Osteopathic Neuromuscular Rehabilitation.

Dr. Eyal Lederman DO, PhD
Director, Centre for Professional Development in Osteopathy and Manual Therapy

This article is a synopsis of seven years of collaborative research between The British School of Osteopathy, King's College Physiotherapy Department, and The Centre for Professional Development in Osteopathy and Manual Therapy. The research, into the neurophysiology of osteopathic and manual therapy techniques, was carried out for my doctoral thesis. Professor Di Newham, a leading researcher in neuromuscular physiology, supervised the research. The whole project was carried out at the BSO research department. Around two hundred students kindly missed their lunch breaks to participate in the study.  The research encompassed a series of studies, which I believe represents the largest osteopathic research of its kind in the UK.
I was prompted to carry out this study by the need to understanding how my osteopathic techniques affected the motor processes in my patients. The study was a long and laborious process and its outcome was surprising and a defining point in my professional life. It has profoundly changed my clinical work and opened new avenues for treating patients that previously I would have not contemplated or used.
In this article, I would like to share with the reader my own, and other researchers' findings, which I believe, will give a better understanding of the neuromuscular system and how osteopathy can affect it.
The place to begin this journey is the set of beliefs used to describe the effects of osteopathy on the neuromuscular system. It starts with the basic belief that motor processes can be affected from the periphery by different forms of osteopathic techniques. It is believed that manual excitation of mechanoreceptors can influence the lower elements of the motor system within the spinal cord - the motoneurons ("the final pathway").
Here are some of the more common examples of the mechanisms used to explain how osteopathic technique can effect the neuromuscular system:
q Change gamma gain:
q Autogenic inhibition of muscle by stimulation of Golgi tendon organ:
q Resetting muscle spindles
q Reciprocal inhibition
q Reflex inhibition and excitation of motoneurons
q Reflex relaxation of muscle
q Altering abnormal muscle tone (hypertonia)

Virtually, all osteopathic techniques claim to be able to bring about such changes in motor processes. These include joint articulation, stretch, soft-tissue, HVT, trigger points, MET, Kinesiology, craniosacral and inhibition techniques etc.
At the heart of these principles lies the belief that motor processes can be manipulated from the periphery by manual therapy techniques. This was the foundation of my study, which in essence asked a simple question - "Can the neuromuscular system be controlled from the periphery"? If it can be shown to be open to peripheral control, it would imply that existing osteopathic techniques could provide an effective therapeutic approach to working with the neuromuscular system. If the result of the study would show the opposite, that motor processes could not be controlled from the periphery, it would suggest that treating the neuromuscular system with the current osteopathic techniques would be ineffective.

A disturbing study

In the study, the tendon reflex method was used to examine the effects of different classes of manual therapy techniques on the gain or excitability of the stretch reflex (n=180). Stimulating the stretch reflex by a tendon tap can give an indication of change in the mechanoreceptors or the spinal motoneurons. This examination would give a clear indication of whether the lower part of the motor system responded to the manual event, or if we look at it in the broader sense, whether the neuromuscular system can be controlled from the periphery.
This method has been used by other researchers to study the response of the spinal motor centres to different stimuli. The stretch reflex amplitude is measured before and after a manual technique has been applied. If the stretch reflex amplitude increases after a manual technique it implies that the system (monosynaptic reflex loop) has been excited. In this situation, more motoneurons have been "primed" by the manual technique and are closer to their threshold of response. If the reverse happens and the stretch reflex amplitude drops, it would imply that the manual technique reduced the motoneuron excitability.
The next problem I faced was how to choose the techniques for the study from all existing osteopathic techniques? I could not test all known manual techniques. To overcome this hurdle, a neurological classification system was devised for all manual techniques (Fig. 1). At the first level of classification all manual techniques were divided into "Passive" or "Active" techniques. Passive being all techniques where the patient is fully relaxed and is not participating in the manual event. Active techniques are those where the patient is participating in the treatment. Each of these two main categories can be further divided into "Static" or "Dynamic" techniques. Static describes techniques where there is no joint movement. Dynamic techniques involve joint movement. So now there are four categories: "Passive-Static", "Passive-Dynamic, "Active-Static" and "Active-Dynamic". Out of each of these categories I used a single manual technique that represented that group. I now had four different manual techniques, and was ready to test them using the stretch reflex method described above.


Nothing in my training and knowledge had prepared me for the outcome. All the techniques tested had no effect on the stretch reflex except one - Active-Dynamic. The excitability of the stretch reflex was reduced following the application of this technique. However, this reduction lasted less then a minute and thereafter the reflex system returned to its pre-manipulation amplitude (state). These results suggested that passive manual techniques have no effect on the neuromuscular system! Other researchers' work in this area confirms these results. All the manual techniques used in their studies showed no significant effect on motor processes, whether they were tested on healthy subject or those with central nervous system damage. I have also used a similar experimental protocol on a group of subjects (n=9) who tested positive for neuromuscular failure following chronic joint injury - no effect. It meant that most of the techniques that I have learned and used clinically were having little or no effect on neuromuscular conditions. This reflects in the teaching and practice of osteopathy - neuromuscular rehabilitation is virtually non-existent in our discipline.

More questions than answers

Now two main questions arise: the first is why can't passive techniques affect motor processes, and second, if active techniques can produce a change, how could these be made permanent?
At this point I had to look at the extensive research into motor control to find the answers to the above questions. The answer to the first question is straightforward: motor processes are organised centrally, flowing in a centrifugal pattern - from the motor centres outward to the muscles. Proprioceptors, surprisingly, do not control motor activity at all! They only provide feedback. Indeed, studies in animals and humans show that when proprioceptors are "disconnected" (by injury, surgical procedure or disease process), movement can still be carried out, almost unaffected (provided it has been learned before the disconnection). The stimulation of proprioceptors by osteopathic techniques will only provide feedback, but cannot influence motor processes, no matter which technique is used.
There are situations where feedback can be used to alter motor processes. This tends to only occur when the system is active, i.e. when there is voluntary movement. This was very unpleasant news. Virtually, all my osteopathic techniques were passive using feedback but against a background of patient inactivity. To effectively alter motor processes my osteopathic techniques had to stimulate "the centre" rather than the periphery (proprioceptors). Research was showing that I had to engage the person cognitively and actively. It implies that passive osteopathic techniques will only stimulate feedback. Without the patient participating actively it is unlikely that motor processes will be affected.
My own study was showing a short lasting effect when an Active-Dynamic technique was used. This brings us to the second question - how do you make the motor change long lasting? Was there a natural motor process which promoted long term changes in the neuromuscular system? The process by which motor patterns seem to be encoded was shown to be through motor learning and neuroplasticity.

Motor learning: breaking the code

The neuromuscular system is well buffered against external influences and it is through the motor learning process that the neuromuscular system adapts. During our normal daily activity we perform many motor acts which do not become encoded in the system. We only retain (remember) some of the patterns. This implies that being active is not enough. There must be other elements to the signal that initiate neuromuscular plasticity. A door with a combination lock is a good analogy for this signal. Only knowledge of the full code allows you in. My next task was to identify the full code for motor learning and apply it to my osteopathic techniques. Presumably, if my osteopathic techniques could imitate the natural process of motor learning my work with the patient would have permanent effects.
Looking at motor learning studies the signal for neuroplasticity has five essential code elements:

1.Cognition-awareness and attention, decision making and understanding of the process
2. Activity - voluntary movement
3. Feedback- which can be proprioceptive, verbal or visual
4. Repetition - repeating the pattern
5. Similarity (transference) principle - we learn what we practice

Each of the code elements is an essential part of the treatment; removing one will result in an ineffective treatment.
At the time I was doing my research I was also in the fortunate position of supervising the fourth year students at the BSO. I was therefore able to involve them in testing some of the new findings. One student, John Dalkirn, elegantly put the five code elements to the test. He tested motor control and coordination through balancing ability, before and after different manual techniques (n=60). He used the neurological classification to select the techniques: soft tissue to the whole leg (Passive-Static); passive articulation of the whole LEX (Passive-Dynamic); isometric leg straightening (Active-Static); and cycling with the LEX against resistance (Active-Dynamic). At my insistence he added one more technique - challenging balance by gently pushing the subjects in different directions while standing on a beam - applying the 'similarity principle'. To his surprise (and my relief) the results followed a predictable pattern. Passive techniques had no significant effect on balance. They were inactive and lacked the similarity elements. In the case of the Passive-Static, the repetition element was also lacking.
Significant changes were observed in the active technique group especially as the techniques became dynamic. The Active-Dynamic group almost had the full code - it was cognitive, active, repetitive, but dissimilar to balancing. The real dramatic change in balancing ability took place when the similarity principle was introduced to the technique; when the subjects' balance was being challenged. This group received the full five elements of the code and consequently showed far greater improvement than any of the other groups.

Osteopathic Neuromuscular Rehabilitation (ONR)

By the time I completed the research it was clear that there were no existing, effective osteopathic techniques for treating the neuromuscular system. There was an urgent need to develop a completely new approach in this area of osteopathy. I have been working on this task over the last four years, developing a methodological approach to treating the neuromuscular system. This approach is called Osteopathic Neuromuscular Rehabilitation (ONR, formally known as Active Technique). ONR is heavily based on the code elements described above. It can be used in different clinical situation where there are observable behavioural and neuromuscular changes. These clinical situations can be divided into two main groups:

1. In the undamaged nervous system: working with posture, movement patterns, relaxation and neuromuscular changes following musculoskeletal injury.
2. In the damaged nervous system: working with neuromuscular manifestations of central nervous system damage (for example stroke patients)

Interestingly, rehabilitation of any of the conditions described above share a fundamental similarity. They all rely on neuromuscular plasticity for change and therefore the use of the five code elements as the signal for adaptation. Whether you are an osteopath working with posture, movement education, ergonomics, exercise, neuromuscular changes following musculoskeletal injury, relaxation techniques, stroke patient, MS patients or children with cerebral palsy, the code elements are the basis of the treatment design.

The future

ONR is a new treatment approach for working with the neuromuscular system. It offers new therapeutic opportunities, increasing the spectrum of conditions we can treat. Further clinical and neurophysiological research is essential for its development. We must see ONR introduced into undergraduate osteopathy training. I am currently initiating more research in this area and looking for further collaborative research with other disciplines and institutes.
ONR is a novel and exciting new approach in osteopathy. It offers a more exact, scientific based therapeutic approach, and, most importantly, it has the potential to provide our patients with a better therapeutic outcome.

Further reading:
Full text and references on neuromuscular rehabilitation can be found in:
E. Lederman 1998 The Effect of Manual Therapy Techniques on the Neuromuscular System. Copy of PhD thesis at BSO library
E. Lederman 1997 Fundamentals of Manual Therapy, Section 2, Churchill Livingston, Edinburgh
DJ Newham & E Lederman 1997 Effect of manual therapy techniques on the stretch reflex in normal human quadriceps. Disability and Rehabilitation 19:8:326-331
Dr. E. Lederman & John Dalkirn 1997 Effects of different types of manual techniques on short term balance ability. (To be published). Copy can be found at BSO library