Atlas of Osteopathic Techniques

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent... 1 Principles of the Osteopathic Examination Osteopat...

Author: Alexander S. Nicholas | Evan A. Nicholas

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1 Principles of the Osteopathic Examination Osteopathic Pri nci ples (P hil osophy) The p ri mar y g o a l o f t he E du c at i on a l C o un c il o n O s t e op a t hi c P r in c i pl e s ( EC O P ) o f t he A me r i ca n A s so c i at i on of Col l eg e s o f O s te o pa t h ic Me d ic i n e i s t o e v al u at e t h e m o s t c ur r e nt kn o wl e d ge ba s e i n t h e f ie l d s o f b io me ch a ni c s , n eu r os c ie n c e, an d o s t eo p at h ic p ri n c ip l es an d pr a c t i ce . By co n s t a n tl y s t ud y i ng th e m o s t c ur r en t tr e nd s i n os t eo p at h i c p ri n c ip l es an d pr a c t i ce , as we l l a s t h e b as i c s c ie n ce d at a ba s e, t hi s c o mm i t te e p ro d u ce s a gl o s sa r y o f o s te o pa t hi c te r mi n ol o g y t ha t i s th e l a ng u a ge s t a nd a r d f or t ea c h in g t h is s ub j ec t . I t w a s o ri g i na l ly cr e a te d t o d e v el o p a s i n gl e , u ni f i ed os t eo p a th i c t er mi no l og y t o be us e d i n a l l A me r i ca n o s te o p at h ic me d i ca l s c ho o l s . On e o f th e r ea s o ns Ni c ho l a s S . Nic h o la s , DO, FAA O , p ub l i sh e d h is o ri g in a l A t la s o f O s t eo p at h ic Tec h n iq u es wa s to he l p i n t h is en d e av o r. He a nd hi s a s s oc i at e , Da vi d H e il i g , DO, FAA O , w e re tw o of th e o r i gi n al me mb er s o f t h i s c om mit t e e a s r ep r e se n ta t iv e s o f o n e o f t he o ri g in a l s p on s or s , t h e P hi l ad e l ph i a Col l e ge of Os t e op a th i c Me di c in e ( P COM ) . O ve r t im e , w i th it s gl o s s a ry r ev i ew co mmit t ee , t h e E COP ha s pr o du c ed f re q ue n t u p da t es of t he G lo s sa r y o f O s te o pa t h ic Te r mi n o lo g y, is s u ed ea c h y e ar in th e Am e ri c an O s t e o pa t hi c A s s oc i at i on Y ea r bo o k a n d Dir e c t o r y o f O s t e o pa t hi c P h y si c ia n s ( 1 ). I t is n ow p ri n te d i n ea c h e di t i on of Fo u n da t io n s f o r O s t e op a t hi c M e di c i ne ( 2) . The E CO P g l os s a ry de f in e s o s te o pa t h ic ph i lo s o ph y a s “ a co n ce p t o f h e al t h c a re s up p o rt e d b y e x pa n di n g s c ie n ti f ic k no wle d ge t ha t e mbr a c es th e c o n ce p t o f t h e u ni t y o f t he l iv i ng or g a ni s m' s s t r uc t ur e ( a n at o my ) a n d f u nc t io n (p h y s i ol o g y) . O s te o p at h ic p hi l o so p hy em p h as i ze s t h e f o ll o wi n g p r in c ip l e s : (a ) T h e h u ma n b e i ng is a d y na mic un i t o f f u nc t io n . ( b ) The bo d y p o s s e s s e s s e lf - re g u la t or y m e c ha n is ms t h at ar e s e l f- h ea l in g i n n a tu r e. (c ) St r uc t ur e an d f u nc t i on ar e i n t er r el a te d at al l l e v el s . ( d) Rat i on a l t re a t me n t i s b a se d o n t h e se pr i nc i p le s .” (1 ) Th e u s es o f t he di a g no s ti c a n d t h er a pe u t ic man e u ve r s i ll u s tr a te d i n th i s a tl a s a r e a ll b as e d u po n th e se pr i n ci p le s .

S tructural Com ponents S tructure and Function S tr u c tu r e a nd f un c ti o n c o nc e pt s o f th e m y of a s ci a l a nd a rt i cu l ar p or t io n s o f t h e mus c u lo s ke l et a l s y s t e m a r e i nh e re n t t o u n de r s ta n di n g o s te o pa t hi c di a gn o s t i c a n d t he r a pe u ti c t e c hn i qu e s . For ex a mp l e , k no wle d g e o f t he o ri g in an d in s er t io n of mu s cl e s ( fu n c ti o na l a n a to my) is i mp e ra t iv e in th e p e r fo r ma n ce o f mus c le e ne r gy te c h ni q ue . Und e r s t a nd i ng t he s t r uc t u re of th e sp i na l j o i nt s h e lp s in th e e v a lu a ti o n o f s p in a l mec h a ni c s a nd i n t he di r e c t i on of a pp l ie d f o r ce s i n t e c hn i qu e s s u ch as hi g h -v e lo c it y , l ow - a mp l it u de ( HV L A) ma n i pu l at i on s , s u ch as whe n i t i s ne c es s ar y to co n si d e r o bl i qu e c er v i ca l f a ce t s a n d c ou p l ed jo i nt mot i on .

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Barri er Concepts B ar r i er s a r e a l so an im p o rt a nt co n c ep t i n t h e u n de r s t a n di n g a nd a pp l ic a ti o n o f o s t e o pa t hi c t e c hn i qu e s . I n o s t e op a t hi c m e di c i ne , v a ri o u s b ar r ie r s t o m o ti o n h a ve be e n c la s s ic a ll y d e s cr i be d w i t hi n t h e f r am e wo r k o f n o rm a l p h y s i ol o gi c mo t io n . The g re a te s t r a ng e o f m o t io n i n a s pe c if i ed r eg i on is t he an a to mi c r an g e, a nd it s p as s i ve li mit i s d es c ri b e d a s t he a na t om i c b a rr i er (1 ) . T h is ba r r ie r m a y b e t h e mos t i mp o r ta n t t o u n de r s t a nd , as mo v em e n t b ey o nd t hi s p o in t ca n d i sr u p t t he ti s s ue s a n d may r es u lt in s ub l ux a ti o n o r d i sl o c at i on . O s t eo p at h ic t ec h ni q ue s sh o ul d n e v er in v ol v e mov e men t p a s t t hi s b a rr i e r! The p hy s io l og i c r a ng e o f mo t io n i s th e l i mi t of ac t iv e mo t io n g i v en no r ma l an a to mic s tr u c tu r es an d th e a r ti c u la r , myo f a s c i al , a n d o s se o us c om p on e nt s (1 ) . The p oi n t a t whi c h t h e p hy s i ol o gi c m o t io n e n ds i s t he ph y s io l og i c b a rr i er . T h e t e rm el a s ti c b a rr i e r i s u se d to de s cr i b e t he mo t i on be t we e n t h e p hy s i ol o gi c a n d a n at o mi c ba r ri e rs , wh i ch is a va i l ab l e s ec o n da r y t o p a s s i ve my o f as c ia l a n d l i ga men t o us s t r et c h in g ( 1 ). P. 6 Whe n a d y s f un c t io n al s t a t e e xi s t s , re d uc e d mo ti o n o r f u nc t io n o c c ur s , a nd a r es t r ic t iv e b a r ri e r b et we en th e p h y si o lo g ic b ar r ie r s ma y b e d em o n s t r at e d ( 1 ). Th e r es t r ic t iv e b a r ri e r, th e ma j or as p e c t of th e ov e ra l l d y s f u nc t io n a l p at t er n , c a n b e e li mi na t ed or min i mi z ed wit h o s te o p at h ic tr e a tm e nt . M a n ip u la t iv e te c hn i qu e s i nc o r po r at e a c t iv a ti n g f o rc e s i n t h e a t t e mp t to re mov e th e r e s t r i c t i ve ba r r ie r , b ut t he s e f or c e s s ho u ld b e k ep t w i t hi n t h e b o un d s o f t h e p hy s io l o gi c b a rr i e rs wh e ne v e r p os s ib l e . A p a t ho l og i c b a rr i er is mor e p e rm a n en t ; i t ma y b e r el a t ed to co n t ra c tu r es wit h in th e s of t ti s su e s , o s t e op h y t i c d e ve l op me nt , a n d o t he r d e ge n e ra t iv e c h a ng e s ( e. g . , o s t e o ar t hr i ti s ) . To a v oi d f u rt h e r i nj u ri n g t h e p at i e nt wi t h d i ag n os t ic o r t he r ap e u ti c t e ch n i qu e s , th e p ra c t it i on e r mu s t un d er s t an d t h e n o rm a l c om p l ia n ce of t is s ue s a n d t h e l im i t s t he y mai n t ai n . The s e d i f f e re n t b a rr i er s mu s t b e u n de r s t o od c om p le t el y , a s t h ey may ca u se t he p hy s ic i an t o a lt e r t h e t ec h ni q u e c ho s en ( i. e . , in d i re c t v er s u s d ir e c t ) , o r m a y l i mi t t he mot i on di r e c t e d i nt o th e t i s s u e s a nd or j oi n t s du r i ng tr e at me nt . I n o s te o pa t hi c pr i nc i pl e s t h e p re s e nt s y s te m of de s cr i b in g t h e c a rd i na l m o t io n d yn a mic s i n s p i na l m e ch a n ic s i s b a s ed on th e po s it i on a l a n d/ o r mo ti o n a s y mmet r y r el a t ed to th e fr e ed o m o f m o ti o n ( 1 ). Pr e vi o u sl y , t he r e h a ve be e n o t he r w a y s t o d es c r ib e t h es e as y mm e tr i e s . Th e d i r ec t io n i n wh i ch th e mo t io n w a s r e s t r ic t e d was th e mos t co mmo n e a r ly me t ho d . O t he r p a s t d es c ri p t io n s i nc l u de d w h et h e r t he jo i n t was o pe n or cl o se d . T h es e w e r e a ls o b a s ed on th e me c ha n ic a l f i nd i ng s re v ea l ed o n p al p a ti o n. To d a y , th e g o v er n in g s y s te m i n u s e n a me s t h e b i om e ch a n ic a l f in d i ng s b a se d o n mo ti o n r es t r ic t io n a n d /o r a s ym me tr y a n d t h e d ir e c t i o ns in wh i c h mot i on i s mos t f r e e. Thi s mo t io n f r e ed o m i s a l so ca l le d ea s e, fr e e , a nd lo o s e. In my o f as c ia l d i a gn o s t i c f in d i ng s , i t i s c o mm o n t o s e e b ot h th e f r ee d o m a nd th e li mit a ti o n u s ed (i . e . , lo o se , t ig h t ; e as e , b i nd ; a n d f r ee , r e s t r i c t e d) . Y e t t h e u se o f t he s e d e s c r ip t io n s d o es no t a ll o w f o r p ro b l em s i n w h i ch mo t io n is s y mme t r ic a ll y a n d /o r u n iv e r sa l ly re s t ri c te d , a s s ee n in so me p a ti e nt s .

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O ne o f t he mo s t i mpo r ta n t p r in c ip l e s i n d ia g n os i s a nd t re a tm e nt i s t o c on t r ol th e t is s u e, jo i nt , or ot h er s tr u c t u re wit h in it s no r ma l ly a da p ti v e mo ti o n l im i t s . Th u s , t he mot i o n i n a t r e at men t t e c hn i qu e s h o ul d b e w i t hi n n o rm a l p h y s i ol o g ic li mit s . C e rt a in l y , t he mot i on us e d s h ou l d a l wa y s b e wi th i n a na t o mi c l i mi t s . I t i s o u r p hi l os o p hy th a t c on t r ol l in g m o t io n w i th i n t h e p hy s i ol o gi c l i mit s e n su r e s g re a te r sa f et y m a r gi n s whi l e s ti l l k e ep i ng e f f i ca c y h i gh , w h er e a s mov i ng c lo s er to t he an a to mi c l im i t s i nc r ea s es r is k wit h li t tl e i n c re a se in e f f i ca c y . For e xa mpl e , i n a n H V LA t ec h ni q ue , th e r e s t r i c t i ve ba r r ie r s h ou l d b e e n ga g e d i f e ng a g em e nt is t ol e ra t ed . Th e m o ve me nt ne c es s a ry to af f e c t th i s b a rr i er , h o wev e r, s ho u l d b e o nl y 1 t o 2 d e g re e s o f mo ti o n ( s t i l l wit h in t he ph y si o l og i c l im i t s) , w h er e a s t he a c t u al ph y s io l og i c b a rr i er of n or mal mo t i on ma y b e 5 t o 6 d e g re e s f ur t h er .

S omatic Dysfunction S om a t ic dy s fu n c ti o n i s t h e d ia g no s t ic cr i te r i on fo r w h i ch os t eo p a th i c man i p ul a ti o n i s i nd i c at e d. Th e EC O P d ef i n it i on of s om a ti c d y s fu n c t i on i s a s f ol l o ws : I mp a i re d o r a l t er e d f un c t io n o f r e l at e d c om p o ne n t s of t he so mat i c ( bo d y f r am e wo r k ) s y s t em : s k e le t al , ar t hr o di a l , a nd my o f as c ia l s tr u c tu r es , a n d r e la t ed v as c ul a r, l ym p ha t ic , an d n e ur a l e l em e nt s . S om a t ic dy s fu n c ti o n i s t r ea t ab l e u s in g o s te o p at h ic ma n i pu l at i ve t re a t me n t . Th e po s it i on a l a n d mot i o n a sp e c t s of so mat i c d y s f u nc t i on a re b es t d e s c r i be d u s in g at le a s t o ne of th r e e p ar a me t e rs : ( a ) t h e p os i t io n o f a b od y p a rt a s d et e rm i n ed by pa l p at i on an d re f er e nc e d t o i t s a dj a ce n t d e fi n ed s t r u c t u re ; ( b ) t h e d ir e c ti o ns in whi c h mot i o n i s f re e r ; a nd (c ) th e d i re c t io n s i n wh ic h m o ti o n i s r e s t r i c t e d ( 1) . A s s o c ia t ed cr i t er i a f or s om a ti c d y s fu n c t i on a re re l at e d t o t i s s u e t e x t u re a bn o rm a li t y , a s y mmet r y , re s t ri c ti o n o f m o ti o n, a nd te n de r n es s ( mne mo ni c : TAR T) . The gl o s sa r y o f o s t e o pa t hi c t e r mi n ol o gy s ta t es th a t a n y o ne o f t he s e mu s t be pr e s en t f o r t h e d ia g n os i s . Th e pr i ma r y f i nd i ng s w e us e f o r t h e d ia g no s i s o f s om a t ic dy s fu n c ti o n a re mot i o n r es t ri c t io n ( a nd r el a te d m o t io n a s ym me tr y , i f p r es e nt ) a n d t i s s u e t e x t u re c ha n g es . T e nd e r ne s s ( so me p r ef e r s e ns i ti v it y ) c a n b e o n e o f t he g re a t p re t e nd e rs in t he c li n ic a l p r es e nt a ti o n o f a pr o b le m. Ten d e rn e s s ma y be el i ci t e d o n p al p a ti o n d ue t o p re s s ur e o r b e c au s e t he p at i en t w a n t s th e p h y si c ia n t o be l ie v e t h er e i s p a i n. Pa i n ma y b e p r es e nt in o ne ar e a b u t t he pr i mar y d y s f u n c t i on or p ro b le m d i s ta n t . Th e r ef o re , w e b el i e ve te n de r n es s ( s en s i ti v it y o r pa i n) to b e t he we a k es t o f t h e a f or e me n t io n ed c ri t e ri a , a nd i n o ur pr a c ti c e i t i s u s ed in a l i mi t ed f as h io n , mo s t l y whe n im p le men t i ng c ou n t er s tr a in t ec h ni q ue s . Cer t a in qu a li t i es of th e s e c ri t er i a a r e p ar t i cu l ar l y c o mm o n i n s p ec i fi c t y p es of d y s f u nc t io n s a r is i ng fr o m a c ut e a n d c h ro n ic s ta t es . I n c re a se d h e a t , mo i s t u r e, h yp e r to n ic i t y , an d s o o n ar e c o mm o n w i th ac u t e p ro c es s e s . De c re a s ed he a t , d ry n es s , a tr o p hy , a n d s t ri n gi n es s of ti s su e s a r e mor e co mmo n w i t h c hr o ni c pr o bl e ms .

Myofasci al-Arti cul ar Com ponents

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A s t h e p re s en c e o f s o ma t i c d y s f un c t io n b y d e f in i ti o n ma y i nc l ud e my o fa s ci a l a n d a rt i c ul a r c om p o ne n t s , t h e p a lp a to r y e x am i na t i on is an i mp o rt a nt p ar t o f t h e e v al u at i o n. P al p a ti o n wil l de t er min e wh e th e r t h er e i s a p ri mar y m y o fa s ci a l o r a r ti c ul a r c o mp o ne n t o r b ot h an d P. 7 l ea d to th e d e v el o pm e nt o f t he mo s t a p pr o pr i a te tr e at me nt pl a n. S pe c if i c t y pe s o f d y s f u nc t io n s a r e b es t t r e at e d b y c e rt a in te c h ni q ue s . Fo r e xa mpl e , a pr i ma r y t i s s u e t ex t u re ab n or ma li t y i n t h e f as c ia i s b es t t r e at e d b y a te c hn i qu e th a t mos t af f ec t s c ha n g e a t t ha t le v el (e . g . , my o fa s c ia l r e le a s e) , w h er e a s a no t he r te c hn i qu e ma y h a ve n o r e al ef f ec t on th e s p e ci f ic ti s s ue in v ol v e d ( e. g . , HVL A ). Ar t i cu l ar dy s f un c ti o ns , on t he o th e r h an d , a r e b es t tr e at e d wi th an ar t i cu l ar te c h ni q ue , s u c h a s HVL A , a n d myo f a s c i al re l e as e w o ul d be le s s a p pr o pr i at e .

V isceral -Autonomic Components S om e dy s fu n c t i o ns ma y d i r ec t ly af f e c t an ar e a ( e .g . , s mal l i n te s t in e s wit h ad h es i on s ) , whi l e o t he r d y s fu n c t i on s ma y b e m o r e r ef l ex i v el y i mpo r t an t ( i .e . , c a rd i ac a rr h y th mia – so ma to v is c er a l r e fl e x) . So mat i c d y s f u nc t io n ma y c a us e re a c t i on s wi t hi n t h e a ut o n om i c n er v o us s y s te m an d r e su l t i n m a ny c li n ic a l p r es e nt a ti o n s o r v is c e ra l d is o r de r s p re s e nt wi t h a nu mbe r o f so mat i c c o mp o ne n t s ( 3) .

Order of Exami nati on The o rd e r o f t h e o s t e op a t hi c p h y s i c al ex a mi n a ti o n i s b e s t ba s ed o n t he pa t i en t 's h is t o ry an d c l i ni c al pr e s en t at i on . In ge n er a l , i t i s b e s t to be g i n t he ex a min a ti o n b y p er f o rm i ng th e s t e ps th a t h a ve th e le a s t im p a c t on th e pa t ie n t p h y s i ca l ly a nd th a t l e ad t o t h e l ea s t t i s s u e r ea c t iv i t y an d le a s t se c o nd a ry re f l ex s t i mu l a ti o n.

General Observation I t i s r e co mme n d ed th e p h y si c ia n b e g in wi t h g e ne r al ob s e rv a ti o n o f t h e s ta t i c p os t ur e a nd t he n d y na mi c p os t ur e (g a it an d re g io n al r an g e o f mo ti o n) . F o r s a fe t y , i t i s b es t to b eg i n b y o b se r v in g f u nc t i on an d r a n ge of mo t i on wi t h a c ti v e r eg i o na l m o ti o n t e s t i ng . A f t e r e x am i ni n g t h e p at i e nt in th i s m a nn e r, t he ph y si c i an ma y d e c id e t o o b s er v e t he p at i e nt ' s l im i t s b y p as s i ve ra n ge o f mot i on ( RO M) t es t i ng . T h e p a s s i ve ra n g es sh o ul d t yp i c al l y b e s l ig h tl y g r e at e r t ha n th o se el i c it e d d ur i n g a c t i ve mot i on as s e s s men t . A f te r i de n t if y in g a n y a s ym met r i es or ab n o rm a li t ie s at th i s p o in t , i t i s r e as o na b l e t o p ro c e ed t o t h e p al p at o r y e xa min a t io n .

Layer-by-Layer Pal pation The p al p at o ry e xa min a ti o n i s a l so b es t s t ar t e d b y o bs e r vi n g t he a re a o f i n t er e s t fo r a ny v as o mo t or , de r ma t ol o g ic , o r d e v el o pm e nt a l a b no r ma l i ti e s . Th e ex a mi n at i o n may t he n pr o ce e d t o t e mp e ra t u re ev a lu a t io n . The p hy s ic i an may no w m a k e c on t ac t wi t h t he p at i e nt fo l lo wi ng a l ay e r -b y -l a ye r ap p ro a ch t o t he ex a min a ti o n t o e v al u at e th e t i s s u e t ex t u re . T h is a pp r oa c h p e rm i t s th e ex a mi n er t o d is t in c t ly mo n it o r e a ch an a t om i c l ay e r f ro m a s up e rf i c ia l t o d e e p p er s pe c t iv e t o b e s t d et e rm i n e t he ma g n it u de of a nd sp e ci f i c t is s u es in v ol v e d i n t he d y s f un c ti o n al s t a te . Th e t i s s u e s a re pr o g re s si v el y ev a lu a te d

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t hr o u gh ea c h e n su i ng la y e r a nd de p t h b y a dd i n g a s l ig h t ly gr e at e r p r es s ur e wi t h t he p al p a ti n g f in g e rs or ha n d . The ph y s ic i an sh o u ld al s o a t te mpt to mon i to r t h e t i s s u e t ex t u re qu a li t y a n d a ny d yn a mi c f l u id mo v em e n t o r c ha n g e i n t is s u e c om p li a n ce . D u ri n g p al p a ti o n o ve r a v is c er a , t h e mob i l it y o f t h a t o rg a n ma y b e e va l u at e d a lo n g w i th an y i nh e r en t m o ti l i t y pr e se n t w i th i n t h at or g an . A no t h er me t ho d th a t we c o mm o nl y u s e i s a s c r e en i ng ev a l ua t io n u s i ng pe r cu s s io n o v er t he p ar a sp i na l mu s cu l at u r e, wi t h p a ti e nt se a t ed or pr o n e, to de t e rm i ne di f f er e nc e s i n mus c l e t on e a t va r io u s s p in a l l ev e l s . In th e th o ra c ic a nd lu mba r ar e as , a h yp e r t y mpa n ic r ea c ti o n t o p e rc u s s i o n a pp e ar s to be as s o ci a te d w i t h t he si d e o f t h e r ot a t io n al co mp on e nt . The s e s t ep s i n th e e x am i n at i on ev a l ua t e t he p os t ur a l a n d r eg i on a l m o ve men t r am i f ic a ti o ns i nv o lv e d i n t h e p at i e nt ' s p ro b l em , i n a d d it i on to e li c it i ng a ny gr o s s a nd f in e ti s su e t e x tu r e c ha n g es . T h e f i na l s t ep i n t he ex a min a ti o n i s t o d e te r min e w h et h e r t he r e i s a re l a te d a r ti c u la r c o mp o n en t t o t h e p a ti e nt ' s p r ob l em . Th i s i nv o l ve s c on t r ol l in g a j oi n t a nd p ut t in g i t th r ou g h v e ry fi n e s mal l m o ti o n a r c s in a ll ph a se s of it s n or ma l c ap a bi l i ti e s ( in t e rs e gm e nt a l m o ti o n t e s t i ng ) . Th e p hy s ic i a n a t t e mp t s w i th a t hr e e -p l an e m o t io n e x am i n at i on to d et e rm i ne whe t he r t h e m o ti o n i s n o rm a l a n d s ym me tr i c o r wh et h er pa t h ol o gy is r es t ri c ti n g m o ti o n, wit h o r w i t ho u t a s y mmet r y i n t h e c ar d i na l a x es . Fo r e x am p l e, th e C 1 se g me n t ma y b e r es t r ic t ed wi t h in it s n o r ma l p hy s i ol o gi c r a n ge of ro t a ti o n a nd e xh i bi t e i t he r a bi l a te r al l y s y mm e tr i c r e s t r ic t io n in r ot a t io n ( e .g . , 3 0 d e gr e e s r ig h t a n d l ef t ) o r a n a s ym me tr y o f m o t io n w i th g re a te r f re e d om in on e di r ec t io n th a n t he o th e r ( e. g . , 3 0 d eg r e es ri g ht , 40 de g re e s l e f t ) . A s s ta t e d p re v io u s ly , m o s t d es c ri p ti o n s o f s om a t ic dy s fu n c ti o n r el a t e t o t he a s y mme t ri c r es t r ic t io n s , b ut s y mme t r ic re s tr i c ti o ns ar e se e n c li n i ca l ly . I n p e rf o rm i ng t he s t e pw i s e l ay e r- b y -l a ye r p a l pa t or y e x a mi n at i on a nd fi n is h i ng wi t h t h e i nt e r se g me n ta l mo t io n e v a lu a ti o n, t he ph y si c i an ca n d e t er min e t h e s p ec i fi c ti s su e s i nv o l ve d i n t h e d y s f u nc t i on (e . g. , mu s cl e , l i ga men t , c a ps u la r ), t he ex t en t to wh i ch i t i s p re s e nt (e . g. , si n gl e s e g me n t , re g i on a l) , a n d w h et h er t he pr o ce s s i s a c ut e , s u ba c ut e , o r c h ro n ic . T h e se de t er mi na t io n s p r ep a re th e ph y si c ia n to de v el o p t h e mos t a pp r o pr i at e t r e at men t p l a n f or th e so mat i c d y s f u nc t io n or dy s fu n c ti o ns . P. 8

References 1 . G l os s a ry Re v ie w Co mmi t te e , E d uc a ti o n al Co u nc i l o n O s te o p at h ic Pr i n ci p le s o f t h e A me r i ca n A s so c i at i on of Col l eg e s o f O s te o pa t h ic Me d ic i n e. Gl o s s a r y o f O s te o pa t h ic Te r mi n o lo g y . ww w. aa c om . or g .

2 . W a rd R ( e d) . F o u nd a ti o ns f or Os t eo p a th i c Med i c in e . P hi l a de l ph i a: L ip p in c ot t Wi ll i am s & Wil k in s , 2 0 03 .

3 . N i ch o l as AS , D e B ia s D A , E h re n fe u ch t e r W, e t a l . A S o ma t i c Com p on e n t t o My oc a rd i a l I nf a rc t i on . B r M e d J 19 8 5; 2 9 1: 1 3– 1 7.

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2 Osteopathic Static Musculoskeletal Examination Th e o s te opat hic st r uct ura l e x ami nat i on has bo th s tat i c and dyn ami c c om po nen ts. T he ph y si c i an wi l l no r ma l ly use st ati c ex ami nat i on as a m etho d t o d i s ce r n obv i ous st r uc tura l a s ym m etr i es of oss eou s a nd my ofa s ci al o r ig i n and ext r ap ol at e f r om tha t i nfo r m at i on to det erm i ne eti olo gie s th at aff ec t fun c ti on. Th ere for e, o n v i su al e x am i na ti on al one , a phy s ic i an c an po s tul ate wh at t he s ub s equ ent sp ec if i c dyn am ic ex ami nat i on w il l e l i ci t. Ob s er v an c e o f g ait m ay pr efa c e t he s ta ti c exa m in atio n, as the pat i en t ca n b e o bs er v ed wa l k in g i nto the ex ami nat i on r oo m . A nu m be r o f co ndi tio ns p r od uce obv i ou s a ntal gic an d as y mm etr i c t end enc i es, su c h as os teo ar th r it i s of t he hip s an d k nee , de gen era ti ve di s co geni c s pon dy lo s is of the lu m ba r sp i ne , a nd ac ute pr oble m s, in c l ud i ng st r ain s a nd s pra i ns . T he v i su al obse r va nce of gai t a nd t he ass oc ia ted st atic ex ami nat i on ( wh i ch m ay be pe r for m ed ei ther be for e or af ter gai t e v al uati on) wi l l h elp th e ph y si c ia n un der s ta nd t he pat i ent ' s m ed i c al an d p s y ch olo gic al s tat us and als o h el p avo i d port i on s o f th e ex ami nat i on tha t m ay b e p ain ful or i n othe r w ays det r im ent al t o t he pati ent . T hese ty pes of s cr uti ny af fec t t he p ati ent l es s t han dyn ami c e x ami nat i on s wi th phy s i ca l c ont ac t and th er ef ore ar e le s s l ik el y to ca use pa i n o r d ama ge t he pat i ent . As an ex am pl e, a p atie nt w it h th e a s ym m etr i c fin di ng s i l lu s tra ted in F ig ure 2. 1 (s ee p. 10) c ou l d be re aso nab l y e x pe c te d to ex hib i t m oti on r est r ic tio n an d m oti on a s ym m et r y i n t he thor aci c a nd l umb ar sp i ne wi th r est r ic ti on s i n l um ba r s i de ben din g t o th e l eft and mi dth or ac i c s id e be ndi ng to t he r ig ht. T he s e fi ndi ngs w ou l d als o ca use th e ph y si c ia n to be co nc er ned wi th r i gh t a nd l eft la ti ss i mu s d or si , p s oa s , a nd er ect or s pin ae ten s i on as y mm etri es aff ec ti ng r an ge o f m oti on o f t he hi p, pe l vi s , a nd s ho ul de r g i rd l e ( F ig . 2. 1). Th ere for e, t he phy s i ci an s ho ul d obs erv e th e p ati ent i n pos teri or, an teri or, an d la ter al ( s ag i tt al and co r on al pl an e) v ie w s t o d eve l op the mo s t c omp l et e un der s ta ndin g o f t he p ati ent ' s p hys i ca l ma k eu p be for e p er fo r mi ng the r em ain der of the exa m in ati on. T he s e v i ew s m ay be s tar ted at the fe et o r a t t he he ad. We gen era l ly r ec omm end s ta r ti ng at t he fee t, a s t hat i s the gr av it ati ona l co nta c t poin t. Th e s tat i c m usc ulo s k el eta l ( s tru c tu r al ) ex ami nat i on use s s uper fic i al ana tom i c l and m ar k s that he l p the ph y si c ia n “s ee the for est fo r th e t r ee s .” Som eti m es s li ght asy m me tri es a r e m is s ed, bu t a l i gn i ng tw o or th r ee la ndma r ks ma k es the as y m me try ob v i ou s . Som e an ato m ic l an dma r ks are im por tant fo r f i ndi ng sp i na l v er te bra l l ev el s . T he s pi ne of the s ca pul a is ty pic al ly at th e le v el of T 3, an d t he i nfe r io r an gle of th e s c ap ul a i s typ i c al l y at the l ev el of t he s pi nous pr oce s s o f T 7 a nd t r an s ve r s e pro c es s es of T 8 ( F ig . 2. 2). So m e l and m ar k s a s si s t i n l oca tin g a m or e c l i ni c al l y i m po r ta nt l and m ar k . T he m as toi d pr oce s s and an gle of the ma ndi bl e are co m m on l y use d to he l p the nov i ce pal pat e t he C 1 t r an s v er s e pro c ess (F i g. 2. 3). Ot her l an dma r k s, su c h as t he c or ac oi d p r oc es s, bi c ip i tal gr oov e of th e h um er us, an d gr eat er and le s se r t uber osi tie s of th e h um er us, he l p d i st i ng ui sh on e t endo n f r om ano the r , henc e d i ff er en tia te betw een a r ot ato r cu ff s yn dr om e a nd anot her so m ati c p r ob l em ( Fi g. 2.4) . T he m ost co m mo nl y use d l andm ark s te nd to be t he one s th at det er mi ne hor i z on tal sy m m et r y or as ym m et r y ( F ig s . 2.5 , 2. 6, 2.7 , 2. 8, 2.9 ) . La ndm ark s su c h as the tib i al tub ero s it i es, an ter i or s up eri or i l ia c s pi ne s , pos teri or s up er io r i l ia c sp i ne s , il i ac cr es ts , n i pp l es, sh oul ders at th e ac r om i oc l avi c ul ar j oin t, ear l obe s , and eye s a s h or iz ont al l eve l s pl ane ar e of ten us ed f or thi s pu r po s e.

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As y mm etr y is on e o f th e t hre e me asu r ab l e c omp one nts of s om atic dy s fu nc ti on ( te nder nes s o r se nsi tiv i ty be i ng mo r e s ubj ect i v e) an d t here for e i s on e o f t he b asi c s teps to de v elo p t he di ag nos i s for s om ati c dy s fu nct i on. P.10

F igu re 2.1. As ymmetr y in sc oliosis . ( Modified with per mis sion fr om Nettina SM. The Lippincott Manual of Nur s ing Pr actice, 7th ed. Baltimore: Lippincott Williams & Wilk ins , 2001.)

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F igu re 2.2. Relating scapular landmar ks to s pinal level. (Modified from Premakur K. Anatomy and Phy siology , 2nd ed. Baltimore: Lippincott Williams & Wilkins, 2004, with per mis sion.)

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F igu re 2.3. A and B. Landmarks to loc ate the C1 tr ansv ers e pr ocess.

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F igu re 2.4. Impor tant landmark s of the s houlder gir dle. ( Repr inted with permiss ion from Clay JH, Pounds DM. Basic Clinical Mas sage T herapy: Integrating Anatomy and Treatment. Baltimore: Lippincott Williams & Wilkins, 2003.)

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F igu re 2.5. Landmark s to help determine horizontal lev elness . (Repr inted with permiss ion from Premakur K. Anatomy and Phys iology , 2nd ed. Baltimore: Lippinc ott Williams & Wilkins, 2004.)

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F igu re 2.6. Planes of the body . The c oronal plane is associated with both the v entr al (anterior) and dorsal ( posterior) aspects. ( Reprinted with permis sion from Clay J H, Pounds DM. Bas ic Clinical Mass age T her apy : Integrating Anatomy and T reatment. Baltimore: Lippincott Williams & Wilkins, 2003.)

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F igu re 2.7. Anter ior view points of r efer enc e. (Modified from Pr emakur K. Anatomy and Physiology, 2nd ed. Baltimor e: Lippinc ott Williams & Wilkins, 2004, with per mis sion.)

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F igu re 2.8. Posterior view points of reference. (Modified with permiss ion from Premakur K. Anatomy and Phy siology , 2nd ed. Baltimore: Lippincott Williams & Wilk ins , 2004.)

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F igu re 2.9. Later al v iew points of refer ence and midgr avity line. ( Modified with permis sion of the AACO M. Copy right 1983–2006. All r ights res erved.)

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3 Spinal Region al Range o f Motion Re g io na l m ot i on t e st in g e va l ua te s p at i en ts ' a bi l it y t o mo v e th rou gh th e c ar di n al a x es o f m ot i on a n d re f le ct s t he i r ab i l i ty to m o ve w i th p a in , d eg en e ra ti v e jo i nt d i se as e , mu s c l e t en s i o n, i n fl am m at io n , st rai n o r sp rai n, an d s o on . Th e s ta t i c e x am in a ti on wi l l gi ve c l ue s o f m ot io n p at t er ns to e x pe ct on i n te rs e gm en t al m o ti on te st i ng t o b e pe rfo rm e d la t er . T he r a ng es th at ar e a c c ep t ed a s n or m al d e pe nd up on th e p at ie n t' s s om at o ty pe . T he y v ar y f ro m on e t yp e o f p at ie n t to an ot h er ; h en ce th e t er m ran ge s . Me s om or p hi c p at ie n ts s h ou ld be m i dr an g e, e c to mo rph i c (l o ng l i ne ar ) p at i en ts at t h e hi g h ra n ge , a nd e n do mo rph i c pa ti e nt s (br ev i l i ne a r) a t t he lo we r r an g e of mo ti o n ex p ec ta t io n. P .1 8

Cervical Spin e: Fo rward Bend ing and Backward Ben ding (Flexion and Ext ensio n), Active

1. The pa tie nt is sea t ed . 2. The ph ysici an stan d s at t he si de of th e pa t ie nt. 3. The ph ysici an pa lp a tes t he C7 -T1 spi n ou s p ro ces s inter spa ce (Fig. 3 .1) o r t he sp in ou s p ro ces se s (Figs. 3 . 2 a nd 3.3) . 4. The pa tie nt is ins t ru cte d t o b en d t he h e ad a n d n ec k for war d t o the f un ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g. 3 .4). 5. The de gr e e of f or war d- b en di n g fle xi on is n oted . N or mal fo rw ar d b en d in g o f the cer vic al spi n e is 45 to 9 0 d eg ree s. 6. The pa tie nt is ins t ru cte d t o b en d t he h e ad a n d n ec k b ac kwa rd as fa r p os sib le wi thin the p hy sio lo g ic a n d p ai n -fre e ran g e of motion (Fig. 3 .5). 7. The de gr e e of ba ckwar d b en d in g is no t ed . Nor mal b a ckwa rd b en d in g o f the cer vic al spi n e is 45 to 9 0 d eg ree s.

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Figur e 3.1 . Ste p 3.

Figur e 3.2 . Ste p 3.

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Figur e 3.3 . Ste p 3.

Figur e 3.4 . Ste p 4, ac tive forwa rd be nd ing .

Figur e 3.5 . Ste p 6, ac tive ba ckw ar d be nd ing .

P .1 9

Cervical Spin e: Fo rward Bend ing and Backward Ben ding (Flexion and Ext ensio n), Passive

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1. The pa tie nt is sea t ed . 2. The ph ysici an stan d s at t he si de of th e pa t ie nt. 3. The ph ysici an pa lp a tes t he C7 -T1 spi n ou s p ro ces s inter spa ce (Fig. 3 .6) o r t he sp in ou s p ro ces se s (Figs. 3 . 7 a nd 3.8) . 4. The ph ysici an be nd s t he pa tie nt's he ad an d n ec k for war d whi le mon itori n g C7 an d T1 a nd stop s whe n motion is d etec t ed a t T1 (Fig. 3 .9). 5. The de gr e e of flex ion is n ote d. No rm al flex ion o f t he ce rv ica l spi ne is 4 5 t o 9 0 de g re es . 6. The ph ysici an then e xte nd s t he p a tien t 's h ea d a nd ne ck wh il e mon itori n g C7 an d T1 a nd stop s whe n motion is d etec t ed a t T1 (Fig. 3 .10 ). 7. The de gr e e of e xte ns io n is n oted . Nor mal e xtens ion o f the cer vic al sp in e is 4 5 to 9 0 d eg re e s.

Figur e 3.6 . Ste p 3.

Figur e 3.7 . Ste p 3.

Figur e 3.8 . Ste p 3.

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P .2 0

Cervical Spin e: Side Bending , Act ive and Passive

1. The pa tie nt is sea t ed . 2. The ph ysici an stan d s at t he si de of th e pa t ie nt. 3. The ph ysici an pa lp a tes t he tran sve rs e p ro ces se s o f C7 an d T1 (Fig. 3.1 1) . 4. The pa tie nt is ins t ru cte d t o sid e- b en d t he h e ad a nd ne ck to th e ri g ht to t he func t io na l a nd p ai n -fre e lim itatio n of motion (Fig. 3 .12) . Thi s is rep ea t ed to the le ft (Fig. 3.1 3) . 5. The ph ysici an sid e -b en d s the p atien t's h ea d a nd ne ck to th e rig h t wh ile mo ni torin g C7 a nd T1 a nd stop s whe n motion is d ete cted at T1 (Fig. 3 .14 ). Th is is rep e ated t o t he le ft (Fig. 3 .15) . 6. The de gr e e of bo th a ctive a n d pa ssi ve si de b en d in g is no t ed . Nor mal side b e nd in g in t he ce rv ica l spi ne is 3 0 t o 4 5 de g re es .

Figure 3 . 11 . S tep 3 .

Figure 3 . 12 . S tep 3 , ac t iv e sid e b en di n g rig h t.

Figure 3 . 13 . S tep 4 , ac t iv e sid e b en di n g left .

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Figure 3 . 14 . S tep 5 , pa ssi ve si de b en d in g rig ht.

Figure 3 . 15 . S tep 5 , pa ssi ve si de b en d in g left.

P .2 1

Cervical Spin e: Ro tatio n, Active and Passive

1. The pa tie nt is sea t ed . 2. The ph ysici an stan d s at t he si de of th e pa t ie nt. 3. The ph ysici an pa lp a tes t he tran sve rs e p ro ces se s o f C7 an d T1 (Fig. 3.1 6) . 4. The pa tie nt is ins t ru cte d t o rotate the he ad to t he ri gh t to t he f un ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g. 3 .17 ). Th is is rep e ated t o t he le ft (Fig. 3 .18) . 5. The ph ysici an ro tat es t he pa tie nt's he ad to

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Figure 3 . 16 . S tep 3 .

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t he ri gh t whi le mon itori n g C7 an d T1 a nd stop s whe n motion is d etec t ed a t T1 (Fig. 3 .19 ). Th is is rep e ated t o t he le ft (Fig. 3 .20) . 6. The de gr e e of bo th a ctive a n d pa ssi ve rota tion is n o ted. No rm a l rota tion in th e ce rvi ca l spi n e is 70 to 9 0 d eg ree s. Figure 3 . 17 . S tep 4 , ac t iv e rotation righ t.

Figure 3 . 18 . S tep 4 , ac t iv e rotation le ft.

Figure 3 . 19 . S tep 5 , pa ssi ve ro tat io n rig h t.

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Figure 3 . 20 . S tep 5 , pa ssi ve ro tat io n left .

P .2 2

Tho racic Spin e: T1 to T 4 Sid e Ben ding, Passive

1. The pa tie nt is sea t ed . 2. The ph ysici an stan d s b eh ind th e pa t ie nt. 3. The ph ysici an ' s le f t ind e x fin ge r o r thu mb may pa lp a te th e t ra n sver se pr o ce sse s of T4 a nd T5 o r t he inte rs pa ce be t we en t he m to mon ito r mo t io n. The we bb ing b e twee n t he ph ysici an ' s ri g ht ind e x fin ge r a nd th um b is p la ce d o n t he p atien t's rig h t sh o ul de r clo ses t t o mi d li ne at th e lev e l of T1 (Fig. 3 .21) . 4. A g e ntle sp ri n gi ng forc e is d ir ec t ed to wa rd the ver t eb ra l b od y o f T4 u ntil the p hy sic ia n fee ls motion o f T4 o n T5. Thi s is d on e b y cr e atin g a vec t or with th e forea rm t ha t is d ir ec t ly in lin e with the ve rte br al bo dy o f T4 (Fi g. 3 . 22 ). This is rep e ated to th e op p os ite sid e (Figs. 3 . 23 a nd 3 .24 ). 5. The de gr e e of pa ssive

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Figur e 3.2 1. St ep 3 .

Figur e 3.2 2. St ep 4 , sid e b en d in g rig ht.

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sid e b en d in g o n ea ch sid e is n oted . N or mal sid e b en d in g f or T1 to T4 is 5 t o 25 de gr e es .

Figur e 3.2 3. St ep 4 .

Figur e 3.2 4. St ep 4 , sid e b en d in g left.

P .2 3

Tho racic Spin e: T5 to T 8 Sid e Ben ding, Passive

1. The pa tie nt is sea t ed . 2. The ph ysici an stan d s b eh ind th e pa t ie nt. 3. The ph ysici an ' s le f t h an d p al p ates the t ra n sver se pr o ce sse s of T8 a nd T9 o r t he inte rs pa ce be t we en t he m to mon ito r mo t io n. The we bb ing b e twee n t he ph ysici an ' s in d ex f in g er a n d thu mb is p la ced o n the pa tie nt's rig h t sh o ul de r h al f wa y b etwee n t he b a se o f the p atien t's n ec k a nd the a cr o mi on pr oc e ss (Fig. 3 .25 ).

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Figure 3 .25. Step 3.

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4. A g e ntle sp ri n gi ng forc e is d ir ec t ed to wa rd the ver t eb ra l b od y o f T8 u ntil the p hy sic ia n fee ls motion o f T8 o n T9. Thi s is d on e b y cr e atin g a vec t or with th e forea rm t ha t is d ir ec t ly in lin e with the ve rte br al bo dy o f T8 (Fi g. 3 . 26 ). This is rep e ated to th e o pp o si te si de (Figs . 3 .27 a nd 3.28 ). 5. The de gr e e of pa ssive sid e b en d in g o n ea ch sid e is n oted . N or mal sid e b en d in g f or T5 to T8 is 10 to 3 0 d eg ree s.

Figure 3 .26. Step 4, side b e nd in g rig h t.

Figure 3 .27. Step 4.

Figure 3 .28. Step 4, side b e nd in g left .

P .2 4

Tho racic Spin e: T9 to T 12 Side Bending , Passive

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1. The pa tie nt is sea t ed . 2. The ph ysici an stan d s b eh ind th e pa t ie nt. 3. The ph ysici an ' s le f t h an d may pa lp a te th e t ra n sver se pr o ce sse s of T12 an d L 1 or the inte rs pa ce be t we en t he m to mon ito r mo t io n. The sp ac e (we b be d ski n) b etwee n t he p h ysic ian 's ind e x fin ge r a nd th um b is p la ce d o n t he p atien t's rig h t sh o ul de r a t t he a cro mi o cl av icu la r reg ion (Fig. 3 .29) . 4. A g e ntle sp ri n gi ng forc e is d ir ec t ed to wa rd the ver t eb ra l b od y o f T12 u ntil the p hy sic ia n fee ls motion o f T12 on L 1 . Thi s is d on e b y cr e atin g a ve ctor wi th the f or ea rm t ha t is d ir ec t ly in lin e with the ve rte br al bo dy o f T12 (Fig. 3 .30) . Thi s is rep ea t ed to the o pp o si te si de (Figs . 3 .31 a nd 3.32 ). 5. The de gr e e of pa ssive sid e b en d in g is no t ed o n e ac h sid e . No rma l sid e b en d in g f or T9 to T12 is 2 0 t o 40 de gr e es .

Figur e 3.2 9. St ep 3 .

Figur e 3.3 0. St ep 4 , sid e b en d in g rig ht.

Figur e 3.3 1. St ep 4 .

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P .2 5

Tho racic Spin e: T9 to T 12 Ro tatio n, Active

1. The pa tie nt is sea t ed with the ar ms cr os sed so t ha t the el bo ws ma ke a V fo rm ation . 2. The ph ysici an stan d s at t he si de of th e pa t ie nt a nd pa lp a tes t he p atien t's tra n sver se p ro ces se s o f T12 a n d L 1, wh ic h a re us ed to mon itor rotation (Fig. 3 .33 ). 3. The pa tie nt is ins t ru cte d t o rotate the up pe r b od y (tru nk ) t o the rig h t to the f un ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g. 3 .34 ). Th is is rep e ated t o t he le ft (Fig. 3 .35) .

Figure 3 .33. Step 2.

Figure 3 .34. Step 3, a ctive ro tat io n ri g ht.

Figure 3 .35. Step 3, a ctive ro tat io n left.

P .2 6

Tho racic Spin e: T9 to T 12 Ro tatio n, Passive

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1. The pa tie nt is sea t ed with the ar ms cr os sed so t ha t the el bo ws ma ke a V fo rm ation . 2. The ph ysici an stan d s at t he si de of th e pa t ie nt a nd pa lp a tes t he p atien t's tra n sver se p ro ces se s o f T12 a n d L 1, wh ic h a re us ed to mon itor rotation (Fig. 3 .33 ). 3. To t es t p as si ve ri g ht rota tion , the ph ysici an ' s rig h t ha n d is pl ac e d on t he pa tie nt's el bo ws or o pp o si ng le ft sh ou lde r. The ph ysici an ro tat es t he pa tie nt to wa rd the rig h t wh ile mo ni torin g motion a t T12 -L1 (Fig. 3 .36 ). Th is re pe ate d to t he op po site sid e (Fig. 3 .37 ). 4. The de gr e e of ac tive a nd pa ssive ro tatio n is n ote d. N o rm al ro tat io n f or T9 to T12 is 7 0 to 9 0 d eg ree s.

Figure 3 .36. Step 3, p a ssiv e rota tion ri g ht.

Figure 3 .37. Step 3, p a ssiv e rota tion le f t.

P .2 7

Lum bar Spine: Forw ard Bendin g and Backward Bending (F lexio n and Ext ensio n), Active

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1. The pa tie nt st an ds in a ne utral p o si tio n with fee t a sh ou ld e r- wi d th a p ar t. 2. The ph ysici an stan d s to the sid e o f the p atien t so as to view th e pa t ie nt in a sag ittal pl an e (Fig. 3.3 8) . 3. The pa tie nt is ins t ru cte d to be nd forw a rd a nd attempt to tou ch the toe s with ou t b en d in g t he kn ee s t o the fun ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g. 3 . 39 ). 4. The de gr e e of ac tive forwa rd be nd ing is n ote d. No rm al flex ion fo r the lum b ar spi n e is 70 to 9 0 d eg re e s. 5. Motion is the n tes t ed fo r ba ckw ar d b en d in g in the lum b ar re gi on . The pa tie nt stan ds in a n e utra l p os ition wi th feet a sho u ld er -wi dth a pa rt. Th e pa t ie nt is ins t ru cte d to be nd ba ckwar d t o the f un ction a l an d p ai n -fre e lim itatio n of motion wh il e t he p h ysic ian su pp or t s the p atien t's u pp e r bo d y (Fi g 3.4 0) . 6. The de gr e e of ac tive ba ckw ar d b en d in g is n oted . N or mal e xtens ion fo r the lum b ar spi n e is 30 to 4 5 d eg re e s.

Figure 3 . 38 . S tep 2 .

Figure 3 . 39 . S tep 3 , a ctive fo rw ar d b en d in g.

Figure 3 . 40 . S tep 5 , a ctive b a ckwa rd b en d in g.

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P .2 8

Lum bar Spine: Side Bend ing, Active

1. The pa tie nt st an ds in a ne utral p o si tio n with fee t a sh ou ld e r- wi d th a p ar t. 2. The ph ysici an stan d s be h in d t he p a tien t so a s to vi ew the p atie n t in a co ron al p la n e (Fi g. 3 . 41 ). 3. The pa tie nt is ins t ru cte d to re ac h d ow n with the ri gh t h an d tow a rd th e kn e e to t he func t io na l a nd pa in -free li mi t atio n o f motion (Fig. 3 .42) . Thi s is rep ea t ed to t he op po site sid e (Fig. 3.43 ). 4. The de gr e e of ac tive si d e be n di ng is n ote d. N o rm al si de be nd ing in the lum b ar sp in e is 25 to 3 0 d eg ree s.

Figure 3 . 41 . S tep 2 .

Figure 3 . 42 . S tep 3 , a ctive side b e nd in g rig h t.

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Figure 3 . 43 . S tep 3 , a ctive side b e nd in g left .

P .2 9

Lum bar Spine: Side Bend ing, Passive, w ith Active Hip Drop Test

1. The pa tie nt st an ds in a ne utral p os ition wi th feet a sh o ul de r-w id t h a pa rt. 2. The ph ysici an stan d s be h in d t he p atien t so as to view th e pa t ie nt in a cor o na l p la ne . The ph ysici an ' s ey e s sho u ld b e lev e l wi t h the lum b ar sp in e (Fig. 3.4 4) . 3. The pa tie nt a t temp t s to ma in t ai n sym metri c wei g ht b e ar in g o n b oth leg s a nd then qu ic kly flex es the rig ht kn ee , cau sin g a rig h t sa cra l b as e d ec lin ation , h en ce ca us ing th e pe lvi s t o com pe n sa te wi th a la t er al t ra n sl ation to the le ft (Fig. 3 .45 ). Th is is rep ea t ed o n the op po site sid e (Fig. 3 .46 ). 4. The de gr e e of le ft lu mb a r si d e be n di ng is n oted . N or mal side b e nd in g in t he lum b ar sp in e is 25 to 3 0 d eg ree s.

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Figure 3 .44 . Ste p 2.

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Figure 3 .45 . Ste p 3, p as si ve si d e be n di ng le ft with rig ht sa cr a l ba se u nl ev e li ng .

Figure 3 .46 . Ste p 3, p as si ve si d e be n di ng ri gh t with left sac ra l b as e u nl ev e li ng .

P .3 0

Norm al Spinal Ra nge s of Motion for Act i ve a nd Pa s sive Test i ng Gui des to Ev a luat i on of Pe r ma nent Impairm e nt (A MA) (1 ) Angus Ca thi e, D. O. (2 )

Rev ise d PC O M (3 )

NORMA L DEGREES O F MOTION– CER VICAL SP INE

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FLEXI ON

50

90

4 5- 9 0

EXTENSION

60

45

4 5- 9 0

SIDE B EN DING R/L

45

3 0- 4 0

3 0- 4 5

ROTATION R/L

80

90

7 0- 9 0

No rm a l degre es of m otion– Thora cic S pine

FLEXI ON

45

EXTENSION

0

SIDE B EN DING R/L

45

ROTATION R/L

30

T1- 3

T4 -8

35

45

T8-L 1

T1- 4

T5 -8

T9- 1 2

5 -2 5

1 0 -3 0

2 0- 4 0

90

7 0- 9 0

NORMAL DE GREES OF MOTION–LUM BAR SP INE FLEXI ON

6 0+

7 0- 9 0

EXTENSION

25

3 0- 4 5

SIDE B EN DING R/L

25

25

2 5- 3 0

ROTATION R/L Fl ex ion = forw a rd b e nd in g ; Ext en si o n = b ac kw a rd b e nd in g ; R/L , ri g ht a n d le f t. 1. Re pr in t ed with p e rm is sio n f ro m Coc ch iar el la L, An de rsson G (e d s) . G ui de s to the E va lu a tion of Pe rm an e nt Impa ir men t. 5th e d. Ne w Yo rk. Amer ic a n Me d ic al Asso cia tio n, 2 0 01 .

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2. Ca thie A, Ph il ad e lp hi a Col leg e o f Ost eo pa t hy . Fro m Dr. Ca thie ' s PC O M (OP P) no teb oo k, pu bl ish ed in THE D.O ., Ju ne 1 9 69 a n d re -pr in t ed in the 19 74 Ye ar b oo k o f the Ame ric an Acad e my o f Oste op ath y. Co lo ra d o Sp rin gs , CO: Amer ica n A ca de my of Osteo pa thy, 19 7 4, p . 7 2. 3. Nich ol a s A. Osteo pa thic Ma n ip ul a tive Me di cin e Man ua l. Ph ila de lph ia : Ph il a de lp h ia Co ll eg e o f O steo p athi c Med ici ne , 2 00 6 .

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4 Osteopathi c Layer-by-Layer Pal pation Examinatio n Seq uence 1. Obs e rv at i on 2. T em p er at u re 3. S k i n t op o gr ap h y an d t ex t ur e 4. F as c ia 5. M us c le 6. T en d on 7. L ig a me nt 8. E ry t he ma fr i c t io n rub

Observatio n Pr io r t o t ou ch i ng t h e pa t ie nt , t he ph y s i c i an sh ou d v i s u al i z e t he ar ea to b e e xa m in ed fo r e v i de n ce o f t ra u ma , in fe c ti on , a no m al ie s , gr o s s a s ym me t ri es , s k i n l es i on s, an d/ o r an a to mi c v ar i at io n s. T h e pa t ie nt sh ou l d be po s i t io ne d c om f or ta b l y s o t ha t t he mo st co mp l et e e xa mi n at io n c an be p e rf or m ed . A t th i s po i nt , t he p rim ar y in te res t i s in ch an g es a s so c i a te d w it h s om at i c dy s fu nc t io n a nd a n y au t on om i c re l at ed ef fe c ts . T he p h y s i c i an sh ou l d v i s ua l l y i ns p ec t t he a rea f o r c l u es t h at s o ma ti c d y s f un ct i on m a y be pr es e nt ( e .g ., hy pe rem ia , a bn o rm al ha ir pa tt e rn s, ne v i , f ol l i c ul a r er u pt io n s) ( F ig . 4 .1 ).

Temperature Te mp e ra tu re i s ev al u at ed by u s in g t he v o la r a sp ec t o f t he w ri s t o r th e d or s al h y po th e na r e mi ne n ce o f t he ha nd . Th e p hy s i c ia n d oe s t hi s b y pl a c i ng th e w ri st s o r h an ds a fe w i nc h es a b ov e t he a rea t o b e t es te d a nd us in g b ot h ha nd s t o e va lu a te t h e pa rav er t eb ra l a re a s bi l at er a l l y a nd s i mu lt a ne ou s l y ( F ig 4 . 2) . C ha ng e s in he at di st rib ut i on ma y b e pa l pa te d p ar a sp in a l l y a s se c on da ry ef f ec ts of m e ta bo l i c p roc es s es , t ra um a , an d s o o n (a c ut e v er su s ch ro n i c f i br ot i c in f la mm a ti on ). He a t ra d ia ti o n ma y a l s o b e p al pa t ed i n o th e r ar e as o f t he bo dy (e .g . , ex t re mi t ie s, ab do m en ). If u n ab le to d e te rm i ne t h e th e rm al st at u s of th e reg io n i n q ue st i on , t he p h y s i c i an m a y at th i s po in t ma ke s l ig h t ph y s i ca l c on t ac t w it h t he a p pr op ria te ar ea of t h e pa l pa ti n g ha n d.

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Figure 4 .1. Vis u al o b se rv a tion of p a tien t .

Skin Topog raphy and Textu re A ve ry l i g ht t o uc h w i l l b e us e d. G e nt le pa lp a ti on wi th th e p al ma r s ur f ac e o f th e t ip s o f t he f i ng er s w i l l p ro v id e t he ne ce s sa ry pr es s ur e. Th e p re s s u re w i l l p e rm it th e f in ge r p ad s t o g l i de ge nt l y ov e r th e s k i n w it h ou t d ra g (fr i c t io n) . Th er e s ho u ld b e n o c ha ng e i n t he c o lo r o f th e p hy s i c ia n 's n a i l be d s. W h en t h e ph y s i c i a n i s to uc h in g t he p a ti en t , it i s i mp o rt an t t o e xp la i n th e n at u re o f t he ex am i na ti o n an d r ec e i v e t he p a ti en t 's a c ce pt a nc e b ef or e c on t in ui n g. Th er e fo re , i t i s im p or ta n t to be p rep ar e d me n ta l l y t o a pp l y th e h an d a s co n fi de n tl y a nd p rof es s io na l l y a s po s s i bl e. P .3 2 S k in to po g ra ph y a nd te xt u re a re ev a lu at e d fo r i nc rea se d o r d ec re a se d h um id i ty , o i l in e s s , t hi c k e ni ng , r ou g hn es s , an d s o on .

Figure 4 .2. A a n d B. Eval u atio n for ther mal a sym me t ry .

Fascia Th e p hy s i c ia n a dd s e no ug h p re s su re to m o ve t h e s k i n wi t h th e h an d t o e va lu a te t h e fa s c i a. Th i s pr es s ur e w i l l ca us e s l i g ht r e dd en i ng o f t he na i l b ed . T he p h y s i c i an m o ve s t he h a nd v e ry g e nt l y in c e ph al a d, c a ud ad , l ef t , ri g ht , c l oc k wi se , a nd co un t er c l o c k wi s e di rec ti o ns t o e l i c it m o ti on an d t en s i o n qu a l i ty ba rr i er s o f ea s e an d b in d ( Fi g . 4. 3) . M in i ma l c ha ng e s in pr es s ur e t o ev a lu at e t he di ff e re nt le ve l s of fa s c i a ar e h el p fu l.

Muscle Mu s c l e i s de ep e r ti s su e; th er e fo re , t he ne xt de gr e e of pa lp a to ry pr es s ur e i s ap p l i ed . T he ph y s i c i an ad ds s l ig h tl y mo re pr es s ur e t o ev a lu at e t he mu s c l e' s c on s i s te nc y a nd de te rmi ne s w he t he r t he re i s r o pi ne s s, r e s i st a nc e t o pr es s ur e, st ri n gi ne s s, a n d so on . T hi s p re s s u re w i l l c a us e b la nc h in g o f th e p hy s i c ia n 's n a i l be d s (F i g. 4 . 4) .

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Figure 4 .3. Fas cia l e va lu a tion for e as e– b in d a symm e try.

Figure 4 .4. Bla n ch in g o f t he n a il b e d wi t h mu scl e d ep th pa lp a tion .

Tendo ns Te nd o ns s h ou ld be t rac ed to t h ei r b on y a tt ac h me nt s a s w el l a s to th ei r c on t in ui t y wi t h mu s c l e. An y f ib ro u s th i c k en in g , ch a ng e i n el a st i c i ty , a nd s o o n s ho ul d b e n ot ed .

Ligam ents Li ga m en ts mu st be c o ns id e re d w he n res tr i ct io n o f j oi nt mo ti o n, h y pe rm o bi l i t y (j o in t l ax it y ), p a in , a nd s o o n a re pr es e nt . Obv io u s l y, l i ga m en ts va ry in t y pe a n d ar e m or e o r l es s p al pa b le d e pe nd i ng o n t he i r an a to mi c pl ac e me nt .

Eryth ema F riction Ru b Th e f in al st ep i s t o p er f or m t he e ryt he m a fr i ct io n r ub , i n w hi ch th e p ad s o f th e p hy s i c ia n 's s e co nd an d t hi rd di gi t s ar e p la ce d j us t p ar a sp in a l l y a nd t h en i n t wo to t h re e q ui c k st ro k es d raw n d ow n t he s p in e c ep ha l ad t o P .3 3 ca ud a d. P a l l or or r e dd en i ng i s e va l ua te d p er sp in a l se g me nt fo r v as om o to r c ha ng e s th a t ma y b e s ec on d ar y t o

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dy sf u nc ti o n. T h i s i s n ot ty pi c al l y do ne on t h e ex t re mi t ie s, as t h e pu rpo se of t h i s t e st i s t o i de nt i fy c e nt ra l s pi n al ar ea s o f a ut on o mi c c ha ng e r el a te d t o se g me nt a l dy s fu nc t io n (Fi g. 4. 5) .

Figure 4 .5. A to C . E ry the ma fric tio n ru b .

P .3 4

Thoracic Region Cross-Section

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Lumbar Reg ion Cross- Section

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5 Intersegmental Motion Testing In ters egm ent al m oti on test i ng is c la s si c al l y d esc r ib ed a s a n e v alu ati on of s pin al ar ti c ul ato r y ( fac et) mo ti on . I n t hi s c ha pte r it is al s o c ons i de r ed as a t ec hn i qu e t o el i ci t a ny m oti on at a jo i nt ( ar tic ula ti on ) , wh ethe r s pin al , pel v ic , co s ta l , or e x tr emi ty . D ep end i ng on the j oi nt, th e mo tio ns ev al uat ed m ay i nc l ud e fl ex io n a nd ex te nsi on; r ot ati on; s id e b end i ng and ro tati on c ou pl in g; tra ns la tio nal m ot i on s a nter i or l y, po s ter i or l y, or l at era l l y; se par atio n o r a ppro x im ati on o f j oin t su r fa c es ; an d t ors i ona l m ove m ent s . In s pi nal mo ti on te s ti ng, the ph y s ic i an at temp ts to di sc ern th e th r ee - pl ane m ot i on an d th e r ela ti on be twe en si de b end i ng and ro tat i on ( co upl i ng) . T he phys i ci an c an det erm i ne the co upli ng s ta tus and wh ethe r t he ar ti cu l ar so m ati c d y sf unct i on is exh i bi tin g a typ e 1 ( op pos i te s id e) or ty pe 2 ( sa m e s i de ) p atte r n ( Fi gs . 5. 1 a n d 5.2) . I n th e t hora c ic or l um bar re gi on , i f t he d y sf unc ti on al pat tern is fo und to be ty pe 1, th e ex am in ati on i s c omp l et e, a s t he s egm ent ha s a neu tra l re l at i on w it h t he c oup l in g. If t he dys func tio n ex hi bi ts a t y pe 2 c oup l i ng pa tte r n, the ph y s ic i an mu s t t y pi c al l y c ont i nu e th e e x am i nat i on to det erm i ne wh ethe r a fl ex io n o r e x ten s io n c om po nen t i s as s oc i at ed w i th th e co upl ed m oti ons of the dy s fu nc ti on. In th e ce r vi c al s pi ne, th es e c ou pli ng r ela tio ns f oll ow a di ffe r en t se t o f b i ome c ha nic al r ule s f r om tho s e of t he th or ac i c and l um bar re gi on s . In the c er v ic al s pin e, fl ex i on , e x ten s io n, and neu tra l co m po nen ts m ay be fo und w it h t y pe 1 o r 2 c ou pli ng; or i n the c as e o f C 1- C2 mo tio n, t her e m ay b e n o c oupl i ng at all .

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F igure 5.1. Type 1 spinal coupled pattern.

So m e p hys i ci ans pre fer to s ta r t w i th th e f l exi on and ext ens i on por tio n o f th e e x am i nat i on an d th en fol l ow wi th r ota tio n an d/o r s i de ben din g to de ter m i ne th e c oupl i ng co m pon ent s f or d ete r mi nati on of a ty pe 1 o r ty pe 2 dy s fu nc ti on. Be c aus e o f t he b i om ech anic al pat tern s P.36 in here nt to s pec i fi c r egio ns, th e mo tio n m os t eas i ly tes ted ma y va r y. Fo r ex amp l e, i n the C2 to C 7 re gi on , i t m ay b e b est to tes t s i de ben din g fi r st . H ow ev er, it i s alw ays bes t t o t es t the co uple d s egm ents to geth er and tes t t he fl ex i on or ext ens i on c om pon ent s be for e o r af ter th e co upl ed test i ng . T hi s i s als o tr ue wh en p erf orm i ng ost eop athi c m ani pula tiv e t r eat m en t ( OM T) , s uch as m us c le ene r gy te c hni que , w hen all th r ee axe s a r e t o b e t r eat ed. Th e co upl i ng s ho uld al w ays be ke pt u nif i ed .

F igure 5.2. Type 2 spinal coupled pattern.

Th er e are a numb er of w ays to te s t m oti on av ai l ab i li ty ( qua l it y an d q uan ti ty ) a t a n ar tic ula ti on . W e p r efe r a m eth od tha t in tro duc es m oti on di re c tl y t o th e j oin t us i ng ph y s ic al c on tact on bo ny l and m ar k s ( e.g ., ce r v ic al art i c ul ar pro c ess es) us i ng a q uic k im pul s e. W e use th e te r m pos i tiv e w hen re ferr i ng to thi s f orm of m ot i on te s tin g. An ex am ple of pos i ti v e m oti on tes ti ng is a l umb ar s pr i ng tes t f or f l ex i on and ex ten s i on co m pon ent s o f dy s fu nct i on. Mo tio n av ail abi l i ty ca n b e in s ta ntl y as c er tai ned i n w hi c hev er dir ec ti on the

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im puls e w as v ect ore d, and the ph y s ic i an ha s a hig h d egre e o f c er ta i nt y t hat the mo ti on pa l pa ted i s oc c urr i ng at thi s l oca ti on . An othe r c omm on m eth od i s u s e of v i su al c lu es . In thi s me tho d, the phy s ic i an l oo k s for a c han ge i n re l ati on ( sy m m et r y or as ym m et r y) of s up erf i c ia l a nat om ic la ndm ar ks as th e pa tie nt ac ti v el y m ov es th r oug h a ra nge of m ot i on. We us e th e t erm pre s um pti v e w hen re ferr i ng to thi s f orm of m ot i on tes tin g. Ex am pl es of pr es ump tiv e mo tio n t es ti ng are the st and i ng and se ated fl exi on ( for w ar d be ndi ng) tes ts for sa c r oi l ia c r egio n d y sf unct i on . I n th i s for m of mo tio n te s ti ng the phy s ic i an has a l owe r d egr ee o f c ert ai nt y th at t he des i gna ted jo i nt has mo ti on re duc ti on or as y m me try (d y s fu nct i on ) . M any po s tur al fac tors (e .g. , sa c r al ba s e unle v el i ng , ti ght ha m s tr i ng mu s c le s ) oth er t han mo ti on di s tu r ban c e at the j oi nt c an c au s e fa l s e pos i ti v es i n thi s ty pe of test i ng , a nd t her efo r e, w e l im i t i ts use . Wh en d ocu m en ti ng th e m otio n p r ef er en c es re v eal ed on i nte r se gme ntal mo tio n te s ti ng, i t i s und er st ood th at t he fol l owi ng abb r evi ati ons are ac c ep ted and us ed c ons i st entl y w i th i n t he ost eopa thi c p r ofe s si on to de note th e x , y , an d z c om pon ent s in th e thr ee - pl ane dia gno s is and wi l l be u s ed in the fo l lo w i ng ch apt er s to des c ri be the dys fun c tio n's fr ee m oti on c har act eri s tic s : F le x i on = F ; Ex te nsi on = E; Ne utr al = N; Si debe ndi ng r i gh t = SR ; Si deb end i ng l ef t = SL; Ro tat i on r ig ht = RR ; a nd R ota tio n l eft = R L. P.37

Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Rotation, Shor t-Leve r Me thod, Prone (L4 Exa m ple )

1. The patient lies prone on the treatment table with the head in neutral (if a fac e hole is pr esent) or r otated to the mor e comfortable side. Remember, the side to which the head is rotated will pas s ively inc r eas e the rotational effect to that side. 2. The phy sic ian stands at either side of the table and palpates the L4 transverse proc ess es (lev el of the iliac cres t) with the

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F igu re 5.3. Step 2, hand pos ition on s keleton.

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3.

4.

5.

6.

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pads of the thumbs (F igs. 5.3 and 5.4). The phy sic ian alternately pres ses on the left and r ight transverse proc ess es of L4 with firm ventrally dir ected impulses to evaluate for eas e (freedom) of left and r ight rotation ( Fig s. 5.5 and 5.6). If the right transverse proc ess moves anteriorly (inward) ( white arr ow) mor e eas ily and the left tr ans ver s e proc ess is res istant, the segment is rotating left mor e fr eely (rotated left) (F ig . 5.7) . If the left tr ansverse proc ess moves anteriorly (white arr ow) mor e eas ily and the right transver se proc ess is res istant, the segment is rotating r ight mor e fr eely (rotated r ight) (F ig . 5.8) . The left transverse

F igu re 5.4. Step 2, hand pos ition on patient.

F igu re 5.5. Step 2, s keleton, r otation left.

F igu re 5.6. Step 3, s keleton, r otation r ight.

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proc ess of L4 in this ex ample may present mor e prominently (pos ter ior ly) on static (layer by lay er) palpation in a rotated left dys func tion. 7. The phy sic ian per forms thes e steps at each segment of the lumbar spine and doc uments the rotational freedom of mov ement.

F igu re 5.7. Step 4, r otation left.

F igu re 5.8. Step 5, r otation right.

P.38

Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Side B ending, Tra nsla tional Short-Lev e r Method, Prone (L4 Exa mple)

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1. The patient lies prone on the treatment table with the head in neutral (if a fac e hole is pr esent) or r otated to the mor e comfortable side. 2. The phy sic ian's thumbs res t on the pos terolateral aspect of the transverse proc ess es (F ig s. 5.9 an d 5.10). 3. The phy sic ian intr oduces an alternating translator y glide, left and right, to evaluate for eas e of left and right s ide bending. 4. If the thumb translates the segment more eas ily from left to r ight, the segment has its eas e in left s ide bending and is ter med side bent left (F ig s. 5.11 an d 5.12). 5. If the thumb translates the segment more eas ily from r ight to left, the segment has its eas e in right side bending

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F igure 5.9. Step 2, hand position on s k eleton.

F igure 5.10. Step 2, hand pos ition on patient.

F igure 5.11. Step 4, s ide bending left on s k eleton.

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P.39

Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Ty pe 2 , Exte nsion (Sphinx Position) and Flexion, Pr one

1. After determining that the rotational and side bending components ar e coupled in a type 2 patter n (same-s ide pattern of eas e) the phy sic ian's thumbs are plac ed on the pos terolateral aspect of the transverse proc ess es (F ig . 5.15) of the prone patient. 2. The patient is ins truc ted to extend the thor acolumbar region by elev ating the ches t off the table with the support of the elbows (F ig. 5.16). 3. The phy sic ian retests the rotational and/or side bending components in this position. If the components impr ove, the dys func tion is extended ( Fig . 5.17). If the dys func tional component

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F igu re 5.15. Step 1.

F igu re 5.16. Step 2, lumbar Sphinx position.

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bec omes more asy mmetric , the dys func tion is flex ed (or neutral). 4. Some pr efer als o to have the patient curl up in a knees-to-c hes t pos ition to promote relative flex ion and retest the dys func tional rotation and side-bending components . If the dys func tional components appear mor e symmetr ic in this position, the dys func tion is ter med flexed. If they ar e more asy mmetric in this position, it is termed extended ( Fig . 5.18). 5. The phy sic ian mus t perform only one of thes e as long as ther e is a known type 2 coupling pattern; perform the mos t comfortable tes t. 6. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of

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F igu re 5.17. Step 3: extension impr oves asymmetr y.

F igu re 5.18. Step 4, flex ion.

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mov ement elic ited.

P.40 P.41

Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Pa s siv e Fle x ion and Ex tension, Late ral Re c umbent Pos ition

1. The patient lies in the lateral rec umbent (side-lying) pos ition. 2. The phy sic ian stands at the side of the treatment table fac ing the patient. 3. The phy sic ian's finger pads of the cephalad hand palpate the spinous proc ess es of L5- S1 ( Fig . 5.19) or the interspinous spac e between L5 and S1 (F ig . 5.20). 4. The phy sic ian's caudad hand controls the patient's flex ed lower extr emities, and the phy sic ian's thigh may be plac ed agains t the patient's tibial tuberos ities for

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F igu re 5.19. Step 3, palpation of s pinous proc esses.

F igu re 5.20. Step 3, palpation of L5-S1 inter space.

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greater balanc e and control dur ing pos itioning ( Fig . 5.21). 5. The phy sic ian slowly flexes and extends the patient's hips with the c audad hand and thigh while the cephalad hand cons tantly monitor s the spinous proc ess es to determine the relativ e freedom of lumbar flex ion and extens ion of L5 on S1 ( Fig s. 5.22 an d 5.23). 6. The phy sic ian ass esses the ability of the upper of the two segments to flex and extend on the lower. If L5 flex es and extends equally (sy mmetric ally ) on S1, then L5 is termed neutral. If there is asymmetry of motion between the two segments, the dys func tion is named for the dir ection of ease of motion of the upper of the two segments ( e.g., if L5 moves mor e easily in flex ion, L5 is

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F igu re 5.21. Step 4.

F igu re 5.22. Step 5, flex ion, s pinous proc ess separate.

F igu re 5.23. Step 5, extension, spinous proc ess approx imate.

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flex ed; if the segment moves mor e fr eely into extension, L5 is extended). 7. The phy sic ian per forms thes e steps at each segmental lev el of the lumbar spine. 8. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of mov ement elic ited.

P.42

Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Pa s siv e Side Bending, Late r al Rec umbe nt Pos ition (L5-S1 Exam ple )

1. The phy sic ian flex es the patient's hips to appr oximately 90 degr ees and gently mov es the patient's lower extr emities slightly off the edge of the table (F ig . 5.24). 2. The phy sic ian slowly flexes and extends the patient's hips until L5 is neutral relative

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F igure 5.24. Step 1.

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to S1. 3. The finger pads of the phy s ician's cephalad hand palpate the left and right transverse proc ess es of L5 (F ig . 5.25) or the inters pac e between their transverse proc ess es. 4. The phy sic ian's caudad hand slowly raises the patient's feet and ank les upward as the cephalad hand monitor s the appr oximation of the transv ers e proc ess es on the side to whic h the feet are raised (or the separation of the transverse proc ess es on the side to whic h the patient is ly ing) (F ig . 5.26). 5. The phy sic ian then lower s the patient's feet and ank les while the cephalad hand monitors the appr oximation of the transv ers e proc ess es on the side to whic h the feet are lowered ( or

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F igure 5.25. Step 3, palpation of L5 tr ans v ers e proc esses.

F igure 5.26. Step 4, s ide bending r ight.

F igure 5.27. Step 5, s ide bending left.

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the separation of the transverse proc ess es on the side opposite to whic h the patient is ly ing) (F ig . 5.27). 6. The phy sic ian ass esses the ability of the upper of the two segments ( L5) to s ide-bend left and side-bend right. In this tes t, s ide bending oc cur s on the side to whic h the feet and ank les ar e mov ed. 7. The phy sic ian per forms thes e steps at each segmental lev el of the lumbar spine. 8. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of mov ement elic ited.

P.43

Thor acic Inte r segmental Motion Te s ting: T1 to T4 Side Bending, Late ral Re cum bent Position (Long Leve r)

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1. The patient lies in the lateral rec umbent pos ition with the bac k close to the side of the table. 2. The phy sic ian sits in fr ont of the patient at the side of the table, fac ing the patient's head. 3. The phy sic ian plac es the finger pads of the caudad hand over the transverse proc ess es of the dys func tional segment or the interspace between them while the cephalad hand reac hes under the patient's head and car efully lifts it off the table (F ig . 5.28). 4. The phy sic ian gently lifts the patient's head while monitor ing the inv olv ed segment's transverse proc ess es or the inters pac e between them. Side bending is intr oduced on the side to which the head is mov ed. This pres ents as a

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Fig u re 5.28. Step 3.

Fig u re 5.29. Step 4, side bending right.

Fig u re 5.30. Step 5, side bending left.

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P.44 P.45

Thor acic Inte r segmental Motion Te s ting: T1 to T4 Pass ive Fle xion, Exte nsion, Side B ending, and R ota tion, Seate d, Long-Le ver Me thod

1. The patient is seated with the phy s ician standing behind the patient. 2. The phy sic ian controls the patient's head with one hand and palpates the s pinous pr oces ses of T1 and T2 with the index and thir d finger of the other hand. 3. The phy sic ian slowly mov es the patient's head forward and bac k war d while constantly monitor ing the ability of the upper of the segments to move in the res pective dir ection tes ted (F igs. 5.31 an d 5.32). 4. The phy sic ian, while controlling the patient's head, palpates the left tr ans ver s e proc ess es of T 1 and T2 and mov es the patient's head to the left shoulder, ass essing the ability of the left T1 transverse pr oces s to appr oximate the left T2 transverse pr oces s. This elicits left side bending (F ig. 5.33). This is r epeated on the r ight to elicit right s ide bending ( Fig . 5.34) . 5. While monitor ing the left transverse pr oces ses , the phy s ician slowly rotates the patient's head to the left. This evaluates left rotation; it is sensed by a simultaneous poster ior mov ement of the transver se proc ess on that s ide (F ig. 5.35). This is repeated on the right to elic it right r otation ( Fig . 5.36) . 6. The phy sic ian per for ms thes e steps at each segmental lev el T2- T 3, T3- T4, and T4-T5. 7. The phy sic ian will document the findings in the progres s note

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F igure 5.31. Step 3, flexion, spinous pr ocess s epar ate.

F igure 5.32. Step 3, ex tens ion, s pinous pr oces s appr oximate.

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acc ording to the pos ition or freedom of motion elicited.

F igure 5.33. Step 4, s ide bending left.

F igure 5.34. Step 4, s ide bending right.

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F igure 5.35. Step 5, r otation left.

F igure 5.36. Step 5, r otation right.

P.46

Thor acic Inte r segmental Motion Te s ting: T1 to T12 Pas s ive Flexion and Extens ion, Tr ans latory Method, Se ate d (T6-T7 e xam ple)

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1. The patient is seated with the phy s ician standing behind and to the side. 2. The phy sic ian plac es the thumb and index finger of one hand between the spinous proc ess es of T 6 and T7, or the index and thir d finger palpate the spinous proc ess es of T 6 and T7, res pectively (F ig . 5.37). 3. The patient's arms ar e cros sed, anteriorly , in a V-formation. T he phy s ician's r ight arm and hand are placed inferior on the patient's cros sed elbows while left hand remains on the T6- T 7 interspace (F ig. 5.38). 4. The phy sic ian ins truc ts the patient to completely relax for ward, r esting the for ehead on the for ear m as the left hand monitor s flex ion of T 6 on T 7 (separation of the spinous

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F igu re 5.37. Step 2.

F igu re 5.38. Step 3.

F igu re 5.39. Step 4, flex ion, s pinous proc esses s epar ate.

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P.47

Thor acic Inte r segmental Motion Te s ting: T1 to T12 Tra nsla tor y Method (Pa ssiv e Side Be nding), Se a ted

1. The patient is seated and the phy s ician stands behind and to the side. 2. The phy sic ian plac es the left thumb and index finger between the spinous proc ess es of T 6 and T7 (F ig. 5.41). Alternativ ely the phy s ician's left thumb and index finger palpate the spinous proc ess of T6. 3. The phy sic ian reac hes ac ros s the front of the patient's ches t with the r ight arm and places the right hand on the patient's left shoulder with the phy s ician's r ight axilla res ting on the patient's right s houlder (F ig . 5.42). 4. The phy sic ian's right axilla applies a downwar d forc e on the patient's right s houlder as the left hand simultaneously glides or pus hes

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F igu re 5.41. Step 2.

F igu re 5.42. Step 3.

F igu re 5.43. Step 4, translator y s ide bending right.

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the T6- T7 interspace to the patient's left. This causes a left tr ans latory effect that produces r ight side bending of T6 on T 7 ( Fig . 5.43). 5. The phy sic ian's right hand applies a downwar d forc e on the patient's left shoulder as the left hand simultaneously glides the T6- T7 interspace to the patient's right. This produces left side bending of T6 on T 7 ( Fig . 5.44). 6. Thes e s teps ar e per formed to evaluate r ight and left s ide bending at eac h thor acic segmental lev el. 7. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited.

F igu re 5.44. Step 5, translator y s ide bending left.

P.48

Thor acic Inte r segmental Motion Te s ting: T1 to T12 Prone Shor t-Leve r Me thod, Pas s ive Rotation, Side B ending (Ex ample T7)

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1. The patient lies prone with the head in neutr al. If this is not pos s ible, the patient should tur n the head to the mor e comfortable side. Note any change below. 2. The phy sic ian stands at either side of the table and palpates the T7 transverse proc ess with the pads of the thumbs or index fingers . 3. The phy sic ian alternately pres ses on the left and r ight transverse proc ess es of T7, evaluating for eas e of mov ement. 4. If the right transverse proc ess moves anteriorly (inward) more eas ily, the segment is rotating left mor e fr eely and vic e versa (F ig s. 5.45 an d 5.46). 5. In the step 4 scenario, the left transverse proc ess may be palpated more prominently (pos ter ior ly) on

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Fig u re 5.45. Step 4, rotation left.

Fig u re 5.46. Step 4, rotation right.

Fig u re 5.47. Step 7, side bending left.

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P.49

Thor acic Inte r segmental Motion Te s ting: T8 to T12 Long-Le ver Method, Pa ssiv e Flex ion and Ex tens ion, Late r al Rec umbe nt

1. The patient lies in the lateral rec umbent pos ition with the hips and k nees flex ed (fetal pos ition). 2. The phy sic ian stands on the side of the table fac ing the patient and controls the patient's knees at the tibial tuberos ity with the caudad hand. 3. The phy sic ian's cephalad hand palpates the spinous proc ess es of T12 and L1 or their interspace with the index and/or long finger (F ig. 5.49). 4. The phy sic ian slowly flexes the hips by br inging the knees to the ches t as the phy s ician's cephalad hand monitor s the separation of the spinous proc ess es (flexion) (F ig . 5.50). 5. The phy sic ian

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F igure 5.49. Step 3, s pinous proces s es of T 12–L1.

F igure 5.50. Step 4, flex ion.

F igure 5.51. Step 5, extension.

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then ex tends the hips by bringing the knees away from the c hes t as the cephalad hand monitors the appr oximation of the spinous proc ess es (ex tens ion) (F ig . 5.51). 6. Thes e s teps ar e per formed to evaluate flex ion and extens ion at eac h thoracic segmental lev el. 7. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited.

P.50

Thor acic Inte r segmental Motion Te s ting: T8 to T12 Long-Le ver Method, Pa ssiv e Side Be nding, Late ral Re cum bent

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1. The patient lies in the lateral rec umbent pos ition with the hips and k nees flex ed (fetal pos ition). 2. The phy sic ian stands on the side of the table fac ing the patient and controls the patient's knees at the tibial tuberos ity with the caudad hand. 3. The phy sic ian mov es the patient's lower legs off the edge of the table, and while monitor ing the transv ers e proc ess es, the phy s ician slowly rais es the patient's feet toward the ceiling and then draws them toward the floor (F ig . 5.52). 4. Side bending is evaluated by monitor ing the appr oximation of the transv ers e proc ess es on the side to which the feet are drawn ( e.g., feet toward the right, side bending right) (F igs. 5.53 an d 5.54). 5. Thes e s teps ar e

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Fig u re 5.52. Step 3.

Fig u re 5.53. Step 4, side bending right.

Fig u re 5.54. Step 4, side bending left.

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P.51

Cos tal Motion Tes ting: C ostal Mec hanics

In res piration, the sternum and ribs move in a simultaneous and combined patter n that expands the chest in the anteroposterior and lateral diameters dur ing inhalation and dec reas es the anteroposterior and lateral diameters in exhalation. T he sternum and r ibs 1 to 10 also ris e in a c ephalad dir ection and des cend caudally in inhalation and exhalation, res pec tively (F ig. 5.55).

Fig ure 5.55. Lateral view of firs t and s eventh ribs in pos ition, showing the movements of the sternum and r ibs . A, or dinary expiration. B, quiet ins pir ation. C, deep inspiration. (Repr inted with per mis sion fr om Clemente CD. G ray 's Anatomy , 30th Amer ican ed. Baltimor e: Lippinc ott Williams & Wilkins, 1985.)

Rib Excursion wit h In halation The ver tebral and sternal attachments combine to promote specific vec tor s of motion dur ing nor mal inhalation, expanding the chest. This expans ion mov es through two major vec tor

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paths. These patter ns are des cribed as occ urr ing thr ough pump handle and buc ket handle axes in both ver tebr osternal ribs 1 to 6 and ver tebr ochondral ribs 7 to 10 (F igs. 5.56 and 5.57).

Fig ure 5.56. Axes of movement (AB and CD) of a ver tebros ternal rib. Inter rupted lines indicate the pos ition of the rib in inhalation. ( Used with per mis sion of the AACOM. Copy r ight 1983–2006. All rights reser ved.)

Fig ure 5.57. Axis of movement (AB) of a ver tebroc hondral rib. Interrupted lines indicate the pos ition of the rib in inhalation. ( Used with

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per mis sion of the AACOM. Copy r ight 1983–2006. All rights reser ved.)

P.52 P.53

Cos tal Motion Tes ting: C ostal Mec hanics

Ang le o f Inclinat ion of the Axes o f Rib 1 and Rib 6 The cos totransver se articulations combine with the cos tov ertebral articulations at eac h ver tebr al lev el to dev elop angles thr ough which ax is of rotation a rib may mov e. T hus , the r ib mov es within this specific axis of rotation, and the angle c hanges fr om superior to infer ior ribs. T he angle, as it relates to the anteroposterior planes and the later al body line, deter mines whether the r ib motion produc ed thr ough normal res pir ation is greates t at the anterior midc lav icular line or the later al clavic ular –midax illary line. Ribs 1 to 10 hav e s ome shared motion par ameter s in eac h of the axes of rotation. However , the motion patter n of

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F igu re 5.58. Rib 1: Most frontal in plane, allowing a mor e purely pump handle rib excur sion.

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the upper ribs is related to a predominant anter ior or frontal plane axis, whereas in the lower ribs a les s frontal, mor e s agittal ax is predominates. These differ ences produce the patter ns of pump handle motion prefer ence of the upper r ibs and the buc ket handle prefer ence of the lower r ibs (F igs. 5.58 an d 5.59). Pum p Handle Rib Mot ion The ter m pump handle rib motion des cribes the mov ement of a rib that c an be compar ed to the motion of the handle of a water pump. Its motion is produc ed by one end being fix ed in s pac e and rotating around an axis that per mits the opposite end to move thr ough space (F ig. 5.60). Bucket Han dle Rib Mot ion The ter m buck et handle rib motion des cribes the mov ement of a rib that c an be best compar ed to the mov ement of the handle of a buck et as it is lifted up and off the rim of the bucket

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F igu re 5.59. Rib 6: Less frontal plane, allowing for greater ability to move in a bucket handle motion than can rib 1.

F igu re 5.60. Pump handle rib motion. ( Reprinted with per mis sion fr om Clay JH, Pounds DM. Bas ic Clinical Massage T her apy : Integrating Anatomy and T reatment. Baltimore: Lippincott Williams & Wilk ins, 2003.)

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and then laid down on the same s ide. The motion is produc ed by both ends of the handle being fixed at a rotational ax is per mitting only the area between the two points to mov e thr ough space (F ig 5.61)

F igu re 5.61. Bucket handle r ib motion. ( Repr inted with permission from Clay J H, Pounds DM. Basic Clinical Massage T her apy : Integrating Anatomy and Tr eatment. Baltimor e: Lippinc ott Williams & Wilk ins , 2003.)

P.54

Cos tal Motion Tes ting: U ppe r R ibs 1 a nd 2, Supine Method

1. The patient lies supine and the phy s ician sits or stands at the head of the table. (Or the patient may s it.) 2. The phy sic ian palpates the firs t ribs at their infr aclavicular pos ition at the ster noc lav icular articulation ( the supr aclavicular pos ition c an

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F igu re 5.62. Step 2, palpation of the fir st r ib.

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3.

4.

5.

6.

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als o be us ed) (F ig . 5.62). The phy sic ian monitor s the relativ e s uper ior (cephalad) and inferior ( caudad) relation of the pair and on the symptomatic side deter mines whether that r ib is prominent or not and pos itioned superiorly or inferiorly . The patient is ins truc ted to inhale and exhale deeply thr ough the mouth as the phy s ician monitor s the ability of the pair of firs t r ibs to mov e super ior ly and inferiorly . If the rib on the symptomatic side is static ally cephalad and on inhalation has greater cephalad ( on exhalation, less caudad) mov ement, it is clas sified as an inhalation rib dys func tion (F ig . 5.63). If the rib on the symptomatic side is static ally caudad and on inhalation has les s cephalad

F igu re 5.63. Step 5, inhalation rib dysfunction.

F igu re 5.64. Step 6, exhalation rib dysfunction.

F igu re 5.65. Step 7, palpation of the s econd r ib.

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(on exhalation, greater caudad) mov ement, it is clas sified as an exhalation rib dys func tion (F ig . 5.64). 7. The phy sic ian nex t palpates the sec ond ribs appr oximately one finger's-breadth below and one finger's-breadth lateral to where the fir st rib was palpated and repeats steps 3 to 6 (F ig. 5.65). 8. The mov ement of the rib on the symptomatic side that was freest is doc umented in the progress note (inhalation or exhalation bas ed on the res pirator y model or elev ated or depr ess ed bas ed on the str uctural model.)

P.55

Cos tal Motion Tes ting: Firs t R ib, Ele vated, Sea ted Me thod

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1. The patient is seated and the phy s ician stands behind the patient. 2. The phy sic ian palpates the pos terolateral shaft of each fir s t r ib immediately lateral to the cos totr ans ver s e articulation ( Fig . 5.66). Note: T he trapezius bor ders may hav e to be pulled pos teriorly ( Fig . 5.67). 3. With firm pres sur e of the thumbs or finger pads , the phy s ician dir ects a downwar d (caudad) forc e alternately on eac h rib ( Fig s. 5.68 an d 5.69). 4. The phy sic ian monitor s the relativ e cephalad or caudad relation of the pair and on the symptomatic side deter mines whether that r ib is prominent superiorly as compared to its mate. 5. If a rib is prominent,

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F igu re 5.66. Step 2, palpation of the fir st r ib.

F igu re 5.67. Step 3, palpation of the fir st r ib.

F igu re 5.68. Step 3, palpation of thir d r ib.

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P.56

Cos tal Motion Tes ting: U ppe r R ibs 3 to 6 , Supine Method

1. The patient lies supine and the phy s ician stands on one side of the patient. 2. The phy sic ian's thumbs palpate the third ribs bilater ally at their cos tochondral articulations for pump handle motion and at the midaxillar y line with the sec ond or thir d fingertips for buc k et handle motion (F ig. 5.70). 3. The phy sic ian monitor s the relativ e cephalad or caudad relation of the pair and on the symptomatic side deter mines whether that r ib is more or les s prominent or superiorly or inferiorly pos itioned. 4. The patient is ins truc ted to inhale and exhale deeply thr ough the mouth as the phy s ician monitor s the

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Fig u re 5.70. Step 2.

Fig u re 5.71. Step 4.

Fig u re 5.72. Step 5, inhalation r ib.

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relativ e cephalad and caudad mov ements of eac h rib with the palpating thumbs and finger tips (F ig . 5.71). 5. If the rib on the symptomatic side is static ally mor e cephalad and on inhalation has greater cephalad mov ement ( on exhalation, less caudad mov ement), it is ter med an inhalation rib (dy s function) (F ig . 5.72). 6. If the rib on the symptomatic side is static ally mor e caudad and on inhalation has les s cephalad mov ement ( on exhalation, greater caudad mov ement), it is ter med an exhalation rib (dy s function) (F ig . 5.73). 7. The phy sic ian nex t palpates ribs 4 to 6 at their cos tochondral ends with the thumbs and at their mid- axillar y lines with the fingertips and repeats steps 3

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Fig u re 5.73. Step 6, ex halation r ib.

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to 6. 8. The freest mov ement of the rib on the symptomatic side is then doc umented in the progress note (inhalation or exhalation bas ed on the res pirator y model or elev ated or depr ess ed bas ed on the str uctural model).

P.57

Cos tal Motion Tes ting: Lowe r R ibs 7 to 1 0, Supine Method

1. The patient is supine and the phy s ician stands on one side of the patient. 2. The phy sic ian's thumbs palpate the sev enth r ibs bilater ally at their cos tochondral articulations for pump handle motion and at the midaxillar y line with the sec ond or thir d fingertips for buc k et handle motion (F igs.

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F igu re 5.74. Step 2.

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5.74 an d 5.75). 3. The phy sic ian monitor s the relativ e cephalad or caudad relation of the pair and determines on the symptomatic side whether that rib is more or less prominent or superiorly or inferiorly pos itioned. 4. The patient is ins truc ted to inhale and exhale deeply thr ough the mouth as the phy s ician monitor s the relativ e cephalad and caudad mov ements of eac h rib with the palpating thumbs and fingertips . 5. If the rib on the symptomatic side is static ally mor e cephalad and on inhalation has greater cephalad mov ement ( on exhalation, less caudad mov ement), it is ter med an inhalation rib (dy s function) (F ig . 5.76). 6. If the rib on the

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F igu re 5.75. Step 2.

F igu re 5.76. Step 5, inhalation dysfunction.

F igu re 5.77. Step 6, exhalation dysfunction.

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symptomatic side is static ally mor e caudad and on inhalation has les s cephalad mov ement ( on exhalation, greater caudad mov ement), it is ter med an exhalation rib (dy s function) (F ig . 5.77). 7. The phy sic ian nex t palpates , sequentially, the 8th thr ough 10th ribs at their cos tochondral ends with the thumbs and at their midaxillary lines with the fingertips and repeats steps 3 to 6. 8. The mov ement of the freest rib on the symptomatic side is then doc umented in the progress note (inhalation or exhalation bas ed on the res pirator y model or elev ated or depr ess ed bas ed on the str uctural model).

P.58 P.59

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Cos tal Motion Tes ting: Floa ting R ibs 11 and 12, Pr one Method

1. The patient lies prone and the phy s ician stands on either side of the patient. 2. The phy sic ian's thumb and thenar eminenc e palpate the s haft of each 11th r ib (F ig . 5.78 an d Fig . 5.79) . 3. The patient is ins truc ted to inhale and exhale deeply thr ough the mouth. 4. The phy sic ian notes any asy mmetric motion at eac h rib. 5. If on the symptomatic side the patient's rib mov es more pos teriorly and inferiorly with inhalation and les s anter ior ly and superiorly with ex halation than its mate, it is c las sified as an inhalation rib (dy s function) (F ig . 5.80). 6. If on the symptomatic side the patient's rib mov es more anteriorly and

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F igu re 5.78. Step 2.

F igu re 5.79. Step 2.

F igu re 5.80. Step 5, inhalation dysfunction.

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superiorly with exhalation and les s posterior ly and inferiorly with inhalation than its mate, it is c las sified as an exhalation rib (dy s function) (F ig . 5.81). 7. Thes e findings are doc umented in the progres s note.

F igu re 5.81. Step 6, exhalation dysfunction.

P.60 P.61

Cer v ica l Inte r segmental Motion Te s ting: Occ ipitoatlantal Articulation (Occ iput-C 1 ), Type I Coupling Motion

1. The patient lies supine on the treatment table. 2. The phy sic ian sits at the head of the table. 3. The phy sic ian's index or thir d finger pad palpates the transverse proc ess es of C1 (F ig . 5.82). 4. The phy sic ian gently mov es the patient's head for ward and bac k , c areful not to bring the segments below the occ iput into this motion ( Fig . 5.83).

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F igu re 5.82. Step 3, C1 transverse proc ess.

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5. The phy sic ian gently mov es the head off the table and to the table in a for ward-and-back translator y mov ement, again car eful not to induce mov ement of the inferior cer v ical segments ( Fig . 5.84). 6. To evaluate s ide bending and rotation, the phy s ician minimally translates the patient's occ iput alternately to the left and r ight ov er C1 ( atlas) without inducing any mov ement of C1 to C7 ( Fig s. 5.85 and 5.86). 7. Thes e s teps ar e evaluated for asy mmetric mov ement patterns that exhibit more s ide bending in one dir ection and mor e rotation in the other as well as ease or freedom of flexion or extension. 8. The phy sic ian will doc ument the findings in the progres s note acc ording to the pos ition or freedom of motion elicited.

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F igu re 5.83. A. Step 4, flex ion.

F igu re 5.83. B. Step 4, extension.

F igu re 5.84. A. Step 5, extension.

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F igu re 5.84. B. Step 5, flex ion.

F igu re 5.85. Step 6, left side bending/rotation c oupling.

F igu re 5.86. Step 6, right s ide bending/rotation c oupling.

P.62

Cer v ica l Inte r segmental Motion Te s ting: Atla ntoaxial A rticulation (C1 -C2), R ota tion

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1. The patient lies supine and the phy s ician sits at the head of the table. 2. The phy sic ian palpates the transverse proc ess es of the atlas (C1) with the pads of the index fingers and the articular proc ess es of the axis ( C2) with the pads of the third or four th finger s (F ig . 5.87). 3. The phy sic ian slowly rotates the patient's head in one dir ection, car eful not to add any side bending or flex ion (F ig. 5.88). (This eliminates any lower c erv ical mov ements and keeps motion vec tored to this lev el.) 4. As the head is rotated, the phy s ician monitor s for any mov ement of the axis ( C2), and stops when this is enc ountered. This is the limit of motion for this ar tic ulation

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F igure 5.87. Step 2, transver se proces s of atlas and C2 ar ticular pr oces s.

F igure 5.88. Step 3, r otation right.

F igure 5.89. Step 4; s top when C2 begins to move.

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P.63

Cer v ica l Inte r segmental Motion Te s ting: Atla ntoaxial (C1-C2), Supine, with Flex ion Alternative

1. The patient lies supine on the treatment table. 2. The phy sic ian sits at the head of the table. 3. The phy sic ian slowly flexes (for war d-bends ) the patient's head and neck to the comfortable pas s ive motion limit to segmentally res tric t the free coupled motions of the occ ipitoatlantal and C2 to C7 segments ( Fig . 5.91). 4. The phy sic ian slowly and alternately rotates the patient's head to the comfor table right and left pas s ive motion limits (F igs. 5.92 an d 5.93). 5. The phy sic ian is aler t for any res tric ted and/or asy mmetric rotation. 6. The phy sic ian then notes the asy mmetric motion preference if

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F igu re 5.91. Step 3, C1 r otation with head flex ed.

F igu re 5.92. Step 4, C1 r otation r ight with head flexed.

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pres ent (C1-RR or C1-RL). 7. Note: Never do this ty pe of motion tes t with either the head and nec k extended. We do not rec ommend this test, as it is pres umptiv e, wher eas the afor ementioned C1 r otation test with head in neutral pos itioning is a pos itiv e test and better tolerated by most patients.

F igu re 5.93. Step 4, C1 r otation left with head flexed.

P.64

Cer v ica l Inte r segmental Motion Te s ting: C2 to C 7 A rtic ula tions, Shor t-Leve r Tr ans latory Effect, Ty pe II Motion

1. The patient lies supine on the treatment table, and the phy s ician sits at the head of the table. 2. The phy sic ian palpates the articular proc ess es of the segment to be evaluated with the pads of the index or thir d finger (F ig s. 5.94 an d

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Fig ure 5.94. Step 2, cervic al articular pillar s on sk eleton.

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5.95). 3. To evaluate asy mmetry in side bending, a translator y motion is intr oduced fr om left to right (F ig. 5.96, left side bending) and then right to left (F ig . 5.97, r ight side bending) thr ough the articular proc ess es. 4. Eac h cervical segment is evaluated in flex ion, extension, and neutral to determine whic h pos ition impr oves the asy mmetry. 5. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited.

Fig ure 5.95. Step 2, cervic al articular pillar s on patient.

Fig ure 5.96. A. Step 4, side bending left.

Fig ure 5.96. B. Step 4, side bending left.

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Fig ure 5.97. A. Step 4, side bending right.

Fig ure 5.97. B. Step 4, side bending right.

P.65

Cer v ica l Inte r segmental Motion Te s ting: C2 to C 7 A rtic ula tions, Long-Le ver Me thod, Type II Motion (e.g., C3 SRRR or SLR L)

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1. Cer v ical intersegmental motion may be evaluated by long-lever method. Move the head in an ear - to- shoulder, arc like mov ement to the lev el of the dys func tional segment for its side bending ability (F ig. 5.98). 2. At the end of the limit of s ide bending, a slight rotation is added to the dir ection of the side bending (F ig. 5.99). 3. With the head in neutral for C2, flex ion is inc r eas ed appr oximately 5 to 7 degrees for eac h des c ending segment to be evaluated. The articular proc ess es are pos itioned in side bending/rotation to the right and then the left until their limit is elic ited ( Fig s. 5.100 and 5.101). 4. Sinc e C2 to C7 side-bend and rotate to the

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F igu re 5.98. Step 1, ear - to- shoulder method.

F igu re 5.99. Step 2, rotation added.

F igu re 5.100. Step 3, side bending/rotation r ight.

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P.66

Sac r oiliac Joint Motion Tes ting: Pelv is on Sacr um (Iliosa cra l), Ante roposterior R ota tion, Supine, Long Leve r (Leg Length)

1. The patient lies supine on the treatment table. 2. The phy sic ian stands at the side of the table at the patient's hip. 3. The phy sic ian palpates the patient's anterior superior iliac spines (ASISs ) and medial malleoli and notes the relation of the pair (c ephalad or c audad, symmetr ic or asy mmetric pattern) ( Fig . 5.102). 4. The phy sic ian ins truc ts the patient to flex the hip and k nee on one side. The phy sic ian's hands then control the patient's knee and ank le (F ig . 5.103). 5. The phy sic ian tak es the patient's hip thr ough a range of motion star ting with 130 degr ees of flex ion,

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Fig ure 5.102. Step 3, palpating the anterior s uperior iliac spine.

Fig ure 5.103. Step 4.

Fig ure 5.104. Step 5, flex ion, ex ter nal

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progres ses thr ough ex ter nal rotation and finally extension, bringing the patient to the neutral starting pos ition ( Fig . 5.104). 6. The phy sic ian notes whether the ASIS on the motion- tes ted side appears mor e cephalad than its original pos ition. This change would be s econdary to freedom in pos terior rotation. 7. The phy sic ian then takes the patient's hip thr ough a range of motion star ting with 90 degr ees of flex ion, progres sing thr ough inter nal rotation and finally extension, bringing the patient to the neutral starting pos ition ( Fig . 5.105). 8. The phy sic ian notes whether the ASIS on the motion- tes ted side appears mor e caudad than its original pos ition. This

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rotation, and ex tens ion.

Fig ure 5.105. Step 7, flex ion, inter nal rotation, and ex tens ion.

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change would be s econdary to freedom in an anterior rotation. 9. This is repeated on the other side to determine whether each joint has freedom in pos terior and anterior r otation and if not, which joint is free or res tric ted in only one dir ection. 10. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited.

P.67

Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint and Pelvic Dys func tions, Pelvic (e .g., Innom inate R ota tion, Shea r , Inflare -Outfla re), Standing Flexion Test

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1. The patient s tands erec t with the feet a shoulder-width apart. 2. The phy sic ian stands or kneels behind the patient with the ey es at the lev el of the patient's pos ter ior superior iliac spines ( PSISs). 3. The phy sic ian's thumbs are placed on the inferior aspect of the patient's PSIS. Maintain firm pres sur e on the PSISs, not skin or fas c ial dr ag, to follow bony landmar k motion ( Fig . 5.106). 4. The patient is instr ucted to activ ely for ward bend and try to touch the toes within a pain-free range (F ig . 5.107). 5. The tes t is positive on the side wher e the thumb ( PSIS) moves mor e cephalad at the end range of motion (F ig. 5.108). A pos itiv e standing flex ion tes t identifies the side on which the sacroiliac joint is dys func tional, not the s pec ific ty pe of dysfunc tion. A positive res ult indicates that an ilios acral dys func tion ( pelv is on s acr um) may be present. T his is usually compared to the r esults of the seated flexion test to r ule out sac r oiliac dy s function ( sac rum on pelv is) . Regar dless the type of dys func tion, the problem is at the sac r oiliac joint. 6. This is a pres umptiv e test reflecting as y mmetry , which may be r elated to dys functions at the sac r oiliac joint. It should not replace more s pec ific motion tes ting that actually elicits motion availability. 7. The phy sic ian will document the findings in the progres s note acc ording to the pos ition or freedom of motion elicited.

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Fig ure 5.106. Step 3.

Fig ure 5.107. Step 4, for war d bending.

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P.68

Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint and Pelvic Dys func tions, Pelvic (Innom ina te) or Sac ral, Se ate d Flexion Tes t

1. The patient is seated on a stool or treatment table with both feet flat on the floor a s houlder -width apar t. 2. The phy sic ian stands or kneels behind the patient with the eyes at the level of the patient's PSISs. 3. The phy sic ian's thumbs are plac ed on the inferior aspec t of the patient's PSISs and a firm pres sur e is dir ected on the PSISs, not sk in or fasc ial dr ag, to follow bony landmar k motion (F ig . 5.109). 4. The patient is ins truc ted to for ward-bend as far as pos sible within a pain-fr ee range (F ig . 5.110). 5. The tes t is pos itiv e on the side where the thumb ( PSIS) mov es more cephalad at the end range of motion (F ig.

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F igu re 5.109. Step 3.

F igu re 5.110. Step 4, for war d bending.

F igu re 5.111. Step 5, pos itive seated flex ion tes t.

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5.111). A pos itiv e s eated flex ion test identifies the side of sacral (sac roiliac or sac r um on pelv is) dys func tion, not the specific type of dysfunc tion. A negative tes t may indicate a pelv ic on sac r um (iliosacral ty pe) dys func tion, suc h as innominate rotation. 6. This is a pres umptiv e test reflecting asy mmetry, whic h may be related to dys func tions at the sac roiliac joint. It should not replac e mor e specific motion tes ting that ac tually elic its motion availability. 7. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited.

P.69

Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion, Pe lvis on Sac r um (Ilios a cra l D ysfunction), A nte roposte rior R ota tion Pr one ,

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Long Le ver

1. The patient lies prone on the treatment table. 2. The phy sic ian stands to one side of the patient at lev el of the hip. 3. The phy sic ian plac es the cephalad hand over the patient's sac r oiliac joint with the finger pads of the index and thir d digits contac ting the sac rum and PSIS; or the index finger contacts the PSIS while the thumb c ontacts the sac rum (F ig. 5.112). If palpating the opposite sac r oiliac joint, the finger pads will contact the landmar k on the other s ide. 4. The phy sic ian's other hand gras ps the patient's fully extended (str aight) lower leg at the lev el of the tibial tuberos ity (F ig. 5.113). 5. The phy sic ian gently lifts the extended leg and then s lowly

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Fig u re 5.112. Step 3.

Fig u re 5.113. Step 4.

Fig u re 5.114. Step 5.

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P.70

and minimally

Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion, Pe lvis on lowers it while Sac r um palpating (Ilios a cra l D ysfunction), Inflare -Outfla re Prone, Long Le ver the

1. 2.

3.

6.

7.

8.

4. 9.

5.

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mov ement of the PSIS as it relates to the The lies sac r patient um (F ig. prone on the 5.114). The treatment phy s ician table. may The sicthe ian als o phy carry stands to one leg acr oss the side of the patient midline (F ig. at the lev el of the 5.115) and then hip. laterally (F ig . The phyQuality sic ian 5.116). plac es the and quantity of cephalad-oriented motion, as well hand ov er the as ease-bind patient's relations, ar e sac r oiliac monitor ed.joint with the finger The phy sic ian pads of the repeats this index on and third digit the opposite contacting the side. sac r um and PSIS, This motion test or the index may determine finger contac ts joint motion the PSIS res tric tionwhile the thumb and/or motion contacts the asy mmetry sac r um (F ig. (e.g., sac roiliac 5.117). If res tric ted, fr ee palpating the pos teriorly). opposite This is a sac oiliac joint, pos ritiv e test, as the finger pads compared to the will contact standing andthe landmar k seated flexion opposite whatare is tes ts, which noted abov e. mor e The sic ian pres phy umptiv e. ins truc ts the The phy sic ian patient to flex the will document lower leg (knee) the findings in appr oximately the progress 90 degr and then note ees ac cor ding gras ps the ank le to the pos ition or (F ig . 5.118). freedom of The phyelicited. sic ian motion

Fig u re 5.115. Step 5.

Fig u re 5.117. Step 3.

Fig u re 5.116. Step 5.

Fig u re 5.118. Step 4.

Fig u re 5.119. Step 5.

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then ex ter nally and internally rotates the patient's hip by mov ing the ank le medially and laterally, res pectively (F ig s. 5.119 and 5.120). This appr oximates (outflare) and separates (inflar e) the sac r oiliac joint. 6. The phy sic ian then repeats this on the opposite side. 7. The above motion tes t may determine joint motion res tric tion and/or motion asy mmetry (e.g., sac r oiliac joint res tric ted, free-inflare) . 8. The phy sic ian will doc ument the findings in the progres s note acc ording to the pos ition or freedom of motion elic ited.

Fig u re 5.120. Step 5.

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Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion, Ge ner a l Res tric tion, Prone, Shor t Leve r

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1. The patient lies prone on the treatment table. 2. The phy sic ian stands to one side of the patient at the lev el of the hip. 3. The phy sic ian plac es the thenar eminenc es over the patient's PSISs ( Fig . 5.121). 4. The phy sic ian alternately intr oduces a mild to moderate impulse through the PSISs with the thenar eminenc es (F ig . 5.122). 5. The phy sic ian notes the quality (end feel) and quantity of motion on eac h side. 6. This is a pos itiv e test that will determine whic h sac r oiliac joint is most res tric ted but will not determine the nature of the dys func tion. 7. The phy sic ian will document the findings in the progress note ac cor ding

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F igure 5.121. Step 3.

F igure 5.122. Step 4, prone s hor t lever with thenar impuls e.

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P.72

Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion, Ge ner a l Res tric tion or Anter opos ter ior Rotation, Supine , Shor t Le ver

1. The patient lies supine on the treatment table. 2. The phy sic ian stands at the lev el of the patient's hip. 3. The phy sic ian's palms or thenar eminenc es are plac ed inferior to the patient's ASISs ( Fig . 5.123). 4. The phy sic ian alternately intr oduces a mild to moderate impulse through the ASISs (may dir ect it pos teriorly or slightly cephalad) (F ig . 5.124). 5. The phy sic ian notes quality (end feel) and quantity of motion on eac h side. 6. This will determine whic h s acr oiliac joint is most res tric ted and may determine whic h motion preference is pres ent (anterior or pos terior

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Fig u re 5.123. Step 3.

Fig u re 5.124. A. Step 4, supine short lev er with thenar impulse on r ight.

Fig u re 5.124. B. Step 4, supine short lev er

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rotation). 7. If a posterior innominate dys func tion is pres ent, the symptomatic and res tricted side will hav e a preference to mov e cephalad (F ig . 5.125). 8. If an anterior innominate dys func tion is pres ent, the symptomatic and res tricted side will hav e a preference to mov e caudad (F ig . 5.126). 9. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited.

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with thenar impulse on left.

Fig u re 5.125. Step 7.

Fig u re 5.126. Step 8.

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6 Principles of Osteopathic Manipulative Techniques O s t e o pa t hi c m a n ip u la t iv e te c hn i qu e s ( O MT ) a r e n u me r ou s . S o me te c h ni q ue s h a v e b ee n k no wn b y m o re t ha n o n e n a me , m a ny n ew te c hn i q ue s h a ve b ee n d e ve l o pe d , a nd s om e h av e se e n r es u r ge n ce af t e r y ea r s o f n e gl e c t . Th e y h av e go n e t hr o u gh a met a mor p ho s is i n d es c ri p t io n , a nd f in a ll y , wi th th e a d v en t o f t h e E d uc a ti o n al Co u nc i l o n O s te o pa t hi c Pr i nc i pl e s ( E CO P ) a n d i t s Gl o s sa r y o f O s te o pa t hi c Te r mi n ol o g y ( ww w. aa c om . or g / om / Gl o s s a r y . d oc ) , h a ve be e n s t an d ar d iz e d i n to th e s t y le s d e s cr i be d i n t h is te x t .

Direct and Indi rect Technique I t i s s o me t im e s e a si e r t o u n de r s t a n d t he pr i n ci p le s o f OM T a c co r d in g t o w h i ch ba r ri e r a nd a na t om i c a r ea th e t e c hn i qu e p r i ma r il y a f f ec t s . Th e fi r s t pr i n ci p le re l a te s t o t h e n at u r e a nd di r e c t i on of t he re s tr i c ti v e b ar r i er . U s in g th i s p ri n c ip l e, mo s t t e ch n iq u e s c an b e c at e go r i ze d a s d i r ec t o r i n d ir e c t . T h u s , a t ec h n iq u e e ng a g in g t h e mo s t r es t r ic t iv e b a r ri e r ( bi n d , t ig h t) i s c la s si f i ed as di r e c t an d a t ec h ni q ue e ng a gi n g t h e l ea s t r e s t r ic t i ve ba r ri e r ( e as e , l o os e ) i s c l as s if i ed a s i nd i re c t . The s ec o nd pr i n ci p le is a s s o ci a te d wi t h whi c h a n at o mi c ma n if e s t a t io n o f t h e d y s f u nc t io n i s pr i ma r y ( e .g . , mus c l e v er s us j oi n t) . T o de t er min e th a t a m u s cl e d y s f u nc t io n i s pr i ma r y , t he se c on d pr i nc i pl e di r ec t s t h e p hy s ic i a n t o u se t ec h ni q ue s s uc h as so f t t i s s u e o r mu s c l e e ne r g y r at h er t ha n h i gh - v el o ci t y , l ow - am p li t u de (H V LA ) t ec h n iq u e o r o s te o pa t hy i n t he cr a n ia l f i el d . G en e r al l y , di r e c t te c hn i q ue s e n ga g e t h e mos t re s tr i c t i v e b ar r ie r , a n d i nd i r ec t t ec h n iq u es en g a ge th e l e a s t re s tr i c ti v e b ar r i er , w h ic h mo s t c om mo nl y i s d e s cr i be d a s t he e dg e o f t h e p h y s i ol o g ic ba r ri e r ( Fig . 6 . 1 ). Fr e qu e n tl y , h ow e v er , a dy s f un c ti o na l s ta t e c a us e s r e s t r ic t iv e ba r ri e rs t o e ac h s i d e o f t he n or mal re s t in g n e ut r a l p oi n t . The s e b i la t er a l r e s t r ic t i ve ba r ri e r s a re mo s t c o mm o nl y as y mm e tr i c i n r e fe r e nc e t o t h e ir d is t a nc e f r om n eu t ra l b u t m a y b e e q ua l ly an d s y mme t ri c a ll y d i s t a n t ( Fi g s . 6 .2 an d 6 . 3 ).

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Figure 6.1 . Asymmetric ran ge o f moti on w ith a normal physio log i c b arrier (Pb ) o ppo site th e si de on whi ch a re stri cte d barrie r (R b) is pre sent.

E xa mi na t io n o f th e b a rr i e rs de l in e a te d i n F i g ur e s 6 .2 a nd 6. 3 s h o ws th a t i t i s p o s s i b le t o t r ea t a re s t ri c ti v e b a rr i er at e it h er th e ea s e o r b i nd qu a li t y e l ic i te d on th e p a l pa t or y e xa mi na t io n . Man y ha v e d es c r ib e d p hy s i ol o gi c p r i nc i pl e s o f m o ti o n o f t h e s pi n e , a nd mo s t f r eq u en t l y t he p ri n ci p le s s t a te d b y Ha r ri s on Fry e t t e , DO , a re th o s e p ri mar i l y t au g ht i n o s t e op a t hi c med i c al s c h oo l s ( f ir s t a n d s ec o nd p ri n ci p le s of ph y si o l og i c mot i o n) . T h es e ru l es ar e s pe c i fi c t o t h e t h or a ci c an d l u mb a r s p in e r e g io n s , bu t th e y h av e ta n ge n ti a l r e la t io n to h ow t he me c ha n i c s of th e ce r vi c al s pi n e a re p er c ei v ed . Ou r n o n- A mer i ca n m a n ua l med i c in e a s so c i at e s h av e ad d ed ot h e r c av e at s to Fr y et t e , y et th e y a g re e w i t h t he b as i s o f t h es e fi n di n gs , wh i ch ha v e b e en du p l ic a te d b y ot h er s ( e . g. , W h it e & P an j ab i , c ou p l ed mo t io n s ) ( 1) . P ar a p hr a si n g C. R . N e ls o n ( who s e p r in c ip l e o f m o ti o n i s c o ns i de r e d t he th i r d o f t he t hr e e p h y s i ol o g ic pr i nc i p le s o f m o t io n ), we s ee th a t t h e i ni t ia t i on of sp i n al P. 7 6 v er t e br a l mot i o n i n o ne p la n e wil l af f ec t m o t io n i n a l l o t he r p l a ne s ( 2 ). O s t e op a th i c t ex t s h a ve de s c ri b ed th i s p r in c ip l e , b ut al wa y s wi t hi n th e c o nt e x t o f a s i n gl e r es t r ic t iv e b a r ri e r c au s i ng as y mm e t ri c al l y r e s t r ic t ed f in d in g s o f m o ti o n p o te n ti a l i n a n a rt i c ul a ti o n. E xp a nd i ng t hi s s t at e men t t o w h a t we h av e ob s er v ed c li n ic a ll y wo u ld t he r e fo r e c or r e la t e wit h Fi g ur e s 6 . 2 a nd 6. 3 . T h is wo u l d a ls o m a k e i t f ea s i bl e t o o r i en t c la s s ic a ll y d e s cr i be d d i r ec t t e ch n i qu e s , su c h a s H V LA , in an in d i re c t man n e r ( wh i ch we

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h av e se e n t au g h t a nd pe r f or med in t e rn a ti o na l l y) . T h e mo s t im p or t a nt cr i te r i a t o u nd e r s t a nd , w h e th e r p er f o rm i ng di r e c t or in d i re c t t ec h n iq u es , a r e t h e n or ma l p hy s i ol o gi c m o t io n s o f t h e s pe c if i c a r ea be i n g e xa min e d a n d/ o r t r ea t ed an d th e c om p l ia n ce of t he ti s su e s i n vo l ve d (e . g. , a c u te ve r su s ch r on i c d y s f u nc t io n ) .

Figure 6.2 . Two restrictive b a rri ers (R b ) a symmetrica lly restri cte d .

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Figure 6.3 . Two restrictive b a rri ers (R b ) symmetri cal ly restricted .

S omatic Dysfunction A s s t at e d e ar l i er , s o ma t i c d y s f un c t io n i s t h e d i ag n os t i c c ri t er i o n t ha t c a l ls fo r O MT. The v ar i ou s q u a li t ie s e l i ci t ed on t he ph y si c a l e xa min a t io n o f a p at i en t m a y l e ad th e p hy s i ci a n t o u n de r s t a nd t ha t t h e n a tu r e o f a dy s fu n c t i o n i n o ne r eg i on is d if f er e nt f ro m t ha t of an o th e r d y s f u nc t i on in a d i f f e re n t r e gi o n. Th u s , t he ph y s ic i an ma y ch o os e t o u se o ne te c hn i q ue fo r o n e d y s f u nc t i on an d a n o th e r t ec h n iq u e f or t he ot h er . I f a p at i e nt e xh i b it s r e gi o n al mo t io n di s tu r ba n c e b ut in t e rs e gm e nt a l m o ti o n i s n o rm a l, a t e ch n iq u e o ri e n te d t o t h e a r ti c ul a r a s pe c t s o f t he an a t om y m a y n o t b e i nd i c at e d. Or a p a ti e nt mig h t p r es e nt f or ne c k a c he th a t o n e x am i na t i on ex h ib i t s p ar a ve r t eb r al mu s c le h yp e r to n ic i t y a nd ge n er a l t e nd e rn e s s b ut no s pe c if i c t e nd e r p oi n t s . Th i s p a ti e nt ma y b en e f it fr o m a my o fa s ci a l t e ch n iq u e b u t n ot c ou n te r s t r a in , a s n o co u nt e rs t r ai n t e nd e r p oi n t s a re pr e s en t . S om e pa t ie n t s e xh i bi t s o mat i c c om p o ne n t s of v is c er a l d i se a se , a n d t h e t re a t me n t o f t hi s co mpo n en t ma y h a ve o nl y a li mi te d e f fe c t , whe r ea s a p at i en t wi t h a p r i ma r y s om a t ic dy s fu n c ti o n a nd a s e co n da r y v i s c e ra l co mpo n en t ma y r e ac t we l l ( so ma ti c al l y a nd v is c er a ll y ) t o a sp e c if i c O MT . Ot h er fa c t or s i n t h e p r es e nt a t io n s o ma t i c d y s f u nc t io n m a y c h an g e t h e t ho u gh t pr o ce s s i n d e ve l op i n g t he tr e a tm e nt pl a n . O th e r v is c e ra l a n d a u to n om i c e f fe c t s , l y mph a ti c c o n ge s ti o n, a nd gr o s s e de ma wil l al l c a us e t he p hy s ic i an t o r ee v al u a te th e p o s si b il i ti e s f o r O MT a nd th e p o t en t ia l f o r a nu mbe r of t ec h n iq u es th a t m a y b e i n di c at e d i n t h at ca s e .

Contraindicati ons

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Con t r ai n di c at i o ns to OM T ha v e c ha n g ed dr a ma t i ca l ly du r i ng ou r y e a rs of cl i n ic a l p ra c t ic e b e ca u s e o f t he d ev e lo p me n t o f n e w a n d/ o r mod i f ie d t e ch n i qu e s a nd b et t er u nd e r s t a nd i ng o f d is e as e pr o ce s se s . T h e a bi l i t y to pe r f or m O MT i n a ra n ge o f e x t r e me l y g en t l e t o mor e fo r ce f ul man n er , c o mbi n ed wi t h a di r ec t or in d ir e c t a pp r oa c h , h as c au s ed us t o l oo k d i f fe r en t ly a t t he ap p l ic a ti o n o f O MT, ge n e ra l ly ma k i ng th e d ec i s io n o n a c as e -b y -c a s e b as i s o f c l in i ca l pr e se n ta t i on . T h is c as e -b y -c a s e o ri e n ta t io n m a y o f te n c h a ng e o n ly t he ch o ic e of th e p a t ie n t' s p o s it i on fo r a t ec h ni q u e a nd n ot be co n s id e re d a c on t ra i nd i c at i on fo r an en t ir e te c hn i qu e ca t eg o ry . Ce r ta i n c on d i ti o ns , s u c h a s f ra c t ur e , d is l o ca t io n , t u mo r , i nf e c ti o n, an d os t eo mye l i ti s , a re c on t r ai n di c at i o ns fo r O MT d i re c tl y ov e r t ha t si t e. Ho we ve r , i t d o es no t p r e cl u de OM T to r el a t ed so mat i c d y s f u nc t i on in ar e a s t ha t a r e p r ox i ma l or di s ta l to th e p r o bl e m. O th e r c o nd i ti o n s t ha t m a y a l te r t h e p h y s i ci a n 's op i ni o n c o nc e rn i n g t he ap p r op r ia t en e s s o f O MT a re Do wn s y nd r om e , r h eu mat o i d a rt h ri t i s , Kl i pp e l -F e il s y n d ro me, P. 7 7 a ch o n dr o pl a s t i c d war f is m, p r eg n an c y , s tr a in s an d s p ra i n s , ac u te h er n ia t ed i nt e r ve r te b ra l di s c , ac u t e i nf l am ma to r y s it u a ti o ns , a n a to mic in s t ab i li t y , h yp e rm o bi l i t y , j oi n t p r os t he s i s , an d s e v er e m a ni f e s t a ti o ns o f v is c er a l d i so r de r s . The s e c o nd i ti o ns may c on t ra i nd i c at e O MT i n t o ta l o r ma y c o nt r a in d ic a te o nl y a sp e c if i c t ec h n iq u e i n a s pe c i fi c r e gi o n . The ph y s ic i an ' s c l in i ca l j u d gm e nt an d a c om p le t e u n de r s t a n di n g o f t h e t ec h n iq u e a re p ar a mo u nt i n t he fi n a l d ec i si o n a s t o w h e th e r O MT i s a pp r op r i at e .

The Osteopathi c Manipulative Treatm ent Prescription The s el e c t i on o f t he te c h ni q ue to b e u se d i s pr i ma r il y fo u nd e d i n t h e n at u r e o f t he s om a t ic dy s fu n c ti o n a nd i t s mo s t p r om i ne n t ma ni f es t at i o ns . T h is a tl a s p re s e nt s 1 2 o s t e o pa t hi c m a n ip u la t iv e te c hn i qu e se c ti o ns . Ea c h s ec t i on ha s a n ex p la n at o r y p re f ac e f or t he sp e ci f i c t ec h ni q u e a nd th e pr i nc i pl e s o f i t s u s e a nd ap p l ic a ti o n. The pr e vi o u sl y s ta t e d a re a s o f d y s f u nc t i on (a r ti c u la r , myo - f as c ia l , v i s c e ra l , v a s c u la r , l y mp h at i c , a nd s o o n ) t ha t c a n b e c o ns i d er e d d ur i n g s el e c t i o n o f t he t re a tm e nt p la n m a y a f fe c t t he d ec i s io n t o u s e a sp e ci f i c t ec h ni q u e a t o ne d y s f un c ti o n al le v el o r a no t he r , d e pe n di n g o n t h e p hy s ic a l f i nd i ng s (i . e. , H V L A v er s us mus c le en e r gy ve r su s fa c il i ta t e d p os i ti o n al r el e a se ve r su s my o fa s ci a l r e le a se o r a c o mb i n at i on ) . Th is wi l l b e d i s c u s s e d f u rt h er a nd mor e sp e ci f ic a l ly in ea c h o f t h e t e ch n iq u e s e c t i on s . The O MT pr e s c r i pt i on is s im i la r t o th a t o f t h e p ha r ma c o lo g ic pr e s cr i pt i on : th e t y pe o f t ec h n iq u e i s c o mp a ra b le t o t he ca t e go r y o f t h e p ha r ma c o lo g ic ag e n t c ho s en ; th e met h o d a nd / or p os i ti o n c h os e n f or t he OM T t e c hn i qu e i s co mpa r ab l e t o t h e r o ut e o f a dm i n is t ra t io n of th e p h a rm a co l og i c a g en t ; t h e f or c es i nv o lv e d i n t h e O MT a nd wh e th e r t he y ar e d i re c t ly or in d i re c tl y a p p li e d a re c om p ar a bl e to th e s t r en g th or d os e o f t h e med i c at i on ; a n d t h e r ep e t it i on s , t i mi n g, an d du r at i on o f t he OM T ar e c o mp a r ab l e t o t h e a mo u n t o f med i c at i on di s p en s ed an d th e f r eq u e nc y o f i t s a d mi n is t r at i on . For e xa mpl e , a 70 - ye a r- o l d p at i en t wh o c o mp l a in s o f c h r on i c l ow b ac k p a in s ec o nd a ry t o l u mb a r d is c o ge n ic sp o n dy l os i s , l um b ar sp i n al s t e no s i s , an d l u mba r s o ma t i c d y s f u nc t io n m a y b e t r ea t e d wit h a r t ic u la t or y an d m y of a s ci a l s of t ti s su e t e c hn i qu e s wee k l y o ve r w e e k s to mo n t hs . H o we v e r, a 1 6- y e ar - ol d p a t ie n t who c om p la i ns o f a cu t e l ow b ac k p a in s ec o nd a ry t o a s p ra i n d u ri n g f o ot b al l p r a c t i ce ma y be tr e at e d w i th a

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c om b i na t io n o f in d ir e c t myo f as c ia l re l ea s e, mus c le en e r gy , a n d c o un t er s tr a i n t ec h n iq u es ev e r y 2 t o 3 d ay s f o r 2 to 4 wee k s . S im p l e r ul e s t o g u id e t h e i mpl e me n t at i on of O MT ar e b e s t s ee n i n th e d o se g ui d el i ne s o ut l i ne d i n t h e F o un d at i o ns fo r O s t eo p at h ic Med i ci n e ( 2 ). In ge n e ra l , o ne mus t u nd e r s t a nd th e na t ur e o f th e d y s f u n c t i on an d th e o t he r cl i ni c al man i fe s ta t i on s b e in g p re s e nt e d, th e se v er i t y a nd en e rg y - de p le t in g ef f ec t s o f t h e c on d i ti o n, th e ag e o f t h e p at i e nt , a n d wh et h er th e co n di t io n is ac u te o r c hr o ni c . C o mm o n me di c al se n s e c om b i ne d w i th a w e ll - gr o u nd e d r is k - be n ef i t r a ti o na l e s h ou l d b e t h e g ui d in g pr i nc i pl e s .

References 1 . W h it e A, Pa n ja b i M . C l in i c al Bi o me c h an i c s of t he Sp i ne . 2n d e d . P h il a de l ph i a : L i pp i nc o t t Wil l ia ms & Wi l ki n s , 1 99 0 .

2 . W a rd R ( e d) . F o u nd a ti o ns f or Os t eo p a th i c Med i c in e . P hi l a de l ph i a: L ip p in c ot t Wi ll i am s & Wil k in s , 2 0 03 .

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7 Soft Tissue Techniques Technique Principl es Soft ti s s ue te c hn i que is de fi ne d b y t he E duc ati on C oun c il on Ost eop athi c P r in c i pl es ( EC OP) as “ a di re c t tech niq ue, w hi c h us ua l ly in v olv es l at er al st r et c hin g, l in ear s tr etc hi ng , d eep pre s su r e, tra c ti on, and /or s epa r at i on of m us c l e ori gin and in s er ti on wh i le m on i to r in g ti s su e r es po nse an d mo tio n c hang es by palp ati on; als o c al le d m y of as ci al tec hniq ue” (1 ) . S ome as pect s o f s oft tis s ue tec hni que s ar e s i mi l ar to thos e o f my ofa s ci al r ele ase i n r es pec t to th e t herm ody nam i c e ffe c ts i n alt eri ng p hys i ca l st ate s ( gel - s ol ) and c au s i ng ti s su e re act i vi ty ( fas c ia l cr eep ) . H owe v er , t he s pec i fi c ma nua l m etho ds by w hic h t he phys i ci an c aus es thes e r eac ti on s a r e s l ig htl y d i ffe r en t. T he m os t d i s ti ngu i sh i ng asp ect s of so ft ti ss ue tech niq ue a s c omp ar ed to my ofas c ia l r el ea s e tec hniq ue are tha t w i th m yo fas c ia l re l ea s e tech niq ue the forc es ar e m or e d eepl y d i re c ted in to the pat i en t an d t hat the s e for c es are im pl em ent ed i n a rh y th m i c, al te r na ti ng (p r es s ure on , p r ess ure of f) f ash i on . T he for c es s ho uld be dir ect ed d eep l y enou gh to enga ge the tis s ue be i ng tre ate d, b ut at the s am e t i m e the tr ea tme nt s hou l d be m i ld l y to m ode r at el y i nt r od uc ed an d c om fo r ta bly acc ept ed by t he pat i ent . T he only ex ce pti on t o t his r ul e i s t he i nhi bit or y pre s su r e s tyl e, i n w hic h t he p hys i ci an m ay c ho os e to use a c ons tan t, d eep l y i ntr odu c ed for c e ove r so m e tim e (i .e. , m or e tha n 3 0 se c on ds or u nti l t he t i ss ue r ele ase s ( as not ed b y a n i nc re ase in i ts le ngt h or de c re as e i n i ts ten s io n) ( 2).

Technique Cl assifi cati on Di rect Technique In d i re c t t ech niq ue, the my ofas c ia l t i s su es are m ov ed tow ar d the re s tri c ti v e barr i er (t ensi on, bi nd). To us e dir ec t tec hni que, th e p hy si c ia n m us t und ers tand th e a nato m ic re l ati ons hip of the ti s s ue s b ein g tr ea ted i n ter m s of m usc ulo tend i no us or ig i n and i ns ert i on , de pth of the mu s cl e or fa s ci a, a nd m us c l e ty pe . T he d i re c ti on, dep th, and fo r ce of pre s su r e w i ll va r y w i th th e sp eci fic are a b ein g tr eat ed beca use of norm al anat omi c c hang es fro m re gio n t o re gio n.

Technique Styles P aral lel Tracti on In p ara l l el tr act i on, th e m y ofa s ci al s tru c tu r e bein g t r ea ted i s c on tact ed at i ts ori gin and in s er ti on , a nd the tr ea tme nt f orc e i s di r ec ted par all el to t he m us c ulo ten din ous axi s , c aus i ng an ove r al l i nc re ase in l en gth of t he s tru c tu r e. T hi s m ay be d one by dir ect i ng a f orc e w i th the ha nd t hat is pro x im al to t he ori gi n, th e hand th at i s p r ox i m al to th e in s er tio n, o r b oth han ds m ov i ng opp osi te e ach ot her at the s am e t i me . Ea c h of t hes e wi l l c au s e a re l at i v e i nc r ea s e i n l eng th o f t he m y of asc i al tis s ue be i ng tre ate d.

P erpendi cular Traction In p erp endi c ul ar tr ac tio n, the m yo fas c i al st r uc ture in qu es ti on i s c ont act ed at i ts m id poin t b etw een the or ig i n and i ns ert i on, an d a per pen dic ul ar fo r ce i s dir ect ed a w ay fr om t he l on gi tu din al ax is .

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Di rect I nhibitory P ressure In d i re c t i nhi bit or y pre s su r e, the my ofas c ia l s tr uc tur e b ei ng tr eat ed i s c ont ac te d o v er the m usc ulo tend i no us port i on of the hy per toni c m usc l e, and a forc e i s d i r ec ted in to i t. H ow ev er , d eep , s pec i fi c pr ess ure on the mu s c le be l ly c an ca use pai nfu l s i de eff ect s an d b r ui s i ng . T her efor e, the pr es s ur e sh oul d b e di r ec ted at the te ndon or mu s c ul ote ndi nous ju nct i on. P.80

I ndicati ons 1. Us e a s p ar t of the m us c ul osk el et al s cr eeni ng exa m i na tio n t o qu i ck l y i den tif y r egio ns of r est r ic ted mo tio n, ti ss ue tex ture ch ang es , and se ns it i vi ty. 2. Re duc e m us cl e h y pe r ton i ci ty, m us c le te ns io n, fas c i al te nsi on, and mu s c le sp asm . 3. St r et c h and i nc r ea s e e l as tic i ty of s ho r ten ed, in el as tic , a nd/o r f i br otic my ofa s c ia l s tru c tur es to im pro v e r egi ona l a nd/o r i nte r s eg m en tal r an ges of m ot i on . 4. Im pro v e c i rc ula tio n to th e s peci fic re gi on be i ng tre ate d b y lo c al ph y s ic al and the r mo dyn am ic ef fec ts or b y r efl ex p hen ome na t o i m pr ov e c ir c ul atio n i n a dis tal ar ea ( e.g ., thro ugh so m at i c- s oma tic or s om ato v is c era l r efl ex es ) . 5. In c re ase v en ous an d ly m ph ati c dr ain age to dec r ea s e l oca l a nd/o r d i st al s w el l in g an d e dem a an d po ten tia l l y i mp r ov e th e o v er al l i mm une r es pon s e. 6. St i mu l at e th e s tre tc h r ef l ex i n hyp oto ni c m us c le s . 7. Pr omo te pati ent re l axa tio n. 8. Re duc e p atie nt gua r din g d uri ng i m pl eme ntat i on of oth er ost eopa thi c m anip ula tiv e te c hn i qu es o r ad dit i on al m edi c al tre atm ent . 9. Po ten tia te t he eff ec t of oth er o s te opa thic te c hn i que s . 10. Im pro v e the phy s ic i an- pat i en t re l at i on s hip , a s t hi s tec hni que typ i ca l l y i mp art s a ple asa nt se nsa tio n to th e p atie nt.

Contraindications Relative Contraindi cations U s e w it h ca uti on, as c om m on m ed i ca l s ense is th e ru l e. Fo r ex amp l e, i n an eld er ly os teo poro tic pa ti en t, the s of t ti s su e pr one pr ess ur e tec hni que m ay be c on tra i nd i c at ed ove r th e t hor ac oc ost al and pel v ic r egi ons , bu t t he l ate r al re c umb ent me thod s c an be m ore sa fely ap pli ed. Als o, c ont act an d st r et c hi ng o v er an a c ut el y s tr ain ed o r s pra i ned my ofa s c ia l , l ig am en tou s , or c aps ula r st r uc tur e ma y e x ac er ba te the c ond i ti on. T he r ef or e, in th es e s it uat i ons ca uti on s hou l d pr ev ail , a nd t he s of t ti s su e t ec hn i qu e m ay b e w i th hel d un til ti s s ue di s ru ptio n a nd i nfl amm ati on h ave st abil i ze d. Othe r p r eca uti ons i n the us e of so ft ti ss ue tec hniq ue:

1. Ac ute sp r ain or st r ain .

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2. Fr act ure or dis l oc atio n. 3. Ne uro l og i c o r v asc ul ar co m pr om is e. 4. Os teo por os is an d o s teo pen i a. 5. Ma l ig nan c y . M os t r es tr i ct i on s ar e f or tr ea tme nt i n t he aff ec te d a r ea of m al i gn ancy ; h owe v er, ca r e sh oul d b e ta k en in oth er dis tal are as depe ndi ng on t y pe of m al i gn anc y an d/o r l y m ph ati c in v ol v em ent. 6. In fec tio n (e .g. , o s teo m ye l it i s ).

Absol ute Contraindi cations N one , a s th e p hys i c ia n m ay w ork pr oxi m al to the pro ble m a bove or be l ow the af fect ed are a an d m ay al te r t he p ati ent ' s p osi tio n or te c hn i que to ac hi ev e s ome ben efi c ia l ef fec t.

General Considerati ons and Rules 1. Th e p ati ent s ho uld be c om for tabl e a nd r ela x ed . 2. Th e p hys i c ia n s hou l d b e i n a pos i ti on of c omf ort s o as to m i ni m iz e e nerg y e x pe ndit ure an d wh ene v er pos s ib l e s hou l d use bod y w eig ht i nst ead of upp er ex tr emi ty s tre ngt h a nd e ner gy. 3. In i ti all y , f orc es m ust be of l ow in ten s i ty an d a ppli ed s lo w l y and rh y thm i ca l ly . As he at deve l op s an d t he ti ss ues be gi n to r ea c t, the pr es su r e m ay be i nc r ea s ed i f c li ni ca l ly in di ca ted an d we l l to l er ate d; h owe v er , th e c ade nc e s ho uld r em ain sl ow ly rh y th m i ca l . 4. Th e a ppl i ed for c es s ho uld al w ays be co m for tab l e and not ca us e pai n. A co m fo r ta bl e and pl easa nt ex per i en c e i s t he i nte nde d e ffec t. 5. Ne v er di r ect fo r ce s di r ec tly i nt o b one , an d l i mi t pr ess ure i nt o t he m usc l e bel l y . 6. As th i s i s n ot a m as sa ge or fr ic tio n t ec hn i qu e, neve r r ub or i r ri tat e th e p ati ent' s s k in by the fr i ct i on of y ou r h ands . T he phys i ci an' s ha nd s ho ul d c ar r y the s ki n w i th i t and not sl i de acr oss it wh en app l y in g t he di re c te d f or ce . 7. De ter m in e ho w y ou w oul d l i ke to emp l oy the fo r ce : a. pus hin g or pu l li ng p erp end i c ul ar to c aus e t r ac ti on to th e lo ng axi s of th e m us cu l ot end i nou s s tr uct ur e b. By app l y in g t r ac ti on in a para l le l d i r ec tio n t o th e l ong axi s , i nc r eas i ng th e di s ta nce bet w ee n th e o r ig i n a nd i ns er ti on of the m us c le fib ers

P.81

Cervi cal Region: Traction, S upine

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1. T he patient lies s upine on the tr eatment table. 2. T he physic ian sits or stands at the head of the table. 3. T he physic ian's one hand gently c r adles the occiput between the thumb and index finger . T he physic ian's other hand lies ac r oss the patient's for ehead or grasps under the chin ( Fig s. 7.1 an d 7.2). (Us e c aution in patients with tempor omandibular joint [TMJ ] dy s functions.) 4. T he physic ian ex erts cephalad tr action with both hands with the head and neck in a neutral to slightly flexed pos ition to av oid extension. T he cr adling hand mus t not s queeze the oc ciput, or the oc c ipitomastoid s uture will be c ompressed (F ig. 7.3). 5. T his trac tional for ce is applied and releas ed s lowly . It may be inc reased in amplitude as per patient toler anc e. 6. T his technique may also be per for med using

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Fig ure 7.1. Step 3, skeleton.

Fig ure 7.2. Step 3, patient.

Fig ure 7.3. Step 4.

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P.82

Cervi cal Region: Forward Bending (Forearm Ful crum ), S upine

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1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian is s eated at the head of the table. 3. T he phy sic ian gently flexes the patient's nec k with one hand while sliding the other hand palm down under the patient's nec k and opposite s houlder ( F ig. 7.5). 4. T he phy sic ian gently r otates the patient's head along the phy sic ian's for ear m toward the elbow, pr oduc ing a unilateral s tr etc h of the c er vic al par avertebral mus culatur e ( F ig. 7.6). 5. T his s tretch c an be r epeated as many times as nec ess ary

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Fig ure 7.5. Step 3.

Fig ure 7.6. Step 4, rotation r ight.

Fig ure 7.7. Step 6, neutral.

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P.83

Cervi cal Region: Forward Bending (Bilateral Fulcrum), S upine

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1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian is s eated at the head of the table. 3. T he phy sic ian's ar ms are c r ossed under the patient's head and the phy sic ian's hands are placed palm down on the patient's anterior s houlder r egion (F ig. 7.9). 4. T he phy sic ian's for ear ms gently flex the patient's nec k, pr oduc ing a longitudinal s tr etc h of the c er vic al par avertebral mus culatur e ( F ig. 7.10). 5. T his tec hnique may be per for med in a gentle, r hy thmic fas hion or in a s ustained manner .

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Fig ure 7.9. Step 3.

Fig ure 7.10. Step 4.

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P.84

Cervi cal Region: Contralateral Traction, S upi ne

1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated. 3. T he phy sic ian's c audad hand r eaches ov er and ar ound the neck to touch with the pads of the finger s the patient's c er vic al par avertebral mus culatur e on the side opposite the phy sic ian ( F ig. 7.11). 4. T he phy sic ian's c ephalad hand lies on the patient's for ehead to s tabilize the head ( Fig . 7.12). 5. Keeping the c audad ar m s tr aight, the phy sic ian gently dr aws

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Fig ure 7.11. Step 3.

Fig ure 7.12. Step 4.

Fig ure 7.13. Step 5.

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the par avertebral mus cles v entrally ( white ar r ow, F ig . 7.13), pr oduc ing minimal ex tens ion of the cervic al s pine. 6. T his tec hnique may be per for med in a gentle, r hy thmic, and k neading fas hion or in a s ustained manner . 7. T is sue tension is r eevaluated to ass ess the effectiveness of the tec hnique.

P.85

Cervi cal Region: Cradl ing wi th Traction, S upi ne

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1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian s its at the head of the table. 3. T he phy sic ian's finger s ar e placed under the patient's nec k bilaterally, with the finger tips lateral to the c er vic al s pinous pr oces ses and the finger pads touching the par avertebral mus culatur e ov erly ing the ar ticular pillar s ( Fig . 7.14). 4. T he phy sic ian ex erts a gentle to moderate for ce, v entrally to engage the s oft tiss ues and cephalad to produc e a longitudinal tr actional effect ( s tretch) ( F igs. 7.15

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Fig ure 7.14. Step 3.

Fig ure 7.15. Step 4.

Fig ure 7.16. Step 4.

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P.86

Cervi cal Region: S uboccipital Release, Supine

1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian s its at the head of the table. 3. T he phy sic ian's finger pads ar e placed palm up beneath the patient's s ubocc ipital r egion, in c ontac t with the tr apez ius and its immediate underlying mus culatur e ( F ig. 7.17). 4. T he phy sic ian s lowly and gently applies pr essure upward into the tissues for a few s ec onds and then r eleases the pr ess ure ( F igs. 7.18 an d 7.19) . 5. T his pr essure may be r eapplied and

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Fig ure 7.17. Step 3.

Fig ure 7.18. Step 4.

Fig ure 7.19. Step 4.

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r eleas ed s lowly and r hy thmically until tis s ue tex tur e c hanges oc c ur or for 2 minutes . T he pr ess ure may also be c ontinued in a more c onstant inhibitor y s ty le for 30 s ec onds to 1 minute.

P.87

Cervi cal Region: Rotation, S upine

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1. T he patient lies s upine on the tr eatment table. 2. T he physic ian sits at the head of the table. 3. T he physic ian's c upped hands ( palmar as pec t) ar e placed to each s ide of the patient's tempor omandibular r egion, making s ur e to not c ompress over the ex ternal acoustic meatus (F ig. 7.20). 4. T he physic ian gently and slowly ax ially r otates the patient's head to the left to the r es trictiv e barr ier at its pas siv e tolerable elastic limit and holds this pos ition for 3 to 5 s ec onds ( Fig . 7.21). 5. T he physic ian then s lowly rotates the head to the r ight r es trictiv e barr ier at its pas siv e tolerable elastic limit and holds this pos ition for 3 to 5 s ec onds ( Fig . 7.22). 6. T his is r epeated to eac h s ide until r eleas e of tissue tension and/or improv ement of r ange of motion.

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Fig ure 7.20. Step 3.

Fig ure 7.21. Step 4.

Fig ure 7.22. Step 5.

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P.88

Cervi cal Region: S upine, Forefingers Cradl ing

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1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian s its or s tands at the head of the table. 3. T he phy sic ian's hands cradle the tempor al r egions ( av oiding pr essure ov er the ear s) with the finger s ov er the c er vic al par aspinal tis sues, pr oximal to the ar tic ular pr oces ses ( F ig. 7.23). 4. T he patient's head is bent s lightly bac kward ( ex tended) and taken thr ough a pr ogression of side bending and r otation to one side and then the other with c ontinuing pr essure fr om the finger pads on the

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Fig ure 7.23. Step 3.

Fig ure 7.24. Step 4.

Fig ure 7.25. Step 4.

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P.89

Cervi cal Region: Thumb Rest, Supine

1. T he patient lies s upine on the tr eatment table with or without a pillow under the head. 2. T he phy sic ian s its or s tands at the head of the table. 3. T he thumb and for efinger of one of the phy sic ian's hands cups the poster ior c er vic al area palm up ( Fig . 7.26). 4. T he phy sic ian's other hand is placed ov er the tempor al and fr ontal r egions of the patient's head and gently br ings the head into s light bac kward bending ( ex tension) and rotation agains t the thumb (F ig s. 7.27 and 7.28).

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Fig ure 7.26. Step 3.

Fig ure 7.27. Step 4.

Fig ure 7.28. Step 4.

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5. T he motion is v er y s light. 6. T ension ( pr ess ure) is r elaxed s lowly and r eapplied s lowly . 7. T he pr ess ure may be r ev ers ed to the other s ide.

P.90

Cervi cal Region: Coupl ing wi th S houlder Bl ock, S upine

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1. T he patient lies s upine on the tr eatment table and the physician s tands or sits at the head of the table. 2. T he physic ian places one hand on top of the patient's ac r omioclavic ular joint on the side to be treated ( F ig. 7.29). 3. T he physic ian's other hand c r osses the midline to contr ol the patient's head from that s ame s ide and gently pus hes the head toward the oppos ite side ( F ig. 7.30). 4. T he physic ian mov es the head until meeting the r es trictiv e barr ier at its pas siv e tolerable elastic limit and holds this position for 3 to 5 s econds and then s lowly r eturns the head to neutral. 5. T his is r epeated r hy thmically and gently until r eleas e of tissue tension and/or improv ement in r ange of motion. 6. T he physic ian's hands may be r ev ers ed and the

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F igure 7.29. Step 2.

F igure 7.30. A. Steps 3 and 4, anterior head control.

F igure 7.30. B. Steps 3 and 4, alternate, posterior head control.

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P.91

Cervi cal Region: Lateral Traction, Seated (Exampl e: Left Cervi cal Paravertebral Muscl e Hypertoni city, Fascial I nelasti city, and Others)

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1. T he patient is s eated on the tr eatment table. 2. T he physic ian s tands behind and to the right s ide of the patient with the patient r esting c omfor tably agains t the phy sic ian's c hest. 3. T he phy sic ian's r ight cupped hand and for ear m ar e pas sed under the patient's c hin s o as to gently touch the patient's left per iauric ular r egion (F ig. 7.31). 4. T he phy sic ian's left hand is placed on top of the patient's left s houlder at the s uperior tr apez ius and s uprac lav icular r egion (F ig. 7.32). 5. T he phy sic ian's r ight hand gently rotates the patient's head to the r ight and ex erts a gentle c ephalad

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Fig ure 7.31. Step 3.

Fig ure 7.32. Step 4.

Fig ure 7.33. Step 5.

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P.92

Cervi cal Region: S i tti ng Traction (Exam ple, Using Ri ght Knee)

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1. T he patient is s eated on the tr eatment table. 2. T he physic ian s tands behind and to the left of the patient. 3. T he phy sic ian's r ight foot is placed on the table with the r ight knee and hip flexed. 4. T he phy sic ian's r ight elbow is placed on the r ight thigh. 5. T he phy sic ian's r ight hand c r adles the oc c iput with the thumb and index finger while the left hand holds the patient's for ehead ( F igs. 7.34 an d 7.35) . 6. T he physic ian s lowly elevates the right thigh and knee by lifting the heel of the right foot ( plantar- flex ing foot), thereby pr oduc ing c er vic al tr action ( Fig . 7.36). 7. T he tr action is r eleas ed when the physic ian

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Fig ure 7.34. Step 5.

Fig ure 7.35. Step 5, alter native hand pos ition.

Fig ure 7.36. Step 6.

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P.93

Cervi cal Region: Head and Chest Positi on, Seated

1. T he patient is s eated on the tr eatment table. 2. T he physic ian s tands fac ing the patient with one leg in fr ont of the other for balanc e. 3. T he patient's fr ontal bone ( forehead) is placed agains t the phy sic ian's infrac lav icular fos sa or s ternum ( Fig . 7.38). 4. T he pads of the phy sic ian's finger s c ontac t the medial as pect of the cer vic al par avertebral mus culatur e ov erly ing the ar ticular pillar s ( Fig . 7.39). 5. T he physic ian leans bac kward, dr awing the patient towar d the physic ian. T his c aus es the phy sic ian's hands to

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Fig ure 7.38. Step 3.

Fig ure 7.39. Step 4.

Fig ure 7.40. Step 5.

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engage the s oft tiss ues, ex erting a gentle ventral for ce with c oncomitant c ephalad tr action. This pr oduc es a longitudinal tr actional effect ( s tretch) ( F ig. 7.40). 6. T his tec hnique may be per for med in a gentle, r hy thmic, and k neading fas hion or in a s us tained manner . 7. T is sue tension is r eevaluated to ass ess the effectiveness of the tec hnique.

P.94

Thoracic Region: P rone Pressure

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1. T he patient is pr one, pr efer ably with the head tur ned toward the phy sic ian. (If the table has a face hole, the head may be kept in neutral.) 2. T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated. 3. T he phy sic ian places the thumb and thenar eminence of one hand on the medial as pect of the patient's thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian ( F ig. 7.41). 4. T he phy sic ian places the thenar eminence of the other hand on top of the

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Fig ure 7.41. Step 3.

Fig ure 7.42. Step 4.

Fig ure 7.43. Step 5.

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P.95

Thoracic Region: P rone Pressure With Two Hands (Catwalk)

1. T he patient is pr one on the tr eatment table, pr efer ably with the head tur ned toward the phy sic ian. (If the table has a face hole, the head may be kept in neutral). 2. T he phy sic ian s tands at the s ide of the table, opposite the s ide to be tr eated. 3. T he phy sic ian's hands are placed palm down s ide by s ide on the medial as pect of the patient's thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian ( F ig. 7.44). 4. T he phy sic ian adds enough

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Fig ure 7.44. Step 3.

Fig ure 7.45. Step 4.

Fig ure 7.46. Step 5.

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5.

6.

7.

8.

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downward pr essure to engage the underlying fas cia and mus culatur e with the c audal hand ( F ig. 7.45). T he phy sic ian adds later al pr essure, tak ing the my o-fascial s tr uctures to their c omfor table elastic limit ( F ig. 7.46). T his forc e is held for s ev eral s ec onds and then s lowly r eleas ed. As the pr essure is being r eleas ed with the caudal hand, the phy sic ian's c ephalad hand begins to add a downward lateral force ( F ig. 7.47). T he c ombination of downwar d and later al for ces and the releas e of this pr essure is alternately applied

Fig ure 7.47. Step 7.

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between the two hands . 9. T he downward and later al pr essure dir ected by eac h hand s hould be r hy thmically applied for s ev eral s ec onds.

P.96

Thoracic Region: P rone Pressure with Counterpressure

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1. T he patient lies prone on the tr eatment table, pr efer ably with the head tur ned toward the physic ian. ( If the table has a fac e hole, the head may be kept in neutral.) 2. T he physic ian s tands at either side of the table. 3. T he physic ian places the thumb and thenar eminence of the caudad hand on the medial as pect of the patient's thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian with the finger s pointing c ephalad. 4. T he physic ian places the hy pothenar eminence of the cephalad hand on the medial as pect of the patient's

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Fig ure 7.48. Step 4.

Fig ure 7.49. Step 4.

Fig ure 7.50. Step 5.

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P.97

Thoracic Region: S i de Leverage, Lateral Recum bent

1. T he patient lies in the lateral r ec umbent ( s ide lying) pos ition, tr eatment side down. 2. T he physic ian is seated on the side of the table, fac ing the patient. 3. T he physic ian r eaches ov er the patient's s houlder with the caudad hand and places the thumb and thenar eminence on the medial as pect of the par a-v ertebral mus cles ov erly ing the upper thorac ic tr ansv ers e pr oces ses at the side on which the patient is ly ing ( F ig. 7.51). 4. T he physic ian r eaches under the patient's fac e with the c ephalad hand and c ontac ts the

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Fig ure 7.51. Step 3.

Fig ure 7.52. Step 4.

Fig ure 7.53. Step 5.

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per iauric ular r egion, c r adling the head ( Fig . 7.52). 5. T he phy sic ian's c audad hand ex erts a gentle for ce v entrally and laterally to engage the s oft tiss ues while the c ephalad hand gently lifts the head to produc e c er vic al and upper thorac ic s ide bending. T he phy sic ian may add slight flexion until meeting the c omfor table elastic limit of the tissues ( F ig. 7.53). 6. Step 5 can be r epeated s ev eral times in a gentle, r hy thmic, and k neading fas hion or us ing deep, s us tained pr essure. 7. T he phy sic ian's c audad hand is r epositioned to contac t differ ent lev els of the

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Fig ure 7.54. Step 7.

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upper thorac ic s pine and steps 5 and 6 are per for med to s tr etc h v ar ious por tions of the upper thorac ic par avertebral mus culatur e ( F ig. 7.54).

P.98

Thoracic Region: Bi lateral Thumb Pressure, Prone

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1. T he patient lies prone on the tr eatment table, pr efer ably with the head tur ned toward the phy sic ian. (If the table has a face hole, the head may be kept in neutral.) The phy sic ian s tands at the head of the table. 2. T he phy sic ian's thumbs bilaterally c ontac t the par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses of T 1 with the finger s fanned out laterally (F ig. 7.55). 3. T he phy sic ian's thumbs ex ert a gentle v entral force to engage the s oft tiss ues and add a c audal and s lightly lateral force until meeting the c omfor table elastic limits

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Fig ure 7.55. Step 2.

Fig ure 7.56. Step 3.

Fig ure 7.57. Step 6.

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P.99

Thoracic Region: Trapezius, I nhi bitory Pressure, Supine

1. T he patient lies s upine on the tr eatment table. 2. T he physic ian s its at the head of the table. 3. T he physic ian's hands are placed on eac h tr apez ius so that the thumbs (pads up) lie approx imately two thumb's-br eadths inferior to the pos ter ior bor der of the tr apez ius and the index and third digits ( pads down) r est on the anterior bor der of the tr apez ius two finger 's- breadths inferiorly (F ig. 7.59). The thumbs and finger pads may be rev ers ed in pos ition if this is mor e c omfortable for the physician ( F ig. 7.60). 4. T he physic ian s lowly adds a s queez ing for ce on the tr apez ius between the thumbs and finger s ( Fig . 7.61). 5. T his pres s ure is held until tissue

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Fig ure 7.59. Step 3.

Fig ure 7.60. Step 3, alter native pos ition.

Fig ure 7.61. Step 4.

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tex tur e c hanges ar e palpated or for 1 to 2 minutes.

P.100

Thoracic Region: Upper Thoracic with S houl der Bl ock, Lateral Recumbent

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1. T he patient lies in the later al r ec umbent pos ition with the s ide to be tr eated up. 2. T he physic ian s tands at the side of the table, facing the patient. 3. T he physic ian's c audad hand is pas sed under the patient's arm, with the pads of the finger s on the medial as pect of the patient's par avertebral mus cles ov erlying the thorac ic tr ansv ers e pr oces ses (F ig. 7.62). 4. T he physic ian's c ephalad hand c ontac ts the anterior portion of the shoulder to pr ovide an effec tiv e c ounterfor ce (F ig. 7.63). Note: The patient's arm may be flexed approx imately 120 degrees and draped ov er the phy sic ian's s houlder- c ontacting ar m as needed ( F ig. 7.64). 5. T he physic ian's c audad hand exer ts a gentle forc e, v entrally to engage the soft tiss ues and laterally to create a per pendic ular s tr etc h of the

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Fig ure 7.62. Step 3.

Fig ure 7.63. Step 4.

Fig ure 7.64. Step 4, alter native pos ition.

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P.101

Thoracic Region: Lower Thoracics Under the Shoul der, Lateral Recumbent

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1. T he patient is in a later al r ec umbent pos ition with the side to be tr eated up. 2. T he phy sic ian s tands at the s ide of the table, fac ing the fr ont of the patient. 3. T he phy sic ian r eaches both hands under the patient's ar m, with the pads of the finger s c ontac ting the medial as pect of the patient's par avertebral mus cles, ov erly ing the thorac ic tr ansv ers e pr oces ses ( F igs. 7.66 an d 7.67) . 4. T he phy sic ian's hands exer t a gentle for ce v entrally to engage the s oft tiss ues and later ally to create a per pendic ular s tr etc h of the thorac ic par avertebral mus culatur e

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Fig ure 7.66. Step 3.

Fig ure 7.67. Step 3.

Fig ure 7.68. Step 4.

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P.102

Thoracic Region: Over and Under Techni que, Seated

1. T he patient is s eated with the ar ms c r ossed and the thumbs hooked into the antec ubital fos sae (F ig. 7.69). 2. T he physic ian s tands fac ing the patient. 3. T he phy sic ian's hands reac h under the patient's for ear ms and ov er the patient's s houlders , allowing the patient's for ehead to r es t on the for ear ms. 4. T he pads of the physic ian's finger s c ontact the upper thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses ( F ig. 7.70). 5. With one leg s lightly behind the other for balanc e, the phy sic ian leans bac kward and

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Fig ure 7.69. Step 1.

Fig ure 7.70. Step 4.

Fig ure 7.71. Step 5.

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dr aws the patient for war d. T he phy sic ian s imultaneously r aises the patient's for ear ms, us ing them as a lever, pr oduc ing minimal thorac ic ex tens ion ( F ig. 7.71). 6. T he pads of the physic ian's finger s ex ert a gentle ventral and cephalad for ce to engage the s oft tiss ues, pr oduc ing a longitudinal s tr etc h of the thorac ic par avertebral mus culatur e ( F ig. 7.72). 7. Steps 5 and 6 may be r epeated s ev eral times in a gentle, r hy thmic, and k neading fas hion or us ing deep, s us tained pr essure. 8. T is sue tension is reevaluated to ass ess the effectiveness of the tec hnique.

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Fig ure 7.72. Step 6.

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P.103

Thoracic Region: Mi dthoracic Extension, Seated

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1. T he patient is s eated on the end of the table with the hands c lasped behind the nec k. 2. T he phy sic ian s tands at the s ide of the patient. 3. T he phy sic ian r eaches under the patient's upper arms and gr asps the patient's far elbow. T he patient's other elbow r es ts on the phy sic ian's for ear m near the antecubital fos sa. 4. With the finger s pointing c ephalad, the phy sic ian's other hand is c upped ov er the thorac ic s pinous pr oces ses , c ontac ting the par avertebral mus culatur e of one side with the thenar eminence

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Fig ure 7.73. Step 4.

Fig ure 7.74. Step 4.

Fig ure 7.75. Step 5.

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P.104

Thoracic Region: Ri b Raising, Supine E xtension

T his procedure is c ommonly us ed in the postoper ative s etting to treat the s omatic c omponents of v isceros omatic r eflexes ( postsur gic al paralytic ileus ). 1. T he patient is s upine on the tr eatment table or hos pital bed and the phy sic ian is s eated on the s ide to be tr eated. 2. T he phy sic ian's hands (palms up) reach under the patient's thorac ic s pine ( F ig. 7.76) with the pads of the finger s on the patient's thorac ic par avertebral mus culatur e between the s pinous and tr ansv ers e pr oces ses on the side c loses t to the phy sic ian ( F ig. 7.77). 3. T he physic ian

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Fig ure 7.76. Step 2.

Fig ure 7.77. Step 2.

Fig ure 7.78. Step 3.

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ex erts a gentle for ce ventrally to engage the s oft tiss ues and later ally per pendic ular to the thorac ic par avertebral mus culatur e. T his is fac ilitated by a downward pr essure thr ough the elbows on the table, cr eating a fulc rum to pr oduc e a v entral lever ac tion at the wr ists and hands, engaging the s oft tiss ues. T he finger s ar e s imultaneously dr awn toward the physic ian, pr oduc ing a lateral s tretch per pendic ular to the thorac ic par avertebral mus culatur e ( F ig. 7.78). 4. T his s tretch is held for s ev eral s ec onds and is slowly r eleas ed. 5. Steps 3 and 4 ar e repeated s ev eral times in a gentle, r hy thmic, and k neading fas hion.

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6. T he phy sic ian's hands are r epositioned to c ontac t the differ ent lev els of the thorac ic s pine and s teps 3 to 6 ar e perfor med to str etc h v ar ious por tions of the thorac ic par avertebral mus culatur e. 7. T his technique may also be per for med us ing deep, s us tained pr essure. 8. T is sue tension is reevaluated to ass ess the effectiveness of the tec hnique.

P.105

Lumbar Region: Prone P ressure

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1. T he patient is pr one, with the head tur ned toward the phy sic ian. (If the table has a face hole, k eep the head in neutral.) 2. T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated ( Fig . 7.79). 3. T he phy sic ian places the thumb and thenar eminence of one hand on the medial as pect of the patient's lumbar par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian ( F ig. 7.80). 4. T he phy sic ian places the thenar eminence of the other hand on the abducted

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Fig ure 7.79. Step 2.

Fig ure 7.80. Step 3.

Fig ure 7.81. Step 4.

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P.106

Lumbar Region: Prone Traction

1. T he patient is pr one with the head turned toward the phy sic ian. (If the table has a face hole, keep the head in neutr al.) 2. T he physic ian s tands at the side of the table at the lev el of the patient's pelvis . 3. T he heel of the phy sic ian's c ephalad hand is placed ov er the bas e of the patient's sac rum with the fingers pointing toward the c oc cyx (F ig. 7.83). 4. T he physic ian does one or both of the following: a. T he phys ician's c audad hand is plac ed over the lumbar s pinous proc ess es with the fingers pointing c ephalad, c ontacting the paraver tebr al s oft tissues with the thenar and

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Fig ure 7.83. Step 3.

Fig ure 7.84. Step 4a.

Fig ure 7.85. Step 5.

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hypothenar eminenc es ( Fig . 7.84) b. T he hand may be plac ed to one s ide of the s pine, c ontacting the paraver tebr al s oft tissues on the far s ide of the lumbar spine with the thenar eminenc e or the near s ide with the hypothenar eminenc e. 5. T he physic ian ex erts a gentle for ce with both hands ventrally to engage the soft tis sues and to c r eate a s eparation and dis traction effect in the dir ection the finger s of each hand are pointing ( F ig. 7.85). Do not pus h direc tly down on the spinous pr oces ses . 6. T his technique may be applied in a gentle, rhy thmic, and kneading fas hion or us ing deep, sus tained pr essure. 7. T he physic ian's c audad hand is r epositioned at other lev els of the

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lumbar spine and s teps 4 to 6 are r epeated. 8. T is sue tension is r eevaluated to as s ess the effectiveness of the technique.

P.107

Lumbar Region: Bil ateral Thum b P ressure, P rone

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1. T he patient is pr one, with the head tur ned toward the phy sic ian. (If the table has a face hole, k eep the head in neutral.) 2. T he phy sic ian s tands at the s ide of the table at the lev el of the patient's thighs or k nees. 3. T he phy sic ian's thumbs ar e placed on both s ides of the spine, c ontac ting the par avertebral mus cles ov erly ing the tr ansv ers e pr oces ses of L5 with the finger s fanned out laterally (F ig. 7.86). 4. T he phy sic ian's thumbs ex ert a gentle for ce v entrally to engage the s oft tiss ues c ephalad, and later ally

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Fig ure 7.86. Step 4.

Fig ure 7.87. Step 4.

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P.108

Lumbar Region: Sci ssors Technique, Prone

1. T he patient is pr one, with the head turned toward the phy sic ian. (If the table has a fac e hole, k eep the head in neutral.) 2. T he physic ian s tands at the s ide of the table opposite the side to be tr eated ( Fig . 7.88). 3. O n the side to be treated, the phy sic ian's c audad hand r eaches ov er to grasp the patient's leg pr oximal to the k nee or at the tibial tuberosity ( F ig. 7.89). 4. T he physic ian lifts the patient's leg, ex tending the hip and adducting it toward the other leg to pr oduc e a s c issors effect ( F ig. 7.90). 5. T he phy sic ian's c audad hand may be placed under the far

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Fig ure 7.88. Step 4.

Fig ure 7.89. Step 4.

Fig ure 7.90. Step 5.

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6.

7.

8.

9.

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leg and then ov er the pr oximal leg s o that the patient's leg c an suppor t the physic ian's for ear m. T he physic ian places the thumb and thenar eminence of the cephalad hand on the patient's par a-v ertebral mus culatur e ov erly ing the lumbar tr ans- ver s e pr oces ses to dir ect a gentle for ce ventrally and later ally to engage the s oft tiss ues while s imultaneously inc reasing the amount of hip ex tens ion and adduction ( F ig. 7.91). T his forc e is held for s ev eral s ec onds and is slowly r eleas ed. Steps 6 and 7 ar e repeated s ev eral times in a s low, r hy thmic, and k neading fas hion. T he phy sic ian's

Fig ure 7.91. Step 5.

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c ephalad hand is then r epositioned to c ontac t other lev els of the lumbar spine and steps 6 to 8 are per for med to s tr etc h the v ar ious por tions of the lumbar par avertebral mus culatur e. 10. T his technique may also be per for med us ing deep, s us tained pr essure. 11. T is sue tension is reevaluated to ass ess the effectiveness of the tec hnique.

P.109

Lumbar Region: Prone P ressure wi th Counterleverage

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1. T he patient is pr one with the head tur ned toward the phy sic ian. (If the table has a face hole, k eep the head in neutral.) 2. T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated ( Fig . 7.92). 3. T he phy sic ian places the thumb and thenar eminences of the cephalad hand on the medial as pect of the par avertebral mus cles ov erly ing the lumbar tr ansv ers e pr oces ses on the side opposite the phy sic ian. 4. T he phy sic ian's c audad hand c ontac ts the patient's anterior s uperior iliac s pine on the s ide to be

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Fig ure 7.92. Step 2.

Fig ure 7.93. Step 4.

Fig ure 7.94. Step 5.

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P.110

Lumbar Region: Lateral Recum bent Positi on

1. T he patient lies in the lateral r ec umbent pos ition with the tr eatment s ide up. 2. T he phy sic ian s tands at the s ide of the table, fac ing the fr ont of the patient. 3. T he patient's k nees and hips are flexed, and the phy sic ian's thigh is placed agains t the patient's infrapatellar r egion (F ig. 7.95). 4. T he phy sic ian r eaches ov er the patient's bac k and places the pads of the finger s on the medial as pect of the patient's par avertebral mus cles ov erly ing the lumbar tr ansv ers e pr oces ses

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Fig ure 7.95. Step 3.

Fig ure 7.96. Step 4.

Fig ure 7.97. Step 5.

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( F ig. 7.96). 5. T o engage the soft tis sues, the phy sic ian ex erts a gentle for ce v entrally and laterally to c r eate a per pendic ular s tr etc h of the lumbar par avertebral mus culatur e ( F ig. 7.97). 6. While the phy sic ian's thigh against the patient's k nees may s imply be us ed for br acing, it may also be flexed to pr ovide a c ombined bowstr ing and longitudinal tr action forc e on the par avertebral mus culatur e. T his tec hnique may be applied in a gentle r hy thmic and k neading fas hion or with deep, s us tained pr essure. 7. T his tec hnique may be

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Fig ure 7.98. Step 7.

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modified by br acing the anterior s uperior iliac s pine with the caudad hand while dr awing the par avertebral mus cles v entrally with the cephalad hand ( Fig . 7.98). 8. T he phy sic ian's hands are r epositioned to contac t differ ent lev els of the lumbar spine and steps 4 to 6 are per for med to s tr etc h v ar ious por tions of the lumbar par avertebral mus culatur e. 9. T is sue tension is r eevaluated to ass ess the effectiveness of the tec hnique.

P.111

Lumbar Region: Supi ne Extensi on

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1. T he patient is s upine. ( T he patient's hips and knees may be flexed for comfor t.) 2. T he physic ian is seated at the side to be tr eated. 3. T he phy sic ian's hands (palms up) reach under the patient's lumbar spine, with the pads of the phy sic ian's finger s on the patient's lumbar par avertebral mus culatur e between the s pinous and tr ansv ers e pr oces ses on the side c loses t the phy sic ian ( F igs. 7.99 and 7.100). 4. T o engage the s oft tiss ues, the physic ian ex erts a gentle v entral and lateral force per pendic ular to the thorac ic par avertebral mus culatur e. T his is fac ilitated by downward pr essure

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Fig ure 7.99. Step 4.

Fig ure 7.100. Step 4.

Fig ure 7.101. Step 5.

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Lumbar Region: Long-Lever Counterlateral with Knees, S upine

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1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian's c audad hand flexes the patient's hips and knees to approx imately 90 degrees eac h ( Fig . 7.102) . 3. T he phy sic ian's c ephalad hand r eac hes ov er the patient and under the patient's lumbar region in the ar ea of the dy s function. 4. T he physic ian c ontrols the patient's lower ex tremities bilaterally at the tibial tuberosities and slowly mov es the k nees laterally away fr om the phy sic ian ( F ig. 7.103). 5. As the patient's k nees are mov ed away fr om the phy sic ian, the phy sic ian

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Fig ure 7.102. Step 2.

Fig ure 7.103. Step 4.

Fig ure 7.104. Step 6.

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Lumbar Region: Left, Lumbar P aravertebral Muscle Spasm, Myofasci al Hypertonici ty, Seated

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1. T he patient is s eated on the end of the table with the phy sic ian s tanding behind the patient and to the right side, opposite the dy s function. 2. T he patient is ins tructed to place the left hand behind the neck and gr asp the left elbow with the right hand. The phy sic ian's r ight hand r eaches under the patient's right ax illa and gr asps the patient's left upper arm ( F ig. 7.106). 3. T he phy sic ian's left thumb and thenar eminence are placed on the medial as pect of the patient's left par avertebral mus culatur e ov erly ing the lumbar tr ansv ers e pr oces ses ( F ig. 7.107). 4. T he patient is ins tructed to

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Fig ure 7.106. Step 2.

Fig ure 7.107. Step 3.

Fig ure 7.108. Step 5.

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P.114

References 1. W ard R C, ed . F ound ati ons for Os teo path i c M ed i c in e. Phi l ade l ph i a: Lip pin c ot t Wi l li ams & W i lk i ns , 20 03.

2. G r ee nm an P. Pr i nci ple s o f Ma nua l M edic i ne . P hi la del - ph i a: Lip pin c ott Wi l li am s & W i lk i ns, 20 03.

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8 Myofascial Release Techniques Technique P rincipl es War d de s cr i be s my o fa s ci a l r e le a se t ec h ni q ue a s “ de s ig n e d t o s tr e t ch an d r e f le x ly r el e a se pa t te r n ed so f t t i s s u e a nd j oi n -r e la t e d r es t ri c t io n s” (1 ) . T h is s t y l e o f o s t e o pa t hi c m a n ip u la t io n ha s h i s t o r ic a l t ie s to ea r ly o s t e op a th i c m a ni p ul a t iv e t r ea t men t a nd s of t t i s s u e t e ch n iq u e , b ut Wa r d c o mb i ne d pr i nc i pl e s o f m a ny o th e r t ec h n iq u es to d ev e l op a d is t i nc t t e ch n i qu e , e ve n th o ug h i t s r o ot s m a y g o b a c k t o e ar l y o s te o pa t hi c p hy s i ci a ns (2 ) . T h e E du c a ti o n Cou n c il on Os t e op a th i c P r in c ip l es h as de f in e d myo f a s c i al re l e as e t e ch n i qu e a s a “ s y s te m o f di a gn o si s an d t r ea t men t f i rs t de s cr i be d b y A n dr e w Tay l o r S ti l l a n d h is ea r l y s tu d en t s , whi c h e n ga g es co n t in u al pa l p at o ry f ee d b ac k t o a c h ie v e r el e a se of my o f as c ia l t i s su e s” (1 ) . I n c o mp a r in g t h is t ec h ni q ue t o o th e r o s te o pa t h ic te c hn i q ue s ( e sp e c ia l ly fo r so f t t is s u e) , i t i s ob v io u s t h at ha n d p la c e me n t a nd f or c e v ec t o r d ir e c t i o ns ar e s i mil a r a nd t ha t t h e p r in c ip l es u se d t o a f f ec t t he v ar i ou s a n a to mic ti s s ue t y p es , mu s cl e o r i gi n s a nd i ns e rt i on s , a n d s o o n a r e a ls o i mp o r ta n t i n t h is s t y le . Wh e re a s s o f t ti s su e te c hn i qu e ha s b e en h is t or i ca l l y d ir e c t i n c la s s if i ca t io n , m y of a s c i a l r el e as e ca n b e p e r fo r me d i n ei t he r a d ir e c t or i nd i re c t man n e r. Th e re f o re , s o me wou l d c la s s if y i t a s a c om b in e d t e ch n iq u e ( 2 ). Myo f a s c i al te c h ni q ue ma y be pe r fo r med wi t h o n e h an d o r tw o . Cli n i ca l ly , a t wo - ha n de d met h o d may be mor e e f fe c t iv e i n d i a gn o si s a n d t r ea t me n t . The os t e op a th i c p h y s i ci a n wil l us e e p ic r i ti c p a lp a t io n t o d e t er min e t h e s o f t ti s s ue co mpl i a nc e ( l oo s e ne s s , ea s e , f re e d om ) a n d s t if f ne s s ( t ig h tn e s s , bi n di n g, r es t ri c ti o n ). Ho wev e r , i n d y s f u nc t io n al s ta t e s t he r e ma y b e a g e n er a l o r u n iv e rs a l b a rr i er (r e s tr i c t i on ) , s o t h at t he s e t is s u es h av e an as y mm e t ri c q u al i t y o r q ua n t it y o f c o mpl i an c e. Thu s , a s e n se of fr e e do m i n o n e o r mo re di r ec t i on s a n d r e s t r ic t io n in th e o t h er s c a n e x is t . The s e a s ym met r i es ar e c li n i ca l ly de s c ri b ed as h av i ng a t i gh t -l o os e or ea s e- b i nd re l at i o ns h ip . W a r d a ls o p o i nt s o ut t ha t t h e t i gh t -l o os e as y mm e tr y ma y b e m o r e c li n ic a l ly re l ev a n t a t t he l oo s e s it e s , whe r e p a in an d in s ta b il i t y may be p re s en t ( 1 ) . The r ef o r e, th e p h y si c ia n m u s t b e a wa r e t ha t th e re ma y be a c au s e -a n d- e f f e c t s it u at i o n whe r eb y (a ) t h e t i gh t o r d i r ec t b a rr i e r i s c au s i ng a s ec o n da r y l oo s e r e ac t io n or (b ) t h e l o os e s i t e i s i nh e r en t ly un s t ab l e, an d e as i n g t he ba r r ie r i n e i t he r d i re c t io n m a y n o t b e c li n i ca l ly ad v i sa b le . B ar r i er s m a y b e i d en t if i e d wit h t h e p a ti e nt p as s iv e o r ac t iv e . Th e t re a tm e n t may al s o c on s i s t of th e s e a lt e rn a t iv e s . Th e pa t ie n t' s re s pi r at o r y a s s i s t a n ce , s p ec i f ic a ll y d ir e c te d i s om e t ri c m u s c l e c o nt r ac t i on s ( e .g . , c l en c hi n g f i s t s o r ja w), to n g ue mov e men t s o r o c ul a r mov e men t s , an d so on ar e of t en us e d t o p o te n t ia t e t he t ec h n iq u e. Th e s e a re ge n e ra l ly re f e rr e d t o a s r e le a se - e nh a nc i ng mec h an i sm s (R E Ms ) ( no t to be co n f us e d wit h ra p id ey e mo v em e nt s ) . A s t h e f as c ia i s s o d ee p l y i nc o rp o r at e d i nt o th e m u s c l e s a nd th e re s t o f t h e b od y , a n y f or c e d i re c te d on it ma y af f ec t t h e l i ga men t o us an d c a p su l ar (a r t ic u la r ) t i s s u es an d s tr u c tu r es ve r y d i s t a l t o t h e s pe c i fi c a r ea b ei n g p al p a te d a n d t r ea t ed . T h e re f or e , t h is

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t ec h n iq u e may e f f e c t wi d e sp r ea d r e a c t i on s . Fo r e xa mpl e , r e le a si n g t h e a re a s ur r o un d in g T 7 an d T 8 m a y c a us e t h e p a ti e nt t o h av e l e s s s ub o c c i p it a l s ym p t om s t hr o u gh th e p o s it i ve ef f e c t of th e te c hn i qu e on th e t r a pe z iu s m u s cl e . A n u mbe r o f p h y si c al an d an a to mic a sp e c t s a r e i mpo r ta n t i n m y of a s ci a l r el e a se as i ll u s tr a te d b y Wa r d ( 1) . Th e se in c l ud e W o lf f ' s l aw , H o o ke ' s l aw , an d N e wt o n 's th i rd l aw . The y re l at e t h e v a ri o us r ea c ti o ns t o f or c e, s uc h a s d e f or mat i on a nd th e f a c t t ha t p hy s i ca l c o nt a c t b et wee n th e p h y s i c ia n a n d p a ti e nt ha s eq u al an d op p os i te f or c e mag n i tu d es . T h e re f or e , b y i n tr o du c i ng la ws o f t h er mod y n am i c s an d en e rg y c on s e rv a ti o n t h eo r ie s , we c a n p ro j e c t th e c h a ng e s t ha t oc c ur in t he pa t ie n t 's ti s su e s whe n pr e s s u re i s i ni t ia t e d i nt o t h e se s t r uc t u re s . J ou l e f o un d t h a t t he am o u nt of en e r gy d on e as wo r k wa s c on v er t e d t o h ea t . T h e r es u l ti n g c ha n g es ma y b e ch a ng e s i n t h e c ol l a ge n ou s s t a te fr o m g e l t o s ol . Wi t h c on t i nu e d t re a t me n t a f f e c ti n g t he s e t i s s u es , t he o pp o rt u ni t y m a y e xi s t t o a l te r th e e l as t i c p ro p er t i es pe r ma n e nt l y ( pl a s ti c c h an g e ). P. 1 16

Technique Classifi cation Direct, Indirect, or Com bined With Two-Handed Technique Myo f a s c i al re l e as e m a y b e p e rf o rm e d d i re c tl y , s o t h at t he re s tr i c ti v e b ar r i er (t e ns i o n, b in d ) i s e n ga g e d, or in d i re c tl y , s o a s t o e n g ag e t h e p h y s i ol o gi c or re s tr i c ti v e b ar r i er at t he e as e ( l oo s e , f re e ) d i re c ti o n o f t e ns i on o r mot i on a s y mme t ry ( se e C h ap t e r 6 , P ri n c ip l es of O s t e op a th i c M a ni p ul a t iv e T e ch n i qu e s) . I t ma y a l so b e p er f or me d i n a s im u l ta n eo u s d i re c t a nd i nd i re c t a p pr o ac h i n wh i ch th e ph y si c ia n us e s o ne h an d t o a pp r o ac h t h e t i gh t b a rr i e r a nd th e ot h er to a pp r oa c h t h e l oo s e b a rr i er . I t ma y a l so b e p er f o rm e d s uc h th a t t he p hy s ic i an a lt e rn a te s be t we e n d i re c t a nd i nd i re c t t y pe s .

Technique S tyl es Light, Moderate, or Heavy in Force Applicati on Myo f a s c i al re l e as e t e ch n i qu e i s i n t er e s t i ng a nd ve r y u s ef u l i n t h at th e f o r ce s m a y b e d ir e c te d i n d i f fe r en t ia t e d l ev e ls ; al s o, th e ph y si c ia n ca n d i re c t t h e f or c e t o wa r d ( d ir e c t ) o r a way fr o m ( i nd i re c t) t he ba r ri e r s b ei n g mo ni t or e d. The r ef o re , th i s t ec h n iq u e i s u s ef u l i n a c ut e a n d c h ro n ic cl i n ic a l p re s e nt a ti o ns wit h t h ei r as s oc i at e d v a ri a ti o n s i n p ai n l ev e l .

I ndi cati ons 1. Use a s p ar t o f th e m u s c u l os k el e ta l s c r ee n in g ex a mi n at i o n t o q ui c k ly id e nt i f y r eg i o ns of po t e nt i al mo t i on re s tr i c ti o n a nd t is s ue te x t ur e c h an g e s . 2. Red u c e mus c le t en s io n a n d f a s c i al t en s io n . 3. S tr e t ch an d i n c re a se el a s ti c it y o f sh o rt e ne d , i n el a s t i c , a nd / or f ib r ot i c my of a s c i al s tr u c tu r es to i mp r ov e r e g io n al an d / or in t er s e gm e nt a l r a ng e s o f mo ti o n. 4. Red u c e t he ti g h t- l oo s e a s ym met r y t o i mpr o ve t he ti s su e co n si s te n c y i n t he l oo s e

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t is s u es by in c r ea s in g e l a s t i ci t y i n t h e t ig h t t i s s u es . 5. I mp r o ve ci r cu l a ti o n t o t h e s pe c if i c r e gi o n b e in g t r ea t e d b y l oc a l p h y s i ca l an d t he r mod y na mic e f f e c t s o r by re f le x ph e no men a to im p ro v e c i rc u la t i on in a d i s t a l a re a (e . g. , t h r ou g h s om a t os o ma t ic , so mat o vi s c er a l r ef l e xe s ). 6. I nc r e as e v e no u s a n d l ym p h at i c d ra i n ag e t o d e c re a se lo c a l a nd / or d is t al sw e l li n g a nd e de ma a nd p ot e nt i al l y i mpr o ve t he ov e ra l l i mmu n e r e sp o ns e . 7. P ot e n ti a te th e ef f ec t o f ot h er os t e op a th i c t e ch n iq u es .

Contraindicati ons Relative Contraindications A s my of a s c i al t ec h ni q ue may be pe r f or med wi t h e x tr e me l y l i gh t p r e s s u re in a d i re c t o r i nd i r ec t m a nn e r , t he r e i s l i t t l e l i ke l ih o od o f a dv e rs e ef f ec t s o t he r t h an a ch e s p os t t re a t me n t t ha t ar e s e co n d ar y t o c o mpe n sa t io n an d d e co mp en s at i on r ea c ti o ns a nd s im i l ar to ac h e s p os t e x e rc i se . A s in ot h er t ec h ni q ue s , i n cr e as e d w a te r i n t ak e a n d i c e p ac k ap p li c at i o n a s n ee d e d p os t t r e at men t w i l l g en e ra l l y r ed u ce a ny su c h r e ac t io n . 1. A cu t e s p ra i n o r s t ra i n. 2. Fra c t ur e o r d i s lo c at i on . 3. Neu r o lo g ic or v as c ul a r c o mp r om i se . 4. O s t e o po r os i s a n d o s t e op e n ia . 5. Mal i g na n c y . M o s t r es t ri c t io n s a re f or tr e at me nt in th e af f ec t ed a re a o f mal i g na n c y ; h o wev e r, ca r e s h ou l d b e t a ke n i n ot h er di s t al ar e as d ep e nd i ng o n t yp e of ma l ig n a nc y a n d/ o r l y mp h at i c i n vo l ve me nt . 6. I nf e c ti o n ( e. g . , o s t e om y e li t is ) .

Absol ute Contraindications Non e , a s t h e t e ch n iq u e ma y b e p er f o rm e d wit h ve r y l ig h t p r es s ur e . T h e p hy s i ci a n may wor k pr o xi mal o r d is t al t o t he af f e c t e d a re a an d a l te r th e p a ti e n t' s p o si t i on or s t y l e o f t ec h n iq u e t o a c hi e ve so me b e ne f ic i a l e f f e c t .

General Considerations and Rules 1. The p hy s ic i an p al p at e s t h e p at i en t us i ng la y e r- b y- l ay e r p a lp a to r y p r in c ip l e s a nd wit h ju s t e no u g h p re s su r e t o c a pt u r e t he s k i n a n d s ub c u ta n eo u s f a s c i al s tr u c tu r es . T h i s i s o ne l ev e l o f p r es s ur e l e s s t ha n t h a t o f s of t ti s su e t e c hn i qu e . A ny mov e me n t o f t h e h an d on th e s k i n s ho u ld c au s e t he s ki n t o m o v e a lo n g wi th t he h an d w i th o u t s li d in g th e h a nd o ve r t h e s k in . 2. The p hy s ic i an g en t ly mo v e s t he pa l p at i ng ha n d o r h a nd s in a l in e a r d ir e c t i o n o f

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c ho i c e ( ha n ds o f t he cl o c k) mo v in g th r ou g h t h e x - a nd y -a x es . T h e z - ax i s h a s a lr e a dy be e n e n ga g ed by t he la y er - b y- l ay e r p a lp a to r y p r es s ur e i n t o t he bo d y , g ai n i ng ac c es s to th e s u p er f ic i al f as c ia . 3. S ym me tr y v e rs u s a s ym met r y o f t i s s u e c o mp l ia n c e i s n ot e d i n t h e l i ne a r d ir e c ti o ns te s t ed . 4. The p hy s ic i an may ad d a v ar i et y o f di r ec t io n s o f m o ti o n , i nc l ud i n g o th e r l i ne a r mov e men t s i n a 36 0 -d e gr e e P. 1 17 r ef e r en c e a nd c lo c kw i se a nd co u nt e r cl o c k wis e ro t at i on a l m o ve men t . A g ai n , s ym me tr y v e rs u s a s ym met r y o f t i s s u e c o mp l ia n c e i s n ot e d . 5. The p re s su r e t h e p hy s ic i a n u se s t o de t er min e co mpl i an c e m a y b e mi ni mal or mod e r at e , d ep e n di n g o n t h e c li n ic a l p r es e nt a t io n o f t h e p a ti e nt ( ac u te pa i n fu l v er s u s c hr o ni c mi n im a ll y pa i nf u l) a nd wh a t t h e p hy s ic i a n b el i ev e s i s a p pr o p ri a te f or t he si t ua t i on . 6. A f t e r d e te r mi n i ng th e e a s e a nd bi n d b a rr i er s of th e t i s su e i n t h e se di r ec t i on s , t he p hy s ic i an d et e rm i ne s wh e th e r g e nt l e o r mo de r at e p r e s s u re in a d i re c t ( t ow a rd b in d ) o r i n di r e c t (t o wa r d e a se ) t e c hn i qu e i s ap p ro p ri a t e. Ag a in , th i s i s d et e r mi n ed by t he cl i ni c a l p re s en t a ti o n a nd e xa min a ti o n f i nd i ng s . I n g e ne r a l, th e g en t l es t m e th o d i s t h e s a fe s t . 7. The p hy s ic i an s lo wly mo v e s t he ha n d -c o nt r ol l e d myo f as c i al ti s su e s t o wa r d t h e a pp r o pr i at e b a r ri e r, an d on me e ti n g t h e b ar r i er , h e o r sh e h o ld s th e t i s s u e a t t ha t po i nt wi t h ou t r e li e v in g t h e p r es s ur e . Th e p hy s ic i a n s ho u ld n ot i ce th a t a f te r a pp r o xi mat e ly 2 0 t o 3 0 s e co n ds , a c ha n ge of t is s ue co mp li a nc e o c c ur s ; t hi s is d em o n s t r at e d b y m o ve men t of th e t i s su e t h ro u g h t he or i g in a ll y d e t er min e d b ar r i er (c r ee p or fa s ci a l c r ee p ). 8. The p hy s ic i an f ol l ow s t h i s c ha n ge a nd co n ti n u es ho l di n g u n ti l n o fu r th e r e vi d e nc e o f c r e ep oc c ur s . T h er e m a y b e a nu mb er of co mp li a nc e c h a ng e s ( cr e e p) be f or e th i s p he n o me n on s t o p s . 9. The p hy s ic i an r ee v al u at e s t h e t is s u e t o d et e r mi n e whe t h er th e t i s su e 's c om p l ia n ce an d qu a li t y h a ve im p ro v e d. Th e t e c hn i qu e m a y b e r e pe a t ed at th e s am e ar e a o r a n ot h er , a n d f o ll o w- u p v i si t s ma y b e p re s c ri b ed fo r a 3 -d a y i n te r va l o r l o ng e r, de p e nd i ng on p at i en t r e a c t i vi t y . B ec a u se of th e va r io u s t i s s u e l ev e l s e nc o un t e re d a n d t h e p ro x im a l -t o -d i s t a l r el a t io n sh i ps ( te n se g ri t y ) a s s o ci a t ed wi t h t h e s om a ti c dy s fu n c t i o n, th e re may be c ou n t le s s way s in wh i ch t o t ou c h a n d p os i ti o n t h e p at i e nt wh e n i mpl e me n ti n g myo f a s c i al re l e as e t e ch n i qu e . We h a ve de s cr i b ed a n um b e r o f c om mo nl y u s ed t ec h n iq u es bu t ha v e a ls o il l us t ra t e d man y o t h er s w i th o u t t he de s c ri p ti v e t e x t be c au s e t he p hy s ic i an may fo l lo w th e g u id e l in e s a nd d ev e lo p a p ar t ic u la r s t r at e gy o r t re a tm e n t p ro t o co l t h at b es t s u it s th e p a ti e n t . P. 1 18

Cervi cal Region: S upi ne Cradling

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1. The pa tie n t lie s supi n e and th e physician sits at the he a d o f the ta ble . 2. The physician 's han ds are pla ced pa l ms up und er the patien t's articu lar pro cess (pi lla r) a t the level of the dysfun cti o n (Fig. 8.1 ). 3. The ph ysi cian lifts upw a rd into the patien t's posterior cervical tissue s w i th onl y e nou g h force to control the skin a nd und erl yin g fascia , so as to not sl ide the han ds acro ss the pa tie n t's ski n. 4. The ph ysi cian mon ito rs inferi or a nd sup eri or, left and ri ght circumfere nti al rotati on, and

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Figure 8.1 . Step 2, arti cul ar pro cesses.

Figure 8.2 . Step 4, mee ting th e b a rri ers.

Figure 8.3 . Step 5, ind i rect b arri er.

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Thoracic Region: Thoraci c Inlet and Outlet, S eated Steering Wheel

1. The pa tie n t i s sea ted . Th e physician sta nds be h ind the pa tie n t. 2. The ph ysi cian pla ces th e han ds pal ms dow n o ver the sho uld er, pro ximal to the cervicoth o racic jun cti on a t the ang le of the neck a nd sho uld er g ird le (Fig. 8.4 ). 3. The ph ysi cian pla ces th e thu mbs ove r the posterior first rib re gio n , a nd laces the ind ex and th ird dig its immedi ate l y sup eri or a nd inferi or to the cla vicle a t the ste rno cla vicu lar joi ns bil a terall y (Fig. 8.5 ). 4. The ph ysi cian lifts upw a rd into the pa tie n t's posterior cervical tissues

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Figur e 8 .4. Ste p 2 .

Figur e 8 .5. Ste p 3 .

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5.

6.

7.

8.

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with o nly eno ugh fo rce to con tro l th e skin and un derl yin g fascia so as to not sl ide across the pa tie n t's ski n. The ph ysi cian mon ito rs inferi or a nd sup eri or, left and ri ght circumfere nti al rotati on, and torsio nal (tw isting ) motion ava ila bil i ty for ease-b ind symmetric or asymme tri c rel ati ons. After determini n g the pre sen ce o f a n ease-b ind asymme try, th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r, respective ly. The fo rce is app lie d i n a very g entl e to mod era te man ner. The ph ysi cian wil l conti nue thi s u nti l a

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rel ease i s pal pated (facial cre ep) an d con tin ue to fol low th i s cre ep unti l i t doe s n ot recu r. Thi s i s h e ld for 20 to 60 second s o r un til a rele ase is pal pated. Dee p inh ala tio n or oth er rel e ase enh ancing mechan isms can be he l pfu l.

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Thoracic Region: P rone

1. The pa tie n t l ies pro ne on the tre atment tab le. 2. The ph ysi cian sta nds be side the pa tie n t, sli ghtly ceph ala d to the il i ac cre sts. 3. The ph ysi cian pla ces bo th han ds pal ms dow n w ith the fin gers sl igh tly spread ap a rt immedi ate l y

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Figure 8.6 . Step 3.

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4.

5.

6.

7.

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parasp ina l on each side (Fig. 8.6 ). The ph ysi cian imp arts a dow nwa rd force into the p ati ent's tho racic tissues with o nly eno ugh force to control the skin a nd und erl yin g fa sci a so as to n ot sli de across th e patien t's ski n. The ph ysi cian mon ito rs i nfe rio r and su peri or, le ft and ri ght circumfere nti al rotati on, and torsio nal (tw isting ) mo tio n ava ila bil i ty for ease-b ind clo ckw ise and cou nte rcl o ckw ise rel ati ons (Figs. 8.7 and 8 .8). After dete rmi nin g the prese n ce of an ease-b i nd asymme try, th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r, respective ly. The fo rce is app lie d i n a very gen tle to

Figure 8.7 . Step 5, infe rio r a nd supe rio r barriers.

Figure 8.8 . Step 5, circumfere nti a l barriers.

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mod era te man ner. 8. Thi s i s h e ld for 20 to 60 seco nds or until a re lea se is pal pate d.

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P elvi c and Sacral Region: Bi lateral Sacroili ac Joint wi th Forearm Pressure, Supine

1. The pa tie n t lie s supi n e and th e physician sits a t th e sid e o f th e patien t a t the le vel of the mid femur to kne e. 2. The physician asks the patien t to ben d the pro ximal kne e so th e physician 's cep hal ad han d can intern all y rotate th e hip un til the pel vis comes off

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Figure 8.9 . Step 3.

Figure 8.1 0. Step 4.

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the ta ble . 3. The physician 's oth er han d is pla ced pal m u p und er the sacrum (Fig. 8.9 ). 4. After return ing the hi p to neu tra l, the physician pla ces th e oth er forearm a n d han d o ver the an teri or sup eri or ili ac spi n es (ASIS) of the patien t's pel vis (Fig. 8.1 0). 5. The physician lea ns dow n on the elb ow of the arm th at i s con tactin g the sa cru m, kee pin g th e sacral ha n d rel axe d a n d with the forearm mon ito rs for ease-b ind asymme try in left a n d

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Figure 8.1 1. Step 5.

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rig ht rotati on (Fig. 8.1 1 ) and le ft a nd rig ht torsion . 6. After determini n g the pre sen ce o f an ease-b ind asymme try, the physician wil l e ith e r ind ire ctl y or directly mee t the ease-b ind barrie r, respective ly. 7. The fo rce is app lie d i n a very g entl e to mod era te man ner. 8. Thi s i s h e ld for 20 to 60 second s o r until a rel ease i s pal pated.

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Lumbosacral Region: P rone

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1. The pa tie n t l ies pro ne. Th e physician sta nds beside th e patien t. 2. The ph ysi cian pla ces on e ha nd ove r the i nfe rio r lumbar se g men t (e.g., L4 -L5) an d the other ove r the su peri or lumbar se g men t (e.g., L1 -L2) (Fig. 8.1 2 ). 3. The ph ysi cian mon ito rs i nfe rio r and su peri or gli de, le ft a nd rig ht rota tio n, and cl ockw ise and cou nte rcl o ckw ise motion ava ila bil i ty for ease-b ind asymme try (Fig. 8.1 3). 4. After dete rmi nin g the prese n ce of an ease-b i nd asymme try, th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r, respective ly. 5. The fo rce is app lie d i n a very gen tle to

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Figure 8.1 2. Step 2.

Figure 8.1 3. Step 3, ea se-b ind asymmetry.

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E xtremities: I nterosseous Membrane, Seated

1. The pa tie n t i s sea ted or sup ine . The ph ysi cian sta nds or sits i n fro nt and to the sid e o f th e patien t o n th e affected side . 2. The ph ysi cian pal pates the affected fore arm ove r the intero sse o us membra ne a nd notes any evi den ce o f a tau t, fib rous ban d, pai n , o r ease-b ind tissue ela sti city asymme try. 3. The ph ysi cian pla ces th e thu mbs ove r the anteri or dysfun cti o nal asp ect of the intero sse o us membra ne w ith the pa lm a nd fin gers e n circli ng the fo rea rm (Fig. 8.1 4). 4. The ph ysi cian mon ito rs cep hal ad a nd cau dad , l e ft and

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Figure 8.1 4. Step 3.

Figure 8.1 5. Step 4.

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rig ht rota tio n, and cl ockw ise and cou nte rcl o ckw ise motion ava ila bil i ty for ease-b ind asymme try (Fig. 8.1 5). 5. After dete rmi nin g the prese n ce of an ease-b i nd asymme try, th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r, respective ly. 6. The fo rce is app lie d i n a very gen tle to mod era te man ner. 7. Thi s i s h e ld for 20 to 60 seco nds or until a re lea se is pal pate d.

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E xtremities: S upine Leg Traction

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1. The pa tie n t lie s supi n e on the tre atment tab le and the physician sta nds at the patien t's fee t. 2. The physician 's han ds (pa lms up ) rea ch und er and con tro l th e patien t's Ach ill es and cal can eal reg ion . 3. The physician lifts both low er leg s to 20 to 3 0 deg ree s o ff the ta ble (Fig. 8.1 6 ). 4. The physician gen tly lea ns backwa rd, add ing sli ght tra cti on throug h th e leg , to

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Figur e 8 .16 . Step 3.

Figur e 8 .17 . Step 4, tra ctio n thro u gh the l eg.

Figur e 8 .18 . Step 5, inte rna l a nd e xte rnal ro tati on; ab duction an d

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P. 1 25 P. 1 26 P. 1 27

Myofasci al Rel ease Techni ques

Fig ure s 8 .20 to 8.3 0 show the con tin ued pri nci ple s of myo fascia l rel ease (d ire ct, ind ire ct) but are wi tho u t wri tte n descri pti o ns. Just u se the arrows as a gui de to the man y vecto red force app licati o ns tha t can b e effective for tre atment of the pi ctu red reg ion .

Figur e 8 .20. Stern o cla vicula r jo int an d a rm traction .

Figur e 8 .21. Lo ng a xis re lea se.

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Figur e 8 .22. Scale n e rele ase .

Figur e 8 .23. Stern a l rele ase .

Figur e 8 .24. Th ora colu mba r re lea se.

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Figur e 8 .25. Il ioti bia l b and – ten sor fa scia l a ta rel e ase .

Figur e 8 .26. Sa cro coccyge al rele ase .

Figur e 8 .27. Ischi o rectal fo ssa (pe lvi c d i aph rag m) rele ase .

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Figur e 8 .28. Pl anta r fascial rel ease.

Figur e 8 .29. Su bma n dib ula r re lea se.

Figur e 8 .30. Hyoid rel ease.

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References

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1 . W a rd R ( e d) . F o u nd a ti o ns f or Os t eo p a th i c Med i c in e . P hi l a de l ph i a: L ip p in c ot t Wi ll i am s & Wil k in s , 2 0 03 .

2 . G r ee n man P. Pr i n ci p le s o f Ma n ua l M e d ic i ne . P h i la d el - ph i a : L ip p in c o t t Wi l li a ms & Wi lk i ns , 20 0 3.

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9 Counterstrain Techniques Techni que Pri nci ples C ount ers tra i n t ech niq ue w as pro pose d b y L aw re nce H. J on es, DO , FA AO ( 19 12–1 996 ) . J one s i nit i all y bel ie v ed th at a pa tie nt c oul d b e pl ace d i n a pos i ti on o f c omf or t s o as to a l le v ia te t he s ym ptom s . Aft er notic i ng a dr am ati c c l i ni c al re s pon s e, he s tu die d t he n atu r e of m usc ulo s k el eta l d y s fu nct i on s an d deter m in ed that te nde r po i nt s c ould be el i c it ed by pr od din g w i th the fi nger tip (1 ) . T hes e t ende r p oin ts w er e eve ntu al ly co l la ted i nt o l oc al ar eas of ten der ness , w hic h ar e r ela ted to s eg m ent al and m us cu l ot end i nou s a r ea s of so m at i c d y sf unc ti on . T end er p oin ts ar e usu all y fo und wi thin te ndi nous attac hme nts , th e b ell y of a m us c l e, an d o ften li gam ents . T hey are de s cr i bed as di s c re te poi nts abo ut the s i z e of a f i nge r ti p t hat are ex quis i te l y tend er, te ns e, an d e dema tou s ( 2) . T he pa ti en t m ay not hav e c onsc i ou s p ai n at the ten der po i nt l oc ati on, and th e ar ea i mm edia tel y s ur ro und i ng the te nde r po i nt , w hen pal pa ted , i s re l at i ve l y n orm al and pai nle s s i n c omp ar is on. Te nder po i nt s ma y b e r el at ed to the tri gge r poi nt s p r op os ed by Si m on and Tr av el l ( 3) but are ge nera l ly di s c us s ed as s ep ara te enti tie s i n th e os teo pat hic c om m un i ty . T hi s tec hni que has be en r efe r re d to as st r ain an d c ount ers tra i n, s tr ain /c ou nte r st r ain , s pon tane ous r el ea s e by posi tio nin g, a nd J on es t ech niq ue. T he Ed uc at i on al C oun c il on Ost eop ath i c P r in c ip l es ( EC OP) has d efi ned thi s t ech ni qu e a s “ a sy s te m o f di agn osi s an d t r ea tm en t t hat c on s id ers the dy s fu nc ti on to be a c onti nui ng, i na ppr opr i ate st r ai n re fle x , w hic h i s i nhib i te d b y ap ply i ng a p osi tio n of mi l d s tra i n i n the di r ec tio n e x act l y opp os it e t o t hat of the r ef l ex ; t hi s i s acc om pa nie d b y sp eci fic dir ect ed posi tio nin g ab out the p oin t o f te nde r ne s s t o a c hi ev e the de s i re d t her apeu tic re s pon s e. ” T here ar e m any pos tul ates as to how t he tec hniq ue w or k s , but mo s t i nvo l ve the al pha Ia aff ere nt a nd gam m a e ffe r en t re l at i on s hip s a nd noc ic ept i on ( 1, 2). Th er e m ay be oth er asp ec ts at pl ay , i nc l ud i ng the Go l gi ten don org an, bi oele c tr i c pheno m en a, and flu i d as pe c ts , s uc h as the l ym pha tic s an d i nte r s ti tia l f l uid ex c ha nge. J ones po s tu l ate d a me c han i sm of i nj ury co nc er nin g t hese te nde r po i nt s a nd t heo r iz ed h ow the tec hni que el i ci ts the app r op r ia te r esp ons e ba s ed on the pr evi ousl y m ent i one d p hys i olo gic pr i nci ple s . T hes e i dea s w er e des c ri bed as fol l ows (2 ) :

1. An eve nt p r od uce s ra pid le ngth eni ng of a mu s cl e. 2. Aff ere nt f eed bac k in dic ate s po s si ble m yo fas c ia l da m ag e f r om a s tra i n. 3. T he bo dy t r ie s t o pr eve nt the m yo fas c i al da m ag e by ra pid l y c ont r ac ti ng th e m y ofa s ci al ti ss ues aff ect ed ( s ho r te ni ng th e a goni s t) . 4. T hi s l engt hen s t he a nta gon i s t m us c le . 5. It i s pr op ose d t hat the ra pi d s ho r te ni ng of th e ag oni s t and l en gth enin g o f t he a nta gon i s t tog eth er pro duc e an in app r opr i at e r efle x t hat i s m an i fe s ted as a tend er poi nt i n t he anta gon i st m us c le .

In cl i ni c al exa m in ati on, thi s o ften pr ese nts as a t ende r p oin t on th e o pen- fac ete d (s tre tch ed) s id e o f th e dy s fu nct i on al s egm ent . Fo r e x am pl e, a C 5, F SR R R dys func tio n w i l l m os t f r equ ent l y ex hi bit a tend er

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poi nt on th e le ft s id e of th e p atie nt' s c er vi c al sp i ne. Th ere fore , w i th a F SRR R d y s fu nct i on , th e r i gh t si de i s fa c et cl os ed an d t he l eft si de i s f ace t op ene d. J ones be l ie v ed tha t p utti ng the j oi nt i nt o it s p osi ti on of gr eate s t c om fort wo uld r ed uce th e co nti nui ng i napp r op r ia te p r op r io c ept or act i v it y . As Gl ov er and R en nie re port , J one s ma de ano ther di s co v ery : t he anter i or as pect s o f t he b ody mu s t b e e v al uate d e v en i f the sy m pto m s are pos ter i or ( 2, 4). Jo nes ev ent ual l y m app ed m an y lo c al ar eas of ten dern ess to w hi c h he r ela ted se gm en tal an d/or my ofa s c ia l dy s fu nct i on . Hi s t end er p oin t l oc at i on s a nd t hei r r el at i on to dys fun c ti on d o n ot ty pi c al l y us e the x- , y- , and z - ax i s para m et ers of fle x io n an d e x te ns io n, r ot atio n, P.13 0 and s i de be ndin g t hat are co m mo n to ar tic ul ar , p osi ti on al, an d mo tio n-b as ed de fin i tio ns of s oma tic dy s fu nct i on ( de s cr i bi ng m oti on r est r ic tio n an d a s ym m etr y ). As c ou nte r st r ain is al s o u s ed fo r mu s cu l ar ( m y of asc i al ) dy s fu nct i ons an d t here ar e o v erl aps be tw ee n t he tw o typ es of d y sf unc ti on s , ten der poi nts c an b e c onf us ed wi th one ano the r . T his ha s ca use d s om e c on fus i on, an d t er ms li k e m ave r ic k t ende r poi nt s h ave bee n u s ed to r es olv e th e f act tha t t he c l as s ic po s i ti on doe s no t a l wa y s e l im i na te t he ten der poi nt . F or ex am ple , a hyp ert oni c de ep c er v i ca l m usc l e m ay be tend er i n an a r ea si m i la r t o t hat of the r efle x t end er p oin t f r om an art i c ul ar c er v i ca l d y sf unct i on . B ut t he pos i tio ns to al le v ia te the pai n m ay b e oppos i te ea c h o the r . T her efo r e, r ec ogn i zi ng t his fa c t s hou l d dr am ati c al l y r edu c e the per c ep ti on of m av er i ck te nder po i nt s , a nd the phy s ic i an ' s u nde r st andi ng of tend er poi nts s ho uld i nc l ud e a nd r eco gni z e the s pec i fi c mu s cl e– tend er poi nt r ela tio ns a s w ell as the ar ti cu l ar re l ati ons . J ones re fer s in so m e ar ea s to sp eci fic m us c le s , y et i n the v er teb r al r eg i on s h e se ems to s ta y m ore foc use d o n ar tic ula r sp i na l s egme nta l l ev el s o f d y s fu nct i on . Anoth er c ri teri on tha t we fi nd c l in i ca l ly i mp ort ant i n thi s t ec hn i qu e i s pr ope r a s s oc i at i on of the dy s fu nct i on pat ter n t o th e t r ea tm en t p osi ti on in th e va r io us ar ti c ul ar ty pe s o f d y s fu nct i on s . N eut r al and nonne utr al dy sf unc tio ns ( typ es 1 an d 2 , r es pe c ti v el y ) m ay hav e sp eci fic ten der po i nts an d p os it i on s t hat al l ev i at e t he t end er poin t. Yet i n m os t p ubli s he d t ex ts (1 ,2, 4,6) th ere i s l it tle m en tio n o f th e c han ge i n pos it i on fo r op pos i te - s id ed c ou pl in g ( typ e 1) an d s am e- s id ed c oup l in g ( ty pe 2) of r ot ati on and s id e bendi ng. Th e mo s t w id es pr ead id ea i s t hat fle x io n d y s fu nct i on s pr odu c e ante r io r t ende r p oin ts a nd ex ten s io n d y s fu nct i on s pr odu c e post eri or tend er poi nts. Ho w ev er , i n w hi c h d i re c ti ons do the neu tra l dy s fu nct i on s ex hib i t tend er poi nts? Ov er m any ye ars of tea c hi ng o s te opa thic ma nip ul at i ve me di ci ne i n the l abo r at or y at Phi l ade l ph i a C oll ege of Ost eop ath i c M edi c in e as we l l as i n o ur Euro pea n o s teo pat hic s em in ars , w e ha v e don e a num ber of s ma l l, non bli nde d su r ve y s of t he c la s s a tte nda nts w he n t each i ng thi s s ub j ec t. F r om ou r li m it ed fi nd i ng s , w e b eli eve tha t n eut r al dys fun c tio ns c an pro duc e a nter i or an d pos te r io r t ende r p oin ts . T hi s m ay b e a n a r ea of fur ther st udy and po ten ti al re s ea r c h. R ev ie w o f t he m any po s i ti ons fo r co unt ers tr ai n t r ea tm en t s how s th at s om e po s it i on s ar e e x am pl es of tr eat m en t o f ty pe I d y s fu nct i on s [e .g. , s i deb end to w ard , r ota te a w ay (S T R A) ] a nd othe r s are exa m pl es of tr eat m en t o f ty pe II dy sf unc tio ns [ e.g ., s i de ben d a w ay r ot ate awa y ( SAR A) ]. Th e m os t i mp ort ant asp ect of an y t ech ni qu e i s t he d i ag nos i s . W it hou t a pro per dia gno s is , th e d ete r m in ati on of t he k ey dys fun c ti on, and w het her the pr i ma r y c omp one nt i s a r ti c ula r , m yo fasc i al or bot h, the tre atm ent w il l b e l es s tha n optim al.

Techni que Cl assi ficati on I ndirect In co unt ers tr ai n t ech ni qu e, the i nd i re c t pati ent po s i ti oni ng m ay be i n r esp ons e t o an ar tic ul ar dy s fu nc ti on w i th i ts x- , y- , a nd z - ax es of m oti on fre edom . T he pati ent ma y al s o be pl ac ed i n ease as s oc i ate d w i th a

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m y ofa s ci al ease - bi nd r ela tio nsh i p. T he ph y s ic i an sh ould kn ow, pri or to posi tio nin g th e p ati ent, wh eth er the d y sf unc ti on is ty pe I or II and /or wh ethe r t her e is a pri m ary or se c ond ary my ofas c ia l c om po nen t ( e.g. , p s oa s hy per ton i c it y c aus i ng l um bar s ym pto m s) , as th e p os it i on ma y va r y acc or di ngl y .

Techni que Styles Ti m e Defi ned or Rel ease Defined T he p hys i ci an m ay use a t i me - de fi ne d m eth od, i n w hi c h t he tre atme nt pos i tio n i s h el d for 90 s ec ond s a nd then r ep osi ti on ed to the neu tra l st art i ng pos i ti on for r ea s se s s me nt. Al tern ati v el y , t he phy s i ci an m ay use a pal pat ory m ar k er of tis s ue re l eas e, w hi c h m ay occ ur p r io r t o th e 9 0-s ec on d t i me - def i ne d m ar ke r . Aft er feeli ng a s ense of re l eas e, r el ax at i on , p ul sa tio n, or s i mi l ar phe nom eno n, t he phy s i ci an m ay for go the ti m e def i ni ti on an d r epos i ti on the pat i en t fo r r eas s ess m en t.

I ndications 1. Acu te, s ub acu te, and ch r on i c s oma tic dys fun c ti ons of art i c ul ar and /or m yo fas c i al or i gi n 2. Adj unc ti ve tr eat m ent of sy s tem i c c om pl ai nts wi th a s so c ia ted s om ati c dy s fu nct i on ( e. g., v is c er os om ati c r efle x c aus i ng r ib dy s fun c ti on)

Contraindications Absolute Contrai ndi cati ons 1. T ra uma ti ze d ( s pr ai ne d o r s tr ai ned ) t i s su es, wh i c h w ou l d be n ega tiv el y aff ect ed b y t he posi tio nin g of the pat i en t 2. Sev ere i ll nes s i n wh i ch st r i ct po s it i ona l r est r i ct i on s p r ecl ude tr eatm ent P.13 1 3. Ins tab i l it y o f t he a r ea be i ng pos i ti oned th at has the po tent i al to pro duc e u nw an ted ne ur ol ogi c o r v as c ul ar s i de ef fect s 4. Vas c ul ar o r n eur ol og i c s yn dr om es, su c h a s b asi l ar i ns uff i c ie ncy or neu r of ora m i na l c omp r omi s e w he r eb y th e p osi ti on of tr eatm ent ha s th e p ote ntia l t o e x ace r ba te the c on dit i on 5. Sev ere deg ene r at i v e s po ndy l osi s w i th l oc al fus i on and no m ot i on at the le v el w he r e tre atme nt pos i ti onin g w oul d no r ma l ly tak e p l ac e

P recautions 1. Pat i en ts w ho c an not v ol unt ar il y r ela x , s o t hat pro per po s i ti oni ng i s d i ff i cu l t 2. Sto i c pati ent s w ho c ann ot di sc ern th e le v el of pai n o r i ts c han ge s eco nda r y to p osi tio ni ng 3. Pat i en ts w ho c an not und ers tand th e i ns tr uct i on s an d q ues ti on s o f t he p hys i ci an ( e.g ., pati ent 6 m on ths of age )

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4. Pat i en ts w i th co nnec tiv e t i s su e d i se as e, ar thr i tis , P ark i nso n d i se as e, an d s o on , i n w hom pos i ti onin g f or tend er poi nt p ain re duct i on ex ac er bat es the dis tal c on nec tiv e ti s su e o r ar thr i ti c pro ble m or no mo ti on is av ai la ble fo r po s it i on i ng

General Consi derati ons and Rules T he p hys i ci an m ust as c ert ain th e so m at i c dy sf unc tio n, i ts s ev er it y , i ts tis s ue lo c ati on and typ e, and w heth er any of the s e pr ec aut i on s or co ntr ai nd i ca tio ns a r e pre s ent . I f w ar ra nte d, the fol l ow i ng s eq uen c e i s ne c es s ar y :

1. F in d t he m ost si gnif i ca nt tend er poi nt w i th th e pa tie nt i n a ne utr al , c om for tabl e p osi ti on . a. Loc at e o ne or m ore te nder po i nt s as s oc i at ed w i th th e pr evi ous l y d i ag nos ed s oma tic dy s fu nct i on by tes tin g wi th a f ew o unc es of f i rm bu t di s cr eet fin ger pa d or th umb pr ess ure . N o ci r cu l ar m ot i on sh ould be pa r t o f t his pre s su r e; i t i s s tr ai gh t i nto the te nde r poi nt . b. If mu l ti ple ten der po i nts ex i st , tr eat th e mo s t pai nful fi r st . Wh en s ev er al te nde r po i nt s l i e i n a r ow , f i r st tr eat the on e i n th e m i dd l e. In add i tio n, tre at p r ox i ma l be for e d i s ta l ( 2). c. Quant i fy th e te nde r p oi nt ' s pai n le v el fo r th e p ati ent as 100 % , 1 0, or a mo net ary uni t s uch as $1 . W e h av e fou nd that th e m onet ary un i t w ork s b es t i n the tea c hi ng of c oun ter s tra i n, as ph y si c ia ns a nd phy s i ci ans in tra i ni ng tend to co nfus e t he anal og pai n sc ale , i n wh i ch the p ati ent i s ask ed to g aug e t heir pa i n on a sc ale of 0 t o 1 0, w i th th e as s ig ned pai n o f 1 0. W i th use of the an alo g sc ale , t he t end enc y is to as k , “ W ha t i s yo ur pai n?” i ns tea d of s ay in g, “ Th i s p ain is a 1 0.” Wi th t he m on etar y s c al e th i s doe s no t o c cu r . 2. Slo w ly and ca r ef ul ly pl ace the pa tie nt i n t he posi tio n o f ea s e or opti m al co m for t. a. F i r st ob tai n a gro s s r edu c ti on of t end ern es s i n the typ i ca l p os it i on re c omm end ed for the l ev el of dy s fun c ti on and ten der poi nt l oc atio n a nd then fi ne- tune th r ou gh s m al l a r c s of m otio n u nti l th e t end er ne s s ( pa i n) i s c om pl et ely al l evi ate d. b. If th e t end er p oin t c anno t b e e l i mi nat ed, a 7 0% r ed uc ti on of pain ma y b e ac c ep tab l e f or tr eat m en t e ffec t. H ow ev er , f or ev er y a s ce ndin g n ume r i c l ev el of p ain th at r ema i ns , an as s oc i at ed 10% of tre atme nt eff ec ti v en ess i s l os t. F or exa m pl e, i f t he tend er poi nt i s r educ ed onl y by 70 % , ther e i s o nl y a 7 0% pote nti al for a g ood tre atm ent eff ect . A ny th i ng l es s tha n 7 0% r edu c ti on c aus es an e v en gr eate r p ote ntia l f or tr ea tme nt fail ure . T here for e, the g oal is 100 % p ain r ed uct i on by pos i ti onin g w hen ev er po s si bl e. c. In ge ner al, ant eri or poin ts r eq ui re so m e l eve l o f f l exi on, de pend i ng on the se gme ntal le v el i nv ol v ed , a nd p ost eri or p oin ts r equ i re so m e l eve l o f ex ten s io n, d epe ndi ng o n t he s egm ent i nv ol v ed . d. As te nde r p oi nt s m ove awa y f r om the mi dli ne, the gr eate r t he poss i bi l it y fo r n ece s s it y o f m or e s id e b endi ng. Ho w eve r , the nat ure of the dy s fu nc ti on ( ty pe I or II ) an d i ts m oti on par am ete r s di ct ate th e pr ope r p os it i on i ng . 3. M ai nta i n t he pos i tio n f or 90 s eco nds . It ha s b een r ep ort ed t hat 12 0 se c on ds i s n ece s sa r y f or c os tal dys fun c ti ons. Pe r so nal c om m un i c at i on wi th v ari ous m em ber s o f EC OP and w it h t hos e wh o w or k ed c lo s el y w i th J on es s how s t hat c os tal dy s fun c ti ons als o t ake 90 s ec ond s . J one s b el ie v ed

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tha t t he p osi tio ns f or tre atme nt of c ost al dys func tio ns c aus ed the pat i en t t o be un abl e to ea s il y r el ax, and th ere fore , h e g av e the m a n ad dit i on al 3 0 s eco nds to r el ax . T he r ef or e, th e 1 20-s eco nd per i od has be en pr om ote d a s th e c l as s i ca l ly de s c ri bed P.13 2 tim e-d efin ed m et hod for ri b dy s fu nct i ons , w her eas c li nic al ly , 9 0 s ec on ds w il l su ffi c e. In our han ds and exp eri ence , t he ti me - de fin ed m eth od w ork s b ett er t han fe el in g f or a ti s su e r el ea s e. We bel i ev e th at J on es 's at tem pts at v ar i ous ti m e i ncr eme nts and hi s c oncl usi on that ho l di ng t he pos i ti on f or 90 s eco nds wa s th e m ost eff ect i ve m et hod mu s t h ave a r eas on. We bel i ev e t hat m os t pro ble m s d i ag nos ed a nd s uc c ess ful l y tr ea ted wi th t his te c hni que in v olv e t he r ese tti ng of neu r ol ogic fe edb ac k m ec han i s ms ea r li er i den tif i ed, an d t hat use of the s e m ec hani s ms re quir es an opt i m um am oun t of ti m e to a c hi eve the de s ir ed c l in i ca l ou tco m e. Oth er tec hniq ues th at m ay app ear s im i la r t o co unt ers tr ai n ( e.g ., f aci l it ated po s it i ona l r ele as e) us e d i ffe r en t r el eas e- en han c in g me c ha nis m s , and so the y c ann ot b e c omp ar ed ex act l y w i th co unte r st r ai n. 4. W hi l e m ain tai nin g th e e ffe c tiv e p osi ti on , t he fi ng er pad s ho uld re m ain at th e si te of the ten der poi nt for the en ti re tr eat m ent pe r io d wh ene v er pos s ib l e, s o the ph y s ic i an ma y in ter m it tent l y thr oug hout th e t r eat m en t p er io d ( per haps ev ery 30 s ec ond s ) r ech eck the le v el of pai n a t th e ten der poi nt. a. T he f i ng er pad i s not put tin g a ny t her ape utic pr ess ur e i nt o t he t i ss ues . b. If th e f i ng er p ad i s r emo v ed , t he p hys i ci an l ose s c ontr ol of the ten der poi nt, re nder i ng th e ev alu ati on us el ess , a s th e t end er p oin t l oc at i on ma y no t b e e x act l y r el oc at ed. Al s o, the patie nt oft en d oes no t be l ie v e the phy s ic i an i s on the ori gin al t end er poin t a nd m ay quest i on th e ex act lo c ati on of the m on i to r i ng fi nge r . I f k eep i ng v ig i la nt a t t he s i te , y ou c an c onfi den tly ass ure th e pa tie nt that yo u a r e i nde ed on t he ori gi na l s i te . c. Al s o, if us i ng the ti s s ue re l ea s e m ark er i nst ead of tim e, the phy s ic i an m us t h ave the fi nge r p ad on t he ten der poi nt s i te to co ns ta ntl y s ense th e t i s su e r eac ti on . 5. Aft er 90 s eco nds ( ti m e- def i ned tr eat m ent ) o r w hen tis s ue app ear s t o re l ea s e ( r el eas e-d efin ed tre atm ent) , s l ow l y r etu r n the pas s iv e pa tie nt thro ugh a path of le as t r es i st ance to th e or i gi nal neu tra l po s it i on i n w hi c h the ten der poi nt w as eli c it ed. T he pa tie nt m ust no t he l p, so i f y ou fe el tha t t he p ati ent i s hel pin g yo u, s to p an d a s k hi m or her to r el ax. 6. R ec hec k th e t end er p oin t. If t he ten der poi nt w as r ed uce d to ze r o i nit i al l y, the r e i s a go od c ha nc e tha t i t wi l l r em ai n at z er o. I t i s p os si ble , h ow ev er, th at t he pai n wi l l ele v ate so m ew hat pos t tre atm ent. If th e po s tt r ea tm en t p ain i s r at ed at 3 co m pa r ed to the ori gin all y as s ig ned l ev el of 10 pri or to t r ea tme nt, 70% ef fect i ve nes s wa s a c hi ev ed in on l y 9 0 s eco nds. Th e e ffec t m ay c ont i nu e to i mp r ove th e p atie nt' s s y m pt oms ov er t i me , o r th e p ati ent m ay ne ed f oll ow up i n a fe w da y s for r ee v al uati on and tre atm ent . 7. R ec hec k th e s oma ti c dys fun c tio n p ara m ete r s ori gi na l ly pr es en t ( e.g ., t he s eg m ent al or m yo fas c i al dy s fu nc ti on) .

T h e s h or t ha n d r u le s a r e a s f o ll o ws:

1. F in d t he t end er poin t a s so c i at ed w it h th e d y sf unct i on . 2. T el l t he p ati ent the te nde r po i nt is a 1 0 o r 1 00 o r a do l l ar ' s w or th o f p ain .

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3. Pla c e the pat i en t in th e p os it i on th at r edu c es the pa i n of t he ten der poi nt 100% (o r a t le ast 70 % ) . 4. H ol d t hi s pos i ti on f or 90 s eco nds . 5. Slo w ly , th r ou gh a pa th of l eas t r esi s tan c e, re turn th e r el ax ed pat i ent to ne utra l . 6. R ec hec k th e t end er p oin t a nd t he oth er s oma tic c om pon ent s of th e d y s fu nct i on ( TA R T) .

Pos tt r ea tme nt r eac tio n ma y i ncl ude gen era l so r en ess thr oug h t he f oll owi ng 2 4 t o 4 8 ho urs . T hi s i s unusu al i n our c li nic al e x pe r ie nc e but ha s be en r ep or te d b y o ther s ( 1). T re ati ng m ore th an s i x ten der poi nt s a t o ne v i si t a ppea r s to be c orr ela ted to thi s re act i on . If th i s oc cu r s, in s tru c t the pat i en t t o in c re ase fl uid s a nd us e i ce pa c k s ove r t he s ore ar eas for 15 to 20 m in utes ev ery 3 h our s a s ne ede d. T r ea tme nts s houl d b e p r esc r ib ed ac co r di ng to t he phy s i ci an' s c l i ni c al ju dgme nt, bu t 3- day in terv als ar e ap pro pri ate. T he p ati ent ' s r esp ons e wi l l det er mi ne how oft en the pat i en t n eeds tr eat m ent .

Abbreviations for Counterstrain Techni que Yates an d G l ove r i ntr oduc ed a s hort han d d es cr i pt i on tha t m any s tu den ts us e to hel p re m em ber the pos it i on i ng for sp eci fi ca l ly lo c ate d t end er p oin ts. T hi s s hor than d u s es the in i ti al s for ty pes of m ot i ons ( di re c ti ons of m ov eme nt) and up per and lo w er c as e f or g r ea ter and le s se r mo v em ent i n the di r ect i on i dent i fi ed, r es pec tiv el y. Th e c om mo n a bbr ev ia tio ns of t his sh or th and me thod ar e: A, a nte r io r ; P , pos te r io r ; F or f, fl ex io n; E o r e, ex ten s i on ; S R o r Sr , s i de P.13 3 bendi ng r ig ht; SL or Sl , s id e b endi ng l ef t; R R o r R r , r ota tio n ri ght ; R L or Rl , r otat i on le ft; IR or i r , i nter nal ro tati on; ER or er, ex tern al r ot atio n; AB or A b, abd uc ti on; AD or ad, ad duct i on ; S U P o r s up, s upin ati on; and PR O o r pr o, pro nati on. Ot hers ab bre v i at i on s r efer to mo ti on to w ar d (t ) a nd aw ay (a ) a nd obv io us bon y la ndm ark s , s uch as s pi nou s p r oce s s ( SP ) , t r an s ve r s e pro c es s (T P), cr es t ( CR ) , and oc c ip ut ( OC C ) . U pp erc as e l et ter s me an m or e of th at part i cu l ar m ot i on an d lo w er c as e me ans le s s ( 3). P.13 4

Anteri or Cervical Counterstrain Techniques: Anterior Cervical Tender Poi nts Anter i or ce r v ic al ( AC ) co unt ers tr ai n t end er p oin ts ar e out l in ed i n T abl e 9. 1 a nd demo nst r at ed i n F i gu r e 9.1.

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T able 9.1 Comm on Ant erio r Cervical Tender Po int s

Ten der Point

L o cation

Classic Treatm ent Positio n

Acronym

AC1, r otation, unc oupled dy s function

Posterior surface of as cending ramus of mandible between earlobe and angle of mandible ( gonion)

Rotate head away; fine-tuning with s ide bending, us ually away

RA

AC2–AC6, type II dy s function

Anter ior aspect of tr ans ver s e proc ess of dy sfunctional c ervical ver tebra

F lex to level of dy s functional s egment; s ide bend away, rotate away

F SA RA

AC7, type I dy s function of C7 or s ternocleidomastoid

Anter ior at origin of c lavicular division of s ternocleidomas toid muscle, approximately 2 cm later al to s ternoclavic ular joint

F lex to level of C7; s ide-bend toward, r otate away

F ST RA

AC8, type II dy s function of C7

O r igin of sternal divis ion of s ternocleidomas toid muscle at medial head of c lav icle at s ternal notc h

F lex, but les s than AC7; s ide-bend away, rotate away

F SA RA

P.13 5

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Fig ure 9.1. Anter ior cervic al counter str ain tender points (5).

P.13 6 P.13 7

Anteri or Cervical Counterstrain Techniques: AC1

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T he following tec hniques ar e des cribed and illustrated in a s tepwise s equence. We hav e abridged the tex t desc ribing eac h individual tec hnique, as the c ounterstrain s equence is the s ame for eac h dy s function. The unique factor s of eac h dysfunc tion ar e the location of the tender point and the c las s ic tr eatment pos ition. T his firs t tec hnique will illustrate the c omplete c ounterstrain s equence with the unique as pec t of the technique highlighted. All of the following tec hniques will be des cribed with only the information unique to that s pec ific s omatic dy s function and its tender point. T he tender point loc ations ar e a c ompilation of des criptions from J ones and as s ociates ( 1), Rennie and G lover ( 4) , Yates and G lover (6), and our clinical

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F igure 9.2. AC1 tender point loc ation ( 5).

F igure 9.3. AC1: RA.

F igure 9.4. AC1: RA.

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P.13 8

Anteri or Cervical Counterstrain Techniques: AC2 to AC6

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function C2 to C6. T en der Po int L o cation T he tender point is at the anterior as pect of the tr ansv ers e pr oces s of the dy s functional c er vic al ver tebr a ( F ig. 9.6). Probe lateral to medial. T reatm ent Po sition Patient's head and nec k are flex ed to the level of the dy s functional s egment, s ide-bent, and r otated away from the tender point ( F igs. 9.7, 9.8, 9.9, 9.10).

F igure 9.6. AC2-AC6 tender points ( 5).

F igure 9.7. AC4: F SA RA.

F igure 9.8. AC4: F SA RA.

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P.13 9

Anteri or Cervical Counterstrain Techniques: AC7 (S ternocl eidomastoi d Muscl e)

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dysfunction C7 (AC7-type I dy s function C7, or s ternocleidomastoid mus cle dy s function) . T en der Po int L o cation Anteriorly, the tender point lies at the or igin of the c lavic ular divis ion of the s ternocleidomastoid mus cle approx imately 2–3 c m lateral to the s ternoclavic ular joint (F ig. 9.11). Pr obe pos ter ior to anterior. T reatm ent Po sition T he patient's head and neck are mar kedly flex ed to the level of lev el of C7, rotated away , and side- bent toward the s ide of the tender point ( F igs. 9.12, 9.13, 9.14, 9.15).

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Fig u re 9.11. AC7 tender point (5) .

Fig u re 9.12. AC7: F ST RA.

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Fig u re 9.13. AC7: F ST RA ( alternativ e hand plac ement) .

Fig u re 9.14. AC7: F ST RA.

Fig u re 9.15. AC7: F ST RA.

P.14 0

Anteri or Cervical Counterstrain Techniques: AC8

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dysfunction C7 (AC8–type II dy s function C7). T en der Po int L o cation T he tender point lies at the origin of the sternal division of the s ternocleidomastoid mus cle, at the medial head of the c lavic le at the s ternal notc h ( pr ess medial to lateral) (F ig . 9.16). T reatm ent Po sition T he patient's head and neck are flexed ( less than C7), r otated away , and s ide-bent away fr om the side of tender point (F igs. 9.17, 9.18, 9.19, 9.20).

Fig u re 9.16. AC8 tender point (5) .

Fig u re 9.17. AC8: F SA RA.

Fig u re 9.18. AC8: F SA RA.

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P.14 1

P osterior Cervical Counterstrain Techni ques: P osteri or Cervical Tender Poi nts

Pos ter ior c er vic al c ounterstrain tender points ar e outlined in T able 9.2 and demons trated in F ig ure 9.21.

F igu re 9.21. Posterior c erv ical counterstrain tender points (5) .

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T able 9.2 Co mmo n Po sterio r Cervical Ten der Po int s Ten der Point L o cation

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Classic T reat men t Po sition

Acro nym

PC1 Inion

2 cm below inion, pushing later ally into muscle mass

F lexion of oc cipitoatlantal ar tic ulation; additional c ervical flexion may be neces sar y

F

PC1 lateral

Halfway between PC2 and mastoid pr ocess as soc iated with s plenius capitis muscle

Ex tension of oc cipitoatlantal ar tic ulation with mild c ompr ess ion on head to reduc e my ofascial tension of s uboc cipital tissues; s light s ide bending and r otation away as needed

E Sa Ra

PC2 lateral

Within s emis pinalis c apitis musc le as soc iated with gr eater occipital nerve

Ex tension of oc cipitoatlantal ar tic ulation with mild c ompr ess ion on head to reduc e my ofascial tension of s uboc cipital tissues; s light s ide bending and r otation away as needed

E Sa Ra

PC2 midline

Super ior lateral s urface of s pinous proc ess of C2

Ex tension of oc cipitoatlantal ar tic ulation with mild c ompr ess ion on head to reduc e my ofascial tension of s uboc cipital tissues; s light s ide bending and r otation away as needed

E Ra

PC3–PC8 midline

Infer ior sur fac es of spinous

Ex tend to level of dy sfunctional

E Sa Ra

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P.14 2

P osterior Cervical Counterstrain Techni ques: P C1 Ini on

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at C0- C1. T en der Po int L o cation T he tender point lies 1–2 cm below the inion (F ig 9.22). Push anterolaterally into mus cle mass.

F igure 9.22. PC1 inion tender point (5) .

T reatm ent Po sition 1. T he phys ician flex es the patient's head by inducing c ephalad trac tion on patient's occiput while inducing c audad motion on patient's frontal area ( Fig s. 9.23, 9.24, 9.25) . 2. T he phys ician fine-tunes through s mall ar cs of motion ( flexion or extension and minimal s ide bending and/or

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F igure 9.23. PC1 inion: F Sa Ra.

F igure 9.24. PC1 inion: F Sa Ra.

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P osterior Cervical Counterstrain Techni ques: P C1 and PC2

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dysfunction at C1- C2. T en der Po int L o cations PC1 (lateral) , halfway between PC2 and the mas toid proc ess as s ociated with the s plenius capitis mus cle (F ig. 9.26). PC2 (lateral) , within the semis pinalis c apitis musc le as s ociated with the gr eater occipital ner ve. Push anteriorly.

F igure 9.26. PC1–PC2 tender points (5) .

T reatm ent Po sition 1. Patient's head is extended to the lev el of the dysfunc tional v ertebr a; s light occipitoatlantal c ompres s ion may be needed ( Fig s. 9.27 an d 9.28). 2. T he phy s ician fine-tunes through small arcs of motion ( slight side bending and r otation away) . 3. Alternative: Extension,

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F igure 9.27. PC1–PC2: E Sa Ra.

F igure 9.28. PC1–PC2: E Sa Ra.

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P.14 4

P osterior Cervical Counterstrain Techni ques: P C3 to P C7, Mi dline

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function C3 to C7. T en der Po int L o cation T he tender point lies at PC3 to PC7 midline and the inferior sur faces of the spinous pr oces ses of C2 to C7 (F ig. 9.31). T reatm ent Po sition 1. Patient's head is extended to the appr opr iate level ( F igs. 9.32, 9.33, 9.34, 9.35, PC3, PC5, PC5, PC7, r espectively). 2. T he phys ician fine-tunes through small arcs of motion with s light s ide bending and s light to moderate r otation

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F ig ure 9.31. PC3–PC7 midline tender points ( 5) .

F ig ure 9.32. PC3: e Sa RA.

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away .

F ig ure 9.33. PC5: e Sa RA.

F ig ure 9.34. PC5: e Sa RA.

F ig ure 9.35. PC7: e-E Sa RA.

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P osterior Cervical Counterstrain Techni ques: P C3 to P C7, Lateral

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at C3 to C7. T en der Po int L o cation T he tender point lies at PC3 to PC7 pos ter olater al, at lateral s urface of the ar tic ular pr oces s as s ociated with the dy sfunctional s egment ( Fig . 9.36). T reatm ent Po sition 1. T he phys ician extends the head and neck to the level of the dysfunc tional s egment with minimal to moderate s ide bending directed at the segment and minimal to moder ate r otation away ( Fig s. 9.37, 9.38, 9.39, 9.40, PC3, PC3, PC6, and PC6, r espectively). 2. T he phys ician

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F igure 9.36. PC3–PC7 lateral tender points ( 5).

F igure 9.37. PC3: e Sa RA.

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P.14 6

Anteri or Thoraci c Counterstrain Techniques: Anterior Thoracic Tender Poi nts

Anterior thor acic c ounterstrain tender points ar e outlined in T able 9.3 and demonstr ated in Figure 9.41.

F ig ure 9.41. Anterior thor acic c ounterstrain tender points ( 5).

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T able 9.3 Co mmo n Anterior Th oracic Ten der Points Ten der Point

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L ocatio n

Classic Treat men t Positio n

Acronym

AT 1

Midline episternal notc h

F lexion to dy s functional lev el

F

AT 2

Midline, junc tion of manubrium and ster num (angle of Louis)

F lexion to dy s functional lev el

F

AT 3-AT 5 AT 6

Midline at lev el of cor r esponding rib; Midline xiphoid–sternal junc tion

F lexion to dy s functional lev el

F

AT 7–AT 9

AT7: Midline or inferolateral to tip of x iphoid; AT8: 3 cm below xiphoid at lev el of T12, midline or lateral AT9: 1–2 c m abov e umbilic us at lev el of L2, midline or 2–3 cm lateral

F lexion to dy s functional lev el, side bending towar d and rotation away

F St RA

AT 10–AT12

AT10: 1–2 cm below umbilic us at lev el of L4, midline or 2–3 cm lateral AT11: 5–6 cm below umbilic us below level of iliac cres ts at superior L5 level, midline or 2–3 cm lateral AT12: Superior , inner s urface of iliac c res t at mid- axillary line

Hip flexion 90–135 degrees, s light side bending, rotation toward (type I) or s ide bending toward, r otation away ( type II)

F St RT F St RA

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P.14 7

Anteri or Thoraci c Counterstrain Techniques: AT1 and AT2

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1- T2, such as anterior T1- T 2 tender point. T en der Po int L o cations AT 1: Midline in the episternal notch ( F ig. 9.42) AT 2: Midline at junction of manubr ium and s ternum ( angle of Louis)

F igure 9.42. AT 1–AT 2 tender points (5) .

T reatm ent Po sition 1. Patient is s eated on the treatment table with hands on top of the head. 2. Phys ician s tands behind patient and wraps ar ms under patient's axillae and around the c hes t and plac es hands over the manubrium. 3. Patient leans back agains t phys ician's c hes t and thigh,

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F igure 9.43. AT 1–AT 2: F.

F igure 9.44. AT 1–AT 2: F.

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Anteri or Thoraci c Counterstrain Techniques: AT1 to AT6

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1 to T 6. T en der Po int L o cations AT 1: Midline in the episternal notch ( F ig. 9.46) AT 2: Midline at junction of manubr ium and s ternum ( angle of Louis) AT 3 to AT 5: Midline at lev el of c or res ponding rib AT 6: Midline x iphoid–s ter nal junction

F igure 9.46. AT 1–AT 6 tender points (5) .

T reatm ent Po sition 1. T he patient lies supine with the ar ms off the side of the table, and the phys ician's thigh is behind the patient's upper thoracic r egion. 2. While the phys ician's index finger pad palpates the tender point, the patient is elev ated fr om the table with

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F igure 9.47. AT 1–AT 6: F IR ( arms ).

F igure 9.48. AT 1–AT 6: F IR ( arms ), alter native hand placement.

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P.14 9

Anteri or Thoraci c Counterstrain Techniques: AT3 to AT4, Al ternati ve Technique

In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at T 3- T4. T en der Po int L o cation AT 3: Midline on the sternum at the level of the 3r d costal c ar tilage (F ig. 9.49) AT 4: Midline on the sternum at the level of the fourth costal c ar tilage T reatm ent Po sition In this technique the physician may not be able to control the tender point fully thr oughout the tr eatment pr oces s. 1. T he patient s its on the end of the treatment table in front of the phys ician, and the phys ician plac es the

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Fig u re 9.49. AT3–AT4 tender points (5).

Fig u re 9.50. AT3–AT4: F IR (ar ms) .

Fig u re 9.51. AT3–AT4: F IR (ar ms) .

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forearms under the patient's axillae. 2. T he phys ician's forearms gras p the medial s ide of the upper ar ms to induc e internal r otation ( Fig . 9.50). 3. T he phys ician leans forward with the c hes t and abdomen while pulling back war d on the patient's arms to flex the thor acic s pine to the des ired level ( F ig. 9.51). 4. T he phys ician fine-tunes through s mall ar cs of motion ( flexion, minimal or no s ide bending or r otation).

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Anteri or Thoraci c Counterstrain Techniques: AT7 to AT9

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 7 to T9. T en der Po int L o cation AT 7: Midline or inferolateral to tip of xiphoid ( F ig. 9.52) AT 8: 3 cm below x iphoid at level of T 12, midline or lateral AT 9: 1–2 cm above umbilic us at lev el of L2, midline or 2–3 cm lateral

F igure 9.52. AT 7–AT 9 tender points (5) .

T reatm ent Po sition 1. T he patient is s eated on the treatment table with the phys ician s tanding behind the patient. 2. T he phys ician's foot on the s ide opposite the tender point is plac ed on the table with the patient's arm res ting on a pillow on the phys ician's thigh.

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F igure 9.53. AT 7–AT 9: F St Ra.

F igure 9.54. AT 7–AT 9: F St Ra (fine-tune).

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Anteri or Thoraci c Counterstrain Techniques: AT9 to AT12

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 9 to T12. T en der Po int L o cation AT 10: 1–2 cm below umbilic us at lev el of L4, midline or 2–3 cm lateral ( F ig. 9.55) AT 11: 5–6 cm below umbilic us below lev el of iliac c r ests at superior L5 lev el, midline or 2–3 cm later al AT 12: Superior, inner sur fac e of ilia c res t at mid-ax illary line

F igure 9.55. AT 9–AT 12 tender points (5) .

T reatm ent Po sition 1. T he patient lies supine, and the phys ician s tands on either s ide of the patient, for bes t phys ical c omfort and c ontrol, and plac es the c audal foot on the table. 2. T he hips and k nees ar e flex ed to the level of the dysfunc tional

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F igure 9.56. AT 9–AT 12 type I: N ST RA.

F igure 9.57. AT 9–AT 12 type II: F RA SA.

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P.15 2

P osterior Thoracic Counterstrain Techni ques: P osteri or Thoracic Tender Poi nts

Pos ter ior thorac ic c ounterstrain tender points ar e outlined in Table 9.4 and demons trated in Figure 9.58.

Fig u re 9.58. Posterior thor acic c ounters train tender points (5) .

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T able 9.4 Co mmo n Po sterio r T h oracic Ten der Po int s Ten der Point

L o cat ion

Classic Treatm ent Positio n

Acron ym

PT 1–PT 3 ( 4)

Midline, or inferolater al tip of s pinous proc ess ( side opposite r otational c omponent) or over transver se proc ess (on s ide of r otational c omponent)

Prone with ar ms hanging ov er s ides of table. Support patient's head by cupping point of chin; gently extend head and neck to engage dys func tional segment. Avoid prefov erex tending. Rotation and s ide bending minimal.

e-E Sa Rt ( type I) or e-E St Rt ( type II). Depending on phys ician preference, may be opposite ( SARA) c oupling.

PT 4–PT 9

Same as abov e

Same as above, exc ept shoulders may be flexed fully to add extens ion or plac ed at the side to decrease extens ion with phy sic ian controlling shoulder from opposite s ide.

Same as abov e

PT 10–PT12

Same as abov e

Patient pr one with arms at side, phy sic ian controlling pelvis.

Same as abov e

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P osterior Thoracic Counterstrain Techni ques: P T1 to P T4, Mi dline

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1 to T4. T en der Po int L o cation T he tender point lies at PT1 to PT4, midline, the inferior lateral tip of the spinous pr oces s of the named ver tebr a. Palpate from inferior to s uperior at a 45-degr ee angle (F ig. 9.59).

F ig ure 9.59. PT1–PT 4 midline tender points ( 5) .

T reatm ent Po sition 1. T he patient lies pr one and the phys ician s tands at the head of the treatment table. 2. T he patient's arms hang over the s ides of the table and the phys ician, s upporting the patient's head and neck by c upping the c hin, gently lifts and extends the neck to the

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F ig ure 9.60. PT3: e-E Sa Rt.

F ig ure 9.61. PT3: e-E Sa Rt.

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P.15 4

P osterior Thoracic Counterstrain Techni ques: P T1 to P T6, Mi dline

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1 to T6. T en der Po int L o cation T he tender point lies at PT1 to PT6 midline, the inferior lateral tip of the spinous pr oces s of the named ver tebr ae. Palpate from inferior to s uperior at a 45-degr ee angle (F ig. 9.62).

F ig ure 9.62. PT1–PT 6 midline tender points ( 5) .

T reatm ent Po sition 1. T he patient lies pr one, and the phys ician s tands at the head of the treatment table. 2. T he patient's arms hang over the s ides of the table, and the phys ician, s upporting the patient's

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F ig ure 9.63. PT6: e-E Sa Rt.

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head and neck by c upping the c hin, gently lifts and extends the thor acic r egion to the level of the thor acic dysfunc tion with the help of the thigh ( Fig . 9.63) . 3. Minimal or no s ide-bending or r otation is needed.

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P osterior Thoracic Counterstrain Techni ques: P T7 to P T9, Mi dline

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 7 to T9. T en der Po int L o cation T he tender point lies at PT1 to PT9, midline, the inferior lateral tip of the spinous pr oces s of the named ver tebr ae. Palpate from inferior to s uperior at a 45-degr ee angle (F ig. 9.64).

F ig ure 9.64. PT7–PT 9 midline tender points ( 5) .

T reatm ent Po sition 1. T he patient lies pr one and the phys ician s tands at the head of the treatment table. 2. T he patient's arms and s houlder s are flex ed forward parallel to the table, and the phys ician, s upporting the patient's head and neck by c upping the c hin, gently

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F ig ure 9.65. PT9: e-E Sa Rt.

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P.15 6

P osterior Thoracic Counterstrain Techni ques: P T4 to P T9, Lateral

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 4 to T9. T en der Po int L o cation T he tender point lies at PT4 to PT9, lateral, at the pos ter olater al tip of the tr ans v ers e pr oces s of the named ver tebr ae ( r otational c omponent) ( F ig. 9.66).

F igure 9.66. PT 4–PT 9 lateral tender points ( 5).

T reatm ent Po sition 1. T he patient lies pr one, and the phys ician s tands or s its at the head of the table. 2. T he phys ician's forearm is plac ed under the patient's axilla on the s ide of the tender point with the hand on the posterolateral c hes t wall.

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F igure 9.67. PT 6 ty pe 1: e Sa Rt.

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3. T he phys ician's forearm gently lifts patient's s houlder , inducing extension and rotation to that side. 4. T he phys ician may add side bending to either s ide to the lev el of the dysfunc tional s egment, depending on the dysfunc tional pattern, such as PT6 type I ( Sa Rt) or PT6 type II ( St Rt) (F igs. 9.67 an d 9.68). 5. T he phys ician fine-tunes through small arcs of motion ( flexion, extension, r otation, and s ide bending) .

F igure 9.68. PT 6 ty pe 2: e St Rt.

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P osterior Thoracic Counterstrain Techni ques: P T4 to P T9, Lateral

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 4 to T9. T en der Po int L o cation T he tender point lies at PT4 to PT9, lateral, pos ter olater al tip of the tr ans v ers e pr oces s of the named ver tebr ae ( r otational c omponent) ( F ig. 9.69).

F igure 9.69. PT 4–PT 9 lateral tender points ( 5).

T reatm ent Po sition 1. T he patient lies pr one. T he phys ician s tands on the side of the table opposite the tender point, gras ps the patient's opposing anterior s houlder (far s ide), and gently lifts the shoulder, inducing extension and rotation to that side ( Fig . 9.70) . 2. T he phys ician

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F igure 9.70. PT 4–PT 9: e-E Rt.

F igure 9.71. PT 4–PT 9 type 1: e-E Sa Rt.

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P osterior Thoracic Counterstrain Techni ques: P T9 to P T12

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 9 to T12 T en der Po int L o cation PT 9 to PT 12: Midline, inferolateral tip of the spinous pr oces s of the named ver tebr ae, r otational c omponent to other side ( F ig. 9.73) PT 9 to PT 12: Lateral, pos ter olater al tip of the tr ans v ers e pr oces s of the named ver tebr ae, r otational c omponent to this s ide T reatm ent Po sition With osteopathic manipulative tr eatment to pr oduc e r otational motion fr om below ( the lower of the two in this v er tebral unit), r otational mov ement oc c urr ing up to but not including the dy sfunctional s egment will elicit a r elativ e r otation of the

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F igure 9.73. PT 9–PT 12 tender points (5) .

F igure 9.74. PT 11 type 1: e- E Sa Rt.

F igure 9.75. PT 11 type 2: e- E St Rt.

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P.15 9

Anteri or Costal Counterstrain Techni ques: Anterior Costal Tender Points

Anterior c os tal c ounterstrain tender points ar e outlined in Table 9.5 and demons trated in Figure 9.76.

F ig ure 9.76. Anterior c ostal counter str ain tender points (5).

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T able 9.5 Comm on Ant erio r Cost al T end er Poin ts Ten der Point

Jo nes's Term

Locatio n

T reat men t Po sit ion , Acron ym

AR1

Depr ess ed r ib

Below clavic le at firs t c hondr osternal ar ticulation

Patient s upine f-F St RT

AR2

Depr ess ed r ib

O n sec ond rib at midclavic ular line

Same as abov e

AR3 AR4 AR5 AR6

Depr ess ed r ibs

Anterior axillar y line on dy s functional rib

Patient s eated f ST RT

P.16 0

Anteri or Costal Counterstrain Techni ques: Anterior Ri b, E xhaled and Depressed, AR1 and AR2

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at r ibs 1 and 2 ( ex halation, depres sed). T en der Po int L o cation AR1: Below c lavic le at firs t c hondr osternal ar ticulation (F ig. 9.77) AR2: O n s econd r ib at midclavic ular line

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F igure 9.77. AR1–AR2 tender points (5) .

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T reatm ent Po sition 1. T he patient lies supine and the phys ician s tands or s its at the head of the table. 2. T he patient's head and neck ar e flex ed to engage the dysfunc tional r ib lev el. 3. T he patient's head and neck ar e s ide-bent and rotated toward the tender point ( Fig s. 9.78, 9.79, 9.80) . 4. T he phys ician fine-tunes through s mall ar cs of motion ( flexion, extension, s ide bending, or r otation).

F igure 9.78. AR1–AR2: f-F St RT.

F igure 9.79. AR1–AR2: f-F St RT.

F igure 9.80. AR1–AR2: f-F St RT ( alternative hand plac ement) .

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Anteri or Costal Counterstrain Techni ques: Anterior Ri b,

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E xhaled and Depressed, AR3 to AR6

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function, ribs 3 to 6 ( exhalation, depres sed). T en der Po int L o cation T he tender point lies at AR3 to AR6: anterior ax illary line on the dy s functional rib ( F ig. 9.81).

F igure 9.81. AR3–AR6 tender points (5) .

T reatm ent Po sition 1. T he patient is s eated with the hips and knees flex ed on the table on the s ide of the tender point. F or comfort, the patient may let the leg on the s ide of the tender point hang off the front of the table, the other leg c ros sed under it. 2. T he phys ician s tands behind the patient with the foot opposite the

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F igure 9.82. AR3–AR6: f ST RT .

F igure 9.83. AR3–AR6: f ST RT .

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P.16 2

P osterior Costal Counterstrai n Techniques: Posterior Costal Tender Points

Pos ter ior cos tal c ounterstrain tender points ar e outlined in T able 9.6 and demons trated in Figure 9.84.

F ig ure 9.84. Pos ter ior cos tal counterstrain tender points (5).

T able 9.6 Comm on Post erior Cost al Ten d er Points

Jo nes's Ten der Point T erm

Locatio n

Classic T reatmen t Positio n an d Acro nym

PR1

Elev ated r ib

Cer vic othorac ic angle jus t anterior to tr apez ius

Patient seated e SA Rt

PR2

Elev ated r ib

Superior sur face

Patient seated e SA Rt or f SA RA

PR3–PR6

Elev ated r ibs

Superior sur face of r ib angles

Patient seated f SA RA

PR, posterior rib.

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P osterior Costal Counterstrai n Techniques: Posterior Rib, I nhaled and E levated, P R1

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at r ib 1 ( inhalation, elevated) . T en der Po int L o cation PR1: Posterior as pect of fir st rib at the c er vic othorac ic angle immediately anterior to the tr apez ius (F ig. 9.85)

F igure 9.85. PR1 tender point (5).

T reatm ent Po sition 1. T he patient is s eated. T he phys ician s tands behind the patient. 2. T he phys ician's foot opposite the tender point is plac ed on the table under the patient's axilla. 3. T he phys ician monitor s the firs t r ib tender point with the index finger pad, which is

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F igure 9.86. PR1 tender point.

F igure 9.87. PR1: e SA Rt.

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P osterior Costal Counterstrai n Techniques: Posterior Rib, I nhaled and E levated, Ribs 2 to 6

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function in r ibs 3 to 6 (inhalation, elevated) . T en der Po int L o cation PR2: posterior as pect of sec ond r ib at its s uper ior s ur fac e ( Fig . 9.89) PR3 to PR6: pos ter ior as pects of the ribs 3 to 6 at the super ior s ur fac e of their rib angles

F igure 9.89. PR2–PR6 tender points (5) .

T reatm ent Po sition 1. T he patient is s eated with legs on the side of table ( for c omfort, the patient may hang the leg opposite the tender point off the table) . 2. T he phys ician s tands behind patient with the foot

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F igure 9.90. PR2–PR6: f SA Ra.

F igure 9.91. PR2–PR6: f SA Ra.

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ipsilateral to the tender point on the table with the thigh under the patient's axilla. 3. T he phys ician gently flex es patient's head, neck, and thor ax to engage the level of the dysfunc tional r ib. 4. T he phys ician elev ates the patient's s houlder with the axilla r esting on the thigh, whic h s ide-bends the trunk away fr om the tender point. 5. T he patient is asked to s lowly extend the s houlder and arm opposite the tender point and allow the arm to hang down. T his induces side bending and r otation away fr om the tender point ( F igs. 9.90 an d

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9.91). 6. T he phys ician fine-tunes through s mall ar cs of motion ( flexion, extension, r otation, and s ide bending) .

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Anteri or Lum bar Counterstrain Techni ques: Anterior Lumbar Tender Points

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Anterior lumbar c ounterstrain tender points ar e outlined in Table 9.7 and demons trated in Figure 9.92. Note: The ac r ony ms for the class ic pos itions r epres ent the point of r eference r elated to the mov ement of the upper of the two s egments inv olv ed in the dy s function. T herefore, the physician may stand on either side of the patient and depending on the dy s function may alter the s ide-bending and rotational elements. In these supine tec hniques with motion initiated fr om below the dy s function, when the k nees and pelvis ar e dir ected

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F igu re 9.92. Anter ior lumbar counters train tender points ( 5)

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T able 9.7 Co mmo n An terior Lum bar Ten der Po int s Ten der Point

L o cat ion

Classic Treatment Po sit ion Patient supine with hip and k nee flexion

AL1

Medial to ASIS

T ype II: F SA Ra T ype I: F ST RA or F SA RT

AL2

Medial to AIIS

T ype II: f- F SA RA T ype I: f-F SA RT

AL3

Lateral to AIIS

Same as AL2

AL4

Inferior to AIIS

Same as AL2

AL5

Anterior as pec t of pubic bone 1 cm lateral to pubic s ymphys is just inferior to pr ominenc e

T ype II: F SA Ra T ype I: F SA Rt

ASIS, anterior s uperior iliac spine; AIIS, anterior inferior iliac spine.

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Anteri or Lum bar Counterstrain Techni ques: AL1

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L1. It may be as s ociated with the ps oas mus cle. T en der Po int L o cation T he tender point lies at AL1, medial to the ASIS; press medial to lateral ( F ig. 9.93).

F igure 9.93. AL1 tender point (5).

T reatm ent Po sition 1. T he patient is s upine and the phys ician s tands at the side of the table on the s ide of the tender point. 2. T he patient's hips and k nees ar e flex ed enough to engage the lower of the two s egments involved ( L2) . 3. T he

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F igure 9.94. AL1 ty pe I ( ST RA).

F igure 9.95. AL1 ty pe II (SA RA) .

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Anteri or Lum bar Counterstrain Techni ques: AL2

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L2. T en der Po int L o cation T he tender point lies at AL2, medial to anterior inferior iliac spine ( AIIS) ; probe laterally (F ig. 9.96).

F igure 9.96. AL2 tender point (5).

T reatm ent Po sition 1. T he patient lies s upine, and the phys ician s tands at the side of the table opposite the tender point. 2. T he patient's hips and k nees ar e flex ed enough to engage the lower of the two s egments involved ( L3) . 3. T he patient's hips and

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F igure 9.97. AL2: F Sa-A RT.

F igure 9.98. AL2: F Sa-A RT.

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Anteri or Lum bar Counterstrain Techni ques: AL3 and AL4

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L3 and L4. T en der Po int L o cation AL3: lateral to the AIIS; pr ess medially (F ig . 9.99). AL4: inferior to the AIIS; pr ess c ephalad.

F igure 9.99. AL3–AL4 tender points (5) .

T reatm ent Po sition 1. T he patient lies supine, and the phys ician s tands at the side of the table opposite the tender point. 2. T he phys ician may plac e the caudad leg on the table and lay the patient's legs on the phys ician's thigh. 3. T he patient's hips and k nees ar e flex ed enough to

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F igure 9.100. AL3–AL4: F SA RT for type I.

F igure 9.101. AL3–AL4: F ST RT for type II.

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Anteri or Lum bar Counterstrain Techni ques: AL5

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L5. T en der Po int L o cation T he tender point lies at AL5, anterior aspect of the pubic bone about 1 cm lateral to the pubic s y mphy sis jus t inferior to its pr ominenc e ( F ig. 9.102) .

F igure 9.102. AL5 tender point ( 5).

T reatm ent Po sition 1. T he patient lies supine, and the phys ician s tands at the side of the table on the s ide of the tender point. 2. T he phys ician plac es the c audad leg on the table and lays the patient's legs on the phys ician's thigh. 3. T he

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F igure 9.103. AL5: F SA RA.

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P osterior Lum bar Counterstrai n Techniques: Posterior Lum bar Tender Points

Pos ter ior lumbar c ounterstrain tender points ar e outlined in Table 9.8 and demons trated in Figure 9.104.

F ig ure 9.104. Posterior lumbar c ounters train tender points ( 5) .

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T ab le 9.8 Co m mon Po sterior Lu mbar Tender Po int s Ten der Point Locatio n

Classic T reat men t Po sition

PL1–PL5

Inferolateral as pec t of s pinous proc ess or laterally on transv ers e pr oces s of dy sfunctional s egment

Patient prone with leg ( hip) ex tens ion and s light exter nal rotation, c ausing lumbar r otation to that s ide; adduc tion or abduc tion as needed e SA Ra- A ( s pinous pr ocess) e SA RA (tr ansv ers e pr ocess)

PL3 later al gluteus ( iliac c r est)

Halfway between UPL5 and PL4 at infer ior as pect of pos ter ior iliac c r est near gluteus medius /maximus

Patient prone E er add

PL4 later al gluteus ( iliac c r est)

Pos ter olater al pelv ic edge halfway between gr eater troc hanter and iliac crest at gluteus max imus

Patient prone E er add

UPL5

Superior sur face of PSIS

Patient prone with hip ex tension E er add

LPL5

2 c m below PSIS on the ilium

Patient prone with hip flexed off table and s light adduc tion F IR add

PSIS, pos ter ior superior iliac s pine.

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P osterior Lum bar Counterstrai n Techniques: PL1 to PL5

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L1 to L5. T en der Po int L o cation T he tender point lies at the inferolateral as pect of the s pinous proc ess or laterally on the tr ansv ers e pr oces s of the dy s functional s egment ( Fig . 9.105) . T reatm ent Po sition 1. T he patient lies pr one and the phys ician, s tanding opposite the tender point, gras ps the patient's lower thigh or tibial tuberos ity on the side of the tender point. 2. T he phys ician extends the patient's thigh and hip until the dysfunc tional s egment is

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F ig ure 9.105. PL1–PL5 midline and later al tender points (5).

F ig ure 9.106. PL4: e SA Ra-A.

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P osterior Lum bar Counterstrai n Techniques P L1 to PL5

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L1 to L5. T en der Po int L o cation T he tender point lies at the inferolateral as pect of the s pinous proc ess or laterally on the tr ansv ers e pr oces s of the dy s functional s egment ( Fig . 9.108) . T reatm ent Po sition T he position is e SA RA. 1. T he patient lies pr one, and the phys ician, s tanding opposite the tender point, gras ps the patient's opposite ASIS. 2. T he phys ician may tak e the patient's leg off midline to r ight or left depending on the type of dysfunc tion. 3. T he patient's

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F igure 9.108. PL1–PL5 midline and later al tender points ( 5).

F igure 9.109. PL4: e SA RA.

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P osterior Lum bar Counterstrai n Techniques: PL3 and P L4, Lateral

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L3 to L4. It is as s ociated with the gluteus medius muscle. T en der Po int L o cation PL3 later al ( gluteus) : Halfway between the UPL5 and PL4 at the inferior aspect of the posterior iliac c r est near the gluteus medius and gluteus max imus ( Fig . 9.111) PL4 later al ( gluteus) : Pos ter olater al pelvic edge, halfway between the gr eater tr ochanter and iliac crest at the gluteus maximus

Fig u re 9.111. PL3–PL4 ( gluteus medius ) tender points (5) .

Fig u re 9.112. PL3–PL4: E er add.

T reatm ent Po sition 1. T he patient lies pr one, and the phys ician s tands on the same

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2.

3.

4.

5.

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s ide as the tender point ( the r otational c omponent s ide of the dysfunc tion). T he phys ician gras ps the patient's thigh or tibial tuberos ity on the side of the tender point. T he phys ician extends the patient's thigh and hip until the level of the dysfunc tion is engaged. T he phys ician externally r otates and adducts the patient's thigh and femur, whic h s ide-bends the lumbar s egment toward the tender point ( Fig s. 9.112 and 9.113). T he phys ician fine-tunes through s mall ar cs of motion ( hip flex ion and extension, external and

Fig u re 9.113. PL3–PL4: E er add.

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internal r otation, and adduction and abduction).

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P osterior Lum bar Counterstrai n Techniques: PL5, Lower P ol e

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L5. T en der Po int L o cation T he tender point lies at PL5 lower pole 2 cm below the PSIS (F ig . 9.114) . T reatm ent Po sition 1. T he patient lies pr one, and the phys ician s its at the s ide of the table on the s ide of the tender point. 2. T he patient's lower extr emity on the side of the tender point hangs off the side of the table with hip and k nee flexed to 90 degr ees . 3. T he phys ician internally r otates the patient's hip and thigh, and the patient's

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Fig u re 9.114. PL5 lower pole tender point (5) .

Fig u re 9.115. PL5LP: F IR add.

Fig u re 9.116. PL5LP: F IR add.

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P el vic Counterstrai n Techniques: Ili acus Dysfunction (Il iacus Tender Point)

In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function of the iliac us mus cle. T en der Po int L o cation T he tender point lies 2 to 3 c m caudal to the point halfway between the ASIS and the midline, deep on the side of the dy sfunction ( F ig. 9.117) .

Fig u re 9.117. Iliacus tender point (5).

T reatm ent Po sition T he position is F ER ( hips) abd (k nees). 1. T he patient is s upine, and the phys ician s tands at the side of the table. 2. T he patient's hips ar e mark edly flex ed and

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Fig u re 9.118. Iliacus: F ER (hips ) abd ( knees).

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externally r otated bilater ally ( ank les are c ros sed with k nees out to the s ides) ( Fig s. 9.118 an d 9.119). 3. T he phys ician fine-tunes through s mall ar cs of motion ( hip flex ion, external r otation, and side bending) .

Fig u re 9.119. Iliacus: F ER (hips ) abd ( knees).

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P el vic Counterstrai n Techniques: Pel vic Dysfuncti on—P iri formis Dysfuncti on (PIR Tender Point)

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function of the pir iformis muscle. T en der Po int L o cation T he tender point lies anywher e in the piriformis mus cle, c las s ically 7 to 10 c m medial to and slightly c ephalad to the gr eater troc hanter on the side of the dy s function ( Fig . 9.120) . T his is near the sciatic notch, and therefore, to av oid s c iatic irritation, we commonly use the tender points pr oximal to either the sacrum or the tr ochanter. If they c an be s imultaneous ly r educed effectively, the tr eatment can be ex tremely s uc ces sful.

F igu re 9.120. Pir ifor mis tender point (5) .

F igu re 9.121. Pir ifor mis : F abd-ABD er .

T reatm ent Po sition 1. T he patient lies pr one, and the phys ician s tands or s its on the s ide of the tender

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F igu re 9.122. Pir ifor mis : F abd-ABD er -ER.

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Upper Extrem i ty Region: Supraspi natus

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In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function of the s upras pinatus mus cle. T en der Po int L o cation T he tender point lies at the mid s upras pinatus mus cle just s uperior to the s pine of the s c apula ( Fig . 9.124) . T reatm ent Po sition 1. T he patient lies supine on the treatment table. 2. T he phy s ician s its bes ide the patient at the lev el of the shoulder girdle. 3. T he phy s ician may palpate the tender point with either hand's fingertip pad or c ontr ol the patient's ipsilateral arm with the other ( F ig. 9.125). 4. T he patient's arm is flex ed to

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F igu re 9.124. Supr aspinatus counterstr ain tender point ( 7).

F igu re 9.125. Palpation of s upr aspinatus tender point.

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Upper Extrem i ty Region: Infraspi natus

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In d icatio ns f or T reatm ent T his treatment is appropriate for s omatic dy s function of the infras pinatus mus cle. T en der Po int L o cation T he tender point lies appr oximately 1 thumb's -width medial to its tendinous por tion at the later al s houlder joint ins ertion and 1 or 2 thumb's-widths below the spine of the sc apula ( infer olater al s pine of scapula at pos ter omedial as pect of glenohumeral joint) ( F ig. 9.128) . O thers may pr esent along the inferior spine of the s c apula to v er tebral bor der of the sc apula. These may neces sitate placing the patient's ar m in mor e or less flexed or abducted pos itions .

F igure 9.128. Infr aspinatus c ounter str ain tender point (7) .

T reatm ent Po sition 1. T he patient lies supine on the treatment table.

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F igure 9.129. Palpation of infraspinatus tender point.

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Upper Extrem i ty Region: Levator S capulae

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In d icatio ns f or T reatm ent T his treatment is appropriate for somatic dy s function of the levator s c apulae mus cle. T en der Po int L o cation T he tender point lies at the s uperior angle of the sc apula ( F ig. 9.131) . T reatm ent Po sition 1. T he patient lies pr one, head r otated away , with the arms at the s ides. T he phys ician s its at the s ide of the affected s houlder . 2. T he phys ician's c audad hand gras ps the patient's wris t while the other hand palpates the tender point ( F ig. 9.132). 3. T he

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F igure 9.131. Levator scapulae c ounter s train tender point (7).

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References 1. Jo nes LH , Ku s un ose R S, Go eri ng E K. J on es S tra i n- C oun ter s tr ai n. Ca r ls bad, CA : J ones Str ai n-C oun ters tra i n, 199 5.

2. Wa r d R ( ed). Fo und atio ns for Ost eop ath i c M edi c in e. P hil ade l phi a: Lip pi nc ott Wi l l ia m s & W i l ki ns, 20 03.

3. Si m on s D , Tr ave l l J , S i mo ns L. M y of asc i al Pai n a nd D y sf unc ti on : T he T r ig ger Po i nt M an ual , vo l 1. Ba l ti m or e: W i ll i am s & W il k in s , 1 999 .

4. Re nni e P , Gl ove r J . Co unt ers tr ai n a nd Ex er c is e: An I nte gra ted App r oa c h ( 2nd ed .) . W i l li ams tow n, M I: R en ni eM atr i xT M , 2 004 .

5. Mo dif i ed w it h p erm i s si on fro m Cl ay J H, Pou nds DM . Ba s ic Cl i nic al M as s age Th era py : Integ r at i ng Ana tom y a nd T r ea tme nt. Bal tim or e: Li ppi nc ot t W i ll i ams & W il k i ns , 2 003 .

6. Ya tes H, Glo v er J. C ou nte r st r ain : A Ha ndbo ok of Os te opa thi c Te c hn i qu e. T uls a, OK: Y K not , 1995.

7. Mo dif i ed w it h p erm i s si on fro m Si m on s D G, T r av ell J G, Si m on LS. My ofa s c ia l P ain and D y s fu nct i on : Th e T r ig ger Poi nt M anu al. Ba l tim ore : L i ppi nco tt W i ll i am s & W il k in s , 1999 .

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10 Muscle Energy Techniques Technique Principles M us c le ene r gy te c hni que (M ET ) i s a f or m of ost eopa thi c m anip ula tiv e tr eat m en t de v el ope d by Fr ed L. M it c he l l , Sr. , D O (1 909 –19 74). It is def i ne d b y th e E duc atio n C oun c i l on Ost eopa thi c P r i nc i pl es ( ECO P) as “ a s y st em of di ag nos i s and tre atm ent i n w hi c h t he pat i ent vo l un tari l y m ov es t he bod y as sp eci fi ca l ly dir ect ed b y t he phys i ci an; thi s d i re c ted pa tie nt a c ti on i s f r om a pr ec i se l y c ont r ol l ed pos i ti on, aga i ns t a def i ne d re s is tan c e b y t he phys i ci an” ( 1) . S ome ost eop ath i c p hys i ci ans ( e. g., H ol l is Wo l f, N ic hol as S . N ic hol as ) hav e s ugge s te d t hat thi s t ec hn i qu e i s a v ar i at i on of a t ec hn i qu e p er fo r me d b y T. J. Ru ddy, DO ( pe r so nal c om m un i c at i on ) . R udd y d eve l ope d a te c hni que ca l l ed rh y th m i c ( ra pid ) re s is tiv e du c ti on. H is tec hni que use d t he p ati ent ' s m usc l e c ont r ac tio n ag ain s t a ph y si c ia n' s c ou nte r for c e bef or e the dev elo pm en t o f M ET ( 2,3 ,4) . In ME T , the phy s ic i an pos i ti ons the pa ti en t s o a s to en gag e th e r est r i ct i ve bar r ie r . F r ed Mi tc he l l, Jr ., u s es th e te r m fea ther ' s edg e to re fer to the le v el of eng agem ent (5 ,6). Th i s ter m r efer s t o t he i nit i al s en s e of m eet i ng th e re s tr i ct i on w it h s l i gh tly mo r e m oti on av ai l ab l e befo r e m ee tin g th e h ard end fe el of r est r ic ti on . I f t he p hys i ci an e nga ges the ba r ri er t o t he end poi nt of i ts r es tri c tio n, i t c aus es the pat i en t t o re s is t, and i t bec om es di ffi c ult to co r r ec t t he dy sf unc tio n. A ddi tio nall y , eng agi ng a l l thr ee a x es of m ot i on (x , y, an d z ) at th e f eath er ' s e dge m ay al s o c aus e a l oc k in g u p of th e dys fun c tio n, r es ul ti ng i n di ff i cu l ty of tre atm ent and re s i st ant dy s fun c ti on. T hi s w as one of the fir s t ost eop athi c t ech ni qu es to us e k no w n and acc ept ed p hys i ol ogic pr i nc i ple s a s i ts m ajo r p r oto c ol of tre atm ent.

Technique C las sification D ire ct In M ET , as in ot her dir ect tec hni que s , t he pat i ent ' s dys func tio n i s po s it i on ed t owa r d the r es tri c tiv e bar r ie r . R ece nt atte m pt s b y so m e m an ual m ed i ci ne p r ac tit i one r s, es peci all y o utsi de the U ni ted St ates , hav e b egun to de s c ri be i nd i r ec t t ech ni qu e.

Technique Styles Post Is ometric Re laxa tion In thi s fo r m of M ET, th e m us cl e i nco r por ate d f or t r ea tme nt e ffe c ti v ene s s ( ag onis t) per form s a n i s ome tri c c on tra c tio n. D ur i ng thi s c ontr act i on , in c re ase d te nsi on i s p l ac ed on t he Gol gi t end on or ga n p r op r i oc ept ors w it hin the mu s cl e te ndo n. T his ca n c ause a r ef l ex i nh i bi ti on an d s ubse que nt i ncr eas e i n mu s cl e l engt h w it hin a h y pe r to ni c m us c le . Mi tch ell bel i ev ed that af ter the co ntr ac ti on a r efra c to r y peri od occ ur re d dur i ng w hi c h the phy s ic i an c ou l d s en s e r ela x at i on and a temp ora r y i ncr eas e i n mu s cl e l engt h ( 1,4 ) . T his m ay be an ove r si m pli fie d e x pla nat i on , an d w e b el ie v e tha t ad dit i on al e ffe c ts are at pl ay . M os t l i k el y t he eff ect s co m mo n t o so ft tis s ue and my ofas c ia l r el ea s e are als o i nvo l v ed in th i s s tyl e o f mu s cl e e nerg y . H ea t i s ge ner ate d du r in g i s ome tri c m us cl e c ont r act i on ; t hi s hea t h as t he s am e ef fec t o n th e m y of as ci al s tr uct ur es as pr opos ed i n the c ha pte r s o n m y of as ci al and s of t t i ss ue t r ea tme nt. T he he at g ene r at i on i s l ik ely P.1 82

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to c au s e t he c on nect i ve ti s s ue s a nd c oll age n b as e, wh i ch are un der ten s io n, to c han ge c oll oid al s tat e ( gel to s ol ) . A s a re s ult , t he fasc i al en v elo pe m ay l en gth en, als o p erm i tti ng the m us c le to l en gth en. D ur i ng th i s i so m et r i c c on tra c tio n, the ten s io n b ui ld i ng up i n the mu s c le is al s o e x pr ess i ng flu i ds ( e. g., ve nous bl ood , l ym ph) fro m t he bell y o f t he m usc l e and s ur r ou ndin g i nte r s ti tia l c om pa r tm ent , wh i ch po tent i at es an i nc r ea s e i n o v er al l l en gth and /or pe r c ei v ed re l axa tio n. As t he ago ni st mu s cl e be i ng co ntra c te d i s mo s t l ik ely the dy s fu nc ti ona l m us cl e i nvo l v ed in ac ute s tr ain s , t his st y l e of tec hniq ue i s m ost us efu l in s ub acu te t o c hro ni c c on dit i ons , i n w hi ch mu s cl e sh ort eni ng a nd fib r osi s m ay be p r es ent , ra the r t han i n acu te c ond i ti ons . Th e f orc e of co ntr ac ti on m ay v ar y , but i t s ho uld be tol era bl e to bot h pa tie nt and phy s ic i an. No te: T he pa tie nt's co ntr ac ti on and phy s ic i an ' s r esi s ta nc e are no t a c om pet i tio n t o s ee w ho i s the st r ong er.

R eciproc al Inhibition T hi s f or m of m us c l e ene r gy use s t he phys i ol ogi c pr i nc i pl e of re c ip r oca l i nhi bi ti on and r el axa tio n. W hen an ago ni st co ntr ac ts , t he anta gon i st s ho uld re l ax ( e. g., bra c hi ali s an d b i ce ps c ont r ac t an d t r ic eps r el axe s ) . T he fo r c e of c on tr ac tio n i n th i s s ty l e o f t ech ni qu e s hou l d b e v ery l ig ht, on l y s l ig htl y mo r e tha n the th ough t t o c ontr act it . If th e f or ce is to o gr eat , t he r efl ex m ay be l os t by ca usi ng a ddi tio nal m us c le s to c on tra c t. W he n m or e tha n o ne m usc l e c ont r ac ts, the in hib i tio n i s l os t ( e. g., pat i en t's m us c le co ntra c ti on m im i cs Val s al v a m ane uve r s, i n w hi c h al l m us c le s ar e i s om etri c al l y c ont r ac tin g) . T hi s t ec hn i qu e, as i t c an us e a fun c ti onal ag oni s t t o r ela x a dys fun c tio nal an tago nis t, i s s tro ngl y in dic ate d in ac ute c on dit i on s , tho ugh i t m ay al s o b e u s ed i n s ub acu te a nd c hr onic st age s .

J oint Mobiliza tion Us ing Mus cle Force M us c le for c e use s pa tie nt posi tio nin g an d m usc l e c ont r ac ti on to re s tor e l i mi ted j oi nt m oti on. As the m us c le s ar e t he pr im ary mo v ers of jo i nts , u s e of a sp eci fi c m us c le c on tra c ti on w i th th e pa tie nt i n a s pe c if i c p osi tio n al l ow s t he f orc es at p l ay to bec ome ve r y p owe r fu l an d b e v ec to r ed sp ec if i ca l ly to a l oca l are a. T his is si m i la r t o t he l ong - le v ere d s tyl e of hi gh v elo c it y , l ow amp l it ude ( HV LA) the r ap y , ex ce pt tha t the pa ti en t i s a c tiv ely co ntra c ti ng m usc l es in s tea d o f t he p hys i ci an p ull i ng the m t o c ause mo v em ent. T he r ef or e, th i s s tyl e o f m us cl e e ner gy c oul d b e th oug ht of a s l ow v elo c it y , l ow amp l it ude ( LV LA) . Th e r es ult i ng c on tra c tio n m ay beco m e m in i m al l y i so toni c . As s ta ted ear l ie r , m oti on i n j oin ts c an be i mp r ove d b y u s e o f f orc es t hat ar e ve c to r ed dir ect l y or i nd i re c tly . M ET i s c l as s ic al ly de s cr i bed as a di re c t tec hniq ue use d to mo bil i z e a r est r i ct ed j oi nt; the r ef or e, po s it i oni ng of the pat i en t is si m il ar t o t he r eci pro c al i nh i bi tio n st y le of pos i ti oni ng. H ow eve r , i n thi s c as e, th e m us cl e c ont r act i on s c an b e m ore pow erf ul ( pos s ib l y i s ot oni c ) up t o m any pou nds of r es i st ance . F or the phy s ic i an' s c omf or t, th e p atie nt s ho ul d be pos i tio ned to enc our age the de v el opme nt of the mo s t a ppr opr i ate lo nge s t-l eve r ed for c e w it h th e l eas t am oun t o f co unt erf or ce fr om the phy s ic i an nec ess ar y for su c c es s .

R espira tory As sis tanc e R es pir ator y a s si s tan c e m ay be use d i n a num ber of ost eop athi c m ani pula tiv e t ec hn i qu es ( e.g ., m yo fas c i al re l ea s e, s of t t i s su e, c ou nter s tr ain , ba l an c ed l ig ame nto us t ens i on , li gam ent ous art i cu l ar s tr ain ) . I n t his s ty l e of M ET, th e p hy si c ia n p os it i on s t he p ati ent to bes t d i r ec t t he forc es of r esp i ra tio n tow ard the ar ea of d y sf unc ti on an d s i m ul tan eou s l y use a fulc r um (e .g., ph y si c i an ' s han d) a s a c ou nte r for c e to help di r ec t th e d y sf unct i on al r egi on thr ough th e r es tr i ct i ve bar r ie r . As d i ap hra gm at i c exc urs i on dur i ng i nh ala tio n ma y a ffe c t m usc l es v er y d i st al ly be c au s e o f f asc i al c on tin ui ty , m oti on a nd tis s ue c ha nge s m ay b e a ppr ec ia ted lo c all y o r p er ip her all y .

Oculoce r vic al Reflex

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W he n a pat i en t i s as k ed to m ak e s pec i fic ey e m ov em ent s , c ert ain ce r v ic al and tru nca l m us cl es c on tr ac t, w hi c h r efl exi v el y re l ax th e an tag oni s t m usc l es ( 1) . T he pati ent ma y be as k ed to l oo k t ow ar d e i th er t he r es tri c tio n o r t he f r ee dom . Th ere for e, i t i s p os si ble to m in i ma l ly i nd uce po s t i s om etr i c r ela x at i on eff ect s or m or e li k el y r ec ip r oc al i nhi bit ory eff ect s . T his st y le i s m os t u s efu l i n v er y s ev ere , ac ute ce r v ic al and upp er thor aci c c ondi tio ns w hen ot her tec hni que s ar e i m po s s ib l e due to s ev eri ty o f p ain , mu s cl e s pasm , or s tr ai n.

Indications Prim ary Indica tions 1. Soma tic dy s fun c ti on of m y of asc i al ori gin , es pec i al l y t o r edu c e h y pe r to ni c m us c le s , l eng the n s hor ten ed m usc l es , o r st r et c h and i mp r ov e el ast i ci ty i n f i br otic mu s cl es 2. Soma tic dy s fun c ti on of a r ti c ul ar o r ig i n to m obi l iz e re s tr i ct ed j oin ts and i mp r ov e th e r ang e of m oti on

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Seconda r y Indications 1. T o i m pr ove l oc al c ir c ula tio n a nd r esp i ra tory fu nct i on 2. T o b ala nce neu r om usc ul ar re l at i ons hip s b y al ter i ng m us c le to ne 3. T o i ncr eas e to ne i n hy po ton i c or w eak mu s c le s

C ontraindic ations R ela tiv e Contr aindica tions 1. M ode r at e t o se v er e m us cl e s tra i ns 2. Seve r e ost eopo r os i s i n w hic h t he p hys i ci an b eli eve s th at a r i s k of ten di no us evu l s io n c oul d oc c ur w i th th e c or re c ti on 3. Seve r e i ll ness (i .e. , po s ts urg i c al or in tens i ve ca r e p ati ent )

A bsolute Contr aindica tions 1. F r ac tur e, di sl oca tio n, o r m ode r ate to se v ere jo i nt i ns tab i li ty a t t r ea tm en t s i te 2. Lack of co oper ati on or a pa tie nt w ho c an not und ers tand th e i ns tr uct i on s of th e t ec hn i qu e ( i .e. , a n i nfa nt or y oun g c hil d or a pat i ent wh o d oesn ' t und er st and th e ph y si c ia n' s l an gua ge)

Gene ral Considera tions a nd R ule s D ep end i ng on the pat i en t's pre s en tat i on, th e s ty le of mu s c le en erg y us ed m ay v ar y . Add i tio nal l y, the nat ure and le ngt h of co ntr ac ti on m ay be alt ere d fr om pat i ent to pa ti en t a nd betw een an atom i c r eg i ons . M us c le s ma y b e m or ph olo gic al ly di ffe r ent , o ne to a not her . Th ere for e, t he w ay the y r esp ond to i so m etr i c

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c on tra c tio ns m ay dif fer . I n so m e are as , hol din g a m us c le c on tra c ti on f or 5 o r mo r e s ec onds ma y b e nec ess ar y; in ot hers , 3 se c ond s m ay s uff i ce . C l i ni c al ex peri enc e w i l l tea c h this . T he es s ent i al st eps for mo s t s tyl es of t his te c hni que ar e as fo l lo w s : 1. T he phy s ic i an pos i ti ons the bo ne, j oi nt, or m us c le to be tre ated at th e fe ath er ' s ed ge of the r est r ic tiv e ba r ri er ( poi nt of i nit i al re s i st anc e) i n a l l thr ee p l an es of m oti on ( x -, y- , z - axe s ). H owe v er , i t ma y b e m or e eff ect i v e to k ee p on e a x is s li ght l y l oos e ( l ax ) , a s t he dy sf unc tio n ma y beco m e v er y re c al c it r ant if si m ult ane ous l y h eld at all th r ee axi s l i mi ts . 2. T he phy s ic i an i ns tru c ts the pa ti en t t o c ontr act a s pec i fi c m us cl e i n a s pe c if i c di re c ti on agai nst th e phys i ci an' s un y ie l di ng c oun ter forc e f or 3 to 5 s ec onds . 3. T he pat i en t ce ase s a l l m usc l e c ont r ac tio n wh en ask ed b y t he phys i ci an to r ela x o r go to sl eep. 4. Afte r s ens i ng tha t t he p ati ent i s not gu ar di ng and i s c om ple tely re l ax ed ( m ay ta k e 1 –2 s ec onds ) , the phy s ic i an s lo w ly r ep osi tio ns t he pat i ent to th e fe ath er ' s ed ge of the new re s tri c ti v e barr i er . 5. Step s 1 to 4 a r e r ep eate d u nti l th e b est pos s ib l e i ncr eas e i n mo tio n i s ob tai ned . Th i s usu al ly r equ i re s t hr ee to se v en r ep eti ti on s , dep endi ng on the aff ect ed b ody re gi on an d t ol er anc e o f th e pati ent . 6. T he phy s ic i an r ee v al uate s t he di ag nos tic par ame ter s of th e o r i gi nal dy s fun c ti on to d ete r mi ne t he effe c ti v en es s of the tec hni que . M us c le ene r gy ma y , l i ke mo s t o the r o s teo pat hic tec hni que s , b e u s ed i n c on j un c tio n w i th oth er tec hniq ues . It i s es pe c ia l ly ben efi c ia l in po ten ti at i ng so ft t i ss ue, m yo fas c ia l re l ea s e, c ou nte r st r ain , a nd H VLA tec hni ques . A s t he t r ea tme nt p osi tio ns a r e s o s i mi l ar to tho s e of H VLA , i t i s na tur al to g o f r om M ET to H VL A i f th e M ET i s n ot c om pl et ely su c c es s fu l ; M ET oft en m ake s H VLA m or e r ead i l y s uc c es s ful . If the phy s ic i an i s uns ucc es sf ul w it h ME T , i t i s m ost li k ely be c au s e o f e i th er a ve r y s eve r e c hr onic dys fun c tio n o r b ec au s e of i nac c ur ate dia gno s is . Du r in g t he c orr ect i v e pro c ed ur e, su c ce s s m ay be dim i ni s hed by in ac cu r at e l oc al i za tio n of co r re c tiv e f orc es ( for c e at a se gme nt t oo hig h or lo w ; posi tio nin g c au s in g th e v ect or ed fo r ce at too hi gh o r t oo l ow a s egm ent) . I t i s im por tan t to un der s tan d t he s pec i fi c it y of the pat i en t's pos i ti oni ng i n t his tec hni que . Th e p hys i c ia n m ust pal pat e t he m oti on i n t he exa c t s eg m en tal or m us c ula r t i ss ue t hat is bei ng tre ated . I nco r r ec t f orc e of co ntr ac ti on by the pat i en t (t oo for c ef ul o r t oo gent l e) ma y hi nde r t he s ucc ess ful c om ple ti on of th e te c hn i qu e. I f t he pati ent ' s c ont r ac tio n i s too s ho r t i n dura tio n ( i .e. , 1 se c ond ) , i t w i ll de c re as e eff ect i v en ess . O ther pr obl em s m ay de v elo p i f t he pat i en t do es not c om ple tel y re l ax pr i or to r ep os it i on i ng . Fu r th erm or e, if th e ph y si c ia n fa i ls to r ee v al uat e the di agno s ti c f i ndi ngs af ter tre atm ent, th e d y s fu nct i on m ay st i ll be pre s en t an d p r ev ent a p osi ti ve r es pon s e. P.1 84

C erv ica l Re gion: Trapezius Musc le Spa s m (Long R e str ictor): Post Isom etr ic R ela xation

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1. T he patient is s upine and the physician s its at the head of the table. 2. T he phys ician gently flex es the patient's neck until the edge of the r estr ictive barrier is r eached (F ig . 10.1) . 3. T he patient ex tends or backward bends the neck and head ( blac k arrow, F ig. 10.2) while the phys ician applies an equal c ounterforc e ( white arrow). 4. T his isometr ic c ontr action is maintained for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. 5. O nce the patient has c ompletely r elax ed, the physician gently flex es the neck (white ar row, F ig. 10.3) to the edge of the new r estric tive barrier. 6. Steps 3 to 5

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Fig u re 10.1. A. Steps 1 and 2, flexion bar r ier .

Fig u re 10.1. B. Alternative hand plac ement.

Fig u re 10.2. Step 3, is ometric contraction.

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C erv ica l Re gion: Left Sternocle idomas toid Spasm (Ac ute Torticollis ): Rec iprocal Inhibition

1. T he patient lies s upine and the physician s its at the head of the table s upporting the patient's head with the hand res ting the patient's head on the k nee or thigh. 2. T he phys ician gently r otates the patient's head to the r ight to position the hypertonic left s ternocleidomas toid muscle v entr ally ( F ig. 10.4) . 3. T he phys ician gently extends the patient's head until the edge of the r estr ictive bar rier is r eached (F ig . 10.5) . 4. T he patient ver y gently extends the head (b lack arr ow, F ig. 10.6) while the physician r esis ts with an equal c ounterforc e (white ar row). 5. T he phys ician palpates the left s ternocleidomas toid muscle to ensur e that adequate r elax ation is oc cur ring. 6. T his isometr ic c ontr action is maintained for 3 to 5 sec onds, and

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F igu re 10.4. Steps 1 and 2.

F igu re 10.5. Step 3, extens ion bar rier .

F igu re 10.6. Step 4, isometr ic contrac tion.

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then the patient is instr ucted to stop an d relax. 7. O nce the patient has c ompletely r elax ed, the physician gently ex tends the patient's head ( white arrow, F ig. 10.7) to the edge of the new res tric tiv e barrier. 8. Steps 4 to 7 ar e r epeated thr ee to five times or until motion is maximally improved. 9. T o deter mine the effec tiv enes s of the technique, the physician palpates the left s ternocleidomas toid muscle for r educ tion in tone and observes the patient's head position in the er ect posture for improved body c arriage.

F igu re 10.7. Step 7, extens ion bar rier .

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C erv ica l Re gion: Left Sternocle idomas toid Contr a cture (Chr onic): Post Is ometric Re laxa tion

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1. T he patient lies s upine and the physician s its at the head of the table s upporting the patient's head with the hand and/or r esting the patient's head on the knee or thigh. 2. T he phys ician gently r otates the patient's head to the r ight to position the hypertonic left s ternocleidomas toid muscle v entr ally ( F ig. 10.8) . 3. T he phys ician gently extends the patient's head until the edge of the r estr ictive bar rier is r eached (F ig . 10.9) . 4. T he patient flexes and r otates the head to the left ( blac k arrow, F ig. 10.10) while the physician r esis ts with an equal c ounterforc e (white ar row). 5. T he phys ician palpates the left s ternocleidomas toid muscle to ensur e that adequate c ontr action is oc cur ring. 6. T his isometr ic c ontr action is maintained for 3 to 5 sec onds, and then the patient is instr ucted to stop an d relax.

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F igu re 10.8. Steps 1 and 2.

F igu re 10.9. Step 3, extens ion bar rier .

F igu re 10.10. Step 4, is ometric c ontrac tion.

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C erv ica l Re gion: C erv ica l R a nge of Motion: Oculocer vic al R eflex

T he oculocervical r eflex c an be c ombined with any of the cer v ical METs using the following guidelines: 1. T o pr oduce ex tension of the neck: Have the patient loo k towar d the top of the head for 3 to 5 s econds. After 3 to 5 s econds, tell the patient to st op and relax ( c los e the ey es) . T he physician s lowly and gently extends the patient's head and nec k to the edge of the new r estr ictive barrier. This may be r epeated thr ee to five times or until motion is maximally improved (F ig. 10.12). 2. T o pr oduce flexion of the neck: Have the patient look down at the feet for 3 to 5 s econds. After 3 to 5 s econds,

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Fig ure 10.12. Step 1.

Fig ure 10.13. Step 2.

Fig ure 10.14. Step 3.

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tell the patient to st op and relax (c los e the ey es) . T he physician s lowly and gently flex es the patient's head and nec k to the edge of the new r estr ictive barrier. This may be r epeated thr ee to five times or until motion is maximally improved (F ig. 10.13). 3. T o pr oduce r ight side bending: Hav e the patient look up and to the r ight for 3 to 5 s econds. After 3 to 5 s econds, tell the patient to st op and relax (c los e the ey es) . T he physician s lowly and gently s ide- bends the patient's head and neck to the edge of the new r estr ictive barrier. This may be r epeated thr ee to five times or until motion is maximally improved (F ig. 10.14). 4. T o pr oduce left

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Fig ure 10.15. Step 4.

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s ide bending: have the patient look up and to the left for 3 to 5 sec onds. After 3 to 5 s econds, tell the patient to st op and relax ( c los e the ey es) . T he physician s lowly and gently s ide- bends the patient's head and neck to the edge of the new r estr ictive barrier. This may be r epeated thr ee to five times or until motion is maximally improved (F ig. 10.15).

P.1 88 P.1 89

C erv ica l Re gion: Occipitoatlantal (C0 —C01 ) D ysfunction Ex a mple: C 0 ESLR R Post Isom etr ic Rela xation*

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1. T he patient is s upine and the physician s its at the head of the table. 2. O ne of the physician's hands is placed under the patient's oc ciput, and the pads of the fingers contact the s uboccipital musculature. T he index and middle fingers of the physician's oppos ite hand ar e plac ed on the patient's c hin beneath the lower lip ( F igs. 10.16 an d 10.17). 3. T he phys ician gently flex es ( white arrow, F ig. 10.18) and s ide- bends the patient's oc ciput to the r ight until the edge of the r estr ictive barriers ar e r eached. The physician is is olating motion to the oc cipitoatlantal ar tic ulation only. The physician may add r otation left if desir ed. 4. T he patient gently extends

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F igure 10.16. Steps 1 and 2, lateral v iew.

F igure 10.17. Steps 1 and 2, anterior v iew.

F igure 10.18. Step 3, flexion, s ide-bending barrier.

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P.1 90 P.1 91

C erv ica l Re gion: Occipitoatlantal (C0 —C01 ) D ysfunction Ex a mple: C 0 FSLR R Post Isom etr ic Rela xation

1. T he patient is s upine and the physician s its at the head of the table. 2. O ne of the physician's hands is placed under the oc ciput, and the pads of the fingers touc h the s uboccipital musculature. T he index and middle fingers of the physician's oppos ite hand lie immediately beneath the patient's c hin ( F ig. 10.21) . T he phys ician is c areful not to c hoke patient. 3. T he phys ician ex tends (w hite ar row) and s ide- bends the oc ciput to the r ight until the r estr ictive barriers ar e engaged. The physician is is olating motion to oc cipitoatlantal ar tic ulation only. The physician may

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F igure 10.21. Steps 1 and 2.

F igure 10.22. Step 3, extens ion, s ide- bending barrier.

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add r otation left if desir ed ( Fig . 10.22). 4. T he patient gently nods the head for war d ( blac k arrow, F ig. 10.23) so that the chin pulls down into the phys ician's r estr aining fingers while the physician applies an equal c ounterforc e ( white arrow). T he phys ician s hould be able to palpate s uboc cipital muscle r elax ation with the hand beneath the oc ciput. 5. T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. 6. O nce the patient has c ompletely r elax ed, the physician further extends the head (white ar row, F ig. 10.24) by pr ess ing to the c eiling with the hand under the oc ciput and lifting cephalad with the finger s

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F igure 10.23. Step 4, isometr ic c ontr action.

F igure 10.24. Step 6, extens ion bar rier .

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beneath the c hin. 7. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

P.1 92

C erv ica l Re gion: A tla ntoaxia l (C1—C2) Dys function Exam ple : RL Post Is ometric Re laxa tion

1. T he patient is s upine and the physician s its at the head of the table. 2. T he phys ician may gently flex the patient's head (C0-C1, about 15–25 degrees) until the edge of the r estr ictive barrier is r eached, or the patient's head may r emain in neutr al. 3. T he phys ician r otates the patient's head

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Fig ure 10.25. Steps 1 to 3, r otation bar rier.

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to the r ight ( white arrow, F ig. 10.25) until the edge of the r estr ictive barrier is r eached. 4. T he patient r otates the head to the left ( blac k arrow, F ig. 10.26) while the physician applies an equal c ounterforc e ( white arrow). Note: In ac ute painful dy sfunctions the patient can v ery gently r otate or look to the r ight ( r eciprocal inhibition, oc ulocer vic al). 5. T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. 6. O nce the patient has c ompletely r elax ed, the physician r otates the patient's head ( white arrow, F ig. 10.27) to the r ight until the edge of the new r estric tive barrier is r eached.

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Fig ure 10.26. Step 4, isometr ic contraction.

Fig ure 10.27. Step 6, r otation barrier.

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7. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

P.1 93

C erv ica l Re gion: C 2—C 7 D ysfunction Ex a mple: C3 FSRR R Post Isom etr ic R ela xation

1. T he patient lies s upine, and the physician is s eated at the head of the table on the s ide of the r otational c omponent. 2. T he firs t metac arpal phalangeal joint of the physician's right hand is plac ed at the artic ular pillar of the s egment being tr eated. The heel of the physician's hand closes in against the

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F igure 10.28. Steps 1 to 3.

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oc ciput. 3. T he phys ician c r adles the patient's head between the hands (may c up the c hin with the left hand). The oc ciput, C1, C2, and C3 are flexed until the dy sfunctional C3 engages C4; the s egments ar e then ex tended s lightly to meet the extension barrier. C3 is then rotated and s ide- bent to the left until the edge of the r estr ictive barriers ar e r eached in all three planes ( F ig. 10.28) . 4. T he patient r otates the head ( blac k arrow, F ig. 10.29) to the r ight while the phys ician applies an equal c ounterforc e ( white arrow). Note: In ac ute, painful dy sfunctions the patient ver y gently r otates or looks to the left while the physician applies an equal c ounterforc e ( r eciprocal inhibition,

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F igure 10.29. Step 4, isometr ic c ontr action.

F igure 10.30. Step 6.

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oc ulocer vic al). 5. T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. 6. O nce the patient has c ompletely r elax ed, the physician r epos itions the dy sfunctional s egment by r otating and s ide- bending left (w hite ar row) and then ex tending until the edge of the new r estric tive barrier is r eached (F ig . 10.30). 7. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

P.1 94 P.1 95

Thor acic Re gion: T1—T4 D ysfunction Ex a mple: T4 ESRR R Post Isom etr ic R ela xation

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1. T he patient is s eated at the end of the table and the physician s tands at the s ide opposite the r otational c omponent. 2. T he phys ician's left hand palpates the s pinous pr ocesses of T 4 and T 5 or the T 4-T 5 inter space to monitor flex ion and extension as the r ight hand flexes the patient's head and neck (white ar row, F ig. 10.31) to the edge of the r estr ictive barrier. 3. T he phys ician's left hand monitors the tr ans ver se pr ocesses of T 4 and T 5 to localize side bending and r otation as the r ight hand s ide- bends ( white arrow, F ig. 10.32) and r otates (w hite ar row, F ig. 10.33) the patient's head and neck to the left until the edge of the

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F igu re 10.31. Steps 1 and 2, flexion barr ier .

F igu re 10.32. Step 3, left side-bending barr ier .

F igu re 10.33. Step 3, left rotation barr ier.

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P.1 96 P.1 97

Thor acic Re gion: T1—T6 D ysfunction Ex a mple: T4 FSRR R Post Isom etr ic R ela xation

1. T he patient is s eated with the r ight hand on the left shoulder and the physician s tands c los e to the patient on the s ide oppos ite the r otational c omponent. 2. T he phys ician's left hand r eaches under the patient's elbow and gr asps the patient's r ight s houlder . T he physician's right hand palpates the s pinous pr ocesses of T 4 and T 5 or T 4-T5 inter space and instr ucts the patient to r elax and r est the full weight of the head and elbow on the physician's arm ( F ig. 10.38) . 3. Starting with the patient in ex treme flex ion, the phys ician, s lowly r ais es the left elbow ( white arrow) as

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F igure 10.38. Steps 1 and 2.

F igure 10.39. Step 3, extens ion bar rier .

F igure 10.40. Step 4, left s ide- bending

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the r ight hand gently tr ans lates the dy sfunctional v ertebra forward (w hite ar row) to the edge of the ex tension barrier (F ig . 10.39). 4. T he phys ician's r ight hand now monitors the tr ans ver se pr ocesses of T 4 and T 5 to localize side bending and r otation, as the left arm and hand r epos itions the patient's left s houlder down ( white arrow) to engage the edge of the left s ide bending barrier (F ig . 10.40). 5. T he phys ician then gently r otates the patient's s houlder s left ( white arrow) to engage the edge of the left r otation bar rier ( F ig. 10.41) . 6. T he patient pushes down with the elbows and forehead against the physician's arm while s imultaneous ly

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barrier.

F igure 10.41. Step 5, left r otation bar rier.

F igure 10.42. Step 6, isometr ic c ontr action.

F igure 10.43. Step 8, left s ide- bending barrier.

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7.

8.

9.

10.

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r otating the tr unk to the r ight (blac k ar row) as the physician applies an unyielding c ounterforc e ( white arrow, F ig. 10.42) . T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician r epos itions the patient to the edge of the new r estr ictive barriers in all three planes : first left s ide bending, (F ig. 10.43) then left r otation (F ig. 10.44), and finally extension ( F ig. 10.45) . Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the

F igure 10.44. Step 8, left r otation bar rier.

F igure 10.45. Step 8, extens ion bar rier .

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effec tiv enes s of the technique.

P.1 98 P.1 99

Thor acic Re gion: T5—T12 Dys func tion Ex ample: T8 ESR RR Pos t Isom etr ic R ela xation

1. Patient is s eated on the end of the table, the left side c lose to the edge. The ar ms ar e folded ac ros s the c hest, r ight ov er left. 2. T he phys ician s tands at the s ide of the patient opposite the r otational c omponent. 3. T he phys ician's left arm r eaches acr oss in fr ont of the patient's elbows and plac es the left hand on the patient's r ight s houlder . 4. T he phys ician's r ight hand monitors the s pinous pr ocesses of T 8 and T 9 or the T 8-T 9 inter space to localize flexion and extension

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F igu re 10.46. Steps 1 to 4, flexion barr ier.

F igu re 10.47. Step 5, left side-bending barr ier .

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as the left arm and hand flex the patient's torso (white ar row, F ig. 10.46) until the edge of the r estr ictive barrier is r eached. 5. T he phys ician's r ight hand monitors the tr ans ver se pr ocesses of T 8 and T 9 to localize side bending and r otation as the left arm and hand pos ition the patient's torso to the engage the edge of the left s ide bending ( white arrow, F ig. 10.47) and left rotation barrier (w hite ar row, F ig. 10.48). 6. T he patient sits up and turns the s houlder s to the r ight ( blac k arrow) as the physician's left hand applies an unyielding c ounterforc e ( white arrow, F ig. 10.49) . 7. T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the

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F igu re 10.48. Step 5, left rotation barr ier.

F igu re 10.49. Step 6, is ometric c ontrac tion.

F igu re 10.50. Step 8, left side-bending barr ier .

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patient is instr ucted to st op and relax. 8. O nce the patient has c ompletely r elax ed, the physician r epos itions the patient to the edge of the new r estr ictive barriers in all three planes : first left s ide bending (F ig . 10.50), then left r otation (F ig. 10.51), and finally flex ion ( F ig. 10.52) . 9. Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. 10. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

F igu re 10.51. Step 8, left rotation barr ier.

F igu re 10.52. Step 8, flexion barr ier .

P.2 00

C ostal R egion: Right Fir st R ib, Inhala tion D ysfunction: R e spiratory A ssist, Sea ted

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1. T he patient is seated. T he phys ician s tands behind the patient, placing the left foot on the table to the left s ide of the patient and k eeping the hip and k nee flexed at about 90 degrees. 2. T he patient's left ar m is dr aped ov er the physician's left thigh. 3. T he metac arpal- phalangeal joint of the physician's r ight index finger c ontacts the super ior s urface of the dy sfunctional r ight r ib posterior and lateral to the c ostotr ansv ers e ar tic ulation. 4. T he patient's head, c ontr olled by the physician's left hand, is gently flexed, s ide- bent towar d, and r otated away fr om the r ight rib to take the tension off the sc alene musculature (F ig. 10.53). 5. T he patient inhales and then ex hales deeply. 6. During exhalation, the physician's right hand follows the fir st rib down and for war d ( white arrow, F ig. 10.54) further into ex halation. 7. T he patient inhales deeply ( blac k arrow, F ig. 10.55) , as the physician's right hand r esis ts (w hite arr ow) the inhalation motion

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F igu re 10.53. Steps 1 to 4.

F igu re 10.54. Step 6, ex halation.

F igu re 10.55. Step 7, resis t inhalation.

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P.2 01

C ostal R egion: Right Fir st R ib, Inhala tion D ysfunction: R e spiratory A ssist, Supine

1. T he patient lies s upine and the phy s ician s tands or s its behind the patient. 2. T he metac arpal- phalangeal joint of the physician's r ight index finger c ontacts the super ior s urface of the dy sfunctional r ight r ib posterior and lateral to the c ostotr ansv ers e ar tic ulation. 3. T he patient's head, c ontr olled by the physician's left hand, is gently flexed, s ide- bent towar d, and r otated away fr om the r ight rib to take the tension off the sc alene musculature (F ig. 10.57). 4. T he patient inhales and then ex hales deeply. 5. During exhalation, the physician's right hand follows the fir st rib down and for war d ( white arrow, F ig. 10.58) further into ex halation. 6. T he patient inhales deeply ( blac k arrow, F ig. 10.59) as the physician's right hand r esis ts (w hite arr ow) the inhalation motion of the firs t rib. 7. During exhalation, the physician's right hand

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F igu re 10.57. Steps 1 to 4.

F igu re 10.58. Step 6, ex halation.

F igu re 10.59. Step 7, resis t inhalation.

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follows the fir st rib down and for war d ( white arrow, F ig. 10.60) towar d ex halation. 8. Steps 7 and 8 are r epeated fiv e to s even times or until motion is maximally improved at the dysfunc tional rib. 9. Motion of the dy sfunctional r ib is r eevaluated to deter mine the effec tiv enes s of the technique. 10. An alter native technique is to have the patient lift the r ight s houlder agains t r esis tance for 3 to 5 s econds and then c arry the r ib toward ex halation during the r elax ation phas e.

F igu re 10.60. Step 8, ex aggerate exhalation.

P.2 02

C ostal R egion: Right Ribs 1 and 2, Inhala tion D y sfunction: Post Isom etr ic R ela xation to Rela x Scalene Mus cle s, Seated

1. T he patient is s eated and the physician s tands behind the patient, placing the left foot on the table to the left side of the patient and k eeping the hip and knee flexed at about 90 degrees.

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Fig ure 10.61. Steps 1 to 3.

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2. T he phys ician's r ight thumb is placed over the anter omedial as pec t of the dy sfunctional r ight rib. 3. T he phys ician's left hand c ontr ols the patient's forehead, r otates it 30 to 45 degrees to the left (white ar row), and adds slight ex tension until meeting the edge of the r estr ictive barrier (F ig . 10.61). 4. T he patient pushes the head for war d into the physician's left hand (b lack ar row, F ig. 10.62) as the physician r esis ts (long white ar row) . T he r ight hand ( s hor t white ar row) s imultaneous ly r esis ts any inhalation movement of the dy sfunctional r ib. 5. T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient

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Fig ure 10.62. Step 4, isometr ic contraction.

Fig ure 10.63. Step 6, extension barr ier .

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is instr ucted to relax. 6. O nce the patient has c ompletely r elax ed, the physician's left hand minimally ex tends the patient's head ( white arrow, F ig. 10.63) until a new r estr ictive barrier is r eached. 7. Steps 5 to 7 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional r ib. 8. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

P.2 03

C ostal R egion: Right Ribs 1 and 2, Inhala tion D y sfunction: Post Isom etr ic R ela xation to Rela x Scalene Mus cle s, Supine

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1. T he patient lies s upine and the physician s its at the head of the table. 2. T he phys ician's r ight thumb is placed over the anter omedial as pec t of the dy sfunctional r ib. 3. T he phys ician's left hand c ontr ols the patient's head and r otates it 30 to 45 degrees to the left (w hite ar row, F ig. 10.64) and adds s light extension by lower ing the thigh until the edge of the r estr ictive barrier is r eached. 4. T he patient flexes the head and neck into the phys ician's left hand ( blac k ar row, F ig. 10.65) as the physician applies an equal c ounterforc e ( long white ar row). The r ight thumb ( s hor t white ar row) s imultaneous ly r esis ts any inhalation movement of

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Fig ure 10.64. Steps 1 to 3, r otation and extens ion bar rier.

Fig ure 10.65. Step 4, isometr ic contraction.

Fig ure 10.66. Step 6, extension barr ier .

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P.2 04

C ostal R egion: Right Ribs 2 to 6, Inha lation Dy s function: R espira tory As sis t

1. T he patient lies s upine and the physician's flexed r ight k nee is plac ed on the table under neath the patient's r ight upper thorac ic r egion at the level of the dy sfunctional r ib. 2. T he patient's upper body is s ide- bent to the s ide of the dy sfunction ( r ight s ide) until tension is taken off the dy sfunctional r ib. 3. T he web formed by the physician's r ight thumb and index finger is placed in the inter cos tal s pace above the dy sfunctional r ib on its s uper ior s urface (F ig . 10.67). 4. T he patient inhales and ex hales deeply. 5. During ex halation the physician's

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F ig ure 10.67. Steps 1 to 3.

F ig ure 10.68. Step 5, exagger ate ex halation.

F ig ure 10.69. Step 6, r esist inhalation.

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6.

7.

8.

9.

r ight hand ex aggerates the exhalation motion ( white ar row, F ig. 10.68) of the dy sfunctional r ib. T he patient inhales again ( blac k arrow, F ig. 10.69) as the phys ician's r ight hand r esis ts (w hite ar row) the inhalation motion of the dy sfunctional r ib. T he patient ex hales, and the phys ician ex aggerates the exhalation motion ( white ar row, F ig. 10.70) of the dy sfunctional r ib. Steps 6 and 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

F ig ure 10.70. Step 7, exagger ate ex halation.

P.2 05

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C ostal R egion: Right Ribs 7 to 10, Inhala tion D y sfunction: R espira tory As sis t

1. T he patient lies s upine, and the physician s tands at the s ide of the dy sfunctional r ib. 2. T he patient's upper body is bent to the side of the dy sfunction ( r ight s ide) until tension is taken off the dy sfunctional r ib. 3. T he web formed by the physician's r ight thumb and index finger is placed in the inter cos tal s pace on the s uper ior s urface of the dy sfunctional r ib ( Fig . 10.71). 4. T he patient inhales and ex hales deeply as the physician's r ight hand ex aggerates ( white arrow, F ig. 10.72) the ex halation motion of the dy sfunctional r ib. 5. O n inhalation ( blac k arrow,

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F ig ure 10.71. Steps 1 to 3.

F ig ure 10.72. Step 4, exagger ate ex halation.

F ig ure 10.73. Step 5, r esist inhalation.

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F ig. 10.73) the physician's r ight hand r esis ts (w hite ar row) the inhalation motion of the dy sfunctional r ib. 6. T he patient ex hales and the physician ex aggerates the exhalation motion ( white ar row, F ig. 10.74) of the dy sfunctional r ib. 7. Steps 5 and 6 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. 8. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

F ig ure 10.74. Step 6, exagger ate ex halation.

P.2 06

C ostal R egion: Right Ribs 1 1 and 1 2, Inha lation Dys function: R espira tory As sis t

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1. T he patient lies pr one, and the physician s tands at the left side of the table and positions the patient's legs 15 to 20 degrees to the r ight, taking tension off the quadr atus lumborum. 2. T he phys ician places the left hy pothenar eminence medial and infer ior to the angle of the dy sfunctional r ib and exer ts gentle, s ustained later al and c ephalad tr action. 3. T he phys ician may gras p the patient's r ight anter ior s uper ior iliac s pine with the r ight hand to s tabiliz e the pelvis ( Fig . 10.75). 4. T he patient inhales and ex hales deeply. 5. During ex halation the physician's left hand ex aggerates ( white arrow, F ig. 10.76) the

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F ig ure 10.75. Steps 1 to 3.

F ig ure 10.76. Step 5, exagger ate ex halation.

F ig ure 10.77. Step 6, r esist inhalation.

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P.2 07

C ostal R egion: Ana tom y of the Scalene Mus cle s

Anterio r Scalene Muscle O rig in T he origin of the anterior s calene musc le is at transver se proc ess es C3 to C6 ( Fig . 10.79). Insertio n T he insertion of the anterior s calene musc le is at the scalene tubercle, s uperior s urface of the fir s t r ib. Action T he anterior s calene musc le elev ates the firs t r ib, flex es laterally, and rotates the nec k .

F igure 10.79. Anatomy of the scalenes and thorac ic outlet ( 7).

Innervat ion T he ventral r ami of the c erv ical s pinal nerv es

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( C4- C6) innervate the anterior s calene musc le. Midd le Scalene Muscle O rig in T he origin of the middle s calene musc le is at transver se proc ess es C1 to C6. Insertio n T he insertion point of the middle s calene musc le is at the superior s urface of firs t r ib posterior to the s ubc lav ian artery. Action T he middle s calene musc le elev ates the firs t r ib during forc ed inspiration and flex es the nec k laterally. Innervat ion

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T he ventral r ami of c erv ical s pinal nerv es C3 to C8 innervate the middle s calene musc le. Post erio r Scalene Muscle O rig in T he origin of the posterior s calene musc le is at transver se proc ess es C4 to C6. Insertio n T he insertion of the posterior s calene musc le is at the sec ond r ib. Action T he posterior s calene musc le elev ates s econd r ib during forc ed inspiration and flex es the nec k laterally. Innervat ion

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T he ventral r ami of c erv ical s pinal nerv es ( C6–C8) innervate the posterior s calene musc le.

P.2 08

C ostal R egion: Right Ribs 1 and 2, Ex hala tion D y sfunction: C ontrac tion of Sc a lene Musc les Mobilizes Dys func tional Ribs

1. T he patient lies s upine, and the physician s tands on the left side of the patient. 2. T he patient's head is rotated approximately 30 degrees to the left. 3. T he patient's r ight wr ist ( dors al s urface) is placed against the forehead ( F ig. 10.80) . 4. T he phys ician's left hand r eaches under the patient, gr asps the s uper ior angle of the r ight dy sfunctional r ib, and ex erts a caudad and

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F igure 10.80. Steps 1 to 3.

F igure 10.81. Step 4.

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5.

6.

7.

8.

9.

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later al trac tion ( white arrow, F ig. 10.81) . T he patient flexes the head and neck ( blac k arrow, F ig. 10.82) without altering the r otation of the head while the phys ician's r ight hand applies an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and the patient is instr ucted to relax. O nce the patient has c ompletely r elax ed, the physician's left hand exerts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( white ar row, F ig. 10.83). Steps 6 to 8 ar e r epeated fiv e to s even times or until motion is maximally improved at the dy sfunctional r ib. Motion of the dy sfunctional

F igure 10.82. Step 5, isometric c ontr action.

F igure 10.83. Step 7.

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r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

P.2 09

C oas tal Region: Pe ctoralis Minor Musc le

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O rig in T he origin of the pectoralis minor musc le is at the anterior s uperior s urface of r ibs 3, 4, and 5 ( F ig. 10.84). Insertio n T he insertion of the pectoralis minor musc le is at the c oracoid proc ess of s capula. Action T he pectoralis minor musc le s tabiliz es s capula by drawing it inferior ly and anterior ly against thor acic wall. Innervat ion T he medial pectoral nerv e ( C8, T 1) innervates the pectoralis

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F igure 10.84. Pectoralis minor musc le ( 7).

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C ostal R egion: Right Rib 3, 4, or 5, Exha lation Dys function: C ontrac tion of Pe c tor alis Minor Mobilizes Dy sfunctiona l R ibs

1. T he patient lies s upine and the physician s tands on the left side of the table. 2. T he patient r aises the r ight ar m and plac e the hand ov er the head (F ig. 10.85). 3. T he phys ician's left hand r eaches under the r ight s ide of the patient, gr asps the s uper ior angle of the dy sfunctional r ib, and ex erts c audad and later al trac tion. 4. T he phys ician's r ight hand is placed over the anter ior as pect of the patient's r ight shoulder at the level of the c oracoid pr ocess (F ig . 10.86). 5. T he patient pr otr acts the s houlder by pushing forward against the phys ician's r ight hand ( blac k arrow, F ig. 10.87) ,

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F ig ure 10.85. Steps 1 and 2.

F ig ure 10.86. Steps 3 and 4.

F ig ure 10.87. Step 5, isometr ic c ontraction.

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6.

7.

8.

9.

which is apply ing an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician's left hand exerts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( white ar row, F ig. 10.88). Steps 5 to 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

F ig ure 10.88. Step 7.

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C ostal R egion: Right Rib 3, 4 or 5 , Ex halation D ysfunc tion:

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C ontrac tion of Pe c tor alis Minor Mobilizes Dy sfunctiona l R ibs

1. T he patient lies s upine, and the physician s tands on the left side of the table. 2. T he patient r aises the r ight ar m and plac e the hand ov er the head (F ig. 10.89). 3. T he phys ician's left hand r eaches under the r ight s ide of the patient, gr asps the s uper ior angle of the dy sfunctional r ib and exer ts c audad and later al trac tion. 4. T he phys ician's r ight hand is placed over the anter ior as pect of the patient's r ight elbow ( F ig. 10.90) . 5. T he patient pushes the elbow agains t the phys icians r ight hand ( blac k arrow, F ig. 10.91) , which is apply ing an unyielding c ounterforc e ( white arrow). 6. T his isometr ic c ontr action is held for 3 to 5 s econds, and

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F ig ure 10.89. Steps 1 and 2.

F ig ure 10.90. Steps 3 and 4.

F ig ure 10.91. Step 5, isometr ic c ontraction.

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then the patient is instr ucted to st op and relax. 7. O nce the patient has c ompletely r elax ed, the physician's left hand exerts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( white ar row, F ig. 10.92). 8. Steps 5 to 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. 9. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

F ig ure 10.92. Step 7.

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C ostal R egion: Se r ratus Ante rior Musc le

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O rig in T he origin of the s err atus anterior musc le is at the anterior s urface of the medial border of the scapula ( Fig . 10.93). Insertio n T he insertion of the ser r atus anterior musc le is at the superior lateral s urface of r ibs 2 to 8. Action T he s err atus anterior musc le protrac ts the scapula and holds it against the thor acic wall. Innervat ion T he long thor acic nerv e ( C5–C7) innervates the ser r atus anterior musc le.

F ig ure 10.93. Serratus anterior musc le (7) .

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C ostal R egion: Right Rib 6, 7, or 8, Exha lation Dys function: C ontrac tion of Se r ratus Ante rior Mobilize s D ysfunctional R ibs

1. T he patient lies s upine and the physician s tands or s its at the s ide of the dy sfunctional r ib. 2. T he patient's r ight shoulder is flexed 90 degrees; the elbow may be flexed for better c ontr ol by the physician. 3. T he phys ician r eaches the r ight hand under the patient and gr asps the s uper ior angle of the dy sfunctional r ib, exerting c audad and later al trac tion ( white arrow, F ig. 10.94) . 4. T he patient pushes the elbow towar d the c eiling ( s capular pr otr action) ( blac k arrow, F ig. 10.95) while the physician applies an unyielding c ounterforc e ( white arrow).

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F ig ure 10.94. Steps 1 to 3.

F ig ure 10.95. Step 4, isometr ic c ontraction.

F ig ure 10.96. Step 6.

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5. T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. 6. O nce the patient has c ompletely r elax ed, the physician's r ight hand ex erts increased c audad and later al trac tion ( white arrow, F ig. 10.96) on the angle of the dy sfunctional r ib. 7. Steps 5 to 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. 8. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

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C ostal R egion: La tiss imus D orsi Muscle

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O rig in T he origin of the latissimus dors i muscle is at s pinous proc ess es of T 7 to S3, the thor acolumbar fasc ia, the inferior angle of s capula, the lower four r ibs , and the iliac c r est ( Fig . 10.97). Insertio n T he ins ertion of the latissimus dors i muscle is at the intertuberc ular ( bic ipital) groove of the humerus . Action T he latissimus dors i muscle extends , adducts , and medially r otates the humerus . Innervat ion T he thor acodors al nerv e ( C6–C8) innervates the latissimus dors i muscle.

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C ostal R egion: Right Ribs 9 and 10 , Ex halation D ysfunc tion: C ontrac tion of La tiss imus D orsi Mobilizes Dy sfunctiona l R ibs

1. T he patient lies s upine, and the physician s tands or s its at the s ide of the dy sfunctional r ib. 2. T he phys ician's left hand abduc ts the patient's r ight s houlder 90 degrees, and the r ight hand r eaches under the patient and gr asps the s uper ior angle of the dy sfunctional r ib, exerting c audad and later al trac tion. 3. T he phys ician's left lateral thigh or knee is placed against the patient's r ight elbow ( F ig. 10.98) . 4. T he patient pushes the r ight ar m into the physician's thigh (blac k ar row, F ig. 10.99) while the physician's left thigh and/or ar m applies an unyielding c ounterforc e

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Fig ure 10.98. Step 3.

Fig ure 10.99. Step 4.

Fig ure 10.100. Step 6.

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( white arrow). 5. T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. 6. O nce the patient has c ompletely r elax ed, the physician's r ight hand ex erts increased c audad and later al trac tion ( white arrow, F ig. 10.100) on the angle of the dy sfunctional r ib. 7. Steps 4 to 6 ar e r epeated fiv e to s even times or until motion is maximally improved at the dy sfunctional r ib. 8. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.

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C ostal R egion: Qua dra tus Lum bor um Mus c le

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O rig in T he origin of the quadratus lumborum musc le is at the iliac c res t and the iliolumbar ligament ( Fig . 10.101) . Insertio n T he insertion of the quadratus lumborum musc le is at the inferior aspect of the 12th rib and the transver se proc ess es of L1 to L4. Action T he quadratus lumborum musc le extends and laterally flex es the v ertebr al c olumn; it also fix es the 12th rib during inhalation.

F igure 10.101. Quadratus lumborum ( 7).

Innervat ion T he ventral branches of T 12 to L4

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C ostal R egion: Right Ribs 1 1 and 1 2, Exha lation Dys function: C ontrac tion of Qua dra tus Lum bor um Mobilizes Dys func tional Ribs

1. T he patient lies pr one and the physician s tands at the left s ide of the table and positions the patient's legs 15 to 20 degrees to the left, putting tension on the quadr atus lumborum. 2. T he phys ician's left thenar eminence or index finger is placed s uper ior and lateral to the angle of the dy sfunctional r ib and exer ts gentle s ustained medial and c audad trac tion ( left-pointing white ar row, F ig. 10.102) . 3. T he phys ician's r ight hand gr asps the patient's r ight anter ior superior iliac spine ( ASIS) and gently lifts towar d the c eiling ( upward- pointing white ar row, F ig. 10.102) . 4. T he patient inhales,

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F ig ure 10.102. Steps 1 to 3.

F ig ure 10.103. Step 5, isometric c ontraction and exagger ate inhalation.

F ig ure 10.104. Step 7.

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ex hales, and then inhales deeply. 5. During inhalation the phys ician instr ucts the patient to pull the r ight ASIS down toward the table (blac k ar row, F ig. 10.103) while the phys ician's r ight hand applies an unyielding c ounterforc e ( opposing white ar row). At the s ame time, the left hand ex aggerates the inhalation motion of the dy sfunctional r ib by ex erting medial and c audad trac tion ( left-pointing white ar row) . 6. T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to relax. 7. O nce the patient has c ompletely r elax ed, the physician's right hand lifts the patient's r ight ASIS toward the c eiling ( upward- pointing white ar row) , and the left hand

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ex erts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( left-pointing white ar row, F ig. 10.104) . 8. Steps 5 to 7 ar e r epeated fiv e to s even times or until motion is maximally improved at the dy sfunctional r ib. 9. Motion of the dy sfunctional r ib is reevaluated to as ses s the effec tiv enes s of the technique.

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C ostal R egion: Right Ribs 1 1 and 1 2, Exha lation Dys function: R espira tory As sis t

1. T he patient lies pr one and the physician s tands at the left s ide of the table. T he patient's legs are positioned 15 to 20 degrees to the left, putting tension on the quadr atus lumborum.

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2. T he phys ician places the left thenar eminence or index finger s uper ior and later al to the angle of the dy sfunctional r ib and exer ts gentle s ustained medial and c audad trac tion. 3. T he phys ician's r ight hand gr asps the patient's r ight ASIS and gently lifts towar d the c eiling (F ig . 10.105). 4. T he patient inhales, ex hales, and then inhales deeply. 5. During inhalation, the physician's left hand ex aggerates the inhalation motion of the dy sfunctional r ib by ex erting medial and c audad trac tion ( left-pointing white ar row, F ig. 10.106) as the r ight hand gently lifts the patient's r ight anter ior superior iliac spine ( upward- pointing white ar row) towar d the c eiling. 6. O n ex halation

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F ig ure 10.105. Steps 1 to 3.

F ig ure 10.106. Step 5, exaggerate inhalation.

F ig ure 10.107. Step 6, res ist ex halation.

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( blac k arrow, F ig. 10.107) the physician's left hand res ists ( white arrow) the exhalation motion of the r ib. 7. Steps 5 and 6 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. 8. Motion of the dy sfunctional r ib is reevaluated to as ses s the effec tiv enes s of the technique.

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Lumbar R egion: Ty pe I Dy sfunction Exa m ple : L2 N SLRR Post Isom etr ic R ela xation

1. T he patient is s eated at the end of the table. T he phys ician s tands to the s ide opposite the r otational c omponent of the dysfunc tion. 2. T he patient places the r ight hand behind the neck and the left hand on the r ight elbow.

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F igu re 10.108. Steps 1 to 3.

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3. T he phys ician passes the left ar m under the patient's left ar m and gras ps the patient's r ight upper arm ( F ig. 10.108). 4. T he phys ician's r ight hand monitors the s pinous pr ocesses of L2 and L3 or the L2-L3 inter space as the left ar m and hand flex and ex tend the patient's torso ( white arrow, F ig. 10.109) until L2 is neutr al in r elation to L3. 5. T he phys ician's r ight hand monitors the tr ans ver se pr ocesses of L2 and L3 to localize side bending and r otation as the left arm and hand pos ition the patient's torso to the edge of the r ight side bending (w hite ar row, F ig. 10.110), and then left r otation bar rier ( white arrow, F ig. 10.111) . 6. T he patient turns or pulls

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F igu re 10.109. Step 4, L2-L3 neutr al.

F igu re 10.110. Step 5, r ight s ide- bending barr ier .

F igu re 10.111. Step 5, left rotation bar r ier .

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7.

8.

9.

10.

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the r ight s houlder bac k to the r ight ( blac k arrow, F ig. 10.112) while the physician's left hand applies an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician, k eeping L2 neutr al, r epos itions the patient to the edge of the r ight s ide- bending barrier (w hite ar row, F ig. 10.113) and left r otation bar rier ( white arrow, F ig. 10.114) . Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. Motion of the dy sfunctional s egment is r eevaluated to

F igu re 10.112. Step 6, isometr ic c ontrac tion.

F igu re 10.113. Step 8, r ight s ide- bending barr ier .

F igu re 10.114. Step 8, left rotation bar r ier .

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as ses s the effec tiv enes s of the technique.

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Lumbar R egion: Ty pe II D ysfunction Ex a mple: L2 ERRSR Post Isom etr ic R ela xation

1. T he patient is s eated and the physician s tands to the left of the patient (side oppos ite the r otational c omponent of the dy sfunction) . 2. T he patient places the r ight hand behind the neck and the left hand on the r ight elbow. ( Variation: the patient may place the hands behind the neck and approximate the elbows anter ior ly.) 3. T he phys ician passes the left ar m over or under the patient's left ar m and gras ps the patient's r ight upper arm ( F ig. 10.115).

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F igu re 10.115. Steps 1 to 3.

F igu re 10.116. Step 4, flex ion bar rier.

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4. T he phys ician's r ight hand monitors the s pinous pr ocesses of L2 and L3 or the L2-L3 inter space to localize flexion and extension as the physician's left hand pos itions the patient's tr unk to the edge of the r estr ictive flexion bar r ier ( F ig. 10.116). 5. T he phys ician's r ight hand monitors the tr ans ver se pr ocesses of L2 and L3 to localize side bending and r otation as the physician's left hand r epos itions the patient's tr unk to the edge of the left s ide- bending barrier (F ig . 10.117) and left r otation bar rier ( F ig. 10.118). 6. T he patient tr ies to sit up and gently pull the r ight s houlder backward ( blac k arrow, F ig. 10.119) while the physician's left

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F igu re 10.117. Step 5, left side-bending barr ier .

F igu re 10.118. Step 5, left rotation bar r ier .

F igu re 10.119. Step 6, isometr ic c ontrac tion.

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7.

8.

9.

10.

hand applies an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician r epos itions the patient (w hite ar rows, Fig . 10.120) to the edge of the left s ide bending, left rotation ( F ig. 10.121), and flex ion barrier (F ig . 10.122). Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. Motion of the dy sfunctional s egment is r eevaluated to as ses s the effec tiv enes s of the technique.

F igu re 10.120. Step 8, left side-bending barr ier .

F igu re 10.121. Step 8, left rotation bar r ier .

F igu re 10.122. Step 8, flex ion bar rier.

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Lumbar R egion: Ty pe I Dy sfunction Exa m ple : L4 N SLRR Post

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Isom etr ic R ela xation

1. T he patient lies in a right lateral r ecumbent position on the s ide of the r otational c omponent of the dysfunc tion and the physician s tands at the s ide of the table facing the patient. 2. T he phys ician's c audad hand or thigh contr ols the patient's flexed k nees and hips while the c ephalad hand palpates the L4 and L5 s pinous pr ocesses or the L4-L5 inter space. 3. T he phys ician's c audad hand or thigh gently flexes and ex tends the patient's hips until the physician's c ephalad hand deter mines the dy sfunctional s egment ( L4-L5) to be positioned in neutr al (F ig . 10.123). 4. T he patient's left leg is lower ed off the edge of the

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F igure 10.123. Steps 1 to 3.

F igure 10.124. Step 4.

F igure 10.125. Step 5.

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5.

6.

7.

8.

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table, c aus ing anter ior rotation of the pelv is, u n til the physician's c ephalad hand detec ts motion at the dy sfunctional s egment (F ig . 10.124). Switc hing hands , the physician us es the c ephalad hand to gently move the patient's s houlder posteriorly ( white arrow, F ig. 10.125) u n til the c audad hand detec ts motion at the dy sfunctional s egment. T he patient g ently pushes the s houlder forward (b lack ar row, F ig. 10.126) against the unyielding c ounterforc e of the phys ician's c ephalad hand ( white arrow). T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is told to stop an d relax. O nce the patient has c ompletely

F igure 10.126. Step 6, is ometric c ontr action.

F igure 10.127. Step 8.

F igure 10.128. Step 9, is ometric c ontr action.

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10.

11.

12.

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r elax ed, the physician gently moves the patient's s houlder posteriorly ( white arrow, F ig. 10.127) , r otating the thoracic and lumbar s pine to the edge of the new r estric tive barrier. T he patient g ently pulls the hip and pelv is c ephalad up towar d the s houlder (black ar row, F ig. 10.128) against the unyielding c ounterforc e of the phys ician's c audad hand ( white arrow). T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is told to stop an d relax. O nce the patient has c ompletely r elax ed, the physician gently moves the patient's pelvis c audad ( white ar row, F ig. 10.129) to the edge of the new r estr ictive barrier. Steps 6 to 11 ar e r epeated

F igure 10.129. Step 11.

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three to fiv e times or until motion is maximally improved at the dy sfunctional s egment ( L4-L5). 13. Steps 6, 7, 9, and 10 may be performed s imultaneous ly, after which the physician r epos itions the patient to the edge of the new r estr ictive barriers . 14. Motion of the dy sfunctional s egment is r eevaluated to as ses s the effec tiv enes s of the technique.

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Lumbar R egion: Ty pe II D ysfunction Ex a mple: L4 E/FSRRR Pos t Isom etr ic R ela xation

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1. T he patient lies on the s ide of the r otational c omponent, and the phys ician s tands facing the patient. 2. T he phys ician's c audad hand or thigh contr ols the patient's flexed k nees and hips while the c ephalad hand palpates the L4 and L5 s pinous pr ocesses or the L4-L5 inter space. 3. T he phys ician's c audad hand or thigh gently flexes and ex tends the patient's hips until the physician's c ephalad hand deter mines the dy sfunctional s egment ( L4-L5) to be positioned in neutr al (F ig . 10.130). 4. T he phys ician's c audad hand places the patient's left foot behind the r ight knee in the popliteal fossa ( F ig. 10.131). 5. Switc hing hands , the physician us es the c ephalad

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F igure 10.130. Steps 1 to 3.

F igure 10.131. Step 4.

F igure 10.132. Step 5.

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P.2 28

Pelv ic R egion: Right Pos ter ior Innominate Dy sfunction: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation

Diag nosis Standing flexion test: Positiv e (r ight posterior s uperior iliac s pine [PSIS] r ises) Loss of pas siv ely induced right s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the right PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Anterior , deep on the r ight

F igure 10.137. Steps 1 to 3.

T ech niq u e 1. T he patient lies s upine on a diagonal, s o the r ight sacroiliac joint is off the edge of the table. 2. T he phys ician s tands at the r ight side of the table. 3. T he phys ician's c ephalad hand is placed ov er the patient's left ASIS to prev ent the patient from r olling off the table. T he c audad hand is placed distal to the patient's

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F igure 10.138. Step 4.

F igure 10.139. Step 5, is ometric c ontr action.

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4.

5.

6.

7.

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k nee (F ig. 10.137). T he phys ician's c audad ( right) hand pas siv ely ex tends the patient's r ight hip ( white ar row, F ig. 10.138), br inging the innominate into anter ior r otation, until the edge of the r estr ictive barrier is r eached. T he patient lifts the r ight leg ( blac k arrow, F ig. 10.139) towar d the c eiling while the physician applies an equal c ounterforc e ( white arrow). T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician ex tends the patient's r ight hip ( white ar row, F ig. 10.140) to the edge of the new

F igure 10.140. Step 7.

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r estr ictive barrier. 8. Steps 5 to 7 ar e r epeated thr ee to five times. 9. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

P.2 29

Pelv ic R egion: Right Pos ter ior Innominate Dy sfunction: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the right PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Anterior , deep on the r ight

F igure 10.141. Step 1.

T ech niq u e 1. T he patient is placed in a left later al modified Sims pos ition: left lateral r ecumbent, with

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2.

3.

4.

5.

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the anterior thorax r esting on the table and ar ms hanging ov er the side of the table ( F ig. 10.141). T he phys ician s tands behind the patient, gr asps the patient's r ight leg with the c audad ( right) hand, and places the hy pothenar eminence of the c ephalad hand on the patient's r ight PSIS. T he phys ician's c audad hand passively ex tends the patient's r ight hip ( white ar row, F ig. 10.142), br inging the innominate into anter ior r otation, until the edge of the r estr ictive barrier is r eached. T he patient pulls the r ight leg forward ( blac k arrow, F ig. 10.143) while the physician applies an equal c ounterforc e ( white arrow). T his isometr ic

F igure 10.142. Steps 2 and 3.

F igure 10.143. Step 4, is ometric c ontr action.

F igure 10.144. Step 6.

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c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to relax. 6. O nce the patient has c ompletely r elax ed, the physician ex tends the patient's r ight hip ( white ar row, F ig. 10.144) to the edge of the new r estr ictive barrier. 7. Steps 4 to 6 ar e r epeated thr ee to five times. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

P.2 30

Pelv ic R egion: Right Pos ter ior Innominate Dy sfunction: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation

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Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the right PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Anterior , deep on the r ight

F igure 10.145. Steps 1 and 2.

T ech niq u e 1. T he patient lies pr one and the physician s tands on the left side of the table. 2. T he hypothenar eminence of the physician's c ephalad (left) hand is plac ed on the patient's r ight PSIS and the phys ician's c audad ( right) hand grasps the patient's r ight leg distal to the tibial tuber osity ( Fig . 10.145). 3. T he phys ician's c audad ( right) hand pas siv ely ex tends the patient's r ight hip ( white ar row, F ig. 10.146),

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F igure 10.146. Step 3.

F igure 10.147. Step 4, is ometric c ontr action.

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P.2 31

PELVIC R EGION: Right Anterior Innomina te Dys func tion: C ombine d Re ciproc a l Inhibition and Mus cle Contr a ction Mobilize A rticula tion

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior, shallow on the right

F igure 10.149. Steps 1 and 2.

T ech niq u e 1. T he patient lies s upine, and the physician is s eated on the table facing the patient. 2. T he phys ician places the patient's r ight heel on the r ight shoulder and pass ively flexes the patient's r ight hip and knee ( white arrow, F ig. 10.149) until the edge of the r estric tive barrier is r eached. 3. An ac ceptable modification is

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F igure 10.150. Step 3, alter native.

F igure 10.151. Step 4, is ometric

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4.

5.

6.

7.

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to have the patient's r ight k nee loc ked in full extens ion and the leg flexed at the hip with the patient's r ight leg on the physician's r ight shoulder ( F ig. 10.150). T he patient pushes the k nee into the physician's hands , ex tending the r ight hip ( blac k ar row, F ig. 10.151), while the phys ician applies an equal c ounterforc e ( white arrow). T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician flexes the patient's r ight hip ( white ar row, F ig. 10.152) to the edge of the new r estr ictive barrier. Steps 4 to 6 ar e

c ontr action.

F igure 10.152. Step 6.

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r epeated thr ee to five times. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

P.2 32

Pelv ic R egion: Right Anterior Innomina te Dys func tion: Com bine d R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior on the r ight

F igure 10.153. Steps 1 and 2.

T ech niq u e 1. T he patient lies in the left lateral r ecumbent position, and the phys ician s tands at the s ide of the table facing the patient. 2. T he phys ician's

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F igure 10.154. Step 3.

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c audad ( left) hand palpates the r ight s acroiliac motion and s tabiliz es the pelvis while the physician's c ephalad (r ight) hand places the patient's r ight foot agains t the physician's thigh (F ig. 10.153). 3. Supporting the patient's r ight k nee, the physician's c ephalad hand flexes the patient's r ight hip, bringing the innominate into posterior r otation until the edge of the r estr ictive barrier is r eached (w hite ar row, F ig. 10.154). 4. T he patient pushes the r ight foot into the phys ician's thigh (blac k ar row, F ig. 10.155) while the phys ician applies an equal c ounterforc e ( white arrow). 5. T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the

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F igure 10.155. Step 4, is ometric c ontr action.

F igure 10.156. Step 6.

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patient is instr ucted to st op and relax. 6. O nce the patient has c ompletely r elax ed, the physician flexes the r ight hip innominate to the edge of the new r estr ictive barrier (w hite ar row, F ig. 10.156). 7. Steps 4 to 6 ar e r epeated thr ee to five times. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

P.2 33

Pelv ic R egion: Anterior Innominate Dy s function: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation

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Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior on the r ight

F igure 10.157. Steps 1 and 2.

T ech niq u e 1. T he patient lies pr one on a diagonal, s o the r ight innominate is off the edge of the table. T he phys ician s tands at the r ight side of the table facing the patient's pelvis. 2. T he phys ician's left hand s tabiliz es the patient's pelvis and s acr um, and the physician's r ight hand, s upporting the patient's r ight leg, places the patient's r ight foot agains t the physician's r ight thigh or tibia (F ig. 10.157). 3. T he phys ician flexes the

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F igure 10.158. Step 3.

F igure 10.159. Step 4, is ometric c ontr action.

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P.2 34

Pelv ic R egion: Right Superior Iliosac r al She ar

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad on the right ASIS: Cephalad on the right Ischial tuberosity : Cephalad on the r ight Sacr otuberous ligament tension: Lax

Fig ure 10.161. Steps 1 and 2.

T ech niq u e 1. T he patient lies either prone or s upine with both feet off the end of the table. 2. T he phys ician s tands at the foot of the table and gras ps the patient's r ight tibia and fibula above the ankle ( F ig. 10.161). 3. T he phys ician inter nally r otates the right leg to c lose-pack the hip joint, lock ing the femoral head into the ac etabulum ( c urv ed white ar row, F ig. 10.162). 4. T he phys ician

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Fig ure 10.162. Step 3.

Fig ure 10.163. Step 4.

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5.

6.

7.

8.

9.

abduc ts the patient's r ight leg 5 to 10 degrees to take tension off the r ight sacroiliac ligament (F ig. 10.163). T he phys ician gently leans back, maintaining ax ial tr action on the patient's r ight leg ( white ar row), and instr ucts the patient to inhale and exhale ( F ig. 10.164). With eac h ex halation the tr actional forc e is increased. T his inhalation, ex halation, tr action cy c le is r epeated fiv e to s even times . With the las t ex halation, the patient may be instr ucted to c ough as the physician s imultaneous ly tugs on the leg. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

Fig ure 10.164. Step 5.

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Pelv ic R egion: Right Outfla r e Innomina te Dys func tion: Pos t Isom etr ic R ela xation

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Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Sacr al s ulc us: Narr ow on the right ASIS: Later ally displac ed on the r ight T ech niq u e 1. T he patient lies s upine, and the physician s tands at the left side of the table. 2. T he patient's r ight hip and k nee are flexed to about 90 degrees, and the r ight foot is later al to the left knee. 3. T he phys ician's c ephalad (r ight) hand is plac ed under the patient's r ight innominate, gr asping the medial aspec t of the r ight PSIS (F ig. 10.165). 4. T he phys ician c ephalad (left) hand adducts the patient's r ight knee ( white arrow, F ig. 10.166) until the edge of

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F igure 10.165. Steps 1 to 3.

F igure 10.166. Step 4.

F igure 10.167. Step 5, is ometric c ontr action.

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P.2 36

Pelv ic R egion: Right Inflar e Innom ina te D ysfunc tion: Post Isom etr ic R ela xation

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Sacr al s ulc us: Wide on the r ight ASIS: Medially displac ed on the r ight T ech niq u e 1. T he patient lies s upine and the physician s tands at the left side of the table. 2. T he patient's r ight hip and k nee are flexed, and the r ight foot is on the lateral as pec t of the left knee. 3. T he phys ician's c ephalad hand is placed on the patient's left ASIS (F ig. 10.169). 4. T he phys ician's c audad hand is placed on the patient's r ight k nee and the r ight hip is ex ter nally r otated (w hite

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F ig ure 10.169. Steps 1 to 3.

F ig ure 10.170. Step 4.

F ig ure 10.171. Step 5, isometric c ontraction.

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5.

6.

7.

8.

9.

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ar row, F ig. 10.170) until the edge of the r estr ictive barrier is r eached. T he patient lifts the r ight k nee towar d the c eiling (b lack ar row, F ig. 10.171) while the phys ician applies an equal c ounterforc e ( white arrow). T his isometr ic c ontr action is maintained for 3 to 5 s econds, and then the patient is instr ucted to relax. O nce the patient has c ompletely r elax ed, the physician further ex ter nally r otates the hip ( white arrow, F ig. 10.172) to the edge of the new r estric tive barrier. Steps 5 to 7 ar e r epeated three to fiv e times . T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s

F ig ure 10.172. Step 7.

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of the technique.

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Pelv ic R egion: Right Superior Pubic Shear Dy sfunction: Mus cle C ontrac tion Mobilizes Ar tic ulation

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Right pubic tuber c le c ephalad (F ig. 10.173) T ech niq u e 1. Patient lies s upine, right s ide close to the edge of the table, and the physician s tands at the r ight side facing the patient. 2. T he phys ician's left hand is placed on the patient's left ASIS to s tabiliz e the pelvis, and the r ight hand abduc ts the patient's r ight leg, allowing it to dr op of the edge of the

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F ig ure 10.173. Right s uper ior pubic shear dy s function.

F ig ure 10.174. Steps 1 to 3.

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table. 3. T he phys ician places the r ight hand jus t pr oximal to the patient's r ight k nee and gently pr ess es down ( white arrow, F ig. 10.174) on the r ight k nee until the edge of the r estr ictive barrier is r eached. 4. T he patient lifts the r ight k nee towar d the c eiling and s lightly medially ( blac k arrow, F ig. 10.175) while the physician applies an equal c ounterforc e ( white arrow). 5. T his isometr ic c ontr action is maintained for 3 to 5 s econds after which the patient is instr ucted to st op and relax. 6. O nce the patient has c ompletely r elax ed, the physician r epos itions the patient's leg further toward the floor ( white ar row, F ig. 10.176) to the

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F ig ure 10.175. Step 4, isometric c ontraction.

F ig ure 10.176. Step 6.

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edge of the new r estr ictive barrier. 7. Steps 4 to 6 ar e r epeated three to fiv e times . 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. Note: A left infer ior s hear looks s tatically similar to a r ight s uper ior shear but will display loss of s acr oiliac motion on the left side and s how a positiv e s tanding flexion test on the left.

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Pelv ic R egion: Right Inferior Pubic Shear Dy sfunction: Mus cle C ontrac tion Mobilizes Ar tic ulation

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Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Pubic tuber cle on r ight is caudad ( F ig. 10.177) T ech niq u e 1. T he patient lies s upine c los e to the left edge of the table, and the phys ician s tands on the left fac ing the patient. 2. T he phys ician's r ight hand flexes and inter nally r otates the patient's r ight hip as the physician places the left thenar eminence beneath the patient's r ight is chial tuber osity to c r eate a fulcr um (F ig . 10.178). 3. T he phys ician's r ight hand flexes the patient's r ight hip ( white ar row, F ig. 10.179) until the edge of the r estr ictive

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F igure 10.177. Right inferior pubic shear dy sfunction.

F igure 10.178. Steps 1 and 2.

F igure 10.179. Step 3.

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P.2 40

PELVIC R EGION: Fix ed Com pre s sion of the Pubic Sy mphysis (Adducte d Pubic B ones ): Mus c le Contra c tion Mobilize s A rticula tion

Diag nosis Suspicion of dysfunc tion by history (tr auma, pregnanc y, deliver y) Palpable bulging of the symphys eal c artilage T ender pubic s ymphys is May hav e ur inary trac t s y mptoms ( Fig . 10.182) T ech niq u e 1. T he patient lies s upine and the physician s tands at either s ide of the table. 2. T he patient's hips are flexed to approximately 45 degrees and the k nees ar e flexed to 90 degrees, with the feet flat on the table. 3. T he phys ician s epar ates the patient's k nees and plac es the forearm between the patient's k nees ( F ig. 10.183). 4. T he patient pulls both

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F ig ure 10.182. F ixed c ompr ess ion of the pubic symphy s is.

F ig ure 10.183. Steps 1 to 3.

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5.

6.

7.

8.

k nees medially ( adduct shown by black ar rows, Fig . 10.184) against the phys ician's palm and elbow ( white arrows) while the physician applies an equal c ounterforc e. T his isometr ic c ontr action is maintained for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the patient's k nees ar e s eparated s lightly far ther fr om the midline ( white arrows, F ig. 10.185) . Steps 4 to 6 ar e r epeated three to sev en times . T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

F ig ure 10.184. Step 4, isometric c ontraction.

F ig ure 10.185. Step 6.

P.2 41

Pelv ic R egion: Fix ed Gapping of the Pubic Sy mphy sis (A bduc ted

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Pubic B ones ): Mus c le Contra c tion Mobilize s A rtic ula tion

Diag nosis Suspicion of dysfunc tion by history (tr auma, pregnanc y, deliver y) Sulc us deeper than normal at the pubic s ymphys is T ender pubic s ymphys is May hav e ur inary trac t s y mptoms ( Fig . 10.186) T ech niq u e 1. T he patient lies s upine, and the physician s tands beside the table. 2. T he patient's hips are flexed to approximately 45 degrees and the k nees ar e flexed to about 90 degrees, with the feet flat on the table. 3. T he patient's k nees ar e s epar ated by approximately 18 inches. 4. T he k nee c loser to the physician is placed against the phys ician's abdomen, and the phys ician gr asps the later al aspect of the other k nee with both

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F igure 10.186. Fix ed gapping of the pubic s y mphysis.

F igure 10.187. Steps 1 to 4.

F igure 10.188. Step 5, is ometric c ontr actions .

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5.

6.

7.

8. 9.

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hands (F ig. 10.187). T he patient pulls both k nees later ally ( abduct shown by black ar rows, Fig . 10.188) against the phys ician's abdomen and hands while the physician applies an equal c ounterforc e ( white arrows) . T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician approximates the patient's k nee 3 to 4 inches ( white ar rows, Fig . 10.189). Steps 7 to 9 ar e r epeated thr ee to seven times. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

F igure 10.189. Step 7.

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Pelv ic R egion: Hip Re gion: Psoa s Major and Psoa s Minor Mus cle s

Psoas Major O rig in T he origin of the psoas major is at the body of 12th thorac ic v ertebr a and the transverse proc ess es and bodies of the firs t four lumbar v ertebr ae ( Fig . 10.190) . Insertio n T he ins ertion of the psoas major is at the less er troc hanter of femur. Action T he psoas major flexes the thigh and trunk and flex es the v ertebr al c olumn laterally.

F igure 10.190. Psoas major and psoas minor muscles (8) .

Innervat ion T he ventral r ami of lumbar nerv es ( L1 to L3) innervate the psoas major. Psoas Minor O rig in T he origin of the psoas minor is at the bodies

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of 12th thorac ic and fir s t lumbar v ertebr ae ( Fig . 10.190) . Insertio n T he ins ertion of the psoas minor is at the iliac fasc ia and the iliopec tineal eminenc e. Action T he psoas minor helps the psoas major flex the pelvis and lumbar r egion of the v ertebr al c olumn. Innervat ion T he ventral r amus of L1 innervates the psoas minor .

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Pelv ic R egion: Hip Re gion: Ilia cus Mus cle

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O rig in T he origin of the iliacus mus cle is at the iliac foss a ( inner s urface of iliac bone) and the lateral aspect of the sac r um ( Fig . 10.191). Insertio n T he ins ertion of the iliacus musc le is at the less er troc hanter of femur. Action T he iliacus musc le flex es the thigh at the hip and s tabiliz es the joint in c onjunc tion with the iliopsoas.

F igure 10.191. Iliacus muscle (8).

Innervat ion T he femoral nerv e ( L2 and L3) innervates the iliacus musc le.

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Pelv ic R egion: Hip Re gion: Psoa s Musc le, Acute D ysfunc tion: R eciproc al Inhibition

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1. Patient lies s upine near the end of the tr eatment table s o that the dy sfunctional leg may hang ov er the end of the table. T he patient flex es the other hip, br inging the k nee to the c hest. T his k eeps the lumbar lordosis flattened. 2. T he phys ician, s tanding at the end of the table, plac es the hands on the patient's dy sfunctional thigh just pr oximal to the k nee (F ig. 10.192). 3. T he phys ician gently positions the patient's thigh towar d the floor (white ar row, F ig. 10.193), ex tending the hip to the edge of the r estr ictive barrier. 4. T he patient pushes the leg very gen tly down toward the floor ( blac k ar row, F ig. 10.194) while the phys ician

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F igure 10.192. Steps 1 and 2.

F igure 10.193. Step 3.

F igure 10.194. Step 4, is ometric c ontr action.

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Pelv ic R egion: Hip Re gion: Psoa s Musc le, Subacute or C hronic D ysfunc tion: Post Isometric Relaxa tion

1. T he patient lies pr one and the physician s tands beside the table. 2. T he phys ician flexes the patient's k nee on the s ide to be tr eated 90 degrees and then grasps the patient's thigh just above the k nee. 3. T he phys ician's c ephalad hand is placed ov er the patient's s acrum to s tabiliz e the pelvis ( Fig . 10.196). 4. T he phys ician's c audad hand gently lifts the patient's thigh upwar d ( white ar row, F ig. 10.197) until the psoas muscle begins to stretch, engaging the edge of the r estr ictive barrier. 5. T he patient pulls the thigh and k nee down ( blac k arrow, F ig. 10.198) into the

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F ig ure 10.196. Steps 1 to 3.

F ig ure 10.197. Step 4.

F ig ure 10.198. Step 5, isometric c ontraction.

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6.

7.

8.

9.

physician's c audad hand, which applies an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician ex tends the patient's hip to the edge of the new r estric tive barrier (w hite ar row, F ig. 10.199). Steps 5 to 7 ar e r epeated three to fiv e times or until motion is maximally improved at the dy sfunctional hip and psoas. Success of the technique is deter mined by r eevaluating passive hip ex tension.

F ig ure 10.199. Step 7.

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Pelv ic R egion: Pir iformis Muscle

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O rig in T he origin of the pir ifor mis musc le is at the anterior s urface of the s acr um and the s uperior margin of greater ischiadic ( sciatic ) notc h ( Fig . 10.200). Insertio n T he ins ertion of the pirifor mis musc le is at the greater troc hanter of the femur.

F igure 10.200. Anterior v iew of pir ifor mis muscle (8).

Action T he pir ifor mis musc le r otates the thigh laterally and abducts it, and it assis ts in holding the femoral head in the acetabulum ( Fig . 10.201).

F igure 10.201. Posterior v iew of pir iformis muscle (8).

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Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , A c ute Dy sfunction: R eciproc al Inhibition

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1. T he patient lies pr one and the physician s tands beside the table. 2. T he phys ician palpates the dy sfunctional piriformis muscle with the c ephalad hand, gr asps the patient's ankle with the caudad hand, and flexes the patient's k nee 90 degrees ( F ig. 10.202). 3. T he phys ician s lowly moves the patient's ankle away ( white arrow, F ig. 10.203) fr om the midline until the edge of the r estric tive barrier is r eached. 4. T he patient very gen tly pulls the ankle away from the midline (b lack ar row, F ig. 10.204) to the later al aspect of the patient's ankle agains t the phys ician's c audad hand, which applies an unyielding c ounterforc e ( white arrow). 5. T his isometr ic c ontr action is

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F igure 10.202. Steps 1 and 2.

F igure 10.203. Step 3.

F igure 10.204. Step 4, is ometric c ontr action.

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Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , A c ute Dy sfunction: R eciproc al Inhibition

1. T he patient lies s upine, and the physician s tands at the s ide of the patient opposite the s ide to be tr eated. 2. T he patient's r ight hip and k nee are flexed s o that the foot on the dy sfunctional s ide may be placed later al to the unaffec ted k nee. 3. T he phys ician's c ephalad hand is placed on the patient's ASIS on the s ide of dy sfunction to s tabiliz e the pelvis ( Fig . 10.206). 4. O n the s ide of dy sfunction, the physician's c audad hand pulls the patient's r ight k nee toward the midline, inter nally r otating the hip, until the piriformis begins to s tretch, engaging the edge of the

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F igure 10.206. Steps 1 to 3.

F igure 10.207. Step 4.

F igure 10.208. Step 5, is ometric c ontr action.

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5.

6.

7.

8.

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r estr ictive barrier (F ig . 10.207). T he patient very gen tly pushes the r ight knee towar d the midline (b lack ar row, F ig. 10.208) to the medial aspec t of the patient's k nee agains t the phys ician's c audad hand, which applies an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to relax. O nce the patient has c ompletely r elax ed, the physician r epos itions the k nee far ther ac ros s the midline, inter nally r otating the hip to the edge of the new r estr ictive barrier (w hite ar row, F ig. 10.209). Steps 5 to 7 ar e r epeated thr ee to five times or until motion is maximally

F igure 10.209. Step 7.

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improved at the dy sfunctional hip and piriformis. 9. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

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Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , Subac ute or Chr onic D ysfunc tion: Post Isometric Relaxa tion

1. T he patient lies pr one on the tr eatment table, and the physician s tands beside the table. 2. T he phys ician palpates the dy sfunctional piriformis muscle with the c ephalad hand and gras ps the patient's ankle with the caudad hand (F ig. 10.210). 3. T he phys ician's c audad hand flexes the patient's k nee 90 degrees and s lowly moves the patient's ankle away

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F igu re 10.210. Steps 1 and 2.

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fr om the midline, inter nally r otating the dy sfunctional hip until the piriformis muscle begins to stretch, engaging the edge of the r estr ictive barrier (F ig . 10.211). 4. T he patient pushes the r ight ankle towar d the midline (b lack ar row, F ig. 10.212) to the medial aspec t of the patient's foot and ank le, against the physician's c audad hand, which applies an unyielding c ounterforc e ( white arrow). 5. T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to relax. 6. O nce the patient has c ompletely r elax ed, the physician r epos itions the ankle farther away from the midline, inter nally r otating the hip

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F igu re 10.211. Step 3.

F igu re 10.212. Step 4, isometr ic c ontrac tion.

F igu re 10.213. Step 6.

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to the edge of the new r estr ictive barrier (w hite ar row, F ig. 10.213). 7. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional hip and piriformis. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

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Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , Subac ute or Chr onic D ysfunc tion: Post Isometric Relaxa tion

1. T he patient lies s upine and the physician s tands at the s ide of the patient opposite the s ide to be tr eated. 2. T he patient's hip and knee ar e flex ed s o that the foot on the dy sfunctional

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F igure 10.214. Steps 1 to 3.

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3.

4.

5.

6.

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s ide may be placed later al to the unaffec ted k nee. T he phys ician's c ephalad hand is placed on the patient's ASIS on the s ide of dy sfunction to s tabiliz e the pelvis ( Fig . 10.214). O n the s ide of dy sfunction, the physician's c audad hand gently pulls the patient's k nee towar d the midline (w hite ar row, F ig. 10.215), inter nally r otating the hip until the piriformis begins to s tretch engaging the edge of the r estr ictive barrier. T he patient pulls the k nee away from the midline (b lack ar row, F ig. 10.216) to the later al aspect of the patient's k nee agains t the phys ician's c audad hand, which applies an unyielding c ounterforc e ( white arrow). T his isometr ic

F igure 10.215. Step 4.

F igure 10.216. Step 5, is ometric c ontr action.

F igure 10.217. Step 7.

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c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. 7. O nce the patient has c ompletely r elax ed, the physician r epos itions the k nee far ther ac ros s the midline, inter nally r otating the hip to the edge of the new r estr ictive barrier (w hite ar row, F ig. 10.217). 8. Steps 5 to 7 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional hip and piriformis. 9. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

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Sacr al R egion: For war d Tors ion About a Le ft Oblique Ax is (Left on Left): C ombine d R e ciproc al Inhibition and Muscle Contr action Mobilize Ar tic ula tion

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Diag nosis Seated flex ion tes t: positiv e right Sacr al s ulc us: deep, anterior right Inferior later al angle ( ILA): s hallow, posterior left Spring test: negative Sphinx test: less asymmetr y L5 NSLRR Left-on- left s acr al tors ion (F ig. 10.218) T ech niq u e 1. T he patient lies in the left modified Sims position on the s ide of the named oblique ax is. The hips and k nees ar e flexed to 90 degrees, with the c hes t down on the table as much as possible and the r ight ar m hanging over the table edge. 2. T he phys ician s its on the right end of the table near the patient's buttocks , facing the patient. 3. T he phys ician gently lifts the patient's k nees and r ests the k nees , legs , and feet on the anter ior thigh.

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F igu re 10.218. Left- on-left sac ral torsion.

F igu re 10.219. Steps 1 to 4.

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Sacr al R egion: For war d Tors ion About a Right Oblique A xis (Right on R ight): Com bine d R eciproc al Inhibition and Muscle C ontr action Mobilize Ar tic ula tion

Diag nosis Seated flex ion tes t: positiv e left Left sac ral sulcus : deep, anter ior Right ILA: shallow, posterior Spring test: negative Sphinx test: less asymmetr y L5 NSRRL Right-on-right sac ral tors ion (F ig. 10.224) T ech niq u e 1. T he patient lies in the r ight modified Sims position on the s ide of the named oblique ax is. The hips and k nees ar e flexed to 90 degrees, with the c hes t down on the table as much as possible and the left ar m hanging over the table edge. 2. T he phys ician s its on the edge of the table behind the patient and r ests the patient's k nees s lightly onto the

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F igu re 10.224. Right- on- right s acr al tors ion.

F igu re 10.225. Steps 1 to 3.

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3.

4.

5.

6.

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r ight anter ior thigh. T he phys ician's c ephalad hand palpates the L5-S1 inter spinous s pace while the c audad hand flexes and ex tends the patient's hips until L5 is felt to be neutr al r elative to S1 ( F ig. 10.225). T he patient inhales and ex hales deeply three times , r eaching with the left hand towar d the floor after each ex halation ( Fig . 10.226). T he phys ician's c audad hand gently lower s the patient's feet (w hite ar row, F ig. 10.227) until the edge of the r estr ictive barrier is r eached. T he phys ician instr ucts the patient to lift both feet s traight up towar d the c eiling with a gentle but s ustained force ( blac k arrow, F ig. 10.228) against the

F igu re 10.226. Step 4.

F igu re 10.227. Step 5.

F igu re 10.228. Step 6, isometr ic c ontrac tion.

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7.

8.

9. 10.

physician's unyielding c audad hand ( white arrow). T his contrac ts the left hip inter nal rotators and the right hip ex ter nal r otators , which ar e both antagonists to the left piriformis muscle. T his isometr ic c ontr action is maintained for 3 to 5 sec onds , and then the patient is instr ucted to st op and relax. O nce the patient is c ompletely r elax ed, the physician gently lower s both feet towar d the floor ( white arrow, F ig. 10.229) to the edge of the new r estric tive barrier. Steps 6 to 8 ar e r epeated thr ee to five times. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

F igu re 10.229. Step 8.

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Sacr al R egion: Ba c kwa rd Tor s ion About a Left Oblique A xis (Right on Left): C ombine d Re ciproc a l Inhibition and Mus cle Contr a ction Mobilize Ar tic ula tion

Diag nosis Seated flex ion test: positive right Right s acral s ulc us: pos ter ior , s hallow Left ILA: deep, anterior Spring test: positiv e Sphinx test: more asymmetr y L5 E/FRLSL Right-on-left s acr al tors ion ( Fig . 10.230) T ech niq u e 1. T he patient lies in the left later al r ecumbent position with the r ight hip and k nee s lightly flexed in fr ont of the left leg. 2. T he physician s tands facing the patient's pelvis, and the c ephalad hand palpates the L5-S1 inter spinous s pace while the c audad hand gently

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Right- on- left s acral tors ion.

A. Steps 1 to 3.

F igu re 10.230.

F ig ure 10.231.

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moves the left leg posteriorly , ex tending the hip until motion is felt at the L5-S1 inter space. 3. T he physician's c audad hand and forearm s tabiliz e the patient's pelvis as the patient gently r otates the tr unk to the r ight (F ig. 10.231). 4. T he patient inhales and ex hales deeply three times . After each ex halation, the patient r eaches back with the r ight ar m and s houlder , r otating the tr unk to the r ight to derotate L5. 5. T he physician's c audad hand moves the patient's r ight foot off the table and applies gentle pr ess ure on the patient's r ight knee ( white arrow,

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F igure 10.231. B. Step 4.

Step 5.

Step 6, isometr ic c ontrac tion.

F ig ure 10.232.

F ig ure 10.233.

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F ig. 10.232) to the edge of the r estr ictive barrier. 6. T he physician instr ucts the patient to lift the r ight k nee str aight up towar d the c eiling with gentle but s ustained force (blac k ar row, F ig. 10.233) against the physician's unyielding c ounterforc e of the c audad hand ( white ar row). 7. T his is ometric c ontr action is maintained for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. 8. O nce the patient has c ompletely r elax ed, the physician gently lower s the r ight foot towar d the floor until a new r estr ictive barrier is

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Step 8.

F ig ure 10.234.

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r eached ( white arrow, F ig. 10.234) . 9. Steps 6 to 8 ar e r epeated three to fiv e times . 10. T he diagnostic parameters of the dy sfunction ar e r eevaluated to deter mine the effec tiv enes s of the technique.

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Sacr al R egion: Ba c kwa rd Tor s ion About a R ight Oblique Axis (Left on R ight): Com bine d R eciproc al Inhibition and Muscle C ontr action Mobilize Ar tic ula tion

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Diag nosis Seated flex ion tes t: positiv e left Left sac ral sulcus : s hallow, posterior Right ILA: deep, anterior Spring test: positive Sphinx test: more asymmetr y L5 E/FRRSR Left-on- right sac r al tors ion (F ig. 10.235) T ech niq u e 1. T he patient is in the r ight later al r ecumbent position with the pelv is c los e to the edge of the table and the left knee r esting slightly flexed on the table in fr ont of the r ight leg. 2. T he phys ician s tands facing the patient's pelvis, and the c ephalad hand palpates the L5-S1 inter spinous s pace while the c audad hand gently moves the patient's r ight leg posteriorly , ex tending the hip until motion is felt at the L5-S1 inter space. 3. T he phys ician's

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F igure 10.235. Left-on-right sac ral tor sion.

F igure 10.236. Steps 1 to 3.

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Sacr al R egion: Ov e rview of Sacr al Tor s ion Dy sfunction T ab l e 10.1 ou tli nes s ac r al tor s io n d y s fu nct i on s ab out an obl i qu e a x i s.

Tab le 10.1 ou tlin es sacral torsio n d ysfu nct ion s ab out an obliqu e axis.

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Sacr al R egion: Unilatera l Flexe d Sacr um on the Left, R espiratory A ssist

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Diag nosis Seated flex ion tes t: Positiv e left Left sac ral sulcus : Ventral, anter ior Left ILA: Dors al, posterior Spring test: Negative Sphinx test: Decr eas ed asymmetr y T ech niq u e 1. T he patient lies pr one and the physician s tands at the left side of the table. 2. T he index finger of the physician's c ephalad hand palpates the patient's left s acral s ulc us ( F ig. 10.241) while the c audad hand abduc ts and adduc ts the patient's left leg to find the loosest- pac k ed position for the left sac roiliac joint (usually about 15 degrees of abduc tion). 3. T he phys ician inter nally r otates the patient's left hip, and the patient maintains this abduc ted,

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F igu re 10.241. Step 2.

F igu re 10.242. Steps 1 to 3.

F igu re 10.243. Step 4.

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Sacr al R egion: Unilatera l Ex tended Sa c rum on the Le ft, R espira tory As sis t

Diag nosis Seated flex ion tes t: Positiv e left Left sac ral sulcus : Dors al, pos ter ior Left ILA: Ventral, anterior Spring test: Positive Sphinx test: Incr eas ed asymmetr y T ech niq u e 1. T he patient lies in the s phinx position ( propped up with the elbows s upporting the upper body) , and the physician s tands at the left side of the table. 2. T he index finger of the physician's c ephalad hand palpates the patient's left s acral s ulc us while the c audad hand abduc ts and adduc ts the patient's left leg to find the loosest- pac k ed position for the left sac roiliac

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F igure 10.248. Steps 1 to 3.

F igure 10.249. Step 4.

F igure 10.250. Step 4.

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3.

4.

5.

6.

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joint (usually about 15 degrees of abduc tion). T he phys ician inter nally r otates the patient's left hip and instruc ts the patient to maintain this abduc ted, inter nally r otated pos ition throughout the tr eatment ( F ig. 10.248). T he hypothenar eminence of the physician's c ephalad hand is placed on the patient's left s acral s ulc us ( F ig. 10.249) and is r einforc ed by the c audad hand (F ig. 10.250). T he phys ician's hands ex ert a s ustained anter ior ( downwar d) force on the patient's left s acral s ulc us to r otate the s acrum anter ior ly, and to disengage the lumbosac ral joint caudally ( F ig. 10.251). T he patient inhales and then ex hales forcefully.

F igure 10.251. Step 5.

F igure 10.252. Steps 6 and 7.

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During ex halation, the physician's hands encourage s acral flex ion ( white arrow, F ig. 10.252) . 7. T he patient inhales slowly. During inhalation, the physician's hands increase the anterior force on the s acral s ulc us to pr event sac r al ex tension ( white ar row, F ig. 10.252). 8. Steps 5 to 7 ar e r epeated fiv e to s even times . 9. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

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Sacr al R egion: Bilate rally Flex ed Sac r um, Re spir atory Ass ist

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Diag nosis Sacr al r ock test: Positiv e Both sac ral sulci: Ventral, anter ior Both ILAs: Dor sal, posterior Spring test: Negative Sphinx test: Decr eas ed asymmetr y Bilater ally flexed s acr um ( Fig . 10.253) T ech niq u e 1. T he patient lies pr one and the physician s tands beside the patient. 2. T he phys ician places the thenar and hy pothenar eminences of the c audad hand on the ILAs of the patient's s acrum ( Fig . 10.254). 3. T he phys ician's c ephalad hand r einforc es the c audad hand ( F igs. 10.255 and 10.256) . 4. T he phys ician applies a c ontinuous anter ior ( downwar d) force on the ILAs of the patient's s acrum.

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10.253. Bilater ally flexed s acr um.

F igu re

F igure 10.254. Step 2.

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Sacr al R egion: Bilate rally Exte nde d Sa crum, Res pira tor y A s sis t

Diag nosis Both sac ral sulci: Dors al, pos ter ior Both ILAs: Ventral, anterior Spring test: Positive Sphinx test: More asymmetr y Bilater ally Ex tended s acr um ( Fig . 10.258) T ech niq u e 1. T he patient lies pr one and the physician s tands beside the patient. 2. T he phys ician places the index finger on the patient's left s acral s ulc us and the long finger on the r ight sacral s ulcus ( Fig . 10.259). 3. T he phys ician's other hand r einforc es the first hand ( Fig . 10.260). 4. A continuous anter ior ( downwar d) force (white ar row, F ig. 10.261) is placed on the s acral s ulc i. 5. T he patient inhales and

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F igure 10.258. Bilaterally extended s acr um.

F igure 10.259. Step 2.

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then exhales deeply. 6. T he phys ician ex aggerates flexion dur ing ex halation and attempts to r esis t extension during inhalation. 7. Steps 4 to 6 ar e r epeated 7 to 10 times . 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

F igure 10.260. Step 3.

F igure 10.261. Steps 4 to 6.

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Extr emities : Poste rior R adia l H ead, Pr ona tion D y sfunction: Post Isom etr ic R ela xation

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1. T he patient is s eated, and the physician s tands in fr ont of and to the s ide of the patient's dy sfunctional ar m. 2. T he phys ician holds the patient's hand ( handshake position) with the hand ipsilateral to the dy sfunction. 3. T he phys ician's other hand lies palm up with the thumb r esting against the posterolater al as pec t of the r adial head ( F ig. 10.262). 4. T he phys ician s upinates the patient's forearm until the edge of the r estr iction barrier is r eached (w hite ar row, F ig. 10.263) at the r adial head. 5. T he phys ician instr ucts the patient to attempt pr onation ( blac k arrow, F ig. 10.264) while the physician applies an

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F igure 10.262. Steps 1 to 3.

F igure 10.263. Step 4.

F igure 10.264. Step 5, is ometric c ontr action.

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Extr emities : A nte r ior Ra dia l He ad, Supina tion D y sfunction: Post Isom etr ic R ela xation

1. T he patient is s eated, and the physician s tands facing the patient. 2. T he phys ician holds the patient's hand ( handshake position) with the hand ipsilateral to the dy sfunction. 3. T he phys ician's other hand is palm up with the thumb r esting against the anterior and medial aspec t of the r adial head (F ig. 10.266). 4. T he phys ician pr onates the patient's forearm (w hite ar row, F ig. 10.267) until the edge of the r estr ictive barrier at the r adial head is r eached. 5. T he phys ician instr ucts the patient to attempt s upination ( blac k arrow, F ig. 10.268) while the physician

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F igure 10.266. Steps 1 to 3.

F igure 10.267. Step 4.

F igure 10.268. Step 5, is ometric c ontr action.

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6.

7.

8.

9.

applies an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician pr onates the patient's forearm to the new r estric tive barrier (w hite ar row, F ig. 10.269) while ex aggerating the posterior r otation of the r adial head with the left hand ( white arrow). Steps 5 to 7 ar e r epeated thr ee to five times or until there is no further improvement in the r estric tive barrier. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

F igure 10.269. Step 7.

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Extr emities : Poste rior Fibular Hea d D y sfunction: Post Isom etr ic R ela xation

1. T he patient lies s upine or sits with the lower legs off the table, and the phys ician s tands or sits at the side of dy sfunction. 2. T he phys ician plac es the hand closes t to the k nee in the popliteal fossa so that the metac arpal- phalangeal joint of the index finger appr oximates the posterior prox imal fibula ( head) ( Fig . 10.270). 3. T he phys ician's other hand controls the patient's foot and ankle, exter nally r otating the patient's lower leg ( white arrow, F ig. 10.271) until the fibular head meets its anter ior res trictive barrier. 4. T he patient internally r otates (b lack arr ow, F ig. 10.272) the lower leg as the phys ician applies an unyielding c ounterforc e (white ar row). 5. T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to stop an d relax. 6. O nce the patient has c ompletely r elaxed, the phys ician attempts to move the fibula ( white arrow, F ig.

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F igu re 10.270. Steps 1 and 2.

F igu re 10.271. Step 3.

F igu re 10.272. Step 4, isometric c ontrac tion.

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10.273) to the new, ex ter nal rotation r estr ictive bar rier. 7. Steps 4 to 7 ar e r epeated thr ee to fiv e times or until there is no further improvement in the r estr ictive bar rier. 8. T he diagnos tic parameters of the dy sfunction are r eevaluated to deter mine the effec tiv enes s of the technique.

F igu re 10.273. Step 6.

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Extr emities : A nte r ior Fibula r H ead Dy s function: Pos t Isom e tric R ela xation

1. T he patient lies s upine or s its with the lower legs off the table, and the physician s tands or s its at the s ide of dy sfunction. 2. T he phys ician places the hand that is near er to the k nee ov er the anter olater al pr oximal fibular head (F ig. 10.274). 3. T he phys ician's other hand c ontr ols the patient's foot

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F igure 10.274. Steps 1 and 2.

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4.

5.

6.

7.

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and ankle and inter nally r otates the patient's lower leg ( white ar row, F ig. 10.275) until the fibular head meets its posterior r estr ictive barrier. T he patient ex ter nally r otates (b lack ar row, F ig. 10.276) the lower leg as the physician applies an unyielding c ounterforc e ( white arrow). T his isometr ic c ontr action is held for 3 to 5 s econds, and then the patient is instr ucted to st op and relax. O nce the patient has c ompletely r elax ed, the physician attempts to move the fibula to the new inter nal rotation r estr ictive barrier (w hite ar row, F ig. 10.277). Steps 4 to 6 ar e r epeated thr ee to five times or until there is no further

F igure 10.275. Step 3.

F igure 10.276. Step 4, is ometric c ontr action.

F igure 10.277. Step 6.

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improvement in the r estric tive barrier. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.

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R efe renc es 1. Wa r d R (e d). Fo unda tio ns for Ost eop athi c M edi c i ne . P hil adel phi a: Li pp i nc ott W il l ia m s & Wi l ki ns, 20 03.

2. Gr een m an P. Pri nc ip l es of M an ual Me di ci ne, 2n d ed . B alt i m or e: W il l i am s & Wi l k in s , 199 6.

3. Mi tch el l F L J r. T he Mu s cl e En erg y M anua l , v ol 1. Eas t L ansi ng, MI : ME T , 199 5.

4. Ne uma nn H D . Int r odu c ti on to M anu al M edi c in e. Berl i n: Sp r i ng er- Ver l ag, 19 89.

5. Mi tch el l F L J r. T he Mu s cl e En erg y M anua l , v ol 2. Eas t L ansi ng, MI : ME T , 199 8.

6. Mi tch el l F L J r. T he Mu s cl e En erg y M anua l , v ol 3. Eas t L ansi ng, MI : ME T , 199 8.

7. Re pri nted wi th perm i ss i on fro m S i mo ns D G, T ra v ell SG , S i m on LS . M y ofa s ci al Pain an d Dy s fu nct i on: Th e T r i gg er Poi nt M anu al. Bal tim ore : Li ppi nco tt W i ll i am s & W il k in s , 1 999 .

8. Mo dif i ed w it h p er mi s si on fr om Cl ay J H , Pou nds D M. Ba s ic C li nic al M ass age Th er ap y : In teg r at i ng Ana tom y an d T r ea tm en t. Bal ti mo r e: Li ppin c ot t W i l li ams & W i lk i ns , 2 003.

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11 High-Velocity, Low-Amplitude Techniques Techni que Pri nci ples Hi gh- v elo c it y , l ow- amp l it ude tec hni que ( HV LA) i s def i ne d by th e E duca tio nal C ou nci l o n Os teo pat hi c Pr i nc i ple s ( ECO P) a s “ a d i r ec t t ech ni qu e w hic h us es hig h- ve l oc i ty /l ow am pli tude fo r ce s ; a l so ca l l ed mo bil i z at i on wi th i m pu l se tre atm ent ” (1 ) . H VL A is al s o l i st ed as thru s t tre atme nt i n the ECO P g l oss ary . Th e a utho r s hav e an af fin i ty for th e te r m m ob i l iz ati on w i th im pul s e, s in c e i t m ore ac c ura tel y d es cr i be s th i s ty pe of ma ni pu l at i on . In an att emp t t o he l p ost eopa thi c m edic al s tu dent s u nde r s ta nd the s uc c es s a nd s afe ty fact ors in v olv ed wi th this te c hn i que , a s w el l as the for c es at pla y i n i ts p r oc ess of tre ati ng m usc ulo s k el eta l d y s fu nct i on s , we be gan to use the te r m hi gh - ac c el er at i on , l ow -d i st anc e te c hn i qu e (H ALD ) t o de s cr i be the te c hn i que pa r am eter s m ore acc ura tel y . W e u s e this te r m to d esc r ib e th e f orc es a t p l ay bec aus e w e be l ie v e that ve l oc i ty, wh i ch i s a c ons tant , d oes not tr uly def i ne th e na tur e o f th e i nit i ati ng for c e. W e bel i eve it is mo r e ac cu r at e t o de fin e t he i nit i at i ng for c e by ac ce l er atio n ( dv/dt, a r api d in c re ase i n v el oci ty w i th re s pe c t t o t i me , ac c el era ti ng to w ar d an d t hen m in i ma l ly thr oug h t he r est r ic ti ve ba r ri er ). As we tau ght th e n ov ic e s tud ents to us e th i s tec hniq ue, it als o b eca m e a ppa r en t th at the i r a bil i ty to und ers tand th e ba s is of thi s t ec hn i qu e w as b ein g u nder m in ed by t he ter m ve l oc i ty . Co m mo nly , th eir id ea o f t his for c e wa s a s tr aig ht, c on s ta nt thru s t by the phy s ic i an, wh i ch i s not ac c ura te. We be l i ev ed tha t th e t erm dis tan c e w as m or e e as il y u nde r s ta nda ble tha n am pl i tud e. T he r efo r e, fo r te ach i ng pur pos es , w e beg an t o d efi ne H VLA as H AL D ; y et for na tio nal ter m in ol og i ca l i nteg r it y , w e co nti nued to pr om ot e t he name of th e te c hn i qu e as HV LA, usi ng H AL D as th e e x pla nat i on of i ts fo r c es . Fo r u s e o f t his v ar i et y o f os teo pat hi c m an i pu l ati v e tre atme nt ( as w it h o the r te c hn i qu es ), it is i mp ort ant to un ders tan d t he r ela tiv e su c ce s s and m or bid i ty fac tor s re l at ed to i ts per form anc e. As w e a r e m ost in ter es te d i n p er fo r mi ng a sa fe tec hniq ue w it h a s uc c es s ful ou tco m e, i t i s i m po r ta nt to r eme m be r th e fo l lo w i ng re l at i ons hip s b as ed on th e HA LD def i nit i on : Lo w d i s ta nce = s afe ty Hi gh ac ce l er ati on = su c ce s s It is app r op r ia te t o t hin k of os teo path i c m an i pul ati on as a fo r m of w ork . U s i ng th i s as a ba s is , we ca n us e t he f orm ula w or k = fo r c e × di st ance (W = fd). Kn owi ng t hat fo r c e = m ass × ac ce l er atio n ( f = m a) , we ca n su bst i tu te m ass an d ac c el era ti on fo r f or ce in th e wo r k for m ula an d c oncl ude th at wo r k = ma s s × a c c el era tio n × dis tan c e, or W = m ad In th i s f orm ula , ac c el era ti on is th e su c ce s s fact or and dis tan c e i s t he s af ety fac tor . Th us, fo r te ach i ng pu r po s es, we ca n de not e t he H ALD (H VLA) fo r mu l a f or s uc c ess an d s afet y a s W = m ad Th ere fore , t o p er fo r m a s uc ce s sf ul and s af e H VLA tec hni que ( wo r k) , th e p hys i c ia n m ust c om bin e a r ap i d ac c el er at i on fo r c e w it h o nl y m in i ma l mo v em ent of the ar ti cu l ar la ndma r k ( se gm en t) tha t is be i ng tr eat ed. T he di s tan c e i n this fo r mu l a s hou l d be o nly en ough to mo v e t he dys func tio nal art i cu l ar s eg m en t

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th r ou gh t he r es tr ic tiv e b ar ri er, no t to ca r ry i t thr oug h th e b arr i er and be y ond th e p hy si olo gic bar r ie r . If, fo r e x amp l e, a s egm ent th at n orm all y ha s 7 de gr ee s o f m otio n i s r es tr i ct ed at i ts 2-d egre e m oti on m ark , th e c or re c ti v e tech niq ue i s t o u s e only en oug h fo r ce to m ov e t he s egm ent an add i ti ona l 1 deg r ee , no t t he re m ai ni ng 5 deg r ees . I n t he e arl y s tage of le ar ni ng thi s te c hn i qu e, i t i s m or e i mp ort ant to use s ho r t di s ta nc e for sa fety ra the r th an hig h ac c el era ti on fo r s uc ce s s. Da v i d H ei l ig , DO , r efe r r ed to th i s a s g i vi ng th e s egme nt a nudge , b eca us e i t i s di ff i cu l t to l i mi t t he m oti on w hen yo u a r e h i gh l y ac ce l er ati ng ( 2). As th e s tude nt bec om es mo r e ac co m pl i sh ed a nd m as ters th e a bi li ty to s top at th e pr eci s e poin t n eed ed P.2 76 (i m me di at ely pa s t t he r es tr ic tiv e b ar ri er i n m i ll i me ter s of di s ta nc e) , i t i s ap pro pri ate to i nc r eas e t he ac c el er at i on to m or e s ucc es sf ul m ob i l iz i ng le v els . Mo s t pr ac tit i on er s k no w t hat w he n t hey att emp t to im pro v e a nd/ or r est ore mo ti on lo s s at t he j oi nt l eve l by us i ng thi s t ec hn i qu e, an ar ti c ul ar p op c an occ ur. Th er e hav e b een m an y t heor i es as to the ca us e of th i s s oun d, i nc l udi ng c av i tat i on (c hang e i n s y nov i al fl ui d to a g as eo us s ta te) and a v acu um phe nome non (3 ) . H owe v er , a n ar tic ula r po p d oes not me an that th e c or re c t art i c ul ati on w as m ob i li z ed, ju s t that an ac ute m ov eme nt w as dir ect ed t o a jo i nt. Th e l ac k of an audi ble so und doe s n ot m ean th at t he c or r ect i on wa s u ns uc c es s fu l . T her efo r e, the ph y s ic i an sh ould be mo s t i nte nt on t he pal pato r y qua l i ty an d q uant i ty of th e d y s fu nct i on al a r ti c ul atio n a s i t go es thr ough th e c or re c ti v e pr oc ess .

Techni que Classi fication Direct Techni que In Am er ic an ost eopa thi c c i r cl es, HV LA i s m ost l y f r eq uen tl y des c ri bed as a d i r ec t t ech ni qu e. T ha t is , t he mo bil i z in g f orc e us ed to c orr ect th e so m at i c dy sf unc tio n is di r ec ted tow ard the re s tr i c ti v e bar r i er . I n ac c om pl is hin g t hi s c or r ec ti on , t he phys i ci an s hou l d att em pt to mo v e t he s eg m ent as li ttle as po s s ib l e th r ou gh t his ba r r ie r . In s oma tic dy s fun c ti on, i nc l ud i ng the ar tic ul ar ab nor m ali tie s , the dys fun c tio n i s de s cr i bed fo r i ts m oti on fr ee dom an d po s it i on i n the x- , y- , a nd z - ax es. Th er ef ore , t he r est r ic ti ve ba r ri er th at i s e nco unt er ed wi th di re c t tec hniq ue i s oppo s it e t he f r ee dom by w hi c h the dys fun c tio n i s n am ed . To sa fely an d s uc ce s sf ull y tr eat a dy sf unc tio n wi th thi s di r ec t m etho d, i t i s p r ob abl y wi s e to focu s o n on e o r tw o a x es and ke ep s ome fr eed om a v ai l ab l e i n t he r ema i ni ng ax is . M eet i ng all th r ee axi s b ar ri ers ma k es the jo i nt v er y r est r i ct ed, an d it be c om es m ore di ffic ult to m an i pu l at e sa fel y . Al so , t he pati ent ha s a gre ater te nde nc y to gua r d a gai nst the th r us t, a nd thi s ca n c aus e pa i n and s ti ffn ess pos t t r ea tm en t. F or ex amp l e, to tre at a sp i na l dy s fu nct i on tha t h as b een de term i ne d t o be fl exe d, r ota ted r ig ht, an d si de- ben t ri ght , th e p hys i c ia n w oul d fl ex to the l ev el of t he dys func tio n, then ex ten d sl i gh tly to i nc l ud e th i s bar r i er , ro tat e to th e r es tr i ct i ve bar r ie r ( l eft ) , but pro duc e o nl y s li ght s id e b end i ng to the bar r ie r t o ke ep tha t ax i s sl i gh tl y fre er ( s im i la r t o th e feat her ' s e dge des c ri bed i n C ha pte r 10 in re fere nce to m us c le en er gy te c hn i que s ). A c orr ect i ve for c e tha t is ve c to r ed thr oug h on l y one or two of the ax es ofte n p r od uc es su c ce s s w i th mi ni ma l s i de eff ect s .

Indirect Technique To tr eat the pa ti en t w i th i nd i re c t tech niq ue as d esc r ib ed e arl i er , th e p hys i c ia n m ust tak e t he ar ea of dy s fu nc ti on awa y fr om the m os t r est r i ct i ve ba r r ie r a nd i n t he dir ec ti on by w hic h i ts bi om ech ani c al pa r am eter s a r e desc r ib ed. If usi ng H VLA in an i nd i re c t m ann er, th e in dir ect bar r ie r c anno t b e t he n orm al ph y si ol og i c bar r i er op pos i te the re s tri c ti on. T hi s e ase bar r ie r m us t be an addi tio nal ( re s tr i ct i v e) co m po nent of th e dy s fu nct i on ( se e F i g. 6.2 ) . T his is in i ts elf a r est r ic tio n, b ut i t i s n ot the m os t re s tr i c te d b arr i er. If th i s b arr i er w er e t he phys i ol ogi c ba r ri er, i nd i re c t tech niq ue w oul d b e

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co ntr ai nd i ca ted as a f orm of m an i pu l ati on. Mo tio n en han c em ent at a j oi nt ma y b e pr odu c ed i n a m ann er s i mi l ar to r em ovi ng a su c ti on c up fro m a pi ece of gla s s. If the cu p is co m pr es se d, i t c an be m ov ed m ost ea s i ly pe r pe ndic ula r t o th e m ost re s tr i c te d d i re c tio n. Sim i l ar l y, as one ve c to r s f orc e t o an d t hro ugh the ar ti cu l at i on , ca usi ng s ome co m pr es si on at the fac et and s yn ovi um , m ot i on i n any di r ect i on pe r pen dic ula r to it s m aj or re s tr i c ti on ca n f ac il i ta te i ncr eas ed m oti on i n the j oi nt, pro duc i ng the su c ti on c up eff ec t.

Techni que Styles In HV LA t ech niq ue, the st anda r d for s et tin g t he b i om ech anic al for c e v ect ors i s det erm i ned by ho w th e se gme ntal le v el of the dy s fun c ti on i s t erm ed. In s om e d y s fu nct i on s , t he phy s i ci an m ay c ho ose to use a te c hn i que wh ose pri m ar y m otio n i s r otat i on to aff ect th e dy s fu nct i ona l m oti on c omp one nts. In ot her dy s fu nc ti ons , t he p hys i ci an m ay c ho os e to use s id e b end i ng as the dir ect i on of c ho i ce and ve c to r th e fo r ce i n tha t p l ane . I n s ti ll ot her dys fun c ti ons, fl exi on o r e x te ns io n i s u s ed. Mo s t H VLA te c hn i que s a r e perf orm ed by d i re c ti ng t he for c es fro m a bove . S ome tec hni que s se t t he fo r ce s fr om bel ow . H ow eve r , f or the tec hni que to be dir ec t, wh en the for c es c om e f r om bel ow, th e in fer i or s eg m en t mu s t be c arr i ed to w ard th e n am ed fr ee m oti on par am et ers of the dy s fu nc ti on, an d th e su per i or s eg m en t mu s t be c arr i ed to w ard th e r es tr i ct i ve bar r ie r . F or exa m pl e, i f t he dy sf unc tio n is at L1 , by de fi ni tio n L 1 is re s tr i c te d o n L 2; L 2 i s n ot d y sf unc ti on al und er L 1. Als o, L 1 i s n ot d y sf unc ti on al as i t re l at es t o T 12. T o tre at a dy s fu nct i on of L1 on L 2, L1 m ust mo v e thro ugh it s re s tr i ct i v e bar r ie r (b i nd ) wh i le L2 i s eit her hel d s tabl e i n n eutr al or c arr i ed th r oug h t he desc r ib ed ease of L1 . Ta k in g t he s egm ent be l ow to the dy s fun c ti ona l se gme nt' s de s cr i be d ea s e aug m ent s t he tech niq ue. Sim ply pu t, i f L 1 i s ro tat ed ri ght , by di r ec t me tho d i t mu s t m ov e to th e l eft. Th i s l eft ro tat i on c an be ach i ev ed by r ota tin g L1 to th e le ft ov er L2 , o r by ro tat i ng L2 to the r ig ht unde r L 1. R ota tin g L 2 to th e l eft und er a st abi l iz ed L 1 w oul d be co nsi dere d a n i ndir ect HV LA t ech niq ue. T hi s i s a c om m on m is c on c ep ti on wi th the l at era l re c um ben t lu m ba r te c hn i qu e. I f t he s i de of th e ro tat i on al c omp one nt i s p l ac ed o ff the tab l e and the th r us t is ma de fr om belo w , c ar r y in g i t t ow ar d i ts barr i er , t he t ech niq ue d oes no t fo l lo w t he d efi nit i on of the dys fun c ti on an d a t be s t w as s uc c es s fu l be c au s e of u nin ten ded s id e-b endi ng eff ec ts , P.2 77 no t r otat i on . I f th e u ppe r se gme nt i s r ota ted i n the op posi ng dir ec ti on, th e te c hn i qu e ma y b e e ffec tiv e be c au s e o f i ndi r ect , n ot di re c t, me as ur es.

Indications HV LA i n g ene r al i s use d t o re s to r e m oti on to a pr evi ous l y m obi l e ar ti c ul ati on t hat is exh i bi tin g re s tr i c ti on i n al l or par t of it s i nter s eg m en tal r an ge of m oti on. Gre enm an ( 3) des c ri bes a n umb er o f po s si bl e eti olo gi es fo r j oi nt re s tr i c ti on. Th es e i nc l ud e al ter ati on o f o ppo s i ng jo i nt s ur fac es, art i cu l ar ca psu l e c han ges or m en i sc oi ds , s hor t- re s tr i ct or m usc l e tens i on , a nd n oci c ep tors . D i ag nost i c s ig ns t hat ar e a ttri but abl e to an ar ti cu l ar dy s fun c ti on ar e l os s o f or re duc ti on of in ters egm ent al j oin t m otio n a nd/ or qu ali tati v e c ha nges in jo i nt pla y o r jo i nt en d fe el. Pa l pab l e tis s ue tex tur e ch ang es m ay be pre s ent ov er th e a r tic ula r a r ea i nv olv ed o r d i st al t o i t, but the y d o no t n ece s s ar i ly me an t hat th e dy s fu nct i on i s ar tic ul ar . P ain i s ano the r fi ndi ng that ma y b e pr ese nt but aga i n does no t d efin i ti v el y me an tha t an ar tic ul ar dy s fu nc ti on i s pr es ent . M otio n a s ym m etr i es as s oci ate d w i th m ot i on l os s a r e the def i ni ti ve si gns of an art i c ul ar dys func tio n. If a m y of asc i al - i nd uce d d y s fu nct i on i s c au s in g th e j oin t re s tr i ct i on, a m yo fasc i al - ba s ed tec hni que m ay be mo r e a ppr opr i ate .

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Contrai ndi cations Rel ati ve Contrai ndicati ons 1. M i ld to m od era te s tra i n or s pra i n i n the are a t o be tr eat ed 2. M i ld os teop eni a o r os teo por os is in th e ar ea tha t wi l l be r ece i vi ng c omp r es s io n, t ors i on , or anot her s uc h f orc e fr om the pos i ti oni ng a nd/ or thru s t 3. Os te oar thri tic jo i nts wi th m ode r at e m otio n l oss 4. R heu m at oi d dis eas e ot her th an i n t he s pin e 5. M i ni m al dis c b ulg e an d/o r h er ni ati on w i th ra dic ul ar sy m pt om s 6. Atyp i ca l jo i nt or fac et and oth er c on di ti ons wi th a s so c ia ted c on gen i tal an oma l i es 7. Some hy perm obi l e s tat es

Absolute Contrai ndicati ons 1. J oin t i ns ta bil i ty 2. Seve r e os te opo r os i s 3. M eta s ta s i s i n the are a t hat w il l b e r ec ei v in g c om pr ess i on , to r si on, or oth er s uch fo r ce fro m t he posi tio ni ng an d/o r th r us t 4. Os te oar thri tic jo i nt w it h a nk yl osi s 5. Seve r e di sc oge nic s po ndy l os i s w i th an k y lo s is 6. Os te omy el it i s i n the are a t hat w il l b e re c ei v in g co m pr ess i on, to r si on, or oth er s uch fo r c e fro m the pos i tio nin g a nd/o r t hru s t 7. Infe c ti on o f t he ti ss ues in the ar ea that wi l l be r ece i vi ng c omp r es s i on fr om the pos i ti onin g a nd/ or thru s t. 8. J oin t r epla c em ent i n the ar ea t hat wi l l b e r ece i v in g c omp r ess i on , t or si on, or oth er s uc h fo r ce and/ or thru s t 9. Seve r e hern i at ed di sc wi th r adi c ul opa thy 10. C ong eni tal ano m al i es s uc h a s Kl i pp el- F eil sy ndr om e, bl ock ed v ert ebr a, a nd s o on 11. C ond i ti ons s uc h a s Do w n s yn dr om e ( esp ec ia l ly ce r v ic al s pi ne) 12. R heu m at oi d art hri ti s of the c er v ic al ( esp eci all y at C1 - C2 ) re gio n 13. Ac ho ndr opla s ti c d w arf i sm (c er vi c al sp i ne)

General Consi derations and Rul es

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HV LA tech niq ue i s o ne of the old est for m s of m anu al m ed i c in e a nd i s o ne tha t ha s b een s tu die d m os t i n te r ms of c li nic al r esp ons e. I t i s t he t ech niq ue t hat is l ea s t tim e co nsu m in g. I t d oes hav e, on the oth er ha nd, a r ela tiv el y l on g l earn i ng cu r v e for co m pet enc e a nd u s er co nfid enc e.

Shorthand Rul es 1. D i ag nos e. 2. Loca l iz e th e s egm ent to be tr ea ted . 3. C ont r ol the ar ea s o t he pat i ent is co m for tab l e and r el axe d. 4. Posi tio n to th e r es tr i ct i ve bar r ie r ( the edg e, not the wa l l ). 5. U s e r el ease - en han c i ng ma neu v ers if ne c ess ary (e .g., pa tie nt's br eat hi ng , i s om etri c c ont r act i on , j aw c le nc hi ng and the n r ela x i ng ) . 6. W hen co nfid ent th at t he pat i ent is re l axe d a nd not gua r de d, a dd a r apid ac c el er at i ng (m obil i zi ng forc e) thru s t w it hi n the ar ti cu l at ory pla ne or pl an es of the j oi nt w i th to tal j oi nt m ov em en t k ept to the abs ol ut e m i ni m um. 7. R eas s es s th e c omp onen ts of the dys fun c tio n ( tis s ue tex tur e ab nor m al i ty, as y mm etry of po s i ti on, r est r ic ti on of mo ti on , t end er ne s s [TA R T ], es pec i all y i nte r s eg m en tal j oi nt m ot i on) .

P.2 78

Cervical Regi on: Occipi toatlantal (C0—C1, OA) Dysfunctions Exampl e: OA, F/E or N-S LRR*

1. The patient lies supine, and the phy sic ian is seated or stands at the head of the table to the patient's right. 2. The physic ian rotates the patient's head to the left. 3. The physic ian places the left forearm under the patient's left-r otated head and with the left hand c ups the patient's chin ( Fig . 11.1). 4. The head r esting on the forear m c reates a minimal s ide bending

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Fig ure 11.1. Steps 1 to 3.

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5.

6.

7.

8.

into the r ight side-bending bar rier . The physic ian's right hand (metac arpo-phalangeal joint [MCP] of the index finger, hypothenar eminence, or thumb) is placed jus t posterior to the mas toid pr ocess. (F igs. 11.2, 11.3, 11.4) The physic ian us es both hands to ex ert continuous tr action (w hite ar r ows , F ig. 11.5). This is k ey to a suc ces sful mobilization. With the patient relaxed and not guarding, the phy sic ian delivers a thr ust (white ar row, Fig . 11.6) towar d the patient's left orbit. T his thr ust is not linear but an arc . Effectiveness of the tec hnique is determined by reassessing motion at the oc cipitoatlantal articulations .

Fig ure 11.2. Step 5, MCP position.

Fig ure 11.3. Step 5, hy pothenar eminence var iation.

Fig ure 11.4. Step 5, thumb var iation.

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Fig ure 11.5. Step 6, cephalad traction.

Fig ure 11.6. Step 7.

P.2 79 P.2 80

Cervical Regi on: Atl antoaxi al (C1—C2, AA) Dysfunction Exampl e: C1 RL

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1. The patient lies supine, and the phy sic ian sits or stands at the head of the table. 2. The phy sic ian's hands sandwich the patient's head, cradling both tempor opar ietal regions ( F ig. 11.7) 3. The physic ian rotates the patient's head to the right, engaging the res trictiv e bar rier ( F ig. 11.8). There is no side bending, flexion, or extens ion with this r otation. 4. The patient c an be ask ed to breathe s lowly, and at exhalation, fur ther s lack may be tak en out of the soft tis sues. 5. With the patient relaxed and totally unguar ded (may use end exhalation as point of relaxation), a thr ust is delivered exaggerating

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F ig ure 11.7. Step 2.

F ig ure 11.8. Step 3.

F ig ure 11.9. Step 5.

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P.2 81

Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C4 FS LRL Short-Lever, Rotational Em phasis

1. The patient is supine, and the physic ian stands or sits at the head of the table on the patient's left s ide. 2. The MCP joint of the index finger of the phy sic ian's left hand is placed pos ter ior to the ar tic ular pillar of the dys functional segment. 3. Side bending to the left is introduced until the phy sic ian elicits the mov ement of C4, which segments the cer vic al s pine to this level. Flexion or extens ion is not neces s ary as a separated motion, as the combination of side bending and subsequent rotation will effectively neutraliz e

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F ig ure 11.10. Steps 1 to 3.

F ig ure 11.11. Step 4.

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these components (F ig. 11.10). 4. With the s ide bending held in place, the phy sic ian grasps the chin with the right hand and rotates the head to the right until the phy sic ian feels motion in the left hand. The head is allowed to rest on the phy sic ian's right for earm, which may elevate slightly to effect fur ther isolation of the C4 on C5 articulation (F ig. 11.11). 5. Slight ax ial traction may be applied (w hite ar r ows , Fig . 11.12) with both hands. 6. With the patient relaxed and not guarding, the phy sic ian's left MCP dir ects an arc lik e thrus t in the plane of the oblique fac et of C4 (w hite ar r ow,

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F ig ure 11.12. Step 5, trac tion.

F ig ure 11.13. Step 6.

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Fig . 11.13). 7. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 82

Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C5 ES RRR Long-Lever Rotati onal E mphasis

1. The patient lies s upine, and the phy sic ian is seated at the head of the table. 2. The phy sic ian's right index finger pad or MCP is placed behind the right articular pillar of C6 to res trict motion at that segment. 3. The patient's head is suppor ted by the phy sic ian's left hand (F ig. 11.14) . 4. The head is

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F ig ure 11.14. Steps 1 to 3.

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side-bent right (w hite ar r ow, Fig . 11.15) until C5 begins to mov e. This tak es tens ion off the par avertebral mus cles at the lev el of the dys function. Flexion s hould be added until C5 again begins to mov e. 5. The physic ian car efully rotates the head to the left until the res trictiv e bar rier engages, being mindful to maintain the original r ight side bending (F ig. 11.16). 6. With the patient relaxed and not guarding, the physic ian, using rapid acc eleration, supinates the left hand and wrist, which dir ects a left rotational arc lik e thrus t in the plane of the oblique fac et (w hite arr ow, F ig . 11.17) . T his produc es s ide

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F ig ure 11.15. Step 4.

F ig ure 11.16. Step 5.

F ig ure 11.17. Step 6.

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bending left and rotation left. 7. The phy sic ian's right hand remains r igid as a fulc r um agains t which to mov e the cer vic al column. 8. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 83

Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C5 NS LRL Short-Lever Technique, Side-Bendi ng E mphasi s

1. The patient lies s upine, and the phy sic ian stands or sits at the head of the table. 2. The physic ian suppor ts the patient's head with the pads of the index finger s on the articular pillar s of the

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F ig ure 11.18. Steps 1 to 3.

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3.

4.

5.

6.

7.

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dys functional ver tebra ( C5) . The physic ian gently flexes the patient's head and nec k until C5 begins to mov e over C6 (F ig. 11.18). The physic ian, while monitoring the pos ter ior articular pillar s of C5, gently rotates the patient's head and nec k to the left until motion at C5 is felt. The physic ian gently side-bends the patient's head and nec k to the right, engaging the side-bending bar rier of C5 on C6 (F ig . 11.19) . The physic ian places the MCP of the right index finger pos ter ior to the right articular pillar of C5 (F ig . 11.20) . The physic ian adjusts flexion or extens ion as needed to

F ig ure 11.19. Steps 4 and 5.

F ig ure 11.20. Step 6.

F ig ure 11.21. Step 8, r ight s ide- bending impuls e.

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loc alize all thr ee planes of motion at the dys functional segment. 8. With the patient relaxed and not guarding, the phy sic ian's right hand (second MCP) dir ects an arc -like thrust caudally (w hite ar r ow, Fig . 11.21), acr oss the midline in the oblique plane of the C5 fac et, engaging the right side-bending and right rotational bar riers. 9. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 84 P.2 85

Thoraci c Regi on: T1 to T12 Dysfuncti ons Exampl e: T4 FSLRL Supine

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F igu re 11.22 demonstr ates the fulc rum principle as used in this technique. 1. The patient lies s upine with the phy sic ian standing at the patient's right side ( opposite the rotational component) . 2. The physic ian draws the patient's left arm ac ros s the patient's chest and places the other arm below it. This should for m a V. The patient grasps the opposite shoulders with the hands (F ig. 11.23). 3. The physic ian car efully and minimally rolls the patient toward the phy sic ian by grasping and lifting the patient's left pos ter ior shoulder gir dle. 4. The physic ian places the right thenar eminence pos ter ior to

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Fig ure 11.22. Lateral s upine v iew of the human spine illustr ating p toward T4 and thenar eminence placement at T4- T 5 interspace as dys func tion with a flex ion component (4) .

Fig ure 11.23. Steps 1 and 2.

Fig ure 11.24. Step 3 and 4.

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P.2 86 P.2 87

Thoraci c Regi on: T1 to T12 Dysfuncti ons Exampl e: T9 ESRRR S upi ne

F igu re 11.27 demonstr ates the fulc rum principle as used in this technique. 1. The patient lies s upine with the phy sic ian standing at the patient's left s ide (oppos ite the rotational component) . 2. The physic ian draws the patient's right arm ac ros s the patient's chest and places the other arm below it. This should for m a V. The patient grasps the opposite shoulders with the hands (F ig. 11.28). 3. The physic ian car efully and minimally rolls the patient by grasping and lifting the patient's right pos ter ior shoulder gir dle.

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F igure 11.27. Lateral supine view of the human s pine illus trating p towar d T 10 and thenar eminence plac ement at T 9 trans ver se proc dy sfunction with a flexion c omponent ( 4).

F igure 11.28. Steps 1 and 2.

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4. The physic ian places the thenar eminence pos ter ior to the upper of the two ver tebrae of the dys functional spinal unit at the right transv ers e proces s ( T 9) (F ig. 11.29). 5. The patient's elbows ar e dir ected to the phy sic ian's upper abdomen just inferior to the cos tal ar c h and xiphoid proces s. 6. The phy sic ian's right hand and arm ar e placed under the patient's head and nec k to add slight tension in for war d bending. Side bending left in the thorac ic spine down to the dys function is car ried out by gently mov ing the patient's thorac ic region to the left ( white arr ow, F ig . 11.30) . T he

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F igure 11.29. Steps 3 and 4.

F igure 11.30. Step 6, side-bending left.

F igure 11.31. Step 7, caudad-dir ected impulse.

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patient inhales and ex hales. 7. On exhalation, the physic ian dir ects s light pressure with the abdomen toward the lower of the two vertebrae in this dys functional spinal unit (T10) (w hite arr ow, F ig . 11.31) . 8. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 88

Thoraci c Regi on: T1 to T8 Dysfunctions E xam ple: T2 FS LRL Supine Over the Thigh

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1. The patient lies supine, and the phy sic ian stands at the head of the table. 2. The physic ian places the flexed left k nee on the table with the patient's left T 2 area r esting on the physic ian's thigh (F ig . 11.32) . Note: The side of rotational component determines which thigh is used on which par avertebral side of the patient. 3. The patient's hands are clasped behind the head with the elbows held outward. 4. The phy sic ian's hands pas s thr ough the space made by the patient's for ear ms and upper arms . 5. The physic ian enc irc les the patient's rib cage with the finger s ov er the rib angles pos ter olaterally (F ig. 11.33). 6. The patient

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Fig ure 11.32. Steps 1 and 2.

Fig ure 11.33. Steps 3 to 5.

Fig ure 11.34. Step 7.

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P.2 89

Thoraci c Regi on: T3 to T8 Dysfunctions E xam ple: T6 FS RRR Prone

1. The patient lies prone with the head and nec k in neutral if pos sible. A pillow may be placed under the patient's chest and/or abdomen to inc rease the pos ter ior cur ve and for inc reased comfor t. 2. The physic ian stands at the patient's left for gr eater efficienc y ; however, either side may be us ed (F ig. 11.35). 3. The physic ian places the right thenar eminence on the right transv ers e proces s of T6 with the finger s pointing cephalad. The caudad or cephalad dir ection of the phy sic ian's hands is determined by

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F ig ure 11.35. Steps 1 and 2.

F ig ure 11.36. Steps 3 and 4.

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the side-bending bar rier. 4. The physic ian places the left hypothenar eminence on the left transv ers e proces s of T6 with the finger s pointing caudally ( Fig . 11.36) . 5. The patient inhales and exhales, and on exhalation, a thrust impuls e is delivered in the direc tion in which the finger s ( white arr ows , F ig. 11.37) ar e pointing with slightly greater pressure on the right transv ers e proces s of T6. Note: In a T6 FSLRL (flexion, side bent left, rotated left) dys function, the left hand points cephalad, the right caudad, and the force is slightly greater on the left. In a T6 NSRRL (side

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F ig ure 11.37. Step 5.

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bent r ight, rotated left) dys function, the hands would be as originally des cribed. 6. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 90

Thoraci c Regi on: T1 to T4 Dysfunctions E xam ple: T2 FS RRR Prone (Long Lever)

1. The patient lies prone with the head and nec k r otated to the left. Note: A pillow may be placed under the patient's chest and/or abdomen to inc rease the pos ter ior cur ve. 2. The physic ian stands at the head of the treatment table and side-bends the

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F ig ure 11.38. Step 2.

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3.

4.

5.

6.

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patient's head to the left until palpating motion at the T2- T3 articulation (F ig. 11.38). The phy sic ian's left thenar eminence is placed ov er the left transv ers e proces s of T3 as a r estr ictor and anchor (F ig. 11.39). The phy sic ian's right hand is cupped and placed ov er the left par ietooc c ipital region of the patient's head (F ig. 11.40). The patient inhales and exhales, and on exhalation, a thrust is made by the hand on the head. This is done in a rapidly acc elerating manner , creating rotation to the left ( white arr ow, F ig . 11.41) . Effectiveness of this tec hnique is determined by

F ig ure 11.39. Step 3.

F ig ure 11.40. Step 4.

F ig ure 11.41. Step 5, long-lever rotation, left impuls e.

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reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 91

Thoraci c Regi on: T8 to T12 Dysfuncti ons Exampl e: T9 ESRRR S eated (Short Lever)

1. The patient is seated str addling the table with the pos ter ior aspect of the pelvis at one end so that the patient is fac ing the length of the table. 2. The physic ian stands behind the patient on the side opposite the rotational component of the dys function (left side in this RR c ase) . 3. The patient places the right hand behind the nec k and the left hand on the right elbow (F ig. 11.42).

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F ig ure 11.42. Steps 1 to 3.

F ig ure 11.43. Steps 4 and 5.

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4.

5.

6.

7.

8.

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(Note: Both hands can be placed behind the neck if this is mor e comfor table.) The physic ian places the left hand under the patient's left axilla and on top of the patient's right upper arm. The physic ian places the right thenar eminence par avertebrally over the r ight T9 transv erse proces s ( F ig. 11.43) . The patient is told to r elax , and the phy sic ian car ries the patient into slight for war d bending and left s ide bending until T9 begins to mov e. The patient inhales deeply and on exhalation is car ried into left rotation while slight flexion and left s ide bending ar e maintained. The patient again inhales , and on exhalation, the

F ig ure 11.44. Step 8, barr ier .

F ig ure 11.45. Step 8, impulse.

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phy sic ian quickly and minimally pulls the patient thr ough the left rotational bar rier ( F ig. 11.44) while the right hand imparts an impuls e on T9 (w hite ar r ow, Fig . 11.45) causing a HVLA effec t in left r otation. 9. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 92

Thoraci c Regi on: T8 to T12 Dysfuncti ons Exampl e: T10 ESRRR S eated (Long Lever)

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1. The patient is seated str addling the table with the pos ter ior aspect of the pelvis at one end, facing the length of the table. 2. The physic ian stands behind the patient on the side opposite the rotational component (left side in this RR c ase) . 3. The patient places the right hand behind the nec k and the left hand on the right elbow (F ig. 11.46). (Note: Both hands can be placed behind the neck if this is mor e comfor table.) 4. The physic ian places the left hand under the patient's left axilla and on top of the patient's right upper arm. 5. The physic ian places the heel of the right hand midline and supras pinously on the lower of

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F ig ure 11.46. Steps 1 to 3.

F ig ure 11.47. Steps 4 and 5.

F ig ure 11.48. Step 7, barr ier .

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P.2 93

Costal Region: Ri ght Fi rst Rib Inhal ation Dysfunction Seated

1. The patient sits on the table with the phy sic ian standing behind the patient. 2. The phy sic ian places the shoeless left foot on the table at the patient's left, so that the patient's left axilla is suppor ted by the phy sic ian's left thigh (F ig. 11.50). 3. The phy sic ian places the left hand on top of the patient's head with the for ear m along side of the patient's fac e. 4. The phy sic ian's places the thumb or sec ond MCP of the right hand superior and pos ter ior to the angle of the

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F ig ure 11.50. Steps 1 and 2.

F ig ure 11.51. Steps 3 to 5.

F ig ure 11.52. Step 7, including direction of

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5.

6.

7.

8.

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dys functional right fir s t r ib. The phy sic ian side-bends the patient's head and nec k to the right and rotates to the left until the motion bar rier is met (F ig. 11.51). (In some patients, rotation r ight may be appropriate.) The patient inhales and exhales. Dur ing exhalation, fur ther s ide bending and rotational slack are tak en up. At the end of exhalation, a for ce is dir ected with the phy sic ian's thumb (or sec ond MCP) downward and forwar d, toward the patient's left nipple (white arr ow, F ig . 11.52) . Effectiveness of the tec hnique is determined by

for ce.

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reassessing motion of the dys functional rib.

P.2 94

Costal Region: Left First Rib Inhalation Dysfuncti on Supi ne

1. The patient is supine, and the phy sic ian sits or stands at the patient's head. 2. The physic ian places the right hand along the patient's right tempor opar ietal area ( Fig . 11.53) . 3. The physic ian places the left sec ond MCP superior and pos ter ior to the angle of the dys functional rib. 4. The patient's head is s lightly for war d bent, rotated r ight, and side- bent left with the control of the phy sic ian's right hand (F ig. 11.54). 5. The patient inhales and exhales. 6. At the end of

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F ig ure 11.53. Steps 1 and 2.

F ig ure 11.54. Steps 3 and 4.

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exhalation, the phy sic ian dir ects a thr ust (w hite ar r ow, Fig . 11.55) with the left hand downward and slightly medially toward the patient's right nipple. 7. Effectiveness of the tec hnique is determined by reassessing motion of the dys functional rib.

F ig ure 11.55. Step 6, including direction of for ce.

P.2 95

Costal Region: Left Rib 6 I nhalation Dysfuncti on S upi ne

1. The patient is supine, and the physic ian stands at the side of the table opposite the side of the r ib dys function. 2. The phy sic ian draws the patient's arm on the side of the rib dys function acr oss the patient's rib cage with the

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F igu re 11.56. Steps 1 and 2.

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3.

4.

5.

6.

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patient's other arm below it. The patient's arms s hould for m a V (F ig. 11.56). The phy sic ian slightly r olls the patient toward the phy sic ian by gently pulling the left pos ter ior shoulder gir dle for war d. The phy sic ian places the thenar eminence of the right hand pos ter ior to the angle of the dys functional rib (F ig. 11.57) . The patient is rolled bac k over the phy sic ian's hand, and the sur fac e created by the patient's crossed arms r ests agains t the phy sic ian's chest or abdomen. Pressure is dir ected thr ough the

F igu re 11.57. Steps 3 and 4.

F igu re 11.58. Steps 5 to 7, inc luding direction of forc e.

F igu re 11.59. Steps 5 to 7, inc luding direction of forc e.

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patient's chest wall, loc alizing at the thenar eminence. 7. The patient inhales and exhales, and at end exhalation a thr ust impuls e (w hite arr ows , F igs. 11.58 and 11.59) is delivered thr ough the patient's chest wall slightly cephalad to the thenar eminence. 8. Effectiveness of the tec hnique is determined by reassessing motion of the dys functional rib.

P.2 96

Costal Region: Left Rib 8 E xhalation Dysfuncti on S upi ne

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1. The patient lies s upine, and the phy sic ian stands at the side of the table opposite the side of the r ib dys function. 2. The phy sic ian draws the patient's arm on the side of the dys function acr oss the patient's rib cage with the patient's other arm below it. The patient's arms s hould for m a V (F ig. 11.60). 3. The phy sic ian slightly r olls the patient toward the phy sic ian by gently pulling the left pos ter ior shoulder gir dle for war d. 4. The phy sic ian places the thenar eminence of the right hand pos ter ior to the angle of the

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F ig ure 11.60. Steps 1 and 2.

F ig ure 11.61. Steps 3 and 4.

F ig ure 11.62. Steps 5 to 7, including dir ection of for ce.

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P.2 97

Costal Region: Ri ght Ri bs 11 and 12 I nhalation Dysfuncti on Prone

1. The patient lies prone on the table. 2. The phy sic ian stands at the left s ide of the table and pos itions the patient's legs 15 to 20 degrees to the right to tak e tens ion off the quadratus lumbor um, which attaches to the infer ior medial aspect of rib 12 (F ig. 11.64) . 3. The phy sic ian places the left hypothenar eminence medial and inferior to the angle of the dys functional rib and exerts gentle sus tained lateral and cephalad traction. 4. The phy sic ian's

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Fig ure 11.64. Steps 1 and 2.

Fig ure 11.65. Steps 3 and 4.

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right hand may gr asp the patient's right anterior superior iliac spine to stabilize the pelvis (F ig. 11.65) . 5. The patient inhales and exhales deeply . 6. Dur ing exhalation the phy sic ian's left hand applies a cephalad and later al HVLA thrus t impuls e (w hite ar r ow, Fig . 11.66). 7. Suc ces s of the tec hnique is determined by reassessing motion of the dys functional rib.

Fig ure 11.66. Steps 5 and 6, including dir ection of for c e.

Note: T his technique is c ommonly done after performing the mus c le energy r espiratory as sis t technique for ribs 11 and 12 held in inhalation.

P.2 98

Costal Region: Ri ght Ri bs 11 and 12 E xhalation Dysfuncti on

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Prone

1. The patient lies prone on the table. 2. The phy sic ian stands at the left s ide of the table and pos itions the patient's legs 15 to 20 degrees to the left to put tension on the quadratus lumbor um, which attaches to the infer ior medial aspect of rib 12 (F ig. 11.67) . 3. The phy sic ian places the left thenar eminence superior and lateral to the angle of the dys functional rib and exerts gentle sus tained medial and caudad traction. 4. The phy sic ian's right hand grasps the patient's right anterior superior iliac spine and

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Fig ure 11.67. Steps 1 and 2.

Fig ure 11.68. Steps 3 and 4.

Fig ure 11.69. Steps 5 and 6.

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gently lifts toward the ceiling ( F ig. 11.68) . 5. The patient inhales and exhales deeply . 6. Dur ing the end exhalation, the phy sic ian's left hand applies a caudad and medial HVLA thr ust as the right hand gently lifts the anter ior superior iliac spine (ASIS) up toward the ceiling (F ig. 11.69). 7. Suc ces s of the tec hnique is determined by reassessing motion of the dys functional rib.

P.2 99

Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L5 NSLRR Lateral Recum bent (Long Lever)

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1. The patient lies in the r ight lateral rec umbent (side- lying) pos ition with the physic ian standing at the side of the table fac ing the patient. 2. The physic ian palpates between the spinous proces ses of L5 and S1 and flexes the patient's knees and hips until L5 is in a neutr al pos ition relative to S1 (F ig. 11.70). 3. The physic ian fur ther pos itions the patient's left leg so that it drops over the side of the table cephalad to the right leg. T he patient's foot mus t not touc h the floor (F ig. 11.71) . 4. While continuing to palpate L5, the phy sic ian places the cephalad hand in the patient's left antec ubital fos sa while

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Fig ure 11.70. Steps 1 and 2.

Fig ure 11.71. Step 3.

Fig ure 11.72. Steps 4 and 5.

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P.3 00

Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L4 FRRS Lateral Recum bent (Long Lever)

1. The patient lies in the r ight lateral rec umbent pos ition with the physic ian standing at the side of the table fac ing the patient. 2. The physic ian palpates between the spinous proces ses of L4 and L5 and flexes the patient's knees and hips until L4 is in a neutr al pos ition relative to L5. It is not nec ess ary to meet the extens ion bar rier at this point (F ig . 11.74) . 3. The physic ian fur ther pos itions the patient's left leg so that it drops over the side of the table cephalad to the right leg. T he patient's foot mus t not touc h the floor (F ig.

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Fig ure 11.74. Steps 1 and 2.

Fig ure 11.75. Step 3.

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11.75) . 4. While continuing to palpate L4, the phy sic ian places the cephalad hand in the antecubital fos sa of the patient's left arm while res ting the for ear m gently on the patient's shoulder. 5. The phy sic ian's caudad hand stabilizes L5 (F ig. 11.76). 6. The patient's shoulder and pelvis ar e axially r otated in opposite dir ections . The patient inhales and exhales, and dur ing exhalation, fur ther rotational slack is taken up. 7. If the rotational slack and/or motion bar rier is not effectively met, the phy sic ian can grasp the patient's right arm, drawing the shoulder

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Fig ure 11.76. Steps 4 and 5.

Fig ure 11.77. Step 8.

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for war d until rotational mov ement is palpated between L4 and L5. 8. With the patient r elax ed and not guarded the phy sic ian delivers an impuls e with the forear ms (w hite ar r ows , Fig . 11.77), simultaneously mov ing the shoulder slightly caudad and the pelvis and sac rum cephalad. 9. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.3 01

Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: Left L5—S1 Radicul iti s* Lateral Recum bent (Long Lever)

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1. The patient is in the right lateral rec umbent pos ition with the physic ian standing at the side of the table fac ing the patient. 2. The phy sic ian palpates between the patient's spinous proces ses of L5- S1 and flexes the patient's hips and knees until L5 is fully flex ed in relation to S1 (F ig. 11.78). 3. The phy sic ian pos itions the patient's left leg so that it drops over the side of the table cephalad to the right leg. The patient's leg should not touch the floor (F ig . 11.79) . 4. While continuing to palpate L5, the physic ian places the cephalad hand in the

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F ig ure 11.78. Steps 1 and 2.

F ig ure 11.79. Step 3.

F ig ure 11.80. Steps 4 and 5.

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P.3 02

Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L4 NSLRR Supine Lum bar Wal k-Around (Long Lever)

1. The patient lies s upine with both hands behind the neck and the finger s interlaced. 2. The physic ian stands at the head of the table to the patient's right and slides the right for earm thr ough the space created by the patient's flexed right arm and shoulder. 3. The dorsal aspect of the phy sic ian's hand is car efully placed at mid sternum on the patient's chest wall (F ig. 11.82). 4. The physic ian then walk s around the head of the table to the left s ide of the patient. 5. The physic ian, while palpating pos ter ior ly with the caudad hand,

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F ig ure 11.82. Steps 1 to 3.

F ig ure 11.83. Steps 4 to 6.

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6.

7.

8.

9.

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side-bends the patient's trunk to the right until L4 begins to mov e. The physic ian begins to rotate the patient to the left while continuing to maintain the original s ide bending ( F ig. 11.83) . The phy sic ian's caudad hand anc hor s the patient's pelvis by placing the palm on the patient's right ASIS. With the patient relaxed and not guarding, the physic ian dir ects an impuls e that pulls the patient minimally into fur ther left rotation ( white arr ows , F ig. 11.84) . Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional

F ig ure 11.84. Steps 7 and 8.

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segment.

P.3 03

Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L2 E SRRR Lum bar Seated Positi on (Short Lever)

1. The patient sits, prefer ably str addling and fac ing the length of the table to res trict the sac rum and pelvis . 2. The physic ian stands behind and to the left of the patient. 3. The patient places the right hand behind the nec k and the left hand on the right elbow (both hands can be placed behind the nec k if this is mor e comfor table) (F ig. 11.85). 4. The physic ian pas ses the left hand under the patient's left axilla and on top of the patient's right

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F ig ure 11.85. Steps 1 to 3.

F ig ure 11.86. Steps 4 and 5.

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upper arm. 5. The physic ian places the right thenar eminence or palm on the par avertebral mus cles ov er the L2 right transv ers e proces s ( F ig. 11.86) . 6. The patient is ins tructed to relax as the phy sic ian pos itions the patient into slight for war d bending and then left side bending until motion is palpated at L2. 7. The patient inhales deeply , and on exhalation the patient is pos itioned into left r otation (while the slight flexion and left s ide bending ar e maintained (F ig. 11.87). 8. With the patient relaxed and not guarding, the physic ian dir ects an impuls e force, pulling the patient minimally thr ough

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F ig ure 11.87. Steps 6 and 7.

F ig ure 11.88. Step 8.

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fur ther left rotation while dir ecting a short lev er thr ust on L2 with the r ight hand ( white arr ows , F ig. 11.88) . 9. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.3 04 P.3 05

Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L2 E SRRR Lum bar Seated Positi on (Long Lever)

1. The patient sits, prefer ably str addling and fac ing the length of the table, to res trict the sac rum and pelvis . 2. The physic ian stands behind and to the left of the patient. 3. The patient places the right hand

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F ig ure 11.89. Steps 1 to 3.

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4.

5.

6.

7.

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behind the nec k and the left hand on the right elbow (both hands can be placed behind the nec k if this is mor e comfor table) (F ig. 11.89). The physic ian pas ses the left hand over the top of the patient's left upper arm and on top of the patient's right upper arm. The physic ian places the right thenar eminence or palm midline at the inters pac e between the L2 and L3 spinous proces ses (F ig. 11.90). The patient is ins tructed to relax, and the phy sic ian pos itions the patient into slight for war d bending and left s ide bending until motion is palpated at L2. The patient inhales deeply , and on exhalation the

F ig ure 11.90. Steps 4 and 5.

F ig ure 11.91. Steps 6 and 7.

F ig ure 11.92. Step 8.

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patient is pos itioned into left r otation while slight flexion and left side bending are maintained (F ig. 11.91). 8. With the patient relaxed and not guarding, the phy sic ian's left hand pulls the patient into further left rotation while stabilizing L3 with the r ight hand ( white arr ows ) ( this rotates L2 to the left in relation to L3) (F ig. 11.92). 9. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.3 06 P.3 07

Pel vic Region: Left Posteri or Innomi nate Dysfuncti on, Lateral Recum bent

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Diag nosis Standing flexion test: Positiv e (left PSIS r ises) Loss of pas siv ely induced left s acr oiliac motion ASIS: Cephalad (s lightly lateral) on the left PSIS: Caudad ( slightly medial) on the left Sacr al s ulc us: Deep, anterior on the left T ech niq u e 1. The patient is in the right lateral rec umbent pos ition, and the physician stands fac ing the patient. 2. The physic ian's cephalad hand palpates between the patient's spinous pr ocesses of L5 and S1. 3. The physic ian's caudad hand flex es the patient's knees and hips until the L5 and S1 spinous proces ses separate ( Fig . 11.93) . 4. The physic ian maintains the left leg in this position and instr ucts the patient to str aighten the r ight leg, plac ing the left foot just dis tal to the right popliteal fos sa. 5. The physic ian places the cephalad hand on

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Fig ure 11.93. Steps 1 to 3.

Fig ure 11.94. Steps 4 and 5.

Fig ure 11.95. Step 6a.

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P.3 08

Pel vic Region: Ri ght Posterior Innom i nate Dysfunction, Leg Pul l, S upi ne

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right sac r oiliac motion ASIS: Cephalad (s lightly lateral) on the r ight PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Deep, anterior on the r ight T ech niq u e 1. The patient is supine, and the phy sic ian stands at the foot of the table. 2. The physic ian grasps the patient's right ank le. 3. The physic ian raises the patient's right leg no mor e than 30 degrees and applies traction down the shaft of the leg (w hite ar r ow, F ig. 11.99) . a. Some prefer to position the leg s lightly off the s ide of the table approximately 10 to 20 degrees ( Fig .

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F ig ure 11.99. Steps 1 to 3.

F ig ure 11.100. Step 3a.

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11.100). 4. This trac tion is maintained as the patient is as ked to tak e 3 to 5 s low breaths. 5. At the end of the las t breath, the phy sic ian delivers a thrust in the dir ection of the traction ( white arr ow, F ig . 11.101). 6. Effectiveness of the technique is determined by reassessing r ight sac roiliac joint motion.

F ig ure 11.101. Step 5.

P.3 09

Pel vic Region: Left Posteri or Innomi nate Dysfuncti on, Supine Ful crum

Diag nosis Standing flexion test: Positive (left PSIS ris es) Loss of pas siv ely induced left s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the left PSIS: Caudad ( slightly medial) on the left Sacr al s ulc us: Deep, anter ior on the left

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F ig ure 11.102. Steps 1 to 4.

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T ech niq u e 1. The patient is supine, and the physic ian stands to the patient's right. 2. The phy sic ian flexes the patient's knees and hips. 3. The phy sic ian rolls the patient's legs toward the phy sic ian. 4. The phy sic ian places the thenar eminence of the cephalad hand under the patient's left PSIS to ser ve as a fulcrum agains t which to mov e the innominate (F ig. 11.102). 5. The phy sic ian rolls the patient onto the left PSIS with the patient's weight dir ectly over the fulcr um (w hite ar r ow, Fig . 11.103). 6. The patient

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F ig ure 11.103. Step 5.

F ig ure 11.104. Steps 5 and 6.

F ig ure 11.105. Step 6.

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extends the left k nee and then s lowly lowers the leg towar d the table (w hite arr ows , F igs. 11.104 and 11.105), causing a short and long lever ing of the left innominate. 7. Effectiveness of the tec hnique is determined by reassessing left s acr oiliac joint motion.

P.3 10

Pel vic Region: Left Anteri or I nnominate Dysfunction, Lateral Recumbent

Diag nosis Standing flexion test: Positive (left PSIS ris es) Loss of pas siv ely induced left s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the left ASIS: Caudad ( slightly medial) on the left Sacr al s ulc us:

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F ig ure 11.106. Step 1.

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Posterior on the left T ech niq u e 1. The patient is in the right lateral rec umbent pos ition, and the physic ian stands at the side of the table fac ing the patient (F ig. 11.106). 2. The phy sic ian palpates between the spinous proces ses of L5 and S1 with the cephalad hand. 3. The phy sic ian's caudad hand flexes the patient's hips and knees until the L5 and S1 spinous proces ses separate. 4. The phy sic ian pos itions the patient's left leg so that it drops off the side of the table, ov er and slightly mor e flex ed than the r ight

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F ig ure 11.107. Steps 2 to 5.

F ig ure 11.108. Step 6.

F ig ure 11.109. Steps 7 and 8.

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leg. T he patient's foot should not touch the floor. 5. The phy sic ian places the caudad for ear m in a line between the patient's left PSIS and trochanter and the cephalad hand or for ear m on the patient's left s houlder (F ig. 11.107). 6. The phy sic ian introduces axial rotation in opposing dir ections by gently pus hing the patient's left shoulder dor sally (posterior ly) and rolling the pelvis ventrally (anter ior ly) (w hite ar r ow, Fig . 11.108). These motions should be continued until mov ement of the sacrum is palpated at the left

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sac roiliac joint. 7. If no motion is felt, the phy sic ian grasps the patient's right arm and draws the shoulder for war d until rotational mov ement is elicited at the left s acr oiliac joint. 8. With the patient relaxed and not guarding, the physic ian delivers an impuls e along the shaft of the femur (w hite arr ows , F ig. 11.109). 9. Effectiveness of the tec hnique is determined by reassessing left s acr oiliac joint motion.

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Pel vic Region: Ri ght Anteri or Innomi nate Dysfuncti on, Leg Pul l

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Diag nosis Standing flexion test: Positive (r ight PSIS ris es) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior on the r ight

F ig ure 11.110. Steps 1 to 3.

T ech niq u e 1. The patient is supine and the physic ian stands at the foot of the table. 2. The phy sic ian grasps the patient's right ank le. 3. The patient's right leg is raised 45 degrees or mor e and traction is applied down the shaft of the leg ( white arr ow, F ig . 11.110) 4. This trac tion is maintained and the patient is ask ed to take 3 to 5 slow breaths. At

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F ig ure 11.111. Step 4.

F ig ure 11.112. Step 5.

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Upper E xtremi ty Regi on: Wri st, Dorsal Carpal Dysfunction

Diag nosis Symptoms : Wris t disc omfort with inability to fully extend the wrist Palpation: Dor sal prominence and/or pain of a s ingle c arpal bone T ech niq u e 1. The patient is seated on the table, and the phy sic ian is standing fac ing the patient. 2. The phy sic ian grasps the patient's wrist with the phy sic ian's thumbs on the dorsal aspect of the wrist (F ig . 11.113). 3. The dorsally dys functional car pal bone is identified with the phy sic ian's thumbs . 4. The phy sic ian places the thumb over the displaced car pal bone and

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F igu re 11.113. Steps 1 and 2.

F igu re 11.114. Steps 3 and 4.

F igu re 11.115. Step 5.

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reinforces it with the other thumb. Phy sic ian's other fingers wrap around palmar sur fac e ( F ig. 11.114). 5. A s imple whipping motion is car ried out, maintaining pressure over the dis placed car pal bone (w hite ar r ow, Fig . 11.115). (No tr action is needed for this tec hnique.) 6. Effectiveness of the tec hnique is determined by reassessing both the prominent car pal bone and wr ist range of motion.

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Upper E xtremi ty Regi on: El bow, Fl exi on Dysfunction (Distal Elbow, Ulna)

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Diag nosis Symptom: Elbow disc omfort Motion: Inability to fully ex tend the elbow Palpation: O lec ranon foss a palpable ev en when elbow is fully extended T ech niq u e 1. The patient is seated on table and the phy sic ian is standing in front of patient. 2. The wr ist of the ar m to be treated is held against the phy sic ian's waist using the elbow (F ig. 11.116). 3. The phy sic ian places the thumbs on top of the for ear m in the ar ea of the antecubital fos sa. 4. Traction is down towar d the floor ; the elbow is car ried into fur ther flexion ( white

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F ig ure 11.116. Steps 1 and 2.

F ig ure 11.117. Steps 3 and 4.

F ig ure 11.118. Step 5.

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Upper E xtremi ty Regi on: El bow, Extension Dysfuncti on (Proxi m al Elbow, Ulna)

Diag nosis Symptom: Elbow disc omfort Motion: Inability to fully flex the elbow Palpation: No palpable olecr anon foss a with the elbow fully extended T ech niq u e 1. The patient is seated on the table, and the phy sic ian is standing fac ing the patient. 2. The patient's arm to be treated is held against phy sic ian's waist with the phy sic ian's elbow against the patient's hand. 3. The phy sic ian places the thumbs on top of the for ear m in the region of the antecubital fos sa (F ig . 11.120). 4. The patient is ask ed to

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F ig ure 11.120. Steps 1 to 3.

F ig ure 11.121. Step 4.

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res ist minimally (b lack arr ows , F igs. 11.121, 11.122, 11.123) as the physic ian applies traction down toward the floor (w hite arr ow, F ig . 11.121). Maintaining this trac tion, the patient's elbow is car ried into full extension (w hite arr ows , F igs. 11.122 an d 11.123). 5. Effectiveness of the tec hnique is determined by reassessing elbow extens ion.

F ig ure 11.122. Step 4.

F ig ure 11.123. Step 4.

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Upper E xtremi ty Regi on: El bow, Radial Head, Supination Dysfunction

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Diag nosis Symptoms : Disc omfort at the r adial head Motion: Los s of pass ive pronation of the forearm Palpation: Anterior prominence and tenderness of the r adial head T ech niq u e 1. The patient is seated on the table and the phy sic ian is standing fac ing the patient. 2. The phy sic ian holds the hand of the dys functional arm as if shaking hands with the patient. The phy sic ian places the thumb of the opposite hand anter ior to the radial head ( Fig 11.124). 3. The phy sic ian rotates the for ear m into pronation until the res trictiv e bar rier is reached.

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F ig ure 11.124. Steps 1 and 2.

F ig ure 11.125. Steps 3 and 4.

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Upper E xtremi ty Regi on: El bow, Radial Head, Pronation Dysfunction

Diag nosis Symptoms : Disc omfort at the r adial head Motion: Los s of pass ive supination of the forearm Palpation: Posterior prominence and tenderness of the r adial head T ech niq u e 1. The patient is seated on the table, and the phy sic ian is standing fac ing the patient. 2. The phy sic ian holds the hand of the dys functional arm as if shaking hands with the patient. The phy sic ian places the thumb of the opposite hand pos ter ior to the radial head ( Fig 11.126). 3. The phy sic ian

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F ig ure 11.126. Steps 1 and 2.

F ig ure 11.127. Steps 3 and 4.

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rotates the for ear m into supination until the res trictiv e bar rier is reached. 4. With the patient completely relaxed, the phy sic ian car ries the for ear m into extens ion and supination while maintaining thumb pressure over the pos ter ior radial head (F ig 11.127). 5. Effectiveness of the tec hnique is determined by retesting pronation of the forear m and palpating for reduc ed prominenc e of the radial head.

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Lower E xtremi ty Regi on: Knee: Anteri or Dysfunction of the Tibia on the Fem ur (Posteri or Fem ur Over Ti bia), S upi ne

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Diag nosis Symptoms : Knee disc omfort, inability to c omfortably ex tend the knee Motion: Res tricted posterior s pring ( drawer - lik e test) with los s of anterior fr ee play motion Palpation: Prominence of tibial tuberos ity

F ig ure 11.128. Steps 1 to 3.

T ech niq u e 1. The patient is supine with the dys functional knee flex ed to 90 degrees with foot flat on the table. 2. The phy sic ian sits on the patient's foot anc hor ing it to the table. 3. The phy sic ian places the thenar eminences over the anterior aspect of the tibial plateau with the finger s wrapping around the leg (F ig. 11.128).

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F ig ure 11.129. Step 4.

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Lower E xtremi ty Regi on: Knee: Anteri or Dysfunction of the Tibia on the Fem ur (Posteri or Fem ur Over Ti bia), S eated

Diag nosis Symptoms : Knee disc omfort, inability to c omfortably ex tend the knee Motion: Res tricted posterior s pring ( drawer - lik e test) with los s of anterior fr ee play motion Palpation: Prominence of tibial tuberos ity

F ig ure 11.130. Steps 1 and 2.

T ech niq u e 1. The patient is seated on the side of the table with a small pillow beneath the thigh as a cus hion. 2. The phy sic ian places the thumbs on the anter ior tibial plateau with the finger s wrapping around the leg (F ig. 11.130). 3. The thigh is spr ung up and down to ens ure total relaxation of

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F ig ure 11.131. Step 3.

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the thigh mus culatur e (w hite arr ows , F ig. 11.131). 4. A thrust is delivered str aight down toward the floor, simultaneous with a pos ter ior pressure impuls e with the thumbs (w hite arr ows , F ig. 11.132). 5. Effectiveness of the tec hnique is determined by reassessing anterior free play glide as well as r ange of motion of the knee.

F ig ure 11.132. Step 4.

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Lower E xtremi ty Regi on: Knee: Posteri or Dysfunction of the Tibia on the Fem ur (Anteri or Femur Over Tibia), Prone

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Diag nosis Symptoms : Knee disc omfort, inability to c omfortably flex the knee Motion: Res tricted anterior spring ( drawer - lik e test) with los s of posterior free play motion T ech niq u e 1. The patient lies prone with the dys functional knee flex ed to approx imately 90 degrees if pos sible. 2. The physic ian stands or sits at the end of the table with the dorsum of the patient's foot on the anteromedial aspect of the phy sic ian's shoulder. Place- ment of patient's foot on phy sic ian's shoulder will plantar-flex the foot, tak ing tension off the gas trocnemius mus cle. 3. The phy sic ian's finger s ar e interlaced and wrapped

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F ig ure 11.133. Steps 1 to 3.

F ig ure 11.134. Step 4.

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Lower E xtremi ty Regi on: Knee: Posteri or Dysfunction of the Tibia on the Fem ur (Anteri or Femur Over Tibia), Seated

Diag nosis Symptoms : Knee disc omfort, inability to c omfortably flex the knee Motion: Res tricted posterior s pring ( drawer - lik e test) with los s of anterior fr ee play motion T ech niq u e 1. The patient is seated on the side of the table with a small pillow beneath the thigh as a cus hion. 2. The phy sic ian places the thumbs on the anter ior tibial plateau with the finger s wrapping around the leg contac ting the popliteal fos sa and adding a slight flexion to the knee so the foot may go under the edge of

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F ig ure 11.135. Steps 1 and 2.

F ig ure 11.136. Steps 3 and 4.

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the table (F ig. 11.135). 3. The thigh is then s prung up and down to ens ure total relaxation of the thigh mus culatur e. 4. A thrust is delivered down towar d the floor (w hite ar r ow, Fig . 11.136), simultaneous with an anterior pressure impuls e with the popliteal contac ting finger s. 5. Effectiveness of the tec hnique is determined by reassessing anterior free play glide and range of motion of the knee.

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Lower E xtremi ty Regi on: Knee: Anteri or Fibular Head Dysfunction

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Diag nosis Symptoms : Lateral leg sor enes s and musc le c ramping with tender nes s ov er the prox imal fibula Motion: Inc reased anterior glide with r estric ted motion of the prox imal fibula posterior glide History : Common following a medial ankle s prain, for c ed dors iflexion of the ankle, genu r ecurvatum deformity

F ig ure 11.137. Steps 1 to 3.

T ech niq u e 1. The patient lies supine with a small pillow under the dys functional knee to maintain the knee in s light flexion. 2. The physic ian's caudad hand internally rotates the patient's ank le to bring the proximal fibula mor e anter ior . 3. The physic ian places the heel of the cephalad hand over the anterior sur fac e of the proximal fibula (F ig. 11.137) . 4. A thrust is delivered

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F ig ure 11.138. Steps 4 and 5.

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Lower E xtremi ty Regi on: Knee: Posteri or Fibular Head Dysfunction

Diag nosis Symptoms : Pain at the lateral knee, pers istent ank le pain bey ond that expected for normal ankle r ecover y Motion: Inc reased posterior glide and decr eas ed anterior glide Palpation: T enderness at the fibular head; fibular head pr ominent posteriorly History : Common following inversion s prains of the ankle

F ig ure 11.139. Steps 1 to 4.

T ech niq u e 1. The patient lies prone with the dys functional knee flex ed at 90 degrees. 2. The phy sic ian stands at the side of the table opposite the side of the dys function. 3. The phy sic ian places the MCP of the

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F ig ure 11.140. Step 5.

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cephalad index finger behind the dys functional fibular head, and the hypothenar eminence is angled down into the hamstr ing mus culatur e to for m a wedge behind the knee. 4. The phy sic ian's caudad hand grasps the ank le on the side of dys function and gently flexes the knee until the res trictiv e bar rier is reached (F ig. 11.139). 5. The patient's foot and leg are gently externally rotated to car ry the fibular head bac k against the fulcr um for med by the phy sic ian's cephalad hand ( white arr ow, F ig . 11.140). 6. The phy sic ian's caudad hand,

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F ig ure 11.141. Step 6.

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controlling the patient's foot and ank le, delivers a thr ust toward the patient's buttoc k in a manner that would nor mally res ult in fur ther flexion of the knee ( white arr ow, F ig . 11.141). However, the wedge fulcrum for med by the phy sic ian's cephalad hand prevents any suc h motion. 7. Effectiveness of the tec hnique is determined by reassessing motion of the fibular head and by palpating for res tor ation of nor mal pos ition of the fibula.

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Lower E xtremi ty Regi on: Knee: Anteri or Medi al Meni scus Dysfunction

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Diag nosis Symptoms : Medial k nee dis comfor t, lock ing of the knee s hor t of full extension Phys ical findings : Palpable bulging of the meniscus just medial to the patellar tendon, positiv e MacMurr ay's test, positiv e Apley 's c ompres s ion test

F ig ure 11.142. Steps 1 to 3.

T ech niq u e 1. The patient lies s upine with hip and knee flex ed. 2. The physic ian stands at the side of the table on the side of the dys function. 3. The physic ian places the ank le of the dys functional leg under the phy sic ian's axilla and agains t the lateral r ib cage ( Fig . 11.142). 4. The physic ian places the thumb of the medial hand over the bulging menisc us. The finger s of the later al

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F ig ure 11.143. Step 4.

F ig ure 11.144. Step 5.

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Lower E xtremi ty Regi on: Ankle: Anteri or Tibia on Talus

Diag nosis Drawer test: Loss of anter ior glide ( free play motion) with dec reased posterior drawer test T ech niq u e 1. The patient lies s upine, and the phy sic ian stands at the foot of the table. 2. The phy sic ian's one hand cups the calcaneus anc hor ing the foot ( slight traction may be applied). 3. The phy sic ian places the other hand on the anterior tibia proximal to the ankle mor tis e ( F ig. 11.146). 4. A thrust is delivered with the hand on the tibia str aight down toward the table (w hite arr ow, F ig .

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F ig ure 11.146. Steps 1 to 3.

F ig ure 11.147. Step 4.

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11.147). 5. Effectiveness of the tec hnique is determined by reassessing ank le range of motion.

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Lower E xtremi ty Regi on: Ankle: Posterior Ti bia on Tal us

Diag nosis Drawer test: Loss of posterior glide ( free play motion) with dec reased anterior dr awer test T ech niq u e 1. The patient lies s upine, and the phy sic ian stands at the foot of the table. 2. The phy sic ian's hands are wrapped around the foot with the finger s interlaced on the dorsum. 3. The foot is dor siflex ed to the motion bar rier us ing

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F ig ure 11.148. Steps 1 to 3.

F ig ure 11.149. Step 4.

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pressure from the phy sic ian's thumbs on the ball of the foot ( Fig . 11.148). 4. Traction is placed on the leg at the same time dor siflex ion of the foot is inc reased (w hite arr ows , F ig. 11.149). 5. The phy sic ian delivers a tractional thr ust foot while inc reasing the degree of dor siflex ion (w hite arr ows , F ig. 11.150). 6. Effectiveness of the tec hnique is determined by reassessing ank le range of motion.

F ig ure 11.150. Step 5.

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Lower E xtremi ty Regi on: Foot: Cuneiform, Pl antar Dysfunction (Dr. Hiss's Whi p Technique)

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Diag nosis Symptom: Plantar disc omfort. Motion: Longitudinal arch and for efoot will not readily spring toward s upination. Palpation: Tender prominence on the plantar sur fac e of the foot ov erlying the dys func tional c uneifor m.

F igu re 11.151. Steps 1 to 3.

T ech niq u e 1. The patient lies prone with the leg off the table flexed at the knee. 2. The phy sic ian stands at the foot of the table. 3. The phy sic ian's hands are wrapped around the foot with the thumbs placed ov er the dr opped cuneiform (F ig. 11.151). 4. A whipping motion is car ried out with the thumbs thr usting str aight down into the s ole

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F igu re 11.152. Step 4.

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Lower E xtremi ty Regi on: Foot: Fifth Metatarsal Dysfuncti on, Plantar Styloid

Diag nosis History : Common following inversion s prain of the ank le. T ech niq u e 1. The patient lies supine. 2. The physic ian sits at the foot of the table. 3. The physic ian places the thumb over the dis tal end of the fifth metatarsal. 4. The physic ian places the MCP of the index finger beneath the sty loid pr ocess (F ig. 11.153) . 5. A thrust is delivered by both fingers simultaneously. The thumb exerts pressure toward the sole, and the index finger exerts a forc e toward the dor sum of the foot ( white arr ows , F ig. 11.154). 6. Effectiveness of the

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F ig ure 11.153. Steps 1 to 4.

F ig ure 11.154. Step 5.

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tec hnique is determined by reassessing pos ition and tender nes s of the styloid proces s of the fifth metatar sal.

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Lower E xtremi ty Regi on: Foot: Cuboid, Pl antar Rotation

Diag nosis T enderness: Lateral plantar aspect of the foot just pr oximal to the s tyloid proces s of the fifth metatar s al and over lying the tendon of the peroneus longus musc le Palpation: Groove distal to the sty loid proc ess of the fifth metatar s al deeper than nor mal; c uboid prominent on the plantar aspect of the lateral foot History : Common following inversion s prain of the ank le

F ig ure 11.155. Steps 1 to 4.

T ech niq u e 1. The patient lies prone with the leg flexed 30 degrees at

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F ig ure 11.156. Step 5.

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the knee. 2. The phy sic ian stands at the foot of the table. 3. The phy sic ian places the thumb on the medial side of the foot over the plantar prominenc e of the cuboid. 4. The phy sic ian's thumb on the lateral s ide of the foot reinforces the medial thumb (F ig . 11.155). 5. The later al aspect of the foot is opened by adducting the for efoot ( Fig . 11.156). 6. The thrus t is delivered in a whipping motion toward the lateral as pec t of the foot (w hite arr ows , F igs. 11.157 and 11.158). 7. Effectiveness of the tec hnique is determined by reassessing the position

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F ig ure 11.157. Step 6.

F ig ure 11.158. Step 6.

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and tender nes s of the cuboid.

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References 1. W ar d R (e d) . F ou nda ti on s f or Os te opa thi c Me dic i ne . Ph i la del phia : L i pp i nco tt W il l i am s & Wi l k in s , 200 3.

2. H ei l ig D. T he Th r us t Te c hn i qu e. J Am Os teop ath As s oc 198 1;8 1:24 4–2 48.

3. Gre enm an P. P r in c ip l es of M an ual M ed i ci ne, 2nd ed . Ba l ti m or e: W i ll i am s & W il k in s , 1 996 .

4. M od i fi ed w i th pe r mi s s io n f r om Agu r A M R, D al l y AF. Gra nt' s A tl as of An atom y , 11t h ed . Ba l tim ore : L i ppi nco tt W i ll i am s & W il k in s , 2005 .

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12 Facilitated Positional Release Techniques Technique P rincipl es Fac i l it a te d p o s it i on a l r e le a se (F P R) t ec h ni q u e i s a p a t ie n t- p as s i ve , i n di r e c t te c hn i q ue , a nd a s s uc h , i t s h ar e s p r in c ip l es wit h t h e o t he r i n di r e c t os t eo p a th i c t ec h n iq u es , e sp e c ia l ly my o f as c ia l r e l ea s e, ba l a nc e d l ig a men t ou s t e n si o n, an d li g am e nt o u s a rt i cu l a r s tr a i n. I t s p o s it i on i ng i s v er y s i mil a r t o c o un t er s tr a i n a nd th e in i ti a l i n di r ec t p o s it i on i ng f or S ti l l t ec h n iq u e. Th e Ed u ca t io n Co u nc i l o n O s te o pa t h ic Pr i nc i p le s ( E CO P ) d e fi n es FPR a s “ a s y s t e m o f i nd i r ec t m y of a s ci a l r el e a se tr e at me nt de v el o p ed by St a n le y S ch i o wi t z , DO . Th e c o mp o n en t r e gi o n o f t h e b o dy is pl a c ed in t o a ne u tr a l p o si t io n , d im i n is h in g t i s su e a n d j o in t t e ns i o n i n a ll p la n es an d an ac t iv a t in g f o rc e (c o mp r es s i on o r t o rs i on ) i s ad d ed ” ( 1 ) . The pr i mar y g o al o f t hi s t e c hn i qu e i s to re d uc e ab n or mal mus c l e h yp e rt o n ic i t y (s u p er f ic i al a nd de e p) a nd re s to r e l o s t mo t i on to a r e s t r ic t ed a rt i c ul a ti o n. A s wi th co u nt e r s t r ai n t e c hn i qu e , t h e p ri mar y ne u ro p hy s i ol o gi c m e c ha n is m a f f ec t ed by FPR i s t ho u gh t to be th e re l at i on s h ip be t we e n I α-a f fe r e nt an d γ - e f f e re n t a c ti v it y ( 1, 2 , 3) . I f t h e d y s f u nc t i on a l r eg i o n i s p os i t io n ed ap p r op r ia t el y , t h e i nt r a fu s al fi b e rs may r et u rn to n or mal le n g th , w h ic h in re t ur n de c re a se s te n si o n i n t h e e x t r a fu s al fi b e rs . Thi s re d uc e d t e ns i on in t he ar e a o f t h e mus c l e s pi n dl e fu r th e r d e cr e as e s t h e I α- a f fe r en t i mp ul s es , w h i ch in tu r n c o nt i nu e s t h is be n e fi c ia l i n t er a c t i on , ev e nt u al l y a ll o win g t h e mu s c l es to a ch i ev e t h e ir no r ma l le n gt h a n d t o ne (4 ) . O t he r b e n ef i ci a l a sp e c t s of th i s f o rm of t re a tm e nt may be re l a te d t o t h e t r ea t me n t p o si t io n ' s s ec o nd a r y e f f e c t s of im p r ov i ng ly mp ha t ic an d ve n ou s d r a in a ge an d ot h er bi o e le c tr i c p h en o me n a a f f e c ti n g f lu i d d y na mic s an d l o ca l me t ab o li c pr o ce s se s . The p ri n ci p le s of po s it i o ni n g i n t h is te c hn i q ue ar e b a s ic to in d i re c t t re a t me n t s , a n d t he r e fo r e, th e ph y si c ia n wi l l a t t e mpt to pl a c e t he dy s f un c ti o na l se g me n t , mus c le , o r o th e r s t ru c tu r e t o wa r d i t s p os i ti o n o f m o ti o n e a se or r ed u ce d t e n si o n. Th i s i s d o ne b y f ir s t a t te mpt i n g t o p la c e t h e myo f a s c i al or a rt i cu l ar d y s f un c ti o n i n a ne u t ra l p o si t i on , whi c h S c hi o wi t z d e s c r ib e s a s f l at t e ni n g t he a nt e ro p os t e ri o r s pi n a l c ur v e ( f ac e t s ar e in a p o s it i on be t wee n t h e b e gi n ni n g o f f l ex i on a nd th e b e g in n in g o f ex t en s io n ) ( 3 ). Wi t h a f le x e d o r e x t e n de d d y s f u n c t i on , t h e i n it i al p os i ti o ni n g i s t o f l a t t e n t he a nt e ro p os t e ri o r s pi n a l c ur v e a n d f in d t h e n e ut r al p os i ti o n wi th i n t he d y s f un c ti o n . Thi s e x a mp l e i s c om mo n t o t yp e I I dy s fu n c ti o ns . W i t h t yp e I d y s f un c ti o n s , le s s a n te r io r a n d /o r p os t e ri o r p os i t io n in g i s ne c es s ar y . I f t h e p ri mar y fo c us is t he tr e at me nt of mu s c le hy p er t o ni c it y a n d t e ns i on ( wh e n t he r e i s n o p r ed o mi n a nt x- , y - , z - ax i s d i ag n os i s) , th e h y pe r t on i c mus c l e i s p la c e d i n a p os i t io n o f e a s e o f t en s i on . T h is i s b as e d o n p a lp a ti n g t h e a bn o r ma l t i s s u e t e x t u re s a nd t he i r r es p o ns e t o p o s it i on i ng ( 3) . I f a d y s f un c ti o n al mu s cl e is ca u si n g t h or a ci c t en s i on an t er i o rl y , f le x i on is th e mo s t p ro b a bl e p o si t i on of ea s e . P os t er i o r t ho r ac i c mus c l e h yp e rt o n ic i t y co mmon l y i s a s so c ia t ed wit h a n e x t en d ed po s i ti o n o f e a se (2 ) .

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The maj o r d is c r im i na t in g fa c to r w e se e i n t h i s t ec h ni q u e whe n c o mpa r in g i t to th e o t h er i nd i r ec t t e ch n i qu e s i s i t s r el e as e - en h an c in g me c ha n is m. D i Gi o va n n a a nd Sc h i ow i t z d es c r ib e t h is a s a f a ci l i ta t in g m u s cl e f o rc e (1 , 3) . T h i s may be a c o mp r es s i on fo r ce , bu t i t c a n a c c o mm o d at e a l l d i re c ti o ns o f mot i on e as e o r d i r ec t io n s i n w h ic h t h e m u s c l e t en s i on is re d u ce d . B ec a u se of si d e b e nd i ng a nd ro t at i o na l c o mp o n en t s i n mo s t d y s f u nc t io n s ( s pi n al an d ex t re mit y ) i t i s g e n er a ll y n e c es s ar y f o r t h e p hy s i ci a n t o a d d s om e fo r m o f t o rs i on (s i d e b en d in g co mbi n ed wit h r o ta t i on ) f o rc e du r in g t h e p o si t io n a l c om p o ne n t o f t h e t ec h ni q u e. On ac h i ev i ng th e pr o pe r p o s it i on of e as e w i th t he f ac i l it a ti n g f o rc e s , th e ph y si c ia n ma y a l so a dd a s li g h t o n- a nd - o f f sp r in g i ng (r o c k i n g) f or c e . The ph y s ic i an ho l d s t he tr e a tm e nt po s i ti o n f or 3 t o 5 se c o nd s , r et u r ns th e p at i e nt to ne u t ra l ( p re t r ea t me n t p o si t io n ), a nd fo l lo ws b y r e as s e s s i ng th e dy s fu n c t i o n u si n g t h e p al p a to r y p ar a met e rs fo r ti s su e t e x tu r e c ha n g es , m o ti o n r e s t r ic t i on , a s y mmet r y , an d te n de r ne s s ( s en s it i v it y ). P. 3 32

Technique Classifi cation I ndi rect A s wi th al l i n d ir e c t te c h ni q ue s , t h e p hy s ic i a n a t t e mp t s t o p o si t i on th e p a t ie n t i n t h e d ir e c ti o n t ha t re d uc e s t h e myo f as c i al ti s su e te n si o n o r i n t h e d i re c ti o n o f t h e mot i o n f re e d om .

Technique S tyl es Myofasci al (Muscle Hypertoni city) To t r ea t a hy p e rt o ni c m u s cl e w i th FPR , t h e p h y s i ci a n f l at t en s t h e s p in a l c u rv e i n t h e r eg i o n o r s eg me nt to be t re a te d o r in th e e x t re mit i es , ad d in g c o mpr e s s i on t ow a rd th e j oi n t . The n t h e p h y s i ci a n a s se s se s fo r t i s s u e t e x t u re c ha n ge s ( e . g. , t e ns i o n, i ne l a s t i ci t y , b og g in e s s ) an d p o si t i on s t h e p a ti e nt un t i l t he s e d y s f u nc t io n a l p ar a me t e rs a re o pt i ma l ly r ed u ce d . Ne x t , t h e p h y s i ci a n a d ds th e a p p ro p ri a te f ac i li t at i n g f or c es ( co mp re s si o n a n d t or s io n ) a n d h ol d s f o r 3 t o 5 s ec o nd s , t h en re t u rn s t h e a f fe c te d a r e a t o a ne u tr a l p o si t io n a n d r e as s es s e s . I t is r ec o mm e nd e d t o u s e t h is s t y le i ni t ia l ly whe n t he p hy s ic i an h as di f fi c u lt y d e te r min i ng th e pr i ma r y c o mp o ne n t o f t h e d y s f u nc t io n ( my o f as c ia l v e r su s a r ti c u la r ).

Arti cular (Intervertebral and I ntersegmental x-, y-, z -Axi s) Dysfunction I n a r ti c ul a r t e ch n iq u e, t he ph y si c i an us e s t h e p al p at o r y c lu e s f o r p ri mar y i nt e r se g me n ta l (j o in t ) d y s f u nc t io n s . The s e c l ue s a r e g e ne r al l y t i s s u e t ex t u re ch a ng e s , r es t r ic t io n o f mo t io n , a s ym met r ic mot i on (m a y e x hi b it s ym met r ic a l ly re d uc e d m o ti o n) , e nd f ee l o r j o i nt fr e e- p l ay qu a li t a ti v e c ha n g es , a n d p a in . T h e p h y s i ci a n s t ar t s b y f la t t en i ng th e an t er o po s t er i or sp i n al cu r ve o f t he re g i on be i ng t re a te d . Th e d y s f u nc t io n al s eg men t s h o ul d t h en b e p os i ti o n ed to war d th e e a se o f mot i on i n a ll a f f e c te d p l an e s . Nex t , t h e p hy s ic i a n a dd s t h e a p pr o pr i a te ax i al f ac i li t at i n g f or c es ( co mp re s si o n a n d t or s io n ) , h ol d s f o r 3 t o 5 s ec o nd s , a n d b ri n gs t he af f ec t e d a re a b a c k

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t o a ne u tr a l p o si t io n f o r r e as s es s men t .

I ndi cati on Myo f a s c i al or a rt i cu l ar s om a ti c d y s fu n c t i on

Contraindicati ons 1. Mod e r at e t o s e v er e j o in t in s ta b il i t y 2. Her n i at e d d is c wh e re th e po s it i on i n g c ou l d e x ac e rb a te t he co n di t i on 3. Mod e r at e t o s e v er e i n te r v er t eb r al f or a mi n al s te n os i s , e sp e ci a ll y in th e p r e se n ce o f r a di c ul a r s y mp t om s a t th e l e ve l to be tr e a te d i f t h e p o si t io n i ng co u ld c au s e e xa c e rb a ti o n o f t h e s ym p t om s b y f u r th e r n ar r o wi n g t he f or a me n 4. S ev e r e s pr a in s an d s t ra i n s whe r e t h e p os i ti o n in g m a y e x ac e rb a te t he in j ur y 5. Cer t a in co n ge n i ta l a n om a l ie s o r c o n di t io n s i n w h ic h t h e p o si t io n ne e de d t o tr e at t he d y s f un c ti o n i s n o t p o s s i bl e ( e . g. , a n k y l o si s ) 6. V er t e br o ba s il a r i n su f fi c i en c y

General Considerations and Rules The p hy s ic i an mus t b e a b l e t o mak e an ac c ur a t e d ia g no s i s a nd wh e n p o s s i bl e to d is t i ng u is h b e t we e n a m y o fa s ci a l a n d a n a rt i c ul a r d y s f u nc t io n . Th e a nt e ro p o s t e ri o r s pi n a l c ur v e i s f l at t en e d , a nd th e n a po s it i o n o f e as e or a p os i t io n t h at max i ma l ly r ed u c es my o fa s c ia l t e ns i o n i s a pp r o ac h ed . A f ac i li t at i n g f or c e o f c o mp r es s i on c om b i ne d w i th s id e b e nd i n g a nd / or r ot a ti o n ( t or s io n ) i s a p pl i ed f or 3 t o 5 se c on d s . A s pr i n gi n g f or c e m a y a ls o be us e d.

S horthand Rules P rim ary Myofascial Dysfuncti on 1. Mak e di a gn o si s (t i s s u e t e x t u re ab n o rm a li t y) . 2. Fla t t en th e a n t er o po s te r i or sp i na l cu r ve to r ed u ce my o f as c ia l t e n si o n. 3. A dd a c o mp r es s i on or to r s io n al fa c i li t at i ng f or c e. 4. P la c e t h e d y s f u nc t io n al myo f as c ia l s t r uc t ur e in t o i t s e as e ( s ho r t en e d, re l a xe d ) p os i t io n . 5. Hol d fo r 3 to 5 s e co n ds , th e n s lo wl y r el e as e pr e s s u re whi l e r et u r ni n g t o n e ut r al . 6. The p hy s ic i an r ea s se s se s th e d y s f u n c t i on a l c o mp o ne n t s ( ti s su e t e x tu r e a bn o r ma l it y , a s ym met r y o f p o si t io n , r e s t r ic t i on of mo t i on , t e nd e r ne s s [ TA RT] .

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P rim ary Articul ar (x-, y-, z -axis) Type I and II Dysfuncti ons 1. Mak e di a gn o si s (e . g. , t y p e I o r I I ) . 2. Fla t t en (f l ex o r e x t e nd ) th e a n te r o po s te r io r cu r ve in t he sp i na l re g io n o f t re a t me n t . 3. A dd t he fa c il i t at i ng fo r c e ( co mpr e s si o n o r t o rs i on ) . P. 3 33 4. Mov e th e d y s f u n c t i on a l s e gm e nt to wa rd it s f l e xi o n o r e x te n si o n e a se . 5. Mov e th e d y s f u n c t i on a l s e gm e nt to wa rd it s s i d e b en d in g an d r o ta t i on a l e as e . 6. Hol d fo r 3 to 5 s e co n ds , th e n s lo wl y r el e as e pr e s s u re whi l e r et u r ni n g t o n e ut r al . 7. Rea s s es s t h e d y s f u nc t io n a l c om p on e n t s (T A RT ) . P. 3 34

Cervi cal Region: Right: S ubocci pital Muscle Hypertonici ty

1. The pa tie n t l ies sup ine , a n d the ph ysi cian sits a t th e h ead of the ta b le. 2. The ph ysi cian gen tly su p ports the occip i tal and up per cervical reg ion s o f th e patien t's hea d with the righ t han d. 3. With the l eft han d o n th e patien t's hea d, the ph ysi cian neu tra lize s the cervical spin e by gen tly fla tte nin g th e

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Figure 12.1. Step s 1 to 5.

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4.

5.

6.

7.

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antero posteri or curve (sl i ght fle xio n). An activa ting force in the form o f a gen tle (1 lb or less) axi a l compre ssi o n i s add ed with th e left h and . Whi le mai nta ini n g compre ssi o n, the ph ysi cian gen tly positi ons the patien t's hea d and ce rvi cal reg ion to w ard extension and rig ht sid e ben din g a n d rotati on (a rrow s, Figs . 12.1 a nd 1 2.2 ) until maxi mal red uction of tissue an d muscle te n sio n is ach ieve d. The ph ysi cian hol ds thi s positi on for 3 to 5 seco n ds and th en slo wly rel eases the compre ssi o n whi le retu rni ng to neu tra l . If a rele a se is

Figure 12.2. Step s 1 to 5.

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not pa lpa ted within a few second s, a xia l compre ssi o n sho uld be rel eased a nd ste ps 3 to 6 can be rep eated. 8. The ph ysi cian rea sse sse s th e compon ents of the dysfu n cti on (TART).

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Cervi cal Region: C2 to C4 Dysfuncti on Exampl e: C4 FSRRR*

1. The pa tie n t l ies sup ine , a n d the ph ysi cian sits a t th e h ead of the ta b le. 2. The ph ysi cian gen tly su p ports the ce rvi cal reg ion wi th the rig ht han d . 3. With the l eft han d o n th e patien t's hea d, the ph ysi cian neu tra lize s the cervical spin e by gen tly fla tte nin g th e antero posteri or

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Figure 12.3. Step s 1 to 5.

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4.

5.

6.

7.

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curve (sl i ght fle xio n). An activa ting force (a rrow) in the fo rm o f a gen tle (1 lb or less) axi a l compre ssi o n i s add ed with th e left h and . Whi le mai nta ini n g compre ssi o n, the ph ysi cian gen tly positi ons the patien t's hea d tow ard fl e xio n and ri ght sid e ben din g a n d rotati on (a rrow s) u nti l maxima l red uction of tissue an d muscle te n sio n is ach ieve d (Figs. 12 .3 a nd 12.4). The ph ysi cian hol ds thi s positi on for 3 to 5 seco n ds and th en slo wly rel eases the compre ssi o n whi le retu rni ng to neu tra l . If a rele a se is not pa lpa ted within a few

Figure 12.4. Step s 1 to 5.

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second s, a xia l compre ssi o n sho uld be rel eased a nd ste ps 3 to 6 can be rep eated. 8. The ph ysi cian rea sse sse s th e compon ents of the dysfu n cti on (TART).

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Thoracic Region: T4 to T12 Dysfunctions E xam ple: T6 E SRRR

1. The pa tie n t sits a t th e edg e o f th e tab le with th e physician sta ndi ng a t the ri ght sid e and sl igh tly posterior to the pa tie n t. 2. The physician 's left h and mon ito rs the patien t's dysfun cti o n at the spi nou s pro cesses of T6 and T7

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Figure 12.5. Step s 1 to 3.

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and th e ri ght tra nsverse pro cess o f T6. 3. The physician pla ces th e rig ht fore arm on the patien t's upp er rig h t tra pezius (sh oul der girdle ) w i th the remain der of the physician 's rig ht fore arm and ha nd restin g across th e patien t's upp er back just b ehi n d the pa tie n t's neck (Fig. 12.5). 4. The pa tie n t sits u p straig ht u nti l the no rma l tho racic curvature is straig hte n ed and fla tte ned , so tha t extension is pal pated a t the le vel of T6.

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Figure 12.6. Step s 4 to 6.

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5. The physician 's rig ht fore arm app lie s a n activa tin g force in the form o f gen tle (1 lb or less) compre ssi o n. 6. Whi le mai nta ini n g compre ssi o n, the ph ysi cian pla ces a cau dad an d posterior force with th e rig ht fore arm (w h ite arrow, Fig. 1 2.6 ) to positi on T6 into furth er extension and ri ght sid e b end i ng and ro tati on. Thi s shou l d be carrie d to a p oin t o f bal ance a n d min imu m muscle to n e. 7. The physician hol ds thi s positi on for 3 to 5 seco n ds and th en slo wly rel eases the compre ssi o n

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whi le return ing to neu tra l. 8. If a rele a se is not pal pated within a few second s, compre ssi o n sho uld be rel eased a nd ste ps 3 to 6 can be rep eated. 9. The physician rea sse sse s the compon ents of the dysfun cti o n (TART).

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Thoracic Region: Right-S i ded Trapez ius Muscl e Hypertonici ty

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1. The pa tie n t l ies pro ne on the tre atment tab le with the h ead and ne ck rota ted to the ri g ht. 2. The ph ysi cian sta nds at the le ft sid e, faci ng the patien t. 3. The ph ysi cian 's left h and pal pates the rig ht, hyp ertoni c tra pezius muscle (Fig. 12.7 ). 4. The ph ysi cian 's rig ht han d rea che s a cross the bo dy o f the patien t a n d gra sps th e patien t's rig ht sho uld er a t the anteri or d eltoid and acromi ocl a vicula r reg ion (Fig. 12.8). 5. The ph ysi cian pla ces a caud ad and po ste rior force (w h i te arrow, Fig. 1 2.9 ) to ach ieve a poi nt of b ala nce and mi nima l muscle te n sio n i n the ri ght tra pezius muscle . 6. On ach ievi ng the

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Figure 12.7. Step s 1 to 3.

Figure 12.8. Step 4.

Figure 12.9. Step 5.

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P. 3 38

Costal Regi on: Left First Ri b Dysfunction, P osterior E levation: Nonrespiratory Model , S oft-Tissue Effect

1. The pa tie n t lie s supi n e and th e physician sta nds fa cing the pa tie n t o n the dysfun cti o nal sid e. 2. The pa tie n t's left a rm i s fle xed at the elb ow, an d a pil low or rol led tow el is p laced und er the patien t's upp er arm. 3. The physician 's l eft han d controls the ol ecra non pro cess w h ile the in dex and thi rd fin g ers of the ri ght han d pal pate th e posterior asp ect of the first rib , mon ito rin g fo r tissue te xture cha nge s (Fig. 12.11). 4. The physician 's l eft

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Figure 12.11. Ste ps 1 to 3.

Figure 12.12. Ste p 4 .

Figure 12.13. Ste p 5 .

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han d flexe s the pa tie n t's sho uld er to app roxima tely 90 deg ree s and th en abd ucts sli ghtly a nd intern all y rotate s th e sho uld er to the positi on that pro duces the most l axi ty a nd soften ing of the ti ssu e s (Fig. 12.1 2). 5. The ph ysi cian add ucts th e arm an d simultane o usl y app lie s a compre ssi o n throug h th e patien t's left upp er arm tow ard th e mon ito rin g fin gers a t th e first rib (strai ght arrow, Fig. 1 2.1 3 ) whi le push ing the pa tie n t's elb ow dow n tow ard th e che st (cu rved arrow) ove r the pi llo w . 6. Thi s p osi tion is hel d for 3 to 5 second s, a nd

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a slig ht on-and -off pre ssu re can be app lie d . 7. After 3 to 5 second s th e arm is bro ugh t throug h fu rth er add uction and the n i nfe riorly swu ng back to the la tera l bod y l ine . 8. The ph ysi cian rea sse sse s th e compon ents of the dysfun cti o n (TART).

P. 3 39

Costal Regi on: Left S eventh Rib, I nhal ati on Dysfunction

1. The pa tie n t l ies in the ri ght latera l recumb ent (si de-lyi n g) positi on w ith th e arm fl exe d an d abd ucted to app roxima tely 90 deg ree s, a nd the physician sta nds or sits o n th e e dge of the ta b le in fro nt of the patien t (Fig. 12.1 4).

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Figure 12.14. Ste p 1 .

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2. The ph ysi cian pla ces th e in dex and /or th i rd fin ger pad s o f th e righ t han d o ver the posterior asp ect of the se ven th rib at the costotran sverse articu lati on. Th e thu mb is p laced ove r the i nfe rio r edg e o f th e l ate ral asp ect of the same rib. 3. The ph ysi cian 's web bin g o f th e l eft han d (thu mb abd ucted) con tou rs the antero late ral asp ect of the seventh ri b, bei ng carefu l n o t to p ut too mu ch p ressure ove r the chon dra l portio n (Fig. 12.15). 4. The ph ysi cian gen tly pu shes th e rib po ste rior (a rrow ), attemp tin g by th is compre ssi o n to diseng age the ri b fro m the vertebra (Fig. 12.1 6). 5. The ph ysi cian add s a cep hal ad-vectore d force (bu cket han dle ) to ward

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Figure 12.15. Ste ps 2 a n d 3 .

Figure 12.16. Ste p 4 .

Figure 12.17. Ste p 5 .

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the in hal a tio n ease (arro w, Fig. 12.17), th rou gh the bu cke t ha ndl e vector. 6. Thi s p osi tion is hel d for 3 to 5 second s, a nd a sli ght on -and -off pre ssu re can be app lie d. 7. After 3 to 5 second s th e rib is pushed sl o wly back to n e utral as the pa tie n t b rin gs the arm d o wn to the la tera l b ody lin e. 8. The ph ysi cian rea sse sse s th e compon ents of th e dysfun cti o n (TART).

P. 3 40

Lumbar Regi on: L1 to L5 Dysfunctions E xam ple: L3 NS LRR

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1. The pa tie n t lie s p ron e on the ta b le. A p ill ow may be pla ced und er the abd ome n to decrea se the no rma l lumbar curvature . 2. The physician sta nds at the left side of the pa tie n t, facing th e patien t. 3. The physician 's left h and mon ito rs the patien t's L3 and L4 spi nou s pro cesses and th e ri ght tra nsverse pro cess o f L3 (Fig. 12.18). 4. The physician rests the left kne e o n th e tab le aga inst th e patien t's left ili um. 5. The physician

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Figure 12.18. Ste ps 1 to 3.

Figure 12.19. Ste ps 4 a n d 5 .

Figure 12.20. Ste p 6 .

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P. 3 41

Lumbar Regi on: L1 to L5 Dysfunctions E xam ple: L4 FS RRR

1. The pa tie n t lie s i n th e l eft latera l recumb ent positi on, and the ph ysi cian sta nds at the sid e o f th e tab le faci ng the pa tie n t. 2. The physician 's rig ht fore arm and ha nd con tro l th e patien t's rig ht antero late ral che st wal l , a nd the le ft fore arm and ha nd con tro l th e rig ht pel vic and lu mba r reg ion (Fig. 12.22). 3. The physician 's rig ht ind e x a nd thi rd fin g er pad s moni tor and co ntro l the tra nsverse pro cesses of L4 whi le the left i nde x an d thi rd fin g er pad s moni tor

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Figure 12.22. Ste ps 1 a n d 2 .

Figure 12.23. Ste p 3 .

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4.

5.

6.

7.

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and co ntro l the tra nsverse pro cesses of L5 (Fig. 12.23). The ph ysi cian gen tly fl e xes the pa tie n t's hip s u nti l L4 is ful ly fle xed on L5. The ph ysi cian carefu lly pushes th e patien t's rig ht sho uld er posteriorl y until L4 i s eng age d a n d rotate s fa rth er to the ri g ht on L5. The ph ysi cian the n g entl y pushes th e patien t's pel vic and lu mba r reg ion anteri orl y un til L5 is ful l y eng age d a n d rotate d to th e left u nde r L4 . The pa tie n t inh ale s a n d exh ale s fu lly. On exh ala tion , the ph ysi cian , with b oth the forearms a nd fin gers o n th e tra nsverse

Figure 12.24. Ste ps 4 to 7.

Figure 12.25. Ste p 8 .

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pro cesses, increa ses the force thro ugh the sa me set of rotati o nal vectors (cu rve d arrows, Fig. 12.24), simultane o usl y app roxima ting the fo rea rms (strai ght arrows), the reb y pro ducing increa sed sid e ben din g ri ght. 8. On ach ievi ng the prope r positi on, the physician app lie s a n activa tin g force (a rrows, Fig. 1 2.2 5 ) i n the fo rm o f a gen tle (1 lb or less) axi a l compre ssi o n for 3 to 5 second s w i th the fi nge r pad s. 9. If a rele a se is not pa lpa ted within a few second s, compre ssi o n sho uld be rel eased, and ste ps 3 to 8

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can be rep eated. 10. The ph ysi cian rea sse sse s th e compon ents of the dysfun cti o n (TART).

P. 3 42

Lumbar Regi on: Left-S ided Erector S pinae Muscle Hypertonici ty

1. The pa tie n t lie s p ron e on the treatment tab le. A pil low ma y be pla ced und er the abd ome n to decrea se the normal lumbar curvature . The physician faces the patien t o n the le ft. 2. Usi ng the left han d, the physician mon ito rs the patien t's dysfun cti o nal ere cto r

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Figure 12.26. Ste ps 1 a n d 2 .

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spi nae hyp ertoni city (Fig. 12.2 6). 3. The physician 's left knee is pla ced on the ta ble aga inst th e patien t's left ili um. 4. The physician cro sse s th e patien t's rig ht ankl e ove r the patien t's left ankle and gra sps th e patien t's rig ht kne e , sli din g b o th of the patien t's leg s to the le ft (Fig. 12.2 7). 5. The physician rep osi tio n s the ri ght han d to gra sp the patien t's rig ht thi g h and di rects a force dorsal ly a nd tow ard extern al rotati on (wh ite

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Figure 12.27. Ste ps 3 a n d 4 .

Figure 12.28. Ste p 5 .

Figure 12.29. Ste p 6 .

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arrows, Fig. 12.28). Th is combin ed moveme nt sho uld be carrie d to a poi nt of bal ance a n d min imu m muscle to n e as percei ved by the physician 's left h and . 6. On ach ievi ng the prope r positi oni n g, the physician 's left h and app lie s a n activa tin g force (w h i te arrow, Fig. 12.29) in the form o f a gen tle (1 lb or less) a xia l compre ssi o n for 3 to 5 second s. 7. If a rele a se is not pal pated within a few second s, compre ssi o n sho uld be rel eased, and steps 3 to 6 can b e rep eated.

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8. The physician rea sse sse s the compon ents of the dysfun cti o n (TART).

P. 3 43

P elvi c Regi on: Left P osterior I nnom inate Dysfunction

1. The pa tie n t l ies in the ri ght latera l recumb ent positi on, and th e physician sta nds in fro nt o f the patien t a t th e side of the ta b le. 2. The ph ysi cian 's rig ht arm rea che s und er the patien t's left thig h and ab ducts i t to app roxima tely 30 deg ree s. The physician con tro ls the le g w i th thi s arm an d th e sho uld er (Fig. 12.30). 3. The ph ysi cian 's left h and is pla ced pa l m d own ove r the supe rio r edg e o f th e i lia c

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Figure 12.30. Ste ps 1 a n d 2 .

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cre st, wi th the thu mb con trol lin g the an teri or sup eri or i lia c spi ne (ASIS) and the ha nd con tro lli n g the sup eri or e dge of the il iac cre st. 4. The ph ysi cian 's rig ht han d is pla ced ove r the posterior ili ac cre st and posterior sup eri or ili ac spi n e (PSIS) with the fore arm on the posterola tera l asp ect of the gre ate r troch anter (Fig. 12.3 1). 5. The ph ysi cian add s a posterior-vectored force with a sli ght arc (righ t-tu rn direction ) wi th the left h and (d o wn arrow) as the ri ght han d a nd fore arm pul l i nfe riorly and anteri orl y (u p arrow) (Fig. 12.32). 6. As the pe l vis rotate s posteriorl y, the physician add s a compre ssi ve force (1 lb or l ess) tow ard th e ta ble

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Figure 12.31. Ste ps 3 a n d 4 .

Figure 12.32. Ste p 5 .

Figure 12.33. Ste p 6 .

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(a rrow , Fig. 12.33) to app roxima te the sacroi lia c jo int surfaces. 7. Thi s p osi tion is hel d for 3 to 5 second s, a nd a gen tle on -and -off pre ssu re can be app lie d. 8. If a rele a se is not pal pated w ith in a few se con d s, compre ssi o n sho uld be rel eased, and ste ps 3 to 8 can be rep eate d. 9. The ph ysi cian rea sse sse s th e compon ents of th e dysfun cti o n (TART).

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P elvi c Regi on: Left Anterior Innom i nate Dysfunction

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1. The pa tie n t lie s i n th e rig ht late ral recumb ent positi on, and the ph ysi cian sta nds in fro nt of the patien t a t th e sid e o f th e tab le. 2. The physician 's rig ht arm rea che s und er the patien t's left thi gh and abd ucts i t to app roxima tely 30 to 40 deg ree s. The physician con tro ls the leg wi th this arm an d th e sho uld er (Fig. 12.34). 3. The ph ysi cian pla ces th e le ft han d p alm dow n o ver the sup eri or e dge of the il i ac cre st with th e thu mb con tro lli n g the ASIS a nd the ha nd con tro lli n g the su peri or

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Figure 12.34. Ste ps 1 a n d 2 .

Figure 12.35. Ste ps 3 a n d 4 .

Figure 12.36. Ste p 5 .

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P. 3 45

References 1 . W a rd R. ( ed . ). Fou n da t io n s f o r O s t e o pa t hi c M e d ic i ne , 2 n d e d . P hi l a de l ph i a: L i pp i nc o t t Wil l ia ms & Wi l ki n s , 2 00 3 .

2 . J o ne s L, Ku s un o s e R, G oe r i ng E. Jo n e s S tr a in - Cou n te r s t r a in . B o is e : J o ne s S t ra i n- Co un t er s tr a i n, 19 9 5.

3 . D i Gi o v an n a E , S c hi o wi t z S . A n O s te o p at h ic Ap p r oa c h t o Di ag n os i s a n d Tr ea t me n t , 3 rd ed . Ph i la d el p h ia : L i pp i n co t t Wil l i am s & Wi l k in s , 2 00 5 .

4 . C a re w TJ . T h e Co nt r ol of Ref l ex Ac t i on : P r in c i pl e s o f Ne ur a l S ci e n ce , 2 n d e d . Ne w Y or k : E l se v ie r , 1 9 85 .

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13 Techniques of Still Te c hnique Pr inciple s As no ted ea r l ie r i n t hi s boo k , m any os teo path i c tec hniq ues ha v e g r os s s i m il ari tie s bu t f all i nt o d i ff er en t c ateg ori es. T ec hni que s of St i ll i s no exc epti on; it m ay be a c l as s ic ex am pl e o f h ow a nu m be r of ot her tec hn i qu es c omb i ne an d un der go a me tam orp hosi s t o b ec om e y et anot her te c hni que , i n th i s c as e, t he Sti l l tec hn i qu e. Basi c al l y, Sti l l tec hniq ue i s a co m bi nat i on of s om e of th e c om po nen ts of i ndi r ec t, a r ti c ul ator y , and l ong - le v ere d h i gh - v el oci ty, l ow - am pli tude (H VLA ) te c hn i qu es . At Phi l ade l ph i a C oll ege of Ost eop ath i c M edic i ne (P C OM) a num ber of the s e t ech niq ues w er e i nc lu ded in the s e oth er c ate gor i es ( HV LA, ar tic ula tor y ) f or y ea r s a nd w er e us ed c om m onl y f or c ost al, lu m bar , i nno m i na te, an d ex tre m it y dy s fu nct i on s (i .e. , Atl as of Os teop ath i c T ech niq ues , 19 74) . I n 20 00, wi th p ubl i ca ti on of Th e St i ll T ec hn i qu e M anua l , by R i ch ard L. Van Bu s ki r k , D O, Ph D , F AAO , m any of the s e t ech niq ues bec ame m or e for ma l ly st r uct ure d a nd c l as s if i ed. Th ere fore , w e h av e r ec l as s i fi ed tho s e p r ev i ou s l y tau ght as H VL A tec hn i qu es i nto th i s c ate gor y .

Te c hnique Cla ssific ation Indire ct, The n D ire ct T he d i ag nos ti c c om pon ents fo r S ti ll te c hn i que ar e t he s ame fo r al l o s te opat hic te c hni que s ( ti ss ue tex ture abnor m al i ty , as y mm etr y of po s it i on, re s tr i c ti on of m oti on, te nder nes s [ T ART ]). Th e ra nge of m ot i on an d eas e- bin d ( ti gh t-l oos e) b arr i er asy m me tri es m ust be not ed, as the st art i ng poi nt of t his te c hni que is i n i ndir ect po s i ti oni ng s i mi l ar to tha t o f f ac il i ta ted pos i ti ona l re l ea s e ( F PR ) a nd othe r i ndi r ect te c hn i que s . F or e x am ple , if th e d y s fu nct i on i s doc ume nted as L4 , fl exe d, r ota ted ri ght, an d s i de- ben t r i ght (L 4 F R R SR ) , the i ni tia l ( i ndi r ec t) posi tio nin g wo uld be to m ov e L 4 in to fle x i on , r ota ti on ri ght , an d s i de bendi ng r ig ht, w hi c h i s t he eas e or mo s t fr ee mo tio n av ail abl e in th e c ar di nal (x , y, z) pl anes of mo ti on . C onti nui ng this pr i nc i ple of in di re c t pos i tio nin g, a sl i gh t c om pr ess i ve for c e m ay be add ed s i mi l ar to F PR tec hn i qu e. T hen , u s in g a par t o f th e p ati ent' s a nat om y ( e. g., tru nk, ex tr em i ty ) t o ca use a l ong - le v er ed for ce ve c to r , t he dys func tio nal s eg m en t i s ca r ri ed thro ugh a m oti on arc or pat h o f le ast re s i st anc e t ow ar d the bi nd - ti ght r es tri c tiv e b arr i er. Ca r ry i ng the se gm en t t hro ugh a p ath of l ea s t r esi s ta nce i s i mp ort ant, as the a r ti c ul ar s urf ace s an d o the r el eme nts ( e. g., bo ny , l ig ame ntou s ) s ho ul d not be c om pro m is ed a nd s tr es s ed ; o ther w is e u ntow ard si de e ffe c ts , su c h as pain , c an r esu l t. Th i s m oti on at t he ter m i na l p has e m ay b e s i mi l ar to a l ong- l ev ere d HV LA; ho w eve r , the dys fun c ti onal se gme nt d oes no t ne c es s ar i l y hav e t o be mo v ed th r oug h t he r est r ic tiv e bi nd bar r i er , a s t he d y sf unc ti on al pat tern ma y b e el i mi nat ed d uri ng the m ov em ent wi thin th e r ange be twe en e ase an d bi nd l im i ts. Th i s i s d i ff ere nt f r om HV LA, w he r ei n th e r es tr i ct i ve bar r ie r i s me t a nd then pa s se d th r ou gh ( alb eit mi ni ma l ly ) . T her efo r e, i n i ts si m ple s t des cr i pt i on , th i s tec hniq ue i s defi ned as “ a s pe c if i c n on- r ep etit i ve ar ti cu l at ory m et hod th at i s i ndi r ect then dir ect ” (1 ,2) .

Te c hnique Sty les C om pre ssion W hen pos i ti onin g t he pati ent at the in dir ec t bar r ie r , t he phy s i ci an m ay att emp t a s li ght co m pre s si on of

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the a r ti c ul ator y s urf ac es be for e be gin nin g th e t r an s fer of th e se gme nt towa r d the r es tri c ti v e b arr i er . Th i s c om pr ess i on m ay he l p i n p r od uci ng a sl i gh t di s en gag em en t o f t he d y sf unc ti on . H owe v er, de pen di ng on the p ati ent ' s h eal th and fun c ti onal ca pac i ty at the are a, i t m ay not be pru den t t o ho l d thi s co m pr ess i on at the o uts et of m ove m en t to w ar d t he r est r ic ti ve ba r ri er , as a s hear ef fec t ca n P.348 be pr odu c ed and th e a r tic ula r c ar ti l ag e m ay b e i nju r ed. Al s o, i f the pa ti en t h as any for ami nal nar r ow i ng, ner ve ro ot i r ri tat i on m ay be an unw ant ed s i de ef fec t. T his te nds to be unco m fo r ta bl e for mo s t p ati ent s , and w e t y pi c all y r ele as e the co m pre s si on s i mu l ta neo us ly wi th the art i cu l ar m ov eme nt.

Tr a ction W hen pos i ti onin g t he pati ent at the in dir ec t bar r ie r , t he phy s i ci an m ay att emp t a s li ght tr ac ti on of the ar tic ula tor y su r fa c es bef ore be gi nn i ng th e tr ans fer of the se gm en t t owa r d t he r es tr ic tiv e b ar ri er. Th i s di s tr act i on m ay he l p i n p r od uci ng a sl i gh t di s en gag em en t o f t he d y sf unc ti on . W e h av e fou nd that th i s i s m or e c om for tabl e i n m any pat i en ts t han th e co m pr ess i on s ty l e.

Indica tions 1. Ar ti c ul ar s oma tic dy s fun c ti ons ass oci ate d wi th i nt er se gme nta l mo tio n r es tr i ct i on 2. M y of asc i al s om ati c d y s fu nct i on s as s oc i at ed w i th mu s c le hy per toni c it y o r fa s ci al bi nd

C ontra indica tions 1. Seve r e l os s of in ter s egm ent al m oti on s ec onda r y to s pon dyl osi s , o s te oar thri tis , o r rh eum ato i d ar th r it i s i n t he are a to be tr eate d 2. M ode r at e t o se v er e j oi nt in s ta bi li ty i n the are a t o be tr eat ed 3. Ac ut e s tra i n o r s pra i n i n t he ar ea to be tre ate d i f th e t i ss ues m ay be fur the r c om pr omi s ed by the m oti on i nt r odu c ed in the te c hn i que

P.349

C e r vic al Region: Oc cipitoa tla nta l (C 0—C 1, OA) Dys func tion Ex a mple: C0 ESRR L, Sea ted*

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1. T he patient s its on the table (if pr efer red, this may be per for med with the patient s upine and phy sic ian s itting at head of table) . 2. T he physician s tands behind the patient and places the left hand on top of patient's head. 3. T he physician places the r ight index finger pad ( or thumb pad) at the right bas ioc ciput to monitor motion ( F ig. 13.1). 4. T he physician adds a slight c ompression on the head ( s traight ar r ow, F ig . 13.2) and s ide-bends the head to the r ight (c ur ved ar r ow) enough to engage the oc c iput on the atlas, approx imately 5 to 7 degrees. 5. T he physician then r otates head to the left ( ar row, F ig. 13.3) only enough to

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F igure 13.1. Steps 1 to 3. Setup.

F igure 13.2. Step 4. Compr ess ion and side bending to r ight.

F igure 13.3. Step 5. Rotation to left.

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P.350

C e r vic al Region: Atlantoax ial (C 1 —C2 ) D ysfunction Ex a mple: C1 R L, Supine

1. T he patient lies s upine on the tr eatment table, and the phy sic ian sits or stands at the head of the table. This may als o be per for med with the patient s eated. 2. T he physician places the hands over the par ietotempor al r egions, and the left index finger pad palpates the left transver se pr oces s of C1 ( F ig. 13.6). 3. T he physician r otates the patient's head to the left ease bar rier ( arr ow, F ig . 13.7). 4. T he physician introduces gentle c ompression thr ough the head directed toward C1 ( F ig. 13.8) and then with moderate ac c eleration begins to r otate the head toward the

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F igu re 13.6. Step 2. Hand placement.

F igu re 13.7. Step 3. Rotate to eas e.

F igu re 13.8. Step 4. Compres sion.

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r ight res tric tiv e bar rier ( arr ow, F ig . 13.9). 5. T he release s hould oc cur before the r es trictive bar rier is engaged. If not, the phy sic ian s hould not c ar ry the head and dy s functional C1 mor e than a few degrees thr ough the bar rier. 6. T he physician r eevaluates the dy s functional ( T ART) c omponents.

F igu re 13.9. Step 4. Rotate to bar r ier .

P.351

C e r vic al Region: C2 to C7 Dys func tion Exam ple: C4 ESR RR, Supine

1. T he patient lies s upine on the tr eatment table. 2. T he phy sic ian's left index finger pad palpates the patient's right C4 articular pr oces s. 3. T he physician places the

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F ig ure 13.10 Steps 1 to 3. Hand plac ement.

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4.

5.

6.

7.

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r ight hand ov er the patient's head s o that the phy sic ian can c ontrol its mov ement ( F ig. 13.10) . T he physician ex tends the head ( arr ow, F ig . 13.11) until C4 is engaged. T he physician then r otates and s ide-bends the head s o that C4 is still engaged ( Fig . 13.12) . T he physician introduces a c ompression for ce (s tr aight ar r ow, F ig . 13.13) through the head dir ected toward C4 and then with moderate ac c eleration begins to r otate and s ide-bend the head to the left ( cur ved ar r ows ), s imultaneous ly adding gr aduated flexion. T he release s hould nor mally occ ur before the r es trictive

F ig ure 13.11. Step 4. Extension to ease.

F ig ure 13.12. Step 5. Side-bend and rotate to eas e.

F ig ure 13.13. Step 6. Compres sion, s ide-bending left and r otation left (SLRL) to bar rier.

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bar rier is engaged. If not, the phy sic ian s hould not c ar ry the head and dy s functional C4 mor e than a few degrees thr ough the bar rier. 8. T he physician r eevaluates the dy s functional ( T ART) c omponents.

P.352

Thorac ic Region: T1 and T2 Dy sfunctions Ex a mple: T1 ERRSR, Se a ted

1. T he patient is s eated (may be per for med with patient s upine). 2. T he physician s tands in fr ont of or behind the patient. 3. T he physician palpates the dy s functional s egment ( T1) with index finger pad of one hand while c ontrolling the patient's head with the other hand ( Fig . 13.14) .

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F ig ure 13.14. Step 3. Setup.

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4. T he physician, with the head-c ontrolling hand, extends the head s lightly until this motion is palpated at T 1 ( ar row, F ig. 13.15) . 5. T he physician then intr oduc es r ight side bending and r otation ( ar rows, Fig . 13.16) until this oc c urs at T1. 6. Nex t, the phy sic ian introduces gentle c ompression for ce thr ough the head toward T 1 and with moderate ac c eleration begins to rotate and side- bend the head to the left ( arr ows , F ig . 13.17), s imultaneous ly adding gr aduated flexion. 7. T his motion is c ar ried towar d the restr ictive bar rier. The r eleas e may oc c ur before the barrier is met. If not, the head must not be car ried more than a few degrees

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F ig ure 13.15. Step 4. Extend to ease.

F ig ure 13.16. Step 5. Side-bend and rotate to eas e.

F ig ure 13.17. Step 6. Compres sion, engage bar rier.

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bey ond. 8. T he physician r eevaluates the dy s functional ( T ART) c omponents.

P.353

Thorac ic Region: T1 and T2 Dy sfunctions Ex a mple: T2 FRLSL, Supine

1. T he patient is s upine on the tr eatment table ( may be per for med with patient s eated). 2. T he physician s its or s tands at the head of the table. 3. T he physician palpates the dy s functional s egment ( T2) with the index finger pad of the left hand, c ontrolling the patient's head with the other hand ( Fig . 13.18) . 4. T he physician, with the head-c ontrolling hand, flexes the patient's nec k s lightly (a r r ow, F ig . 13.19) until this motion is palpated at T 2. 5. T he physician

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Fig u re 13.18. Step 3. Setup.

Fig u re 13.19. Step 4. Flex to ease.

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introduces left r otation and s ide bending ( ar rows, Fig . 13.20) until this motion oc cur s at T2. 6. T he physician introduces gentle c ompression for ce thr ough the head ( s traight ar r ow, F ig . 13.21) toward T2 and then with moderate ac c eleration begins to rotate and side- bend the head to the r ight (c ur ved ar r ows , F ig. 13.21) with a s imultaneous gr aduated ex tens ion (F ig. 13.22) . 7. T his motion is c ar ried towar d the restr ictive bar rier, and the r eleas e may oc c ur before the barrier is met. If not, the head must not be car ried more than a few degrees bey ond. 8. T he physician r eevaluates the dy s functional ( T ART) c omponents.

Fig u re 13.20. Step 5. Side- bend and r otate to eas e.

Fig u re 13.21. Step 6. Compr ess ion, rotate right and s ide-bend r ight ( RRSR).

Fig u re 13.22. Step 6. Engaging extens ion, rotation r ight, s ide- bend r ight (ERRSR) barr ier .

P.354

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Thorac ic Region: T3 to T12 Dy sfunctions Ex a mple: T5 N SLR R, Se a ted

1. T he patient is s eated on the tr eatment table. 2. T he physician s tands or sits to the left of the patient. 3. T he physician ins tructs the patient to place the right hand behind the neck and the left hand palm down ov er the right antecubital fos sa. 4. T he phy sic ian's left hand r eac hes under the patient's left ar m or lies palm down ov er the patient's right humerus ( Fig . 13.23) . 5. T he physician places the r ight thenar eminence over the T6 left tr ansv ers e pr oces s and the thumb and index finger ov er the left and right tr ansv ers e pr oces ses of T 5, r es pec tiv ely

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F igure 13.23. Steps 1 to 4. Positioning.

F igure 13.24. Step 5. Monitor ing T5- T6.

F igure 13.25. Step 6. Side-bend left, r otate r ight (SLRR) .

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( F ig. 13.24) . 6. T he physician gently pos itions the patient's thorac ic spine to T5 in side bending left and rotation r ight (a r r ows , F ig . 13.25). 7. T he physician, while maintaining the s pine in neutral pos ition r elative to T 5- T6, adds a c ompression for ce thr ough the spine to T5 ( ar row, F ig. 13.26) by gently pulling or leaning down on the patient. The phy sic ian s imultaneous ly introduces s ide bending r ight (c ur ved s weep arr ow) and rotation left ( cur ved ar r ow, F ig . 13.27) . 8. T his motion is c ar ried towar d the restr ictive bar rier, and the release may oc cur before the bar rier is met. If not, the head mus t not be c ar ried more

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F igure 13.26 Step 7. Add c ompres sion.

F igure 13.27. Step 7. Acc eler ating to s ide- bend right, rotate left (SRRL) bar rier.

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than a few degrees bey ond. 9. T he physician r eevaluates the dy s functional ( T ART) c omponents.

P.355

C oa sta l R egion: Fir st R ib Dys func tion Exam ple: Right, Poste rior , Ele vated Fir s t R ib (Nonphy siologic, Nonres pira tor y)

1. T he patient is s eated, and the physician s tands behind the patient. 2. T he phy sic ian's c upped left hand r eac hes ov er the patient's left s houlder and ac r oss the patient's chest to lie palm down over the patient's right s houlder with the second and third finger pads anc hor ing the fir st rib (F ig. 13.28) . An alternative pos ition similar to an HVLA tec hnique may be prefer red

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F igure 13.28. Steps 1 and 2. Pos itioning.

F igure 13.29. Steps 1 and 2. Alternativ e

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( F ig. 13.29) . 3. T he phy sic ian's r ight hand s ide-bends the patient's head to the left ( ar row, F ig. 13.30) while the left arm k eeps the patient's tr unk fr om following. 4. T he phy sic ian's r ight hand adds a gentle c ompression for ce (a r r ow, F ig . 13.31) toward the r ight fir st r ib. 5. T he physician ins tructs the patient to inhale and ex hale. 6. O n exhalation the physician pus hes the patient's head to the right ( ar row, F ig. 13.32) while maintaining c ompression on the head and on the r ib with the finger. 7. T his motion is c ar ried towar d the restr ictive bar rier, and the release may oc cur before the bar rier is met. If not, the head mus t not be

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technique position.

F igure 13.30. Step 3. Side bending left.

F igure 13.31. Step 4. Compres siv e force.

F igure 13.32. Step 6. Side bending r ight.

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c ar ried more than a few degrees bey ond. 8. T he physician r eevaluates the dy s functional ( T ART) c omponents.

P.356

C os tal Re gion: Firs t or Se cond R ib Exam ple : Le ft, Fir st Rib Ex hala tion D y sfunction, Se ate d

1. T he patient is s eated, and the physician s tands behind the patient on the side of the dy s functional r ib. 2. T he phy sic ian's left hand gras ps the patient's left forearm. 3. T he physician places the other hand ( thumb) over the posterior as pect of the dy s functional left firs t r ib immediately lateral to the T 1 transv ers e c os tal ar ticulation ( F ig. 13.33) . 4. T he physician

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F igure 13.33. Step 1 to 3. Positioning.

F igure 13.34. Step 4. Drawing patient's

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dr aws the patient's left ar m anter ior ly, adducts it ac r oss the patient's c hest, and pulls (a r r ow, F ig . 13.34) the adducted arm toward the floor. 5. With moderate ac c eleration, the physician lifts the ar m, s imultaneous ly flexing and abducting with a c ir cumduc tion motion (F ig. 13.35) . 6. T he ac c eleration is c ontinued pos ter ior ly and then back to the side of the patient ( Fig . 13.36) . 7. T he physician r eevaluates the dy s functional ( T ART) c omponents.

ar m.

F igure 13.35. Step 5. Acc eler ate to barrier.

F igure 13.36. Step 6. Acc eler ate poster ior ly.

P.357

C os tal Re gion: Firs t R ib Exam ple : Right, First Rib Ex halation D y s function, Sea ted

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1. T he patient is s eated and the phy sic ian s tands behind the patient. 2. T he physician's r ight hand palpates the pos ter ior as pect of the first rib at the attac hment at its c os totransver se ar ticulation. 3. T he physician places the left hand over the patient's head. 4. T he physician's left hand slowly flexes the patient's head ( c urved arrow, F ig . 13.37) until the T1 segment and first rib ar e engaged. 5. T he patient's head is then s ide-bent and r otated r ight ( c urved arrows, F ig . 13.38) until these motion v ec tor s engage T 1 and the first r ib, ex aggerating its ex halation dy s function pos ition. 6. T he patient is ins tructed to inhale and ex hale, and on r epeated inhalation, the patient's head is

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F igu re 13.37. Steps 1 to 4. Setup, engage T 1 and firs t r ib.

F igu re 13.38. Step 5. Side bending and r otation to right.

F igu re 13.39. Step 6. Head c arr ied toward SLRL.

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P.358

Lum bar Re gion: L1 to L5 Dy sfunctions Ex ample: L4 NSR R L, Supine

1. T he patient lies s upine, and the phy sic ian s tands on the s ide of the r otational c omponent ( left) . 2. T he physician places the r ight hand under the patient to monitor the tr ansv ers e pr oces ses of L4 and L5. 3. T he physician ins tructs the patient to flex the right hip and knee. 4. T he phy sic ian's other hand c ontrols the patient's flexed r ight leg at the tibial tuberosity and flexes the hip until the L5 s egment is engaged and r otated to the r ight under L4 ( F ig. 13.41) . 5. T he physician ex ternally r otates and abducts the hip while the

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Fig ure 13.41. Steps 1 to 4. Setup toward rotational ease.

Fig ure 13.42. Step 5. Exter nally rotate hip.

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other hand monitors motion at L4- L5. This pos ition should place the L4 s egment indirectly ( s ide- bent r ight, rotated left [SRRL]) as it relates to its dy s functional pos ition on L5, while L5 has been r otated to the right ( F ig. 13.42) . 6. T he physician, with moderate ac c eleration, pulls the patient's right leg to the left in adduction and inter nal r otation (F ig . 13.43) and then fully ex tends the leg ac ros s the midline to the left ( Fig . 13.44) . 7. T his motion c ar ries L5 ( SRRL) under L4 (SLRR) toward the L4- L5 r es trictive bar riers, and the release may oc cur before the bar rier is met. 8. T he physician r eevaluates the

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Fig ure 13.43. Step 6. Accelerate into internal r otation and adduc tion.

Fig ure 13.44 Step 6. Ex tens ion ac ros s midline.

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dy s functional ( T ART) c omponents.

P.359

Lum bar Re gion: L1 to L5 Dy sfunctions Ex ample: L3 ESR R R, La tera l R ecum bent

1. T he patient lies in the r ight lateral r ec umbent ( s ide- lying) pos ition. 2. T he physician s tands at the s ide of the table in front of the patient. 3. T he phy sic ian's c audad hand c ontrols the patient's legs and flexes the hips while the c ephalad hand monitors motion at L3- L4. 4. T he patient's legs are flex ed until L3 is engaged ( Fig . 13.45) . 5. T he phy sic ian's for ear m pulls the patient's left s houlder gir dle forwar d ( ar row, F ig. 13.46) and the

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F igure 13.45. Steps 1 to 4. Hips flexed to engage segment.

F igure 13.46. Step 5. Pos ition into r otational ease.

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c audal ar m pus hes the patient's ilium pos ter ior ly ( ar row) while the fingers c ontinue to monitor the L3- L4 v er tebral unit. 6. T he physician adds s light tr action ( ar rows, Fig . 13.47) between the s houlder gir dle and the pelv is and then, with a moderate ac c eleration, r ev ers es this tr action ( s traight ar r ows , F ig. 13.48) and s imultaneous ly pus hes the s houlder pos ter ior ly ( pulsed arrow at right, Fig. 13.48) and the pelvis anteriorly ( pulsed arrow at left, Fig. 13.48) to ac hiev e s ide bending left and rotation left. 7. T he release may oc cur before the bar rier is met. If not, the s egment s hould be

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F igure 13.47. Step 6.

F igure 13.48. Step 6. Acc eler ate to SLRL.

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c ar ried only minimally thr ough it. 8. T he physician r eevaluates the dy s functional ( T ART) c omponents.

P.360

Pe lvic Re gion: Innomina te Dys func tion Exam ple: Right Anterior Innominate, Modifie d Sims Pos ition

Diag nosis Standing flex ion tes t: Positiv e (r ight pos terior superior iliac s pine [PSIS] ris es) Los s of pas siv ely induced right sac r oiliac motion PSIS: Cephalad (slightly lateral) on the right Anterior s uper ior iliac s pine ( ASIS): Caudad (slightly medial) on the right Sac r al sulcus : Pos terior on the right

F igure 13.49. Step 1. Pos itioning.

Tech niq ue 1. T he patient is in the left modified Sims pos ition, and the physician s tands behind the patient

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F igure 13.50. Steps 2 and 3. Hand

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( F ig. 13.49) . 2. T he physician places the c ephalad hand on the patient's s ac rum to r es ist sacral mov ement. 3. T he phy sic ian's c audad hand gr asps the patient's right leg distal to the k nee ( tibial tuberosity) ( F ig. 13.50) . 4. T he phy sic ian's c audad hand flexes the patient's right hip and k nee ( F ig. 13.51) and then r eturns them to an extended pos ition (F ig . 13.52) . 5. T his motion is r epeated thr ee times, and at the end of the third flexion, the patient's hip is ac c elerated into flex ion ( c urved white ar r ow) with a c ephalad impuls e ( thrus t) while the left hand immobiliz es to s ac rum ( s traight white ar r ow, F ig .

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placement.

F igure 13.51. Step 4. Flex hip and k nee.

F igure 13.52. Step 4. Return to extension.

F igure 13.53. Step 5. Cephalad impulse.

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13.53) . 6. T he right leg and hip are then extended and right s ac roiliac motion is r etested to as s ess the effectivenes s of the tec hnique.

P.361

Pe lvic Re gion: Innomina te Dys func tion Exam ple: Right Pos ter ior Innominate, Modifie d Sims Pos ition

Diag nosis Standing flex ion tes t: Positiv e (r ight PSIS rises ) Los s of pas siv ely induced right sac r oiliac motion ASIS: Cephalad (slightly lateral) on the right PSIS: Caudad (slightly medial) on the right Sac r al sulcus : Deep, anter ior on the right

Fig ure 13.54. Steps 1 and 2. Setup.

Tech niq ue 1. T he patient is in the left modified Sims pos ition and the physician s tands behind the patient.

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2. T he physician places the left hand on the patient's right PSIS while the r ight hand gr asps the patient's right leg just dis tal to the knee ( tibial tuberosity) ( F ig. 13.54) . 3. T he patient's r ight leg is mov ed in an upward, outwar d c ir cular motion ( white ar rows , F ig . 13.55) as the hip is flexed, abducted, ex ternally r otated, and c ar ried into ex tens ion ( F ig. 13.56) to c heck hip r ange of motion. 4. T his c irc ular motion is applied for thr ee cyc les , and at the end of the third c y c le, the patient is ins tructed to k ic k the leg s tr aight, pos itioning the hip and k nee into extension. 5. While this k ick is tak ing place ( ar row at left,

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Fig ure 13.55. Step 3. Circ ular hip motion.

Fig ure 13.56. Step 3. Abduc tion, external rotation, and ex tens ion.

Fig ure 13.57. Steps 4 and 5. Kick leg str aight with impuls e on PSIS.

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F ig . 13.57) the phy sic ian's left hand on the patient's right PSIS deliver s an impuls e ( ar row at right) toward the patient's umbilicus . 6. Right s ac roiliac motion is r etested to as s ess the effectivenes s of the tec hnique.

P.362

U pper Extrem ity Region: Elbow: R a dia l H ead, Pr ona tion D y s function

Diag nosis Symptoms: Elbow dis c omfort with inability to fully supinate the for earm Motion: Res tricted supination of the for earm Palpation: Tenderness at the radial head with pos terior prominence of the radial head

Fig ure 13.58. Steps 1 to 3. Setup, hand placement.

Tech niq ue 1. T he patient is s eated on the

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2.

3.

4.

5.

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table, and the phy sic ian s tands in fr ont of the patient. T he physician holds the patient's hand on the dy s functional ar m as if s haking hands with the patient. T he physician places the index finger pad and thumb of the other hand s o that the thumb is anterior and the index finger pad is pos ter ior to the radial head ( F ig. 13.58) . T he physician r otates the hand into the indirect pr onation pos ition and pus hes the r adial head pos ter ior ly with the thumb until the eas e bar rier is engaged ( Fig . 13.59) . F inally, the phy sic ian, with a moderate ac c eleration thr ough an ar c lik e path of least r es istanc e, s upinates the

Fig ure 13.59. Step 4. Engage pronation and radial head ease.

Fig ure 13.60. Step 5. Supinate.

Fig ure 13.61. Step 5. Anter ior counter for ce.

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for ear m toward the r es trictive bind bar rier ( Fig . 13.60) and adds an anterior dir ected c ounterforce ( ar row, F ig. 13.61) with the index finger pad. 6. T he release may oc cur before the bar rier is met. If not, the r adial head mus t not be c ar ried more than a few degrees bey ond. 7. T he physician r eevaluates the dy s functional ( T ART) c omponents.

P.363

U pper Extrem ity Region: Elbow: R a dia l H ead, Supination D y s function

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Diag nosis Symptoms: Elbow dis c omfort with inability to fully pronate the forearm Motion: Res tricted pronation of the for earm Palpation: Tenderness at the radial head with anterior ( ventral) prominence of the radial head Tech niq ue 1. T he patient is s eated on the table, and the phy sic ian s tands in fr ont of the patient. 2. T he physician holds the patient's hand on the dy s functional ar m as if s haking hands with the patient. 3. T he physician places the index finger pad and thumb of the other hand s o that the thumb is anterior and the index finger pad is pos ter ior to the radial head ( F ig. 13.62) . 4. T he physician r otates the hand into the

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F igure 13.62. Steps 1 to 3. Setup, hand placement.

F igure 13.63. Step 4. Engage supination.

F igure 13.64. Step 4. Engage radial head ease.

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P.364

U pper Extrem ity Region: Ac rom ioc lavicular J oint Exam ple: Right D is tal Clavic le Ele vate d

Diag nosis Symptoms: Acr omioclav icular dis c omfort with inability to fully abduct and flex the shoulder Findings: Dis tal clav icle palpably elev ated relative to the acr omion and res ists caudad pr ess ure Tech niq ue 1. T he patient is s eated, and the phy sic ian stands behind the patient toward the s ide to be tr eated. 2. T he physician, using the hand clos est to the patient, places the second metacarpophalangeal joint over the distal third of the clavic le to be treated. 3. T he physician maintains constant c audad pr ess ure ov er the patient's c lavic le thr oughout the tr eatment s equence. 4. T he physician's other hand gr asps the patient's ar m on the side to be treated jus t below the elbow ( F ig. 13.66) . 5. T he patient's ar m is pulled down and then dr awn bac kwar d into

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F igure 13.66. Steps 1 to 4. Setup, hand placement.

F igure 13.67. Steps 4 and 5. Bac kward ex tension.

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ex tens ion (F ig. 13.67) with a c ontinuous motion s imilar to throwing a ball over hand, c ir cumduc ting the ar m (F ig. 13.68) until it is onc e again in fr ont of the patient, finishing with the arm ac r oss the c hest in adduction (F ig. 13.69) . 6. T he release may oc c ur before the bar rier is met. 7. T he physician r eevaluates the dy s functional ( T ART) components.

F igure 13.68. Step 5. Overhand motion.

F igure 13.69. Step 5. Arm ac r oss chest.

P.365

U pper Extrem ity Region: Ac rom ioc lavicular J oint Exam ple: Right, Pr oxim al Cla v icle Elev a ted (D ista l C lav ica l De pre sse d)

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Diag nosis Symptoms: Tenderness at the ster noc lav icular joint with inability to abduct the shoulder fully without pain Motion: Res tricted abduction of the clav icle Palpation: Prominence and elev ation of the prox imal end of the clav icle

F igure 13.70. Steps 1 to 4. Setup, hand placement.

Tech niq ue 1. T he patient is s eated with the phy sic ian s tanding behind the patient. 2. T he phy sic ian's left hand r eac hes ar ound in fr ont of the patient and places the thumb over the pr oximal end of the patient's r ight clavic le. 3. T he phy sic ian's left thumb maintains c onstant c audad pr essure over the patient's c lavic le thr oughout the tr eatment s equence. 4. T he phy sic ian's

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F igure 13.71. Step 5. Flex ion and abduc tion.

F igure 13.72. Step 5. Bac k str oke motion.

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P.366

R e fere nce s 1. V an Busk i rk RL . Th e S til l Te c hn i qu e Ma nua l : Appl i ca tio ns o f a Re di sc ove r ed T ec hni que of Andr ew T ayl or Sti l l , M D. In di an apo l is : Am eri c an Aca dem y o f Os teo pat hy , 200 0.

2. W ard R ( ed. ) . F oun dat i on s fo r O s te opat hic Me di ci ne. Ph i l ad elp hia : Li ppi nco tt W i ll i am s & W i lk i ns , 20 03.

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14 Balanced Ligamentous Tension and Ligamentous Articular Strain Techniques Technique Principles Bal anc ed l i ga m en tous te nsi on ( BLT ) a nd l i ga m en tous ar tic ul ar st r ai n (L AS) te c hni que s m ay b e c on s id er ed as tw o se par ate tec hni que s or as on e. T he his tory of th e de v el opm ent of the s e t ech niq ues pro bab l y s tar ted dur i ng A. T . Sti l l' s ti m e, bu t de v el ope d gr eat l y thro ugh th e wo r k of a nu m be r o f ost eop athi c p hys i c ia ns i nc l udi ng, bu t no t l i mi ted to W . G. S uth erl and, DO ; H . A. Li ppi nc ot t, D O; R . Lip pin c ott , D O; R . B eck er, D O; an d A . Wa l es , D O (1 ,2) . I t ap pea r s that a geo gr ap hic se para tio n a nd m in i ma l co nta c t betw een tw o gr oup s m ay h ave ca us ed th e s am e tec hni que to be k now n b y t w o n ame s . T ho s e i n t he c en tr al Un i te d St ate s ( i .e. , T exa s ) e v en tua l l y pro m ot ed t he ter m LA S, and tho s e i n the nor the as te r n U ni ted Sta tes ( i. e., Ne w Je r se y a nd N ew Eng l and ) p r om oted th e t er m BLT . A s th e t w o nam es s ugg est , s om e v ar i an c e i n t he tech niq ues dev elo ped , an d t he pr ac tit i on er s dev elo ped the i r ow n par tic ul ar nu anc e fo r t he appl i ca tio n of th e t r eat m en t. T he ter m L AS s eem s t o de s cr i be the dy s fu nc ti on, w hi l e the ter m B LT d esc r ib es t he pro c ess or go al o f t he tr ea tme nt. Sut her l and ma y h av e bee n m os t r es pon s i bl e f or the tec hni que bei ng taug ht i n earl y o s te opat hic st udy gro ups . In th e 1 940s , h e b egan te ach i ng a m eth od o f t r ea tm en t o f t he b ody an d ex tre m it i es w it h t he pri nci pl es pr omo ted for th e tr eat m en t of th e c r ani um. He tal k ed ab out the jo i nt' s r ela ti on wi th i ts l ig ame nts, fa s ci a, a nd s o on ( l ig ame ntou s a r ti c ula r m ech anis m ), an d we ca n e x tra pol ate thi s t o i nc lu de the po tent i al fo r me c ha nor ec ep tor ex c i ta tio n i n dy s fu nct i ona l s tat es . One of Sut her l an d' s i de as, a k ey c on c ep t in th i s ar ea , w as that no r ma l mo v em ent s of a j oi nt o r a r ti c ula tio n d o no t c aus e as y mm etr i c ten s io ns i n t he l i ga m en ts and tha t t he t ens i on dis tri but ed t hro ugh the li gam ents in an y gi v en jo i nt i s bal anc ed ( 2,3 ) . T hes e t ens i ons ca n c hang e w hen the li gam ent or j oi nt i s s tre s s ed (s tra i n o r unit def orm atio n) i n the pre s en c e o f a l te r ed m ec han i c al fo r ce . To day , t hi s pri nci pl e i s s im i l ar to th e arc hit ec tu r al an d bi ome c ha ni ca l ( s tr uc tu r al ) p r i nc i pl es of t ens egr i ty, as se en i n t he geod esi c d om e of R . Buc k mi ns te r F ull er a nd the art of Ke nnet h S nel s on, hi s s tude nt ( 4, 5,6) . T his pri nci ple i s c om m on l y pro m ot ed i n t he post ula te that an an teri or ana tomi c ( fas c i al ) b ows tr in g i s p r ese nt i n the bod y . T he the ory i s tha t th e k ey dy sf unc tio n ma y p r od uc e bot h p r oxi m al an d di s ta l e ffec ts. Th es e eff ect s ca n p r od uc e s ym pto m s b oth an teri orl y a nd p ost eri or ly (1 ) . One of the as pec ts m ent i on ed i n s ome ost eop ath i c m ani pul ativ e t ech ni qu e ( OMT ) st y le s i s a r el eas e- en han c in g me c ha nis m . T his me c han i sm ma y be is ome tr ic co ntr ac ti on of a mu s cl e, a re s pi r at or y m ov eme nt o f t he di ap hra gm, eye an d t ongu e m ove m ent s , or i n t he c as e of BL T o r LA S, the use of in here nt for c es , su c h as c i rc ula tor y (T r au be- H eri ng- M ay er ), ly m ph atic , o r a v ar i et y o f ot her fa c tor s ( e.g ., p r im ary r es pir ator y m ech anis m ) ( 2) . Th e p hys i c ia n i ntr oduc es a f or ce to po s i ti on the pat i en t s o th at a f ul cr um m ay be s et . T his ful c ru m , pair ed w it h th e s ubs eque nt l ev er a c ti on of t he tis s ues (l i ga m ent s ), co m bin es w it h f l uid dy nam i c s and ot her fac tor s to pr odu c e a ch ang e in th e d y s fu nct i on al s tat e. In s ome ca s es, th e tec hni que i s use d to af fec t th e m y of as ci al s tr uc tu r es . I n th e c ase of tre ati ng a my ofa s c ia l s tru c tur e, the dif fer enti ati ng fact or bet w een BL T /L AS a nd m yo fasc i al re l eas e ( M FR ) is th at an i nhe r en t fo r ce (f l uid m od el) i s the re l eas e-e nha nc in g m ech anis m i n B LT /L AS; in M FR , t he ther m od y na m i c r ea c ti on t o pre s su r e i s t he pr im ary re l eas e f act or .

Technique C las sification

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Indirec t Te chnique In the c as e o f B LT /L AS, th e ph y si c ia n po s it i on s th e p ati ent' s d y sf unct i on al ar ea to w ar d th e e ase bar r ie r . T hi s P.3 68 i nd i re c t p osi tio ni ng is th e cl ass i c m eth od of tr ea tme nt i n t his te c hni que . H ow ev er, so m e L AS tec hniq ues are ex ac tl y l i ke M FR di r ec t te c hn i qu es , and th os e are in c l ud ed i n this ch apt er r ath er than Ch apt er 8 , o n m yo fas c i al re l ea s e ( 1). W he n b egin nin g t he t r ea tme nt, the ph y s ic i an ty pi ca l ly at temp ts to pr od uce so m e fr ee pl ay i n t he art i cu l ati on. Th i s a tte m pt to all ow the m os t m otio n t o o c c ur wi tho ut r esi s ta nc e i s ter m ed dis eng agem ent . It c an be pro duc ed b y c omp r ess i on or tra c ti on ( 1). Ex agg er at i on is the se c on d st ep des c r ib ed. It i s pro duc ed b y m ovi ng t owa r d the eas e o r to wh at s ome re fer as the or i gin al pos i tio n o f i nj ur y ( 1). Pla c in g the ti s s ue s i n a n op tim al bala nce of ten s io n a t th e a r ti c ula tio n o r ar ea of dy sf unc tio n is th e f i nal pos i ti onin g s tep of thi s t ec hn i qu e. Some re fer to thi s p oi nt as th e wo bbl e p oi nt . T his i s s im i la r to th e s en s at i on of bal anci ng an obje c t on the fin ger ti p. Th e w obbl e poin t is ce ntr al t o a l l r adi ati ng tens i on s , and tho s e tens i on s f eel asy m me tr ic wh en not at the poi nt. Wh i l e hol din g th i s pos i tio n, the phy s ic i an awa i ts a r el eas e. T his re l eas e h as been de s cr i bed as a gent l e m ov em en t t owa r d t he eas e an d t hen a s l ow m ov eme nt b ack w ar d to w ar d t he b ala nce poi nt ( eb b an d f l ow ) . F or ex am pl e, i f the dys fun c tio n b ein g tr eat ed i s d esc r ib ed a s L 4, F SL RL , t he e ase or dir ect i on of fre edo m is in th e fo l lo w in g di r ec tio ns : fle x io n, s i de be ndin g l eft , an d r ota ti on le ft. M ov i ng L4 ( ov er a s ta bil i z ed L5 ) i n th i s dir ec ti on i s desc r ib ed as m ovi ng aw ay fr om the r es tri c tiv e b arr i er and th er ef ore def i ne s th e t ech ni qu e a s i ndir ect .

D ire ct Technique LAS so m eti m es va r i es ; i t c an b e p erf or me d a s a dir ect te c hni que wh en t he m us c ula tur e i s ca usi ng a v ec tor of ten s io n in on e d i r ec tio n, but to bal ance th e a r tic ula tio n it fe els tha t y ou ar e m ov i ng tow ard th e dir ect ( re s tr i ct i v e) ba r ri er . It fol l ows th e d i r ec t s tyl e of MF R t ec hn i qu e d es cr i be d i n Ch apt er 8. S pee c e and Cr ow ( 1) i ll us tr ate th i s i n t hei r bo ok as tech niq ues use d i n d y s fu nct i on s of fi r st r ib , i l io ti bi al ban d, pel v ic dia phr agm , an d s o o n.

Technique Styles D iagnos is a nd Tre a tme nt with Re spiration In thi s me tho d, the phy s ic i an pal pat es t he are a in v ol v ed and at tem pts to dis c ern th e p atte r n of dy sf unc tio n w it h e x tre m el y l i ght pa l pa tory te c hn i que . T his c ou l d be desc r ib ed as n udg i ng the se gme nt t hro ugh the x- , y -, an d z- axe s w i th the mo v eme nts ca us ed by re s pir ati on. T he r ef ore , th e m ove m ent s u s ed i n the at temp t to dia gnos e a nd tr ea t t he dy sf unc tio n ar e e x tr em el y s m al l .

D iagnos is a nd Tre a tme nt with Inter segm ental Motion Tes ting (Phy sic ian Active ) In i nt er se gme nta l mo tio n t es ti ng/ tre atme nt s ty l e, s li ght l y m ore mo ti on an d/o r fo r ce ca n be us ed to t est m ot i on par ame ter s in th e d y s fu nct i on al s i te an d to be gin to m ov e t he s i te in to t he app r opr i at e i ndir ect pos i ti on o f b ala nc ed te nsi ons. Th ere m ay be mo r e c omp r es s i on or tr ac ti on i n this fo r m as w ell , dep end i ng on the dys fun c ti onal st ate , si te, or pre fer enc e of th e t r eat i ng ph y s ic i an .

Indications

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1. Soma tic dy s fun c ti ons of art i cu l ar bas i s 2. Soma tic dy s fun c ti ons of m yo fas c i al ba s is 3. Ar ea s o f l y m ph ati c c onge s ti on or l oca l e dema

R ela tiv e Contr aindica tions 1. F r ac tur e, di sl oca tio n, o r g r os s in s ta bil i ty i n are a to be tr eate d 2. M ali gna ncy , in fec tio n, o r s eve r e o s te opo r osi s i n a r ea to be tr ea ted

Gene ral Considera tions a nd R ule s T he te c hni que is s pe c if i c palp ato r y bala nci ng of t he tis s ues su r ro undi ng and i nh ere nt to a jo i nt or the m yo fas c i al st r uc ture s r ela ted to i t. T he ob j ec t is to ba l anc e t he ar ti c ul ar s urf ace s o r ti s su es i n t he dir ect i ons of ph y s io l og i c m oti on c om m on to tha t ar tic ula ti on . T he phys i ci an i s n ot s o m uch ca usi ng t he c ha nge as hel pin g th e b ody to hel p i ts el f. In this re s pe c t, i t i s v ery os teo path i c, as the fl uid and ot her dyn ami c s o f t he neur omu s cu l osk ele tal s ys tem fi nd a n o v er al l nor m al i z at i on or bal anc e. It i s i m po r tan t n ot to put too mu c h pr es s ur e i nto the te c hni que ; t he t i ss ue m ust no t b e ta k en be y ond it s e l ast i c l im i ts, an d t he phy s ic i an m us t n ot p r od uce dis c om for t to a l ev el t hat ca us es gu ard i ng. It ge nera l ly sh ould be ve r y tol era bl e to the pat i en t.

Gene ral Inform ation for All Dys functions Positioning 1. T he phy s ic i an m ak es a di agn osi s of so m at i c d y sf unc ti on in al l pl ane s o f pe r mi tte d mo tio n. 2. T he phy s ic i an pos i ti ons the su peri or ( up per or pro x i ma l ) s eg m ent ov er the s ta bil i z ed in fer i or P.3 69 ( l ow er or di st al) se gm en t t o a poi nt of bala nce d l i gam ent ous ten s io n i n al l p l an es o f p erm i tte d m oti on, si m ult ane ous l y i f p oss i ble . a. T hi s typ i ca l l y m ea ns m ovi ng awa y fr om the bar r ie r (s ) to a l oo s e ( eas e) s i te . b. Al l p l an es m ust be fi ne t une d t o th e m ost bal anc ed poin t. 3. F i ne - tu ne: H av e p ati ent bre ath e sl owl y i n an d o ut to a s se s s phas e o f r es pi r at i on tha t f eel s mo s t l oos e ( r el ax ed , s oft , et c .) ; p atie nt hol ds b r ea th at t he poi nt ( i t m ay be onl y p ar ti all y c om pl ete i nha l at i on or exh ala ti on ) w her e th e b ala nc e i s m ax i m al .

Trea tme nt 1. At t he poi nt o f b ala nc ed li gam ento us ten s i on , t he phys i ci an adju s ts th e re l at i ve pos i ti on betw een the s up eri or a nd i nf er io r s egm ents to ma i nta i n bal ance . a. T hi s typ i ca l l y m ea ns s hif tin g t he t op s eg m ent co nti nuou s ly aw ay f r om th e di r ec t b ar ri er to pr eve nt the tis s ue s f r om tig hte ni ng as th ey r ele ase . b. T he t i ss ues , as th ey r ele ase , a r e o fte n d es cr i be d a s if th ey ar e m el tin g or so fte ni ng .

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c. T i s su e t ext ur e c ha nge s sh oul d o c c ur du r in g th e r ele as e; if th ey a r e not pal pat ed, the pos it i on of bal anc ed l i ga m en tou s te nsi on has not be en s et. 2. W hen a tot al r ele ase i s not ed, the ph y si c i an re ass es se s t he c omp one nts of s om ati c dy s fu nct i on ( tis s ue te x tur e a bno r m al i ty , a s y mm etr y o f po s it i on , re s tr i ct i on of m ot i on, te nde r nes s [ T AR T ]). Th e phys i ci an r epe ats if nec ess ary .

T he sh or th and ru l es for th i s a r e as foll ows (1 ) : 1. D i se nga gem ent 2. Ex ag ger ati on 3. Bala nce un ti l r el eas e oc c ur s

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C erv ica l Re gion: Occipitoatlantal (C0 —C1, OA ) D y sfunction Exam ple : C0 -C1 ESLRR*

1. T he patient lies s upine and the physician s its at the head of the table. 2. T he patient is far enough away to permit the physician's forearms and elbows to r est on the table. 3. T he phys ician places the hands palms up under the patient's head s o that the c ontact is made at the level of the tentorium c erebelli ( 1), mostly with the heel of the hands towar d the hypothenar eminences. 4. T he phys ician's index or third

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Fig ure 14.1. Head and v ertebral c ontact.

Fig ure 14.2. Steps 3 and 4.

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fingers palpate the patient's C1 tr ans ver se pr ocesses ( F igs. 14.1 and 14.2) . 5. T he phys ician's palpating fingers s imultaneous ly c arry the C1 tr ans ver se pr ocesses upwar d and c ephalad ( arrows, F ig . 14.3) towar d the ex tension ease and toward s ide bending right, r otation left under the oc ciput. This s hould produce a relative s ide bending left, r otation right effec t at the oc ciput. 6. As the phys ician introduc es the v ectored for ce, the head is gently s ide- bent left and rotated r ight (arrows, F ig. 14.4) until a balanced point of tension is met. 7. When this balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf, and the physician will

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Fig ure 14.3. Step 5.

Fig ure 14.4. Step 6.

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hold this position agains t it until a r elease in the direc tion of ease occ urs. 8. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

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C erv ica l Re gion: A tla ntoaxia l (C1—C2, AA) Dy sfunction Exa m ple : C1 RR

1. T he patient lies s upine, and the physician s its at the head of the table. 2. T he patient is far enough away to per mit the phys ician's forearms and elbows to r est on the table. 3. T he phys ician places the hands palms up under the patient's head s o that the c ontact is made at the level of the tentorium c erebelli ( 1), mostly with the heel of the hands towar d the hypothenar eminences. 4. T he phys ician's

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F igu re 14.5. Palpation of C2 ar tic ular pillars .

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index or third fingers palpate the patient's C2 ar tic ular pr ocesses ( F igs. 14.5 and F ig. 14.6). 5. T he phys ician's palpating fingers s imultaneous ly c arry the C2 ar tic ular pr ocesses upwar d and c ephalad to disengage C1-C2 while s imultaneous ly r otating C2 left ( s weep arrow) under C1 ( c urv ed arr ow, F ig. 14.7). This s hould produce a relative C1, r otation right effec t. 6. As the physician introduc es the v ectored for ce, the head with C1 may be minimally and gently r otated r ight (arrow, F ig. 14.8) until a balanc ed point of tension is met. 7. When this balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf, and the

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F igu re 14.6. Steps 3 and 4.

F igu re 14.7. Step 5, rotation r ight effec t.

F igu re 14.8. Step 6.

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physician will hold the pos ition against it until a r elease in the direc tion of ease occ urs . 8. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

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C erv ica l Re gion: A tla ntoaxia l (C1—C 2 ) Dy sfunction Exa mple : C 1 R ight, Late ral Tr a nslation

1. T he patient lies s upine, and the physician s its at the head of the table. 2. T he phys ician's hands cup the head by c ontouring over the parietotemporal r egions. 3. T he phys ician places the index finger pads over the C1 tr ans ver se pr ocesses ( F ig. 14.9) . 4. T he phys ician gently and s lowly introduc es a tr ans lational force (arrow, F ig. 14.10) that is direc ted from

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F igu re 14.9. Steps 2 and 3, hand position.

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left to right towar d the ease barrier. The physician may have to go back and forth between left and r ight to deter mine the balanced position (F igs. 14.10 and 14.11). 5. When this balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf, and the physician will hold the pos ition against it until a r elease in the direc tion of ease occ urs . 6. T his can be performed as a direc t technique if pr eferred or indic ated. 7. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

F igu re 14.10. Step 4, tr ans lation left to r ight.

F igu re 14.11. Step 4, tr ans lation right to left.

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C erv ica l Re gion: C 2 to C 7 D y sfunction Exa mple: C 4 ESRR R

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1. T he patient lies s upine, and the physician s its at the head of the table. 2. T he patient is far enough away to permit the physician's forearms and elbows to r est on the table. 3. T he phys ician places the hands palms up under the patient's head s o that the c ontact is made at the level of the tentorium c erebelli ( 1), mostly with the heel of the hands towar d the hypothenar eminences ( F ig. 14.12). 4. T he phys ician's index or third fingers palpate the patient's C5 ar tic ular pr ocesses ( arrow, Fig . 14.13). 5. T he phys ician's palpating fingers s imultaneous ly c arry the C5 ar tic ular pr ocesses upwar d and c ephalad to disengage C4-C5, while s imultaneous ly r otating and

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Fig ure 14.12. Steps 1 to 3, head contact.

Fig ure 14.13. Step 4.

Fig ure 14.14. Step 5, SRRR.

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Thor acic Re gion: T1 a nd T2 D ysfunc tions Exam ple : T1 FSRRR

1. T he patient lies s upine, and the physician s its at the head of the table. 2. T he patient is far enough away to per mit the phys ician's forearms and elbows to r est on the table. 3. T he phys ician places the hands palms up under the patient's c ervical spine at the level of C2 or C3 so that the c erv ical s pine rests c omfortably on them. 4. T he phys ician places the index finger pads on the transver se pr ocesses of T1 and the thir d finger pads on the transver se pr ocesses of T2 ( F igs. 14.16 and 14.17). 5. T he phys ician's palpating fingers lift the T2 tr ans ver se pr ocesses up and down ( arrows, F ig . 14.18) to find a point of

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F igu re 14.16. Steps 3 and 4, hand and finger positioning.

F igu re 14.17. Step 3 and 4, palpation of patient.

F igu re 14.18. Step 5, neutr al balance

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disengagement between the flexion and ex tension barriers . 6. Us ing the third finger pads , the physician gently s ide- bends ( c urv ed arr ow) and r otates ( s weep arrow) T 2 to the left, which causes a r elative side bending right and r otation r ight at T1 (F ig. 14.19). 7. As the physician introduc es the v ectored for ce, the index finger pads on the T1 s egment may minimally and gently r otate and s ide-bend T 1 to the r ight until a balanced point of tension is met ( Fig . 14.20). 8. When this balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf, and the physician holds the position against it until a r elease in the direc tion of ease occ urs .

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point.

F igu re 14.19. Step 6, T2, SLRL.

F igu re 14.20. Step 7, T1, SRRR.

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9. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

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C erv icothor acic R e gion: Ante rior C erv ical Fa scia , D ire ct Technique

1. T he patient lies s upine, and the physician s its or s tands at the head of the table. 2. T he phys ician abduc ts the thumbs and plac es the thumbs and thenar eminences ov er the c lavicles in the s upraclavic ular fossa immediately later al to the s ternocleidomas toid muscles (F ig . 14.21). 3. T he phys ician applies a downward, s lightly posterior force ( arrows, F ig . 14.22) that is v ectored toward the feet. 4. T he phys ician moves the hands back and for th from left to right ( arr ows , F ig. 14.23) to engage the r estr ictive bar rier. 5. If there appear s to

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F igu re 14.21. Steps 1 and 2.

F igu re 14.22. Step 3.

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be sy mmetric r estr iction, both hands can be direc ted (ar rows, F ig. 14.24) toward the bilater al r estr iction. 6. As the tens ion r eleases , the thumb or thumbs c an be pushed farther later ally. 7. T his pressur e is maintained until no further improvement is noted. 8. T he phys ician r eass ess es the c omponents of the dy sfunction ( T ART ).

F igu re 14.23. Step 4.

F igu re 14.24. Step 5, bilateral tension if needed.

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Thor acic And Lumba r R egions : T3 to L4 Exa mple: T12 ESLRL

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1. T he patient lies pr one, and the physician s tands beside the table. 2. T he phys ician places the left thumb ov er the left transv erse pr ocess of T 12 and the index and thir d finger pads of the left hand over the r ight tr ans v ers e pr ocess of T 12. 3. T he phys ician places the r ight thumb ov er the left transv erse pr ocess of L1 and the index and thir d finger pads over the r ight tr ans v ers e pr ocess of L1 ( F ig. 14.25) . 4. T he patient inhales and ex hales, and on ex halation, the physician follows the motion of these two s egments . 5. T he phys ician adds a c ompr ess ion force (long ar rows) approximating T 12 and L1 and then dir ects a force downward ( s hor t arrows) towar d the table to vector it to the extension

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Fig ure 14.25. Steps 1 to 3.

Fig ure 14.26. Step 5.

Fig ure 14.27. Step 6.

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Thor acic And Lumba r R egions : T8 to L5 Exa mple: L5 FSRR R with Sacr al Tethering

If no s acral c omponent is pres ent, the hands may contact each s egment of the v ertebr al unit involved in the dysfunc tion (e.g., L2 and L3) . 1. T he patient lies s upine, and the physician s its at the s ide of the patient. 2. T he phys ician places the c audad hand under the patient's s acrum s o that the finger pads ar e at the s acral base and the heel is towar d the s acrococ cygeal r egion. 3. T he phys ician places the c ephalad hand ac ros s the s pine at the level of the dy sfunctional s egment so that the heel of the hand and finger pads contac t the left and right L5 tr ans ver s e pr ocesses ( F igs. 14.28

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Fig ure 14.28. Steps 2 and 3, hand pos itioning.

Fig ure 14.29. Hand positioning with sac rum and lumbar v ertebra.

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an d 14.29). 4. T he s acr al hand moves the s acrum c ephalad and c audad ( arrows, F ig . 14.30) to find a point of eas e as the lumbar c ontacting hand does the same. 5. T he lumbar hand may need to lift upward and downwar d ( arrows, F ig . 14.31) to balance between flex ion and extension. 6. T he lumbar c ontacting hand then side-bends and r otates L5 to the r ight ( arrows) to find balanced tension in thes e direc tions ( Fig . 14.32). 7. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 8. T he phys ician

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Fig ure 14.30. Step 4.

Fig ure 14.31. Step 5.

Fig ure 14.32. Step 6, L5, SRRR.

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r eass ess es the c omponents of the dysfunc tion ( T ART ).

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C ostal R egion: Fir st Rib Dy s function Exam ple : Le ft, Poste r ior , Elev ate d First Rib (N onphys iologic , N onre spiratory)

1. T he patient sits or lies supine, and the physician s its at the head of the table. 2. T he phys ician places the left thumb ov er the posterior as pec t of the elev ated left fir st r ib at the c ostotransv erse ar tic ulation (F ig. 14.33). 3. T he phys ician direc ts a force c audally (ar row, F ig. 14.34) through the ov erlying tissues and into the elev ated left first rib. 4. T he forc e applied should be moder ate but not s evere. 5. T he pres sur e is maintained until a releas e oc cur s as indic ated by the

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Fig ure 14.33. Step 2, thumb placement.

Fig ure 14.34. Step 3, c audal forc e.

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thumb being permitted to move thr ough the r estric tive barrier. 6. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

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C ostal R egion: Dy s function of the Res pira tor y D iaphragm a nd/or Exha lation Dys func tion of the Lowe r R ibs

1. T he patient lies s upine, and the physician s its or s tands at the s ide of the patient. 2. T he phys ician places one hand palm up with the fingers c ontouring the angle of the rib c age posteriorly . 3. T he other hand is placed palm down with the fingers c ontouring the angle of the rib c age anteriorly ( F ig. 14.35) . 4. T he hands impar t a moder ated c ompr ess ion force (arrows, F ig. 14.36) that

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F igu re 14.35. Steps 2 and 3, hand plac ement.

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is vectored towar d the x iphoid pr ocess. 5. T his pressur e is adjus ted toward the ease of movement of the r ibs and under lying tissues until a balance of tension is ac hieved. 6. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 7. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

F igu re 14.36. Step 4, compr ession for c e.

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U ppe r Ex tre mity R e gion: Cla v icle: Left Sternocla vic ula r D ysfunc tion (D ire c t Method)

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Symp tom and Diag nosis T he symptom is pain at either end of the c lav icle. T ech niq u e 1. T he patient sits on the s ide of the table. 2. T he phys ician s its on a s lightly lower stool and faces the patient. 3. T he phys ician's left thumb is placed on the tip of the infer omedial s ternal end of the c lavicle immediately later al to the s ternoclavic ular joint (F ig. 14.37) . 4. T he phys ician places the r ight thumb on the later al clav icle just medial and infer ior to the ac romioc lav icular joint (F ig. 14.38) . 5. T he patient may dr ape the forearm of the dy sfunctional ar m over the physician's upper ar m. 6. T he phys ician moves both thumbs ( arr ows, F ig. 14.39) later ally, s uper ior ly, and s lightly

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Fig ure 14.37. Step 3.

Fig ure 14.38. Step 4.

Fig ure 14.39. Step 6.

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U ppe r Ex tre mity R e gion: Shoulde r: Spa s m in the Tere s Minor Musc le (Dir ect Me thod)

Symp tom s an d Diag nosis T he indication is pain in the posterior axillar y fold. T ech niq u e 1. T he patient lies in the later al r ecumbent ( s ide-ly ing) position with the injur ed shoulder up. 2. T he phys ician s tands at the s ide of the table behind the patient. 3. T he phys ician locates the teres minor muscle at the posterior ax illary fold. 4. T he pad of the physician's thumbs are placed at a right angle to the fiber s of the muscle ( thumb pr ess ure direc ted par allel to muscle) at the point of maximum hy per tonicity ( F ig. 14.41) . 5. T he phys ician maintains a s teady

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Fig ure 14.41. Step 4, thumbs at point of greatest tens ion.

Fig ure 14.42. Step 5.

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pr ess ure s uper ior ly, medially , and s lightly anter ior ly ( arrows, F ig . 14.42) until a r elease of the s pasm is noted. 6. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

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U ppe r Ex tre mity R e gion: Shoulde r: Gle nohumer al D ysfunc tion

Symp tom s an d Diag nosis T he indication is s ubdeltoid bur sitis or froz en s houlder. T ech niq u e 1. T he patient lies in the later al r ecumbent position with the injur ed shoulder up. 2. T he phys ician s tands at the s ide of the table behind the patient. 3. T he phys ician places the olecr anon pr ocess of the patient's flexed and r elaxed

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F igu re 14.43. Step 3.

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4.

5.

6.

7.

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elbow in the palm of the distal hand and gr asps the patient's s houlder with the opposite hand (F ig. 14.43). T he phys ician c ontr ols the humer us from the patient's elbow and c ompr ess es it into the glenoid fossa (arrow, F ig. 14.44) . T he phys ician dr aws the elbow later ally and s lightly anter ior ly or posteriorly ( arrows, F ig . 14.45) to br ing balanced tension thr ough the s houlder . T he phys ician dr aws the s houlder anter ior ly or posteriorly and s imultaneous ly c ompr ess es it infer ior ly ( arrows, F ig . 14.46), dir ecting the v ector into the opposite glenohumeral joint. T he phys ician holds the position of balanced tension until a r elease is felt.

F igu re 14.44. Step 4, compr ess toward glenoid.

F igu re 14.45. Step 5, balanc ing tensions.

F igu re 14.46. Step 6, point of balanc e.

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8. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 9. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ). After the r elease, the humerus may be c arr ied superiorly and anteriorly , making a sweep pas t the ear and down in front of the face (1) .

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U ppe r Ex tre mity R e gion: For e arm and Elbow: U lnohume ral and R adioulnar Dys func tions

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Symp tom s an d Diag nosis T he indication is elbow pain or s tiffnes s. T ech niq u e 1. T he patient lies s upine, and the physician s tands or s its at the s ide of the patient. 2. T he phys ician gr asps the patient's olecr anon pr ocess with the thumb ( lateral as pect) and index finger ( medial aspect) at the prox imal tip of the olecr anon pr ocess at the gr oov es, bilaterally . 3. T he phys ician's other hand gr asps the dorsum of the patient's flexed wr ist (F ig. 14.47). 4. T he phys ician r otates the patient's forearm into full pr onation ( c urv ed arr ow, F ig. 14.48) and the hand into full flexion ( s hor t arrow). 5. T he phys ician's hands

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F igure 14.47. Steps 2 and 3.

F igure 14.48. Step 4, pronation and flexion.

F igure 14.49. Step 5, compres sion and ex tension.

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U ppe r Ex tre mity R e gion: Wris t: Car pal Tunnel Sy ndrome

1. T he patient lies s upine, and the physician s tands next to the outs tretched ar m of the dy sfunctional wr ist. 2. T he phys ician's medial hand c ontr ols the patient's thumb and thenar eminence (F ig. 14.50). 3. T he phys ician's other hand gr asps the patient's hy pothenar eminence and then supinates the forearm ( arrow, Fig . 14.51). 4. At full supination the patient's wr ist is flexed to its tolerable limit ( long ar row, F ig. 14.52) and the thumb is pushed dors ally ( s hor t arrow). 5. T he phys ician, maintaining the forces, slowly pr onates the forearm to its c omfortable limit and adds a force (arrow, F ig. 14.53) v ectored toward

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Fig ure 14.50. Steps 1 and 2.

Fig ure 14.51. Step 3, s upination.

Fig ure 14.52. Step 4, wris t flexion.

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ulnar deviation. 6. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

Fig ure 14.53. Step 5, ulnar deviation.

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Lowe r Ex tre mity R e gion: Hype rtonic ity of the Ex ternal Hip R ota tor s and A bduc tor s of the Femur (Exam ple : Piriform is H ype rtonicity and Fibrous Inela sticity )

1. T he patient lies in the later al r ecumbent position with s y mptomatic s ide up and both hips flexed to 90 to 120 degrees. 2. T he patient's k nees ar e flexed to approximately 100 degr ees . 3. T he phys ician s tands in fr ont of the patient at the level of the patient's hip, facing the table. 4. T he phys ician locates the hy per tonic or painful pir ifor mis

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F igu re 14.54. Steps 1 to 5.

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muscle s lightly posterior and infer ior to the s uper ior por tion of the greater tr ochanter. 5. T he phys ician maintains a fir m pr ess ure with the pad of the thumb medially ( down towar d the table) over the musc le until a releas e is palpated (F ig. 14.54). 6. Alter native: The physician may us e the olecr anon pr ocess of the elbow instead of the thumbs ( F ig. 14.55) . T he olec ranon is sensitiv e to the pres sur e ( arrow) and is able to deter mine the tendon's r esis tance and the differential anatomy of the ar ea. It is als o easier on the physician, as this sty le of technique c an fatigue the thumbs. 7. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

F igu re 14.55. Step 6, alter nate contac t with elbow.

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Lowe r Ex tre mity R e gion: Kne e : Posterior Fibular Hea d D ysfunc tion

1. T he patient lies s upine and the physician s its at the s ide of the dy sfunctional leg. 2. T he patient's hip and k nee ar e both flexed to approximately 90 degrees. 3. T he thumb of the phys ician's c ephalad hand is placed at the s uper olater al as pec t of the fibular head. 4. T he phys ician's other hand c ontr ols the foot just inferior to the distal fibula ( F ig. 14.56) . 5. T he phys ician's thumb adds pr ess ure on the pr oximal fibula in a vec tor s traight toward the foot (ar row at right, F ig. 14.57) while the other hand ( arrows at left) inver ts the foot and ankle. 6. T he phys ician attempts to deter mine a point of balanced tension at the pr oximal fibula and maintains

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Fig ure 14.56. Steps 1 to 4.

Fig ure 14.57. Step 5.

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this pos ition. 7. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 8. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

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Lowe r Ex tre mity R e gion: Kne e : Femorotibia l D ysfunctions Exam ple : Sprain of the C ruc iate Ligam e nts

1. T he patient lies s upine, and the physician s tands at the s ide of the dy sfunctional k nee. 2. T he phys ician places the c ephalad hand palm down ov er the anterior distal femur . 3. T he phys ician places the

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F igu re 14.58. Steps 1 to 3.

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4.

5.

6.

7.

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c audad hand palm down ov er the tibial tuber osity ( Fig . 14.58). T he phys ician leans down onto the patient's leg ( arrows, F ig . 14.59), dir ecting a for ce toward the table. T he phys ician adds a c ompr ess ive force (arrows, F ig. 14.60) in an attempt to approximate the femur and tibia. T he phys ician adds internal or ex ter nal rotation to the tibia ( arrows, F ig . 14.61) with the c audad hand to deter mine which is fr eer . T he physician attempts to maintain this position. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of

F igu re 14.59. Step 4, downward for ce.

F igu re 14.60. Step 5, joint compression.

F igu re 14.61. Step 6, inter nal or external r otation.

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ease occ urs . 8. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

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Lowe r Ex tre mity R e gion: Gas troc nem ius Hypertonic ity , D ire c t Method

1. T he patient lies s upine and the physician s its at the s ide of the table just distal to the patient's c alf, facing the head of the table (F ig. 14.62). 2. T he phys ician places both hands side by s ide under the gastr ocnemius muscle. The physician's fingers should be slightly bent ( arrow, Fig . 14.63), and the weight of the leg s hould r est on the phys ician's fingertips. 3. T he phys ician's fingers apply an upwar d forc e ( arrow at left, F ig. 14.64) into the musc le and then pull

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Fig ure 14.62. Step 1.

Fig ure 14.63. Step 2.

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infer ior ly ( arr ow at right) us ing the weight of the leg to c ompr ess the area. 4. T his pressur e is maintained until a releas e oc cur s. 5. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

Fig ure 14.64. Step 3.

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Lowe r Ex tre mity R e gion: Ank le: Pos ter ior Tibia on Talus

1. T he patient lies s upine with the heel of the foot on the table. 2. T he phys ician s tands at the foot of the table on the s ide of s y mptomatic ank le. 3. T he phys ician plac es the prox imal hand palm down ac ros s the distal tibia with the metac arpal- phalangeal joint of the index finger pr oximal to the distal tibia (F ig. 14.65) . 4. T he phys ician pres ses direc tly down ( arr ow, F ig. 14.66) toward the table and balances the tension coming up through the heel and the tibiotalar joint. 5. T he phys ician's other hand can be placed on top of the treating

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Fig ure 14.65. Steps 1 to 3.

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hand to create mor e pr ess ure. T he physician inter nally r otates (F ig . 14.67) or ex ter nally r otates ( F ig. 14.68) the tibia s lightly to bring the c ompr ess ion to a point of balanced tension. 6. When this total balanced pos ition is ac hieved, a slow r hythmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position agains t it until a releas e in the direc tion of ease oc cur s. 7. T he phys ician r eass ess es the c omponents of the dy sfunction (TART) .

Fig ure 14.66. Step 4, pres s ing downward.

Fig ure 14.67. Step 5, inter nal rotation.

Fig ure 14.68. Step 5, exter nal rotation.

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Lowe r Ex tre mity R e gion: Foot and A nkle Ex ample: Left C alc a neus D ysfunc tion, the B oot Ja ck Technique (1)

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1. T he patient lies s upine, and the physician s tands on the left, facing the foot of the table. 2. T he patient's left lower thigh and k nee ar e placed under the phys ician's r ight ax illa and against the later al rib cage for balance and c ontr ol. 3. T he phys ician gr asps the patient's left c alcaneus with the r ight thumb and index finger ( F ig. 14.69) . 4. T he phys ician flexes the patient's left hip and k nee approximately 90 degrees and gently ex ter nally r otates and abduc ts the patient's femur ( arrow, Fig . 14.70). 5. T he phys ician's r ight distal humer us and elbow touch the patient's distal femur just above the popliteal fossa as a fulcrum to gener ate pr oximal pr ess ure.

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F igure 14.69. Steps 1 to 3.

F igure 14.70. Step 4, external r otation and abduc tion of femur .

F igure 14.71. Steps 5 to 7.

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Lowe r Ex tre mity R e gion: Foot Dy sfunction: Me tata rsa lgia

1. T he patient lies s upine, and the physician s tands or is s eated at the foot of the table. 2. T he phys ician gr asps the foot with both hands , the fingers on the plantar as pec t of the distal metatars als ( F ig. 14.73) and the thumbs on the dors al as pec t of the foot (F ig. 14.74). 3. T he phys ician flexes the distal forefoot (ar row, F ig. 14.75) s lightly by c ontr acting the fingers on the plantar aspect of the foot. 4. T he phys ician then presses the thumbs downward into the metatar s als towar d the table ( arrow, Fig . 14.76). 5. T he phys ician attempts to position the foot at a point of balanced tension. 6. When this total

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F igure 14.73. Steps 1 and 2, finger s on plantar s urface.

F igure 14.74. Steps 1 and 2, thumbs on dorsal s urface.

F igure 14.75. Step 3, flexion of forefoot.

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balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 7. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

F igure 14.76. Step 4, press toward table.

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Lowe r Ex tre mity R e gion: Foot: Plantar Fas ciitis , Direc t Me thod

1. T he patient lies s upine, and the physician s its at the foot of the table. 2. T he phys ician's thumbs are c r oss ed, mak ing an X, with the thumb pads ov er the ar ea of c oncern (tar sal to distal metatars al) at the plantar fascia. 3. T he thumbs impar t an inwar d

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Fig ure 14.77. Steps 1 to 3.

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force (arrows, F ig. 14.77) that is vectored distal and later al. This pr ess ure is c ontinued until meeting the r estr ictive (bind) barrier. 4. T he pres sur e is held until a r elease is palpated. 5. T his is repeated with the foot alter nately attempting plantarflex ion ( F ig. 14.78) and dorsiflexion ( F ig. 14.79) . 6. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

Fig ure 14.78. Step 5, plantarflex ion.

Fig ure 14.79. Step 5, dors iflexion.

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R efe renc es 1. Sp eec e C, Cr ow T . L i ga m en tous Ar tic ul ar St r ai n: O s te opa thic Te c hn i que s f or the Bod y . Seat tle : Ea s tl and , 20 01.

2. Wa r d R (e d.) . F ound ati ons for Os teo path i c M ed i c in e. Phi l ade l ph i a: Lip pin c ot t Wi l li ams & W i lk i ns , 20 03.

3. Su the r l an d W G. T eac hin gs i n t he Sci ence of Os teop ath y . W ale s A (e d.). Po r tl and, OR : R udra , 19 90.

4. Fu l le r RB . S y ne r get i cs . N ew Y ork : M ac mi l la n, 1975 .

5. Sn els on, K. htt p:// w ww .ke nnet hsn els on.n et/ . F r equ ent l y As ke d Q ues ti on s ( F AQ ) an d S tru c tur e &

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Te nse gri ty . Acc ess ed F ebr uar y 4, 20 07.

6. In gbe r DE . T he ar ch i te c tu r e o f l i fe . Sc i A m 1 998; 278 :48 –57.

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15 Visceral Techniques Techni que Pri nci ples Os teo path i c v is c era l t ech ni qu es ( VI S) a r e def i ned in th e gl oss ary of ost eop athi c t erm i nol ogy by the Ed uca ti on al C ou nc il on Os teop ath i c Pr in c ip l es ( EC OP) as “ a s ys tem of dia gno s i s and tr eatm ent di r ect ed to th e vi s ce r a to i m pr ove phy s io l og i c f unc tio n; t y pi c al l y t he v is c era ar e m ov ed to w ar d th eir fa s c ia l at tac hm en ts to a po i nt of fas c ia l b al an c e; al s o c all ed v ent r al te c hni que s ” ( 1). Vi s ce r al tec hni ques ha v e be en part of th e os teo pat hi c m an i pu l ati v e arm am en tar i um s in c e the tim e o f S ti ll , a s h e de v el ope d an d pr omo ted his sy s tem of di agno s is an d th e f oll ow in g m ani pula tiv e t ec hn i qu es for hum an i l ln ess , n ot j ust mu s cu l osk ele tal pai n. In fact , m ost of Sti l l' s wr i ti ng has to do w i th th e c i r cu l at ory ( ar ter i al , ve nou s , and ly m ph atic ) , neu r olo gic , v i s ce r al , a nd h ume r al s ys tem s . H e d i d not w ri te a t r eat i se on l ow ba c k pain an d so on . Al l o s te opat hic in terv ent i on w as ba s ed on try i ng to tre at pati ent s i n a m or e b enig n a nd effe c ti v e ma nne r . At ma ny o s te opa thic me dic al s c ho ols VIS te c hn i que s w ere r ed uce d i n fa v or of tea c hi ng the tec hni ques th at w ere mo r e di re c tl y a s s oc i at ed w i th th e m us cu l os k el etal dy s fu nc ti ons th at c aus ed head , n eck , lo w ba c k, and ex tre m i ty pa i n. H ow eve r , m any of th e te c hn i qu es ( hep ati c , s ple nic , ga s tr oin test i na l , pu l mo nary , a nd l y mp hat i c) tha t h ad s uch po s it i v e eff ect s on th e v i s ce r a and gen era l h ealt h s tat us co nti nued to be tau ght . I n ad dit i on , th e s oma tovi s ce r al and vi s ce r oso m at i c r ela tio ns and the ef fect s o f dy s au tono m ia co ntin ued to be i mp ort ant i n the ove r al l o s teo pat hic c ur r ic ulu m . A r ea s o f so m at i c dy s fu nc ti on adv er se l y aff ec ti ng the v is c er al s y st ems ma y be tr eat ed w i th an y of th e v ar io us ost eopa thi c ma nip ul at i ve tr eatm ent s ( OM T) me nti oned in th i s a tla s . If O M T add r ess es a s om at i c c om pone nt of di s ea s e a nd the eff ect is to i mp r ov e th e c ond i tio n o f t he p ati ent , th at tec hniq ue c ou l d b e c ons i der ed a vi s ce r al tec hni que. Th ere fore , t his c ha pte r i l l us tra tes s om e t ech ni qu es tha t ha v e an i ndi r ec t o r di s ta l ef fec t on th e v i s ce r al sy s tem , b ut i n m ost ca s es i t i ll us tr ate s t ec hn i qu es that ar e m or e dir ect l y as s oc i ate d w i th i t. Ot her c ha pte r s di sc uss os teop ath i c palp ato r y di ag nos i s for det ect i on of s om atic dy s fu nc ti on. Th e sa m e ea s e- bi nd as y mm etri es of ti ss ue ten s i on an d m otio n u s ed for th e d i agn osi s a nd d eve l op m ent of tr eat m ent ve c to r s a r e als o ap pro pri ate for th e vi s ce r a. T he na tur e of th e o r gan ' s m ob i l it y s hou l d b e ac c ep ted by m os t ph y si c ia ns ; how eve r , t he m or e ev olv ed thin k in g o f mo til i ty , as is pr om ot ed i n os teo path y i n t he c r an i al fie l d, as the in her ent m ot i on w it hin th e or gan it s elf , e x pa nded th e t hi nk i ng of os teo path i c tre atme nt i n this ar ea. W it h p r ac ti ce , t he phys i ci an c an not on l y p alp ate org ano m eg al y and re s tr i c ti on of m obi l it y b ut c an als o di s ce r n fi ne ch ang es i n t he i nhe r en t m otil i ty of the or gan i ts elf . Mo r e r ece ntl y , the w or k s of B arr al have ag ain exc i te d t hose wh o h ad l ost to uc h w it h t ec hn i qu es affe c ti ng th e v i s ce r a ( 2) . An y o s te opat hic di agno s ti c e x ami nat i on s ho uld in c l ud e a la y er- by- l ay er p alp ato r y ap pro ac h, wh i ch w he n u s ed i n the vi s c er al r eg i ons ma y d eter m in e t i s su e t ext ur e c ha nge s , a s ym m et r y o f st r uc ture an d/o r mo tio n ( m obi l it y a nd m oti l it y ) , r es tri c tio n o f s uc h m ot i on , an d t end er ne s s ( se ns it i vi ty) .

Techni que Classi fication Di r ec t , I n di r ec t , o r C o mb in ed

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Techni que Styles All evi ation of S omatic Dysfunction In so m ati c d y sf unct i on th at a ppe ars to dir ect l y c aus e a n or gan to fun c ti on abno r ma l ly , tr eat i ng the ar ea of re l ate d s oma ti c dys fun c tio n s ome ti me s c an r edu c e or abla te the v is c er al abno r ma l it y . T his is an ex amp l e o f a P.3 96 so m at ov is c er al r efl ex bei ng q uie ted by the el i m in ati on of t he s om atic dy s fu nc ti on. Th e ab nor m al s om ati c af fer ent bom bar dm en t i s e l i mi nat ed, c au s in g t he p r ev i ou s l y ass oci ated (a bno r m al ) r eac ti on ary vi s c er al ef fer ent i nn erv atio n t o b e no r ma l iz ed.

Reflex Ori ented Th ese tec hni que s at tem pt to p r od uce a s eco nda r y r eac tio n in an or gan s ys tem by aff ect i ng the au tono m ic ne r vo us s y st em ( usu all y s y m pa the tic but so m et i m es pa r as y m pa the tic ) . T his is s im i la r t o us i ng ot her au ton om ic re fle x es, su c h as c aro tid m as s ag e, v aga l i ndu c tio n t hro ugh Val s al v a m ane uve r , o c ul ar pr ess ur e, ic e w ater im m er s i on , a nd s o o n. T he s e t r ea tme nts are in are as tha t ca n a ffe c t t he aut onom i c ne r vo us s y st em i n s pec i fi c wa y s ass oc ia ted wi th e i th er s y mp ath eti c or pa r as y m pa the tic r ea c ti v it y . T hey ar e a n at tem pt ei th er to i ncr eas e o r to de c re as e the le v els of au tono m ic ou tput at th e ar ea i n ques tio n. Ro uti nely , w e p r efe r t o t hi nk of re duci ng the are a o f s om at i c dys func tio n r athe r t han i nc r ea s in g or de c re as in g t he l eve l o f a uton omi c a c tiv i ty . H ow ev er, in s om e c ase s th i s app ears to pr oduc e t he ap pro pr ia te c li ni ca l r esp onse , s uch as a p ati ent w it h a s thm a h avi ng t he s ym path eti c p or ti on of the au ton om ic sy s te m st i mu l at ed b y t hor ac ic pu m p i n t he upp er t hor aci c re gio n a nd e x hi bit i ng l es s a i r wa y re act i v it y .

Myofascial Oriented Th e f as ci al c om pone nt to v i sc era l m obil i ty is the pr i ma r y a s pe c t i n d i ag nos i s a nd tre atme nt i n this te c hn i que . ( T he s ty l e l ab el ed ba l an c ed l ig ame ntou s t ens i on, or li game nto us ar ti c ul ar s tra i n [BL T /LA S] i s si ngl ed o ut bec ause of it s di ffe r en t pa l pa tor y ex pre s si on o f d i ag nosi s a nd tr ea tme nt, alt hou gh i t u s es th e sa m e ti ss ues to eff ect ch ange th at m y of asc i al r el eas e [ M F R] us es) . Us i ng th e la y er - by - l ay er app r oac h, th e p hy si c ia n p al pa tes at v ar i ou s l ev el s i n t he r egi on of t he s pe c i fi c o r ga n an d d ete r m in es w he ther an y te the r i ng is ta k i ng pl ace i n r el ati on t o e ase - bin d b arr i er c on c ep ts . T he n t he p hys i ci an d eci des w he the r t o us e a dir ect or i nd i re c t M F R- l ik e t ec hn i qu e. T his ca n d i r ec tly af fect th e v enou s a nd l y mp hat i c dr ai nag e fr om the r eg i on ( in c lu din g in ter s ti ti al sp ace s ) i nha bit ed b y t he v i sc era l o r gan , w i th c li nic al r esp ons e fr om the r ed uct i on i n i nf l amm ato r y r esp ons e, noci c ep tio n, a nd s o on.

Bal anced Ligamentous Tensi on, or Ligamentous Articular Strain Th e B LT /L AS m et hod of dia gnos i s and tre atm ent i s an att em pt to di s c er n t he ease - bi nd as ym m et r y. Th en, usi ng pal pato r y tec hniq ues to s en s e the i nh ere nt m oti l it y o f th e o r ga n, t he phy s i ci an att em pt s t o ba l an c e t he tis s ues th r ou gh i ndi r ec t (a nd s om etim es dir ec t) te c hn i que by di s eng agi ng the org an fr om it s re s tr i c ti v e pre s ent ati on ( c om pre s si on, tra c ti on), ex agg er at i ng it s fr ee m ot i on pat ter n, a nd the n ba l an c in g at a poin t t hat exh i bi ts equa l t ens i on i n the x -, y- , a nd z - ax es.

Vibratory or Sti m ulatory Technique

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Vi bra tory or st i m ul ato r y tech niq ue us es a r ep etit i ve mo ti on ov er the org an, gen tly to m od era tel y vi bra ti ng , s hak i ng, or pe r c us s in g o v er the or gan to fac i l it ate fl ui d m ov eme nt t hro ugh the ar ter i al, ve nou s , an d l y m ph ati c v es se l s and to hel p d ec on ges t t he o r ga n. T hes e t ech ni qu es are oft en use d in sp l en i c a nd he pat i c p r ob l em s wh en thi s ty pe of forc e i s n ot c ont r ai ndic ate d.

Indications Th e i ndic ati ons for vi bra tory or st i m ul ato r y tr ea tme nt ar e org an dy sf unc tio ns e x pr ess i ng the m se l v es in ma ny c l in i ca l m anif est ati ons, in c lu di ng bu t n ot l i mi ted to the fo l l ow i ng (1 ) :

1. C ard i ac arr hyt hm ia , c ong es ti v e hea r t f ail ure , an d h y pe r ten s io n 2. As th m a, bro nch i tis , p neu m oni a, ate l ect asi s , and emp hys em a 3. Gast r oes oph age al r efl ux, gas tri tis , an d h i at al h ern i a 4. H epa ti ti s , c ho l eli thi asi s , c hol ecy s tit i s, pa nc re ati tis , ch r on i c fati gue , a nd h orm ona l im bal anc e 5. D i ve r tic ulo s is , ul c er ati v e c oli tis , ir r it abl e bo w el , c onst i pa tio n, d i ar r he a, a nd hem or rh oid s 6. Py el onep hri tis and re nal l it hia s is 7. R ecu r r en t c y st i tis , i nte r s ti tia l c y s ti tis , a nd s tre s s i nco nti nen c e 8. D y sm enor r he a, dy sp are uni a, a nd i nf er ti l it y

Contrai ndi cations Th ere are no ab s olu te c on tr ai ndi c at i ons to th i s t y pe of tre atm ent ; ho w ev er, c li nic al j udg m en t a gain is th e ru l e. Pre s su r e, c om pre s si on, or tra c tio n o v er an i nf l am ed, s er i ou s l y i nf ect ed, or ble edin g o r ga n is no t ap pro pr ia te.

General Consi derations and Rul es Th e p hy si c ia n m us t det erm i ne w he the r th ere is a s oma tic c om pon ent to the di s eas e s tat e. D epe ndi ng o n th e d i s ea s e and the na tur e of th e a s s oc i at ed dy sf unc tio n, P.3 97 th e p hy si c ia n m us t dev elo p a tre atm ent pla n t hat r ed uce s th e s oma ti c dys fun c tio n i n a s af e, ben i gn ma nne r . T he phy s i ci an m us t al s o not e wh eth er ther e i s a n au ton omi c co m pl i ca ti on (e .g. , fa c il i ta ted se gme nt) and if the r e i s s uch , t r ea t th at fir s t, i f pos s i bl e. Ch apm an's re fle x is an oth er p ote nti al d i ag nos ti c aid in the de ter m i na tio n o f th e e x ac t di agn osi s an d t he ke y d y s fu nct i on . Th i s r ef l ex has be en u s ed mo s tly as a di ag nos tic too l a nd i s n ot i nc l ude d i n t he te c hn i que se c ti on. P.3 98 P.3 99

Reflex Ori ented Treatment Occi pitomastoi d S uture P ressure

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Indicat ions T he indications for occipitomas toid s utur e pres sur e release are tachycar dia ( hypopar asy mpathetic s tate) and bradyc ardia ( hyperparas ympathetic s tate). Physiolo gic Go al T he goal is to us e a r eflex ( par asy mpathetic) to decr eas e the patient's puls e by influenc ing c ardiac rate v ia c ranial nerv e X (vagus ) or by treating cr anial s omatic dys function at this ar ea ( Fig . 15.1) that could be caus ing a secondary bradycar dia ( somatov isc eral ty pe) .

F ig ure 15.1 T he occ ipitomastoid s uture.

T ech niq u e 1. The patient lies supine and the phy sic ian is seated at the head of the table. 2. The phy sic ian palpates the occ ipitomastoid grooves bilater ally. 3. The phy sic ian places the index finger s ov er eac h mas toid pr ocess immediately proximal to the anterior aspect of the gr oove. 4. The phy sic ian places the third

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F ig ure 15.2 Steps 3 and 4, finger placement.

F ig ure 15.3 Step 5, tr action with fingers.

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P.4 00 P.4 01

Reflex Ori ented Treatment Alternating Pressure, Left Second Rib

Indicat ions T he indications for treatment are tac hycardia ( hypers y mpathetic state) and br ady car dia ( hyposy mpathetic s tate). Physiolo gic Go al T he goal is to us e the s ympathetic reflex to incr eas e the patient's puls e by influencing car diac r ate via sy mpathetic chain ganglia (F ig. 15.5) or treating thoracoc ostal s omatic dys func tion at this area, which may influenc e c ardiac rate. T ech niq u e 1. The patient lies supine, and the phy s ician is seated at the head of the table. 2. The phy sic ian reaches under the patient and places the pads of the index and middle finger s on the angle of the left sec ond rib near the c ostotr ansv ers e ar tic ulation. 3. The phy sic ian places the pads of the other index and middle finger on the anter ior aspect of the left s econd r ib near the cos toc hondral junction (F ig . 15.6). 4. The phy sic ian pr esses upwar d with the bottom hand while releasing pr ess ure from the top hand (F ig . 15.7). 5. The phy sic ian holds this position for sever al sec onds , after which the bottom hand releas es pres sur e and the top hand ex erts downwar d pres sur e (F ig. 15.8). 6. This pr ess ure is lik ewise held for s ever al sec onds befor e s witc hing again. T his alternating pres s ure is continued until the des ired effec ts are obtained or it is determined that the tec hnique will be ineffec tiv e.

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F igure 15.6 Steps 1 to 3, anterior a placement of finger s.

F igure 15.7 Step 4, anter ior - dir ecte

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F igure 15.8 Step 5, posterior -direc pr ess ure.

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F igu re 15.5 Anatomic loc ation of the s ympathetic chain ganglia. Pos terior view (3

P.4 02 P.4 03

Reflex Ori ented Treatment S ingultus (Hiccups)

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T he phr enic nerve arises pr imar ily fr om C4, but als o r eceives fiber s fr om C3 and C5. It runs deep to the omohyoid muscle and s uperfic ial to the anter ior s calene mus cle. It is the only motor nerv e s upplying the diaphragm (F ig . 15.9). T ech niq u e 1. The patient may be s eated or lie supine. 2. The phy sic ian loc ates the triangle formed by the sternal and c lav icular heads of the left sternoc leidomastoid mus cle (F ig. 15.10). 3. The phy sic ian, us ing the thumb, index , or middle finger , pr ess es deep into this tr iangle (F igs. 15.11 and 15.12) . 4. This pr ess ure should elicit a mild degree of pain (to tolerance) and be maintained for at least a minute after the hic cups c ease to br eak the reflex arc . 5. If the tec hnique is uns ucc essful on the left, it may be repeated on the right.

F ig ure 15.10 Steps 1 and 2.

F ig ure 15.11 Finger pr essure.

F ig ure 15.12 Thumb pres sur e v

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P.4 04

Reflex Ori ented Treatment Rib Rai sing

See Chapter 16, Lymphatic T echniques. Indicat ions T o r elieve postoper ative paralytic ileus T o impr ove r espiratory ex cur s ion of the r ibs T o facilitate lymphatic drainage Cont rain dications Rib frac tur e Spinal c ord injur y and s urgery Malignancy

F ig ure 15.13 Skeletal hand contac t.

T ech niq u e 1. The patient lies supine, and the phy sic ian is seated at the side of the patient. 2. The phy sic ian slides both hands under the patient's thorac olumbar region (F igs. 15.13 and 15.14) . 3. The pads of the finger s lie on the par aver tebral tis sues ov er the cos totr ans ver se articulation on the side near

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F ig ure 15.14 Patient hand contac t.

F ig ure 15.15 Phy sic ian and patient

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the phy sic ian (F ig. 15.15). 4. Leaning down with the elbows, the phy sic ian lifts the finger s into the par aver tebral tis sues , simultaneously drawing the finger s (arrows, Fig . 15.16) in. 5. This lifts the spine off the table and places a later al str etc h on the par aver tebral tis sues . 6. This technique may be per for med as an intermittent kneading tec hnique or with s ustained deep inhibitory pressur e.

pos itioning.

F ig ure 15.16 Step 4, v entr al, then lateral pr essure.

P.4 05

Sti mul atory/V ibratory Treatment Colonic Sti mul ation

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Indicat ion Cons tipation Cont rain dications Bowel obstr uction Abdominal neoplas m Undiagnosed abdominal pain T ech niq u e 1. The patient lies s upine, and the phy sic ian stands at the patient's side. 2. The phy sic ian places the pads of the finger s on the abdominal wall ov erlying the splenic flexur e of the colon ( Fig . 15.17) . 3. The phy sic ian rolls the finger s along the bowel in the dir ection of colonic flow ( arrows, Fig . 15.18). 4. The phy sic ian releas es pressur e and repositions the hands one hand's - width far ther along the colon toward the sigmoid region.

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F ig ure 15.17 Steps 1 and 2.

F ig ure 15.18 Step 3.

F ig ure 15.19 Step 5.

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P.4 06

Sti mul atory/V ibratory Treatment S plenic Sti mul ation

Indicat ions Any infectious disease; also prev entive Cont rain dications Infectious mononuc leos is; any splenic enlargement Neoplas m infiltr ating the s pleen T ech niq u e 1. The patient lies s upine, and the phy sic ian stands at the left s ide of the patient. 2. The phy sic ian's right hand abducts the patient's left arm 90 degrees and exerts gentle traction (a r row, F ig. 15.21) . 3. The phy sic ian places the left hand on the lower c ostal car tilages overly ing the spleen, with the finger s following the interc ostal

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F igure 15.21 Steps 1 to 3.

F igure 15.22 Step 5.

F igure 15.23 Step 6, s udden r elease

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4.

5.

6.

7.

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spaces (F ig. 15.21) . The phy sic ian's left hand exerts pressur e dir ectly toward the center of the patient's body, spr inging the ribs inwar d. A s pringing motion (a r row, F ig. 15.22) is car ried out at two per sec ond and continued for 30 sec onds to sev eral minutes . One modific ation of this tec hnique inv olv es compres sing the lower left rib cage slowly between the phy sic ian's hands with a sudden releas e (also call a chugging motion) (F igs. 15.23 and 15.24) . A s econd modific ation has the phy sic ian place one

modification (c ompr ess ion).

F igure 15.24 Step 6, r elease.

F igure 15.25 Step 7, perc uss ive modification.

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hand ov er the lower c ostal car tilages and thump and per cus s the bac k of the hand with a fist or for ear m (a r row, F ig. 15.25) .

P.4 07

Reflex Ori ented Treatment S acral Rock

Indicat ions Dysmenor rhea Pelv ic c ongestion s yndrome Sacr oiliac dysfunc tion Cont rain dications Undiagnosed pelvic pain Pelv ic malignancy T ech niq u e 1. The patient lies pr one, and the phy sic ian stands at the side of the table. 2. The phy sic ian places the cephalad hand with the heel of the hand at the sac ral bas e,

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F ig ure 15.26 Cephalad hand.

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P.4 08

finger s

Myofascial pointing Release/Blt Treatment Gastric Release

toward the coc cyx (F ig. 15.26) . 3. The Indicat ions phy sic ian's G astroes ophageal r efluxcaudad hand reinfor ces the G astric ptosis cephalad hand T ech niq u ewith finger s 1. The pointing patient in the is oppositeand the seated, dir ection phy sic ian stands F ig ure 15.27 Caudad hand. (F ig. 15.27). behind the patient. 4. The phy sic ian 2. phy sic ian, places the left and keeping right hands the over F ig ure 15.30 Steps 1 and 2. elbows the left and right str aight, s ubc ostal anterior exerts and subxiphoid gentle pressur e on region, the pec res sactively rum. (F ig . 5. 15.30) The phy . sic ian 3. The introduces phy sic a ian's roc kingc ontour the hands motionabdominal upper to the sac rum quadrants, and F ig ure 15.28 Sac ral ex tens ion synchr the finger onous pads ( c ounternutation). withl sthe cur lightly and patient's press inward resr rows (a pir ation. , F ig. Sac ral . 15.31) F ig ure 15.31 Step 3. 4. The extens phy ion sic ian (a r row, adds s lightly F ig. mor e 15.28) occ pressur e inward urs dur ing and then tests for inhalation. tis sue tex tur e Sac ral flexion changes and (a r row, asy mmetry F ig.in 15.29) eas e-bind occ motion urs dur ing freedom. 5. The exhalation. phy sic ian 6. dir This ects a constant F ig ure 15.29 Sac ral flexion ( nutation). tec hnique pressur e to is the continued eas e ( indirec for t) or sev eral bind ( direct) , minutes . on the depending

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patient's tolerance and phy sic ian's prefer ence (F igs. 15.32 and 15.33) . 6. The phy sic ian holds this until a releas e is palpated and continues until no fur ther improv ement is produc ed. 7. A releas e-enhancing mec hanism, such as deep inhalation and ex halation, can be helpful.

F ig ure 15.32 Step 5, indir ect for ce (ease) .

F ig ure 15.33 Step 5, direc t ( bind).

P.4 09

Myofascial Release/Blt Treatment Hepatic Release

Indicat ions Hepatitis Cirr hos is Cholelithiasis T ech niq u e 1. The patient lies supine, and the phy sic ian sits to the right and fac es the patient. 2. The phy sic ian places the left hand under the r ib cage at the level of the liv er. 3. The phy sic ian places the right hand immediately inferior to the

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F ig ure 15.34 Steps 1 to 3.

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4.

5.

6.

7.

8.

subcos tal angle at the patient's right upper quadrant (F ig. 15.34). The phy sic ian gently compres ses the patient with both hands ( arr ows , Fig . 15.35) and attempts to palpate the liver . The phy sic ian nex t tests for any eas e-bind tis sue tex tur e and motion asy mmetries. On noting any asy mmetry, the phy sic ian maintains a constant pres sur e at either the eas e (indir ect) or the bind ( direct) , depending on the patient's tolerance and phy sic ian's prefer ence (F ig. 15.36) . The phy sic ian holds this until a releas e is palpated and continues until no fur ther improv ement is produc ed. A releas e-enhancing mec hanism, such as deep inhalation and ex halation, can be helpful.

F ig ure 15.35 Compress to palpate liv er.

F ig ure 15.36 Step 6, direc t or indir ect for ce.

P.4 10

Myofascial Release/Blt Treatment Gal l bladder

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Indicat ions Cholecy s titis Cholestasis Chronic upper abdominal pain T ech niq u e 1. The patient is seated, and the phy sic ian stands behind the patient. 2. The phy sic ian places the index , third, and fourth finger s of the left hand just inferior to the xiphoid proces s , midline to slightly r ight. 3. The phy sic ian places the index , third, and fourth finger s of the r ight hand just inferior to the subcos tal mar gin, just lateral of midline immediately to the right of the gallbladder ( Fig . 15.37) . 4. The phy sic ian tes ts for any eas e-bind tis sue tex tur e and motion asy mmetries. 5. On noting any asy mmetry, the phy sic ian maintains constant pres sur e (a r rows , F igs. 15.38 and 15.39) at either the eas e (indir ect) or the bind ( direct) , depending on the

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F ig ure 15.37 Steps 1 to 3.

F ig ure 15.38 Step 5, indir ect for ce (ease) .

F ig ure 15.39 Step 5, direc t forc e (bind).

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P.4 11

Myofascial Release/Blt Treatment Kidney Rel ease

Indicat ions Pyelonephritis Renal lithiasis F lank and inguinal pain T ech niq u e 1. The patient lies supine with the hip and knee flex ed on the affected side. 2. The phy sic ian stands on the affected s ide at the lev el of the hip. 3. The patient's knee is plac ed anterior to the phy sic ian's axilla at the cor acoid proc ess , and hip flexion is added to r elax the anterior abdominal region (F ig. 15.40) . 4. The phy sic ian places the later al hand palm up under the patient's bac k just below the floating ribs . 5. The phy sic ian's medial hand reaches ar ound the patient's thigh to lie over the upper abdominal quadrant on the affected s ide and presses downwar d (poster ior ly) (top

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F ig ure 15.40 Steps 1 to 3.

F ig ure 15.41 Steps 4 to 6.

F ig ure 15.42 Step 8, direc t or indir ect for ce.

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6.

7.

8.

9.

10.

arr ow, Fig . 15.41) until palpating the kidney . The phy sic ian's pos ter ior hand lifts (b ottom ar row, Fig . 15.41) upward (anter ior ) to fac ilitate the renal palpation. The phy sic ian nex t tests for any eas e-bind tis sue tex tur e and motion asy mmetries. On noting asy mmetry, the phy sic ian maintains a constant pres sur e (a r rows , F ig. 15.42) at either the eas e ( indirec t) or the bind (direc t), depending on the patient's tolerance and phy sic ian's prefer ence. The phy sic ian holds until a releas e is palpated and continues until no fur ther improv ement is produc ed. A releas e-enhancing mec hanism, such as deep inhalation and ex halation, can be helpful

P.4 12

References

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1. W ar d R . Fo und ati ons for Os teop ath i c M edi c in e. Phil ade l ph i a: Lip pin c ott Wi l li am s & W i lk i ns, 200 3.

2. Bar r al J P, Me r ci er P . V i sc er al Ma nip ul at i on . S eatt l e: Ea s tla nd, 19 88.

3. R ep r in ted w it h p er mi s si on fr om Ag ur AM R, Da l le y AF . G r an t' s Atl as of A nat omy , 11 th ed. Bal tim ore : Li ppi nco tt W i ll i am s & W il k in s , 2 005 .

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16 Lymphatic Techniques Techni que Pri nci ples Ly m ph atic te c hn i que s h ave not un til r ec ent l y been co nsi dere d a sp ec if i c c at egor y o f o s teo pat hic ma nip ul at i on . T hey w er e t y pic all y i nc lu ded in the vi s ce r al s ec tio ns o f o s te opat hic pr i nci ple s a nd pr act i c e. Th e E duca tio nal C ou nci l o n Os teo pat hi c Pri nci pl es (E C OP ) of fer s n o de fin i ti on o f l y mp hati c s as a s epa r at e t y pe of ost eopa thi c m anip ula tio n. I n t he EC OP gl oss ar y, th e o nl y s pe c if i c m ent i on of ly m ph atic te c hn i que is th at o f t he l y mp hat i c ( M il l er ) p um p and th e pe dal (D al ry m pl e) pump (1 ) . T hes e te c hn i que s a r e i ncl ude d i n th i s c ha pter as we l l a s r efe r enc ed i n F oun dat i on s fo r O s te opat hic Me di ci ne (1 ) . It is a p r in c ip l e t hat al l os teo pat hi c tec hni ques ha v e s ome ef fec t on ly m ph atic s . T hi s is ac c om pl is hed di r ec tl y, by st i m ul ati ng fl ow or re m ovi ng i mp edim ent s t o fl ow, or i nd i re c tl y , b y t he al le v ia tio n of so m at i c dy s fu nc ti on and the co nse quen tia l n or ma l iz ati on o r b ala nc in g ( par as ym pat het i c o r s y mp athe tic ) o f th e au ton om ic ne r vo us s y st em. H ow eve r , c ert ain te c hni que s s eem to hav e a m or e d i r ec t e ffe c t o n t he ly m ph atic sy s te m th an oth er s and he nc e are de s c ri bed in thi s c hap ter. Ly m ph - pot ent i at i ng tec hni ques ar e d es cr i be d i n ot her ch apte r s. Ex am pl es of tech niq ues w it h g r ea t ly m ph ati c po ten tia l of th eir own ar e ba l an c ed l ig ame ntou s t ens i on, or li game nto us ar ti c ul ar s tra i n ( BL T /LA S); so ft t i ss ue; v is c er al; my ofa s c ia l r ele as e ( MF R ); and ar tic ul at ory te c hni que s . T hes e a r e desc r ib ed i n t hei r r es pe c ti v e ch apt er s. Ma ny os te opa thi c ph y si c ia ns h ave at temp ted to aff ect th e ly m ph ati c sy s te m . T he pri nci pl e of uni m ped ed va s cu l ar s up ply has be en pr om ote d e x ten s iv ely , an d m ost ost eop ath i c s tud ent s ha v e hea r d A . T . S ti ll ' s ru l e of t he art er y quo ted ; ho w ev er, he als o s tate d t hat he c on s id er ed th e l y m ph ati c s y s te m p r im ar y i n the ma i nt enan c e of heal th, an d wh en i t i s s tre s se d, a ma j or c on tri but or t o d i se as e and in c r ea s ed mo r bid i ty . He ex pr es s ed hi s ph i lo s op hy w i th wo r ds s uc h a s “l i fe an d de ath ” w hen s pe aki ng a bou t t hi s s ys tem ( 2) . Ph i la delp hia os teop ath i c phys i ci ans w er e i m po r tan t t o t he u nde r st andi ng of the l ym pha ti c s ys tem and in de v el opin g t ech ni qu es to affe c t i t. W il l ia m G al br eat h ( Phil ade l ph i a C oll ege of Ost eop athi c M edi c i ne [P C OM ], 1 905 ) d ev el ope d m andi bul ar dr ai nag e, a te c hn i qu e in c lu ded i n thi s t ex t ( 3, 4). Ano the r P C OM al umn us , J . Gor don Z in k , w as a p r om i nen t l ect ur er on th e my ofa s ci al a s pe c ts of l ym pha ti c c on ges ti on an d i ts t r ea tme nt. W e bel i eve th at of t he flu i d s y st ems , it is th e lo w -p r es s ure ly m ph atic sy s te m th at c an mo s t easi l y be i m pe ded an d mo s t c li ni ca l ly be nefi ted . W e ar e a tte m pti ng to us e tec hni ques wi th a st r on g ef fec t on th i s s y st em to tr ea t s ome of our mo s t d i ff i cu l t c hro nic c as es tha t ar e c omp l i ca ted by au toi m m un e a nd othe r i nfl am ma tor y c ondi tio ns. St ude nts of ost eopa thi c m edic i ne ar e ty pic all y in s tr uct ed i n t he terr i bl e e ffec ts of the i nf l ue nz a pan dem i c of 19 18 a nd 191 9. I n t his r es pec t, m any st ude nts hav e b een tau ght the ly m ph atic (t hor ac ic ) p ump de v el oped by C. Ear l M i ll er , D O, a gr ad uat e o f th e C hic ago C ol l eg e of Os teo path y w ho pr ac tic ed j ust no r th of Phi l ad el ph i a. He beg an usi ng t his te c hni que an d pr omo tin g it to ot her ost eop athi c p hys i c ia ns i n th e m i d-1 920 s . H owe v er , M i l le r 's te c hni que wa s no t b ein g us ed dur i ng the in fl ue nza ep i dem i c, an d it wa s m os t l ik ely s of t t i ss ue a nd art i c ul ato r y tech niq ues tha t w ere m os t c omm only us ed at t hat ti m e. A few y ea r s ago , Mi l le r 's s on , h i ms el f a d oct or o f m edi c i ne , d i sc us se d w i th us the ma ny c ase s a nd

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te c hn i que s t hat he s aw hi s fa the r u s e a nd tha t he co nti nued to us e in hi s o w n i nte r na l me dic i ne pra c ti c e. He wa s ki nd eno ugh to don ate s om e o f hi s f ath er 's eq uip m ent to th e PC OM arc hi ve s . W ha t wa s m ost in ter es ti ng to us w ere th e po s it i ve eff ect s h e sa i d his fat her ' s tech niq ue had on s o m any va r ie d co ndi ti on s . Som e we r e not c on dit i on s th at hav e be en his tori c al l y taug ht as i ndi c at i on s fo r i ts us e. Th i s ha d a pro fou nd effe c t on us , and we are P.4 14 at tem ptin g t o d ev el op m or e re s ea r ch i n thi s f i eld (e .g. , Pa r ki nso n di s ea s e, m ul tip l e s c le r os i s) . Be l l' s pa l sy w as th e c ondi tio n t hat piq ued our in ter es t m os t w hen c on s id er in g i ts c l in i ca l v al ue . M i ll er ev i de ntly ha d e x tre m el y r apid po s it i v e c li nic al r esp ons es w hen tr eati ng Bel l ' s pal s y w i th th i s tech niq ue. It ch ange d o ur v i ew s o n t he s y mp tom s as s oc i at ed w i th th i s p r oc ess and wh y s ti mu l at i on to the ch es t wa l l and pul m on ar y c av i ty c ou l d r es ul t i n an al mo s t i mm edia te c li ni ca l r esp onse in a s y nd r om e w i th mo s t of i ts s ym ptom s i n t he f aci al c r an i um . W e be l ie v e that th e f l uid - st i mu l ati ng eff ec ts ca n d ec on ges t th e f or am en thr ough wh i ch the fa c ia l ne r ve pa s s es , t hus all evi ati ng t he s ym ptom s . Th e c l i ni c al ef fect s t hat c an be se en w i th ly m pha tic te c hni que s m ay b e s eco ndar y t o t he e l im i na ti on of so m at i c d y sf unc ti on , w her eby r el ate d au ton omi c ch ang es and pot ent i al fac i li tate d s egm ents ar e no r ma l i ze d. T hi s no r ma l iz atio n n ot only ha s e ffec ts on s oma tic an d vi s ce r al r ef l ex es, noc i ce pti on, and va s cu l ar ton e; i t c an als o af fec t t he l y mp hat i c s y st em, w hi c h r ec ei ve s a uto nomi c s tim ul at i on . T he l arg er ly m ph atic ve s se l s m ay eve n ch ang e d i ame ter fo l l ow i ng sy m pat het i c s tim ula tio n (1 ,5) .

Techni que Classi fication Techni ques Removi ng Restri ctions to Lymphatic Flow Re s tr i c ti ons to l ym pha tic flo w t hat are re l at ed t o s pec i fic so m at i c d y sf unc ti on s m ay be r emo v ed by te c hn i que s f r om m an y c ate gori es ( e. g., BLT /LA S; h i gh - vo l ume , l ow- am pl i tu de [H VL A]) . T hi s c an be th oug ht o f a s b r eak i ng th e da m . An ex am ple is a f i rs t r i b d y sf unc ti on . B esi des c au s in g pa i n, li m i te d mo tio n, a nd s o on, a f i rs t ri b d y sf unct i on ha s th e p ote ntia l t o r es tr i ct fl ow t hro ugh the th ora c i c i nl et. Mo bil i z in g t he r i b and re s tor i ng it s no r ma l r ange of mo ti on an d f unct i on ma y re m ov e t he r est r ic ti on to ly m ph atic fl ow. T he r ef ore , an y t ech ni qu e t hat i s i nd i ca ted for fi r s t r ib so m ati c d y sf unct i on (e .g., MF R , mu s cl e en erg y t ec hn i qu e [ M ET] ) a l so has th e p oten tia l t o be a l ym phat i c tec hniq ue. An othe r i m po r tan t pr i nc i ple is to r em ove so m ati c d y sf unct i on s t hat are ca us in g s eco ndar y a uto nomi c e ffe c ts ( e. g., tho r ac i c dy s fu nc ti ons ca us in g h y pe r s ym pat het i c t one wi th c ons equ ent l ym pha ti c c on s tr i c ti on) . So m e othe r c omm on a r ea s o f dy s fu nct i on w it h w hi ch th i s ty pe of te c hni que ca n be he l pf ul a r e su bma ndib ula r r es tr i ct i on s , t hor aci c in l et re s tri c ti on s eco nda r y to m y of asc i al ten s io n, a bdo m in al di aph r agm dy s fu nc ti on, ps oas m us c le dys fun c ti on, and dy s fun c ti ons aff ect i ng the ax i ll a, a nte c ub i tal fo s sa , po pli tea l fo s sa , a nd p l an tar fas c ia .

Techni ques Promoting Lymphatic Fl ow Te c hn i que s p r om otin g l y mp hati c f l ow are ge ner al ly st i mu l ato r y, st r oki ng, or v ib r at ory . Ef fle ura ge a nd pé tri s s ag e a r e c omm on m as s age va r ia ti on s o f t hi s typ e o f te c hn i qu e. T hor aci c pu m p, pe dal pum p, ma ndi bula r d r ai nage , a nd ante r io r c er vi c al ch ai n dra i na ge a r e c la s s ic al exa m ple s o f o s teo pat hic te c hn i que s t hat s ti m ul ate flo w . Th i s m oda l it y h as b een in v olv ed i n di sc uss i on s co nce r ni ng t r ea tme nt o f p ati ents wi th a ma l ig nan c y . So m e beli eve th at i t i s n ot w i se to pro m ot e l y m ph ati c f l ow, wh i le oth ers be l i ev e i t i s in dic ate d be c au s e pr omo ti ng no r ma l fl ow all ow s gre ate r cl ear anc e of ab nor m al c el l s. M or e r ese ar ch is ne eded , b ut w e

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be l ie v e t hat if exe r ci s e c an be pre s c ri bed fo r sp eci fic pat i en ts w i th a m al i gna ncy , t hen l ym pha ti c flo w st i mu l ati on s ho ul d als o b e in dic ate d in th ose pat i en ts.

Techni que Styles Th e v ar io us s ty l es of l ym phat i c tec hniq ue bel ong to the i r o w n c at egor y o f o s teo pat hic m an i pu l at i v e tr eat m ent (O M T) . Su bcl ass i fic ati on i n t his ca tego r y i nc l ude s t ech ni qu es tha t af fec t t he i ntr i ns i c a nd ex tri ns ic ly m ph atic pu m ps .

Intrinsic Lym phatic Pum p Th ese tec hni que s al ter au tono m ic to ne o r t i ss ue t ext ure i n the in ters tit i al s pa c es . I n th e i nte r s ti tiu m , fl uid c an ac c um ul at e a nd ev en tua l ly dis r up t n or ma l l y mp hati c f l ow . Ex amp l es of thi s s ty le in c lu de tr eat m ent of fa c i li tat ed s egm ent s i n th e t hor ac ol umb ar r egi on and i nd i re c t m y of asc i al r el eas e t o th e in ter os se ous me m bra ne.

Extrinsic Lym phatic Flow Th e e x tri nsi c p um p i s r el ated to th e ef fec ts of m usc l e c ont r ac tio n an d m oti on o n t he l y mp hat i c s y st em. Th ere fore , a ny tech niq ue that af fec ts t his me c han i sm is c on s id ere d an ex tri ns ic st y le . Ex amp l es i nc l ud e ab dom i nal di aph r agm or pe l v ic di aph r agm tr eat m ent wi th m y of asc i al r el eas e, M ET, or tr eati ng the so m at i c c omp one nt o f a dy s fun c ti on w i th HV LA ( e.g ., C 3 to C 5 d y sf unct i on af fect i ng th e di aph r ag m ) . Any fo r m of e x er c is e or te c hn i que af fec ti ng mu s cl e ac tiv i ty ( e. g., di r ect pr ess ur e, st r ok i ng, ef fle ur ag e) i s in c lu ded i n thi s st y le .

Indications Ly mp hati c c ong es ti on, po s tsu r gi c al ede m a ( e. g., m as tec tomy ) P.4 15 M i ld to m od era te c ong est i v e hea r t fail ure U ppe r an d l owe r re s pi r at or y i nf ect i ons an d o ther ar eas of i nf ect i on As th m a, c hr oni c ob s tr uct i v e pul m on ar y dis eas e Pain due to ly m pha tic co nges tio n a nd s w el l in g

Contrai ndi cations Ac ut e in dur ate d ly m ph no de ( do not tre at dir ec tl y ) F r ac ture , d i sl oc at i on , o r os teo por os is if te c hni que st y l e w ou l d ex ac erb ate c on dit i on Or ga n fr i ab i li ty a s s een i n s pl een w it h i nfe c tio us m on onuc l eo s is Ac ut e he pat i ti s M ali gnan c y

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General Consi derations and Rul es Ly m ph atic te c hn i que s a r e s i mi l ar in s co pe of pr in c ip l e to t he v is c era l t ech ni qu es. Th e ph y si c ia n mu s t co nsi der the pa ti en t's he al th st atu s al ong wi th t he s pe c i fi c p r es enti ng s ym ptom s b efo r e d eci din g to us e a pa r ti c ula r t ech ni qu e. T he are a m ust be s ta ble , an d t he i nte gum ent m us t b e a bl e to tol er at e t he ty pe of pr ess ur e, wh eth er p r ob i ng or fri c ti onal . F or v i br ato r y or c omp r es s i on te c hn i que s , the pat i en t's mu s cu l osk ele tal s ta tus in r es pec t t o bo ne den s i ty an d m otio n a v ai l abi l it y m us t be r el ativ ely no r m al . I f th e p atie nt has l ym pha tic s eq uel ae of a uto nom i c d i st urb ance , t he appr opr i at e so m at i c c omp one nt m ust be tr eate d w i th w hi c he v er tec hni que the ph y si c i an de ter m i ne s i s i ndic ate d. Th ese tec hni que s , i n a ddi ti on to af fect i ng ly m pha tic ci r c ul ati on, m ay af fec t th e e ndo c r in e, aut oi mm une , an d n euro m us c ul os ke l et al s y st ems , r es ul tin g i n in c re ase d mo tio n, l ess pa i n, and a bet ter ove r al l se nse of we l l -b ein g. T he fol l ow i ng tec hni ques , a s s tate d p r ev i ous l y, ar e no t t he only on es affe c ti ng the ly m ph atic s . Ple as e s ee ot her c ha pte r s f or w ay s to en han c e l y mp hat i c f l ow , r educ e r est r i ct i on , o r no r ma l i ze au ton om ic in ner v ati on. P.4 16

Head and Neck Anteri or Cervical Arches: Hyoid and Cri coi d Rel ease

Indicat ions Lary ngitis Phar yngitis Cough Any dys func tion or lymphatic c ongestion in the ear, nos e, or throat ( ENT ) r egion T ech niq u e 1. The patient lies s upine, and the phy sic ian sits at the head of the table. 2. The phy sic ian stabilizes the patient's head by placing the

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Fig u re 16.1. Steps 1 to 3, setup.

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cephalad hand beneath the head or by gently grasping the for ehead. 3. The thumb and index finger of the phy sic ian's caudad hand form a hor ses hoe shape (inver ted C) over the anterior cer vic al arc hes (F ig. 16.1). 4. The phy sic ian mak es alternating contac t (a r rows , Fig s. 16.2 and 16.3) with the lateral aspects of the hy oid bone, lar yngeal car tilages , and upper tracheal rings, gently pus hing them fr om one side to the other. 5. The phy sic ian continues this alternating pressur e up

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Fig u re 16.2. Step 4, hy oid.

Fig u re 16.3. Step 4, cr icoid.

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and down the length of the anterior nec k. 6. If ther e is crepitus between the anterior car tilaginous str uctures and the cer vic al spine, the nec k may be slightly flexed or extended to eliminate exc ess friction. (Some crepitus is nor mal.) 7. This tec hnique is continued for 30 sec onds to 2 minutes.

P.4 17

Head and Neck Cervical Chai n Drai nage Technique

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Indicat ions T his tec hnique is indicated for any dysfunc tion or ly mphatic c ongestion in the ENT r egion. T ech niq u e 1. The patient lies supine, and the phy sic ian sits at the head of the table. 2. The phy sic ian stabilizes the patient's head by placing the cephalad hand beneath the head to elevate it slightly or by gently grasping the for ehead. 3. The phy sic ian's caudad hand (palmar as pec t of the finger s) mak es broad c ontact ov er the sternoc leidomastoid (SCM) musc le near the angle of the mandible ( arr ow, Fig . 16.4) . 4. From c ephalad to caudad the finger s roll along the mus cle in a milk ing fas hion (arrows, Fig . 16.5) . T he hand then mov es slightly more caudad along the mus cle and repeats the rolling motion. 5. This s ame procedure is applied both anterior to and pos ter ior to the

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F ig ure 16.4. Steps 1 to 3, hand plac ement.

F ig ure 16.5. Step 4, milking motion.

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P.4 18

Head and Neck Mandibular Drainage: Galbreath Technique

Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT or s ubmandibular r egion, especially dysfunc tion in the Eustachian tubes. Care mus t be taken in patients with ac tive temporomandibular joint ( T MJ) dysfunc tion (e.g., painful click) with s evere loss of mobility and/or lock ing.

F ig ure 16.6. Steps 1 to 3, setup and hand placement.

T ech niq u e 1. The patient lies s upine with the head tur ned slightly toward the phy sic ian and the phy sic ian sits at the head of the table. 2. The phy sic ian stabilizes the patient's head by placing the cephalad hand beneath the head to

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F ig ure 16.7. Step 5, c audad pres s ure on mandible.

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3.

4.

5.

6.

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elevate it slightly. The phy sic ian places the caudad hand with the thir d, fourth, and fifth fingertips along the pos ter ior ramus of the mandible and the hypothenar eminenc e along the body of the mandible (F ig. 16.6). The patient opens the mouth slightly. The phy sic ian's caudad hand presses on the mandible so as to draw it slightly for war d (a r rows , F ig. 16.7) at the TMJ and gently toward the midline. This procedure is applied and releas ed in a slow rhy thmic fas hion for 30 sec onds to 2 minutes . It may be repeated on the other

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side.

P.4 19

Head and Neck Auricular Drainage Technique

Indicat ions Any dys func tion or lymphatic c ongestion in the ear region O titis media O titis externa T ech niq u e 1. The patient lies supine with the head turned slightly toward the phy sic ian, and the physician sits at the head of the table. 2. The phy sic ian stabilizes the patient's head by placing the cephalad hand beneath the head to elev ate it slightly. 3. The phy sic ian places the caudad hand flat agains t the s ide of the head, finger s pointing cephalad and the ear between the fourth and third finger s (F ig. 16.8). 4. The phy sic ian's caudad hand

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F ig ure 16.8. Steps 1 to 3, hand plac ement.

F ig ure 16.9. Step 4, c lock wis e.

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mak es c loc kwise and counter clockwise cir cular motions (a r rows , F igs. 16.9 and 16.10), mov ing the sk in and fas cia ov er the sur fac e of the sk ull. There should be no sliding ov er the skin and no friction. 5. This pr ocedur e is applied for 30 sec onds to 2 minutes .

F ig ure 16.10. Step 4, c ounter cloc kwise.

P.4 20

Head and Neck Al ternati ng Nasal P ressure Techni que

Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region, especially the ethmoid sinus. T ech niq u e 1. The patient lies s upine, and the phy sic ian sits at the head of the table. 2. The phy sic ian

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F ig ure 16.11. Step 4, left.

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uses an index finger to pres s on a diagonal (a r rows , Fig s. 16.11 and 16.12) into the junction of the nas al and fr ontal bones, fir st in one dir ection and then the other. 3. This procedure is applied for 30 sec onds to 2 minutes. 4. Alternativ e methods bas ed on per sonal modific ations of hand pos ition are acc eptable (F ig.16.13).

F ig ure 16.12. Step 4, r ight.

F ig ure 16.13. Modification.

P.4 21

Head and Neck Submandibular Release

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Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region, especially those affecting the tongue, salivary glands, lower teeth, and temporomandibular dysfunc tions. T ech niq u e 1. The patient lies s upine, and the phy sic ian sits at the head of the table. 2. The phy sic ian places the index and third fingertips (may include fourth finger s) immediately below the inferior r im of the mandible (F ig. 16.14). 3. The finger s are then dir ected superiorly into the submandibular fas cia to determine whether an eas e-bind asy mmetry is present (a r rows , F ig. 16.15) .

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F igure 16.14. Hand and finger position.

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P.4 22 P.4 23

Head and Neck Tri gem inal S timulation Techni que

Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region affecting or exac erbated by inflammation of c ranial ner ve V ( Fig . 16.18). T ech niq u e 1. The patient lies s upine, and the phy sic ian sits at the head of the table. 2. The phy sic ian palpates along the superior orbital ridge, identifying the supraor bital for amen. 3. The phy sic ian places the pads of the index and middle finger jus t inferior to the or bital ridge and produc es a

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Fig u re 16.19. Steps 2 and 3, s upr aorbital for amen.

Fig u re 16.20. Steps 4 and 5, infr aorbital for amen.

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cir cular motion with the finger s of both hands (a r rows , Fig . 16.19). 4. The phy sic ian palpates along the inferior orbital ridge, identifying the infraor bital for amen. 5. The phy sic ian places the pads of the index and middle finger s just inferior to the infraor bital for amen and produc es a cir cular motion with the finger s of both hands (a r rows , Fig . 16.20). 6. The phy sic ian palpates along the mandible, knowing that the thr ee for amina for m a str aight line, identifying the

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Fig u re 16.21. Steps 6 and 7, mandibular for amen.

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mandibular for amen. 7. The phy sic ian places the pads of the index and middle finger s ov er the mandibular branch of the trigeminal ner ve and produc es a cir cular motion with the finger s of both hands (a r rows , Fig . 16.21). 8. This trigeminal stimulation procedure is applied for 30 sec onds to 2 minutes at eac h of the thr ee loc ations.

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F igu re 16.18. Cranial nerve V distribution ( 6).

P.4 24

Head and Neck Maxill ary Drainage: Effleurage

Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region, especially those affecting the maxillar y s inuses . T ech niq u e 1. The patient lies s upine, and the phy sic ian sits at the head of the table. 2. The phy sic ian places the index finger tip pads ( may inc lude third finger s ) just inferior to the

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F ig ure 16.22. Step 2, finger plac ement.

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3.

4.

5.

6.

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infraor bital for amina (F ig. 16.22). The phy sic ian's finger s begin a s low, gentle str oking (effleurage) over the patient's skin immediately par allel to the lateral as pec t of the nos e until they meet the dental ridge of the gums (a r rows , F ig. 16.23) . The finger s continue laterally in a continuous gentle motion toward the alar as pec t of the zy goma (F ig. 16.24). This is repeated for 30 sec onds to 2 minutes. This may be modified by either ver y gentle skin rolling ov er the ar ea or gently lifting the sk in and its contiguous subcutaneous tis sues and holding at differ ent lev els for 20 to 30

F ig ure 16.23. Step 3, effleur age.

F ig ure 16.24. Step 4, motion toward the z y goma.

F ig ure 16.25. Modification.

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sec onds at eac h level in steps 3 and 4 (F ig. 16.25).

P.4 25

Head and Neck Frontal Temporom andibul ar Drainage: Effleurage

Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region, especially those affecting the frontal thr ough mandibular r egions or in tens ion headache. T ech niq u e 1. The patient lies s upine, and the phy sic ian sits at the head of the table. 2. The phy sic ian places the index finger tips (may inc lude third finger s ) immediately above and

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F ig ure 16.26. Step 2, finger plac ement.

F ig ure 16.27. Step 3, effleur age.

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medial to the eyebrows (F ig. 16.26) . 3. The phy sic ian's finger s begin a slow, gentle, str oking (effleurage) laterally that tak es them immediately par allel to the supraor bital ridge until they meet the ar ea of the pterion (a r rows , Fig . 16.27). 4. The finger s continue inferiorly in a continuous gentle motion toward the TMJ and inferiorly over the mandible (F ig. 16.28) . 5. This is repeated for 30 sec onds to 2 minutes .

F ig ure 16.28. Step 4, motion toward TMJ .

P.4 26

Thoraci c Regi on Thoraci c I nlet and Outlet: Myofascial Rel ease, Direct or I ndi rect, S eated, Steeri ng Wheel

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Techni que Indications Th i s tech niq ue i s i ndi c at ed f or any dys fun c ti on o r l y mp hati c c ong es ti on c au s ed or exa c erb ate d b y fa s ci al to ne as ym m et r y i n t he are a of th e t hora c ic in l et and ou tl et .

Contrai ndi cations Th i s tech niq ue has no abs ol ut e c ont r ain dic ati ons.

Techni que Se e C hapt er 8, M y of asc i al R el eas e T ec hn i qu es, for de tai l s . P.4 27

Thoraci c Regi on Thoraci c I nlet and Outlet: Myofascial Rel ease, Direct, Supine

Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion c aus ed or exac erbated by fasc ial tone asymmetr y in the area of the thor acic inlet and outlet. Cont rain dications T his pr ocedure should not be used if the patient has painful, s everely restr icted motion of the shoulder ( e.g., fibr ous adhesive c aps ulitis, rotator c uff tear ). T ech niq u e

F ig ure 16.29. Steps 1 and 2, setup.

1. The patient lies supine with the arm on the dys func tional side abducted to approx imately 90 degrees . 2. The phy sic ian

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3.

4.

5.

6.

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stands or sits at the side of the dys func tional thorac ic inlet either caudal or cephalad to the abducted upper extremity (F ig. 16.29) . The arm may be suppor ted by the phy sic ian's thigh if needed (F ig. 16.30). The phy sic ian places the index and third finger pads of the cephalad hand over the area of the thorac ic inlet so as to palpate the fas cial tone at the ins ertion of the fir st r ib at the manubr ium and the suprac lavicular fas cia (F ig. 16.31) . The phy sic ian's caudad hand controls the patient's arm. The phy sic ian gently mov es the patient's arm thr ough a ser ies of motions (a r rows , F ig. 16.32) to vec tor a line of tension toward the thorac ic inlet. When s uccessful, the phy sic ian will palpate the tension at that site. The phy sic ian

F ig ure 16.30. Modified suppor tiv e position.

F ig ure 16.31. Palpation of the thoracic inlet.

F ig ure 16.32. Step 5, arm thr ough series of motions.

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waits for a r elease (fascial c reep) and continues until ther e is no fur ther improv ement in the res trictive bar rier . Deep inhalation or other releas e-enhancing mec hanisms can be helpful, as c an a v ibr ator y motion produc ed through the upper extremity with the wrist- c ontrolling hand.

P.4 28

Thoraci c Regi on Mill er Thoraci c (Lym phatic) Pum p

Indicat ions T his tec hnique is indicated for infection, fev er, lymphatic c ongestion, rales , and chr onic productive cough; also pr eventiv e, it may inc r eas e titer s post vac cination ( 7,8,9,10,11). Cont rain dications T his pr ocedure s hould not be used if the patient has frac tur es, osteopor osis, moderate to sever e dyspnea, regional incisions,

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F ig ure 16.33. Steps 1 and 2, setup.

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s ubc lav ian lines, metastatic cancer , and so on. Physiolo gic Go al T he goal is to accentuate negativ e intr athorac ic pres sur e, incr eas e lymphatic r eturn, loos en mucus plugs v ia the v ibr ator y c omponent, and potentially s timulate the autoimmune s ystem. T ech niq u e 1. The patient lies s upine with the head tur ned to one side ( to avoid breathing or coughing into the fac e of the phy sic ian) with the hips and knees flexed and the feet flat on the table. 2. The phy sic ian stands at the head of the table with one foot in fr ont of the other (F ig. 16.33). 3. The phy sic ian places the thenar eminenc es inferior to the patient's clavic les with the finger s

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F ig ure 16.34. Hand pos ition.

F ig ure 16.35. Modified hand position.

F ig ure 16.36. Two c ompr ess ions per minute.

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4.

5.

6.

7.

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spr eading out over the upper r ib cage ( F ig. 16.34) . For female patients, the phy sic ian may place the hands more midline ov er the sternum (F ig. 16.35). The patient is ins truc ted to tak e a deep breath and exhale fully. Dur ing exhalation, the phy sic ian inc reas es the pressur e on the anterior rib cage, exagger ating the ex halation motion. At end exhalation, the phy sic ian imparts a vibratory motion to the rib cage at two compres sions per sec ond (p ulsed arr ows , F ig. 16.36) . Should the patient need to breathe, pressur e is relaxed slightly, but the compres sions

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are continued for sev eral minutes .

P.4 29

Thoraci c Regi on Mill er Thoraci c (Lym phatic) Pum p, Exaggerated Respi ration

Indicat ions T his tec hnique is indicated for infection, fever, lymphatic c ongestion, rales , and c hronic produc tiv e c ough; it is also prev entive. Cont rain dications T his pr ocedure should not be used if the patient has a frac tur e, osteopor osis, moderate to sever e dyspnea, regional incision, s ubc lav ian line, metas tatic c anc er, or a s imilar c ondition. Physiolo gic Go al T he goal is to accentuate negativ e intr athorac ic pres sur e and inc r eas e lymphatic r eturn. T ech niq u e 1. The patient lies supine with the head turned to one side ( to avoid breathing or coughing into the fac e of the

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Fig u re 16.37. Hand position.

Fig u re 16.38. Modified hand position.

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2.

3.

4.

5.

6.

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phy sic ian) with the hips and knees flex ed and the feet flat on the table. The phy sic ian stands at the head of the table with one foot in front of the other. The phy sic ian places the thenar eminenc es inferior to the patient's clavic les with the finger s spr eading out over the upper rib cage ( Fig . 16.37) . For female patients the phy sic ian places the hands mor e midline over the s ter num (F ig. 16.38). The patient is ins truc ted to tak e a deep breath and exhale fully. Dur ing exhalation, the phy sic ian inc reas es the pressur e on anterior r ib cage, exagger ating the exhalation motion (a r row, Fig . 16.39). Dur ing the next inhalation the phy sic ian releas es the

Fig u re 16.39. Pressure with ex halation.

Fig u re 16.40. Releas e pr ess ure on inhalation and reins tate it on ex halation.

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pressur e (u pwar d ar row, Fig . 16.40), then reinstates it (d ownward arr ow) with the nex t ex halation. 7. This v ersion of the thorac ic pump may be repeated for 5 to 10 res pirator y cyc les . This may hyperv entilate the patient, and light- headedness and diz ziness are fairly common.

P.4 30

Thoraci c Regi on Thoraci c (Lymphatic) Pum p, Side Modifi cati on

1. The patient lies s upine, and the phy sic ian stands at the side of the table at the lev el of the patient's rib cage. 2. The patient's arm is abducted 90 degrees or greater , and the phy sic ian

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Fig u re 16.41. Steps 1 to 3, setup and hand plac ement.

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3.

4.

5.

6.

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exerts traction on the ar m with the cephalad hand. The phy sic ian places the caudad hand ov er the lower cos tal car tilages with the finger s following the interc ostal spaces (F ig. 16.41) . The patient is ins truc ted to tak e a deep br eath and ex hale fully. At end of exhalation, a per cus s ive or vibr atory motion (a r row, F ig. 16.42) is exerted by the phy sic ian at two per sec ond. Should the patient feel the need to breathe, pressur e is releas ed jus t enough to per mit eas y

Fig u re 16.42. Step 5, percussive or vibr atory motion.

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res pir ation and the vibratory motion continued. 7. This tec hnique is continued for sev eral minutes . It should be repeated, when pos sible, on the opposite side of the chest.

P.4 31

Thoraci c Regi on Thoraci c (Lymphatic) Pum p, Atel ectasi s Modifi cati on

Indicat ions T his tec hnique is indicated for atelectasis . Cont rain dications T his pr ocedure s hould not be used if the patient has a frac tur e, osteopor osis, s evere c ongestion, incision, s ubc lav ian line, metastatic cancer , or s imilar c ondition. Physiolo gic Go al T he goal is to accentuate the negativ e phase of

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F igure 16.43. Steps 1 to 3, s etup and hand placement.

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r espiration and c lear mucus plugs . T ech niq u e 1. The patient lies s upine with the head tur ned to one side ( to avoid breathing or coughing into the fac e of the phy sic ian) with the hips and knees flexed and feet flat on the table. 2. The phy sic ian stands at the head of the table with one foot in fr ont of the other. 3. The phy sic ian places the thenar eminenc es inferior to the patient's clavic les with the finger s spr eading out over the upper r ib cage ( F ig. 16.43) . For female patients the phy sic ian places the hands more midline ov er the sternum (F ig. 16.44). 4. The patient is ins truc ted to tak e a deep

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F igure 16.44. Modified hand position.

F igure 16.45. Steps 5 and 6, exaggerating ex halation, res tric ting inhalation.

F igure 16.46. Sudden r elease of pressur e.

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breath and exhale fully. 5. Dur ing exhalation, the phy sic ian inc reas es the pressur e on the anterior rib cage, exagger ating the ex halation motion. 6. Dur ing the nex t s ever al inhalations, the phy sic ian maintains heavy pressur e on the chest wall (F ig. 16.45). 7. On the las t ins truc tion to inhale, the phy sic ian suddenly releas es the pressur e, causing the patient to tak e a ver y rapid, deep inhalation, inflating any atelec tatic segments that may be present (F ig. 16.46) .

P.4 32

Thoraci c Regi on P ectoral Traction: P ectoral is Major, Pectoralis Mi nor, and Anterior Deltoi d

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Indicat ions T his tec hnique is indicated for lymphatic c ongestion, upper extr emity edema, mild to moderate dyspnea or wheeze, and/or r eac tiv e airway or asthma; it facilitates the thor acic pump. Cont rain dications T his pr ocedure s hould not be used if the patient has hypersensitivity to touc h at the anterior ax illary fold, s ubclavian line, s ome pacemak ers, metastatic cancer , or s imilar condition. Physiolo gic Go al T he goal is to incr eas e ly mphatic r eturn. T ech niq u e 1. The patient lies s upine with the hips and knees flexed and the feet flat on the table. 2. The phy sic ian sits or stands at the head of the table with one foot in front of the other. 3. The phy sic ian places the finger pads

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F ig ure 16.47. Steps 1 to 3, hand pos ition.

F ig ure 16.48. Steps 4 to 5, forc e towar d c eiling.

F ig ure 16.49. Step 6, deep inhalation.

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P.4 33

Upper E xtremi ty Regi on Anterior Axil l ary Folds: Pectoral i s Maj or and Anteri or Deltoid Muscles

Indicat ions T his tec hnique is indicated for lymphatic c ongestion and upper ex tremity edema. Cont rain dications T his pr ocedure s hould not be used if the patient has hypersensitivity to touc h at the anterior ax illary fold, s ubclavian line, s ome pacemak ers, metastatic cancer , or s imilar condition. Physiolo gic Go al T he goal is to incr eas e ly mphatic r eturn. T ech niq u e 1. The patient lies s upine, and the phy sic ian sits or stands at the side of the patient on the side of the dys func tional upper extremity. 2. The phy sic ian palpates for any inc reas ed tone, edema, and

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F ig ure 16.51. Steps 1 to 3, s etup.

F ig ure 16.52. Step 4, hand and finger placement.

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bogginess of the tis sues (F ig. 16.51). 3. The phy sic ian, finding tissue tex tur e changes , places the index and third fingers on the ventral sur fac e of the anterior axillar y fold and the thumb in the axilla, palpating the anterior por tion fr om within the axilla (F igs. 16.52 and 16.53) . 4. The phy sic ian may ver y slowly and minimally squeez e the anterior axillar y fold with the thumb and finger s . 5. This is held for 30 to 60 sec onds . It may be repeated on the opposite side as needed.

F ig ure 16.53. Step 5, hand and finger placement.

P.4 34 P.4 35

Thoracoabdomi nal Region Dom ing the Di aphragm

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Indicat ions T his tec hnique is indicated for ly mphatic c ongestion dis tal to the diaphr agm and/or r espiration that does not ( myofasc ially) extend fully to the pubic sy mphysis . Cont rain dications T his pr ocedure should not be us ed if the patient has drainage tubes , intr avenous lines , thoracic or abdominal incision, or moder ate to sev ere hiatal hernia or gastroes ophageal r eflux symptoms. Physiolo gic Go al T he goal is to improv e lymphatic and v enous r eturn; it may improv e immune func tion. T ech niq u e 1. The patient lies supine with the hips and knees flex ed and feet flat on the table. 2. The phy sic ian stands to one side at the lev el of the pelvis , facing c ephalad. 3. The phy sic ian places the thumbs or thenar eminenc e just inferior to the patient's lower cos tal mar gin and xiphoid proc ess with the thumbs pointing c ephalad ( F igs. 16.54, 16.55 and 16.56) . 4. The patient is instr ucted to take a deep breath and ex hale. O n exhalation, the phy sic ian's thumbs follow the diaphr agm (a r rows , F ig. 16.57) , whic h permits the thumbs to mov e posteriorly . 5. The patient is instr ucted to inhale, and the phy sic ian gently res ists this motion. 6. The patient is instr ucted to exhale, and the phy sic ian gently follows this motion pos ter iorly and c ephalad ( arrows, F ig . 16.58) , as the thumbs are now beneath the cos tal mar gin and xiphoid proc ess . 7. The patient inhales as the phy sic ian maintains pressur e on the upper abdomen and then, on repeated exhalation, enc our ages further c ephalad ex cur sion. 8. This pr ocedur e is repeated for three to fiv e res pir ator y c ycles.

F ig ure 16.55. Thumb placement.

F ig ure 16.56. Variation of thenar em placement.

F ig ure 16.57. Step 4, following exh

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P.4 36

Thoraci c Regi on Rib Rai sing: Bilateral Upper Thoracic Variati on

Indicat ions T his tec hnique is indicated to facilitate lymphatic drainage, impr ove res pir ator y excursion of the r ibs , and alleviate postoper ative paralytic ileus. Cont rain dications T his pr ocedure s hould not be used if the patient has r ib or v ertebr al frac tur e, s pinal c ord injur y , thor acic surgery, or malignancy in the area to be treated. T ech niq u e 1. The patient lies supine, and the phy sic ian is seated at the head of the table. 2. The phy sic ian slides both hands under the patient's thorac ic r egion. 3. The finger pads of both hands contac t the par aver tebral tis sues ov er the cos totr ans ver se articulation (F ig. 16.59). 4. By leaning down with the elbows, the phy sic ian elevates the

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F igu re 16.59. Steps 1 to 3, setup and hand plac ement.

F igu re 16.60. Step 4, anter ior cephalad lateral for ce.

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finger s into the par aver tebral tis sues (s olid arr ows , F ig. 16.60) and then pulls them (b r oken ar rows) toward the phy sic ian cephalad and lateral. 5. This ex tends the spine and places a lateral str etc h on the par aver tebral tis sues . 6. This technique may be per for med as an intermittent kneading tec hnique or with s ustained deep inhibitory pressur e for 2 to 5 minutes.

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Abdomi nal and Pel vic Region Marian Cl ark Drainage

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Indicat ions T his tec hnique is indicated to impr ove pas siv e v enous and lymphatic drainage fr om the lower abdomen and pelv is; it als o helps to allev iate mens trual c ramps. T ech niq u e 1. The patient is in semipr one pos ition on all fours with the contac t points being the hands, elbows , and knees ( Fig . 16.61) . 2. The phy sic ian stands at the side of the patient fac ing the foot of the table. 3. The phy sic ian hooks the pads of the finger s medial to both anterior superior iliac s pines (F ig. 16.62) . 4. The phy sic ian

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Fig u re 16.61. Step 1, patient pos ition.

Fig u re 16.62. Hand position.

Fig u re 16.63. Step 4, c ephalad dir ection.

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Abdomi nal Region Mesenteri c Release, Small Intesti ne

Indicat ions T his tec hnique is indicated to enhance lymphatic and venous drainage and allev iate c ongestion s econdar y to v isc eral ptosis . Cont rain dications T his pr ocedure should not be us ed if the patient has an abdominal incis ion, acute is chemic bowel dis eas e, obstruc tion, or s imilar condition. T ech niq u e T he mes entery of the small intestine fans out fr om its short root to accommodate the length of the jejunum and ileum (F ig. 16.65), and treatment is focus ed along its length ( Fig . 16.66). 1. The patient lies supine (F ig. 16.67) or in the left later al rec umbent (side- lying) (F ig . 16.68) pos ition. 2. The phy sic ian sits on the patient's right s ide or stands behind the patient. 3. The phy sic ian places the hand or hands at the left border of the mes enteric region of the s mall intestine with the fingers cur led slightly. 4. The finger s gently push (s olid arr ows , F igs. 16.67 and 16.68) toward the patient's back and then towar d the patient's r ight side ( c urv ed arr ows) until meeting the r estr ictive tis sue bar rier . 5. This position is held until the phy sic ian palpates a releas e (20–30 sec onds), and then the phy sic ian follows this mov ement (fascial c reep) to the new bar rier and c ontinues until no

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F ig ure 16.67. Supine position.

F ig ure 16.68. Later al r ecumbent position.

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fur ther improvement is detected.

F igu re 16.65. Abdominal mes entery, small intestine (12).

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F igu re 16.66. Mes enteric vec tor s of s mall intes tine tr eatment (12).

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Abdomi nal Region Mesenteri c Release, Ascending Col on

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Indicat ions T his tec hnique is indicated to enhanc e ly mphatic and v enous drainage and alleviate c ongestion sec ondary to v isc eral ptosis . Cont rain dications T his pr ocedure should not be us ed if the patient has an abdominal incis ion, acute is chemic bowel dis ease, obstruc tion, or s imilar condition. T ech niq u e T reatment is focus ed along the mes enteric as cending c olon attac hment ( Fig s. 16.69 and 16.70). 1. The patient lies supine (F ig. 16.71) or in the right lateral rec umbent (F ig. 16.72) pos ition. 2. The phy sic ian sits on the left side or s tands behind the patient. 3. The phy sic ian places the hand or hands at the right border of the mes enteric region of the asc ending colon with the fingers cur led slightly. 4. The finger s gently push toward the patient's bac k ( s olid arrows, Fig s. 16.71 and 16.72) and then dr aw toward the patient's left s ide (c urv ed arr ows ) until meeting the r estric tiv e tissue bar rier . 5. This position is held until the phys ician palpates a r elease (20–30 sec onds), and then the phy sic ian follows this mov ement ( fas c ial cr eep) to the new barrier and continues until no further improv ement is detec ted.

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F ig ure 16.71. Supine position.

F ig ure 16.72. Later al r ecumben

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Abdomi nal Region Mesenteri c Release, Descending Colon

Indicat ions T his tec hnique is indicated to enhanc e ly mphatic and venous drainage and to alleviate c ongestion s econdar y to v isc eral ptosis . Cont rain dications T his pr ocedure should not be us ed if the patient has abdominal inc isions, ac ute isc hemic bowel disease, obstr uction, or similar c ondition. T ech niq u e T reatment is focus ed along the mes enteric ascending c olon attac hment ( Fig s. 16.73 and 16.74). 1. The patient lies supine (F ig. 16.75) or in the left lateral rec umbent (F ig. 16.76) pos ition. 2. The phy sic ian sits on the r ight s ide or stands behind the patient. 3. The phy sic ian places the hand or hands at the left border of the mes enteric region of the des cending c olon and s igmoid with the finger s curled s lightly . 4. The finger s gently push toward the patient's bac k ( s traight ar rows, Fig s. 16.75 and 16.76) and then draw towar d the patient's right s ide (c urv ed arrows) until meeting the r estr ictive tis sue barrier. 5. This position is held until the phys ician palpates a releas e ( 20–30 s econds ), and then the phys ician follows this movement (fascial c reep) to the new bar rier and continues until no further improv ement is detected.

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F ig ure 16.75. Supine position.

F ig ure 16.76. Later al r ecumbent posi

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F igu re 16.73. Abdominal mes entery, des cending c olon (12).

F igu re 16.74. Mes enteric vec tor s of descending c olon treatment ( 12) .

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Abdomi nal Region Presacral Rel ease, Direct or I ndi rect

Indicat ions T his tec hnique is indicated to enhance lymphatic drainage and relieve venous c ongestion in the lower abdomen, pelvic r egion, and lower extr emities . Cont rain dications T his pr ocedure should not be used if the patient has abdominal

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incision, acute ischemic bowel disease, obstr uction, or s imilar condition. T ech niq u e 1. The patient lies supine, and the phy sic ian stands at either side of the patient. 2. The phy sic ian, with the index and third finger s approx imated and the thumb abducted, mak es a C shape. 3. The phy sic ian places the finger s and thumb downwar d in the lower abdominal region jus t above the ramus of the pubic bone (F ig. 16.77) . 4. The phy sic ian determines whether an eas e-bind asy mmetry is present by applying and vec tor ing for ces in multiple dir ections , inc luding pos ter ior, superior, inferior, clockwise, and counter clockwise (a r rows , F ig. 16.78) . 5. The phy sic ian, on determining the dy s functional asy mmetry,

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F ig ure 16.77. Hand plac ement.

F ig ure 16.78. Step 4, ease-bind determination.

F ig ure 16.79 Step 5, ease- bind determination.

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applies forces in an indirec t or dir ect manner until meeting the eas e or bind bar rier s, res pec tively (F ig. 16.79). 6. This position is held until the phy sic ian palpates a releas e (20–30 sec onds ), and then the phy sic ian follows this movement (fascial c reep) to the new barrier and continues until no further improv ement is detected.

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Pel vic Region Ischiorectal Fossa Rel ease, S upi ne

Indicat ions T his tec hnique is indicated to impr ove motion of the pelv ic diaphragm and lymphatic and venous drainage fr om the pelv ic v isc era and pelv ic floor. T ech niq u e 1. The patient lies supine with the hips and k nees flexed. 2. The phy sic ian sits

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F ig ure 16.80. Physician and patient pos itioning.

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3.

4.

5.

6.

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at the side of the table opposite the side of the dys func tion to be treated. The phy sic ian places the thumb of the hand closes t to the table medial to the isc hial tuber osity (a r row, F igs. 16.80 and 16.81) on the dys func tional side. The phy sic ian exerts gentle pressur e c ephalad (a r row, F ig. 16.81) into the isc hior ectal fos s a until r esistance is met and then applies a lateral for ce ( cur ved arr ow, Fig . 16.82) . The phy sic ian can attempt to feel a fluid ebb and flow with a res ultant releas e or add a releas e-enhancing mec hanism by ins truc ting the patient to inhale and ex hale deeply . With each exhalation, the phy sic ian exerts inc reas ed cephalad pres sur e on the pelvic diaphr agm until no fur ther cephalad and lateral exc urs ion is

F ig ure 16.81. Thumb pos itioning.

F ig ure 16.82. Cephalad lateral force.

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pos sible. 7. This technique is repeated on the opposite s ide of the pelvis as needed.

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Pel vic Region Ischiorectal Fossa Rel ease, P rone

Indicat ions T his tec hnique impr oves motion of the pelv ic diaphragm and v enous and lymphatic drainage fr om the pelv ic v isc era and pelv ic floor. T ech niq u e 1. The patient lies prone, and the phy sic ian stands at the side of the table facing the head of the table. 2. The phy sic ian places the thumbs medial to the isc hial tuber osities on eac h side (F ig . 16.83) . 3. Gentle pressure is exerted cephalad (a r rows , F ig. 16.84) into the isc hior ectal fos s a until r esistance is met, and then a lateral force (a r rows , F ig. 16.85) is applied. 4. The patient is

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F ig ure 16.83. Thumb placement.

F ig ure 16.84. Cephalad for ce.

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ins truc ted to inhale and ex hale deeply . 5. The phy sic ian can attempt to feel a fluid ebb and flow with a res ultant releas e or add a releas e-enhancing mec hanism by ins truc ting the patient to inhale and ex hale deeply . 6. With each exhalation, the phy sic ian exerts inc reas ed cephalad pres sur e on the pelvic diaphr agm until no fur ther cephalad and lateral exc urs ion in a dir ection is pos sible. 7. This technique is repeated on the opposite s ide of the pelvis as needed.

F ig ure 16.85. Later al forc e.

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Lower E xtremi ty REGI ON Pedal P ump (Dalrympl e Techni que), S upi ne

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Indicat ions T his tec hnique is indicated for lymphatic c ongestion, fever , infection, and inability to use the thor acic pump. Cont rain dications T his pr ocedure s hould not be used if the patient has v enous thrombos is; ac ute ankle s prain; Achilles strain, gastroc nemius s train, or other acute pr ocess and/or painful lower ex tremity c onditions. It s hould also be avoided in the acute postoper ative period in s ome abdominal s urgery patients . Physiolo gic Go al T he goal is to accentuate negativ e intr aabdominal pres sur e, incr eas e lymphatic r eturn, and inc r eas e endothelial nitrous oxide, whic h may offer anti-inflammatory benefit (13,14). T ech niq u e 1. The patient lies s upine. 2. The phy sic ian stands at the

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F ig ure 16.86. Steps 1 to 3, s etup, plantarflexion.

F ig ure 16.87. Step 4, plantar flex ion.

F ig ure 16.88. Step 5, s etup, dor s iflexion.

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Lower E xtremi ty Regi on Pedal P ump (Dalrympl e Technique), Prone V ari ati on

Indicat ions T his tec hnique is indicated for lymphatic c ongestion, fever , infection, and inability to use the thor acic pump. Cont rain dications T his pr ocedure s hould not be used if the patient has v enous thrombos is; ac ute ankle s prain; Achilles strain, gastroc nemius s train, or other acute pr ocess; or painful lower extr emity c onditions. It s hould also be avoided in the acute postoper ative period in s ome abdominal s urgery patients . Physiolo gic Go al T he goal is to accentuate negativ e intr aabdominal pres sur e, incr eas e lymphatic r eturn, and inc r eas e endothelial nitrous oxide, whic h may be of anti-inflammatory benefit. T ech niq u e

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F ig ure 16.90. Step 1, phys ician and patient pos itioning.

F ig ure 16.91. Hand and foot positioning.

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P.4 49

Lower1.EThe xtremi patient ty and Pel vic Region Hi p, I ndi rect LAS/BLT, Supine lies pr one

with the feet slightly off the table, and the phy sic ian Indicat ions an d stands Physiolo gic at Gothe al foothnique of theis T his tec tabletowith one indicated enhance foot sdrainage lightly and lymphatic behind the r elieve venous other (inFig . pelvic c ongestion the . r egion16.90) and lower F ig ure 16.92. Step 3, c ephalad pr ess ure. 2.emities The phy extr . sic ian grasps T ech niq u e the patient's feet at the dis tal lies 1. The patient metatarwith sal the hip supine region andflex ed and knee F ig ure 16.93. Steps 1 to 3, initiating hand dir ects a on the side to be placement. for ce treated. (a r rows F ig. 2. The phy,sic ian 16.91) to stands at the side achiev e of the table on the bilater side toalbe tr eated. dor siflexion. 3. The phy sic ian 3. places At the the comfor table cephalad thenar limit of e on the eminenc dor siflexion, patient's greater the phy sic ian trochanter with begins a s the finger rhyected thmic medially dir on- andoff and thumb cephalad contour ing F ig ure 16.94. Step 4, posterosuperior pressur e The laterally. v ec tor ed for c e. (a r rows , force F ig. is initiating 16.92) at one applied to two per anteromedially sec ond.F ig. (a r row, 4. 16.93) This pr. ess ure is dirabducted ected 4. The par alleland to the thumb fir st length of the two finger s in an table andC shape inv erted continued for ian's of the phy sic 1 to 2 hand caudal minutes .

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attempt to contr ol the head of the femur anteriorly . This hand applies a forc e pos ter olaterally (a r row, F ig. 16.94) . 5. The patient's knee on the dys func tional side is controlled by the phy sic ian's anterior pectoral region or axilla and is placed toward the ease bar rier 's balanc e point, determined by mov ing the hip thr ough flexion and ex tens ion, slight abduction and adduction, and internal and external r otation (a r rows , F ig. 16.95) . 6. The phy sic ian uses the s houlder to apply compres sion (a r row, F ig. 16.96) to the patient's knee toward the hip, finding the position of greates t ease with s light hip motions in all thr ee planes. This is the third for c e to be applied. 7. All thr ee for ces are applied simultaneously to find the indirec t pos ition of ease. A releas e-enhancing

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F ig ure 16.95. Step 5, balancing three for ces .

F ig ure 16.96. Step 6, c ompres sion through hip.

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mec hanism may be added by ins truc ting the patient to inhale and ex hale deeply . The releas e is per ceiv ed by an inc reas ed mov ement toward the indirect bar rier .

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Lower E xtremi ty Regi on Popl iteal Fossa Release, Supine

Indicat ions an d Physiolo gic Go al T his tec hnique is indicated to impr ove lymphatic and venous drainage fr om the lower extr emities (k nee, calf, ankle, and foot) and to r elease any fascial r estric tion(s) of the popliteal foss a. T ech niq u e 1. The patient lies supine with legs extended on table. 2. The phy sic ian, fac ing the head of the table, sits at the side to be treated. 3. The phy sic ian's medial hand reaches ar ound to the medial as pec t of the popliteal fos sa as the

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F ig ure 16.97. Steps 1 to 3, s etup and hand placement.

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4.

5.

6.

7.

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lateral hand grasps the later al aspect of the popliteal fos sa (F ig. 16.97). The phy sic ian palpates for any fas cial res tric tions, inc luding cephalad, caudad, medial, and later al (F ig. 16.98). The phy sic ian engages the tis sues with an anterior forc e thr ough the finger tips while engaging any fas cial barriers (e.g., cephalad, caudad, medial, lateral) until res istance is met (F ig. 16.99). The phy sic ian can attempt to feel a fluid ebb and flow with a res ultant releas e or add a releas e-enhancing mec hanism by ins truc ting the patient to inhale and ex hale deeply . Force is dir ected into the bar rier until no fur ther ex cur sion or relaxation of the tis sues is pos sible. This technique is repeated on the opposite s ide as needed.

F ig ure 16.98. Step 4, determining barriers .

F ig ure 16.99. Step 5, direct MFR.

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References 1. W ar d R ( ed .). Fo unda tio ns for Ost eop athi c M edi c i ne , 2 nd ed. Phi l ad el ph i a: Li ppin c ot t W i l li ams & W i lk i ns , 20 03.

2. Sti l l AT . Phi l os ophy of Os teop ath y . Ki rk s vi l le , MO : A . T . St i ll , 1 809: 108 .

3. Gal bre ath W O. Ac ute Oti tis M ed i a, In c l ud i ng it s Po s tu r al and Ma nip ul at i ve Tr eatm ent . J Am Ost eop ath Ass oc. Ja n 19 29.

4. Pra tt- H arr i ng ton D . Gal bre ath tec hni que: a m an i pul ati v e tr ea tme nt for oti tis m ed i a r ev i s it ed. J Am Ost eop ath Ass oc. 200 0;1 00: 635– 639 .

5. C hi k ly B. Sil ent W av es: Th eory an d P r act i ce of Lym ph D ra i nag e T her apy. An Os teop ath i c Lym pha tic T ec h-n i qu e, 2 nd ed. Sco tts dal e AZ : I H H, 200 4.

6. R ep r in ted w it h p er mi s si on fr om Ag ur AM R, Da l le y AF . G r an t' s Atl as of A nat omy , 11 th ed. Bal tim ore : Li ppi nco tt W i ll i am s an d W i lk i ns, 20 05.

7. Kno t E M , T une JD , St oll ST , Do w ne y H F . I ncr eas ed L y mp hat i c F l ow in the Th ora c i c D uc t D ur i ng Ma ni pu - la tiv e In ter v en ti on . J Am Ost eop ath Ass oc 200 5;10 5: 593 –596 .

8. J ac k so n KM , S tee l e T G, D ug an E P, Kuk ul ka G, Bl ue W , R obe r ts A. Eff ec t of Lym phat i c and Spl eni c P um p T ec hni ques on th e An tib ody R es pon s e to H epa tit i s B Va c ci ne: A P i lo t St udy . J Am Ost eop ath Ass oc 199 8;98 :15 5–1 60.

9. Ste ele T , J ac k so n K, Du gan E. T he Ef fect of Os teop ath i c M ani pul ati v e T r ea tme nt o n t he Anti bod y R es pon s e to H epa tit i s B Va c ci ne. J A m O s teo pat h A s s oc 19 96; 96(9 ) .

10. Br eit haup t T , H ar ri s K , E l l is J. , P ur ce l l E, W eir J, Cl othi er M , Boes l er D. T ho r ac i c Ly mp hat i c Pum pin g a nd t he Eff i c ac y o f I nflu enz a V ac ci nat i on i n H ea l th y Yo ung an d El der l y Popu l at i on s . J Am Ost eop ath Ass oc 200 1;10 1(1 ) .

11. Me s in a J, Ha m pt on D , E v an s R, Zi egl er T , M i ke s k a C , T ho m as K, F er r ett i J . T r ans i en t Bas oph i li a Fo l lo w in g th e A ppl i c at i on s o f Ly m ph ati c Pu m p T ec hniq ues : A Pil ot Stu dy . J A m Ost eop ath Ass oc 199 8;98 ( 2) .

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12. Mo dif i ed w it h p er mi s si on fr om Ag ur AM R, Da l le y AF . G r an t' s Atl as of A nat omy , 11 th ed. Bal tim ore : Li ppi nco tt W i ll i am s an d W i lk i ns, 20 05.

13. Ku c he r a M , D agh i gh F . D et er mi nat i on of Enh anc ed N i tr i c Ox id e P r od uc ti on U si ng E x te r na l M ec han i ca l St i mu l i. J A m O s te opat h A s so c 20 04; 104 :344 ( ab s tr ac t) .

14. Ku c he r a M . O s te opat hic Ma ni pu l at i ve M ed i ci ne C ons i de r at i ons in Pa ti en ts w it h Ch r on i c Pain . J Am Ost eop ath Ass oc 2005 ;10 5(s uppl 4) .

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17 Articulatory and Combined Techniques Technique P rincipl es T his ch apt er d esc r ib es a r ti c ul ator y a nd c omb i ne d t ec hn i qu es. T he s e tec hniq ues ar e di s cu s se d in th e s ame ch apt er b eca use w e bel i ev e th ey ten d to ha v e m any si m il ar it i es , u s i ng pr i nc i ple s f r om oth er tech niq ues , es pec i al l y s oft ti s s ue , l y mp hati c , m us c l e ene r gy , an d h i gh - v el oci ty, l ow - am pli tude (H VLA ) . T he Edu c at i on C ou nci l on Os teo path i c Pri nc ip l es (E C OP) de fin es t he art i c ul ato r y tr ea tme nt ( ART ) m oda l it y a s “a lo w v el oc i ty /mo dera te- to- hi gh am pli tude te c hn i que wh ere a j oin t i s ca r ri ed thro ugh it s fu l l m oti on w it h th e t her apeu tic go al o f i ncr ease d f r ee dom r an ge of m ove m en t. T he act i v at i ng fo r c e i s eit her a sp r in gin g mo tio n o r re pet i ti v e c onc ent r i c m ov eme nt o f t he j oin t t hro ugh the re s tri c ti v e barr i er .”( 1) A t the Phi l ad el ph i a C ol l ege of Os teop ath i c M edi c in e ( PC OM ) , w e have re fer r ed to i t s i mp l y as s pri ngi ng tech niq ue. It has si m i la r it i es to bot h s oft tis s ue and HV LA i n t hat it c an af fec t th e m y of as ci al c om pone nts and art i cu l ar c om pon ents , r esp ec ti v el y . H owe v er , t he m ode r at e to hi gh am pl i tu de desc r ib ed i n t he defi nit i on doe s n ot m ean mo v in g th r ou gh the r es tri c tiv e b arr i er at hig h am pli tud e. T he r el atio nsh i p betw een th e pa tho l og i c , phy s io l ogi c , and ana tom i c barr i er s s houl d r ema i n c ons i st ent w it h t he p r in c ip l es of H VLA : m otio n t hro ugh the re s tri c ti v e barr i er sh ould st i ll be m od era ted and ke pt t o a mi ni mu m . T he am pl i tu de i s t he dis tanc e a v ai l abl e w i th i n t he dys func tio nal pre s en tat i on' s r ang e. C omb i ne d m etho d ( tec hniq ue) is def i ne d b y EC OP as “ 1. T re atm ent s tr ate gy w her e t he i nit i al m ove m en ts ar e i nd i re c t; as the tec hni que i s c om ple ted, th e m ov em ent s c hang e t o d i r ec t f orc es . 2. A m ani pul ati v e s equ enc e in v ol v in g tw o o r m or e ost eop athi c m ani pula tiv e t r eat m en t s y s te m s ( e. g., Spe nce r tech niq ue c omb i ne d w i th m us c le ene r gy te c hni que ) . 3. A co nce pt d esc r ib ed b y P aul Kim ber l y, D O” (1 ) . Ki mb erl y u s ed thi s t er m r el ati v e t o t he s eco nda r y defi nit i on i n r el ati ng t he c om bi na tio n o f va r io us forc es, i ncl udi ng di re c t, in di re c t, in here nt, gr av it ati ona l , p hys i ci an d i re c te d, r esp i ra tory as s is t, a nd oth er s i n tr ea tme nt. ( 2) T he r ef or e, th e t ec hn i qu es i n t his ch apte r c oul d we l l hav e be en c la s s if i ed in oth er c ha pter s base d o n t he p r im ary foc us of each te c hn i que . AR T, al tho ugh pri m ar i l y aff ect i ng the my ofas c ia l a nd a r ti c ul ar c omp one nts of the dys fun c ti on, als o s i gn i fi c an tl y aff ect s th e c i rc ul at ory an d ly m ph ati c sy s te m s. T he s e s ty l es of tec hniq ue hav e be en par t of the r ec omm enda tio ns for the os teop ath i c tr ea tme nt of t he ger i atr i c pat i ent fo r m any y ea r s and are r ela tiv ely s af e a nd w ell to l er ated .

Technique Cl assifi cati on Di rect, Indi rect, or Combined D epe ndi ng on t he ART or c om bin atio n o f m etho ds, th es e tec hni ques al l c an b e d i re c t, i nd i re c t, or bot h; henc e t he defi nit i on . Ar tic ula tory wa s c l ass i ca l ly def i ne d a s a dir ect tec hni que , bu t d epe ndin g o n t he phys i ci an' s pr efe r en c e, the ea s e a nd bin d ba r ri ers m ay bo th be m et w it h a gen tle s pr i ng i ng m ot i on .

Technique S tyles Rhythmic

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T he phy s ic i an m ay ch oose a r hy thmi c a r ti c ula tor y t r eat m en t t o ch ang e t he s oft ti s s ue s o r t o re l ea s e an ar ti c ul ar r est r ic tio n. T he c ad ence of th e st r et c h and r el eas e in th i s tech niq ue has bee n d es cr i be d b y N. S. N i ch ola s , D O, as “ m ak e a nd br ea k ,” re l ati ng to the on- off pre s su r e appl i ed . T hi s m ay be s lo w o r m ode r at e a nd m ay bec om e osc i ll ator y . P. 454

Mi xed T he phy s ic i an m ay ch oose an y v ar ia tio n o f rh y th m s, amp l it ude , or ac c el er at i on (v el oc i ty ) d epen din g o n the pat i en t' s pre s en tati on. Th er ef ore , t he p ati ent m ay be tr eate d w i th a v ari ety of c om bin ed t ech niq ues.

I ndicati ons 1. R est r i ct ed m ot i on i n the pre s en c e of a r ti c ul ar a nd/ or m y of asc i al s om ati c d y s fu nct i on ( es pec i al l y i n t he f r ai l o r el der l y) 2. C i rc ul at ory an d ly m ph ati c co nge s ti on

Contraindications 1. Ac ut e mo der ate to s ev ere s tr ain or s pr ain 2. F r ac ture , d i sl oc at i on , o r jo i nt in s tab i li ty i n t he are a af fec ted by the tr eatm ent 3. Ac ut e in fla m ma tory jo i nt dis eas e i n th e a r ea aff ect ed by t he tre atme nt 4. M eta s tas i s i n the are a a ffec ted by the tr eat m ent

General Considerations and Rules T he per for m anc e o f t hese te c hn i que s c an v ary wi th the phy s ic i an' s i m pr es si on of the s ev eri ty o f t he dy sf unc tio n an d a ny c omp l ic ati ng f act ors . Th e t ech ni qu es r an ge f r om ex tr em ely ge ntle , w i th m in i ma l am pl i tu de, to for c ef ul t r ac tio n. T he r hy thmi c a s pe c ts m ay al s o v ary fr om s l ow to fas t. In gene r al , c omp r es s iv e fo r ce s s houl d b e l i m it ed i n thos e w i th ost eop oro s i s, an k yl os is , a nd s o o n. T he s e t ech niq ues have a w id e ra nge of app l ic ati on f or i nc r eas i ng mo ti on an d d ec re asi ng edem a. P. 455

Upper Extrem ity Region Shoul der Girdle: S pencer Technique I ndicati ons Adhe s i ve ca psu l i ti s Burs i tis T eno s y no v it i s Ar th r i ti s

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General Considerations N i ch ola s S . Ni c ho l as , DO , F AAO , pr omo ted thi s t ech ni qu e m ore tha n a ny othe r . Bes i des pu bli s hin g o ne of t he ear l y a r ti c le s ex tol l in g it s v i rt ue, he s pe nt y ear s l ec tu r in g a nd p r es ent i ng i t to m any or gan i z at i on s , es pe c ia l ly i n ath l et i c m edi c in e. O v er hi s ma ny y ea r s i n s por ts m edi c in e an d a s a c on s ul tan t to te ams , es pe c ia l ly as a p hys i c ia n f or the Vil l an ov a U ni v er s i ty fo otb al l tea m f r om the 19 40s to 196 0, h e h ad m any s ucc ess ful out c om es w i th th i s tr ea tme nt w hen ot her tre atm ent s ha d f ail ed. T hi s t r eat m en t p r oto c ol , w hen us ed in co nj un c ti on w i th ot her ost eop ath i c m ani pul ativ e t ech ni qu es to tr ea t t he c erv i ca l , thor aci c , and c ost al r eg i ons , g i ve s th e p ati ent an exc el le nt c ha nc e of r ec ov er y . T hi s te c hn i qu e wa s , for all i te r at i on purp ose s , taug ht as the “ se v en s ta ges of Spe nce r ” ev en th oug h th ere ar e ei ght st ages . A t P C OM, we have ta ugh t th i s tec hniq ue as havi ng s ta ges 5A and 5B to acc om mo dat e t he e i gh t s tage s i nto s ev en. T he pat i en t li es i n the l at era l re c um ben t po s it i on w it h t he s hou l de r t o be tr eat ed a w ay fr om t he tab l e. T he pati ent ' s back is pe r pen dic ula r to th e t able , w i th the lo w er k ne e a nd hi p fle x ed to pre v en t an y f orw ar d r oll . A pi l l ow is pl ac ed un der the pa tie nt's he ad to r emo v e any dra g o n th e s hou l der fr om the c er v ic al a nd s hou l de r g i r dl e m usc ul at ure . P. 456

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 1S houl der Extension wi th E lbow Flexed

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1. T he phys ician s tands facing the patient. 2. T he phys ician's c ephalad hand br idges the s houlder to loc k out any ac romioc lav icular and s c apulothor acic motion. The fingers are on the s pine of the s c apula, the thumb on the anter ior sur fac e of the c lav icle. 3. T he phys ician's c audad hand gr asps the patient's elbow. 4. T he patient's s houlder is moved into ex tension in the horiz ontal plane to the edge of the r estr ictive barrier. 5. A slow, gentle s pringing ( articulator y, make and br eak) motion ( arr ows, F ig. 17.1) is applied at the end r ange of motion. 6. Muscle ener gy ac tiv ation: The patient is instr ucted to attempt to flex the s houlder ( blac k ar row, F ig. 17.2) against the physician's

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F igu re 17.1. Stage 1, steps 1 to 5.

F igu re 17.2. Stage 1, step 6.

F igu re 17.3. Stage 1, step 7.

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P. 457

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 2S houl der Fl exi on with El bow Extended

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1. T he phys ician's hands rever s e s houlder and ar m c ontact pos itions. T he c audad hand r eaches over and behind the patient and bridges the s houlder to loc k out ac romioc lav icular and s c apulothor acic motion. The fingers are on the anter ior sur fac e of the c lav icle, the heel of the hand on the spine of the s capula. 2. Us ing the other hand, the physician takes the patient's s houlder into its flexion motion in the horizontal plane to the edge of its r estr ictive barrier. 3. A slow, spr inging ( articulator y, make and br eak) motion ( arr ows, F ig. 17.5) is applied at the end r ange of motion. 4. Muscle ener gy ac tiv ation: The patient is instr ucted to ex tend the s houlder (black ar row, F ig. 17.6) against the physician's r esis tance ( white ar row). This

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F igu re 17.5. Stage 2, steps 1 to 3.

F igu re 17.6. Stage 2, step 4.

F igu re 17.7. Stage 2, step 5.

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P. 458

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 3Circumducti on with Sl ight Compressi on and El bow Fl exed

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1. T he original starting pos ition is resumed with the c ephalad hand. 2. T he patient's s houlder is abduc ted to the edge of the r estr ictive bar rier (F ig. 17.9) . 3. T he patient's arm is moved through full c lock wis e c ircumduction ( small diameter ) with slight c ompr ess ion. Larger and larger c onc entr ic c irc les ar e made, increasing the r ange of motion (F ig. 17.10). 4. Circumduction may be tuned to a particular bar rier . T he s ame maneuv er is r epeated counterclockwise ( F ig. 17.11) . 5. T here is no specific musc le energy activ ation for this s tep; howev er, dur ing fine- tuning of the c ircumduction, it may be feasible to implement it in a portion of the res tric ted ar c . 6. T his is repeated for approximately 15 to 30 s econds in each dir ection, and c irc umduction is r eass ess ed.

Fig u re 17.9. Stage 3, s teps 1 to 2.

Fig u re 17.10. Stage 3, s tep 3.

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P. 459

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 4Circumducti on and Tracti on with El bow Extended

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1. T he patient's s houlder is abduc ted to the edge of the r estr ictive bar rier with the elbow ex tended. 2. T he phys ician's caudad hand grasps the patient's wr ist and ex erts v ertical tr action. T he phys ician's c ephalad hand brac es the s houlder as in stage 1 (F ig. 17.12). 3. T he patient's arm is moved through full c lock wis e c ircumduction with s y nchronous traction. Larger and larger c oncentr ic c irc les are made, increasing the r ange of motion ( F ig. 17.13) . 4. T he s ame maneuv er is r epeated c ounterclock wise ( F ig. 17.14) . 5. T here is no specific musc le energy activ ation for this s tep; howev er, dur ing fine- tuning of the c ircumduction, it may be feasible to implement it in a portion of the res tric ted ar c. 6. T his is repeated for approximately 15 to 30 s econds in each dir ection, and c irc umduction is r eass ess ed.

F igure 17.12. Stage 4, steps 1 to 2.

F igure 17.13. Stage 4, step 3.

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P. 460

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 5A—Abduction wi th E lbow Fl exed

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1. T he patient's s houlder is abduc ted to the edge of the r estric tive barrier. 2. T he physician's c ephalad ar m is positioned parallel to the s urface of the table. 3. T he patient is instr ucted to gr asp the physician's forearm with the hand of the arm being tr eated (F ig . 17.15). 4. T he patient's elbow is moved towar d the head, abduc ting the s houlder , until a motion barrier is engaged. Slight inter nal r otation may be added. 5. A slow, gentle ( articulator y, make and br eak ) motion ( arrows, F ig . 17.16) is applied at the end r ange of motion. 6. Muscle energy ac tiv ation: T he patient is

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F igu re 17.15. Stage 5A, steps 1 to 3.

F igu re 17.16. Stage 5A, steps 4 to 5.

F igu re 17.17. Stage 5A, step 6.

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P. 461

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 5BAdducti on and External Rotation wi th Elbow Flexed

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1. T he patient's ar m is flex ed s ufficiently to allow the elbow to pas s in fr ont of the c hest wall. 2. T he physician's forearm is s till parallel to the table with the patient's wr ist resting against the forearm. 3. T he patient's s houlder is adduc ted to the edge of the r estric tive barrier (F ig . 17.20). 4. A slow, gentle ( articulator y, make and br eak ) motion ( arrow, Fig . 17.21) is applied at the end r ange of motion. 5. Muscle energy ac tiv ation: T he patient lifts the elbow ( blac k ar row, F ig. 17.22) against the physician's r esis tance ( white ar row). T his c ontr action is held for 3 to 5 s econds. 6. After a

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F igu re 17.20. Stage 5B, steps 1 to 3.

F igu re 17.21. Stage 5B, step 4.

F igu re 17.22. Stage 5B, step 5.

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P. 462

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 6—Internal Rotation wi th Arm Abducted, Hand Behind Back

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1. T he patient's s houlder is abduc ted 45 degrees and inter nally r otated approximately 90 degrees. T he dors um of the patient's hand is placed in the s mall of the back . 2. T he physician's c ephalad hand r einforc es the anter ior portion of the patient's s houlder . 3. T he patient's elbow is ver y gently pulled forward ( internal r otation) to the edge of the r estric tive barrier (F ig . 17.25). Do not push the elbow backward, as this can dislocate an unstable s houlder . 4. A slow, gentle ( articulator y, make and br eak ) motion ( arrows, F ig . 17.26) is applied at the end r ange of

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F igu re 17.25. Stage 6, s teps 1 to 3.

F igu re 17.26. Stage 6, s tep 4.

F igu re 17.27. Stage 6, s tep 5.

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P. 463

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 7Distraction, S tretchi ng Tissues, and E nhanci ng Flui d Drainage wi th Arm Extended

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1. T he phys ician turns and faces the head of the table. 2. T he patient's s houlder is abduc ted, and the patient's hand and forearm ar e plac ed on the physician's s houlder c losest to the patient. 3. With finger s inter lac ed, the physician's hands ar e positioned just dis tal to the acromion pr ocess (F ig . 17.30). 4. T he patient's s houlder is s c ooped infer ior ly ( arrow, Fig . 17.31) c r eating a tr ans latory motion ac ros s the infer ior edge of the glenoid fossa. T his is done r epeatedly in an ar tic ulator y fashion. 5. Alter natively, the arm may be pushed

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F igu re 17.30. Stage 7, s teps 1 to 3.

F igu re 17.31. Stage 7, s tep 4.

F igu re 17.32. Stage 7, s tep 5.

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P. 464

Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tage 1Hip Flexion

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1. T he patient lies s upine, and the physician s tands at the s ide of the table next to the dy sfunctional hip. 2. T he phys ician flexes the patient's k nee and c arr ies the hip to the flexion- res tric tiv e barrier (F ig 17.34). 3. A slow, gentle ar tic ulator y ( make and br eak ) motion ( arrows, F ig . 17.35) is applied at the end r ange of motion. 4. Muscle ener gy ac tiv ation: The patient pus hes ( hip extens ion) the k nee into the physician's r esis tance ( arrows, F ig . 17.36). This c ontr action is held for 3 to 5 s econds. 5. After a sec ond of r elax ation, the hip is c arr ied farther into the new r estric tive barrier (F ig . 17.37). 6. Steps 4 and 5 ar e r epeated three to fiv e times , and flex ion is reass ess ed. 7. Resis tance against

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F igu re 17.34. Stage 1, s teps 1 and 2.

F igu re 17.35. Stage 1, s tep 3.

F igu re 17.36. Stage 1, s tep 4.

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P. 465

Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tage 2Hip E xtensi on

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1. T he patient's leg is moved off the s ide of the table and is allowed to desc end towar d the floor until it meets its ex tension-r estr ictive barrier (F ig . 17.39). 2. A slow, gentle ar tic ulator y (make and break) motion ( arrows, F ig . 17.40) is applied at the end r ange of motion. 3. Muscle ener gy ac tiv ation: The patient is instruc ted to pull the knee ( hip flexion) (black ar row, F ig. 17.41) into the phy sic ian's r esis tance ( white ar row). This c ontr action is held for 3 to 5 s econds . 4. After a sec ond of r elax ation, the hip is c arried far ther into the new res tric tiv e barrier (F ig . 17.42). 5. Steps 3 and 4 are r epeated thr ee to five times, and ex tension is r eass ess ed. 6. Resis tance against attempted hip ex tension ( r eciprocal inhibition) has been found to be helpful in augmenting the effec t ( Fig . 17.43).

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F igu re 17.39. Stage 2, s tep 1.

F igu re 17.40. Stage 2, s tep 2.

F igu re 17.41. Stage 2, s tep 3.

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P. 466

Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tages 3 and 4Circumducti on

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1. T he phys ician flexes the patient's hip ( with k nee flexed) towar d the flex ion barrier and adds s light c ompr ess ion ( arrow, Fig . 17.44). 2. T he phys ician c ircumducts ( arrows, F ig . 17.45) the patient's hip through small and then enlarging c ircles (clockwise and c ounterc loc k wis e) for appr oximately 30 seconds while maintaining c ompr ess ion. 3. T he phys ician ex tends the patient's k nee and gr asps the foot and ankle, adding moder ate tr action ( arrow, Fig . 17.46). 4. Continuing to hold tr action, the physician c ircumducts the patient's hip through small and then inc reas ingly large circles ( arrows, F ig . 17.47) both c lock wis e and c ounterc loc k wis e for appr oximately 15 to 30 sec onds.

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F igu re 17.44. Stages 3 and 4, s tep 1.

F igu re 17.45. Stages 3 and 4, s tep 2.

F igu re 17.46. Stages 3 and 4, s tep 3.

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P. 467

Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tages 5 and 6I nternal and E xternal Rotati on

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1. T he phys ician flexes the patient's hip and k nee and inter nally r otates the hip to its barrier. 2. A slow, gentle ( articulator y, make and br eak ) motion ( arrows, F ig . 17.48) is applied at the end r ange of motion. 3. Muscle energy ac tiv ation: T he patient is instr ucted to push the k nee ( external r otation) ( blac k ar row, F ig. 17.49) into the physician's r esis tance ( white ar row). T his c ontr action is held for 3 to 5 s econds. After a s econd of r elax ation, the hip is c arried to the new r estr ictive barrier. 4. Step 3 is r epeated three to fiv e times , and

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F igu re 17.48. Stage 5, s teps 1 and 2.

F igu re 17.49. Stage 5, s tep 3.

F igu re 17.50. Stage 6, s tep 5.

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P. 468

Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tages 7 and 8—Abducti on and Adduction

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1. T he patient lies supine on the treatment table, and the physician gently takes the patient's s traightened leg and abduc ts it to its r estric tive barrier. 2. A slow, gentle ar tic ulator y ( make and br eak ) motion ( arrows, F ig . 17.52) is applied at the end r ange of motion. 3. Muscle energy ac tiv ation: T he patient is instr ucted to pull (b lack ar row, F ig. 17.53) the k nee (hip adduc tion) into the physician's r esis tance ( white ar row). T his c ontr action is held for 3 to 5 s econds. After a s econd of r elax ation, the hip is c arried to the new r estr ictive barrier. 4. Step 3 is

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F igu re 17.52. Stage 7, s teps 1 and 2.

F igu re 17.53. Stage 7, s tep 3.

F igu re 17.54. Stage 8, s tep 5.

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P. 469

Upper Extrem ity Region El bow: Radioulnar Dysfunction, Long Axi s, P ronati on Dysfunction (Loss of Supination), Muscl e E nergy, HVLA

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T he long-ax is dysfunc tions r elate to a rotational movement along the length of the radius without anterior and posterior displac ement. They are different dysfunc tions from the sees aw motions desc ribed in the anteroposterior dysfunc tions, in whic h the r adial head and styloid proc ess mov e in opposing direc tions. 1. T he patient is s eated on the table, and the physician s tands in fr ont of the patient. 2. T he phys ician holds the patient's dy sfunctional ar m as if s haking hands and plac es the thumb of the oppos ite hand anter ior to the r adial head. 3. T he phys ician then rotates the hand into s upination until the r estric tive barrier is engaged (F ig . 17.56). 4. T he patient is instr ucted to attempt to pr onate the

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F igu re 17.56. Steps 1 to 3.

F igu re 17.57. Step 4.

F igu re 17.58. Steps 7 to 9.

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P. 470

Upper Extrem ity Region El bow: Radioulnar Dysfunction, Long Axi s, S upi nation Dysfuncti on (Loss of Pronation), Muscl e E nergy, HVLA

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1. T he patient is s eated on the table, and the physician s tands in fr ont of the patient. 2. T he phys ician holds the patient's dy sfunctional ar m as if s haking hands and plac es the thumb of the oppos ite hand posterior to the r adial head giving s upport. 3. T he phys ician r otates the forearm into pr onation ( arrow, Fig . 17.59) until the r estr ictive barrier is r eached. 4. T he patient is instr ucted to attempt to s upinate the wr ist (blac k ar row, F ig. 17.60) while the phys ician applies an unyielding c ounterforc e ( white ar row). 5. After a sec ond of relax ation, the patient's forearm is taken into further pr onation. 6. Steps 4 and 5 ar e r epeated

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F igu re 17.59. Steps 1 to 3.

F igu re 17.60. Step 4.

F igu re 17.61. Steps 7 to 9.

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P. 471

P elvi c Regi on Right Anterior Innomi nate Dysfunction: HV LA wi th Respiratory Assi stance, Leg-Pull Technique

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1. T he patient lies supine, and the physician s tands at the foot of the table. 2. T he phys ician gr asps the patient's r ight ankle and r aises the patient's r ight leg to 45 degrees or more and applies tr action on the s haft of the leg (w hite ar row, F ig. 17.62). 3. T his traction is maintained, and the patient is as ked to tak e three to fiv e s low, deep br eaths. At the end of each ex halation, tr action is increased. 4. At the end of the last br eath, the physician deliv ers an impulse thrus t in the direc tion of the trac tion ( arrow, Fig . 17.63). 5. T he phys ician r eass ess es

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F igu re 17.62. Steps 1 and 2.

F igu re 17.63. Steps 3 to 4.

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P. 472

Cervi cal Region C2 to C7, Articulatory, Type 2 Moti on

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1. T he patient lies supine, and the physician s its at head of table. 2. T he physician palpates the ar tic ular pr ocesses of the s egment to be ev aluated with the pad of the s econd or third finger. 3. A tr ans lational motion is introduc ed fr om left to r ight (left side bending) and then right to left (right side bending) through the ar tic ular pr ocesses ( F igs. 17.64 an d 17.65). 4. At the limit of each tr ans lational motion, a r otational s pringing may be applied in the direc tion fr om which the tr ans lation emanated ( e.g., s ide bending left, r otation left)

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F igure 17.64. Steps 1 to 3, translation to r ight.

F igure 17.65. Steps 1 to 3, translation to left.

F igure 17.66. Step 4.

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P. 473

Thoracic Region T1 to T4, Articulatory, S i de Bending

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1. T he patient is s eated, and the phys ician either s tands behind or s its next to the patient. 2. T he phys ician places the thenar eminence of the posterior hand on the pr oximal paras pinal thoracic tissues in the dy sfunctional ar ea. 3. T he physician's other hand r eaches in fr ont of the patient and c ups the side of the patient's head ( F ig. 17.67) . 4. As the physician adds a gentle s ide- bending motion of the head toward the physician's s ide, the thoracic hand applies a s pringing force perpendicular to the length of the v ertebral c olumn ( Fig . 17.68).

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F igu re 17.67. Steps 1 to 3.

F igu re 17.68. Step 4.

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P. 474

References 1. W ard R ( ed .) . F ou nda ti on s f or Os te opa thi c Me dic i ne . Ph i la del phia : L i pp i nco tt W il l i am s & W il k i ns , 2 003 .

2. Ki mb erl y P , Fu nk S ( eds. ) . Out l i ne of Os teop ath i c M ani pul ati v e P r oc edu r es: Th e K i m be r ly M an ual M il l en ni um Ed i ti on. M ar c el i ne, MO : W al sw ort h, 2000 .

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18 Osteopathy in the Cranial Field Technique P rincipl es O s t e o pa t hy in t he cr a ni a l f i el d ( O CF) as de f i ne d b y t h e E d uc a ti o n al Co u nc i l o n O s t e o pa t hi c P r i nc i pl e s ( E CO P ) i s a “s y s t e m o f d i ag n os i s a n d t re a t me n t b y a n o s t e o pa t hi c p r a c t i ti o ne r us i ng th e pr i ma r y r e sp i ra t or y me c ha n is m an d b a la n c ed mem b r an o us te n s io n f i rs t de s cr i be d by Wi l li a m G a rn e r S u th e rl a nd , DO , a n d i s t h e t it l e o f t h e r ef e re n c e wor k b y Ha r ol d M a g ou n , S r. ” ( 1) . S u th e r la n d, a s t ud e nt of A . T. S ti l l , b eg a n a li f el o n g s tu d y o f t h e c ra n i um an d i t s a n at o my a nd bi o me c h an i c s as t he y r el a t ed to he a l th an d d i s ea s e. Hi s in t er e s t i n t he cr a n iu m b e ga n af t er he v ie wed a d is a r ti c ul a te d s k u ll wh e n s t ud y in g in Ki r k s v i ll e , MO ( A me r ic a n S c ho o l o f O s te o pa t hy ) . A lt h o ug h S u th e r la n d i s t h e n am e m o s t o f t e n a s so c ia t ed wit h t h is f or m o f t e c hn i qu e , man y ot h er s t o o k u p h is wor k a n d c o nt i nu e d t h e s tu d y , r es e ar c h, a nd te a ch i n g ( 2, 3 ). E CO P ha s d e fi n e d t he pr i mar y r e sp i r at o ry me c h an i sm as “ a mod e l p r op o se d b y Wi l li a m G ar n e r S ut h er l a nd , D O t o de s cr i be t he in t er d e pe n de n t f u nc t io n s a mon g f i ve b od y c om p o ne n t s as f ol l ow s ” ( 1 ): 1. The i nh e re n t mo ti l it y o f th e b r ai n an d s p in a l c o rd 2. Flu c t ua t io n o f th e c e re b r os p in a l f l ui d 3. Mob i l it y o f t h e i n tr a cr a n ia l a n d i n tr a sp i na l me mbr a ne s 4. A rt i c ul a r mob i l it y o f t h e c r an i al b on e s 5. The i nv o lu n ta r y m o bi l it y of th e s a c ru m b e tw e e n t he il i a ( p el v ic b on e s) O CF h as al s o b e en ca l le d cr a ni a l o s te o pa t hy ( CO ) ( 1 ), c ra n io s ac r a l t ec h ni q u e ( 4) , a n d s im p l y c ra n ia l te c hn i qu e . I t i s i mp or t an t t h a t O CF be u se d w i th t he af o re me nt i on e d p ri n c ip l es . O t h er os t eo p a th i c t ec h n iq u es ca n be us e d o n t h e c ra n i um bu t a r e u s ed wi t h t he i r s p ec i fi c pr i nc i pl e s f o r t re a t me n t e f f e c t o n s om a t ic dy s fu n c ti o n. Fo r ex a mp l e, c ou n t er s tr a in , so f t t is s u e, my o fa s c ia l r e le a s e, an d l y mph a ti c t e c hn i qu e s c a n a ll be u se d in th i s r e gi o n b ut a re no t c l a s s i fi e d a s O CF, CO , or cr a ni o s ac r al te c h ni q ue . Man y ph y si c ia n s w e re re l u c t a nt to b el i ev e t h a t t he cr a n ia l b o ne s we r e c ap a b le of mov e men t o r t h a t t he ph y s ic i an co u l d p al p at e mo v em e nt . A n um b er o f s tu d ie s ha v e s ho wn e v id e nc e of su c h mo ti o n a nd s ug g es t t h a t t he cr a n ia l s u tu r e s may no t c om p l et e ly os s i f y (1 ) . A si mpl e e x a mp l e t o i l lu s tr a te t ha t t h e s u tu r es al l o w c ra n ia l bo n e mob i l it y i s t o ha v e o ne s tu d en t f i x a pa r tn e r 's fr o nt o z yg o ma t ic s ut u re s b i l at e ra l ly . Th i s i s d o ne by pl a c in g o n e t h um b o v er o ne fr o nt o z yg o ma t ic s ut u re an d th e p a d o f t h e i nd e x f i ng e r o f t h e s am e ha n d o n t h e o pp o si t e f r on t oz y g om a ti c s u t ur e . The n th e s tu d e nt ge n tl y ro c k s th e z y g om a ti c po r ti o n f r om si d e t o s i de wh i l e t he ot h e r h an d i s c ra d l in g t h e h e ad . A n a u d ib l e a rt i c ul a r c li c k m a y o c c u r . The op e r at o r, th e pa t ie n t , o r

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b ot h ma y f e el t hi s m o ti o n . We h av e no t s e en a ny ad v er s e e f fe c t s f ro m t h is man e uv e r a nd t he r ef o re h av e c o nf i d en c e i n a po s it i ve e du c at i on a l o u t c o me . The r ea s on pa t i en t s r ea c t p o si t iv e l y t o O CF i s n ot co mp le t el y u n d er s to o d, a nd th e u nd e r ly i ng ca u s e a nd ef f e c t ma y b e a c om b in a t io n o f t h e s t at e d p r in c ip l es . So me o th e r r ea s o ns ma y i n c lu d e r ef l e x p he n om e n a f ro m c o n ne c ti v e t i s s u e mec h a no r ec e pt o r s a nd / o r n oc i ce p t or s o r m i c ro s co p ic a nd ma c ro s c op i c f lu i d e x ch a ng e ei t he r p e r ip h er a ll y ( Tr a u be - He r in g - Ma y er os c i ll a ti o ns ) (5 ) o r i n th e c e nt r a l n er v ou s s y s te m. S u th e rl a nd , a f t e r p a lp a ti n g m a ny pa t i en t s , fe l t s p ec i fi c t y p es of mot i on s , a n d h e c ou l d n o t a c c o u nt f or t he s e mot i o ns ba s ed o n mus c le a c t i vi t y u p on re v ie wi ng cr a ni a l a n at o my . Th e re f or e , h e b e ga n p o s t u l at i ng an i nh e re n t i n vo l un t ar y me c ha n is m an d e v en t u al l y c am e to th e t er m pr i ma r y r e sp i ra t or y me c ha n is m (6 ) . P ri ma ry re s pi r a to r y mec h a ni s m i s f u rt h er de f i ne d t h us : P. 4 76 P ri ma ry re f er s to in t er n a l t is s ue r es p ir a to r y p r oc e s s . Res p i ra t or y r e f er s t o t h e p r oc e s s o f i nt e rn a l r e sp i ra t i on (i . e. , th e e x ch a n ge of r es p i ra t or y g a s es be t we e n t i s s u e c e ll s a n d t h ei r i n te r n al en v ir o n me n t , co n s is t in g o f t h e f lu i ds b at h in g t h e c e ll s ). Mec h a ni s m r ef e r s t o t he i nt e rd e pe n d en t m o ve me nt of ti s s ue an d f l u id wi t h a s pe c i fi c p u rp o s e. I t i s b e li e ve d th a t a s p e ci f ic pa t t er n o f m o t io n e x is t s a n d i s r e ad i ly ap p a re n t a nd p al p a bl e i n e a c h p er s on . Th i s mot i o n p at t er n is de t er mi ne d b y a v ar i et y o f fa c to r s b u t i s t h ou g ht to b e r el a te d to th e b e v el i ng of t he su t ur e s a n d t he a t t a ch men t s o f t h e d ur a . T h er e fo r e , t o d ia g n os e a n d t r ea t u s in g OC F, t he p hy s ic i an mus t k n ow c ra n ia l a na t o my (e . g. , at th e p t e ri o n t he b on e s o ve r l ap as fo l l ow s : f ro n t al , p a ri e t al , s p he n o id , a nd t em p or a l, i n a lp h ab e t ic a l o rd e r f r om in n e r t o o ut e r t a bl e ). The i nt e rn a l d u ra l r e fl e c ti o ns of t he fa l x c e re b ri , t h e f a lx ce r e be l li , a n d t h e t en t o ri u m c er e b el l i a re c ol l ec t iv e l y k no wn a s t h e r ec i p ro c al te n s io n m e mb r a ne . D i s t o r ti o n i n t h e p os i t io n o r m o t io n o f a n y c r an i al b on e m a y b e t r an s mi t t ed to th e ba s e a nd v au l t t hr o u gh th i s r e ci p ro c al t en s io n m e mbr a ne . T h e re f or e , r e s t r ic t io n of cr a ni a l b o ne mo t i on wit h di s to r ti o n o f i t s s y mm e tr i c mo ti o n p at t e rn is te r med cr a ni a l s o ma t ic d y s f un c ti o n . The b ip h as i c f l uc t ua t io n of mo t io n th a t i s p a lp a te d i n th e c r an i a l b on e s h a s b ee n r ef e r re d t o a s th e c r an i a l r hy t hm i c i mpu l se ( CR I ). Th e em p ha s is i n O CF is p la c ed on t he s yn c hr o no u s m o ve men t of th e c r a ni u m wit h th e s a cr u m ( c ra n io s a cr a l mec h a ni s m) . The mot i on be t wee n t h e c r an i um an d sa c ru m i s be l ie v ed t o b e a s s o c ia t ed wi t h t h e a t t a c hm e nt s o f th e d u ra l tu b e a t t h e f or a me n ma g nu m a n d t h e s ec o n d s ac r al s eg men t a t t h e r es p ir a t or y a x is . Th i s i s s o me t im e s c a ll e d t he c or e l i nk . I t fo l lo ws a rh y th mi c c ad e n ce at 8 t o 1 4 c y cl e s p e r min u t e ( 1, 4 ). Thi s i mpu l s e may be p al p at e d a n yw h er e i n t he b od y , a nd i t i s u se d no t o n ly i n o s t e op a t hy in th e cr a ni a l f i el d b u t a l so in ba l a nc e d l ig a men t ou s t e n si o n, or l ig a me n to u s a r ti c ul a r s t ra i n ( B LT / LA S ) t e ch n iq u es . I t s r a te a nd a mp l i tu d e may v ar y i n c e r ta i n d is e a se pr o ce s s es (e . g. , fe v er ) .

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Cra n i al no men c l at u re is g en e ra l ly r ef e re n ce d to mo t io n oc c ur r in g at th e s p h en o ba s il a r s ym p h y s i s , or s yn c ho n dr o s is (S B S) . I t is sl i g ht l y c on v e x o n t he s up e ri o r s i de , a n d t h is c on v e xi t y i s i n cr e as e d d u ri n g f le x i on . T h is c an al s o b e t h ou g ht o f a s t he i nf e ri o r p or t i on of th e SB S c r ea t i ng an an g l e s o t ha t th i s i nf e r io r -s i de d an g le be c o me s s mal l e r o r mo re ac u te wit h f l ex i o n o f t he S BS . I n s p he n ob a si l a r f le x io n , t h e b as i o c c i pu t a n d b a si s ph e n oi d m o ve c ep h al a d wh il e t h e o c c i p it a l s qu a ma a nd th e wi n gs of t he sp h en o i d mov e m o r e c au d al l y . The s e f l ex i on an d e x t e n si o n mot i o ns ar e r o t at i on a l a b ou t t r an s v er s e a xe s : o n e a t t h e l ev e l o f t h e f or a men ma g nu m an d t h e o t he r t h ro u g h t he bo d y o f t h e s p he n oi d ( 6 ) . A ll mi d l in e u np a i re d c r an i a l b on e s a r e d es c ri b e d a s mov i n g i n f le x i on an d e x t en s io n .

Flexi on and Extension of the Sphenobasilar S ynchondrosi s Dur i n g f le x io n of th e c r a ni a l b as e (F i g. 18 . 1 ), th e p e t ro u s p or t i on s o f t h e t e mp o ra l b on e s m o ve ce p h al a d wit h th e S B S. Thi s p r od u c es a f la r i ng ou t wa r d o f t h e t e mp o ra l s qu a ma c al l ed e x t e rn a l r o ta t io n o f th e t e mp o r al bo n es . Al l p a ir e d b o ne s m o v e i nt o e x t e r na l r o ta t i on s y n ch r o no u s wit h sp h en o ba s i la r f l ex i o n. In t er n a l r ot a ti o n o f t h e p a ir e d b on e s i s s y nc h r on o us wi t h s p he n ob a s il a r e x t e n si o n. Th e r ef o re , i t ca n b e s a i d t ha t i n f le x i on , t h e s k ul l s h or t e ns in th e an t er o po s t er i or di a met e r a nd wid e ns la t e ra l ly . I n e x t e n si o n ( Fi g . 1 8 .2 ) , t h e s ku l l l e ng t he n s i n t h e a nt e r op o s t e ri o r d i am e te r an d n a rr o ws l at e r al l y . B ec a u se of th e li n k b et we en th e c r a ni u m a nd t he sa c ru m, t h e s ac r u m wil l m o v e wit h t he c ra n iu m. I n S B S f le x i on , t h e s a cr a l b as e mo v es po s t er o su p er i o rl y ( 1 ), a nd in SB S e x t e n si o n, th e sa c ru m m o v es an t er o i nf e ri o rl y . T h is mo r e r e ce n t c r an i os a cr a l mec h a ni s m t er mi no l og y h a s c a us e d s o me co n fu s i on be c au s e o f i t s d i f f e re n ce f ro m t h e p re v i ou s ly us e d n o me n cl a t ur e f o r P. 4 77 g ro s s s a cr a l mo ti o n. In g ro s s s ac r a l b io mec h a ni c s , a s a cr a l b as e an t er i or mov e me n t was d es c ri b ed a s f le x io n of th e s a c ru m. How e v er , f l ex i o n i n c ra n i os a cr a l me ch a ni s m t er mi no l og y i s de f in e d a s t h e s ac r a l b as e m o v in g p o s t e r io r ly . S o me h av e d e c id e d t o d es c r ib e s a cr a l b a se mo v e me n t s as n od d in g m o t io n s . Th u s , f or war d mo v em e nt o f t he s ac r a l b as e i s ca l le d n u t at i on , a n d b a c k war d mo v em e nt o f t he sa c r al ba s e i s c a ll e d c ou n t er n ut a ti o n . No mat t e r whi c h t e rm s o n e c h oo s es (f l e xi o n a nd e x t e ns i on o r n ut a ti o n a nd c ou n te r nu t a ti o n) , t h e s a cr a l b a se go e s f o rw a rd in g ro s s f le x i on an d i n cr a ni o sa c r al e x t e n si o n. Th e sa c ra l b a s e mov e s b a c k war d i n gr o s s ex t e ns i on an d cr a ni o sa c r al f le x i on .

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Figure 18 .1. Fle xio n of th e sp hen oba sil a r synchon d rosis. O, occipi tal axi s o f ro tation ; S, sp hen oid a l a xis of rotati on.

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Figure 18 .2. Extensi on of the sph eno basi lar synch o ndrosi s. O, occipi tal axi s o f ro tation ; S, sp hen oid a l a xis of rotati on.

Crani osacral Mechanism Dy s f u nc t io n al p at t er n s o f c r an i al mot i on ha v e b e en de s c ri b ed as e it h er ph y s io l og i c o r n ot . Ex a mp l es o f p hy s io l o gi c d y s f u n c t i on s i n c lu d e t or s i on , s i de b en d in g a n d r o ta t io n , a nd f ix e d ( fl e x io n a n d e x te n si o n) . Co mpr e s s i o n, ve r ti c a l s tr a in s (s h ea r ), a nd la t er a l s tr a i ns ar e e x a mp l es of n on p hy s io l o gi c d y s f u n c t i on s . Th ey ma y b e se c on d ar y to he a d t ra u ma, bi r th t ra u ma , d e n ta l p r oc e d ur e s , in f e ri o r mus c u lo s ke l et a l s t re s s a n d d y s f u nc t io n , a n d p os t ur a l a b no r ma l i ti e s . Tor s i on in v ol v e s r ot a ti o n o f t h e S B S a ro u nd a n a nt e ro p o s t e ri o r a x is . T h e s p he n oi d a n d o c c i p ut ro t at e in op p os i t e d ir e c t i o ns . P a lp a t io n o f a r ig h t t or s i on fe e ls a s i f t he g re a te r win g of th e s p h en o id on t he ri g ht e le v at e s a n d r ot a te s to th e l e f t whi l e t h e o c c i pi t a l s qu a ma o n t he r ig h t d ro p s i n to th e ha n ds an d ro t at e s t o t h e r ig h t ( Fig . 1 8 . 3) . S id e be n di n g/ r o ta t io n i s si d e b en d i ng an d r o t at i on th a t o c cu r s i mul t an e ou s l y a t t he S BS . Si d e b en d i ng oc c ur s by ro t at i o n a ro u nd t wo ve r ti c a l a xe s , o n e t hr o ug h th e c e nt e r o f t h e b od y o f th e s p he n o id an d o n e a t t h e f o ra men ma g n um . T h e s p he n oi d a n d t h e o c c i p ut ro t at e in op p os i t e d ir e c t i o ns ab o ut t he s e a xe s . T h e r ot a t io n c o mp o n en t o f t h e d y s f u nc t io n o c c ur s a r ou n d a n a n te r o po s te r io r ax i s , bu t th e s p he n o id an d t h e o c ci p ut r ot a t e i n s am e di r ec t io n . R o ta t io n oc c ur s t o war d t h e s i de of co n v ex i t y (t h e i n fe r io r s id e ) . Whi l e p a lp a ti n g a le f t s id e be n di n g r o ta t io n , o n e n ot e s t h at th e l e f t h an d f e e ls a

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f ul l n es s a s c o mpa r ed to t he ri g ht h an d ( s id e be n di n g) a nd on e a l s o f ee l s t h at th e l e f t h an d is be i ng d ra wn c au d a ll y b o th a t t he sp h e no i d a nd o c c i pu t ( r o ta t io n ) ( Fig . 1 8 .4 ) . S BS c om p re s si o n e i th e r f e el s r o c k h ar d , l ik e a b ow l in g ba l l ( vo i d o f a n y mo ti o n) , o r th e p hy s i ci a n b eg i n s t o f ee l al l o f t h e d y s f u nc t i on a l s tr a i n p at t er n s t o ge t he r (F i g. 18 . 5 ). S up e r io r /i n fe r i or ve r ti c a l s tr a in s in v ol v e e i th e r f le x i on at th e sp h en o id a nd ex t en s i on at t he o c c i pu t ( s u pe r io r ) o r e x te n si o n a t t h e s p he n oi d a n d f l ex i on a t t he oc c i pu t ( i nf e r io r ). The d y s f un c ti o n i s n a me d by th e p o s it i on of t he ba s is p h en o id . D u r in g p a lp a t io n , a s up e r io r v e rt i c al sh e ar f ee l s a s i f t h e g re a t er wi n gs o f t he sp h e no i d a re d ra wn t oo f ar c au d a ll y . I n a n i n fe r io r ve r ti c al s he a r, th e sp h en o id mov e s min i mal l y c au d a d ( Fi g . 1 8. 6 ) .

Figure 18 .3. Rig ht SBS torsio n .

L at e r al s t r ai n in v ol v es r ot a ti o n a r ou n d t wo v er t ic a l a x es , b u t t h e r ot a ti o n o c cu r s i n t h e s am e di r ec t io n . T h is ca u s es a l at e r al sh e ar i n g f or c e a t t h e S BS . Th e d y s f u n c t i on is n am e d f o r t he p os i ti o n o f t h e b as i s ph e no i d. Dur i ng pa l p at i on , t h e l a te r al s tr a in s f e e l a s i f t h e h an d s a r e o n a p a r al l el o gr a m ( Fig . 1 8 . 7) .

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Technique Classifi cation Direct Technique I n d i re c t c ra n i al os t eo p a th y , t he d y s f un c ti o n i s m o ve d to war d t h e r e s t r ic t i ve ba r ri e r ( bi n d , t en s io n ) . The ph y s ic i an sh o u ld ge n tl y ap p ro a ch t he ba r ri e r a n d mai n t ai n a li g h t f or c e u n ti l a r el e as e o c c ur s . I f t h e d y s f un c t io n a p pe a r s t o b e mo s t l y a rt i c ul a r, a d i re c t t ec h n iq u e i s a p pr o pr i at e . T h is te c h ni q ue is c om mon l y u s ed on in f a nt s a n d c h il d re n b ef o r e f ul l d e v el o pm e nt o f t he cr a n ia l s u tu r e s a nd in v er y s p ec i f ic dy s fu n c ti o ns in a du l t s ( 4) .

I ndi rect Techni que I n i n di r ec t c r a ni a l o s t e o pa t hy , t h e d y s f u nc t i on is mo v e d a wa y f r o m t he re s t ri c ti v e b ar r i er or to wa rd th e e a s e ( fr e ed o m, l oo s e) . Th e p h y s i c ia n a t te mp t s to mo v e t h e d y s f u nc t io n i n th e d i re c t io n o f f r e ed o m u nt i l a ba l an c e o f t e ns i o n o c c u rs ( ba l an c ed mem b r an o us te n s io n ) ( 4, 6 ) b e tw e en t he ea s e a n d b in d . Th e CRI is mon i to r ed , an d t h e i nh e r en t f o rc e s e v en t ua l l y c au s e a sl i gh t i n c re a se P. 4 78 t ow a r d t he ea s e a n d t he n mo v em e nt b ac k t o t h e o r ig i na l ba l an c e p o si t io n , wh ic h i s a s ig n of th e r e l ea s e. Th i s t e ch n iq u e i s m o s t a pp r op r ia t e i f t h e k e y d y s f un c t io n i s s ec o n da r y t o a me mbr a no u s r e s t r ic t i on (4 ) .

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Figure 18 .4. Left SBS side be n din g/rota tion .

E xaggeration E xa g g er a ti o n me th o d i s p e rf o rm e d wi th th e p h y si c ia n m o v in g t h e d y s f u nc t io n to war d t he e as e , s im i l ar to in d i re c t , bu t wh e n mee t i ng th e e a s e b ar r ie r an ac t iv a t in g f o rc e is a dd e d .

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Figure 18 .5. SBS co mpre ssi on.

Disengagement I n d i se n ga g em e n t , th e p h y si c ia n a t t em p t s to o pe n o r s e p ar a te th e ar t ic u la t i on . Dep e n di n g o n h o w t he ar t i cu l at i on i s f el t t o be re s tr i c te d , t ra c t io n o r a c om p re s si v e f or c e m a y b e a d de d .

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Figure 18 .6. SBS in feri or vertica l stra i n. O, occi pital axi s of rotati on; S, sph eno i dal axis o f rota tio n .

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Figure 18 .7. SBS la tera l stra i n.

Technique S tyl es I nherent Force Use o f t he bo d y 's in h er e n t f or c e t h ro u gh th e pr i ma r y r e sp i ra t or y me c ha n is m is th e maj o r m e th o d o f O CF. Us i n g t he fl u c tu a ti o n o f t h e c er e b ro s pi n al f lu i d, th e ph y si c ia n c an a lt e r t he p re s su r e i n o n e a re a or an o th e r a n d c au s e t h is fl u i d t o c ha n g e t he v ar i o us ba r ri e r s . Th i s i s m o s t ev i d en t i n t h e V - sp r ea d te c hn i qu e (4 ) .

Respi ratory Assistance A s i n o t he r t e c hn i qu e s , t he us e o f pu l mo n ar y re s pi r at i o n c an fa c i li t at e o s t eo p at h ic t ec h n iq u e. Th i s r e le a se - e nh a nc i ng mec h an i sm wil l i n cr e a se mo v em e n t s as s oc i a te d w i th i nh a l at i on an d ex h al a ti o n . For ex a mpl e , i t i s b e li e ve d th a t d ur i n g i nh a la t i on , t h e S B S t en d s t o m o ve t ow a rd fl e x io n , wit h th e p a ir e d b o ne s m o v in g m o re t ow a rd ex t e rn a l r ot a t io n . I n e x ha l at i on , th e u n pa i r ed bo n es mov e p r ef e r en t ia l ly t ow a rd ex t e ns i on an d

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t he p ai r ed bo n e s i nt o i n t er n al ro t a ti o n. Th e ph y si c ia n ca n h a ve t he pa t ie n t b r ea t he i n t he d ir e c t i on p re f er r ed f or it s r e l at e d c ra n i al ef f ec t an d t e ll t he pa t ie n t t o h o ld t he b re a t h a t f ul l in h al a ti o n o r e x ha l a ti o n. Th i s w i ll en h a nc e a re l e as e .

Distal Acti vati on I n c e rt a in co n d it i on s , t h e p hy s ic i a n may pr e f er to tr e a t t he pa t i en t 's pr o b le m f r om t he s ac r a l r eg i on o r e x t r em i t ie s . B y a p pl y in g t e n si o n o n t h e s ac r um , th e p h y s i c ia n c a n g ui d e t h e mec h a ni s m f ro m be l ow an d ef f ec t t h e m o ve men t of th e S B S . I n a dd i t io n , t he p hy s i ci a n may h av e t h e p a ti e nt ac t i ve l y a t t e mpt pl a nt a r fl e xi o n o r d o rs i fl e x io n t o g a i n a p ar t i cu l ar ef f e c t on th e SB S . Dor s i fl e xi o n e n ha n ce s S B S f l ex i on , wh i le pl a n ta r fl e xi o n e nh a n ce s e x te n s io n ( 4 ).

S til l Point I n t h is me t ho d , t h e p hy s i ci a n a t t e mpt s t o r e s is t t h e p r im a ry re s p ir a to r y me ch a ni s m t ha t is be i ng mon i to r ed t hr o ug h t h e C RI . Th i s i s m o s t c om mon l y c a ll e d c om p r es s io n o f t he f ou r th ve n t ri c le (C V 4 ). Su c ce s s o f t h e CV 4 t ec h ni q u e r el i es o n i nh e re n t f o rc e s . I n t hi s te c hn i qu e , t h e p hy s i ci a n mon i t or s s e ve r a l c y c l es o f CRI an d th e n p er mi t s e xh a l at i on mo t i on at th e bo n e b ei n g p a lp a te d (u s ua l ly t he oc c ip i t al sq u am a ) . The n t h e p hy s i ci a n g en t l y r es i s t s fl e xi o n u n ti l a ce s s at i on of t he ce r eb r a l s pi n al f lu i d f lu c t ua t io n i s p a lp a te d . Th is is ca l l ed a s ti l l p o in t . Th is po s it i o n i s h el d fo r 1 5 s e c on d s t o a fe w min u t es , u n ti l th e p h y s i c ia n a p pr e c ia t es a r e tu r n o f t h e CRI . T h i s c an be a pp l ie d t o th e s ac r u m whe n c o n ta c ti n g t h e h ea d i s co n tr a in d i ca t ed (e . g . , ac u te h ea d t r au ma ) ( 4, 6 ).

I ndi cati ons 1. Hea d a ch e s 2. Mil d to se v er e wh i pl a sh s tr a in an d sp r ai n i n j ur i es 3. V er t i go an d t i n ni t us 4. O ti t i s med i a wi th ef f us i o n a nd se r o us ot i ti s me d ia 5. Tem p o ro man d ib u l ar jo i nt d y s f un c ti o n 6. S in u s it i s

Contraindicati ons 1. A cu t e i n tr a cr a n ia l b l ee d i ng an d h e mor r ha g e 2. I nc r e as e d i nt r a cr a ni a l p r es s ur e 3. A cu t e s k ul l f r a c t u re 4. Cer t a in se i zu r e s t at e s ( r el a ti v e)

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General Considerations and Rules O CF may he l p a nu mbe r o f co n di t io n s . I t s ad v e rs e r e ac t i on s a r e f e w, bu t t h e p h y s i ci a n s ho u l d b e o n a l er t , a s h e ad a ch e , v e rt i go , t i n ni t us , n a u se a , a nd v om i ti n g c a n o c c u r, a s c an s om e a u to n o mi c r e la t e d P. 4 80 e f f e c t s (e . g. , br a dy c ar d i a) . T h es e ar e m o s t l y s e en wh e n s t ud e nt s ar e f i rs t le a rn i ng t he t ec h n iq u e a nd d o n ot re a l iz e t h e p r es s ur e b e i ng im p ar t e d i nt o t h e ir pa t ie n t 's cr a ni u m. Thi s is co mmo n , w i th im p r op e r h ol d i ng te c hn i q ue (l o ca t i on an d i n c or r ec t p r e s s u re ) s e e n a t t i me s a t t h e o c ci p it o mas t oi d s u t ur e . Hea d a ch e s , na u s ea , a n d v o mi t in g , wh il e n o t c om mo n, ar e s e e n o c c a si o n al l y . The r e fo r e, th e ph y si c ia n mu s t t ak e ca r e t o c o nt a c t th e pa t ie n t p r op e rl y a n d a p pl y e no u g h b ut no t to o m u ch p re s su r e f o r t he ap p r op r ia t e a mou n t o f t i me . T h e p h y s i ci a n s ho u l d a ls o m a k e s ur e t h a t t he pr i mar y r e sp i r at o ry me c h an i sm is p re s en t w h e n d ec i d in g t o e n d t h e t re a t me n t . A v a r ia t io n o f th i s t ec h n iq u e i s u s in g a mu l t ip l e- h an d ap p ro a ch . Wh i le on e op e ra t or i s p al p a ti n g t he c ra n iu m, a n ot h er ca n be on th e sa c ru m o r an o th e r a r ea of th e pa t ie n t' s b od y . T h is ca n po t en t ia t e t h e e f f e c t o f a t r e at men t . P. 4 81

Crani al Vault Hold

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Objective s The ob jective is to assess the prima ry resp ira tory mechan ism as it man i fests itself in the crani u m a nd the deg ree of participa tion of each b one in the ge n era l motion of the crani u m. Tec hnique 1. The pa tie n t l ies sup ine , a n d the physician is sea ted at the he ad o f the tab l e. 2. The ph ysi cian establ ish e s a fu lcru m by restin g bo th forearms o n the tab l e. 3. The ph ysi cian 's han d s cra dle th e pa tie nt's hea d, maki ng ful l pal mar co n tact o n b o th sid es. 4. The ph ysi cian 's ind e x fin gers re st on the gre ate r w i ngs of th e patien t's sph eno id (A, Fig. 1 8.8 ). 5. The ph ysi cian 's mid d le fin gers re st on the zyg oma tic pro cesses of the pa tien t's temporal b one s (B, Fig. 1 8.8 ). 6. The ph ysi cian 's rin g fin gers re st on the mastoi d p roce sse s o f the pa tie n t's te mpo ral bon es (C , Fig. 1 8.8 ). 7. The ph ysi cian 's little fin gers re st on the

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Figur e 1 8.8 . L a teral vie w of skull with d ots for fi ng (7).

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P. 4 82

Fronto-occi pital Hold

Objective s The ob jective s a re to assess th e prima ry respirato ry mech ani sm a s i t man ife sts itself in the cra niu m; to a sse ss the fre edo m o f mo tio n o f th e cra nia l b a se, especi all y a t the SBS; a nd to asse ss the fro nta l b o ne as it rela tes to the re st o f the CRI. Tec hnique 1. The pa tie n t l ies sup ine , a n d the physician is sea ted at the si de o f the hea d of the ta ble . 2. The ph ysi cian pl ace s the ca uda d ha nd und er the patien t's occipi tal squ ama wi th the fo rea rm resting on the ta ble establ ish i ng a fulcrum. 3. The ph ysi cian 's cep hal ad h and bridg e s across th e pa tie nt's fro nta l b o ne, wi th the elb ow resting on th e tab le esta bli shi ng a ful cru m. 4. The th umb and mi ddl e fin ger of the physician 's ceph ala d han d rest on the gre ate r w i ngs of th e patien t's sph eno id (if

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Figure 18.11. Ste ps 1 to 5.

Figure 18.12. Ste ps 1 to 5.

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5.

6.

7.

8.

9.

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the ha nd spre ad is too sho rt, ap p roxima te the gre ate r w i ngs). The ph ysi cian ma kes ful l p alma r contact with both h and s (Figs . 18.11, 18 .12 and 18.13). The ph ysi cian pal pates the CRI. a. Extension /intern al rotati on: corona l dia meter n arrows, antero posteri or dia meter increa ses, he igh t increa ses. b. Fle xio n/e xternal rotati on: corona l dia meter w ide ns, antero posteri or dia meter decrea ses, he igh t decrea ses. The ph ysi cian no tes the ampli tude , rate , and re gul a rity o f th e CRI. The ph ysi cian no tes whi ch bon e s, if any, have a n a l tered amp litude , ra te, an d reg ula rity. The ph ysi cian pa ys particula r atten tio n to the SBS, d ete rmi nin g whe the r th ere is an y pre ferred motion of the sph eno id a nd the occipu t.

Figure 18.13. Ste ps 1 to 5.

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The ph ysi cian ma y i n struct the pa tie n t to stop bre ath ing to furthe r distin gui sh the rhythmi c sen sation s th at occu rs in the CR I. The physici an can also h ave the pa tie n t i nha le and exhal e fu lly to increa se the ampli tude of th e CR I, whi ch can make i t e a sie r to fee l.

P. 4 83

S acral Hold

Objective The ob jective is to cre ate fre e a nd symmetric motion of the sa cru m by pal pation of the CR I. Tec hnique 1. The pa tie n t l ies sup ine , a n d the physician is sea ted at the sid e o f th e tab le cau d ad to the sa cru m. 2. The pa tie n t i s instru cte d to ben d the far kne e a nd roll tow ard th e physician . 3. The ph ysi cian sli des th e

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Figure 18.14. Ste ps 1 to 4.

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cau dad ha n d betwee n th e patien t's leg s and un der the sacrum, a n d the pa tie n t dro ps his or her wei ght is on thi s h and . 4. The ph ysi cian all ows th e han d to mo ld to the sh ape of the sa cru m wi th the me dia n sacral cre st lyi ng betw een the th ird and fou rth fi n gers, the fi nge rtip s app roxima ting the ba se a nd the pa lm cra dli ng the ape x (Figs . 18.14 and 18.15). 5. The ph ysi cian pre sse s th e elb ow dow n into the tabl e, establ ish i ng a ful cru m. 6. The ph ysi cian pal pates the cra nio sacral mechan ism. Sph eno basi lar fle xio n i s syn chrono u s with sacra l cou nte rnu tati on

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Figure 18.15. Ste ps 1 to 4.

Figure 18.16. Lumbar an d sa cra l con tact.

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(sa cra l b a se moves posterior). Sph eno basi lar extension is syn chrono u s with sacra l nutati on (sacral base move s anteri or). 7. The ph ysi cian 's han d foll o ws the se moti ons, encouragi n g symmetric and ful l rang e of sacral mo tion . 8. The ph ysi cian con tin ues to fol low an d encourage sacral mo tion until pal p ati on of a rele a se, whi ch is usu all y accomp ani e d by a sensa tio n of soften i ng and wa rmi n g o f the sa cra l tissue s. 9. The ph ysi cian retests th e qua nti ty a nd qua lity o f sacral mo tion to assess the effective n ess of the te chn i que .

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The ph ysi cian ca n also u se the cep hal ad h and , either sl i din g i t und er the patien t's lumbar are a (Fig. 18.16) la ying th e forearm a cross b oth anteri or supe rio r ili ac spi n es (ASIS). The ad diti ona l h and pla cement gives the physician more informati o n a bou t how th e sa cru m rel ate s to th e respective areas.

P. 4 84

Decom pressi on of the Occi pital Condyles

Objective s The ob jective is to bal ance th e reciproca l te nsi on membra ne a t the hyp ogl ossa l can al, pe rmittin g normal ize d fun cti on o f cran ial nerve XII. Tec hnique 1. The pa tie n t lie s supi n e, and th e physician is sea ted at the

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Figure 18.17. Ste ps 1 a n d 2 .

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hea d o f th e tab le with both forearms restin g o n the ta ble , establ ish i ng a fulcrum. 2. The pa tie n t's hea d rests on the physician 's pal ms, an d the physician 's ind ex and mid dle fin gers (o r the mi ddl e and ri ng fin gers) app roxima te the pa tie n t's con dyl ar pro cesses (as fa r cau dad on the occip u t as the so ft tissue an d C1 wil l all ow) (Figs. 18.17, 18 .18 and 18 .19 ). 3. The fi nge rs of both han ds ini tia te a gen tle cep hal ad and la tera l force at the

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Figure 18.18. Ste ps 1 a n d 2 .

Figure 18.19. Ste ps 1 a n d 2 .

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base o f th e occipu t. 4. The fo rce is mai nta ine d until a rel ease i s fel t. 5. The ra te a nd amp litude of the CR I a s it man ife sts in the basioccip i tal reg ion are retested to assess th e effective n ess of the techni que .

P. 4 85

Occi pitoatl antal Decompressi on (8)

Objective s To tre at occipi toa tlan tal somati c d ysfu nction tha t resu l ts fro m rotati on o f the occipu t o n its antero posteri or axi s, resu lti ng in misali gnme nt of the con dyl es i n the facets of the atlas. In gen era l , this techni que sho uld be

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Figure 18.20. Ste ps 1 a n d 2 .

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performed after decomp ression of the occip i tal con dyl es. Tec hnique 1. The pa tie n t l ies sup ine , a n d the physician is sea ted at the hea d o f th e tab le with bo th forearms restin g o n th e tab le, establ ish i ng a ful cru m. 2. The ph ysi cian pla ces th e pad s o f b o th mid dle fi n gers on the posterior asp ect of the cra niu m a n d sli des th e se fin gers d o wn the occip u t until the fin gers are ag ain st the posterior arches of the atl as (Figs. 18.20, 18 .21 and 18 .22 ). 3. The ph ysi cian app lie s ca uda d pre ssu re w ith both midd l e fin gers to sep ara te the facets fro m the

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Figure 18.21. Ste ps 1 a n d 2 .

Figure 18.22. Ste ps 1 a n d 2 .

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4.

5.

6.

7.

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con dyl ar p arts. Whi le the physician mai nta ins thi s cau dad pre ssu re, the patien t tu cks the ch in i nto the ch est, making su re NOT to fl e x the neck (thi s is the no ddi n g moveme nt that occurs at the occipi toa tlan tal joi nt). Thi s moti o n carrie s th e occipi tal con dyl es posteriorl y, ten ses th e lig ame nts in the re gio n , a nd stretches the con tra cte d muscle s i n th e occipi tal tri ang le. The ph ysi cian mai nta ins thi s positi on w hil e the pa tie n t hol ds one or more d eep inspirati o ns to the ir limi t. Thi s wil l e nha n ce articu lar rel ease. The ra te a nd

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amp litude of the CR I, a s i t man ife sts in the basioccip i tal reg ion , a re retested to assess th e effective n ess of the te chn i que . Occipi toa tlan tal motion te stin g can al so b e assessed for normal iza tion .

P. 4 86

Compression of the Fourth Ventricl e

Objective s Tre atment often sta rts wi th compre ssi o n o f C V4 for il l p a tie nts. Th e tre atment aug men ts the he ali n g cap abi liti es of the patien t, rela xes th e patien t, a nd imp roves the motion of the CR I. Tec hnique

Figure 18.24. Ste ps 1 to 3.

1. The pa tie n t l ies sup ine , a n d the physician is sea ted at the

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hea d o f th e tab le with bo th forearms resting on the ta b le, establ ish i ng a ful cru m. 2. The ph ysi cian cro sse s o r interl ace s th e fin gers o f bo th han ds, cra dli ng the pa tie n t's occipi tal squ ama . 3. The ph ysi cian pla ces th e the nar emi nen ces posterome d ial to the pa tien t's occipi toma sto id suture s. If the the nar emi nen ces are on the ma stoi d pro cesses of the te mpo ral bon es, th e compre ssi o n tha t foll o ws wil l bil ate ral l y extern all y ro tate the te mpo ral bon es, wh i ch may ca use extreme untowa rd rea cti ons (Figs. 18.23, 18 .24, 18.25 and 18.26). 4. The ph ysi cian

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Figure 18.25. Sup eri or view of ha n d posi tio n.

Figure 18.26. Ste ps 1 to 3.

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encourage s extension of the patien t's occipu t by fol low i ng the occipu t a s it moves into extension . 5. The ph ysi cian resists fl exi on by hol din g th e patien t's occipu t in extensi on with b ila tera l med ial fo rces. Note: The occipu t i s no t forced in to extension . Rather, i t is pre ven ted fro m moving in to fle xio n. It i s a s i f the ph ysi cian is taking up the sla ck cre a ted by extension and hol din g i t th ere . 6. Thi s force is mai nta ine d un til the ampli tude of the CR I decrea ses, a sti ll poi n t i s rea che d, a nd/or a sense o f rel ease i s fe lt (a sen se of soften ing and warmth in the reg ion of the occipu t). 7. As the CR I

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resume s, the physician slo wly re l eases the fo rce , all owi ng the CRI to un d erg o new fou nd excursion . 8. The ra te a nd amp litude of the CRI are retested to assess th e effective n ess of the te chn i que .

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Figure 18 .23. Steps 1 to 3 .

P. 4 87 P. 4 88

I nterparietal S utural Opening (V-S pread)

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Objective To restore freed om of moveme n t to the sag ittal sutu re, increa sin g th e dra ina ge o f the sup eri or sagi tta l sin us. Tec hnique 1. The pa tie n t l ies sup ine , a n d the ph ysi cian is sea ted at the hea d o f th e tab le with bo th forearms restin g o n tab le, establ ish i ng a ful cru m. 2. The physician 's thu mbs are cro sse d o ver the pa tie n t's sag ittal sutu re just a nte rior and su peri or to lambda . 3. The re mai n der of the physician 's fin gers re st on the la tera l surfaces o f the patien t's parietal b one s (Figs. 18 .27, 18.28 and 18.29).

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Figure 18.27. Ste ps 1 to 3.

Figure 18.28. Ste ps 1 to 3.

Figure 18.29. Ste ps 1 to 3.

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P. 4 89

S utural Spread (V-Spread, Di rection-of-Fl uid Techni que)

Objective The ob jective is to rel ease a restri cte d cra nia l su ture (e.g ., left o cci p ito mastoi d suture ). Tec hnique 1. The pa tie n t lie s supi n e, and th e physician is sea ted at the hea d o f th e tab le with both e lbo w s restin g o n th e tab le, establ ish i ng a ful cru m. 2. The ph ysi cian pla ces th e ind ex and mid dle fi n gers on the tw o sid es of the patien t's restri cte d suture . 3. The ph ysi cian pla ces on e or two fi nge rs o f the other han d on the patien t's cra niu m a t a poi nt opp o site the su ture to

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Figure 18.30. Ste ps 1 to 3.

Figure 18.31. Ste ps 1 to 3.

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be rel ease d (Figs. 18 .30, 18.31 and 18.32). 4. With the lig hte st force possib le, the physician directs a n imp ulse tow ard th e restri cte d suture wi th the ha nd opp osi te the suture , ini tia tin g a flu id wave . The ob ject is not to physicall y push flui d throug h to th e opp osi te side . Instea d, the physician is usi ng the flu ctu ati o n o f the cerebrosp i nal flu id to rel ease th e restri cti o n. The ph ysi cian use s i nte n tio n to ini tia te this wave; thi s method con tra cts the few est mu scle fib ers an d so app lie s th e

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Figure 18.32. Ste ps 1 to 3.

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sli ghtest force. 5. Thi s flui d wave may bou nce off th e restri cte d suture an d return to the ini tia tin g han d, whi ch sho uld receive a n d red ire ct the return ed w ave tow ard th e restri cte d suture . 6. Thi s back-a nd-forth action ma y be rep eated for severa l cycle s before th e physician fee ls the suture sp read and th e w a ve pen etrati n g the su ture doe s n ot return to the ini tia tin g han d. 7. The ra te a nd amp litude of the CR I a t th at suture are retested to assess th e effective n ess of the techni que .

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P. 4 90 P. 4 91

V enous S inus Drainage (6)

Objective s The ob jective is to increa se intracran i al ven ous dra ina ge by affecti ng the dural memb ran es tha t comp rise th e sin use s. Thoraci c outlet, ce rvi cal , and occipi toa tlan tal joi nt soma tic dysfun cti o ns sho uld be tre ate d first to a llo w dra ina ge from th e ven ous si n use s. Tec hnique 1. The pa tie n t lie s supi n e, and th e physician is sea ted at the hea d o f th e tab le with both e lbo w s restin g o n the ta ble , establ ish i ng a fulcrum. 2. For tra nsverse sin us dra ina ge the physician

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Figure 18.33. Tra nsverse si nus.

Figure 18.34. Ste ps 1 a n d 2 .

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pla ces th e first and second fin ger pa d s of both han ds across th e sup eri or nuchal li n e (b l ue lin e , Fig. 1 8.3 3 ) (Fig. 18.3 4). 3. Thi s p osi tion is mai nta ine d with mini mal pre ssu re (th e w eig h t of the patien t's hea d shou l d suffice) u nti l a rele ase is fel t (ap parent soften ing und er the fin gers). 4. The physician mai nta ins thi s p ressure until both sid es rel ease. 5. For drain a ge at the con flu ence s of sin use s the physician cra dle s th e

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Figure 18.35. Con flu ence of si nuse s.

Figure 18.36. Ste p 5 .

Figure 18.37. Occipi tal sin us.

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back o f th e patien t's hea d a nd pla ces th e mid dle fi n ger of one ha n d on the in i on (b l ue dot, Fig. 1 8.3 5 ) (Fig. 18.3 6). 6. Ste p 4 is rep eated until a soften ing is fel t. 7. For occip i tal sin us dra ina ge the physician cra dle s th e back o f th e patien t's hea d a nd pla ces th e second to fou rth fin gers o f both h and s in opp osi tion alo ng the mid lin e from the in ion to the sub occipi tal tissue s (b lue lin e, Fig. 18.37) (Fig. 18.38). 8. Ste p 4 is rep eated until a soften ing is

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Figure 18.38. Ste p 7 .s

Figure 18.39. Sup eri or sagi tta l si nus.

Figure 18.40. Ste ps 9 a n d 1 0.

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fel t. 9. For drain a ge of the sup eri or sag ittal sin us, th e physician pla ces tw o cro sse d thu mbs at lambda an d exe rts opp osi ng forces wi th each thumb to diseng a ge the su ture . 10. Once l oca l rel ease i s fel t, the physician moves anteri orl y and sup eri orl y alo ng the sup eri or sag ittal suture wi th the crosse d thu mb forces noting rel eases a t each locati on tow ard bre gma (b l ue lin e , Fig. 1 8.3 9 ) (Fig. 18.4 0). 11. Once a t bre gma , th e

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Figure 18.41. Metopi c su ture.

Figure 18.42. Ste p 1 1.

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physician pla ces th e second to fou rth fin gers o f both h and s in opp osi tion alo ng the mid lin e o n the fronta l bon e a t th e locati on o f the me top i c suture (b l ue lin e, Fig. 18.41) (Fig. 18.42). 12. The physician con tin ues anteri orl y on the fronta l bon e, diseng agi n g the su ture by gen tly sep ara tin g each fing e r on opp osi n g han ds. 13. The ra te a nd amp litude of the CR I, esp eci all y flu id flu ctu ati o ns, are re tested to assess the effective n ess of the techni que .

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P. 4 92

Unil ateral Tem poral Rocki ng Exampl e: Left Tem poral Bone i n E xternal or Internal Rotation

Objective The ob jective is to tre at a dysfun cti o n i n whi ch the temporal b one is hel d i n extern al/i nte rna l rotati on. Tec hnique 1. The pa tie n t lie s supi n e, and th e physician is sea ted at the hea d o f th e tab le with both forearms restin g o n the ta ble , establ ish i ng a fulcrum. 2. The physician 's left h and cra dle s th e patien t's occipu t. 3. The physician 's rig ht thu mb and in dex fin ger gra sp the zyg oma tic

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Figure 18.43. Ste ps 1 to 5, an ato mic locati o n o f fing e r p lace

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portio n o f th e patien t's rig ht temporal bon e, thu mb cep hal ad, ind ex fin g er cau dad . 4. The physician 's rig ht mid d le fin ger re sts on the extern al aco ustic mea tus of the ear. 5. The physician 's rig ht rin g an d little fi n gers rest o n th e inferi or portio n o f th e patien t's mastoi d pro cess (Figs. 18 .43, 18.44 and 18.45). 6. During th e fle xio n p h ase of cra nia l motion , th e physician 's rin g a nd l ittle fin gers e xert med ial pre ssu re. Thi s pre ssu re i s accomp ani e d

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Figure 18.44. Ste ps 1 to 5, fi nge rs o n zygo ma.

Figure 18.45. Ste ps 1 to 5.

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by cep hal a d liftin g o f th e patien t's zyg oma tic arch w ith the physician 's thu mb and ind ex fin gers, encouragi n g extern al rotati on o f the te mpo ral bon e. 7. During th e extension pha se of cra nia l motion , th e physician 's fin gers re sist motion of the patien t's temporal bon e towa rd intern al rotati on. 8. An altern ati ve method encourage s intern al rotati on a nd inh ibi ts the extern al rotati on. 9. The ra te a nd amp litude of the prima ry respirato ry mechan ism, esp eci all y at

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the te mpo ral bon e, are retested to assess th e effective n ess of the techni que .

P. 4 93

Frontal Lift (8)

Objective The ob jective is to tre at dysfun cti o ns of the fronta l b one s in rel ati o n to thei r sutura l o r du ral con nectio n s (i.e ., fro nto pari eta l compre ssi o n, fro nto nasa l compre ssi o n). Tec hnique

Figure 18.46. Ste ps 1 to 3, ha nd pla ceme nt.

1. The pa tie n t lie s supi n e, and th e physician is sea ted at the hea d o f th e tab le with both forearms restin g o n the ta ble , establ ish i ng

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a fulcrum. 2. The physician pla ces bo th hyp oth ena r emi nen ces on the latera l ang les of the fro nta l b o nes and th e the nar emi nen ces of both han ds anteri or to the la tera l asp ects o f the co ron a l suture . 3. The physician interl ace s the fi nge rs abo ve the metopi c suture (Fig. 18.46). 4. The physician 's the nar an d hyp oth ena r emi nen ces pro vid e a gen tle compre ssi ve force med ial ly to diseng age the fronta ls fro m the parietals

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Figure 18.47. Ste p 4 , co mpressive force.

Figure 18.48. Ste p 5 , a n terior gu i ded force.

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(a rrow s, Fig. 18.47), intern all y rotati ng the fro nta l bon es. 5. The physician , whi le mai nta ini n g thi s medi a l compre ssi ve force, app lie s a gen tle anteri or force eith er on one si d e or both a s nee ded to diseng age the su tura l restri cti o ns (a rrow s, Fig. 18.48). 6. Thi s p osi tion is hel d u n til the physician fee ls the latera l ang les of the fro nta l b o nes move i nto extern al rotati on (expan sio n und er the hyp oth ena r emi nen ces). 7. The physician

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the n g entl y rel eases the hea d. 8. The ra te a nd amp litude of the prima ry respirato ry mechan ism, esp eci all y at the fronta l bon es, are retested to assess th e effective n ess of the techni que .

P. 4 94

P ari etal Li ft (8)

Objective The ob jective is to tre at dysfun cti o n o f the parietal b one s i n rel ati on to thei r su tural or dural conn ection s (i.e., pa rietote mpo ral, parietofro nta l). Tec hnique 1. The pa tie n t l ies sup ine , a n d the physician is sea ted at the he ad of the ta b le with both fore a rms restin g o n th e

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Figure 18.49. Ste ps 1 to 3.

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2.

3.

4.

5.

6.

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tab le, establ ish ing a fulcrum. The ph ysi cian pla ces th e fin gertip s on bo th parietal b one s j ust sup eri or to the parietal-squa mou s suture s. The ph ysi cian cro sse s th e thu mbs ju st a bove the sa gittal suture (Fig. 18.4 9). No te: The th umb s are NOT to to u ch the patien t. The ph ysi cian pre sse s o n e thu mb aga i nst th e oth er (arrows, Fig. 18.50) (o n e thumb pre sse s u p ward whi le the oth er resists i t). Pre ssi ng o ne thu mb aga i nst th e oth er app roxima tes the fin gertip s. This ind uce s i n ternal rotati on o f the parietal b one s a t the parietal-squa mou s suture s. Whi le mai n tai nin g pre ssu re, the physician lifts both han ds cep h ala d until ful l ness i s fel t o ver the

Figure 18.50. Ste p 4 .

Figure 18.51. Ste p 6 , e xternal ro tati on of pari eta ls.

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fin gertip s; this ful lne ss i s extern al rota tio n of the pa rietal bon es (a rrows, Fig. 1 8.5 1 ). 7. The ph ysi cian gen tly re l eases the he ad. 8. The ra te a nd amp litude of the pri mary respirato ry mechan ism, esp eci all y at th e fro nta l b o nes, a re retested to a sse ss the effective ness of the te chni que .

P. 4 95

References 1 . W a rd R ( e d. ) . Fo un d at i on s fo r O s te o p at h ic Me d i ci n e, 2n d ed . P h il a d el p hi a : L i pp i nc o t t Wil l ia ms & Wi l ki n s , 2 00 3 .

2 . A r bu c k le B. Th e Se l ec t ed Wri t in g s o f B e ry l E . Ar b uc k le . Ca mp Hil l , P A : Nat i o na l O s te o pa t h ic In s ti t u te an d C e r eb r al Pa l s y Fou n da t i on .

3 . W e av e r C . T h e Cr an i al Ve r t eb r ae , J A m O s t e op a t h A s s o c 1 9 36 ; 35 : 32 8 – 33 6 .

4 . G r ee n man P. Pr i n ci p le s o f Ma n ua l M e d ic i ne , 3 r d e d . P hi l a de l ph i a: L ip p in c ot t Wi ll i am s & Wil k in s , 2 0 03 .

5 . N e ls o n K , S e rg u e f f N, Li p i ns k y C, e t a l . Cra n i al rh y th mi c i mp u ls e re l at e d t o t h e Tr au b e- He ri n g- May e r o s ci l la t i on : C o mp a r in g l a se r Do p pl e r f l ow met r y a n d p al p at i o n. J Am Os t e op a th As s o c 2 00 1 ;1 0 1 :1 6 3– 1 73 .

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6 . D i Gi o v an n a, E, S ch i ow i t z S . A n O s t e o pa t hi c A p p ro a ch to Dia g no s is a nd Tr ea t me n t . P hi l ad e l ph i a: Li p p in c ot t W i l li a ms & Wi lk i ns , 2 0 0 5.

7 . M o di f i ed wi t h p e rm i s s i on f ro m A g ur A MR , D a ll e y A F. G ra n t 's At l as o f A na t om y , 1 1 th ed . Ba l ti mor e : L i pp i nc o t t Wil l ia ms & Wi l ki n s , 2 00 5 .

8 . M a go u n H . O s te o p at h y i n t h e Cra n ia l Fi e ld , 3 r d e d . B oi s e : Nor t hw e s t P ri n ti n g , 1 9 76 .

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Glossary of Osteopathic Terminology Usage Guide The Glossary of Osteopathic Terminology is revised twice each year by the Educational Council on Osteopathic Principles, Chairman, John C. Glover, DO. Forward any comments or suggestions to John Glover, DO, FAAO, Chairman, Department of Osteopathic Manipulative Medicine, Touro University, California, 1310 Johnson Lane, Vallejo, CA 94592. Office Phone: (707) 638-5245, E-mail: [email protected]. The Glossary first appeared in the Journal of the American Osteopathic Association (JAOA 80: 552-567) in April of 1981. The 1995 version of the Glossary of Osteopathic Terminology was also published in the textbook, Foundations for Osteopathic Medicine, Ward RC (ed.) (1997) pp. 1126-1140: Williams & Wilkins, Baltimore, MD, and in Foundations for Osteopathic Medicine, Ward RC (ed.) (2003) pp. 1229-1253: Williams & Wilkins, Baltimore, MD. The most current and revised version is available on the AACOM website at www.aacom.org in PDF format. It is also available on the AOA website at www.osteopathic.org. The April 2006 glossary review was performed by Andrea Clem, D.O., Lisa DeStefano, D.O., William Devine, D.O., Walter Ehrenfreuchter, D.O., FAAO, David Essig-Beatty, D.O., Heather Ferrell, D.O., Tom Fotopolis, D.O., Wolfgang Gilliar, D.O., John Glover, D.O., FAAO, Kurt Heinking, D.O., Jan Hendryx, D.O., Ray Hruby, D.O., FAAO, John Jones, D.O., Robert Kappler, D.O., FAAO, Sean Kerger, D.O., Randy Litman, D.O., Michael Lockwood, D.O., David Mason, D.O., Evan Nicholas, D.O., Kendi Pim, D.O., Paul Rennie, D.O., FAAO, Mark Sandhouse, D.O., Harriet Shaw, D.O., Greg Thompson, D.O., Kevin Treffer, D.O. Purpose: The purpose of this osteopathic glossary is to present important and often used words, terms and phrases of the osteopathic profession. It is not meant to replace a dictionary. The glossary offers the consensus of a large segment of the osteopathic profession and serves to standardize terminology. The ECOP Glossary Review Committee specifically seeks to include those definitions that are uniquely osteopathic in their origin or common usage, distinctive in the osteopathic usage of a common word, and/or important in describing OPP/OMT. In the glossary, the term “osteopathic practitioner” refers to an osteopath, an osteopathic physician or an allopathic physician who has been trained in osteopathic principles, practices and philosophy. “Methods” are described as being direct, indirect or combined. “Osteopathic manipulative treatment systems” are complete systems of diagnosis and treatment such as high velocity low amplitude (HVLA), muscle energy and osteopathy in the cranial field. “Techniques” are those methods used within a treatment system such as lumbar rolls, rib-raising, etc. This glossary should be useful to the student of osteopathic medicine and helpful to authors and other professionals in understanding and making proper use of osteopathic vocabulary. The five models used in discussion of osteopathic patient care are the respiratory-circulatory model, the biomechanical-structural, metabolicnutritional, neurological and behavioral-biopsychosocial. For a more complete description of the models and their application to patient care, please refer to the Educational Council on Osteopathic Principles Core Curriculum, copyright 1987, second edition copyright 2000. Electronic copies are available from the American Association of Colleges of Osteopathic Medicine. Definitions are included from: Dorland’s Medical Dictionary, 29th edition, 2000 The William & Wilkins Company, Baltimore, MD

Stedman’s Medical Dictionary, 27th edition, 2000 W.B. Saunders Company, Philadelphia, PA

Foundations for Osteopathic Medicine, 2nd edition, 2003 Ward, Robert, ed. Lippincott Williams & Wilkins, Philadelphia, PA

Rehabilitation Medicine, Principles and Practices, 1st edition, 1988 DeLisa, Joel A., ed. J.B. Lippincott, Philadelphia, PA

Glossary of Osteopathic Terminology Prepared by the Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine (AACOM). Revised July 2006. ©2006 The Educational Council on Osteopathic Principles and the American Association of Colleges of Osteopathic Medicine

IND: indirect treatment

OMT: osteopathic manipulative treatment

INR: integrated neuromusculoskeletal release treatment

PINS: progressive inhibition of neuromuscular structures

LAS: ligamentous articular strain treatment ME: muscle energy treatment

ST: soft tissue treatment

I: indirect treatment

A abbreviations: types of osteopathic manipulative treatment. ART: articulatory treatment BLT: balanced ligamentous tension treatment CR: osteopathy in the cranial field CS: counterstrain treatment D: direct treatment DIR: direct treatment FPR: facilitated positional release treatment HVLA: high velocity/low amplitude treatment

MFR: myofascial release treatment NMM-OMM: neuromusculoskeletal medicine OCF: osteopathy in the cranial field/cranial treatment OMTh: osteopathic manipulative therapy (non-US terminology)

VIS: visceral manipulative treatment accessory joint motions: See secondary joint motion. accessory movements: Movements used to potentiate, accentuate, or compensate for an impairment in a physiologic motion (e.g., the movements needed to move a paralyzed limb).

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Figure 1. Lumbolumbar angle (L2-L5). accommodation: A self-reversing and nonpersistent adaptation. active motion: See motion, active. acute somatic dysfunction: See somatic dysfunction, acute. allopathy: 1. A therapeutic system in which a disease is treated by producing a second condition that is incompatible with or antagonistic to the first. (Stedman’s)

rotation, the left side is the anterior component; usually refers to the less prominent transverse process; See also posterior component. anterior compression test: See ASIS (anterior superior iliac spine) compression test. anterior iliac rotation: See ilium, somatic dysfunction of, anterior (forward) innominate (iliac) rotation.

allopath: A term used to refer those holding a Doctor of Medicine (MD) degree, a non-osteopathic medical degree.

anterior nutation, See nutation.

anatomical barrier: See barrier, (motion barrier).

articular pillar: 1. Refers to the columnar arrangement of the articular portions of the cervical vertebrae. 2. Those parts of the lateral arches of the cervical vertebrae that contain a superior and inferior articular facet.

angle: Ferguson a., See angle, lumbosacral. lumbolumbar lordotic a., an objective quantification of lumbar lordosis typically determined by measuring the angle between the superior surface of the second lumbar vertebra and the inferior surface of the fifth lumbar vertebra; best measured from a standing lateral x-ray film. (Fig. 1) lumbosacral a., represents the angle of the lumbosacral junction as measured by the inclination of the superior surface of the first sacral vertebra to the horizontal (this is actually a sacral angle); usually measured from standing lateral x-ray films; also known as Ferguson’s angle. (Fig. 2) lumbosacral lordotic a., an objective quantification of lumbar lordosis typically determined by measuring the angle between the superior surface of the second lumbar vertebra and the superior surface of the first sacral segment; best measured from a standing lateral x-ray film. (Fig. 3) anterior component: A positional descriptor used to identify the side of reference when rotation of a vertebra has occurred; in a condition of right

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Figure 3. Lumbosacral lordotic angle.

Figure 2. Lumbosacral angle (S1-horizon) (Ferguson’s angle).

anterior rib: See rib somatic dysfunction, inhalation rib dysfunction. ART: See TART.

articulation: 1. The place of union or junction between two or more bones of the skeleton. 2. The active or passive process of moving a joint through its permitted anatomic range of motion. See also osteopathic manipulative treatment, articulatory treatment (ART) system. articulatory pop: The sound made when cavitation occurs in a joint. See also cavitation. articulatory technique: See also technique. See osteopathic manipulative treatment, articulatory treatment (ART) system. asymmetry: Absence of symmetry of position or motion; dissimilarity in corresponding parts or organs on opposite sides of the body that are normally alike; of particular use when describing position or motion alteration resulting from somatic dysfunction. axis: 1. An imaginary line about which motion occurs. 2. The second cervical vertebra. 3. One component of an axis system.

Figure 4. ASIS compression test

axis of rib motion: See rib motion, axis. ASIS (anterior superior iliac spine) compression test: 1. A test for lateralization of somatic dysfunction of the sacrum, innominate or pubic symphysis. 2. Application of a force through the ASIS into one of the pelvic axes to assess the mechanics of the pelvis. See also sacral motion, axis of (Fig. 4). axis of sacral motion: See sacral motion, axis of. axoplasmic flow: See axoplasmic transport. axoplasmic transport: The antegrade movement of substances from the nerve cell along the axon toward the terminals, and the retrograde movement from the terminals toward the nerve cell.

B backward bending: Opposite of forward bending. See extension. backward bending test: 1. This test discriminates between forward and backward sacral torsion/rotation. 2. This test discriminates between

an audible “pop” in certain forms of OMT.

unilateral sacral flexion and unilateral sacral extension. backward torsion: See sacrum, somatic dysfunctions of, backward torsions.

cephalad: Toward the head. cephalad pubic dysfunction: See pubic bone, somatic dysfunctions of, superior pubic shear.

balanced ligamentous tension technique: See osteopathic manipulative treatment, balanced ligamentous tension. See also osteopathic manipulative treatment, ligamentous articular strain.

cerebrospinal fluid, fluctuation of: A description of the hypothesized action of cerebrospinal fluid with regard to the craniosacral mechanism.

barrier (motion barrier): The limit to motion; in defining barriers, the palpatory end-feel characteristics are useful. (Fig. 5)

cervicolumbar reflex: See reflex, cervicolumbar r. Chapman reflex: 1. A system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunction or pathology. 2. Originally used by Frank Chapman, DO, and described by Charles Owens, DO.

anatomic b., the limit of motion imposed by anatomic structure; the limit of passive motion. elastic b., the range between the physiologic and anatomic barrier of motion in which passive ligamentous stretching occurs before tissue disruption. pathologic b., a restriction of joint motion associated with pathologic change of tissues (example: osteophytes). See also barrier, restrictive b.

chronic somatic dysfunction: See somatic dysfunction, chronic. circumduction: 1. The circular movement of a limb. 2. The rotary movement by which a structure is made to describe a cone, the apex of the cone being a fixed point (e.g., the circular movement of the shoulder).

physiologic b., the limit of active motion. restrictive b., a functional limit that abnormally diminishes the normal physiologic range.

combined technique: See osteopathic manipulative treatment, combined method.

batwing deformity: See transitional vertebrae, sacralization.

common compensatory pattern: See fascial patterns, common compensatory pattern.

bind: Palpable resistance to motion of an articulation or tissue. Synonym: resistance. Antonyms: ease, compliance, resilience.

compensatory fascial patterns: See fascial patterns, common compensatory pattern.

biomechanics: Mechanical principles applied to the study of biological functions; the application of mechanical laws to living structures; the study and knowledge of biological function from an application of mechanical principles. body unity: One of the basic tenets of the osteopathic philosophy; the human being is a dynamic unit of function; See also osteopathic philosophy. bogginess: A tissue texture abnormality characterized principally by a palpable sense of sponginess in the tissue, interpreted as resulting from congestion due to increased fluid content.

complete motor asymmetry: Asymmetry of palpatory responses to all regional motion inputs including rotation, translation and active respiration.

Figure 5. Somatic dysfunction in a single plane: three methods illustrating the “restrictive barrier” (the restrainer): AB, anatomic barrier; PB, physiologic barrier; RB, restrictive barrier; SD, somatic dysfunction (From Foundations for Osteopathic Medicine, Baltimore, William & Wilkins, 1997:484.

bucket handle rib motion: See rib motion, bucket handle.

caught in inhalation: See inhalation rib dysfunction.

C

caught in exhalation: See exhalation rib dysfunction.

caliper rib motion: See rib motion, caliper rib motion. caudad: Toward the tail or inferiorly.

cavitation: The formation of small vapor and gas bubbles within fluid caused by local reduction in pressure. This phenomenon is believed to produce

compliance: 1. The ease with which a tissue may be deformed. 2. Direction of ease in motion testing. compression: 1. Somatic dysfunction in which two structures are forced together. 2. A force that approximates two structures. conditioned reflex: See reflex, conditioned r. contraction: Shortening and/or development of tension in muscle. concentric c., contraction of muscle resulting in approximation of attachments. eccentric c., lengthening of muscle during contraction due to an external force. isokinetic c., 1. A concentric contraction against resistance in which the angular change of joint motion is at

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the same rate. 2. The counterforce is less than the patient force. isolytic c., 1. A form of eccentric contraction designed to break adhesions using an operator-induced force to lengthen the muscle. 2. The counterforce is greater than the patient force. isometric c., 1. Change in the tension of a muscle without approximation of muscle origin and insertion. 2. Operator force equal to patient force. isotonic c., 1. A form of concentric contraction in which a constant force is applied. 2. Operator force less than patient force. contracted muscle: The physiologic response to a neuromuscular excitation. See also contractured muscle. contracture: A condition of fixed high resistance to passive stretch of a muscle, resulting from fibrosis of the tissues supporting the muscles or the joints, or from disorders of the muscle fibers. Dupuytren c., shortening, thickening and fibrosis of the palmar fascia, producing a flexion deformity of a finger (Dorland’s). contractured muscle: histological change substituting non-contractile tissue for muscle tissue, which prevents the muscle from reaching normal relaxed length. See also contracted muscle.

Figure 6. Dermatomal map (anterior). (Modified from Agur AMR, Grant’s Atlas of Anatomy, 9th ed. Baltimore Md: Williams & Wilkins; 1991:37).

core link: The connection of the spinal dura mater from the occiput at the foramen magnum to the sacrum. It coordinates the synchronous motion of these two structures.

between the occiput and the sacrum by the spinal dura mater. 2. A term coined by William G. Sutherland, DO. See also extension, craniosacral extension and flexion, craniosacral flexion.

coronal plane: See plane, frontal. costal dysfunction: See rib, dysfunction. counternutation: Posterior movement of the sacral base around a transverse axis in relation to the ilia. See also nutation. counterstrain technique: See osteopathic manipulative treatment, counterstrain. cranial manipulation: See osteopathic manipulative treatment, cranial manipulation. cranial rhythmic impulse (CRI): 1. A palpable, rhythmic fluctuation believed to be synchronous with the primary respiratory mechanism. 2. Term coined by John Woods, DO, and Rachel Woods, DO. cranial technique: See osteopathic manipulative treatment, osteopathy in the cranial field. See also primary respiratory mechanism. craniosacral manipulation: See osteopathic manipulative treatment, osteopathy in the cranial field. craniosacral mechanism: 1. A term used to refer to the anatomical connection

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C-SPOMM: Certification Special Proficiency in Osteopathic Manipulative Medicine. Granted by the American Osteopathic Association through the American Osteopathic Board of Special Proficiency in Osteopathic Manipulative Medicine from 1989 through 1999. See also NMM-OMM. creep: The capacity of fascia and other tissue to lengthen when subjected to a constant tension load resulting in less resistance to a second load application. CV-4: See osteopathic manipulative treatment, CV-4.

D Dalrymple treatment: See osteopathic manipulative treatment, pedal pump. decompensation: A dysfunctional, persistent pattern, in some cases

Figure 7. Dermatomal map (posterior). (Modified from Agur AMR, Grant’s Atlas of Anatomy, 9th ed. Baltimore Md: Williams & Wilkins; 1991:37).

reversible, resulting when homeostatic mechanisms are partially or totally overwhelmed depressed rib: See rib somatic dysfunction, exhalation rib dysfunction. dermatome: 1. The area of skin supplied by cutaneous branches from a single spinal nerve. (Neighboring dermatomes may overlap.) 2. Cutis plate; the dorsolateral part of an embryonic somite. (Fig. 6 and Fig. 7) diagnostic palpation: See palpatory diagnosis. diagonal axis: See sacral, oblique axis, diagonal. direct method (technique): See osteopathic manipulative treatment, direct treatment. DO: 1. Doctor of Osteopathy (accredited by the American Osteopathic Association). 2. Doctor of Osteopathic Medicine (accredited by the American Osteopathic Association). 3. Diplomate in Osteopathy (The first degree granted by American School of Osteopathy). 4. Diplomate of Osteopathy, a degree granted by some schools of osteopathy outside the United States.

drag: See skin drag.

E ease: Relative palpable freedom of motion of an articulation or tissue. Synonyms: compliance, resilience. Antonyms: bind, resistance. easy normal: See neutral, definition number 2. -ed: A suffix describing status, position, or condition (e.g., extended, flexed, rotated, restricted). effleurage: Stroking movement used to move fluids. elastic deformation: Any recoverable deformation. See also plastic deformation.

exhalation rib dysfunction: See rib somatic dysfunction, exhalation rib dysfunction. exhalation rib restriction: See rib motion, exhalation rib restriction. See also rib somatic dysfunction, inhalation rib dysfunction. exhalation strain: See rib somatic dysfunction, exhalation rib dysfunction. extension: 1. Accepted universal term for backward motion of the spine in a sagittal plane about a transverse axis; in a vertebral unit when the superior part moves backward. 2. In extremities, it is the straightening of a curve or angle (biomechanics). 3. Separation of the ends of a curve in a spinal region; See extension, regional extension.

Figure 9. Regional extension.

craniosacral extension, motion occurring during the cranial rhythmic impulse when the sphenobasilar symphysis descends and sacral base moves anteriorly. (Fig. 8)

elasticity: Ability of a strained body or tissue to recover its original shape after deformation. See also plasticity and viscosity. elevated rib: See rib somatic dysfunction, inhalation rib dysfunction. See also rib motion, exhalation rib restriction. end feel: Perceived quality of motion as an anatomic or physiologic restrictive barrier is approached. enthesitis: 1. Traumatic disease occurring at the insertion of muscles where recurring concentration of muscle stress provokes inflammation with a strong tendency toward fibrosis and calcification (Stedman’s). 2. Inflammation of the muscular or tendinous attachment to bone (Dorland’s). ERS: A descriptor of spinal somatic dysfunction used to denote a combination extended (E), rotated (R), and sidebent (S) vertebral position.

Figure 10. Sacral extension. Figure 8. Craniosacral extension.

ERS left, somatic dysfunction in which the vertebral unit is extended, rotated and sidebent left; usually preceded by a designation of the vertebral unit(s) involved (e.g., T5 ERS left or T5 ERLSL). ERS right, somatic dysfunction in which the vertebral unit is extended, rotated and sidebent right; usually preceded by a designation of the vertebral unit(s) involved (e.g., C3-5 ERS right or C3-5 ERRSR). exaggeration method: See osteopathic manipulative treatment, exaggeration method. exaggeration technique: See osteopathic manipulative treatment, exaggeration technique. exhaled rib: (Archaic) using positional (static) diagnosis. See rib somatic dysfunction, exhalation rib dysfunction.

regional extension, historically, the straightening in the sagittal plane of a spinal region; also called Fryette’s regional extension. (Fig. 9) sacral extension, posterior movement of the base of the sacrum in relation to the ilia. (Fig. 10) See also flexion, sacral flexion. extrinsic corrective forces: Treatment forces external to the patient that may include operator effort, effect of gravity, mechanical tables, etc. See also intrinsic corrective forces.

their commitment to osteopathic principles and practice through teaching, writing, and professional service, performed at the highest level of professional and ethical standards. facet asymmetry: Configuration in which the structure, position and/or motion of the facets are not equal bilaterally. See also facet symmetry and tropism, facet. facet symmetry: Configuration in which the structure, position and/or motion of the facets are equal bilaterally. See also facet asymmetry and symmetry. facilitated positional release: See osteopathic manipulative treatment, facilitated positional release.

F

facilitated segment: See spinal facilitation.

FAAO: 1. Fellow of American Academy of Osteopathy. 2. This fellowship is an earned post-doctoral degree conferred by the American Academy of Osteopathy. Those who earn the FAAO degree must have demonstrated

facilitation: See spinal facilitation. fascial patterns: 1. Systems for classifying and recording the preferred directions of fascial motion throughout the body. 2. Based on the observations

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of J. Gordon Zink, DO, and W. Neidner, DO.

flexion: 1. Accepted universal term for forward motion of the spine, in its

common compensatory pattern (CCP), the specific finding of alternating fascial motion preference at transitional regions of the body described by Zink and Neidner. (Fig. 11)

Figure 15. Sacral flexion. Figure 13. Craniosacral flexion.

flexion left: See sidebending. f lexion right: See sidebending.

Figure 11. Common compensatory fascial pattern (Zink)

flexion tests: Tests for iliosacral or sacroiliac somatic dysfunction. seated flexion test, a screening test that determines the side of sacroiliac somatic dysfunction (motion of the sacrum on the ilium).

uncommon compensatory pattern, the finding of alternating fascial motion preference in the direction opposite that of the common compensatory pattern described by Zink and Neidner. (Fig. 12)

standing flexion test, a screening test that determines the side of iliosacral somatic dysfunction (motion of ilium on the sacrum). forward bending. Reciprocal of backward bending. See flexion. forward torsions: See sacrum, somatic dysfunctions of, forward torsions.

Figure 14. Regional flexion.

Figure 12. Uncommon compensatory fascial pattern (Zink). uncompensated fascial pattern, the finding of fascial preferences that do not demonstrate alternating patterns of findings at transitional regions. Because they occur following stress or trauma, they tend to be symptomatic.

sagittal plane about a transverse axis, where the superior part moves forward. 2. In the extremities, it is the approximation of a curve or angle (biomechanics). 3. Approximation of the ends of a curve in a spinal region; also called Fryette’s regional flexion. See flexion, regional flexion. craniosacral flexion, motion occurring during the cranial rhythmic impulse, when the sphenobasilar symphysis ascends and the sacral base moves posteriorly. (Fig. 13)

FRS: A descriptor of spinal somatic dysfunction used to denote a combination flexed (F), rotated (R), and sidebent (S) vertebral position. FRS left, somatic dysfunction in which the vertebral unit is flexed, rotated and sidebent left; usually preceded by a designation of the vertebral unit(s) involved (e.g., T5 FRS left or T5 FRLSL). FRS right, somatic dysfunction in which the vertebral unit is flexed, rotated and sidebent right; usually preceded by a designation of the vertebral unit(s) involved (e.g., C3-5 FRS right or C3-5 FRRSR). frontal plane: See plane, frontal.

fascial release technique: See osteopathic manipulative treatment, myofascial release.

regional flexion, historically, is the approximation of the ends of a curve in the sagittal plane of the spine; also called Fryette’s regional flexion. (See flexion (Fig. 14).

fascial unwinding: See osteopathic manipulative treatment, fascial unwinding. Ferguson angle: See angle, lumbosacral.

sacral flexion, anterior movement of sacral base in relation to the ilia. (Fig. 15) See also extension, sacral extension.

Fryette regional extension: See extension, regional extension.

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Fryette laws: See laws, Fryette’s. See physiologic motion of the spine. Fryette principles: See physiologic motion of the spine.

Fryette regional flexion: See flexion, regional flexion.

FSR: A descriptor of spinal somatic dysfunction used to denote a combination flexed (F), sidebent (S), and rotated (R) vertebral position. See FRS. functional method: See osteopathic manipulative treatment, functional method. functional technique: See osteopathic manipulative treatment, functional method.

G gait: a forward translation of the body's center of gravity by bipedal locomotion. (DeLisa) Galbreath treatment: See osteopathic manipulative treatment, mandibular drainage. gravitational line: Viewing the patient from the side, an imaginary line in a coronal plane which, in the theoretical ideal posture, starts slightly anterior to the lateral malleolus, passes across the lateral condyle of the knee, the greater trochanter, through the lateral head of the humerus at the tip of the shoulder to the external auditory meatus; if this were a plane through the body, it would intersect the middle of the third lumbar vertebra and the anterior one third of the sacrum. It is used to evaluate the A-P (anterior-posterior) curves of the spine. See also midmalleolar line. (Fig. 16)

guiding: Gentle movement by the operator following the path of least resistance in the movement of a body part within its normal range.

H habituation: Decreased physiologic response to repeated stimulation. hatchet head: See scaphocephaly. health: Adaptive and optimal attainment of physical, mental, emotional, spiritual and environmental well-being. hepatic pump: See osteopathic manipulative treatment, hepatic pump. high velocity/low amplitude technique (HVLA): See osteopathic manipulative treatment, high velocity/low amplitude technique (HVLA). hip bone: See innominate. See also innominate, somatic dysfunctions of. homeostasis: 1. Maintenance of static or constant conditions in the internal environment. 2. The level of wellbeing of an individual maintained by internal physiologic harmony that is the result of a relatively stable state or equilibrium among the interdependent body functions. homeostatic mechanism: A system of control activated by negative feedback (Dorland’s). Hoover technique: See osteopathic manipulative treatment, Hoover technique. hysteresis: During the loading and unloading of connective tissue, the restoration of the final length of the tissue occurs at a rate and to an extent less than during deformation (loading). These differences represent energy loss in the connective tissue system. This difference in viscoelastic behavior (and energy loss) is known as hysteresis (or “stress-strain”). (Foundations, Second Edition, page 1158). hypertonicity: 1. A condition of excessive tone of the skeletal muscles. 2. Increased resistance of muscle to passive stretching.

I ILA: See sacrum, inferior lateral angle of. ilia: The plural of ilium. See ilium. ilial compression test: See ASIS compression test. ilial rocking test: See ASIS compression test.

Figure 16. Gravitational

iliosacral motion: Motion of one innominate (ilium) with respect to the sacrum. Iliosacral motion is part of pelvic motion during the gait cycle.

ilium: the expansive superior portion of the innominate (hip bone or os coxae). indirect method: See osteopathic manipulative treatment, indirect method. inferior ilium: See innominate, somatic dysfunctions of, inferior innominate shear. inferior lateral angle (ILA) of the sacrum: See sacrum, inferior lateral angle. inferior pubis: See pubic bone, somatic dysfunctions of, inferior pubic shear. inferior transverse axis: See sacral motion axis, inferior transverse axis. inhalation rib: See rib somatic dysfunction, inhalation rib dysfunction. inhalation rib restriction: See rib somatic dysfunction, inhalation rib dysfunction. inhalation strain: See rib somatic dysfunction, inhalation rib dysfunction. inhibition reflex: 1. In osteopathic usage, a term that describes the application of steady pressure to soft tissues to effect relaxation and normalize reflex activity. 2. Effect on antagonist muscles due to reciprocal inhibition when the agonist is stimulated. See also law, Sherrington’s. See also osteopathic manipulative treatment, inhibitory pressure technique. inhibitory pressure technique: See osteopathic manipulative treatment, inhibitory pressure technique. innominate: The os coxae is a large irregular shaped bone that consists of three parts: ilium, ischium and pubis, which meet at the acetabulum, the cup shaped cavity for the head of the femur at the hip (femoroacetabular) joint. Also called the innominate bone or pelvic bone. See also hip bone. innominate rotation: Rotational motion of one innominate bone relative to the sacrum on the inferior transverse axis. innominate, somatic dysfunctions of: anterior innominate rotation, a somatic dysfunction in which the anterior superior iliac spine (ASIS) is anterior and inferior to the contralateral landmark. The innominate (os coxae) moves more freely in an anterior and inferior direction, and is restricted from movement in a posterior and superior direction. (Fig. 17) downslipped innominate, See inferior innominate shear. inferior innominate shear, a somatic dysfunction in which the anterior superior iliac spine (ASIS) and posterior superior iliac spines (PSIS) are inferior to the contralateral landmarks. The innominate (os coxa)

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Figure 19. Inflared right innominate. Figure 17. Anterior right innominate. Forced anterior rotation can also result in an inferior pubic shear.

Figure 21. Right posterior innominate. Forced posterior rotation may or may not result in a superior pubic shear.

Figure 20. Outflare right innominate. Figure 18. Right inferior innominate shear. This also may or may not result in an inferior pubic shear. moves more freely in an inferior direction, and is restricted from movement in a superior direction. (Fig. 18) inflared innominate, a somatic dysfunction of the innominate (os coxae) resulting in medial positioning of the anterior superior iliac spine (ASIS). The innominate moves more freely in a medial direction, and is restricted from movement in a lateral direction. (Fig. 19) outflared innominate, a somatic dysfunction of the innominate (os coxae) resulting in lateral positioning of the anterior superior iliac spine (ASIS). The innominate moves more freely in a lateral direction, and is restricted from movement in a medial direction. (Fig. 20) posterior innominate rotation, a somatic dysfunction in which the anterior superior iliac spine (ASIS) is posterior and superior to the contralateral landmarks. The

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innominate (os coxae) moves more freely in a posterior and superior direction, and is restricted from movement in an anterior and inferior direction. (Fig. 21) superior innominate shear, a somatic dysfunction in which the anterior superior iliac spine (ASIS) and posterior superior iliac spines (PSIS) are superior to the contralateral landmarks. The innominate (os coxa) moves more freely in a superior direction, and is restricted from movement in an inferior direction. (Fig. 22) upslipped innominate, See superior innominate shear.

Figure 22. Right superior innominate shear. This also may or may not result in a superior pubic shear.

intrinsic corrective forces: Voluntary or involuntary forces from within the patient that assist in the manipulative treatment process. See also extrinsic corrective forces. -ion: A suffix describing a process or movement (e.g., extension, flexion, rotation, restriction). isokinetic exercise: Exercise using a constant speed of movement of the body part. isolytic contraction: See contraction, isolytic c.

integrated neuromusculoskeletal release: See osteopathic manipulative treatment, integrated neuromusculoskeletal release.

isometric contraction: See contraction, isometric c.

intersegmental motion: Designates relative motion taking place between two adjacent vertebral segments or within a vertebral unit that is described as the upper vertebral segment moving on the lower.

J

isotonic contraction: See contraction, isotonic c.

Jones technique: See osteopathic manipulative treatment, counterstrain.

junctional region: See transitional region.

K key lesion: The somatic dysfunction that maintains a total dysfunction pattern including other secondary dysfunctions. kinesthesia: The sense by which muscular motion, weight, position, etc., are perceived. kinesthetic: Pertaining to kinesthesia. kinetics: The body of knowledge that deals with the effects of forces that produce or modify body motion. klapping: Striking the skin with cupped palms to produce vibrations with the intention of loosening material in the lumen of hollow tubes or sacs within the body, particularly the lungs. kneading: A soft tissue technique that utilizes an intermittent force applied perpendicular to the long axis of the muscle. kyphoscoliosis: A spinal curve pattern combining kyphosis and scoliosis. See also kyphosis. See also scoliosis. kyphosis: 1. The exaggerated (pathologic) A-P curve of the thoracic spine with concavity anteriorly. 2. Abnormally increased convexity in the curvature of the thoracic spine as viewed from the side (Dorland’s). kyphotic: Pertaining to or characterized by kyphosis.

L lateral flexed vertebral body: See sidebent. lateral flexion: Also called lateroflexion. See sidebending.

and inferior thoracic biomechanics. For example, if C1 is in a right posterior positional lesion, L5 also moves into a right posterior position. In this case, L5 is the " Lovett partner" of C1. The treatment of L5 helps to stabilize C1 and the skull by changing the lines of gravity. (French usage). Sherrington l., 1. Every posterior spinal nerve root supplies a specific region of the skin, although fibers from adjacent spinal segments may invade such a region. 2. When a muscle receives a nerve impulse to contract, its antagonist receives, simultaneously, an impulse to relax. (These are only two of Sherrington’s contributions to neurophysiology; these are the ones most relevant to osteopathic principles.) Wolff l., every change in form and function of a bone, or in its function alone, is followed by certain definite changes in its internal architecture, and secondary alterations in its external conformations (Stedman’s, 25th ed.); (e.g., bone is laid down along lines of stress). lesioned components: See osteopathic lesion. See somatic dysfunction. lesion (osteopathic): See osteopathic lesion. l. articular strain, any somatic dysfunction resulting in abnormal ligamentous tension or strain. See also osteopathic manipulative treatment, ligamentous articular strain technique. l. articular strain technique, See osteopathic manipulative treatment, ligamentous articular strain technique. l. strain, motion and/or positional asymmetry associated with elastic deformation of connective tissue (fascia, ligament, membrane). See strain and ligamentous articular strain. line of gravity: See gravitational line.

lateroflexion: See sidebending.

linkage: See somatic dysfunction, linkage.

law:

liver pump: See osteopathic manipulative treatment, hepatic pump.

Head l., when a painful stimulus is applied to a body part of low sensitivity (e.g., viscus) that is in close central connection with a point of higher sensitivity (e.g., soma), the pain is felt at the point of higher sensitivity rather than at the point where the stimulus was applied. Lovett l., States that there is an association between the superior and inferior vertebrae, which are paired two by two. The cervical and superior thoracic biomechanics act in a synchronous manner with the lumbar

lordotic: Pertaining to or characterized by lordosis. lumbarization: See transitional vertebrae, lumbarization. lumbolumbar lordotic angle: See angle, lumbolumbar lordotic. lumbosacral angle: See angle, lumbosacral. lumbosacral lordotic angle: See angle, lumbosacral lordotic. lumbosacral spring test: See spring test. lymphatic pumps: See osteopathic manipulative treatment, lymphatic pump. See also osteopathic manipulative treatment, pedal pump. See also osteopathic manipulative treatment, thoracic pump. lymphatic treatment: Techniques used to optimize function of the lymphatic system. See osteopathic manipulative treatment, lymphatic pump. See also osteopathic manipulative treatment, pedal pump. See also osteopathic manipulative treatment, thoracic pump.

ligamentous:

lateral masses (of the atlas): The most bulky and solid parts of the atlas that support the weight of the head.

Fryette l. of motion, See physiologic motion of the spine.

normal curvature (normal lordosis). (Dorland’s). 2. Hollow back or saddle back; an abnormal extension deformity; anteroposterior curvature of the spine, generally lumbar with the convexity looking anteriorly (Stedman’s).

localization: 1. In manipulative technique, the precise positioning of the patient and vector application of forces required to produce a desired result. 2. The reference of a sensation to a particular locality in the body. longitudinal axis: See sacral, sacral motion axis, longitudinal axis. lordosis: 1. The anterior convexity in the curvature of the lumbar and cervical spine as viewed from the side. The term is used to refer to abnormally increased curvature (hollow back, saddle back, sway back) and to the

M mandibular drainage technique: See osteopathic manipulative treatment, mandibular drainage technique. manipulation: Therapeutic application of manual force. See also technique. See also osteopathic manipulative treatment. manual medicine: The skillful use of the hands to diagnose and treat structural and functional abnormalities in various tissues and organs throughout the body, including bones, joints, muscles and other soft tissues as an integral part of complete medical care. 1. This term originated from the German Manuelle Medizin (manual medicine) and has been used interchangeably with the term manipulation. 2. This term is not identical to manual therapy, which has been used by non-physician practitioners (e.g. physical therapists). massage: Therapeutic friction, stroking, and kneading of the body. See also osteopathic manipulative treatment, soft tissue treatment. mechanoreceptor: A receptor excited by mechanical pressures or distortions, such as those responding to touch and muscular contractions. (Dorland’s).

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membranous articular strain: Any cranial somatic dysfunction resulting in abnormal dural membrane tensions. membranous balance: The ideal physiologic state of harmonious equilibrium in the tension of the dura mater of the brain and spinal cord. mesenteric lift: See osteopathic manipulative treatment, mesenteric release technique. mesenteric release technique: See osteopathic manipulative treatment, mesenteric release technique. middle transverse axis: See sacral motion axis, middle transverse axis (postural). mid-heel line: A vertical line used as a reference in standing anteroposterior (A-P) x-rays and postural evaluation, passing equidistant between the heels. mid-gravitational line: See gravitational line. mid-malleolar line: A vertical line passing through the lateral malleolus, used as a point of reference in standing lateral x-rays and postural evaluation. See also gravitational line. mirror-image motion asymmetries: A grouping of primary and secondary sites of somatic dysfunction describing a three-segment complex fundamental to dysfunction in a mobile system. Each adjacent segment, above and below the primary locus, demonstrates opposing asymmetries to that locus. For example, if the primary locus resists rotation right, the segments above and below resist rotation left. mobile point: In counterstrain, the final position of treatment at which tenderness is no longer elicited by palpation of the tender point. mobile segment: A term in functional methods to describe a bony structure with its articular surfaces and adnexal tissues (neuromuscular and connective) for segmental motion which affects movement, stabilizes position and allows coordinated participation in passive movement. mobile system: An osteopathic construct associated with functional methods in which the body as a whole is viewed as a centrally integrated system in which all of the individual elements (e.g. mobile segments) have coordinated and specific motion characteristics. See also functional methods. mobile unit: See mobile segment. models of osteopathic care: Five models that articulate how an osteopathic practitioner seeks to influence a patient’s physiological processes. structural model, the goal of the structural model is biomechanical

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adjustment and the mobilization of joints. This model also seeks to address problems in the myofascial connective tissues, as well as in the bony and soft tissues to remove restrictive forces and enhance motion. This is accomplished by the use of a wide range of osteopathic manipulative techniques such as high velocity-low amplitude, muscle energy, counterstrain, myofascial release, ligamentous articular techniques and functional techniques. respiratory-circulatory model, the goal of the respiratory-circulatory model is to improve all of the diaphragm restrictions in the body. Diaphragms are considered to be “transverse restrictors” of motion, venous and lymphatic drainage and cerebrospinal fluid. The techniques used in this model are osteopathy in the cranial field, ligamentous articular strain, myofascial release and lymphatic pump techniques. metabolic model, the goal of the metabolic model is to enhance the selfregulatory and self-healing mechanisms, to foster energy conservation by balancing the body’s energy expenditure and exchange, and to enhance immune system function, endocrine function and organ function. The osteopathic considerations in this area are not manipulative in nature except for the use of lymphatic pump techniques. Nutritional counseling, diet and exercise advice are the most common approaches to balancing the body through this model. neurologic model, the goal of the neurologic model is to attain autonomic balance and address neural reflex activity, remove facilitated segments, decrease afferent nerve signals and relieve pain. The osteopathic manipulative techniques used to influence this area of patient health include counterstrain and Chapman reflex points. behavioral model, the goal of this model is to improve the biological, psychological and social components of the health spectrum. This includes emotional balancing and compensatory mechanisms. Reproductive processes and behavioral adaption are also included under this model. motion: 1. A change of position (rotation, and/or translation) with respect to a fixed system; 2. An act or process of a body changing position in terms of direction, course and velocity. active m., movement produced voluntarily by the patient.

inherent m., spontaneous motion of every cell, organ, system and their component units within the body. m. barrier, See barrier (motion barrier). passive m., motion induced by the osteopathic practitioner while the patient remains passive or relaxed. physiologic m., changes in position of body structures within the normal range. See also physiologic motion of the spine. translatory m., motion of a body part along an axis. See also translation. muscle energy technique: See osteopathic manipulative treatment, muscle energy. myofascial release technique: See osteopathic manipulative treatment, myofascial release. myofascial technique: See osteopathic manipulative treatment, myofascial technique. myofascial trigger point: See trigger point. myogenic tonus: 1. Tonic contraction of muscle dependent on some property of the muscle itself or of its intrinsic nerve cells. 2. Contraction of a muscle caused by intrinsic properties of the muscle or by its intrinsic innervation (Stedman’s). myotome: 1. All muscles derived from one somite and innervated by one segmental spinal nerve. 2. That part of the somite that develops into skeletal muscle (Stedman’s).

N neurotrophicity: See neurotrophy. neurotrophy: The nutrition and maintenance of tissues as regulated by direct innervation. neutral: 1. The range of sagittal plane spinal positioning in which the first principle of physiologic motion of the spine applies. See also physiologic motion of the spine. 2. The point of balance of an articular surface from which all the motions physiologic to that articulation may take place. (Fig. 23) NMM-OMM: Osteopathic neuromusculoskeletal medicine certification is granted by the American Osteopathic Association through the American Osteopathic Board of Neuromusculoskeletal Medicine. First granted in 1999. non-neutral: The range of sagittal plane spinal positioning in which the second principle of physiologic motion of the

standards for osteopaths practicing within their countries (International usage). 2. Considered by the American Osteopathic Association to be an archaic term when applied to graduates of U.S. schools. osteopathic lesion (osteopathic lesion complex): Archaic term used to describe somatic dysfunction. See somatic dysfunction. Osteopathic Manipulative Medicine (OMM): The application of osteopathic philosophy, structural diagnosis and use of OMT in the diagnosis and management of the patient.

Figure 23. Neutral spinal position.

spine applies. See also extension. See also flexion. See also physiologic motion of the spine. normalization: The therapeutic use of anatomic and physiologic mechanisms to facilitate the body’s response toward homeostasis and improved health. NSR: A descriptor of spinal somatic dysfunction used to denote a combination neutral (N), sidebent (S), and rotated (R) vertebral position; similar descriptors may involve flexed (F) and extended (E) position. nutation: Nodding forward; anterior movement of the sacral base around a transverse axis in relation to the ilia.

O oblique axis: See sacral motion axis, oblique (diagonal). OMM: See osteopathic manipulative medicine. OMTh: See osteopathic manipulative therapy. OMT: See osteopathic manipulative treatment. ONM: See NMM-OMM. OP&P: Osteopathic principles and practice. See also osteopathic philosophy. os coxae: See innominate. -osis: word element [GR], disease; morbid state; abnormal increase. osteopath: 1. A person who has achieved the nationally recognized academic and professional standards within her or his country to independently practice diagnosis and treatment based upon the principles of osteopathic philosophy. Individual countries establish the national academic and professional

Osteopathic Manipulative Therapy (OMTh): the therapeutic application of manually guided forces by an osteopath (non-physician) to improve physiological function and homeostasis that has been altered by somatic dysfunction. Osteopathic Manipulative Treatment (OMT): The therapeutic application of manually guided forces by an osteopathic physician (US Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. OMT employs a variety of techniques including: active method, technique in which the person voluntarily performs an osteopathic practitioner-directed motion. articulatory treatment, (archaic). See osteopathic manipulative treatment, articulatory treatment system. articulatory treatment system (ART), a low velocity/moderate to high amplitude technique where a joint is carried through its full motion with the therapeutic goal of increased range of movement. The activating force is either a repetitive springing motion or repetitive concentric movement of the joint through the restrictive barrier. balanced ligamentous tension (BLT), 1. According to Sutherland’s model, all the joints in the body are balanced ligamentous articular mechanisms. The ligaments provide proprioceptive information that guides the muscle response for positioning the joint and the ligaments themselves guide the motion of the articular components. (Foundations) 2. First described in “Osteopathic Technique of William G. Sutherland”, that was published in the 1949 Year Book of Academy of Applied Osteopathy. See also ligamentous articular strain. Chapman reflex, See Chapman reflex. combined method, 1. A treatment strategy where the initial movements are indirect; as the technique is

completed the movements change to direct forces. 2. A manipulative sequence involving two or more different osteopathic manipulative treatment systems (e.g., Spencer technique combined with muscle energy technique). 3. A concept described by Paul Kimberly, DO. combined treatment, (archaic). See osteopathic manipulative treatment, combined method. compression of the fourth ventricle (CV-4), a cranial technique in which the lateral angles of the occipital squama are manually approximated slightly exaggerating the posterior convexity of the occiput and taking the cranium into sustained extension. counterstrain (CS), 1. A system of diagnosis and treatment that considers the dysfunction to be a continuing, inappropriate strain reflex, which is inhibited by applying a position of mild strain in the direction exactly opposite to that of the reflex; this is accomplished by specific directed positioning about the point of tenderness to achieve the desired therapeutic response. 2. Australian and French use: Jones technique, (correction spontaneous by position), spontaneous release by position. 3. Developed by Lawrence Jones, DO. cranial treatment (CR), See primary respiratory mechanism. See osteopathy in the cranial field. CV-4, Abbreviation for compression of the fourth ventricle. See osteopathic manipulative treatment, compression of the fourth ventricle. Dalrymple treatment, See osteopathic manipulative treatment, pedal pump. direct method (D/DIR), an osteopathic treatment strategy by which the restrictive barrier is engaged and a final activating force is applied to correct somatic dysfunction. exaggeration method, an osteopathic treatment strategy by which the dysfunctional component is carried away from the restrictive barrier and beyond the range of voluntary motion to a point of palpably increased tension. exaggeration technique, an indirect procedure that involves carrying the dysfunctional part away from the restrictive barrier, then applying a high velocity/low amplitude force in the same direction. facilitated oscillatory release technique (FOR), 1. A technique intended to normalize neuromuscular function by applying a manual oscillatory force, which may be combined with any other ligamentous

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or myofascial technique. 2. A refinement of a long-standing use of oscillatory force in osteopathic diagnosis and treatment as published in early osteopathic literature. 3. A technique developed by Zachary Comeaux, DO.

indirect method (I/IND), a manipulative technique where the restrictive barrier is disengaged and the dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in one or all planes and directions.

facilitated positional release (FPR), a system of indirect myofascial release treatment. The component region of the body is placed into a neutral position, diminishing tissue and joint tension in all planes, and an activating force (compression or torsion) is added. 2. A technique developed by Stanley Schiowitz, DO.

inhibitory pressure technique, the application of steady pressure to soft tissues to reduce reflex activity and produce relaxation.

fascial release treatment, See osteopathic manipulative treatment, myofascial release. fascial unwinding, a manual technique involving constant feedback to the osteopathic practitioner who is passively moving a portion of the patient’s body in response to the sensation of movement. Its forces are localized using the sensations of ease and bind over wider regions. functional method, an indirect treatment approach that involves finding the dynamic balance point and one of the following: applying an indirect guiding force, holding the position or adding compression to exaggerate position and allow for spontaneous readjustment. The osteopathic practitioner guides the manipulative procedure while the dysfunctional area is being palpated in order to obtain a continuous feedback of the physiologic response to induced motion. The osteopathic practitioner guides the dysfunctional part so as to create a decreasing sense of tissue resistance (increased compliance). Galbreath treatment, See osteopathic manipulative treatment, mandibular drainage. hepatic pump, rhythmic compression applied over the liver for purposes of increasing blood flow through the liver and enhancing bile and lymphatic drainage from the liver. high velocity/low amplitude technique (HVLA), An osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. Also known as thrust technique. Hoover technique, 1. A form of functional method. 2. Developed by H.V. Hoover, DO. See also osteopathic manipulative treatment, functional technique.

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integrated neuromusculoskeletal release (INR), a treatment system in which combined procedures are designed to stretch and reflexly release patterned soft tissue and joint-related restrictions. Both direct and indirect methods are used interactively. Jones technique, See osteopathic manipulative treatment, counterstrain. ligamentous articular strain technique (LAS), 1. A manipulative technique in which the goal of treatment is to balance the tension in opposing ligaments where there is abnormal tension present. 2. A set of myofascial release techniques described by Howard Lippincott, DO, and Rebecca Lippincott, DO. 3. Title of reference work by Conrad Speece, DO, and William Thomas Crow, DO. liver pump, See hepatic pump lymphatic pump, 1. A term used to describe the impact of intrathoracic pressure changes on lymphatic flow. This was the name originally given to the thoracic pump technique before the more extensive physiologic effects of the technique were recognized. 2. A term coined by C. Earl Miller, DO. mandibular drainage technique, soft tissue manipulative technique using passively induced jaw motion to effect increased drainage of middle ear structures via the eustachian tube and lymphatics. mesenteric release technique (mesenteric lift), technique in which tension is taken off the attachment of the root of the mesentery to the posterior body wall. Simultaneously, the abdominal contents are compressed to enhance venous and lymphatic drainage from the bowel. muscle energy, 1. A system of diagnosis and treatment in which the patient voluntarily moves the body as specifically directed by the osteopathic practitioner. This directed patient action is from a precisely controlled position against a defined resistance by the osteopathic practitioner. 2. Refers to a concept first used by Fred L. Mitchell, Sr, DO, originally called muscle energy treatment.

myofascial release (MFR), a system of diagnosis and treatment first described by Andrew Taylor Still and his early students, which engages continual palpatory feedback to achieve release of myofascial tissues. direct MFR, a myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with a constant force until tissue release occurs. indirect MFR, the dysfunctional tissues are guided along the path of least resistance until free movement is achieved. myofascial technique, any technique directed at the muscles and fascia. See also osteopathic manipulative treatment, myofascial release. See also osteopathic manipulative treatment, soft tissue technique. myotension, a system of diagnosis and treatment that uses muscular contractions and relaxations under resistance of the osteopathic practitioner to relax, strengthen or stretch muscles, or mobilize joints. Osteopathy in the Cranial Field (OCF), 1. A system of diagnosis and treatment by an osteopathic practitioner using the primary respiratory mechanism and balanced membranous tension. See also primary respiratory mechanism. 2. Refers to the system of diagnosis and treatment first described by William G. Sutherland, DO. 3. Title of reference work by Harold Magoun, Sr, DO. passive method, based on techniques in which the patient refrains from voluntary muscle contraction. pedal pump, a venous and lymphatic drainage technique applied through the lower extremities; also called the pedal fascial pump or Dalrymple treatment. percussion vibrator technique, 1. A manipulative technique involving the specific application of mechanical vibratory force to treat somatic dysfunction. 2. An osteopathic manipulative technique developed by Robert Fulford, DO. positional technique, a direct segmental technique in which a combination of leverage, patient ventilatory movements and a fulcrum are used to achieve mobilization of the dysfunctional segment. May be combined with springing or thrust technique. progressive inhibition of neuromuscular structures (PINS), 1. A system of diagnosis and treatment in which the osteopathic practitioner

locates two related points and sequentially applies inhibitory pressure along a series of related points. 2. Developed by Dennis Dowling, DO. range of motion technique, active or passive movement of a body part to its physiologic or anatomic limit in any or all planes of motion. soft tissue (ST), A system of diagnosis and treatment directed toward tissues other than skeletal or arthrodial elements. soft tissue technique, a direct technique that usually involves lateral stretching, linear stretching, deep pressure, traction and/or separation of muscle origin and insertion while monitoring tissue response and motion changes by palpation. Also called myofascial treatment. Spencer technique, a series of direct manipulative procedures to prevent or decrease soft tissue restrictions about the shoulder. See also osteopathic manipulative treatment (OMT), articulatory treatment (ART) splenic pump technique, rhythmic compression applied over the spleen for the purpose of enhancing the patient’s immune response. See also osteopathic manipulative treatment (OMT), lymphatic pump. spontaneous release by positioning, See osteopathic manipulative treatment, counterstrain. springing technique, a low velocity/ moderate amplitude technique where the restrictive barrier is engaged repeatedly to produce an increased freedom of motion. See also osteopathic manipulative treatment, articulatory treatment system. Still Technique, 1. Characterized as a specific non-repetitive articulatory method that is indirect then direct. 2. Attributed to A.T. Still. 3. A term coined by Richard Van Buskirk, DO, PhD. Strain-Counterstrain®, An osteopathic system of diagnosis and indirect treatment in which the patient’s somatic dysfunction, diagnosed by (an) associated myofascial tenderpoint(s), is treated by using a passive position, resulting in spontaneous tissue release and at least 70 percent decrease in tenderness. 2). Developed by Lawrence H. Jones, DO, in 1955. See osteopathic treatments, counterstrain.

an allopathic physician who has been trained in osteopathic principles, practices and philosophy.

high velocity/low amplitude technique (HVLA). toggle technique, short lever technique using compression and shearing forces. traction technique, a procedure of high or low amplitude in which the parts are stretched or separated along a longitudinal axis with continuous or intermittent force. v-spread, technique using forces transmitted across the diameter of the skull to accomplish sutural gapping. ventral techniques, See osteopathic manipulative treatment, visceral manipulation. visceral manipulation (VIS), a system of diagnosis and treatment directed to the viscera to improve physiologic function. Typically, the viscera are moved toward their fascial attachments to a point of fascial balance. Also called ventral techniques. osteopathic musculoskeletal evaluation: The osteopathic musculoskeletal evaluation provides information regarding the health of the patient. Utilizing the concepts of body unity, self-regulation and structure-function interrelationships, the osteopathic physician uses data from the musculoskeletal evaluation to assess the patient’s status and develop a treatment plan. (AOA House of Delegates) osteopathic philosophy: a concept of health care supported by expanding scientific knowledge that embraces the concept of the unity of the living organism’s structure (anatomy) and function (physiology). Osteopathic philosophy emphasizes the following principles: 1. The human being is a dynamic unit of function. 2. The body possesses self-regulatory mechanisms that are self-healing in nature. 3. Structure and function are interrelated at all levels. 4. Rational treatment is based on these principles. osteopathic physician: a person with full unlimited medical practice rights who has achieved the nationally recognized academic and professional standards within his or her country to practice diagnosis and treatment based upon the principles of osteopathic philosophy. Individual countries establish the national academic and professional standards for osteopathic physicians practicing within their countries.

thoracic pump, 1. A technique that consists of intermittent compression of the thoracic cage. 2. Developed by C. Earl Miller, DO

osteopathic postural examination: The part of the osteopathic musculoskeletal examination that focuses on the static and dynamic responses of the body to gravity while in the erect position.

thrust technique (HVLA), See osteopathic manipulative treatment,

osteopathic practitioner: Refers to an osteopath, an osteopathic physician or

osteopathic structural examination: The examination of a patient by an osteopathic practitioner with emphasis on the neuromusculoskeletal system including palpatory diagnosis for somatic dysfunction and viscerosomatic change within the context of total patient care. The examination is concerned with finding somatic dysfunction in all parts of the body, and is performed with the patient in multiple positions to provide static and dynamic evaluation. osteopathy (osteopathic medicine): A complete system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery and obstetrics. Emphasizes the interrelationship between structure and function, and has an appreciation of the body’s ability to heal itself.

P palpation: The application of the fingers to the surface of the skin or other tissues, using varying amounts of pressure, to selectively determine the condition of the parts beneath. palpatory diagnosis: A term used by osteopathic practitioners to denote the process of palpating the patient to evaluate the structure and function of the neuromusculoskeletal and visceral systems. palpatory skills: Sensory skills used in performing palpatory diagnosis and osteopathic manipulative treatment. passive method: See osteopathic manipulative treatment, passive method. passive motion: See motion, passive motion. patient cooperation: Voluntary movement by the patient (on instruction from the osteopathic practitioner) to assist in the palpatory diagnosis and treatment process. pedal pump: See osteopathic manipulative treatment, pedal pump. pelvic bone: See hip bone. pelvic declination (pelvic unleveling): Pelvic rotation about an anteriorposterior (A-P) axis. pelvic index (PI): Represents a ratio of the measurements determined from postural radiograph: One (y) beginning from a vertical line originating at the sacral promontory to the intersection with the horizontal line from the anterior-superior position of the pubic bone. The second measurement (x) is

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along this same horizontal line. Normal values are age-related and increase in subjects with sagittal plane postural decompensation. Pelvic index (PI) equals x/y. (Fig. 24)

opposite directions (with rotation occurring toward the convexity). (Fig. 25). See somatic dysfunction, type I s.d.

III. 1. Initiating motion of a vertebral segment in any plane of motion will modify the movement of that segment in other planes of motion. 2. Principles I and II of thoracic and lumbar spinal motion described by Harrison H. Fryette, DO (1918), Principle III was described by C.R. Nelson, DO (1948). See rotation. See also rotation of vertebra. plagiocephaly: An asymmetric condition of the head. plane: A flat surface determined by the position of three points in space. Any of a number of imaginary surfaces passing through the body and dividing it into segments. (Fig. 27) AP plane, See plane, sagittal plane.

Figure 24. Pelvic index (PI). (Modified from Kuchera WA, Kuchera ML, Osteopathic Principles in Practice, Greyden Press, Columbus, OH, 1994:263). pelvic rotation: Movement of the entire pelvis in a relatively horizontal plane about a vertical (longitudinal) axis. pelvic sideshift: Deviation of the pelvis to the right or left of the central vertical axis as translation occurs along the horizontal (z) axis. Usually observed in the standing position.

Figure 25. Physiologic motion of the thoracic or lumbar spine resulting from a neutral spinal position (Type I motion). II. When the thoracic and lumbar spine are sufficiently forward or backward bent (non-neutral), the coupled motions of sidebending and rotation in a single vertebral unit occur in the same direction. (Fig. 26) See somatic dysfunction, type II, s.d.

pelvic tilt: Pelvic rotation about a transverse (horizontal) axis (forward or backward tilt) or about an anteriorposterior axis (right or left side tilt).

Figure 27. Planes of the body.

pelvis: Within the context of structural diagnosis, the pelvis is made up of the right and left innominates, (hip bone or os coxae) the sacrum and coccyx.

coronal plane (frontal plane), a plane passing longitudinally through the body from one side to the other, and dividing the body into anterior and posterior portions.

percussion vibrator technique: See osteopathic manipulative treatment, percussion vibrator technique.

frontal plane, See plane, coronal plane.

pétrissage: Deep kneading or squeezing action to express swelling.

horizontal plane, See plane, transverse plane.

physiologic barrier: See barrier, physiologic barrier.

sagittal plane, a plane passing longitudinally through the body from front to back and dividing it into right and left portions. The median or midsagittal plane divides the body into approximately equal right and left portions.

physiologic motion: See motion, physiologic motion. physiologic motion of the spine: The three major principles of physiologic motion are: I. When the thoracic and lumbar spine are in a neutral position (easy normal; See neutral Fig. 23), the coupled motions of sidebending and rotation for a group of vertebrae are such that sidebending and rotation occur in

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Figure 26. Physiologic motion of the thoracic or lumbar spine resulting from a non-neutral spinal position (Type II motion).

transverse plane (horizontal plane), a plane passing horizontally through the body perpendicular to the sagittal and frontal planes, dividing the body into upper and lower portions.

plastic deformation: A non-recoverable deformation. See also elastic deformation. plasticity: Ability to retain a shape attained by deformation. See also elasticity. See also viscosity. positional technique: See osteopathic manipulative treatment, positional technique. posterior component: A positional descriptor used to identify the side of reference when rotation of a vertebral segment has occurred. In a condition of right rotation, the right side is the posterior component. It usually refers to a prominent vertebral transverse process. See also anterior component. posterior nutation: See counternutation. post-isometric relaxation: Immediately following an isometric contraction, the neuromuscular apparatus is in a refractory state during which enhanced passive stretching may be performed. The osteopathic practitioner may take up the myofascial slack during the relaxed refractory period. postural axis: See sacral motion axis, postural axis. postural balance: A condition of optimal distribution of body mass in relation to gravity. postural decompensation: Distribution of body mass away from ideal when postural homeostatic mechanisms are overwhelmed. It occurs in all cardinal planes, but is classified by the major plane(s) affected. See planes of the body (Fig. 27). coronal plane p. d., causes scoliotic changes. horizontal plane p. d., may cause postural changes where part or all of the body rotates to the right or left. When viewed from the right or left sides, alignment appears asymmetrical. sagittal plane p. d., causes kyphotic and/or lordotic changes. postural imbalance: A condition in which ideal body mass distribution is not achieved. posture: Position of the body. The distribution of body mass in relation to gravity. primary machinery of life: The neuromusculoskeletal system. A term used to denote that body parts act together to transmit and modify force and motion through which man acts out his life. This integration is achieved via the central nervous system acting in response to continued sensory input from the internal and external environment. 2. A term coined by I.M. Korr, PhD.

primary respiratory mechanism: 1. A conceptual model that describes a process involving five interactive, involuntary functions: (1). The inherent motility of the brain and spinal cord. (2). Fluctuation of the cerebrospinal fluid. (3). Mobility of the intracranial and intraspinal membranes. (4). Articular mobility of the cranial bones. (5). Mobility of the sacrum between the ilia (pelvic bones) that is interdependent with the motion at the sphenobasilar synchondrosis. This mechanism refers to the presumed inherent (primordial) driving mechanism of internal respiration as opposed to the cycle of diaphragmatic respiration (inhalation and exhalation). It further refers to the innate interconnected movement of every tissue and structure of the body. Optimal health promotes optimal function and the inherent function of this interdependent movement can be negatively altered by trauma, disease states or other pathology. 2. This mechanism was first described by William G. Sutherland, DO, and is thought to affect cellular respiration and other body processes. In the original definition, the following descriptions were given: primary, because it is directly concerned with the internal tissue respiration of the central nervous system. respiratory, because it further concerns the physiological function of the interchange of fluids necessary for normal metabolism and biochemistry, not only of the central nervous system, but also of all body cells.

resulting in lowering of the medial margin of the foot. See also supination. prone: Lying face downward (Dorland’s). psoas syndrome: A painful low back condition characterized by hypertonicity of psoas musculature. The syndrome consists of a constellation of typically related signs and symptoms: typical posture, flexion at the hip and sidebending of the lumbar spine to the side of the most hypertonic psoas muscle. typical gait, Trendelenburg gait. typical pain pattern, low back pain frequently accompanied by pain on the lateral aspect of the lower extremity extending no lower than the knee. typical associated somatic dysfunctions, as a long restrictor muscle, psoas hypertonicity is frequently associated with flexed dysfunctions of the upper lumbars, extended dysfunction of L5, and variable sacral and innominate dysfunctions. Tender points typically are found in the ipsilateral iliacus and contralateral piriformis muscles. pubic bone, somatic dysfunctions of: anterior pubic shear, a somatic dysfunction in which one pubic bone is displaced anteriorly with relation to its normal mate. inferior pubic shear, a somatic dysfunction in which one pubic bone is displaced inferiorly with relation to its normal mate. (Fig. 28)

mechanism, because all the constituent parts work together as a unit carrying out this fundamental physiology. See also osteopathic manipulative treatment (OMT), osteopathy in the cranial field prime mover: A muscle primarily responsible for causing a specific joint action.

Figure 28. Right inferior pubic shear.

progressive inhibition of neuromuscular structures (PINS): See osteopathic manipulative treatment, Progressive Inhibition of Neuromuscular Structures.

posterior pubic shear, a somatic dysfunction in which one pubic bone is displaced posteriorly with relation to its normal mate.

prolotherapy: See sclerotherapy. pronation: In relation to the anatomical position, as applied to the hand, rotation of the forearm in such a way that the palmar surface turns backward (internal rotation) in relationship to the anatomical position. Applied to the foot: a combination of eversion and abduction movements taking place in the tarsal and metatarsal joints,

pubic abduction, See pubic gapping. pubic adduction, See pubic compression. pubic compression (pubic adduction), a somatic dysfunction in which the pubic bones are forced toward each other at the pubic symphysis. This dysfunction is characterized by tenderness to palpation over the pubic symphysis, lack of apparent asymmetry, but

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associated with restricted motion of the pelvic ring. (Fig. 29)

reciprocal tension membrane: The intracranial and spinal dural membrane including the falx cerebri, falx cerebelli, tentorium and spinal dura. red reflex: See reflex, red r. reflex: An involuntary nervous system response to a sensory input. The sum total of any particular involuntary activity. See also Chapman reflexes. cephalogyric reflex, See oculocephalogyric r.

Figure 29. Pubic compression. pubic gapping (pubic abduction), a somatic dysfunction in which the pubic bones are pulled away from each other at the pubic symphysis. This dysfunction is frequently seen in women following childbirth. (Fig. 30)

cervicolumbar r., automatic contraction of the lumbar paravertebral muscles in response to contraction of postural muscles in the neck. conditioned r., one that does not occur naturally in the organism or system, but that is developed by regular association of some physiological function with a related outside event. myotatic r., tonic contraction of the muscles in response to a stretching force, due to stimulation of muscle receptors (e.g.: deep tendon reflex).

Seated flexion test = Bilaterally (+) (False negative)

Figure 30. Pubic gapping ( pubic abduction) superior pubic shear, a somatic dysfunction in which one pubic bone is displaced superiorly with relation to its normal mate. (Fig. 31)

Figure 31. Right superior pubic shear. pubic symphysis, somatic dysfunctions of: See pubic bone, somatic dysfunctions of. pump handle rib motion: See rib motion, pump handle motion.

R range of motion technique: See osteopathic manipulative treatment, range of motion technique. reciprocal inhibition: The inhibition of antagonist muscles when the agonist is stimulated. See also laws, Sherrington’s.

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oculocephalogyric r., (oculogyric reflex, cephalogyric reflex), automatic movement of the head that leads or accompanies movement of the eyes. oculogyric reflex. See oculocephalogyric r. red r., 1. The erythematous biochemical reaction (reactive hyperemia) of the skin in an area that has been stimulated mechanically by friction. The reflex is greater in degree and duration in an area of acute somatic dysfunction as compared to an area of chronic somatic dysfunction. It is a reflection of the segmentally related sympathicotonia commonly observed in the paraspinal area. 2. A red glow reflected from the fundus of the eye when a light is cast upon the retina. somatosomatic r., localized somatic stimuli producing patterns of reflex response in segmentally related somatic structures. somatovisceral r., localized somatic stimulation producing patterns of reflex response in segmentally related visceral structures. viscerosomatic r., localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures. viscerovisceral r., localized visceral stimuli producing patterns of reflex response in segmentally related visceral structures. regenerative injection therapy (RIT): See sclerotherapy. region: 1. An anatomical division of the body defined either by natural,

functional or arbitrary boundaries. 2. Body areas for the diagnosis and coding of somatic dysfunction as defined in the International Classification of Diseases (currently ICD-9 CM) using the codes: 739.0 somatic dysfunction, head 739.1 somatic dysfunction, cervical 739.2 somatic dysfunction, thoracic 739.3 somatic dysfunction, lumbar 739.4 somatic dysfunction, sacrum 739.5 somatic dysfunction, pelvis 739.6 somatic dysfunction, lower extremity 739.7 somatic dysfunction, upper extremity 739.8 somatic dysfunction, rib cage 739.9 somatic dysfunction, abdomen/other See also transitional region. regional extension: See extension, regional extension. regional motor inputs: Motion initiated by an osteopathic practitioner through body contact and vector input that produces a specific response at each segment in the mobile system. resilience: Property of returning to the former shape or size after mechanical distortion. See also elasticity. See also plasticity. respiratory axis of the sacrum: See sacral motion axis, superior transverse axis. respiratory cooperation: An osteopathic practitioner-directed inhalation and/or exhalation by the patient to assist the manipulative treatment process. restriction: A resistance or impediment to movement. For joint restriction, See barrier (motion barrier). retrolisthesis: Posterior displacement of one vertebra relative to the one immediately below. rib lesion: (Archaic) See rib somatic dysfunction. rib motion: axis of rib motion, an imaginary line through the costotransverse and the costovertebral articulations of the rib. anteroposterior rib axis, (Fig. 32) See also bucket handle rib motion. bucket handle motion, movement of the ribs during respiration such that with inhalation, the lateral aspect of the rib moves cephalad resulting in an increase of transverse diameter of the thorax. This type of rib motion is predominantly found in lower ribs, increasing in motion from the upper to the lower ribs. (Fig. 33) See also rib motion, axis of. See also rib motion, pump handle. caliper rib motion, Rib motion of ribs 11 and 12 characterized by single joint

being held in a position of inhalation such that motion toward inhalation is more free and motion toward exhalation is restricted. Synonyms: inhaled rib, anterior rib, elevated rib, ropiness: A tissue texture abnormality characterized by a cord-like feeling. See also tissue texture abnormality. rotation: Motion about an axis. rotation dysfunction of the sacrum, See sacrum, somatic dysfunctions of.

Figure 32. The functional anterior-posterior rib axis.

Figure 33. Bucket handle rib motion.

motion; analogous to internal and external rotation. exhalation rib restriction, involves a rib or group of ribs that first stops moving during exhalation. The key rib is the bottom rib in the group. See also rib somatic dysfunction, inhalation rib dysfunction. inhalation rib restriction, involves a rib or group of ribs that first stops moving during inhalation. The key rib is the top rib in the group. See also rib somatic dysfunction, exhalation rib dysfunction. pump handle motion, movement of the ribs during respiration such that with inhalation the anterior aspect of the rib moves cephalad and causes an increase in the anteroposterior diameter of the thorax. This type of rib motion is found predominantly in the upper ribs, decreasing in motion from the upper to the lower ribs. (Fig. 34) See rib motion, axis of. See also rib motion, bucket handle motion. transverse rib axis, (Fig. 35) See rib motion, pump handle rib motion

.

Figure 34. Pump handle rib motion.

rotation of sacrum, movement of the sacrum about a vertical (y) axis (usually in relation to the innominate bones). rotation of vertebra, movement about the anatomical vertical axis (y axis) of a vertebra; named by the motion of a midpoint on the anterior-superior surface of the vertebral body. (Fig. 36)

Figure 35. The functional transverse rib axis. inhalation. See also rib motion, inhalation rib restriction. See also rib motion, exhalation rib restriction. rib somatic dysfunction: A somatic dysfunction in which movement or position of one or several ribs is altered or disrupted. For example, an elevated rib is one held in a position of inhalation such that motion toward inhalation is freer, and motion toward exhalation is restricted. A depressed rib is one held in a position of exhalation such that motion toward exhalation is freer and there is a restriction in inhalation. See also rib motion, inhalation rib restriction. See also rib motion, exhalation rib restriction. exhalation rib dysfunction, 1. Somatic dysfunction characterized by a rib being held in a position of exhalation such that motion toward exhalation is more free and motion toward inhalation is restricted. Synonyms: inhalation rib restriction depressed rib. 2. An anterior rib tender point in counterstrain. See also rib motion, inhalation rib restriction. inhalation rib dysfunction, A somatic dysfunction characterized by a rib

Figure 36. Rotation of a vertebra (lumbar).

rule of threes: A method to locate the approximate position of the transverse process (TP) of a thoracic segment by using the location of the spinous process (SP) of that same vertebra. The relationship is as follows: T1 to T3, TP is at the same level as tip of the SP T4 to T6, TP is one half vertebral level above the tip of the SP T7 to T9, TP is one full vertebral level above the tip of the SP T10, TP is one full vertebral level above the tip of the SP T11, TP is one half vertebral level above the tip of the SP T12, TP is at the same level as tip of the SP.

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S sacral base: 1. In osteopathic palpation, the uppermost posterior portion of the sacrum. 2. The most cephalad portion of the first sacral segment (Gray’s Anatomy). sacral base anterior: See sacrum, somatic dysfunctions of, bilateral sacral flexion. sacral base declination (unleveling): With the patient in a standing or seated position, any deviation of the sacral base from the horizontal in a coronal plane. Generally, the rotation of the sacrum about an anterior-posterior axis. sacral base posterior: See sacrum, somatic dysfunctions of, bilateral sacral flexion. sacral base unleveling: See sacral base declination. sacralization: See transitional vertebrae, sacralization. sacral movement axis: any of the hypothetical axes for motion of the sacrum. (Fig. 37, Fig. 38)

anterior-posterior (x) axis, axis formed at the line of intersection of a sagittal and transverse plane. inferior transverse axis (innominate), the hypothetical functional axis of sacral motion that passes from side to side on a line through the inferior auricular surface of the sacrum and ilia, and represents the axis for movement of the ilia on the sacrum. 2. A term described by Fred Mitchell, Sr, DO. (Fig. 37) longitudinal axis, the hypothetical axis formed at the line of intersection of the midsagittal plane and a coronal plane, See sacral motion axis, vertical (y) axis longitudinal. (Fig. 38) middle transverse axis (postural), the hypothetical functional axis of sacral nutation/counternutation in the standing position, passing horizontally through the anterior aspect of the sacrum at the level of the second sacral segment. 2. A term described by Fred Mitchell, Sr, DO. (Fig. 37)

sacral torsion: 1. A physiologic function occurring in the sacrum during ambulation and forward bending. 2. A sacral somatic dysfunction around an oblique axis in which a torque occurs between the sacrum and innominates. The L5 vertebra rotates in the opposite direction of the sacrum. 3. If the L5 does not rotate opposite to the sacrum, L5 is termed maladapted. 4. Other terms for this maladaption include: rotations about an oblique axis, anterior or posterior sacrum and a torsion with a non-compensated L5 (Archaic use). See also sacrum, somatic dysfunctions of. sacroiliac motion: Motion of the sacrum in relationship to the innominate(s) (ilium/ilia). sacrum, inferior lateral angle (ILA) of: The point on the lateral surface of the sacrum where it curves medially to the body of the fifth sacral vertebrae (Gray’s Anatomy). (Fig. 39, Fig. 40)

oblique axis (diagonal), a hypothetical functional axis from the superior area of a sacroiliac articulation to the contralateral inferior sacroiliac articulation. It is designated as right or left relevant to its superior point of origin. 2. A term described by Fred Mitchell, Sr, DO. (Fig. 38) postural axis, See sacrum, middle transverse axis (postural). (Fig. 37) respiratory axis, See sacrum, superior transverse axis (respiratory). (Fig. 37)

Figure 37. Sacral transverse axes (lateral view).

superior transverse axis (respiratory), the hypothetical transverse axis about which the sacrum moves during the respiratory cycle. It passes from side to side through the articular processes posterior to the point of attachment of the dura at the level of the second sacral segment. Involuntary sacral motion occurs as part of the craniosacral mechanism, and is believed to occur about this axis. 2. A term described by Fred Mitchell, Sr, DO. (Fig. 37)

Figure 39. Anatomical sacral divisions.

transverse (z) axes, axes formed by intersection of the coronal and transverse planes about which nutation/counternutation occurs. (Fig. 37) vertical (y) axis (longitudinal), the axis formed by the intersection of the sagittal and coronal planes. (Fig. 38) sacral somatic dysfunction: See sacrum, somatic dysfunctions of. Figure 38. Axes of sacral motion (posterior view).

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sacral sulcus: A depression just medial to the posterior superior iliac spine (PSIS) as a result of the spatial relationship of the PSIS to the dorsal aspect of the sacrum. (Fig. 39, Fig. 40)

Figure 40. Clinical sacral divisions: sacral sulcus at the base, and inferior lateral angles (ILA).

sacrum, somatic dysfunctions of: any of a group of somatic dysfunctions involving the sacrum. These may be the result of restriction of normal physiologic motion or trauma to the sacrum. See also T.A.R.T. anterior sacrum, a positional term based on the Strachan model referring to sacral somatic dysfunction in which the sacral base has rotated anterior and sidebent to the side opposite the rotation. The upper limb (pole) of the SI joint has restricted motion and is named for the side on which forward rotation had occurred. Tissue texture changes are found at the deep sulcus. (The motion characteristics of L5 are not described.) (Fig. 41)

backward torsions, 1. A backward sacral torsion is a physiologic rotation of the sacrum around an oblique axis such that the side of the sacral base contralateral to the named axis rotates posteriorly. L5 rotates in the direction opposite to the rotation of the sacral base. 2. Referred to as non-neutral sacral somatic dysfunctions (Archaic use). 3. A term by Fred Mitchell, Sr, DO, that describes the backward torsion as being non-physiologic in terms of the walking cycle. bilateral sacral extension (sacral base posterior), 1. A sacral somatic dysfunction that involves rotation of the sacrum about a middle transverse axis such that the sacral base has moved posteriorly relative to the pelvic bones. Backward movement of the sacral base is freer, forward movement is restricted and both sulci are shallow. 2. The reverse of bilateral sacral flexion. (Fig 43)

Figure 41. Anterior sacrum left. Motion of L5 is not described. There is tissue texture change (t) over the left sacral base. The superior pole of the left sacroiliac joint is affected and the left sacral base will not move posteriorly when an anterior test pressure is applied over the right lower sacrum.

anterior translated sacrum, a sacral somatic dysfunction in which the entire sacrum has moved anteriorly (forward) between the ilia. Anterior motion is freer, and the posterior motion is restricted. (Fig. 42)

Figure 42 Anterior translated sacrum.

Figure 44. Bilateral sacral flexion. (Sacral base anterior)

Figure 45. Left on left sacral torsion. (Left on left forward torsion)

Figure 43. Bilateral sacral extension. (Sacral base posterior)

left on left (forward) sacral torsion, Refers to left rotation torsion around a left oblique axis. (Fig. 45) See also sacral torsion.

bilateral sacral flexion (sacral base anterior), 1. A sacral somatic dysfunction that involves rotation of the sacrum about a middle transverse axis such that the sacral base has moved anteriorly between the pelvic bones. Forward movement of the sacral base is freer, backward movement is restricted and both sulci are deep. 2. The reverse of bilateral sacral extension. (Fig 44)

left on right (backward) sacral torsion, Refers to left rotation around a right oblique axis. Findings: The left superior sacral sulcus is posterior or shallow, and the right ILA is anterior or deep. There is a positive seated flexion test on the left. L5 is nonneutral SRRR. Left superior sacral sulcus will be restricted when springing. The lumbosacral spring test is positive, and the sphinx test is positive. (Fig. 46) See sacral torsion.

forward torsions, 1. Forward torsion is a physiologic rotation of the sacrum around an oblique axis such that the side of the sacral base contralateral to the named axis glides anteriorly and produces a deep sulcus. L5 rotates in the direction opposite to the rotation of the sacral base. 2. Referred to as neutral sacral somatic dysfunctions (Archaic use) 3. A group of somatic dysfunctions described by Fred Mitchell, Sr, DO, based on the motion cycle of walking.

posterior sacrum, a positional term based on the Strachan model referring to a sacral somatic dysfunction in which the sacral base has rotated posterior and sidebent to the side opposite to the rotation. The dysfunction is named for the side on which the posterior rotation occurs. The tissue texture changes are found at the lower pole on the side of rotation. (Foundations). (The motion characteristics of L5 are not described.) (Fig. 47)

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Seated flexion test = L (+)

Figure 46. Left on right sacral torsion. (Left on right backward torsion)

Figure 47. Posterior sacrum right. Motion of L5 is not described. There is tissue texture change (t) over the right sacroiliac joint (SI). The inferior pole of the right SI joint is affected. During motion testing, there is resistance to an anterior/superior test pressure applied over the right lower sacrum.

Figure 49. Right on left backward torsion. (Right on left sacral torsion)

Figure 52. Right unilateral sacral extension. (Right superior sacral shear) Figure 50. Right on right forward torsion.

shallow, and the left ILA is anterior or deep. The seated flexion test is positive on the right. L5 is non-neutral SLRL. The right superior sacral sulcus is restricted when springing. The lumbosacral spring test is positive. The sphinx test is positive. (Fig. 49) See sacral torsion. posterior translated sacrum, a sacral somatic dysfunction in which the entire sacrum has moved posteriorly (backward) between the ilia. Posterior motion is freer, and anterior motion is restricted. (Fig. 48) right on right (forward) torsion, refers to a right rotation about a right oblique axis. (Fig. 50) See sacral torsion.

Figure 48. Posterior translated sacrum.

right on left (backward) sacral torsion, Refers to right rotation on a left oblique axis. Findings: The right superior sacral sulcus is posterior or

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Figure 51. Right rotated dysfunction of the sacrum. (Right rotation about a vertical axis)

rotated dysfunction of the sacrum, a sacral somatic dysfunction in which the sacrum has rotated about an axis approximating the longitudinal (y) axis. Motion is freer in the direction that rotation has occurred, and is restricted in the opposite direction. (Fig. 51) sacral shear, a complex translational motion of the sacrum in its relationship

Figure 53. Right unilateral sacral flexion. (Right inferior sacral shear)

to the innominates. (Sometimes described as a sidebending in one direction and rotation in the opposite direction. Alternatively described as a unilateral movement along the arc of the L-shaped curve of the sacroiliac joint.) See also sacrum, somatic dysfunctions of, unilateral sacral flexion and sacrum, somatic dysfunctions of, unilateral sacral extension. unilateral sacral extension, is a sacral somatic dysfunction described as a superior shear of one side of the sacrum resulting in a shallow (full) of, sacral sulcus and ipsilateral superioranterior inferolateral angle of the sacrum. (Fig.52) See sacrum, somatic dysfunctions of, sacral shear.

unilateral sacral flexion, is a sacral somatic dysfunction described as an inferior shear of one side of the sacrum resulting in a deep sacral sulcus and ipsilateral inferior-posterior inferolateral angle of the sacrum. (Fig. 53) See sacrum, somatic dysfunctions of, sacral shear. sagittal plane: See plane, sagittal plane. scan: An intermediate detailed examination of specific body regions that have been identified by findings emerging from the initial examination. scaphocephaly: Also called scaphoid head or hatchet head, it is a transverse compression of the cranium with a resultant mid-sagittal ridge. scaphoid head: See also scaphocephaly. sclerotherapy: 1. Treatment involving injection of a proliferant solution at the osseous-ligamentous junction. 2. Treatment involving injection of irritating substances into weakened connective tissue areas such as fascia, varicose veins, hemorrhoids, esophageal varices, or weakened ligaments. The intended body’s response to the irritant is fibrous \proliferation with shortening/ strengthening of the tissues injected. sclerotome: 1. The pattern of innervation of structures derived from embryonal mesenchyme (joint capsule, ligament and bone). 2. The area of bone innervated by a single spinal segment. 3. The group of mesenchymal cells emerging from the ventromedial part of a mesodermal somite and migrating toward the notochord. Sclerotomal cells from adjacent somites become merged in inter-somatically located masses that are the primordia of the centra of the vertebrae. (Fig. 54) sclerotomal pain: Deep, dull achy pain associated with tissues derived from a common sclerotome. (Fig. 54) scoliosis: 1. Pathological or functional lateral curvature of the spine. 2. An appreciable lateral deviation in the normally straight vertical line of the spine (Dorland’s. (Fig. 55) screen: The initial general somatic examination to determine signs of somatic dysfunction in various regions of the body. See also scan. secondary joint motion: Involuntary or passive motion of a joint. Also called accessory joint motion. segment: 1. A portion of a larger body or structure set off by natural or arbitrarily established boundaries, often equated with spinal segment. 2. To describe a single vertebrae or a vertebral segment. corresponding to the sites of origin of

rootlets of individual spinal nerves. 3. A portion of the spinal cord segmental diagnosis: The final stage of the spinal somatic examination in which the nature of the somatic problem is detailed at a segmental level. See also scan. See also screen. segmental dysfunction: dysfunction in a mobile system located at explicit segmental mobile units. Palpable characteristics of a dysfunctional segment are those associated with somatic dysfunction. (See also STAR, TART and ART) Responses to regional motor inputs at the dysfunctional segment support the concepts of complete motor asymmetry and mirrorimage motion asymmetries. segmental mobile unit: A unit of the human movement system consisting of a bone, with articular surfaces for movement, as well as the adnexal tissues that create movement, allow movement and establish position under motor control. segmental motion: Movement within a vertebral unit described by displacement of a point at the anteriorsuperior aspect of the superior vertebral body with respect to the segment below. sensitization: Hypothetically, a shortlived (minutes or hours) increase in central nervous system (CNS) response to repeated sensory stimulation that generally follows habituation. shear: An action or force causing or tending to cause two contiguous parts of an articulation to slide relative to each other in a direction parallel to their plane of contact. See also pubic bone, somatic dysfunctions of. See also innominates, somatic dysfunctions of, inferior innominate shear. See also innominates, somatic dysfunction of, superior innominate shear. See also sacrum, somatic dysfunctions of, sacral shear. Sherrington law: See law, Sherrington. sidebending: Movement in a coronal (frontal) plane about an anteriorposterior (x) axis. Also called lateral flexion, lateroflexion, or flexion right (or left). sidebent: The position of any one or several vertebral bodies after sidebending has occurred. (Fig. 56) See also sidebending. skin drag: Sense of resistance to light traction applied to the skin. Related to the degree of moisture and degree of sympathetic nervous system activity. soft tissue (ST): See osteopathic manipulative treatment, soft tissue.

soft tissue technique: See osteopathic manipulative treatment, soft tissue technique. somatic dysfunction: Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1). The position of a body part as determined by palpation and referenced to its adjacent defined structure, 2). The directions in which motion is freer, and 3). The directions in which motion is restricted. See also T.A.R.T. See also S.T.A.R. acute s. d., immediate or short-term impairment or altered function of related components of the somatic (body framework) system. Characterized in early stages by vasodilation, edema, tenderness, pain and tissue contraction. Diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion and tissue texture change (T.A.R.T.). See also T.A.R.T. chronic s. d., impairment or altered function of related components of the somatic (body framework) system. It is characterized by tenderness, itching, fibrosis, paresthesias and tissue contraction. Identified by T.A.R.T. See also T.A.R.T. linkage, dysfunctional segmental behavior where a single vertebra and an adjacent rib respond to the same regional motion tests with identical asymmetric behaviors (rather than opposing behaviors). This suggests visceral reflex inputs. primary s. d., 1. The somatic dysfunction that maintains a total pattern of dysfunction. See also key lesion. 2. The initial or first somatic dysfunction to appear temporally. secondary s. d., somatic dysfunction arising either from mechanical or neurophysiologic response subsequent to or as a consequence of other etiologies. type I s. d., 1. A group curve of thoracic and/or lumbar vertebrae in which the freedoms of motion are in neutral with sidebending and rotation in opposite directions with maximum rotation at the apex (rotation occurs toward the convexity of the curve) based upon the Principles of Fryette. (American usage). 2. Second degree

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Figure 54. Anterior and posterior sclerotomal innervations. (Modified from Foundations for Osteopathic Medicine, Ward RC—Ed., William & Wilkins; 1997:644). dysfunction based upon the Laws of Lovett (French usage). type II s. d., 1. Thoracic or lumbar somatic dysfunction of a single vertebral unit in which the vertebra is significantly flexed or extended with sidebending and rotation in the same direction (rotation occurs into the concavity of the curve) based upon the Principles of Fryette (American usage). 2. First degree dysfunction based upon the Laws of Lovett (French usage).

Figure 56. Sidebent.

somatogenic: That which is produced by activity, reaction and change originating in the musculoskeletal system. somatosomatic reflex: See reflex, somatosomatic r.

Figure 55. Scoliosis.

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somatovisceral reflex: See reflex, somatovisceral r.

Figure 57. Extension (SBS). Figure 59. Right lateral strain (SBS).

Figure 61. Right torsion (SBS).

Figure 62. Superior vertical strain (SBS). Figure 60. Left sidebending/rotation (SBS).

Figure 58. Flexion (SBS).

basiocciput and basisphenoid are both inferior in SBS extension with a decrease in the dorsal convexity between these two bones. (Fig. 57)

spasm: (compare with hypertonicity) a sudden, violent, involuntary contraction of a muscle or group of muscles, attended by pain and interference with function, producing involuntary movement and distortion (Dorland’s).

SBS flexion, sphenoid and occiput have rotated in opposite directions around parallel transverse axes; the basiocciput and basisphenoid are both superior in SBS extension with an increase in the dorsal convexity between these two bones. (Fig. 58)

Spencer technique: See osteopathic manipulative treatment, Spencer technique.

lateral strain, sphenoid and occiput have rotated in the same direction around parallel vertical axes. Lateral strains of the SBS are named for the position of the basisphenoid, right or left. (Fig. 59)

sphenobasilar synchondrosis (symphysis), somatic dysfunctions of: any of a group of somatic dysfunctions involving primarily the interrelationship between the basilar portion of the sphenoid (basisphenoid) and the basilar portion of the occiput (basiocciput). The abbreviation, SBS, is often used in reporting the following somatic dysfunctions: SBS compression, somatic dysfunction in which the basisphenoid and basiocciput are held forced together significantly limiting SBS motion. SBS extension, sphenoid and occiput have rotated in opposite directions around parallel transverse axes; the

sidebending-rotation, sphenoid and occiput have rotated in opposite directions around parallel vertical axes and rotate in the same direction around an A-P axis. SBS sidebending-rotations are named for the convexity, right or left. (Fig. 60) torsion, sphenoid and occiput have rotated in opposite directions around an anterior-posterior (A-P) axis. SBS torsions are named for the high greater wing of the sphenoid, right or left. (Fig. 61) vertical strain, sphenoid and occiput have rotated in the same direction

around parallel transverse axes. Vertical strains of the SBS are named for the position of the basisphenoid, superior or inferior. (Fig. 62) spinal facilitation: 1. The maintenance of a pool of neurons (e.g., premotor neurons, motor neurons or preganglionic sympathetic neurons in one or more segments of the spinal cord) in a state of partial or subthreshold excitation; in this state, less afferent stimulation is required to trigger the discharge of impulses. 2. A theory regarding the neurophysiological mechanisms underlying the neuronal activity associated with somatic dysfunction. 3. Facilitation may be due to sustained increase in afferent input, aberrant patterns of afferent input, or changes within the affected neurons themselves or their chemical environment. Once established, facilitation can be sustained by normal central nervous system (CNS) activity. splenic pump technique: See osteopathic manipulative treatment, splenic pump technique. spondylo-: Combining form denoting relationship to a vertebra, or to the spinal column (Dorland’s). spondylitis: Inflammation of vertebrae. (Dorland’s).

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spondylolisthesis: Anterior displacement of one vertebra relative to one immediately below (usually L-5 over the body of the sacrum or L-4 over L5). spondylolysis: Dissolution of a vertebra, aplasia of the vertebral arch, and separation at the pars interarticularis; platyspondylia, pre-spondylolisthesis. spondylosis: 1. Ankylosis of adjacent vertebral bodies. 2. Degeneration of the intervertebral disk. spontaneous release by positioning: See osteopathic manipulative treatment, counterstrain. sprain: Stretching injuries of ligamentous tissue (compare with strain). First degree: microtrauma; second degree: partial tear; third degree: complete disruption. springing technique: See osteopathic manipulative treatment, springing technique. See also osteopathic manipulative treatment, articulatory treatment system. sphinx test: See backward bending test. spring test: 1. A test used to differentiate between backward or forward sacral torsions/rotations. 2. A test used to differentiate bilateral sacral extension and bilateral sacral flexion. 3. A test used to differentiate unilateral sacral extension and unilateral sacral flexion. S.T.A.R.: A mnemonic for four diagnostic criteria of somatic dysfunction: sensitivity changes, tissue texture abnormality, asymmetry and alteration of the quality and quantity of range of motion. static contraction: See contraction, isometric contraction. Still, MD, DO: Andrew Taylor. Founder of osteopathy; 1828-1917. First announced the tenets of osteopathy on June 22, 1874, established the American School of Osteopathy in 1892 at Kirksville, MO. still point: A term used to identify and describe the temporary cessation of the rhythmic motion of the primary respiratory mechanism. It may occur during osteopathic manipulative treatment when a point of balanced membranous or ligamentous tension is achieved. 2. A term used by William G. Sutherland, DO. Still Technique: See osteopathic manipulative treatment, Still Technique. strain: 1. Stretching injuries of muscle tissue. 2. Distortion with deformation of tissue. See also ligamentous strain. Strachan model: See sacrum, somatic dysfunctions of, anterior sacrum. See

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sacrum, somatic dysfunctions of, posterior sacrum. Strain-Counterstrain®: See osteopathic manipulative treatment, counterstrain. stretching: Separation of the origin and insertion of a muscle and/or attachments of fascia and ligaments. stringiness: A palpable tissue texture abnormality characterized by fine or stringlike myofascial structures. structural examination: See osteopathic structural examination. subluxation: 1. A partial or incomplete dislocation. 2. A term describing an abnormal anatomical position of a joint which exceeds the normal physiologic limit, but does not exceed the joint’s anatomical limit. superior (upslipped) innominate: See innominate, somatic dysfunctions of, superior innominate shear. superior pubic shear: See pubic bone, somatic dysfunctions of. See also symphyseal shear. (Fig. 31) superior transverse axis: See sacral motion axis, superior transverse axis (respiratory) and (z) axis. supination: 1. Beginning in anatomical position, applied to the hand, the act of turning the palm forward (anteriorly) or upward, performed by lateral external rotation of the forearm. 2. Applied to the foot, it generally applies to movements (adduction and inversion) resulting in raising of the medial margin of the foot, hence of the longitudinal arch. A compound motion of plantar flexion, adduction and inversion. See also pronation. supine: Lying with the face upward (Dorland’s). symmetry: The similar arrangement in form and relationships of parts around a common axis, or on each side of a plane of the body (Dorland’s). Sutherland fulcrum: A shifting suspension fulcrum of the reciprocal tension membrane located along the straight sinus at the junction of the falx cerebri and tentorium cerebelli. See also reciprocal tension membrane. See also osteopathic manipulative treatment, Osteopathy in the Cranial Field (OCF). symphyseal shear: The resultant of an action or force causing or tending to cause the two parts of the symphysis to slide relative to each other in a direction parallel to their plane of contact. It is usually found in an inferior/superior direction but is occasionally found to be in an anterior/posterior direction. (Fig. 28, Fig. 31)

T tapotement: Striking the belly of a muscle with the hypothenar edge of the open hand in rapid succession in an attempt to increase its tone and arterial perfusion. T.A.R.T.: A mnemonic for four diagnostic criteria of somatic dysfunction: tissue texture abnormality, asymmetry, restriction of motion and tenderness, any one of which must be present for the diagnosis. technic: See technique. technique: Methods, procedures and details of a mechanical process or surgical operation. (Dorland’s). See also osteopathic manipulative treatment. tenderness: 1. Discomfort or pain elicited by the osteopathic practitioner through palpation. 2. A state of unusual sensitivity to touch or pressure (Dorland’s). tender points: 1. Small, hypersensitive points in the myofascial tissues of the body that do not have a pattern of pain radiation. These points are a manifestation of somatic dysfunction and are used as diagnostic criteria and for monitoring treatment. 2. A system of diagnosis and treatment originally described by Lawrence Jones, DO, FAAO. See also osteopathic manipulative treatment, counterstrain. terminal barrier: See barrier, physiologic b. thoracic aperture (superior): See thoracic inlet. thoracic outlet: 1. The functional thoracic inlet consists of T1-4 vertebrae, ribs 1 and 2 plus their costicartilages, and the manubrium of the sternum. See fascial patterns. 2. The anatomical thoracic inlet consists of T1 vertebra, the first ribs and their costal cartilages, and the superior end of the manubrium. thoracic pump: See osteopathic manipulative treatment, thoracic pump. thrust technique: See osteopathic manipulative treatment, thrust technique. See also osteopathic manipulative treatment, high velocity/low amplitude technique (HVLA). tissue texture abnormality (TTA): A palpable change in tissues from skin to periarticular structures that represents any combination of the following signs: vasodilation, edema, flaccidity, hypertonicity, contracture, fibrosis, as well as the following symptoms: itching, pain, tenderness, paresthesias. Types of TTA’s include: bogginess, thickening, stringiness, ropiness,

firmness (hardening), increased/decreased temperature and increased/decreased moisture. toggle technique: See osteopathic manipulative treatment, toggle technique. tonus: The slight continuous contraction of muscle, which in skeletal muscles, aids in the maintenance of posture and in the return of blood to the heart (Dorland’s). torsion: 1. A motion or state where one end of a part is twisted about a longitudinal axis while the opposite end is held fast or turned in the opposite direction. 2. An unphysiologic motion pattern about an anteroposterior axis of the sphenobasilar symphysis/synchondrosis. See also sphenobasilar synchondrosis (symphysis), somatic dysfunctions of, torsion. torsion, sacral: See sacral torsion. See also sacrum, somatic dysfunctions of, sacral torsions. traction: A linear force acting to draw structures apart. traction technique: See osteopathic manipulative treatment, traction technique.

develops characteristic(s) of the adjoining structure or region. lumbarization, a transitional segment in which the first sacral segment becomes like an additional lumbar vertebra articulating with the second sacral segment. sacralization, 1. Incomplete separation and differentiation of the fifth lumbar vertebra (L5) such that it takes on characteristics of a sacral vertebra. 2. When transverse processes of the fifth lumbar (L5) are atypically large, causing pseudoarthrosis with the sacrum and/or ilia(um), referred to as batwing deformity, if bilateral. translation: Motion along an axis. translatory motion: See motion, translatory motion. transverse axis of sacrum: See sacral, sacral movement axis, transverse (z) axis. (Fig. 37) transverse process: Projects laterally from the region of each pedicle. The pedicle connects the posterior elements to the vertebral body. (Fig. 63) transverse rib axis: See (Fig. 35). See also rib motion, pump handle rib motion. (Fig. 34)

treatment, osteopathic manipulative techniques: See osteopathic manipulative treatment. Trendelenburg test: The patient, with back to the examiner, is told to lift first one foot and then the other. The position and movements of the gluteal fold are watched. When standing on the affected limb the gluteal fold on the sound side falls instead of rising. Seen in poliomyelitis, un-united fracture of the femoral neck, coxa vara and congenital dislocations. trigger point (myofascial trigger point): 1. A small hypersensitive site that, when stimulated, consistently produces a reflex mechanism that gives rise to referred pain and/or other manifestations in a consistent reference zone that is consistent from person to person. 2. These points were most extensively and systematically documented by Janet Travell, MD, and David Simons, MD. trophic: Pertaining to nutrition, especially in the cellular environment (e.g., trophic function — a nutritional function). trophicity: 1. A nutritional function or relation. 2. The natural tendency to replenish the body stores that have been depleted. trophotropic: Concerned with or pertaining to the natural tendency for maintenance and/or restoration of nutritional stores. -tropic: A word termination denoting turning toward, changing or tendency to change. tropism, facet: Unequal size and/or facing of the zygapophyseal joints of a vertebra. See also facet asymmetry.

Figure 63. The pedicle (B) is the key structure from which other vertebral parts can be identified. (Ward RC, Ex. Ed., Foundations for Osteopathic Medicine, Second Edition, Lippincott Williams & Wilkins, Philadelphia, 2003:730. transitional region: Areas of the axial skeleton where structure changes significantly lead to functional changes; transitional areas commonly include the following:

thoracolumbar region (TL), typically T10-L1.

Traube-Herring-Mayer wave: An oscillation that has been measured in association with blood pressure, heart rate, cardiac contractility, pulmonary blood flow, cerebral blood flow and movement of the cerebrospinal fluid, and peripheral blood flow including venous volume and thermal regulation. This whole-body phenomenon, which exhibits a rate typically slightly less than and independent of respiration, bears a striking resemblance to the primary respiratory mechanism.

lumbosacral region (LS), typically L5-S1.

Travell trigger point: See trigger point.

occipitocervical region (OA), typically the OA-AA-C2 region is described. cervicothoracic region (CT), typically C7-T1.

transitional vertebrae: A congenital anomaly of a vertebra in which it

treatment, active: (archaic). See osteopathic manipulative treatment, active method.

type I somatic dysfunction: See somatic dysfunction, type I s.d. See also physiologic motion of the spine. type II somatic dysfunction: See somatic dysfunction, type II s.d. See also physiologic motion of the spine

U uncommon compensatory pattern: See fascial patterns, uncommon compensatory pattern. uncompensated fascial pattern: See fascial patterns, uncompensated fascial pattern.

V v-spread: See osteopathic manipulative treatment, v-spread. velocity: The instantaneous rate of motion in a given direction.

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viscerovisceral reflex: See reflex, viscerovisceral r.

ventral technique: See osteopathic manipulative treatment, visceral manipulation.

viscosity: 1. A measurement of the rate of deformation of any material under load. 2. The capability possessed by a solid of yielding continually under stress. See also elasticity. See also plasticity.

vertebral unit: Two adjacent vertebrae with their associated intervertebral disk, arthrodial, ligamentous, muscular, vascular, lymphatic and neural elements. (Fig. 64) visceral dysfunction: Impaired or altered mobility or motility of the visceral system and related fascial, neurological, vascular, skeletal and lymphatic elements. visceral manipulation: See osteopathic manipulative treatment, visceral manipulation.

W weight-bearing line of L3: See gravitational line. (Fig. 16) vertical axis: See sacral motion axis, vertical (y) axis (longitudinal). Figure 64. Vertebral unit.

viscerosomatic reflex: See reflex, viscerosomatic r. File: D:/Glossary/Glossary of 08-15-2006

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