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©Elsevier Ltd 2007. All rights reserved.

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Notice
Neither the Publisher nor the Author assumes any responsibility for any loss or injury and/or
damage to persons or property arising out of or related to any use of the material contained in
this book. It is the responsibility of the treating practitioner, relying on independent expertise
and knowledge of the patient, to determine the best treatment and method of application for
the patient.
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Printed in China
 vii

Forewords

I have known Caroline for 20 years, initially as a Visceral manipulation permits patients to feel
postgraduate osteopath learning visceral manipu- better in their life and it is something that
lation, and later as someone who has enabled many osteopaths must include in their evaluation of
other osteopaths to grow and develop. I have seen patients and their dysfunctions. In particular,
her evolve as a practitioner and as a teacher of vis- osteopaths have a special contribution to make in
ceral work and the osteopathic approach in gen- the field of gynaecology and obstetrics. To help a
eral; in bringing this to the broader profession, woman to have a child and for her to achieve this
she has made an indispensable contribution to in the best conditions is a chance that should be
osteopathy. open to all. We have certain unique keys to
As soon as we met, I felt she had very good improve factors around fertility, pregnancy and
hands and that she would do something special in delivery, and it is our duty to do it, as health and
the visceral field; indeed, she has made many function can be subtly but powerfully influenced
important contributions to the profession’s under- by the osteopath’s gentle, and knowing, ‘listening’
standing and appreciation of visceral manipula- touch.
tions within osteopathy, and how to help patients I commend this book to anyone wanting a
on many different levels, accordingly. deeper understanding of the osteopathic approach
In her teaching, Caroline integrates many dif- to healthcare, and applaud Caroline on her con-
ferent components and brings alive the concepts tinuing dedication and contribution to osteopathy.
of three-dimensional biomechanics in her inclusion
of visceral tensions, torsions and dysfunctions.
Just as importantly, she reveals the interaction Grenoble 2006 Jean-Pierre Barral
between anatomy and physiology, thereby illustrat-
ing how soft tissue, organ, fascial and other tissue
tensions can impact on homeostasis, function and Churchill said, ‘I always avoid prophesying
recovery from pathology and injury. This helps beforehand, because it is a much better policy to
osteopaths to approach the management, not only prophesy after the event has already taken place.’
of patients with musculoskeletal symptoms, but I wish hindsight were my assigned task; however,
also those with more complex visceral dysfunc- I was asked to write a ‘foreword’ and not a ‘back-
tions and disorders. This book is important for all word’. In concluding this foreword, therefore, I
those wishing to appreciate and incorporate work decided to be somewhat bold in my assessment of
within the visceral field to their osteopathic practice. this book. Please read on to understand why.
It will also help to guide those outside the profession My global foreword is simply this: Visceral and
towards an understanding of the osteopathic Obstetric Osteopathy is a valuable, clinically applicable
approach to patient care. text written without pretence. In it, the author easily
viii FOREWORDS

communicates her clinical expertise by translating are taught and valued. Interestingly, these
static anatomy into a palpable experience. reservations were not felt outside of the
Techniques are clearly and concisely written and Introduction. My overall summary: this part
follow directly from their anatomical descriptions. of the book is of an easily read, simplified
The elegance of the technique presentation in this discussion of commonly and less-commonly
book lies in the simplicity of the diagrams used to used osteopathic approaches constituting a
summarise them. nice background for the rest of the text.
Chapter details in this foreword could be broadly ■ Overview of individual systems (Chapters 4–8).
painted because there is a clarity in the overall This is the essence of the text and the reason
structure of the book. There are three parts to this to own it! Building on clear anatomic descrip-
book: (1) The Introduction and first three chapters tions, the simple-yet-elegant diagrams facilitate
are basically overview materials; (2) Chapters 4–8 acquisition of these often under-appreciated
are visceral-system specific and literally constitute clinical techniques. These are not chapters
the heart of this text; and (3) Chapters 9–10 contain written to validate the approach, rather they
the author’s clinical application perspective. are careful, clear descriptions of how to man-
ually contact and balance anatomy. For prac-
■ Introduction and Chapters 1–3. Don’t judge titioners wishing to learn for themselves the
the value of this text by its overview alone. value of integrating such techniques, this is
Aware of the impossibility of writing the place to start. While the sections are not
overview materials to please everyone, the exhaustive in their overall scope to influence
author wisely and simply states her perspec- visceral function (e.g., sternal techniques were
tive. The result is an interesting synopsis of absent and viscerosomatic approaches were
concepts and clinical-approach models as superficially addressed), the author’s intent
understood and/or postulated in her train- was fully met. The text excels in presenting
ing as an osteopathic professional. There is the manual approach to the viscera them-
little attempt to convince any healthcare selves in an unambiguous and complete fash-
practitioner (osteopathic or otherwise) with ion. Finally, I would also be remiss if I did
outcome studies about the value of upcom- not praise the author for including arterial,
ing techniques … but then that was never her venous and lymphatic vasculature as approach-
stated purpose. Note that the Introduction is able visceral structures.
clearly written from the perspective of a ■ Patient management: visceral and obstetric.
practitioner whose medical education and The last two chapters of the textbook were
permitted scope-of-practice are more limited clinically delightful and particularly appeal-
in her own country than in the USA. I there- ing. Some patient management scenarios
fore felt occasional reservations about the suggested much more care than I currently
historical or clinical perspectives presented. provide (or would have been willing to have
There are significant differences in American considered prior to reading this text); some
and non-American applications of osteo- scenarios suggested much less osteopathic
pathic care in part because ‘osteopathic med- care than I thought could be done and her
icine’ in the United States is practised by description didn’t change my opinion about
more than 60,0001 complete physicians, includ- what I would do for my patients; and many
ing D.O. obstetricians and gynaecologists, scenarios I secretly applauded because I felt
internists, and family medicine specialists. we would have managed that patient with
Osteopathic medicine is therefore a much that condition in exactly the same fashion. As
less ‘contentious’ word in the United States, a clinical educator, the key appeal to this sec-
where residencies exist in these and other tion is that the scenarios that I interpreted as
fields, including NMM/OMM (neuromuscu- too much, too little or ‘just right’ are unlikely
loskeletal medicine/osteopathic manipula- to be the same ones that the reader identifies.
tive medicine) where many of the visceral Such food for thought can only serve to help
and homeostatic concepts noted in her text us to ‘dig on’ in our clinical understanding
 Forewords ix

and to evolve in our respective arts and In conclusion and in my opinion, Visceral and
practices. Obstetric Osteopathy has the potential to be an
instrument of reformation … if not of a profession,
That brings me back to my foreword’s ‘brave’
at least of one practice at a time.
prophecy that this text has the potential to positively
Osteopathic founder, A. T. Still, M.D., D.O.
reform the healthcare we provide our patients.
said, ‘Know you are right and do your work
■ ‘Reform must come from within, not without.’ accordingly.’ In sharing anatomic fact and her
As an osteopathic practitioner, I thank clinical perspective, Caroline Stone has con-
Caroline Stone for this contribution to the structed a text that empowers the reader to con-
osteopathic profession. sider that possibility.
■ ‘Reform, that you may preserve.’ As someone
who has had a successful practice for over Michael L. Kuchera,
25 years, I thank this book for continuing to Philadelphia 2006 D.O., FAAO2
remind me to integrate new (and/or redis-
covered) science, philosophy and art into my
practice.
■ ‘If you try to make a big reform you are told you 12006 figures. Osteopathic medicine is the
are doing too much, and if you make a modest fastest growing segment of healthcare providers
contribution you are told you are only tinkering in the USA so numbers will increase significantly
with the problem.’ I don’t believe reform was after publication of this text.
on the author’s mind at all. Nonetheless, 2Dr Michael Kuchera and his father, William

intentionally or not, as an outside reviewer Kuchera, are also the authors of Osteopathic
and educator I want to go on record as saying Principles in Practice and of Osteopathic Considerations
that this book strikes a happy balance to do so. in Systemic Dysfunction (Greyden Press).
 xi

Preface

Osteopathy is a great profession, and I have been approaches in the visceral and obstetric fields of
very happy to help actively promote and develop osteopathic healthcare.
it over the past 20 years. Establishing a firm basis Some of the techniques and approaches dis-
and enthusiasm for the practice of visceral cussed in Chapter 10 ‘Osteopathy and obstetrics’
osteopathy has been a huge part of my profes- may be subject to practice restrictions in the UK.
sional life; of this I am very proud. Osteopathic Readers and practitioners are advised to check
care for pregnant women and patients suffering current legal boundaries for practice in their
from a wide variety of ‘visceral’ problems need region/location. Their inclusion in this book does
not be complex or confusing. This book aims to not in itself infer practice rights.
help all practitioners, regardless of their individ-
ual approaches to patient care, to appreciate a
range of basic, advanced, subtle and integrated Mount Lawley 2006 Caroline Stone
 xiii

Acknowledgements

In writing this book, I would like to thank the and helpful comments. Thanks also to Claire Wilson
following people who have all helped in a number and Gail Wright at Elsevier for their efficient and
of ways: Ray and Catherine Power for help with friendly work on this book.
illustrations; Julie Peipers for support; Amanda I would most like to thank my husband, Brad,
Heyes for lots of care, comments and treatment; and for his love and enthusiasm for this project, and our
other colleagues who have attended recent courses beautiful daughter Jasmine for her self-sufficiency
and offered great feedback. I would also like to and patience! Love also to our second child, who
thank Anne Cooper and Jenni Paul for their insights will arrive as this book nears publication.
 1

Introduction

CHAPTER CONTENTS Considering the whole 5

Where is the problem? 7
Basic concepts of visceral and obstetric
Tissue awareness and interpretation 7
osteopathy 1
Overview of patient assessment 7
Visceral osteopathy 2
Obstetric osteopathy 2 Basic components of visceral osteopathy 9
Osteopathic medicine 3
Points to remember in visceral osteopathy 9
Definitive osteopathic tenets 4
About this book 10

The field of visceral and obstetric osteopathy is not ■ postpartum pelvic problems, including
new but is increasingly popular and relevant in pelvic floor injuries
current patient-oriented healthcare systems in ■ headaches and TMJ pain
which the body’s inherent self-regulating and self- ■ ENT problems
healing mechanisms are increasingly recognized ■ developmental, feeding, sleeping and other
and valued therapeutically. problems in babies and children.
Osteopaths themselves are also keen to maintain
Any or all of the above problems may benefit from
and develop their scope of practice and as general
the application of visceral osteopathy, even if the
and professional awareness of the potential of
symptoms arise within the musculoskeletal system
osteopathic care is reawakened, practitioners are
(and the patient has no accompanying visceral
more enthusiastic than ever to explore the human
symptoms or disorders). In other words, although
dynamic in increasingly three-dimensional and
a visceral approach can be used when patients
integrative ways.
present with visceral symptoms, it is also helpful
Osteopaths see a variety of patients complaining
when there are only musculoskeletal symptoms of
of many problems, including but not limited to:
biomechanical origin.
■ low back and neck pain
■ repetitive work-related injuries or strain
■ effects of trauma such as whiplash BASIC CONCEPTS OF VISCERAL AND
■ asthma and other breathing problems OBSTETRIC OSTEOPATHY
■ colic and irritable bowel syndrome
■ postoperative pain and adhesion problems Visceral osteopathy is a way of exploring those
■ back, joint and soft tissue pain during tensions of the body that reside within the organs
pregnancy and associated tissues, with the aim of improving
2 VISCERAL AND OBSTETRIC OSTEOPATHY

overall movement, lessening any barriers to better For most patients and presentations, a variety
function and allowing the body’s own self-healing of tensions, torsions, stresses and strains are appar-
and self-regulating mechanisms to function more ent throughout the whole of the body and the
optimally. Any problem within the body may osteopath often applies a combination of treatment
have a visceral component. to ‘old injuries’ or sites of infection/inflammation
These types of factors can be present in people and fresh or recent problems and traumas.
with no symptoms of visceral disease, in much Osteopaths are aiming to interact with the physio-
the same way that many of the biomechanical/ logical functions within the body and to promote
musculoskeletal tensions and restrictions present health and better function by removing irritating
in someone with, for example, low back pain are factors and barriers to the homeostatic self-
not in themselves always symptomatic. regulating mechanisms of the body. Better movement
Obstetric care by osteopaths centres around is considered the key to this process, and visceral osteopa-
allowing the woman to accommodate her preg- thy is at its simplest the study of movement within the
nancy as comfortably and physiologically as pos- visceral systems and related tissues and structures.
sible, with the aim of reducing or removing stress
and strain not only for the mother and for labour,
OBSTETRIC OSTEOPATHY
but for the developing baby as well.
Osteopathy in these contexts is an understand- Many women and many health practitioners
ing of how three-dimensional anatomy relates to consider that much of the pain and discomfort
physiological function and how manual treat- associated with pregnancy and birth is ‘part of
ments can help restore optimum functioning and one’s lot’ and not really amenable to treatment.
improve healing. Most women experience physical problems and
often the majority wait for the end of pregnancy to
bring relief to their suffering. This does not have
VISCERAL OSTEOPATHY
to be the case, as many of the problems associated
Visceral osteopathy is a field concerned with: with pregnancy can be managed or alleviated
using an osteopathic approach.
■ the three-dimensional dynamics of body
Osteopathic care for pregnant women, pre- and
biomechanics (including musculoskeletal,
postnatally, focuses on helping the mother’s struc-
myofascial, connective tissue and organ
ture (spine, joints and soft tissues) to cope with the
structures)
increasing demands of the pregnancy. It helps to
■ reflex activity in the central and peripheral
alleviate some of the pains and problems associ-
nervous systems
ated with changes in posture, weight bearing, and
■ neuroemotional–immune links
the stretching of various ligaments and tissues
■ effective circulation and drainage of all the
that support the uterus. It also helps to prepare the
body fluid systems and tissues.
body and pelvis for labour and delivery, may have
A patient does not need to present with a visceral a role to play during labour and helps the woman
problem (e.g. irritable bowel or hiatus hernia) for recover from the traumas and strains imposed
a visceral approach to be relevant. Many cases of during the birth process (be that ‘natural’ delivery
musculoskeletal pain can be helped by releasing or ‘caesarean’). Osteopaths can help in managing
asymptomatic problems within various organs existing spinal and joint problems during preg-
and body tissues. Also, just because someone has nancy, aiming to reduce the impact that the preg-
presented with some sort of visceral symptom nancy has on the disc disease or ligamentous and
does not mean that the primary treatment is applied muscular strain problems, for example.
to those organs. It could be equally if not more Obstetric osteopathy also aims to make the
important to consider the surrounding or related space available for the developing baby as ‘com-
musculoskeletal system components. Visceral fortable’ as possible, thus potentially reducing
approaches within osteopathy are merely another mechanical stress on the baby during pregnancy.
tool for the osteopath to utilize when managing a This may have many effects, including giving space
whole variety of patient presentations. for the baby to freely rotate and move around
 Introduction 3

within the uterus, and get into an optimum posi-

Consequently, osteopaths consider that a nor-
tion for labour and birth. Improving the mechan-
mal part of medical management of pathology
ics of the joints and muscles of the pelvis in
and disease should be restoring or improving
particular is also thought to help ensure that the
movement in all body tissues where possible,
birth canal is as accommodating as naturally possi-
as they believe that this will aid physiological
ble. This is thought to reduce the risk of injury not
recovery.
only to the mother but also to the baby. There is also
a large field of study called paediatric osteopathy
which is concerned with the osteopathic manage-
ment of problems from birth through infancy and If movement is restored, communication
childhood to early adulthood, which is not fully between parts is more efficient, fluid circulation
addressed in this book. and drainage improve, irritating signals are
Intrapartum care is also an area of practice in reduced and the body’s homeostatic and immune
osteopathy. Here, the osteopath is legally a ‘birth mechanisms can operate more effectively, thus
partner’ to the labouring woman and does not restoring health and better function.
have medical control of the situation. Their role The term ‘osteopathic medicine’ is a con-
is to support the mother and offer whatever tentious one, as it has often been interpreted as
osteopathic services all parties (including the meaning that osteopaths are working outside
midwifery and obstetric carers) agree upon, with their scope of practice. Osteopaths have histori-
the aim of reducing strain in labour and poten- cally defended the use of their principles in the
tially improving birth processes and outcomes for management of health and disease issues, as sup-
the mother and child. This is an area of special plementary care, complementary care or alterna-
interest and not one that all osteopaths would tive care, depending on the situation. Providing
routinely offer. the pathological nature of conditions is under-
stood and appropriate considerations made, for
example in terms of techniques used, forces
OSTEOPATHIC MEDICINE
applied and ethics and legalities observed, then
Using osteopathy as part of a management system osteopathic management can provide sometimes
for the very sick, the diseased or those with a quite marked relief of symptoms associated with
weakened immune system is not contraindicated, those conditions. Not only that, but the impact on
nor is (as mentioned above) its use in natural con- physiological processes may enable the body to
ditions such as pregnancy or during labour. utilize its own self-regulating and healing mecha-
Osteopathic medicine is a term used to describe nisms more effectively, and thus may contribute in
how osteopaths view health and disease, and how some way to the resolution of ill health. Osteopaths
they consider that effective and efficient move- contend that treating the person, rather than the
ment in all body tissues, structures and fluid cir- disease, leads to improved outcomes on more levels
culations contributes to health and balanced than simple application of disease-oriented therapy
homeostatic function. Osteopaths consider that alone.
irritations in tissues and nerves and barriers to Whilst part of their work is aimed at symptom
effective fluid circulations are all related (in part) management, through the link between move-
to movement and biomechanical restrictions in ment and physiology and the way that osteopaths
the body tissues (including muscles, joints, con- consider that movement restrictions impact on physi-
nective tissues, organs, blood vessels and so on). ology and hence reduce tissue health and function-
ing, there is some consideration of the potential
Osteopaths consider that there is a biomechani- aetiological impact of the movement restrictions
cal component to pathological processes and on pathological development and progression.
disease, and that examination of the body’s tis- Hence osteopaths also theorize that some of their
sues for movement disorders should form part management addresses pathological change. This
of any general medical screening procedure. is an area where the evidence base for osteopathic
concepts is currently small.
4 VISCERAL AND OBSTETRIC OSTEOPATHY

Ethics, risk/benefit equations, evidence-based Structure and function are reciprocally related
medicine, diagnostic rights, consumer (patient) Things function in a certain way as a result of
protection, regulatory issues, safety and medicolegal how they are made and structured. If the structure
considerations, research options and patient- alters, then so will the function. This concept
centred care are all important topics for any prac- informs osteopathic practice in the following way.
titioner to be aware of. The osteopath and patient
■ Anatomy governs physiology.
negotiate between them a contract of care that
■ Soft tissue dynamics relate to physiological
enables them both to contribute to the patient’s
efficiency and effective homeostatic balance.
health management, with the aim of reducing
■ Altered soft tissue mobility both reflects and
symptoms and suffering. Osteopaths respect patho-
contributes to poor physiological function
logical and tissue state changes, meaning that if
and pathological change.
appropriately applied, there are very few absolute
■ Improvement of mobility and restoration or
contraindications to practice. Consequently, osteo-
normalization of movement patterns improve
paths become engaged in the management of
the self-regulatory and self-healing functions
people with cancer, immune insufficiency, genetic
of the body, thus promoting better function,
disorders, in postoperative care and many other
health and well-being.
situations. Osteopaths bring their principles to bear
■ Osteopaths therefore examine the body to
so that relative contraindications (for example, to
identify areas of altered or poor movement,
mode of technique applied at a certain time) can be
and make attempts at restoring that move-
identified and management adjusted accordingly.
ment, to improve function and therefore
Pathology creates tissue change, including
reduce symptoms.
protective spasm, rebound, pain and tenderness,
oedema and congestion, which reacts upon palpa-
tion. When these factors are placed in context with The rule of the artery is supreme
case history and other examination components Circulation is immensely important to health and
such as special tests and imaging, the osteopath without adequate nutrition, tissues cannot per-
can tailor their application of therapeutic manipu- form efficiently. At a cellular level, the dynamics
lations and mobilizations accordingly, in a safe of the extracellular matrix (ECM) and the micro-
manner with low risk. Awareness of tissues states circulation are important to function and immu-
and pathological processes forms part of the safety nity where movement of cells and fluid through
net for patient and practitioner. the ECM plays a key role. Drainage is also impor-
tant, as without effective lymphatic and venous
drainage, the appropriate ‘chemical’ homeostatic
DEFINITIVE OSTEOPATHIC TENETS balance is not maintained and waste removal is
inefficient.
Osteopathy is not a two-dimensional mechanistic In identifying the ‘rule of the artery’ as supreme,
approach; viewing the body as a complex Meccano osteopathy’s founder, Dr AT Still, focused on
set is not what osteopaths are about. Osteopaths see nutrition and felt a lot of manual treatment should
the body as something where mind, body and spirit be directed at ‘irrigation of withering fields’.
interact and are reciprocally related, and where the Although the language may be somewhat old-
building blocks of the body (its tissues) interact and fashioned, the physiological implication is clear.
both influence and are influenced by internal physio- Osteopaths are also particularly interested in the
logy and homeostasis. Note that the word ‘tissues’ role of the autonomic nervous system. Historically,
has been used, as most observers erroneously con- the functioning of the sympathetic nervous system
sider that osteopaths are interested only in bones, and its influence on circulation through vasocon-
ligaments, muscles and tendons. Osteopaths work striction mechanisms was an area of considerable
with all body tissues and fluids, even though they osteopathic interest and research. Increased sym-
may sometimes use the musculoskeletal tissues as patheticotonia was attributed to a variety of
a ‘handle’ into deeper, less accessible structures, mechanical disturbances and other stressors in
tissues and circulatory pathways. the body, with resultant ischaemia and other
 Introduction 5

physiological changes in the end organ or target as exist within the orthodox medical model, is
tissue. Adapting sympathetic outflow in some way anathema to osteopaths. Vitalistic concepts apply.
would presumably affect these aspects and influ-
ence nutrition in the end tissue or field (and there- Motion is life
fore impact on tissue health and healing). Today, Whether it be an electrical current passing along a
osteopaths continue to work with all parts of the nerve, blood circulating through the body or mus-
autonomic and somatic nervous systems, in order cles twitching and joints articulating, motion is an
to interact with the body’s physiology in general, absolute characteristic of life. For an osteopath,
and circulation and fluid movement in particular. assessing quality of motion is like assessing some-
one’s quality of life: poor movement not only indi-
The body has self-healing and cates that the person is not able to physically live
self-regulatory mechanisms their lives to the full or express themselves with
Communication is vital to health and good func- ease, but also that their body systems are not func-
tion. The body has built up some amazing meth- tioning optimally and that their health and immu-
ods of communication between its diverse parts nity are compromised as a result.
and tissues, which are still being investigated and
discovered. Osteopaths consider that movement Find it, fix it and leave it alone
restrictions negatively impact on communication The aim is to find the main focus of distress or
(be it chemical, neural, mechanical or otherwise), dysfunction in the body, address that as far as pos-
thus affecting homeostatic balance. Remove or sible and then leave the body to carry on sorting
reduce these movement barriers and the body will itself out from that input. Osteopaths work on the
naturally reorient itself towards health and better concept that the body knows what is good for it,
functioning. and will always aim to bring itself into a healthy
state wherever possible. If it can be given the right
The musculoskeletal system is the primary sort of helping hand, it will ‘run with that impe-
machinery of life tus’ and shift its function away from dis-ease and
The musculoskeletal system is more than a frame- towards health and better function.
work to carry our internal organs around. It is the As Dr Still said: ‘To find health is the mission of
means by which we express ourselves, how we any doctor – anyone can find disease’.
perform tasks and care for others, and by which It is the osteopathic ability to tune into the
we can recognize in others their actions and feel- body’s needs and integrated functioning that
ings. Without an effectively functioning and coor- creates a different approach to other manual
dinated musculoskeletal system, the way we live therapy practitioners. The ability of osteopaths to
our life is indeed compromised. utilize a highly refined palpatory awareness to
Through its contact with and acknowledge- work on many levels of bodily and human func-
ment of these factors, and the subsequent manual tion at once is a special skill, and one that enables
therapy applied to the body, osteopathy is uniquely a deeper understanding of health and disease to
placed to interact with the patient’s prime motives, emerge.
emotions and functions, on all levels.

The whole is more than the sum of its parts CONSIDERING THE WHOLE
Integration within and between parts is essential
for effective body function. We are more than just Figure I.1 shows a typical patient, one who presents
a collection of cells; there is something about the with a variety of biomechanical and soft tissue
way all those cells work together that summates restrictions. The actual torsion pattern is not impor-
and enables life as we know it to be expressed. tant – we all recognize that patients have restric-
Osteopaths accordingly never consider how any tions throughout their bodies; it is the practitioner’s
particular joint, muscle tissue or organ works in job to interpret those tension patterns with respect
isolation, and do not look at body systems sepa- to the presenting symptoms and underlying physio-
rately. The concept of ‘specialisms’ within practice, logical processes.
6 VISCERAL AND OBSTETRIC OSTEOPATHY

Eye strain and Headaches

TMJ/jaw
congestion Head in lateral
tension
flexion TMJ pain and bite
Salivary gland function, Scalene and rotation problems
ear drainage problems tension Pectoral
Neck pain
Shoulder muscle
Thyroid and throat
girdle tension
function Cervicobrachial
shifted irritation
inferiorly Arm rotation
Respiratory problems
Rotator cuff problems
Upper GIT irritation, Diaphragm
hiatus hernia Rib strain and dorsal
torsion
spine restriction
Kidney and ureter Pelvis Thorax
irritation shifted rotation Lumbar pain and
superiorly dysfunction
Irritable bowel syndrome Psoas
tension Disc herniation and
Pelvic pain, congestion, neural irritation
gynaecological problems
Sacroiliac pain and
Bladder and prostate Pelvic symphysis dysfunction
function Lower limb rotation
imbalance Hip problems

Gait imbalance and

knee and foot symptoms
Figure I.1 Three-dimensional torsion pattern.

This ‘typical’ patient could be presenting with a ■ The torsion within the chest may have spread
variety of symptoms, which may be manifesting through to the mediastinum and be creating
within the musculoskeletal field or the visceral field tension in the central tendon of the diaphragm.
(or both!). This may be contributing to mechanical aches
and pains in the ribs, costal margin or crurae
■ The torsion at the head, with some side- and upper lumbar spine or may be affecting
bending/lateral flexion and rotation, may the gastro-oesophageal junction and con-
present with pain and aches in the temporo- tributing to symptoms of gastric reflux or
mandibular joint (TMJ) or with headaches indigestion.
or, because of the way the torsion affects ■ The pelvic torsion may be consequent to
the jaw, tongue and throat tissues, may be lower limb problems but could also be related
presenting with chronic ear infections and to the pelvic floor and hence prostate or blad-
congestion. der, for example.
■ The torsion within the chest may be related ■ Coccygeal torsions could be related to the
to dorsal spine aches and rib strains or may cranial base and cervical restriction pattern
be related to respiratory symptoms, lung (through dural links) and could be involved
and chest wall stiffness and decreased lung in uterine or vaginal problems from pelvic
volume, for example. fascial tension from the coccyx.
 Introduction 7

WHERE IS THE PROBLEM? Working in the visceral and obstetric osteo-

pathic fields simply means the practitioner
This is the biggest question in any management
increases their ability to work three-dimensionally
scenario – where to apply the therapeutic input in
within the body.
the most beneficial, least stressful and most eco-
nomic way, meeting the needs of both the patient
and the ethics, principles and constraints of the TISSUE AWARENESS AND
healthcare system being utilized. It depends on INTERPRETATION
your diagnostic and healthcare belief systems, and
any individual practitioner’s hypotheses all have Diagnosing any visceral component means that
a certain risk/benefit equation attached to them. In the practitioner must explore those tissues carefully
other words, your beliefs determine how you exam- and whilst there are some basic screening techniques
ine someone, how you interpret those findings, designed to give an overview. there is no substitute
what other information you take into consideration for a sensitive, thorough and thoughtful evaluation.
and what you think will be a beneficial therapeu- (Note: ‘diagnosing’ in this context means identify-
tic intervention. The anticipated beneficial effects ing and describing in osteopathic terms a move-
of any management applied have to be weighed ment change in or around a particular organ or
against the risks imposed through its application. related structure). Adding visceral osteopathy to
As indicated by the figure and previous discus- one’s repertoire will mean that additional time has
sions, finding the primary cause of a problem or to be set aside when evaluating a problem but this
the underlying main restriction or tension pattern should lead to more effective management of the
is not easy, as the body works in so many recipro- patient’s problem through a more refined overall
cally integrated ways; it is a bit like asking the working hypothesis and diagnosis.
chicken and egg question. The patient does not Invariably, in all cases there are some tensions
have to have any particular symptoms in the found within the musculoskeletal system and some
visceral tissues for the organs to be participating within the visceral, vascular or nervous systems of
in the overall biomechanical problem that is con- the body. It is the practitioner’s job to interpret the
tributing to the patient’s presentation. The organs relevance and importance of the different compo-
and associated tissues may be tight, scarred, tense nents of a patient’s presentation and how they all
or irritated subclinically – they may just be fit together, before formulating a management plan
moving awkwardly. This could be sufficient to based on that working hypothesis.
physically constrain certain parts of the muscu- Visceral osteopaths utilize a variety of tech-
loskeletal system (through anatomical links) or may niques to explore the organs and related tissues, to
be reflexly irritating the musculoskeletal system interpret findings and to treat what they find. As one
(through shared/segmentally related parts of the is exploring tissues that may be scarred, inflamed,
nervous system). irritated or have some sort of pathological process
This means that the visceral system must be going on, tissue awareness and medical knowl-
examined generally as part of any overall assess- edge must be part of the practitioner’s training prior
ment, to evaluate its relevance in that particular to examining the visceral field. That said, there are
patient. The osteopath could then eventually treat several components that can easily form a general
asymptomatic areas of the patient’s body in order examination of the visceral system and associated
to resolve symptoms elsewhere. Of course, if the musculoskeletal components, which are listed
patient does have visceral symptoms (either cur- below (the list is not exclusive). With experience,
rently or in the past) then the osteopath already some or all of these may be incorporated into an
has indicators that various organs should be individual’s practice.
explored for signs that they are maintaining poor
or restricted movement within the musculoskele-
Overview of patient assessment
tal system, or are in part maintaining the visceral
dysfunction itself. To requote one of the basic The following types of routines are widely used
tenets: ‘You can’t fix it till you’ve found it, and you and may form part of global assessment of the
can’t find it until you look’. patient when making an initial diagnosis or
8 VISCERAL AND OBSTETRIC OSTEOPATHY

hypothesis, as well as part of an ongoing review ■ Practitioner observation of the patient, active
of progress. They can be individualized according movement by the patient, and passive exami-
to situation and need and represent an averaged nation of the patient can all be used.
style of approach. ■ Special tests such as orthopaedic, respiratory
or cranial nerve testing can be used, as required.
Case history taking ■ General listening techniques can be utilized.
Includes the use of analytical questioning, a range ■ Evaluation of spinally located reflex fields
of communication and observation tools, differen- can be performed.
tial diagnostic sieving, development and explo-
ration of working hypotheses.
Supine (and sometimes sidelying or prone)
assessment of the body
Use of special tests
■ Passive exploration of the tissues, be they
According to case needs, general screening of sev-
musculoskeletal, vascular, neural, visceral or
eral body systems may be required. Osteopaths can
fascial, is undertaken.
utilize various basic medical screening tests such
■ Mobility and motility tests can be performed.
as manual neurological testing, percussion and
Mobility tests include testing articulations of
auscultation, and can be aware of the need for
the organs, testing sliding surfaces, examining
blood and urine tests, x-rays, ultrasound and other
the elasticity, compliance or stretch within an
imaging techniques. Where medical diagnosis is
organ or its attachments/supporting tissues.
required or may be advisable, the osteopath will
Motility in this context is not peristalsis of the
refer on for further care, often whilst continuing
hollow/tubular organs such as the gut, but
to manage the patient in a way that does not
an osteopathic term relating to inherent
compromise them receiving the necessary tests
movement within the structure being evalu-
or treatment and is not detrimental to any possible
ated. Both these concepts are discussed later.
potential condition awaiting diagnosis.
■ Local listening techniques can be utilized.
■ Soft tissue and dermatome reflex zones can
Standing assessment
be explored.
■ When assessing a person, do not look just at
their spinal mechanics using a posterior view. Passive examinations require sensitivity, espe-
View the person from all sides, and in particular, cially in the presence of any particular pathologi-
don’t forget your patient has a front. cal process within the tissues being examined.
■ The objective is to identify areas of the body Medical diagnostic indicators from the case his-
which are affecting overall posture and tory and physical appearance of the patient can all
standing balance. point to certain pathological processes, of which
■ Passive observation can be used, as well as the practitioner must be aware. On palpation of
active movements by the patient, to identify the abdomen, for example, there are various
general body parts or sections that are not conditions that require consideration. The pres-
partaking in normal posture and movement. ence of aortic aneurysm, oesophageal varices,
■ General listening techniques can be utilized. ulcers, carcinoma and infection, to name but a few,
Listening techniques make use of fascial and all involve particular changes within the tissues
connective tissue tensions and torsion pat- which render them weak, easily damaged and
terns that are created through restrictions in irritated. Overforceful palpation can further dam-
organs, muscles, joints or other body tissues, age and injure the tissues, sometimes with serious
to identify significant problems. This concept consequences, and there is a risk of further spread
is discussed later. of the pathological condition. Hence the practi-
tioner cannot physically examine the patient with-
Sitting assessment out an awareness of underlying conditions and
■ Removing the influence of the lower limbs associated risks.
can often reveal more specific patterns of Medical diagnosis is the remit of orthodox doc-
restriction within the torso, neck and head. tors, consultants and specialists but all allied
 Introduction 9

health professionals must have training in this ■ functional, listening and ‘involuntary’
area, for the above reasons. That said, visceral pal- manipulations*
pation is possible in many cases, by using gentle
in order to evaluate all components of visceral
direct techniques or indirect techniques; there are
movement.
few absolute contraindications. Note: ‘direct’ and
Manual treatments are applied to:
‘indirect’ are osteopathic technical terms for styles
of physical examination and treatment and will be ■ change the way the musculoskeletal system
discussed later. is responding
■ change the way the organs are responding
■ affect circulation and fluid drainage
BASIC COMPONENTS OF VISCERAL ■ affect neural reflexes and input (and other
OSTEOPATHY forms of communication within the body)

‘Organs move’... and that movement (both gross and are aimed at improving function and reducing
and internal to the organ) contributes to physio- symptoms.
logical function. Organ manipulation is:
‘Visceral mobility’ can be: ■ about improving movement, locally to the
■ between adjacent organs, such as the liver organ or at a distant point
and right kidney, lobes of the lungs, bladder ■ aimed at changing function and physiology/
and uterus, etc. homeostasis. Knowing the effects of reduced/
■ between organs and adjacent somatic altered mobility helps you critically appraise
structures, such as the lungs and the ribs/ your treatment protocol.
intercostals, the kidney and psoas, stomach The protocol for osteopathic intervention is
and diaphragm, etc. simple.
■ organs can express movement such as peri-
stalsis of the gut tube, fallopian tube or ureters, ■ Reflect on the nature of the condition.
and be motile, such as the heart and its rhyth- ■ Explore for tissue barriers to circulation,
mic pumping, and the expansion and defla- immune function and effective neural and
tion of the lungs. other communication.
■ Analyse impact of physical touch on the
‘Visceral motility’ can be: pathologically adapted tissue.
■ an expression of its embryological derivation ■ Understand implications of altered blood flow,
or migration immune function and neural communication
■ an expression of its vitality on the pathological processes or condition.
■ this is not the same as ‘peristalsis’. Note: vis- ■ Rationalize the impact and aim of the intended
ceral motility is discussed in a later chapter. therapeutic input and consider the risk/
benefit equation.
Both mobility and motility can be explored and ■ Be able to justify and communicate actions in
evaluated by osteopaths, and both can be improved osteopathic as well as medical/scientific
through a variety of manual techniques (both direct terms where possible.
and indirect). ■ Practise ethically and safely, with informed
Organ manipulation can consist of: consent.
■ articulation
■ stretching POINTS TO REMEMBER IN
■ inhibition VISCERAL OSTEOPATHY
■ general mobilization*
■ recoil techniques* ■ The patient does not need to be complaining
of any visceral symptoms (objective or sub-
jective) in order for their organs to require
*These terms will be explored in later chapters. ‘treatment’.
10 VISCERAL AND OBSTETRIC OSTEOPATHY

■ Osteopathy has a role to play in the manage- clear to patients, medical professionals and
ment of various pathological states and dis- others with no osteopathic training. Confusion
ease processes. often arises when discussing the issue.
■ Not all treatment to help resolve visceral dys- ■ The scope of osteopathic practice as per-
function is applied to the organs. ceived outside the profession is quite limited;
■ There are very few contraindications to for example, that it mostly deals with back
osteopathy – just to how it is applied. pain, various sporting injuries and general
■ Differential diagnostic medical knowledge is biomechanical problems.
required in order to rationalize patient care ■ The scope of practice as perceived within the
and to manage people appropriately, includ- profession is much broader, even though the
ing referral to other medical specialties as current evidence base is insufficient to define
indicated. best practice.
■ It is not possible to identify everything by ■ Expanding one’s scope of practice means that
feel alone. Palpatory quality may give much the onus for illustrating competence rests
interesting information but it is not a replace- with the osteopath (or practitioner) concerned.
ment for diagnostic imaging or other types
of tests.
■ A few manual techniques applied to the organs ABOUT THIS BOOK
are not going to reverse severe tissue changes
such as deep ulceration, scarring and fibrosis. The following chapters introduce the range of
■ Mobilizing the organs in the presence of anatomical (and therefore physiological and
conditions such as bacterial infection, biomechanical) inter-relationships between the
haematoma and carcinoma is contentious. different body systems and how the body func-
■ General osteopathic care of patients with the tions in an integrated manner. Various examina-
above types of condition is not contentious, tion and treatment techniques are introduced, and
when used as a supportive or complementary discussions on patient management in various
(as opposed to alternative) care regime. situations are included. Some case histories are
■ What an osteopath may mean by mobiliza- given to illustrate how the approaches discussed
tion of an organ may not be immediately throughout the book are applied in practice.
 11

Chapter 1

General principles

CHAPTER CONTENTS Gross visceral mobility 21

Sliding surfaces 21
Visceral support 11
Articulations 22
Body cavity dynamics 11 Axes of movement 23
Core-links of fascia and their ‘transverse’ Influence of ‘ligaments’ 23
attachments 12 Influence of vascular pedicles 23
Tensegrity and reciprocal tension Influence of surrounding structures 23
membranes 13
Organ flexibility, deformity and compliance -
Fluid dynamics 16
‘internal mobility’ 27
Mechanical influences on fluid movement 16
Motion changes in relation to function
Visceral movement, posture and tension or pathology 28
receptors 17
Peristalsis and pacemaker activity in smooth
Viscero-ptosis 17 muscle organs 30
Mechanical effects of poor organ support 17
Visceral ‘motility’ and embryology 30
Physiological effects of poor organ support 18
Basic visceral motility 31
Visceral motion 20 Tests 31

VISCERAL SUPPORT mostly bounded by various muscles. The thoracic

and abdominal cavities also have differing pres-
The organs are supported and contained by the sures, which are balanced against each other, so
efficient biomechanical couplings of the musculo- that the overall relationship between the two
skeletal system, without which the organs would cavities is in equilibrium.
not function effectively. There are various muscu-
lar and fascial supports to the visceral systems
and these help to hold the viscera in a vertically BODY CAVITY DYNAMICS
oriented stack or column. The thoracic and pelvic
cavities are bounded by skeletal components, The body cavities house the viscera, with a few
making their internal mechanics more constrained exceptions (notably the thyroid and parathyroid
than those of the abdominal cavity, which is glands, oropharyngeal glands and the testes).
12 VISCERAL AND OBSTETRIC OSTEOPATHY

The body cavities include the cranium and spinal links the central nervous system as one continuous
column (bounded by the dura); the thoracic cavity organ. The dura connects various cranial bones
bounded by the pleura, pericardium and cervical and vertebrae running along the length of the
fasciae superiorly and the thoracic diaphragm infe- spine, through to the coccyx. This has been labelled
riorly; and the abdominopelvic cavity bounded by as the ‘core-link’ of fascia, in osteopathic concepts.1
the thoracic diaphragm above and the pelvic floor There is also a connection between many organs
muscles below. and structures which runs from its attachments at
As will be explored in detail later, the mechan- the cranial base, through the cervical region, down
ics of the muscles and articulations of the somatic into the mediastinum, onto the diaphragm and
body cavities are reciprocally related to the viscera then from below that, down through the abdominal
and their fascial and serous membrane attach- cavity and into the pelvic bowl. This can be thought
ments. In order to appreciate this relationship, its of as a ‘visceral core-link’ as opposed to the above
three-dimensional (3D) movement dynamics must ‘neural core-link’.
be recognized. Clinical work is much more effec- These fascial cores of the body run longitudi-
tive once a 3D picture of the person and their nally and are traversed horizontally by various
movement patterns has been built up. This makes structures which help to separate the body cavities
their management much easier to rationalize and or divide them into subsections. The neural core-
tailor individually. link is traversed by the tentorium and denticulate
All the body cavities are interconnected and ligaments and the visceral core-link is traversed by
movement in one area will be transmitted to another. the thoracic diaphragm, the vertebropericardial
For example, respiratory movements from the ligament, the broad ligament and the pelvic floor.
thoracic diaphragm cause tissue movement in the These are shown in Figure 1.1.
cervical as well as the pelvic regions, and any Osteopaths do not limit their understanding of
weakness or damage to the diaphragm will lead to body cavities to the ‘traditional’ descriptions of
herniation of abdominal contents into the thorax ‘thorax, abdomen and pelvis’. For them, a body
as a result of the differing pressures between the cavity is any space which is bounded by fascia
two cavities. Osteopaths believe that the biome- (connective tissue), including vascular space,
chanical relationships between the cavities are more muscle sheaths, individual cell membranes, the
complex than these simple examples, and much of extracellular matrix surrounding the interstitial
the transference of movement is via fascial and spaces containing interstitial fluid, muscle fasciculi,
connective tissue structures, which link the vis- and so on. All these body cavities are intercon-
cera to each other and to various musculoskeletal nected through the microscopic cytoskeleton,
system structures. The body cavities should not in extracellular matrix and generalized fascial sheaths
fact be viewed as separate but are continuous with to larger structures such as the mesenteries,
various ‘transverse stabilizing’ structures such as ligaments, tendons and ultimately bones and
the diaphragm and peritoneal mesenteries to give muscles. The fascial structures not only support
support, anchorage and, sometimes, motion. structures but allow movement and reduce fric-
Embryologically, the body cavities are initially con- tion and tissue stress.
tinuous and only become artificially divided by the Fascial structures run continuously through the
further development of other structures such as body and osteopaths do not favour the artificial
the diaphragm. breakdown into separate structures given different
names by various anatomists over the centuries
(www.osteodoc.com/fascia.htm). This confuses
CORE-LINKS OF FASCIA AND THEIR
any understanding of how these fascial structures
‘TRANSVERSE’ ATTACHMENTS
are functionally linked. Osteopaths are very inter-
One of the reasons why the mechanics of the body ested in the ‘unity of function’, which is a way of
are so integrated is the way in which all the struc- thinking that tries to understand how all parts of
tures are linked. There is a connection from the the body work together as a unit. As such, fascia is
brain along the spinal cord and out to the periph- intimately involved in all body mechanics and is
eral nerves, which is formed by the dura, which part of the structural dynamic of the person.2
 General principles 13

Falx

Tentorium
Pharynx
Anterior longitudinal
ligament Larynx

Dura Suprahyoid muscles

Hyoid
Vertebropericardial
ligament Sternum

Bronchi
Sternopericardial
Liver ligament

Coronary ligament
Renal fascia

Falciform ligament

Colon
Kidney
Umbilicus

Urachus
Uterosacral
ligament
Small intestine

Filum terminale Bladder

Pubis
Pelvic floor

Figure 1.1 Neural and visceral fascial core-links.

the fascial structures. Practically, osteopaths will

Tensegrity and reciprocal tension
feel through these fascial structures and can iden-
membranes
tify tension patterns that spread diversely through-
Core-links of fascia connect all the body cavities, out the body, by contacting and moving one or two
from the macro- to the microscopic. Movement can distant parts and appreciating the way the move-
be transmitted almost simultaneously from one ment passes through all the body’s structures, on a
area to another, through the tensile properties of gross level and even down to a cellular level.2
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