By Wayne Oliver, M.OMSc and Lee Jarvis, M.OMSc. Proofreading and editing by Chantalle Fortin.
Wayne Oliver graduated from the Canadian Academy of Osteopathy (CAO) in 2017 and is currently the Director of Labs at the CAO.
Continuing from our last article,
It was at this point of our conversation Wayne conducted a physical demonstration on the treatment table. I was the demonstration patient in this case, and though I do not have any issues with excess fluid it was still an effective demonstration of the process.
In this demonstration Wayne chose to start at the top of the patient, and work his way down. He indicated that a top down approach is not the only way to do it; but is in this case the approach best used. The indication for starting at the top is, sometimes, simply that there appears to be more of an issue (structural or fluid) in the superior portions of the body. This warrants determining some of the larger problems before we follow the lesion elsewhere.
If we are seated above the patient’s head, it’s only natural to first assess the Superior Thoracic Aperture (STA) since it’s relevant both in hand position and fluid significance. The STA is a significant area of fluid flow, as we have the lymphatic ducts and the thoracic duct passing right through this area into the chest. In addition to these lymphatic drainage pathways there is extensive vascular and nervous tissue that passes through this region.
A clear pathway for drainage and supply must exist in order for a working anatomical/ physiological relationship between the STA, and body as a unit. The cranium returns its blood supply into the superior vena cava via the internal and external jugular veins, which feed into the brachiocephalic vein on the left, and subclavian on the right. The head and neck are supplied with blood via the carotid artery through its internal and external branches. These vessels are all found in the carotid sheath with the Vagus nerve. This nerve travels down through the sheath, from the cranium to the supply afferent and efferent branches to the face, neck, thoracic and abdominal viscera as it relays motor and sensory information.
Additionally, the STA area gives us an impression of the breathing capacity of the patient as we are also checking respiration. This gives us an idea of ribcage motion as well as respiratory diaphragm motion. Because this is the top of the rib cage, it is only a partial impression but it is something to compare to when we work lower into the ribcage later on.
From the STA Wayne then worked his way out to the Axilla area. Based on his handhold, Wayne was checking a wider area, his fingers wrapped over the Pectoral region into the axilla and his palms were able to palpate the clavicles.
With this hold, he was able to lift up and down demonstrating one side (the left) was held down. To be more specific the region was unable to be lifted towards the head (Cephalad) and so we would say it is being held towards the lower body (Caudad).
At this point Wayne did a brief check of my neck (Cervical Spine) region. Brief, only because he was surprised by his findings, and remarked “Hey, this actually moves.” I was also equally confused by this because normally, after having done many years of martial arts in my youth (and being punched in the head arguably more than was necessary), my neck is usually poorly moving at best. I have known Wayne for sometime now and he is aware of my typical neck mobility, hence the reason we were both surprised by the good quality movement in that area. I chalk it up to having received several Osteopathic treatments in the previous few weeks which resulted in improved motion quality of the area.
Typically when considering fluid in a treatment process, we work our way through not only the back/spinal portion, but the lateral sides and anterior portions of the neck. These lateral and anterior regions have an extensive amount of lymph nodes and many multi-directional muscles for these lymph nodes and vessels to wrap around.
Prioritizing movement in the neck should be considered of high importance in this type of treatment, though as the assessment proved it was moving more than well enough, Wayne moved on. Since it was still assessment at this point, he went to the lower portion of the body starting in the Inguinal region (see part 1 of this interview article for a review of this anatomic region).
Utilizing a double hand hold, Wayne assessed the inguinal region. This hold was a wide contact made by placing the hands together over the inguinal ligament. The lowest part of the palms were on the inguinal ligament, spanning the entirety of it, and the fingers were loosely contacting the abdominal region.
Lifting his hands superiorly Wayne explained he was attempting to “bow” the inguinal area as a whole. The term “Bow” in this case indicates turning a relatively straight tissue into a curved shape, like the bow of a bow and arrow. This takes the tissue through a significant range of motion as a whole.
Being able to see the general characteristics of an area of tissue first, is often a good idea as it helps us to determine how well something moves, and if it’s worth assessing further. Once we’ve assessed a general area and found it to be restricted in some way, the direction of restriction will usually give us an indication of more specific work to be done.
It is notable that Wayne was checking lines as he went throughout this demonstration. For those unfamiliar with this methodology, it is something (mostly) specific to the CAO and would need a great deal of explanation outside of this particular article and so will be omitted.
Wayne then moved back to the top of the table. From the top of the table used a double arm lifting maneuver, lifting vertical relative to the body or leaning backwards from the operator perspective.
As he was doing this, Wayne explained that he had discovered something in the left inguinal and could relate it to what he initially found in the left upper ribs. At that point, he specifically pulled (created long leverage) from the arm to the inguinal region as a method of addressing both.
I want to mention that Wayne connected the left shoulder to the left inguinal area very well. As a patient, I could feel the clearly established pull being generated from the shoulder to the inguinal region. Any extra pull done through the arm could be immediately felt in the inguinal area, the tissue slack between each region having been taken out. That being said, the pull was created and carried out very gently. Needing almost no effort on his part other than a lean back while still satisfying the leverage component and the release component. This is yet another example of how manual methods do not have to be forceful to be effective.
Continuing on, Wayne showed re-testing an area after treating it, saying “Do something, check something. Do something, check something.” This expression indicates a successful approach, often called “reassessment” as it ensures you know what your original findings were and you are observing them change for the better (hopefully). The re-tested area in this case being the inguinal which Wayne found to have satisfactorily changed.
From here on in the interview, Wayne largely explained the next steps in the process and treatment.
We then discussed treatment of the Respiratory Diaphragm via upper body through long leverage of the arms as shown previously. Here we are pulling deeper (or lower down) and using the attachments of the arms to help lift the ribs.
Approaching the respiratory diaphragm directly on its attachments is a completely normal thing to do (and sometimes what is necessary to get the job done); but approaching any kind of a distal structure through a long leverage helps to create an understanding of the connection between those related areas that is not as obvious with a short lever approach. Relative to this position Wayne talked about utilizing “Staccato Breathing”, something he explained was inspired from his previous Pilates training. Sometimes this type of breathing is also called “Step Breathing” wherein the patient takes a breath, briefly holds it, takes another breath in, holds it briefly again, and so on until a comfortable maximum intake of air is reached. This allows the individual to follow a more gradual process of taking deeper breaths, fully expanding their ribs, and fully dropping the respiratory diaphragm down. When the practitioner is holding the arms and tractions them backwards, this type of staccato breathing also gives us the opportunity to coordinate with the gradual process of raising the ribs and encourages them to rise as needed on each side.
Another method of achieving a similar effect to a staccato breathing approach is to alternate between diaphragmatic breath and chest breath. Diaphragmatic breath keeps the ribs relatively still on the breath in and allows the abdominal region to expand to create space for a fuller vertically inhalation. Breathing “with the chest” still uses the diaphragm, but we are attempting to expand the ribcage as much as possible. Though there is still some vertical lowering of the diaphragm, we get a lot more lateral expansion and spinal extension with a chest breath. As each breathing style allows for more focused movement to be brought into the specific anatomy, it will also allow the practitioner to better determine where a lacking in motion might be, and so it is a form of assessment. We can subsequently, with this double arm hold, encourage the motion lacking with our direction of pull/leverage.
Wayne then touched on the idea that once the trunk was sufficiently treated, we would work our way out through the appendages by following the neurovascular pathways. As this was outlined in the previous article, and a more thorough explanation would require a separate article entirely, it will be omitted in this write up.
I very much appreciated Wayne taking the time out of his very busy schedule to talk about Osteopathy and learning about it in a professional clinic. Wayne is one who is truly “built” for the profession, whether in practice or in educating others, and so it is always an exciting and worthwhile experience.