http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

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

1 of 6

21/08/07 22:00

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

2 of 6

21/08/07 22:00

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

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

Myofasci al-Arti cul ar Com ponents

3 of 6

21/08/07 22:00

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

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

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

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

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

4 of 6

21/08/07 22:00

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

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

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

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

5 of 6

21/08/07 22:00

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

6 of 6

21/08/07 22:00

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

1 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

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

2 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

3 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

P.11

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

P.12

4 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

P.13

5 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

P.14

6 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

P.15

7 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

P.16

8 of 9

21/08/07 22:01

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

9 of 9

21/08/07 22:01

3 .. 3 . T he y v ar y f ro m on e t yp e o f p at ie n t to an ot h er . The de gr e e of f or war d. The de gr e e of ba ckwar d b en d in g is no t ed . The pa tie nt is ins t ru cte d t o b en d t he h e ad a n d n ec k for war d t o the f un ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g. a nd e n do mo rph i c pa ti e nt s (br ev i l i ne a r) a t t he lo we r r an g e of mo ti o n ex p ec ta t io n. N or mal fo rw ar d b en d in g o f the cer vic al spi n e is 45 to 9 0 d eg ree s. The ph ysici an stan d s at t he si de of th e pa t ie nt. Th e s ta t i c e x am in a ti on wi l l gi ve c l ue s o f m ot io n p at t er ns to e x pe ct on i n te rs e gm en t al m o ti on te st i ng t o b e pe rfo rm e d la t er .lww.1) o r t he sp in ou s p ro ces se s (Figs. st rai n o r sp rai n. d eg en e ra ti v e jo i nt d i se as e . Figur e 3. 1 of 18 21/08/07 22:01 .1 . The pa tie nt is ins t ru cte d t o b en d t he h e ad a n d n ec k b ac kwa rd as fa r p os sib le wi thin the p hy sio lo g ic a n d p ai n -fre e ran g e of motion (Fig. 3 Spinal Region al Range o f Motion Re g io na l m ot i on t e st in g e va l ua te s p at i en ts ' a bi l it y t o mo v e th rou gh th e c ar di n al a x es o f m ot i on a n d re f le ct s t he i r ab i l i ty to m o ve w i th p a in . mu s c l e t en s i o n.com/pt/re/9780781763714/bookContent.4). Ste p 3.1 8 Cervical Spin e: Fo rward Bend ing and Backward Ben ding (Flexion and Ext ensio n). T he r a ng es th at ar e a c c ep t ed a s n or m al d e pe nd up on th e p at ie n t' s s om at o ty pe .b en di n g fle xi on is n oted . 3. h en ce th e t er m ran ge s . 4.. 3 . The ph ysici an pa lp a tes t he C7 -T1 spi n ou s p ro ces s inter spa ce (Fig. Nor mal b a ckwa rd b en d in g o f the cer vic al spi n e is 45 to 9 0 d eg ree s. 6. The pa tie nt is sea t ed . Active 1. 7. Me s om or p hi c p at ie n ts s h ou ld be m i dr an g e. 3 . Ste p 3.5). P .2 .3) . 2. e c to mo rph i c (l o ng l i ne ar ) p at i en ts at t h e hi g h ra n ge . 5. 2 a nd 3. an d s o on . Figur e 3.http://thepointeedition. i n fl am m at io n .

5 .http://thepointeedition.. Ste p 4.. Ste p 3.4 . ac tive ba ckw ar d be nd ing .1 9 Cervical Spin e: Fo rward Bend ing and Backward Ben ding (Flexion and Ext ensio n). Ste p 6.3 .com/pt/re/9780781763714/bookContent. Figur e 3. Figur e 3. ac tive forwa rd be nd ing . Figur e 3. Passive 2 of 18 21/08/07 22:01 . P .lww.

The ph ysici an pa lp a tes t he C7 -T1 spi n ou s p ro ces s inter spa ce (Fig.7 . Ste p 3. 4. 6.lww. 1.6) o r t he sp in ou s p ro ces se s (Figs. 3 . 3 . Figur e 3. No rm al flex ion o f t he ce rv ica l spi ne is 4 5 t o 9 0 de g re es . 5. Nor mal e xtens ion o f the cer vic al sp in e is 4 5 to 9 0 d eg re e s.8) .6 .http://thepointeedition... The ph ysici an then e xte nd s t he p a tien t 's h ea d a nd ne ck wh il e mon itori n g C7 an d T1 a nd stop s whe n motion is d etec t ed a t T1 (Fig. The pa tie nt is sea t ed . 7 a nd 3. 2. The ph ysici an be nd s t he pa tie nt's he ad an d n ec k for war d whi le mon itori n g C7 an d T1 a nd stop s whe n motion is d etec t ed a t T1 (Fig. Figur e 3.8 .com/pt/re/9780781763714/bookContent. 3. Figur e 3. The de gr e e of e xte ns io n is n oted . 3 of 18 21/08/07 22:01 . Ste p 3.10 ). 3 . Ste p 3. The de gr e e of flex ion is n ote d. 7. 3 . The ph ysici an stan d s at t he si de of th e pa t ie nt.9).

S tep 4 . 13 . The pa tie nt is ins t ru cte d t o sid e. 4. The de gr e e of bo th a ctive a n d pa ssi ve si de b en d in g is no t ed . 6. Nor mal side b e nd in g in t he ce rv ica l spi ne is 3 0 t o 4 5 de g re es . Thi s is rep ea t ed to the le ft (Fig. ac t iv e sid e b en di n g left . 3..http://thepointeedition. 11 . S tep 3 . Act ive and Passive 1. Figure 3 . 3. The ph ysici an pa lp a tes t he tran sve rs e p ro ces se s o f C7 an d T1 (Fig. Figure 3 .2 0 Cervical Spin e: Side Bending .com/pt/re/9780781763714/bookContent.12) . The ph ysici an stan d s at t he si de of th e pa t ie nt. 2. 5.b en d t he h e ad a nd ne ck to th e ri g ht to t he func t io na l a nd p ai n -fre e lim itatio n of motion (Fig.15) .lww.14 ). 4 of 18 21/08/07 22:01 . 3 . P .1 1) .. 3. ac t iv e sid e b en di n g rig h t. The pa tie nt is sea t ed . 12 . 3 . Th is is rep e ated t o t he le ft (Fig. S tep 3 .1 3) . Figure 3 . The ph ysici an sid e -b en d s the p atien t's h ea d a nd ne ck to th e rig h t wh ile mo ni torin g C7 a nd T1 a nd stop s whe n motion is d ete cted at T1 (Fig. 3 .

14 . 5. 15 . 16 .. Active and Passive 1. 4. The ph ysici an pa lp a tes t he tran sve rs e p ro ces se s o f C7 an d T1 (Fig.17 ). pa ssi ve si de b en d in g left. S tep 3 . Figure 3 . P . S tep 5 .http://thepointeedition.18) . The pa tie nt is sea t ed .1 6) .com/pt/re/9780781763714/bookContent. Figure 3 .lww. 3. The ph ysici an stan d s at t he si de of th e pa t ie nt. 2.. Th is is rep e ated t o t he le ft (Fig. The pa tie nt is ins t ru cte d t o rotate the he ad to t he ri gh t to t he f un ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g. 3 . 3. The ph ysici an ro tat es t he pa tie nt's he ad to Figure 3 . S tep 5 . 3 . pa ssi ve si de b en d in g rig ht. 5 of 18 21/08/07 22:01 .2 1 Cervical Spin e: Ro tatio n.

ac t iv e rotation le ft.. 18 . 3 . Figure 3 . 17 . No rm a l rota tion in th e ce rvi ca l spi n e is 70 to 9 0 d eg ree s..20) . S tep 4 .http://thepointeedition. 19 .com/pt/re/9780781763714/bookContent. ac t iv e rotation righ t. Figure 3 . 6 of 18 21/08/07 22:01 . 3 .lww. The de gr e e of bo th a ctive a n d pa ssi ve rota tion is n o ted. 6. pa ssi ve ro tat io n rig h t. S tep 4 . Figure 3 . t he ri gh t whi le mon itori n g C7 an d T1 a nd stop s whe n motion is d etec t ed a t T1 (Fig. S tep 5 .19 ). Th is is rep e ated t o t he le ft (Fig.

Figure 3 . This is rep e ated to th e op p os ite sid e (Figs. 3 . Passive 1. P .http://thepointeedition.21) . sid e b en d in g rig ht. Thi s is d on e b y cr e atin g a vec t or with th e forea rm t ha t is d ir ec t ly in lin e with the ve rte br al bo dy o f T4 (Fi g.24 ). 2. 3 . 7 of 18 21/08/07 22:01 . 20 . St ep 3 . 3.. 5. 23 a nd 3 . pa ssi ve ro tat io n left ..com/pt/re/9780781763714/bookContent. S tep 5 .lww.2 2 Tho racic Spin e: T1 to T 4 Sid e Ben ding. The ph ysici an stan d s b eh ind th e pa t ie nt.2 2. St ep 4 . 3 . The ph ysici an ' s le f t ind e x fin ge r o r thu mb may pa lp a te th e t ra n sver se pr o ce sse s of T4 a nd T5 o r t he inte rs pa ce be t we en t he m to mon ito r mo t io n.2 1. Figur e 3. The de gr e e of pa ssive Figur e 3. A g e ntle sp ri n gi ng forc e is d ir ec t ed to wa rd the ver t eb ra l b od y o f T4 u ntil the p hy sic ia n fee ls motion o f T4 o n T5. 22 ). The pa tie nt is sea t ed . 4. The we bb ing b e twee n t he ph ysici an ' s ri g ht ind e x fin ge r a nd th um b is p la ce d o n t he p atien t's rig h t sh o ul de r clo ses t t o mi d li ne at th e lev e l of T1 (Fig.

The pa tie nt is sea t ed . Figure 3 .lww. 3.25.25 ).. Figur e 3. sid e b en d in g o n ea ch sid e is n oted .2 3 Tho racic Spin e: T5 to T 8 Sid e Ben ding. St ep 4 . 2. The ph ysici an stan d s b eh ind th e pa t ie nt. The we bb ing b e twee n t he ph ysici an ' s in d ex f in g er a n d thu mb is p la ced o n the pa tie nt's rig h t sh o ul de r h al f wa y b etwee n t he b a se o f the p atien t's n ec k a nd the a cr o mi on pr oc e ss (Fig. P . Figur e 3. St ep 4 .2 3.. Step 3.2 4. sid e b en d in g left.com/pt/re/9780781763714/bookContent. 3 . N or mal sid e b en d in g f or T1 to T4 is 5 t o 25 de gr e es .http://thepointeedition. The ph ysici an ' s le f t h an d p al p ates the t ra n sver se pr o ce sse s of T8 a nd T9 o r t he inte rs pa ce be t we en t he m to mon ito r mo t io n. 8 of 18 21/08/07 22:01 . Passive 1.

4.2 4 Tho racic Spin e: T9 to T 12 Side Bending .com/pt/re/9780781763714/bookContent. side b e nd in g left . Step 4.28. Step 4. Passive 9 of 18 21/08/07 22:01 . The de gr e e of pa ssive sid e b en d in g o n ea ch sid e is n oted .lww. 26 ). side b e nd in g rig h t.http://thepointeedition. 3 .. P .27 a nd 3.28 ). Figure 3 . 5. Figure 3 .27. A g e ntle sp ri n gi ng forc e is d ir ec t ed to wa rd the ver t eb ra l b od y o f T8 u ntil the p hy sic ia n fee ls motion o f T8 o n T9. Step 4. 3 . Thi s is d on e b y cr e atin g a vec t or with th e forea rm t ha t is d ir ec t ly in lin e with the ve rte br al bo dy o f T8 (Fi g.26. This is rep e ated to th e o pp o si te si de (Figs . Figure 3 . N or mal sid e b en d in g f or T5 to T8 is 10 to 3 0 d eg ree s..

3 . The ph ysici an ' s le f t h an d may pa lp a te th e t ra n sver se pr o ce sse s of T12 an d L 1 or the inte rs pa ce be t we en t he m to mon ito r mo t io n. 10 of 18 21/08/07 22:01 .29) . St ep 4 . Thi s is d on e b y cr e atin g a ve ctor wi th the f or ea rm t ha t is d ir ec t ly in lin e with the ve rte br al bo dy o f T12 (Fig. The ph ysici an stan d s b eh ind th e pa t ie nt.http://thepointeedition. Figur e 3.30) . Thi s is rep ea t ed to the o pp o si te si de (Figs . The de gr e e of pa ssive sid e b en d in g is no t ed o n e ac h sid e .. 2.31 a nd 3. sid e b en d in g rig ht.2 9. St ep 3 . Figur e 3. 3 . The pa tie nt is sea t ed .32 ).. Figur e 3. 3 .3 1. A g e ntle sp ri n gi ng forc e is d ir ec t ed to wa rd the ver t eb ra l b od y o f T12 u ntil the p hy sic ia n fee ls motion o f T12 on L 1 .3 0. 5.com/pt/re/9780781763714/bookContent. The sp ac e (we b be d ski n) b etwee n t he p h ysic ian 's ind e x fin ge r a nd th um b is p la ce d o n t he p atien t's rig h t sh o ul de r a t t he a cro mi o cl av icu la r reg ion (Fig.lww. 3. 4. 1. St ep 4 . No rma l sid e b en d in g f or T9 to T12 is 2 0 t o 40 de gr e es .

Step 2. 3 . Step 3. a ctive ro tat io n ri g ht.35. Figure 3 . Passive 11 of 18 21/08/07 22:01 . 3. wh ic h a re us ed to mon itor rotation (Fig.2 6 Tho racic Spin e: T9 to T 12 Ro tatio n. Figure 3 .http://thepointeedition. Th is is rep e ated t o t he le ft (Fig. P .34.lww. Figure 3 .35) . Active 1. 3 . Step 3.2 5 Tho racic Spin e: T9 to T 12 Ro tatio n. The pa tie nt is sea t ed with the ar ms cr os sed so t ha t the el bo ws ma ke a V fo rm ation ..33 ). P . a ctive ro tat io n left. 3 . 2.com/pt/re/9780781763714/bookContent. The ph ysici an stan d s at t he si de of th e pa t ie nt a nd pa lp a tes t he p atien t's tra n sver se p ro ces se s o f T12 a n d L 1.34 ). The pa tie nt is ins t ru cte d t o rotate the up pe r b od y (tru nk ) t o the rig h t to the f un ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g.33..

P .37 ). 2. The ph ysici an stan d s at t he si de of th e pa t ie nt a nd pa lp a tes t he p atien t's tra n sver se p ro ces se s o f T12 a n d L 1. wh ic h a re us ed to mon itor rotation (Fig. Step 3. The de gr e e of ac tive a nd pa ssive ro tatio n is n ote d. the ph ysici an ' s rig h t ha n d is pl ac e d on t he pa tie nt's el bo ws or o pp o si ng le ft sh ou lde r. p a ssiv e rota tion ri g ht.lww.. Figure 3 ..2 7 Lum bar Spine: Forw ard Bendin g and Backward Bending (F lexio n and Ext ensio n).37. Figure 3 . 3 .http://thepointeedition. 3. The ph ysici an ro tat es t he pa tie nt to wa rd the rig h t wh ile mo ni torin g motion a t T12 -L1 (Fig. 3 . p a ssiv e rota tion le f t. 4. Th is re pe ate d to t he op po site sid e (Fig.com/pt/re/9780781763714/bookContent. The pa tie nt is sea t ed with the ar ms cr os sed so t ha t the el bo ws ma ke a V fo rm ation .36 ). 3 . Active 12 of 18 21/08/07 22:01 .36. 1.33 ). Step 3. To t es t p as si ve ri g ht rota tion . N o rm al ro tat io n f or T9 to T12 is 7 0 to 9 0 d eg ree s.

3. The pa tie nt is ins t ru cte d to be nd forw a rd a nd attempt to tou ch the toe s with ou t b en d in g t he kn ee s t o the fun ction a l an d p ai n -fre e lim itatio n of mo tio n (Fi g. Th e pa t ie nt is ins t ru cte d to be nd ba ckwar d t o the f un ction a l an d p ai n -fre e lim itatio n of motion wh il e t he p h ysic ian su pp or t s the p atien t's u pp e r bo d y (Fi g 3. Figure 3 . S tep 2 . 40 . 3 . The de gr e e of ac tive ba ckw ar d b en d in g is n oted .4 0) .com/pt/re/9780781763714/bookContent. a ctive fo rw ar d b en d in g. 13 of 18 21/08/07 22:01 . 3. a ctive b a ckwa rd b en d in g. 39 . S tep 5 . No rm al flex ion fo r the lum b ar spi n e is 70 to 9 0 d eg re e s. 6.wi d th a p ar t. 4. Figure 3 . 1. 2. The ph ysici an stan d s to the sid e o f the p atien t so as to view th e pa t ie nt in a sag ittal pl an e (Fig.3 8) . Figure 3 .lww. The pa tie nt stan ds in a n e utra l p os ition wi th feet a sho u ld er -wi dth a pa rt..http://thepointeedition.. S tep 3 . 39 ). The de gr e e of ac tive forwa rd be nd ing is n ote d. The pa tie nt st an ds in a ne utral p o si tio n with fee t a sh ou ld e r. 38 . N or mal e xtens ion fo r the lum b ar spi n e is 30 to 4 5 d eg re e s. 5. Motion is the n tes t ed fo r ba ckw ar d b en d in g in the lum b ar re gi on .

2. 41 .43 ).http://thepointeedition. The de gr e e of ac tive si d e be n di ng is n ote d. S tep 2 . 3 . 3.42) . Figure 3 . The pa tie nt is ins t ru cte d to re ac h d ow n with the ri gh t h an d tow a rd th e kn e e to t he func t io na l a nd pa in -free li mi t atio n o f motion (Fig.. S tep 3 .com/pt/re/9780781763714/bookContent. The ph ysici an stan d s be h in d t he p a tien t so a s to vi ew the p atie n t in a co ron al p la n e (Fi g. 3 .lww. Active 1. a ctive side b e nd in g rig h t. N o rm al si de be nd ing in the lum b ar sp in e is 25 to 3 0 d eg ree s. 14 of 18 21/08/07 22:01 . The pa tie nt st an ds in a ne utral p o si tio n with fee t a sh ou ld e r.wi d th a p ar t. 41 ). 3.. Thi s is rep ea t ed to t he op po site sid e (Fig.2 8 Lum bar Spine: Side Bend ing. 42 . Figure 3 . 4. P .

Th is is rep ea t ed o n the op po site sid e (Fig. N or mal side b e nd in g in t he lum b ar sp in e is 25 to 3 0 d eg ree s. 3 .4 4) .46 ). P .44 . 4. The ph ysici an ' s ey e s sho u ld b e lev e l wi t h the lum b ar sp in e (Fig.lww. 2.http://thepointeedition. 3 . Passive. a ctive side b e nd in g left . The pa tie nt a t temp t s to ma in t ai n sym metri c wei g ht b e ar in g o n b oth leg s a nd then qu ic kly flex es the rig ht kn ee . 43 .. S tep 3 .2 9 Lum bar Spine: Side Bend ing. w ith Active Hip Drop Test 1. The pa tie nt st an ds in a ne utral p os ition wi th feet a sh o ul de r-w id t h a pa rt. The de gr e e of le ft lu mb a r si d e be n di ng is n oted . 3. Ste p 2.45 ). The ph ysici an stan d s be h in d t he p atien t so as to view th e pa t ie nt in a cor o na l p la ne . Figure 3 .com/pt/re/9780781763714/bookContent. h en ce ca us ing th e pe lvi s t o com pe n sa te wi th a la t er al t ra n sl ation to the le ft (Fig. cau sin g a rig h t sa cra l b as e d ec lin ation . Figure 3 .. 15 of 18 21/08/07 22:01 . 3.

.. P . p as si ve si d e be n di ng ri gh t with left sac ra l b as e u nl ev e li ng . p as si ve si d e be n di ng le ft with rig ht sa cr a l ba se u nl ev e li ng .3 0 Norm al Spinal Ra nge s of Motion for Act i ve a nd Pa s sive Test i ng Gui des to Ev a luat i on of Pe r ma nent Impairm e nt (A MA) (1 ) Angus Ca thi e.46 .http://thepointeedition.com/pt/re/9780781763714/bookContent. D. (2 ) Rev ise d PC O M (3 ) NORMA L DEGREES O F MOTION– CER VICAL SP INE 16 of 18 21/08/07 22:01 .45 . Ste p 3. O. Figure 3 . Figure 3 .lww. Ste p 3.

9 0 3 0.4 0 T4 -8 T8-L 1 T1. Re pr in t ed with p e rm is sio n f ro m Coc ch iar el la L.9 0 NORMAL DE GREES OF MOTION–LUM BAR SP INE FLEXI ON EXTENSION SIDE B EN DING R/L ROTATION R/L Fl ex ion = forw a rd b e nd in g .3 0 17 of 18 21/08/07 22:01 . R/L . 6 0+ 25 25 25 7 0..4 T5 -8 T9.9 0 No rm a l degre es of m otion– Thora cic S pine T1. 2 0 01 .lww. FLEXI ON EXTENSION SIDE B EN DING R/L ROTATION R/L 50 60 45 90 45 3 0. ri g ht a n d le f t. 1.4 5 80 90 7 0. G ui de s to the E va lu a tion of Pe rm an e nt Impa ir men t.4 5 2 5. Ext en si o n = b ac kw a rd b e nd in g . Amer ic a n Me d ic al Asso cia tio n..3 FLEXI ON EXTENSION SIDE B EN DING R/L ROTATION R/L 45 0 45 35 45 5 -2 5 1 0 -3 0 2 0.9 0 3 0. Ne w Yo rk. An de rsson G (e d s) .http://thepointeedition. 5th e d.1 2 30 90 7 0.4 0 4 5.9 0 4 5.com/pt/re/9780781763714/bookContent.

. CO: Amer ica n A ca de my of Osteo pa thy. Co lo ra d o Sp rin gs . Fro m Dr. Nich ol a s A.. pu bl ish ed in THE D. 2. Ph il ad e lp hi a Col leg e o f Ost eo pa t hy .http://thepointeedition. 2 00 6 . Ca thie ' s PC O M (OP P) no teb oo k.O . Ph ila de lph ia : Ph il a de lp h ia Co ll eg e o f O steo p athi c Med ici ne ..lww. p . 7 2. 18 of 18 21/08/07 22:01 . 3. 19 7 4.com/pt/re/9780781763714/bookContent. Ju ne 1 9 69 a n d re -pr in t ed in the 19 74 Ye ar b oo k o f the Ame ric an Acad e my o f Oste op ath y. Ca thie A. Osteo pa thic Ma n ip ul a tive Me di cin e Man ua l.

. t he p h y s i c i an m a y at th i s po in t ma ke s l ig h t ph y s i ca l c on t ac t w it h t he a p pr op ria te ar ea of t h e pa l pa ti n g ha n d. ab do m en ). . a bn o rm al ha ir pa tt e rn s.1 ). If u n ab le to d e te rm i ne t h e th e rm al st at u s of th e reg io n i n q ue st i on . M us c le 6. E ry t he ma fr i c t io n rub Observatio n Pr io r t o t ou ch i ng t h e pa t ie nt . a no m al ie s . gr o s s a s ym me t ri es . hy pe rem ia . 2) . 4 . S k i n t op o gr ap h y an d t ex t ur e 4. A t th i s po i nt . an d/ o r an a to mi c v ar i at io n s. t he p rim ar y in te res t i s in ch an g es a s so c i a te d w it h s om at i c dy s fu nc t io n a nd a n y au t on om i c re l at ed ef fe c ts .http://thepointeedition. ne v i .. 4 Osteopathi c Layer-by-Layer Pal pation Examinatio n Seq uence 1. s k i n l es i on s. ex t re mi t ie s.lww. T em p er at u re 3. He a t ra d ia ti o n ma y a l s o b e p al pa t ed i n o th e r ar e as o f t he bo dy (e .. f ol l i c ul a r er u pt io n s) ( F ig .g .g . T en d on 7. C ha ng e s in he at di st rib ut i on ma y b e pa l pa te d p ar a sp in a l l y a s se c on da ry ef f ec ts of m e ta bo l i c p roc es s es . Temperature Te mp e ra tu re i s ev al u at ed by u s in g t he v o la r a sp ec t o f t he w ri s t o r th e d or s al h y po th e na r e mi ne n ce o f t he ha nd . Th e p hy s i c ia n d oe s t hi s b y pl a c i ng th e w ri st s o r h an ds a fe w i nc h es a b ov e t he a rea t o b e t es te d a nd us in g b ot h ha nd s t o e va lu a te t h e pa rav er t eb ra l a re a s bi l at er a l l y a nd s i mu lt a ne ou s l y ( F ig 4 . T h e pa t ie nt sh ou l d be po s i t io ne d c om f or ta b l y s o t ha t t he mo st co mp l et e e xa mi n at io n c an be p e rf or m ed . an d s o o n (a c ut e v er su s ch ro n i c f i br ot i c in f la mm a ti on ). L ig a me nt 8. t ra um a . 1 of 5 21/08/07 22:01 .com/pt/re/9780781763714/bookContent. F as c ia 5. t he ph y s i c i an sh ou d v i s u al i z e t he ar ea to b e e xa m in ed fo r e v i de n ce o f t ra u ma . Obs e rv at i on 2. in fe c ti on . T he p h y s i c i an sh ou l d v i s ua l l y i ns p ec t t he a rea f o r c l u es t h at s o ma ti c d y s f un ct i on m a y be pr es e nt ( e .

1. Th e p re s s u re w i l l p e rm it th e f in ge r p ad s t o g l i de ge nt l y ov e r th e s k i n w it h ou t d ra g (fr i c t io n) .lww. l ef t . T he ph y s i c i an ad ds s l ig h tl y mo re pr es s ur e t o ev a lu at e t he mu s c l e' s c on s i s te nc y a nd de te rmi ne s w he t he r t he re i s r o pi ne s s. it i s i mp o rt an t t o e xp la i n th e n at u re o f t he ex am i na ti o n an d r ec e i v e t he p a ti en t 's a c ce pt a nc e b ef or e c on t in ui n g.2.http://thepointeedition. t hi c k e ni ng . 4. Eval u atio n for ther mal a sym me t ry . Fascia Th e p hy s i c ia n a dd s e no ug h p re s su re to m o ve t h e s k i n wi t h th e h an d t o e va lu a te t h e fa s c i a. P . 3) . Vis u al o b se rv a tion of p a tien t . Th er e fo re . M in i ma l c ha ng e s in pr es s ur e t o ev a lu at e t he di ff e re nt le ve l s of fa s c i a ar e h el p fu l. 4 .. i t i s im p or ta n t to be p rep ar e d me n ta l l y t o a pp l y th e h an d a s co n fi de n tl y a nd p rof es s io na l l y a s po s s i bl e. an d s o on . c a ud ad . G e nt le pa lp a ti on wi th th e p al ma r s ur f ac e o f th e t ip s o f t he f i ng er s w i l l p ro v id e t he ne ce s sa ry pr es s ur e. 2 of 5 21/08/07 22:01 . r e s i st a nc e t o pr es s ur e. T he p h y s i c i an m o ve s t he h a nd v e ry g e nt l y in c e ph al a d. W h en t h e ph y s i c i a n i s to uc h in g t he p a ti en t . Th i s pr es s ur e w i l l ca us e s l i g ht r e dd en i ng o f t he na i l b ed . t he ne xt de gr e e of pa lp a to ry pr es s ur e i s ap p l i ed . Muscle Mu s c l e i s de ep e r ti s su e. Figure 4 . st ri n gi ne s s. Th er e s ho u ld b e n o c ha ng e i n t he c o lo r o f th e p hy s i c ia n 's n a i l be d s.com/pt/re/9780781763714/bookContent. ri g ht . th er e fo re . o i l in e s s . T hi s p re s s u re w i l l c a us e b la nc h in g o f th e p hy s i c ia n 's n a i l be d s (F i g. a nd co un t er c l o c k wi s e di rec ti o ns t o e l i c it m o ti on an d t en s i o n qu a l i ty ba rr i er s o f ea s e an d b in d ( Fi g . 4) . Figure 4 . a n d so on . A a n d B..3 2 S k in to po g ra ph y a nd te xt u re a re ev a lu at e d fo r i nc rea se d o r d ec re a se d h um id i ty . c l oc k wi se . r ou g hn es s . Skin Topog raphy and Textu re A ve ry l i g ht t o uc h w i l l b e us e d.

Ligam ents Li ga m en ts mu st be c o ns id e re d w he n res tr i ct io n o f j oi nt mo ti o n. l i ga m en ts va ry in t y pe a n d ar e m or e o r l es s p al pa b le d e pe nd i ng o n t he i r an a to mi c pl ac e me nt .3 3 ca ud a d. An y f ib ro u s th i c k en in g .com/pt/re/9780781763714/bookContent.3. Obv io u s l y. Eryth ema F riction Ru b Th e f in al st ep i s t o p er f or m t he e ryt he m a fr i ct io n r ub .http://thepointeedition. p a in . i n w hi ch th e p ad s o f th e p hy s i c ia n 's s e co nd an d t hi rd di gi t s ar e p la ce d j us t p ar a sp in a l l y a nd t h en i n t wo to t h re e q ui c k st ro k es d raw n d ow n t he s p in e c ep ha l ad t o P . Bla n ch in g o f t he n a il b e d wi t h mu scl e d ep th pa lp a tion ..4. ch a ng e i n el a st i c i ty . Figure 4 .lww. Fas cia l e va lu a tion for e as e– b in d a symm e try. h y pe rm o bi l i t y (j o in t l ax it y ). Figure 4 . Tendo ns Te nd o ns s h ou ld be t rac ed to t h ei r b on y a tt ac h me nt s a s w el l a s to th ei r c on t in ui t y wi t h mu s c l e.. a nd s o o n a re pr es e nt . a nd s o o n s ho ul d b e n ot ed . P a l l or or r e dd en i ng i s e va l ua te d p er sp in a l se g me nt fo r v as om o to r c ha ng e s th a t ma y b e s ec on d ar y t o 3 of 5 21/08/07 22:01 .

3 4 Thoracic Region Cross-Section 4 of 5 21/08/07 22:01 .5. T h i s i s n ot ty pi c al l y do ne on t h e ex t re mi t ie s.lww.com/pt/re/9780781763714/bookContent. Figure 4 . as t h e pu rpo se of t h i s t e st i s t o i de nt i fy c e nt ra l s pi n al ar ea s o f a ut on o mi c c ha ng e r el a te d t o se g me nt a l dy s fu nc t io n (Fi g.. 4. E ry the ma fric tio n ru b .http://thepointeedition.. dy sf u nc ti o n. P . A to C . 5) .

com/pt/re/9780781763714/bookContent.. Lumbar Reg ion Cross.http://thepointeedition..lww.Section 5 of 5 21/08/07 22:01 .

pel v ic . 5 Intersegmental Motion Testing In ters egm ent al m oti on test i ng is c la s si c al l y d esc r ib ed a s a n e v alu ati on of s pin al ar ti c ul ato r y ( fac et) mo ti on . D ep end i ng on the j oi nt. In s pi nal mo ti on te s ti ng. I n th e t hora c ic or l um bar re gi on .http://thepointeedition.pl ane m ot i on an d th e r ela ti on be twe en si de b end i ng and ro tat i on ( co upl i ng) .. co s ta l . s id e b end i ng and ro tati on c ou pl in g.C2 mo tio n. If t he dys func tio n ex hi bi ts a t y pe 2 c oup l i ng pa tte r n. tra ns la tio nal m ot i on s a nter i or l y. r ot ati on. or l at era l l y. or i n the c as e o f C 1. In th e ce r vi c al s pi ne.2) . th e ex am in ati on i s c omp l et e. th es e c ou pli ng r ela tio ns f oll ow a di ffe r en t se t o f b i ome c ha nic al r ule s f r om tho s e of t he th or ac i c and l um bar re gi on s .. fl ex i on .com/pt/re/9780781763714/bookContent. and neu tra l co m po nen ts m ay be fo und w it h t y pe 1 o r 2 c ou pli ng. po s ter i or l y. or e x tr emi ty . 1 a n d 5. a s t he s egm ent ha s a neu tra l re l at i on w it h t he c oup l in g. 5. the ph y s ic i an at temp ts to di sc ern th e th r ee . e x ten s io n. wh ethe r s pin al . In the c er v ic al s pin e. the ph y s ic i an mu s t t y pi c al l y c ont i nu e th e e x am i nat i on to det erm i ne wh ethe r a fl ex io n o r e x ten s io n c om po nen t i s as s oc i at ed w i th th e co upl ed m oti ons of the dy s fu nc ti on.lww. T he phys i ci an c an det erm i ne the co upli ng s ta tus and wh ethe r t he ar ti cu l ar so m ati c d y sf unct i on is exh i bi tin g a typ e 1 ( op pos i te s id e) or ty pe 2 ( sa m e s i de ) p atte r n ( Fi gs . t her e m ay b e n o c oupl i ng at all . an d t ors i ona l m ove m ent s . th e mo tio ns ev al uat ed m ay i nc l ud e fl ex io n a nd ex te nsi on. i f t he d y sf unc ti on al pat tern is fo und to be ty pe 1. 1 of 59 21/08/07 22:02 . se par atio n o r a ppro x im ati on o f j oin t su r fa c es . I n t hi s c ha pte r it is al s o c ons i de r ed as a t ec hn i qu e t o el i ci t a ny m oti on at a jo i nt ( ar tic ula ti on ) .

i t m ay b e b est to tes t s i de ben din g fi r st .1.. So m e p hys i ci ans pre fer to s ta r t w i th th e f l exi on and ext ens i on por tio n o f th e e x am i nat i on an d th en fol l ow wi th r ota tio n an d/o r s i de ben din g to de ter m i ne th e c oupl i ng co m pon ent s f or d ete r mi nati on of a ty pe 1 o r ty pe 2 dy s fu nc ti on. Mo tio n av ail abi l i ty ca n b e in s ta ntl y as c er tai ned i n w hi c hev er dir ec ti on the 2 of 59 21/08/07 22:02 . Type 1 spinal coupled pattern. Be c aus e o f t he b i om ech anic al pat tern s P. i n the C2 to C 7 re gi on .36 in here nt to s pec i fi c r egio ns.lww. F igure 5.2.http://thepointeedition.. W e p r efe r a m eth od tha t in tro duc es m oti on di re c tl y t o th e j oin t us i ng ph y s ic al c on tact on bo ny l and m ar k s ( e. s uch as m us c le ene r gy te c hni que . Th er e are a numb er of w ays to te s t m oti on av ai l ab i li ty ( qua l it y an d q uan ti ty ) a t a n ar tic ula ti on . it i s alw ays bes t t o t es t the co uple d s egm ents to geth er and tes t t he fl ex i on or ext ens i on c om pon ent s be for e o r af ter th e co upl ed test i ng . An ex am ple of pos i ti v e m oti on tes ti ng is a l umb ar s pr i ng tes t f or f l ex i on and ex ten s i on co m pon ent s o f dy s fu nct i on. T hi s i s als o tr ue wh en p erf orm i ng ost eop athi c m ani pula tiv e t r eat m en t ( OM T) . w hen all th r ee axe s a r e t o b e t r eat ed. W e use th e te r m pos i tiv e w hen re ferr i ng to thi s f orm of m ot i on te s tin g. Th e co upl i ng s ho uld al w ays be ke pt u nif i ed . ce r v ic al art i c ul ar pro c ess es) us i ng a q uic k im pul s e. Fo r ex amp l e.. F igure 5.g . H ow ev er. Type 2 spinal coupled pattern.com/pt/re/9780781763714/bookContent. th e mo tio n m os t eas i ly tes ted ma y va r y.

an d z c om pon ent s in th e thr ee .. Ro tat i on r ig ht = RR . Si deb end i ng l ef t = SL. Shor t-Leve r Me thod. hand pos ition on s keleton. im puls e w as v ect ore d. w e l im i t i ts use . Wh en d ocu m en ti ng th e m otio n p r ef er en c es re v eal ed on i nte r se gme ntal mo tio n te s ti ng. y . the side to which the head is rotated will pas s ively inc r eas e the rotational effect to that side. . the phy s ic i an l oo k s for a c han ge i n re l ati on ( sy m m et r y or as ym m et r y) of s up erf i c ia l a nat om ic la ndm ar ks as th e pa tie nt ac ti v el y m ov es th r oug h a ra nge of m ot i on.pl ane dia gno s is and wi l l be u s ed in the fo l lo w i ng ch apt er s to des c ri be the dys fun c tio n's fr ee m oti on c har act eri s tic s : F le x i on = F . The patient lies prone on the treatment table with the head in neutral (if a fac e hole is pr esent) or r otated to the mor e comfortable side. Step 2.. a nd R ota tio n l eft = R L.com/pt/re/9780781763714/bookContent. Ex te nsi on = E. a nd t her efo r e.37 Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Rotation. We us e th e t erm pre s um pti v e w hen re ferr i ng to thi s f orm of m ot i on tes tin g. Ne utr al = N. i t i s und er st ood th at t he fol l owi ng abb r evi ati ons are ac c ep ted and us ed c ons i st entl y w i th i n t he ost eopa thi c p r ofe s si on to de note th e x . 3 of 59 21/08/07 22:02 . P. An othe r c omm on m eth od i s u s e of v i su al c lu es .g. In thi s me tho d. and the ph y s ic i an ha s a hig h d egre e o f c er ta i nt y t hat the mo ti on pa l pa ted i s oc c urr i ng at thi s l oca ti on . The phy sic ian stands at either side of the table and palpates the L4 transverse proc ess es (lev el of the iliac cres t) with the F igu re 5. sa c r al ba s e unle v el i ng . I n th i s for m of mo tio n te s ti ng the phy s ic i an has a l owe r d egr ee o f c ert ai nt y th at t he des i gna ted jo i nt has mo ti on re duc ti on or as y m me try (d y s fu nct i on ) . ti ght ha m s tr i ng mu s c le s ) oth er t han mo ti on di s tu r ban c e at the j oi nt c an c au s e fa l s e pos i ti v es i n thi s ty pe of test i ng .lww. Remember.http://thepointeedition. 2. Ex am pl es of pr es ump tiv e mo tio n t es ti ng are the st and i ng and se ated fl exi on ( for w ar d be ndi ng) tes ts for sa c r oi l ia c r egio n d y sf unct i on . M any po s tur al fac tors (e . Si debe ndi ng r i gh t = SR . Prone (L4 Exa m ple ) 1.3.

. 5. 3. 5. the segment is rotating r ight mor e fr eely (rotated r ight) (F ig . 4. s keleton.4.5 and 5. 6. Step 3. F igu re 5.6. If the left tr ansverse proc ess moves anteriorly (white arr ow) mor e eas ily and the right transver se proc ess is res istant. Step 2. 5.6). The phy sic ian alternately pres ses on the left and r ight transverse proc ess es of L4 with firm ventrally dir ected impulses to evaluate for eas e (freedom) of left and r ight rotation ( Fig s. the segment is rotating left mor e fr eely (rotated left) (F ig . If the right transverse proc ess moves anteriorly (inward) ( white arr ow) mor e eas ily and the left tr ans ver s e proc ess is res istant. pads of the thumbs (F igs. r otation left. hand pos ition on patient. r otation r ight.com/pt/re/9780781763714/bookContent. 5.8) .lww..http://thepointeedition. s keleton.7) .5. Step 2. The left transverse F igu re 5.4). 4 of 59 21/08/07 22:02 .3 and 5. 5. F igu re 5.

com/pt/re/9780781763714/bookContent.. 7. The phy sic ian per forms thes e steps at each segment of the lumbar spine and doc uments the rotational freedom of mov ement. F igu re 5. Step 4. Tra nsla tional Short-Lev e r Method.38 Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Side B ending.lww.7. Prone (L4 Exa mple) 5 of 59 21/08/07 22:02 . Step 5. P. r otation left. proc ess of L4 in this ex ample may present mor e prominently (pos ter ior ly) on static (layer by lay er) palpation in a rotated left dys func tion.8. F igu re 5.http://thepointeedition. r otation right..

If the thumb translates the segment more eas ily from left to r ight. to evaluate for eas e of left and right s ide bending. left and right. If the thumb translates the segment more eas ily from r ight to left.9 an d 5.11. the segment has its eas e in left s ide bending and is ter med side bent left (F ig s. 3. hand position on s k eleton. 1. The phy sic ian intr oduces an alternating translator y glide. 2.10. 6 of 59 21/08/07 22:02 .10). 4.com/pt/re/9780781763714/bookContent. the segment has its eas e in right side bending F igure 5. F igure 5. The patient lies prone on the treatment table with the head in neutral (if a fac e hole is pr esent) or r otated to the mor e comfortable side.. s ide bending left on s k eleton.9. The phy sic ian's thumbs res t on the pos terolateral aspect of the transverse proc ess es (F ig s.http://thepointeedition. 5.. Step 4.12). 5. Step 2. 5.lww. F igure 5.11 an d 5. hand pos ition on patient. Step 2.

Step 1. If the dys func tional component F igu re 5. 5. lumbar Sphinx position.16). The patient is ins truc ted to extend the thor acolumbar region by elev ating the ches t off the table with the support of the elbows (F ig. 5. 3.com/pt/re/9780781763714/bookContent. The phy sic ian retests the rotational and/or side bending components in this position. F igu re 5.. 2. 5. Step 2.. the dys func tion is extended ( Fig .http://thepointeedition. Exte nsion (Sphinx Position) and Flexion.39 Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Ty pe 2 .lww. 7 of 59 21/08/07 22:02 . P. Pr one 1.15. If the components impr ove.17).16.15) of the prone patient. After determining that the rotational and side bending components ar e coupled in a type 2 patter n (same-s ide pattern of eas e) the phy sic ian's thumbs are plac ed on the pos terolateral aspect of the transverse proc ess es (F ig .

18). Step 4. the dys func tion is flex ed (or neutral). If they ar e more asy mmetric in this position. If the dys func tional components appear mor e symmetr ic in this position.com/pt/re/9780781763714/bookContent. 5. Step 3: extension impr oves asymmetr y.lww..17. perform the mos t comfortable tes t. 6. bec omes more asy mmetric . The phy sic ian mus t perform only one of thes e as long as ther e is a known type 2 coupling pattern. 4.http://thepointeedition.18. the dys func tion is ter med flexed.. it is termed extended ( Fig . The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of F igu re 5. Some pr efer als o to have the patient curl up in a knees-to-c hes t pos ition to promote relative flex ion and retest the dys func tional rotation and side-bending components . 8 of 59 21/08/07 22:02 . 5. flex ion. F igu re 5.

com/pt/re/9780781763714/bookContent.20). The phy sic ian's finger pads of the cephalad hand palpate the spinous proc ess es of L5.41 Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Pa s siv e Fle x ion and Ex tension.. 5.40 P. 4. Step 3. Late ral Re c umbent Pos ition 1. The phy sic ian's caudad hand controls the patient's flex ed lower extr emities. 2. 3. Step 3..http://thepointeedition. 5.20. palpation of L5-S1 inter space. 9 of 59 21/08/07 22:02 .19) or the interspinous spac e between L5 and S1 (F ig . P. The patient lies in the lateral rec umbent (side-lying) pos ition. F igu re 5. palpation of s pinous proc esses.19. The phy sic ian stands at the side of the treatment table fac ing the patient.S1 ( Fig . and the phy sic ian's thigh may be plac ed agains t the patient's tibial tuberos ities for F igu re 5.lww. mov ement elic ited.

L5 is F igu re 5.g. if L5 moves mor e easily in flex ion.22. 5.23. then L5 is termed neutral.com/pt/re/9780781763714/bookContent.23).21. If L5 flex es and extends equally (sy mmetric ally ) on S1.22 an d 5. 6... If there is asymmetry of motion between the two segments. s pinous proc ess separate. spinous proc ess approx imate. 10 of 59 21/08/07 22:02 .21). Step 4.http://thepointeedition.lww. flex ion. 5. Step 5. Step 5. F igu re 5. 5. F igu re 5.. the dys func tion is named for the dir ection of ease of motion of the upper of the two segments ( e. The phy sic ian ass esses the ability of the upper of the two segments to flex and extend on the lower. The phy sic ian slowly flexes and extends the patient's hips with the c audad hand and thigh while the cephalad hand cons tantly monitor s the spinous proc ess es to determine the relativ e freedom of lumbar flex ion and extens ion of L5 on S1 ( Fig s. extension. greater balanc e and control dur ing pos itioning ( Fig .

The phy sic ian slowly flexes and extends the patient's hips until L5 is neutral relative F igure 5.http://thepointeedition.24. 5..24). 11 of 59 21/08/07 22:02 . Step 1.lww.com/pt/re/9780781763714/bookContent. L5 is extended).. 2. if the segment moves mor e fr eely into extension. 8. flex ed.42 Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Pa s siv e Side Bending. The phy sic ian flex es the patient's hips to appr oximately 90 degr ees and gently mov es the patient's lower extr emities slightly off the edge of the table (F ig . P. The phy sic ian per forms thes e steps at each segmental lev el of the lumbar spine. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of mov ement elic ited. 7. Late r al Rec umbe nt Pos ition (L5-S1 Exam ple ) 1.

25.26). to S1. The phy sic ian then lower s the patient's feet and ank les while the cephalad hand monitors the appr oximation of the transv ers e proc ess es on the side to whic h the feet are lowered ( or F igure 5. The phy sic ian's caudad hand slowly raises the patient's feet and ank les upward as the cephalad hand monitor s the appr oximation of the transv ers e proc ess es on the side to whic h the feet are raised (or the separation of the transverse proc ess es on the side to whic h the patient is ly ing) (F ig . F igure 5. 12 of 59 21/08/07 22:02 . s ide bending left. Step 3. 3..27.. Step 5. Step 4. 5. palpation of L5 tr ans v ers e proc esses.lww. s ide bending r ight.26. The finger pads of the phy s ician's cephalad hand palpate the left and right transverse proc ess es of L5 (F ig . 5. 4.25) or the inters pac e between their transverse proc ess es.http://thepointeedition.com/pt/re/9780781763714/bookContent. F igure 5. 5.

. P. In this tes t. s ide bending oc cur s on the side to whic h the feet and ank les ar e mov ed. 6.lww. 8. the separation of the transverse proc ess es on the side opposite to whic h the patient is ly ing) (F ig . Late ral Re cum bent Position (Long Leve r) 13 of 59 21/08/07 22:02 .. 5. The phy sic ian per forms thes e steps at each segmental lev el of the lumbar spine.com/pt/re/9780781763714/bookContent. 7.43 Thor acic Inte r segmental Motion Te s ting: T1 to T4 Side Bending. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of mov ement elic ited.http://thepointeedition.27). The phy sic ian ass esses the ability of the upper of the two segments ( L5) to s ide-bend left and side-bend right.

4. The phy sic ian gently lifts the patient's head while monitor ing the inv olv ed segment's transverse proc ess es or the inters pac e between them. 5.. side bending left. Step 3. This pres ents as a Fig u re 5.28. Step 5. The patient lies in the lateral rec umbent pos ition with the bac k close to the side of the table. The phy sic ian sits in fr ont of the patient at the side of the table. The phy sic ian plac es the finger pads of the caudad hand over the transverse proc ess es of the dys func tional segment or the interspace between them while the cephalad hand reac hes under the patient's head and car efully lifts it off the table (F ig .http://thepointeedition. Fig u re 5. Side bending is intr oduced on the side to which the head is mov ed. 14 of 59 21/08/07 22:02 ..28).30.lww.com/pt/re/9780781763714/bookContent. side bending right. 1. 2.29. Step 4. Fig u re 5. 3. fac ing the patient's head.

33). s pinous pr oces s appr oximate. Step 3. and R ota tion. it is sensed by a simultaneous poster ior mov ement of the transver se proc ess on that s ide (F ig. The phy sic ian will document the findings in the progres s note F igure 5. P.com/pt/re/9780781763714/bookContent. 5. This is r epeated on the r ight to elicit right s ide bending ( Fig .32. T3. ex tens ion. Seate d. The phy sic ian slowly mov es the patient's head forward and bac k war d while constantly monitor ing the ability of the upper of the segments to move in the res pective dir ection tes ted (F igs. F igure 5. 5. while controlling the patient's head.31 an d 5. 5. 7. The phy sic ian controls the patient's head with one hand and palpates the s pinous pr oces ses of T1 and T2 with the index and thir d finger of the other hand. ass essing the ability of the left T1 transverse pr oces s to appr oximate the left T2 transverse pr oces s. Step 3. The phy sic ian per for ms thes e steps at each segmental lev el T2.T 3. Exte nsion. 5.http://thepointeedition. This is repeated on the right to elic it right r otation ( Fig . Side B ending. While monitor ing the left transverse pr oces ses . The phy sic ian.34) . spinous pr ocess s epar ate. This elicits left side bending (F ig... 3. 2. flexion.35). This evaluates left rotation. 15 of 59 21/08/07 22:02 . 5. and T4-T5. 5. the phy s ician slowly rotates the patient's head to the left.45 Thor acic Inte r segmental Motion Te s ting: T1 to T4 Pass ive Fle xion. The patient is seated with the phy s ician standing behind the patient.36) . palpates the left tr ans ver s e proc ess es of T 1 and T2 and mov es the patient's head to the left shoulder.32). Long-Le ver Me thod 1.T4. 4.44 P. 6.31.lww.

s ide bending left.33.34.. acc ording to the pos ition or freedom of motion elicited. F igure 5. F igure 5. Step 4.lww.. 16 of 59 21/08/07 22:02 .com/pt/re/9780781763714/bookContent. Step 4. s ide bending right.http://thepointeedition.

35. F igure 5. P. r otation left..46 Thor acic Inte r segmental Motion Te s ting: T1 to T12 Pas s ive Flexion and Extens ion.lww. r otation right.36.com/pt/re/9780781763714/bookContent. Step 5. Tr ans latory Method.. F igure 5. Step 5.http://thepointeedition. Se ate d (T6-T7 e xam ple) 17 of 59 21/08/07 22:02 .

37. 5.http://thepointeedition.. 2. T he phy s ician's r ight arm and hand are placed inferior on the patient's cros sed elbows while left hand remains on the T6. F igu re 5. The patient is seated with the phy s ician standing behind and to the side. 18 of 59 21/08/07 22:02 .com/pt/re/9780781763714/bookContent. flex ion. 5.38). r esting the for ehead on the for ear m as the left hand monitor s flex ion of T 6 on T 7 (separation of the spinous F igu re 5.lww. 4. F igu re 5. s pinous proc esses s epar ate.37). or the index and thir d finger palpate the spinous proc ess es of T 6 and T7. anteriorly . Step 3. in a V-formation. 1. Step 4.. The phy sic ian plac es the thumb and index finger of one hand between the spinous proc ess es of T 6 and T7.T 7 interspace (F ig. 3. The patient's arms ar e cros sed. res pectively (F ig . Step 2.38. The phy sic ian ins truc ts the patient to completely relax for ward.39.

P.http://thepointeedition.42.com/pt/re/9780781763714/bookContent. F igu re 5.41. The patient is seated and the phy s ician stands behind and to the side. 2. 4. The phy sic ian plac es the left thumb and index finger between the spinous proc ess es of T 6 and T7 (F ig. Step 2. 5.43. 5.. Step 3. 3. translator y s ide bending right. The phy sic ian reac hes ac ros s the front of the patient's ches t with the r ight arm and places the right hand on the patient's left shoulder with the phy s ician's r ight axilla res ting on the patient's right s houlder (F ig .41).. Step 4.42). 19 of 59 21/08/07 22:02 . The phy sic ian's right axilla applies a downwar d forc e on the patient's right s houlder as the left hand simultaneously glides or pus hes F igu re 5. Se a ted 1.lww. F igu re 5. Alternativ ely the phy s ician's left thumb and index finger palpate the spinous proc ess of T6.47 Thor acic Inte r segmental Motion Te s ting: T1 to T12 Tra nsla tor y Method (Pa ssiv e Side Be nding).

P. Pas s ive Rotation. translator y s ide bending left.44.44).com/pt/re/9780781763714/bookContent.43). Side B ending (Ex ample T7) 20 of 59 21/08/07 22:02 . The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited. 5. Step 5. the T6.http://thepointeedition. 5.lww. 5. Thes e s teps ar e per formed to evaluate r ight and left s ide bending at eac h thor acic segmental lev el. This causes a left tr ans latory effect that produces r ight side bending of T6 on T 7 ( Fig .. This produces left side bending of T6 on T 7 ( Fig .T7 interspace to the patient's left. F igu re 5.. 7.T7 interspace to the patient's right. 6.48 Thor acic Inte r segmental Motion Te s ting: T1 to T12 Prone Shor t-Leve r Me thod. The phy sic ian's right hand applies a downwar d forc e on the patient's left shoulder as the left hand simultaneously glides the T6.

the patient should tur n the head to the mor e comfortable side. 5.45 an d 5. 3. 1. Step 4. evaluating for eas e of mov ement. The patient lies prone with the head in neutr al.com/pt/re/9780781763714/bookContent. the left transverse proc ess may be palpated more prominently (pos ter ior ly) on Fig u re 5. The phy sic ian stands at either side of the table and palpates the T7 transverse proc ess with the pads of the thumbs or index fingers . If this is not pos s ible. Step 7. 4.46. 5. side bending left. Note any change below. If the right transverse proc ess moves anteriorly (inward) more eas ily.http://thepointeedition.46). In the step 4 scenario. the segment is rotating left mor e fr eely and vic e versa (F ig s..lww. Fig u re 5. Step 4. 2. Fig u re 5.45..47. rotation left. The phy sic ian alternately pres ses on the left and r ight transverse proc ess es of T7. 21 of 59 21/08/07 22:02 . rotation right.

The phy sic ian slowly flexes the hips by br inging the knees to the ches t as the phy s ician's cephalad hand monitor s the separation of the spinous proc ess es (flexion) (F ig . 3.50). 2. The phy sic ian F igure 5. 4.49. Step 3. P.lww. s pinous proces s es of T 12–L1..50. Step 4. F igure 5. Late r al Rec umbe nt 1. The patient lies in the lateral rec umbent pos ition with the hips and k nees flex ed (fetal pos ition). extension. The phy sic ian stands on the side of the table fac ing the patient and controls the patient's knees at the tibial tuberos ity with the caudad hand. flex ion.. 5. The phy sic ian's cephalad hand palpates the spinous proc ess es of T12 and L1 or their interspace with the index and/or long finger (F ig. Pa ssiv e Flex ion and Ex tens ion. F igure 5. 5. 5.49).51.http://thepointeedition. Step 5. 22 of 59 21/08/07 22:02 .com/pt/re/9780781763714/bookContent.49 Thor acic Inte r segmental Motion Te s ting: T8 to T12 Long-Le ver Method.

The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited. then ex tends the hips by bringing the knees away from the c hes t as the cephalad hand monitors the appr oximation of the spinous proc ess es (ex tens ion) (F ig .51). Pa ssiv e Side Be nding.com/pt/re/9780781763714/bookContent. 7.50 Thor acic Inte r segmental Motion Te s ting: T8 to T12 Long-Le ver Method.. Late ral Re cum bent 23 of 59 21/08/07 22:02 . 5.. P. Thes e s teps ar e per formed to evaluate flex ion and extens ion at eac h thoracic segmental lev el.http://thepointeedition.lww. 6.

Fig u re 5.52.. the phy s ician slowly rais es the patient's feet toward the ceiling and then draws them toward the floor (F ig . The phy sic ian mov es the patient's lower legs off the edge of the table. Step 3. 24 of 59 21/08/07 22:02 .. The patient lies in the lateral rec umbent pos ition with the hips and k nees flex ed (fetal pos ition). feet toward the right. 3.g.http://thepointeedition. Fig u re 5. side bending right. 5. Step 4.. Step 4.54).54. side bending right) (F igs.53 an d 5. 5. Side bending is evaluated by monitor ing the appr oximation of the transv ers e proc ess es on the side to which the feet are drawn ( e. The phy sic ian stands on the side of the table fac ing the patient and controls the patient's knees at the tibial tuberos ity with the caudad hand. 2.com/pt/re/9780781763714/bookContent. 1.53. 5.lww. side bending left. 4. and while monitor ing the transv ers e proc ess es.52). Thes e s teps ar e Fig u re 5.

or dinary expiration.http://thepointeedition. G ray 's Anatomy .. the sternum and ribs move in a simultaneous and combined patter n that expands the chest in the anteroposterior and lateral diameters dur ing inhalation and dec reas es the anteroposterior and lateral diameters in exhalation. T he sternum and r ibs 1 to 10 also ris e in a c ephalad dir ection and des cend caudally in inhalation and exhalation. 30th Amer ican ed.55).) 25 of 59 21/08/07 22:02 . 1985. This expans ion mov es through two major vec tor Fig ure 5. Rib Excursion wit h In halation The ver tebral and sternal attachments combine to promote specific vec tor s of motion dur ing nor mal inhalation. C. P.55. 5. res pec tively (F ig. (Repr inted with per mis sion fr om Clemente CD.. expanding the chest.lww.51 Cos tal Motion Tes ting: C ostal Mec hanics In res piration.com/pt/re/9780781763714/bookContent. Baltimor e: Lippinc ott Williams & Wilkins. showing the movements of the sternum and r ibs . B. deep inspiration. A. Lateral view of firs t and s eventh ribs in pos ition. quiet ins pir ation.

These patter ns are des cribed as occ urr ing thr ough pump handle and buc ket handle axes in both ver tebr osternal ribs 1 to 6 and ver tebr ochondral ribs 7 to 10 (F igs.lww.57). Inter rupted lines indicate the pos ition of the rib in inhalation. Interrupted lines indicate the pos ition of the rib in inhalation. Copy r ight 1983–2006.com/pt/re/9780781763714/bookContent. ( Used with per mis sion of the AACOM.. paths.57.56. 5.56 and 5. Axes of movement (AB and CD) of a ver tebros ternal rib. ( Used with 26 of 59 21/08/07 22:02 . All rights reser ved.) Fig ure 5. Fig ure 5.http://thepointeedition. Axis of movement (AB) of a ver tebroc hondral rib..

58.com/pt/re/9780781763714/bookContent. 27 of 59 21/08/07 22:02 . All rights reser ved.http://thepointeedition. and the angle c hanges fr om superior to infer ior ribs. deter mines whether the r ib motion produc ed thr ough normal res pir ation is greates t at the anterior midc lav icular line or the later al clavic ular –midax illary line. the motion patter n of F igu re 5. However .) P. per mis sion of the AACOM. allowing a mor e purely pump handle rib excur sion. Rib 1: Most frontal in plane.53 Cos tal Motion Tes ting: C ostal Mec hanics Ang le o f Inclinat ion of the Axes o f Rib 1 and Rib 6 The cos totransver se articulations combine with the cos tov ertebral articulations at eac h ver tebr al lev el to dev elop angles thr ough which ax is of rotation a rib may mov e. Copy r ight 1983–2006. T hus .lww. Ribs 1 to 10 hav e s ome shared motion par ameter s in eac h of the axes of rotation. the r ib mov es within this specific axis of rotation..52 P. T he angle.. as it relates to the anteroposterior planes and the later al body line.

60). ( Reprinted with per mis sion fr om Clay JH. whereas in the lower ribs a les s frontal.lww.com/pt/re/9780781763714/bookContent. 2003. Baltimore: Lippincott Williams & Wilk ins.60. Pum p Handle Rib Mot ion The ter m pump handle rib motion des cribes the mov ement of a rib that c an be compar ed to the motion of the handle of a water pump. Rib 6: Less frontal plane.) 28 of 59 21/08/07 22:02 . Pump handle rib motion.http://thepointeedition.58 an d 5.. Pounds DM. 5. Bas ic Clinical Massage T her apy : Integrating Anatomy and T reatment. 5. the upper ribs is related to a predominant anter ior or frontal plane axis.59. mor e s agittal ax is predominates. Its motion is produc ed by one end being fix ed in s pac e and rotating around an axis that per mits the opposite end to move thr ough space (F ig. These differ ences produce the patter ns of pump handle motion prefer ence of the upper r ibs and the buc ket handle prefer ence of the lower r ibs (F igs. allowing for greater ability to move in a bucket handle motion than can rib 1.. F igu re 5. Bucket Han dle Rib Mot ion The ter m buck et handle rib motion des cribes the mov ement of a rib that c an be best compar ed to the mov ement of the handle of a buck et as it is lifted up and off the rim of the bucket F igu re 5.59).

. Bucket handle r ib motion.lww.61. 2003. and then laid down on the same s ide. The motion is produc ed by both ends of the handle being fixed at a rotational ax is per mitting only the area between the two points to mov e thr ough space (F ig 5. Pounds DM. Step 2. The patient lies supine and the phy s ician sits or stands at the head of the table. Basic Clinical Massage T her apy : Integrating Anatomy and Tr eatment. 29 of 59 21/08/07 22:02 . The phy sic ian palpates the firs t ribs at their infr aclavicular pos ition at the ster noc lav icular articulation ( the supr aclavicular pos ition c an F igu re 5.) 2. (Or the patient may s it.http://thepointeedition.62.54 Cos tal Motion Tes ting: U ppe r R ibs 1 a nd 2.) P.. Supine Method 1.com/pt/re/9780781763714/bookContent. Baltimor e: Lippinc ott Williams & Wilk ins . palpation of the fir st r ib. ( Repr inted with permission from Clay J H.61) F igu re 5.

The patient is ins truc ted to inhale and exhale deeply thr ough the mouth as the phy s ician monitor s the ability of the pair of firs t r ibs to mov e super ior ly and inferiorly . If the rib on the symptomatic side is static ally caudad and on inhalation has les s cephalad F igu re 5. inhalation rib dysfunction.com/pt/re/9780781763714/bookContent.. 4. 6. The phy sic ian monitor s the relativ e s uper ior (cephalad) and inferior ( caudad) relation of the pair and on the symptomatic side deter mines whether that r ib is prominent or not and pos itioned superiorly or inferiorly .62). 5.63.63). F igu re 5. exhalation rib dysfunction. Step 5. 5. 30 of 59 21/08/07 22:02 . F igu re 5.. 3.65. als o be us ed) (F ig . If the rib on the symptomatic side is static ally cephalad and on inhalation has greater cephalad ( on exhalation.http://thepointeedition. Step 6.lww.64. Step 7. it is clas sified as an inhalation rib dys func tion (F ig . palpation of the s econd r ib. 5. less caudad) mov ement.

http://thepointeedition. (on exhalation. 8. Sea ted Me thod 31 of 59 21/08/07 22:02 . 5. 5. greater caudad) mov ement.com/pt/re/9780781763714/bookContent.65). The mov ement of the rib on the symptomatic side that was freest is doc umented in the progress note (inhalation or exhalation bas ed on the res pirator y model or elev ated or depr ess ed bas ed on the str uctural model.55 Cos tal Motion Tes ting: Firs t R ib.64). The phy sic ian nex t palpates the sec ond ribs appr oximately one finger's-breadth below and one finger's-breadth lateral to where the fir st rib was palpated and repeats steps 3 to 6 (F ig..) P. 7.lww.. Ele vated. it is clas sified as an exhalation rib dys func tion (F ig .

Step 2.69). 32 of 59 21/08/07 22:02 . The phy sic ian monitor s the relativ e cephalad or caudad relation of the pair and on the symptomatic side deter mines whether that r ib is prominent superiorly as compared to its mate. F igu re 5. 5. Step 3. If a rib is prominent. Note: T he trapezius bor ders may hav e to be pulled pos teriorly ( Fig .68 an d 5. palpation of thir d r ib.http://thepointeedition. F igu re 5. 4..com/pt/re/9780781763714/bookContent. F igu re 5. palpation of the fir st r ib.66.lww.. 5. palpation of the fir st r ib. 5. 2. Step 3.67.68.67). With firm pres sur e of the thumbs or finger pads . 5. The phy sic ian palpates the pos terolateral shaft of each fir s t r ib immediately lateral to the cos totr ans ver s e articulation ( Fig .66). 1. The patient is seated and the phy s ician stands behind the patient. the phy s ician dir ects a downwar d (caudad) forc e alternately on eac h rib ( Fig s. 3.

Supine Method 1.http://thepointeedition. The phy sic ian's thumbs palpate the third ribs bilater ally at their cos tochondral articulations for pump handle motion and at the midaxillar y line with the sec ond or thir d fingertips for buc k et handle motion (F ig. inhalation r ib.70). Step 4.com/pt/re/9780781763714/bookContent.72. Fig u re 5.lww.. The patient lies supine and the phy s ician stands on one side of the patient. Step 2. 3. 2.56 Cos tal Motion Tes ting: U ppe r R ibs 3 to 6 . P. The phy sic ian monitor s the relativ e cephalad or caudad relation of the pair and on the symptomatic side deter mines whether that r ib is more or les s prominent or superiorly or inferiorly pos itioned.70. 33 of 59 21/08/07 22:02 . 5. The patient is ins truc ted to inhale and exhale deeply thr ough the mouth as the phy s ician monitor s the Fig u re 5.71. Fig u re 5.. Step 5. 4.

greater caudad mov ement).71). ex halation r ib. 6..http://thepointeedition. 5. relativ e cephalad and caudad mov ements of eac h rib with the palpating thumbs and finger tips (F ig . 5. If the rib on the symptomatic side is static ally mor e cephalad and on inhalation has greater cephalad mov ement ( on exhalation. 5.73. it is ter med an inhalation rib (dy s function) (F ig . Step 6.73). 34 of 59 21/08/07 22:02 .com/pt/re/9780781763714/bookContent. 7. less caudad mov ement). If the rib on the symptomatic side is static ally mor e caudad and on inhalation has les s cephalad mov ement ( on exhalation. The phy sic ian nex t palpates ribs 4 to 6 at their cos tochondral ends with the thumbs and at their mid. it is ter med an exhalation rib (dy s function) (F ig .72)..lww. 5.axillar y lines with the fingertips and repeats steps 3 Fig u re 5.

F igu re 5. The patient is supine and the phy s ician stands on one side of the patient.. 8. The phy sic ian's thumbs palpate the sev enth r ibs bilater ally at their cos tochondral articulations for pump handle motion and at the midaxillar y line with the sec ond or thir d fingertips for buc k et handle motion (F igs. Step 2.com/pt/re/9780781763714/bookContent.lww. P. The freest mov ement of the rib on the symptomatic side is then doc umented in the progress note (inhalation or exhalation bas ed on the res pirator y model or elev ated or depr ess ed bas ed on the str uctural model). 2..http://thepointeedition.74. to 6.57 Cos tal Motion Tes ting: Lowe r R ibs 7 to 1 0. 35 of 59 21/08/07 22:02 . Supine Method 1.

76. If the rib on the symptomatic side is static ally mor e cephalad and on inhalation has greater cephalad mov ement ( on exhalation.75. 5. 4.76). F igu re 5. 5. 36 of 59 21/08/07 22:02 .com/pt/re/9780781763714/bookContent.. Step 5. exhalation dysfunction. less caudad mov ement).http://thepointeedition.77. 3.lww. 5. F igu re 5.74 an d 5. it is ter med an inhalation rib (dy s function) (F ig .75). The phy sic ian monitor s the relativ e cephalad or caudad relation of the pair and determines on the symptomatic side whether that rib is more or less prominent or superiorly or inferiorly pos itioned. inhalation dysfunction. The patient is ins truc ted to inhale and exhale deeply thr ough the mouth as the phy s ician monitor s the relativ e cephalad and caudad mov ements of eac h rib with the palpating thumbs and fingertips .. 6. Step 6. Step 2. If the rib on the F igu re 5.

com/pt/re/9780781763714/bookContent.58 P. the 8th thr ough 10th ribs at their cos tochondral ends with the thumbs and at their midaxillary lines with the fingertips and repeats steps 3 to 6... greater caudad mov ement). 5.77). The mov ement of the freest rib on the symptomatic side is then doc umented in the progress note (inhalation or exhalation bas ed on the res pirator y model or elev ated or depr ess ed bas ed on the str uctural model). 7. it is ter med an exhalation rib (dy s function) (F ig . P.59 37 of 59 21/08/07 22:02 .lww.http://thepointeedition. 8. The phy sic ian nex t palpates . symptomatic side is static ally mor e caudad and on inhalation has les s cephalad mov ement ( on exhalation. sequentially.

it is c las sified as an inhalation rib (dy s function) (F ig .79. Step 2.79) .78. 4. F igu re 5. 38 of 59 21/08/07 22:02 . 3.com/pt/re/9780781763714/bookContent. 5. Step 2. Pr one Method 1. The phy sic ian notes any asy mmetric motion at eac h rib. 6. F igu re 5.78 an d Fig . 5.80). 5. Step 5. 5. The patient is ins truc ted to inhale and exhale deeply thr ough the mouth. inhalation dysfunction. The patient lies prone and the phy s ician stands on either side of the patient.http://thepointeedition.80.. Cos tal Motion Tes ting: Floa ting R ibs 11 and 12. The phy sic ian's thumb and thenar eminenc e palpate the s haft of each 11th r ib (F ig .. If on the symptomatic side the patient's rib mov es more pos teriorly and inferiorly with inhalation and les s anter ior ly and superiorly with ex halation than its mate. If on the symptomatic side the patient's rib mov es more anteriorly and F igu re 5.lww. 2.

83). The phy sic ian's index or thir d finger pad palpates the transverse proc ess es of C1 (F ig .http://thepointeedition.. F igu re 5. Type I Coupling Motion 1. superiorly with exhalation and les s posterior ly and inferiorly with inhalation than its mate. F igu re 5. Step 6. 4. 2.com/pt/re/9780781763714/bookContent. 5.82. 5..82). Thes e findings are doc umented in the progres s note. it is c las sified as an exhalation rib (dy s function) (F ig . 39 of 59 21/08/07 22:02 . The patient lies supine on the treatment table.81. 3. exhalation dysfunction. 5. P. Step 3. c areful not to bring the segments below the occ iput into this motion ( Fig . 7.61 Cer v ica l Inte r segmental Motion Te s ting: Occ ipitoatlantal Articulation (Occ iput-C 1 ).lww. The phy sic ian gently mov es the patient's head for ward and bac k . C1 transverse proc ess.81).60 P. The phy sic ian sits at the head of the table.

5. extension. the phy s ician minimally translates the patient's occ iput alternately to the left and r ight ov er C1 ( atlas) without inducing any mov ement of C1 to C7 ( Fig s. To evaluate s ide bending and rotation. Step 5. The phy sic ian will doc ument the findings in the progres s note acc ording to the pos ition or freedom of motion elicited.84. flex ion. A. 8. B. 40 of 59 21/08/07 22:02 . The phy sic ian gently mov es the head off the table and to the table in a for ward-and-back translator y mov ement..http://thepointeedition..84). A. 6.83.lww.86).83. 7.85 and 5. Step 4. F igu re 5. 5. 5.com/pt/re/9780781763714/bookContent. Thes e s teps ar e evaluated for asy mmetric mov ement patterns that exhibit more s ide bending in one dir ection and mor e rotation in the other as well as ease or freedom of flexion or extension. Step 4. F igu re 5. again car eful not to induce mov ement of the inferior cer v ical segments ( Fig . extension. F igu re 5.

F igu re 5. left side bending/rotation c oupling. R ota tion 41 of 59 21/08/07 22:02 . Step 6. P.. Step 6. F igu re 5.84. B.com/pt/re/9780781763714/bookContent.85.lww. flex ion.86.. F igu re 5.62 Cer v ica l Inte r segmental Motion Te s ting: Atla ntoaxial A rticulation (C1 -C2).http://thepointeedition. right s ide bending/rotation c oupling. Step 5.

3. 2. The patient lies supine and the phy s ician sits at the head of the table. 5.com/pt/re/9780781763714/bookContent.lww. F igure 5. car eful not to add any side bending or flex ion (F ig. r otation right. F igure 5. This is the limit of motion for this ar tic ulation F igure 5. Step 4. Step 3. As the head is rotated. transver se proces s of atlas and C2 ar ticular pr oces s. the phy s ician monitor s for any mov ement of the axis ( C2). The phy sic ian palpates the transverse proc ess es of the atlas (C1) with the pads of the index fingers and the articular proc ess es of the axis ( C2) with the pads of the third or four th finger s (F ig .87). (This eliminates any lower c erv ical mov ements and keeps motion vec tored to this lev el. Step 2.87..88). 1.89. s top when C2 begins to move. 42 of 59 21/08/07 22:02 . 5. and stops when this is enc ountered..) 4. The phy sic ian slowly rotates the patient's head in one dir ection.88.http://thepointeedition.

The patient lies supine on the treatment table.92. 5. The phy sic ian slowly and alternately rotates the patient's head to the comfor table right and left pas s ive motion limits (F igs.com/pt/re/9780781763714/bookContent.. 5. Supine. Step 3. Step 4.lww. F igu re 5. 6.93).92 an d 5. The phy sic ian sits at the head of the table.91. with Flex ion Alternative 1. 4. 43 of 59 21/08/07 22:02 . The phy sic ian then notes the asy mmetric motion preference if F igu re 5. The phy sic ian is aler t for any res tric ted and/or asy mmetric rotation. C1 r otation with head flex ed.91). The phy sic ian slowly flexes (for war d-bends ) the patient's head and neck to the comfortable pas s ive motion limit to segmentally res tric t the free coupled motions of the occ ipitoatlantal and C2 to C7 segments ( Fig . 2.http://thepointeedition. 3.63 Cer v ica l Inte r segmental Motion Te s ting: Atla ntoaxial (C1-C2). 5. P. C1 r otation r ight with head flexed..

http://thepointeedition. Step 4. The phy sic ian palpates the articular proc ess es of the segment to be evaluated with the pads of the index or thir d finger (F ig s. Step 2. 44 of 59 21/08/07 22:02 . F igu re 5. The patient lies supine on the treatment table.94. wher eas the afor ementioned C1 r otation test with head in neutral pos itioning is a pos itiv e test and better tolerated by most patients. 7. 2. Note: Never do this ty pe of motion tes t with either the head and nec k extended. We do not rec ommend this test.. P. Shor t-Leve r Tr ans latory Effect. C1 r otation left with head flexed. cervic al articular pillar s on sk eleton. pres ent (C1-RR or C1-RL).93. 5. Ty pe II Motion 1..com/pt/re/9780781763714/bookContent.64 Cer v ica l Inte r segmental Motion Te s ting: C2 to C 7 A rtic ula tions. as it is pres umptiv e.lww.94 an d Fig ure 5. and the phy s ician sits at the head of the table.

96. Eac h cervical segment is evaluated in flex ion. 5. 3. left side bending) and then right to left (F ig . extension.95). Fig ure 5. side bending left. Fig ure 5. A.97.http://thepointeedition.. Step 2. 45 of 59 21/08/07 22:02 .. B. 4. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited. Fig ure 5. a translator y motion is intr oduced fr om left to right (F ig.lww. 5. Step 4. To evaluate asy mmetry in side bending. r ight side bending) thr ough the articular proc ess es.com/pt/re/9780781763714/bookContent. 5. Step 4. side bending left.95. cervic al articular pillar s on patient. and neutral to determine whic h pos ition impr oves the asy mmetry. 5.96.96.

side bending right.97. Fig ure 5. P.. A. B.http://thepointeedition.g.97. Step 4.65 Cer v ica l Inte r segmental Motion Te s ting: C2 to C 7 A rtic ula tions..lww. C3 SRRR or SLR L) 46 of 59 21/08/07 22:02 . Type II Motion (e. Long-Le ver Me thod.. Step 4. Fig ure 5.com/pt/re/9780781763714/bookContent. side bending right.

rotation added. side bending/rotation r ight. a slight rotation is added to the dir ection of the side bending (F ig. 5. F igu re 5.com/pt/re/9780781763714/bookContent.98.99. Sinc e C2 to C7 side-bend and rotate to the F igu re 5.lww. 3. flex ion is inc r eas ed appr oximately 5 to 7 degrees for eac h des c ending segment to be evaluated. With the head in neutral for C2. At the end of the limit of s ide bending. F igu re 5.shoulder method. arc like mov ement to the lev el of the dys func tional segment for its side bending ability (F ig.100 and 5.99).. 4. 47 of 59 21/08/07 22:02 . Step 1.http://thepointeedition.to.98).to. ear . Cer v ical intersegmental motion may be evaluated by long-lever method. Step 3. The articular proc ess es are pos itioned in side bending/rotation to the right and then the left until their limit is elic ited ( Fig s. Step 2.100..101). 5.shoulder. Move the head in an ear . 2. 1. 5.

5. Supine. symmetr ic or asy mmetric pattern) ( Fig . The patient lies supine on the treatment table.. Step 4. The phy sic ian's hands then control the patient's knee and ank le (F ig . Fig ure 5.104. Long Leve r (Leg Length) 1. ex ter nal 48 of 59 21/08/07 22:02 . Fig ure 5.103. The phy sic ian stands at the side of the table at the patient's hip. The phy sic ian ins truc ts the patient to flex the hip and k nee on one side. palpating the anterior s uperior iliac spine. Step 3. The phy sic ian palpates the patient's anterior superior iliac spines (ASISs ) and medial malleoli and notes the relation of the pair (c ephalad or c audad.lww.102.102).com/pt/re/9780781763714/bookContent.103). 5. Step 5. Fig ure 5. Ante roposterior R ota tion. flex ion.66 Sac r oiliac Joint Motion Tes ting: Pelv is on Sacr um (Iliosa cra l).. 5.http://thepointeedition. 3. The phy sic ian tak es the patient's hip thr ough a range of motion star ting with 130 degr ees of flex ion. P. 2. 4.

6. bringing the patient to the neutral starting pos ition ( Fig . Fig ure 5. 8. 49 of 59 21/08/07 22:02 .105.tes ted side appears mor e cephalad than its original pos ition.104). 5.. The phy sic ian notes whether the ASIS on the motion. 7. The phy sic ian notes whether the ASIS on the motion. and ex tens ion. progres sing thr ough inter nal rotation and finally extension.lww. The phy sic ian then takes the patient's hip thr ough a range of motion star ting with 90 degr ees of flex ion. Step 7..http://thepointeedition. and ex tens ion. This rotation. 5. inter nal rotation. This change would be s econdary to freedom in pos terior rotation.105).com/pt/re/9780781763714/bookContent.tes ted side appears mor e caudad than its original pos ition. bringing the patient to the neutral starting pos ition ( Fig . progres ses thr ough ex ter nal rotation and finally extension. flex ion.

10.com/pt/re/9780781763714/bookContent. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited. P. which joint is free or res tric ted in only one dir ection. This is repeated on the other side to determine whether each joint has freedom in pos terior and anterior r otation and if not.. Inflare -Outfla re). Shea r ..lww.g. Standing Flexion Test 50 of 59 21/08/07 22:02 .67 Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint and Pelvic Dys func tions. Pelvic (e .http://thepointeedition. change would be s econdary to freedom in an anterior rotation.. Innom inate R ota tion. 9.

A positive res ult indicates that an ilios acral dys func tion ( pelv is on s acr um) may be present. Regar dless the type of dys func tion. 51 of 59 21/08/07 22:02 . 5. Step 4. 1..108). 5. The tes t is positive on the side wher e the thumb ( PSIS) moves mor e cephalad at the end range of motion (F ig. not skin or fas c ial dr ag.107). The phy sic ian stands or kneels behind the patient with the ey es at the lev el of the patient's pos ter ior superior iliac spines ( PSISs). T his is usually compared to the r esults of the seated flexion test to r ule out sac r oiliac dy s function ( sac rum on pelv is) . This is a pres umptiv e test reflecting as y mmetry . 3. Fig ure 5. not the s pec ific ty pe of dysfunc tion. 2. Fig ure 5. 5. The patient is instr ucted to activ ely for ward bend and try to touch the toes within a pain-free range (F ig .106).106. to follow bony landmar k motion ( Fig .. The patient s tands erec t with the feet a shoulder-width apart. The phy sic ian's thumbs are placed on the inferior aspect of the patient's PSIS. 7. for war d bending. the problem is at the sac r oiliac joint.107. 5. Step 3.com/pt/re/9780781763714/bookContent.http://thepointeedition. 4. 6. which may be r elated to dys functions at the sac r oiliac joint. A pos itiv e standing flex ion tes t identifies the side on which the sacroiliac joint is dys func tional. It should not replace more s pec ific motion tes ting that actually elicits motion availability.lww. The phy sic ian will document the findings in the progres s note acc ording to the pos ition or freedom of motion elicited. Maintain firm pres sur e on the PSISs.

5.110. 5. P. The patient is seated on a stool or treatment table with both feet flat on the floor a s houlder -width apar t. not sk in or fasc ial dr ag. The tes t is pos itiv e on the side where the thumb ( PSIS) mov es more cephalad at the end range of motion (F ig.lww. pos itive seated flex ion tes t.109). 2. The phy sic ian stands or kneels behind the patient with the eyes at the level of the patient's PSISs. for war d bending. F igu re 5. 52 of 59 21/08/07 22:02 . F igu re 5.110). Se ate d Flexion Tes t 1. Step 4. 5. Step 3. 4. The patient is ins truc ted to for ward-bend as far as pos sible within a pain-fr ee range (F ig .http://thepointeedition. The phy sic ian's thumbs are plac ed on the inferior aspec t of the patient's PSISs and a firm pres sur e is dir ected on the PSISs. to follow bony landmar k motion (F ig .. Step 5.68 Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint and Pelvic Dys func tions. Pelvic (Innom ina te) or Sac ral.111.. 3. F igu re 5.109.com/pt/re/9780781763714/bookContent.

53 of 59 21/08/07 22:02 . It should not replac e mor e specific motion tes ting that ac tually elic its motion availability. 7. suc h as innominate rotation. not the specific type of dysfunc tion. A pos itiv e s eated flex ion test identifies the side of sacral (sac roiliac or sac r um on pelv is) dys func tion. whic h may be related to dys func tions at the sac roiliac joint. P. 5.com/pt/re/9780781763714/bookContent.lww.69 Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion.http://thepointeedition. 6.111).. A negative tes t may indicate a pelv ic on sac r um (iliosacral ty pe) dys func tion. This is a pres umptiv e test reflecting asy mmetry. The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited. Pe lvis on Sac r um (Ilios a cra l D ysfunction). A nte roposte rior R ota tion Pr one ..

4. Long Le ver 1.112). 2. or the index finger contacts the PSIS while the thumb c ontacts the sac rum (F ig.http://thepointeedition. Step 4.114. If palpating the opposite sac r oiliac joint. 54 of 59 21/08/07 22:02 .com/pt/re/9780781763714/bookContent.lww. The patient lies prone on the treatment table.. Step 5. the finger pads will contact the landmar k on the other s ide. 5. Fig u re 5. The phy sic ian plac es the cephalad hand over the patient's sac r oiliac joint with the finger pads of the index and thir d digits contac ting the sac rum and PSIS.113.112. 5. 5. The phy sic ian's other hand gras ps the patient's fully extended (str aight) lower leg at the lev el of the tibial tuberos ity (F ig. The phy sic ian stands to one side of the patient at lev el of the hip.. Fig u re 5. The phy sic ian gently lifts the extended leg and then s lowly Fig u re 5. Step 3. 3.113).

laterally (F ig . Fig u re 5. sac r um and test This motion PSIS.118). Inflare -Outfla re Prone.118. 3. Step 3.. Step 4. (e. fr ee res tric If palpating the pos teriorly). sac roiliac 5. sac r oiliac joint monitor ed. Step 5. opposite This is a sac r oiliac joint. Step 5. 7.115) and of the hip. pos itiv e test. The phyQuality 5..http://thepointeedition..ted.g. 5. 5.com/pt/re/9780781763714/bookContent.116. Fig u re 5. 9. at the lev el then 5.70 Sac r oiliac Joint while lowers it Motion Tes ting: Sacr oiliac Joint Motion. 55 of 59 21/08/07 22:02 . P. 2. Long Le ver (Ilios a cra l mov ement of the PSIS as it relates to the Ther patient lies sac um (F ig.lww. as well hand ov er the as ease-bind patient's ar e relations. as the finger pads compared to the will contact the standing and landmarflexion seated k opposite what is tes ts. Fig u re 5. ins truc tssic ian The phy the patient to flex the will document lower leg (knee) the findings in appr oximately 90 the progress degr ees and then note ac cor ding gras pspos ition or to the the ank le (F ig . 4. and minimally 1. Step 5. 6. sic ian plac es the of and quantity cephalad-oriented motion.117. Fig u re 5.119. mor e The phy sic ian pres umptiv e.115. or the index may determine finger contac ts joint motion the tric tion res PSIS while the thumb and/or motion contacts the asy mmetry sac r um (F ig. 8.117).114).116). The treatment table. which are noted abov e. with the sic ian The phy finger pads of the index repeats this on and opposite the third digit contacting the side. prone on the 5. freedom of The phy sic ian motion elicited. Pe lvis on Sac r um palpating theD ysfunction). phy s ician may The phy sicthe als o carry ian stands ossone leg acr to the side of the patient midline (F ig. Fig u re 5.

Ge ner a l Res tric tion. then ex ter nally and internally rotates the patient's hip by mov ing the ank le medially and laterally.. This appr oximates (outflare) and separates (inflar e) the sac r oiliac joint. Prone.71 Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion.lww. The above motion tes t may determine joint motion res tric tion and/or motion asy mmetry (e. 7. P. Fig u re 5. 5.http://thepointeedition.119 and 5. Step 5.120). The phy sic ian then repeats this on the opposite side. Shor t Leve r 56 of 59 21/08/07 22:02 .. 6. 8.g. free-inflare) . The phy sic ian will doc ument the findings in the progres s note acc ording to the pos ition or freedom of motion elic ited.120. sac r oiliac joint res tric ted. res pectively (F ig s.com/pt/re/9780781763714/bookContent..

The phy sic ian will document the findings in the progress note ac cor ding F igure 5.lww. 6.122. F igure 5. This is a pos itiv e test that will determine whic h sac r oiliac joint is most res tric ted but will not determine the nature of the dys func tion. 5.122).com/pt/re/9780781763714/bookContent. 7. prone s hor t lever with thenar impuls e.121. The phy sic ian plac es the thenar eminenc es over the patient's PSISs ( Fig . 4.121).. 5. 2. The phy sic ian stands to one side of the patient at the lev el of the hip.http://thepointeedition. Step 3. Step 4.. 5. 3. 1. The phy sic ian alternately intr oduces a mild to moderate impulse through the PSISs with the thenar eminenc es (F ig . The patient lies prone on the treatment table. 57 of 59 21/08/07 22:02 . The phy sic ian notes the quality (end feel) and quantity of motion on eac h side.

123). This will determine whic h s acr oiliac joint is most res tric ted and may determine whic h motion preference is pres ent (anterior or pos terior Fig u re 5.. Step 4.124. 5. Fig u re 5. Supine . Step 3.124.com/pt/re/9780781763714/bookContent.lww.124). 6. 4. The phy sic ian notes quality (end feel) and quantity of motion on eac h side. A. Shor t Le ver 1. supine short lev er 58 of 59 21/08/07 22:02 . B. The phy sic ian alternately intr oduces a mild to moderate impulse through the ASISs (may dir ect it pos teriorly or slightly cephalad) (F ig ..72 Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion. Step 4. The patient lies supine on the treatment table. 5. P. 2.http://thepointeedition. The phy sic ian's palms or thenar eminenc es are plac ed inferior to the patient's ASISs ( Fig . 3. 5. Ge ner a l Res tric tion or Anter opos ter ior Rotation. The phy sic ian stands at the lev el of the patient's hip. Fig u re 5. supine short lev er with thenar impulse on r ight.123.

the symptomatic and res tricted side will hav e a preference to mov e cephalad (F ig . 9. the symptomatic and res tricted side will hav e a preference to mov e caudad (F ig .lww. rotation). The phy sic ian will document the findings in the progress note ac cor ding to the pos ition or freedom of motion elicited..126. with thenar impulse on left. 8. 5.http://thepointeedition.125).com/pt/re/9780781763714/bookContent. Step 7. 7.125. If an anterior innominate dys func tion is pres ent.126). If a posterior innominate dys func tion is pres ent. Step 8. Fig u re 5. 5. 59 of 59 21/08/07 22:02 . Fig u re 5..

a dy s f un c ti o na l s ta t e c a us e s r e s t r ic t iv e ba r ri e rs t o e ac h s i d e o f t he n or mal re s t in g n e ut r a l p oi n t .2 an d 6 .g . a t ec h n iq u e e ng a g in g t h e mo s t r es t r ic t iv e b a r ri e r ( bi n d . 6 Principles of Osteopathic Manipulative Techniques O s t e o pa t hi c m a n ip u la t iv e te c hn i qu e s ( O MT ) a r e n u me r ou s .lww. or g / om / Gl o s s a r y .com/pt/re/9780781763714/bookContent. 1 ). 1 of 6 21/08/07 22:03 . G en e r al l y . The s ec o nd pr i n ci p le is a s s o ci a te d wi t h whi c h a n at o mi c ma n if e s t a t io n o f t h e d y s f u nc t io n i s pr i ma r y ( e . The s e b i la t er a l r e s t r ic t i ve ba r ri e r s a re mo s t c o mm o nl y as y mm e tr i c i n r e fe r e nc e t o t h e ir d is t a nc e f r om n eu t ra l b u t m a y b e e q ua l ly an d s y mme t ri c a ll y d i s t a n t ( Fi g s . Fr e qu e n tl y . a nd f in a ll y . . T h u s . a n d i nd i r ec t t ec h n iq u es en g a ge th e l e a s t re s tr i c ti v e b ar r i er . mus c l e v er s us j oi n t) . h a ve be e n s t an d ar d iz e d i n to th e s t y le s d e s cr i be d i n t h is te x t . t ig h t) i s c la s si f i ed as di r e c t an d a t ec h ni q ue e ng a gi n g t h e l ea s t r e s t r ic t i ve ba r ri e r ( e as e .am p li t u de (H V LA ) t ec h n iq u e o r o s te o pa t hy i n t he cr a n ia l f i el d . 6 . a nd s om e h av e se e n r es u r ge n ce af t e r y ea r s o f n e gl e c t . di r e c t te c hn i q ue s e n ga g e t h e mos t re s tr i c t i v e b ar r ie r . h ow e v er .. t he se c on d pr i nc i pl e di r ec t s t h e p hy s ic i a n t o u se t ec h ni q ue s s uc h as so f t t i s s u e o r mu s c l e e ne r g y r at h er t ha n h i gh . S o me te c h ni q ue s h a v e b ee n k no wn b y m o re t ha n o n e n a me . 6 .http://thepointeedition. Th e y h av e go n e t hr o u gh a met a mor p ho s is i n d es c ri p t io n . l o os e ) i s c l as s if i ed a s i nd i re c t . d oc ) . 3 ). Direct and Indi rect Technique I t i s s o me t im e s e a si e r t o u n de r s t a n d t he pr i n ci p le s o f OM T a c co r d in g t o w h i ch ba r ri e r a nd a na t om i c a r ea th e t e c hn i qu e p r i ma r il y a f f ec t s . T o de t er min e th a t a m u s cl e d y s f u nc t io n i s pr i ma r y . m a ny n ew te c hn i q ue s h a ve b ee n d e ve l o pe d .. w h ic h mo s t c om mo nl y i s d e s cr i be d a s t he e dg e o f t h e p h y s i ol o g ic ba r ri e r ( Fig . l ow . wi th th e a d v en t o f t h e E d uc a ti o n al Co u nc i l o n O s te o pa t hi c Pr i nc i pl e s ( E CO P ) a n d i t s Gl o s sa r y o f O s te o pa t hi c Te r mi n ol o g y ( ww w. Th e fi r s t pr i n ci p le re l a te s t o t h e n at u r e a nd di r e c t i on of t he re s tr i c ti v e b ar r i er . aa c om . U s in g th i s p ri n c ip l e. mo s t t e ch n iq u e s c an b e c at e go r i ze d a s d i r ec t o r i n d ir e c t .v el o ci t y .

c ou p l ed mo t io n s ) ( 1) . y et th e y a g re e w i t h t he b as i s o f t h es e fi n di n gs . wh i ch ha v e b e en du p l ic a te d b y ot h er s ( e . Figure 6.1 ..A mer i ca n m a n ua l med i c in e a s so c i at e s h av e ad d ed ot h e r c av e at s to Fr y et t e . 3 . b ut al wa y s wi t hi n th e c o nt e x t o f a s i n gl e r es t r ic t iv e b a r ri e r c au s i ng as y mm e t ri c al l y r e s t r ic t ed f in d in g s o f m o ti o n p o te n ti a l i n a n a rt i c ul a ti o n. W h it e & P an j ab i . in an in d i re c t man n e r ( wh i ch we 2 of 6 21/08/07 22:03 . R . bu t th e y h av e ta n ge n ti a l r e la t io n to h ow t he me c ha n i c s of th e ce r vi c al s pi n e a re p er c ei v ed . DO .2 a nd 6.http://thepointeedition. T h es e ru l es ar e s pe c i fi c t o t h e t h or a ci c an d l u mb a r s p in e r e g io n s . E xa mi na t io n o f th e b a rr i e rs de l in e a te d i n F i g ur e s 6 .com/pt/re/9780781763714/bookContent. a re th o s e p ri mar i l y t au g ht i n o s t e op a t hi c med i c al s c h oo l s ( f ir s t a n d s ec o nd p ri n ci p le s of ph y si o l og i c mot i o n) . 3 s h o ws th a t i t i s p o s s i b le t o t r ea t a re s t ri c ti v e b a rr i er at e it h er th e ea s e o r b i nd qu a li t y e l ic i te d on th e p a l pa t or y e xa mi na t io n . O s t e op a th i c t ex t s h a ve de s c ri b ed th i s p r in c ip l e . P ar a p hr a si n g C.. T h is wo u l d a ls o m a k e i t f ea s i bl e t o o r i en t c la s s ic a ll y d e s cr i be d d i r ec t t e ch n i qu e s . E xp a nd i ng t hi s s t at e men t t o w h a t we h av e ob s er v ed c li n ic a ll y wo u ld t he r e fo r e c or r e la t e wit h Fi g ur e s 6 . a nd mo s t f r eq u en t l y t he p ri n ci p le s s t a te d b y Ha r ri s on Fry e t t e . Asymmetric ran ge o f moti on w ith a normal physio log i c b arrier (Pb ) o ppo site th e si de on whi ch a re stri cte d barrie r (R b) is pre sent. Man y ha v e d es c r ib e d p hy s i ol o gi c p r i nc i pl e s o f m o ti o n o f t h e s pi n e . g. 2 a nd 6. we s ee th a t t h e i ni t ia t i on of sp i n al P. N e ls o n ( who s e p r in c ip l e o f m o ti o n i s c o ns i de r e d t he th i r d o f t he t hr e e p h y s i ol o g ic pr i nc i p le s o f m o t io n ). 7 6 v er t e br a l mot i o n i n o ne p la n e wil l af f ec t m o t io n i n a l l o t he r p l a ne s ( 2 ). .lww. Ou r n o n. su c h a s H V LA .

a r e t h e n or ma l p hy s i ol o gi c m o t io n s o f t h e s pe c if i c a r ea be i n g e xa min e d a n d/ o r t r ea t ed an d th e c om p l ia n ce of t he ti s su e s i n vo l ve d (e . g. h av e se e n t au g h t a nd pe r f or med in t e rn a ti o na l l y) . 3 of 6 21/08/07 22:03 .com/pt/re/9780781763714/bookContent. a c u te ve r su s ch r on i c d y s f u nc t io n ) .. w h e th e r p er f o rm i ng di r e c t or in d i re c t t ec h n iq u es . .http://thepointeedition.lww.2 . Figure 6. T h e mo s t im p or t a nt cr i te r i a t o u nd e r s t a nd . Two restrictive b a rri ers (R b ) a symmetrica lly restri cte d ..

t he ph y s ic i an ma y ch o os e t o u se o ne te c hn i q ue fo r o n e d y s f u nc t i on an d a n o th e r t ec h n iq u e f or t he ot h er . a t e ch n iq u e o ri e n te d t o t h e a r ti c ul a r a s pe c t s o f t he an a t om y m a y n o t b e i nd i c at e d. S om e pa t ie n t s e xh i bi t s o mat i c c om p o ne n t s of v is c er a l d i se a se . Figure 6. whe r ea s a p at i en t wi t h a p r i ma r y s om a t ic dy s fu n c ti o n a nd a s e co n da r y v i s c e ra l co mpo n en t ma y r e ac t we l l ( so ma ti c al l y a nd v is c er a ll y ) t o a sp e c if i c O MT . Th u s . a nd gr o s s e de ma wil l al l c a us e t he p hy s ic i an t o r ee v al u a te th e p o s si b il i ti e s f o r O MT a nd th e p o t en t ia l f o r a nu mbe r of t ec h n iq u es th a t m a y b e i n di c at e d i n t h at ca s e .. Two restrictive b a rri ers (R b ) symmetri cal ly restricted . Th i s p a ti e nt ma y b en e f it fr o m a my o fa s ci a l t e ch n iq u e b u t n ot c ou n te r s t r a in .3 . Contraindicati ons 4 of 6 21/08/07 22:03 .http://thepointeedition. The v ar i ou s q u a li t ie s e l i ci t ed on t he ph y si c a l e xa min a t io n o f a p at i en t m a y l e ad th e p hy s i ci a n t o u n de r s t a nd t ha t t h e n a tu r e o f a dy s fu n c t i o n i n o ne r eg i on is d if f er e nt f ro m t ha t of an o th e r d y s f u nc t i on in a d i f f e re n t r e gi o n. a s n o co u nt e rs t r ai n t e nd e r p oi n t s a re pr e s en t .com/pt/re/9780781763714/bookContent. a n d t h e t re a t me n t o f t hi s co mpo n en t ma y h a ve o nl y a li mi te d e f fe c t . l y mph a ti c c o n ge s ti o n. Ot h er fa c t or s i n t h e p r es e nt a t io n s o ma t i c d y s f u nc t io n m a y c h an g e t h e t ho u gh t pr o ce s s i n d e ve l op i n g t he tr e a tm e nt pl a n . s o ma t i c d y s f un c t io n i s t h e d i ag n os t i c c ri t er i o n t ha t c a l ls fo r O MT. I f a p at i e nt e xh i b it s r e gi o n al mo t io n di s tu r ba n c e b ut in t e rs e gm e nt a l m o ti o n i s n o rm a l. O th e r v is c e ra l a n d a u to n om i c e f fe c t s .. Or a p a ti e nt mig h t p r es e nt f or ne c k a c he th a t o n e x am i na t i on ex h ib i t s p ar a ve r t eb r al mu s c le h yp e r to n ic i t y a nd ge n er a l t e nd e rn e s s b ut no s pe c if i c t e nd e r p oi n t s . S omatic Dysfunction A s s t at e d e ar l i er .lww.

p r eg n an c y . Con t r ai n di c at i o ns to OM T ha v e c ha n g ed dr a ma t i ca l ly du r i ng ou r y e a rs of cl i n ic a l p ra c t ic e b e ca u s e o f t he d ev e lo p me n t o f n e w a n d/ o r mod i f ie d t e ch n i qu e s a nd b et t er u nd e r s t a nd i ng o f d is e as e pr o ce s se s . s tr a in s an d s p ra i n s .f as c ia l . t u mo r . c o mbi n ed wi t h a di r ec t or in d ir e c t a pp r oa c h . 7 7 a ch o n dr o pl a s t i c d war f is m. a 1 6. ge n e ra l ly ma k i ng th e d ec i s io n o n a c as e -b y -c a s e b as i s o f c l in i ca l pr e se n ta t i on . For e xa mpl e . O th e r c o nd i ti o n s t ha t m a y a l te r t h e p h y s i ci a n 's op i ni o n c o nc e rn i n g t he ap p r op r ia t en e s s o f O MT a re Do wn s y nd r om e ..ye a r.http://thepointeedition. a re c on t r ai n di c at i o ns fo r O MT d i re c tl y ov e r t ha t si t e. l y mp h at i c .com/pt/re/9780781763714/bookContent. d e pe n di n g o n t h e p hy s ic a l f i nd i ng s (i . a n d t h e r ep e t it i on s . r h eu mat o i d a rt h ri t i s . The O MT pr e s c r i pt i on is s im i la r t o th a t o f t h e p ha r ma c o lo g ic pr e s cr i pt i on : th e t y pe o f t ec h n iq u e i s c o mp a ra b le t o t he ca t e go r y o f t h e p ha r ma c o lo g ic ag e n t c ho s en . an d du r at i on o f t he OM T ar e c o mp a r ab l e t o t h e a mo u n t o f med i c at i on di s p en s ed an d th e f r eq u e nc y o f i t s a d mi n is t r at i on . Ho we ve r .o l d p at i en t wh o c o mp l a in s o f c h r on i c l ow b ac k p a in s ec o nd a ry t o l u mb a r d is c o ge n ic sp o n dy l os i s . v a s c u la r . T h is c as e -b y -c a s e o ri e n ta t io n m a y o f te n c h a ng e o n ly t he ch o ic e of th e p a t ie n t' s p o s it i on fo r a t ec h ni q u e a nd n ot be co n s id e re d a c on t ra i nd i c at i on fo r an en t ir e te c hn i qu e ca t eg o ry . The ph y s ic i an ' s c l in i ca l j u d gm e nt an d a c om p le t e u n de r s t a n di n g o f t h e t ec h n iq u e a re p ar a mo u nt i n t he fi n a l d ec i si o n a s t o w h e th e r O MT i s a pp r op r i at e . T h is a tl a s p re s e nt s 1 2 o s t e o pa t hi c m a n ip u la t iv e te c hn i qu e se c ti o ns .. P. T h e a bi l i t y to pe r f or m O MT i n a ra n ge o f e x t r e me l y g en t l e t o mor e fo r ce f ul man n er . The pr e vi o u sl y s ta t e d a re a s o f d y s f u nc t i on (a r ti c u la r . The s e c o nd i ti o ns may c on t ra i nd i c at e O MT i n t o ta l o r ma y c o nt r a in d ic a te o nl y a sp e c if i c t ec h n iq u e i n a s pe c i fi c r e gi o n . s u c h a s f ra c t ur e . a n a to mic in s t ab i li t y .lww. i nf e c ti o n. l um b ar sp i n al s t e no s i s . a 70 . h yp e rm o bi l i t y . an d s e v er e m a ni f e s t a ti o ns o f v is c er a l d i so r de r s . t i mi n g. e. ac u te h er n ia t ed i nt e r ve r te b ra l di s c . d is l o ca t io n . The Osteopathi c Manipulative Treatm ent Prescription The s el e c t i on o f t he te c h ni q ue to b e u se d i s pr i ma r il y fo u nd e d i n t h e n at u r e o f t he s om a t ic dy s fu n c ti o n a nd i t s mo s t p r om i ne n t ma ni f es t at i o ns . j oi n t p r os t he s i s . a nd s o o n ) t ha t c a n b e c o ns i d er e d d ur i n g s el e c t i o n o f t he t re a tm e nt p la n m a y a f fe c t t he d ec i s io n t o u s e a sp e ci f i c t ec h ni q u e a t o ne d y s f un c ti o n al le v el o r a no t he r . v i s c e ra l . H V L A v er s us mus c le en e r gy ve r su s fa c il i ta t e d p os i ti o n al r el e a se ve r su s my o fa s ci a l r e le a se o r a c o mb i n at i on ) . H o we v e r.ol d p a t ie n t who c om p la i ns o f a cu t e l ow b ac k p a in s ec o nd a ry t o a s p ra i n d u ri n g f o ot b al l p r a c t i ce ma y be tr e at e d w i th a 5 of 6 21/08/07 22:03 . th e met h o d a nd / or p os i ti o n c h os e n f or t he OM T t e c hn i qu e i s co mpa r ab l e t o t h e r o ut e o f a dm i n is t ra t io n of th e p h a rm a co l og i c a g en t . Kl i pp e l -F e il s y n d ro me. ac u t e i nf l am ma to r y s it u a ti o ns . an d l u mba r s o ma t i c d y s f u nc t io n m a y b e t r ea t e d wit h a r t ic u la t or y an d m y of a s ci a l s of t ti s su e t e c hn i qu e s wee k l y o ve r w e e k s to mo n t hs . an d os t eo mye l i ti s . Ce r ta i n c on d i ti o ns . Th is wi l l b e d i s c u s s e d f u rt h er a nd mor e sp e ci f ic a l ly in ea c h o f t h e t e ch n iq u e s e c t i on s . . h as c au s ed us t o l oo k d i f fe r en t ly a t t he ap p l ic a ti o n o f O MT. t h e f or c es i nv o lv e d i n t h e O MT a nd wh e th e r t he y ar e d i re c t ly or in d i re c tl y a p p li e d a re c om p ar a bl e to th e s t r en g th or d os e o f t h e med i c at i on .y e ar . Ea c h s ec t i on ha s a n ex p la n at o r y p re f ac e f or t he sp e ci f i c t ec h ni q u e a nd th e pr i nc i pl e s o f i t s u s e a nd ap p l ic a ti o n. myo . i t d o es no t p r e cl u de OM T to r el a t ed so mat i c d y s f u nc t i on in ar e a s t ha t a r e p r ox i ma l or di s ta l to th e p r o bl e m.

http://thepointeedition. W a rd R ( e d) .de p le t in g ef f ec t s o f t h e c on d i ti o n. P h il a de l ph i a : L i pp i nc o t t Wil l ia ms & Wi l ki n s . 6 of 6 21/08/07 22:03 . F o u nd a ti o ns f or Os t eo p a th i c Med i c in e . 2 0 03 . C o mm o n me di c al se n s e c om b i ne d w i th a w e ll . W h it e A.. References 1 .gr o u nd e d r is k . th e se v er i t y a nd en e rg y . a n d wh et h er th e co n di t io n is ac u te o r c hr o ni c . th e ag e o f t h e p at i e nt .lww..com/pt/re/9780781763714/bookContent. C l in i c al Bi o me c h an i c s of t he Sp i ne . o ne mus t u nd e r s t a nd th e na t ur e o f th e d y s f u n c t i on an d th e o t he r cl i ni c al man i fe s ta t i on s b e in g p re s e nt e d. P hi l a de l ph i a: L ip p in c ot t Wi ll i am s & Wil k in s . 2 . mus c le en e r gy . S im p l e r ul e s t o g u id e t h e i mpl e me n t at i on of O MT ar e b e s t s ee n i n th e d o se g ui d el i ne s o ut l i ne d i n t h e F o un d at i o ns fo r O s t eo p at h ic Med i ci n e ( 2 ). Pa n ja b i M . a n d c o un t er s tr a i n t ec h n iq u es ev e r y 2 t o 3 d ay s f o r 2 to 4 wee k s . In ge n e ra l . 1 99 0 .be n ef i t r a ti o na l e s h ou l d b e t h e g ui d in g pr i nc i pl e s . c om b i na t io n o f in d ir e c t myo f as c ia l re l ea s e. 2n d e d .

e. and fo r ce of pre s su r e w i ll va r y w i th th e sp eci fic are a b ein g tr eat ed beca use of norm al anat omi c c hang es fro m re gio n t o re gio n. T he m os t d i s ti ngu i sh i ng asp ect s of so ft ti ss ue tech niq ue a s c omp ar ed to my ofas c ia l r el ea s e tec hniq ue are tha t w i th m yo fas c ia l re l ea s e tech niq ue the forc es ar e m or e d eepl y d i re c ted in to the pat i en t an d t hat the s e for c es are im pl em ent ed i n a rh y th m i c. als o c al le d m y of as ci al tec hniq ue” (1 ) . th e p hy si c ia n m us t und ers tand th e a nato m ic re l ati ons hip of the ti s s ue s b ein g tr ea ted i n ter m s of m usc ulo tend i no us or ig i n and i ns ert i on . Ea c h of t hes e wi l l c au s e a re l at i v e i nc r ea s e i n l eng th o f t he m y of asc i al tis s ue be i ng tre ate d.lww. th e hand th at i s p r ox i m al to th e in s er tio n. 1 of 64 21/08/07 22:03 .s ol ) and c au s i ng ti s su e re act i vi ty ( fas c ia l cr eep ) . t he s pec i fi c ma nua l m etho ds by w hic h t he phys i ci an c aus es thes e r eac ti on s a r e s l ig htl y d i ffe r en t. m or e tha n 3 0 se c on ds or u nti l t he t i ss ue r ele ase s ( as not ed b y a n i nc re ase in i ts le ngt h or de c re as e i n i ts ten s io n) ( 2). a nd the tr ea tme nt f orc e i s di r ec ted par all el to t he m us c ulo ten din ous axi s . To us e dir ec t tec hni que.http://thepointeedition. c aus i ng an ove r al l i nc re ase in l en gth of t he s tru c tu r e. T hi s m ay be d one by dir ect i ng a f orc e w i th the ha nd t hat is pro x im al to t he ori gi n. H owe v er . bi nd). dep th.com/pt/re/9780781763714/bookContent. i n w hic h t he p hys i ci an m ay c ho os e to use a c ons tan t. P erpendi cular Traction In p erp endi c ul ar tr ac tio n. d eep pre s su r e. tra c ti on. . de pth of the mu s cl e or fa s ci a. d eep l y i ntr odu c ed for c e ove r so m e tim e (i . T he for c es s ho uld be dir ect ed d eep l y enou gh to enga ge the tis s ue be i ng tre ate d. T he d i re c ti on. the m yo fas c i al st r uc ture in qu es ti on i s c ont act ed at i ts m id poin t b etw een the or ig i n and i ns ert i on. p r ess ure of f) f ash i on . Technique Styles P aral lel Tracti on In p ara l l el tr act i on. b ut at the s am e t i m e the tr ea tme nt s hou l d be m i ld l y to m ode r at el y i nt r od uc ed an d c om fo r ta bly acc ept ed by t he pat i ent . l in ear s tr etc hi ng . al te r na ti ng (p r es s ure on . w hi c h us ua l ly in v olv es l at er al st r et c hin g. S ome as pect s o f s oft tis s ue tec hni que s ar e s i mi l ar to thos e o f my ofa s ci al r ele ase i n r es pec t to th e t herm ody nam i c e ffe c ts i n alt eri ng p hys i ca l st ate s ( gel . a nd m us c l e ty pe . 7 Soft Tissue Techniques Technique Principl es Soft ti s s ue te c hn i que is de fi ne d b y t he E duc ati on C oun c il on Ost eop athi c P r in c i pl es ( EC OP) as “ a di re c t tech niq ue. the my ofas c ia l t i s su es are m ov ed tow ar d the re s tri c ti v e barr i er (t ensi on. and /or s epa r at i on of m us c l e ori gin and in s er ti on wh i le m on i to r in g ti s su e r es po nse an d mo tio n c hang es by palp ati on. Technique Cl assifi cati on Di rect Technique In d i re c t t ech niq ue. th e m y ofa s ci al s tru c tu r e bein g t r ea ted i s c on tact ed at i ts ori gin and in s er ti on .. T he only ex ce pti on t o t his r ul e i s t he i nhi bit or y pre s su r e s tyl e. an d a per pen dic ul ar fo r ce i s dir ect ed a w ay fr om t he l on gi tu din al ax is .. o r b oth han ds m ov i ng opp osi te e ach ot her at the s am e t i me .

the s of t ti s su e pr one pr ess ur e tec hni que m ay be c on tra i nd i c at ed ove r th e t hor ac oc ost al and pel v ic r egi ons .g . and a forc e i s d i r ec ted in to i t.s oma tic or s om ato v is c era l r efl ex es ) . Im pro v e the phy s ic i an. 6. the pr es s ur e sh oul d b e di r ec ted at the te ndon or mu s c ul ote ndi nous ju nct i on. in th es e s it uat i ons ca uti on s hou l d pr ev ail . fas c i al te nsi on. Othe r p r eca uti ons i n the us e of so ft ti ss ue tec hniq ue: 1. c ont act an d st r et c hi ng o v er an a c ut el y s tr ain ed o r s pra i ned my ofa s c ia l . Re duc e p atie nt gua r din g d uri ng i m pl eme ntat i on of oth er ost eopa thi c m anip ula tiv e te c hn i qu es o r ad dit i on al m edi c al tre atm ent . 3. Fo r ex amp l e. a nd t he s of t ti s su e t ec hn i qu e m ay b e w i th hel d un til ti s s ue di s ru ptio n a nd i nfl amm ati on h ave st abil i ze d. or c aps ula r st r uc tur e ma y e x ac er ba te the c ond i ti on. 5. T her efor e. Pr omo te pati ent re l axa tio n. a nd/o r f i br otic my ofa s c ia l s tru c tur es to im pro v e r egi ona l a nd/o r i nte r s eg m en tal r an ges of m ot i on .. and se ns it i vi ty.com/pt/re/9780781763714/bookContent. 4. St r et c h and i nc r ea s e e l as tic i ty of s ho r ten ed. H ow ev er . 8. St i mu l at e th e s tre tc h r ef l ex i n hyp oto ni c m us c le s . 7. the my ofas c ia l s tr uc tur e b ei ng tr eat ed i s c ont ac te d o v er the m usc ulo tend i no us port i on of the hy per toni c m usc l e. P. and mu s c le sp asm . ti ss ue tex ture ch ang es . In c re ase v en ous an d ly m ph ati c dr ain age to dec r ea s e l oca l a nd/o r d i st al s w el l in g an d e dem a an d po ten tia l l y i mp r ov e th e o v er al l i mm une r es pon s e. m us c le te ns io n. 2. 9. 10. in el as tic . Po ten tia te t he eff ec t of oth er o s te opa thic te c hn i que s . l ig am en tou s . i n an eld er ly os teo poro tic pa ti en t. Di rect I nhibitory P ressure In d i re c t i nhi bit or y pre s su r e. Contraindications Relative Contraindi cations U s e w it h ca uti on. as c om m on m ed i ca l s ense is th e ru l e. a s t hi s tec hni que typ i ca l l y i mp art s a ple asa nt se nsa tio n to th e p atie nt. T he r ef or e. Us e a s p ar t of the m us c ul osk el et al s cr eeni ng exa m i na tio n t o qu i ck l y i den tif y r egio ns of r est r ic ted mo tio n. bu t t he l ate r al re c umb ent me thod s c an be m ore sa fely ap pli ed. s pec i fi c pr ess ure on the mu s c le be l ly c an ca use pai nfu l s i de eff ect s an d b r ui s i ng .http://thepointeedition.pat i en t re l at i on s hip . thro ugh so m at i c.80 I ndicati ons 1. Als o. Im pro v e c i rc ula tio n to th e s peci fic re gi on be i ng tre ate d b y lo c al ph y s ic al and the r mo dyn am ic ef fec ts or b y r efl ex p hen ome na t o i m pr ov e c ir c ul atio n i n a dis tal ar ea ( e. 2 of 64 21/08/07 22:03 . Ac ute sp r ain or st r ain .lww... d eep . Re duc e m us cl e h y pe r ton i ci ty.

In i ti all y . th e c ade nc e s ho uld r em ain sl ow ly rh y th m i ca l . As th i s i s n ot a m as sa ge or fr ic tio n t ec hn i qu e. pus hin g or pu l li ng p erp end i c ul ar to c aus e t r ac ti on to th e lo ng axi s of th e m us cu l ot end i nou s s tr uct ur e b. Th e p ati ent s ho uld be c om for tabl e a nd r ela x ed . Fr act ure or dis l oc atio n. 5. T he phys i ci an' s ha nd s ho ul d c ar r y the s ki n w i th i t and not sl i de acr oss it wh en app l y in g t he di re c te d f or ce . As he at deve l op s an d t he ti ss ues be gi n to r ea c t. Os teo por os is an d o s teo pen i a. neve r r ub or i r ri tat e th e p ati ent' s s k in by the fr i ct i on of y ou r h ands . . 4.. h owe v er.. 4. f orc es m ust be of l ow in ten s i ty an d a ppli ed s lo w l y and rh y thm i ca l ly . 2. 3. S upine 3 of 64 21/08/07 22:03 .g. General Considerati ons and Rules 1. Ne uro l og i c o r v asc ul ar co m pr om is e. A co m fo r ta bl e and pl easa nt ex per i en c e i s t he i nte nde d e ffec t. Ne v er di r ect fo r ce s di r ec tly i nt o b one . M os t r es tr i ct i on s ar e f or tr ea tme nt i n t he aff ec te d a r ea of m al i gn ancy . the pr es su r e m ay be i nc r ea s ed i f c li ni ca l ly in di ca ted an d we l l to l er ate d. h owe v er . Th e a ppl i ed for c es s ho uld al w ays be co m for tab l e and not ca us e pai n. Th e p hys i c ia n s hou l d b e i n a pos i ti on of c omf ort s o as to m i ni m iz e e nerg y e x pe ndit ure an d wh ene v er pos s ib l e s hou l d use bod y w eig ht i nst ead of upp er ex tr emi ty s tre ngt h a nd e ner gy. De ter m in e ho w y ou w oul d l i ke to emp l oy the fo r ce : a. ca r e sh oul d b e ta k en in oth er dis tal are as depe ndi ng on t y pe of m al i gn anc y an d/o r l y m ph ati c in v ol v em ent. 5. 6. 7.81 Cervi cal Region: Traction.lww. Absol ute Contraindi cations N one . Ma l ig nan c y . By app l y in g t r ac ti on in a para l le l d i r ec tio n t o th e l ong axi s . 2. 3. i nc r eas i ng th e di s ta nce bet w ee n th e o r ig i n a nd i ns er ti on of the m us c le fib ers P.http://thepointeedition. o s teo m ye l it i s ). an d l i mi t pr ess ure i nt o t he m usc l e bel l y . In fec tio n (e .com/pt/re/9780781763714/bookContent. 6. a s th e p hys i c ia n m ay w ork pr oxi m al to the pro ble m a bove or be l ow the af fect ed are a an d m ay al te r t he p ati ent ' s p osi tio n or te c hn i que to ac hi ev e s ome ben efi c ia l ef fec t.

T he physic ian's one hand gently c r adles the occiput between the thumb and index finger .com/pt/re/9780781763714/bookContent. 4 of 64 21/08/07 22:03 . 1..2. Step 4. T he patient lies s upine on the tr eatment table.) 4. It may be inc reased in amplitude as per patient toler anc e. T his trac tional for ce is applied and releas ed s lowly . 7. or the oc c ipitomastoid s uture will be c ompressed (F ig. T he physic ian's other hand lies ac r oss the patient's for ehead or grasps under the chin ( Fig s. patient.1. Fig ure 7. 3.http://thepointeedition.2). 2.. 5.lww. Step 3. 7.3. Fig ure 7. T he cr adling hand mus t not s queeze the oc ciput. T he physic ian sits or stands at the head of the table. (Us e c aution in patients with tempor omandibular joint [TMJ ] dy s functions. T his technique may also be per for med using Fig ure 7. T he physic ian ex erts cephalad tr action with both hands with the head and neck in a neutral to slightly flexed pos ition to av oid extension. Step 3.3).1 an d 7. skeleton. 6.

.com/pt/re/9780781763714/bookContent.http://thepointeedition.. P.82 Cervi cal Region: Forward Bending (Forearm Ful crum ).lww. S upine 5 of 64 21/08/07 22:03 .

Step 4. 2.. T his s tretch c an be r epeated as many times as nec ess ary Fig ure 7. T he phy sic ian gently r otates the patient's head along the phy sic ian's for ear m toward the elbow.5. Step 3. 7.. 7.com/pt/re/9780781763714/bookContent. 3. 6 of 64 21/08/07 22:03 . Fig ure 7. 1. 5. rotation r ight.7. T he patient lies s upine on the tr eatment table.http://thepointeedition. neutral. 4. T he phy sic ian is s eated at the head of the table.6.lww. T he phy sic ian gently flexes the patient's nec k with one hand while sliding the other hand palm down under the patient's nec k and opposite s houlder ( F ig.5). Step 6. pr oduc ing a unilateral s tr etc h of the c er vic al par avertebral mus culatur e ( F ig.6). Fig ure 7.

lww.com/pt/re/9780781763714/bookContent. S upine 7 of 64 21/08/07 22:03 .http://thepointeedition.. P.83 Cervi cal Region: Forward Bending (Bilateral Fulcrum)..

7. 7. T he phy sic ian's ar ms are c r ossed under the patient's head and the phy sic ian's hands are placed palm down on the patient's anterior s houlder r egion (F ig. 3.9).lww. T he phy sic ian's for ear ms gently flex the patient's nec k. 4. Step 4.9. T he patient lies s upine on the tr eatment table. 5.10). 1. T his tec hnique may be per for med in a gentle..com/pt/re/9780781763714/bookContent. 8 of 64 21/08/07 22:03 . pr oduc ing a longitudinal s tr etc h of the c er vic al par avertebral mus culatur e ( F ig.http://thepointeedition. T he phy sic ian is s eated at the head of the table.10. r hy thmic fas hion or in a s ustained manner . Step 3. Fig ure 7. Fig ure 7.. 2.

. 3..11. Keeping the c audad ar m s tr aight. T he phy sic ian's c ephalad hand lies on the patient's for ehead to s tabilize the head ( Fig . P. 5. Step 4. 7.13. the phy sic ian gently dr aws Fig ure 7.84 Cervi cal Region: Contralateral Traction. 4.11). S upi ne 1. 9 of 64 21/08/07 22:03 . T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated. T he phy sic ian's c audad hand r eaches ov er and ar ound the neck to touch with the pads of the finger s the patient's c er vic al par avertebral mus culatur e on the side opposite the phy sic ian ( F ig. 2. 7. Step 3.lww. Fig ure 7. Fig ure 7.12.12).com/pt/re/9780781763714/bookContent. T he patient lies s upine on the tr eatment table.http://thepointeedition. Step 5.

and k neading fas hion or in a s ustained manner . 7. T his tec hnique may be per for med in a gentle.com/pt/re/9780781763714/bookContent.lww. the par avertebral mus cles v entrally ( white ar r ow.85 Cervi cal Region: Cradl ing wi th Traction.13). r hy thmic. 6. S upi ne 10 of 64 21/08/07 22:03 . F ig ...http://thepointeedition. T is sue tension is r eevaluated to ass ess the effectiveness of the tec hnique. P. pr oduc ing minimal ex tens ion of the cervic al s pine. 7.

T he patient lies s upine on the tr eatment table. 2.. 3..15. 11 of 64 21/08/07 22:03 .16. Fig ure 7. 7.14.15 Fig ure 7. Fig ure 7. 7. with the finger tips lateral to the c er vic al s pinous pr oces ses and the finger pads touching the par avertebral mus culatur e ov erly ing the ar ticular pillar s ( Fig . Step 4. 4. T he phy sic ian ex erts a gentle to moderate for ce.14).lww. T he phy sic ian's finger s ar e placed under the patient's nec k bilaterally. v entrally to engage the s oft tiss ues and cephalad to produc e a longitudinal tr actional effect ( s tretch) ( F igs. T he phy sic ian s its at the head of the table. 1. Step 3.com/pt/re/9780781763714/bookContent.http://thepointeedition. Step 4.

19. Fig ure 7.19) . P. 7.18. T he phy sic ian s its at the head of the table.86 Cervi cal Region: S uboccipital Release.17).lww. in c ontac t with the tr apez ius and its immediate underlying mus culatur e ( F ig.. 4. T he phy sic ian s lowly and gently applies pr essure upward into the tissues for a few s ec onds and then r eleases the pr ess ure ( F igs. 5.17. 2. T his pr essure may be r eapplied and Fig ure 7.18 an d 7. Step 3. 12 of 64 21/08/07 22:03 . Fig ure 7. T he patient lies s upine on the tr eatment table.http://thepointeedition. Step 4.. 7. Supine 1. Step 4. 3.com/pt/re/9780781763714/bookContent. T he phy sic ian's finger pads ar e placed palm up beneath the patient's s ubocc ipital r egion.

lww. P.http://thepointeedition.com/pt/re/9780781763714/bookContent. r eleas ed s lowly and r hy thmically until tis s ue tex tur e c hanges oc c ur or for 2 minutes . T he pr ess ure may also be c ontinued in a more c onstant inhibitor y s ty le for 30 s ec onds to 1 minute.. S upine 13 of 64 21/08/07 22:03 .87 Cervi cal Region: Rotation..

T his is r epeated to eac h s ide until r eleas e of tissue tension and/or improv ement of r ange of motion.com/pt/re/9780781763714/bookContent. Fig ure 7. Fig ure 7. 3.22.22).. 14 of 64 21/08/07 22:03 .. Step 3. 4. T he physic ian then s lowly rotates the head to the r ight r es trictiv e barr ier at its pas siv e tolerable elastic limit and holds this pos ition for 3 to 5 s ec onds ( Fig . T he physic ian gently and slowly ax ially r otates the patient's head to the left to the r es trictiv e barr ier at its pas siv e tolerable elastic limit and holds this pos ition for 3 to 5 s ec onds ( Fig .http://thepointeedition. T he physic ian's c upped hands ( palmar as pec t) ar e placed to each s ide of the patient's tempor omandibular r egion.21). 2.lww.20). making s ur e to not c ompress over the ex ternal acoustic meatus (F ig.21. T he physic ian sits at the head of the table. T he patient lies s upine on the tr eatment table. 7.20. Step 4. 1. Step 5. 7. 5. Fig ure 7. 7. 6.

P.http://thepointeedition. Forefingers Cradl ing 15 of 64 21/08/07 22:03 ..lww..88 Cervi cal Region: S upine.com/pt/re/9780781763714/bookContent.

Fig ure 7. T he patient's head is bent s lightly bac kward ( ex tended) and taken thr ough a pr ogression of side bending and r otation to one side and then the other with c ontinuing pr essure fr om the finger pads on the Fig ure 7.http://thepointeedition. 1...23). 2. pr oximal to the ar tic ular pr oces ses ( F ig. Step 4. 4. Step 4. 7. T he patient lies s upine on the tr eatment table.lww.25. Fig ure 7. 16 of 64 21/08/07 22:03 . T he phy sic ian s its or s tands at the head of the table.24. 3.23. Step 3. T he phy sic ian's hands cradle the tempor al r egions ( av oiding pr essure ov er the ear s) with the finger s ov er the c er vic al par aspinal tis sues.com/pt/re/9780781763714/bookContent.

T he thumb and for efinger of one of the phy sic ian's hands cups the poster ior c er vic al area palm up ( Fig . T he phy sic ian s its or s tands at the head of the table. Fig ure 7. Fig ure 7. 17 of 64 21/08/07 22:03 . P.27 and 7. Step 3.com/pt/re/9780781763714/bookContent. Step 4.http://thepointeedition.. T he phy sic ian's other hand is placed ov er the tempor al and fr ontal r egions of the patient's head and gently br ings the head into s light bac kward bending ( ex tension) and rotation agains t the thumb (F ig s.. 7.89 Cervi cal Region: Thumb Rest. 7.27.26.lww. Step 4. 3. Fig ure 7. Supine 1.26).28. 2.28). 4. T he patient lies s upine on the tr eatment table with or without a pillow under the head.

com/pt/re/9780781763714/bookContent.. S upine 18 of 64 21/08/07 22:03 .90 Cervi cal Region: Coupl ing wi th S houlder Bl ock. 5.http://thepointeedition.lww. 6. T he motion is v er y s light. P. 7.. T he pr ess ure may be r ev ers ed to the other s ide. T ension ( pr ess ure) is r elaxed s lowly and r eapplied s lowly .

T he physic ian places one hand on top of the patient's ac r omioclavic ular joint on the side to be treated ( F ig. F igure 7.http://thepointeedition. 1. Steps 3 and 4.29.29). anterior head control. 7. T his is r epeated r hy thmically and gently until r eleas e of tissue tension and/or improv ement in r ange of motion. 5. 3.. 4. B. Step 2.30. posterior head control.. T he physic ian's hands may be r ev ers ed and the F igure 7.com/pt/re/9780781763714/bookContent. 19 of 64 21/08/07 22:03 . 2.lww.30.30). T he patient lies s upine on the tr eatment table and the physician s tands or sits at the head of the table. T he physic ian mov es the head until meeting the r es trictiv e barr ier at its pas siv e tolerable elastic limit and holds this position for 3 to 5 s econds and then s lowly r eturns the head to neutral. alternate. T he physic ian's other hand c r osses the midline to contr ol the patient's head from that s ame s ide and gently pus hes the head toward the oppos ite side ( F ig. F igure 7. A. 7. Steps 3 and 4. 6.

Seated (Exampl e: Left Cervi cal Paravertebral Muscl e Hypertoni city.. Fascial I nelasti city.lww.91 Cervi cal Region: Lateral Traction.. P. and Others) 20 of 64 21/08/07 22:03 .http://thepointeedition.com/pt/re/9780781763714/bookContent.

com/pt/re/9780781763714/bookContent..31). T he phy sic ian's left hand is placed on top of the patient's left s houlder at the s uperior tr apez ius and s uprac lav icular r egion (F ig. T he physic ian s tands behind and to the right s ide of the patient with the patient r esting c omfor tably agains t the phy sic ian's c hest.32). 2. Step 4. 1. 21 of 64 21/08/07 22:03 .33. 7. 3. 5. 4. Step 5.31..lww. T he patient is s eated on the tr eatment table. T he phy sic ian's r ight hand gently rotates the patient's head to the r ight and ex erts a gentle c ephalad Fig ure 7. Fig ure 7.http://thepointeedition. Fig ure 7. 7.32. Step 3. T he phy sic ian's r ight cupped hand and for ear m ar e pas sed under the patient's c hin s o as to gently touch the patient's left per iauric ular r egion (F ig.

. Using Ri ght Knee) 22 of 64 21/08/07 22:03 .com/pt/re/9780781763714/bookContent. P.http://thepointeedition.lww..92 Cervi cal Region: S i tti ng Traction (Exam ple.

1.34 an d 7.http://thepointeedition. 6.34. T he patient is s eated on the tr eatment table. T he phy sic ian's r ight elbow is placed on the r ight thigh. T he tr action is r eleas ed when the physic ian Fig ure 7.36. 2. Step 5. 7.35. alter native hand pos ition. Fig ure 7. T he physic ian s tands behind and to the left of the patient.. 7.36).com/pt/re/9780781763714/bookContent. 7.35) . T he physic ian s lowly elevates the right thigh and knee by lifting the heel of the right foot ( plantar. T he phy sic ian's r ight foot is placed on the table with the r ight knee and hip flexed. 4. 23 of 64 21/08/07 22:03 . thereby pr oduc ing c er vic al tr action ( Fig . 3.lww. Step 6. 5.. Step 5. T he phy sic ian's r ight hand c r adles the oc c iput with the thumb and index finger while the left hand holds the patient's for ehead ( F igs.flex ing foot). Fig ure 7.

3. 7. T he patient's fr ontal bone ( forehead) is placed agains t the phy sic ian's infrac lav icular fos sa or s ternum ( Fig . 4. Step 4. 7.. T his c aus es the phy sic ian's hands to Fig ure 7. Fig ure 7. Fig ure 7.lww.. T he physic ian leans bac kward. 5. Step 5. T he patient is s eated on the tr eatment table. Step 3.com/pt/re/9780781763714/bookContent. T he physic ian s tands fac ing the patient with one leg in fr ont of the other for balanc e.39. dr awing the patient towar d the physic ian.http://thepointeedition.39).38. 24 of 64 21/08/07 22:03 . 2. Seated 1. P.38).40.93 Cervi cal Region: Head and Chest Positi on. T he pads of the phy sic ian's finger s c ontac t the medial as pect of the cer vic al par avertebral mus culatur e ov erly ing the ar ticular pillar s ( Fig .

.lww. P. engage the s oft tiss ues. 6.http://thepointeedition.. This pr oduc es a longitudinal tr actional effect ( s tretch) ( F ig.com/pt/re/9780781763714/bookContent.94 Thoracic Region: P rone Pressure 25 of 64 21/08/07 22:03 . ex erting a gentle ventral for ce with c oncomitant c ephalad tr action.40). 7. r hy thmic. T his tec hnique may be per for med in a gentle. and k neading fas hion or in a s us tained manner . 7. T is sue tension is r eevaluated to ass ess the effectiveness of the tec hnique.

42. 3. the head may be kept in neutral.. Fig ure 7. 1. Step 4.lww.41. 4. T he phy sic ian places the thumb and thenar eminence of one hand on the medial as pect of the patient's thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian ( F ig.com/pt/re/9780781763714/bookContent.http://thepointeedition.. (If the table has a face hole.41). T he phy sic ian places the thenar eminence of the other hand on top of the Fig ure 7. Step 5. T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated. 7.) 2. T he patient is pr one. Step 3.43. pr efer ably with the head tur ned toward the phy sic ian. 26 of 64 21/08/07 22:03 . Fig ure 7.

com/pt/re/9780781763714/bookContent. T he phy sic ian's hands are placed palm down s ide by s ide on the medial as pect of the patient's thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian ( F ig. Step 3. Step 5. Step 4. Fig ure 7.. 3. 27 of 64 21/08/07 22:03 .95 Thoracic Region: P rone Pressure With Two Hands (Catwalk) 1. opposite the s ide to be tr eated. T he phy sic ian adds enough Fig ure 7.lww. 7.46. Fig ure 7. the head may be kept in neutral).45.http://thepointeedition. pr efer ably with the head tur ned toward the phy sic ian.. P.44). T he phy sic ian s tands at the s ide of the table. (If the table has a face hole.44. T he patient is pr one on the tr eatment table. 4. 2.

T his forc e is held for s ev eral s ec onds and then s lowly r eleas ed. downward pr essure to engage the underlying fas cia and mus culatur e with the c audal hand ( F ig..47). 6. 28 of 64 21/08/07 22:03 . 7. 7. T he phy sic ian adds later al pr essure.lww.. tak ing the my o-fascial s tr uctures to their c omfor table elastic limit ( F ig. 7. T he c ombination of downwar d and later al for ces and the releas e of this pr essure is alternately applied Fig ure 7.45). the phy sic ian's c ephalad hand begins to add a downward lateral force ( F ig.47.46). 7. Step 7.http://thepointeedition. As the pr essure is being r eleas ed with the caudal hand. 5. 8.com/pt/re/9780781763714/bookContent.

T he downward and later al pr essure dir ected by eac h hand s hould be r hy thmically applied for s ev eral s ec onds. between the two hands .lww. 9.com/pt/re/9780781763714/bookContent. P.http://thepointeedition..96 Thoracic Region: P rone Pressure with Counterpressure 29 of 64 21/08/07 22:03 ..

Fig ure 7. Fig ure 7.49.50.) 2.http://thepointeedition..48. 3. the head may be kept in neutral. T he physic ian places the hy pothenar eminence of the cephalad hand on the medial as pect of the patient's Fig ure 7.lww. Step 4. Step 5. T he physic ian s tands at either side of the table. T he physic ian places the thumb and thenar eminence of the caudad hand on the medial as pect of the patient's thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian with the finger s pointing c ephalad. pr efer ably with the head tur ned toward the physic ian. 4. 30 of 64 21/08/07 22:03 .. 1. ( If the table has a fac e hole. Step 4.com/pt/re/9780781763714/bookContent. T he patient lies prone on the tr eatment table.

T he physic ian is seated on the side of the table.. Step 3. Step 5.52. 3. fac ing the patient. 4.53. Fig ure 7. 31 of 64 21/08/07 22:03 . T he physic ian r eaches ov er the patient's s houlder with the caudad hand and places the thumb and thenar eminence on the medial as pect of the par a-v ertebral mus cles ov erly ing the upper thorac ic tr ansv ers e pr oces ses at the side on which the patient is ly ing ( F ig. 7. Step 4.com/pt/re/9780781763714/bookContent.lww..51). T he physic ian r eaches under the patient's fac e with the c ephalad hand and c ontac ts the Fig ure 7. T he patient lies in the lateral r ec umbent ( s ide lying) pos ition.97 Thoracic Region: S i de Leverage. Fig ure 7. Lateral Recum bent 1. 2.http://thepointeedition.51. P. tr eatment side down.

T he phy sic ian's c audad hand ex erts a gentle for ce v entrally and laterally to engage the s oft tiss ues while the c ephalad hand gently lifts the head to produc e c er vic al and upper thorac ic s ide bending. 32 of 64 21/08/07 22:03 . Step 7. 6.53).lww. 7. c r adling the head ( Fig . and k neading fas hion or us ing deep. T he phy sic ian's c audad hand is r epositioned to contac t differ ent lev els of the Fig ure 7. T he phy sic ian may add slight flexion until meeting the c omfor table elastic limit of the tissues ( F ig. 5.http://thepointeedition.52).. Step 5 can be r epeated s ev eral times in a gentle.54. 7. 7. r hy thmic. per iauric ular r egion. s us tained pr essure..com/pt/re/9780781763714/bookContent.

Prone 33 of 64 21/08/07 22:03 .http://thepointeedition..98 Thoracic Region: Bi lateral Thumb Pressure.54).lww.com/pt/re/9780781763714/bookContent.. upper thorac ic s pine and steps 5 and 6 are per for med to s tr etc h v ar ious por tions of the upper thorac ic par avertebral mus culatur e ( F ig. 7. P.

Step 2. Fig ure 7. Step 3. 7. 2.56. T he phy sic ian's thumbs ex ert a gentle v entral force to engage the s oft tiss ues and add a c audal and s lightly lateral force until meeting the c omfor table elastic limits Fig ure 7.http://thepointeedition.55).com/pt/re/9780781763714/bookContent. T he phy sic ian's thumbs bilaterally c ontac t the par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses of T 1 with the finger s fanned out laterally (F ig. the head may be kept in neutral.. Step 6. (If the table has a face hole. 34 of 64 21/08/07 22:03 ..57. pr efer ably with the head tur ned toward the phy sic ian. T he patient lies prone on the tr eatment table. 1.55. Fig ure 7.) The phy sic ian s tands at the head of the table. 3.lww.

5.com/pt/re/9780781763714/bookContent. I nhi bitory Pressure. Step 3.59). 2.61). 7.. T he patient lies s upine on the tr eatment table. T he physic ian s lowly adds a s queez ing for ce on the tr apez ius between the thumbs and finger s ( Fig .60. Fig ure 7. alter native pos ition. 3. T he physic ian's hands are placed on eac h tr apez ius so that the thumbs (pads up) lie approx imately two thumb's-br eadths inferior to the pos ter ior bor der of the tr apez ius and the index and third digits ( pads down) r est on the anterior bor der of the tr apez ius two finger 's.59.http://thepointeedition. T he physic ian s its at the head of the table. P.61. 7. 7. Step 4.60).breadths inferiorly (F ig. The thumbs and finger pads may be rev ers ed in pos ition if this is mor e c omfortable for the physician ( F ig. T his pres s ure is held until tissue Fig ure 7. 35 of 64 21/08/07 22:03 .. Step 3.99 Thoracic Region: Trapezius. Supine 1. Fig ure 7.lww. 4.

http://thepointeedition..lww.. P.com/pt/re/9780781763714/bookContent. Lateral Recumbent 36 of 64 21/08/07 22:03 . tex tur e c hanges ar e palpated or for 1 to 2 minutes.100 Thoracic Region: Upper Thoracic with S houl der Bl ock.

Fig ure 7. T he physic ian's c audad hand is pas sed under the patient's arm. 7. 3.64). Step 3. T he physic ian's c ephalad hand c ontac ts the anterior portion of the shoulder to pr ovide an effec tiv e c ounterfor ce (F ig. Step 4.. 1. T he patient lies in the later al r ec umbent pos ition with the s ide to be tr eated up.. 37 of 64 21/08/07 22:03 .62. Fig ure 7. 7. v entrally to engage the soft tiss ues and laterally to create a per pendic ular s tr etc h of the Fig ure 7. with the pads of the finger s on the medial as pect of the patient's par avertebral mus cles ov erlying the thorac ic tr ansv ers e pr oces ses (F ig. Step 4. 7.64.http://thepointeedition. 2. T he physic ian's c audad hand exer ts a gentle forc e. facing the patient. T he physic ian s tands at the side of the table.63. alter native pos ition. 4. 5.com/pt/re/9780781763714/bookContent. Note: The patient's arm may be flexed approx imately 120 degrees and draped ov er the phy sic ian's s houlder.62).lww.c ontacting ar m as needed ( F ig.63).

P.http://thepointeedition..lww.com/pt/re/9780781763714/bookContent..101 Thoracic Region: Lower Thoracics Under the Shoul der. Lateral Recumbent 38 of 64 21/08/07 22:03 .

.68.66. 3. fac ing the fr ont of the patient.. with the pads of the finger s c ontac ting the medial as pect of the patient's par avertebral mus cles. Step 4. 4. Step 3. T he phy sic ian r eaches both hands under the patient's ar m.67) .http://thepointeedition. Fig ure 7.lww. T he phy sic ian's hands exer t a gentle for ce v entrally to engage the s oft tiss ues and later ally to create a per pendic ular s tr etc h of the thorac ic par avertebral mus culatur e Fig ure 7.com/pt/re/9780781763714/bookContent. Step 3. T he patient is in a later al r ec umbent pos ition with the side to be tr eated up. 2. 7. 39 of 64 21/08/07 22:03 . 1.66 an d 7. Fig ure 7. T he phy sic ian s tands at the s ide of the table. ov erly ing the thorac ic tr ansv ers e pr oces ses ( F igs.67.

T he pads of the physic ian's finger s c ontact the upper thorac ic par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses ( F ig..70.69). Fig ure 7. T he physic ian s tands fac ing the patient. 5. 7. T he phy sic ian's hands reac h under the patient's for ear ms and ov er the patient's s houlders .http://thepointeedition. 40 of 64 21/08/07 22:03 .lww. Step 1. Fig ure 7. 2. 7. Seated 1. 4.102 Thoracic Region: Over and Under Techni que.69. 3. With one leg s lightly behind the other for balanc e. Step 5. Step 4. T he patient is s eated with the ar ms c r ossed and the thumbs hooked into the antec ubital fos sae (F ig.70). allowing the patient's for ehead to r es t on the for ear ms. P..71.com/pt/re/9780781763714/bookContent. the phy sic ian leans bac kward and Fig ure 7.

T he phy sic ian s imultaneously r aises the patient's for ear ms. 8. 6. 7.71). pr oduc ing minimal thorac ic ex tens ion ( F ig. Fig ure 7. dr aws the patient for war d. T he pads of the physic ian's finger s ex ert a gentle ventral and cephalad for ce to engage the s oft tiss ues. s us tained pr essure. and k neading fas hion or us ing deep. 7. 7.72...72).lww. r hy thmic. Steps 5 and 6 may be r epeated s ev eral times in a gentle. Step 6. pr oduc ing a longitudinal s tr etc h of the thorac ic par avertebral mus culatur e ( F ig. 41 of 64 21/08/07 22:03 .com/pt/re/9780781763714/bookContent. us ing them as a lever. T is sue tension is reevaluated to ass ess the effectiveness of the tec hnique.http://thepointeedition.

com/pt/re/9780781763714/bookContent.lww. P..103 Thoracic Region: Mi dthoracic Extension.http://thepointeedition. Seated 42 of 64 21/08/07 22:03 ..

75.http://thepointeedition.73. 43 of 64 21/08/07 22:03 . T he phy sic ian r eaches under the patient's upper arms and gr asps the patient's far elbow. 2. With the finger s pointing c ephalad. T he patient is s eated on the end of the table with the hands c lasped behind the nec k. Fig ure 7. 4. 1. Step 5. T he phy sic ian s tands at the s ide of the patient. Step 4. Fig ure 7... T he patient's other elbow r es ts on the phy sic ian's for ear m near the antecubital fos sa.74. 3. c ontac ting the par avertebral mus culatur e of one side with the thenar eminence Fig ure 7.lww. the phy sic ian's other hand is c upped ov er the thorac ic s pinous pr oces ses . Step 4.com/pt/re/9780781763714/bookContent.

Fig ure 7. T he phy sic ian's hands (palms up) reach under the patient's thorac ic s pine ( F ig...76) with the pads of the finger s on the patient's thorac ic par avertebral mus culatur e between the s pinous and tr ansv ers e pr oces ses on the side c loses t to the phy sic ian ( F ig. 44 of 64 21/08/07 22:03 .lww. T he patient is s upine on the tr eatment table or hos pital bed and the phy sic ian is s eated on the s ide to be tr eated. 1.78. P.77.com/pt/re/9780781763714/bookContent. 2. Step 2. Step 3. Supine E xtension T his procedure is c ommonly us ed in the postoper ative s etting to treat the s omatic c omponents of v isceros omatic r eflexes ( postsur gic al paralytic ileus ).http://thepointeedition.77). 3. Fig ure 7. 7. 7. T he physic ian Fig ure 7.76.104 Thoracic Region: Ri b Raising. Step 2.

T he finger s ar e s imultaneously dr awn toward the physic ian. r hy thmic. T his s tretch is held for s ev eral s ec onds and is slowly r eleas ed.lww. Steps 3 and 4 ar e repeated s ev eral times in a gentle. 45 of 64 21/08/07 22:03 .. engaging the s oft tiss ues. 7. 4.com/pt/re/9780781763714/bookContent. T his is fac ilitated by a downward pr essure thr ough the elbows on the table. ex erts a gentle for ce ventrally to engage the s oft tiss ues and later ally per pendic ular to the thorac ic par avertebral mus culatur e. 5.http://thepointeedition.78). and k neading fas hion.. pr oduc ing a lateral s tretch per pendic ular to the thorac ic par avertebral mus culatur e ( F ig. cr eating a fulc rum to pr oduc e a v entral lever ac tion at the wr ists and hands.

. T is sue tension is reevaluated to ass ess the effectiveness of the tec hnique.. T his technique may also be per for med us ing deep.lww.105 Lumbar Region: Prone P ressure 46 of 64 21/08/07 22:03 . T he phy sic ian's hands are r epositioned to c ontac t the differ ent lev els of the thorac ic s pine and s teps 3 to 6 ar e perfor med to str etc h v ar ious por tions of the thorac ic par avertebral mus culatur e. 7. s us tained pr essure. 8.com/pt/re/9780781763714/bookContent.http://thepointeedition. 6. P.

47 of 64 21/08/07 22:03 . T he phy sic ian places the thenar eminence of the other hand on the abducted Fig ure 7. T he phy sic ian places the thumb and thenar eminence of one hand on the medial as pect of the patient's lumbar par avertebral mus culatur e ov erly ing the tr ansv ers e pr oces ses on the side opposite the phy sic ian ( F ig.http://thepointeedition. T he patient is pr one. Fig ure 7. k eep the head in neutral. 7.. Step 2. T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated ( Fig . with the head tur ned toward the phy sic ian..79).) 2. 1.81. 3.79. Step 4.lww. (If the table has a face hole.com/pt/re/9780781763714/bookContent.80). Fig ure 7. 4. 7. Step 3.80.

7...83. T he patient is pr one with the head turned toward the phy sic ian. keep the head in neutr al. Step 3. 3. 48 of 64 21/08/07 22:03 .84.com/pt/re/9780781763714/bookContent. T he phys ician's c audad hand is plac ed over the lumbar s pinous proc ess es with the fingers pointing c ephalad. T he physic ian does one or both of the following: a.) 2. T he physic ian s tands at the side of the table at the lev el of the patient's pelvis .lww. Fig ure 7. T he heel of the phy sic ian's c ephalad hand is placed ov er the bas e of the patient's sac rum with the fingers pointing toward the c oc cyx (F ig. Step 4a.85. c ontacting the paraver tebr al s oft tissues with the thenar and Fig ure 7.http://thepointeedition. Fig ure 7.83). P. Step 5. (If the table has a face hole.106 Lumbar Region: Prone Traction 1. 4.

T he hand may be plac ed to one s ide of the s pine. Do not pus h direc tly down on the spinous pr oces ses . sus tained pr essure. 7. hypothenar eminenc es ( Fig .com/pt/re/9780781763714/bookContent. 7. and kneading fas hion or us ing deep. 6. 7. T his technique may be applied in a gentle.85). rhy thmic. 5.84) b.lww. T he physic ian's c audad hand is r epositioned at other lev els of the 49 of 64 21/08/07 22:03 . T he physic ian ex erts a gentle for ce with both hands ventrally to engage the soft tis sues and to c r eate a s eparation and dis traction effect in the dir ection the finger s of each hand are pointing ( F ig.http://thepointeedition. c ontacting the paraver tebr al s oft tissues on the far s ide of the lumbar spine with the thenar eminenc e or the near s ide with the hypothenar eminenc e...

http://thepointeedition.com/pt/re/9780781763714/bookContent.107 Lumbar Region: Bil ateral Thum b P ressure. 8.lww. P rone 50 of 64 21/08/07 22:03 . T is sue tension is r eevaluated to as s ess the effectiveness of the technique.. lumbar spine and s teps 4 to 6 are r epeated. P..

Step 4. with the head tur ned toward the phy sic ian. T he patient is pr one.. k eep the head in neutral.com/pt/re/9780781763714/bookContent.lww. c ontac ting the par avertebral mus cles ov erly ing the tr ansv ers e pr oces ses of L5 with the finger s fanned out laterally (F ig. T he phy sic ian s tands at the s ide of the table at the lev el of the patient's thighs or k nees. 3. 7. and later ally Fig ure 7.. T he phy sic ian's thumbs ar e placed on both s ides of the spine. T he phy sic ian's thumbs ex ert a gentle for ce v entrally to engage the s oft tiss ues c ephalad.) 2.86). 4. (If the table has a face hole.86. Step 4.http://thepointeedition. Fig ure 7.87. 1. 51 of 64 21/08/07 22:03 .

ex tending the hip and adducting it toward the other leg to pr oduc e a s c issors effect ( F ig. Step 4.lww. Prone 1. (If the table has a fac e hole. T he phy sic ian's c audad hand may be placed under the far Fig ure 7.) 2. O n the side to be treated. 7. 52 of 64 21/08/07 22:03 . the phy sic ian's c audad hand r eaches ov er to grasp the patient's leg pr oximal to the k nee or at the tibial tuberosity ( F ig. P. T he physic ian lifts the patient's leg. 5. 7.88.90). Fig ure 7.com/pt/re/9780781763714/bookContent. Step 5.90.108 Lumbar Region: Sci ssors Technique..89). Fig ure 7. 4. 3.. Step 4.88).http://thepointeedition. 7. k eep the head in neutral. T he physic ian s tands at the s ide of the table opposite the side to be tr eated ( Fig .89. T he patient is pr one. with the head turned toward the phy sic ian.

7. 9.91.. T he physic ian places the thumb and thenar eminence of the cephalad hand on the patient's par a-v ertebral mus culatur e ov erly ing the lumbar tr ans. T he phy sic ian's Fig ure 7. Step 5.. T his forc e is held for s ev eral s ec onds and is slowly r eleas ed. 53 of 64 21/08/07 22:03 .com/pt/re/9780781763714/bookContent.http://thepointeedition. 8. r hy thmic. 7. Steps 6 and 7 ar e repeated s ev eral times in a s low. leg and then ov er the pr oximal leg s o that the patient's leg c an suppor t the physic ian's for ear m. 6.lww.ver s e pr oces ses to dir ect a gentle for ce ventrally and later ally to engage the s oft tiss ues while s imultaneously inc reasing the amount of hip ex tens ion and adduction ( F ig. and k neading fas hion.91).

c ephalad hand is then r epositioned to c ontac t other lev els of the lumbar spine and steps 6 to 8 are per for med to s tr etc h the v ar ious por tions of the lumbar par avertebral mus culatur e. T his technique may also be per for med us ing deep. 11. s us tained pr essure. 10. P.lww.109 Lumbar Region: Prone P ressure wi th Counterleverage 54 of 64 21/08/07 22:03 . T is sue tension is reevaluated to ass ess the effectiveness of the tec hnique...com/pt/re/9780781763714/bookContent.http://thepointeedition.

(If the table has a face hole. 3. T he phy sic ian places the thumb and thenar eminences of the cephalad hand on the medial as pect of the par avertebral mus cles ov erly ing the lumbar tr ansv ers e pr oces ses on the side opposite the phy sic ian. Fig ure 7.93. T he phy sic ian s tands at the s ide of the table opposite the s ide to be tr eated ( Fig . k eep the head in neutral. Step 2. 7. Step 4. 1.. T he phy sic ian's c audad hand c ontac ts the patient's anterior s uperior iliac s pine on the s ide to be Fig ure 7.http://thepointeedition. 55 of 64 21/08/07 22:03 .) 2. T he patient is pr one with the head tur ned toward the phy sic ian.94. Fig ure 7..lww.92). Step 5.92. 4.com/pt/re/9780781763714/bookContent.

Step 5. and the phy sic ian's thigh is placed agains t the patient's infrapatellar r egion (F ig.http://thepointeedition.lww. 2.97. T he phy sic ian s tands at the s ide of the table.95). fac ing the fr ont of the patient. Fig ure 7.. Step 3. Fig ure 7. Step 4. 7. 4..com/pt/re/9780781763714/bookContent. T he patient lies in the lateral r ec umbent pos ition with the tr eatment s ide up.95. 3.110 Lumbar Region: Lateral Recum bent Positi on 1. T he patient's k nees and hips are flexed. T he phy sic ian r eaches ov er the patient's bac k and places the pads of the finger s on the medial as pect of the patient's par avertebral mus cles ov erly ing the lumbar tr ansv ers e pr oces ses Fig ure 7. 56 of 64 21/08/07 22:03 .96. P.

97). While the phy sic ian's thigh against the patient's k nees may s imply be us ed for br acing. s us tained pr essure.http://thepointeedition. 7. 57 of 64 21/08/07 22:03 .com/pt/re/9780781763714/bookContent. T o engage the soft tis sues.. T his tec hnique may be Fig ure 7. T his tec hnique may be applied in a gentle r hy thmic and k neading fas hion or with deep. 5. ( F ig. Step 7. the phy sic ian ex erts a gentle for ce v entrally and laterally to c r eate a per pendic ular s tr etc h of the lumbar par avertebral mus culatur e ( F ig. 7. 6. 7.96)..lww. it may also be flexed to pr ovide a c ombined bowstr ing and longitudinal tr action forc e on the par avertebral mus culatur e.98.

8. modified by br acing the anterior s uperior iliac s pine with the caudad hand while dr awing the par avertebral mus cles v entrally with the cephalad hand ( Fig .http://thepointeedition. P. 9. T is sue tension is r eevaluated to ass ess the effectiveness of the tec hnique.111 Lumbar Region: Supi ne Extensi on 58 of 64 21/08/07 22:03 .. 7.com/pt/re/9780781763714/bookContent.98).lww. T he phy sic ian's hands are r epositioned to contac t differ ent lev els of the lumbar spine and steps 4 to 6 are per for med to s tr etc h v ar ious por tions of the lumbar par avertebral mus culatur e..

Step 4. T o engage the s oft tiss ues. T he physic ian is seated at the side to be tr eated.101.99 and 7.http://thepointeedition.. Step 5.com/pt/re/9780781763714/bookContent. 1.99. Fig ure 7.100). with the pads of the phy sic ian's finger s on the patient's lumbar par avertebral mus culatur e between the s pinous and tr ansv ers e pr oces ses on the side c loses t the phy sic ian ( F igs. 3. T he phy sic ian's hands (palms up) reach under the patient's lumbar spine. T he patient is s upine.) 2. 59 of 64 21/08/07 22:03 . 7. the physic ian ex erts a gentle v entral and lateral force per pendic ular to the thorac ic par avertebral mus culatur e. ( T he patient's hips and knees may be flexed for comfor t.. 4.lww. Fig ure 7. T his is fac ilitated by downward pr essure Fig ure 7. Step 4.100.

P.112 Lumbar Region: Long-Lever Counterlateral with Knees.lww...http://thepointeedition.com/pt/re/9780781763714/bookContent. S upine 60 of 64 21/08/07 22:03 .

102) . the phy sic ian Fig ure 7.. 4. As the patient's k nees are mov ed away fr om the phy sic ian.103. 61 of 64 21/08/07 22:03 . Step 2.103). 5.http://thepointeedition. T he physic ian c ontrols the patient's lower ex tremities bilaterally at the tibial tuberosities and slowly mov es the k nees laterally away fr om the phy sic ian ( F ig.104. Fig ure 7. T he phy sic ian's c audad hand flexes the patient's hips and knees to approx imately 90 degrees eac h ( Fig .. 2.lww.102. Step 4. 7. T he phy sic ian's c ephalad hand r eac hes ov er the patient and under the patient's lumbar region in the ar ea of the dy s function. 3. Fig ure 7. 1.com/pt/re/9780781763714/bookContent. 7. Step 6. T he patient lies s upine on the tr eatment table.

..http://thepointeedition.com/pt/re/9780781763714/bookContent. Seated 62 of 64 21/08/07 22:03 . Myofasci al Hypertonici ty. P. Lumbar P aravertebral Muscle Spasm.lww.113 Lumbar Region: Left.

107).. T he phy sic ian's left thumb and thenar eminence are placed on the medial as pect of the patient's left par avertebral mus culatur e ov erly ing the lumbar tr ansv ers e pr oces ses ( F ig.http://thepointeedition. T he patient is ins tructed to place the left hand behind the neck and gr asp the left elbow with the right hand. 2. Step 3. T he patient is ins tructed to Fig ure 7. opposite the dy s function. 3.lww. Fig ure 7.107. 7. Step 2. 1. 63 of 64 21/08/07 22:03 . 4. Fig ure 7. T he patient is s eated on the end of the table with the phy sic ian s tanding behind the patient and to the right side.com/pt/re/9780781763714/bookContent.106). Step 5..108. The phy sic ian's r ight hand r eaches under the patient's right ax illa and gr asps the patient's left upper arm ( F ig.106. 7.

114 References 1.http://thepointeedition. ed . G r ee nm an P. 2.lww. Pr i nci ple s o f Ma nua l M edic i ne . P hi la del . Phi l ade l ph i a: Lip pin c ot t Wi l li ams & W i lk i ns . 64 of 64 21/08/07 22:03 . 20 03.com/pt/re/9780781763714/bookContent. W ard R C. 20 03.. F ound ati ons for Os teo path i c M ed i c in e..ph i a: Lip pin c ott Wi l li am s & W i lk i ns. P.

r es t ri c ti o n ).b i nd re l at i o ns h ip . i t i s ob v io u s t h at ha n d p la c e me n t a nd f or c e v ec t o r d ir e c t i o ns ar e s i mil a r a nd t ha t t h e p r in c ip l es u se d t o a f f ec t t he v ar i ou s a n a to mic ti s s ue t y p es .g . m y of a s c i a l r el e as e ca n b e p e r fo r me d i n ei t he r a d ir e c t or i nd i re c t man n e r. a t wo . The s e a s ym met r i es ar e c li n i ca l ly de s c ri b ed as h av i ng a t i gh t -l o os e or ea s e. a n y f or c e d i re c te d on it ma y af f ec t t h e l i ga men t o us an d c a p su l ar (a r t ic u la r ) t i s s u es an d s tr u c tu r es ve r y d i s t a l t o t h e s pe c i fi c a r ea b ei n g p al p a te d a n d t r ea t ed . f re e d om ) a n d s t if f ne s s ( t ig h tn e s s . c l en c hi n g f i s t s o r ja w).http://thepointeedition. ea s e . Th e t re a tm e n t may al s o c on s i s t of th e s e a lt e rn a t iv e s . W a r d a ls o p o i nt s o ut t ha t t h e t i gh t -l o os e as y mm e tr y ma y b e m o r e c li n ic a l ly re l ev a n t a t t he l oo s e s it e s . th e p h y si c ia n m u s t b e a wa r e t ha t th e re ma y be a c au s e -a n d. a n d s o o n a r e a ls o i mp o r ta n t i n t h is s t y le . Th e re f o re . s p ec i f ic a ll y d ir e c te d i s om e t ri c m u s c l e c o nt r ac t i on s ( e . The os t e op a th i c p h y s i ci a n wil l us e e p ic r i ti c p a lp a t io n t o d e t er min e t h e s o f t ti s s ue co mpl i a nc e ( l oo s e ne s s . Thu s . whe r e p a in an d in s ta b il i t y may be p re s en t ( 1 ) . T h is s t y l e o f o s t e o pa t hi c m a n ip u la t io n ha s h i s t o r ic a l t ie s to ea r ly o s t e op a th i c m a ni p ul a t iv e t r ea t men t a nd s of t t i s s u e t e ch n iq u e . Th e pa t ie n t' s re s pi r at o r y a s s i s t a n ce . The r ef o r e. B ar r i er s m a y b e i d en t if i e d wit h t h e p a ti e nt p as s iv e o r ac t iv e . T h e E du c a ti o n Cou n c il on Os t e op a th i c P r in c ip l es h as de f in e d myo f a s c i al re l e as e t e ch n i qu e a s a “ s y s te m o f di a gn o si s an d t r ea t men t f i rs t de s cr i be d b y A n dr e w Tay l o r S ti l l a n d h is ea r l y s tu d en t s . Wh e re a s s o f t ti s su e te c hn i qu e ha s b e en h is t or i ca l l y d ir e c t i n c la s s if i ca t io n . Myo f a s c i al te c h ni q ue ma y be pe r fo r med wi t h o n e h an d o r tw o . a s e n se of fr e e do m i n o n e o r mo re di r ec t i on s a n d r e s t r ic t io n in th e o t h er s c a n e x is t . an d e as i n g t he ba r r ie r i n e i t he r d i re c t io n m a y n o t b e c li n i ca l ly ad v i sa b le . t h is 1 of 21 21/08/07 22:04 .e f f e c t s it u at i o n whe r eb y (a ) t h e t i gh t o r d i r ec t b a rr i e r i s c au s i ng a s ec o n da r y l oo s e r e ac t io n or (b ) t h e l o os e s i t e i s i nh e r en t ly un s t ab l e. Th e s e a re ge n e ra l ly re f e rr e d t o a s r e le a se . T h e re f or e . 8 Myofascial Release Techniques Technique P rincipl es War d de s cr i be s my o fa s ci a l r e le a se t ec h ni q ue a s “ de s ig n e d t o s tr e t ch an d r e f le x ly r el e a se pa t te r n ed so f t t i s s u e a nd j oi n -r e la t e d r es t ri c t io n s” (1 ) . . b ut Wa r d c o mb i ne d pr i nc i pl e s o f m a ny o th e r t ec h n iq u es to d ev e l op a d is t i nc t t e ch n i qu e . bi n di n g. whi c h e n ga g es co n t in u al pa l p at o ry f ee d b ac k t o a c h ie v e r el e a se of my o f as c ia l t i s su e s” (1 ) . s o me wou l d c la s s if y i t a s a c om b in e d t e ch n iq u e ( 2 ). A s t h e f as c ia i s s o d ee p l y i nc o rp o r at e d i nt o th e m u s c l e s a nd th e re s t o f t h e b od y . mu s cl e o r i gi n s a nd i ns e rt i on s . s o t h at t he s e t is s u es h av e an as y mm e t ri c q u al i t y o r q ua n t it y o f c o mpl i an c e. i n d y s f u nc t io n al s ta t e s t he r e ma y b e a g e n er a l o r u n iv e rs a l b a rr i er (r e s tr i c t i on ) .ha n de d met h o d may be mor e e f fe c t iv e i n d i a gn o si s a n d t r ea t me n t ..lww. e ve n th o ug h i t s r o ot s m a y g o b a c k t o e ar l y o s te o pa t hi c p hy s i ci a ns (2 ) .com/pt/re/9780781763714/bookContent.. Cli n i ca l ly .e nh a nc i ng mec h an i sm s (R E Ms ) ( no t to be co n f us e d wit h ra p id ey e mo v em e nt s ) . I n c o mp a r in g t h is t ec h ni q ue t o o th e r o s te o pa t h ic te c hn i q ue s ( e sp e c ia l ly fo r so f t t is s u e) . an d so on ar e of t en us e d t o p o te n t ia t e t he t ec h n iq u e. to n g ue mov e men t s o r o c ul a r mov e men t s . Ho wev e r .

we c a n p ro j e c t th e c h a ng e s t ha t oc c ur in t he pa t ie n t 's ti s su e s whe n pr e s s u re i s i ni t ia t e d i nt o t h e se s t r uc t u re s . 2. th i s t ec h n iq u e i s u s ef u l i n a c ut e a n d c h ro n ic cl i n ic a l p re s e nt a ti o ns wit h t h ei r as s oc i at e d v a ri a ti o n s i n p ai n l ev e l . b y i n tr o du c i ng la ws o f t h er mod y n am i c s an d en e rg y c on s e rv a ti o n t h eo r ie s . or in d i re c tl y . i n el a s t i c . The r ef o re . a nd / or f ib r ot i c my of a s c i al s tr u c tu r es to i mp r ov e r e g io n al an d / or in t er s e gm e nt a l r a ng e s o f mo ti o n. J ou l e f o un d t h a t t he am o u nt of en e r gy d on e as wo r k wa s c on v er t e d t o h ea t .. 1 16 Technique Classifi cation Direct. I t ma y a l so b e p er f o rm e d s uc h th a t t he p hy s ic i an a lt e rn a te s be t we e n d i re c t a nd i nd i re c t t y pe s .http://thepointeedition. th e ph y si c ia n ca n d i re c t t h e f or c e t o wa r d ( d ir e c t ) o r a way fr o m ( i nd i re c t) t he ba r ri e r s b ei n g mo ni t or e d. s o t h at t he re s tr i c ti v e b ar r i er (t e ns i o n. Wi t h c on t i nu e d t re a t me n t a f f e c ti n g t he s e t i s s u es . I ndi cati ons 1. f re e ) d i re c ti o n o f t e ns i on o r mot i on a s y mme t ry ( se e C h ap t e r 6 . or Heavy in Force Applicati on Myo f a s c i al re l e as e t e ch n i qu e i s i n t er e s t i ng a nd ve r y u s ef u l i n t h at th e f o r ce s m a y b e d ir e c te d i n d i f fe r en t ia t e d l ev e ls . al s o. T h e r es u l ti n g c ha n g es ma y b e ch a ng e s i n t h e c ol l a ge n ou s s t a te fr o m g e l t o s ol .lww. I t ma y a l so b e p er f or me d i n a s im u l ta n eo u s d i re c t a nd i nd i re c t a p pr o ac h i n wh i ch th e ph y si c ia n us e s o ne h an d t o a pp r o ac h t h e t i gh t b a rr i e r a nd th e ot h er to a pp r oa c h t h e l oo s e b a rr i er . or Com bined With Two-Handed Technique Myo f a s c i al re l e as e m a y b e p e rf o rm e d d i re c tl y . s uc h a s d e f or mat i on a nd th e f a c t t ha t p hy s i ca l c o nt a c t b et wee n th e p h y s i c ia n a n d p a ti e nt ha s eq u al an d op p os i te f or c e mag n i tu d es . H o o ke ' s l aw . S tr e t ch an d i n c re a se el a s ti c it y o f sh o rt e ne d . Th e se in c l ud e W o lf f ' s l aw . t he o pp o rt u ni t y m a y e xi s t t o a l te r th e e l as t i c p ro p er t i es pe r ma n e nt l y ( pl a s ti c c h an g e ). Moderate. 4. Indirect.. Technique S tyl es Light.com/pt/re/9780781763714/bookContent. t ec h n iq u e may e f f e c t wi d e sp r ea d r e a c t i on s . Use a s p ar t o f th e m u s c u l os k el e ta l s c r ee n in g ex a mi n at i o n t o q ui c k ly id e nt i f y r eg i o ns of po t e nt i al mo t i on re s tr i c ti o n a nd t is s ue te x t ur e c h an g e s .l oo s e a s ym met r y t o i mpr o ve t he ti s su e co n si s te n c y i n t he l oo s e 2 of 21 21/08/07 22:04 . Red u c e t he ti g h t. A n u mbe r o f p h y si c al an d an a to mic a sp e c t s a r e i mpo r ta n t i n m y of a s ci a l r el e a se as i ll u s tr a te d b y Wa r d ( 1) . The y re l at e t h e v a ri o us r ea c ti o ns t o f or c e. r e le a si n g t h e a re a s ur r o un d in g T 7 an d T 8 m a y c a us e t h e p a ti e nt t o h av e l e s s s ub o c c i p it a l s ym p t om s t hr o u gh th e p o s it i ve ef f e c t of th e te c hn i qu e on th e t r a pe z iu s m u s cl e . s o a s t o e n g ag e t h e p h y s i ol o gi c or re s tr i c ti v e b ar r i er at t he e as e ( l oo s e . an d N e wt o n 's th i rd l aw . Red u c e mus c le t en s io n a n d f a s c i al t en s io n . 3. P ri n c ip l es of O s t e op a th i c M a ni p ul a t iv e T e ch n i qu e s) . P. Fo r e xa mpl e . b in d ) i s e n ga g e d. T h e re f or e .

a s t h e t e ch n iq u e ma y b e p er f o rm e d wit h ve r y l ig h t p r es s ur e . g . o s t e om y e li t is ) .b y. 4. 5.. g. I nc r e as e v e no u s a n d l ym p h at i c d ra i n ag e t o d e c re a se lo c a l a nd / or d is t al sw e l li n g a nd e de ma a nd p ot e nt i al l y i mpr o ve t he ov e ra l l i mmu n e r e sp o ns e . Fra c t ur e o r d i s lo c at i on . Absol ute Contraindications Non e . ca r e s h ou l d b e t a ke n i n ot h er di s t al ar e as d ep e nd i ng o n t yp e of ma l ig n a nc y a n d/ o r l y mp h at i c i n vo l ve me nt . h o wev e r. 5. 2. Contraindicati ons Relative Contraindications A s my of a s c i al t ec h ni q ue may be pe r f or med wi t h e x tr e me l y l i gh t p r e s s u re in a d i re c t o r i nd i r ec t m a nn e r . General Considerations and Rules 1.com/pt/re/9780781763714/bookContent. I nf e c ti o n ( e.l ay e r p a lp a to r y p r in c ip l e s a nd wit h ju s t e no u g h p re s su r e t o c a pt u r e t he s k i n a n d s ub c u ta n eo u s f a s c i al s tr u c tu r es . . Neu r o lo g ic or v as c ul a r c o mp r om i se . t is s u es by in c r ea s in g e l a s t i ci t y i n t h e t ig h t t i s s u es . A ny mov e me n t o f t h e h an d on th e s k i n s ho u ld c au s e t he s ki n t o m o v e a lo n g wi th t he h an d w i th o u t s li d in g th e h a nd o ve r t h e s k in . A s in ot h er t ec h ni q ue s . The p hy s ic i an g en t ly mo v e s t he pa l p at i ng ha n d o r h a nd s in a l in e a r d ir e c t i o n o f 3 of 21 21/08/07 22:04 . The p hy s ic i an p al p at e s t h e p at i en t us i ng la y e r. P ot e n ti a te th e ef f ec t o f ot h er os t e op a th i c t e ch n iq u es . 1. . 6.lww.. 2. A cu t e s p ra i n o r s t ra i n. Mal i g na n c y . t h r ou g h s om a t os o ma t ic . t he r e i s l i t t l e l i ke l ih o od o f a dv e rs e ef f ec t s o t he r t h an a ch e s p os t t re a t me n t t ha t ar e s e co n d ar y t o c o mpe n sa t io n an d d e co mp en s at i on r ea c ti o ns a nd s im i l ar to ac h e s p os t e x e rc i se . 3. M o s t r es t ri c t io n s a re f or tr e at me nt in th e af f ec t ed a re a o f mal i g na n c y .http://thepointeedition. 7. I mp r o ve ci r cu l a ti o n t o t h e s pe c if i c r e gi o n b e in g t r ea t e d b y l oc a l p h y s i ca l an d t he r mod y na mic e f f e c t s o r by re f le x ph e no men a to im p ro v e c i rc u la t i on in a d i s t a l a re a (e . so mat o vi s c er a l r ef l e xe s ). i n cr e as e d w a te r i n t ak e a n d i c e p ac k ap p li c at i o n a s n ee d e d p os t t r e at men t w i l l g en e ra l l y r ed u ce a ny su c h r e ac t io n . O s t e o po r os i s a n d o s t e op e n ia . 6. T h i s i s o ne l ev e l o f p r es s ur e l e s s t ha n t h a t o f s of t ti s su e t e c hn i qu e . T h e p hy s i ci a n may wor k pr o xi mal o r d is t al t o t he af f e c t e d a re a an d a l te r th e p a ti e n t' s p o si t i on or s t y l e o f t ec h n iq u e t o a c hi e ve so me b e ne f ic i a l e f f e c t .

The p re s su r e t h e p hy s ic i a n u se s t o de t er min e co mpl i an c e m a y b e mi ni mal or mod e r at e . de p e nd i ng on p at i en t r e a c t i vi t y . We h a ve de s cr i b ed a n um b e r o f c om mo nl y u s ed t ec h n iq u es bu t ha v e a ls o il l us t ra t e d man y o t h er s w i th o u t t he de s c ri p ti v e t e x t be c au s e t he p hy s ic i an may fo l lo w th e g u id e l in e s a nd d ev e lo p a p ar t ic u la r s t r at e gy o r t re a tm e n t p ro t o co l t h at b es t s u it s th e p a ti e n t .ax i s h a s a lr e a dy be e n e n ga g ed by t he la y er .lww. t hi s is d em o n s t r at e d b y m o ve men t of th e t i s su e t h ro u g h t he or i g in a ll y d e t er min e d b ar r i er (c r ee p or fa s ci a l c r ee p ).. The p hy s ic i an r ee v al u at e s t h e t is s u e t o d et e r mi n e whe t h er th e t i s su e 's c om p l ia n ce an d qu a li t y h a ve im p ro v e d. th e g en t l es t m e th o d i s t h e s a fe s t . 5. T h e z . Th e p hy s ic i a n s ho u ld n ot i ce th a t a f te r a pp r o xi mat e ly 2 0 t o 3 0 s e co n ds . a c ha n ge of t is s ue co mp li a nc e o c c ur s . h e o r sh e h o ld s th e t i s s u e a t t ha t po i nt wi t h ou t r e li e v in g t h e p r es s ur e . 8.http://thepointeedition. A f t e r d e te r mi n i ng th e e a s e a nd bi n d b a rr i er s of th e t i s su e i n t h e se di r ec t i on s . T h er e m a y b e a nu mb er of co mp li a nc e c h a ng e s ( cr e e p) be f or e th i s p he n o me n on s t o p s . 9. 7.u p v i si t s ma y b e p re s c ri b ed fo r a 3 -d a y i n te r va l o r l o ng e r.l ay e r p a lp a to r y p r es s ur e i n t o t he bo d y . 6. S ym me tr y v e rs u s a s ym met r y o f t i s s u e c o mp l ia n c e i s n ot e d i n t h e l i ne a r d ir e c ti o ns te s t ed . Th e t e c hn i qu e m a y b e r e pe a t ed at th e s am e ar e a o r a n ot h er . a n d f o ll o w. th i s i s d et e r mi n ed by t he cl i ni c a l p re s en t a ti o n a nd e xa min a ti o n f i nd i ng s . g ai n i ng ac c es s to th e s u p er f ic i al f as c ia . s ym me tr y v e rs u s a s ym met r y o f t i s s u e c o mp l ia n c e i s n ot e d . B ec a u se of th e va r io u s t i s s u e l ev e l s e nc o un t e re d a n d t h e p ro x im a l -t o -d i s t a l r el a t io n sh i ps ( te n se g ri t y ) a s s o ci a t ed wi t h t h e s om a ti c dy s fu n c t i o n. The p hy s ic i an s lo wly mo v e s t he ha n d -c o nt r ol l e d myo f as c i al ti s su e s t o wa r d t h e a pp r o pr i at e b a r ri e r. c ho i c e ( ha n ds o f t he cl o c k) mo v in g th r ou g h t h e x .b y. i nc l ud i n g o th e r l i ne a r mov e men t s i n a 36 0 -d e gr e e P. The p hy s ic i an may ad d a v ar i et y o f di r ec t io n s o f m o ti o n . I n g e ne r a l. The p hy s ic i an f ol l ow s t h i s c ha n ge a nd co n ti n u es ho l di n g u n ti l n o fu r th e r e vi d e nc e o f c r e ep oc c ur s . 1 17 r ef e r en c e a nd c lo c kw i se a nd co u nt e r cl o c k wis e ro t at i on a l m o ve men t . 1 18 Cervi cal Region: S upi ne Cradling 4 of 21 21/08/07 22:04 .a nd y -a x es . th e re may be c ou n t le s s way s in wh i ch t o t ou c h a n d p os i ti o n t h e p at i e nt wh e n i mpl e me n ti n g myo f a s c i al re l e as e t e ch n i qu e . d ep e n di n g o n t h e c li n ic a l p r es e nt a t io n o f t h e p a ti e nt ( ac u te pa i n fu l v er s u s c hr o ni c mi n im a ll y pa i nf u l) a nd wh a t t h e p hy s ic i a n b el i ev e s i s a p pr o p ri a te f or t he si t ua t i on . 4. t he p hy s ic i an d et e rm i ne s wh e th e r g e nt l e o r mo de r at e p r e s s u re in a d i re c t ( t ow a rd b in d ) o r i n di r e c t (t o wa r d e a se ) t e c hn i qu e i s ap p ro p ri a t e.. an d on me e ti n g t h e b ar r i er . A g ai n . Ag a in . P. 3.com/pt/re/9780781763714/bookContent.

so as to not sl ide the han ds acro ss the pa tie n t's ski n. 3. arti cul ar pro cesses.1 . Step 2. Figure 8.3 . 8. The ph ysi cian mon ito rs inferi or a nd sup eri or. The physician 's han ds are pla ced pa l ms up und er the patien t's articu lar pro cess (pi lla r) a t the level of the dysfun cti o n (Fig. Figure 8. 1.. 4. Step 4.1 ). 2. The ph ysi cian lifts upw a rd into the patien t's posterior cervical tissue s w i th onl y e nou g h force to control the skin a nd und erl yin g fascia .http://thepointeedition.2 . 5 of 21 21/08/07 22:04 .com/pt/re/9780781763714/bookContent. mee ting th e b a rri ers.lww. left and ri ght circumfere nti al rotati on.. and Figure 8. Step 5. ind i rect b arri er. The pa tie n t lie s supi n e and th e physician sits at the he a d o f the ta ble .

8. The pa tie n t i s sea ted .5. a nd laces the ind ex and th ird dig its immedi ate l y sup eri or a nd inferi or to the cla vicle a t the ste rno cla vicu lar joi ns bil a terall y (Fig. 1 19 Thoracic Region: Thoraci c Inlet and Outlet. 2.http://thepointeedition. The ph ysi cian pla ces th e han ds pal ms dow n o ver the sho uld er. The ph ysi cian lifts upw a rd into the pa tie n t's posterior cervical tissues Figur e 8 . 8.4. 4.5 ). 6 of 21 21/08/07 22:04 .4 ). Th e physician sta nds be h ind the pa tie n t.com/pt/re/9780781763714/bookContent. Ste p 3 . Figur e 8 .lww.. 3. The ph ysi cian pla ces th e thu mbs ove r the posterior first rib re gio n . Ste p 2 . pro ximal to the cervicoth o racic jun cti on a t the ang le of the neck a nd sho uld er g ird le (Fig. P. S eated Steering Wheel 1..

left and ri ght circumfere nti al rotati on. 7. The fo rce is app lie d i n a very g entl e to mod era te man ner. 5.com/pt/re/9780781763714/bookContent. with o nly eno ugh fo rce to con tro l th e skin and un derl yin g fascia so as to not sl ide across the pa tie n t's ski n.http://thepointeedition. 6.lww. th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r.. respective ly. 8.. and torsio nal (tw isting ) motion ava ila bil i ty for ease-b ind symmetric or asymme tri c rel ati ons. After determini n g the pre sen ce o f a n ease-b ind asymme try. The ph ysi cian mon ito rs inferi or a nd sup eri or. The ph ysi cian wil l conti nue thi s u nti l a 7 of 21 21/08/07 22:04 .

.6 .. sli ghtly ceph ala d to the il i ac cre sts. 1 20 Thoracic Region: P rone 1. The ph ysi cian pla ces bo th han ds pal ms dow n w ith the fin gers sl igh tly spread ap a rt immedi ate l y Figure 8. Dee p inh ala tio n or oth er rel e ase enh ancing mechan isms can be he l pfu l. 3. P. Thi s i s h e ld for 20 to 60 second s o r un til a rele ase is pal pated. 8 of 21 21/08/07 22:04 . Step 3. The pa tie n t l ies pro ne on the tre atment tab le.lww.http://thepointeedition. rel ease i s pal pated (facial cre ep) an d con tin ue to fol low th i s cre ep unti l i t doe s n ot recu r. The ph ysi cian sta nds be side the pa tie n t. 2.com/pt/re/9780781763714/bookContent.

lww. 9 of 21 21/08/07 22:04 . 4.7 . The ph ysi cian mon ito rs i nfe rio r and su peri or. The fo rce is app lie d i n a very gen tle to Figure 8. 6.com/pt/re/9780781763714/bookContent.http://thepointeedition. 8.8 . After dete rmi nin g the prese n ce of an ease-b i nd asymme try.7 and 8 . Step 5.. 5.6 ). parasp ina l on each side (Fig. Step 5. 8.8). le ft and ri ght circumfere nti al rotati on. respective ly. th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r. infe rio r a nd supe rio r barriers. and torsio nal (tw isting ) mo tio n ava ila bil i ty for ease-b ind clo ckw ise and cou nte rcl o ckw ise rel ati ons (Figs.. 7. The ph ysi cian imp arts a dow nwa rd force into the p ati ent's tho racic tissues with o nly eno ugh force to control the skin a nd und erl yin g fa sci a so as to n ot sli de across th e patien t's ski n. Figure 8. circumfere nti a l barriers.

The physician asks the patien t to ben d the pro ximal kne e so th e physician 's cep hal ad han d can intern all y rotate th e hip un til the pel vis comes off Figure 8. Supine 1. Step 4. Step 3. P. 1 21 P elvi c and Sacral Region: Bi lateral Sacroili ac Joint wi th Forearm Pressure.lww. mod era te man ner. Figure 8. 2.9 .com/pt/re/9780781763714/bookContent... 10 of 21 21/08/07 22:04 . The pa tie n t lie s supi n e and th e physician sits a t th e sid e o f th e patien t a t the le vel of the mid femur to kne e. Thi s i s h e ld for 20 to 60 seco nds or until a re lea se is pal pate d.1 0. 8.http://thepointeedition.

5. the physician pla ces th e oth er forearm a n d han d o ver the an teri or sup eri or ili ac spi n es (ASIS) of the patien t's pel vis (Fig.lww. The physician lea ns dow n on the elb ow of the arm th at i s con tactin g the sa cru m. 8... After return ing the hi p to neu tra l.9 ).1 1. 4. The physician 's oth er han d is pla ced pal m u p und er the sacrum (Fig. 11 of 21 21/08/07 22:04 . the ta ble . 3. Step 5. kee pin g th e sacral ha n d rel axe d a n d with the forearm mon ito rs for ease-b ind asymme try in left a n d Figure 8.1 0).http://thepointeedition. 8.com/pt/re/9780781763714/bookContent.

1 22 Lumbosacral Region: P rone 12 of 21 21/08/07 22:04 .com/pt/re/9780781763714/bookContent.1 1 ) and le ft a nd rig ht torsion . 7. P. 8. the physician wil l e ith e r ind ire ctl y or directly mee t the ease-b ind barrie r. The fo rce is app lie d i n a very g entl e to mod era te man ner. 8. rig ht rotati on (Fig.lww..http://thepointeedition. respective ly. 6.. Thi s i s h e ld for 20 to 60 second s o r until a rel ease i s pal pated. After determini n g the pre sen ce o f an ease-b ind asymme try.

.http://thepointeedition.. After dete rmi nin g the prese n ce of an ease-b i nd asymme try. Step 3.g.com/pt/re/9780781763714/bookContent. 8. 8..1 3. th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r. 1. 3. The pa tie n t l ies pro ne. The ph ysi cian pla ces on e ha nd ove r the i nfe rio r lumbar se g men t (e. 13 of 21 21/08/07 22:04 . L1 -L2) (Fig. Figure 8.1 3). 2.1 2 ).1 2.g. The ph ysi cian mon ito rs i nfe rio r and su peri or gli de. Th e physician sta nds beside th e patien t. respective ly. and cl ockw ise and cou nte rcl o ckw ise motion ava ila bil i ty for ease-b ind asymme try (Fig. ea se-b ind asymmetry.lww. L4 -L5) an d the other ove r the su peri or lumbar se g men t (e. le ft a nd rig ht rota tio n. 5. The fo rce is app lie d i n a very gen tle to Figure 8.. 4. Step 2.

Figure 8. 4.1 4. The ph ysi cian pal pates the affected fore arm ove r the intero sse o us membra ne a nd notes any evi den ce o f a tau t. The ph ysi cian mon ito rs cep hal ad a nd cau dad . 1 23 E xtremities: I nterosseous Membrane. 14 of 21 21/08/07 22:04 . l e ft and Figure 8. Seated 1. 8.http://thepointeedition.1 5.1 4). The ph ysi cian pla ces th e thu mbs ove r the anteri or dysfun cti o nal asp ect of the intero sse o us membra ne w ith the pa lm a nd fin gers e n circli ng the fo rea rm (Fig. 2.. 3. pai n .lww. Step 4. The pa tie n t i s sea ted or sup ine . Step 3..com/pt/re/9780781763714/bookContent. o r ease-b ind tissue ela sti city asymme try. The ph ysi cian sta nds or sits i n fro nt and to the sid e o f th e patien t o n th e affected side . fib rous ban d. P.

5.http://thepointeedition.. rig ht rota tio n. 7. 6.com/pt/re/9780781763714/bookContent. 1 24 E xtremities: S upine Leg Traction 15 of 21 21/08/07 22:04 .. P. respective ly.1 5). and cl ockw ise and cou nte rcl o ckw ise motion ava ila bil i ty for ease-b ind asymme try (Fig. Thi s i s h e ld for 20 to 60 seco nds or until a re lea se is pal pate d. The fo rce is app lie d i n a very gen tle to mod era te man ner. th e physician wil l either in d ire ctl y or directl y meet the ea se-b ind barrie r. 8. After dete rmi nin g the prese n ce of an ease-b i nd asymme try.lww.

ab duction an d 16 of 21 21/08/07 22:04 .http://thepointeedition.1 6 ). Figur e 8 . tra ctio n thro u gh the l eg.18 . Step 4.17 .. 2. The pa tie n t lie s supi n e on the tre atment tab le and the physician sta nds at the patien t's fee t. Figur e 8 . to Figur e 8 . 4. 3. 1. The physician lifts both low er leg s to 20 to 3 0 deg ree s o ff the ta ble (Fig. The physician 's han ds (pa lms up ) rea ch und er and con tro l th e patien t's Ach ill es and cal can eal reg ion .. The physician gen tly lea ns backwa rd.lww. inte rna l a nd e xte rnal ro tati on. Step 5.com/pt/re/9780781763714/bookContent.16 . add ing sli ght tra cti on throug h th e leg . 8. Step 3.

1 27 Myofasci al Rel ease Techni ques Fig ure s 8 ..20.http://thepointeedition.com/pt/re/9780781763714/bookContent. Lo ng a xis re lea se. Stern o cla vicula r jo int an d a rm traction . ind ire ct) but are wi tho u t wri tte n descri pti o ns.lww. Just u se the arrows as a gui de to the man y vecto red force app licati o ns tha t can b e effective for tre atment of the pi ctu red reg ion . Figur e 8 .. P. Figur e 8 .3 0 show the con tin ued pri nci ple s of myo fascia l rel ease (d ire ct.20 to 8.21. 1 25 P. 1 26 P. 17 of 21 21/08/07 22:04 .

Scale n e rele ase . Figur e 8 .lww.24.. Figur e 8 . 18 of 21 21/08/07 22:04 .http://thepointeedition.com/pt/re/9780781763714/bookContent. Figur e 8 . Th ora colu mba r re lea se. Stern a l rele ase ..23.22.

Sa cro coccyge al rele ase ... Ischi o rectal fo ssa (pe lvi c d i aph rag m) rele ase .27. Figur e 8 . Il ioti bia l b and – ten sor fa scia l a ta rel e ase .com/pt/re/9780781763714/bookContent. 19 of 21 21/08/07 22:04 .lww.http://thepointeedition. Figur e 8 . Figur e 8 .26.25.

com/pt/re/9780781763714/bookContent. 1 28 References 20 of 21 21/08/07 22:04 .28. Hyoid rel ease.http://thepointeedition. Figur e 8 .29.. Su bma n dib ula r re lea se. Figur e 8 .. Figur e 8 .30. Pl anta r fascial rel ease.lww. P.

http://thepointeedition. 21 of 21 21/08/07 22:04 . 2 . W a rd R ( e d) . 2 0 03 . G r ee n man P.lww. Pr i n ci p le s o f Ma n ua l M e d ic i ne .com/pt/re/9780781763714/bookContent. F o u nd a ti o ns f or Os t eo p a th i c Med i c in e . 1 .ph i a : L ip p in c o t t Wi l li a ms & Wi lk i ns .. 20 0 3.. P hi l a de l ph i a: L ip p in c ot t Wi ll i am s & Wil k in s . P h i la d el .

http://thepointeedition. w hic h i s i nhib i te d b y ap ply i ng a p osi tio n of mi l d s tra i n i n the di r ec tio n e x act l y opp os it e t o t hat of the r ef l ex . s pon tane ous r el ea s e by posi tio nin g. and flu i d as pe c ts . ” T here ar e m any pos tul ates as to how t he tec hniq ue w or k s . an d o ften li gam ents . T hey are de s cr i bed as di s c re te poi nts abo ut the s i z e of a f i nge r ti p t hat are ex quis i te l y tend er. an d e dema tou s ( 2) . T hes e i dea s w er e des c ri bed as fol l ows (2 ) : 1.. An eve nt p r od uce s ra pid le ngth eni ng of a mu s cl e.fac ete d (s tre tch ed) s id e o f th e dy s fu nct i on al s egm ent . a nd J on es t ech niq ue. 9 Counterstrain Techniques Techni que Pri nci ples C ount ers tra i n t ech niq ue w as pro pose d b y L aw re nce H. s uc h as the l ym pha tic s an d i nte r s ti tia l f l uid ex c ha nge. T hes e t ende r p oin ts w er e eve ntu al ly co l la ted i nt o l oc al ar eas of ten der ness . F SR R R dys func tio n w i l l m os t f r equ ent l y ex hi bit a tend er 1 of 85 21/08/07 22:05 . 3. and th e ar ea i mm edia tel y s ur ro und i ng the te nde r po i nt . 5. i nc l ud i ng the Go l gi ten don org an. J on es. bi oele c tr i c pheno m en a. i s re l at i ve l y n orm al and pai nle s s i n c omp ar is on. Th er e m ay be oth er asp ec ts at pl ay . T end er p oin ts ar e usu all y fo und wi thin te ndi nous attac hme nts . thi s o ften pr ese nts as a t ende r p oin t on th e o pen. a C 5. s tr ain /c ou nte r st r ain . J ones po s tu l ate d a me c han i sm of i nj ury co nc er nin g t hese te nde r po i nt s a nd t heo r iz ed h ow the tec hni que el i ci ts the app r op r ia te r esp ons e ba s ed on the pr evi ousl y m ent i one d p hys i olo gic pr i nci ple s . te ns e. In cl i ni c al exa m in ati on.. but mo s t i nvo l ve the al pha Ia aff ere nt a nd gam m a e ffe r en t re l at i on s hip s a nd noc ic ept i on ( 1. FA AO ( 19 12–1 996 ) . t hi s i s acc om pa nie d b y sp eci fic dir ect ed posi tio nin g ab out the p oin t o f te nde r ne s s t o a c hi ev e the de s i re d t her apeu tic re s pon s e. 2). T hi s l engt hen s t he a nta gon i s t m us c le .lww. th e b ell y of a m us c l e. w hen pal pa ted . Te nder po i nt s ma y b e r el at ed to the tri gge r poi nt s p r op os ed by Si m on and Tr av el l ( 3) but are ge nera l ly di s c us s ed as s ep ara te enti tie s i n th e os teo pat hic c om m un i ty . It i s pr op ose d t hat the ra pi d s ho r te ni ng of th e ag oni s t and l en gth enin g o f t he a nta gon i s t tog eth er pro duc e an in app r opr i at e r efle x t hat i s m an i fe s ted as a tend er poi nt i n t he anta gon i st m us c le . i na ppr opr i ate st r ai n re fle x .com/pt/re/9780781763714/bookContent. Aft er notic i ng a dr am ati c c l i ni c al re s pon s e. 4. 2. J one s i nit i all y bel ie v ed th at a pa tie nt c oul d b e pl ace d i n a pos i ti on o f c omf or t s o as to a l le v ia te t he s ym ptom s . Fo r e x am pl e. T he bo dy t r ie s t o pr eve nt the m yo fas c i al da m ag e by ra pid l y c ont r ac ti ng th e m y ofa s ci al ti ss ues aff ect ed ( s ho r te ni ng th e a goni s t) . T he Ed uc at i on al C oun c il on Ost eop ath i c P r in c ip l es ( EC OP) has d efi ned thi s t ech ni qu e a s “ a sy s te m o f di agn osi s an d t r ea tm en t t hat c on s id ers the dy s fu nc ti on to be a c onti nui ng. DO . T hi s tec hni que has be en r efe r re d to as st r ain an d c ount ers tra i n. Aff ere nt f eed bac k in dic ate s po s si ble m yo fas c ia l da m ag e f r om a s tra i n. w hic h ar e r ela ted to s eg m ent al and m us cu l ot end i nou s a r ea s of so m at i c d y sf unc ti on . he s tu die d t he n atu r e of m usc ulo s k el eta l d y s fu nct i on s an d deter m in ed that te nde r po i nt s c ould be el i c it ed by pr od din g w i th the fi nger tip (1 ) . T he pa ti en t m ay not hav e c onsc i ou s p ai n at the ten der po i nt l oc ati on.

an d mo tio n-b as ed de fin i tio ns of s oma tic dy s fu nct i on ( de s cr i bi ng m oti on r est r ic tio n an d a s ym m etr y ).lww. T he pati ent ma y al s o be pl ac ed i n ease as s oc i ate d w i th a 2 of 85 21/08/07 22:05 . J one s ma de ano ther di s co v ery : t he anter i or as pect s o f t he b ody mu s t b e e v al uate d e v en i f the sy m pto m s are pos ter i or ( 2. a nd z . T her efo r e.com/pt/re/9780781763714/bookContent. P. w e ha v e don e a num ber of s ma l l. As Gl ov er and R en nie re port . a hyp ert oni c de ep c er v i ca l m usc l e m ay be tend er i n an a r ea si m i la r t o t hat of the r efle x t end er p oin t f r om an art i c ul ar c er v i ca l d y sf unct i on . a nd the phy s ic i an ' s u nde r st andi ng of tend er poi nts s ho uld i nc l ud e a nd r eco gni z e the s pec i fi c mu s cl e– tend er poi nt r ela tio ns a s w ell as the ar ti cu l ar re l ati ons . T hi s m ay b e a n a r ea of fur ther st udy and po ten ti al re s ea r c h. Th ere fore . m yo fasc i al or bot h. Th e mo s t w id es pr ead id ea i s t hat fle x io n d y s fu nct i on s pr odu c e ante r io r t ende r p oin ts a nd ex ten s io n d y s fu nct i on s pr odu c e post eri or tend er poi nts. s i deb end to w ard . . y et i n the v er teb r al r eg i on s h e se ems to s ta y m ore foc use d o n ar tic ula r sp i na l s egme nta l l ev el s o f d y s fu nct i on .. F or ex am ple .s id ed c ou pl in g ( typ e 1) an d s am e. F r om ou r li m it ed fi nd i ng s .g. As c ou nte r st r ain is al s o u s ed fo r mu s cu l ar ( m y of asc i al ) dy s fu nct i ons an d t here ar e o v erl aps be tw ee n t he tw o typ es of d y sf unc ti on s .13 0 and s i de be ndin g t hat are co m mo n to ar tic ul ar . and w het her the pr i ma r y c omp one nt i s a r ti c ula r . Jo nes ev ent ual l y m app ed m an y lo c al ar eas of ten dern ess to w hi c h he r ela ted se gm en tal an d/or my ofa s c ia l dy s fu nct i on . Ho w ev er .s id ed c oup l in g ( ty pe 2) of r ot ati on and s id e bendi ng. w e b eli eve tha t n eut r al dys fun c tio ns c an pro duc e a nter i or an d pos te r io r t ende r p oin ts .http://thepointeedition.. non bli nde d su r ve y s of t he c la s s a tte nda nts w he n t each i ng thi s s ub j ec t. r ota te a w ay (S T R A) ] a nd othe r s are exa m pl es of tr eat m en t o f ty pe II dy sf unc tio ns [ e.2. r ec ogn i zi ng t his fa c t s hou l d dr am ati c al l y r edu c e the per c ep ti on of m av er i ck te nder po i nt s . y. J ones re fer s in so m e ar ea s to sp eci fic m us c le s . the tre atm ent w il l b e l es s tha n optim al. i n w hi c h d i re c ti ons do the neu tra l dy s fu nct i on s ex hib i t tend er poi nts? Ov er m any ye ars of tea c hi ng o s te opa thic ma nip ul at i ve me di ci ne i n the l abo r at or y at Phi l ade l ph i a C oll ege of Ost eop ath i c M edi c in e as we l l as i n o ur Euro pea n o s teo pat hic s em in ars . 4). T his ha s ca use d s om e c on fus i on. W it hou t a pro per dia gno s is .. th e r i gh t si de i s fa c et cl os ed an d t he l eft si de i s f ace t op ene d. s i de ben d a w ay r ot ate awa y ( SAR A) ].ax i s para m et ers of fle x io n an d e x te ns io n. ten der poi nts c an b e c onf us ed wi th one ano the r . p osi ti on al. R ev ie w o f t he m any po s i ti ons fo r co unt ers tr ai n t r ea tm en t s how s th at s om e po s it i on s ar e e x am pl es of tr eat m en t o f ty pe I d y s fu nct i on s [e .g . th e d ete r m in ati on of t he k ey dys fun c ti on. w i th a F SRR R d y s fu nct i on . poi nt on th e le ft s id e of th e p atie nt' s c er vi c al sp i ne. 4.. B ut t he pos i tio ns to al le v ia te the pai n m ay b e oppos i te ea c h o the r . r es pe c ti v el y ) m ay hav e sp eci fic ten der po i nts an d p os it i on s t hat al l ev i at e t he t end er poin t. y..6) th ere i s l it tle m en tio n o f th e c han ge i n pos it i on fo r op pos i te . N eut r al and nonne utr al dy sf unc tio ns ( typ es 1 an d 2 . r ot atio n.ax es of m oti on fre edom . Th e m os t i mp ort ant asp ect of an y t ech ni qu e i s t he d i ag nos i s . the i nd i re c t pati ent po s i ti oni ng m ay be i n r esp ons e t o an ar tic ul ar dy s fu nc ti on w i th i ts x. Yet i n m os t p ubli s he d t ex ts (1 . an d t er ms li k e m ave r ic k t ende r poi nt s h ave bee n u s ed to r es olv e th e f act tha t t he c l as s ic po s i ti on doe s no t a l wa y s e l im i na te t he ten der poi nt ... Anoth er c ri teri on tha t we fi nd c l in i ca l ly i mp ort ant i n thi s t ec hn i qu e i s pr ope r a s s oc i at i on of the dy s fu nct i on pat ter n t o th e t r ea tm en t p osi ti on in th e va r io us ar ti c ul ar ty pe s o f d y s fu nct i on s . and z . Techni que Cl assi ficati on I ndirect In co unt ers tr ai n t ech ni qu e. J ones be l ie v ed tha t p utti ng the j oi nt i nt o it s p osi ti on of gr eate s t c om fort wo uld r ed uce th e co nti nui ng i napp r op r ia te p r op r io c ept or act i v it y . Hi s t end er p oin t l oc at i on s a nd t hei r r el at i on to dys fun c ti on d o n ot ty pi c al l y us e the x.

t he phy s i ci an m ay for go the ti m e def i ni ti on an d r epos i ti on the pat i en t fo r r eas s ess m en t. pati ent 6 m on ths of age ) 3 of 85 21/08/07 22:05 . Sto i c pati ent s w ho c ann ot di sc ern th e le v el of pai n o r i ts c han ge s eco nda r y to p osi tio ni ng 3. t he phy s i ci an m ay use a pal pat ory m ar k er of tis s ue re l eas e.def i ne d m ar ke r . Ins tab i l it y o f t he a r ea be i ng pos i ti oned th at has the po tent i al to pro duc e u nw an ted ne ur ol ogi c o r v as c ul ar s i de ef fect s 4. Techni que Styles Ti m e Defi ned or Rel ease Defined T he p hys i ci an m ay use a t i me .http://thepointeedition. i n w hi c h t he tre atme nt pos i tio n i s h el d for 90 s ec ond s a nd then r ep osi ti on ed to the neu tra l st art i ng pos i ti on for r ea s se s s me nt. Acu te. s o t hat pro per po s i ti oni ng i s d i ff i cu l t 2.13 1 3. or s i mi l ar phe nom eno n.. Pat i en ts w ho c an not und ers tand th e i ns tr uct i on s an d q ues ti on s o f t he p hys i ci an ( e.. as th e p os it i on ma y va r y acc or di ngl y . Aft er feeli ng a s ense of re l eas e. Sev ere deg ene r at i v e s po ndy l osi s w i th l oc al fus i on and no m ot i on at the le v el w he r e tre atme nt pos i ti onin g w oul d no r ma l ly tak e p l ac e P recautions 1. . Sev ere i ll nes s i n wh i ch st r i ct po s it i ona l r est r i ct i on s p r ecl ude tr eatm ent P. Al tern ati v el y .. T he ph y s ic i an sh ould kn ow.lww.. g. su c h a s b asi l ar i ns uff i c ie ncy or neu r of ora m i na l c omp r omi s e w he r eb y th e p osi ti on of tr eatm ent ha s th e p ote ntia l t o e x ace r ba te the c on dit i on 5. I ndications 1. w hi c h m ay occ ur p r io r t o th e 9 0-s ec on d t i me . r el ax at i on . Pat i en ts w ho c an not v ol unt ar il y r ela x . p s oa s hy per ton i c it y c aus i ng l um bar s ym pto m s) . Vas c ul ar o r n eur ol og i c s yn dr om es. v is c er os om ati c r efle x c aus i ng r ib dy s fun c ti on) Contraindications Absolute Contrai ndi cati ons 1. s ub acu te.g . and ch r on i c s oma tic dys fun c ti ons of art i c ul ar and /or m yo fas c i al or i gi n 2.com/pt/re/9780781763714/bookContent.bi nd r ela tio nsh i p. T ra uma ti ze d ( s pr ai ne d o r s tr ai ned ) t i s su es. m y ofa s ci al ease .g.de fi ne d m eth od. Adj unc ti ve tr eat m ent of sy s tem i c c om pl ai nts wi th a s so c ia ted s om ati c dy s fu nct i on ( e. pri or to posi tio nin g th e p ati ent. wh i c h w ou l d be n ega tiv el y aff ect ed b y t he posi tio nin g of the pat i en t 2. wh eth er the d y sf unc ti on is ty pe I or II and /or wh ethe r t her e is a pri m ary or se c ond ary my ofas c ia l c om po nen t ( e. p ul sa tio n.

d.http://thepointeedition. i ts tis s ue lo c ati on and typ e. i ts s ev er it y . Loc at e o ne or m ore te nder po i nt s as s oc i at ed w i th th e pr evi ous l y d i ag nos ed s oma tic dy s fu nct i on by tes tin g wi th a f ew o unc es of f i rm bu t di s cr eet fin ger pa d or th umb pr ess ure . d epe ndi ng o n t he s egm ent i nv ol v ed . a 7 0% r ed uc ti on of pain ma y b e ac c ep tab l e f or tr eat m en t e ffec t. c. a. t he t end enc y is to as k . Ho w eve r . 2. the fol l ow i ng s eq uen c e i s ne c es s ar y : 1. the nat ure of the dy s fu nc ti on ( ty pe I or II ) an d i ts m oti on par am ete r s di ct ate th e pr ope r p os it i on i ng . A ny th i ng l es s tha n 7 0% r edu c ti on c aus es an e v en gr eate r p ote ntia l f or tr ea tme nt fail ure .lww.com/pt/re/9780781763714/bookContent. b. as ph y si c ia ns a nd phy s i ci ans in tra i ni ng tend to co nfus e t he anal og pai n sc ale .tune th r ou gh s m al l a r c s of m otio n u nti l th e t end er ne s s ( pa i n) i s c om pl et ely al l evi ate d. Pe r so nal c om m un i c at i on wi th v ari ous m em ber s o f EC OP and w it h t hos e wh o w or k ed c lo s el y w i th J on es s how s t hat c os tal dy s fun c ti ons als o t ake 90 s ec ond s . an d s o on . ther e i s o nl y a 7 0% pote nti al for a g ood tre atm ent eff ect . N o ci r cu l ar m ot i on sh ould be pa r t o f t his pre s su r e. an as s oc i at ed 10% of tre atme nt eff ec ti v en ess i s l os t. In ge ner al. W i th use of the an alo g sc ale . i n w hom pos i ti onin g f or tend er poi nt p ain re duct i on ex ac er bat es the dis tal c on nec tiv e ti s su e o r ar thr i ti c pro ble m or no mo ti on is av ai la ble fo r po s it i on i ng General Consi derati ons and Rules T he p hys i ci an m ust as c ert ain th e so m at i c dy sf unc tio n. or a mo net ary uni t s uch as $1 . Pat i en ts w i th co nnec tiv e t i s su e d i se as e. 3. a nd p ost eri or p oin ts r equ i re so m e l eve l o f ex ten s io n. Quant i fy th e te nde r p oi nt ' s pai n le v el fo r th e p ati ent as 100 % . If mu l ti ple ten der po i nts ex i st . tr eat th e mo s t pai nful fi r st . F i r st ob tai n a gro s s r edu c ti on of t end ern es s i n the typ i ca l p os it i on re c omm end ed for the l ev el of dy s fun c ti on and ten der poi nt l oc atio n a nd then fi ne. Wh en s ev er al te nde r po i nt s l i e i n a r ow . M ai nta i n t he pos i tio n f or 90 s eco nds .. P ark i nso n d i se as e. c om for tabl e p osi ti on . If th e t end er p oin t c anno t b e e l i mi nat ed. tre at p r ox i ma l be for e d i s ta l ( 2). i n wh i ch the p ati ent i s ask ed to g aug e t heir pa i n on a sc ale of 0 t o 1 0. ar thr i tis . F in d t he m ost si gnif i ca nt tend er poi nt w i th th e pa tie nt i n a ne utr al . a. b. It ha s b een r ep ort ed t hat 12 0 se c on ds i s n ece s sa r y f or c os tal dys fun c ti ons. and w heth er any of the s e pr ec aut i on s or co ntr ai nd i ca tio ns a r e pre s ent . W e h av e fou nd that th e m onet ary un i t w ork s b es t i n the tea c hi ng of c oun ter s tra i n. I f w ar ra nte d. de pend i ng on the se gme ntal le v el i nv ol v ed . i f t he tend er poi nt i s r educ ed onl y by 70 % . the gr eate r t he poss i bi l it y fo r n ece s s it y o f m or e s id e b endi ng. T here for e. 4.” Wi th t he m on etar y s c al e th i s doe s no t o c cu r . the g oal is 100 % p ain r ed uct i on by pos i ti onin g w hen ev er po s si bl e. In add i tio n. c.. F or exa m pl e. “ Th i s p ain is a 1 0. f i r st tr eat the on e i n th e m i dd l e. J one s b el ie v ed 4 of 85 21/08/07 22:05 . i t i s s tr ai gh t i nto the te nde r poi nt . w i th th e as s ig ned pai n o f 1 0. f or ev er y a s ce ndin g n ume r i c l ev el of p ain th at r ema i ns . Slo w ly and ca r ef ul ly pl ace the pa tie nt i n t he posi tio n o f ea s e or opti m al co m for t. H ow ev er . As te nde r p oi nt s m ove awa y f r om the mi dli ne. “ W ha t i s yo ur pai n?” i ns tea d of s ay in g. 1 0. ant eri or poin ts r eq ui re so m e l eve l o f f l exi on.

6. the r e i s a go od c ha nc e tha t i t wi l l r em ai n at z er o. T he f i ng er pad i s not put tin g a ny t her ape utic pr ess ur e i nt o t he t i ss ues . R ec hec k th e s oma ti c dys fun c tio n p ara m ete r s ori gi na l ly pr es en t ( e. and so the y c ann ot b e c omp ar ed ex act l y w i th co unte r st r ai n. y ou c an c onfi den tly ass ure th e pa tie nt that yo u a r e i nde ed on t he ori gi na l s i te . 4. Al s o. a s th e t end er p oin t l oc at i on ma y no t b e e x act l y r el oc at ed. 7. s l ow l y r etu r n the pas s iv e pa tie nt thro ugh a path of le as t r es i st ance to th e or i gi nal neu tra l po s it i on i n w hi c h the ten der poi nt w as eli c it ed. s to p an d a s k hi m or her to r el ax.def i ned tr eat m ent ) o r w hen tis s ue app ear s t o re l ea s e ( r el eas e-d efin ed tre atm ent) . t he s eg m ent al or m yo fas c i al dy s fu nc ti on) .. T he pa tie nt m ust no t he l p. th at t he pai n wi l l ele v ate so m ew hat pos t tre atm ent.13 2 tim e-d efin ed m et hod for ri b dy s fu nct i ons . F in d t he t end er poin t a s so c i at ed w it h th e d y sf unct i on . t he p hys i ci an l ose s c ontr ol of the ten der poi nt. 70% ef fect i ve nes s wa s a c hi ev ed in on l y 9 0 s eco nds. th e 1 20-s eco nd per i od has be en pr om ote d a s th e c l as s i ca l ly de s c ri bed P. 5 of 85 21/08/07 22:05 .g . If th e po s tt r ea tm en t p ain i s r at ed at 3 co m pa r ed to the ori gin all y as s ig ned l ev el of 10 pri or to t r ea tme nt. R ec hec k th e t end er p oin t. T he r ef or e. s o the ph y s ic i an ma y in ter m it tent l y thr oug hout th e t r eat m en t p er io d ( per haps ev ery 30 s ec ond s ) r ech eck the le v el of pai n a t th e ten der poi nt.http://thepointeedition. a. w her eas c li nic al ly .lww. an d t hat use of the s e m ec hani s ms re quir es an opt i m um am oun t of ti m e to a c hi eve the de s ir ed c l in i ca l ou tco m e. if us i ng the ti s s ue re l ea s e m ark er i nst ead of tim e. t he fi ng er pad s ho uld re m ain at th e si te of the ten der poi nt for the en ti re tr eat m ent pe r io d wh ene v er pos s ib l e. so i f y ou fe el tha t t he p ati ent i s hel pin g yo u. tha t t he p osi tio ns f or tre atme nt of c ost al dys func tio ns c aus ed the pat i en t t o be un abl e to ea s il y r el ax.de fin ed m eth od w ork s b ett er t han fe el in g f or a ti s su e r el ea s e. h ow ev er. and th ere fore .com/pt/re/9780781763714/bookContent. Al s o. c. re nder i ng th e ev alu ati on us el ess . the phy s ic i an m us t h ave the fi nge r p ad on t he ten der poi nt s i te to co ns ta ntl y s ense th e t i s su e r eac ti on . o r th e p ati ent m ay ne ed f oll ow up i n a fe w da y s for r ee v al uati on and tre atm ent . W hi l e m ain tai nin g th e e ffe c tiv e p osi ti on . T el l t he p ati ent the te nde r po i nt is a 1 0 o r 1 00 o r a do l l ar ' s w or th o f p ain .en han c in g me c ha nis m s . 5. t he ti me . I f k eep i ng v ig i la nt a t t he s i te . f aci l it ated po s it i ona l r ele as e) us e d i ffe r en t r el eas e. In our han ds and exp eri ence . Oth er tec hniq ues th at m ay app ear s im i la r t o co unt ers tr ai n ( e. We bel i ev e t hat m os t pro ble m s d i ag nos ed a nd s uc c ess ful l y tr ea ted wi th t his te c hni que in v olv e t he r ese tti ng of neu r ol ogic fe edb ac k m ec han i s ms ea r li er i den tif i ed. We bel i ev e th at J on es 's at tem pts at v ar i ous ti m e i ncr eme nts and hi s c oncl usi on that ho l di ng t he pos i ti on f or 90 s eco nds wa s th e m ost eff ect i ve m et hod mu s t h ave a r eas on. b. Th e e ffec t m ay c ont i nu e to i mp r ove th e p atie nt' s s y m pt oms ov er t i me . 2.. the patie nt oft en d oes no t be l ie v e the phy s ic i an i s on the ori gin al t end er poin t a nd m ay quest i on th e ex act lo c ati on of the m on i to r i ng fi nge r . I t i s p os si ble . If th e f i ng er p ad i s r emo v ed . T h e s h or t ha n d r u le s a r e a s f o ll o ws: 1. If t he ten der poi nt w as r ed uce d to ze r o i nit i al l y.g .. h e g av e the m a n ad dit i on al 3 0 s eco nds to r el ax . 9 0 s ec on ds w il l su ffi c e. Aft er 90 s eco nds ( ti m e..

. 3. R ec hec k th e t end er p oin t a nd t he oth er s oma tic c om pon ent s of th e d y s fu nct i on ( TA R T) .http://thepointeedition. i nter nal ro tati on. cr es t ( CR ) . SL or Sl . pro nati on. T hi s s hor than d u s es the in i ti al s for ty pes of m ot i ons ( di re c ti ons of m ov eme nt) and up per and lo w er c as e f or g r ea ter and le s se r mo v em ent i n the di r ect i on i dent i fi ed. T r ea tme nts s houl d b e p r esc r ib ed ac co r di ng to t he phy s i ci an' s c l i ni c al ju dgme nt. T hi s i s unusu al i n our c li nic al e x pe r ie nc e but ha s be en r ep or te d b y o ther s ( 1). r es pec tiv el y.com/pt/re/9780781763714/bookContent. ex tern al r ot atio n. abd uc ti on. Pos tt r ea tme nt r eac tio n ma y i ncl ude gen era l so r en ess thr oug h t he f oll owi ng 2 4 t o 4 8 ho urs . s i de P. Pla c e the pat i en t in th e p os it i on th at r edu c es the pa i n of t he ten der poi nt 100% (o r a t le ast 70 % ) . F or f.13 4 Anteri or Cervical Counterstrain Techniques: Anterior Cervical Tender Poi nts Anter i or ce r v ic al ( AC ) co unt ers tr ai n t end er p oin ts ar e out l in ed i n T abl e 9.lww. S R o r Sr . and PR O o r pr o.13 3 bendi ng r ig ht. 6 of 85 21/08/07 22:05 . Abbreviations for Counterstrain Techni que Yates an d G l ove r i ntr oduc ed a s hort han d d es cr i pt i on tha t m any s tu den ts us e to hel p re m em ber the pos it i on i ng for sp eci fi ca l ly lo c ate d t end er p oin ts.. r ota tio n ri ght . AB or A b. AD or ad. ad duct i on . If th i s oc cu r s. T re ati ng m ore th an s i x ten der poi nt s a t o ne v i si t a ppea r s to be c orr ela ted to thi s re act i on . 5. a nte r io r . 6. S U P o r s up. in s tru c t the pat i en t t o in c re ase fl uid s a nd us e i ce pa c k s ove r t he s ore ar eas for 15 to 20 m in utes ev ery 3 h our s a s ne ede d. pos te r io r . s upin ati on. bu t 3. Th e c om mo n a bbr ev ia tio ns of t his sh or th and me thod ar e: A. H ol d t hi s pos i ti on f or 90 s eco nds . 4. ex ten s i on . Ot hers ab bre v i at i on s r efer to mo ti on to w ar d (t ) a nd aw ay (a ) a nd obv io us bon y la ndm ark s . T he p ati ent ' s r esp ons e wi l l det er mi ne how oft en the pat i en t n eeds tr eat m ent . Slo w ly . IR or i r . s uch as s pi nou s p r oce s s ( SP ) . fl ex io n. R L or Rl . r otat i on le ft. P. E o r e. R R o r R r . P . U pp erc as e l et ter s me an m or e of th at part i cu l ar m ot i on an d lo w er c as e me ans le s s ( 3). s id e b endi ng l ef t. 1 a nd demo nst r at ed i n F i gu r e 9. th r ou gh a pa th of l eas t r esi s tan c e.1.day in terv als ar e ap pro pri ate. t r an s ve r s e pro c es s (T P). re turn th e r el ax ed pat i ent to ne utra l . and oc c ip ut ( OC C ) . ER or er.

type II dy s function of C7 F lex. T able 9. but les s than AC7. s ide-bend toward. rotate away F lex to level of C7.1 Comm on Ant erio r Cervical Tender Po int s Classic Treatm ent Positio n Rotate head away. unc oupled dy s function L o cation Posterior surface of as cending ramus of mandible between earlobe and angle of mandible ( gonion) Anter ior aspect of tr ans ver s e proc ess of dy sfunctional c ervical ver tebra Acronym RA AC2–AC6. us ually away F lex to level of dy s functional s egment. fine-tuning with s ide bending.13 5 7 of 85 21/08/07 22:05 .http://thepointeedition. approximately 2 cm later al to s ternoclavic ular joint O r igin of sternal divis ion of s ternocleidomas toid muscle at medial head of c lav icle at s ternal notc h F ST RA AC8. r otate away Ten der Point AC1. s ide bend away. r otation..lww. type I dy s function of C7 or s ternocleidomastoid Anter ior at origin of c lavicular division of s ternocleidomas toid muscle.. s ide-bend away.com/pt/re/9780781763714/bookContent. rotate away F SA RA P. type II dy s function F SA RA AC7.

1..13 7 Anteri or Cervical Counterstrain Techniques: AC1 8 of 85 21/08/07 22:05 .lww. Anter ior cervic al counter str ain tender points (5).http://thepointeedition. Fig ure 9. P.13 6 P..com/pt/re/9780781763714/bookContent.

T his firs t tec hnique will illustrate the c omplete c ounterstrain s equence with the unique as pec t of the technique highlighted.. We hav e abridged the tex t desc ribing eac h individual tec hnique. AC1: RA.2.lww. as the c ounterstrain s equence is the s ame for eac h dy s function. AC1 tender point loc ation ( 5). and our clinical F igure 9. AC1: RA. The unique factor s of eac h dysfunc tion ar e the location of the tender point and the c las s ic tr eatment pos ition.com/pt/re/9780781763714/bookContent. Yates and G lover (6). 9 of 85 21/08/07 22:05 . Rennie and G lover ( 4) . All of the following tec hniques will be des cribed with only the information unique to that s pec ific s omatic dy s function and its tender point. F igure 9.http://thepointeedition. T he following tec hniques ar e des cribed and illustrated in a s tepwise s equence. F igure 9..4.3. T he tender point loc ations ar e a c ompilation of des criptions from J ones and as s ociates ( 1).

com/pt/re/9780781763714/bookContent..http://thepointeedition.13 8 Anteri or Cervical Counterstrain Techniques: AC2 to AC6 10 of 85 21/08/07 22:05 . P..lww.

7..10). AC4: F SA RA.com/pt/re/9780781763714/bookContent. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function C2 to C6. 9. 9.6). F igure 9.8. T en der Po int L o cation T he tender point is at the anterior as pect of the tr ansv ers e pr oces s of the dy s functional c er vic al ver tebr a ( F ig.9. AC4: F SA RA. and r otated away from the tender point ( F igs.http://thepointeedition. 11 of 85 21/08/07 22:05 . s ide-bent. 9. F igure 9.lww.7. 9.6. AC2-AC6 tender points ( 5).. F igure 9. 9. Probe lateral to medial.8. T reatm ent Po sition Patient's head and nec k are flex ed to the level of the dy s functional s egment.

9. AC7 tender point (5) . 12 of 85 21/08/07 22:05 . 9. Fig u re 9. 9.lww. T en der Po int L o cation Anteriorly. Fig u re 9. P.15).12. 9. AC7: F ST RA.12.13. rotated away . Pr obe pos ter ior to anterior.14. T reatm ent Po sition T he patient's head and neck are mar kedly flex ed to the level of lev el of C7. and side.http://thepointeedition.bent toward the s ide of the tender point ( F igs.11. 9..13 9 Anteri or Cervical Counterstrain Techniques: AC7 (S ternocl eidomastoi d Muscl e) In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dysfunction C7 (AC7-type I dy s function C7.. the tender point lies at the or igin of the c lavic ular divis ion of the s ternocleidomastoid mus cle approx imately 2–3 c m lateral to the s ternoclavic ular joint (F ig.com/pt/re/9780781763714/bookContent. or s ternocleidomastoid mus cle dy s function) .11).

Fig u re 9. AC7: F ST RA. AC7: F ST RA ( alternativ e hand plac ement) .com/pt/re/9780781763714/bookContent.13.http://thepointeedition.14 0 Anteri or Cervical Counterstrain Techniques: AC8 13 of 85 21/08/07 22:05 .14.. AC7: F ST RA. Fig u re 9.lww. P.. Fig u re 9.15.

. 9. and s ide-bent away fr om the side of tender point (F igs.lww.17.com/pt/re/9780781763714/bookContent. AC8 tender point (5) .18. 9. T en der Po int L o cation T he tender point lies at the origin of the sternal division of the s ternocleidomastoid mus cle.17. 14 of 85 21/08/07 22:05 .16). T reatm ent Po sition T he patient's head and neck are flexed ( less than C7).18. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dysfunction C7 (AC8–type II dy s function C7). r otated away . AC8: F SA RA. AC8: F SA RA. 9.20). Fig u re 9. 9. at the medial head of the c lavic le at the s ternal notc h ( pr ess medial to lateral) (F ig . Fig u re 9. Fig u re 9.19.http://thepointeedition.. 9.16.

. F igu re 9. Posterior c erv ical counterstrain tender points (5) . P..21.14 1 P osterior Cervical Counterstrain Techni ques: P osteri or Cervical Tender Poi nts Pos ter ior c er vic al c ounterstrain tender points ar e outlined in T able 9.http://thepointeedition. 15 of 85 21/08/07 22:05 .2 and demons trated in F ig ure 9.lww.com/pt/re/9780781763714/bookContent.21.

s light s ide bending and r otation away as needed Ex tend to level of dy sfunctional Acro nym F PC1 lateral Halfway between PC2 and mastoid pr ocess as soc iated with s plenius capitis muscle E Sa Ra PC2 lateral Within s emis pinalis c apitis musc le as soc iated with gr eater occipital nerve E Sa Ra PC2 midline Super ior lateral s urface of s pinous proc ess of C2 E Ra PC3–PC8 midline Infer ior sur fac es of spinous E Sa Ra 16 of 85 21/08/07 22:05 . s light s ide bending and r otation away as needed Ex tension of oc cipitoatlantal ar tic ulation with mild c ompr ess ion on head to reduc e my ofascial tension of s uboc cipital tissues. s light s ide bending and r otation away as needed Ex tension of oc cipitoatlantal ar tic ulation with mild c ompr ess ion on head to reduc e my ofascial tension of s uboc cipital tissues. T able 9...lww. additional c ervical flexion may be neces sar y Ex tension of oc cipitoatlantal ar tic ulation with mild c ompr ess ion on head to reduc e my ofascial tension of s uboc cipital tissues. pushing later ally into muscle mass Classic T reat men t Po sition F lexion of oc cipitoatlantal ar tic ulation.com/pt/re/9780781763714/bookContent.2 Co mmo n Po sterio r Cervical Ten der Po int s Ten der Point L o cation PC1 Inion 2 cm below inion.http://thepointeedition.

com/pt/re/9780781763714/bookContent..14 2 P osterior Cervical Counterstrain Techni ques: P C1 Ini on 17 of 85 21/08/07 22:05 . P.lww..http://thepointeedition.

PC1 inion: F Sa Ra. T en der Po int L o cation T he tender point lies 1–2 cm below the inion (F ig 9. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at C0. PC1 inion: F Sa Ra..com/pt/re/9780781763714/bookContent. T he phys ician fine-tunes through s mall ar cs of motion ( flexion or extension and minimal s ide bending and/or F igure 9. 2.24. 9. PC1 inion tender point (5) . T he phys ician flex es the patient's head by inducing c ephalad trac tion on patient's occiput while inducing c audad motion on patient's frontal area ( Fig s.25) . 9.22).23.22. 9. Push anterolaterally into mus cle mass.lww. T reatm ent Po sition 1.23. F igure 9..http://thepointeedition. 18 of 85 21/08/07 22:05 . F igure 9.C1.24.

.lww. P..14 3 P osterior Cervical Counterstrain Techni ques: P C1 and PC2 19 of 85 21/08/07 22:05 .http://thepointeedition.com/pt/re/9780781763714/bookContent.

F igure 9. F igure 9. PC2 (lateral) ..26). 3.28).27. Alternative: Extension. PC1–PC2 tender points (5) .http://thepointeedition. Patient's head is extended to the lev el of the dysfunc tional v ertebr a..com/pt/re/9780781763714/bookContent. T en der Po int L o cations PC1 (lateral) . T reatm ent Po sition 1.lww. F igure 9. 9. Push anteriorly. 9. T he phy s ician fine-tunes through small arcs of motion ( slight side bending and r otation away) . halfway between PC2 and the mas toid proc ess as s ociated with the s plenius capitis mus cle (F ig. PC1–PC2: E Sa Ra. s light occipitoatlantal c ompres s ion may be needed ( Fig s. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dysfunction at C1. within the semis pinalis c apitis musc le as s ociated with the gr eater occipital ner ve. 2. PC1–PC2: E Sa Ra.27 an d 9.C2.26.28. 20 of 85 21/08/07 22:05 .

P. Patient's head is extended to the appr opr iate level ( F igs. PC5.32. PC3: e Sa RA. 9. PC5. PC3. PC3–PC7 midline tender points ( 5) . 9. 9.31). PC7.14 4 P osterior Cervical Counterstrain Techni ques: P C3 to P C7.lww. T reatm ent Po sition 1.32. T he phys ician fine-tunes through small arcs of motion with s light s ide bending and s light to moderate r otation F ig ure 9.31.http://thepointeedition. 9. Mi dline In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function C3 to C7. F ig ure 9.33.com/pt/re/9780781763714/bookContent.34... T en der Po int L o cation T he tender point lies at PC3 to PC7 midline and the inferior sur faces of the spinous pr oces ses of C2 to C7 (F ig. 9.35. 2. r espectively). 21 of 85 21/08/07 22:05 .

14 5 P osterior Cervical Counterstrain Techni ques: P C3 to P C7. PC7: e-E Sa RA.33.lww. Lateral 22 of 85 21/08/07 22:05 .. PC5: e Sa RA.com/pt/re/9780781763714/bookContent.35. F ig ure 9.http://thepointeedition. P. away ..34. F ig ure 9. PC5: e Sa RA. F ig ure 9.

36). 9. T he phys ician F igure 9. at lateral s urface of the ar tic ular pr oces s as s ociated with the dy sfunctional s egment ( Fig .37. T en der Po int L o cation T he tender point lies at PC3 to PC7 pos ter olater al. T he phys ician extends the head and neck to the level of the dysfunc tional s egment with minimal to moderate s ide bending directed at the segment and minimal to moder ate r otation away ( Fig s.com/pt/re/9780781763714/bookContent. 23 of 85 21/08/07 22:05 ...36. 9.http://thepointeedition. PC3. and PC6.40.39. PC3: e Sa RA.lww. 9. PC6. PC3–PC7 lateral tender points ( 5). 9. PC3.38. F igure 9. 9. 2.37. r espectively). In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at C3 to C7. T reatm ent Po sition 1.

24 of 85 21/08/07 22:05 .14 6 Anteri or Thoraci c Counterstrain Techniques: Anterior Thoracic Tender Poi nts Anterior thor acic c ounterstrain tender points ar e outlined in T able 9. Anterior thor acic c ounterstrain tender points ( 5).http://thepointeedition. P.. F ig ure 9.lww.com/pt/re/9780781763714/bookContent.41.3 and demonstr ated in Figure 9.41..

lww.. midline or 2–3 cm lateral AT10: 1–2 cm below umbilic us at lev el of L4. midline or 2–3 cm lateral AT11: 5–6 cm below umbilic us below level of iliac cres ts at superior L5 level. junc tion of manubrium and ster num (angle of Louis) Midline at lev el of cor r esponding rib. r otation away ( type II) F St RT F St RA 25 of 85 21/08/07 22:05 . midline or 2–3 cm lateral AT12: Superior . T able 9. rotation toward (type I) or s ide bending toward. midline or lateral AT9: 1–2 c m abov e umbilic us at lev el of L2.3 Co mmo n Anterior Th oracic Ten der Points Ten der Point AT 1 L ocatio n Midline episternal notc h Classic Treat men t Positio n F lexion to dy s functional lev el F lexion to dy s functional lev el Acronym F AT 2 Midline. inner s urface of iliac c res t at mid.axillary line F AT 3-AT 5 AT 6 F lexion to dy s functional lev el F AT 7–AT 9 F lexion to dy s functional lev el..http://thepointeedition.com/pt/re/9780781763714/bookContent. AT8: 3 cm below xiphoid at lev el of T12. side bending towar d and rotation away F St RA AT 10–AT12 Hip flexion 90–135 degrees. Midline xiphoid–sternal junc tion AT7: Midline or inferolateral to tip of x iphoid. s light side bending.

http://thepointeedition...lww. P.com/pt/re/9780781763714/bookContent.14 7 Anteri or Thoraci c Counterstrain Techniques: AT1 and AT2 26 of 85 21/08/07 22:05 .

. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1.. F igure 9. Patient leans back agains t phys ician's c hes t and thigh. Patient is s eated on the treatment table with hands on top of the head.42) AT 2: Midline at junction of manubr ium and s ternum ( angle of Louis) T reatm ent Po sition 1. 9.42.com/pt/re/9780781763714/bookContent.43. 27 of 85 21/08/07 22:05 . such as anterior T1. F igure 9. 3.T 2 tender point. Phys ician s tands behind patient and wraps ar ms under patient's axillae and around the c hes t and plac es hands over the manubrium.http://thepointeedition. 2.44. AT 1–AT 2: F. AT 1–AT 2 tender points (5) . F igure 9. T en der Po int L o cations AT 1: Midline in the episternal notch ( F ig.T2. AT 1–AT 2: F.lww.

lww.http://thepointeedition.com/pt/re/9780781763714/bookContent.. P.14 8 Anteri or Thoraci c Counterstrain Techniques: AT1 to AT6 28 of 85 21/08/07 22:05 ..

F igure 9. 9.46. and the phys ician's thigh is behind the patient's upper thoracic r egion.com/pt/re/9780781763714/bookContent. alter native hand placement. AT 1–AT 6 tender points (5) .46) AT 2: Midline at junction of manubr ium and s ternum ( angle of Louis) AT 3 to AT 5: Midline at lev el of c or res ponding rib AT 6: Midline x iphoid–s ter nal junction T reatm ent Po sition 1.48..lww. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1 to T 6. AT 1–AT 6: F IR ( arms ). the patient is elev ated fr om the table with F igure 9. AT 1–AT 6: F IR ( arms ).. T en der Po int L o cations AT 1: Midline in the episternal notch ( F ig.47. While the phys ician's index finger pad palpates the tender point. 2. F igure 9. T he patient lies supine with the ar ms off the side of the table. 29 of 85 21/08/07 22:05 .http://thepointeedition.

AT3–AT4 tender points (5).49) AT 4: Midline on the sternum at the level of the fourth costal c ar tilage T reatm ent Po sition In this technique the physician may not be able to control the tender point fully thr oughout the tr eatment pr oces s. and the phys ician plac es the Fig u re 9.. 9.49. Fig u re 9.lww. AT3–AT4: F IR (ar ms) .51. T en der Po int L o cation AT 3: Midline on the sternum at the level of the 3r d costal c ar tilage (F ig.14 9 Anteri or Thoraci c Counterstrain Techniques: AT3 to AT4.T4..http://thepointeedition. T he patient s its on the end of the treatment table in front of the phys ician.com/pt/re/9780781763714/bookContent. AT3–AT4: F IR (ar ms) . P. 30 of 85 21/08/07 22:05 . Fig u re 9.50. Al ternati ve Technique In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at T 3. 1.

..http://thepointeedition.50). 3. T he phys ician leans forward with the c hes t and abdomen while pulling back war d on the patient's arms to flex the thor acic s pine to the des ired level ( F ig. minimal or no s ide bending or r otation). 9.51). 4. 2.com/pt/re/9780781763714/bookContent. forearms under the patient's axillae.15 0 31 of 85 21/08/07 22:05 . T he phys ician fine-tunes through s mall ar cs of motion ( flexion. P. T he phys ician's forearms gras p the medial s ide of the upper ar ms to induc e internal r otation ( Fig .lww. 9.

Anteri or Thoraci c Counterstrain Techniques: AT7 to AT9 32 of 85 21/08/07 22:05 .http://thepointeedition..lww.com/pt/re/9780781763714/bookContent..

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 7 to T9. midline or lateral AT 9: 1–2 cm above umbilic us at lev el of L2. F igure 9.http://thepointeedition.com/pt/re/9780781763714/bookContent.lww. midline or 2–3 cm lateral T reatm ent Po sition 1.54.52. F igure 9. T he phys ician's foot on the s ide opposite the tender point is plac ed on the table with the patient's arm res ting on a pillow on the phys ician's thigh. T he patient is s eated on the treatment table with the phys ician s tanding behind the patient. T en der Po int L o cation AT 7: Midline or inferolateral to tip of xiphoid ( F ig.53..52) AT 8: 3 cm below x iphoid at level of T 12. AT 7–AT 9: F St Ra. 2.. F igure 9. AT 7–AT 9 tender points (5) . 33 of 85 21/08/07 22:05 . AT 7–AT 9: F St Ra (fine-tune). 9.

15 1 Anteri or Thoraci c Counterstrain Techniques: AT9 to AT12 34 of 85 21/08/07 22:05 .. P.com/pt/re/9780781763714/bookContent.http://thepointeedition..lww.

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 9 to T12.http://thepointeedition.55) AT 11: 5–6 cm below umbilic us below lev el of iliac c r ests at superior L5 lev el. 2.. and plac es the c audal foot on the table. F igure 9. F igure 9. 35 of 85 21/08/07 22:05 . AT 9–AT 12 type I: N ST RA. and the phys ician s tands on either s ide of the patient. AT 9–AT 12 type II: F RA SA. for bes t phys ical c omfort and c ontrol..com/pt/re/9780781763714/bookContent. inner sur fac e of ilia c res t at mid-ax illary line T reatm ent Po sition 1. T he patient lies supine. midline or 2–3 cm lateral ( F ig.56. T en der Po int L o cation AT 10: 1–2 cm below umbilic us at lev el of L4.55. 9. midline or 2–3 cm later al AT 12: Superior.lww. AT 9–AT 12 tender points (5) .57. T he hips and k nees ar e flex ed to the level of the dysfunc tional F igure 9.

15 2 P osterior Thoracic Counterstrain Techni ques: P osteri or Thoracic Tender Poi nts Pos ter ior thorac ic c ounterstrain tender points ar e outlined in Table 9..lww.58. P.com/pt/re/9780781763714/bookContent.http://thepointeedition. 36 of 85 21/08/07 22:05 ..58.4 and demons trated in Figure 9. Fig u re 9. Posterior thor acic c ounters train tender points (5) .

Rotation and s ide bending minimal. Depending on phys ician preference. Avoid prefov erex tending.lww. Patient pr one with arms at side.4 Co mmo n Po sterio r T h oracic Ten der Po int s Ten der Point PT 1–PT 3 ( 4) L o cat ion Midline. Mi dline 37 of 85 21/08/07 22:05 . Acron ym e-E Sa Rt ( type I) or e-E St Rt ( type II). may be opposite ( SARA) c oupling.15 3 P osterior Thoracic Counterstrain Techni ques: P T1 to P T4. phy sic ian controlling pelvis. gently extend head and neck to engage dys func tional segment. PT 4–PT 9 Same as above. T able 9.. or inferolater al tip of s pinous proc ess ( side opposite r otational c omponent) or over transver se proc ess (on s ide of r otational c omponent) Same as abov e Classic Treatm ent Positio n Prone with ar ms hanging ov er s ides of table.http://thepointeedition..com/pt/re/9780781763714/bookContent. exc ept shoulders may be flexed fully to add extens ion or plac ed at the side to decrease extens ion with phy sic ian controlling shoulder from opposite s ide. Same as abov e PT 10–PT12 Same as abov e Same as abov e P. Support patient's head by cupping point of chin.

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1 to T4. T en der Po int L o cation T he tender point lies at PT1 to PT4, midline, the inferior lateral tip of the spinous pr oces s of the named ver tebr a. Palpate from inferior to s uperior at a 45-degr ee angle (F ig. 9.59). T reatm ent Po sition 1. T he patient lies pr one and the phys ician s tands at the head of the treatment table. 2. T he patient's arms hang over the s ides of the table and the phys ician, s upporting the patient's head and neck by c upping the c hin, gently lifts and extends the neck to the

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

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

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

38 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.15 4

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

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 1 to T6. T en der Po int L o cation T he tender point lies at PT1 to PT6 midline, the inferior lateral tip of the spinous pr oces s of the named ver tebr ae. Palpate from inferior to s uperior at a 45-degr ee angle (F ig. 9.62). T reatm ent Po sition 1. T he patient lies pr one, and the phys ician s tands at the head of the treatment table. 2. T he patient's arms hang over the s ides of the table, and the phys ician, s upporting the patient's

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

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

39 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

P.15 5

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

40 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 7 to T9. T en der Po int L o cation T he tender point lies at PT1 to PT9, midline, the inferior lateral tip of the spinous pr oces s of the named ver tebr ae. Palpate from inferior to s uperior at a 45-degr ee angle (F ig. 9.64). T reatm ent Po sition 1. T he patient lies pr one and the phys ician s tands at the head of the treatment table. 2. T he patient's arms and s houlder s are flex ed forward parallel to the table, and the phys ician, s upporting the patient's head and neck by c upping the c hin, gently

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

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

41 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.15 6

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

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 4 to T9. T en der Po int L o cation T he tender point lies at PT4 to PT9, lateral, at the pos ter olater al tip of the tr ans v ers e pr oces s of the named ver tebr ae ( r otational c omponent) ( F ig. 9.66). T reatm ent Po sition 1. T he patient lies pr one, and the phys ician s tands or s its at the head of the table. 2. T he phys ician's forearm is plac ed under the patient's axilla on the s ide of the tender point with the hand on the posterolateral c hes t wall.

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

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

42 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

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

P.15 7

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

43 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at T 4 to T9. T en der Po int L o cation T he tender point lies at PT4 to PT9, lateral, pos ter olater al tip of the tr ans v ers e pr oces s of the named ver tebr ae ( r otational c omponent) ( F ig. 9.69). T reatm ent Po sition 1. T he patient lies pr one. T he phys ician s tands on the side of the table opposite the tender point, gras ps the patient's opposing anterior s houlder (far s ide), and gently lifts the shoulder, inducing extension and rotation to that side ( Fig . 9.70) . 2. T he phys ician

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

F igure 9.70. PT 4–PT 9: e-E Rt.

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

44 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.15 8

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

45 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

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

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

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

46 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.15 9

Anteri or Costal Counterstrain Techni ques: Anterior Costal Tender Points

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

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

47 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

T able 9.5 Comm on Ant erio r Cost al T end er Poin ts Ten der Point AR1 T reat men t Po sit ion , Acron ym Patient s upine f-F St RT Same as abov e Patient s eated f ST RT

Jo nes's Term Depr ess ed r ib

Locatio n Below clavic le at firs t c hondr osternal ar ticulation O n sec ond rib at midclavic ular line Anterior axillar y line on dy s functional rib

AR2

Depr ess ed r ib Depr ess ed r ibs

AR3 AR4 AR5 AR6

P.16 0

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

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

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

48 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

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

F igure 9.78. AR1–AR2: f-F St RT.

F igure 9.79. AR1–AR2: f-F St RT.

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

P.16 1

Anteri or Costal Counterstrain Techni ques: Anterior Ri b,

49 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

E xhaled and Depressed, AR3 to AR6

50 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function, ribs 3 to 6 ( exhalation, depres sed). T en der Po int L o cation T he tender point lies at AR3 to AR6: anterior ax illary line on the dy s functional rib ( F ig. 9.81). T reatm ent Po sition 1. T he patient is s eated with the hips and knees flex ed on the table on the s ide of the tender point. F or comfort, the patient may let the leg on the s ide of the tender point hang off the front of the table, the other leg c ros sed under it. 2. T he phys ician s tands behind the patient with the foot opposite the

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

F igure 9.82. AR3–AR6: f ST RT .

F igure 9.83. AR3–AR6: f ST RT .

51 of 85

21/08/07 22:05

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.16 2

P osterior Costal Counterstrai n Techniques: Posterior Costal Tender Points

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

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

T able 9.6 Comm on Post erior Cost al Ten d er Points Classic T reatmen t Positio n an d Acro nym Patient seated e SA Rt Patient seated e SA Rt or f SA RA Patient seated f SA RA

Jo nes's Ten der Point T erm PR1 Elev ated r ib

Locatio n Cer vic othorac ic angle jus t anterior to tr apez ius Superior sur face

PR2

Elev ated r ib

PR3–PR6

Elev ated r ibs

Superior sur face of r ib angles

PR, posterior rib.

P.16 3

52 of 85

21/08/07 22:05

P R1 53 of 85 21/08/07 22:05 .http://thepointeedition. P osterior Costal Counterstrai n Techniques: Posterior Rib.. I nhaled and E levated..lww.com/pt/re/9780781763714/bookContent.

. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at r ib 1 ( inhalation. PR1: e SA Rt.85. PR1 tender point. 2. PR1 tender point (5).. 54 of 85 21/08/07 22:05 . which is F igure 9. T he patient is s eated.85) T reatm ent Po sition 1. 3. F igure 9. T he phys ician monitor s the firs t r ib tender point with the index finger pad. T he phys ician's foot opposite the tender point is plac ed on the table under the patient's axilla.http://thepointeedition.86. T he phys ician s tands behind the patient.lww.87. elevated) . 9.com/pt/re/9780781763714/bookContent. F igure 9. T en der Po int L o cation PR1: Posterior as pect of fir st rib at the c er vic othorac ic angle immediately anterior to the tr apez ius (F ig.

com/pt/re/9780781763714/bookContent. elevated) .89. F igure 9. F igure 9. T he patient is s eated with legs on the side of table ( for c omfort. P.lww. PR2–PR6: f SA Ra.89) PR3 to PR6: pos ter ior as pects of the ribs 3 to 6 at the super ior s ur fac e of their rib angles T reatm ent Po sition 1.91.16 4 P osterior Costal Counterstrai n Techniques: Posterior Rib..90. PR2–PR6 tender points (5) . T en der Po int L o cation PR2: posterior as pect of sec ond r ib at its s uper ior s ur fac e ( Fig . Ribs 2 to 6 In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function in r ibs 3 to 6 (inhalation. T he phys ician s tands behind patient with the foot F igure 9. 2.http://thepointeedition. 9. the patient may hang the leg opposite the tender point off the table) . PR2–PR6: f SA Ra.. I nhaled and E levated. 55 of 85 21/08/07 22:05 .

. ipsilateral to the tender point on the table with the thigh under the patient's axilla. 5. 3.90 an d 56 of 85 21/08/07 22:05 . 4. T his induces side bending and r otation away fr om the tender point ( F igs. T he phys ician elev ates the patient's s houlder with the axilla r esting on the thigh. neck. 9.com/pt/re/9780781763714/bookContent.. T he phys ician gently flex es patient's head. whic h s ide-bends the trunk away fr om the tender point. and thor ax to engage the level of the dysfunc tional r ib.lww. T he patient is asked to s lowly extend the s houlder and arm opposite the tender point and allow the arm to hang down.http://thepointeedition.

6.lww.com/pt/re/9780781763714/bookContent. r otation.. P. and s ide bending) . 9. T he phys ician fine-tunes through s mall ar cs of motion ( flexion. extension.16 5 Anteri or Lum bar Counterstrain Techni ques: Anterior Lumbar Tender Points 57 of 85 21/08/07 22:05 .91).http://thepointeedition..

. In these supine tec hniques with motion initiated fr om below the dy s function. Anterior lumbar c ounterstrain tender points ar e outlined in Table 9.lww.7 and demons trated in Figure 9.http://thepointeedition. when the k nees and pelvis ar e dir ected F igu re 9.92.com/pt/re/9780781763714/bookContent. T herefore. the physician may stand on either side of the patient and depending on the dy s function may alter the s ide-bending and rotational elements.. Note: The ac r ony ms for the class ic pos itions r epres ent the point of r eference r elated to the mov ement of the upper of the two s egments inv olv ed in the dy s function. Anter ior lumbar counters train tender points ( 5) 58 of 85 21/08/07 22:05 .92.

anterior inferior iliac spine. AIIS.16 6 Anteri or Lum bar Counterstrain Techni ques: AL1 59 of 85 21/08/07 22:05 .. anterior s uperior iliac spine. T able 9.7 Co mmo n An terior Lum bar Ten der Po int s Ten der Point L o cat ion Classic Treatment Po sit ion Patient supine with hip and k nee flexion AL1 Medial to ASIS T ype II: F SA Ra T ype I: F ST RA or F SA RT T ype II: f..lww.F SA RA T ype I: f-F SA RT Same as AL2 Same as AL2 T ype II: F SA Ra T ype I: F SA Rt AL2 Medial to AIIS AL3 AL4 AL5 Lateral to AIIS Inferior to AIIS Anterior as pec t of pubic bone 1 cm lateral to pubic s ymphys is just inferior to pr ominenc e ASIS.com/pt/re/9780781763714/bookContent. P.http://thepointeedition.

press medial to lateral ( F ig. medial to the ASIS. It may be as s ociated with the ps oas mus cle. 60 of 85 21/08/07 22:05 . F igure 9. T reatm ent Po sition 1.com/pt/re/9780781763714/bookContent. 2.. 9.. F igure 9. AL1 tender point (5). T he patient's hips and k nees ar e flex ed enough to engage the lower of the two s egments involved ( L2) .93. In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L1. AL1 ty pe I ( ST RA).94. T en der Po int L o cation T he tender point lies at AL1. 3. T he F igure 9.lww.93). AL1 ty pe II (SA RA) .95.http://thepointeedition. T he patient is s upine and the phys ician s tands at the side of the table on the s ide of the tender point.

http://thepointeedition.. P.com/pt/re/9780781763714/bookContent.lww..16 7 Anteri or Lum bar Counterstrain Techni ques: AL2 61 of 85 21/08/07 22:05 .

3. In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L2.com/pt/re/9780781763714/bookContent. T he patient lies s upine. F igure 9. probe laterally (F ig. AL2: F Sa-A RT. F igure 9.http://thepointeedition. 62 of 85 21/08/07 22:05 .97.96). 9. T he patient's hips and F igure 9. and the phys ician s tands at the side of the table opposite the tender point. AL2 tender point (5).96..lww.98. T en der Po int L o cation T he tender point lies at AL2. AL2: F Sa-A RT. medial to anterior inferior iliac spine ( AIIS) .. 2. T reatm ent Po sition 1. T he patient's hips and k nees ar e flex ed enough to engage the lower of the two s egments involved ( L3) .

http://thepointeedition. P.lww.16 8 Anteri or Lum bar Counterstrain Techni ques: AL3 and AL4 63 of 85 21/08/07 22:05 .com/pt/re/9780781763714/bookContent...

F igure 9. 2. T reatm ent Po sition 1. T he phys ician may plac e the caudad leg on the table and lay the patient's legs on the phys ician's thigh. AL3–AL4: F SA RT for type I.com/pt/re/9780781763714/bookContent.99. T he patient lies supine.. 9. In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L3 and L4.101. T he patient's hips and k nees ar e flex ed enough to F igure 9. T en der Po int L o cation AL3: lateral to the AIIS. AL3–AL4 tender points (5) . pr ess c ephalad. and the phys ician s tands at the side of the table opposite the tender point.99).lww. AL4: inferior to the AIIS. 3.100. pr ess medially (F ig . F igure 9. 64 of 85 21/08/07 22:05 .http://thepointeedition.. AL3–AL4: F ST RT for type II.

http://thepointeedition.lww.16 9 Anteri or Lum bar Counterstrain Techni ques: AL5 65 of 85 21/08/07 22:05 .com/pt/re/9780781763714/bookContent.. P..

AL5 tender point ( 5). 9.102. In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function at L5. 66 of 85 21/08/07 22:05 . anterior aspect of the pubic bone about 1 cm lateral to the pubic s y mphy sis jus t inferior to its pr ominenc e ( F ig.lww. T en der Po int L o cation T he tender point lies at AL5. T he phys ician plac es the c audad leg on the table and lays the patient's legs on the phys ician's thigh.com/pt/re/9780781763714/bookContent.103. T he F igure 9. 2.. 3. T he patient lies supine.. T reatm ent Po sition 1. and the phys ician s tands at the side of the table on the s ide of the tender point.102) . F igure 9. AL5: F SA RA.http://thepointeedition.

F ig ure 9.8 and demons trated in Figure 9. P. Posterior lumbar c ounters train tender points ( 5) ..104..104.lww.http://thepointeedition. 67 of 85 21/08/07 22:05 .com/pt/re/9780781763714/bookContent.17 0 P osterior Lum bar Counterstrai n Techniques: Posterior Lum bar Tender Points Pos ter ior lumbar c ounterstrain tender points ar e outlined in Table 9.

http://thepointeedition.17 1 P osterior Lum bar Counterstrai n Techniques: PL1 to PL5 68 of 85 21/08/07 22:05 .A ( s pinous pr ocess) e SA RA (tr ansv ers e pr ocess) Patient prone E er add PL3 later al gluteus ( iliac c r est) Halfway between UPL5 and PL4 at infer ior as pect of pos ter ior iliac c r est near gluteus medius /maximus Pos ter olater al pelv ic edge halfway between gr eater troc hanter and iliac crest at gluteus max imus Superior sur face of PSIS 2 c m below PSIS on the ilium PL4 later al gluteus ( iliac c r est) Patient prone E er add UPL5 Patient prone with hip ex tension E er add Patient prone with hip flexed off table and s light adduc tion F IR add LPL5 PSIS. P.8 Co m mon Po sterior Lu mbar Tender Po int s Ten der Point Locatio n PL1–PL5 Inferolateral as pec t of s pinous proc ess or laterally on transv ers e pr oces s of dy sfunctional s egment Classic T reat men t Po sition Patient prone with leg ( hip) ex tens ion and s light exter nal rotation.com/pt/re/9780781763714/bookContent. pos ter ior superior iliac s pine. adduc tion or abduc tion as needed e SA Ra. T ab le 9..lww.. c ausing lumbar r otation to that s ide.

105.com/pt/re/9780781763714/bookContent. PL4: e SA Ra-A.lww..106. F ig ure 9. T en der Po int L o cation T he tender point lies at the inferolateral as pect of the s pinous proc ess or laterally on the tr ansv ers e pr oces s of the dy s functional s egment ( Fig .. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L1 to L5. 2. T he phys ician extends the patient's thigh and hip until the dysfunc tional s egment is F ig ure 9. PL1–PL5 midline and later al tender points (5).105) . gras ps the patient's lower thigh or tibial tuberos ity on the side of the tender point.http://thepointeedition. 69 of 85 21/08/07 22:05 . T he patient lies pr one and the phys ician. T reatm ent Po sition 1. 9. s tanding opposite the tender point.

http://thepointeedition.17 2 P osterior Lum bar Counterstrai n Techniques P L1 to PL5 70 of 85 21/08/07 22:05 .lww.com/pt/re/9780781763714/bookContent.. P..

gras ps the patient's opposite ASIS. 9. PL1–PL5 midline and later al tender points ( 5). 2.109.. T reatm ent Po sition T he position is e SA RA.108) .com/pt/re/9780781763714/bookContent. T en der Po int L o cation T he tender point lies at the inferolateral as pect of the s pinous proc ess or laterally on the tr ansv ers e pr oces s of the dy s functional s egment ( Fig . 71 of 85 21/08/07 22:05 .http://thepointeedition. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L1 to L5. 1. PL4: e SA RA. T he phys ician may tak e the patient's leg off midline to r ight or left depending on the type of dysfunc tion.lww. and the phys ician. 3.108. s tanding opposite the tender point. T he patient lies pr one. F igure 9.. T he patient's F igure 9.

and the phys ician s tands on the same Fig u re 9. halfway between the gr eater tr ochanter and iliac crest at the gluteus maximus T reatm ent Po sition 1.112. PL3–PL4 ( gluteus medius ) tender points (5) . 9. It is as s ociated with the gluteus medius muscle. T he patient lies pr one.lww..111) PL4 later al ( gluteus) : Pos ter olater al pelvic edge.http://thepointeedition. Fig u re 9. 72 of 85 21/08/07 22:05 . PL3–PL4: E er add.17 3 P osterior Lum bar Counterstrai n Techniques: PL3 and P L4. P. Lateral In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L3 to L4..111.com/pt/re/9780781763714/bookContent. T en der Po int L o cation PL3 later al ( gluteus) : Halfway between the UPL5 and PL4 at the inferior aspect of the posterior iliac c r est near the gluteus medius and gluteus max imus ( Fig .

113.http://thepointeedition. T he phys ician gras ps the patient's thigh or tibial tuberos ity on the side of the tender point.112 and 9. whic h s ide-bends the lumbar s egment toward the tender point ( Fig s. T he phys ician externally r otates and adducts the patient's thigh and femur. PL3–PL4: E er add.lww. 9.com/pt/re/9780781763714/bookContent.113)... 73 of 85 21/08/07 22:05 . s ide as the tender point ( the r otational c omponent s ide of the dysfunc tion). 5. external and Fig u re 9. T he phys ician extends the patient's thigh and hip until the level of the dysfunc tion is engaged. T he phys ician fine-tunes through s mall ar cs of motion ( hip flex ion and extension. 4. 2. 3.

internal r otation.http://thepointeedition...com/pt/re/9780781763714/bookContent. P. and adduction and abduction).17 4 P osterior Lum bar Counterstrai n Techniques: PL5. Lower P ol e 74 of 85 21/08/07 22:05 .lww.

9.115. 2.114.. PL5LP: F IR add. T en der Po int L o cation T he tender point lies at PL5 lower pole 2 cm below the PSIS (F ig .com/pt/re/9780781763714/bookContent. T he phys ician internally r otates the patient's hip and thigh. In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function at L5. Fig u re 9. PL5LP: F IR add. and the patient's Fig u re 9.116.http://thepointeedition. PL5 lower pole tender point (5) .114) .. T he patient lies pr one. 75 of 85 21/08/07 22:05 . 3. T he patient's lower extr emity on the side of the tender point hangs off the side of the table with hip and k nee flexed to 90 degr ees . T reatm ent Po sition 1.lww. Fig u re 9. and the phys ician s its at the s ide of the table on the s ide of the tender point.

17 5 P el vic Counterstrai n Techniques: Ili acus Dysfunction (Il iacus Tender Point) In d icatio n f o r T reatm ent T his proc edur e is appropriate for somatic dy s function of the iliac us mus cle. 2. 76 of 85 21/08/07 22:05 .117) . Fig u re 9. 1. and the phys ician s tands at the side of the table.com/pt/re/9780781763714/bookContent..118. Iliacus: F ER (hips ) abd ( knees).117. Iliacus tender point (5). T he patient is s upine. T he patient's hips ar e mark edly flex ed and Fig u re 9.. T reatm ent Po sition T he position is F ER ( hips) abd (k nees). 9. T en der Po int L o cation T he tender point lies 2 to 3 c m caudal to the point halfway between the ASIS and the midline. P. deep on the side of the dy sfunction ( F ig.http://thepointeedition.lww.

Iliacus: F ER (hips ) abd ( knees). T he phys ician fine-tunes through s mall ar cs of motion ( hip flex ion. 9.118 an d 9. P.lww.17 6 P el vic Counterstrai n Techniques: Pel vic Dysfuncti on—P iri formis Dysfuncti on (PIR Tender Point) 77 of 85 21/08/07 22:05 . Fig u re 9.. 3. externally r otated bilater ally ( ank les are c ros sed with k nees out to the s ides) ( Fig s. external r otation..http://thepointeedition. and side bending) .119.com/pt/re/9780781763714/bookContent.119).

and the phys ician s tands or s its on the s ide of the tender F igu re 9.120) . F igu re 9. we commonly use the tender points pr oximal to either the sacrum or the tr ochanter. T his is near the sciatic notch. F igu re 9. If they c an be s imultaneous ly r educed effectively. 78 of 85 21/08/07 22:05 .http://thepointeedition. T he patient lies pr one. 9. to av oid s c iatic irritation..120. Pir ifor mis : F abd-ABD er . Pir ifor mis tender point (5) . T en der Po int L o cation T he tender point lies anywher e in the piriformis mus cle.122. the tr eatment can be ex tremely s uc ces sful.lww.. c las s ically 7 to 10 c m medial to and slightly c ephalad to the gr eater troc hanter on the side of the dy s function ( Fig . In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function of the pir iformis muscle. T reatm ent Po sition 1. Pir ifor mis : F abd-ABD er -ER. and therefore.com/pt/re/9780781763714/bookContent.121.

17 7 Upper Extrem i ty Region: Supraspi natus 79 of 85 21/08/07 22:05 ..http://thepointeedition. P..lww.com/pt/re/9780781763714/bookContent.

http://thepointeedition. Supr aspinatus counterstr ain tender point ( 7). Palpation of s upr aspinatus tender point.com/pt/re/9780781763714/bookContent. 80 of 85 21/08/07 22:05 . 9.lww.125). 9. 3. T en der Po int L o cation T he tender point lies at the mid s upras pinatus mus cle just s uperior to the s pine of the s c apula ( Fig . T reatm ent Po sition 1. T he phy s ician s its bes ide the patient at the lev el of the shoulder girdle. 2.124) . In d icatio n f o r T reatm ent T his proc edur e is appropriate for s omatic dy s function of the s upras pinatus mus cle. 4.. T he patient lies supine on the treatment table. T he patient's arm is flex ed to F igu re 9.125. F igu re 9. T he phy s ician may palpate the tender point with either hand's fingertip pad or c ontr ol the patient's ipsilateral arm with the other ( F ig.124..

.http://thepointeedition.lww.com/pt/re/9780781763714/bookContent. P.17 8 Upper Extrem i ty Region: Infraspi natus 81 of 85 21/08/07 22:05 ..

T reatm ent Po sition 1. In d icatio ns f or T reatm ent T his treatment is appropriate for s omatic dy s function of the infras pinatus mus cle.128) .com/pt/re/9780781763714/bookContent.129.http://thepointeedition. Palpation of infraspinatus tender point.128. These may neces sitate placing the patient's ar m in mor e or less flexed or abducted pos itions . 9.lww... T en der Po int L o cation T he tender point lies appr oximately 1 thumb's -width medial to its tendinous por tion at the later al s houlder joint ins ertion and 1 or 2 thumb's-widths below the spine of the sc apula ( infer olater al s pine of scapula at pos ter omedial as pect of glenohumeral joint) ( F ig. Infr aspinatus c ounter str ain tender point (7) . 82 of 85 21/08/07 22:05 . T he patient lies supine on the treatment table. O thers may pr esent along the inferior spine of the s c apula to v er tebral bor der of the sc apula. F igure 9. F igure 9.

P.17 9 Upper Extrem i ty Region: Levator S capulae 83 of 85 21/08/07 22:05 .http://thepointeedition.lww..com/pt/re/9780781763714/bookContent..

132).131. T en der Po int L o cation T he tender point lies at the s uperior angle of the sc apula ( F ig..131) . T reatm ent Po sition 1. T he patient lies pr one.lww.http://thepointeedition. 9. head r otated away .. 2. T he phys ician s its at the s ide of the affected s houlder . 84 of 85 21/08/07 22:05 . In d icatio ns f or T reatm ent T his treatment is appropriate for somatic dy s function of the levator s c apulae mus cle.com/pt/re/9780781763714/bookContent. 3. Levator scapulae c ounter s train tender point (7). 9. T he F igure 9. with the arms at the s ides. T he phys ician's c audad hand gras ps the patient's wris t while the other hand palpates the tender point ( F ig.

Ba l tim ore : L i ppi nco tt W i ll i am s & W il k in s . Wa r d R ( ed). P. 6. 199 5. Mo dif i ed w it h p erm i s si on fro m Cl ay J H.) . P hil ade l phi a: Lip pi nc ott Wi l l ia m s & W i l ki ns. CA : J ones Str ai n-C oun ters tra i n.C oun ter s tr ai n. Re nni e P . S i mo ns L. Ku s un ose R S. 5. Bal tim or e: Li ppi nc ot t W i ll i ams & W il k i ns . Ba l ti m or e: W i ll i am s & W il k in s . 2. 1999 . Si m on s D . Fo und atio ns for Ost eop ath i c M edi c in e. vo l 1. OK: Y K not . Si m on LS. 3. Pou nds DM . T uls a.18 0 References 1. 2 004 . Ya tes H. Jo nes LH . Mo dif i ed w it h p erm i s si on fro m Si m on s D G.. M I: R en ni eM atr i xT M . 20 03. W i l li ams tow n.lww. 7. Glo v er J. My ofa s c ia l P ain and D y s fu nct i on : Th e T r ig ger Poi nt M anu al.com/pt/re/9780781763714/bookContent. J on es S tra i n. T r av ell J G. 1995. Gl ove r J . Go eri ng E K. Co unt ers tr ai n a nd Ex er c is e: An I nte gra ted App r oa c h ( 2nd ed . Ba s ic Cl i nic al M as s age Th era py : Integ r at i ng Ana tom y a nd T r ea tme nt. 1 999 . C ou nte r st r ain : A Ha ndbo ok of Os te opa thi c Te c hn i qu e. 2 003 .http://thepointeedition. M y of asc i al Pai n a nd D y sf unc ti on : T he T r ig ger Po i nt M an ual . 4.. Tr ave l l J . Ca r ls bad. 85 of 85 21/08/07 22:05 .

thi s d i re c ted pa tie nt a c ti on i s f r om a pr ec i se l y c ont r ol l ed pos i ti on.. M os t l i k el y t he eff ect s co m mo n t o so ft tis s ue and my ofas c ia l r el ea s e are als o i nvo l v ed in th i s s tyl e o f mu s cl e e nerg y . Sr. an d z ) at th e f eath er ' s e dge m ay al s o c aus e a l oc k in g u p of th e dys fun c tio n. DO ( pe r so nal c om m un i c at i on ) . R ece nt atte m pt s b y so m e m an ual m ed i ci ne p r ac tit i one r s. es peci all y o utsi de the U ni ted St ates . an d w e b el ie v e tha t ad dit i on al e ffe c ts are at pl ay . F r ed Mi tc he l l. 10 Muscle Energy Techniques Technique Principles M us c le ene r gy te c hni que (M ET ) i s a f or m of ost eopa thi c m anip ula tiv e tr eat m en t de v el ope d by Fr ed L. aga i ns t a def i ne d re s is tan c e b y t he phys i ci an” ( 1) . In ME T . y. Ru ddy. Technique C las sification D ire ct In M ET . Technique Styles Post Is ometric Re laxa tion In thi s fo r m of M ET. M it c he l l . S ome ost eop ath i c p hys i ci ans ( e. J. A ddi tio nall y . Th i s ter m r efer s t o t he i nit i al s en s e of m eet i ng th e re s tr i ct i on w it h s l i gh tly mo r e m oti on av ai l ab l e befo r e m ee tin g th e h ard end fe el of r est r ic ti on . Jr . T hi s w as one of the fir s t ost eop athi c t ech ni qu es to us e k no w n and acc ept ed p hys i ol ogic pr i nc i ple s a s i ts m ajo r p r oto c ol of tre atm ent.4) . i t c aus es the pat i en t t o re s is t. hav e b egun to de s c ri be i nd i r ec t t ech ni qu e. as in ot her dir ect tec hni que s . H ea t i s ge ner ate d du r in g i s ome tri c m us cl e c ont r act i on . g. T his m ay be an ove r si m pli fie d e x pla nat i on . r es ul ti ng i n di ff i cu l ty of tre atm ent and re s i st ant dy s fun c ti on. t he pat i ent ' s dys func tio n i s po s it i on ed t owa r d the r es tri c tiv e bar r ie r .4 ) .lww.http://thepointeedition. and i t bec om es di ffi c ult to co r r ec t t he dy sf unc tio n.. Mi tch ell bel i ev ed that af ter the co ntr ac ti on a r efra c to r y peri od occ ur re d dur i ng w hi c h the phy s ic i an c ou l d s en s e r ela x at i on and a temp ora r y i ncr eas e i n mu s cl e l engt h ( 1. th e m us cl e i nco r por ate d f or t r ea tme nt e ffe c ti v ene s s ( ag onis t) per form s a n i s ome tri c c on tra c tio n. R udd y d eve l ope d a te c hni que ca l l ed rh y th m i c ( ra pid ) re s is tiv e du c ti on. D ur i ng thi s c ontr act i on . T his ca n c ause a r ef l ex i nh i bi ti on an d s ubse que nt i ncr eas e i n mu s cl e l engt h w it hin a h y pe r to ni c m us c le .. H is tec hni que use d t he p ati ent ' s m usc l e c ont r ac tio n ag ain s t a ph y si c ia n' s c ou nte r for c e bef or e the dev elo pm en t o f M ET ( 2.6). u s es th e te r m fea ther ' s edg e to re fer to the le v el of eng agem ent (5 .3 . D O (1 909 –19 74). It is def i ne d b y th e E duc atio n C oun c i l on Ost eopa thi c P r i nc i pl es ( ECO P) as “ a s y st em of di ag nos i s and tre atm ent i n w hi c h t he pat i ent vo l un tari l y m ov es t he bod y as sp eci fi ca l ly dir ect ed b y t he phys i ci an.. I f t he p hys i ci an e nga ges the ba r ri er t o t he end poi nt of i ts r es tri c tio n. the phy s ic i an pos i ti ons the pa ti en t s o a s to en gag e th e r est r i ct i ve bar r ie r . t hi s hea t h as t he s am e ef fec t o n th e m y of as ci al s tr uct ur es as pr opos ed i n the c ha pte r s o n m y of as ci al and s of t t i ss ue t r ea tme nt. H ol l is Wo l f. N ic hol as ) hav e s ugge s te d t hat thi s t ec hn i qu e i s a v ar i at i on of a t ec hn i qu e p er fo r me d b y T. eng agi ng a l l thr ee a x es of m ot i on (x . .1 82 1 of 134 21/08/07 22:07 . N ic hol as S . T he he at g ene r at i on i s l ik ely P. in c re ase d te nsi on i s p l ac ed on t he Gol gi t end on or ga n p r op r i oc ept ors w it hin the mu s cl e te ndo n.com/pt/re/9780781763714/bookContent.

g. T hi s t ec hn i qu e.. the r ef or e. No te: T he pa tie nt's co ntr ac ti on and phy s ic i an ' s r esi s ta nc e are no t a c om pet i tio n t o s ee w ho i s the st r ong er. D ur i ng th i s i so m et r i c c on tra c tio n.g . i n w hi ch mu s cl e sh ort eni ng a nd fib r osi s m ay be p r es ent . l ow amp l it ude ( HV LA) the r ap y . but i t s ho uld be tol era bl e to bot h pa tie nt and phy s ic i an. W he n m or e tha n o ne m usc l e c ont r ac ts. ve nous bl ood . to c au s e t he c on nect i ve ti s s ue s a nd c oll age n b as e. the ten s io n b ui ld i ng up i n the mu s c le is al s o e x pr ess i ng flu i ds ( e. c ou nter s tr ain . I n t his s ty l e of M ET.le v ere d s tyl e of hi gh v elo c it y .. As t he ago ni st mu s cl e be i ng co ntra c te d i s mo s t l ik ely the dy s fu nc ti ona l m us cl e i nvo l v ed in ac ute s tr ain s . th e p atie nt s ho ul d be pos i tio ned to enc our age the de v el opme nt of the mo s t a ppr opr i ate lo nge s t-l eve r ed for c e w it h th e l eas t am oun t o f co unt erf or ce fr om the phy s ic i an nec ess ar y for su c c es s . po s it i oni ng of the pat i en t is si m il ar t o t he r eci pro c al i nh i bi tio n st y le of pos i ti oni ng. s of t t i s su e. t he fasc i al en v elo pe m ay l en gth en. ra the r t han i n acu te c ond i ti ons . T his is si m i la r t o t he l ong . l ym ph) fro m t he bell y o f t he m usc l e and s ur r ou ndin g i nte r s ti tia l c om pa r tm ent . T he r ef or e. th e m us cl e c ont r act i on s c an b e m ore pow erf ul ( pos s ib l y i s ot oni c ) up t o m any pou nds of r es i st ance ..com/pt/re/9780781763714/bookContent. wh i ch po tent i at es an i nc r ea s e i n o v er al l l en gth and /or pe r c ei v ed re l axa tio n. i n w hi c h al l m us c le s ar e i s om etri c al l y c ont r ac tin g) .lww. t his st y l e of tec hniq ue i s m ost us efu l in s ub acu te t o c hro ni c c on dit i ons . pat i en t's m us c le co ntra c ti on m im i cs Val s al v a m ane uve r s. As d i ap hra gm at i c exc urs i on dur i ng i nh ala tio n ma y a ffe c t m usc l es v er y d i st al ly be c au s e o f f asc i al c on tin ui ty . as i t c an us e a fun c ti onal ag oni s t t o r ela x a dys fun c tio nal an tago nis t.. J oint Mobiliza tion Us ing Mus cle Force M us c le for c e use s pa tie nt posi tio nin g an d m usc l e c ont r ac ti on to re s tor e l i mi ted j oi nt m oti on. W hen an ago ni st co ntr ac ts . u s e of a sp eci fi c m us c le c on tra c ti on w i th th e pa tie nt i n a s pe c if i c p osi tio n al l ow s t he f orc es at p l ay to bec ome ve r y p owe r fu l an d b e v ec to r ed sp ec if i ca l ly to a l oca l are a. i n thi s c as e.. als o p erm i tti ng the m us c le to l en gth en. As s ta ted ear l ie r . bra c hi ali s an d b i ce ps c ont r ac t an d t r ic eps r el axe s ) . m yo fas c i al re l ea s e. Oculoce r vic al Reflex 2 of 134 21/08/07 22:07 . As the m us c le s ar e t he pr im ary mo v ers of jo i nts . th e p hy si c ia n p os it i on s t he p ati ent to bes t d i r ec t t he forc es of r esp i ra tio n tow ard the ar ea of d y sf unc ti on an d s i m ul tan eou s l y use a fulc r um (e . T he fo r c e of c on tr ac tio n i n th i s s ty l e o f t ech ni qu e s hou l d b e v ery l ig ht. Th e f orc e of co ntr ac ti on m ay v ar y . t he anta gon i st s ho uld re l ax ( e. ba l an c ed l ig ame nto us t ens i on . H ow eve r . R eciproc al Inhibition T hi s f or m of m us c l e ene r gy use s t he phys i ol ogi c pr i nc i pl e of re c ip r oca l i nhi bi ti on and r el axa tio n.. F or the phy s ic i an' s c omf or t. t he r efl ex m ay be l os t by ca usi ng a ddi tio nal m us c le s to c on tra c t. If th e f or ce is to o gr eat . l ow amp l it ude ( LV LA) .. i s s tro ngl y in dic ate d in ac ute c on dit i on s . g. g. the in hib i tio n i s l os t ( e.http://thepointeedition. R espira tory As sis tanc e R es pir ator y a s si s tan c e m ay be use d i n a num ber of ost eop athi c m ani pula tiv e t ec hn i qu es ( e. m oti on i n j oin ts c an be i mp r ove d b y u s e o f f orc es t hat ar e ve c to r ed dir ect l y or i nd i re c tly . m oti on a nd tis s ue c ha nge s m ay b e a ppr ec ia ted lo c all y o r p er ip her all y . ex ce pt tha t the pa ti en t i s a c tiv ely co ntra c ti ng m usc l es in s tea d o f t he p hys i ci an p ull i ng the m t o c ause mo v em ent. Th e r es ult i ng c on tra c tio n m ay beco m e m in i m al l y i so toni c . li gam ent ous art i cu l ar s tr ain ) . M ET i s c l as s ic al ly de s cr i bed as a di re c t tec hniq ue use d to mo bil i z e a r est r i ct ed j oi nt. on l y s l ig htl y mo r e tha n the th ough t t o c ontr act it . ph y si c i an ' s han d) a s a c ou nte r for c e to help di r ec t th e d y sf unct i on al r egi on thr ough th e r es tr i ct i ve bar r ie r . tho ugh i t m ay al s o b e u s ed i n s ub acu te a nd c hr onic st age s . wh i ch are un der ten s io n. g. A s a re s ult . th i s s tyl e o f m us cl e e ner gy c oul d b e th oug ht of a s l ow v elo c it y . to c han ge c oll oid al s tat e ( gel to s ol ) .

ac ute ce r v ic al and upp er thor aci c c ondi tio ns w hen ot her tec hni que s ar e i m po s s ib l e due to s ev eri ty o f p ain . t he w ay the y r esp ond to i so m etr i c 3 of 134 21/08/07 22:07 . po s ts urg i c al or in tens i ve ca r e p ati ent ) A bsolute Contr aindica tions 1.. di sl oca tio n.e. Seve r e i ll ness (i .com/pt/re/9780781763714/bookContent. th e s ty le of mu s c le en erg y us ed m ay v ar y . Soma tic dy s fun c ti on of a r ti c ul ar o r ig i n to m obi l iz e re s tr i ct ed j oin ts and i mp r ov e th e r ang e of m oti on P. . or s tr ai n. T his st y le i s m os t u s efu l i n v er y s ev ere . Th ere for e. Seve r e ost eopo r os i s i n w hic h t he p hys i ci an b eli eve s th at a r i s k of ten di no us evu l s io n c oul d oc c ur w i th th e c or re c ti on 3. c ert ain ce r v ic al and tru nca l m us cl es c on tr ac t. T o i m pr ove l oc al c ir c ula tio n a nd r esp i ra tory fu nct i on 2. M us c le s ma y b e m or ph olo gic al ly di ffe r ent . F r ac tur e. a n i nfa nt or y oun g c hil d or a pat i ent wh o d oesn ' t und er st and th e ph y si c ia n' s l an gua ge) Gene ral Considera tions a nd R ule s D ep end i ng on the pat i en t's pre s en tat i on. T o i ncr eas e to ne i n hy po ton i c or w eak mu s c le s C ontraindic ations R ela tiv e Contr aindica tions 1. Add i tio nal l y.lww. Lack of co oper ati on or a pa tie nt w ho c an not und ers tand th e i ns tr uct i on s of th e t ec hn i qu e ( i . i t i s p os si ble to m in i ma l ly i nd uce po s t i s om etr i c r ela x at i on eff ect s or m or e li k el y r ec ip r oc al i nhi bit ory eff ect s . the nat ure and le ngt h of co ntr ac ti on m ay be alt ere d fr om pat i ent to pa ti en t a nd betw een an atom i c r eg i ons . es pec i al l y t o r edu c e h y pe r to ni c m us c le s . W he n a pat i en t i s as k ed to m ak e s pec i fic ey e m ov em ent s . Soma tic dy s fun c ti on of m y of asc i al ori gin . w hi c h r efl exi v el y re l ax th e an tag oni s t m usc l es ( 1) . Indications Prim ary Indica tions 1. . T o b ala nce neu r om usc ul ar re l at i ons hip s b y al ter i ng m us c le to ne 3. l eng the n s hor ten ed m usc l es . o ne to a not her . T he pati ent ma y be as k ed to l oo k t ow ar d e i th er t he r es tri c tio n o r t he f r ee dom .http://thepointeedition. M ode r at e t o se v er e m us cl e s tra i ns 2..1 83 Seconda r y Indications 1. mu s cl e s pasm . o r m ode r ate to se v ere jo i nt i ns tab i li ty a t t r ea tm en t s i te 2. o r st r et c h and i mp r ov e el ast i ci ty i n f i br otic mu s cl es 2. Th ere for e.e.

posi tio nin g c au s in g th e v ect or ed fo r ce at too hi gh o r t oo l ow a s egm ent) . 5. C l i ni c al ex peri enc e w i l l tea c h this . or m us c le to be tre ated at th e fe ath er ' s ed ge of the r est r ic tiv e ba r ri er ( poi nt of i nit i al re s i st anc e) i n a l l thr ee p l an es of m oti on ( x -.axe s ).. 3 se c ond s m ay s uff i ce .. I f t he pati ent ' s c ont r ac tio n i s too s ho r t i n dura tio n ( i . z . in ot hers .lww. i t i s m ost li k ely be c au s e o f e i th er a ve r y s eve r e c hr onic dys fun c tio n o r b ec au s e of i nac c ur ate dia gno s is . a s t he dy sf unc tio n ma y beco m e v er y re c al c it r ant if si m ult ane ous l y h eld at all th r ee axi s l i mi ts . A s t he t r ea tme nt p osi tio ns a r e s o s i mi l ar to tho s e of H VLA . Th i s usu al ly r equ i re s t hr ee to se v en r ep eti ti on s . T he phy s ic i an pos i ti ons the bo ne. I nco r r ec t f orc e of co ntr ac ti on by the pat i en t (t oo for c ef ul o r t oo gent l e) ma y hi nde r t he s ucc ess ful c om ple ti on of th e te c hn i qu e. dep endi ng on the aff ect ed b ody re gi on an d t ol er anc e o f th e pati ent . H owe v er . a nd H VLA tec hni ques . P.. T he es s ent i al st eps for mo s t s tyl es of t his te c hni que ar e as fo l lo w s : 1. . y. 4. I t i s im por tan t to un der s tan d t he s pec i fi c it y of the pat i en t's pos i ti oni ng i n t his tec hni que . It i s es pe c ia l ly ben efi c ia l in po ten ti at i ng so ft t i ss ue. b e u s ed i n c on j un c tio n w i th oth er tec hniq ues . th e d y s fu nct i on m ay st i ll be pre s en t an d p r ev ent a p osi ti ve r es pon s e. T he phy s ic i an i ns tru c ts the pa ti en t t o c ontr act a s pec i fi c m us cl e i n a s pe c if i c di re c ti on agai nst th e phys i ci an' s un y ie l di ng c oun ter forc e f or 3 to 5 s ec onds . c on tra c tio ns m ay dif fer . M ET oft en m ake s H VLA m or e r ead i l y s uc c es s ful . i t ma y b e m or e eff ect i v e to k ee p on e a x is s li ght l y l oos e ( l ax ) . O ther pr obl em s m ay de v elo p i f t he pat i en t do es not c om ple tel y re l ax pr i or to r ep os it i on i ng . If the phy s ic i an i s uns ucc es sf ul w it h ME T . Afte r s ens i ng tha t t he p ati ent i s not gu ar di ng and i s c om ple tely re l ax ed ( m ay ta k e 1 –2 s ec onds ) . Fu r th erm or e. the phy s ic i an s lo w ly r ep osi tio ns t he pat i ent to th e fe ath er ' s ed ge of the new re s tri c ti v e barr i er .http://thepointeedition. 3. Du r in g t he c orr ect i v e pro c ed ur e.e.1 84 C erv ica l Re gion: Trapezius Musc le Spa s m (Long R e str ictor): Post Isom etr ic R ela xation 4 of 134 21/08/07 22:07 . if th e ph y si c ia n fa i ls to r ee v al uat e the di agno s ti c f i ndi ngs af ter tre atm ent. I n so m e are as . i t w i ll de c re as e eff ect i v en ess . T he phy s ic i an r ee v al uate s t he di ag nos tic par ame ter s of th e o r i gi nal dy s fun c ti on to d ete r mi ne t he effe c ti v en es s of the tec hni que . Step s 1 to 4 a r e r ep eate d u nti l th e b est pos s ib l e i ncr eas e i n mo tio n i s ob tai ned . 6. hol din g a m us c le c on tra c ti on f or 5 o r mo r e s ec onds ma y b e nec ess ar y. c ou nte r st r ain . T he pat i en t ce ase s a l l m usc l e c ont r ac tio n wh en ask ed b y t he phys i ci an to r ela x o r go to sl eep. 2. m yo fas c ia l re l ea s e. l i ke mo s t o the r o s teo pat hic tec hni que s . Th e p hys i c ia n m ust pal pat e t he m oti on i n t he exa c t s eg m en tal or m us c ula r t i ss ue t hat is bei ng tre ated . j oi nt. su c ce s s m ay be dim i ni s hed by in ac cu r at e l oc al i za tio n of co r re c tiv e f orc es ( for c e at a se gme nt t oo hig h or lo w . M us c le ene r gy ma y .com/pt/re/9780781763714/bookContent. i t i s na tur al to g o f r om M ET to H VL A i f th e M ET i s n ot c om pl et ely su c c es s fu l . 1 se c ond ) .

5. Fig u re 10. Fig u re 10. T he patient is s upine and the physician s its at the head of the table. B. Alternative hand plac ement.3) to the edge of the new r estric tive barrier. 5 of 134 21/08/07 22:07 . T his isometr ic c ontr action is maintained for 3 to 5 s econds.2) while the phys ician applies an equal c ounterforc e ( white arrow).http://thepointeedition.. Step 3.1) .2. 4. 2. T he patient ex tends or backward bends the neck and head ( blac k arrow. and then the patient is instr ucted to st op and relax. 1. Steps 3 to 5 Fig u re 10. F ig. the physician gently flex es the neck (white ar row. is ometric contraction. flexion bar r ier . 10. F ig. A. 6. Steps 1 and 2. 3. O nce the patient has c ompletely r elax ed.1. T he phys ician gently flex es the patient's neck until the edge of the r estr ictive barrier is r eached (F ig . 10.com/pt/re/9780781763714/bookContent. 10..1.lww.

3.4. 10. 2. extens ion bar rier . F ig. 10. Steps 1 and 2..6.1 85 C erv ica l Re gion: Left Sternocle idomas toid Spasm (Ac ute Torticollis ): Rec iprocal Inhibition 1. F igu re 10. P. 4.5. T his isometr ic c ontr action is maintained for 3 to 5 sec onds. T he patient lies s upine and the physician s its at the head of the table s upporting the patient's head with the hand res ting the patient's head on the k nee or thigh. T he phys ician palpates the left s ternocleidomas toid muscle to ensur e that adequate r elax ation is oc cur ring. T he phys ician gently extends the patient's head until the edge of the r estr ictive bar rier is r eached (F ig . Step 4.. isometr ic contrac tion.http://thepointeedition. Step 3. 5. 6 of 134 21/08/07 22:07 .5) . 6.6) while the physician r esis ts with an equal c ounterforc e (white ar row). and F igu re 10.com/pt/re/9780781763714/bookContent.lww.4) . F igu re 10. 10. T he patient ver y gently extends the head (b lack arr ow. T he phys ician gently r otates the patient's head to the r ight to position the hypertonic left s ternocleidomas toid muscle v entr ally ( F ig.

1 86 C erv ica l Re gion: Left Sternocle idomas toid Contr a cture (Chr onic): Post Is ometric Re laxa tion 7 of 134 21/08/07 22:07 ..lww. Step 7. the physician palpates the left s ternocleidomas toid muscle for r educ tion in tone and observes the patient's head position in the er ect posture for improved body c arriage.7) to the edge of the new res tric tiv e barrier. then the patient is instr ucted to stop an d relax. O nce the patient has c ompletely r elax ed. 10.. extens ion bar rier . F ig.com/pt/re/9780781763714/bookContent. 9. 8. the physician gently ex tends the patient's head ( white arrow. F igu re 10. T o deter mine the effec tiv enes s of the technique.http://thepointeedition. P. 7. Steps 4 to 7 ar e r epeated thr ee to five times or until motion is maximally improved.7.

Step 3. Steps 1 and 2. 10.10) while the physician r esis ts with an equal c ounterforc e (white ar row). T he patient lies s upine and the physician s its at the head of the table s upporting the patient's head with the hand and/or r esting the patient's head on the knee or thigh.9. T he patient flexes and r otates the head to the left ( blac k arrow. F igu re 10. 6. F igu re 10. T he phys ician palpates the left s ternocleidomas toid muscle to ensur e that adequate c ontr action is oc cur ring. 3. F ig.8. extens ion bar rier . 8 of 134 21/08/07 22:07 . T his isometr ic c ontr action is maintained for 3 to 5 sec onds.. 1. 5.lww.com/pt/re/9780781763714/bookContent.8) . is ometric c ontrac tion. T he phys ician gently r otates the patient's head to the r ight to position the hypertonic left s ternocleidomas toid muscle v entr ally ( F ig. 10. and then the patient is instr ucted to stop an d relax.10. 4..http://thepointeedition. 10. F igu re 10. Step 4. 2.9) . T he phys ician gently extends the patient's head until the edge of the r estr ictive bar rier is r eached (F ig .

.14.com/pt/re/9780781763714/bookContent.lww. Step 1. Fig ure 10. Fig ure 10.13. T he physician s lowly and gently extends the patient's head and nec k to the edge of the new r estr ictive barrier.12. P. Step 3.http://thepointeedition. 2.12). tell the patient to st op and relax ( c los e the ey es) . 10. T o pr oduce ex tension of the neck: Have the patient loo k towar d the top of the head for 3 to 5 s econds. After 3 to 5 s econds. Step 2. After 3 to 5 s econds. Fig ure 10.1 87 C erv ica l Re gion: C erv ica l R a nge of Motion: Oculocer vic al R eflex T he oculocervical r eflex c an be c ombined with any of the cer v ical METs using the following guidelines: 1. 9 of 134 21/08/07 22:07 . This may be r epeated thr ee to five times or until motion is maximally improved (F ig. T o pr oduce flexion of the neck: Have the patient look down at the feet for 3 to 5 s econds..

http://thepointeedition. 3. tell the patient to st op and relax (c los e the ey es) . 10 of 134 21/08/07 22:07 . T o pr oduce r ight side bending: Hav e the patient look up and to the r ight for 3 to 5 s econds. tell the patient to st op and relax (c los e the ey es) .bends the patient's head and neck to the edge of the new r estr ictive barrier.15. After 3 to 5 s econds.com/pt/re/9780781763714/bookContent. This may be r epeated thr ee to five times or until motion is maximally improved (F ig. 10. T o pr oduce left Fig ure 10.13).. Step 4. This may be r epeated thr ee to five times or until motion is maximally improved (F ig. 10..lww.14). 4. T he physician s lowly and gently s ide. T he physician s lowly and gently flex es the patient's head and nec k to the edge of the new r estr ictive barrier.

1 89 C erv ica l Re gion: Occipitoatlantal (C0 —C01 ) D ysfunction Ex a mple: C 0 ESLR R Post Isom etr ic Rela xation* 11 of 134 21/08/07 22:07 .15). tell the patient to st op and relax ( c los e the ey es) .com/pt/re/9780781763714/bookContent. 10.http://thepointeedition. T he physician s lowly and gently s ide.. After 3 to 5 s econds. This may be r epeated thr ee to five times or until motion is maximally improved (F ig.1 88 P. s ide bending: have the patient look up and to the left for 3 to 5 sec onds.. P.lww.bends the patient's head and neck to the edge of the new r estr ictive barrier.

and the pads of the fingers contact the s uboccipital musculature. F ig.18) and s ide.17.com/pt/re/9780781763714/bookContent. anterior v iew.. 10. F igure 10. s ide-bending barrier.lww. T he phys ician gently flex es ( white arrow. 4. flexion. T he patient is s upine and the physician s its at the head of the table. O ne of the physician's hands is placed under the patient's oc ciput. 1. 2. Steps 1 and 2.bends the patient's oc ciput to the r ight until the edge of the r estr ictive barriers ar e r eached. 10.16 an d 10. 12 of 134 21/08/07 22:07 . The physician may add r otation left if desir ed. T he patient gently extends F igure 10.18. The physician is is olating motion to the oc cipitoatlantal ar tic ulation only.16. Step 3. Steps 1 and 2. 3.. lateral v iew.http://thepointeedition.17). F igure 10. T he index and middle fingers of the physician's oppos ite hand ar e plac ed on the patient's c hin beneath the lower lip ( F igs.

bends the oc ciput to the r ight until the r estr ictive barriers ar e engaged. 13 of 134 21/08/07 22:07 . and the pads of the fingers touc h the s uboccipital musculature. O ne of the physician's hands is placed under the oc ciput. T he index and middle fingers of the physician's oppos ite hand lie immediately beneath the patient's c hin ( F ig.com/pt/re/9780781763714/bookContent. P. The physician may F igure 10. F igure 10.http://thepointeedition.lww.bending barrier.1 91 C erv ica l Re gion: Occipitoatlantal (C0 —C01 ) D ysfunction Ex a mple: C 0 FSLR R Post Isom etr ic Rela xation 1. 10.. The physician is is olating motion to oc cipitoatlantal ar tic ulation only. Step 3. T he patient is s upine and the physician s its at the head of the table. 2.21) . s ide.1 90 P.21. Steps 1 and 2. T he phys ician is c areful not to c hoke patient.22.. extens ion. T he phys ician ex tends (w hite ar row) and s ide. 3.

O nce the patient has c ompletely r elax ed.com/pt/re/9780781763714/bookContent. isometr ic c ontr action.24. add r otation left if desir ed ( Fig . 10. 10.22).23.http://thepointeedition. F igure 10. F ig.lww. 4. Step 6. 6.. T his isometr ic c ontr action is maintained for 3 to 5 sec onds .23) so that the chin pulls down into the phys ician's r estr aining fingers while the physician applies an equal c ounterforc e ( white arrow). 14 of 134 21/08/07 22:07 . T he phys ician s hould be able to palpate s uboc cipital muscle r elax ation with the hand beneath the oc ciput.24) by pr ess ing to the c eiling with the hand under the oc ciput and lifting cephalad with the finger s F igure 10. Step 4. extens ion bar rier . and then the patient is instr ucted to st op and relax. 5. T he patient gently nods the head for war d ( blac k arrow.. the physician further extends the head (white ar row. F ig. 10.

about 15–25 degrees) until the edge of the r estr ictive barrier is r eached.lww.1 92 C erv ica l Re gion: A tla ntoaxia l (C1—C2) Dys function Exam ple : RL Post Is ometric Re laxa tion 1. or the patient's head may r emain in neutr al. P..com/pt/re/9780781763714/bookContent. 2. 15 of 134 21/08/07 22:07 . 3. beneath the c hin. T he phys ician may gently flex the patient's head (C0-C1.25. T he patient is s upine and the physician s its at the head of the table. 7. T he phys ician r otates the patient's head Fig ure 10. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique..http://thepointeedition. r otation bar rier. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. Steps 1 to 3. 8.

to the r ight ( white arrow. Step 6. the physician r otates the patient's head ( white arrow. 5.25) until the edge of the r estr ictive barrier is r eached.http://thepointeedition. 10.27) to the r ight until the edge of the new r estric tive barrier is r eached. isometr ic contraction. F ig. 6. 10. r otation barrier. and then the patient is instr ucted to st op and relax. oc ulocer vic al). F ig. 10. F ig. T he patient r otates the head to the left ( blac k arrow. Fig ure 10. 16 of 134 21/08/07 22:07 . Step 4. Fig ure 10.com/pt/re/9780781763714/bookContent.26) while the physician applies an equal c ounterforc e ( white arrow). T his isometr ic c ontr action is maintained for 3 to 5 sec onds . O nce the patient has c ompletely r elax ed.26.. 4.27. Note: In ac ute painful dy sfunctions the patient can v ery gently r otate or look to the r ight ( r eciprocal inhibition.lww..

7. and the physician is s eated at the head of the table on the s ide of the r otational c omponent. 17 of 134 21/08/07 22:07 .. 8.lww. The heel of the physician's hand closes in against the F igure 10. T he patient lies s upine. 2. P. T he firs t metac arpal phalangeal joint of the physician's right hand is plac ed at the artic ular pillar of the s egment being tr eated.28. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment.http://thepointeedition.com/pt/re/9780781763714/bookContent. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. Steps 1 to 3..1 93 C erv ica l Re gion: C 2—C 7 D ysfunction Ex a mple: C3 FSRR R Post Isom etr ic R ela xation 1.

10. and C3 are flexed until the dy sfunctional C3 engages C4.29) to the r ight while the phys ician applies an equal c ounterforc e ( white arrow). Note: In ac ute. F ig. F igure 10.30. C1.29. painful dy sfunctions the patient ver y gently r otates or looks to the left while the physician applies an equal c ounterforc e ( r eciprocal inhibition. Step 6. isometr ic c ontr action.lww.28) . the s egments ar e then ex tended s lightly to meet the extension barrier.http://thepointeedition. C2. 18 of 134 21/08/07 22:07 .. oc ciput.com/pt/re/9780781763714/bookContent.bent to the left until the edge of the r estr ictive barriers ar e r eached in all three planes ( F ig. The oc ciput. 4. 10. T he phys ician c r adles the patient's head between the hands (may c up the c hin with the left hand). 3. Step 4. T he patient r otates the head ( blac k arrow. F igure 10.. C3 is then rotated and s ide.

1 94 P.bending left (w hite ar row) and then ex tending until the edge of the new r estric tive barrier is r eached (F ig .30). O nce the patient has c ompletely r elax ed. 5. 6. oc ulocer vic al). 7.1 95 Thor acic Re gion: T1—T4 D ysfunction Ex a mple: T4 ESRR R Post Isom etr ic R ela xation 19 of 134 21/08/07 22:07 . T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.com/pt/re/9780781763714/bookContent. T his isometr ic c ontr action is maintained for 3 to 5 sec onds .lww. 10. 8. the physician r epos itions the dy sfunctional s egment by r otating and s ide. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment.http://thepointeedition.. and then the patient is instr ucted to st op and relax.. P.

F ig.. T he patient is s eated at the end of the table and the physician s tands at the s ide opposite the r otational c omponent. flexion barr ier .32. F ig. Step 3. T he phys ician's left hand palpates the s pinous pr ocesses of T 4 and T 5 or the T 4-T 5 inter space to monitor flex ion and extension as the r ight hand flexes the patient's head and neck (white ar row.lww. 1. F igu re 10. Steps 1 and 2.32) and r otates (w hite ar row. 2. 10.bends ( white arrow.http://thepointeedition. F ig.33. 20 of 134 21/08/07 22:07 . 10. F igu re 10.. Step 3. left rotation barr ier.31.com/pt/re/9780781763714/bookContent. 10.33) the patient's head and neck to the left until the edge of the F igu re 10. 3.31) to the edge of the r estr ictive barrier. left side-bending barr ier . T he phys ician's left hand monitors the tr ans ver se pr ocesses of T 4 and T 5 to localize side bending and r otation as the r ight hand s ide.

39.. Step 4.40. P.com/pt/re/9780781763714/bookContent. 3. T he phys ician's left hand r eaches under the patient's elbow and gr asps the patient's r ight s houlder . F igure 10. extens ion bar rier .38.1 97 Thor acic Re gion: T1—T6 D ysfunction Ex a mple: T4 FSRR R Post Isom etr ic R ela xation 1.38) . Step 3. Starting with the patient in ex treme flex ion.lww..bending 21 of 134 21/08/07 22:07 . 10. T he physician's right hand palpates the s pinous pr ocesses of T 4 and T 5 or T 4-T5 inter space and instr ucts the patient to r elax and r est the full weight of the head and elbow on the physician's arm ( F ig. left s ide. F igure 10.1 96 P. Steps 1 and 2. s lowly r ais es the left elbow ( white arrow) as F igure 10. the phys ician. 2. T he patient is s eated with the r ight hand on the left shoulder and the physician s tands c los e to the patient on the s ide oppos ite the r otational c omponent.http://thepointeedition.

F igure 10. 10. as the left arm and hand r epos itions the patient's left s houlder down ( white arrow) to engage the edge of the left s ide bending barrier (F ig . 4. 5. isometr ic c ontr action. F igure 10.41) .42. Step 6. T he phys ician then gently r otates the patient's s houlder s left ( white arrow) to engage the edge of the left r otation bar rier ( F ig. 22 of 134 21/08/07 22:07 . T he patient pushes down with the elbows and forehead against the physician's arm while s imultaneous ly barrier.39).41.lww.com/pt/re/9780781763714/bookContent. T he phys ician's r ight hand now monitors the tr ans ver se pr ocesses of T 4 and T 5 to localize side bending and r otation. 6. 10. left r otation bar rier. Step 5.43. 10.. the r ight hand gently tr ans lates the dy sfunctional v ertebra forward (w hite ar row) to the edge of the ex tension barrier (F ig . F igure 10. left s ide.http://thepointeedition..40).bending barrier. Step 8.

10. 10. O nce the patient has c ompletely r elax ed. 10.lww.45) .http://thepointeedition. 23 of 134 21/08/07 22:07 . 7. Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. 8.com/pt/re/9780781763714/bookContent. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the F igure 10.44).45. r otating the tr unk to the r ight (blac k ar row) as the physician applies an unyielding c ounterforc e ( white arrow.43) then left r otation (F ig. Step 8. 10.42) . and then the patient is instr ucted to st op and relax.. T his isometr ic c ontr action is maintained for 3 to 5 sec onds .. and finally extension ( F ig. (F ig. 10. extens ion bar rier . Step 8. F igure 10. the physician r epos itions the patient to the edge of the new r estr ictive barriers in all three planes : first left s ide bending.44. F ig. left r otation bar rier. 9.

47. r ight ov er left. T he phys ician's left arm r eaches acr oss in fr ont of the patient's elbows and plac es the left hand on the patient's r ight s houlder . 24 of 134 21/08/07 22:07 . T he phys ician s tands at the s ide of the patient opposite the r otational c omponent. The ar ms ar e folded ac ros s the c hest. effec tiv enes s of the technique. 4.http://thepointeedition.1 98 P.com/pt/re/9780781763714/bookContent. P. Steps 1 to 4.46. T he phys ician's r ight hand monitors the s pinous pr ocesses of T 8 and T 9 or the T 8-T 9 inter space to localize flexion and extension F igu re 10. Patient is s eated on the end of the table. 3. F igu re 10.. flexion barr ier. Step 5. the left side c lose to the edge. left side-bending barr ier .1 99 Thor acic Re gion: T5—T12 Dys func tion Ex ample: T8 ESR RR Pos t Isom etr ic R ela xation 1.lww. 2..

50. T his isometr ic c ontr action is maintained for 3 to 5 sec onds .. Step 5.48). 10. is ometric c ontrac tion. 10.http://thepointeedition. 10. 6. T he phys ician's r ight hand monitors the tr ans ver se pr ocesses of T 8 and T 9 to localize side bending and r otation as the left arm and hand pos ition the patient's torso to the engage the edge of the left s ide bending ( white arrow.49) . and then the F igu re 10.47) and left rotation barrier (w hite ar row. 7.48.lww. as the left arm and hand flex the patient's torso (white ar row. 25 of 134 21/08/07 22:07 . F ig. F igu re 10. Step 6.com/pt/re/9780781763714/bookContent.. F ig. F igu re 10. left side-bending barr ier . T he patient sits up and turns the s houlder s to the r ight ( blac k arrow) as the physician's left hand applies an unyielding c ounterforc e ( white arrow. 5.46) until the edge of the r estr ictive barrier is r eached.49. left rotation barr ier. F ig. Step 8. F ig. 10.

P. and finally flex ion ( F ig.. Step 8. 9. 10. Inhala tion D ysfunction: R e spiratory A ssist. the physician r epos itions the patient to the edge of the new r estr ictive barriers in all three planes : first left s ide bending (F ig .com/pt/re/9780781763714/bookContent.52.51). 10. then left r otation (F ig. F igu re 10. patient is instr ucted to st op and relax. 10. O nce the patient has c ompletely r elax ed. flexion barr ier .http://thepointeedition. F igu re 10.lww. Step 8. Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment.2 00 C ostal R egion: Right Fir st R ib. left rotation barr ier.52) .50).51. 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.. 10. Sea ted 26 of 134 21/08/07 22:07 .

6. is gently flexed. and r otated away fr om the r ight rib to take the tension off the sc alene musculature (F ig. resis t inhalation. 10. placing the left foot on the table to the left s ide of the patient and k eeping the hip and k nee flexed at about 90 degrees. T he patient is seated.54. F igu re 10. T he phys ician s tands behind the patient. 10.phalangeal joint of the physician's r ight index finger c ontacts the super ior s urface of the dy sfunctional r ight r ib posterior and lateral to the c ostotr ansv ers e ar tic ulation. T he patient inhales and then ex hales deeply.55) . F igu re 10. 4. 2.53). T he metac arpal..54) further into ex halation. c ontr olled by the physician's left hand. F ig.bent towar d.http://thepointeedition. 3. 1. 5. During exhalation. T he patient's left ar m is dr aped ov er the physician's left thigh. as the physician's right hand r esis ts (w hite arr ow) the inhalation motion F igu re 10. Step 7. ex halation. 7.53. Steps 1 to 4.55. Step 6..lww.com/pt/re/9780781763714/bookContent. T he patient inhales deeply ( blac k arrow. F ig. 27 of 134 21/08/07 22:07 . 10. the physician's right hand follows the fir st rib down and for war d ( white arrow. s ide. T he patient's head.

4. 28 of 134 21/08/07 22:07 . ex halation.. resis t inhalation.58) further into ex halation. T he patient inhales and then ex hales deeply.lww. 6. c ontr olled by the physician's left hand. is gently flexed. F ig. and r otated away fr om the r ight rib to take the tension off the sc alene musculature (F ig. 2. Steps 1 to 4. 3.com/pt/re/9780781763714/bookContent. 10.bent towar d.57).. During exhalation. F igu re 10. P. 7. T he patient lies s upine and the phy s ician s tands or s its behind the patient.phalangeal joint of the physician's r ight index finger c ontacts the super ior s urface of the dy sfunctional r ight r ib posterior and lateral to the c ostotr ansv ers e ar tic ulation.59) as the physician's right hand r esis ts (w hite arr ow) the inhalation motion of the firs t rib.2 01 C ostal R egion: Right Fir st R ib. the physician's right hand follows the fir st rib down and for war d ( white arrow.59. Inhala tion D ysfunction: R e spiratory A ssist. s ide. T he metac arpal. T he patient inhales deeply ( blac k arrow. Step 7.58.http://thepointeedition. During exhalation. F ig. F igu re 10. 5. the physician's right hand F igu re 10. 10.57. Supine 1. T he patient's head. Step 6. 10.

9. Inhala tion D y sfunction: Post Isom etr ic R ela xation to Rela x Scalene Mus cle s. ex aggerate exhalation.http://thepointeedition. F ig.61. Steps 7 and 8 are r epeated fiv e to s even times or until motion is maximally improved at the dysfunc tional rib. 10. P.60.2 02 C ostal R egion: Right Ribs 1 and 2. 29 of 134 21/08/07 22:07 .com/pt/re/9780781763714/bookContent.. Fig ure 10. placing the left foot on the table to the left side of the patient and k eeping the hip and knee flexed at about 90 degrees.lww. Step 8. Seated 1. Motion of the dy sfunctional r ib is r eevaluated to deter mine the effec tiv enes s of the technique. Steps 1 to 3. F igu re 10. An alter native technique is to have the patient lift the r ight s houlder agains t r esis tance for 3 to 5 s econds and then c arry the r ib toward ex halation during the r elax ation phas e. follows the fir st rib down and for war d ( white arrow.60) towar d ex halation. 8. 10.. T he patient is s eated and the physician s tands behind the patient.

and adds slight ex tension until meeting the edge of the r estr ictive barrier (F ig . r otates it 30 to 45 degrees to the left (white ar row). Step 6.com/pt/re/9780781763714/bookContent. T he phys ician's r ight thumb is placed over the anter omedial as pec t of the dy sfunctional r ight rib. T he patient pushes the head for war d into the physician's left hand (b lack ar row.62.62) as the physician r esis ts (long white ar row) . T he r ight hand ( s hor t white ar row) s imultaneous ly r esis ts any inhalation movement of the dy sfunctional r ib. 5. extension barr ier .http://thepointeedition.. F ig. 10. isometr ic contraction.63. 3.61). 2. T his isometr ic c ontr action is held for 3 to 5 s econds. Fig ure 10. 30 of 134 21/08/07 22:07 . and then the patient Fig ure 10. 4. T he phys ician's left hand c ontr ols the patient's forehead..lww. Step 4. 10.

is instr ucted to relax. 10...com/pt/re/9780781763714/bookContent.http://thepointeedition. O nce the patient has c ompletely r elax ed. 7. F ig.lww. the physician's left hand minimally ex tends the patient's head ( white arrow. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique. 6.63) until a new r estr ictive barrier is r eached. Supine 31 of 134 21/08/07 22:07 . Steps 5 to 7 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional r ib. Inhala tion D y sfunction: Post Isom etr ic R ela xation to Rela x Scalene Mus cle s.2 03 C ostal R egion: Right Ribs 1 and 2. P. 8.

.65) as the physician applies an equal c ounterforc e ( long white ar row).64.66. Fig ure 10. T he patient lies s upine and the physician s its at the head of the table.. Fig ure 10. 3. 32 of 134 21/08/07 22:07 . 2.64) and adds s light extension by lower ing the thigh until the edge of the r estr ictive barrier is r eached.65. 1. 4. isometr ic contraction. Steps 1 to 3. F ig.com/pt/re/9780781763714/bookContent. r otation and extens ion bar rier. F ig. T he phys ician's left hand c ontr ols the patient's head and r otates it 30 to 45 degrees to the left (w hite ar row. The r ight thumb ( s hor t white ar row) s imultaneous ly r esis ts any inhalation movement of Fig ure 10. 10. T he patient flexes the head and neck into the phys ician's left hand ( blac k ar row.http://thepointeedition. 10. Step 6.lww. Step 4. extension barr ier . T he phys ician's r ight thumb is placed over the anter omedial as pec t of the dy sfunctional r ib.

3. P.67. T he patient lies s upine and the physician's flexed r ight k nee is plac ed on the table under neath the patient's r ight upper thorac ic r egion at the level of the dy sfunctional r ib.. Step 5. 5. Inha lation Dy s function: R espira tory As sis t 1. Steps 1 to 3. 2. exagger ate ex halation.67).lww. T he web formed by the physician's r ight thumb and index finger is placed in the inter cos tal s pace above the dy sfunctional r ib on its s uper ior s urface (F ig .com/pt/re/9780781763714/bookContent. Step 6.69. F ig ure 10.68. T he patient's upper body is s ide. 4.bent to the s ide of the dy sfunction ( r ight s ide) until tension is taken off the dy sfunctional r ib. 33 of 134 21/08/07 22:07 .2 04 C ostal R egion: Right Ribs 2 to 6.http://thepointeedition. 10. During ex halation the physician's F ig ure 10. F ig ure 10. r esist inhalation.. T he patient inhales and ex hales deeply.

T he patient ex hales. and the phys ician ex aggerates the exhalation motion ( white ar row.http://thepointeedition. F ig. 9. exagger ate ex halation. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique. 7..68) of the dy sfunctional r ib.70. Step 7.lww.com/pt/re/9780781763714/bookContent. F ig. 6. Steps 6 and 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib.. 10. F ig ure 10. 8.70) of the dy sfunctional r ib. F ig. r ight hand ex aggerates the exhalation motion ( white ar row. 10. 10. P.69) as the phys ician's r ight hand r esis ts (w hite ar row) the inhalation motion of the dy sfunctional r ib. T he patient inhales again ( blac k arrow.2 05 34 of 134 21/08/07 22:07 .

10. exagger ate ex halation. T he web formed by the physician's r ight thumb and index finger is placed in the inter cos tal s pace on the s uper ior s urface of the dy sfunctional r ib ( Fig . r esist inhalation. 2. Step 5. Step 4. O n inhalation ( blac k arrow. F ig ure 10. and the physician s tands at the s ide of the dy sfunctional r ib.http://thepointeedition. Inhala tion D y sfunction: R espira tory As sis t 1. F ig ure 10.71.71). T he patient lies s upine. 3.com/pt/re/9780781763714/bookContent. F ig.72.72) the ex halation motion of the dy sfunctional r ib. 4. 35 of 134 21/08/07 22:07 . 10.lww. C ostal R egion: Right Ribs 7 to 10. F ig ure 10... T he patient's upper body is bent to the side of the dy sfunction ( r ight s ide) until tension is taken off the dy sfunctional r ib. T he patient inhales and ex hales deeply as the physician's r ight hand ex aggerates ( white arrow. 5. Steps 1 to 3.73.

Step 6.http://thepointeedition. Steps 5 and 6 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. F ig.. T he patient ex hales and the physician ex aggerates the exhalation motion ( white ar row.74) of the dy sfunctional r ib. 7.. exagger ate ex halation. F ig. Inha lation Dys function: R espira tory As sis t 36 of 134 21/08/07 22:07 .2 06 C ostal R egion: Right Ribs 1 1 and 1 2. 10. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique. P. F ig ure 10. 6.73) the physician's r ight hand r esis ts (w hite ar row) the inhalation motion of the dy sfunctional r ib.lww.com/pt/re/9780781763714/bookContent. 10. 8.74.

3.77. T he phys ician places the left hy pothenar eminence medial and infer ior to the angle of the dy sfunctional r ib and exer ts gentle. 10. During ex halation the physician's left hand ex aggerates ( white arrow. r esist inhalation. Step 6. 2. 5. F ig ure 10.lww. exagger ate ex halation.75).. T he phys ician may gras p the patient's r ight anter ior s uper ior iliac s pine with the r ight hand to s tabiliz e the pelvis ( Fig . Step 5.75. and the physician s tands at the left side of the table and positions the patient's legs 15 to 20 degrees to the r ight. s ustained later al and c ephalad tr action. T he patient lies pr one. 1.76) the F ig ure 10.com/pt/re/9780781763714/bookContent. 10.http://thepointeedition. F ig ure 10. Steps 1 to 3.76.. T he patient inhales and ex hales deeply. taking tension off the quadr atus lumborum. 4. 37 of 134 21/08/07 22:07 . F ig.

http://thepointeedition.79.2 07 C ostal R egion: Ana tom y of the Scalene Mus cle s Anterio r Scalene Muscle O rig in T he origin of the anterior s calene musc le is at transver se proc ess es C3 to C6 ( Fig . Anatomy of the scalenes and thorac ic outlet ( 7). P. flex es laterally.lww. s uperior s urface of the fir s t r ib. Innervat ion T he ventral r ami of the c erv ical s pinal nerv es F igure 10.79)..com/pt/re/9780781763714/bookContent. and rotates the nec k .. Action T he anterior s calene musc le elev ates the firs t r ib. Insertio n T he insertion of the anterior s calene musc le is at the scalene tubercle. 38 of 134 21/08/07 22:07 . 10.

com/pt/re/9780781763714/bookContent.. Insertio n T he insertion point of the middle s calene musc le is at the superior s urface of firs t r ib posterior to the s ubc lav ian artery.http://thepointeedition.lww. Midd le Scalene Muscle O rig in T he origin of the middle s calene musc le is at transver se proc ess es C1 to C6. Action T he middle s calene musc le elev ates the firs t r ib during forc ed inspiration and flex es the nec k laterally..C6) innervate the anterior s calene musc le. Innervat ion 39 of 134 21/08/07 22:07 . ( C4.

lww..http://thepointeedition. Insertio n T he insertion of the posterior s calene musc le is at the sec ond r ib.. Action T he posterior s calene musc le elev ates s econd r ib during forc ed inspiration and flex es the nec k laterally. Innervat ion 40 of 134 21/08/07 22:07 . T he ventral r ami of c erv ical s pinal nerv es C3 to C8 innervate the middle s calene musc le. Post erio r Scalene Muscle O rig in T he origin of the posterior s calene musc le is at transver se proc ess es C4 to C6.com/pt/re/9780781763714/bookContent.

T he patient lies s upine. F igure 10.2 08 C ostal R egion: Right Ribs 1 and 2. Step 4. and the physician s tands on the left side of the patient... 10. 3. gr asps the s uper ior angle of the r ight dy sfunctional r ib. P. T he patient's head is rotated approximately 30 degrees to the left. T he ventral r ami of c erv ical s pinal nerv es ( C6–C8) innervate the posterior s calene musc le.80. Ex hala tion D y sfunction: C ontrac tion of Sc a lene Musc les Mobilizes Dys func tional Ribs 1. 4. Steps 1 to 3.80) .http://thepointeedition.com/pt/re/9780781763714/bookContent. 2.81. and ex erts a caudad and F igure 10.lww. T he patient's r ight wr ist ( dors al s urface) is placed against the forehead ( F ig. T he phys ician's left hand r eaches under the patient. 41 of 134 21/08/07 22:07 .

8. the physician's left hand exerts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( white ar row. 10. T his isometr ic c ontr action is maintained for 3 to 5 sec onds . 42 of 134 21/08/07 22:07 . Steps 6 to 8 ar e r epeated fiv e to s even times or until motion is maximally improved at the dy sfunctional r ib.82) without altering the r otation of the head while the phys ician's r ight hand applies an unyielding c ounterforc e ( white arrow). 9. Motion of the dy sfunctional F igure 10. F ig. isometric c ontr action. 7. 10. and the patient is instr ucted to relax. F ig. 5. Step 5.82.83. later al trac tion ( white arrow. 6. O nce the patient has c ompletely r elax ed.. F igure 10.83). T he patient flexes the head and neck ( blac k arrow.com/pt/re/9780781763714/bookContent.lww. 10.81) .. F ig. Step 7.http://thepointeedition.

.. r ib is r eevaluated to as ses s the effec tiv enes s of the technique.2 09 C oas tal Region: Pe ctoralis Minor Musc le 43 of 134 21/08/07 22:07 .lww. P.http://thepointeedition.com/pt/re/9780781763714/bookContent.

and 5 ( F ig. 10.lww.84). 44 of 134 21/08/07 22:07 .. 4. T 1) innervates the pectoralis F igure 10.. Insertio n T he insertion of the pectoralis minor musc le is at the c oracoid proc ess of s capula. O rig in T he origin of the pectoralis minor musc le is at the anterior s uperior s urface of r ibs 3.84. Innervat ion T he medial pectoral nerv e ( C8.com/pt/re/9780781763714/bookContent. Pectoralis minor musc le ( 7). Action T he pectoralis minor musc le s tabiliz es s capula by drawing it inferior ly and anterior ly against thor acic wall.http://thepointeedition.

Step 5. 3. T he patient lies s upine and the physician s tands on the left side of the table. F ig. Steps 3 and 4.87) . 45 of 134 21/08/07 22:07 .86).. 4. 10. and ex erts c audad and later al trac tion. 2. 10.. Steps 1 and 2.lww. F ig ure 10. or 5.http://thepointeedition. T he phys ician's r ight hand is placed over the anter ior as pect of the patient's r ight shoulder at the level of the c oracoid pr ocess (F ig .2 10 C ostal R egion: Right Rib 3. T he patient r aises the r ight ar m and plac e the hand ov er the head (F ig. P. isometr ic c ontraction. 10.87. gr asps the s uper ior angle of the dy sfunctional r ib. Exha lation Dys function: C ontrac tion of Pe c tor alis Minor Mobilizes Dy sfunctiona l R ibs 1.85). F ig ure 10. T he phys ician's left hand r eaches under the r ight s ide of the patient.86. F ig ure 10. 4.com/pt/re/9780781763714/bookContent. T he patient pr otr acts the s houlder by pushing forward against the phys ician's r ight hand ( blac k arrow. 5.85.

7. 10.com/pt/re/9780781763714/bookContent. which is apply ing an unyielding c ounterforc e ( white arrow). Ex halation D ysfunc tion: 46 of 134 21/08/07 22:07 .2 11 C ostal R egion: Right Rib 3.http://thepointeedition. 6. Step 7. 4 or 5 . F ig. 8.lww.88.. O nce the patient has c ompletely r elax ed. Steps 5 to 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. and then the patient is instr ucted to st op and relax. F ig ure 10. the physician's left hand exerts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( white ar row. P..88). Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique. T his isometr ic c ontr action is held for 3 to 5 s econds. 9.

47 of 134 21/08/07 22:07 . T he patient r aises the r ight ar m and plac e the hand ov er the head (F ig. 10.. 10.91. 2. Steps 1 and 2. Step 5. T he phys ician's left hand r eaches under the r ight s ide of the patient. 5. T he patient pushes the elbow agains t the phys icians r ight hand ( blac k arrow. gr asps the s uper ior angle of the dy sfunctional r ib and exer ts c audad and later al trac tion.89..90) .91) . and F ig ure 10. T his isometr ic c ontr action is held for 3 to 5 s econds. Steps 3 and 4. 3. F ig.http://thepointeedition. T he patient lies s upine.com/pt/re/9780781763714/bookContent.lww. isometr ic c ontraction. 10. which is apply ing an unyielding c ounterforc e ( white arrow).90. F ig ure 10. F ig ure 10. T he phys ician's r ight hand is placed over the anter ior as pect of the patient's r ight elbow ( F ig. 4. and the physician s tands on the left side of the table.89). 6. C ontrac tion of Pe c tor alis Minor Mobilizes Dy sfunctiona l R ibs 1.

92).92. 8.com/pt/re/9780781763714/bookContent. the physician's left hand exerts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( white ar row.. Steps 5 to 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib.. 7. 9. F ig ure 10. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique. O nce the patient has c ompletely r elax ed. Step 7.2 12 C ostal R egion: Se r ratus Ante rior Musc le 48 of 134 21/08/07 22:07 . P. 10.lww.http://thepointeedition. F ig. then the patient is instr ucted to st op and relax.

http://thepointeedition. Insertio n T he insertion of the ser r atus anterior musc le is at the superior lateral s urface of r ibs 2 to 8.. F ig ure 10.93). P. 10. Serratus anterior musc le (7) . Innervat ion T he long thor acic nerv e ( C5–C7) innervates the ser r atus anterior musc le. O rig in T he origin of the s err atus anterior musc le is at the anterior s urface of the medial border of the scapula ( Fig .com/pt/re/9780781763714/bookContent.2 13 49 of 134 21/08/07 22:07 .lww.. Action T he s err atus anterior musc le protrac ts the scapula and holds it against the thor acic wall.93.

T he patient pushes the elbow towar d the c eiling ( s capular pr otr action) ( blac k arrow. F ig ure 10. 2..94) . 10. exerting c audad and later al trac tion ( white arrow. T he patient lies s upine and the physician s tands or s its at the s ide of the dy sfunctional r ib.95) while the physician applies an unyielding c ounterforc e ( white arrow). 10. F ig. F ig ure 10. Steps 1 to 3. the elbow may be flexed for better c ontr ol by the physician.http://thepointeedition. 3. Step 6. T he phys ician r eaches the r ight hand under the patient and gr asps the s uper ior angle of the dy sfunctional r ib..com/pt/re/9780781763714/bookContent. 4. 7.96. isometr ic c ontraction.94.95. F ig. Step 4.lww. 50 of 134 21/08/07 22:07 . or 8. Exha lation Dys function: C ontrac tion of Se r ratus Ante rior Mobilize s D ysfunctional R ibs 1. T he patient's r ight shoulder is flexed 90 degrees. C ostal R egion: Right Rib 6. F ig ure 10.

and then the patient is instr ucted to st op and relax.com/pt/re/9780781763714/bookContent. F ig.96) on the angle of the dy sfunctional r ib. O nce the patient has c ompletely r elax ed. the physician's r ight hand ex erts increased c audad and later al trac tion ( white arrow. 8.lww. P.. 6. 5. T his isometr ic c ontr action is held for 3 to 5 s econds. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique. Steps 5 to 7 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib..2 14 C ostal R egion: La tiss imus D orsi Muscle 51 of 134 21/08/07 22:07 . 7. 10.http://thepointeedition.

lww.. 10. adducts . 52 of 134 21/08/07 22:07 . the lower four r ibs . the thor acolumbar fasc ia. and medially r otates the humerus . and the iliac c r est ( Fig . Insertio n T he ins ertion of the latissimus dors i muscle is at the intertuberc ular ( bic ipital) groove of the humerus . O rig in T he origin of the latissimus dors i muscle is at s pinous proc ess es of T 7 to S3. Action T he latissimus dors i muscle extends ..com/pt/re/9780781763714/bookContent.97). the inferior angle of s capula. Innervat ion T he thor acodors al nerv e ( C6–C8) innervates the latissimus dors i muscle.http://thepointeedition.

3. F ig. and the physician s tands or s its at the s ide of the dy sfunctional r ib. Step 4. Fig ure 10. 2. and the r ight hand r eaches under the patient and gr asps the s uper ior angle of the dy sfunctional r ib. 10.99) while the physician's left thigh and/or ar m applies an unyielding c ounterforc e Fig ure 10.. Fig ure 10. 53 of 134 21/08/07 22:07 .100. T he patient pushes the r ight ar m into the physician's thigh (blac k ar row. Step 6. Step 3. T he phys ician's left hand abduc ts the patient's r ight s houlder 90 degrees. T he phys ician's left lateral thigh or knee is placed against the patient's r ight elbow ( F ig. 10.. P. 4.http://thepointeedition. Ex halation D ysfunc tion: C ontrac tion of La tiss imus D orsi Mobilizes Dy sfunctiona l R ibs 1.2 15 C ostal R egion: Right Ribs 9 and 10 .98. T he patient lies s upine.99.lww. exerting c audad and later al trac tion.com/pt/re/9780781763714/bookContent.98) .

10. the physician's r ight hand ex erts increased c audad and later al trac tion ( white arrow.com/pt/re/9780781763714/bookContent.http://thepointeedition.. 7. ( white arrow).100) on the angle of the dy sfunctional r ib. Motion of the dy sfunctional r ib is r eevaluated to as ses s the effec tiv enes s of the technique.lww. P. 6. T his isometr ic c ontr action is held for 3 to 5 s econds.2 16 C ostal R egion: Qua dra tus Lum bor um Mus c le 54 of 134 21/08/07 22:07 . 5. O nce the patient has c ompletely r elax ed. Steps 4 to 6 ar e r epeated fiv e to s even times or until motion is maximally improved at the dy sfunctional r ib. 8.. F ig. and then the patient is instr ucted to st op and relax.

55 of 134 21/08/07 22:07 .lww.. Innervat ion T he ventral branches of T 12 to L4 F igure 10. Action T he quadratus lumborum musc le extends and laterally flex es the v ertebr al c olumn.101) . Quadratus lumborum ( 7).http://thepointeedition. 10. O rig in T he origin of the quadratus lumborum musc le is at the iliac c res t and the iliolumbar ligament ( Fig . Insertio n T he insertion of the quadratus lumborum musc le is at the inferior aspect of the 12th rib and the transver se proc ess es of L1 to L4. it also fix es the 12th rib during inhalation.com/pt/re/9780781763714/bookContent..101.

putting tension on the quadr atus lumborum. T he patient lies pr one and the physician s tands at the left s ide of the table and positions the patient's legs 15 to 20 degrees to the left. Step 5. F ig ure 10. Exha lation Dys function: C ontrac tion of Qua dra tus Lum bor um Mobilizes Dys func tional Ribs 1. 4. F ig ure 10.103. F ig. 3.pointing white ar row. Steps 1 to 3. T he phys ician's r ight hand gr asps the patient's r ight anter ior superior iliac spine ( ASIS) and gently lifts towar d the c eiling ( upward. Step 7.2 17 C ostal R egion: Right Ribs 1 1 and 1 2. T he phys ician's left thenar eminence or index finger is placed s uper ior and lateral to the angle of the dy sfunctional r ib and exer ts gentle s ustained medial and c audad trac tion ( left-pointing white ar row. 2.102) ..102. 56 of 134 21/08/07 22:07 . P..lww. 10.104.102) . 10.com/pt/re/9780781763714/bookContent.http://thepointeedition. isometric c ontraction and exagger ate inhalation. T he patient inhales. F ig. F ig ure 10.

pointing white ar row) .lww.103) while the phys ician's r ight hand applies an unyielding c ounterforc e ( opposing white ar row). O nce the patient has c ompletely r elax ed.http://thepointeedition.. F ig. 5. 6. and then the patient is instr ucted to relax. T his isometr ic c ontr action is maintained for 3 to 5 sec onds . the physician's right hand lifts the patient's r ight ASIS toward the c eiling ( upward. At the s ame time. the left hand ex aggerates the inhalation motion of the dy sfunctional r ib by ex erting medial and c audad trac tion ( left-pointing white ar row) . ex hales.com/pt/re/9780781763714/bookContent. 10.. During inhalation the phys ician instr ucts the patient to pull the r ight ASIS down toward the table (blac k ar row. 7. and the left hand 57 of 134 21/08/07 22:07 . and then inhales deeply.

com/pt/re/9780781763714/bookContent. Steps 5 to 7 ar e r epeated fiv e to s even times or until motion is maximally improved at the dy sfunctional r ib.2 18 P. P. F ig. 9.. putting tension on the quadr atus lumborum. 58 of 134 21/08/07 22:07 .104) . 8. Motion of the dy sfunctional r ib is reevaluated to as ses s the effec tiv enes s of the technique. T he patient lies pr one and the physician s tands at the left s ide of the table.2 19 C ostal R egion: Right Ribs 1 1 and 1 2. ex erts increased c audad and later al trac tion on the angle of the dy sfunctional r ib ( left-pointing white ar row. Exha lation Dys function: R espira tory As sis t 1. 10.lww.. T he patient's legs are positioned 15 to 20 degrees to the left.http://thepointeedition.

6. Steps 1 to 3..http://thepointeedition. F ig ure 10. the physician's left hand ex aggerates the inhalation motion of the dy sfunctional r ib by ex erting medial and c audad trac tion ( left-pointing white ar row. Step 6. 59 of 134 21/08/07 22:07 . Step 5. 3. T he patient inhales.106) as the r ight hand gently lifts the patient's r ight anter ior superior iliac spine ( upward. F ig.com/pt/re/9780781763714/bookContent.pointing white ar row) towar d the c eiling. exaggerate inhalation.105. T he phys ician places the left thenar eminence or index finger s uper ior and later al to the angle of the dy sfunctional r ib and exer ts gentle s ustained medial and c audad trac tion.107. ex hales. 10.lww. F ig ure 10. During inhalation. O n ex halation F ig ure 10. 2. 4. and then inhales deeply. 5.105).106.. 10. T he phys ician's r ight hand gr asps the patient's r ight ASIS and gently lifts towar d the c eiling (F ig . res ist ex halation.

2. 8. F ig. Motion of the dy sfunctional r ib is reevaluated to as ses s the effec tiv enes s of the technique.2 20 P. 7. T he patient is s eated at the end of the table..lww. P.107) the physician's left hand res ists ( white arrow) the exhalation motion of the r ib. ( blac k arrow.2 21 Lumbar R egion: Ty pe I Dy sfunction Exa m ple : L2 N SLRR Post Isom etr ic R ela xation 1. F igu re 10.108.. 10.com/pt/re/9780781763714/bookContent. Steps 5 and 6 ar e r epeated five to sev en times or until motion is maximally improved at the dy sfunctional r ib. Steps 1 to 3. T he patient places the r ight hand behind the neck and the left hand on the r ight elbow.http://thepointeedition. 60 of 134 21/08/07 22:07 . T he phys ician s tands to the s ide opposite the r otational c omponent of the dysfunc tion.

108). T he patient turns or pulls F igu re 10. L2-L3 neutr al. Step 5.109) until L2 is neutr al in r elation to L3.109.bending barr ier .111. F ig. T he phys ician passes the left ar m under the patient's left ar m and gras ps the patient's r ight upper arm ( F ig. T he phys ician's r ight hand monitors the tr ans ver se pr ocesses of L2 and L3 to localize side bending and r otation as the left arm and hand pos ition the patient's torso to the edge of the r ight side bending (w hite ar row. r ight s ide. F ig.. 10. Step 4. F ig. 6. 10. F igu re 10. 4.. 10.lww.com/pt/re/9780781763714/bookContent.http://thepointeedition. F igu re 10. 3.111) .110. 5. Step 5. T he phys ician's r ight hand monitors the s pinous pr ocesses of L2 and L3 or the L2-L3 inter space as the left ar m and hand flex and ex tend the patient's torso ( white arrow. 10. and then left r otation bar rier ( white arrow. 61 of 134 21/08/07 22:07 .110). left rotation bar r ier .

113.bending barr ier .http://thepointeedition. and then the patient is instr ucted to st op and relax. 10.com/pt/re/9780781763714/bookContent. 7. O nce the patient has c ompletely r elax ed. isometr ic c ontrac tion. k eeping L2 neutr al. T his isometr ic c ontr action is maintained for 3 to 5 sec onds . the r ight s houlder bac k to the r ight ( blac k arrow. 10. 10. Step 8. r ight s ide. 62 of 134 21/08/07 22:07 . F ig.113) and left r otation bar rier ( white arrow.. Step 6. Step 8. Motion of the dy sfunctional s egment is r eevaluated to F igu re 10.114) .114. r epos itions the patient to the edge of the r ight s ide. F ig. 9. F igu re 10.lww. 10.112. the physician.bending barrier (w hite ar row. left rotation bar r ier . F igu re 10. 8.. Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment.112) while the physician's left hand applies an unyielding c ounterforc e ( white arrow). F ig.

as ses s the effec tiv enes s of the technique. T he patient is s eated and the physician s tands to the left of the patient (side oppos ite the r otational c omponent of the dy sfunction) .com/pt/re/9780781763714/bookContent. T he patient places the r ight hand behind the neck and the left hand on the r ight elbow. F igu re 10. Steps 1 to 3. T he phys ician passes the left ar m over or under the patient's left ar m and gras ps the patient's r ight upper arm ( F ig.116.2 23 Lumbar R egion: Ty pe II D ysfunction Ex a mple: L2 ERRSR Post Isom etr ic R ela xation 1. ( Variation: the patient may place the hands behind the neck and approximate the elbows anter ior ly. Step 4..lww. 2.) 3. 10. flex ion bar rier.115. P.http://thepointeedition.115).. 63 of 134 21/08/07 22:07 .2 22 P. F igu re 10.

119. T he phys ician's r ight hand monitors the s pinous pr ocesses of L2 and L3 or the L2-L3 inter space to localize flexion and extension as the physician's left hand pos itions the patient's tr unk to the edge of the r estr ictive flexion bar r ier ( F ig. 10. 64 of 134 21/08/07 22:07 . 6.. 10. F ig. Step 5. isometr ic c ontrac tion. left side-bending barr ier .lww. F igu re 10.118).119) while the physician's left F igu re 10.bending barrier (F ig ..117. Step 5.http://thepointeedition. left rotation bar r ier .com/pt/re/9780781763714/bookContent. T he phys ician's r ight hand monitors the tr ans ver se pr ocesses of L2 and L3 to localize side bending and r otation as the physician's left hand r epos itions the patient's tr unk to the edge of the left s ide. T he patient tr ies to sit up and gently pull the r ight s houlder backward ( blac k arrow.117) and left r otation bar rier ( F ig. Step 6. 10. 4. F igu re 10. 10.116). 5.118.

left side-bending barr ier .120. and then the patient is instr ucted to st op and relax.com/pt/re/9780781763714/bookContent. Step 8. 8. and flex ion barrier (F ig . 10. the physician r epos itions the patient (w hite ar rows.lww. Steps 6 to 8 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional s egment. Motion of the dy sfunctional s egment is r eevaluated to as ses s the effec tiv enes s of the technique. F igu re 10. flex ion bar rier. Fig . 9. left rotation ( F ig. F igu re 10.2 25 Lumbar R egion: Ty pe I Dy sfunction Exa m ple : L4 N SLRR Post 65 of 134 21/08/07 22:07 .http://thepointeedition. 10.122).. 10.121. 7.120) to the edge of the left s ide bending. left rotation bar r ier .2 24 P. O nce the patient has c ompletely r elax ed. P. hand applies an unyielding c ounterforc e ( white arrow). Step 8. Step 8. 10. F igu re 10.. T his isometr ic c ontr action is maintained for 3 to 5 sec onds .122.121).

124. T he patient's left leg is lower ed off the edge of the F igure 10. F igure 10.125. 3.. Step 4. 10. T he phys ician's c audad hand or thigh gently flexes and ex tends the patient's hips until the physician's c ephalad hand deter mines the dy sfunctional s egment ( L4-L5) to be positioned in neutr al (F ig . F igure 10.http://thepointeedition.. 4. T he phys ician's c audad hand or thigh contr ols the patient's flexed k nees and hips while the c ephalad hand palpates the L4 and L5 s pinous pr ocesses or the L4-L5 inter space.123). 66 of 134 21/08/07 22:07 .123. Steps 1 to 3. T he patient lies in a right lateral r ecumbent position on the s ide of the r otational c omponent of the dysfunc tion and the physician s tands at the s ide of the table facing the patient. Isom etr ic R ela xation 1.lww.com/pt/re/9780781763714/bookContent. Step 5. 2.

Switc hing hands . 5.com/pt/re/9780781763714/bookContent. O nce the patient has c ompletely F igure 10.126. Step 9. the physician us es the c ephalad hand to gently move the patient's s houlder posteriorly ( white arrow. 6. 10. F igure 10. u n til the physician's c ephalad hand detec ts motion at the dy sfunctional s egment (F ig . T his isometr ic c ontr action is held for 3 to 5 s econds. and then the patient is told to stop an d relax. 8. 67 of 134 21/08/07 22:07 .128. is ometric c ontr action.125) u n til the c audad hand detec ts motion at the dy sfunctional s egment. table... F igure 10.lww. F ig. 7. 10. T he patient g ently pushes the s houlder forward (b lack ar row. c aus ing anter ior rotation of the pelv is. 10.127.124). is ometric c ontr action. Step 6. Step 8. F ig.http://thepointeedition.126) against the unyielding c ounterforc e of the phys ician's c ephalad hand ( white arrow).

http://thepointeedition. Step 11. F ig. 10. 9. 10.com/pt/re/9780781763714/bookContent.. 10. 68 of 134 21/08/07 22:07 . F ig.129) to the edge of the new r estr ictive barrier. the physician gently moves the patient's pelvis c audad ( white ar row. and then the patient is told to stop an d relax. 10. T his isometr ic c ontr action is held for 3 to 5 s econds.129. the physician gently moves the patient's s houlder posteriorly ( white arrow. F ig. O nce the patient has c ompletely r elax ed.lww. 12. Steps 6 to 11 ar e r epeated F igure 10. 11. T he patient g ently pulls the hip and pelv is c ephalad up towar d the s houlder (black ar row. r elax ed. r otating the thoracic and lumbar s pine to the edge of the new r estric tive barrier.128) against the unyielding c ounterforc e of the phys ician's c audad hand ( white arrow)..127) .

13. 14. and 10 may be performed s imultaneous ly. 9.lww.com/pt/re/9780781763714/bookContent.2 27 Lumbar R egion: Ty pe II D ysfunction Ex a mple: L4 E/FSRRR Pos t Isom etr ic R ela xation 69 of 134 21/08/07 22:07 . Motion of the dy sfunctional s egment is r eevaluated to as ses s the effec tiv enes s of the technique. three to fiv e times or until motion is maximally improved at the dy sfunctional s egment ( L4-L5).. 7..http://thepointeedition. after which the physician r epos itions the patient to the edge of the new r estr ictive barriers . Steps 6. P.2 26 P.

com/pt/re/9780781763714/bookContent.lww. Switc hing hands . 5. 1. 4. Step 4.. 70 of 134 21/08/07 22:07 .132. 10. 2.. the physician us es the c ephalad F igure 10. T he phys ician's c audad hand or thigh contr ols the patient's flexed k nees and hips while the c ephalad hand palpates the L4 and L5 s pinous pr ocesses or the L4-L5 inter space. T he phys ician's c audad hand or thigh gently flexes and ex tends the patient's hips until the physician's c ephalad hand deter mines the dy sfunctional s egment ( L4-L5) to be positioned in neutr al (F ig .130). T he phys ician's c audad hand places the patient's left foot behind the r ight knee in the popliteal fossa ( F ig. F igure 10. and the phys ician s tands facing the patient. T he patient lies on the s ide of the r otational c omponent.130.131). 3. F igure 10.http://thepointeedition. 10.131. Step 5. Steps 1 to 3.

137. 3. Steps 1 to 3.2 28 Pelv ic R egion: Right Pos ter ior Innominate Dy sfunction: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation Diag nosis Standing flexion test: Positiv e (r ight posterior s uperior iliac s pine [PSIS] r ises) Loss of pas siv ely induced right s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the right PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Anterior . deep on the r ight T ech niq u e 1. F igure 10. T he c audad hand is placed distal to the patient's F igure 10.http://thepointeedition. Step 5.. T he phys ician's c ephalad hand is placed ov er the patient's left ASIS to prev ent the patient from r olling off the table.. T he phys ician s tands at the r ight side of the table. P.139.com/pt/re/9780781763714/bookContent. 2.lww. Step 4. F igure 10. 71 of 134 21/08/07 22:07 .138. is ometric c ontr action. T he patient lies s upine on a diagonal. s o the r ight sacroiliac joint is off the edge of the table.

F ig. 10. the physician ex tends the patient's r ight hip ( white ar row. 7.138). 6. O nce the patient has c ompletely r elax ed.140) to the edge of the new F igure 10. br inging the innominate into anter ior r otation. 72 of 134 21/08/07 22:07 . T he phys ician's c audad ( right) hand pas siv ely ex tends the patient's r ight hip ( white ar row. 4. T he patient lifts the r ight leg ( blac k arrow.lww. F ig. k nee (F ig. until the edge of the r estr ictive barrier is r eached. F ig.http://thepointeedition. 10..com/pt/re/9780781763714/bookContent. 5..140. T his isometr ic c ontr action is maintained for 3 to 5 sec onds .139) towar d the c eiling while the physician applies an equal c ounterforc e ( white arrow). and then the patient is instr ucted to st op and relax. 10.137). 10. Step 7.

http://thepointeedition. T he patient is placed in a left later al modified Sims pos ition: left lateral r ecumbent.141... deep on the r ight T ech niq u e 1. 8.2 29 Pelv ic R egion: Right Pos ter ior Innominate Dy sfunction: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the right PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Anterior . Steps 5 to 7 ar e r epeated thr ee to five times.com/pt/re/9780781763714/bookContent.lww. 9. Step 1. r estr ictive barrier. with F igure 10. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. 73 of 134 21/08/07 22:07 . P.

10.http://thepointeedition. Steps 2 and 3. Step 6. gr asps the patient's r ight leg with the c audad ( right) hand. F igure 10. T he phys ician s tands behind the patient. T he phys ician's c audad hand passively ex tends the patient's r ight hip ( white ar row.144. 4. br inging the innominate into anter ior r otation. 10.com/pt/re/9780781763714/bookContent.143) while the physician applies an equal c ounterforc e ( white arrow).141). until the edge of the r estr ictive barrier is r eached. F ig. 3. and places the hy pothenar eminence of the c ephalad hand on the patient's r ight PSIS. T he patient pulls the r ight leg forward ( blac k arrow.142. the anterior thorax r esting on the table and ar ms hanging ov er the side of the table ( F ig. F ig. is ometric c ontr action.lww.. T his isometr ic F igure 10. 74 of 134 21/08/07 22:07 .142). F igure 10. Step 4. 10.. 2. 5.143.

and then the patient is instr ucted to relax.2 30 Pelv ic R egion: Right Pos ter ior Innominate Dy sfunction: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation 75 of 134 21/08/07 22:07 . 7. 8. 6. P. O nce the patient has c ompletely r elax ed.lww. c ontr action is maintained for 3 to 5 sec onds .com/pt/re/9780781763714/bookContent. the physician ex tends the patient's r ight hip ( white ar row. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. F ig..http://thepointeedition. Steps 4 to 6 ar e r epeated thr ee to five times. 10.144) to the edge of the new r estr ictive barrier..

Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the right PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Anterior . F igure 10.http://thepointeedition. deep on the r ight T ech niq u e 1. 3. 10. is ometric c ontr action. 76 of 134 21/08/07 22:07 . T he phys ician's c audad ( right) hand pas siv ely ex tends the patient's r ight hip ( white ar row.lww.146).. 10.145). F ig.147. Step 3. T he patient lies pr one and the physician s tands on the left side of the table. 2. T he hypothenar eminence of the physician's c ephalad (left) hand is plac ed on the patient's r ight PSIS and the phys ician's c audad ( right) hand grasps the patient's r ight leg distal to the tibial tuber osity ( Fig . Steps 1 and 2. F igure 10.com/pt/re/9780781763714/bookContent.145. Step 4..146. F igure 10.

F igure 10.2 31 PELVIC R EGION: Right Anterior Innomina te Dys func tion: C ombine d Re ciproc a l Inhibition and Mus cle Contr a ction Mobilize A rticula tion Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior. F igure 10. 3. T he patient lies s upine.com/pt/re/9780781763714/bookContent. An ac ceptable modification is F igure 10. Steps 1 and 2. alter native. 10.149) until the edge of the r estric tive barrier is r eached. 2. Step 3. F ig.150. and the physician is s eated on the table facing the patient. T he phys ician places the patient's r ight heel on the r ight shoulder and pass ively flexes the patient's r ight hip and knee ( white arrow. shallow on the right T ech niq u e 1..http://thepointeedition. Step 4. P.151..149.lww. is ometric 77 of 134 21/08/07 22:07 .

10. to have the patient's r ight k nee loc ked in full extens ion and the leg flexed at the hip with the patient's r ight leg on the physician's r ight shoulder ( F ig.152. F ig.152) to the edge of the new r estr ictive barrier. 10. 5. 6. Steps 4 to 6 ar e c ontr action.150).lww. the physician flexes the patient's r ight hip ( white ar row.. T his isometr ic c ontr action is maintained for 3 to 5 sec onds . F ig.. F igure 10. T he patient pushes the k nee into the physician's hands . 4. Step 6. while the phys ician applies an equal c ounterforc e ( white arrow). 10.com/pt/re/9780781763714/bookContent. 78 of 134 21/08/07 22:07 . 7.http://thepointeedition. O nce the patient has c ompletely r elax ed.151). ex tending the r ight hip ( blac k ar row. and then the patient is instr ucted to st op and relax.

lww. T he phys ician's F igure 10..http://thepointeedition.2 32 Pelv ic R egion: Right Anterior Innomina te Dys func tion: Com bine d R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior on the r ight T ech niq u e 1. 2. r epeated thr ee to five times. Step 3.153. 8. T he patient lies in the left lateral r ecumbent position..com/pt/re/9780781763714/bookContent. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. and the phys ician s tands at the s ide of the table facing the patient.154. F igure 10. 79 of 134 21/08/07 22:07 . P. Steps 1 and 2.

T his isometr ic c ontr action is maintained for 3 to 5 sec onds . F ig. 80 of 134 21/08/07 22:07 . c audad ( left) hand palpates the r ight s acroiliac motion and s tabiliz es the pelvis while the physician's c ephalad (r ight) hand places the patient's r ight foot agains t the physician's thigh (F ig.lww. 3.155) while the phys ician applies an equal c ounterforc e ( white arrow). F igure 10.. 10. the physician's c ephalad hand flexes the patient's r ight hip. F ig.http://thepointeedition. is ometric c ontr action. Step 6.154). and then the F igure 10. 10. T he patient pushes the r ight foot into the phys ician's thigh (blac k ar row. Supporting the patient's r ight k nee.com/pt/re/9780781763714/bookContent.155. 10. 4.153).156. 5. bringing the innominate into posterior r otation until the edge of the r estr ictive barrier is r eached (w hite ar row. Step 4..

6. 10.http://thepointeedition. P.lww. 8.156). patient is instr ucted to st op and relax.2 33 Pelv ic R egion: Anterior Innominate Dy s function: Com bined R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation 81 of 134 21/08/07 22:07 . 7. F ig.com/pt/re/9780781763714/bookContent.. O nce the patient has c ompletely r elax ed. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. Steps 4 to 6 ar e r epeated thr ee to five times. the physician flexes the r ight hip innominate to the edge of the new r estr ictive barrier (w hite ar row..

T he phys ician's left hand s tabiliz es the patient's pelvis and s acr um. Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior on the r ight T ech niq u e 1. Steps 1 and 2.lww.159. T he phys ician s tands at the r ight side of the table facing the patient's pelvis.. Step 4. T he phys ician flexes the F igure 10. 10. T he patient lies pr one on a diagonal.157). s upporting the patient's r ight leg. and the physician's r ight hand. Step 3. 3. s o the r ight innominate is off the edge of the table. 82 of 134 21/08/07 22:07 . F igure 10. is ometric c ontr action.158. 2.http://thepointeedition.157. places the patient's r ight foot agains t the physician's r ight thigh or tibia (F ig.com/pt/re/9780781763714/bookContent. F igure 10..

Step 4.com/pt/re/9780781763714/bookContent.2 34 Pelv ic R egion: Right Superior Iliosac r al She ar Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad on the right ASIS: Cephalad on the right Ischial tuberosity : Cephalad on the r ight Sacr otuberous ligament tension: Lax T ech niq u e 1. Steps 1 and 2. 10. 83 of 134 21/08/07 22:07 . T he phys ician s tands at the foot of the table and gras ps the patient's r ight tibia and fibula above the ankle ( F ig. 2. 10. P.161.http://thepointeedition. Fig ure 10..163. T he phys ician Fig ure 10.162.162).. T he phys ician inter nally r otates the right leg to c lose-pack the hip joint. F ig.lww. T he patient lies either prone or s upine with both feet off the end of the table. 4. 3. lock ing the femoral head into the ac etabulum ( c urv ed white ar row.161). Step 3. Fig ure 10.

the patient may be instr ucted to c ough as the physician s imultaneous ly tugs on the leg. and instr ucts the patient to inhale and exhale ( F ig. With eac h ex halation the tr actional forc e is increased. Fig ure 10. 6. tr action cy c le is r epeated fiv e to s even times . 5. abduc ts the patient's r ight leg 5 to 10 degrees to take tension off the r ight sacroiliac ligament (F ig. With the las t ex halation.. 8. 7. maintaining ax ial tr action on the patient's r ight leg ( white ar row). 10. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.164).2 35 Pelv ic R egion: Right Outfla r e Innomina te Dys func tion: Pos t Isom etr ic R ela xation 84 of 134 21/08/07 22:07 . 9.lww. ex halation. T he phys ician gently leans back..http://thepointeedition.com/pt/re/9780781763714/bookContent. T his inhalation. P. Step 5. 10.163).164.

Step 4. T he phys ician c ephalad (left) hand adducts the patient's r ight knee ( white arrow. and the r ight foot is later al to the left knee. Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Sacr al s ulc us: Narr ow on the right ASIS: Later ally displac ed on the r ight T ech niq u e 1..http://thepointeedition. gr asping the medial aspec t of the r ight PSIS (F ig. Step 5.. 10. 85 of 134 21/08/07 22:07 . 10.lww. is ometric c ontr action.165. Steps 1 to 3. T he phys ician's c ephalad (r ight) hand is plac ed under the patient's r ight innominate.165).166. T he patient lies s upine.com/pt/re/9780781763714/bookContent. 4.167. F ig. and the physician s tands at the left side of the table. 3. F igure 10. F igure 10.166) until the edge of F igure 10. T he patient's r ight hip and k nee are flexed to about 90 degrees. 2.

F ig ure 10. T he phys ician's c audad hand is placed on the patient's r ight k nee and the r ight hip is ex ter nally r otated (w hite F ig ure 10. T he phys ician's c ephalad hand is placed on the patient's left ASIS (F ig. Steps 1 to 3.2 36 Pelv ic R egion: Right Inflar e Innom ina te D ysfunc tion: Post Isom etr ic R ela xation Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Sacr al s ulc us: Wide on the r ight ASIS: Medially displac ed on the r ight T ech niq u e 1. isometric c ontraction.169. 10.. 2.171. Step 4. T he patient lies s upine and the physician s tands at the left side of the table.169).. P. F ig ure 10. 3.com/pt/re/9780781763714/bookContent. Step 5. 86 of 134 21/08/07 22:07 .http://thepointeedition. T he patient's r ight hip and k nee are flexed.lww. 4. and the r ight foot is on the lateral as pec t of the left knee.170.

10.com/pt/re/9780781763714/bookContent. O nce the patient has c ompletely r elax ed. F ig. 9.172.lww. 6. T he patient lifts the r ight k nee towar d the c eiling (b lack ar row. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s F ig ure 10. F ig.172) to the edge of the new r estric tive barrier. 10. T his isometr ic c ontr action is maintained for 3 to 5 s econds. 5.171) while the phys ician applies an equal c ounterforc e ( white arrow). 8. F ig.http://thepointeedition. 7. Step 7.. 87 of 134 21/08/07 22:07 . Steps 5 to 7 ar e r epeated three to fiv e times .170) until the edge of the r estr ictive barrier is r eached. 10. and then the patient is instr ucted to relax. ar row. the physician further ex ter nally r otates the hip ( white arrow..

and the r ight hand abduc ts the patient's r ight leg. 2. Right s uper ior pubic shear dy s function. P.174. 10.com/pt/re/9780781763714/bookContent. and the physician s tands at the r ight side facing the patient. Steps 1 to 3. T he phys ician's left hand is placed on the patient's left ASIS to s tabiliz e the pelvis.http://thepointeedition. F ig ure 10.lww. allowing it to dr op of the edge of the F ig ure 10.. right s ide close to the edge of the table. of the technique.173..173) T ech niq u e 1. Patient lies s upine.2 37 Pelv ic R egion: Right Superior Pubic Shear Dy sfunction: Mus cle C ontrac tion Mobilizes Ar tic ulation Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Right pubic tuber c le c ephalad (F ig. 88 of 134 21/08/07 22:07 .

table. F ig. 10. the physician r epos itions the patient's leg further toward the floor ( white ar row. 3.http://thepointeedition. 10. O nce the patient has c ompletely r elax ed. Step 6.lww. T he phys ician places the r ight hand jus t pr oximal to the patient's r ight k nee and gently pr ess es down ( white arrow. Step 4. T his isometr ic c ontr action is maintained for 3 to 5 s econds after which the patient is instr ucted to st op and relax. isometric c ontraction..com/pt/re/9780781763714/bookContent.176) to the F ig ure 10. 6. 5.174) on the r ight k nee until the edge of the r estr ictive barrier is r eached.175) while the physician applies an equal c ounterforc e ( white arrow). 4. F ig.176. 89 of 134 21/08/07 22:07 . F ig..175. F ig ure 10. 10. T he patient lifts the r ight k nee towar d the c eiling and s lightly medially ( blac k arrow.

Steps 4 to 6 ar e r epeated three to fiv e times . edge of the new r estr ictive barrier.2 39 Pelv ic R egion: Right Inferior Pubic Shear Dy sfunction: Mus cle C ontrac tion Mobilizes Ar tic ulation 90 of 134 21/08/07 22:07 . 8. Note: A left infer ior s hear looks s tatically similar to a r ight s uper ior shear but will display loss of s acr oiliac motion on the left side and s how a positiv e s tanding flexion test on the left. 7.lww.http://thepointeedition.. P..2 38 P. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.com/pt/re/9780781763714/bookContent.

Steps 1 and 2. T he phys ician's r ight hand flexes and inter nally r otates the patient's r ight hip as the physician places the left thenar eminence beneath the patient's r ight is chial tuber osity to c r eate a fulcr um (F ig . F igure 10.http://thepointeedition.179) until the edge of the r estr ictive F igure 10..179.177.lww. T he phys ician's r ight hand flexes the patient's r ight hip ( white ar row. Right inferior pubic shear dy sfunction. 3. 91 of 134 21/08/07 22:07 . F ig.. 2. T he patient lies s upine c los e to the left edge of the table. Step 3. and the phys ician s tands on the left fac ing the patient.178). 10.178.com/pt/re/9780781763714/bookContent. Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right s acr oiliac motion Pubic tuber cle on r ight is caudad ( F ig.177) T ech niq u e 1. 10. 10. F igure 10.

2.2 40 PELVIC R EGION: Fix ed Com pre s sion of the Pubic Sy mphysis (Adducte d Pubic B ones ): Mus c le Contra c tion Mobilize s A rticula tion Diag nosis Suspicion of dysfunc tion by history (tr auma. with the feet flat on the table. 10. T he patient lies s upine and the physician s tands at either s ide of the table. T he patient pulls both F ig ure 10. F ixed c ompr ess ion of the pubic symphy s is. 92 of 134 21/08/07 22:07 .com/pt/re/9780781763714/bookContent.183. Steps 1 to 3.182) T ech niq u e 1. P.lww.. T he patient's hips are flexed to approximately 45 degrees and the k nees ar e flexed to 90 degrees.182. F ig ure 10. 10. deliver y) Palpable bulging of the symphys eal c artilage T ender pubic s ymphys is May hav e ur inary trac t s y mptoms ( Fig . 4. pregnanc y.http://thepointeedition. T he phys ician s epar ates the patient's k nees and plac es the forearm between the patient's k nees ( F ig. 3.183)..

k nees medially ( adduct shown by black ar rows. T his isometr ic c ontr action is maintained for 3 to 5 s econds.185) . F ig. 10. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. Fig . the patient's k nees ar e s eparated s lightly far ther fr om the midline ( white arrows. 7. Step 4. F ig ure 10.185. 8. Steps 4 to 6 ar e r epeated three to sev en times .184) against the phys ician's palm and elbow ( white arrows) while the physician applies an equal c ounterforc e.com/pt/re/9780781763714/bookContent. 6. 5. F ig ure 10. 10..184. Step 6.2 41 Pelv ic R egion: Fix ed Gapping of the Pubic Sy mphy sis (A bduc ted 93 of 134 21/08/07 22:07 . O nce the patient has c ompletely r elax ed. and then the patient is instr ucted to st op and relax. P.http://thepointeedition. isometric c ontraction.lww..

Step 5. T he patient lies s upine. T he patient's hips are flexed to approximately 45 degrees and the k nees ar e flexed to about 90 degrees.com/pt/re/9780781763714/bookContent. Pubic B ones ): Mus c le Contra c tion Mobilize s A rtic ula tion Diag nosis Suspicion of dysfunc tion by history (tr auma. and the physician s tands beside the table. and the phys ician gr asps the later al aspect of the other k nee with both F igure 10. 10. 94 of 134 21/08/07 22:07 .187.186. 3..188.. with the feet flat on the table. is ometric c ontr actions . pregnanc y.lww. 2. F igure 10.http://thepointeedition. Steps 1 to 4. deliver y) Sulc us deeper than normal at the pubic s ymphys is T ender pubic s ymphys is May hav e ur inary trac t s y mptoms ( Fig . Fix ed gapping of the pubic s y mphysis. 4.186) T ech niq u e 1. T he k nee c loser to the physician is placed against the phys ician's abdomen. T he patient's k nees ar e s epar ated by approximately 18 inches. F igure 10.

10. 7. Fig .188) against the phys ician's abdomen and hands while the physician applies an equal c ounterforc e ( white arrows) . Fig . 6.187). 8.com/pt/re/9780781763714/bookContent. O nce the patient has c ompletely r elax ed. F igure 10. 5.189. T he patient pulls both k nees later ally ( abduct shown by black ar rows. 9. 95 of 134 21/08/07 22:07 .http://thepointeedition. 10. Step 7. the physician approximates the patient's k nee 3 to 4 inches ( white ar rows. hands (F ig.. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.lww.. 10.189). T his isometr ic c ontr action is maintained for 3 to 5 sec onds . and then the patient is instr ucted to st op and relax. Steps 7 to 9 ar e r epeated thr ee to seven times.

Innervat ion T he ventral r ami of lumbar nerv es ( L1 to L3) innervate the psoas major. 96 of 134 21/08/07 22:07 ...com/pt/re/9780781763714/bookContent. Action T he psoas major flexes the thigh and trunk and flex es the v ertebr al c olumn laterally.lww.2 42 Pelv ic R egion: Hip Re gion: Psoa s Major and Psoa s Minor Mus cle s Psoas Major O rig in T he origin of the psoas major is at the body of 12th thorac ic v ertebr a and the transverse proc ess es and bodies of the firs t four lumbar v ertebr ae ( Fig . Insertio n T he ins ertion of the psoas major is at the less er troc hanter of femur. Psoas Minor O rig in T he origin of the psoas minor is at the bodies F igure 10.190.http://thepointeedition. 10. Psoas major and psoas minor muscles (8) .190) . P.

lww. Insertio n T he ins ertion of the psoas minor is at the iliac fasc ia and the iliopec tineal eminenc e. 10..2 43 Pelv ic R egion: Hip Re gion: Ilia cus Mus cle 97 of 134 21/08/07 22:07 . of 12th thorac ic and fir s t lumbar v ertebr ae ( Fig . Action T he psoas minor helps the psoas major flex the pelvis and lumbar r egion of the v ertebr al c olumn. P.190) .http://thepointeedition.com/pt/re/9780781763714/bookContent.. Innervat ion T he ventral r amus of L1 innervates the psoas minor .

P..lww.191). O rig in T he origin of the iliacus mus cle is at the iliac foss a ( inner s urface of iliac bone) and the lateral aspect of the sac r um ( Fig . Insertio n T he ins ertion of the iliacus musc le is at the less er troc hanter of femur. F igure 10.com/pt/re/9780781763714/bookContent.191. Iliacus muscle (8). Acute D ysfunc tion: R eciproc al Inhibition 98 of 134 21/08/07 22:07 .. Innervat ion T he femoral nerv e ( L2 and L3) innervates the iliacus musc le.2 44 Pelv ic R egion: Hip Re gion: Psoa s Musc le. Action T he iliacus musc le flex es the thigh at the hip and s tabiliz es the joint in c onjunc tion with the iliopsoas. 10.http://thepointeedition.

194. F igure 10. 3. F ig. Step 3.193. ex tending the hip to the edge of the r estr ictive barrier. plac es the hands on the patient's dy sfunctional thigh just pr oximal to the k nee (F ig. T he patient pushes the leg very gen tly down toward the floor ( blac k ar row..192). Patient lies s upine near the end of the tr eatment table s o that the dy sfunctional leg may hang ov er the end of the table. Steps 1 and 2. F igure 10. T he phys ician. 10.192. T he phys ician gently positions the patient's thigh towar d the floor (white ar row.com/pt/re/9780781763714/bookContent.http://thepointeedition. 10.lww.194) while the phys ician F igure 10. 2. T he patient flex es the other hip. s tanding at the end of the table. br inging the k nee to the c hest. is ometric c ontr action. 1. 99 of 134 21/08/07 22:07 .193). T his k eeps the lumbar lordosis flattened. 4. 10.. F ig. Step 4.

100 of 134 21/08/07 22:07 . F ig ure 10. Steps 1 to 3. T he phys ician flexes the patient's k nee on the s ide to be tr eated 90 degrees and then grasps the patient's thigh just above the k nee. T he phys ician's c ephalad hand is placed ov er the patient's s acrum to s tabiliz e the pelvis ( Fig . T he patient pulls the thigh and k nee down ( blac k arrow. 10. F ig. T he patient lies pr one and the physician s tands beside the table. engaging the edge of the r estr ictive barrier.. T he phys ician's c audad hand gently lifts the patient's thigh upwar d ( white ar row.http://thepointeedition. 3.196. 2.196).197.com/pt/re/9780781763714/bookContent. isometric c ontraction.197) until the psoas muscle begins to stretch. Subacute or C hronic D ysfunc tion: Post Isometric Relaxa tion 1. P. F ig ure 10. Step 4. 5. Step 5..2 45 Pelv ic R egion: Hip Re gion: Psoa s Musc le.198. F ig. 4.198) into the F ig ure 10. 10.lww. 10.

9. and then the patient is instr ucted to st op and relax.. F ig ure 10. Step 7. F ig.2 46 Pelv ic R egion: Pir iformis Muscle 101 of 134 21/08/07 22:07 ..199. Success of the technique is deter mined by r eevaluating passive hip ex tension. 7.199). 10. O nce the patient has c ompletely r elax ed. T his isometr ic c ontr action is held for 3 to 5 s econds. P. physician's c audad hand.com/pt/re/9780781763714/bookContent. 8. 6.lww.http://thepointeedition. which applies an unyielding c ounterforc e ( white arrow). Steps 5 to 7 ar e r epeated three to fiv e times or until motion is maximally improved at the dy sfunctional hip and psoas. the physician ex tends the patient's hip to the edge of the new r estric tive barrier (w hite ar row.

. P. Anterior v iew of pir ifor mis muscle (8). F igure 10.lww.200).201.. 10. Posterior v iew of pir iformis muscle (8).2 47 Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle . O rig in T he origin of the pir ifor mis musc le is at the anterior s urface of the s acr um and the s uperior margin of greater ischiadic ( sciatic ) notc h ( Fig . A c ute Dy sfunction: R eciproc al Inhibition 102 of 134 21/08/07 22:07 . F igure 10. 10.201). and it assis ts in holding the femoral head in the acetabulum ( Fig .http://thepointeedition.com/pt/re/9780781763714/bookContent. Insertio n T he ins ertion of the pirifor mis musc le is at the greater troc hanter of the femur.200. Action T he pir ifor mis musc le r otates the thigh laterally and abducts it.

202). Step 4. 4. T he phys ician palpates the dy sfunctional piriformis muscle with the c ephalad hand. 10. 5. gr asps the patient's ankle with the caudad hand.http://thepointeedition.204) to the later al aspect of the patient's ankle agains t the phys ician's c audad hand. 2. F igure 10. and flexes the patient's k nee 90 degrees ( F ig. Step 3. 10. which applies an unyielding c ounterforc e ( white arrow).202. 10. is ometric c ontr action. F igure 10. F ig.203. T his isometr ic c ontr action is F igure 10.lww.203) fr om the midline until the edge of the r estric tive barrier is r eached. T he patient very gen tly pulls the ankle away from the midline (b lack ar row. Steps 1 and 2.. 103 of 134 21/08/07 22:07 . 1.204.. T he patient lies pr one and the physician s tands beside the table. 3. F ig. T he phys ician s lowly moves the patient's ankle away ( white arrow.com/pt/re/9780781763714/bookContent.

until the piriformis begins to s tretch. 4. T he patient's r ight hip and k nee are flexed s o that the foot on the dy sfunctional s ide may be placed later al to the unaffec ted k nee. T he patient lies s upine. O n the s ide of dy sfunction. 3. the physician's c audad hand pulls the patient's r ight k nee toward the midline. Step 5. engaging the edge of the F igure 10. F igure 10. inter nally r otating the hip.206). and the physician s tands at the s ide of the patient opposite the s ide to be tr eated. 2.lww.207..2 48 Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle . T he phys ician's c ephalad hand is placed on the patient's ASIS on the s ide of dy sfunction to s tabiliz e the pelvis ( Fig . A c ute Dy sfunction: R eciproc al Inhibition 1. Steps 1 to 3.208.206..http://thepointeedition. 10. F igure 10. 104 of 134 21/08/07 22:07 . is ometric c ontr action. Step 4. P.com/pt/re/9780781763714/bookContent.

Steps 5 to 7 ar e r epeated thr ee to five times or until motion is maximally F igure 10. Step 7. F ig. F ig. 10. 8.209). T his isometr ic c ontr action is held for 3 to 5 s econds. which applies an unyielding c ounterforc e ( white arrow). 6. 10.209. r estr ictive barrier (F ig .com/pt/re/9780781763714/bookContent. the physician r epos itions the k nee far ther ac ros s the midline. 105 of 134 21/08/07 22:07 ..lww.. inter nally r otating the hip to the edge of the new r estr ictive barrier (w hite ar row. 5. and then the patient is instr ucted to relax. 10. 7. T he patient very gen tly pushes the r ight knee towar d the midline (b lack ar row.207).208) to the medial aspec t of the patient's k nee agains t the phys ician's c audad hand.http://thepointeedition. O nce the patient has c ompletely r elax ed.

9.http://thepointeedition. improved at the dy sfunctional hip and piriformis. 106 of 134 21/08/07 22:07 . 10. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. T he phys ician's c audad hand flexes the patient's k nee 90 degrees and s lowly moves the patient's ankle away F igu re 10. 3. Subac ute or Chr onic D ysfunc tion: Post Isometric Relaxa tion 1.210). P..com/pt/re/9780781763714/bookContent.lww. 2. T he phys ician palpates the dy sfunctional piriformis muscle with the c ephalad hand and gras ps the patient's ankle with the caudad hand (F ig. T he patient lies pr one on the tr eatment table. Steps 1 and 2. and the physician s tands beside the table..210.2 49 Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle .

http://thepointeedition. F igu re 10. inter nally r otating the dy sfunctional hip until the piriformis muscle begins to stretch. 107 of 134 21/08/07 22:07 . T his isometr ic c ontr action is held for 3 to 5 s econds. which applies an unyielding c ounterforc e ( white arrow). isometr ic c ontrac tion.211). 10. the physician r epos itions the ankle farther away from the midline. 4.211.com/pt/re/9780781763714/bookContent.lww. Step 6.212) to the medial aspec t of the patient's foot and ank le. and then the patient is instr ucted to relax. engaging the edge of the r estr ictive barrier (F ig . 5. Step 4. F ig. 6.. T he patient pushes the r ight ankle towar d the midline (b lack ar row. fr om the midline. F igu re 10.213. 10. inter nally r otating the hip F igu re 10. Step 3.212. against the physician's c audad hand. O nce the patient has c ompletely r elax ed..

to the edge of the new r estr ictive barrier (w hite ar row.http://thepointeedition.213).214. Steps 1 to 3.2 51 Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle . F ig. 108 of 134 21/08/07 22:07 . 2. Subac ute or Chr onic D ysfunc tion: Post Isometric Relaxa tion 1.. Steps 4 to 6 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional hip and piriformis. 8.2 50 P. 10.lww.com/pt/re/9780781763714/bookContent.. P. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. T he patient lies s upine and the physician s tands at the s ide of the patient opposite the s ide to be tr eated. 7. T he patient's hip and knee ar e flex ed s o that the foot on the dy sfunctional F igure 10.

5. F ig. F igure 10. s ide may be placed later al to the unaffec ted k nee. Step 7.lww.com/pt/re/9780781763714/bookContent. 4. which applies an unyielding c ounterforc e ( white arrow). T he phys ician's c ephalad hand is placed on the patient's ASIS on the s ide of dy sfunction to s tabiliz e the pelvis ( Fig .216. T his isometr ic F igure 10. 10. 10. Step 4.216) to the later al aspect of the patient's k nee agains t the phys ician's c audad hand. F ig.http://thepointeedition.. O n the s ide of dy sfunction.217. 10. 3. the physician's c audad hand gently pulls the patient's k nee towar d the midline (w hite ar row. 109 of 134 21/08/07 22:07 .215). T he patient pulls the k nee away from the midline (b lack ar row. is ometric c ontr action. F igure 10. inter nally r otating the hip until the piriformis begins to s tretch engaging the edge of the r estr ictive barrier.. 6.214).215. Step 5.

8. O nce the patient has c ompletely r elax ed. 9.2 52 P..lww.http://thepointeedition. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. 10.2 53 Sacr al R egion: For war d Tors ion About a Le ft Oblique Ax is (Left on Left): C ombine d R e ciproc al Inhibition and Muscle Contr action Mobilize Ar tic ula tion 110 of 134 21/08/07 22:07 . F ig. inter nally r otating the hip to the edge of the new r estr ictive barrier (w hite ar row. P. Steps 5 to 7 ar e r epeated thr ee to five times or until motion is maximally improved at the dy sfunctional hip and piriformis. c ontr action is held for 3 to 5 s econds. 7. and then the patient is instr ucted to st op and relax. the physician r epos itions the k nee far ther ac ros s the midline..com/pt/re/9780781763714/bookContent.217).

facing the patient. Left.218. 10. 3.on-left sac ral torsion. and feet on the anter ior thigh.http://thepointeedition. The hips and k nees ar e flexed to 90 degrees. anterior right Inferior later al angle ( ILA): s hallow. with the c hes t down on the table as much as possible and the r ight ar m hanging over the table edge..218) T ech niq u e 1. F igu re 10. F igu re 10. 111 of 134 21/08/07 22:07 . T he phys ician gently lifts the patient's k nees and r ests the k nees . Diag nosis Seated flex ion tes t: positiv e right Sacr al s ulc us: deep.lww.. legs .com/pt/re/9780781763714/bookContent. posterior left Spring test: negative Sphinx test: less asymmetr y L5 NSLRR Left-on.219. T he phys ician s its on the right end of the table near the patient's buttocks . Steps 1 to 4. T he patient lies in the left modified Sims position on the s ide of the named oblique ax is. 2.left s acr al tors ion (F ig.

2 54 P. 112 of 134 21/08/07 22:07 ..lww. Steps 1 to 3. T he phys ician s its on the edge of the table behind the patient and r ests the patient's k nees s lightly onto the F igu re 10. posterior Spring test: negative Sphinx test: less asymmetr y L5 NSRRL Right-on-right sac ral tors ion (F ig. 2. anter ior Right ILA: shallow.224.com/pt/re/9780781763714/bookContent.http://thepointeedition. P. 10.on. Right.right s acr al tors ion.2 55 Sacr al R egion: For war d Tors ion About a Right Oblique A xis (Right on R ight): Com bine d R eciproc al Inhibition and Muscle C ontr action Mobilize Ar tic ula tion Diag nosis Seated flex ion tes t: positiv e left Left sac ral sulcus : deep..225. with the c hes t down on the table as much as possible and the left ar m hanging over the table edge.224) T ech niq u e 1. The hips and k nees ar e flexed to 90 degrees. F igu re 10. T he patient lies in the r ight modified Sims position on the s ide of the named oblique ax is.

5. 10. 10. T he phys ician's c ephalad hand palpates the L5-S1 inter spinous s pace while the c audad hand flexes and ex tends the patient's hips until L5 is felt to be neutr al r elative to S1 ( F ig.http://thepointeedition. 3. isometr ic c ontrac tion.226).228. F igu re 10. 10. T he phys ician instr ucts the patient to lift both feet s traight up towar d the c eiling with a gentle but s ustained force ( blac k arrow.com/pt/re/9780781763714/bookContent.lww. 6. 113 of 134 21/08/07 22:07 . F igu re 10. 4. Step 5. 10. F ig. r ight anter ior thigh.227.228) against the F igu re 10. T he patient inhales and ex hales deeply three times .. Step 4.225).226. r eaching with the left hand towar d the floor after each ex halation ( Fig . F ig..227) until the edge of the r estr ictive barrier is r eached. Step 6. T he phys ician's c audad hand gently lower s the patient's feet (w hite ar row.

8.229) to the edge of the new r estric tive barrier. and then the patient is instr ucted to st op and relax. F ig. physician's unyielding c audad hand ( white arrow). 7.http://thepointeedition. T his isometr ic c ontr action is maintained for 3 to 5 sec onds . the physician gently lower s both feet towar d the floor ( white arrow. 9. O nce the patient is c ompletely r elax ed..229. Steps 6 to 8 ar e r epeated thr ee to five times. T his contrac ts the left hip inter nal rotators and the right hip ex ter nal r otators . 10.2 56 114 of 134 21/08/07 22:07 . P. 10.. F igu re 10. Step 8. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.lww.com/pt/re/9780781763714/bookContent. which ar e both antagonists to the left piriformis muscle.

anterior Spring test: positiv e Sphinx test: more asymmetr y L5 E/FRLSL Right-on-left s acr al tors ion ( Fig . F igu re 10.230..http://thepointeedition. 2..left s acral tors ion. 115 of 134 21/08/07 22:07 .231.lww. T he patient lies in the left later al r ecumbent position with the r ight hip and k nee s lightly flexed in fr ont of the left leg. P. A. 10.230) T ech niq u e 1. T he physician s tands facing the patient's pelvis.2 57 Sacr al R egion: Ba c kwa rd Tor s ion About a Left Oblique A xis (Right on Left): C ombine d Re ciproc a l Inhibition and Mus cle Contr a ction Mobilize Ar tic ula tion Diag nosis Seated flex ion test: positive right Right s acral s ulc us: pos ter ior . F ig ure 10.com/pt/re/9780781763714/bookContent. and the c ephalad hand palpates the L5-S1 inter spinous s pace while the c audad hand gently Right.on. Steps 1 to 3. s hallow Left ILA: deep.

lww. F ig ure 10. moves the left leg posteriorly .231). F igure 10. 116 of 134 21/08/07 22:07 .http://thepointeedition. ex tending the hip until motion is felt at the L5-S1 inter space. 5. T he physician's c audad hand moves the patient's r ight foot off the table and applies gentle pr ess ure on the patient's r ight knee ( white arrow. isometr ic c ontrac tion.com/pt/re/9780781763714/bookContent. B.. Step 6. F ig ure 10. T he physician's c audad hand and forearm s tabiliz e the patient's pelvis as the patient gently r otates the tr unk to the r ight (F ig. Step 5. the patient r eaches back with the r ight ar m and s houlder . 3. T he patient inhales and ex hales deeply three times . 4.232.233.. r otating the tr unk to the r ight to derotate L5. 10. Step 4. After each ex halation.231.

232) to the edge of the r estr ictive barrier.com/pt/re/9780781763714/bookContent. 7.234. the physician gently lower s the r ight foot towar d the floor until a new r estr ictive barrier is Step 8.233) against the physician's unyielding c ounterforc e of the c audad hand ( white ar row). T he physician instr ucts the patient to lift the r ight k nee str aight up towar d the c eiling with gentle but s ustained force (blac k ar row.. 117 of 134 21/08/07 22:07 . O nce the patient has c ompletely r elax ed. 8. T his is ometric c ontr action is maintained for 3 to 5 s econds.http://thepointeedition. 10. 10.. F ig ure 10. F ig.lww. 6. F ig. and then the patient is instr ucted to st op and relax.

Steps 6 to 8 ar e r epeated three to fiv e times .2 58 P.http://thepointeedition. 9. 10. r eached ( white arrow... 10. T he diagnostic parameters of the dy sfunction ar e r eevaluated to deter mine the effec tiv enes s of the technique.2 59 Sacr al R egion: Ba c kwa rd Tor s ion About a R ight Oblique Axis (Left on R ight): Com bine d R eciproc al Inhibition and Muscle C ontr action Mobilize Ar tic ula tion 118 of 134 21/08/07 22:07 .234) .com/pt/re/9780781763714/bookContent.lww. F ig. P.

posterior Right ILA: deep. ex tending the hip until motion is felt at the L5-S1 inter space. T he patient is in the r ight later al r ecumbent position with the pelv is c los e to the edge of the table and the left knee r esting slightly flexed on the table in fr ont of the r ight leg.right sac r al tors ion (F ig. and the c ephalad hand palpates the L5-S1 inter spinous s pace while the c audad hand gently moves the patient's r ight leg posteriorly .235. 3.com/pt/re/9780781763714/bookContent. T he phys ician's F igure 10.236... 119 of 134 21/08/07 22:07 . Left-on-right sac ral tor sion.lww.http://thepointeedition. F igure 10. Diag nosis Seated flex ion tes t: positiv e left Left sac ral sulcus : s hallow. 2. T he phys ician s tands facing the patient's pelvis. 10.235) T ech niq u e 1. anterior Spring test: positive Sphinx test: more asymmetr y L5 E/FRRSR Left-on. Steps 1 to 3.

R espiratory A ssist 120 of 134 21/08/07 22:07 .2 60 P.2 62 P.com/pt/re/9780781763714/bookContent.1 ou tlin es sacral torsio n d ysfu nct ion s ab out an obliqu e axis.http://thepointeedition.2 63 Sacr al R egion: Unilatera l Flexe d Sacr um on the Left.. P. Tab le 10.. P.2 61 Sacr al R egion: Ov e rview of Sacr al Tor s ion Dy sfunction T ab l e 10.1 ou tli nes s ac r al tor s io n d y s fu nct i on s ab out an obl i qu e a x i s.lww.

Steps 1 to 3. and the patient maintains this abduc ted. F igu re 10. posterior Spring test: Negative Sphinx test: Decr eas ed asymmetr y T ech niq u e 1. T he patient lies pr one and the physician s tands at the left side of the table.242. 121 of 134 21/08/07 22:07 . anter ior Left ILA: Dors al.http://thepointeedition.. F igu re 10. Step 4. F igu re 10. T he index finger of the physician's c ephalad hand palpates the patient's left s acral s ulc us ( F ig.pac k ed position for the left sac roiliac joint (usually about 15 degrees of abduc tion).com/pt/re/9780781763714/bookContent. 2.243.241) while the c audad hand abduc ts and adduc ts the patient's left leg to find the loosest.. 3. 10.241. Step 2.lww. Diag nosis Seated flex ion tes t: Positiv e left Left sac ral sulcus : Ventral. T he phys ician inter nally r otates the patient's left hip.

T he index finger of the physician's c ephalad hand palpates the patient's left s acral s ulc us while the c audad hand abduc ts and adduc ts the patient's left leg to find the loosest. P. F igure 10.lww. 122 of 134 21/08/07 22:07 .pac k ed position for the left sac roiliac F igure 10. anterior Spring test: Positive Sphinx test: Incr eas ed asymmetr y T ech niq u e 1. F igure 10.2 64 P.http://thepointeedition. Step 4.2 65 Sacr al R egion: Unilatera l Ex tended Sa c rum on the Le ft..250. Step 4.com/pt/re/9780781763714/bookContent.248. T he patient lies in the s phinx position ( propped up with the elbows s upporting the upper body) . pos ter ior Left ILA: Ventral.249. R espira tory As sis t Diag nosis Seated flex ion tes t: Positiv e left Left sac ral sulcus : Dors al. Steps 1 to 3.. and the physician s tands at the left side of the table. 2.

249) and is r einforc ed by the c audad hand (F ig. T he hypothenar eminence of the physician's c ephalad hand is placed on the patient's left s acral s ulc us ( F ig. Steps 6 and 7.com/pt/re/9780781763714/bookContent. 5. 10. F igure 10. 123 of 134 21/08/07 22:07 . T he phys ician's hands ex ert a s ustained anter ior ( downwar d) force on the patient's left s acral s ulc us to r otate the s acrum anter ior ly. 4. joint (usually about 15 degrees of abduc tion).251).250). 3. 6. T he patient inhales and then ex hales forcefully. 10. 10.lww.248). Step 5. 10.. T he phys ician inter nally r otates the patient's left hip and instruc ts the patient to maintain this abduc ted. F igure 10.252. inter nally r otated pos ition throughout the tr eatment ( F ig.251.. and to disengage the lumbosac ral joint caudally ( F ig.http://thepointeedition.

the physician's hands increase the anterior force on the s acral s ulc us to pr event sac r al ex tension ( white ar row..lww. 10. Steps 5 to 7 ar e r epeated fiv e to s even times .com/pt/re/9780781763714/bookContent. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.252). 8. Re spir atory Ass ist 124 of 134 21/08/07 22:07 . P..2 66 P. the physician's hands encourage s acral flex ion ( white arrow. During inhalation. 9.252) . F ig. F ig. During ex halation. 7.2 67 Sacr al R egion: Bilate rally Flex ed Sac r um. T he patient inhales slowly. 10.http://thepointeedition.

T he phys ician applies a c ontinuous anter ior ( downwar d) force on the ILAs of the patient's s acrum. 10. Bilater ally flexed s acr um. anter ior Both ILAs: Dor sal.com/pt/re/9780781763714/bookContent.253.254. 3. 10.254).. 2. F igu re F igure 10. 10.http://thepointeedition. T he phys ician places the thenar and hy pothenar eminences of the c audad hand on the ILAs of the patient's s acrum ( Fig .lww. 10.256) . Step 2. posterior Spring test: Negative Sphinx test: Decr eas ed asymmetr y Bilater ally flexed s acr um ( Fig . T he patient lies pr one and the physician s tands beside the patient.. T he phys ician's c ephalad hand r einforc es the c audad hand ( F igs.255 and 10. 125 of 134 21/08/07 22:07 . 4.253) T ech niq u e 1. Diag nosis Sacr al r ock test: Positiv e Both sac ral sulci: Ventral.

T he patient inhales and F igure 10. 3. 10. P.lww. 2.259. 10.2 68 Sacr al R egion: Bilate rally Exte nde d Sa crum.258.. 10.259). anterior Spring test: Positive Sphinx test: More asymmetr y Bilater ally Ex tended s acr um ( Fig .. Res pira tor y A s sis t Diag nosis Both sac ral sulci: Dors al. F igure 10. 4. T he phys ician's other hand r einforc es the first hand ( Fig .261) is placed on the s acral s ulc i.com/pt/re/9780781763714/bookContent.260). 5. 10. A continuous anter ior ( downwar d) force (white ar row. T he phys ician places the index finger on the patient's left s acral s ulc us and the long finger on the r ight sacral s ulcus ( Fig . Step 2. 126 of 134 21/08/07 22:07 . Bilaterally extended s acr um. pos ter ior Both ILAs: Ventral. T he patient lies pr one and the physician s tands beside the patient.http://thepointeedition.258) T ech niq u e 1. F ig.

261. 7. Pr ona tion D y sfunction: Post Isom etr ic R ela xation 127 of 134 21/08/07 22:07 . Steps 4 to 6.2 69 Extr emities : Poste rior R adia l H ead. then exhales deeply. F igure 10. F igure 10. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique.260. Steps 4 to 6 ar e r epeated 7 to 10 times . Step 3. 8.lww... T he phys ician ex aggerates flexion dur ing ex halation and attempts to r esis t extension during inhalation. 6. P.com/pt/re/9780781763714/bookContent.http://thepointeedition.

T he phys ician's other hand lies palm up with the thumb r esting against the posterolater al as pec t of the r adial head ( F ig.com/pt/re/9780781763714/bookContent. 10. 128 of 134 21/08/07 22:07 . F ig.lww. is ometric c ontr action.262).264.. T he phys ician s upinates the patient's forearm until the edge of the r estr iction barrier is r eached (w hite ar row.264) while the physician applies an F igure 10. T he phys ician instr ucts the patient to attempt pr onation ( blac k arrow.263. 10. Steps 1 to 3. F ig.263) at the r adial head.. 5. T he patient is s eated. Step 5. and the physician s tands in fr ont of and to the s ide of the patient's dy sfunctional ar m.262. Step 4. T he phys ician holds the patient's hand ( handshake position) with the hand ipsilateral to the dy sfunction. F igure 10. 3. 2. F igure 10. 1. 10. 4.http://thepointeedition.

Supina tion D y sfunction: Post Isom etr ic R ela xation 1. is ometric c ontr action. F ig. 4. 10.268. 3. F ig. T he phys ician's other hand is palm up with the thumb r esting against the anterior and medial aspec t of the r adial head (F ig. 5. T he phys ician instr ucts the patient to attempt s upination ( blac k arrow. 129 of 134 21/08/07 22:07 . 10.. F igure 10.268) while the physician F igure 10. Step 4..266). T he phys ician pr onates the patient's forearm (w hite ar row.http://thepointeedition. 2.lww.266. T he patient is s eated.267.com/pt/re/9780781763714/bookContent.2 70 Extr emities : A nte r ior Ra dia l He ad. Step 5.267) until the edge of the r estr ictive barrier at the r adial head is r eached. T he phys ician holds the patient's hand ( handshake position) with the hand ipsilateral to the dy sfunction. F igure 10. and the physician s tands facing the patient. 10. Steps 1 to 3. P.

Steps 5 to 7 ar e r epeated thr ee to five times or until there is no further improvement in the r estric tive barrier. and then the patient is instr ucted to st op and relax. 10. 6.2 71 130 of 134 21/08/07 22:07 .269) while ex aggerating the posterior r otation of the r adial head with the left hand ( white arrow). F igure 10.. 8. applies an unyielding c ounterforc e ( white arrow). 9..lww. O nce the patient has c ompletely r elax ed. 7.http://thepointeedition. P. F ig. the physician pr onates the patient's forearm to the new r estric tive barrier (w hite ar row.com/pt/re/9780781763714/bookContent. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. T his isometr ic c ontr action is held for 3 to 5 s econds. Step 7.269.

and the phys ician s tands or sits at the side of dy sfunction. T he phys ician plac es the hand closes t to the k nee in the popliteal fossa so that the metac arpal.271) until the fibular head meets its anter ior res trictive barrier. 131 of 134 21/08/07 22:07 .. Steps 1 and 2. 10. 4. F ig.270). 6. F ig. O nce the patient has c ompletely r elaxed. T he patient internally r otates (b lack arr ow. Step 4.http://thepointeedition.lww. 10. 2. 3. isometric c ontrac tion. and then the patient is instr ucted to stop an d relax. T his isometr ic c ontr action is held for 3 to 5 s econds.phalangeal joint of the index finger appr oximates the posterior prox imal fibula ( head) ( Fig . F ig.270. Extr emities : Poste rior Fibular Hea d D y sfunction: Post Isom etr ic R ela xation 1. 5.. F igu re 10. F igu re 10. Step 3.272) the lower leg as the phys ician applies an unyielding c ounterforc e (white ar row).com/pt/re/9780781763714/bookContent. the phys ician attempts to move the fibula ( white arrow.272.271. F igu re 10. exter nally r otating the patient's lower leg ( white arrow. T he patient lies s upine or sits with the lower legs off the table. T he phys ician's other hand controls the patient's foot and ankle. 10.

lww. T he phys ician's other hand c ontr ols the patient's foot F igure 10.273.273) to the new. 3.. P..274. T he diagnos tic parameters of the dy sfunction are r eevaluated to deter mine the effec tiv enes s of the technique.http://thepointeedition.274). 8. Steps 1 and 2. and the physician s tands or s its at the s ide of dy sfunction. 10. 132 of 134 21/08/07 22:07 . 2. Step 6. Steps 4 to 7 ar e r epeated thr ee to fiv e times or until there is no further improvement in the r estr ictive bar rier.2 72 Extr emities : A nte r ior Fibula r H ead Dy s function: Pos t Isom e tric R ela xation 1. T he phys ician places the hand that is near er to the k nee ov er the anter olater al pr oximal fibular head (F ig. F igu re 10. 10. ex ter nal rotation r estr ictive bar rier. 7.com/pt/re/9780781763714/bookContent. T he patient lies s upine or s its with the lower legs off the table.

F ig. Step 3. 133 of 134 21/08/07 22:07 . the physician attempts to move the fibula to the new inter nal rotation r estr ictive barrier (w hite ar row. Step 6.277).lww.276.http://thepointeedition.275. F igure 10. Steps 4 to 6 ar e r epeated thr ee to five times or until there is no further F igure 10. 10. F igure 10. Step 4. and ankle and inter nally r otates the patient's lower leg ( white ar row.276) the lower leg as the physician applies an unyielding c ounterforc e ( white arrow). 4. F ig.com/pt/re/9780781763714/bookContent.. 7. 10. 10. O nce the patient has c ompletely r elax ed. T he patient ex ter nally r otates (b lack ar row. T his isometr ic c ontr action is held for 3 to 5 s econds.275) until the fibular head meets its posterior r estr ictive barrier. F ig. and then the patient is instr ucted to st op and relax.. 6. 5.277. is ometric c ontr action.

Eas t L ansi ng. Eas t L ansi ng. P.2 73 R efe renc es 1. Berl i n: Sp r i ng er. Gr een m an P. Int r odu c ti on to M anu al M edi c in e. MI : ME T .lww. Mi tch el l F L J r. 6. 2. 199 8. MI : ME T . v ol 1. Wa r d R (e d). S i m on LS . v ol 3. Mi tch el l F L J r. Bal ti mo r e: Li ppin c ot t W i l li ams & W i lk i ns . improvement in the r estric tive barrier. B alt i m or e: W il l i am s & Wi l k in s . Bal tim ore : Li ppi nco tt W i ll i am s & W il k in s . v ol 2. Eas t L ansi ng. T he diagnos tic parameters of the dysfunc tion ar e r eev aluated to deter mine the effec tiv enes s of the technique. 1 999 . 2 003. M y ofa s ci al Pain an d Dy s fu nct i on: Th e T r i gg er Poi nt M anu al. 4. T ra v ell SG . Re pri nted wi th perm i ss i on fro m S i mo ns D G. 20 03. MI : ME T . Ba s ic C li nic al M ass age Th er ap y : In teg r at i ng Ana tom y an d T r ea tm en t. 7. 2n d ed . 199 5. Mi tch el l F L J r. 8. 199 8.. Ne uma nn H D .. T he Mu s cl e En erg y M anua l . 5. Pri nc ip l es of M an ual Me di ci ne. 134 of 134 21/08/07 22:07 . P hil adel phi a: Li pp i nc ott W il l ia m s & Wi l ki ns.http://thepointeedition. 199 6. 8.com/pt/re/9780781763714/bookContent. T he Mu s cl e En erg y M anua l . Fo unda tio ns for Ost eop athi c M edi c i ne . 3. T he Mu s cl e En erg y M anua l .Ver l ag. 19 89. Mo dif i ed w it h p er mi s si on fr om Cl ay J H . Pou nds D M.

w e beg an t o d efi ne H VLA as H AL D . th e p hys i c ia n m ust c om bin e a r ap i d ac c el er at i on fo r c e w it h o nl y m in i ma l mo v em ent of the ar ti cu l ar la ndma r k ( se gm en t) tha t is be i ng tr eat ed. Th e a utho r s hav e an af fin i ty for th e te r m m ob i l iz ati on w i th im pul s e. i t i s i m po r ta nt to r eme m be r th e fo l lo w i ng re l at i ons hip s b as ed on th e HA LD def i nit i on : Lo w d i s ta nce = s afe ty Hi gh ac ce l er ati on = su c ce s s It is app r op r ia te t o t hin k of os teo path i c m an i pul ati on as a fo r m of w ork . it is i mp ort ant to un ders tan d t he r ela tiv e su c ce s s and m or bid i ty fac tor s re l at ed to i ts per form anc e. As w e a r e m ost in ter es te d i n p er fo r mi ng a sa fe tec hniq ue w it h a s uc c es s ful ou tco m e. we ca n de not e t he H ALD (H VLA) fo r mu l a f or s uc c ess an d s afet y a s W = m ad Th ere fore . usi ng H AL D as th e e x pla nat i on of i ts fo r c es . a s w el l as the for c es at pla y i n i ts p r oc ess of tre ati ng m usc ulo s k el eta l d y s fu nct i on s . y et for na tio nal ter m in ol og i ca l i nteg r it y . U s i ng th i s as a ba s is . As we tau ght th e n ov ic e s tud ents to us e th i s tec hniq ue. a l so ca l l ed mo bil i z at i on wi th i m pu l se tre atm ent ” (1 ) . th eir id ea o f t his for c e wa s a s tr aig ht.com/pt/re/9780781763714/bookContent. H VL A is al s o l i st ed as thru s t tre atme nt i n the ECO P g l oss ary . s in c e i t m ore ac c ura tel y d es cr i be s th i s ty pe of ma ni pu l at i on . w e co nti nued to pr om ot e t he name of th e te c hn i qu e as HV LA. we be gan to use the te r m hi gh . Co m mo nly . fo r te ach i ng pu r po s es. d oes not tr uly def i ne th e na tur e o f th e i nit i ati ng for c e. l ow -d i st anc e te c hn i qu e (H ALD ) t o de s cr i be the te c hn i que pa r am eter s m ore acc ura tel y . we ca n us e t he f orm ula w or k = fo r c e × di st ance (W = fd). wh i ch i s a c ons tant . Fo r u s e o f t his v ar i et y o f os teo pat hi c m an i pu l ati v e tre atme nt ( as w it h o the r te c hn i qu es ).ve l oc i ty /l ow am pli tude fo r ce s .. fo r te ach i ng pur pos es . 11 High-Velocity.amp l it ude tec hni que ( HV LA) i s def i ne d by th e E duca tio nal C ou nci l o n Os teo pat hi c Pr i nc i ple s ( ECO P) a s “ a d i r ec t t ech ni qu e w hic h us es hig h. W e u s e this te r m to d esc r ib e th e f orc es a t p l ay bec aus e w e be l ie v e that ve l oc i ty. We be l i ev ed tha t th e t erm dis tan c e w as m or e e as il y u nde r s ta nda ble tha n am pl i tud e. c on s ta nt thru s t by the phy s ic i an. t o p er fo r m a s uc ce s sf ul and s af e H VLA tec hni que ( wo r k) . Low-Amplitude Techniques Techni que Pri nci ples Hi gh. ac c el era ti ng to w ar d an d t hen m in i ma l ly thr oug h t he r est r ic ti ve ba r ri er ). it als o b eca m e a ppa r en t th at the i r a bil i ty to und ers tand th e ba s is of thi s t ec hn i qu e w as b ein g u nder m in ed by t he ter m ve l oc i ty . l ow. or W = m ad In th i s f orm ula . Th us.. T he di s tan c e i n this fo r mu l a s hou l d be o nly en ough to mo v e t he dys func tio nal art i cu l ar s eg m en t 1 of 87 21/08/07 22:09 . W e bel i eve it is mo r e ac cu r at e t o de fin e t he i nit i at i ng for c e by ac ce l er atio n ( dv/dt. ac c el era ti on is th e su c ce s s fact or and dis tan c e i s t he s af ety fac tor .v elo c it y . we ca n su bst i tu te m ass an d ac c el era ti on fo r f or ce in th e wo r k for m ula an d c oncl ude th at wo r k = ma s s × a c c el era tio n × dis tan c e. a r api d in c re ase i n v el oci ty w i th re s pe c t t o t i me . In an att emp t t o he l p ost eopa thi c m edic al s tu dent s u nde r s ta nd the s uc c es s a nd s afe ty fact ors in v olv ed wi th this te c hn i que . Kn owi ng t hat fo r c e = m ass × ac ce l er atio n ( f = m a) . T he r efo r e.lww.ac c el er at i on . wh i ch i s not ac c ura te.http://thepointeedition.

T hi s e ase bar r ie r m us t be an addi tio nal ( re s tr i ct i v e) co m po nent of th e dy s fu nct i on ( se e F i g. As th e s tude nt bec om es mo r e ac co m pl i sh ed a nd m as ters th e a bi li ty to s top at th e pr eci s e poin t n eed ed P. t he r est r ic ti ve ba r ri er th at i s e nco unt er ed wi th di re c t tec hniq ue i s oppo s it e t he f r ee dom by w hi c h the dys fun c tio n i s n am ed . th e p hys i c ia n m ust tak e t he ar ea of dy s fu nc ti on awa y fr om the m os t r est r i ct i ve ba r r ie r a nd i n t he dir ec ti on by w hic h i ts bi om ech ani c al pa r am eter s a r e desc r ib ed. If. an d si de.. Th er ef ore . Da v i d H ei l ig . H owe v er . b eca us e i t i s di ff i cu l t to l i mi t t he m oti on w hen yo u a r e h i gh l y ac ce l er ati ng ( 2). i t i s ap pro pri ate to i nc r eas e t he ac c el er at i on to m or e s ucc es sf ul m ob i l iz i ng le v els . t he phys i ci an s hou l d att em pt to mo v e t he s eg m ent as li ttle as po s s ib l e th r ou gh t his ba r r ie r . T his is in i ts elf a r est r ic tio n.com/pt/re/9780781763714/bookContent. Al so .. Mo s t pr ac tit i on er s k no w t hat w he n t hey att emp t to im pro v e a nd/ or r est ore mo ti on lo s s at t he j oi nt l eve l by us i ng thi s t ec hn i qu e. i t i s m or e i mp ort ant to use s ho r t di s ta nc e for sa fety ra the r th an hig h ac c el era ti on fo r s uc ce s s. Indirect Technique To tr eat the pa ti en t w i th i nd i re c t tech niq ue as d esc r ib ed e arl i er . F or ex amp l e.2 76 (i m me di at ely pa s t t he r es tr ic tiv e b ar ri er i n m i ll i me ter s of di s ta nc e) . a nd z . In s oma tic dy s fun c ti on. the dys fun c tio n i s de s cr i bed fo r i ts m oti on fr ee dom an d po s it i on i n the x. th r ou gh t he r es tr ic tiv e b ar ri er. t he mo bil i z in g f orc e us ed to c orr ect th e so m at i c dy sf unc tio n is di r ec ted tow ard the re s tr i c ti v e bar r i er . ro tat e to th e r es tr i ct i ve bar r ie r ( l eft ) . then ex ten d sl i gh tly to i nc l ud e th i s bar r i er . a n ar tic ula r po p d oes not me an that th e c or re c t art i c ul ati on w as m ob i li z ed.ben t ri ght . th e p hys i c ia n w oul d fl ex to the l ev el of t he dys func tio n. r ota ted r ig ht. I n t he e arl y s tage of le ar ni ng thi s te c hn i qu e. no t t he re m ai ni ng 5 deg r ees . the ph y s ic i an sh ould be mo s t i nte nt on t he pal pato r y qua l i ty an d q uant i ty of th e d y s fu nct i on al a r ti c ul atio n a s i t go es thr ough th e c or re c ti v e pr oc ess . to tre at a sp i na l dy s fu nct i on tha t h as b een de term i ne d t o be fl exe d. T her efo r e. ju s t that an ac ute m ov eme nt w as dir ect ed t o a jo i nt. t he pati ent ha s a gre ater te nde nc y to gua r d a gai nst the th r us t. To sa fely an d s uc ce s sf ull y tr eat a dy sf unc tio n wi th thi s di r ec t m etho d. M eet i ng all th r ee axi s b ar ri ers ma k es the jo i nt v er y r est r i ct ed. Th e l ac k of an audi ble so und doe s n ot m ean th at t he c or r ect i on wa s u ns uc c es s fu l . th e in dir ect bar r ie r c anno t b e t he n orm al ph y si ol og i c bar r i er op pos i te the re s tri c ti on. an ar ti c ul ar p op c an occ ur. T ha t is . b ut i t i s n ot the m os t re s tr i c te d b arr i er. 6. y.2 ) . DO . Th er e hav e b een m an y t heor i es as to the ca us e of th i s s oun d. no t to ca r ry i t thr oug h th e b arr i er and be y ond th e p hy si olo gic bar r ie r .http://thepointeedition.. a nd thi s ca n c aus e pa i n and s ti ffn ess pos t t r ea tm en t. If th i s b arr i er w er e t he phys i ol ogi c ba r ri er. A c orr ect i ve for c e tha t is ve c to r ed thr oug h on l y one or two of the ax es ofte n p r od uc es su c ce s s w i th mi ni ma l s i de eff ect s . th e c or re c ti v e tech niq ue i s t o u s e only en oug h fo r ce to m ov e t he s egm ent an add i ti ona l 1 deg r ee . i nc l udi ng c av i tat i on (c hang e i n s y nov i al fl ui d to a g as eo us s ta te) and a v acu um phe nome non (3 ) . HV LA i s m ost l y f r eq uen tl y des c ri bed as a d i r ec t t ech ni qu e. r efe r r ed to th i s a s g i vi ng th e s egme nt a nudge . a s egm ent th at n orm all y ha s 7 de gr ee s o f m otio n i s r es tr i ct ed at i ts 2-d egre e m oti on m ark .. i nc l ud i ng the ar tic ul ar ab nor m ali tie s . i t i s p r ob abl y wi s e to focu s o n on e o r tw o a x es and ke ep s ome fr eed om a v ai l ab l e i n t he r ema i ni ng ax is .ax es. Techni que Classi fication Direct Techni que In Am er ic an ost eopa thi c c i r cl es. I n ac c om pl is hin g t hi s c or r ec ti on . i nd i re c t tech niq ue w oul d b e 2 of 87 21/08/07 22:09 .lww. an d it be c om es m ore di ffic ult to m an i pu l at e sa fel y . but pro duc e o nl y s li ght s id e b end i ng to the bar r ie r t o ke ep tha t ax i s sl i gh tl y fre er ( s im i la r t o th e feat her ' s e dge des c ri bed i n C ha pte r 10 in re fere nce to m us c le en er gy te c hn i que s ). fo r e x amp l e. If usi ng H VLA in an i nd i re c t m ann er.

Sim ply pu t. i f t he dy sf unc tio n is at L1 . i t c an be m ov ed m ost ea s i ly pe r pe ndic ula r t o th e m ost re s tr i c te d d i re c tio n. the st anda r d for s et tin g t he b i om ech anic al for c e v ect ors i s det erm i ned by ho w th e se gme ntal le v el of the dy s fun c ti on i s t erm ed. Th i s l eft ro tat i on c an be ach i ev ed by r ota tin g L1 to th e le ft ov er L2 . art i cu l ar ca psu l e c han ges or m en i sc oi ds .com/pt/re/9780781763714/bookContent. In ot her dy s fu nc ti ons . Pa l pab l e tis s ue tex tur e ch ang es m ay be pre s ent ov er th e a r tic ula r a r ea i nv olv ed o r d i st al t o i t. ca usi ng s ome co m pr es si on at the fac et and s yn ovi um . M otio n a s ym m etr i es as s oci ate d w i th m ot i on l os s a r e the def i ni ti ve si gns of an art i c ul ar dys func tio n. In s om e d y s fu nct i on s . by de fi ni tio n L 1 is re s tr i c te d o n L 2. S ome tec hni que s se t t he fo r ce s fr om bel ow . co ntr ai nd i ca ted as a f orm of m an i pu l ati on. t he p hys i ci an m ay c ho os e to use s id e b end i ng as the dir ect i on of c ho i ce and ve c to r th e fo r ce i n tha t p l ane . fl exi on o r e x te ns io n i s u s ed. wh en the for c es c om e f r om bel ow. Sim i l ar l y. D i ag nost i c s ig ns t hat ar e a ttri but abl e to an ar ti cu l ar dy s fun c ti on ar e l os s o f or re duc ti on of in ters egm ent al j oin t m otio n a nd/ or qu ali tati v e c ha nges in jo i nt pla y o r jo i nt en d fe el. I n s ti ll ot her dys fun c ti ons.. me as ur es.re s tr i ct or m usc l e tens i on . by di r ec t me tho d i t mu s t m ov e to th e l eft. I f th e u ppe r se gme nt i s r ota ted i n the op posi ng dir ec ti on. F or exa m pl e. but the y d o no t n ece s s ar i ly me an t hat th e dy s fu nct i on i s ar tic ul ar . L1 m ust mo v e thro ugh it s re s tr i ct i v e bar r ie r (b i nd ) wh i le L2 i s eit her hel d s tabl e i n n eutr al or c arr i ed th r oug h t he desc r ib ed ease of L1 . P ain i s ano the r fi ndi ng that ma y b e pr ese nt but aga i n does no t d efin i ti v el y me an tha t an ar tic ul ar dy s fu nc ti on i s pr es ent . If the cu p is co m pr es se d. s hor t. m ot i on i n any di r ect i on pe r pen dic ula r to it s m aj or re s tr i c ti on ca n f ac il i ta te i ncr eas ed m oti on i n the j oi nt. Gre enm an ( 3) des c ri bes a n umb er o f po s si bl e eti olo gi es fo r j oi nt re s tr i c ti on. Ta k in g t he s egm ent be l ow to the dy s fun c ti ona l se gme nt' s de s cr i be d ea s e aug m ent s t he tech niq ue. c ar r y in g i t t ow ar d i ts barr i er . f or the tec hni que to be dir ec t. 3 of 87 21/08/07 22:09 .2 77 no t r otat i on . i f L 1 i s ro tat ed ri ght . as one ve c to r s f orc e t o an d t hro ugh the ar ti cu l at i on . Mo tio n en han c em ent at a j oi nt ma y b e pr odu c ed i n a m ann er s i mi l ar to r em ovi ng a su c ti on c up fro m a pi ece of gla s s. o r by ro tat i ng L2 to the r ig ht unde r L 1. T o tre at a dy s fu nct i on of L1 on L 2.. R ota tin g L 2 to th e l eft und er a st abi l iz ed L 1 w oul d be co nsi dere d a n i ndir ect HV LA t ech niq ue. I f t he s i de of th e ro tat i on al c omp one nt i s p l ac ed o ff the tab l e and the th r us t is ma de fr om belo w . n ot di re c t. L 2 i s n ot d y sf unc ti on al und er L 1. P.lww. Als o. Th es e i nc l ud e al ter ati on o f o ppo s i ng jo i nt s ur fac es.i nd uce d d y s fu nct i on i s c au s in g th e j oin t re s tr i ct i on. L 1 i s n ot d y sf unc ti on al as i t re l at es t o T 12. th e te c hn i qu e ma y b e e ffec tiv e be c au s e o f i ndi r ect . Mo s t H VLA te c hn i que s a r e perf orm ed by d i re c ti ng t he for c es fro m a bove . t he t ech niq ue d oes no t fo l lo w t he d efi nit i on of the dys fun c ti on an d a t be s t w as s uc c es s fu l be c au s e of u nin ten ded s id e-b endi ng eff ec ts . t he phy s i ci an m ay c ho ose to use a te c hn i que wh ose pri m ar y m otio n i s r otat i on to aff ect th e dy s fu nct i ona l m oti on c omp one nts. Techni que Styles In HV LA t ech niq ue.ba s ed tec hni que m ay be mo r e a ppr opr i ate .http://thepointeedition. H ow eve r . a nd n oci c ep tors . T hi s i s a c om m on m is c on c ep ti on wi th the l at era l re c um ben t lu m ba r te c hn i qu e. If a m y of asc i al . Indications HV LA i n g ene r al i s use d t o re s to r e m oti on to a pr evi ous l y m obi l e ar ti c ul ati on t hat is exh i bi tin g re s tr i c ti on i n al l or par t of it s i nter s eg m en tal r an ge of m oti on. a m yo fasc i al . pro duc i ng the su c ti on c up eff ec t. th e in fer i or s eg m en t mu s t be c arr i ed to w ard th e n am ed fr ee m oti on par am et ers of the dy s fu nc ti on. an d th e su per i or s eg m en t mu s t be c arr i ed to w ard th e r es tr i ct i ve bar r ie r .

Ac ho ndr opla s ti c d w arf i sm (c er vi c al sp i ne) General Consi derations and Rul es 4 of 87 21/08/07 22:09 .com/pt/re/9780781763714/bookContent. Os te oar thri tic jo i nt w it h a nk yl osi s 5. to r si on. J oin t i ns ta bil i ty 2. R heu m at oi d art hri ti s of the c er v ic al ( esp eci all y at C1 . J oin t r epla c em ent i n the ar ea t hat wi l l b e r ece i v in g c omp r ess i on . Atyp i ca l jo i nt or fac et and oth er c on di ti ons wi th a s so c ia ted c on gen i tal an oma l i es 7. M i ni m al dis c b ulg e an d/o r h er ni ati on w i th ra dic ul ar sy m pt om s 6. Os te oar thri tic jo i nts wi th m ode r at e m otio n l oss 4. 8. Seve r e di sc oge nic s po ndy l os i s w i th an k y lo s is 6.C2 ) re gio n 13..lww. Seve r e hern i at ed di sc wi th r adi c ul opa thy 10. bl ock ed v ert ebr a. or oth er s uch fo r c e fro m the pos i tio nin g a nd/o r t hru s t 7. t or si on.. Seve r e os te opo r os i s 3.F eil sy ndr om e. C ong eni tal ano m al i es s uc h a s Kl i pp el. Os te omy el it i s i n the are a t hat w il l b e re c ei v in g co m pr ess i on. Contrai ndi cations Rel ati ve Contrai ndicati ons 1. or oth er s uc h fo r ce and/ or thru s t 9. t ors i on .http://thepointeedition. Infe c ti on o f t he ti ss ues in the ar ea that wi l l be r ece i vi ng c omp r es s i on fr om the pos i ti onin g a nd/ or thru s t. M i ld to m od era te s tra i n or s pra i n i n the are a t o be tr eat ed 2. M eta s ta s i s i n the are a t hat w il l b e r ec ei v in g c om pr ess i on . a nd s o on 11. C ond i ti ons s uc h a s Do w n s yn dr om e ( esp ec ia l ly ce r v ic al s pi ne) 12. M i ld os teop eni a o r os teo por os is in th e ar ea tha t wi l l be r ece i vi ng c omp r es s io n. or oth er s uch fo r ce fro m t he posi tio ni ng an d/o r th r us t 4. Some hy perm obi l e s tat es Absolute Contrai ndicati ons 1. or anot her s uc h f orc e fr om the pos i ti oni ng a nd/ or thru s t 3. to r si on. R heu m at oi d dis eas e ot her th an i n t he s pin e 5.

a r ela tiv el y l on g l earn i ng cu r v e for co m pet enc e a nd u s er co nfid enc e.en han c i ng ma neu v ers if ne c ess ary (e .g. Steps 1 to 3. OA) Dysfunctions Exampl e: OA. HV LA tech niq ue i s o ne of the old est for m s of m anu al m ed i c in e a nd i s o ne tha t ha s b een s tu die d m os t i n te r ms of c li nic al r esp ons e.2 78 Cervical Regi on: Occipi toatlantal (C0—C1. W hen co nfid ent th at t he pat i ent is re l axe d a nd not gua r de d. es pec i all y i nte r s eg m en tal j oi nt m ot i on) . r est r ic ti on of mo ti on . 11.com/pt/re/9780781763714/bookContent. and the phy sic ian is seated or stands at the head of the table to the patient's right. pa tie nt's br eat hi ng . F/E or N-S LRR* 1. The physic ian rotates the patient's head to the left. 3. 4. 2. Shorthand Rul es 1. C ont r ol the ar ea s o t he pat i ent is co m for tab l e and r el axe d. Posi tio n to th e r es tr i ct i ve bar r ie r ( the edg e. 7.. The patient lies supine. i s om etri c c ont r act i on . 2.lww. t end er ne s s [TA R T ].http://thepointeedition. I t i s t he t ech niq ue t hat is l ea s t tim e co nsu m in g. 5 of 87 21/08/07 22:09 . P. a dd a r apid ac c el er at i ng (m obil i zi ng forc e) thru s t w it hi n the ar ti cu l at ory pla ne or pl an es of the j oi nt w i th to tal j oi nt m ov em en t k ept to the abs ol ut e m i ni m um. Loca l iz e th e s egm ent to be tr ea ted . as y mm etry of po s i ti on. 5. 6. 3. not the wa l l ). j aw c le nc hi ng and the n r ela x i ng ) . The head r esting on the forear m c reates a minimal s ide bending Fig ure 11. The physic ian places the left forearm under the patient's left-r otated head and with the left hand c ups the patient's chin ( Fig . 4.1).1.. R eas s es s th e c omp onen ts of the dys fun c tio n ( tis s ue tex tur e ab nor m al i ty. on the oth er ha nd.. D i ag nos e. U s e r el ease . I t d oes hav e.

3. hy pothenar eminence var iation.6) towar d the patient's left orbit. 6 of 87 21/08/07 22:09 . the phy sic ian delivers a thr ust (white ar row. T his thr ust is not linear but an arc .2. or thumb) is placed jus t posterior to the mas toid pr ocess.4) The physic ian us es both hands to ex ert continuous tr action (w hite ar r ows . Fig . hypothenar eminence. Fig ure 11. F ig. 11. thumb var iation. 6. into the r ight side-bending bar rier . 11. 11. 5.. MCP position. Fig ure 11.5). Fig ure 11. With the patient relaxed and not guarding. 11. This is k ey to a suc ces sful mobilization.2.http://thepointeedition.3. Step 5. Step 5. Step 5. 8.com/pt/re/9780781763714/bookContent. Effectiveness of the tec hnique is determined by reassessing motion at the oc cipitoatlantal articulations . 7.4.. The physic ian's right hand (metac arpo-phalangeal joint [MCP] of the index finger. (F igs. 11.lww.

http://thepointeedition...com/pt/re/9780781763714/bookContent. Step 7. P. Fig ure 11.lww. Fig ure 11.2 80 Cervical Regi on: Atl antoaxi al (C1—C2. Step 6.5. cephalad traction.6.2 79 P. AA) Dysfunction Exampl e: C1 RL 7 of 87 21/08/07 22:09 .

flexion. fur ther s lack may be tak en out of the soft tis sues.8.8). 1. Step 3. The phy sic ian's hands sandwich the patient's head. 8 of 87 21/08/07 22:09 . or extens ion with this r otation.7. F ig ure 11. 4. The physic ian rotates the patient's head to the right. 11.7) 3.. The patient lies supine. engaging the res trictiv e bar rier ( F ig. cradling both tempor opar ietal regions ( F ig. 5. Step 2. The patient c an be ask ed to breathe s lowly. F ig ure 11. Step 5. There is no side bending. 2..http://thepointeedition. a thr ust is delivered exaggerating F ig ure 11.lww. and at exhalation. 11.com/pt/re/9780781763714/bookContent. and the phy sic ian sits or stands at the head of the table.9. With the patient relaxed and totally unguar ded (may use end exhalation as point of relaxation).

as the combination of side bending and subsequent rotation will effectively neutraliz e F ig ure 11.10.2 81 Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C4 FS LRL Short-Lever. Side bending to the left is introduced until the phy sic ian elicits the mov ement of C4.com/pt/re/9780781763714/bookContent..11. Step 4. P. F ig ure 11.http://thepointeedition. Flexion or extens ion is not neces s ary as a separated motion. Rotational Em phasis 1.lww. and the physic ian stands or sits at the head of the table on the patient's left s ide. The MCP joint of the index finger of the phy sic ian's left hand is placed pos ter ior to the ar tic ular pillar of the dys functional segment.. The patient is supine. Steps 1 to 3. 9 of 87 21/08/07 22:09 . 2. which segments the cer vic al s pine to this level. 3.

With the s ide bending held in place. Step 6. these components (F ig.12. 10 of 87 21/08/07 22:09 .lww. F ig ure 11. 5. 6. Slight ax ial traction may be applied (w hite ar r ows . 11. trac tion. which may elevate slightly to effect fur ther isolation of the C4 on C5 articulation (F ig. Fig . 11.12) with both hands. With the patient relaxed and not guarding. 4. 11.11).com/pt/re/9780781763714/bookContent. F ig ure 11.10). the phy sic ian's left MCP dir ects an arc lik e thrus t in the plane of the oblique fac et of C4 (w hite ar r ow. the phy sic ian grasps the chin with the right hand and rotates the head to the right until the phy sic ian feels motion in the left hand. The head is allowed to rest on the phy sic ian's right for earm...13.http://thepointeedition. Step 5.

13).14) .2 82 Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C5 ES RRR Long-Lever Rotati onal E mphasis 1.lww. 2. Steps 1 to 3. Fig . The phy sic ian's right index finger pad or MCP is placed behind the right articular pillar of C6 to res trict motion at that segment.com/pt/re/9780781763714/bookContent. The patient lies s upine. 11 of 87 21/08/07 22:09 . P. and the phy sic ian is seated at the head of the table.http://thepointeedition. 4. 11. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.. 3..14. 7. The head is F ig ure 11. The patient's head is suppor ted by the phy sic ian's left hand (F ig. 11.

the physic ian. 6.http://thepointeedition. 11. Step 4. Step 5. F ig ure 11. The physic ian car efully rotates the head to the left until the res trictiv e bar rier engages. 11. using rapid acc eleration. being mindful to maintain the original r ight side bending (F ig.15) until C5 begins to mov e.. Fig . This tak es tens ion off the par avertebral mus cles at the lev el of the dys function.17.. Step 6. supinates the left hand and wrist.com/pt/re/9780781763714/bookContent. 11.16. F ig ure 11. which dir ects a left rotational arc lik e thrus t in the plane of the oblique fac et (w hite arr ow. With the patient relaxed and not guarding. side-bent right (w hite ar r ow. Flexion s hould be added until C5 again begins to mov e.15. 12 of 87 21/08/07 22:09 .17) . F ig . 5. T his produc es s ide F ig ure 11.16).lww.

The phy sic ian's right hand remains r igid as a fulc r um agains t which to mov e the cer vic al column. bending left and rotation left. 8. and the phy sic ian stands or sits at the head of the table. The patient lies s upine. 13 of 87 21/08/07 22:09 . Side-Bendi ng E mphasi s 1. Steps 1 to 3.lww.http://thepointeedition.. The physic ian suppor ts the patient's head with the pads of the index finger s on the articular pillar s of the F ig ure 11.2 83 Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C5 NS LRL Short-Lever Technique.. 2. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.18. P. 7.com/pt/re/9780781763714/bookContent.

4.20) .19. dys functional ver tebra ( C5) . The physic ian adjusts flexion or extens ion as needed to F ig ure 11. r ight s ide. gently rotates the patient's head and nec k to the left until motion at C5 is felt. Step 6. while monitoring the pos ter ior articular pillar s of C5. 3..http://thepointeedition. 11.. 11.bending impuls e. 5. F ig ure 11. Step 8.lww.20. 14 of 87 21/08/07 22:09 .18). The physic ian gently side-bends the patient's head and nec k to the right. 11.com/pt/re/9780781763714/bookContent. F ig ure 11. The physic ian gently flexes the patient's head and nec k until C5 begins to mov e over C6 (F ig. The physic ian places the MCP of the right index finger pos ter ior to the right articular pillar of C5 (F ig .21. Steps 4 and 5. 6. The physic ian. engaging the side-bending bar rier of C5 on C6 (F ig . 7.19) .

Fig . loc alize all thr ee planes of motion at the dys functional segment.2 84 P.. 11. 8.2 85 Thoraci c Regi on: T1 to T12 Dysfuncti ons Exampl e: T4 FSLRL Supine 15 of 87 21/08/07 22:09 .http://thepointeedition. P. the phy sic ian's right hand (second MCP) dir ects an arc -like thrust caudally (w hite ar r ow. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment. engaging the right side-bending and right rotational bar riers.. 9.lww. With the patient relaxed and not guarding.21).com/pt/re/9780781763714/bookContent. acr oss the midline in the oblique plane of the C5 fac et.

Step 3 and 4. 16 of 87 21/08/07 22:09 . 4.lww. 11. The physic ian car efully and minimally rolls the patient toward the phy sic ian by grasping and lifting the patient's left pos ter ior shoulder gir dle.22 demonstr ates the fulc rum principle as used in this technique. Fig ure 11. Lateral s upine v iew of the human spine illustr ating p toward T4 and thenar eminence placement at T4. 3.. The patient grasps the opposite shoulders with the hands (F ig.http://thepointeedition. 2.22. F igu re 11.23).T 5 interspace as dys func tion with a flex ion component (4) . Fig ure 11..23. The physic ian places the right thenar eminence pos ter ior to Fig ure 11. 1.24. This should for m a V. Steps 1 and 2. The physic ian draws the patient's left arm ac ros s the patient's chest and places the other arm below it. The patient lies s upine with the phy sic ian standing at the patient's right side ( opposite the rotational component) .com/pt/re/9780781763714/bookContent.

17 of 87 21/08/07 22:09 . The physic ian car efully and minimally rolls the patient by grasping and lifting the patient's right pos ter ior shoulder gir dle.2 86 P. F igure 11. This should for m a V.. The patient grasps the opposite shoulders with the hands (F ig. Lateral supine view of the human s pine illus trating p towar d T 10 and thenar eminence plac ement at T 9 trans ver se proc dy sfunction with a flexion c omponent ( 4).27. 3.com/pt/re/9780781763714/bookContent.2 87 Thoraci c Regi on: T1 to T12 Dysfuncti ons Exampl e: T9 ESRRR S upi ne F igu re 11. The physic ian draws the patient's right arm ac ros s the patient's chest and places the other arm below it. P. 1. 11.28). 2.27 demonstr ates the fulc rum principle as used in this technique. F igure 11.http://thepointeedition. Steps 1 and 2. The patient lies s upine with the phy sic ian standing at the patient's left s ide (oppos ite the rotational component) .lww.28..

18 of 87 21/08/07 22:09 . 6.lww. 5.30. Steps 3 and 4. F igure 11. T he F igure 11. caudad-dir ected impulse. The physic ian places the thenar eminence pos ter ior to the upper of the two ver tebrae of the dys functional spinal unit at the right transv ers e proces s ( T 9) (F ig. Step 6. Side bending left in the thorac ic spine down to the dys function is car ried out by gently mov ing the patient's thorac ic region to the left ( white arr ow. side-bending left.. F igure 11. 11.com/pt/re/9780781763714/bookContent. The phy sic ian's right hand and arm ar e placed under the patient's head and nec k to add slight tension in for war d bending.29).30) .. Step 7.http://thepointeedition.31. 11. The patient's elbows ar e dir ected to the phy sic ian's upper abdomen just inferior to the cos tal ar c h and xiphoid proces s.29. 4. F ig .

http://thepointeedition..31) .com/pt/re/9780781763714/bookContent. On exhalation. 7. P.. F ig . 11. patient inhales and ex hales.lww. the physic ian dir ects s light pressure with the abdomen toward the lower of the two vertebrae in this dys functional spinal unit (T10) (w hite arr ow. 8.2 88 Thoraci c Regi on: T1 to T8 Dysfunctions E xam ple: T2 FS LRL Supine Over the Thigh 19 of 87 21/08/07 22:09 . Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

. Steps 1 and 2. 5. 20 of 87 21/08/07 22:09 . Step 7. Fig ure 11.33). 2. The patient lies supine. 4.lww. and the phy sic ian stands at the head of the table.32.com/pt/re/9780781763714/bookContent. 11. The physic ian places the flexed left k nee on the table with the patient's left T 2 area r esting on the physic ian's thigh (F ig . The physic ian enc irc les the patient's rib cage with the finger s ov er the rib angles pos ter olaterally (F ig. Note: The side of rotational component determines which thigh is used on which par avertebral side of the patient. 1.32) . 11.34. 6. The patient's hands are clasped behind the head with the elbows held outward. The phy sic ian's hands pas s thr ough the space made by the patient's for ear ms and upper arms .http://thepointeedition.. Steps 3 to 5. The patient Fig ure 11. Fig ure 11. 3.33.

Steps 1 and 2.35.com/pt/re/9780781763714/bookContent. however.35). 21 of 87 21/08/07 22:09 . either side may be us ed (F ig. 11..http://thepointeedition.36.2 89 Thoraci c Regi on: T3 to T8 Dysfunctions E xam ple: T6 FS RRR Prone 1. F ig ure 11. The caudad or cephalad dir ection of the phy sic ian's hands is determined by F ig ure 11. The physic ian stands at the patient's left for gr eater efficienc y . A pillow may be placed under the patient's chest and/or abdomen to inc rease the pos ter ior cur ve and for inc reased comfor t. The patient lies prone with the head and nec k in neutral if pos sible. P. 2.lww. Steps 3 and 4.. 3. The physic ian places the right thenar eminence on the right transv ers e proces s of T6 with the finger s pointing cephalad.

Step 5.36) . The patient inhales and exhales..37) ar e pointing with slightly greater pressure on the right transv ers e proces s of T6.http://thepointeedition. a thrust impuls e is delivered in the direc tion in which the finger s ( white arr ows . 11.37. In a T6 NSRRL (side F ig ure 11.lww. 22 of 87 21/08/07 22:09 . and the force is slightly greater on the left. Note: In a T6 FSLRL (flexion. and on exhalation. side bent left.com/pt/re/9780781763714/bookContent. The physic ian places the left hypothenar eminence on the left transv ers e proces s of T6 with the finger s pointing caudally ( Fig . the left hand points cephalad. 5. F ig. 4.. the side-bending bar rier. rotated left) dys function. the right caudad. 11.

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

bent r ight, rotated left) dys function, the hands would be as originally des cribed. 6. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 90

Thoraci c Regi on: T1 to T4 Dysfunctions E xam ple: T2 FS RRR Prone (Long Lever)

1. The patient lies prone with the head and nec k r otated to the left. Note: A pillow may be placed under the patient's chest and/or abdomen to inc rease the pos ter ior cur ve. 2. The physic ian stands at the head of the treatment table and side-bends the

F ig ure 11.38. Step 2.

23 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

3.

4.

5.

6.

patient's head to the left until palpating motion at the T2- T3 articulation (F ig. 11.38). The phy sic ian's left thenar eminence is placed ov er the left transv ers e proces s of T3 as a r estr ictor and anchor (F ig. 11.39). The phy sic ian's right hand is cupped and placed ov er the left par ietooc c ipital region of the patient's head (F ig. 11.40). The patient inhales and exhales, and on exhalation, a thrust is made by the hand on the head. This is done in a rapidly acc elerating manner , creating rotation to the left ( white arr ow, F ig . 11.41) . Effectiveness of this tec hnique is determined by

F ig ure 11.39. Step 3.

F ig ure 11.40. Step 4.

F ig ure 11.41. Step 5, long-lever rotation, left impuls e.

24 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 91

Thoraci c Regi on: T8 to T12 Dysfuncti ons Exampl e: T9 ESRRR S eated (Short Lever)

1. The patient is seated str addling the table with the pos ter ior aspect of the pelvis at one end so that the patient is fac ing the length of the table. 2. The physic ian stands behind the patient on the side opposite the rotational component of the dys function (left side in this RR c ase) . 3. The patient places the right hand behind the nec k and the left hand on the right elbow (F ig. 11.42).

F ig ure 11.42. Steps 1 to 3.

F ig ure 11.43. Steps 4 and 5.

25 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

4.

5.

6.

7.

8.

(Note: Both hands can be placed behind the neck if this is mor e comfor table.) The physic ian places the left hand under the patient's left axilla and on top of the patient's right upper arm. The physic ian places the right thenar eminence par avertebrally over the r ight T9 transv erse proces s ( F ig. 11.43) . The patient is told to r elax , and the phy sic ian car ries the patient into slight for war d bending and left s ide bending until T9 begins to mov e. The patient inhales deeply and on exhalation is car ried into left rotation while slight flexion and left s ide bending ar e maintained. The patient again inhales , and on exhalation, the

F ig ure 11.44. Step 8, barr ier .

F ig ure 11.45. Step 8, impulse.

26 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

phy sic ian quickly and minimally pulls the patient thr ough the left rotational bar rier ( F ig. 11.44) while the right hand imparts an impuls e on T9 (w hite ar r ow, Fig . 11.45) causing a HVLA effec t in left r otation. 9. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.

P.2 92

Thoraci c Regi on: T8 to T12 Dysfuncti ons Exampl e: T10 ESRRR S eated (Long Lever)

27 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

1. The patient is seated str addling the table with the pos ter ior aspect of the pelvis at one end, facing the length of the table. 2. The physic ian stands behind the patient on the side opposite the rotational component (left side in this RR c ase) . 3. The patient places the right hand behind the nec k and the left hand on the right elbow (F ig. 11.46). (Note: Both hands can be placed behind the neck if this is mor e comfor table.) 4. The physic ian places the left hand under the patient's left axilla and on top of the patient's right upper arm. 5. The physic ian places the heel of the right hand midline and supras pinously on the lower of

F ig ure 11.46. Steps 1 to 3.

F ig ure 11.47. Steps 4 and 5.

F ig ure 11.48. Step 7, barr ier .

28 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.2 93

Costal Region: Ri ght Fi rst Rib Inhal ation Dysfunction Seated

1. The patient sits on the table with the phy sic ian standing behind the patient. 2. The phy sic ian places the shoeless left foot on the table at the patient's left, so that the patient's left axilla is suppor ted by the phy sic ian's left thigh (F ig. 11.50). 3. The phy sic ian places the left hand on top of the patient's head with the for ear m along side of the patient's fac e. 4. The phy sic ian's places the thumb or sec ond MCP of the right hand superior and pos ter ior to the angle of the

F ig ure 11.50. Steps 1 and 2.

F ig ure 11.51. Steps 3 to 5.

F ig ure 11.52. Step 7, including direction of

29 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

5.

6.

7.

8.

dys functional right fir s t r ib. The phy sic ian side-bends the patient's head and nec k to the right and rotates to the left until the motion bar rier is met (F ig. 11.51). (In some patients, rotation r ight may be appropriate.) The patient inhales and exhales. Dur ing exhalation, fur ther s ide bending and rotational slack are tak en up. At the end of exhalation, a for ce is dir ected with the phy sic ian's thumb (or sec ond MCP) downward and forwar d, toward the patient's left nipple (white arr ow, F ig . 11.52) . Effectiveness of the tec hnique is determined by

for ce.

30 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

reassessing motion of the dys functional rib.

P.2 94

Costal Region: Left First Rib Inhalation Dysfuncti on Supi ne

1. The patient is supine, and the phy sic ian sits or stands at the patient's head. 2. The physic ian places the right hand along the patient's right tempor opar ietal area ( Fig . 11.53) . 3. The physic ian places the left sec ond MCP superior and pos ter ior to the angle of the dys functional rib. 4. The patient's head is s lightly for war d bent, rotated r ight, and side- bent left with the control of the phy sic ian's right hand (F ig. 11.54). 5. The patient inhales and exhales. 6. At the end of

F ig ure 11.53. Steps 1 and 2.

F ig ure 11.54. Steps 3 and 4.

31 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

exhalation, the phy sic ian dir ects a thr ust (w hite ar r ow, Fig . 11.55) with the left hand downward and slightly medially toward the patient's right nipple. 7. Effectiveness of the tec hnique is determined by reassessing motion of the dys functional rib.

F ig ure 11.55. Step 6, including direction of for ce.

P.2 95

Costal Region: Left Rib 6 I nhalation Dysfuncti on S upi ne

1. The patient is supine, and the physic ian stands at the side of the table opposite the side of the r ib dys function. 2. The phy sic ian draws the patient's arm on the side of the rib dys function acr oss the patient's rib cage with the

F igu re 11.56. Steps 1 and 2.

32 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

3.

4.

5.

6.

patient's other arm below it. The patient's arms s hould for m a V (F ig. 11.56). The phy sic ian slightly r olls the patient toward the phy sic ian by gently pulling the left pos ter ior shoulder gir dle for war d. The phy sic ian places the thenar eminence of the right hand pos ter ior to the angle of the dys functional rib (F ig. 11.57) . The patient is rolled bac k over the phy sic ian's hand, and the sur fac e created by the patient's crossed arms r ests agains t the phy sic ian's chest or abdomen. Pressure is dir ected thr ough the

F igu re 11.57. Steps 3 and 4.

F igu re 11.58. Steps 5 to 7, inc luding direction of forc e.

F igu re 11.59. Steps 5 to 7, inc luding direction of forc e.

33 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

patient's chest wall, loc alizing at the thenar eminence. 7. The patient inhales and exhales, and at end exhalation a thr ust impuls e (w hite arr ows , F igs. 11.58 and 11.59) is delivered thr ough the patient's chest wall slightly cephalad to the thenar eminence. 8. Effectiveness of the tec hnique is determined by reassessing motion of the dys functional rib.

P.2 96

Costal Region: Left Rib 8 E xhalation Dysfuncti on S upi ne

34 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

1. The patient lies s upine, and the phy sic ian stands at the side of the table opposite the side of the r ib dys function. 2. The phy sic ian draws the patient's arm on the side of the dys function acr oss the patient's rib cage with the patient's other arm below it. The patient's arms s hould for m a V (F ig. 11.60). 3. The phy sic ian slightly r olls the patient toward the phy sic ian by gently pulling the left pos ter ior shoulder gir dle for war d. 4. The phy sic ian places the thenar eminence of the right hand pos ter ior to the angle of the

F ig ure 11.60. Steps 1 and 2.

F ig ure 11.61. Steps 3 and 4.

F ig ure 11.62. Steps 5 to 7, including dir ection of for ce.

35 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.2 97

Costal Region: Ri ght Ri bs 11 and 12 I nhalation Dysfuncti on Prone

1. The patient lies prone on the table. 2. The phy sic ian stands at the left s ide of the table and pos itions the patient's legs 15 to 20 degrees to the right to tak e tens ion off the quadratus lumbor um, which attaches to the infer ior medial aspect of rib 12 (F ig. 11.64) . 3. The phy sic ian places the left hypothenar eminence medial and inferior to the angle of the dys functional rib and exerts gentle sus tained lateral and cephalad traction. 4. The phy sic ian's

Fig ure 11.64. Steps 1 and 2.

Fig ure 11.65. Steps 3 and 4.

36 of 87

21/08/07 22:09

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

right hand may gr asp the patient's right anterior superior iliac spine to stabilize the pelvis (F ig. 11.65) . 5. The patient inhales and exhales deeply . 6. Dur ing exhalation the phy sic ian's left hand applies a cephalad and later al HVLA thrus t impuls e (w hite ar r ow, Fig . 11.66). 7. Suc ces s of the tec hnique is determined by reassessing motion of the dys functional rib. Note: T his technique is c ommonly done after performing the mus c le energy r espiratory as sis t technique for ribs 11 and 12 held in inhalation.

Fig ure 11.66. Steps 5 and 6, including dir ection of for c e.

P.2 98

Costal Region: Ri ght Ri bs 11 and 12 E xhalation Dysfuncti on

37 of 87

21/08/07 22:09

Steps 5 and 6. 11. 3. The phy sic ian places the left thenar eminence superior and lateral to the angle of the dys functional rib and exerts gentle sus tained medial and caudad traction. The phy sic ian stands at the left s ide of the table and pos itions the patient's legs 15 to 20 degrees to the left to put tension on the quadratus lumbor um.69.67.com/pt/re/9780781763714/bookContent. 38 of 87 21/08/07 22:09 .lww. Fig ure 11.68.67) . Steps 3 and 4.. which attaches to the infer ior medial aspect of rib 12 (F ig. Steps 1 and 2. 2. Fig ure 11.. 4. The phy sic ian's right hand grasps the patient's right anterior superior iliac spine and Fig ure 11. The patient lies prone on the table.http://thepointeedition. Prone 1.

Dur ing the end exhalation. gently lifts toward the ceiling ( F ig. The patient inhales and exhales deeply . Suc ces s of the tec hnique is determined by reassessing motion of the dys functional rib.http://thepointeedition. P.lww.69). the phy sic ian's left hand applies a caudad and medial HVLA thr ust as the right hand gently lifts the anter ior superior iliac spine (ASIS) up toward the ceiling (F ig. 6.com/pt/re/9780781763714/bookContent. 11. 7. 11.68) .. 5.2 99 Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L5 NSLRR Lateral Recum bent (Long Lever) 39 of 87 21/08/07 22:09 ..

T he patient's foot mus t not touc h the floor (F ig.71. 11. The physic ian fur ther pos itions the patient's left leg so that it drops over the side of the table cephalad to the right leg. 1.lww. While continuing to palpate L5. Fig ure 11. 2. Steps 4 and 5. Step 3. Fig ure 11.70. 11. Steps 1 and 2. The patient lies in the r ight lateral rec umbent (side. 3..http://thepointeedition. 4.71) .com/pt/re/9780781763714/bookContent. The physic ian palpates between the spinous proces ses of L5 and S1 and flexes the patient's knees and hips until L5 is in a neutr al pos ition relative to S1 (F ig. the phy sic ian places the cephalad hand in the patient's left antec ubital fos sa while Fig ure 11. 40 of 87 21/08/07 22:09 .72.lying) pos ition with the physic ian standing at the side of the table fac ing the patient.70)..

P. Steps 1 and 2.74) . 11. Fig ure 11. The physic ian palpates between the spinous proces ses of L4 and L5 and flexes the patient's knees and hips until L4 is in a neutr al pos ition relative to L5.lww. 41 of 87 21/08/07 22:09 .com/pt/re/9780781763714/bookContent.. T he patient's foot mus t not touc h the floor (F ig.http://thepointeedition. Fig ure 11. Step 3.75. 2. It is not nec ess ary to meet the extens ion bar rier at this point (F ig .74.. The physic ian fur ther pos itions the patient's left leg so that it drops over the side of the table cephalad to the right leg.3 00 Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L4 FRRS Lateral Recum bent (Long Lever) 1. The patient lies in the r ight lateral rec umbent pos ition with the physic ian standing at the side of the table fac ing the patient. 3.

Step 8.lww. 4. 6. The patient inhales and exhales.com/pt/re/9780781763714/bookContent. 42 of 87 21/08/07 22:09 . 7. Steps 4 and 5. 5. The patient's shoulder and pelvis ar e axially r otated in opposite dir ections . and dur ing exhalation.. the phy sic ian can grasp the patient's right arm. 11.76. While continuing to palpate L4. 11.76). Fig ure 11. The phy sic ian's caudad hand stabilizes L5 (F ig. If the rotational slack and/or motion bar rier is not effectively met. drawing the shoulder Fig ure 11.. fur ther rotational slack is taken up.http://thepointeedition.75) . the phy sic ian places the cephalad hand in the antecubital fos sa of the patient's left arm while res ting the for ear m gently on the patient's shoulder.77.

8. P. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment. for war d until rotational mov ement is palpated between L4 and L5.com/pt/re/9780781763714/bookContent. 9.lww...77).http://thepointeedition. 11. simultaneously mov ing the shoulder slightly caudad and the pelvis and sac rum cephalad. With the patient r elax ed and not guarded the phy sic ian delivers an impuls e with the forear ms (w hite ar r ows .3 01 Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: Left L5—S1 Radicul iti s* Lateral Recum bent (Long Lever) 43 of 87 21/08/07 22:09 . Fig .

11.80.lww. F ig ure 11.78).com/pt/re/9780781763714/bookContent. 11. 2. 3.http://thepointeedition. the physic ian places the cephalad hand in the F ig ure 11.79.. F ig ure 11. 4. While continuing to palpate L5.78. The phy sic ian palpates between the patient's spinous proces ses of L5.79) . The phy sic ian pos itions the patient's left leg so that it drops over the side of the table cephalad to the right leg. 44 of 87 21/08/07 22:09 .. Steps 1 and 2. Step 3. The patient is in the right lateral rec umbent pos ition with the physic ian standing at the side of the table fac ing the patient. Steps 4 and 5. 1. The patient's leg should not touch the floor (F ig .S1 and flexes the patient's hips and knees until L5 is fully flex ed in relation to S1 (F ig.

4. The dorsal aspect of the phy sic ian's hand is car efully placed at mid sternum on the patient's chest wall (F ig. 5.83. F ig ure 11. F ig ure 11. P..82).lww.. Steps 1 to 3.http://thepointeedition. The physic ian then walk s around the head of the table to the left s ide of the patient.82. The physic ian stands at the head of the table to the patient's right and slides the right for earm thr ough the space created by the patient's flexed right arm and shoulder. The physic ian.3 02 Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L4 NSLRR Supine Lum bar Wal k-Around (Long Lever) 1. 45 of 87 21/08/07 22:09 . Steps 4 to 6. 2.com/pt/re/9780781763714/bookContent. 11. while palpating pos ter ior ly with the caudad hand. 3. The patient lies s upine with both hands behind the neck and the finger s interlaced.

84) . side-bends the patient's trunk to the right until L4 begins to mov e. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional F ig ure 11. 7. 11. 6. 9.84.. The phy sic ian's caudad hand anc hor s the patient's pelvis by placing the palm on the patient's right ASIS. the physic ian dir ects an impuls e that pulls the patient minimally into fur ther left rotation ( white arr ows .83) . F ig. 11. 46 of 87 21/08/07 22:09 .. Steps 7 and 8.com/pt/re/9780781763714/bookContent.http://thepointeedition. With the patient relaxed and not guarding. The physic ian begins to rotate the patient to the left while continuing to maintain the original s ide bending ( F ig. 8.lww.

86. The patient places the right hand behind the nec k and the left hand on the right elbow (both hands can be placed behind the nec k if this is mor e comfor table) (F ig. P. The physic ian pas ses the left hand under the patient's left axilla and on top of the patient's right F ig ure 11..com/pt/re/9780781763714/bookContent.lww.85). 2. Steps 1 to 3. The physic ian stands behind and to the left of the patient. The patient sits.. F ig ure 11. 3. prefer ably str addling and fac ing the length of the table to res trict the sac rum and pelvis . 11.http://thepointeedition. Steps 4 and 5.85. 4. 47 of 87 21/08/07 22:09 . segment.3 03 Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L2 E SRRR Lum bar Seated Positi on (Short Lever) 1.

pulling the patient minimally thr ough F ig ure 11.87).com/pt/re/9780781763714/bookContent. 11. 6. F ig ure 11.87. The physic ian places the right thenar eminence or palm on the par avertebral mus cles ov er the L2 right transv ers e proces s ( F ig. The patient inhales deeply .http://thepointeedition. upper arm. the physic ian dir ects an impuls e force.. Step 8. 11.lww. 7. 48 of 87 21/08/07 22:09 . The patient is ins tructed to relax as the phy sic ian pos itions the patient into slight for war d bending and then left side bending until motion is palpated at L2.86) . 5. and on exhalation the patient is pos itioned into left r otation (while the slight flexion and left s ide bending ar e maintained (F ig.88. 8.. With the patient relaxed and not guarding. Steps 6 and 7.

3 04 P. The patient places the right hand F ig ure 11. to res trict the sac rum and pelvis . Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment. Steps 1 to 3. 11. prefer ably str addling and fac ing the length of the table. The patient sits. fur ther left rotation while dir ecting a short lev er thr ust on L2 with the r ight hand ( white arr ows . 3..lww. 2. P. The physic ian stands behind and to the left of the patient.3 05 Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L2 E SRRR Lum bar Seated Positi on (Long Lever) 1. 49 of 87 21/08/07 22:09 .com/pt/re/9780781763714/bookContent.88) .89. F ig. 9.http://thepointeedition..

Steps 6 and 7.91.92. 4.lww..89). The patient inhales deeply . F ig ure 11.90). The patient is ins tructed to relax. and on exhalation the F ig ure 11.http://thepointeedition.. and the phy sic ian pos itions the patient into slight for war d bending and left s ide bending until motion is palpated at L2. 50 of 87 21/08/07 22:09 . 11. The physic ian places the right thenar eminence or palm midline at the inters pac e between the L2 and L3 spinous proces ses (F ig. Step 8. Steps 4 and 5. 6. F ig ure 11.com/pt/re/9780781763714/bookContent.90. behind the nec k and the left hand on the right elbow (both hands can be placed behind the nec k if this is mor e comfor table) (F ig. 11. 5. The physic ian pas ses the left hand over the top of the patient's left upper arm and on top of the patient's right upper arm. 7.

patient is pos itioned into left r otation while slight flexion and left side bending are maintained (F ig. Lateral Recum bent 51 of 87 21/08/07 22:09 . the phy sic ian's left hand pulls the patient into further left rotation while stabilizing L3 with the r ight hand ( white arr ows ) ( this rotates L2 to the left in relation to L3) (F ig. 11. 8.lww.com/pt/re/9780781763714/bookContent. 11...91). With the patient relaxed and not guarding. P. 9.3 07 Pel vic Region: Left Posteri or Innomi nate Dysfuncti on. Effectiveness of the tec hnique is determined by reassessing inters egmental motion at the lev el of the dys functional segment.92).http://thepointeedition.3 06 P.

Steps 1 to 3.http://thepointeedition. 52 of 87 21/08/07 22:09 .com/pt/re/9780781763714/bookContent.95. Step 6a. Fig ure 11. 5. Diag nosis Standing flexion test: Positiv e (left PSIS r ises) Loss of pas siv ely induced left s acr oiliac motion ASIS: Cephalad (s lightly lateral) on the left PSIS: Caudad ( slightly medial) on the left Sacr al s ulc us: Deep. 4. The patient is in the right lateral rec umbent pos ition.. 11.94. The physic ian's cephalad hand palpates between the patient's spinous pr ocesses of L5 and S1. 3. The physic ian maintains the left leg in this position and instr ucts the patient to str aighten the r ight leg.lww. The physic ian places the cephalad hand on Fig ure 11.93. The physic ian's caudad hand flex es the patient's knees and hips until the L5 and S1 spinous proces ses separate ( Fig . 2.93) . Fig ure 11. plac ing the left foot just dis tal to the right popliteal fos sa. Steps 4 and 5. anterior on the left T ech niq u e 1.. and the physician stands fac ing the patient.

a.100. The physic ian grasps the patient's right ank le. The physic ian raises the patient's right leg no mor e than 30 degrees and applies traction down the shaft of the leg (w hite ar r ow. anterior on the r ight T ech niq u e 1. 53 of 87 21/08/07 22:09 .99) . The patient is supine. 11. Step 3a. and the phy sic ian stands at the foot of the table..3 08 Pel vic Region: Ri ght Posterior Innom i nate Dysfunction. Leg Pul l. Some prefer to position the leg s lightly off the s ide of the table approximately 10 to 20 degrees ( Fig .com/pt/re/9780781763714/bookContent. 3. Steps 1 to 3.lww.99. F ig. 2. F ig ure 11.http://thepointeedition. S upi ne Diag nosis Standing flexion test: Positiv e (r ight PSIS r ises) Loss of pas siv ely induced right sac r oiliac motion ASIS: Cephalad (s lightly lateral) on the r ight PSIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Deep. P.. F ig ure 11.

.100). 54 of 87 21/08/07 22:09 . F ig .101). Steps 1 to 4. Effectiveness of the technique is determined by reassessing r ight sac roiliac joint motion. anter ior on the left F ig ure 11. 4. 11. Step 5.102. At the end of the las t breath.101.com/pt/re/9780781763714/bookContent. Supine Ful crum Diag nosis Standing flexion test: Positive (left PSIS ris es) Loss of pas siv ely induced left s acr oiliac motion ASIS: Cephalad ( slightly lateral) on the left PSIS: Caudad ( slightly medial) on the left Sacr al s ulc us: Deep. 11.3 09 Pel vic Region: Left Posteri or Innomi nate Dysfuncti on.. P. 6. F ig ure 11. 5.lww. This trac tion is maintained as the patient is as ked to tak e 3 to 5 s low breaths.http://thepointeedition. the phy sic ian delivers a thrust in the dir ection of the traction ( white arr ow.

2. 55 of 87 21/08/07 22:09 . Step 5. F ig ure 11.103). and the physic ian stands to the patient's right. 3.http://thepointeedition.. 11. Steps 5 and 6. The phy sic ian rolls the patient onto the left PSIS with the patient's weight dir ectly over the fulcr um (w hite ar r ow. The phy sic ian places the thenar eminence of the cephalad hand under the patient's left PSIS to ser ve as a fulcrum agains t which to mov e the innominate (F ig.lww. The phy sic ian flexes the patient's knees and hips.. Fig .103. The patient F ig ure 11.105. 11. 4. 6. 5.com/pt/re/9780781763714/bookContent. Step 6. F ig ure 11.102). The phy sic ian rolls the patient's legs toward the phy sic ian. The patient is supine.104. T ech niq u e 1.

Lateral Recumbent Diag nosis Standing flexion test: Positive (left PSIS ris es) Loss of pas siv ely induced left s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the left ASIS: Caudad ( slightly medial) on the left Sacr al s ulc us: F ig ure 11. 7.104 and 11.http://thepointeedition.106. causing a short and long lever ing of the left innominate.com/pt/re/9780781763714/bookContent. P. F igs.105).. extends the left k nee and then s lowly lowers the leg towar d the table (w hite arr ows .. Step 1. 11. Effectiveness of the tec hnique is determined by reassessing left s acr oiliac joint motion.lww.3 10 Pel vic Region: Left Anteri or I nnominate Dysfunction. 56 of 87 21/08/07 22:09 .

Steps 2 to 5.106). 11. ov er and slightly mor e flex ed than the r ight F ig ure 11. The phy sic ian palpates between the spinous proces ses of L5 and S1 with the cephalad hand. Posterior on the left T ech niq u e 1. F ig ure 11.http://thepointeedition. 2. 3. Step 6. The patient is in the right lateral rec umbent pos ition.. 57 of 87 21/08/07 22:09 . The phy sic ian's caudad hand flexes the patient's hips and knees until the L5 and S1 spinous proces ses separate.109. and the physic ian stands at the side of the table fac ing the patient (F ig. F ig ure 11.com/pt/re/9780781763714/bookContent.lww.108.107. The phy sic ian pos itions the patient's left leg so that it drops off the side of the table. Steps 7 and 8.. 4.

Fig . T he patient's foot should not touch the floor.. 11.http://thepointeedition. 5..com/pt/re/9780781763714/bookContent. 11.107). These motions should be continued until mov ement of the sacrum is palpated at the left 58 of 87 21/08/07 22:09 . The phy sic ian places the caudad for ear m in a line between the patient's left PSIS and trochanter and the cephalad hand or for ear m on the patient's left s houlder (F ig. leg.lww. The phy sic ian introduces axial rotation in opposing dir ections by gently pus hing the patient's left shoulder dor sally (posterior ly) and rolling the pelvis ventrally (anter ior ly) (w hite ar r ow.108). 6.

Effectiveness of the tec hnique is determined by reassessing left s acr oiliac joint motion. 11...http://thepointeedition. With the patient relaxed and not guarding.com/pt/re/9780781763714/bookContent.3 11 Pel vic Region: Ri ght Anteri or Innomi nate Dysfuncti on. 7. Leg Pul l 59 of 87 21/08/07 22:09 . 9. P.lww. If no motion is felt. 8.109). the physic ian delivers an impuls e along the shaft of the femur (w hite arr ows . the phy sic ian grasps the patient's right arm and draws the shoulder for war d until rotational mov ement is elicited at the left s acr oiliac joint. sac roiliac joint. F ig.

http://thepointeedition. 2. Steps 1 to 3. At F ig ure 11.. The patient is supine and the physic ian stands at the foot of the table.com/pt/re/9780781763714/bookContent. 11.lww. Step 4. Step 5. F ig ure 11.112.110) 4. This trac tion is maintained and the patient is ask ed to take 3 to 5 slow breaths.. 60 of 87 21/08/07 22:09 . F ig .111. F ig ure 11. The phy sic ian grasps the patient's right ank le.110. 3. The patient's right leg is raised 45 degrees or mor e and traction is applied down the shaft of the leg ( white arr ow. Diag nosis Standing flexion test: Positive (r ight PSIS ris es) Loss of pas siv ely induced right s acr oiliac motion PSIS: Cephalad ( slightly lateral) on the right ASIS: Caudad ( slightly medial) on the right Sacr al s ulc us: Posterior on the r ight T ech niq u e 1.

http://thepointeedition. 3. 11. F igu re 11. Steps 3 and 4. Steps 1 and 2. and the phy sic ian is standing fac ing the patient.113. 4. The phy sic ian grasps the patient's wrist with the phy sic ian's thumbs on the dorsal aspect of the wrist (F ig . F igu re 11. Dorsal Carpal Dysfunction Diag nosis Symptoms : Wris t disc omfort with inability to fully extend the wrist Palpation: Dor sal prominence and/or pain of a s ingle c arpal bone T ech niq u e 1.3 12 Upper E xtremi ty Regi on: Wri st. Step 5.115. The phy sic ian places the thumb over the displaced car pal bone and F igu re 11. The dorsally dys functional car pal bone is identified with the phy sic ian's thumbs . The patient is seated on the table.. P.lww.com/pt/re/9780781763714/bookContent.113).114.. 2. 61 of 87 21/08/07 22:09 .

P. Fig . Ulna) 62 of 87 21/08/07 22:09 . Phy sic ian's other fingers wrap around palmar sur fac e ( F ig.) 6. reinforces it with the other thumb. A s imple whipping motion is car ried out..lww. Effectiveness of the tec hnique is determined by reassessing both the prominent car pal bone and wr ist range of motion.115).com/pt/re/9780781763714/bookContent.3 13 Upper E xtremi ty Regi on: El bow.. maintaining pressure over the dis placed car pal bone (w hite ar r ow. 5. 11. (No tr action is needed for this tec hnique.114). 11.http://thepointeedition. Fl exi on Dysfunction (Distal Elbow.

the elbow is car ried into fur ther flexion ( white F ig ure 11. The wr ist of the ar m to be treated is held against the phy sic ian's waist using the elbow (F ig.116. The patient is seated on table and the phy sic ian is standing in front of patient.117.com/pt/re/9780781763714/bookContent. F ig ure 11. 11. Steps 3 and 4. The phy sic ian places the thumbs on top of the for ear m in the ar ea of the antecubital fos sa.. Steps 1 and 2. 2.http://thepointeedition.116). 63 of 87 21/08/07 22:09 .118. Diag nosis Symptom: Elbow disc omfort Motion: Inability to fully ex tend the elbow Palpation: O lec ranon foss a palpable ev en when elbow is fully extended T ech niq u e 1. 3.. 4.lww. F ig ure 11. Traction is down towar d the floor . Step 5.

4.120.120). 3. 64 of 87 21/08/07 22:09 . 2. F ig ure 11. The patient is seated on the table. Steps 1 to 3. Ulna) Diag nosis Symptom: Elbow disc omfort Motion: Inability to fully flex the elbow Palpation: No palpable olecr anon foss a with the elbow fully extended T ech niq u e 1.. Step 4. P. and the phy sic ian is standing fac ing the patient.3 14 Upper E xtremi ty Regi on: El bow.121.com/pt/re/9780781763714/bookContent.http://thepointeedition.lww. The patient's arm to be treated is held against phy sic ian's waist with the phy sic ian's elbow against the patient's hand. The patient is ask ed to F ig ure 11. The phy sic ian places the thumbs on top of the for ear m in the region of the antecubital fos sa (F ig . Extension Dysfuncti on (Proxi m al Elbow.. 11.

P.123). F igs.121).3 15 Upper E xtremi ty Regi on: El bow. the patient's elbow is car ried into full extension (w hite arr ows .123. res ist minimally (b lack arr ows . Effectiveness of the tec hnique is determined by reassessing elbow extens ion. F ig ure 11. F ig .123) as the physic ian applies traction down toward the floor (w hite arr ow. 11. Radial Head. Step 4. 11.. Step 4.122. 11.http://thepointeedition. 11. F ig ure 11. Maintaining this trac tion.com/pt/re/9780781763714/bookContent. 11. 5.lww.121. Supination Dysfunction 65 of 87 21/08/07 22:09 .. F igs.122 an d 11.122.

Steps 3 and 4. F ig ure 11. Diag nosis Symptoms : Disc omfort at the r adial head Motion: Los s of pass ive pronation of the forearm Palpation: Anterior prominence and tenderness of the r adial head T ech niq u e 1. F ig ure 11. Steps 1 and 2. The phy sic ian places the thumb of the opposite hand anter ior to the radial head ( Fig 11. The patient is seated on the table and the phy sic ian is standing fac ing the patient. The phy sic ian holds the hand of the dys functional arm as if shaking hands with the patient.com/pt/re/9780781763714/bookContent.. 66 of 87 21/08/07 22:09 . The phy sic ian rotates the for ear m into pronation until the res trictiv e bar rier is reached.125.124.http://thepointeedition. 3.124).. 2.lww.

3.127. The phy sic ian places the thumb of the opposite hand pos ter ior to the radial head ( Fig 11.. The patient is seated on the table.3 16 Upper E xtremi ty Regi on: El bow. Pronation Dysfunction Diag nosis Symptoms : Disc omfort at the r adial head Motion: Los s of pass ive supination of the forearm Palpation: Posterior prominence and tenderness of the r adial head T ech niq u e 1. 2.http://thepointeedition.lww. P. F ig ure 11. Radial Head. The phy sic ian holds the hand of the dys functional arm as if shaking hands with the patient. Steps 1 and 2. 67 of 87 21/08/07 22:09 . Steps 3 and 4..126). The phy sic ian F ig ure 11.com/pt/re/9780781763714/bookContent. and the phy sic ian is standing fac ing the patient.126.

With the patient completely relaxed.lww.127).com/pt/re/9780781763714/bookContent. 4. rotates the for ear m into supination until the res trictiv e bar rier is reached. the phy sic ian car ries the for ear m into extens ion and supination while maintaining thumb pressure over the pos ter ior radial head (F ig 11. S upi ne 68 of 87 21/08/07 22:09 .3 17 Lower E xtremi ty Regi on: Knee: Anteri or Dysfunction of the Tibia on the Fem ur (Posteri or Fem ur Over Ti bia). P.http://thepointeedition. 5.. Effectiveness of the tec hnique is determined by retesting pronation of the forear m and palpating for reduc ed prominenc e of the radial head..

Step 4.129. The phy sic ian sits on the patient's foot anc hor ing it to the table.http://thepointeedition.128. Diag nosis Symptoms : Knee disc omfort.lww. F ig ure 11. 3.128)...lik e test) with los s of anterior fr ee play motion Palpation: Prominence of tibial tuberos ity T ech niq u e 1. 69 of 87 21/08/07 22:09 . 2. The patient is supine with the dys functional knee flex ed to 90 degrees with foot flat on the table.com/pt/re/9780781763714/bookContent. The phy sic ian places the thenar eminences over the anterior aspect of the tibial plateau with the finger s wrapping around the leg (F ig. Steps 1 to 3. 11. inability to c omfortably ex tend the knee Motion: Res tricted posterior s pring ( drawer . F ig ure 11.

Step 3. The phy sic ian places the thumbs on the anter ior tibial plateau with the finger s wrapping around the leg (F ig.http://thepointeedition. 11. Steps 1 and 2. S eated Diag nosis Symptoms : Knee disc omfort. 70 of 87 21/08/07 22:09 . 3. The thigh is spr ung up and down to ens ure total relaxation of F ig ure 11.3 18 Lower E xtremi ty Regi on: Knee: Anteri or Dysfunction of the Tibia on the Fem ur (Posteri or Fem ur Over Ti bia). F ig ure 11.. 2.130.lik e test) with los s of anterior fr ee play motion Palpation: Prominence of tibial tuberos ity T ech niq u e 1. inability to c omfortably ex tend the knee Motion: Res tricted posterior s pring ( drawer . P.lww.130).com/pt/re/9780781763714/bookContent..131. The patient is seated on the side of the table with a small pillow beneath the thigh as a cus hion.

simultaneous with a pos ter ior pressure impuls e with the thumbs (w hite arr ows . Effectiveness of the tec hnique is determined by reassessing anterior free play glide as well as r ange of motion of the knee. 5. 11. F ig ure 11. 11..132.3 19 Lower E xtremi ty Regi on: Knee: Posteri or Dysfunction of the Tibia on the Fem ur (Anteri or Femur Over Tibia).http://thepointeedition. A thrust is delivered str aight down toward the floor.lww.. F ig. the thigh mus culatur e (w hite arr ows . 4. P. Step 4.132).com/pt/re/9780781763714/bookContent. Prone 71 of 87 21/08/07 22:09 . F ig.131).

72 of 87 21/08/07 22:09 . The patient lies prone with the dys functional knee flex ed to approx imately 90 degrees if pos sible. 3.134. 2. tak ing tension off the gas trocnemius mus cle. Steps 1 to 3.133.com/pt/re/9780781763714/bookContent. Step 4. The physic ian stands or sits at the end of the table with the dorsum of the patient's foot on the anteromedial aspect of the phy sic ian's shoulder.http://thepointeedition.. F ig ure 11. Place.lww. The phy sic ian's finger s ar e interlaced and wrapped F ig ure 11..lik e test) with los s of posterior free play motion T ech niq u e 1. Diag nosis Symptoms : Knee disc omfort.ment of patient's foot on phy sic ian's shoulder will plantar-flex the foot. inability to c omfortably flex the knee Motion: Res tricted anterior spring ( drawer .

.3 20 Lower E xtremi ty Regi on: Knee: Posteri or Dysfunction of the Tibia on the Fem ur (Anteri or Femur Over Tibia). The patient is seated on the side of the table with a small pillow beneath the thigh as a cus hion. F ig ure 11. 73 of 87 21/08/07 22:09 .136.http://thepointeedition. The phy sic ian places the thumbs on the anter ior tibial plateau with the finger s wrapping around the leg contac ting the popliteal fos sa and adding a slight flexion to the knee so the foot may go under the edge of F ig ure 11.lik e test) with los s of anterior fr ee play motion T ech niq u e 1. Seated Diag nosis Symptoms : Knee disc omfort. Steps 3 and 4. P.. 2. Steps 1 and 2.com/pt/re/9780781763714/bookContent.135.lww. inability to c omfortably flex the knee Motion: Res tricted posterior s pring ( drawer .

3 21 Lower E xtremi ty Regi on: Knee: Anteri or Fibular Head Dysfunction 74 of 87 21/08/07 22:09 . 4.. P. 11. 5.com/pt/re/9780781763714/bookContent. 11. Effectiveness of the tec hnique is determined by reassessing anterior free play glide and range of motion of the knee.lww.http://thepointeedition. the table (F ig. Fig .136)..135). simultaneous with an anterior pressure impuls e with the popliteal contac ting finger s. The thigh is then s prung up and down to ens ure total relaxation of the thigh mus culatur e. 3. A thrust is delivered down towar d the floor (w hite ar r ow.

http://thepointeedition.137) . 11.138.. Diag nosis Symptoms : Lateral leg sor enes s and musc le c ramping with tender nes s ov er the prox imal fibula Motion: Inc reased anterior glide with r estric ted motion of the prox imal fibula posterior glide History : Common following a medial ankle s prain. The physic ian places the heel of the cephalad hand over the anterior sur fac e of the proximal fibula (F ig. 2. Steps 4 and 5. 75 of 87 21/08/07 22:09 . 3.lww..com/pt/re/9780781763714/bookContent. The physic ian's caudad hand internally rotates the patient's ank le to bring the proximal fibula mor e anter ior . genu r ecurvatum deformity T ech niq u e 1. 4. for c ed dors iflexion of the ankle. The patient lies supine with a small pillow under the dys functional knee to maintain the knee in s light flexion.137. A thrust is delivered F ig ure 11. F ig ure 11. Steps 1 to 3.

F ig ure 11. 2. Steps 1 to 4. 3. P.com/pt/re/9780781763714/bookContent. The phy sic ian stands at the side of the table opposite the side of the dys function. The phy sic ian places the MCP of the F ig ure 11..140.139.. fibular head pr ominent posteriorly History : Common following inversion s prains of the ankle T ech niq u e 1. 76 of 87 21/08/07 22:09 . pers istent ank le pain bey ond that expected for normal ankle r ecover y Motion: Inc reased posterior glide and decr eas ed anterior glide Palpation: T enderness at the fibular head. Step 5.http://thepointeedition.lww. The patient lies prone with the dys functional knee flex ed at 90 degrees.3 22 Lower E xtremi ty Regi on: Knee: Posteri or Fibular Head Dysfunction Diag nosis Symptoms : Pain at the lateral knee.

139). The phy sic ian's caudad hand. 5. 11. 6.140).141.. 11. cephalad index finger behind the dys functional fibular head. Step 6.lww. The phy sic ian's caudad hand grasps the ank le on the side of dys function and gently flexes the knee until the res trictiv e bar rier is reached (F ig.http://thepointeedition. 77 of 87 21/08/07 22:09 . and the hypothenar eminence is angled down into the hamstr ing mus culatur e to for m a wedge behind the knee. F ig . The patient's foot and leg are gently externally rotated to car ry the fibular head bac k against the fulcr um for med by the phy sic ian's cephalad hand ( white arr ow. 4.. F ig ure 11.com/pt/re/9780781763714/bookContent.

141)..lww. 7.http://thepointeedition.com/pt/re/9780781763714/bookContent. F ig . Effectiveness of the tec hnique is determined by reassessing motion of the fibular head and by palpating for res tor ation of nor mal pos ition of the fibula.3 23 Lower E xtremi ty Regi on: Knee: Anteri or Medi al Meni scus Dysfunction 78 of 87 21/08/07 22:09 . P. controlling the patient's foot and ank le.. the wedge fulcrum for med by the phy sic ian's cephalad hand prevents any suc h motion. 11. However. delivers a thr ust toward the patient's buttoc k in a manner that would nor mally res ult in fur ther flexion of the knee ( white arr ow.

142. 11. Steps 1 to 3.. 3. The physic ian places the thumb of the medial hand over the bulging menisc us. The physic ian places the ank le of the dys functional leg under the phy sic ian's axilla and agains t the lateral r ib cage ( Fig .142). The finger s of the later al F ig ure 11. The physic ian stands at the side of the table on the side of the dys function. The patient lies s upine with hip and knee flex ed. lock ing of the knee s hor t of full extension Phys ical findings : Palpable bulging of the meniscus just medial to the patellar tendon. positiv e Apley 's c ompres s ion test T ech niq u e 1. 2.http://thepointeedition. 4. F ig ure 11. Step 4. F ig ure 11.144..143.lww. Step 5. Diag nosis Symptoms : Medial k nee dis comfor t. positiv e MacMurr ay's test.com/pt/re/9780781763714/bookContent. 79 of 87 21/08/07 22:09 .

Steps 1 to 3. The phy sic ian's one hand cups the calcaneus anc hor ing the foot ( slight traction may be applied)..lww.147. 80 of 87 21/08/07 22:09 . F ig ure 11. P.146. and the phy sic ian stands at the foot of the table. 2. 4.. F ig ure 11.http://thepointeedition. F ig . 11. The phy sic ian places the other hand on the anterior tibia proximal to the ankle mor tis e ( F ig. The patient lies s upine. A thrust is delivered with the hand on the tibia str aight down toward the table (w hite arr ow.3 24 Lower E xtremi ty Regi on: Ankle: Anteri or Tibia on Talus Diag nosis Drawer test: Loss of anter ior glide ( free play motion) with dec reased posterior drawer test T ech niq u e 1. 3.com/pt/re/9780781763714/bookContent.146). Step 4.

and the phy sic ian stands at the foot of the table. Effectiveness of the tec hnique is determined by reassessing ank le range of motion. The phy sic ian's hands are wrapped around the foot with the finger s interlaced on the dorsum. 3. 81 of 87 21/08/07 22:09 .148. The patient lies s upine. 5. 2. Step 4.3 25 Lower E xtremi ty Regi on: Ankle: Posterior Ti bia on Tal us Diag nosis Drawer test: Loss of posterior glide ( free play motion) with dec reased anterior dr awer test T ech niq u e 1. 11.com/pt/re/9780781763714/bookContent. P..149. F ig ure 11. Steps 1 to 3.http://thepointeedition. The foot is dor siflex ed to the motion bar rier us ing F ig ure 11..147).lww.

Hiss's Whi p Technique) 82 of 87 21/08/07 22:09 . F ig..150.3 26 Lower E xtremi ty Regi on: Foot: Cuneiform.. P. 11. The phy sic ian delivers a tractional thr ust foot while inc reasing the degree of dor siflex ion (w hite arr ows . 11. F ig. pressure from the phy sic ian's thumbs on the ball of the foot ( Fig . 6.148). 4. Step 5.lww.com/pt/re/9780781763714/bookContent. 11. F ig ure 11. Traction is placed on the leg at the same time dor siflex ion of the foot is inc reased (w hite arr ows . Pl antar Dysfunction (Dr.150).http://thepointeedition. Effectiveness of the tec hnique is determined by reassessing ank le range of motion.149). 5.

152. F igu re 11. Palpation: Tender prominence on the plantar sur fac e of the foot ov erlying the dys func tional c uneifor m.. 11. 2. A whipping motion is car ried out with the thumbs thr usting str aight down into the s ole F igu re 11.http://thepointeedition.com/pt/re/9780781763714/bookContent. T ech niq u e 1. Step 4. Motion: Longitudinal arch and for efoot will not readily spring toward s upination. The phy sic ian stands at the foot of the table. 83 of 87 21/08/07 22:09 .lww.. Diag nosis Symptom: Plantar disc omfort. The patient lies prone with the leg off the table flexed at the knee.151. 4. Steps 1 to 3. 3. The phy sic ian's hands are wrapped around the foot with the thumbs placed ov er the dr opped cuneiform (F ig.151).

153) ..154). 3.3 27 Lower E xtremi ty Regi on: Foot: Fifth Metatarsal Dysfuncti on. 84 of 87 21/08/07 22:09 . The patient lies supine. The thumb exerts pressure toward the sole. Plantar Styloid Diag nosis History : Common following inversion s prain of the ank le. T ech niq u e 1. F ig ure 11. 11. 2.http://thepointeedition. 11. Step 5. The physic ian places the MCP of the index finger beneath the sty loid pr ocess (F ig. F ig. 4.. The physic ian sits at the foot of the table. and the index finger exerts a forc e toward the dor sum of the foot ( white arr ows .com/pt/re/9780781763714/bookContent. The physic ian places the thumb over the dis tal end of the fifth metatarsal. P. 6.lww. A thrust is delivered by both fingers simultaneously.153. Effectiveness of the F ig ure 11. Steps 1 to 4. 5.154.

. F ig ure 11.3 28 Lower E xtremi ty Regi on: Foot: Cuboid. The patient lies prone with the leg flexed 30 degrees at F ig ure 11. Step 5.155..156. tec hnique is determined by reassessing pos ition and tender nes s of the styloid proces s of the fifth metatar sal. c uboid prominent on the plantar aspect of the lateral foot History : Common following inversion s prain of the ank le T ech niq u e 1. 85 of 87 21/08/07 22:09 .lww. Steps 1 to 4. Pl antar Rotation Diag nosis T enderness: Lateral plantar aspect of the foot just pr oximal to the s tyloid proces s of the fifth metatar s al and over lying the tendon of the peroneus longus musc le Palpation: Groove distal to the sty loid proc ess of the fifth metatar s al deeper than nor mal.com/pt/re/9780781763714/bookContent. P.http://thepointeedition.

86 of 87 21/08/07 22:09 . 4. F ig ure 11.lww.157. Step 6.158). Effectiveness of the tec hnique is determined by reassessing the position F ig ure 11. 11.156).157 and 11. 7. The phy sic ian places the thumb on the medial side of the foot over the plantar prominenc e of the cuboid.com/pt/re/9780781763714/bookContent. 11.158. Step 6.http://thepointeedition. 2. The later al aspect of the foot is opened by adducting the for efoot ( Fig . 11. F igs. The phy sic ian stands at the foot of the table.. 6. The thrus t is delivered in a whipping motion toward the lateral as pec t of the foot (w hite arr ows . 3. 5. the knee. The phy sic ian's thumb on the lateral s ide of the foot reinforces the medial thumb (F ig ..155).

200 3. 11t h ed . 4. M od i fi ed w i th pe r mi s s io n f r om Agu r A M R.com/pt/re/9780781763714/bookContent. D al l y AF.lww. Ba l ti m or e: W i ll i am s & W il k in s . P.3 29 References 1. W ar d R (e d) .. Ba l tim ore : L i ppi nco tt W i ll i am s & W il k in s . 2.. T he Th r us t Te c hn i qu e. J Am Os teop ath As s oc 198 1. P r in c ip l es of M an ual M ed i ci ne. 1 996 . 87 of 87 21/08/07 22:09 . and tender nes s of the cuboid.http://thepointeedition. H ei l ig D. 2nd ed .8 1:24 4–2 48. F ou nda ti on s f or Os te opa thi c Me dic i ne . Gra nt' s A tl as of An atom y . 3. 2005 . Ph i la del phia : L i pp i nco tt W il l i am s & Wi l k in s . Gre enm an P.

ev e nt u al l y a ll o win g t h e mu s c l es to a ch i ev e t h e ir no r ma l le n gt h a n d t o ne (4 ) . an d li g am e nt o u s a rt i cu l a r s tr a i n. o r o th e r s t ru c tu r e t o wa r d i t s p os i ti o n o f m o ti o n e a se or r ed u ce d t e n si o n. Th e c o mp o n en t r e gi o n o f t h e b o dy is pl a c ed in t o a ne u tr a l p o si t io n . P os t er i o r t ho r ac i c mus c l e h yp e rt o n ic i t y co mmon l y i s a s so c ia t ed wit h a n e x t en d ed po s i ti o n o f e a se (2 ) . 2 . i n di r e c t te c hn i q ue . t h e i n it i al p os i ti o ni n g i s t o f l a t t e n t he a nt e ro p os t e ri o r s pi n a l c ur v e a n d f in d t h e n e ut r al p os i ti o n wi th i n t he d y s f un c ti o n .. I f a d y s f un c ti o n al mu s cl e is ca u si n g t h or a ci c t en s i on an t er i o rl y . T h is i s b as e d o n p a lp a ti n g t h e a bn o r ma l t i s s u e t e x t u re s a nd t he i r r es p o ns e t o p o s it i on i ng ( 3) . th e ph y si c ia n wi l l a t t e mpt to pl a c e t he dy s f un c ti o na l se g me n t .a f fe r en t i mp ul s es .ax i s d i ag n os i s) . I f t h e d y s f u nc t i on a l r eg i o n i s p os i t io n ed ap p r op r ia t el y .e f f e re n t a c ti v it y ( 1. A s wi th co u nt e r s t r ai n t e c hn i qu e . whi c h S c hi o wi t z d e s c r ib e s a s f l at t e ni n g t he a nt e ro p os t e ri o r s pi n a l c ur v e ( f ac e t s ar e in a p o s it i on be t wee n t h e b e gi n ni n g o f f l ex i on a nd th e b e g in n in g o f ex t en s io n ) ( 3 ). O t he r b e n ef i ci a l a sp e c t s of th i s f o rm of t re a tm e nt may be re l a te d t o t h e t r ea t me n t p o si t io n ' s s ec o nd a r y e f f e c t s of im p r ov i ng ly mp ha t ic an d ve n ou s d r a in a ge an d ot h er bi o e le c tr i c p h en o me n a a f f e c ti n g f lu i d d y na mic s an d l o ca l me t ab o li c pr o ce s se s .p as s i ve . t h e i nt r a fu s al fi b e rs may r et u rn to n or mal le n g th . mus c le . I f t h e p ri mar y fo c us is t he tr e at me nt of mu s c le hy p er t o ni c it y a n d t e ns i on ( wh e n t he r e i s n o p r ed o mi n a nt x. Thi s re d uc e d t e ns i on in t he ar e a o f t h e mus c l e s pi n dl e fu r th e r d e cr e as e s t h e I α.. ba l a nc e d l ig a men t ou s t e n si o n. 3) . Thi s e x a mp l e i s c om mo n t o t yp e I I dy s fu n c ti o ns . 12 Facilitated Positional Release Techniques Technique P rincipl es Fac i l it a te d p o s it i on a l r e le a se (F P R) t ec h ni q u e i s a p a t ie n t.http://thepointeedition. d im i n is h in g t i s su e a n d j o in t t e ns i o n i n a ll p la n es an d an ac t iv a t in g f o rc e (c o mp r es s i on o r t o rs i on ) i s ad d ed ” ( 1 ) .. Th i s i s d o ne b y f ir s t a t te mpt i n g t o p la c e t h e myo f a s c i al or a rt i cu l ar d y s f un c ti o n i n a ne u t ra l p o si t i on . z . Th e Ed u ca t io n Co u nc i l o n O s te o pa t h ic Pr i nc i p le s ( E CO P ) d e fi n es FPR a s “ a s y s t e m o f i nd i r ec t m y of a s ci a l r el e a se tr e at me nt de v el o p ed by St a n le y S ch i o wi t z . f le x i on is th e mo s t p ro b a bl e p o si t i on of ea s e . w h i ch in tu r n c o nt i nu e s t h is be n e fi c ia l i n t er a c t i on .com/pt/re/9780781763714/bookContent. I t s p o s it i on i ng i s v er y s i mil a r t o c o un t er s tr a i n a nd th e in i ti a l i n di r ec t p o s it i on i ng f or S ti l l t ec h n iq u e. th e h y pe r t on i c mus c l e i s p la c e d i n a p os i t io n o f e a s e o f t en s i on . w h ic h in re t ur n de c re a se s te n si o n i n t h e e x t r a fu s al fi b e rs . e sp e c ia l ly my o f as c ia l r e l ea s e. a nd a s s uc h . DO . 1 of 29 21/08/07 22:10 . le s s a n te r io r a n d /o r p os t e ri o r p os i t io n in g i s ne c es s ar y . t h e p ri mar y ne u ro p hy s i ol o gi c m e c ha n is m a f f ec t ed by FPR i s t ho u gh t to be th e re l at i on s h ip be t we e n I α-a f fe r e nt an d γ . i t s h ar e s p r in c ip l es wit h t h e o t he r i n di r e c t os t eo p a th i c t ec h n iq u es .. a n d t he r e fo r e. y .lww. Wi t h a f le x e d o r e x t e n de d d y s f u n c t i on . The p ri n ci p le s of po s it i o ni n g i n t h is te c hn i q ue ar e b a s ic to in d i re c t t re a t me n t s . W i t h t yp e I d y s f un c ti o n s . The pr i mar y g o al o f t hi s t e c hn i qu e i s to re d uc e ab n or mal mus c l e h yp e rt o n ic i t y (s u p er f ic i al a nd de e p) a nd re s to r e l o s t mo t i on to a r e s t r ic t ed a rt i c ul a ti o n.

P. th e ph y si c ia n ma y a l so a dd a s li g h t o n. Nex t .en h an c in g me c ha n is m.lww. a n d p a in . e nd f ee l o r j o i nt fr e e. I t is r ec o mm e nd e d t o u s e t h is s t y le i ni t ia l ly whe n t he p hy s ic i an h as di f fi c u lt y d e te r min i ng th e pr i ma r y c o mp o ne n t o f t h e d y s f u nc t io n ( my o f as c ia l v e r su s a r ti c u la r ). r et u r ns th e p at i e nt to ne u t ra l ( p re t r ea t me n t p o si t io n ). Ne x t . The maj o r d is c r im i na t in g fa c to r w e se e i n t h i s t ec h ni q u e whe n c o mpa r in g i t to th e o t h er i nd i r ec t t e ch n i qu e s i s i t s r el e as e .p l ay qu a li t a ti v e c ha n g es . t h e p h y s i ci a n f l at t en s t h e s p in a l c u rv e i n t h e r eg i o n o r s eg me nt to be t re a te d o r in th e e x t re mit i es . a n d b ri n gs t he af f ec t e d a re a b a c k 2 of 29 21/08/07 22:10 . an d te n de r ne s s ( s en s it i v it y ). Th e d y s f u nc t io n al s eg men t s h o ul d t h en b e p os i ti o n ed to war d th e e a se o f mot i on i n a ll a f f e c te d p l an e s . D i Gi o va n n a a nd Sc h i ow i t z d es c r ib e t h is a s a f a ci l i ta t in g m u s cl e f o rc e (1 . h ol d s f o r 3 t o 5 s ec o nd s . r es t r ic t io n o f mo t io n . The s e c l ue s a r e g e ne r al l y t i s s u e t ex t u re ch a ng e s . m o ti o n r e s t r ic t i on . t h en re t u rn s t h e a f fe c te d a r e a t o a ne u tr a l p o si t io n a n d r e as s es s e s . a nd fo l lo ws b y r e as s e s s i ng th e dy s fu n c t i o n u si n g t h e p al p a to r y p ar a met e rs fo r ti s su e t e x tu r e c ha n g es . 3 32 Technique Classifi cation I ndi rect A s wi th al l i n d ir e c t te c h ni q ue s .. bu t i t c a n a c c o mm o d at e a l l d i re c ti o ns o f mot i on e as e o r d i r ec t io n s i n w h ic h t h e m u s c l e t en s i on is re d u ce d . a s y mmet r y . t h e p h y s i ci a n a d ds th e a p p ro p ri a te f ac i li t at i n g f or c es ( co mp re s si o n a n d t or s io n ) a n d h ol d s f o r 3 t o 5 s ec o nd s .com/pt/re/9780781763714/bookContent. t e ns i o n. T h i s may be a c o mp r es s i on fo r ce . Technique S tyl es Myofasci al (Muscle Hypertoni city) To t r ea t a hy p e rt o ni c m u s cl e w i th FPR . 3) . Arti cular (Intervertebral and I ntersegmental x-. .o f f sp r in g i ng (r o c k i n g) f or c e . t h e p hy s ic i a n a t t e mp t s t o p o si t i on th e p a t ie n t i n t h e d ir e c ti o n t ha t re d uc e s t h e myo f as c i al ti s su e te n si o n o r i n t h e d i re c ti o n o f t h e mot i o n f re e d om . B ec a u se of si d e b e nd i ng a nd ro t at i o na l c o mp o n en t s i n mo s t d y s f u nc t io n s ( s pi n al an d ex t re mit y ) i t i s g e n er a ll y n e c es s ar y f o r t h e p hy s i ci a n t o a d d s om e fo r m o f t o rs i on (s i d e b en d in g co mbi n ed wit h r o ta t i on ) f o rc e du r in g t h e p o si t io n a l c om p o ne n t o f t h e t ec h ni q u e. y-. g..a nd . ad d in g c o mpr e s s i on t ow a rd th e j oi n t . The n t h e p h y s i ci a n a s se s se s fo r t i s s u e t e x t u re c ha n ge s ( e . t he ph y si c i an us e s t h e p al p at o r y c lu e s f o r p ri mar y i nt e r se g me n ta l (j o in t ) d y s f u nc t io n s . i ne l a s t i ci t y . T h e p h y s i ci a n s t ar t s b y f la t t en i ng th e an t er o po s t er i or sp i n al cu r ve o f t he re g i on be i ng t re a te d . The ph y s ic i an ho l d s t he tr e a tm e nt po s i ti o n f or 3 t o 5 se c o nd s . z -Axi s) Dysfunction I n a r ti c ul a r t e ch n iq u e. t h e p hy s ic i a n a dd s t h e a p pr o pr i a te ax i al f ac i li t at i n g f or c es ( co mp re s si o n a n d t or s io n ) . On ac h i ev i ng th e pr o pe r p o s it i on of e as e w i th t he f ac i l it a ti n g f o rc e s . b og g in e s s ) an d p o si t i on s t h e p a ti e nt un t i l t he s e d y s f u nc t io n a l p ar a me t e rs a re o pt i ma l ly r ed u ce d . a s ym met r ic mot i on (m a y e x hi b it s ym met r ic a l ly re d uc e d m o ti o n) .http://thepointeedition.

4. 2. r e s t r ic t i on of mo t i on . A f ac i li t at i n g f or c e o f c o mp r es s i on c om b i ne d w i th s id e b e nd i n g a nd / or r ot a ti o n ( t or s io n ) i s a p pl i ed f or 3 t o 5 se c on d s .lww. re l a xe d ) p os i t io n . t e nd e r ne s s [ TA RT] . a n k y l o si s ) 6. P la c e t h e d y s f u nc t io n al myo f as c ia l s t r uc t ur e in t o i t s e as e ( s ho r t en e d. 6. The p hy s ic i an r ea s se s se s th e d y s f u n c t i on a l c o mp o ne n t s ( ti s su e t e x tu r e a bn o r ma l it y . 3 of 29 21/08/07 22:10 . Cer t a in co n ge n i ta l a n om a l ie s o r c o n di t io n s i n w h ic h t h e p o si t io n ne e de d t o tr e at t he d y s f un c ti o n i s n o t p o s s i bl e ( e .. e sp e ci a ll y in th e p r e se n ce o f r a di c ul a r s y mp t om s a t th e l e ve l to be tr e a te d i f t h e p o si t io n i ng co u ld c au s e e xa c e rb a ti o n o f t h e s ym p t om s b y f u r th e r n ar r o wi n g t he f or a me n 4. a nd th e n a po s it i o n o f e as e or a p os i t io n t h at max i ma l ly r ed u c es my o fa s c ia l t e ns i o n i s a pp r o ac h ed . 5. th e n s lo wl y r el e as e pr e s s u re whi l e r et u r ni n g t o n e ut r al . Mak e di a gn o si s (t i s s u e t e x t u re ab n o rm a li t y) . A dd a c o mp r es s i on or to r s io n al fa c i li t at i ng f or c e. I ndi cati on Myo f a s c i al or a rt i cu l ar s om a ti c d y s fu n c t i on Contraindicati ons 1. Fla t t en th e a n t er o po s te r i or sp i na l cu r ve to r ed u ce my o f as c ia l t e n si o n. Mod e r at e t o s e v er e j o in t in s ta b il i t y 2. 3. . Mod e r at e t o s e v er e i n te r v er t eb r al f or a mi n al s te n os i s . Hol d fo r 3 to 5 s e co n ds . g. A s pr i n gi n g f or c e m a y a ls o be us e d. Th e a nt e ro p o s t e ri o r s pi n a l c ur v e i s f l at t en e d .. S horthand Rules P rim ary Myofascial Dysfuncti on 1. V er t e br o ba s il a r i n su f fi c i en c y General Considerations and Rules The p hy s ic i an mus t b e a b l e t o mak e an ac c ur a t e d ia g no s i s a nd wh e n p o s s i bl e to d is t i ng u is h b e t we e n a m y o fa s ci a l a n d a n a rt i c ul a r d y s f u nc t io n .com/pt/re/9780781763714/bookContent. Her n i at e d d is c wh e re th e po s it i on i n g c ou l d e x ac e rb a te t he co n di t i on 3. a s ym met r y o f p o si t io n .http://thepointeedition. S ev e r e s pr a in s an d s t ra i n s whe r e t h e p os i ti o n in g m a y e x ac e rb a te t he in j ur y 5. t o a ne u tr a l p o si t io n f o r r e as s es s men t .

4 of 29 21/08/07 22:10 . 5.http://thepointeedition. 2. P. 3. A dd t he fa c il i t at i ng fo r c e ( co mpr e s si o n o r t o rs i on ) . The pa tie n t l ies sup ine . Step s 1 to 5. z -axis) Type I and II Dysfuncti ons 1. Fla t t en (f l ex o r e x t e nd ) th e a n te r o po s te r io r cu r ve in t he sp i na l re g io n o f t re a t me n t . the ph ysi cian neu tra lize s the cervical spin e by gen tly fla tte nin g th e Figure 12. 2. Rea s s es s t h e d y s f u nc t io n a l c om p on e n t s (T A RT ) . th e n s lo wl y r el e as e pr e s s u re whi l e r et u r ni n g t o n e ut r al . t y p e I o r I I ) . g.. P rim ary Articul ar (x-. 7. 3 34 Cervi cal Region: Right: S ubocci pital Muscle Hypertonici ty 1. The ph ysi cian gen tly su p ports the occip i tal and up per cervical reg ion s o f th e patien t's hea d with the righ t han d.com/pt/re/9780781763714/bookContent. P. Mak e di a gn o si s (e .lww. With the l eft han d o n th e patien t's hea d. Mov e th e d y s f u n c t i on a l s e gm e nt to wa rd it s s i d e b en d in g an d r o ta t i on a l e as e .1. 3 33 4. Mov e th e d y s f u n c t i on a l s e gm e nt to wa rd it s f l e xi o n o r e x te n si o n e a se . 6. Hol d fo r 3 to 5 s e co n ds . . a n d the ph ysi cian sits a t th e h ead of the ta b le. 3. y-..

7. 5 of 29 21/08/07 22:10 .com/pt/re/9780781763714/bookContent. antero posteri or curve (sl i ght fle xio n).lww.. Step s 1 to 5. 12. The ph ysi cian hol ds thi s positi on for 3 to 5 seco n ds and th en slo wly rel eases the compre ssi o n whi le retu rni ng to neu tra l .2. Figs . If a rele a se is Figure 12. An activa ting force in the form o f a gen tle (1 lb or less) axi a l compre ssi o n i s add ed with th e left h and .2 ) until maxi mal red uction of tissue an d muscle te n sio n is ach ieve d.http://thepointeedition. 4..1 a nd 1 2. Whi le mai nta ini n g compre ssi o n. 6. the ph ysi cian gen tly positi ons the patien t's hea d and ce rvi cal reg ion to w ard extension and rig ht sid e ben din g a n d rotati on (a rrow s. 5.

3.. not pa lpa ted within a few second s. 3.com/pt/re/9780781763714/bookContent. a n d the ph ysi cian sits a t th e h ead of the ta b le. 2..lww. The ph ysi cian gen tly su p ports the ce rvi cal reg ion wi th the rig ht han d . 3 35 Cervi cal Region: C2 to C4 Dysfuncti on Exampl e: C4 FSRRR* 1. Step s 1 to 5. 6 of 29 21/08/07 22:10 . 8. P. The pa tie n t l ies sup ine . a xia l compre ssi o n sho uld be rel eased a nd ste ps 3 to 6 can be rep eated. The ph ysi cian rea sse sse s th e compon ents of the dysfu n cti on (TART).http://thepointeedition. the ph ysi cian neu tra lize s the cervical spin e by gen tly fla tte nin g th e antero posteri or Figure 12. With the l eft han d o n th e patien t's hea d.

7. Step s 1 to 5. An activa ting force (a rrow) in the fo rm o f a gen tle (1 lb or less) axi a l compre ssi o n i s add ed with th e left h and . 5. 7 of 29 21/08/07 22:10 .4).. 4.com/pt/re/9780781763714/bookContent.http://thepointeedition.. 6.3 a nd 12. Whi le mai nta ini n g compre ssi o n. 12 . the ph ysi cian gen tly positi ons the patien t's hea d tow ard fl e xio n and ri ght sid e ben din g a n d rotati on (a rrow s) u nti l maxima l red uction of tissue an d muscle te n sio n is ach ieve d (Figs.lww. If a rele a se is not pa lpa ted within a few Figure 12.4. The ph ysi cian hol ds thi s positi on for 3 to 5 seco n ds and th en slo wly rel eases the compre ssi o n whi le retu rni ng to neu tra l . curve (sl i ght fle xio n).

. The ph ysi cian rea sse sse s th e compon ents of the dysfu n cti on (TART). The physician 's left h and mon ito rs the patien t's dysfun cti o n at the spi nou s pro cesses of T6 and T7 Figure 12. P.5. 3 36 Thoracic Region: T4 to T12 Dysfunctions E xam ple: T6 E SRRR 1. a xia l compre ssi o n sho uld be rel eased a nd ste ps 3 to 6 can be rep eated.lww.com/pt/re/9780781763714/bookContent.. 2. 8 of 29 21/08/07 22:10 . Step s 1 to 3. 8.http://thepointeedition. second s. The pa tie n t sits a t th e edg e o f th e tab le with th e physician sta ndi ng a t the ri ght sid e and sl igh tly posterior to the pa tie n t.

http://thepointeedition.com/pt/re/9780781763714/bookContent. Figure 12.6.5).. 3.. 9 of 29 21/08/07 22:10 . 12. and th e ri ght tra nsverse pro cess o f T6. The physician pla ces th e rig ht fore arm on the patien t's upp er rig h t tra pezius (sh oul der girdle ) w i th the remain der of the physician 's rig ht fore arm and ha nd restin g across th e patien t's upp er back just b ehi n d the pa tie n t's neck (Fig. Step s 4 to 6. The pa tie n t sits u p straig ht u nti l the no rma l tho racic curvature is straig hte n ed and fla tte ned . so tha t extension is pal pated a t the le vel of T6.lww. 4.

http://thepointeedition.com/pt/re/9780781763714/bookContent.6 ) to positi on T6 into furth er extension and ri ght sid e b end i ng and ro tati on. 1 2. 7. The physician hol ds thi s positi on for 3 to 5 seco n ds and th en slo wly rel eases the compre ssi o n 10 of 29 21/08/07 22:10 .lww.. 6. Fig. the ph ysi cian pla ces a cau dad an d posterior force with th e rig ht fore arm (w h ite arrow. 5.. Thi s shou l d be carrie d to a p oin t o f bal ance a n d min imu m muscle to n e. The physician 's rig ht fore arm app lie s a n activa tin g force in the form o f gen tle (1 lb or less) compre ssi o n. Whi le mai nta ini n g compre ssi o n.

http://thepointeedition. compre ssi o n sho uld be rel eased a nd ste ps 3 to 6 can be rep eated.lww.com/pt/re/9780781763714/bookContent. The physician rea sse sse s the compon ents of the dysfun cti o n (TART). If a rele a se is not pal pated within a few second s. 3 37 Thoracic Region: Right-S i ded Trapez ius Muscl e Hypertonici ty 11 of 29 21/08/07 22:10 . 8. 9. P. whi le return ing to neu tra l...

lww.9 ) to ach ieve a poi nt of b ala nce and mi nima l muscle te n sio n i n the ri ght tra pezius muscle . The ph ysi cian sta nds at the le ft sid e. Step 4. Figure 12.7. 6. The ph ysi cian 's left h and pal pates the rig ht. 12. faci ng the patien t.8. Figure 12. 12 of 29 21/08/07 22:10 . The pa tie n t l ies pro ne on the tre atment tab le with the h ead and ne ck rota ted to the ri g ht.http://thepointeedition. 12. On ach ievi ng the Figure 12. Fig. 3.8).com/pt/re/9780781763714/bookContent. 2. 4..7 ). The ph ysi cian 's rig ht han d rea che s a cross the bo dy o f the patien t a n d gra sps th e patien t's rig ht sho uld er a t the anteri or d eltoid and acromi ocl a vicula r reg ion (Fig. Step 5. Step s 1 to 3.9.. 1. The ph ysi cian pla ces a caud ad and po ste rior force (w h i te arrow. hyp ertoni c tra pezius muscle (Fig. 1 2. 5.

http://thepointeedition. The pa tie n t's left a rm i s fle xed at the elb ow.. Ste p 4 .lww. Ste p 5 .11. 13 of 29 21/08/07 22:10 .12. 12. mon ito rin g fo r tissue te xture cha nge s (Fig. The physician 's l eft han d controls the ol ecra non pro cess w h ile the in dex and thi rd fin g ers of the ri ght han d pal pate th e posterior asp ect of the first rib . an d a pil low or rol led tow el is p laced und er the patien t's upp er arm. Figure 12. Figure 12. The pa tie n t lie s supi n e and th e physician sta nds fa cing the pa tie n t o n the dysfun cti o nal sid e. Ste ps 1 to 3. The physician 's l eft Figure 12. 2. P. S oft-Tissue Effect 1. P osterior E levation: Nonrespiratory Model .com/pt/re/9780781763714/bookContent. 4. 3 38 Costal Regi on: Left First Ri b Dysfunction. 3..11).13.

a nd 14 of 29 21/08/07 22:10 ..http://thepointeedition.lww. Thi s p osi tion is hel d for 3 to 5 second s.. 6. Fig. 5. han d flexe s the pa tie n t's sho uld er to app roxima tely 90 deg ree s and th en abd ucts sli ghtly a nd intern all y rotate s th e sho uld er to the positi on that pro duces the most l axi ty a nd soften ing of the ti ssu e s (Fig. The ph ysi cian add ucts th e arm an d simultane o usl y app lie s a compre ssi o n throug h th e patien t's left upp er arm tow ard th e mon ito rin g fin gers a t th e first rib (strai ght arrow.1 3 ) whi le push ing the pa tie n t's elb ow dow n tow ard th e che st (cu rved arrow) ove r the pi llo w . 1 2. 12.1 2).com/pt/re/9780781763714/bookContent.

14. Figure 12.. a nd the physician sta nds or sits o n th e e dge of the ta b le in fro nt of the patien t (Fig. 3 39 Costal Regi on: Left S eventh Rib. I nhal ati on Dysfunction 1. 15 of 29 21/08/07 22:10 . 8.. The pa tie n t l ies in the ri ght latera l recumb ent (si de-lyi n g) positi on w ith th e arm fl exe d an d abd ucted to app roxima tely 90 deg ree s. a slig ht on-and -off pre ssu re can be app lie d . The ph ysi cian rea sse sse s th e compon ents of the dysfun cti o n (TART).com/pt/re/9780781763714/bookContent. Ste p 1 . 12. P. 7. After 3 to 5 second s th e arm is bro ugh t throug h fu rth er add uction and the n i nfe riorly swu ng back to the la tera l bod y l ine .1 4).lww.http://thepointeedition.

The ph ysi cian pla ces th e in dex and /or th i rd fin ger pad s o f th e righ t han d o ver the posterior asp ect of the se ven th rib at the costotran sverse articu lati on.15. Figure 12. bei ng carefu l n o t to p ut too mu ch p ressure ove r the chon dra l portio n (Fig.1 6). Th e thu mb is p laced ove r the i nfe rio r edg e o f th e l ate ral asp ect of the same rib. 12.17.http://thepointeedition.com/pt/re/9780781763714/bookContent. Figure 12. 12. 5.16. Ste p 4 . Ste ps 2 a n d 3 . attemp tin g by th is compre ssi o n to diseng age the ri b fro m the vertebra (Fig. The ph ysi cian gen tly pu shes th e rib po ste rior (a rrow ).lww. 3.15). The ph ysi cian 's web bin g o f th e l eft han d (thu mb abd ucted) con tou rs the antero late ral asp ect of the seventh ri b... 16 of 29 21/08/07 22:10 . 2. The ph ysi cian add s a cep hal ad-vectore d force (bu cket han dle ) to ward Figure 12. 4. Ste p 5 .

lww.com/pt/re/9780781763714/bookContent. 3 40 Lumbar Regi on: L1 to L5 Dysfunctions E xam ple: L3 NS LRR 17 of 29 21/08/07 22:10 .. th rou gh the bu cke t ha ndl e vector. 8. P. The ph ysi cian rea sse sse s th e compon ents of th e dysfun cti o n (TART). 6. the in hal a tio n ease (arro w. Thi s p osi tion is hel d for 3 to 5 second s.http://thepointeedition. Fig. After 3 to 5 second s th e rib is pushed sl o wly back to n e utral as the pa tie n t b rin gs the arm d o wn to the la tera l b ody lin e. a nd a sli ght on -and -off pre ssu re can be app lie d. 12. 7.17)..

Figure 12. Figure 12.20.lww.18). 12.. facing th e patien t. Ste ps 1 to 3. 3. 2. 5.19. 4. Ste p 6 . A p ill ow may be pla ced und er the abd ome n to decrea se the no rma l lumbar curvature .com/pt/re/9780781763714/bookContent. The physician Figure 12. The physician sta nds at the left side of the pa tie n t. The physician 's left h and mon ito rs the patien t's L3 and L4 spi nou s pro cesses and th e ri ght tra nsverse pro cess o f L3 (Fig. The physician rests the left kne e o n th e tab le aga inst th e patien t's left ili um. Ste ps 4 a n d 5 . 1. 18 of 29 21/08/07 22:10 . The pa tie n t lie s p ron e on the ta b le.18.http://thepointeedition..

com/pt/re/9780781763714/bookContent. a nd the le ft fore arm and ha nd con tro l th e rig ht pel vic and lu mba r reg ion (Fig.22. 2.23. Figure 12. 3. Ste ps 1 a n d 2 . and the ph ysi cian sta nds at the sid e o f th e tab le faci ng the pa tie n t. The physician 's rig ht fore arm and ha nd con tro l th e patien t's rig ht antero late ral che st wal l . Ste p 3 .lww. 12. 19 of 29 21/08/07 22:10 . The physician 's rig ht ind e x a nd thi rd fin g er pad s moni tor and co ntro l the tra nsverse pro cesses of L4 whi le the left i nde x an d thi rd fin g er pad s moni tor Figure 12.22). 3 41 Lumbar Regi on: L1 to L5 Dysfunctions E xam ple: L4 FS RRR 1.http://thepointeedition... The pa tie n t lie s i n th e l eft latera l recumb ent positi on. P.

5. 6. Ste p 8 . 4.25.. 20 of 29 21/08/07 22:10 . The ph ysi cian the n g entl y pushes th e patien t's pel vic and lu mba r reg ion anteri orl y un til L5 is ful l y eng age d a n d rotate d to th e left u nde r L4 ..lww. the ph ysi cian . 7. The ph ysi cian gen tly fl e xes the pa tie n t's hip s u nti l L4 is ful ly fle xed on L5. and co ntro l the tra nsverse pro cesses of L5 (Fig. Figure 12. Ste ps 4 to 7. On exh ala tion .24.com/pt/re/9780781763714/bookContent. with b oth the forearms a nd fin gers o n th e tra nsverse Figure 12. 12. The ph ysi cian carefu lly pushes th e patien t's rig ht sho uld er posteriorl y until L4 i s eng age d a n d rotate s fa rth er to the ri g ht on L5.23).http://thepointeedition. The pa tie n t inh ale s a n d exh ale s fu lly.

compre ssi o n sho uld be rel eased. Fig. If a rele a se is not pa lpa ted within a few second s. 8. simultane o usl y app roxima ting the fo rea rms (strai ght arrows). Fig. increa ses the force thro ugh the sa me set of rotati o nal vectors (cu rve d arrows. 9.http://thepointeedition. pro cesses. 12. and ste ps 3 to 8 21 of 29 21/08/07 22:10 . the physician app lie s a n activa tin g force (a rrows. the reb y pro ducing increa sed sid e ben din g ri ght.com/pt/re/9780781763714/bookContent. On ach ievi ng the prope r positi on.24). 1 2..lww.2 5 ) i n the fo rm o f a gen tle (1 lb or less) axi a l compre ssi o n for 3 to 5 second s w i th the fi nge r pad s..

Usi ng the left han d.26.lww. P. Ste ps 1 a n d 2 ..http://thepointeedition. can be rep eated. The physician faces the patien t o n the le ft. A pil low ma y be pla ced und er the abd ome n to decrea se the normal lumbar curvature . 3 42 Lumbar Regi on: Left-S ided Erector S pinae Muscle Hypertonici ty 1. The pa tie n t lie s p ron e on the treatment tab le. 22 of 29 21/08/07 22:10 . 10. 2..com/pt/re/9780781763714/bookContent. the physician mon ito rs the patien t's dysfun cti o nal ere cto r Figure 12. The ph ysi cian rea sse sse s th e compon ents of the dysfun cti o n (TART).

The physician 's left knee is pla ced on the ta ble aga inst th e patien t's left ili um.28.2 7).http://thepointeedition. 3.lww. 23 of 29 21/08/07 22:10 . Ste ps 3 a n d 4 . 4. Figure 12. 12.29. spi nae hyp ertoni city (Fig..2 6). The physician rep osi tio n s the ri ght han d to gra sp the patien t's rig ht thi g h and di rects a force dorsal ly a nd tow ard extern al rotati on (wh ite Figure 12..com/pt/re/9780781763714/bookContent. Ste p 5 . Ste p 6 . The physician cro sse s th e patien t's rig ht ankl e ove r the patien t's left ankle and gra sps th e patien t's rig ht kne e . 5. sli din g b o th of the patien t's leg s to the le ft (Fig. Figure 12. 12.27.

12.29) in the form o f a gen tle (1 lb or less) a xia l compre ssi o n for 3 to 5 second s. 24 of 29 21/08/07 22:10 ..com/pt/re/9780781763714/bookContent. Fig. 7. arrows.http://thepointeedition.28). If a rele a se is not pal pated within a few second s. Th is combin ed moveme nt sho uld be carrie d to a poi nt of bal ance a n d min imu m muscle to n e as percei ved by the physician 's left h and . compre ssi o n sho uld be rel eased. 6. and steps 3 to 6 can b e rep eated. Fig.lww.. the physician 's left h and app lie s a n activa tin g force (w h i te arrow. On ach ievi ng the prope r positi oni n g. 12.

P. The pa tie n t l ies in the ri ght latera l recumb ent positi on. and th e physician sta nds in fro nt o f the patien t a t th e side of the ta b le.lww. The ph ysi cian 's left h and is pla ced pa l m d own ove r the supe rio r edg e o f th e i lia c Figure 12.30.. 8. 3..http://thepointeedition. 25 of 29 21/08/07 22:10 . The physician rea sse sse s the compon ents of the dysfun cti o n (TART).30).com/pt/re/9780781763714/bookContent. 3 43 P elvi c Regi on: Left P osterior I nnom inate Dysfunction 1. 2. Ste ps 1 a n d 2 . The physician con tro ls the le g w i th thi s arm an d th e sho uld er (Fig. 12. The ph ysi cian 's rig ht arm rea che s und er the patien t's left thig h and ab ducts i t to app roxima tely 30 deg ree s.

Ste p 6 . Figure 12.. The ph ysi cian add s a posterior-vectored force with a sli ght arc (righ t-tu rn direction ) wi th the left h and (d o wn arrow) as the ri ght han d a nd fore arm pul l i nfe riorly and anteri orl y (u p arrow) (Fig.31. Ste p 5 .. 6. Ste ps 3 a n d 4 . 12. 4. cre st.32. 12.com/pt/re/9780781763714/bookContent. the physician add s a compre ssi ve force (1 lb or l ess) tow ard th e ta ble Figure 12.32).3 1).33.lww. 26 of 29 21/08/07 22:10 . 5. The ph ysi cian 's rig ht han d is pla ced ove r the posterior ili ac cre st and posterior sup eri or ili ac spi n e (PSIS) with the fore arm on the posterola tera l asp ect of the gre ate r troch anter (Fig. As the pe l vis rotate s posteriorl y. Figure 12.http://thepointeedition. wi th the thu mb con trol lin g the an teri or sup eri or i lia c spi ne (ASIS) and the ha nd con tro lli n g the sup eri or e dge of the il iac cre st.

9. The ph ysi cian rea sse sse s th e compon ents of th e dysfun cti o n (TART).33) to app roxima te the sacroi lia c jo int surfaces. P. (a rrow . If a rele a se is not pal pated w ith in a few se con d s. Thi s p osi tion is hel d for 3 to 5 second s. 3 44 P elvi c Regi on: Left Anterior Innom i nate Dysfunction 27 of 29 21/08/07 22:10 .. 12.lww. a nd a gen tle on -and -off pre ssu re can be app lie d. compre ssi o n sho uld be rel eased. and ste ps 3 to 8 can be rep eate d. Fig.http://thepointeedition. 7. 8.com/pt/re/9780781763714/bookContent..

36. 1.com/pt/re/9780781763714/bookContent.lww.. 12. The pa tie n t lie s i n th e rig ht late ral recumb ent positi on. Ste p 5 .35.. The physician con tro ls the leg wi th this arm an d th e sho uld er (Fig. 28 of 29 21/08/07 22:10 .34). 2. 3. Ste ps 3 a n d 4 . Ste ps 1 a n d 2 . The physician 's rig ht arm rea che s und er the patien t's left thi gh and abd ucts i t to app roxima tely 30 to 40 deg ree s. Figure 12.http://thepointeedition. and the ph ysi cian sta nds in fro nt of the patien t a t th e sid e o f th e tab le.34. Figure 12. The ph ysi cian pla ces th e le ft han d p alm dow n o ver the sup eri or e dge of the il i ac cre st with th e thu mb con tro lli n g the ASIS a nd the ha nd con tro lli n g the su peri or Figure 12.

S c hi o wi t z S . 19 9 5. C a re w TJ . Ku s un o s e R. G oe r i ng E. 4 . 3 rd ed . Jo n e s S tr a in . B o is e : J o ne s S t ra i n.Cou n te r s t r a in . T h e Co nt r ol of Ref l ex Ac t i on : P r in c i pl e s o f Ne ur a l S ci e n ce . 2 00 3 ..http://thepointeedition. 2 00 5 . Fou n da t io n s f o r O s t e o pa t hi c M e d ic i ne . D i Gi o v an n a E . P hi l a de l ph i a: L i pp i nc o t t Wil l ia ms & Wi l ki n s . W a rd R.lww. J o ne s L. 2 n d e d . 2 n d e d . ( ed . 1 9 85 ..Co un t er s tr a i n. Ne w Y or k : E l se v ie r . 3 45 References 1 . 3 . ).com/pt/re/9780781763714/bookContent. Ph i la d el p h ia : L i pp i n co t t Wil l i am s & Wi l k in s . P. 2 . A n O s te o p at h ic Ap p r oa c h t o Di ag n os i s a n d Tr ea t me n t . 29 of 29 21/08/07 22:10 .

u s in g a par t o f th e p ati ent' s a nat om y ( e. fl exe d. w e h av e r ec l as s i fi ed tho s e p r ev i ou s l y tau ght as H VL A tec hn i qu es i nto th i s c ate gor y . m any os teo path i c tec hniq ues ha v e g r os s s i m il ari tie s bu t f all i nt o d i ff er en t c ateg ori es. tru nk. r ota ted ri ght. as the a r ti c ul ar s urf ace s an d o the r el eme nts ( e. te nder nes s [ T ART ]).lww. Th i s m oti on at t he ter m i na l p has e m ay b e s i mi l ar to a l ong. wi th p ubl i ca ti on of Th e St i ll T ec hn i qu e M anua l . Basi c al l y. a sl i gh t c om pr ess i ve for c e m ay be add ed s i mi l ar to F PR tec hn i qu e. g. bo ny . lu m bar . it m ay be a c l as s ic ex am pl e o f h ow a nu m be r of ot her tec hn i qu es c omb i ne an d un der go a me tam orp hosi s t o b ec om e y et anot her te c hni que . t he phy s i ci an m ay att emp t a s li ght co m pre s si on of 1 of 33 21/08/07 22:10 . Ca r ry i ng the se gm en t t hro ugh a p ath of l ea s t r esi s ta nce i s i mp ort ant. D O.http://thepointeedition. 19 74) . a s t he d y sf unc ti on al pat tern ma y b e el i mi nat ed d uri ng the m ov em ent wi thin th e r ange be twe en e ase an d bi nd l im i ts. t he Sti l l tec hn i qu e.2) . o ther w is e u ntow ard si de e ffe c ts . i nno m i na te.. t he dys func tio nal s eg m en t i s ca r ri ed thro ugh a m oti on arc or pat h o f le ast re s i st anc e t ow ar d the bi nd .. an d ex tre m it y dy s fu nct i on s (i . w he r ei n th e r es tr i ct i ve bar r ie r i s me t a nd then pa s se d th r ou gh ( alb eit mi ni ma l ly ) . I n 20 00. c an r esu l t. Atl as of Os teop ath i c T ech niq ues .bin d ( ti gh t-l oos e) b arr i er asy m me tri es m ust be not ed. Th ere fore .e.v el oci ty. T ec hni que s of St i ll i s no exc epti on.le v ere d h i gh . 13 Techniques of Still Te c hnique Pr inciple s As no ted ea r l ie r i n t hi s boo k . T hen .am pli tude (H VLA ) te c hn i qu es . . if th e d y s fu nct i on i s doc ume nted as L4 . ex tr em i ty ) t o ca use a l ong . y. Te c hnique Cla ssific ation Indire ct. su c h as pain . F AAO . ho w eve r . w hi c h i s t he eas e or mo s t fr ee mo tio n av ail abl e in th e c ar di nal (x . m any of the s e t ech niq ues bec ame m or e for ma l ly st r uct ure d a nd c l as s if i ed.r ep etit i ve ar ti cu l at ory m et hod th at i s i ndi r ect then dir ect ” (1 .le v er ed for ce ve c to r . by R i ch ard L. Ph D . an d s i de. l ow .ti ght r es tri c tiv e b arr i er. r ota ti on ri ght .ben t r i ght (L 4 F R R SR ) . the dys fun c ti onal se gme nt d oes no t ne c es s ar i l y hav e t o be mo v ed th r oug h t he r est r ic tiv e bi nd bar r i er . Van Bu s ki r k . as the st art i ng poi nt of t his te c hni que is i n i ndir ect po s i ti oni ng s i mi l ar to tha t o f f ac il i ta ted pos i ti ona l re l ea s e ( F PR ) a nd othe r i ndi r ect te c hn i que s .. the i ni tia l ( i ndi r ec t) posi tio nin g wo uld be to m ov e L 4 in to fle x i on .. and l ong . z) pl anes of mo ti on . At Phi l ade l ph i a C oll ege of Ost eop ath i c M edic i ne (P C OM) a num ber of the s e t ech niq ues w er e i nc lu ded in the s e oth er c ate gor i es ( HV LA. as y mm etr y of po s it i on. g. Te c hnique Sty les C om pre ssion W hen pos i ti onin g t he pati ent at the in dir ec t bar r ie r . F or e x am ple . ar tic ula tor y ) f or y ea r s a nd w er e us ed c om m onl y f or c ost al. th i s tec hniq ue i s defi ned as “ a s pe c if i c n on. Th i s i s d i ff ere nt f r om HV LA. T her efo r e. The n D ire ct T he d i ag nos ti c c om pon ents fo r S ti ll te c hn i que ar e t he s ame fo r al l o s te opat hic te c hni que s ( ti ss ue tex ture abnor m al i ty . i n th i s c as e.l ev ere d HV LA.com/pt/re/9780781763714/bookContent. re s tr i c ti on of m oti on. i n i ts si m ple s t des cr i pt i on . C onti nui ng this pr i nc i ple of in di re c t pos i tio nin g. a r ti c ul ator y . l ig ame ntou s ) s ho ul d not be c om pro m is ed a nd s tr es s ed . Sti l l tec hniq ue i s a co m bi nat i on of s om e of th e c om po nen ts of i ndi r ec t. Th e ra nge of m ot i on an d eas e. an d s i de bendi ng r ig ht.

349 C e r vic al Region: Oc cipitoa tla nta l (C 0—C 1.lww. ner ve ro ot i r ri tat i on m ay be an unw ant ed s i de ef fec t.. OA) Dys func tion Ex a mple: C0 ESRR L. H owe v er. M ode r at e t o se v er e j oi nt in s ta bi li ty i n the are a t o be tr eat ed 3.http://thepointeedition. Al s o. i t m ay not be pru den t t o ho l d thi s co m pr ess i on at the o uts et of m ove m en t to w ar d t he r est r ic ti ve ba r ri er . M y of asc i al s om ati c d y s fu nct i on s as s oc i at ed w i th mu s c le hy per toni c it y o r fa s ci al bi nd C ontra indica tions 1.348 be pr odu c ed and th e a r tic ula r c ar ti l ag e m ay b e i nju r ed. Indica tions 1. T his te nds to be unco m fo r ta bl e for mo s t p ati ent s . Th i s c om pr ess i on m ay he l p i n p r od uci ng a sl i gh t di s en gag em en t o f t he d y sf unc ti on . Sea ted* 2 of 33 21/08/07 22:10 . de pen di ng on the p ati ent ' s h eal th and fun c ti onal ca pac i ty at the are a. o r rh eum ato i d ar th r it i s i n t he are a to be tr eate d 2. Tr a ction W hen pos i ti onin g t he pati ent at the in dir ec t bar r ie r . t he phy s i ci an m ay att emp t a s li ght tr ac ti on of the ar tic ula tor y su r fa c es bef ore be gi nn i ng th e tr ans fer of the se gm en t t owa r d t he r es tr ic tiv e b ar ri er. as a s hear ef fec t ca n P. the a r ti c ul ator y s urf ac es be for e be gin nin g th e t r an s fer of th e se gme nt towa r d the r es tri c ti v e b arr i er . and w e t y pi c all y r ele as e the co m pre s si on s i mu l ta neo us ly wi th the art i cu l ar m ov eme nt.. Th i s di s tr act i on m ay he l p i n p r od uci ng a sl i gh t di s en gag em en t o f t he d y sf unc ti on . Ar ti c ul ar s oma tic dy s fun c ti ons ass oci ate d wi th i nt er se gme nta l mo tio n r es tr i ct i on 2. i f the pa ti en t h as any for ami nal nar r ow i ng. Seve r e l os s of in ter s egm ent al m oti on s ec onda r y to s pon dyl osi s . o s te oar thri tis . W e h av e fou nd that th i s i s m or e c om for tabl e i n m any pat i en ts t han th e co m pr ess i on s ty l e.com/pt/re/9780781763714/bookContent. Ac ut e s tra i n o r s pra i n i n t he ar ea to be tre ate d i f th e t i ss ues m ay be fur the r c om pr omi s ed by the m oti on i nt r odu c ed in the te c hn i que P.

2) and s ide-bends the head to the r ight (c ur ved ar r ow) enough to engage the oc c iput on the atlas. 1. 4. T he patient s its on the table (if pr efer red. this may be per for med with the patient s upine and phy sic ian s itting at head of table) . F ig. approx imately 5 to 7 degrees. 5.lww. Steps 1 to 3. Setup. T he physician s tands behind the patient and places the left hand on top of patient's head.1. Compr ess ion and side bending to r ight. 13. F igure 13. 13. T he physician places the r ight index finger pad ( or thumb pad) at the right bas ioc ciput to monitor motion ( F ig. T he physician then r otates head to the left ( ar row. Rotation to left.1).com/pt/re/9780781763714/bookContent. Step 4. 3. F ig .3.3) only enough to F igure 13. 2. Step 5..2. F igure 13. 3 of 33 21/08/07 22:10 .http://thepointeedition. T he physician adds a slight c ompression on the head ( s traight ar r ow.. 13.

T he physician introduces gentle c ompression thr ough the head directed toward C1 ( F ig. 3.7). T he physician r otates the patient's head to the left ease bar rier ( arr ow. 4. 13.6). Compres sion. F igu re 13.6.com/pt/re/9780781763714/bookContent. Step 3. and the left index finger pad palpates the left transver se pr oces s of C1 ( F ig. 4 of 33 21/08/07 22:10 .http://thepointeedition. Step 4..8) and then with moderate ac c eleration begins to r otate the head toward the F igu re 13. This may als o be per for med with the patient s eated. and the phy sic ian sits or stands at the head of the table. 13.8.lww. Step 2. F ig .. 13. T he physician places the hands over the par ietotempor al r egions. Rotate to eas e.350 C e r vic al Region: Atlantoax ial (C 1 —C2 ) D ysfunction Ex a mple: C1 R L. Hand placement. P. F igu re 13. T he patient lies s upine on the tr eatment table. 2. Supine 1.7.

351 C e r vic al Region: C2 to C7 Dys func tion Exam ple: C4 ESR RR. T he physician places the F ig ure 13..com/pt/re/9780781763714/bookContent. T he phy sic ian's left index finger pad palpates the patient's right C4 articular pr oces s. 2. 13. 5. Hand plac ement. r ight res tric tiv e bar rier ( arr ow. Step 4. Rotate to bar r ier . F ig . 3. 6. the phy sic ian s hould not c ar ry the head and dy s functional C1 mor e than a few degrees thr ough the bar rier. T he physician r eevaluates the dy s functional ( T ART) c omponents. T he release s hould oc cur before the r es trictive bar rier is engaged.lww.. Supine 1.http://thepointeedition. F igu re 13.9). T he patient lies s upine on the tr eatment table. P.9. If not. 5 of 33 21/08/07 22:10 .10 Steps 1 to 3.

13.11) until C4 is engaged.. 6. s imultaneous ly adding gr aduated flexion. 5. 13.11. Extension to ease.10) .http://thepointeedition. Side-bend and rotate to eas e. T he physician then r otates and s ide-bends the head s o that C4 is still engaged ( Fig . 7.13) through the head dir ected toward C4 and then with moderate ac c eleration begins to r otate and s ide-bend the head to the left ( cur ved ar r ows ). s ide-bending left and r otation left (SLRL) to bar rier.com/pt/re/9780781763714/bookContent.12) . 13. Step 5. 6 of 33 21/08/07 22:10 .lww. r ight hand ov er the patient's head s o that the phy sic ian can c ontrol its mov ement ( F ig. F ig ure 13. T he physician introduces a c ompression for ce (s tr aight ar r ow.13. F ig ure 13. 4.. F ig . T he release s hould nor mally occ ur before the r es trictive F ig ure 13. F ig . 13. Step 6. Step 4.12. T he physician ex tends the head ( arr ow. Compres sion.

F ig ure 13. 3. 2. 7 of 33 21/08/07 22:10 .. Step 3. If not. 13. bar rier is engaged.352 Thorac ic Region: T1 and T2 Dy sfunctions Ex a mple: T1 ERRSR.http://thepointeedition. T he physician r eevaluates the dy s functional ( T ART) c omponents. T he patient is s eated (may be per for med with patient s upine). T he physician s tands in fr ont of or behind the patient. 8.. T he physician palpates the dy s functional s egment ( T1) with index finger pad of one hand while c ontrolling the patient's head with the other hand ( Fig . Setup.com/pt/re/9780781763714/bookContent.14.lww. Se a ted 1. the phy sic ian s hould not c ar ry the head and dy s functional C4 mor e than a few degrees thr ough the bar rier. P.14) .

5.16) until this oc c urs at T1. 13. 13.17. T he physician then intr oduc es r ight side bending and r otation ( ar rows. F ig ure 13. the phy sic ian introduces gentle c ompression for ce thr ough the head toward T 1 and with moderate ac c eleration begins to rotate and side. T he physician. If not. 4.16. the head must not be car ried more than a few degrees F ig ure 13. F ig ure 13. Compres sion. 6. extends the head s lightly until this motion is palpated at T 1 ( ar row. Extend to ease. s imultaneous ly adding gr aduated flexion. Step 5. Fig . Step 6.15.. 13. 8 of 33 21/08/07 22:10 .15) . Nex t.http://thepointeedition. F ig .lww. F ig. Side-bend and rotate to eas e. 7.. Step 4. T his motion is c ar ried towar d the restr ictive bar rier. engage bar rier.bend the head to the left ( arr ows .17).com/pt/re/9780781763714/bookContent. The r eleas e may oc c ur before the barrier is met. with the head-c ontrolling hand.

com/pt/re/9780781763714/bookContent. Supine 1..lww. 9 of 33 21/08/07 22:10 . 13. F ig . Flex to ease.http://thepointeedition. Step 3. 4. T he physician palpates the dy s functional s egment ( T2) with the index finger pad of the left hand. 2. with the head-c ontrolling hand. T he physician. 8. P. T he patient is s upine on the tr eatment table ( may be per for med with patient s eated).19) until this motion is palpated at T 2.18. Step 4. bey ond. 13. flexes the patient's nec k s lightly (a r r ow. Fig u re 13. T he physician s its or s tands at the head of the table. 5. c ontrolling the patient's head with the other hand ( Fig .353 Thorac ic Region: T1 and T2 Dy sfunctions Ex a mple: T2 FRLSL. 3.19.18) . T he physician Fig u re 13.. Setup. T he physician r eevaluates the dy s functional ( T ART) c omponents.

rotate right and s ide-bend r ight ( RRSR). Fig u re 13. Step 5. s ide. Step 6.22.20) until this motion oc cur s at T2. Compr ess ion. Fig u re 13.bend the head to the r ight (c ur ved ar r ows . 7. F ig . and the r eleas e may oc c ur before the barrier is met. 8. Side.http://thepointeedition. T he physician r eevaluates the dy s functional ( T ART) c omponents. P. If not.21) with a s imultaneous gr aduated ex tens ion (F ig. rotation r ight.bend r ight (ERRSR) barr ier .com/pt/re/9780781763714/bookContent. Fig u re 13.22) .354 10 of 33 21/08/07 22:10 . 13. Step 6. 13. Fig . 13. 13. introduces left r otation and s ide bending ( ar rows. T he physician introduces gentle c ompression for ce thr ough the head ( s traight ar r ow. 6.20.. the head must not be car ried more than a few degrees bey ond.lww. Engaging extens ion. F ig.21) toward T2 and then with moderate ac c eleration begins to rotate and side..bend and r otate to eas e.21. T his motion is c ar ried towar d the restr ictive bar rier.

Se a ted 1. 2. T he patient is s eated on the tr eatment table. Step 5. T he phy sic ian's left hand r eac hes under the patient's left ar m or lies palm down ov er the patient's right humerus ( Fig .com/pt/re/9780781763714/bookContent. Step 6. T he physician places the r ight thenar eminence over the T6 left tr ansv ers e pr oces s and the thumb and index finger ov er the left and right tr ansv ers e pr oces ses of T 5. Thorac ic Region: T3 to T12 Dy sfunctions Ex a mple: T5 N SLR R. Steps 1 to 4. 11 of 33 21/08/07 22:10 . 5.23) . r otate r ight (SLRR) . r es pec tiv ely F igure 13. Side-bend left.24.lww.23.http://thepointeedition. 13. F igure 13...T6. T he physician s tands or sits to the left of the patient.25. Positioning. T he physician ins tructs the patient to place the right hand behind the neck and the left hand palm down ov er the right antecubital fos sa. 3. 4. F igure 13. Monitor ing T5.

com/pt/re/9780781763714/bookContent. Acc eler ating to s ide. 7. F ig. ( F ig. Step 7. rotate left (SRRL) bar rier. T he physician gently pos itions the patient's thorac ic spine to T5 in side bending left and rotation r ight (a r r ows . 6. F ig .26 Step 7. the head mus t not be c ar ried more F igure 13. T his motion is c ar ried towar d the restr ictive bar rier. Add c ompres sion. The phy sic ian s imultaneous ly introduces s ide bending r ight (c ur ved s weep arr ow) and rotation left ( cur ved ar r ow.25). F ig . 13.bend right.lww. and the release may oc cur before the bar rier is met. 12 of 33 21/08/07 22:10 . 13. 8.27) .T6. If not. 13. F igure 13.24) . adds a c ompression for ce thr ough the spine to T5 ( ar row.26) by gently pulling or leaning down on the patient.http://thepointeedition. T he physician. 13..27.. while maintaining the s pine in neutral pos ition r elative to T 5.

T he phy sic ian's c upped left hand r eac hes ov er the patient's left s houlder and ac r oss the patient's chest to lie palm down over the patient's right s houlder with the second and third finger pads anc hor ing the fir st rib (F ig. Alternativ e 13 of 33 21/08/07 22:10 .29.355 C oa sta l R egion: Fir st R ib Dys func tion Exam ple: Right. T he patient is s eated.28) .. F igure 13. Steps 1 and 2. P. 13. An alternative pos ition similar to an HVLA tec hnique may be prefer red F igure 13.http://thepointeedition. than a few degrees bey ond.lww. 9. 2.com/pt/re/9780781763714/bookContent. Poste rior .. Steps 1 and 2. Ele vated Fir s t R ib (Nonphy siologic.28. Pos itioning. Nonres pira tor y) 1. T he physician r eevaluates the dy s functional ( T ART) c omponents. and the physician s tands behind the patient.

the head mus t not be technique position. T his motion is c ar ried towar d the restr ictive bar rier. F ig. 13. 13. F igure 13.32) while maintaining c ompression on the head and on the r ib with the finger.31) toward the r ight fir st r ib. F igure 13.29) . 14 of 33 21/08/07 22:10 . Side bending left. 6. F ig. T he phy sic ian's r ight hand s ide-bends the patient's head to the left ( ar row. Step 3. 3. If not. T he physician ins tructs the patient to inhale and ex hale. 7..30.lww.http://thepointeedition. ( F ig. 13. Compres siv e force.. Step 6. and the release may oc cur before the bar rier is met. Side bending r ight. O n exhalation the physician pus hes the patient's head to the right ( ar row. Step 4. 13. F ig .31.com/pt/re/9780781763714/bookContent.32.30) while the left arm k eeps the patient's tr unk fr om following. 5. F igure 13. 4. T he phy sic ian's r ight hand adds a gentle c ompression for ce (a r r ow.

Se ate d 1. and the physician s tands behind the patient on the side of the dy s functional r ib.33) . Step 1 to 3.lww. 8. T he physician r eevaluates the dy s functional ( T ART) c omponents. T he patient is s eated.34. Fir st Rib Ex hala tion D y sfunction.33.356 C os tal Re gion: Firs t or Se cond R ib Exam ple : Le ft. Drawing patient's 15 of 33 21/08/07 22:10 .. T he physician F igure 13. 13. F igure 13. T he physician places the other hand ( thumb) over the posterior as pect of the dy s functional left firs t r ib immediately lateral to the T 1 transv ers e c os tal ar ticulation ( F ig.. Step 4. c ar ried more than a few degrees bey ond.http://thepointeedition. P. 4. 2. T he phy sic ian's left hand gras ps the patient's left forearm.com/pt/re/9780781763714/bookContent. 3. Positioning.

.35) .357 C os tal Re gion: Firs t R ib Exam ple : Right.35. 5. Sea ted 16 of 33 21/08/07 22:10 . 13.com/pt/re/9780781763714/bookContent. F igure 13. 13.36. First Rib Ex halation D y s function. the physician lifts the ar m. ar m. 6. F igure 13.lww. F ig . and pulls (a r r ow. Acc eler ate to barrier.http://thepointeedition. P.34) the adducted arm toward the floor. Step 5. 7. T he physician r eevaluates the dy s functional ( T ART) c omponents. dr aws the patient's left ar m anter ior ly. Acc eler ate poster ior ly.. adducts it ac r oss the patient's c hest. 13.36) . With moderate ac c eleration. T he ac c eleration is c ontinued pos ter ior ly and then back to the side of the patient ( Fig . s imultaneous ly flexing and abducting with a c ir cumduc tion motion (F ig. Step 6.

T he physician's r ight hand palpates the pos ter ior as pect of the first rib at the attac hment at its c os totransver se ar ticulation. the patient's head is F igu re 13. ex aggerating its ex halation dy s function pos ition. F ig . T he patient is s eated and the phy sic ian s tands behind the patient. Steps 1 to 4. T he patient is ins tructed to inhale and ex hale. T he patient's head is then s ide-bent and r otated r ight ( c urved arrows. 17 of 33 21/08/07 22:10 . Step 5.. Side bending and r otation to right. 6.38. 5. 3.38) until these motion v ec tor s engage T 1 and the first r ib. T he physician places the left hand over the patient's head. 4. 13.39. F igu re 13.37. F ig . 1. Step 6.http://thepointeedition.com/pt/re/9780781763714/bookContent.37) until the T1 segment and first rib ar e engaged.lww. 13. and on r epeated inhalation. Setup. Head c arr ied toward SLRL. engage T 1 and firs t r ib. T he physician's left hand slowly flexes the patient's head ( c urved arrow.. 2. F igu re 13.

41.358 Lum bar Re gion: L1 to L5 Dy sfunctions Ex ample: L4 NSR R L.com/pt/re/9780781763714/bookContent.. 13. 5. T he physician places the r ight hand under the patient to monitor the tr ansv ers e pr oces ses of L4 and L5. 4. 3.http://thepointeedition.42. Step 5. 2. T he physician ins tructs the patient to flex the right hip and knee. Exter nally rotate hip.41) . T he physician ex ternally r otates and abducts the hip while the Fig ure 13. Fig ure 13. Supine 1. P.lww. T he phy sic ian's other hand c ontrols the patient's flexed r ight leg at the tibial tuberosity and flexes the hip until the L5 s egment is engaged and r otated to the r ight under L4 ( F ig. T he patient lies s upine. 18 of 33 21/08/07 22:10 .. Steps 1 to 4. Setup toward rotational ease. and the phy sic ian s tands on the s ide of the r otational c omponent ( left) .

42) . 8.http://thepointeedition. pulls the patient's right leg to the left in adduction and inter nal r otation (F ig . T he physician.. 6.44) . Step 6. Accelerate into internal r otation and adduc tion.L5.com/pt/re/9780781763714/bookContent. This pos ition should place the L4 s egment indirectly ( s ide. 19 of 33 21/08/07 22:10 . rotated left [SRRL]) as it relates to its dy s functional pos ition on L5. 13. 7. and the release may oc cur before the bar rier is met..44 Step 6. 13. while L5 has been r otated to the right ( F ig.L5 r es trictive bar riers. Ex tens ion ac ros s midline. T he physician r eevaluates the Fig ure 13. 13.lww.bent r ight. other hand monitors motion at L4. T his motion c ar ries L5 ( SRRL) under L4 (SLRR) toward the L4. with moderate ac c eleration.43) and then fully ex tends the leg ac ros s the midline to the left ( Fig . Fig ure 13.43.

dy s functional ( T ART) c omponents.. F igure 13. Steps 1 to 4.46. T he patient's legs are flex ed until L3 is engaged ( Fig . 5. 20 of 33 21/08/07 22:10 . P. 13.46) and the F igure 13.lww.45) . 13. Step 5.http://thepointeedition. Pos ition into r otational ease.lying) pos ition.45. La tera l R ecum bent 1.. T he physician s tands at the s ide of the table in front of the patient.L4. 4. F ig. T he phy sic ian's for ear m pulls the patient's left s houlder gir dle forwar d ( ar row. 3. 2.359 Lum bar Re gion: L1 to L5 Dy sfunctions Ex ample: L3 ESR R R. T he phy sic ian's c audad hand c ontrols the patient's legs and flexes the hips while the c ephalad hand monitors motion at L3. Hips flexed to engage segment.com/pt/re/9780781763714/bookContent. T he patient lies in the r ight lateral r ec umbent ( s ide.

48) to ac hiev e s ide bending left and rotation left. 13. c audal ar m pus hes the patient's ilium pos ter ior ly ( ar row) while the fingers c ontinue to monitor the L3. 7. 13. Fig. 6.48) and s imultaneous ly pus hes the s houlder pos ter ior ly ( pulsed arrow at right. with a moderate ac c eleration.. Step 6. Acc eler ate to SLRL.47) between the s houlder gir dle and the pelv is and then.com/pt/re/9780781763714/bookContent. Step 6. F ig.48) and the pelvis anteriorly ( pulsed arrow at left. T he release may oc cur before the bar rier is met.. T he physician adds s light tr action ( ar rows. the s egment s hould be F igure 13. 13. r ev ers es this tr action ( s traight ar r ows .http://thepointeedition. Fig . 21 of 33 21/08/07 22:10 .lww.L4 v er tebral unit.47. Fig. F igure 13. 13.48. If not.

c ar ried only minimally thr ough it. Modifie d Sims Pos ition Diag nosis Standing flex ion tes t: Positiv e (r ight pos terior superior iliac s pine [PSIS] ris es) Los s of pas siv ely induced right sac r oiliac motion PSIS: Cephalad (slightly lateral) on the right Anterior s uper ior iliac s pine ( ASIS): Caudad (slightly medial) on the right Sac r al sulcus : Pos terior on the right Tech niq ue 1. Step 1.lww. T he physician r eevaluates the dy s functional ( T ART) c omponents. Hand 22 of 33 21/08/07 22:10 . F igure 13. 8. T he patient is in the left modified Sims pos ition. P.com/pt/re/9780781763714/bookContent.49. and the physician s tands behind the patient F igure 13. Pos itioning..http://thepointeedition.360 Pe lvic Re gion: Innomina te Dys func tion Exam ple: Right Anterior Innominate.50.. Steps 2 and 3.

52) . F igure 13.53.. the patient's hip is ac c elerated into flex ion ( c urved white ar r ow) with a c ephalad impuls e ( thrus t) while the left hand immobiliz es to s ac rum ( s traight white ar r ow. F ig . 2. 5. Return to extension.52. and at the end of the third flexion. F igure 13. placement. Step 5.50) .com/pt/re/9780781763714/bookContent. Cephalad impulse.. 13. F igure 13. T he phy sic ian's c audad hand gr asps the patient's right leg distal to the k nee ( tibial tuberosity) ( F ig. 13. ( F ig. Step 4. 13. T he phy sic ian's c audad hand flexes the patient's right hip and k nee ( F ig.51) and then r eturns them to an extended pos ition (F ig . 23 of 33 21/08/07 22:10 . T he physician places the c ephalad hand on the patient's s ac rum to r es ist sacral mov ement. T his motion is r epeated thr ee times. 3.http://thepointeedition.49) .51.lww. Flex hip and k nee. 13. 4. Step 4.

. Fig ure 13. Setup.http://thepointeedition. 13. 6. Modifie d Sims Pos ition Diag nosis Standing flex ion tes t: Positiv e (r ight PSIS rises ) Los s of pas siv ely induced right sac r oiliac motion ASIS: Cephalad (slightly lateral) on the right PSIS: Caudad (slightly medial) on the right Sac r al sulcus : Deep. anter ior on the right Tech niq ue 1. T he patient is in the left modified Sims pos ition and the physician s tands behind the patient..com/pt/re/9780781763714/bookContent. Steps 1 and 2.54.361 Pe lvic Re gion: Innomina te Dys func tion Exam ple: Right Pos ter ior Innominate. T he right leg and hip are then extended and right s ac roiliac motion is r etested to as s ess the effectivenes s of the tec hnique. 24 of 33 21/08/07 22:10 .53) . P.lww.

13. 4. While this k ick is tak ing place ( ar row at left. abducted. 2. and at the end of the third c y c le. T his c irc ular motion is applied for thr ee cyc les . and c ar ried into ex tens ion ( F ig. Step 3. 5.57. 3. external rotation.56. Kick leg str aight with impuls e on PSIS. Steps 4 and 5. 13.com/pt/re/9780781763714/bookContent. T he patient's r ight leg is mov ed in an upward. T he physician places the left hand on the patient's right PSIS while the r ight hand gr asps the patient's right leg just dis tal to the knee ( tibial tuberosity) ( F ig.lww. outwar d c ir cular motion ( white ar rows .55. Step 3. F ig . Fig ure 13. Circ ular hip motion. Fig ure 13..56) to c heck hip r ange of motion. ex ternally r otated. Fig ure 13. Abduc tion. 25 of 33 21/08/07 22:10 .54) .http://thepointeedition. the patient is ins tructed to k ic k the leg s tr aight. 13..55) as the hip is flexed. pos itioning the hip and k nee into extension. and ex tens ion.

.57) the phy sic ian's left hand on the patient's right PSIS deliver s an impuls e ( ar row at right) toward the patient's umbilicus . 13. hand placement. Pr ona tion D y s function Diag nosis Symptoms: Elbow dis c omfort with inability to fully supinate the for earm Motion: Res tricted supination of the for earm Palpation: Tenderness at the radial head with pos terior prominence of the radial head Tech niq ue 1. F ig .com/pt/re/9780781763714/bookContent. 6. T he patient is s eated on the Fig ure 13.lww.58..http://thepointeedition. 26 of 33 21/08/07 22:10 . Setup. P.362 U pper Extrem ity Region: Elbow: R a dia l H ead. Steps 1 to 3. Right s ac roiliac motion is r etested to as s ess the effectivenes s of the tec hnique.

13.59.. Step 5. 2. Step 5. Anter ior counter for ce. Fig ure 13. s upinates the Fig ure 13.60. Supinate. T he physician r otates the hand into the indirect pr onation pos ition and pus hes the r adial head pos ter ior ly with the thumb until the eas e bar rier is engaged ( Fig . 4.61. Fig ure 13. F inally. 3. 13. Step 4. table.lww.. 27 of 33 21/08/07 22:10 . and the phy sic ian s tands in fr ont of the patient. Engage pronation and radial head ease. 5. T he physician places the index finger pad and thumb of the other hand s o that the thumb is anterior and the index finger pad is pos ter ior to the radial head ( F ig. with a moderate ac c eleration thr ough an ar c lik e path of least r es istanc e.58) . T he physician holds the patient's hand on the dy s functional ar m as if s haking hands with the patient. the phy sic ian.http://thepointeedition.59) .com/pt/re/9780781763714/bookContent.

for ear m toward the r es trictive bind bar rier ( Fig . 13.http://thepointeedition.. F ig. T he release may oc cur before the bar rier is met. P.60) and adds an anterior dir ected c ounterforce ( ar row. the r adial head mus t not be c ar ried more than a few degrees bey ond.363 U pper Extrem ity Region: Elbow: R a dia l H ead.61) with the index finger pad. 6.com/pt/re/9780781763714/bookContent. 7.. 13. If not. Supination D y s function 28 of 33 21/08/07 22:10 . T he physician r eevaluates the dy s functional ( T ART) c omponents.lww.

.lww.62) . 13. 2.http://thepointeedition. T he physician places the index finger pad and thumb of the other hand s o that the thumb is anterior and the index finger pad is pos ter ior to the radial head ( F ig. T he physician r otates the hand into the F igure 13.64..62. F igure 13. Engage supination. Setup.com/pt/re/9780781763714/bookContent. 3. T he patient is s eated on the table. Engage radial head ease. hand placement. and the phy sic ian s tands in fr ont of the patient. T he physician holds the patient's hand on the dy s functional ar m as if s haking hands with the patient. F igure 13.63. Step 4. Diag nosis Symptoms: Elbow dis c omfort with inability to fully pronate the forearm Motion: Res tricted pronation of the for earm Palpation: Tenderness at the radial head with anterior ( ventral) prominence of the radial head Tech niq ue 1. 29 of 33 21/08/07 22:10 . Step 4. Steps 1 to 3. 4.

http://thepointeedition.364 U pper Extrem ity Region: Ac rom ioc lavicular J oint Exam ple: Right D is tal Clavic le Ele vate d Diag nosis Symptoms: Acr omioclav icular dis c omfort with inability to fully abduct and flex the shoulder Findings: Dis tal clav icle palpably elev ated relative to the acr omion and res ists caudad pr ess ure Tech niq ue 1. T he physician's other hand gr asps the patient's ar m on the side to be treated jus t below the elbow ( F ig. F igure 13. T he physician maintains constant c audad pr ess ure ov er the patient's c lavic le thr oughout the tr eatment s equence..lww. places the second metacarpophalangeal joint over the distal third of the clavic le to be treated. Bac kward ex tension. 4. Setup. Steps 4 and 5. 30 of 33 21/08/07 22:10 ..com/pt/re/9780781763714/bookContent. hand placement.67. Steps 1 to 4.66. 5. 3. T he patient is s eated. 2. T he patient's ar m is pulled down and then dr awn bac kwar d into F igure 13. P.66) . using the hand clos est to the patient. 13. T he physician. and the phy sic ian stands behind the patient toward the s ide to be tr eated.

com/pt/re/9780781763714/bookContent. P.69.69) . Arm ac r oss chest. T he physician r eevaluates the dy s functional ( T ART) components. Overhand motion.68) until it is onc e again in fr ont of the patient. 6.lww.http://thepointeedition. T he release may oc c ur before the bar rier is met. Step 5. finishing with the arm ac r oss the c hest in adduction (F ig. 13. c ir cumduc ting the ar m (F ig.. 13. 7.67) with a c ontinuous motion s imilar to throwing a ball over hand. 13.365 U pper Extrem ity Region: Ac rom ioc lavicular J oint Exam ple: Right. F igure 13.. ex tens ion (F ig. F igure 13. Step 5. Pr oxim al Cla v icle Elev a ted (D ista l C lav ica l De pre sse d) 31 of 33 21/08/07 22:10 .68.

lww..72. F igure 13. Step 5. F igure 13.http://thepointeedition. 3. 2. 32 of 33 21/08/07 22:10 . T he phy sic ian's left thumb maintains c onstant c audad pr essure over the patient's c lavic le thr oughout the tr eatment s equence.71. Flex ion and abduc tion. Bac k str oke motion.. Step 5. Diag nosis Symptoms: Tenderness at the ster noc lav icular joint with inability to abduct the shoulder fully without pain Motion: Res tricted abduction of the clav icle Palpation: Prominence and elev ation of the prox imal end of the clav icle Tech niq ue 1. Setup. Steps 1 to 4.70.com/pt/re/9780781763714/bookContent. T he phy sic ian's left hand r eac hes ar ound in fr ont of the patient and places the thumb over the pr oximal end of the patient's r ight clavic le. hand placement. T he phy sic ian's F igure 13. 4. T he patient is s eated with the phy sic ian s tanding behind the patient.

http://thepointeedition. 2. Th e S til l Te c hn i qu e Ma nua l : Appl i ca tio ns o f a Re di sc ove r ed T ec hni que of Andr ew T ayl or Sti l l . Ph i l ad elp hia : Li ppi nco tt W i ll i am s & W i lk i ns .lww. 200 0. ) . W ard R ( ed. In di an apo l is : Am eri c an Aca dem y o f Os teo pat hy ... M D. 20 03.com/pt/re/9780781763714/bookContent. 33 of 33 21/08/07 22:10 .366 R e fere nce s 1. P. F oun dat i on s fo r O s te opat hic Me di ci ne. V an Busk i rk RL .

Th e p hys i c ia n i ntr oduc es a f or ce to po s i ti on the pat i en t s o th at a f ul cr um m ay be s et . p r im ary r es pir ator y m ech anis m ) ( 2) . Lip pin c ott . In s ome ca s es. One of Sut her l an d' s i de as. fa s ci a. o r a v ar i et y o f ot her fa c tor s ( e. DO .M ay er ). T . D O (1 . D O. a nd s o on ( l ig ame ntou s a r ti c ula r m ech anis m ). Li ppi nc ot t.3 ) . T exa s ) e v en tua l l y pro m ot ed t he ter m LA S. and tho s e i n the nor the as te r n U ni ted Sta tes ( i. h e b egan te ach i ng a m eth od o f t r ea tm en t o f t he b ody an d ex tre m it i es w it h t he pri nci pl es pr omo ted for th e tr eat m en t of th e c r ani um. Wa l es . T his ful c ru m . In th e 1 940s . 5. pair ed w it h th e s ubs eque nt l ev er a c ti on of t he tis s ues (l i ga m ent s ). I n th e c ase of tre ati ng a my ofa s c ia l s tru c tur e. an d t he pr ac tit i on er s dev elo ped the i r ow n par tic ul ar nu anc e fo r t he appl i ca tio n of th e t r eat m en t. B eck er. t hi s pri nci pl e i s s im i l ar to th e arc hit ec tu r al an d bi ome c ha ni ca l ( s tr uc tu r al ) p r i nc i pl es of t ens egr i ty. an d we ca n e x tra pol ate thi s t o i nc lu de the po tent i al fo r me c ha nor ec ep tor ex c i ta tio n i n dy s fu nct i ona l s tat es .2) . a k ey c on c ep t in th i s ar ea . T his pri nci ple i s c om m on l y pro m ot ed i n t he post ula te that an an teri or ana tomi c ( fas c i al ) b ows tr in g i s p r ese nt i n the bod y . su c h as c i rc ula tor y (T r au be.. D O.6) . R . H . A s th e t w o nam es s ugg est . as se en i n t he geod esi c d om e of R . 14 Balanced Ligamentous Tension and Ligamentous Articular Strain Techniques Technique Principles Bal anc ed l i ga m en tous te nsi on ( BLT ) a nd l i ga m en tous ar tic ul ar st r ai n (L AS) te c hni que s m ay b e c on s id er ed as tw o se par ate tec hni que s or as on e.e. w hi l e the ter m B LT d esc r ib es t he pro c ess or go al o f t he tr ea tme nt. He tal k ed ab out the jo i nt' s r ela ti on wi th i ts l ig ame nts. . or i n t he c as e of BL T o r LA S. Technique C las sification 1 of 40 21/08/07 22:11 . T he the ory i s tha t th e k ey dy sf unc tio n ma y p r od uc e bot h p r oxi m al an d di s ta l e ffec ts. the use of in here nt for c es . D O. Buc k mi ns te r F ull er a nd the art of Ke nnet h S nel s on. T he his tory of th e de v el opm ent of the s e t ech niq ues pro bab l y s tar ted dur i ng A. A. bu t de v el ope d gr eat l y thro ugh th e wo r k of a nu m be r o f ost eop athi c p hys i c ia ns i nc l udi ng. bu t no t l i mi ted to W . t he ther m od y na m i c r ea c ti on t o pre s su r e i s t he pr im ary re l eas e f act or . e. s om e v ar i an c e i n t he tech niq ues dev elo ped . th e tec hni que i s use d to af fec t th e m y of as ci al s tr uc tu r es .en han c in g me c ha nis m . S uth erl and. To day . eye an d t ongu e m ove m ent s . I t ap pea r s that a geo gr ap hic se para tio n a nd m in i ma l co nta c t betw een tw o gr oup s m ay h ave ca us ed th e s am e tec hni que to be k now n b y t w o n ame s .lww. hi s s tude nt ( 4. w as that no r ma l mo v em ent s of a j oi nt o r a r ti c ula tio n d o no t c aus e as y mm etr i c ten s io ns i n t he l i ga m en ts and tha t t he t ens i on dis tri but ed t hro ugh the li gam ents in an y gi v en jo i nt i s bal anc ed ( 2. T hes e t ens i ons ca n c hang e w hen the li gam ent or j oi nt i s s tre s s ed (s tra i n o r unit def orm atio n) i n the pre s en c e o f a l te r ed m ec han i c al fo r ce . T ho s e i n t he c en tr al Un i te d St ate s ( i . in M FR . ly m ph atic . Ne w Je r se y a nd N ew Eng l and ) p r om oted th e t er m BLT . Sut her l and ma y h av e bee n m os t r es pon s i bl e f or the tec hni que bei ng taug ht i n earl y o s te opat hic st udy gro ups . a re s pi r at or y m ov eme nt o f t he di ap hra gm. T he ter m L AS s eem s t o de s cr i be the dy s fu nc ti on.. Sti l l' s ti m e.H eri ng. One of the as pec ts m ent i on ed i n s ome ost eop ath i c m ani pul ativ e t ech ni qu e ( OMT ) st y le s i s a r el eas e.com/pt/re/9780781763714/bookContent. R .. T his me c han i sm ma y be is ome tr ic co ntr ac ti on of a mu s cl e. the dif fer enti ati ng fact or bet w een BL T /L AS a nd m yo fasc i al re l eas e ( M FR ) is th at an i nhe r en t fo r ce (f l uid m od el) i s the re l eas e-e nha nc in g m ech anis m i n B LT /L AS. G.http://thepointeedition. co m bin es w it h f l uid dy nam i c s and ot her fac tor s to pr odu c e a ch ang e in th e d y s fu nct i on al s tat e..g . Th es e eff ect s ca n p r od uc e s ym pto m s b oth an teri orl y a nd p ost eri or ly (1 ) . an d A .

D iagnos is a nd Tre a tme nt with Inter segm ental Motion Tes ting (Phy sic ian Active ) In i nt er se gme nta l mo tio n t es ti ng/ tre atme nt s ty l e. D ire ct Technique LAS so m eti m es va r i es .. It fol l ows th e d i r ec t s tyl e of MF R t ec hn i qu e d es cr i be d i n Ch apt er 8. t he e ase or dir ect i on of fre edo m is in th e fo l lo w in g di r ec tio ns : fle x io n.http://thepointeedition. It i s pro duc ed b y m ovi ng t owa r d the eas e o r to wh at s ome re fer as the or i gin al pos i tio n o f i nj ur y ( 1). but to bal ance th e a r tic ula tio n it fe els tha t y ou ar e m ov i ng tow ard th e dir ect ( re s tr i ct i v e) ba r ri er . Indications 2 of 40 21/08/07 22:11 . y -.lww. th e ph y si c ia n po s it i on s th e p ati ent' s d y sf unct i on al ar ea to w ar d th e e ase bar r ie r . i t c an b e p erf or me d a s a dir ect te c hni que wh en t he m us c ula tur e i s ca usi ng a v ec tor of ten s io n in on e d i r ec tio n. Th ere m ay be mo r e c omp r es s i on or tr ac ti on i n this fo r m as w ell .. s i de be ndin g l eft . an d s o o n. Th i s a tte m pt to all ow the m os t m otio n t o o c c ur wi tho ut r esi s ta nc e i s ter m ed dis eng agem ent . the phy s ic i an pal pat es t he are a in v ol v ed and at tem pts to dis c ern th e p atte r n of dy sf unc tio n w it h e x tre m el y l i ght pa l pa tory te c hn i que . Pla c in g the ti s s ue s i n a n op tim al bala nce of ten s io n a t th e a r ti c ula tio n o r ar ea of dy sf unc tio n is th e f i nal pos i ti onin g s tep of thi s t ec hn i qu e.com/pt/re/9780781763714/bookContent. si te. s li ght l y m ore mo ti on an d/o r fo r ce ca n be us ed to t est m ot i on par ame ter s in th e d y s fu nct i on al s i te an d to be gin to m ov e t he s i te in to t he app r opr i at e i ndir ect pos i ti on o f b ala nc ed te nsi ons. W he n b egin nin g t he t r ea tme nt. T hi s P. T his i s s im i la r to th e s en s at i on of bal anci ng an obje c t on the fin ger ti p. o n m yo fas c i al re l ea s e ( 1). T his c ou l d be desc r ib ed as n udg i ng the se gme nt t hro ugh the x. pel v ic dia phr agm . or pre fer enc e of th e t r eat i ng ph y s ic i an . T his re l eas e h as been de s cr i bed as a gent l e m ov em en t t owa r d t he eas e an d t hen a s l ow m ov eme nt b ack w ar d to w ar d t he b ala nce poi nt ( eb b an d f l ow ) . F or ex am pl e.axe s w i th the mo v eme nts ca us ed by re s pir ati on. Th e w obbl e poin t is ce ntr al t o a l l r adi ati ng tens i on s . the ph y s ic i an ty pi ca l ly at temp ts to pr od uce so m e fr ee pl ay i n t he art i cu l ati on. i l io ti bi al ban d. so m e L AS tec hniq ues are ex ac tl y l i ke M FR di r ec t te c hn i qu es . an d r ota ti on le ft. T he r ef ore . an d z. and tho s e tens i on s f eel asy m me tr ic wh en not at the poi nt. Indirec t Te chnique In the c as e o f B LT /L AS. th e m ove m ent s u s ed i n the at temp t to dia gnos e a nd tr ea t t he dy sf unc tio n ar e e x tr em el y s m al l . Technique Styles D iagnos is a nd Tre a tme nt with Re spiration In thi s me tho d. It c an be pro duc ed b y c omp r ess i on or tra c ti on ( 1). F SL RL . dep end i ng on the dys fun c ti onal st ate .3 68 i nd i re c t p osi tio ni ng is th e cl ass i c m eth od of tr ea tme nt i n t his te c hni que . the phy s ic i an awa i ts a r el eas e. H ow ev er. Wh i l e hol din g th i s pos i tio n. Some re fer to thi s p oi nt as th e wo bbl e p oi nt . and th os e are in c l ud ed i n this ch apt er r ath er than Ch apt er 8 .. M ov i ng L4 ( ov er a s ta bil i z ed L5 ) i n th i s dir ec ti on i s desc r ib ed as m ovi ng aw ay fr om the r es tri c tiv e b arr i er and th er ef ore def i ne s th e t ech ni qu e a s i ndir ect . i f the dys fun c tio n b ein g tr eat ed i s d esc r ib ed a s L 4. S pee c e and Cr ow ( 1) i ll us tr ate th i s i n t hei r bo ok as tech niq ues use d i n d y s fu nct i on s of fi r st r ib . Ex agg er at i on is the se c on d st ep des c r ib ed.

3 of 40 21/08/07 22:11 . At t he poi nt o f b ala nc ed li gam ento us ten s i on . T he ob j ec t is to ba l anc e t he ar ti c ul ar s urf ace s o r ti s su es i n t he dir ect i ons of ph y s io l og i c m oti on c om m on to tha t ar tic ula ti on .com/pt/re/9780781763714/bookContent. T he phys i ci an i s n ot s o m uch ca usi ng t he c ha nge as hel pin g th e b ody to hel p i ts el f. a. T hi s typ i ca l l y m ea ns m ovi ng awa y fr om the bar r ie r (s ) to a l oo s e ( eas e) s i te .tu ne: H av e p ati ent bre ath e sl owl y i n an d o ut to a s se s s phas e o f r es pi r at i on tha t f eel s mo s t l oos e ( r el ax ed . Ar ea s o f l y m ph ati c c onge s ti on or l oca l e dema R ela tiv e Contr aindica tions 1. t he t i ss ue m ust no t b e ta k en be y ond it s e l ast i c l im i ts. Soma tic dy s fun c ti ons of m yo fas c i al ba s is 3. 2. si m ult ane ous l y i f p oss i ble . b. T he t i ss ues . 1. F r ac tur e. in fec tio n. o r g r os s in s ta bil i ty i n are a to be tr eate d 2.3 69 ( l ow er or di st al) se gm en t t o a poi nt of bala nce d l i gam ent ous ten s io n i n al l p l an es o f p erm i tte d m oti on. t he phys i ci an adju s ts th e re l at i ve pos i ti on betw een the s up eri or a nd i nf er io r s egm ents to ma i nta i n bal ance . di sl oca tio n. 3. It i s i m po r tan t n ot to put too mu c h pr es s ur e i nto the te c hni que . an d t he phy s ic i an m us t n ot p r od uce dis c om for t to a l ev el t hat ca us es gu ard i ng.. as the fl uid and ot her dyn ami c s o f t he neur omu s cu l osk ele tal s ys tem fi nd a n o v er al l nor m al i z at i on or bal anc e. T hi s typ i ca l l y m ea ns s hif tin g t he t op s eg m ent co nti nuou s ly aw ay f r om th e di r ec t b ar ri er to pr eve nt the tis s ue s f r om tig hte ni ng as th ey r ele ase .. It ge nera l ly sh ould be ve r y tol era bl e to the pat i en t. i t i s v ery os teo path i c. a r e o fte n d es cr i be d a s if th ey ar e m el tin g or so fte ni ng . In this re s pe c t. Gene ral Inform ation for All Dys functions Positioning 1. et c . Soma tic dy s fun c ti ons of art i cu l ar bas i s 2.http://thepointeedition. Al l p l an es m ust be fi ne t une d t o th e m ost bal anc ed poin t. M ali gna ncy . T he phy s ic i an pos i ti ons the su peri or ( up per or pro x i ma l ) s eg m ent ov er the s ta bil i z ed in fer i or P. as th ey r ele ase . b. F i ne . p atie nt hol ds b r ea th at t he poi nt ( i t m ay be onl y p ar ti all y c om pl ete i nha l at i on or exh ala ti on ) w her e th e b ala nc e i s m ax i m al . o r s eve r e o s te opo r osi s i n a r ea to be tr ea ted Gene ral Considera tions a nd R ule s T he te c hni que is s pe c if i c palp ato r y bala nci ng of t he tis s ues su r ro undi ng and i nh ere nt to a jo i nt or the m yo fas c i al st r uc ture s r ela ted to i t. a. s oft .) . Trea tme nt 1.lww. T he phy s ic i an m ak es a di agn osi s of so m at i c d y sf unc ti on in al l pl ane s o f pe r mi tte d mo tio n.

re s tr i ct i on of m ot i on. T i s su e t ext ur e c ha nge s sh oul d o c c ur du r in g th e r ele as e.. D i se nga gem ent 2.1. T he phys ician's index or third Fig ure 14. T he phys ician places the hands palms up under the patient's head s o that the c ontact is made at the level of the tentorium c erebelli ( 1). Ex ag ger ati on 3. te nde r nes s [ T AR T ]). 4. Th e phys i ci an r epe ats if nec ess ary ..http://thepointeedition. W hen a tot al r ele ase i s not ed. 3.2. T he patient lies s upine and the physician s its at the head of the table. the ph y si c i an re ass es se s t he c omp one nts of s om ati c dy s fu nct i on ( tis s ue te x tur e a bno r m al i ty . mostly with the heel of the hands towar d the hypothenar eminences.3 70 C erv ica l Re gion: Occipitoatlantal (C0 —C1. a s y mm etr y o f po s it i on . 2. Fig ure 14. T he sh or th and ru l es for th i s a r e as foll ows (1 ) : 1.lww. Head and v ertebral c ontact. if th ey a r e not pal pat ed.com/pt/re/9780781763714/bookContent. Steps 3 and 4. T he patient is far enough away to permit the physician's forearms and elbows to r est on the table. 4 of 40 21/08/07 22:11 . the pos it i on of bal anc ed l i ga m en tou s te nsi on has not be en s et. c. Bala nce un ti l r el eas e oc c ur s P. OA ) D y sfunction Exam ple : C0 -C1 ESLRR* 1. 2.

7. the head is gently s ide. Step 6.1 and 14..4) until a balanced point of tension is met.bent left and rotated r ight (arrows.com/pt/re/9780781763714/bookContent. F ig . 6. fingers palpate the patient's C1 tr ans ver se pr ocesses ( F igs.. 5 of 40 21/08/07 22:11 . r otation left under the oc ciput.http://thepointeedition. As the phys ician introduc es the v ectored for ce.lww. and the physician will Fig ure 14. When this balanced position is ac hieved. 5.3. This s hould produce a relative s ide bending left. 14. 14. 14. F ig.3) towar d the ex tension ease and toward s ide bending right.2) . Fig ure 14. a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf.4. r otation right effec t at the oc ciput. Step 5. T he phys ician's palpating fingers s imultaneous ly c arry the C1 tr ans ver se pr ocesses upwar d and c ephalad ( arrows.

T he patient is far enough away to per mit the phys ician's forearms and elbows to r est on the table.lww. P. 2. 3.. 6 of 40 21/08/07 22:11 . T he patient lies s upine. T he phys ician places the hands palms up under the patient's head s o that the c ontact is made at the level of the tentorium c erebelli ( 1). and the physician s its at the head of the table. 8. T he phys ician's F igu re 14. mostly with the heel of the hands towar d the hypothenar eminences. 4. AA) Dy sfunction Exa m ple : C1 RR 1.com/pt/re/9780781763714/bookContent. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).http://thepointeedition.3 71 C erv ica l Re gion: A tla ntoaxia l (C1—C2.. Palpation of C2 ar tic ular pillars . hold this position agains t it until a r elease in the direc tion of ease occ urs.5.

7.8.. When this balanced position is ac hieved. 6.6. 14. T he phys ician's palpating fingers s imultaneous ly c arry the C2 ar tic ular pr ocesses upwar d and c ephalad to disengage C1-C2 while s imultaneous ly r otating C2 left ( s weep arrow) under C1 ( c urv ed arr ow. 14. F ig. 5. r otation right effec t.lww. F igu re 14. This s hould produce a relative C1.5 and F ig. Steps 3 and 4. Step 6.7).. Step 5. 7. 14. As the physician introduc es the v ectored for ce.com/pt/re/9780781763714/bookContent. F ig. rotation r ight effec t.6). and the F igu re 14. the head with C1 may be minimally and gently r otated r ight (arrow. a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf. index or third fingers palpate the patient's C2 ar tic ular pr ocesses ( F igs.8) until a balanc ed point of tension is met. F igu re 14. 7 of 40 21/08/07 22:11 .http://thepointeedition. 14.

T he phys ician places the index finger pads over the C1 tr ans ver se pr ocesses ( F ig.9) . 8.http://thepointeedition. 3. T he patient lies s upine.. and the physician s its at the head of the table.. Steps 2 and 3.lww. P. Late ral Tr a nslation 1. T he phys ician's hands cup the head by c ontouring over the parietotemporal r egions. physician will hold the pos ition against it until a r elease in the direc tion of ease occ urs .10) that is direc ted from F igu re 14. 4. 8 of 40 21/08/07 22:11 .9. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).com/pt/re/9780781763714/bookContent.3 72 C erv ica l Re gion: A tla ntoaxia l (C1—C 2 ) Dy sfunction Exa mple : C 1 R ight. 14. hand position. 2. T he phys ician gently and s lowly introduc es a tr ans lational force (arrow. 14. F ig.

and the physician will hold the pos ition against it until a r elease in the direc tion of ease occ urs . tr ans lation left to r ight.lww.http://thepointeedition.3 73 C erv ica l Re gion: C 2 to C 7 D y sfunction Exa mple: C 4 ESRR R 9 of 40 21/08/07 22:11 ..10. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ). F igu re 14.11). T his can be performed as a direc t technique if pr eferred or indic ated.com/pt/re/9780781763714/bookContent. F igu re 14. 5. The physician may have to go back and forth between left and r ight to deter mine the balanced position (F igs.. 14. Step 4. When this balanced position is ac hieved. tr ans lation right to left. left to right towar d the ease barrier. Step 4.11. 7. a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf. P.10 and 14. 6.

Step 5. 10 of 40 21/08/07 22:11 . while s imultaneous ly r otating and Fig ure 14. SRRR.http://thepointeedition. head contact. 14. T he patient lies s upine. Steps 1 to 3. 1.14. Fig . mostly with the heel of the hands towar d the hypothenar eminences ( F ig. 2.13). 4.lww. Fig ure 14. T he phys ician's index or third fingers palpate the patient's C5 ar tic ular pr ocesses ( arrow. 5. Step 4. T he phys ician's palpating fingers s imultaneous ly c arry the C5 ar tic ular pr ocesses upwar d and c ephalad to disengage C4-C5. and the physician s its at the head of the table. T he patient is far enough away to permit the physician's forearms and elbows to r est on the table.12). 14. 3. Fig ure 14.13.12. T he phys ician places the hands palms up under the patient's head s o that the c ontact is made at the level of the tentorium c erebelli ( 1).com/pt/re/9780781763714/bookContent...

14.17.com/pt/re/9780781763714/bookContent. Step 3 and 4. 2..lww. 3.16. T he patient lies s upine.18) to find a point of F igu re 14.17). 5.16 and 14. 4. Step 5. F igu re 14.18. hand and finger positioning. Steps 3 and 4.3 74 Thor acic Re gion: T1 a nd T2 D ysfunc tions Exam ple : T1 FSRRR 1. T he phys ician places the index finger pads on the transver se pr ocesses of T1 and the thir d finger pads on the transver se pr ocesses of T2 ( F igs. F igu re 14.. T he phys ician places the hands palms up under the patient's c ervical spine at the level of C2 or C3 so that the c erv ical s pine rests c omfortably on them. 14. P. T he patient is far enough away to per mit the phys ician's forearms and elbows to r est on the table. neutr al balance 11 of 40 21/08/07 22:11 . palpation of patient. F ig . and the physician s its at the head of the table.http://thepointeedition. T he phys ician's palpating fingers lift the T2 tr ans ver se pr ocesses up and down ( arrows.

the physician gently s ide. T1. T2. When this balanced position is ac hieved.lww.19. which causes a r elative side bending right and r otation r ight at T1 (F ig.20. SLRL. Step 7. F igu re 14.19). 12 of 40 21/08/07 22:11 .http://thepointeedition. 6. and the physician holds the position against it until a r elease in the direc tion of ease occ urs . 8. a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf. Us ing the third finger pads . 14. the index finger pads on the T1 s egment may minimally and gently r otate and s ide-bend T 1 to the r ight until a balanced point of tension is met ( Fig .com/pt/re/9780781763714/bookContent.. point. Step 6. 14. F igu re 14.20). SRRR.bends ( c urv ed arr ow) and r otates ( s weep arrow) T 2 to the left.. 7. As the physician introduc es the v ectored for ce. disengagement between the flexion and ex tension barriers .

If there appear s to F igu re 14. F igu re 14.22. 14. 4.. 5.http://thepointeedition.com/pt/re/9780781763714/bookContent. 3.3 75 C erv icothor acic R e gion: Ante rior C erv ical Fa scia . T he phys ician abduc ts the thumbs and plac es the thumbs and thenar eminences ov er the c lavicles in the s upraclavic ular fossa immediately later al to the s ternocleidomas toid muscles (F ig . F ig.. D ire ct Technique 1.22) that is v ectored toward the feet. T he phys ician moves the hands back and for th from left to right ( arr ows .23) to engage the r estr ictive bar rier. 14. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ). 9. F ig . T he phys ician applies a downward. P. Step 3. Steps 1 and 2. T he patient lies s upine. 2.lww. 14.21). 13 of 40 21/08/07 22:11 . s lightly posterior force ( arrows. and the physician s its or s tands at the head of the table.21.

the thumb or thumbs c an be pushed farther later ally..3 76 Thor acic And Lumba r R egions : T3 to L4 Exa mple: T12 ESLRL 14 of 40 21/08/07 22:11 . 6.23. both hands can be direc ted (ar rows. F igu re 14.http://thepointeedition. 8.lww. F ig. Step 4. 14. Step 5. P. 7. be sy mmetric r estr iction.com/pt/re/9780781763714/bookContent.24) toward the bilater al r estr iction. F igu re 14.. T his pressur e is maintained until no further improvement is noted. T he phys ician r eass ess es the c omponents of the dy sfunction ( T ART ).24. As the tens ion r eleases . bilateral tension if needed.

T he patient lies pr one..com/pt/re/9780781763714/bookContent.25) .. T he phys ician adds a c ompr ess ion force (long ar rows) approximating T 12 and L1 and then dir ects a force downward ( s hor t arrows) towar d the table to vector it to the extension Fig ure 14. Step 6. 2. 4.27. 3. T he phys ician places the r ight thumb ov er the left transv erse pr ocess of L1 and the index and thir d finger pads over the r ight tr ans v ers e pr ocess of L1 ( F ig. 1. and the physician s tands beside the table.25. and on ex halation. T he phys ician places the left thumb ov er the left transv erse pr ocess of T 12 and the index and thir d finger pads of the left hand over the r ight tr ans v ers e pr ocess of T 12. Steps 1 to 3. the physician follows the motion of these two s egments . Step 5. 14. 15 of 40 21/08/07 22:11 .lww.http://thepointeedition.26. Fig ure 14. T he patient inhales and ex hales. 5. Fig ure 14.

2. Hand positioning with sac rum and lumbar v ertebra. 3. T he patient lies s upine.http://thepointeedition. 16 of 40 21/08/07 22:11 . 1.com/pt/re/9780781763714/bookContent. and the physician s its at the s ide of the patient.3 77 Thor acic And Lumba r R egions : T8 to L5 Exa mple: L5 FSRR R with Sacr al Tethering If no s acral c omponent is pres ent.29.g. T he phys ician places the c ephalad hand ac ros s the s pine at the level of the dy sfunctional s egment so that the heel of the hand and finger pads contac t the left and right L5 tr ans ver s e pr ocesses ( F igs.. T he phys ician places the c audad hand under the patient's s acrum s o that the finger pads ar e at the s acral base and the heel is towar d the s acrococ cygeal r egion. L2 and L3) .. the hands may contact each s egment of the v ertebr al unit involved in the dysfunc tion (e. Fig ure 14. 14.28 Fig ure 14. hand pos itioning.28. Steps 2 and 3..lww. P.

Step 6. 14. a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. T he phys ician Fig ure 14. an d 14. Step 4. 7.http://thepointeedition..30.29). 8. F ig . T he s acr al hand moves the s acrum c ephalad and c audad ( arrows.32).32. 6. T he lumbar hand may need to lift upward and downwar d ( arrows. SRRR..31. Fig ure 14. 17 of 40 21/08/07 22:11 . L5. F ig .30) to find a point of eas e as the lumbar c ontacting hand does the same.31) to balance between flex ion and extension. When this total balanced position is ac hieved.lww.com/pt/re/9780781763714/bookContent. T he lumbar c ontacting hand then side-bends and r otates L5 to the r ight ( arrows) to find balanced tension in thes e direc tions ( Fig . 14. 4. Fig ure 14. 14. Step 5. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 5.

34. and the physician s its at the head of the table. 18 of 40 21/08/07 22:11 . 5. T he forc e applied should be moder ate but not s evere.lww. Poste r ior .3 78 C ostal R egion: Fir st Rib Dy s function Exam ple : Le ft. 3. 14.33. c audal forc e. r eass ess es the c omponents of the dysfunc tion ( T ART ).. 4. T he phys ician places the left thumb ov er the posterior as pec t of the elev ated left fir st r ib at the c ostotransv erse ar tic ulation (F ig. T he patient sits or lies supine. Step 2.. Step 3. Elev ate d First Rib (N onphys iologic . Fig ure 14. 14. T he phys ician direc ts a force c audally (ar row. 2. N onre spiratory) 1. T he pres sur e is maintained until a releas e oc cur s as indic ated by the Fig ure 14. P.34) through the ov erlying tissues and into the elev ated left first rib.33).com/pt/re/9780781763714/bookContent. F ig. thumb placement.http://thepointeedition.

and the physician s its or s tands at the s ide of the patient.36) that F igu re 14. 2. Steps 2 and 3.. F ig. thumb being permitted to move thr ough the r estric tive barrier. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ). P. 14.com/pt/re/9780781763714/bookContent.lww.35) . 4. 3. 14. T he other hand is placed palm down with the fingers c ontouring the angle of the rib c age anteriorly ( F ig. 6..http://thepointeedition. hand plac ement. T he phys ician places one hand palm up with the fingers c ontouring the angle of the rib c age posteriorly .35.3 79 C ostal R egion: Dy s function of the Res pira tor y D iaphragm a nd/or Exha lation Dys func tion of the Lowe r R ibs 1. T he patient lies s upine. T he hands impar t a moder ated c ompr ess ion force (arrows. 19 of 40 21/08/07 22:11 .

a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment.lww.. 6. compr ession for c e.36. P. F igu re 14. 5. is vectored towar d the x iphoid pr ocess. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).com/pt/re/9780781763714/bookContent.http://thepointeedition.3 80 U ppe r Ex tre mity R e gion: Cla v icle: Left Sternocla vic ula r D ysfunc tion (D ire c t Method) 20 of 40 21/08/07 22:11 . The physician holds the position against it until a r elease in the direc tion of ease occ urs . T his pressur e is adjus ted toward the ease of movement of the r ibs and under lying tissues until a balance of tension is ac hieved.. Step 4. When this total balanced position is ac hieved. 7.

14. 4. s uper ior ly.37..com/pt/re/9780781763714/bookContent. Step 3. Fig ure 14. 14. Fig ure 14. 14.38. T he patient may dr ape the forearm of the dy sfunctional ar m over the physician's upper ar m. T ech niq u e 1. 21 of 40 21/08/07 22:11 . 5. Step 6. T he patient sits on the s ide of the table. T he phys ician's left thumb is placed on the tip of the infer omedial s ternal end of the c lavicle immediately later al to the s ternoclavic ular joint (F ig.lww. 6.http://thepointeedition. T he phys ician places the r ight thumb on the later al clav icle just medial and infer ior to the ac romioc lav icular joint (F ig. T he phys ician moves both thumbs ( arr ows. Symp tom and Diag nosis T he symptom is pain at either end of the c lav icle.39. T he phys ician s its on a s lightly lower stool and faces the patient. and s lightly Fig ure 14.37) . 3. 2.39) later ally..38) . F ig. Step 4.

T he phys ician locates the teres minor muscle at the posterior ax illary fold. 5. thumbs at point of greatest tens ion. Step 4. 3.com/pt/re/9780781763714/bookContent. T he patient lies in the later al r ecumbent ( s ide-ly ing) position with the injur ed shoulder up. 2.41) . T ech niq u e 1. P... 22 of 40 21/08/07 22:11 . 4.41. T he pad of the physician's thumbs are placed at a right angle to the fiber s of the muscle ( thumb pr ess ure direc ted par allel to muscle) at the point of maximum hy per tonicity ( F ig.lww.http://thepointeedition. Fig ure 14.42. 14. Step 5. T he phys ician maintains a s teady Fig ure 14. T he phys ician s tands at the s ide of the table behind the patient.3 81 U ppe r Ex tre mity R e gion: Shoulde r: Spa s m in the Tere s Minor Musc le (Dir ect Me thod) Symp tom s an d Diag nosis T he indication is pain in the posterior axillar y fold.

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

pr ess ure s uper ior ly, medially , and s lightly anter ior ly ( arrows, F ig . 14.42) until a r elease of the s pasm is noted. 6. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

P.3 82

U ppe r Ex tre mity R e gion: Shoulde r: Gle nohumer al D ysfunc tion

Symp tom s an d Diag nosis T he indication is s ubdeltoid bur sitis or froz en s houlder. T ech niq u e 1. T he patient lies in the later al r ecumbent position with the injur ed shoulder up. 2. T he phys ician s tands at the s ide of the table behind the patient. 3. T he phys ician places the olecr anon pr ocess of the patient's flexed and r elaxed

F igu re 14.43. Step 3.

23 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

4.

5.

6.

7.

elbow in the palm of the distal hand and gr asps the patient's s houlder with the opposite hand (F ig. 14.43). T he phys ician c ontr ols the humer us from the patient's elbow and c ompr ess es it into the glenoid fossa (arrow, F ig. 14.44) . T he phys ician dr aws the elbow later ally and s lightly anter ior ly or posteriorly ( arrows, F ig . 14.45) to br ing balanced tension thr ough the s houlder . T he phys ician dr aws the s houlder anter ior ly or posteriorly and s imultaneous ly c ompr ess es it infer ior ly ( arrows, F ig . 14.46), dir ecting the v ector into the opposite glenohumeral joint. T he phys ician holds the position of balanced tension until a r elease is felt.

F igu re 14.44. Step 4, compr ess toward glenoid.

F igu re 14.45. Step 5, balanc ing tensions.

F igu re 14.46. Step 6, point of balanc e.

24 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

8. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 9. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ). After the r elease, the humerus may be c arr ied superiorly and anteriorly , making a sweep pas t the ear and down in front of the face (1) .

P.3 83

U ppe r Ex tre mity R e gion: For e arm and Elbow: U lnohume ral and R adioulnar Dys func tions

25 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

Symp tom s an d Diag nosis T he indication is elbow pain or s tiffnes s. T ech niq u e 1. T he patient lies s upine, and the physician s tands or s its at the s ide of the patient. 2. T he phys ician gr asps the patient's olecr anon pr ocess with the thumb ( lateral as pect) and index finger ( medial aspect) at the prox imal tip of the olecr anon pr ocess at the gr oov es, bilaterally . 3. T he phys ician's other hand gr asps the dorsum of the patient's flexed wr ist (F ig. 14.47). 4. T he phys ician r otates the patient's forearm into full pr onation ( c urv ed arr ow, F ig. 14.48) and the hand into full flexion ( s hor t arrow). 5. T he phys ician's hands

F igure 14.47. Steps 2 and 3.

F igure 14.48. Step 4, pronation and flexion.

F igure 14.49. Step 5, compres sion and ex tension.

26 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.3 84

U ppe r Ex tre mity R e gion: Wris t: Car pal Tunnel Sy ndrome

1. T he patient lies s upine, and the physician s tands next to the outs tretched ar m of the dy sfunctional wr ist. 2. T he phys ician's medial hand c ontr ols the patient's thumb and thenar eminence (F ig. 14.50). 3. T he phys ician's other hand gr asps the patient's hy pothenar eminence and then supinates the forearm ( arrow, Fig . 14.51). 4. At full supination the patient's wr ist is flexed to its tolerable limit ( long ar row, F ig. 14.52) and the thumb is pushed dors ally ( s hor t arrow). 5. T he phys ician, maintaining the forces, slowly pr onates the forearm to its c omfortable limit and adds a force (arrow, F ig. 14.53) v ectored toward

Fig ure 14.50. Steps 1 and 2.

Fig ure 14.51. Step 3, s upination.

Fig ure 14.52. Step 4, wris t flexion.

27 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

ulnar deviation. 6. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

Fig ure 14.53. Step 5, ulnar deviation.

P.3 85

Lowe r Ex tre mity R e gion: Hype rtonic ity of the Ex ternal Hip R ota tor s and A bduc tor s of the Femur (Exam ple : Piriform is H ype rtonicity and Fibrous Inela sticity )

1. T he patient lies in the later al r ecumbent position with s y mptomatic s ide up and both hips flexed to 90 to 120 degrees. 2. T he patient's k nees ar e flexed to approximately 100 degr ees . 3. T he phys ician s tands in fr ont of the patient at the level of the patient's hip, facing the table. 4. T he phys ician locates the hy per tonic or painful pir ifor mis

F igu re 14.54. Steps 1 to 5.

28 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

muscle s lightly posterior and infer ior to the s uper ior por tion of the greater tr ochanter. 5. T he phys ician maintains a fir m pr ess ure with the pad of the thumb medially ( down towar d the table) over the musc le until a releas e is palpated (F ig. 14.54). 6. Alter native: The physician may us e the olecr anon pr ocess of the elbow instead of the thumbs ( F ig. 14.55) . T he olec ranon is sensitiv e to the pres sur e ( arrow) and is able to deter mine the tendon's r esis tance and the differential anatomy of the ar ea. It is als o easier on the physician, as this sty le of technique c an fatigue the thumbs. 7. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

F igu re 14.55. Step 6, alter nate contac t with elbow.

P.3 86

29 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

Lowe r Ex tre mity R e gion: Kne e : Posterior Fibular Hea d D ysfunc tion

1. T he patient lies s upine and the physician s its at the s ide of the dy sfunctional leg. 2. T he patient's hip and k nee ar e both flexed to approximately 90 degrees. 3. T he thumb of the phys ician's c ephalad hand is placed at the s uper olater al as pec t of the fibular head. 4. T he phys ician's other hand c ontr ols the foot just inferior to the distal fibula ( F ig. 14.56) . 5. T he phys ician's thumb adds pr ess ure on the pr oximal fibula in a vec tor s traight toward the foot (ar row at right, F ig. 14.57) while the other hand ( arrows at left) inver ts the foot and ankle. 6. T he phys ician attempts to deter mine a point of balanced tension at the pr oximal fibula and maintains

Fig ure 14.56. Steps 1 to 4.

Fig ure 14.57. Step 5.

30 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

this pos ition. 7. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 8. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

P.3 87

Lowe r Ex tre mity R e gion: Kne e : Femorotibia l D ysfunctions Exam ple : Sprain of the C ruc iate Ligam e nts

1. T he patient lies s upine, and the physician s tands at the s ide of the dy sfunctional k nee. 2. T he phys ician places the c ephalad hand palm down ov er the anterior distal femur . 3. T he phys ician places the

F igu re 14.58. Steps 1 to 3.

31 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

4.

5.

6.

7.

c audad hand palm down ov er the tibial tuber osity ( Fig . 14.58). T he phys ician leans down onto the patient's leg ( arrows, F ig . 14.59), dir ecting a for ce toward the table. T he phys ician adds a c ompr ess ive force (arrows, F ig. 14.60) in an attempt to approximate the femur and tibia. T he phys ician adds internal or ex ter nal rotation to the tibia ( arrows, F ig . 14.61) with the c audad hand to deter mine which is fr eer . T he physician attempts to maintain this position. When this total balanced position is ac hieved, a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position against it until a r elease in the direc tion of

F igu re 14.59. Step 4, downward for ce.

F igu re 14.60. Step 5, joint compression.

F igu re 14.61. Step 6, inter nal or external r otation.

32 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

ease occ urs . 8. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

P.3 88

Lowe r Ex tre mity R e gion: Gas troc nem ius Hypertonic ity , D ire c t Method

1. T he patient lies s upine and the physician s its at the s ide of the table just distal to the patient's c alf, facing the head of the table (F ig. 14.62). 2. T he phys ician places both hands side by s ide under the gastr ocnemius muscle. The physician's fingers should be slightly bent ( arrow, Fig . 14.63), and the weight of the leg s hould r est on the phys ician's fingertips. 3. T he phys ician's fingers apply an upwar d forc e ( arrow at left, F ig. 14.64) into the musc le and then pull

Fig ure 14.62. Step 1.

Fig ure 14.63. Step 2.

33 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

infer ior ly ( arr ow at right) us ing the weight of the leg to c ompr ess the area. 4. T his pressur e is maintained until a releas e oc cur s. 5. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).

Fig ure 14.64. Step 3.

P.3 89

Lowe r Ex tre mity R e gion: Ank le: Pos ter ior Tibia on Talus

1. T he patient lies s upine with the heel of the foot on the table. 2. T he phys ician s tands at the foot of the table on the s ide of s y mptomatic ank le. 3. T he phys ician plac es the prox imal hand palm down ac ros s the distal tibia with the metac arpal- phalangeal joint of the index finger pr oximal to the distal tibia (F ig. 14.65) . 4. T he phys ician pres ses direc tly down ( arr ow, F ig. 14.66) toward the table and balances the tension coming up through the heel and the tibiotalar joint. 5. T he phys ician's other hand can be placed on top of the treating

Fig ure 14.65. Steps 1 to 3.

34 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

hand to create mor e pr ess ure. T he physician inter nally r otates (F ig . 14.67) or ex ter nally r otates ( F ig. 14.68) the tibia s lightly to bring the c ompr ess ion to a point of balanced tension. 6. When this total balanced pos ition is ac hieved, a slow r hythmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. The physician holds the position agains t it until a releas e in the direc tion of ease oc cur s. 7. T he phys ician r eass ess es the c omponents of the dy sfunction (TART) .

Fig ure 14.66. Step 4, pres s ing downward.

Fig ure 14.67. Step 5, inter nal rotation.

Fig ure 14.68. Step 5, exter nal rotation.

P.3 90

Lowe r Ex tre mity R e gion: Foot and A nkle Ex ample: Left C alc a neus D ysfunc tion, the B oot Ja ck Technique (1)

35 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

1. T he patient lies s upine, and the physician s tands on the left, facing the foot of the table. 2. T he patient's left lower thigh and k nee ar e placed under the phys ician's r ight ax illa and against the later al rib cage for balance and c ontr ol. 3. T he phys ician gr asps the patient's left c alcaneus with the r ight thumb and index finger ( F ig. 14.69) . 4. T he phys ician flexes the patient's left hip and k nee approximately 90 degrees and gently ex ter nally r otates and abduc ts the patient's femur ( arrow, Fig . 14.70). 5. T he phys ician's r ight distal humer us and elbow touch the patient's distal femur just above the popliteal fossa as a fulcrum to gener ate pr oximal pr ess ure.

F igure 14.69. Steps 1 to 3.

F igure 14.70. Step 4, external r otation and abduc tion of femur .

F igure 14.71. Steps 5 to 7.

36 of 40

21/08/07 22:11

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.3 91

Lowe r Ex tre mity R e gion: Foot Dy sfunction: Me tata rsa lgia

1. T he patient lies s upine, and the physician s tands or is s eated at the foot of the table. 2. T he phys ician gr asps the foot with both hands , the fingers on the plantar as pec t of the distal metatars als ( F ig. 14.73) and the thumbs on the dors al as pec t of the foot (F ig. 14.74). 3. T he phys ician flexes the distal forefoot (ar row, F ig. 14.75) s lightly by c ontr acting the fingers on the plantar aspect of the foot. 4. T he phys ician then presses the thumbs downward into the metatar s als towar d the table ( arrow, Fig . 14.76). 5. T he phys ician attempts to position the foot at a point of balanced tension. 6. When this total

F igure 14.73. Steps 1 and 2, finger s on plantar s urface.

F igure 14.74. Steps 1 and 2, thumbs on dorsal s urface.

F igure 14.75. Step 3, flexion of forefoot.

37 of 40

21/08/07 22:11

T he phys ician's thumbs are c r oss ed.http://thepointeedition. 7. T he patient lies s upine. 38 of 40 21/08/07 22:11 .. mak ing an X. press toward table. P.3 92 Lowe r Ex tre mity R e gion: Foot: Plantar Fas ciitis . a s low rhy thmic ebb and flow of pr ess ure may pr esent its elf at the dy sfunctional s egment. 3. T he thumbs impar t an inwar d Fig ure 14. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ).77. with the thumb pads ov er the ar ea of c oncern (tar sal to distal metatars al) at the plantar fascia.. Direc t Me thod 1.lww. F igure 14. Step 4. and the physician s its at the foot of the table. Steps 1 to 3.com/pt/re/9780781763714/bookContent. The physician holds the position against it until a r elease in the direc tion of ease occ urs . 2. balanced position is ac hieved.76.

Su the r l an d W G. 14.79) . 14. dors iflexion. T he phys ician r eass ess es the c omponents of the dysfunc tion ( T ART ). 2.78) and dorsiflexion ( F ig. 19 90. 14. K. S y ne r get i cs . 20 03. 4. Sn els on. Fig ure 14.http://thepointeedition. Step 5.77) that is vectored distal and later al.. 5.ke nnet hsn els on. Cr ow T . This pr ess ure is c ontinued until meeting the r estr ictive (bind) barrier.). Wa r d R (e d. L i ga m en tous Ar tic ul ar St r ai n: O s te opa thic Te c hn i que s f or the Bod y . T he pres sur e is held until a r elease is palpated.n et/ .79. F ound ati ons for Os teo path i c M ed i c in e. F ig. P. 20 01. Sp eec e C.lww. Step 5. W ale s A (e d. N ew Y ork : M ac mi l la n. Phi l ade l ph i a: Lip pin c ot t Wi l li ams & W i lk i ns . Seat tle : Ea s tl and . Fu l le r RB . 1975 . OR : R udra . 5. 6. htt p:// w ww . T his is repeated with the foot alter nately attempting plantarflex ion ( F ig. 3. force (arrows.78. plantarflex ion. Po r tl and. F r equ ent l y As ke d Q ues ti on s ( F AQ ) an d S tru c tur e & 39 of 40 21/08/07 22:11 . Fig ure 14. 4.) ..3 93 R efe renc es 1.com/pt/re/9780781763714/bookContent. T eac hin gs i n t he Sci ence of Os teop ath y .

In gbe r DE .lww. Sc i A m 1 998.. 278 :48 –57.http://thepointeedition. Acc ess ed F ebr uar y 4. 20 07. 40 of 40 21/08/07 22:11 . 6..com/pt/re/9780781763714/bookContent. T he ar ch i te c tu r e o f l i fe . Te nse gri ty .

An y o s te opat hic di agno s ti c e x ami nat i on s ho uld in c l ud e a la y er. A r ea s o f so m at i c dy s fu nc ti on adv er se l y aff ec ti ng the v is c er al s y st ems ma y be tr eat ed w i th an y of th e v ar io us ost eopa thi c ma nip ul at i ve tr eatm ent s ( OM T) me nti oned in th i s a tla s . e x pa nded th e t hi nk i ng of os teo path i c tre atme nt i n this ar ea. H ow eve r .l ay er p alp ato r y ap pro ac h. t y pi c al l y t he v is c era ar e m ov ed to w ar d th eir fa s c ia l at tac hm en ts to a po i nt of fas c ia l b al an c e.com/pt/re/9780781763714/bookContent. 15 Visceral Techniques Techni que Pri nci ples Os teo path i c v is c era l t ech ni qu es ( VI S) a r e def i ned in th e gl oss ary of ost eop athi c t erm i nol ogy by the Ed uca ti on al C ou nc il on Os teop ath i c Pr in c ip l es ( EC OP) as “ a s ys tem of dia gno s i s and tr eatm ent di r ect ed to th e vi s ce r a to i m pr ove phy s io l og i c f unc tio n.by. Th ere fore . a nd l y mp hat i c) tha t h ad s uch po s it i v e eff ect s on th e v i s ce r a and gen era l h ealt h s tat us co nti nued to be tau ght . n eck . as is pr om ot ed i n os teo path y i n t he c r an i al fie l d. m ost of Sti l l' s wr i ti ng has to do w i th th e c i r cu l at ory ( ar ter i al . a nd h ume r al s ys tem s . an d t end er ne s s ( se ns it i vi ty) . m any of th e te c hn i qu es ( hep ati c . H e d i d not w ri te a t r eat i se on l ow ba c k pain an d so on . At ma ny o s te opa thic me dic al s c ho ols VIS te c hn i que s w ere r ed uce d i n fa v or of tea c hi ng the tec hni ques th at w ere mo r e di re c tl y a s s oc i at ed w i th th e m us cu l os k el etal dy s fu nc ti ons th at c aus ed head . Vi s ce r al tec hni ques ha v e be en part of th e os teo pat hi c m an i pu l ati v e arm am en tar i um s in c e the tim e o f S ti ll . T he na tur e of th e o r gan ' s m ob i l it y s hou l d b e ac c ep ted by m os t ph y si c ia ns . Al l o s te opat hic in terv ent i on w as ba s ed on try i ng to tre at pati ent s i n a m or e b enig n a nd effe c ti v e ma nne r . and ly m ph atic ) . wh i ch w he n u s ed i n the vi s c er al r eg i ons ma y d eter m in e t i s su e t ext ur e c ha nge s . W it h p r ac ti ce . r es tri c tio n o f s uc h m ot i on .. pu l mo nary . al s o c all ed v ent r al te c hni que s ” ( 1). a s ym m et r y o f st r uc ture an d/o r mo tio n ( m obi l it y a nd m oti l it y ) . Techni que Classi fication Di r ec t . t his c ha pte r i l l us tra tes s om e t ech ni qu es tha t ha v e an i ndi r ec t o r di s ta l ef fec t on th e v i s ce r al sy s tem . n ot j ust mu s cu l osk ele tal pai n. th at tec hniq ue c ou l d b e c ons i der ed a vi s ce r al tec hni que. Ot her c ha pte r s di sc uss os teop ath i c palp ato r y di ag nos i s for det ect i on of s om atic dy s fu nc ti on. In fact . ve nou s . t he phys i ci an c an not on l y p alp ate org ano m eg al y and re s tr i c ti on of m obi l it y b ut c an als o di s ce r n fi ne ch ang es i n t he i nhe r en t m otil i ty of the or gan i ts elf . b ut i n m ost ca s es i t i ll us tr ate s t ec hn i qu es that ar e m or e dir ect l y as s oc i ate d w i th i t. I n di r ec t .. I n ad dit i on . v i s ce r al . as the in her ent m ot i on w it hin th e or gan it s elf . ga s tr oin test i na l .bi nd as y mm etri es of ti ss ue ten s i on an d m otio n u s ed for th e d i agn osi s a nd d eve l op m ent of tr eat m ent ve c to r s a r e als o ap pro pri ate for th e vi s ce r a. Mo r e r ece ntl y .lww. th e s oma tovi s ce r al and vi s ce r oso m at i c r ela tio ns and the ef fect s o f dy s au tono m ia co ntin ued to be i mp ort ant i n the ove r al l o s teo pat hic c ur r ic ulu m . lo w ba c k. t he m or e ev olv ed thin k in g o f mo til i ty . o r C o mb in ed 1 of 21 21/08/07 22:12 . a s h e de v el ope d an d pr omo ted his sy s tem of di agno s is an d th e f oll ow in g m ani pula tiv e t ec hn i qu es for hum an i l ln ess .http://thepointeedition. and ex tre m i ty pa i n. how eve r . s ple nic . If O M T add r ess es a s om at i c c om pone nt of di s ea s e a nd the eff ect is to i mp r ov e th e c ond i tio n o f t he p ati ent . Th e sa m e ea s e. the w or k s of B arr al have ag ain exc i te d t hose wh o h ad l ost to uc h w it h t ec hn i qu es affe c ti ng th e v i s ce r a ( 2) . neu r olo gic .

( T he s ty l e l ab el ed ba l an c ed l ig ame ntou s t ens i on. th e p hy si c ia n p al pa tes at v ar i ou s l ev el s i n t he r egi on of t he s pe c i fi c o r ga n an d d ete r m in es w he ther an y te the r i ng is ta k i ng pl ace i n r el ati on t o e ase ..bin d b arr i er c on c ep ts . ic e w ater im m er s i on .. v aga l i ndu c tio n t hro ugh Val s al v a m ane uve r .l ay er app r oac h. ex agg er at i ng it s fr ee m ot i on pat ter n. Ro uti nely . Reflex Ori ented Th ese tec hni que s at tem pt to p r od uce a s eco nda r y r eac tio n in an or gan s ys tem by aff ect i ng the au tono m ic ne r vo us s y st em ( usu all y s y m pa the tic but so m et i m es pa r as y m pa the tic ) . usi ng pal pato r y tec hniq ues to s en s e the i nh ere nt m oti l it y o f th e o r ga n. a nd s o on. o c ul ar pr ess ur e. T he s e t r ea tme nts are in are as tha t ca n a ffe c t t he aut onom i c ne r vo us s y st em i n s pec i fi c wa y s ass oc ia ted wi th e i th er s y mp ath eti c or pa r as y m pa the tic r ea c ti v it y . Th e ab nor m al s om ati c af fer ent bom bar dm en t i s e l i mi nat ed. Vibratory or Sti m ulatory Technique 2 of 21 21/08/07 22:12 . T his ca n d i r ec tly af fect th e v enou s a nd l y mp hat i c dr ai nag e fr om the r eg i on ( in c lu din g in ter s ti ti al sp ace s ) i nha bit ed b y t he v i sc era l o r gan . y.by .lww. T his is an ex amp l e o f a P. a nd the n ba l an c in g at a poin t t hat exh i bi ts equa l t ens i on i n the x -. su c h as c aro tid m as s ag e. H ow ev er.l ik e t ec hn i qu e. or Ligamentous Articular Strain Th e B LT /L AS m et hod of dia gnos i s and tre atm ent i s an att em pt to di s c er n t he ease . Bal anced Ligamentous Tensi on. T his is s im i la r t o us i ng ot her au ton om ic re fle x es.http://thepointeedition. T hey ar e a n at tem pt ei th er to i ncr eas e o r to de c re as e the le v els of au tono m ic ou tput at th e ar ea i n ques tio n. in s om e c ase s th i s app ears to pr oduc e t he ap pro pr ia te c li ni ca l r esp onse . alt hou gh i t u s es th e sa m e ti ss ues to eff ect ch ange th at m y of asc i al r el eas e [ M F R] us es) . c au s in g t he p r ev i ou s l y ass oci ated (a bno r m al ) r eac ti on ary vi s c er al ef fer ent i nn erv atio n t o b e no r ma l iz ed. Myofascial Oriented Th e f as ci al c om pone nt to v i sc era l m obil i ty is the pr i ma r y a s pe c t i n d i ag nos i s a nd tre atme nt i n this te c hn i que . s uch as a p ati ent w it h a s thm a h avi ng t he s ym path eti c p or ti on of the au ton om ic sy s te m st i mu l at ed b y t hor ac ic pu m p i n t he upp er t hor aci c re gio n a nd e x hi bit i ng l es s a i r wa y re act i v it y ..bi nd as ym m et r y. a nd s o o n. t he phy s i ci an att em pt s t o ba l an c e t he tis s ues th r ou gh i ndi r ec t (a nd s om etim es dir ec t) te c hn i que by di s eng agi ng the org an fr om it s re s tr i c ti v e pre s ent ati on ( c om pre s si on. or li game nto us ar ti c ul ar s tra i n [BL T /LA S] i s si ngl ed o ut bec ause of it s di ffe r en t pa l pa tor y ex pre s si on o f d i ag nosi s a nd tr ea tme nt. Techni que Styles All evi ation of S omatic Dysfunction In so m ati c d y sf unct i on th at a ppe ars to dir ect l y c aus e a n or gan to fun c ti on abno r ma l ly . T he n t he p hys i ci an d eci des w he the r t o us e a dir ect or i nd i re c t M F R. noci c ep tio n. a nd z . w i th c li nic al r esp ons e fr om the r ed uct i on i n i nf l amm ato r y r esp ons e. tra c ti on). w e p r efe r t o t hi nk of re duci ng the are a o f s om at i c dys func tio n r athe r t han i nc r ea s in g or de c re as in g t he l eve l o f a uton omi c a c tiv i ty . Th en. Us i ng th e la y er .ax es.com/pt/re/9780781763714/bookContent. tr eat i ng the ar ea of re l ate d s oma ti c dys fun c tio n s ome ti me s c an r edu c e or abla te the v is c er al abno r ma l it y .3 96 so m at ov is c er al r efl ex bei ng q uie ted by the el i m in ati on of t he s om atic dy s fu nc ti on.

dy sp are uni a. c onst i pa tio n. ve nou s .3 97 th e p hy si c ia n m us t dev elo p a tre atm ent pla n t hat r ed uce s th e s oma ti c dys fun c tio n i n a s af e.. c hol ecy s tit i s. ul c er ati v e c oli tis .g. H epa ti ti s . or ble edin g o r ga n is no t ap pro pr ia te. c om pre s si on. a nd s tre s s i nco nti nen c e 8. or tra c tio n o v er an i nf l am ed.3 99 Reflex Ori ented Treatment Occi pitomastoi d S uture P ressure 3 of 21 21/08/07 22:12 . s hak i ng. Th i s r ef l ex has be en u s ed mo s tly as a di ag nos tic too l a nd i s n ot i nc l ude d i n t he te c hn i que se c ti on. a nd h orm ona l im bal anc e 5. D i ve r tic ulo s is . an d l y m ph ati c v es se l s and to hel p d ec on ges t t he o r ga n. i nte r s ti tia l c y s ti tis . ben i gn ma nne r . Indications Th e i ndic ati ons for vi bra tory or st i m ul ato r y tr ea tme nt ar e org an dy sf unc tio ns e x pr ess i ng the m se l v es in ma ny c l in i ca l m anif est ati ons. gas tri tis . ch r on i c fati gue . gen tly to m od era tel y vi bra ti ng . R ecu r r en t c y st i tis . T hes e t ech ni qu es are oft en use d in sp l en i c a nd he pat i c p r ob l em s wh en thi s ty pe of forc e i s n ot c ont r ai ndic ate d. C ard i ac arr hyt hm ia . or pe r c us s in g o v er the or gan to fac i l it ate fl ui d m ov eme nt t hro ugh the ar ter i al.com/pt/re/9780781763714/bookContent. bro nch i tis .http://thepointeedition. Pre s su r e. D epe ndi ng o n th e d i s ea s e and the na tur e of th e a s s oc i at ed dy sf unc tio n. c ong es ti v e hea r t f ail ure . General Consi derations and Rul es Th e p hy si c ia n m us t det erm i ne w he the r th ere is a s oma tic c om pon ent to the di s eas e s tat e. Vi bra tory or st i m ul ato r y tech niq ue us es a r ep etit i ve mo ti on ov er the org an. Ch apm an's re fle x is an oth er p ote nti al d i ag nos ti c aid in the de ter m i na tio n o f th e e x ac t di agn osi s an d t he ke y d y s fu nct i on . an d h y pe r ten s io n 2. P. p neu m oni a. s er i ou s l y i nf ect ed. P. c ho l eli thi asi s . an d h i at al h ern i a 4. As th m a. pa nc re ati tis . ir r it abl e bo w el . c li nic al j udg m en t a gain is th e ru l e. ho w ev er. a nd i nf er ti l it y Contrai ndi cations Th ere are no ab s olu te c on tr ai ndi c at i ons to th i s t y pe of tre atm ent .. Gast r oes oph age al r efl ux. Py el onep hri tis and re nal l it hia s is 7. t r ea t th at fir s t. and emp hys em a 3. ate l ect asi s . T he phy s i ci an m us t al s o not e wh eth er ther e i s a n au ton omi c co m pl i ca ti on (e . i f pos s i bl e. D y sm enor r he a. fa c il i ta ted se gme nt) and if the r e i s s uch .3 98 P. . d i ar r he a. in c lu di ng bu t n ot l i mi ted to the fo l l ow i ng (1 ) : 1.lww. a nd hem or rh oid s 6.

1 T he occ ipitomastoid s uture. 4. 4 of 21 21/08/07 22:12 .2 Steps 3 and 4.1) that could be caus ing a secondary bradycar dia ( somatov isc eral ty pe) . T ech niq u e 1. finger placement. The phy sic ian places the index finger s ov er eac h mas toid pr ocess immediately proximal to the anterior aspect of the gr oove. 2.com/pt/re/9780781763714/bookContent.3 Step 5. The phy sic ian palpates the occ ipitomastoid grooves bilater ally. Physiolo gic Go al T he goal is to us e a r eflex ( par asy mpathetic) to decr eas e the patient's puls e by influenc ing c ardiac rate v ia c ranial nerv e X (vagus ) or by treating cr anial s omatic dys function at this ar ea ( Fig . 15. Indicat ions T he indications for occipitomas toid s utur e pres sur e release are tachycar dia ( hypopar asy mpathetic s tate) and bradyc ardia ( hyperparas ympathetic s tate).. F ig ure 15. 3.. tr action with fingers.lww. F ig ure 15. The phy sic ian places the third F ig ure 15. The patient lies supine and the phy sic ian is seated at the head of the table.http://thepointeedition.

T his alternating pres s ure is continued until the des ired effec ts are obtained or it is determined that the tec hnique will be ineffec tiv e.4 01 Reflex Ori ented Treatment Alternating Pressure. 15.com/pt/re/9780781763714/bookContent. which may influenc e c ardiac rate. T ech niq u e 1.dir ecte 5 of 21 21/08/07 22:12 . The phy sic ian places the pads of the other index and middle finger on the anter ior aspect of the left s econd r ib near the cos toc hondral junction (F ig . This pr ess ure is lik ewise held for s ever al sec onds befor e s witc hing again. anter ior . 6.8).7).. The phy sic ian pr esses upwar d with the bottom hand while releasing pr ess ure from the top hand (F ig .lww. P.5) or treating thoracoc ostal s omatic dys func tion at this area.http://thepointeedition. The patient lies supine.4 00 P.. 15. 15. Physiolo gic Go al T he goal is to us e the s ympathetic reflex to incr eas e the patient's puls e by influencing car diac r ate via sy mpathetic chain ganglia (F ig. The phy sic ian holds this position for sever al sec onds .7 Step 4. 2.6 Steps 1 to 3. 3. The phy sic ian reaches under the patient and places the pads of the index and middle finger s on the angle of the left sec ond rib near the c ostotr ansv ers e ar tic ulation. 15.6). anterior a placement of finger s. Left Second Rib Indicat ions T he indications for treatment are tac hycardia ( hypers y mpathetic state) and br ady car dia ( hyposy mpathetic s tate). after which the bottom hand releas es pres sur e and the top hand ex erts downwar d pres sur e (F ig. 5. 4. and the phy s ician is seated at the head of the table. F igure 15. F igure 15.

. 6 of 21 21/08/07 22:12 . posterior -direc pr ess ure..8 Step 5.lww.http://thepointeedition.com/pt/re/9780781763714/bookContent. F igure 15.

.4 03 Reflex Ori ented Treatment S ingultus (Hiccups) 7 of 21 21/08/07 22:12 . Pos terior view (3 P. F igu re 15.http://thepointeedition.com/pt/re/9780781763714/bookContent.lww..4 02 P.5 Anatomic loc ation of the s ympathetic chain ganglia.

This pr ess ure should elicit a mild degree of pain (to tolerance) and be maintained for at least a minute after the hic cups c ease to br eak the reflex arc .12) . us ing the thumb. or middle finger . 15.http://thepointeedition. T ech niq u e 1. index .12 Thumb pres sur e v 8 of 21 21/08/07 22:12 . F ig ure 15. but als o r eceives fiber s fr om C3 and C5. 15.com/pt/re/9780781763714/bookContent.10 Steps 1 and 2.. T he phr enic nerve arises pr imar ily fr om C4.lww. it may be repeated on the right. It runs deep to the omohyoid muscle and s uperfic ial to the anter ior s calene mus cle. F ig ure 15. 3.11 Finger pr essure. 5. The phy sic ian loc ates the triangle formed by the sternal and c lav icular heads of the left sternoc leidomastoid mus cle (F ig.. F ig ure 15. If the tec hnique is uns ucc essful on the left. The patient may be s eated or lie supine.11 and 15. 15. The phy sic ian. pr ess es deep into this tr iangle (F igs.10). 4. 2.9). It is the only motor nerv e s upplying the diaphragm (F ig .

2.13 and 15.com/pt/re/9780781763714/bookContent.15 Phy sic ian and patient 9 of 21 21/08/07 22:12 . F ig ure 15. and the phy sic ian is seated at the side of the patient. P. F ig ure 15.http://thepointeedition. The phy sic ian slides both hands under the patient's thorac olumbar region (F igs. The pads of the finger s lie on the par aver tebral tis sues ov er the cos totr ans ver se articulation on the side near F ig ure 15. 15. Indicat ions T o r elieve postoper ative paralytic ileus T o impr ove r espiratory ex cur s ion of the r ibs T o facilitate lymphatic drainage Cont rain dications Rib frac tur e Spinal c ord injur y and s urgery Malignancy T ech niq u e 1..13 Skeletal hand contac t. 3. Lymphatic T echniques. The patient lies supine.lww.4 04 Reflex Ori ented Treatment Rib Rai sing See Chapter 16.14 Patient hand contac t.14) ..

15). then lateral pr essure. 4.16) in. the phy sic ian lifts the finger s into the par aver tebral tis sues . 15. v entr al.4 05 Sti mul atory/V ibratory Treatment Colonic Sti mul ation 10 of 21 21/08/07 22:12 . 6.lww. P. 15. simultaneously drawing the finger s (arrows. the phy sic ian (F ig.. This lifts the spine off the table and places a later al str etc h on the par aver tebral tis sues .16 Step 4.http://thepointeedition. Fig .com/pt/re/9780781763714/bookContent. pos itioning. Leaning down with the elbows. 5.. This technique may be per for med as an intermittent kneading tec hnique or with s ustained deep inhibitory pressur e. F ig ure 15.

http://thepointeedition.18). 15. 3.lww. 11 of 21 21/08/07 22:12 . 4.width far ther along the colon toward the sigmoid region. Fig . The patient lies s upine. 15. The phy sic ian rolls the finger s along the bowel in the dir ection of colonic flow ( arrows. The phy sic ian releas es pressur e and repositions the hands one hand's . and the phy sic ian stands at the patient's side.17 Steps 1 and 2. F ig ure 15. The phy sic ian places the pads of the finger s on the abdominal wall ov erlying the splenic flexur e of the colon ( Fig . F ig ure 15..18 Step 3.com/pt/re/9780781763714/bookContent. F ig ure 15. 2.17) . Indicat ion Cons tipation Cont rain dications Bowel obstr uction Abdominal neoplas m Undiagnosed abdominal pain T ech niq u e 1..19 Step 5.

21) . s udden r elease 12 of 21 21/08/07 22:12 .. The phy sic ian's right hand abducts the patient's left arm 90 degrees and exerts gentle traction (a r row. with the finger s following the interc ostal F igure 15. The phy sic ian places the left hand on the lower c ostal car tilages overly ing the spleen. The patient lies s upine.23 Step 6. F ig. 3. 2.lww.http://thepointeedition.22 Step 5. P. F igure 15.4 06 Sti mul atory/V ibratory Treatment S plenic Sti mul ation Indicat ions Any infectious disease. F igure 15. also prev entive Cont rain dications Infectious mononuc leos is. any splenic enlargement Neoplas m infiltr ating the s pleen T ech niq u e 1.com/pt/re/9780781763714/bookContent. 15. and the phy sic ian stands at the left s ide of the patient.21 Steps 1 to 3..

r elease. spr inging the ribs inwar d. The phy sic ian's left hand exerts pressur e dir ectly toward the center of the patient's body. F igure 15.24) . F ig.22) is car ried out at two per sec ond and continued for 30 sec onds to sev eral minutes . 13 of 21 21/08/07 22:12 .http://thepointeedition. A s pringing motion (a r row. 6.. F igure 15. A s econd modific ation has the phy sic ian place one modification (c ompr ess ion). spaces (F ig. 5. 15. 15. perc uss ive modification. 4..com/pt/re/9780781763714/bookContent. 7. One modific ation of this tec hnique inv olv es compres sing the lower left rib cage slowly between the phy sic ian's hands with a sudden releas e (also call a chugging motion) (F igs.21) .lww.25 Step 7.23 and 15. 15.24 Step 6.

25) .http://thepointeedition. and the phy sic ian stands at the side of the table.. 15. F ig ure 15. hand ov er the lower c ostal car tilages and thump and per cus s the bac k of the hand with a fist or for ear m (a r row. 2. The phy sic ian places the cephalad hand with the heel of the hand at the sac ral bas e.com/pt/re/9780781763714/bookContent.lww. P. 14 of 21 21/08/07 22:12 . F ig..4 07 Reflex Ori ented Treatment S acral Rock Indicat ions Dysmenor rhea Pelv ic c ongestion s yndrome Sacr oiliac dysfunc tion Cont rain dications Undiagnosed pelvic pain Pelv ic malignancy T ech niq u e 1.26 Cephalad hand. The patient lies pr one.

15. 4. behind the patient. 5.29 Sac ral flexion ( nutation). exhalation. ian The phy sic 6. the pec tively (F ig . P.. 3.28) occ urs and then tests for dur ing tis sue tex inhalation.29) occ motion freedom. 2. 15. and the opposite phy sic ian dir ection stands F ig ure 15. pressur e is tec hnique to the eas e ( indirec continued for t) or bind ( direct) . s ubc ostal and subxiphoid exerts gentle region. on the 15 of 21 21/08/07 22:12 . The Indicat ions phy ophageal G astroessic ian's r efluxcaudad hand reinfor ces G astric ptosis the cephalad hand T ech niq u ewith finger s 1.in eas e-bind urs 15.27 Caudad hand.4 08 Myofascial Release/Blt Treatment Gastric Release pointing finger s toward the coc cyx (F ig.http://thepointeedition. The phy sic ian places the phy sic ian. and sac rum F ig ure 15.. cur l the with s lightly and press inward patient's (a r pir ation. left and right hands keeping the over F ig ure 15.28 Sac ral ex tens ion the finger pads synchr onous ( c ounternutation). pressur e on res sac rum.27). 3. F ig.com/pt/re/9780781763714/bookContent. extens ion ian The phy sic adds s F ig.lightly mor e pressur e inward 15. introduces a The phy sic ian's hands c roc king ontour the upper to the motionabdominal quadrants. (F ig. 4. This dir ects a constant F ig ure 15.30 Steps 1 and 2. F ig.31 Step 3. dur ing 5. (a r row.tur e changes and Sac ral flexion asy mmetry (a r row. the left elbows and right anterior str aight. F ig ure 15.31) Sac ral . pointing in the The patient is seated. The phy sic ian 15.26) . resrows .lww. sev eral depending minutes . 15.30) .

3.33) . The phy sic ian places the left hand under the r ib cage at the level of the liv er. P. 6.32 and 15. The patient lies supine. 7..4 09 Myofascial Release/Blt Treatment Hepatic Release Indicat ions Hepatitis Cirr hos is Cholelithiasis T ech niq u e 1.34 Steps 1 to 3.com/pt/re/9780781763714/bookContent.http://thepointeedition.lww. 16 of 21 21/08/07 22:12 . can be helpful. The phy sic ian places the right hand immediately inferior to the F ig ure 15. F ig ure 15.33 Step 5. F ig ure 15. patient's tolerance and phy sic ian's prefer ence (F igs.. 15. indir ect for ce (ease) .32 Step 5. The phy sic ian holds this until a releas e is palpated and continues until no fur ther improv ement is produc ed. direc t ( bind). A releas e-enhancing mec hanism. such as deep inhalation and ex halation. and the phy sic ian sits to the right and fac es the patient. 2.

.35 Compress to palpate liv er.com/pt/re/9780781763714/bookContent. The phy sic ian gently compres ses the patient with both hands ( arr ows .36) . 15. F ig ure 15. 15. Fig . A releas e-enhancing mec hanism. P. subcos tal angle at the patient's right upper quadrant (F ig.4 10 Myofascial Release/Blt Treatment Gal l bladder 17 of 21 21/08/07 22:12 .. The phy sic ian nex t tests for any eas e-bind tis sue tex tur e and motion asy mmetries. 8. can be helpful. 7. On noting any asy mmetry.http://thepointeedition.36 Step 6. 4.35) and attempts to palpate the liver . the phy sic ian maintains a constant pres sur e at either the eas e (indir ect) or the bind ( direct) .34). 5. F ig ure 15. 15. such as deep inhalation and ex halation. direc t or indir ect for ce. 6. depending on the patient's tolerance and phy sic ian's prefer ence (F ig.lww. The phy sic ian holds this until a releas e is palpated and continues until no fur ther improv ement is produc ed.

The phy sic ian places the index . depending on the F ig ure 15. third. and fourth finger s of the r ight hand just inferior to the subcos tal mar gin.39 Step 5. midline to slightly r ight. third. 15. 5. F ig ure 15. The phy sic ian tes ts for any eas e-bind tis sue tex tur e and motion asy mmetries. On noting any asy mmetry.lww. the phy sic ian maintains constant pres sur e (a r rows . 3.37) .37 Steps 1 to 3. 4.38 Step 5. The phy sic ian places the index .38 and 15. 15..com/pt/re/9780781763714/bookContent. indir ect for ce (ease) . direc t forc e (bind).http://thepointeedition.39) at either the eas e (indir ect) or the bind ( direct) .. 2. just lateral of midline immediately to the right of the gallbladder ( Fig . F ig ure 15. and the phy sic ian stands behind the patient. F igs. 18 of 21 21/08/07 22:12 . and fourth finger s of the left hand just inferior to the xiphoid proces s . The patient is seated. Indicat ions Cholecy s titis Cholestasis Chronic upper abdominal pain T ech niq u e 1.

4. The phy sic ian stands on the affected s ide at the lev el of the hip. 5. The patient lies supine with the hip and knee flex ed on the affected side.40) . and hip flexion is added to r elax the anterior abdominal region (F ig.http://thepointeedition..lww. F ig ure 15.41 Steps 4 to 6. 3. The patient's knee is plac ed anterior to the phy sic ian's axilla at the cor acoid proc ess .. The phy sic ian's medial hand reaches ar ound the patient's thigh to lie over the upper abdominal quadrant on the affected s ide and presses downwar d (poster ior ly) (top F ig ure 15. 2.4 11 Myofascial Release/Blt Treatment Kidney Rel ease Indicat ions Pyelonephritis Renal lithiasis F lank and inguinal pain T ech niq u e 1. The phy sic ian places the later al hand palm up under the patient's bac k just below the floating ribs . 19 of 21 21/08/07 22:12 .40 Steps 1 to 3. F ig ure 15. direc t or indir ect for ce.42 Step 8.com/pt/re/9780781763714/bookContent. P. 15.

can be helpful P. The phy sic ian holds until a releas e is palpated and continues until no fur ther improv ement is produc ed. 8. 15. arr ow.com/pt/re/9780781763714/bookContent. The phy sic ian nex t tests for any eas e-bind tis sue tex tur e and motion asy mmetries.41) until palpating the kidney .http://thepointeedition. 9.42) at either the eas e ( indirec t) or the bind (direc t).4 12 References 20 of 21 21/08/07 22:12 . 7. 10. 6.41) upward (anter ior ) to fac ilitate the renal palpation. Fig . the phy sic ian maintains a constant pres sur e (a r rows . A releas e-enhancing mec hanism. On noting asy mmetry. 15. 15.. Fig .lww. F ig. depending on the patient's tolerance and phy sic ian's prefer ence. such as deep inhalation and ex halation.. The phy sic ian's pos ter ior hand lifts (b ottom ar row.

S eatt l e: Ea s tla nd. Bal tim ore : Li ppi nco tt W i ll i am s & W il k in s . 11 th ed. R ep r in ted w it h p er mi s si on fr om Ag ur AM R. 2 005 .com/pt/re/9780781763714/bookContent. 3. Me r ci er P . Phil ade l ph i a: Lip pin c ott Wi l li am s & W i lk i ns. G r an t' s Atl as of A nat omy .. 200 3. W ar d R .http://thepointeedition.. 19 88. Da l le y AF . V i sc er al Ma nip ul at i on . 2. 21 of 21 21/08/07 22:12 . 1.lww. Bar r al J P. Fo und ati ons for Os teop ath i c M edi c in e.

T hey w er e t y pic all y i nc lu ded in the vi s ce r al s ec tio ns o f o s te opat hic pr i nci ple s a nd pr act i c e. Ex am pl es of tech niq ues w it h g r ea t ly m ph ati c po ten tia l of th eir own ar e ba l an c ed l ig ame ntou s t ens i on. T hes e a r e desc r ib ed i n t hei r r es pe c ti v e ch apt er s. T he pri nci pl e of uni m ped ed va s cu l ar s up ply has be en pr om ote d e x ten s iv ely . S ti ll ' s ru l e of t he art er y quo ted .lww. 16 Lymphatic Techniques Techni que Pri nci ples Ly m ph atic te c hn i que s h ave not un til r ec ent l y been co nsi dere d a sp ec if i c c at egor y o f o s teo pat hic ma nip ul at i on . m any st ude nts hav e b een tau ght the ly m ph atic (t hor ac ic ) p ump de v el oped by C. Ano the r P C OM al umn us . so ft t i ss ue. d i sc us se d w i th us the ma ny c ase s a nd 1 of 59 21/08/07 22:13 .. a ma j or c on tri but or t o d i se as e and in c r ea s ed mo r bid i ty . ho w ev er. Gor don Z in k . St ude nts of ost eopa thi c m edic i ne ar e ty pic all y in s tr uct ed i n t he terr i bl e e ffec ts of the i nf l ue nz a pan dem i c of 19 18 a nd 191 9. It is a p r in c ip l e t hat al l os teo pat hi c tec hni ques ha v e s ome ef fec t on ly m ph atic s . T . H ow eve r . J . b y t he al le v ia tio n of so m at i c dy s fu nc ti on and the co nse quen tia l n or ma l iz ati on o r b ala nc in g ( par as ym pat het i c o r s y mp athe tic ) o f th e au ton om ic ne r vo us s y st em. an d wh en i t i s s tre s se d. by st i m ul ati ng fl ow or re m ovi ng i mp edim ent s t o fl ow. M i l le r 's te c hni que wa s no t b ein g us ed dur i ng the in fl ue nza ep i dem i c. He ex pr es s ed hi s ph i lo s op hy w i th wo r ds s uc h a s “l i fe an d de ath ” w hen s pe aki ng a bou t t hi s s ys tem ( 2) . Mi l le r 's s on .com/pt/re/9780781763714/bookContent. Th e E duca tio nal C ou nci l o n Os teo pat hi c Pri nci pl es (E C OP ) of fer s n o de fin i ti on o f l y mp hati c s as a s epa r at e t y pe of ost eopa thi c m anip ula tio n. an d m ost ost eop ath i c s tud ent s ha v e hea r d A . D O. 1 905 ) d ev el ope d m andi bul ar dr ai nag e. w as a p r om i nen t l ect ur er on th e my ofa s ci al a s pe c ts of l ym pha ti c c on ges ti on an d i ts t r ea tme nt. h i ms el f a d oct or o f m edi c i ne . I n t his r es pec t. 4). th e o nl y s pe c if i c m ent i on of ly m ph atic te c hn i que is th at o f t he l y mp hat i c ( M il l er ) p um p and th e pe dal (D al ry m pl e) pump (1 ) . W il l ia m G al br eat h ( Phil ade l ph i a C oll ege of Ost eop athi c M edi c i ne [P C OM ]. Ma ny os te opa thi c ph y si c ia ns h ave at temp ted to aff ect th e ly m ph ati c sy s te m . c ert ain te c hni que s s eem to hav e a m or e d i r ec t e ffe c t o n t he ly m ph atic sy s te m th an oth er s and he nc e are de s c ri bed in thi s c hap ter.pot ent i at i ng tec hni ques ar e d es cr i be d i n ot her ch apte r s. Ph i la delp hia os teop ath i c phys i ci ans w er e i m po r tan t t o t he u nde r st andi ng of the l ym pha ti c s ys tem and in de v el opin g t ech ni qu es to affe c t i t. or li game nto us ar ti c ul ar s tra i n ( BL T /LA S). Ly m ph . H owe v er . v is c er al. T hi s is ac c om pl is hed di r ec tl y. T hes e te c hn i que s a r e i ncl ude d i n th i s c ha pter as we l l a s r efe r enc ed i n F oun dat i on s fo r O s te opat hic Me di ci ne (1 ) . or i nd i re c tl y .. a te c hn i qu e in c lu ded i n thi s t ex t ( 3.http://thepointeedition. W e ar e a tte m pti ng to us e tec hni ques wi th a st r on g ef fec t on th i s s y st em to tr ea t s ome of our mo s t d i ff i cu l t c hro nic c as es tha t ar e c omp l i ca ted by au toi m m un e a nd othe r i nfl am ma tor y c ondi tio ns. W e bel i eve th at of t he flu i d s y st ems . it is th e lo w -p r es s ure ly m ph atic sy s te m th at c an mo s t easi l y be i m pe ded an d mo s t c li ni ca l ly be nefi ted . my ofa s c ia l r ele as e ( MF R ). and ar tic ul at ory te c hni que s . Ear l M i ll er . he als o s tate d t hat he c on s id er ed th e l y m ph ati c s y s te m p r im ar y i n the ma i nt enan c e of heal th. I n t he EC OP gl oss ar y. He beg an usi ng t his te c hni que an d pr omo tin g it to ot her ost eop athi c p hys i c ia ns i n th e m i d-1 920 s . an d it wa s m os t l ik ely s of t t i ss ue a nd art i c ul ato r y tech niq ues tha t w ere m os t c omm only us ed at t hat ti m e. A few y ea r s ago . a gr ad uat e o f th e C hic ago C ol l eg e of Os teo path y w ho pr ac tic ed j ust no r th of Phi l ad el ph i a.

T he r ef ore . w hi c h r ec ei ve s a uto nomi c s tim ul at i on . Be l l' s pa l sy w as th e c ondi tio n t hat piq ued our in ter es t m os t w hen c on s id er in g i ts c l in i ca l v al ue . M i ll er ev i de ntly ha d e x tre m el y r apid po s it i v e c li nic al r esp ons es w hen tr eati ng Bel l ' s pal s y w i th th i s tech niq ue. So m e othe r c omm on a r ea s o f dy s fu nct i on w it h w hi ch th i s ty pe of te c hni que ca n be he l pf ul a r e su bma ndib ula r r es tr i ct i on s . st r oki ng.5) . B esi des c au s in g pa i n. W e be l ie v e that th e f l uid . Th i s m oda l it y h as b een in v olv ed i n di sc uss i on s co nce r ni ng t r ea tme nt o f p ati ents wi th a ma l ig nan c y .. Ef fle ura ge a nd pé tri s s ag e a r e c omm on m as s age va r ia ti on s o f t hi s typ e o f te c hn i qu e. and dy s fun c ti ons aff ect i ng the ax i ll a. a nd ante r io r c er vi c al ch ai n dra i na ge a r e c la s s ic al exa m ple s o f o s teo pat hic te c hn i que s t hat s ti m ul ate flo w . b ut w e 2 of 59 21/08/07 22:13 . te c hn i que s t hat he s aw hi s fa the r u s e a nd tha t he co nti nued to us e in hi s o w n i nte r na l me dic i ne pra c ti c e. BLT /LA S. An othe r i m po r tan t pr i nc i ple is to r em ove so m ati c d y sf unct i on s t hat are ca us in g s eco ndar y a uto nomi c e ffe c ts ( e. m ul tip l e s c le r os i s) . T he l arg er ly m ph atic ve s se l s m ay eve n ch ang e d i ame ter fo l l ow i ng sy m pat het i c s tim ula tio n (1 .g. So m e beli eve th at i t i s n ot w i se to pro m ot e l y m ph ati c f l ow. a f i rs t ri b d y sf unct i on ha s th e p ote ntia l t o r es tr i ct fl ow t hro ugh the th ora c i c i nl et. a bdo m in al di aph r agm dy s fu nc ti on. Techni que Classi fication Techni ques Removi ng Restri ctions to Lymphatic Flow Re s tr i c ti ons to l ym pha tic flo w t hat are re l at ed t o s pec i fic so m at i c d y sf unc ti on s m ay be r emo v ed by te c hn i que s f r om m an y c ate gori es ( e. It ch ange d o ur v i ew s o n t he s y mp tom s as s oc i at ed w i th th i s p r oc ess and wh y s ti mu l at i on to the ch es t wa l l and pul m on ar y c av i ty c ou l d r es ul t i n an al mo s t i mm edia te c li ni ca l r esp onse in a s y nd r om e w i th mo s t of i ts s ym ptom s i n t he f aci al c r an i um .. tho r ac i c dy s fu nc ti ons ca us in g h y pe r s ym pat het i c t one wi th c ons equ ent l ym pha ti c c on s tr i c ti on) . and we are P. T hor aci c pu m p. mu s cl e en erg y t ec hn i qu e [ M ET] ) a l so has th e p oten tia l t o be a l ym phat i c tec hniq ue. t hus all evi ati ng t he s ym ptom s .st i mu l ati ng eff ec ts ca n d ec on ges t th e f or am en thr ough wh i ch the fa c ia l ne r ve pa s s es .vo l ume ..http://thepointeedition.am pl i tu de [H VL A]) . MF R . w her eby r el ate d au ton omi c ch ang es and pot ent i al fac i li tate d s egm ents ar e no r ma l i ze d.lww. Som e we r e not c on dit i on s th at hav e be en his tori c al l y taug ht as i ndi c at i on s fo r i ts us e. t hor aci c in l et re s tri c ti on s eco nda r y to m y of asc i al ten s io n. g. l ow. Techni ques Promoting Lymphatic Fl ow Te c hn i que s p r om otin g l y mp hati c f l ow are ge ner al ly st i mu l ato r y. T hi s c an be th oug ht o f a s b r eak i ng th e da m . . li m i te d mo tio n. and va s cu l ar ton e. Pa r ki nso n di s ea s e. noc i ce pti on. a nte c ub i tal fo s sa . An ex am ple is a f i rs t r i b d y sf unc ti on .4 14 at tem ptin g t o d ev el op m or e re s ea r ch i n thi s f i eld (e . ma ndi bula r d r ai nage . Mo bil i z in g t he r i b and re s tor i ng it s no r ma l r ange of mo ti on an d f unct i on ma y re m ov e t he r est r ic ti on to ly m ph atic fl ow. or v ib r at ory . M or e r ese ar ch is ne eded . a nd s o on. He wa s ki nd eno ugh to don ate s om e o f hi s f ath er 's eq uip m ent to th e PC OM arc hi ve s .g.com/pt/re/9780781763714/bookContent. g. Th e c l i ni c al ef fect s t hat c an be se en w i th ly m pha tic te c hni que s m ay b e s eco ndar y t o t he e l im i na ti on of so m at i c d y sf unc ti on . pe dal pum p. Th i s ha d a pro fou nd effe c t on us . T hi s no r ma l iz atio n n ot only ha s e ffec ts on s oma tic an d vi s ce r al r ef l ex es. po pli tea l fo s sa .. i t c an als o af fec t t he l y mp hat i c s y st em.. a nd p l an tar fas c ia . ps oas m us c le dys fun c ti on. an y t ech ni qu e t hat i s i nd i ca ted for fi r s t r ib so m ati c d y sf unct i on (e . h i gh . W ha t wa s m ost in ter es ti ng to us w ere th e po s it i ve eff ect s h e sa i d his fat her ' s tech niq ue had on s o m any va r ie d co ndi ti on s . wh i le oth ers be l i ev e i t i s in dic ate d be c au s e pr omo ti ng no r ma l fl ow all ow s gre ate r cl ear anc e of ab nor m al c el l s.

http://thepointeedition.. Su bcl ass i fic ati on i n t his ca tego r y i nc l ude s t ech ni qu es tha t af fec t t he i ntr i ns i c a nd ex tri ns ic ly m ph atic pu m ps . o r os teo por os is if te c hni que st y l e w ou l d ex ac erb ate c on dit i on Or ga n fr i ab i li ty a s s een i n s pl een w it h i nfe c tio us m on onuc l eo s is Ac ut e he pat i ti s M ali gnan c y 3 of 59 21/08/07 22:13 ..4 15 M i ld to m od era te c ong est i v e hea r t fail ure U ppe r an d l owe r re s pi r at or y i nf ect i ons an d o ther ar eas of i nf ect i on As th m a. M ET. ef fle ur ag e) i s in c lu ded i n thi s st y le . C 3 to C 5 d y sf unct i on af fect i ng th e di aph r ag m ) . be l ie v e t hat if exe r ci s e c an be pre s c ri bed fo r sp eci fic pat i en ts w i th a m al i gna ncy . m as tec tomy ) P. di r ect pr ess ur e. I n th e i nte r s ti tiu m . Techni que Styles Th e v ar io us s ty l es of l ym phat i c tec hniq ue bel ong to the i r o w n c at egor y o f o s teo pat hic m an i pu l at i v e tr eat m ent (O M T) .. Intrinsic Lym phatic Pum p Th ese tec hni que s al ter au tono m ic to ne o r t i ss ue t ext ure i n the in ters tit i al s pa c es . t hen l ym pha ti c flo w st i mu l ati on s ho ul d als o b e in dic ate d in th ose pat i en ts. or tr eati ng the so m at i c c omp one nt o f a dy s fun c ti on w i th HV LA ( e.g . a ny tech niq ue that af fec ts t his me c han i sm is c on s id ere d an ex tri ns ic st y le . d i sl oc at i on . Th ere fore .lww.. Ex amp l es of thi s s ty le in c lu de tr eat m ent of fa c i li tat ed s egm ent s i n th e t hor ac ol umb ar r egi on and i nd i re c t m y of asc i al r el eas e t o th e in ter os se ous me m bra ne. c hr oni c ob s tr uct i v e pul m on ar y dis eas e Pain due to ly m pha tic co nges tio n a nd s w el l in g Contrai ndi cations Ac ut e in dur ate d ly m ph no de ( do not tre at dir ec tl y ) F r ac ture . Indications Ly mp hati c c ong es ti on.com/pt/re/9780781763714/bookContent. fl uid c an ac c um ul at e a nd ev en tua l ly dis r up t n or ma l l y mp hati c f l ow . Extrinsic Lym phatic Flow Th e e x tri nsi c p um p i s r el ated to th e ef fec ts of m usc l e c ont r ac tio n an d m oti on o n t he l y mp hat i c s y st em. Any fo r m of e x er c is e or te c hn i que af fec ti ng mu s cl e ac tiv i ty ( e. po s tsu r gi c al ede m a ( e. g. g.. st r ok i ng. Ex amp l es i nc l ud e ab dom i nal di aph r agm or pe l v ic di aph r agm tr eat m ent wi th m y of asc i al r el eas e.

Steps 1 to 3. t he appr opr i at e so m at i c c omp one nt m ust be tr eate d w i th w hi c he v er tec hni que the ph y si c i an de ter m i ne s i s i ndic ate d. The patient lies s upine. 2. F or v i br ato r y or c omp r es s i on te c hn i que s . ar e no t t he only on es affe c ti ng the ly m ph atic s .4 16 Head and Neck Anteri or Cervical Arches: Hyoid and Cri coi d Rel ease Indicat ions Lary ngitis Phar yngitis Cough Any dys func tion or lymphatic c ongestion in the ear. setup. aut oi mm une .. l ess pa i n. nos e.http://thepointeedition.. an d n euro m us c ul os ke l et al s y st ems . I f th e p atie nt has l ym pha tic s eq uel ae of a uto nom i c d i st urb ance .lww. an d t he i nte gum ent m us t b e a bl e to tol er at e t he ty pe of pr ess ur e. m ay af fec t th e e ndo c r in e. i n a ddi ti on to af fect i ng ly m pha tic ci r c ul ati on. Th ese tec hni que s . and a bet ter ove r al l se nse of we l l -b ein g. r educ e r est r i ct i on . Ple as e s ee ot her c ha pte r s f or w ay s to en han c e l y mp hat i c f l ow . o r no r ma l i ze au ton om ic in ner v ati on.1. wh eth er p r ob i ng or fri c ti onal . the pat i en t's mu s cu l osk ele tal s ta tus in r es pec t t o bo ne den s i ty an d m otio n a v ai l abi l it y m us t be r el ativ ely no r m al .com/pt/re/9780781763714/bookContent. or throat ( ENT ) r egion T ech niq u e 1. a s s tate d p r ev i ous l y. and the phy sic ian sits at the head of the table. General Consi derations and Rul es Ly m ph atic te c hn i que s a r e s i mi l ar in s co pe of pr in c ip l e to t he v is c era l t ech ni qu es. Th e ph y si c ia n mu s t co nsi der the pa ti en t's he al th st atu s al ong wi th t he s pe c i fi c p r es enti ng s ym ptom s b efo r e d eci din g to us e a pa r ti c ula r t ech ni qu e. The phy sic ian stabilizes the patient's head by placing the Fig u re 16. r es ul tin g i n in c re ase d mo tio n. 4 of 59 21/08/07 22:13 . T he fol l ow i ng tec hni ques . P. T he are a m ust be s ta ble .

3. Fig s. The phy sic ian mak es alternating contac t (a r rows .2 and 16. hy oid.. and upper tracheal rings. The thumb and index finger of the phy sic ian's caudad hand form a hor ses hoe shape (inver ted C) over the anterior cer vic al arc hes (F ig.3) with the lateral aspects of the hy oid bone.1).http://thepointeedition.lww. 4. cr icoid. 16. gently pus hing them fr om one side to the other. Step 4. The phy sic ian continues this alternating pressur e up Fig u re 16. 3. 5 of 59 21/08/07 22:13 .2. Fig u re 16.. cephalad hand beneath the head or by gently grasping the for ehead. lar yngeal car tilages . 5. 16. Step 4.com/pt/re/9780781763714/bookContent.

.. (Some crepitus is nor mal. the nec k may be slightly flexed or extended to eliminate exc ess friction.http://thepointeedition.) 7. 6. This tec hnique is continued for 30 sec onds to 2 minutes.com/pt/re/9780781763714/bookContent. If ther e is crepitus between the anterior car tilaginous str uctures and the cer vic al spine.lww. P. and down the length of the anterior nec k.4 17 Head and Neck Cervical Chai n Drai nage Technique 6 of 59 21/08/07 22:13 .

7 of 59 21/08/07 22:13 . Step 4.4. Steps 1 to 3.http://thepointeedition. hand plac ement. milking motion. T he hand then mov es slightly more caudad along the mus cle and repeats the rolling motion.com/pt/re/9780781763714/bookContent. Fig .. The phy sic ian's caudad hand (palmar as pec t of the finger s) mak es broad c ontact ov er the sternoc leidomastoid (SCM) musc le near the angle of the mandible ( arr ow.lww. The patient lies supine. and the phy sic ian sits at the head of the table. Indicat ions T his tec hnique is indicated for any dysfunc tion or ly mphatic c ongestion in the ENT r egion.. 2. 4. 16.5) . 5. 16. F ig ure 16. This s ame procedure is applied both anterior to and pos ter ior to the F ig ure 16. 3. T ech niq u e 1. From c ephalad to caudad the finger s roll along the mus cle in a milk ing fas hion (arrows.4) .5. Fig . The phy sic ian stabilizes the patient's head by placing the cephalad hand beneath the head to elevate it slightly or by gently grasping the for ehead.

8 of 59 21/08/07 22:13 .4 18 Head and Neck Mandibular Drainage: Galbreath Technique Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT or s ubmandibular r egion.7. c audad pres s ure on mandible. The phy sic ian stabilizes the patient's head by placing the cephalad hand beneath the head to F ig ure 16.com/pt/re/9780781763714/bookContent. The patient lies s upine with the head tur ned slightly toward the phy sic ian and the phy sic ian sits at the head of the table.g. F ig ure 16. Care mus t be taken in patients with ac tive temporomandibular joint ( T MJ) dysfunc tion (e.http://thepointeedition. 2. Steps 1 to 3. painful click) with s evere loss of mobility and/or lock ing. Step 5. P. especially dysfunc tion in the Eustachian tubes. T ech niq u e 1..lww. setup and hand placement.6...

16. This procedure is applied and releas ed in a slow rhy thmic fas hion for 30 sec onds to 2 minutes .com/pt/re/9780781763714/bookContent.7) at the TMJ and gently toward the midline.6). fourth. elevate it slightly. and fifth fingertips along the pos ter ior ramus of the mandible and the hypothenar eminenc e along the body of the mandible (F ig. 4. It may be repeated on the other 9 of 59 21/08/07 22:13 .. 5. The phy sic ian places the caudad hand with the thir d. 16.. F ig. The patient opens the mouth slightly. 3.http://thepointeedition. 6. The phy sic ian's caudad hand presses on the mandible so as to draw it slightly for war d (a r rows .lww.

. side.http://thepointeedition. hand plac ement. c lock wis e. finger s pointing cephalad and the ear between the fourth and third finger s (F ig. and the physician sits at the head of the table.com/pt/re/9780781763714/bookContent. The phy sic ian stabilizes the patient's head by placing the cephalad hand beneath the head to elev ate it slightly. The phy sic ian places the caudad hand flat agains t the s ide of the head.lww.8. Step 4. 2. The phy sic ian's caudad hand F ig ure 16. F ig ure 16. 10 of 59 21/08/07 22:13 . 16. 4. Steps 1 to 3.9.4 19 Head and Neck Auricular Drainage Technique Indicat ions Any dys func tion or lymphatic c ongestion in the ear region O titis media O titis externa T ech niq u e 1.8).. 3. The patient lies supine with the head turned slightly toward the phy sic ian. P.

c ounter cloc kwise. 5. 16.4 20 Head and Neck Al ternati ng Nasal P ressure Techni que Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region.http://thepointeedition. left. and the phy sic ian sits at the head of the table. F igs.9 and 16. Step 4. mak es c loc kwise and counter clockwise cir cular motions (a r rows . T ech niq u e 1. 2. F ig ure 16.10). The phy sic ian F ig ure 16.11.. This pr ocedur e is applied for 30 sec onds to 2 minutes .com/pt/re/9780781763714/bookContent. mov ing the sk in and fas cia ov er the sur fac e of the sk ull. Step 4. especially the ethmoid sinus. The patient lies s upine.lww.10. There should be no sliding ov er the skin and no friction. P. 11 of 59 21/08/07 22:13 ..

.4 21 Head and Neck Submandibular Release 12 of 59 21/08/07 22:13 . uses an index finger to pres s on a diagonal (a r rows . fir st in one dir ection and then the other.http://thepointeedition.13). F ig ure 16.16.. Step 4.lww.13. r ight. 4.11 and 16. P. 16.12. 3. This procedure is applied for 30 sec onds to 2 minutes. F ig ure 16. Fig s. Modification.12) into the junction of the nas al and fr ontal bones. Alternativ e methods bas ed on per sonal modific ations of hand pos ition are acc eptable (F ig.com/pt/re/9780781763714/bookContent.

The finger s are then dir ected superiorly into the submandibular fas cia to determine whether an eas e-bind asy mmetry is present (a r rows .15) . 3. F igure 16. and temporomandibular dysfunc tions..14). 13 of 59 21/08/07 22:13 .http://thepointeedition.com/pt/re/9780781763714/bookContent. F ig. especially those affecting the tongue. The patient lies s upine. Hand and finger position. 16. and the phy sic ian sits at the head of the table. 16. lower teeth.14. T ech niq u e 1. 2. salivary glands.. Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region.lww. The phy sic ian places the index and third fingertips (may include fourth finger s) immediately below the inferior r im of the mandible (F ig.

Steps 2 and 3.com/pt/re/9780781763714/bookContent. 3.http://thepointeedition.19.20. 14 of 59 21/08/07 22:13 .. identifying the supraor bital for amen.4 23 Head and Neck Tri gem inal S timulation Techni que Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region affecting or exac erbated by inflammation of c ranial ner ve V ( Fig . Steps 4 and 5. and the phy sic ian sits at the head of the table.lww. Fig u re 16. The patient lies s upine. T ech niq u e 1. 16.18). The phy sic ian places the pads of the index and middle finger jus t inferior to the or bital ridge and produc es a Fig u re 16.. infr aorbital for amen.4 22 P. 2. s upr aorbital for amen. The phy sic ian palpates along the superior orbital ridge. P.

20).. mandibular for amen. knowing that the thr ee for amina for m a str aight line. Fig . 16.. Steps 6 and 7. 16. identifying the Fig u re 16. 4. The phy sic ian places the pads of the index and middle finger s just inferior to the infraor bital for amen and produc es a cir cular motion with the finger s of both hands (a r rows . The phy sic ian palpates along the mandible. 6.http://thepointeedition.com/pt/re/9780781763714/bookContent. 5. Fig . The phy sic ian palpates along the inferior orbital ridge. identifying the infraor bital for amen. cir cular motion with the finger s of both hands (a r rows .19).lww.21. 15 of 59 21/08/07 22:13 .

This trigeminal stimulation procedure is applied for 30 sec onds to 2 minutes at eac h of the thr ee loc ations.http://thepointeedition.lww. 16 of 59 21/08/07 22:13 .. Fig . 7.. The phy sic ian places the pads of the index and middle finger s ov er the mandibular branch of the trigeminal ner ve and produc es a cir cular motion with the finger s of both hands (a r rows .com/pt/re/9780781763714/bookContent. 16. mandibular for amen.21). 8.

P.com/pt/re/9780781763714/bookContent. finger plac ement.18. Step 2. T ech niq u e 1.lww. 2... F igu re 16. and the phy sic ian sits at the head of the table. Cranial nerve V distribution ( 6).4 24 Head and Neck Maxill ary Drainage: Effleurage Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region. 17 of 59 21/08/07 22:13 . The patient lies s upine.22. The phy sic ian places the index finger tip pads ( may inc lude third finger s ) just inferior to the F ig ure 16.http://thepointeedition. especially those affecting the maxillar y s inuses .

18 of 59 21/08/07 22:13 . 4.23.http://thepointeedition.23) . 16. gentle str oking (effleurage) over the patient's skin immediately par allel to the lateral as pec t of the nos e until they meet the dental ridge of the gums (a r rows . F ig ure 16. 3. Step 4.. 5.22). This is repeated for 30 sec onds to 2 minutes.25. motion toward the z y goma. 16. F ig.com/pt/re/9780781763714/bookContent.lww. F ig ure 16. Step 3. 6. The phy sic ian's finger s begin a s low. The finger s continue laterally in a continuous gentle motion toward the alar as pec t of the zy goma (F ig.24). Modification. infraor bital for amina (F ig.. 16. effleur age. This may be modified by either ver y gentle skin rolling ov er the ar ea or gently lifting the sk in and its contiguous subcutaneous tis sues and holding at differ ent lev els for 20 to 30 F ig ure 16.24.

http://thepointeedition. sec onds at eac h level in steps 3 and 4 (F ig.. effleur age. F ig ure 16. 19 of 59 21/08/07 22:13 . T ech niq u e 1.lww. 2. 16.com/pt/re/9780781763714/bookContent. The patient lies s upine.4 25 Head and Neck Frontal Temporom andibul ar Drainage: Effleurage Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion in the ENT region.25).27.26. The phy sic ian places the index finger tips (may inc lude third finger s ) immediately above and F ig ure 16. and the phy sic ian sits at the head of the table. Step 2. P. especially those affecting the frontal thr ough mandibular r egions or in tens ion headache.. Step 3. finger plac ement.

28. 16.26) . gentle.4 26 Thoraci c Regi on Thoraci c I nlet and Outlet: Myofascial Rel ease.27). This is repeated for 30 sec onds to 2 minutes .lww. 5.. str oking (effleurage) laterally that tak es them immediately par allel to the supraor bital ridge until they meet the ar ea of the pterion (a r rows . 16. Fig . F ig ure 16.28) . P. Direct or I ndi rect. The phy sic ian's finger s begin a slow. S eated. 4. Step 4. 3.. The finger s continue inferiorly in a continuous gentle motion toward the TMJ and inferiorly over the mandible (F ig. motion toward TMJ . medial to the eyebrows (F ig. Steeri ng Wheel 20 of 59 21/08/07 22:13 .http://thepointeedition. 16.com/pt/re/9780781763714/bookContent.

29. 2. Cont rain dications T his pr ocedure should not be used if the patient has painful. Techni que Se e C hapt er 8.4 27 Thoraci c Regi on Thoraci c I nlet and Outlet: Myofascial Rel ease. M y of asc i al R el eas e T ec hn i qu es. 21 of 59 21/08/07 22:13 .lww. Techni que Indications Th i s tech niq ue i s i ndi c at ed f or any dys fun c ti on o r l y mp hati c c ong es ti on c au s ed or exa c erb ate d b y fa s ci al to ne as ym m et r y i n t he are a of th e t hora c ic in l et and ou tl et . Direct. s everely restr icted motion of the shoulder ( e.. setup. T ech niq u e 1. Contrai ndi cations Th i s tech niq ue has no abs ol ut e c ont r ain dic ati ons. Supine Indicat ions T his tec hnique is indicated for any dysfunc tion or lymphatic c ongestion c aus ed or exac erbated by fasc ial tone asymmetr y in the area of the thor acic inlet and outlet. The phy sic ian F ig ure 16. rotator c uff tear ). Steps 1 and 2. fibr ous adhesive c aps ulitis.com/pt/re/9780781763714/bookContent. The patient lies supine with the arm on the dys func tional side abducted to approx imately 90 degrees . P.http://thepointeedition.g... for de tai l s .

32. stands or sits at the side of the dys func tional thorac ic inlet either caudal or cephalad to the abducted upper extremity (F ig.29) . The phy sic ian's caudad hand controls the patient's arm.30). 16. 4. 22 of 59 21/08/07 22:13 . F ig ure 16. 5.com/pt/re/9780781763714/bookContent.31) . 3. 16. 16. Step 5.lww.http://thepointeedition. When s uccessful. arm thr ough series of motions. F ig. F ig ure 16.30.. 16.31. Palpation of the thoracic inlet. the phy sic ian will palpate the tension at that site. Modified suppor tiv e position.32) to vec tor a line of tension toward the thorac ic inlet. The phy sic ian F ig ure 16. The phy sic ian gently mov es the patient's arm thr ough a ser ies of motions (a r rows . The arm may be suppor ted by the phy sic ian's thigh if needed (F ig. 6. The phy sic ian places the index and third finger pads of the cephalad hand over the area of the thorac ic inlet so as to palpate the fas cial tone at the ins ertion of the fir st r ib at the manubr ium and the suprac lavicular fas cia (F ig..

4 28 Thoraci c Regi on Mill er Thoraci c (Lym phatic) Pum p Indicat ions T his tec hnique is indicated for infection.c ontrolling hand. and chr onic productive cough. lymphatic c ongestion. it may inc r eas e titer s post vac cination ( 7.11).10.. regional incisions.8. Cont rain dications T his pr ocedure s hould not be used if the patient has frac tur es. P. Deep inhalation or other releas e-enhancing mec hanisms can be helpful. moderate to sever e dyspnea.9. waits for a r elease (fascial c reep) and continues until ther e is no fur ther improv ement in the res trictive bar rier . 23 of 59 21/08/07 22:13 . also pr eventiv e. fev er.http://thepointeedition. as c an a v ibr ator y motion produc ed through the upper extremity with the wrist. Steps 1 and 2. osteopor osis.com/pt/re/9780781763714/bookContent.33.. setup.lww. F ig ure 16. rales .

lww.33). The phy sic ian places the thenar eminenc es inferior to the patient's clavic les with the finger s F ig ure 16. s ubc lav ian lines.. Hand pos ition.http://thepointeedition. T ech niq u e 1.35. The phy sic ian stands at the head of the table with one foot in fr ont of the other (F ig.36. 24 of 59 21/08/07 22:13 .34. incr eas e lymphatic r eturn. Modified hand position. 3. 2. metastatic cancer . The patient lies s upine with the head tur ned to one side ( to avoid breathing or coughing into the fac e of the phy sic ian) with the hips and knees flexed and the feet flat on the table. Physiolo gic Go al T he goal is to accentuate negativ e intr athorac ic pres sur e. and so on. F ig ure 16. F ig ure 16. Two c ompr ess ions per minute..com/pt/re/9780781763714/bookContent. loos en mucus plugs v ia the v ibr ator y c omponent. 16. and potentially s timulate the autoimmune s ystem.

the phy sic ian imparts a vibratory motion to the rib cage at two compres sions per sec ond (p ulsed arr ows . exagger ating the ex halation motion. The patient is ins truc ted to tak e a deep breath and exhale fully. the phy sic ian inc reas es the pressur e on the anterior rib cage. Dur ing exhalation. spr eading out over the upper r ib cage ( F ig. At end exhalation.http://thepointeedition. pressur e is relaxed slightly..lww..36) . For female patients. but the compres sions 25 of 59 21/08/07 22:13 .34) . Should the patient need to breathe. 7.com/pt/re/9780781763714/bookContent. 16. 6. 16. 5. 4. F ig.35). 16. the phy sic ian may place the hands more midline ov er the sternum (F ig.

rales . metas tatic c anc er. Hand position. fever. lymphatic c ongestion. it is also prev entive. osteopor osis. Cont rain dications T his pr ocedure should not be used if the patient has a frac tur e. s ubc lav ian line.http://thepointeedition.. 26 of 59 21/08/07 22:13 . P. Physiolo gic Go al T he goal is to accentuate negativ e intr athorac ic pres sur e and inc r eas e lymphatic r eturn. T ech niq u e 1. or a s imilar c ondition.com/pt/re/9780781763714/bookContent.4 29 Thoraci c Regi on Mill er Thoraci c (Lym phatic) Pum p.37.lww. Exaggerated Respi ration Indicat ions T his tec hnique is indicated for infection.. Fig u re 16. Modified hand position. and c hronic produc tiv e c ough.38. regional incision. are continued for sev eral minutes . moderate to sever e dyspnea. The patient lies supine with the head turned to one side ( to avoid breathing or coughing into the fac e of the Fig u re 16.

The patient is ins truc ted to tak e a deep breath and exhale fully.com/pt/re/9780781763714/bookContent. Fig u re 16. 3. Dur ing exhalation.. The phy sic ian stands at the head of the table with one foot in front of the other. 4.http://thepointeedition. 5. 6.38). For female patients the phy sic ian places the hands mor e midline over the s ter num (F ig. Dur ing the next inhalation the phy sic ian releas es the Fig u re 16. Releas e pr ess ure on inhalation and reins tate it on ex halation.37) . the phy sic ian inc reas es the pressur e on anterior r ib cage.. 16. Fig . The phy sic ian places the thenar eminenc es inferior to the patient's clavic les with the finger s spr eading out over the upper rib cage ( Fig . exagger ating the exhalation motion (a r row. phy sic ian) with the hips and knees flex ed and the feet flat on the table. Pressure with ex halation.40. 16. 16. 2. 27 of 59 21/08/07 22:13 .lww.39.39).

and the phy sic ian stands at the side of the table at the lev el of the patient's rib cage..http://thepointeedition. This may hyperv entilate the patient. 28 of 59 21/08/07 22:13 .headedness and diz ziness are fairly common. This v ersion of the thorac ic pump may be repeated for 5 to 10 res pirator y cyc les . P. 16. 2. then reinstates it (d ownward arr ow) with the nex t ex halation.lww.4 30 Thoraci c Regi on Thoraci c (Lymphatic) Pum p. Steps 1 to 3. Fig . and the phy sic ian Fig u re 16.com/pt/re/9780781763714/bookContent. and light. Side Modifi cati on 1.40). The patient's arm is abducted 90 degrees or greater .. pressur e (u pwar d ar row.41. setup and hand plac ement. The patient lies s upine. 7.

. exerts traction on the ar m with the cephalad hand. 4. The patient is ins truc ted to tak e a deep br eath and ex hale fully.42.41) .42) is exerted by the phy sic ian at two per sec ond. a per cus s ive or vibr atory motion (a r row. 3. 5. 16. pressur e is releas ed jus t enough to per mit eas y Fig u re 16.http://thepointeedition. percussive or vibr atory motion. The phy sic ian places the caudad hand ov er the lower cos tal car tilages with the finger s following the interc ostal spaces (F ig. 16. 6.lww. Step 5.com/pt/re/9780781763714/bookContent. At end of exhalation. 29 of 59 21/08/07 22:13 . Should the patient feel the need to breathe.. F ig.

res pir ation and the vibratory motion continued. Atel ectasi s Modifi cati on Indicat ions T his tec hnique is indicated for atelectasis . when pos sible. P. metastatic cancer . or s imilar c ondition. osteopor osis. s ubc lav ian line.http://thepointeedition. on the opposite side of the chest.43. It should be repeated.4 31 Thoraci c Regi on Thoraci c (Lymphatic) Pum p. s etup and hand placement. incision. Physiolo gic Go al T he goal is to accentuate the negativ e phase of F igure 16.. s evere c ongestion. This tec hnique is continued for sev eral minutes .lww. 30 of 59 21/08/07 22:13 .com/pt/re/9780781763714/bookContent.. Cont rain dications T his pr ocedure s hould not be used if the patient has a frac tur e. 7. Steps 1 to 3.

r espiration and c lear mucus plugs .43) .45. 4. 2. 3. F igure 16. Steps 5 and 6. Sudden r elease of pressur e.http://thepointeedition. The phy sic ian stands at the head of the table with one foot in fr ont of the other. F igure 16.com/pt/re/9780781763714/bookContent. exaggerating ex halation. T ech niq u e 1. The phy sic ian places the thenar eminenc es inferior to the patient's clavic les with the finger s spr eading out over the upper r ib cage ( F ig. For female patients the phy sic ian places the hands more midline ov er the sternum (F ig.46. 31 of 59 21/08/07 22:13 .lww. 16.44. Modified hand position. 16.. The patient is ins truc ted to tak e a deep F igure 16. The patient lies s upine with the head tur ned to one side ( to avoid breathing or coughing into the fac e of the phy sic ian) with the hips and knees flexed and feet flat on the table. res tric ting inhalation..44).

inflating any atelec tatic segments that may be present (F ig..com/pt/re/9780781763714/bookContent.lww. 16. deep inhalation. causing the patient to tak e a ver y rapid.. 5. the phy sic ian maintains heavy pressur e on the chest wall (F ig. breath and exhale fully.http://thepointeedition.45). P. exagger ating the ex halation motion. Dur ing the nex t s ever al inhalations.46) . 16. the phy sic ian inc reas es the pressur e on the anterior rib cage. 6. Pectoralis Mi nor. and Anterior Deltoi d 32 of 59 21/08/07 22:13 . the phy sic ian suddenly releas es the pressur e.4 32 Thoraci c Regi on P ectoral Traction: P ectoral is Major. 7. Dur ing exhalation. On the las t ins truc tion to inhale.

deep inhalation. The patient lies s upine with the hips and knees flexed and the feet flat on the table. 33 of 59 21/08/07 22:13 . Steps 1 to 3. The phy sic ian sits or stands at the head of the table with one foot in front of the other. and/or r eac tiv e airway or asthma. hand pos ition.47. it facilitates the thor acic pump. metastatic cancer .com/pt/re/9780781763714/bookContent. s ome pacemak ers. F ig ure 16.. s ubclavian line. Physiolo gic Go al T he goal is to incr eas e ly mphatic r eturn. 3. Cont rain dications T his pr ocedure s hould not be used if the patient has hypersensitivity to touc h at the anterior ax illary fold. forc e towar d c eiling.48. or s imilar condition. Step 6. upper extr emity edema.http://thepointeedition.49. Indicat ions T his tec hnique is indicated for lymphatic c ongestion. T ech niq u e 1.. 2. Steps 4 to 5. mild to moderate dyspnea or wheeze. F ig ure 16. The phy sic ian places the finger pads F ig ure 16.lww.

edema. and the phy sic ian sits or stands at the side of the patient on the side of the dys func tional upper extremity. Steps 1 to 3.. s ubclavian line. metastatic cancer . Step 4. T ech niq u e 1.com/pt/re/9780781763714/bookContent. 34 of 59 21/08/07 22:13 . P. F ig ure 16.4 33 Upper E xtremi ty Regi on Anterior Axil l ary Folds: Pectoral i s Maj or and Anteri or Deltoid Muscles Indicat ions T his tec hnique is indicated for lymphatic c ongestion and upper ex tremity edema.52.. Physiolo gic Go al T he goal is to incr eas e ly mphatic r eturn. and F ig ure 16. hand and finger placement. The patient lies s upine. 2. The phy sic ian palpates for any inc reas ed tone. or s imilar condition. Cont rain dications T his pr ocedure s hould not be used if the patient has hypersensitivity to touc h at the anterior ax illary fold.51. s etup.http://thepointeedition. s ome pacemak ers.lww.

http://thepointeedition. palpating the anterior por tion fr om within the axilla (F igs. finding tissue tex tur e changes . The phy sic ian. F ig ure 16.. This is held for 30 to 60 sec onds .53) . places the index and third fingers on the ventral sur fac e of the anterior axillar y fold and the thumb in the axilla.4 35 Thoracoabdomi nal Region Dom ing the Di aphragm 35 of 59 21/08/07 22:13 . 3. 4. It may be repeated on the opposite side as needed. bogginess of the tis sues (F ig. Step 5. hand and finger placement.. 16.52 and 16. 16.53.lww.4 34 P. The phy sic ian may ver y slowly and minimally squeez e the anterior axillar y fold with the thumb and finger s .51). P. 5.com/pt/re/9780781763714/bookContent.

Cont rain dications T his pr ocedure should not be us ed if the patient has drainage tubes . 4. F ig ure 16. it may improv e immune func tion. 6.54. The patient is instr ucted to inhale. the phy sic ian's thumbs follow the diaphr agm (a r rows . 16. 7. enc our ages further c ephalad ex cur sion. following exh 36 of 59 21/08/07 22:13 .57.http://thepointeedition. The phy sic ian stands to one side at the lev el of the pelvis .55. The patient is instr ucted to take a deep breath and ex hale. The phy sic ian places the thumbs or thenar eminenc e just inferior to the patient's lower cos tal mar gin and xiphoid proc ess with the thumbs pointing c ephalad ( F igs.57) . 3.56. on repeated exhalation. F ig ure 16.55 and 16. or moder ate to sev ere hiatal hernia or gastroes ophageal r eflux symptoms. F ig ure 16.com/pt/re/9780781763714/bookContent. Thumb placement. The patient inhales as the phy sic ian maintains pressur e on the upper abdomen and then. whic h permits the thumbs to mov e posteriorly . facing c ephalad. and the phy sic ian gently res ists this motion. intr avenous lines . 8. 2. Indicat ions T his tec hnique is indicated for ly mphatic c ongestion dis tal to the diaphr agm and/or r espiration that does not ( myofasc ially) extend fully to the pubic sy mphysis ..56) . Physiolo gic Go al T he goal is to improv e lymphatic and v enous r eturn. and the phy sic ian gently follows this motion pos ter iorly and c ephalad ( arrows. F ig . This pr ocedur e is repeated for three to fiv e res pir ator y c ycles.lww. The patient lies supine with the hips and knees flex ed and feet flat on the table.. T ech niq u e 1. 5. as the thumbs are now beneath the cos tal mar gin and xiphoid proc ess .58) . F ig. 16. The patient is instr ucted to exhale. Variation of thenar em placement. Step 4. thoracic or abdominal incision. 16. O n exhalation. 16.

or malignancy in the area to be treated. and alleviate postoper ative paralytic ileus.com/pt/re/9780781763714/bookContent.59. 4. 37 of 59 21/08/07 22:13 .60. By leaning down with the elbows. 16. impr ove res pir ator y excursion of the r ibs . The patient lies supine. The phy sic ian slides both hands under the patient's thorac ic r egion. the phy sic ian elevates the F igu re 16.http://thepointeedition. Cont rain dications T his pr ocedure s hould not be used if the patient has r ib or v ertebr al frac tur e. F igu re 16.lww. Step 4. 3. Steps 1 to 3. P.4 36 Thoraci c Regi on Rib Rai sing: Bilateral Upper Thoracic Variati on Indicat ions T his tec hnique is indicated to facilitate lymphatic drainage. setup and hand plac ement. anter ior cephalad lateral for ce. and the phy sic ian is seated at the head of the table. thor acic surgery. 2. s pinal c ord injur y . The finger pads of both hands contac t the par aver tebral tis sues ov er the cos totr ans ver se articulation (F ig. T ech niq u e 1.59)...

F ig. P. 16..60) and then pulls them (b r oken ar rows) toward the phy sic ian cephalad and lateral. finger s into the par aver tebral tis sues (s olid arr ows ..http://thepointeedition.com/pt/re/9780781763714/bookContent. 5.lww. 6. This technique may be per for med as an intermittent kneading tec hnique or with s ustained deep inhibitory pressur e for 2 to 5 minutes. This ex tends the spine and places a lateral str etc h on the par aver tebral tis sues .4 37 Abdomi nal and Pel vic Region Marian Cl ark Drainage 38 of 59 21/08/07 22:13 .

Indicat ions T his tec hnique is indicated to impr ove pas siv e v enous and lymphatic drainage fr om the lower abdomen and pelv is. it als o helps to allev iate mens trual c ramps.62) .61) .62. T ech niq u e 1. c ephalad dir ection.com/pt/re/9780781763714/bookContent. 2. Fig u re 16. Step 1. and knees ( Fig .lww. Step 4. patient pos ition. Hand position. The phy sic ian stands at the side of the patient fac ing the foot of the table.61. 4. elbows .63. 16. 16.. Fig u re 16.http://thepointeedition. 39 of 59 21/08/07 22:13 . The phy sic ian hooks the pads of the finger s medial to both anterior superior iliac s pines (F ig. The phy sic ian Fig u re 16.. 3. The patient is in semipr one pos ition on all fours with the contac t points being the hands.

68. The phy sic ian sits on the patient's right s ide or stands behind the patient. Supine position.4 39 Abdomi nal Region Mesenteri c Release.67) or in the left later al rec umbent (side. 16. P. 40 of 59 21/08/07 22:13 . 5. 16. 2. T ech niq u e T he mes entery of the small intestine fans out fr om its short root to accommodate the length of the jejunum and ileum (F ig.68) pos ition.66). 4. F ig ure 16. 16. 3. This position is held until the phy sic ian palpates a releas e (20–30 sec onds). The phy sic ian places the hand or hands at the left border of the mes enteric region of the s mall intestine with the fingers cur led slightly. or s imilar condition.67. Later al r ecumbent position.67 and 16. 1.4 38 P. Small Intesti ne Indicat ions T his tec hnique is indicated to enhance lymphatic and venous drainage and allev iate c ongestion s econdar y to v isc eral ptosis .http://thepointeedition.lying) (F ig .65). F igs. obstruc tion.68) toward the patient's back and then towar d the patient's r ight side ( c urv ed arr ows) until meeting the r estr ictive tis sue bar rier . The finger s gently push (s olid arr ows .. and then the phy sic ian follows this mov ement (fascial c reep) to the new bar rier and c ontinues until no F ig ure 16. and treatment is focus ed along its length ( Fig . 16..com/pt/re/9780781763714/bookContent.lww. acute is chemic bowel dis eas e. Cont rain dications T his pr ocedure should not be us ed if the patient has an abdominal incis ion. The patient lies supine (F ig. 16.

Abdominal mes entery..lww.com/pt/re/9780781763714/bookContent. fur ther improvement is detected..65. 41 of 59 21/08/07 22:13 . F igu re 16. small intestine (12).http://thepointeedition.

. F igu re 16.4 41 Abdomi nal Region Mesenteri c Release..lww.66. P.4 40 P.http://thepointeedition.com/pt/re/9780781763714/bookContent. Ascending Col on 42 of 59 21/08/07 22:13 . Mes enteric vec tor s of s mall intes tine tr eatment (12).

1.72) and then dr aw toward the patient's left s ide (c urv ed arr ows ) until meeting the r estric tiv e tissue bar rier . 16. 2. 16. Supine position.72.http://thepointeedition. T ech niq u e T reatment is focus ed along the mes enteric as cending c olon attac hment ( Fig s. This position is held until the phys ician palpates a r elease (20–30 sec onds).71) or in the right lateral rec umbent (F ig. The patient lies supine (F ig. F ig ure 16. Cont rain dications T his pr ocedure should not be us ed if the patient has an abdominal incis ion.. F ig ure 16. Later al r ecumben 43 of 59 21/08/07 22:13 . The phy sic ian places the hand or hands at the right border of the mes enteric region of the asc ending colon with the fingers cur led slightly. obstruc tion.71. or s imilar condition. 3.72) pos ition.com/pt/re/9780781763714/bookContent.69 and 16.. and then the phy sic ian follows this mov ement ( fas c ial cr eep) to the new barrier and continues until no further improv ement is detec ted. The phy sic ian sits on the left side or s tands behind the patient. The finger s gently push toward the patient's bac k ( s olid arrows. Fig s.70). acute is chemic bowel dis ease. 16. 16. Indicat ions T his tec hnique is indicated to enhanc e ly mphatic and v enous drainage and alleviate c ongestion sec ondary to v isc eral ptosis .71 and 16. 4.lww. 5.

P. obstr uction.lww. 5. 16. The phy sic ian sits on the r ight s ide or stands behind the patient.76) and then draw towar d the patient's right s ide (c urv ed arrows) until meeting the r estr ictive tis sue barrier.76. This position is held until the phys ician palpates a releas e ( 20–30 s econds ). Supine position.76) pos ition.. 1. 2. Fig s. 3. The patient lies supine (F ig. The phy sic ian places the hand or hands at the left border of the mes enteric region of the des cending c olon and s igmoid with the finger s curled s lightly .75 and 16. ac ute isc hemic bowel disease.4 43 Abdomi nal Region Mesenteri c Release. T ech niq u e T reatment is focus ed along the mes enteric ascending c olon attac hment ( Fig s. Later al r ecumbent posi 44 of 59 21/08/07 22:13 . 16. and then the phys ician follows this movement (fascial c reep) to the new bar rier and continues until no further improv ement is detected. 4..73 and 16.75) or in the left lateral rec umbent (F ig.http://thepointeedition. The finger s gently push toward the patient's bac k ( s traight ar rows.75. 16. or similar c ondition.74).com/pt/re/9780781763714/bookContent. 16. Descending Colon Indicat ions T his tec hnique is indicated to enhanc e ly mphatic and venous drainage and to alleviate c ongestion s econdar y to v isc eral ptosis . F ig ure 16. F ig ure 16. Cont rain dications T his pr ocedure should not be us ed if the patient has abdominal inc isions.4 42 P.

http://thepointeedition.com/pt/re/9780781763714/bookContent.lww. 45 of 59 21/08/07 22:13 ...

http://thepointeedition.74.com/pt/re/9780781763714/bookContent. Direct or I ndi rect Indicat ions T his tec hnique is indicated to enhance lymphatic drainage and relieve venous c ongestion in the lower abdomen. Abdominal mes entery. pelvic r egion.4 44 Abdomi nal Region Presacral Rel ease.73.. des cending c olon (12).. Cont rain dications T his pr ocedure should not be used if the patient has abdominal 46 of 59 21/08/07 22:13 . F igu re 16. P. Mes enteric vec tor s of descending c olon treatment ( 12) . and lower extr emities . F igu re 16.lww.

T ech niq u e 1. The patient lies supine. clockwise.78) .. 16. and counter clockwise (a r rows . 3. incision. F ig.. with the index and third finger s approx imated and the thumb abducted. ease. 5. or s imilar condition. acute ischemic bowel disease. mak es a C shape. obstr uction.http://thepointeedition. ease-bind determination.lww. F ig ure 16. The phy sic ian determines whether an eas e-bind asy mmetry is present by applying and vec tor ing for ces in multiple dir ections . on determining the dy s functional asy mmetry. inc luding pos ter ior.77) . 2.bind determination. Step 4. 16. F ig ure 16. 47 of 59 21/08/07 22:13 .com/pt/re/9780781763714/bookContent. and the phy sic ian stands at either side of the patient. inferior. The phy sic ian.78. F ig ure 16.77. 4. The phy sic ian.79 Step 5. The phy sic ian places the finger s and thumb downwar d in the lower abdominal region jus t above the ramus of the pubic bone (F ig. Hand plac ement. superior.

The patient lies supine with the hips and k nees flexed. P. T ech niq u e 1. res pec tively (F ig. This position is held until the phy sic ian palpates a releas e (20–30 sec onds ).80. 2. S upi ne Indicat ions T his tec hnique is indicated to impr ove motion of the pelv ic diaphragm and lymphatic and venous drainage fr om the pelv ic v isc era and pelv ic floor.. and then the phy sic ian follows this movement (fascial c reep) to the new barrier and continues until no further improv ement is detected. 48 of 59 21/08/07 22:13 .http://thepointeedition.79).. The phy sic ian sits F ig ure 16.lww. applies forces in an indirec t or dir ect manner until meeting the eas e or bind bar rier s. 6.4 45 Pel vic Region Ischiorectal Fossa Rel ease. 16. Physician and patient pos itioning.com/pt/re/9780781763714/bookContent.

lww. The phy sic ian exerts gentle pressur e c ephalad (a r row..http://thepointeedition. 16. the phy sic ian exerts inc reas ed cephalad pres sur e on the pelvic diaphr agm until no fur ther cephalad and lateral exc urs ion is F ig ure 16. 49 of 59 21/08/07 22:13 . Cephalad lateral force. Fig . 16. F ig ure 16. The phy sic ian places the thumb of the hand closes t to the table medial to the isc hial tuber osity (a r row.com/pt/re/9780781763714/bookContent.81) into the isc hior ectal fos s a until r esistance is met and then applies a lateral for ce ( cur ved arr ow. 4. With each exhalation. 16. F igs. Thumb pos itioning. at the side of the table opposite the side of the dys func tion to be treated.80 and 16.82) . 3.. 5. The phy sic ian can attempt to feel a fluid ebb and flow with a res ultant releas e or add a releas e-enhancing mec hanism by ins truc ting the patient to inhale and ex hale deeply . 6.81. F ig.82.81) on the dys func tional side.

pos sible. Cephalad for ce. Thumb placement. 50 of 59 21/08/07 22:13 . P. 16. 3. F ig ure 16. P rone Indicat ions T his tec hnique impr oves motion of the pelv ic diaphragm and v enous and lymphatic drainage fr om the pelv ic v isc era and pelv ic floor. F ig.85) is applied. The phy sic ian places the thumbs medial to the isc hial tuber osities on eac h side (F ig .84) into the isc hior ectal fos s a until r esistance is met. 2. 4. Gentle pressure is exerted cephalad (a r rows .83.. This technique is repeated on the opposite s ide of the pelvis as needed. The patient is F ig ure 16.com/pt/re/9780781763714/bookContent. and the phy sic ian stands at the side of the table facing the head of the table.http://thepointeedition..83) .84. 16.4 46 Pel vic Region Ischiorectal Fossa Rel ease. The patient lies prone. and then a lateral force (a r rows .lww. 16. T ech niq u e 1. 7. F ig.

6.. The phy sic ian can attempt to feel a fluid ebb and flow with a res ultant releas e or add a releas e-enhancing mec hanism by ins truc ting the patient to inhale and ex hale deeply . 7. P.com/pt/re/9780781763714/bookContent. This technique is repeated on the opposite s ide of the pelvis as needed. F ig ure 16.85. the phy sic ian exerts inc reas ed cephalad pres sur e on the pelvic diaphr agm until no fur ther cephalad and lateral exc urs ion in a dir ection is pos sible.lww. Later al forc e. With each exhalation. S upi ne 51 of 59 21/08/07 22:13 .4 47 Lower E xtremi ty REGI ON Pedal P ump (Dalrympl e Techni que). ins truc ted to inhale and ex hale deeply . 5..http://thepointeedition.

F ig ure 16. infection. Steps 1 to 3. It s hould also be avoided in the acute postoper ative period in s ome abdominal s urgery patients .88.. s etup.87. T ech niq u e 1.. The patient lies s upine. The phy sic ian stands at the F ig ure 16. Step 5. 2. 52 of 59 21/08/07 22:13 . s etup. dor s iflexion.http://thepointeedition. plantar flex ion. ac ute ankle s prain. incr eas e lymphatic r eturn. Indicat ions T his tec hnique is indicated for lymphatic c ongestion. Achilles strain. Cont rain dications T his pr ocedure s hould not be used if the patient has v enous thrombos is.14). Physiolo gic Go al T he goal is to accentuate negativ e intr aabdominal pres sur e. or other acute pr ocess and/or painful lower ex tremity c onditions. Step 4. gastroc nemius s train.com/pt/re/9780781763714/bookContent. fever . plantarflexion.86. and inability to use the thor acic pump. F ig ure 16.lww. and inc r eas e endothelial nitrous oxide. whic h may offer anti-inflammatory benefit (13.

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.4 48

Lower E xtremi ty Regi on Pedal P ump (Dalrympl e Technique), Prone V ari ati on

Indicat ions T his tec hnique is indicated for lymphatic c ongestion, fever , infection, and inability to use the thor acic pump. Cont rain dications T his pr ocedure s hould not be used if the patient has v enous thrombos is; ac ute ankle s prain; Achilles strain, gastroc nemius s train, or other acute pr ocess; or painful lower extr emity c onditions. It s hould also be avoided in the acute postoper ative period in s ome abdominal s urgery patients . Physiolo gic Go al T he goal is to accentuate negativ e intr aabdominal pres sur e, incr eas e lymphatic r eturn, and inc r eas e endothelial nitrous oxide, whic h may be of anti-inflammatory benefit. T ech niq u e

F ig ure 16.90. Step 1, phys ician and patient pos itioning.

F ig ure 16.91. Hand and foot positioning.

53 of 59

21/08/07 22:13

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.4 49

Lower1. The patientand Pel vic Region Hi p, I ndi rect LAS/BLT, E xtremi ty Supine lies pr one

with the feet slightly off the table, and the phy sic an Indicat ionsian d stands Go al Physiolo gic at the foot of the T his tec hnique is table with one indicated to enhance foot drainage lymphatic s lightly and behind the r elieve venous other Fig . c ongestion (in the pelvic 16.90) . r egion and lower F ig ure 16.92. Step 3, c ephalad pr ess ure. 2. The phy extr emities . sic ian grasps T ech niq u e the patient's feet 1. at the dis tal lies The patient metatarwith the hip supine sal region and and knee flex ed F ig ure 16.93. Steps 1 to 3, initiating hand dir ects side to be on the a placement. for ce treated. 2. (a r rows ,sicig. The phy F ian 16.91) to the side stands at achiev table on the of the e bilater albe tr eated. side to 3. dor siflexion. The phy sic ian 3. At the the places comfor table cephalad thenar limit of e on the eminenc dor siflexion, patient's greater the phy sic ian trochanter with begins a s the finger rhy thmic medially dir ected on- and- off and thumb cephalad contour ing F ig ure 16.94. Step 4, posterosuperior pressur e The laterally. v ec tor ed for c e. (a r rows , force is initiating F ig. 16.92) at one applied to two per anteromedially sec ond.F ig. (a r row, 4. This pr ess ure 16.93) . 4. is dirabducted The ected par allel to thest thumb and fir length of the an two finger s in table andC shape inv erted continued sic ian's of the phy for 1 to 2 hand caudal minutes .

54 of 59

21/08/07 22:13

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

attempt to contr ol the head of the femur anteriorly . This hand applies a forc e pos ter olaterally (a r row, F ig. 16.94) . 5. The patient's knee on the dys func tional side is controlled by the phy sic ian's anterior pectoral region or axilla and is placed toward the ease bar rier 's balanc e point, determined by mov ing the hip thr ough flexion and ex tens ion, slight abduction and adduction, and internal and external r otation (a r rows , F ig. 16.95) . 6. The phy sic ian uses the s houlder to apply compres sion (a r row, F ig. 16.96) to the patient's knee toward the hip, finding the position of greates t ease with s light hip motions in all thr ee planes. This is the third for c e to be applied. 7. All thr ee for ces are applied simultaneously to find the indirec t pos ition of ease. A releas e-enhancing

F ig ure 16.95. Step 5, balancing three for ces .

F ig ure 16.96. Step 6, c ompres sion through hip.

55 of 59

21/08/07 22:13

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

mec hanism may be added by ins truc ting the patient to inhale and ex hale deeply . The releas e is per ceiv ed by an inc reas ed mov ement toward the indirect bar rier .

P.4 50

Lower E xtremi ty Regi on Popl iteal Fossa Release, Supine

Indicat ions an d Physiolo gic Go al T his tec hnique is indicated to impr ove lymphatic and venous drainage fr om the lower extr emities (k nee, calf, ankle, and foot) and to r elease any fascial r estric tion(s) of the popliteal foss a. T ech niq u e 1. The patient lies supine with legs extended on table. 2. The phy sic ian, fac ing the head of the table, sits at the side to be treated. 3. The phy sic ian's medial hand reaches ar ound to the medial as pec t of the popliteal fos sa as the F ig ure 16.97. Steps 1 to 3, s etup and hand placement.

56 of 59

21/08/07 22:13

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

4.

5.

6.

7.

lateral hand grasps the later al aspect of the popliteal fos sa (F ig. 16.97). The phy sic ian palpates for any fas cial res tric tions, inc luding cephalad, caudad, medial, and later al (F ig. 16.98). The phy sic ian engages the tis sues with an anterior forc e thr ough the finger tips while engaging any fas cial barriers (e.g., cephalad, caudad, medial, lateral) until res istance is met (F ig. 16.99). The phy sic ian can attempt to feel a fluid ebb and flow with a res ultant releas e or add a releas e-enhancing mec hanism by ins truc ting the patient to inhale and ex hale deeply . Force is dir ected into the bar rier until no fur ther ex cur sion or relaxation of the tis sues is pos sible. This technique is repeated on the opposite s ide as needed.

F ig ure 16.98. Step 4, determining barriers .

F ig ure 16.99. Step 5, direct MFR.

57 of 59

21/08/07 22:13

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P.4 51

References
1. W ar d R ( ed .). Fo unda tio ns for Ost eop athi c M edi c i ne , 2 nd ed. Phi l ad el ph i a: Li ppin c ot t W i l li ams & W i lk i ns , 20 03.

2. Sti l l AT . Phi l os ophy of Os teop ath y . Ki rk s vi l le , MO : A . T . St i ll , 1 809: 108 .

3. Gal bre ath W O. Ac ute Oti tis M ed i a, In c l ud i ng it s Po s tu r al and Ma nip ul at i ve Tr eatm ent . J Am Ost eop ath Ass oc. Ja n 19 29.

4. Pra tt- H arr i ng ton D . Gal bre ath tec hni que: a m an i pul ati v e tr ea tme nt for oti tis m ed i a r ev i s it ed. J Am Ost eop ath Ass oc. 200 0;1 00: 635– 639 .

5. C hi k ly B. Sil ent W av es: Th eory an d P r act i ce of Lym ph D ra i nag e T her apy. An Os teop ath i c Lym pha tic T ec h-n i qu e, 2 nd ed. Sco tts dal e AZ : I H H, 200 4.

6. R ep r in ted w it h p er mi s si on fr om Ag ur AM R, Da l le y AF . G r an t' s Atl as of A nat omy , 11 th ed. Bal tim ore : Li ppi nco tt W i ll i am s an d W i lk i ns, 20 05.

7. Kno t E M , T une JD , St oll ST , Do w ne y H F . I ncr eas ed L y mp hat i c F l ow in the Th ora c i c D uc t D ur i ng Ma ni pu - la tiv e In ter v en ti on . J Am Ost eop ath Ass oc 200 5;10 5: 593 –596 .

8. J ac k so n KM , S tee l e T G, D ug an E P, Kuk ul ka G, Bl ue W , R obe r ts A. Eff ec t of Lym phat i c and Spl eni c P um p T ec hni ques on th e An tib ody R es pon s e to H epa tit i s B Va c ci ne: A P i lo t St udy . J Am Ost eop ath Ass oc 199 8;98 :15 5–1 60.

9. Ste ele T , J ac k so n K, Du gan E. T he Ef fect of Os teop ath i c M ani pul ati v e T r ea tme nt o n t he Anti bod y R es pon s e to H epa tit i s B Va c ci ne. J A m O s teo pat h A s s oc 19 96; 96(9 ) .

10. Br eit haup t T , H ar ri s K , E l l is J. , P ur ce l l E, W eir J, Cl othi er M , Boes l er D. T ho r ac i c Ly mp hat i c Pum pin g a nd t he Eff i c ac y o f I nflu enz a V ac ci nat i on i n H ea l th y Yo ung an d El der l y Popu l at i on s . J Am Ost eop ath Ass oc 200 1;10 1(1 ) .

11. Me s in a J, Ha m pt on D , E v an s R, Zi egl er T , M i ke s k a C , T ho m as K, F er r ett i J . T r ans i en t Bas oph i li a Fo l lo w in g th e A ppl i c at i on s o f Ly m ph ati c Pu m p T ec hniq ues : A Pil ot Stu dy . J A m Ost eop ath Ass oc 199 8;98 ( 2) .

58 of 59

21/08/07 22:13

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

12. Mo dif i ed w it h p er mi s si on fr om Ag ur AM R, Da l le y AF . G r an t' s Atl as of A nat omy , 11 th ed. Bal tim ore : Li ppi nco tt W i ll i am s an d W i lk i ns, 20 05.

13. Ku c he r a M , D agh i gh F . D et er mi nat i on of Enh anc ed N i tr i c Ox id e P r od uc ti on U si ng E x te r na l M ec han i ca l St i mu l i. J A m O s te opat h A s so c 20 04; 104 :344 ( ab s tr ac t) .

14. Ku c he r a M . O s te opat hic Ma ni pu l at i ve M ed i ci ne C ons i de r at i ons in Pa ti en ts w it h Ch r on i c Pain . J Am Ost eop ath Ass oc 2005 ;10 5(s uppl 4) .

59 of 59

21/08/07 22:13

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

17 Articulatory and Combined Techniques
Technique P rincipl es
T his ch apt er d esc r ib es a r ti c ul ator y a nd c omb i ne d t ec hn i qu es. T he s e tec hniq ues ar e di s cu s se d in th e s ame ch apt er b eca use w e bel i ev e th ey ten d to ha v e m any si m il ar it i es , u s i ng pr i nc i ple s f r om oth er tech niq ues , es pec i al l y s oft ti s s ue , l y mp hati c , m us c l e ene r gy , an d h i gh - v el oci ty, l ow - am pli tude (H VLA ) . T he Edu c at i on C ou nci l on Os teo path i c Pri nc ip l es (E C OP) de fin es t he art i c ul ato r y tr ea tme nt ( ART ) m oda l it y a s “a lo w v el oc i ty /mo dera te- to- hi gh am pli tude te c hn i que wh ere a j oin t i s ca r ri ed thro ugh it s fu l l m oti on w it h th e t her apeu tic go al o f i ncr ease d f r ee dom r an ge of m ove m en t. T he act i v at i ng fo r c e i s eit her a sp r in gin g mo tio n o r re pet i ti v e c onc ent r i c m ov eme nt o f t he j oin t t hro ugh the re s tri c ti v e barr i er .”( 1) A t the Phi l ad el ph i a C ol l ege of Os teop ath i c M edi c in e ( PC OM ) , w e have re fer r ed to i t s i mp l y as s pri ngi ng tech niq ue. It has si m i la r it i es to bot h s oft tis s ue and HV LA i n t hat it c an af fec t th e m y of as ci al c om pone nts and art i cu l ar c om pon ents , r esp ec ti v el y . H owe v er , t he m ode r at e to hi gh am pl i tu de desc r ib ed i n t he defi nit i on doe s n ot m ean mo v in g th r ou gh the r es tri c tiv e b arr i er at hig h am pli tud e. T he r el atio nsh i p betw een th e pa tho l og i c , phy s io l ogi c , and ana tom i c barr i er s s houl d r ema i n c ons i st ent w it h t he p r in c ip l es of H VLA : m otio n t hro ugh the re s tri c ti v e barr i er sh ould st i ll be m od era ted and ke pt t o a mi ni mu m . T he am pl i tu de i s t he dis tanc e a v ai l abl e w i th i n t he dys func tio nal pre s en tat i on' s r ang e. C omb i ne d m etho d ( tec hniq ue) is def i ne d b y EC OP as “ 1. T re atm ent s tr ate gy w her e t he i nit i al m ove m en ts ar e i nd i re c t; as the tec hni que i s c om ple ted, th e m ov em ent s c hang e t o d i r ec t f orc es . 2. A m ani pul ati v e s equ enc e in v ol v in g tw o o r m or e ost eop athi c m ani pula tiv e t r eat m en t s y s te m s ( e. g., Spe nce r tech niq ue c omb i ne d w i th m us c le ene r gy te c hni que ) . 3. A co nce pt d esc r ib ed b y P aul Kim ber l y, D O” (1 ) . Ki mb erl y u s ed thi s t er m r el ati v e t o t he s eco nda r y defi nit i on i n r el ati ng t he c om bi na tio n o f va r io us forc es, i ncl udi ng di re c t, in di re c t, in here nt, gr av it ati ona l , p hys i ci an d i re c te d, r esp i ra tory as s is t, a nd oth er s i n tr ea tme nt. ( 2) T he r ef or e, th e t ec hn i qu es i n t his ch apte r c oul d we l l hav e be en c la s s if i ed in oth er c ha pter s base d o n t he p r im ary foc us of each te c hn i que . AR T, al tho ugh pri m ar i l y aff ect i ng the my ofas c ia l a nd a r ti c ul ar c omp one nts of the dys fun c ti on, als o s i gn i fi c an tl y aff ect s th e c i rc ul at ory an d ly m ph ati c sy s te m s. T he s e s ty l es of tec hniq ue hav e be en par t of the r ec omm enda tio ns for the os teop ath i c tr ea tme nt of t he ger i atr i c pat i ent fo r m any y ea r s and are r ela tiv ely s af e a nd w ell to l er ated .

Technique Cl assifi cati on Di rect, Indi rect, or Combined
D epe ndi ng on t he ART or c om bin atio n o f m etho ds, th es e tec hni ques al l c an b e d i re c t, i nd i re c t, or bot h; henc e t he defi nit i on . Ar tic ula tory wa s c l ass i ca l ly def i ne d a s a dir ect tec hni que , bu t d epe ndin g o n t he phys i ci an' s pr efe r en c e, the ea s e a nd bin d ba r ri ers m ay bo th be m et w it h a gen tle s pr i ng i ng m ot i on .

Technique S tyles Rhythmic

1 of 39

21/08/07 22:14

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

T he phy s ic i an m ay ch oose a r hy thmi c a r ti c ula tor y t r eat m en t t o ch ang e t he s oft ti s s ue s o r t o re l ea s e an ar ti c ul ar r est r ic tio n. T he c ad ence of th e st r et c h and r el eas e in th i s tech niq ue has bee n d es cr i be d b y N. S. N i ch ola s , D O, as “ m ak e a nd br ea k ,” re l ati ng to the on- off pre s su r e appl i ed . T hi s m ay be s lo w o r m ode r at e a nd m ay bec om e osc i ll ator y . P. 454

Mi xed
T he phy s ic i an m ay ch oose an y v ar ia tio n o f rh y th m s, amp l it ude , or ac c el er at i on (v el oc i ty ) d epen din g o n the pat i en t' s pre s en tati on. Th er ef ore , t he p ati ent m ay be tr eate d w i th a v ari ety of c om bin ed t ech niq ues.

I ndicati ons
1. R est r i ct ed m ot i on i n the pre s en c e of a r ti c ul ar a nd/ or m y of asc i al s om ati c d y s fu nct i on ( es pec i al l y i n t he f r ai l o r el der l y) 2. C i rc ul at ory an d ly m ph ati c co nge s ti on

Contraindications
1. Ac ut e mo der ate to s ev ere s tr ain or s pr ain 2. F r ac ture , d i sl oc at i on , o r jo i nt in s tab i li ty i n t he are a af fec ted by the tr eatm ent 3. Ac ut e in fla m ma tory jo i nt dis eas e i n th e a r ea aff ect ed by t he tre atme nt 4. M eta s tas i s i n the are a a ffec ted by the tr eat m ent

General Considerations and Rules
T he per for m anc e o f t hese te c hn i que s c an v ary wi th the phy s ic i an' s i m pr es si on of the s ev eri ty o f t he dy sf unc tio n an d a ny c omp l ic ati ng f act ors . Th e t ech ni qu es r an ge f r om ex tr em ely ge ntle , w i th m in i ma l am pl i tu de, to for c ef ul t r ac tio n. T he r hy thmi c a s pe c ts m ay al s o v ary fr om s l ow to fas t. In gene r al , c omp r es s iv e fo r ce s s houl d b e l i m it ed i n thos e w i th ost eop oro s i s, an k yl os is , a nd s o o n. T he s e t ech niq ues have a w id e ra nge of app l ic ati on f or i nc r eas i ng mo ti on an d d ec re asi ng edem a. P. 455

Upper Extrem ity Region Shoul der Girdle: S pencer Technique I ndicati ons
Adhe s i ve ca psu l i ti s Burs i tis T eno s y no v it i s Ar th r i ti s

2 of 39

21/08/07 22:14

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

General Considerations
N i ch ola s S . Ni c ho l as , DO , F AAO , pr omo ted thi s t ech ni qu e m ore tha n a ny othe r . Bes i des pu bli s hin g o ne of t he ear l y a r ti c le s ex tol l in g it s v i rt ue, he s pe nt y ear s l ec tu r in g a nd p r es ent i ng i t to m any or gan i z at i on s , es pe c ia l ly i n ath l et i c m edi c in e. O v er hi s ma ny y ea r s i n s por ts m edi c in e an d a s a c on s ul tan t to te ams , es pe c ia l ly as a p hys i c ia n f or the Vil l an ov a U ni v er s i ty fo otb al l tea m f r om the 19 40s to 196 0, h e h ad m any s ucc ess ful out c om es w i th th i s tr ea tme nt w hen ot her tre atm ent s ha d f ail ed. T hi s t r eat m en t p r oto c ol , w hen us ed in co nj un c ti on w i th ot her ost eop ath i c m ani pul ativ e t ech ni qu es to tr ea t t he c erv i ca l , thor aci c , and c ost al r eg i ons , g i ve s th e p ati ent an exc el le nt c ha nc e of r ec ov er y . T hi s te c hn i qu e wa s , for all i te r at i on purp ose s , taug ht as the “ se v en s ta ges of Spe nce r ” ev en th oug h th ere ar e ei ght st ages . A t P C OM, we have ta ugh t th i s tec hniq ue as havi ng s ta ges 5A and 5B to acc om mo dat e t he e i gh t s tage s i nto s ev en. T he pat i en t li es i n the l at era l re c um ben t po s it i on w it h t he s hou l de r t o be tr eat ed a w ay fr om t he tab l e. T he pati ent ' s back is pe r pen dic ula r to th e t able , w i th the lo w er k ne e a nd hi p fle x ed to pre v en t an y f orw ar d r oll . A pi l l ow is pl ac ed un der the pa tie nt's he ad to r emo v e any dra g o n th e s hou l der fr om the c er v ic al a nd s hou l de r g i r dl e m usc ul at ure . P. 456

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 1S houl der Extension wi th E lbow Flexed

3 of 39

21/08/07 22:14

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

1. T he phys ician s tands facing the patient. 2. T he phys ician's c ephalad hand br idges the s houlder to loc k out any ac romioc lav icular and s c apulothor acic motion. The fingers are on the s pine of the s c apula, the thumb on the anter ior sur fac e of the c lav icle. 3. T he phys ician's c audad hand gr asps the patient's elbow. 4. T he patient's s houlder is moved into ex tension in the horiz ontal plane to the edge of the r estr ictive barrier. 5. A slow, gentle s pringing ( articulator y, make and br eak) motion ( arr ows, F ig. 17.1) is applied at the end r ange of motion. 6. Muscle ener gy ac tiv ation: The patient is instr ucted to attempt to flex the s houlder ( blac k ar row, F ig. 17.2) against the physician's

F igu re 17.1. Stage 1, steps 1 to 5.

F igu re 17.2. Stage 1, step 6.

F igu re 17.3. Stage 1, step 7.

4 of 39

21/08/07 22:14

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P. 457

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 2S houl der Fl exi on with El bow Extended

5 of 39

21/08/07 22:14

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

1. T he phys ician's hands rever s e s houlder and ar m c ontact pos itions. T he c audad hand r eaches over and behind the patient and bridges the s houlder to loc k out ac romioc lav icular and s c apulothor acic motion. The fingers are on the anter ior sur fac e of the c lav icle, the heel of the hand on the spine of the s capula. 2. Us ing the other hand, the physician takes the patient's s houlder into its flexion motion in the horizontal plane to the edge of its r estr ictive barrier. 3. A slow, spr inging ( articulator y, make and br eak) motion ( arr ows, F ig. 17.5) is applied at the end r ange of motion. 4. Muscle ener gy ac tiv ation: The patient is instr ucted to ex tend the s houlder (black ar row, F ig. 17.6) against the physician's r esis tance ( white ar row). This

F igu re 17.5. Stage 2, steps 1 to 3.

F igu re 17.6. Stage 2, step 4.

F igu re 17.7. Stage 2, step 5.

6 of 39

21/08/07 22:14

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

P. 458

Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 3Circumducti on with Sl ight Compressi on and El bow Fl exed

7 of 39

21/08/07 22:14

http://thepointeedition.lww.com/pt/re/9780781763714/bookContent...

1. T he original starting pos ition is resumed with the c ephalad hand. 2. T he patient's s houlder is abduc ted to the edge of the r estr ictive bar rier (F ig. 17.9) . 3. T he patient's arm is moved through full c lock wis e c ircumduction ( small diameter ) with slight c ompr ess ion. Larger and larger c onc entr ic c irc les ar e made, increasing the r ange of motion (F ig. 17.10). 4. Circumduction may be tuned to a particular bar rier . T he s ame maneuv er is r epeated counterclockwise ( F ig. 17.11) . 5. T here is no specific musc le energy activ ation for this s tep; howev er, dur ing fine- tuning of the c ircumduction, it may be feasible to implement it in a portion of the res tric ted ar c . 6. T his is repeated for approximately 15 to 30 s econds in each dir ection, and c irc umduction is r eass ess ed.

Fig u re 17.9. Stage 3, s teps 1 to 2.

Fig u re 17.10. Stage 3, s tep 3.

8 of 39

21/08/07 22:14

lww.. 459 Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 4Circumducti on and Tracti on with El bow Extended 9 of 39 21/08/07 22:14 ..http://thepointeedition.com/pt/re/9780781763714/bookContent. P.

T he phys ician's caudad hand grasps the patient's wr ist and ex erts v ertical tr action. T he patient's s houlder is abduc ted to the edge of the r estr ictive bar rier with the elbow ex tended. steps 1 to 2. Larger and larger c oncentr ic c irc les are made.. and c irc umduction is r eass ess ed. T he patient's arm is moved through full c lock wis e c ircumduction with s y nchronous traction. 4.tuning of the c ircumduction. 10 of 39 21/08/07 22:14 . Stage 4.. dur ing fine.lww.13. 2. 17.14) . 3.12. 1. 17. F igure 17. it may be feasible to implement it in a portion of the res tric ted ar c.com/pt/re/9780781763714/bookContent.12). 5. step 3. T here is no specific musc le energy activ ation for this s tep. F igure 17. howev er. increasing the r ange of motion ( F ig. T he s ame maneuv er is r epeated c ounterclock wise ( F ig. 17.http://thepointeedition.13) . 6. T his is repeated for approximately 15 to 30 s econds in each dir ection. Stage 4. T he phys ician's c ephalad hand brac es the s houlder as in stage 1 (F ig.

460 Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 5A—Abduction wi th E lbow Fl exed 11 of 39 21/08/07 22:14 .http://thepointeedition...lww. P.com/pt/re/9780781763714/bookContent.

5.16) is applied at the end r ange of motion. 17.com/pt/re/9780781763714/bookContent.17.16.. A slow. Stage 5A. 3. abduc ting the s houlder . steps 1 to 3. 2. F igu re 17. until a motion barrier is engaged. Muscle energy ac tiv ation: T he patient is F igu re 17.15. F ig . Slight inter nal r otation may be added. make and br eak ) motion ( arrows. 12 of 39 21/08/07 22:14 . 6. 17.15). T he patient's s houlder is abduc ted to the edge of the r estric tive barrier. T he patient's elbow is moved towar d the head.http://thepointeedition.. F igu re 17. steps 4 to 5. Stage 5A. gentle ( articulator y. 4. 1. Stage 5A. T he physician's c ephalad ar m is positioned parallel to the s urface of the table. T he patient is instr ucted to gr asp the physician's forearm with the hand of the arm being tr eated (F ig .lww. step 6.

http://thepointeedition. P.com/pt/re/9780781763714/bookContent.. 461 Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 5BAdducti on and External Rotation wi th Elbow Flexed 13 of 39 21/08/07 22:14 .lww..

20. 17. 5. Stage 5B. 2.21) is applied at the end r ange of motion.com/pt/re/9780781763714/bookContent. F ig. Stage 5B. Muscle energy ac tiv ation: T he patient lifts the elbow ( blac k ar row.http://thepointeedition. T he physician's forearm is s till parallel to the table with the patient's wr ist resting against the forearm. 17. make and br eak ) motion ( arrow. A slow. 6. T he patient's ar m is flex ed s ufficiently to allow the elbow to pas s in fr ont of the c hest wall. Stage 5B. After a F igu re 17. F igu re 17.21. 1.lww. T his c ontr action is held for 3 to 5 s econds. step 4.22. steps 1 to 3. F igu re 17.22) against the physician's r esis tance ( white ar row). step 5. 4. 3. 17.. 14 of 39 21/08/07 22:14 . T he patient's s houlder is adduc ted to the edge of the r estric tive barrier (F ig .20).. gentle ( articulator y. Fig .

.lww. P.com/pt/re/9780781763714/bookContent. 462 Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 6—Internal Rotation wi th Arm Abducted..http://thepointeedition. Hand Behind Back 15 of 39 21/08/07 22:14 .

s teps 1 to 3. 2. F igu re 17.25. 17. s tep 4. 4.lww. A slow..25). 1. Stage 6. 3. T he patient's s houlder is abduc ted 45 degrees and inter nally r otated approximately 90 degrees.. T he dors um of the patient's hand is placed in the s mall of the back . F ig . s tep 5.26) is applied at the end r ange of F igu re 17.27. Stage 6.http://thepointeedition. as this can dislocate an unstable s houlder . T he physician's c ephalad hand r einforc es the anter ior portion of the patient's s houlder . 16 of 39 21/08/07 22:14 . F igu re 17. gentle ( articulator y. T he patient's elbow is ver y gently pulled forward ( internal r otation) to the edge of the r estric tive barrier (F ig . Do not push the elbow backward. 17.26. Stage 6.com/pt/re/9780781763714/bookContent. make and br eak ) motion ( arrows.

com/pt/re/9780781763714/bookContent.lww.http://thepointeedition. P.. and E nhanci ng Flui d Drainage wi th Arm Extended 17 of 39 21/08/07 22:14 .. S tretchi ng Tissues. 463 Upper Extrem ity Region Shoul der Girdle: S pencer Technique S tage 7Distraction.

s tep 5. s tep 4. 17. 5. F igu re 17. T he patient's s houlder is s c ooped infer ior ly ( arrow. and the patient's hand and forearm ar e plac ed on the physician's s houlder c losest to the patient.30). the physician's hands ar e positioned just dis tal to the acromion pr ocess (F ig . Fig .http://thepointeedition.lww. F igu re 17. 17. s teps 1 to 3. Stage 7. With finger s inter lac ed. 2.31) c r eating a tr ans latory motion ac ros s the infer ior edge of the glenoid fossa. T he patient's s houlder is abduc ted. 3..32.30.. 18 of 39 21/08/07 22:14 .com/pt/re/9780781763714/bookContent. Stage 7. the arm may be pushed F igu re 17. Alter natively.31. 4. T he phys ician turns and faces the head of the table. Stage 7. 1. T his is done r epeatedly in an ar tic ulator y fashion.

464 Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tage 1Hip Flexion 19 of 39 21/08/07 22:14 ..lww.http://thepointeedition. P.com/pt/re/9780781763714/bookContent..

17. s tep 4. Muscle ener gy ac tiv ation: The patient pus hes ( hip extens ion) the k nee into the physician's r esis tance ( arrows. gentle ar tic ulator y ( make and br eak ) motion ( arrows. Stage 1. 17. T he patient lies s upine. 4. F ig . F igu re 17.. 5.34. A slow. This c ontr action is held for 3 to 5 s econds. After a sec ond of r elax ation.37). Steps 4 and 5 ar e r epeated three to fiv e times . and the physician s tands at the s ide of the table next to the dy sfunctional hip. T he phys ician flexes the patient's k nee and c arr ies the hip to the flexion.res tric tiv e barrier (F ig 17.36.35. the hip is c arr ied farther into the new r estric tive barrier (F ig . Resis tance against F igu re 17.36). s tep 3.35) is applied at the end r ange of motion. 17. Stage 1. 6.lww. and flex ion is reass ess ed. F ig . s teps 1 and 2. F igu re 17. 20 of 39 21/08/07 22:14 . 3.. 2. Stage 1. 7. 1.http://thepointeedition.34).com/pt/re/9780781763714/bookContent.

lww.. P..http://thepointeedition. 465 Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tage 2Hip E xtensi on 21 of 39 21/08/07 22:14 .com/pt/re/9780781763714/bookContent.

lww. 17. After a sec ond of r elax ation.43).. Stage 2. F ig . Stage 2.40) is applied at the end r ange of motion. Muscle ener gy ac tiv ation: The patient is instruc ted to pull the knee ( hip flexion) (black ar row. Resis tance against attempted hip ex tension ( r eciprocal inhibition) has been found to be helpful in augmenting the effec t ( Fig . 4. F igu re 17.41) into the phy sic ian's r esis tance ( white ar row). 22 of 39 21/08/07 22:14 . 5. Steps 3 and 4 are r epeated thr ee to five times. 6. F ig. This c ontr action is held for 3 to 5 s econds . T he patient's leg is moved off the s ide of the table and is allowed to desc end towar d the floor until it meets its ex tension-r estr ictive barrier (F ig . the hip is c arried far ther into the new res tric tiv e barrier (F ig . 17. 17.42).com/pt/re/9780781763714/bookContent. A slow. 17. 3.http://thepointeedition. 1. s tep 3. 17.39).39. and ex tension is r eass ess ed. 2. gentle ar tic ulator y (make and break) motion ( arrows.41. F igu re 17. Stage 2.. F igu re 17. s tep 1.40. s tep 2.

466 Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tages 3 and 4Circumducti on 23 of 39 21/08/07 22:14 .http://thepointeedition..lww.. P.com/pt/re/9780781763714/bookContent.

46).com/pt/re/9780781763714/bookContent.lww. Stages 3 and 4. 17. T he phys ician ex tends the patient's k nee and gr asps the foot and ankle. 24 of 39 21/08/07 22:14 . 17.44.. s tep 3. 2.45. s tep 1. 4.45) the patient's hip through small and then enlarging c ircles (clockwise and c ounterc loc k wis e) for appr oximately 30 seconds while maintaining c ompr ess ion.http://thepointeedition. Stages 3 and 4. F igu re 17. T he phys ician c ircumducts ( arrows. Continuing to hold tr action. the physician c ircumducts the patient's hip through small and then inc reas ingly large circles ( arrows. Stages 3 and 4. 3. F ig .47) both c lock wis e and c ounterc loc k wis e for appr oximately 15 to 30 sec onds. 17.44). Fig . F igu re 17. F igu re 17. 1.46. 17. F ig . T he phys ician flexes the patient's hip ( with k nee flexed) towar d the flex ion barrier and adds s light c ompr ess ion ( arrow.. Fig . adding moder ate tr action ( arrow. s tep 2.

.com/pt/re/9780781763714/bookContent.. P. 467 Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tages 5 and 6I nternal and E xternal Rotati on 25 of 39 21/08/07 22:14 .http://thepointeedition.lww.

F igu re 17. 4.http://thepointeedition.48) is applied at the end r ange of motion. F igu re 17. F ig.. Stage 5.. Stage 6.50. 17. s teps 1 and 2. T he phys ician flexes the patient's hip and k nee and inter nally r otates the hip to its barrier. 17. make and br eak ) motion ( arrows. 2. s tep 5. the hip is c arried to the new r estr ictive barrier. 26 of 39 21/08/07 22:14 . 3.49) into the physician's r esis tance ( white ar row). Step 3 is r epeated three to fiv e times . T his c ontr action is held for 3 to 5 s econds. s tep 3. F ig . A slow. and F igu re 17.lww. gentle ( articulator y.48. 1. Muscle energy ac tiv ation: T he patient is instr ucted to push the k nee ( external r otation) ( blac k ar row.com/pt/re/9780781763714/bookContent.49. After a s econd of r elax ation. Stage 5.

468 Lower Extrem ity Region Hi p Girdl e: Spencer Technique S tages 7 and 8—Abducti on and Adduction 27 of 39 21/08/07 22:14 . P..http://thepointeedition.lww.com/pt/re/9780781763714/bookContent..

52) is applied at the end r ange of motion. A slow. 2. gentle ar tic ulator y ( make and br eak ) motion ( arrows.http://thepointeedition.lww. Step 3 is F igu re 17. Stage 7.54. the hip is c arried to the new r estr ictive barrier. Stage 7. 28 of 39 21/08/07 22:14 . 17. 1. s tep 5.com/pt/re/9780781763714/bookContent. 3.53.. T his c ontr action is held for 3 to 5 s econds. After a s econd of r elax ation. 17. F ig . F igu re 17. F igu re 17. F ig. and the physician gently takes the patient's s traightened leg and abduc ts it to its r estric tive barrier. Stage 8. s teps 1 and 2. Muscle energy ac tiv ation: T he patient is instr ucted to pull (b lack ar row. T he patient lies supine on the treatment table. 4.53) the k nee (hip adduc tion) into the physician's r esis tance ( white ar row). s tep 3..52.

HVLA 29 of 39 21/08/07 22:14 .lww.com/pt/re/9780781763714/bookContent.. 469 Upper Extrem ity Region El bow: Radioulnar Dysfunction. P ronati on Dysfunction (Loss of Supination).http://thepointeedition. Long Axi s. Muscl e E nergy. P..

57. T he phys ician holds the patient's dy sfunctional ar m as if s haking hands and plac es the thumb of the oppos ite hand anter ior to the r adial head.com/pt/re/9780781763714/bookContent.http://thepointeedition. 4.lww..58. T he phys ician then rotates the hand into s upination until the r estric tive barrier is engaged (F ig . Steps 7 to 9.. T he patient is s eated on the table. in whic h the r adial head and styloid proc ess mov e in opposing direc tions.56. T he long-ax is dysfunc tions r elate to a rotational movement along the length of the radius without anterior and posterior displac ement. 17. Step 4. 2. 1. and the physician s tands in fr ont of the patient. F igu re 17. 3.56). Steps 1 to 3. They are different dysfunc tions from the sees aw motions desc ribed in the anteroposterior dysfunc tions. T he patient is instr ucted to attempt to pr onate the F igu re 17. F igu re 17. 30 of 39 21/08/07 22:14 .

HVLA 31 of 39 21/08/07 22:14 . 470 Upper Extrem ity Region El bow: Radioulnar Dysfunction.http://thepointeedition.. Long Axi s. P. Muscl e E nergy. S upi nation Dysfuncti on (Loss of Pronation).com/pt/re/9780781763714/bookContent.lww..

60.60) while the phys ician applies an unyielding c ounterforc e ( white ar row). Steps 1 to 3. 5. and the physician s tands in fr ont of the patient. 2. T he patient is instr ucted to attempt to s upinate the wr ist (blac k ar row. 3. F ig. Steps 4 and 5 ar e r epeated F igu re 17.. 4. 17. F igu re 17. After a sec ond of relax ation. 17. T he phys ician r otates the forearm into pr onation ( arrow. T he patient is s eated on the table. Fig .61. Steps 7 to 9. T he phys ician holds the patient's dy sfunctional ar m as if s haking hands and plac es the thumb of the oppos ite hand posterior to the r adial head giving s upport. the patient's forearm is taken into further pr onation.59. 1.lww.http://thepointeedition.59) until the r estr ictive barrier is r eached. F igu re 17. 32 of 39 21/08/07 22:14 . Step 4.com/pt/re/9780781763714/bookContent. 6..

http://thepointeedition. P...com/pt/re/9780781763714/bookContent. Leg-Pull Technique 33 of 39 21/08/07 22:14 . 471 P elvi c Regi on Right Anterior Innomi nate Dysfunction: HV LA wi th Respiratory Assi stance.lww.

At the end of the last br eath. T he patient lies supine. F ig. 2. tr action is increased. 4. and the patient is as ked to tak e three to fiv e s low. 17.. T his traction is maintained.63. and the physician s tands at the foot of the table. T he phys ician r eass ess es F igu re 17. T he phys ician gr asps the patient's r ight ankle and r aises the patient's r ight leg to 45 degrees or more and applies tr action on the s haft of the leg (w hite ar row. 3. Steps 3 to 4. 34 of 39 21/08/07 22:14 .lww.62. Steps 1 and 2. the physician deliv ers an impulse thrus t in the direc tion of the trac tion ( arrow.63).com/pt/re/9780781763714/bookContent. 17. deep br eaths. F igu re 17. 1. 5.. Fig .62). At the end of each ex halation.http://thepointeedition.

472 Cervi cal Region C2 to C7.http://thepointeedition. Type 2 Moti on 35 of 39 21/08/07 22:14 .lww.. P. Articulatory..com/pt/re/9780781763714/bookContent.

T he patient lies supine. Steps 1 to 3.64 an d 17. translation to left.64.lww. 1. Step 4.. T he physician palpates the ar tic ular pr ocesses of the s egment to be ev aluated with the pad of the s econd or third finger.66. 17. 4. A tr ans lational motion is introduc ed fr om left to r ight (left side bending) and then right to left (right side bending) through the ar tic ular pr ocesses ( F igs. At the limit of each tr ans lational motion. F igure 17. r otation left) F igure 17.. translation to r ight. Steps 1 to 3.. a r otational s pringing may be applied in the direc tion fr om which the tr ans lation emanated ( e. 2. F igure 17.g. s ide bending left.65.http://thepointeedition.65). and the physician s its at head of table. 36 of 39 21/08/07 22:14 . 3.com/pt/re/9780781763714/bookContent.

S i de Bending 37 of 39 21/08/07 22:14 ..com/pt/re/9780781763714/bookContent. Articulatory. P. 473 Thoracic Region T1 to T4..http://thepointeedition.lww.

http://thepointeedition.68. and the phys ician either s tands behind or s its next to the patient.67) . 1. 4. As the physician adds a gentle s ide.68). T he physician's other hand r eaches in fr ont of the patient and c ups the side of the patient's head ( F ig. T he phys ician places the thenar eminence of the posterior hand on the pr oximal paras pinal thoracic tissues in the dy sfunctional ar ea.. Steps 1 to 3. 17.67. Step 4.bending motion of the head toward the physician's s ide. 3. the thoracic hand applies a s pringing force perpendicular to the length of the v ertebral c olumn ( Fig . 2. 38 of 39 21/08/07 22:14 .com/pt/re/9780781763714/bookContent. F igu re 17.. T he patient is s eated. F igu re 17. 17.lww.

39 of 39 21/08/07 22:14 . M ar c el i ne. Ki mb erl y P . ) .. Out l i ne of Os teop ath i c M ani pul ati v e P r oc edu r es: Th e K i m be r ly M an ual M il l en ni um Ed i ti on.lww. P.) . 474 References 1.com/pt/re/9780781763714/bookContent. 2. MO : W al sw ort h. W ard R ( ed . F ou nda ti on s f or Os te opa thi c Me dic i ne . 2 003 .. 2000 . Fu nk S ( eds. Ph i la del phia : L i pp i nco tt W il l i am s & W il k i ns .http://thepointeedition.

A rt i c ul a r mob i l it y o f t h e c r an i al b on e s 5. T. Flu c t ua t io n o f th e c e re b r os p in a l f l ui d 3. th e pa t ie n t . 18 Osteopathy in the Cranial Field Technique P rincipl es O s t e o pa t hy in t he cr a ni a l f i el d ( O CF) as de f i ne d b y t h e E d uc a ti o n al Co u nc i l o n O s t e o pa t hi c P r i nc i pl e s ( E CO P ) i s a “s y s t e m o f d i ag n os i s a n d t re a t me n t b y a n o s t e o pa t hi c p r a c t i ti o ne r us i ng th e pr i ma r y r e sp i ra t or y me c ha n is m an d b a la n c ed mem b r an o us te n s io n f i rs t de s cr i be d by Wi l li a m G a rn e r S u th e rl a nd . a n d i s t h e t it l e o f t h e r ef e re n c e wor k b y Ha r ol d M a g ou n . The op e r at o r. so f t t is s u e. S r. E CO P ha s d e fi n e d t he pr i mar y r e sp i r at o ry me c h an i sm as “ a mod e l p r op o se d b y Wi l li a m G ar n e r S ut h er l a nd . or cr a ni o s ac r al te c h ni q ue . CO . A n um b er o f s tu d ie s ha v e s ho wn e v id e nc e of su c h mo ti o n a nd s ug g es t t h a t t he cr a n ia l s u tu r e s may no t c om p l et e ly os s i f y (1 ) . A si mpl e e x a mp l e t o i l lu s tr a te t ha t t h e s u tu r es al l o w c ra n ia l bo n e mob i l it y i s t o ha v e o ne s tu d en t f i x a pa r tn e r 's fr o nt o z yg o ma t ic s ut u re s b i l at e ra l ly . b eg a n a li f el o n g s tu d y o f t h e c ra n i um an d i t s a n at o my a nd bi o me c h an i c s as t he y r el a t ed to he a l th an d d i s ea s e. O t h er os t eo p a th i c t ec h n iq u es ca n be us e d o n t h e c ra n i um bu t a r e u s ed wi t h t he i r s p ec i fi c pr i nc i pl e s f o r t re a t me n t e f f e c t o n s om a t ic dy s fu n c ti o n.. A lt h o ug h S u th e r la n d i s t h e n am e m o s t o f t e n a s so c ia t ed wit h t h is f or m o f t e c hn i qu e . MO ( A me r ic a n S c ho o l o f O s te o pa t hy ) . o r 1 of 48 21/08/07 22:14 . Th i s i s d o ne by pl a c in g o n e t h um b o v er o ne fr o nt o z yg o ma t ic s ut u re an d th e p a d o f t h e i nd e x f i ng e r o f t h e s am e ha n d o n t h e o pp o si t e f r on t oz y g om a ti c s u t ur e . Man y ph y si c ia n s w e re re l u c t a nt to b el i ev e t h a t t he cr a n ia l b o ne s we r e c ap a b le of mov e men t o r t h a t t he ph y s ic i an co u l d p al p at e mo v em e nt . r es e ar c h. The i nv o lu n ta r y m o bi l it y of th e s a c ru m b e tw e e n t he il i a ( p el v ic b on e s) O CF h as al s o b e en ca l le d cr a ni a l o s te o pa t hy ( CO ) ( 1 ). 3 ).lww. The n th e s tu d e nt ge n tl y ro c k s th e z y g om a ti c po r ti o n f r om si d e t o s i de wh i l e t he ot h e r h an d i s c ra d l in g t h e h e ad . an d l y mph a ti c t e c hn i qu e s c a n a ll be u se d in th i s r e gi o n b ut a re no t c l a s s i fi e d a s O CF. D O t o de s cr i be t he in t er d e pe n de n t f u nc t io n s a mon g f i ve b od y c om p o ne n t s as f ol l ow s ” ( 1 ): 1. a n d s im p l y c ra n ia l te c hn i qu e . I t i s i mp or t an t t h a t O CF be u se d w i th t he af o re me nt i on e d p ri n c ip l es . S u th e r la n d. Mob i l it y o f t h e i n tr a cr a n ia l a n d i n tr a sp i na l me mbr a ne s 4. c ra n io s ac r a l t ec h ni q u e ( 4) . S ti l l . a s t ud e nt of A . DO . The i nh e re n t mo ti l it y o f th e b r ai n an d s p in a l c o rd 2. c ou n t er s tr a in .com/pt/re/9780781763714/bookContent. a nd te a ch i n g ( 2. Hi s in t er e s t i n t he cr a n iu m b e ga n af t er he v ie wed a d is a r ti c ul a te d s k u ll wh e n s t ud y in g in Ki r k s v i ll e .http://thepointeedition. my o fa s c ia l r e le a s e. Fo r ex a mp l e. A n a u d ib l e a rt i c ul a r c li c k m a y o c c u r . man y ot h er s t o o k u p h is wor k a n d c o nt i nu e d t h e s tu d y .. ” ( 1) .

. h e b e ga n p o s t u l at i ng an i nh e re n t i n vo l un t ar y me c ha n is m an d e v en t u al l y c am e to th e t er m pr i ma r y r e sp i ra t or y me c ha n is m (6 ) . We h av e no t s e en a ny ad v er s e e f fe c t s f ro m t h is man e uv e r a nd t he r ef o re h av e c o nf i d en c e i n a po s it i ve e du c at i on a l o u t c o me ...lww. D i s t o r ti o n i n t h e p os i t io n o r m o t io n o f a n y c r an i al b on e m a y b e t r an s mi t t ed to th e ba s e a nd v au l t t hr o u gh th i s r e ci p ro c al t en s io n m e mbr a ne .He r in g . The b ip h as i c f l uc t ua t io n of mo t io n th a t i s p a lp a te d i n th e c r an i a l b on e s h a s b ee n r ef e r re d t o a s th e c r an i a l r hy t hm i c i mpu l se ( CR I ). The r ea s on pa t i en t s r ea c t p o si t iv e l y t o O CF i s n ot co mp le t el y u n d er s to o d. Th e re f or e . . So me o th e r r ea s o ns ma y i n c lu d e r ef l e x p he n om e n a f ro m c o n ne c ti v e t i s s u e mec h a no r ec e pt o r s a nd / o r n oc i ce p t or s o r m i c ro s co p ic a nd ma c ro s c op i c f lu i d e x ch a ng e ei t he r p e r ip h er a ll y ( Tr a u be . t he p hy s ic i an mus t k n ow c ra n ia l a na t o my (e . 2 of 48 21/08/07 22:14 . t o d ia g n os e a n d t r ea t u s in g OC F. S u th e rl a nd .http://thepointeedition. Th i s mot i o n p at t er n is de t er mi ne d b y a v ar i et y o f fa c to r s b u t i s t h ou g ht to b e r el a te d to th e b e v el i ng of t he su t ur e s a n d t he a t t a ch men t s o f t h e d ur a . T h er e fo r e . g. s p he n o id . or l ig a me n to u s a r ti c ul a r s t ra i n ( B LT / LA S ) t e ch n iq u es . fe l t s p ec i fi c t y p es of mot i on s . fe v er ) . r e s t r ic t io n of cr a ni a l b o ne mo t i on wit h di s to r ti o n o f i t s s y mm e tr i c mo ti o n p at t e rn is te r med cr a ni a l s o ma t ic d y s f un c ti o n . e. Mec h a ni s m r ef e r s t o t he i nt e rd e pe n d en t m o ve me nt of ti s s ue an d f l u id wi t h a s pe c i fi c p u rp o s e. p a ri e t al . 4 ). i n a lp h ab e t ic a l o rd e r f r om in n e r t o o ut e r t a bl e ). a nd th e u nd e r ly i ng ca u s e a nd ef f e c t ma y b e a c om b in a t io n o f t h e s t at e d p r in c ip l es . Th i s i s s o me t im e s c a ll e d t he c or e l i nk . The i nt e rn a l d u ra l r e fl e c ti o ns of t he fa l x c e re b ri . g. a nd t em p or a l. . a n d h e c ou l d n o t a c c o u nt f or t he s e mot i o ns ba s ed o n mus c le a c t i vi t y u p on re v ie wi ng cr a ni a l a n at o my . The mot i on be t wee n t h e c r an i um an d sa c ru m i s be l ie v ed t o b e a s s o c ia t ed wi t h t h e a t t a c hm e nt s o f th e d u ra l tu b e a t t h e f or a me n ma g nu m a n d t h e s ec o n d s ac r al s eg men t a t t h e r es p ir a t or y a x is . P ri ma ry re s pi r a to r y mec h a ni s m i s f u rt h er de f i ne d t h us : P. 4 76 P ri ma ry re f er s to in t er n a l t is s ue r es p ir a to r y p r oc e s s . I t i s b e li e ve d th a t a s p e ci f ic pa t t er n o f m o t io n e x is t s a n d i s r e ad i ly ap p a re n t a nd p al p a bl e i n e a c h p er s on . I t s r a te a nd a mp l i tu d e may v ar y i n c e r ta i n d is e a se pr o ce s s es (e . th e e x ch a n ge of r es p i ra t or y g a s es be t we e n t i s s u e c e ll s a n d t h ei r i n te r n al en v ir o n me n t . a n d t h e t en t o ri u m c er e b el l i a re c ol l ec t iv e l y k no wn a s t h e r ec i p ro c al te n s io n m e mb r a ne . b ot h ma y f e el t hi s m o ti o n . T h e re f or e . a nd i t i s u se d no t o n ly i n o s t e op a t hy in th e cr a ni a l f i el d b u t a l so in ba l a nc e d l ig a men t ou s t e n si o n. co n s is t in g o f t h e f lu i ds b at h in g t h e c e ll s ). a f t e r p a lp a ti n g m a ny pa t i en t s . I t fo l lo ws a rh y th mi c c ad e n ce at 8 t o 1 4 c y cl e s p e r min u t e ( 1.com/pt/re/9780781763714/bookContent. Res p i ra t or y r e f er s t o t h e p r oc e s s o f i nt e rn a l r e sp i ra t i on (i . t h e f a lx ce r e be l li . at th e p t e ri o n t he b on e s o ve r l ap as fo l l ow s : f ro n t al .Ma y er os c i ll a ti o ns ) (5 ) o r i n th e c e nt r a l n er v ou s s y s te m. Thi s i mpu l s e may be p al p at e d a n yw h er e i n t he b od y . Th e em p ha s is i n O CF is p la c ed on t he s yn c hr o no u s m o ve men t of th e c r a ni u m wit h th e s a cr u m ( c ra n io s a cr a l mec h a ni s m) .

T h is c an al s o b e t h ou g ht o f a s t he i nf e ri o r p or t i on of th e SB S c r ea t i ng an an g l e s o t ha t th i s i nf e r io r -s i de d an g le be c o me s s mal l e r o r mo re ac u te wit h f l ex i o n o f t he S BS . 4 77 g ro s s s a cr a l mo ti o n. t h e b as i o c c i pu t a n d b a si s ph e n oi d m o ve c ep h al a d wh il e t h e o c c i p it a l s qu a ma a nd th e wi n gs of t he sp h en o i d mov e m o r e c au d al l y . B ec a u se of th e li n k b et we en th e c r a ni u m a nd t he sa c ru m.com/pt/re/9780781763714/bookContent. i t ca n b e s a i d t ha t i n f le x i on . S o me h av e d e c id e d t o d es c r ib e s a cr a l b a se mo v e me n t s as n od d in g m o t io n s . In g ro s s s ac r a l b io mec h a ni c s . Th e sa c ra l b a s e mov e s b a c k war d i n gr o s s ex t e ns i on an d cr a ni o sa c r al f le x i on . a n d b a c k war d mo v em e nt o f t he sa c r al ba s e i s c a ll e d c ou n t er n ut a ti o n . th e p e t ro u s p or t i on s o f t h e t e mp o ra l b on e s m o ve ce p h al a d wit h th e S B S. In t er n a l r ot a ti o n o f t h e p a ir e d b on e s i s s y nc h r on o us wi t h s p he n ob a s il a r e x t e n si o n.2 ) . Th u s . th e sa c ru m m o v es an t er o i nf e ri o rl y . T h is mo r e r e ce n t c r an i os a cr a l mec h a ni s m t er mi no l og y h a s c a us e d s o me co n fu s i on be c au s e o f i t s d i f f e re n ce f ro m t h e p re v i ou s ly us e d n o me n cl a t ur e f o r P. a n d t h is c on v e xi t y i s i n cr e as e d d u ri n g f le x i on .http://thepointeedition. 3 of 48 21/08/07 22:14 . The s e f l ex i on an d e x t e n si o n mot i o ns ar e r o t at i on a l a b ou t t r an s v er s e a xe s : o n e a t t h e l ev e l o f t h e f or a men ma g nu m an d t h e o t he r t h ro u g h t he bo d y o f t h e s p he n oi d ( 6 ) . f or war d mo v em e nt o f t he s ac r a l b as e i s ca l le d n u t at i on . 1 ). Flexi on and Extension of the Sphenobasilar S ynchondrosi s Dur i n g f le x io n of th e c r a ni a l b as e (F i g. How e v er . I n s p he n ob a si l a r f le x io n . f l ex i o n i n c ra n i os a cr a l me ch a ni s m t er mi no l og y i s de f in e d a s t h e s ac r a l b as e m o v in g p o s t e r io r ly ..lww.. or s yn c ho n dr o s is (S B S) . Al l p a ir e d b o ne s m o v e i nt o e x t e r na l r o ta t i on s y n ch r o no u s wit h sp h en o ba s i la r f l ex i o n. a nd in SB S e x t e n si o n. t h e s k ul l s h or t e ns in th e an t er o po s t er i or di a met e r a nd wid e ns la t e ra l ly . I t is sl i g ht l y c on v e x o n t he s up e ri o r s i de . Cra n i al no men c l at u re is g en e ra l ly r ef e re n ce d to mo t io n oc c ur r in g at th e s p h en o ba s il a r s ym p h y s i s . 18 . t h e s a cr a l b a se go e s f o rw a rd in g ro s s f le x i on an d i n cr a ni o sa c r al e x t e n si o n. A ll mi d l in e u np a i re d c r an i a l b on e s a r e d es c ri b e d a s mov i n g i n f le x i on an d e x t en s io n . 1 8 . Thi s p r od u c es a f la r i ng ou t wa r d o f t h e t e mp o ra l s qu a ma c al l ed e x t e rn a l r o ta t io n o f th e t e mp o r al bo n es . a s a cr a l b as e an t er i or mov e me n t was d es c ri b ed a s f le x io n of th e s a c ru m. No mat t e r whi c h t e rm s o n e c h oo s es (f l e xi o n a nd e x t e ns i on o r n ut a ti o n a nd c ou n te r nu t a ti o n) . t h e s ac r u m wil l m o v e wit h t he c ra n iu m. I n e x t e n si o n ( Fi g . t h e s a cr a l b as e mo v es po s t er o su p er i o rl y ( 1 ). t h e s ku l l l e ng t he n s i n t h e a nt e r op o s t e ri o r d i am e te r an d n a rr o ws l at e r al l y . I n S B S f le x i on . Th e r ef o re .

sp hen oid a l a xis of rotati on.1.http://thepointeedition. Figure 18 .lww. S.com/pt/re/9780781763714/bookContent. Fle xio n of th e sp hen oba sil a r synchon d rosis. O. occipi tal axi s o f ro tation ... 4 of 48 21/08/07 22:14 .

Figure 18 . sp hen oid a l a xis of rotati on. R o ta t io n oc c ur s t o war d t h e s i de of co n v ex i t y (t h e i n fe r io r s id e ) . Tor s i on in v ol v e s r ot a ti o n o f t h e S B S a ro u nd a n a nt e ro p o s t e ri o r a x is . o n e t hr o ug h th e c e nt e r o f t h e b od y o f th e s p he n o id an d o n e a t t h e f o ra men ma g n um . bu t th e s p he n o id an d t h e o c ci p ut r ot a t e i n s am e di r ec t io n . 3) . occipi tal axi s o f ro tation . Co mpr e s s i o n. Crani osacral Mechanism Dy s f u nc t io n al p at t er n s o f c r an i al mot i on ha v e b e en de s c ri b ed as e it h er ph y s io l og i c o r n ot . d e n ta l p r oc e d ur e s .. 1 8 . O.com/pt/re/9780781763714/bookContent. T h e r ot a t io n c o mp o n en t o f t h e d y s f u nc t io n o c c ur s a r ou n d a n a n te r o po s te r io r ax i s . S id e be n di n g/ r o ta t io n i s si d e b en d i ng an d r o t at i on th a t o c cu r s i mul t an e ou s l y a t t he S BS . in f e ri o r mus c u lo s ke l et a l s t re s s a n d d y s f u nc t io n . S. a nd f ix e d ( fl e x io n a n d e x te n si o n) . Th ey ma y b e se c on d ar y to he a d t ra u ma. bi r th t ra u ma . P a lp a t io n o f a r ig h t t or s i on fe e ls a s i f t he g re a te r win g of th e s p h en o id on t he ri g ht e le v at e s a n d r ot a te s to th e l e f t whi l e t h e o c c i pi t a l s qu a ma o n t he r ig h t d ro p s i n to th e ha n ds an d ro t at e s t o t h e r ig h t ( Fig .. T h e s p he n oi d a n d t h e o c c i p ut ro t at e in op p os i t e d ir e c t i o ns ab o ut t he s e a xe s . Ex a mp l es o f p hy s io l o gi c d y s f u n c t i on s i n c lu d e t or s i on .2. o n e n ot e s t h at th e l e f t h an d f e e ls a 5 of 48 21/08/07 22:14 . Extensi on of the sph eno basi lar synch o ndrosi s. s i de b en d in g a n d r o ta t io n .http://thepointeedition. Whi l e p a lp a ti n g a le f t s id e be n di n g r o ta t io n . T h e s p he n oi d a n d o c c i p ut ro t at e in op p os i t e d ir e c t i o ns . ve r ti c a l s tr a in s (s h ea r ). Si d e b en d i ng oc c ur s by ro t at i o n a ro u nd t wo ve r ti c a l a xe s . a n d p os t ur a l a b no r ma l i ti e s . a nd la t er a l s tr a i ns ar e e x a mp l es of n on p hy s io l o gi c d y s f u n c t i on s .lww.

S BS c om p re s si o n e i th e r f e el s r o c k h ar d .lww. 7) . 6 ) . D u r in g p a lp a t io n . I n a n i n fe r io r ve r ti c al s he a r. b u t t h e r ot a ti o n o c cu r s i n t h e s am e di r ec t io n . S up e r io r /i n fe r i or ve r ti c a l s tr a in s in v ol v e e i th e r f le x i on at th e sp h en o id a nd ex t en s i on at t he o c c i pu t ( s u pe r io r ) o r e x te n si o n a t t h e s p he n oi d a n d f l ex i on a t t he oc c i pu t ( i nf e r io r ). l ik e a b ow l in g ba l l ( vo i d o f a n y mo ti o n) .com/pt/re/9780781763714/bookContent. 1 8 . 5 ).3. 6 of 48 21/08/07 22:14 . Dur i ng pa l p at i on . Rig ht SBS torsio n . Figure 18 . Th e d y s f u n c t i on is n am e d f o r t he p os i ti o n o f t h e b as i s ph e no i d.4 ) . o r th e p hy s i ci a n b eg i n s t o f ee l al l o f t h e d y s f u nc t i on a l s tr a i n p at t er n s t o ge t he r (F i g. f ul l n es s a s c o mpa r ed to t he ri g ht h an d ( s id e be n di n g) a nd on e a l s o f ee l s t h at th e l e f t h an d is be i ng d ra wn c au d a ll y b o th a t t he sp h e no i d a nd o c c i pu t ( r o ta t io n ) ( Fig . 1 8... T h is ca u s es a l at e r al sh e ar i n g f or c e a t t h e S BS . The d y s f un c ti o n i s n a me d by th e p o s it i on of t he ba s is p h en o id . 1 8 . a s up e r io r v e rt i c al sh e ar f ee l s a s i f t h e g re a t er wi n gs o f t he sp h e no i d a re d ra wn t oo f ar c au d a ll y .http://thepointeedition. L at e r al s t r ai n in v ol v es r ot a ti o n a r ou n d t wo v er t ic a l a x es . t h e l a te r al s tr a in s f e e l a s i f t h e h an d s a r e o n a p a r al l el o gr a m ( Fig . th e sp h en o id mov e s min i mal l y c au d a d ( Fi g . 18 .

6 ) b e tw e en t he ea s e a n d b in d . Th e p h y s i c ia n a t te mp t s to mo v e t h e d y s f u nc t io n i n th e d i re c t io n o f f r e ed o m u nt i l a ba l an c e o f t e ns i o n o c c u rs ( ba l an c ed mem b r an o us te n s io n ) ( 4.. an d t h e i nh e r en t f o rc e s e v en t ua l l y c au s e a sl i gh t i n c re a se P. I f t h e d y s f un c t io n a p pe a r s t o b e mo s t l y a rt i c ul a r.com/pt/re/9780781763714/bookContent. Technique Classifi cation Direct Technique I n d i re c t c ra n i al os t eo p a th y . t h e d y s f u nc t i on is mo v e d a wa y f r o m t he re s t ri c ti v e b ar r i er or to wa rd th e e a s e ( fr e ed o m. T h is te c h ni q ue is c om mon l y u s ed on in f a nt s a n d c h il d re n b ef o r e f ul l d e v el o pm e nt o f t he cr a n ia l s u tu r e s a nd in v er y s p ec i f ic dy s fu n c ti o ns in a du l t s ( 4) .lww. l oo s e) . Th e CRI is mon i to r ed . 7 of 48 21/08/07 22:14 . Th i s t e ch n iq u e i s m o s t a pp r op r ia t e i f t h e k e y d y s f un c t io n i s s ec o n da r y t o a me mbr a no u s r e s t r ic t i on (4 ) . t he d y s f un c ti o n i s m o ve d to war d t h e r e s t r ic t i ve ba r ri e r ( bi n d . a d i re c t t ec h n iq u e i s a p pr o pr i at e . 4 78 t ow a r d t he ea s e a n d t he n mo v em e nt b ac k t o t h e o r ig i na l ba l an c e p o si t io n . wh ic h i s a s ig n of th e r e l ea s e. I ndi rect Techni que I n i n di r ec t c r a ni a l o s t e o pa t hy . The ph y s ic i an sh o u ld ge n tl y ap p ro a ch t he ba r ri e r a n d mai n t ai n a li g h t f or c e u n ti l a r el e as e o c c ur s . t en s io n ) ..http://thepointeedition.

s im i l ar to in d i re c t .4. E xaggeration E xa g g er a ti o n me th o d i s p e rf o rm e d wi th th e p h y si c ia n m o v in g t h e d y s f u nc t io n to war d t he e as e . 8 of 48 21/08/07 22:14 . Figure 18 ..com/pt/re/9780781763714/bookContent.lww. bu t wh e n mee t i ng th e e a s e b ar r ie r an ac t iv a t in g f o rc e is a dd e d .http://thepointeedition.. Left SBS side be n din g/rota tion .

Figure 18 . Dep e n di n g o n h o w t he ar t i cu l at i on i s f el t t o be re s tr i c te d .5.com/pt/re/9780781763714/bookContent. t ra c t io n o r a c om p re s si v e f or c e m a y b e a d de d ..lww. Disengagement I n d i se n ga g em e n t .http://thepointeedition. SBS co mpre ssi on.. 9 of 48 21/08/07 22:14 . th e p h y si c ia n a t t em p t s to o pe n o r s e p ar a te th e ar t ic u la t i on .

P.com/pt/re/9780781763714/bookContent.. sph eno i dal axis o f rota tio n . occi pital axi s of rotati on.http://thepointeedition.6.. O. S.lww. Figure 18 . 4 79 10 of 48 21/08/07 22:14 . SBS in feri or vertica l stra i n.

Respi ratory Assistance A s i n o t he r t e c hn i qu e s .com/pt/re/9780781763714/bookContent.sp r ea d te c hn i qu e (4 ) . Th i s i s m o s t ev i d en t i n t h e V . Technique S tyl es I nherent Force Use o f t he bo d y 's in h er e n t f or c e t h ro u gh th e pr i ma r y r e sp i ra t or y me c ha n is m is th e maj o r m e th o d o f O CF. th e ph y si c ia n c an a lt e r t he p re s su r e i n o n e a re a or an o th e r a n d c au s e t h is fl u i d t o c ha n g e t he v ar i o us ba r ri e r s . t h e S B S t en d s t o m o ve t ow a rd fl e x io n .http://thepointeedition. For ex a mpl e . I n e x ha l at i on .7.. Us i n g t he fl u c tu a ti o n o f t h e c er e b ro s pi n al f lu i d.e nh a nc i ng mec h an i sm wil l i n cr e a se mo v em e n t s as s oc i a te d w i th i nh a l at i on an d ex h al a ti o n . Th i s r e le a se . t he us e o f pu l mo n ar y re s pi r at i o n c an fa c i li t at e o s t eo p at h ic t ec h n iq u e.lww. wit h th e p a ir e d b o ne s m o v in g m o re t ow a rd ex t e rn a l r ot a t io n . th e u n pa i r ed bo n es mov e p r ef e r en t ia l ly t ow a rd ex t e ns i on an d 11 of 48 21/08/07 22:14 . i t i s b e li e ve d th a t d ur i n g i nh a la t i on . SBS la tera l stra i n. Figure 18 ..

I n a dd i t io n . A cu t e i n tr a cr a n ia l b l ee d i ng an d h e mor r ha g e 2. I ndi cati ons 1. Su c ce s s o f t h e CV 4 t ec h ni q u e r el i es o n i nh e re n t f o rc e s . T h i s c an be a pp l ie d t o th e s ac r u m whe n c o n ta c ti n g t h e h ea d i s co n tr a in d i ca t ed (e . Cer t a in se i zu r e s t at e s ( r el a ti v e) 12 of 48 21/08/07 22:14 .lww. Hea d a ch e s 2.http://thepointeedition. t h e p hy s i ci a n mon i t or s s e ve r a l c y c l es o f CRI an d th e n p er mi t s e xh a l at i on mo t i on at th e bo n e b ei n g p a lp a te d (u s ua l ly t he oc c ip i t al sq u am a ) . ac u te h ea d t r au ma ) ( 4. t h e p hy s ic i a n may pr e f er to tr e a t t he pa t i en t 's pr o b le m f r om t he s ac r a l r eg i on o r e x t r em i t ie s . Th is is ca l l ed a s ti l l p o in t . O ti t i s med i a wi th ef f us i o n a nd se r o us ot i ti s me d ia 5. I nc r e as e d i nt r a cr a ni a l p r es s ur e 3. A cu t e s k ul l f r a c t u re 4.com/pt/re/9780781763714/bookContent. t h e p hy s i ci a n a t t e mpt s t o r e s is t t h e p r im a ry re s p ir a to r y me ch a ni s m t ha t is be i ng mon i to r ed t hr o ug h t h e C RI . t he p hy s i ci a n may h av e t h e p a ti e nt ac t i ve l y a t t e mpt pl a nt a r fl e xi o n o r d o rs i fl e x io n t o g a i n a p ar t i cu l ar ef f e c t on th e SB S . Th is po s it i o n i s h el d fo r 1 5 s e c on d s t o a fe w min u t es . V er t i go an d t i n ni t us 4. g .. Distal Acti vati on I n c e rt a in co n d it i on s . I n t hi s te c hn i qu e . S in u s it i s Contraindicati ons 1. 6 ). . S til l Point I n t h is me t ho d . Th i s i s m o s t c om mon l y c a ll e d c om p r es s io n o f t he f ou r th ve n t ri c le (C V 4 ). th e p h y s i c ia n c a n g ui d e t h e mec h a ni s m f ro m be l ow an d ef f ec t t h e m o ve men t of th e S B S . Mil d to se v er e wh i pl a sh s tr a in an d sp r ai n i n j ur i es 3. Dor s i fl e xi o n e n ha n ce s S B S f l ex i on .. Tem p o ro man d ib u l ar jo i nt d y s f un c ti o n 6. u n ti l th e p h y s i c ia n a p pr e c ia t es a r e tu r n o f t h e CRI . wh i le pl a n ta r fl e xi o n e nh a n ce s e x te n s io n ( 4 ). The n t h e p hy s i ci a n g en t l y r es i s t s fl e xi o n u n ti l a ce s s at i on of t he ce r eb r a l s pi n al f lu i d f lu c t ua t io n i s p a lp a te d . Th e ph y si c ia n ca n h a ve t he pa t ie n t b r ea t he i n t he d ir e c t i on p re f er r ed f or it s r e l at e d c ra n i al ef f ec t an d t e ll t he pa t ie n t t o h o ld t he b re a t h a t f ul l in h al a ti o n o r e x ha l a ti o n. B y a p pl y in g t e n si o n o n t h e s ac r um . Th i s w i ll en h a nc e a re l e as e . t he p ai r ed bo n e s i nt o i n t er n al ro t a ti o n.

. The r e fo r e. I t s ad v e rs e r e ac t i on s a r e f e w.http://thepointeedition. T h is ca n po t en t ia t e t h e e f f e c t o f a t r e at men t .h an d ap p ro a ch .. a n d v o mi t in g . Hea d a ch e s . g. ar e s e e n o c c a si o n al l y . w i th im p r op e r h ol d i ng te c hn i q ue (l o ca t i on an d i n c or r ec t p r e s s u re ) s e e n a t t i me s a t t h e o c ci p it o mas t oi d s u t ur e . T h es e ar e m o s t l y s e en wh e n s t ud e nt s ar e f i rs t le a rn i ng t he t ec h n iq u e a nd d o n ot re a l iz e t h e p r es s ur e b e i ng im p ar t e d i nt o t h e ir pa t ie n t 's cr a ni u m. th e ph y si c ia n mu s t t ak e ca r e t o c o nt a c t th e pa t ie n t p r op e rl y a n d a p pl y e no u g h b ut no t to o m u ch p re s su r e f o r t he ap p r op r ia t e a mou n t o f t i me . a s c an s om e a u to n o mi c r e la t e d P.com/pt/re/9780781763714/bookContent. 4 80 e f f e c t s (e . A v a r ia t io n o f th i s t ec h n iq u e i s u s in g a mu l t ip l e. T h e p h y s i ci a n s ho u l d a ls o m a k e s ur e t h a t t he pr i mar y r e sp i r at o ry me c h an i sm is p re s en t w h e n d ec i d in g t o e n d t h e t re a t me n t . bu t t h e p h y s i ci a n s ho u l d b e o n a l er t . General Considerations and Rules O CF may he l p a nu mbe r o f co n di t io n s . v e rt i go . t i n ni t us . 4 81 Crani al Vault Hold 13 of 48 21/08/07 22:14 . br a dy c ar d i a) .lww.. a nd v om i ti n g c a n o c c u r. a n ot h er ca n be on th e sa c ru m o r an o th e r a r ea of th e pa t ie n t' s b od y . Wh i le on e op e ra t or i s p al p a ti n g t he c ra n iu m. na u s ea . a s h e ad a ch e . wh il e n o t c om mo n. Thi s is co mmo n . n a u se a . P.

. L a teral vie w of skull with d ots for fi ng (7). 1 8. Fig.8 ). 1 8. The ph ysi cian 's rin g fin gers re st on the mastoi d p roce sse s o f the pa tie n t's te mpo ral bon es (C . The ph ysi cian 's ind e x fin gers re st on the gre ate r w i ngs of th e patien t's sph eno id (A. The ph ysi cian 's mid d le fin gers re st on the zyg oma tic pro cesses of the pa tien t's temporal b one s (B.8 ). The pa tie n t l ies sup ine .com/pt/re/9780781763714/bookContent.8 . 4.. The ph ysi cian 's han d s cra dle th e pa tie nt's hea d. 1 8. The ph ysi cian establ ish e s a fu lcru m by restin g bo th forearms o n the tab l e.8 ). 6. Objective s The ob jective is to assess the prima ry resp ira tory mechan ism as it man i fests itself in the crani u m a nd the deg ree of participa tion of each b one in the ge n era l motion of the crani u m. Fig. The ph ysi cian 's little fin gers re st on the Figur e 1 8. Fig. Tec hnique 1. 3. 2.lww. 5. a n d the physician is sea ted at the he ad o f the tab l e. 14 of 48 21/08/07 22:14 . 7. maki ng ful l pal mar co n tact o n b o th sid es.http://thepointeedition.

The ph ysi cian 's cep hal ad h and bridg e s across th e pa tie nt's fro nta l b o ne. Tec hnique 1. P. especi all y a t the SBS. The ph ysi cian pl ace s the ca uda d ha nd und er the patien t's occipi tal squ ama wi th the fo rea rm resting on the ta ble establ ish i ng a fulcrum. a n d the physician is sea ted at the si de o f the hea d of the ta ble .com/pt/re/9780781763714/bookContent. The th umb and mi ddl e fin ger of the physician 's ceph ala d han d rest on the gre ate r w i ngs of th e patien t's sph eno id (if Figure 18. 15 of 48 21/08/07 22:14 . Figure 18. 4. wi th the elb ow resting on th e tab le esta bli shi ng a ful cru m. a nd to asse ss the fro nta l b o ne as it rela tes to the re st o f the CRI. 4 82 Fronto-occi pital Hold Objective s The ob jective s a re to assess th e prima ry respirato ry mech ani sm a s i t man ife sts itself in the cra niu m.12.lww. Ste ps 1 to 5..http://thepointeedition. 2.. 3. Ste ps 1 to 5. to a sse ss the fre edo m o f mo tio n o f th e cra nia l b a se. The pa tie n t l ies sup ine .11.

http://thepointeedition. d ete rmi nin g whe the r th ere is an y pre ferred motion of the sph eno id a nd the occipu t. if any. he igh t increa ses.lww. 5. 6. antero posteri or dia meter increa ses. have a n a l tered amp litude . and re gul a rity o f th e CRI. Figure 18. The ph ysi cian no tes the ampli tude ..13. Extension /intern al rotati on: corona l dia meter n arrows. rate . The ph ysi cian no tes whi ch bon e s. Fle xio n/e xternal rotati on: corona l dia meter w ide ns. a.com/pt/re/9780781763714/bookContent.13). Ste ps 1 to 5. 7. 16 of 48 21/08/07 22:14 . 8. ap p roxima te the gre ate r w i ngs).11. the ha nd spre ad is too sho rt. b. he igh t decrea ses. 18. 9. The ph ysi cian pal pates the CRI. an d reg ula rity. The ph ysi cian pa ys particula r atten tio n to the SBS. antero posteri or dia meter decrea ses. The ph ysi cian ma kes ful l p alma r contact with both h and s (Figs .12 and 18.. 18 . ra te.

17 of 48 21/08/07 22:14 . The pa tie n t i s instru cte d to ben d the far kne e a nd roll tow ard th e physician .. P. 4 83 S acral Hold Objective The ob jective is to cre ate fre e a nd symmetric motion of the sa cru m by pal pation of the CR I. The physici an can also h ave the pa tie n t i nha le and exhal e fu lly to increa se the ampli tude of th e CR I..lww.http://thepointeedition. whi ch can make i t e a sie r to fee l. Tec hnique 1. The pa tie n t l ies sup ine . 2. The ph ysi cian sli des th e Figure 18. 3. Ste ps 1 to 4.14.com/pt/re/9780781763714/bookContent. a n d the physician is sea ted at the sid e o f th e tab le cau d ad to the sa cru m. The ph ysi cian ma y i n struct the pa tie n t to stop bre ath ing to furthe r distin gui sh the rhythmi c sen sation s th at occu rs in the CR I.

Figure 18. Ste ps 1 to 4.. a n d the pa tie n t dro ps his or her wei ght is on thi s h and . Sph eno basi lar fle xio n i s syn chrono u s with sacra l cou nte rnu tati on Figure 18. 18.15). 4. cau dad ha n d betwee n th e patien t's leg s and un der the sacrum.16.14 and 18.. The ph ysi cian pal pates the cra nio sacral mechan ism. establ ish i ng a ful cru m. 18 of 48 21/08/07 22:14 . Lumbar an d sa cra l con tact. 6.com/pt/re/9780781763714/bookContent. the fi nge rtip s app roxima ting the ba se a nd the pa lm cra dli ng the ape x (Figs .15.lww. The ph ysi cian pre sse s th e elb ow dow n into the tabl e.http://thepointeedition. 5. The ph ysi cian all ows th e han d to mo ld to the sh ape of the sa cru m wi th the me dia n sacral cre st lyi ng betw een the th ird and fou rth fi n gers.

. The ph ysi cian con tin ues to fol low an d encourage sacral mo tion until pal p ati on of a rele a se.http://thepointeedition. 7.lww. 19 of 48 21/08/07 22:14 . 8. 9. whi ch is usu all y accomp ani e d by a sensa tio n of soften i ng and wa rmi n g o f the sa cra l tissue s.com/pt/re/9780781763714/bookContent. The ph ysi cian 's han d foll o ws the se moti ons.. The ph ysi cian retests th e qua nti ty a nd qua lity o f sacral mo tion to assess the effective n ess of the te chn i que . Sph eno basi lar extension is syn chrono u s with sacra l nutati on (sacral base move s anteri or). encouragi n g symmetric and ful l rang e of sacral mo tion . (sa cra l b a se moves posterior).

P.lww. 18. The ad diti ona l h and pla cement gives the physician more informati o n a bou t how th e sa cru m rel ate s to th e respective areas. Ste ps 1 a n d 2 .16) la ying th e forearm a cross b oth anteri or supe rio r ili ac spi n es (ASIS).http://thepointeedition.com/pt/re/9780781763714/bookContent. 4 84 Decom pressi on of the Occi pital Condyles Objective s The ob jective is to bal ance th e reciproca l te nsi on membra ne a t the hyp ogl ossa l can al.. either sl i din g i t und er the patien t's lumbar are a (Fig. The pa tie n t lie s supi n e. The ph ysi cian ca n also u se the cep hal ad h and . and th e physician is sea ted at the Figure 18.17. 20 of 48 21/08/07 22:14 . Tec hnique 1.. pe rmittin g normal ize d fun cti on o f cran ial nerve XII.

18.http://thepointeedition.17.. The pa tie n t's hea d rests on the physician 's pal ms.lww. The fi nge rs of both han ds ini tia te a gen tle cep hal ad and la tera l force at the Figure 18. 18.19. Ste ps 1 a n d 2 .. 2. hea d o f th e tab le with both forearms restin g o n the ta ble . 21 of 48 21/08/07 22:14 . 18 . an d the physician 's ind ex and mid dle fin gers (o r the mi ddl e and ri ng fin gers) app roxima te the pa tie n t's con dyl ar pro cesses (as fa r cau dad on the occip u t as the so ft tissue an d C1 wil l all ow) (Figs.18 and 18 . establ ish i ng a fulcrum.com/pt/re/9780781763714/bookContent. Ste ps 1 a n d 2 .19 ). 3. Figure 18.

.http://thepointeedition. 5.com/pt/re/9780781763714/bookContent. P. resu lti ng in misali gnme nt of the con dyl es i n the facets of the atlas. 4.20. this techni que sho uld be Figure 18.lww. The ra te a nd amp litude of the CR I a s it man ife sts in the basioccip i tal reg ion are retested to assess th e effective n ess of the techni que . 22 of 48 21/08/07 22:14 . Ste ps 1 a n d 2 . base o f th e occipu t.. In gen era l . The fo rce is mai nta ine d until a rel ease i s fel t. 4 85 Occi pitoatl antal Decompressi on (8) Objective s To tre at occipi toa tlan tal somati c d ysfu nction tha t resu l ts fro m rotati on o f the occipu t o n its antero posteri or axi s.

The ph ysi cian app lie s ca uda d pre ssu re w ith both midd l e fin gers to sep ara te the facets fro m the Figure 18. Figure 18. 18 . Ste ps 1 a n d 2 .20.com/pt/re/9780781763714/bookContent. 23 of 48 21/08/07 22:14 . a n d the physician is sea ted at the hea d o f th e tab le with bo th forearms restin g o n th e tab le. 3.21. The ph ysi cian pla ces th e pad s o f b o th mid dle fi n gers on the posterior asp ect of the cra niu m a n d sli des th e se fin gers d o wn the occip u t until the fin gers are ag ain st the posterior arches of the atl as (Figs. establ ish i ng a ful cru m. Ste ps 1 a n d 2 . Tec hnique 1. performed after decomp ression of the occip i tal con dyl es. 18.21 and 18 .http://thepointeedition..22.lww.. The pa tie n t l ies sup ine . 2.22 ).

The ph ysi cian mai nta ins thi s positi on w hil e the pa tie n t hol ds one or more d eep inspirati o ns to the ir limi t.com/pt/re/9780781763714/bookContent. con dyl ar p arts. Whi le the physician mai nta ins thi s cau dad pre ssu re. 5. 6. Thi s wil l e nha n ce articu lar rel ease. The ra te a nd 24 of 48 21/08/07 22:14 . ten ses th e lig ame nts in the re gio n . Thi s moti o n carrie s th e occipi tal con dyl es posteriorl y. a nd stretches the con tra cte d muscle s i n th e occipi tal tri ang le. 7. 4.lww...http://thepointeedition. the patien t tu cks the ch in i nto the ch est. making su re NOT to fl e x the neck (thi s is the no ddi n g moveme nt that occurs at the occipi toa tlan tal joi nt).

4 86 Compression of the Fourth Ventricl e Objective s Tre atment often sta rts wi th compre ssi o n o f C V4 for il l p a tie nts..com/pt/re/9780781763714/bookContent. 25 of 48 21/08/07 22:14 .. Ste ps 1 to 3. rela xes th e patien t. The pa tie n t l ies sup ine . a n d the physician is sea ted at the Figure 18. Occipi toa tlan tal motion te stin g can al so b e assessed for normal iza tion . amp litude of the CR I. Tec hnique 1.http://thepointeedition. Th e tre atment aug men ts the he ali n g cap abi liti es of the patien t. a re retested to assess th e effective n ess of the te chn i que .lww.24. a s i t man ife sts in the basioccip i tal reg ion . P. a nd imp roves the motion of the CR I.

25 and 18.23. hea d o f th e tab le with bo th forearms resting on the ta b le. The ph ysi cian Figure 18. 26 of 48 21/08/07 22:14 .. 18.25. 3. Figure 18. 18 . The ph ysi cian pla ces th e the nar emi nen ces posterome d ial to the pa tien t's occipi toma sto id suture s.com/pt/re/9780781763714/bookContent. Ste ps 1 to 3. establ ish i ng a ful cru m. cra dli ng the pa tie n t's occipi tal squ ama .26. th e compre ssi o n tha t foll o ws wil l bil ate ral l y extern all y ro tate the te mpo ral bon es.24. 2.http://thepointeedition. The ph ysi cian cro sse s o r interl ace s th e fin gers o f bo th han ds. 18.. If the the nar emi nen ces are on the ma stoi d pro cesses of the te mpo ral bon es. Sup eri or view of ha n d posi tio n. 4.lww. wh i ch may ca use extreme untowa rd rea cti ons (Figs.26).

It i s a s i f the ph ysi cian is taking up the sla ck cre a ted by extension and hol din g i t th ere . The ph ysi cian resists fl exi on by hol din g th e patien t's occipu t in extensi on with b ila tera l med ial fo rces.com/pt/re/9780781763714/bookContent. a sti ll poi n t i s rea che d. a nd/or a sense o f rel ease i s fe lt (a sen se of soften ing and warmth in the reg ion of the occipu t). Rather.http://thepointeedition.. i t is pre ven ted fro m moving in to fle xio n.lww. As the CR I 27 of 48 21/08/07 22:14 . 5.. Note: The occipu t i s no t forced in to extension . encourage s extension of the patien t's occipu t by fol low i ng the occipu t a s it moves into extension . 7. 6. Thi s force is mai nta ine d un til the ampli tude of the CR I decrea ses.

com/pt/re/9780781763714/bookContent. 28 of 48 21/08/07 22:14 . 8.lww.. The ra te a nd amp litude of the CRI are retested to assess th e effective n ess of the te chn i que . the physician slo wly re l eases the fo rce .. resume s. all owi ng the CRI to un d erg o new fou nd excursion .http://thepointeedition.

lww. Figure 18 ..http://thepointeedition. 4 87 P. P.23. 4 88 I nterparietal S utural Opening (V-S pread) 29 of 48 21/08/07 22:14 ..com/pt/re/9780781763714/bookContent. Steps 1 to 3 .

27. a n d the ph ysi cian is sea ted at the hea d o f th e tab le with bo th forearms restin g o n tab le. establ ish i ng a ful cru m. 3.27.. increa sin g th e dra ina ge o f the sup eri or sagi tta l sin us. 18.29). Tec hnique 1. The pa tie n t l ies sup ine . Figure 18.lww. Ste ps 1 to 3. Figure 18.http://thepointeedition. Figure 18. 18 .29.com/pt/re/9780781763714/bookContent.28 and 18. The re mai n der of the physician 's fin gers re st on the la tera l surfaces o f the patien t's parietal b one s (Figs. Ste ps 1 to 3. Objective To restore freed om of moveme n t to the sag ittal sutu re. 2.28. Ste ps 1 to 3.. The physician 's thu mbs are cro sse d o ver the pa tie n t's sag ittal sutu re just a nte rior and su peri or to lambda . 30 of 48 21/08/07 22:14 .

4 89 S utural Spread (V-Spread.lww.31. Ste ps 1 to 3. 2.g . Figure 18.. The ph ysi cian pla ces th e ind ex and mid dle fi n gers on the tw o sid es of the patien t's restri cte d suture . The ph ysi cian pla ces on e or two fi nge rs o f the other han d on the patien t's cra niu m a t a poi nt opp o site the su ture to Figure 18. Ste ps 1 to 3.com/pt/re/9780781763714/bookContent.30.. P. left o cci p ito mastoi d suture ).. 31 of 48 21/08/07 22:14 . and th e physician is sea ted at the hea d o f th e tab le with both e lbo w s restin g o n th e tab le. 3. Di rection-of-Fl uid Techni que) Objective The ob jective is to rel ease a restri cte d cra nia l su ture (e. establ ish i ng a ful cru m. The pa tie n t lie s supi n e. Tec hnique 1.http://thepointeedition.

ini tia tin g a flu id wave . the physician directs a n imp ulse tow ard th e restri cte d suture wi th the ha nd opp osi te the suture ..com/pt/re/9780781763714/bookContent.30..32.http://thepointeedition.31 and 18. the physician is usi ng the flu ctu ati o n o f the cerebrosp i nal flu id to rel ease th e restri cti o n. Ste ps 1 to 3. 18. be rel ease d (Figs. 18 .lww.32). Instea d. 4. The ob ject is not to physicall y push flui d throug h to th e opp osi te side . The ph ysi cian use s i nte n tio n to ini tia te this wave. With the lig hte st force possib le. 32 of 48 21/08/07 22:14 . thi s method con tra cts the few est mu scle fib ers an d so app lie s th e Figure 18.

. 5.http://thepointeedition. The ra te a nd amp litude of the CR I a t th at suture are retested to assess th e effective n ess of the techni que . Thi s back-a nd-forth action ma y be rep eated for severa l cycle s before th e physician fee ls the suture sp read and th e w a ve pen etrati n g the su ture doe s n ot return to the ini tia tin g han d.. 7. sli ghtest force. 6. Thi s flui d wave may bou nce off th e restri cte d suture an d return to the ini tia tin g han d. 33 of 48 21/08/07 22:14 .lww.com/pt/re/9780781763714/bookContent. whi ch sho uld receive a n d red ire ct the return ed w ave tow ard th e restri cte d suture .

The pa tie n t lie s supi n e. Ste ps 1 a n d 2 . establ ish i ng a fulcrum.http://thepointeedition. Figure 18. and th e physician is sea ted at the hea d o f th e tab le with both e lbo w s restin g o n the ta ble . Thoraci c outlet. Tra nsverse si nus. P. and occipi toa tlan tal joi nt soma tic dysfun cti o ns sho uld be tre ate d first to a llo w dra ina ge from th e ven ous si n use s.lww..33. 34 of 48 21/08/07 22:14 .34. Tec hnique 1. 4 90 P.com/pt/re/9780781763714/bookContent. ce rvi cal . 2. 4 91 V enous S inus Drainage (6) Objective s The ob jective is to increa se intracran i al ven ous dra ina ge by affecti ng the dural memb ran es tha t comp rise th e sin use s.. For tra nsverse sin us dra ina ge the physician Figure 18.

Figure 18.36.37. Figure 18. 35 of 48 21/08/07 22:14 . Con flu ence of si nuse s.http://thepointeedition..3 3 ) (Fig.. 3. pla ces th e first and second fin ger pa d s of both han ds across th e sup eri or nuchal li n e (b l ue lin e . Ste p 5 . 4. Fig.35.lww.com/pt/re/9780781763714/bookContent. 1 8. 18. Occipi tal sin us. For drain a ge at the con flu ence s of sin use s the physician cra dle s th e Figure 18. Thi s p osi tion is mai nta ine d with mini mal pre ssu re (th e w eig h t of the patien t's hea d shou l d suffice) u nti l a rele ase is fel t (ap parent soften ing und er the fin gers). The physician mai nta ins thi s p ressure until both sid es rel ease. 5.3 4).

http://thepointeedition.com/pt/re/9780781763714/bookContent. 1 8..3 6).38.40. Ste ps 9 a n d 1 0. Fig. 6.lww.. 18.38).37) (Fig. Figure 18. For occip i tal sin us dra ina ge the physician cra dle s th e back o f th e patien t's hea d a nd pla ces th e second to fou rth fin gers o f both h and s in opp osi tion alo ng the mid lin e from the in ion to the sub occipi tal tissue s (b lue lin e. Ste p 4 is rep eated until a soften ing is Figure 18. 36 of 48 21/08/07 22:14 . Sup eri or sagi tta l si nus.3 5 ) (Fig. 8. Ste p 7 . back o f th e patien t's hea d a nd pla ces th e mid dle fi n ger of one ha n d on the in i on (b l ue dot. Fig.39. 7. Ste p 4 is rep eated until a soften ing is fel t. 18.s Figure 18. 18.

the physician moves anteri orl y and sup eri orl y alo ng the sup eri or sag ittal suture wi th the crosse d thu mb forces noting rel eases a t each locati on tow ard bre gma (b l ue lin e . 18. th e physician pla ces tw o cro sse d thu mbs at lambda an d exe rts opp osi ng forces wi th each thumb to diseng a ge the su ture .42.3 9 ) (Fig.. Fig. Ste p 1 1. fel t.com/pt/re/9780781763714/bookContent. 1 8. Figure 18. Once l oca l rel ease i s fel t.lww.4 0). 9..41. 10. Once a t bre gma . For drain a ge of the sup eri or sag ittal sin us.http://thepointeedition. 37 of 48 21/08/07 22:14 . th e Figure 18. Metopi c su ture. 11.

42).. Fig. The physician con tin ues anteri orl y on the fronta l bon e.lww. 13. 12. 18. 38 of 48 21/08/07 22:14 .com/pt/re/9780781763714/bookContent. are re tested to assess the effective n ess of the techni que . 18. physician pla ces th e second to fou rth fin gers o f both h and s in opp osi tion alo ng the mid lin e o n the fronta l bon e a t th e locati on o f the me top i c suture (b l ue lin e.http://thepointeedition.. esp eci all y flu id flu ctu ati o ns. diseng agi n g the su ture by gen tly sep ara tin g each fing e r on opp osi n g han ds.41) (Fig. The ra te a nd amp litude of the CR I.

3.http://thepointeedition. Tec hnique 1. The pa tie n t lie s supi n e.com/pt/re/9780781763714/bookContent. 4 92 Unil ateral Tem poral Rocki ng Exampl e: Left Tem poral Bone i n E xternal or Internal Rotation Objective The ob jective is to tre at a dysfun cti o n i n whi ch the temporal b one is hel d i n extern al/i nte rna l rotati on. an ato mic locati o n o f fing e r p lace 39 of 48 21/08/07 22:14 . 2. P.43... establ ish i ng a fulcrum. Ste ps 1 to 5.lww. and th e physician is sea ted at the hea d o f th e tab le with both forearms restin g o n the ta ble . The physician 's left h and cra dle s th e patien t's occipu t. The physician 's rig ht thu mb and in dex fin ger gra sp the zyg oma tic Figure 18.

thu mb cep hal ad.45).com/pt/re/9780781763714/bookContent. th e physician 's rin g a nd l ittle fin gers e xert med ial pre ssu re. 18. Ste ps 1 to 5.http://thepointeedition. Thi s pre ssu re i s accomp ani e d Figure 18. During th e fle xio n p h ase of cra nia l motion . Ste ps 1 to 5. ind ex fin g er cau dad .44. fi nge rs o n zygo ma. 18 . 6.44 and 18. 5.lww. The physician 's rig ht mid d le fin ger re sts on the extern al aco ustic mea tus of the ear. Figure 18.43. 4.45.. portio n o f th e patien t's rig ht temporal bon e.. The physician 's rig ht rin g an d little fi n gers rest o n th e inferi or portio n o f th e patien t's mastoi d pro cess (Figs. 40 of 48 21/08/07 22:14 .

th e physician 's fin gers re sist motion of the patien t's temporal bon e towa rd intern al rotati on. by cep hal a d liftin g o f th e patien t's zyg oma tic arch w ith the physician 's thu mb and ind ex fin gers. An altern ati ve method encourage s intern al rotati on a nd inh ibi ts the extern al rotati on. encouragi n g extern al rotati on o f the te mpo ral bon e..com/pt/re/9780781763714/bookContent. esp eci all y at 41 of 48 21/08/07 22:14 ..http://thepointeedition.lww. During th e extension pha se of cra nia l motion . 9. The ra te a nd amp litude of the prima ry respirato ry mechan ism. 7. 8.

e . establ ish i ng Figure 18. ha nd pla ceme nt.. P. 4 93 Frontal Lift (8) Objective The ob jective is to tre at dysfun cti o ns of the fronta l b one s in rel ati o n to thei r sutura l o r du ral con nectio n s (i. are retested to assess th e effective n ess of the techni que .46.lww.. The pa tie n t lie s supi n e. Ste ps 1 to 3. fro nto pari eta l compre ssi o n. Tec hnique 1.com/pt/re/9780781763714/bookContent.http://thepointeedition. fro nto nasa l compre ssi o n). 42 of 48 21/08/07 22:14 . and th e physician is sea ted at the hea d o f th e tab le with both forearms restin g o n the ta ble .. the te mpo ral bon e.

The physician pla ces bo th hyp oth ena r emi nen ces on the latera l ang les of the fro nta l b o nes and th e the nar emi nen ces of both han ds anteri or to the la tera l asp ects o f the co ron a l suture . 4. Figure 18.lww. Ste p 5 .46).47. The physician 's the nar an d hyp oth ena r emi nen ces pro vid e a gen tle compre ssi ve force med ial ly to diseng age the fronta ls fro m the parietals Figure 18.48. co mpressive force. a n terior gu i ded force... Ste p 4 .com/pt/re/9780781763714/bookContent. 3. a fulcrum. 43 of 48 21/08/07 22:14 .http://thepointeedition. The physician interl ace s the fi nge rs abo ve the metopi c suture (Fig. 18. 2.

Fig. Fig. The physician . (a rrow s. 18.com/pt/re/9780781763714/bookContent.lww. 7.. app lie s a gen tle anteri or force eith er on one si d e or both a s nee ded to diseng age the su tura l restri cti o ns (a rrow s. 5. 18. The physician 44 of 48 21/08/07 22:14 .47). intern all y rotati ng the fro nta l bon es. Thi s p osi tion is hel d u n til the physician fee ls the latera l ang les of the fro nta l b o nes move i nto extern al rotati on (expan sio n und er the hyp oth ena r emi nen ces). whi le mai nta ini n g thi s medi a l compre ssi ve force.http://thepointeedition..48). 6.

Tec hnique 1. parietofro nta l).http://thepointeedition. P. Ste ps 1 to 3.e.49. are retested to assess th e effective n ess of the techni que .com/pt/re/9780781763714/bookContent. a n d the physician is sea ted at the he ad of the ta b le with both fore a rms restin g o n th e Figure 18.. 8.. pa rietote mpo ral. The ra te a nd amp litude of the prima ry respirato ry mechan ism.. the n g entl y rel eases the hea d. 45 of 48 21/08/07 22:14 . esp eci all y at the fronta l bon es. 4 94 P ari etal Li ft (8) Objective The ob jective is to tre at dysfun cti o n o f the parietal b one s i n rel ati on to thei r su tural or dural conn ection s (i. The pa tie n t l ies sup ine .lww.

establ ish ing a fulcrum.. the physician lifts both han ds cep h ala d until ful l ness i s fel t o ver the Figure 18.com/pt/re/9780781763714/bookContent. The ph ysi cian cro sse s th e thu mbs ju st a bove the sa gittal suture (Fig. 3. Pre ssi ng o ne thu mb aga i nst th e oth er app roxima tes the fin gertip s. Figure 18. The ph ysi cian pla ces th e fin gertip s on bo th parietal b one s j ust sup eri or to the parietal-squa mou s suture s.50.4 9). Whi le mai n tai nin g pre ssu re. No te: The th umb s are NOT to to u ch the patien t. This ind uce s i n ternal rotati on o f the parietal b one s a t the parietal-squa mou s suture s. Ste p 6 . 18.http://thepointeedition. Fig. tab le. 6.lww.51. The ph ysi cian pre sse s o n e thu mb aga i nst th e oth er (arrows. e xternal ro tati on of pari eta ls. 5.. 2. 4. 46 of 48 21/08/07 22:14 . 18. Ste p 4 .50) (o n e thumb pre sse s u p ward whi le the oth er resists i t).

) . The ph ysi cian gen tly re l eases the he ad. this ful lne ss i s extern al rota tio n of the pa rietal bon es (a rrows.lww. Li p i ns k y C. a re retested to a sse ss the effective ness of the te chni que . Ar b uc k le . 35 : 32 8 – 33 6 . esp eci all y at th e fro nta l b o nes. The ra te a nd amp litude of the pri mary respirato ry mechan ism.http://thepointeedition.. 3 .He ri n g. Pr i n ci p le s o f Ma n ua l M e d ic i ne . e t a l .. Fo un d at i on s fo r O s te o p at h ic Me d i ci n e. G r ee n man P. 1 8. N e ls o n K . P hi l a de l ph i a: L ip p in c ot t Wi ll i am s & Wil k in s . 2 . 4 95 References 1 . 5 . 2 00 3 . T h e Cr an i al Ve r t eb r ae . 7. 2n d ed . J A m O s t e op a t h A s s o c 1 9 36 . P. P A : Nat i o na l O s te o pa t h ic In s ti t u te an d C e r eb r al Pa l s y Fou n da t i on . Th e Se l ec t ed Wri t in g s o f B e ry l E . 4 .1 0 1 :1 6 3– 1 73 . Cra n i al rh y th mi c i mp u ls e re l at e d t o t h e Tr au b e. S e rg u e f f N. J Am Os t e op a th As s o c 2 00 1 . Ca mp Hil l .5 1 ). P h il a d el p hi a : L i pp i nc o t t Wil l ia ms & Wi l ki n s . 2 0 03 . 47 of 48 21/08/07 22:14 .May e r o s ci l la t i on : C o mp a r in g l a se r Do p pl e r f l ow met r y a n d p al p at i o n. Fig. W a rd R ( e d. fin gertip s.com/pt/re/9780781763714/bookContent. 3 r d e d . A r bu c k le B. 8. W e av e r C .

1 1 th ed . S ch i ow i t z S . O s te o p at h y i n t h e Cra n ia l Fi e ld . P hi l ad e l ph i a: Li p p in c ot t W i l li a ms & Wi lk i ns .http://thepointeedition. 6 . 8 . B oi s e : Nor t hw e s t P ri n ti n g . A n O s t e o pa t hi c A p p ro a ch to Dia g no s is a nd Tr ea t me n t . 3 r d e d . D a ll e y A F.. 1 9 76 . G ra n t 's At l as o f A na t om y . 48 of 48 21/08/07 22:14 .. E. 2 00 5 . M o di f i ed wi t h p e rm i s s i on f ro m A g ur A MR . M a go u n H . 2 0 0 5. D i Gi o v an n a. 7 .com/pt/re/9780781763714/bookContent. Ba l ti mor e : L i pp i nc o t t Wil l ia ms & Wi l ki n s .lww.

or compensate for an impairment in a physiologic motion (e. Michael Lockwood.O. PA Rehabilitation Medicine.B. Lisa DeStefano. D. Robert Kappler. Chairman. Kurt Heinking. Office Phone: (707) 638-5245. D.O. copyright 1987.O.. Ward RC (ed. and/or important in describing OPP/OMT. The most current and revised version is available on the AACOM website at www. “Techniques” are those methods used within a treatment system such as lumbar rolls.. Saunders Company. D. The five models used in discussion of osteopathic patient care are the respiratory-circulatory model. DO. Principles and Practices. D. This glossary should be useful to the student of osteopathic medicine and helpful to authors and other professionals in understanding and making proper use of osteopathic vocabulary. William Devine. D. D. 27th edition. ART: articulatory treatment BLT: balanced ligamentous tension treatment CR: osteopathy in the cranial field CS: counterstrain treatment D: direct treatment DIR: direct treatment FPR: facilitated positional release treatment HVLA: high velocity/low amplitude treatment I: indirect treatment IND: indirect treatment INR: integrated neuromusculoskeletal release treatment LAS: ligamentous articular strain treatment ME: muscle energy treatment MFR: myofascial release treatment NMM-OMM: neuromusculoskeletal medicine OCF: osteopathy in the cranial field/cranial treatment OMTh: osteopathic manipulative therapy (non-US terminology) OMT: osteopathic manipulative treatment PINS: progressive inhibition of neuromuscular structures ST: soft tissue treatment VIS: visceral manipulative treatment accessory joint motions: See secondary joint motion. D. Walter Ehrenfreuchter. D.. Robert. D. 2000 W. 2000 The William & Wilkins Company. D. Revised July 2006. 1126-1140: Williams & Wilkins. PA Stedman’s Medical Dictionary. The Glossary first appeared in the Journal of the American Osteopathic Association (JAOA 80: 552-567) in April of 1981. D.. D. D. practices and philosophy.. the biomechanical-structural. It is also available on the AOA website at www. MD Foundations for Osteopathic Medicine.O. D. D. the term “osteopathic practitioner” refers to an osteopath.org in PDF format.Glossary of Osteopathic Terminology Usage Guide The Glossary of Osteopathic Terminology is revised twice each year by the Educational Council on Osteopathic Principles.O.O.g. 1 . accessory movements: Movements used to potentiate.O. D. Evan Nicholas. Ward RC (ed. 29th edition. distinctive in the osteopathic usage of a common word..O.. In the glossary.O. Baltimore..O. Chairman. please refer to the Educational Council on Osteopathic Principles Core Curriculum.O. Joel A. Sean Kerger.O.O.O. Baltimore.O. the movements needed to move a paralyzed limb)... FAAO. The glossary offers the consensus of a large segment of the osteopathic profession and serves to standardize terminology. Baltimore.edu.. John C. FAAO. rib-raising..aacom..osteopathic..O. Glover.. 1st edition. D. DO.. For a more complete description of the models and their application to patient care.. The 1995 version of the Glossary of Osteopathic Terminology was also published in the textbook. Randy Litman. Harriet Shaw. accentuate. California. Kevin Treffer. an osteopathic physician or an allopathic physician who has been trained in osteopathic principles. ed. PA Glossary of Osteopathic Terminology Prepared by the Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine (AACOM).org. David Mason. D. ed. 1229-1253: Williams & Wilkins. Heather Ferrell.O.) (2003) pp. Jan Hendryx.. Foundations for Osteopathic Medicine. Purpose: The purpose of this osteopathic glossary is to present important and often used words. Tom Fotopolis. Philadelphia.O. Forward any comments or suggestions to John Glover. Definitions are included from: Dorland’s Medical Dictionary. D.. Paul Rennie. and in Foundations for Osteopathic Medicine. D. It is not meant to replace a dictionary. FAAO. Vallejo. D. muscle energy and osteopathy in the cranial field.O. ©2006 The Educational Council on Osteopathic Principles and the American Association of Colleges of Osteopathic Medicine A abbreviations: types of osteopathic manipulative treatment.O... 1988 DeLisa. D. Lippincott... “Methods” are described as being direct. Philadelphia.. FAAO. etc. Lippincott Williams & Wilkins. terms and phrases of the osteopathic profession.) (1997) pp.O. Greg Thompson. indirect or combined.B. 2nd edition. 1310 Johnson Lane. D. E-mail: jglover@touro. D. John Jones. 2003 Ward. Department of Osteopathic Manipulative Medicine.O.. J.O. Electronic copies are available from the American Association of Colleges of Osteopathic Medicine.O. “Osteopathic manipulative treatment systems” are complete systems of diagnosis and treatment such as high velocity low amplitude (HVLA). Wolfgang Gilliar. MD. MD. The April 2006 glossary review was performed by Andrea Clem. Philadelphia.O. Ray Hruby. Touro University. D. second edition copyright 2000. FAAO. The ECOP Glossary Review Committee specifically seeks to include those definitions that are uniquely osteopathic in their origin or common usage. Kendi Pim. neurological and behavioral-biopsychosocial.. CA 94592. John Glover. metabolicnutritional. FAAO. David Essig-Beatty. Mark Sandhouse.

best measured from a standing lateral x-ray film. (motion barrier). axis of. 3. (Fig. also known as Ferguson’s angle.. Figure 4. anterior rib: See rib somatic dysfunction.Figure 1. 2. backward bending test: 1. See also osteopathic manipulative treatment. articulatory treatment (ART) system. axis. 3) anterior component: A positional descriptor used to identify the side of reference when rotation of a vertebra has occurred. 2. lumbolumbar lordotic a. acute somatic dysfunction: See somatic dysfunction. in a condition of right Figure 2. See also sacral motion. The place of union or junction between two or more bones of the skeleton. rotation. 1) lumbosacral a. lumbosacral. accommodation: A self-reversing and nonpersistent adaptation.. anterior (forward) innominate (iliac) rotation.. B backward bending: Opposite of forward bending. articular pillar: 1. usually refers to the less prominent transverse process. See also posterior component. innominate or pubic symphysis. An imaginary line about which motion occurs. ASIS (anterior superior iliac spine) compression test: 1.. active motion: See motion. of particular use when describing position or motion alteration resulting from somatic dysfunction. This test discriminates between forward and backward sacral torsion/rotation. A therapeutic system in which a disease is treated by producing a second condition that is incompatible with or antagonistic to the first. axis of sacral motion: See sacral motion. axoplasmic transport: The antegrade movement of substances from the nerve cell along the axon toward the terminals. Lumbosacral angle (S1-horizon) (Ferguson’s angle). (Stedman’s) allopath: A term used to refer those holding a Doctor of Medicine (MD) degree. anatomical barrier: See barrier. 2. best measured from a standing lateral x-ray film. One component of an axis system. ART: See TART. See also cavitation. 2. represents the angle of the lumbosacral junction as measured by the inclination of the superior surface of the first sacral vertebra to the horizontal (this is actually a sacral angle). an objective quantification of lumbar lordosis typically determined by measuring the angle between the superior surface of the second lumbar vertebra and the superior surface of the first sacral segment. inhalation rib dysfunction. anterior compression test: See ASIS (anterior superior iliac spine) compression test. active. (Fig. usually measured from standing lateral x-ray films. (Fig. 2) lumbosacral lordotic a. axis of (Fig. Figure 3. anterior nutation. anterior iliac rotation: See ilium. axoplasmic flow: See axoplasmic transport. angle: Ferguson a. Lumbosacral lordotic angle. an objective quantification of lumbar lordosis typically determined by measuring the angle between the superior surface of the second lumbar vertebra and the inferior surface of the fifth lumbar vertebra. articulatory treatment (ART) system. 2. articulation: 1. acute. articulatory technique: See also technique. and the retrograde movement from the terminals toward the nerve cell. Application of a force through the ASIS into one of the pelvic axes to assess the mechanics of the pelvis. See osteopathic manipulative treatment. This test discriminates between 2 . 4). ASIS compression test axis of rib motion: See rib motion. Those parts of the lateral arches of the cervical vertebrae that contain a superior and inferior articular facet. allopathy: 1. axis: 1. dissimilarity in corresponding parts or organs on opposite sides of the body that are normally alike. somatic dysfunction of. the left side is the anterior component. The active or passive process of moving a joint through its permitted anatomic range of motion. a non-osteopathic medical degree. Lumbolumbar angle (L2-L5). See angle. The second cervical vertebra. Refers to the columnar arrangement of the articular portions of the cervical vertebrae. See extension. See nutation. articulatory pop: The sound made when cavitation occurs in a joint. asymmetry: Absence of symmetry of position or motion. A test for lateralization of somatic dysfunction of the sacrum.

restrictive b. biomechanics: Mechanical principles applied to the study of biological functions. contraction: Shortening and/or development of tension in muscle. Baltimore. Antonyms: ease. balanced ligamentous tension. Somatic dysfunction in a single plane: three methods illustrating the “restrictive barrier” (the restrainer): AB.. physiologic barrier.. combined technique: See osteopathic manipulative treatment. William & Wilkins. Originally used by Frank Chapman. physiologic b. chronic somatic dysfunction: See somatic dysfunction. The circular movement of a limb. conditioned r. interpreted as resulting from congestion due to increased fluid content. RB. barrier (motion barrier): The limit to motion. the limit of passive motion. somatic dysfunction (From Foundations for Osteopathic Medicine. superior pubic shear. See also osteopathic manipulative treatment. in defining barriers. concentric c. restrictive b. compensatory fascial patterns: See fascial patterns. lengthening of muscle during contraction due to an external force. circumduction: 1. 5) anatomic b.unilateral sacral flexion and unilateral sacral extension. a functional limit that abnormally diminishes the normal physiologic range. 2. compliance: 1. PB. the palpatory end-feel characteristics are useful. the limit of active motion. A concentric contraction against resistance in which the angular change of joint motion is at caught in inhalation: See inhalation rib dysfunction. 2. A force that approximates two structures. body unity: One of the basic tenets of the osteopathic philosophy. cephalad: Toward the head. common compensatory pattern. the study and knowledge of biological function from an application of mechanical principles. pathologic b. DO. caliper rib motion. cervicolumbar reflex: See reflex. ligamentous articular strain.. batwing deformity: See transitional vertebrae. cerebrospinal fluid. Direction of ease in motion testing. conditioned reflex: See reflex. and described by Charles Owens.. isokinetic c. compliance. backward torsions. caught in exhalation: See exhalation rib dysfunction. complete motor asymmetry: Asymmetry of palpatory responses to all regional motion inputs including rotation. the circular movement of the shoulder). (Fig. 1. cervicolumbar r. combined method. somatic dysfunctions of. The rotary movement by which a structure is made to describe a cone. somatic dysfunctions of. 3 . cavitation: The formation of small vapor and gas bubbles within fluid caused by local reduction in pressure. common compensatory pattern: See fascial patterns. compression: 1. the range between the physiologic and anatomic barrier of motion in which passive ligamentous stretching occurs before tissue disruption. restrictive barrier. a restriction of joint motion associated with pathologic change of tissues (example: osteophytes).g. the human being is a dynamic unit of function.. the apex of the cone being a fixed point (e. 2. an audible “pop” in certain forms of OMT. Figure 5. fluctuation of: A description of the hypothesized action of cerebrospinal fluid with regard to the craniosacral mechanism.. This phenomenon is believed to produce C caliper rib motion: See rib motion.. backward torsion: See sacrum. DO. 2. contraction of muscle resulting in approximation of attachments.. See also osteopathic philosophy. A system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunction or pathology. eccentric c. SD. elastic b. Synonym: resistance. bucket handle rib motion: See rib motion. cephalad pubic dysfunction: See pubic bone. balanced ligamentous tension technique: See osteopathic manipulative treatment.. Chapman reflex: 1. resilience. Somatic dysfunction in which two structures are forced together. bucket handle. chronic. translation and active respiration. the application of mechanical laws to living structures. anatomic barrier. the limit of motion imposed by anatomic structure. caudad: Toward the tail or inferiorly. bogginess: A tissue texture abnormality characterized principally by a palpable sense of sponginess in the tissue. common compensatory pattern. The ease with which a tissue may be deformed. bind: Palpable resistance to motion of an articulation or tissue. 1997:484. See also barrier. sacralization.

craniosacral manipulation: See osteopathic manipulative treatment. Operator force equal to patient force. contracted muscle: The physiologic response to a neuromuscular excitation. CV-4: See osteopathic manipulative treatment. DO. It coordinates the synchronous motion of these two structures. 1. See also NMM-OMM. Diplomate of Osteopathy.. Diplomate in Osteopathy (The first degree granted by American School of Osteopathy). 2. Dupuytren c. cranial technique: See osteopathic manipulative treatment. Term coined by John Woods. 2. DO: 1. or from disorders of the muscle fibers. counternutation: Posterior movement of the sacral base around a transverse axis in relation to the ilia. in some cases 4 . A form of concentric contraction in which a constant force is applied. 3. craniosacral extension and flexion. core link: The connection of the spinal dura mater from the occiput at the foramen magnum to the sacrum. creep: The capacity of fascia and other tissue to lengthen when subjected to a constant tension load resulting in less resistance to a second load application. reversible. dysfunction. oblique axis.the same rate. DO. coronal plane: See plane. 6 and Fig. 9th ed. 9th ed. costal dysfunction: See rib. 1991:37).. and Rachel Woods.. which prevents the muscle from reaching normal relaxed length. frontal. (Neighboring dermatomes may overlap. Sutherland. Grant’s Atlas of Anatomy. persistent pattern. DO. 1. counterstrain. Grant’s Atlas of Anatomy. Doctor of Osteopathy (accredited by the American Osteopathic Association).) 2. cranial manipulation. contractured muscle: histological change substituting non-contractile tissue for muscle tissue. dermatome: 1. Cutis plate. Dermatomal map (anterior). shortening. cranial manipulation: See osteopathic manipulative treatment. D Dalrymple treatment: See osteopathic manipulative treatment. exhalation rib dysfunction. cranial rhythmic impulse (CRI): 1. Doctor of Osteopathic Medicine (accredited by the American Osteopathic Association). 4. A form of eccentric contraction designed to break adhesions using an operator-induced force to lengthen the muscle. diagonal. contracture: A condition of fixed high resistance to passive stretch of a muscle. osteopathy in the cranial field. The counterforce is greater than the patient force. (Modified from Agur AMR. The area of skin supplied by cutaneous branches from a single spinal nerve. osteopathy in the cranial field. isotonic c. C-SPOMM: Certification Special Proficiency in Osteopathic Manipulative Medicine. See also nutation. isolytic c. Baltimore Md: Williams & Wilkins. See also contractured muscle. decompensation: A dysfunctional. a degree granted by some schools of osteopathy outside the United States. 7) diagnostic palpation: See palpatory diagnosis. the dorsolateral part of an embryonic somite. resulting when homeostatic mechanisms are partially or totally overwhelmed depressed rib: See rib somatic dysfunction. 2. direct treatment. pedal pump. Figure 7. (Fig. producing a flexion deformity of a finger (Dorland’s). 2. A palpable. See also extension. 2. 1. resulting from fibrosis of the tissues supporting the muscles or the joints. between the occiput and the sacrum by the spinal dura mater. A term used to refer to the anatomical connection Figure 6. Operator force less than patient force. craniosacral flexion. A term coined by William G. Baltimore Md: Williams & Wilkins. 2. 1991:37). thickening and fibrosis of the palmar fascia. rhythmic fluctuation believed to be synchronous with the primary respiratory mechanism. Granted by the American Osteopathic Association through the American Osteopathic Board of Special Proficiency in Osteopathic Manipulative Medicine from 1989 through 1999. craniosacral mechanism: 1. (Modified from Agur AMR. Dermatomal map (posterior). CV-4. diagonal axis: See sacral. isometric c. counterstrain technique: See osteopathic manipulative treatment. The counterforce is less than the patient force. direct method (technique): See osteopathic manipulative treatment. See also primary respiratory mechanism.. Change in the tension of a muscle without approximation of muscle origin and insertion. 2. See also contracted muscle.

usually preceded by a designation of the vertebral unit(s) involved (e. exhalation rib dysfunction. 2. Craniosacral extension. sacral flexion. Based on the observations F FAAO: 1. See also intrinsic corrective forces. resilience. exhalation rib restriction. and sidebent (S) vertebral position. mechanical tables. flexed. rotated. also called Fryette’s regional extension. historically. motion occurring during the cranial rhythmic impulse when the sphenobasilar symphysis descends and sacral base moves anteriorly. facilitated positional release. extended. the straightening in the sagittal plane of a spinal region. position and/or motion of the facets are equal bilaterally. regional extension. Synonyms: compliance. or condition (e. facilitated segment: See spinal facilitation. ERS left. Inflammation of the muscular or tendinous attachment to bone (Dorland’s). exaggeration technique. exaggeration technique: See osteopathic manipulative treatment. facet. facet asymmetry: Configuration in which the structure. This fellowship is an earned post-doctoral degree conferred by the American Academy of Osteopathy. Antonyms: bind. ERS: A descriptor of spinal somatic dysfunction used to denote a combination extended (E). somatic dysfunction in which the vertebral unit is extended. it is the straightening of a curve or angle (biomechanics). usually preceded by a designation of the vertebral unit(s) involved (e. rotated (R). inhalation rib dysfunction. effleurage: Stroking movement used to move fluids. Fellow of American Academy of Osteopathy. exhalation rib dysfunction. C3-5 ERS right or C3-5 ERRSR). Figure 10. facilitation: See spinal facilitation. (Fig.drag: See skin drag. See also rib motion. Systems for classifying and recording the preferred directions of fascial motion throughout the body. facet symmetry: Configuration in which the structure.g. E ease: Relative palpable freedom of motion of an articulation or tissue. (Fig. craniosacral extension. exhalation rib dysfunction. end feel: Perceived quality of motion as an anatomic or physiologic restrictive barrier is approached.. 2. Traumatic disease occurring at the insertion of muscles where recurring concentration of muscle stress provokes inflammation with a strong tendency toward fibrosis and calcification (Stedman’s). somatic dysfunction in which the vertebral unit is extended. exhaled rib: (Archaic) using positional (static) diagnosis. in a vertebral unit when the superior part moves backward. and professional service. See also facet asymmetry and symmetry.g. elastic deformation: Any recoverable deformation. elevated rib: See rib somatic dysfunction. Separation of the ends of a curve in a spinal region. See also facet symmetry and tropism. exhalation strain: See rib somatic dysfunction. rotated and sidebent left. etc. Sacral extension. position and/or motion of the facets are not equal bilaterally. definition number 2.g. posterior movement of the base of the sacrum in relation to the ilia. their commitment to osteopathic principles and practice through teaching. regional extension. 2. 3. facilitated positional release: See osteopathic manipulative treatment. T5 ERS left or T5 ERLSL). writing. exhalation rib restriction: See rib motion. Regional extension. exhalation rib restriction. fascial patterns: 1. ERS right. easy normal: See neutral. 10) See also flexion. 2. inhalation rib dysfunction. In extremities. rotated and sidebent right. See also plastic deformation. Those who earn the FAAO degree must have demonstrated 5 . exaggeration method: See osteopathic manipulative treatment. (Fig. extrinsic corrective forces: Treatment forces external to the patient that may include operator effort. effect of gravity. -ed: A suffix describing status. extension: 1. Figure 8. See also plasticity and viscosity.. performed at the highest level of professional and ethical standards. See extension. enthesitis: 1. See also rib somatic dysfunction. 9) sacral extension. Accepted universal term for backward motion of the spine in a sagittal plane about a transverse axis. See rib somatic dysfunction. exhalation rib dysfunction: See rib somatic dysfunction. position. exaggeration method. 8) Figure 9. resistance.. restricted). elasticity: Ability of a strained body or tissue to recover its original shape after deformation.

See flexion. Figure 13. Figure 11. (Fig. 13) regional flexion. Neidner. common compensatory pattern (CCP). motion occurring during the cranial rhythmic impulse. and sidebent (S) vertebral position. frontal plane: See plane. myofascial release. FRS left. standing flexion test. when the sphenobasilar symphysis ascends and the sacral base moves posteriorly. fascial unwinding. usually preceded by a designation of the vertebral unit(s) involved (e. Ferguson angle: See angle.of J. a screening test that determines the side of sacroiliac somatic dysfunction (motion of the sacrum on the ilium). Sacral flexion. 3. See flexion. Reciprocal of backward bending. is the approximation of the ends of a curve in the sagittal plane of the spine. forward torsions. historically. anterior movement of sacral base in relation to the ilia. Craniosacral flexion. T5 FRS left or T5 FRLSL). fascial unwinding: See osteopathic manipulative treatment. 6 . sacral flexion. usually preceded by a designation of the vertebral unit(s) involved (e. in its Figure 15. the finding of alternating fascial motion preference in the direction opposite that of the common compensatory pattern described by Zink and Neidner. forward torsions: See sacrum. rotated and sidebent left. a screening test that determines the side of iliosacral somatic dysfunction (motion of ilium on the sacrum). 12) Figure 14. f lexion right: See sidebending. 15) See also extension.. and W. DO. the specific finding of alternating fascial motion preference at transitional regions of the body described by Zink and Neidner. flexion tests: Tests for iliosacral or sacroiliac somatic dysfunction. (See flexion (Fig. Approximation of the ends of a curve in a spinal region. (Fig. rotated (R). C3-5 FRS right or C3-5 FRRSR). rotated and sidebent right. somatic dysfunction in which the vertebral unit is flexed. Fryette’s. also called Fryette’s regional flexion. the finding of fascial preferences that do not demonstrate alternating patterns of findings at transitional regions. also called Fryette’s regional flexion. Accepted universal term for forward motion of the spine. Fryette laws: See laws. Figure 12. fascial release technique: See osteopathic manipulative treatment. somatic dysfunctions of. they tend to be symptomatic. forward bending. Fryette principles: See physiologic motion of the spine. craniosacral flexion. Gordon Zink. Fryette regional extension: See extension. seated flexion test. (Fig. DO. regional flexion. regional flexion. In the extremities. lumbosacral. where the superior part moves forward. 14). it is the approximation of a curve or angle (biomechanics). (Fig.g. frontal. 11) flexion: 1. Regional flexion. Fryette regional flexion: See flexion. sacral extension. sagittal plane about a transverse axis. Common compensatory fascial pattern (Zink) uncommon compensatory pattern. 2. FRS: A descriptor of spinal somatic dysfunction used to denote a combination flexed (F).. Uncommon compensatory fascial pattern (Zink). Because they occur following stress or trauma. flexion left: See sidebending. See physiologic motion of the spine. FRS right. uncompensated fascial pattern. regional extension.g. somatic dysfunction in which the vertebral unit is flexed.

See also hip bone. (Foundations. a somatic dysfunction in which the anterior superior iliac spine (ASIS) and posterior superior iliac spines (PSIS) are inferior to the contralateral landmarks. inferior lateral angle. Hoover technique: See osteopathic manipulative treatment. the cup shaped cavity for the head of the femur at the hip (femoroacetabular) joint. inferior pubic shear. See ilium. See FRS. inhalation strain: See rib somatic dysfunction. Second Edition. inferior transverse axis: See sacral motion axis. a term that describes the application of steady pressure to soft tissues to effect relaxation and normalize reflex activity. A condition of excessive tone of the skeletal muscles. ilial compression test: See ASIS compression test. and is restricted from movement in a posterior and superior direction. hysteresis: During the loading and unloading of connective tissue. passes across the lateral condyle of the knee. spiritual and environmental well-being. inferior pubis: See pubic bone. innominate. somatic dysfunctions of. (Fig. Gravitational 7 . inferior lateral angle of. indirect method: See osteopathic manipulative treatment. See also midmalleolar line. inhalation rib restriction: See rib somatic dysfunction. hepatic pump. This difference in viscoelastic behavior (and energy loss) is known as hysteresis (or “stress-strain”). Increased resistance of muscle to passive stretching. mental.FSR: A descriptor of spinal somatic dysfunction used to denote a combination flexed (F). inhalation rib dysfunction. hatchet head: See scaphocephaly. emotional. gravitational line: Viewing the patient from the side. a somatic dysfunction in which the anterior superior iliac spine (ASIS) is anterior and inferior to the contralateral landmark. 2. Also called the innominate bone or pelvic bone. See inferior innominate shear. (DeLisa) Galbreath treatment: See osteopathic manipulative treatment. the restoration of the final length of the tissue occurs at a rate and to an extent less than during deformation (loading). ilial rocking test: See ASIS compression test. health: Adaptive and optimal attainment of physical. inferior innominate shear. 16) I ILA: See sacrum. Hoover technique. guiding: Gentle movement by the operator following the path of least resistance in the movement of a body part within its normal range. Effect on antagonist muscles due to reciprocal inhibition when the agonist is stimulated. sidebent (S). functional method: See osteopathic manipulative treatment. hip bone: See innominate. ilium: the expansive superior portion of the innominate (hip bone or os coxae). an imaginary line in a coronal plane which. Figure 16. inhibitory pressure technique. it would intersect the middle of the third lumbar vertebra and the anterior one third of the sacrum. G gait: a forward translation of the body's center of gravity by bipedal locomotion. inferior ilium: See innominate. page 1158). inhalation rib dysfunction. The innominate (os coxa) H habituation: Decreased physiologic response to repeated stimulation. homeostasis: 1. if this were a plane through the body. See also law. These differences represent energy loss in the connective tissue system. The level of wellbeing of an individual maintained by internal physiologic harmony that is the result of a relatively stable state or equilibrium among the interdependent body functions. somatic dysfunctions of. in the theoretical ideal posture. inhibitory pressure technique. homeostatic mechanism: A system of control activated by negative feedback (Dorland’s). The innominate (os coxae) moves more freely in an anterior and inferior direction. inferior transverse axis. 17) downslipped innominate. innominate: The os coxae is a large irregular shaped bone that consists of three parts: ilium. inhibition reflex: 1. Maintenance of static or constant conditions in the internal environment. inhibitory pressure technique: See osteopathic manipulative treatment. (Fig. inhalation rib: See rib somatic dysfunction. high velocity/low amplitude technique (HVLA). and rotated (R) vertebral position. In osteopathic usage. See also osteopathic manipulative treatment. inferior lateral angle (ILA) of the sacrum: See sacrum. innominate rotation: Rotational motion of one innominate bone relative to the sacrum on the inferior transverse axis. inhalation rib dysfunction. See also innominate. functional technique: See osteopathic manipulative treatment. somatic dysfunctions of: anterior innominate rotation. functional method. indirect method. inferior innominate shear. mandibular drainage. ilia: The plural of ilium. iliosacral motion: Motion of one innominate (ilium) with respect to the sacrum. Iliosacral motion is part of pelvic motion during the gait cycle. 2. hypertonicity: 1. which meet at the acetabulum. somatic dysfunctions of. through the lateral head of the humerus at the tip of the shoulder to the external auditory meatus. high velocity/low amplitude technique (HVLA): See osteopathic manipulative treatment. ischium and pubis. hepatic pump: See osteopathic manipulative treatment. functional method. 2. the greater trochanter. Sherrington’s. starts slightly anterior to the lateral malleolus. It is used to evaluate the A-P (anterior-posterior) curves of the spine.

18) inflared innominate. Right posterior innominate. counterstrain. (Fig. integrated neuromusculoskeletal release: See osteopathic manipulative treatment. innominate (os coxae) moves more freely in a posterior and superior direction.. 19) outflared innominate. 22) upslipped innominate. isokinetic exercise: Exercise using a constant speed of movement of the body part. and is restricted from movement in a superior direction. isolytic contraction: See contraction. J Jones technique: See osteopathic manipulative treatment. a somatic dysfunction of the innominate (os coxae) resulting in medial positioning of the anterior superior iliac spine (ASIS). a somatic dysfunction in which the anterior superior iliac spine (ASIS) and posterior superior iliac spines (PSIS) are superior to the contralateral landmarks. Forced anterior rotation can also result in an inferior pubic shear. isometric contraction: See contraction.g. moves more freely in an inferior direction. isotonic c. Forced posterior rotation may or may not result in a superior pubic shear. (Fig. Figure 21. and is restricted from movement in an inferior direction. Right superior innominate shear. (Fig. flexion. The Figure 22. and is restricted from movement in a medial direction. (Fig. isometric c. The innominate moves more freely in a medial direction. rotation. Figure 18. See superior innominate shear. extension. a somatic dysfunction in which the anterior superior iliac spine (ASIS) is posterior and superior to the contralateral landmarks. This also may or may not result in an inferior pubic shear. Inflared right innominate. isolytic c. The innominate moves more freely in a lateral direction. Right inferior innominate shear. Figure 20. 8 . Outflare right innominate. intersegmental motion: Designates relative motion taking place between two adjacent vertebral segments or within a vertebral unit that is described as the upper vertebral segment moving on the lower. 21) superior innominate shear. a somatic dysfunction of the innominate (os coxae) resulting in lateral positioning of the anterior superior iliac spine (ASIS). (Fig. See also extrinsic corrective forces. This also may or may not result in a superior pubic shear. Anterior right innominate. and is restricted from movement in a lateral direction. isotonic contraction: See contraction. intrinsic corrective forces: Voluntary or involuntary forces from within the patient that assist in the manipulative treatment process. -ion: A suffix describing a process or movement (e. and is restricted from movement in an anterior and inferior direction. restriction). 20) posterior innominate rotation. integrated neuromusculoskeletal release.Figure 19. Figure 17. The innominate (os coxa) moves more freely in a superior direction.

The exaggerated (pathologic) A-P curve of the thoracic spine with concavity anteriorly.. ligamentous: l. See osteopathic manipulative treatment. lumbosacral spring test: See spring test. law: Fryette l. See osteopathic manipulative treatment. lesioned components: See osteopathic lesion. are perceived. Every posterior spinal nerve root supplies a specific region of the skin. linkage. See also scoliosis. l. 2. liver pump: See osteopathic manipulative treatment. K key lesion: The somatic dysfunction that maintains a total dysfunction pattern including other secondary dysfunctions. such as those responding to touch and muscular contractions. and kneading of the body. klapping: Striking the skin with cupped palms to produce vibrations with the intention of loosening material in the lumen of hollow tubes or sacs within the body. lordotic: Pertaining to or characterized by lordosis. these are the ones most relevant to osteopathic principles. lymphatic pump. weight. lumbolumbar lordotic angle: See angle. In manipulative technique. and secondary alterations in its external conformations (Stedman’s. hepatic pump. mandibular drainage technique.. See sidebending.) Wolff l. anteroposterior curvature of the spine. In this case. an impulse to relax. any somatic dysfunction resulting in abnormal ligamentous tension or strain. See also technique. soma). For example. Abnormally increased convexity in the curvature of the thoracic spine as viewed from the side (Dorland’s). 1. which has been used by non-physician practitioners (e. lymphatic pump. the pain is felt at the point of higher sensitivity rather than at the point where the stimulus was applied. particularly the lungs. muscles and other soft tissues as an integral part of complete medical care. Sherrington l. This term is not identical to manual therapy.. See strain and ligamentous articular strain. 2. lateral flexion: Also called lateroflexion. L5 also moves into a right posterior position. See also osteopathic manipulative treatment. 2. including bones. (e. 25th ed. lateroflexion: See sidebending. ligamentous articular strain technique. See somatic dysfunction. pedal pump. lumbosacral lordotic angle: See angle. kyphosis: 1. (These are only two of Sherrington’s contributions to neurophysiology. longitudinal axis. The cervical and superior thoracic biomechanics act in a synchronous manner with the lumbar 9 . kyphotic: Pertaining to or characterized by kyphosis. The anterior convexity in the curvature of the lumbar and cervical spine as viewed from the side. physical therapists). See physiologic motion of the spine. manual medicine: The skillful use of the hands to diagnose and treat structural and functional abnormalities in various tissues and organs throughout the body.g. See also osteopathic manipulative treatment. although fibers from adjacent spinal segments may invade such a region.junctional region: See transitional region. See also osteopathic manipulative treatment. bone is laid down along lines of stress). saddle back. The reference of a sensation to a particular locality in the body. This term originated from the German Manuelle Medizin (manual medicine) and has been used interchangeably with the term manipulation.. an abnormal extension deformity. See also osteopathic manipulative treatment. See also kyphosis. soft tissue treatment. L5 is the " Lovett partner" of C1. kneading: A soft tissue technique that utilizes an intermittent force applied perpendicular to the long axis of the muscle. lumbosacral.. See also osteopathic manipulative treatment. kinesthetic: Pertaining to kinesthesia.). lateral masses (of the atlas): The most bulky and solid parts of the atlas that support the weight of the head. l. 2. 1.. line of gravity: See gravitational line. articular strain. kinesthesia: The sense by which muscular motion. simultaneously. ligament. The term is used to refer to abnormally increased curvature (hollow back. kinetics: The body of knowledge that deals with the effects of forces that produce or modify body motion. States that there is an association between the superior and inferior vertebrae. See also osteopathic manipulative treatment. longitudinal axis: See sacral. position.g. sway back) and to the normal curvature (normal lordosis). motion and/or positional asymmetry associated with elastic deformation of connective tissue (fascia. Head l. or in its function alone. which are paired two by two.. viscus) that is in close central connection with a point of higher sensitivity (e. kyphoscoliosis: A spinal curve pattern combining kyphosis and scoliosis. (Dorland’s). (Dorland’s). thoracic pump. lumbarization: See transitional vertebrae. lumbarization. (French usage). 2.g. manipulation: Therapeutic application of manual force. lumbolumbar lordotic. when a painful stimulus is applied to a body part of low sensitivity (e. strain. M mandibular drainage technique: See osteopathic manipulative treatment. and inferior thoracic biomechanics. etc. linkage: See somatic dysfunction. The treatment of L5 helps to stabilize C1 and the skull by changing the lines of gravity. lymphatic treatment: Techniques used to optimize function of the lymphatic system. L lateral flexed vertebral body: See sidebent.g. lumbosacral angle: See angle. if C1 is in a right posterior positional lesion. of motion. pedal pump. Hollow back or saddle back. localization: 1. Lovett l. lesion (osteopathic): See osteopathic lesion. its antagonist receives. massage: Therapeutic friction. When a muscle receives a nerve impulse to contract. stroking. ligamentous articular strain technique. lymphatic pumps: See osteopathic manipulative treatment. thoracic pump. every change in form and function of a bone.. is followed by certain definite changes in its internal architecture. joints. generally lumbar with the convexity looking anteriorly (Stedman’s). See also osteopathic manipulative treatment. mechanoreceptor: A receptor excited by mechanical pressures or distortions. the precise positioning of the patient and vector application of forces required to produce a desired result. lordosis: 1. sacral motion axis. articular strain technique. lumbosacral lordotic. membrane).

changes in position of body structures within the normal range. the goal of the structural model is biomechanical adjustment and the mobilization of joints. See also gravitational line. counterstrain. spontaneous motion of every cell. the goal of the neurologic model is to attain autonomic balance and address neural reflex activity. See also functional methods. m. ligamentous articular strain. course and velocity. the segments above and below resist rotation left. That part of the somite that develops into skeletal muscle (Stedman’s). mesenteric release technique: See osteopathic manipulative treatment. myofascial release and lymphatic pump techniques. See also physiologic motion of the spine. membranous balance: The ideal physiologic state of harmonious equilibrium in the tension of the dura mater of the brain and spinal cord. as well as in the bony and soft tissues to remove restrictive forces and enhance motion. the final position of treatment at which tenderness is no longer elicited by palpation of the tender point. The osteopathic considerations in this area are not manipulative in nature except for the use of lymphatic pump techniques. Nutritional counseling. mobile point: In counterstrain. Tonic contraction of muscle dependent on some property of the muscle itself or of its intrinsic nerve cells. above and below the primary locus. Diaphragms are considered to be “transverse restrictors” of motion. See also physiologic motion of the spine. if the primary locus resists rotation right. 2. For example.. See barrier (motion barrier). myofascial trigger point: See trigger point. mobile segments) have coordinated and specific motion characteristics. The techniques used in this model are osteopathy in the cranial field. the goal of the metabolic model is to enhance the selfregulatory and self-healing mechanisms. N neurotrophicity: See neurotrophy. mirror-image motion asymmetries: A grouping of primary and secondary sites of somatic dysfunction describing a three-segment complex fundamental to dysfunction in a mobile system.. and to enhance immune system function. mesenteric release technique. neurologic model. myotome: 1. passive m. mobile segment: A term in functional methods to describe a bony structure with its articular surfaces and adnexal tissues (neuromuscular and connective) for segmental motion which affects movement. (Fig. demonstrates opposing asymmetries to that locus. to foster energy conservation by balancing the body’s energy expenditure and exchange. myogenic tonus: 1. mesenteric release technique. mobile system: An osteopathic construct associated with functional methods in which the body as a whole is viewed as a centrally integrated system in which all of the individual elements (e. psychological and social components of the health spectrum. decrease afferent nerve signals and relieve pain. myofascial release technique: See osteopathic manipulative treatment. myofascial technique. neurotrophy: The nutrition and maintenance of tissues as regulated by direct innervation. 2. passing equidistant between the heels. organ. system and their component units within the body. inherent m. mobile unit: See mobile segment.g. barrier. behavioral model. remove facilitated segments. the goal of the respiratory-circulatory model is to improve all of the diaphragm restrictions in the body. This is accomplished by the use of a wide range of osteopathic manipulative techniques such as high velocity-low amplitude. muscle energy. 2.. All muscles derived from one somite and innervated by one segmental spinal nerve. Each adjacent segment. mid-gravitational line: See gravitational line. Contraction of a muscle caused by intrinsic properties of the muscle or by its intrinsic innervation (Stedman’s). the goal of this model is to improve the biological. mid-malleolar line: A vertical line passing through the lateral malleolus. middle transverse axis: See sacral motion axis.. See also translation. muscle energy technique: See osteopathic manipulative treatment. myofascial release. This model also seeks to address problems in the myofascial connective tissues. used as a point of reference in standing lateral x-rays and postural evaluation. Reproductive processes and behavioral adaption are also included under this model.membranous articular strain: Any cranial somatic dysfunction resulting in abnormal dural membrane tensions. motion induced by the osteopathic practitioner while the patient remains passive or relaxed. myofascial release. diet and exercise advice are the most common approaches to balancing the body through this model. mid-heel line: A vertical line used as a reference in standing anteroposterior (A-P) x-rays and postural evaluation. The range of sagittal plane spinal positioning in which the first principle of physiologic motion of the spine applies. ligamentous articular techniques and functional techniques. This includes emotional balancing and compensatory mechanisms.. models of osteopathic care: Five models that articulate how an osteopathic practitioner seeks to influence a patient’s physiological processes. venous and lymphatic drainage and cerebrospinal fluid. The point of balance of an articular surface from which all the motions physiologic to that articulation may take place. mesenteric lift: See osteopathic manipulative treatment. structural model. middle transverse axis (postural). translatory m. respiratory-circulatory model. The osteopathic manipulative techniques used to influence this area of patient health include counterstrain and Chapman reflex points. 23) NMM-OMM: Osteopathic neuromusculoskeletal medicine certification is granted by the American Osteopathic Association through the American Osteopathic Board of Neuromusculoskeletal Medicine. neutral: 1. and/or translation) with respect to a fixed system. myofascial technique: See osteopathic manipulative treatment. An act or process of a body changing position in terms of direction. metabolic model. motion: 1. A change of position (rotation. endocrine function and organ function. stabilizes position and allows coordinated participation in passive movement. physiologic m. 2. motion of a body part along an axis. non-neutral: The range of sagittal plane spinal positioning in which the second principle of physiologic motion of the 10 . First granted in 1999. active m. muscle energy. movement produced voluntarily by the patient.

1. combined method. balanced ligamentous tension (BLT). See somatic dysfunction. disease. spontaneous release by position. an osteopathic treatment strategy by which the restrictive barrier is engaged and a final activating force is applied to correct somatic dysfunction. osteopathic lesion (osteopathic lesion complex): Archaic term used to describe somatic dysfunction. os coxae: See innominate. The ligaments provide proprioceptive information that guides the muscle response for positioning the joint and the ligaments themselves guide the motion of the articular components. See osteopathy in the cranial field. Osteopathic Manipulative Therapy (OMTh): the therapeutic application of manually guided forces by an osteopath (non-physician) to improve physiological function and homeostasis that has been altered by somatic dysfunction. NSR: A descriptor of spinal somatic dysfunction used to denote a combination neutral (N). an osteopathic treatment strategy by which the dysfunctional component is carried away from the restrictive barrier and beyond the range of voluntary motion to a point of palpably increased tension. 3. See also osteopathic philosophy. First described in “Osteopathic Technique of William G. The activating force is either a repetitive springing motion or repetitive concentric movement of the joint through the restrictive barrier. 1. (Foundations) 2. DO. See also flexion. similar descriptors may involve flexed (F) and extended (E) position. normalization: The therapeutic use of anatomic and physiologic mechanisms to facilitate the body’s response toward homeostasis and improved health. and rotated (R) vertebral position. 2. morbid state. OMT: See osteopathic manipulative treatment. (archaic). a low velocity/moderate to high amplitude technique where a joint is carried through its full motion with the therapeutic goal of increased range of movement. Australian and French use: Jones technique. articulatory treatment system.S. Osteopathic Manipulative Treatment (OMT): The therapeutic application of manually guided forces by an osteopathic physician (US Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction. (archaic). See osteopathic manipulative treatment. pedal pump. as the technique is completed the movements change to direct forces. cranial treatment (CR). counterstrain (CS). CV-4. A treatment strategy where the initial movements are indirect. schools. OMT employs a variety of techniques including: active method. an indirect procedure that involves carrying the dysfunctional part away from the restrictive barrier. Dalrymple treatment. articulatory treatment system (ART). See osteopathic manipulative treatment.standards for osteopaths practicing within their countries (International usage). Chapman reflex. Neutral spinal position. 1. 3. OMM: See osteopathic manipulative medicine. exaggeration method. See also ligamentous articular strain. (correction spontaneous by position). a cranial technique in which the lateral angles of the occipital squama are manually approximated slightly exaggerating the posterior convexity of the occiput and taking the cranium into sustained extension. direct method (D/DIR).. inappropriate strain reflex. then applying a high velocity/low amplitude force in the same direction.g. compression of the fourth ventricle. nutation: Nodding forward. OMTh: See osteopathic manipulative therapy. See osteopathic manipulative treatment. A system of diagnosis and treatment that considers the dysfunction to be a continuing. 1. facilitated oscillatory release technique (FOR). See osteopathic manipulative treatment. 2. A person who has achieved the nationally recognized academic and professional standards within her or his country to independently practice diagnosis and treatment based upon the principles of osteopathic philosophy. OP&P: Osteopathic principles and practice. combined treatment. Spencer technique combined with muscle energy technique). -osis: word element [GR]. ONM: See NMM-OMM. Abbreviation for compression of the fourth ventricle. osteopath: 1. Developed by Lawrence Jones. 2. oblique (diagonal). spine applies. See Chapman reflex. compression of the fourth ventricle (CV-4). all the joints in the body are balanced ligamentous articular mechanisms. Considered by the American Osteopathic Association to be an archaic term when applied to graduates of U. According to Sutherland’s model. See also extension. A manipulative sequence involving two or more different osteopathic manipulative treatment systems (e. which is inhibited by applying a position of mild strain in the direction exactly opposite to that of the reflex. combined method. A concept described by Paul Kimberly. structural diagnosis and use of OMT in the diagnosis and management of the patient. See also physiologic motion of the spine. A technique intended to normalize neuromuscular function by applying a manual oscillatory force. anterior movement of the sacral base around a transverse axis in relation to the ilia. See primary respiratory mechanism. Osteopathic Manipulative Medicine (OMM): The application of osteopathic philosophy. DO. technique in which the person voluntarily performs an osteopathic practitioner-directed motion. abnormal increase. O oblique axis: See sacral motion axis. this is accomplished by specific directed positioning about the point of tenderness to achieve the desired therapeutic response. Sutherland”. exaggeration technique. Individual countries establish the national academic and professional 11 . articulatory treatment. that was published in the 1949 Year Book of Academy of Applied Osteopathy. sidebent (S). which may be combined with any other ligamentous Figure 23.

DO. soft tissue manipulative technique using passively induced jaw motion to effect increased drainage of middle ear structures via the eustachian tube and lymphatics. any technique directed at the muscles and fascia. a direct segmental technique in which a combination of leverage. muscle energy. a system of diagnosis and treatment first described by Andrew Taylor Still and his early students. Sr. indirect method (I/IND). Mitchell. the application of steady pressure to soft tissues to reduce reflex activity and produce relaxation. 3. mandibular drainage. A refinement of a long-standing use of oscillatory force in osteopathic diagnosis and treatment as published in early osteopathic literature. 1. 2. DO. A technique developed by Zachary Comeaux. the dysfunctional tissues are guided along the path of least resistance until free movement is achieved. 1. This was the name originally given to the thoracic pump technique before the more extensive physiologic effects of the technique were recognized. originally called muscle energy treatment. 3. An osteopathic technique employing a rapid. Jones technique. counterstrain. A system of diagnosis and treatment in which the osteopathic practitioner 12 . technique in which tension is taken off the attachment of the root of the mesentery to the posterior body wall. May be combined with springing or thrust technique. indirect MFR. a manual technique involving constant feedback to the osteopathic practitioner who is passively moving a portion of the patient’s body in response to the sensation of movement. mandibular drainage technique. DO. high velocity/low amplitude technique (HVLA). A term used to describe the impact of intrathoracic pressure changes on lymphatic flow. myofascial release (MFR). an indirect treatment approach that involves finding the dynamic balance point and one of the following: applying an indirect guiding force. A form of functional method. Hoover. DO. the abdominal contents are compressed to enhance venous and lymphatic drainage from the bowel. Title of reference work by Conrad Speece. diminishing tissue and joint tension in all planes. The component region of the body is placed into a neutral position. Galbreath treatment. myofascial release. See hepatic pump lymphatic pump. Developed by H. myotension. myofascial technique. fascial unwinding. DO. hepatic pump. rhythmic compression applied over the liver for purposes of increasing blood flow through the liver and enhancing bile and lymphatic drainage from the liver. 1. patient ventilatory movements and a fulcrum are used to achieve mobilization of the dysfunctional segment. 2. or mobilize joints. An osteopathic manipulative technique developed by Robert Fulford. strengthen or stretch muscles.or myofascial technique. based on techniques in which the patient refrains from voluntary muscle contraction. positional technique. and William Thomas Crow. DO. A term coined by C. DO. functional method. 2. also called the pedal fascial pump or Dalrymple treatment. and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. 3. The osteopathic practitioner guides the dysfunctional part so as to create a decreasing sense of tissue resistance (increased compliance). inhibitory pressure technique. which engages continual palpatory feedback to achieve release of myofascial tissues. Earl Miller. and an activating force (compression or torsion) is added. 1. therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint. functional technique. a venous and lymphatic drainage technique applied through the lower extremities. integrated neuromusculoskeletal release (INR). 1. A system of diagnosis and treatment by an osteopathic practitioner using the primary respiratory mechanism and balanced membranous tension. 2. soft tissue technique. a system of indirect myofascial release treatment. Osteopathy in the Cranial Field (OCF). Also known as thrust technique. 2. Refers to the system of diagnosis and treatment first described by William G. ligamentous articular strain technique (LAS). Sr. 2. See also primary respiratory mechanism. See osteopathic manipulative treatment. A technique developed by Stanley Schiowitz. Sutherland. See also osteopathic manipulative treatment. Its forces are localized using the sensations of ease and bind over wider regions. DO. See also osteopathic manipulative treatment. This directed patient action is from a precisely controlled position against a defined resistance by the osteopathic practitioner. holding the position or adding compression to exaggerate position and allow for spontaneous readjustment. Title of reference work by Harold Magoun. Hoover technique. DO. 1. Refers to a concept first used by Fred L. direct MFR. A manipulative technique involving the specific application of mechanical vibratory force to treat somatic dysfunction. A system of diagnosis and treatment in which the patient voluntarily moves the body as specifically directed by the osteopathic practitioner. 2. A set of myofascial release techniques described by Howard Lippincott. passive method. and Rebecca Lippincott. See osteopathic manipulative treatment. See also osteopathic manipulative treatment. a myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with a constant force until tissue release occurs.V. Both direct and indirect methods are used interactively. 2. pedal pump. a system of diagnosis and treatment that uses muscular contractions and relaxations under resistance of the osteopathic practitioner to relax. DO. myofascial release. See osteopathic manipulative treatment. The osteopathic practitioner guides the manipulative procedure while the dysfunctional area is being palpated in order to obtain a continuous feedback of the physiologic response to induced motion. progressive inhibition of neuromuscular structures (PINS). DO. a treatment system in which combined procedures are designed to stretch and reflexly release patterned soft tissue and joint-related restrictions. liver pump. Simultaneously. fascial release treatment. facilitated positional release (FPR). a manipulative technique where the restrictive barrier is disengaged and the dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in one or all planes and directions. mesenteric release technique (mesenteric lift). DO. percussion vibrator technique. A manipulative technique in which the goal of treatment is to balance the tension in opposing ligaments where there is abnormal tension present. 1.

a series of direct manipulative procedures to prevent or decrease soft tissue restrictions about the shoulder. ventral techniques. lymphatic pump. practices and philosophy. Developed by Dennis Dowling. linear stretching. counterstrain. Also called ventral techniques. An osteopathic system of diagnosis and indirect treatment in which the patient’s somatic dysfunction. Typically. Earl Miller. osteopathic structural examination: The examination of a patient by an osteopathic practitioner with emphasis on the neuromusculoskeletal system including palpatory diagnosis for somatic dysfunction and viscerosomatic change within the context of total patient care. Still. and is performed with the patient in multiple positions to provide static and dynamic evaluation. passive motion. passive method: See osteopathic manipulative treatment. 3. articulatory treatment (ART) splenic pump technique. is treated by using a passive position. Osteopathic philosophy emphasizes the following principles: 1. See osteopathic manipulative treatment. (AOA House of Delegates) osteopathic philosophy: a concept of health care supported by expanding scientific knowledge that embraces the concept of the unity of the living organism’s structure (anatomy) and function (physiology). a low velocity/ moderate amplitude technique where the restrictive barrier is engaged repeatedly to produce an increased freedom of motion. See also osteopathic manipulative treatment (OMT). 2. Characterized as a specific non-repetitive articulatory method that is indirect then direct. springing technique. a direct technique that usually involves lateral stretching. an osteopathic physician or an allopathic physician who has been trained in osteopathic principles. pedal pump: See osteopathic manipulative treatment. osteopathy (osteopathic medicine): A complete system of medical care with a philosophy that combines the needs of the patient with current practice of medicine. to selectively determine the condition of the parts beneath. osteopathic musculoskeletal evaluation: The osteopathic musculoskeletal evaluation provides information regarding the health of the patient. 2. self-regulation and structure-function interrelationships. using varying amounts of pressure. active or passive movement of a body part to its physiologic or anatomic limit in any or all planes of motion. pelvic bone: See hip bone. osteopathic practitioner: Refers to an osteopath. Rational treatment is based on these principles. See osteopathic treatments. Spencer technique. soft tissue (ST). visceral manipulation. deep pressure. Utilizing the concepts of body unity. Strain-Counterstrain®. 1. Developed by C. Also called myofascial treatment. P palpation: The application of the fingers to the surface of the skin or other tissues. The body possesses self-regulatory mechanisms that are self-healing in nature. See osteopathic manipulative treatment. a system of diagnosis and treatment directed to the viscera to improve physiologic function. a procedure of high or low amplitude in which the parts are stretched or separated along a longitudinal axis with continuous or intermittent force. DO. 2. resulting in spontaneous tissue release and at least 70 percent decrease in tenderness. traction and/or separation of muscle origin and insertion while monitoring tissue response and motion changes by palpation. The examination is concerned with finding somatic dysfunction in all parts of the body. patient cooperation: Voluntary movement by the patient (on instruction from the osteopathic practitioner) to assist in the palpatory diagnosis and treatment process. Emphasizes the interrelationship between structure and function. The human being is a dynamic unit of function. spontaneous release by positioning. technique using forces transmitted across the diameter of the skull to accomplish sutural gapping. 4. short lever technique using compression and shearing forces. the viscera are moved toward their fascial attachments to a point of fascial balance. See also osteopathic manipulative treatment. visceral manipulation (VIS). passive motion: See motion. rhythmic compression applied over the spleen for the purpose of enhancing the patient’s immune response. passive method. palpatory diagnosis: A term used by osteopathic practitioners to denote the process of palpating the patient to evaluate the structure and function of the neuromusculoskeletal and visceral systems. articulatory treatment system. See osteopathic manipulative treatment. high velocity/low amplitude technique (HVLA). counterstrain. osteopathic postural examination: The part of the osteopathic musculoskeletal examination that focuses on the static and dynamic responses of the body to gravity while in the erect position. v-spread. 3. thoracic pump. surgery and obstetrics. in 1955. 1. Individual countries establish the national academic and professional standards for osteopathic physicians practicing within their countries.T. pedal pump. A technique that consists of intermittent compression of the thoracic cage. pelvic index (PI): Represents a ratio of the measurements determined from postural radiograph: One (y) beginning from a vertical line originating at the sacral promontory to the intersection with the horizontal line from the anterior-superior position of the pubic bone. PhD.locates two related points and sequentially applies inhibitory pressure along a series of related points. soft tissue technique. A term coined by Richard Van Buskirk. Still Technique. DO. pelvic declination (pelvic unleveling): Pelvic rotation about an anteriorposterior (A-P) axis. the osteopathic physician uses data from the musculoskeletal evaluation to assess the patient’s status and develop a treatment plan. toggle technique. See also osteopathic manipulative treatment (OMT). osteopathic physician: a person with full unlimited medical practice rights who has achieved the nationally recognized academic and professional standards within his or her country to practice diagnosis and treatment based upon the principles of osteopathic philosophy. DO. 2. and has an appreciation of the body’s ability to heal itself. DO thrust technique (HVLA). 2). diagnosed by (an) associated myofascial tenderpoint(s). Attributed to A. Developed by Lawrence H. The second measurement (x) is 13 . range of motion technique. palpatory skills: Sensory skills used in performing palpatory diagnosis and osteopathic manipulative treatment. A system of diagnosis and treatment directed toward tissues other than skeletal or arthrodial elements. traction technique. Jones. Structure and function are interrelated at all levels.

Physiologic motion of the thoracic or lumbar spine resulting from a neutral spinal position (Type I motion). 27) AP plane. See neutral Fig. DO (1918). transverse plane (horizontal plane). pelvic tilt: Pelvic rotation about a transverse (horizontal) axis (forward or backward tilt) or about an anteriorposterior axis (right or left side tilt). Pelvic index (PI) equals x/y. the coupled motions of sidebending and rotation for a group of vertebrae are such that sidebending and rotation occur in Figure 25. 26) See somatic dysfunction. 25). Osteopathic Principles in Practice. See somatic dysfunction. When the thoracic and lumbar spine are in a neutral position (easy normal. Principle III was described by C. II. DO (1948). 1. Normal values are age-related and increase in subjects with sagittal plane postural decompensation. physiologic motion of the spine: The three major principles of physiologic motion are: I. Usually observed in the standing position. See plane. Principles I and II of thoracic and lumbar spinal motion described by Harrison H. sagittal plane. pelvis: Within the context of structural diagnosis. 1994:263). and dividing the body into anterior and posterior portions. physiologic motion: See motion. percussion vibrator technique.d. a plane passing longitudinally through the body from one side to the other. type I s. a plane passing longitudinally through the body from front to back and dividing it into right and left portions. (hip bone or os coxae) the sacrum and coccyx. 24) opposite directions (with rotation occurring toward the convexity). pétrissage: Deep kneading or squeezing action to express swelling. coronal plane. frontal plane. See rotation. the coupled motions of sidebending and rotation in a single vertebral unit occur in the same direction. Planes of the body. Figure 26. 14 . pelvic sideshift: Deviation of the pelvis to the right or left of the central vertical axis as translation occurs along the horizontal (z) axis.R. Figure 24. a plane passing horizontally through the body perpendicular to the sagittal and frontal planes. See plane. Nelson. Physiologic motion of the thoracic or lumbar spine resulting from a non-neutral spinal position (Type II motion). Kuchera ML. III. The median or midsagittal plane divides the body into approximately equal right and left portions. sagittal plane. Greyden Press.d. See also rotation of vertebra. s. horizontal plane. (Fig. percussion vibrator technique: See osteopathic manipulative treatment. OH. dividing the body into upper and lower portions. pelvic rotation: Movement of the entire pelvis in a relatively horizontal plane about a vertical (longitudinal) axis. (Fig. physiologic barrier. (Modified from Kuchera WA. (Fig. coronal plane (frontal plane). (Fig. See plane. plane: A flat surface determined by the position of three points in space. Initiating motion of a vertebral segment in any plane of motion will modify the movement of that segment in other planes of motion. type II.along this same horizontal line. Columbus. 23). Figure 27. Any of a number of imaginary surfaces passing through the body and dividing it into segments. 2. the pelvis is made up of the right and left innominates. transverse plane. Pelvic index (PI). plagiocephaly: An asymmetric condition of the head. Fryette. When the thoracic and lumbar spine are sufficiently forward or backward bent (non-neutral). physiologic motion. physiologic barrier: See barrier.

A term used to denote that body parts act together to transmit and modify force and motion through which man acts out his life. The distribution of body mass in relation to gravity.plastic deformation: A non-recoverable deformation. posture: Position of the body. rotation of the forearm in such a way that the palmar surface turns backward (internal rotation) in relationship to the anatomical position. coronal plane p. 27). See also elasticity. postural axis: See sacral motion axis. and variable sacral and innominate dysfunctions. positional technique: See osteopathic manipulative treatment. prone: Lying face downward (Dorland’s). Optimal health promotes optimal function and the inherent function of this interdependent movement can be negatively altered by trauma. typical gait. (4). pubic bone. Applied to the foot: a combination of eversion and abduction movements taking place in the tarsal and metatarsal joints. See also anterior component. involuntary functions: (1). See planes of the body (Fig. prolotherapy: See sclerotherapy. psoas hypertonicity is frequently associated with flexed dysfunctions of the upper lumbars.. mechanism.M. It usually refers to a prominent vertebral transverse process. (5). but also of all body cells. but 15 . The syndrome consists of a constellation of typically related signs and symptoms: typical posture. and is thought to affect cellular respiration and other body processes. A conceptual model that describes a process involving five interactive. typical associated somatic dysfunctions. post-isometric relaxation: Immediately following an isometric contraction. causes scoliotic changes. a somatic dysfunction in which the pubic bones are forced toward each other at the pubic symphysis. primary respiratory mechanism: 1. pubic abduction. This mechanism was first described by William G. inferior pubic shear. Progressive Inhibition of Neuromuscular Structures. Korr. The osteopathic practitioner may take up the myofascial slack during the relaxed refractory period. the following descriptions were given: primary. Tender points typically are found in the ipsilateral iliacus and contralateral piriformis muscles. the neuromuscular apparatus is in a refractory state during which enhanced passive stretching may be performed. See pubic gapping. alignment appears asymmetrical. because it is directly concerned with the internal tissue respiration of the central nervous system. A term coined by I. This mechanism refers to the presumed inherent (primordial) driving mechanism of internal respiration as opposed to the cycle of diaphragmatic respiration (inhalation and exhalation). The inherent motility of the brain and spinal cord. psoas syndrome: A painful low back condition characterized by hypertonicity of psoas musculature. resulting in lowering of the medial margin of the foot. osteopathy in the cranial field prime mover: A muscle primarily responsible for causing a specific joint action. typical pain pattern. posterior component: A positional descriptor used to identify the side of reference when rotation of a vertebral segment has occurred. Trendelenburg gait. a somatic dysfunction in which one pubic bone is displaced inferiorly with relation to its normal mate. posterior pubic shear. It occurs in all cardinal planes. posterior nutation: See counternutation. postural axis. Fluctuation of the cerebrospinal fluid. lack of apparent asymmetry. pronation: In relation to the anatomical position. 28) Figure 28. postural decompensation: Distribution of body mass away from ideal when postural homeostatic mechanisms are overwhelmed. (3). because it further concerns the physiological function of the interchange of fluids necessary for normal metabolism and biochemistry. When viewed from the right or left sides. progressive inhibition of neuromuscular structures (PINS): See osteopathic manipulative treatment. This dysfunction is characterized by tenderness to palpation over the pubic symphysis.. (2). flexion at the hip and sidebending of the lumbar spine to the side of the most hypertonic psoas muscle. Articular mobility of the cranial bones. d. In the original definition. postural balance: A condition of optimal distribution of body mass in relation to gravity. pubic compression (pubic adduction). In a condition of right rotation. See also osteopathic manipulative treatment (OMT). causes kyphotic and/or lordotic changes. but is classified by the major plane(s) affected. Mobility of the intracranial and intraspinal membranes. may cause postural changes where part or all of the body rotates to the right or left. It further refers to the innate interconnected movement of every tissue and structure of the body. 2. positional technique. See also supination. pubic adduction. as a long restrictor muscle. Sutherland. d. See also elastic deformation. as applied to the hand. postural imbalance: A condition in which ideal body mass distribution is not achieved. because all the constituent parts work together as a unit carrying out this fundamental physiology. low back pain frequently accompanied by pain on the lateral aspect of the lower extremity extending no lower than the knee.. respiratory. Mobility of the sacrum between the ilia (pelvic bones) that is interdependent with the motion at the sphenobasilar synchondrosis. extended dysfunction of L5. somatic dysfunctions of: anterior pubic shear. disease states or other pathology. the right side is the posterior component. d. See also viscosity. (Fig. plasticity: Ability to retain a shape attained by deformation. This integration is achieved via the central nervous system acting in response to continued sensory input from the internal and external environment. a somatic dysfunction in which one pubic bone is displaced posteriorly with relation to its normal mate. PhD. sagittal plane p. Right inferior pubic shear. primary machinery of life: The neuromusculoskeletal system. a somatic dysfunction in which one pubic bone is displaced anteriorly with relation to its normal mate. See pubic compression. not only of the central nervous system. 2. horizontal plane p. DO.

respiratory axis of the sacrum: See sacral motion axis.6 somatic dysfunction. reciprocal inhibition: The inhibition of antagonist muscles when the agonist is stimulated. somatic dysfunctions of. regional extension. oculocephalogyric r. (Fig. but that is developed by regular association of some physiological function with a related outside event. See oculocephalogyric r. cervical 739. localized visceral stimuli producing patterns of reflex response in segmentally related visceral structures.. An anatomical division of the body defined either by natural.1 somatic dysfunction. See oculocephalogyric r. pump handle rib motion: See rib motion.3 somatic dysfunction. 2.8 somatic dysfunction.. localized somatic stimuli producing patterns of reflex response in segmentally related somatic structures. (Fig. somatovisceral r.4 somatic dysfunction. viscerosomatic r. regional extension: See extension. See barrier (motion barrier). tentorium and spinal dura. 31) Figure 31. cephalogyric reflex. anteroposterior rib axis. Seated flexion test = Bilaterally (+) (False negative) Figure 30. falx cerebelli. pump handle. head 739. 16 . red r.g. caliper rib motion. functional or arbitrary boundaries. red r. rib lesion: (Archaic) See rib somatic dysfunction. an imaginary line through the costotransverse and the costovertebral articulations of the rib. rib motion: axis of rib motion.: deep tendon reflex). respiratory cooperation: An osteopathic practitioner-directed inhalation and/or exhalation by the patient to assist the manipulative treatment process. myotatic r. increasing in motion from the upper to the lower ribs. pubic symphysis. (Fig.. localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures. somatosomatic r... red reflex: See reflex. The sum total of any particular involuntary activity. lumbar 739. Body areas for the diagnosis and coding of somatic dysfunction as defined in the International Classification of Diseases (currently ICD-9 CM) using the codes: 739. The erythematous biochemical reaction (reactive hyperemia) of the skin in an area that has been stimulated mechanically by friction. (Fig. regional motor inputs: Motion initiated by an osteopathic practitioner through body contact and vector input that produces a specific response at each segment in the mobile system. Right superior pubic shear. range of motion technique. Pubic gapping ( pubic abduction) superior pubic shear. This dysfunction is frequently seen in women following childbirth. viscerovisceral r. somatic dysfunctions of: See pubic bone. 2. one that does not occur naturally in the organism or system. The reflex is greater in degree and duration in an area of acute somatic dysfunction as compared to an area of chronic somatic dysfunction. upper extremity 739.associated with restricted motion of the pelvic ring. retrolisthesis: Posterior displacement of one vertebra relative to the one immediately below. See also elasticity. 33) See also rib motion. 29) reciprocal tension membrane: The intracranial and spinal dural membrane including the falx cerebri.0 somatic dysfunction. region: 1. movement of the ribs during respiration such that with inhalation. oculogyric reflex. the lateral aspect of the rib moves cephalad resulting in an increase of transverse diameter of the thorax..2 somatic dysfunction. resilience: Property of returning to the former shape or size after mechanical distortion. Pubic compression. See also laws. lower extremity 739. For joint restriction. reflex: An involuntary nervous system response to a sensory input.7 somatic dysfunction.9 somatic dysfunction. pelvis 739. 32) See also bucket handle rib motion.5 somatic dysfunction. conditioned r. (Fig. pubic gapping (pubic abduction).. regenerative injection therapy (RIT): See sclerotherapy. A red glow reflected from the fundus of the eye when a light is cast upon the retina. thoracic 739. automatic contraction of the lumbar paravertebral muscles in response to contraction of postural muscles in the neck. This type of rib motion is predominantly found in lower ribs. a somatic dysfunction in which one pubic bone is displaced superiorly with relation to its normal mate. restriction: A resistance or impediment to movement. Sherrington’s. It is a reflection of the segmentally related sympathicotonia commonly observed in the paraspinal area. See also rib motion. tonic contraction of the muscles in response to a stretching force. a somatic dysfunction in which the pubic bones are pulled away from each other at the pubic symphysis. cephalogyric reflex). 1. superior transverse axis. R range of motion technique: See osteopathic manipulative treatment. See also Chapman reflexes. sacrum 739. axis of. bucket handle motion. (oculogyric reflex. rib cage 739.. See also plasticity. localized somatic stimulation producing patterns of reflex response in segmentally related visceral structures. automatic movement of the head that leads or accompanies movement of the eyes. pump handle motion. 30) cervicolumbar r. due to stimulation of muscle receptors (e. abdomen/other See also transitional region.. Rib motion of ribs 11 and 12 characterized by single joint Figure 29.

inhalation rib dysfunction. exhalation rib restriction. See also rib motion. A somatic dysfunction characterized by a rib motion. TP is at the same level as tip of the SP. axis of. movement of the sacrum about a vertical (y) axis (usually in relation to the innominate bones). See also rib motion. and motion toward exhalation is restricted. rotation dysfunction of the sacrum. Bucket handle rib motion. elevated rib. rotation of vertebra. pump handle rib motion Figure 36. Synonyms: inhalation rib restriction depressed rib. rotation: Motion about an axis. (Fig. exhalation rib restriction. The relationship is as follows: T1 to T3. 2. 36) Figure 32. involves a rib or group of ribs that first stops moving during exhalation. For example. See also rib motion. inhalation rib restriction. Rotation of a vertebra (lumbar). inhalation. 17 . TP is at the same level as tip of the SP T4 to T6. 35) See rib motion. involves a rib or group of ribs that first stops moving during inhalation. See also rib motion. TP is one full vertebral level above the tip of the SP T10. See sacrum. exhalation rib restriction. The functional anterior-posterior rib axis. pump handle motion. rib somatic dysfunction: A somatic dysfunction in which movement or position of one or several ribs is altered or disrupted. somatic dysfunctions of. inhalation rib restriction. TP is one half vertebral level above the tip of the SP T7 to T9. exhalation rib dysfunction. A depressed rib is one held in a position of exhalation such that motion toward exhalation is freer and there is a restriction in inhalation. TP is one full vertebral level above the tip of the SP T11. See also rib motion. (Fig. The functional transverse rib axis. decreasing in motion from the upper to the lower ribs. rotation of sacrum.being held in a position of inhalation such that motion toward inhalation is more free and motion toward exhalation is restricted. 34) See rib motion. an elevated rib is one held in a position of inhalation such that motion toward inhalation is freer. named by the motion of a midpoint on the anterior-superior surface of the vertebral body. rule of threes: A method to locate the approximate position of the transverse process (TP) of a thoracic segment by using the location of the spinous process (SP) of that same vertebra. See also rib somatic dysfunction. Somatic dysfunction characterized by a rib being held in a position of exhalation such that motion toward exhalation is more free and motion toward inhalation is restricted. (Fig. analogous to internal and external rotation. 1. exhalation rib dysfunction. An anterior rib tender point in counterstrain. bucket handle motion. TP is one half vertebral level above the tip of the SP T12. See also rib motion. The key rib is the top rib in the group. anterior rib. Figure 34. The key rib is the bottom rib in the group. This type of rib motion is found predominantly in the upper ribs. See also tissue texture abnormality. Figure 35. movement of the ribs during respiration such that with inhalation the anterior aspect of the rib moves cephalad and causes an increase in the anteroposterior diameter of the thorax. inhalation rib restriction. movement about the anatomical vertical axis (y axis) of a vertebra. transverse rib axis. See also rib somatic dysfunction. Synonyms: inhaled rib. inhalation rib dysfunction. Pump handle rib motion. inhalation rib restriction. . Figure 33. ropiness: A tissue texture abnormality characterized by a cord-like feeling.

See sacral motion axis. (Fig. 18 . (Fig. any deviation of the sacral base from the horizontal in a coronal plane. 37) longitudinal axis. A physiologic function occurring in the sacrum during ambulation and forward bending. Fig. DO. (Fig. A sacral somatic dysfunction around an oblique axis in which a torque occurs between the sacrum and innominates. The most cephalad portion of the first sacral segment (Gray’s Anatomy). 2. 39. It is designated as right or left relevant to its superior point of origin. anterior or posterior sacrum and a torsion with a non-compensated L5 (Archaic use). Sr. axis formed at the line of intersection of a sagittal and transverse plane. 2. 2. somatic dysfunctions of. (Fig. Axes of sacral motion (posterior view). 39. axes formed by intersection of the coronal and transverse planes about which nutation/counternutation occurs. the rotation of the sacrum about an anterior-posterior axis. 40) Figure 40. Fig. If the L5 does not rotate opposite to the sacrum. (Fig. sacral base anterior: See sacrum. bilateral sacral flexion. the hypothetical axis formed at the line of intersection of the midsagittal plane and a coronal plane. inferior lateral angle (ILA) of: The point on the lateral surface of the sacrum where it curves medially to the body of the fifth sacral vertebrae (Gray’s Anatomy). inferior transverse axis (innominate). sacral movement axis: any of the hypothetical axes for motion of the sacrum. A term described by Fred Mitchell. See sacrum. Sr. 37) transverse (z) axes. 37. 38) anterior-posterior (x) axis. 40) Figure 37. Anatomical sacral divisions. A term described by Fred Mitchell. sacroiliac motion: Motion of the sacrum in relationship to the innominate(s) (ilium/ilia). 37) superior transverse axis (respiratory). L5 is termed maladapted. 37) vertical (y) axis (longitudinal). 37) respiratory axis. passing horizontally through the anterior aspect of the sacrum at the level of the second sacral segment. (Fig. vertical (y) axis longitudinal. the hypothetical functional axis of sacral nutation/counternutation in the standing position. a hypothetical functional axis from the superior area of a sacroiliac articulation to the contralateral inferior sacroiliac articulation. sacral torsion: 1. Sacral transverse axes (lateral view). somatic dysfunctions of. (Fig. 2. 38) middle transverse axis (postural). and is believed to occur about this axis. DO. sacralization. See sacrum. 2. and inferior lateral angles (ILA). Generally. Clinical sacral divisions: sacral sulcus at the base. middle transverse axis (postural). sacral base posterior: See sacrum. somatic dysfunctions of. Fig. 38) postural axis. 37) oblique axis (diagonal). Figure 38.S sacral base: 1. DO. Involuntary sacral motion occurs as part of the craniosacral mechanism. sacral base declination (unleveling): With the patient in a standing or seated position. Sr. 4. the axis formed by the intersection of the sagittal and coronal planes. and represents the axis for movement of the ilia on the sacrum. (Fig. (Fig. bilateral sacral flexion. Other terms for this maladaption include: rotations about an oblique axis. somatic dysfunctions of. sacralization: See transitional vertebrae. (Fig. sacral base unleveling: See sacral base declination. sacral sulcus: A depression just medial to the posterior superior iliac spine (PSIS) as a result of the spatial relationship of the PSIS to the dorsal aspect of the sacrum. The L5 vertebra rotates in the opposite direction of the sacrum. sacrum. the uppermost posterior portion of the sacrum. Figure 39. superior transverse axis (respiratory). It passes from side to side through the articular processes posterior to the point of attachment of the dura at the level of the second sacral segment. the hypothetical functional axis of sacral motion that passes from side to side on a line through the inferior auricular surface of the sacrum and ilia. DO. See also sacrum. the hypothetical transverse axis about which the sacrum moves during the respiratory cycle. 2. (Fig. Sr. 38) sacral somatic dysfunction: See sacrum. A term described by Fred Mitchell. In osteopathic palpation. A term described by Fred Mitchell. (Fig. 3.

(Foundations). Backward movement of the sacral base is freer. The dysfunction is named for the side on which the posterior rotation occurs. Figure 43. Left on left sacral torsion.T. DO. Refers to left rotation torsion around a left oblique axis. 47) anterior translated sacrum. (Sacral base anterior) Figure 41. 42) Figure 42 Anterior translated sacrum. The upper limb (pole) of the SI joint has restricted motion and is named for the side on which forward rotation had occurred. Findings: The left superior sacral sulcus is posterior or shallow. a positional term based on the Strachan model referring to a sacral somatic dysfunction in which the sacral base has rotated posterior and sidebent to the side opposite to the rotation. The superior pole of the left sacroiliac joint is affected and the left sacral base will not move posteriorly when an anterior test pressure is applied over the right lower sacrum. DO. A backward sacral torsion is a physiologic rotation of the sacrum around an oblique axis such that the side of the sacral base contralateral to the named axis rotates posteriorly. Figure 45. 2. left on right (backward) sacral torsion.) (Fig. (Fig.) (Fig. A sacral somatic dysfunction that involves rotation of the sacrum about a middle transverse axis such that the sacral base has moved anteriorly between the pelvic bones. Bilateral sacral extension. backward movement is restricted and both sulci are deep. Anterior motion is freer. Forward movement of the sacral base is freer. Sr. Motion of L5 is not described. These may be the result of restriction of normal physiologic motion or trauma to the sacrum. (The motion characteristics of L5 are not described.A. 1. 2. anterior sacrum. 1. There is a positive seated flexion test on the left. bilateral sacral extension (sacral base posterior). L5 is nonneutral SRRR. See also T. (The motion characteristics of L5 are not described. (Fig. and the sphinx test is positive. 1. Referred to as non-neutral sacral somatic dysfunctions (Archaic use). based on the motion cycle of walking. (Fig 43) Figure 44. The reverse of bilateral sacral flexion. Forward torsion is a physiologic rotation of the sacrum around an oblique axis such that the side of the sacral base contralateral to the named axis glides anteriorly and produces a deep sulcus. 2. Bilateral sacral flexion. that describes the backward torsion as being non-physiologic in terms of the walking cycle. There is tissue texture change (t) over the left sacral base. posterior sacrum. 3. L5 rotates in the direction opposite to the rotation of the sacral base. The reverse of bilateral sacral extension. The lumbosacral spring test is positive. and the posterior motion is restricted. A group of somatic dysfunctions described by Fred Mitchell. 46) See sacral torsion. (Sacral base posterior) bilateral sacral flexion (sacral base anterior). Refers to left rotation around a right oblique axis. 1. Tissue texture changes are found at the deep sulcus. Left superior sacral sulcus will be restricted when springing. A sacral somatic dysfunction that involves rotation of the sacrum about a middle transverse axis such that the sacral base has moved posteriorly relative to the pelvic bones. (Fig. The tissue texture changes are found at the lower pole on the side of rotation. A term by Fred Mitchell. and the right ILA is anterior or deep. L5 rotates in the direction opposite to the rotation of the sacral base. 45) See also sacral torsion. 19 . Anterior sacrum left.sacrum. forward movement is restricted and both sulci are shallow. a sacral somatic dysfunction in which the entire sacrum has moved anteriorly (forward) between the ilia. 2. somatic dysfunctions of: any of a group of somatic dysfunctions involving the sacrum. (Fig 44) forward torsions.R. 41) backward torsions. (Left on left forward torsion) left on left (forward) sacral torsion. Sr. a positional term based on the Strachan model referring to sacral somatic dysfunction in which the sacral base has rotated anterior and sidebent to the side opposite the rotation. Referred to as neutral sacral somatic dysfunctions (Archaic use) 3.

50) See sacral torsion. refers to a right rotation about a right oblique axis. (Sometimes described as a sidebending in one direction and rotation in the opposite direction. unilateral sacral flexion and sacrum. Posterior translated sacrum. Motion of L5 is not described. (Right rotation about a vertical axis) Figure 47. The inferior pole of the right SI joint is affected. is a sacral somatic dysfunction described as a superior shear of one side of the sacrum resulting in a shallow (full) of. Posterior motion is freer. Right unilateral sacral extension. somatic dysfunctions of. During motion testing. (Left on right backward torsion) Figure 49.) See also sacrum. sacral shear. (Fig. Left on right sacral torsion. There is tissue texture change (t) over the right sacroiliac joint (SI). Right on right forward torsion. and the left ILA is anterior or deep. sacral sulcus and ipsilateral superioranterior inferolateral angle of the sacrum. unilateral sacral extension. posterior translated sacrum. Right unilateral sacral flexion. The lumbosacral spring test is positive. 49) See sacral torsion. 51) sacral shear.Seated flexion test = L (+) Figure 46.52) See sacrum. Refers to right rotation on a left oblique axis. Posterior sacrum right. Figure 52. (Fig. (Right on left sacral torsion) Figure 51. (Right inferior sacral shear) Figure 48. a complex translational motion of the sacrum in its relationship Figure 53. unilateral sacral extension. to the innominates. shallow. (Fig. somatic dysfunctions of. The right superior sacral sulcus is restricted when springing. The seated flexion test is positive on the right. rotated dysfunction of the sacrum. L5 is non-neutral SLRL. and anterior motion is restricted. (Fig. there is resistance to an anterior/superior test pressure applied over the right lower sacrum. a sacral somatic dysfunction in which the entire sacrum has moved posteriorly (backward) between the ilia. (Fig. Alternatively described as a unilateral movement along the arc of the L-shaped curve of the sacroiliac joint. and is restricted in the opposite direction. Right on left backward torsion. Motion is freer in the direction that rotation has occurred. (Right superior sacral shear) Figure 50. The sphinx test is positive. a sacral somatic dysfunction in which the sacrum has rotated about an axis approximating the longitudinal (y) axis. Right rotated dysfunction of the sacrum. 48) right on right (forward) torsion. Findings: The right superior sacral sulcus is posterior or 20 . somatic dysfunctions of. right on left (backward) sacral torsion.

Identified by T. (Fig. See also T. sidebending: Movement in a coronal (frontal) plane about an anteriorposterior (x) axis. scan: An intermediate detailed examination of specific body regions that have been identified by findings emerging from the initial examination. inferior innominate shear. The directions in which motion is restricted.A. lymphatic. (Fig. sclerotherapy: 1.A.A. soft tissue. primary s. and their related vascular.R. The area of bone innervated by a single spinal segment. See also S. See also sacrum. scaphocephaly: Also called scaphoid head or hatchet head. fibrosis. A group curve of thoracic and/or lumbar vertebrae in which the freedoms of motion are in neutral with sidebending and rotation in opposite directions with maximum rotation at the apex (rotation occurs toward the convexity of the curve) based upon the Principles of Fryette.T.. To describe a single vertebrae or a vertebral segment. somatic dysfunction arising either from mechanical or neurophysiologic response subsequent to or as a consequence of other etiologies.T. Diagnosed by history and palpatory assessment of tenderness. acute s. sagittal plane: See plane. a shortlived (minutes or hours) increase in central nervous system (CNS) response to repeated sensory stimulation that generally follows habituation. It is characterized by tenderness. corresponding to the sites of origin of rootlets of individual spinal nerves.. with articular surfaces for movement. See also key lesion. The group of mesenchymal cells emerging from the ventromedial part of a mesodermal somite and migrating toward the notochord. lateroflexion. Also called lateral flexion. ligament and bone). Second degree 21 . as well as the adnexal tissues that create movement. 54) scoliosis: 1. d. 3. somatic dysfunction of.. The initial or first somatic dysfunction to appear temporally. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1). superior innominate shear. See also pubic bone. See also innominates. pain and tissue contraction. 2. See also screen. (Fig. varicose veins. The pattern of innervation of structures derived from embryonal mesenchyme (joint capsule. Also called accessory joint motion. This suggests visceral reflex inputs. somatic dysfunction: Impaired or altered function of related components of the somatic (body framework) system: skeletal. sagittal plane. Sclerotomal cells from adjacent somites become merged in inter-somatically located masses that are the primordia of the centra of the vertebrae. sacral shear. Treatment involving injection of irritating substances into weakened connective tissue areas such as fascia. dull achy pain associated with tissues derived from a common sclerotome. chronic s. scaphoid head: See also scaphocephaly. 55) screen: The initial general somatic examination to determine signs of somatic dysfunction in various regions of the body. shear: An action or force causing or tending to cause two contiguous parts of an articulation to slide relative to each other in a direction parallel to their plane of contact.R.T. somatic dysfunctions of. sacral shear. 1. 56) See also sidebending. soft tissue technique. d. skin drag: Sense of resistance to light traction applied to the skin. An appreciable lateral deviation in the normally straight vertical line of the spine (Dorland’s. d.A. d. is a sacral somatic dysfunction described as an inferior shear of one side of the sacrum resulting in a deep sacral sulcus and ipsilateral inferior-posterior inferolateral angle of the sacrum. and 3). often equated with spinal segment. immediate or short-term impairment or altered function of related components of the somatic (body framework) system. hemorrhoids. 3. segmental dysfunction: dysfunction in a mobile system located at explicit segmental mobile units. 53) See sacrum. somatic dysfunctions of. linkage. Palpable characteristics of a dysfunctional segment are those associated with somatic dysfunction. (Fig. or flexion right (or left). soft tissue technique: See osteopathic manipulative treatment. 54) sclerotomal pain: Deep. secondary joint motion: Involuntary or passive motion of a joint.R.A. Somatic dysfunction is treatable using osteopathic manipulative treatment. paresthesias and tissue contraction. See also scan. The position of a body part as determined by palpation and referenced to its adjacent defined structure.R. 2. (See also STAR. restriction of motion and tissue texture change (T.T.T. Pathological or functional lateral curvature of the spine. 2). allow movement and establish position under motor control. segmental motion: Movement within a vertebral unit described by displacement of a point at the anteriorsuperior aspect of the superior vertebral body with respect to the segment below. Treatment involving injection of a proliferant solution at the osseous-ligamentous junction. esophageal varices. and neural elements. edema. Characterized in early stages by vasodilation. See also T. itching.. or weakened ligaments. somatic dysfunctions of.R. TART and ART) Responses to regional motor inputs at the dysfunctional segment support the concepts of complete motor asymmetry and mirrorimage motion asymmetries. impairment or altered function of related components of the somatic (body framework) system. it is a transverse compression of the cranium with a resultant mid-sagittal ridge. A portion of the spinal cord segmental diagnosis: The final stage of the spinal somatic examination in which the nature of the somatic problem is detailed at a segmental level.).. (Fig. 2. See also scan. type I s. Sherrington. See also innominates. soft tissue (ST): See osteopathic manipulative treatment.T. The somatic dysfunction that maintains a total pattern of dysfunction.R. The intended body’s response to the irritant is fibrous \proliferation with shortening/ strengthening of the tissues injected. A portion of a larger body or structure set off by natural or arbitrarily established boundaries. 2. d. The directions in which motion is freer. See also T. tenderness. asymmetry of motion and relative position. 1. somatic dysfunctions of. 2. Sherrington law: See law. sensitization: Hypothetically.unilateral sacral flexion. secondary s. 2. segmental mobile unit: A unit of the human movement system consisting of a bone. sclerotome: 1. Related to the degree of moisture and degree of sympathetic nervous system activity. arthrodial and myofascial structures. segment: 1.A. sidebent: The position of any one or several vertebral bodies after sidebending has occurred. dysfunctional segmental behavior where a single vertebra and an adjacent rib respond to the same regional motion tests with identical asymmetric behaviors (rather than opposing behaviors). (American usage).

type II s. somatosomatic r. (Modified from Foundations for Osteopathic Medicine.Figure 54. somatovisceral r. Thoracic or lumbar somatic dysfunction of a single vertebral unit in which the vertebra is significantly flexed or extended with sidebending and rotation in the same direction (rotation occurs into the concavity of the curve) based upon the Principles of Fryette (American usage). First degree dysfunction based upon the Laws of Lovett (French usage). 1.. Sidebent. Anterior and posterior sclerotomal innervations. d. 1997:644).. dysfunction based upon the Laws of Lovett (French usage). Ward RC—Ed. somatovisceral reflex: See reflex. 2. Scoliosis. William & Wilkins. 22 . somatogenic: That which is produced by activity. somatosomatic reflex: See reflex. Figure 56. reaction and change originating in the musculoskeletal system. Figure 55.

59) sidebending-rotation. sphenoid and occiput have rotated in opposite directions around parallel transverse axes. The abbreviation. 58) lateral strain. Facilitation may be due to sustained increase in afferent input. Figure 62. Figure 61. splenic pump technique: See osteopathic manipulative treatment. Extension (SBS). somatic dysfunctions of: any of a group of somatic dysfunctions involving primarily the interrelationship between the basilar portion of the sphenoid (basisphenoid) and the basilar portion of the occiput (basiocciput). spasm: (compare with hypertonicity) a sudden. Spencer technique. sphenobasilar synchondrosis (symphysis). aberrant patterns of afferent input. Lateral strains of the SBS are named for the position of the basisphenoid. Spencer technique: See osteopathic manipulative treatment. SBS torsions are named for the high greater wing of the sphenoid. Figure 58. right or left. the basiocciput and basisphenoid are both inferior in SBS extension with a decrease in the dorsal convexity between these two bones. Figure 59. SBS. sphenoid and occiput have rotated in opposite directions around parallel vertical axes and rotate in the same direction around an A-P axis. sphenoid and occiput have rotated in the same direction around parallel vertical axes. (Fig. sphenoid and occiput have rotated in the same direction 23 . violent. around parallel transverse axes.Figure 57. (Fig. right or left. SBS sidebending-rotations are named for the convexity. in this state. or changes within the affected neurons themselves or their chemical environment. Once established. (Dorland’s). involuntary contraction of a muscle or group of muscles. 62) spinal facilitation: 1. spondylo-: Combining form denoting relationship to a vertebra.g. splenic pump technique. producing involuntary movement and distortion (Dorland’s). spondylitis: Inflammation of vertebrae. facilitation can be sustained by normal central nervous system (CNS) activity. somatic dysfunction in which the basisphenoid and basiocciput are held forced together significantly limiting SBS motion. 57) SBS flexion. sphenoid and occiput have rotated in opposite directions around parallel transverse axes. Superior vertical strain (SBS). Right lateral strain (SBS). is often used in reporting the following somatic dysfunctions: SBS compression. A theory regarding the neurophysiological mechanisms underlying the neuronal activity associated with somatic dysfunction. or to the spinal column (Dorland’s). Right torsion (SBS). sphenoid and occiput have rotated in opposite directions around an anterior-posterior (A-P) axis. 2. (Fig. (Fig. attended by pain and interference with function.. Left sidebending/rotation (SBS). less afferent stimulation is required to trigger the discharge of impulses. (Fig. SBS extension. Vertical strains of the SBS are named for the position of the basisphenoid. motor neurons or preganglionic sympathetic neurons in one or more segments of the spinal cord) in a state of partial or subthreshold excitation. 61) vertical strain. (Fig. Flexion (SBS). superior or inferior. 60) torsion. 3. the basiocciput and basisphenoid are both superior in SBS extension with an increase in the dorsal convexity between these two bones. The maintenance of a pool of neurons (e. premotor neurons. right or left. Figure 60.

somatic dysfunctions of. 2. spring test: 1. thickening. DO. thrust technique. 2. second degree: partial tear. See also reciprocal tension membrane. These points are a manifestation of somatic dysfunction and are used as diagnostic criteria and for monitoring treatment. stretching: Separation of the origin and insertion of a muscle and/or attachments of fascia and ligaments. edema. See also ligamentous strain. structural examination: See osteopathic structural examination. Discomfort or pain elicited by the osteopathic practitioner through palpation. 2. hypertonicity.R. See also osteopathic manipulative treatment. 1874. Strachan model: See sacrum. as well as the following symptoms: itching. MO. Small. A test used to differentiate bilateral sacral extension and bilateral sacral flexion. contracture. superior (upslipped) innominate: See innominate. paresthesias. tenderness: 1. sprain: Stretching injuries of ligamentous tissue (compare with strain). Beginning in anatomical position. thoracic aperture (superior): See thoracic inlet. thoracic pump: See osteopathic manipulative treatment. 2. spontaneous release by positioning: See osteopathic manipulative treatment. 28.T. See also osteopathic manipulative treatment. A test used to differentiate unilateral sacral extension and unilateral sacral flexion. 2. technic: See technique. See also osteopathic manipulative treatment. A compound motion of plantar flexion. See also symphyseal shear. hypersensitive points in the myofascial tissues of the body that do not have a pattern of pain radiation. asymmetry and alteration of the quality and quantity of range of motion. 31) superior transverse axis: See sacral motion axis. high velocity/low amplitude technique (HVLA). Fig. 31) T tapotement: Striking the belly of a muscle with the hypothenar edge of the open hand in rapid succession in an attempt to increase its tone and arterial perfusion. symmetry: The similar arrangement in form and relationships of parts around a common axis. symphyseal shear: The resultant of an action or force causing or tending to cause the two parts of the symphysis to slide relative to each other in a direction parallel to their plane of contact. the act of turning the palm forward (anteriorly) or upward. Sutherland fulcrum: A shifting suspension fulcrum of the reciprocal tension membrane located along the straight sinus at the junction of the falx cerebri and tentorium cerebelli. sphinx test: See backward bending test. (Dorland’s). Still. and the manubrium of the sternum. still point: A term used to identify and describe the temporary cessation of the rhythmic motion of the primary respiratory mechanism. counterstrain. 2. supine: Lying with the face upward (Dorland’s). performed by lateral external rotation of the forearm. Still Technique: See osteopathic manipulative treatment. Osteopathy in the Cranial Field (OCF). ribs 1 and 2 plus their costicartilages. First announced the tenets of osteopathy on June 22. A system of diagnosis and treatment originally described by Lawrence Jones. and the superior end of the manubrium.R. Types of TTA’s include: bogginess. third degree: complete disruption. fibrosis. DO. isometric contraction. superior innominate shear. pain. adduction and inversion. See also osteopathic manipulative treatment. Applied to the foot. counterstrain. spondylolysis: Dissolution of a vertebra. posterior sacrum. ropiness. anterior sacrum.A. MD. 24 . Degeneration of the intervertebral disk.T. physiologic b. articulatory treatment system. (Fig. superior transverse axis (respiratory) and (z) axis. and separation at the pars interarticularis. thoracic outlet: 1. It may occur during osteopathic manipulative treatment when a point of balanced membranous or ligamentous tension is achieved. springing technique. T. DO: Andrew Taylor. technique: Methods. Distortion with deformation of tissue. S. 3. See also osteopathic manipulative treatment. but does not exceed the joint’s anatomical limit. or on each side of a plane of the body (Dorland’s). Stretching injuries of muscle tissue. stringiness: A palpable tissue texture abnormality characterized by fine or stringlike myofascial structures. A partial or incomplete dislocation. pre-spondylolisthesis. 2. asymmetry. springing technique: See osteopathic manipulative treatment.A. Sutherland. procedures and details of a mechanical process or surgical operation. hence of the longitudinal arch. strain: 1. it generally applies to movements (adduction and inversion) resulting in raising of the medial margin of the foot. aplasia of the vertebral arch. Strain-Counterstrain®: See osteopathic manipulative treatment. A test used to differentiate between backward or forward sacral torsions/rotations. Ankylosis of adjacent vertebral bodies. somatic dysfunctions of. tenderness. somatic dysfunctions of. counterstrain. Still Technique. It is usually found in an inferior/superior direction but is occasionally found to be in an anterior/posterior direction. 2. spondylosis: 1. platyspondylia. superior pubic shear: See pubic bone. somatic dysfunctions of. static contraction: See contraction. thoracic pump. 2. flaccidity. terminal barrier: See barrier.: A mnemonic for four diagnostic criteria of somatic dysfunction: tissue texture abnormality.: A mnemonic for four diagnostic criteria of somatic dysfunction: sensitivity changes. tissue texture abnormality (TTA): A palpable change in tissues from skin to periarticular structures that represents any combination of the following signs: vasodilation. stringiness. 1828-1917. The anatomical thoracic inlet consists of T1 vertebra. See fascial patterns. (Fig. See sacrum. thrust technique: See osteopathic manipulative treatment. supination: 1. A term used by William G. The functional thoracic inlet consists of T1-4 vertebrae. restriction of motion and tenderness. A term describing an abnormal anatomical position of a joint which exceeds the normal physiologic limit. tissue texture abnormality.spondylolisthesis: Anterior displacement of one vertebra relative to one immediately below (usually L-5 over the body of the sacrum or L-4 over L5). the first ribs and their costal cartilages. First degree: microtrauma. A state of unusual sensitivity to touch or pressure (Dorland’s). subluxation: 1. tender points: 1. any one of which must be present for the diagnosis. Founder of osteopathy. FAAO. established the American School of Osteopathy in 1892 at Kirksville. applied to the hand. See also pronation.

uncommon compensatory pattern. V v-spread: See osteopathic manipulative treatment. a transitional segment in which the first sacral segment becomes like an additional lumbar vertebra articulating with the second sacral segment. traction technique: See osteopathic manipulative treatment. See osteopathic manipulative treatment. transverse (z) axis. facet: Unequal size and/or facing of the zygapophyseal joints of a vertebra. (Fig. Foundations for Osteopathic Medicine. somatic dysfunctions of. toggle technique. torsion: 1. (Fig. trigger point (myofascial trigger point): 1. 2003:730. This whole-body phenomenon. type II s. typically T10-L1. osteopathic manipulative techniques: See osteopathic manipulative treatment. See also facet asymmetry. -tropic: A word termination denoting turning toward. MD. is told to lift first one foot and then the other. aids in the maintenance of posture and in the return of blood to the heart (Dorland’s). See also sacrum. The natural tendency to replenish the body stores that have been depleted. Ed. pump handle rib motion. These points were most extensively and systematically documented by Janet Travell. U uncommon compensatory pattern: See fascial patterns. consistently produces a reflex mechanism that gives rise to referred pain and/or other manifestations in a consistent reference zone that is consistent from person to person. trophicity: 1. transitional region: Areas of the axial skeleton where structure changes significantly lead to functional changes. When standing on the affected limb the gluteal fold on the sound side falls instead of rising. v-spread. velocity: The instantaneous rate of motion in a given direction. coxa vara and congenital dislocations.d. A small hypersensitive site that. translation: Motion along an axis. and peripheral blood flow including venous volume and thermal regulation. especially in the cellular environment (e. Ex. sacral movement axis. if bilateral. uncompensated fascial pattern: See fascial patterns. The position and movements of the gluteal fold are watched. 2. See also physiologic motion of the spine Figure 63. pulmonary blood flow. traction: A linear force acting to draw structures apart. when stimulated. See also rib motion. sacral: See sacral torsion. The pedicle (B) is the key structure from which other vertebral parts can be identified. traction technique. 2. which in skeletal muscles. MD. type I s. 37) transverse process: Projects laterally from the region of each pedicle. translatory motion. treatment. 2. sacralization. cervicothoracic region (CT). transitional areas commonly include the following: occipitocervical region (OA). cerebral blood flow and movement of the cerebrospinal fluid. tonus: The slight continuous contraction of muscle. transverse axis of sacrum: See sacral. See also sphenobasilar synchondrosis (symphysis). transitional vertebrae: A congenital anomaly of a vertebra in which it Traube-Herring-Mayer wave: An oscillation that has been measured in association with blood pressure. sacral torsions. Travell trigger point: See trigger point. tropism. (Fig. changing or tendency to change. lumbosacral region (LS). bears a striking resemblance to the primary respiratory mechanism.firmness (hardening). referred to as batwing deformity. typically L5-S1. Second Edition. Incomplete separation and differentiation of the fifth lumbar vertebra (L5) such that it takes on characteristics of a sacral vertebra. translatory motion: See motion. 2. A nutritional function or relation. Trendelenburg test: The patient. 1. A motion or state where one end of a part is twisted about a longitudinal axis while the opposite end is held fast or turned in the opposite direction. which exhibits a rate typically slightly less than and independent of respiration. type II somatic dysfunction: See somatic dysfunction.d. thoracolumbar region (TL). trophic: Pertaining to nutrition. causing pseudoarthrosis with the sacrum and/or ilia(um). The pedicle connects the posterior elements to the vertebral body. trophotropic: Concerned with or pertaining to the natural tendency for maintenance and/or restoration of nutritional stores. trophic function — a nutritional function). uncompensated fascial pattern. increased/decreased temperature and increased/decreased moisture. See also physiologic motion of the spine.. active method. toggle technique: See osteopathic manipulative treatment.g. Lippincott Williams & Wilkins. typically the OA-AA-C2 region is described. 63) transverse rib axis: See (Fig. An unphysiologic motion pattern about an anteroposterior axis of the sphenobasilar symphysis/synchondrosis. active: (archaic). develops characteristic(s) of the adjoining structure or region. and David Simons. heart rate. lumbarization. type I somatic dysfunction: See somatic dysfunction. typically C7-T1. somatic dysfunctions of. 35). with back to the examiner. When transverse processes of the fifth lumbar (L5) are atypically large. cardiac contractility. Seen in poliomyelitis. (Ward RC.. 25 . torsion. Philadelphia. torsion. 34) treatment. un-united fracture of the femoral neck.

See also elasticity. See also plasticity. File: D:/Glossary/Glossary of 08-15-2006 26 . viscerovisceral r. muscular. W weight-bearing line of L3: See gravitational line. viscosity: 1.ventral technique: See osteopathic manipulative treatment. vascular. visceral manipulation. (Fig. viscerosomatic r. 64) visceral dysfunction: Impaired or altered mobility or motility of the visceral system and related fascial. neurological. Figure 64. visceral manipulation. viscerovisceral reflex: See reflex. The capability possessed by a solid of yielding continually under stress. skeletal and lymphatic elements. Vertebral unit. A measurement of the rate of deformation of any material under load. ligamentous. vertebral unit: Two adjacent vertebrae with their associated intervertebral disk. visceral manipulation: See osteopathic manipulative treatment. viscerosomatic reflex: See reflex. 2. lymphatic and neural elements. vascular. 16) vertical axis: See sacral motion axis. (Fig. arthrodial. vertical (y) axis (longitudinal).