen to witness the scene.

Before he acquires that skill, a time-consuming procedure, a student or young

practitioner will have to resort to more intellectual solutions, i.e., he will have to use

his wits on what he has learned. I have found that, if for no other reason, the theory

of the three links offers a good initial framework of osteopathic diagnosis andtreatment.

Let us take a simple, common example. A patient comes to our consultation

complaining of knee pain. From his description of symptoms, we can often

determine which link is predominantly affected.

For instance, he says that his pains are only moderately aggravated by knee motion.

Standing still or sitting for a while typically bring on a diffuse pain. He often has

pains at night in bed, whilst lying still. There may also be a feeling of heaviness in

the knee.

We would obviously suspect here a disturbance of the fluid link in the knee

region. The pain syndrome strongly evokes fluid stasis and is aggravated by factorsthat lead to fluid stasis. Treatment will have to concentrate on the vascular system of

the knee: most probably treating the vein/lymphatic drainage of the knee.

Another patient may come with knee pains that are localized in some specific area,

are somewhat aggravated by motion but only at the extremes. The pain comes in

waves and can stay for a long spell irrespective of motion or posture (such as

standing or sitting). Even at times when there is no pain, the patient, with

concentration, can feel some local sensitivity. This clinical picture is strongly

evocative of the neurological link. The pain may be a projected, reflex pain from

some other area or organ (foot, ovary, colon etc.), it can come from a local


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neurological scar (previous disease or physical trauma, surgical scar, somatization

of some psycho-emotional trauma etc.).

Treatment will have to concentrate on the neurological link, something that can take

us far away from the knee.

A third case, will be the common presentation of knee pain mainly upon motion,

and lack of pain at rest. This evokes obviously the mechanical link and should betreated accordingly.

One could multiply examples of this kind for all articulations of the body

(articulations in the wider sense proposed in this text). Most pathologies that come

to the osteopaths office can be integrated, classified within the three links. In many

cases, it certainly supplies us with a framework: what to treat mainly or first. In all

cases, where the lesion is known to be primarily biochemical/genetic, this model

largely fails, as most other therapeutic models do.

Often, however, this simple classification helps to devise the treatment program. We

remember that, according to the principles formulated here, no tissue is out of reach

of osteopathic treatment so long as we has reduced all tissues to their fundamentalnetwork and found their links. So that, if a patient comes with a problem that

seems (or is known) to be due to problems (non-chemical in nature) in some deep

artery, we would be able to reach this artery and adjust it. In other words, problem is

not will we be able to adjust? but what to adjust. In the type of osteopathy we

describe here, unlike the more structural type, it is postulated that every single tissue

of the body can be directly accessed. The limit is then not so much our technique but

our ability to determine what should be treated. This determination is often an

intellectual process, i.e., it requires general medical and specific osteopathic

knowledge, to determine what functions are disturbed in this patient. Again, I wish

to differentiate that from diagnostic skills that stem from the development of the

senses of touch or vision, and which take time and constant exercising. Here, wepropose a working model that allows the practitioner to transform what he has

learned of anatomy, physiology and osteopathic principles into a treatment

procedure.

This can only be achieved through a solid grounding in principles osteopathy and

basic medical knowledge. Although nothing equals diagnostic skill and acumen, it is

my experience that impeccable knowledge and application of principles has time

and again shown that it could help in clinical problems unsolved by intuition and

skill.


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General Principlesof Osteopathic Technique

on the Three Links.

I have proposed so far to distinguish

three fundamental actions of the osteopaths hand three fundamental webs in all tissues three fundamental links between tissues three fundamental etiopathological processes

We have found the strict continuity between all four levels, owing to their common

nature: neurological, fluid and mechanical. The first distinction, the one we used as

a foundation stone of our analysis, dealt with the abilities of the hand of the

osteopath. In other words, it implicitly indicates the possibilities and limits of

osteopathic manipulation. We have already discussed these in general. We can,

however, further refine this initial distinction in the therapeutic abilities of the

osteopathic hand. It is possible, indeed, to classify all osteopathic techniques

according to which link it can work on. Again this classification will not be clear-cut

since the three links are thoroughly interrelated and the hand of the osteopath affects

the three links at the same time when it is laid on somebodys skin. It remains

clinically important, however, to introduce a distinction between the three

links/webs present in our tissues. Let us admit this distinction and let us admit that,

from the pathological standpoint, in a given disease process, one of the three links

has been predominantly affected. It follows then that the osteopath must have, at his

disposition an arsenal of therapeutic

measures specific to that link. In other words, he must be able to apply a measure

that will reverse the etio-pathological process. We are dealing again with a pure

osteopath, accordingly a mythical figure, i.e., one that does not allow himself to

think of any pathology in chemical terms and would not give an anti-inflammatorydrug, potion, homeopathic preparation or diet when confronted with an

inflammation. Such an osteopath would make all possible efforts to find and apply

the irreducibly osteopathic contribution to therapeutics, something that would not

prevent him, for the sake of his patients to work in a team where other approaches

are used in an equally rigorous way. Such an osteopath, having identified through

his interrogation of the patient, through his clinical experience and physical

examination that a particular link has been predominantly affected will have to

apply a technique specific to that link.

For example, a patient comes for a sprained ankle. The articulation is painful and

swollen. The patient sprained his ankle when he strongly kicked a football. This


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piece of information combined with palpatory evidence suggesting that one of the

bones of the ankle joint has been moderately derailed, imposes an obvious

measure: the displaced bone has to be set back to its proper position. The swelling

is secondary. A treatment centered on the fluid link would be rather symptomatic

and, here, the mechanical link is crucial. An orthopedic surgeon who receives a

patient with a dislocated shoulder would certainly not propose as a main course oftreatment ice-packs to reduce the inflammation or a benzodiazepin to allay the

anxiety. He would propose to reduce the dislocation.

In another instance, a lady who would come with pain in the lower limbs due to

poor venous return, an elderly man with pain evocative of arteritis should receive a

treatment centered on the fluid link. The value of ankle or knee manipulation would

be rather doubtful in their case. A more classical osteopath or a chiropractor would

suggest that in those cases, one should treat the mechanics of the spine or the pelvis,

with the hope of affecting the innervation of the blood vessels of the lower limb. In

other words, a vascular problem has been reduced to a mechanical and a

neurological disturbance. At the beginning of this chapter, I have proposed thatalthough it may be clinically effective, this approach is reductive. Indeed, the strong

interrelation of all three links allows us to affect any one or two of them through the

third one. This is an indirect procedure, however, one chosen not by true choice

or principle but by the limitations of the technique used. An osteopath will always

try and reduce the pathology of his patient to what his hands have learned to

achieve. I believe that an osteopathic treatment that will address a chronic sinusitis

or a trigeminal neuralgia with cranio-sacral and vertebral manipulations is better,

more encompassing, than a treatment that will be content with modulating the

innervation of the sinus mucosae through manipulation of the upper dorsal

vertebrae. Chronic sinusitis certainly supposes neuro-vegetative disturbances but

also poor mechanics of the bones that bear the sinuses, poor venous and lymphaticdrainage etc.

An osteopath should thus possess a palette of techniques that will allow to address

directly all the pathologies in which his skills are indicated.

We propose to make a brief review of the main techniques available in osteopathy

and classify them according to their affinity to one of the three links.

Early in osteopathic history, however, a major distinction has occurred between so-

called functional and structural techniques. These two basic forms have reached

such a degree of independence of principles and practice (although they still share

the initial Stillian model) that their affinity for the three links has to be treated

separately.There are a great number of osteopathic techniques nowadays and the distinction

between functional and structural is often blurred. I propose to classify all

osteopathic techniques under these two headings according to the following criteria:

functional techniques are those osteopathic approaches where theintervention of the operator, voluntary or involuntary, is minimal and that of

the patient, voluntary or involuntary, is maximal

structural techniques are those osteopathic procedures where theintervention of the operator, voluntary or involuntary, are maximal and those

of the patient, voluntary or involuntary, are minimal.


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According to these criteria, a technique like muscle energy (authored by Fred

Mitchell Sr. D.O.) would be clearly functional although it implies much voluntary

motion and stretching since that motion is enacted by the patient. Manipulations

(whether thrusts or passive articulatory techniques) are clearly structural since the

operator does all the work and asks his patient to be as relaxed as possible, i.e., as

unobtrusive as possible.We call thrusts those manipulative procedures where the operator applies a

sudden force (or a series of sudden forces) to a passive patient. When applied to

articulations, this often produces a popping noise.

For each of the three links, various specific osteopathic procedures have developed

over time, either structural or functional. Confronted with any given clinical

situation, an osteopath, according to his capacities, his preferences or his formation,

will thus resort to one of the following approaches.

For a full description of each of the techniques, please consult the Year Books of the

American Academy of Osteopathy.

Neurological Link

Functional technique: Hoovers, Bowles and Johnsons Functional Technique,

Lawrence H. Joness Strain and Counterstrain, Fred Mitchells Muscle Energy,

Rollin Beckers Fluid Reciprocal Balance Technique, John Upledgers

Unwinding A. Abehseras Connective Osteopathy.

Structural Technique: all reflexologies (such as Chapmans reflexes). Through its

specificity, a reflex treatment is equivalent to a thrust of the nervous system.

Fluidic Link

Functional technique: A. Abehseras Connective Osteopathy on vessels

Structural technique: all pumping and manual drainage techniques. Thoracic

pump, liver pump, anterior throat pump, thymus pump etc. All these procedures are

equivalent to thrusting the vascular system.

Mechanical Link

Functional Technique: WG Sutherland cranio-sacral and general technique, all

techniques based on the exaggeration of the lesion.

Structural Technique: massage, traction, direct manipulations of all kinds including

thrusts.

I must reiterate that these distinctions are tenuous at best and artificial at worst,

owing to the systematic inter-relationship of body structures. It is clear that thrusts

have an effect on the nervous and vascular system. It is clear also that a technique

like Mitchells Muscle Energy moves the bones and as such has an effect on the

mechanical link. The same goes for exaggerating the lesion techniques. These

very clear overlaps should not make us forget, however, the irreducible specificity of

each technique, and it is in virtue of that specificity that I have proposed this

classification. Thrusts are the most specific way of returning a structure to its

original position, first and foremost a mechanical effect, which will be followed by

neurological and vascular repercussions. Mitchells Muscle Energy is a kind of

neurological reeducation procedure mainly enacted by the patient. Pumping


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procedures are definitely aimed at moving directly fluids and not the bones that may

overly them (e.g. the ribs in case of the thoracic pump). Exaggerating the lesion

techniques definitely use a mechanical terminology in their procedure. The bone

or articulation has to be moved in a certain direction for the release to occur. The

classification is less obvious in techniques such as R. Beckers Reciprocal

balance, Upledgers brand of unwinding technique and the the present authorsConnective Osteopathy. Their functional nature is obvious, their affinity is less so.

I can only speak clearly for Connective Osteopathy , and I believe that it is the

only functional approach for the fluid link since it allows the specific treatment of

any blood or other fluid-carrying vessel. Regarding this particular approach, there is

however an inconsistency in the criteria used for distinguishing functional from

structural technique. Indeed, in this approach, it looks like the operator is

intervening in a minimal way, leaving the patients tissues to do the corrective work.

This is only correct part of the times since, when the operator makes a surgical

procedure in his visualization field, he is indeed very active although an observer

would see no motion. In other words, at times, what looks like a functionaltechnique is actually a structural one in its principles.

As a pedagogic guide to osteopathic practice, the above classification seems fairly

correct. If we associate what we have discussed on etiology and technique, we

see that the practitioner may, from his diagnosis and understanding of the etiology

of his patients problem, choose the technique that is homogenous, first to his taste

and capacities, and second, to the affected link(s).

Obviously, we will not develop here the use of techniques such as structural or

cranio-sacral osteopathy which have been abundantly described elsewhere. The

specificity of the type of osteopathy we are interested in developing here over the

other techniques mentioned in our classification is clear: connective osteopathyallows for a highly specific anatomic approach, meaning that we can reach and treat

any anatomical structure directly, something not generally possible with most of the

other techniques which, often, are either indirect or incapable of treating a too deep

or too small anatomical structure. This specificity stems from the simples principles

we have formulated until this point: all parts of the body, whatever their size, depth

and texture are accessible to osteopathic treatment as long as

we reduce tissues to the three substances which our hands can affect we reduce all possible links between tissues to the three that our hands can

affect

we reduce all etiologic factors to the three that our hands can affectWhen the patient comes with a specific complaint, the above principles will be

applied in the following axiom:

Confronted with any pathology - known to be treatable by osteopathy - the

therapist will ask himself the following question: what links the organ or tissue

that suffers to the rest of the body from a neurological, fluidic or mechanical

point of view?

We suppose again that it is not the tissues themselves that are primarily affected but

the links. Since the links are continuous with the internal webs of all tissues, a

treatment of the links will extend into the tissues. The main lesion process, however,


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or better, that part of the lesion process that is the indication of osteopathic

treatment is the link and its extension as the internal web of the tissue, but not the

cellular substance of the tissue.

Let us take two examples, a medical one, chronic sinusitis, and a surgical one, anal

fistulae. These are commonly encountered in practice, making useful pedagogic

examples.

Chronic sinusitis

The osteopath, as an individual or as part of a team, is asked to offer his contribution

to the treatment of a patient with chronic sinusitis. We suppose that all other

etiologic factors are taken care of (smoking, poor diet etc.). We are left with having

to make a pure osteopathic analysis.

We are not interested here in the exact details of diagnosis or of etiology (allergy,

infection from an apical granuloma, tooth,etc.). We are interested in devising an

osteopathic treatment to the sinuses that are affected, whatever the reason. The firstquestion that we must ask ourselves is: what structures link the symptomatic

sinus(es) to the rest of the body. The information derived from this question must be

separated into three categories:

all the connective tissue structures that unite the sinus (es) to its neighboringtissues

all the nerve fibers that unite the sinus(es) to the rest of the body all the vessels (blood, lymph or other) that drain or irrigate the sinus(es)We consider that these "links" are the weak points through which pathology has

settled in the sinuses and they must be our initial target for treatment. The

classification above has produced three "boxes of information", each box having its

own types of etiology and osteopathic procedures.

The mechanical link is naturally affected by physical trauma in which one (or more)

of the sinuses have been slightly but significantly displaced or immobilized (blow,

falls, tooth extraction etc.). The fluid link is naturally affected by poor drainage and

irrigation in the anterior throat and superior thoracic inlet. The neurological link

would be affected by nociceptive stimuli coming from many centers, neurological

and visceral. Again, the inter-relationships between all these links is marked and

will not be developped.

The interrogation of the patient may bring out clearly one of the etiologies above:

the sinusitis began after a period of intense dental treatment, after a hepatitis, after a

period of recurring throat infections.Often, even most often, no clear etiological factor may be brought to light.

Frequently, for example, the therapist is confronted with a person who is a heavy

smoker and/or suffers from chronic upper respiratory tract allergies since he was a

young child. In all of these cases, particularly in the case of the smoker who has no

intention of stopping to smoke, we are left with the necessity to treat directly,

osteopathically, i.e., to evaluate and balance the anatomical relationships of the

patient's sinus system. Relieving the sinuses of a heavy smoker may sound like a

useless or even unethical act in the long run since we are actually making it easier

for him to continue indulging in his habits. I certainly do not agree with this kind of

thinking and every therapist should advise his patient as to what is best in the long


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run but, at the same time, he owes him the best symptomatic treatment he can offer,

so long as it is given ethically.

The three "boxes" we have just created thus contain facts of etiological relevance -

sometimes not - but mainly anatomy, i.e., anatomy of the three links. An anatomical

picture can be read as a description of relationships (links) and as such, of weak

points. These anatomical facts can be immediately transformed into osteopathictechniques. In other words, the path taken by an artery or a nerve, the structures that

surround it during its path supply me with the necessary information as to

where I should lay my hands, for instance, at both ends of its path what my visualization will consist ofDefined in the broadest possible way, osteopathic technique is the application of my

hands or my visualization on every one of the relationships that make up anatomical

structures.

Anatomical textbooks are thus my primary osteopathic technique textbooks. They

contain as many osteopathic techniques as there are relationships ("links") in the

body.I am returning to a fundamentally Stillian approach of osteopathy, since the Old

Doctor used to say that osteopathy is only anatomy and more anatomy. An

osteopathic student should thus consider that his first and foremost osteopathic

technique texbook is his anatomical textbook and that he should be able to derive

alone the necessary techniques for sinusitis or any other pathology for which

osteopathy is an indication by carefully studying anatomical drawings.

We will formulate this in the following axiom:

An osteopathic lesion is primarily a lesion of the three links. Osteopathic

technique must aim at restoring mobility to the lesioned three links. Anatomical

textbooks give the detailed description of the three links. Anatomical textbooksmay thus be read as osteopathic textbooks, i.e., every anatomical relationship is,

potentially, an osteopathic technique.

Let us return to the treatment of sinusitis and try and apply the above axiom for each

of the links.

Neurological link

Looking at an anatomical description of the sinuses, two sets of nerves will draw our

attention

the Vth cranial or trigeminal nerve

the cervical and stellar plexuses in the neck and upper dorsal regionThe pathway of these nerves will have to be treated as well as some of their key

structures. For instance, for the trigeminal nerve, a key point is the ganglion of

Gasser that lies on the petrous portion of the temporal bone. For the cervical and

stellar plexuses, the anterior tissues of the neck, the domes of the pleura, the various

vertebral articulations will have to be treated, thus addressing the mechanical

aspect of the neurological link. For the neurological link proper, reflexes to the sinus

area can come from as far below as the gall-bladder, the liver or even the uterus.

Fluidic link


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Again, our treatment will deal with the mechanical aspect as the fluidic aspect of

that link. Anatomic textbooks will show us the venous and lymphatic drainage of

the sinuses and all the mechanical structures that may prevent proper circulation in

them. In sinus pathologies, it is not so much the arterial supply which is at fault as

the fluid drainage, since sinusitis is, almost by definition, accompanied by

congestion, oedema and thickening of the mucosa. The direct work on the fluid linkwill consist in encouraging flow along the drainage routes.

Mechanical link

Whilst looking at an anatomical textbook, the question will be: what are the

mechanical links of the sinuses to the rest of the body? The most obvious answers

will be: the various articulations of the cranial bones that contain the sinuses: the

ethmoid, the sphenoid, the frontal, the maxillary bones. Beyond these bones, various

fascial bands or ligaments relate the sinuses to higher and lower structures (e.g. the

stylohyoid ligament, the muscles that insert on the hyoid bone and beyond etc.

In other words, as soon as I have asked myself the question as to what relates the

sinuses to the rest of the body, three boxes of information appear: neurological,

vascular and mechanical relationships. Each of these relationships can be visualized

and thus transformed into an osteopathic technique. A systematic treatment, one that

will use the information from all three boxes, may be considered as a thorough

osteopathic treatment of the sinuses.

At first sight, this approach seems to turn every treatment into a formidable task

since it proposes to relate, ultimately, all parts of the body to the sinuses. In theabsolute, this is true and it should be so since the body is an organism made of

highly interrelated parts. We may thus find, in a given patient, that the pain and

congestion will respond best to the treatment of the mechanical link between the

colon and the left frontal sinus, or the neurological link between the right maxillary

sinus and the uterus. Generally, we need only treat the local three links. The more

distant and unusual link will be resorted to when there is a clear clinical indication

of a particular relationship (the sinusitis began a month after I had my gall-bladder

removed ) or when, with experience, the operator finds that his hands are drawn

towards some distant organ6.

Quite often too, there is no clear etiological indication or one that is extremelygeneral (such as smoking in the case of sinusitis). In those cases, we can simply go

through the three links, one after the other. As mentioned above, we first treat the

link itself (for instance the Vth nerve) and then its extension into the tissues that are

linked (the medullary centers of the Vth nerve in the brain stem, the mucosa of the

sinuses and, through their innervation, any organ that is linked to the sinusitis). We

remember that the link and the network inside the organ are continuous. A recent

and moderate lesion will basically affect the link, whereas the older and the greater

the amplitude of the lesion, the more involved the linked tissues themselves will

be.For instance, in a recent trauma of the knee, we suppose that, at the beginning,

6This is part of diagnostic procedures, a subject to be discussed further.


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the strain will concern mainly the ligaments that link the tibia and femur. With time,

the lesion pattern will penetrate progressively deeper into the actual bones of the

tibia and the femur, reaching, with time, all the way down to the foot and all the way

up to the hip and beyond.

The elements of time and amplitude of the causing stress play also an important role

in the degree of involvement of the three links. As we mentioned above, a recentlesion tends to implicate one link (the one through which the disturbance has

penetrated the body), but with time, all three links are implied. This means that,

when confronted with well entrenched pathologies like chronic esophagitis,

sinusitis, prostatitis or cystitis, the osteopath will find it useful to resort to the

treatment of all three links as a matter of routine.


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Practice of Connective Osteopathy I

Rollin Becker DO

Listening Technique

At the very beginning of this course, I conveyed to you the difficulties posed by

teaching the type of osteopathic practice we had set out to learn together. The main

difficulty lies in the fact that it is, at least at first sight, a completely subjective form

of practice, i.e., there is no technique involved. Whether we use our hands or not,

no actual manipulation occurs. The actual treatment is enacted in the mind of the

operator and whether he treats this or that pathology, this or that anatomical

structure, the operator is never seen moving, doing something with his hands.

Teaching such a form of therapy comes down to teaching how to think in an

effective way. How does one teach someone else how to think ? Apart from theethical dangers involved, the pedagogic challenges are immense. I therefore

suggested, at the beginning of the course, that I will take a historical approach, i.e.,

that I would take you step by step through the various stages that led me to such a

practice.

We have so far surveyed the theoretical background, i.e., we have dissected the

various theoretical elements that fed and inspired osteopathic practice in general and

my own practice in particular. We have now to dissect the practical background, i.e.

the actual technical approaches from which I derived connective osteopathy. This

will be achieved through a progressive series of exercises.

The first series of exercises will be hands on, followed by a second series of

hands off exercises.

Some Biographical Notes

Before we proceed with these exercises, I wish to give their biographical

background. This will allow us to pinpoint as precisely as possible the location of

this approach in the map of osteopathic practice.

My initial practice of osteopathy, that of my early student years, was so-called

structural osteopathy. As I mentioned before, in my late student years (3rd and 4th),

I was exposed to other approaches. I can see two reasons for my early rejection ofstructural osteopathy and my search for other approaches:

there seemed to be a large disparity between the art of Medicine, in general,with all its wealth of information in human pathology and the osteopathy we

were taught. For most pathologies, the same basic corrective mechanism

was suggested: manipulating such and such a vertebra. The manipulation of

D4 and D5 for instance was the choice measure for the treatment of all

cardiac and pulmonary diseases. These limitations seemed to be vindicated

by the scope of osteopathic practice: back pain seemed to make up 90% of

osteopathic consultations. In other words, osteopathy claimed it was a

general medicine but was actually practiced as a highly specialized system.

In practice and in principle, it seemed to fall short of its ideals.


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there seemed to be a major problem of objectivity in the practice ofstructural osteopathic technique. I was never convinced that two structural

osteopaths can find the same lesions on the same patient. Structural

osteopathy is grounded on the assumption that the body is made of matter

and, as such, it can be measured as an object, i.e. objectively.

The trained osteopath is he who can feel the objective state of, for instance,intervertebral relationships. Although possible in principle, I could never

achieve myself any measure of agreement with my colleagues, probably a

reflection of my incompetence, but neither could I see such agreement

amongst others. It became clear to me, then, that the subjective element in

osteopathy was paramount and that osteopathic technique should be

grounded

the three links

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