Note: This version is a longer more complete version of a recent article titled “holism in Osteopathic treatment” which appeared in “Osteo life; Osteopathy Australia Magazine; winter edition 2017, p28.” I have included this version here because it offers some practical examples of implementing holistic principles in practice which i feel would be of benefit, not only to Osteopathic readers but also for practitioners in any manual health profession.
Introduction
This article describes a framework for holistic practice which supports the application of Osteopathic philosophy and principles on a practical integrative level. Osteopathy is based upon the principles of 1) Unity of function; 2) structure and function are interrelated 3) the body has self-healing mechanisms and 4) treatment requires a sound understanding of the first three principles (1). However, it is one thing to ‘know of’ these principles conceptually on an intellectual level and another to ‘understand’ these principles at a deep integrative practical level. This author conducted grounded theory research investigating the meaning of holism to experienced Osteopathic practitioners with the goal of developing a theory which bridges the gap between concept and practice and also to explore how holistic and biomedical approaches inter-relate. For detailed information on the theoretical framework of holism, please refer to this research (2). Here I will discuss a few of the key elements of this research relative to practice and then talk through a practical example of how a holistic assessment may be applied for interest of readers.
Key Research insights (2, 4)
Firstly, it emerged that holism (theoretically and practically) can mean different things to different practitioners. The whole person to some includes only the ‘whole musculoskeletal system’; for others the ‘whole physical body’ and yet others will include or omit (according to their temperaments, education or beliefs about what constitutes one’s scope of practice) other components such as energies, forces, emotions, mind, spirit, social (relationship with others) and environmental components, nutrition, time components (in that past issues can set the stage for issues manifesting in the present moment) or other possible links (2). With consideration of all of the components that make up a whole person, it could be argued that a practitioner can manipulate joints within, or massage, the whole person (top to toe) but this is technically not holistic because it does not cater for the rest of the whole being and other life influences. Obviously the more components one includes into one’s awareness the more potentially holistic one is in practice.
Secondly, it emerged that considering components (in isolation) was not enough to define holistic practice. The more important factor to consider was ‘RELATIONSHIPS’ between components. This is particularly important to understand patients with chronic health issues. Simple issues may involve one or a few relationship imbalances within a problem pattern, whereas chronic issues may involve the complex inter-relation of many involved component parts and relationship conflicts (2). The idea of Unity of body, mind, Spirit in Osteopathic philosophy relates to their being harmonious function within the whole person where all components of the whole exist in balanced relationship. We treat the person with the problem rather than only the part with symptoms. We treat to restore unity of function (relationships), which is a different emphasis to focusing on structural symmetry alone.
Furthermore, through recognising and directing treatments to helping to remove impediments (in any contributing relationship) to the natural healing process, we can better support the self-healing mechanisms do their work unimpeded to optimise patient recovery.
To understand these principles in action and also how holism and biomedicine relate and what each contribute to the bigger picture, there are two important KEY relationships to consider.
- The relationship between the tissues or condition causing the symptoms and the symptoms themselves.
- The relationship between everything else going on in a whole person’s life (coded ’WHAT ELSE’) and the tissues causing symptoms.
Relationship 1) is the primary relationship explored with traditional biomedical education (e.g. regional assessments/tests to identify tissues or conditions and the knowledge of anatomy, possible conditions and so forth). Relationship 2) comprises other relationships explored with holistic assessment and treatment. It is not hard to appreciate that if a practitioner understood relationship 2) it would provide the context for better understanding relationship 1) and thus help towards structuring a more complete assessment, treatment and management plan. Participants in this author’s study felt that both approaches were necessary for balanced education and practice (2).
Biomedical educational knowledge and information from a history, although important, does not tell a practitioner what to treat but rather only informs him/her of possibilities to explore during assessment. There may be other unknown possibilities of relationship conflicts outside of this sphere of considered knowledge or issues the patient may not tell us about but which are there underlying. To discover the ‘what else’ it is advisable, therefore, to lay this (theoretical and verbal) information aside (temporarily so it doesn’t distract from, or limit the, exploring the ‘what else’) and always perform a general assessment of the whole person for meaningful ‘non-verbal tissue’ clues about what is actually happening in any given case. This serves to open the mind to other leads, teach us something new and, once found, may guide us to explore other verbal or non-verbal (tissue) leads for further information to make the total picture clearer.
What determines what actually is there to treat is therefore not directed by the text books, but rather through identifying the ‘what else’ is actually present from our holistic assessment.
A holistic assessment is necessary for the simple reason that we don’t know ‘what else’ is present unless we look for it and if there, we may find it and be able to include it into the treatment process to some degree (2). At the very least, if certain components emerge as present and influencing the presenting condition and which a practitioner is not personally comfortable treating; they can be catered for by referring to the appropriate health professional that is trained in dealing with those components. If we consider other relationships, we are more likely to recognise them. If we recognise them we are more able to include them into our treatment directly (engaging involved components/relationships with any treatment technique) or indirectly (via influencing these relationship imbalances through other tissues we do comfortably treat; such as articulating vertebral levels relating to sympathetic innervations to organs while we think about the relationships between what we are doing and the organ system we are trying to effect). Otherwise they are out of mind out of sight. Articulating a vertebra to improve its relationship with another joint is one thing but articulating it to influence its relationship with muscles, other areas, organs, mind, emotions and so on may be a very different thing entirely. The only limit being what components and relationships we do actually consider throughout assessment and treatment.
Once all potential components and relationship imbalances have been identified from history and assessment, our biomedical education then becomes useful again by providing the language we need to first relate (all verbal and non-verbal clues present) and explain the relationships between the ‘what else’ and the ‘tissues causing symptoms’ and thus explain, as best as able, the entire pattern of dysfunction – cause, maintaining and contributing factors to effect. This is a more accurate definition, to this authors mind, of a complete working diagnosis. This sets the stage for a rational and holistic management program which can support the resolution of all involved conflicted relationships.
Identifying the ‘what else’
How then do we recognise significant (non-verbal) clues from our assessment to identify the “what else” in addition to identifying the tissues causing symptoms?
The first requirement is an open mind free of preconceived expectation or limited belief. How, for example, is one to observe for the presence of emotional clues (be they visual, textural or other) if the mind is firmly fixed only on muscles and joints and not open to anything else?
The next requirement is having a good general assessment process for uncovering the ‘what else’. This, fortunately we do have with our General screening process. We have only to use it with clear purpose about what it is for.
Finally, we need to train our human instruments (our minds and senses) to be able to ‘receive’ information from our assessment processes (through a balanced practitioner-patient interaction) to observe, feel or otherwise sense what is actually present. In this way we allow the body’s tissues to reveal to us its story and help us to understand not only what is causing pain/symptoms, but how this all came to be (i.e. provide context). It is very well to run through a general assessment but it is another thing to actually pay attention (or listen) to what the tissues have to say in response to our assessment processes. One must get good at ‘receiving, listening, feeling, observing’ responses to our investigations (what we notice) and not merely doing (and/or relying on patients verbal feedback alone).
Although most participants in this author’s study felt investigating the area with symptoms was important, it emerged that symptoms and pain had very little to do with how they determined ‘what else’ was actually present. All participants included other areas in treatment or they wouldn’t get good results. When they analysed how they recognised these areas it emerged that it was primarily through ‘feeling’ TISSUE TEXTURE and the presence of dysfunction that guided them (2). Dysfunction can be recognised by the QUALITY of movement between any two components of the whole person. It is either balanced or not (i.e. they communicate or are in conflict).
Range of motion is not sufficient on its own because although range may be limited, the quality of movement throughout this limited range may be healthy and thus is technically functioning. Why would we ignore the tissue clues, when this is the case, and treat a relationship that may actually be functioning ok, just because it might be tight, asymmetrical or even symptomatic? Compensatory structures, for example (including often symptomatic tissues) may be asymmetrical and/or limited in range and even tender and yet be functioning perfectly ok. In fact, if they weren’t they couldn’t maintain posture. Symptomatic components are often tissues trying to cope with stressful forces (compressive or tensile) which they can do up to a point. When they can’t cope anymore, they break down and suffer structural damage. Treating them on their own therefore (with first aid or symptomatic treatment) only results in getting them coping with the stress again (which is often still there predisposing). Until the ‘what else’ (if present) is also dealt with, symptomatic treatment is only temporary at best.
The KEY to identifying the ‘What else’ is therefore by observing/feeling and sensing for primary areas of A.R.T. (Asymmetry, Range of Motion Abnormality and Tissue Texture Changes). Note that the word ‘range’ is a little misleading in the context of relationship imbalanced (as described above) whereas the word abnormality, to my thinking, is more revealing. ‘R.’ should technically refer to a ‘quality of motion’ (i.e. relationship) imbalance. The primary area of A.R.T. therefore represents the manifestation within the physical body of all of the potential relationship imbalances present within a person’s whole life and being (2). I will talk about how to link it up to other non-musculoskeletal links in a moment but for now ART is how we recognise the “what else” within the whole posture.
It is worth mentioning here also that some Osteopathic text books mention A.R.T. (3) whereas others mention T.A.R.T. (the other T. refers to tenderness) (1). This authors research did not support the use of T.A.R.T., at least in terms of identifying the ‘what else’ which is potentially present. However, if we consider the emphasis in modern education on a biomedical approach which focuses primarily on the relationship between the tissues causing symptoms and the symptoms, then the T.A.R.T concept may be more applicable to identifying the key dysfunctional tissues in the region with symptoms (2). It could also be argued that tenderness is more a subjective finding (what the patient feels) and rather than an objective finding (what a practitioner feels) and thus allies more with symptomatic tissues (which technically may relate more to a breakdown in structural integrity in a tissue under imbalanced load than the dysfunctional relationships elsewhere setting up this load). Understanding the two key relationships mentioned earlier therefore throws light on concepts such as A.R.T and T.A.R.T and how they fit into our model of practice.
The use of A.R.T to identify the ‘What else’ is going on could well be a connecting link to understanding the ART and uniqueness of the holistic Osteopathic approach to practice and to treating people rather than parts. Also, A.R.T should not be confined to joints but can represent any tissue or area of the whole person.
Practical example
With this all in mind it may be useful to talk through a brief example of how all this works in practice and fill in some other potential important gaps in our understanding of how it all fits together as we go.
Consider a patient presenting with shoulder pain. Our education makes us immediately think of possible conditions and tissues which might be causing symptoms (our possible Differential diagnosis list so to speak). Of course it is quite possible that all of these possibilities are present or none of them and there is something else entirely going on outside of our possibilities list. So logic dictates we keep an open mind, even in relation to the tissues causing symptoms. So we ask all the usual questions about the current problem to obtain as many verbal clues as possible (present and past history). In reference to our two key relationships this gives us verbal clues to everything to do with relationship 1).
Being holistic Osteopathic practitioners however we know there are likely to be other possible relationship issues in other elements of a person’s life which may be contributing to, or complicating recovery from, the presenting situation (i.e. interfering with the self-healing mechanisms). We therefore inquire about relationship 2) – the ‘what else’. So we ask about life history, past history, old accidents, injuries and operations, general health questions, questions about the organ systems, sporting, lifestyle, diet and other questions. In this author’s experience these questions are a part of our traditional education and are often thought about to identify contraindications or other more life threatening issues that we need to be aware of or other external factors (such as technique at sport) that may need to be managed in addition to treatment or for referral purposes. Since we are exploring connections with ‘other things’ and following them up like a good detective, they can also reveal much more. They inform us verbally about ‘what else’ may be potentially present and once uncovered, we shouldn’t forget about them and move onto a purely ‘musculoskeletal’ treatment just because we think we only treat muscles and joints (i.e. without being mindful of links). It reminds us to explore these relationships when we are observing, feeling and sensing the tissues.
In this example, in addition to shoulder pain, the patient reports some gastrointestinal tract (G.I.T.) issues, some occasional low back ache and a few weeks prior to the shoulder problem starting there were some marital issues resulting in a breakup. She plays badminton also. To make this meaningful and mindful, this should immediately make us think of potential components likely to be present (e.g. shoulder anatomy and postural links with other regions, G.I.T. organs, neural links via relevant spinal segments to the shoulder, back or G.I.T., emotional and mental components and possibly other links not immediately apparent). This should mean we investigate (or at least be mindful of) these relationships during our assessment to explore if there is any non-verbal textural evidence to their presence. This is an example of thinking always about relationships and not just anatomical parts (muscles, bones, conditions etc) in isolation.
We then move onto assessment. The following are some important concepts to be aware of (Note – this is derived in part from research(2) and in part from common sense clinical reasoning):
- Assess the whole person (general screening) for key areas of A.R.T (the ‘what else’) – including a more detailed regional assessment here to identify any primary areas component parts and relationships.
- Assess symptomatic regions to Identify tissues causing symptoms (damaged, impinged and otherwise stressed tissues) and any local A.R.T.s which give a clue what tissues may need treatment and which are adaptive in the symptomatic area (if present at all).
- Assess using a variety of assessment tools, especially observation (visual clues), palpation (tactile clues) of symmetry and textural clues and motion tests for motion quality (which you likewise may see and/or feel). Progress from general to regional to local as the assessment progresses. Observe the whole posture, feel the tissues generally (with palms for general impression) and assess movement and gait, not for details at the start but, for general areas of healthy and dysfunctional movement. Then repeat on a regional level for more details and to identify involved components.
- Notice how symmetry, texture and motion quality changes in different postures (e.g. standing, sitting, lying), particularly in the area of primary A.R.T and in the region with symptoms. This can be very revealing. If for example findings change in different postures then they may indicate adaptive issues. Some tissues may function in one posture and not in another. If we reason it thorough we can see that their function is contingent on other areas/tissues and so technically are able to (adaptively) function and not a true (fixed) dysfunction. They are merely adapting in the same way a person can’t bend right (limited range) when another person is pushing them left and holding them there. A true dysfunction is present in every posture (i.e. it is consistent). However, it may be masked in relieving postures and more obvious in aggravating postures (perhaps relating to verbal clues from the history about aggravating/relieving factors).
- Observe, feel, sense for the presence of health (texture) and healthy movement because this gives contrast to the areas which are dysfunctional and can also indicate (with experience) where and when to treat certain areas in accordance with the self-healing mechanisms.
Having done all of this, a working diagnosis (explanation) explaining the relationships between the ‘what else’ and the symptoms might look something like this:
A primary restriction in the right sacroiliac joint, sacrum (marked left rotation and side tilt) and lower thoracic-upper lumbar (T/L) region, associated with a hypertonic right Quadrates Lumborum is holding the lumbar region in a right side bending and slight left rotation (pulling the right pelvis upwards) with the trunk above pulling inferior on the right and rotating right, resulting in the right scapula shifting up and laterally effecting right scapulo-thoracic rhythm (not upwardly rotating on shoulder abduction). The right humeral head being held forward and internal rotated to compensate for the altered trunk and scapular position. This together with her overhead movements with badminton is impinging the right supraspinatus tendon and causing pain. The restriction in the sacrum and the T/L region (linking with PNS and SNS innervations to the bowel) may contribute to G.I T. Issues. Contributing factors may be emotional/mental stress from a recent marriage breakup further contributing to neural tension and imbalance between the T/L region and the sacral regions (which were not communicating on assessment).
This explanation forms a possible working diagnosis (or working hypothesis that most fits the findings) that a practitioner can use to formulate a rational treatment and rehabilitation plan.
Developing the mind and senses as screening tools
If the primary area of A.R.T. (being between the T/L and pelvic regions) represents the physical expression of other life imbalances (in this case digestive and potential psychological issues from a marriage break up), how then can we confirm in the tissues the presence of these other issues? This can be explored using the concept of layer palpation or the exercise of thinking through layers of anatomy (skin, fascia, muscle, etc) and feeling the response in the tissues as our minds explore each component in turn; observing also how the relationship changes as we move from one structure to another (3). The hands stay in the same spot but the mind explores the tissues. This concept can be extended further by simply adding in ‘extra anatomy’ (other than only the musculoskeletal), which allows us to explore other relationship links potentially present in the tissues (organ links, mind, emotion, vitality, diet, etc).
An important concept emerging from this author’s research was that if mindful of a component (from assessment) then it may automatically become incorporated into treatment (at some level)(4)
For example: if we are mindful that a patient is emotionally distressed then our treatment will more likely be gentle, soothing and supportive. Simply being mindful of the presence of this component changes the way we interact with the tissues, even if occurs on a purely subconscious level. Having felt a region of A.R.T. from postural assessment and felt the state of the musculoskeletal anatomy we could try a layer palpation exercise to feel what happens in response to non-verbal questions (e.g. our thoughts). For example, when we think about a patient’s emotional state while feeling the back muscles, we might find the whole area tenses up or relaxes to reflect that state.
For a mechanical practitioner this may be a useful way to explore the tissues. For example, feel the muscles on their own, then feel the same structures when thinking of their nerve supply, relationship with bony landmarks surrounding, underlying organs or neurological organ links, emotional or mental state. If the mind is open to feeling things ‘as they are’ you may notice the symmetry-texture-motion changes as you explore the anatomy.
For a bio-energetic practitioner, the same concept applies except one feels the effect on inner rhythms (motion), texture and symmetry as the various tissues, layers and relationships are mentally explored. Assessment and treatment therefore is only limited by the anatomy considered as one explores various relationships within or without the human body. The mind is the connecting link.
During treatment one literally holds all the relationships uncovered from assessment in one’s awareness while treatment is carried out. How else are we to tell if any relationship imbalance has improved if we are not aware of it to begin with? The clue that any treatment has been successful is not necessarily about pain/symptoms but rather the restoration of balanced function in any involved relationships and more importantly, in the whole person as an integrated unit of function.
Conclusion
It can be seen therefore from the above discussion that in order to practice holistically, one has to have an understanding about what components make up the whole person (which is influenced by background education, belief and life experience) as well as to understand the relationship between these components. Relationships are assessed through acknowledging function (in addition to texture and symmetry) between any two components of the whole person (i.e. the quality of relationship). A balanced relationship functions in harmony and an imbalanced one doesn’t. Two key relationships are explored during a holistic assessment: 1) between the tissues causing symptoms and the symptoms themselves (primarily emphasised with a biomedical education) and 2) between the ‘what else’ and the symptomatic tissues (identified primarily through a general or holistic assessment for primary areas of A.R.T). By exploring both of these relationships and discussing some practical clues about how holistic elements can be implemented in practice, it is hoped that the holistic theoretical framework presented will help rebalance the emphasis in both education and clinical practice in order to support a more integrated model of healthcare.
References
- Ward RC, editor. Foundations for Osteopathic Medicine. Baltimore, Maryland: Williams & Wilkins; 1997.
- Turner PWD, Holroyd E. Holism in Osteopathy – Bridging the gap between concept and practice: A grounded theory study. International Journal of Osteopathic Medicine. 2016 12//;22:40-51.
- Greenman PE. Principles of Manual Medicine. Baltimore, Maryland: Williams & Wilkins; 1989.
- Turner P. Holism in [Osteopathic] Health Care, RMIT Health Sciences, Melbourne, Australia. [Unpublished Thesis]. In press 2014.
