unified osteopathic field theory - academy of...

Biomechanics of the Unified Osteopathic Field Theory

Clarence L. Nicodemus, D.O., Ph.D. (with inspiration and contribution by Ken Lossing, D.O.)

AAO Convocation Louisville, KY

March 22-23, 2012

Examine the components:

“Osteopathic Field”

“Unified”

“Biomechanics”

Biomechanics of the Unified Osteopathic Field

March 22-23, 2012 C. L. Nicodemus, DO, PhD

2

It all starts with Dr. Still. He was:

An original

Unique

Creative

A Visionary

Correct

“_____________________________________”


3

The “Osteopathic Field” Commonly “Taught”

Approaches HVLA Muscle Energy Myofascial Release Strain/Counterstrain Soft Tissue Lymphatics

4

“Other” Common Approaches • Balanced Ligamentous

Tension and Ligamentous Articular Strain

• Facilitated Positional Release

• Osteopathy in the Cranial Field

• Progressive Inhibition of Neuromuscular Structures

• Functional Technique • Visceral Manipulation • Still Technique • Chapman’s Approach • Fulford Percussion • Energy


Chila, Anthony. Foundations of Osteopathic Medicine, 3rd Edition. Lippincott Williams & Wilkins, 2010

Unified Field Theory

Einstein's attempt to unify the General Theory of Relativity with electromagnetism

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Wrong Field Theory

Unified Osteopathic Field Theory

All theories of manual medicine are based on manipulating the same basic human tissues.

Further, all human tissues exhibit the same fundamental biomechanical property, namely, viscoelasticity.

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Many different aspects/models

Fascial Model- Distensability, tested with motion testing and fascial pull.

Fluid model- circulation, tested with doppler ultrasound, perfusion studies, or palpation.

Neurological Model- electrochemical information, tested with palpation and motion testing, EMG.

Biomechanical Model- Inherent and induced-Tested with palpation, ROM, sensing

Energetic Model- temperature changes, electricity, etc….

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What is common among these approaches?


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Commonly “Taught” Approaches HVLA Muscle Energy Myofascial Release Strain/Counterstrain Soft Tissue Lymphatics

“Other” Common Approaches • Balanced Ligamentous

Tension and Ligamentous Articular Strain

• Facilitated Positional Release

• Osteopathy in the Cranial Field

• Progressive Inhibition of Neuromuscular Structures

• Functional Technique • Visceral Manipulation • Still Technique • Chapman’s Approach • Fulford Percussion • Energy

Hands and Tissues (and more)

It is called Manipulative Medicine because hands manipulate tissues

We also engage our mind, energy, intuition, spirit

It is very difficult to measure the latter

So we focus on the former


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Biomechanics

“the application of mechanical laws to living structures.”

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Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc.


Fundamental Biomechanics Review

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Histology of Connective Tissue

March 22-23, 2012 12 C. L. Nicodemus, DO, PhD

Ken Lossing, D.O. personal correspondence

Origin and Classes of Connective Tissue

March 22-23, 2012 C. L. Nicodemus, DO, PhD 13

http://classes.midlandstech.edu/carterp/Courses/bio210/chap04/

Molecular Structure of Collagen

March 22-23, 2012 C. L. Nicodemus, DO, PhD 14 http://classes.midlandstech.edu/carterp/Courses/bio210/chap04/

•Elongated •Linear

Other Components


Loose, areolar Connective Tissue


Loose, adipose Connective Tissue


Loose, recticular Connective Tissue


Dense, regular Connective Tissue


Dense, irregular Connective Tissue


Types of Connective Tissue

21 March 22-23, 2012 C. L. Nicodemus, DO, PhD

Ken Lossing, D.O. personal correspondence

Fascia The fascia is a loose, areolar connective tissue

composed of:

collagen-( literally glue –making) 14 types , most common is type 1 (90%)

ground substance

fibrin

Elastin- maintains the tensile strength of connective tissue

The collagen fibers are connected to other collagen fibers through chemical bonds.


Effects of loading

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Collagen Structure

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Muscle Fiber Structure

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Terminology

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terminology [tur-muh-nol-uh-jee]


Strain and Stress

Strain: is a measure of the degree or intensity of deformation. Elongation per unit gage length. Units of strain – mm/mm, in/in STRAIN = ΔL/L

Stress: force per unit area, may be shear stress, tensile stress, or compressive stress. Units of stress- N/m2 (pascal), dyn/cm2, lbs/in2. STRESS=F/A

Shear stress is a “cross fiber” action. Units of stress- N/m2 (pascal), dyn/cm2, lbs/in2. SHEAR STRESS = F’/A

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Elastic Deformation

IDEAL or PURELY elastic

Stress > PE > KE

E= elastic modulus = Δ stress/Δ strain

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Stre

ss

Strain

Strain

E

1

loading unloading


Think rubber band

Ken Lossing, DO

Real Deformation

Stress > PE > KE + H

H = Heat loss, fluid motion, molecule structure

The area in the hysteresis loop (H) represents the energy dissipated as heat during loading and recovery and the work done in mechanically altering fibrin and collagen structures.

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Stre

ss

Strain

loading

unloading H


Ken Lossing, DO

Actual Data for a Tendon (rat)

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Repetitive cycles change the response

10 cycles = stable


http://www.engin.umich.edu/class/bme456/

Creep and Hysteresis

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? Hysteresis??


Creep I

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Creep II

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Viscoelasticity

having viscous as well as elastic properties

a combination of viscous and elastic properties in a material, with the relative contribution of each being

, , , and . [and

]

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Actual Data for a Tendon (rat)

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Repetitive cycles change the response

10 cycles = stable



Fluid - Viscosity Stress > HEAT only

Each fluid has a “coefficient of viscosity”.

The higher the coefficient of viscosity, the thicker the fluid.

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Stre

ss

Strain

N=coefficient of viscosity

1 N


Ken Lossing, DO

Viscosity


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Catsup

Peanut Butter

OR

Viscoelastic change Resulting stress is not

only a function of strain, and temperature, but also the strain rate, in other words the speed at which a load ( strain) is applied will affect the amount of stress in the tissue. This is called “time dependant material behavior”.

Rhythm of the tissue!

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Strain

Stre

ss

Increasing stiffness


Ken Lossing, DO

Strain Rate

Temperature


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Creep and Hysteresis

When a load (stress) is applied to a viscoelastic material, molecular bonding is re-arranged and thus the material elongates or “creeps”.

As the re-arrangement occurs, a back-stress develops. When the back stress matches the applied stress, creep stops.

When the load is released, the back stress returns, the original length returns (with losses of energy due to the heat of mechanical re-arrangement). This is hysteresis.

Visco = creep; Back stress return = elastic

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Viscoelasticity

having viscous as well as elastic properties

The property of a substance of exhibiting both elastic and viscous behavior, the application of stress causing temporary deformation if the stress is quickly removed but permanent deformation if it is maintained

a combination of viscous and elastic properties in a material, with the relative contribution of each being dependent on time, temperature, stress, and strain rate. [and electrical field]

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Full Tendon Stress/Strain Curve

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A = Relaxed (Elastic) B = Operating (Hysteresis) C = Overload (Plastic) D = Failure E = Rupture



Stre

ss

Strain

Elastic Deformation A strain applied to a tissue will

result in a stress in the tissue

P=Proportionality limit-linear until then, and loading is matched with unloading

E=elastic limit

Y= yield strength, considerable elongation occurs without corresponding increase of stress

PD= Plastic deformation area

U=ultimate strength

R=rupture

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Strain

Stre

ss

P E

Y

U

R

Strain

unloading

PD


Ken Lossing, DO

Plastic Deformation A stress load that is

larger than the yield strength of a tissue will cause a plastic (or permanent) deformation.

The whole curve changes.

The plastic deformation will remain unless something changes it.

Sounds like a visceral dysfunction!

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Strain

Stre

ss

P E Y

U

R

Strain


Ken Lossing, DO

PD

Summary


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Pizoelectricity


Force Effects in Connective Tissues •Elastic Deformation •Plastic Deformation •Viscosity •Stress •Strain •Creep •Hysteresis •Temperature •Density

Pizoelectric properties of Collagen Transducer (Stress > Current > vibration)

Biphasic signal (- load, + release)

Stress related signal (Current α Stress)

Stimulates osteocytes (- charge)

Stimulates and directs the migration of electrically sensitive cells (chemotaxis)

Activates cells (electro-sensitive cells)

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Acupuncture is a pizoelectric fascial phenomenon.


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Now look at applications

Visceral

Mechanical


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Visceral (Broad) Ligament


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Sacral Ligament

VS

Comparison of Young’s Modulus

March 22-23, 2012 C. L. Nicodemus, DO, PhD 50

0

200

400

600

800

1000

1200

1400

1600

0 5 10 15

Fascia Tendon

E = 150 MPa

E = 1500 MPa

As Applied to Visceral Dysfunction

Constantly applied loads on visceral ligaments and fascia will have caused them to maximally elongate and to stiffen as a result of the molecular re-arrangement.

Releasing the cause of the chronic loading by re-balancing muscles, reducing joint restrictions, and balancing fascial strain patterns, internal stress of the tissues is reduced.

Reduction of the internal stress and stiffness causes release of constrained fluids held with in, such a lymph, venus and arteriol vessels.

Circulation returns, pain is reduced, and function returns.

Temperature changes occur; heat of inflammation is reduced, heat of circulation is increased, and heat of tissue molecular re-arrangement is increased.

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Visceral Dysfunction

“Impaired or altered mobility or motility of the visceral system and related fascial, neurological, vascular, skeletal, and lymphatic elements”. American Osteopathic Association Glossary, 2011

This is reflected in abnormal motion tests, showing a change in the distensability of the attachments, or a change in their normal viscoelasticity.

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SO,(to quote Dr. Lossing):

If there is a visceral dysfunction, the ligament has a certain amount of strain stored (potential) energy- “potency”, in a certain direction, and that tissue has a certain strain rate (speed) that it will respond to. This results in an altered viscoelasticity curve for that ligament. ( The viscosity is more, the elasticity is less).

When the internal strain is exactly matched, by application of force, direction, and speed, the tissue will change. Increasing the fluid exchange should accelerate the change. In the process there is a dissipation of heat, movement of fluid, and a restructuring of the elasticity curve.

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Multiple strains The body generally

accumulates many strains over a life time. The strain takes a certain amount of force to hold it there, exerting tension into the fascia. The one with the most force will have the biggest effect on the fascia.

Therefore, removing the biggest strain will have the largest effect on the body

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50

20

30

10


Ken Lossing, DO

Lines of tension

Liver-superiorly-coronary, triangular and falciform ligaments to resp diaphragm- inferiorly- right kidney

Right kidney, colon

iliacus and psoas

Pancreas can affect whole peritoneum, duodenum, both kidneys, stomach, etc..


Ken Lossing, DO

Visceral Dysfunction, a Plastic Deformation

A stress load that is larger than the yield strength of a tissue will cause a plastic or permanent deformation.

The area under the graph represents therapeutic gold, the potency of the stored charge.

The distensability of the tissue is changed

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Strain

Stre

ss

P E Y

U R

Strain

Potency


Ken Lossing, DO

Ligaments and Fluid Shift With minimal additional

mechanical tension in ligaments, the first fluid vessels to be compressed (compromised) will be those of lowest pressure, the lymphatic vessels- relative edema, retention of metabolic byproducts.

With increased tension, comes venous congestion, increased retention of metabolic byproducts

and with more tension comes arterial compression- decreased nutrition, oxygen, and eventual death.

“obstructive lymphedema” - Robbins Pathologic Basis of Disease 57

Artery Vein

Lymph vessel


Ken Lossing, DO

Nerve

Neurovascular Bundle

Barriers

Physiologic Barrier: the limit of active motion.

Anatomic Barrier: The limit of motion imposed by anatomic structure: the limit of passive motion. Neutral: The point of balance of an articular surface from which all the motions physiologic to that articulation may take place


Ken Lossing, DO

Mechanical

End feel

Tightness

Bogginess

Hypertonic

Stiff


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Motion testing Elastic Barrier:

The range between the physiologic barrier and anatomic barrier of motion in which passive ligamentous stretching occurs before tissue disruption.

If we move a ligament to its physiological barrier, it removes any slack in the ligament and starts to engage the elasticity of the ligament At this point, we are still below the elasticity limit of that tissue.

When we remove the straining force, the ligament returns to it’s original configuration- an elastic deformation.

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This Applies to the whole body

Embryology, Histology , Gross anatomy, micro anatomy.

Ear, nose and throat

Visceral System

Lymphatic system

Nervous System

Endocrine system, immune system

Musculoskeletal System

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Summary

Therefore, we need to expand our vision of osteopathy, to have the same vision as Dr Still.

All problems/symptoms that a patient experiences may have a functional component that is treatable.

Most of how we diagnose and treat is a function of its viscoelasticity….

No matter which dysfunction or treatment model we use.


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A very unifying idea!

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Niles, Superdog

Thank you! Any questions?

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