Parietal Osteopathy
An introduction to parietal osteopathy — the structural dimension of manual treatment, working with muscles, joints, fascia and tendons.
A twinge in the back, a pulling sensation in the neck, a shoulder that simply won’t cooperate properly: the musculoskeletal system – that is, the interplay of muscles, joints, ligaments, fascia and bones – often only makes itself felt when something isn’t quite right. Just like a finely tuned clockwork mechanism, a single jammed cog or a spring that loses its tension is enough to throw the entire system out of sync. Contrary to popular belief, parietal osteopathy does not focus solely on the site of the pain. We view the body as an interconnected system, in which a problem in the foot can certainly lead to neck pain. The body compensates for minor disturbances for a surprisingly long time, until this compensation itself becomes a problem – and that is precisely where we intervene.
The Spider’s Web Beneath the Skin
Our musculoskeletal system is far more than a collection of individual parts. At its heart lies the fascial system, a continuous network of connective tissue that envelops and connects every muscle, organ and bone. If you pull on a thread in a spider’s web, the movement is transmitted throughout the entire web; the fasciae in the body function in a similar way. For a long time, fasciae were regarded as passive sheaths for the muscles. Today we know that they are active structures: they contain contractile cells and can contract independently (1,2,3), and are rich in nerve endings through which they transmit stimuli and pain signals (7). Because nerves and blood vessels run right through this tissue, the health of this tissue is also important for blood circulation and pain regulation in the body.
Because fascia is rich in pain receptors and nerve endings, much of what is thought to be ‘muscle pain’ may in fact originate in the fascial tissue (7,8). Anatomical studies also show continuous tissue connections between different muscle groups – known as myofascial chains – through which mechanical tension can be transmitted (4,5,6,9). A disturbance in the plantar fascia could, in theory, radiate in this way to distant parts of the body. Research into myofascial chains is largely based on anatomical studies, and their clinical significance is still a matter of debate within the scientific community (4). In osteopathic practice, however, the principle has proven its worth over many years.
The Body in the Mind
Our brain continuously creates an internal ‘map’ of our own body, known as the sensorimotor representation. This determines how we move, how we experience pain and how we perceive our body. However, this perception of the body does not always correspond to the body’s actual reality. The concept of the ‘neuromatrix’ describes how the brain constructs bodily sensations from far more than just actual tissue damage (11,12). In cases of chronic symptoms, this map can become distorted. Painful areas become overrepresented, whilst other regions ‘fade’. The brain receives an inaccurate picture of the body. This leads to misinterpretations of its actual condition. This is important to know for treatment purposes, as sometimes the cause of persistent symptoms no longer lies in the tissue itself, but in this altered perception. Through touch, the body receives new sensory information that can help to correct this internal map.
Understanding pain
If a distorted ‘map’ in the brain can contribute to pain, this map can be corrected not only through touch, but also through knowledge. Studies show that imparting knowledge about pain mechanisms can bring about measurable improvements in chronic lower back pain (13,14,15). The concept developed in the book ‘Explain Pain’ demonstrates that understanding the neurobiological basis of pain can help to overcome chronic symptoms and establish new movement patterns (10). In particular, it has been shown that knowledge of pain neurophysiology can improve not only pain perception but also physical performance (15). That is why educating you about your symptoms is just as important a part of your treatment as the manual therapy itself. The vicious circle of compensatory posture Alongside this altered perception, however, the body also reacts to pain in a very practical way: with compensatory movements that make sense at first but can themselves become a problem in the long term. If a joint is painful or restricted, the nervous system automatically develops compensatory patterns. Initially, these are helpful; they enable us to remain functional despite an injury. The problem arises when this stopgap measure becomes a habit and new patterns of tension become entrenched. Over time, the perception of pain often shifts. The joint that was originally affected fades from our awareness, whilst symptoms manifest elsewhere – in the areas where the compensatory movements are causing extra strain. In this way, a stiff ankle can lead to knee pain, even though the actual problem in the foot is no longer noticeable. Parietal osteopathy therefore addresses both aspects: the visible postural imbalance and the often-unnoticed underlying cause. The vicious circle of stress and pain An often-overlooked aspect of parietal osteopathy is the effect of pain on the autonomic nervous system. Chronic pain and restricted movement constantly trigger the body’s stress response. This leads to a vicious circle: stress increases muscle tension, which in turn exacerbates pain and restricted movement. There are osteopathic techniques that can stimulate the vagus nerve (21,22). This is the main nerve of our relaxation system. Sometimes, the path out of pain begins with relaxation, with pain relief coming only as a second step.
How touch works
Tactile stimuli affect not only the tissue itself but, as we have seen, also perception in the brain and the autonomic nervous system. At a cellular level, the body converts every mechanical stimulus – that is, touch or a specific technique – into a biological signal, a process known as mechanotransduction. Fascia researcher Robert Schleip posits that connective tissue contains so-called myofibroblasts – cells that can actively contract, much like smooth muscle, and thus help to influence the tissue’s state of tension (2,3). To understand just how complex this effect is, it helps to look at the types of tissue involved. In histology, connective tissue is a distinct tissue type, alongside epithelial, muscle and nervous tissue. It includes fasciae, ligaments, tendons and cartilage, which is also classified as connective tissue. Muscle tissue itself is not classified as connective tissue; it is a distinct type of tissue comprising contractile muscle fibres. However, every muscle is enveloped by connective tissue; the endomysium, perimysium and epimysium together form the fascial system. Muscle and connective tissue are therefore inextricably linked, but not identical. And connective tissue does not end at the muscle boundary. It continues as a continuous network, also enveloping nerves, blood vessels and internal organs. This is precisely why treatment at one point in the musculoskeletal system can have effects that extend far beyond that point.
Touch and pressure have different effects depending on the type of tissue
Muscle tissue Muscles respond to manual stimulation by reducing tension in the muscle fibres, mediated by reflexes in the nervous system. This effect is noticeable and real, but usually lasts only for hours to days (16). That is why we prefer to use techniques that encourage the body to release tension on its own, rather than applying direct pressure to the muscle fibres to induce relaxation. Connective tissue Fascia responds to slow, sustained pressure with a change in the viscosity of the hyaluronic acid within the tissue. Put simply, this makes the tissue ‘more fluid’ and allows it to glide more easily between its layers, thereby releasing tension (8). Joint capsules and ligaments can be positively influenced in terms of their elasticity and sensitivity to pain through mobilisation – that is, movement combined with targeted pressure (16). Cartilage tissue benefits from controlled compression, which stimulates the exchange of nutrients, as cartilage has no blood supply of its own and relies on such variations in pressure. What does the research say? Although much of osteopathic practice is based on experience and careful observation, it is worth taking a look at the research. Several studies have examined the effectiveness of parietal osteopathy. In the case of chronic back pain, a systematic review of six randomised trials showed significant improvements that lasted for at least three months (24). Another large-scale review confirmed significant improvements in pain and mobility (23). In cases of chronic neck pain, a different study showed that osteopathic treatment improved not only pain but also sleep, fatigue and mood (25). Whether it’s a painful joint, a tense shoulder or a stiff neck – this is usually just the tip of the iceberg when it comes to compensatory postures and adaptations. Pain is linked to muscles, fascia, the nervous system and sometimes even to the way we feel. This is precisely what osteopathy is all about. We never focus solely on the site of the pain, but on the interplay of all the elements that make up the body. Where appropriate, we supplement the treatment with visceral or craniosacral techniques, and where necessary, we work closely with your treating doctors.