WHAT is the problem?
Another important component in determining a treatment plan is determining what tissue or tissues
are primarily affected in the restricted area, as the treatment protocol may vary with the tissue(s) that
HIERARCHY of PROTECTION order for the INJURED BODY
The body responds to an injury in a certain order to protect crucial parts of the body from damage
and increase the chances for survival. Andrew Stills, D.O. called this the "Rule of the Artery" because
the blood supply is vital for every living creature. He felt that this hierarchy was essential for survival;
for example, if the blood supply were compromised secondary to an injury, there would be limited life
force available to help the body heal.
The body protects itself in the following order:
1. Vascular system (arterial/venous), lymphatic system, and unifying fascia
2. Central, peripheral, and autonomic nervous system
4. Endocrine system
5. Musculoskeletal system
With this concept in mind, it's essential to adjust osteopathic techniques for the appropriate dys-
functional area in the body. In this hierarchy, it is useful to think simplistically of muscles as having
only two functions: Muscles are "movers" or muscles are "protectors". Muscles' primary function
are to move two or multiple bones when a muscle contracts. This is the healthy, normal function of
But if a muscle is "stuck" in contraction (spasm) while not moving anything, the muscle is protecting
around something. One goal of the osteopathic exam is to find out what the muscles are protecting
around. Using the hierarchy model while examining an AGR, the practitioner asks what structure
(starting with the vascular system and working down) the muscles are protecting around. When you
have figured out what the muscle(s) are protecting around, you can adjust the appropriate technique
for the right problem. For example, sub-lumbar muscle spasm (e.g. iliopsoas) may arise from a problem
with nearby vascular structures (e.g. the aorta), nervous system structures (e.g. spinal cord and nerves),
organs (e.g. kidneys and ureters); endocrine system (e.g. ovaries) or a problem with the muscle itself.
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WHERE is the problem?
HOW will I fix the problem?