Somatic Dysfunction: Clinical Guidelines

List of Abbreviations

GBD – global biomechanic disorder

GND – global neurodynamic disorder

GRD – global rhythmogenic disorder

PSIS – posterior superior iliac spine

SIJ – sacroiliac joint

OC – osteopathic correction

ACS – acute coronary syndrome

CVA – cerebrovascular accident

ASIS – anterior superior iliac spine

RBD – regional biomechanical dysfunction

RND – regional neurodynamic dysfunction

RRD – regional rhythmogenic dysfunction

SD – somatic dysfunction

CT – connective tissue

SBS – sphenobasilar synchondrosis

Dura – dura mater

Terms and Definitions

Combined primary diseases – competing or comorbid conditions, primary and background disease.

Complications of the primary disease – includes all complications, including a fatal complication (always one), complications of medical interventions (iatrogenic complications, unless they become the equivalent of the primary disease), as well as indications for resuscitation measures, intensive care, and their complications.

Primary disease – one or more nosological entities that were the reason for examination or treatment during the latest episode of seeking medical care. During the patient's treatment, the diagnosis of the primary disease may change, sometimes repeatedly.

Osteopathy is a field of clinical medicine that includes the provision of medical care to patients with somatic dysfunctions at the stages of prevention, diagnosis, treatment, and rehabilitation, based on the anatomical and functional unity of the body and utilizing manual methods that restore the body's self-correction capabilities. Osteopathy views the human body as a holistic system, which is something more complex than the simple sum of its parts (Mokhov D.E. et al., 2020).

Concomitant diseases – one or more nosological entities that at the current time (during the latest episode of medical care, at the time of death) were not directly (etiologically or pathogenetically) related to the primary disease and, in the event of death, did not take part in thanatogenesis. At the same time, certain diagnostic and treatment procedures could be performed for concomitant diseases. Concomitant diseases may also have complications, but cannot have fatal complications.

Background disease – a nosological form (disease, injury, less commonly a syndrome) that is pathogenetically (but not etiologically) related to the primary disease, served as one of the causes of its development (having become part of its pathogenesis), subsequently burdened its course, and contributed to the occurrence of fatal complications (in the event of death).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Somatic dysfunction is a potentially reversible structural and functional impairment in tissues and organs, manifested by palpatorily determined restrictions of various types of movement and mobility.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Among all possible damaging influences, the following main causes can lead to the occurrence of SD:

• physical (static and dynamic mechanical impacts, as well as various injuries);

• chemical/metabolic (hormonal shifts, nutritional disorders, sleep and rest disturbances, various intoxications including drug-induced);

• psychoemotional (emotional and sensory reactions in response to environmental influences).

Structural and functional impairments in the body can occur acutely (injury, acute intoxication, stress) or insidiously, chronically (prolonged forced posture, chronic intoxication, chronic psychoemotional stress, etc.). When damaging factors act, changes in the body are initially, as a rule, functional and reversible in nature. If the patient does not receive adequate medical care and their own adaptive resources are insufficient, somatization of the impairments occurs, meaning that pathological changes in the structure and functional properties of tissues and organs progress and gradually become irreversible from being reversible (Fig. 1) [1]. This is precisely why SDs can be detected both in the presence and in the absence of overt signs of disease. The localization of SD may not coincide with the localization of clinical manifestations. At the reversible stage, osteopathic correction is maximally effective.

Figure 1. Relationship between the concepts of "health", "disease", and "somatic dysfunction".

In somatic dysfunction, 3 main components can be distinguished: biomechanical, hydrodynamic, and neurodynamic. These three components unite all organs and subsystems of the body into a single holistic system.

The concept of "somatic dysfunction" in ICD-10 belongs to the category of biomechanical disorders, but the subject of osteopathic diagnosis and treatment is not limited solely to biomechanical disorders [2].

The biomechanical component of SD is mainly associated with adaptive changes in connective tissue. Connective tissue (CT) and its derivatives account for 85% of body weight [3]. In addition to forming the organs of the musculoskeletal system (bones, ligaments, joints, fascia, etc.), as well as the skin and blood vessels, CT is present in all organs without exception. Connective tissue performs biomechanical (supportive), trophic (metabolic), protective (barrier), structure-forming (plastic, reparative), and regulatory (local humoral regulation) functions [4]. Connective tissue is active; its activity is expressed in cell migration, synthesis and resorption of the extracellular matrix by cells, and the release of physiologically active substances.

Local acute SD is nothing other than an adaptive response of connective tissue (CT), expressed as a functional reaction of the metabolic-buffer system (extracellular matrix) and the main cells of the connective tissue, manifested by the production of molecules that increase or decrease the hydrophilicity of CT (proteoglycans, glycosaminoglycans, including hyaluronic acid), and by changes in the quantity and nature of intermolecular interactions of collagen and elastin fibers within the extracellular matrix structure. In cases where the homeostatic potential of the main CT cells is insufficient to form an adequate functional response, the cells complete their life cycle via apoptosis, having previously produced a larger amount of collagen fibers and proteins that form a non-systemic conglomeration of collagen molecules, which underlies the formation of fibrosis [4,5]. The presence of fibrosis or scar tissue can be an important link in the pathogenesis of SD.

In cases where an inflammatory reaction in response to a local damaging factor participates in the pathogenesis of SD, alteration, microcirculatory disorders, and proliferation develop, which are aimed at destroying and removing the damaging agent, as well as restoring (or replacing) the damaged tissues. The inflammatory reaction ends with complete recovery or alteration of the damaged tissue with the formation of fibrosis or scarring, the consequence of which may be the formation of chronic SD.

The above-described impairments manifest as restriction of tissue mobility, a decrease in elasticity, and an increase in stiffness of varying degrees of severity.

Mechanical impacts of an exogenous and endogenous nature (originating from the external environment and arising within the body itself), which are specific to CT, play a significant role in the etiology of the formation of the biomechanical component of SD. Its cells and extracellular matrix are characterized by structural remodeling in accordance with the strength and nature of the mechanical impact [6]. If, due to various mechanical impacts, excessive tension of any structure (fascia, ligament, etc.) occurs, the synthetic activity of fibroblasts increases, resulting in an increased number of molecules affecting tissue hydrophilicity, procollagen molecules, and collagen fibers themselves, along with a change in the shape of elastin fibers and their relationship with collagen fibers.

Microcirculatory and metabolic disorders also contribute to this. Initially, the connective tissue becomes more hydrophile, subsequently densifies, loses its capacity for dynamics, and chronic biomechanical SD is formed. The body attempts to compensate for the resulting mobility impairments. Primary SD can alter the tension and mobility of other structures, potentially leading to the emergence of new SDs at local and regional levels.

Thus, the biomechanical component of SD represents various variants of the adaptive response of CT with changes in its qualitative and quantitative characteristics, in some cases with the formation of fibrosis and sclerosis accompanied by an increase in the number of collagen fibers and changes in their mutual arrangement. In addition, connective tissue remodels during circulatory disorders (hypoxia and hypercapnia) [7], nutritional changes, and with aging.

The hydrodynamic component of somatic dysfunction (SD) is a reversible change in hydrophilicity followed by impaired turgor, viscosity, fluidity, production, and conduction of global endogenous rhythms. Hydrodynamic changes in tissues can be associated with altered metabolism and their colloidal properties [8,9,10], as well as a decrease in arterial inflow, microcirculation, venous and/or lymphatic outflow, and CSF dynamics. The state of the metabolic-buffer system represented by the intercellular matrix determines the metabolism and energy of the main cells of connective tissue. It can be viewed as a solution of high-molecular-weight compounds characterized by hydrophilicity, fluidity, and viscosity, and possessing a mesh-framework structure.

The neurodynamic component of somatic dysfunction represents a reversible impairment of nerve signal conduction in one of the links of the reflex arc due to increased excitability (acute impairment) or uncoupling of connections between neurons in nerve centers as a manifestation of CNS plasticity (chronic impairment). As a result, the tone and contraction of skeletal muscles and smooth muscle organs change, pain or tenderness appears, sensitivity is altered, and reflexes are impaired. The neurodynamic component may be more pronounced at the suprasegmental level — psychoviscerosomatic disorders, the intersegmental level — postural disorders and disorders of the motor stereotype and movement coordination, or the segmental level — viscero-somatic or somato-visceral manifestations.

The existence of viscero-motor and motor-viscero relationships was convincingly proven by V.N. Chernigovsky's physiological school [11]. Studies by Irvin Korr showed that excessive afferent input into the spinal cord causes increased excitability of spinal neurons, provoking heightened motor and sympathetic responses at the level of the involved segment in response to normal stimuli [12,13]. Overexcitation of peripheral sensory receptors is most often caused by changes in the surrounding connective tissue. The accumulation of inflammatory mediators sensitizes mechanoreceptors, which can lead to pain perception under normal, non-tissue-traumatizing mechanical stress. Such peripheral sensitization is hypothesized to underlie the increased touch sensitivity found in SD [14]. Disruption of connective tissue architectonics (fibrosis) can lead to distorted proprioception and impaired postural reflexes [15]. Such disorders "accumulate" with age.

1.3 Epidemiology of the Disease or Condition

SD is the result of an organism's adaptive response aimed at maintaining homeostasis in response to exogenous and endogenous factors. As a rule, this response is individual and depends on the adaptive capabilities of a particular organism. Individuals exposed to similar damaging factors, as well as patients with similar diseases, may have different structures of somatic dysfunctions. Understanding this fact determines the individual nature of osteopathic correction. In this regard, population-based studies on the prevalence of SD are limited. At the same time, sufficient data have already been accumulated on the prevalence of somatic dysfunctions in patients with a wide variety of pathologies.

1.4 Features of Coding the Disease or Condition

Somatic dysfunctions (SD) are included in the International Classification of Diseases, Injuries and Causes of Death, 10th Revision.

M99.0 Segmental or somatic dysfunction:

• M99.00 Biomechanical dysfunction — cervical region.

• M99.01 Somatic dysfunction — head region.

• M99.02 Somatic dysfunction — thoracic region.

• M99.03 Somatic dysfunction — lumbar region.

• M99.04 Somatic dysfunction — sacral region.

• M99.05 Somatic dysfunction — pelvic region.

• M99.06 Somatic dysfunction — lower extremity.

• M99.07 Somatic dysfunction — upper extremity.

• M99.08 Somatic dysfunction — rib cage.

• M99.09 Somatic dysfunction — abdomen and other regions.

M99.8 Other biomechanical lesions.

M99.9 Biomechanical lesion, unspecified.

In ICD-10, practically only regional SDs are present. Global and local levels are absent in this classification.

1.5 Classification of the disease or condition

1. Classification by mechanism of functional disorder

The structure of somatic dysfunction conventionally distinguishes biomechanical, hydrodynamic/rhythmogenic, and neurodynamic components:

1. biomechanical component of SD — a potentially reversible impairment of mobility, compliance, and elasticity of human body tissues;

2. hydrodynamic component of SD — a potentially reversible impairment of tissue viscoelastic properties and the natural flow of human body fluids, determined by palpation also as an impairment of the production, transmission, and synchronization of endogenous rhythms (synonym: rhythmogenic component of SD);

3. neurodynamic component of SD — a potentially reversible impairment of neural regulation processes.

Impairment of mobility, i.e., SD, can have several components:

• fascial (biomechanical) — decreased elasticity (resilience), displaceability, compliance, increased stiffness;

• metabolic (fluid) — increased viscosity, impaired "metabolic" rhythms;

• neurodynamic — impaired neural regulation (tone and contraction of skeletal muscles and smooth muscle organs).

These components can be combined and have varying degrees of severity. They are identified by osteopathic physicians during palpatory examination and special tests. Typical palpatory diagnostic indicators for SD are impairments in the biomechanical properties of tissues: abnormal tissue texture (viscosity, elasticity, stiffness), asymmetry, restriction of motion and mobility (Fig. 4).

Figure 4. Abnormalities detected during osteopathic diagnosis

Restoration of mobility leads to the normalization of the functional state of tissues and is the goal of applying osteopathic treatment techniques.

In 2010, the World Health Organization formulated five core models of structural and functional relationships that osteopathic physicians should use to guide diagnosis and treatment [17]:

1. Biomechanical. This model emphasizes the importance of proper posture and body equilibrium for maintaining balance. Tension or imbalance arising in the mechanisms supporting them alters joint structure and affects self-body perception. Consequently, motor functions may be impaired, and energy expenditure for maintaining posture and moving the body in space increases. Accordingly, the goal of the osteopathic physician is to restore posture, body balance, and promote efficient musculoskeletal function.

2. Respiratory-circulatory. This model considers the main condition for normal organ functioning to be unobstructed fluid exchange between the cell and the interstitium: the delivery of oxygen and nutrients and the removal of cellular metabolic products. Pathological tension, if it arises in tissues, impedes fluid flows, leading to tissue damage. Accordingly, the osteopathic physician strives to eliminate obstacles to external respiration, blood circulation, and other body fluids.

3. Neurological. In this model, the main element is the neuroimmunoendocrine system with its balance of afferent-efferent flows and nociception. Changes in interoception and, especially, nociception cause dysfunctions of spinal efferent neurons (increased their excitability) and lead to pathological functioning of the organs they innervate. This model emphasizes the interaction between the autonomic (vegetative) and somatic nervous systems. By reducing mechanical tension, the osteopathic physician strives to balance afferent flows and eliminate pathological changes in nociception.

4. Biopsychosocial. At the center of this model is the sum of ecological, socio-economic, cultural, physical, and psychological factors affecting a person, and the task of the osteopathic physician is to eliminate the consequences of biopsychosocial stress.

5. Bioenergetic. This model is based on the balance between energy production and energy expenditure and the proper distribution of energy in the body, which is necessary for adaptation to various stressors (immunological, nutritional, psychological, etc.). Osteopathic physicians' efforts should be aimed at eliminating factors that hinder the body's proper energy balance and disrupt the regulation of energy production, distribution, or expenditure.

Recently, an additional model has been proposed — the peptide model. This model is based on accumulated evidence showing the effect of osteopathic intervention, expressed in the release of various peptide components of the body's regulatory homeostatic mechanisms [18].

All models include the central concept of osteopathy: somatic dysfunction. Each individual model carries a limited, specific approach to selecting certain parameters for analyzing the human body. These models complement each other, which is why in real osteopathic practice it is necessary to use them in combination.

Using these models allows us, based on potential damaging factors causing pathological changes in the body and knowledge of typical pathological processes, to designate (highlight) which structures should primarily receive the diagnostic and therapeutic attention of the osteopathic physician.

In accordance with these components, osteopathic diagnostics is performed, which will be discussed in detail below. Somatic dysfunctions in the body can manifest at the global, regional, or local levels. The patient's condition can also be described (characterized) at these three levels in terms of biomechanical, rhythmogenic, and neurodynamic disorders (Fig. 5).

Figure 5. Classification of somatic dysfunctions

2. Classification by level of functional disorder

2.1 Global Level of Somatic Dysfunction Manifestation (Level of the Organism as a Whole)

1. Global biomechanical disorder (GBD) is a reversible change in tissue characteristics that does not correspond to age, is not associated with acute pain syndrome, affects three or more axial regions (polyregionality), and is accompanied by a significant restriction of body mobility in one of the planes of space.

2. Global rhythmogenic/hydrodynamic disorder (GRD) is a reversible disorder of endogenous rhythm generation. From a clinical standpoint, it can be caused by both functional factors and a combination of functional and organic causes, and it manifests in all tissues of the integral organism.

The following endogenous rhythms are most frequently evaluated: cranial, thoracic (respiratory), and cardiac. Evaluation is performed according to the following parameters: frequency, strength, and amplitude.

• Global rhythmogenic cranial disorder is a disorder of cranial rhythmic impulse (CRI) generation, which at the level of the head region manifests as a decrease in CRI frequency, amplitude, and strength, and at the peripheral level as a change in global expansion/compression (external and internal rotation) of body tissues.

• Global rhythmogenic cardiac disorder is a disorder of cardiac rhythmic impulse generation that forms secondary polyregional somatic dysfunctions. It manifests at the heart level as a rhythm change, a decrease in the amplitude and strength of the cardiac rhythmic impulse, and at the periphery as a change in the main characteristics of the pulse, as well as a change in the hydrodynamic characteristics of tissues due to their hypoxia.

• Global rhythmogenic thoracic disorder is a disorder of thoracic rhythmic impulse generation that forms secondary polyregional somatic dysfunctions. It manifests at the lung level as a rhythm change, a decrease in the amplitude and strength of the thoracic rhythmic impulse, and at the periphery as a change in the hydrodynamic characteristics of tissues due to their hypoxia.

3. Global neurodynamic disorder (GND) is a reversible disorder of the nervous regulation of the organism, manifesting as psychoviszerosomatic disorders, postural disorders, and/or motor stereotype disorders. A postural disorder is a change in tissue mobility and body position in space associated with impaired proprioception processes.

Psychoviszerosomatic disorder (PVSD) is a state of tissues characterized by secondary polyregional somatic mobility restrictions associated with the psycho-emotional component.

Disorder of motor stereotypes (normal syncinesias) is a change in tissue mobility associated with functional disorders of unconditioned reflex complexes of interrelated movements (walking, associated movements of the head and eyes, parts of the body, etc.) due to dissociation in the central links of reflex arcs.

2.2 Regional Level of Somatic Dysfunction Manifestation (Level of One of the Body Regions)

1. Regional biomechanical disorder (RBD) is a reversible change in tissue mobility, compliance, and elasticity identified in one of the body regions.

Osteopaths conventionally distinguish the following regions: head region, neck region, thoracic, lumbar, and pelvic regions, upper limb regions (right and left) and lower limb regions (right and left), and the region of the dura mater (craniosacral system as a separate region).

2. Regional rhythmogenic disorder (RRD)

At the regional level, the rhythmogenic component may not be singled out separately, as it is associated to one degree or another with a certain regional tissue rigidity and, therefore, is evaluated in the section on regional biomechanical disorders. At the same time, hydrodynamic disorders can occur at the regional level: deterioration of arterial inflow, microcirculation, venous and/or lymphatic drainage. The causes of these disorders can be tension or compression of connective tissue structures, remodeling of connective tissue, or spastic muscles.

3. Regional neurodynamic disorder (RND) is a change in the state of body tissues associated with the irritation of one or more links of the reflex arc: receptors; processes of sensory, autonomic, and motor neurons running within peripheral nerves; autonomic ganglia or the sympathetic trunk; spinal nerve roots; spinal cord segments. Regional neurodynamic disorder can manifest as viscerosomatic, viscero-visceral, somato-somatic, and somatovisceral dysfunctions. The mechanism of RND formation is described quite fully by Irwin Korr, who formulated the theory of the "facilitated medullary segment" based on numerous experimental and clinical studies.

2.3. Local Level (Level of Functional Changes in One or More Body Organs)

At the local level, individual somatic dysfunctions of a particular organ are determined. Furthermore, somatic dysfunction at this level, based on the evaluation of biomechanical, rhythmogenic, and neurodynamic components, can be defined as acute or chronic (Table 1). The distinction between acute and chronic dysfunctions can also be made at other levels, but it is of greater clinical significance specifically for local SDs.

Table 1. Components of local somatic dysfunction

Local somatic dysfunctions

1. Somatic dysfunctions of the musculoskeletal system.

1.1 SOMATIC DYSFUNCTIONS OF THE UPPER LIMB

• Somatic dysfunctions of the sternoclavicular joint

· Somatic dysfunction of the sternoclavicular joint in compression — clavicle dysfunction consisting of its medial displacement, accompanied by global mobility restriction in the sternoclavicular joint.

· Somatic dysfunction of the clavicle in the superior position — displacement of the sternal end of the clavicle in a cephalic direction with restriction of mobility in the caudal direction.

· Somatic dysfunction of the clavicle in the inferior position — displacement of the sternal end of the clavicle in a caudal direction with restriction of mobility in the cephalic direction.

· Somatic dysfunction of the clavicle in the anterior position — displacement of the sternal end of the clavicle ventrally with restriction of dorsolateral movement.

• Somatic dysfunctions of the acromioclavicular joint

· Somatic dysfunction of the acromioclavicular joint in opening — displacement of the acromial end of the clavicle ventrally with restriction of mobility in the dorsal direction.

· Somatic dysfunction of the acromioclavicular joint in closure — displacement of the acromial end of the clavicle dorsally with restriction of mobility in the ventral direction.

• Somatic dysfunctions of the shoulder joint

· Somatic dysfunction of the humeral head in the superior position — displacement of the humeral head cephalically with restriction of caudal movement.

· Somatic dysfunction of the humerus in the anterior position — displacement of the humeral head ventrally with restriction of mobility in the dorsal direction.

· Somatic dysfunction of the humerus in the posterior position — displacement of the humeral head dorsally with restriction of mobility in the ventral direction.

· Somatic dysfunction of the humerus in the anterosuperior position — displacement of the humeral head cephalically and ventrally with restriction of the caudal and dorsal movement vectors.

• Somatic dysfunctions of the radioulnar joint

· Somatic dysfunction: posterior displacement of the radial head

· Somatic dysfunction: anterior displacement of the radial head

• Somatic dysfunctions of the humeroulnar joint

· Somatic dysfunction: ulna in adduction

· Somatic dysfunction: ulna in abduction

• Somatic dysfunctions of the radiocarpal joint

· Somatic dysfunction of flexion-extension, radial-ulnar deviation, supination-pronation

• Somatic dysfunctions of the metacarpophalangeal and interphalangeal joints

1.2 LOWER EXTREMITY SOMATIC DYSFUNCTIONS

• Somatic dysfunctions of the hip joint

· Somatic dysfunction of the femoral head in anterior position — ventral displacement of the femoral head relative to the acetabulum.

· Somatic dysfunction of the femoral head in posterior position — dorsal displacement of the femoral head relative to the acetabulum.

• Somatic dysfunctions of the knee joint

· Somatic dysfunction of the tibia in anterior position — ventral displacement of the tibia beneath the femur.

· Somatic dysfunction of the tibia in posterior position — dorsal displacement of the tibia beneath the femur.

· Somatic dysfunction of the tibia in adduction — displacement of the distal part of the tibia toward the midline.

· Somatic dysfunction of the tibia in abduction — lateral displacement of the distal part of the tibia.

· Somatic dysfunction of the tibia in lateral translation — outward displacement of the tibia beneath the femur (traumatic dysfunction).

· Somatic dysfunction of the tibia in medial translation — inward displacement of the entire tibia beneath the femur (traumatic dysfunction).

· Somatic dysfunction of the medial meniscus in medial position — external rotation of the tibia relative to the femur with medial and ventral displacement of the medial meniscus.

· Somatic dysfunction of the lateral meniscus in lateral position — internal rotation of the tibia relative to the femur with lateral and ventral displacement of the lateral meniscus.

• Somatic dysfunctions of the fibula

· Somatic dysfunction of the fibular head in anterior position — ventral displacement of the fibular head relative to the tibia.

· Somatic dysfunction of the fibular head in posterior position — dorsal displacement of the fibular head relative to the tibia.

· Somatic dysfunction of the lateral malleolus in anterior position — ventral displacement of the lateral malleolus (distal part of the fibula) relative to the tibia.

· Somatic dysfunction of the lateral malleolus in posterior position — dorsal displacement of the lateral malleolus (distal part of the fibula) relative to the tibia.

· Somatic dysfunction of the fibula in superior position — cephalic displacement of the fibula relative to the tibia at the superior and inferior tibiofibular joints.

· Somatic dysfunction of the fibula in external rotation — position of the fibula in external rotation relative to the tibia.

· Somatic dysfunction of the fibula in internal rotation — position of the fibula in internal rotation relative to the tibia.

• Somatic dysfunctions of the ankle joint

· Somatic dysfunction of the talus in anterior position — ventral displacement of the talus relative to the ankle mortise.

· Somatic dysfunction of the ankle mortise in anterior position — dorsal displacement of the talus relative to the ankle mortise.

• Somatic dysfunctions of the subtalar joint

· Somatic dysfunction of the talar head in anteromedial displacement — medial and ventral displacement of the talar head relative to the calcaneus.

· Somatic dysfunction of the talar head in posterolateral displacement — posterior and lateral displacement of the talar head relative to the calcaneus.

• Somatic dysfunctions of the cuneonavicular complex

· Somatic dysfunction of the navicular in superior position — cephalic displacement of the navicular relative to the talus in the supination pattern of the foot.

· Somatic dysfunction of the cuboid in superior position — cephalic displacement of the cuboid relative to the calcaneus in the pronation pattern of the foot.

· Somatic dysfunction of the cuboid in inferior position — caudal displacement of the cuboid relative to the calcaneus in the supination pattern of the foot.

· Somatic dysfunction of the navicular in inferior position — caudal displacement of the navicular relative to the talus in the pronation pattern of the foot.

• Somatic dysfunctions of the cuneiform bones

· Somatic dysfunction of the first cuneiform in superior position — cephalic displacement of the first cuneiform relative to the navicular.

· Somatic dysfunction of the first cuneiform in inferior position — caudal displacement of the first cuneiform relative to the navicular.

· Somatic dysfunction of the second cuneiform in superior position — cephalic displacement of the second cuneiform relative to the navicular.

· Somatic dysfunction of the third cuneiform in superior position — cephalic displacement of the third cuneiform relative to the cuboid.

· Somatic dysfunction of the third cuneiform in inferior position — caudal displacement of the third cuneiform relative to the cuboid.

1.3 SOMATIC DYSFUNCTIONS OF THE PUBIC SYMPHYSIS

• Somatic dysfunction of the pubic symphysis in compression — dysfunction of the pubic bones consisting of medial displacement of both bones with severe restriction of all types of movement in the pubic symphysis.

• Somatic dysfunction of the pubic bone in posterior (posterosuperior) position — cephalodorsal displacement of the pubic bone with restriction of mobility in the caudoventral direction. Accompanied by functional lengthening of the limb on the side of dysfunction.

• Somatic dysfunction of the pubic bone in anterior (anteroinferior) position — caudoventral displacement of the pubic bone with restriction of mobility in the cephalodorsal direction. Accompanied by functional shortening of the limb on the side of dysfunction.

1.4 SOMATIC DYSFUNCTIONS OF THE ILIUM

• Somatic dysfunction of the ilium in anterior position — displacement of the ilium into anterior rotation. Posterior rotation is restricted. On the side of dysfunction, the anterior superior iliac spine (ASIS) is located caudally, the posterior superior iliac spine (PSIS) cephalically, and the ischial tuberosity dorsocaudally relative to the contralateral side; the limb on the side of dysfunction is lengthened.

• Somatic dysfunction of the ilium in posterior position — displacement of the ilium into posterior rotation. Anterior rotation is restricted. On the side of dysfunction, the ASIS is located cephalically, the PSIS caudally, and the ischial tuberosity ventrocephalically relative to the contralateral side; the limb on the side of dysfunction is shortened.

• Somatic dysfunction of the ilium in flaring (external rotation) — displacement of the ilium into external rotation such that on the side of dysfunction the ASIS is positioned more laterally and the PSIS more medially (filling the sacroiliac sulcus). The distance from the umbilicus to the ASIS is greater on the side of dysfunction. Internal rotation is restricted.

• Somatic dysfunction of the ilium in declination (internal rotation) — displacement of the ilium into internal rotation such that on the side of dysfunction the ASIS is positioned more medially and the PSIS more laterally (deepening the sacroiliac sulcus). The distance from the umbilicus to the ASIS is smaller on the side of dysfunction. External rotation is restricted.

• Somatic dysfunction of the ilium in superior position (upsleep dysfunction) — cephalic displacement of the ilium. On the side of dysfunction, the ASIS, PSIS, ischial tuberosity, and iliac crest are located more cephalically; the limb is functionally shortened.

1.5 SACRAL SOMATIC DYSFUNCTIONS

• Somatic dysfunction of the sacrum in anterior (physiological) torsion (left on left axis) — impairment of sacral mobility around its axis of physiological mechanical motion, consisting of sacral displacement such that the upper right quadrant of the sacrum is ventral, while the lower left quadrant is dorsal and caudal.

• Somatic dysfunction of the sacrum in anterior (physiological) torsion (right on right axis) — is the mirror image of left torsion on the left axis.

• Somatic sacral dysfunction in backward (non-physiological) torsion (right on left axis) is a restriction of sacral mobility around its physiological mechanical movement axis, characterized by such displacement of the sacrum that the right upper quadrant of the sacrum is positioned dorsally, while the left lower quadrant is ventral and cephalic.

• Somatic sacral dysfunction in backward (non-physiological) torsion (left on right axis) is a mirror image of the right torsion on the left axis.

• Somatic sacral dysfunction in unilateral flexion is a sacral dysfunction characterized by its displacement such that on the side of the dysfunction, the base is ventral, and the inferolateral angle is caudal and dorsal. Sacral extension is restricted. Limb lengthening is observed on the side of the dysfunction (in the prone position).

• Somatic sacral dysfunction in unilateral extension is a sacral dysfunction characterized by its displacement such that on the side of the dysfunction, the base is dorsal, and the inferolateral angle is ventral. Sacral flexion is restricted. Limb shortening is observed on the side of the dysfunction (in the prone position).

• Somatic sacral dysfunction in bilateral flexion is a sacral dysfunction characterized by its bilateral displacement into the position of mechanical flexion (nutation, forward tilt). Sacral extension is restricted.

• Somatic sacral dysfunction in bilateral extension is a sacral dysfunction characterized by its bilateral displacement into the position of mechanical extension (counternutation, backward tilt). Sacral flexion is restricted.

1.6 SPINAL SOMATIC DYSFUNCTIONS

• Webster somatic dysfunction is a specific thoracic vertebra dysfunction consisting of its translation in the frontal plane with ipsilateral rotation, accompanied by craniosacral system asynchrony.

• FRS somatic dysfunction is a dysfunction of the vertebral motion segment consisting of the displacement of the superior vertebra relative to the inferior one. The superior vertebra is in a position of flexion accompanied by unilateral rotation and lateral bending (lateroflexion). Movements of extension, rotation, and opposite lateral bending are restricted.

• ERS somatic dysfunction is a dysfunction of the vertebral motion segment consisting of the displacement of the superior vertebra relative to the inferior one. The superior vertebra is in a position of extension accompanied by unilateral rotation and lateral bending (lateroflexion). Movements of flexion, rotation, and opposite lateral bending are restricted.

• NSR somatic dysfunction is a group dysfunction of vertebrae consisting of their displacement into a position of rotation and lateral bending. Rotation and opposite lateral bending are restricted.

• Spinal segment somatic dysfunction is a combined dysfunction of a group of vertebrae that includes two or more dysfunctions (with indication of the dysfunction directions). It should be differentiated from a regional somatic dysfunction.

1.7 RIB SOMATIC DYSFUNCTIONS

• Rib somatic dysfunction in compression is a rib dysfunction characterized by the displacement of the rib head ventrally and the sternal end dorsally. Meanwhile, the axillary portion of the rib protrudes (displaces laterally). The dysfunction severely restricts all types of rib movement.

• Rib somatic dysfunction in distortion is a rib dysfunction characterized by the displacement of its head dorsally and the sternal portion ventrally. The axillary portion of the rib recedes (displaces medially). The dysfunction severely restricts all types of rib movement.

• Inhalation rib somatic dysfunction is the displacement of a rib into the inhalation position with restriction of its movement during exhalation.

• Exhalation rib somatic dysfunction is the displacement of a rib into the exhalation position with restriction of its movement during inhalation.

• Anterior rib somatic dysfunction (anterior subluxation) is the displacement of the rib head ventrally, accompanied by recession of the posterior angle of the rib.

• Posterior rib somatic dysfunction (posterior subluxation) is the displacement of the rib head dorsally, accompanied by bulging of the posterior angle of the rib.

2. Somatic dysfunctions of the craniosacral system and head organs.

Physiological SBS dysfunctions:

1. SBS somatic dysfunction: flexion — an SBS dysfunction manifested by the predominance of the flexion amplitude compared to the extension amplitude in the SBS within the cranial rhythmic impulse.

2. SBS somatic dysfunction: extension — an SBS dysfunction manifested by the predominance of the extension amplitude compared to the flexion amplitude in the SBS within the cranial rhythmic impulse.

3. SBS somatic dysfunction: torsion — an SBS dysfunction manifested by multidirectional rotation of the sphenoid and occipital bones around the anteroposterior movement axis (sagittal axis). The dysfunction is physiological (movements around the physiological axes of the occipital and sphenoid bones are preserved).

4. SBS somatic dysfunction: side-bend-rotation (SBR) — an SBS dysfunction manifested by multidirectional rotation of the sphenoid and occipital bones around pathological vertical axes and ipsilateral inclination of these bones around a pathological sagittal axis. The dysfunction is physiological (movements around the physiological axes of the occipital and sphenoid bones are preserved).

Non-physiological SBS dysfunctions:

5. SBS somatic dysfunction: vertical strain — an SBS dysfunction manifested by the displacement of the sphenoid body superiorly (superior-high strain) or inferiorly (inferior-low strain) relative to the basiocciput, formed as a result of unidirectional rotation of the occipital and sphenoid bones relative to their own transverse axes.

6. SBS somatic dysfunction: lateral strain — an SBS dysfunction manifested by the displacement of the sphenoid body to the left (left strain) or to the right (right strain) relative to the basiocciput, formed as a result of unidirectional rotation of the occipital and sphenoid bones relative to their own vertical axes.

7. SBS somatic dysfunction in compression — an SBS dysfunction consisting of the approximation of the sphenoid body to the basiocciput, leading to a sharp restriction of the SBS movement amplitude in the cranial rhythm.

8. Temporal bone somatic dysfunction — temporal bone rotation: external (manifested by the predominance of external rotation amplitude relative to internal rotation amplitude) or internal (manifested by the predominance of internal rotation amplitude relative to external rotation amplitude).

9. Frontal bone somatic dysfunction — frontal bone rotation: external (manifested by the predominance of external rotation amplitude relative to internal rotation amplitude) or internal (manifested by the predominance of internal rotation amplitude relative to external rotation amplitude).

10. Parietal bone somatic dysfunction — parietal bone rotation: external (manifested by the predominance of external rotation amplitude relative to internal rotation amplitude) or internal (manifested by the predominance of internal rotation amplitude relative to external rotation amplitude).

11. Zygomatic bone somatic dysfunction — zygomatic bone rotation: external (manifested by the predominance of external rotation amplitude relative to internal rotation amplitude) or internal (manifested by the predominance of internal rotation amplitude relative to external rotation amplitude).

12. Maxilla somatic dysfunction — maxilla rotation: external (manifested by the predominance of external rotation amplitude relative to internal rotation amplitude) or internal (manifested by the predominance of internal rotation amplitude relative to external rotation amplitude).

13. Facial skull bones somatic dysfunction — a dysfunction manifested by the restriction of mobility of a specific bone relative to its own physiological axes.

14. Dura mater (DM) somatic dysfunction — a dysfunction manifested by the restriction of DM mobility at its physiological attachment sites. Characterized by restricted freedom of the DM.

15. Whiplash somatic dysfunction (whiplash injury type) — a dysfunction characterized by asynchronous movement of the occipital bone and the sacrum. Accompanied by restricted DM movement.

16. Temporomandibular joint (TMJ) somatic dysfunction — restriction of mobility and/or displacement of the mandible.

17. Cranial nerves somatic dysfunction — compression or disturbance of the normal (physiological) position of one of the nerves in osteopathic conflict zones (somatic dysfunctions, cranial bones, dura mater).

18. Cranial sutures somatic dysfunction — a dysfunction manifested by the restriction of mobility in the cranial sutures.

19. Craniosacral asynchrony somatic dysfunction — a dysfunction manifested by impaired phase synchronization between the cranial and sacral components of the craniosacral system.

20. Somatic dysfunction "intraosseous lesion" — a dysfunction characterized by altered tension in specific parts of the bone (often caused by peculiarities of cranial bone embryological development or direct trauma).

21. Somatic dysfunction of the autonomic nervous system (ANS) structures — a dysfunction involving damage to the sympathetic or parasympathetic components of the ANS.

3. Somatic dysfunctions of the peripheral nervous system.

4. Somatic dysfunctions of internal organs.

• Somatic dysfunctions of the laryngopharyngeal complex

· Somatic dysfunction of the laryngopharyngeal complex in right rotation — a dysfunction characterized by a predominance of rotation of the laryngopharyngeal complex to the right relative to the vertical axis.

· Somatic dysfunction of the laryngopharyngeal complex in left rotation — a dysfunction characterized by a predominance of rotation of the laryngopharyngeal complex to the left relative to the vertical axis.

· Somatic dysfunction of the laryngopharyngeal complex in right side-bending — a dysfunction characterized by a predominance of right side-bending of the laryngopharyngeal complex relative to the anteroposterior axis.

· Somatic dysfunction of the laryngopharyngeal complex in left side-bending — a dysfunction characterized by a predominance of left side-bending of the laryngopharyngeal complex relative to the anteroposterior axis.

· Somatic dysfunction of the laryngopharyngeal complex in the superior position — a dysfunction characterized by a predominance of cranial displacement of the laryngopharyngeal complex.

· Somatic dysfunction of the laryngopharyngeal complex in the inferior position — a dysfunction characterized by a predominance of caudal displacement of the laryngopharyngeal complex.

· Combined somatic dysfunction of the laryngopharyngeal complex — a dysfunction that includes two or more somatic dysfunctions (specifying the directions of the dysfunctions).

• Somatic dysfunctions of the lungs

· Somatic dysfunction of a lung lobe (specifying the lobe) in inspiration — a dysfunction characterized by a predominance of movement of the lung lobe in the diaphragmatic inspiration phase compared to the expiration phase.

· Somatic dysfunction of a lung lobe (specifying the lobe) in expiration — a dysfunction characterized by a predominance of movement of the lung lobe in the diaphragmatic expiration phase compared to the inspiration phase.

These somatic dysfunctions may be combined, meaning they can include any number of lung lobes in any dysfunctions.

1. Restriction of superior lung lobe mobility, predominantly caused by restriction of the pleural dome ligaments

2. Restriction of superior lung lobe mobility, predominantly caused by restriction of the racket ligament (ligament of the lung root)

3. Restriction of inferior lung lobe mobility, predominantly caused by pleural fixations

4. Restriction of inferior lung lobe mobility, predominantly caused by restriction of the interpleural ligament

5. Restriction of superior/inferior lung lobe motility with a predominance of the expiratory phase

6. Restriction of superior/inferior lung lobe motility with a predominance of the inspiratory phase

· Somatic dysfunction of a lung lobe (specifying the lobe) in the expiratory motility phase — a dysfunction characterized by a predominance of movement of the lung lobe in the expiratory motility phase compared to the inspiratory phase.

· Somatic dysfunction of a lung lobe (specifying the lobe) in the inspiratory motility phase — a dysfunction characterized by a predominance of movement of the lung lobe in the inspiratory motility phase compared to the expiratory phase.

• Somatic dysfunctions of the pleura

· Somatic dysfunction of the pleura — restriction of pleural mobility (specifying the zone) during diaphragmatic inspiration.

• Somatic dysfunctions of the mediastinum

· Somatic dysfunction of the mediastinal organs in right rotation — a dysfunction characterized by a predominance of movement of the mediastinal volume in right rotation relative to the vertical axis.

· Somatic dysfunction of the mediastinal organs in left rotation — a dysfunction characterized by a predominance of movement of the mediastinal volume in left rotation relative to the vertical axis.

· Somatic dysfunction of the mediastinal organs in right side-bending — a dysfunction characterized by a predominance of movement of the mediastinal volume in right side-bending relative to the anteroposterior axis.

· Somatic dysfunction of the mediastinal organs in left side-bending — a dysfunction characterized by a predominance of movement of the mediastinal volume in left side-bending relative to the anteroposterior axis.

· Somatic dysfunction of the mediastinal organs in flexion — a dysfunction characterized by a predominance of anterior tilt movement of the mediastinal volume relative to the horizontal axis.

· Somatic dysfunction of the mediastinal organs in extension — a dysfunction characterized by a predominance of posterior tilt movement of the mediastinal volume relative to the horizontal axis.

· Combined somatic dysfunction of the mediastinal organs — a dysfunction that includes two or more dysfunctions (specifying the directions of the dysfunctions).

· Somatic dysfunctions of the pericardium (dysfunctions characterized by tension of the pericardial ligaments) — impaired pericardial mobility.

· Somatic dysfunction of the vertebropericardial ligament — tension of the vertebropericardial ligament.

· Somatic dysfunction of the superior sternopericardial ligament — tension of the superior sternopericardial ligament.

· Somatic dysfunction of the inferior sternopericardial ligament — tension of the inferior sternopericardial ligament.

· Somatic dysfunction of the phrenicopericardial ligament — tension of the phrenicopericardial ligament.

· Combined somatic dysfunction — a dysfunction that includes two or more somatic dysfunctions: tension of two or more pericardial ligaments.

• Somatic dysfunctions of the stomach

1. Restriction of stomach mobility:

· Somatic dysfunction of the stomach in right side-bending — a dysfunction characterized by a predominance of right side-bending movement of the stomach relative to the anteroposterior axis.

· Somatic dysfunction of the stomach in left side-bending — a dysfunction characterized by a predominance of left side-bending movement of the stomach relative to the anteroposterior axis.

· Somatic dysfunction of the stomach in right rotation — a dysfunction characterized by a predominance of right rotation of the stomach relative to the vertical axis.

· Somatic dysfunction of the stomach in left rotation — a dysfunction characterized by a predominance of left rotation of the stomach relative to the vertical axis.

· Somatic dysfunction of the stomach of the ptosis type — a dysfunction characterized by a predominance of stomach mobility in the caudal direction.

· Somatic dysfunction of the stomach in the superior direction in the presence of a hiatal hernia of the thoracoabdominal diaphragm — a dysfunction characterized by a predominance of stomach mobility in the cranial direction.

· Combined somatic dysfunction of the stomach — a dysfunction that includes two or more somatic dysfunctions (specifying the direction of the dysfunctions).

· Somatic dysfunction — pyloric sphincter spasm.

2. Restriction of stomach motility

· Somatic dysfunction of the stomach in the expiratory motility phase — a dysfunction characterized by a predominance of stomach movement in the expiratory motility phase compared to the inspiratory phase.

· Somatic dysfunction of the stomach in the inspiratory motility phase — a dysfunction characterized by a predominance of stomach movement in the inspiratory motility phase compared to the expiratory phase.

• Somatic dysfunctions of the liver

1. Restriction of liver mobility:

· Somatic dysfunction of the liver in right side-bending — a dysfunction characterized by a predominance of right side-bending movement of the liver relative to the anteroposterior axis.

· Somatic dysfunction of the liver in left side-bending — a dysfunction characterized by a predominance of left side-bending movement of the liver relative to the anteroposterior axis.

· Somatic dysfunction of the liver in right rotation — a dysfunction characterized by a predominance of right rotation of the liver relative to the vertical axis.

· Somatic dysfunction of the liver in left rotation — a dysfunction characterized by a predominance of left rotation of the liver relative to the vertical axis.

· Somatic dysfunction of the liver of the ptosis type — a dysfunction characterized by a predominance of liver mobility in the caudal direction.

· Somatic dysfunction of the liver in the superior direction — a dysfunction characterized by a predominance of liver mobility in the cranial direction.

· Combined somatic dysfunction of the liver — a dysfunction that includes two or more somatic dysfunctions (indicating the direction of the dysfunctions).

2. Impairment of liver motility

· Somatic dysfunction of the liver in the expiration phase of motility — a dysfunction characterized by a predominance of liver movement in the expiration phase of motility compared to the inspiration phase.

· Somatic dysfunction of the liver in the inspiration phase of motility — a dysfunction characterized by a predominance of liver movement in the inspiration phase of motility compared to the expiration phase.

· Somatic dysfunctions of the liver ligaments

· Somatic dysfunction of the right triangular ligament of the liver — tension of the right triangular ligament of the liver.

· Somatic dysfunction of the left triangular ligament of the liver — tension of the left triangular ligament of the liver.

· Somatic dysfunction of the coronary ligament of the liver — tension of the coronary ligament of the liver.

· Somatic dysfunction of the falciform ligament of the liver — tension of the falciform ligament of the liver.

· Somatic dysfunction of the round ligament of the liver — tension of the round ligament of the liver.

· Somatic dysfunction of the hepatoduodenal ligament — tension of the hepatoduodenal ligament.

· Somatic dysfunction of the hepatogastric ligament — tension of the hepatogastric ligament.

· Somatic dysfunction of the hepatocolic ligament — tension of the hepatocolic ligament.

· Somatic dysfunction of the hepatorenal ligament — tension of the hepatorenal ligament.

· Combined somatic dysfunction — a dysfunction that includes two or more somatic dysfunctions: tension of two or more liver ligaments.

• Somatic dysfunctions of the duodenum

1. Impairment of mobility:

· Somatic dysfunction of the duodenum — restriction of duodenal mobility.

· Somatic dysfunction of the sphincter of Oddi — tone disturbance of the sphincter of Oddi.

2. Impairment of motility:

· Somatic dysfunction of the duodenum in the expiration phase of motility — a dysfunction characterized by a predominance of duodenal movement in the expiration phase of motility compared to the inspiration phase.

· Somatic dysfunction of the duodenum in the inspiration phase of motility — a dysfunction characterized by a predominance of duodenal movement in the inspiration phase of motility compared to the expiration phase.

• Somatic dysfunctions of the jejunum

1. Impairment of mobility:

· Somatic dysfunction of the jejunum in the inferior position (ptosis) — a dysfunction characterized by a predominance of jejunal mobility/displacability in the caudal direction.

· Somatic dysfunction of the duodenojejunal junction — restriction of mobility of the duodenojejunal junction.

2. Impairment of motility:

· Somatic dysfunction of the jejunum in the expiration phase of motility — a dysfunction characterized by a predominance of jejunal movement in the expiration phase of motility compared to the inspiration phase.

· Somatic dysfunction of the jejunum in the inspiration phase of motility — a dysfunction characterized by a predominance of jejunal movement in the inspiration phase of motility compared to the expiration phase.

· Somatic dysfunctions of the ileum and ileocecal region

· Somatic dysfunction of the ileum in the inferior position — a dysfunction characterized by a predominance of ileal mobility/displacability in the caudal direction. The dysfunction is accompanied by an alteration of the ileocecal angle.

· Somatic dysfunction of the ileocecal valve (bauhin valve) sphincter — tone disturbance of the ileocecal valve sphincter.

• Somatic dysfunctions of the cecum

Impairment of mobility (spasm, fixation)

· Somatic dysfunction of the cecum in the inferior position — a dysfunction characterized by a predominance of cecal mobility/displacability in the caudal direction.

· Somatic dysfunction of the cecum in the right iliac region — fixation of the cecum in the right iliac region.

Impairment of motility:

· Somatic dysfunction of the cecum in the expiration phase of motility — a dysfunction characterized by a predominance of cecal movement in the expiration phase of motility compared to the inspiration phase.

· Somatic dysfunction of the cecum in the inspiration phase of motility — a dysfunction characterized by a predominance of cecal movement in the inspiration phase of motility compared to the expiration phase.

• Somatic dysfunctions of the ascending and descending colon

Impairment of mobility (fixation, spasm)

· Somatic dysfunction of the ascending (descending) colon — restriction of lateral displacement of the ascending (descending) colon — a dysfunction characterized by a predominance of medial displacement of the ascending (descending) colon.

· Somatic dysfunction of the ascending (descending) colon — restriction of medial displacement of the ascending (descending) colon — a dysfunction characterized by a predominance of lateral displacement of the ascending (descending) colon.

Impairment of motility:

· Somatic dysfunction of the ascending (descending) colon in the expiration phase of motility — a dysfunction characterized by a predominance of movement of the ascending (descending) colon in the expiration phase of motility compared to the inspiration phase.

· Somatic dysfunction of the ascending (descending) colon in the inspiration phase of motility — a dysfunction characterized by a predominance of movement of the ascending (descending) colon in the inspiration phase of motility compared to the expiration phase.

• Somatic dysfunctions of the sigmoid colon

Impairment of mobility (fixation, spasm)

· Somatic dysfunction of the sigmoid colon — restriction of sigmoid colon mobility.

· Somatic dysfunction of the sigmoid colon in the inferior position — a dysfunction characterized by a predominance of sigmoid colon mobility/displacability in the caudal direction.

Impairment of motility:

· Somatic dysfunction of the sigmoid colon in the expiration phase of motility — a dysfunction characterized by a predominance of sigmoid colon movement in the expiration phase of motility compared to the inspiration phase.

· Somatic dysfunction of the sigmoid colon in the inspiration phase of motility — a dysfunction characterized by a predominance of sigmoid colon movement in the inspiration phase of motility compared to the expiration phase.

• Somatic dysfunctions of the rectum

Impairment of mobility (fixation, spasm)

· Somatic dysfunction of the rectum in the inferior position — a dysfunction characterized by a predominance of mobility/displacability of the rectal wall in the caudal direction.

• Somatic dysfunctions of the kidneys

Impairment of mobility (fixation, ptosis)

· Somatic dysfunction of the kidney in the inferior position — a dysfunction characterized by a predominance of caudal displacement of the kidney during diaphragmatic inhalation.

· Somatic dysfunction "Frozen" kidney — a dysfunction characterized by sharply restricted kidney movement during diaphragmatic respiratory phases.

Impairment of motility

· Somatic dysfunction of the kidney in the expiration phase of motility — a dysfunction characterized by a predominance of kidney movement in the expiration phase of motility compared to the inspiration phase.

· Somatic dysfunction of the kidney in the inspiration phase of motility — a dysfunction characterized by a predominance of kidney movement in the inspiration phase of motility compared to the expiration phase.

• Somatic dysfunctions of the urinary bladder

Mobility impairment (fixation, spasm, ptosis)

· Right sidebending somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of right sidebending motion of the urinary bladder relative to the anteroposterior axis.

· Left sidebending somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of left sidebending motion of the urinary bladder relative to the anteroposterior axis.

· Right rotation somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of right rotation of the urinary bladder relative to the vertical axis.

· Left rotation somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of left rotation of the urinary bladder relative to the vertical axis.

· Ptosis-type somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of caudal mobility/displacement of the urinary bladder.

· High-position somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of cranial mobility/displacement of the urinary bladder.

· Combined somatic dysfunction of the urinary bladder — a dysfunction that includes two or more somatic dysfunctions (indicating the direction of the dysfunctions).

Impairment of motility:

· Expiratory-phase motility somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of urinary bladder motion in the expiratory phase of motility compared to the inspiratory phase.

· Inspiratory-phase motility somatic dysfunction of the urinary bladder — a dysfunction characterized by a predominance of urinary bladder motion in the inspiratory phase of motility compared to the expiratory phase.

• Somatic dysfunctions of the uterus

Mobility impairment (fixations, ptosis, spasm)

· Somatic dysfunction of the uterus — Retroflexion of the uterus — posterior tilting of the uterine body relative to the horizontal axis with preservation of the uterocervical angle.

· Somatic dysfunction of the uterus — Retroversion of the uterus — posterior tilting of the uterine body relative to the horizontal axis with alteration of the uterocervical angle.

· Somatic dysfunction of the uterus — Lateroflexion of the uterus — lateral tilting of the uterine body relative to the anteroposterior axis (indicating the direction of the tilt) with preservation of the uterocervical angle.

· Somatic dysfunction of the uterus — Lateroversion of the uterus — lateral tilting of the uterine body relative to the anteroposterior axis (indicating the direction of the tilt) with alteration of the uterocervical angle.

· Somatic dysfunction of the uterus — Uterine prolapse — a dysfunction characterized by a predominance of caudal mobility/displacement of the uterus.

· Somatic dysfunction of the uterus — High position of the uterus — a dysfunction characterized by a predominance of cranial mobility/displacement of the uterus.

· Combined somatic dysfunction of the uterus — a dysfunction that includes two or more somatic dysfunctions (indicating the direction of the dysfunction).

Uterine motility impairment:

· Expiratory-phase motility somatic dysfunction of the uterus — a dysfunction characterized by a predominance of uterine motion in the expiratory phase of motility compared to the inspiratory phase.

· Inspiratory-phase motility somatic dysfunction of the uterus — a dysfunction characterized by a predominance of uterine motion in the inspiratory phase of motility compared to the expiratory phase.

1.6 Clinical presentation of the disease or condition

According to one definition, disease is life disrupted in its course by damage to the structure and function of the organism under the influence of external and internal factors, accompanied by the mobilization of its compensatory and adaptive mechanisms. It can be argued that any disease has both a functional and a structural component.

Disruptions of structure and function can be: reversible, partially reversible, irreversible. Somatic dysfunction is a reversible structural and functional disorder in tissues and organs. Structural alteration is caused by: changes in the connective tissue system, the ratio of different types of collagen, as well as collagen and elastin (biomechanics); changes in the qualitative characteristics of body fluids and their movement (hydrodynamics); difficulties in nerve signal conduction (neurodynamics). SDs can be detected both in the presence and absence of overt signs of disease. As a result of adaptation and compensation processes, as well as their impairment (in maladaptation and decompensation), the SD forming in the body may in some cases cause various clinical manifestations that may not coincide with it in localization.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The recommendations are based on a systematic review of publications on osteopathic dysfunction. The recommendations fully comply with modern global approaches to somatic dysfunction, but are considered "weak" from an evidence-based medicine perspective. This is due to the lack of clinical studies on both diagnostic and treatment methods for somatic dysfunction for the following reasons:

1. Both diagnosis and treatment involve direct interaction between the physician and the patient, which hinders their standardization and, consequently, their study.

2. Most conducted studies focus on investigating the effect of osteopathy on clinical symptoms and comorbid conditions in specific diseases or states (e.g., headache in migraine, impact on delayed speech development, etc., see also Appendix A3.2), which is correct from the perspective of evidence-based medicine, but does not correspond to modern principles of osteopathy and does not allow extrapolating data to the entire population of patients with somatic dysfunction.

These specific features, which prevent the full implementation of evidence-based medicine principles in the field of osteopathy, are currently being actively discussed in the global community with the aim of developing research standards for osteopathic methods from an evidence-based medicine perspective.

Criteria for establishing the diagnosis/condition: presence of pathognomonic data:

1. anamestic data;

2. physical examination.

• All patients with suspected somatic dysfunction are recommended to have an appointment (examination, consultation) with an osteopathic physician in order to establish a diagnosis and subsequently correct the identified somatic dysfunctions [19,20].

Leveled Evidence 5, Grade of Recommendation C

Comments: A diagnosis is a concise medical conclusion regarding the pathological health status of the examined individual, their existing diseases (injuries), or the cause of death, drawn up in accordance with current standards and expressed in terms stipulated by current classifications and nomenclature of diseases.

The diagnosis must be:

• factually and logically substantiated;

• structurally formatted in the form of three standardized headings;

• nosological, complying with the requirements of the International Statistical Classification of Diseases and Related Health Problems 10th Revision and the nomenclature of diseases (taking into account the specific features of national classifications);

• detailed, pathogenetic, containing additional intranosological characteristics of pathological processes;

• clinical — timely.

In addition to the generally accepted formulation of the diagnosis, an osteopathic conclusion is prepared, indicating biomechanic, rhythmogenic, and neurodynamic disorders at the global, regional, and local levels (Table 2).

Table 2. Osteopathic conclusion.

The table also indicates the dominant somatic dysfunction, the correction of which will serve as the logical ultimate goal of the given osteopathic session.

Determination of the dominant somatic dysfunction follows these principles:

1. When filling out the osteopathic report and identifying the dominant somatic dysfunction, we follow the principle of hierarchy, where global disorders prevail over regional ones, and regional ones over local ones.

2. In the presence of several somatic dysfunctions of a global or regional level, the dominant one is generally the dysfunction with the maximum severity score. If several somatic dysfunctions have equal severity, an inhibition test is performed to identify the dominant dysfunction.

3. A local somatic dysfunction can be classified as dominant only in the case of acute trauma. In this case, the acute local somatic dysfunction prevails over regional and global disorders.

4. Along with a global-level somatic dysfunction, the most significant regional dysfunction may also be entered under the «Dominant somatic dysfunction» section. In this case, the most significant regional dysfunction refers to the one that causes the greatest maladaptation of the body at the time of examination. As a rule, such a regional dysfunction also has a higher severity score compared to the other dysfunctions.

5. The dominant somatic dysfunction serves as the vector of correction during the osteopathic session. Accordingly, this must be confirmed by the listed techniques in the «Treatment» section.

2.1 Complaints and Anamnesis

Level of Availability of Evidence (LAE) 4, Level of Urgency of Recommendations (LUR) C

Leveled Evidence 5, Grade of Recommendation C

Comments: The patient's complaints must be taken in detail (for the complaint-taking algorithm, see Appendix B2).

When identifying complaints, it is important not only to state them, but also to specify and detail them, for example, the character, intensity, and localization of pain, its duration, etc.

When clarifying complaints, one should not be limited only to the patient's statements; it is necessary to actively elicit complaints regarding organs and systems that may be involved in the pathological process, missed by the patient, and observed not only on the day of examination but also previously occurring in their life.

It should be noted that differential diagnosis is carried out already at the stage of eliciting complaints. Questions should be asked to the patient concretely, based on theoretical knowledge of the mechanism of development of a given subjective symptom in a particular disease.

Subsequently, complaints are recorded in the patient chart: leading complaints related syndromically to the underlying disease are indicated first, and only then the remaining ones that do not fit into its clinical picture.

Inquiry by organs and systems begins with the system whose lesion dominates the clinical picture (see Appendix G1).

Leveled Evidence 5, Grade of Recommendation C

Comments: the present illness should be understood as the underlying disease (the morbid condition that served as the reason for seeking medical attention). The clinical picture of the history of the present illness should be formed by the osteopathic physician as a result of interviewing the patient and their accompanying persons, as well as analyzing medical documentation data (extracts from medical histories or outpatient charts, consultation reports, data from laboratory and instrumental diagnostic methods, etc.).

Data are indicated regarding the circumstances of the onset of the disease, its first manifestations, the dynamics of initial symptoms, the features of the disease course and the duration of remissions, complications that have arisen, previous treatment and its effectiveness, previously performed diagnostic measures and their results, as well as work capacity during the period of the disease.

Sample outline of the most frequently asked questions:

1. For how long has the patient considered themselves ill?

2. With the appearance of what signs (symptoms or syndromes) did the present illness begin? Where and under what circumstances did these signs (complaints) first appear?

3. What factors, in your opinion, contributed to the onset of the illness?

4. When and where did the first visit to a doctor take place? What were the results of the examinations performed, and the nature and results of the treatment administered at that time?

5. Subsequent course of the disease:

a) dynamics of initial symptoms, appearance of new symptoms;

b) frequency of exacerbations, duration of remissions, complications of the disease;

c) hospital admissions for this reason;

d) applied therapeutic measures (drug and non-drug), results of diagnostic examinations, effectiveness of previously administered treatment;

e) work capacity during the period of the disease.

6. When and in connection with what did the present deterioration in condition occur?

7. What are the results of the treatment and examination performed (if any)?

8. The motive for seeking care from an osteopathic physician.

It must be remembered that the true onset of the disease may long precede the period when the patient develops the first signs of illness.

Leveled Evidence 5, Grade of Recommendation C

Comments: the following information is collected:

1. Brief information on mental and intellectual development: how they grew and developed in childhood, education, start of working career, attitude to military service, sports activities;

2. Living conditions: in childhood, at present;

3. Dietary conditions: regimen and regularity, variety of food, diet, craving for salty, sweet foods, etc.;

4. Occupational history: from what age, who, and where they started working. Subsequent employment history in chronological order (with indication of workplaces and positions, if necessary). Working conditions and regimen (night shifts, exposure to drafts, prolonged static load, physical and psycho-emotional stress, temperature conditions, etc.). Occupational hazards.

5. Bad habits: smoking (from what age, in what quantity), use of alcohol, narcotic substances, strong tea, coffee, addiction to certain medicinal substances (caffeine, phenacetin, tranquilizers);

6. Past illnesses: all past illnesses, surgeries, injuries, wounds, concussions are set out in chronological order, indicating the patient's age, duration and severity of these illnesses, their complications, and the treatment administered. Note whether blood and blood substitutes were previously transfused, and whether there were reactions to the transfusion. Immunological data are clarified: vaccinations given (which, when, how many times, time of the last vaccination); administration of sera; infectious diseases suffered in the past.

7. Allergic history: intolerance to food products, various medications, sera, presence of allergic reactions (vasomotor rhinitis, urticaria, angioedema, pollinosis);

8. Marital status: presence of children, state of health of family members (wife/husband, children);

9. Heredity: information on the health of close relatives, their past illnesses (psychiatric, endocrine, cardiovascular, oncological, infectious); information on the causes of death of relatives (father, mother, grandfather, grandmother, aunts, uncles, brothers, sisters, and their children).

10. Epidemiological history. Epidemiological history has a suggestive value when an infectious disease is suspected. The epidemiological history aims to identify the possible source of infection, routes of transmission, and immune status. When collecting the epidemiological history, the presence of contact with infectious patients is identified (at home, with neighbors, at work; contact with febrile patients). It should be clarified whether there were cases of infectious diseases at home, in the yard, or in the immediate environment. Recent travel, trips, contact with visitors, living in an epidemically unfavorable area. Contact with sick animals, animal care, participation in hunting, staying abroad; nature of work activity. If contact is present, find out: who was sick, when, what was the contact (short-term, long-term, in which period of the disease).

11. Expert labor history: periods of medical leave (sick leave certificates) over the past year; presence of a disability group, causes, and duration.

When taking a history from a child or their legal representative, it is necessary to pay attention to the following:

• important questions for identifying neurological complaints in a child include questions concerning sleep and the process of falling asleep, the child's temperament, behavioral characteristics, emotional state (tearfulness, sudden mood swings, irritability, etc.), academic performance, memory, concentration, and weather sensitivity. For an infant in the first months of life, it is important to clarify whether there are any feeding difficulties with breastfeeding or bottle-feeding (difficult, sluggish suckling, choking, getting tired quickly). Another important question during the first year of life is compliance with age-related norms of motor activity and psychoemotional development (developmental delays). At an older age, it is important to pay attention to speech development delays, dyslalia, and dysgraphia.

• specific respiratory complaints include various types of breathing disorders, such as apnea episodes, congenital stridor, respiratory arrhythmia, dyspnea, and tachypnea.

• specific digestive complaints in infants during the first year of life include regurgitation, colic, increased flatulence, functional disorders of food passage (constipation and frequent stools), and hypersalivation. Special attention should be paid to the appetite of a child of any age and changes in body weight.

• specific urogenital complaints in boys, especially in the first year of life, include hydrocele, cryptorchidism, phimosis, and inguinal and inguinoscrotal hernias. In girls during puberty, inquiries should be made regarding the establishment of menstrual function.

• specific musculoskeletal complaints include gait abnormalities (depending on age, especially in young children: walking "on tiptoes", intoeing, lower leg curvature), posture disorders (sitting crookedly at the desk), joint crepitus, leg pains (during periods of intensive growth), night pains, inability to walk for long periods (getting tired from prolonged walking, leg pain), inability or reluctance to perform simple movements (inability to climb playground equipment, walk up stairs, jump), limitation of joint mobility, and presence of deformities.

Level of Availability of Evidence (LAE) 4, Level of Urgency of Recommendations (LUR) C

Comments: the following information is collected:

1. which pregnancy this child was born from (outcomes of previous pregnancies), IVF;

2. how the current pregnancy proceeded (threatened miscarriage, diseases including urogenital infections, early toxicosis, gestosis, preeclampsia, fetoplacental insufficiency, anemia, medication use, antibiotics, maternal bad habits);

3. how labor proceeded: gestational age in weeks (premature, post-term), duration of the first stage of labor (rapid, precipitous, prolonged), cesarean section (elective, emergency, indications for it), complications in labor (early rupture of membranes, amniotic fluid with meconium or blood, prolonged anhydrous interval), obstetric maneuvers (forceps, vacuum extractor, medical or mechanical labor stimulation), fetal presentation (breech, footling, transverse, occiput posterior position, brow, face), condition of the umbilical cord (nuchal cord, knots);

4. condition of the child at birth: weight, head circumference, whether they cried immediately (after stimulation, clearance of the upper respiratory tract), Apgar score, when they were put to the breast, how the first day of life went;

5. early adaptation period in the maternity hospital: how they suckled, what problems occurred, whether vaccinations were given, whether there were complications or diseases during the stay in the maternity hospital, on which day of life they were discharged home;

6. condition in the neonatal period: diseases, problems, type of feeding;

7. how they grew and developed in the first year of life: physical and psychomotor development in accordance with norms, timing and sequence of teething.

2.2 Physical Examination

Assessment of the patient's general condition is based on objective signs—consciousness, behavioral activity, and the entire complex of direct physical examination; the severity of intoxication and/or functional impairment of body systems must be taken into account. The final conclusion is made upon completion of the physical examination. The general condition is classified as satisfactory, moderately severe, severe, or extremely severe [20].

• All patients with suspected somatic dysfunction are recommended to undergo a general osteopathic examination (visual osteopathic inspection and osteopathic palpation) with the determination of the dominant somatic dysfunction in order to establish a diagnosis [20,29,30]. For the osteopathic examination algorithm, see Appendices B3 and B4.

Leveled Evidence 5, Grade of Recommendation C

Comments: Inspection of the skin is performed from top to bottom, ensuring that the physician does not overlook the scalp, retroauricular regions, axillary vaults, gluteal folds, and interdigital spaces. The method includes a description of skin coloration and visible mucous membranes, skin cleanliness (presence of a rash), and the state of subcutaneous veins and venous capillaries.

Information regarding the state of the blood vessels is obtained by palpation of the arterial pulse at the radial arteries. The characteristics of the pulse at the a. radialis include a comprehensive assessment of its following properties: frequency, rhythm, tension, volume, magnitude, and contour.

Blood pressure is measured using the auscultatory method proposed by N.S. Korotkov. Blood pressure in both arms should not differ by more than 5–10 mm Hg. In the diagnosis of certain diseases, measuring blood pressure not only in the brachial artery, but also in the femoral artery is significant. Blood pressure values in the lower extremities exceed those in the upper extremities by 20–30 mm Hg. Blood pressure in the legs may differ between sides by no more than 5–10 mm Hg.

Auscultation of the lungs determines respiratory sounds (main and additional). The character of breathing (vesicular, harsh, and bronchial) is determined by the ratio of the auscultated inspiration to expiration. The sonority of breathing—normal, enhanced, and weakened breathing—should also be noted.

The abdomen is usually examined with the patient in both the supine and standing positions. The size and shape of the abdomen and its participation in the act of respiration are noted. Superficial and deep palpation of the abdomen are performed.

In infants under one year of age, an important component of the examination is the assessment of the nervous system. It begins with observing the child's behavior, head position (forced tilt or rotation to one side), trunk (lateroflexion, arching

backwards with head retraction), activity of movements, their symmetry, and reaction to others. Motor function testing is performed: analysis of the range of passive and active movements in the arms and legs in the supine position. It is important to assess the tone of the extremities (during passive movements) and neck muscles (by palpation).

During the initial examination of infants under one year of age, an osteopathic physician must be able to assess unconditional reflexes (grasp, Moro, Babkin, rooting, sucking, search, Bauer crawling, Robinson, asymmetrical tonic neck, symmetrical tonic neck, support, and automatic stepping) and take into account the timeframes of their fading.

In the first year of a child's life, it is necessary to assess the shape of the head, the state of the cranial bones, the anterior fontanelle, and the posterior fontanelles, which may normally be open in premature infants (their dimensions, state of the edges, bulging or depression, pulsation). The state of the cranial sutures (pliability or diastasis), bone density (presence of softening), and determination of cephalhematoma (dimensions, tension, skin changes) are also important.

In infants under one year of age, an important component of the nervous system status is psychomotor development. The osteopathic physician must be able to assess whether the level of psychomotor development corresponds to the child's age.

2.3 Laboratory Diagnostics

Laboratory diagnostic tests are not routinely used for the diagnosis of SD, but may be useful to rule out other diseases and conditions—when performing differential diagnosis and identifying contraindications to treatment (see relevant clinical guidelines) [31].

2.4 Instrumental Diagnostics

Instrumental diagnostic tests are not routinely used for the diagnosis of SD, but may be useful to rule out other diseases and conditions—when performing differential diagnosis and identifying contraindications to treatment (see relevant clinical guidelines) [31].

2.5 Other Procedures

Other diagnostic tests are not routinely used for the diagnosis of SD, but may be useful to rule out other diseases and conditions—when performing differential diagnosis and identifying contraindications to treatment (see relevant clinical guidelines) [31].

• Adult patients with established SD are recommended to consult a psychiatrist or medical psychologist in order to assess the need and expediency of clinical psychological treatment [32].

LoE 1 GoR C

• Patients with established somatic dysfunction are recommended to consult a physical therapy doctor to assess the need and advisability of prescribing a set of exercises (physical therapy) [33].

Leveled Evidence 5, Grade of Recommendation C

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

The recommendations are based on a systematic review of publications on osteopathic dysfunction. The recommendations fully comply with modern global approaches to somatic dysfunction, but are considered "weak" from an evidence-based medicine perspective. This is due to the lack of clinical studies on both diagnostic and treatment methods for somatic dysfunction for the following reasons:

1. Both diagnosis and treatment involve direct interaction between the physician and the patient, which hinders their standardization and, consequently, their study.

2. Most conducted studies focus on investigating the effect of osteopathy on clinical symptoms and comorbid conditions in specific diseases or states (e.g., headache in migraine, impact on delayed speech development, etc., see also Appendix A3.2), which is correct from the perspective of evidence-based medicine, but does not correspond to modern principles of osteopathy and does not allow extrapolating data to the entire population of patients with somatic dysfunction.

These specific features, which prevent the full implementation of evidence-based medicine principles in the field of osteopathy, are currently being actively discussed in the global community with the aim of developing research standards for osteopathic methods from an evidence-based medicine perspective.

3.1 Osteopathic correction

• Patients with somatic dysfunction are recommended to undergo osteopathic correction of somatic dysfunctions. The treatment regimen is determined individually based on complaints, medical history, somatic and osteopathic status assessments, in accordance with the formulated osteopathic conclusion, while determining the number, nature (type) of techniques, and the sequence of their use in a given session [24, 34-39].

LoE 1 GoR C

Comments: Appendix A3.2 also presents a list of diseases for which the efficacy of osteopathic correction of somatic dysfunction has been proven.

In the practice of osteopathic physicians, there is a huge number of methods and techniques, the correct and selective application of which helps achieve high results. However, the correct and selective application of certain techniques is only possible if there is a specific order or algorithm for identifying the dysfunction and its level. Implementing these algorithms in daily practice ensures long-term and predictable positive outcomes for patients.

The main indications for osteopathic correction (OC) are:

• as monotherapy – the presence of somatic dysfunctions in the patient with absent or minimal clinical manifestations (in the absence of a nosological diagnosis) and no contraindications to osteopathic treatment,

• as part of combination therapy – in secondary somatic dysfunction – with co-management of the patient by a physician of the relevant specialty – for all nosological entities in the absence of contraindications.

During the patient's initial visit, the osteopathic physician must determine whether there are any contraindications for OC. To clarify the diagnosis and rule out contraindications, the osteopathic physician must refer the patient for additional examination

Absolute contraindications for OC are:

• Febrile states.

• Acute infectious diseases (except for the convalescence period).

• Chronic infectious diseases in the acute phase.

• Contagious diseases of the skin, nails, and hair.

• Malignant systemic blood diseases.

• Bleeding or suspected bleeding.

• Acute surgical pathology.

• Systemic connective tissue diseases in the active phase.

• Acute inflammatory diseases of blood and lymphatic vessels, acute thrombosis.

• Aortic and cardiac aneurysm.

• Grade 3 cor pulmonale / cardiopulmonary failure.

• Hypertensive and hypotensive crisis.

• Acute coronary syndrome.

• Traumatic brain injury (acute period).

• Acute traumatic injuries of the spine and joints with damage to the integrity of bone structures.

• Acute cerebrovascular and spinal cord accidents (hyperacute period).

• Acute and subacute inflammatory diseases of the brain and spinal cord and their membranes, spine, and joints.

• Diagnostically unclear cases with suspected pathology that is a contraindication to osteopathic correction.

• Endogenous mental illnesses in the acute phase, exogenous mental disorders with excessive agitation.

Relative contraindications for OC:

• Anomalies of the craniovertebral region and cervical spine (including Kimmerle anomaly, Chiari malformation).

• Ankylosing spondylitis (Bechterew's disease).

• Cervical disc herniation in the acute period of the disease with pronounced pain syndrome.

• Diseases of internal organs in the stage of decompensation.

• Osteoporosis.

• Malignant neoplasms of any localization.

• Benign formations (active growth).

• Early postoperative period following surgical interventions.

• Purulent processes of any localization.

It is worth noting that the above-listed diseases and conditions are more of a contraindication to the use of specific osteopathic techniques and approaches rather than to osteopathic correction as a whole.

At the end of the first session, it is necessary to provide the patient or their legal representative with detailed recommendations on nutrition (diet) and physical activity, lifestyle, and discuss the follow-up visit to the osteopathic physician (subsequent sessions, interval between them).

3.1.1. Control testing of corrected regions (re-test)

• Upon completion of therapy, a follow-up examination of the patient by the osteopathic physician and testing of the regions corrected during the osteopathic session (follow-up testing of corrected regions, re-test) are recommended in order to assess the dynamics of tests after the performed treatment [19,20].

Leveled Evidence 5, Grade of Recommendation C

3.2 Other methods

• Adult patients with somatic dysfunction lasting no more than 1 year are recommended cognitive behavioral therapy as part of combination therapy (in accordance with the recommendations of a specialized expert) [40].

LoE 1 GoR C

• Patients with somatic dysfunction are recommended physical activity as part of combination therapy [41,42]

Leveled Evidence 5, Grade of Recommendation C

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not required.

5. Prevention and Dispensary Observation

Leveled Evidence 5, Grade of Recommendation C

6. Organization of Medical Care

For the procedure for providing medical care in the field of "osteopathy" and requirements for an osteopathic physician, see Appendix A3.1. Also, Appendix A3.2 provides, for informational purposes, a list of diseases for which positive results of osteopathic correction have been proven.

6.1 Completion of medical documentation

In accordance with the current regulatory framework, during the appointment, the osteopathic physician fills out the "Initial Examination by an Osteopathic Physician" form or the "Osteopathic Physician Examination (Dynamic Observation)" form. These medical documents serve as an insert to Accounting Form No. 025/u approved by Order of the Russian Ministry of Health No. 834n dated December 15, 2014.

The insert "Initial Examination by an Osteopathic Physician" (hereinafter referred to as Insert-1) (see Appendix A3.4) to the Medical Record of an Outpatient is filled out by the osteopathic physician of a medical organization (other organization providing outpatient medical care in the field of "osteopathy"). Insert-1 is filled out for each newly presenting patient. All entries are made in Russian, neatly; all necessary corrections in Insert-1 are made immediately and confirmed by the signature of the osteopathic physician filling out Insert-1.

The insert "Osteopathic Physician Examination (Dynamic Observation)" to the Medical Record of an Outpatient (hereinafter referred to as Insert-2) (see Appendix A3.5) is filled out by the osteopathic physician of a medical organization (other organization providing outpatient medical care in the field of "osteopathy"). Insert-2 is filled out for each returning patient. Insert-2 is filled out at each follow-up visit. Entries are made in Russian, neatly; all necessary corrections in Insert-2 are made immediately and confirmed by the signature of the osteopathic physician filling out Insert-2.

6.2 Indications for hospital admission

none.

7. Additional Information

Not required.

Criteria for Evaluating the Quality of Medical Care

The problem of assessing the quality of medical care in osteopathy is quite acute. Initially, a maximally personalized approach to each patient is postulated, which makes the development of universal protocols for osteopathic correction practically impossible.

If the required medical documentation is filled out timely and competently, and the treatment performed logically follows from the completed osteopathic conclusion, it is possible to preliminarily conclude at the initial stage that medical procedures of proper quality have been provided.

References

Appendix A1. Working Group Composition

Dmitry E. Mokhov — Doctor of Medical Sciences, Honored Worker of Healthcare of the Russian Federation, Director of the Institute of Osteopathy and Integrative Medicine, Head of the Department of Osteopathy at the North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, Director of the Institute of Osteopathy at the Faculty of Medicine of Saint Petersburg State University, osteopathic physician.

Vladimir O. Belash — Candidate of Medical Sciences, Associate Professor, Associate Professor at the Department of Osteopathy at the North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, neurologist, ultrasound diagnostics physician.

Igor A. Aptekar — Candidate of Medical Sciences, Director of the Tyumen Institute of Manual Medicine (ANO), Tyumen Institute of Osteopathic Medicine (NOU DPO), osteopathic physician, manual therapist.

Elvira N. Nenashkina — Assistant at the Institute of Osteopathy, Faculty of Medicine, Saint Petersburg State University, osteopathic physician, obstetrician-gynecologist.

Yulia P. Potekhina — Doctor of Medical Sciences, Professor, Professor at the Department of Normal Physiology named after N.Yu. Belenkov at the Privolzhsky Research Medical University of the Russian Ministry of Health, Deputy Director for Scientific and Methodological Work at the Institute of Osteopathy (CHOU DPO).

Elena S. Tregubova — Doctor of Medical Sciences, Professor at the Department of Osteopathy at the North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, Deputy Director of the Institute of Osteopathy at the Faculty of Medicine of Saint Petersburg State University.

Anatoly F. Belyaev — Doctor of Medical Sciences, Professor, Professor at the Institute of Clinical Neurology and Rehabilitation Medicine at the Pacific State Medical University of the Russian Ministry of Health, Director of the Primorsky Regional Public Institution "Institute of Vertebroneurology and Manual Medicine", Honored Doctor of the Russian Federation, osteopathic physician, manual therapist, neurologist.

The authors declare no financial support or conflicts of interest that need to be disclosed.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Osteopathic physicians;

2. Medical students enrolled in the specialty "Osteopathy" (undergraduate specialist degree);

3. Physicians undergoing continuing professional education programs in osteopathy;

4. Residents in the specialty "Osteopathy".

1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Clinical practice guidelines will be updated at least once every three years.

The decision to update will be made based on proposals submitted by professional medical non-profit organizations, taking into account the results of comprehensive evaluations of medicinal products and medical devices, as well as the results of clinical approbation, upon the emergence of new evidence-based medicine data.

Appendix A3. Reference Materials

Appendix A3.1 Organization of medical care for the population in the profile "osteopathy"

State regulation of osteopathy began in 2012 and currently covers almost all basic aspects of providing osteopathic medical care to the population of the Russian Federation. In their practice, osteopathic physicians are guided by the Russian Government resolutions and executive authority orders listed below.

1. Order of the Ministry of Health of the Russian Federation No. 1183n dated December 20, 2012, "On Approval of the Nomenclature of Positions of Medical and Pharmaceutical Workers."

2. Order of the Ministry of Education and Science of the Russian Federation No. 1061 dated September 12, 2013, "On Approval of Lists of Specialties and Areas of Training in Higher Education."

3. Order of the Ministry of Health of the Russian Federation No. 236 dated May 23, 2014, "On Amendments to Order of the Ministry of Health of the Russian Federation No. 444 dated October 25, 2012, 'On Chief Freelance Specialists of the Ministry of Health of the Russian Federation'."

4. Order of the Ministry of Health of the Russian Federation No. 959 dated December 30, 2014, "On the List of Chief Freelance Specialists of the Ministry of Health of the Russian Federation in Federal Districts of the Russian Federation."

5. Order of the Ministry of Health of the Russian Federation No. 481n dated July 24, 2015, "On Approval of Exemplary Additional Professional Programs of Medical Education in the Specialty 'Osteopathy'."

6. Order of the Ministry of Health of the Russian Federation No. 655n dated September 28, 2018, "On Approval of the Exemplary Additional Professional Program in the Specialty 'Osteopathy'."

7. Order of the Ministry of Health of the Russian Federation No. 700n dated October 7, 2015, "On the Nomenclature of Specialties of Specialists with Higher Medical and Pharmaceutical Education."

8. Order of the Ministry of Health of the Russian Federation No. 707n dated October 8, 2015, "On Approval of Qualification Requirements for Medical and Pharmaceutical Workers with Higher Education in the Field of Study 'Healthcare and Medical Sciences'."

9. Resolution of the Government of the Russian Federation No. 1327 dated December 8, 2016, "On Amendments to the Appendix to the Regulations on Licensing Medical Activities (Excluding Such Activities Carried Out by Medical Organizations and Other Organizations Included in the Private Healthcare System on the Territory of the Skolkovo Innovation Center)."

10. Order of the Ministry of Health of the Russian Federation No. 157 dated March 11, 2016, "On the Federal Methodological Center for Osteopathy."

11. Order of the Ministry of Health of the Russian Federation No. 334n dated June 2, 2016, "On Approval of the Regulations on the Accreditation of Specialists."

12. Order of the Ministry of Education and Science of the Russian Federation No. 320 dated April 10, 2017, "On Amendments to the Lists of Specialties and Areas of Training in Higher Education."

13. Order of the Ministry of Health of the Russian Federation No. 325n dated June 13, 2017, "On Amendments to the Requirements for the Organization and Performance of Works (Services) in the Provision of Primary Health Care, Specialized (Including High-Tech) Medical Care, Ambulance (Including Specialized Ambulance) Care, Palliative Medical Care, Provision of Medical Care in Sanator-Resort Treatment, Conduction of Medical Expertises, Medical Examinations, Medical Inspections, and Sanitary-Anti-Epidemic (Preventive) Measures within the Provision of Medical Care, in Organ and/or Tissue Transplantation, Circulation of Donated Blood and/or Its Components for Medical Purposes, Approved by Order of the Ministry of Health of the Russian Federation No. 121n dated March 11, 2013."

14. Order of the Ministry of Health of the Russian Federation No. 328n dated June 15, 2017, "On Amendments to the Qualification Requirements for Medical and Pharmaceutical Workers with Higher Education in the Field of Study 'Healthcare and Medical Sciences', Approved by Order of the Ministry of Health of the Russian Federation No. 707 dated October 8, 2015."

15. Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services."

16. Order of the Ministry of Health of the Russian Federation No. 1043 dated December 22, 2017, "On Approval of the Schedules and Stages of Specialist Accreditation, as Well as Categories of Persons Having Medical, Pharmaceutical or Other Education and Subject to Specialist Accreditation."

17. Order of the Ministry of Health of the Russian Federation No. 898n dated December 21, 2018, "On Amendments to the Schedules and Stages of Specialist Accreditation, as Well as Categories of Persons Having Medical, Pharmaceutical or Other Education and Subject to Specialist Accreditation, Approved by Order of the Ministry of Health of the Russian Federation No. 1043n dated December 22, 2017."

18. Order of the Ministry of Health of the Russian Federation No. 21n dated January 19, 2018, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Osteopathy'."

19. Order of the Ministry of Health of the Russian Federation No. 1186n dated November 2, 2020, "On Amendments to Order of the Ministry of Health of the Russian Federation No. 834n dated December 15, 2014, 'On Approval of Unified Forms of Medical Documentation Used in Medical Organizations Providing Outpatient Medical Care and Procedures for Their Completion'."

20. Order of the Ministry of Labor and Social Protection of the Russian Federation No. 358n dated June 2, 2021, "On Approval of the Professional Standard 'Osteopathic Physician'."

21. Order of the Ministry of Science and Higher Education of the Russian Federation (Minobrnauki of Russia) No. 1187 dated September 16, 2020, "On Approval of the Federal State Educational Standard of Higher Education – Specialist Degree in Specialty 31.05.04 Osteopathy"

The right to engage in medical practice in the specialty "Osteopathy" (both in medical organizations of various forms of ownership and in private practice) is granted to individuals who meet the qualification requirements for an osteopathic physician and the professional standard for an "Osteopathic Physician".

Qualification requirements for osteopathic physicians are set forth in Order of the Russian Ministry of Health No. 707n, with amendments introduced by Orders of the Russian Ministry of Health No. 328n dated June 15, 2017, and No. 940н dated September 4, 2020.

According to current legislation in the Russian Federation, only a specialist with higher medical education may practice as an osteopathic physician. In accordance with Federal Law No. 273-FZ dated December 29, 2012, "On Education in the Russian Federation", the training of medical specialists is carried out through higher education programs and additional professional education programs (Art. 82, cl. 1); residency is a level of higher education. The training of osteopathic physicians is carried out through residency and extended professional retraining cycles, which may only be conducted by licensed educational organizations based on model programs approved by the Russian Ministry of Health (Art. 82, cl. 3).

In 2017, the Ministry of Education and Science of the Russian Federation approved the introduction of specialist degree programs in osteopathy at medical universities — osteopathy became one of the basic medical specialties alongside general medicine, pediatrics, and dentistry. By Order of the Ministry of Education and Science of the Russian Federation No. 320 dated April 10, 2017, "On Amendments to the Lists of Specialties and Fields of Higher Education Training", the list of higher education specialties — specialist degree programs under the UGS (Broad Group of Specialties) "Healthcare and Medical Sciences", field 31.00.00 "Clinical Medicine", was supplemented with another specialty — 31.05.04 "Osteopathy". By Order of the Ministry of Science and Higher Education No. 1187 dated September 16, 2020, the federal state educational standard of higher education for the specialist degree in specialty 31.05.04 Osteopathy was approved.

Thus, a multivariant model for training osteopathic physicians has been adopted in the Russian Federation (unlike other medical specialties, for which residency training is the primary method of acquiring the required qualification):

1) training in a higher education program (specialist degree level) in specialty 31.05.04 "Osteopathy";

2) training in a higher education program for the training of top-qualification personnel (residency) in specialty 31.08.52 "Osteopathy";

3) training in an additional professional education program — professional retraining in the specialty "Osteopathy" provided the candidate has completed residency in one of 56 specialties in accordance with Order of the Ministry of Health of the Russian Federation No. 707n (as amended).

Regardless of the form of education, an osteopathic physician will have the right to provide medical care in the specialty "Osteopathy".

A prerequisite for engaging in professional activity is holding a certificate in the specialty "Osteopathy", and starting from 2020, passing the accreditation procedure is mandatory (Order of the Ministry of Health of the Russian Federation No. 898n dated December 21, 2018, "On Amendments to the Deadlines and Stages of Specialist Accreditation, as Well as Categories of Persons Having Medical, Pharmaceutical, or Other Education and Subject to Specialist Accreditation, Approved by Order of the Ministry of Health of the Russian Federation No. 1043n dated December 22, 2017").

An osteopathic physician may provide medical care to the population in the specialty "Osteopathy" in medical organizations and other entities carrying out medical activities that hold a license for medical activity, including osteopathy services.

Medical care in the specialty "Osteopathy" is defined as a set of diagnostic, therapeutic, rehabilitation, and preventive measures performed for patients with somatic dysfunctions (reversible structural and functional disorders of connective tissue), which may either present as an independent nosological form or accompany acute and chronic diseases of therapeutic, neurological, pediatric, or dental profiles (excluding acute surgical pathology) and traumatic injuries.

Medical care in the specialty "Osteopathy" is provided in the form of primary health care, specialized (except high-tech) medical care, and medical care during sanatorium-resort treatment in the following settings:

• outpatient (in settings not providing round-the-clock medical monitoring and treatment);

• in a day hospital (under conditions providing medical observation and treatment during the day, but not requiring round-the-clock observation and treatment);

• inpatient (in settings providing round-the-clock medical observation and treatment).

Forms of medical care in the specialty "Osteopathy":

• scheduled;

• emergency.

Scheduled care is provided during preventive measures, for diseases and conditions not accompanied by a threat to the patient's life, not requiring emergency and urgent medical care, and the postponement of which for a certain period will not lead to a deterioration of the patient's condition or a threat to their life and health.

Emergency care is provided for sudden acute diseases, conditions, exacerbations of chronic diseases, without obvious signs of a threat to the patient's life, not requiring urgent medical care.

Primary specialized health care is provided by an osteopathic physician upon medical indications when a patient applies independently or upon referral by a general practitioner, district general practitioner, general family physician, pediatrician, district pediatrician, manual therapy doctor, or paramedic. To ensure the principle of continuity when referring a patient to an osteopathic physician, the patient is provided with an extract from their medical documentation, certified by the signature of the attending physician and the head (authorized person) of the referring medical organization, containing the diagnosis of the disease (condition), the diagnosis code according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), information on the patient's health status, diagnostics and treatment performed, and confirming the need for medical care in the specialty "Osteopathy". The extract from the patient's medical documentation is accompanied by the results of laboratory, instrumental, and other types of examinations confirming the established diagnosis.

If additional examination of the patient is required, the osteopathic physician recommends it (indicating the necessary scope of the additional examination).

If it is impossible to provide medical care within the framework of primary specialized health care and in the presence of medical indications, the patient is referred to a medical organization providing specialized medical care in inpatient settings and day hospital settings.

In the presence of medical indications, the patient is referred for rehabilitation measures to specialized medical and sanatorium-resort organizations.

A medical service in the specialty "Osteopathy" may be simple (indivisible) or complex (a set of simple services reflecting the technological process of providing osteopathic care for a specific somatic dysfunction), which is reflected in the nomenclature of medical services approved by Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services". As a rule, an osteopathic medical service is a complex of medical interventions aimed at the prevention, diagnosis, and treatment of diseases, as well as medical rehabilitation, and has independent completed significance.

The medical record-keeping system in medical organizations must ensure a strong and logical connection between:

• the nomenclature of services and the nomenclature of specialists;

• the rules for filling out patient medical records and the names of services;

• documents on insurance liability for the quality of medical service and forensic medical examination reports;

• standards of medical care and paid service agreements;

• informed consents and, again, the nomenclature of services.

An individualized, personalized approach to the patient, which distinguishes the provision of medical care in the specialty "Osteopathy", does not preclude the implementation of uniform diagnostic algorithms and involves the selection of osteopathic correction tactics based on the patient's osteopathic status and the identified dominant somatic dysfunction (osteopathic conclusion in the medical documentation — the osteopathic physician's examination form).

The individualization of osteopathic services is determined not only by the osteopathic status of a particular patient, but also by their age and anatomical and physiological characteristics (neonates and infants, children, elderly individuals, pregnant women), as well as the physical and emotional state of the osteopathic physician and the patient at the time the service is received.

In some cases, an individualized approach to a patient reduces the predictability of outcomes while increasing the quality of the osteopathic service.

The evaluation of outcomes of osteopathic medical services is not always straightforward. Osteopathic diagnostics makes it possible to identify functional disorders as early as the pre-disease stage or at its early, preclinical stage. In some cases, this involves conducting additional advanced diagnostic methods, including laboratory and instrumental ones. As a result of diagnostic procedures, various diseases may be detected, and their detection is not always evaluated positively by the patient. At the same time, early diagnosis of diseases allows therapy to be administered even at the preclinical stage, which significantly improves the prognosis of a positive outcome for the patient.

A proven fact is the phenomenon of the delayed therapeutic effect, which is observed within 72 hours after the provision of osteopathic care. The therapeutic effect after a session is not regarded by patients as positive in 20–30% of cases. At the same time, 72 hours after therapy, the self-correction and recovery mechanisms triggered during the osteopathic session significantly improve the patient's condition, up to the complete disappearance of clinical symptoms.

Cooperation between the osteopathic physician and the patient during the provision of osteopathic medical services significantly influences the subjective component of the evaluation of the quality of the service itself.

Thus, it can be said that the specific features of medical services in the specialty of "Osteopathy" are:

• perceptual "dialogue with the body" and high efficacy of palpatory diagnostics;

• personalization;

• wholeness and comprehensiveness;

• intangibility until receipt;

• subjectivity of outcome evaluation;

• dependence on interaction with the patient.

The provision of medical care in the specialty of "Osteopathy" is a segment of the general market of medical goods and services, providing specialized osteopathic services for the restoration, preservation, and improvement of citizens' health.

Appendix A3.2 Diseases for which positive outcomes of osteopathic correction have been proven

Despite the fact that osteopathy developed relatively independently of conventional medicine, a sufficiently large body of evidence regarding its efficacy and safety in a wide range of diseases has been accumulated, including through controlled randomized trials both in Russia and abroad. In these studies, the outcomes of OC are compared with those obtained using standard allopathic treatment or OC sham. Evidence of OC outcomes relies on comparing the severity of patient complaints, quality of life assessments, amounts of medications taken, psychological test results, as well as data from objective examination methods (goniometry, ultrasound, stabilometry, etc.).

Diseases for which positive outcomes of osteopathic correction have been proven

Appendix A3.3 Effect of osteopathic correction on the body

The mechanisms of the health-improving and therapeutic effects of OM on the body are actively being studied, and the main ones have been confirmed by experimental and clinical studies (Fig. 6).

Figure 6. Effects of osteopathic manipulative treatment.

The effects of osteopathic correction (OC) can vary in severity, being local (in the form of changes in the colloidal state, degree of hydration, and tissue structure), segmental (in the form of a reflex response), regional (in the form of improved blood supply and lymph flow), or global (in the form of hormonal effects), and may occur at various intervals after an OC session — from several minutes to several weeks. The described effects of OC generally increase the body's adaptive reserves, its resistance to various damaging factors, and stimulate its own self-correction and self-healing processes.

Osteopathy is distinguished by a systemic approach to human treatment and rehabilitation, and reliance on the body's adaptive and compensatory reserves. An individual approach to the patient makes it possible to improve the adaptive capabilities of their body. Osteopathy does not treat diseases, but promotes recovery by eliminating functional disorders and improves the quality of life. Consequently, OC can be used at all stages of medical care delivery to the population (Fig. 7).

Figure 7. The place of osteopathy in the system of medical care delivery to the population.

OC can be used before, concurrently with, or after pharmacological or surgical treatment and can enhance the therapeutic effect, significantly shortening the patient's rehabilitation period and reducing the risk of complications. An important result of OC is a reduction in the drug load on the patient's body, and consequently,

- reduction of the risk of allergic reactions,

- reduction of side effects of medicinal products,

- prevention of polypharmacy development,

- reduction of intoxication.

Appendix A3.4 Insert form No. 1 "Primary examination by an osteopathic physician"

3.9. Unconditional reflexes (for infants under one year of life):

3.10. Psychomotor development (for children): corresponds to age  does not correspond to age

For infants under one year of life:

4. Osteopathic status

4.1 General inspection

4.8. Assessment of joint and surrounding soft tissue rigidity:

4.8.1. Joints of the lower extremities and pelvis:

4.8.2. Joints of the shoulder girdle and upper extremities:

Appendix A3.5 Insert form No. 2 "Examination by an osteopathic physician (dynamic observation)"

Appendix B. Physician Action Algorithms

Appendix B1. Physician action algorithm

Appendix B2. Algorithm for collecting complaints

Appendix B3. Algorithm for general osteopathic examination

Appendix B4. Additional tests performed during a general osteopathic examination of a child (in addition to Appendix B3. Algorithm for a general osteopathic examination)

Appendix C. Patient Information

Somatic dysfunctions are reversible disorders of tissue mobility, innervation, and blood supply, which can either occur independently or accompany a wide variety of diseases. In some cases, somatic dysfunctions precede the development of a particular disease, serving as an additional triggering factor.

The diagnosis of somatic dysfunctions falls within the competence of an osteopathic physician and is carried out through manual diagnostics—conducting a clinical osteopathic examination. Based on the examination results, a standardized osteopathic report is filled out, reflecting the dysfunctions identified in this specific patient.

The average duration of an appointment with an osteopathic physician is about 45 minutes. If necessary, the physician may increase or decrease the duration of the appointment depending on treatment needs and the patient's condition. During the appointment, the patient needs to undress to their underwear; if this causes you discomfort, you should bring clothing made of soft, thin material to change into.

The approach to each patient is personalized and based on the results of prior osteopathic diagnostics. The interval between appointments can range from 3–5 days in acute situations, and from 10–14 days to several months in chronic processes.

Following an appointment with an osteopathic physician, intense physical exertion should be avoided for 2–3 days, and an adequate fluid intake should be maintained (according to age, physical activity, and existing chronic diseases).

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

None provided.