Essentials of Complementary and Alternative Medicine (June 1999)

THE STRUCTURAL EXAMINATION
General Considerations
As in any approach to medicine, the physician must develop certain clinical skills to gather sufficient data. There are many exercises that assist the clinician or 
student in further developing palpatory abilities (
6
). For example, some of my teachers had us practice placing our hand on the center of a long table which had a coin 
tucked under one of its legs. Our job was to identify the location of the coin by palpating the center of the table. Another exercise involved placing a hair under 
successive sheets of paper and then to accurately identify its location under the many sheets. An elderly clinician who graduated from an osteopathic college in the 
early 1940s told me that he was asked to identify bones placed in a bag. Normally this would not be difficult; however, all of the bones has been disfigured, with many 
of the major landmarks removed, and the remainder of the bones were cut into small pieces. From this point, the physician graduates to palpating the living system in 
all of its subtlety and dynamic manifestation.
Just as someone who lives in a foreign country is under a tremendous handicap if he or she fails to comprehend the local language, so too will the physician be 
extremely limited in his or her work with the living system if he or she fails to learn the language of the living body. The system is  alive. The living body has the ability 
to communicate to the physician in the most incredible manner, but only if the physician is open to receiving the information being offered. Many clinicians view the 
body as a thing to be experienced via the lens of laboratory tests, radiography, and other static interactions with a living, dynamic system. From the osteopathic 
perspective, the overreliance on static information is one of the greatest shortcomings of medicine, especially when it becomes the main arbiter of how one 
approaches the patient.
R
ESPIRATION

In observing the patient, the physician should note the full extent of respiration. Subtle respiration may be sensed all the way from the clavicles to the pubes in a 
healthy patient; anything less than this is dysfunctional and is later addressed in treatment. The osteopathic approach to functional anatomy identifies several 
diaphragms, including, but not limited to, the tentorium cerebri, tentorium cerebelli, fascial-muscular aspect of the thoracic inlet, the diaphragm proper at the thoracic 
outlet, and the pelvic diaphragm. Any asynchronous functioning of these structures is noted.
P
OSTURE
Posture in both the static and dynamic state is a major source of clinical data. Because osteopathy is particularly concerned with the structure–function relationship in 
the living system, osteopaths are especially interested in understanding the ways the musculoskeletal system homeostatically adapts to various physical (e.g., gravity) 
and nonphysical (e.g., emotional) stressors. On one level, this is referred to as postural compensation and takes in all structures from the base of the skull to the feet. 
Because of gravity, osteopaths are especially interested in the more caudad structures like the lower extremities, sacrum, and pelvis and their relationship relative to 
more cephalad regions. This perspective enables the practitioner to readily identify structural compensation for somatic dysfunction in other areas. These patterns 
manifest underlying tendencies on the part of a system that is constantly seeking homeostatic balance on all levels.
Several factors lead to postural compensation, including traumatic, personal conditions (e.g., emotional state), and abnormal gait. Other patterns, including various 
forms of scoliosis, kyphosis, and lordosis, of both anatomic and functional nature, are noted.
L
EG
 L
ENGTH
Apparent leg length discrepancies are important to identify because they adversely affect the structure–function of anything cephalad. In general, osteopathic 
physicians have noted that actual anatomic leg length discrepancies are rare compared with functional states secondary to sacral base dysfunction and lumbar 
rotoscoliosis.
Observation and Palpation
Observation is conducted on numerous levels, ranging from the gross to the subtle. Gross observation may reveal relative asymmetry of the body in general (e.g., left 
versus right), as well as of specific regions or structures relative one to the other (e.g., scapulae, levels of the iliac crests, levels of the mastoid processes).
Palpation may also be conducted on numerous levels, ranging from the gross to the subtle. Certain osteopathic practitioners have reputations for their skills in 
palpation on very subtle levels. Major factors that greatly influence palpation results include personal intention when undertaking the task as well as where or on what 
level the physician's attention or focus is placed.
The practitioner must learn to distinguish normally functioning tissue from any variation from the anatomico-physiological norm. Because most medical curricula focus 
on disease, recognition of normal function requires additional study on the part of the physician.
Basic palpatory skills may help confirm the acuteness or chronicity of a complaint. Much of this is related to the action of the sympathetic nervous system over time on 
the musculoskeletal realm. Another vital component noted during palpation is  skin drag. Skin drag represents relative resiliency of the superficial tissues and fascia. 
For example, with the patient in the supine position, the physician places the palm of his or her hand on the sternum and with slight posterior pressure makes contact 
and then slowly rotates the hand to the right and then to the left. In a dysfunctional state, the hand rotates better in one direction compared with the other. Variations 
of this maneuver may be performed all over the body and can provide valuable information regarding the functional state of the fascias.
Tissue findings during palpation, including tone, temperature, relative resistance to pressure, texture, and moisture, also provide information regarding the 
sympathetic nervous function in the region. In addition, segmental muscle and visceral function may be evaluated both directly and indirectly using palpation.
Informed muscular palpation may yield extremely valuable information. For example, one of the most commonly found causes of sciatica is secondary to contraction of 
the piriformis muscle. Evaluation takes approximately 5 to 10 seconds and, besides providing instant feedback, may save much needless and costly traditional 
workup. Other important muscles commonly implicated in major symptomatic complaints include the scalenes (so-called thoracic outlet syndrome); various intraoral 
muscles, especially the masseter (temporomandibular joint pain); and the psoas (incapacitating low back pain). The writings of Janet Travell, MD, are most helpful for 
students of such palpation (
7
).
Evaluation of fascial function is key to the osteopathic evaluation. The main dysfunctions found in the fascia, which is ubiquitous, being continuous from the most 
macroscopic to the microscopic levels (it actually ensheathes individual muscle fibers), involve sprains and various strain patterns. These are secondary to a variety 
of sources, including postural, emotional, traumatic, and others. Some of these patterns may be recent, whereas others may be traced back to early traumas. One 
aspect of such palpation actually allows the clinician to approximately date the onset of the dysfunction. Regardless of the origin, these fascial dysfunctions all 
inevitably contribute to functional impairment, resulting in disease and pathology on many levels. Dr. Still said, “I know of no part of the body that equals the fascia as 
a hunting ground”(
8
).
E
VALUATION OF
 J
OINT
 F
UNCTION
Evaluation of joint function is a mainstay of the osteopathic examination. The major function of the joint, regardless of its size or location, is motion. Therefore, this 
aspect must be evaluated thoroughly because any decrease in joint function leads to compensation and dysfunction on other levels as a simple concomitant of the 
homeostatic process. Range of motion exists and may be palpated in any joint of the body, whether on a gross level (e.g., the hip joint), a less gross level (e.g., the 
individual vertebral facets), or a subtle level (e.g., the relatively microscopic motion documented in the cranial sutures). A clinician's failure to palpate this motion 
should not be interpreted as lack of motion in the system.
On a gross level, the patient is examined for joint motion in standing, sitting, and supine/prone positions. The axial skeleton is evaluated for motion range using side 
bending, rotation, and anteroposterior movement (forward-to-backward bending), as is the sacrum and sacrococcygeal joint. The same evaluation is done for the ribs, 
clavicles, scapulae, bones of the pelvis, lower and upper extremities, and cranium. In addition, bones without joints (e.g., the hyoid) may be evaluated. The form in 
which this range of motion is expressed follows specifically defined osteopathic terminology, which is addressed later in this chapter.
Because of the intimate link between structure and function, the body's motion preferences (i.e., the way the tissues move with least resistance) may lead to a deeper 
understanding of the state of the autonomic nervous system. Many clinicians are unaware that much of the autonomic innervation is directed to the musculoskeletal 
system, which comprises 60% of the body. When this is evaluated during examination, findings may lead a physician to suspect changes in the internal milieu of the 
patient merely from examining the musculoskeletal system. The further a physician journeys in the realm of osteopathy, the more he or she will encounter this method 
of clinical reasoning. This method, which is based on basic applied anatomy and neurophysiology, has been substantiated in the laboratory by researchers such as 
Denslow, Korr, and others (
9
).
L
YMPHATIC
 S
YSTEM
The lymphatic system is found in all regions of the body and instantly responds to homeostatic changes. By carefully examining the regional lymphatics, a physician 
can receive valuable feedback as to where to hunt for dysfunction on many levels. A number of osteopathic physicians, most notably F.P. Millard, DO, author of the 
text Applied Anatomy of the Lymphatics, and one of his students, Gordon Zink, DO, have contributed to our clinical understanding in this field. Dr. Millard developed a 
quick total-body lymphatic screen that the experienced clinician may complete in 2 to 3 minutes (
10
).
C
ONNECTIVE
 T
ISSUE
The connective tissue system, particularly the fascia, provides another fruitful avenue of clinical exploration. Because fascial continuity is uninterrupted from the 
cranium to the feet, skilled assessment provides a total-body picture of major areas of somatic dysfunction. From this, regional, transregional, and interregional 
sprains and strain patterns can provide invaluable information about the body's functioning, especially when considering that all the vasculature, nervous structures, 

and lymphatics must pass through the various layers of fascia and will be adversely affected by fascial dysfunction. These fascial patterns underlie the essential 
motion patterns found in our muscles, bones, and organs. Our habitual postural patterns may only be addressed adequately by working on the level of the fascias as 
the students of Ida Rolf, PhD, (founder of  rolfing, an approach to structural realignment that focuses mainly on the fascias, and a student-patient of an osteopathic 
physician over many years) will attest. You may thus understand why Dr. Still wrote, “We see in the fascia the framework of life, the dwelling place in which life 
sojourns” (
8
).
Additional Approaches to the Structural Examination
Frank Chapman, DO, an early twentieth century osteopathic practitioner, discovered a large number of reflex points throughout the body. He noted that these reflex 
points had a direct correspondence with visceral dysfunction and, when stimulated and diminished, brought about a corresponding decrease in the visceral 
dysfunction. These points, which feel like small BBs or lumps, are chiefly found on both sides of the torso and are generally uncomfortable when palpated. Chapman 
believed that these gangliform contractures were neurolymphatic reflexes. One of the most famous of the Chapman reflex points is found on the tip of the right twelfth 
rib. It is tender in appendicitis and reverts to a nontender state after the problem is corrected. This is one of many useful osteopathic clinical pearls (
11
).
Lawrence Jones, DO, an osteopathic physician who lived and practiced most of his life in a small town in Oregon, discovered another well-known system of diagnosis 
used in the osteopathic exam. Dr. Jones found a correspondence between certain well-delineated tender points and specific joint dysfunctions. After many years of 
clinical observation and experimentation, he described points for virtually the entire panoply of somatic dysfunction. The treatment of these points referred to as 
“Jones tenderpoints” in the literature actually leads to correction of these joint dysfunctions, as determined by subsequent range of motion retesting of the joints. He 
called his approach Strain/Counterstrain, and he taught it widely both in classes and in written form until his recent death (
12
). This approach is now a standard part of 
the curriculum in osteopathic colleges in the United States.
The work of William Garner Sutherland, DO, of Mankato, Minnesota, has revolutionized our understanding of the system in ways which we are still just beginning to 
comprehend. A student at the American School of Osteopathy in Kirksville, Missouri, in the late nineteenth century, Dr. Sutherland noticed that the beveling of the 
temporal bone was similar in form to the gills of a fish. Understanding that structure and function are intimately interrelated, he later spent many years experimenting 
on himself in a lengthy series of trials. He determined that there was small but definitely palpable movement in the dural membranes surrounding the central nervous 
system. These membranes are continuous in nature with the inner plane of the cranial bone, the bone itself once having been membrane in its development. In the 
living person, these sutures always have some movement which, as in any joint, may be palpated. Unfortunately, research on cadavers did not detect this until recent 
research at Michigan State University in East Lansing corroborated Dr. Sutherland's findings in a laboratory setting (
13
, 
14
, 
15
, 
16
, 
17
 and 
18
). Today the examination 
and treatment of the cranial-sacral system is a standard part of all American osteopathic curricula. Postgraduate courses in this field are also offered to licensed 
physicians and medical students (contact the Cranial Academy, 3500 Depauw Blvd., Indianapolis, IN 46268). Cranial diagnosis and treatment is a subdivision of the 
wider osteopathic approach and is not intended to be used in an isolated fashion.
Fred Mitchell, Jr., DO, at the Michigan State University College of Osteopathic Medicine, has elaborated a 10-step screening examination. This examination is highly 
recommended to any physician wishing guidance in learning the gross osteopathic evaluation (
19
).
DISEASE CLASSIFICATION: TAXONOMY IN OSTEOPATHY
The manner in which dysfunction is classified in osteopathy reflects the profession's understanding of the relationship of structure and function. Although standard 
medical and surgical terminology is fully used, uniquely osteopathic descriptors are also used. Essentially, much of the terminology describes findings in terms of 
either restrictions or allowances in range of motion. One approach is based on the work of Harrison Fryette, DO. In 1918, Dr. Fryette first described what he called the 
“physiologic movement” of the spine (
20
, 
21
).
Guidelines for discriminating different types of dysfunction in the axial skeleton are known as Fryette's Laws. There are three types of patterns described, the first two 
of which exclusively apply to the thoracic and lumbar spines and the third to any part of the spine. Thus, the reader of osteopathic literature may encounter references 
to Type I or Type II dysfunctions.
The general term for osteopathic musculoskeletal dysfunction is  somatic dysfunction. Somatic dysfunction is currently defined as “impaired or altered function of 
related components of the somatic system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic and neural elements” (
22
). The American 
Osteopathic Association annually publishes a yearbook that is widely available and that contains the complete “Glossary of Osteopathic Terminology,” which is an 
excellent resource for anyone seeking information relating to osteopathic terminology (
22
).
International Classification of Disease (ICD-9) codes for somatic dysfunction exist and are widely used by practitioners and third-party payers specifically to code 
osteopathic findings. They are qualified by body region to be more specific. All of the specialized approaches to osteopathic evaluation previously mentioned (e.g., 
cranial, fascial, Jones tenderpoints) have also developed specialized vocabulary depending on their unique orientation.
DETERMINANTS OF TREATMENT
Treatment is specifically determined by body feedback that is gained from the physical evaluation, while accounting for the key elements of the patient's history. In 
considering the restrictions and dysfunctions enumerated, an osteopathic physician tries to understand conditions from the system's viewpoint, why it was that the 
system developed this symptomatic manifestation, and how it was accomplished. These factors, as well as the acuteness or chronicity of the condition, compensatory 
nature of the findings, age of the patient, previous experience with osteopathic treatment, and sensitivity to treatment, play a role in determining treatment. Treatment 
is based on specific findings of an anatomicofunctional nature and  not, as in allopathic practice, a disease label. There is no protocol, for example, for the treatment of 
otitis media. An osteopathic physician will treat the  patient who may carry such a diagnostic label but he or she will never provide routine treatment for the diagnostic 
label itself. Osteopathic physicians diagnose specific deviations from normal function and work solely towards the restoration of normalized function.
THERAPY AND OUTCOMES
When considering osteopathic therapeutic intervention, most people immediately think of manipulation. However, manipulation may not always be used. Because the 
practitioner is a licensed physician and surgeon, there is a vast array of treatment possibilities. The founders of osteopathy considered the unique osteopathic 
philosophy, not manipulation, to be the profession's key contribution to the world. Manipulation is one of a number of tools used by the physician to implement 
osteopathic philosophical goals, the result of which is the restoration of homeostasis and functional normalcy in the system.
Other means to achieve treatment goals include (but are not limited to) nutrition, psychotherapy, various types of pharmacology, surgery, physical therapy, 
occupational therapy, speech therapy, exercise, orthotic and prosthetic devices, biofeedback, and spiritual support. These tools are frequently combined with 
manipulation, which is one “spoke” on the therapeutic “wheel.” To insist on the exclusive use of manipulation to treat all conditions is as medically unwarranted as to 
believe that pharmacological therapy, for example, is a panacea. The osteopathic physician is a complete physician and uses a variety of tools.
Osteopathic Manipulative Treatment
Osteopathic manipulative treatment (OMT) is often used to support the homeostatic forces of the body, promote healing, combat the effects of compensation and 
decompensation, and help relieve underlying dysfunctional patterns.
Some research on the basic mechanisms by which OMT promotes homeostasis has been done. Michael Patterson, PhD, a reflex neurophysiologist, has 
demonstrated that all disease is characterized by a hypersympathetic component to one degree or another, that facilitated spinal cord segments are perpetuated by 
somatic dysfunction, and that osteopathic manipulation specifically works to reduce this hypersympathetic activity locally and systemically (
24
). Dr. Patterson has also 
demonstrated how somatic dysfunction specifically promotes visceral dysfunction via somatovisceral reflex arcs and may be a harbinger of chronic disease. Clearly, 
more research on OMT mechanisms and effects is needed.
Basic Treatment Approaches

Many of the basic approaches for diagnosis and assessment previously discussed equally apply to treatment. As in diagnosis, the physician is constantly receiving 
feedback from the system regarding the treatment effect. This feedback, in turn, helps guide the treatment, similarly to how a skilled navigator uses data and feedback 
during his or her journey. In addition, the physician's intention and focus of attention are critical determinants in any treatment. Always the ultimate goal of treatment is 
not the removal of symptoms but rather the restoration of homeostasis and normalized function.
A manipulative prescription based on diagnostic findings is used to plan treatment. It accounts for goals, method of application of treatment, dosing (how long to treat), 
and frequency of treatment. The degree of dysfunction in the patient must also be understood. For example, purely structural dysfunction (e.g., patient falls and 
sprains ankle) is approached in one way. However, a condition involving both structural and related functional–structural dysfunction (e.g., patient falls but the pain 
disappears on its own in a few days, then after a while the patient develops a persistent headache related to compensation for the first injury) or a condition involving 
structural and visceral dysfunction of the entire system must be treated differently.
Other determinants of treatment involve, but are not limited to, acuteness or chronicity of the problem, structural or bodily responses, age, sex, other dysfunction, size 
of patient, responses to similar treatments, and metastatic, surgical, or arthrodial joint restriction (
23
).
In general, OMT may be classified into two categories—direct and indirect (
Table 16.1
). In direct techniques, the dysfunctional unit is placed into at least one of 
several barriers to motion and force is applied against the barrier. Indirect treatment takes the dysfunctional unit away from the restricted motion barrier and uses the 
body's inherent forces via balanced tension to make a correction.