The practice of osteopathy

A postural defect is any abnormal position, congenital or acquired, of the body, assumed in sitting, standing or walking. This leads to a symmetrical development, causes structural changes, and as a sequel, disturbance of function and organic life results.

Defects in posture are of very common occurrence. A perfect posture, in fact, is somewhat rare. Considerable is being accomplished, especially of late years, by the laity through various physical methods and exercises to correct the many defects of position in sitting, standing and walking. The originators of the many so-termed systems of exercises have gone so far as to even advertise to cure various diseases of the body as well as attempting to improve the normal tissues and structure.

Exercises, undoubtedly, have their place, particularly in the life of those of sedentary habits. Most of us do not exercise enough, neither do we as a rule get enough fresh air and pure water. But there are many defects of the anatomical that mere gymnastics can not adjust. And there are still other defects that gymnastics may decidedly aggravate. In these cases the mechanism of the body has become so deranged and disturbed that nothing short of actual readjustment can be effective.

In the consideration of postural defects there are a few points that should be particularly emphasized. First, these defects may not only be the result of laziness or carelessness, but of more frequent occurrence is some previous strain or injury to the spinal column or other parts of the body framework. Some defect of position or symmetry of the body may easily follow as a result. Here gymnastic work may reduce the defect to a minimum, but rarely can the compensatory forces of nature entirely obliterate the structural disorder, unless assisted by actual, specific readjustment. Second, in the examination and treatment of the patient due attention should be given the symmetry and figure of the body as a whole so that relation of the part to the whole and vice versa may be rightly proportioned. Remember that the spinal column is only one part of the body outline, thus one should consider the transverse section of the body in relation to the spinal column and not the spinal column alone. In a word, correction of postural defects implies both structural rearrangement and molding of the contour. Do not make the mistake, for example, when correcting a deformity that involves the chest, of paying attention to the spine alone, but take into consideration the thorax as a whole of which the spine is only a part.

Round Shoulders

Round Shoulders are a defective posture with which everyone is familiar. How many children have escaped the parents’ criticism to sit, stand, and walk erect? And not a few of the afflicted have not succeeded after persistently doing their best.

Round shoulders or stoop shoulders are commonly attributed to indifference. Probably a few cases are due simply to laziness and indifference, and others may be carelessness, and usually when they arrive at an age where pride of their physical demeanor and powers enters as a life factor, the child soon overcomes the postural weakness. With still others the correct, persistent physical training, as exemplified in military schools, will readjust the defect. But there is a class, and by far the largest, where round shoulders are a very real and active weakness of the physical body. And the weakness is not primarily in the shoulders as nearly everyone thinks. The stoop is a result. The origin is in the lower dorsal spinal column. Here will be found a posterior curvature that involves nearly the entire dorsal and lumbar areas. This is the real, the original cause of the larger number of round shoulders.

This backward curve of the spinal column, instead of the forward curve as it should normally be at the waist, obliterates the brace or truss of the spinal column that is so essential in maintaining an erect posture of the shoulders. It allows the individual to “fall into his stomach,” to drop the shoulders, and as a consequence the chest cavity is depressed. The spine is one continuous backward bow, and when he does try to sit straight, and it is always with a constant effort, the normal, the physiological curves of the spine are not apparent.

First, then, there is a spinal weakness in the region of the innervation to the digestive organs. Indigestion of various forms is a common accompaniment. Second, there is lessened lung and heart capacity. The ribs are depressed, interfering with perfect aeration and elimination on the part of the lungs and with normal activity and tone of the heart muscles. Phthisis is predisposed. Is it any wonder the child’s blood is impoverished and anemia results from the insufficient aeration and poor digestion and assimilation? Costogenic anemia may also be a result. And, third, the shoulders are “round” from the spinal weakness and flattened chest, really an effect; but while the most noticeable, it is the least serious.

It is evident from careful observation and study of these cases that the treatment resolves itself into the treatment of a posterior spinal curvature. Shoulder braces, steel braces and jackets, and casts have very little place, if any, although there may be diseased bone of such character and severity that a cast will be necessary; this, however, would refer to treatment of Pott’s disease and similar conditions.

Hence, the treatment is, first to replace and readjust the malaligned vertebræ. There must be an actual physical manipulation in order to correct the vertebræ at fault. This is the essential, and by far the primal, treatment for the key to the truss or brace that holds and retains the body in an erect position is then replaced.

Second, raising the depressed ribs. Remember the depressed ribs are dependent upon the spinal condition. The thorax should be treated as a comprehensive whole, not the spinal column alone.

Third, exercises are a valuable aid. The individual’s part is as necessary, in a way, as the physician’s, for in order to accomplish the maximum there should be consistent and appreciative work on the part of the patient. Holding the shoulders back, the head erect and the chin in, drawing the abdomen in and up, all with deep breathing by the use of the chest muscles, the patient will be able to retain the correction obtained during treatments. “Setting up” exercises are helpful. Developing the muscles of forced expiration is excellent. Thus the patient must be conscious of the work required of him and act in concert with the physician. Minute instruction on the requirements of each case is demanded.

Good food, pure water, and fresh air are necessary, particularly in the anemic. Right living and correct environment are always in order.

Painful Shoulders

Under this heading may come a variety of conditions affecting one or both shoulders causing much distress and, at times, total disability. The conditions may be the result of direct injury to the joint, systemic, or from spinal lesions. Anatomically the shoulder offers frequent opportunity to injury as it has the greatest range of motion of any joint, is least secure in its articulation, and is most vulnerable from location. Once the shoulder has been dislocated it is rarely back to normal functioning again as this injury tears the capsular ligament and stretches the structures in relation. Many times there is only a subluxation in which the head of the humerus is driven upwards in the fossa, usually from a fall or blow on the point of the elbow. As a rule, after such an accident, the only thing done is to rest the joint and apply a liniment and, after a time, begin the use of the arm. It is, however, painful and to save himself, the patient each time restricts movement until he reaches a point where he is unable to dress without assistance. It is then found that normal motion is reduced fully one-half and even this will be accompanied by pain on movement and in bed. A radiograph will, usually, show the condition. Articular crepitus and fibrous adhesions are present while the adjoining structures have undergone changes so that a reduction is impossible without certain preparation. Very often a trivial cause will disable a joint; a sudden movement which finds the muscles about the shoulder unprepared and the resulting lesion is so slight as to, often, defy detection. At first there will be swelling and pain but, in time, it settles down to a limited motion with more or less distress.

Bursitis.—This is a condition in which the subdeltoid bursa is involved or where there have been a number of bursæ formed from overuse of the joint. One authority reports as many as twenty-five in a shoulder. There may be, also, tenosynovitis primarily or from extension. These conditions may not be easily diagnosed at first.

Brachial neuritis (chronic) beginning with or without an acute attack is usually from a cervical lesion involving the brachial plexus but most frequently it is the 5th and 6th cervicals at the origin of the circumflex nerve. From this the deltoid is particularly affected and its contraction leads to pressure on the nerve and subsequent partial or complete paralysis. Brachial neuritis is found in an increasing number of osteopathic practicians and is the result of overwork of the arms and to strain of the upper dorsals and lower cervicals. There are contractions of structures about the joint constantly limiting motion and pain when a strain is put on them.

Many methods for the treatment of the conditions described have been employed, all involving the same principle but none of them systematized. C. H. Spencer has worked out a technique which, while originally intended for bursitis, has been found well adapted to all conditions described. It gives a stretching of all structures and gradually breaks up adhesions, both in the joint and in the tendon sheaths, so there is no resulting irritation which could easily result if suddenly done. His technique is[43]:

“First: The patient on the side, the affected shoulder up; operator facing the patient, places one hand on the top of the shoulder, does nothing more than fixing it; with the hand grasping the forearm above the wrist, push the elbow backward, the arm parallel to and almost in contact with the body, then pull forward in the same plane. Second: Elevate the elbow with the hands of the operator in the same position as before, carry the elbow in as wide a circle as possible. Third: With the hands still in the same position, extend the forearm with traction; carry it as high in front of the patient as possible. The foregoing are designed to relieve the congestion about the shoulder, bring pressure to bear on the subdeltoid bursa and moderate traction on the supraspinatus, infraspinatus, subscapularis, teres minor and major, latissimus dorsi and the tendon of the biceps. These manipulations will be all that is possible in the more aggravated cases for some considerable period of time. As the tenderness subsides, the second group may be cautiously started, the hands in the same position as above noted, with the arm extended as nearly as possible at right angles with the body, carry the arm in as wide a circle as the pain will permit. Again, with the arm flexed at the elbow, one hand of the operator on the point of the shoulder and the forearm of the patient across the forearm of the operator, the other hand of the operator resting on the point of the patient’s elbow, push down toward the middle line of the body and carry the elbow toward the head. Then flex the arm and place the back of the hand behind the patient, flexing the shoulder in front with one hand grasping the point of the elbow and pull forward. This group of movements accomplishes with greater force the same ends obtained in the previous, and the first in this group is the most effective in overcoming swelling of the subdeltoid bursa. Direct manipulation of the muscle masses and this bursa is desirable from the first.” It will be noticed in all these movements that the joint is protected by one hand of the operator while the other is grasping the arm of the patient. This is desirable as it makes the technique absolutely safe. An additional treatment will be found very effective, especially where the deltoid is involved. With the patient on the well side, facing the operator, locate the quadrilateral space which is bounded by the subscapularis above, the teres minor below and the long head of the biceps medially and the surgical neck of the humerus externally, and the circumflex nerve can be easily palpated along with the artery. If these structures are stretched and the deltoid lifted from the shoulder it will be found to free the action of both nerve and artery, one supplying the joint with nutrition and the other innervating it.

Certain conditions for which these movements are contraindicated arise and the following differential points by H. Glasscock are well to remember[44]: “Rheumatism: Fever in the joint, with redness, swelling and other joints involved. Tuberculosis: Daily temperature and other tubercular foci. Neuritis: Pain in the neck and shoulder muscles, also near insertion of deltoid and in the forearm, particularly musculo spiral. Pain worse at night. No pain on movement. No swelling. Bursitis: No pain in neck. Pain in anterior and posterior part of joint and on motion. Pain near insertion of deltoid. Arm held close to the body, motionless. Infection: Chill, limited motion, severe pain with temperature. Dislocation: Deformity with preternatural mobility. Dislocation of acromio-clavicular joint: Tenderness over articulation. Arm cannot be raised beyond right angle with the body, but elbow may be brought across the chest with external rotation of arm and raised perpendicular with the body without pain.” The infected joint should never be manipulated and all conditions showing swelling, redness and pain on touch should be viewed with suspicion. Remember that all other conditions will almost invariably have vertebral lesions, primary or secondary and a permanent result will depend upon their correction.

The Prominent Hip

A hip that is prominent and larger than its fellow is of frequent occurrence. It may not be necessarily conducive to a defect in posture, but it often is. The female is more frequently afflicted with this anatomical irregularity than the male. In the first place, the female pelvis is not so stable and rugged as the male pelvis, i. e., a mechanical wrench or fall will more easily displace the relative position of the tissues in the female. Then, in the second place, the dress of the woman accentuates irregularities of the figure, so that possibly in some instances the defect, from a diseased or deformed point of view, is more apparent than real. But of still more importance is the fact that many cases of a prominent hip are due to a lateral curvature of the lumbar spinal column. Lumbar curvatures are of common occurrence in the woman; first, the spinal column is not so strong as in man, simply on account of the physique not being so robust; second, modern dress constricts the waist by the use of corsets and many waist bands, and the weight of heavy skirts upon the waist, hips and abdomen; and, third, severe strains from childbirth. Care should be taken that there is no congenital abnormalities of the lumbar spine, or that congenital asymmetry of one-half of body, or trunk or leg is not present.

Thus the principal cause of a prominent hip is the lateral lumbar curvature. This, through compensatory action, renders the hip on the concave side prominent and high, while the hip on the convex side is depressed and less pronounced in appearance. Dressmakers and tailors are all too familiar with this feature of the irregularly outlined figure, and, consequently, have to resort to “padding” to round out the symmetry of the body. The mere irregularity of the figure, unfortunately, is by far the less serious part of the defect. Many ailments and diseases can be readily and directly traced to this. Not that the prominent hip itself necessarily always plays a leading part, but rather the lumbar curvature is the cause of very much suffering and misery. To enumerate the many disorders that arise from malaligned lumbar vertebræ may be unnecessary but a few will be given. A point to be emphasized is that the prominent hip often plays the role of a sign or symptom, or an effect, that an ailment or disease may be elsewhere.

In the female one of the most common causes, if not the most common cause by far, of disorders of menstruation, whether painful, profuse, or irregular, is irritation or obstruction of the lumbar spinal nerves due to lumbar curvatures. It is well known the lumbar spinal nerves control, to a large extent, the pelvic organs; consequently the osteopath pays particular attention to this area. Then certain intestinal disorders, such as appendicitis, typhoid fever, dysentery, rectal diseases, owe their origin to predisposing lesions here; also, bladder ailments, and sexual diseases of men, and many affections of the legs, as sciatica, varicose veins, etc.

In a number of instances the prominent hip will be due to a displaced innominatum. Then a lumbar curvature will result as a compensatory condition. This reverses the compensatory act as heretofore referred to; the prominent hip, in this instance, is the cause and not the effect. To diagnose which is cause and which is effect will frequently require considerable technical knowledge and experience. The slipped innominatum then produces symptoms and disorders directly from its changed anatomical relations; the points of diagnosis are given in the chapter on Diagnosis. The prominent hip can easily be detected when the subject sits down upon an even, firm surface, or stands up, and the one side is compared with the other. In some cases where the prominent hip is due to a lumbar curvature, and the prominence is a secondary feature, the legs will be found uneven in length, but not always, for the lumbar curvature may straighten out when the patient lies flat upon the back. To diagnose the cause from effect and to differentiate the maze of signs and symptoms that may be present is not always easy even for the skilled practitioner.

The correction of a prominent hip is not ordinarily a difficult matter. In the cases where lumbar vertebræ are principally at fault, and these include the greater number, the problem is one of correcting the spinal curvature. Lumbar curvatures are the easiest of any of the curvatures to correct, for one is not hampered by the rib articulations, and the lumbar section presents an area where a leverage can readily be obtained. Where the innominatum is primarily at fault it is simply a matter of readjusting this, with probably some attention to the lumbar region. Care should be taken that the prominent hip is not caused by a tubercular sacro-iliac disease, by hip-joint disease, by a dislocated hip, or by an overlapping of thigh or leg bones from fracture.

Standing erect will, of course, be a valuable help, for standing with the weight on one foot will tend to make the hip on that side more prominent. But generally the reason why one favors a certain side is because the other side is weaker; a weak back, a slipped innominatum, or an injured leg are common causes. There are many cases where the skirts will have to be considerably altered after the hips have been made symmetrical.

Pendulous Abdomen

The pendulous abdomen is another defect that is all too common. A great many people have prominent abdomens because they do not stand properly, but a pendulous or prominent abdomen is not necessarily synonymous with a stout abdomen. They attempt to stand erect by drawing the shoulders back and extending the abdomen. If they would hold the head erect and the chin in, with the shoulders back and the chest forward, and draw the abdomen inward and upward, their figures and physiques would undergo shortly a wonderful transformation. These directions also apply to pregnant women. Drawing the abdomen upward and inward will at first require considerable effort. It certainly will not be an involuntary act for the first few days.

The sagging of the abdomen not only causes an unsightly appearance but results in great relaxation of the abdominal muscles, interferes with digestive functions, displaces the pelvic organs, and weakens the action of the lungs and heart.

The laxity of the abdominal muscles allows the abdominal organs—the intestines, stomach, kidneys, etc.—to displace downward. This tends to indigestion, constipation, inactivity of the liver, etc., and causes a score of reflex symptoms. The organs become simply weakened from a lack of proper tone. This is a frequent cause of nervous prostration. Also it is one of the common causes of prolapsed and displaced pelvic organs, because the abdominal organs sag down upon them and the pelvic organs thus receive the brunt of the gravitative effect. Internal local treatment of the pelvic organs can only be a makeshift in these cases. The lungs and heart are weakened because the abdominal organs are dragging on the chest, the lungs can not aerate the blood freely owing to the abdominal weight and to the blood being obstructed in passing from the abdominal organs through the liver to the heart and lungs. The heart is handicapped in its work through lessened chest capacity and obstructed circulation. Just “suck” up the abdominal organs and see how much easier it is to expand the chest and to breathe.

There are other causes for a pendulous abdomen, such as a weakened spinal nerve supply to the abdominal muscles and organs. The weakened nerve supply may cause a loss of tone to the abdominal organs themselves, so that certain organs, as the stomach and intestines, become dilated and prolapsed; to the ligaments, and to the tissues and organs as a whole so that they become gravitated.

Through childbirth muscular fibres of the abdominal walls often rupture, leaving scars and a relaxed condition. Actual ruptures, hernia, of the abdominal muscles occur and cause a pendulous abdomen. Then there are cases of obesity where the pendulous abdomen is a symptom.

Much can be done with all of these conditions through osteopathic work; the patient must also help himself. The center of gravity of the body must be changed, and kept changed; correct posture and a constant effort will accomplish considerable. The “setting up” military exercises are excellent. Even in some cases of obesity the abdominal prominence can be markedly lessened by careful exercising and keeping the abdomen drawn in so that the abdominal muscles, the diaphragm, and the chest may be strengthened. For the relaxed, flabby abdomen, self manipulation of the weak muscles when lying on the back will materially aid.

Postural Curvatures of the Spinal Column

Undoubtedly, the great percentage of postural defects, or slumped states, are dependent, directly or indirectly, upon weaknesses in the spinal column. As was seen, round shoulders, the prominent hip, or the pendulous abdomen, are often initiated by spinal deviations and deformities, so naturally spinal column curvatures are a most fruitful source of direct defects of posture.

It is somewhat uncommon to find an anatomically true spinal column, although this does not preclude that one’s posture is defective, for often through pride and effort one may consciously overcome a defective posture.

It is the purpose here to offer a few suggestions relative to the development of a greater symmetry of the body. Nearly every one is more or less interested in physical exercises and development. And especially to those of sedentary habits do means and methods of exercise appeal. Curiously enough, in a way, nearly every layman looks upon defects in posture, symmetry and stature as an effect arising from lack of, or improper, exercise. He seems to be imbued with the idea that the body in most instances is practically permanent in construction and when irregularities in figure occur certain exercises will correct the defect. Thus have individuals been prone to look upon osteopathy as a method of passive exercises. Osteopaths should believe most thoroughly in exercising, personal hygiene, etc., but the idea of osteopathic manipulation is primarily one of anatomical reconstruction, and not muscular development alone. The work of the osteopath is to readjust or to re-mold the body framework and the many tissues that clothe it so that normality of function may predominate. The manipulation is not routinism but mechanical rebuilding of the tissues so that perfect freedom of vital forces may be forthcoming.

The spinal column presents the most frequent as well as many extremely interesting phases for re-correcting work. The number of abnormalities as to contour to which it is subject are many and varied. Emphasis should be placed upon possible congenital abnormalities and developmental defects as sources of certain derangements. Any variation or combination of variations with the normal or physiological curves constitutes an abnormality or pathological curve. And as a consequence defective posture, unless thoroughly compensated, is readily initiated. Not only may the normal curves be exaggerated, lessened, eliminated or reversed, but lateral and rotary curvatures are of frequent occurrence.

Curvatures involving the cervical region to the extent of producing noticeable defects of posture are principally lateral deviations of several vertebræ. Wry-neck is probably the most noticeable disturbance. The head and neck being drawn and slightly twisted to one side is a defect that is both noticeable and painful. Another common source of postural affection is an exaggerated forward curving of the neck vertebræ. This produces a stooped appearance of the neck.

The dorsal vertebræ are often curved backward too far. This produces roundness with too decided a fullness of the upper back and shoulders. The chest may be somewhat flattened as a secondary effect but not necessarily so. Neither are the shoulders what may be termed “round shoulders,” still such a condition may occur, for “round shoulders” are more often caused by a backward swerve of the column at the waist line. There is often a shortening of the anterior structures which pull the point of the shoulders forward. Forcing them backward will aid in correcting the fault. The dorsal vertebræ may be forward from what is termed a “straight” spine; this results in an exaggerated “braced” back position. Then lateral curvatures of the dorsal spine are common, which in time may develop into a rotary curvature; that is, the vertebræ are actually rotated on their axes. Lateral curvatures of the dorsal spine are slow and difficult to correct, for the ribs complicate matters very materially. Then, also, the vertebræ are apt to be deformed.

Curvatures of the lumbar spine, whether posterior, lateral or anterior, are common. Both dorsal and lumbar curvatures, as any one can readily see, are extremely common sources of postural defects. Erect positions of the body are maintained through the support of the dorsal and lumbar vertebræ. Stooped shoulders, one shoulder lower than its fellow, sitting humped over, sitting on the sacrum instead of squarely on the buttocks, the prominent hip, standing first on one foot and then on the other in order to rest the back, and the many allied variations of incorrect postures are largely dependent on the condition of the lumbar and dorsal spines.

It is not to be supposed that the above defects are the only ailments and disturbances that spinal curvatures cause, for, indeed, the defective posture may be by far a minor consideration. Disorders of body functions and affection of organic life itself are very often traced to the malaligned vertebræ.

The causes of spinal curvatures are many, but without question one of the most common causes is mechanical wrenching or twisting of the column from falls, jars, etc. Often the strain or sprain of the sections are readjusted through the inherent powers of the body, but there is a point where vis medicatrix naturae requires extraneous help to correct the perversion; and, naturally, such aid, by virtue of the cause of the disturbance, should be physical force mechanically applied. Other causes of spinal curvatures are contractions of muscles on one side of the column or paralysis of the muscles on one side; in either instance, muscular action is greater on one side than the other, which easily results in a curvature. This imbalance of muscular tension, whether due to the above or other sources such as overfatigue or various deleterious habits, is a prolific source of lesions. And among still other causes may be noted, bone diseases of the spinal column, compensatory deformities, and constitutional weakening and irritating diseases. Also, some occupations predispose to certain curvatures.

One can readily see that the treatment which is directed specifically to the cause of the vertebral deviation would be the most scientific. This is just what osteopathic work implies, direct readjustment of the sections at fault—not exercises, or routine stretching, or braces; although these latter methods may in some cases have their place as secondary aids. Of course exercises are usually physiological and may be employed, in many instances, as an auxiliary. Care should be taken to eradicate infectious foci when present.

Where curvatures are extreme, complicating and deforming the ribs, and absorbing the bodies of the vertebræ so they become wedge-shaped, and resulting from abscesses, no one can expect within reason to absolutely correct the posture. Some aggressive work can be accomplished, but a perfect symmetry will not be forthcoming. It may be well to emphasize again that where the ribs are involved the osteopath is not contending with the deformity of the spinal column alone, but in addition the entire transverse area of the body. (See also Spinal Curvatures).

Conclusion.—In concluding this rapid survey of a number of postural defects the principal lesson to be drawn is not one of developing the physique and thus perfecting a better posture, so much as curtailing and eliminating insidious beginnings of disease. These little ailments and deformities, of which postural defects may be the most noticeable, are so often the inception of more serious disorders. The anatomical structure being maladjusted, -aligned, or -positioned, easily and readily leads to consequences that require much time and patience to overcome.

Poise of body represents much to every one. Poise or correct posture coupled with careful and methodical exercise and correct breathing are material aids in constructive development, as well as in eliminating disease, for not alone may abdominal, pelvic and thoracic integrity be benefited, but the upper respiratory tract may be toned.

The most important goal that osteopathic science and art is striving for is that of a fully developed and rounded out prophylaxis or preventive treatment. When the public realizes that the proverbial ounce of prevention is an established medical reality then it can truly be said our science has reached its ultimate good. To those who are familiar with osteopathic theory, facts, and development, it is an open secret that this school holds the key to successful preventive treatment. The time is rapidly approaching when the actual lessening of diseases will be an established fact. Then will be the universal practice of the layman going periodically to his osteopath to see if there are any small or insidious beginnings of disorder or disease.

Not only must the many deleterious habits and errors of the daily regimen be corrected, but after environmental, physiological and structural adjustment, in so far as possible, has been attained, a daily regimen to maintain the normal should be instituted.