Osteopathic Principles, Practice, and Manipulative Treatment
The Osteopathic Principles, Practice, and Manipulative Treatment domain asks you to reason from structure to function at the point of independent practice. Level 3 items rarely ask you to name a technique in isolation; they describe a patient whose somatic dysfunction must be characterized, linked to visceral or behavioral contributors through the five osteopathic models (structural, respiratory-circulatory, metabolic, neurologic, behavioral/biopsychosocial), and then treated, or deliberately not treated.
Somatic dysfunction and Fryette's laws
Somatic dysfunction is impaired or altered function of related components of the somatic system, documented as TART: Tissue texture change, Asymmetry, Restriction of motion, and Tenderness. Fryette's laws classify spinal mechanics. Type I (neutral) dysfunction has sidebending and rotation to opposite sides, occurs as a group of three or more segments, and is most common in the thoracic and lumbar spine. Type II (non-neutral) has sidebending and rotation to the same side at a single segment and is the classic acute lumbar or cervical finding.
Matching technique to patient
- HVLA: a direct thrust into the restrictive barrier; needs a cooperative patient and no fracture, instability, severe osteoporosis, myelopathy, or aneurysm. Anticoagulation is a relative caution.
- Muscle energy: patient-initiated post-isometric relaxation; the choice when HVLA is unsafe, as in osteoporosis or anticoagulation.
- Counterstrain: indirect positioning of a tender point for about 90 seconds.
- Myofascial release, Still, facilitated positional release, lymphatic pump, and cranial techniques round out the toolbox.
Viscerosomatic reflexes
Sympathetic levels: heart T1-T4, lungs T2-T7, stomach and liver/gallbladder T5-T9, small intestine T9-T11, colon and bladder T11-L2, kidneys T10-L1, uterus T10-L2, lower extremities L2-L4. Parasympathetic: vagal (occiput/C1-C2) and sacral S2-S4.
Worked example
A 68-year-old woman has chronic low back pain six weeks after an osteoporotic T12 compression fracture. Examination shows L3 left rotation restriction, tissue texture change, and tenderness. The diagnosis is L3 somatic dysfunction, type II. Because osteoporosis and recent fracture make HVLA inappropriate, muscle energy and myofascial release are chosen, with diaphragmatic breathing addressing the respiratory-circulatory model. Red flags are screened: no bowel or bladder change, saddle anesthesia, fever, or cancer history.
Traps
Treating T4 tenderness as a musculoskeletal problem in a patient with chest pressure is a viscerosomatic reflex from ischemia until proven otherwise. Reversing Fryette's laws is a classic error. Do not use HVLA on a patient taking warfarin, and never document 'OMT performed' without segment, technique, and response.