Written by Lee Jarvis. Proofreading and editing by Rebecca Anderson.
I’ve been doing interview articles for the CJO with Osteopathic Manual Therapists for over a year now and have noticed a quality that always arises in these interviews, which is highly regarded by both myself and these practitioners. This quality is considered highly valuable because it speaks to the practitioner’s desire to improve the care delivered to their patients and the desire to continue learning. The quality I’m speaking of is the capacity for self-reflection and self-correction. I could see this quality again when I interviewed Kristen Jarvis in November of 2024, wherein she said, “What haven’t I looked at yet?”
On its own, such a statement almost appears to be an admission of fault and a feeling of guilt for that fault, but this is not the case. Earlier in our conversation, Kristen (see first article based on this conversation here) stated that she saw 22 to 30 patients per day. Technically, this was not the highest number of daily patients I’ve heard a practitioner mention, but it’s darn near close and a number that most seasoned practitioners would agree is challenging to sustain for any length of time unless you are quite intelligent with how you work. However, I’ve covered the concepts of low physical effort manual methods in the past and will not be explaining that subject here.
Kristen stated that with the mental effort it takes to keep up with this busy practice, it is very common to work in effective but too easily repeatable ways. A reliable method is typically suitable, but “reliable” does not always mean “best.” Osteopathic Manual Therapy should always be done in a way that is safe for patient and practitioner and neither should be injured because of the treatment. After ensuring we are safe practitioners, we must also be effective practitioners (or you will find that very few people will be interested in seeking your care). How a practitioner achieves safety and effectiveness is on some level individual to them, as everyone has their own ways of sequencing treatment, moving their body proportions around the table, and moving the patient’s body proportions on the table. When you’ve worked for many years, it’s very common to develop ways that work best “just for you,” which are different but still as effective as ways that work for other practitioners. In repeating these methods you’ve developed, which have been proven safe and effective, we can become complacent and start to expect a result without necessarily first observing the findings that support the use of that method.
In Osteopathy, if we believe that the body works together (as a unit), then it’s worth investigating as many areas of the body as possible to complete our assessment and treatment processes. If the body works together, each part of the body can potentially contribute to the overall issue(s). From this viewpoint, we would say that it is vital to investigate even small parts of the body, even ones we don’t think contribute to the patient’s complaints. It is essential to view the whole body and investigate thoroughly outside the habits of “what typically works well” when things are not progressing with specific patients or when they are not improving fast enough.
When Kristen said that in practice, she asked herself, “What haven’t I looked at yet?” it is a strategy to combat both complacency and unknown areas that could be contributing to the problem. Kristen further stated that in a successful practice, “You can just do the things that work well, but in that process, you leave Osteopathy.” This is a remarkably accurate statement and a fantastic way of acknowledging that though the manual manipulation you perform can be effective, Osteopathy should always require thought and care for the specific patient with their specific bodily circumstances right in front of you. To do manual work without assessment or understanding the body is to apply manipulation mindlessly.
This concept is also readily applicable to other non-manual concepts. We should all be well-versed and reminded of red flags and indicators of emergency or pathology, especially as the field of pathophysiology grows. The physical habits and practices (amount of exercise for instance) done in the patient’s daily life (or the lack thereof) are always a good thing to be aware of as they can help to define the goals of and/or capacity for recovery. In your patients with diagnosed diseases, it’s essential to regularly review the potential signs and symptoms of the general disease to understand the progression of the disease better. Often, on that same note, understanding the potential for emerging side effects of a medication in the short and long term can help to understand a patient’s progression in the treatment of their disease.
Turning back to the manual application of this idea, Kristen defined some of the areas that are small, often forgotten, but still capable of being significant enough to cause or be part of a larger problem.
The following is not an absolute list; it is just things Kristen and I noted in our conversation. In no particular order:
The Popliteus, bordered on all sides by the Hamstrings and Gastrocnemius
The Coccyx, with its relation to the pelvic floor
The Iliolumbar Ligaments, connecting the Ilium to the L5-4
The Intercostal Spaces, though, be cautious as they can be very uncomfortable
The Costal Chondral Cartilages, strongly constructed
The Pronator Teres, hidden amongst the forearm flexors
The Hyoid Muscles, bridging the mandible and Sternum
We hope this information helps the reader in their process and understanding of the lesser-discussed parts of the body. As with anything, the practitioner’s capacity to utilize treatment of these smaller regions is determined by your willingness to investigate and patience. So, what else haven’t we looked at yet?