Spinal Manipulation Made Simple

"Meeting the plasticity of the body with a flexible
and gentle somatic response"

As somatic therapists our goal is not to make clients measure up to
some external standard that we impose on them by means of somatic
ideals and formulistic protocols, but to try to discover the limitations
that stand in the way of them becoming who they areand then to
release their fixations in the right order. f rom the text
In Spacious Body: Explorations in Somatic Ontology, Jeffrey Maitland expl ored
the phi l osophi cal implications of Rol fi ng, interrogating different kinds of
will and showing how peopl e can begi n to understand their core fixations
and conf l i ct ed ori entati ons and move to creative transf ormati ons. His
movi ng descriptions of heal i ng showed how a new understandi ng of how
the human body works can create a transformation of the spirit.
In this new more physiological book, Maitiand stays with the myofascial
release techni ques invented by Rol fi ng, but focuses the reader' s attention
on the pr obl em of j oi nt fixations whi ch underl i e many soft-tissue pai n
syndromes. His attention is especially on how to ease back pain and bri ng
the body into a more comf ortabl e alignment, because back pain is a maj or
compl ai nt dealt with by chi ropractors, Rol f ers, massage therapists, and
physical therapists. Maitland shows how to el egandy release j oi nt fixations
in the spi ne, sacrum, pelvis, and ri bcage by using subtle soft-tissue tech-
niques, rather than the high-velocity low-amplitude thrusting techni ques
that " po p" the j oi nts. This gentl er kind of individualized Rol f i ng work is
thoroughl y descri bed within an expl anati on of bi omechani cs, ai ded by
drawings and phot ographs whi ch depi ct techni ques and anatomy.
Jeffrey Maitland, Ph.D., is a phi l osophi cal counsel or and advanced Rolfer. He is
a seni or i nst ruct or and Di rect or of Academi c Affairs at t he Int ernat i onal Rol f
Institute. Spacious Body: Explorations in Somatic Ontology was publ i shed by North
Atlantic Books in 1 9 9 5 . He lives and practices in Scottsdale, Ari zona.
North Atlantic Books
Berkeley, California
www. nor t hat l ant i cbooks. com
Health/Somatics
US $20.00 / $24.95 CAN
Spinal
Manipulation
Made Simple
Spinal
Manipulation
Made Simple
A Manual
of Soft Tissue
Techniques
Jeffrey Maitland
Photographs by Kelley Kirkpatrick
Nort h Atlantic Books
Berkeley, California
Copyright 2001 by Jeffrey Maitland. Photographs 2001 by Kelley Kirkpatrick.
All rights reserved. No portion of this book, except for brief review, may be repro-
duced, stored in a retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise without the writ-
ten permission of the publisher. For information contact North Atlantic Books.
Published by
North Atlantic Books
P.O. Box 12327
Berkeley, California 94712
Cover photograph by Brandy Wilkins
Cover and book design by Paula Morrison
Printed in the United States of America
Spinal Manipulation Made Simple is sponsored by the Society for the Study of Native
Arts and Sciences, a nonprofit educational corporation whose goals are to develop
an educational and crosscultural perspective linking various scientific, social, and
artistic fields; to nurture a holistic view of arts, sciences, humanities, and
healing; and to publish and distribute literature on the relationship of mind,
body, and nature.
ISBN-13: 978-1-55643-352-8
Library of Congress Cataloging-in-Publication Data
Maitland, Jeffrey, 1943-
Spinal manipulation made simple : a manual of soft tissue techniques /
by Jeffrey Maitland.
p. cm.
ISBN 1-55643-352-2 (trade paper : alk. paper)
1. Spinal adjustmentHandbooks, manuals, etc. 2. Manipulation
(Therapeutics)Handbooks, manuals, etc. I. Title.
RZ265.S64 M35 2000
615.8' 2 dc21
00-041133
6 7 8 9 1 0 DATA 11 10 09 08 07
ACKNOWLEDGMENTS
Spinal Manipulation Made Simple answers a quest i on that many somati c
manual therapists have ponder ed: Is it possible to release spinal fixations
wi thout resorti ng to high-velocity, l ow- ampl i tude thrusti ng t echni ques
empl oyed by osteopaths and chi ropractors? This b o o k delineates my very
straightforward and si mpl e techni cal sol uti on to this pr obl em. But sim-
ple solutions often have c ompl ex histories that result f rom the conf l uence
of many disparate influences. There are so many peopl e that have hel ped
me find my way that I woul d be disrespectful and remiss if I di dn' t try to
thank some of them.
With respect to somatic therapy, the most i mportant i nf l uence on the
evolution of my approach c omes f rom the many peopl e at the Rol f Insti-
tute who l abored i n the service of teachi ng me the theory and art of the
Rolfing
1
met hod of Structural Integration and how to teach it. I am espe-
cially i ndebted to the teaching and gifts of seni or teachers Jan Sultan and
Michael Salveson and I want to acknowl edge their unti ri ng dedi cati on to
the educati on of Rolfers. Thei r i nf l uence can be f ound i n various places
t hr oughout this b o o k. I am also very grateful f or what I l earned f r om
Emmett Hutchi ns and Peter Mel chi or when they were still member s of
the Rol f Institute. My understanding of the functional side of somatic ther-
apy has benefitted greatly f rom the work of the movement teachers at the
Rol f Institute, especially f rom the f ol l owi ng peopl e: Hubert Godard, Jane
Harri ngton, Megan James, Vivian Jaye, Gael Ohl gren, and Heather Wi ng.
I also want to acknowledge John (Nottingham, physical therapist, researcher,
and Rol f er not onl y f or his support , generosi ty of heart, and sparkl i ng
intellect, but also for his sensational research on holistic manual and move-
ment therapy. I feel privileged to have worked with hi m and to have been
able to publish two articles with hi m. His research is not onl y elegant, but
some of the best on holistic manual therapy.
SPINAL MANIPULATION MADE SIMPLE
I have greatly benef i tted, bot h professionally and personally, f rom the
wonderf ul work of osteopathy. I owe a special debt of gratitude to the guid-
ance and generosity of my f ri end and mentor, the late Dr. Walter Wi rth,
D. O. His brilliant work and teachi ng changed not onl y my body, but the
di recti on of my work as a somati c practitioner. I am also grateful for the
i nt roduct i on to the mysteries of the crani um and i ndi rect t ouch that I
received f rom Dr. John Upledger, D. O. early in my devel opment as a Rolfer.
I feel especially f ortunate to have been abl e to train with the Upl edger
Institute and Di di er Prat, D. O. in the revolutionary Visceral Manipulation
devel oped by Jean-Pierre Barral, D. O. Many thanks to Dr. Marilyn Wells,
D. O. and the ot her Ari zona osteopaths with who m I have had the great
pleasure to associate. I have learned more than I can say f rom a great num-
ber of books on osteopathy, but I particularly appreciate the work of Phillip
Greenman, D. O.
I also want to thank Dr. Joseph DeBri un, D. C. and Dr. L. Jon Porman,
D. C. f or their excel l ent work on myj oi nt s and f or i ntroduci ng me to the
principles and practice of Dynamic Chiropractic. Although I do not empl oy
chi ropract i c t echni que i n my practi ce, I have f o und their approach to
mot i on testing and understandi ng spinal fixation invaluable.
I am by instinct and training a phi l osopher above all else. Phi l osophy
has many faces, but the o ne I am most attracted to concerns the nature
of bei ng. Ano t he r i mport ant aspect of phi l osophy consists i n exposi ng
and exami ni ng the veracity of the presupposi ti ons that i nf orm our every
at t empt to underst and the nature of reality. Thi s aspect has l ed s ome
thinkers to dub phi l osophy "the queen of the sci ences. " Al t hough i t may
not be i mmedi atel y obvi ous, these two concerns are at work in the back-
gr ound of this manual . To all the phi l osophers who have contri buted so
muc h to my growth over the years I give heartfelt thanks.
One of the greatest practical phi l osophers with who m I have had the
g o o d f ortune to study is my Zen teacher. I caught my first glimpse of how
the body speaks to an open heart while cuddl i ng my infant daughters. But
this truth about the activity of bei ng di d not really bl ossom until it was
simultaneously articulated and manifested by my Roshi. His influence con-
tinues to alter the course of my life and work. Even the Oxf or d English
Di cti onary cannot supply enough words to express the dept h of my grat-
itude to hi m. I r emember asking hi m, " How do you heal peopl e? " Wi th a
ACKNOWLEDGMENTS
spacious imperturbability that showed no hesitation, he said, " Ahh, you
must be c o me one with t hem! " His simple answer port ends a great dept h.
Today, twenty years later, I think I am j ust begi nni ng to grasp the wi sdom
he demonstrated. I ho pe some small part of his pr of ound teachi ngs has
also f ound its way i nto this book.
I want to thank Kelley Kirkpatrick f or her wonderf ul phot ographs that
so clearly demonstrate my techni ques. Her skill, pati ence, and aesthetic
sensitivity are a gift. Al so many thanks go to David Robi nson, Rolfer, who
generousl y agreed to be the model .
Finally, I want to give thanks to my pai n f or l eadi ng me to a new and
better life. But most of all, I want to give my deepest bo w of gratitude to
my detractors. From them I have l earned the i mpossi bl e.
Note
1. Rolfing is a service mark of the Rol f Institute of Structural Integration.
ILLUSTRATIONS
Permission to use their illustrations was granted from the following publications:
The illustrations of the spine in forward and backward bending and the dys-
functional vertebrae (Figures 2.1, 2.2, and 2.3) come from Greenman, Phillip E.
The Principles of Manual Medicine, second edition. Baltimore, Maryland: Williams
and Wilkins, 1996, figures 5.24 and 5.25 on p. 61 and figure 6.1 on p. 67.
The illustration of rib tender points (Figure 9.5) comes from DiGiovanna,
Eileen L. and Schiowitz, Stanley. An Osteopathic Approach to Diagnosis and Treat-
ment. New York, New York: Williams and Wilkins, 1991, figures 17.7 and 17.10 on
pp. 261-262.
The following illustrations come from Kapandji, I. A The Physiology of the Joints,
Vol Three. New York, New York: Churchill Livingstone, 1974.
Figure 4.2 is 34 on p. 193.
Figure 7.14 and 10.11 are 8, 9, and 10 on p. 61.
Figure 7.13 is 2 on p. 11.
Figure 8.1 is 11 and 12 on p.63.
Figurel0.3 is 11 and 12 on p. 63.
Figure 10.7 is 75 p.233.
Figure 10.10 is 6 on p. 59 and 8, 9, 10 on p. 61.
The photograph in Figure 8.3 displaying an posteriorly tilted and anteriorly
shifted pelvis comes from Kendall, Florence Peterson and McCreary, Elizabeth
Kendall. Muscles: Testing and Function, Third edition. Baltimore, Maryland: Williams
and Wilkins, 1983, p. 284.
The illustration of the of the Ideal Body (Figure 10.8) comes from Kendall,
Florence Peterson and McCreary, Elizabeth Kendall. Muscles: Testing and Func-
tion, Third edition. Baltimore: (Williams and Wilkins), 1983, p. 280.
The illustration of the rib/vertebral complex (Figure 9.1) comes from Schultz,
R. Louis and Feitis, Rosemary. The Endless Web. Berkeley, California: North Adantic
Books, 1996, figure 9.1 is 8.5 on p. 30.
The illustration of the possible positions of the sciatic nerve in relation to the
piriformis muscle (Figure 10.4) comes from Ward, Robert, ed. Foundations for
Osteopathic Medicine. Baltimore, Maryland: Williams and Wilkins, 1997, figure 10.4
is 49.6 p. 606.
The illustration of the ideal spine (Figure 10.9) comes from Rolf, Ida P. Rolf-
ing: The Integration of Human Structures. Santa Monica: Dennis-Landman Pub-
lishers, 1977, figure 10.9 is 13.3 on p. 209.
CONTENTS
Introducti on xi
Chapter 1: Our Fine Spi ne: The Backbone of Structural Integrity 1
Chapter 2: Primates in Troubl e
Or where does your back go when i t goes out? 13
Chapter 3: Fi ndi ng and Fixing the Fixations 27
Chapter 4: The Neck 35
Chapter 5: Mot i on Testing the Cervical Spi ne 51
Chapter 6: The Atlas and Oc c i put 61
Chapter 7: The Sacrum 71
Chapter 8: The Pelvis 95
Chapter 9: The Ribs 113
Chapter 10: Odds and Ends 129
Bibliography 157
Index 161
INTRODUCTION
T
HIS BOOK GREW OUT OF MY BACK PAIN AND MY DEEP APPRECI ATI ON FOR
the somatic manual therapists who al l owed me to heal and find a new
life. I r emember all t oo well the day my back "went out " f or the first time.
I was 27 years ol d, fresh out of graduate school , and into my second semes-
ter of teachi ng phi l osophy at Purdue University. Feel i ng the need to get
into better shape, I had begun a rather thoughtless program of exerci se.
A few days later, I awoke to a nasty pai n in my l ower back conf i ned to an
area about the size of a 50-cent pi ece. By no o n I coul dn' t stand up straight.
I was pi tched f orward at a 45-degree angle and f orced to lean on a b r o o m
handl e to move about. My wife arrived h o me f r om r unni ng errands to
f i nd me i n this depl orabl e c ondi t i on. She drove me to the l ocal emer -
gency r o o m where I was pr o dde d and poked, and then sent ho me with
muscle relaxants. The muscl e relaxants were useless; their onl y effect was
to turn me i nto a stuporous versi on of the l ocal village i di ot. Whe n the
effects wore off, I i mmedi atel y fl ushed my medi cati ons down the toilet.
That day marked the begi nni ng of a seven-year search f or relief.
At first I tried the conventi onal medi cal approach. On the first visit to
my doctor, an orthopedi c surgeon, I was i nf ormed I had back pain because
human bei ngs were not desi gned to stand upri ght. "What a bizarre the-
ory! " I thought. "Does he think that I woul d not have devel oped back pain
if I had spent my life crawling around on my hands and knees? Obviously
we are not desi gned f or that way of getting about either. " I knew better
than to express my obj ect i ons to his t heory because he, like t o o many
other authoritarian practitioners, made up speci ous expl anati ons at the
dr op of a hat. Besides, I was in pai n, and at that mo me nt in my life he was
my onl y ho pe . I certainly di dn' t want hi m angry with me . He then sent
me to a physical therapist who gave me a set of useless exercises. Over time
xi
my pain subsi ded and I began j o ggi ng in the naive belief that I was hel p-
i ng my back pr obl em.
Over the next few years my back regularly "went out. " When the pain
was at its worst, I made another appoi ntment with my doctor. Even though
I had no pai n radi ati ng down ei ther l eg, he i nf or med me, wi thout the
benef i t of X-rays or any ot her ki nd of i mages of my back, that I had a
bul gi ng disk, and said, "You know, if I have to see you t oo often, we are
goi ng to have to do surgery." His ultimatum was compel l i ng and I drew
the onl y concl usi on I c o ul dI woul d never go to see hi m again.
"Surely," I thought, " somebody must understand how backs work, why
they get in troubl e, and how they can be hel ped. " A friend r ec ommended
that I go to a chi ropractor who had hel ped her. I made an appoi ntment.
His secretary appl i ed ul trasound to my l ow back and then he "adjusted"
it. He sold me a back brace and after a few weeks of his treatment, my pain
began to subside. I woul d make an appoi ntment every time my back flared
up. Unfortunately, even t hough my chi ropractor coul d ease my pain, he
coul d never keep me that way. After many treatments my neck also began
to cause me troubl e and every session I had to remi nd hi m to "adjust" my
neck. I cont i nued to j o g and my pai n cont i nued to get worse.
A numbe r of years later I al l owed anot her chi ropract or to strap me
ont o a table that l ooked like it had been built in the last century. As he
ti ghtened the straps I felt vaguely uneasy and had a moment ary vision of
myself as a victim of the Crusades. As he slowly t urned the crank, I was
tortuously and painfully stretched. I c oul d barely stand afterwards and I
s oon devel oped a horri bl e case of sciatica. If you have never experi enced
this pai n, you never want to. It is like having the worl d' s worst toothache
in your butt and legs. So I knew I had to find another way.
Whi l e I was on sabbatical f r om Purdue, on the r ec ommendat i on of
f ri ends I made an appoi nt ment with a very tal ented Rol fer. To make a
l ong process short, after thirty five or so sessions with a number of other
Rol f ers and with the addi ti onal hel p of a gifted osteopath, I was finally
f reed of my back pain. I subsequently bec ame a Rol f er and then a Rolf-
i ng teacher.
As my understandi ng and ability as a Rol f er grew, my frustration with
certain aspects of the traditional approach to Rol f i ng also grew. Ol d style
Rol f i ng was of ten t oo painful and muc h t oo general to properl y handl e
xii
INTRODUCTION
local areas of i mmobi l i ty and pai n. Bef ore be c o mi ng a Rolfer, I had been
practicing Zen medi tati on intensely f or a number of years and had some-
what unintentionally devel oped the ability to feel energy in and around
my clients' bodi es. Unfortunatel y the heavy pressure I was taught to use
when applying the techniques of Rol fi ng made it impossible f or me to feel
the subde energy connecti ons throughout the body. For a number of years
I experi mented with trying to find a gentler approach that woul d not sac-
rifice the prof ound structural changes f or whi ch Rol fi ng is known. I bum-
bl ed along until I finally learned how to feel the energies of the body while
still applying the heavy pressure often requi red by Rolfing. My conf i dence
grew as I realized that I was able to apply a full range of pressures, f rom
very light to very heavy, wi thout causi ng unnecessary di scomf ort to the
client or sacrificing the goals of Rol fi ng. These expl orati ons also al l owed
me to penetrate mor e deepl y i nto and through the body' s tangl ed webs
of fascial and energeti c conf usi on.
My clients were happy because I was getting better results without caus-
ing unnecessary di scomf ort. Many reported that their experi ence of mas-
sage was actually mor e uncomf ort abl e than the way I Rol f ed. I was feel i ng
better about my work because I was also able to be very specific wi thout
losing sight of the whol e. Unfortunately, I did not remain content for l ong.
As if some universal principle were bei ng worked out in my life that nobody
had i nf ormed me about, the better a Rol f er I bec ame, the mor e difficult
my client' s probl ems became.
While I was training to bec ome a teacher of advanced Rol fi ng I l earned
that two seni or teachers, Jan Sultan and Mi chael Salveson, were already
i n the process of trying to solve many of the same pr obl ems that I had
been struggling with. I was able to bui l d on their insights and my investi-
gations revealed that many of the traditional Rol f i ng techni ques were all
t oo often i ncapabl e of releasing facet restrictions i n the spi ne and ot her
j oi nts of the body. As Rol f i ng instructors, we had no interest i n teachi ng
the high-velocity, low-amplitude thrusting techni ques pi oneered by osteo-
paths and later adopt ed by chi ropractors. Since Rol f i ng is a f or m of myo-
fascial mani pul ati on and educat i on, we wanted our t echni ques to l ook
and feel like a variation of our already established approach to soft-tissue
mani pul ati on. Crudel y stated, high-velocity techni ques are desi gned to
" po p" j oi nt f i xati ons free, but they l ook and feel not hi ng like Rol fi ng.
xiii
We had expl ored ot her soft-tissue techni ques similar to ours, but soon
realized that they were incapable of produci ng the global structural changes
of Rol fi ng. We also di scovered that many of the popul ari zed myofascial-
release techni ques that were mi sappropri ated f rom osteopathy and Rolf-
i ng t ended to merel y " unwi nd" the tissue around the j oi nt wi thout ever
releasing the actual fixation. Our goal was to find met hods of mobi l i zi ng
j oi nt fixations that were consistent with the way Rol fi ng works with soft tis-
sue, but we had no interest in i mporti ng techniques f rom other disciplines.
Af ter studying how j oi nt s work and b e c o me restricted, I experi ment ed
with and finally managed to devel op a range of soft-tissue techni ques that
effectively release j oi nt fixation wi thout resorting to high-velocity thrust-
i ng techniques or any other techniques devel oped in other systems of man-
ual therapy. These soft-tissue techni ques, c oupl ed with an understandi ng
of how the spine gets i n and out of troubl e compri se the cont ent of this
bo o k.
Like so many ot her peopl e struggling to over c ome debilitating back
pai n, I was worked on by many different practitioners f rom many differ-
ent school s of therapy. I not i ced that a few were astonishingly mor e effec-
tive than others and that they all had similar qualities and abilities that
were missing in the average therapist. You will often hear the average prac-
titioner boast that his t echni que or approach is so muc h better than all
the others because he doi ng somet hi ng remarkably and uni quel y differ-
ent f r om everyone else. But my exper i enc e as a pati ent and teacher of
manual therapy l ed me to j ust the opposi te concl usi on: what makes f or a
really g o o d practitioner is not what is different about his or her approach,
but what he or she shares in c o mmo n with all great practitioners in every
discipline. In the end there is nothi ng uni que about bei ng uni que, because
the power is not in what is uni que, but in what is c o mmo n.
These qualities are fairly easy to state, but not so easy to teach. All of
the gifted practitioners who worked with me exhi bi ted an uncanny per-
ceptual vitality and sensitivity that allowed them to see and feel the details
of my probl ems with an exquisite specificity and mastery of techni que that
never lost sight of my whol e person. They were capabl e of releasing local
areas of dysfunction in a way that benefitted my entire body. They released
my symptoms without ever getting caught in the trap of chasing them and
they were always abl e to track how thei r l ocal mani pul ati ons cascaded
xiv
INTRODUCTION
throughout my whol e body. As a result, they almost always knew where to
work next and they rarely drove probl ems to other areas of my body. Since
my body was constantly changi ng and i mprovi ng under their care, they
rarely repeated the same session. But most importandy, because they coul d
keep the whol e of me in view and affect the whol e as they addressed l ocal
areas of my body, their work of ten pr o duc e d far-reaching and long-last-
i ng changes.
All of these practi ti oners were also wel l - educated and well-versed i n
their disciplines. They had a t horough and detailed knowl edge that they
continually expanded t hrough f urther study and research. Part of what
made them masters of their arts was their daunti ng knowl edge, their c o m-
mi tment to always l earni ng more, and a most remarkable mastery of tech-
nique. But there was another, mor e elusive, factor that contri buted to their
masterythei r way of bei ng. At least for the duration of each session, they
lived their art with a clarity, compassi on, and openness quite beyond every-
day life. I felt that my bei ng and pain were seen and understood. I was not
treated like a speci men with a pr obl em who was in need of some sort of
outside intervention that f orced me to measure up to some objective stan-
dard of normality. Thei r uncanny percept i on, exquisite di scri mi nati on,
and sense of t ouch were not r oot ed i n any sort of obj ecti ve, j udgment al
separation f rom me, but in a deepl y felt participatory understandi ng free
of conflict, grandiosity, and self-importance. They never tried to convi nce
me that they knew what was best f or me or that onl y they had the answer
to my probl ems. If I di dn' t respond to their treatment as they expect ed,
they di dn' t make me feel like it was my fault and were always willing to try
another approach or refer me to other practitioners. Unlike so many prac-
titioners who only chased symptoms while paying lip service to a holistic
approach, they were truly holistic practitioners.
This way of bei ng, not the mere accumul ati on of techni ques, i s bot h
the source of all healing and the limitless heart of life itself. Worki ng this
way is not a matter of goi ng into an altered state, but of returni ng to our
senses, to our native condi t i on free of the contami nati ons and conflicts of
self and culture. Onc e we are f reed f rom our conflicts, we see and feel the
worl d differently, and we no l onger stand apart f r om what we sense. We
live and perceive our worl d with a participatory sensorial affinity that gen-
tly embraces and is embraced by both soma and nature. There is a wi sdom
XV
and spacious clarity that arises f rom resting in our primordial unconf l i cted
statewi thout it a therapist is but a mere techni ci an; but with it amazing
things are possible.
For this wi sdom to evolve i nto a heal i ng ability, however, it must also
be c oupl ed with the right kind of rationality and objective knowl edge that
i s then fully i ntegrated i nto the somati c i ntel l i gence of the therapi st
knowl edge and wi sdom must go hand i n hand. To paraphrase Kant: wis-
d o m wi thout knowl edge is bl i nd and knowl edge without wi sdom is empty.
Si nce I have already discussed the nature of transformati on in my b o o k
Spacious Body, I will not dwell on this way of bei ng here, I onl y ment i on it
because it is so i mmensel y i mport ant . Every practi ti oner has probabl y
exper i enc ed mo me nt s of this spaci ous openness, i n whi ch every inter-
venti on produces almost magical and effortless results. It is, after all, the
heart of all heal i ng. Thr ough its cultivation the heal er heals herself and
bec omes effortlessly mor e effective i n heal i ng others.
Whi l e no less i mport ant than articulating the heal er' s way of bei ng,
this b o o k is not so ambitious. It is rather a practical manual of techni ques
f or treating the spi ne. It offers all manual therapists some of the knowl-
edge and specificity of t echni que that i s requi red to treat a number of
di f f erent ki nds of somati c dysf uncti ons that they see every day in their
practices.
However, knowl edge and specificity of techni que, is not the be-all and
end-all of therapy. It is one thing to know how to apply techniques and it is
quite another to know when and in what order to apply them. Beyond the
mere application of techni que there are the three fundamental questions
of therapy: "What do I do first, What do I do next, and When am I finished?"
Answeri ng these questi ons to the benef i t of our clients is crucial f or any
holistic approach. However, as i mportant as understandi ng these consi d-
erations is to the devel opment of every practitioner, this bo o k is also not a
treatise on the clinical deci si on process, but a manual of techniques.
The mastery of techni que i s i mportant f or many obvi ous reasons, not
the least of whi ch is the benef i t it provi des f or our clients. But there is
anot her benef i t f or the practi ti oner who puts the ti me and ef f ort i nto
l earni ng how to effectively apply techni que: this mastery is one of the nec-
essary stepping stones f or cultivating the healer' s way of bei ng. Just as prac-
ticing scales can be preparatory f or the i nspi red per f or manc e of music,
xvi
INTRODUCTION
so t oo can practi ci ng t echni ques b e c o me part of the cultivation of the
healer' s way of bei ng.
No matter what f orm of manual therapy you were trained in, and regard-
less of whether you work with a correcti ve or holistic approach, you will
find these techni ques deceptively simple to apply and yet highly effective
i n deal i ng with most f orms of back pai n. The techni ques all arose f rom
my frustration with my inability to resolve the mo r e difficult back pr o b-
lems that I was seei ng in my practi ce. After I created these techni ques I
tested them in my practice, classes, and in collaboration with my colleagues,
Jan Sultan and Mi chael Salveson, at the Rol f Institute.
Understanding this bo o k requires a working knowl edge of the anatomy
of the muscul ar and skeletal systems. I discuss anatomy where it is rel e-
vant, but in the simplest of terms. My goal is to give you the skills you need
to evaluate and i mmedi at el y treat your pati ents. The r e are many wo n-
derful books available that go i nto consi derabl e detail regardi ng manual
therapy and I see no need to repeat what has already been said well. The
texts I have f ound most useful are i ncl uded in the bibliography.
xvii
CHAPTER
1
take of thinking that when their pai n disappears their pr obl em also goes
away. But experi enced clinicians know that this bel i ef is based on an illu-
sion. We coul d term the confusi on of the experi ence of pain with the prob-
l em causing the pain the "fallacy of mi spl aced hope. " A facet restriction
can exist at a subclinical level, showi ng no obvi ous signs of pai n, and then
suddenly rear its painful count enance at the most i nopport une times. You
arise f rom a chair to greet a friend and suddenly there' s that stabbing pain
i n your back again. Back pain can c o me and go, but the pr obl em almost
always remains. And if left untreated, it often gets worse as time and grav-
ity take their unforgi vi ng toll on our bodi es.
Whol e disciplines and theories of manual therapy have been created
based on the idea that the spine is the most i mportant and someti mes the
only area of the body that needs to be treated. As naive as that view is, it
i s certai nl y not hard to appreci at e its appeal . You d o n' t ne e d a l ot of
research to understand that if you cannot treat spinal dysfunctions, you
are i ncapabl e of hel pi ng many peopl e. If you are a holistic practi ti oner
trying to provi de hi gher and hi gher levels of organi zati on and bal ance
for your clients and you cannot release peopl e f rom their spinal dysfunc-
tions, then your grandest noti ons of what can be achi eved f or t hem will
1
F YOUR BACK HAS EVER " GONE OUT , " T HE EASE WI T H WHI C H YOU GO
about your life goes right out the wi ndow with it. And you are not al o ne
at least 80 mi l l i on Ameri cans are in the same fix. Many make the mis-
Our Fine Spine: The Backbone
of Structural Integrity
not be realized. Ther e i s no doubt about it: understandi ng and success-
fully treating the spine is i mportant to every somatic practitioner, no mat-
ter what your poi nt of view.
In or der to be effective when you attempt to release a painful j oi nt ,
you need to know how the j oi nt works when it's normal and how i t works
when it's i n t r o ubl e and how to tell the di f f erence. In order to experi -
enc e what we are goi ng to be discussing bef ore you read a l ot of theory,
here is a si mpl e exerci se you can do with your own spine.
Stand up and pl ace your t humbs on your spi ne over the transverse
processes ( TP) of L4 or L5. Don' t worry t oo muc h at this poi nt about how
accurat e yo u are. Just use your t humbs t o make your best guess. No w
si debend ( or laterally fl ex) to your left. Whe n you si debend to the left,
the left side of your l umbar spine will be concave and the right will be con-
vex (Figure 1.1). Notice what happens under your thumbs. As you sidebend
to your left, your right t humb is f or c ed posteri orl y a bit while your left
t humb sinks anteri orl y a little. No w si debend the ot her way and noti ce
that j ust the opposi te occurs: your left t humb is pushed a little posteriorly
and your right t humb sinks anteriorly.
What you are f eel i ng is your vertebra rotate as you si debend. The con-
venti on f or descri bi ng rotation is to descri be the di recti on in whi ch the
ant eri or f ace of the vertebra turns. So whi l e standi ng or sitting, i f you
si debend right, your vertebra will rotate left, and if you si debend left, your
vertebra will rotate right. Si debendi ng is difficult to feel at first and not
somet hi ng you ne e d to be c o nc e r ne d with at this poi nt. But rotation i s
easy to pal pate. As you will s oon see, by knowi ng the di recti on in whi ch a
vertebra i s rotated you can gather lots of the necessary i nf ormati on f or
deal i ng with a painful back.
If you have a history of back troubl e, you may noti ce that the vertebral
movement you are moni t ori ng with your thumbs is not exactly the same
as you si debend f r om side to side. Thi s di scovery may be no surprise to
y o ui t probabl y means you have a facet restriction that is inhibiting nor-
mal mo t i o n t hr ough the area you are pal pati ng. If o ne of the facets i s
restricted, you will feel the vertebra rotate mor e as you si debend one way
and less as you si debend the other. If you feel rotation mor e in one direc-
ti on than the ot her and you haven' t had a history of back troubl e, don' t
pani c. Perhaps you haven' t pl aced fingers in quite the right area or maybe
2
OUR FINE SPINE: THE BACKBONE OF STRUCTURAL INTEGRITY
Figure 1.1
you are having troubl e clearly differentiating between what the vertebra
is doi ng and how the soft tissues are respondi ng. In some peopl e the t one
of the musculature al ong the sides of the spi ne is not the same and as a
result each side responds differently to si debendi ng. Of course, i t c oul d
mean that you do have some sort of facet restriction that hasn' t reached
your awareness through the attention-getting medi um of pain. But again
don' t pani c, we will learn how to deal with these probl ems a little later.
What you have learned so far is that si debendi ng and rotation are always
coupl ed. What you are about to feel next is that they are not always c ou-
pl ed the same way in the thoraci c and l umbar spines. Stand up again and
place your thumbs on either L4 or L5. If you have a history of back pain
and your back is presently in troubl e you may not want to try this next
exercise. But if you are game, first be nd way f orward and then si debend
to the left (Figure 1.2). As you si debend left you will noti ce that the left
transverse process pushes your t humb a little posteriorly and on the right
transverse process your other t humb sinks anteriorly a bit. What you are
f eel i ng can be descri bed by saying that as you si debend left in f orward
bendi ng your vertebra rotates left. Now, while you are still in the f orward
3
Figure 1.2
bent position, si debend right and you will noti ce that your vertebra rotates
right. Next, straighten up and then back bend. In the back-bent posi ti on,
si debend right and left, and noti ce that your vertebra behaves the same
way as it di d in the f orward bent posi ti on: as you si debend left, your ver-
tebra rotates left and as you si debend right your vertebra rotates right.
Standing or sitting with the spine comfortabl y straight is called the neu-
tral posi ti on In neutral posi ti on the facets do not engage when you side-
be nd. In the non- neut ral posi ti ons of f orward be ndi ng and backward
bendi ng the facets of the thoraci c and l umbar spines do get engaged and
their relationship alters the way the vertebrae rotate. What you have learned
t hrough di rect pal patory experi ence are two i mport ant facts about the
thoraci c and l umbar spines: 1) in neutral posi ti on, si debendi ng and rota-
tion are always opposi tel y c oupl ed and 2) in the non-neutral positions of
f orward and backward bendi ng, si debendi ng and rotation are always cou-
pl ed to the same side. So i n neutral posi ti on when you right si debend,
your vertebra rotates left and when you left si debend, your vertebra rotates
right. In the non-neutral posi ti ons, when you si debend right, your verte-
bra rotates right and when you si debend left, your vertebra rotates left.
Whe n si debendi ng and rotation are c oupl ed to opposi te sides it is called
Type I mo t i o n and when they are c o upl e d to the same sides it is called
Type II mot i on. This classification of spinal mot i on i nto Type I and Type
II is a descri pti on of normal mot i on. Dysf uncti on arises onl y if there is
some sort of restriction or facet f i xati on involved.
An i mpor t ant poi nt t o r e me mbe r i s that s i debendi ng and rotati on
always happen together al ong the spine. A vertebra or group of vertebrae
can never rotate wi thout also si debendi ng and never si debend wi thout
also rotating. Interestingly, the l umbar spine can si debend mor e than it
can rotate and the thoraci c spine can rotate mor e than it can si debend.
The cervical spine behaves differendy f rom the lumbar and thoracic spines
i n one very i mportant respect: regardless of whether you forward or back-
ward bend, the mot i on of C2- C7 is always Type II. The neck is different
enough f rom the thoracic and l umbar spines that it deserves its own chap-
ter. So f or the remai nder of this chapter and through the next coupl e of
chapters we will be discussing onl y the thoraci c and l umbar spines.
Si nce we will be using rotati on as our starting poi nt f or determi ni ng
and treating facet dysfuncti on, let' s expl ore palpating vertebral rotation
4
a bit mor e. If you are a soft-tissue practi ti oner and you haven' t assessed
vertebral rotation bef ore, your highly devel oped palpatory skills f or assess-
ing soft tissue strain and tightness may mislead you in your first attempts
to feel bone. If you are like many soft-tissue practitioners I have taught,
when you try to get a sense of the tissue beneath your fingers, you of ten
gently ni ggl e i t y o u poke a bit here and pr o d a bit t he r e o f t e n you
move your fingers up and down, back and f orth, and i n small circles. But
when you feel f or bo ne , you must resist the temptati on to palpate in this
way. Instead, you shoul d apply gentl e but firm and constant pressure as
you let your fingers sink into the tissue until they c o me to an obvi ous stop-
pi ng poi nt where they can sink no further. When they can sink no further
and you feel a hard st oppi ng poi nt , you have r eac hed bo ne . Thi s hard
stoppi ng poi nt feels different than tight or strained soft tissue.
I magi ne that a vert ebra yo u are pal pat i ng i s ri ght rot at ed. As your
thumbs sink through the tissue and c o me to rest on the bony surface of
the vertebra, you will noti ce that your right t humb stops sinking i nto the
tissue bef ore the left t humb does. To say it differently, you will noti ce that
your right t humb has c o me to rest on a bony b ump that is a little mo r e
post eri or and pr o mi ne nt than where the left t humb l anded. Your left
thumb in contrast seems to have sunk into a littie indentation and is hence
a little more anterior than the right t humb. If you ni ggl e the tissue as you
are letting your thumbs sink toward the vertebra, you can easily get c on-
fused about what you are feeling.
Ask o ne of your friends or clients to vol unt eer his back and sit c o m-
fortably straight in the neutral posi ti on. Keep your thumbs in the same
hori zontal pl ane faci ng each other, each j ust slightly lateral to the spin-
ous processes of the vertebra you are palpating. Make sure that the pal mer
surfaces of your t humbs cover the transverse processes. Keepi ng your
thumbs i n this hori zontal posi ti on, run them up and down your fri end' s
thoracic spine until you find a vertebra with o ne transverse process that
is obviously more posterior or promi nent than the others (Figures 1.3 and
1.4, page 6) . Do n' t wor r y about those vertebrae that you are not sure
abo ut i gno r e them f or now and onl y l ook f or the most obvi ous ones.
Onc e you find a transverse process that is obviously mo r e pr omi nent or
posteri or on one side, you have f ound a rotated vertebra. The vertebra i s
rotated to the side where you feel the promi nent transverse process. The
5
Figure 1.4
6
Figure 1.3
easy way to r emember how to designate rotation is to r emember that the
side of the bump is the side of the rotation. If you feel the bump on the left (with
an i ndentati on on the ri ght) , the vertebra is left-rotated. If you feel the
bump on the right (with an i ndentati on on the l eft), the vertebra is right-
rotated.
To be mo r e preci se i n your descri pt i on, you shoul d f ol l ow the c o n-
venti on and designate the rotation you feel in ref erence to the next ver-
tebra j ust bel ow it. This convent i on makes g o o d sense because what you
are ultimately interested in understandi ng is j oi nt fixation and you can-
not have a j oi nt , let al one a fixated o ne , wi thout two cont i guous bones.
So if you find that T7 is right-rotated, you woul d say that T7 is rotated right
on T8. You can say it any reasonable way you want to, of course, and there
are many different conventions for designating rotation. But I have adopted
the conventions of the osteopaths, because they constantly scrutinize their
language for consistency and accuracy. I shoul d ment i on that even though
I use descriptive conventi ons derived f rom osteopathy, I do not discuss or
bor r ow their t echni ques f or this bo o k. Unl ess otherwi se not ed, all the
techni ques you will learn in this b o o k were my own creati on and are soft-
tissue techniques, not high-velocity, low-amplitude osseous manipulations.
Experi ment with f eel i ng f or rotation with a l ot of different backs and
always begi n with the most obvi ous rotations al ong the thoracic spine first.
On the whol e it is muc h easier to feel rotations of the thoraci c spi ne in a
sitting position than it is to feel them in the l umbar spine. Above all, don' t
fret about the vertebrae whose rotational patterns are not clear to your
fingers. As you gain conf i dence in f eel i ng f or the obvi ous cases, in ti me
you will also gain sensitivity in f eel i ng f or the less obvi ous ones.
After you gain some conf i dence with the thoraci c spi ne, try feel i ng f or
rotations in the l umbar spine. First feel f or rotation in the sitting position.
Then ask your vol unteer to lie prone on your treatment table and feel the
same areas in this posi ti on. In the sitting posi ti on the erectors are work-
i ng to maintain an upri ght posture and since many peopl e' s back muscles
are overdevel oped, you will find that it is of ten difficult to feel t hrough
these muscles to the bo ne beneath. In the pr one posi ti on you will find it
is muc h easier to feel the transverse processes through the back muscl es.
In order to better det ermi ne whi ch vertebrae you are pal pati ng you
need a few landmarks f rom which to take your bearings. If you trace a hor-
7
at level of L4
Iliac crests
Sacral
base
izontal line across from
the crest of the ilium to
the spine, your fingers
will l and the spi nous
process of L4 (Figure
1. 5). Fr om there you
can c o unt down o ne
spinous process to find
L5 or up to determi ne
L3, L2, and LI .
Figure 1.5
To f i nd Tl pl ace
your f i ngers on your
best guess to locate C6
and ask your vol unteer to be nd his head and neck backward. If you are
on C6 as your vol unteer bends, it will slide obviously anteriorly. If you are
on C7 it will not move in this way at all. If you don' t have a vol unteer as
you read this, you can try i t on yourself. Onc e you have l ocated C6 you
can easily c ount down spi nous processes to f i nd T l , T2, and so forth. This
test f or anteri or sliding of C6 with back bendi ng works quite well most of
the time f or most peopl e. But be f orewarned: on occasi on you will fi nd a
person whose cervi cothoraci c j unc t i on is fixated in a way that makes this
test useless.
Anot her useful l andmark f or finding your way through the spine is the
i nf eri or tip of the scapula. If you trace a hori zontal line f rom the inferior
tip to the spi ne, your fingers will most likely land around T8.
A Simple Indirect Technique
N
OW THAT YOU HAVE SOME EXPERI ENCE PALPATI NG ROTATI ON, WE CAN
bui l d on your knowl edge by practi ci ng a si mpl e, i ndi rect techni que
f or derotati ng vertebrae. This t echni que was di scovered by a number of
therapists i ndependent l y of each other. Ask your vol unt eer to sit c o m-
fortably. Fi nd the most obvi ousl y rotated vertebra in his thoraci c spi ne.
For the pur pose of this di scussi on, let' s assume that you find that T4 is
right rotated on T5. What you will feel i s your right t humb resting on the
b ump (the promi nent , posteri or transverse process of T4) and your left
8
t humb resting i n an i ndentati on (the anteri or transverse process of T4 ) .
To begin the technique, use your left thumb to apply a coupl e of pounds
of gentl e but f i rm pressure to the left transverse process ( TP) with the
i ntenti on of maki ng i t sink mo r e anteriorly (Figure 1. 6). If you are not
used to this sort of t echni que, the i dea of pushi ng the anteri or TP mo r e
anteriorly may seem counter-intuitive and a bit o dd. You mi ght be think-
ing that it woul d make mor e mechani cal sense to push the right posteri or
TP anteriorly as a way to derotate it. But bodi es are not machi nes and they
have pr of oundl y interesting ways of r espondi ng to i ntel l i gent pressure
that will make your life as a somati c practi ti oner easier than you mi ght
i magi ne. This is called an i ndi rect techni que because it does not directly
f orce change on the spine the way high-velocity, l ow-ampl i tude thrusting
techni ques do. Indirect techni ques begi n by pushi ng a dysfunctional seg-
ment further into its dysfunction and letting it wi nd its way back to where
a normal posi ti on is. Do n' t worry about why this t echni que works. Just
enj oy how your vol unteer' s body responds to pushi ng the left anterior TP
mor e anteriorly.
9
Figure 1.6
Whe n you apply your pressure to the left TP of T4, i magi ne that you
are pushi ng a boat away f rom a dock. If you push too quickly and too hard,
you will experi ence resistance. But if you push in a slow, gentl e, firm way,
the boat will almost effortlessly drift away f rom the dock. As you first push
anteriorly on the left TP, not hi ng happens f or a few seconds. But noti ce
that as you keep the pressure up, your left t humb begi ns to sink a little
mor e anteriorly as your right t humb begi ns to move a little mor e poste-
riorly. You are actually f eel i ng T4 go further i nto right rotation. You may
even feel i t go i nto si debendi ng. Maintain the i mage of pushi ng a boat
away f rom a doc k in the back of your mi nd, and keep the pressure up, but
don' t f orce the issue; j ust push and cont i nue to f ol l ow this mot i on until
it stops. Bef ore it stops the vertebra may rotate and si debend in o dd and
unpredi ct abl e ways. Do n' t worry about i t or questi on it, j ust f ol l ow the
mot i on until it stops.
At that poi nt, T4 will have moved as far it can go i nto right rotation.
Ther e will be a pause, someti mes ac c ompani ed by the f eel i ng of a little
pulsation under your thumbs. Just wait and soon you will feel the impulse
of the vertebra to start derotati ng as if it were movi ng i nto left rotation.
You may feel it si debend and rotate left, then right, and in other o dd and
unpredi ctabl e ways bef ore it finally stops, but stay with it. It will stop mov-
i ng when it is derotated and when it stops you will also feel a softening of
the tissues under your thumbs. If you wait a little l onger you may also feel
the spi ne l engt heni ng above a n d / o r bel ow your thumbs, as i f the body
were organi zi ng itself al ong vertical lines in response to the release of the
vertebra. Whe n you feel the tissue softeni ng and sense the body organiz-
i ng itself al ong the sagittal pl ane you are fi ni shed. If you don' t feel the
body organi zi ng itself al ong this l i ne, do n' t worry about i t as l ong as
your thumbs remain in contact with the body, it will organize itself around
the release whether you feel it or not. Just wait f or the softening and then
wait j ust a bit l onger afterward. If you use this techni que with the expec-
tation of f eel i ng that you can sense how the body organizes itself around
the vertical release, in time you will actually sense this orthotropi c effect.
Bei ng able to feel how the body organizes or fails to organi ze itself in
relation to your i nterventi on is a very useful skill to learn and it will allow
you to tell immediately what ot her areas body require intervention. Inter-
estingly, not onl y does the body organi ze itself around the sagittal pl ane,
10
it also organizes itself simultaneously around the transverse and coronal
planes. Knowi ng how to feel f or the presence or absence of this or t hogo-
nal relationship tells you when you are finished with your t echni que and
where to go next.
The simple techni que you have j ust l earned will o pe n many interest-
ing doorways for you if you j ust keep practicing it and feel i ng f or as muc h
i nformati on as you can. But this i ndi rect techni que, like so many i ndi rect
techni ques ( or so-called "unwi ndi ng t echni ques" ) , is not always effective.
You will noti ce that someti mes you will achieve easy and amazi ng results
with it and at other times the pr obl em you thought you had taken care of
reasserts itself within a matter of mi nutes or hours. The drawback with
most unwi ndi ng techni ques i s that they often do not address o ne of the
most i mportant aspects of a painful b a c kt he underl yi ng facet restric-
tion. Most i ndi rect t echni ques tend to unwi nd the tissues and vertebra
around the j oi nt fixation. Since the j oi nt fixation has not been resol ved,
the pr obl em quickly returns. To deal with the facet restriction, you fi rst
need to understand how facet fi xati ons work and then you need a soft-tis-
sue techni que that challenges the j oi nt fixation. This is what you will learn
in the next two chapters.
I I
CHAPTER
2
13
Primates in Trouble,
or where does your back go
when it goes out?
OW MANY TI MES HAVE YOU HEARD THI S SURPRISED COMMENT FROM
a client? ' You know, I was j ust bendi ng over to pi ck up somethi ng,
when all of a sudden I felt somet hi ng slip in my l ower back and
the next thing I know I' m on my knees in terrible pai n! "
Ther e are many levels to, and c o mpe t i ng expl anati ons for, how the
spine bec omes compromi sed. The i mportant poi nt i s that facets not onl y
get engaged i n f orward bendi ng and si debendi ng, they someti mes esca-
late an al ready strai ned rel at i onshi p i nt o a bad marri age and remai n
severely f i xated. Whe n we f orward b e nd or bac k b e nd and t hen twist
( s i debend) , we put our l ow backs at risk. If you were to exami ne your
client' s unhappy marri age when he is in the neutral posi ti on (sitting or
standing comf ortabl y straight), you woul d di scover that o ne or mo r e of
his l umbar vertebra is stuck so that it is si debent and rotated to the same
side. In neutral posi ti on, thoracic and l umbar vertebrae are not supposed
to act this way. So if you f i nd a vertebra in neutral posi ti on that is stuck
rotated and si debent to the same side, you are probabl y l ooki ng at a per-
son in pain.
At this poi nt you may be thi nki ng, "Wait a mi nut e, if, as you say, it is
much easier to feel rotation than si debendi ng, how can you know whether
a vertebra is rotated to the same or opposi t e side of the si debendi ng? "
The answer is simple: every time you find a vertebra in neutral posi ti on
that is stuck si debent and rotated to the same side, vou have di scovered
restricted facets. Because the facets are restricted, there is loss of normal
mot i on in the area. If facets are fixed, the vertebra will not be able to move
normal l y i n back bendi ng and f orward bendi ng. The restricted facets will
act as fi xed pi vot poi nts that will f orce the vertebra to move in character-
istically errant ways as your cl i ent bends f orward and backward. By feel-
i ng how the vertebra rotates around this fixed pivot poi nt in forward and
bac k be ndi ng yo u will be abl e to det er mi ne preci sel y whi ch facets are
restricted and how they are restricted. Onc e you know this, treating them
is easy and obvi ous.
But bef ore we consi der the facet-restriction test, let' s deal with a very
i mport ant clinical questi on: where does your back go when i t goes out?
This i s one of those o dd questions like "Where does your lap go when you
stand up?" or "Where does fire go when it goes out?" that seems as though
it shoul d have an answer, but doesn' t. These sorts of questions don' t have
answers not because they are too difficult for anyone to answer, but because
they are conf used questi ons.
I stated the questi on this way to make an i mport ant poi nt about the
nature of spinal dysfunction. Somati c therapists and non-therapists alike
tend to descri be back pain by saying, ' Your back is out. " But this expres-
sion is i mpreci se and even quite misleading. The critical poi nt is not that
a client' s back "went out, " as if its new posi ti on were the primary probl em,
but that there are facet restrictions and loss of functi on associated with the
client' s pai n. Treatment consists not of putti ng it back where it bel ongs,
but in releasing the restricted facets in order to restore f uncti on. Where
the vertebra goes after you release it f rom its facet restrictions is sometimes
quite different f or each person. Al ong the same lines, if you were able to
get the vertebra to " go back to where it bel ongs" (derotate it) and you didn' t
release the restricted facets, the person' s back woul d still be dysfunctional
and i t woul d not be l ong until the pain returned. If you have been exper-
i menti ng with the simple i ndi rect techni que i ntroduced in the last chap-
ter, you already know that it is not always effective. Now you know why.
Some vertebral dysfuncti ons also have very little to do with the posi-
ti on of the vertebrae. For exampl e, of ten the facets on bot h sides of the
spine can be restricted, but the vertebra shows no obvious palpatable signs
of bei ng " out of pl ace" (rotated and si debent ) . Whe n bot h sides are re-
stricted, your cl i ent will have pai n and loss of mot i on in the area. Agai n,
14
PRIMATES IN TROUBLE, OR WHERE DOES YOUR BACK GO WHEN IT GOES OUT?
the treatment goal is to release the facet restrictions so that you can restore
pr oper f unct i oni ng, not reposi ti on vertebrae. Many times you will f i nd
vertebrae that are rotated and still perfectly functi onal because no facet
or myofascial restrictions are i nterferi ng with mot i on in the area. Given
the unique structure of that person in relation to how his body has adapted
to gravity and the stresses of life, his vertebrae probabl y can onl y be right
where they are. They are not likely to be functi onal in any ot her posi ti on.
If you had the power to f orce his vertebrae i nto some version of the ideal
posi ti on, you woul d probabl y j ust create pai n f or hi m.
In order to mor e clearly understand the role of j oi nt mani pul ati on and
the role of posi ti oni ng body structure and segments, it is very hel pf ul to
preview the words of physiologist I.M. Korr. Discussing the non- segmented
"symphoni es" of mot or activity that are orchestrated and carri ed out by
the spinal cord and hi gher centers, he says:
The important poi nt is that these patterns of activity involve neu-
rons up and down the spinal cord, each bei ng called i nto play
accordi ng to the pattern requi red at the mo me n t n o t accord-
ing to where the neuron is l ocated in the cord but accordi ng to
what structure it i nnervates. Wher e it "lives" segmental l y is of
no i mportance . . .
This presents us with an interesting paradox: the normal pat-
terns of activity medi ated by the spinal cord are compl etel y non-
segmental in nature . . . yet the spinal cord is obviously segmented
and the physician is very muc h c onc er ned with segmental rela-
ti onshi ps Neverthel ess, i n nor mal life segmental rel ati on-
ships do not appear.
The reason f or this paradox may be best conveyed by [ an]
illustrative simile. Consider a beautifully executed parade of skilled
marchi ng men, where the many ranks and col umns are seen as
patterned activity of the whol e parade. We do not see individual
ranks and certainly not individual marchers, we see patterned
moti on. But let somethi ng go wrong, let one of the marchers lose
step and his rank immediately bec omes conspi cuous. The other
marchers cannot compensate in a coordi nated manner and soon
the ranks on either side are thrown i nto conf usi on and then we
15
do see segmental relationship. It is somethi ng like this that causes
segmental relationships in the spi ne to emerge into vi ew. . . . A
segment "in view" is a segment in trouble
Ho w shall we reconci l e this paradox? First by realizing that
the thi ng that is segment ed is the ar mor that houses and pro-
tects the c or d In normal life the segmentati on is not of the
spinal c or d itself; the segmentati on is in the assembling of the
nerve fibers into "cabl es"roots and nervest hat can pass out
to the tissues innervated. What is segmented is ingress and egress,
not the function of the c or d itself.
1
We can see even mo r e clearly f rom Dr. Korr' s wonderf ul exampl e of
the marchers how spinal mani pul ati on is not a si mpl e matter of reposi-
ti oni ng or putti ng bones " back i nto pl ace. " The ultimate aim of spinal
mani pul ati on i s the recovery of normal patterned mot i on, not the cre-
ation of an ideal posi ti on f or the segments. By i mpl i cati on, the aim is also
not the creati on of a spi ne that measures up to some ideal pattern. When
a vertebral segment or a gr oup of vertebrae be c o me "segments in view,"
to use Dr. Korr' s phrase, we percei ve a loss of patterned mot i on through-
out the spi ne. Part of what we see are breaks or fixations i n the overall
continuity of structure and movement. We see loss of continuity and appro-
priate mot i on. The "segments in view" of ten show up as fixations in the
myofascial, ligamentous, and articular systems. These fixations create vary-
i ng degrees of local immobility, whi ch i n turn inhibit normal integrated
movement t hroughout the whol e body.
With this new understanding, let's reconsider those peopl e whose backs
"went out" when they bent over. All of them were well on their way to hav-
i ng back probl ems bef ore they first experi enced back pain. Thi nk of what
happens when you put water on the stove to boi l . You turn up the heat
and the water gets hot t er and hotter. Suddenl y it passes a certain tem-
perature threshol d and boils. If the water were consci ous, the first time it
was brought to a boi l it mi ght say, ' You know it was really weird, I was j ust
hangi ng out on the stove f eel i ng the heat when all of sudden I began to
boi l ! " Anal ogousl y your clients' backs were "heati ng up" to " go out. "
Myofascial, l i gamentous, and facet restrictions were already present;
there were larger overall patterns of i mbal ance in their bodi es; their legs
16
17
probabl y were not provi di ng adequate support; there were dysfunctional
adaptations to ol d injuries and to gravity; and vertebrae were slighdy mor e
toward a Type II posi t i on than was g o o d f or t hem. The n the fatal day
arrived when your client passed his critical threshold by bendi ng over and
slightly twisting ( si debendi ng) to pi ck somet hi ng up. Duri ng this move-
ment, his vertebra sl i pped a little t oo quickly and a little t oo far past what
was normal f or a Type II posi ti on. The nervous system registered the dan-
ger and sent the muscles i nto a fearful spasm thereby l ocki ng the verte-
bra into a Type II posi ti on and creating facet restrictions. There are ot her
ways you can l ock up your back, of course, but this si mpl e case is useful
because i t allows us to underst and ho w facets b e c o me restri cted. The
i mport ant poi nt is that f acet fi xati ons create a mo t i o n restri cti on that
adversely affects the way the rest of the spine behaves in walking and other
forms of movement. And over time it can facilitate other facet restrictions.
If your spi ne has no facet restrictions, when you f orward be nd, your
facets slide o pe n i n an accordi on- l i ke fashi on and when you back be nd
they slide closed. As you forward bend, each vertebra in relation to the one
inferior to it slides slightly superiorly and anteriorly. Whe n you back bend
the opposi te occurs: each vertebra slides slightly inferiorly and posteriorly.
Now, if facets are restricted, they will act as a fi xed poi nt around whi ch
the vertebra will be f or c ed to rotate when you f orward and back be nd.
The side on whi ch the facets are restricted remai ns fi xed duri ng f orward
and backward bendi ng, while the ot her side appears to rotate and dero-
tate. To say it differently, o ne side of the vertebra remai ns a f i xed pi vot
poi nt around whi ch the other side moves anteriorly and posteriorly in for-
ward and backward bendi ng, respectively.
Figures 2.1 and 2.2, page 18, show rather clearly the effects of f orward
bendi ng and backward bendi ng on the behavior of the facets. Duri ng back
bendi ng the facets slide toward a closed position and duri ng forward bend-
ing they slide toward an o pe n posi ti on.
Figure 2.3 shows a dysfunctional vertebra. What you are l ooki ng at are
two vertebrae i n neutral posi t i on. The superi or vertebra i s stuck ri ght
rotated and right sidebent. Notice how the facets on the left have slid open
and the facets on the right have slid cl osed. Since we are l ooki ng at a Type
II dysfunction, one side must be restricted. Either the left facets are fixed
open (in f l exi on or f orward bendi ng) or the right facets are fi xed cl osed
Figure 2.1
(in extensi on or backward be ndi ng) . But whi ch facets are fi xed?
Remember that restricted facets create a fixed pivot poi nt around which
the vertebra is f or c ed to rotate in f orward and backward bendi ng. So if
you were to pl ace your t humbs on the transverse processes of the supe-
ri or vertebra and feel f or how it rotates and derotates duri ng forward and
backward be ndi ng, you c o ul d det er mi ne whi ch facets were f i xed. You
woul d know whet her the left facets were f i xed o pe n or the right facets
were f i xed cl osed. And o nc e yo u knew whi ch and how the facets were
restricted, you c oul d simply and easily release them.
But bef ore you learn how to apply the test, let' s expl ore a techni que
f or releasing facet restrictions first. For many somatic therapists, learning
a si mpl e facet release t echni que that doesn' t requi re precise knowl edge
of whi ch facet is fixed is the best way to deepen their pal patory and con-
ceptual understandi ng of how to apply the test. Many hands-on therapists
find that if they can get this understandi ng into their hands first, they have
an easier time getting it i nto their heads. The techni que you are about to
learn is a ki nd of shotgun approach to a mor e specific way to address facet
restrictions. Fr om the clinical standpoi nt, this approach is less efficient
than the o ne you will use o nc e you know how to apply the test. But f rom
the learning standpoint this approach is a far more effective teaching tech-
ni que. You will also be happy to know that it is, f or the most part, as effec-
tive as the mo r e efficient approach.
18
Figure 2.2 Figure 2.3
When you find a rotated vertebra, j ust pret end that it is a Type II fixa-
tion. It may turn out, of course, that the rotated vertebra you pi cked is
not dysfunctional at all. If it isn' t stuck rotated and si debent to the same
side when in the neutral posi ti on and you apply this shotgun approach,
the worst thing that will happen is that you will have wasted your time (and
your client' s). Since rotated vertebrae with restricted facets are mor e c o m-
mo n than flowers in the Spring, the best thing that will happen is that you
will actually put your f i nger on the source of your cl i ent' s pai n and by
applying this techni que release her f rom her misery.
If the rotated vertebra you pick is sidebent and rotated to the same side
in the neutral posi ti on, it will have restricted facets and it will be a dys-
functional Type II. And this is always true: either the facets are fixed cl osed
on the side of the promi nent or posteri or TP (the same side to whi ch i t
i s rotated) or they are fi xed o pe n opposi te to the side of the pr omi nent
TP ( opposi te to the side to whi ch it is rotated) .
The t echni que f or releasing f i xed o pe n or f i xed cl osed facets i s sim-
ple. Since you don' t know which facets are restricted, you simply treat both
sides as if they were fixed. Let' s say that you f ound T3 is right rotated on
T4. If the probl em is with the right facets, it is because they are fixed cl osed
and cannot open in forward bendi ng. If the probl em is with the left facets,
they are fixed open and cannot close in back bendi ng. Pick the right facets
first. If your client is sitting, ask hi m to curl over i nto a f orward bent posi-
tion. Put a knuckl e or el bow in the right spinal groove on the presumed
fixed cl osed facets (Figures 2.4 and 2.5, page 20) . Slowly and firmly apply
5 to 10 pounds of cont i nuous pressure to the facets and let your knuckl e
or el bow sink to where it can go no further. Wait until you feel the tissue
soften and give way unde r your pressure. ( See i f yo u can also f eel the
ort hot ropi c ef f ect as the body l engthens and organi zes itself al ong the
sagittal pl ane after the facets release.) Then return your cl i ent to a neu-
tral sitting posi ti on. Put your knuckl e or el bow in the left spinal groove
on the facets that are presumed fixed open. Instruct your client to back
bend while you slowly and firmly apply 5 to 10 pounds of pressure (Fig-
ure 2.6, page 21) . Let your knuckl e or el bow sink to where i t can sink no
further and wait until you feel the tissue soften and give way under your
pressure. ( Agai n, see i f you can f eel the or t hot r opi c ef f ect as the body
l engthens and organi zes itself al ong the sagittal pl ane after the facets
19
Figure 2.4
Figure 2.5
20
Figure 2.6
release.) After you have appl i ed this techni que to bot h sides, check T3 to
make sure that it is no l onger rotated.
Whether you are releasing fi xed cl osed or fixed open facets, as l ong as
you keep the pressure up (just waiting f or the softening, the sense of the
tissue giving way, and the spi ne l engt heni ng and organi zi ng itself al ong
the sagittal pl ane) it is enough to release the facets. Wi th time and prac-
tice you may begi n to feel the facets actually close or open, but it is not nec-
essary f or you to feel the facets release f or the techni que to work. As you
learn to feel the facets release, you will also begi n to feel a corol l ary phe-
no me no n, namel y that not muc h happens under your fingers when you
apply pressure to unrestricted facets. In time you want to be able to feel
the facets release, the tissue soften, and the body l engthen and organi ze
itself al ong the sagittal pl ane. Al t hough tenderness or pai n is not always
the best evaluative tool , you will often find that the soft tissues associated
with the probl emati c facets is tender or painful when you apply pressure.
Practice this shot gun t echni que on the thoraci c vertebrae first with
your cl i ent in a sitting posi ti on. The n practi ce it with the l umbar verte-
21
Figure 2.7
Figure 2.8
22
brae. Until you are mor e conf i dent
in your ability to feel rotation in the
lumbar vertebrae, always check what
yo u f eel i n the sitting posi t i on a-
gai nst what yo u f eel i n the pr o ne
posi t i on. Onc e you are sure that a
l umbar vertebra is rotated, you can
use the sitting posi t i on to rel ease
facet restrictions in muc h the same
way you l earned to release the tho-
racic vertebrae.
You can also release l umbar facet
restrictions with your cl i ent pr one.
Suppos e yo u f i nd that L5 i s left
rotated. Begi n with the assumpti on
that the right facets are f i xed open.
Instruct your cl i ent to raise hi msel f
up on his el bows and to rest i n that
position. Then apply pressure to the right side of the spinal groove where
the presumed fixed o pe n facets are and wait f or t hem to release (Figure
2. 7). Then doubl e over a pillow and pl ace i t under your client' s abdo me n
so that the l umbar spine is appropriately f l exed. Appl y pressure to the left
side where the pr es umed f i xed c l osed facets are and wait f or t hem to
release (Figures 2.8 and 2. 9) .
The side-lying position is also a very effective way to release facet restric-
tions i n bot h l umbar and thoraci c vertebrae. To release presumed f i xed-
cl osed facets, instruct your client to lie in a tight fetal posi ti on on the side
of his body opposi te the cl osed facets. Appl y pressure with your knuckl e
or el bow to the facets and wait f or them to release (Figures 2.10, 2. 11, and
2. 12, pages 24 and 25) . Ask hi m to roll over on his ot her side and back
bend as you apply pressure to the presumed f i xed o pe n facets and wait
for them to release (Figure 2. 12) .
It will make your life as a manual therapi st j ust a little easi er if you
underst and s omet hi ng about ho w the t horaci c facets of the spi ne are
arranged: parallel to the coronal pl ane. You can use this arrangement to
your advantage. Whe n you are releasing cl osed thoraci c facets you will be
23
Figure 2.9
Figure 2.10
Figure 2.11
slightly mo r e effective and effi ci ent if you apply pressure in a cephal ad
di recti on. Wi th open- f i xed thoraci c facets, the techni que will work j ust a
litde bit better if you apply pressure in a caudad direction. The lumbar and
cervi cal facets are clearly not arranged in the same way as the thoraci c
facets, so the di recti on in whi ch you apply pressure is not as important.
As you practice this techni que you will quickly understand why it is more
24
effective than the indirect technique intro-
duc e d i n the last chapter. The pr obl em
with the i ndi rect t echni que is that it
doesn' t address the fixed facets, whereas
this new technique actually challenges the
facet restrictions. If the facets are f i xed
closed the technique requires that you put
your client in a forward-bent posi ti on to
encourage the facets to o pe n while you
release the tissues responsi bl e f or the
restri cti on. In the same way, when the
facets are f i xed o pe n, back bendi ng en-
courages the facets to close as you release
the restricting tissues. The indirect tech-
nique is probably only successful when the
restrictions are not very severe. Generally
speaking, if you want to release a j oi nt any-
where in the body, it is almost always more
effective to use a technique that challenges the restricted facets rather than
a technique that simply unwinds tissue around the fixation.
Keep practicing this shotgun approach until you gain conf i dence with
feel i ng rotation and releasing facet restrictions. In the next chapter, you
will learn how to apply the test so you don' t waste time trying to release
what is not restricted.
Figure 2.12
Note
1. Korr, I.M. "Vulnerability of the Segmental Nervous System to Somati c
Insults" in The Physiological Basis of Osteopathic Medicine, George W. Nort hup
ed. , ( New York, 1982) , pp 56- 57. Emphasis added.
25
CHAPTER
3
(the side to whi ch it is rotated) are always cl osed and the opposi te facets
are open. If all is normal and no facets are restricted, normal mot i on is
possi bl e t hr ough the area. If the si tuati on i s dysf unct i onal , there are
restricted facets and an obvi ous loss of mot i on. So when you find a rota-
tion, you need a way to determi ne whi ch facets are restricted so you don' t
waste time trying to release facets that are not restricted. If you find re-
stricted facets in the l umbar or thoraci c spi ne, then they are either fixed
o pe n or f i xed cl osed. Agai n, you need a way to det ermi ne whet her the
open facets are fixed or the cl osed facets are fixed to avoid wasting time.
The cervical facets are unlike the thoraci c and l umbar facets in that o ne
side can be fixed open while the other is fixed closed. If C3 is right-rotated
and right sidebent on C4, it is possible for the right facets to be fixed cl osed
and the left facets to be fixed open. But this kind of bilateral fixation does
not oc c ur i n the thoraci c and l umbar facets. For now we are onl y goi ng
to deal with the l umbar and thoraci c facets. In the next chapter we will
exami ne the cervical facets.
The test f or determi ni ng whi ch thoracic or l umbar facets are restricted
and how they are restricted is fairly easy to per f or m, but somewhat c o m-
plicated to expl ai n, al though there is a very si mpl e way to r emember the
27
HENEVER YOU ARE LOOKI NG AT A VERTEBRA THAT I S ROTATED
and si debent to the same side ( Type II) , whether it is dysfunc-
tional or normal , the facets on the side with the promi nent TP
Finding and Fixing the Fixations
i mportant i nf ormati on you can gather f rom it.
Wi th your cl i ent in a sitting posi ti on, find the most obviously rotated
t horaci c vertebra. Say you f i nd that T3 i s ri ght rotated on T4 and let' s
assume that the left facets are the restricted ones. Si nce they are f i xed
open, i n a posi ti on of fl exi on or forward bendi ng, when your client bends
f orward the left TP remai ns stationary, f i xed slightly anteriorly. Mean-
while, your right t humb will f ol l ow the right TP as it moves anteriorly dur-
i ng f or war d be ndi ng. The ri ght TP moves anteri orl y dur i ng f orward
bendi ng, because that is what it does normally. But because the left side
is already fixed anteriorly, the right TP is f orced to pivot around the open-
f i xed left f acet as your cl i ent bends f orward. As a result, the right side
appears to derotate. To say it differently, when your client f orward bends,
the bump on the right seems to disappear and the i ndentati on on the left
stays where it is (Figure 3. 1). Whe n your client returns to neutral position,
the bump on the right reappears. If your client now back bends, the bump
on the right will appear to get mor e extreme and the vertebra will move
mor e i nto right rotation (Figure 3. 2). As your client back bends the fi xed
pi vot poi nt created by left facets keeps the left TP fixed anteriorly. Since
back bendi ng f orces the right side to move mor e posteriorly i n compari -
son to the fixed i ndentati on on the left, the right TP appears to move fur-
ther i nto right rotati on.
Now let's i magi ne the opposi te situation in whi ch the right side is fixed
cl osed, as if the right facets were backward bent ( or ext ended) . As a result,
the right TP will be fi xed posteriorly. Whe n your client back bends, your
thumbs feel the vertebra derotate and the b ump seems to go away. Why?
Because the right TP is already fixed posteriorly and the left TP is f orced
to pi vot around the fixed right facets and move posteriorly as your client
back bends. Si nce the left side is free to move posteri orl y and the right
side is fi xed posteriorly already, back bendi ng removes the i ndentati on as
the left TP moves posteri orl y to mat ch the ri ght TP. Whe n your cl i ent
returns to neutral, the b ump on the right returns. If your client now for-
ward bends, the b ump seems to b e c o me mo r e ext reme. Since the right
facets are fixed cl osed, the right TP is fixed posteriorly. Since the left facets
are free, as your client f orward bends they allow the left TP to move ante-
riorly in c ompar i son to the right TP whi ch is f i xed posteriorly. The dif-
f erence between the two TP' s is now mor e extreme and your thumbs seem
28
Figure 3.2
29
Figure 3.1
FINDING AND FIXING THE FIXATIONS
to sense that the vertebra has moved i nto a mor e extreme right rotation.
The precedi ng pr oc edur e is the basis of the test f or determi ni ng rota-
ti on and si debendi ng, and identifying whi ch facets are restricted. But let
me cauti on you about a very i mportant poi nt: i f you are like most other
practitioners who are new to this test, you will probabl y try to think your
way through what happens each time you per f or m the test. As your client
f orward and backward bends, you will be t empt ed to descri be to yourself
what you are f eel i ng, similar to the way I j ust descri bed it. Don' t do it,
because there is an easy way to r emember the i nf ormati on f or identifying
whi ch facet to release. Descri bi ng to yourself a compl i cated phe no me no n
(that also de mands that you de duc e the si de on whi ch the facets are
restricted f r om the way a vertebra rotates and derotates duri ng f orward
and backward bendi ng as you r emember that it is si debent and rotated to
the same side) while simultaneously trying to feel what is happeni ng under
your thumbs f or the first time in your life is 100 times mor e difficult than
trying to f ol l ow this awkward sentence I am writing trying to describe what
you shoul dn' t attempt. What you need is a si mpl e rule that will allow you
to identify and treat the facet fixation with pal patory ease and very little
concept ual thought.
First you determi ne rotation in neutral position. Keep your thumbs on
the TP' s of the rotated vertebra, forward and backward bend your client,
and feel and watch what happens under your thumbs. Look for the posi-
tion (whether in forward or backward bendi ng) where the bump (the pos-
terior or promi nent TP of the rotated vertebra) disappears. Some peopl e
obj ect to saying the bump disappears and like to say that the vertebra appears
to derotate. This is a matter of taste, so use whatever description works best.
But remember this i mportant poi nt: the position where the bump disappears (or
the vertebra appears to derotate) is the position in which the facets are restricted. If
the b ump disappears in f orward bendi ng, the facets are fixed in the for-
ward bent position, whi ch means the facets are fixed open (flexion fixed).
If the bump disappears in back bendi ng, the facets are fixed in the back
bent position, whi ch means the facets are fixed cl osed (extension fixed).
Ther e i s o ne mor e i mportant remi nder: i f the bump, or posteri or TP,
disappears in f orward bendi ng, the fixed-open facets are on the opposi te
side of the rotation, or posteri or TP. If the bump disappears in back bend-
i ng, the fixed-closed facets are on the same side of the rotation. In other
30
words, if a vertebra in neutral posi ti on is rotated and si debent to the same
side (Type II dysfunction), it has a facet restriction and the facets are either
fixed open or fixed cl osed. If they are fi xed cl osed, the fi xed facets are on
the same side as the rotati on, or posteri or TP. If they are fi xed o pe n, the
fi xed facets are on the opposi te side of the rotati on, or pr omi nent TP.
So here are two very simple rules that will allow you to keep your san-
ity as you practice this test:
In backward bending if the prominent TP disappears,
the facets on the side of the rotation are fixed closed.
In forward bending if the prominent TP disappears,
the facets on the side opposite to the rotation are fixed open.
You can ref ormul ate these rules any way you want, but keep a c opy of
them where you can easily see them as you practice per f or mi ng the test.
Agai n, don' t try to think through the l ogi c of this test as you per f or m it.
Learn how to apply the test and get the i nf ormat i on you ne e d by usi ng
these rules first. In ti me, if it is i mport ant to you to be abl e to state the
logic of the test to yourself or to others, you can practice doi ng it. For now,
use this easy met hod to det ermi ne whether the facets are restricted and
whether they are fi xed o pe n or cl osed so that you can directly and effort-
lessly release them.
The techni ques f or releasing facet restrictions are the same as those
you l earned in the last chapter. Since you now have a qui ck way to deter-
mi ne whether you are deal i ng with fi xed o pe n or f i xed cl osed facets, you
only need to apply the techni que to the side with the facet restriction. So
i f the facets are fi xed open, apply the t echni que i n any of the back bend-
ing positions (sitting, pr one, or si del yi ng). If the facets are fixed cl osed,
apply the techni que i n any of the f orward bendi ng posi ti ons.
Previously I menti oned that facets can be bilaterally fixed open or closed.
These fixations are not as easy to find through palpation because they do
not show up as rotated and sidebent. Test f or them by putting your client
in the sitting posi ti on. Find the suspected vertebrae and put a finger or
thumb on the spinous process of the superi or vertebra and put the f i nger
or thumb of the other hand on the spi nous process i mmedi atel y inferior,
and instruct your client to be nd f orward and backward (Figures 3.3 and
31
Figure 3.3
Figure 3.4
32
Figure 3.5
3. 4). If your thumbs move away f rom each other in f orward bendi ng, but
do not approxi mate in backward bendi ng, the facets are bilaterally fi xed
open. If your thumbs approxi mate i n backward bendi ng, but do not move
apart in forward bendi ng, the facets are bilaterally fixed cl osed.
Releasing ei ther is quite si mpl e. Agai n with your cl i ent in the sitting
posi ti on, pl ace the knuckl e of your ri ght f oref i nger i n the ri ght spinal
groove and the knuckl e of your left f oref i nger in the left spinal groove. If
the facets are bilaterally fixed open, ask your client to back bend over your
knuckles as you apply pressure to bot h sides and wait f or the release (Fig-
ure 3. 5) . If the facets are bilaterally fixed cl osed, ask your cl i ent to f or-
ward bend, apply pressure to bot h facets, and wait f or the release (Figure
3. 6). You can apply these techni ques i n the pr one or sidelying posi ti ons
if you wish, but f or obvi ous reasons you will probabl y find the sitting posi -
tion the easiest and most efficient.
As you practice the test for unilateral facet restrictions, you will find ver-
tebrae that are obviously rotated, but do not respond to forward and back-
ward bendi ng by appeari ng to rotate and derotate. You will probabl y also
noti ce that these vertebrae often group themselves together into a curva-
33
Figure 3.6
ture. What you are l ooki ng at are Type I gr oup fi xati ons. When you for-
ward and backward be nd clients with gr oup f i xati ons, the rotated verte-
brae stay in their rotated position all the way through the process of forward
and backward bendi ng. If, as is of ten the case, they are a part of a rot o-
scoliosis (Figure 3. 7), their positions are fixed because of larger myofascial
restrictions and because the shape of the vertebrae has been altered as part
of the curvature. Type I dysfunctions tend not to be restricted at the facet
level by the small muscles and the ligaments like Type II dysfunctions are.
You shoul d be aware that within a Type I curvature you can find indi-
vidual dysfunctional Type II vertebrae. As you mi ght imagine, they are a lit-
tle hard to find. Suppose your client's thoracic vertebrae are all right sidebent
and left rotated, except f or one. That one vertebra coul d be left rotated
and left si debent or right rotated and right sidebent. If it is rotated right
and si debent right it will be nearly impossible to differentiate it f rom the
other vertebrae that are also right rotated by feel al one. If it is left rotated
and left sidebent, since it is also shaped in the Type I pattern, it will still be
very difficult to differentiate. You can find it if you apply the f orward/ back-
ward bendi ng test. But realize that it is also part of the curvature, so don' t
expect it to appear to derotate all the
way. Si nce o ne of the facets i s re-
stricted, it will appear to rotate and
derotate to s ome degr ee. And i t i s
that degree of rotating and derotat-
i ng you have to get a feel f or if you
want to l ocate Type II dysfunctions
in the midst of Type I patterns.
In any case, if you find some ver-
tebrae i n thoraci c or l umbar spi ne
that do no t c hange ho w they are
rot at ed i n f or war d and backward
bendi ng, they are Type I fixations.
They requi re a slightly mo r e c o m-
pl i cat ed t ec hni que than what yo u
have l ear ned so far and you will
l earn these t echni ques i n Chapter
Ten.
Crossover
Apex
Crossover
Crossover
Figure 3.7
Apex
34
CHAPTER
4
understandi ng the body. Well, after many years of worki ng with peopl e in
various kinds of distress, I have c o me to see that they are bot h wr o n g
it's the neck!
Of course, my claim is an exaggerati on. But like all such exaggerations
it contains some degree of truth. The cervical vertebrae support a rather
large and heavy egg shaped thing that is constantly movi ng about, stick-
i ng a fleshy prot uberance cal l ed a nose i nto situations that of ten do n' t
c onc er n it. Our emoti ons often begi n their j our ney toward expressi on i n
our bellies and wind their way through our n e c k o n e of the maj or thor-
oughf ares t hrough whi ch they eventually get expressed. If we suppress
our emoti ons, we often do i t by ti ghteni ng the compl i cat ed muscul ature
of the neck. If we do this over a l ong enough peri od of ti me, we can lose
a g o o d deal of our flexibility and create a rather painful bottl eneck. Al so,
since the cervical spine is not e mbe dde d as securely in bony, myofascial,
membranous structures as the thoracic and l umbar spines, it can move in
many interesting and compl i cat ed waysand as a result get i nto troubl e
more easily. Since the neck is so highly fl exi bl e, it is better able to adapt
to imbalances in the rest of the body than ot her parts of the spi ne.
Try standing up and si debendi ng to the right. Noti ce how your shoul der
35
N HIS MONUMENTAL WORK, The Interpretation of Dreams, FREUD SAI D THAT
the royal road to the unconsci ous is through dream interpretation. His
brilliant col l eague, Wi l hel m Rei ch, said that the royal road is t hrough
The Neck
girdle and neck respond. You woul d actually be mor e comf ortabl e i f your
neck f ol l owed the si debendi ng. But because of your righting reflexes you
instinctively l ook ahead with your eyes roughl y hori zontal to the ground
pl ane. Not i ce how your neck loses some of its fl exi bi l i ty as you attempt to
keep your head on straight while si debendi ng. In a less exaggerated, but
no less i mportant way, our necks are always adjusting to imbalances every-
where i n our bodi es. Since no ne of us have perfectly bal anced bodi es, to
some extent we have all lost some degree of mobility and adaptability in
the cervi cal regi on. Because of this loss of adaptability, you will almost
always find probl ems with peopl e' s necks, even those who do not c o me to
you compl ai ni ng about their necks. You will find restrictions in the necks
of young peopl e and see the effects of unresolved restrictions in the severely
restricted necks of ol der clients. The i mpl i cati on of these observations i s
significant: muc h of the time it will be difficult to adequately treat neck
probl ems unless you understand and manage the i mbal ances and c o m-
pensatory patterns in the whol e body. Al t hough this situation is especially
true f or the neck, it also applies to the entire body. Any time you consi der
mani pul ati ng a l ocal restriction, do your best to also understand how it is
related to all the ot her areas of compensat i on and strain throughout the
body. If your client' s body cannot adapt to or support the release of a local
fixation, then ei ther the l ocal area will revert to its dysfunctional state or
strain will be driven el s ewher eor bot h.
Al t hough necks are very compl i cated, describing their mot i on is easy.
Wi th the excepti on of CI , all mot i on of the cervical spine is always Type II.
Whe n you si debend and rotate your neck, whether you f orward or back
bend, and whether there are facet restrictions or not, sidebending and rota-
tion are always coupl ed to the same side. This fact makes your life as a ther-
apist a litde easier. Unlike the rest of the spine, once you know how a cervical
vertebra is rotated you automatically know it must be sidebent to the same
side. From the previous chapters you also know that the facets on the side
to whi ch the vertebra is rotated are cl osed and that the facets on the oppo-
site side are open. You coul d use the f orward/ backward bendi ng test you
l earned in the last chapter to determi ne whi ch facets are restricted, but if
you try it you will realize rather quickly that it is not easily appl i ed to the
neck and that a different test woul d be useful. It turns out that there is a
rather el egant mot i on test f or determi ni ng facet restrictions, but we will
36
THE NECK
save it f or the next chapter. In this chapter you will learn some easy tech-
niques that do not requi re knowi ng whi ch facets are fixed. The rationale
f or this appr oac h is based on exper i enc e and is the same as the o ne I
explained in Chapter Two: on average, somatic practitioners tend to learn
theory and t echni que mo r e easily and qui ckl y when they can get their
hands to understand first.
Indirect Cervical Techniques
T
HE FI RST T WO TECHNI QUES WE ARE GOI NG TO LOOK AT ARE SI MPLE
i ndi rect techni ques that do not chal l enge facet restrictions. They are
similar to the first techni que you l earned f or derotati ng l umbar and tho-
racic vertebrae i n Chapter One . Even t hough these i ndi rect techni ques
are not as consistently effective as the techni ques that chal l enge the re-
stricted facets, they can be effective on many occasi ons and they are fun
to practice. But more importantly they can assist your l earni ng in two very
useful ways: practicing them will give you experi ence in f eel i ng i nto and
through the body, and they will also teach your hands and mi nd the clear
difference between addressing the myofascial level and the articular level.
In order to det ermi ne whether to apply these i ndi rect techni ques the
only piece of information you need to know is whether a vertebra is rotated.
With your client supine, place the ti ps of your i ndex fingers touchi ng each
ot her on o ne of the spi nous processes of the cervi cal spi ne. Make sure
that your fingers are on the same hori zontal pl ane and that they are per-
pendi cul ar to the sagittal pl ane. The n slowly pul l your fi ngers laterally
apart al ong the hori zontal pl ane. Al most i mmedi atel y you will feel your
fingertips sink into the spinal groove. If the vertebra is right rotated, you
will feel that your right fi nger is a little posteri or and your left fi nger is a
little anterior. The bump is on the right and the i ndentati on is on the left.
Test all of the cervical vertebrae in this way until you find one that is obvi-
ously rotated. And again, don' t fret about the ones that are not clear. For
now, j ust find the ones that are obviously rotated.
If you are not familiar with l ocati ng cervical vertebrae, here is a sim-
pl e met hod f or f i ndi ng your way. Locat e the i nf eri or tip of the mastoi d
process and let your fi nger sink f rom there medially i nto the edge of the
cervical spine. Your fi nger will land on the articular pillar and transverse
37
Figure 4.1
process of C2. The cervical vertebrae are spaced about a finger-width apart
f rom each other. From C2, move down o ne f i nger- wi dt h and pl ace your
f i rst f i nger on the right articular pillar of C3. Then let your other f i ngers
fall i n line under your i ndex fi nger on each successive vertebrae. You now
have your mi ddl e f i nger on C4, your ri ng f i nger on C5, and your pinky
on C6 (Figure 4. 1) .
Figure 4.2 is a illustration of a typical cervical vertebra. The anterior
and posteri or tubercles in this particular vertebra constitute its transverse
processes. In ot her cervical vertebrae, the transverse process is c ompos ed
of onl y one pr omi nenc e. Onc e you realize how cl ose the articular pillars
are to the tubercles, or transverse processes, you can appreciate how your
fingertips, in many cases, are bi g enough to cover bot h at onc e. The artic-
ular pillars are also known as the articular processes. If you l ook at how
the cervi cal vertebrae line up over o ne another, you can easily see how
these articular processes f uncti on as supporti ng pillars.
Let' s go back to your client' s neck and f i nd the most obviously rotated
cervical vertebra so that you can practice the first i ndi rect techni que f or
38
THE NECK
Articular pillar
derotati ng it. Let' s assume you di scover that C3 i s ri ght rotated on C4.
Place the tips of your thumbs on the TP' s of C3 and let your forefi ngers
sink into the spinal groove at the level of C3 (Figures 4.3 and 4.4, page
40) . Gently but firmly squeeze C3 between your fingers together i n the
following way: press the tips of your thumbs toward each other in a medi al
direction as you squeeze your forefingers into the spinal groove in an ante-
rior and slightly superi or di recti on. Wait and you will feel the marvel ous
response of your client' s body to your t ouch as it begi ns to correct itself.
You will probabl y fi rst feel C3 move further i nto right rotati on and right
si debendi ng and then c hange di rect i on and possi bl y move toward left
rotation and left si debendi ng, perhaps movi ng in unpredi ctabl e and sur-
prising ways bef ore it setdes and releases. Don' t try to anticipate its mot i on,
j ust fol l ow the dance. Whe n it releases you will feel the associated tissues
soften and the neck organi ze itself al ong the sagittal pl ane. If the tech-
ni que was successful your client will report that his pai n is either go ne or
lessened and you will noti ce that C3 is no l onger right rotated. Practice
this techni que f or a while until you try the next one.
39
Figure 4.2
Posterior tubercle
Anterior tubercle
Facet
Spinous process
Body
Facet
Figure 4.3
Figure 4.4
40
THE NECK
The second i ndi rect techni que i s not onl y si mpl e, but rather elegant.
It was created by my f ri end and col l eague, Jan Sultan, who j oki ngl y and
appropri atel y calls it "Dial-a-Neck. " You may f i nd this t echni que a little
more effective than the previous one because it involves larger movements
of the head and neck whi ch may, i n turn, have mo r e of an effect on the
facet restrictions.
Grasp the TP' s of C3 bet ween the t humb and mi ddl e f i nger of your
right hand (Figures 4.5, 4.6, and 4. 7) . Wi th your left hand grasp the t op
of your client' s head and rotate it to the right so that its rotati on, accord-
ing to your best guess, matches the rotation of C3. Now wait f or a mo me nt
and you will experi ence a remarkable devel opment C3 and your client' s
head will both begi n to move further i nto right rotati on. Just f ol l ow this
mot i on until the head and neck rotate no further and wait. In a few sec-
onds you may feel a slight pulsation under your fingers (it doesn' t really
matter whether you feel this pulsation or not; but since many therapists
do feel it, it is worth menti oni ng) . Continue to wait for a few more moments
and you will feel an i mpul se i n your client' s neck and head to c o me out
Figure 4.5
41
Figure 4.7
42
Figure 4.6
THE NECK
of its extreme rotation. Agai n, j ust f ol l ow the directions in whi ch the head
and neck want to move. They may rotate to the left and then back to the
right as they si debend, f orward and backward be nd, this way and that.
Don' t i mpose your notions of what is possible or what you think they shoul d
do , j ust f ol l ow the danc e. Eventually, the head and nec k will cease all
si debendi ng and rotating, and setde in a straight line. Wait f or the tissues
to soften under your fingers and f or the ort hot ropi c ef f ect as the nec k
lengthens and organizes itself al ong the sagittal axis. Palpate C3 and see
if it derotated. If the techni que was successful, C3 will no l onger be rotated,
the tissues will feel mor e rel axed, and your client will report that his pai n
is lessened or compl etel y gone.
You may have not i ced that my favorite expressi on f or how to respond
to the body as it finds normal is "Just f ol l ow the dance. " The ref i ned aes-
thetic sensibilities of some Italian students that I onc e taught in Ro me l ed
them to coi n the phrase, ' The Dance of the Tissues " t o describe this aston-
ishing ability of the body to f i nd its way back ho me when given permi s-
sion. Wi th a little practi ce and pati ence everyone can l earn to percei ve
this dance. All it requires is that you let go of your t endency to anticipate
and c o mme nt on the process that i s unf ol di ng under your hands and let
what is happeni ng unf ol d in its own way. Resist the temptati on to step out
of the f l ow of l i ved- experi ence and reflect on what i s happeni ng.
Reflectively thinking about experi ence certainly has a pl ace in life, but
not when you are applying these techni ques. Athletes someti mes refer to
this pre-reflective way of bei ng and doi ng as the " Zo ne . " If a basketball
player were to think to himself as he was about to score the wi nni ng poi nt
in the last seconds of the game, " Oh, this is great I am about to score two
bi g ones, " he probabl y woul dn' t . If, duri ng an i nspi red per f or manc e, a
great concert musician were to continually c omment to herself, "I am play-
ing this beautifully, Mozart woul d be so i mpressed! " her inspiration woul d
soon b e c o me a fl eeti ng memor y. In the same way, i f you refl ect on the
process or c o mme nt to yourself i n elation, skepticism, or self-doubt, you
will j ust as surely lose your ability to f ol l ow the dance of the tissues.
All t oo often when therapists first attempt to f ol l ow the dance of the
tissues they adopt all sorts of silent, self-defeating mo no l o gue s and atti-
tudes that instantly hi nder their ability to feel the obvi ous. Since they are
often not prepared f or the experi ence of the body movi ng under its own
43
di rect i on i ndependent l y of their or the client' s consci ous cont rol , they
doubt what they are feel i ng. Someti mes their skepticism gets in their way
and they think, " Oh, this can' t be happeni ng! " and suddenl y what they
were feel i ng disappears under their hands. At other times their own aston-
i shment brings the dance to a compl et e standstill. Bef ore they even touch
the body, s ome therapists assume that they are not sensitive e no ugh to
feel such movement s and j ust as surely as they let their feelings of i nade-
quacy take over, they l ose their i nnate ability to f ol l ow the dance of the
tissues. However, you can learn to put all such noti ons aside and j ust let
yoursel f feel what the body wants to do .
The most c o mmo n mistake that begi nni ng followers of the dance make
is to anticipate what the body wants to do as it transitions f rom one posi-
ti on to another. At first they f i nd themselves f ol l owi ng the dance quite
well as the body conti nues to rotate and si debend i n one di recti on. But
at the very mo me nt the body stops movi ng in the di recti on they are fol-
l owi ng and begi ns to shift in another di recti on, they immediately wonder
what is happeni ng, al though mo r e than likely they will not even f or m a
compl et e thought about it. Either the moment ary cessation of movement
i n a cl ear di rect i on or a slow but obvi ous c hange of di recti on compel s
t hem to instinctively wonder about what is goi ng on. It is muc h like what
happens when you see movement f rom the corner of your eyeyou instinc-
tively and inquisitively turn to see what the mo ve me nt is. Al t hough no
words may be spoken, your ori ent at i on and c o mpo r t me nt say "What' s
that?"
It doesn' t really matter what therapists say or don' t say to themselves
when the body changes directions duri ng treatment. What matters is that
they step out of the flow of l i ved- experi ence and lose track of the dance.
If you are not pre-reflectively there to f ol l ow the body' s lead, you are no
l onger able to recogni ze its pattern of strai nthere is no l onger anything
f or you to f ol l ow and so you stop movi ng. Since it takes two to tango, the
body also stops movi ng. If this happens to you duri ng the transitions, all
that you ne e d to do i s simply stop thi nki ng about what you are feel i ng.
Let go of your surprise, puzzl ement, or wordless "What' s that?" and j ust
feel again how the body slow dances toward its own correcti on.
Learni ng to work this way is an exercise in l earni ng how not to think,
how not to worry, and how to be happy with what is. The mor e you learn
44
THE NECK
to live in this pl ace of no-thi nki ng, the happi er you will be c o me . Expl ore
this open way of not reflectively thinking about what is occurri ng, because
it is a gateway i nto the heal er' s way of bei ng that I briefly ment i oned in
the i nt roduct i on. Expl ore this spaci ous way of bei ng when you are not
working with clients and you can transform your life. Explore it while work-
ing with your clients and their bodi es will reveal mor e and mor e of what
they need f r om you. In ti me you will be less and less c o nc e r ne d about
i mposi ng your will and presupposi ti ons on your clients, or the worl d, and
things will unf ol d with an i mpeccabl e clarity.
Like most indirect techni ques of this nature Dial-a-Neck will someti mes
produce wonderf ul and astounding results and at other times it will seem
like a waste of effort. Now you know whyi t' s because these techniques do
not direcdy challenge j oi nt fixations. Since we are approachi ng all j oi nt fix-
ations in this book f rom the soft-tissue perspective, we need a way to chal-
l enge the j oi nt fixation wi thout resorting to high-velocity, low-amplitude
thrusting techniques, and that is what the next techni que will accompl i sh.
A Joint Challenging Technique
T
HI S J OI NT - C HA L L E NGI NG T E C HNI QUE I S VERY LI KE T HE S HO T G UN
techni que you l earned i n Chapter Two to release facet restrictions i n
the thoracic and l umbar sections of the spi ne. Al t hough there are a num-
ber of small di f f erences, let me descri be the t echni que simply, wi thout
menti oni ng these di fferences so you know you are in familiar territory. It
works j ust as you mi ght expect: you locate the rotated vertebra and assume
that it is fixed cl osed on the side to whi ch it is rotated and fixed o pe n on
the opposi te side, put pressure on the fixed-closed facets in f orward bend-
i ng and wait f or the release, and put pressure on the f i xed- open facets i n
backward bendi ng and wait f or the release.
You will be happy to learn that this shotgun t echni que does not waste
as muc h time when appl i ed to the cervical spi ne. In the thoraci c or l um-
bar spines, the facets are either fixed o pe n or fixed cl osed. So every time
you apply this shotgun approach to a l umbar or thoracic vertebra, you are
always addressing o ne side t oo many. But the cervical spi ne is different.
Very often you will find that the facets on bot h sides are fixed. It is very
c o mmo n to find a cervical vertebra that is bilaterally restricted with facets
45
that are f i xed cl osed on one side and f i xed open on the other side. Your
efficiency, theref ore, goes up somewhat when you use this techni que for
the neck.
There are some important differences between the vertebra of the neck
and the rest of the spi ne that you need to understand. One of these dif-
f erences is reason f or cauti on. Ther e are two vertebral arteries that run
al ong and inside the cervical vertebrae and irritating or cutting them off,
especially i n ol der clients, can be very dangerous. The vertebral arteries
are especially at risk at C6, C7, and at the occiptioatlantal j unct i on. Even
if your arteries are normal , when you rotate your neck they can narrow as
muc h as 9 0 % on the side opposi t e the rotati on. Forward bendi ng and
si debendi ng the neck will not put these arteries at risk, but back bendi ng
will greatly exaggerate what happens in rotati on. Back bendi ng a client' s
nec k while appl yi ng a high-velocity, l ow-ampl i tude thrusting techni que,
f or exampl e, i s a very danger ous appr oac h. Be caref ul . Whe n you are
attempti ng to release o pe n fixed cervical facets, even using the soft-tissue
techni ques taught i n this bo o k, you must modi f y them and not put your
clients' s neck very far i nto extensi on.
If you put your cl i ent i nto back bendi ng and rotation by mistake and
she compl ai ns of dizziness or you noti ce that her eyes begi n to move invol-
untarily in a rhythmic back and forth pattern ( known as nystagmus) take
her out of extensi on i mmedi atel y and suggest that she see her doctor. If
you have any doubt s about the integrity of a cl i ent' s vertebral arteries,
there is a si mpl e test you can apply. Put your cl i ent in a sitting posi ti on
with her spi ne comf ortabl y straight. Ask her to back bend her head and
then turn her head to the right and to the left. Watch f or the appearance
of nystagmus or dizziness.
Si nce the neck i s capabl e of mor e mot i on than the rest of the spi ne,
you can i nt roduce si debendi ng and rotation as a way to further chal l enge
facet restrictions. In fact, you shoul d use si debendi ng and rotation in place
of i nt roduci ng significant extensi on as you mani pul ate o pe n f i xed facets.
In the case of cl osed- f i xed facets, you can apply extreme f orward bend-
i ng wi thout worry when you apply si debendi ng and rotation.
Not i ce also how the facets are arranged in the cervical spine. Not only
are they are almost parallel to the transverse pl ane, the facets are acces-
sible to your fi ngers in three pl aces: in the spinal groove, at the lateral
46
THE NECK
edges where the articular pillars and transverse processes are, and j ust
slighdy anterior and medial to the articular pillars and transverse processes.
Having a number of places where the facets are accessible to your fingers
makes the application of this techni que j ust a little bit easier, because you
can adjust the appl i cati on of pressure to allow f or how the bo dy i s best
able to release.
So let' s take a mor e careful l ook at this techni que. For the purposes of
illustration, assume again that C3 is right rotated on C4. Either the right
facets are fixed cl osed or the left facets are fixed o p e n o r bot h sides are
fixed. Since C3 is right rotated, you know that it also must be right sidebent.
If it is right si debent, it will be restricted in left si debendi ng and rotati on,
whi ch means that it can easily si debend and rotate right, but cannot side-
bend and rotate left. You need to know the di recti on i n whi ch C3 cannot
si debend and rotate in order to chal l enge the facets.
Release the right facets fi rst. Cradl e the back of your client' s head i n
your left hand and lift i t of f the table. Lean your el bow on the table so
that you can comf ortabl y support your client' s head. The n left si debend
and left rotate your client' s head and neck as far as they will comf ortabl y
go. Forward bendi ng and si debendi ng both challenge the presumed fi xed-
closed right facets. Then put your i ndex or mi ddl e fi nger on the presumed
fixed cl osed facets in the right spinal groove or on the articular pillars, as
shown in Figure 4.8, page 48. As you keep your cl i ent' s head in its left-
si debent posi t i on, let your f i nger sink i nt o the spinal gr oove and wait.
When the facets release, you will noti ce the usual indicators: sof teni ng of
the tissue and a sense of the neck l engt heni ng al ong the sagittal pl ane.
But you will also feel somet hi ng else. Re me mb e r that C3 i s not abl e to
si debend and rotate left because of the presumed right-fixed facets. Whe n
the facets release, you will also feel your client's head and neck left si debend
and rotate j ust a little further. If these are the onl y facets restricted in the
neck, then the left si debendi ng and rotation will be very obvi ous.
Now let' s release the presumed f i xed- open facets on the left. Agai n,
cradle the back of your client' s head in your right hand, lift it up, and rest
your el bow on the table. Put your left i ndex or mi ddl e f i nger on the f i xed
open facets by placing your left finger in the left spinal groove or between
the articular pillars as shown in Figures 4.9 and 4.10, page 49. To make
things easier f or yourself, allow your client' s head to rest on the webbi ng
47
Figure 4.8
between the t humb and f oref i nger of your left hand. Push ever so slightly
i n an anteri or di recti on to give j ust the suggestion of back bendi ng. With
your right hand, si debend and rotate your client' s head and neck to the
left as far as they will comf ort abl y go and wait. Whe n the facets release,
you will feel the tissues soften, the sense of l engtheni ng al ong the sagittal
pl ane, and your client' s head and neck turning further into left si debend-
i ng and rotati on.
It is a g o o d i dea to experi ment with and modi f y this techni que a bit.
Try different pl acements of your left i ndex fi nger. See how the techni que
works for you when you put your i ndex finger in the spinal groove, between
the TP' s of C3 and C4, or j ust slightly i n f ront of and between the TP' s of
C3 and C4 as you si debend and rotate your client' s head and neck to the
left. Al so, you don' t have to wait passively f or the facets to release. Exper-
i ment with gently twisting and j i ggl i ng your client' s head in the di recti on
of left si debendi ng as you appl y pressure ei ther on the o pe n or cl osed
facets. You can also very effectively c o mbi ne the di rect and i ndi rect ap-
proaches. By twisting and then j i ggl i ng your client' s head and neck in the
48
Figure 4.9
Figure 4.10
49
THE NECK
di rect i on i t c annot si debend and rotate, you are chal l engi ng the facet
restriction by perf ormi ng a direct techni que. But if you then wait for your
client' s body to respond to your di rect chal l enge and f ol l ow the dance of
the tissues you are approachi ng the fi xati on indirectly. Try j i ggl i ng and
rotating while waiting f or the dance, and then mor e j i ggl i ng and rotating
and again waiting f or the dance, and so on until you secure a satisfactory
release. Do n' t be surprised i f you have to per f or m the techni que a cou-
pl e of times to compl etel y release the fi xati on.
Thi s j oi nt- chal l engi ng t echni que can also be used with a new mot i on
test f or det ermi ni ng whi ch facets are fixed and how they are fixed. That
you will learn in the next chapter. The test will allow you to be mor e effi-
ci ent i n your approach and provi de an i mportant i ndi cator of facet f i xa-
tion. Re me mbe r that fixation is mor e i mportant than posi ti on. Checki ng
f or rotati on bef ore and after the appl i cati on of a techni que is not a per-
fecdy reliable indicator of dysfunction or its release. A vertebra may appear
to have derotated and yet not have been compl etel y released f rom its facet
restriction. You shoul d also realize that a vertebra can appear to be slightly
rotated and not actually have any facet restrictions. The mot i on testing
that you are about to learn will give you a very clear way to know, without
relying on palpating rotati on, whether you have di scovered cervical facet
restrictions and whether you were successful i n releasing them.
50
CHAPTER
5
or curved pl ane. The test i s si mpl e and quite elegant: you f orward be nd
and backward be nd your client' s head and neck and then push each ver-
tebra f rom right to left and f rom left to right al ong a hori zontal pl ane. If
you f i nd that the vertebra moves f r om right to left but not f r om left to
right, you have di scovered a facet restriction.
When you hol d your client' s neck i n f orward bendi ng while you trans-
late the vertebra, you are testing to see if the facets can open. If there are
no facet restrictions, the facets will o pe n in f orward bendi ng and you will
be able to translate the vertebra f rom left to right and right to left. How-
ever, if you find that you can translate f rom right to left, but not f r om left
to right in f orward bendi ng, you have di scovered fixed cl osed facets that
will not permi t translatory mot i on. Likewise, when you put your client' s
neck in a back bendi ng position and translate, you are testing f or whether
the facets can close. If you find that you cannot translate f rom right to left
with your client' s nec k i n backward bendi ng, then you have di scovered
fi xed open facets that will not permi t translatory mot i on.
The absence of translatory mot i on indicates the l ocati on of the facet
restriction. In the forward bendi ng position, loss of mot i on indicates fixed-
cl osed facets and i n the backward bendi ng posi ti on, loss of mot i on i ndi -
51
HE MOT I ON TEST DEVELOPED BY OSTEOPATHS FOR DETERMI NI NG
facet restrictions in the cervical spine is called the Translation Test.
Translation in this context refers to mot i on i nduced al ong a straight
Motion Testing the Cervical Spine
cates fixed-open facets. In the f orward bendi ng posi ti on the facet restric-
ti on is on the side opposi t e the mot i on restriction and in the backward
bendi ng posi ti on the facet restriction is on the same side as the mot i on
restriction. This may sound o dd, or even paradoxi cal at first, but it makes
perf ectl y g o o d sense o nc e you understand the l ogi c of the test and the
Type II bi omechani cs of C2- C7.
Don' t c onc er n yourself with the l ogi c of the test j ust yet or with how to
determi ne on which side the facet restriction is. We will get to these i mpor-
tant aspects of the test soon enough. Bef ore we do , there is an i mportant
distinction to keep in mi nd. Not understandi ng or hearing this simple dis-
ti ncti on at the outset has been e no ugh to drive s ome rather intelligent
and normal therapists around the bend. The distinction is between a facet
restriction and a motion restriction.
A facet restriction is the cause of the mot i on restriction. If you cannot
translate a cervi cal vertebra i n o ne di rect i on, the cause of this lack of
mot i on is a facet restriction. After you apply this test you then use the dis-
covery of the mot i on restriction to deduc e where the facet restriction is.
Unl i ke what you l earned in the f orward and backward bendi ng tests for
the thoraci c and l umbar spi nes, you will be deduc i ng facet restrictions
f rom mot i on restrictions i n the cervical spi ne, not f rom the how the ver-
tebra appears to derotate. Remember this distinction and that you are tak-
i ng your ref erence poi nt f rom mot i on restriction, not f rom rotation.
In order to understand what translation is and how it works, practice
it with your client' s head lying comf ortabl y on the treatment table, mak-
i ng sure that his neck is relatively straight. Admittedly, this posi ti on is not
very useful f or getti ng the i nf ormat i on you need f or det ermi ni ng facet
restrictions. You must use translation i n the f orward and back bendi ng
posi ti ons to get that i nf ormati on. However, we are practicing translation
this way first so that you can understand how it works wi thout the added
effort of mai ntai ni ng your client' s head and neck i n f orward and back-
ward bendi ng.
Let' s start by translating C3 with your client' s head and neck lying c om-
fortably straight on the table. Find C3 and pl ace your i ndex and mi ddl e
fi ngers on each TR Use your palms and thenar emi nences to stabilize and
hol d the upper part of the cervical spine and the head. Introduce trans-
lation by movi ng your fingers and hands (as a whol e, as if their were no
52
MOTION TESTING THE CERVICAL SPINE
Figure 5.1
j oi nt s i n your hands) f r o m left t o ri ght
and f rom right to left al ong the hori zon-
tal plane (Figure 5. 1). Be certain that you
are i nt r oduc i ng mo t i o n onl y al ong the
hori zontal p l a ne b e very careful not to
actually si debend your client' s neck. The
neck and C3 will automatically si debend
as a result of mo vi ng i t al ong the hor i -
zontal. If you inadvertently si debend your
cl i ent while you are attempti ng to trans-
late C3, you will not get a clear readi ng.
Feel what happens unde r your f i ngers.
Does C3 move better left to right or right
t o left? If yo u are no t sure c he c k C2
through C7 until you find a vertebra that
cl earl y does no t mo v e as easily i n o n e
direction as it does the other. Don' t worry
yet about how to i nterpret your findings.
You may actually f i nd some vertebrae that do n' t translate at all. I gnor e
these cases until you find a vertebra that obviously translates one way and
not the other. Just make sure you are translating correctl y and not inad-
vertently i ntroduci ng si debendi ng i nto your mot i on. Do you noti ce how
translation al one is sufficient to create si debendi ng?
Onc e you are comf ort abl e with translating C2- C7, try translating C3
i n the f orward bendi ng posi ti on. Prop your el bows on the table. Cradl e
and stabilize your client' s head and cervical vertebrae above C3 with your
palms and thenar emi nences and lift the head of f the table (Figure 5.2,
page 54) . It i s very i mportant that you pr o p up your el bows so that you
are not exerti ng a l ot of unnecessary ef f ort trying to ho l d your cl i ent' s
head still. Many clients have a difficult time relinquishing control of their
necks to your hands, so the more stable and secure they feel in your hands,
the more they can give up control . If you cannot comf ortabl y manage this
posi ti on f or yourself, you mi ght try using a face cradl e f or your table that
will allow your client' s head to rest easily on it in the f orward and back-
ward bendi ng positions (Figure 5. 3).
In any case, put your client' s neck in f l exi on by lifting it of f the table.
53
Figure 5.2
Figure 5.3
54
Stabilize the head and C1 - C2 with your
palms and thenar eminences, and then trans-
late C3 along the horizontal plane f rom right
to left and then f r om left to right. Does i t
translate better one way than another? If so,
you have discovered a moti on restriction that
will allow you to deduc e the side on whi ch
the facets are fixed cl osed. If C3 translates
f rom right to left, but not f rom left to right,
the mot i on restriction is on the left. Don' t
c onc er n yourself right now with how to de-
duc e the si de with the f i xed- cl osed facets
f rom the discovery of moti on restriction, j ust
feel the restriction. If C3 translates both ways,
go l ooki ng f or a vertebra that doesn' t.
No w try transl ati ng i n the backward
bendi ng posi ti on. To achieve an easy exten-
sion of the neck, simply slide the lateral edge
of your forefi nger under the neck and gently push i t i n an anterior di rec-
tion while you simultaneously and gently push your client' s head i n an
inferior position. Stabilize the head and C1- C2 with your palms and thenar
emi nences, and translate C3 first one way and then the other (Figure 5. 4).
If you find that C3 translates o ne way better than another, you have dis-
covered a mot i on restriction that will al l ow you to de duc e the si de on
which the facets are fixed open. If C3 translates f rom left to right, but not
f rom right to left, the mot i on restriction is on the right. Agai n, don' t c on-
cern yoursel f at this poi nt with l earni ng whi ch si de i s f i xed o pe n, j ust
learn to feel f or the mot i on restriction. If you don' t find a mot i on restric-
tion at C3 on C4, then test other cervical vertebrae until you find a mot i on
restriction.
Practice translation on all the cervical vertebrae with the except i on of
CI : i n f orward and backward bendi ng until you are fairly conf i dent that
you can locate each individual vertebra and feel its free or restricted moti on.
After practicing on a number of di f f erent clients, you will be amazed at
the prof ound differences between necks. Some necks seem to be very flex-
i bl e, with suppl e soft tissues, and yet still show facet restrictions. Ot her
55
Figure 5.4
necks seem to be tight and rigid at every level. Of course, you will f i nd
those necks that seem at first as t hough they shoul d be fixated at every
level, but are relatively free of facet restrictions. What experi ence teaches
you is that everyone is different and that the feeling of a restriction in one
per son may be unrestri cted mo t i o n f or another. Ultimately, no matter
what part of the body you are evaluating, you must learn to feel what con-
stitutes a restriction f or each individual person.
Now that you have some familiarity with translation, let' s l ook a little
mo r e closely at the mot i on test and the i nf ormati on you can glean f rom
it. Translation automatically i ntroduces si debendi ng and rotation to the
same side. Since si debendi ng and rotation are always coupl ed to the same
side i n the neck (with the except i on of CI ) , i f you know whi ch di recti on
a vertebra cannot si debend, you also know the way it cannot rotate. Regard-
less of whet her you translate your client' s nec k i n f orward or backward
bendi ng, i f C3 can translate f r om the right to the left, but not f rom the
left to the right, you i mmedi atel y know that the vertebra is right si debent
and right rotated, with f i xed facets somewhere that are preventi ng left
si debendi ng and left rotati on.
Figuring out whi ch facets are restricted is quite simple. Suppose in for-
ward bendi ng you can translate C3 f rom right to left, but not f rom left to
right. The di scovery of a mot i on restriction on the left means that C3 is
right si debent and right rotated on C4 and that C3 cannot left si debend
and left rotate. Si nce you are testing in f orward bendi ng, you also know
that you have di scovered fixed cl osed facets. So since C3 has facets that
are fixed cl osed and C3 is right si debent and right rotated, then you know
the fi xed cl osed facets must be on the right.
Suppose you test anot her client' s neck i n back bendi ng and you f i nd
the same mot i on restriction. In back bendi ng you discover a moti on restric-
ti on on the left: C3 translates easily f rom right to left but, not f rom left to
right. This di scovery tells you that C3 is right si debent and right rotated
and c annot left si debend and left rotate. Si nce you are testing i n back
bendi ng, you know that you have di scovered f i xed o pe n facets. Since C3
i s right si debent and right rotated on C4 and the facets are fi xed open,
you know that the f i xed o pe n facets must be on the left.
Two simple rules i mmedi atel y emerge f rom this exercise: 1) when you
translate in f orward bendi ng and meet a mot i on restriction, the facets are
56
f i xed cl osed on the side opposi te to the mot i on restriction, and 2) when
you translate i n back bendi ng and meet a mot i on restriction, the facets
are fixed o pe n on the same side as the mot i on restriction.
Don' t let your me mo r y of the f orward and backward bendi ng tests f or
the thoraci c and l umbar spines conf use your understandi ng of the trans-
lation test. Remember that f or the cervical spine you are deduc i ng where
the facet restriction is f rom determi ni ng where the mot i on restriction is.
You are not deduc i ng the l ocati on of the facet restriction f r om how the
vertebra appears to derotate, as you di d in the thoracic and l umbar spines.
The ref erence poi nt you are using to deduc e the facet restriction i n the
cervical spi ne, i s mot i on restriction, not rotati on. For the thoraci c and
l umbar spines, you deduc e that the f i xed- cl osed facets are on the same
side as the rotation and that the fixed-open facets are on the opposi te side
of the rotati on. In the cervi cal spi ne, you de duc e that the f i xed- cl osed
facets are on the side opposi te to the mot i on restriction and that the fixed
open facets are on the same side as the mot i on restriction. Wi th cervical
translation, the ref erence po i nt t he side to whi ch the facet fixation is
either opposi te or the s amei s reversed i n relation to the f orward and
backward bendi ng test f or the thoraci c and l umbar spines.
Why does it work this way? Let' s stick with the same exampl e. If there
are no f i xed- cl osed facets, then when you f orward bend your client' s neck
all the facets will open and when you translate you will not meet any mot i on
restriction. Whe n you translate i n f orward bendi ng and meet a mot i on
restriction, the cause is fixed cl osed facets. In our exampl e translation tells
you that C3 is right si debent and right rotated on C4 and that the right
facets are fixed closed. Whe n you translate right to left the left facets must
be free to o pe n to allow that mo t i o n to occur. Si nce the left facets are
i ndeed free to open, you are able to translate right to left. But when you
try to translate left to right the situation changes. Translating left to right
can onl y happen i f the ri ght facets can o pe n. But si nce they are f i xed
cl osed, they cannot o pe n and will not permi t left-to-right translation. You
feel the mot i on restriction on the left, because the right facets will not
open, and are f i xed cl osed. You do not feel the mot i on restriction on the
right because the left facets are able to o pe n as you translate right to left.
Whe n you back be nd your cl i ent' s nec k, i f there are no f i xed- open
facets, all the cervical facets will cl ose and you will not meet any mot i on
57
restri cti ons when you translate. If you meet a mot i on restriction while
translating in back bendi ng, the cause is f i xed o pe n facets. Translation
tells you that C3 is right si debent and right rotated on C4 and that the left
facets are fi xed open. In back bendi ng, when you translate f rom right to
left, the right facets must be capabl e of cl osi ng f or that mot i on to occur.
Si nce the right facets are free and able to cl ose, you can easily translate
f rom right to left. In order f or you to be able to translate C3 f rom left to
right, the left facets must be capabl e of closing. But since they are fixed
open, they cannot cl ose, and henc e you cannot translate C3 f rom left to
right. You feel the mot i on restriction on the left, because the left facets
will not cl ose, because they are f i xed o pe n. You do not feel the mot i on
restriction on the right, because the right facets are able to cl ose to per-
mit translation f rom right to left.
After translating the necks of a number of peopl e, you may noti ce a
rather c o mmo n oc c ur r enc e, i n whi ch you meet a mot i on restriction on
the same side i n bot h f orward and backward bendi ng. For exampl e, sup-
pose you f i nd that you can translate C4 f r om left to right but not f rom
right to left i n bot h f orward and backward bendi ng. When you discover
a case like this where the mot i on restriction is on the right in bot h for-
ward and backward bendi ng, i t means that the facets on bot h sides are
fixed. The left facets are fixed cl osed and the right facets are fixed open.
If you detect a mot i on restriction on the left i n bot h f orward and back
bendi ng, it means that the right facets are fixed cl osed and the left facets
are f i xed open.
You will also encount er necks that exhi bi t mot i on restriction on both
sides in both f orward and backward bendi ng. Bilateral mot i on restriction
can be the result of arthritis or somethi ng si mpl e, like rigid tight muscles
and fasciae. In the latter case, you must release these myofascial restric-
tions first.
When you are first learning how to moti on test the neck for facet restric-
tions, do not conf use yourself by trying to elucidate the l ogi c of the test.
Just learn to feel f or mot i on restrictions and use the simple rules provided
to deduc e the facet restriction. Unlike the f orward and backward bend-
i ng tests f or the thoracics and l umbars, cervical translation involves not
onl y si debendi ng, rotation, f orward bendi ng, and backward bendi ng, but
also left and right translation. Tryi ng to understand the results of the test
58
while attempting to remember all these condi ti ons can be c o me very c o m-
plicated. So here are the simple rules f or C2- C7:
If translation reveals a motion restriction in backward bending, then
the facets are fixed open on the same side as the motion restriction.
If translation reveals a motion restriction in forward bending, then the
facets are fixed closed on the side opposite to the motion restriction.
As with the ot her rules provi ded, you can ref ormul ate these any way
that suits your understandi ng. If you memori ze these rules or keep a copy
where you can see them, you will save yourself a l ot of gri ef as you work
with your clients. If you are like most therapists, you do not want to try to
think your way t hrough the l ogi c of these tests whi l e you are appl yi ng
t he my o u j ust want to apply the tests so that you can quickly det ermi ne
whi ch facets are fixed.
If you have been practi ci ng the shot gun t echni ques f r om Chapter 3
that chal l enge cervical facet restrictions, then you already know how to
release them. The translation test gives you the added ability to locate more
precisely where and how the facet is restricted. The translation test has
another great advantage. As previously not ed, if your onl y way of knowi ng
whether a cervical facet restriction has been released is the appearance of
derotati on, then you do not have a fully reliable i ndi cator. Transl ati on
gives you a far more accurate way to determi ne whether the facet has been
released than checki ng f or derotati on.
As you practice these techni ques, allow yourself the f r eedom to let the
client' s body tell you how it wants to release itself. Whe n you rotate and
si debend the head and neck to chal l enge a facet restriction, someti mes
the body wants to rotate and sidebend to the opposite side before it releases.
Be prepared to f ol l ow the dance of the tissues, even if it means f ol l owi ng
the body into seemingly o dd positions. Learn to easily shift f rom di rect to
indirect techniques and back again as the body demands. When you begi n
with chal l engi ng a facet restriction, wait to see how the body responds to
your invitation. The head and neck may want to rotate and si debend to
the side opposi te to how you are hol di ng them. They may want to go i nto
f l exi on and then extensi on as they si debend and rotate this way and that
until they finally release. Or the facets may simply go directly into a release
59
in the di recti on you are encouragi ng it to go.
Always check the results of your work. After you have appl i ed a tech-
ni que, translate the cervical vertebra again to make sure you released the
facet restriction compl etel y. Don' t be surprised i f you have to apply the
techni que a few times bef ore the facets release to your satisfaction. Unlike
the techni ques you l earned f or releasing the rest of the spi ne, the cervi-
cal vertebrae someti mes requi re a few applications of the techni que until
the facets release.
In the next chapter you will learn how to release atlas-on-axis restric-
tions and occiput-on-atlas restrictions.
60
CHAPTER
6
already l earned and are very easy to apply.
Ninety percent of normal atias mot i on on the axis is rotation. There is
some sidebending, but f rom a clinical standpoint it is not important enough
to worry about. Whe n the atlas gets in troubl e, it is due to restricted rota-
ti on. You can det er mi ne whet her CI i s rotated on C2 by pal pati ng f or
whether one TP is anterior and the other is posterior, but in many necks
CI rotation is someti mes difficult to feel. Besides, someti mes the atlas can
be slightly rotated and show no restricted facets. In general , the most reli-
able way to det ermi ne dysfunction is by using a si mpl e mot i on test.
Begi n with your cl i ent i n a supi ne posi ti on on your treatment table.
Grasp his head with bot h hands and flex the cervi cal spi ne so that the
head is lifted up about 45 degrees. Posi ti oni ng the cervical spi ne in this
way locks C2- C7 and f orces the atlas to rotate with the occi put . Maintain
the cervical spine in this posi ti on and rotate your client' s head to the left
and then to the right (Figures 6.1 and 6.2, page 62) . If CI is not restricted
on C2, then you will be able to easily and obviously rotate his head freely
to each side. If the atlas rotation is restricted, you will be able to rotate his
head easily i n o ne di rect i on, but not as far i n the other. So i f his head
rotates to the ri ght and no t as well to the left, CI i s ri ght rot at ed and
61
O COMPLETE YOUR UNDERSTANDING OF THE NECK YOU NEED TO KNOW
how to release atlas on axis ( AA) restrictions and occi put on atlas
( OA) restri cti ons. The t echni ques are similar t o what yo u have
The Atlas and Occiput
Figure 6.2
62
Figure 6.1
THE ATLAS AND OCCIPUT
restricted in left rotati on. If his head rotates better to the left than the
right, then the atlas is left rotated and restricted in right rotati on.
Releasing the atlas is easy: keep your client' s head in 45 degrees flex-
i on and rotate it in the di recti on it is restricted. If the test shows you that
the atlas is left rotated, turn his head to the right as far as it can comf ort -
ably go. Place your right i ndex a n d / o r mi ddl e fingers on the post eri or
arch of the adas close to the posterior surface of the right transverse process
(Figure 6.3, page 64) and let the full wei ght of his head rest on your fin-
gers (Figure 6. 4) . Make sure you do not pl ace your f i ngers on the tip of
the right transverse process of the atlas. Not onl y will this t echni que not
work with this finger pl acement , it will also create unnecessary pai n f or
your client. Just let his wei ght rest on your fingers while you wait f or the
release. You will feel all the familiar i ndi cati ons of release as his head an
atlas begi n to slowly rotate mo r e and mo r e to the right. You can ei ther
wait for the tissues to release or encourage the release by gently turni ng
a nd / o r j i ggl i ng his head to the right. Retest to make sure you have c o m-
pletely released the rotation restriction. It may take mor e than one appli-
cation of this techni que to compl etel y release the atlas.
Restrictions of the oc c i put on the atlas are very c o mmo n and i f not
released these restrictions will c o me back to haunt you. The most sterling
and pr of ound releases of the C1 - C7 of ten will not relieve your cl i ent' s
pain i f you do not address the i nf l uence of the occi put. Someti mes an OA
restriction i s e no ugh to reestablish an AA restriction even after the AA
restriction has been rel eased. And over ti me those restri cti ons can be
responsi bl e f or ot her restrictions showi ng up t hr oughout your cl i ent' s
spine.
Whet her normal or abnormal , i n bot h f orward or backward bendi ng,
all mo do n of the occi put on the atlas is Type I. There are no discs between
the occi put and the atlas, and the j oi nts do not o pe n and cl ose i n f orward
and backward bendi ng the way they do in the rest of the spine. Rather the
convex condyl es of the occi put gl i de posteriorly on the superi or concave
facets of the atlas when you forward bend and glide anteriorly on the adas
when you backward bend. When you si debend to the right, f or exampl e,
the right condyl e will slide inferiorly on a facet of the atlas and the left
condyl e will slide superiorly. If you find an OA restriction, you can say that
the occi put is fixed in extensi on ( or backward bendi ng) or in f l exi on ( or
63
Figure 6.3
Figure 6.4
64
forward bendi ng) . Since the condyl es do not o pe n and cl ose i n f orward
and backward bendi ng, you cannot say that they are fi xed cl osed or fi xed
open.
You can reliably test f or restrictions of the occi put on the atlas by using
the lateral translation test. If you meet a restriction while translating in
forward bendi ng, it means that the occipital condyl e cannot gl i de poste-
riorly because it is fixed anteriorly, in extensi on, or back bendi ng. If you
meet a mot i on restriction while translating in backward bendi ng it means
that the occipital condyl e cannot glide anteriorly because it is fi xed pos-
teriorly, in flexion, or f orward bendi ng.
You can easily and quickly release OA restrictions by using a techni que
that is almost the same as the one you l earned f or releasing the atlas. The
only difference between the two techniques is where you place your fingers.
To locate the restriction, translate your client' s head f rom right to left
and f rom left to right i n bot h f l exi on and extensi on. Suppose you f i nd
that you can translate your client' s occi put f rom left to right but not f rom
right to left in f orward bendi ng. Since translation i ntroduces si debend-
ing and you are testing in f orward bendi ng, finding a mot i on restriction
on the right means that his occi put is left si debent and right rotated and
f i xed i n extensi on, or backward bendi ng. To release this back- bendi ng
restriction, keep his head and nec k i n the f orward- bendi ng posi ti on to
chal l enge the facet restriction. Si debend and rotate hi m in the di recti on
he cannot si debend, whi ch i n this case i s to the right. Pl ace your right
i ndex and mi ddl e f i ngers on the base of the occi put near the right oc c i p-
ital condl ye and let the full wei ght of his head rest on your fingers (Fig-
ure 6.5, page 66) . Agai n, either j ust wait f or the release or encourage the
release by gently turni ng, si debendi ng a n d / o r j i ggl i ng his head to the
right. You will feel the tissues soften while his head slowly si debends and
turns right. Retest to make sure you released the restriction compl etel y.
The test and techni que are basically the same in the backward bend-
i ng posi ti on. Backward be nd your client' s head and nec k and translate
the occi put bot h ways. If his head translates easily f r om right to left but
not f rom left to right, then you know that the occi put is right si debent,
left rotated, and fixed in flexion or f orward bendi ng. To release this f or-
ward-bendi ng restriction, keep his head in a back bendi ng posi ti on and
si debend and turn i t to the left while resting the base of the o c c i p ut
65
Figure 6.5
near the left occi pi tal c o n d y l e o n your left i ndex and mi ddl e fingers.
Agai n, j ust wait f or the release or encourage the release by gently turning
a n d / o r j i ggl i ng the head mo r e to the left. You will feel the tissues soften
as his head si debends and turns left. Be sure to retest your results and
do n' t be surpri sed i f i t takes mo r e than o ne appl i cati on to adequatel y
release OA restrictions.
Descri bi ng the bi omechani cs of OA restrictions can be compl i cated,
but testing f or and releasing them, as you have discovered, is fairly straight-
forward. If translation reveals a mo d o n restriction in forward or backward
bendi ng, you si debend and turn the head in the di recti on it won' t trans-
late, whi ch is the di recti on in whi ch it cannot si debend. Keep the head in
ei ther f orward or backward bendi ng, dependi ng on whi ch posi ti on you
fi nd the mo t i o n restri cti on, and apply pressure accordi ngl yt hat ' s all
there is to it.
You may be tempted to f ormul ate a rule f or yourself like the following:
when you translate the occi put on the atlas in forward and backward bend-
ing the side on whi ch you meet the mot i on restriction is the side on which
the facet restriction is f ound. The t echni que actually works as if this rule
66
were correct, but it's not. When you meet a mot i on restriction in f orward
bendi ng the facet restriction is on the side opposi t e the mot i on restric-
tion. In backward bendi ng the facet restriction is on the same side as the
mot i on restriction. In backward bendi ng it makes g o o d clinical sense to
both turn your client' s head in the di recti on of the mot i on restriction and
apply your pressure to the side of the mot i on restriction. But in f orward
bendi ng, si nce the facet restriction i s on the side opposi t e the mo t i o n
restriction, al though it makes g o o d sense to turn your client' s head in the
di recti on of the mot i on restriction, i t doesn' t seem sensible to apply your
pressure to the side of the mot i on restriction. You woul d think i t woul d
be mor e effective to apply your pressure to the side opposi t e the mot i on
restriction. Interestingly, the techni que works quite well in f orward bend-
ing, but I don' t know exactly why it does. I coul d speculate about why and
how it works, but I am not sure that woul d further your techni cal skills.
Instead let's l ook at why the rule is not correct and try to c o me up with a
rule that reflects the specifics of what is actually goi ng on and that will
allow you to be mor e specific i n how you apply the t echni que.
Whe n you back be nd and translate the oc c i put on the atlas, you are
testing f or whether the occipital condyl es can gl i de anteriorly. If you find
a mot i on restriction i t means that o ne of condyl es i s f i xed posteri orl y.
When you forward bend and translate the occi put, you are trying to deter-
mi ne whether the condyles can glide posteriorly. Finding a mot i on restric-
tion indicates that o ne of the condyl es i s fi xed anteriorly. To f ormul ate
the correct rule we need to know how to deduc e the f i xed condyl e f rom
a mot i on restriction.
Suppose you translate your client' s occi put i n back bendi ng and dis-
cover that i t can translate f r om left to right, but not f r om ri ght to left.
Since you know that the occi put always si debends and rotates to opposi t e
sides, the discovery of this mot i on restriction tells you that the occi put is
left sidebent and right rotated. In back bendi ng, since translation tests f or
the ability of the condyl es to glide anteriorly, if you meet a mot i on restric-
tion you also know that one of the condyl es is fixed in f l exi on or f orward
bendi ng. If it is fixed in f l exi on or f orward bendi ng, then it is fixed pos-
teriorly. You now have all the i nf ormati on you need to figure out the side
on which the condyl e is fixed. If the occi put is right rotated, then the right
side of the occi put is posteri or and the left side is anterior. If it is fixed
67
posteriorly and right rotated, the posteri or fi xati on must be on the right.
Why does it work this way? In back bendi ng, translation of the occi put
requi res that the occi pi tal condyl es gl i de anteriorly. Whe n you meet a
mot i on restriction translating right to left it means that the right condyl e
is fixed posteri orl y and will not permi t anteri or gl i de. You can translate
the ot her way, f rom left to right, because the left condyl e is not fixed and
will permi t anterior gl i de. Since the right condyl e is fixed posteriorly, left
si debent , and ri ght rotated, when yo u translate f r om left to ri ght, the
occi put sidebends left and rotates right. As a result, the left occipital condyle
gl i des anteri orl y and si debends left, while the right side of the occi put
slides posteriorly, in the direction it is already rotated and posteriorly fixed.
So when you translate the occi put in back bendi ng, you will feel the moti on
restriction on the same side as the facet restriction.
No w suppose you translate your client' s occi put i n f orward bendi ng
and meet a mot i on restriction goi ng f rom right to left, but not f rom left
to right. The facet restriction is on the left, the side opposi te to the moti on
restriction. But how do you get to this concl usi on? Fi ndi ng the mot i on
restri cti on on the ri ght tells you that the oc c i put i s left si debent, right
rotated, and that one of the condyles is fixed anteriorly because it is unable
to gl i de posteriorly. Onc e you know that the occi put is right rotated and
one condyl e is fixed anteriorly, you know that the anteriorly fixed condyl e
has to be on the left. If the occi put is right rotated, it is posteri or on the
right and anteri or on the left. Since translation revealed that a condyl e is
fi xed anteriorly, you know that the fi xati on must be on the left.
You can probabl y figure out yourself why it works this way in forward
bendi ng, but let' s go through the l ogi c of it. In order f or the occi put to
translate bot h ways, the condyl es must be capabl e of gliding anteriorly. In
the above exampl e, the mot i on restriction i s on the right. The occi put
can translate f r om left to right because it is capabl e of si debendi ng left
while the left condyl e glides anteriorly. As the left condyl e glides anteri-
orly the occi put rotates right. Since the right condyle is already right rotated
and posterior, it can gl i de in that di recti on. But in order f or you to trans-
late the occi put f rom right to left, the left condyl e must be capable of glid-
i ng posteriorly. Since the left condyl e is fixed anteriorly, it will not permi t
translation and you will feel the mot i on restriction on the right.
You can use the "as if rul e" and simply turn your client' s head in the
68
direction of the mot i on restriction and apply pressure to that side in bot h
forward and backward bendi ng to very effectively release the gl i di ng fix-
ations of the occipital condyl es. Or you can be mor e specific i n your tech-
ni que now that you know where the gl i di ng fi xati ons are to be f ound i n
fl exi on and extensi on. The rules are: i n f orward bendi ng the anteriorly
fixed condyl e is on the side opposi te to the mot i on restriction and in back-
ward bendi ng the posteri orl y fi xed c ondyl e i s on the same si de as the
mot i on restriction.
If you find a mot i on restriction in backward bendi ng, j ust appl y the
technique outlined above. If you find a mot i on restriction in forward bend-
ing you can vary your techni que to directly address the posteriorly fixed
condyl e. Suppose you find a mot i on restriction in f orward bendi ng while
translating f rom left to right but not f rom right to left. The right condyl e
is fixed anteriorly and the occi put cannot si debend to the left. Hol d your
client' s head in f orward bendi ng, and si debend and rotate it to the left
with your left hand. Place your right i ndex a n d / o r mi ddl e f i ngers near
the right anteriorly fixed condyl e and apply pressure in a posteri or supe-
rior di recti on as if you were trying to pry the right condyl e f rom its ante-
riorly fixed posi ti on (Figure 6.6, page 70) . Or try laying the radial edge
of your left i ndex f i nger al ong the base of the occi put and pl ace the tip
of your right t humb into the area near the right anteriorly fixed condyl e.
Appl y pressure with your t humb in a posteri or superi or di recti on as you
si debend and rotate your cl i ent' s head to the left (Figure 6. 7) . You are
chal l engi ng the facet restriction by turni ng your cl i ent' s head left and
applying pressure with your right fi ngers or t humb. Turni ng your client' s
head left encourages left si debendi ng and right rotation and henc e pos-
terior glide. Meanwhile, the fi ngers or t humb of your ri ght hand are clear-
i ng the restrictions so that posteri or gl i de can actually occur. As always,
j ust wait f or the release, or encourage it a little by gently turni ng a n d / o r
j i ggl i ng the head mor e to the left. Don' t f orget to f ol l ow the dance and
always check your results by retesting.
In the next chapter we will turn our attention to the ot her end of the
spine and l ook at the bi omechani cs of the sacrum and how to release i t
f rom its restrictions.
69
Figure 6.7
70
Figure 6.6
CHAPTER
7
word "sacrum" means "the sacred bo ne . "
The sacroiliac (SI) j oi nt is f or med by the articulation of the pelvis and
the sacrum. Dysfunction of this j oi nt can result f rom how the pelvis impacts
on the sacrum or how the sacrum i mpacts on the pelvis. If the pelvis i s
responsible f or a fixed SI j oi nt , then it is called a iliosacral dysfuncti on. If
the sacrum is responsi bl e, then it is called a sacroiliac dysfunction. In this
chapter you will l earn how to recogni ze and mani pul ate sacroiliac dys-
functi ons and in the next you will learn about how to deal with iliosacral
dysfunctions.
Ac c or di ng to some experts the sacrum is capabl e of 14 di fferent types
of mot i on. Descri bi ng all of these mot i ons can be very interesting, but
somewhat tedi ous unless you j ust happen to l ove such activities. My ap-
proach in this chapter is to provide a series of quick and easy ways to release
the sacrum wi thout f i rst l oadi ng you down with compl i cat ed bi omec han-
ical expl anati ons. We will start our expl orat i on of the sacrum with onl y
the simplest of bi omechani cal descri pti ons so that you can begi n practic-
ing techni ques f or releasing the sacrum right away. After your hands are
familiar with how the sacrum works, you will learn a mo r e t horough ap-
proach to the bi omechani cs.
71
The Sacrum
HE SACROI LI AC J OI NT I S I NFAMOUS I N ITS REPUTATI ON FOR CAUSI NG
pain to featherless bipeds. Given the enormous amount of discomfort
and pain that is associated with this j oi nt, it is very curi ous that the
Sacral Motion
W
HEN YOU FORWARD BEND, YOUR SACRAL BASE MOVES I N A POSTERI OR
and sl i ghdy superi or di r ec don. Whe n you back be nd your sacral
base moves in the opposi te di recti on, anteriorly and inferiorly. This ante-
rior and posteri or movement of the sacrum occurs al ong a transverse axis
that runs through S2. The anteri or and posteri or movement of the sacral
base is called nutation and counternutati on, but I will use the simpler des-
ignations of anteri or nutati on and posteri or nutation when referring to
this mot i on. The word "nutati on" means " noddi ng. "
To fi nd the sacral base on your client, fi rst l ocate the spi nous process
of L4. Begi n with your cl i ent seated i n neutral posi ti on. Wi th one of your
fingers trace an i magi nary hori zontal line f rom the crest of the ilium to
the spi ne. The spi nous process your f i nger lands on bel ongs to L4 (Fig-
ure 7. 1) . Count down t o the spi nous process of L5 and then o ne mor e
not c h to the sacral base. Or find the sacral base by finding the sacral sul-
cus (Figure 7. 2). The sacral sulcus are vertical grooves that your thumbs
will sink i nto if you roll them j ust medially of f the posteri or superi or iliac
spines (PSIS). Place your right t humb on the right sacral base or sulcus
and your left t humb on the left sacral base or sulcus. Ask your client to
forward and backward bend while you moni tor how the sacral base nutates
posteriorly i n f orward bendi ng and anteriorly i n backward bendi ng.
Sacral sulcus
Ischial tuberosity
PSIS
Iliac crests at
level of L4
Median sacral crest
Sacral base
Inferior lateral
angle
Figure 7.1
72
Figure 7.2
Figure 7.3
73
THE SACRUM
It is useful to be able to feel sacral mot i on in a number of positions so
you can doubl e check your results. So ask your client to lay in a prone posi-
tion on your treatment table. Agai n place your thumbs on the sacral base.
Ask your client to raise himself up and pr op himself on his elbows as illus-
trated in Figure 7.3, page 73, while you feel f or whether the sacral base
moves anteriorly. Ask your client to lie back down and to then tilt his pelvis
posteriorly. This action will accompl i sh the same results as forward bend-
ing. Since most peopl e do not understand what tilting their pelvis poste-
riorly means, you mi ght suggest that he turn his pelvis under as if to slowly
thrust his pubi c area forward toward the surface of the table. As he tilts his
pelvis posteriorly, feel for whether the sacral base nutates posteriorly. If you
do not feel the sacral base nutate either posteriorly or anteriorly, you have
di scovered a bilateral sacral fixation. Either the sacral base is fixed in bilat-
eral posteri or nutation or bilateral anterior nutation.
Sacrums are also capabl e of si debendi ng and rotating. If there are no
j oi nt fixations, then this is what your sacrum does in walking as you shift
your weight f rom one leg to the other. Most experts agree that the sacrum
only exhibits Type I moti on and that si debendi ng and rotadon are coupl ed
to opposi te sides. Si debendi ng and rotation of the sacrum are also called
torsion. Rotation and torsion of the sacrum are named the same as rotadon
of the vertebrae. If the right sacral base is posterior, then the sacrum is right
rotated or right torsi oned (and left si debent) . If the left sacral base is pos-
terior, then the sacrum is left rotated or left torsioned (and right sidebent).
It i s mo r e accurate but also mo r e compl i cat ed to descri be rotation and
si debendi ng in terms of torsion but let's leave these complexifies for later.
If the sacral base is right rotated in neutral posi ti on then it is probabl y
dysfunctional and henc e the j oi nt is fixed in s ome way. Either the right
sacral base is fixed in posteri or nutation or the left sacral base in fixed in
anterior nutation, but how do you determi ne whi ch side i s the fi xed side?
Forward and backward bend your client and watch how each side behaves.
Whe n your cl i ent f orward and backward bends, i f the rotation of his
sacrum appears to go away in forward bendi ng and gets worse in backward
bendi ng, then you know that the right side of his sacrum is fixed posteri-
orly. The right side of the sacrum becomes a fixed poi nt around which the
sacrum is f orced to turn in forward and backward bendi ng. Since his sacral
base is fixed posteriorly, it cannot move anteriorly in backward bendi ng.
74
THE SACRUM
So in backward bendi ng his right sacral base stays where it is, posteriorly
fixed, while his left sacral base moves further in an anterior direction thereby
making it appear that the sacral rotation has worsened. In f orward bend-
i ng his right sacral base again stays where it is, while his left sacral base
moves posteriorly, maki ng it appear that the rotation has di sappeared.
What happens if your client' s sacrum is right rotated, left sidebent, and
the left sacral base is fixed anteriorly? His left sacral base in this case will
be the f i xed pivot poi nt ar ound whi ch his sacrum turns i n f orward and
backward bendi ng. Whe n your cl i ent f orward bends, his left sacral base
stays fixed anteriorly and his right sacral base moves f urther in a poste-
rior direction and as a result the rotation seems to worsen. When you back
be nd your client, again his left sacral base remai ns fixed in its anteri or
position, but this time his right sacral base moves in an anterior di recti on,
maki ng it seem like the rotation disappears.
Thus, when you find a rotated sacrum, you can create a simple rule f or
determi ni ng whi ch side is fixed. If sacral rotation bec omes mor e extreme
in back bendi ng, then the side to whi ch the sacrum is rotated is fixed pos-
teriorly. If sacral rotation seems to di sappear in back bendi ng, then the
side opposi te to the rotation is fixed anteriorly. You can state the rule dif-
ferently if you wish. I choose to state the rule solely in terms of back bend-
ing because so often my evaluation of sacral dysfunction takes pl ace with
my client in a pr one posi ti on on my treatment table. Rather than asking
the client to get of f the table and sit on the exami nati on stool , it is usu-
ally muc h mor e conveni ent and easier to read sacral rotation with hi m in
the prone position. For the sake of practi ce, however, you shoul d learn to
test the sacrum in bot h the pr one and seated posi ti ons.
In any case, there are always a number of ways to state these rules. Here
is another possibility you mi ght prefer: if the rotation disappears in back
bendi ng, then the sacrum is fixed anteriorly on the side opposi te its rota-
tion, and if the rotation disappears in f orward bendi ng, then the sacrum
is fixed posteriorly on the side to whi ch it is rotated.
Techniques
F PALPATI ON REVEALS T HAT T HE SACRUM I S ROTATED, YOU CAN USE A
simple indirect technique to derotate it. Recall the first indirect technique
75
that you l earned i n Chapter One to derotate vertebrae: i t can be appl i ed
in the same way to the sacrum. Wi th your client in either a seated or prone
posi ti on, pl ace your thumbs on each side of the sacral base. If his sacrum
is left rotated, the left sacral base will be posterior and the right sacral base
will be anterior. Push the sacrum further i nto rotation by increasing the
pressure of your right t humb, wait, f ol l ow the dance, and let the sacrum
derotate itself.
As you already know, this sort of indirect techni que does not challenge
the facet restriction. As a result, it tends to be a less effective way to release
fixations. Bef ore you can chal l enge a j oi nt fi xati on, you must know the
l ocati on of the fixation and whether it is fi xed anteriorly or posteriorly.
Do this by using the f orward and backward bendi ng test in order to deter-
mi ne whether o ne side i s fi xed anteriorly or posteriorly.
If the sacrum is right rotated and fixed posteriorly on the right, back
be nd your client to encourage the right side of his sacrum to move ante-
riorly and apply several pounds of pressure to his right sacral base in an
anteri or and slightly i nf eri or di recti on. Wait f or the dance of the tissues
and f or the rel ease. You can appl y this t ec hni que with your cl i ent i n a
seated posi ti on (Figure 7. 3) , or with your client pr one pr opped up, and
resting on his el bows as a way to back be nd and chal l enge the posteriorly
fi xed side (Figure 7. 4).
If his sacrum is right rotated and fixed anteriorly on the left, forward
be nd your client to encourage the left side of the sacrum to move poste-
riorly. Appl y several pounds of pressure to his left base in an inferior direc-
tion with your thumb. With your other thumb, push the right base, or push
further down on the right side, in an anterior di recti on, as if you were try-
i ng to lever the left side free by pushi ng on the right. Wait for the dance
and the release. You can use this t echni que with your cl i ent in a seated
position (Figure 7.5, page 78) or prone. In the prone position place a dou-
bl ed- up pi l l ow under your client' s abdo me n t o f orward be nd and chal-
l enge the anteriorly fixed side and then apply your pressure (Figure 7.6).
If your evaluation of the sacrum reveals that it is bilaterally fixed in pos-
terior nutati on, then back be nd your cl i ent to chal l enge the bilateral fi x-
ation and equally apply several pounds of pressure with your thumbs to
each side of his sacral base (Figure 7. 7). Appl y your pressure in an ante-
ri or and slightly i nferi or di recti on and wait f or the dance and the release.
76
THE SACRUM
You can of course use this techni que
with your cl i ent in ei ther a seated or
pr one posi ti on.
If the sacrum is bilaterally fi xed in
anterior nutation, f orward be nd your
cl i ent to chal l enge the bilateral fixa-
tion and equally apply several pounds
of pressure to bot h sides of his sacral
base in an i nf eri or di recti on (Figure
7.8, page 79) . Wait f or the dance and
f or the rel ease. Agai n you can appl y
this techni que in either the seated or
pr one posi ti on. If you el ect to release
a sac r um f i xed in bi l ateral ant eri or
nut at i on, use a do ubl e d- up pi l l ow
unde r your cl i ent' s a b d o me n t o en-
courage posteri or nutati on.
77
Figure 7.3
Figure 7.4
Figures 7.5
Figure 7.6
78
THE SACRUM
Figure 7.8
79
Figures 7.7
LR RSB RR LSB
Left torsion (or rotation) on Right axis Right torsion (or rotation) on Right axis
OU NOW HAVE ENOUGH I NFORMATI ON AND TECHNI QUES TO RELEASE
I most sacral dysfunctions. There is another ki nd of sacral dysfunction
that involves a sacral shear, but bef ore we expl ore this, let' s expand our
understandi ng of sacral torsion. To some degree you already know what
sacral torsion is, because I i ntroduced it as rotation and sidebending. Intro-
duci ng torsi on as another way to talk about sacral rotation and si debend-
i ng will not requi re l earni ng any new techni ques. The techni ques remain
the s ame o nl y the l anguage changes. You mi ght be tempted to skip this
discussion, but I r e c o mme nd that you persist because it will hel p you to
b e c o me a mo r e effective therapist.
Si debendi ng and rotati on of the sacrum are cal l ed " t orsi on" whi ch
occurs around either right or left obl i que axis. The conventi on states that
the left obl i que axis runs f rom the superi or aspect of the left articulation
of the sacrum on the ilium to the right inferior aspect of the sacrum where
it articulates with the right ilium and the right obl i que axis runs f rom the
superi or aspect of the right articulation of the sacrum on the ilium to the
left i nf eri or aspect of the sacrum where it articulates with the left ilium.
The right and left obl i que axes and varieties of torsion are shown i n
Figures 7.9, 7.10, 7.11, and 7.12. Noti ce that each of the f our kinds of tor-
Sacral Torsion
80
THE SACRUM
RR LSB
Right torsion (or rotation) on Left axis
LR RSB
Left torsion (or rotation) on Left axis
Figure 7.12
si on shown i s descri bed i n terms of the obl i que axis on whi ch i t i s tor-
si oned and as well as in terms of rotation and si debendi ng. So, f or exam-
pl e, Figure 7.12 shows a sacrum in left torsi on on the left obl i que axis
whi ch is also desi gnated as LR and RSB (left rotated and right si debent ) .
You can correctl y say that the sacrum is left rotated on the left obl i que
axis or left torsi oned on the left axis.
Proper body movement whi l e walking i s i nf l uenced by ability of the
sacrum to torsi on left on the left axis and right on the right axis. Si nce
most walking is accompl i shed with your spi ne relatively upri ght and ver-
tical, f or the purposes of illustration we will assume that your spi ne and
sacrum are in neutral while you walk. You mi ght want to stand and slowly
do what i s about to be descri bed here so you can get a sense of what hap-
pens with your body i n normal walking.
As your right l eg moves f rom heel strike to toe off, your body wei ght
begi ns to move over your right leg, causing your pelvis to shift laterally to
the right. As the mo ve me nt cont i nues toward toe off, your ri ght pel vi c
i nnomi nate bo ne begi ns to rotate anteriorly while your left i nnomi nat e
begi ns to rotate posteriorly. As your right i nnomi nat e rotates anteriorly,
your sacrum moves i nto right torsion on the right obl i que axis (i. e. , right
rotates and left si debends because the left sacral base moves in anteri or
81
Posterior nutatioji
Anterior nutation
Figure 7.11
Figure 7.13
nutati on) . Your l umbar spine sidebends right and rotates
left, your thoraci c spine si debends left and rotates right,
and your cervical spine sidebends right and rotates right.
As the left l eg moves f rom wei ght beari ng to toe off, the
left i nnomi nat e, the sacrum, lumbars, and thoracics tor-
sion, rotate, and si debend in an opposi te manner. Notice
in Figure 7.13 how this same c ompl ex pattern of pelvic
shift, sacral torsi on, spinal si debendi ng, and rotation is
i nt roduced as the weight of the body shifts to rest on the
left leg. Walking and standing with your weight over one
l eg i nt roduces and requi res this ki nd of curvature f or
normal movement .
The way our axial c o mpl e x alternately undul ates i n
si debendi ng and rotati on as we walk is very interesting
and very i mport ant to our wel l -bei ng. Its movement is
remi ni scent of the vermi cul ar undul ati on of a snake as
it slithers through the grass. The big difference, of course,
is that our snake-like spine has been up- ended and given two legs on which
to walk. Can you i magi ne how a snake woul d be f orced to move through
its worl d if we were to snap a number of very tight rubber bands around
its body? The resulting dis-ease woul d spread through its entire but lim-
ited experi ence and body. In an anal ogous, but mor e compl i cat ed way,
j oi nt fi xati ons anywhere al ong our spine act like the rubber bands around
the snake' s body. So if at the level of the sacroiliac j oi nt we experi ence any
f i xati on, whet her i t i s due to pelvis on sacrum or sacrum on pelvis dys-
f uncti ons, i t can eventually cause troubl e t hroughout our bodi es.
So far I have onl y descri bed neutral sacral t orsi onsR on R or L on L
torsions. Whe n you f orward be nd and si debend you i ntroduce non- neu-
tral mechani cs i nto your sacroiliac j oi nt and you create what are called
backward or post er i or t orsi ons. Take a l o o k at the di agrams (Fi gures
7. 9- 7. 12) and you will see that i n backward or posteri or sacral torsions
the sacrum ei ther torsions ( or rotates) right on the left axis or torsions
( or rotates) left on the right axis. Not i ce that when the sacrum torsions
R on L the right sacral base moves posteriorly and when the sacrum tor-
sions L on R the left sacral base moves posteriorly.
No w j ust as the sacrum can torsion normal l y in these f our ways, it can
82
THE SACRUM
also get stuck in any o ne of these ways. So if you f i nd a rotated sacrum
when your client is in neutral posi ti on, either seated or pr one, you can be
pretty sure you are l ooki ng at a dysfunctional sacrum. In the next chap-
ter on the pelvis you will learn another test to det ermi ne sacral dysfunc-
tion. It is called the sitting fl exi on test. But f or the time bei ng use rotation
as your gui de. Then use the f orward and back bendi ng tests to determi ne
whether one side is fixed anteriorly or posteriorly. If you discover that the
sacral base is fixed anteriorly, it is dysfunctional and you have di scovered
what is called an anteri or sacral torsion. If the sacral base is fixed poste-
riorly, it is called a posteri or sacral torsion. Lo o k o nc e again at the draw-
ings of sacral torsion and noti ce that there are f our ways the sacrum can
be c o me dysfunctional in torsion: 1) if the sacrum is torsi oned left on the
left obl i que axis (L on L) and the right sacral base is fixed anteriorly, 2)
if the sacrum is torsi oned right on the right obl i que axis (R on R) and the
left base is fixed anteriorly, 3) if the sacral base is torsi oned right on the
left obl i que axis (R on L) and the right sacral base is fixed posteriorly, and
4) if the sacral base is torsi oned left on the right obl i que axis (L on R)
and the left sacral base is posteriorly fixed.
Sacral Shear
T
HERE I S ONE LAST TYPE OF SACRAL DYSFUNCTI ON THAT YOU SHOULD
know about, cal l ed sacral shear. Shear occurs when two surfaces i n
contact with each other slide on each other in a di recti on parallel to their
plane of contact. Imagi ne putting two pi eces of glass together whose sur-
faces are wet and pushi ng them so that they slide on each other. You have
j ust created a shear. Sacral shear is muc h less c o mmo n than torsi on and
its origin, as you probably guessed, is usually traumatic. Someti mes a sacral
shear can result f rom a l ong- standi ng l umbar l ordosi s or a rotoscol i osi s
in whi ch the l umbar spi ne curves in o dd and unexpec t ed ways.
If you palpate onl y the sacral base, you cannot distinguish shear f rom
torsion. You mi ght be surprised to know, however, that the techni ques you
j ust l earned f or releasing dysfuncti onal sacral torsi ons will also, by and
large, release sacral shears, whether you correctl y distinguish t hem f r om
torsions or not. So even i f you do not know the di f f erence between shear
and torsion, you c oul d unknowi ngl y release a sacral shear, thinking you
83
are rel easi ng torsi on. For the most part, the very same t echni ques you
l earned to release torsi on will also release shear. Since these techni ques
do do ubl e duty f or torsi on and shear, you c oul d skip this discussion of
sacral shear and still do a l ot of g o o d f or your clients. But there are some
i mport ant subtleties that can someti mes make a stunni ng di f f erence in
your effectiveness in deal i ng with sacral dysfunctions. I will discuss one of
these subtleties a little later, because it reveals why the mere mechani cal
appl i cati on of techni que is not as effective as i nf or med touch.
Figure 7.14 shows quite clearly how the facet of the sacrum fits into a
facet on the i nnomi nate. The facets are shaped like a fat "L" or "C. " Notice
how the wi de variations i n the shape and c ont our of these facets are cor-
related to types of spinal curvature. These drawings dramatically demon-
strate that any attempt to reposition the sacrum is limited by these inherent
shapes and underscores onc e again the clinical priority of releasing j oi nt
restrictions over attempti ng to reposi ti on bo ny segments ac c or di ng to
some external ideal.
Whe n the sacrum is fi xed in a shear the sacral base slips anteriorly or
posteriorly around a transverse axis on the facet of the i nnomi nate. When
84
Figure 7.14
THE SACRUM
Transverse axis
Figure 7.15
Sacral hiatus
you first palpate the sacral base in a
sacrum that has got t en stuck i n
shear, you will think you are f eel i ng
rot at i on, bec aus e o n e si de of the
sacral base will be posteri or and the
other anterior. So you need another
r ef er enc e po i nt on the sacrum t o
differentiate shear f rom torsi on.
In or der to distinguish the two,
you palpate the right and left sides
of the inferior lateral angle (ILA) of
the sacrum. You can f i nd the poste-
rior aspect of the ILA by locating the
sacral hiatus. Find the sacral hiatus
by runni ng one of your f i ngers down
the center of the sacrum al ong the
spinous processes until your finger lands in the i ndentati on of the sacral
hiatus. From the sacral hiatus move your thumbs laterally about o ne half
to three quarters of an i nch and you will land on the posteri or ILA. The
posterior ILA is the transverse process of S5 (Figure 7.15). Let your thumbs
slip inferiorly j ust ever so slightly so that they are resting on the i nf eri or
aspect of the ILA and use this aspect of the ILA as your ref erence poi nt.
Let' s i magi ne that you find a sacrum in whi ch the right base is poste-
rior and the left is anterior. If the sacrum is torsi oned, the ILA' s will fol-
l ow the pattern of the t orsi on and also be post eri or on the ri ght and
anterior on the left. But if the sacrum is fixed in anteri or shear, then the
left sacral base will be anteri or and the left ILA will be mor e i nf eri or and
posteri or than the right ILA. The left ILA also will be mo r e i nf eri or than
it is posterior. So in order to distinguish between shear and torsi on, you
shoul d always palpate not j ust the sacral base, but also the ILA' s. If the left
sacral base is anterior and the left ILA is anterior and the right ILA is pos-
terior, then you are l ooki ng at a torsion. If the left sacral base is anteri or
and the left ILA is mor e i nf eri or and posteri or than the right ILA ( and
mor e i nferi or than post eri or) , then you are l ooki ng at a sacral shear.
Anterior sacral shear is much more c o mmo n than posterior sacral shear.
Some think that posteri or sacral shear may be no mo r e than j ust a theo-
85
Left ILA Right ILA
retical possibility, but I have f ound them and know they exist. So for exam-
pl e, in a right posteri or shear of the sacral base, the right sacral base is
posteri or and the left sacral base is anterior. The right ILA is mor e supe-
ri or and anteri or than the left ILA and the right ILA will be mor e supe-
ri or than it is anterior.
A sacrum f i xed in anteri or shear is called a unilateral sacral fl exi on or
a unilateral anteriorly nutated sacrum, and a sacrum f i xed in posteri or
shear is cal l ed a uni l ateral sacral ext ensi on or a uni l ateral posteri orl y
nutated sacrum. But I pref er to call these two fixations anterior and pos-
terior shear of the sacral base. This way of nami ng shear is a bit clearer, I
bel i eve, in that it designates the fixation in the descri pti on and therefore
i mmedi atel y tells you where you need to work to facilitate a release. You
can call it what you will, of course, but the critical questi on f or you as the
therapist is to det ermi ne whet her the sacral base is f i xed in anteri or or
posteri or shear.
First you palpate the sacral base. If you find that o ne side is posteri or
and the ot her is anterior, in order to differentiate shear and torsion you
then palpate the I I A' s. If pal pati on of the ILA' s reveals shear, your next
step is to det ermi ne whether the anterior base or the posteri or base is the
fixed side. Testing f or whether the sacral base is fixed in anterior or pos-
terior shear is the same as testing f or
whet her the sacral base is f i xed in
anteri or or posteri or sacral torsi on.
Yo u f or war d and bac k b e n d your
client and watch how the sacral base
behaves.
Let' s l ook at anterior sacral shear
first (Figure 7. 16) . If the left sacral
base is fixed in anterior sacral shear,
the left sacral base will be anteri or
and the right sacral base will be pos-
terior. The left ILA will be more infe-
ri or and pos t er i or than the ri ght
ILA, and the left ILA will be mo r e
inferior than it is posterior. Put your
t humbs on eac h si de of the sacral
Left ILA
inferior/
posterior
Right ILA
superi or/
anterior
86
Anterior shear
Figure 7.16
THE SACRUM
base and watch what happens i n f orward and backward bendi ng. Si nce
the left side is fi xed in anteri or shear, it will b e c o me a f i xed pi vot poi nt
around whi ch the right sacral base will be f orced to move i n f orward and
backward bendi ng. When you forward bend your client her left sacral base
will stay fixed anteriorly and the right sacral base will move in a mor e pos-
terior direction making the difference between the two sides more extreme.
When you backward be nd your client her left anterior base remains fixed
anteriorly and her right sacral base moves in a mor e anteri or di recti on,
maki ng the di f f erence between the two sides disappear.
Let' s l ook at what happens if your client' s right sacral base is f i xed in
posterior shear (Figure 7. 17). Palpation will reveal that her left sacral base
is anterior and her right sacral base is posterior. It will also show that the
right ILA is mor e superi or and anteri or than the left ILA, and the right
ILA is mor e superi or than it is anterior. In f orward and backward bend-
ing her right sacral base bec omes the fi xed pi vot poi nt around whi ch her
left sacral base i s f orced to move. Whe n you backward be nd your client,
her right sacral base will stay in its posteriorly fixed posi ti on and her left
sacral base will move mo r e in an anteri or di recti on. As a result, the dif-
f erence between her two sides will b e c o me mor e extreme. Whe n you f or-
ward bend your client her right sacral base maintains its posteriorly fixed
posi t i on and her left sacral base
moves in a mor e posteri or posi ti on,
maki ng the di f f erence between the
two sides disappear.
The f orward and back be ndi ng
test reveals whether the sacral base
is f i xed anteriorly or posteri orl y in
exactl y the same way f or bo t h tor-
sion and shear. Theref ore, you can
use the same rul es we f or mul at ed
f or t orsi on t o hel p yo u f i gure out
whether the sacral base is fixed ante-
riorly or posteriorly in sacral shear.
Thus, f or exampl e, i f the posteri or
sacral base remai ns posteri or while
the anteri or si de moves anteri orl y Figure 7.17
87
Left ILA
inferior/
posterior
Right ILA
superi or/
anterior
duri ng back bendi ng, then the posteri or side is fixed in posteri or shear.
If the anterior sacral base remains anterior while the posteri or side moves
anteriorly duri ng back bendi ng, then the anterior side is fixed in anterior
shear.
The Rum pel stilts kin Effect
F YOU DO NOT PALPATE T HE I LA' s, YOU HAVE NO WAY TO DI STI NGUI SH
between shear and torsion. The same is true if you onl y use the forward
and backward bendi ng tests. Forward and backward bendi ng can only test
f or whi ch side is fixed anteriorly or posteri orl yi t cannot tell you all by
itself whether the anteri or or posteri or fixation it reveals goes with a tor-
sion or a shear. You must palpate the ILA' s to det ermi ne the di f f erence.
Interestingly e no ugh the very same techni ques you l earned f or releasing
an anteriorly or posteriorly fixed sacral base in a torsion will also release
an anteriorly or posteri orl y fixed sacral base associated with shear. The
upshot of this di scussi on is a bit peculiar. If you onl y pal pate the sacral
base and use the f orward and backward bendi ng tests wi thout palpating
the ILA' s, and if you onl y use the j oi nt challenging techniques you learned
f or releasing sacral torsions, you will also be able to release sacral shear
wi thout bei ng aware that it even exists. In practical terms, since the tech-
ni que is pretty much the same in both cases, it might seem as though know-
i ng how to differentiate shear f rom torsion is unnecessary.
So you mi ght be wonder i ng why bot her l earni ng how to distinguish
between shear and torsion in the first place? One answer is that a thera-
pist shoul d j ust know these things. Anot her answer is that onc e you know
what these di f f erences are you can add variations to your techni ques that
will make them mor e effective in releasing shear. The last answer is harder
to understand, but is probabl y the most significant. Knowi ng what you are
rel easi ng in a client' s body adds to your clarity of purpose and actually
makes you a mor e effective therapist. If you know what it is that needs to
change, then the techni ques you apply will be mor e effective than i f you
do n' t know preci sel y what you are rel easi ng. Thi s characteristic of the
somati c manual arts r emi nded my wife of the psychotherapeuti c setting
where, metaphorically, you must name your demons i f you want to get rid
of them. She calls this phe no me no n, " The Rumpelstiltskin Effect."
88
THE SACRUM
As strange as it may sound, I am c onvi nc ed that your recogni t i on of
the fixation is mo r e than j ust an intellectual ac c ompl i shment that hap-
pens to ac c o mpany your appl i cat i on of a t e c hni q ue i t i s actually an
i mportant part of the techni que itself. Bef ore I knew how to tell the dif-
f erence between shear and torsi on, I had devel oped the techni ques de-
scribed in this chapter for releasing torsion. Duri ng the time I was readi ng
about and trying to understand shear, I was worki ng with a client who had
what I bel i eved was a posteri or torsion in whi ch the right base was poste-
riorly fixed. For a number of sessions I had appl i ed my techni que f or pos-
terior torsion. I was able to give hi m some relief from his pain, but I coul dn' t
get rid of all of it. My client told me at the begi nni ng and end of every ses-
sion that even though the other pains around his l ow back area had go ne
away, the pain in his butt never went away. The pain he was compl ai ni ng
about was in cl ose proxi mi ty to the right ILA. I now realize that it is c o m-
mo n for clients with sacral shear probl ems to compl ai n of pain in the area
of one of their ILA' s, especially in weight beari ng situations. When I finally
got clear about how to tell the di fference between shear and torsion, I pal-
pated my client' s ILA' s and di scovered that he had a right posteri or sacral
shear. Addi ng this r ec ogni t i ont hat his sacrum was actually in posteri or
shear, not posterior t or si ont o the very same techni que I had used when
I believed his sacrum was posteriorly torsi oned fully released his sacrum
for the fi rst time. And f or the fi rst time the pai n i n the right side of his
buttocks di sappeared.
This exampl e i s not an isolated case. My experi ence and the experi -
ence of my friends and col l eagues has shown us over and over again that
knowing and nami ng what you are worki ng on is an essential part of effec-
tive therapy. I have a l ot of ideas about why this is so and c oul d lay out
what I think is a rather interesting theory about what is happeni ng. But
it woul d require a rather lengthy phi l osophi cal discussion that woul d take
us well beyond the scope of this manual . If your understandi ng is stimu-
lated by poetry, you mi ght appreciate how a line f rom the great poet , Ste-
fan George, explains how prof oundl y our lives can be i nf l uenced by not
knowi ng the name of somethi ng: " Where the name breaks off, no thing
may be. "
In any case, my observati on is very easy to test and woul d make f or an
interesting study in somatic manual therapy. Find 20 experi enced thera-
89
pists and 20 patients with sacral shear. Teach 10 therapists how to recog-
nize and treat f or sacral torsion only, teach the other 10 therapists how to
treat and recogni ze the di f f erence between shear and torsion, and make
sure bot h groups of therapists learn the same techni que f or releasing an
anteri or and posteri or sacral base. Then turn them l oose on the patients
and see what happens.
The most i mportant concl usi on f or you as a therapist to draw f rom this
discussion is that the clearer you are about what you are worki ng on the
mor e effective you will bec ome. In terms of the techniques you learn f rom
this bo o k, you will find that the simple i ndi rect and shotgun techni ques
are less effective f or the reasons already given earlier, but also because
they do n' t de mand the same level of knowl edge as the techni ques that
are specific to the j oi nt fixation. I i ntroduced these simple techniques first
as a pedagogi cal devi ce. Thei r simplicity is desi gned to give you a kind of
pal patory understandi ng that prepares the way and makes it easier under-
standi ng the mo r e compl i cat ed bi omechani cal descriptions.
If a therapist is mor e i ncl i ned to use these simple indirect and shotgun
techni ques, it usually means that he doesn' t fully grasp the bi omechani cal
descriptions and how to mor e precisely locate the j oi nt f i xati on. The bi o-
mechani cal descriptions are i mportant to your grasp of your client' s prob-
l em. If a therapist doesn' t have this understandi ng, he won' t fully grasp
the pr obl em in his client' s body. As a result he won' t have the same clarity
of purpose as the therapist who is ori ented toward the specifics of the j oi nt
fixationand without this clarity of purpose, his application of techni que
will be less effective. If a therapist knows how to locate the j oi nt fixation,
she will c ho o s e the t ec hni que that specifically addresses the pr o bl e m,
because the other met hod is inefficient and time consumi ng. But the expe-
ri enced therapist also picks the mor e specific approach because at some
level she understands the Rumpelstiltskin effect and how powerful clarity
of purpose is f or effective therapy. This understanding also constitutes part
of what I descri bed in the i ntroducti on as the healer' s way of bei ng.
Variations on Technique
90
EFORE WE CONCLUDE THI S CHAPTER ON THE SACRUM, I WANT TO PRESENT
some variations on the techni ques that you l earned f or anterior and
THE SACRUM
posteri or torsion that make them mor e specific to anteri or and posteri or
shear. The idea is to hel p you bec ome more specific and hence more effec-
tive i n your approach to anteri or and post eri or shear. You may want to
refer to the drawings of the sacrum in anterior and posteri or shear ( 7. 16-
7.17) as you read through these variations
Recall the technique f or manipulating a torsi oned sacrum with an ante-
riorly f i xed sacral base. You f orward be nd your client, put your thumbs
on each side of the sacral base, apply pressure in an i nferi or di recti on to
the anteriorly fixed base, wait f or the dance of the tissues, and then the
release. Remember that you can further add to your effectiveness i f you
also add some pressure i n an i nf eri or/ ant eri or di recti on to the opposi t e
sacral base or in an anterior direction to the opposi te ILA as a way to lever
the anteriorly fixed base in a posteri or di recti on.
Now for the sake of compari son let's say you find a sacral shear in which
the left sacral base is fixed anteriorly. You can use pretty muc h the same
techni que: ask your client to f orward be nd and apply pressure in an i nfe-
rior direction to the left sacral base (Figure 7. 18). You can also apply some
Figure 7.18
91
Figure 7.19
anteri or pressure to the right sacral base to lever the anterior fixed side
in a posteri or di recti on. But make sure you don' t use the other variation
f or anterior torsion in whi ch you apply anterior pressure to the right ILA.
It works f or left anteri or torsion because the right ILA is posi ti oned pos-
teriorly. But it won' t work f or left anteri or shear, because the right ILA is
posi ti oned superiorly and anteriorly. Instead, you c oul d add to your effec-
tiveness by applying pressure to the right ILA in an inferior di recti on, as in
Figure 7.19, where the client is lying on a doubl ed- up pillow. Or you coul d
add to your effectiveness by worki ng with the left ILA. Since the left ILA
i s posi t i oned i nferi orl y and posteriorly, you can facilitate the release of
the left sacral base by applying pressure to the left ILA in a superi or and
anteri or di rect i on. So, f or exampl e, with your cl i ent i n a f orward bent
posi ti on (in Figure 7.20 the cl i ent is again lying on a doubl ed- up pi l l ow) ,
you can put o ne t humb on the left sacral base and the other on the left
ILA. Wi th your thumbs posi t i oned in this way you can rock the left side
of the sacrum out of its anteri or f i xati on. Alternately push inferiorly on
the left sacral base, and superi orl y and anteriorly on the left ILA. Rock
92
THE SACRUM
the left side of the sacrum
in this way in a cont i nuous
easy moti on, stop, and then
apply appropri ate pressure
to either the left base or the
left ILA and wait f or the
dance and release.
Recal l ho w you mani p-
ul ate a t or s i oned sac r um
with a post eri orl y f i xed
sacral base. You back be nd
your client, apply pressure
in an anteri or di recti on to
the posteri orl y f i xed base,
wait f or the danc e , and
then the release. For c o m-
pari son, let' s suppose you
find a sacrum fixed in right
posteri or shear. You can of
course use the same t ech-
ni que for posteri or shear that you used f or posteri or torsi on. Or you can
further your effectiveness by addi ng some pressure to the right ILA. Since
the right ILA is posi ti oned superiorly and anteriorly, you coul d push supe-
riorly on the right ILA while you c oul d push anteriorly on the right pos-
teriorly fixed sacral base (Figure 7.21, page 94) . Or you can put one t humb
on the right posteriorly f i xed sacral base and the heel of your ot her hand
on the left ILA. Since the left ILA is posi ti oned superiorly and posteriorly,
you coul d push anteriorly and inferiorly on the left ILA while you push
anteriorly on the right sacral base (Figure 7. 22).
Onc e you have a clear understandi ng of the type of fixation you are
deal i ng with and the ways the sacrum can be posi t i oned, then you can
make up your own techni ques and variations.
In this chapter you l earned how to recogni ze and mani pul ate sacroil-
iac dysfunctions that were caused by eight different sacral fixations. In the
next you will learn how to recogni ze and release fixations that are created
by the pelvis.
Figure 7.20
93
Figure 7.21
Figure 7.22
94
CHAPTER
8
with normal mot i on, pai n and mi sery can des c end quickly, like a bl ack
cl oud capabl e of obscuri ng even the best of our shi ni ng moment s . You
already know the ways the sacrum can create painful probl ems in this area.
The i nf l uence of the pelvis on the sacroiliac (SI) j oi nt can be j ust as pr ob-
lematic. Knowing how to recogni ze and treat the many dysfunctions caused
by the pelvis is extremel y i mportant if you want to be able to resolve your
client's low back pain. If you do a great j o b of releasing your client's sacrum,
but do not take care of its interaction with the pelvis, muc h of your work
will be in vain. If you do not release iliosacral (pelvis on sacrum) fixations,
it will not be l ong bef ore most, if not all, of your client' s pain returns.
Like every area of the body you deci de to study, the pelvic area is very
compl i cat ed and i nt erconnect ed to the rest of the body. In this chapter
you will be l earni ng primarily about j oi nt dysfuncti on, but you also want
to appreci at e the i nti mate c o nne c t i o ns that exi st bet ween the pel vi s,
sacrum, spine, and the rest of the body. Whe n you study Figure 8.1, page
96, showing the iliosacral and sacroiliac ligaments, you can clearly see how
tightly c onnec t ed the pelvis, sacrum, L4, and L5 are. Whenever you work
on any of these structures, r emember how they are c onnec t ed and be cer-
tain that you have released all the associated restrictions. As you are about
95
The Pelvis
HE SACRUM AND THE PELVIS ARE SO CLOSELY TI ED TOGETHER THAT
when they exist freely i n their natural state of cooperat i ve i nde-
pendenc e life can be grand. But when o ne or the ot her interferes
6
4
3
1
2
6 Anterior plane of the sacroiliac ligaments
Inferior band of the iliolumbar ligament
3 & 4 Intermediate plane of the sacroiliac
ligaments
Superior band of the iliolumbar ligament
8&9 Anterior sacroiliac
ligament
7 Sacrotuburous ligament
6 Sacrospinous ligament
to l earn, the pelvis can cause probl ems i n three ways. Any o ne or combi -
nation of these patterns of pelvic dysfunction will also strain the ligaments
and create further dysfunction in the l ow back and sacrum.
Be aware that the i l i ol umbar, sacrospi nous, and sacrot uberous liga-
ment s are three very i mport ant l i gaments i n this area. Al o ng with the
pelvic rotaters (especially the piriformis) and the psoas, they must be capa-
ble of adapting to your manipulations in order to create l ong lasting change
f or your clients. You probabl y already have your favorite ways of releasing
these muscl es and ligaments. Make sure you address them either bef ore
or after releasing all sacroiliac or iliosacral fixations.
Li gament ous structures are clearly i mport ant f or pr oper j oi nt f unc-
ti on, but so i s overall body structure and posture. The al i gnment of your
body i n gravity can pr of oundl y affect how your pelvis i s posi t i oned and
this i n turn can det ermi ne how well your j oi nts f uncti on. The drawings
in Figure 8.2 represent f our ways the pelvis can be posi ti oned with respect
to the entire body. " Tilt" refers to the anteri or or posteri or torsi oni ng of
the entire pelvis around a transverse axis that runs through the inferior
aspect of the sacroiliac j oi nt . "Shift" refers to the anteri or or posteri or
96
5
7 1
2
8
9
7
6
Figure 8.1
THE PELVIS
Anterior Tilt
Posterior Shift
translation of the enti re pelvis al ong the transverse pl ane. The c ur ved
arrows represent tilt and the straight arrows indicate shift. The di f f erence
between tilt and shift was first recogni zed by Jan Sultan and is part of a
brilliant typology he devel oped f or identifying c o mmo n structural types
and their associated myofascial strain and gait patterns. His understand-
ing of tilt/shift was further refi ned by Swiss Rolfer, Dr. Hans Flury.
Many myofascial structures cont ri but e to these overall patterns. For
exampl e, a posteriorly tilted pelvis is often tied to tight, short hamstrings
while an anteriorly tilted pelvis is often tied to tight, short quadriceps. These
postural issues are also of ten associated with typical sacral dysfuncti ons.
When the sacrum gets stuck bilaterally in posteri or nutation it often drags
the lumbars with it, especially L4 and L5. As it turns out, a person whose
pelvis inclines toward posterior tilt will mor e likely show bilateral posterior
nutation fixations of the sacrum than a person with an anterior pelvis.
Not recogni zi ng the di fference between tilt and shift has mislead many
97
Figure 8.2
TILT occurs as an anterior or posterior torsioning of the entire pelvis around a trans-
verse axis that runs through the inferior aspect of the sacroiliac joint.
SHI R occurs as an anterior or posterior translation of the entire pelvis along the
transverse plane.
Anterior Tilt
Anterior Shift
Posterior Tilt
Anterior Shift
Posterior Tilt
Posterior Shift
therapists in their evaluations of clients' overall alignment.
Whe n a cl i ent' s pelvis is posteri orl y tilted, but shows an
anteri or shift well beyond the mid-sagittal axis, it is c o m-
mo n to misread this pattern as a lordosis or a swayback. As
the pelvis shifts anteriorly, the thorax shifts posteriorly giv-
i ng the person the appearance of falling backward. But if
you l ook carefully, you will of ten see a l umbar spine that is
actually lacking an appropri ate lordosis. The illusion of a
swayback is created by an anteri or shift of the pelvis. Fig-
ure 8.3 is f rom Kendall and McCreary' s Muscles: Testing and
Function
1
and is a clear case of an anteriorly shifted pelvis
with a posteri or tilt. Noti ce that this person' s l umbar spine
is actually rather flat and displays very little l ordoti c curve.
Al t hough this exampl e is not extreme, clearly Kendall and
McCreary are misled by the anterior shift of a posteriorly
tilted pelvis and wrongl y descri be this person as having a
swayback post ure. Thi s pattern of the anteri or shift of a
posteri orl y tilted pelvis can be slight f or o ne person and
very extreme in another, but in most cases you will see that
the l ordoti c curve is lacking to some degree.
Al t hough deal i ng with these many and varied postural
issues is well beyond the sc ope of this manual , some dis-
cussion is helpful. It serves to remi nd you of the of i mpor-
tance of always trying to understand how local fixations are
intimately related to whol e body structure and gravity. In
a very real sense, you can never work on any local area of
the body without bei ng in contact with the whol e body and
its compl i cat ed network of compensati ons. If a local change is i ntroduced
i nto a body wi thout taking account of its network of compensati ons and
postural habi ts, then typically the bo dy will not be abl e to sustain the
change. If it cannot adapt above or support the change below, then either
the body will return to its original dysfunction or devel op strain and dys-
f uncti on el s ewher eor bot h.
Figure 8.3
98
pelvis can create dysf uncti on are torsi on, flare, and shear. First you will
learn what these patterns are and then you will learn how to test and release
them. You have already encountered pelvic torsion in the last chapter where
I descri bed the vermi cul ar undul ati on of the spi ne duri ng walking. You
may recall how normal walking requires that each i nnomi nate rotate ( or
torsion) anteriorly and posteriorly in response to how each leg moves f rom
heel strike to toe off. Torsi on of the i nnomi nates occurs around a trans-
verse axis that runs through the inferior aspect of the sacroiliac j oi nt . Just
as it is possible for the i nnomi nates to torsion normally, it is also possible
for one of them to get stuck i n either anterior or posteri or torsion.
Flare of the i nnomi nate can oc c ur as either out-flare or in-flare. Whe n
out-flared, the ilium rotates laterally, or away f rom the mid-sagittal axis as
the ischial tuberosity rotates medially, or toward the mid-sagittal axis. In-
flare behaves in the opposi t e f ashi on: the ilium rotates medi al l y toward
the mid-sagittal axis and the tuberosity rotates away f rom the mid-sagittal
axis.
Shear is a j ust a bit mor e compl i cat ed, because it can oc c ur in two dis-
tinct ways, either as ant eri or/ post eri or shear or superi or/ i nf eri or shear.
In superi or/ i nf eri or shear, also known as up-slip and down- sl i p, o ne of
the innominates either slips upward on the sacrum in relation to the other
i nnomi nate or i t slips downward. In ant eri or/ post eri or ( A/ P) shear, o ne
of the i nnomi nates either slips anteriorly in relation to the ot her i nnom-
inates or i t slips posteriorly. You coul d reasonably call A / P shear anteri or
and posteri or slip.
You are probabl y wonder i ng how you det er mi ne whet her a cl i ent i s
mani festi ng o ne of these iliosacral fixations and, i f she is, how you tell
whether the i nnomi nate is fixed anteriorly or posteriorly or inferiorly or
superiorly. As you mi ght have guessed, the osteopaths have created some
rather simple tests to hel p you answer these questi ons.
The first test f or det er mi ni ng iliosacral dysf uncti on is the standi ng
f l exi on test. To per f or m i t you need to pl ace your thumbs on the i nferi or
99
Testing and Palpating for Iliosacral Dysfunction
ET' S LEAVE THESE LARGER I SSUES AND T URN OUR AT T ENT I ON TO T HE
specifics of how the pelvis creates j oi nt fi xati ons. The three ways the
Inferior slope
of PSIS
Ischial
tuberosity
Sacral
sulcus
Median sacral
crest
Iliac crests at
level of L4
Inferior lateral
angle
Sacral base
Figure 8.4
sl opes of the posteri or superi or iliac spines (PSIS), illustrated in Figure
8.4. You can find the PSIS by l ooki ng f or the di mpl es most peopl e have
in this area, l ocated about two i nches lateral to the lumbosacral j unct i on.
By pl aci ng the pads of your thumbs over them you will find the most pos-
terior aspect of the PSIS. Drag your thumbs in an inferior di recti on until
you find the inferior slopes of the PSIS. You will know you are there when
you feel your thumbs j ust begi n to slide of f the inferior aspect of the PSIS.
Wi th your cl i ent standing, pl ace the pads of your thumbs on the infe-
ri or sl ope of the PSIS and ask hi m to bend f orward as far as he comf ort -
ably can. Wat ch what happens to your t humbs. If there i s an iliosacral
fixation, o ne of your thumbs will ride up i n a superi or di recti on and the
ot her o ne will stay where it is. The side on whi ch the t humb rides up is
the fixed side. Figure 8.5 shows the restriction on the right side. This test
works quite well, unless the hamstrings or the quadratus l umbor um are
asymmetrically tight. If the hamstrings are tight on the side opposi te to
where your t humb rides up, or if the quadratus l umbor um is tight on the
same side as where your t humb rides up, the superi or movement of your
t humb will not be a true indicator.
The standing f l exi on test will not tell you whether o ne i nnomi nate is
100
THE PELVIS
in-flared or out-flared, whether o ne i nnomi nat e i s up- sl i pped or down-
slipped, whether one is anteriorly slipped or posteriorly slipped, or whether
one is posteriorly torsi oned or anteriorly torsi oned. The tests will onl y tell
you the side on whi ch the i nnomi nate i s fi xed on the sacrum. In order to
tell what kind of iliosacral fixation you are l ooki ng at you must palpate a
number of ot her areas on the pelvis, a t echni que that will be descri bed
shortly. For now, j ust practi ce the standi ng flexion test and not i ce what
happens to your thumbs.
Now that you have l earned how to use this test to det ermi ne iliosacral
dysfuncti on, you can use the sitting version of i t to hel p you det er mi ne
unilateral sacroiliac fixations. Ask your client to assume a seated posi ti on,
once again place the pads of your thumbs on the inferior slope of the PSIS,
and ask hi m to forward bend as far as he comf ortabl y can. If o ne of your
thumbs rides superiorly, as it does in Figure 8.6, you have di scovered a
sacroiliac fixation. Like the standing flexion test, the sitting flexion test
onl y tells you on whi ch the side the sacral fixation exists, it doesn' t tell
whether it is fixed in anteri or/ posteri or torsion or anteri or/ posteri or shear.
101
The sitting f l exi on test effecti vel y
removes the i nf l uence of your client' s
legs and pelvis on the sacrum and there-
f ore allows you t o det er mi ne whet her
sacroiliac fixations are present. In con-
trast, the standing flexion test adds the
i nf l uence of the pelvis and legs, and lets
you det er mi ne whet her iliosacral f i xa-
ti ons are present. If your t humb rides
up in bot h the sitting and standing flex-
i on tests, t hen yo u have di scovered a
sacroi l i ac and i l i osacral dysf unct i on.
Knowi ng how to use these tests is hel p-
ful to sorting out what ki nd of fi xati ons
are present.
Often you may be working with clients
whos e l ow bac k pr o bl e ms create t o o
muc h pai n when they try to f orward
bend f rom a standing position. In these
cases, and as a way to doubl e check your results, the so-called stork test is
also very useful. Ask your cl i ent to stand faci ng a wall so he can stabilize
himself while perf ormi ng the test. Put the pad of your right t humb on the
posteri or aspect of his right PSIS and your left t humb at the same level on
the medi an sacral crest, whi ch is basically the mid-line of the sacrum. Ask
your cl i ent to raise his knee to at least 90 degrees and watch what your
right t humb does (Figure 8. 7) . If there is no iliosacral fixation, your right
t humb will ri de i nf eri orl y as he raises his l eg and your left t humb will
remain where it is. If there is a fixation, then your right thumb will remain
where it is and not move inferiorly. Test the ot her side in the same way.
Pl ace your left t humb on the post eri or aspect of his left PSIS and your
right t humb at the same level on the medi al sacral crest, ask hi m to raise
his knee to at least 90 degrees, and watch how your left t humb responds.
If it doesn' t move inferiorly, you have di scovered an iliosacral fixation.
If ei ther the standing flexion or the stork test reveals an iliosacral fix-
ation, the next part of your evaluation requires you to figure out by means
of pal pati on whether you are deal i ng with flare, shear, torsion, or a cora-
102
Figure 8.7
THE PELVIS
bination of some or all of them. Let' s take a simplified l ook at an exam-
ple. Suppose you find an iliosacral fixation on the right by using the stand-
ing flexion test, and you palpate the i nnomi nates to discover that the right
i nnomi nate seems out-flared and the left seems in-flared. If you had pal-
pated the i nnomi nates wi thout havi ng pe r f o r me d the standi ng f l exi on
test, it woul d be very difficult f or you to be able to say whether the right
i nnomi nate was out-flared or the left i nnomi nat e was in-flared. But since
you per f or med the standing f l exi on test and it revealed that the fixation
was on the right, you can c o nc l ude that the ri ght i nnomi nat e must be
fixed in an out-flared position. So here is how it works: first you determi ne
the side on whi ch the fixation is present; then you palpate to det ermi ne
whether the iliosacral fixation is an in-flare or out-flare, an anterior or pos-
terior shear, an up-slip or down-slip, an anteri or or posteri or torsi on, or
some combi nat i on.
Palpating for In-flare/Out-flare
Let' s l ook mor e carefully at where and how you palpate f or each of these
condi ti ons. We will begi n with pal pati ng f or in-flare and out-flare. Fi nd
the anterior superi or iliac spine (ASIS) (Figure 8.8) with your cl i ent in a
supine position. The easiest way to do this is to first pl ace your palms over
the ASIS to l ocate it and noti ce how the shape of this area feels to your
t ouc h. The n pl ace the pads of
your thumbs on the medi al infe-
ri or edge of each ASIS. Next
draw an imaginary line down the
cent er of your cl i ent' s bo dy t o
represent the mid-sagittal axis.
On most peopl e the navel i s on
this center l i ne. The n c o mpar e
how far each t humb is f rom this
center line. If the t humb on the
ri ght ASIS seems cl oser to the
mi dl i ne than the left, then you
are probabl y l ooki ng at an uni -
lateral in-flare or out-flare. If the
standing flexion test or the stork
Inferior
sl ope of
ASIS
Ischial
tuberosity
Figure 8.8
103
Left
pube
test reveals a fixation on the right, then you have di scovered a right in-
flare. If the tests show that the fixation is on the left, then you have f ound
a left out-flare.
Palpating for Up-slip/Down-slip (Superior/Inferior Shear)
Shear is most often the result of trauma and although down-slips do occur,
they are very rare. Whe n o ne does oc c ur it is usually correct ed by walk-
ing. So if your pal pati on reveals one i nnomi nat e that seems inferior and
one that seems superior, you can pretty much be assured that you are l ook-
i ng at up-slip. Begi n your pal pati on sequence with your client in a prone
posi ti on. Be sure that your thumbs are always pl aced on exactly the same
level. Pl ace the pads of your t humbs on each of the ischial tuberosities
and compare their relative positions to one another. Does one seem supe-
ri or and the ot her inferior? If so, and the standing flexion and stork tests
show a fixation on the same side as the superi or tuberosity, then you have
probabl y di scovered an up-slip. The posi ti on of the tuberosities is a fairly
rel i abl e i ndi cator, but you can be mi sl ed under certain ci rcumstances.
Someti mes what appears to be an up-slip is the result of curvature in which
the l umbar spi ne si debends to the same side as the apparent up-slip. A
Type I gr oup curvature with a right si debendi ng, f or exampl e, will make
the right i nnomi nat e seem mo r e superi or than the left.
Next pal pate the PSIS's f or their relative superi or/ i nf eri or positions
and then roll your client over and palpate the ASIS' s. If the ASIS and PSIS
of o ne of the i nnomi nates are bot h superior, then you are probabl y l ook-
i ng at an up-slip. Ask your client to return to a pr one posi ti on and check
the sacrotuberous ligaments. To fi nd these ligaments, pl ace your thumbs
between the apex of the sacrum and the ischial tuberosities. The sacro-
tuberous l i gament will be lax on the same side as the up-slip and tight on
the same side as the down-slip. Ask your cl i ent to turn over again and in
a supi ne posi ti on pal pate the superi or edges of the pubes to see if they
seem superi or and i nf eri or with respect to each other. Lastly check the
i ngui nal l i gaments f or tenderness. The i ngui nal l i gament will likely be
tender on the same side as shear: if it's a right up-slip, it will be tender on
the right, and if it's a left down-slip, tender on the left. Be aware that ten-
derness is a less reliable i ndi cator than posi ti on. If the standing flexion
and stork tests reveal a fixation on the right and all pal patory indicators
104
THE PELVIS
show the right side superi or in relation to the left, you have di scovered a
right up-slip.
Palpating for Anterior/Posterior Shear
Wi th your client i n a supi ne posi ti on pl ace the pads of your thumbs on
the most anterior aspect of each pube and evaluate for whether one seems
anteri or and the ot her posteri or. If the standi ng f l exi on and stork tests
reveals a fixation on the right and the right pube is anterior, then the right
i nnomi nate is fixed in anterior shear. If the tests reveal the fixation on the
left, then the left i nnomi nate is fixed in posteri or shear.
Palpating for Anterior/Posterior Torsion
I left torsion f or last because of all the f orms of dysfunction we have dis-
cussed, it is usually the least likely type of pelvic dysfunction. So, I suggest
that in your palpation sequence you also save torsi on f or last. If you find
a shear or flare fixation correct them first bef ore you even palpate f or tor-
sion. Al most everybody' s i nnomi nates torsion in the same way. The nor-
mal and expec t ed pattern you will see over and over again i s the ri ght
i nnomi nate torsi oned anteriorly and the left posteriorly. If you find the
opposi te situation you may be l ooki ng at trauma, or a soccer player who
kicks with his left f oot. If the standing flexion test and the stork tests reveal
an iliosacral fixation and you palpate torsion first you will predictably find
the right i nnomi nate torsi oned anteriorly and the left posteriorly. Mor e
than likely the torsion is normal and the fixation the test revealed is due
to shear or fl are. So your best bet i s to pal pate f or shear and fl are fi rst,
correct what you fi nd, and per f or m the standing fl exi on and stork tests
to check your results. If the fixation is no l onger present, there is no need
to bot her yourself with palpating f or torsion. If the fixation persists after
correcti ng shear and fl are, then correct f or torsion. But i f you palpate f or
torsion bef ore you paipate f or fl are or shear, you may be mislead i nto cor-
recting a torsion fixation when no ne is present.
Palpate f or torsi on with your cl i ent i n a supi ne posi t i on. Pl ace your
thumbs on the ASIS's and compare their relative positions to one another.
Does o ne i nnomi nat e seem t orsi oned anteriorly and the ot her posteri -
orly? Let' s assume that either you have already released flare or shear dys-
functions or none are present. If the standing fl exi on and stork tests show
105
a fixation on the right and the right i nnomi nat e is torsi oned anteriorly,
then the right i nnomi nat e is fixed in anteri or torsion. If you discover the
fixation on the left and the left i nnomi nate is torsi oned posteriorly, then
the left i nnomi nat e is fixed in posteri or torsion.
I have never worked with a client who showed all three iliosacral fixa-
tions at o nc e , but I bel i eve it is possi bl e. Of ten, however, you will find a
combi nat i on of two of these f i xat i ons. Dependi ng on the uni queness of
each client' s body, someti mes it is very easy to palpate these patterns and
ot her times it is mor e difficult. Don' t be di scouraged if at first you are not
quite sure what pattern you l ooki ng at. If you are not certain, correct f or
what you thi nk the pr obl em i s and retest. The techni ques descri bed i n
this b o o k f or releasing iliosacral fixations are gentle enough that they will
not cause harm i f you mi sread the posi ti on of the i nnomi nat e and cor-
rect f or a pr obl em that is not present. If the standi ng f l exi on and stork
tests show a fixation and you are uncl ear f rom palpation whether you are
l ooki ng at shear or flare, correct f or bot h on the side on whi ch the f i xa-
tion shows up. For instance, correct f or shear and then retest and, If the
test is negative you know the pr obl em was shear. If the test is still positive,
correct f or flare and retest again. Always palpate bef ore and after mani p-
ulation so that you learn to see and feel subtle but i mportant differences.
And in time you will learn to see and feel mor e and mor e subtle patterns.
Techniques for Pelvis-on-Sacrum Dysfunctions
A
LL OF THE TECHNIQUES YOU ARE ABOUT TO LEARN WORK BEST IF YOU
free up all the associated soft tissues and ligaments in this area. For
exampl e, be sure that the hamstrings, gluteals, rotators, psoas, quadratus
l umbo r um, errectors, and ligaments are bal anced and free enough f or
your client' s pelvis to accept pelvic mani pul ati ons.
Out-flare
Put your client i n a supi ne posi ti on. On the out-flared side bri ng one of
your client' s knees up ( f oot flat on the tabl e) . Sit on the same side of the
table as the out-flare. Place the fingers of one hand on the medial surface
of the ischial tuberosity and the heel of the other hand on the ilium with
fingers wrapped around the ASIS (Figures 8.9 and 8. 10). Gently but firmly
106
THE PELVIS
Figure 8.10
107
Figure 8.9
Figure 8.11
traction the tuberosity laterally while
pushi ng the ilium medi al l y and wait.
Either the i nnomi nat e will release its
restriction by goi ng t hrough a dance
or by moving directly to its normal posi-
tion. This technique was created by Jan
Sultan.
In-flare
Place your cl i ent in a supine posi ti on
and stand on the opposi te side of the
tabl e f r o m the in-flare. As shown i n
Figure 8. 11, reach across to the knee
of the in-flared side. Bend the knee,
ho o k your arm underneat h, lift, and
bri ng it across the mi dl i ne as you pull
it in a superi or di recti on. As you hol d
the knee in this position, pull it toward
yo u ever so slightly to stabilize the
tuberosity. Put the heel of your ot her hand j ust medi al to the ASIS and
gently but firmly push the ilium laterally and wait. Either the i nnomi nate
will go t hrough its dance and release or it will move directly to its normal
posi ti on.
Up-slip
Wi th your cl i ent lying on the side opposi te the up-slip, use the leg of the
up-slipped side as a handl e to gui de the i nnomi nate. Using the direct tech-
ni que you gently but firmly pull the leg inferiorly and wait for the i nnom-
inate to glide into its normal position (Figure 8. 12). The indirect technique
requires a few mo r e steps. Use the f emur to gently but firmly and slowly
push the i nnomi nat e superiorly and henc e further into its up-slip. Wait.
You will feel the i nnomi nat e move further i nto the up-slip. Next you may
feel a pulsation and then an i mpul se in the client' s body f or the i nnomi -
nate to move inferiorly. Whe n you f eel the i mpul se to move inferiorly,
encourage that movement by slowly and gently pul l i ng the leg inferiorly
at a speed that matches the speed with whi ch the client' s body releases. If
108
THE PELVIS
at first you are unabl e to feel the i mpul se of the body to move inferiorly,
don' t worry about it. Perf orm the t echni que as di rected: use the f emur
to push the i nnomi nate further i nto its up-slip, and simply hol d it in that
posi ti on f or about 5 to 10 seconds, and then traction the l eg and pelvis
inferiorly. These two met hods f or releasing an up-slip were also created
by Jan Sultan.
Down-slip
Simply reverse the direct and indirect up-slip techni que. You can use your
client' s l eg to directly push the pelvis superi orl y. Or you can pul l your
client' s leg inferiorly to increase the down-slip and wait f or the i mpul se
to release superiorly.
Anterior Shear
Wi th your cl i ent pr one, stand on the same side of the table as the ante-
rior shear. Place the fingers of one hand on the anteri or pube and pl ace
the f orearm of your ot her arm on the opposi t e i nnomi nat e. Wi th your
f orearm, stabilize the pelvis while you gently but firmly push the anteri or
109
Figure 8.12
Figure 8.13
Anterior Torsion
pub e i n a post eri or di rect i on ( Fi gure
8. 13) and wait. Either the i nnomi nat e
will danc e to its release or it will move
directly to its normal posi ti on.
Posterior Shear
Wi t h your cl i ent pr o ne , stand on the
opposi te side of the posterior shear. Use
the same hand and f orearm pl acement
as descri bed f or the anterior shear, but
this time use your fingers to stabilize the
pube while you use your forearm to gen-
tly but firmly push the opposi te i nnom-
i nate (with the post eri or pube ) i n an
anteri or di recti on. Wait. Either the in-
nomi nat e will release its restriction by
danci ng this way and that or by movi ng
directly to its normal posi ti on.
Wi t h your cl i ent supi ne, stand on the
same si de as the ant eri or torsi on and
pl ace the heel of one hand on the ASIS
of the anteriorly torsi oned i nnomi nate
(Figure 8. 14) . Bring the f emur perpen-
di cul ar to the table with the knee bent
and lean a little of your body wei ght on
the knee. Wi th your ot her hand, gently
but f i rml y appl y pressure on the ASIS
i n the di recti on of posteri or torsi on as
you use your body wei ght to move the
f emur to enc our age the post eri or tor-
s i oni ng of the i nnomi nat e and wait.
Either the i nnomi nat e will go through
its danc e or it will move di rectl y to its
normal posi ti on.
Figure 8.14
110
THE PELVIS
Posterior Torsion
With your client prone, stand on the side with the posteri or torsion. Place
one hand under the f emur j ust above the knee of the posteriorly torsioned
i nnomi nate and the ot her hand on the posteri or aspect of the i nnomi -
nate itself. Lift the f emur slightly of f the table and pl ace your knee under
it so you don' t have to hol d the leg up as you perf orm the techni que (Fig-
ure 8. 15) . Gently but fi rml y appl y pressure to the i nnomi nat e with the
ot her hand i n the di recti on of an anteri or torsi on and wait. Ei ther the
i nnomi nate will release its restriction by unwi ndi ng or by movi ng directly
to its normal posi ti on.
As a general rule, remember that these iliosacral techni ques, as well as all
the other techni ques discussed in this book, work best if you prepare the
myofascial and l i gamentous tissues associated with the fixations you are
attempting to release. Preparing the tissues means that you release the asso-
ciated strain patterns and bri ng enough bal ance to the appropri ate areas
of your client' s body so that he is able to adapt to your mani pul ati ons. It
1 1 1
Figure 8.15
also helps if you are able to address the alignment of the whol e body al ong
with its many patterns of c ompens at i on. As a somati c practi ti oner you
already have your favorite ways of releasing and bal anci ng these tissues,
and your techni ques are certainly a useful adj unct to the techni ques you
learn f r om this book. However, even i f you do not hi ng to prepare the tis-
sues or address patterns of compensat i on, the techni ques taught in this
b o o k are still powerf ul enough to get g o o d results all by themselves.
Note
1. Kendal l , Fl orence Peterson and McCreary, Elizabeth Kendall. Muscles:
Testing and Function. Thi rd edi t i on, Bal ti more: (Williams and Wi l ki ns) ,
1983.
112
CHAPTER
9
The Ribs
N THE LAST CHAPTER YOU LEARNED HO W T HE PELVIS CONTRI BUTES TO
back pain. In this chapter you will learn how the ribs contri bute to and
hel p perpetuate back pai n. The organi zati on of the thorax, as well as
its myofascial, l i gamentous, and articular fixations, can prof oundl y affect
the organization, integrity, and f uncti oni ng of the whol e body. If you c on-
sider onl y the j oi nts of the thorax, there are 150 articulations, and most
ribs can be involved in 6 articulations al one. Just by f reei ng a myriad of
thoraci c restrictions, whi ch mi ght i ncl ude rib fixations in the ribs, ster-
num, clavicles, the l i gaments and fascia f r om whi ch the l ungs are sus-
pended, and so on, i t i s someti mes possible to release nec k and l ow back
facet restrictions wi thout ever even worki ng on the nec k or l ower back
themselves. In this chapter, however, we will limit our discussion to the
ribs only. Onc e you learn how to recogni ze and release rib dysfunctions,
you will be surprised and pl eased at how this knowl edge will contri bute
greatly to your ability to release many facet restrictions in the thoracic and
cervical spines.
The Influence of the Ribs
S
I NCE THE RIBS ARTI CULATE WI T H THE SPINE I N VERY SPECIFIC WAYS,
they play a significant role in spinal dysfunction. Ri b 1 articulates with
Tl and ribs 11 and 12 articulate with T i l and T12 respectively. Ribs 1, 11,
113
and 12 articulate with the spine by means of unifacets, whereas ribs 2- 10
articulate by means of demi f acets. All the ribs, with the except i on of 11
and 12, articulate in the f ront of the thorax by means of strong cartilagi-
nous attachments and this cartilage in turn also articulates with the ster-
num. Lo o k at the f ront of the thorax and you will see that there are really
two attachments, called the costochondral and sternochondral j uncti ons,
that are associated with most of these ribs. The costochondral j uncti on acts
like a j oi nt and i s f or med by the insertion of the concave end of the rib
i nto a cone- shaped pi ece of cartilage. The sternochondral articulation is
f or med by the costal cartilage inserting i nto the triangular notches of the
sternum, in whi ch are f ound small synovial j oi nts. Mot i on occurs at both
of these articulations and releasing a rib requi res addressi ng the costo-
chondral j unct i on and someti mes the sternochondral articulations as well.
The c ompl ex relation between the ribs and vertebrae illustrated in Fig-
ure 9.1 shows why dysfunctional rib torsions usually result f rom vertebral
rotations and Type II dysfunctions in the thoracic spine. The ribs that con-
nect to the spi ne by means of demi f acets articulate with two vertebrae.
Inferior costal
articular facet
Superior costal
articular facet
Costal facet of transverse
process
Figure 9.1
114
THE RIBS
Let' s l ook at the fifth rib as an exampl e. Ri b 5 attaches to the i nf eri or
costal facet of T4, the superi or costal facet of T5, and the costal facet of
the transverse process of T5. If T4 rotates right on T5, T4 pulls the supe-
rior aspect of the rib with it, while the i nferi or aspect of the ri b, whi ch is
attached to T5, remains unaf f ected by the rotation. The right rotation of
T4 will thus cause the right fifth rib to torsion externally and the left fifth
rib to torsion internally.
Ribs that articulate by means of demi f acets have two costovertebral
connect i ons and o ne costotransverse c onnec t i on. The fl oati ng ribs, 11
and 12, whi ch attach by means of a uni facet do not have a costotranverse
articulation. Even t hough they do not attach to the f ront of the rib cage
itself, they do have interesting connect i ons to the muscl es of the poste-
rior abdomi nal wall. These connect i ons are i mportant, because when the
articulations of ribs 11 or 12 are fixed, they are ac c ompani ed by myofas-
cial strain patterns in the abdomi nal muscles. As my col l eague and fri end
Jan Sultan di scovered, these strain patterns are often in the f or m of a vor-
tex and they must also be released if you want to successfully release these
ribs as well. The ribs even have a tough little l i gament that attaches to the
annulus of the intervertebral disk. All of these connect i ons mean that a
rib in troubl e can of ten cause mo r e pai n than a dysfuncti onal vertebra
and l earni ng how to release rib fixations will contri bute greatly to your
skills.
Due to the intimate relationships between ribs and spine, you can often
release rib dysfunctions simply by releasing the vertebral dysfunctions. So
the best strategy is to release Type II fixations first. But many times releas-
ing the dysfunctional thoraci c vertebra will not be enough to release the
rib. So always test and retest bot h vertebral and rib fixations to make sure
your mani pul ati ons are successful. Just r emember that releasing Type II
fixations will someti mes release the rib and someti mes not. Be aware that
it also works the other wayType II fixations will not always remain released
until the rib fixations are released.
If you successfully release a dysfunctional thoracic vertebra, your client
will probabl y i mmedi atel y report f eel i ng better. But i f you do n' t release
the associated ri b fi xati on, you can expect to hear how the pain returned
within a few hours or days. Somet i mes this report means that the unre-
solved rib fixation was enough to make the facet restriction reassert itself.
115
And ot her times it means that your cl i ent is still in pai n because of the
unresol ved ri b fi xati ons, even t hough your release of the vertebral dys-
f uncti on was compl et el y successful. Ribs are very i mportant in perpetu-
ating back and neck pain. Many cervical fixations are hel d and maintained
by upper rib fixations. I have seen t oo many clients who recei ved treat-
ments f r om therapists who knew how to release vertebral dysfunctions,
but di d not know how to release rib fixations. The result of onl y releasing
the thoraci c vertebrae is that often the rib fixations worsen and the client
ends up with more pain than bef ore she started treatment. So always check
f or and release rib fixations. Your clients will love you f or it.
Finding the Fixed Ribs
R
IBS CAN GET I NTO TROUBLE I N A NUMBER OF WAYS. THEY CAN TORSI ON
internally or externally, they can subl ux anteriorly or posteriorly, the
first rib can slip superiorly, and they can be c o me distorted and dysfunc-
tional t hrough trauma. We will expl ore how to understand and treat tor-
sion, subl uxati on, and first rib dysfunction.
The techni que for releasing the ribs is very simple and straightforward.
All you need to know is how to l ocate the fixed rib. There are two simple
ways to l ocate a fixed rib that do not requi re you to know whether the rib
is torsi oned or subl uxed. Onc e you locate the fixed rib, applying the tech-
ni que will tell you how the rib is posi t i oned as you f ol l ow how it dances
toward its rel easeeval uati on and treatment merge together as one and
the same process.
Noti ce that there are two grooves associated with the spine. The spinal
groove is between the spi nous and transverse processes of the spine. An-
other groove is f ormed where the ribs articulate with the spine at the costo-
transverse j uncti on. Illustrated by the drawing in Figure 9.2, this articulation
is roughl y at the lateral borders of the errectors. To find this rib groove,
place the pad of your thumb on the spinous process, and drag your thumb
laterally. Al most immediately you will feel your t humb sink into the spinal
groove. Conti nue to drag your t humb laterally over the transverse process
until you feel i t o nc e again fall i nto an i ndentati on or groove. This sec-
o nd groove is the costotransverse groove and you will noti ce that it is not
as de e p as the spinal groove. Practice finding the costotransverse groove
116
THE RIBS
because the two tests that
you will learn f or determi n-
ing rib fixations require you
to pl ace your fi ngers here.
Although the costotransverse
gr oove i s the best pl ace to
feel for rib fixations, it is not
as useful if you are trying to
pal pate f or torsi on or sub-
luxation.
Bef ore you learn the two
methods for determining rib
fixation, let's first l ook at how
to pal pate f or torsi on and
subl uxati on. Al t hough it is
117
Rib angle
Costotransverse groove Spinal groove
Figure 9.2
not altogether necessary, it hel ps if you can l ook at a skeleton while prac-
ticing rib pal pati on. The first thing to noti ce is that the superi or borders
of ribs are not as easy to feel as the i nf eri or borders. The shape and posi -
tion of these borders is such that the superi or bo r de r feels less distinct
than the inferior border. So don' t let this feature of how the ribs are shaped
mislead you i nto thinking you are palpating internal torsi on.
To determi ne torsion, palpate the superi or and inferior borders of the
suspected rib at about the rib angle. If the rib is externally torsi oned, then
you will fi nd two telltale signs: the superi or bor der will be mo r e pr omi -
nent and the i nf eri or less pr omi nent than nor mal , and the intercostal
space above the rib will be wi der and the intercostal space bel ow the rib
will be narrower than normal . Internal torsion displays j ust the opposi t e
features. The inferior border of the suspected rib will be mor e promi nent
and the superior border will be less promi nent than normal , and the inter-
costal space bel ow the rib will be wi der and the intercostal space above
the rib will be narrower than usual.
To det ermi ne subl uxati on, palpate the head of the suspected rib on
the front of the rib cage at the cost ochondral j unc t i on and the rib angles
on the posteri or side of the rib cage. The n c ompar e the suspected rib to
the rib on the ot her side. Is the posteri or rib angl e of the suspected rib
mor e ant eri or/ post eri or? Is the rib head mo r e ant eri or/ post eri or than
the rib on the ot her side at the cost ochondral j unct i on? If the rib angle
and the rib head at the cost ochondral j unct i on are both mor e anterior in
compari son to the rib on the ot her side, then the suspected rib is proba-
bly anteri orl y subl uxed. If the ri b angl e and the ri b head at the cost o-
chondral j unct i on are both mor e posteri or than the rib on the other side,
then the suspected rib is probabl y posteriorly subl uxed.
Palpating ribs f or torsi on and subl uxati on can be difficult, especially
on clients whose back muscul ature i s highly devel oped. To increase your
pal patory skills it is best f or you to practice feel i ng these rib patterns. But
fortunately, you really don' t have to go through the above process of pal-
pati on to find a fixed rib and free it. You can simply put your t humb in
the costotransverse groove on the suspected rib and mot i on test it.
Use the so-called "spring test" to motion-test ribs. Put your thumb on
the suspected rib where it articulates with the costotransverse process and
with firm pressure quickly push anteriorly and j ust as quickly release the
pressure. Do this a coupl e of times in rapid succession so that you can feel
whether the rib springs or not. If you cannot feel the rib spring, it is prob-
ably fixed. Spri ng test a numbe r of ribs until you can feel the clear dif-
f erence between a fixed rib that has no spring to it and a free rib that easily
springs with pressure.
Anot her way to mot i on test for rib fixations is through a kind of assisted
spring test. Place your cl i ent in a sitting posi ti on and ask hi m to put each
hand on his opposi te shoul der so that his arms are crossed. Stand behi nd
your cl i ent and hol d up his crossed arms at his el bows with o ne of your
hands. Make sure that your client gives you the full weight of his arms and
is not unconsciously trying to hel p you hol d his arms up. Place your thumb
in the area of the suspected rib and then smoothl y but rapidly raise and
l ower your client' s arms. As you raise his arms, push your t humb anteri-
orly and then let the pressure of f as you l ower his arms (Figures 9.3 and
9 . 4 ) . If either or bot h the costotransverse or costovertebral j oi nts are fixed,
your t humb will not sink in an anterior di recti on as you raise your client' s
arms. If your t humb doesn' t sink anteriorly as you raise your client' s arms,
you have di scovered a fixed rib.
Both of these tests will give you all the i nf ormati on you need to release
rib fixations, but the assisted spring test is a little mor e reliable and accu-
rate, especially if you are new to pal pati ng f or rib fixations. Not i ce that
118

THE RIBS
Figure 9.3
these tests onl y tell you whi ch ribs are fi xed but they do not also tell you
whether the ribs are fixed in anterior or posteri or subluxation or in exter-
nal or internal torsion. Fortunately you don' t really need to make these
kinds of discriminations in order to use the techni que f or releasing ribs.
You onl y need to know where the fi xati on i s l ocated.
By the way, as a me t ho d to increase evaluation skills, you shoul d also
know that rib fixations are usually ac c ompani ed by characteristic tender
points in the soft tissues, illustrated in Figure 9.5, page 120. Not i ce that a
number of these tender poi nts are al ong the edge of the scapula. Whe n
clients have fixed ribs, it is quite c o mmo n f or t hem to tell you that they
are experi enci ng pain at the edge of their scapula. However, don' t be mis-
l ed by where your clients tell you to l o o k f or pai nful spots. Mo r e of ten
than not the pain they feel in the area of the r homboi ds is secondary to
and a result of the rib fi xati on. If you release the r homboi ds and do not
release the of f endi ng rib, your client' s pai n will return very shortly. How-
ever, after you release the rib, releasing the myofasciae al ong the shoul -
der bl ade will support your release of the rib.
119
Figure 9.4
Anot her way to locate fixations is to run your thumbs or fingers down
the costotransverse groove on o ne side of the spine and then the other,
and not i ce i f you feel somet hi ng that makes you want to investigate. Do
this wi thout any pr ec onc ept i ons and you will be surprised by how often
your fingers will land on a rib fixation. You can do the same thing in the
spinal groove if you want to practice a qui ck way to find vertebral facet fix-
ations. Onc e you gain conf i dence in your ability to feel for fixations in this
way, you can search out dysf uncti ons in the same way anywhere in your
client' s body. This met hod of locating probl ems in your clients is quite ele-
gant and somethi ng you can easily practice every time you treat them.
As you may remember, the first rib behaves a little differently than ribs
2- 10. Whe n the first rib bec omes dysfunctional it tends to get fi xed in a
superi or position. When it is in trouble you will also find that the scalenes
will be hypertoni c on the same side as the fixed rib and that there will be
marked tenderness in the area of the superi or aspect of the first rib near
where it articulates with Tl . Have you ever had the experi ence of doi ng a
great j o b of releasing your client' s cervical pain only to have him report that
his neck still hurt sand that it especially hurts when he turns his head to
one side where he feels the pain shooti ng al ong the right superior edge of
his traps? Such a report is usually an indication that the right first rib is fixed.
120
Rib tenderpoints
Figure 9.5
THE RIBS
There are two ways of testing f or whether the first rib is in troubl e. The
first met hod is j ust another variation of the spring test. Wi th your cl i ent
in a sitting posi ti on, pl ace the pad of your t humb over where the first rib
articulates with Tl and spring test downwardl y in a caudad di recti on. If it
doesn' t spring it is probabl y fixed. Anot her way to test the first rib is to
put your cl i ent i n a sitting posi ti on and pl ace the f i ngers of each hand
over the first ribs, with your forefi ngers very cl ose to the spinal articula-
tion and ask your cl i ent to take a de e p breath. If o ne of the first ribs is
fixed it will not move with the inhalation.
Rib Techniques
B
EFORE YOU RELEASE ANY RI B FI XATI ONS, BE CERTAI N THAT THE SOFT
tissues of the t horaci c r egi on are adequat el y pr epar ed, especi al l y
around the costotransverse, costovertebral , c ost oc hondr al , and sterno-
chondral regi ons. First release all Type II facet fixations in the thoraci c
spine.
All of the f ol l owi ng t echni ques f or rel easi ng ribs are d o n e with the
client in a sitting posi ti on. For dysfunctions of ribs 2- 10, pl ace the finger
or t humb of one hand on the costotransverse articulation and a f i nger of
the other hand on the cost ochondral articulation of the dysfunctional rib
(Figures 9.6, 9.7, and 9.8, pages 122- 123) . Slowly, but with gentl e, firm
pressure push your fingers toward each other. As you apply pressure, ask
your client to si debend his body to the same side as the fixed rib. Hol d and
wait. Follow the dance of the rib as it unwinds, releases its restrictions, and
the tissue softens. Conti nue to hol d and wait until you feel the body orga-
nize itself as muc h as it can ar ound vertical and hori zontal pl anes. You
may remember f rom earlier chapters that there are two stages to the final
release of a j o i nt fixation. First you will feel the sof teni ng of the tissues
and then, if you waitjust a little longer, you may feel the orthotropi c effect
as your client' s body organi zes itself around the sagittal, transverse, and
coronal planes. For most somati c practitioners f eel i ng the body organi ze
itself around vertical lines is the easiest. So don' t worry about not f eel i ng
all of these planes c o me in duri ng the release. Just practi ce f eel i ng what
you can and in time you will feel even more. These planes intersect at right
angles and as a short hand way to talk about how the body organizes itself
121
Figure 9.6
Figure 9.7
122
THE RIBS
around these pl anes, I refer to it as
ort hogonal organi zati on.
Let' s suppose the rib you are at-
tempting to release is stuck in exter-
nal torsion. As the rib goes through
its danc e , yo u will not i c e i t of t en
moves further i nto external torsion
bef ore it releases. The rib will move
in many o dd ways, but eventually it
will move further i nto external tor-
si on. Whe n the ri b c ompl et es this
movement i t will then move out of
external torsion toward a mor e nor-
mal posi ti on. Tracki ng this rib mo -
tion and taking not e of its posi ti ons
while you are attempti ng to release
it is the way you det ermi ne how the
rib is stuck. When the rib finally comes
to rest in what is normal posi ti on in relation to the rest of the body, it will
stop movi ng. You will then feel the tissue sof ten and the characteristic
attempt of the body to organi ze orthotropi cal l y and orthogonal l y around
the release.
For dysfunctions of the 11th and 12th ribs, pl ace the t humb or fi nger
of one hand as cl ose as possible to the costovertebral articulation and the
forefi nger and t humb of the ot her hand al ong the l ength of the rib as i t
wraps its way around the body, as shown in Figures 9.9 and 9.10, page 124.
Slowly apply gentl e but firm pressure to the costovertebral j unc t i on and
si debend your client to the side on which the rib is fixed. Follow the dance
and wait f or the rib to release and f or the body to organi ze orthogonal l y.
Don' t forget that there are fascial vortices in the posteri or abdomi nal wall
that are often associated with restrictions in the 11th and 12th ribs, and
that these myofascial strain patterns must also be rel eased f or this tech-
ni que to be fully effective.
To release these associated fascial vortices, ask your client to lie supi ne.
If any vortices are present, they will be f ound medial to the tips of the 11th
and 12th ribs roughly in the area of the external abdomi nal obl i que, trans-
123
Figure 9.8
Figure 9.9
Figure 9.10
124
THE RIBS
versus, and rectus abdomi nus. To search f or these vortices, gently push
the pad of your t humb or forefi nger and mi ddl e f i nger into various places
in the area j ust descri bed and wait to see if your fingers are drawn down
and into the tissue in a spiraling fashi on, as shown in Figures 9. 11, 9. 12,
and 9.13. If this happens you have di scovered a fascial vortex. Place the
forefingers, or the forefi ngers and mi ddl e f i ngers, of bot h hands i n the
area of the vortex and gently sink i nto the tissue waiting f or the body' s
response. More often than not your fingers will gently f ol l ow the tissue by
spiraling deeper i nto the vortex. Whe n you reach the end of the spiral-
ing, you will feel a sof teni ng of the tissue and an i mpul se f or the vortex
to unwi nd itself up and out of its spiral. Let this happen. Someti mes your
fingers j ust spiral down into the tissue and the body will simply release the
strain without spiraling back out. Either way the release happens, you will
know the techni que is finished when you feel the tissues soften and release
al ong a vertical line. Like all releases, the body will try to organi ze itself
orthogonally, but feel i ng the ot her pl anes while releasing fascial vortices
is someti mes a little difficult.
Figure 9.11
125
Figure 9.13
126
Figure 9.12
THE RIBS
If you mot i on test and find a restricted first rib, mor e than likely it will
be fixed superiorly. Let' s suppose you find the restriction in the right first
rib. Wi th your cl i ent in a sitting posi ti on, snuggl e the edge of your ul na
(the part that is closest to your ol ecranon) ont o your client' s first rib where
it attaches to Tl at the costotransverse j unct i on. Ask your client to dr op his
head as far forward as is comf ortabl e and to remai n in this posi ti on while
he slowly turns his head to the left. As he turns left, let your el bow sink fur-
ther i nto the j oi nt space (Figure 9. 14) . The n ask hi m to bri ng his head
back to center and very slowly turn to the right, all the while keepi ng his
head in the forward bent posi ti on (Figure 9. 15) . As he slowly turns right,
conti nue to apply gentle but firm pressure in a caudad di recti on to the rib
head. Wait f or the rib to go through its unwi ndi ng, release its restriction,
and f or the tissues to soften. Cont i nue with the pressure until the body
organi zes itself ort hogonal l y as muc h as it can. The n be sure to release
scalenes on the ipsilateral side.
This chapter on the ribs really brings this manual on spinal manipula-
tion to a close. In the next and last chapter I will discuss a few odds and ends
that will clarify some important points and suggest a few other techniques.
127
CHAPTER
10
Odds and Ends
T
HE BODY I S NOT A SOFT MACHI NE OR A COMPLEX T HI NG MADE OF
parts. It is a seamless unified living whol e capabl e of adapting to an
ever- changi ng i nternal and external envi r onment . What we are
tempted to call "parts" of the body are really not parts at al l our bodi es
are not c obbl ed together f r om pre- shaped parts the way machi nes are.
Any attempt to take apart a body the way you mi ght disassemble a machi ne
into its parts only results in a heap of lifeless pieces that cannot be reassem-
bl ed as a body. So we speak t oo loosely when we refer to the liver or brain
or the f oot as a part of the body. Whenever we refer to some aspect of the
living body, such as the hand or the heart, we are really ref erri ng to an
aspect or expression of the whol e. An organ is not in the body in the same
way a carburetor is in a car. Conceptual l y, we can distinguish these dif-
ferent aspects of the whol e, but no one of these aspects is functionally sep-
arate f rom the whol e.
What we call organs and other anatomical structures are in reality orga-
nized, unified relationships related to the living whol e which is also a living,
organized, unified relationship. Every unified relationship is c ompos ed of
other unified relationships and every relationship is an integral aspect of
other relationships. The connecti ons, communi cati on networks, and forces
between bodily relationships are themselves unified relationships and the
way they all function together is a unified relationship. What we are tempted
to call parts are not only unified relationships, but also organi zed whol es.
129
These organi zed whol es exist i n relationship to ot her organi zed whol es
and overl ap as networks of c ommuni c at i on and c onnec t i on that are all
expressions of a deliquescent, but exquisitely and hierarchically organized
whol e. So me uni f i ed rel ati onshi ps, like the heart and brai n, are mo r e
i mportant to the survival of the whol e than others. But since the body is
not c ompos ed of parts, there is nothi ng more fundamental to the makeup
and organi zati on of the whol e than the whol e itself. Since the body is an
i rreduci bl e compl exi ty and not c obbl ed together f rom pre-shaped parts,
every detail of the whol e is an expressi on of the uni fi ed, seamless organ-
ization of the whol e. The shape of every bo ne i n your body, f or exampl e,
is a matchless manifestation of your uni que morphol ogy.
All living organi sms are self-organizing and we humans are the most
hi ghl y plastic of all. Organi sms persist over time because they are c on-
stantly i n the pr oc ess of f o r mi ng and r e- f or mi ng thei r boundar i es i n
response to their ever-changi ng envi ronments. Living bei ngs are able to
accompl i sh this remarkable feat in the face of persistent internal and exter-
nal change because their order and organi zati on is self-maintained and
sel f-contai ned. An organi sm is like a fountai n of water whose constituent
materials are bei ng rapidly repl aced, while variations in the f orm remain
the same over time. But unlike a f ountai n where the f or m is mai ntai ned
by outsi de f orces, organi sms have the i nherent power to mai ntai n and
adapt their f or m to their envi ronment. Maintaining, adapting, and evolv-
ing bodily f orm in an ever-changing envi ronment are part of what it means
to be alive. Ho w well our bodi es accompl i sh these amazi ng feats are also
an i mportant part of what determi nes our level of health, happiness, and
sense of well-being and f r eedom.
These characteristics result in a body that is also highly adaptive and
plastic. If a per son is i nj ured, say in an aut omobi l e acci dent , her body
of ten devel ops patterns of compensat i on i n relation to the original pat-
tern of injury. The aut omobi l e acci dent does not j ust cause a local pr ob-
l em with some "part" of the body, it also creates gl obal patterns of strain
that i n turn affect the organi zati on and f unct i oni ng of the entire body
and its relation to gravity.
The ori gi nal pattern of i nj ury mo r e of t en than not i s laid down on
ot her previous injuries and postural i mbal ances. Al ong with the resulting
patterns of c ompens at i on i n rel ati on to gravity, these i mbal ances and
130
ODDS AND ENDS
injury patterns result in a compl i cated loss of inherent plasticity and adapt-
ability throughout the entire body. Over time, further losses in movement ,
plasticity, and adaptability will appear as the body struggles with gravity in
its daily activities. If these compl i cat ed patterns of strain and compensa-
tion are not released, and perhaps mor e importantly, not released i n the
proper order, the body will not be able to respond properl y to i nterven-
tions desi gned to release the original injury site or any ot her area of dys-
f uncti on. Treating the body as an assemblage of dysfunctional parts and
releasing the parts sympt om by sympt om is the most c o mmo n way that
somatic practitioners approach therapy. This met hodol ogy can be called
the "correcti ve appr oac h. " It certai nl y has its pl ace in the t herapeut i c
arena, but it is usually less effective than the "holistic appr oac h" whi ch
requires understanding the i nterconnected living whol e in whi ch all these
local dysfunctions are embodi ed.
The human body i s amazi ng i n its i nt erconnect ed, i rreduci bl e c o m-
plexity and equally ast oundi ng i n its seamless simplicity. The mo r e we
understand about the uni f i ed, systematic, i nt erconnect ed nature of our
bodi es and how the whol e person responds to i nj ury and i nterventi on,
the better our therapy bec omes . This realization means that as muc h as
possible we must keep expandi ng our understandi ng of, and our ability
to feel, this uni fi ed living whol e that we are. It also means that if we want
our manipulations to be l ong lasting, we must expand our understandi ng
so that we can work holistically rather than j ust correctively. The holistic
approach to somati c therapy aims not onl y to remedi ate symptoms, but
also to enhance the whol e person. Effective holistic somati c therapy de-
mands that the practi ti oner not onl y be able to percei ve the whol e, but
to also track the effects of her l ocal mani pul ati ons on the whol e.
So in a sense, even t hough this b o o k is about spinal mani pul ati on, it
shoul d also be about the whol e body. But such a goal is t oo vast f or a man-
ual of technique. In order to make this book manageable, I have approached
therapeutic i nterventi on f rom the correcti ve perspective. Unfortunately,
since the correcti ve approach tends to understand the client as a col l ec-
tion of symptoms, it is almost always j ust a little t oo shortsighted. Since so
many local areas of dysfunction are tied to, and hel d, by mor e gl obal pat-
terns of strain, the holistic perspecti ve i s requi red to gai n s ome under -
standing of these whole body connections. That is why I menti on the holistic
131
perspective now and also why I have taken some limited excursi ons into
ot her areas of the body. Like all therapists, you want your clients to expe-
ri ence long-lasting relief as a result of your spinal mani pul ati ons. These
digressions will hel p you to understand and treat some of the mor e sig-
nificant compensati ons and fixations that contri bute to your client' s body
maintaining its dysf unct i onsbut obviously not all of them.
The i nherent difficulties with the correcti ve approach to therapy can
only be overcome with a more compl ete discussion of the holistic approach.
Such a discussion woul d have to show that the corrective approach is based
on a mechani cal understandi ng of the body that sees it as a compl ex thing
made of parts. It woul d also have to articulate a pr oper phi l osophy and
sci ence of living whol es that woul d f or m the bi ol ogi cal f oundati on f or a
holistic medi cal system. It woul d also i ncl ude understandi ng and treating
the whol e body, not j ust the spi ne. Thus, we woul d also have to expl ore
ho w to treat the crani um, the extremi ti es, and the organs, the cel omi c
sacs, and the many energeti c di mensi ons, neurol ogi cal and psychological
dysfunctions, and so on.
Even assuming that we had all this knowl edge and were able to effec-
tively treat all these different aspects of the whol e person, it woul d still not
be enough. On what basis do we take all of the i nformati on gathered f rom
our evaluation and prioritize all the relevant techni ques into a treatment
strategy that takes ac c ount of how our client' s whol e body can adapt to
and support our i nterventi ons? Ho w we answer the three f undamental
questi ons of therapy i s critical: What do I do fi rst, What do I do next, and
Whe n am I finished?
After we have fully evaluated our client' s kinds and levels of dysfunc-
tion, we need a way to create a treatment strategy that is based on some-
thing other than simply following already determi ned formulistic protocols
or j ust treating the probl ems sympt om by sympt om. Treati ng clients by
following a treatment recipe is a useful way to learn in the begi nni ng stages
of b e c o mi ng a somati c practi ti oner, but this me t ho d i s not fully appro-
priate f or most clients and it is not appropri ate f or us as we cont i nue to
mature as therapists. In order to learn how to treat our clients in all their
individuality, wi thout the benef i t of f ormul i sti c prot ocol s, we must also
know ho w to engage i n a pr i nc i pl e- c ent er ed cl i ni cal deci si on- maki ng
process. So a compl et e discussion of holistic somatic therapy woul d also
132
ODDS AND ENDS
require a lengthy investigation i nto the principles of i nterventi on: what a
pri nci pl e is, how principles are di fferent f rom strategies, how pri nci pl es
f uncti on in f ormul ati ng treatment strategies, and j ust exactly what these
principles are.
All of these i mportant topics are obviously beyond the scope of a man-
ual on soft-tissue techni ques. But ment i oni ng them illuminates the full
scope of somatic therapy and discussing them keeps us humbl e by remi nd-
ing us how muc h we have to learn.
Since we have to start somewhere, and this b o o k marks a way to begi n,
let's return to a mor e manageabl e task. This chapter of the b o o k will be
devoted to a few details that I purposel y left f or the end. Understandi ng
them will contribute further to your ability to manipulate the spine. Some
of these details c onc er n the issue of adaptabi l i tyi n this discussion you
will learn what can appropriately be called preparatory techni ques. But I
also want to give you a few simple ways to approach spinal curvature. You
may r emember that I briefly talked about curvature when I i nt roduced
what are cal l ed Type I gr oup curves toward the e nd of Chapt er Thr ee.
We will l ook at adaptability issues first and then take a bri ef tour of spinal
curvature.
Adaptability
A
S I SUGGESTED ABOVE, FORMULATI NG A TREATMENT STRATEGY THAT IS
not dependent on formulistic protocol s or treating your clients symp-
tom by symptom requires a clinical-decision maki ng process that is based
on the principles of i nterventi on. I f ormul ated a pri nci pl e- centered deci -
sion-making process i n col l aborati on with my col l eague and f ri end, Jan
Sultan. One of the principles is called the "Adaptability Pri nci pl e. " I have
discussed the rationale behi nd this pri nci pl e a number of times through-
out this book. The idea behi nd it is simple and quite obvious: if your client' s
body i s not capabl e of adapti ng to or accepti ng your i nterventi on, then
either his body will return to its dysfunctional state or your mani pul ati on
will drive strain to other areas of his b o d y o r bot h. This is very often the
unwel c ome c ons equenc e of treating sympt om by sympt om. But experi -
enced holistic therapists understand what happens when they do not prop-
erly prepare a client' s body to adapt to the effects of their mani pul ati ons.
133
Your cl i ent compl ai ns that his pai n ret urned al most i mmedi atel y after
your treatment, or that his pain is now worse, or has spread to other areas
of his body. Of course, there coul d be other explanations for why this hap-
pens, but failure to prepare the client' s body i s certainly one of the mor e
c o mmo n reasons.
Techni ques f or prepari ng your client' s body so that it can adapt to your
interventions can vary f rom simply relaxing the appropriate tissues around
a vertebra bef ore you release its facet restriction to maki ng sure that the
body as a whol e can adapt to your manipulations above and support them
bel ow. Someti mes psychol ogi cal issues i nterfere with your i nterventi on.
It is not at all unc o mmo n to treat clients who have been sexually and phys-
ically abused. For some of these clients every attempt you make to mani p-
ulate the pelvis and l ow back is met with unconsci ous resistance. These
unf ortunate clients c annot adapt to your i nterventi on because they are
not psychol ogi cal l y pr epar ed to deal with the memor i es and emot i ons
that mi ght result if they were to allow changes in their bodi es.
Anot her very i mportant pri nci pl e of intervention is the "Support Prin-
ci pl e. " It is actually a specific appl i cati on of the adaptability pri nci pl e and
also deri ved f rom the pi oneeri ng work of Dr. Ida P. Rolf. It says that order
is a f uncti on of available support in gravity. Agai n, the rationale behi nd
this pri nci pl e is simple and obvious: if your client' s body is not able to sup-
port the changes you i nt roduce, then either it will revert to its pri or dys-
functi onal state or you will drive strain el sewher eor both. If you deci de
to release a number of fixations in the pelvic and lumbar region, for exam-
ple, and your client' s legs are not under hi m properly supporting the pelvis
and the rest of his body, then the ability of your cl i ent to hol d ont o the
results of your treatment will be limited.
Imagi ne how you mi ght pr oc eed i f your evaluation revealed that your
client c oul d nei ther adapt above or bel ow, or support your interventions.
You woul d have to create a treatment strategy that addressed all of her
specific adaptability and support issues. In a situation like this, it is usu-
ally best to begi n by addressing the most i mportant adaptability issues first
and the support issues last. The reason f or this particular approach rests
on the observati on that work on the feet and legs tends to release upward
through the body. If your client' s body cannot adapt above to this upwardly
rising wave of release that almost always results f rom worki ng on feet and
134
ODDS AND ENDS
legs, then your mani pul ati ons c oul d cause s ome nasty probl ems i n your
client' s thorax, neck, and head. Onl y after these adaptability and support
issues have been handl ed shoul d you begi n worki ng to release the myofas-
cial and j oi nt fixations in the pelvic regi on.
As you probabl y real i zed, there are ot her pri nci pl es of i nterventi on
and other considerations about how to evaluate the structural, functional,
and energetic aspects of the whol e person that are i mportant to this holis-
tic deci si on-maki ng process. I ment i on onl y the support and adaptability
principles because they are obvi ous and can be used to give you an i dea
of how pri nci pl e- centered deci si on maki ng works and a sense of ho w a
holistic somatic practitioner operates accordi ng to pri nci pl es.
In this chapter we will limit our discussion to issues of l ocal adaptabil-
ity. Discussing the mo r e gl obal compensat i ons and strain patterns that
manifest i n a person' s structural, f unct i onal , emot i onal , and energet i c
ways of bei ng woul d require another bo o k on how to evaluate these gl obal
patterns, as well as a c ompl et e di scussi on of the pri nci pl es of i nterven-
tion. To keep things si mpl e we will onl y discuss those l ocal areas of the
body that are directly relevant to releasing the j oi nt fixations we have dis-
cussed in this book.
What to Prepare
T
HI S SECTI ON DESCRI BES MANY OF T HE LOCAL AREAS OF MYOFASCI AL
and l i gamentous dysfunction that are c ommonl y associated with j oi nt
fixations. As a general rul e, you shoul d consi der releasing these associ-
ated areas first bef or e deal i ng with the speci f i c j o i nt f i xati on. You can
release the tissues after you release the j oi nt fixation, but it is usually eas-
ier on you and on your client if you release the relevant tissues first. As I
ment i oned previously, all the techni ques I discuss in this b o o k will work
quite well if you do not attempt to release these associated soft tissue restric-
tions. But you definitely will be muc h mo r e effective i f you release these
myofascial and l i gamentous restrictions first. This discussion is not meant
to be exhaustive, it contains only the most i mportant areas the ones you
shoul d always be sure not to overl ook.
Also I will not devote much discussion to the techniques to use to release
these areas, because there are many ways to accompl i sh the desired results
135
and most readers of this b o o k already know many of them. Besides, there
are many classes and workshops on soft tissue techni ques readily available
to somati c practitioners in bot h the Uni ted States and Europe.
The most i mport ant r ec ommendat i on I want to make is to find ways
to release soft-tissue restrictions that do not cause unnecessary pai n to
your clients. When it comes to treating the human body, more is not always
better. To o many soft tissue practitioners apply way t oo muc h pressure to
the body and willfully push their way through the tissues. This willful appli-
cati on of el bows and knuckles not onl y causes unnecessary pain and tis-
sue damage, it also interferes with your ability to feel the orthotropi c effect.
Appl yi ng the " no pai n, no gai n" phi l osophy i s not the most effective ap-
pr oac h, and can of ten be abusive. Use what you have l earned f rom this
b o o k when you appr oac h the release of myofasci ae and ligaments, and
do n' t f orce your way t hrough the tissue. Let your client' s body tell you
what it wants and how it wants to release. If you respect the way the body
wants to release and find its way to its own i nherent order, you can apply
heavy pressure and not worry about causing unnecessary pain. Sink into
the tissue and wait f or the dance. Your clients will be muc h happi er if you
do and your results will also be better.
Dr. Rolf, the creator and f ounder of Rol f i ng, taught a shotgun tech-
ni que that is someti mes useful f or releasing the musculature of the back,
but it also has its dangers. Si nce this techni que has gai ned a lot of popu-
larity amo ng many ot her somati c practitioners, I want to make sure you
know when to use i t and when not to.
The t echni que works this way: pl ace your cl i ent in a sitting posi ti on
and l ean your ri ght el bow on his ri ght uppe r bac k at about the cervi -
cothoraci c j unct i on over the spinal groove and transverse processes. Don' t
use the poi nt of your el bow, use the flatter aspectj ust superi or to the ol e-
cranon. Let your el bow sink i nto the tissue by letting your weight do most
of the work. Ask your cl i ent to slowly be nd f orward (Figure 10. 1) . As he
does so, keep your pressure up and slide your el bow down his back at a
rate that keeps up with the rate at whi ch the tissue releases. Be sure to
slide your el bow all the way down and through the tissue around the sacroil-
iac j oi nt (Figure 10. 2) . Ask your client to sit up and repeat the process on
the left side. You can run your el bow down your client' s back a coupl e of
times on each side. As a matter of course you may even release some closed
136
ODDS AND ENDS
Figure 10.1
fixed facets. But as you also probabl y realized, this techni que wall have no
effect on all the open- f i xed facets.
This techni que is a very useful shotgun approach f or releasing the back
muscul ature. But be careful with it. If your cl i ent has severe back pai n,
degenerative j oi nt disease, a nd / o r disc probl ems, don' t use this techni que,
because you can actually make her back pai n muc h muc h worse. If your
client has disc probl ems you may even cause the disc to herni ate further.
Any time you release sacroi l i ac, iliosacral, or l umbar f acet f i xati ons,
check the hamstrings, the gluteals, the pelvic rotators, the adductors, the
quadratus l umbor um, the psoas, the myofasciae of the l umbar and tho-
racolumbar regions, and the pelvic ligaments. Normalize those areas where
you find strain, tightness, and i mbal ances f rom side to side. Figure 10.3,
page 138, shows the c o mpl e x l i gamentous structure of this area. Whe n
releasing the sacrum, be sure to pay special attention to the sacrotuber-
ous ( 7) , sacrospinous ( 6) , sacroiliac ( 5) , and the piriformis (Figure 10. 4) .
When you are releasing the sacrum, L5, and L4 also be certain you check
137
Figure 10.2
the i l i ol umbar ligaments (1 and 2) .
If your client is compl ai ni ng of sciatic pain, you want to be sure to eval-
uate L4, L5, the sacrum, the ligaments previously ment i oned, and espe-
cially the pi ri formi s muscl e. It is usually not enough to release the c o m-
pressi on on the sciatic nerve at L4 on L5, because L5, the sacrum, the
ligaments, and the pelvic rotators, especially the piriformis, are often part
of the pr obl em. The drawings in Figure 10.4 present f our different ways
the sciatic nerve can thread its way around or through the piriformis and
the percent age of ti me each shows up i n the human popul ati on. It also
dramatically illustrates why sciatic pain can be mai ntai ned by a dysfunc-
tional piriformis muscl e l ong after the compressi on on the nerve root has
been alleviated. So always check the piriformis muscle when you are releas-
i ng the sacrum or deal i ng with sciatic pai n.
The hamstri ngs al most always cont ri but e to mai ntai ni ng strain and
fi xati on t hrough the l umbar and pelvic regi ons. Ti me and again I have
wat ched a sacrum derotate as I rel eased the hamstrings. Whe n you see
l umbar si debendi ng, mo r e than likely you will also see bot h a tight and
138
5
7
1
2
3
4
6
85%
10%
2-3% 1%
1
2
8
7
6
ODDS AND ENDS
short psoas and quadratus l umbo r um on the side to whi ch the spi ne i s
si debendi ng. Thi nk of the l umbar spine as a tent pol e and the psoas mus-
cles as guy wires. Every l umbar vertebrae is attached to the psoas and if
one of these guy wires is pul l i ng mor e than the ot her it is sure to unbal -
ance the spi ne. Even i f you j ust find the c o mmo n dysfunctional pattern
where L4 and L5 are si debent and rotated to the same side, you shoul d
treat the psoas and the quadratus l umbor um on the side to whi ch L4 and
L5 are si debent.
You shoul d also pay attention to the adductors, especially where they
attach at the pelvic ramus. Manipulating dysfunctionally shortened adduc-
tors will gready contri bute to your attempt to release the sacrum and l um-
bars. Since the adductors and the psoas are intimately c onnec t ed in this
area, if you release the adductors you shoul d also release the psoas. And
then make sure that the l umbar and t horacol umbar myofasciae will per-
mit the full release of this area. It is very c o mmo n to find myofascial strain
and tightness in the t horacol umbar regi on of clients who have had a his-
tory of l ow back pain.
Even if you have prepared all the associated tissues properly, and do ne
a great j o b of releasing all the fixations in the sacrum, lumbars, and pelvis,
someti mes your cl i ent compl ai ns that he still has j ust a little bit of pai n
and stiffness either in the center of his sacrum or around the SI j oi nts and
ILA' s. If this happens, you probabl y need to be mor e specific i n how you
release the associated myofasciae and ligaments. Ask your cl i ent to sit on
your treatment benc h and f orward be nd as far over as he is comf ort abl e.
Use the knuckles of bot h hands to apply 20 to 30 pounds of pressure to
the area around the right side of the l umbosacral j unc t i on. Sink i nto the
tissues and wait f or them to respond (Figure 10.5, page 140) . Whe n you
feel the tissues begi n to soften, slide inferiorly al ong the right SI j oi nt with
your left knuckl e on the medi al side of the SI j oi nt and the right knuckl e
on the lateral side of the SI j oi nt . Slide through this area at a speed that
matches t i ssues' rel ease, then do the ot her si de. If your cl i ent i s c o m-
plaining of l i ngeri ng pain i n the center of the sacrum, pl ace the knuck-
les of each hand close together, apply the same amount of pressure starting
at the lumbosacral j unct i on, sink i nto the tissues, wait f or them to soften,
and slide inferiorly al ong the body of the sacrum. This t echni que can be
somewhat i ntense f or the cl i ent ( me ani ng i t may hur t ) , but i t i s very
139
SPI NAL MANI PULATI ON MADE SI MPLE
effective f or releasing this last bit of
strain. Appl y the techni que a coupl e
of times in a way that your client can
tol erate and he shoul d feel i mme-
diate relief.
Whenever you release fixations
at one end of the spine, be sure you
attend to the other end and release
whatever f i xati ons you f i nd. A
c hange i n the l umbars can create
c hange i n the cervi cal s and visa
versa. So it is always a g o o d i dea to
make sure that bot h ends of the
spine are happy and free bef ore you
send your clients ho me .
Bef ore you release facet restric-
tions in the neck, use whatever tech-
niques you know to ease and release
the muscles and fascial sheets al ong
the back and sides of the neck and the tissues around the OA. Figure 10.6
shows a useful shotgun techni que you may want to try. Pick up your client' s
head and rest the back of his head i n the c r ook of your right hand (the
part f or med by webbi ng of your t humb and f oref i nger) . Wi th the i ndex
a n d / o r mi ddl e fingers of your left hand, apply pressure and sink into the
tissue of the left spinal groove around the atlas. Whe n you feel the tissue
soften, slide inferiorly with the fingers of your right hand to about Tl and
T2. Reverse your hands and treat the right cervical spinal groove the same
way. Besides releasing the posteri or myofasciae, this techni que will often
release some of the less severe fixed-closed facets. Of course it won' t release
the fixed-open facets, but because it does doubl e-duty in releasing soft tis-
sues and extensi on restrictions, it saves you time and energy.
Whenever you work in the neck area be sure that you always attend to
the subocci pi tal muscl es. This regi on is almost always involved with dys-
f uncti onal patterns i n the neck. In Figure 10. 7, not i ce how all of these
subocci pi tal muscl es, with the except i on of the obl i quus capitus inferior
(3) ( and the interspinous muscl es) , attach to the base of the occi put. The
140
Figure 10.5
ODDS AND ENDS
Figure 10.6
2 Rectus capitus posterior minor
3 Obliquus capitus inferior
5 Interspinous muscl es
Figure 10.7
rectus capitus posteri or maj or (1) attaches to the spi nous process of C2
and the occi put, the rectus capitus posteri or mi nor (2) attaches to CI and
the occi put , the obl i quus capitus superi or (4) attaches to the transverse
141
2
4
3
4 Obliquus capitus superior
l Rectus capitus posterior major
process of CI and the occiput, and the obliquus capitus inferior (3) attaches
to C2 and the transverse process of CI . New dissection procedures have
revealed the existence of a previously unknown muscle and ligament c om-
pl ex that extends f r om the subocci pi tal muscl es to the dura mater that
surrounds the brai n. Whe n you put this newly underst ood connect i on to
the cranial dura together with what happens when the suboccipital mus-
cles get tight and short in response to stress or facet restrictions, then you
easily understand why these muscl es can be the source of a real pain in
the n e c k a n d s o me really nasty headaches. So always make sure this
entire regi on is soft and at ease bef ore you end your treatment.
Bef ore you release ribs, it is very hel pful to ease the back musculature
and the tissues al ong the sides and the f ront of the rib cage, especially
ar ound the st ernum, and the c os t oc hondr al and ster-
noc hondr al j unct i ons. Pay special attention to the inter-
costal muscl es, especially above and bel ow the fixed ribs
you pl an to treat, and make sure they are at ease. As I
ment i oned i n Chapter Ni ne, the r homboi ds are always
involved in rib restrictions, but you shoul d also pay atten-
ti on to the levator scapulae and serratus posteri or supe-
ri or muscl es.
Curvature
Treati ng curvatures i n the human bo dy i s a very c o m-
pl i cated affair. Curvature is i nherent to our bodi es and
al ong with curvature comes asymmetry. Many school s of
manual and movement therapy l ook upo n all bodi l y cur-
vature and asymmetry as dysfunctional and try their best
to i ntervene and change these patterns. Many of these
school s adhere to s ome not i on of an "Ideal Body" that
they use as a standard against whi ch to evaluate thei r
clients' bodi es.
A g o o d exampl e of the theory of the ideally al i gned
body and its use in evaluating dysfunction is descri bed by
Kendall and McCreary.
1
Pictured in Figure 10.8, the ideal
body i s def i ned by dr oppi ng a pl umb line t hrough the Figure 10.8
142
ODDS AND ENDS
center of gravity of the body (i. e. , slightly anteri or to the f i rst or s ec ond
sacral segment) . If the centers of gravity of the ot her segments fall al ong
this pl umb line, it is consi dered properl y aligned. Ac c or di ng to this view,
the line of gravity shoul d fall through the mi ddl e of the ear l obe, through
the middle of the acromi on process, through the greater trochanter, slighdy
anterior to the axis of the knee j oi nt , and slightly anteri or to the lateral
mal l eol us. Thi s c o nc e pt of the ideal body has i nf l uenc ed many practi -
ti oners, who of ten i nappropri atel y evaluate and treat thei r patients i n
terms of how well they measure up to this external ideal. Unfortunatel y
this concept i on rests on the gratuitous assumption that the human body
is equally dense t hroughout . Si nce it is not, it cannot be l i ned up the way
you mi ght align a pile of bl ocks.
Like Dr. Rol f and many other theorists, Kendall and McCreary assume
that the closer bodi es match this ideal, the better they f uncti on. This view
has some truth to it, but when appl i ed indiscriminately to every patient,
dysf uncti on can result. Consi der a few obvi ous exampl es. A pr egnant
woman or an overwei ght patient with a large " pot belly" woul d be al i gned
in a most peculiar way if any attempt were made to bal ance them around
the line of gravity. Consi der patients with uppe r ne ur o n pr obl ems like
cerebral palsy. In many of these patients, any attempt to align their heads
on top of their bodi es, as this ideal r ec ommends, will often result in tonal
overflow to the extremities, possible increase in non-functi onal reflex pat-
terns of movement , and loss of control .
We shoul dn' t automatically assume that clients are manifesting some
sort of dysfunction solely because their bodi es do not measure up to this
external ideal of g o o d posture. Any attempt to compl etel y rid the body of
curvature and asymmetry is a hopel ess enterprise. If such an i mpossi bl e
goal coul d be realized, i t woul d probabl y cause the utmost distress and
pain to the po o r person who recei ved this wel l -i ntenti oned therapy.
As you mi ght well imagine, most theorists who believe that there is stan-
dard that all bodi es shoul d measure up to also believe in an "Ideal Spi ne. "
Figure 10.9, page 144, shows Dr. Ro l f s view of what this ideal spine shoul d
l ook like. But when you c ompar e her view to what actually exists, you see
there is quite a disparity. The f or m and curvature of any given spi ne is a
uni que expression of the mor phol ogy and f uncti oni ng of the entire body.
If you l ook carefully at the great di fferences between your clients' spines,
143
you will realize that any attempt to mani pul ate them to
match the shape of the ideal spine is an impossible goal.
Do you r emember Figure 10.10? It accompani ed the dis-
cussion of the shape of the facets of the i nnomi nate and
sacrum in Chapter Seven. Noti ce how clearly it shows the
rel at i onshi p bet ween the facets and the shape of the
sacrum. The impossibility of ever manipulating the sacrum
of spine A in Figure 10.10 toward a position like spine B's
is all t oo obvi ous. There is no way to change the position
of a sacrum with that shape, because the shape of the
facets woul d never permi t it. Remember, the shape of any
given b o ne i s an expressi on of the uni que mor phol ogy
of the entire body. If you cannot get the sacrum into this
idealized position, you will never get the spine there either.
I have seen t oo many dysfunctional spines that l ook j ust
like the ideal spine and many very functional spines l ook
like spi ne A. So we cannot automatically c onc l ude that
A c B
8
144
Figure 10.10
Figure 10.9
ODDS AND ENDS
j ust because a client' s spi ne or body doesn' t measure up to an ideal that
it is dysfunctional and in need of mani pul ati on. In fact, many times the
attempt to make a client' s body c o nf o r m to an ideal either has no ef f ect
or, worse, actually creates further dysfunction.
Somatic practitioners in every discipline have been taught to evaluate
clients by compari ng their bodies to some conscious or unconsci ous somatic
ideal. To o often, contour, posi ti on, curvature, and asymmetry are used as
the onl y i ndi cators of somati c dysf unct i on and di sorder. On c e we see
t hrough the limitations of evaluating o ur clients against these somati c
ideals, we will see the o dd contours and the o dd posi ti oni ng of segments,
curvatures, and asymmetries that show up in every body in an entirely dif-
ferent light. All of these o dd patterns must be evaluated i n terms of the
uni que limitations and possibilities f or each bo dy and each bo dy type.
Rej ecti ng the noti ons of an ideal body and ideal posi ti ons f or individual
segments does not under mi ne our ability to evaluate our clients' bodi es.
There are recognizable patterns of dysfunction that show up in every body
type, as well as c o mmo n patterns of asymmetry that show up in various
types of bodi es, and there are asymmetries uni que to the individual client.
Some of these patterns are associated with dysfunction and some are not.
When patterns that are associated with structural, f uncti onal , and ener-
getic fixations are properl y managed in accordance with individual needs,
overall f uncti on can be restored and enhanced.
So when you see oddl y posi ti oned segments, curvature, and asymme-
tries, what do you do about them? My suggestion is that you view an oddl y
positioned segment or curvature as no more than a clue to possible somatic
dysfunction or disorder, not the certainty of it. So always l ook f or loss of
function in the f orm of fixations first (myofascial, articular, energeti c, et c) .
Unless ac c ompani ed by s ome level of f i xati on, asymmetri es and curva-
tures may not be even clinically significant. Asymmetries, oddl y posi ti oned
segments, curvatures, and o d d cont ours do not always demand i nterven-
tion. When they do demand attention and manipulation, it is usually under
the f ol l owi ng condi ti ons: 1) when they are ac c ompani ed by a fixation or
fixations (at the structural, functi onal , a n d / o r energeti c levels), 2) when
they cont ri but e to a dysf uncti on or f i xati on, or 3) when mani pul at i ng
them will clearly enhance the overall f uncti oni ng of the whol e.
So our j o b i s to always try to understand and recogni ze the c o mmo n
145
patterns of dysf uncti on wi thout l osi ng sight of the uni queness of each
individual cl i ent and how her organi sm is organi zed as a whol e. For each
individual, the appropri ate posi ti on of structures is det ermi ned by appro-
priate f unct i on. If a segment seems to be in an o dd posi ti on, but works
the way it is supposed to, don' t mess with it. The same is true f or all local
and gl obal asymmetries. A percei ved asymmetry may be dysfunctional in
o ne bo dy and entirely f uncti onal and nor mal i n another. Appropri at e
f uncti on is det er mi ned by understandi ng what is possi bl e in relation to
each i ndi vi dual ' s uni que patterns of c hangi ng and unc hangi ng limita-
tions. In turn, these limitations must be seen in terms of how well the per-
son has adapted to gravity and his or her envi ronment. Position can never
be abstracted f rom what is functionally appropri ate f or each individual in
relation to gravity and the envi ronment.
So what is normal , then? Etymologically, "normal " is rooted in the idea
of measuri ng up to a no r m, model , or pattern, like a carpenter' s square.
This meani ng is the one most often associated with somatic idealism. But
" normal " also carries another meani ng. It can mean "natural" in the sense
of " bei ng in accordance with the i nherent nature of a person or a thing. "
This meani ng is at work when we say that a person is a natural-born artist
or healer.
Whe n I use the word " normal " I mean it in this second sense as bei ng
natural or i nherent t o the bei ng of the whol e person. Thi s c o nc e pt of
" normal " is clearly quite different in scope and implication f rom the idea
of measuri ng up to a no r m, statistical average, or standard that is exter-
nal to the body. Templ ates and nor ms make sense when your ai m i s to
mass pr o duc e machi nes and ot her non- l i vi ng product s. Templ ates and
norms are i mportant i n the devel opment of quality controls. But our bod-
ies are not machi nes or products, and it makes little sense to claim that
all human bodi es f uncti on best when they measure up to some external
standard or statistical average.
" Nor mal " in the sense in whi ch I use it, refers to what is appropri ate
and opti mal f or each individual person. It cannot be det ermi ned without
a careful case-by-case examination of what is possible for each person, given
the fixations and limitations i nherent to his or her body. Normal is also
not a static state that we can attain permanently. Living organisms are self-
organi zi ng, self-regulating whol es characterized by the continual ongoi ng
146
ODDS AND ENDS
attempt to bal ance, organi ze, enhance, and harmoni ze their lives. Gi ven
the tremendous plasticity and resulting diversity that actually exist amo ng
humans, clearly there cannot be one ideal way f or every body or every seg-
ment of the body. Our world and lives are always in flux, and, whether our
bodi es mai ntai n severe f i xati ons or not , we are always striving toward
bec omi ng mor e fully ourselves. Some of our limitations are t i me- bound
and changeabl e and some are not. What i s not changeabl e i n the present
may be changeabl e i n the future. What i s changeabl e f or one person may
not be f or another. Normal i ty i s an achi evement that i s wo n agai n and
again in the course of our lives.
As a somatic therapist you are always up against three limitations: your
own limitations as a therapist, the limitations of the therapeutic discipline
that you l earned, and the limitations of your client. Some of these limi-
tations cannot be over c ome. Most f orms of manual therapy will not cure
cancer, for exampl e. But many of these limitations can be over c ome. For
instance, you can always learn mo r e and i mprove your skills. What of ten
appear to be severe limitations i n your clients can change over time and
what was i ncapabl e of changi ng yesterday may change t omorrow. So we
must learn to recogni ze and respect what we can change today, what we
can change in the future, and what we cannot change at al l and of course,
how to tell the di f f erence. As somati c therapists our goal is not to make
clients measure up to some external standard that we i mpose on them by
means of somatic ideals and formulistic prot ocol s, but to try to di scover
the limitations that stand in the way of t hem be c o mi ng who they are and
then to release their fixations in the right order. Normal i ty is not a mat-
ter of measuri ng up to an ideal f or m or way of f uncti oni ng, but a matter
of uncovering what is natural or inherent in the bei ng of the whole. Somatic
therapy is, therefore, best practi ced as a process of discovery, not as an act
of i mposi ng pr e de t e r mi ne d standards on o ur cl i ents by means of f or-
mulistic protocol s.
Let' s return to the more practical issues at hand and l ook at how to deal
with curvature. As I ment i oned earlier, curvature is a compl i cat ed affair.
As you know, the spine has a number of curves in the ant eri or/ post eri or
di mensi on. These are the l umbar lordosis, the thoraci c kyphosis, and the
cervical lordosis. These A / P curves can be shallow or deep, dependi ng on
the structure of each person. And like all curvature, understandi ng them
147
Apex
Crossover
Apex
Crossover
Crossover
Figure 10.11
requi res under st andi ng the struc-
ture of the whol e body.
We are not goi ng to discuss how
to manipulate these A / P curves, but
rather onl y Type I curves where
there is an appreci abl e lateral devi-
ation f rom the sagittal axis. The draw-
i ng in Fi gure 10. 11 is a schemat i c
representation of a scoliosis that dis-
plays how si debendi ng and rotation
are coupl ed to opposi te sides. There
are f our pl aces i n the spi ne where
the curve might cross over and bend
in the opposi te direction. These typ-
ical transi ti on poi nt s are the l um-
bosacral , the t hor ac ol umbar , the
cervi cot horaci c, and atlantocciptal
j unc t i ons. Thr ee of these transitional j unct i ons are displayed schemati-
cally in the drawing. You can almost always count on these crossover points
bei ng the site of myofascial strain and tightness. There are many differ-
ent kinds of laterally devi ated curvatures and no two are the same. But
they all involve compl i cat ed twisting patterns that go through the entire
body f rom the crani um to the feet and they all involve varying degrees of
characteristic changes in the shape of the bones. Figure 10.12 shows the
di recti on of the scoliosis and its effect on the shape of a vertebra. Noti ce,
f or exampl e, how the shape of the facets and the spinal canal have been
modi f i ed by the twisting f orces of the curvature. Since the shape of the
vertebrae and other bones of the body sometimes have been so profoundly
modi f i ed by the scoliosis, your ability to affect curvature will be constrained
by these bony changes.
You shoul d always r emember that a scoliosis is really a curvature that
twists and spirals t hroughout the whol e body at every l evel i t is not j ust
a curvature of the spi ne. Any attempt to mani pul ate the spi ne wi thout
addressing how the entire body is involved in the curvature is almost always
hopel ess. Bef ore you can expect any significant and lasting change, you
must make sure the crani um, the pelvis, the extremities, and the ribs are
148
ODDS AND ENDS
abl e to adapt to any unwi ndi ng of
the curvat ure you mi ght manage.
Many times a curvature will wi nd its
way do wn mo r e i nt o o ne l eg than
the o t he r and rel easi ng the c o m-
pensat ory patterns i n that l eg can
someti mes significantly change the
curvature.
Treating a scoliosis requires bei ng
abl e to percei ve the whol e with all
its compensatory patterns and bei ng
abl e t o track the ef f ect of your
mani pul ati ons on the whol e. This is
Figure 10.12
a bi g and compl i cat ed j o b . A scoliosis is a mul ti di mensi onal shape that
does not respond to a two-di mensi onal treatment approach. If you had a
magi c wand that permi tted you to onl y affect the spi ne by f orci ng the S-
shaped curvature straight (the way that surgically i mpl anti ng Harri ngton
rods does, f or exampl e) , you woul d alter the si debendi ng wi thout signif-
icantly changi ng the rotational f orce and, as a result, send a mess of spi-
rals and compensat ory strain patterns t hroughout the entire body. The
holistic approach is really the best met hod f or treating a scoliosis, because
it is based on seei ng and treating the whol e. The correcti ve approach is
almost always less than satisfactory. A holistic appr oac h somet i mes pr o-
duces amazing results, especially when the curvature is not too pr onounc ed
and has not dramatically spun its way down i nto the legs or up i nto the
cranium. In some clients you may see an actual lessening of the curve and
i n other cases no significant change at all. What you can reasonably ho pe
f or is a general l engtheni ng of the body and the spi ne, and greater free-
d o m and mobility t hroughout your client' s body. Lengt heni ng the body
and the spine gives the scoliosis a softer and less compressed appearance.
Technique for Type I Group Curvatures
T
HE TECHNI QUE FOR TREATI NG TYPE I CURVATURES WAS CREATED BY MY
col l eague, Ji m Asher, an advanced Rol f i ng Instructor. If you keep all
the above consi derati ons in mi nd, you may find his approach very useful.
149
Facets
You can certainly attempt to apply the techni que wi thout addressing the
whol e body, provi ded you make sure bot h ends of the spine are relatively
free and at ease, that you have released iliosacral, sacroiliac, and all spinal
facet ( i ncl udi ng the OA) and rib restrictions. If you release these areas
first, you will not cause any harm to your client if you do not address the
rest of the b o d y y o u may even see some surprising results.
Some gr oup curvatures are easy to see and others are quite difficult.
If you are not quite sure whi ch way the spine is si debent, ask you client to
stand or sit and si debend to the right and then to the left. If your client
can si debend mo r e easily to the right than the left, you will noti ce that in
right si debendi ng the curve is clear and pronounced while in left sidebend-
i ng the spinal curvature is not as pr onounc ed. You will also noti ce that in
ri ght s i de be ndi ng the vert ebrae will rotate mo r e than they do i n left
si debendi ng. Check each curve in the spine the same way and note where
the apex of each curve i s on the convex side.
In preparati on f or understandi ng this t echni que, also noti ce how on
the convex side of the curve the errectors are pul l ed toward, and packed
in cl ose to, the spi ne in a way that seems to di mi ni sh the dept h of the
spinal groove. On the concave side the errectors are pul l ed away f rom the
spi ne and seem to be lying flat across the ribs.
Let' s assume your cl i ent has a curvature like the o ne previously illus-
trated. His l umbar spine is right si debent and left rotated and his thoracic
spi ne is left si debent and right rotated. For ease of understandi ng we will
start on the thoraci c spine. Place your client in a side-lying position on his
left side with his left arm behi nd hi m, as shown in Figure 10.13. This posi-
ti on chal l enges the existing si debendi ng and rotati onal pattern. Place
your f i ngers (Figure 10. 14) , el bow (Figure 10. 15, page 152) , or knuckles
in the right spinal groove al ong the convexity of the curvature. Sink into
the spinal groove, wait f or the tissues to soften, and then push in a lateral
direction away f rom the spine. Your effort shoul d be partly directed toward
f reei ng the tissue f rom bei ng packed in t oo cl ose to the spinal groove. If
you start at the bot t om of the convexity, push laterally as you move supe-
riorly. If you start at the t op of the convexity, push laterally as you move
inferiorly. Be sure to put some extra effort i nto the apex of the curve.
The n ask your cl i ent to rol l over o nt o his ot her si de. But do n' t ask
hi m to lay with his arm behi nd his back. Place your el bow (Figure 10. 16),
1 5 0
ODDS AND ENDS
Figure 10.13
Figure 10.14
151
Figure 10.15
fingers, or knuckl es (Figure 10. 17) on the lateral borders of the erectors
al ong the concavi ty of the curvature. Sink i nto the tissue as if you were
trying to get under the erectors, wait f or the softening, and then push in
a medi al di recti on toward the spi ne. Si nce these tissues are pul l ed wide
and away f rom the spine, your effort is di rected at easing them toward the
spi ne.
The techni que f or treating the l umbar curvature is exactly the same.
The onl y di f f erence is how you posi ti on your client' s legs to chal l enge his
right si debendi ng, left rotational pattern. Use the side-lying position again
and instruct your client to lay on his right side with his right knee slightly
bent. In order to chal l enge the curvature a bit mor e, ask hi m to place his
left l eg in f ront of his body and be nd his knee to 90 degrees as shown in
Figure 10.18, page 154. Work in the left spinal groove al ong the length of
the convexi ty of the curvature. Agai n, apply pressure laterally, as if you
were trying to release the tissues away f rom the spinal groove and put a
little mo r e ef f ort i nto the apex of the curve (Figure 10. 19) . Turn your
cl i ent over on his left si de, but this ti me make sure he keeps his knees
152
ODDS AND ENDS
Figure 10.17
153
Figure 10.16
Figure 10.19
154
ODDS AND ENDS
Figure 10.20
together and slightly bent . Appl y pressure to the lateral borders of the
errectors toward the spi ne al ong the l ength of the concavity of the curve
(Figure 10. 20) .
Experi ment with this techni que, because on occasi on i t may pr oduc e
surprising results. Someti mes you will see an actual reduct i on or l ength-
eni ng of the curvature. Many times you will see a general i mpr ovement
i n range of mot i on t hroughout the entire spi ne, but someti mes you will
see no obvious change at all. Always try to see the whol e person with who m
you are worki ng and track the effects of your l ocal mani pul ati ons on the
whol e, maki ng sure your cl i ent can adapt to your i nterventi ons.
Remember that this bo o k is j ust an i ntroducti on to the spine and I have
left out some discussion of the o dd things spines do. For exampl e, the cer-
vical vertebrae have a bad habit of side slipping in some clients. Al so, many
peopl e' s spines have vertebrae that have sl i pped j ust a little bit t oo poste-
rior. They are not full bl own exampl es of what is cal l ed a retrolisthesis,
but they are j ust posteri or enough to cause some loss of mot i on t hrough
the enti re spi ne. I have also di scovered that the facets can be f i xed i n
155
planes ot her than the ones presented i n this bo o k. Unfortunately, delin-
eating the tests and techni ques f or addressing these fixations woul d make
this bo o k unnecessarily compl i cated. As you probably suspected, not every-
body is in full agreement that the spi ne works in the ways this bo o k de-
scribes. This is no surprise, but if you use the i nf ormati on and techni ques
presented here, they will serve you well. Above all else, don' t f orget to do
everythi ng you can to i mprove your understandi ng, your technical skills,
and your ability to see and feel your way i nto the si mpl e compl exi t y of
what we humans truly are in relation to all of this to whi ch we are neither
identical nor separate.
Go o d l uck! It has been a pleasure writing this b o o k f or you.
Note
1. Kendal l , Fl orence Peterson and McCreary, Elizabeth Kendall. Muscles:
Testing and Function. Thi rd edi ti on, Bal ti more: (Williams and Wi l ki ns) ,
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156
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160
INDEX
A
AA (atlas on atlas) restrictions, 61, 63
Adaptability, 1 33- 1 35
Adductors, 139
Anterior nutation, 72
Anterior superior iliac spine (ASIS),
1 03- 1 06, 108, 1 1 0
Articular pillars/processes, 38
Asher j i m, 149
Atlantocciptal j uncti on, 148
Atlas, 61, 63. See also AA restrictions; OA
restrictions
B
Back. See also Spine
"goes out," 14, 1 6- 1 7
pain vs. problems, 1 6- 1 7
releasing musculature of, 1 36- 1 37
Backward bending
cervical spine and, 46, 5 1 - 5 2, 59
lumbar and thoracic spine and, 17,
30- 31
OA restrictions and, 65 - 69
sacrum and, 7475
Bilateral fixations
cervical, 27, 45 - 46
lumbar and thoracic, 31, 33
sacral, 76- 77
C
C2- C7
finding, 8, 38
Type II biomechanics of, 52
Cervical spine. See also Neck
arrangement of facets in, 24, 46- 47
backward bending and, 46, 5 1 - 5 2, 59
bilateral fixations in, 45 - 46
finding rotated vertebrae in, 38- 39
forward bending and, 5 1 - 5 2
indirect techniques for, 37- 45
joint-challenging technique for,
45 - 5 0
locating vertebrae, 37- 38
motion of, 4, 36
motion testing, 5 1 - 60
sidebending and, 35- 36, 56
vertebral arteries and, 46
Cervicothoracic j uncti on, 148
Corrective approach, 1 3 1 - 1 3 2
Costochondral j uncti on, 114, 142
Costotransverse groove, 1 1 6- 1 1 7
Counternutation, 72
Curvature, 1 42- 1 5 5
as clues, 145
"ideal body," 1 42- 1 45
Type I, 148, 1 49- 1 5 5
D
Dance of the tissues, 43- 44
Demifacets, 114, 1 1 5
Dial-a-Neck technique, 4 1 - 4 5
Down-slip, 99, 1 04- 1 05 , 1 08- 1 09
F
Facet restrictions. See also Techniques
backward bending and, 17
bilateral fi xati ons, 27, 31, 33, 45 - 46
discovery of, 1 3 - 1 4
forward bending and, 17
motion restrictions vs., 52
161
sidebending and, 2- 3
test for, in cervical spine, 5 1 - 60
test for, in l umbar and thoracic
spine, 27- 31
Flare, 99, 1 03- 1 04, 106, 108
Flury, Hans, 97
Forward bending
cervical spine and, 5 1 - 5 2
l umbar and thoracic spine and, 17,
30- 31
OA restrictions and, 65 - 69
sacrum and, 72, 74- 75
G
Gait patterns, 97
H
Hamstrings, 97, 138
Holistic approach, 1 3 1 - 1 3 2
I
"Ideal body," 1 42- 1 45
ILA. See Inferior lateral angle
Iliolumbar ligament, 96
Iliosacral dysfunction, 71, 95. See also
Pelvis
f l are, 99, 1 03- 1 04, 106, 108
shear, 99, 1 04- 1 05 , 1 0 8 - 1 1 0
techniques for, 1 0 6- 1 1 2
testing and palpating for, 9 9 - 1 0 6
torsion, 99, 1 05 - 1 06, 1 1 0 - 1 1 1
Iliosacral ligament, 95
Indirect techniques
for cervical spine, 37- 45
drawback of, 11, 25
for l umbar and thoracic spine, 8- 1 1
nature of, 9
sacral, 75 - 76
Inferior lateral angle (ILA), 85- 89, 139
In-flare, 99, 1 03- 1 04, 108
Innominates, 84, 99
Interspinous muscles, 140
K
Kendall, Florence, 143
Korr, I.M., 1 5 - 1 6
Kyphosis, 147
L
L4, finding, 8
Levator scapulae, 142
Ligamentous structures, 95 - 96, 136
Lordosis, 83, 98, 147
Lumbar spine
arrangement of facets in, 24
psoas and, 1 39
rotation and, 4, 7
shotgun technique and, 21, 23
test for finding facet restrictions in,
27- 31
Type I fixations in, 34
Lumbosacral j unction, 148
M
McCreary, Elizabeth, 143
Motion restrictions
cervical spine and, 5 6- 5 9
facet restrictions vs., 52
OA restrictions and, 65, 69
Myofasciae, 135, 136, 139
N
Neck. See also Cervical spine
AA (atlas on atlas) restrictions, 61, 63
emotions and, 35
imbalances and, 35 - 36
OA (occiput on atlas) restrictions,
63, 65 - 69
ri bs and, 1 1 6
sidebending and, 46
suboccipital muscles and, 1 40- 1 42
Neutral position, 4
"Normal," definition of, 1 46- 1 47
Nutation, 72
Nystagmus, 46
162
INDEX
O
OA (occiput on atlas) restrictions, 63,
65- 69
Obliquus capitus inferior, 140, 142
Obliquus capitus superior, 141
Occiput, 63, 1 40- 1 42. See also OA
restrictions
Organisms, 130
Organs, 129
Out-flare, 99, 1 03- 1 04, 106, 108
P
Pelvis, 95 - 98. See also Iliosacral
dysfunction
Piriformis, 96, 138
Posterior nutation, 72
Posterior superior iliac spine (PSIS),
1 00- 1 02, 104
Preparation techniques, 134, 1 35 - 1 42
Pre-reflection, 43- 45
Psoas, 96, 139
Q
Quadratus l umborum, 139
Quadriceps, 97
R
Rectus capitus posterior major, 141
Rectus capitus posterior minor, 141
Retrolisthesis, 155
Rhomboids, 142
Ribs, 1 1 3 - 1 27
articulating with spine, 1 1 3 - 1 1 4
dysfunctional thoracic vertebrae and,
1 1 5 - 1 1 6, 121
11th and 12th, 123
f i ndi ng f i xed, 1 1 6- 1 21
f i r st , 1 20- 1 21 , 127
f l oat i ng, 115
influence of, 1 1 3 - 1 1 6
motion-testing, 1 1 8 - 1 1 9
preparation for, 142
subluxation of, 1 1 7 - 1 1 8
techniques for, 1 21 - 1 27
tender points and, 1 1 9 - 1 20
torsion of, 1 1 7 - 1 1 8 , 123
Rolf, Ida P., 134, 136, 143
Rotoscoliosis, 34, 83
Rumpelstiltskin effect, 88- 90
S
Sacral base, 72
Sacral sulcus, 72
Sacroiliac dysfunction, 71. See also
Sacrum
palpating for, 72, 74- 75
shear, 83- 93
techniques for, 75- 77, 90- 93
torsion, 74, 80- 83
Sacroiliac j oi nt, 71, 95, 139. See also
Pelvis; Sacrum
Sacroiliac ligament, 95
Sacrospinous ligament, 96
Sacrotuberous ligament, 96
Sacrum, 71 - 75 . See also Sacroiliac
dysfunction
Scapula, pain at edge of, 119
Sciatic pain, 138
Scoliosis, 1 48- 1 49
Serratus posterior superior, 142
Shear
pelvic, 99, 1 04- 1 05 , 1 0 8 - 1 1 0
sacral, 83- 88
Shift, 96- 98
Shotgun techniques
cervical, 45 - 5 0
l umbar and thoracic, 1 8- 25
preparation, 1 36- 1 37, 140
Sidebending
cervical spine and, 3536, 56
lumbar and thoracic spine and, 2- 4
sacrum and, 74, 80- 82
Sitting flexion test, 1 0 1 - 1 0 2
Skepticism, 43- 44
Spinal groove, 1 1 6
1 63
Spine. See also Cervical spine; Curvature;
Lumbar spine; Thoracic spine
classification of motion of, 4
explanations for compromise of, 13
"ideal," 15, 16, 1 43- 1 45
importance of treating, 1- 2
landmarks, 7- 8
neutral position of, 4
ribs articulating with, 1 1 3 - 1 1 4
segmentation and, 1 5 - 1 6
Spring test, 1 1 8 - 1 1 9
Standing flexion test, 99- 1 02
Sternochondral j uncti on, 114, 142
Stork test, 102
Suboccipital muscles, 1 40- 1 42
Sultan, Jan, 41, 97, 115, 133
Support Principle, 134
Swayback, 98
T
Tl
finding, 8
first rib articulating with, 1 20- 1 21
T8, finding, 8
Techniques
for AA restrictions, 63
cervical, indirect, 37- 45
cervical, joint-challenging, 45 - 5 0
Dial-a-Neck, 4 1 - 4 5
iliosacral, 1 0 6- 1 1 2
lumbar and thoracic, direct, 31, 33
lumbar and thoracic, indirect, 8- 1 1 ,
25
lumbar and thoracic, shotgun
approach, 1 8- 25
for OA restrictions, 65- 69
preparation, 134, 1 35 - 1 42
rib, 1 21 - 1 27
sacroiliac, 75- 77, 90- 93
for Type I curvatures, 1 49- 1 5 5
Thoracic spine
arrangement of facets in, 23- 24
rotation and, 4, 7
shotgun technique and, 21
test for finding facet restrictions in,
27- 31
Type I dysfunction in, 34
Type II dysfunction in, 114, 115, 121
Thoracol umbar j unction, 148
Tilt, 96- 99
Torsion
pelvic, 99, 1 05 - 1 06, 1 1 0 - 1 1 1
rib, 1 1 7 - 1 1 8 , 123
sacral, 74, 80- 83
Translation Test, 5 1 - 60
Tranverse processes, 5, 7, 38
Treatment strategy, creating, 132, 133
Type I dysfunctions, 34, 148, 1 49- 1 5 5
Type II dysfunctions, 17, 19, 27, 31, 114,
1 1 5 , 1 21
Type I motion, 4, 63, 74
Type II motion, 4, 36
U
Unified relationships, 1 29- 1 30
Unilateral sacral extension, 86
Unilateral sacral flexion, 86
Unwinding techniques. See Indirect
techniques
Up-slip, 99, 1 04- 1 05 , 1 08- 1 09
V
Vertebrae. See also Spine
derotating, 8- 1 1
designating rotation of, 7
landmarks, 7- 8
palpating, 2- 5, 7
sidebending and, 2- 4
tranverse process and, 5, 7
Type II motion and, 27
W
Walking, 81 - 82, 99
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