Written by Lee Jarvis. Proofreading and editing by Bobby-Jean Marrandino.
One of the hallmarks of the Osteopathic Manual Treatment (OMT) is that it is calming and gentle (with some exceptions of course). We see this tendency and capacity to calm the patient as an advantage in OMT because a patient who is calmer, not expecting a painful treatment, is much easier to work with. In the long term, it has been well established that chronic stress and pain are detrimental to one’s health [1, 2, 3, 4]. Patients who have either chronic or acute pain are not suffering solely from stress but are most often, experiencing stress because of the pain. Also, those patients who have diseases and/or medical conditions are typically under a great deal of stress from dealing with their symptoms and will greatly appreciate even a small reprieve if OMT can provide that for them. Of course, there are other more direct effects of stress (or sympathetic nervous system activation) that we could mention but the above points are sufficient for this article.
This calm state after Osteopathic Manual Treatment can be shown immediately and can have lasting effects for some days post treatment [5, 6]. One of the methods we use to generate this calmness is conducting our treatment in a rhythmic manner. In November of 2024, I discussed this topic of rhythm with Kristen Jarvis in reference to methods for working with patients and the experimentation with those methods in one’s practice. Kristin informed me that in her practice, one of her major problems is, at this point, keeping up with the workload, which is a very good problem to have as it means you are very busy with work (and in this profession you wouldn’t get paid otherwise). However, we do have to respect the quality of our work as well as our endurance at this level of workload. Kristin, as a comical anecdote, explained to me that at one of her days of experimentation in practice, she made sure that every single patient she saw that day received a very rhythmic treatment.
For those who are unaware, a rhythmic treatment involves continuous movement by the practitioner’s whole body to keep the patients’ body constantly moving. It is important to note though, it is not the patient’s entire body that must be moving, largely just an appendage plus the area of the trunk that that appendage attaches to. Though Osteopathic Manual Therapy will often use arm and hand motions, often the arm(s) holding the patients’ appendage are relatively still and the rhythmic movement is being generated from the legs and trunk of the practitioner. When the practitioner keeps their arms still and moves mainly from their lower body this tends to require much less muscular exertion (as compared to Post Isometric Relaxation maneuvers for instance which require the practitioner’s muscular resistance). Kristen had said that by the end of that day of entirely rhythmic treatments she was “completely exhausted” and that “this was probably the wrong way of going about experimenting.” Even though this point was said in a comedic way, it did lead us to the important discussion of several points regarding rhythm within our treatment methodology.
In our practice, we “practice” working in different ways as an attempt to explore better methods of being efficient and effective (or even just ways we find interesting) for both the patient and us as the practitioner. Sometimes we are successful, sometimes not, and sometimes we are successful but not in a way that’s sustainable or practical. Kristen stated that rhythm and smoothness in assessment and treatment are certainly very calming to the patient, but they can also be very physically demanding on the practitioner if done for a long duration of time. This understanding becomes an important lesson in effectively determining which patients would most benefit from this type of rhythmic treatment, in turn this also helps limit the energy needed by the practitioner themselves. It’s necessary to regularly question for whom a certain type of treatment or approach is most appropriate for if we want the best results for the patient. Consider that, if a certain way of treating a patient calms them down, it would probably be most useful in the type of patient who has excess stress or active tension. Arguably, the majority of our patients are “stressed” because they’re either in pain or suffering from a chronic disease (often both) but certainly there are patients where irritation and stress are not the main issue. As a different example, this concept is the same as when a patient has particularly stiff tissues. We, as practitioners, should aim to lengthen said tissues, which may require sustained pressure over time (which might also be called Myofascial Release).
As my discussion with Kristen continued, we quickly agreed that it was the “feel of the tissue” that is most important for determining where and when a method should be applied. The understanding of anatomy, physiology, pathology, and the patients’ history are an essential starting point but once proficiency is achieved with those things, we must be aware of what the patient in front of us is doing and react specifically to that. The “feel of the tissue” is not just passive palpation. For instance, an actively contracting muscle may feel harder or denser but so would a thickened, non-contracting tissue (as would a metallic implant as another example) and so we have to be able to differentiate between these things. To test with better accuracy, we should still palpate, but then we must pick up the appendage and move it around to test how much it moves through the expected range of motion along with the quality of movement within that range. In the case of limited range of motion, if we can see where the appendage (or part) cannot move towards and then compare it to the tissue fibre direction (muscle, ligament, fascia) that must lengthen to allow that movement, it is likely that those tissues are the unmoving culprit. Depending on the patient, this may be a localized area, several areas, or their entire body that needs to be the target of the treatment; regardless, we are better off for determining the specific work that needs to be done. Again, applying a full body rhythmic treatment to every patient can be energetically costly, we want to make sure we are only use it to the patients and areas that need it, which is unlikely to be every part of every patient that you see.
During movement through the ranges of motion of an area, feeling how the tissue allows for (or doesn’t allow for) smooth movement gives us an idea of how much active contraction is occurring. A muscle that is actively contracting cannot do so without the nerve that controls it being heightened in tone. In addition, a muscle that is “jumpy” in movement (lacks a smooth quality in range) could mean that it is irritated and contracting intermittently which means, having more than necessary movement in certain positions but not enough to halt motion entirely in others. Relative to this movement testing process, it is very important to move the region slowly and gently enough as to not illicit unnecessary contraction (which would create a false positive) or in a way that initiates an increase in pain for the patient. Determining exactly how much movement and/or force it takes to illicit a contraction can also be valuable knowledge. Possessing this knowledge tells you exactly what not to do (but this should never be done in a way that is truly painful) or better still, it defines the ranges you can safely work within with a rhythmic treatment.
An area may also be painful, whether on palpation or at rest, and this can be useful sensorial information in determining sites needing more treatment. The irritation or pain, is not always necessary for the body to be producing and this overload often can be reduced with OMT. Any reduction in unnecessary pain represents a reduction energy expenditure by the body. It also tends to be that we consciously move differently and guard our painful areas which is a mental stressor and another form of energy that does not need to be expended.
When an area of the body is found to be moving less than optimally, actively contracting, moving without smoothness through range, and painful (or any combination of these) an approach such as a gentle, rhythmically moving treatment is a wise choice by the practitioner within their treatment methodology. This rhythmic approach tends to reduce pain slowly without creating more of it, it decreases motor/muscle tone without creating a stretch reflex (more contraction), and it increases range of motion in soft tissues and joints without pain. Anything that reduces pain is inherently relaxing, however, when moving the body in this way there is usually trust gained by the patient towards the practitioner. Why might this be? Because they are often expecting the treatment to hurt or to be excessively forceful. A change in this approach is what makes them feel safe. If done correctly, palpation should cause the patient to feel more relaxed as a whole, appear more relaxed on the table, and they may even remark that they feel VERY relaxed after the treatment (which is subjective but still tends to make the practitioner feel VERY good about their work).
Additionally, this rhythmic approach seems to work better when the hand contact (or arm and body contact depending on your hold) is a relatively soft touch, using only as much pressure as is necessary to securely hold the appendage. Also, spending some of the treatment time properly communicating the goal of your manual application helps to make the patient feel at ease and begin to trust you as their practitioner.
To conclude, when the patient is not in need of this type of rhythmic treatment the benefits are no more effective than any other treatment approach (and at times not particularly effective at all). When the treatment is right for the patient, at the right time, done in the way that the patient needs it to be done, the benefits are immediately clear. We hope this explanation of rhythmic treatment and the process of applying it is clear to the reader and the ideas contained within can be applied to many other facets of their practice.
References
Blanchflower DG, Bryson A (2022) Chronic pain: Evidence from the national child development study. PLoS ONE 17(11): e0275095. https://doi.org/10.1371/journal.pone.0275095
Coyle PC, Pugliese JM, Sions JM, Eskander MS, Schrack JA, Hicks GE. Pain Provocation and the Energy Cost of Walking: A Matched Comparison Study of Older Adults With and Without Chronic Low Back Pain With Radiculopathy. J Geriatr Phys Ther. 2019 Oct/Dec;42(4):E97-E104. doi: 10.1519/JPT.0000000000000212. PMID: 30998562; PMCID: PMC6783346.
Coyle PC, Schrack JA, Hicks GE. Pain Energy Model of Mobility Limitation in the Older Adult. Pain Med. 2018 Aug 1;19(8):1559-1569. doi: 10.1093/pm/pnx089. Erratum in: Pain Med. 2019 Jun 1;20(6):1257. doi: 10.1093/pm/pnx239. PMID: 28531299; PMCID: PMC6084583.
Ellen E Barhorst, Alexander E Boruch, Dane B Cook, Jacob B Lindheimer, Pain-Related Post-Exertional Malaise in Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS) and Fibromyalgia: A Systematic Review and Three-Level Meta-Analysis, Pain Medicine, Volume 23, Issue 6, June 2022, Pages 1144–1157, https://doi.org/10.1093/pm/pnab308
Haller, H., Lauche, R., Sundberg, T. et al. Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 21, 1 (2020). https://doi.org/10.1186/s12891-019-3017-y
Rehman, Yasir, Ferguson, Hannah, Bozek, Adelina, Blair, Joshua, Allison, Ashley and Johnston, Robert. “Osteopathic Manual Treatment for Pain Severity, Functional Improvement, and Return to Work in Patients With Chronic Pain” Journal of Osteopathic Medicine, vol. 120, no. 12, 2020, pp. 888-906. https://doi.org/10.7556/jaoa.2020.128