Osteopathic Atlas First Nicholas

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Principles of the Osteopathic Examination
Osteopathic Pri nci ples (P hil osophy)

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

S tr u c tu r e a nd f un c ti o n c o nc e pt s o f th e m y of a s ci a l a nd a rt i cu l ar p or t io n s o f t h e
mus c u lo s ke l et a l s y s t e m a r e i nh e re n t t o u n de r s ta n di n g o s te o pa t hi c di a gn o s t i c a n d
t he r a pe u ti c t e c hn i qu e s . For ex a mp l e , k no wle d g e o f t he o ri g in an d in s er t io n of mu s cl e s
( fu n c ti o na l a n a to my) is i mp e ra t iv e in th e p e r fo r ma n ce o f mus c le e ne r gy te c h ni q ue .
Und e r s t a nd i ng t he s t r uc t u re of th e sp i na l j o i nt s h e lp s in th e e v a lu a ti o n o f s p in a l
mec h a ni c s a nd i n t he di r e c t i on of a pp l ie d f o r ce s i n t e c hn i qu e s s u ch as hi g h -v e lo c it y ,
l ow - a mp l it u de ( HV L A) ma n i pu l at i on s , s u ch as whe n i t i s ne c es s ar y to co n si d e r o bl i qu e
c er v i ca l f a ce t s a n d c ou p l ed jo i nt mot i on .
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Barri er Concepts
B ar r i er s a r e a l so an im p o rt a nt co n c ep t i n t h e u n de r s t a n di n g a nd a pp l ic a ti o n o f
o s t e o pa t hi c t e c hn i qu e s . I n o s t e op a t hi c m e di c i ne , v a ri o u s b ar r ie r s t o m o ti o n h a ve be e n
c la s s ic a ll y d e s cr i be d w i t hi n t h e f r am e wo r k o f n o rm a l p h y s i ol o gi c mo t io n .
The g re a te s t r a ng e o f m o t io n i n a s pe c if i ed r eg i on is t he an a to mi c r an g e, a nd it s
p as s i ve li mit i s d es c ri b e d a s t he a na t om i c b a rr i er (1 ) . T h is ba r r ie r m a y b e t h e mos t
i mp o r ta n t t o u n de r s t a nd , as mo v em e n t b ey o nd t hi s p o in t ca n d i sr u p t t he ti s s ue s a n d
may r es u lt in s ub l ux a ti o n o r d i sl o c at i on . O s t eo p at h ic t ec h ni q ue s sh o ul d n e v er in v ol v e
mov e men t p a s t t hi s b a rr i e r!
The p hy s io l og i c r a ng e o f mo t io n i s th e l i mi t of ac t iv e mo t io n g i v en no r ma l an a to mic
s tr u c tu r es an d th e a r ti c u la r , myo f a s c i al , a n d o s se o us c om p on e nt s (1 ) . The p oi n t a t
whi c h t h e p hy s i ol o gi c m o t io n e n ds i s t he ph y s io l og i c b a rr i er . T h e t e rm el a s ti c b a rr i e r i s
u se d to de s cr i b e t he mo t i on be t we e n t h e p hy s i ol o gi c a n d a n at o mi c ba r ri e rs , wh i ch is
a va i l ab l e s ec o n da r y t o p a s s i ve my o f as c ia l a n d l i ga men t o us s t r et c h in g ( 1 ).
P. 6
Whe n a d y s f un c t io n al s t a t e e xi s t s , re d uc e d mo ti o n o r f u nc t io n o c c ur s , a nd a
r es t r ic t iv e b a r ri e r b et we en th e p h y si o lo g ic b ar r ie r s ma y b e d em o n s t r at e d ( 1 ). Th e
r es t r ic t iv e b a r ri e r, th e ma j or as p e c t of th e ov e ra l l d y s f u nc t io n a l p at t er n , c a n b e
e li mi na t ed or min i mi z ed wit h o s te o p at h ic tr e a tm e nt . M a n ip u la t iv e te c hn i qu e s
i nc o r po r at e a c t iv a ti n g f o rc e s i n t h e a t t e mp t to re mov e th e r e s t r i c t i ve ba r r ie r , b ut t he s e
f or c e s s ho u ld b e k ep t w i t hi n t h e b o un d s o f t h e p hy s io l o gi c b a rr i e rs wh e ne v e r p os s ib l e .
A p a t ho l og i c b a rr i er is mor e p e rm a n en t ; i t ma y b e r el a t ed to co n t ra c tu r es wit h in th e
s of t ti s su e s , o s t e op h y t i c d e ve l op me nt , a n d o t he r d e ge n e ra t iv e c h a ng e s ( e. g . ,
o s t e o ar t hr i ti s ) .
To a v oi d f u rt h e r i nj u ri n g t h e p at i e nt wi t h d i ag n os t ic o r t he r ap e u ti c t e ch n i qu e s , th e
p ra c t it i on e r mu s t un d er s t an d t h e n o rm a l c om p l ia n ce of t is s ue s a n d t h e l im i t s t he y
mai n t ai n . The s e d i f f e re n t b a rr i er s mu s t b e u n de r s t o od c om p le t el y , a s t h ey may ca u se
t he p hy s ic i an t o a lt e r t h e t ec h ni q u e c ho s en ( i. e . , in d i re c t v er s u s d ir e c t ) , o r m a y l i mi t
t he mot i on di r e c t e d i nt o th e t i s s u e s a nd or j oi n t s du r i ng tr e at me nt .
I n o s te o pa t hi c pr i nc i pl e s t h e p re s e nt s y s te m of de s cr i b in g t h e c a rd i na l m o t io n
d yn a mic s i n s p i na l m e ch a n ic s i s b a s ed on th e po s it i on a l a n d/ o r mo ti o n a s y mmet r y
r el a t ed to th e fr e ed o m o f m o ti o n ( 1 ). Pr e vi o u sl y , t he r e h a ve be e n o t he r w a y s t o
d es c r ib e t h es e as y mm e tr i e s . Th e d i r ec t io n i n wh i ch th e mo t io n w a s r e s t r ic t e d was th e
mos t co mmo n e a r ly me t ho d . O t he r p a s t d es c ri p t io n s i nc l u de d w h et h e r t he jo i n t was
o pe n or cl o se d . T h es e w e r e a ls o b a s ed on th e me c ha n ic a l f i nd i ng s re v ea l ed o n
p al p a ti o n. To d a y , th e g o v er n in g s y s te m i n u s e n a me s t h e b i om e ch a n ic a l f in d i ng s b a se d
o n mo ti o n r es t r ic t io n a n d /o r a s ym me tr y a n d t h e d ir e c t i o ns in wh i c h mot i on i s mos t f r e e.
Thi s mo t io n f r e ed o m i s a l so ca l le d ea s e, fr e e , a nd lo o s e. In my o f as c ia l d i a gn o s t i c
f in d i ng s , i t i s c o mm o n t o s e e b ot h th e f r ee d o m a nd th e li mit a ti o n u s ed (i . e . , lo o se ,
t ig h t ; e as e , b i nd ; a n d f r ee , r e s t r i c t e d) . Y e t t h e u se o f t he s e d e s c r ip t io n s d o es no t
a ll o w f o r p ro b l em s i n w h i ch mo t io n is s y mme t r ic a ll y a n d /o r u n iv e r sa l ly re s t ri c te d , a s
s ee n in so me p a ti e nt s .
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O ne o f t he mo s t i mpo r ta n t p r in c ip l e s i n d ia g n os i s a nd t re a tm e nt i s t o c on t r ol th e
t is s u e, jo i nt , or ot h er s tr u c t u re wit h in it s no r ma l ly a da p ti v e mo ti o n l im i t s . Th u s , t he
mot i o n i n a t r e at men t t e c hn i qu e s h o ul d b e w i t hi n n o rm a l p h y s i ol o g ic li mit s . C e rt a in l y ,
t he mot i on us e d s h ou l d a l wa y s b e wi th i n a na t o mi c l i mi t s . I t i s o u r p hi l os o p hy th a t
c on t r ol l in g m o t io n w i th i n t h e p hy s i ol o gi c l i mit s e n su r e s g re a te r sa f et y m a r gi n s whi l e
s ti l l k e ep i ng e f f i ca c y h i gh , w h er e a s mov i ng c lo s er to t he an a to mi c l im i t s i nc r ea s es r is k
wit h li t tl e i n c re a se in e f f i ca c y .
For e xa mpl e , i n a n H V LA t ec h ni q ue , th e r e s t r i c t i ve ba r r ie r s h ou l d b e e n ga g e d i f
e ng a g em e nt is t ol e ra t ed . Th e m o ve me nt ne c es s a ry to af f e c t th i s b a rr i er , h o wev e r,
s ho u l d b e o nl y 1 t o 2 d e g re e s o f mo ti o n ( s t i l l wit h in t he ph y si o l og i c l im i t s) , w h er e a s
t he a c t u al ph y s io l og i c b a rr i er of n or mal mo t i on ma y b e 5 t o 6 d e g re e s f ur t h er .
S omatic Dysfunction
S om a t ic dy s fu n c ti o n i s t h e d ia g no s t ic cr i te r i on fo r w h i ch os t eo p a th i c man i p ul a ti o n i s
i nd i c at e d. Th e EC O P d ef i n it i on of s om a ti c d y s fu n c t i on i s a s f ol l o ws :
I mp a i re d o r a l t er e d f un c t io n o f r e l at e d c om p o ne n t s of t he so mat i c
( bo d y f r am e wo r k ) s y s t em : s k e le t al , ar t hr o di a l , a nd my o f as c ia l
s tr u c tu r es , a n d r e la t ed v as c ul a r, l ym p ha t ic , an d n e ur a l e l em e nt s .
S om a t ic dy s fu n c ti o n i s t r ea t ab l e u s in g o s te o p at h ic ma n i pu l at i ve
t re a t me n t . Th e po s it i on a l a n d mot i o n a sp e c t s of so mat i c d y s f u nc t i on
a re b es t d e s c r i be d u s in g at le a s t o ne of th r e e p ar a me t e rs : ( a ) t h e
p os i t io n o f a b od y p a rt a s d et e rm i n ed by pa l p at i on an d re f er e nc e d t o
i t s a dj a ce n t d e fi n ed s t r u c t u re ; ( b ) t h e d ir e c ti o ns in whi c h mot i o n i s
f re e r ; a nd (c ) th e d i re c t io n s i n wh ic h m o ti o n i s r e s t r i c t e d ( 1) .
A s s o c ia t ed cr i t er i a f or s om a ti c d y s fu n c t i on a re re l at e d t o t i s s u e t e x t u re a bn o rm a li t y ,
a s y mmet r y , re s t ri c ti o n o f m o ti o n, a nd te n de r n es s ( mne mo ni c : TAR T) . The gl o s sa r y o f
o s t e o pa t hi c t e r mi n ol o gy s ta t es th a t a n y o ne o f t he s e mu s t be pr e s en t f o r t h e
d ia g n os i s . Th e pr i ma r y f i nd i ng s w e us e f o r t h e d ia g no s i s o f s om a t ic dy s fu n c ti o n a re
mot i o n r es t ri c t io n ( a nd r el a te d m o t io n a s ym me tr y , i f p r es e nt ) a n d t i s s u e t e x t u re
c ha n g es . T e nd e r ne s s ( so me p r ef e r s e ns i ti v it y ) c a n b e o n e o f t he g re a t p re t e nd e rs in
t he c li n ic a l p r es e nt a ti o n o f a pr o b le m. Ten d e rn e s s ma y be el i ci t e d o n p al p a ti o n d ue t o
p re s s ur e o r b e c au s e t he p at i en t w a n t s th e p h y si c ia n t o be l ie v e t h er e i s p a i n. Pa i n ma y
b e p r es e nt in o ne ar e a b u t t he pr i mar y d y s f u n c t i on or p ro b le m d i s ta n t . Th e r ef o re , w e
b el i e ve te n de r n es s ( s en s i ti v it y o r pa i n) to b e t he we a k es t o f t h e a f or e me n t io n ed
c ri t e ri a , a nd i n o ur pr a c ti c e i t i s u s ed in a l i mi t ed f as h io n , mo s t l y whe n im p le men t i ng
c ou n t er s tr a in t ec h ni q ue s .
Cer t a in qu a li t i es of th e s e c ri t er i a a r e p ar t i cu l ar l y c o mm o n i n s p ec i fi c t y p es of
d y s f u nc t io n s a r is i ng fr o m a c ut e a n d c h ro n ic s ta t es . I n c re a se d h e a t , mo i s t u r e,
h yp e r to n ic i t y , an d s o o n ar e c o mm o n w i th ac u t e p ro c es s e s . De c re a s ed he a t , d ry n es s ,
a tr o p hy , a n d s t ri n gi n es s of ti s su e s a r e mor e co mmo n w i t h c hr o ni c pr o bl e ms .
Myofasci al-Arti cul ar Com ponents
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A s t h e p re s en c e o f s o ma t i c d y s f un c t io n b y d e f in i ti o n ma y i nc l ud e my o fa s ci a l a n d
a rt i c ul a r c om p o ne n t s , t h e p a lp a to r y e x am i na t i on is an i mp o rt a nt p ar t o f t h e e v al u at i o n.
P al p a ti o n wil l de t er min e wh e th e r t h er e i s a p ri mar y m y o fa s ci a l o r a r ti c ul a r c o mp o ne n t o r
b ot h an d
P. 7
l ea d to th e d e v el o pm e nt o f t he mo s t a p pr o pr i a te tr e at me nt pl a n. S pe c if i c t y pe s o f
d y s f u nc t io n s a r e b es t t r e at e d b y c e rt a in te c h ni q ue s . Fo r e xa mpl e , a pr i ma r y t i s s u e
t ex t u re ab n or ma li t y i n t h e f as c ia i s b es t t r e at e d b y a te c hn i qu e th a t mos t af f ec t s
c ha n g e a t t ha t le v el (e . g . , my o fa s c ia l r e le a s e) , w h er e a s a no t he r te c hn i qu e ma y h a ve
n o r e al ef f ec t on th e s p e ci f ic ti s s ue in v ol v e d ( e. g . , HVL A ). Ar t i cu l ar dy s f un c ti o ns , on
t he o th e r h an d , a r e b es t tr e at e d wi th an ar t i cu l ar te c h ni q ue , s u c h a s HVL A , a n d
myo f a s c i al re l e as e w o ul d be le s s a p pr o pr i at e .
V isceral -Autonomic Components

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

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

The p al p at o ry e xa min a ti o n i s a l so b es t s t ar t e d b y o bs e r vi n g t he a re a o f i n t er e s t fo r
a ny v as o mo t or , de r ma t ol o g ic , o r d e v el o pm e nt a l a b no r ma l i ti e s . Th e ex a mi n at i o n may
t he n pr o ce e d t o t e mp e ra t u re ev a lu a t io n . The p hy s ic i an may no w m a k e c on t ac t wi t h t he
p at i e nt fo l lo wi ng a l ay e r -b y -l a ye r ap p ro a ch t o t he ex a min a ti o n t o e v al u at e th e t i s s u e
t ex t u re . T h is a pp r oa c h p e rm i t s th e ex a mi n er t o d is t in c t ly mo n it o r e a ch an a t om i c l ay e r
f ro m a s up e rf i c ia l t o d e e p p er s pe c t iv e t o b e s t d et e rm i n e t he ma g n it u de of a nd sp e ci f i c
t is s u es in v ol v e d i n t he d y s f un c ti o n al s t a te . Th e t i s s u e s a re pr o g re s si v el y ev a lu a te d
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t hr o u gh ea c h e n su i ng la y e r a nd de p t h b y a dd i n g a s l ig h t ly gr e at e r p r es s ur e wi t h t he
p al p a ti n g f in g e rs or ha n d . The ph y s ic i an sh o u ld al s o a t te mpt to mon i to r t h e t i s s u e
t ex t u re qu a li t y a n d a ny d yn a mi c f l u id mo v em e n t o r c ha n g e i n t is s u e c om p li a n ce . D u ri n g
p al p a ti o n o ve r a v is c er a , t h e mob i l it y o f t h a t o rg a n ma y b e e va l u at e d a lo n g w i th an y
i nh e r en t m o ti l i t y pr e se n t w i th i n t h at or g an .
A no t h er me t ho d th a t we c o mm o nl y u s e i s a s c r e en i ng ev a l ua t io n u s i ng pe r cu s s io n o v er
t he p ar a sp i na l mu s cu l at u r e, wi t h p a ti e nt se a t ed or pr o n e, to de t e rm i ne di f f er e nc e s i n
mus c l e t on e a t va r io u s s p in a l l ev e l s . In th e th o ra c ic a nd lu mba r ar e as , a
h yp e r t y mpa n ic r ea c ti o n t o p e rc u s s i o n a pp e ar s to be as s o ci a te d w i t h t he si d e o f t h e
r ot a t io n al co mp on e nt .
The s e s t ep s i n th e e x am i n at i on ev a l ua t e t he p os t ur a l a n d r eg i on a l m o ve men t
r am i f ic a ti o ns i nv o lv e d i n t h e p at i e nt ' s p ro b l em , i n a d d it i on to e li c it i ng a ny gr o s s a nd
f in e ti s su e t e x tu r e c ha n g es . T h e f i na l s t ep i n t he ex a min a ti o n i s t o d e te r min e w h et h e r
t he r e i s a re l a te d a r ti c u la r c o mp o n en t t o t h e p a ti e nt ' s p r ob l em . Th i s i nv o l ve s
c on t r ol l in g a j oi n t a nd p ut t in g i t th r ou g h v e ry fi n e s mal l m o ti o n a r c s in a ll ph a se s of it s
n or ma l c ap a bi l i ti e s ( in t e rs e gm e nt a l m o ti o n t e s t i ng ) . Th e p hy s ic i a n a t t e mp t s w i th a
t hr e e -p l an e m o t io n e x am i n at i on to d et e rm i ne whe t he r t h e m o ti o n i s n o rm a l a n d
s ym me tr i c o r wh et h er pa t h ol o gy is r es t ri c ti n g m o ti o n, wit h o r w i t ho u t a s y mmet r y i n t h e
c ar d i na l a x es . Fo r e x am p l e, th e C 1 se g me n t ma y b e r es t r ic t ed wi t h in it s n o r ma l
p hy s i ol o gi c r a n ge of ro t a ti o n a nd e xh i bi t e i t he r a bi l a te r al l y s y mm e tr i c r e s t r ic t io n in
r ot a t io n ( e .g . , 3 0 d e gr e e s r ig h t a n d l ef t ) o r a n a s ym me tr y o f m o t io n w i th g re a te r
f re e d om in on e di r ec t io n th a n t he o th e r ( e. g . , 3 0 d eg r e es ri g ht , 40 de g re e s l e f t ) . A s
s ta t e d p re v io u s ly , m o s t d es c ri p ti o n s o f s om a t ic dy s fu n c ti o n r el a t e t o t he a s y mme t ri c
r es t r ic t io n s , b ut s y mme t r ic re s tr i c ti o ns ar e se e n c li n i ca l ly .
I n p e rf o rm i ng t he s t e pw i s e l ay e r- b y -l a ye r p a l pa t or y e x a mi n at i on a nd fi n is h i ng wi t h t h e
i nt e r se g me n ta l mo t io n e v a lu a ti o n, t he ph y si c i an ca n d e t er min e t h e s p ec i fi c ti s su e s
i nv o l ve d i n t h e d y s f u nc t i on (e . g. , mu s cl e , l i ga men t , c a ps u la r ), t he ex t en t to wh i ch i t i s
p re s e nt (e . g. , si n gl e s e g me n t , re g i on a l) , a n d w h et h er t he pr o ce s s i s a c ut e , s u ba c ut e ,
o r c h ro n ic . T h e se de t er mi na t io n s p r ep a re th e ph y si c ia n to de v el o p t h e mos t
a pp r o pr i at e t r e at men t p l a n f or th e so mat i c d y s f u nc t io n or dy s fu n c ti o ns .
P. 8
References
1 . G l os s a ry Re v ie w Co mmi t te e , E d uc a ti o n al Co u nc i l o n O s te o p at h ic Pr i n ci p le s o f
t h e A me r i ca n A s so c i at i on of Col l eg e s o f O s te o pa t h ic Me d ic i n e. Gl o s s a r y o f
O s te o pa t h ic Te r mi n o lo g y . ww w. aa c om . or g .
2 . W a rd R ( e d) . F o u nd a ti o ns f or Os t eo p a th i c Med i c in e . P hi l a de l ph i a: L ip p in c ot t
Wi ll i am s & Wil k in s , 2 0 03 .
3 . N i ch o l as AS , D e B ia s D A , E h re n fe u ch t e r W, e t a l . A S o ma t i c Com p on e n t t o
My oc a rd i a l I nf a rc t i on . B r M e d J 19 8 5; 2 9 1: 1 3– 1 7.
5 of 6 21/08/07 22:00
6 of 6 21/08/07 22:00
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
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
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
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
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
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
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
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
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
Spinal Region al Range o f Motion
Re g io na l m ot i on t e st in g e va l ua te s p at i en ts ' a bi l it y t o mo v e th rou gh th e c ar di n al a x es o f m ot i on a n d re f le ct s t he i r
ab i l i ty to m o ve w i th p a in , d eg en e ra ti v e jo i nt d i se as e , mu s c l e t en s i o n, i n fl am m at io n , st rai n o r sp rai n, an d s o on .
Th e s ta t i c e x am in a ti on wi l l gi ve c l ue s o f m ot io n p at t er ns to e x pe ct on i n te rs e gm en t al m o ti on te st i ng t o b e
pe rfo rm e d la t er . T he r a ng es th at ar e a c c ep t ed a s n or m al d e pe nd up on th e p at ie n t' s s om at o ty pe . T he y v ar y f ro m
on e t yp e o f p at ie n t to an ot h er ; h en ce th e t er m ran ge s . Me s om or p hi c p at ie n ts s h ou ld be m i dr an g e, e c to mo rph i c
(l o ng l i ne ar ) p at i en ts at t h e hi g h ra n ge , a nd e n do mo rph i c pa ti e nt s (br ev i l i ne a r) a t t he lo we r r an g e of mo ti o n
ex p ec ta t io n.
P .1 8
Cervical Spin e: Fo rward Bend ing and Backward Ben ding (Flexion and
Ext ensio n), Active
1. The pa tie nt is sea t ed .

2. The ph ysici an stan d s at
t he si de of th e pa t ie nt.
3. The ph ysici an pa lp a tes
t he C7 -T1 spi n ou s
p ro ces s inter spa ce (Fig.
3 .1) o r t he sp in ou s
p ro ces se s (Figs. 3 . 2
a nd 3.3) .
4. The pa tie nt is ins t ru cte d
t o b en d t he h e ad a n d
n ec k for war d t o the
f un ction a l an d p ai n -fre e
lim itatio n of mo tio n (Fi g. Figur e 3.1 . Ste p 3.
3 .4).
5. The de gr e e of
f or war d- b en di n g fle xi on
is n oted . N or mal fo rw ar d
b en d in g o f the cer vic al
spi n e is 45 to 9 0
d eg ree s.
t o b en d t he h e ad a n d
n ec k b ac kwa rd as fa r
p os sib le wi thin the
p hy sio lo g ic a n d
p ai n -fre e ran g e of
motion (Fig. 3 .5). Figur e 3.2 . Ste p 3.
7. The de gr e e of ba ckwar d
b en d in g is no t ed .
Nor mal b a ckwa rd
b en d in g o f the cer vic al
d eg ree s.
1 of 18 21/08/07 22:01
Figur e 3.3 . Ste p 3.
Figur e 3.4 . Ste p 4, ac tive forwa rd

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

be nd ing .
P .1 9
Cervical Spin e: Fo rward Bend ing and Backward Ben ding (Flexion and
Ext ensio n), Passive
2 of 18 21/08/07 22:01

t he C7 -T1 spi n ou s
p ro ces s inter spa ce (Fig.
3 .6) o r t he sp in ou s
p ro ces se s (Figs. 3 . 7
a nd 3.8) .
4. The ph ysici an be nd s
t he pa tie nt's he ad an d
n ec k for war d whi le
mon itori n g C7 an d T1
a nd stop s whe n motion Figur e 3.6 . Ste p 3.
is d etec t ed a t T1 (Fig.
3 .9).
5. The de gr e e of flex ion is
n ote d. No rm al flex ion o f
t he ce rv ica l spi ne is 4 5
t o 9 0 de g re es .
6. The ph ysici an then
e xte nd s t he p a tien t 's
h ea d a nd ne ck wh il e
a nd stop s whe n motion
3 .10 ).
7. The de gr e e of Figur e 3.7 . Ste p 3.
e xte ns io n is n oted .
Nor mal e xtens ion o f the
cer vic al sp in e is 4 5 to
9 0 d eg re e s.
Figur e 3.8 . Ste p 3.
3 of 18 21/08/07 22:01
P .2 0
Cervical Spin e: Side Bending , Act ive and Passive

t he tran sve rs e
p ro ces se s o f C7 an d T1
(Fig. 3.1 1) .
t o sid e- b en d t he h e ad
a nd ne ck to th e ri g ht to
t he func t io na l a nd
p ai n -fre e lim itatio n of
motion (Fig. 3 .12) . Thi s
is rep ea t ed to the le ft Figure 3 . 11 . S tep 3 .
(Fig. 3.1 3) .
5. The ph ysici an
sid e -b en d s the p atien t's
h ea d a nd ne ck to th e
rig h t wh ile mo ni torin g
C7 a nd T1 a nd stop s
whe n motion is
d ete cted at T1 (Fig.
3 .14 ). Th is is rep e ated
t o t he le ft (Fig. 3 .15) .
6. The de gr e e of bo th
a ctive a n d pa ssi ve si de
b en d in g is no t ed .
Nor mal side b e nd in g in Figure 3 . 12 . S tep 3 , ac t iv e sid e b en di n g
t he ce rv ica l spi ne is 3 0 rig h t.
t o 4 5 de g re es .
Figure 3 . 13 . S tep 4 , ac t iv e sid e b en di n g

left .
4 of 18 21/08/07 22:01
Figure 3 . 14 . S tep 5 , pa ssi ve si de

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

b en d in g left.
P .2 1
Cervical Spin e: Ro tatio n, Active and Passive

t he tran sve rs e
p ro ces se s o f C7 an d T1
(Fig. 3.1 6) .
t o rotate the he ad to
t he ri gh t to t he
lim itatio n of mo tio n (Fi g.
t o t he le ft (Fig. 3 .18) . Figure 3 . 16 . S tep 3 .
5. The ph ysici an ro tat es
t he pa tie nt's he ad to
5 of 18 21/08/07 22:01
t he ri gh t whi le
a nd stop s whe n motion
6. The de gr e e of bo th
a ctive a n d pa ssi ve
rota tion is n o ted. No rm a l
rota tion in th e ce rvi ca l
d eg ree s.
Figure 3 . 17 . S tep 4 , ac t iv e rotation righ t.
Figure 3 . 18 . S tep 4 , ac t iv e rotation le ft.
Figure 3 . 19 . S tep 5 , pa ssi ve ro tat io n

rig h t.
6 of 18 21/08/07 22:01
Figure 3 . 20 . S tep 5 , pa ssi ve ro tat io n

left .
P .2 2
Tho racic Spin e: T1 to T 4 Sid e Ben ding, Passive

2. The ph ysici an stan d s
b eh ind th e pa t ie nt.
3. The ph ysici an ' s le f t
ind e x fin ge r o r thu mb
may pa lp a te th e
t ra n sver se pr o ce sse s of
T4 a nd T5 o r t he
inte rs pa ce be t we en
t he m to mon ito r mo t io n.
The we bb ing b e twee n
t he ph ysici an ' s ri g ht
ind e x fin ge r a nd th um b
is p la ce d o n t he Figur e 3.2 1. St ep 3 .
p atien t's rig h t sh o ul de r
clo ses t t o mi d li ne at th e
lev e l of T1 (Fig. 3 .21) .
4. A g e ntle sp ri n gi ng forc e
is d ir ec t ed to wa rd the
ver t eb ra l b od y o f T4
u ntil the p hy sic ia n fee ls
motion o f T4 o n T5. Thi s
is d on e b y cr e atin g a
vec t or with th e forea rm
t ha t is d ir ec t ly in lin e
with the ve rte br al bo dy
o f T4 (Fi g. 3 . 22 ). This is
rep e ated to th e op p os ite Figur e 3.2 2. St ep 4 , sid e b en d in g rig ht.
sid e (Figs. 3 . 23 a nd
3 .24 ).
5. The de gr e e of pa ssive
7 of 18 21/08/07 22:01
sid e b en d in g o n ea ch
sid e is n oted . N or mal
sid e b en d in g f or T1 to
T4 is 5 t o 25 de gr e es .
Figur e 3.2 3. St ep 4 .
Figur e 3.2 4. St ep 4 , sid e b en d in g left.
P .2 3
Tho racic Spin e: T5 to T 8 Sid e Ben ding, Passive

h an d p al p ates the
T8 a nd T9 o r t he
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 Figure 3 .25. Step 3.
b etwee n t he b a se o f the
p atien t's n ec k a nd the
a cr o mi on pr oc e ss (Fig.
3 .25 ).
8 of 18 21/08/07 22:01
motion o f T8 o n T9. Thi s
is d on e b y cr e atin g a
vec t or with th e forea rm
o f T8 (Fi g. 3 . 26 ). This is
rep e ated to th e
o pp o si te si de (Figs .
3 .27 a nd 3.28 ).
5. The de gr e e of pa ssive Figure 3 .26. Step 4, side b e nd in g rig h t.
sid e b en d in g o n ea ch
sid e is n oted . N or mal
sid e b en d in g f or T5 to
T8 is 10 to 3 0 d eg ree s.
Figure 3 .27. Step 4.
Figure 3 .28. Step 4, side b e nd in g left .
P .2 4
Tho racic Spin e: T9 to T 12 Side Bending , Passive
9 of 18 21/08/07 22:01

h an d may pa lp a te th e
T12 an d L 1 or the
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 Figur e 3.2 9. St ep 3 .
a t t he a cro mi o cl av icu la r
reg ion (Fig. 3 .29) .
motion o f T12 on L 1 .
Thi s is d on e b y cr e atin g
a ve ctor wi th the f or ea rm
o f T12 (Fig. 3 .30) . Thi s
is rep ea t ed to the
o pp o si te si de (Figs . Figur e 3.3 0. St ep 4 , sid e b en d in g rig ht.
3 .31 a nd 3.32 ).
5. The de gr e e of pa ssive
sid e b en d in g is no t ed o n
e ac h sid e . No rma l sid e
b en d in g f or T9 to T12 is
2 0 t o 40 de gr e es .
Figur e 3.3 1. St ep 4 .
10 of 18 21/08/07 22:01
P .2 5
Tho racic Spin e: T9 to T 12 Ro tatio n, Active
1. The pa tie nt is sea t ed

with the ar ms cr os sed so
t ha t the el bo ws ma ke a
V fo rm ation .
t he si de of th e pa t ie nt
a nd pa lp a tes t he
p atien t's tra n sver se
p ro ces se s o f T12 a n d
L 1, wh ic h a re us ed to
mon itor rotation (Fig.
3 .33 ).
t o rotate the up pe r b od y Figure 3 .33. Step 2.
(tru nk ) t o the rig h t to the
lim itatio n of mo tio n (Fi g.
Figure 3 .34. Step 3, a ctive ro tat io n

ri g ht.
Figure 3 .35. Step 3, a ctive ro tat io n left.
P .2 6
Tho racic Spin e: T9 to T 12 Ro tatio n, Passive
11 of 18 21/08/07 22:01
1. The pa tie nt is sea t ed

with the ar ms cr os sed so
t ha t the el bo ws ma ke a
V fo rm ation .
t he si de of th e pa t ie nt
a nd pa lp a tes t he
p atien t's tra n sver se
p ro ces se s o f T12 a n d
L 1, wh ic h a re us ed to
mon itor rotation (Fig.
3 .33 ).
3. To t es t p as si ve ri g ht
rota tion , the ph ysici an ' s Figure 3 .36. Step 3, p a ssiv e rota tion
rig h t ha n d is pl ac e d on ri g ht.
t he pa tie nt's el bo ws or
o pp o si ng le ft sh ou lde r.
The ph ysici an ro tat es
t he pa tie nt to wa rd the
rig h t wh ile mo ni torin g
motion a t T12 -L1 (Fig.
3 .36 ). Th is re pe ate d to
t he op po site sid e (Fig.
3 .37 ).
4. The de gr e e of ac tive
a nd pa ssive ro tatio n is
n ote d. N o rm al ro tat io n
f or T9 to T12 is 7 0 to 9 0
d eg ree s. Figure 3 .37. Step 3, p a ssiv e rota tion
le f t.
P .2 7
Lum bar Spine: Forw ard Bendin g and Backward Bending (F lexio n and
Ext ensio n), Active
12 of 18 21/08/07 22:01
1. The pa tie nt st an ds in a ne utral p o si tio n

with fee t a sh ou ld e r- wi d th a p ar t.
2. The ph ysici an stan d s to the sid e o f the
p atien t so as to view th e pa t ie nt in a
sag ittal pl an e (Fig. 3.3 8) .
3. The pa tie nt is ins t ru cte d to be nd forw a rd
a nd attempt to tou ch the toe s with ou t
b en d in g t he kn ee s t o the fun ction a l an d
p ai n -fre e lim itatio n of mo tio n (Fi g. 3 . 39 ).
4. The de gr e e of ac tive forwa rd be nd ing is
n ote d. No rm al flex ion fo r the lum b ar
spi n e is 70 to 9 0 d eg re e s.
5. Motion is the n tes t ed fo r ba ckw ar d
b en d in g in the lum b ar re gi on . The pa tie nt
stan ds in a n e utra l p os ition wi th feet a
sho u ld er -wi dth a pa rt. Th e pa t ie nt is
ins t ru cte d to be nd ba ckwar d t o the Figure 3 . 38 . S tep 2 .
f un ction a l an d p ai n -fre e lim itatio n of
motion wh il e t he p h ysic ian su pp or t s the
p atien t's u pp e r bo d y (Fi g 3.4 0) .
6. The de gr e e of ac tive ba ckw ar d b en d in g
is n oted . N or mal e xtens ion fo r the lum b ar
spi n e is 30 to 4 5 d eg re e s.
Figure 3 . 39 . S tep 3 ,
a ctive fo rw ar d b en d in g.
a ctive b a ckwa rd
b en d in g.
13 of 18 21/08/07 22:01
P .2 8
Lum bar Spine: Side Bend ing, Active
1. The pa tie nt st an ds in a ne utral p o si tio n

with fee t a sh ou ld e r- wi d th a p ar t.
2. The ph ysici an stan d s be h in d t he p a tien t
so a s to vi ew the p atie n t in a co ron al
p la n e (Fi g. 3 . 41 ).
3. The pa tie nt is ins t ru cte d to re ac h d ow n
with the ri gh t h an d tow a rd th e kn e e to
t he func t io na l a nd pa in -free li mi t atio n o f
motion (Fig. 3 .42) . Thi s is rep ea t ed to
t he op po site sid e (Fig. 3.43 ).
4. The de gr e e of ac tive si d e be n di ng is
n ote d. N o rm al si de be nd ing in the
lum b ar sp in e is 25 to 3 0 d eg ree s.
Figure 3 . 41 . S tep 2 .
a ctive side b e nd in g rig h t.
14 of 18 21/08/07 22:01
a ctive side b e nd in g left .
P .2 9
Lum bar Spine: Side Bend ing, Passive, w ith Active Hip Drop Test
1. The pa tie nt st an ds in a ne utral

p os ition wi th feet a sh o ul de r-w id t h
a pa rt.
2. The ph ysici an stan d s be h in d t he
p atien t so as to view th e pa t ie nt in a
cor o na l p la ne . The ph ysici an ' s ey e s
sho u ld b e lev e l wi t h the lum b ar sp in e
(Fig. 3.4 4) .
3. The pa tie nt a t temp t s to ma in t ai n
sym metri c wei g ht b e ar in g o n b oth leg s
a nd then qu ic kly flex es the rig ht kn ee ,
cau sin g a rig h t sa cra l b as e
d ec lin ation , h en ce ca us ing th e pe lvi s
t o com pe n sa te wi th a la t er al
t ra n sl ation to the le ft (Fig. 3 .45 ). Th is
is rep ea t ed o n the op po site sid e (Fig.
3 .46 ). Figure 3 .44 . Ste p 2.
4. The de gr e e of le ft lu mb a r si d e be n di ng
is n oted . N or mal side b e nd in g in t he
lum b ar sp in e is 25 to 3 0 d eg ree s.
15 of 18 21/08/07 22:01
Figure 3 .45 . Ste p 3,

p as si ve si d e be n di ng le ft
with rig ht sa cr a l ba se
u nl ev e li ng .
Figure 3 .46 . Ste p 3,

p as si ve si d e be n di ng ri gh t
with left sac ra l b as e
u nl ev e li ng .
P .3 0
Norm al Spinal Ra nge s of Motion for Act i ve a nd Pa s sive Test i ng
Gui des to
Ev a luat i on
of
Pe r ma nent
Impairm e nt
(A MA) (1 ) Angus Ca thi e, D. O. (2 ) Rev ise d PC O M (3 )
NORMA L DEGREES O F MOTION– CER VICAL SP INE
16 of 18 21/08/07 22:01
FLEXI ON 50 90 4 5- 9 0
EXTENSION 60 45 4 5- 9 0
SIDE B EN DING 45 3 0- 4 0 3 0- 4 5
R/L
ROTATION 80 90 7 0- 9 0
R/L
No rm a l degre es of m otion– Thora cic S pine
T1- 3 T4 -8 T8-L 1 T1- 4 T5 -8 T9- 1 2
FLEXI ON 45
EXTENSION 0
SIDE B EN DING 45 35 45 5 -2 5 1 0 -3 0 2 0- 4 0
R/L
ROTATION 30 90 7 0- 9 0
R/L
NORMAL DE GREES OF MOTION–LUM BAR SP INE
FLEXI ON 6 0+ 7 0- 9 0
EXTENSION 25 3 0- 4 5
SIDE B EN DING 25 25 2 5- 3 0
R/L
ROTATION
R/L
Fl ex ion = forw a rd b e nd in g ; Ext en si o n = b ac kw a rd b e nd in g ; R/L , ri g ht a n d le f t.

1. Re pr in t ed with p e rm is sio n f ro m Coc ch iar el la L, An de rsson G (e d s) . G ui de s to
the E va lu a tion of Pe rm an e nt Impa ir men t. 5th e d. Ne w Yo rk. Amer ic a n Me d ic al
Asso cia tio n, 2 0 01 .
17 of 18 21/08/07 22:01
2. Ca thie A, Ph il ad e lp hi a Col leg e o f Ost eo pa t hy . Fro m Dr. Ca thie ' s PC O M (OP P)

no teb oo k, pu bl ish ed in THE D.O ., Ju ne 1 9 69 a n d re -pr in t ed in the 19 74
Ye ar b oo k o f the Ame ric an Acad e my o f Oste op ath y. Co lo ra d o Sp rin gs , CO:
Amer ica n A ca de my of Osteo pa thy, 19 7 4, p . 7 2.
3. Nich ol a s A. Osteo pa thic Ma n ip ul a tive Me di cin e Man ua l. Ph ila de lph ia :
Ph il a de lp h ia Co ll eg e o f O steo p athi c Med ici ne , 2 00 6 .
18 of 18 21/08/07 22:01
4
Osteopathi c Layer-by-Layer Pal pation
Examinatio n Seq uence

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

A ve ry l i g ht t o uc h w i l l b e us e d. G e nt le pa lp a ti on wi th th e p al ma r s ur f ac e o f th e t ip s o f t he f i ng er s w i l l p ro v id e t he
ne ce s sa ry pr es s ur e. Th e p re s s u re w i l l p e rm it th e f in ge r p ad s t o g l i de ge nt l y ov e r th e s k i n w it h ou t d ra g (fr i c t io n) .
Th er e s ho u ld b e n o c ha ng e i n t he c o lo r o f th e p hy s i c ia n 's n a i l be d s. W h en t h e ph y s i c i a n i s to uc h in g t he p a ti en t ,
it i s i mp o rt an t t o e xp la i n th e n at u re o f t he ex am i na ti o n an d r ec e i v e t he p a ti en t 's a c ce pt a nc e b ef or e c on t in ui n g.
Th er e fo re , i t i s im p or ta n t to be p rep ar e d me n ta l l y t o a pp l y th e h an d a s co n fi de n tl y a nd p rof es s io na l l y a s
po s s i bl e.
P .3 2
S k in to po g ra ph y a nd te xt u re a re ev a lu at e d fo r i nc rea se d o r d ec re a se d h um id i ty , o i l in e s s , t hi c k e ni ng , r ou g hn es s ,
an d s o on .
Figure 4 .2. A a n d B. Eval u atio n for ther mal a sym me t ry .
Fascia
Th e p hy s i c ia n a dd s e no ug h p re s su re to m o ve t h e s k i n wi t h th e h an d t o e va lu a te t h e fa s c i a. Th i s pr es s ur e w i l l
ca us e s l i g ht r e dd en i ng o f t he na i l b ed . T he p h y s i c i an m o ve s t he h a nd v e ry g e nt l y in c e ph al a d, c a ud ad , l ef t , ri g ht ,
c l oc k wi se , a nd co un t er c l o c k wi s e di rec ti o ns t o e l i c it m o ti on an d t en s i o n qu a l i ty ba rr i er s o f ea s e an d b in d ( Fi g .
4. 3) . M in i ma l c ha ng e s in pr es s ur e t o ev a lu at e t he di ff e re nt le ve l s of fa s c i a ar e h el p fu l.
Muscle
Mu s c l e i s de ep e r ti s su e; th er e fo re , t he ne xt de gr e e of pa lp a to ry pr es s ur e i s ap p l i ed . T he ph y s i c i an ad ds s l ig h tl y
mo re pr es s ur e t o ev a lu at e t he mu s c l e' s c on s i s te nc y a nd de te rmi ne s w he t he r t he re i s r o pi ne s s, r e s i st a nc e t o
pr es s ur e, st ri n gi ne s s, a n d so on . T hi s p re s s u re w i l l c a us e b la nc h in g o f th e p hy s i c ia n 's n a i l be d s (F i g. 4 . 4) .
2 of 5 21/08/07 22:01
Figure 4 .3. Fas cia l e va lu a tion for e as e– b in d a symm e try.
Figure 4 .4. Bla n ch in g o f t he n a il b e d wi t h mu scl e d ep th pa lp a tion .
Tendo ns
Te nd o ns s h ou ld be t rac ed to t h ei r b on y a tt ac h me nt s a s w el l a s to th ei r c on t in ui t y wi t h mu s c l e. An y f ib ro u s
th i c k en in g , ch a ng e i n el a st i c i ty , a nd s o o n s ho ul d b e n ot ed .
Ligam ents
Li ga m en ts mu st be c o ns id e re d w he n res tr i ct io n o f j oi nt mo ti o n, h y pe rm o bi l i t y (j o in t l ax it y ), p a in , a nd s o o n a re
pr es e nt . Obv io u s l y, l i ga m en ts va ry in t y pe a n d ar e m or e o r l es s p al pa b le d e pe nd i ng o n t he i r an a to mi c
pl ac e me nt .
Eryth ema F riction Ru b

Th e f in al st ep i s t o p er f or m t he e ryt he m a fr i ct io n r ub , i n w hi ch th e p ad s o f th e p hy s i c ia n 's s e co nd an d t hi rd di gi t s
ar e p la ce d j us t p ar a sp in a l l y a nd t h en i n t wo to t h re e q ui c k st ro k es d raw n d ow n t he s p in e c ep ha l ad t o
P .3 3
ca ud a d. P a l l or or r e dd en i ng i s e va l ua te d p er sp in a l se g me nt fo r v as om o to r c ha ng e s th a t ma y b e s ec on d ar y t o
3 of 5 21/08/07 22:01
dy sf u nc ti o n. T h i s i s n ot ty pi c al l y do ne on t h e ex t re mi t ie s, as t h e pu rpo se of t h i s t e st i s t o i de nt i fy c e nt ra l s pi n al
ar ea s o f a ut on o mi c c ha ng e r el a te d t o se g me nt a l dy s fu nc t io n (Fi g. 4. 5) .
Figure 4 .5. A to C . E ry the ma fric tio n ru b .
P .3 4
Thoracic Region Cross-Section
4 of 5 21/08/07 22:01
Lumbar Reg ion Cross- Section
5 of 5 21/08/07 22:01
5
Intersegmental Motion Testing
In ters egm ent al m oti on test i ng is c la s si c al l y d esc r ib ed a s a n e v alu ati on of s pin al ar ti c ul ato r y ( fac et)
mo ti on . I n t hi s c ha pte r it is al s o c ons i de r ed as a t ec hn i qu e t o el i ci t a ny m oti on at a jo i nt ( ar tic ula ti on ) ,
wh ethe r s pin al , pel v ic , co s ta l , or e x tr emi ty . D ep end i ng on the j oi nt, th e mo tio ns ev al uat ed m ay i nc l ud e
fl ex io n a nd ex te nsi on; r ot ati on; s id e b end i ng and ro tati on c ou pl in g; tra ns la tio nal m ot i on s a nter i or l y,
po s ter i or l y, or l at era l l y; se par atio n o r a ppro x im ati on o f j oin t su r fa c es ; an d t ors i ona l m ove m ent s .
In s pi nal mo ti on te s ti ng, the ph y s ic i an at temp ts to di sc ern th e th r ee - pl ane m ot i on an d th e r ela ti on be twe en

si de b end i ng and ro tat i on ( co upl i ng) . T he phys i ci an c an det erm i ne the co upli ng s ta tus and wh ethe r t he
ar ti cu l ar so m ati c d y sf unct i on is exh i bi tin g a typ e 1 ( op pos i te s id e) or ty pe 2 ( sa m e s i de ) p atte r n ( Fi gs .
5. 1 a n d 5.2) . I n th e t hora c ic or l um bar re gi on , i f t he d y sf unc ti on al pat tern is fo und to be ty pe 1, th e
ex am in ati on i s c omp l et e, a s t he s egm ent ha s a neu tra l re l at i on w it h t he c oup l in g. If t he dys func tio n
ex hi bi ts a t y pe 2 c oup l i ng pa tte r n, the ph y s ic i an mu s t t y pi c al l y c ont i nu e th e e x am i nat i on to det erm i ne
wh ethe r a fl ex io n o r e x ten s io n c om po nen t i s as s oc i at ed w i th th e co upl ed m oti ons of the dy s fu nc ti on. In
th e ce r vi c al s pi ne, th es e c ou pli ng r ela tio ns f oll ow a di ffe r en t se t o f b i ome c ha nic al r ule s f r om tho s e of t he
th or ac i c and l um bar re gi on s . In the c er v ic al s pin e, fl ex i on , e x ten s io n, and neu tra l co m po nen ts m ay be
fo und w it h t y pe 1 o r 2 c ou pli ng; or i n the c as e o f C 1- C2 mo tio n, t her e m ay b e n o c oupl i ng at all .
1 of 59 21/08/07 22:02
F igure 5.1. Type 1 spinal coupled pattern.
So m e p hys i ci ans pre fer to s ta r t w i th th e f l exi on and ext ens i on por tio n o f th e e x am i nat i on an d th en fol l ow
wi th r ota tio n an d/o r s i de ben din g to de ter m i ne th e c oupl i ng co m pon ent s f or d ete r mi nati on of a ty pe 1 o r
ty pe 2 dy s fu nc ti on. Be c aus e o f t he b i om ech anic al pat tern s
P.36
in here nt to s pec i fi c r egio ns, th e mo tio n m os t eas i ly tes ted ma y va r y. Fo r ex amp l e, i n the C2 to C 7
re gi on , i t m ay b e b est to tes t s i de ben din g fi r st . H ow ev er, it i s alw ays bes t t o t es t the co uple d s egm ents
to geth er and tes t t he fl ex i on or ext ens i on c om pon ent s be for e o r af ter th e co upl ed test i ng . T hi s i s als o tr ue
wh en p erf orm i ng ost eop athi c m ani pula tiv e t r eat m en t ( OM T) , s uch as m us c le ene r gy te c hni que , w hen all
th r ee axe s a r e t o b e t r eat ed. Th e co upl i ng s ho uld al w ays be ke pt u nif i ed .
F igure 5.2. Type 2 spinal coupled pattern.
Th er e are a numb er of w ays to te s t m oti on av ai l ab i li ty ( qua l it y an d q uan ti ty ) a t a n ar tic ula ti on . W e p r efe r

a m eth od tha t in tro duc es m oti on di re c tl y t o th e j oin t us i ng ph y s ic al c on tact on bo ny l and m ar k s ( e.g .,
ce r v ic al art i c ul ar pro c ess es) us i ng a q uic k im pul s e. W e use th e te r m pos i tiv e w hen re ferr i ng to thi s f orm
of m ot i on te s tin g. An ex am ple of pos i ti v e m oti on tes ti ng is a l umb ar s pr i ng tes t f or f l ex i on and ex ten s i on
co m pon ent s o f dy s fu nct i on. Mo tio n av ail abi l i ty ca n b e in s ta ntl y as c er tai ned i n w hi c hev er dir ec ti on the
2 of 59 21/08/07 22:02
im puls e w as v ect ore d, and the ph y s ic i an ha s a hig h d egre e o f c er ta i nt y t hat the mo ti on pa l pa ted i s
oc c urr i ng at thi s l oca ti on .
An othe r c omm on m eth od i s u s e of v i su al c lu es . In thi s me tho d, the phy s ic i an l oo k s for a c han ge i n

re l ati on ( sy m m et r y or as ym m et r y) of s up erf i c ia l a nat om ic la ndm ar ks as th e pa tie nt ac ti v el y m ov es
th r oug h a ra nge of m ot i on. We us e th e t erm pre s um pti v e w hen re ferr i ng to thi s f orm of m ot i on tes tin g.
Ex am pl es of pr es ump tiv e mo tio n t es ti ng are the st and i ng and se ated fl exi on ( for w ar d be ndi ng) tes ts for
sa c r oi l ia c r egio n d y sf unct i on . I n th i s for m of mo tio n te s ti ng the phy s ic i an has a l owe r d egr ee o f c ert ai nt y
th at t he des i gna ted jo i nt has mo ti on re duc ti on or as y m me try (d y s fu nct i on ) . M any po s tur al fac tors (e .g. ,
sa c r al ba s e unle v el i ng , ti ght ha m s tr i ng mu s c le s ) oth er t han mo ti on di s tu r ban c e at the j oi nt c an c au s e
fa l s e pos i ti v es i n thi s ty pe of test i ng , a nd t her efo r e, w e l im i t i ts use .
Wh en d ocu m en ti ng th e m otio n p r ef er en c es re v eal ed on i nte r se gme ntal mo tio n te s ti ng, i t i s und er st ood
th at t he fol l owi ng abb r evi ati ons are ac c ep ted and us ed c ons i st entl y w i th i n t he ost eopa thi c p r ofe s si on to
de note th e x , y , an d z c om pon ent s in th e thr ee - pl ane dia gno s is and wi l l be u s ed in the fo l lo w i ng ch apt er s
to des c ri be the dys fun c tio n's fr ee m oti on c har act eri s tic s : F le x i on = F ; Ex te nsi on = E; Ne utr al = N;
Si debe ndi ng r i gh t = SR ; Si deb end i ng l ef t = SL; Ro tat i on r ig ht = RR ; a nd R ota tio n l eft = R L.
P.37
Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Rotation,
Shor t-Leve r Me thod, Prone (L4 Exa m ple )
1. The patient lies

prone on the
treatment table
with the head in
neutral (if a fac e
hole is pr esent)
or r otated to the
mor e
comfortable
side.
Remember, the
side to which
the head is
rotated will F igu re 5.3. Step 2, hand pos ition on
pas s ively s keleton.
inc r eas e the
rotational effect
to that side.
2. The phy sic ian
stands at either
side of the table
and palpates the
L4 transverse
proc ess es (lev el
of the iliac
cres t) with the
3 of 59 21/08/07 22:02
pads of the
thumbs (F igs.
5.3 and 5.4).
3. 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 F igu re 5.4. Step 2, hand pos ition on
eas e (freedom) patient.
of left and r ight
rotation ( Fig s.
5.5 and 5.6).
4. If the right
transverse
proc ess moves
anteriorly
(inward) ( white
arr ow) mor e
eas ily and the
left tr ans ver s e
proc ess is
res istant, the
segment is F igu re 5.5. Step 2, s keleton, r otation left.
rotating left
mor e fr eely
(rotated left)
(F ig . 5.7) .
5. If the left
tr ansverse
proc ess moves
anteriorly (white
arr ow) mor e
eas ily and the
right transver se
proc ess is
res istant, the
segment is F igu re 5.6. Step 3, s keleton, r otation
rotating r ight r ight.
mor e fr eely
(rotated r ight)
(F ig . 5.8) .
6. The left
transverse
4 of 59 21/08/07 22:02
proc ess of L4 in
this ex ample
may present
mor e
prominently
(pos ter ior ly) on
static (layer by
lay er) palpation
in a rotated left
dys func tion.
7. The phy sic ian
per forms thes e
steps at each
segment of the F igu re 5.7. Step 4, r otation left.
lumbar spine
and doc uments
the rotational
freedom of
mov ement.
F igu re 5.8. Step 5, r otation right.
P.38
Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Side B ending,
Tra nsla tional Short-Lev e r Method, Prone (L4 Exa mple)
5 of 59 21/08/07 22:02
1. The patient lies

prone on the
treatment table
with the head in
neutral (if a fac e
hole is pr esent)
or r otated to the
mor e
comfortable
side.
2. The phy sic ian's
thumbs res t on
the
pos terolateral F igure 5.9. Step 2, hand position on
aspect of the s k eleton.
transverse
proc ess es
(F ig s. 5.9 an d
5.10).
3. The phy sic ian
intr oduces an
alternating
translator y
glide, left and
right, to
evaluate for
eas e of left and
right s ide
bending. F igure 5.10. Step 2, hand pos ition on
4. If the thumb patient.
translates the
segment more
eas ily from left
to r ight, the
segment has its
eas e in left s ide
bending and is
ter med side
bent left (F ig s.
5.11 an d 5.12).
5. If the thumb
translates the
segment more
eas ily from r ight F igure 5.11. Step 4, s ide bending left on
to left, the s k eleton.
segment has its
eas e in right
side bending
6 of 59 21/08/07 22:02
P.39
Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Ty pe 2 ,

Exte nsion (Sphinx Position) and Flexion, Pr one
1. After
determining that
the rotational
and side
bending
components ar e
coupled in a
type 2 patter n
(same-s ide
pattern of eas e)
the phy sic ian's
thumbs are
plac ed on the
pos terolateral F igu re 5.15. Step 1.
aspect of the
transverse
proc ess es (F ig .
5.15) of the
prone patient.
2. The patient is
ins truc ted to
extend the
thor acolumbar
region by
elev ating the
ches t off the
table with the
support of the F igu re 5.16. Step 2, lumbar Sphinx
elbows (F ig. position.
5.16).
3. The phy sic ian
retests the
rotational and/or
side bending
components in
this position. If
the components
impr ove, the
dys func tion is
extended ( Fig .
5.17). If the
dys func tional
component
7 of 59 21/08/07 22:02
bec omes more

asy mmetric , the
dys func tion is
flex ed (or
neutral).
4. Some pr efer
als o to have the
patient curl up in
a
knees-to-c hes t
pos ition to
promote relative
flex ion and
retest the
dys func tional
rotation and F igu re 5.17. Step 3: extension impr oves
side-bending asymmetr y.
components . If
the
dys func tional
components
appear mor e
symmetr ic in
this position, the
dys func tion is
ter med flexed. If
they ar e more
asy mmetric in
this position, it
is termed
extended ( Fig . F igu re 5.18. Step 4, flex ion.
5.18).
5. The phy sic ian
mus t perform
only one of
thes e as long as
ther e is a known
type 2 coupling
pattern; perform
the mos t
comfortable
tes t.
6. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition or
freedom of
8 of 59 21/08/07 22:02
mov ement
elic ited.
P.40
P.41
Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Pa s siv e
Fle x ion and Ex tension, Late ral Re c umbent Pos ition
1. The patient lies

in the lateral
rec umbent
(side-lying)
pos ition.
2. The phy sic ian
stands at the
side of the
treatment table
fac ing the
patient.
finger pads of
the cephalad F igu re 5.19. Step 3, palpation of s pinous
hand palpate the proc esses.
spinous
proc ess es of
L5- S1 ( Fig .
5.19) or the
interspinous
spac e between
L5 and S1 (F ig .
5.20).
caudad hand
controls the
patient's flex ed
lower
extr emities, and F igu re 5.20. Step 3, palpation of L5-S1
the phy sic ian's inter space.
thigh may be
plac ed agains t
the patient's
tibial
tuberos ities for
9 of 59 21/08/07 22:02
greater balanc e
and control
dur ing
pos itioning ( Fig .
5.21).
5. The phy sic ian
slowly flexes
and extends the
patient's hips
with the c audad
hand and thigh
while the
cephalad hand
cons tantly F igu re 5.21. Step 4.
monitor s the
spinous
proc ess es to
determine the
relativ e freedom
of lumbar flex ion
and extens ion of
L5 on S1 ( Fig s.
5.22 an d 5.23).
6. The phy sic ian
ass esses the
ability of the
upper of the two
segments to flex F igu re 5.22. Step 5, flex ion, s pinous
and extend on proc ess separate.
the lower. If L5
flex es and
extends equally
(sy mmetric ally )
on S1, then L5
is termed
neutral. If there
is asymmetry of
motion between
the two
segments, the
dys func tion is
named for the
dir ection of ease F igu re 5.23. Step 5, extension, spinous
of motion of the proc ess approx imate.
upper of the two
segments ( e.g.,
if L5 moves
mor e easily in
flex ion, L5 is
10 of 59 21/08/07 22:02
flex ed; if the

segment moves
mor e fr eely into
extension, L5 is
extended).
7. The phy sic ian
per forms thes e
steps at each
segmental lev el
of the lumbar
spine.
8. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition or
freedom of
mov ement
elic ited.
P.42
Lum bar Inters e gme nta L Motion Tes ting: L1 to L5 -S1 Pa s siv e Side
Bending, Late r al Rec umbe nt Pos ition (L5-S1 Exam ple )
1. The phy sic ian

flex es the
patient's hips to
appr oximately
90 degr ees and
gently mov es
the patient's
lower
extr emities
slightly off the
edge of the table
(F ig . 5.24).
2. The phy sic ian
slowly flexes F igure 5.24. Step 1.
and extends the
patient's hips
until L5 is
neutral relative
11 of 59 21/08/07 22:02
to S1.
3. The finger pads
of the
phy s ician's
cephalad hand
palpate the left
and right
transverse
proc ess es of L5
(F ig . 5.25) or
the inters pac e
between their
transverse
proc ess es. F igure 5.25. Step 3, palpation of L5
4. The phy sic ian's tr ans v ers e proc esses.
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 F igure 5.26. Step 4, s ide bending r ight.
of the
transverse
proc ess es on
the side to
whic h the
patient is ly ing)
(F ig . 5.26).
5. The phy sic ian
then lower s the
patient's feet
and ank les while
the cephalad
hand monitors
the F igure 5.27. Step 5, s ide bending left.
appr oximation of
the transv ers e
proc ess es on
the side to
whic h the feet
are lowered ( or
12 of 59 21/08/07 22:02
the separation
of the
transverse
proc ess es on
the side
opposite to
whic h the
patient is ly ing)
(F ig . 5.27).
6. The phy sic ian
ass esses the
ability of the
upper of the two
segments ( L5)
to s ide-bend left
and side-bend
right. In this
tes t, s ide
bending oc cur s
on the side to
whic h the feet
and ank les ar e
mov ed.
7. The phy sic ian
per forms thes e
steps at each
segmental lev el
of the lumbar
spine.
8. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition
or freedom of
mov ement
elic ited.
P.43
Thor acic Inte r segmental Motion Te s ting: T1 to T4 Side Bending,

Late ral Re cum bent Position (Long Leve r)
13 of 59 21/08/07 22:02
1. The patient lies

in the lateral
rec umbent
pos ition with the
bac k close to
the side of the
table.
2. The phy sic ian
sits in fr ont of
the patient at the
side of the table,
fac ing the
patient's head.
3. The phy sic ian Fig u re 5.28. Step 3.
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 Fig u re 5.29. Step 4, side bending right.
head and
car efully lifts it
off the table
(F ig . 5.28).
4. The phy sic ian
gently lifts the
patient's head
while monitor ing
the inv olv ed
segment's
transverse
proc ess es or
the inters pac e
between them. Fig u re 5.30. Step 5, side bending left.
Side bending is
intr oduced on
the side to which
the head is
mov ed. This
pres ents as a
14 of 59 21/08/07 22:02
P.44
P.45
Thor acic Inte r segmental Motion Te s ting: T1 to T4 Pass ive Fle xion,
Exte nsion, Side B ending, and R ota tion, Seate d, Long-Le ver Me thod
1. The patient is seated with the

phy s ician standing behind the
patient.
2. The phy sic ian controls the
patient's head with one hand and
palpates the s pinous pr oces ses of
T1 and T2 with the index and thir d
finger of the other hand.
3. The phy sic ian slowly mov es the
patient's head forward and
bac k war d while constantly
monitor ing the ability of the upper
of the segments to move in the
res pective dir ection tes ted (F igs.
5.31 an d 5.32).
4. The phy sic ian, while controlling F igure 5.31. Step 3,
the patient's head, palpates the flexion, spinous pr ocess
left tr ans ver s e proc ess es of T 1 s epar ate.
and T2 and mov es the patient's
head to the left shoulder,
ass essing the ability of the left T1
transverse pr oces s to
appr oximate the left T2
transverse pr oces s. This elicits
left side bending (F ig. 5.33). This
is r epeated on the r ight to elicit
right s ide bending ( Fig . 5.34) .
5. While monitor ing the left
transverse pr oces ses , the
phy s ician slowly rotates the
patient's head to the left. This
evaluates left rotation; it is sensed
by a simultaneous poster ior
mov ement of the transver se
proc ess on that s ide (F ig. 5.35). F igure 5.32. Step 3,
This is repeated on the right to ex tens ion, s pinous
elic it right r otation ( Fig . 5.36) . pr oces s appr oximate.
6. The phy sic ian per for ms thes e
steps at each segmental lev el
T2- T 3, T3- T4, and T4-T5.
7. The phy sic ian will document the
findings in the progres s note
15 of 59 21/08/07 22:02
acc ording to the pos ition or

freedom of motion elicited.
F igure 5.33. Step 4,

s ide bending left.

s ide bending right.
16 of 59 21/08/07 22:02

r otation left.

r otation right.
P.46
Thor acic Inte r segmental Motion Te s ting: T1 to T12 Pas s ive Flexion
and Extens ion, Tr ans latory Method, Se ate d (T6-T7 e xam ple)
17 of 59 21/08/07 22:02
1. The patient is
seated with the
phy s ician
standing behind
and to the side.
2. The phy sic ian
plac es the
thumb and index
finger of one
hand between
the spinous
proc ess es of T 6
and T7, or the
index and thir d
finger palpate F igu re 5.37. Step 2.
the spinous
proc ess es of T 6
and T7,
res pectively
(F ig . 5.37).
3. The patient's
arms ar e
cros sed,
anteriorly , in a
V-formation. T he
phy s ician's r ight
arm and hand
are placed
inferior on the F igu re 5.38. Step 3.
patient's
cros sed elbows
while left hand
remains on the
T6- T 7
interspace (F ig.
5.38).
4. The phy sic ian
ins truc ts the
patient to
completely relax
for ward, r esting
the for ehead on
the for ear m as F igu re 5.39. Step 4, flex ion, s pinous
the left hand proc esses s epar ate.
monitor s flex ion
of T 6 on T 7
(separation of
the spinous
18 of 59 21/08/07 22:02
P.47
Thor acic Inte r segmental Motion Te s ting: T1 to T12 Tra nsla tor y
Method (Pa ssiv e Side Be nding), Se a ted
1. The patient is
seated and the
phy s ician
stands behind
and to the side.
2. The phy sic ian
plac es the left
thumb and index
finger between
the spinous
proc ess es of T 6
and T7 (F ig.
5.41).
Alternativ ely the F igu re 5.41. Step 2.
phy s ician's left
thumb and index
finger palpate
the spinous
proc ess of T6.
3. The phy sic ian
reac hes ac ros s
the front of the
patient's ches t
with the r ight
arm and places
the right hand
on the patient's
left shoulder F igu re 5.42. Step 3.
with the
phy s ician's r ight
axilla res ting on
the patient's
right s houlder
(F ig . 5.42).
right axilla
applies a
downwar d forc e
on the patient's
right s houlder
as the left hand
simultaneously F igu re 5.43. Step 4, translator y s ide
glides or pus hes bending right.
19 of 59 21/08/07 22:02
the T6- T7
interspace to
the patient's left.
This causes a
left tr ans latory
effect that
produces r ight
side bending of
T6 on T 7 ( Fig .
5.43).
right hand
applies a
downwar d forc e F igu re 5.44. Step 5, translator y s ide
on the patient's bending left.
left shoulder as
the left hand
simultaneously
glides the T6- T7
interspace to
the patient's
right. This
produces left
side bending of
T6 on T 7 ( Fig .
5.44).
6. Thes e s teps ar e
per formed to
evaluate r ight
and left s ide
bending at eac h
thor acic
segmental lev el.
7. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition or
freedom of
motion elicited.
P.48
Thor acic Inte r segmental Motion Te s ting: T1 to T12 Prone

Shor t-Leve r Me thod, Pas s ive Rotation, Side B ending (Ex ample T7)
20 of 59 21/08/07 22:02
1. The patient lies

prone with the
head in neutr al.
If this is not
pos s ible, the
patient should
tur n the head to
the mor e
comfortable
side. Note any
change below.
2. The phy sic ian
stands at either
side of the table Fig u re 5.45. Step 4, rotation left.
and palpates the
T7 transverse
proc ess with the
pads of the
thumbs or index
fingers .
3. The phy sic ian
alternately
pres ses on the
left and r ight
transverse
proc ess es of
T7, evaluating
for eas e of Fig u re 5.46. Step 4, rotation right.
mov ement.
4. If the right
transverse
proc ess moves
anteriorly
(inward) more
eas ily, the
segment is
rotating left
mor e fr eely and
vic e versa
(F ig s. 5.45 an d
5.46).
5. In the step 4 Fig u re 5.47. Step 7, side bending left.
scenario, the left
transverse
proc ess may be
palpated more
prominently
(pos ter ior ly) on
21 of 59 21/08/07 22:02
P.49
Thor acic Inte r segmental Motion Te s ting: T8 to T12 Long-Le ver

Method, Pa ssiv e Flex ion and Ex tens ion, Late r al Rec umbe nt
1. The patient lies

in the lateral
rec umbent
pos ition with the
hips and k nees
flex ed (fetal
pos ition).
2. The phy sic ian
stands on the
side of the table
fac ing the
patient and
controls the
patient's knees F igure 5.49. Step 3, s pinous proces s es of
at the tibial T 12–L1.
tuberos ity with
the caudad
hand.
cephalad hand
palpates the
spinous
proc ess es of
T12 and L1 or
their interspace
with the index
and/or long
finger (F ig.
5.49). F igure 5.50. Step 4, flex ion.
4. The phy sic ian
slowly flexes the
hips by br inging
the knees to the
ches t as the
phy s ician's
cephalad hand
monitor s the
separation of
the spinous
proc ess es
(flexion) (F ig .
5.50).
5. The phy sic ian F igure 5.51. Step 5, extension.
22 of 59 21/08/07 22:02
then ex tends
the hips by
bringing the
knees away
from the c hes t
as the cephalad
hand monitors
the
appr oximation of
the spinous
proc ess es
(ex tens ion)
(F ig . 5.51).
per formed to
evaluate flex ion
and extens ion at
eac h thoracic
segmental lev el.
7. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition
or freedom of
motion elicited.
P.50
Thor acic Inte r segmental Motion Te s ting: T8 to T12 Long-Le ver

Method, Pa ssiv e Side Be nding, Late ral Re cum bent
23 of 59 21/08/07 22:02
1. The patient lies

in the lateral
rec umbent
pos ition with the
hips and k nees
flex ed (fetal
pos ition).
2. The phy sic ian
stands on the
side of the table
fac ing the
patient and
controls the
patient's knees Fig u re 5.52. Step 3.
at the tibial
tuberos ity with
the caudad
hand.
3. The phy sic ian
mov es the
patient's lower
legs off the edge
of the table, and
while monitor ing
the transv ers e
proc ess es, the
phy s ician slowly
rais es the Fig u re 5.53. Step 4, side bending right.
patient's feet
toward the
ceiling and then
draws them
toward the floor
(F ig . 5.52).
4. Side bending is
evaluated by
monitor ing the
appr oximation of
the transv ers e
proc ess es on
the side to which
the feet are Fig u re 5.54. Step 4, side bending left.
drawn ( e.g., feet
toward the right,
side bending
right) (F igs.
5.53 an d 5.54).
24 of 59 21/08/07 22:02
P.51
Cos tal Motion Tes ting: C ostal Mec hanics
In res piration,
the sternum and
ribs move in a
simultaneous
and combined
patter n that
expands the
chest in the
anteroposterior
and lateral
diameters dur ing
inhalation and
dec reas es the
anteroposterior
and lateral
diameters in
exhalation. T he
sternum and r ibs
1 to 10 also ris e
in a c ephalad
dir ection and
des cend Fig ure 5.55. Lateral view of firs t and s eventh ribs
caudally in in pos ition, showing the movements of the
inhalation and sternum and r ibs . A, or dinary expiration. B, quiet
exhalation, ins pir ation. C, deep inspiration. (Repr inted with
res pec tively per mis sion fr om Clemente CD. G ray 's Anatomy ,
(F ig. 5.55). 30th Amer ican ed. Baltimor e: Lippinc ott Williams &
Wilkins, 1985.)
Rib Excursion
wit h In halation
The ver tebral
and sternal
attachments
combine to
promote specific
vec tor s of
motion dur ing
nor mal
inhalation,
expanding the
chest. This
expans ion
mov es through
two major vec tor
25 of 59 21/08/07 22:02
paths. These
patter ns are
des cribed as
occ urr ing
thr ough pump
handle and
buc ket handle
axes in both
ver tebr osternal
ribs 1 to 6 and
ver tebr ochondral
ribs 7 to 10
(F igs. 5.56 and
5.57).
Fig ure 5.56. Axes of movement (AB and CD) of a

ver tebros ternal rib. Inter rupted lines indicate the
pos ition of the rib in inhalation. ( Used with
per mis sion of the AACOM. Copy r ight 1983–2006.
All rights reser ved.)
Fig ure 5.57. Axis of movement (AB) of a

ver tebroc hondral rib. Interrupted lines indicate the
pos ition of the rib in inhalation. ( Used with
26 of 59 21/08/07 22:02
per mis sion of the AACOM. Copy r ight 1983–2006.

All rights reser ved.)
P.52
P.53
Cos tal Motion Tes ting: C ostal Mec hanics
Ang le o f Inclinat ion

of the Axes o f Rib 1
and Rib 6
The cos totransver se
articulations combine
with the
cos tov ertebral
articulations at eac h
ver tebr al lev el to
dev elop angles
thr ough which ax is of
rotation a rib may
mov e. T hus , the r ib
mov es within this
specific axis of
rotation, and the
angle c hanges fr om
superior to infer ior
ribs. T he angle, as it
relates to the
anteroposterior
planes and the later al
body line, deter mines
whether the r ib F igu re 5.58. Rib 1: Most frontal in plane, allowing
motion produc ed a mor e purely pump handle rib excur sion.
thr ough normal
res pir ation is
greates t at the
anterior midc lav icular
line or the later al
clavic ular –midax illary
line. Ribs 1 to 10
hav e s ome shared
motion par ameter s in
eac h of the axes of
rotation. However ,
the motion patter n of
27 of 59 21/08/07 22:02
the upper ribs is

related to a
predominant anter ior
or frontal plane axis,
whereas in the lower
ribs a les s frontal,
mor e s agittal ax is
predominates. These
differ ences produce
the patter ns of pump
handle motion
prefer ence of the
upper r ibs and the
buc ket handle
prefer ence of the
lower r ibs (F igs.
5.58 an d 5.59).
F igu re 5.59. Rib 6: Less frontal plane, allowing
Pum p Handle Rib for greater ability to move in a bucket handle
Mot ion motion than can rib 1.
The ter m pump
handle rib motion
des cribes the
mov ement of a rib
that c an be
compar ed to the
motion of the handle
of a water pump. Its
motion is produc ed
by one end being
fix ed in s pac e and
rotating around an
axis that per mits the
opposite end to move
thr ough space (F ig.
5.60). F igu re 5.60. Pump handle rib motion. ( Reprinted
with per mis sion fr om Clay JH, Pounds DM. Bas ic
Bucket Han dle Rib Clinical Massage T her apy : Integrating Anatomy
Mot ion and T reatment. Baltimore: Lippincott Williams &
The ter m buck et Wilk ins, 2003.)
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
28 of 59 21/08/07 22:02
and then laid down

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

( Repr inted with permission from Clay J H, Pounds
DM. Basic Clinical Massage T her apy : Integrating
Anatomy and Tr eatment. Baltimor e: Lippinc ott
Williams & Wilk ins , 2003.)
P.54
Cos tal Motion Tes ting: U ppe r R ibs 1 a nd 2, Supine Method
1. The patient lies

supine and the
phy s ician sits or
stands at the
head of the
table. (Or the
patient may s it.)
2. The phy sic ian
palpates the firs t
ribs at their
infr aclavicular
pos ition at the
ster noc lav icular
articulation ( the F igu re 5.62. Step 2, palpation of the fir st
supr aclavicular r ib.
pos ition c an
29 of 59 21/08/07 22:02
als o be us ed)
(F ig . 5.62).
3. 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 F igu re 5.63. Step 5, inhalation rib
pos itioned dysfunction.
superiorly or
inferiorly .
4. 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 . F igu re 5.64. Step 6, exhalation rib
5. If the rib on the dysfunction.
symptomatic
side is static ally
cephalad and on
inhalation has
greater
cephalad ( on
exhalation, less
caudad)
mov ement, it is
clas sified as an
inhalation rib
dys func tion
(F ig . 5.63).
6. If the rib on the F igu re 5.65. Step 7, palpation of the
symptomatic s econd r ib.
side is static ally
caudad and on
inhalation has
les s cephalad
30 of 59 21/08/07 22:02
(on exhalation,
greater caudad)
mov ement, it is
clas sified as an
exhalation rib
dys func tion
(F ig . 5.64).
7. The phy sic ian
nex t palpates
the sec ond ribs
appr oximately
one
finger's-breadth
below and one
finger's-breadth
lateral to where
the fir st rib was
palpated and
repeats steps 3
to 6 (F ig. 5.65).
8. The mov ement
of the rib on the
symptomatic
side that was
freest is
doc umented in
the progress
note (inhalation
or exhalation
bas ed on the
res pirator y
model or
elev ated or
depr ess ed
bas ed on the
str uctural
model.)
P.55
Cos tal Motion Tes ting: Firs t R ib, Ele vated, Sea ted Me thod
31 of 59 21/08/07 22:02
1. The patient is
seated and the
phy s ician
stands behind
the patient.
2. The phy sic ian
palpates the
pos terolateral
shaft of each
fir s t r ib
immediately
lateral to the
cos totr ans ver s e
articulation ( Fig . F igu re 5.66. Step 2, palpation of the fir st
5.66). Note: T he r ib.
trapezius
bor ders may
hav e to be
pulled
pos teriorly ( Fig .
5.67).
3. With firm
pres sur e of the
thumbs or finger
pads , the
phy s ician
dir ects a
downwar d
(caudad) forc e F igu re 5.67. Step 3, palpation of the fir st
alternately on r ib.
eac h rib ( Fig s.
5.68 an d 5.69).
4. The phy sic ian
monitor s the
relativ e
cephalad or
caudad relation
of the pair and
on the
symptomatic
side deter mines
whether that r ib
is prominent
superiorly as F igu re 5.68. Step 3, palpation of thir d r ib.
compared to its
mate.
5. If a rib is
prominent,
32 of 59 21/08/07 22:02
P.56
Cos tal Motion Tes ting: U ppe r R ibs 3 to 6 , Supine Method
1. The patient lies

supine and the
phy s ician stands
on one side of
the patient.
thumbs palpate
the third ribs
bilater ally at
their
cos tochondral
articulations for
pump handle
motion and at Fig u re 5.70. Step 2.
the midaxillar y
line with the
sec ond or thir d
fingertips for
buc k et handle
motion (F ig.
5.70).
3. The phy sic ian
monitor s the
relativ e
cephalad or
caudad relation
of the pair and
on the Fig u re 5.71. Step 4.
symptomatic
side deter mines
whether that r ib
is more or les s
prominent or
superiorly or
inferiorly
pos itioned.
4. The patient is
ins truc ted to
inhale and
exhale deeply
thr ough the
mouth as the Fig u re 5.72. Step 5, inhalation r ib.
phy s ician
monitor s the
33 of 59 21/08/07 22:02
relativ e
cephalad and
caudad
mov ements of
eac h rib with the
palpating thumbs
and finger tips
(F ig . 5.71).
5. If the rib on the
symptomatic
side is static ally
mor e cephalad
and on inhalation
has greater Fig u re 5.73. Step 6, ex halation r ib.
cephalad
mov ement ( on
exhalation, less
caudad
mov ement), it is
ter med an
inhalation rib
(dy s function)
(F ig . 5.72).
symptomatic
side is static ally
mor e caudad
and on inhalation
has les s
cephalad
mov ement ( on
exhalation,
greater caudad
mov ement), it is
ter med an
exhalation rib
(dy s function)
(F ig . 5.73).
7. The phy sic ian
nex t palpates
ribs 4 to 6 at
their
cos tochondral
ends with the
thumbs and at
their midaxillar y
lines with the
fingertips and
repeats steps 3
34 of 59 21/08/07 22:02
to 6.
8. The freest
mov ement of the
rib on the
symptomatic
side is then
doc umented in
the progress
note (inhalation
or exhalation
bas ed on the
res pirator y
model or
elev ated or
depr ess ed
bas ed on the
str uctural
model).
P.57
Cos tal Motion Tes ting: Lowe r R ibs 7 to 1 0, Supine Method
1. The patient is
supine and the
phy s ician
stands on one
side of the
patient.
thumbs palpate
the sev enth r ibs
bilater ally at
their
cos tochondral
articulations for
pump handle F igu re 5.74. Step 2.
motion and at
the midaxillar y
line with the
sec ond or thir d
fingertips for
buc k et handle
motion (F igs.
35 of 59 21/08/07 22:02
5.74 an d 5.75).
3. The phy sic ian
monitor s the
relativ e
cephalad or
caudad relation
of the pair and
determines on
the symptomatic
side whether
that rib is more
or less
prominent or
superiorly or F igu re 5.75. Step 2.
inferiorly
pos itioned.
4. The patient is
ins truc ted to
inhale and
exhale deeply
thr ough the
mouth as the
phy s ician
monitor s the
relativ e
cephalad and
caudad
mov ements of F igu re 5.76. Step 5, inhalation
eac h rib with the dysfunction.
palpating
thumbs and
fingertips .
symptomatic
side is static ally
mor e cephalad
and on
inhalation has
greater
cephalad
mov ement ( on
exhalation, less
caudad F igu re 5.77. Step 6, exhalation
mov ement), it is dysfunction.
ter med an
inhalation rib
(dy s function)
(F ig . 5.76).
36 of 59 21/08/07 22:02
symptomatic
side is static ally
mor e caudad
and on
inhalation has
les s cephalad
mov ement ( on
exhalation,
greater caudad
mov ement), it is
ter med an
exhalation rib
(dy s function)
(F ig . 5.77).
7. The phy sic ian
nex t palpates ,
sequentially, the
8th thr ough 10th
ribs at their
cos tochondral
ends with the
thumbs and at
their midaxillary
lines with the
fingertips and
repeats steps 3
to 6.
8. The mov ement
of the freest rib
on the
symptomatic
side is then
doc umented in
the progress
note (inhalation
or exhalation
bas ed on the
res pirator y
model or
elev ated or
depr ess ed
bas ed on the
str uctural
model).
P.58
P.59
37 of 59 21/08/07 22:02
Cos tal Motion Tes ting: Floa ting R ibs 11 and 12, Pr one Method
1. The patient lies

prone and the
phy s ician
stands on either
side of the
patient.
thumb and
thenar eminenc e
palpate the s haft
of each 11th r ib
(F ig . 5.78 an d
Fig . 5.79) .
3. The patient is F igu re 5.78. Step 2.
ins truc ted to
inhale and
exhale deeply
thr ough the
mouth.
4. The phy sic ian
notes any
asy mmetric
motion at eac h
rib.
5. If on the
symptomatic
side the
patient's rib F igu re 5.79. Step 2.
mov es more
pos teriorly and
inferiorly with
inhalation and
les s anter ior ly
and superiorly
with ex halation
than its mate, it
is c las sified as
an inhalation rib
(dy s function)
(F ig . 5.80).
6. If on the
symptomatic F igu re 5.80. Step 5, inhalation
side the dysfunction.
patient's rib
mov es more
anteriorly and
38 of 59 21/08/07 22:02
superiorly with
exhalation and
les s posterior ly
and inferiorly
with inhalation
than its mate, it
is c las sified as
an exhalation rib
(dy s function)
(F ig . 5.81).
7. Thes e findings
are doc umented
in the progres s
note. F igu re 5.81. Step 6, exhalation
dysfunction.
P.60
P.61
Cer v ica l Inte r segmental Motion Te s ting: Occ ipitoatlantal

Articulation (Occ iput-C 1 ), Type I Coupling Motion
1. The patient lies

supine on the
treatment table.
2. The phy sic ian
sits at the head
of the table.
index or thir d
finger pad
palpates the
transverse
proc ess es of C1
(F ig . 5.82).
4. The phy sic ian F igu re 5.82. Step 3, C1 transverse
gently mov es the proc ess.
patient's head
for ward and
bac k , c areful not
to bring the
segments below
the occ iput into
this motion ( Fig .
5.83).
39 of 59 21/08/07 22:02
5. The phy sic ian

gently mov es the
head off the table
and to the table in
a
for ward-and-back
translator y
mov ement, again
car eful not to
induce mov ement
of the inferior
cer v ical
segments ( Fig .
5.84). F igu re 5.83. A. Step 4, flex ion.
6. To evaluate s ide
bending and
rotation, the
phy s ician
minimally
translates the
patient's occ iput
alternately to the
left and r ight ov er
C1 ( atlas) without
inducing any
mov ement of C1
to C7 ( Fig s. 5.85
and 5.86). F igu re 5.83. B. Step 4, extension.
evaluated for
asy mmetric
mov ement
patterns that
exhibit more s ide
bending in one
dir ection and
mor e rotation in
the other as well
as ease or
freedom of flexion
or extension.
8. The phy sic ian will F igu re 5.84. A. Step 5, extension.
doc ument the
findings in the
progres s note
acc ording to the
pos ition or
freedom of
motion elicited.
40 of 59 21/08/07 22:02
F igu re 5.84. B. Step 5, flex ion.
F igu re 5.85. Step 6, left side

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

bending/rotation c oupling.
P.62
Cer v ica l Inte r segmental Motion Te s ting: Atla ntoaxial A rticulation

(C1 -C2), R ota tion
41 of 59 21/08/07 22:02
1. The patient lies

supine and the
phy s ician sits at
the head of the
table.
2. The phy sic ian
palpates the
transverse
proc ess es of
the atlas (C1)
with the pads of
the index
fingers and the
articular F igure 5.87. Step 2, transver se proces s
proc ess es of of atlas and C2 ar ticular pr oces s.
the axis ( C2)
with the pads of
the third or
four th finger s
(F ig . 5.87).
3. The phy sic ian
slowly rotates
the patient's
head in one
dir ection,
car eful not to
add any side
bending or
flex ion (F ig. F igure 5.88. Step 3, r otation right.
5.88). (This
eliminates any
lower c erv ical
mov ements and
keeps motion
vec tored to this
lev el.)
4. As the head is
rotated, the
phy s ician
monitor s for
any mov ement
of the axis ( C2),
and stops when F igure 5.89. Step 4; s top when C2 begins
this is to move.
enc ountered.
This is the limit
of motion for
this ar tic ulation
42 of 59 21/08/07 22:02
P.63
Cer v ica l Inte r segmental Motion Te s ting: Atla ntoaxial (C1-C2),

Supine, with Flex ion Alternative
1. The patient lies

supine on the
treatment table.
2. The phy sic ian
sits at the head
of the table.
3. The phy sic ian
slowly flexes
(for war d-bends )
the patient's
head and neck
to the
comfortable
pas s ive motion F igu re 5.91. Step 3, C1 r otation with head
limit to flex ed.
segmentally
res tric t the free
coupled motions
of the
occ ipitoatlantal
and C2 to C7
segments ( Fig .
5.91).
4. The phy sic ian
slowly and
alternately
rotates the
patient's head to
the comfor table F igu re 5.92. Step 4, C1 r otation r ight with
right and left head flexed.
pas s ive motion
limits (F igs.
5.92 an d 5.93).
5. The phy sic ian is
aler t for any
res tric ted and/or
asy mmetric
rotation.
6. The phy sic ian
then notes the
asy mmetric
motion
preference if
43 of 59 21/08/07 22:02
pres ent (C1-RR F igu re 5.93. Step 4, C1 r otation left with

or C1-RL). head flexed.
7. Note: Never do
this ty pe of
motion tes t with
either the head
and nec k
extended. We do
not rec ommend
this test, as it is
pres umptiv e,
wher eas the
afor ementioned
C1 r otation test
with head in
neutral
pos itioning is a
pos itiv e test and
better tolerated
by most
patients.
P.64
Cer v ica l Inte r segmental Motion Te s ting: C2 to C 7 A rtic ula tions,

Shor t-Leve r Tr ans latory Effect, Ty pe II Motion
1. The patient lies

supine on the
treatment table,
and the
phy s ician sits at
the head of the
table.
2. The phy sic ian
palpates the
articular
proc ess es of
the segment to
be evaluated
with the pads of Fig ure 5.94. Step 2, cervic al articular
the index or pillar s on sk eleton.
thir d finger
(F ig s. 5.94 an d
44 of 59 21/08/07 22:02
5.95).
3. To evaluate
asy mmetry in
side bending, a
translator y
motion is
intr oduced fr om
left to right (F ig.
5.96, left side
bending) and
then right to left
(F ig . 5.97, r ight
side bending)
thr ough the Fig ure 5.95. Step 2, cervic al articular
articular pillar s on patient.
proc ess es.
4. Eac h cervical
segment is
evaluated in
flex ion,
extension, and
neutral to
determine whic h
pos ition
impr oves the
asy mmetry.
5. The phy sic ian
will document
the findings in Fig ure 5.96. A. Step 4, side bending left.
the progress
note ac cor ding
to the pos ition
or freedom of
motion elicited.
Fig ure 5.96. B. Step 4, side bending left.
45 of 59 21/08/07 22:02
Fig ure 5.97. A. Step 4, side bending right.
Fig ure 5.97. B. Step 4, side bending right.
P.65
Cer v ica l Inte r segmental Motion Te s ting: C2 to C 7 A rtic ula tions,

Long-Le ver Me thod, Type II Motion (e.g., C3 SRRR or SLR L)
46 of 59 21/08/07 22:02
1. Cer v ical
intersegmental
motion may be
evaluated by
long-lever
method. Move
the head in an
ear - to- shoulder,
arc like
mov ement to the
lev el of the
dys func tional
segment for its
side bending F igu re 5.98. Step 1, ear - to- shoulder
ability (F ig. method.
5.98).
2. At the end of the
limit of s ide
bending, a slight
rotation is added
to the dir ection
of the side
bending (F ig.
5.99).
3. With the head in
neutral for C2,
flex ion is
inc r eas ed
appr oximately 5 F igu re 5.99. Step 2, rotation added.
to 7 degrees for
eac h
des c ending
segment to be
evaluated. The
articular
proc ess es are
pos itioned in
side
bending/rotation
to the right and
then the left until
their limit is
elic ited ( Fig s. F igu re 5.100. Step 3, side
5.100 and bending/rotation r ight.
5.101).
4. Sinc e C2 to C7
side-bend and
rotate to the
47 of 59 21/08/07 22:02
P.66
Sac r oiliac Joint Motion Tes ting: Pelv is on Sacr um (Iliosa cra l),
Ante roposterior R ota tion, Supine, Long Leve r (Leg Length)
1. The patient lies

supine on the
treatment table.
2. The phy sic ian
stands at the
side of the table
at the patient's
hip.
3. The phy sic ian
palpates the
patient's
anterior
superior iliac
spines (ASISs ) Fig ure 5.102. Step 3, palpating the
and medial anterior s uperior iliac spine.
malleoli and
notes the
relation of the
pair (c ephalad
or c audad,
symmetr ic or
asy mmetric
pattern) ( Fig .
5.102).
4. The phy sic ian
ins truc ts the
patient to flex
the hip and k nee
on one side. Fig ure 5.103. Step 4.
The phy sic ian's
hands then
control the
patient's knee
and ank le (F ig .
5.103).
5. The phy sic ian
tak es the
patient's hip
thr ough a range
of motion
star ting with 130
degr ees of
flex ion, Fig ure 5.104. Step 5, flex ion, ex ter nal
48 of 59 21/08/07 22:02
progres ses rotation, and ex tens ion.

thr ough ex ter nal
rotation and
finally
extension,
bringing the
patient to the
neutral starting
pos ition ( Fig .
5.104).
6. The phy sic ian
notes whether
the ASIS on the
motion- tes ted
side appears Fig ure 5.105. Step 7, flex ion, inter nal
mor e cephalad rotation, and ex tens ion.
than its original
pos ition. This
change would
be s econdary to
freedom in
pos terior
rotation.
7. The phy sic ian
then takes the
patient's hip
thr ough a range
of motion
star ting with 90
degr ees of
flex ion,
progres sing
thr ough inter nal
rotation and
finally
extension,
bringing the
patient to the
neutral starting
pos ition ( Fig .
5.105).
8. The phy sic ian
notes whether
the ASIS on the
motion- tes ted
side appears
mor e caudad
than its original
pos ition. This
49 of 59 21/08/07 22:02
change would
be s econdary to
freedom in an
anterior
rotation.
9. This is repeated
on the other
side to
determine
whether each
joint has
freedom in
pos terior and
anterior r otation
and if not, which
joint is free or
res tric ted in
only one
dir ection.
10. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition
or freedom of
motion elicited.
P.67
Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint and Pelvic
Dys func tions, Pelvic (e .g., Innom inate R ota tion, Shea r ,
Inflare -Outfla re), Standing Flexion Test
50 of 59 21/08/07 22:02
1. The patient s tands erec t with the

feet a shoulder-width apart.
2. The phy sic ian stands or kneels
behind the patient with the ey es at
the lev el of the patient's pos ter ior
superior iliac spines ( PSISs).
3. The phy sic ian's thumbs are placed
on the inferior aspect of the
patient's PSIS. Maintain firm
pres sur e on the PSISs, not skin or
fas c ial dr ag, to follow bony
landmar k motion ( Fig . 5.106).
4. The patient is instr ucted to activ ely
for ward bend and try to touch the
toes within a pain-free range (F ig .
5.107). Fig ure 5.106. Step 3.
5. The tes t is positive on the side
wher e the thumb ( PSIS) moves
mor e cephalad at the end range of
motion (F ig. 5.108). A pos itiv e
standing flex ion tes t identifies the
side on which the sacroiliac joint is
dys func tional, not the s pec ific ty pe
of dysfunc tion. A positive res ult
indicates that an ilios acral
dys func tion ( pelv is on s acr um)
may be present. T his is usually
compared to the r esults of the
seated flexion test to r ule out
sac r oiliac dy s function ( sac rum on
pelv is) . Regar dless the type of
dys func tion, the problem is at the
sac r oiliac joint. Fig ure 5.107. Step 4,
6. This is a pres umptiv e test for war d bending.
reflecting as y mmetry , which may
be r elated to dys functions at the
sac r oiliac joint. It should not
replace more s pec ific motion
tes ting that actually elicits motion
availability.
7. The phy sic ian will document the
findings in the progres s note
acc ording to the pos ition or
freedom of motion elicited.
51 of 59 21/08/07 22:02
P.68
Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint and Pelvic
Dys func tions, Pelvic (Innom ina te) or Sac ral, Se ate d Flexion Tes t
1. The patient is
seated on a
stool or
treatment table
with both feet
flat on the floor
a s houlder -width
apar t.
2. The phy sic ian
stands or kneels
behind the
patient with the
eyes at the level
of the patient's F igu re 5.109. Step 3.
PSISs.
thumbs are
plac ed on the
inferior aspec t
of the patient's
PSISs and a firm
pres sur e is
dir ected on the
PSISs, not sk in
or fasc ial dr ag,
to follow bony
landmar k motion
(F ig . 5.109). F igu re 5.110. Step 4, for war d bending.
4. The patient is
ins truc ted to
for ward-bend as
far as pos sible
within a
pain-fr ee range
(F ig . 5.110).
5. The tes t is
pos itiv e on the
side where the
thumb ( PSIS)
mov es more
cephalad at the
end range of F igu re 5.111. Step 5, pos itive seated
motion (F ig. flex ion tes t.
52 of 59 21/08/07 22:02
5.111). A
pos itiv e s eated
flex ion test
identifies the
side of sacral
(sac roiliac or
sac r um on
pelv is)
dys func tion, not
the specific type
of dysfunc tion.
A negative tes t
may indicate a
pelv ic on
sac r um
(iliosacral ty pe)
dys func tion,
suc h as
innominate
rotation.
6. This is a
pres umptiv e test
reflecting
asy mmetry,
whic h may be
related to
dys func tions at
the sac roiliac
joint. It should
not replac e
mor e specific
motion tes ting
that ac tually
elic its motion
availability.
7. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition or
freedom of
motion elicited.
P.69
Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion, Pe lvis on
Sac r um (Ilios a cra l D ysfunction), A nte roposte rior R ota tion Pr one ,
53 of 59 21/08/07 22:02
Long Le ver
1. The patient lies

prone on the
treatment table.
2. The phy sic ian
stands to one
side of the
patient at lev el
of the hip.
3. The phy sic ian
plac es the
cephalad hand
over the
patient's
sac r oiliac joint Fig u re 5.112. Step 3.
with the finger
pads of the
index and thir d
digits contac ting
the sac rum and
PSIS; or the
index finger
contacts the
PSIS while the
thumb c ontacts
the sac rum (F ig.
5.112). If
palpating the
opposite Fig u re 5.113. Step 4.
sac r oiliac joint,
the finger pads
will contact the
landmar k on the
other s ide.
other hand
gras ps the
patient's fully
extended
(str aight) lower
leg at the lev el
of the tibial
tuberos ity (F ig. Fig u re 5.114. Step 5.
5.113).
5. The phy sic ian
gently lifts the
extended leg
and then s lowly
54 of 59 21/08/07 22:02
P.70
and minimally
Sac r oiliac Joint
lowers Motion Tes ting: Sacr oiliac Joint Motion, Pe lvis on
it while
Sac r um palpating
(Ilios a cra l D ysfunction), Inflare -Outfla re Prone, Long Le ver
the
mov ement of the
PSIS as it
relates to the
1. The
sac r patient
um (F ig. lies
prone
5.114). Theon the
treatment
phy s ician table. may
2. The
als o phycarry sictheian
stands to
leg acr oss the one
side
midline of the
(F ig. patient
at the lev
5.115) and then el of the
hip.
laterally (F ig . Fig u re 5.115. Step 5.
3. The
5.116). phyQuality
sic ian
plac es the
and quantity of
cephalad-oriented
motion, as well
hand ov er the
as ease-bind
patient's
relations, ar e
sac r oiliac
monitor ed.joint Fig u re 5.117. Step 3.
6. with the
The phy sic finger
ian
pads
repeats this index
of the on
and third digit
the opposite
contacting
side. the
7. sac r um
This motion testand PSIS,
or the index
may determine
finger contac ts
joint motion
the
res tric tionwhile
PSIS Fig u re 5.116. Step 5.
the
and/orthumb motion
contacts
asy mmetry the
sac r um (F
(e.g., sac roiliac ig.
5.117). If
res tric ted, fr ee
palpating
pos teriorly). the
8. opposite
This is a Fig u re 5.118. Step 4.
sac
pos ritiv
oiliac
e test, joint,
as
the finger
compared to the pads
will contact
standing andthe
landmar
seated flexion k
opposite
tes ts, which whatare is
noted
mor e abov e.
4. The
pres phyumptiv sic ian
e.
9. ins truc
The phy sic ts theian
patient
will document to flex the
lower leg (knee)
the findings in
appr
the progress 90
oximately
degr
note ees ac cor and then
ding
gras ps the
to the pos ition or ank le
(F ig .
freedom of5.118). Fig u re 5.119. Step 5.
5. The
motion phyelicited.
sic ian
55 of 59 21/08/07 22:02
then ex ter nally

and internally
rotates the
patient's hip by
mov ing the ank le
medially and
laterally,
res pectively
(F ig s. 5.119 and
5.120). This
appr oximates
(outflare) and
separates
(inflar e) the Fig u re 5.120. Step 5.
sac r oiliac joint.
6. The phy sic ian
then repeats this
on the opposite
side.
7. The above motion
tes t may
determine joint
motion res tric tion
and/or motion
asy mmetry (e.g.,
sac r oiliac joint
res tric ted,
free-inflare) .
8. The phy sic ian will
doc ument the
findings in the
progres s note
acc ording to the
pos ition or
freedom of motion
elic ited.
P.71
Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion, Ge ner a l
Res tric tion, Prone, Shor t Leve r
56 of 59 21/08/07 22:02
1. The patient lies

prone on the
treatment table.
2. The phy sic ian
stands to one
side of the
patient at the
lev el of the hip.
3. The phy sic ian
plac es the
thenar
eminenc es over
the patient's
PSISs ( Fig . F igure 5.121. Step 3.
5.121).
4. The phy sic ian
alternately
intr oduces a
mild to
moderate
impulse through
the PSISs with
the thenar
eminenc es
(F ig . 5.122).
5. The phy sic ian
notes the
quality (end F igure 5.122. Step 4, prone s hor t lever
feel) and with thenar impuls e.
quantity of
motion on eac h
side.
6. This is a
pos itiv e test
that will
determine whic h
sac r oiliac joint
is most
res tric ted but
will not
determine the
nature of the
dys func tion.
7. The phy sic ian
will document
the findings in
the progress
note ac cor ding
57 of 59 21/08/07 22:02
P.72
Sac r oiliac Joint Motion Tes ting: Sacr oiliac Joint Motion, Ge ner a l
Res tric tion or Anter opos ter ior Rotation, Supine , Shor t Le ver
1. The patient lies

supine on the
treatment table.
2. The phy sic ian
stands at the
lev el of the
patient's hip.
palms or thenar
eminenc es are
plac ed inferior
to the patient's
ASISs ( Fig .
5.123). Fig u re 5.123. Step 3.
4. The phy sic ian
alternately
intr oduces a
mild to
moderate
impulse through
the ASISs (may
dir ect it
pos teriorly or
slightly
cephalad) (F ig .
5.124).
5. The phy sic ian
notes quality Fig u re 5.124. A. Step 4, supine short lev er
(end feel) and with thenar impulse on r ight.
quantity of
motion on eac h
side.
6. This will
determine
whic h s acr oiliac
joint is most
res tric ted and
may determine
whic h motion
preference is
pres ent
(anterior or
pos terior Fig u re 5.124. B. Step 4, supine short lev er
58 of 59 21/08/07 22:02
rotation). with thenar impulse on left.

7. If a posterior
innominate
dys func tion is
pres ent, the
symptomatic
and res tricted
side will hav e a
preference to
mov e cephalad
(F ig . 5.125).
8. If an anterior
innominate
dys func tion is
pres ent, the Fig u re 5.125. Step 7.
symptomatic
and res tricted
side will hav e a
preference to
mov e caudad
(F ig . 5.126).
9. The phy sic ian
will document
the findings in
the progress
note ac cor ding
to the pos ition
or freedom of
motion elicited. Fig u re 5.126. Step 8.
59 of 59 21/08/07 22:02
6
Principles of Osteopathic Manipulative Techniques
O s t e o pa t hi c m a n ip u la t iv e te c hn i qu e s ( O MT ) a r e n u me r ou s . S o me te c h ni q ue s h a v e b ee n
k no wn b y m o re t ha n o n e n a me , m a ny n ew te c hn i q ue s h a ve b ee n d e ve l o pe d , a nd s om e
h av e se e n r es u r ge n ce af t e r y ea r s o f n e gl e c t . Th e y h av e go n e t hr o u gh a
met a mor p ho s is i n d es c ri p t io n , a nd f in a ll y , wi th th e a d v en t o f t h e E d uc a ti o n al Co u nc i l
o n O s te o pa t hi c Pr i nc i pl e s ( E CO P ) a n d i t s Gl o s sa r y o f O s te o pa t hi c Te r mi n ol o g y
( ww w. aa c om . or g / om / Gl o s s a r y . d oc ) , h a ve be e n s t an d ar d iz e d i n to th e s t y le s d e s cr i be d
i n t h is te x t .
Direct and Indi rect Technique

I t i s s o me t im e s e a si e r t o u n de r s t a n d t he pr i n ci p le s o f OM T a c co r d in g t o w h i ch ba r ri e r
a nd a na t om i c a r ea th e t e c hn i qu e p r i ma r il y a f f ec t s . Th e fi r s t pr i n ci p le re l a te s t o t h e
n at u r e a nd di r e c t i on of t he re s tr i c ti v e b ar r i er . U s in g th i s p ri n c ip l e, mo s t t e ch n iq u e s
c an b e c at e go r i ze d a s d i r ec t o r i n d ir e c t . T h u s , a t ec h n iq u e e ng a g in g t h e mo s t
r es t r ic t iv e b a r ri e r ( bi n d , t ig h t) i s c la s si f i ed as di r e c t an d a t ec h ni q ue e ng a gi n g t h e
l ea s t r e s t r ic t i ve ba r ri e r ( e as e , l o os e ) i s c l as s if i ed a s i nd i re c t .
The s ec o nd pr i n ci p le is a s s o ci a te d wi t h whi c h a n at o mi c ma n if e s t a t io n o f t h e
d y s f u nc t io n i s pr i ma r y ( e .g . , mus c l e v er s us j oi n t) . T o de t er min e th a t a m u s cl e
d y s f u nc t io n i s pr i ma r y , t he se c on d pr i nc i pl e di r ec t s t h e p hy s ic i a n t o u se t ec h ni q ue s
s uc h as so f t t i s s u e o r mu s c l e e ne r g y r at h er t ha n h i gh - v el o ci t y , l ow - am p li t u de (H V LA )
t ec h n iq u e o r o s te o pa t hy i n t he cr a n ia l f i el d .
G en e r al l y , di r e c t te c hn i q ue s e n ga g e t h e mos t re s tr i c t i v e b ar r ie r , a n d i nd i r ec t
t ec h n iq u es en g a ge th e l e a s t re s tr i c ti v e b ar r i er , w h ic h mo s t c om mo nl y i s d e s cr i be d a s
t he e dg e o f t h e p h y s i ol o g ic ba r ri e r ( Fig . 6 . 1 ). Fr e qu e n tl y , h ow e v er , a dy s f un c ti o na l
s ta t e c a us e s r e s t r ic t iv e ba r ri e rs t o e ac h s i d e o f t he n or mal re s t in g n e ut r a l p oi n t .
The s e b i la t er a l r e s t r ic t i ve ba r ri e r s a re mo s t c o mm o nl y as y mm e tr i c i n r e fe r e nc e t o t h e ir
d is t a nc e f r om n eu t ra l b u t m a y b e e q ua l ly an d s y mme t ri c a ll y d i s t a n t ( Fi g s . 6 .2 an d 6 . 3 ).
1 of 6 21/08/07 22:03
Figure 6.1 . Asymmetric ran ge o f moti on w ith a normal

physio log i c b arrier (Pb ) o ppo site th e si de on whi ch a re stri cte d
barrie r (R b) is pre sent.
E xa mi na t io n o f th e b a rr i e rs de l in e a te d i n F i g ur e s 6 .2 a nd 6. 3 s h o ws th a t i t i s p o s s i b le
t o t r ea t a re s t ri c ti v e b a rr i er at e it h er th e ea s e o r b i nd qu a li t y e l ic i te d on th e p a l pa t or y
e xa mi na t io n .
Man y ha v e d es c r ib e d p hy s i ol o gi c p r i nc i pl e s o f m o ti o n o f t h e s pi n e , a nd mo s t f r eq u en t l y
t he p ri n ci p le s s t a te d b y Ha r ri s on Fry e t t e , DO , a re th o s e p ri mar i l y t au g ht i n o s t e op a t hi c
med i c al s c h oo l s ( f ir s t a n d s ec o nd p ri n ci p le s of ph y si o l og i c mot i o n) . T h es e ru l es ar e
s pe c i fi c t o t h e t h or a ci c an d l u mb a r s p in e r e g io n s , bu t th e y h av e ta n ge n ti a l r e la t io n to
h ow t he me c ha n i c s of th e ce r vi c al s pi n e a re p er c ei v ed . Ou r n o n- A mer i ca n m a n ua l
med i c in e a s so c i at e s h av e ad d ed ot h e r c av e at s to Fr y et t e , y et th e y a g re e w i t h t he
b as i s o f t h es e fi n di n gs , wh i ch ha v e b e en du p l ic a te d b y ot h er s ( e . g. , W h it e & P an j ab i ,
c ou p l ed mo t io n s ) ( 1) .
P ar a p hr a si n g C. R . N e ls o n ( who s e p r in c ip l e o f m o ti o n i s c o ns i de r e d t he th i r d o f t he
t hr e e p h y s i ol o g ic pr i nc i p le s o f m o t io n ), we s ee th a t t h e i ni t ia t i on of sp i n al
P. 7 6
v er t e br a l mot i o n i n o ne p la n e wil l af f ec t m o t io n i n a l l o t he r p l a ne s ( 2 ). O s t e op a th i c
t ex t s h a ve de s c ri b ed th i s p r in c ip l e , b ut al wa y s wi t hi n th e c o nt e x t o f a s i n gl e
r es t r ic t iv e b a r ri e r c au s i ng as y mm e t ri c al l y r e s t r ic t ed f in d in g s o f m o ti o n p o te n ti a l i n a n
a rt i c ul a ti o n. E xp a nd i ng t hi s s t at e men t t o w h a t we h av e ob s er v ed c li n ic a ll y wo u ld
t he r e fo r e c or r e la t e wit h Fi g ur e s 6 . 2 a nd 6. 3 . T h is wo u l d a ls o m a k e i t f ea s i bl e t o o r i en t
c la s s ic a ll y d e s cr i be d d i r ec t t e ch n i qu e s , su c h a s H V LA , in an in d i re c t man n e r ( wh i ch we
2 of 6 21/08/07 22:03
h av e se e n t au g h t a nd pe r f or med in t e rn a ti o na l l y) . T h e mo s t im p or t a nt cr i te r i a t o
u nd e r s t a nd , w h e th e r p er f o rm i ng di r e c t or in d i re c t t ec h n iq u es , a r e t h e n or ma l
p hy s i ol o gi c m o t io n s o f t h e s pe c if i c a r ea be i n g e xa min e d a n d/ o r t r ea t ed an d th e
c om p l ia n ce of t he ti s su e s i n vo l ve d (e . g. , a c u te ve r su s ch r on i c d y s f u nc t io n ) .
Figure 6.2 . Two restrictive b a rri ers (R b ) a symmetrica lly

restri cte d .
3 of 6 21/08/07 22:03
Figure 6.3 . Two restrictive b a rri ers (R b ) symmetri cal ly restricted .
S omatic Dysfunction
A s s t at e d e ar l i er , s o ma t i c d y s f un c t io n i s t h e d i ag n os t i c c ri t er i o n t ha t c a l ls fo r O MT.
The v ar i ou s q u a li t ie s e l i ci t ed on t he ph y si c a l e xa min a t io n o f a p at i en t m a y l e ad th e
p hy s i ci a n t o u n de r s t a nd t ha t t h e n a tu r e o f a dy s fu n c t i o n i n o ne r eg i on is d if f er e nt f ro m
t ha t of an o th e r d y s f u nc t i on in a d i f f e re n t r e gi o n. Th u s , t he ph y s ic i an ma y ch o os e t o
u se o ne te c hn i q ue fo r o n e d y s f u nc t i on an d a n o th e r t ec h n iq u e f or t he ot h er . I f a p at i e nt
e xh i b it s r e gi o n al mo t io n di s tu r ba n c e b ut in t e rs e gm e nt a l m o ti o n i s n o rm a l, a t e ch n iq u e
o ri e n te d t o t h e a r ti c ul a r a s pe c t s o f t he an a t om y m a y n o t b e i nd i c at e d. Or a p a ti e nt
mig h t p r es e nt f or ne c k a c he th a t o n e x am i na t i on ex h ib i t s p ar a ve r t eb r al mu s c le
h yp e r to n ic i t y a nd ge n er a l t e nd e rn e s s b ut no s pe c if i c t e nd e r p oi n t s . Th i s p a ti e nt ma y
b en e f it fr o m a my o fa s ci a l t e ch n iq u e b u t n ot c ou n te r s t r a in , a s n o co u nt e rs t r ai n t e nd e r
p oi n t s a re pr e s en t .
S om e pa t ie n t s e xh i bi t s o mat i c c om p o ne n t s of v is c er a l d i se a se , a n d t h e t re a t me n t o f
t hi s co mpo n en t ma y h a ve o nl y a li mi te d e f fe c t , whe r ea s a p at i en t wi t h a p r i ma r y
s om a t ic dy s fu n c ti o n a nd a s e co n da r y v i s c e ra l co mpo n en t ma y r e ac t we l l ( so ma ti c al l y
a nd v is c er a ll y ) t o a sp e c if i c O MT . Ot h er fa c t or s i n t h e p r es e nt a t io n s o ma t i c
d y s f u nc t io n m a y c h an g e t h e t ho u gh t pr o ce s s i n d e ve l op i n g t he tr e a tm e nt pl a n . O th e r
v is c e ra l a n d a u to n om i c e f fe c t s , l y mph a ti c c o n ge s ti o n, a nd gr o s s e de ma wil l al l c a us e
t he p hy s ic i an t o r ee v al u a te th e p o s si b il i ti e s f o r O MT a nd th e p o t en t ia l f o r a nu mbe r of
t ec h n iq u es th a t m a y b e i n di c at e d i n t h at ca s e .
Contraindicati ons
4 of 6 21/08/07 22:03
Con t r ai n di c at i o ns to OM T ha v e c ha n g ed dr a ma t i ca l ly du r i ng ou r y e a rs of cl i n ic a l
p ra c t ic e b e ca u s e o f t he d ev e lo p me n t o f n e w a n d/ o r mod i f ie d t e ch n i qu e s a nd b et t er
u nd e r s t a nd i ng o f d is e as e pr o ce s se s . T h e a bi l i t y to pe r f or m O MT i n a ra n ge o f
e x t r e me l y g en t l e t o mor e fo r ce f ul man n er , c o mbi n ed wi t h a di r ec t or in d ir e c t a pp r oa c h ,
h as c au s ed us t o l oo k d i f fe r en t ly a t t he ap p l ic a ti o n o f O MT, ge n e ra l ly ma k i ng th e
d ec i s io n o n a c as e -b y -c a s e b as i s o f c l in i ca l pr e se n ta t i on . T h is c as e -b y -c a s e
o ri e n ta t io n m a y o f te n c h a ng e o n ly t he ch o ic e of th e p a t ie n t' s p o s it i on fo r a t ec h ni q u e
a nd n ot be co n s id e re d a c on t ra i nd i c at i on fo r an en t ir e te c hn i qu e ca t eg o ry . Ce r ta i n
c on d i ti o ns , s u c h a s f ra c t ur e , d is l o ca t io n , t u mo r , i nf e c ti o n, an d os t eo mye l i ti s , a re
c on t r ai n di c at i o ns fo r O MT d i re c tl y ov e r t ha t si t e. Ho we ve r , i t d o es no t p r e cl u de OM T to
r el a t ed so mat i c d y s f u nc t i on in ar e a s t ha t a r e p r ox i ma l or di s ta l to th e p r o bl e m.
O th e r c o nd i ti o n s t ha t m a y a l te r t h e p h y s i ci a n 's op i ni o n c o nc e rn i n g t he ap p r op r ia t en e s s
o f O MT a re Do wn s y nd r om e , r h eu mat o i d a rt h ri t i s , Kl i pp e l -F e il s y n d ro me,
P. 7 7
a ch o n dr o pl a s t i c d war f is m, p r eg n an c y , s tr a in s an d s p ra i n s , ac u te h er n ia t ed
i nt e r ve r te b ra l di s c , ac u t e i nf l am ma to r y s it u a ti o ns , a n a to mic in s t ab i li t y , h yp e rm o bi l i t y ,
j oi n t p r os t he s i s , an d s e v er e m a ni f e s t a ti o ns o f v is c er a l d i so r de r s . The s e c o nd i ti o ns
may c on t ra i nd i c at e O MT i n t o ta l o r ma y c o nt r a in d ic a te o nl y a sp e c if i c t ec h n iq u e i n a
s pe c i fi c r e gi o n . The ph y s ic i an ' s c l in i ca l j u d gm e nt an d a c om p le t e u n de r s t a n di n g o f t h e
t ec h n iq u e a re p ar a mo u nt i n t he fi n a l d ec i si o n a s t o w h e th e r O MT i s a pp r op r i at e .
The Osteopathi c Manipulative Treatm ent Prescription

The s el e c t i on o f t he te c h ni q ue to b e u se d i s pr i ma r il y fo u nd e d i n t h e n at u r e o f t he
s om a t ic dy s fu n c ti o n a nd i t s mo s t p r om i ne n t ma ni f es t at i o ns . T h is a tl a s p re s e nt s 1 2
o s t e o pa t hi c m a n ip u la t iv e te c hn i qu e se c ti o ns . Ea c h s ec t i on ha s a n ex p la n at o r y p re f ac e
f or t he sp e ci f i c t ec h ni q u e a nd th e pr i nc i pl e s o f i t s u s e a nd ap p l ic a ti o n. The pr e vi o u sl y
s ta t e d a re a s o f d y s f u nc t i on (a r ti c u la r , myo - f as c ia l , v i s c e ra l , v a s c u la r , l y mp h at i c , a nd
s o o n ) t ha t c a n b e c o ns i d er e d d ur i n g s el e c t i o n o f t he t re a tm e nt p la n m a y a f fe c t t he
d ec i s io n t o u s e a sp e ci f i c t ec h ni q u e a t o ne d y s f un c ti o n al le v el o r a no t he r , d e pe n di n g
o n t h e p hy s ic a l f i nd i ng s (i . e. , H V L A v er s us mus c le en e r gy ve r su s fa c il i ta t e d p os i ti o n al
r el e a se ve r su s my o fa s ci a l r e le a se o r a c o mb i n at i on ) . Th is wi l l b e d i s c u s s e d f u rt h er a nd
mor e sp e ci f ic a l ly in ea c h o f t h e t e ch n iq u e s e c t i on s .
The O MT pr e s c r i pt i on is s im i la r t o th a t o f t h e p ha r ma c o lo g ic pr e s cr i pt i on : th e t y pe o f
t ec h n iq u e i s c o mp a ra b le t o t he ca t e go r y o f t h e p ha r ma c o lo g ic ag e n t c ho s en ; th e
met h o d a nd / or p os i ti o n c h os e n f or t he OM T t e c hn i qu e i s co mpa r ab l e t o t h e r o ut e o f
a dm i n is t ra t io n of th e p h a rm a co l og i c a g en t ; t h e f or c es i nv o lv e d i n t h e O MT a nd wh e th e r
t he y ar e d i re c t ly or in d i re c tl y a p p li e d a re c om p ar a bl e to th e s t r en g th or d os e o f t h e
med i c at i on ; a n d t h e r ep e t it i on s , t i mi n g, an d du r at i on o f t he OM T ar e c o mp a r ab l e t o t h e
a mo u n t o f med i c at i on di s p en s ed an d th e f r eq u e nc y o f i t s a d mi n is t r at i on .
For e xa mpl e , a 70 - ye a r- o l d p at i en t wh o c o mp l a in s o f c h r on i c l ow b ac k p a in s ec o nd a ry
t o l u mb a r d is c o ge n ic sp o n dy l os i s , l um b ar sp i n al s t e no s i s , an d l u mba r s o ma t i c
d y s f u nc t io n m a y b e t r ea t e d wit h a r t ic u la t or y an d m y of a s ci a l s of t ti s su e t e c hn i qu e s
wee k l y o ve r w e e k s to mo n t hs . H o we v e r, a 1 6- y e ar - ol d p a t ie n t who c om p la i ns o f a cu t e
l ow b ac k p a in s ec o nd a ry t o a s p ra i n d u ri n g f o ot b al l p r a c t i ce ma y be tr e at e d w i th a
5 of 6 21/08/07 22:03
c om b i na t io n o f in d ir e c t myo f as c ia l re l ea s e, mus c le en e r gy , a n d c o un t er s tr a i n
t ec h n iq u es ev e r y 2 t o 3 d ay s f o r 2 to 4 wee k s .
S im p l e r ul e s t o g u id e t h e i mpl e me n t at i on of O MT ar e b e s t s ee n i n th e d o se g ui d el i ne s
o ut l i ne d i n t h e F o un d at i o ns fo r O s t eo p at h ic Med i ci n e ( 2 ). In ge n e ra l , o ne mus t
u nd e r s t a nd th e na t ur e o f th e d y s f u n c t i on an d th e o t he r cl i ni c al man i fe s ta t i on s b e in g
p re s e nt e d, th e se v er i t y a nd en e rg y - de p le t in g ef f ec t s o f t h e c on d i ti o n, th e ag e o f t h e
p at i e nt , a n d wh et h er th e co n di t io n is ac u te o r c hr o ni c . C o mm o n me di c al se n s e
c om b i ne d w i th a w e ll - gr o u nd e d r is k - be n ef i t r a ti o na l e s h ou l d b e t h e g ui d in g pr i nc i pl e s .
References
1 . W h it e A, Pa n ja b i M . C l in i c al Bi o me c h an i c s of t he Sp i ne . 2n d e d . P h il a de l ph i a :
L i pp i nc o t t Wil l ia ms & Wi l ki n s , 1 99 0 .
6 of 6 21/08/07 22:03
7
Soft Tissue Techniques
Technique Principl es
Soft ti s s ue te c hn i que is de fi ne d b y t he E duc ati on C oun c il on Ost eop athi c P r in c i pl es ( EC OP) as “ a di re c t
tech niq ue, w hi c h us ua l ly in v olv es l at er al st r et c hin g, l in ear s tr etc hi ng , d eep pre s su r e, tra c ti on, and /or
s epa r at i on of m us c l e ori gin and in s er ti on wh i le m on i to r in g ti s su e r es po nse an d mo tio n c hang es by
palp ati on; als o c al le d m y of as ci al tec hniq ue” (1 ) . S ome as pect s o f s oft tis s ue tec hni que s ar e s i mi l ar to
thos e o f my ofa s ci al r ele ase i n r es pec t to th e t herm ody nam i c e ffe c ts i n alt eri ng p hys i ca l st ate s ( gel - s ol )
and c au s i ng ti s su e re act i vi ty ( fas c ia l cr eep ) . H owe v er , t he s pec i fi c ma nua l m etho ds by w hic h t he
phys i ci an c aus es thes e r eac ti on s a r e s l ig htl y d i ffe r en t. T he m os t d i s ti ngu i sh i ng asp ect s of so ft ti ss ue
tech niq ue a s c omp ar ed to my ofas c ia l r el ea s e tec hniq ue are tha t w i th m yo fas c ia l re l ea s e tech niq ue the
forc es ar e m or e d eepl y d i re c ted in to the pat i en t an d t hat the s e for c es are im pl em ent ed i n a rh y th m i c,
al te r na ti ng (p r es s ure on , p r ess ure of f) f ash i on .
T he for c es s ho uld be dir ect ed d eep l y enou gh to enga ge the tis s ue be i ng tre ate d, b ut at the s am e t i m e the
tr ea tme nt s hou l d be m i ld l y to m ode r at el y i nt r od uc ed an d c om fo r ta bly acc ept ed by t he pat i ent . T he only
ex ce pti on t o t his r ul e i s t he i nhi bit or y pre s su r e s tyl e, i n w hic h t he p hys i ci an m ay c ho os e to use a
c ons tan t, d eep l y i ntr odu c ed for c e ove r so m e tim e (i .e. , m or e tha n 3 0 se c on ds or u nti l t he t i ss ue r ele ase s
( as not ed b y a n i nc re ase in i ts le ngt h or de c re as e i n i ts ten s io n) ( 2).
Technique Cl assifi cati on
Di rect Technique
In d i re c t t ech niq ue, the my ofas c ia l t i s su es are m ov ed tow ar d the re s tri c ti v e barr i er (t ensi on, bi nd). To
us e dir ec t tec hni que, th e p hy si c ia n m us t und ers tand th e a nato m ic re l ati ons hip of the ti s s ue s b ein g
tr ea ted i n ter m s of m usc ulo tend i no us or ig i n and i ns ert i on , de pth of the mu s cl e or fa s ci a, a nd m us c l e
ty pe . T he d i re c ti on, dep th, and fo r ce of pre s su r e w i ll va r y w i th th e sp eci fic are a b ein g tr eat ed beca use of
norm al anat omi c c hang es fro m re gio n t o re gio n.
Technique Styles
P aral lel Tracti on

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

In p erp endi c ul ar tr ac tio n, the m yo fas c i al st r uc ture in qu es ti on i s c ont act ed at i ts m id poin t b etw een the
or ig i n and i ns ert i on, an d a per pen dic ul ar fo r ce i s dir ect ed a w ay fr om t he l on gi tu din al ax is .
1 of 64 21/08/07 22:03
Di rect I nhibitory P ressure

In d i re c t i nhi bit or y pre s su r e, the my ofas c ia l s tr uc tur e b ei ng tr eat ed i s c ont ac te d o v er the
m usc ulo tend i no us port i on of the hy per toni c m usc l e, and a forc e i s d i r ec ted in to i t. H ow ev er , d eep ,
s pec i fi c pr ess ure on the mu s c le be l ly c an ca use pai nfu l s i de eff ect s an d b r ui s i ng . T her efor e, the
pr es s ur e sh oul d b e di r ec ted at the te ndon or mu s c ul ote ndi nous ju nct i on.
P.80
I ndicati ons
1. Us e a s p ar t of the m us c ul osk el et al s cr eeni ng exa m i na tio n t o qu i ck l y i den tif y r egio ns of r est r ic ted
mo tio n, ti ss ue tex ture ch ang es , and se ns it i vi ty.
2. Re duc e m us cl e h y pe r ton i ci ty, m us c le te ns io n, fas c i al te nsi on, and mu s c le sp asm .
3. St r et c h and i nc r ea s e e l as tic i ty of s ho r ten ed, in el as tic , a nd/o r f i br otic my ofa s c ia l s tru c tur es to
im pro v e r egi ona l a nd/o r i nte r s eg m en tal r an ges of m ot i on .
4. Im pro v e c i rc ula tio n to th e s peci fic re gi on be i ng tre ate d b y lo c al ph y s ic al and the r mo dyn am ic
ef fec ts or b y r efl ex p hen ome na t o i m pr ov e c ir c ul atio n i n a dis tal ar ea ( e.g ., thro ugh
so m at i c- s oma tic or s om ato v is c era l r efl ex es ) .
5. In c re ase v en ous an d ly m ph ati c dr ain age to dec r ea s e l oca l a nd/o r d i st al s w el l in g an d e dem a an d

po ten tia l l y i mp r ov e th e o v er al l i mm une r es pon s e.
6. St i mu l at e th e s tre tc h r ef l ex i n hyp oto ni c m us c le s .
7. Pr omo te pati ent re l axa tio n.
8. Re duc e p atie nt gua r din g d uri ng i m pl eme ntat i on of oth er ost eopa thi c m anip ula tiv e te c hn i qu es o r
ad dit i on al m edi c al tre atm ent .
9. Po ten tia te t he eff ec t of oth er o s te opa thic te c hn i que s .
10. Im pro v e the phy s ic i an- pat i en t re l at i on s hip , a s t hi s tec hni que typ i ca l l y i mp art s a ple asa nt
se nsa tio n to th e p atie nt.
Contraindications
Relative Contraindi cations

U s e w it h ca uti on, as c om m on m ed i ca l s ense is th e ru l e. Fo r ex amp l e, i n an eld er ly os teo poro tic pa ti en t,
the s of t ti s su e pr one pr ess ur e tec hni que m ay be c on tra i nd i c at ed ove r th e t hor ac oc ost al and pel v ic
r egi ons , bu t t he l ate r al re c umb ent me thod s c an be m ore sa fely ap pli ed. Als o, c ont act an d st r et c hi ng o v er
an a c ut el y s tr ain ed o r s pra i ned my ofa s c ia l , l ig am en tou s , or c aps ula r st r uc tur e ma y e x ac er ba te the
c ond i ti on. T he r ef or e, in th es e s it uat i ons ca uti on s hou l d pr ev ail , a nd t he s of t ti s su e t ec hn i qu e m ay b e
w i th hel d un til ti s s ue di s ru ptio n a nd i nfl amm ati on h ave st abil i ze d.
Othe r p r eca uti ons i n the us e of so ft ti ss ue tec hniq ue:
1. Ac ute sp r ain or st r ain .
2 of 64 21/08/07 22:03
2. Fr act ure or dis l oc atio n.
3. Ne uro l og i c o r v asc ul ar co m pr om is e.
4. Os teo por os is an d o s teo pen i a.
5. Ma l ig nan c y . M os t r es tr i ct i on s ar e f or tr ea tme nt i n t he aff ec te d a r ea of m al i gn ancy ; h owe v er, ca r e

sh oul d b e ta k en in oth er dis tal are as depe ndi ng on t y pe of m al i gn anc y an d/o r l y m ph ati c
in v ol v em ent.
6. In fec tio n (e .g. , o s teo m ye l it i s ).
Absol ute Contraindi cations

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

1. Th e p ati ent s ho uld be c om for tabl e a nd r ela x ed .
2. Th e p hys i c ia n s hou l d b e i n a pos i ti on of c omf ort s o as to m i ni m iz e e nerg y e x pe ndit ure an d

wh ene v er pos s ib l e s hou l d use bod y w eig ht i nst ead of upp er ex tr emi ty s tre ngt h a nd e ner gy.
3. In i ti all y , f orc es m ust be of l ow in ten s i ty an d a ppli ed s lo w l y and rh y thm i ca l ly . As he at deve l op s

an d t he ti ss ues be gi n to r ea c t, the pr es su r e m ay be i nc r ea s ed i f c li ni ca l ly in di ca ted an d we l l
to l er ate d; h owe v er , th e c ade nc e s ho uld r em ain sl ow ly rh y th m i ca l .
4. Th e a ppl i ed for c es s ho uld al w ays be co m for tab l e and not ca us e pai n. A co m fo r ta bl e and pl easa nt
ex per i en c e i s t he i nte nde d e ffec t.
5. Ne v er di r ect fo r ce s di r ec tly i nt o b one , an d l i mi t pr ess ure i nt o t he m usc l e bel l y .
6. As th i s i s n ot a m as sa ge or fr ic tio n t ec hn i qu e, neve r r ub or i r ri tat e th e p ati ent' s s k in by the

fr i ct i on of y ou r h ands . T he phys i ci an' s ha nd s ho ul d c ar r y the s ki n w i th i t and not sl i de acr oss it
wh en app l y in g t he di re c te d f or ce .
7. De ter m in e ho w y ou w oul d l i ke to emp l oy the fo r ce :
a. pus hin g or pu l li ng p erp end i c ul ar to c aus e t r ac ti on to th e lo ng axi s of th e m us cu l ot end i nou s

s tr uct ur e
b. By app l y in g t r ac ti on in a para l le l d i r ec tio n t o th e l ong axi s , i nc r eas i ng th e di s ta nce

bet w ee n th e o r ig i n a nd i ns er ti on of the m us c le fib ers
P.81
Cervi cal Region: Traction, S upine
3 of 64 21/08/07 22:03
1. T he patient lies
s upine on the
tr eatment table.
2. T he physic ian sits
or stands at the
head of the table.
3. T he physic ian's
one hand gently
c r adles the occiput
between the thumb
and index finger .
T he physic ian's
other hand lies
ac r oss the
patient's for ehead Fig ure 7.1. Step 3, skeleton.
or grasps under
the chin ( Fig s. 7.1
an d 7.2). (Us e
c aution in patients
with
tempor omandibular
joint [TMJ ]
dy s functions.)
4. T he physic ian
ex erts cephalad
tr action with both
hands with the
head and neck in a
neutral to slightly Fig ure 7.2. Step 3, patient.
flexed pos ition to
av oid extension.
T he cr adling hand
mus t not s queeze
the oc ciput, or the
oc c ipitomastoid
s uture will be
c ompressed (F ig.
7.3).
5. T his trac tional
for ce is applied
and releas ed
s lowly . It may be
inc reased in
amplitude as per Fig ure 7.3. Step 4.
patient toler anc e.
6. T his technique
may also be
per for med using
4 of 64 21/08/07 22:03
P.82
Cervi cal Region: Forward Bending (Forearm Ful crum ),

S upine
5 of 64 21/08/07 22:03
1. T he patient
lies s upine
on the
tr eatment
table.
2. T he
phy sic ian is
s eated at the
head of the
table.
3. T he
phy sic ian
gently flexes
the patient's
nec k with Fig ure 7.5. Step 3.
one hand
while sliding
the other
hand palm
down under
the patient's
nec k and
opposite
s houlder
( F ig. 7.5).
4. T he
phy sic ian
gently
r otates the Fig ure 7.6. Step 4, rotation r ight.
patient's
head along
the
phy sic ian's
for ear m
toward the
elbow,
pr oduc ing a
unilateral
s tr etc h of the
c er vic al
par avertebral
mus culatur e
( F ig. 7.6).
5. T his s tretch Fig ure 7.7. Step 6, neutral.
c an be
r epeated as
many times
as nec ess ary
6 of 64 21/08/07 22:03
P.83
Cervi cal Region: Forward Bending (Bilateral Fulcrum),

S upine
7 of 64 21/08/07 22:03
1. T he patient
lies s upine
on the
tr eatment
table.
2. T he
phy sic ian is
s eated at the
head of the
table.
3. T he
phy sic ian's
ar ms are
c r ossed
under the Fig ure 7.9. Step 3.
patient's
head and the
phy sic ian's
hands are
placed palm
down on the
patient's
anterior
s houlder
r egion (F ig.
7.9).
4. T he
phy sic ian's
for ear ms Fig ure 7.10. Step 4.
gently flex
the patient's
nec k,
pr oduc ing a
longitudinal
s tr etc h of the
c er vic al
par avertebral
mus culatur e
( F ig. 7.10).
5. T his
tec hnique
may be
per for med in
a gentle,
r hy thmic
fas hion or in
a s ustained
manner .
8 of 64 21/08/07 22:03
P.84
Cervi cal Region: Contralateral Traction, S upi ne
1. T he patient
lies s upine
on the
tr eatment
table.
2. T he
phy sic ian
s tands at the
s ide of the
table
opposite the
s ide to be
tr eated.
3. T he
phy sic ian's Fig ure 7.11. Step 3.
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 Fig ure 7.12. Step 4.
( F ig. 7.11).
4. T he
phy sic ian's
c ephalad
hand lies on
the patient's
for ehead to
s tabilize the
head ( Fig .
7.12).
5. Keeping the
c audad ar m
s tr aight, the
phy sic ian
gently dr aws Fig ure 7.13. Step 5.
9 of 64 21/08/07 22:03
the
par avertebral
mus cles
v entrally
( white ar r ow,
F ig . 7.13),
pr oduc ing
minimal
ex tens ion of
the cervic al
s pine.
6. T his
tec hnique
may be
per for med in
a gentle,
r hy thmic, and
k neading
fas hion or in
a s ustained
manner .
7. T is sue
tension is
r eevaluated
to ass ess the
effectiveness
of the
tec hnique.
P.85
Cervi cal Region: Cradl ing wi th Traction, S upi ne
10 of 64 21/08/07 22:03
1. T he patient
lies s upine
on the
tr eatment
table.
2. T he
phy sic ian
s its at the
head of the
table.
3. T he
phy sic ian's
finger s ar e
placed under
the patient's Fig ure 7.14. Step 3.
nec k
bilaterally,
with the
finger tips
lateral to the
c er vic al
s pinous
pr oces ses
and the
finger pads
touching the
par avertebral
mus culatur e
ov erly ing the Fig ure 7.15. Step 4.
ar ticular
pillar s ( Fig .
7.14).
4. T he
phy sic ian
ex erts a
gentle to
moderate
for ce,
v entrally to
engage the
s oft tiss ues
and cephalad
to produc e a
longitudinal Fig ure 7.16. Step 4.
tr actional
effect
( s tretch)
( F igs. 7.15
11 of 64 21/08/07 22:03
P.86
Cervi cal Region: S uboccipital Release, Supine
1. T he patient
lies s upine
on the
tr eatment
table.
2. T he
phy sic ian
s its at the
head of the
table.
3. T he
phy sic ian's
finger pads
ar e placed
palm up Fig ure 7.17. Step 3.
beneath the
patient's
s ubocc ipital
r egion, in
c ontac t with
the tr apez ius
and its
immediate
underlying
mus culatur e
( F ig. 7.17).
4. T he
phy sic ian
s lowly and Fig ure 7.18. Step 4.
gently
applies
pr essure
upward into
the tissues
for a few
s ec onds and
then r eleases
the pr ess ure
( F igs. 7.18
an d 7.19) .
5. T his
pr essure
may be
r eapplied and Fig ure 7.19. Step 4.
12 of 64 21/08/07 22:03
r eleas ed
s lowly and
r hy thmically
until tis s ue
tex tur e
c hanges
oc c ur or for
2 minutes .
T he pr ess ure
may also be
c ontinued in
a more
c onstant
inhibitor y
s ty le for 30
s ec onds to 1
minute.
P.87
Cervi cal Region: Rotation, S upine
13 of 64 21/08/07 22:03
s upine on the
tr eatment table.
2. T he physic ian sits
at the head of the
table.
c upped hands
( palmar as pec t)
ar e placed to each
s ide of the
patient's
tempor omandibular
r egion, making
s ur e to not Fig ure 7.20. Step 3.
c ompress over the
ex ternal acoustic
meatus (F ig.
7.20).
4. T he physic ian
gently and slowly
ax ially r otates the
patient's head to
the left to the
r es trictiv e barr ier
at its pas siv e
tolerable elastic
limit and holds this
pos ition for 3 to 5 Fig ure 7.21. Step 4.
s ec onds ( Fig .
7.21).
5. T he physic ian then
s lowly rotates the
head to the r ight
r es trictiv e barr ier
at its pas siv e
tolerable elastic
limit and holds this
pos ition for 3 to 5
s ec onds ( Fig .
7.22).
6. T his is r epeated to
eac h s ide until
r eleas e of tissue Fig ure 7.22. Step 5.
tension and/or
improv ement of
r ange of motion.
14 of 64 21/08/07 22:03
P.88
Cervi cal Region: S upine, Forefingers Cradl ing
15 of 64 21/08/07 22:03
1. T he patient
lies s upine
on the
tr eatment
table.
2. T he
phy sic ian
s its or
s tands at the
head of the
table.
3. T he
phy sic ian's
hands cradle
the tempor al Fig ure 7.23. Step 3.
r egions
( av oiding
pr essure
ov er the
ear s) with
the finger s
ov er the
c er vic al
par aspinal
tis sues,
pr oximal to
the ar tic ular
pr oces ses
( F ig. 7.23). Fig ure 7.24. Step 4.
4. T he patient's
head is bent
s lightly
bac kward
( ex tended)
and taken
thr ough a
pr ogression
of side
bending and
r otation to
one side and
then the
other with
c ontinuing Fig ure 7.25. Step 4.
pr essure
fr om the
finger pads
on the
16 of 64 21/08/07 22:03
P.89
Cervi cal Region: Thumb Rest, Supine
1. T he patient
lies s upine
on the
tr eatment
table with or
without a
pillow under
the head.
2. T he
phy sic ian
s its or
s tands at the
head of the
table.
3. T he thumb Fig ure 7.26. Step 3.
and
for efinger of
one of the
phy sic ian's
hands cups
the poster ior
c er vic al area
palm up ( Fig .
7.26).
4. T he
phy sic ian's
other hand is
placed ov er
the tempor al Fig ure 7.27. Step 4.
and fr ontal
r egions of
the patient's
head and
gently br ings
the head into
s light
bac kward
bending
( ex tension)
and rotation
agains t the
thumb (F ig s.
7.27 and
7.28). Fig ure 7.28. Step 4.
17 of 64 21/08/07 22:03
5. T he motion is
v er y s light.
6. T ension
( pr ess ure) is
r elaxed
s lowly and
r eapplied
s lowly .
7. T he pr ess ure
may be
r ev ers ed to
the other
s ide.
P.90
Cervi cal Region: Coupl ing wi th S houlder Bl ock, S upine
18 of 64 21/08/07 22:03
s upine on the
tr eatment table
and the physician
s tands or sits at
the head of the
table.
2. T he physic ian
places one hand
on top of the
patient's
ac r omioclavic ular
joint on the side
to be treated
( F ig. 7.29). F igure 7.29. Step 2.
other hand
c r osses the
midline to contr ol
the patient's
head from that
s ame s ide and
gently pus hes
the head toward
the oppos ite side
( F ig. 7.30).
4. T he physic ian
mov es the head
until meeting the F igure 7.30. A. Steps 3 and 4, anterior
r es trictiv e barr ier head control.
at its pas siv e
tolerable elastic
limit and holds
this position for 3
to 5 s econds and
then s lowly
r eturns the head
to neutral.
5. T his is r epeated
r hy thmically and
gently until
r eleas e of tissue
tension and/or
improv ement in
r ange of motion. F igure 7.30. B. Steps 3 and 4, alternate,
6. T he physic ian's posterior head control.
hands may be
r ev ers ed and the
19 of 64 21/08/07 22:03
P.91
Cervi cal Region: Lateral Traction, Seated (Exampl e: Left

Cervi cal Paravertebral Muscl e Hypertoni city, Fascial
I nelasti city, and Others)
20 of 64 21/08/07 22:03
1. T he patient is
s eated on the
tr eatment
table.
2. T he physic ian
s tands behind
and to the right
s ide of the
patient with the
patient r esting
c omfor tably
agains t the
phy sic ian's
c hest.
3. T he Fig ure 7.31. Step 3.
phy sic ian's
r ight cupped
hand and
for ear m ar e
pas sed under
the patient's
c hin s o as to
gently touch
the patient's
left
per iauric ular
r egion (F ig.
7.31).
phy sic ian's left
hand is placed
on top of the
patient's left
s houlder at the
s uperior
tr apez ius and
s uprac lav icular
r egion (F ig.
7.32).
5. T he
phy sic ian's
r ight hand
gently rotates
head to the
r ight and
ex erts a gentle
c ephalad
21 of 64 21/08/07 22:03
P.92
Cervi cal Region: S i tti ng Traction (Exam ple, Using Ri ght

Knee)
22 of 64 21/08/07 22:03
1. T he patient is
s eated on the
tr eatment
table.
2. T he physic ian
s tands behind
and to the left
of the patient.
3. T he
phy sic ian's
r ight foot is
placed on the
table with the
r ight knee and
hip flexed. Fig ure 7.34. Step 5.
4. T he
phy sic ian's
r ight elbow is
placed on the
r ight thigh.
5. T he
phy sic ian's
r ight hand Fig ure 7.35. Step 5, alter native hand
c r adles the pos ition.
oc c iput with
the thumb and
index finger
while the left
hand holds the
patient's
for ehead
( F igs. 7.34
an d 7.35) .
6. T he physic ian
s lowly elevates
the right thigh
and knee by
lifting the heel
of the right foot Fig ure 7.36. Step 6.
( plantarflex ing
foot), thereby
pr oduc ing
c er vic al
tr action ( Fig .
7.36).
7. T he tr action is
r eleas ed when
the physic ian
23 of 64 21/08/07 22:03
P.93
Cervi cal Region: Head and Chest Positi on, Seated
1. T he patient is
s eated on the
tr eatment
table.
2. T he physic ian
s tands fac ing
the patient
with one leg in
fr ont of the
other for
balanc e.
3. T he patient's
fr ontal bone
( forehead) is
placed Fig ure 7.38. Step 3.
agains t the
phy sic ian's
infrac lav icular
fos sa or
s ternum ( Fig .
7.38).
4. T he pads of
the
phy sic ian's
finger s
c ontac t the
medial as pect
of the cer vic al
par avertebral Fig ure 7.39. Step 4.
mus culatur e
ov erly ing the
ar ticular
pillar s ( Fig .
7.39).
5. T he physic ian
leans
bac kward,
dr awing the
patient towar d
the physic ian.
T his c aus es
the
phy sic ian's
hands to Fig ure 7.40. Step 5.
24 of 64 21/08/07 22:03
engage the
s oft tiss ues,
ex erting a
gentle ventral
for ce with
c oncomitant
c ephalad
tr action. This
pr oduc es a
longitudinal
tr actional
effect
( s tretch)
( F ig. 7.40).
6. T his
tec hnique
may be
per for med in
a gentle,
r hy thmic, and
k neading
fas hion or in a
s us tained
manner .
7. T is sue
tension is
r eevaluated
to ass ess the
effectiveness
of the
tec hnique.
P.94
Thoracic Region: P rone Pressure
25 of 64 21/08/07 22:03
1. T he patient is
pr one,
pr efer ably
with the head
tur ned
toward the
phy sic ian. (If
the table has
a face hole,
the head may
be kept in
neutral.)
2. T he
phy sic ian
s tands at the Fig ure 7.41. Step 3.
s ide of the
table
opposite the
s ide to be
tr eated.
3. T he
phy sic ian
places the
thumb and
thenar
eminence of
one hand on
the medial
as pect of the Fig ure 7.42. Step 4.
patient's
thorac ic
par avertebral
mus culatur e
ov erly ing the
tr ansv ers e
pr oces ses on
the side
opposite the
phy sic ian
( F ig. 7.41).
4. T he
phy sic ian
places the
thenar Fig ure 7.43. Step 5.
eminence of
the other
hand on top
of the
26 of 64 21/08/07 22:03
P.95
Thoracic Region: P rone Pressure With Two Hands (Catwalk)
1. T he patient is
pr one on the
tr eatment
table,
pr efer ably
with the head
tur ned
toward the
phy sic ian. (If
the table has
a face hole,
the head may
be kept in
neutral).
phy sic ian
s tands at the
s ide of the
table,
opposite the
s ide to be
tr eated.
3. T he
phy sic ian's
hands are
placed palm
down s ide by
s ide on the
medial Fig ure 7.45. Step 4.
as pect of the
patient's
thorac ic
par avertebral
mus culatur e
ov erly ing the
tr ansv ers e
pr oces ses on
the side
opposite the
phy sic ian
( F ig. 7.44).
4. T he
phy sic ian
adds enough Fig ure 7.46. Step 5.
27 of 64 21/08/07 22:03
downward
pr essure to
engage the
underlying
fas cia and
mus culatur e
with the
c audal hand
( F ig. 7.45).
5. T he
phy sic ian
adds later al
pr essure,
tak ing the
my o-fascial Fig ure 7.47. Step 7.
s tr uctures to
their
c omfor table
elastic limit
( F ig. 7.46).
6. T his forc e is
held for
s ev eral
s ec onds and
then s lowly
r eleas ed.
7. As the
pr essure is
being
r eleas ed with
the caudal
hand, the
phy sic ian's
c ephalad
hand begins
to add a
downward
lateral force
( F ig. 7.47).
8. T he
c ombination
of downwar d
and later al
for ces and
the releas e
of this
pr essure is
alternately
applied
28 of 64 21/08/07 22:03
between the
two hands .
9. T he
downward
and later al
pr essure
dir ected by
eac h hand
s hould be
r hy thmically
applied for
s ev eral
s ec onds.
P.96
Thoracic Region: P rone Pressure with Counterpressure
29 of 64 21/08/07 22:03
1. T he patient
lies prone on
the tr eatment
table,
pr efer ably
with the head
tur ned toward
the physic ian.
( If the table
has a fac e
hole, the head
may be kept
in neutral.)
2. T he physic ian
s tands at Fig ure 7.48. Step 4.
either side of
the table.
3. T he physic ian
places the
thumb and
thenar
eminence of
the caudad
hand on the
medial as pect
of the
patient's
thorac ic
mus culatur e
ov erly ing the
tr ansv ers e
pr oces ses on
the side
opposite the
phy sic ian with
the finger s
pointing
c ephalad.
4. T he physic ian
places the
hy pothenar
eminence of
the cephalad Fig ure 7.50. Step 5.
hand on the
medial as pect
of the
patient's
30 of 64 21/08/07 22:03
P.97
Thoracic Region: S i de Leverage, Lateral Recum bent
1. T he patient
lies in the
lateral
r ec umbent
( s ide lying)
pos ition,
tr eatment side
down.
2. T he physic ian
is seated on
the side of the
table, fac ing
the patient.
3. T he physic ian
r eaches ov er Fig ure 7.51. Step 3.
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 Fig ure 7.52. Step 4.
thorac ic
tr ansv ers e
pr oces ses at
the side on
which the
patient is ly ing
( F ig. 7.51).
4. T he physic ian
r eaches
under the
patient's fac e
with the
c ephalad
hand and
c ontac ts the Fig ure 7.53. Step 5.
31 of 64 21/08/07 22:03
per iauric ular

r egion,
c r adling the
head ( Fig .
7.52).
5. T he
phy sic ian's
c audad hand
ex erts a
gentle for ce
v entrally and
laterally to
engage the
s oft tiss ues
while the Fig ure 7.54. Step 7.
c ephalad
hand gently
lifts the head
to produc e
c er vic al and
upper
thorac ic s ide
bending. T he
phy sic ian may
add slight
flexion until
meeting the
c omfor table
elastic limit of
the tissues
( F ig. 7.53).
6. Step 5 can be
r epeated
s ev eral times
in a gentle,
r hy thmic, and
k neading
fas hion or
us ing deep,
s us tained
pr essure.
7. T he
phy sic ian's
c audad hand
is
r epositioned
to contac t
differ ent
lev els of the
32 of 64 21/08/07 22:03
upper
thorac ic s pine
and steps 5
and 6 are
per for med to
s tr etc h
v ar ious
por tions of the
upper
thorac ic
par avertebral
mus culatur e
( F ig. 7.54).
P.98
Thoracic Region: Bi lateral Thumb Pressure, Prone
33 of 64 21/08/07 22:03
1. T he patient
lies prone on
the tr eatment
table,
pr efer ably
with the head
tur ned
toward the
phy sic ian. (If
the table has
a face hole,
the head may
be kept in
neutral.) The
s tands at the
head of the
table.
2. T he
phy sic ian's
thumbs
bilaterally
c ontac t the
par avertebral
mus culatur e
ov erly ing the
tr ansv ers e
pr oces ses of
T 1 with the Fig ure 7.56. Step 3.
finger s
fanned out
laterally (F ig.
7.55).
3. T he
phy sic ian's
thumbs ex ert
a gentle
v entral force
to engage the
s oft tiss ues
and add a
c audal and
s lightly
lateral force Fig ure 7.57. Step 6.
until meeting
the
c omfor table
elastic limits
34 of 64 21/08/07 22:03
P.99
Thoracic Region: Trapezius, I nhi bitory Pressure, Supine
s upine on the
tr eatment table.
2. T he physic ian
s its at the head
of the table.
hands are placed
on eac h
tr apez ius so that
the thumbs (pads
up) lie
approx imately
two
thumb's-br eadths Fig ure 7.59. Step 3.
inferior to the
pos ter ior bor der
of the tr apez ius
and the index
and third digits
( pads down) r est
on the anterior
bor der of the
tr apez ius two
finger 's- breadths
inferiorly (F ig.
7.59). The
thumbs and
finger pads may Fig ure 7.60. Step 3, alter native pos ition.
be rev ers ed in
pos ition if this is
mor e c omfortable
for the physician
( F ig. 7.60).
4. T he physic ian
s lowly adds a
s queez ing for ce
on the tr apez ius
between the
thumbs and
finger s ( Fig .
7.61).
5. T his pres s ure is
held until tissue Fig ure 7.61. Step 4.
35 of 64 21/08/07 22:03
tex tur e c hanges

ar e palpated or
for 1 to 2
minutes.
P.100
Thoracic Region: Upper Thoracic with S houl der Bl ock,

Lateral Recumbent
36 of 64 21/08/07 22:03
1. T he patient lies in
the later al
r ec umbent pos ition
with the s ide to be
tr eated up.
2. T he physic ian
s tands at the side
of the table, facing
the patient.
c audad hand is
pas sed under the
patient's arm, with
the pads of the
finger s on the Fig ure 7.62. Step 3.
medial as pect of
the patient's
par avertebral
mus cles ov erlying
the thorac ic
tr ansv ers e
pr oces ses (F ig.
7.62).
c ephalad hand
c ontac ts the
anterior portion of
the shoulder to
pr ovide an effec tiv e Fig ure 7.63. Step 4.
c ounterfor ce (F ig.
7.63). Note: The
patient's arm may
be flexed
approx imately 120
degrees and draped
ov er the
phy sic ian's
s houlder- c ontacting
ar m as needed
( F ig. 7.64).
c audad hand exer ts
a gentle forc e,
v entrally to engage Fig ure 7.64. Step 4, alter native pos ition.
the soft tiss ues and
laterally to create a
per pendic ular
s tr etc h of the
37 of 64 21/08/07 22:03
P.101
Thoracic Region: Lower Thoracics Under the Shoul der,

Lateral Recumbent
38 of 64 21/08/07 22:03
1. T he patient is
in a later al
r ec umbent
pos ition with
the side to be
tr eated up.
2. T he
phy sic ian
s tands at the
s ide of the
table, fac ing
the fr ont of
the patient.
3. T he
r eaches both
hands under
the patient's
ar m, with the
pads of the
finger s
c ontac ting
the medial
as pect of the
patient's
par avertebral
mus cles,
ov erly ing the
thorac ic Fig ure 7.67. Step 3.
tr ansv ers e
pr oces ses
( F igs. 7.66
an d 7.67) .
4. T he
phy sic ian's
hands exer t
a gentle
for ce
v entrally to
engage the
s oft tiss ues
and later ally
to create a
per pendic ular Fig ure 7.68. Step 4.
s tr etc h of the
thorac ic
par avertebral
mus culatur e
39 of 64 21/08/07 22:03
P.102
Thoracic Region: Over and Under Techni que, Seated
1. T he patient is
s eated with
the ar ms
c r ossed and
the thumbs
hooked into
the antec ubital
fos sae (F ig.
7.69).
2. T he physic ian
s tands fac ing
the patient.
3. T he
phy sic ian's
hands reac h Fig ure 7.69. Step 1.
under the
patient's
for ear ms and
ov er the
patient's
s houlders ,
allowing the
patient's
for ehead to
r es t on the
for ear ms.
4. T he pads of
the physic ian's
finger s c ontact Fig ure 7.70. Step 4.
the upper
thorac ic
par avertebral
mus culatur e
ov erly ing the
tr ansv ers e
pr oces ses
( F ig. 7.70).
5. With one leg
s lightly behind
the other for
balanc e, the
phy sic ian
leans
bac kward and Fig ure 7.71. Step 5.
40 of 64 21/08/07 22:03
dr aws the
patient
for war d. T he
phy sic ian
s imultaneously
r aises the
patient's
for ear ms,
us ing them as
a lever,
pr oduc ing
minimal
thorac ic
ex tens ion
( F ig. 7.71). Fig ure 7.72. Step 6.
6. T he pads of
the physic ian's
finger s ex ert a
gentle ventral
and cephalad
for ce to
engage the
s oft tiss ues,
pr oduc ing a
longitudinal
s tr etc h of the
thorac ic
par avertebral
mus culatur e
( F ig. 7.72).
7. Steps 5 and 6
may be
r epeated
s ev eral times
in a gentle,
r hy thmic, and
k neading
fas hion or
us ing deep,
s us tained
pr essure.
8. T is sue tension
is reevaluated
to ass ess the
effectiveness
of the
tec hnique.
41 of 64 21/08/07 22:03
P.103
Thoracic Region: Mi dthoracic Extension, Seated
42 of 64 21/08/07 22:03
1. T he patient is
s eated on the
end of the
table with the
hands
c lasped
behind the
nec k.
2. T he
phy sic ian
s tands at the
s ide of the
patient.
3. T he
r eaches
under the
patient's
upper arms
and gr asps
the patient's
far elbow.
T he patient's
other elbow
r es ts on the
phy sic ian's
for ear m near
the
antecubital Fig ure 7.74. Step 4.
fos sa.
4. With the
finger s
pointing
c ephalad, the
phy sic ian's
other hand is
c upped ov er
the thorac ic
s pinous
pr oces ses ,
c ontac ting
the
par avertebral
mus culatur e Fig ure 7.75. Step 5.
of one side
with the
thenar
eminence
43 of 64 21/08/07 22:03
P.104
Thoracic Region: Ri b Raising, Supine E xtension
T his procedure is
c ommonly us ed in
the postoper ative
s etting to treat the
s omatic
c omponents of
v isceros omatic
r eflexes
( postsur gic al
paralytic ileus ).
1. T he patient is
s upine on the
tr eatment table
or hos pital bed Fig ure 7.76. Step 2.
and the
phy sic ian is
s eated on the
s ide to be
tr eated.
2. T he
phy sic ian's
hands (palms
up) reach
under the
patient's
thorac ic s pine
( F ig. 7.76)
with the pads Fig ure 7.77. Step 2.
of the finger s
on the
patient's
thorac ic
par avertebral
mus culatur e
between the
s pinous and
tr ansv ers e
pr oces ses on
the side
c loses t to the
phy sic ian
( F ig. 7.77).
3. T he physic ian Fig ure 7.78. Step 3.
44 of 64 21/08/07 22:03
ex erts a gentle
for ce ventrally
to engage the
s oft tiss ues
and later ally
per pendic ular
to the thorac ic
par avertebral
mus culatur e.
T his is
fac ilitated by a
downward
pr essure
thr ough the
elbows on the
table, cr eating
a fulc rum to
pr oduc e a
v entral lever
ac tion at the
wr ists and
hands,
engaging the
s oft tiss ues.
T he finger s
ar e
s imultaneously
dr awn toward
the physic ian,
pr oduc ing a
lateral s tretch
per pendic ular
to the thorac ic
par avertebral
mus culatur e
( F ig. 7.78).
4. T his s tretch is
held for
s ev eral
s ec onds and
is slowly
r eleas ed.
5. Steps 3 and 4
ar e repeated
s ev eral times
in a gentle,
r hy thmic, and
k neading
fas hion.
45 of 64 21/08/07 22:03
6. T he
phy sic ian's
hands are
r epositioned to
c ontac t the
differ ent lev els
of the thorac ic
s pine and
s teps 3 to 6
ar e perfor med
to str etc h
v ar ious
por tions of the
thorac ic
par avertebral
mus culatur e.
7. T his technique
may also be
per for med
us ing deep,
s us tained
pr essure.
8. T is sue tension
is reevaluated
to ass ess the
effectiveness
of the
tec hnique.
P.105
Lumbar Region: Prone P ressure
46 of 64 21/08/07 22:03
1. T he patient is
pr one, with
the head
tur ned
toward the
phy sic ian. (If
the table has
a face hole,
k eep the
head in
neutral.)
2. T he
phy sic ian
s tands at the
s ide of the Fig ure 7.79. Step 2.
table
opposite the
s ide to be
tr eated ( Fig .
7.79).
3. T he
phy sic ian
places the
thumb and
thenar
eminence of
one hand on
the medial
as pect of the Fig ure 7.80. Step 3.
patient's
lumbar
par avertebral
mus culatur e
ov erly ing the
tr ansv ers e
pr oces ses on
the side
opposite the
phy sic ian
( F ig. 7.80).
4. T he
phy sic ian
places the
thenar Fig ure 7.81. Step 4.
eminence of
the other
hand on the
abducted
47 of 64 21/08/07 22:03
P.106
Lumbar Region: Prone Traction
1. T he patient is
pr one with the
head turned
toward the
phy sic ian. (If the
table has a face
hole, keep the
head in neutr al.)
2. T he physic ian
s tands at the side
of the table at the
lev el of the
patient's pelvis .
3. T he heel of the
phy sic ian's Fig ure 7.83. Step 3.
c ephalad hand is
placed ov er the
bas e of the
patient's sac rum
with the fingers
pointing toward the
c oc cyx (F ig.
7.83).
4. T he physic ian
does one or both
of the following:
a. T he
phys ician's
c audad hand Fig ure 7.84. Step 4a.
is plac ed
over the
lumbar
s pinous
proc ess es
with the
fingers
pointing
c ephalad,
c ontacting
the
paraver tebr al
s oft tissues
with the
thenar and Fig ure 7.85. Step 5.
48 of 64 21/08/07 22:03
hypothenar
eminenc es
( Fig . 7.84)
b. T he hand
may be
plac ed to one
s ide of the
s pine,
c ontacting
the
paraver tebr al
s oft tissues
on the far
s ide of the
lumbar spine
with the
thenar
eminenc e or
the near s ide
with the
hypothenar
eminenc e.
5. T he physic ian
ex erts a gentle
for ce with both
hands ventrally to
engage the soft
tis sues and to
c r eate a
s eparation and
dis traction effect
in the dir ection the
finger s of each
hand are pointing
( F ig. 7.85). Do not
pus h direc tly down
on the spinous
pr oces ses .
6. T his technique
may be applied in
a gentle, rhy thmic,
and kneading
fas hion or us ing
deep, sus tained
pr essure.
c audad hand is
r epositioned at
other lev els of the
49 of 64 21/08/07 22:03
lumbar spine and

s teps 4 to 6 are
r epeated.
8. T is sue tension is
r eevaluated to
as s ess the
effectiveness of
the technique.
P.107
Lumbar Region: Bil ateral Thum b P ressure, P rone
50 of 64 21/08/07 22:03
1. T he patient is
pr one, with
the head
tur ned
toward the
phy sic ian. (If
the table has
a face hole,
k eep the
head in
neutral.)
2. T he
phy sic ian
s tands at the
table at the
lev el of the
patient's
thighs or
k nees.
3. T he
phy sic ian's
thumbs ar e
placed on
both s ides of
the spine,
c ontac ting
the
mus cles
ov erly ing the
tr ansv ers e
pr oces ses of
L5 with the
finger s
fanned out
laterally (F ig.
7.86).
4. T he
phy sic ian's
thumbs ex ert
a gentle
for ce
v entrally to
engage the
s oft tiss ues
c ephalad,
and later ally
51 of 64 21/08/07 22:03
P.108
Lumbar Region: Sci ssors Technique, Prone
1. T he patient is
pr one, with the
head turned
toward the
phy sic ian. (If
the table has a
fac e hole,
k eep the head
in neutral.)
2. T he physic ian
s tands at the
s ide of the
table opposite
the side to be
tr eated ( Fig . Fig ure 7.88. Step 4.
7.88).
3. O n the side to
be treated, the
phy sic ian's
c audad hand
r eaches ov er
to grasp the
patient's leg
pr oximal to the
k nee or at the
tibial
tuberosity
( F ig. 7.89).
4. T he physic ian Fig ure 7.89. Step 4.
lifts the
patient's leg,
ex tending the
hip and
adducting it
toward the
other leg to
pr oduc e a
s c issors effect
( F ig. 7.90).
5. T he
phy sic ian's
c audad hand
may be placed
under the far Fig ure 7.90. Step 5.
52 of 64 21/08/07 22:03
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. T he physic ian
places the
thumb and
thenar
eminence of
the cephalad
hand on the Fig ure 7.91. Step 5.
patient's
par a-v ertebral
mus culatur e
ov erly ing the
lumbar
tr ans- ver s e
pr oces ses to
dir ect a gentle
for ce ventrally
and later ally to
engage the
s oft tiss ues
while
s imultaneously
inc reasing the
amount of hip
ex tens ion and
adduction
( F ig. 7.91).
7. T his forc e is
held for
s ev eral
s ec onds and
is slowly
r eleas ed.
8. Steps 6 and 7
ar e repeated
s ev eral times
in a s low,
r hy thmic, and
k neading
fas hion.
9. T he
phy sic ian's
53 of 64 21/08/07 22:03
c ephalad hand
is then
r epositioned to
c ontac t other
lev els of the
lumbar spine
and steps 6 to
8 are
per for med to
s tr etc h the
v ar ious
por tions of the
lumbar
par avertebral
mus culatur e.
10. T his technique
may also be
per for med
us ing deep,
s us tained
pr essure.
11. T is sue tension
is reevaluated
to ass ess the
effectiveness
of the
tec hnique.
P.109
Lumbar Region: Prone P ressure wi th Counterleverage
54 of 64 21/08/07 22:03
1. T he patient is
pr one with
the head
tur ned
toward the
phy sic ian. (If
the table has
a face hole,
k eep the
head in
neutral.)
2. T he
phy sic ian
s tands at the
table
opposite the
s ide to be
tr eated ( Fig .
7.92).
3. T he
phy sic ian
places the
thumb and
thenar
eminences of
the cephalad
hand on the
medial Fig ure 7.93. Step 4.
as pect of the
par avertebral
mus cles
ov erly ing the
lumbar
tr ansv ers e
pr oces ses on
the side
opposite the
phy sic ian.
4. T he
phy sic ian's
c audad hand
c ontac ts the
patient's Fig ure 7.94. Step 5.
anterior
s uperior iliac
s pine on the
s ide to be
55 of 64 21/08/07 22:03
P.110
Lumbar Region: Lateral Recum bent Positi on
1. T he patient
lies in the
lateral
r ec umbent
pos ition with
the tr eatment
s ide up.
2. T he
phy sic ian
s tands at the
s ide of the
table, fac ing
the fr ont of
the patient.
3. T he patient's Fig ure 7.95. Step 3.
k nees and
hips are
flexed, and
the
phy sic ian's
thigh is
placed
agains t the
patient's
infrapatellar
r egion (F ig.
7.95).
4. T he
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 7.97. Step 5.
56 of 64 21/08/07 22:03
( F ig. 7.96).
5. T o engage
the soft
tis sues, the
phy sic ian
ex erts a
gentle for ce
v entrally and
laterally to
c r eate a
per pendic ular
s tr etc h of the
lumbar
par avertebral
mus culatur e Fig ure 7.98. Step 7.
( F ig. 7.97).
6. While the
phy sic ian's
thigh against
the patient's
k nees may
s imply be
us ed for
br acing, it
may also be
flexed to
pr ovide a
c ombined
bowstr ing
and
longitudinal
tr action forc e
on the
par avertebral
mus culatur e.
T his
tec hnique
may be
applied in a
gentle
r hy thmic and
k neading
fas hion or
with deep,
s us tained
pr essure.
7. T his
tec hnique
may be
57 of 64 21/08/07 22:03
modified by
br acing the
anterior
s uperior iliac
s pine with
the caudad
hand while
dr awing the
par avertebral
mus cles
v entrally with
the cephalad
hand ( Fig .
7.98).
8. T he
phy sic ian's
hands are
r epositioned
to contac t
differ ent
lev els of the
lumbar spine
and steps 4
to 6 are
per for med to
s tr etc h
v ar ious
por tions of
the lumbar
par avertebral
mus culatur e.
9. T is sue
tension is
r eevaluated
to ass ess the
effectiveness
of the
tec hnique.
P.111
Lumbar Region: Supi ne Extensi on
58 of 64 21/08/07 22:03
1. T he patient is
s upine. ( T he
patient's hips
and knees
may be flexed
for comfor t.)
2. T he physic ian
is seated at
the side to be
tr eated.
3. T he
phy sic ian's
hands (palms
up) reach
under the Fig ure 7.99. Step 4.
patient's
lumbar spine,
with the pads
of the
phy sic ian's
finger s on the
patient's
lumbar
par avertebral
mus culatur e
between the
s pinous and
tr ansv ers e
pr oces ses on Fig ure 7.100. Step 4.
the side
c loses t the
phy sic ian
( F igs. 7.99
and 7.100).
4. T o engage the
s oft tiss ues,
the physic ian
ex erts a gentle
v entral and
lateral force
per pendic ular
to the thorac ic
par avertebral
mus culatur e. Fig ure 7.101. Step 5.
T his is
fac ilitated by
downward
pr essure
59 of 64 21/08/07 22:03
P.112
Lumbar Region: Long-Lever Counterlateral with Knees,

S upine
60 of 64 21/08/07 22:03
1. T he patient
lies s upine on
the tr eatment
table.
2. T he
phy sic ian's
c audad hand
flexes the
patient's hips
and knees to
approx imately
90 degrees
eac h ( Fig .
7.102) .
phy sic ian's
c ephalad
hand r eac hes
ov er the
patient and
under the
patient's
lumbar region
in the ar ea of
the
dy s function.
4. T he physic ian
c ontrols the
lower
ex tremities
bilaterally at
the tibial
tuberosities
and slowly
mov es the
k nees
laterally away
fr om the
phy sic ian
( F ig. 7.103).
5. As the
patient's
k nees are Fig ure 7.104. Step 6.
mov ed away
fr om the
phy sic ian, the
phy sic ian
61 of 64 21/08/07 22:03
P.113
Lumbar Region: Left, Lumbar P aravertebral Muscle Spasm,

Myofasci al Hypertonici ty, Seated
62 of 64 21/08/07 22:03
1. T he patient is
s eated on the
end of the
table with the
phy sic ian
s tanding
behind the
patient and to
the right side,
opposite the
dy s function.
2. T he patient is
ins tructed to
place the left
hand behind Fig ure 7.106. Step 2.
the neck and
gr asp the left
elbow with
the right
hand. The
phy sic ian's
r ight hand
r eaches
under the
patient's right
ax illa and
gr asps the
patient's left
upper arm Fig ure 7.107. Step 3.
( F ig. 7.106).
3. T he
phy sic ian's
left thumb
and thenar
eminence are
placed on the
medial
as pect of the
patient's left
par avertebral
mus culatur e
ov erly ing the
lumbar
tr ansv ers e Fig ure 7.108. Step 5.
pr oces ses
( F ig. 7.107).
4. T he patient is
ins tructed to
63 of 64 21/08/07 22:03
P.114
References
1. W ard R C, ed . F ound ati ons for Os teo path i c M ed i c in e. Phi l ade l ph i a: Lip pin c ot t Wi l li ams &
W i lk i ns , 20 03.
2. G r ee nm an P. Pr i nci ple s o f Ma nua l M edic i ne . P hi la del - ph i a: Lip pin c ott Wi l li am s & W i lk i ns, 20 03.
64 of 64 21/08/07 22:03
8
Myofascial Release Techniques
Technique P rincipl es
War d de s cr i be s my o fa s ci a l r e le a se t ec h ni q ue a s “ de s ig n e d t o s tr e t ch an d r e f le x ly
r el e a se pa t te r n ed so f t t i s s u e a nd j oi n -r e la t e d r es t ri c t io n s” (1 ) . T h is s t y l e o f
o s t e o pa t hi c m a n ip u la t io n ha s h i s t o r ic a l t ie s to ea r ly o s t e op a th i c m a ni p ul a t iv e t r ea t men t
a nd s of t t i s s u e t e ch n iq u e , b ut Wa r d c o mb i ne d pr i nc i pl e s o f m a ny o th e r t ec h n iq u es to
d ev e l op a d is t i nc t t e ch n i qu e , e ve n th o ug h i t s r o ot s m a y g o b a c k t o e ar l y o s te o pa t hi c
p hy s i ci a ns (2 ) . T h e E du c a ti o n Cou n c il on Os t e op a th i c P r in c ip l es h as de f in e d
myo f a s c i al re l e as e t e ch n i qu e a s a “ s y s te m o f di a gn o si s an d t r ea t men t f i rs t de s cr i be d
b y A n dr e w Tay l o r S ti l l a n d h is ea r l y s tu d en t s , whi c h e n ga g es co n t in u al pa l p at o ry
f ee d b ac k t o a c h ie v e r el e a se of my o f as c ia l t i s su e s” (1 ) . I n c o mp a r in g t h is t ec h ni q ue t o
o th e r o s te o pa t h ic te c hn i q ue s ( e sp e c ia l ly fo r so f t t is s u e) , i t i s ob v io u s t h at ha n d
p la c e me n t a nd f or c e v ec t o r d ir e c t i o ns ar e s i mil a r a nd t ha t t h e p r in c ip l es u se d t o a f f ec t
t he v ar i ou s a n a to mic ti s s ue t y p es , mu s cl e o r i gi n s a nd i ns e rt i on s , a n d s o o n a r e a ls o
i mp o r ta n t i n t h is s t y le . Wh e re a s s o f t ti s su e te c hn i qu e ha s b e en h is t or i ca l l y d ir e c t i n
c la s s if i ca t io n , m y of a s c i a l r el e as e ca n b e p e r fo r me d i n ei t he r a d ir e c t or i nd i re c t
man n e r. Th e re f o re , s o me wou l d c la s s if y i t a s a c om b in e d t e ch n iq u e ( 2 ).
Myo f a s c i al te c h ni q ue ma y be pe r fo r med wi t h o n e h an d o r tw o . Cli n i ca l ly , a t wo - ha n de d

met h o d may be mor e e f fe c t iv e i n d i a gn o si s a n d t r ea t me n t . The os t e op a th i c p h y s i ci a n
wil l us e e p ic r i ti c p a lp a t io n t o d e t er min e t h e s o f t ti s s ue co mpl i a nc e ( l oo s e ne s s , ea s e ,
f re e d om ) a n d s t if f ne s s ( t ig h tn e s s , bi n di n g, r es t ri c ti o n ). Ho wev e r , i n d y s f u nc t io n al
s ta t e s t he r e ma y b e a g e n er a l o r u n iv e rs a l b a rr i er (r e s tr i c t i on ) , s o t h at t he s e t is s u es
h av e an as y mm e t ri c q u al i t y o r q ua n t it y o f c o mpl i an c e. Thu s , a s e n se of fr e e do m i n o n e
o r mo re di r ec t i on s a n d r e s t r ic t io n in th e o t h er s c a n e x is t . The s e a s ym met r i es ar e
c li n i ca l ly de s c ri b ed as h av i ng a t i gh t -l o os e or ea s e- b i nd re l at i o ns h ip . W a r d a ls o p o i nt s
o ut t ha t t h e t i gh t -l o os e as y mm e tr y ma y b e m o r e c li n ic a l ly re l ev a n t a t t he l oo s e s it e s ,
whe r e p a in an d in s ta b il i t y may be p re s en t ( 1 ) . The r ef o r e, th e p h y si c ia n m u s t b e a wa r e
t ha t th e re ma y be a c au s e -a n d- e f f e c t s it u at i o n whe r eb y (a ) t h e t i gh t o r d i r ec t b a rr i e r i s
c au s i ng a s ec o n da r y l oo s e r e ac t io n or (b ) t h e l o os e s i t e i s i nh e r en t ly un s t ab l e, an d
e as i n g t he ba r r ie r i n e i t he r d i re c t io n m a y n o t b e c li n i ca l ly ad v i sa b le .
B ar r i er s m a y b e i d en t if i e d wit h t h e p a ti e nt p as s iv e o r ac t iv e . Th e t re a tm e n t may al s o
c on s i s t of th e s e a lt e rn a t iv e s . Th e pa t ie n t' s re s pi r at o r y a s s i s t a n ce , s p ec i f ic a ll y
d ir e c te d i s om e t ri c m u s c l e c o nt r ac t i on s ( e .g . , c l en c hi n g f i s t s o r ja w), to n g ue
mov e men t s o r o c ul a r mov e men t s , an d so on ar e of t en us e d t o p o te n t ia t e t he
t ec h n iq u e. Th e s e a re ge n e ra l ly re f e rr e d t o a s r e le a se - e nh a nc i ng mec h an i sm s (R E Ms )
( no t to be co n f us e d wit h ra p id ey e mo v em e nt s ) .
A s t h e f as c ia i s s o d ee p l y i nc o rp o r at e d i nt o th e m u s c l e s a nd th e re s t o f t h e b od y , a n y
f or c e d i re c te d on it ma y af f ec t t h e l i ga men t o us an d c a p su l ar (a r t ic u la r ) t i s s u es an d
s tr u c tu r es ve r y d i s t a l t o t h e s pe c i fi c a r ea b ei n g p al p a te d a n d t r ea t ed . T h e re f or e , t h is
1 of 21 21/08/07 22:04
t ec h n iq u e may e f f e c t wi d e sp r ea d r e a c t i on s . Fo r e xa mpl e , r e le a si n g t h e a re a
s ur r o un d in g T 7 an d T 8 m a y c a us e t h e p a ti e nt t o h av e l e s s s ub o c c i p it a l s ym p t om s
t hr o u gh th e p o s it i ve ef f e c t of th e te c hn i qu e on th e t r a pe z iu s m u s cl e .
A n u mbe r o f p h y si c al an d an a to mic a sp e c t s a r e i mpo r ta n t i n m y of a s ci a l r el e a se as

i ll u s tr a te d b y Wa r d ( 1) . Th e se in c l ud e W o lf f ' s l aw , H o o ke ' s l aw , an d N e wt o n 's th i rd l aw .
The y re l at e t h e v a ri o us r ea c ti o ns t o f or c e, s uc h a s d e f or mat i on a nd th e f a c t t ha t
p hy s i ca l c o nt a c t b et wee n th e p h y s i c ia n a n d p a ti e nt ha s eq u al an d op p os i te f or c e
mag n i tu d es . T h e re f or e , b y i n tr o du c i ng la ws o f t h er mod y n am i c s an d en e rg y
c on s e rv a ti o n t h eo r ie s , we c a n p ro j e c t th e c h a ng e s t ha t oc c ur in t he pa t ie n t 's ti s su e s
whe n pr e s s u re i s i ni t ia t e d i nt o t h e se s t r uc t u re s . J ou l e f o un d t h a t t he am o u nt of en e r gy
d on e as wo r k wa s c on v er t e d t o h ea t . T h e r es u l ti n g c ha n g es ma y b e ch a ng e s i n t h e
c ol l a ge n ou s s t a te fr o m g e l t o s ol . Wi t h c on t i nu e d t re a t me n t a f f e c ti n g t he s e t i s s u es ,
t he o pp o rt u ni t y m a y e xi s t t o a l te r th e e l as t i c p ro p er t i es pe r ma n e nt l y ( pl a s ti c c h an g e ).
P. 1 16
Technique Classifi cation
Direct, Indirect, or Com bined With Two-Handed Technique

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

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

1. Use a s p ar t o f th e m u s c u l os k el e ta l s c r ee n in g ex a mi n at i o n t o q ui c k ly id e nt i f y
r eg i o ns of po t e nt i al mo t i on re s tr i c ti o n a nd t is s ue te x t ur e c h an g e s .
2. Red u c e mus c le t en s io n a n d f a s c i al t en s io n .
3. S tr e t ch an d i n c re a se el a s ti c it y o f sh o rt e ne d , i n el a s t i c , a nd / or f ib r ot i c my of a s c i al
s tr u c tu r es to i mp r ov e r e g io n al an d / or in t er s e gm e nt a l r a ng e s o f mo ti o n.
4. Red u c e t he ti g h t- l oo s e a s ym met r y t o i mpr o ve t he ti s su e co n si s te n c y i n t he l oo s e
2 of 21 21/08/07 22:04
t is s u es by in c r ea s in g e l a s t i ci t y i n t h e t ig h t t i s s u es .
5. I mp r o ve ci r cu l a ti o n t o t h e s pe c if i c r e gi o n b e in g t r ea t e d b y l oc a l p h y s i ca l an d
t he r mod y na mic e f f e c t s o r by re f le x ph e no men a to im p ro v e c i rc u la t i on in a d i s t a l
a re a (e . g. , t h r ou g h s om a t os o ma t ic , so mat o vi s c er a l r ef l e xe s ).
6. I nc r e as e v e no u s a n d l ym p h at i c d ra i n ag e t o d e c re a se lo c a l a nd / or d is t al sw e l li n g
a nd e de ma a nd p ot e nt i al l y i mpr o ve t he ov e ra l l i mmu n e r e sp o ns e .
7. P ot e n ti a te th e ef f ec t o f ot h er os t e op a th i c t e ch n iq u es .
Contraindicati ons
Relative Contraindications
A s my of a s c i al t ec h ni q ue may be pe r f or med wi t h e x tr e me l y l i gh t p r e s s u re in a d i re c t o r
i nd i r ec t m a nn e r , t he r e i s l i t t l e l i ke l ih o od o f a dv e rs e ef f ec t s o t he r t h an a ch e s p os t
t re a t me n t t ha t ar e s e co n d ar y t o c o mpe n sa t io n an d d e co mp en s at i on r ea c ti o ns a nd
s im i l ar to ac h e s p os t e x e rc i se . A s in ot h er t ec h ni q ue s , i n cr e as e d w a te r i n t ak e a n d i c e
p ac k ap p li c at i o n a s n ee d e d p os t t r e at men t w i l l g en e ra l l y r ed u ce a ny su c h r e ac t io n .
1. A cu t e s p ra i n o r s t ra i n.
2. Fra c t ur e o r d i s lo c at i on .
3. Neu r o lo g ic or v as c ul a r c o mp r om i se .
4. O s t e o po r os i s a n d o s t e op e n ia .
5. Mal i g na n c y . M o s t r es t ri c t io n s a re f or tr e at me nt in th e af f ec t ed a re a o f
mal i g na n c y ; h o wev e r, ca r e s h ou l d b e t a ke n i n ot h er di s t al ar e as d ep e nd i ng o n
t yp e of ma l ig n a nc y a n d/ o r l y mp h at i c i n vo l ve me nt .
6. I nf e c ti o n ( e. g . , o s t e om y e li t is ) .
Absol ute Contraindications

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

1. The p hy s ic i an p al p at e s t h e p at i en t us i ng la y e r- b y- l ay e r p a lp a to r y p r in c ip l e s a nd
wit h ju s t e no u g h p re s su r e t o c a pt u r e t he s k i n a n d s ub c u ta n eo u s f a s c i al
s tr u c tu r es . T h i s i s o ne l ev e l o f p r es s ur e l e s s t ha n t h a t o f s of t ti s su e t e c hn i qu e .
A ny mov e me n t o f t h e h an d on th e s k i n s ho u ld c au s e t he s ki n t o m o v e a lo n g wi th
t he h an d w i th o u t s li d in g th e h a nd o ve r t h e s k in .
2. The p hy s ic i an g en t ly mo v e s t he pa l p at i ng ha n d o r h a nd s in a l in e a r d ir e c t i o n o f
3 of 21 21/08/07 22:04
c ho i c e ( ha n ds o f t he cl o c k) mo v in g th r ou g h t h e x - a nd y -a x es . T h e z - ax i s h a s
a lr e a dy be e n e n ga g ed by t he la y er - b y- l ay e r p a lp a to r y p r es s ur e i n t o t he bo d y ,
g ai n i ng ac c es s to th e s u p er f ic i al f as c ia .
3. S ym me tr y v e rs u s a s ym met r y o f t i s s u e c o mp l ia n c e i s n ot e d i n t h e l i ne a r
d ir e c ti o ns te s t ed .
4. The p hy s ic i an may ad d a v ar i et y o f di r ec t io n s o f m o ti o n , i nc l ud i n g o th e r l i ne a r
mov e men t s i n a 36 0 -d e gr e e
P. 1 17
r ef e r en c e a nd c lo c kw i se a nd co u nt e r cl o c k wis e ro t at i on a l m o ve men t . A g ai n ,
s ym me tr y v e rs u s a s ym met r y o f t i s s u e c o mp l ia n c e i s n ot e d .
5. The p re s su r e t h e p hy s ic i a n u se s t o de t er min e co mpl i an c e m a y b e mi ni mal or

mod e r at e , d ep e n di n g o n t h e c li n ic a l p r es e nt a t io n o f t h e p a ti e nt ( ac u te pa i n fu l
v er s u s c hr o ni c mi n im a ll y pa i nf u l) a nd wh a t t h e p hy s ic i a n b el i ev e s i s a p pr o p ri a te
f or t he si t ua t i on .
6. A f t e r d e te r mi n i ng th e e a s e a nd bi n d b a rr i er s of th e t i s su e i n t h e se di r ec t i on s ,
t he p hy s ic i an d et e rm i ne s wh e th e r g e nt l e o r mo de r at e p r e s s u re in a d i re c t ( t ow a rd
b in d ) o r i n di r e c t (t o wa r d e a se ) t e c hn i qu e i s ap p ro p ri a t e. Ag a in , th i s i s
d et e r mi n ed by t he cl i ni c a l p re s en t a ti o n a nd e xa min a ti o n f i nd i ng s . I n g e ne r a l, th e
g en t l es t m e th o d i s t h e s a fe s t .
7. The p hy s ic i an s lo wly mo v e s t he ha n d -c o nt r ol l e d myo f as c i al ti s su e s t o wa r d t h e

a pp r o pr i at e b a r ri e r, an d on me e ti n g t h e b ar r i er , h e o r sh e h o ld s th e t i s s u e a t
t ha t po i nt wi t h ou t r e li e v in g t h e p r es s ur e . Th e p hy s ic i a n s ho u ld n ot i ce th a t a f te r
a pp r o xi mat e ly 2 0 t o 3 0 s e co n ds , a c ha n ge of t is s ue co mp li a nc e o c c ur s ; t hi s is
d em o n s t r at e d b y m o ve men t of th e t i s su e t h ro u g h t he or i g in a ll y d e t er min e d
b ar r i er (c r ee p or fa s ci a l c r ee p ).
8. The p hy s ic i an f ol l ow s t h i s c ha n ge a nd co n ti n u es ho l di n g u n ti l n o fu r th e r
e vi d e nc e o f c r e ep oc c ur s . T h er e m a y b e a nu mb er of co mp li a nc e c h a ng e s
( cr e e p) be f or e th i s p he n o me n on s t o p s .
9. The p hy s ic i an r ee v al u at e s t h e t is s u e t o d et e r mi n e whe t h er th e t i s su e 's

c om p l ia n ce an d qu a li t y h a ve im p ro v e d. Th e t e c hn i qu e m a y b e r e pe a t ed at th e
s am e ar e a o r a n ot h er , a n d f o ll o w- u p v i si t s ma y b e p re s c ri b ed fo r a 3 -d a y i n te r va l
o r l o ng e r, de p e nd i ng on p at i en t r e a c t i vi t y .
B ec a u se of th e va r io u s t i s s u e l ev e l s e nc o un t e re d a n d t h e p ro x im a l -t o -d i s t a l
r el a t io n sh i ps ( te n se g ri t y ) a s s o ci a t ed wi t h t h e s om a ti c dy s fu n c t i o n, th e re may be
c ou n t le s s way s in wh i ch t o t ou c h a n d p os i ti o n t h e p at i e nt wh e n i mpl e me n ti n g
myo f a s c i al re l e as e t e ch n i qu e . We h a ve de s cr i b ed a n um b e r o f c om mo nl y u s ed
t ec h n iq u es bu t ha v e a ls o il l us t ra t e d man y o t h er s w i th o u t t he de s c ri p ti v e t e x t be c au s e
t he p hy s ic i an may fo l lo w th e g u id e l in e s a nd d ev e lo p a p ar t ic u la r s t r at e gy o r t re a tm e n t
p ro t o co l t h at b es t s u it s th e p a ti e n t .
P. 1 18
Cervi cal Region: S upi ne Cradling
4 of 21 21/08/07 22:04
1. The pa tie n t
lie s supi n e
and th e
physician sits
at the he a d o f
the ta ble .
2. The
physician 's
han ds are
pla ced pa l ms
up und er the
patien t's
articu lar Figure 8.1 . Step 2, arti cul ar pro cesses.
pro cess
(pi lla r) a t the
level of the
dysfun cti o n
(Fig. 8.1 ).
3. The ph ysi cian
lifts upw a rd
into the
patien t's
posterior
cervical
tissue s w i th
onl y e nou g h Figure 8.2 . Step 4, mee ting th e b a rri ers.
force to control
the skin a nd
und erl yin g
fascia , so as to
not sl ide the
han ds acro ss
the pa tie n t's
ski n.
4. The ph ysi cian
mon ito rs
inferi or a nd
sup eri or, left
and ri ght Figure 8.3 . Step 5, ind i rect b arri er.
circumfere nti al
rotati on, and
5 of 21 21/08/07 22:04
P. 1 19
Thoracic Region: Thoraci c Inlet and Outlet, S eated Steering

Wheel
1. The pa tie n t i s
sea ted . Th e
physician
sta nds be h ind
the pa tie n t.
2. The ph ysi cian
pla ces th e
han ds pal ms
dow n o ver the
sho uld er,
pro ximal to the
cervicoth o racic
jun cti on a t the Figur e 8 .4. Ste p 2 .
ang le of the
neck a nd
sho uld er g ird le
(Fig. 8.4 ).
3. The ph ysi cian
pla ces th e
thu mbs ove r the
posterior first
rib re gio n , a nd
laces the ind ex
and th ird dig its
immedi ate l y
sup eri or a nd Figur e 8 .5. Ste p 3 .
inferi or to the
cla vicle a t the
ste rno cla vicu lar
joi ns bil a terall y
(Fig. 8.5 ).
4. The ph ysi cian
lifts upw a rd into
the pa tie n t's
posterior
cervical tissues
6 of 21 21/08/07 22:04
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.
5. The ph ysi cian
mon ito rs
inferi or a nd
sup eri or, left
and ri ght
circumfere nti al
rotati on, and
torsio nal
(tw isting )
motion
ava ila bil i ty for
ease-b ind
symmetric or
asymme tri c
rel ati ons.
6. After
determini n g the
pre sen ce o f a n
ease-b ind
asymme try, th e
physician wil l
either in d ire ctl y
or directl y meet
the ea se-b ind
barrie r,
respective ly.
7. The fo rce is
app lie d i n a
very g entl e to
mod era te
man ner.
8. The ph ysi cian
wil l conti nue
thi s u nti l a
7 of 21 21/08/07 22:04
rel ease i s
pal pated (facial
cre ep) an d
con tin ue to
fol low th i s
cre ep unti l i t
doe s n ot recu r.
Thi s i s h e ld for
20 to 60
second s o r un til
a rele ase is
pal pated. Dee p
inh ala tio n or
oth er rel e ase
enh ancing
mechan isms
can be he l pfu l.
P. 1 20
Thoracic Region: P rone
1. The pa tie n t l ies

pro ne on the
tre atment tab le.
2. The ph ysi cian
sta nds be side
the pa tie n t,
sli ghtly ceph ala d
to the il i ac
cre sts.
3. The ph ysi cian
pla ces bo th
han ds pal ms
dow n w ith the Figure 8.6 . Step 3.
fin gers sl igh tly
spread ap a rt
immedi ate l y
8 of 21 21/08/07 22:04
parasp ina l on
each side (Fig.
8.6 ).
4. 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 Figure 8.7 . Step 5, infe rio r a nd supe rio r
across th e barriers.
patien t's ski n.
5. The ph ysi cian
mon ito rs i nfe rio r
and su peri or, le ft
and ri ght
circumfere nti al
rotati on, and
torsio nal
(tw isting ) mo tio n
ease-b ind
clo ckw ise and
cou nte rcl o ckw ise Figure 8.8 . Step 5, circumfere nti a l
rel ati ons (Figs. barriers.
8.7 and 8 .8).
6. After dete rmi nin g
the prese n ce of
an ease-b i nd
asymme try, th e
physician wil l
or directl y meet
the ea se-b ind
barrie r,
respective ly.
7. The fo rce is
app lie d i n a very
gen tle to
9 of 21 21/08/07 22:04
mod era te
man ner.
8. Thi s i s h e ld for
20 to 60 seco nds
or until a re lea se
is pal pate d.
P. 1 21
P elvi c and Sacral Region: Bi lateral Sacroili ac Joint wi th

Forearm Pressure, Supine
1. The pa tie n t
lie s supi n e
and th e
physician
sits a t th e
sid e o f th e
patien t a t
the le vel of
the
mid femur to
kne e.
2. The
physician Figure 8.9 . Step 3.
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 8.1 0. Step 4.
10 of 21 21/08/07 22:04
the ta ble .
3. The
physician 's
oth er han d
is pla ced
pal m u p
und er the
sacrum (Fig.
8.9 ).
4. After
return ing
the hi p to
neu tra l, the Figure 8.1 1. Step 5.
physician
pla ces th e
oth er
forearm a n d
han d o ver
the an teri or
sup eri or
ili ac spi n es
(ASIS) of the
patien t's
pel vis (Fig.
8.1 0).
5. The
physician
lea ns dow n
on the
elb ow of the
arm th at i s
con tactin g
the sa cru m,
kee pin g th e
sacral ha n d
rel axe d a n d
with the
forearm
mon ito rs for
ease-b ind
asymme try
in left a n d
11 of 21 21/08/07 22:04
rig ht
rotati on
(Fig. 8.1 1 )
and le ft a nd
rig ht torsion .
6. After
determini n g
the
pre sen ce o f
an
ease-b ind
asymme try,
the
physician
wil l e ith e r
ind ire ctl y or
directly
mee t the
ease-b ind
barrie r,
respective ly.
7. The fo rce is
app lie d i n a
very g entl e
to mod era te
man ner.
8. Thi s i s h e ld
for 20 to 60
second s o r
until a
rel ease i s
pal pated.
P. 1 22
Lumbosacral Region: P rone
12 of 21 21/08/07 22:04

pro ne. Th e
physician sta nds
beside th e
patien t.
2. The ph ysi cian
pla ces on e ha nd
ove r the i nfe rio r
lumbar se g men t
(e.g., L4 -L5) an d
the other ove r
the su peri or
lumbar se g men t Figure 8.1 2. Step 2.
(e.g., L1 -L2)
(Fig. 8.1 2 ).
3. The ph ysi cian
mon ito rs i nfe rio r
and su peri or
gli de, le ft a nd
rig ht rota tio n,
and cl ockw ise
and
cou nte rcl o ckw ise
motion
ease-b ind Figure 8.1 3. Step 3, ea se-b ind
asymme try (Fig. asymmetry.
8.1 3).
the prese n ce of
an ease-b i nd
asymme try, th e
physician wil l
or directl y meet
the ea se-b ind
barrie r,
respective ly.
5. The fo rce is
gen tle to
13 of 21 21/08/07 22:04
P. 1 23
E xtremities: I nterosseous Membrane, Seated
sea ted or sup ine .
The ph ysi cian
sta nds or sits i n
fro nt and to the
sid e o f th e
patien t o n th e
affected side .
2. The ph ysi cian
pal pates the
affected fore arm
ove r the
intero sse o us Figure 8.1 4. Step 3.
membra ne a nd
notes any
evi den ce o f a
tau t, fib rous
ban d, pai n , o r
ease-b ind tissue
ela sti city
asymme try.
3. The ph ysi cian
pla ces th e
thu mbs ove r the
anteri or
dysfun cti o nal Figure 8.1 5. Step 4.
asp ect of the
intero sse o us
membra ne w ith
the pa lm a nd
fin gers e n circli ng
the fo rea rm (Fig.
8.1 4).
4. The ph ysi cian
mon ito rs
cep hal ad a nd
cau dad , l e ft and
14 of 21 21/08/07 22:04
rig ht rota tio n,

and cl ockw ise
and
cou nte rcl o ckw ise
motion
ease-b ind
asymme try (Fig.
8.1 5).
the prese n ce of
an ease-b i nd
asymme try, th e
physician wil l
or directl y meet
the ea se-b ind
barrie r,
respective ly.
6. The fo rce is
gen tle to
mod era te
man ner.
7. Thi s i s h e ld for
20 to 60 seco nds
or until a re lea se
is pal pate d.
P. 1 24
E xtremities: S upine Leg Traction
15 of 21 21/08/07 22:04
1. The pa tie n t
lie s supi n e
on the
tre atment
tab le and
the
physician
sta nds at
the
patien t's
fee t.
2. The
physician 's Figur e 8 .16 . Step 3.
han ds
(pa lms up )
rea ch
und er and
con tro l th e
patien t's
Ach ill es
and
cal can eal
reg ion .
3. The
physician
lifts both Figur e 8 .17 . Step 4, tra ctio n thro u gh the
low er leg s l eg.
to 20 to 3 0
deg ree s o ff
the ta ble
(Fig. 8.1 6 ).
4. The
physician
gen tly
lea ns
backwa rd,
add ing
sli ght
tra cti on
throug h th e Figur e 8 .18 . Step 5, inte rna l a nd
leg , to e xte rnal ro tati on; ab duction an d
16 of 21 21/08/07 22:04
P. 1 25
P. 1 26
P. 1 27
Myofasci al Rel ease Techni ques
Fig ure s 8 .20 to

8.3 0 show the
con tin ued
pri nci ple s of
myo fascia l
rel ease (d ire ct,
ind ire ct) but
are wi tho u t
wri tte n
descri pti o ns.
Just u se the
arrows as a
gui de to the Figur e 8 .20. Stern o cla vicula r jo int an d
man y vecto red a rm traction .
force
app licati o ns
tha t can b e
effective for
tre atment of
the pi ctu red
reg ion .
Figur e 8 .21. Lo ng a xis re lea se.
17 of 21 21/08/07 22:04
Figur e 8 .22. Scale n e rele ase .
Figur e 8 .23. Stern a l rele ase .
Figur e 8 .24. Th ora colu mba r re lea se.
18 of 21 21/08/07 22:04
Figur e 8 .25. Il ioti bia l b and – ten sor fa scia

l a ta rel e ase .
Figur e 8 .26. Sa cro coccyge al rele ase .
Figur e 8 .27. Ischi o rectal fo ssa (pe lvi c

d i aph rag m) rele ase .
19 of 21 21/08/07 22:04
Figur e 8 .28. Pl anta r fascial rel ease.
Figur e 8 .29. Su bma n dib ula r re lea se.
Figur e 8 .30. Hyoid rel ease.
P. 1 28
References
20 of 21 21/08/07 22:04
2 . G r ee n man P. Pr i n ci p le s o f Ma n ua l M e d ic i ne . P h i la d el - ph i a : L ip p in c o t t Wi l li a ms &
Wi lk i ns , 20 0 3.
21 of 21 21/08/07 22:04
9
Counterstrain Techniques
Techni que Pri nci ples

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

aff ect ed ( s ho r te ni ng th e a goni s t) .
4. T hi s l engt hen s t he a nta gon i s t m us c le .
5. It i s pr op ose d t hat the ra pi d s ho r te ni ng of th e ag oni s t and l en gth enin g o f t he a nta gon i s t tog eth er
pro duc e an in app r opr i at e r efle x t hat i s m an i fe s ted as a tend er poi nt i n t he anta gon i st m us c le .
In cl i ni c al exa m in ati on, thi s o ften pr ese nts as a t ende r p oin t on th e o pen- fac ete d (s tre tch ed) s id e o f th e
dy s fu nct i on al s egm ent . Fo r e x am pl e, a C 5, F SR R R dys func tio n w i l l m os t f r equ ent l y ex hi bit a tend er
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poi nt on th e le ft s id e of th e p atie nt' s c er vi c al sp i ne. Th ere fore , w i th a F SRR R d y s fu nct i on , th e r i gh t si de

i s fa c et cl os ed an d t he l eft si de i s f ace t op ene d.
J ones be l ie v ed tha t p utti ng the j oi nt i nt o it s p osi ti on of gr eate s t c om fort wo uld r ed uce th e co nti nui ng
i napp r op r ia te p r op r io c ept or act i v it y . As Gl ov er and R en nie re port , J one s ma de ano ther di s co v ery : t he
anter i or as pect s o f t he b ody mu s t b e e v al uate d e v en i f the sy m pto m s are pos ter i or ( 2, 4). Jo nes
ev ent ual l y m app ed m an y lo c al ar eas of ten dern ess to w hi c h he r ela ted se gm en tal an d/or my ofa s c ia l
dy s fu nct i on . Hi s t end er p oin t l oc at i on s a nd t hei r r el at i on to dys fun c ti on d o n ot ty pi c al l y us e the x- , y- ,
and z - ax i s para m et ers of fle x io n an d e x te ns io n, r ot atio n,
P.13 0
and s i de be ndin g t hat are co m mo n to ar tic ul ar , p osi ti on al, an d mo tio n-b as ed de fin i tio ns of s oma tic
dy s fu nct i on ( de s cr i bi ng m oti on r est r ic tio n an d a s ym m etr y ). As c ou nte r st r ain is al s o u s ed fo r mu s cu l ar
( m y of asc i al ) dy s fu nct i ons an d t here ar e o v erl aps be tw ee n t he tw o typ es of d y sf unc ti on s , ten der poi nts
c an b e c onf us ed wi th one ano the r . T his ha s ca use d s om e c on fus i on, an d t er ms li k e m ave r ic k t ende r
poi nt s h ave bee n u s ed to r es olv e th e f act tha t t he c l as s ic po s i ti on doe s no t a l wa y s e l im i na te t he ten der
poi nt . F or ex am ple , a hyp ert oni c de ep c er v i ca l m usc l e m ay be tend er i n an a r ea si m i la r t o t hat of the
r efle x t end er p oin t f r om an art i c ul ar c er v i ca l d y sf unct i on . B ut t he pos i tio ns to al le v ia te the pai n m ay b e
oppos i te ea c h o the r . T her efo r e, r ec ogn i zi ng t his fa c t s hou l d dr am ati c al l y r edu c e the per c ep ti on of
m av er i ck te nder po i nt s , a nd the phy s ic i an ' s u nde r st andi ng of tend er poi nts s ho uld i nc l ud e a nd r eco gni z e
the s pec i fi c mu s cl e– tend er poi nt r ela tio ns a s w ell as the ar ti cu l ar re l ati ons . J ones re fer s in so m e ar ea s
to sp eci fic m us c le s , y et i n the v er teb r al r eg i on s h e se ems to s ta y m ore foc use d o n ar tic ula r sp i na l
s egme nta l l ev el s o f d y s fu nct i on .
Anoth er c ri teri on tha t we fi nd c l in i ca l ly i mp ort ant i n thi s t ec hn i qu e i s pr ope r a s s oc i at i on of the

dy s fu nct i on pat ter n t o th e t r ea tm en t p osi ti on in th e va r io us ar ti c ul ar ty pe s o f d y s fu nct i on s . N eut r al and
nonne utr al dy sf unc tio ns ( typ es 1 an d 2 , r es pe c ti v el y ) m ay hav e sp eci fic ten der po i nts an d p os it i on s t hat
al l ev i at e t he t end er poin t. Yet i n m os t p ubli s he d t ex ts (1 ,2, 4,6) th ere i s l it tle m en tio n o f th e c han ge i n
pos it i on fo r op pos i te - s id ed c ou pl in g ( typ e 1) an d s am e- s id ed c oup l in g ( ty pe 2) of r ot ati on and s id e
bendi ng. Th e mo s t w id es pr ead id ea i s t hat fle x io n d y s fu nct i on s pr odu c e ante r io r t ende r p oin ts a nd
ex ten s io n d y s fu nct i on s pr odu c e post eri or tend er poi nts. Ho w ev er , i n w hi c h d i re c ti ons do the neu tra l
dy s fu nct i on s ex hib i t tend er poi nts? Ov er m any ye ars of tea c hi ng o s te opa thic ma nip ul at i ve me di ci ne i n
the l abo r at or y at Phi l ade l ph i a C oll ege of Ost eop ath i c M edi c in e as we l l as i n o ur Euro pea n o s teo pat hic
s em in ars , w e ha v e don e a num ber of s ma l l, non bli nde d su r ve y s of t he c la s s a tte nda nts w he n t each i ng
thi s s ub j ec t. F r om ou r li m it ed fi nd i ng s , w e b eli eve tha t n eut r al dys fun c tio ns c an pro duc e a nter i or an d
pos te r io r t ende r p oin ts . T hi s m ay b e a n a r ea of fur ther st udy and po ten ti al re s ea r c h.
R ev ie w o f t he m any po s i ti ons fo r co unt ers tr ai n t r ea tm en t s how s th at s om e po s it i on s ar e e x am pl es of

tr eat m en t o f ty pe I d y s fu nct i on s [e .g. , s i deb end to w ard , r ota te a w ay (S T R A) ] a nd othe r s are exa m pl es of
tr eat m en t o f ty pe II dy sf unc tio ns [ e.g ., s i de ben d a w ay r ot ate awa y ( SAR A) ]. Th e m os t i mp ort ant asp ect
of an y t ech ni qu e i s t he d i ag nos i s . W it hou t a pro per dia gno s is , th e d ete r m in ati on of t he k ey dys fun c ti on,
and w het her the pr i ma r y c omp one nt i s a r ti c ula r , m yo fasc i al or bot h, the tre atm ent w il l b e l es s tha n
optim al.
Techni que Cl assi ficati on
I ndirect
In co unt ers tr ai n t ech ni qu e, the i nd i re c t pati ent po s i ti oni ng m ay be i n r esp ons e t o an ar tic ul ar dy s fu nc ti on
w i th i ts x- , y- , a nd z - ax es of m oti on fre edom . T he pati ent ma y al s o be pl ac ed i n ease as s oc i ate d w i th a
2 of 85 21/08/07 22:05
m y ofa s ci al ease - bi nd r ela tio nsh i p. T he ph y s ic i an sh ould kn ow, pri or to posi tio nin g th e p ati ent, wh eth er
the d y sf unc ti on is ty pe I or II and /or wh ethe r t her e is a pri m ary or se c ond ary my ofas c ia l c om po nen t
( e.g. , p s oa s hy per ton i c it y c aus i ng l um bar s ym pto m s) , as th e p os it i on ma y va r y acc or di ngl y .
Techni que Styles
Ti m e Defi ned or Rel ease Defined

T he p hys i ci an m ay use a t i me - de fi ne d m eth od, i n w hi c h t he tre atme nt pos i tio n i s h el d for 90 s ec ond s a nd
then r ep osi ti on ed to the neu tra l st art i ng pos i ti on for r ea s se s s me nt. Al tern ati v el y , t he phy s i ci an m ay use
a pal pat ory m ar k er of tis s ue re l eas e, w hi c h m ay occ ur p r io r t o th e 9 0-s ec on d t i me - def i ne d m ar ke r . Aft er
feeli ng a s ense of re l eas e, r el ax at i on , p ul sa tio n, or s i mi l ar phe nom eno n, t he phy s i ci an m ay for go the
ti m e def i ni ti on an d r epos i ti on the pat i en t fo r r eas s ess m en t.
I ndications
1. Acu te, s ub acu te, and ch r on i c s oma tic dys fun c ti ons of art i c ul ar and /or m yo fas c i al or i gi n
2. Adj unc ti ve tr eat m ent of sy s tem i c c om pl ai nts wi th a s so c ia ted s om ati c dy s fu nct i on ( e. g.,
v is c er os om ati c r efle x c aus i ng r ib dy s fun c ti on)
Contraindications
Absolute Contrai ndi cati ons

1. T ra uma ti ze d ( s pr ai ne d o r s tr ai ned ) t i s su es, wh i c h w ou l d be n ega tiv el y aff ect ed b y t he posi tio nin g
of the pat i en t
2. Sev ere i ll nes s i n wh i ch st r i ct po s it i ona l r est r i ct i on s p r ecl ude tr eatm ent
P.13 1
3. Ins tab i l it y o f t he a r ea be i ng pos i ti oned th at has the po tent i al to pro duc e u nw an ted ne ur ol ogi c o r
v as c ul ar s i de ef fect s
4. Vas c ul ar o r n eur ol og i c s yn dr om es, su c h a s b asi l ar i ns uff i c ie ncy or neu r of ora m i na l c omp r omi s e
w he r eb y th e p osi ti on of tr eatm ent ha s th e p ote ntia l t o e x ace r ba te the c on dit i on
5. Sev ere deg ene r at i v e s po ndy l osi s w i th l oc al fus i on and no m ot i on at the le v el w he r e tre atme nt
pos i ti onin g w oul d no r ma l ly tak e p l ac e
P recautions
1. Pat i en ts w ho c an not v ol unt ar il y r ela x , s o t hat pro per po s i ti oni ng i s d i ff i cu l t
2. Sto i c pati ent s w ho c ann ot di sc ern th e le v el of pai n o r i ts c han ge s eco nda r y to p osi tio ni ng
3. Pat i en ts w ho c an not und ers tand th e i ns tr uct i on s an d q ues ti on s o f t he p hys i ci an ( e.g ., pati ent 6
m on ths of age )
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4. Pat i en ts w i th co nnec tiv e t i s su e d i se as e, ar thr i tis , P ark i nso n d i se as e, an d s o on , i n w hom

pos i ti onin g f or tend er poi nt p ain re duct i on ex ac er bat es the dis tal c on nec tiv e ti s su e o r ar thr i ti c
pro ble m or no mo ti on is av ai la ble fo r po s it i on i ng
General Consi derati ons and Rules

T he p hys i ci an m ust as c ert ain th e so m at i c dy sf unc tio n, i ts s ev er it y , i ts tis s ue lo c ati on and typ e, and
w heth er any of the s e pr ec aut i on s or co ntr ai nd i ca tio ns a r e pre s ent . I f w ar ra nte d, the fol l ow i ng s eq uen c e
i s ne c es s ar y :
1. F in d t he m ost si gnif i ca nt tend er poi nt w i th th e pa tie nt i n a ne utr al , c om for tabl e p osi ti on .
a. Loc at e o ne or m ore te nder po i nt s as s oc i at ed w i th th e pr evi ous l y d i ag nos ed s oma tic

dy s fu nct i on by tes tin g wi th a f ew o unc es of f i rm bu t di s cr eet fin ger pa d or th umb
pr ess ure . N o ci r cu l ar m ot i on sh ould be pa r t o f t his pre s su r e; i t i s s tr ai gh t i nto the te nde r
poi nt .
b. If mu l ti ple ten der po i nts ex i st , tr eat th e mo s t pai nful fi r st . Wh en s ev er al te nde r po i nt s l i e

i n a r ow , f i r st tr eat the on e i n th e m i dd l e. In add i tio n, tre at p r ox i ma l be for e d i s ta l ( 2).
c. Quant i fy th e te nde r p oi nt ' s pai n le v el fo r th e p ati ent as 100 % , 1 0, or a mo net ary uni t s uch
as $1 . W e h av e fou nd that th e m onet ary un i t w ork s b es t i n the tea c hi ng of c oun ter s tra i n,
as ph y si c ia ns a nd phy s i ci ans in tra i ni ng tend to co nfus e t he anal og pai n sc ale , i n wh i ch
the p ati ent i s ask ed to g aug e t heir pa i n on a sc ale of 0 t o 1 0, w i th th e as s ig ned pai n o f 1 0.
W i th use of the an alo g sc ale , t he t end enc y is to as k , “ W ha t i s yo ur pai n?” i ns tea d of
s ay in g, “ Th i s p ain is a 1 0.” Wi th t he m on etar y s c al e th i s doe s no t o c cu r .
2. Slo w ly and ca r ef ul ly pl ace the pa tie nt i n t he posi tio n o f ea s e or opti m al co m for t.
a. F i r st ob tai n a gro s s r edu c ti on of t end ern es s i n the typ i ca l p os it i on re c omm end ed for the
l ev el of dy s fun c ti on and ten der poi nt l oc atio n a nd then fi ne- tune th r ou gh s m al l a r c s of
m otio n u nti l th e t end er ne s s ( pa i n) i s c om pl et ely al l evi ate d.
b. If th e t end er p oin t c anno t b e e l i mi nat ed, a 7 0% r ed uc ti on of pain ma y b e ac c ep tab l e f or

tr eat m en t e ffec t. H ow ev er , f or ev er y a s ce ndin g n ume r i c l ev el of p ain th at r ema i ns , an
as s oc i at ed 10% of tre atme nt eff ec ti v en ess i s l os t. F or exa m pl e, i f t he tend er poi nt i s
r educ ed onl y by 70 % , ther e i s o nl y a 7 0% pote nti al for a g ood tre atm ent eff ect . A ny th i ng
l es s tha n 7 0% r edu c ti on c aus es an e v en gr eate r p ote ntia l f or tr ea tme nt fail ure . T here for e,
the g oal is 100 % p ain r ed uct i on by pos i ti onin g w hen ev er po s si bl e.
c. In ge ner al, ant eri or poin ts r eq ui re so m e l eve l o f f l exi on, de pend i ng on the se gme ntal le v el
i nv ol v ed , a nd p ost eri or p oin ts r equ i re so m e l eve l o f ex ten s io n, d epe ndi ng o n t he s egm ent
i nv ol v ed .
d. As te nde r p oi nt s m ove awa y f r om the mi dli ne, the gr eate r t he poss i bi l it y fo r n ece s s it y o f
m or e s id e b endi ng. Ho w eve r , the nat ure of the dy s fu nc ti on ( ty pe I or II ) an d i ts m oti on
par am ete r s di ct ate th e pr ope r p os it i on i ng .
3. M ai nta i n t he pos i tio n f or 90 s eco nds . It ha s b een r ep ort ed t hat 12 0 se c on ds i s n ece s sa r y f or

c os tal dys fun c ti ons. Pe r so nal c om m un i c at i on wi th v ari ous m em ber s o f EC OP and w it h t hos e wh o
w or k ed c lo s el y w i th J on es s how s t hat c os tal dy s fun c ti ons als o t ake 90 s ec ond s . J one s b el ie v ed
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tha t t he p osi tio ns f or tre atme nt of c ost al dys func tio ns c aus ed the pat i en t t o be un abl e to ea s il y
r el ax, and th ere fore , h e g av e the m a n ad dit i on al 3 0 s eco nds to r el ax . T he r ef or e, th e 1 20-s eco nd
per i od has be en pr om ote d a s th e c l as s i ca l ly de s c ri bed
P.13 2
tim e-d efin ed m et hod for ri b dy s fu nct i ons , w her eas c li nic al ly , 9 0 s ec on ds w il l su ffi c e. In our
han ds and exp eri ence , t he ti me - de fin ed m eth od w ork s b ett er t han fe el in g f or a ti s su e r el ea s e. We
bel i ev e th at J on es 's at tem pts at v ar i ous ti m e i ncr eme nts and hi s c oncl usi on that ho l di ng t he
pos i ti on f or 90 s eco nds wa s th e m ost eff ect i ve m et hod mu s t h ave a r eas on. We bel i ev e t hat m os t
pro ble m s d i ag nos ed a nd s uc c ess ful l y tr ea ted wi th t his te c hni que in v olv e t he r ese tti ng of
neu r ol ogic fe edb ac k m ec han i s ms ea r li er i den tif i ed, an d t hat use of the s e m ec hani s ms re quir es
an opt i m um am oun t of ti m e to a c hi eve the de s ir ed c l in i ca l ou tco m e. Oth er tec hniq ues th at m ay
app ear s im i la r t o co unt ers tr ai n ( e.g ., f aci l it ated po s it i ona l r ele as e) us e d i ffe r en t
r el eas e- en han c in g me c ha nis m s , and so the y c ann ot b e c omp ar ed ex act l y w i th co unte r st r ai n.
4. W hi l e m ain tai nin g th e e ffe c tiv e p osi ti on , t he fi ng er pad s ho uld re m ain at th e si te of the ten der
poi nt for the en ti re tr eat m ent pe r io d wh ene v er pos s ib l e, s o the ph y s ic i an ma y in ter m it tent l y
thr oug hout th e t r eat m en t p er io d ( per haps ev ery 30 s ec ond s ) r ech eck the le v el of pai n a t th e
ten der poi nt.
a. T he f i ng er pad i s not put tin g a ny t her ape utic pr ess ur e i nt o t he t i ss ues .
b. If th e f i ng er p ad i s r emo v ed , t he p hys i ci an l ose s c ontr ol of the ten der poi nt, re nder i ng th e
ev alu ati on us el ess , a s th e t end er p oin t l oc at i on ma y no t b e e x act l y r el oc at ed. Al s o, the
patie nt oft en d oes no t be l ie v e the phy s ic i an i s on the ori gin al t end er poin t a nd m ay
quest i on th e ex act lo c ati on of the m on i to r i ng fi nge r . I f k eep i ng v ig i la nt a t t he s i te , y ou c an
c onfi den tly ass ure th e pa tie nt that yo u a r e i nde ed on t he ori gi na l s i te .
c. Al s o, if us i ng the ti s s ue re l ea s e m ark er i nst ead of tim e, the phy s ic i an m us t h ave the

fi nge r p ad on t he ten der poi nt s i te to co ns ta ntl y s ense th e t i s su e r eac ti on .
5. Aft er 90 s eco nds ( ti m e- def i ned tr eat m ent ) o r w hen tis s ue app ear s t o re l ea s e ( r el eas e-d efin ed
tre atm ent) , s l ow l y r etu r n the pas s iv e pa tie nt thro ugh a path of le as t r es i st ance to th e or i gi nal
neu tra l po s it i on i n w hi c h the ten der poi nt w as eli c it ed. T he pa tie nt m ust no t he l p, so i f y ou fe el
tha t t he p ati ent i s hel pin g yo u, s to p an d a s k hi m or her to r el ax.
6. R ec hec k th e t end er p oin t. If t he ten der poi nt w as r ed uce d to ze r o i nit i al l y, the r e i s a go od c ha nc e

tha t i t wi l l r em ai n at z er o. I t i s p os si ble , h ow ev er, th at t he pai n wi l l ele v ate so m ew hat pos t
tre atm ent. If th e po s tt r ea tm en t p ain i s r at ed at 3 co m pa r ed to the ori gin all y as s ig ned l ev el of 10
pri or to t r ea tme nt, 70% ef fect i ve nes s wa s a c hi ev ed in on l y 9 0 s eco nds. Th e e ffec t m ay c ont i nu e
to i mp r ove th e p atie nt' s s y m pt oms ov er t i me , o r th e p ati ent m ay ne ed f oll ow up i n a fe w da y s for
r ee v al uati on and tre atm ent .
7. R ec hec k th e s oma ti c dys fun c tio n p ara m ete r s ori gi na l ly pr es en t ( e.g ., t he s eg m ent al or
m yo fas c i al dy s fu nc ti on) .
T h e s h or t ha n d r u le s a r e a s f o ll o ws:
1. F in d t he t end er poin t a s so c i at ed w it h th e d y sf unct i on .
2. T el l t he p ati ent the te nde r po i nt is a 1 0 o r 1 00 o r a do l l ar ' s w or th o f p ain .
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3. Pla c e the pat i en t in th e p os it i on th at r edu c es the pa i n of t he ten der poi nt 100% (o r a t le ast 70 % ) .
4. H ol d t hi s pos i ti on f or 90 s eco nds .
5. Slo w ly , th r ou gh a pa th of l eas t r esi s tan c e, re turn th e r el ax ed pat i ent to ne utra l .
6. R ec hec k th e t end er p oin t a nd t he oth er s oma tic c om pon ent s of th e d y s fu nct i on ( TA R T) .
Pos tt r ea tme nt r eac tio n ma y i ncl ude gen era l so r en ess thr oug h t he f oll owi ng 2 4 t o 4 8 ho urs . T hi s i s
unusu al i n our c li nic al e x pe r ie nc e but ha s be en r ep or te d b y o ther s ( 1). T re ati ng m ore th an s i x ten der
poi nt s a t o ne v i si t a ppea r s to be c orr ela ted to thi s re act i on . If th i s oc cu r s, in s tru c t the pat i en t t o in c re ase
fl uid s a nd us e i ce pa c k s ove r t he s ore ar eas for 15 to 20 m in utes ev ery 3 h our s a s ne ede d. T r ea tme nts
s houl d b e p r esc r ib ed ac co r di ng to t he phy s i ci an' s c l i ni c al ju dgme nt, bu t 3- day in terv als ar e ap pro pri ate.
T he p ati ent ' s r esp ons e wi l l det er mi ne how oft en the pat i en t n eeds tr eat m ent .
Abbreviations for Counterstrain
Techni que
Yates an d G l ove r i ntr oduc ed a s hort han d d es cr i pt i on tha t m any s tu den ts us e to hel p re m em ber the
pos it i on i ng for sp eci fi ca l ly lo c ate d t end er p oin ts. T hi s s hor than d u s es the in i ti al s for ty pes of m ot i ons
( di re c ti ons of m ov eme nt) and up per and lo w er c as e f or g r ea ter and le s se r mo v em ent i n the di r ect i on
i dent i fi ed, r es pec tiv el y. Th e c om mo n a bbr ev ia tio ns of t his sh or th and me thod ar e: A, a nte r io r ; P ,
pos te r io r ; F or f, fl ex io n; E o r e, ex ten s i on ; S R o r Sr , s i de
P.13 3
bendi ng r ig ht; SL or Sl , s id e b endi ng l ef t; R R o r R r , r ota tio n ri ght ; R L or Rl , r otat i on le ft; IR or i r ,
i nter nal ro tati on; ER or er, ex tern al r ot atio n; AB or A b, abd uc ti on; AD or ad, ad duct i on ; S U P o r s up,
s upin ati on; and PR O o r pr o, pro nati on. Ot hers ab bre v i at i on s r efer to mo ti on to w ar d (t ) a nd aw ay (a ) a nd
obv io us bon y la ndm ark s , s uch as s pi nou s p r oce s s ( SP ) , t r an s ve r s e pro c es s (T P), cr es t ( CR ) , and
oc c ip ut ( OC C ) . U pp erc as e l et ter s me an m or e of th at part i cu l ar m ot i on an d lo w er c as e me ans le s s ( 3).
P.13 4
Anteri or Cervical Counterstrain Techniques: Anterior

Cervical Tender Poi nts
Anter i or ce r v ic al ( AC ) co unt ers tr ai n t end er p oin ts ar e out l in ed i n T abl e 9. 1 a nd demo nst r at ed i n F i gu r e
9.1.
6 of 85 21/08/07 22:05
T able 9.1 Comm on Ant erio r Cervical Tender Po int s
Classic
Treatm ent
Ten der Point L o cation Positio n Acronym
AC1, r otation, Posterior surface of Rotate head RA

unc oupled as cending ramus of away;
dy s function mandible between fine-tuning
earlobe and angle with s ide
of mandible bending,
( gonion) us ually away
AC2–AC6, type II Anter ior aspect of F lex to level F SA

dy s function tr ans ver s e proc ess of RA
of dy sfunctional dy s functional
c ervical ver tebra s egment;
s ide bend
away, rotate
away
AC7, type I Anter ior at origin of F lex to level F ST

dy s function of C7 c lavicular division of C7; RA
or of s ide-bend
s ternocleidomastoid s ternocleidomas toid toward,
muscle, r otate away
approximately 2 cm
later al to
s ternoclavic ular
joint
AC8, type II O r igin of sternal F lex, but F SA

dy s function of C7 divis ion of les s than RA
s ternocleidomas toid AC7;
muscle at medial s ide-bend
head of c lav icle at away, rotate
s ternal notc h away
P.13 5
7 of 85 21/08/07 22:05
Fig ure 9.1. Anter ior cervic al counter str ain tender points (5).
P.13 6
P.13 7
Anteri or Cervical Counterstrain Techniques: AC1
8 of 85 21/08/07 22:05
T he following
tec hniques ar e
des cribed and
illustrated in a
s tepwise
s equence. We
hav e abridged the
tex t desc ribing
eac h individual
tec hnique, as the
c ounterstrain F igure 9.2. AC1 tender point loc ation ( 5).
s equence is the
s ame for eac h
dy s function. The
unique factor s of
eac h dysfunc tion
ar e the location of
the tender point
and the c las s ic
tr eatment pos ition.
T his firs t
tec hnique will
illustrate the
c omplete
c ounterstrain
s equence with the F igure 9.3. AC1: RA.
unique as pec t of
the technique
highlighted. All of
the following
tec hniques will be
des cribed with
only the
information unique
to that s pec ific
s omatic
dy s function and
its tender point.
T he tender point
loc ations ar e a F igure 9.4. AC1: RA.
c ompilation of
des criptions from
J ones and
as s ociates ( 1),
Rennie and G lover
( 4) , Yates and
G lover (6), and
our clinical
9 of 85 21/08/07 22:05
P.13 8
Anteri or Cervical Counterstrain Techniques: AC2 to AC6
10 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 C2 to
C6.
T en der Po int
L o cation
T he tender point
is at the anterior
as pect of the
tr ansv ers e F igure 9.6. AC2-AC6 tender points ( 5).
pr oces s of the
dy s functional
c er vic al ver tebr a
( F ig. 9.6). Probe
lateral to medial.
T reatm ent
Po sition
Patient's head and
nec k are flex ed to
the level of the
dy s functional
s egment,
s ide-bent, and
r otated away from F igure 9.7. AC4: F SA RA.
the tender point
( F igs. 9.7, 9.8,
9.9, 9.10).
F igure 9.8. AC4: F SA RA.
11 of 85 21/08/07 22:05
P.13 9

(S ternocl eidomastoi d Muscl e)
In d icatio n f o r
T reatm ent
appropriate for
s omatic dysfunction
C7 (AC7-type I
dy s function C7, or
s ternocleidomastoid
mus cle
dy s function) .
T en der Po int
L o cation
Anteriorly, the
tender point lies at
Fig u re 9.11. AC7 tender point (5) .
the or igin of the
c lavic ular divis ion
of the
mus cle
approx imately 2–3
c m lateral to the
s ternoclavic ular
joint (F ig. 9.11).
Pr obe pos ter ior to
anterior.
T reatm ent
Po sition
T he patient's head Fig u re 9.12. AC7: F ST RA.
and neck are
mar kedly flex ed to
the level of lev el of
C7, rotated away ,
and sidebent
toward the s ide of
the tender point
( F igs. 9.12, 9.13,
9.14, 9.15).
12 of 85 21/08/07 22:05
Fig u re 9.13. AC7: F ST RA ( alternativ e hand

plac ement) .
Fig u re 9.14. AC7: F ST RA.
Fig u re 9.15. AC7: F ST RA.
P.14 0
13 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
C7 (AC8–type II
dy s function C7).
T en der Po int
L o cation
T he tender point
lies at the origin of
the sternal division
of the
mus cle, at the
Fig u re 9.16. AC8 tender point (5) .
medial head of the
c lavic le at the
s ternal notc h
( pr ess medial to
lateral) (F ig . 9.16).
T reatm ent
Po sition
T he patient's head
and neck are flexed
( less than C7),
r otated away , and
s ide-bent away
fr om the side of
tender point (F igs. Fig u re 9.17. AC8: F SA RA.
9.17, 9.18, 9.19,
9.20).
Fig u re 9.18. AC8: F SA RA.
14 of 85 21/08/07 22:05
P.14 1
P osterior Cervical Counterstrain Techni ques: P osteri or

Cervical Tender Poi nts
Pos ter ior

c er vic al
c ounterstrain
tender points ar e
outlined in T able
9.2 and
demons trated in
F ig ure 9.21.
F igu re 9.21. Posterior c erv ical counterstrain

tender points (5) .
15 of 85 21/08/07 22:05
T able 9.2 Co mmo n Po sterio r Cervical Ten der Po int s
Classic T reat men t

Ten der Point L o cation Po sition Acro nym
PC1 Inion 2 cm below F lexion of F

inion, pushing oc cipitoatlantal
later ally into ar tic ulation; additional
muscle mass c ervical flexion may
be neces sar y
PC1 Halfway Ex tension of E Sa

lateral between PC2 oc cipitoatlantal Ra
and mastoid ar tic ulation with mild
pr ocess c ompr ess ion on head
as soc iated with to reduc e my ofascial
s plenius capitis tension of
muscle s uboc cipital tissues;
s light s ide bending
and r otation away as
needed
PC2 Within Ex tension of E Sa

lateral s emis pinalis oc cipitoatlantal Ra
c apitis musc le ar tic ulation with mild
as soc iated with c ompr ess ion on head
gr eater occipital to reduc e my ofascial
nerve tension of
s uboc cipital tissues;
needed
PC2 Super ior lateral Ex tension of E Ra

midline s urface of oc cipitoatlantal
s pinous proc ess ar tic ulation with mild
of C2 c ompr ess ion on head
to reduc e my ofascial
tension of
s uboc cipital tissues;
needed
PC3–PC8 Infer ior sur fac es Ex tend to level of E Sa

midline of spinous dy sfunctional Ra
16 of 85 21/08/07 22:05
P.14 2
P osterior Cervical Counterstrain Techni ques: P C1 Ini on
17 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at
C0- C1.
T en der Po int
L o cation
T he tender point F igure 9.22. PC1 inion tender point (5) .
lies 1–2 cm below
the inion (F ig
9.22). Push
anterolaterally into
mus cle mass.
T reatm ent
Po sition
1. T he
phys ician
flex es the
patient's
head by
inducing F igure 9.23. PC1 inion: F Sa Ra.
c ephalad
trac tion on
patient's
occiput while
inducing
c audad
motion on
patient's
frontal area
( Fig s. 9.23,
9.24, 9.25) .
2. T he
phys ician
fine-tunes
F igure 9.24. PC1 inion: F Sa Ra.
through
s mall ar cs of
motion
( flexion or
extension
and minimal
s ide bending
and/or
18 of 85 21/08/07 22:05
P.14 3
P osterior Cervical Counterstrain Techni ques: P C1 and PC2
19 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
at C1- C2.
T en der Po int
L o cations
PC1 (lateral) ,
halfway between
PC2 and the
mas toid proc ess
as s ociated with the
s plenius capitis
mus cle (F ig. 9.26). F igure 9.26. PC1–PC2 tender points (5) .
PC2 (lateral) , within
the semis pinalis
c apitis musc le
as s ociated with the
gr eater occipital
ner ve. Push
anteriorly.
T reatm ent
Po sition
1. Patient's head
is extended to
the lev el of the
dysfunc tional F igure 9.27. PC1–PC2: E Sa Ra.
v ertebr a;
s light
occipitoatlantal
c ompres s ion
may be
needed ( Fig s.
9.27 an d
9.28).
2. T he phy s ician
fine-tunes
through small
arcs of motion
( slight side
bending and
r otation away) . F igure 9.28. PC1–PC2: E Sa Ra.
3. Alternative:
Extension,
20 of 85 21/08/07 22:05
P.14 4
P osterior Cervical Counterstrain Techni ques: P C3 to P C7,

Mi dline
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function C3 to
C7.
T en der Po int
L o cation
T he tender point
lies at PC3 to PC7
midline and the
inferior sur faces of
the spinous
pr oces ses of C2
to C7 (F ig. 9.31).
T reatm ent
Po sition
1. Patient's
head is
extended to F ig ure 9.31. PC3–PC7 midline tender points
the ( 5) .
appr opr iate
level ( F igs.
9.32, 9.33,
9.34, 9.35,
PC3, PC5,
PC5, PC7,
r espectively).
2. T he
phys ician
fine-tunes
through small
arcs of
motion with
s light s ide
bending and F ig ure 9.32. PC3: e Sa RA.
s light to
moderate
r otation
21 of 85 21/08/07 22:05
away .
F ig ure 9.33. PC5: e Sa RA.
F ig ure 9.34. PC5: e Sa RA.
F ig ure 9.35. PC7: e-E Sa RA.
P.14 5
P osterior Cervical Counterstrain Techni ques: P C3 to P C7,

Lateral
22 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at C3
to C7.
T en der Po int
L o cation
T he tender point
lies at PC3 to PC7
pos ter olater al, at
lateral s urface of
the ar tic ular
pr oces s
as s ociated with
the dy sfunctional
s egment ( Fig .
9.36).
F igure 9.36. PC3–PC7 lateral tender points
T reatm ent ( 5).
Po sition
1. T he
phys ician
extends the
head and
neck to the
level of the
dysfunc tional
s egment with
minimal to
moderate
s ide bending
directed at F igure 9.37. PC3: e Sa RA.
the segment
and minimal
to moder ate
r otation away
( Fig s. 9.37,
9.38, 9.39,
9.40, PC3,
PC3, PC6,
and PC6,
r espectively).
2. T he
phys ician
23 of 85 21/08/07 22:05
P.14 6
Anteri or Thoraci c Counterstrain Techniques: Anterior

Thoracic Tender Poi nts
Anterior thor acic

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

c ounterstrain tender points ( 5).
24 of 85 21/08/07 22:05
T able 9.3 Co mmo n Anterior Th oracic Ten der Points
Classic Treat men t

Ten der Point L ocatio n Positio n Acronym
AT 1 Midline episternal F lexion to F

notc h dy s functional
lev el
AT 2 Midline, junc tion of F lexion to F

manubrium and dy s functional
ster num (angle of lev el
Louis)
AT 3-AT 5 Midline at lev el of F lexion to F

AT 6 cor r esponding rib; dy s functional
Midline lev el
xiphoid–sternal
junc tion
AT 7–AT 9 AT7: Midline or F lexion to F St

inferolateral to tip dy s functional RA
of x iphoid; lev el, side
AT8: 3 cm below bending towar d
xiphoid at lev el of and rotation away
T12, midline or
lateral
AT9: 1–2 c m
abov e umbilic us at
lev el of L2, midline
or 2–3 cm lateral
AT 10–AT12 AT10: 1–2 cm Hip flexion F St

below umbilic us at 90–135 degrees, RT
lev el of L4, midline s light side F St
or 2–3 cm lateral bending, rotation RA
AT11: 5–6 cm toward (type I) or
below umbilic us s ide bending
below level of iliac toward, r otation
cres ts at superior away ( type II)
L5 level, midline or
2–3 cm lateral
AT12: Superior ,
inner s urface of
iliac c res t at
midaxillary line
25 of 85 21/08/07 22:05
P.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
appropriate for
s omatic
dy s function at
T 1- T2, such as
anterior T1- T 2
tender point.
T en der Po int
L o cations F igure 9.42. AT 1–AT 2 tender points (5) .
AT 1: Midline in the
episternal notch
( F ig. 9.42)
AT 2: Midline at
junction of
manubr ium and
s ternum ( angle of
Louis)
T reatm ent
Po sition
1. Patient is
s eated on
the treatment F igure 9.43. AT 1–AT 2: F.
table with
hands on top
of the head.
2. Phys ician
s tands
behind
patient and
wraps ar ms
under
patient's
axillae and
around the
c hes t and
plac es hands
over the F igure 9.44. AT 1–AT 2: F.
manubrium.
3. Patient leans
back agains t
phys ician's
c hes t and
thigh,
27 of 85 21/08/07 22:05
P.14 8
Anteri or Thoraci c Counterstrain Techniques: AT1 to AT6
28 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at T 1 to
T 6.
T en der Po int
L o cations
AT 1: Midline in the
episternal notch
( F ig. 9.46)
AT 2: Midline at
junction of
manubr ium and
s ternum ( angle of F igure 9.46. AT 1–AT 6 tender points (5) .
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. T he patient
lies supine
with the ar ms F igure 9.47. AT 1–AT 6: F IR ( arms ).
off the side of
the table, and
the
phys ician's
thigh is behind
the patient's
upper thoracic
r egion.
2. While the
phys ician's
index finger
pad palpates
the tender
point, the
patient is F igure 9.48. AT 1–AT 6: F IR ( arms ),
elev ated fr om alter native hand placement.
the table with
29 of 85 21/08/07 22:05
P.14 9
Anteri or Thoraci c Counterstrain Techniques: AT3 to AT4,

Al ternati ve Technique
In d icatio n f o r
T reatm ent
T his proc edur e
is appropriate
for somatic
dy s function at
T 3- T4.
T en der Po int
L o cation
AT 3: Midline on
the sternum at
the level of the Fig u re 9.49. AT3–AT4 tender points (5).
3r d costal
c ar tilage (F ig.
9.49)
AT 4: Midline on
the sternum at
the level of the
fourth costal
c ar tilage
T reatm ent
Po sition
In this technique
the physician
may not be able
Fig u re 9.50. AT3–AT4: F IR (ar ms) .
to control the
tender point fully
thr oughout the
tr eatment
pr oces s.
1. T he patient
s its on the
end of the
treatment
table in
front of the
phys ician,
and the Fig u re 9.51. AT3–AT4: F IR (ar ms) .
phys ician
plac es the
30 of 85 21/08/07 22:05
forearms
under the
patient's
axillae.
2. T he
phys ician's
forearms
gras p the
medial s ide
of the
upper ar ms
to induc e
internal
r otation
( Fig .
9.50).
3. T he
phys ician
leans
forward
with the
c hes t and
abdomen
while
pulling
back war d
on the
patient's
arms to
flex the
thor acic
s pine to
the des ired
level ( F ig.
9.51).
4. T he
phys ician
fine-tunes
through
s mall ar cs
of motion
( flexion,
minimal or
no s ide
bending or
r otation).
P.15 0
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32 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at T 7
to T9.
T en der Po int
L o cation
AT 7: Midline or
inferolateral to tip
of xiphoid ( F ig.
9.52)
AT 8: 3 cm below
x iphoid at level of
T 12, midline or
lateral
AT 9: 1–2 cm F igure 9.52. AT 7–AT 9 tender points (5) .
above umbilic us at
or 2–3 cm lateral
T reatm ent
Po sition
1. T he patient
is s eated on
the treatment
table with the
phys ician
s tanding
behind the
patient. F igure 9.53. AT 7–AT 9: F St Ra.
2. T he
phys ician's
foot on the
s ide opposite
the tender
point is
plac ed on
the table with
the patient's
arm res ting
on a pillow
on the
phys ician's
thigh.
F igure 9.54. AT 7–AT 9: F St Ra (fine-tune).
33 of 85 21/08/07 22:05
P.15 1
34 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
to T12.
T en der Po int
L o cation
AT 10: 1–2 cm
below umbilic us at
or 2–3 cm lateral
( F ig. 9.55)
AT 11: 5–6 cm
below umbilic us
below lev el of iliac
c r ests at superior F igure 9.55. AT 9–AT 12 tender points (5) .
L5 lev el, midline or
2–3 cm later al
AT 12: Superior,
inner sur fac e of
ilia c res t at
mid-ax illary line
T reatm ent
Po sition
1. T he patient
lies supine,
and the
phys ician
s tands on F igure 9.56. AT 9–AT 12 type I: N ST RA.
either s ide of
the patient,
for bes t
phys ical
c omfort and
c ontrol, and
plac es the
c audal foot
on the table.
2. T he hips and
k nees ar e
flex ed to the
level of the
dysfunc tional F igure 9.57. AT 9–AT 12 type II: F RA SA.
35 of 85 21/08/07 22:05
P.15 2
P osterior Thoracic Counterstrain Techni ques: P osteri or

Thoracic Tender Poi nts
Pos ter ior

thorac ic
c ounterstrain
tender points
ar e outlined
in Table 9.4
and
demons trated
in Figure
9.58.
Fig u re 9.58. Posterior thor acic c ounters train tender points (5) .
36 of 85 21/08/07 22:05
T able 9.4 Co mmo n Po sterio r T h oracic Ten der Po int s
Classic Treatm ent

Ten der Point L o cat ion Positio n Acron ym
PT 1–PT 3 Midline, or Prone with ar ms e-E Sa Rt

( 4) inferolater al hanging ov er s ides ( type I) or
tip of of table. Support e-E St Rt
s pinous patient's head by ( type II).
proc ess cupping point of Depending
( side chin; gently extend on
opposite head and neck to phys ician
r otational engage preference,
c omponent) dys func tional may be
or over segment. Avoid opposite
transver se prefov erex tending. ( SARA)
proc ess (on Rotation and s ide c oupling.
s ide of bending minimal.
r otational
c omponent)
PT 4–PT 9 Same as Same as above, Same as

abov e exc ept shoulders abov e
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.
PT 10–PT12 Same as Patient pr one with Same as

abov e arms at side, abov e
phy sic ian
controlling pelvis.
P.15 3
P osterior Thoracic Counterstrain Techni ques: P T1 to P T4,

Mi dline
37 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
to T4.
T en der Po int
L o cation
T he tender point
lies at PT1 to PT4,
midline, the
inferior lateral tip F ig ure 9.59. PT1–PT 4 midline tender points
of the spinous ( 5) .
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 F ig ure 9.60. PT3: e-E Sa Rt.
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 F ig ure 9.61. PT3: e-E Sa Rt.
lifts and
extends the
neck to the
38 of 85 21/08/07 22:05
P.15 4

Mi dline
In d icatio n f o r
T reatm ent
appropriate for
s omatic
to T6.
T en der Po int
L o cation
T he tender point
lies at PT1 to PT6
midline, the F ig ure 9.62. PT1–PT 6 midline tender points
inferior lateral tip ( 5) .
of the spinous
pr oces s of the
named ver tebr ae.
Palpate from
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 F ig ure 9.63. PT6: e-E Sa Rt.
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
39 of 85 21/08/07 22:05
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

Mi dline
40 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
to T9.
T en der Po int
L o cation
T he tender point
lies at PT1 to PT9,
midline, the
inferior lateral tip F ig ure 9.64. PT7–PT 9 midline tender points
of the spinous ( 5) .
pr oces s of the
named ver tebr ae.
Palpate from
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 F ig ure 9.65. PT9: e-E Sa Rt.
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
41 of 85 21/08/07 22:05
P.15 6

Lateral
In d icatio n f o r
T reatm ent
appropriate for
s omatic
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 F igure 9.66. PT 4–PT 9 lateral tender points
of the tr ans v ers e ( 5).
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 F igure 9.67. PT 6 ty pe 1: e Sa Rt.
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.
42 of 85 21/08/07 22:05
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 F igure 9.68. PT 6 ty pe 2: e St Rt.
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) .
P.15 7

Lateral
43 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
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 F igure 9.69. PT 4–PT 9 lateral tender points
of the tr ans v ers e ( 5).
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 F igure 9.70. PT 4–PT 9: e-E Rt.
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 F igure 9.71. PT 4–PT 9 type 1: e-E Sa Rt.
( Fig . 9.70) .
2. T he
phys ician
44 of 85 21/08/07 22:05
P.15 8
P osterior Thoracic Counterstrain Techni ques: P T9 to P T12
45 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
to T12
T en der Po int
L o cation
PT 9 to PT 12:
Midline,
inferolateral tip of
the spinous F igure 9.73. PT 9–PT 12 tender points (5) .
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 F igure 9.74. PT 11 type 1: e- E Sa Rt.
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 F igure 9.75. PT 11 type 2: e- E St Rt.
the dy sfunctional
s egment will elicit
a r elativ e r otation
of the
46 of 85 21/08/07 22:05
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
T able 9.5 Comm on Ant erio r Cost al T end er Poin ts
T reat men t
Ten der Po sit ion ,
Point Jo nes's Term Locatio n Acron ym
AR1 Depr ess ed Below clavic le at firs t Patient

r ib c hondr osternal s upine
ar ticulation f-F St RT
AR2 Depr ess ed O n sec ond rib at Same as

r ib midclavic ular line abov e
AR3 Depr ess ed Anterior axillar y line on Patient

AR4 r ibs dy s functional rib s eated
AR5 f ST RT
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
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 F igure 9.77. AR1–AR2 tender points (5) .
ar ticulation (F ig.
9.77)
AR2: O n s econd
r ib at
midclavic ular line
48 of 85 21/08/07 22:05
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 F igure 9.78. AR1–AR2: f-F St RT.
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 F igure 9.79. AR1–AR2: f-F St RT.
fine-tunes
through
s mall ar cs of
motion
( flexion,
extension,
s ide bending,
or r otation).
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
E xhaled and Depressed, AR3 to AR6
50 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
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 F igure 9.81. AR3–AR6 tender points (5) .
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 igure 9.82. AR3–AR6: f ST RT .
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 F igure 9.83. AR3–AR6: f ST RT .
behind the
patient with
the foot
opposite the
51 of 85 21/08/07 22:05
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
Jo nes's Positio n an d
Ten der Point T erm Locatio n Acro nym
PR1 Elev ated Cer vic othorac ic angle Patient

r ib jus t anterior to seated
tr apez ius e SA Rt
PR2 Elev ated Superior sur face Patient

r ib seated
e SA Rt or f
SA RA
PR3–PR6 Elev ated Superior sur face of Patient

r ibs r ib angles seated
f SA RA
PR, posterior rib.
P.16 3
52 of 85 21/08/07 22:05
P osterior Costal Counterstrai n Techniques: Posterior Rib,

I nhaled and E levated, P R1
53 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at r ib
1 ( inhalation,
elevated) .
T en der Po int
L o cation
PR1: Posterior
as pect of fir st rib F igure 9.85. PR1 tender point (5).
at the
c er vic othorac ic
angle immediately
anterior to the
tr apez ius (F ig.
9.85)
T reatm ent
Po sition
1. T he patient
is s eated.
T he
phys ician
s tands F igure 9.86. PR1 tender point.
behind the
patient.
2. T he
phys ician's
foot opposite
the tender
point is
plac ed on
the table
under the
patient's
axilla.
3. T he
phys ician F igure 9.87. PR1: e SA Rt.
monitor s the
firs t r ib
tender point
with the
index finger
pad, which is
54 of 85 21/08/07 22:05
P.16 4
P osterior Costal Counterstrai n Techniques: Posterior Rib,

I nhaled and E levated, Ribs 2 to 6
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function in r ibs
3 to 6 (inhalation,
elevated) .
T en der Po int
L o cation
PR2: posterior
as pect of sec ond F igure 9.89. PR2–PR6 tender points (5) .
r ib at its s uper ior
s ur fac e ( Fig .
9.89)
PR3 to PR6:
pos ter ior as pects
of the ribs 3 to 6
at the super ior
s ur fac e of their rib
angles
T reatm ent
Po sition
1. T he patient
is s eated F igure 9.90. PR2–PR6: f SA Ra.
with legs on
the side of
table ( for
c omfort, the
patient may
hang the leg
opposite the
tender point
off the table) .
2. T he
phys ician
s tands
behind
patient with F igure 9.91. PR2–PR6: f SA Ra.
the foot
55 of 85 21/08/07 22:05
ipsilateral to
the tender
point on the
table with the
thigh under
the patient's
axilla.
3. T he
phys ician
gently flex es
patient's
head, neck,
and thor ax to
engage the
level of the
dysfunc tional
r ib.
4. T he
phys ician
elev ates the
patient's
s houlder with
the axilla
r esting on
the thigh,
whic h
s ide-bends
the trunk
away fr om
the tender
point.
5. T he patient
is asked to
s lowly
extend the
s houlder and
arm opposite
the tender
point and
allow the arm
to hang
down. T his
induces side
bending and
r otation
away fr om
the tender
point ( F igs.
9.90 an d
56 of 85 21/08/07 22:05
9.91).
6. T he
phys ician
fine-tunes
through
s mall ar cs of
motion
( flexion,
extension,
r otation, and
s ide
bending) .
P.16 5
Anteri or Lum bar Counterstrain Techni ques: Anterior Lumbar

Tender Points
57 of 85 21/08/07 22:05
Anterior
lumbar
c ounterstrain
tender points
ar e outlined
in Table 9.7
and
demons trated
in Figure
9.92.
Note: The
ac r ony ms for
the class ic
pos itions
r epres ent the
point of
r eference
r elated to the
mov ement of
the upper of
the two
s egments F igu re 9.92. Anter ior lumbar counters train tender points ( 5)
inv olv ed in
the
dy s function.
T herefore,
the physician
may stand on
either side of
the patient
and
depending on
the
dy s function
may alter the
s ide-bending
and rotational
elements. In
these supine
tec hniques
with motion
initiated fr om
below the
dy s function,
when the
k nees and
pelvis ar e
dir ected
58 of 85 21/08/07 22:05
T able 9.7 Co mmo n An terior Lum bar Ten der Po int s
Ten der Classic Treatment

Point L o cat ion Po sit ion
Patient supine
with hip and
k nee flexion
AL1 Medial to ASIS T ype II: F SA Ra

T ype I: F ST RA
or F SA RT
AL2 Medial to AIIS T ype II: f- F SA

RA
T ype I: f-F SA
RT
AL3 Lateral to AIIS Same as AL2
AL4 Inferior to AIIS Same as AL2
AL5 Anterior as pec t of pubic bone 1 cm T ype II: F SA Ra

lateral to pubic s ymphys is just T ype I: F SA Rt
inferior to pr ominenc e
ASIS, anterior s uperior iliac spine; AIIS, anterior inferior iliac spine.
P.16 6
Anteri or Lum bar Counterstrain Techni ques: AL1
59 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 somatic
dy s function at
L1. It may be
as s ociated with
the ps oas
mus cle.
T en der Po int
L o cation
T he tender point
lies at AL1,
medial to the
ASIS; press F igure 9.93. AL1 tender point (5).
medial to lateral
( F ig. 9.93).
T reatm ent
Po sition
1. T he
patient is
s upine and
the
phys ician
s tands at
the side of
the table
on the s ide F igure 9.94. AL1 ty pe I ( ST RA).
of the
tender
point.
2. T he
patient's
hips and
k nees ar e
flex ed
enough to
engage the
lower of
the two
s egments
involved
( L2) . F igure 9.95. AL1 ty pe II (SA RA) .
3. T he
60 of 85 21/08/07 22:05
P.16 7
61 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 somatic
dy s function at
L2.
T en der Po int
L o cation
T he tender point
lies at AL2,
medial to
anterior inferior
iliac spine
( AIIS) ; probe
laterally (F ig. F igure 9.96. AL2 tender point (5).
9.96).
T reatm ent
Po sition
1. T he
patient lies
s upine,
and the
phys ician
s tands at
the side of
the table
opposite
the tender F igure 9.97. AL2: F Sa-A RT.
point.
2. T he
patient's
hips and
k nees ar e
flex ed
enough to
engage the
lower of
the two
s egments
involved
( L3) .
3. T he
patient's F igure 9.98. AL2: F Sa-A RT.
hips and
62 of 85 21/08/07 22:05
P.16 8
Anteri or Lum bar Counterstrain Techni ques: AL3 and AL4
63 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 somatic
dy s function at
L3 and L4.
T en der Po int
L o cation
AL3: lateral to
the AIIS; pr ess
medially (F ig .
9.99).
AL4: inferior to
the AIIS; pr ess
c ephalad. F igure 9.99. AL3–AL4 tender points (5) .
T reatm ent
Po sition
1. T he patient
lies supine,
and the
phys ician
s tands at
the side of
the table
opposite
the tender
point.
2. T he F igure 9.100. AL3–AL4: F SA RT for type I.
phys ician
may plac e
the caudad
leg on the
table and
lay the
patient's
legs on the
phys ician's
thigh.
3. T he
patient's
hips and
k nees ar e
flex ed F igure 9.101. AL3–AL4: F ST RT for type II.
enough to
64 of 85 21/08/07 22:05
P.16 9
65 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 somatic
dy s function at
L5.
T en der Po int
L o cation
T he tender point
lies at AL5,
anterior aspect
of the pubic
bone about 1 cm
lateral to the
pubic F igure 9.102. AL5 tender point ( 5).
s y mphy sis jus t
inferior to its
pr ominenc e
( F ig. 9.102) .
T reatm ent
Po sition
1. T he patient
lies supine,
and the
phys ician
s tands at
the side of
the table F igure 9.103. AL5: F SA RA.
on the s ide
of the
tender
point.
2. T he
phys ician
plac es the
c audad leg
on the
table and
lays the
patient's
legs on the
phys ician's
thigh.
3. T he
66 of 85 21/08/07 22:05
P.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 9.8
and
demons trated
in Figure
9.104.
F ig ure 9.104. Posterior lumbar c ounters train tender points

( 5) .
67 of 85 21/08/07 22:05
T ab le 9.8 Co m mon Po sterior Lu mbar Tender Po int s
Classic T reat men t

Ten der Point Locatio n Po sition
PL1–PL5 Inferolateral as pec t of Patient prone with leg

s pinous proc ess or ( hip) ex tens ion and
laterally on transv ers e s light exter nal rotation,
pr oces s of dy sfunctional c ausing lumbar
s egment r otation to that s ide;
adduc tion or abduc tion
as needed
e SA Ra- A ( s pinous
pr ocess)
e SA RA (tr ansv ers e
pr ocess)
PL3 later al Halfway between UPL5 Patient prone

gluteus and PL4 at infer ior E er add
( iliac as pect of pos ter ior iliac
c r est) c r est near gluteus
medius /maximus
PL4 later al Pos ter olater al pelv ic Patient prone

gluteus edge halfway between E er add
( iliac gr eater troc hanter and
c r est) iliac crest at gluteus
max imus
UPL5 Superior sur face of Patient prone with hip

PSIS ex tension E er add
LPL5 2 c m below PSIS on the Patient prone with hip

ilium flexed off table and
s light adduc tion
F IR add
PSIS, pos ter ior superior iliac s pine.
P.17 1
P osterior Lum bar Counterstrai n Techniques: PL1 to PL5
68 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at L1
to L5.
T en der Po int
L o cation
T he tender point
lies at the
inferolateral
as pect of the
s pinous proc ess
or laterally on the
tr ansv ers e
pr oces s of the
dy s functional
s egment ( Fig .
9.105) .
T reatm ent
Po sition
1. T he patient F ig ure 9.105. PL1–PL5 midline and later al

lies pr one tender points (5).
and the
phys ician,
s tanding
opposite the
tender point,
gras ps the
patient's
lower thigh
or tibial
tuberos ity on
the side of
the tender
point.
2. T he F ig ure 9.106. PL4: e SA Ra-A.
phys ician
extends the
patient's
thigh and hip
until the
dysfunc tional
s egment is
69 of 85 21/08/07 22:05
P.17 2
P osterior Lum bar Counterstrai n Techniques P L1 to PL5
70 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at L1
to L5.
T en der Po int
L o cation
T he tender point
lies at the
inferolateral
as pect of the
s pinous proc ess
or laterally on the
tr ansv ers e
pr oces s of the
dy s functional
s egment ( Fig .
9.108) .
T reatm ent
Po sition
T he position is e
SA RA. F igure 9.108. PL1–PL5 midline and later al
tender points ( 5).
1. T he patient
lies pr one,
and the
phys ician,
s tanding
opposite the
tender point,
gras ps the
patient's
opposite
ASIS.
2. T he
phys ician
may tak e the F igure 9.109. PL4: e SA RA.
patient's leg
off midline to
r ight or left
depending on
the type of
dysfunc tion.
3. T he patient's
71 of 85 21/08/07 22:05
P.17 3
P osterior Lum bar Counterstrai n Techniques: PL3 and P L4,

Lateral
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at L3
to L4. It is
as s ociated with
the gluteus
medius muscle.
T en der Po int
L o cation Fig u re 9.111. PL3–PL4 ( gluteus medius ) tender
PL3 later al points (5) .
( gluteus) : Halfway
between the UPL5
and PL4 at the
inferior aspect of
the posterior iliac
c r est near the
gluteus medius
and gluteus
max imus ( Fig .
9.111)
PL4 later al
( gluteus) :
Pos ter olater al
pelvic edge,
halfway between Fig u re 9.112. PL3–PL4: E er add.
the gr eater
tr ochanter and
iliac crest at the
gluteus maximus
T reatm ent
Po sition
1. T he patient
lies pr one,
and the
phys ician
s tands on
the same
72 of 85 21/08/07 22:05
s ide as the Fig u re 9.113. PL3–PL4: E er add.

tender point
( the
r otational
c omponent
s ide of the
dysfunc tion).
2. T he
phys ician
gras ps the
patient's
thigh or tibial
tuberos ity on
the side of
the tender
point.
3. T he
phys ician
extends the
patient's
thigh and hip
until the
level of the
dysfunc tion
is engaged.
4. T he
phys ician
externally
r otates and
adducts the
patient's
thigh and
femur, whic h
s ide-bends
the lumbar
s egment
toward the
tender point
( Fig s. 9.112
and 9.113).
5. T he
phys ician
fine-tunes
through
s mall ar cs of
motion ( hip
flex ion and
extension,
external and
73 of 85 21/08/07 22:05
internal
r otation, and
adduction
and
abduction).
P.17 4
P osterior Lum bar Counterstrai n Techniques: PL5, Lower

P ol e
74 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function at L5.
T en der Po int
L o cation
T he tender point
lies at PL5 lower
pole 2 cm below
the PSIS (F ig .
9.114) .
T reatm ent
Po sition Fig u re 9.114. PL5 lower pole tender point
(5) .
1. T he patient
lies pr one,
and the
phys ician
s its at the
s ide of the
table on the
s ide of the
tender point.
2. T he
patient's
lower
extr emity on
the side of
the tender Fig u re 9.115. PL5LP: F IR add.
point hangs
off the side
of the table
with hip and
k nee flexed
to 90
degr ees .
3. T he
phys ician
internally
r otates the
patient's hip
and thigh,
and the Fig u re 9.116. PL5LP: F IR add.
patient's
75 of 85 21/08/07 22:05
P.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.
T en der Po int
L o cation
T he tender
point lies 2 to 3
c m caudal to
the point
halfway
between the
ASIS and the
midline, deep
on the side of
the dy sfunction Fig u re 9.117. Iliacus tender point (5).
( F ig. 9.117) .
T reatm ent
Po sition
T he position is
F ER ( hips)
abd (k nees).
1. T he
patient is
s upine,
and the
phys ician
s tands at
the side Fig u re 9.118. Iliacus: F ER (hips ) abd ( knees).
of the
table.
2. T he
patient's
hips ar e
mark edly
flex ed and
76 of 85 21/08/07 22:05
externally
r otated
bilater ally
( ank les
are
c ros sed
with
k nees out
to the
s ides)
( Fig s.
9.118 an d
9.119).
3. T he
phys ician Fig u re 9.119. Iliacus: F ER (hips ) abd ( knees).
fine-tunes
through
s mall ar cs
of motion
( hip
flex ion,
external
r otation,
and side
bending) .
P.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
In d icatio n f o r
T reatm ent
appropriate for
s omatic
dy s function of the
pir iformis muscle.
T en der Po int
L o cation
T he tender point
lies anywher e in F igu re 9.120. Pir ifor mis tender point (5) .
the piriformis
mus cle, c las s ically
7 to 10 c m medial
to and slightly
c ephalad to the
gr eater troc hanter
on the side of the
dy s function ( Fig .
9.120) . T his is
near the sciatic
notch, and
therefore, to av oid
s c iatic irritation,
we commonly use
the tender points F igu re 9.121. Pir ifor mis : F abd-ABD er .
pr oximal to either
the sacrum or the
tr ochanter. If they
c an be
s imultaneous ly
r educed
effectively, the
tr eatment can be
ex tremely
s uc ces sful.
T reatm ent
Po sition
1. T he patient F igu re 9.122. Pir ifor mis : F abd-ABD er -ER.

lies pr one,
and the
phys ician
s tands or s its
on the s ide of
the tender
78 of 85 21/08/07 22:05
P.17 7
Upper Extrem i ty Region: Supraspi natus
79 of 85 21/08/07 22:05
In d icatio n f o r
T reatm ent
appropriate for
s omatic
s upras pinatus
mus cle.
T en der Po int
L o cation
T he tender point
lies at the mid
s upras pinatus
mus cle just
s uperior to the
s pine of the
s c apula ( Fig .
9.124) .
F igu re 9.124. Supr aspinatus counterstr ain tender
T reatm ent point ( 7).
Po sition
1. T he patient
lies supine on
the treatment
table.
2. T he phy s ician
s its bes ide
the patient at
the lev el of
the shoulder
girdle.
3. T he phy s ician F igu re 9.125. Palpation of s upr aspinatus tender
may palpate point.
the tender
point with
either hand's
fingertip pad
or c ontr ol the
patient's
ipsilateral
arm with the
other ( F ig.
9.125).
4. T he patient's
arm is flex ed
to
80 of 85 21/08/07 22:05
P.17 8
Upper Extrem i ty Region: Infraspi natus
81 of 85 21/08/07 22:05
In d icatio ns f or
T reatm ent
T his treatment is
appropriate for
s omatic
infras pinatus
mus cle.
T en der Po int
L o cation
T he tender point
lies appr oximately
1 thumb's -width
medial to its
tendinous por tion
at the later al
s houlder joint
ins ertion and 1 or 2
thumb's-widths
below the spine of
the sc apula
( infer olater al s pine
of scapula at
pos ter omedial
as pect of
glenohumeral joint)
( F ig. 9.128) .
O thers may F igure 9.128. Infr aspinatus c ounter str ain tender
pr esent along the point (7) .
inferior spine of the
s c apula to
v er tebral bor der of
the sc apula. These
may neces sitate
placing the
patient's ar m in
mor e or less flexed
or abducted
pos itions .
T reatm ent
Po sition
F igure 9.129. Palpation of infraspinatus tender
1. T he patient
point.
lies supine on
the treatment
table.
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P.17 9
Upper Extrem i ty Region: Levator S capulae
83 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.
T en der Po int
L o cation
T he tender point
lies at the
s uperior angle
of the sc apula
( F ig. 9.131) .
T reatm ent
Po sition
1. T he patient
lies pr one,
head
r otated
away , with
the arms
at the
s ides. T he
phys ician
s its at the
s ide of the
affected
s houlder .
2. T he F igure 9.131. Levator scapulae c ounter s train
phys ician's tender point (7).
c audad
hand
gras ps the
patient's
wris t while
the other
hand
palpates
the tender
point ( F ig.
9.132).
3. T he
84 of 85 21/08/07 22:05
P.18 0
References
1. Jo nes LH , Ku s un ose R S, Go eri ng E K. J on es S tra i n- C oun ter s tr ai n. Ca r ls bad, CA : J ones

Str ai n-C oun ters tra i n, 199 5.
2. Wa r d R ( ed). Fo und atio ns for Ost eop ath i c M edi c in e. P hil ade l phi a: Lip pi nc ott Wi l l ia m s &
W i l ki ns, 20 03.
3. Si m on s D , Tr ave l l J , S i mo ns L. M y of asc i al Pai n a nd D y sf unc ti on : T he T r ig ger Po i nt M an ual , vo l

1. Ba l ti m or e: W i ll i am s & W il k in s , 1 999 .
4. Re nni e P , Gl ove r J . Co unt ers tr ai n a nd Ex er c is e: An I nte gra ted App r oa c h ( 2nd ed .) .

W i l li ams tow n, M I: R en ni eM atr i xT M , 2 004 .
5. Mo dif i ed w it h p erm i s si on fro m Cl ay J H, Pou nds DM . Ba s ic Cl i nic al M as s age Th era py :

Integ r at i ng Ana tom y a nd T r ea tme nt. Bal tim or e: Li ppi nc ot t W i ll i ams & W il k i ns , 2 003 .
6. Ya tes H, Glo v er J. C ou nte r st r ain : A Ha ndbo ok of Os te opa thi c Te c hn i qu e. T uls a, OK: Y K not ,
1995.
7. Mo dif i ed w it h p erm i s si on fro m Si m on s D G, T r av ell J G, Si m on LS. My ofa s c ia l P ain and

D y s fu nct i on : Th e T r ig ger Poi nt M anu al. Ba l tim ore : L i ppi nco tt W i ll i am s & W il k in s , 1999 .
85 of 85 21/08/07 22:05
10
Muscle Energy Techniques
Technique Principles
M us c le ene r gy te c hni que (M ET ) i s a f or m of ost eopa thi c m anip ula tiv e tr eat m en t de v el ope d by Fr ed L.
M it c he l l , Sr. , D O (1 909 –19 74). It is def i ne d b y th e E duc atio n C oun c i l on Ost eopa thi c P r i nc i pl es ( ECO P)
as “ a s y st em of di ag nos i s and tre atm ent i n w hi c h t he pat i ent vo l un tari l y m ov es t he bod y as sp eci fi ca l ly
dir ect ed b y t he phys i ci an; thi s d i re c ted pa tie nt a c ti on i s f r om a pr ec i se l y c ont r ol l ed pos i ti on, aga i ns t a
def i ne d re s is tan c e b y t he phys i ci an” ( 1) . S ome ost eop ath i c p hys i ci ans ( e. g., H ol l is Wo l f, N ic hol as S .
N ic hol as ) hav e s ugge s te d t hat thi s t ec hn i qu e i s a v ar i at i on of a t ec hn i qu e p er fo r me d b y T. J. Ru ddy, DO
( pe r so nal c om m un i c at i on ) . R udd y d eve l ope d a te c hni que ca l l ed rh y th m i c ( ra pid ) re s is tiv e du c ti on. H is
tec hni que use d t he p ati ent ' s m usc l e c ont r ac tio n ag ain s t a ph y si c ia n' s c ou nte r for c e bef or e the
dev elo pm en t o f M ET ( 2,3 ,4) . In ME T , the phy s ic i an pos i ti ons the pa ti en t s o a s to en gag e th e r est r i ct i ve
bar r ie r . F r ed Mi tc he l l, Jr ., u s es th e te r m fea ther ' s edg e to re fer to the le v el of eng agem ent (5 ,6). Th i s
ter m r efer s t o t he i nit i al s en s e of m eet i ng th e re s tr i ct i on w it h s l i gh tly mo r e m oti on av ai l ab l e befo r e
m ee tin g th e h ard end fe el of r est r ic ti on . I f t he p hys i ci an e nga ges the ba r ri er t o t he end poi nt of i ts
r es tri c tio n, i t c aus es the pat i en t t o re s is t, and i t bec om es di ffi c ult to co r r ec t t he dy sf unc tio n. A ddi tio nall y ,
eng agi ng a l l thr ee a x es of m ot i on (x , y, an d z ) at th e f eath er ' s e dge m ay al s o c aus e a l oc k in g u p of th e
dys fun c tio n, r es ul ti ng i n di ff i cu l ty of tre atm ent and re s i st ant dy s fun c ti on. T hi s w as one of the fir s t
ost eop athi c t ech ni qu es to us e k no w n and acc ept ed p hys i ol ogic pr i nc i ple s a s i ts m ajo r p r oto c ol of
tre atm ent.
Technique C las sification
D ire ct
In M ET , as in ot her dir ect tec hni que s , t he pat i ent ' s dys func tio n i s po s it i on ed t owa r d the r es tri c tiv e
bar r ie r . R ece nt atte m pt s b y so m e m an ual m ed i ci ne p r ac tit i one r s, es peci all y o utsi de the U ni ted St ates ,
hav e b egun to de s c ri be i nd i r ec t t ech ni qu e.
Technique Styles
Post Is ometric Re laxa tion

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

s tr uct ur es as pr opos ed i n the c ha pte r s o n m y of as ci al and s of t t i ss ue t r ea tme nt. T he he at g ene r at i on i s
l ik ely
P.1 82
1 of 134 21/08/07 22:07

to c au s e t he c on nect i ve ti s s ue s a nd c oll age n b as e, wh i ch are un der ten s io n, to c han ge c oll oid al s tat e ( gel
to s ol ) . A s a re s ult , t he fasc i al en v elo pe m ay l en gth en, als o p erm i tti ng the m us c le to l en gth en. D ur i ng th i s
i so m et r i c c on tra c tio n, the ten s io n b ui ld i ng up i n the mu s c le is al s o e x pr ess i ng flu i ds ( e. g., ve nous bl ood ,
l ym ph) fro m t he bell y o f t he m usc l e and s ur r ou ndin g i nte r s ti tia l c om pa r tm ent , wh i ch po tent i at es an
i nc r ea s e i n o v er al l l en gth and /or pe r c ei v ed re l axa tio n. As t he ago ni st mu s cl e be i ng co ntra c te d i s mo s t
l ik ely the dy s fu nc ti ona l m us cl e i nvo l v ed in ac ute s tr ain s , t his st y l e of tec hniq ue i s m ost us efu l in
s ub acu te t o c hro ni c c on dit i ons , i n w hi ch mu s cl e sh ort eni ng a nd fib r osi s m ay be p r es ent , ra the r t han i n
acu te c ond i ti ons . Th e f orc e of co ntr ac ti on m ay v ar y , but i t s ho uld be tol era bl e to bot h pa tie nt and
phy s ic i an. No te: T he pa tie nt's co ntr ac ti on and phy s ic i an ' s r esi s ta nc e are no t a c om pet i tio n t o s ee w ho i s
the st r ong er.
R eciproc al Inhibition
T hi s f or m of m us c l e ene r gy use s t he phys i ol ogi c pr i nc i pl e of re c ip r oca l i nhi bi ti on and r el axa tio n. W hen
an ago ni st co ntr ac ts , t he anta gon i st s ho uld re l ax ( e. g., bra c hi ali s an d b i ce ps c ont r ac t an d t r ic eps
r el axe s ) . T he fo r c e of c on tr ac tio n i n th i s s ty l e o f t ech ni qu e s hou l d b e v ery l ig ht, on l y s l ig htl y mo r e tha n
the th ough t t o c ontr act it . If th e f or ce is to o gr eat , t he r efl ex m ay be l os t by ca usi ng a ddi tio nal m us c le s to
c on tra c t. W he n m or e tha n o ne m usc l e c ont r ac ts, the in hib i tio n i s l os t ( e. g., pat i en t's m us c le co ntra c ti on
m im i cs Val s al v a m ane uve r s, i n w hi c h al l m us c le s ar e i s om etri c al l y c ont r ac tin g) . T hi s t ec hn i qu e, as i t
c an us e a fun c ti onal ag oni s t t o r ela x a dys fun c tio nal an tago nis t, i s s tro ngl y in dic ate d in ac ute c on dit i on s ,
tho ugh i t m ay al s o b e u s ed i n s ub acu te a nd c hr onic st age s .
J oint Mobiliza tion Us ing Mus cle Force

M us c le for c e use s pa tie nt posi tio nin g an d m usc l e c ont r ac ti on to re s tor e l i mi ted j oi nt m oti on. As the
m us c le s ar e t he pr im ary mo v ers of jo i nts , u s e of a sp eci fi c m us c le c on tra c ti on w i th th e pa tie nt i n a
s pe c if i c p osi tio n al l ow s t he f orc es at p l ay to bec ome ve r y p owe r fu l an d b e v ec to r ed sp ec if i ca l ly to a l oca l
are a. T his is si m i la r t o t he l ong - le v ere d s tyl e of hi gh v elo c it y , l ow amp l it ude ( HV LA) the r ap y , ex ce pt tha t
the pa ti en t i s a c tiv ely co ntra c ti ng m usc l es in s tea d o f t he p hys i ci an p ull i ng the m t o c ause mo v em ent.
T he r ef or e, th i s s tyl e o f m us cl e e ner gy c oul d b e th oug ht of a s l ow v elo c it y , l ow amp l it ude ( LV LA) . Th e
r es ult i ng c on tra c tio n m ay beco m e m in i m al l y i so toni c .
As s ta ted ear l ie r , m oti on i n j oin ts c an be i mp r ove d b y u s e o f f orc es t hat ar e ve c to r ed dir ect l y or

i nd i re c tly . M ET i s c l as s ic al ly de s cr i bed as a di re c t tec hniq ue use d to mo bil i z e a r est r i ct ed j oi nt;
the r ef or e, po s it i oni ng of the pat i en t is si m il ar t o t he r eci pro c al i nh i bi tio n st y le of pos i ti oni ng. H ow eve r , i n
thi s c as e, th e m us cl e c ont r act i on s c an b e m ore pow erf ul ( pos s ib l y i s ot oni c ) up t o m any pou nds of
r es i st ance . F or the phy s ic i an' s c omf or t, th e p atie nt s ho ul d be pos i tio ned to enc our age the de v el opme nt of
the mo s t a ppr opr i ate lo nge s t-l eve r ed for c e w it h th e l eas t am oun t o f co unt erf or ce fr om the phy s ic i an
nec ess ar y for su c c es s .
R espira tory As sis tanc e

R es pir ator y a s si s tan c e m ay be use d i n a num ber of ost eop athi c m ani pula tiv e t ec hn i qu es ( e.g .,
m yo fas c i al re l ea s e, s of t t i s su e, c ou nter s tr ain , ba l an c ed l ig ame nto us t ens i on , li gam ent ous art i cu l ar
s tr ain ) . I n t his s ty l e of M ET, th e p hy si c ia n p os it i on s t he p ati ent to bes t d i r ec t t he forc es of r esp i ra tio n
tow ard the ar ea of d y sf unc ti on an d s i m ul tan eou s l y use a fulc r um (e .g., ph y si c i an ' s han d) a s a
c ou nte r for c e to help di r ec t th e d y sf unct i on al r egi on thr ough th e r es tr i ct i ve bar r ie r . As d i ap hra gm at i c
exc urs i on dur i ng i nh ala tio n ma y a ffe c t m usc l es v er y d i st al ly be c au s e o f f asc i al c on tin ui ty , m oti on a nd
tis s ue c ha nge s m ay b e a ppr ec ia ted lo c all y o r p er ip her all y .
Oculoce r vic al Reflex
2 of 134 21/08/07 22:07

W he n a pat i en t i s as k ed to m ak e s pec i fic ey e m ov em ent s , c ert ain ce r v ic al and tru nca l m us cl es c on tr ac t,

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

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

m oti on
P.1 83
Seconda r y Indications
1. T o i m pr ove l oc al c ir c ula tio n a nd r esp i ra tory fu nct i on
2. T o b ala nce neu r om usc ul ar re l at i ons hip s b y al ter i ng m us c le to ne
3. T o i ncr eas e to ne i n hy po ton i c or w eak mu s c le s
C ontraindic ations
R ela tiv e Contr aindica tions

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

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

D ep end i ng on the pat i en t's pre s en tat i on, th e s ty le of mu s c le en erg y us ed m ay v ar y . Add i tio nal l y, the
nat ure and le ngt h of co ntr ac ti on m ay be alt ere d fr om pat i ent to pa ti en t a nd betw een an atom i c r eg i ons .
M us c le s ma y b e m or ph olo gic al ly di ffe r ent , o ne to a not her . Th ere for e, t he w ay the y r esp ond to i so m etr i c
3 of 134 21/08/07 22:07

c on tra c tio ns m ay dif fer . I n so m e are as , hol din g a m us c le c on tra c ti on f or 5 o r mo r e s ec onds ma y b e

nec ess ar y; in ot hers , 3 se c ond s m ay s uff i ce . C l i ni c al ex peri enc e w i l l tea c h this .
T he es s ent i al st eps for mo s t s tyl es of t his te c hni que ar e as fo l lo w s :
1. T he phy s ic i an pos i ti ons the bo ne, j oi nt, or m us c le to be tre ated at th e fe ath er ' s ed ge of the
r est r ic tiv e ba r ri er ( poi nt of i nit i al re s i st anc e) i n a l l thr ee p l an es of m oti on ( x -, y- , z - axe s ).
H owe v er , i t ma y b e m or e eff ect i v e to k ee p on e a x is s li ght l y l oos e ( l ax ) , a s t he dy sf unc tio n ma y
beco m e v er y re c al c it r ant if si m ult ane ous l y h eld at all th r ee axi s l i mi ts .
2. T he phy s ic i an i ns tru c ts the pa ti en t t o c ontr act a s pec i fi c m us cl e i n a s pe c if i c di re c ti on agai nst th e

phys i ci an' s un y ie l di ng c oun ter forc e f or 3 to 5 s ec onds .
3. T he pat i en t ce ase s a l l m usc l e c ont r ac tio n wh en ask ed b y t he phys i ci an to r ela x o r go to sl eep.
4. Afte r s ens i ng tha t t he p ati ent i s not gu ar di ng and i s c om ple tely re l ax ed ( m ay ta k e 1 –2 s ec onds ) ,
the phy s ic i an s lo w ly r ep osi tio ns t he pat i ent to th e fe ath er ' s ed ge of the new re s tri c ti v e barr i er .
5. Step s 1 to 4 a r e r ep eate d u nti l th e b est pos s ib l e i ncr eas e i n mo tio n i s ob tai ned . Th i s usu al ly
r equ i re s t hr ee to se v en r ep eti ti on s , dep endi ng on the aff ect ed b ody re gi on an d t ol er anc e o f th e
pati ent .
6. T he phy s ic i an r ee v al uate s t he di ag nos tic par ame ter s of th e o r i gi nal dy s fun c ti on to d ete r mi ne t he
effe c ti v en es s of the tec hni que .
M us c le ene r gy ma y , l i ke mo s t o the r o s teo pat hic tec hni que s , b e u s ed i n c on j un c tio n w i th oth er tec hniq ues .
It i s es pe c ia l ly ben efi c ia l in po ten ti at i ng so ft t i ss ue, m yo fas c ia l re l ea s e, c ou nte r st r ain , a nd H VLA
tec hni ques . A s t he t r ea tme nt p osi tio ns a r e s o s i mi l ar to tho s e of H VLA , i t i s na tur al to g o f r om M ET to
H VL A i f th e M ET i s n ot c om pl et ely su c c es s fu l ; M ET oft en m ake s H VLA m or e r ead i l y s uc c es s ful .
If the phy s ic i an i s uns ucc es sf ul w it h ME T , i t i s m ost li k ely be c au s e o f e i th er a ve r y s eve r e c hr onic

dys fun c tio n o r b ec au s e of i nac c ur ate dia gno s is . Du r in g t he c orr ect i v e pro c ed ur e, su c ce s s m ay be
dim i ni s hed by in ac cu r at e l oc al i za tio n of co r re c tiv e f orc es ( for c e at a se gme nt t oo hig h or lo w ; posi tio nin g
c au s in g th e v ect or ed fo r ce at too hi gh o r t oo l ow a s egm ent) . I t i s im por tan t to un der s tan d t he s pec i fi c it y
of the pat i en t's pos i ti oni ng i n t his tec hni que . Th e p hys i c ia n m ust pal pat e t he m oti on i n t he exa c t
s eg m en tal or m us c ula r t i ss ue t hat is bei ng tre ated . I nco r r ec t f orc e of co ntr ac ti on by the pat i en t (t oo
for c ef ul o r t oo gent l e) ma y hi nde r t he s ucc ess ful c om ple ti on of th e te c hn i qu e. I f t he pati ent ' s c ont r ac tio n
i s too s ho r t i n dura tio n ( i .e. , 1 se c ond ) , i t w i ll de c re as e eff ect i v en ess . O ther pr obl em s m ay de v elo p i f t he
pat i en t do es not c om ple tel y re l ax pr i or to r ep os it i on i ng . Fu r th erm or e, if th e ph y si c ia n fa i ls to r ee v al uat e
the di agno s ti c f i ndi ngs af ter tre atm ent, th e d y s fu nct i on m ay st i ll be pre s en t an d p r ev ent a p osi ti ve
r es pon s e.
P.1 84
C erv ica l Re gion: Trapezius Musc le Spa s m (Long R e str ictor): Post
Isom etr ic R ela xation
4 of 134 21/08/07 22:07

1. T he patient is
s upine and the
physician s its
at the head of
the table.
2. T he phys ician
gently flex es
the patient's
neck until the
edge of the
r estr ictive
barrier is
r eached (F ig .
10.1) . Fig u re 10.1. A. Steps 1 and 2, flexion
3. T he patient bar r ier .
ex tends or
backward
bends the neck
and head
( blac k arrow,
F ig. 10.2) while
the phys ician
applies an
equal
c ounterforc e
( white arrow).
4. T his isometr ic
c ontr action is
maintained for Fig u re 10.1. B. Alternative hand
3 to 5 s econds, plac ement.
and then the
patient is
instr ucted to
st op and
relax.
5. O nce the
patient has
c ompletely
r elax ed, the
physician
gently flex es
the neck (white
ar row, F ig.
10.3) to the Fig u re 10.2. Step 3, is ometric contraction.
edge of the
new r estric tive
barrier.
6. Steps 3 to 5
5 of 134 21/08/07 22:07

P.1 85
C erv ica l Re gion: Left Sternocle idomas toid Spasm (Ac ute
Torticollis ): Rec iprocal Inhibition
s upine and the
physician s its at the
head of the table
s upporting the
patient's head with
the hand res ting the
patient's head on
the k nee or thigh.
2. T he phys ician
gently r otates the
patient's head to
the r ight to position
the hypertonic left F igu re 10.4. Steps 1 and 2.
s ternocleidomas toid
muscle v entr ally
( F ig. 10.4) .
3. T he phys ician
gently extends the
patient's head until
the edge of the
r estr ictive bar rier is
r eached (F ig .
10.5) .
4. T he patient ver y
gently extends the
head (b lack arr ow,
F ig. 10.6) while the F igu re 10.5. Step 3, extens ion bar rier .
physician r esis ts
with an equal
c ounterforc e (white
ar row).
5. T he phys ician
palpates the left
muscle to ensur e
that adequate
r elax ation is
oc cur ring.
6. T his isometr ic
c ontr action is
maintained for 3 to F igu re 10.6. Step 4, isometr ic contrac tion.
5 sec onds, and
6 of 134 21/08/07 22:07

then the patient is

instr ucted to stop
an d relax.
7. O nce the patient
has c ompletely
r elax ed, the
physician gently
ex tends the
patient's head
( white arrow, F ig.
10.7) to the edge of
the new res tric tiv e
barrier.
8. Steps 4 to 7 ar e F igu re 10.7. Step 7, extens ion bar rier .
r epeated thr ee to
five times or until
motion is maximally
improved.
9. T o deter mine the
effec tiv enes s of the
technique, the
physician palpates
the left
muscle for
r educ tion in tone
and observes the
patient's head
position in the er ect
posture for
improved body
c arriage.
P.1 86
C erv ica l Re gion: Left Sternocle idomas toid Contr a cture (Chr onic):
7 of 134 21/08/07 22:07

s upine and the
physician s its at the
head of the table
s upporting the
patient's head with
the hand and/or
r esting the patient's
head on the knee or
thigh.
2. T he phys ician
gently r otates the
patient's head to
the r ight to position F igu re 10.8. Steps 1 and 2.
the hypertonic left
muscle v entr ally
( F ig. 10.8) .
3. T he phys ician
gently extends the
patient's head until
the edge of the
r estr ictive bar rier is
r eached (F ig .
10.9) .
4. T he patient flexes
and r otates the
head to the left F igu re 10.9. Step 3, extens ion bar rier .
( blac k arrow, F ig.
10.10) while the
physician r esis ts
with an equal
ar row).
5. T he phys ician
palpates the left
muscle to ensur e
that adequate
c ontr action is
oc cur ring.
6. T his isometr ic F igu re 10.10. Step 4, is ometric
c ontr action is c ontrac tion.
maintained for 3 to
5 sec onds, and
then the patient is
instr ucted to stop
an d relax.
8 of 134 21/08/07 22:07

P.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. 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. Fig ure 10.12. Step 1.
After 3 to 5
s econds, tell
the patient to
st op and relax
( c los e the
ey es) . T he
physician
s lowly and
gently extends
the patient's
head and nec k
to the edge of
the new
r estr ictive Fig ure 10.13. Step 2.
barrier. This
may be
r epeated thr ee
to five times or
until motion is
maximally
improved (F ig.
10.12).
2. T o pr oduce
flexion of the
neck: Have the
patient look
down at the feet
for 3 to 5 Fig ure 10.14. Step 3.
s econds. After
3 to 5 s econds,
9 of 134 21/08/07 22:07

tell the patient

to st op and
relax (c los e the
ey es) . T he
physician
s lowly and
gently flex es
the patient's
head and nec k
to the edge of
the new
r estr ictive
barrier. This
may be Fig ure 10.15. Step 4.
r epeated thr ee
to five times or
until motion is
maximally
improved (F ig.
10.13).
3. T o pr oduce
r ight side
bending: Hav e
the patient look
up and to the
r ight for 3 to 5
s econds. After
3 to 5 s econds,
tell the patient
to st op and
relax (c los e the
ey es) . T he
physician
s lowly and
gently
s ide- bends the
patient's head
and neck to the
edge of the new
r estr ictive
barrier. This
may be
r epeated thr ee
to five times or
until motion is
maximally
improved (F ig.
10.14).
4. T o pr oduce left
10 of 134 21/08/07 22:07

s ide bending:
have the patient
look up and to
the left for 3 to
5 sec onds.
After 3 to 5
s econds, tell
the patient to
st op and relax
( c los e the
ey es) . T he
physician
s lowly and
gently
s ide- bends the
patient's head
and neck to the
edge of the new
r estr ictive
barrier. This
may be
r epeated thr ee
to five times or
until motion is
maximally
improved (F ig.
10.15).
P.1 88
P.1 89
C erv ica l Re gion: Occipitoatlantal (C0 —C01 ) D ysfunction Ex a mple:

C 0 ESLR R Post Isom etr ic Rela xation*
11 of 134 21/08/07 22:07

1. T he patient is
s upine and the
physician s its at
the head of the
table.
2. O ne of the
physician's
hands is placed
under the
patient's
oc ciput, and the
pads of the
fingers contact
the s uboccipital F igure 10.16. Steps 1 and 2, lateral v iew.
musculature.
T he index and
middle fingers
of the
physician's
oppos ite hand
ar e plac ed on
the patient's
c hin beneath
the lower lip
( F igs. 10.16
an d 10.17).
3. T he phys ician
gently flex es F igure 10.17. Steps 1 and 2, anterior
( white arrow, v iew.
F ig. 10.18) and
s ide- bends the
patient's oc ciput
to the r ight until
the edge of the
r estr ictive
barriers ar e
r eached. The
physician is
is olating motion
to the
oc cipitoatlantal
ar tic ulation
only. The F igure 10.18. Step 3, flexion, s ide-bending
physician may barrier.
add r otation left
if desir ed.
4. T he patient
gently extends
12 of 134 21/08/07 22:07

P.1 90
P.1 91
C erv ica l Re gion: Occipitoatlantal (C0 —C01 ) D ysfunction Ex a mple:

C 0 FSLR R Post Isom etr ic Rela xation
1. T he patient is
s upine and the
physician s its at
the head of the
table.
2. O ne of the
physician's
hands is placed
under the
oc ciput, and the
pads of the
fingers touc h
the s uboccipital
musculature. F igure 10.21. Steps 1 and 2.
T he index and
middle fingers
of the
physician's
oppos ite hand
lie immediately
beneath the
patient's c hin
( F ig. 10.21) .
T he phys ician is
c areful not to
c hoke patient.
3. T he phys ician
ex tends (w hite F igure 10.22. Step 3, extens ion,
ar row) and s ide- bending barrier.
s ide- bends the
oc ciput to the
r ight until the
r estr ictive
barriers ar e
engaged. The
physician is
is olating motion
to
oc cipitoatlantal
ar tic ulation
only. The
physician may
13 of 134 21/08/07 22:07

add r otation left F igure 10.23. Step 4, isometr ic

if desir ed ( Fig . c ontr action.
10.22).
4. T he patient
gently nods the
head for war d
( blac k arrow,
F ig. 10.23) so
that the chin
pulls down into
the phys ician's
r estr aining
fingers while the
physician
applies an equal
c ounterforc e F igure 10.24. Step 6, extens ion bar rier .
( white arrow).
T he phys ician
s hould be able
to palpate
s uboc cipital
muscle
r elax ation with
the hand
beneath the
oc ciput.
5. T his isometr ic
c ontr action is
maintained for 3
to 5 sec onds ,
and then the
patient is
instr ucted to
st op and relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
further extends
the head (white
ar row, F ig.
10.24) by
pr ess ing to the
c eiling with the
hand under the
oc ciput and
lifting cephalad
with the finger s
14 of 134 21/08/07 22:07

beneath the
c hin.
7. Steps 4 to 6 ar e
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
s egment.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine the
effec tiv enes s of
the technique.
P.1 92
C erv ica l Re gion: A tla ntoaxia l (C1—C2) Dys function Exam ple : RL
1. T he patient is
s upine and the
physician s its
at the head of
the table.
2. T he phys ician
may gently flex
the patient's
head (C0-C1,
about 15–25
degrees) until
the edge of the
r estr ictive
barrier is Fig ure 10.25. Steps 1 to 3, r otation
r eached, or the bar rier.
patient's head
may r emain in
neutr al.
3. T he phys ician
r otates the
patient's head
15 of 134 21/08/07 22:07

to the r ight
( white arrow,
F ig. 10.25) until
the edge of the
r estr ictive
barrier is
r eached.
4. T he patient
r otates the
head to the left
( blac k arrow,
F ig. 10.26)
while the
physician Fig ure 10.26. Step 4, isometr ic
applies an equal contraction.
c ounterforc e
( white arrow).
Note: In ac ute
painful
dy sfunctions
the patient can
v ery gently
r otate or look to
the r ight
( r eciprocal
inhibition,
oc ulocer vic al).
5. T his isometr ic
c ontr action is Fig ure 10.27. Step 6, r otation barrier.
maintained for 3
to 5 sec onds ,
and then the
patient is
instr ucted to
st op and relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
r otates the
patient's head
( white arrow,
F ig. 10.27) to
the r ight until
the edge of the
new r estric tive
barrier is
r eached.
16 of 134 21/08/07 22:07

r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
s egment.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine the
effec tiv enes s of
the technique.
P.1 93
C erv ica l Re gion: C 2—C 7 D ysfunction Ex a mple: C3 FSRR R Post

s upine, and the
physician is
s eated at the
head of the
table on the
s ide of the
r otational
c omponent.
2. T he firs t
metac arpal
phalangeal joint
of the
physician's right F igure 10.28. Steps 1 to 3.
hand is plac ed
at the artic ular
pillar of the
s egment being
tr eated. The
heel of the
physician's
hand closes in
against the
17 of 134 21/08/07 22:07

oc ciput.
3. T he phys ician
c r adles the
patient's head
between the
hands (may c up
the c hin with the
left hand). The
oc ciput, C1, C2,
and C3 are
flexed until the
dy sfunctional
C3 engages C4;
the s egments F igure 10.29. Step 4, isometr ic
ar e then c ontr action.
ex tended
s lightly to meet
the extension
barrier. C3 is
then rotated and
s ide- bent to the
left until the
edge of the
r estr ictive
barriers ar e
r eached in all
three planes
( F ig. 10.28) .
4. T he patient F igure 10.30. Step 6.
r otates the head
( blac k arrow,
F ig. 10.29) to
the r ight while
the phys ician
applies an equal
c ounterforc e
( white arrow).
Note: In ac ute,
painful
dy sfunctions
the patient ver y
gently r otates
or looks to the
left while the
physician
applies an equal
c ounterforc e
( r eciprocal
inhibition,
18 of 134 21/08/07 22:07

oc ulocer vic al).

5. T his isometr ic
c ontr action is
maintained for 3
to 5 sec onds ,
and then the
patient is
instr ucted to
st op and relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
r epos itions the
dy sfunctional
s egment by
r otating and
s ide- bending
left (w hite
ar row) and then
ex tending until
the edge of the
new r estric tive
barrier is
r eached (F ig .
10.30).
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
s egment.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine the
effec tiv enes s of
the technique.
P.1 94
P.1 95
Thor acic Re gion: T1—T4 D ysfunction Ex a mple: T4 ESRR R Post

19 of 134 21/08/07 22:07

1. T he patient is
s eated at the
end of the table
and the
physician
s tands at the
s ide opposite
the r otational
c omponent.
2. T he phys ician's
left hand
palpates the
s pinous
pr ocesses of F igu re 10.31. Steps 1 and 2, flexion
T 4 and T 5 or barr ier .
the T 4-T 5
inter space to
monitor flex ion
and extension
as the r ight
hand flexes the
patient's head
and neck (white
ar row, F ig.
10.31) to the
edge of the
r estr ictive
barrier.
3. T he phys ician's F igu re 10.32. Step 3, left side-bending
left hand barr ier .
monitors the
tr ans ver se
pr ocesses of
T 4 and T 5 to
localize side
bending and
r otation as the
r ight hand
s ide- bends
( white arrow,
F ig. 10.32) and
r otates (w hite
ar row, F ig.
10.33) the F igu re 10.33. Step 3, left rotation barr ier.
patient's head
and neck to the
left until the
edge of the
20 of 134 21/08/07 22:07

P.1 96
P.1 97
Thor acic Re gion: T1—T6 D ysfunction Ex a mple: T4 FSRR R Post

1. T he patient is
s eated with the
r ight hand on
the left shoulder
and the
physician
s tands c los e to
the patient on
the s ide
oppos ite the
r otational
c omponent.
left hand F igure 10.38. Steps 1 and 2.
r eaches under
the patient's
elbow and
gr asps the
patient's r ight
s houlder . T he
physician's right
hand palpates
the s pinous
pr ocesses of
T 4 and T 5 or
T 4-T5
inter space and
instr ucts the F igure 10.39. Step 3, extens ion bar rier .
patient to r elax
and r est the full
weight of the
head and elbow
on the
physician's arm
( F ig. 10.38) .
3. Starting with the
patient in
ex treme flex ion,
the phys ician,
s lowly r ais es
the left elbow
( white arrow) as F igure 10.40. Step 4, left s ide- bending
21 of 134 21/08/07 22:07

the r ight hand barrier.

gently
tr ans lates the
dy sfunctional
v ertebra
forward (w hite
ar row) to the
edge of the
ex tension
barrier (F ig .
10.39).
r ight hand now
monitors the
tr ans ver se F igure 10.41. Step 5, left r otation bar rier.
pr ocesses of
T 4 and T 5 to
localize side
bending and
r otation, as the
left arm and
hand
r epos itions the
patient's left
s houlder down
( white arrow) to
engage the
edge of the left
s ide bending F igure 10.42. Step 6, isometr ic
barrier (F ig . c ontr action.
10.40).
5. T he phys ician
then gently
r otates the
patient's
s houlder s left
( white arrow) to
engage the
edge of the left
r otation bar rier
( F ig. 10.41) .
6. T he patient
pushes down
with the elbows F igure 10.43. Step 8, left s ide- bending
and forehead barrier.
against the
physician's arm
while
s imultaneous ly
22 of 134 21/08/07 22:07

r otating the
tr unk to the
r ight (blac k
ar row) as the
physician
applies an
unyielding
c ounterforc e
( white arrow,
F ig. 10.42) .
7. T his isometr ic
c ontr action is
maintained for 3
to 5 sec onds , F igure 10.44. Step 8, left r otation bar rier.
and then the
patient is
instr ucted to
st op and relax.
8. O nce the
patient has
c ompletely
r elax ed, the
physician
r epos itions the
patient to the
edge of the new
r estr ictive
barriers in all F igure 10.45. Step 8, extens ion bar rier .
three planes :
first left s ide
bending, (F ig.
10.43) then left
r otation (F ig.
10.44), and
finally extension
( F ig. 10.45) .
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
s egment.
10. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine the
23 of 134 21/08/07 22:07

effec tiv enes s of

the technique.
P.1 98
P.1 99
Thor acic Re gion: T5—T12 Dys func tion Ex ample: T8 ESR RR Pos t
1. Patient is
s eated on the
end of the table,
the left side
c lose to the
edge. The ar ms
ar e folded
ac ros s the
c hest, r ight
ov er left.
2. T he phys ician
s tands at the
s ide of the
patient opposite F igu re 10.46. Steps 1 to 4, flexion barr ier.
the r otational
c omponent.
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 .
r ight hand
monitors the F igu re 10.47. Step 5, left side-bending
s pinous barr ier .
pr ocesses of
T 8 and T 9 or
the T 8-T 9
inter space to
localize flexion
and extension
24 of 134 21/08/07 22:07

as the left arm

and hand flex
the patient's
torso (white
ar row, F ig.
10.46) until the
edge of the
r estr ictive
barrier is
r eached.
r ight hand
monitors the
tr ans ver se F igu re 10.48. Step 5, left rotation barr ier.
pr ocesses of
T 8 and T 9 to
localize side
bending and
r otation as the
left arm and
hand pos ition
the patient's
torso to the
engage the
edge of the left
s ide bending
( white arrow, F igu re 10.49. Step 6, is ometric
F ig. 10.47) and c ontrac tion.
left rotation
barrier (w hite
ar row, F ig.
10.48).
6. T he patient sits
up and turns
the s houlder s
to the r ight
( blac k arrow)
as the
physician's left
hand applies an
unyielding
c ounterforc e F igu re 10.50. Step 8, left side-bending
( white arrow, barr ier .
F ig. 10.49) .
7. T his isometr ic
c ontr action is
maintained for 3
to 5 sec onds ,
and then the
25 of 134 21/08/07 22:07

patient is
instr ucted to
st op and relax.
8. O nce the
patient has
c ompletely
r elax ed, the
physician
r epos itions the
patient to the
edge of the new
r estr ictive
barriers in all
three planes : F igu re 10.51. Step 8, left rotation barr ier.
first left s ide
bending (F ig .
10.50), then left
r otation (F ig.
10.51), and
finally flex ion
( F ig. 10.52) .
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional F igu re 10.52. Step 8, flexion barr ier .
s egment.
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 00
C ostal R egion: Right Fir st R ib, Inhala tion D ysfunction: R e spiratory

A ssist, Sea ted
26 of 134 21/08/07 22:07

1. T he patient is seated.
T he phys ician s tands
behind the patient,
placing the left foot on
the table to the left
s ide of the patient and
k eeping the hip and
k nee flexed at about
90 degrees.
2. T he patient's left ar m
is dr aped ov er the
physician's left thigh.
3. T he
metac arpal- phalangeal F igu re 10.53. Steps 1 to 4.
joint of the physician's
r ight index finger
c ontacts the super ior
s urface of the
dy sfunctional r ight r ib
posterior and lateral to
the c ostotr ansv ers e
ar tic ulation.
4. T he patient's head,
c ontr olled by the
physician's left hand,
is gently flexed,
s ide- bent towar d, and
r otated away fr om the F igu re 10.54. Step 6, ex halation.
r ight rib to take the
tension off the sc alene
musculature (F ig.
10.53).
5. T he patient inhales
and then ex hales
deeply.
6. During exhalation, the
physician's right hand
follows the fir st rib
down and for war d
10.54) further into
ex halation. F igu re 10.55. Step 7, resis t inhalation.
deeply ( blac k arrow,
F ig. 10.55) , as the
r esis ts (w hite arr ow)
the inhalation motion
27 of 134 21/08/07 22:07

P.2 01
C ostal R egion: Right Fir st R ib, Inhala tion D ysfunction: R e spiratory

A ssist, Supine
1. T he patient lies s upine

and the phy s ician
s tands or s its behind
the patient.
2. T he
metac arpal- phalangeal
joint of the physician's
r ight index finger
c ontacts the super ior
s urface of the
dy sfunctional r ight r ib
posterior and lateral to
the c ostotr ansv ers e
ar tic ulation. F igu re 10.57. Steps 1 to 4.
3. T he patient's head,
c ontr olled by the
physician's left hand,
is gently flexed,
s ide- bent towar d, and
r otated away fr om the
r ight rib to take the
tension off the sc alene
musculature (F ig.
10.57).
and then ex hales
deeply.
5. During exhalation, the F igu re 10.58. Step 6, ex halation.
down and for war d
10.58) further into
ex halation.
deeply ( blac k arrow,
F ig. 10.59) as the
r esis ts (w hite arr ow)
the inhalation motion
of the firs t rib.
7. During exhalation, the F igu re 10.59. Step 7, resis t inhalation.
28 of 134 21/08/07 22:07


down and for war d
10.60) towar d
ex halation.
8. Steps 7 and 8 are
r epeated fiv e to s even
times or until motion is
maximally improved at
the dysfunc tional rib.
9. Motion of the
dy sfunctional r ib is
r eevaluated to
deter mine the F igu re 10.60. Step 8, ex aggerate
effec tiv enes s of the exhalation.
technique.
10. An alter native
technique is to have
the patient lift the r ight
s houlder agains t
r esis tance for 3 to 5
s econds and then
c arry the r ib toward
ex halation during the
r elax ation phas e.
P.2 02
C ostal R egion: Right Ribs 1 and 2, Inhala tion D y sfunction: Post

Isom etr ic R ela xation to Rela x Scalene Mus cle s, Seated
1. T he patient is
s eated and the
physician
s tands behind
the patient,
placing the left
foot on the table
to the left side
of the patient
and k eeping the
hip and knee
flexed at about
90 degrees.
Fig ure 10.61. Steps 1 to 3.
29 of 134 21/08/07 22:07

r ight thumb is
placed over the
anter omedial
as pec t of the
dy sfunctional
r ight rib.
left hand
c ontr ols the
patient's
forehead,
r otates it 30 to
45 degrees to Fig ure 10.62. Step 4, isometr ic
the left (white contraction.
ar row), and
adds slight
ex tension until
meeting the
edge of the
r estr ictive
barrier (F ig .
10.61).
4. T he patient
pushes the
head for war d
into the
physician's left
hand (b lack Fig ure 10.63. Step 6, extension barr ier .
ar row, F ig.
10.62) as the
physician
r esis ts (long
white ar row) .
T he r ight hand
( s hor t white
ar row)
s imultaneous ly
r esis ts any
inhalation
movement of
the
dy sfunctional
r ib.
5. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
30 of 134 21/08/07 22:07

is instr ucted to
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician's left
hand minimally
ex tends the
patient's head
( white arrow,
F ig. 10.63) until
a new
r estr ictive
barrier is
r eached.
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
r ib.
8. Motion of the
dy sfunctional
r ib is
r eevaluated to
as ses s the
effec tiv enes s of
the technique.
P.2 03
C ostal R egion: Right Ribs 1 and 2, Inhala tion D y sfunction: Post

Isom etr ic R ela xation to Rela x Scalene Mus cle s, Supine
31 of 134 21/08/07 22:07

s upine and the
physician s its
at the head of
the table.
r ight thumb is
placed over the
anter omedial
as pec t of the
dy sfunctional
r ib.
left hand Fig ure 10.64. Steps 1 to 3, r otation and
c ontr ols the extens ion bar rier.
patient's head
and r otates it
30 to 45
degrees to the
left (w hite
ar row, F ig.
10.64) and adds
s light extension
by lower ing the
thigh until the
edge of the
r estr ictive
barrier is
r eached. Fig ure 10.65. Step 4, isometr ic
4. T he patient contraction.
flexes the head
and neck into
the phys ician's
left hand ( blac k
ar row, F ig.
10.65) as the
physician
applies an equal
c ounterforc e
( long white
ar row). The
r ight thumb
( s hor t white
ar row) Fig ure 10.66. Step 6, extension barr ier .
s imultaneous ly
r esis ts any
inhalation
movement of
32 of 134 21/08/07 22:07

P.2 04
C ostal R egion: Right Ribs 2 to 6, Inha lation Dy s function:

R espira tory As sis t
s upine and the
physician's
flexed r ight
k nee is plac ed
on the table
under neath the
patient's r ight
upper thorac ic
r egion at the
level of the
dy sfunctional
r ib.
2. T he patient's F ig ure 10.67. Steps 1 to 3.
upper body is
s ide- bent to the
s ide of the
dy sfunction
( r ight s ide) until
tension is taken
off the
dy sfunctional
r ib.
3. T he web
formed by the
physician's
r ight thumb and
index finger is F ig ure 10.68. Step 5, exagger ate
placed in the ex halation.
inter cos tal
s pace above
the
dy sfunctional
r ib on its
s uper ior
s urface (F ig .
10.67).
4. T he patient
inhales and
ex hales deeply.
5. During
ex halation the
physician's F ig ure 10.69. Step 6, r esist inhalation.
33 of 134 21/08/07 22:07

r ight hand
ex aggerates
the exhalation
motion ( white
ar row, F ig.
10.68) of the
dy sfunctional
r ib.
6. T he patient
inhales again
( blac k arrow,
F ig. 10.69) as
the phys ician's
r ight hand F ig ure 10.70. Step 7, exagger ate
r esis ts (w hite ex halation.
ar row) the
inhalation
motion of the
dy sfunctional
r ib.
7. T he patient
ex hales, and
the phys ician
ex aggerates
the exhalation
motion ( white
ar row, F ig.
10.70) of the
dy sfunctional
r ib.
8. 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.
9. Motion of the
dy sfunctional
r ib is
r eevaluated to
as ses s the
effec tiv enes s
of the
technique.
P.2 05
34 of 134 21/08/07 22:07

C ostal R egion: Right Ribs 7 to 10, Inhala tion D y sfunction:

s upine, and the
physician
s tands at the
s ide of the
dy sfunctional
r ib.
2. T he patient's
upper body is
bent to the side
of the
dy sfunction
( r ight s ide) until
tension is taken F ig ure 10.71. Steps 1 to 3.
off the
dy sfunctional
r ib.
3. T he web
formed by the
physician's
r ight thumb and
index finger is
placed in the
inter cos tal
s pace on the
s uper ior
s urface of the
dy sfunctional F ig ure 10.72. Step 4, exagger ate
r ib ( Fig . ex halation.
10.71).
4. T he patient
inhales and
ex hales deeply
as the
physician's
r ight hand
ex aggerates
( white arrow,
F ig. 10.72) the
ex halation
motion of the
dy sfunctional
r ib. F ig ure 10.73. Step 5, r esist inhalation.
5. O n inhalation
( blac k arrow,
35 of 134 21/08/07 22:07

F ig. 10.73) the

physician's
r ight hand
r esis ts (w hite
ar row) the
inhalation
motion of the
dy sfunctional
r ib.
6. T he patient
ex hales and the
physician
ex aggerates
the exhalation F ig ure 10.74. Step 6, exagger ate
motion ( white ex halation.
ar row, F ig.
10.74) of the
dy sfunctional
r ib.
7. Steps 5 and 6
ar e r epeated
five to sev en
times or until
motion is
maximally
improved at the
dy sfunctional
r ib.
8. Motion of the
dy sfunctional
r ib is
r eevaluated to
as ses s the
effec tiv enes s
of the
technique.
P.2 06
C ostal R egion: Right Ribs 1 1 and 1 2, Inha lation Dys function:

36 of 134 21/08/07 22:07

pr one, and the
physician
s tands at the
left side of the
table and
positions the
patient's legs
15 to 20
degrees to the
r ight, taking
tension off the
quadr atus
lumborum. F ig ure 10.75. Steps 1 to 3.
2. T he phys ician
places the left
hy pothenar
eminence
medial and
infer ior to the
angle of the
dy sfunctional
r ib and exer ts
gentle,
s ustained
later al and
c ephalad
tr action. F ig ure 10.76. Step 5, exagger ate
3. T he phys ician ex halation.
may gras p the
patient's r ight
anter ior
s uper ior iliac
s pine with the
r ight hand to
s tabiliz e the
pelvis ( Fig .
10.75).
4. T he patient
inhales and
ex hales deeply.
5. During
ex halation the F ig ure 10.77. Step 6, r esist inhalation.
physician's left
hand
ex aggerates
( white arrow,
F ig. 10.76) the
37 of 134 21/08/07 22:07

P.2 07
C ostal R egion: Ana tom y of the Scalene Mus cle s
Anterio r
Scalene
Muscle
O rig in
T he origin
of the
anterior
s calene
musc le is at
transver se
proc ess es
C3 to C6
( Fig .
10.79).
Insertio n
T he
insertion of
the anterior
s calene
musc le is at
the scalene
tubercle,
s uperior
s urface of
the fir s t r ib.
Action
T he anterior
s calene
musc le
elev ates the
firs t r ib,
flex es
laterally,
and rotates
the nec k . F igure 10.79. Anatomy of the scalenes and thorac ic outlet ( 7).
Innervat ion
T he ventral
r ami of the
c erv ical
s pinal
nerv es
38 of 134 21/08/07 22:07

( C4- C6)
innervate
the anterior
s calene
musc le.
Midd le
Scalene
Muscle
O rig in
T he origin
of the
middle
s calene
musc le is at
transver se
proc ess es
C1 to C6.
Insertio n
T he
insertion
point of the
middle
s calene
musc le is at
the superior
s urface of
firs t r ib
posterior to
the
s ubc lav ian
artery.
Action
T he middle
s calene
musc le
elev ates the
firs t r ib
during
forc ed
inspiration
and flex es
the nec k
laterally.
Innervat ion
39 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.
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
( C6–C8)
innervate
the
posterior
s calene
musc le.
P.2 08
C ostal R egion: Right Ribs 1 and 2, Ex hala tion D y sfunction:

C ontrac tion of Sc a lene Musc les Mobilizes Dys func tional Ribs
s upine, and the
physician
s tands on the
left side of the
patient.
2. T he patient's
head is rotated
approximately
30 degrees to
the left.
3. T he patient's
r ight wr ist
( dors al F igure 10.80. Steps 1 to 3.
s urface) is
placed against
the forehead
( F ig. 10.80) .
left hand
r eaches under
the patient,
gr asps the
s uper ior angle
of the r ight
dy sfunctional
r ib, and ex erts
a caudad and F igure 10.81. Step 4.
41 of 134 21/08/07 22:07

later al trac tion

( white arrow,
F ig. 10.81) .
5. T he patient
flexes the head
and neck
( blac k arrow,
F ig. 10.82)
without altering
the r otation of
the head while
the phys ician's
r ight hand
applies an F igure 10.82. Step 5, isometric
unyielding c ontr action.
c ounterforc e
( white arrow).
6. T his isometr ic
c ontr action is
maintained for 3
to 5 sec onds ,
and the patient
is instr ucted to
relax.
7. O nce the
patient has
c ompletely
r elax ed, the
physician's left F igure 10.83. Step 7.
hand exerts
increased
c audad and
later al trac tion
on the angle of
the
dy sfunctional
r ib ( white
ar row, F ig.
10.83).
r epeated fiv e to
s even times or
until motion is
maximally
improved at the
dy sfunctional
r ib.
9. Motion of the
dy sfunctional
42 of 134 21/08/07 22:07

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

O rig in
T he origin
of the
pectoralis
minor
musc le is at
the anterior
s uperior
s urface of
r ibs 3, 4,
and 5 ( F ig.
10.84).
Insertio n
T he
insertion of
the
pectoralis
minor
musc le is at
the
c oracoid
proc ess of
s capula.
Action
T he
pectoralis
minor
musc le
s tabiliz es
s capula by
drawing it
inferior ly
and
anterior ly
against
thor acic
wall.
F igure 10.84. Pectoralis minor musc le ( 7).
Innervat ion
T he medial
pectoral
nerv e ( C8,
T 1)
innervates
the
pectoralis
44 of 134 21/08/07 22:07

P.2 10
C ostal R egion: Right Rib 3, 4, or 5, Exha lation Dys function:

C ontrac tion of Pe c tor alis Minor Mobilizes Dy sfunctiona l R ibs
s upine and the
physician
s tands on the
left side of the
table.
2. T he patient
r aises the r ight
ar m and plac e
the hand ov er
the head (F ig.
10.85).
left hand F ig ure 10.85. Steps 1 and 2.
r eaches under
the r ight s ide of
the patient,
gr asps the
s uper ior angle
of the
dy sfunctional
r ib, and ex erts
c audad and
later al trac tion.
r ight hand is
placed over the
anter ior as pect F ig ure 10.86. Steps 3 and 4.
of the patient's
r ight shoulder
at the level of
the c oracoid
pr ocess (F ig .
10.86).
5. T he patient
pr otr acts the
s houlder by
pushing
forward against
the phys ician's
r ight hand
( blac k arrow, F ig ure 10.87. Step 5, isometr ic
F ig. 10.87) , c ontraction.
45 of 134 21/08/07 22:07

which is
apply ing an
unyielding
c ounterforc e
( white arrow).
6. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
st op and
relax.
7. O nce the F ig ure 10.88. Step 7.
patient has
c ompletely
r elax ed, the
physician's left
hand exerts
increased
c audad and
later al trac tion
on the angle of
the
dy sfunctional
r ib ( white
ar row, F ig.
10.88).
8. Steps 5 to 7
ar e r epeated
five to sev en
times or until
motion is
maximally
improved at the
dy sfunctional
r ib.
9. Motion of the
dy sfunctional
r ib is
r eevaluated to
as ses s the
effec tiv enes s
of the
technique.
P.2 11
C ostal R egion: Right Rib 3, 4 or 5 , Ex halation D ysfunc tion:
46 of 134 21/08/07 22:07

C ontrac tion of Pe c tor alis Minor Mobilizes Dy sfunctiona l R ibs
s upine, and the
physician
s tands on the
left side of the
table.
2. T he patient
r aises the r ight
ar m and plac e
the hand ov er
the head (F ig.
10.89).
left hand F ig ure 10.89. Steps 1 and 2.
r eaches under
the r ight s ide of
the patient,
gr asps the
s uper ior angle
of the
dy sfunctional
r ib and exer ts
c audad and
later al trac tion.
r ight hand is
placed over the
anter ior as pect F ig ure 10.90. Steps 3 and 4.
of the patient's
r ight elbow
( F ig. 10.90) .
5. T he patient
pushes the
elbow agains t
the phys icians
r ight hand
( blac k arrow,
F ig. 10.91) ,
which is
apply ing an
unyielding
c ounterforc e F ig ure 10.91. Step 5, isometr ic
( white arrow). c ontraction.
6. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
47 of 134 21/08/07 22:07

then the patient

is instr ucted to
st op and
relax.
7. O nce the
patient has
c ompletely
r elax ed, the
physician's left
hand exerts
increased
c audad and
later al trac tion
on the angle of F ig ure 10.92. Step 7.
the
dy sfunctional
r ib ( white
ar row, F ig.
10.92).
8. Steps 5 to 7
ar e r epeated
five to sev en
times or until
motion is
maximally
improved at the
dy sfunctional
r ib.
9. Motion of the
dy sfunctional
r ib is
r eevaluated to
as ses s the
effec tiv enes s
of the
technique.
P.2 12
C ostal R egion: Se r ratus Ante rior Musc le
48 of 134 21/08/07 22:07

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

C ostal R egion: Right Rib 6, 7, or 8, Exha lation Dys function:

C ontrac tion of Se r ratus Ante rior Mobilize s D ysfunctional R ibs
s upine and the
physician
s tands or s its
at the s ide of
the
dy sfunctional
r ib.
2. T he patient's
r ight shoulder
is flexed 90
degrees; the
elbow may be
flexed for F ig ure 10.94. Steps 1 to 3.
better c ontr ol
by the
physician.
3. T he phys ician
r eaches the
r ight hand
under the
patient and
gr asps the
s uper ior angle
of the
dy sfunctional
r ib, exerting
c audad and F ig ure 10.95. Step 4, isometr ic
later al trac tion c ontraction.
( white arrow,
F ig. 10.94) .
4. T he patient
pushes the
elbow towar d
the c eiling
( s capular
pr otr action)
( blac k arrow,
F ig. 10.95)
while the
physician
applies an
unyielding F ig ure 10.96. Step 6.
c ounterforc e
( white arrow).
50 of 134 21/08/07 22:07

5. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
st op and
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician's
r ight hand
ex erts
increased
c audad and
later al trac tion
( white arrow,
F ig. 10.96) on
the angle of the
dy sfunctional
r ib.
7. Steps 5 to 7
ar e r epeated
five to sev en
times or until
motion is
maximally
improved at the
dy sfunctional
r ib.
8. Motion of the
dy sfunctional
r ib is
r eevaluated to
as ses s the
effec tiv enes s
of the
technique.
P.2 14
C ostal R egion: La tiss imus D orsi Muscle
51 of 134 21/08/07 22:07

O rig in
T he origin of
the latissimus
dors i muscle
is at s pinous
proc ess es of
T 7 to S3, the
thor acolumbar
fasc ia, the
inferior angle
of s capula,
the lower four
r ibs , and the
iliac c r est
( Fig . 10.97).
Insertio n
T he ins ertion
of the
latissimus
dors i muscle
is at the
intertuberc ular
( bic ipital)
groove of the
humerus .
Action
T he latissimus
dors i muscle
extends ,
adducts , and
medially
r otates the
humerus .
Innervat ion
T he
thor acodors al
nerv e
( C6–C8)
innervates the
latissimus
dors i muscle.
52 of 134 21/08/07 22:07

P.2 15
C ostal R egion: Right Ribs 9 and 10 , Ex halation D ysfunc tion:

C ontrac tion of La tiss imus D orsi Mobilizes Dy sfunctiona l R ibs
s upine, and the
physician
s tands or s its
at the s ide of
the
dy sfunctional
r ib.
left hand
abduc ts the
patient's r ight
s houlder 90
degrees, and Fig ure 10.98. Step 3.
the r ight hand
r eaches under
the patient and
gr asps the
s uper ior angle
of the
dy sfunctional
r ib, exerting
c audad and
later al trac tion.
left lateral thigh
or knee is
placed against Fig ure 10.99. Step 4.
the patient's
r ight elbow
( F ig. 10.98) .
4. T he patient
pushes the r ight
ar m into the
physician's
thigh (blac k
ar row, F ig.
10.99) while the
physician's left
thigh and/or
ar m applies an
unyielding Fig ure 10.100. Step 6.
c ounterforc e
53 of 134 21/08/07 22:07

( white arrow).
5. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
st op and relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician's
r ight hand
ex erts
increased
c audad and
later al trac tion
( white arrow,
F ig. 10.100) on
the angle of the
dy sfunctional
r ib.
r epeated fiv e to
s even times or
until motion is
maximally
improved at the
dy sfunctional
r ib.
8. Motion of the
dy sfunctional
r ib is
r eevaluated to
as ses s the
effec tiv enes s of
the technique.
P.2 16
C ostal R egion: Qua dra tus Lum bor um Mus c le
54 of 134 21/08/07 22:07

O rig in
T he origin
of the
quadratus
lumborum
musc le is at
the iliac
c res t and
the
iliolumbar
ligament
( Fig .
10.101) .
Insertio n
T he
insertion of
the
quadratus
lumborum
musc le is at
the inferior
aspect of
the 12th rib
and the
transver se
proc ess es
of L1 to L4.
Action
T he
quadratus
lumborum F igure 10.101. Quadratus lumborum ( 7).
musc le
extends and
laterally
flex es the
v ertebr al
c olumn; it
also fix es
the 12th rib
during
inhalation.
Innervat ion
T he ventral
branches of
T 12 to L4
55 of 134 21/08/07 22:07

P.2 17
C ostal R egion: Right Ribs 1 1 and 1 2, Exha lation Dys function:

C ontrac tion of Qua dra tus Lum bor um Mobilizes Dys func tional Ribs
pr one and the
physician
s tands at the left
s ide of the table
and positions
the patient's
legs 15 to 20
degrees to the
left, putting
tension on the
quadr atus
lumborum.
2. T he phys ician's F ig ure 10.102. Steps 1 to 3.
left thenar
eminence or
index finger is
placed s uper ior
and lateral to the
angle of the
dy sfunctional r ib
and exer ts
gentle s ustained
medial and
c audad trac tion
( left-pointing
white ar row,
F ig. 10.102) . F ig ure 10.103. Step 5, isometric
3. T he phys ician's c ontraction and exagger ate inhalation.
r ight hand
gr asps the
patient's r ight
anter ior superior
iliac spine
( ASIS) and
gently lifts
towar d the
c eiling
( upward- pointing
white ar row,
F ig. 10.102) .
4. T he patient
inhales, F ig ure 10.104. Step 7.
56 of 134 21/08/07 22:07

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

ex erts
increased
c audad and
later al trac tion
on the angle of
the
dy sfunctional r ib
( left-pointing
white ar row,
F ig. 10.104) .
r epeated fiv e to
s even times or
until motion is
maximally
improved at the
dy sfunctional
r ib.
9. Motion of the
dy sfunctional r ib
is reevaluated to
as ses s the
effec tiv enes s of
the technique.
P.2 18
P.2 19
C ostal R egion: Right Ribs 1 1 and 1 2, Exha lation Dys function:

pr one and the
physician
s tands at the left
s ide of the table.
T he patient's
legs are
positioned 15 to
20 degrees to
the left, putting
tension on the
quadr atus
lumborum.
58 of 134 21/08/07 22:07

2. T he phys ician F ig ure 10.105. Steps 1 to 3.

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.
r ight hand
gr asps the F ig ure 10.106. Step 5, exaggerate
patient's r ight inhalation.
ASIS and gently
lifts towar d the
c eiling (F ig .
10.105).
4. T he patient
inhales,
ex hales, and
then inhales
deeply.
5. During
inhalation, the
physician's left
hand
ex aggerates the F ig ure 10.107. Step 6, res ist ex halation.
inhalation motion
of the
dy sfunctional r ib
by ex erting
medial and
c audad trac tion
( left-pointing
white ar row,
F ig. 10.106) as
the r ight hand
gently lifts the
patient's r ight
anter ior superior
iliac spine
( upward- pointing
white ar row)
towar d the
c eiling.
6. O n ex halation
59 of 134 21/08/07 22:07

( blac k arrow,
F ig. 10.107) the
physician's left
hand res ists
( white arrow)
the exhalation
motion of the r ib.
7. Steps 5 and 6
ar e r epeated
five to sev en
times or until
motion is
maximally
improved at the
dy sfunctional
r ib.
8. Motion of the
dy sfunctional r ib
is reevaluated to
as ses s the
effec tiv enes s of
the technique.
P.2 20
P.2 21
Lumbar R egion: Ty pe I Dy sfunction Exa m ple : L2 N SLRR Post

1. T he patient is
s eated at the
end of the table.
T he phys ician
s tands to the
s ide opposite
the r otational
c omponent of
the dysfunc tion.
2. T he patient
places the r ight
hand behind the
neck and the
left hand on the F igu re 10.108. Steps 1 to 3.
r ight elbow.
60 of 134 21/08/07 22:07

3. T he phys ician
passes the left
ar m under the
patient's left
ar m and gras ps
the patient's
r ight upper arm
( F ig. 10.108).
r ight hand
monitors the
s pinous
pr ocesses of
L2 and L3 or F igu re 10.109. Step 4, L2-L3 neutr al.
the L2-L3
inter space as
the left ar m and
hand flex and
ex tend the
patient's torso
( white arrow,
F ig. 10.109)
until L2 is
neutr al in
r elation to L3.
r ight hand
monitors the F igu re 10.110. Step 5, r ight s ide- bending
tr ans ver se barr ier .
pr ocesses of
L2 and L3 to
localize side
bending and
r otation as the
left arm and
hand pos ition
the patient's
torso to the
edge of the
r ight side
bending (w hite
ar row, F ig.
10.110), and F igu re 10.111. Step 5, left rotation bar r ier .
then left
r otation bar rier
( white arrow,
F ig. 10.111) .
6. T he patient
turns or pulls
61 of 134 21/08/07 22:07

the r ight
s houlder bac k
to the r ight
( blac k arrow,
F ig. 10.112)
while the
physician's left
hand applies an
unyielding
c ounterforc e
( white arrow).
7. T his isometr ic
c ontr action is
maintained for 3 F igu re 10.112. Step 6, isometr ic
to 5 sec onds , c ontrac tion.
and then the
patient is
instr ucted to
st op and relax.
8. O nce the
patient has
c ompletely
r elax ed, the
physician,
k eeping L2
neutr al,
r epos itions the
patient to the
edge of the F igu re 10.113. Step 8, r ight s ide- bending
r ight barr ier .
s ide- bending
barrier (w hite
ar row, F ig.
10.113) and left
r otation bar rier
( white arrow,
F ig. 10.114) .
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional F igu re 10.114. Step 8, left rotation bar r ier .
s egment.
10. Motion of the
dy sfunctional
s egment is
r eevaluated to
62 of 134 21/08/07 22:07

as ses s the
effec tiv enes s of
the technique.
P.2 22
P.2 23
Lumbar R egion: Ty pe II D ysfunction Ex a mple: L2 ERRSR Post

1. T he patient is
s eated and the
physician
s tands to the
left of the
patient (side
oppos ite the
r otational
c omponent of
the
dy sfunction) .
2. T he patient
places the r ight
hand behind the F igu re 10.115. Steps 1 to 3.
neck and the
left hand on the
r ight elbow.
( Variation: the
patient may
place the hands
behind the neck
and
approximate the
elbows
anter ior ly.)
3. T he phys ician
passes the left
ar m over or F igu re 10.116. Step 4, flex ion bar rier.
under the
patient's left
ar m and gras ps
the patient's
r ight upper arm
( F ig. 10.115).
63 of 134 21/08/07 22:07

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 F igu re 10.117. Step 5, left side-bending
tr unk to the barr ier .
edge of the
r estr ictive
flexion bar r ier
( F ig. 10.116).
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 F igu re 10.118. Step 5, left rotation bar r ier .
hand
r epos itions the
patient's tr unk
to the edge of
the left
s ide- bending
barrier (F ig .
10.117) and left
r otation bar rier
( F ig. 10.118).
6. T he patient
tr ies to sit up
and gently pull
the r ight F igu re 10.119. Step 6, isometr ic
s houlder c ontrac tion.
backward
( blac k arrow,
F ig. 10.119)
while the
physician's left
64 of 134 21/08/07 22:07

hand applies an
unyielding
c ounterforc e
( white arrow).
7. 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.
8. O nce the
patient has F igu re 10.120. Step 8, left side-bending
c ompletely barr ier .
r elax ed, the
physician
r epos itions the
patient (w hite
ar rows, Fig .
10.120) to the
edge of the left
s ide bending,
left rotation
( F ig. 10.121),
and flex ion
barrier (F ig .
10.122).
9. Steps 6 to 8 ar e F igu re 10.121. Step 8, left rotation bar r ier .
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
s egment.
10. 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 10.122. Step 8, flex ion bar rier.
P.2 24
P.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

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. F igure 10.123. Steps 1 to 3.
c audad hand or
thigh contr ols
the patient's
flexed k nees
and hips while
the c ephalad
hand palpates
the L4 and L5
s pinous
pr ocesses or
the L4-L5
inter space.
3. T he phys ician's F igure 10.124. Step 4.
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 10.125. Step 5.
10.123).
4. T he patient's
left leg is
lower ed off the
edge of the
66 of 134 21/08/07 22:07

table, c aus ing

anter ior rotation
of the pelv is,
u n til the
physician's
c ephalad hand
detec ts motion
at the
dy sfunctional
s egment (F ig .
10.124).
5. Switc hing
hands , the
physician us es F igure 10.126. Step 6, is ometric
the c ephalad c ontr action.
hand to gently
move the
patient's
s houlder
posteriorly
( white arrow,
F ig. 10.125)
u n til the
c audad hand
detec ts motion
at the
dy sfunctional
s egment.
6. T he patient F igure 10.127. Step 8.
g ently pushes
the s houlder
forward (b lack
ar row, F ig.
10.126) against
the unyielding
c ounterforc e of
the phys ician's
c ephalad hand
( white arrow).
7. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and F igure 10.128. Step 9, is ometric
then the patient c ontr action.
is told to stop
an d relax.
8. O nce the
patient has
c ompletely
67 of 134 21/08/07 22:07

r elax ed, the

physician gently
moves the
patient's
s houlder
posteriorly
( white arrow,
F ig. 10.127) ,
r otating the
thoracic and
lumbar s pine to
the edge of the
new r estric tive
barrier. F igure 10.129. Step 11.
9. T he patient
g ently pulls the
hip and pelv is
c ephalad up
towar d the
s houlder (black
ar row, F ig.
10.128) against
the unyielding
c ounterforc e of
the phys ician's
c audad hand
( white arrow).
10. 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.
11. O nce the
patient has
c ompletely
r elax ed, the
physician gently
moves the
patient's pelvis
c audad ( white
ar row, F ig.
10.129) to the
edge of the new
r estr ictive
barrier.
12. Steps 6 to 11
ar e r epeated
68 of 134 21/08/07 22:07

three to fiv e
times or until
motion is
maximally
improved at the
dy sfunctional
s egment
( L4-L5).
13. Steps 6, 7, 9,
and 10 may be
performed
s imultaneous ly,
after which the
physician
r epos itions the
patient to the
edge of the new
r estr ictive
barriers .
14. Motion of the
dy sfunctional
s egment is
r eevaluated to
as ses s the
effec tiv enes s of
the technique.
P.2 26
P.2 27
Lumbar R egion: Ty pe II D ysfunction Ex a mple: L4 E/FSRRR Pos t

69 of 134 21/08/07 22:07

on the s ide of
the r otational
c omponent, and
the phys ician
s tands facing
the patient.
c audad hand or
thigh contr ols
the patient's
flexed k nees
and hips while
the c ephalad F igure 10.130. Steps 1 to 3.
hand palpates
the L4 and L5
s pinous
pr ocesses or
the L4-L5
inter space.
c audad hand or
thigh gently
flexes and
ex tends the
patient's hips
until the
physician's F igure 10.131. Step 4.
c ephalad hand
deter mines the
dy sfunctional
s egment
( L4-L5) to be
positioned in
neutr al (F ig .
10.130).
c audad hand
places the
patient's left
foot behind the
r ight knee in the F igure 10.132. Step 5.
popliteal fossa
( F ig. 10.131).
5. Switc hing
hands , the
physician us es
the c ephalad
70 of 134 21/08/07 22:07

P.2 28
Pelv ic R egion: Right Pos ter ior Innominate Dy sfunction: Com bined
R eciproc al Inhibition and Muscle C ontr action Mobilize Articulation
Diag nosis
Standing flexion test:
Positiv e (r ight
posterior s uperior
iliac s pine [PSIS]
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
ASIS: Cephalad
( slightly lateral) on
the right
PSIS: Caudad
( slightly medial) on F igure 10.137. Steps 1 to 3.
the right
Sacr al s ulc us:
Anterior , deep on the
r ight
T ech niq u e
s upine on a
diagonal, s o the
r ight sacroiliac
joint is off the
edge of the
table. F igure 10.138. Step 4.
2. T he phys ician
s tands at the
r ight side of the
table.
c ephalad hand
is placed ov er
the patient's left
ASIS to prev ent
the patient from
r olling off the
table. T he
c audad hand is
placed distal to F igure 10.139. Step 5, is ometric
the patient's c ontr action.
71 of 134 21/08/07 22:07

k nee (F ig.
10.137).
c audad ( right)
hand pas siv ely
ex tends the
patient's r ight
hip ( white
ar row, F ig.
10.138),
br inging the
innominate into
anter ior
r otation, until F igure 10.140. Step 7.
the edge of the
r estr ictive
barrier is
r eached.
5. T he patient lifts
the r ight leg
( blac k arrow,
F ig. 10.139)
towar d the
c eiling while the
physician
applies an
equal
c ounterforc e
( white arrow).
6. 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.
7. O nce the
patient has
c ompletely
r elax ed, the
physician
ex tends the
patient's r ight
hip ( white
ar row, F ig.
10.140) to the
edge of the new
72 of 134 21/08/07 22:07

r estr ictive
barrier.
r epeated thr ee
to five times.
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 29
Diag nosis
Positiv e (r ight PSIS
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
ASIS: Cephalad
the right
PSIS: Caudad
( slightly medial) on
the right
Sacr al s ulc us: F igure 10.141. Step 1.
r ight
T ech niq u e
1. T he patient is
placed in a left
later al modified
Sims pos ition:
left lateral
r ecumbent, with
73 of 134 21/08/07 22:07

the anterior
thorax r esting
on the table and
ar ms hanging
ov er the side of
the table ( F ig.
10.141).
2. T he phys ician
s tands behind
the patient,
gr asps the
patient's r ight
leg with the
c audad ( right) F igure 10.142. Steps 2 and 3.
hand, and
places the
hy pothenar
eminence of the
c ephalad hand
on the patient's
r ight PSIS.
c audad hand
passively
ex tends the
patient's r ight
hip ( white
ar row, F ig. F igure 10.143. Step 4, is ometric
10.142), c ontr action.
br inging the
innominate into
anter ior
r otation, until
the edge of the
r estr ictive
barrier is
r eached.
4. T he patient
pulls the r ight
leg forward
( blac k arrow,
F ig. 10.143)
while the F igure 10.144. Step 6.
physician
applies an
equal
c ounterforc e
( white arrow).
5. T his isometr ic
74 of 134 21/08/07 22:07

c ontr action is
maintained for 3
to 5 sec onds ,
and then the
patient is
instr ucted to
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
ex tends the
patient's r ight
hip ( white
ar row, F ig.
10.144) to the
edge of the new
r estr ictive
barrier.
r epeated thr ee
to five times.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 30
75 of 134 21/08/07 22:07

Diag nosis
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
ASIS: Cephalad
the right
PSIS: Caudad
the right
Sacr al s ulc us: F igure 10.145. Steps 1 and 2.
r ight
T ech niq u e
pr one and the
physician
s tands on the
left side of the
table.
2. T he hypothenar
eminence of the
physician's F igure 10.146. Step 3.
c ephalad (left)
hand is plac ed
on the patient's
r ight PSIS and
the phys ician's
c audad ( right)
hand grasps
the patient's
r ight leg distal
to the tibial
tuber osity ( Fig .
10.145).
c audad ( right) F igure 10.147. Step 4, is ometric
hand pas siv ely c ontr action.
ex tends the
patient's r ight
hip ( white
ar row, F ig.
10.146),
76 of 134 21/08/07 22:07

P.2 31
PELVIC R EGION: Right Anterior Innomina te Dys func tion:

C ombine d Re ciproc a l Inhibition and Mus cle Contr a ction Mobilize
A rticula tion
Diag nosis
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
PSIS: Cephalad
the right
ASIS: Caudad
the right
Posterior, shallow on
the right
T ech niq u e
s upine, and the
physician is
s eated on the
table facing the
patient.
2. T he phys ician
places the
patient's r ight F igure 10.150. Step 3, alter native.
heel on the
r ight shoulder
and pass ively
flexes the
patient's r ight
hip and knee
( white arrow,
F ig. 10.149)
until the edge of
the r estric tive
barrier is
r eached.
3. An ac ceptable
modification is F igure 10.151. Step 4, is ometric
77 of 134 21/08/07 22:07

to have the c ontr action.

patient's r ight
k nee loc ked in
full extens ion
and the leg
flexed at the hip
with the
patient's r ight
leg on the
physician's
r ight shoulder
( F ig. 10.150).
4. T he patient
pushes the
k nee into the F igure 10.152. Step 6.
physician's
hands ,
ex tending the
r ight hip ( blac k
ar row, F ig.
10.151), while
the phys ician
applies an
equal
c ounterforc e
( white arrow).
5. T his isometr ic
c ontr action is
maintained for 3
to 5 sec onds ,
and then the
patient is
instr ucted to
st op and
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
flexes the
patient's r ight
hip ( white
ar row, F ig.
10.152) to the
edge of the new
r estr ictive
barrier.
78 of 134 21/08/07 22:07

r epeated thr ee
to five times.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 32
Pelv ic R egion: Right Anterior Innomina te Dys func tion: Com bine d
Diag nosis
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
PSIS: Cephalad
the right
ASIS: Caudad
the right
Posterior on the r ight
T ech niq u e
in the left lateral
r ecumbent
position, and
the phys ician
s tands at the
s ide of the table
facing the
patient.
2. T he phys ician's F igure 10.154. Step 3.
79 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. F igure 10.155. Step 4, is ometric
10.153). c ontr action.
3. Supporting the
patient's r ight
k nee, the
physician's
c ephalad hand
flexes the
patient's r ight
hip, bringing the
innominate into
posterior
r otation until
the edge of the
r estr ictive
barrier is F igure 10.156. Step 6.
r eached (w hite
ar row, F ig.
10.154).
4. T he patient
pushes the
r ight foot into
the phys ician's
thigh (blac k
ar row, F ig.
10.155) while
the phys ician
applies an
equal
c ounterforc e
( white arrow).
5. T his isometr ic
c ontr action is
maintained for 3
to 5 sec onds ,
and then the
80 of 134 21/08/07 22:07

patient is
instr ucted to
st op and
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
flexes the r ight
hip innominate
to the edge of
the new
r estr ictive
barrier (w hite
ar row, F ig.
10.156).
r epeated thr ee
to five times.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 33
Pelv ic R egion: Anterior Innominate Dy s function: Com bined

81 of 134 21/08/07 22:07

Diag nosis
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
PSIS: Cephalad
the right
ASIS: Caudad
the right
Posterior on the r ight
T ech niq u e
pr one on a
diagonal, s o the
r ight innominate
is off the edge
of the table.
T he phys ician
s tands at the
r ight side of the
table facing the F igure 10.158. Step 3.
patient's pelvis.
left hand
s tabiliz es the
patient's pelvis
and s acr um,
and the
physician's
r ight hand,
s upporting the
patient's r ight
leg, places the
patient's r ight
foot agains t the F igure 10.159. Step 4, is ometric
physician's c ontr action.
r ight thigh or
tibia (F ig.
10.157).
3. T he phys ician
flexes the
82 of 134 21/08/07 22:07

P.2 34
Pelv ic R egion: Right Superior Iliosac r al She ar
Diag nosis
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 Fig ure 10.161. Steps 1 and 2.
ligament tension: Lax
T ech niq u e
either prone or
s upine with both
feet off the end
of the table.
2. T he phys ician
s tands at the
foot of the table
and gras ps the
patient's r ight Fig ure 10.162. Step 3.
tibia and fibula
above the ankle
( F ig. 10.161).
3. T he phys ician
inter nally
r otates the right
leg to
c lose-pack the
hip joint, lock ing
the femoral
head into the
ac etabulum
( c urv ed white
ar row, F ig. Fig ure 10.163. Step 4.
10.162).
4. T he phys ician
83 of 134 21/08/07 22:07

abduc ts the
patient's r ight
leg 5 to 10
degrees to take
tension off the
r ight sacroiliac
ligament (F ig.
10.163).
5. T he phys ician
gently leans
back,
maintaining
ax ial tr action on
r ight leg ( white
ar row), and
instr ucts the
patient to inhale
and exhale
( F ig. 10.164).
6. With eac h
ex halation the
tr actional forc e
is increased.
7. T his inhalation,
ex halation,
tr action cy c le is
r epeated fiv e to
s even times .
8. With the las t
ex halation, the
patient may be
instr ucted to
c ough as the
physician
s imultaneous ly
tugs on the leg.
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine the
effec tiv enes s of
the technique.
P.2 35
Pelv ic R egion: Right Outfla r e Innomina te Dys func tion: Pos t

84 of 134 21/08/07 22:07

Diag nosis
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 F igure 10.165. Steps 1 to 3.
s upine, and the
physician
s tands at the
left side of the
table.
2. T he patient's
r ight hip and
k nee are flexed
to about 90
degrees, and
the r ight foot is
later al to the F igure 10.166. Step 4.
left knee.
c ephalad (r ight)
hand is plac ed
under the
patient's r ight
innominate,
gr asping the
medial aspec t
of the r ight
PSIS (F ig.
10.165).
4. T he phys ician
c ephalad (left) F igure 10.167. Step 5, is ometric
hand adducts c ontr action.
the patient's
r ight knee
( white arrow,
F ig. 10.166)
until the edge of
85 of 134 21/08/07 22:07

P.2 36
Pelv ic R egion: Right Inflar e Innom ina te D ysfunc tion: Post

Diag nosis
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 F ig ure 10.169. Steps 1 to 3.
s upine and the
physician
s tands at the
left side of the
table.
2. T he patient's
r ight hip and
k nee are
flexed, and the
r ight foot is on
the lateral
as pec t of the F ig ure 10.170. Step 4.
left knee.
c ephalad hand
is placed on the
patient's left
ASIS (F ig.
10.169).
c audad hand is
placed on the
patient's r ight
k nee and the
r ight hip is
ex ter nally F ig ure 10.171. Step 5, isometric
r otated (w hite c ontraction.
86 of 134 21/08/07 22:07

ar row, F ig.
10.170) until
the edge of the
r estr ictive
barrier is
r eached.
the r ight k nee
towar d the
c eiling (b lack
ar row, F ig.
10.171) while
the phys ician
applies an F ig ure 10.172. Step 7.
equal
c ounterforc e
( white arrow).
6. T his isometr ic
c ontr action is
maintained for
3 to 5 s econds,
and then the
patient is
instr ucted to
relax.
7. O nce the
patient has
c ompletely
r elax ed, the
physician
further
ex ter nally
r otates the hip
( white arrow,
F ig. 10.172) to
the edge of the
new r estric tive
barrier.
8. Steps 5 to 7
ar e r epeated
three to fiv e
times .
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s
87 of 134 21/08/07 22:07

of the
technique.
P.2 37
Pelv ic R egion: Right Superior Pubic Shear Dy sfunction: Mus cle

C ontrac tion Mobilizes Ar tic ulation
Diag nosis
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
Right pubic tuber c le
c ephalad (F ig.
10.173)
T ech niq u e
1. Patient lies
s upine, right F ig ure 10.173. Right s uper ior pubic shear
s ide close to dy s function.
the edge of the
table, and the
physician
s tands at the
r ight side
facing the
patient.
left hand is
placed on the
patient's left
ASIS to
s tabiliz e the
pelvis, and the
F ig ure 10.174. Steps 1 to 3.
r ight hand
abduc ts the
patient's r ight
leg, allowing it
to dr op of the
edge of the
88 of 134 21/08/07 22:07

table.
3. T he phys ician
places the r ight
hand jus t
pr oximal to the
patient's r ight
k nee and gently
pr ess es down
( white arrow,
F ig. 10.174) on
the r ight k nee
until the edge
of the
r estr ictive F ig ure 10.175. Step 4, isometric
barrier is c ontraction.
r eached.
the r ight k nee
towar d the
c eiling and
s lightly medially
( blac k arrow,
F ig. 10.175)
while the
physician
applies an
equal
c ounterforc e
( white arrow). F ig ure 10.176. Step 6.
5. T his isometr ic
c ontr action is
maintained for
3 to 5 s econds
after which the
patient is
instr ucted to
st op and
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
r epos itions the
patient's leg
further toward
the floor ( white
ar row, F ig.
10.176) to the
89 of 134 21/08/07 22:07

edge of the new

r estr ictive
barrier.
7. Steps 4 to 6
ar e r epeated
three to fiv e
times .
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s
of the
technique.
Note: A left infer ior

s hear looks
s tatically similar to a
r ight s uper ior shear
but will display loss
of s acr oiliac motion
on the left side and
s how a positiv e
s tanding flexion test
on the left.
P.2 38
P.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

Diag nosis
r ises)
Loss of pas siv ely
induced right
s acr oiliac motion
Pubic tuber cle on
r ight is caudad ( F ig.
10.177)
T ech niq u e
s upine c los e to F igure 10.177. Right inferior pubic shear
the left edge of dy sfunction.
the table, and
the phys ician
s tands on the
left fac ing the
patient.
r ight hand
flexes and
inter nally
r otates the
patient's r ight
hip as the
physician
places the left F igure 10.178. Steps 1 and 2.
thenar
eminence
beneath the
patient's r ight
is chial
tuber osity to
c r eate a
fulcr um (F ig .
10.178).
r ight hand
flexes the
patient's r ight
hip ( white F igure 10.179. Step 3.
ar row, F ig.
10.179) until
the edge of the
r estr ictive
91 of 134 21/08/07 22:07

P.2 40
PELVIC R EGION: Fix ed Com pre s sion of the Pubic Sy mphysis

(Adducte d Pubic B ones ): Mus c le Contra c tion Mobilize s
A rticula tion
Diag nosis
Suspicion of
dysfunc tion by
history (tr auma,
pregnanc y, deliver y)
Palpable bulging of
the symphys eal
c artilage
T ender pubic
s ymphys is
May hav e ur inary
trac t s y mptoms
( Fig . 10.182)
T ech niq u e F ig ure 10.182. F ixed c ompr ess ion of the

pubic symphy s is.
s upine and the
physician
s tands at either
s ide of the
table.
2. T he patient's
hips are flexed
to
approximately
45 degrees and
the k nees ar e
flexed to 90
degrees, with F ig ure 10.183. Steps 1 to 3.
the feet flat on
the table.
3. T he phys ician
s epar ates the
patient's k nees
and plac es the
forearm
between the
patient's k nees
( F ig. 10.183).
4. T he patient
pulls both
92 of 134 21/08/07 22:07

k nees medially
( adduct shown
by black
ar rows, Fig .
10.184) against
the phys ician's
palm and elbow
( white arrows)
while the
physician
applies an
equal
c ounterforc e.
5. T his isometr ic F ig ure 10.184. Step 4, isometric
c ontr action is c ontraction.
maintained for
3 to 5 s econds,
and then the
patient is
instr ucted to
st op and
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
patient's k nees
ar e s eparated
s lightly far ther F ig ure 10.185. Step 6.
fr om the midline
( white arrows,
F ig. 10.185) .
7. Steps 4 to 6
ar e r epeated
three to sev en
times .
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s
of the
technique.
P.2 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

Pubic B ones ): Mus c le Contra c tion Mobilize s A rtic ula tion
Diag nosis
Suspicion of
dysfunc tion by
history (tr auma,
pregnanc y, deliver y)
Sulc us deeper than
normal at the pubic
s ymphys is
T ender pubic
s ymphys is
May hav e ur inary
trac t s y mptoms
( Fig . 10.186)
T ech niq u e F igure 10.186. Fix ed gapping of the pubic

s y mphysis.
s upine, and the
physician
s tands beside
the table.
2. T he patient's
hips are flexed
to
approximately
45 degrees and
the k nees ar e
flexed to about
90 degrees,
with the feet flat F igure 10.187. Steps 1 to 4.
on the table.
3. T he patient's
k nees ar e
s epar ated by
approximately
18 inches.
4. T he k nee
c loser to the
physician is
placed against
the phys ician's
abdomen, and
the phys ician
gr asps the F igure 10.188. Step 5, is ometric
later al aspect c ontr actions .
of the other
k nee with both
94 of 134 21/08/07 22:07

hands (F ig.
10.187).
5. T he patient
pulls both
k nees later ally
( abduct shown
by black
ar rows, Fig .
10.188) against
the phys ician's
abdomen and
hands while the
physician
applies an F igure 10.189. Step 7.
equal
c ounterforc e
( white arrows) .
6. 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.
7. O nce the
patient has
c ompletely
r elax ed, the
physician
approximates
the patient's
k nee 3 to 4
inches ( white
ar rows, Fig .
10.189).
r epeated thr ee
to seven times.
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
95 of 134 21/08/07 22:07

P.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 .
10.190) .
Insertio n
T he ins ertion of
the psoas major
is at the less er
troc hanter of
femur.
Action
T he psoas
major flexes the F igure 10.190. Psoas major and psoas minor
thigh and trunk muscles (8) .
and flex es the
v ertebr al
c olumn
laterally.
Innervat ion
T he ventral
r ami of lumbar
nerv es ( L1 to
L3) innervate
the psoas
major.
Psoas Minor
O rig in
T he origin of
the psoas minor
is at the bodies
96 of 134 21/08/07 22:07

of 12th thorac ic
and fir s t lumbar
v ertebr ae ( Fig .
10.190) .
Insertio n
T he ins ertion of
the psoas minor
is at the iliac
fasc ia and the
iliopec tineal
eminenc e.
Action
T he psoas
minor helps the
psoas major
flex the pelvis
and lumbar
r egion of the
v ertebr al
c olumn.
Innervat ion
T he ventral
r amus of L1
innervates the
psoas minor .
P.2 43
Pelv ic R egion: Hip Re gion: Ilia cus Mus cle
97 of 134 21/08/07 22:07

O rig in
T he origin of the
iliacus mus cle
is at the iliac
foss a ( inner
s urface of iliac
bone) and the
lateral aspect of
the sac r um
( Fig . 10.191).
Insertio n
T he ins ertion of
the iliacus
musc le is at the
less er
troc hanter of
femur.
Action
T he iliacus
musc le flex es
the thigh at the
hip and
s tabiliz es the F igure 10.191. Iliacus muscle (8).
joint in
c onjunc tion with
the iliopsoas.
Innervat ion
T he femoral
nerv e ( L2 and
L3) innervates
the iliacus
musc le.
P.2 44
Pelv ic R egion: Hip Re gion: Psoa s Musc le, Acute D ysfunc tion:
98 of 134 21/08/07 22:07

1. Patient lies
s upine near the
end of the
tr eatment table
s o that the
dy sfunctional
leg may hang
ov er the end of
the table. T he
patient flex es
the other hip,
br inging the
k nee to the
c hest. T his F igure 10.192. Steps 1 and 2.
k eeps the
lumbar lordosis
flattened.
2. T he phys ician,
s tanding at the
end of the
table, plac es
the hands on
the patient's
dy sfunctional
thigh just
pr oximal to the
k nee (F ig.
10.192). F igure 10.193. Step 3.
3. T he phys ician
gently positions
the patient's
thigh towar d the
floor (white
ar row, F ig.
10.193),
ex tending the
hip to the edge
of the
r estr ictive
barrier.
4. T he patient
pushes the leg F igure 10.194. Step 4, is ometric
very gen tly c ontr action.
down toward
the floor ( blac k
ar row, F ig.
10.194) while
the phys ician
99 of 134 21/08/07 22:07

P.2 45
Pelv ic R egion: Hip Re gion: Psoa s Musc le, Subacute or C hronic

D ysfunc tion: Post Isometric Relaxa tion
pr one and the
physician
s tands beside
the table.
2. T he phys ician
flexes the
patient's k nee
on the s ide to
be tr eated 90
degrees and
then grasps the
patient's thigh
just above the F ig ure 10.196. Steps 1 to 3.
k nee.
c ephalad hand
is placed ov er
the patient's
s acrum to
s tabiliz e the
pelvis ( Fig .
10.196).
c audad hand
gently lifts the
patient's thigh
upwar d ( white F ig ure 10.197. Step 4.
ar row, F ig.
10.197) until
the psoas
muscle begins
to stretch,
engaging the
edge of the
r estr ictive
barrier.
5. T he patient
pulls the thigh
and k nee down
( blac k arrow,
F ig. 10.198) F ig ure 10.198. Step 5, isometric
into the c ontraction.
100 of 134 21/08/07 22:07

physician's
c audad hand,
which applies
an unyielding
c ounterforc e
( white arrow).
6. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
st op and
relax. F ig ure 10.199. Step 7.
7. O nce the
patient has
c ompletely
r elax ed, the
physician
ex tends the
patient's hip to
the edge of the
new r estric tive
barrier (w hite
ar row, F ig.
10.199).
8. 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.
9. Success of the
technique is
deter mined by
r eevaluating
passive hip
ex tension.
P.2 46
Pelv ic R egion: Pir iformis Muscle
101 of 134 21/08/07 22:07

O rig in
T he origin of
the pir ifor mis
musc le is at
the anterior
s urface of the
s acr um and the
s uperior
margin of
greater
ischiadic
( sciatic ) notc h
( Fig . 10.200).
Insertio n
T he ins ertion
of the
pirifor mis F igure 10.200. Anterior v iew of pir ifor mis
musc le is at muscle (8).
the greater
troc hanter of
the femur.
Action
T he pir ifor mis
musc le r otates
the thigh
laterally and
abducts it, and
it assis ts in
holding the
femoral head in
the acetabulum
( Fig . 10.201).
F igure 10.201. Posterior v iew of pir iformis

muscle (8).
P.2 47
Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , A c ute Dy sfunction:
102 of 134 21/08/07 22:07

pr one and the
physician
s tands beside
the table.
2. T he phys ician
palpates the
dy sfunctional
piriformis
muscle with the
c ephalad hand,
gr asps the
patient's ankle
with the caudad F igure 10.202. Steps 1 and 2.
hand, and
flexes the
patient's k nee
90 degrees
( F ig. 10.202).
3. T he phys ician
s lowly moves
the patient's
ankle away
( white arrow,
F ig. 10.203)
fr om the midline
until the edge of
the r estric tive F igure 10.203. Step 3.
barrier is
r eached.
4. T he patient
very gen tly
pulls the ankle
away from the
midline (b lack
ar row, F ig.
10.204) to the
later al aspect
of the patient's
ankle agains t
the phys ician's
c audad hand, F igure 10.204. Step 4, is ometric
which applies c ontr action.
an unyielding
c ounterforc e
( white arrow).
5. T his isometr ic
c ontr action is
103 of 134 21/08/07 22:07

P.2 48
Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , A c ute Dy sfunction:
s upine, and the
physician
s tands at the
s ide of the
patient opposite
the s ide to be
tr eated.
2. T he patient's
r ight hip and
k nee are flexed
s o that the foot
on the
dy sfunctional F igure 10.206. Steps 1 to 3.
s ide may be
placed later al to
the unaffec ted
k nee.
c ephalad hand
is placed on the
patient's ASIS
on the s ide of
dy sfunction to
s tabiliz e the
pelvis ( Fig .
10.206).
4. O n the s ide of F igure 10.207. Step 4.
dy sfunction, the
physician's
c audad hand
pulls the
patient's r ight
k nee toward
the midline,
inter nally
r otating the hip,
until the
piriformis
begins to
s tretch,
engaging the F igure 10.208. Step 5, is ometric
edge of the c ontr action.
104 of 134 21/08/07 22:07

r estr ictive
barrier (F ig .
10.207).
5. T he patient
very gen tly
pushes the
r ight knee
towar d the
midline (b lack
ar row, F ig.
10.208) to the
medial aspec t
of the patient's
k nee agains t F igure 10.209. Step 7.
the phys ician's
c audad hand,
which applies
an unyielding
c ounterforc e
( white arrow).
6. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
relax.
7. O nce the
patient has
c ompletely
r elax ed, the
physician
r epos itions the
k nee far ther
ac ros s the
midline,
inter nally
r otating the hip
to the edge of
the new
r estr ictive
barrier (w hite
ar row, F ig.
10.209).
r epeated thr ee
to five times or
until motion is
maximally
105 of 134 21/08/07 22:07

improved at the
dy sfunctional
hip and
piriformis.
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 49
Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , Subac ute or Chr onic
pr one on the
tr eatment table,
and the
physician
s tands beside
the table.
2. T he phys ician
palpates the
dy sfunctional
piriformis
muscle with the
c ephalad hand
and gras ps the F igu re 10.210. Steps 1 and 2.
patient's ankle
with the caudad
hand (F ig.
10.210).
c audad hand
flexes the
patient's k nee
90 degrees and
s lowly moves
the patient's
ankle away
106 of 134 21/08/07 22:07

fr om the
midline,
inter nally
r otating the
dy sfunctional
hip until the
piriformis
muscle begins
to stretch,
engaging the
edge of the
r estr ictive
barrier (F ig .
10.211). F igu re 10.211. Step 3.
4. T he patient
pushes the
r ight ankle
towar d the
midline (b lack
ar row, F ig.
10.212) to the
medial aspec t
of the patient's
foot and ank le,
against the
physician's
c audad hand,
which applies F igu re 10.212. Step 4, isometr ic
an unyielding c ontrac tion.
c ounterforc e
( white arrow).
5. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician F igu re 10.213. Step 6.
r epos itions the
ankle farther
away from the
midline,
inter nally
r otating the hip
107 of 134 21/08/07 22:07

to the edge of
the new
r estr ictive
barrier (w hite
ar row, F ig.
10.213).
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
hip and
piriformis.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 50
P.2 51
Pelv ic R egion: Hip Re gion: Pirifor mis Mus cle , Subac ute or Chr onic
s upine and the
physician
s tands at the
s ide of the
patient opposite
the s ide to be
tr eated.
2. T he patient's
hip and knee
ar e flex ed s o
that the foot on
the
dy sfunctional F igure 10.214. Steps 1 to 3.
108 of 134 21/08/07 22:07

s ide may be
placed later al to
the unaffec ted
k nee.
c ephalad hand
is placed on the
patient's ASIS
on the s ide of
dy sfunction to
s tabiliz e the
pelvis ( Fig .
10.214).
4. O n the s ide of F igure 10.215. Step 4.
dy sfunction, the
physician's
c audad hand
gently pulls the
patient's k nee
towar d the
midline (w hite
ar row, F ig.
10.215),
inter nally
r otating the hip
until the
piriformis
begins to F igure 10.216. Step 5, is ometric
s tretch c ontr action.
engaging the
edge of the
r estr ictive
barrier.
5. T he patient
pulls the k nee
away from the
midline (b lack
ar row, F ig.
10.216) to the
later al aspect
of the patient's
k nee agains t
the phys ician's F igure 10.217. Step 7.
c audad hand,
which applies
an unyielding
c ounterforc e
( white arrow).
6. T his isometr ic
109 of 134 21/08/07 22:07

c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
st op and
relax.
7. O nce the
patient has
c ompletely
r elax ed, the
physician
r epos itions the
k nee far ther
ac ros s the
midline,
inter nally
r otating the hip
to the edge of
the new
r estr ictive
barrier (w hite
ar row, F ig.
10.217).
r epeated thr ee
to five times or
until motion is
maximally
improved at the
dy sfunctional
hip and
piriformis.
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 52
P.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

Diag nosis
Seated flex ion tes t:
positiv e right
Sacr al s ulc us: deep,
anterior right
Inferior later al angle
( ILA): s hallow,
posterior left
Spring test: negative
Sphinx test: less
asymmetr y
L5 NSLRR
Left-on- left s acr al
tors ion (F ig. 10.218)
T ech niq u e
in the left
modified Sims
position on the
s ide of the
named oblique
ax is. The hips
and k nees ar e
flexed to 90 F igu re 10.218. Left- on-left sac ral torsion.
degrees, with
the c hes t down
on the table as
much as
possible and
the r ight ar m
hanging over
the table edge.
2. T he phys ician
s its on the right
end of the table
near the
patient's
buttocks , facing F igu re 10.219. Steps 1 to 4.
the patient.
3. T he phys ician
gently lifts the
patient's k nees
and r ests the
k nees , legs ,
and feet on the
anter ior thigh.
111 of 134 21/08/07 22:07

P.2 54
P.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
Diag nosis
positiv e left
Left sac ral sulcus :
deep, anter ior
Right ILA: shallow,
posterior
Spring test: negative
Sphinx test: less
asymmetr y
L5 NSRRL
Right-on-right sac ral
T ech niq u e
in the r ight
modified Sims
position on the
s ide of the
named oblique
ax is. The hips
and k nees ar e
flexed to 90
degrees, with F igu re 10.224. Right- on- right s acr al
the c hes t down tors ion.
on the table as
much as
possible and
the left ar m
hanging over
the table edge.
2. T he phys ician
s its on the edge
of the table
behind the
patient and
r ests the
patient's k nees
s lightly onto the F igu re 10.225. Steps 1 to 3.
112 of 134 21/08/07 22:07

r ight anter ior

thigh.
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 F igu re 10.226. Step 4.
r elative to S1
( F ig. 10.225).
4. T he patient
inhales and
ex hales deeply
three times ,
r eaching with
the left hand
towar d the floor
after each
ex halation ( Fig .
10.226).
c audad hand F igu re 10.227. Step 5.
gently lower s
the patient's
feet (w hite
ar row, F ig.
10.227) until the
edge of the
r estr ictive
barrier is
r eached.
6. T he phys ician
instr ucts the
patient to lift
both feet
s traight up F igu re 10.228. Step 6, isometr ic
towar d the c ontrac tion.
c eiling with a
gentle but
s ustained force
( blac k arrow,
F ig. 10.228)
against the
113 of 134 21/08/07 22:07

physician's
unyielding
c audad hand
( white arrow).
T his contrac ts
the left hip
inter nal rotators
and the right hip
ex ter nal
r otators , which
ar e both
antagonists to
the left
piriformis F igu re 10.229. Step 8.
muscle.
7. 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.
8. O nce the
patient is
c ompletely
r elax ed, the
physician
gently lower s
both feet
towar d the floor
( white arrow,
F ig. 10.229) to
the edge of the
new r estric tive
barrier.
r epeated thr ee
to five times.
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 56
114 of 134 21/08/07 22:07

P.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
Diag nosis
Seated flex ion
test: positive right
Right s acral
s ulc us: pos ter ior ,
s hallow
Left ILA: deep,
anterior
Spring test:
positiv e
Sphinx test: more
asymmetr y
L5 E/FRLSL
Right-on-left
s acr al tors ion
( Fig . 10.230)
T ech niq u e
1. T he patient
lies in the left
later al
r ecumbent
position with
the r ight hip
and k nee F igu re 10.230.
s lightly Right- on- left s acral tors ion.
flexed in
fr ont of the
left leg.
2. T he
physician
s tands facing
the patient's
pelvis, and
the c ephalad
hand
palpates the
L5-S1
inter spinous F ig ure 10.231.
s pace while A. Steps 1 to 3.
the c audad
hand gently
115 of 134 21/08/07 22:07

moves the
left leg
posteriorly ,
ex tending the
hip until
motion is felt
at the L5-S1
inter space.
3. T he
physician's
c audad hand
and forearm
s tabiliz e the
patient's
pelvis as the
patient gently
r otates the
tr unk to the F igure 10.231. B. Step 4.
r ight (F ig.
10.231).
4. T he patient
inhales and
ex hales
deeply three
times . After
each
ex halation,
the patient
r eaches
back with the
r ight ar m and F ig ure 10.232.
s houlder , Step 5.
r otating the
tr unk to the
r ight to
derotate L5.
5. T he
physician's
c audad hand
moves the
patient's r ight
foot off the
table and
applies
gentle F ig ure 10.233.
pr ess ure on Step 6, isometr ic c ontrac tion.
the patient's
r ight knee
( white arrow,
116 of 134 21/08/07 22:07

F ig. 10.232)
to the edge
of the
r estr ictive
barrier.
6. T he
physician
instr ucts the
patient to lift
the r ight
k nee str aight
up towar d
the c eiling F ig ure 10.234.
with gentle Step 8.
but s ustained
force (blac k
ar row, F ig.
10.233)
against the
physician's
unyielding
c ounterforc e
of the
c audad hand
( white
ar row).
7. T his
is ometric
c ontr action
is maintained
for 3 to 5
s econds, and
then the
patient is
instr ucted to
st op and
relax.
8. O nce the
patient has
c ompletely
r elax ed, the
physician
gently lower s
the r ight foot
towar d the
floor until a
new
r estr ictive
barrier is
117 of 134 21/08/07 22:07

r eached
( white arrow,
F ig. 10.234) .
9. Steps 6 to 8
ar e r epeated
three to fiv e
times .
10. T he
diagnostic
parameters
of the
dy sfunction
ar e
r eevaluated
to deter mine
the
effec tiv enes s
of the
technique.
P.2 58
P.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
118 of 134 21/08/07 22:07

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

P.2 60
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.
Tab le 10.1 ou tlin es sacral torsio n d ysfu nct ion s ab out an obliqu e axis.
P.2 62
P.2 63
Sacr al R egion: Unilatera l Flexe d Sacr um on the Left, R espiratory

A ssist
120 of 134 21/08/07 22:07

Diag nosis
Positiv e left
Ventral, anter ior
Left ILA: Dors al,
posterior
Spring test: Negative
Sphinx test:
Decr eas ed
asymmetr y
T ech niq u e
F igu re 10.241. Step 2.
pr one and the
physician
s tands at the
left side of the
table.
2. T he index finger
of the
physician's
c ephalad hand
palpates the
patient's left
s acral s ulc us
( F ig. 10.241) F igu re 10.242. Steps 1 to 3.
while the
c audad hand
abduc ts and
adduc ts the
patient's left leg
to find the
loosest- pac k ed
position for the
left sac roiliac
joint (usually
about 15
degrees of
abduc tion).
3. T he phys ician F igu re 10.243. Step 4.
inter nally
r otates the
patient's left hip,
and the patient
maintains this
abduc ted,
121 of 134 21/08/07 22:07

P.2 64
P.2 65
Sacr al R egion: Unilatera l Ex tended Sa c rum on the Le ft,

Diag nosis
Positiv e left
Dors al, pos ter ior
Left ILA: Ventral,
anterior
Spring test: Positive
Sphinx test:
Incr eas ed
asymmetr y
T ech niq u e
F igure 10.248. Steps 1 to 3.
in the s phinx
position
( propped up
with the elbows
s upporting the
upper body) ,
and the
physician
s tands at the
left side of the
table.
2. T he index finger
of the F igure 10.249. Step 4.
physician's
c ephalad hand
palpates the
patient's left
s acral s ulc us
while the
c audad hand
abduc ts and
adduc ts the
patient's left leg
to find the
loosest- pac k ed
position for the
left sac roiliac F igure 10.250. Step 4.
122 of 134 21/08/07 22:07

joint (usually
about 15
degrees of
abduc tion).
3. T he phys ician
inter nally
r otates the
patient's left hip
and instruc ts
the patient to
maintain this
abduc ted,
inter nally
r otated pos ition F igure 10.251. Step 5.
throughout the
tr eatment ( F ig.
10.248).
4. T he hypothenar
eminence of the
physician's
c ephalad hand
is placed on the
patient's left
s acral s ulc us
( F ig. 10.249)
and is
r einforc ed by
the c audad F igure 10.252. Steps 6 and 7.
hand (F ig.
10.250).
hands ex ert a
s ustained
anter ior
( downwar d)
force on the
patient's left
s acral s ulc us to
r otate the
s acrum
anter ior ly, and
to disengage
the lumbosac ral
joint caudally
( F ig. 10.251).
6. T he patient
inhales and then
ex hales
forcefully.
123 of 134 21/08/07 22:07

During
ex halation, the
physician's
hands
encourage
s acral flex ion
( white arrow,
F ig. 10.252) .
7. T he patient
inhales slowly.
During
inhalation, the
physician's
hands increase
the anterior
force on the
s acral s ulc us to
pr event sac r al
ex tension ( white
ar row, F ig.
10.252).
r epeated fiv e to
s even times .
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine the
effec tiv enes s of
the technique.
P.2 66
P.2 67
Sacr al R egion: Bilate rally Flex ed Sac r um, Re spir atory Ass ist
124 of 134 21/08/07 22:07

Diag nosis
Sacr al r ock test:
Positiv e
Both sac ral sulci:
Ventral, anter ior
Both ILAs: Dor sal,
posterior
Spring test: Negative
Sphinx test:
Decr eas ed
asymmetr y
Bilater ally flexed
s acr um ( Fig .
10.253)
T ech niq u e
pr one and the
physician
s tands beside F igu re
the patient. 10.253. Bilater ally flexed s acr um.
2. T he phys ician
places the
thenar and
hy pothenar
eminences of
the c audad
hand on the
ILAs of the
patient's
s acrum ( Fig .
10.254).
c ephalad hand
r einforc es the F igure 10.254. Step 2.
c audad hand
( F igs. 10.255
and 10.256) .
4. T he phys ician
applies a
c ontinuous
anter ior
( downwar d)
force on the
ILAs of the
patient's
s acrum.
125 of 134 21/08/07 22:07

P.2 68
Sacr al R egion: Bilate rally Exte nde d Sa crum, Res pira tor y A s sis t
Diag nosis
Both sac ral sulci:
Dors al, pos ter ior
Both ILAs: Ventral,
anterior
Spring test: Positive
Sphinx test: More
asymmetr y
Bilater ally Ex tended
s acr um ( Fig .
10.258)
T ech niq u e
pr one and the
physician
s tands beside
the patient.
2. T he phys ician
places the
index finger on F igure 10.258.
the patient's left Bilaterally extended s acr um.
s acral s ulc us
and the long
finger on the
r ight sacral
s ulcus ( Fig .
10.259).
other hand
r einforc es the
first hand ( Fig .
10.260).
4. A continuous
anter ior
( downwar d) F igure 10.259. Step 2.
force (white
ar row, F ig.
10.261) is
placed on the
s acral s ulc i.
5. T he patient
inhales and
126 of 134 21/08/07 22:07

then exhales
deeply.
6. T he phys ician
ex aggerates
flexion dur ing
ex halation and
attempts to
r esis t extension
during
inhalation.
r epeated 7 to
10 times .
8. T he diagnos tic F igure 10.260. Step 3.
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
F igure 10.261. Steps 4 to 6.
P.2 69
Extr emities : Poste rior R adia l H ead, Pr ona tion D y sfunction: Post
127 of 134 21/08/07 22:07

1. T he patient is
s eated, and the
physician
s tands in fr ont
of and to the
s ide of the
patient's
dy sfunctional
ar m.
2. T he phys ician
holds the
patient's hand
( handshake
position) with F igure 10.262. Steps 1 to 3.
the hand
ipsilateral to the
dy sfunction.
other hand lies
palm up with
the thumb
r esting against
the
posterolater al
as pec t of the
r adial head
( F ig. 10.262).
4. T he phys ician F igure 10.263. Step 4.
s upinates the
patient's
forearm until
the edge of the
r estr iction
barrier is
r eached (w hite
ar row, F ig.
10.263) at the
r adial head.
5. T he phys ician
instr ucts the
patient to
attempt F igure 10.264. Step 5, is ometric
pr onation c ontr action.
( blac k arrow,
F ig. 10.264)
while the
physician
applies an
128 of 134 21/08/07 22:07

P.2 70
Extr emities : A nte r ior Ra dia l He ad, Supina tion D y sfunction: Post
1. T he patient is
s eated, and the
physician
s tands facing
the patient.
2. T he phys ician
holds the
patient's hand
( handshake
position) with
the hand
ipsilateral to the
dy sfunction.
3. T he phys ician's F igure 10.266. Steps 1 to 3.
other hand is
palm up with
the thumb
r esting against
the anterior and
medial aspec t
of the r adial
head (F ig.
10.266).
4. T he phys ician
pr onates the
patient's
forearm (w hite
ar row, F ig. F igure 10.267. Step 4.
10.267) until
the edge of the
r estr ictive
barrier at the
r adial head is
r eached.
5. T he phys ician
instr ucts the
patient to
attempt
s upination
( blac k arrow,
F ig. 10.268)
while the F igure 10.268. Step 5, is ometric
physician c ontr action.
129 of 134 21/08/07 22:07

applies an
unyielding
c ounterforc e
( white arrow).
6. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient
is instr ucted to
st op and
relax.
7. O nce the
patient has F igure 10.269. Step 7.
c ompletely
r elax ed, the
physician
pr onates the
patient's
forearm to the
new r estric tive
barrier (w hite
ar row, F ig.
10.269) while
ex aggerating
the posterior
r otation of the
r adial head with
the left hand
( white arrow).
r epeated thr ee
to five times or
until there is no
further
improvement in
the r estric tive
barrier.
9. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 71
130 of 134 21/08/07 22:07

Extr emities : Poste rior Fibular Hea d D y sfunction: Post Isom etr ic
R ela xation

or sits with the lower
legs off the table, and
the phys ician s tands
or sits at the side of
dy sfunction.
2. T he phys ician plac es
the hand closes t to
the k nee in the
popliteal fossa so that
the
joint of the index
finger appr oximates F igu re 10.270. Steps 1 and 2.
the posterior prox imal
fibula ( head) ( Fig .
10.270).
3. T he phys ician's other
hand controls the
patient's foot and
ankle, exter nally
r otating the patient's
lower leg ( white arrow,
F ig. 10.271) until the
fibular head meets its
anter ior res trictive
barrier.
4. T he patient internally F igu re 10.271. Step 3.
r otates (b lack arr ow,
F ig. 10.272) the lower
leg as the phys ician
applies an unyielding
ar row).
5. T his isometr ic
c ontr action is held for
3 to 5 s econds, and
then the patient is
instr ucted to stop
an d relax.
6. O nce the patient has
c ompletely r elaxed, F igu re 10.272. Step 4, isometric
the phys ician attempts c ontrac tion.
to move the fibula
131 of 134 21/08/07 22:07

10.273) to the new,

ex ter nal rotation
r estr ictive bar rier.
r epeated thr ee to fiv e
times or until there is
no further
improvement in the
8. T he diagnos tic
parameters of the
dy sfunction are
r eevaluated to
deter mine the F igu re 10.273. Step 6.
effec tiv enes s of the
technique.
P.2 72
Extr emities : A nte r ior Fibula r H ead Dy s function: Pos t Isom e tric
R ela xation
s upine or s its
with the lower
legs off the
table, and the
physician
s tands or s its
at the s ide of
dy sfunction.
2. T he phys ician
places the hand
that is near er to
the k nee ov er
the F igure 10.274. Steps 1 and 2.
anter olater al
pr oximal fibular
head (F ig.
10.274).
other hand
c ontr ols the
patient's foot
132 of 134 21/08/07 22:07

and ankle and

inter nally
r otates the
patient's lower
leg ( white
ar row, F ig.
10.275) until
the fibular head
meets its
posterior
r estr ictive
barrier.
4. T he patient
ex ter nally F igure 10.275. Step 3.
r otates (b lack
ar row, F ig.
10.276) the
lower leg as the
physician
applies an
unyielding
c ounterforc e
( white arrow).
5. T his isometr ic
c ontr action is
held for 3 to 5
s econds, and
then the patient F igure 10.276. Step 4, is ometric
is instr ucted to c ontr action.
st op and
relax.
6. O nce the
patient has
c ompletely
r elax ed, the
physician
attempts to
move the fibula
to the new
inter nal rotation
r estr ictive
barrier (w hite
ar row, F ig. F igure 10.277. Step 6.
10.277).
r epeated thr ee
to five times or
until there is no
further
133 of 134 21/08/07 22:07

improvement in
the r estric tive
barrier.
8. T he diagnos tic
parameters of
the dysfunc tion
ar e r eev aluated
to deter mine
the
effec tiv enes s of
the technique.
P.2 73
R efe renc es
1. Wa r d R (e d). Fo unda tio ns for Ost eop athi c M edi c i ne . P hil adel phi a: Li pp i nc ott W il l ia m s & Wi l ki ns,
20 03.
2. Gr een m an P. Pri nc ip l es of M an ual Me di ci ne, 2n d ed . B alt i m or e: W il l i am s & Wi l k in s , 199 6.
3. Mi tch el l F L J r. T he Mu s cl e En erg y M anua l , v ol 1. Eas t L ansi ng, MI : ME T , 199 5.
4. Ne uma nn H D . Int r odu c ti on to M anu al M edi c in e. Berl i n: Sp r i ng er- Ver l ag, 19 89.
7. Re pri nted wi th perm i ss i on fro m S i mo ns D G, T ra v ell SG , S i m on LS . M y ofa s ci al Pain an d

Dy s fu nct i on: Th e T r i gg er Poi nt M anu al. Bal tim ore : Li ppi nco tt W i ll i am s & W il k in s , 1 999 .
8. Mo dif i ed w it h p er mi s si on fr om Cl ay J H , Pou nds D M. Ba s ic C li nic al M ass age Th er ap y :

In teg r at i ng Ana tom y an d T r ea tm en t. Bal ti mo r e: Li ppin c ot t W i l li ams & W i lk i ns , 2 003.
134 of 134 21/08/07 22:07

11
High-Velocity, Low-Amplitude Techniques

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

us e t he f orm ula w or k = fo r c e × di st ance (W = fd). Kn owi ng t hat fo r c e = m ass × ac ce l er atio n ( f = m a) ,
we ca n su bst i tu te m ass an d ac c el era ti on fo r f or ce in th e wo r k for m ula an d c oncl ude th at
wo r k = ma s s × a c c el era tio n × dis tan c e, or W = m ad
In th i s f orm ula , ac c el era ti on is th e su c ce s s fact or and dis tan c e i s t he s af ety fac tor . Th us, fo r te ach i ng
pu r po s es, we ca n de not e t he H ALD (H VLA) fo r mu l a f or s uc c ess an d s afet y a s
W = m ad
Th ere fore , t o p er fo r m a s uc ce s sf ul and s af e H VLA tec hni que ( wo r k) , th e p hys i c ia n m ust c om bin e a r ap i d
ac c el er at i on fo r c e w it h o nl y m in i ma l mo v em ent of the ar ti cu l ar la ndma r k ( se gm en t) tha t is be i ng
tr eat ed. T he di s tan c e i n this fo r mu l a s hou l d be o nly en ough to mo v e t he dys func tio nal art i cu l ar s eg m en t
1 of 87 21/08/07 22:09
th r ou gh t he r es tr ic tiv e b ar ri er, no t to ca r ry i t thr oug h th e b arr i er and be y ond th e p hy si olo gic bar r ie r . If,
fo r e x amp l e, a s egm ent th at n orm all y ha s 7 de gr ee s o f m otio n i s r es tr i ct ed at i ts 2-d egre e m oti on m ark ,
th e c or re c ti v e tech niq ue i s t o u s e only en oug h fo r ce to m ov e t he s egm ent an add i ti ona l 1 deg r ee , no t t he
re m ai ni ng 5 deg r ees . I n t he e arl y s tage of le ar ni ng thi s te c hn i qu e, i t i s m or e i mp ort ant to use s ho r t
di s ta nc e for sa fety ra the r th an hig h ac c el era ti on fo r s uc ce s s. Da v i d H ei l ig , DO , r efe r r ed to th i s a s g i vi ng
th e s egme nt a nudge , b eca us e i t i s di ff i cu l t to l i mi t t he m oti on w hen yo u a r e h i gh l y ac ce l er ati ng ( 2). As
th e s tude nt bec om es mo r e ac co m pl i sh ed a nd m as ters th e a bi li ty to s top at th e pr eci s e poin t n eed ed
P.2 76
(i m me di at ely pa s t t he r es tr ic tiv e b ar ri er i n m i ll i me ter s of di s ta nc e) , i t i s ap pro pri ate to i nc r eas e t he
ac c el er at i on to m or e s ucc es sf ul m ob i l iz i ng le v els .
Mo s t pr ac tit i on er s k no w t hat w he n t hey att emp t to im pro v e a nd/ or r est ore mo ti on lo s s at t he j oi nt l eve l
by us i ng thi s t ec hn i qu e, an ar ti c ul ar p op c an occ ur. Th er e hav e b een m an y t heor i es as to the ca us e of
th i s s oun d, i nc l udi ng c av i tat i on (c hang e i n s y nov i al fl ui d to a g as eo us s ta te) and a v acu um phe nome non
(3 ) . H owe v er , a n ar tic ula r po p d oes not me an that th e c or re c t art i c ul ati on w as m ob i li z ed, ju s t that an
ac ute m ov eme nt w as dir ect ed t o a jo i nt. Th e l ac k of an audi ble so und doe s n ot m ean th at t he c or r ect i on
wa s u ns uc c es s fu l . T her efo r e, the ph y s ic i an sh ould be mo s t i nte nt on t he pal pato r y qua l i ty an d q uant i ty of
th e d y s fu nct i on al a r ti c ul atio n a s i t go es thr ough th e c or re c ti v e pr oc ess .
Techni que Classi fication
Direct Techni que

In Am er ic an ost eopa thi c c i r cl es, HV LA i s m ost l y f r eq uen tl y des c ri bed as a d i r ec t t ech ni qu e. T ha t is , t he
mo bil i z in g f orc e us ed to c orr ect th e so m at i c dy sf unc tio n is di r ec ted tow ard the re s tr i c ti v e bar r i er . I n
ac c om pl is hin g t hi s c or r ec ti on , t he phys i ci an s hou l d att em pt to mo v e t he s eg m ent as li ttle as po s s ib l e
th r ou gh t his ba r r ie r . In s oma tic dy s fun c ti on, i nc l ud i ng the ar tic ul ar ab nor m ali tie s , the dys fun c tio n i s
de s cr i bed fo r i ts m oti on fr ee dom an d po s it i on i n the x- , y- , a nd z - ax es. Th er ef ore , t he r est r ic ti ve ba r ri er
th at i s e nco unt er ed wi th di re c t tec hniq ue i s oppo s it e t he f r ee dom by w hi c h the dys fun c tio n i s n am ed .
To sa fely an d s uc ce s sf ull y tr eat a dy sf unc tio n wi th thi s di r ec t m etho d, i t i s p r ob abl y wi s e to focu s o n

on e o r tw o a x es and ke ep s ome fr eed om a v ai l ab l e i n t he r ema i ni ng ax is . M eet i ng all th r ee axi s b ar ri ers
ma k es the jo i nt v er y r est r i ct ed, an d it be c om es m ore di ffic ult to m an i pu l at e sa fel y . Al so , t he pati ent ha s
a gre ater te nde nc y to gua r d a gai nst the th r us t, a nd thi s ca n c aus e pa i n and s ti ffn ess pos t t r ea tm en t. F or
ex amp l e, to tre at a sp i na l dy s fu nct i on tha t h as b een de term i ne d t o be fl exe d, r ota ted r ig ht, an d si de- ben t
ri ght , th e p hys i c ia n w oul d fl ex to the l ev el of t he dys func tio n, then ex ten d sl i gh tly to i nc l ud e th i s bar r i er ,
ro tat e to th e r es tr i ct i ve bar r ie r ( l eft ) , but pro duc e o nl y s li ght s id e b end i ng to the bar r ie r t o ke ep tha t ax i s
sl i gh tl y fre er ( s im i la r t o th e feat her ' s e dge des c ri bed i n C ha pte r 10 in re fere nce to m us c le en er gy
te c hn i que s ). A c orr ect i ve for c e tha t is ve c to r ed thr oug h on l y one or two of the ax es ofte n p r od uc es
su c ce s s w i th mi ni ma l s i de eff ect s .
Indirect Technique
To tr eat the pa ti en t w i th i nd i re c t tech niq ue as d esc r ib ed e arl i er , th e p hys i c ia n m ust tak e t he ar ea of
dy s fu nc ti on awa y fr om the m os t r est r i ct i ve ba r r ie r a nd i n t he dir ec ti on by w hic h i ts bi om ech ani c al
pa r am eter s a r e desc r ib ed. If usi ng H VLA in an i nd i re c t m ann er, th e in dir ect bar r ie r c anno t b e t he n orm al
ph y si ol og i c bar r i er op pos i te the re s tri c ti on. T hi s e ase bar r ie r m us t be an addi tio nal ( re s tr i ct i v e)
co m po nent of th e dy s fu nct i on ( se e F i g. 6.2 ) . T his is in i ts elf a r est r ic tio n, b ut i t i s n ot the m os t
re s tr i c te d b arr i er. If th i s b arr i er w er e t he phys i ol ogi c ba r ri er, i nd i re c t tech niq ue w oul d b e
2 of 87 21/08/07 22:09
co ntr ai nd i ca ted as a f orm of m an i pu l ati on.
Mo tio n en han c em ent at a j oi nt ma y b e pr odu c ed i n a m ann er s i mi l ar to r em ovi ng a su c ti on c up fro m a

pi ece of gla s s. If the cu p is co m pr es se d, i t c an be m ov ed m ost ea s i ly pe r pe ndic ula r t o th e m ost
re s tr i c te d d i re c tio n. Sim i l ar l y, as one ve c to r s f orc e t o an d t hro ugh the ar ti cu l at i on , ca usi ng s ome
co m pr es si on at the fac et and s yn ovi um , m ot i on i n any di r ect i on pe r pen dic ula r to it s m aj or re s tr i c ti on
ca n f ac il i ta te i ncr eas ed m oti on i n the j oi nt, pro duc i ng the su c ti on c up eff ec t.
Techni que Styles

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

be mo r e a ppr opr i ate .
3 of 87 21/08/07 22:09
Contrai ndi cations
Rel ati ve Contrai ndicati ons

1. M i ld to m od era te s tra i n or s pra i n i n the are a t o be tr eat ed
2. M i ld os teop eni a o r os teo por os is in th e ar ea tha t wi l l be r ece i vi ng c omp r es s io n, t ors i on , or

anot her s uc h f orc e fr om the pos i ti oni ng a nd/ or thru s t
3. Os te oar thri tic jo i nts wi th m ode r at e m otio n l oss
4. R heu m at oi d dis eas e ot her th an i n t he s pin e
5. M i ni m al dis c b ulg e an d/o r h er ni ati on w i th ra dic ul ar sy m pt om s
6. Atyp i ca l jo i nt or fac et and oth er c on di ti ons wi th a s so c ia ted c on gen i tal an oma l i es
7. Some hy perm obi l e s tat es
Absolute Contrai ndicati ons

1. J oin t i ns ta bil i ty
2. Seve r e os te opo r os i s
3. M eta s ta s i s i n the are a t hat w il l b e r ec ei v in g c om pr ess i on , to r si on, or oth er s uch fo r ce fro m t he

posi tio ni ng an d/o r th r us t
4. Os te oar thri tic jo i nt w it h a nk yl osi s
5. Seve r e di sc oge nic s po ndy l os i s w i th an k y lo s is
6. Os te omy el it i s i n the are a t hat w il l b e re c ei v in g co m pr ess i on, to r si on, or oth er s uch fo r c e fro m
the pos i tio nin g a nd/o r t hru s t
7. Infe c ti on o f t he ti ss ues in the ar ea that wi l l be r ece i vi ng c omp r es s i on fr om the pos i ti onin g a nd/ or
thru s t.
8. J oin t r epla c em ent i n the ar ea t hat wi l l b e r ece i v in g c omp r ess i on , t or si on, or oth er s uc h fo r ce
and/ or thru s t
9. Seve r e hern i at ed di sc wi th r adi c ul opa thy
10. C ong eni tal ano m al i es s uc h a s Kl i pp el- F eil sy ndr om e, bl ock ed v ert ebr a, a nd s o on
11. C ond i ti ons s uc h a s Do w n s yn dr om e ( esp ec ia l ly ce r v ic al s pi ne)
12. R heu m at oi d art hri ti s of the c er v ic al ( esp eci all y at C1 - C2 ) re gio n
13. Ac ho ndr opla s ti c d w arf i sm (c er vi c al sp i ne)
General Consi derations and Rul es
4 of 87 21/08/07 22:09
HV LA tech niq ue i s o ne of the old est for m s of m anu al m ed i c in e a nd i s o ne tha t ha s b een s tu die d m os t i n
te r ms of c li nic al r esp ons e. I t i s t he t ech niq ue t hat is l ea s t tim e co nsu m in g. I t d oes hav e, on the oth er
ha nd, a r ela tiv el y l on g l earn i ng cu r v e for co m pet enc e a nd u s er co nfid enc e.
Shorthand Rul es
1. D i ag nos e.
2. Loca l iz e th e s egm ent to be tr ea ted .
3. C ont r ol the ar ea s o t he pat i ent is co m for tab l e and r el axe d.
4. Posi tio n to th e r es tr i ct i ve bar r ie r ( the edg e, not the wa l l ).
5. U s e r el ease - en han c i ng ma neu v ers if ne c ess ary (e .g., pa tie nt's br eat hi ng , i s om etri c c ont r act i on ,
j aw c le nc hi ng and the n r ela x i ng ) .
6. W hen co nfid ent th at t he pat i ent is re l axe d a nd not gua r de d, a dd a r apid ac c el er at i ng (m obil i zi ng
forc e) thru s t w it hi n the ar ti cu l at ory pla ne or pl an es of the j oi nt w i th to tal j oi nt m ov em en t k ept to
the abs ol ut e m i ni m um.
7. R eas s es s th e c omp onen ts of the dys fun c tio n ( tis s ue tex tur e ab nor m al i ty, as y mm etry of po s i ti on,
r est r ic ti on of mo ti on , t end er ne s s [TA R T ], es pec i all y i nte r s eg m en tal j oi nt m ot i on) .
P.2 78
Cervical Regi on: Occipi toatlantal (C0—C1, OA) Dysfunctions

Exampl e: OA, F/E or N-S LRR*
1. The patient lies

supine, and the
phy sic ian is seated or
stands at the head of
the table to the
patient's right.
2. The physic ian rotates
the patient's head to
the left.
3. The physic ian places
the left forearm under
the patient's
left-r otated head and
with the left hand c ups
the patient's chin ( Fig . Fig ure 11.1. Steps 1 to 3.
11.1).
4. The head r esting on
the forear m c reates a
minimal s ide bending
5 of 87 21/08/07 22:09
into the r ight

side-bending bar rier .
5. The physic ian's right
hand
(metac arpo-phalangeal
joint [MCP] of the
index finger,
hypothenar eminence,
or thumb) is placed
jus t posterior to the
mas toid pr ocess.
(F igs. 11.2, 11.3,
11.4)
6. The physic ian us es
both hands to ex ert Fig ure 11.2. Step 5, MCP position.
continuous tr action
(w hite ar r ows , F ig.
11.5). This is k ey to a
suc ces sful
mobilization.
7. With the patient
relaxed and not
guarding, the
phy sic ian delivers a
thr ust (white ar row,
Fig . 11.6) towar d the
patient's left orbit. T his
thr ust is not linear but
an arc .
Fig ure 11.3. Step 5, hy pothenar eminence
8. Effectiveness of the
var iation.
tec hnique is
determined by
reassessing motion at
the oc cipitoatlantal
articulations .
Fig ure 11.4. Step 5, thumb var iation.
6 of 87 21/08/07 22:09
Fig ure 11.5. Step 6, cephalad traction.
Fig ure 11.6. Step 7.
P.2 79
P.2 80
Cervical Regi on: Atl antoaxi al (C1—C2, AA) Dysfunction

Exampl e: C1 RL
7 of 87 21/08/07 22:09
1. The patient lies

supine, and the
phy sic ian sits
or stands at
the head of the
table.
2. The
phy sic ian's
hands
sandwich the
patient's head,
cradling both
tempor opar ietal
regions ( F ig.
11.7) F ig ure 11.7. Step 2.
3. The physic ian
rotates the
patient's head
to the right,
engaging the
res trictiv e
bar rier ( F ig.
11.8). There is
no side
bending,
flexion, or
extens ion with
this r otation.
4. The patient c an F ig ure 11.8. Step 3.
be ask ed to
breathe s lowly,
and at
exhalation,
fur ther s lack
may be tak en
out of the soft
tis sues.
5. With the patient
relaxed and
totally
unguar ded
(may use end
exhalation as
point of F ig ure 11.9. Step 5.
relaxation), a
thr ust is
delivered
exaggerating
8 of 87 21/08/07 22:09
P.2 81
Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C4 FS LRL

Short-Lever, Rotational Em phasis
1. The patient is
supine, and
the physic ian
stands or sits
at the head of
the table on
the patient's
left s ide.
2. The MCP joint
of the index
finger of the
phy sic ian's
left hand is
placed
pos ter ior to F ig ure 11.10. Steps 1 to 3.
the ar tic ular
pillar of the
dys functional
segment.
3. Side bending
to the left is
introduced
until the
phy sic ian
elicits the
mov ement of
C4, which
segments the
cer vic al s pine F ig ure 11.11. Step 4.
to this level.
Flexion or
extens ion is
not neces s ary
as a
separated
motion, as the
combination of
side bending
and
subsequent
rotation will
effectively
neutraliz e
9 of 87 21/08/07 22:09
these F ig ure 11.12. Step 5, trac tion.

components
(F ig. 11.10).
4. With the s ide
bending held
in place, the
phy sic ian
grasps the
chin with the
right hand and
rotates the
head to the
right until the
phy sic ian
feels motion in
the left hand. F ig ure 11.13. Step 6.
The head is
allowed to rest
on the
phy sic ian's
right for earm,
which may
elevate
slightly to
effect fur ther
isolation of the
C4 on C5
articulation
(F ig. 11.11).
5. Slight ax ial
traction may
be applied
(w hite ar r ows ,
Fig . 11.12)
with both
hands.
6. With the
patient
relaxed and
not guarding,
the
phy sic ian's
left MCP
dir ects an
arc lik e thrus t
in the plane of
the oblique
fac et of C4
(w hite ar r ow,
10 of 87 21/08/07 22:09
Fig . 11.13).
7. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.2 82
Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C5 ES RRR

Long-Lever Rotati onal E mphasis
1. The patient
lies s upine,
and the
phy sic ian is
seated at the
head of the
table.
2. The
phy sic ian's
right index
finger pad or
MCP is placed
behind the
right articular
pillar of C6 to F ig ure 11.14. Steps 1 to 3.
res trict motion
at that
segment.
3. The patient's
head is
suppor ted by
the
phy sic ian's
left hand (F ig.
11.14) .
4. The head is
11 of 87 21/08/07 22:09
side-bent right
(w hite ar r ow,
Fig . 11.15)
until C5
begins to
mov e. This
tak es tens ion
off the
par avertebral
mus cles at the
lev el of the
dys function.
Flexion s hould
be added until
C5 again F ig ure 11.15. Step 4.
begins to
mov e.
5. The physic ian
car efully
rotates the
head to the
left until the
res trictiv e
bar rier
engages,
being mindful
to maintain the
original r ight
side bending
F ig ure 11.16. Step 5.
(F ig. 11.16).
6. With the
patient
relaxed and
not guarding,
the physic ian,
using rapid
acc eleration,
supinates the
left hand and
wrist, which
dir ects a left
rotational
arc lik e thrus t
in the plane of F ig ure 11.17. Step 6.
the oblique
fac et (w hite
arr ow, F ig .
11.17) . T his
produc es s ide
12 of 87 21/08/07 22:09
bending left
and rotation
left.
7. The
phy sic ian's
right hand
remains r igid
as a fulc r um
agains t which
to mov e the
cer vic al
column.
8. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.2 83
Cervical Regi on: C2 to C7 Dysfunctions E xam ple: C5 NS LRL

Short-Lever Technique, Side-Bendi ng E mphasi s
1. The patient
lies s upine,
and the
phy sic ian
stands or sits
at the head of
the table.
2. The physic ian
suppor ts the
patient's head
with the pads
of the index
finger s on the
articular
pillar s of the F ig ure 11.18. Steps 1 to 3.
13 of 87 21/08/07 22:09
dys functional
ver tebra ( C5) .
3. The physic ian
gently flexes
the patient's
head and
nec k until C5
begins to
mov e over C6
(F ig. 11.18).
4. The physic ian,
while
monitoring the
pos ter ior
articular F ig ure 11.19. Steps 4 and 5.
pillar s of C5,
gently rotates
the patient's
head and
nec k to the
left until
motion at C5
is felt.
5. The physic ian
gently
side-bends
the patient's
head and
nec k to the
right,
engaging the
side-bending
bar rier of C5
on C6 (F ig .
11.19) .
6. The physic ian
places the
MCP of the
right index
finger
pos ter ior to
the right
articular pillar
of C5 (F ig . F ig ure 11.21. Step 8, r ight s ide- bending
11.20) . impuls e.
7. The physic ian
adjusts flexion
or extens ion
as needed to
14 of 87 21/08/07 22:09
loc alize all

thr ee planes
of motion at
the
dys functional
segment.
8. With the
patient
relaxed and
not guarding,
the
phy sic ian's
right hand
(second MCP)
dir ects an
arc -like thrust
caudally
(w hite ar r ow,
Fig . 11.21),
acr oss the
midline in the
oblique plane
of the C5
fac et,
engaging the
right
side-bending
and right
rotational
bar riers.
9. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.2 84
P.2 85
Thoraci c Regi on: T1 to T12 Dysfuncti ons Exampl e: T4 FSLRL

Supine
15 of 87 21/08/07 22:09
F igu re 11.22
demonstr ates the
fulc rum principle as
used in this
technique.
1. The patient
lies s upine
with the
phy sic ian Fig ure 11.22. Lateral s upine v iew of the human spine illustr ating p
standing at the toward T4 and thenar eminence placement at T4- T 5 interspace as
patient's right dys func tion with a flex ion component (4) .
side ( opposite
the rotational
component) .
2. The physic ian
draws the
patient's left
arm ac ros s
the patient's
chest and
places the
other arm
below it. This
should for m a
V. The patient
grasps the Fig ure 11.23. Steps 1 and 2.
opposite
shoulders with
the hands
(F ig. 11.23).
3. The physic ian
car efully and
minimally rolls
the patient
toward the
phy sic ian by
grasping and
lifting the
patient's left
pos ter ior
shoulder Fig ure 11.24. Step 3 and 4.
gir dle.
4. The physic ian
places the
right thenar
eminence
pos ter ior to
16 of 87 21/08/07 22:09
P.2 86
P.2 87
Thoraci c Regi on: T1 to T12 Dysfuncti ons Exampl e: T9

ESRRR S upi ne
F igu re 11.27
demonstr ates the
fulc rum principle as
used in this
technique.
1. The patient
lies s upine
with the
phy sic ian
standing at F igure 11.27. Lateral supine view of the human s pine illus trating p
the patient's towar d T 10 and thenar eminence plac ement at T 9 trans ver se proc
left s ide dy sfunction with a flexion c omponent ( 4).
(oppos ite the
rotational
component) .
2. The physic ian
draws the
patient's right
arm ac ros s
the patient's
chest and
places the
other arm
below it. This
should for m a
V. The patient
grasps the F igure 11.28. Steps 1 and 2.
opposite
shoulders with
the hands
(F ig. 11.28).
3. The physic ian
car efully and
minimally rolls
the patient by
grasping and
lifting the
patient's right
pos ter ior
shoulder
gir dle.
17 of 87 21/08/07 22:09
4. The physic ian F igure 11.29. Steps 3 and 4.

places the
thenar
eminence
pos ter ior to
the upper of
the two
ver tebrae of
the
dys functional
spinal unit at
the right
transv ers e
proces s ( T 9)
(F ig. 11.29).
5. The patient's F igure 11.30. Step 6, side-bending left.
elbows ar e
dir ected to the
phy sic ian's
upper
abdomen just
inferior to the
cos tal ar c h
and xiphoid
proces s.
6. The
phy sic ian's
right hand and
arm ar e
placed under
F igure 11.31. Step 7, caudad-dir ected impulse.
the patient's
head and
nec k to add
slight tension
in for war d
bending. Side
bending left in
the thorac ic
spine down to
the
dys function is
car ried out by
gently mov ing
the patient's
thorac ic
region to the
left ( white
arr ow, F ig .
11.30) . T he
18 of 87 21/08/07 22:09
patient inhales
and ex hales.
7. On exhalation,
the physic ian
dir ects s light
pressure with
the abdomen
toward the
lower of the
two vertebrae
in this
dys functional
spinal unit
(T10) (w hite
arr ow, F ig .
11.31) .
8. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.2 88
Thoraci c Regi on: T1 to T8 Dysfunctions E xam ple: T2 FS LRL

Supine Over the Thigh
19 of 87 21/08/07 22:09
1. The patient lies

supine, and the
phy sic ian
stands at the
head of the
table.
2. The physic ian
places the
flexed left k nee
on the table
with the
patient's left T 2
area r esting on
the physic ian's
thigh (F ig . Fig ure 11.32. Steps 1 and 2.
11.32) . Note:
The side of
rotational
component
determines
which thigh is
used on which
par avertebral
side of the
patient.
3. The patient's
hands are
clasped behind
the head with Fig ure 11.33. Steps 3 to 5.
the elbows
held outward.
4. The
phy sic ian's
hands pas s
thr ough the
space made by
the patient's
for ear ms and
upper arms .
5. The physic ian
enc irc les the
patient's rib
cage with the
finger s ov er Fig ure 11.34. Step 7.
the rib angles
pos ter olaterally
(F ig. 11.33).
6. The patient
20 of 87 21/08/07 22:09
P.2 89
Thoraci c Regi on: T3 to T8 Dysfunctions E xam ple: T6 FS RRR

Prone
1. The patient
lies prone with
the head and
nec k in
neutral if
pos sible. A
pillow may be
placed under
the patient's
chest and/or
abdomen to
inc rease the
pos ter ior
cur ve and for
inc reased F ig ure 11.35. Steps 1 and 2.
comfor t.
2. The physic ian
stands at the
patient's left
for gr eater
efficienc y ;
however,
either side
may be us ed
(F ig. 11.35).
3. The physic ian
places the
right thenar
eminence on F ig ure 11.36. Steps 3 and 4.
the right
transv ers e
proces s of T6
with the
finger s
pointing
cephalad. The
caudad or
cephalad
dir ection of
the
phy sic ian's
hands is
determined by
21 of 87 21/08/07 22:09
the F ig ure 11.37. Step 5.

side-bending
bar rier.
4. The physic ian
places the left
hypothenar
eminence on
the left
transv ers e
proces s of T6
with the
finger s
pointing
caudally ( Fig .
11.36) .
5. The patient
inhales and
exhales, and
on exhalation,
a thrust
impuls e is
delivered in
the direc tion
in which the
finger s ( white
arr ows , F ig.
11.37) ar e
pointing with
slightly
greater
pressure on
the right
transv ers e
proces s of T6.
Note: In a T6
FSLRL
(flexion, side
bent left,
rotated left)
dys function,
the left hand
points
cephalad, the
right caudad,
and the force
is slightly
greater on the
left. In a T6
NSRRL (side
22 of 87 21/08/07 22:09
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 F ig ure 11.38. Step 2.
stands at the
head of the
treatment table
and
side-bends the
23 of 87 21/08/07 22:09
patient's head
to the left until
palpating
motion at the
T2- T3
articulation
(F ig. 11.38).
3. The
phy sic ian's left
thenar
eminence is
placed ov er
the left
transv ers e
proces s of T3 F ig ure 11.39. Step 3.
as a r estr ictor
and anchor
(F ig. 11.39).
4. 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).
5. 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 . F ig ure 11.41. Step 5, long-lever rotation, left
11.41) . impuls e.
6. Effectiveness
of this
tec hnique is
determined by
24 of 87 21/08/07 22:09
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.2 91

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 F ig ure 11.42. Steps 1 to 3.
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 F ig ure 11.43. Steps 4 and 5.
the right elbow
(F ig. 11.42).
25 of 87 21/08/07 22:09
(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 F ig ure 11.44. Step 8, barr ier .
places the
right thenar
eminence
par avertebrally
over the r ight
T9 transv erse
proces s ( F ig.
11.43) .
6. The patient is
told to r elax ,
and the
phy sic ian
car ries the
patient into
F ig ure 11.45. Step 8, impulse.
slight for war d
bending and
left s ide
bending until
T9 begins to
mov e.
7. The patient
inhales deeply
and on
exhalation is
car ried into left
rotation while
slight flexion
and left s ide
bending ar e
maintained.
8. The patient
again inhales ,
and on
exhalation, the
26 of 87 21/08/07 22:09
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

ESRRR S eated (Long Lever)
27 of 87 21/08/07 22:09
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 F ig ure 11.46. Steps 1 to 3.
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 F ig ure 11.47. Steps 4 and 5.
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 F ig ure 11.48. Step 7, barr ier .
hand midline
and
supras pinously
on the lower of
28 of 87 21/08/07 22:09
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 F ig ure 11.50. Steps 1 and 2.
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
F ig ure 11.51. Steps 3 to 5.
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 11.52. Step 7, including direction of
29 of 87 21/08/07 22:09
dys functional for ce.

right fir s t r ib.
5. 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.)
6. The patient
inhales and
exhales.
Dur ing
exhalation,
fur ther s ide
bending and
rotational
slack are
tak en up.
7. 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) .
8. Effectiveness
of the
tec hnique is
determined
by
30 of 87 21/08/07 22:09
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 F ig ure 11.53. Steps 1 and 2.
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 sidebent
left with the
control of the
phy sic ian's
F ig ure 11.54. Steps 3 and 4.
right hand
(F ig. 11.54).
5. The patient
inhales and
exhales.
6. At the end of
31 of 87 21/08/07 22:09
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 F ig ure 11.55. Step 6, including direction of
determined by for ce.
reassessing
motion of the
dys functional
rib.
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 F igu re 11.56. Steps 1 and 2.
dys function
acr oss the
patient's rib
cage with the
32 of 87 21/08/07 22:09
patient's
other arm
below it. The
patient's
arms s hould
for m a V
(F ig. 11.56).
3. The
phy sic ian
slightly r olls
the patient
toward the
phy sic ian by
gently pulling
the left F igu re 11.57. Steps 3 and 4.
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 igu re 11.58. Steps 5 to 7, inc luding
dys functional
direction of forc e.
rib (F ig.
11.57) .
5. 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 F igu re 11.59. Steps 5 to 7, inc luding
abdomen. direction of forc e.
6. Pressure is
dir ected
thr ough the
33 of 87 21/08/07 22:09
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
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 F ig ure 11.60. Steps 1 and 2.
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 F ig ure 11.61. Steps 3 and 4.
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 F ig ure 11.62. Steps 5 to 7, including
the right hand dir ection of for ce.
pos ter ior to
the angle of
the
35 of 87 21/08/07 22:09
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 Fig ure 11.64. Steps 1 and 2.
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 Fig ure 11.65. Steps 3 and 4.
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
36 of 87 21/08/07 22:09
right hand Fig ure 11.66. Steps 5 and 6, including

may gr asp dir ection of for c e.
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.
P.2 98
Costal Region: Ri ght Ri bs 11 and 12 E xhalation Dysfuncti on
37 of 87 21/08/07 22:09
Prone
1. The patient
lies prone on
the table.
2. The
phy sic ian
stands at the
left s ide of
the table and
pos itions the
patient's legs
15 to 20
degrees to
the left to put
tension on
the Fig ure 11.67. Steps 1 and 2.
quadratus
lumbor um,
which
attaches to
the infer ior
medial
aspect of rib
12 (F ig.
11.67) .
3. The
phy sic ian
places the
left thenar
eminence Fig ure 11.68. Steps 3 and 4.
superior and
lateral to the
angle of the
dys functional
rib and
exerts gentle
sus tained
medial and
caudad
traction.
4. The
phy sic ian's
right hand
grasps the
patient's Fig ure 11.69. Steps 5 and 6.
right anterior
superior iliac
spine and
38 of 87 21/08/07 22:09
gently lifts
toward the
ceiling ( F ig.
11.68) .
5. The patient
inhales and
exhales
deeply .
6. Dur ing the
end
exhalation,
the
phy sic ian's
left hand
applies a
caudad and
medial HVLA
thr ust as the
right hand
gently lifts
the anter ior
superior iliac
spine (ASIS)
up toward
the ceiling
(F ig. 11.69).
7. Suc ces s of
the
tec hnique is
determined
by
reassessing
motion of the
dys functional
rib.
P.2 99
Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L5 NSLRR

Lateral Recum bent (Long Lever)
39 of 87 21/08/07 22:09
1. The patient
lies in the r ight
lateral
rec umbent
(side- lying)
pos ition with
the physic ian
standing at the
side of the
table fac ing
the patient.
2. The physic ian
palpates
between the
spinous Fig ure 11.70. Steps 1 and 2.
proces ses of
L5 and S1 and
flexes the
patient's
knees and
hips until L5 is
in a neutr al
pos ition
relative to S1
(F ig. 11.70).
3. The physic ian
fur ther
pos itions the
patient's left Fig ure 11.71. Step 3.
leg so that it
drops over the
side of the
table cephalad
to the right
leg. T he
patient's foot
mus t not touc h
the floor (F ig.
11.71) .
4. While
continuing to
palpate L5, the
phy sic ian
places the Fig ure 11.72. Steps 4 and 5.
cephalad hand
in the patient's
left antec ubital
fos sa while
40 of 87 21/08/07 22:09
P.3 00
Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L4 FRRS

Lateral Recum bent (Long Lever)
1. The patient
lies in the r ight
lateral
rec umbent
pos ition with
the physic ian
standing at the
side of the
table fac ing
the patient.
2. The physic ian
palpates
between the
spinous
proces ses of Fig ure 11.74. Steps 1 and 2.
L4 and L5 and
flexes the
patient's
knees and
hips until L4 is
in a neutr al
pos ition
relative to L5.
It is not
nec ess ary to
meet the
extens ion
bar rier at this
point (F ig . Fig ure 11.75. Step 3.
11.74) .
3. The physic ian
fur ther
pos itions the
patient's left
leg so that it
drops over the
side of the
table cephalad
to the right
leg. T he
patient's foot
mus t not touc h
the floor (F ig.
41 of 87 21/08/07 22:09
11.75) . Fig ure 11.76. Steps 4 and 5.

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

rotational
mov ement is
palpated
between L4
and L5.
8. With the
patient r elax ed
and not
guarded the
phy sic ian
delivers an
impuls e with
the forear ms
(w hite ar r ows ,
Fig . 11.77),
simultaneously
mov ing the
shoulder
slightly
caudad and
the pelvis and
sac rum
cephalad.
9. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.3 01
Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: Left L5—S1

Radicul iti s* Lateral Recum bent (Long Lever)
43 of 87 21/08/07 22:09
1. The patient is
in the right
lateral
rec umbent
pos ition with
the physic ian
standing at
the side of
the table
fac ing the
patient.
2. The
phy sic ian
palpates
between the F ig ure 11.78. Steps 1 and 2.
patient's
spinous
proces ses of
L5- S1 and
flexes the
patient's hips
and knees
until L5 is
fully flex ed in
relation to S1
(F ig. 11.78).
3. The
phy sic ian
pos itions the F ig ure 11.79. Step 3.
patient's left
leg so that it
drops over
the side of
the table
cephalad to
the right leg.
The patient's
leg should
not touch the
floor (F ig .
11.79) .
4. While
continuing to
palpate L5, F ig ure 11.80. Steps 4 and 5.
the physic ian
places the
cephalad
hand in the
44 of 87 21/08/07 22:09
P.3 02
Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L4 NSLRR

Supine Lum bar Wal k-Around (Long Lever)
1. The patient
lies s upine
with both
hands behind
the neck and
the finger s
interlaced.
2. The physic ian
stands at the
head of the
table to the
patient's right
and slides the
right for earm
thr ough the F ig ure 11.82. Steps 1 to 3.
space created
by the
patient's
flexed right
arm and
shoulder.
3. The dorsal
aspect of the
phy sic ian's
hand is
car efully
placed at mid
sternum on
the patient's F ig ure 11.83. Steps 4 to 6.
chest wall
(F ig. 11.82).
4. The physic ian
then walk s
around the
head of the
table to the
left s ide of the
patient.
5. The physic ian,
while palpating
pos ter ior ly
with the
caudad hand,
45 of 87 21/08/07 22:09
side-bends F ig ure 11.84. Steps 7 and 8.

the patient's
trunk to the
right until L4
begins to
mov e.
6. The physic ian
begins to
rotate the
patient to the
left while
continuing to
maintain the
original s ide
bending ( F ig.
11.83) .
7. The
phy sic ian's
caudad hand
anc hor s the
patient's
pelvis by
placing the
palm on the
patient's right
ASIS.
8. With the
patient
relaxed and
not guarding,
the physic ian
dir ects an
impuls e that
pulls the
patient
minimally into
fur ther left
rotation ( white
arr ows , F ig.
11.84) .
9. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
46 of 87 21/08/07 22:09
segment.
P.3 03
Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L2 E SRRR

Lum bar Seated Positi on (Short Lever)
1. The patient
sits,
prefer ably
str addling and
fac ing the
length of the
table to
res trict the
sac rum and
pelvis .
2. The physic ian
stands behind
and to the left
of the patient.
3. The patient F ig ure 11.85. Steps 1 to 3.
places the
right hand
behind the
nec k and the
left hand on
the right elbow
(both hands
can be placed
behind the
nec k if this is
mor e
comfor table)
(F ig. 11.85).
4. The physic ian F ig ure 11.86. Steps 4 and 5.
pas ses the
left hand
under the
patient's left
axilla and on
top of the
patient's right
47 of 87 21/08/07 22:09
upper arm.
5. The physic ian
places the
right thenar
eminence or
palm on the
par avertebral
mus cles ov er
the L2 right
transv ers e
proces s ( F ig.
11.86) .
6. The patient is
ins tructed to
relax as the F ig ure 11.87. Steps 6 and 7.
phy sic ian
pos itions the
patient into
slight for war d
bending and
then left side
bending until
motion is
palpated at
L2.
7. The patient
inhales
deeply , and on
exhalation the
patient is
pos itioned into
left r otation
(while the
slight flexion
and left s ide
bending ar e
maintained
(F ig. 11.87).
8. With the
patient
relaxed and
not guarding,
the physic ian
dir ects an
impuls e force,
pulling the
patient
minimally
thr ough
48 of 87 21/08/07 22:09
fur ther left

rotation while
dir ecting a
short lev er
thr ust on L2
with the r ight
hand ( white
arr ows , F ig.
11.88) .
9. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.3 04
P.3 05
Lum bar Region: L1 to L5 Dysfuncti ons Exampl e: L2 E SRRR

Lum bar Seated Positi on (Long Lever)
1. The patient
sits,
prefer ably
str addling and
fac ing the
length of the
table, to
res trict the
sac rum and
pelvis .
2. The physic ian
stands behind
and to the left
of the patient.
places the
right hand
49 of 87 21/08/07 22:09
behind the
nec k and the
left hand on
the right elbow
(both hands
can be placed
behind the
nec k if this is
mor e
comfor table)
(F ig. 11.89).
4. The physic ian
pas ses the
left hand over
the top of the F ig ure 11.90. Steps 4 and 5.
patient's left
upper arm and
on top of the
patient's right
upper arm.
5. The physic ian
places the
right thenar
eminence or
palm midline
at the
inters pac e
between the
L2 and L3
spinous
proces ses
(F ig. 11.90).
6. The patient is
ins tructed to
relax, and the
phy sic ian
pos itions the
patient into
slight for war d
bending and
left s ide
bending until
motion is
palpated at F ig ure 11.92. Step 8.
L2.
7. The patient
inhales
deeply , and on
exhalation the
50 of 87 21/08/07 22:09
patient is
pos itioned into
left r otation
while slight
flexion and left
side bending
are maintained
(F ig. 11.91).
8. With the
patient
relaxed and
not guarding,
the
phy sic ian's
left hand pulls
the patient
into further left
rotation while
stabilizing L3
with the r ight
hand ( white
arr ows ) ( this
rotates L2 to
the left in
relation to L3)
(F ig. 11.92).
9. Effectiveness
of the
tec hnique is
determined by
reassessing
inters egmental
motion at the
lev el of the
dys functional
segment.
P.3 06
P.3 07
Pel vic Region: Left Posteri or Innomi nate Dysfuncti on,

Lateral Recum bent
51 of 87 21/08/07 22:09
Diag nosis
Positiv e (left PSIS r ises)
Loss of pas siv ely
induced left s acr oiliac
motion
ASIS: Cephalad (s lightly
lateral) on the left
PSIS: Caudad ( slightly
medial) on the left
Sacr al s ulc us: Deep,
anterior on the left
T ech niq u e
Fig ure 11.93. Steps 1 to 3.
1. The patient is in the
right lateral
rec umbent pos ition,
and the physician
stands fac ing the
patient.
2. The physic ian's
cephalad hand
palpates between
the patient's
spinous pr ocesses
of L5 and S1.
3. The physic ian's
caudad hand flex es Fig ure 11.94. Steps 4 and 5.
the patient's knees
and hips until the
L5 and S1 spinous
proces ses
separate ( Fig .
11.93) .
4. The physic ian
maintains the left
leg in this position
and instr ucts the
patient to
str aighten the r ight
leg, plac ing the left
foot just dis tal to
the right popliteal Fig ure 11.95. Step 6a.
fos sa.
5. The physic ian
places the
cephalad hand on
52 of 87 21/08/07 22:09
P.3 08
Pel vic Region: Ri ght Posterior Innom i nate Dysfunction, Leg

Pul l, S upi ne
Diag nosis
r ises)
Loss of pas siv ely
induced right sac r oiliac
motion
ASIS: Cephalad (s lightly
lateral) on the r ight
PSIS: Caudad ( slightly
medial) on the right
Sacr al s ulc us: Deep,
anterior on the r ight
T ech niq u e F ig ure 11.99. Steps 1 to 3.
1. The patient is
supine, and the
phy sic ian stands
at the foot of the
table.
2. The physic ian
grasps the
patient's right
ank le.
3. The physic ian
raises the patient's
right leg no mor e
than 30 degrees F ig ure 11.100. Step 3a.
and applies
traction down the
shaft of the leg
(w hite ar r ow, F ig.
11.99) .
a. Some prefer
to position
the leg
s lightly off the
s ide of the
table
approximately
10 to 20
degrees ( Fig .
53 of 87 21/08/07 22:09
11.100). F ig ure 11.101. Step 5.

4. This trac tion is
maintained as the
patient is as ked to
tak e 3 to 5 s low
breaths.
5. At the end of the
las t breath, the
phy sic ian delivers
a thrust in the
dir ection of the
traction ( white
arr ow, F ig .
11.101).
6. Effectiveness of
the technique is
determined by
reassessing r ight
sac roiliac joint
motion.
P.3 09
Pel vic Region: Left Posteri or Innomi nate Dysfuncti on,

Supine Ful crum
Diag nosis
Standing flexion
test: Positive (left
PSIS ris es)
Loss of pas siv ely
induced left
s acr oiliac motion
ASIS: Cephalad
the left
PSIS: Caudad
the left
Sacr al s ulc us:
Deep, anter ior on F ig ure 11.102. Steps 1 to 4.
the left
54 of 87 21/08/07 22:09
T ech niq u e
1. The patient is
supine, and
the physic ian
stands to the
patient's
right.
2. The
phy sic ian
flexes the
patient's
knees and
hips.
3. The F ig ure 11.103. Step 5.
phy sic ian
rolls the
patient's legs
toward the
phy sic ian.
4. The
phy sic ian
places the
thenar
eminence of
the cephalad
hand under
the patient's
left PSIS to
ser ve as a
fulcrum
agains t which
to mov e the
innominate
(F ig.
11.102).
5. The
phy sic ian
rolls the
patient onto
the left PSIS
with the
patient's
weight F ig ure 11.105. Step 6.
dir ectly over
the fulcr um
(w hite ar r ow,
Fig . 11.103).
6. The patient
55 of 87 21/08/07 22:09
extends the
left k nee and
then s lowly
lowers the
leg towar d
the table
(w hite
arr ows , F igs.
11.104 and
11.105),
causing a
short and
long lever ing
of the left
innominate.
7. Effectiveness
of the
tec hnique is
determined
by
reassessing
left s acr oiliac
joint motion.
P.3 10
Pel vic Region: Left Anteri or I nnominate Dysfunction, Lateral

Recumbent
Diag nosis
Standing flexion
test: Positive (left
PSIS ris es)
Loss of pas siv ely
induced left
s acr oiliac motion
PSIS: Cephalad
the left
ASIS: Caudad
the left
Sacr al s ulc us:
56 of 87 21/08/07 22:09
Posterior on the
left
T ech niq u e
1. The patient is
in the right
lateral
rec umbent
pos ition, and
the physic ian
stands at the
side of the
table fac ing
the patient F ig ure 11.107. Steps 2 to 5.
(F ig.
11.106).
2. The
phy sic ian
palpates
between the
spinous
proces ses of
L5 and S1
with the
cephalad
hand.
3. The
phy sic ian's
caudad hand
flexes the
patient's hips
and knees
until the L5
and S1
spinous
proces ses
separate.
4. The
phy sic ian
pos itions the
patient's left
leg so that it
drops off the F ig ure 11.109. Steps 7 and 8.
side of the
table, ov er
and slightly
mor e flex ed
than the r ight
57 of 87 21/08/07 22:09
leg. T he
patient's foot
should not
touch the
floor.
5. The
phy sic ian
places the
caudad
for ear m in a
line between
the patient's
left PSIS and
trochanter
and the
cephalad
hand or
for ear m on
the patient's
left s houlder
(F ig.
11.107).
6. The
phy sic ian
introduces
axial rotation
in opposing
dir ections by
gently
pus hing the
patient's left
shoulder
dor sally
(posterior ly)
and rolling
the pelvis
ventrally
(anter ior ly)
(w hite ar r ow,
Fig . 11.108).
These
motions
should be
continued
until
mov ement of
the sacrum is
palpated at
the left
58 of 87 21/08/07 22:09
sac roiliac
joint.
7. If no motion
is felt, the
phy sic ian
grasps the
patient's right
arm and
draws the
shoulder
for war d until
rotational
mov ement is
elicited at the
left s acr oiliac
joint.
8. With the
patient
relaxed and
not guarding,
the physic ian
delivers an
impuls e along
the shaft of
the femur
(w hite
arr ows , F ig.
11.109).
9. Effectiveness
of the
tec hnique is
determined
by
reassessing
left s acr oiliac
joint motion.
P.3 11
Pel vic Region: Ri ght Anteri or Innomi nate Dysfuncti on, Leg
Pul l
59 of 87 21/08/07 22:09
Diag nosis
Standing flexion
test: Positive (r ight
PSIS ris es)
Loss of pas siv ely
induced right
s acr oiliac motion
PSIS: Cephalad
the right
ASIS: Caudad
the right
Sacr al s ulc us:
Posterior on the F ig ure 11.110. Steps 1 to 3.
r ight
T ech niq u e
1. The patient is
supine and
the physic ian
stands at the
foot of the
table.
2. The
phy sic ian
grasps the
patient's right F ig ure 11.111. Step 4.
ank le.
3. The patient's
right leg is
raised 45
degrees or
mor e and
traction is
applied down
the shaft of
the leg ( white
arr ow, F ig .
11.110)
4. This trac tion
is maintained
and the F ig ure 11.112. Step 5.
patient is
ask ed to take
3 to 5 slow
breaths. At
60 of 87 21/08/07 22:09
P.3 12
Upper E xtremi ty Regi on: Wri st, Dorsal Carpal Dysfunction
Diag nosis
Symptoms : Wris t
disc omfort with
inability to fully
extend the wrist
Palpation: Dor sal
prominence and/or
pain of a s ingle
c arpal bone
T ech niq u e
1. The patient is
seated on the
table, and the F igu re 11.113. Steps 1 and 2.
phy sic ian is
standing
fac ing the
patient.
2. The
phy sic ian
grasps the
patient's
wrist with the
phy sic ian's
thumbs on
the dorsal
aspect of the
wrist (F ig .
F igu re 11.114. Steps 3 and 4.
11.113).
3. The dorsally
dys functional
car pal bone
is identified
with the
phy sic ian's
thumbs .
4. The
phy sic ian
places the
thumb over
the displaced
car pal bone
and F igu re 11.115. Step 5.
61 of 87 21/08/07 22:09
reinforces it
with the other
thumb.
Phy sic ian's
other fingers
wrap around
palmar
sur fac e ( F ig.
11.114).
5. A s imple
whipping
motion is
car ried out,
maintaining
pressure
over the
dis placed
car pal bone
(w hite ar r ow,
Fig . 11.115).
(No tr action
is needed for
this
tec hnique.)
6. Effectiveness
of the
tec hnique is
determined
by
reassessing
both the
prominent
car pal bone
and wr ist
range of
motion.
P.3 13
Upper E xtremi ty Regi on: El bow, Fl exi on Dysfunction (Distal

Elbow, Ulna)
62 of 87 21/08/07 22:09
Diag nosis
Symptom: Elbow
disc omfort
Motion: Inability to
fully ex tend the
elbow
Palpation:
O lec ranon foss a
palpable ev en
when elbow is fully
extended
T ech niq u e
1. The patient is F ig ure 11.116. Steps 1 and 2.

seated on
table and the
phy sic ian is
standing in
front of
patient.
2. The wr ist of
the ar m to be
treated is
held against
the
phy sic ian's
waist using
the elbow F ig ure 11.117. Steps 3 and 4.
(F ig.
11.116).
3. The
phy sic ian
places the
thumbs on
top of the
for ear m in
the ar ea of
the
antecubital
fos sa.
4. Traction is
down towar d
the floor ; the F ig ure 11.118. Step 5.
elbow is
car ried into
fur ther
flexion ( white
63 of 87 21/08/07 22:09
P.3 14
Upper E xtremi ty Regi on: El bow, Extension Dysfuncti on

(Proxi m al Elbow, Ulna)
Diag nosis
Symptom: Elbow
disc omfort
Motion: Inability to
fully flex the elbow
Palpation: No
palpable olecr anon
foss a with the
elbow fully
extended
T ech niq u e
1. The patient is
seated on the F ig ure 11.120. Steps 1 to 3.
table, and the
phy sic ian is
standing
fac ing the
patient.
2. The patient's
arm to be
treated is
held against
phy sic ian's
waist with the
phy sic ian's
elbow against
the patient's F ig ure 11.121. Step 4.
hand.
3. The
phy sic ian
places the
thumbs on
top of the
for ear m in
the region of
the
antecubital
fos sa (F ig .
11.120).
4. The patient is
ask ed to
64 of 87 21/08/07 22:09
res ist F ig ure 11.122. Step 4.

minimally
(b lack
arr ows , F igs.
11.121,
11.122,
11.123) as
the physic ian
applies
traction down
toward the
floor (w hite
arr ow, F ig .
11.121).
Maintaining
this trac tion, F ig ure 11.123. Step 4.
the patient's
elbow is
car ried into
full extension
(w hite
arr ows , F igs.
11.122 an d
11.123).
5. Effectiveness
of the
tec hnique is
determined
by
reassessing
elbow
extens ion.
P.3 15
Upper E xtremi ty Regi on: El bow, Radial Head, Supination

Dysfunction
65 of 87 21/08/07 22:09
Diag nosis
Symptoms :
Disc omfort at the
r adial head
Motion: Los s of
pass ive pronation
of the forearm
Palpation: Anterior
prominence and
tenderness of the
r adial head
T ech niq u e
1. The patient is F ig ure 11.124. Steps 1 and 2.

seated on the
table and the
phy sic ian is
standing
fac ing the
patient.
2. The
phy sic ian
holds the
hand of the
dys functional
arm as if
shaking
hands with F ig ure 11.125. Steps 3 and 4.
the patient.
The
phy sic ian
places the
thumb of the
opposite
hand anter ior
to the radial
head ( Fig
11.124).
3. The
phy sic ian
rotates the
for ear m into
pronation
until the
res trictiv e
bar rier is
reached.
66 of 87 21/08/07 22:09
P.3 16
Upper E xtremi ty Regi on: El bow, Radial Head, Pronation

Dysfunction
Diag nosis
Symptoms :
Disc omfort at the
r adial head
Motion: Los s of
pass ive supination
of the forearm
Palpation:
Posterior
prominence and
tenderness of the
r adial head
T ech niq u e
1. The patient is
seated on the
table, and the
phy sic ian is
standing
fac ing the
patient.
2. The
phy sic ian
holds the
hand of the
dys functional
arm as if
shaking F ig ure 11.127. Steps 3 and 4.
hands with
the patient.
The
phy sic ian
places the
thumb of the
opposite
hand
pos ter ior to
the radial
head ( Fig
11.126).
3. The
phy sic ian
67 of 87 21/08/07 22:09
rotates the
for ear m into
supination
until the
res trictiv e
bar rier is
reached.
4. With the
patient
completely
relaxed, the
phy sic ian
car ries the
for ear m into
extens ion
and
supination
while
maintaining
thumb
pressure
over the
pos ter ior
radial head
(F ig 11.127).
5. Effectiveness
of the
tec hnique is
determined
by retesting
pronation of
the forear m
and palpating
for reduc ed
prominenc e
of the radial
head.
P.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), S upi ne
68 of 87 21/08/07 22:09
Diag nosis
Symptoms : Knee
disc omfort,
inability to
c omfortably ex tend
the knee
Motion: Res tricted
posterior s pring
( drawer - lik e test)
with los s of
anterior fr ee play
motion
Palpation:
Prominence of
tibial tuberos ity F ig ure 11.128. Steps 1 to 3.
T ech niq u e
1. The patient is
supine with
the
dys functional
knee flex ed
to 90
degrees with
foot flat on
the table.
2. The
phy sic ian sits F ig ure 11.129. Step 4.
on the
patient's foot
anc hor ing it
to the table.
3. The
phy sic ian
places the
thenar
eminences
over the
anterior
aspect of the
tibial plateau
with the
finger s
wrapping
around the
leg (F ig.
11.128).
69 of 87 21/08/07 22:09
P.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), S eated
Diag nosis
Symptoms : Knee
disc omfort,
inability to
c omfortably ex tend
the knee
Motion: Res tricted
posterior s pring
with los s of
anterior fr ee play
motion
Palpation:
Prominence of
tibial tuberos ity F ig ure 11.130. Steps 1 and 2.
T ech niq u e
1. The patient is
seated on the
side of the
table with a
small pillow
beneath the
thigh as a
cus hion.
2. The
phy sic ian
places the F ig ure 11.131. Step 3.
thumbs on
the anter ior
tibial plateau
with the
finger s
wrapping
around the
leg (F ig.
11.130).
3. The thigh is
spr ung up
and down to
ens ure total
relaxation of
70 of 87 21/08/07 22:09
the thigh F ig ure 11.132. Step 4.

mus culatur e
(w hite
arr ows , F ig.
11.131).
4. A thrust is
delivered
str aight down
toward the
floor,
simultaneous
with a
pos ter ior
pressure
impuls e with
the thumbs
(w hite
arr ows , F ig.
11.132).
5. Effectiveness
of the
tec hnique is
determined
by
reassessing
anterior free
play glide as
well as r ange
of motion of
the knee.
P.3 19
Lower E xtremi ty Regi on: Knee: Posteri or Dysfunction of the

Tibia on the Fem ur (Anteri or Femur Over Tibia), Prone
71 of 87 21/08/07 22:09
Diag nosis
Symptoms : Knee
disc omfort, inability
to c omfortably flex
the knee
Motion: Res tricted
anterior spring
with los s of
posterior free play
motion
T ech niq u e

lies prone with
the
dys functional
knee flex ed to
approx imately
90 degrees if
pos sible.
2. The physic ian
stands or sits
at the end of
the table with
the dorsum of
the patient's
foot on the F ig ure 11.134. Step 4.
anteromedial
aspect of the
phy sic ian's
shoulder.
Place- ment of
patient's foot
on phy sic ian's
shoulder will
plantar-flex
the foot,
tak ing tension
off the
gas trocnemius
mus cle.
3. The
phy sic ian's
finger s ar e
interlaced and
wrapped
72 of 87 21/08/07 22:09
P.3 20
Lower E xtremi ty Regi on: Knee: Posteri or Dysfunction of the

Tibia on the Fem ur (Anteri or Femur Over Tibia), Seated
Diag nosis
Symptoms : Knee
disc omfort,
inability to
c omfortably flex
the knee
Motion: Res tricted
posterior s pring
with los s of
anterior fr ee play
motion
T ech niq u e
1. The patient is
seated on the
side of the
table with a
small pillow
beneath the
thigh as a
cus hion.
2. The
phy sic ian
places the
thumbs on
the anter ior
tibial plateau F ig ure 11.136. Steps 3 and 4.
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
73 of 87 21/08/07 22:09
the table
(F ig.
11.135).
3. The thigh is
then s prung
up and down
to ens ure
total
relaxation of
the thigh
mus culatur e.
4. A thrust is
delivered
down towar d
the floor
(w hite ar r ow,
Fig . 11.136),
simultaneous
with an
anterior
pressure
impuls e with
the popliteal
contac ting
finger s.
5. Effectiveness
of the
tec hnique is
determined
by
reassessing
anterior free
play glide and
range of
motion of the
knee.
P.3 21
Lower E xtremi ty Regi on: Knee: Anteri or Fibular Head

Dysfunction
74 of 87 21/08/07 22:09
Diag nosis
Symptoms : Lateral
leg sor enes s and
musc le c ramping
with tender nes s ov er
the prox imal fibula
Motion: Inc reased
anterior glide with
r estric ted motion of
the prox imal fibula
posterior glide
History : Common
following a medial
ankle s prain, for c ed
dors iflexion of the F ig ure 11.137. Steps 1 to 3.
ankle, genu
r ecurvatum
deformity
T ech niq u e
1. The patient lies

supine with a
small pillow
under the
dys functional
knee to
maintain the
knee in s light F ig ure 11.138. Steps 4 and 5.
flexion.
2. The physic ian's
caudad hand
internally
rotates the
patient's ank le
to bring the
proximal fibula
mor e anter ior .
3. The physic ian
places the heel
of the cephalad
hand over the
anterior
sur fac e of the
proximal fibula
(F ig. 11.137) .
4. A thrust is
delivered
75 of 87 21/08/07 22:09
P.3 22
Lower E xtremi ty Regi on: Knee: Posteri or Fibular Head

Dysfunction
Diag nosis
Symptoms : Pain at
the lateral knee,
pers istent ank le
pain bey ond that
expected for
normal ankle
r ecover y
Motion: Inc reased
posterior glide and
decr eas ed anterior
glide
Palpation:
T enderness at the
fibular head; fibular F ig ure 11.139. Steps 1 to 4.
head pr ominent
posteriorly
History : Common
following inversion
s prains of the
ankle
T ech niq u e
1. The patient
lies prone
with the
dys functional
knee flex ed F ig ure 11.140. Step 5.
at 90
degrees.
2. The
phy sic ian
stands at the
side of the
table
opposite the
side of the
dys function.
3. The
phy sic ian
places the
MCP of the
76 of 87 21/08/07 22:09
cephalad F ig ure 11.141. Step 6.

index finger
behind the
dys functional
fibular head,
and the
hypothenar
eminence is
angled down
into the
hamstr ing
mus culatur e
to for m a
wedge behind
the knee.
4. The
phy sic ian's
caudad hand
grasps the
ank le on the
side of
dys function
and gently
flexes the
knee until the
res trictiv e
bar rier is
reached
(F ig.
11.139).
5. The patient's
foot and leg
are gently
externally
rotated to
car ry the
fibular head
bac k against
the fulcr um
for med by
the
phy sic ian's
cephalad
hand ( white
arr ow, F ig .
11.140).
6. The
phy sic ian's
caudad hand,
77 of 87 21/08/07 22:09
controlling
the patient's
foot and
ank le,
delivers a
thr ust toward
the patient's
buttoc k in a
manner that
would
nor mally
res ult in
fur ther
flexion of the
knee ( white
arr ow, F ig .
11.141).
However, the
wedge
fulcrum
for med by
the
phy sic ian's
cephalad
hand
prevents any
suc h motion.
7. Effectiveness
of the
tec hnique is
determined
by
reassessing
motion of the
fibular head
and by
palpating for
res tor ation of
nor mal
pos ition of
the fibula.
P.3 23
Lower E xtremi ty Regi on: Knee: Anteri or Medi al Meni scus

Dysfunction
78 of 87 21/08/07 22:09
Diag nosis
Symptoms : Medial
k nee dis comfor t,
lock ing of the knee
s hor t of full
extension
Phys ical findings :
Palpable bulging of
the meniscus just
medial to the
patellar tendon,
positiv e
MacMurr ay's test,
positiv e Apley 's
c ompres s ion test F ig ure 11.142. Steps 1 to 3.
T ech niq u e
1. The patient
lies s upine
with hip and
knee flex ed.
2. The physic ian
stands at the
side of the
table on the
side of the
dys function.
3. The physic ian F ig ure 11.143. Step 4.
places the
ank le of the
dys functional
leg under the
phy sic ian's
axilla and
agains t the
lateral r ib
cage ( Fig .
11.142).
4. The physic ian
places the
thumb of the
medial hand
over the F ig ure 11.144. Step 5.
bulging
menisc us.
The finger s of
the later al
79 of 87 21/08/07 22:09
P.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. The patient
lies s upine,
and the
phy sic ian
stands at the F ig ure 11.146. Steps 1 to 3.
foot of the
table.
2. The
phy sic ian's
one hand
cups the
calcaneus
anc hor ing the
foot ( slight
traction may
be applied).
3. The
phy sic ian
places the
other hand
on the
anterior tibia
proximal to
the ankle
mor tis e ( F ig.
11.146).
4. A thrust is
delivered with
the hand on
the tibia
str aight down
toward the
table (w hite
arr ow, F ig .
80 of 87 21/08/07 22:09
11.147).
5. Effectiveness
of the
tec hnique is
determined
by
reassessing
ank le range
of motion.
P.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. The patient
lies s upine,
and the
phy sic ian
stands at the F ig ure 11.148. Steps 1 to 3.
foot of the
table.
2. The
phy sic ian's
hands are
wrapped
around the
foot with the
finger s
interlaced on
the dorsum.
3. The foot is
dor siflex ed to
the motion
bar rier us ing
81 of 87 21/08/07 22:09
pressure
from the
phy sic ian's
thumbs on
the ball of the
foot ( Fig .
11.148).
4. Traction is
placed on the
leg at the
same time
dor siflex ion
of the foot is
inc reased
(w hite F ig ure 11.150. Step 5.
arr ows , F ig.
11.149).
5. The
phy sic ian
delivers a
tractional
thr ust foot
while
inc reasing
the degree of
dor siflex ion
(w hite
arr ows , F ig.
11.150).
6. Effectiveness
of the
tec hnique is
determined
by
reassessing
ank le range
of motion.
P.3 26
Lower E xtremi ty Regi on: Foot: Cuneiform, Pl antar

Dysfunction (Dr. Hiss's Whi p Technique)
82 of 87 21/08/07 22:09
Diag nosis
Symptom: Plantar
disc omfort.
Motion:
Longitudinal arch
and for efoot will
not readily spring
toward s upination.
Palpation: Tender
prominence on the
plantar sur fac e of
the foot ov erlying
the dys func tional
c uneifor m.
F igu re 11.151. Steps 1 to 3.
T ech niq u e
1. The patient
lies prone
with the leg
off the table
flexed at the
knee.
2. The
phy sic ian
stands at the
foot of the
table.
3. The
F igu re 11.152. Step 4.
phy sic ian's
hands are
wrapped
around the
foot with the
thumbs
placed ov er
the dr opped
cuneiform
(F ig.
11.151).
4. A whipping
motion is
car ried out
with the
thumbs
thr usting
str aight down
into the s ole
83 of 87 21/08/07 22:09
P.3 27
Lower E xtremi ty Regi on: Foot: Fifth Metatarsal Dysfuncti on,

Plantar Styloid
Diag nosis
History : Common
following inversion
s prain of the ank le.
T ech niq u e
1. The patient lies

supine.
2. The physic ian
sits at the foot
of the table.
3. The physic ian
places the
thumb over the F ig ure 11.153. Steps 1 to 4.
dis tal end of
the fifth
metatarsal.
4. The physic ian
places the
MCP of the
index finger
beneath the
sty loid pr ocess
(F ig. 11.153) .
5. A thrust is
delivered by
both fingers
simultaneously. F ig ure 11.154. Step 5.
The thumb
exerts
pressure
toward the
sole, and the
index finger
exerts a forc e
toward the
dor sum of the
foot ( white
arr ows , F ig.
11.154).
6. Effectiveness
of the
84 of 87 21/08/07 22:09
tec hnique is
determined by
reassessing
pos ition and
tender nes s of
the styloid
proces s of the
fifth metatar sal.
P.3 28
Lower E xtremi ty Regi on: Foot: Cuboid, Pl antar Rotation
Diag nosis
T enderness:
Lateral plantar
aspect of the foot
just pr oximal to the
s tyloid proces s of
the fifth metatar s al
and over lying the
tendon of the
peroneus longus
musc le
Palpation: Groove
distal to the sty loid
proc ess of the fifth
metatar s al deeper F ig ure 11.155. Steps 1 to 4.
than nor mal;
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. The patient
lies prone
with the leg
flexed 30
degrees at
85 of 87 21/08/07 22:09
the knee.
2. The
phy sic ian
stands at the
foot of the
table.
3. The
phy sic ian
places the
thumb on the
medial side of
the foot over
the plantar
prominenc e
of the cuboid. F ig ure 11.157. Step 6.
4. The
phy sic ian's
thumb on the
lateral s ide of
the foot
reinforces
the medial
thumb (F ig .
11.155).
5. The later al
aspect of the
foot is
opened by
adducting the
for efoot ( Fig .
11.156).
6. The thrus t is
delivered in a
whipping
motion
toward the
lateral as pec t
of the foot
(w hite
arr ows , F igs.
11.157 and
11.158).
7. Effectiveness
of the
tec hnique is
determined
by
reassessing
the position
86 of 87 21/08/07 22:09
and
tender nes s
of the cuboid.
P.3 29
References
1. W ar d R (e d) . F ou nda ti on s f or Os te opa thi c Me dic i ne . Ph i la del phia : L i pp i nco tt W il l i am s &

Wi l k in s , 200 3.
2. H ei l ig D. T he Th r us t Te c hn i qu e. J Am Os teop ath As s oc 198 1;8 1:24 4–2 48.
3. Gre enm an P. P r in c ip l es of M an ual M ed i ci ne, 2nd ed . Ba l ti m or e: W i ll i am s & W il k in s , 1 996 .
4. M od i fi ed w i th pe r mi s s io n f r om Agu r A M R, D al l y AF. Gra nt' s A tl as of An atom y , 11t h ed .

Ba l tim ore : L i ppi nco tt W i ll i am s & W il k in s , 2005 .
87 of 87 21/08/07 22:09
12
Facilitated Positional Release Techniques
Fac i l it a te d p o s it i on a l r e le a se (F P R) t ec h ni q u e i s a p a t ie n t- p as s i ve , i n di r e c t te c hn i q ue ,
a nd a s s uc h , i t s h ar e s p r in c ip l es wit h t h e o t he r i n di r e c t os t eo p a th i c t ec h n iq u es ,
e sp e c ia l ly my o f as c ia l r e l ea s e, ba l a nc e d l ig a men t ou s t e n si o n, an d li g am e nt o u s a rt i cu l a r
s tr a i n. I t s p o s it i on i ng i s v er y s i mil a r t o c o un t er s tr a i n a nd th e in i ti a l i n di r ec t p o s it i on i ng
f or S ti l l t ec h n iq u e. Th e Ed u ca t io n Co u nc i l o n O s te o pa t h ic Pr i nc i p le s ( E CO P ) d e fi n es
FPR a s “ a s y s t e m o f i nd i r ec t m y of a s ci a l r el e a se tr e at me nt de v el o p ed by St a n le y
S ch i o wi t z , DO . Th e c o mp o n en t r e gi o n o f t h e b o dy is pl a c ed in t o a ne u tr a l p o si t io n ,
d im i n is h in g t i s su e a n d j o in t t e ns i o n i n a ll p la n es an d an ac t iv a t in g f o rc e (c o mp r es s i on
o r t o rs i on ) i s ad d ed ” ( 1 ) . The pr i mar y g o al o f t hi s t e c hn i qu e i s to re d uc e ab n or mal
mus c l e h yp e rt o n ic i t y (s u p er f ic i al a nd de e p) a nd re s to r e l o s t mo t i on to a r e s t r ic t ed
a rt i c ul a ti o n.
A s wi th co u nt e r s t r ai n t e c hn i qu e , t h e p ri mar y ne u ro p hy s i ol o gi c m e c ha n is m a f f ec t ed by
FPR i s t ho u gh t to be th e re l at i on s h ip be t we e n I α-a f fe r e nt an d γ - e f f e re n t a c ti v it y
( 1, 2 , 3) . I f t h e d y s f u nc t i on a l r eg i o n i s p os i t io n ed ap p r op r ia t el y , t h e i nt r a fu s al fi b e rs
may r et u rn to n or mal le n g th , w h ic h in re t ur n de c re a se s te n si o n i n t h e e x t r a fu s al fi b e rs .
Thi s re d uc e d t e ns i on in t he ar e a o f t h e mus c l e s pi n dl e fu r th e r d e cr e as e s t h e
I α- a f fe r en t i mp ul s es , w h i ch in tu r n c o nt i nu e s t h is be n e fi c ia l i n t er a c t i on , ev e nt u al l y
a ll o win g t h e mu s c l es to a ch i ev e t h e ir no r ma l le n gt h a n d t o ne (4 ) . O t he r b e n ef i ci a l
a sp e c t s of th i s f o rm of t re a tm e nt may be re l a te d t o t h e t r ea t me n t p o si t io n ' s s ec o nd a r y
e f f e c t s of im p r ov i ng ly mp ha t ic an d ve n ou s d r a in a ge an d ot h er bi o e le c tr i c p h en o me n a
a f f e c ti n g f lu i d d y na mic s an d l o ca l me t ab o li c pr o ce s se s .
The p ri n ci p le s of po s it i o ni n g i n t h is te c hn i q ue ar e b a s ic to in d i re c t t re a t me n t s , a n d
t he r e fo r e, th e ph y si c ia n wi l l a t t e mpt to pl a c e t he dy s f un c ti o na l se g me n t , mus c le , o r
o th e r s t ru c tu r e t o wa r d i t s p os i ti o n o f m o ti o n e a se or r ed u ce d t e n si o n. Th i s i s d o ne b y
f ir s t a t te mpt i n g t o p la c e t h e myo f a s c i al or a rt i cu l ar d y s f un c ti o n i n a ne u t ra l p o si t i on ,
whi c h S c hi o wi t z d e s c r ib e s a s f l at t e ni n g t he a nt e ro p os t e ri o r s pi n a l c ur v e ( f ac e t s ar e in
a p o s it i on be t wee n t h e b e gi n ni n g o f f l ex i on a nd th e b e g in n in g o f ex t en s io n ) ( 3 ). Wi t h a
f le x e d o r e x t e n de d d y s f u n c t i on , t h e i n it i al p os i ti o ni n g i s t o f l a t t e n t he a nt e ro p os t e ri o r
s pi n a l c ur v e a n d f in d t h e n e ut r al p os i ti o n wi th i n t he d y s f un c ti o n . Thi s e x a mp l e i s
c om mo n t o t yp e I I dy s fu n c ti o ns . W i t h t yp e I d y s f un c ti o n s , le s s a n te r io r a n d /o r
p os t e ri o r p os i t io n in g i s ne c es s ar y .
I f t h e p ri mar y fo c us is t he tr e at me nt of mu s c le hy p er t o ni c it y a n d t e ns i on ( wh e n t he r e
i s n o p r ed o mi n a nt x- , y - , z - ax i s d i ag n os i s) , th e h y pe r t on i c mus c l e i s p la c e d i n a
p os i t io n o f e a s e o f t en s i on . T h is i s b as e d o n p a lp a ti n g t h e a bn o r ma l t i s s u e t e x t u re s
a nd t he i r r es p o ns e t o p o s it i on i ng ( 3) . I f a d y s f un c ti o n al mu s cl e is ca u si n g t h or a ci c
t en s i on an t er i o rl y , f le x i on is th e mo s t p ro b a bl e p o si t i on of ea s e . P os t er i o r t ho r ac i c
mus c l e h yp e rt o n ic i t y co mmon l y i s a s so c ia t ed wit h a n e x t en d ed po s i ti o n o f e a se (2 ) .
1 of 29 21/08/07 22:10
The maj o r d is c r im i na t in g fa c to r w e se e i n t h i s t ec h ni q u e whe n c o mpa r in g i t to th e o t h er

i nd i r ec t t e ch n i qu e s i s i t s r el e as e - en h an c in g me c ha n is m. D i Gi o va n n a a nd Sc h i ow i t z
d es c r ib e t h is a s a f a ci l i ta t in g m u s cl e f o rc e (1 , 3) . T h i s may be a c o mp r es s i on fo r ce , bu t
i t c a n a c c o mm o d at e a l l d i re c ti o ns o f mot i on e as e o r d i r ec t io n s i n w h ic h t h e m u s c l e
t en s i on is re d u ce d . B ec a u se of si d e b e nd i ng a nd ro t at i o na l c o mp o n en t s i n mo s t
d y s f u nc t io n s ( s pi n al an d ex t re mit y ) i t i s g e n er a ll y n e c es s ar y f o r t h e p hy s i ci a n t o a d d
s om e fo r m o f t o rs i on (s i d e b en d in g co mbi n ed wit h r o ta t i on ) f o rc e du r in g t h e p o si t io n a l
c om p o ne n t o f t h e t ec h ni q u e. On ac h i ev i ng th e pr o pe r p o s it i on of e as e w i th t he
f ac i l it a ti n g f o rc e s , th e ph y si c ia n ma y a l so a dd a s li g h t o n- a nd - o f f sp r in g i ng (r o c k i n g)
f or c e . The ph y s ic i an ho l d s t he tr e a tm e nt po s i ti o n f or 3 t o 5 se c o nd s , r et u r ns th e
p at i e nt to ne u t ra l ( p re t r ea t me n t p o si t io n ), a nd fo l lo ws b y r e as s e s s i ng th e dy s fu n c t i o n
u si n g t h e p al p a to r y p ar a met e rs fo r ti s su e t e x tu r e c ha n g es , m o ti o n r e s t r ic t i on ,
a s y mmet r y , an d te n de r ne s s ( s en s it i v it y ).
P. 3 32
I ndi rect
A s wi th al l i n d ir e c t te c h ni q ue s , t h e p hy s ic i a n a t t e mp t s t o p o si t i on th e p a t ie n t i n t h e
d ir e c ti o n t ha t re d uc e s t h e myo f as c i al ti s su e te n si o n o r i n t h e d i re c ti o n o f t h e mot i o n
f re e d om .
Technique S tyl es
Myofasci al (Muscle Hypertoni city)

To t r ea t a hy p e rt o ni c m u s cl e w i th FPR , t h e p h y s i ci a n f l at t en s t h e s p in a l c u rv e i n t h e
r eg i o n o r s eg me nt to be t re a te d o r in th e e x t re mit i es , ad d in g c o mpr e s s i on t ow a rd th e
j oi n t . The n t h e p h y s i ci a n a s se s se s fo r t i s s u e t e x t u re c ha n ge s ( e . g. , t e ns i o n,
i ne l a s t i ci t y , b og g in e s s ) an d p o si t i on s t h e p a ti e nt un t i l t he s e d y s f u nc t io n a l p ar a me t e rs
a re o pt i ma l ly r ed u ce d . Ne x t , t h e p h y s i ci a n a d ds th e a p p ro p ri a te f ac i li t at i n g f or c es
( co mp re s si o n a n d t or s io n ) a n d h ol d s f o r 3 t o 5 s ec o nd s , t h en re t u rn s t h e a f fe c te d a r e a
t o a ne u tr a l p o si t io n a n d r e as s es s e s . I t is r ec o mm e nd e d t o u s e t h is s t y le i ni t ia l ly whe n
t he p hy s ic i an h as di f fi c u lt y d e te r min i ng th e pr i ma r y c o mp o ne n t o f t h e d y s f u nc t io n
( my o f as c ia l v e r su s a r ti c u la r ).
Arti cular (Intervertebral and I ntersegmental x-, y-, z -Axi s)

Dysfunction
I n a r ti c ul a r t e ch n iq u e, t he ph y si c i an us e s t h e p al p at o r y c lu e s f o r p ri mar y
i nt e r se g me n ta l (j o in t ) d y s f u nc t io n s . The s e c l ue s a r e g e ne r al l y t i s s u e t ex t u re ch a ng e s ,
r es t r ic t io n o f mo t io n , a s ym met r ic mot i on (m a y e x hi b it s ym met r ic a l ly re d uc e d m o ti o n) ,
e nd f ee l o r j o i nt fr e e- p l ay qu a li t a ti v e c ha n g es , a n d p a in . T h e p h y s i ci a n s t ar t s b y
f la t t en i ng th e an t er o po s t er i or sp i n al cu r ve o f t he re g i on be i ng t re a te d . Th e
d y s f u nc t io n al s eg men t s h o ul d t h en b e p os i ti o n ed to war d th e e a se o f mot i on i n a ll
a f f e c te d p l an e s . Nex t , t h e p hy s ic i a n a dd s t h e a p pr o pr i a te ax i al f ac i li t at i n g f or c es
( co mp re s si o n a n d t or s io n ) , h ol d s f o r 3 t o 5 s ec o nd s , a n d b ri n gs t he af f ec t e d a re a b a c k
2 of 29 21/08/07 22:10
t o a ne u tr a l p o si t io n f o r r e as s es s men t .
I ndi cati on
Myo f a s c i al or a rt i cu l ar s om a ti c d y s fu n c t i on
Contraindicati ons
1. Mod e r at e t o s e v er e j o in t in s ta b il i t y
2. Her n i at e d d is c wh e re th e po s it i on i n g c ou l d e x ac e rb a te t he co n di t i on
3. Mod e r at e t o s e v er e i n te r v er t eb r al f or a mi n al s te n os i s , e sp e ci a ll y in th e p r e se n ce
o f r a di c ul a r s y mp t om s a t th e l e ve l to be tr e a te d i f t h e p o si t io n i ng co u ld c au s e
e xa c e rb a ti o n o f t h e s ym p t om s b y f u r th e r n ar r o wi n g t he f or a me n
4. S ev e r e s pr a in s an d s t ra i n s whe r e t h e p os i ti o n in g m a y e x ac e rb a te t he in j ur y
5. Cer t a in co n ge n i ta l a n om a l ie s o r c o n di t io n s i n w h ic h t h e p o si t io n ne e de d t o tr e at
t he d y s f un c ti o n i s n o t p o s s i bl e ( e . g. , a n k y l o si s )
6. V er t e br o ba s il a r i n su f fi c i en c y

The p hy s ic i an mus t b e a b l e t o mak e an ac c ur a t e d ia g no s i s a nd wh e n p o s s i bl e to
d is t i ng u is h b e t we e n a m y o fa s ci a l a n d a n a rt i c ul a r d y s f u nc t io n . Th e a nt e ro p o s t e ri o r
s pi n a l c ur v e i s f l at t en e d , a nd th e n a po s it i o n o f e as e or a p os i t io n t h at max i ma l ly
r ed u c es my o fa s c ia l t e ns i o n i s a pp r o ac h ed . A f ac i li t at i n g f or c e o f c o mp r es s i on
c om b i ne d w i th s id e b e nd i n g a nd / or r ot a ti o n ( t or s io n ) i s a p pl i ed f or 3 t o 5 se c on d s . A
s pr i n gi n g f or c e m a y a ls o be us e d.
S horthand Rules
P rim ary Myofascial Dysfuncti on

1. Mak e di a gn o si s (t i s s u e t e x t u re ab n o rm a li t y) .
2. Fla t t en th e a n t er o po s te r i or sp i na l cu r ve to r ed u ce my o f as c ia l t e n si o n.
3. A dd a c o mp r es s i on or to r s io n al fa c i li t at i ng f or c e.
4. P la c e t h e d y s f u nc t io n al myo f as c ia l s t r uc t ur e in t o i t s e as e ( s ho r t en e d, re l a xe d )
p os i t io n .
5. Hol d fo r 3 to 5 s e co n ds , th e n s lo wl y r el e as e pr e s s u re whi l e r et u r ni n g t o n e ut r al .
6. The p hy s ic i an r ea s se s se s th e d y s f u n c t i on a l c o mp o ne n t s ( ti s su e t e x tu r e
a bn o r ma l it y , a s ym met r y o f p o si t io n , r e s t r ic t i on of mo t i on , t e nd e r ne s s [ TA RT] .
3 of 29 21/08/07 22:10
P rim ary Articul ar (x-, y-, z -axis) Type I and II Dysfuncti ons
1. Mak e di a gn o si s (e . g. , t y p e I o r I I ) .
2. Fla t t en (f l ex o r e x t e nd ) th e a n te r o po s te r io r cu r ve in t he sp i na l re g io n o f
t re a t me n t .
3. A dd t he fa c il i t at i ng fo r c e ( co mpr e s si o n o r t o rs i on ) .
P. 3 33
4. Mov e th e d y s f u n c t i on a l s e gm e nt to wa rd it s f l e xi o n o r e x te n si o n e a se .
5. Mov e th e d y s f u n c t i on a l s e gm e nt to wa rd it s s i d e b en d in g an d r o ta t i on a l e as e .
6. Hol d fo r 3 to 5 s e co n ds , th e n s lo wl y r el e as e pr e s s u re whi l e r et u r ni n g t o n e ut r al .
7. Rea s s es s t h e d y s f u nc t io n a l c om p on e n t s (T A RT ) .
P. 3 34
Cervi cal Region: Right: S ubocci pital Muscle Hypertonici ty

sup ine , a n d
the ph ysi cian
sits a t th e h ead
of the ta b le.
2. The ph ysi cian
gen tly su p ports
the occip i tal
and up per
cervical
reg ion s o f th e
patien t's hea d
with the righ t Figure 12.1. Step s 1 to 5.
han d.
3. With the l eft
han d o n th e
patien t's hea d,
the ph ysi cian
neu tra lize s the
cervical spin e
by gen tly
fla tte nin g th e
4 of 29 21/08/07 22:10
antero posteri or
curve (sl i ght
fle xio n).
4. 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 .
5. Whi le
mai nta ini n g Figure 12.2. Step s 1 to 5.
compre ssi o n,
the ph ysi cian
gen tly
positi ons the
patien t's hea d
and ce rvi cal
reg ion to w ard
extension and
rig ht sid e
ben din g a n d
rotati on
(a rrow s, Figs .
12.1 a nd 1 2.2 )
until maxi mal
red uction of
tissue an d
muscle te n sio n
is ach ieve d.
6. 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 .
7. If a rele a se is
5 of 29 21/08/07 22:10
not pa lpa ted

within a few
second s, a xia l
compre ssi o n
sho uld be
rel eased a nd
ste ps 3 to 6
can be
rep eated.
8. The ph ysi cian
rea sse sse s th e
compon ents of
the dysfu n cti on
(TART).
P. 3 35
Cervi cal Region: C2 to C4 Dysfuncti on Exampl e: C4 FSRRR*

sup ine , a n d
the ph ysi cian
sits a t th e h ead
of the ta b le.
2. The ph ysi cian
gen tly su p ports
the ce rvi cal
reg ion wi th the
rig ht han d .
3. With the l eft
han d o n th e
patien t's hea d, Figure 12.3. Step s 1 to 5.
the ph ysi cian
neu tra lize s the
cervical spin e
by gen tly
fla tte nin g th e
antero posteri or
6 of 29 21/08/07 22:10
curve (sl i ght

fle xio n).
4. 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. Whi le
mai nta ini n g
compre ssi o n, Figure 12.4. Step s 1 to 5.
the ph ysi cian
gen tly
positi ons the
patien t's hea d
tow ard fl e xio n
and ri ght sid e
ben din g a n d
rotati on
(a rrow s) u nti l
maxima l
red uction of
tissue an d
muscle te n sio n
is ach ieve d
(Figs. 12 .3 a nd
12.4).
6. 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 .
not pa lpa ted
within a few
7 of 29 21/08/07 22:10
second s, a xia l
compre ssi o n
sho uld be
rel eased a nd
ste ps 3 to 6
can be
rep eated.
8. The ph ysi cian
rea sse sse s th e
compon ents of
the dysfu n cti on
(TART).
P. 3 36
Thoracic Region: T4 to T12 Dysfunctions E xam ple: T6

E SRRR
1. The pa tie n t
sits a t th e
edg e o f th e
tab le with th e
physician
sta ndi ng a t
the ri ght sid e
and sl igh tly
posterior to
the pa tie n t.
2. The
physician 's
left h and Figure 12.5. Step s 1 to 3.
mon ito rs the
patien t's
dysfun cti o n
at the
spi nou s
pro cesses of
T6 and T7
8 of 29 21/08/07 22:10
and th e ri ght
tra nsverse
pro cess o f
T6.
3. The
physician
pla ces th e
rig ht fore arm
on the
patien t's
upp er rig h t
tra pezius
(sh oul der Figure 12.6. Step s 4 to 6.
girdle ) w i th
the
remain der of
the
physician 's
rig ht fore arm
and ha nd
restin g
across th e
patien t's
upp er back
just b ehi n d
the pa tie n t's
neck (Fig.
12.5).
4. The pa tie n t
sits u p
straig ht u nti l
the no rma l
tho racic
curvature is
straig hte n ed
and
fla tte ned , so
tha t
extension is
pal pated a t
the le vel of
T6.
9 of 29 21/08/07 22:10
5. The
physician 's
rig ht fore arm
app lie s a n
activa tin g
force in the
form o f
gen tle (1 lb
or less)
compre ssi o n.
6. Whi le
mai nta ini n g
compre ssi o n,
the ph ysi cian
pla ces a
cau dad an d
posterior
force with th e
rig ht fore arm
(w h ite arrow,
Fig. 1 2.6 ) to
positi on T6
into furth er
extension
and ri ght
sid e b end i ng
and ro tati on.
Thi s shou l d
be carrie d to
a p oin t o f
bal ance a n d
min imu m
muscle to n e.
7. The
physician
hol ds thi s
positi on for 3
to 5 seco n ds
and th en
slo wly
rel eases the
compre ssi o n
10 of 29 21/08/07 22:10
whi le
return ing to
neu tra l.
8. If a rele a se
is not
pal pated
within a few
second s,
compre ssi o n
sho uld be
rel eased a nd
ste ps 3 to 6
can be
rep eated.
9. The
physician
rea sse sse s
the
compon ents
of the
dysfun cti o n
(TART).
P. 3 37
Thoracic Region: Right-S i ded Trapez ius Muscl e

Hypertonici ty
11 of 29 21/08/07 22:10

pro ne on the
tre atment tab le
with the h ead
and ne ck rota ted
to the ri g ht.
2. The ph ysi cian
sta nds at the le ft
sid e, faci ng the
patien t.
3. The ph ysi cian 's
left h and
pal pates the Figure 12.7. Step s 1 to 3.
rig ht, hyp ertoni c
tra pezius muscle
(Fig. 12.7 ).
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 Figure 12.8. Step 4.
acromi ocl a vicula r
reg ion (Fig.
12.8).
5. The ph ysi cian
pla ces a caud ad
and po ste rior
force (w h i te
arrow, Fig. 1 2.9 )
to ach ieve a
poi nt of b ala nce
and mi nima l
muscle te n sio n i n
the ri ght Figure 12.9. Step 5.
tra pezius muscle .
6. On ach ievi ng the
12 of 29 21/08/07 22:10
P. 3 38
Costal Regi on: Left First Ri b Dysfunction, P osterior

E levation: Nonrespiratory Model , S oft-Tissue Effect
1. The pa tie n t
lie s supi n e
and th e
physician
sta nds fa cing
the pa tie n t o n
the
Figure 12.11. Ste ps 1 to 3.
dysfun cti o nal
sid e.
2. The pa tie n t's
left a rm i s
fle xed at the
elb ow, an d a
pil low or rol led
tow el is p laced
und er the
patien t's upp er
arm.
3. The
physician 's l eft
Figure 12.12. Ste p 4 .
han d controls
the ol ecra non
pro cess w h ile
the in dex and
thi rd fin g ers of
the ri ght han d
pal pate th e
posterior
asp ect of the
first rib ,
mon ito rin g fo r
tissue te xture
cha nge s (Fig. Figure 12.13. Ste p 5 .
12.11).
4. The
physician 's l eft
13 of 29 21/08/07 22:10
han d flexe s
the pa tie n t's
sho uld er to
app roxima tely
90 deg ree s
and th en
abd ucts
sli ghtly a nd
intern all y
rotate s th e
sho uld er to the
positi on that
pro duces the
most l axi ty a nd
soften ing of
the ti ssu e s
(Fig. 12.1 2).
5. The ph ysi cian
add ucts th e
arm an d
simultane o usl y
app lie s a
compre ssi o n
throug h th e
patien t's left
upp er arm
tow ard th e
mon ito rin g
fin gers a t th e
first rib
(strai ght arrow,
Fig. 1 2.1 3 )
whi le push ing
the pa tie n t's
elb ow dow n
tow ard th e
che st (cu rved
arrow) ove r
the pi llo w .
6. Thi s p osi tion is
hel d for 3 to 5
second s, a nd
14 of 29 21/08/07 22:10
a slig ht
on-and -off
pre ssu re can
be app lie d .
7. After 3 to 5
second s th e
arm is bro ugh t
throug h fu rth er
add uction and
the n i nfe riorly
swu ng back to
the la tera l
bod y l ine .
8. The ph ysi cian
rea sse sse s th e
compon ents of
the
dysfun cti o n
(TART).
P. 3 39
Costal Regi on: Left S eventh Rib, I nhal ati on Dysfunction
1. The pa tie n t l ies in

the ri ght latera l
recumb ent
(si de-lyi n g)
positi on w ith th e
arm fl exe d an d
abd ucted to
app roxima tely 90
deg ree s, a nd the
physician sta nds
or sits o n th e e dge
of the ta b le in
fro nt of the patien t Figure 12.14. Ste p 1 .
(Fig. 12.1 4).
15 of 29 21/08/07 22:10
2. The ph ysi cian

pla ces th e in dex
and /or th i rd fin ger
pad s o f th e righ t
han d o ver the
posterior asp ect of
the se ven th rib at
the
costotran sverse
articu lati on. Th e
thu mb is p laced
ove r the i nfe rio r
edg e o f th e l ate ral Figure 12.15. Ste ps 2 a n d 3 .
asp ect of the
same rib.
web bin g o f th e l eft
han d (thu mb
abd ucted)
con tou rs the
antero late ral
asp ect of the
seventh ri b, bei ng
carefu l n o t to p ut
too mu ch p ressure
ove r the chon dra l Figure 12.16. Ste p 4 .
portio n (Fig.
12.15).
4. The ph ysi cian
gen tly pu shes th e
rib po ste rior
(a rrow ),
attemp tin g by th is
compre ssi o n to
diseng age the ri b
fro m the vertebra
(Fig. 12.1 6).
5. The ph ysi cian
add s a Figure 12.17. Ste p 5 .
cep hal ad-vectore d
force (bu cket
han dle ) to ward
16 of 29 21/08/07 22:10
the in hal a tio n

ease (arro w, Fig.
12.17), th rou gh
the bu cke t ha ndl e
vector.
hel d for 3 to 5
second s, a nd a
sli ght on -and -off
pre ssu re can be
app lie d.
7. After 3 to 5
second s th e rib is
pushed sl o wly
back to n e utral as
the pa tie n t b rin gs
the arm d o wn to
the la tera l b ody
lin e.
8. The ph ysi cian
rea sse sse s th e
compon ents of th e
dysfun cti o n
(TART).
P. 3 40
Lumbar Regi on: L1 to L5 Dysfunctions E xam ple: L3 NS LRR
17 of 29 21/08/07 22:10
1. The pa tie n t
lie s p ron e
on the ta b le.
A p ill ow may
be pla ced
und er the
abd ome n to
decrea se
the no rma l
lumbar
curvature .
2. The
physician Figure 12.18. Ste ps 1 to 3.
sta nds at the
left side of
the pa tie n t,
facing th e
patien t.
3. The
physician 's
left h and
mon ito rs the
patien t's L3
and L4
spi nou s
pro cesses Figure 12.19. Ste ps 4 a n d 5 .
and th e ri ght
tra nsverse
pro cess o f
L3 (Fig.
12.18).
4. The
physician
rests the left
kne e o n th e
tab le
aga inst th e
patien t's left
ili um. Figure 12.20. Ste p 6 .
5. The
physician
18 of 29 21/08/07 22:10
P. 3 41
Lumbar Regi on: L1 to L5 Dysfunctions E xam ple: L4 FS RRR
1. The pa tie n t
lie s i n th e l eft
latera l
recumb ent
positi on, and
the ph ysi cian
sta nds at the
sid e o f th e
tab le faci ng
the pa tie n t.
2. The
physician 's
rig ht fore arm Figure 12.22. Ste ps 1 a n d 2 .
and ha nd
con tro l th e
patien t's rig ht
antero late ral
che st wal l , a nd
the le ft fore arm
and ha nd
con tro l th e
rig ht pel vic
and lu mba r
reg ion (Fig.
12.22).
3. The Figure 12.23. Ste p 3 .
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
19 of 29 21/08/07 22:10
and co ntro l the Figure 12.24. Ste ps 4 to 7.

tra nsverse
pro cesses of
L5 (Fig.
12.23).
4. 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.
5. The ph ysi cian
carefu lly
pushes th e Figure 12.25. Ste p 8 .
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.
6. 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 .
7. The pa tie n t
inh ale s a n d
exh ale s fu lly.
On exh ala tion ,
the ph ysi cian ,
with b oth the
forearms a nd
fin gers o n th e
tra nsverse
20 of 29 21/08/07 22:10
pro cesses,
increa ses the
force thro ugh
the sa me set
of rotati o nal
vectors
(cu rve d
arrows, Fig.
12.24),
simultane o usl y
app roxima ting
the fo rea rms
(strai ght
arrows),
the reb y
pro ducing
increa sed sid e
ben din g ri ght.
8. On ach ievi ng
the prope r
positi on, the
physician
app lie s a n
activa tin g
force (a rrows,
Fig. 1 2.2 5 ) i n
the fo rm o f a
gen tle (1 lb or
less) axi a l
compre ssi o n
for 3 to 5
second s w i th
the fi nge r
pad s.
not pa lpa ted
within a few
second s,
compre ssi o n
sho uld be
rel eased, and
ste ps 3 to 8
21 of 29 21/08/07 22:10
can be
rep eated.
10. The ph ysi cian
rea sse sse s th e
compon ents of
the
dysfun cti o n
(TART).
P. 3 42
Lumbar Regi on: Left-S ided Erector S pinae Muscle

Hypertonici ty
1. The pa tie n t
lie s p ron e on
the treatment
tab le. A
pil low ma y
be pla ced
und er the
abd ome n to
decrea se the
normal
lumbar
curvature .
The Figure 12.26. Ste ps 1 a n d 2 .
physician
faces the
patien t o n
the le ft.
2. Usi ng the left
han d, the
physician
mon ito rs the
patien t's
dysfun cti o nal
ere cto r
22 of 29 21/08/07 22:10
spi nae
hyp ertoni city
(Fig. 12.2 6).
3. The
physician 's
left knee is
pla ced on
the ta ble
aga inst th e
patien t's left
ili um.
4. The
physician Figure 12.27. Ste ps 3 a n d 4 .
cro sse s th e
patien t's
rig ht ankl e
ove r the
patien t's left
ankle and
gra sps th e
patien t's
rig ht kne e ,
sli din g b o th
of the
patien t's leg s
to the le ft Figure 12.28. Ste p 5 .
(Fig. 12.2 7).
5. The
physician
rep osi tio n s
the ri ght
han d to
gra sp the
patien t's
rig ht thi g h
and di rects a
force
dorsal ly a nd
tow ard Figure 12.29. Ste p 6 .
extern al
rotati on
(wh ite
23 of 29 21/08/07 22:10
arrows, Fig.
12.28). Th is
combin ed
moveme nt
sho uld be
carrie d to a
poi nt of
bal ance a n d
min imu m
muscle to n e
as percei ved
by the
physician 's
left h and .
6. On ach ievi ng
the prope r
positi oni n g,
the
physician 's
left h and
app lie s a n
activa tin g
force (w h i te
arrow, Fig.
12.29) in the
form o f a
gen tle (1 lb
or less) a xia l
compre ssi o n
for 3 to 5
second s.
7. If a rele a se
is not
pal pated
within a few
second s,
compre ssi o n
sho uld be
rel eased,
and steps 3
to 6 can b e
rep eated.
24 of 29 21/08/07 22:10
8. The
physician
rea sse sse s
the
compon ents
of the
dysfun cti o n
(TART).
P. 3 43
P elvi c Regi on: Left P osterior I nnom inate Dysfunction
1. The pa tie n t l ies in

the ri ght latera l
recumb ent
positi on, and th e
physician sta nds
in fro nt o f the
patien t a t th e side
of the ta b le.
rig ht arm rea che s
und er the
patien t's left thig h
and ab ducts i t to Figure 12.30. Ste ps 1 a n d 2 .
app roxima tely 30
deg ree s. The
physician con tro ls
the le g w i th thi s
arm an d th e
sho uld er (Fig.
12.30).
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
25 of 29 21/08/07 22:10
cre st, wi th the Figure 12.31. Ste ps 3 a n d 4 .

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.
rig ht han d is
pla ced ove r the
posterior ili ac
cre st and Figure 12.32. Ste p 5 .
posterior sup eri or
ili ac spi n e (PSIS)
with the fore arm
on the
posterola tera l
asp ect of the
gre ate r troch anter
(Fig. 12.3 1).
5. The ph ysi cian
add s a
posterior-vectored
force with a sli ght
arc (righ t-tu rn Figure 12.33. Ste p 6 .
direction ) wi th the
left h and (d o wn
arrow) as the ri ght
han d a nd fore arm
pul l i nfe riorly and
anteri orl y (u p
arrow) (Fig.
12.32).
6. As the pe l vis
rotate s
posteriorl y, the
physician add s a
compre ssi ve force
(1 lb or l ess)
tow ard th e ta ble
26 of 29 21/08/07 22:10
(a rrow , Fig.
12.33) to
app roxima te the
sacroi lia c jo int
surfaces.
hel d for 3 to 5
second s, a nd a
gen tle on -and -off
pre ssu re can be
app lie d.
8. If a rele a se is not
pal pated w ith in a
few se con d s,
compre ssi o n
sho uld be
rel eased, and
ste ps 3 to 8 can
be rep eate d.
9. The ph ysi cian
rea sse sse s th e
compon ents of th e
dysfun cti o n
(TART).
P. 3 44
P elvi c Regi on: Left Anterior Innom i nate Dysfunction
27 of 29 21/08/07 22:10
1. The pa tie n t
lie s i n th e
rig ht late ral
recumb ent
positi on, and
the ph ysi cian
sta nds in
fro nt of the
patien t a t th e
sid e o f th e
tab le.
2. The
physician 's Figure 12.34. Ste ps 1 a n d 2 .
rig ht arm
rea che s
und er the
patien t's left
thi gh and
abd ucts i t to
app roxima tely
30 to 40
deg ree s. The
physician
con tro ls the
leg wi th this
arm an d th e Figure 12.35. Ste ps 3 a n d 4 .
sho uld er (Fig.
12.34).
3. The ph ysi cian
pla ces th e le ft
han d p alm
dow n o ver the
sup eri or e dge
of the il i ac
cre st with th e
thu mb
con tro lli n g
the ASIS a nd
the ha nd Figure 12.36. Ste p 5 .
con tro lli n g
the su peri or
28 of 29 21/08/07 22:10
P. 3 45
References
1 . W a rd R. ( ed . ). Fou n da t io n s f o r O s t e o pa t hi c M e d ic i ne , 2 n d e d . P hi l a de l ph i a:
2 . J o ne s L, Ku s un o s e R, G oe r i ng E. Jo n e s S tr a in - Cou n te r s t r a in . B o is e : J o ne s
S t ra i n- Co un t er s tr a i n, 19 9 5.
3 . D i Gi o v an n a E , S c hi o wi t z S . A n O s te o p at h ic Ap p r oa c h t o Di ag n os i s a n d
Tr ea t me n t , 3 rd ed . Ph i la d el p h ia : L i pp i n co t t Wil l i am s & Wi l k in s , 2 00 5 .
4 . C a re w TJ . T h e Co nt r ol of Ref l ex Ac t i on : P r in c i pl e s o f Ne ur a l S ci e n ce , 2 n d e d .
Ne w Y or k : E l se v ie r , 1 9 85 .
29 of 29 21/08/07 22:10
13
Techniques of Still
Te c hnique Pr inciple s
As no ted ea r l ie r i n t hi s boo k , m any os teo path i c tec hniq ues ha v e g r os s s i m il ari tie s bu t f all i nt o d i ff er en t
c ateg ori es. T ec hni que s of St i ll i s no exc epti on; it m ay be a c l as s ic ex am pl e o f h ow a nu m be r of ot her
tec hn i qu es c omb i ne an d un der go a me tam orp hosi s t o b ec om e y et anot her te c hni que , i n th i s c as e, t he Sti l l
tec hn i qu e. Basi c al l y, Sti l l tec hniq ue i s a co m bi nat i on of s om e of th e c om po nen ts of i ndi r ec t, a r ti c ul ator y ,
and l ong - le v ere d h i gh - v el oci ty, l ow - am pli tude (H VLA ) te c hn i qu es . At Phi l ade l ph i a C oll ege of Ost eop ath i c
M edic i ne (P C OM) a num ber of the s e t ech niq ues w er e i nc lu ded in the s e oth er c ate gor i es ( HV LA,
ar tic ula tor y ) f or y ea r s a nd w er e us ed c om m onl y f or c ost al, lu m bar , i nno m i na te, an d ex tre m it y
dy s fu nct i on s (i .e. , Atl as of Os teop ath i c T ech niq ues , 19 74) . I n 20 00, wi th p ubl i ca ti on of Th e St i ll
T ec hn i qu e M anua l , by R i ch ard L. Van Bu s ki r k , D O, Ph D , F AAO , m any of the s e t ech niq ues bec ame m or e
for ma l ly st r uct ure d a nd c l as s if i ed. Th ere fore , w e h av e r ec l as s i fi ed tho s e p r ev i ou s l y tau ght as H VL A
tec hn i qu es i nto th i s c ate gor y .
Te c hnique Cla ssific ation
Indire ct, The n D ire ct

T he d i ag nos ti c c om pon ents fo r S ti ll te c hn i que ar e t he s ame fo r al l o s te opat hic te c hni que s ( ti ss ue tex ture
abnor m al i ty , as y mm etr y of po s it i on, re s tr i c ti on of m oti on, te nder nes s [ T ART ]). Th e ra nge of m ot i on an d
eas e- bin d ( ti gh t-l oos e) b arr i er asy m me tri es m ust be not ed, as the st art i ng poi nt of t his te c hni que is i n
i ndir ect po s i ti oni ng s i mi l ar to tha t o f f ac il i ta ted pos i ti ona l re l ea s e ( F PR ) a nd othe r i ndi r ect te c hn i que s .
F or e x am ple , if th e d y s fu nct i on i s doc ume nted as L4 , fl exe d, r ota ted ri ght, an d s i de- ben t r i ght (L 4
F R R SR ) , the i ni tia l ( i ndi r ec t) posi tio nin g wo uld be to m ov e L 4 in to fle x i on , r ota ti on ri ght , an d s i de
bendi ng r ig ht, w hi c h i s t he eas e or mo s t fr ee mo tio n av ail abl e in th e c ar di nal (x , y, z) pl anes of mo ti on .
C onti nui ng this pr i nc i ple of in di re c t pos i tio nin g, a sl i gh t c om pr ess i ve for c e m ay be add ed s i mi l ar to F PR
tec hn i qu e. T hen , u s in g a par t o f th e p ati ent' s a nat om y ( e. g., tru nk, ex tr em i ty ) t o ca use a l ong - le v er ed
for ce ve c to r , t he dys func tio nal s eg m en t i s ca r ri ed thro ugh a m oti on arc or pat h o f le ast re s i st anc e t ow ar d
the bi nd - ti ght r es tri c tiv e b arr i er. Ca r ry i ng the se gm en t t hro ugh a p ath of l ea s t r esi s ta nce i s i mp ort ant, as
the a r ti c ul ar s urf ace s an d o the r el eme nts ( e. g., bo ny , l ig ame ntou s ) s ho ul d not be c om pro m is ed a nd
s tr es s ed ; o ther w is e u ntow ard si de e ffe c ts , su c h as pain , c an r esu l t. Th i s m oti on at t he ter m i na l p has e
m ay b e s i mi l ar to a l ong- l ev ere d HV LA; ho w eve r , the dys fun c ti onal se gme nt d oes no t ne c es s ar i l y hav e t o
be mo v ed th r oug h t he r est r ic tiv e bi nd bar r i er , a s t he d y sf unc ti on al pat tern ma y b e el i mi nat ed d uri ng the
m ov em ent wi thin th e r ange be twe en e ase an d bi nd l im i ts. Th i s i s d i ff ere nt f r om HV LA, w he r ei n th e
r es tr i ct i ve bar r ie r i s me t a nd then pa s se d th r ou gh ( alb eit mi ni ma l ly ) . T her efo r e, i n i ts si m ple s t
des cr i pt i on , th i s tec hniq ue i s defi ned as “ a s pe c if i c n on- r ep etit i ve ar ti cu l at ory m et hod th at i s i ndi r ect
then dir ect ” (1 ,2) .
Te c hnique Sty les
C om pre ssion
W hen pos i ti onin g t he pati ent at the in dir ec t bar r ie r , t he phy s i ci an m ay att emp t a s li ght co m pre s si on of
1 of 33 21/08/07 22:10
the a r ti c ul ator y s urf ac es be for e be gin nin g th e t r an s fer of th e se gme nt towa r d the r es tri c ti v e b arr i er . Th i s
c om pr ess i on m ay he l p i n p r od uci ng a sl i gh t di s en gag em en t o f t he d y sf unc ti on . H owe v er, de pen di ng on
the p ati ent ' s h eal th and fun c ti onal ca pac i ty at the are a, i t m ay not be pru den t t o ho l d thi s co m pr ess i on at
the o uts et of m ove m en t to w ar d t he r est r ic ti ve ba r ri er , as a s hear ef fec t ca n
P.348
be pr odu c ed and th e a r tic ula r c ar ti l ag e m ay b e i nju r ed. Al s o, i f the pa ti en t h as any for ami nal nar r ow i ng,
ner ve ro ot i r ri tat i on m ay be an unw ant ed s i de ef fec t. T his te nds to be unco m fo r ta bl e for mo s t p ati ent s ,
and w e t y pi c all y r ele as e the co m pre s si on s i mu l ta neo us ly wi th the art i cu l ar m ov eme nt.
Tr a ction
W hen pos i ti onin g t he pati ent at the in dir ec t bar r ie r , t he phy s i ci an m ay att emp t a s li ght tr ac ti on of the
ar tic ula tor y su r fa c es bef ore be gi nn i ng th e tr ans fer of the se gm en t t owa r d t he r es tr ic tiv e b ar ri er. Th i s
di s tr act i on m ay he l p i n p r od uci ng a sl i gh t di s en gag em en t o f t he d y sf unc ti on . W e h av e fou nd that th i s i s
m or e c om for tabl e i n m any pat i en ts t han th e co m pr ess i on s ty l e.
Indica tions
1. Ar ti c ul ar s oma tic dy s fun c ti ons ass oci ate d wi th i nt er se gme nta l mo tio n r es tr i ct i on
2. M y of asc i al s om ati c d y s fu nct i on s as s oc i at ed w i th mu s c le hy per toni c it y o r fa s ci al bi nd
C ontra indica tions

1. Seve r e l os s of in ter s egm ent al m oti on s ec onda r y to s pon dyl osi s , o s te oar thri tis , o r rh eum ato i d
ar th r it i s i n t he are a to be tr eate d
2. M ode r at e t o se v er e j oi nt in s ta bi li ty i n the are a t o be tr eat ed
3. Ac ut e s tra i n o r s pra i n i n t he ar ea to be tre ate d i f th e t i ss ues m ay be fur the r c om pr omi s ed by the

m oti on i nt r odu c ed in the te c hn i que
P.349
C e r vic al Region: Oc cipitoa tla nta l (C 0—C 1, OA) Dys func tion
Ex a mple: C0 ESRR L, Sea ted*
2 of 33 21/08/07 22:10
1. T he patient
s its on the
table (if
pr efer red, this
may be
per for med with
the patient
s upine and
phy sic ian
s itting at head
of table) .
2. T he physician
s tands behind
the patient and F igure 13.1. Steps 1 to 3. Setup.
places the left
hand on top of
patient's head.
3. T he physician
places the
r ight index
finger pad ( or
thumb pad) at
the right
bas ioc ciput to
monitor motion
( F ig. 13.1). F igure 13.2. Step 4. Compr ess ion and side
4. T he physician bending to r ight.
adds a slight
c ompression
on the head
( s traight
ar r ow, F ig .
13.2) and
s ide-bends the
head to the
r ight (c ur ved
ar r ow) enough
to engage the
oc c iput on the
atlas,
approx imately F igure 13.3. Step 5. Rotation to left.
5 to 7 degrees.
5. T he physician
then r otates
head to the left
( ar row, F ig.
13.3) only
enough to
3 of 33 21/08/07 22:10
P.350
C e r vic al Region: Atlantoax ial (C 1 —C2 ) D ysfunction Ex a mple: C1

R L, Supine
s upine on the
tr eatment
table, and the
phy sic ian sits
or stands at
the head of the
table. This may
als o be
per for med with
the patient
s eated.
2. T he physician
places the F igu re 13.6. Step 2. Hand placement.
hands over the
par ietotempor al
r egions, and
the left index
finger pad
palpates the
left transver se
pr oces s of C1
( F ig. 13.6).
3. T he physician
r otates the
patient's head
to the left ease
bar rier ( arr ow,
F ig . 13.7). F igu re 13.7. Step 3. Rotate to eas e.
4. T he physician
introduces
gentle
c ompression
thr ough the
head directed
toward C1
( F ig. 13.8) and
then with
moderate
ac c eleration
begins to
r otate the head
toward the F igu re 13.8. Step 4. Compres sion.
4 of 33 21/08/07 22:10
r ight res tric tiv e

bar rier ( arr ow,
F ig . 13.9).
5. T he release
s hould oc cur
before the
r es trictive
bar rier is
engaged. If
not, the
phy sic ian
s hould not
c ar ry the head
and F igu re 13.9. Step 4. Rotate to bar r ier .
dy s functional
C1 mor e than a
few degrees
thr ough the
bar rier.
6. T he physician
r eevaluates the
dy s functional
( T ART)
c omponents.
P.351
C e r vic al Region: C2 to C7 Dys func tion Exam ple: C4 ESR RR,

Supine
1. T he patient
lies s upine on
the tr eatment
table.
2. T he
phy sic ian's
left index
finger pad
palpates the
patient's right
C4 articular
pr oces s.
3. T he physician
places the F ig ure 13.10 Steps 1 to 3. Hand plac ement.
5 of 33 21/08/07 22:10
r ight hand
ov er the
patient's head
s o that the
phy sic ian can
c ontrol its
mov ement
( F ig. 13.10) .
4. T he physician
ex tends the
head ( arr ow,
F ig . 13.11)
until C4 is
engaged.
5. T he physician F ig ure 13.11. Step 4. Extension to ease.
then r otates
and
s ide-bends the
head s o that
C4 is still
engaged ( Fig .
13.12) .
6. T he physician
introduces a
c ompression
for ce (s tr aight
ar r ow, F ig .
13.13) through
the head
dir ected
toward C4 and F ig ure 13.12. Step 5. Side-bend and rotate to
then with eas e.
moderate
ac c eleration
begins to
r otate and
s ide-bend the
head to the
left ( cur ved
ar r ows ),
s imultaneous ly
adding
gr aduated
flexion.
7. T he release
s hould
nor mally occ ur F ig ure 13.13. Step 6. Compres sion,
before the s ide-bending left and r otation left (SLRL) to
r es trictive bar rier.
6 of 33 21/08/07 22:10
bar rier is
engaged. If
not, the
phy sic ian
s hould not
c ar ry the head
and
dy s functional
C4 mor e than
a few degrees
thr ough the
bar rier.
8. T he physician
r eevaluates
the
dy s functional
( T ART)
c omponents.
P.352
Thorac ic Region: T1 and T2 Dy sfunctions Ex a mple: T1 ERRSR,

Se a ted
1. T he patient is
s eated (may be
per for med with
patient s upine).
2. T he physician
s tands in fr ont
of or behind the
patient.
3. T he physician
palpates the
dy s functional
s egment ( T1)
with index
finger pad of F ig ure 13.14. Step 3. Setup.
one hand while
c ontrolling the
patient's head
with the other
hand ( Fig .
13.14) .
7 of 33 21/08/07 22:10
4. T he physician,
with the
head-c ontrolling
hand, extends
the head
s lightly until this
motion is
palpated at T 1
( ar row, F ig.
13.15) .
5. T he physician
then intr oduc es
r ight side
bending and
r otation F ig ure 13.15. Step 4. Extend to ease.
( ar rows, Fig .
13.16) until this
oc c urs at T1.
6. Nex t, the
phy sic ian
introduces
gentle
c ompression
for ce thr ough
the head toward
T 1 and with
moderate
ac c eleration
begins to rotate
and side- bend
the head to the F ig ure 13.16. Step 5. Side-bend and rotate to
left ( arr ows , eas e.
F ig . 13.17),
s imultaneous ly
adding
gr aduated
flexion.
7. T his motion is
c ar ried towar d
the restr ictive
bar rier. The
r eleas e may
oc c ur before
the barrier is
met. If not, the
head must not
be car ried more F ig ure 13.17. Step 6. Compres sion, engage
than a few bar rier.
degrees
8 of 33 21/08/07 22:10
bey ond.
8. T he physician
r eevaluates the
dy s functional
( T ART)
c omponents.
P.353
Thorac ic Region: T1 and T2 Dy sfunctions Ex a mple: T2 FRLSL,

Supine
1. T he patient is
s upine on the
tr eatment table
( may be
per for med with
patient s eated).
2. T he physician
s its or s tands
at the head of
the table.
3. T he physician
palpates the
dy s functional
s egment ( T2)
with the index Fig u re 13.18. Step 3. Setup.
finger pad of
the left hand,
c ontrolling the
patient's head
with the other
hand ( Fig .
13.18) .
4. T he physician,
with the
head-c ontrolling
hand, flexes the
patient's nec k
s lightly (a r r ow,
F ig . 13.19) until
this motion is
palpated at T 2. Fig u re 13.19. Step 4. Flex to ease.
5. T he physician
9 of 33 21/08/07 22:10
introduces left
r otation and
s ide bending
( ar rows, Fig .
13.20) until this
motion oc cur s
at T2.
6. T he physician
introduces
gentle
c ompression
for ce thr ough
the head
( s traight ar r ow,
F ig . 13.21) Fig u re 13.20. Step 5. Side- bend and r otate to
toward T2 and eas e.
then with
moderate
ac c eleration
begins to rotate
and side- bend
the head to the
r ight (c ur ved
ar r ows , F ig.
13.21) with a
s imultaneous
gr aduated
ex tens ion (F ig.
13.22) .
7. T his motion is
c ar ried towar d Fig u re 13.21. Step 6. Compr ess ion, rotate
the restr ictive right and s ide-bend r ight ( RRSR).
bar rier, and the
r eleas e may
oc c ur before
the barrier is
met. If not, the
head must not
be car ried more
than a few
degrees
bey ond.
8. T he physician
r eevaluates the
dy s functional
( T ART) Fig u re 13.22. Step 6. Engaging extens ion,
c omponents. rotation r ight, s ide- bend r ight (ERRSR) barr ier .
P.354
10 of 33 21/08/07 22:10
Thorac ic Region: T3 to T12 Dy sfunctions Ex a mple: T5 N SLR R,

Se a ted
1. T he patient is
s eated on the
tr eatment
table.
2. T he physician
s tands or sits
to the left of
the patient.
3. T he physician
ins tructs the
patient to
place the right
hand behind
the neck and F igure 13.23. Steps 1 to 4. Positioning.
the left hand
palm down
ov er the right
antecubital
fos sa.
4. T he
phy sic ian's left
hand r eac hes
under the
patient's left
ar m or lies
palm down
ov er the
patient's right
F igure 13.24. Step 5. Monitor ing T5- T6.
humerus ( Fig .
13.23) .
5. T he physician
places the
r ight thenar
eminence over
the T6 left
tr ansv ers e
pr oces s and
the thumb and
index finger
ov er the left
and right
tr ansv ers e
pr oces ses of F igure 13.25. Step 6. Side-bend left, r otate
T 5, r ight (SLRR) .
r es pec tiv ely
11 of 33 21/08/07 22:10
( F ig. 13.24) .
6. T he physician
gently
pos itions the
patient's
thorac ic spine
to T5 in side
bending left
and rotation
r ight (a r r ows ,
F ig . 13.25).
7. T he physician,
while
maintaining the F igure 13.26 Step 7. Add c ompres sion.
s pine in
neutral
pos ition
r elative to
T 5- T6, adds a
c ompression
for ce thr ough
the spine to T5
( ar row, F ig.
13.26) by
gently pulling
or leaning
down on the
patient. The
phy sic ian F igure 13.27. Step 7. Acc eler ating to
s imultaneous ly s ide- bend right, rotate left (SRRL) bar rier.
introduces
s ide bending
r ight (c ur ved
s weep arr ow)
and rotation
left ( cur ved
ar r ow, F ig .
13.27) .
8. T his motion is
c ar ried towar d
the restr ictive
bar rier, and
the release
may oc cur
before the
bar rier is met.
If not, the head
mus t not be
c ar ried more
12 of 33 21/08/07 22:10
than a few
degrees
bey ond.
9. T he physician
r eevaluates
the
dy s functional
( T ART)
c omponents.
P.355
C oa sta l R egion: Fir st R ib Dys func tion Exam ple: Right, Poste rior ,
Ele vated Fir s t R ib (Nonphy siologic, Nonres pira tor y)
1. T he patient is
s eated, and
the physician
s tands behind
the patient.
2. T he
phy sic ian's
c upped left
hand r eac hes
ov er the
patient's left
s houlder and
ac r oss the
patient's chest F igure 13.28. Steps 1 and 2. Pos itioning.
to lie palm
down over the
patient's right
s houlder with
the second
and third finger
pads
anc hor ing the
fir st rib (F ig.
13.28) . An
alternative
pos ition similar
to an HVLA
tec hnique may
be prefer red F igure 13.29. Steps 1 and 2. Alternativ e
13 of 33 21/08/07 22:10
( F ig. 13.29) . technique position.

3. T he
phy sic ian's
r ight hand
s ide-bends the
patient's head
to the left
( ar row, F ig.
13.30) while
the left arm
k eeps the
patient's tr unk
fr om following.
4. T he
phy sic ian's F igure 13.30. Step 3. Side bending left.
r ight hand
adds a gentle
c ompression
for ce (a r r ow,
F ig . 13.31)
toward the
r ight fir st r ib.
5. T he physician
ins tructs the
patient to
inhale and
ex hale.
6. O n exhalation
the physician
pus hes the F igure 13.31. Step 4. Compres siv e force.
patient's head
to the right
( ar row, F ig.
13.32) while
maintaining
c ompression
on the head
and on the r ib
with the finger.
7. T his motion is
c ar ried towar d
the restr ictive
bar rier, and
the release F igure 13.32. Step 6. Side bending r ight.
may oc cur
before the
bar rier is met.
If not, the head
mus t not be
14 of 33 21/08/07 22:10
c ar ried more
than a few
degrees
bey ond.
8. T he physician
r eevaluates
the
dy s functional
( T ART)
c omponents.
P.356
C os tal Re gion: Firs t or Se cond R ib Exam ple : Le ft, Fir st Rib

Ex hala tion D y sfunction, Se ate d
1. T he patient is
s eated, and
the physician
s tands behind
the patient on
the side of the
dy s functional
r ib.
2. T he
phy sic ian's left
hand gras ps
the patient's
left forearm.
3. T he physician F igure 13.33. Step 1 to 3. Positioning.
places the
other hand
( thumb) over
the posterior
as pect of the
dy s functional
left firs t r ib
immediately
lateral to the
T 1 transv ers e
c os tal
ar ticulation
( F ig. 13.33) .
4. T he physician
F igure 13.34. Step 4. Drawing patient's
15 of 33 21/08/07 22:10
dr aws the ar m.
patient's left
ar m anter ior ly,
adducts it
ac r oss the
patient's
c hest, and
pulls (a r r ow,
F ig . 13.34) the
adducted arm
toward the
floor.
5. With moderate
ac c eleration,
the physician F igure 13.35. Step 5. Acc eler ate to
lifts the ar m, barrier.
s imultaneous ly
flexing and
abducting with
a
c ir cumduc tion
motion (F ig.
13.35) .
6. T he
ac c eleration is
c ontinued
pos ter ior ly and
then back to
the side of the
patient ( Fig .
F igure 13.36. Step 6. Acc eler ate
13.36) .
poster ior ly.
7. T he physician
r eevaluates
the
dy s functional
( T ART)
c omponents.
P.357
C os tal Re gion: Firs t R ib Exam ple : Right, First Rib Ex halation

D y s function, Sea ted
16 of 33 21/08/07 22:10
1. T he patient is
s eated and the
phy sic ian
s tands behind
the patient.
2. T he physician's
r ight hand
palpates the
pos ter ior as pect
of the first rib at
the attac hment
at its
c os totransver se
ar ticulation. F igu re 13.37. Steps 1 to 4. Setup, engage
3. T he physician T 1 and firs t r ib.
places the left
hand over the
patient's head.
4. T he physician's
left hand slowly
flexes the
patient's head
( c urved arrow,
F ig . 13.37) until
the T1 segment
and first rib ar e
engaged.
5. T he patient's
head is then
F igu re 13.38. Step 5. Side bending and
s ide-bent and
r otation to right.
r otated r ight
( c urved arrows,
F ig . 13.38) until
these motion
v ec tor s engage
T 1 and the first
r ib,
ex aggerating its
ex halation
dy s function
pos ition.
6. T he patient is
ins tructed to
inhale and
ex hale, and on F igu re 13.39. Step 6. Head c arr ied toward
r epeated SLRL.
inhalation, the
patient's head is
17 of 33 21/08/07 22:10
P.358
Lum bar Re gion: L1 to L5 Dy sfunctions Ex ample: L4 NSR R L,

Supine
1. T he patient
lies s upine,
and the
phy sic ian
s tands on the
s ide of the
r otational
c omponent
( left) .
2. T he physician
places the
r ight hand
under the
patient to Fig ure 13.41. Steps 1 to 4. Setup toward
monitor the rotational ease.
tr ansv ers e
pr oces ses of
L4 and L5.
3. T he physician
ins tructs the
patient to flex
the right hip
and knee.
4. T he
phy sic ian's
other hand
c ontrols the
patient's flexed
r ight leg at the
tibial Fig ure 13.42. Step 5. Exter nally rotate hip.
tuberosity and
flexes the hip
until the L5
s egment is
engaged and
r otated to the
r ight under L4
( F ig. 13.41) .
5. T he physician
ex ternally
r otates and
abducts the
hip while the
18 of 33 21/08/07 22:10
other hand Fig ure 13.43. Step 6. Accelerate into

monitors internal r otation and adduc tion.
motion at
L4- L5. This
pos ition should
place the L4
s egment
indirectly
( s ide- bent
r ight, rotated
left [SRRL]) as
it relates to its
dy s functional
pos ition on L5,
while L5 has
been r otated Fig ure 13.44 Step 6. Ex tens ion ac ros s
to the right midline.
( F ig. 13.42) .
6. T he physician,
with moderate
ac c eleration,
pulls the
patient's right
leg to the left
in adduction
and inter nal
r otation (F ig .
13.43) and
then fully
ex tends the
leg ac ros s the
midline to the
left ( Fig .
13.44) .
7. T his motion
c ar ries L5
( SRRL) under
L4 (SLRR)
toward the
L4- L5
r es trictive
bar riers, and
the release
may oc cur
before the
bar rier is met.
8. T he physician
r eevaluates
the
19 of 33 21/08/07 22:10
dy s functional
( T ART)
c omponents.
P.359
Lum bar Re gion: L1 to L5 Dy sfunctions Ex ample: L3 ESR R R,

La tera l R ecum bent
1. T he patient
lies in the r ight
lateral
r ec umbent
( s ide- lying)
pos ition.
2. T he physician
s tands at the
s ide of the
table in front of
the patient.
3. T he
phy sic ian's
c audad hand F igure 13.45. Steps 1 to 4. Hips flexed to
c ontrols the engage segment.
patient's legs
and flexes the
hips while the
c ephalad hand
monitors
motion at
L3- L4.
4. T he patient's
legs are flex ed
until L3 is
engaged ( Fig .
13.45) .
5. T he
phy sic ian's
for ear m pulls F igure 13.46. Step 5. Pos ition into
the patient's r otational ease.
left s houlder
gir dle forwar d
( ar row, F ig.
13.46) and the
20 of 33 21/08/07 22:10
c audal ar m
pus hes the
patient's ilium
pos ter ior ly
( ar row) while
the fingers
c ontinue to
monitor the
L3- L4
v er tebral unit.
6. T he physician
adds s light
tr action
( ar rows, Fig . F igure 13.47. Step 6.
13.47)
between the
s houlder gir dle
and the pelv is
and then, with
a moderate
ac c eleration,
r ev ers es this
tr action
( s traight
ar r ows , F ig.
13.48) and
s imultaneous ly
pus hes the
s houlder F igure 13.48. Step 6. Acc eler ate to SLRL.
pos ter ior ly
( pulsed arrow
at right, Fig.
13.48) and the
pelvis
anteriorly
( pulsed arrow
at left, Fig.
13.48) to
ac hiev e s ide
bending left
and rotation
left.
7. T he release
may oc cur
before the
bar rier is met.
If not, the
s egment
s hould be
21 of 33 21/08/07 22:10
c ar ried only
minimally
thr ough it.
8. T he physician
r eevaluates
the
dy s functional
( T ART)
c omponents.
P.360
Pe lvic Re gion: Innomina te Dys func tion Exam ple: Right Anterior
Innominate, Modifie d Sims Pos ition
Diag nosis
Standing flex ion
tes t: Positiv e (r ight
pos terior superior
iliac s pine [PSIS]
ris es)
Los s of pas siv ely
induced right
sac r oiliac motion
PSIS: Cephalad
(slightly lateral) on
the right
Anterior s uper ior
iliac s pine ( ASIS): F igure 13.49. Step 1. Pos itioning.
Caudad (slightly
medial) on the right
Sac r al sulcus :
Pos terior 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 F igure 13.50. Steps 2 and 3. Hand
22 of 33 21/08/07 22:10
( F ig. 13.49) . placement.

2. T he physician
places the
c ephalad hand
on the
patient's
s ac rum to
r es ist sacral
mov ement.
3. T he
phy sic ian's
c audad hand
gr asps the
patient's right
leg distal to the F igure 13.51. Step 4. Flex hip and k nee.
k nee ( tibial
tuberosity)
( F ig. 13.50) .
4. T he
phy sic ian's
c audad hand
flexes the
patient's right
hip and k nee
( F ig. 13.51)
and then
r eturns them
to an extended
pos ition (F ig .
13.52) . F igure 13.52. Step 4. Return to extension.
5. T his motion is
r epeated thr ee
times, and at
the end of the
third flexion,
the patient's
hip is
ac c elerated
into flex ion
( c urved white
ar r ow) with a
c ephalad
impuls e
( thrus t) while F igure 13.53. Step 5. Cephalad impulse.
the left hand
immobiliz es to
s ac rum
( s traight white
ar r ow, F ig .
23 of 33 21/08/07 22:10
13.53) .
6. T he right leg
and hip are
then extended
and right
s ac roiliac
motion is
r etested to
as s ess the
effectivenes s
of the
tec hnique.
P.361
Pe lvic Re gion: Innomina te Dys func tion Exam ple: Right Pos ter ior
Innominate, Modifie d Sims Pos ition
Diag nosis
Standing flex ion
tes t: Positiv e (r ight
PSIS rises )
Los s of pas siv ely
induced right
sac r oiliac motion
ASIS: Cephalad
(slightly lateral) on
the right
PSIS: Caudad
(slightly medial) on
the right
Sac r al sulcus : Fig ure 13.54. Steps 1 and 2. Setup.
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.
24 of 33 21/08/07 22:10
2. T he physician
places the left
hand on the
patient's right
PSIS while the
r ight hand
gr asps the
patient's right
leg just dis tal
to the knee
( tibial
tuberosity)
( F ig. 13.54) .
3. T he patient's Fig ure 13.55. Step 3. Circ ular hip motion.
r ight leg is
mov ed in an
upward,
outwar d
c ir cular motion
( white ar rows ,
F ig . 13.55) as
the hip is
flexed,
abducted,
ex ternally
r otated, and
c ar ried into
ex tens ion
( F ig. 13.56) to Fig ure 13.56. Step 3. Abduc tion, external
c heck hip rotation, and ex tens ion.
r ange of
motion.
4. T his c irc ular
motion is
applied for
thr ee cyc les ,
and at the end
of the third
c y c le, the
patient is
ins tructed to
k ic k the leg
s tr aight,
pos itioning the Fig ure 13.57. Steps 4 and 5. Kick leg
hip and k nee str aight with impuls e on PSIS.
into extension.
5. While this k ick
is tak ing place
( ar row at left,
25 of 33 21/08/07 22:10
F ig . 13.57) the
phy sic ian's left
hand on the
patient's right
PSIS deliver s
an impuls e
( ar row at right)
toward the
patient's
umbilicus .
6. Right
s ac roiliac
motion is
r etested to
as s ess the
effectivenes s
of the
tec hnique.
P.362
U pper Extrem ity Region: Elbow: R a dia l H ead, Pr ona tion

D y s function
Diag nosis
Symptoms: Elbow
dis c omfort with
inability to fully
supinate the
for earm
Motion: Res tricted
supination of the
for earm
Palpation:
Tenderness at the
radial head with
pos terior
prominence of the Fig ure 13.58. Steps 1 to 3. Setup, hand
radial head placement.
Tech niq ue
1. T he patient is
s eated on the
26 of 33 21/08/07 22:10
table, and the

phy sic ian
s tands in fr ont
of the patient.
2. T he physician
holds the
patient's hand
on the
dy s functional
ar m as if
s haking hands
with the
patient.
3. T he physician Fig ure 13.59. Step 4. Engage pronation
places the and radial head ease.
index finger
pad and thumb
of the other
hand s o that
the thumb is
anterior and
the index
finger pad is
pos ter ior to
the radial head
( F ig. 13.58) .
4. T he physician
r otates the
hand into the
indirect Fig ure 13.60. Step 5. Supinate.
pr onation
pos ition and
pus hes the
r adial head
pos ter ior ly
with the thumb
until the eas e
bar rier is
engaged ( Fig .
13.59) .
5. F inally, the
phy sic ian, with
a moderate
ac c eleration Fig ure 13.61. Step 5. Anter ior
thr ough an counter for ce.
ar c lik e path of
least
r es istanc e,
s upinates the
27 of 33 21/08/07 22:10
for ear m
toward the
r es trictive bind
bar rier ( Fig .
13.60) and
adds an
anterior
dir ected
c ounterforce
( ar row, F ig.
13.61) with the
index finger
pad.
6. T he release
may oc cur
before the
bar rier is met.
If not, the
r adial head
mus t not be
c ar ried more
than a few
degrees
bey ond.
7. T he physician
r eevaluates
the
dy s functional
( T ART)
c omponents.
P.363
U pper Extrem ity Region: Elbow: R a dia l H ead, Supination

D y s function
28 of 33 21/08/07 22:10
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 F igure 13.62. Steps 1 to 3. Setup, hand
placement.
Tech niq ue
1. T he patient is
s eated on the
table, and the
phy sic ian
s tands in fr ont
of the patient.
2. T he physician
holds the
patient's hand
on the
dy s functional
ar m as if
s haking hands F igure 13.63. Step 4. Engage supination.
with the
patient.
3. T he physician
places the
index finger
pad and thumb
of the other
hand s o that
the thumb is
anterior and
the index
finger pad is
pos ter ior to
the radial head F igure 13.64. Step 4. Engage radial head
( F ig. 13.62) . ease.
4. T he physician
r otates the
hand into the
29 of 33 21/08/07 22:10
P.364
U pper Extrem ity Region: Ac rom ioc lavicular J oint Exam ple: Right
D is tal Clavic le Ele vate d
Diag nosis
Symptoms:
Acr omioclav icular
dis c omfort with inability to
fully abduct and flex the
shoulder
Findings: Dis tal clav icle
palpably elev ated relative
to the acr omion and
res ists caudad pr ess ure
Tech niq ue
1. T he patient is F igure 13.66. Steps 1 to 4. Setup, hand

s eated, and the placement.
phy sic ian stands
behind the patient
toward the s ide to be
tr eated.
2. T he physician, using
the hand clos est to
the patient, places
the second
metacarpophalangeal
joint over the distal
third of the clavic le
to be treated.
3. T he physician
maintains constant
c audad pr ess ure F igure 13.67. Steps 4 and 5. Bac kward
ov er the patient's ex tension.
c lavic le thr oughout
the tr eatment
s equence.
4. T he physician's
other hand gr asps
the patient's ar m on
the side to be treated
jus t below the elbow
( F ig. 13.66) .
5. T he patient's ar m is
pulled down and then
dr awn bac kwar d into
30 of 33 21/08/07 22:10
ex tens ion (F ig.

13.67) with a
c ontinuous motion
s imilar to throwing a
ball over hand,
c ir cumduc ting the
ar m (F ig. 13.68) until
it is onc e again in
fr ont of the patient,
finishing with the arm
ac r oss the c hest in
adduction (F ig.
13.69) .
6. T he release may F igure 13.68. Step 5. Overhand motion.
oc c ur before the
bar rier is met.
7. T he physician
r eevaluates the
dy s functional
( T ART) components.
F igure 13.69. Step 5. Arm ac r oss chest.
P.365
U pper Extrem ity Region: Ac rom ioc lavicular J oint Exam ple: Right,
Pr oxim al Cla v icle Elev a ted (D ista l C lav ica l De pre sse d)
31 of 33 21/08/07 22:10
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 F igure 13.70. Steps 1 to 4. Setup, hand
clav icle placement.
Tech niq ue
1. T he patient is
s eated with the
phy sic ian
s tanding
behind the
patient.
2. T he
phy sic ian's left
hand r eac hes
ar ound in fr ont
of the patient
and places the F igure 13.71. Step 5. Flex ion and
thumb over the abduc tion.
pr oximal end
of the patient's
r ight clavic le.
3. T he
phy sic ian's left
thumb
maintains
c onstant
c audad
pr essure over
the patient's
c lavic le
thr oughout the
tr eatment F igure 13.72. Step 5. Bac k str oke motion.
s equence.
4. T he
phy sic ian's
32 of 33 21/08/07 22:10
P.366
R e fere nce s
1. V an Busk i rk RL . Th e S til l Te c hn i qu e Ma nua l : Appl i ca tio ns o f a Re di sc ove r ed T ec hni que of

Andr ew T ayl or Sti l l , M D. In di an apo l is : Am eri c an Aca dem y o f Os teo pat hy , 200 0.
2. W ard R ( ed. ) . F oun dat i on s fo r O s te opat hic Me di ci ne. Ph i l ad elp hia : Li ppi nco tt W i ll i am s &
W i lk i ns , 20 03.
33 of 33 21/08/07 22:10
14
Balanced Ligamentous Tension and Ligamentous
Articular Strain Techniques
Technique Principles
Bal anc ed l i ga m en tous te nsi on ( BLT ) a nd l i ga m en tous ar tic ul ar st r ai n (L AS) te c hni que s m ay b e
c on s id er ed as tw o se par ate tec hni que s or as on e. T he his tory of th e de v el opm ent of the s e t ech niq ues
pro bab l y s tar ted dur i ng A. T . Sti l l' s ti m e, bu t de v el ope d gr eat l y thro ugh th e wo r k of a nu m be r o f
ost eop athi c p hys i c ia ns i nc l udi ng, bu t no t l i mi ted to W . G. S uth erl and, DO ; H . A. Li ppi nc ot t, D O; R .
Lip pin c ott , D O; R . B eck er, D O; an d A . Wa l es , D O (1 ,2) . I t ap pea r s that a geo gr ap hic se para tio n a nd
m in i ma l co nta c t betw een tw o gr oup s m ay h ave ca us ed th e s am e tec hni que to be k now n b y t w o n ame s .
T ho s e i n t he c en tr al Un i te d St ate s ( i .e. , T exa s ) e v en tua l l y pro m ot ed t he ter m LA S, and tho s e i n the
nor the as te r n U ni ted Sta tes ( i. e., Ne w Je r se y a nd N ew Eng l and ) p r om oted th e t er m BLT . A s th e t w o
nam es s ugg est , s om e v ar i an c e i n t he tech niq ues dev elo ped , an d t he pr ac tit i on er s dev elo ped the i r ow n
par tic ul ar nu anc e fo r t he appl i ca tio n of th e t r eat m en t. T he ter m L AS s eem s t o de s cr i be the dy s fu nc ti on,
w hi l e the ter m B LT d esc r ib es t he pro c ess or go al o f t he tr ea tme nt.
Sut her l and ma y h av e bee n m os t r es pon s i bl e f or the tec hni que bei ng taug ht i n earl y o s te opat hic st udy
gro ups . In th e 1 940s , h e b egan te ach i ng a m eth od o f t r ea tm en t o f t he b ody an d ex tre m it i es w it h t he
pri nci pl es pr omo ted for th e tr eat m en t of th e c r ani um. He tal k ed ab out the jo i nt' s r ela ti on wi th i ts
l ig ame nts, fa s ci a, a nd s o on ( l ig ame ntou s a r ti c ula r m ech anis m ), an d we ca n e x tra pol ate thi s t o i nc lu de
the po tent i al fo r me c ha nor ec ep tor ex c i ta tio n i n dy s fu nct i ona l s tat es . One of Sut her l an d' s i de as, a k ey
c on c ep t in th i s ar ea , w as that no r ma l mo v em ent s of a j oi nt o r a r ti c ula tio n d o no t c aus e as y mm etr i c
ten s io ns i n t he l i ga m en ts and tha t t he t ens i on dis tri but ed t hro ugh the li gam ents in an y gi v en jo i nt i s
bal anc ed ( 2,3 ) . T hes e t ens i ons ca n c hang e w hen the li gam ent or j oi nt i s s tre s s ed (s tra i n o r unit
def orm atio n) i n the pre s en c e o f a l te r ed m ec han i c al fo r ce . To day , t hi s pri nci pl e i s s im i l ar to th e
arc hit ec tu r al an d bi ome c ha ni ca l ( s tr uc tu r al ) p r i nc i pl es of t ens egr i ty, as se en i n t he geod esi c d om e of R .
Buc k mi ns te r F ull er a nd the art of Ke nnet h S nel s on, hi s s tude nt ( 4, 5,6) . T his pri nci ple i s c om m on l y
pro m ot ed i n t he post ula te that an an teri or ana tomi c ( fas c i al ) b ows tr in g i s p r ese nt i n the bod y . T he the ory
i s tha t th e k ey dy sf unc tio n ma y p r od uc e bot h p r oxi m al an d di s ta l e ffec ts. Th es e eff ect s ca n p r od uc e
s ym pto m s b oth an teri orl y a nd p ost eri or ly (1 ) .
One of the as pec ts m ent i on ed i n s ome ost eop ath i c m ani pul ativ e t ech ni qu e ( OMT ) st y le s i s a
r el eas e- en han c in g me c ha nis m . T his me c han i sm ma y be is ome tr ic co ntr ac ti on of a mu s cl e, a re s pi r at or y
m ov eme nt o f t he di ap hra gm, eye an d t ongu e m ove m ent s , or i n t he c as e of BL T o r LA S, the use of in here nt
for c es , su c h as c i rc ula tor y (T r au be- H eri ng- M ay er ), ly m ph atic , o r a v ar i et y o f ot her fa c tor s ( e.g ., p r im ary
r es pir ator y m ech anis m ) ( 2) . Th e p hys i c ia n i ntr oduc es a f or ce to po s i ti on the pat i en t s o th at a f ul cr um
m ay be s et . T his ful c ru m , pair ed w it h th e s ubs eque nt l ev er a c ti on of t he tis s ues (l i ga m ent s ), co m bin es
w it h f l uid dy nam i c s and ot her fac tor s to pr odu c e a ch ang e in th e d y s fu nct i on al s tat e. In s ome ca s es, th e
tec hni que i s use d to af fec t th e m y of as ci al s tr uc tu r es . I n th e c ase of tre ati ng a my ofa s c ia l s tru c tur e, the
dif fer enti ati ng fact or bet w een BL T /L AS a nd m yo fasc i al re l eas e ( M FR ) is th at an i nhe r en t fo r ce (f l uid
m od el) i s the re l eas e-e nha nc in g m ech anis m i n B LT /L AS; in M FR , t he ther m od y na m i c r ea c ti on t o
pre s su r e i s t he pr im ary re l eas e f act or .
Technique C las sification
1 of 40 21/08/07 22:11
Indirec t Te chnique
In the c as e o f B LT /L AS, th e ph y si c ia n po s it i on s th e p ati ent' s d y sf unct i on al ar ea to w ar d th e e ase bar r ie r .
T hi s
P.3 68
i nd i re c t p osi tio ni ng is th e cl ass i c m eth od of tr ea tme nt i n t his te c hni que . H ow ev er, so m e L AS tec hniq ues
are ex ac tl y l i ke M FR di r ec t te c hn i qu es , and th os e are in c l ud ed i n this ch apt er r ath er than Ch apt er 8 , o n
m yo fas c i al re l ea s e ( 1).
W he n b egin nin g t he t r ea tme nt, the ph y s ic i an ty pi ca l ly at temp ts to pr od uce so m e fr ee pl ay i n t he

art i cu l ati on. Th i s a tte m pt to all ow the m os t m otio n t o o c c ur wi tho ut r esi s ta nc e i s ter m ed dis eng agem ent .
It c an be pro duc ed b y c omp r ess i on or tra c ti on ( 1). Ex agg er at i on is the se c on d st ep des c r ib ed. It i s
pro duc ed b y m ovi ng t owa r d the eas e o r to wh at s ome re fer as the or i gin al pos i tio n o f i nj ur y ( 1). Pla c in g
the ti s s ue s i n a n op tim al bala nce of ten s io n a t th e a r ti c ula tio n o r ar ea of dy sf unc tio n is th e f i nal
pos i ti onin g s tep of thi s t ec hn i qu e. Some re fer to thi s p oi nt as th e wo bbl e p oi nt . T his i s s im i la r to th e
s en s at i on of bal anci ng an obje c t on the fin ger ti p. Th e w obbl e poin t is ce ntr al t o a l l r adi ati ng tens i on s , and
tho s e tens i on s f eel asy m me tr ic wh en not at the poi nt. Wh i l e hol din g th i s pos i tio n, the phy s ic i an awa i ts a
r el eas e. T his re l eas e h as been de s cr i bed as a gent l e m ov em en t t owa r d t he eas e an d t hen a s l ow
m ov eme nt b ack w ar d to w ar d t he b ala nce poi nt ( eb b an d f l ow ) .
F or ex am pl e, i f the dys fun c tio n b ein g tr eat ed i s d esc r ib ed a s L 4, F SL RL , t he e ase or dir ect i on of
fre edo m is in th e fo l lo w in g di r ec tio ns : fle x io n, s i de be ndin g l eft , an d r ota ti on le ft. M ov i ng L4 ( ov er a
s ta bil i z ed L5 ) i n th i s dir ec ti on i s desc r ib ed as m ovi ng aw ay fr om the r es tri c tiv e b arr i er and th er ef ore
def i ne s th e t ech ni qu e a s i ndir ect .
D ire ct Technique
LAS so m eti m es va r i es ; i t c an b e p erf or me d a s a dir ect te c hni que wh en t he m us c ula tur e i s ca usi ng a
v ec tor of ten s io n in on e d i r ec tio n, but to bal ance th e a r tic ula tio n it fe els tha t y ou ar e m ov i ng tow ard th e
dir ect ( re s tr i ct i v e) ba r ri er . It fol l ows th e d i r ec t s tyl e of MF R t ec hn i qu e d es cr i be d i n Ch apt er 8. S pee c e
and Cr ow ( 1) i ll us tr ate th i s i n t hei r bo ok as tech niq ues use d i n d y s fu nct i on s of fi r st r ib , i l io ti bi al ban d,
pel v ic dia phr agm , an d s o o n.
Technique Styles
D iagnos is a nd Tre a tme nt with Re spiration

In thi s me tho d, the phy s ic i an pal pat es t he are a in v ol v ed and at tem pts to dis c ern th e p atte r n of dy sf unc tio n
w it h e x tre m el y l i ght pa l pa tory te c hn i que . T his c ou l d be desc r ib ed as n udg i ng the se gme nt t hro ugh the x- ,
y -, an d z- axe s w i th the mo v eme nts ca us ed by re s pir ati on. T he r ef ore , th e m ove m ent s u s ed i n the at temp t
to dia gnos e a nd tr ea t t he dy sf unc tio n ar e e x tr em el y s m al l .
D iagnos is a nd Tre a tme nt with Inter segm ental Motion Tes ting
(Phy sic ian Active )
In i nt er se gme nta l mo tio n t es ti ng/ tre atme nt s ty l e, s li ght l y m ore mo ti on an d/o r fo r ce ca n be us ed to t est
m ot i on par ame ter s in th e d y s fu nct i on al s i te an d to be gin to m ov e t he s i te in to t he app r opr i at e i ndir ect
pos i ti on o f b ala nc ed te nsi ons. Th ere m ay be mo r e c omp r es s i on or tr ac ti on i n this fo r m as w ell ,
dep end i ng on the dys fun c ti onal st ate , si te, or pre fer enc e of th e t r eat i ng ph y s ic i an .
Indications
2 of 40 21/08/07 22:11
1. Soma tic dy s fun c ti ons of art i cu l ar bas i s
2. Soma tic dy s fun c ti ons of m yo fas c i al ba s is
3. Ar ea s o f l y m ph ati c c onge s ti on or l oca l e dema
R ela tiv e Contr aindica tions

1. F r ac tur e, di sl oca tio n, o r g r os s in s ta bil i ty i n are a to be tr eate d
2. M ali gna ncy , in fec tio n, o r s eve r e o s te opo r osi s i n a r ea to be tr ea ted
Gene ral Considera tions a nd R ule s

T he te c hni que is s pe c if i c palp ato r y bala nci ng of t he tis s ues su r ro undi ng and i nh ere nt to a jo i nt or the
m yo fas c i al st r uc ture s r ela ted to i t. T he ob j ec t is to ba l anc e t he ar ti c ul ar s urf ace s o r ti s su es i n t he
dir ect i ons of ph y s io l og i c m oti on c om m on to tha t ar tic ula ti on . T he phys i ci an i s n ot s o m uch ca usi ng t he
c ha nge as hel pin g th e b ody to hel p i ts el f. In this re s pe c t, i t i s v ery os teo path i c, as the fl uid and ot her
dyn ami c s o f t he neur omu s cu l osk ele tal s ys tem fi nd a n o v er al l nor m al i z at i on or bal anc e. It i s i m po r tan t n ot
to put too mu c h pr es s ur e i nto the te c hni que ; t he t i ss ue m ust no t b e ta k en be y ond it s e l ast i c l im i ts, an d t he
phy s ic i an m us t n ot p r od uce dis c om for t to a l ev el t hat ca us es gu ard i ng. It ge nera l ly sh ould be ve r y
tol era bl e to the pat i en t.
Gene ral Inform ation for All Dys functions
Positioning
1. T he phy s ic i an m ak es a di agn osi s of so m at i c d y sf unc ti on in al l pl ane s o f pe r mi tte d mo tio n.
2. T he phy s ic i an pos i ti ons the su peri or ( up per or pro x i ma l ) s eg m ent ov er the s ta bil i z ed in fer i or
P.3 69
( l ow er or di st al) se gm en t t o a poi nt of bala nce d l i gam ent ous ten s io n i n al l p l an es o f p erm i tte d
m oti on, si m ult ane ous l y i f p oss i ble .
a. T hi s typ i ca l l y m ea ns m ovi ng awa y fr om the bar r ie r (s ) to a l oo s e ( eas e) s i te .
b. Al l p l an es m ust be fi ne t une d t o th e m ost bal anc ed poin t.
3. F i ne - tu ne: H av e p ati ent bre ath e sl owl y i n an d o ut to a s se s s phas e o f r es pi r at i on tha t f eel s mo s t

l oos e ( r el ax ed , s oft , et c .) ; p atie nt hol ds b r ea th at t he poi nt ( i t m ay be onl y p ar ti all y c om pl ete
i nha l at i on or exh ala ti on ) w her e th e b ala nc e i s m ax i m al .
Trea tme nt
1. At t he poi nt o f b ala nc ed li gam ento us ten s i on , t he phys i ci an adju s ts th e re l at i ve pos i ti on betw een
the s up eri or a nd i nf er io r s egm ents to ma i nta i n bal ance .
a. T hi s typ i ca l l y m ea ns s hif tin g t he t op s eg m ent co nti nuou s ly aw ay f r om th e di r ec t b ar ri er to

pr eve nt the tis s ue s f r om tig hte ni ng as th ey r ele ase .
b. T he t i ss ues , as th ey r ele ase , a r e o fte n d es cr i be d a s if th ey ar e m el tin g or so fte ni ng .
3 of 40 21/08/07 22:11
c. T i s su e t ext ur e c ha nge s sh oul d o c c ur du r in g th e r ele as e; if th ey a r e not pal pat ed, the

pos it i on of bal anc ed l i ga m en tou s te nsi on has not be en s et.
2. W hen a tot al r ele ase i s not ed, the ph y si c i an re ass es se s t he c omp one nts of s om ati c dy s fu nct i on
( tis s ue te x tur e a bno r m al i ty , a s y mm etr y o f po s it i on , re s tr i ct i on of m ot i on, te nde r nes s [ T AR T ]). Th e
phys i ci an r epe ats if nec ess ary .
T he sh or th and ru l es for th i s a r e as foll ows (1 ) :
1. D i se nga gem ent
2. Ex ag ger ati on
3. Bala nce un ti l r el eas e oc c ur s
P.3 70
C erv ica l Re gion: Occipitoatlantal (C0 —C1, OA ) D y sfunction

Exam ple : C0 -C1 ESLRR*
s upine and the
physician s its at
the head of the
table.
2. T he patient is
far enough away
to permit the
physician's
forearms and
elbows to r est
on the table.
3. T he phys ician
places the Fig ure 14.1. Head and v ertebral c ontact.
hands palms up
under the
patient's head
s o that the
c ontact is made
at the level of
the tentorium
c erebelli ( 1),
mostly with the
heel of the
hands towar d
the hypothenar
eminences.
4. T he phys ician's Fig ure 14.2. Steps 3 and 4.
index or third
4 of 40 21/08/07 22:11
fingers palpate
the patient's C1
tr ans ver se
pr ocesses
( F igs. 14.1 and
14.2) .
palpating fingers
s imultaneous ly
c arry the C1
tr ans ver se
pr ocesses
upwar d and
c ephalad Fig ure 14.3. Step 5.
( arrows, F ig .
14.3) towar d the
ex tension ease
and toward s ide
bending right,
r otation left
under the
oc ciput. This
s hould produce
a relative s ide
bending left,
r otation right
effec t at the
oc ciput. Fig ure 14.4. Step 6.
6. As the phys ician
introduc es the
v ectored for ce,
the head is
gently s ide- bent
left and rotated
r ight (arrows,
F ig. 14.4) until a
balanced point
of tension is
met.
7. When this
balanced
position is
ac hieved, a
s low rhy thmic
ebb and flow of
pr ess ure may
pr esent its elf,
and the
physician will
5 of 40 21/08/07 22:11
hold this
position agains t
it until a r elease
in the direc tion
of ease occ urs.
8. T he phys ician
r eass ess es the
c omponents of
the dysfunc tion
( T ART ).
P.3 71
C erv ica l Re gion: A tla ntoaxia l (C1—C2, AA) Dy sfunction Exa m ple :
C1 RR
s upine, and the
physician s its at
the head of the
table.
2. T he patient is
far enough
away to per mit
the phys ician's
forearms and
elbows to r est
on the table.
3. T he phys ician
places the F igu re 14.5. Palpation of C2 ar tic ular
hands palms up pillars .
under the
patient's head
s o that the
c ontact is made
at the level of
the tentorium
c erebelli ( 1),
mostly with the
heel of the
hands towar d
the hypothenar
eminences.
6 of 40 21/08/07 22:11
index or third F igu re 14.6. Steps 3 and 4.

fingers palpate
the patient's C2
ar tic ular
pr ocesses
( F igs. 14.5 and
F ig. 14.6).
palpating fingers
s imultaneous ly
c arry the C2
ar tic ular
pr ocesses
upwar d and
c ephalad to F igu re 14.7. Step 5, rotation r ight effec t.
disengage
C1-C2 while
s imultaneous ly
r otating C2 left
( s weep arrow)
under C1
( c urv ed arr ow,
F ig. 14.7). This
s hould produce
a relative C1,
r otation right
effec t.
6. As the
physician F igu re 14.8. Step 6.
introduc es the
v ectored for ce,
the head with
C1 may be
minimally and
gently r otated
r ight (arrow,
F ig. 14.8) until
a balanc ed point
of tension is
met.
7. When this
balanced
position is
ac hieved, a
s low rhy thmic
ebb and flow of
pr ess ure may
pr esent its elf,
and the
7 of 40 21/08/07 22:11
physician will
hold the pos ition
against it until a
r elease in the
direc tion of
ease occ urs .
8. T he phys ician
r eass ess es the
c omponents of
the dysfunc tion
( T ART ).
P.3 72
C erv ica l Re gion: A tla ntoaxia l (C1—C 2 ) Dy sfunction Exa mple : C 1

R ight, Late ral Tr a nslation
s upine, and the
physician s its at
the head of the
table.
hands cup the
head by
c ontouring over
the
parietotemporal
r egions.
3. T he phys ician
places the index F igu re 14.9. Steps 2 and 3, hand position.
finger pads over
the C1
tr ans ver se
pr ocesses ( F ig.
14.9) .
4. T he phys ician
gently and
s lowly
introduc es a
tr ans lational
force (arrow,
F ig. 14.10) that
is direc ted from
8 of 40 21/08/07 22:11
left to right F igu re 14.10. Step 4, tr ans lation left to

towar d the ease r ight.
barrier. The
physician may
have to go back
and forth
between left and
r ight to
deter mine the
balanced
position (F igs.
14.10 and
14.11).
5. When this
balanced
position is F igu re 14.11. Step 4, tr ans lation right to
ac hieved, a left.
s low rhy thmic
ebb and flow of
pr ess ure may
pr esent its elf,
and the
physician will
hold the pos ition
against it until a
r elease in the
direc tion of
ease occ urs .
6. T his can be
performed as a
direc t technique
if pr eferred or
indic ated.
7. T he phys ician
r eass ess es the
c omponents of
the dysfunc tion
( T ART ).
P.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
s upine, and the
physician s its at
the head of the
table.
2. T he patient is
far enough away
to permit the
physician's
forearms and
elbows to r est
on the table.
3. T he phys ician
places the Fig ure 14.12. Steps 1 to 3, head contact.
hands palms up
under the
patient's head
s o that the
c ontact is made
at the level of
the tentorium
c erebelli ( 1),
mostly with the
heel of the
hands towar d
the hypothenar
eminences ( F ig.
14.12). Fig ure 14.13. Step 4.
index or third
fingers palpate
the patient's C5
ar tic ular
pr ocesses
( arrow, Fig .
14.13).
palpating fingers
s imultaneous ly
c arry the C5
ar tic ular
pr ocesses Fig ure 14.14. Step 5, SRRR.
upwar d and
c ephalad to
disengage
C4-C5, while
s imultaneous ly
r otating and
10 of 40 21/08/07 22:11
P.3 74
Thor acic Re gion: T1 a nd T2 D ysfunc tions Exam ple : T1 FSRRR
s upine, and the
physician s its at
the head of the
table.
2. T he patient is
far enough
away to per mit
the phys ician's
forearms and
elbows to r est
on the table.
3. T he phys ician
places the F igu re 14.16. Steps 3 and 4, hand and
hands palms up finger positioning.
under the
patient's
c ervical spine at
the level of C2
or C3 so that
the c erv ical
s pine rests
c omfortably on
them.
4. T he phys ician
places the index
finger pads on
the transver se
pr ocesses of T1 F igu re 14.17. Step 3 and 4, palpation of
and the thir d patient.
finger pads on
the transver se
pr ocesses of T2
( F igs. 14.16
and 14.17).
palpating fingers
lift the T2
tr ans ver se
pr ocesses up
and down
( arrows, F ig .
14.18) to find a
point of F igu re 14.18. Step 5, neutr al balance
11 of 40 21/08/07 22:11
disengagement point.
between the
flexion and
ex tension
barriers .
6. Us ing the third
finger pads , the
physician gently
s ide- bends
( c urv ed arr ow)
and r otates
( s weep arrow)
T 2 to the left,
which causes a
r elative side F igu re 14.19. Step 6, T2, SLRL.
bending right
and r otation
r ight at T1 (F ig.
14.19).
7. As the
physician
introduc es the
v ectored for ce,
the index finger
pads on the T1
s egment may
minimally and
gently r otate
and s ide-bend F igu re 14.20. Step 7, T1, SRRR.
T 1 to the r ight
until a balanced
point of tension
is met ( Fig .
14.20).
8. When this
balanced
position is
ac hieved, a
s low rhy thmic
ebb and flow of
pr ess ure may
pr esent its elf,
and the
physician holds
the position
against it until a
r elease in the
direc tion of
ease occ urs .
12 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 ).
P.3 75
C erv icothor acic R e gion: Ante rior C erv ical Fa scia , D ire ct
Technique
s upine, and the
physician s its or
s tands at the head
of the table.
2. T he phys ician
abduc ts the thumbs
and plac es the
thumbs and thenar
eminences ov er the
c lavicles in the
s upraclavic ular
fossa immediately
later al to the F igu re 14.21. Steps 1 and 2.
muscles (F ig .
14.21).
3. T he phys ician
applies a
downward, s lightly
posterior force
( arrows, F ig .
14.22) that is
v ectored toward the
feet.
4. T he phys ician
moves the hands
back and for th from F igu re 14.22. Step 3.
left to right ( arr ows ,
F ig. 14.23) to
engage the
5. If there appear s to
13 of 40 21/08/07 22:11
be sy mmetric
r estr iction, both
hands can be
direc ted (ar rows,
F ig. 14.24) toward
the bilater al
r estr iction.
6. As the tens ion
r eleases , the thumb
or thumbs c an be
pushed farther
later ally.
7. T his pressur e is
maintained until no F igu re 14.23. Step 4.
further
improvement is
noted.
8. T he phys ician
r eass ess es the
c omponents of the
dy sfunction
( T ART ).
F igu re 14.24. Step 5, bilateral tension if

needed.
P.3 76
Thor acic And Lumba r R egions : T3 to L4 Exa mple: T12 ESLRL
14 of 40 21/08/07 22:11
pr one, and the
physician
s tands beside
the table.
2. T he phys ician
places the left
thumb ov er the
left transv erse
pr ocess of T 12
and the index
and thir d finger
pads of the left
hand over the Fig ure 14.25. Steps 1 to 3.
r ight tr ans v ers e
pr ocess of T 12.
3. T he phys ician
places the r ight
thumb ov er the
left transv erse
pr ocess of L1
and the index
and thir d finger
pads over the
r ight tr ans v ers e
pr ocess of L1
( F ig. 14.25) .
4. T he patient Fig ure 14.26. Step 5.
inhales and
ex hales, and on
ex halation, the
physician
follows the
motion of these
two s egments .
5. T he phys ician
adds a
c ompr ess ion
force (long
ar rows)
approximating
T 12 and L1 and Fig ure 14.27. Step 6.
then dir ects a
force downward
( s hor t arrows)
towar d the table
to vector it to
the extension
15 of 40 21/08/07 22:11
P.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, the hands
may contact each
s egment of the
v ertebr al unit
involved in the
dysfunc tion (e.g., L2
and L3) .
s upine, and the
physician s its
at the s ide of Fig ure 14.28. Steps 2 and 3, hand
the patient. pos itioning.
2. T he phys ician
places the
c audad hand
under the
patient's
s acrum s o that
the finger pads
ar e at the
s acral base and
the heel is
towar d the
s acrococ cygeal
r egion.
3. T he phys ician Fig ure 14.29. Hand positioning with
places the sac rum and lumbar v ertebra.
c ephalad hand
ac ros s the
s pine at the
level of the
dy sfunctional
s egment so that
the heel of the
hand and finger
pads contac t
the left and right
L5 tr ans ver s e
pr ocesses
( F igs. 14.28
16 of 40 21/08/07 22:11
an d 14.29). Fig ure 14.30. Step 4.

4. T he s acr al hand
moves the
s acrum
c ephalad and
c audad
( arrows, F ig .
14.30) to find a
point of eas e as
the lumbar
c ontacting hand
does the same.
5. T he lumbar
hand may need
to lift upward Fig ure 14.31. Step 5.
and downwar d
( arrows, F ig .
14.31) to
balance
between flex ion
and extension.
6. T he lumbar
c ontacting hand
then side-bends
and r otates L5
to the r ight
( arrows) to find
balanced
tension in thes e Fig ure 14.32. Step 6, L5, SRRR.
direc tions ( Fig .
14.32).
7. When this total
balanced
position is
ac hieved, a
s low rhy thmic
ebb and flow of
pr ess ure may
pr esent its elf at
the
dy sfunctional
s egment. The
physician holds
the position
against it until a
r elease in the
direc tion of
ease occ urs .
8. T he phys ician
17 of 40 21/08/07 22:11
r eass ess es the

c omponents of
the dysfunc tion
( T ART ).
P.3 78
C ostal R egion: Fir st Rib Dy s function Exam ple : Le ft, Poste r ior ,
Elev ate d First Rib (N onphys iologic , N onre spiratory)
or lies supine,
and the
physician s its at
the head of the
table.
2. T he phys ician
places the left
thumb ov er the
posterior as pec t
of the elev ated
left fir st r ib at
the
c ostotransv erse Fig ure 14.33. Step 2, thumb placement.
ar tic ulation (F ig.
14.33).
3. T he phys ician
direc ts a force
c audally (ar row,
F ig. 14.34)
through the
ov erlying
tissues and into
the elev ated left
first rib.
4. T he forc e
applied should
be moder ate but Fig ure 14.34. Step 3, c audal forc e.
not s evere.
5. T he pres sur e is
maintained until
a releas e
oc cur s as
indic ated by the
18 of 40 21/08/07 22:11
thumb being
permitted to
move thr ough
the r estric tive
barrier.
6. T he phys ician
r eass ess es the
c omponents of
the dysfunc tion
( T ART ).
P.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
s upine, and the
physician s its or
s tands at the
s ide of the
patient.
2. T he phys ician
places one hand
palm up with the
fingers
c ontouring the
angle of the rib
c age
posteriorly . F igu re 14.35. Steps 2 and 3, hand
3. T he other hand plac ement.
is placed palm
down with the
fingers
c ontouring the
angle of the rib
c age anteriorly
( F ig. 14.35) .
4. T he hands
impar t a
moder ated
c ompr ess ion
force (arrows,
F ig. 14.36) that
19 of 40 21/08/07 22:11
is vectored F igu re 14.36. Step 4, compr ession for c e.

towar d the
x iphoid
pr ocess.
adjus ted toward
the ease of
movement of
the r ibs and
under lying
tissues until a
balance of
tension is
ac hieved.
6. When this total
balanced
position is
ac hieved, a
s low rhy thmic
ebb and flow of
pr ess ure may
pr esent its elf at
the
dy sfunctional
s egment. The
physician holds
the position
against it until a
r elease in the
direc tion of
ease occ urs .
7. T he phys ician
r eass ess es the
c omponents of
the dysfunc tion
( T ART ).
P.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
Symp tom and

Diag nosis
T he symptom is pain
at either end of the
c lav icle.
T ech niq u e
on the s ide of the
table.
2. T he phys ician
s its on a s lightly
lower stool and Fig ure 14.37. Step 3.
faces the patient.
left thumb is
placed on the tip
of the
infer omedial
s ternal end of the
c lavicle
immediately
later al to the
s ternoclavic ular
joint (F ig. 14.37) .
4. T he phys ician
places the r ight Fig ure 14.38. Step 4.
thumb on the
later al clav icle
just medial and
infer ior to the
ac romioc lav icular
joint (F ig. 14.38) .
5. T he patient may
dr ape the
forearm of the
dy sfunctional
ar m over the
physician's upper
ar m.
6. T he phys ician Fig ure 14.39. Step 6.
moves both
thumbs ( arr ows,
F ig. 14.39)
later ally,
s uper ior ly, and
s lightly
21 of 40 21/08/07 22:11
P.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.
T ech niq u e
in the later al
r ecumbent
( s ide-ly ing)
position with the
injur ed shoulder Fig ure 14.41. Step 4, thumbs at point of
up. greatest tens ion.
2. T he phys ician
s tands at the
s ide of the table
behind the
patient.
3. T he phys ician
locates the
teres minor
muscle at the
posterior
ax illary fold.
4. T he pad of the
physician's
thumbs are Fig ure 14.42. Step 5.
placed at a right
angle to the
fiber s of the
muscle ( thumb
pr ess ure
direc ted par allel
to muscle) at
the point of
maximum
hy per tonicity
( F ig. 14.41) .
5. T he phys ician
maintains a
s teady
22 of 40 21/08/07 22:11
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
in the later al
r ecumbent
position with the
injur ed shoulder
up. F igu re 14.43. Step 3.
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
23 of 40 21/08/07 22:11
elbow in the
palm of the
distal hand and
gr asps the
patient's
s houlder with
the opposite
hand (F ig.
14.43).
4. T he phys ician
c ontr ols the
humer us from
the patient's
elbow and F igu re 14.44. Step 4, compr ess toward
c ompr ess es it glenoid.
into the glenoid
fossa (arrow,
F ig. 14.44) .
5. 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 . F igu re 14.45. Step 5, balanc ing tensions.
6. 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. F igu re 14.46. Step 6, point of balanc e.
7. T he phys ician
holds the
position of
balanced
tension until a
r elease is felt.
24 of 40 21/08/07 22:11
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
Symp tom s an d
Diag nosis
T he indication is
elbow pain or
s tiffnes s.
T ech niq u e
s upine, and the
physician
s tands or s its at
the s ide of the
patient. F igure 14.47. Steps 2 and 3.
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, F igure 14.48. Step 4, pronation and
bilaterally . flexion.
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 F igure 14.49. Step 5, compres sion and
the hand into ex tension.
full flexion
( s hor t arrow).
hands
26 of 40 21/08/07 22:11
P.3 84
U ppe r Ex tre mity R e gion: Wris t: Car pal Tunnel Sy ndrome
s upine, and the
physician
s tands next to
the outs tretched
ar m of the
dy sfunctional
wr ist.
medial hand
c ontr ols the
patient's thumb
and thenar
eminence (F ig. Fig ure 14.50. Steps 1 and 2.
14.50).
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 Fig ure 14.51. Step 3, s upination.
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, Fig ure 14.52. Step 4, wris t flexion.
F ig. 14.53)
v ectored toward
27 of 40 21/08/07 22:11
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 )
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 . F igu re 14.54. Steps 1 to 5.
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
28 of 40 21/08/07 22:11
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 F igu re 14.55. Step 6, alter nate contac t
a releas e is with elbow.
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 ).
P.3 86
29 of 40 21/08/07 22:11
Lowe r Ex tre mity R e gion: Kne e : Posterior Fibular Hea d

D ysfunc tion
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 Fig ure 14.56. Steps 1 to 4.
is placed at the
s uper olater al
as pec t of the
fibular head.
other hand
c ontr ols the foot
just inferior to
the distal fibula
( F ig. 14.56) .
thumb adds
pr ess ure on the
pr oximal fibula Fig ure 14.57. Step 5.
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
30 of 40 21/08/07 22:11
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
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 F igu re 14.58. Steps 1 to 3.
places the
31 of 40 21/08/07 22:11
c audad hand
palm down ov er
the tibial
tuber osity ( Fig .
14.58).
4. T he phys ician
leans down onto
the patient's leg
( arrows, F ig .
14.59), dir ecting
a for ce toward
the table.
5. T he phys ician
adds a F igu re 14.59. Step 4, downward for ce.
c ompr ess ive
force (arrows,
F ig. 14.60) in
an attempt to
approximate the
femur and tibia.
6. 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 F igu re 14.60. Step 5, joint compression.
is fr eer . T he
physician
attempts to
maintain this
position.
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 F igu re 14.61. Step 6, inter nal or external
dy sfunctional r otation.
s egment. The
physician holds
the position
against it until a
r elease in the
direc tion of
32 of 40 21/08/07 22:11
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
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 Fig ure 14.62. Step 1.
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.
fingers apply an
upwar d forc e Fig ure 14.63. Step 2.
( arrow at left,
F ig. 14.64) into
the musc le and
then pull
33 of 40 21/08/07 22:11
infer ior ly ( arr ow

at right) us ing
the weight of the
leg to c ompr ess
the area.
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

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
joint of the index finger
pr oximal to the distal Fig ure 14.65. Steps 1 to 3.
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
34 of 40 21/08/07 22:11
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 Fig ure 14.66. Step 4, pres s ing downward.
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 14.67. 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
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 F igure 14.69. Steps 1 to 3.
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 F igure 14.70. Step 4, external r otation and
90 degrees and abduc tion of femur .
gently
ex ter nally
r otates and
abduc ts the
patient's femur
( arrow, Fig .
14.70).
r ight distal
humer us and
elbow touch the
patient's distal
femur just
above the F igure 14.71. Steps 5 to 7.
popliteal fossa
as a fulcrum to
gener ate
pr oximal
pr ess ure.
36 of 40 21/08/07 22:11
P.3 91
Lowe r Ex tre mity R e gion: Foot Dy sfunction: Me tata rsa lgia
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 igure 14.73. Steps 1 and 2, finger s on
( F ig. 14.73) and plantar s urface.
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. F igure 14.74. Steps 1 and 2, thumbs on
4. T he phys ician dorsal s urface.
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 14.75. Step 3, flexion of forefoot.
37 of 40 21/08/07 22:11
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 F igure 14.76. Step 4, press toward table.
direc tion of
ease occ urs .
7. T he phys ician
r eass ess es the
c omponents of
the dysfunc tion
( T ART ).
P.3 92
Lowe r Ex tre mity R e gion: Foot: Plantar Fas ciitis , Direc t Me thod
s upine, and the
physician s its at
the foot of the
table.
thumbs are
c r oss ed, mak ing
an X, with the
thumb pads
ov er the ar ea of
c oncern (tar sal
to distal
metatars al) at Fig ure 14.77. Steps 1 to 3.
the plantar
fascia.
3. T he thumbs
impar t an inwar d
38 of 40 21/08/07 22:11
force (arrows,
F ig. 14.77) that
is vectored
distal and
later al. This
pr ess ure is
c ontinued until
meeting the
r estr ictive (bind)
barrier.
4. T he pres sur e is
held until a
r elease is
palpated. Fig ure 14.78. Step 5, plantarflex ion.
5. T his is repeated
with the foot
alter nately
attempting
plantarflex ion
( F ig. 14.78) and
dorsiflexion
( F ig. 14.79) .
6. T he phys ician
r eass ess es the
c omponents of
the dysfunc tion
( T ART ).
Fig ure 14.79. Step 5, dors iflexion.
P.3 93
R efe renc es
1. Sp eec e C, Cr ow T . L i ga m en tous Ar tic ul ar St r ai n: O s te opa thic Te c hn i que s f or the Bod y . Seat tle :
Ea s tl and , 20 01.
2. Wa r d R (e d.) . F ound ati ons for Os teo path i c M ed i c in e. Phi l ade l ph i a: Lip pin c ot t Wi l li ams & W i lk i ns ,
20 03.
3. Su the r l an d W G. T eac hin gs i n t he Sci ence of Os teop ath y . W ale s A (e d.). Po r tl and, OR : R udra ,
19 90.
4. Fu l le r RB . S y ne r get i cs . N ew Y ork : M ac mi l la n, 1975 .
5. Sn els on, K. htt p:// w ww .ke nnet hsn els on.n et/ . F r equ ent l y As ke d Q ues ti on s ( F AQ ) an d S tru c tur e &
39 of 40 21/08/07 22:11
Te nse gri ty . Acc ess ed F ebr uar y 4, 20 07.
6. In gbe r DE . T he ar ch i te c tu r e o f l i fe . Sc i A m 1 998; 278 :48 –57.
40 of 40 21/08/07 22:11
15
Visceral Techniques

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

Di r ec t , I n di r ec t , o r C o mb in ed
1 of 21 21/08/07 22:12
Techni que Styles
All evi ation of S omatic Dysfunction

In so m ati c d y sf unct i on th at a ppe ars to dir ect l y c aus e a n or gan to fun c ti on abno r ma l ly , tr eat i ng the ar ea
of re l ate d s oma ti c dys fun c tio n s ome ti me s c an r edu c e or abla te the v is c er al abno r ma l it y . T his is an
ex amp l e o f a
P.3 96
so m at ov is c er al r efl ex bei ng q uie ted by the el i m in ati on of t he s om atic dy s fu nc ti on. Th e ab nor m al s om ati c
af fer ent bom bar dm en t i s e l i mi nat ed, c au s in g t he p r ev i ou s l y ass oci ated (a bno r m al ) r eac ti on ary vi s c er al
ef fer ent i nn erv atio n t o b e no r ma l iz ed.
Reflex Ori ented

Th ese tec hni que s at tem pt to p r od uce a s eco nda r y r eac tio n in an or gan s ys tem by aff ect i ng the au tono m ic
ne r vo us s y st em ( usu all y s y m pa the tic but so m et i m es pa r as y m pa the tic ) . T his is s im i la r t o us i ng ot her
au ton om ic re fle x es, su c h as c aro tid m as s ag e, v aga l i ndu c tio n t hro ugh Val s al v a m ane uve r , o c ul ar
pr ess ur e, ic e w ater im m er s i on , a nd s o o n. T he s e t r ea tme nts are in are as tha t ca n a ffe c t t he aut onom i c
ne r vo us s y st em i n s pec i fi c wa y s ass oc ia ted wi th e i th er s y mp ath eti c or pa r as y m pa the tic r ea c ti v it y . T hey
ar e a n at tem pt ei th er to i ncr eas e o r to de c re as e the le v els of au tono m ic ou tput at th e ar ea i n ques tio n.
Ro uti nely , w e p r efe r t o t hi nk of re duci ng the are a o f s om at i c dys func tio n r athe r t han i nc r ea s in g or
de c re as in g t he l eve l o f a uton omi c a c tiv i ty . H ow ev er, in s om e c ase s th i s app ears to pr oduc e t he
ap pro pr ia te c li ni ca l r esp onse , s uch as a p ati ent w it h a s thm a h avi ng t he s ym path eti c p or ti on of the
au ton om ic sy s te m st i mu l at ed b y t hor ac ic pu m p i n t he upp er t hor aci c re gio n a nd e x hi bit i ng l es s a i r wa y
re act i v it y .
Myofascial Oriented
Th e f as ci al c om pone nt to v i sc era l m obil i ty is the pr i ma r y a s pe c t i n d i ag nos i s a nd tre atme nt i n this
te c hn i que . ( T he s ty l e l ab el ed ba l an c ed l ig ame ntou s t ens i on, or li game nto us ar ti c ul ar s tra i n [BL T /LA S] i s
si ngl ed o ut bec ause of it s di ffe r en t pa l pa tor y ex pre s si on o f d i ag nosi s a nd tr ea tme nt, alt hou gh i t u s es th e
sa m e ti ss ues to eff ect ch ange th at m y of asc i al r el eas e [ M F R] us es) . Us i ng th e la y er - by - l ay er app r oac h,
th e p hy si c ia n p al pa tes at v ar i ou s l ev el s i n t he r egi on of t he s pe c i fi c o r ga n an d d ete r m in es w he ther an y
te the r i ng is ta k i ng pl ace i n r el ati on t o e ase - bin d b arr i er c on c ep ts . T he n t he p hys i ci an d eci des w he the r t o
us e a dir ect or i nd i re c t M F R- l ik e t ec hn i qu e. T his ca n d i r ec tly af fect th e v enou s a nd l y mp hat i c dr ai nag e
fr om the r eg i on ( in c lu din g in ter s ti ti al sp ace s ) i nha bit ed b y t he v i sc era l o r gan , w i th c li nic al r esp ons e
fr om the r ed uct i on i n i nf l amm ato r y r esp ons e, noci c ep tio n, a nd s o on.
Bal anced Ligamentous Tensi on, or Ligamentous Articular

Strain
Th e B LT /L AS m et hod of dia gnos i s and tre atm ent i s an att em pt to di s c er n t he ease - bi nd as ym m et r y.
Th en, usi ng pal pato r y tec hniq ues to s en s e the i nh ere nt m oti l it y o f th e o r ga n, t he phy s i ci an att em pt s t o
ba l an c e t he tis s ues th r ou gh i ndi r ec t (a nd s om etim es dir ec t) te c hn i que by di s eng agi ng the org an fr om it s
re s tr i c ti v e pre s ent ati on ( c om pre s si on, tra c ti on), ex agg er at i ng it s fr ee m ot i on pat ter n, a nd the n ba l an c in g
at a poin t t hat exh i bi ts equa l t ens i on i n the x -, y- , a nd z - ax es.
Vibratory or Sti m ulatory Technique
2 of 21 21/08/07 22:12
Vi bra tory or st i m ul ato r y tech niq ue us es a r ep etit i ve mo ti on ov er the org an, gen tly to m od era tel y
vi bra ti ng , s hak i ng, or pe r c us s in g o v er the or gan to fac i l it ate fl ui d m ov eme nt t hro ugh the ar ter i al, ve nou s ,
an d l y m ph ati c v es se l s and to hel p d ec on ges t t he o r ga n. T hes e t ech ni qu es are oft en use d in sp l en i c a nd
he pat i c p r ob l em s wh en thi s ty pe of forc e i s n ot c ont r ai ndic ate d.
Indications
Th e i ndic ati ons for vi bra tory or st i m ul ato r y tr ea tme nt ar e org an dy sf unc tio ns e x pr ess i ng the m se l v es in
ma ny c l in i ca l m anif est ati ons, in c lu di ng bu t n ot l i mi ted to the fo l l ow i ng (1 ) :
1. C ard i ac arr hyt hm ia , c ong es ti v e hea r t f ail ure , an d h y pe r ten s io n
2. As th m a, bro nch i tis , p neu m oni a, ate l ect asi s , and emp hys em a
3. Gast r oes oph age al r efl ux, gas tri tis , an d h i at al h ern i a
4. H epa ti ti s , c ho l eli thi asi s , c hol ecy s tit i s, pa nc re ati tis , ch r on i c fati gue , a nd h orm ona l im bal anc e
5. D i ve r tic ulo s is , ul c er ati v e c oli tis , ir r it abl e bo w el , c onst i pa tio n, d i ar r he a, a nd hem or rh oid s
6. Py el onep hri tis and re nal l it hia s is
7. R ecu r r en t c y st i tis , i nte r s ti tia l c y s ti tis , a nd s tre s s i nco nti nen c e
8. D y sm enor r he a, dy sp are uni a, a nd i nf er ti l it y
Contrai ndi cations

Th ere are no ab s olu te c on tr ai ndi c at i ons to th i s t y pe of tre atm ent ; ho w ev er, c li nic al j udg m en t a gain is th e
ru l e. Pre s su r e, c om pre s si on, or tra c tio n o v er an i nf l am ed, s er i ou s l y i nf ect ed, or ble edin g o r ga n is no t
ap pro pr ia te.

Th e p hy si c ia n m us t det erm i ne w he the r th ere is a s oma tic c om pon ent to the di s eas e s tat e. D epe ndi ng o n
th e d i s ea s e and the na tur e of th e a s s oc i at ed dy sf unc tio n,
P.3 97
th e p hy si c ia n m us t dev elo p a tre atm ent pla n t hat r ed uce s th e s oma ti c dys fun c tio n i n a s af e, ben i gn
ma nne r . T he phy s i ci an m us t al s o not e wh eth er ther e i s a n au ton omi c co m pl i ca ti on (e .g. , fa c il i ta ted
se gme nt) and if the r e i s s uch , t r ea t th at fir s t, i f pos s i bl e.
Ch apm an's re fle x is an oth er p ote nti al d i ag nos ti c aid in the de ter m i na tio n o f th e e x ac t di agn osi s an d t he
ke y d y s fu nct i on . Th i s r ef l ex has be en u s ed mo s tly as a di ag nos tic too l a nd i s n ot i nc l ude d i n t he
te c hn i que se c ti on.
P.3 98
P.3 99
Reflex Ori ented Treatment Occi pitomastoi d S uture P ressure
3 of 21 21/08/07 22:12
Indicat ions
T he indications for
occipitomas toid s utur e
pres sur e release are
tachycar dia
( hypopar asy mpathetic
s tate) and bradyc ardia
( hyperparas ympathetic
s tate).
Physiolo gic Go al
T he goal is to us e a
r eflex
( par asy mpathetic) to
decr eas e the patient's
F ig ure 15.1 T he occ ipitomastoid s uture.
puls e by influenc ing
c ardiac rate v ia c ranial
nerv e X (vagus ) or by
treating cr anial
s omatic dys function at
this ar ea ( Fig . 15.1)
that could be caus ing
a secondary
bradycar dia
( somatov isc eral ty pe) .
T ech niq u e
1. The patient lies

supine and the F ig ure 15.2 Steps 3 and 4, finger
phy sic ian is placement.
seated at the
head of the table.
2. The phy sic ian
palpates the
occ ipitomastoid
grooves
bilater ally.
3. The phy sic ian
places the index
finger s ov er eac h
mas toid pr ocess
immediately
proximal to the
anterior aspect of
the gr oove. F ig ure 15.3 Step 5, tr action with fingers.
4. The phy sic ian
places the third
4 of 21 21/08/07 22:12
P.4 00
P.4 01
Reflex Ori ented Treatment Alternating Pressure, Left Second

Rib
Indicat ions
T he indications for treatment are tac hycardia
( hypers y mpathetic state) and br ady car dia
( hyposy mpathetic s tate).
Physiolo gic Go al
T he goal is to us e the s ympathetic reflex to
incr eas e the patient's puls e by influencing car diac
r ate via sy mpathetic chain ganglia (F ig. 15.5) or
treating thoracoc ostal s omatic dys func tion at this
area, which may influenc e c ardiac rate.
T ech niq u e
1. The patient lies supine, and the phy s ician is F igure 15.6 Steps 1 to 3, anterior a
seated at the head of the table. placement of finger s.
2. The phy sic ian reaches under the patient and
places the pads of the index and middle
finger s on the angle of the left sec ond rib
near the c ostotr ansv ers e ar tic ulation.
3. The phy sic ian places the pads of the other
index and middle finger on the anter ior
aspect of the left s econd r ib near the
cos toc hondral junction (F ig . 15.6).
4. The phy sic ian pr esses upwar d with the
bottom hand while releasing pr ess ure from
the top hand (F ig . 15.7).
5. The phy sic ian holds this position for sever al
sec onds , after which the bottom hand
releas es pres sur e and the top hand ex erts
F igure 15.7 Step 4, anter ior - dir ecte
downwar d pres sur e (F ig. 15.8).
6. This pr ess ure is lik ewise held for s ever al
sec onds befor e s witc hing again. T his
alternating pres s ure is continued until the
des ired effec ts are obtained or it is
determined that the tec hnique will be
ineffec tiv e.
5 of 21 21/08/07 22:12
F igure 15.8 Step 5, posterior -direc

pr ess ure.
6 of 21 21/08/07 22:12
F igu re 15.5 Anatomic loc ation of the s ympathetic chain ganglia. Pos terior view (3
P.4 02
P.4 03
Reflex Ori ented Treatment S ingultus (Hiccups)
7 of 21 21/08/07 22:12
T he phr enic nerve arises pr imar ily fr om C4, but als o

r eceives fiber s fr om C3 and C5. It runs deep to the
omohyoid muscle and s uperfic ial to the anter ior
s calene mus cle. It is the only motor nerv e s upplying
the diaphragm (F ig . 15.9).
T ech niq u e
1. The patient may be s eated or lie supine.

2. The phy sic ian loc ates the triangle formed by the
sternal and c lav icular heads of the left
sternoc leidomastoid mus cle (F ig. 15.10).
3. The phy sic ian, us ing the thumb, index , or middle
finger , pr ess es deep into this tr iangle (F igs.
15.11 and 15.12) . F ig ure 15.10 Steps 1 and 2.
4. This pr ess ure should elicit a mild degree of pain
(to tolerance) and be maintained for at least a
minute after the hic cups c ease to br eak the
reflex arc .
5. If the tec hnique is uns ucc essful on the left, it
may be repeated on the right.
F ig ure 15.11 Finger pr essure.
F ig ure 15.12 Thumb pres sur e v
8 of 21 21/08/07 22:12
P.4 04
Reflex Ori ented Treatment Rib Rai sing
See Chapter 16,

Lymphatic
T echniques.
Indicat ions
T o r elieve
postoper ative
paralytic ileus
T o impr ove
r espiratory ex cur s ion
of the r ibs
T o facilitate lymphatic
drainage
Cont rain dications F ig ure 15.13 Skeletal hand contac t.

Rib frac tur e
Spinal c ord injur y and
s urgery
Malignancy
T ech niq u e
1. The patient lies

supine, and the
phy sic ian is
seated at the
side of the
patient.
2. The phy sic ian
F ig ure 15.14 Patient hand contac t.
slides both
hands under the
patient's
thorac olumbar
region (F igs.
15.13 and
15.14) .
3. The pads of the
finger s lie on
the
par aver tebral
tis sues ov er the
cos totr ans ver se
articulation on
the side near F ig ure 15.15 Phy sic ian and patient
9 of 21 21/08/07 22:12
the phy sic ian pos itioning.

(F ig. 15.15).
4. Leaning down
with the elbows,
the phy sic ian
lifts the finger s
into the
par aver tebral
tis sues ,
simultaneously
drawing the
finger s (arrows,
Fig . 15.16) in.
5. This lifts the
spine off the
table and places F ig ure 15.16 Step 4, v entr al, then lateral
a later al str etc h pr essure.
on the
par aver tebral
tis sues .
6. This technique
may be
per for med as an
intermittent
kneading
tec hnique or
with s ustained
deep inhibitory
pressur e.
P.4 05
Sti mul atory/V ibratory Treatment Colonic Sti mul ation
10 of 21 21/08/07 22:12
Indicat ion
Cons tipation
Cont rain dications

Bowel obstr uction
Abdominal
neoplas m
Undiagnosed
abdominal pain
T ech niq u e
1. The patient
lies s upine,
and the F ig ure 15.17 Steps 1 and 2.
phy sic ian
stands at the
patient's side.
2. The phy sic ian
places the
pads of the
finger s on the
abdominal
wall ov erlying
the splenic
flexur e of the
colon ( Fig .
15.17) .
3. The phy sic ian
F ig ure 15.18 Step 3.
rolls the
finger s along
the bowel in
the dir ection
of colonic
flow ( arrows,
Fig . 15.18).
4. The phy sic ian
releas es
pressur e and
repositions
the hands
one
hand's - width
far ther along F ig ure 15.19 Step 5.
the colon
toward the
sigmoid
region.
11 of 21 21/08/07 22:12
P.4 06
Sti mul atory/V ibratory Treatment S plenic Sti mul ation
Indicat ions
Any infectious
disease; also
prev entive
Cont rain dications

Infectious
mononuc leos is;
any splenic
enlargement
Neoplas m
infiltr ating the
s pleen
T ech niq u e F igure 15.21 Steps 1 to 3.
1. The patient
lies s upine,
and the
phy sic ian
stands at the
left s ide of
the patient.
2. The
phy sic ian's
right hand
abducts the
patient's left
arm 90
F igure 15.22 Step 5.
degrees and
exerts gentle
traction
(a r row, F ig.
15.21) .
3. The phy sic ian
places the left
hand on the
lower c ostal
car tilages
overly ing the
spleen, with
the finger s
following the
interc ostal F igure 15.23 Step 6, s udden r elease
12 of 21 21/08/07 22:12
spaces (F ig. modification (c ompr ess ion).

15.21) .
4. The
phy sic ian's
left hand
exerts
pressur e
dir ectly
toward the
center of the
patient's
body,
spr inging the
ribs inwar d.
5. A s pringing
motion F igure 15.24 Step 6, r elease.
(a r row, F ig.
15.22) is
car ried out at
two per
sec ond and
continued for
30 sec onds
to sev eral
minutes .
6. One
modific ation
of this
tec hnique
inv olv es
F igure 15.25 Step 7, perc uss ive
compres sing
modification.
the lower left
rib cage
slowly
between the
phy sic ian's
hands with a
sudden
releas e (also
call a
chugging
motion)
(F igs. 15.23
and 15.24) .
7. A s econd
modific ation
has the
phy sic ian
place one
13 of 21 21/08/07 22:12
hand ov er the
lower c ostal
car tilages
and thump
and per cus s
the bac k of
the hand with
a fist or
for ear m
(a r row, F ig.
15.25) .
P.4 07
Reflex Ori ented Treatment S acral Rock
Indicat ions
Dysmenor rhea
Pelv ic c ongestion
s yndrome
Sacr oiliac
dysfunc tion
Cont rain dications

Undiagnosed pelvic
pain
Pelv ic malignancy
T ech niq u e
1. The patient F ig ure 15.26 Cephalad hand.

lies pr one,
and the
phy sic ian
stands at the
side of the
table.
2. The phy sic ian
places the
cephalad
hand with the
heel of the
hand at the
sac ral bas e,
14 of 21 21/08/07 22:12
P.4 08
finger s
Myofascial Release/Blt Treatment Gastric Release
pointing
toward the
coc cyx (F ig.
15.26) .
3. The
Indicat ions
phy sic
G astroes ian's
ophageal
r efluxcaudad hand
reinfor
G astric ptosis ces the
cephalad
hand
T ech niq u ewith
finger s
1. The
pointing
patient in the
is
oppositeand the
seated,
sic ian stands F ig ure 15.27 Caudad hand.
dir ection
phy
(F ig. 15.27).
behind the patient.
4. The phy sic ian
2.
phy sic ian,
places the left and
keeping
right hands the over
elbows
the left and right F ig ure 15.30 Steps 1 and 2.
str aight, s ubc ostal
anterior
exerts
and subxiphoid
gentle
pressur e on
region,
the pec
res sactively
rum. (F ig .
5. 15.30)
The phy . sic ian
3. The
introduces
phy sic a ian's
roc kingc ontour the
hands
motionabdominal
upper to the
sac rum
quadrants, and
F ig ure 15.28 Sac ral ex tens ion
synchr
the finger onouspads
( c ounternutation).
withl sthe
cur lightly and
patient's
press inward
resr rows
(a pir ation.
, F ig.
Sac ral .
15.31)
F ig ure 15.31 Step 3.
4. The
extens phy ionsic ian
(a r row,
adds s lightly
F ig. mor e
15.28) occ
pressur e inward
urs
dur ing
and then tests for
inhalation.
tis sue tex tur e
Sac ral flexion
changes and
(a r row,
asy mmetry F ig.in
15.29)
eas e-bind occ motion
urs
dur ing
freedom.
5. The
exhalation.
phy sic ian
6. dir
Thisects a constant F ig ure 15.29 Sac ral flexion ( nutation).
tec hnique
pressur e tois the
continued
eas e ( indirec for t) or
sev eral
bind ( direct) ,
minutes . on the
depending
15 of 21 21/08/07 22:12
patient's tolerance F ig ure 15.32 Step 5, indir ect for ce (ease) .

and phy sic ian's
prefer ence (F igs.
15.32 and 15.33) .
6. The phy sic ian
holds this until a
releas e is
palpated and
continues until no
fur ther
improv ement is
produc ed.
7. A
releas e-enhancing
mec hanism, such
as deep inhalation F ig ure 15.33 Step 5, direc t ( bind).
and ex halation,
can be helpful.
P.4 09
Myofascial Release/Blt Treatment Hepatic Release
Indicat ions
Hepatitis
Cirr hos is
Cholelithiasis
T ech niq u e
1. The patient lies

supine, and the
phy sic ian sits to
the right and
fac es the patient.
2. The phy sic ian
places the left
hand under the r ib F ig ure 15.34 Steps 1 to 3.
cage at the level
of the liv er.
3. The phy sic ian
places the right
hand immediately
inferior to the
16 of 21 21/08/07 22:12
subcos tal angle at

the patient's right
upper quadrant
(F ig. 15.34).
4. The phy sic ian
gently
compres ses the
patient with both
hands ( arr ows ,
Fig . 15.35) and
attempts to
palpate the liver .
5. The phy sic ian
nex t tests for any
eas e-bind tis sue F ig ure 15.35 Compress to palpate liv er.
tex tur e and motion
asy mmetries.
6. On noting any
asy mmetry, the
phy sic ian
maintains a
constant pres sur e
at either the eas e
(indir ect) or the
bind ( direct) ,
depending on the
patient's tolerance
and phy sic ian's
prefer ence (F ig.
F ig ure 15.36 Step 6, direc t or indir ect for ce.
15.36) .
7. The phy sic ian
holds this until a
releas e is
palpated and
continues until no
fur ther
improv ement is
produc ed.
8. A
releas e-enhancing
mec hanism, such
as deep inhalation
and ex halation,
can be helpful.
P.4 10
Myofascial Release/Blt Treatment Gal l bladder
17 of 21 21/08/07 22:12
Indicat ions
Cholecy s titis
Cholestasis
Chronic upper
abdominal pain
T ech niq u e
1. The patient is
seated, and the
phy sic ian stands
behind the patient.
2. The phy sic ian
places the index ,
third, and fourth F ig ure 15.37 Steps 1 to 3.
finger s of the left
hand just inferior
to the xiphoid
proces s , midline
to slightly r ight.
3. The phy sic ian
places the index ,
third, and fourth
finger s of the r ight
hand just inferior
to the subcos tal
mar gin, just lateral
of midline
immediately to the
F ig ure 15.38 Step 5, indir ect for ce (ease) .
right of the
gallbladder ( Fig .
15.37) .
4. The phy sic ian
tes ts for any
eas e-bind tis sue
asy mmetries.
5. On noting any
asy mmetry, the
phy sic ian
maintains
constant pres sur e
(a r rows , F igs.
15.38 and 15.39) F ig ure 15.39 Step 5, direc t forc e (bind).
at either the eas e
(indir ect) or the
bind ( direct) ,
depending on the
18 of 21 21/08/07 22:12
P.4 11
Myofascial Release/Blt Treatment Kidney Rel ease
Indicat ions
Pyelonephritis
Renal lithiasis
F lank and inguinal pain
T ech niq u e
1. The patient lies

supine with the hip
and knee flex ed
on the affected
side.
2. The phy sic ian
stands on the
affected s ide at F ig ure 15.40 Steps 1 to 3.
the lev el of the
hip.
3. The patient's knee
is plac ed anterior
to the phy sic ian's
axilla at the
cor acoid proc ess ,
and hip flexion is
added to r elax the
anterior abdominal
region (F ig.
15.40) .
4. The phy sic ian
places the later al
F ig ure 15.41 Steps 4 to 6.
hand palm up
under the patient's
bac k just below
the floating ribs .
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 15.42 Step 8, direc t or indir ect for ce.
19 of 21 21/08/07 22:12
arr ow, Fig . 15.41)

until palpating the
kidney .
pos ter ior hand lifts
(b ottom ar row,
Fig . 15.41)
upward (anter ior )
to fac ilitate the
renal palpation.
7. The phy sic ian
nex t tests for any
eas e-bind tis sue
asy mmetries.
8. On noting
asy mmetry, the
phy sic ian
maintains a
constant pres sur e
(a r rows , F ig.
15.42) at either
the eas e ( indirec t)
or the bind
(direc t),
depending on the
patient's tolerance
and phy sic ian's
prefer ence.
9. The phy sic ian
holds until a
releas e is
palpated and
continues until no
fur ther
improv ement is
produc ed.
10. A
releas e-enhancing
mec hanism, such
as deep inhalation
and ex halation,
can be helpful
P.4 12
References
20 of 21 21/08/07 22:12
1. W ar d R . Fo und ati ons for Os teop ath i c M edi c in e. Phil ade l ph i a: Lip pin c ott Wi l li am s & W i lk i ns,
200 3.
2. Bar r al J P, Me r ci er P . V i sc er al Ma nip ul at i on . S eatt l e: Ea s tla nd, 19 88.
3. R ep r in ted w it h p er mi s si on fr om Ag ur AM R, Da l le y AF . G r an t' s Atl as of A nat omy , 11 th ed.

Bal tim ore : Li ppi nco tt W i ll i am s & W il k in s , 2 005 .
21 of 21 21/08/07 22:12
16
Lymphatic Techniques

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

He wa s ki nd eno ugh to don ate s om e o f hi s f ath er 's eq uip m ent to th e PC OM arc hi ve s . W ha t wa s m ost
in ter es ti ng to us w ere th e po s it i ve eff ect s h e sa i d his fat her ' s tech niq ue had on s o m any va r ie d
co ndi ti on s . Som e we r e not c on dit i on s th at hav e be en his tori c al l y taug ht as i ndi c at i on s fo r i ts us e. Th i s
ha d a pro fou nd effe c t on us , and we are
P.4 14
at tem ptin g t o d ev el op m or e re s ea r ch i n thi s f i eld (e .g. , Pa r ki nso n di s ea s e, m ul tip l e s c le r os i s) . Be l l' s
pa l sy w as th e c ondi tio n t hat piq ued our in ter es t m os t w hen c on s id er in g i ts c l in i ca l v al ue . M i ll er
ev i de ntly ha d e x tre m el y r apid po s it i v e c li nic al r esp ons es w hen tr eati ng Bel l ' s pal s y w i th th i s tech niq ue.
It ch ange d o ur v i ew s o n t he s y mp tom s as s oc i at ed w i th th i s p r oc ess and wh y s ti mu l at i on to the ch es t
wa l l and pul m on ar y c av i ty c ou l d r es ul t i n an al mo s t i mm edia te c li ni ca l r esp onse in a s y nd r om e w i th
mo s t of i ts s ym ptom s i n t he f aci al c r an i um . W e be l ie v e that th e f l uid - st i mu l ati ng eff ec ts ca n d ec on ges t
th e f or am en thr ough wh i ch the fa c ia l ne r ve pa s s es , t hus all evi ati ng t he s ym ptom s .
Th e c l i ni c al ef fect s t hat c an be se en w i th ly m pha tic te c hni que s m ay b e s eco ndar y t o t he e l im i na ti on of

so m at i c d y sf unc ti on , w her eby r el ate d au ton omi c ch ang es and pot ent i al fac i li tate d s egm ents ar e
no r ma l i ze d. T hi s no r ma l iz atio n n ot only ha s e ffec ts on s oma tic an d vi s ce r al r ef l ex es, noc i ce pti on, and
va s cu l ar ton e; i t c an als o af fec t t he l y mp hat i c s y st em, w hi c h r ec ei ve s a uto nomi c s tim ul at i on . T he l arg er
ly m ph atic ve s se l s m ay eve n ch ang e d i ame ter fo l l ow i ng sy m pat het i c s tim ula tio n (1 ,5) .
Techni ques Removi ng Restri ctions to Lymphatic Flow

Re s tr i c ti ons to l ym pha tic flo w t hat are re l at ed t o s pec i fic so m at i c d y sf unc ti on s m ay be r emo v ed by
te c hn i que s f r om m an y c ate gori es ( e. g., BLT /LA S; h i gh - vo l ume , l ow- am pl i tu de [H VL A]) . T hi s c an be
th oug ht o f a s b r eak i ng th e da m . An ex am ple is a f i rs t r i b d y sf unc ti on . B esi des c au s in g pa i n, li m i te d
mo tio n, a nd s o on, a f i rs t ri b d y sf unct i on ha s th e p ote ntia l t o r es tr i ct fl ow t hro ugh the th ora c i c i nl et.
Mo bil i z in g t he r i b and re s tor i ng it s no r ma l r ange of mo ti on an d f unct i on ma y re m ov e t he r est r ic ti on to
ly m ph atic fl ow. T he r ef ore , an y t ech ni qu e t hat i s i nd i ca ted for fi r s t r ib so m ati c d y sf unct i on (e .g., MF R ,
mu s cl e en erg y t ec hn i qu e [ M ET] ) a l so has th e p oten tia l t o be a l ym phat i c tec hniq ue. An othe r i m po r tan t
pr i nc i ple is to r em ove so m ati c d y sf unct i on s t hat are ca us in g s eco ndar y a uto nomi c e ffe c ts ( e. g., tho r ac i c
dy s fu nc ti ons ca us in g h y pe r s ym pat het i c t one wi th c ons equ ent l ym pha ti c c on s tr i c ti on) .
So m e othe r c omm on a r ea s o f dy s fu nct i on w it h w hi ch th i s ty pe of te c hni que ca n be he l pf ul a r e

su bma ndib ula r r es tr i ct i on s , t hor aci c in l et re s tri c ti on s eco nda r y to m y of asc i al ten s io n, a bdo m in al
di aph r agm dy s fu nc ti on, ps oas m us c le dys fun c ti on, and dy s fun c ti ons aff ect i ng the ax i ll a, a nte c ub i tal
fo s sa , po pli tea l fo s sa , a nd p l an tar fas c ia .
Techni ques Promoting Lymphatic Fl ow

Te c hn i que s p r om otin g l y mp hati c f l ow are ge ner al ly st i mu l ato r y, st r oki ng, or v ib r at ory . Ef fle ura ge a nd
pé tri s s ag e a r e c omm on m as s age va r ia ti on s o f t hi s typ e o f te c hn i qu e. T hor aci c pu m p, pe dal pum p,
ma ndi bula r d r ai nage , a nd ante r io r c er vi c al ch ai n dra i na ge a r e c la s s ic al exa m ple s o f o s teo pat hic
te c hn i que s t hat s ti m ul ate flo w .
Th i s m oda l it y h as b een in v olv ed i n di sc uss i on s co nce r ni ng t r ea tme nt o f p ati ents wi th a ma l ig nan c y .

So m e beli eve th at i t i s n ot w i se to pro m ot e l y m ph ati c f l ow, wh i le oth ers be l i ev e i t i s in dic ate d be c au s e
pr omo ti ng no r ma l fl ow all ow s gre ate r cl ear anc e of ab nor m al c el l s. M or e r ese ar ch is ne eded , b ut w e
2 of 59 21/08/07 22:13
be l ie v e t hat if exe r ci s e c an be pre s c ri bed fo r sp eci fic pat i en ts w i th a m al i gna ncy , t hen l ym pha ti c flo w
st i mu l ati on s ho ul d als o b e in dic ate d in th ose pat i en ts.
Techni que Styles

Th e v ar io us s ty l es of l ym phat i c tec hniq ue bel ong to the i r o w n c at egor y o f o s teo pat hic m an i pu l at i v e
tr eat m ent (O M T) . Su bcl ass i fic ati on i n t his ca tego r y i nc l ude s t ech ni qu es tha t af fec t t he i ntr i ns i c a nd
ex tri ns ic ly m ph atic pu m ps .
Intrinsic Lym phatic Pum p

Th ese tec hni que s al ter au tono m ic to ne o r t i ss ue t ext ure i n the in ters tit i al s pa c es . I n th e i nte r s ti tiu m ,
fl uid c an ac c um ul at e a nd ev en tua l ly dis r up t n or ma l l y mp hati c f l ow . Ex amp l es of thi s s ty le in c lu de
tr eat m ent of fa c i li tat ed s egm ent s i n th e t hor ac ol umb ar r egi on and i nd i re c t m y of asc i al r el eas e t o th e
in ter os se ous me m bra ne.
Extrinsic Lym phatic Flow

Th e e x tri nsi c p um p i s r el ated to th e ef fec ts of m usc l e c ont r ac tio n an d m oti on o n t he l y mp hat i c s y st em.
Th ere fore , a ny tech niq ue that af fec ts t his me c han i sm is c on s id ere d an ex tri ns ic st y le . Ex amp l es i nc l ud e
ab dom i nal di aph r agm or pe l v ic di aph r agm tr eat m ent wi th m y of asc i al r el eas e, M ET, or tr eati ng the
so m at i c c omp one nt o f a dy s fun c ti on w i th HV LA ( e.g ., C 3 to C 5 d y sf unct i on af fect i ng th e di aph r ag m ) . Any
fo r m of e x er c is e or te c hn i que af fec ti ng mu s cl e ac tiv i ty ( e. g., di r ect pr ess ur e, st r ok i ng, ef fle ur ag e) i s
in c lu ded i n thi s st y le .
Indications
Ly mp hati c c ong es ti on, po s tsu r gi c al ede m a ( e. g., m as tec tomy )
P.4 15
M i ld to m od era te c ong est i v e hea r t fail ure
U ppe r an d l owe r re s pi r at or y i nf ect i ons an d o ther ar eas of i nf ect i on
As th m a, c hr oni c ob s tr uct i v e pul m on ar y dis eas e
Pain due to ly m pha tic co nges tio n a nd s w el l in g
Contrai ndi cations

Ac ut e in dur ate d ly m ph no de ( do not tre at dir ec tl y )
F r ac ture , d i sl oc at i on , o r os teo por os is if te c hni que st y l e w ou l d ex ac erb ate c on dit i on
Or ga n fr i ab i li ty a s s een i n s pl een w it h i nfe c tio us m on onuc l eo s is
Ac ut e he pat i ti s
M ali gnan c y
3 of 59 21/08/07 22:13

Ly m ph atic te c hn i que s a r e s i mi l ar in s co pe of pr in c ip l e to t he v is c era l t ech ni qu es. Th e ph y si c ia n mu s t
co nsi der the pa ti en t's he al th st atu s al ong wi th t he s pe c i fi c p r es enti ng s ym ptom s b efo r e d eci din g to us e a
pa r ti c ula r t ech ni qu e. T he are a m ust be s ta ble , an d t he i nte gum ent m us t b e a bl e to tol er at e t he ty pe of
pr ess ur e, wh eth er p r ob i ng or fri c ti onal . F or v i br ato r y or c omp r es s i on te c hn i que s , the pat i en t's
mu s cu l osk ele tal s ta tus in r es pec t t o bo ne den s i ty an d m otio n a v ai l abi l it y m us t be r el ativ ely no r m al . I f
th e p atie nt has l ym pha tic s eq uel ae of a uto nom i c d i st urb ance , t he appr opr i at e so m at i c c omp one nt m ust
be tr eate d w i th w hi c he v er tec hni que the ph y si c i an de ter m i ne s i s i ndic ate d.
Th ese tec hni que s , i n a ddi ti on to af fect i ng ly m pha tic ci r c ul ati on, m ay af fec t th e e ndo c r in e, aut oi mm une ,
an d n euro m us c ul os ke l et al s y st ems , r es ul tin g i n in c re ase d mo tio n, l ess pa i n, and a bet ter ove r al l se nse
of we l l -b ein g. T he fol l ow i ng tec hni ques , a s s tate d p r ev i ous l y, ar e no t t he only on es affe c ti ng the
ly m ph atic s . Ple as e s ee ot her c ha pte r s f or w ay s to en han c e l y mp hat i c f l ow , r educ e r est r i ct i on , o r
no r ma l i ze au ton om ic in ner v ati on.
P.4 16
Head and Neck Anteri or Cervical Arches: Hyoid and Cri coi d
Rel ease
Indicat ions
Lary ngitis
Phar yngitis
Cough
Any dys func tion
or lymphatic
c ongestion in the
ear, nos e, or
throat ( ENT )
r egion
T ech niq u e
1. The patient
lies s upine, Fig u re 16.1. Steps 1 to 3, setup.
and the
phy sic ian
sits at the
head of the
table.
2. The
phy sic ian
stabilizes
the patient's
head by
placing the
4 of 59 21/08/07 22:13
cephalad
hand
beneath the
head or by
gently
grasping the
for ehead.
3. The thumb
and index
finger of the
phy sic ian's
caudad
hand form a
hor ses hoe
shape Fig u re 16.2. Step 4, hy oid.
(inver ted C)
over the
anterior
cer vic al
arc hes (F ig.
16.1).
4. The
phy sic ian
mak es
alternating
contac t
(a r rows ,
Fig s. 16.2
and 16.3)
Fig u re 16.3. Step 4, cr icoid.
with the
lateral
aspects of
the hy oid
bone,
lar yngeal
car tilages ,
and upper
tracheal
rings, gently
pus hing
them fr om
one side to
the other.
5. The
phy sic ian
continues
this
alternating
pressur e up
5 of 59 21/08/07 22:13
and down
the length of
the anterior
nec k.
6. If ther e is
crepitus
between the
anterior
car tilaginous
str uctures
and the
cer vic al
spine, the
nec k may
be slightly
flexed or
extended to
eliminate
exc ess
friction.
(Some
crepitus is
nor mal.)
7. This
tec hnique is
continued
for 30
sec onds to
2 minutes.
P.4 17
Head and Neck Cervical Chai n Drai nage Technique
6 of 59 21/08/07 22:13
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or ly mphatic
c ongestion in the ENT
r egion.
T ech niq u e
1. The patient lies

supine, and the
phy sic ian sits at the
head of the table.
2. The phy sic ian
stabilizes the
patient's head by F ig ure 16.4. Steps 1 to 3, hand plac ement.
placing the
cephalad hand
beneath the head to
elevate it slightly or
by gently grasping
the for ehead.
caudad hand
(palmar as pec t of
the finger s) mak es
broad c ontact ov er
the
sternoc leidomastoid
(SCM) musc le near
F ig ure 16.5. Step 4, milking motion.
the angle of the
mandible ( arr ow,
Fig . 16.4) .
4. From c ephalad to
caudad the finger s
roll along the
mus cle in a milk ing
fas hion (arrows,
Fig . 16.5) . T he
hand then mov es
slightly more
caudad along the
mus cle and repeats
the rolling motion.
5. This s ame
procedure is
applied both
anterior to and
pos ter ior to the
7 of 59 21/08/07 22:13
P.4 18
Head and Neck Mandibular Drainage: Galbreath Technique
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or
lymphatic
c ongestion in the
ENT or
s ubmandibular
r egion, especially
dysfunc tion in the
Eustachian tubes.
Care mus t be
taken in patients
with ac tive
temporomandibular F ig ure 16.6. Steps 1 to 3, setup and hand
joint ( T MJ) placement.
dysfunc tion (e.g.,
painful click) with
s evere loss of
mobility and/or
lock ing.
T ech niq u e
1. The patient
lies s upine
with the head
tur ned
slightly
toward the
F ig ure 16.7. Step 5, c audad pres s ure on
phy sic ian
mandible.
and the
phy sic ian sits
at the head of
the table.
2. The
phy sic ian
stabilizes the
patient's
head by
placing the
cephalad
hand beneath
the head to
8 of 59 21/08/07 22:13
elevate it
slightly.
3. The
phy sic ian
places the
caudad hand
with the thir d,
fourth, and
fifth fingertips
along the
pos ter ior
ramus of the
mandible and
the
hypothenar
eminenc e
along the
body of the
mandible
(F ig. 16.6).
4. The patient
opens the
mouth
slightly.
5. The
phy sic ian's
caudad hand
presses on
the mandible
so as to draw
it slightly
for war d
(a r rows , F ig.
16.7) at the
TMJ and
gently toward
the midline.
6. This
procedure is
applied and
releas ed in a
slow
rhy thmic
fas hion for 30
sec onds to 2
minutes . It
may be
repeated on
the other
9 of 59 21/08/07 22:13
side.
P.4 19
Head and Neck Auricular Drainage Technique
Indicat ions
Any dys func tion or
lymphatic c ongestion
in the ear region
O titis media
O titis externa
T ech niq u e
1. The patient lies

supine with the
head turned
slightly toward
the phy sic ian,
and the physician F ig ure 16.8. Steps 1 to 3, hand plac ement.
sits at the head
of the table.
2. The phy sic ian
stabilizes the
patient's head by
placing the
cephalad hand
beneath the head
to elev ate it
slightly.
3. The phy sic ian
places the
caudad hand flat
agains t the s ide
F ig ure 16.9. Step 4, c lock wis e.
of the head,
finger s pointing
cephalad and the
ear between the
fourth and third
finger s (F ig.
16.8).
caudad hand
10 of 59 21/08/07 22:13
mak es c loc kwise

and
counter clockwise
cir cular motions
(a r rows , F igs.
16.9 and 16.10),
mov ing the sk in
and fas cia ov er
the sur fac e of
the sk ull. There
should be no
sliding ov er the
skin and no
friction.
5. This pr ocedur e is F ig ure 16.10. Step 4, c ounter cloc kwise.
applied for 30
sec onds to 2
minutes .
P.4 20
Head and Neck Al ternati ng Nasal P ressure Techni que
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or
lymphatic
c ongestion in the
ENT region,
especially the
ethmoid sinus.
T ech niq u e
1. The patient
lies s upine,
and the F ig ure 16.11. Step 4, left.
phy sic ian
sits at the
head of the
table.
2. The
phy sic ian
11 of 59 21/08/07 22:13
uses an
index finger
to pres s on
a diagonal
(a r rows ,
Fig s. 16.11
and 16.12)
into the
junction of
the nas al
and fr ontal
bones, fir st
in one
dir ection and
then the F ig ure 16.12. Step 4, r ight.
other.
3. This
procedure is
applied for
30 sec onds
to 2 minutes.
4. Alternativ e
methods
bas ed on
per sonal
modific ations
of hand
pos ition are
acc eptable
F ig ure 16.13. Modification.
(F ig.16.13).
P.4 21
Head and Neck Submandibular Release
12 of 59 21/08/07 22:13
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or
lymphatic
c ongestion in the
ENT region,
especially those
affecting the
tongue, salivary
glands, lower teeth,
and
temporomandibular
dysfunc tions.
T ech niq u e
1. The patient
lies s upine,
and the
phy sic ian sits
at the head of
the table.
2. The phy sic ian
places the
index and
third fingertips
(may include
fourth finger s)
immediately
below the
inferior r im of
the mandible
(F ig. 16.14).
3. The finger s
are then F igure 16.14. Hand and finger position.
dir ected
superiorly into
the
submandibular
fas cia to
determine
whether an
eas e-bind
asy mmetry is
present
(a r rows , F ig.
16.15) .
13 of 59 21/08/07 22:13
P.4 22
P.4 23
Head and Neck Tri gem inal S timulation Techni que
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or
lymphatic
c ongestion in the
ENT region
affecting or
exac erbated by
inflammation of
c ranial ner ve V
( Fig . 16.18).
T ech niq u e
Fig u re 16.19. Steps 2 and 3, s upr aorbital
1. The patient for amen.
lies s upine,
and the
phy sic ian
sits at the
head of the
table.
2. The
phy sic ian
palpates
along the
superior
orbital ridge,
identifying
the
Fig u re 16.20. Steps 4 and 5, infr aorbital
supraor bital
for amen.
for amen.
3. The
phy sic ian
places the
pads of the
index and
middle
finger jus t
inferior to
the or bital
ridge and
produc es a
14 of 59 21/08/07 22:13
cir cular
motion with
the finger s
of both
hands
(a r rows ,
Fig . 16.19).
4. The
phy sic ian
palpates
along the
inferior
orbital ridge,
identifying
the Fig u re 16.21. Steps 6 and 7, mandibular
infraor bital for amen.
for amen.
5. The
phy sic ian
places the
pads of the
index and
middle
finger s just
inferior to
the
infraor bital
for amen and
produc es a
cir cular
motion with
the finger s
of both
hands
(a r rows ,
Fig . 16.20).
6. The
phy sic ian
palpates
along the
mandible,
knowing
that the
thr ee
for amina
for m a
str aight line,
identifying
the
15 of 59 21/08/07 22:13
mandibular
for amen.
7. The
phy sic ian
places the
pads of the
index and
middle
finger s ov er
the
mandibular
branch of
the
trigeminal
ner ve and
produc es a
cir cular
motion with
the finger s
of both
hands
(a r rows ,
Fig . 16.21).
8. This
trigeminal
stimulation
procedure
is applied
for 30
sec onds to
2 minutes at
eac h of the
thr ee
loc ations.
16 of 59 21/08/07 22:13
F igu re 16.18. Cranial nerve V distribution ( 6).
P.4 24
Head and Neck Maxill ary Drainage: Effleurage
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or
lymphatic
c ongestion in the
ENT region,
especially those
affecting the
maxillar y s inuses .
T ech niq u e
1. The patient
lies s upine,
and the F ig ure 16.22. Step 2, finger plac ement.
phy sic ian sits
at the head of
the table.
2. The phy sic ian
places the
index finger
tip pads ( may
inc lude third
finger s ) just
inferior to the
17 of 59 21/08/07 22:13
infraor bital
for amina
(F ig. 16.22).
3. The
phy sic ian's
finger s begin
a s low, gentle
str oking
(effleurage)
over the
patient's skin
immediately
par allel to the
lateral as pec t
of the nos e F ig ure 16.23. Step 3, effleur age.
until they
meet the
dental ridge
of the gums
(a r rows , F ig.
16.23) .
4. The finger s
continue
laterally in a
continuous
gentle motion
toward the
alar as pec t of
the zy goma
F ig ure 16.24. Step 4, motion toward the
(F ig. 16.24).
z y goma.
5. This is
repeated for
30 sec onds
to 2 minutes.
6. 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 F ig ure 16.25. Modification.
holding at
differ ent
lev els for 20
to 30
18 of 59 21/08/07 22:13
sec onds at
eac h level in
steps 3 and 4
(F ig. 16.25).
P.4 25
Head and Neck Frontal Temporom andibul ar Drainage:

Effleurage
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or
lymphatic
c ongestion in the
ENT region,
especially those
affecting the
frontal thr ough
mandibular
r egions or in
tens ion
headache.
T ech niq u e F ig ure 16.26. Step 2, finger plac ement.
1. The patient
lies s upine,
and the
phy sic ian
sits at the
head of the
table.
2. The
phy sic ian
places the
index
finger tips
(may
F ig ure 16.27. Step 3, effleur age.
inc lude third
finger s )
immediately
above and
19 of 59 21/08/07 22:13
medial to
the
eyebrows
(F ig.
16.26) .
3. The
phy sic ian's
finger s
begin a
slow, gentle,
str oking
(effleurage)
laterally that
tak es them
immediately F ig ure 16.28. Step 4, motion toward TMJ .
par allel to
the
supraor bital
ridge until
they meet
the ar ea of
the pterion
(a r rows ,
Fig . 16.27).
4. The finger s
continue
inferiorly in
a
continuous
gentle
motion
toward the
TMJ and
inferiorly
over the
mandible
(F ig.
16.28) .
5. This is
repeated for
30 sec onds
to 2
minutes .
P.4 26
Thoraci c Regi on Thoraci c I nlet and Outlet: Myofascial

Rel ease, Direct or I ndi rect, S eated, Steeri ng Wheel
20 of 59 21/08/07 22:13
Techni que
Indications
Th i s tech niq ue i s i ndi c at ed f or any dys fun c ti on o r l y mp hati c c ong es ti on c au s ed or exa c erb ate d b y fa s ci al
to ne as ym m et r y i n t he are a of th e t hora c ic in l et and ou tl et .
Contrai ndi cations

Th i s tech niq ue has no abs ol ut e c ont r ain dic ati ons.
Techni que
Se e C hapt er 8, M y of asc i al R el eas e T ec hn i qu es, for de tai l s .
P.4 27
Thoraci c Regi on Thoraci c I nlet and Outlet: Myofascial

Rel ease, Direct, Supine
Indicat ions
T his tec hnique is
indicated for any
dysfunc tion or
lymphatic c ongestion
c aus ed or exac erbated
by fasc ial tone
asymmetr y in the area
of the thor acic inlet and
outlet.
Cont rain dications
T his pr ocedure should
not be used if the
patient has painful,
s everely restr icted F ig ure 16.29. Steps 1 and 2, setup.
motion of the shoulder
( e.g., fibr ous adhesive
c aps ulitis, rotator c uff
tear ).
T ech niq u e
1. The patient lies

supine with the
arm on the
dys func tional side
abducted to
approx imately 90
degrees .
2. The phy sic ian
21 of 59 21/08/07 22:13
stands or sits at F ig ure 16.30. Modified suppor tiv e position.

the side of the
dys func tional
thorac ic inlet
either caudal or
cephalad to the
abducted upper
extremity (F ig.
16.29) . The arm
may be suppor ted
by the phy sic ian's
thigh if needed
(F ig. 16.30).
3. The phy sic ian
places the index
and third finger F ig ure 16.31. Palpation of the thoracic inlet.
pads of the
cephalad hand
over the area of
the thorac ic inlet
so as to palpate
the fas cial tone at
the ins ertion of the
fir st r ib at the
manubr ium and
the
suprac lavicular
fas cia (F ig.
16.31) .
F ig ure 16.32. Step 5, arm thr ough series of
caudad hand
motions.
controls the
patient's arm.
5. The phy sic ian
gently mov es the
patient's arm
thr ough a ser ies
of motions
(a r rows , F ig.
16.32) to vec tor a
line of tension
toward the
thorac ic inlet.
When s uccessful,
the phy sic ian will
palpate the
tension at that
site.
6. The phy sic ian
22 of 59 21/08/07 22:13
waits for a r elease

(fascial c reep)
and continues
until ther e is no
fur ther
improv ement in
the res trictive
bar rier . Deep
inhalation or other
releas e-enhancing
mec hanisms can
be helpful, as c an
a v ibr ator y motion
produc ed through
the upper
extremity with the
wrist- c ontrolling
hand.
P.4 28
Thoraci c Regi on Mill er Thoraci c (Lym phatic) Pum p
Indicat ions
T his tec hnique is
indicated for
infection, fev er,
lymphatic
c ongestion, rales ,
and chr onic
productive cough;
also pr eventiv e, it
may inc r eas e titer s
post vac cination
( 7,8,9,10,11).
Cont rain dications
T his pr ocedure
s hould not be used F ig ure 16.33. Steps 1 and 2, setup.
if the patient has
frac tur es,
osteopor osis,
moderate to sever e
dyspnea, regional
incisions,
23 of 59 21/08/07 22:13
s ubc lav ian lines,

metastatic cancer ,
and so on.
Physiolo gic Go al
T he goal is to
accentuate
negativ e
intr athorac ic
pres sur e, incr eas e
lymphatic r eturn,
loos en mucus
plugs v ia the
v ibr ator y
c omponent, and
potentially F ig ure 16.34. Hand pos ition.
s timulate the
autoimmune
s ystem.
T ech niq u e
1. The patient
lies s upine
with the head
tur ned to one
side ( to avoid
breathing or
coughing into
the fac e of
the phy sic ian)
F ig ure 16.35. Modified hand position.
with the hips
and knees
flexed and the
feet flat on
the table.
2. The phy sic ian
stands at the
head of the
table with one
foot in fr ont of
the other
(F ig. 16.33).
3. The phy sic ian
places the
thenar F ig ure 16.36. Two c ompr ess ions per
eminenc es minute.
inferior to the
patient's
clavic les with
the finger s
24 of 59 21/08/07 22:13
spr eading out

over the
upper r ib
cage ( F ig.
16.34) . For
female
patients, the
phy sic ian
may place the
hands more
midline ov er
the sternum
(F ig. 16.35).
4. The patient is
ins truc ted to
tak e a deep
breath and
exhale fully.
5. Dur ing
exhalation,
the phy sic ian
inc reas es the
pressur e on
the anterior
rib cage,
exagger ating
the ex halation
motion.
6. At end
exhalation,
the phy sic ian
imparts a
vibratory
motion to the
rib cage at
two
compres sions
per sec ond
(p ulsed
arr ows , F ig.
16.36) .
7. Should the
patient need
to breathe,
pressur e is
relaxed
slightly, but
the
compres sions
25 of 59 21/08/07 22:13
are continued
for sev eral
minutes .
P.4 29
Thoraci c Regi on Mill er Thoraci c (Lym phatic) Pum p,

Exaggerated Respi ration
Indicat ions
T his tec hnique is
indicated for infection,
fever, lymphatic
c ongestion, rales , and
c hronic produc tiv e
c ough; it is also
prev entive.
Cont rain dications
not be used if the
patient has a frac tur e,
osteopor osis,
moderate to sever e
dyspnea, regional Fig u re 16.37. Hand position.
incision, s ubc lav ian
line, metas tatic
c anc er, or a s imilar
c ondition.
Physiolo gic Go al
T he goal is to
accentuate negativ e
intr athorac ic pres sur e
and inc r eas e
lymphatic r eturn.
T ech niq u e
1. The patient lies

supine with the
Fig u re 16.38. Modified hand position.
head turned to
one side ( to
avoid breathing
or coughing into
the fac e of the
26 of 59 21/08/07 22:13
phy sic ian) with

the hips and
knees flex ed and
the feet flat on
the table.
2. The phy sic ian
stands at the
head of the table
with one foot in
front of the
other.
3. The phy sic ian
places the
thenar
eminenc es Fig u re 16.39. Pressure with ex halation.
inferior to the
patient's
clavic les with
the finger s
spr eading out
over the upper
rib cage ( Fig .
16.37) . For
female patients
the phy sic ian
places the hands
mor e midline
over the s ter num
(F ig. 16.38).
Fig u re 16.40. Releas e pr ess ure on
4. The patient is
inhalation and reins tate it on ex halation.
ins truc ted to
tak e a deep
breath and
exhale fully.
5. Dur ing
exhalation, the
phy sic ian
inc reas es the
pressur e on
anterior r ib
cage,
exagger ating the
exhalation
motion (a r row,
Fig . 16.39).
6. Dur ing the next
inhalation the
phy sic ian
releas es the
27 of 59 21/08/07 22:13
pressur e
(u pwar d ar row,
Fig . 16.40), then
reinstates it
(d ownward
arr ow) with the
nex t ex halation.
7. This v ersion of
the thorac ic
pump may be
repeated for 5 to
10 res pirator y
cyc les . This may
hyperv entilate
the patient, and
light- headedness
and diz ziness
are fairly
common.
P.4 30
Thoraci c Regi on Thoraci c (Lymphatic) Pum p, Side

Modifi cati on
1. The patient
lies s upine,
and the
phy sic ian
stands at
the side of
the table at
the lev el of
the patient's
rib cage.
2. The
patient's
arm is
abducted 90
degrees or Fig u re 16.41. Steps 1 to 3, setup and hand
greater , and plac ement.
the
phy sic ian
28 of 59 21/08/07 22:13
exerts
traction on
the ar m with
the
cephalad
hand.
3. The
phy sic ian
places the
caudad
hand ov er
the lower
cos tal
car tilages
with the Fig u re 16.42. Step 5, percussive or
finger s vibr atory motion.
following the
interc ostal
spaces
(F ig.
16.41) .
4. The patient
is ins truc ted
to tak e a
deep br eath
and ex hale
fully.
5. At end of
exhalation,
a
per cus s ive
or vibr atory
motion
(a r row, F ig.
16.42) is
exerted by
the
phy sic ian at
two per
sec ond.
6. Should the
patient feel
the need to
breathe,
pressur e is
releas ed
jus t enough
to per mit
eas y
29 of 59 21/08/07 22:13
res pir ation

and the
vibratory
motion
continued.
7. This
tec hnique is
continued
for sev eral
minutes . It
should be
repeated,
when
pos sible, on
the opposite
side of the
chest.
P.4 31
Thoraci c Regi on Thoraci c (Lymphatic) Pum p, Atel ectasi s

Modifi cati on
Indicat ions
T his tec hnique is
indicated for
atelectasis .
Cont rain dications
T his pr ocedure
s hould not be used
if the patient has a
frac tur e,
osteopor osis,
s evere c ongestion,
incision,
s ubc lav ian line,
metastatic cancer ,
or s imilar F igure 16.43. Steps 1 to 3, s etup and hand
c ondition. placement.
Physiolo gic Go al
T he goal is to
accentuate the
negativ e phase of
30 of 59 21/08/07 22:13
r espiration and
c lear mucus plugs .
T ech niq u e
1. The patient
lies s upine
with the head
tur ned to one
side ( to avoid
breathing or
coughing into
the fac e of
the
phy sic ian)
with the hips F igure 16.44. Modified hand position.
and knees
flexed and
feet flat on
the table.
2. The phy sic ian
stands at the
head of the
table with one
foot in fr ont of
the other.
3. The phy sic ian
places the
thenar
eminenc es
F igure 16.45. Steps 5 and 6, exaggerating
inferior to the
ex halation, res tric ting inhalation.
patient's
clavic les with
the finger s
spr eading out
over the
upper r ib
cage ( F ig.
16.43) . For
female
patients the
phy sic ian
places the
hands more
midline ov er
the sternum F igure 16.46. Sudden r elease of pressur e.
(F ig. 16.44).
4. The patient is
ins truc ted to
tak e a deep
31 of 59 21/08/07 22:13
breath and
exhale fully.
5. Dur ing
exhalation,
the phy sic ian
inc reas es the
pressur e on
the anterior
rib cage,
exagger ating
the ex halation
motion.
6. Dur ing the
nex t s ever al
inhalations,
the phy sic ian
maintains
heavy
pressur e on
the chest wall
(F ig. 16.45).
7. On the las t
ins truc tion to
inhale, the
phy sic ian
suddenly
releas es the
pressur e,
causing the
patient to
tak e a ver y
rapid, deep
inhalation,
inflating any
atelec tatic
segments
that may be
present (F ig.
16.46) .
P.4 32
Thoraci c Regi on P ectoral Traction: P ectoral is Major,

Pectoralis Mi nor, and Anterior Deltoi d
32 of 59 21/08/07 22:13
Indicat ions
T his tec hnique is
indicated for
lymphatic
c ongestion, upper
extr emity edema,
mild to moderate
dyspnea or
wheeze, and/or
r eac tiv e airway or
asthma; it
facilitates the
thor acic pump.
Cont rain dications
T his pr ocedure F ig ure 16.47. Steps 1 to 3, hand pos ition.
s hould not be used
if the patient has
hypersensitivity to
touc h at the
anterior ax illary
fold, s ubclavian
line, s ome
pacemak ers,
metastatic cancer ,
or s imilar condition.
Physiolo gic Go al
T he goal is to
incr eas e ly mphatic
r eturn.
F ig ure 16.48. Steps 4 to 5, forc e towar d
T ech niq u e
c eiling.
1. The patient
lies s upine
with the hips
and knees
flexed and the
feet flat on
the table.
2. The phy sic ian
sits or stands
at the head of
the table with
one foot in
front of the
other. F ig ure 16.49. Step 6, deep inhalation.
3. The phy sic ian
places the
finger pads
33 of 59 21/08/07 22:13
P.4 33
Upper E xtremi ty Regi on Anterior Axil l ary Folds: Pectoral i s

Maj or and Anteri or Deltoid Muscles
Indicat ions
T his tec hnique is
indicated for
lymphatic
c ongestion and
upper ex tremity
edema.
Cont rain dications
T his pr ocedure
s hould not be used
if the patient has
hypersensitivity to
touc h at the
anterior ax illary
fold, s ubclavian F ig ure 16.51. Steps 1 to 3, s etup.
line, s ome
pacemak ers,
metastatic cancer ,
Physiolo gic Go al
T he goal is to
incr eas e ly mphatic
r eturn.
T ech niq u e
1. The patient
lies s upine,
and the
phy sic ian sits
F ig ure 16.52. Step 4, hand and finger
or stands at
placement.
the side of
the patient on
the side of
the
dys func tional
upper
extremity.
2. The phy sic ian
palpates for
any
inc reas ed
tone, edema,
and
34 of 59 21/08/07 22:13
bogginess of
the tis sues
(F ig. 16.51).
3. The
phy sic ian,
finding tissue
tex tur e
changes ,
places the
index and
third fingers
on the ventral
sur fac e of the
anterior
axillar y fold F ig ure 16.53. Step 5, hand and finger
and the placement.
thumb in the
axilla,
palpating the
anterior
por tion fr om
within the
axilla (F igs.
16.52 and
16.53) .
4. The phy sic ian
may ver y
slowly and
minimally
squeez e the
anterior
axillar y fold
with the
thumb and
finger s .
5. This is held
for 30 to 60
sec onds . It
may be
repeated on
the opposite
side as
needed.
P.4 34
P.4 35
Thoracoabdomi nal Region Dom ing the Di aphragm
35 of 59 21/08/07 22:13
Indicat ions
T his tec hnique is indicated for ly mphatic
c ongestion dis tal to the diaphr agm and/or
r espiration that does not ( myofasc ially) extend
fully to the pubic sy mphysis .
Cont rain dications
T his pr ocedure should not be us ed if the patient
has drainage tubes , intr avenous lines , thoracic or
abdominal incision, or moder ate to sev ere hiatal
hernia or gastroes ophageal r eflux symptoms.
Physiolo gic Go al
T he goal is to improv e lymphatic and v enous
r eturn; it may improv e immune func tion.
T ech niq u e
F ig ure 16.55. Thumb placement.
1. The patient lies supine with the hips and
knees flex ed and feet flat on the table.
2. The phy sic ian stands to one side at the lev el
of the pelvis , facing c ephalad.
3. The phy sic ian places the thumbs or thenar
eminenc e just inferior to the patient's lower
cos tal mar gin and xiphoid proc ess with the
thumbs pointing c ephalad ( F igs. 16.54, 16.55
and 16.56) .
4. The patient is instr ucted to take a deep
breath and ex hale. O n exhalation, the
phy sic ian's thumbs follow the diaphr agm
(a r rows , F ig. 16.57) , whic h permits the
thumbs to mov e posteriorly .
F ig ure 16.56. Variation of thenar em
5. The patient is instr ucted to inhale, and the
placement.
phy sic ian gently res ists this motion.
6. The patient is instr ucted to exhale, and the
phy sic ian gently follows this motion
pos ter iorly and c ephalad ( arrows, F ig .
16.58) , as the thumbs are now beneath the
cos tal mar gin and xiphoid proc ess .
7. The patient inhales as the phy sic ian
maintains pressur e on the upper abdomen
and then, on repeated exhalation,
enc our ages further c ephalad ex cur sion.
8. This pr ocedur e is repeated for three to fiv e
res pir ator y c ycles.
F ig ure 16.57. Step 4, following exh
36 of 59 21/08/07 22:13
P.4 36
Thoraci c Regi on Rib Rai sing: Bilateral Upper Thoracic

Variati on
Indicat ions
T his tec hnique is
indicated to facilitate
lymphatic drainage,
impr ove res pir ator y
excursion of the r ibs ,
and alleviate
postoper ative
paralytic ileus.
Cont rain dications
T his pr ocedure
s hould not be used if
the patient has r ib or
v ertebr al frac tur e,
s pinal c ord injur y , F igu re 16.59. Steps 1 to 3, setup and hand
thor acic surgery, or plac ement.
malignancy in the
area to be treated.
T ech niq u e
1. The patient lies

supine, and the
phy sic ian is
seated at the
head of the
table.
2. The phy sic ian
slides both
hands under the
patient's
F igu re 16.60. Step 4, anter ior cephalad
thorac ic r egion.
lateral for ce.
3. The finger pads
of both hands
contac t the
par aver tebral
tis sues ov er the
cos totr ans ver se
articulation
(F ig. 16.59).
4. By leaning down
with the elbows,
the phy sic ian
elevates the
37 of 59 21/08/07 22:13
finger s into the

par aver tebral
tis sues (s olid
arr ows , F ig.
16.60) and then
pulls them
(b r oken ar rows)
toward the
phy sic ian
cephalad and
lateral.
5. This ex tends
the spine and
places a lateral
str etc h on the
par aver tebral
tis sues .
6. This technique
may be
per for med as an
intermittent
kneading
tec hnique or
with s ustained
deep inhibitory
pressur e for 2
to 5 minutes.
P.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.
T ech niq u e
1. The patient Fig u re 16.61. Step 1, patient pos ition.

is in
semipr one
pos ition on
all fours
with the
contac t
points being
the hands,
elbows , and
knees ( Fig .
16.61) .
2. The
phy sic ian
stands at
Fig u re 16.62. Hand position.
the side of
the patient
fac ing the
foot of the
table.
3. The
phy sic ian
hooks the
pads of the
finger s
medial to
both
anterior
superior
iliac s pines Fig u re 16.63. Step 4, c ephalad dir ection.
(F ig.
16.62) .
4. The
phy sic ian
39 of 59 21/08/07 22:13
P.4 38
P.4 39
Abdomi nal Region Mesenteri c Release, Small Intesti ne
Indicat ions
T his tec hnique is indicated to
enhance lymphatic and venous
drainage and allev iate c ongestion
s econdar y to v isc eral ptosis .
Cont rain dications
T his pr ocedure should not be us ed if
the patient has an abdominal incis ion,
acute is chemic bowel dis eas e,
obstruc tion, or s imilar condition.
T ech niq u e
T he mes entery of the small intestine
fans out fr om its short root to
accommodate the length of the
jejunum and ileum (F ig. 16.65), and F ig ure 16.67. Supine position.
treatment is focus ed along its length
( Fig . 16.66).
1. The patient lies supine (F ig.

16.67) or in the left later al
rec umbent (side- lying) (F ig .
16.68) pos ition.
2. The phy sic ian sits on the
patient's right s ide or stands
behind the patient.
3. The phy sic ian places the hand
or hands at the left border of the
mes enteric region of the s mall
intestine with the fingers cur led
F ig ure 16.68. Later al r ecumbent position.
slightly.
4. The finger s gently push (s olid
arr ows , F igs. 16.67 and 16.68)
toward the patient's back and
then towar d the patient's r ight
side ( c urv ed arr ows) until
meeting the r estr ictive tis sue
bar rier .
5. This position is held until the
phy sic ian palpates a releas e
(20–30 sec onds), and then the
phy sic ian follows this mov ement
(fascial c reep) to the new
bar rier and c ontinues until no
40 of 59 21/08/07 22:13
fur ther improvement is detected.
F igu re 16.65. Abdominal mes entery, small intestine (12).
41 of 59 21/08/07 22:13
F igu re 16.66. Mes enteric vec tor s of s mall intes tine tr eatment (12).
P.4 40
P.4 41
Abdomi nal Region Mesenteri c Release, Ascending Col on
42 of 59 21/08/07 22:13
Indicat ions
T his tec hnique is indicated to enhanc e ly mphatic and
v enous drainage and alleviate c ongestion sec ondary
to v isc eral ptosis .
Cont rain dications
T his pr ocedure should not be us ed if the patient has
an abdominal incis ion, acute is chemic bowel dis ease,
obstruc tion, or s imilar condition.
T ech niq u e
T reatment is focus ed along the mes enteric as cending
c olon attac hment ( Fig s. 16.69 and 16.70).
1. The patient lies supine (F ig. 16.71) or in the

right lateral rec umbent (F ig. 16.72) pos ition.
2. The phy sic ian sits on the left side or s tands F ig ure 16.71. Supine position.
behind the patient.
3. The phy sic ian places the hand or hands at the
right border of the mes enteric region of the
asc ending colon with the fingers cur led slightly.
4. The finger s gently push toward the patient's
bac k ( s olid arrows, Fig s. 16.71 and 16.72) and
then dr aw toward the patient's left s ide (c urv ed
arr ows ) until meeting the r estric tiv e tissue
bar rier .
5. This position is held until the phys ician palpates
a r elease (20–30 sec onds), and then the
phy sic ian follows this mov ement ( fas c ial cr eep)
to the new barrier and continues until no further
improv ement is detec ted.
F ig ure 16.72. Later al r ecumben
43 of 59 21/08/07 22:13
P.4 42
P.4 43
Abdomi nal Region Mesenteri c Release, Descending Colon
Indicat ions
T his tec hnique is indicated to enhanc e ly mphatic
and venous drainage and to alleviate c ongestion
s econdar y to v isc eral ptosis .
Cont rain dications
T his pr ocedure should not be us ed if the patient
has abdominal inc isions, ac ute isc hemic bowel
disease, obstr uction, or similar c ondition.
T ech niq u e
T reatment is focus ed along the mes enteric
ascending c olon attac hment ( Fig s. 16.73 and
16.74).
1. The patient lies supine (F ig. 16.75) or in

the left lateral rec umbent (F ig. 16.76) F ig ure 16.75. Supine position.
pos ition.
2. The phy sic ian sits on the r ight s ide or
stands behind the patient.
3. The phy sic ian places the hand or hands at
the left border of the mes enteric region of
the des cending c olon and s igmoid with the
finger s curled s lightly .
4. The finger s gently push toward the
patient's bac k ( s traight ar rows, Fig s. 16.75
and 16.76) and then draw towar d the
patient's right s ide (c urv ed arrows) until
meeting the r estr ictive tis sue barrier.
5. This position is held until the phys ician
palpates a releas e ( 20–30 s econds ), and
F ig ure 16.76. Later al r ecumbent posi
then the phys ician follows this movement
(fascial c reep) to the new bar rier and
continues until no further improv ement is
detected.
44 of 59 21/08/07 22:13
45 of 59 21/08/07 22:13
F igu re 16.73. Abdominal mes entery, des cending c olon (12).
F igu re 16.74. Mes enteric vec tor s of descending c olon treatment ( 12) .
P.4 44
Abdomi nal Region Presacral Rel ease, Direct or I ndi rect
Indicat ions
T his tec hnique is
indicated to enhance
lymphatic drainage
and relieve venous
c ongestion in the
lower abdomen, pelvic
r egion, and lower
extr emities .
Cont rain dications
not be used if the
patient has abdominal
46 of 59 21/08/07 22:13
incision, acute F ig ure 16.77. Hand plac ement.

ischemic bowel
disease, obstr uction,
T ech niq u e
1. The patient lies

supine, and the
phy sic ian stands
at either side of
the patient.
2. The phy sic ian,
with the index
and third finger s
approx imated
and the thumb F ig ure 16.78. Step 4, ease-bind
abducted, mak es determination.
a C shape.
3. The phy sic ian
places the
finger s and
thumb downwar d
in the lower
abdominal region
jus t above the
ramus of the
pubic bone (F ig.
16.77) .
4. The phy sic ian
determines
whether an
F ig ure 16.79 Step 5, ease- bind
eas e-bind
determination.
asy mmetry is
present by
applying and
vec tor ing for ces
in multiple
dir ections ,
inc luding
pos ter ior,
superior, inferior,
clockwise, and
counter clockwise
(a r rows , F ig.
16.78) .
5. The phy sic ian,
on determining
the dy s functional
asy mmetry,
47 of 59 21/08/07 22:13
applies forces in
an indirec t or
dir ect manner
until meeting the
eas e or bind
bar rier s,
res pec tively
(F ig. 16.79).
6. This position is
held until the
phy sic ian
palpates a
releas e (20–30
sec onds ), and
then the
phy sic ian follows
this movement
(fascial c reep) to
the new barrier
and continues
until no further
improv ement is
detected.
P.4 45
Pel vic Region Ischiorectal Fossa Rel ease, S upi ne
Indicat ions
T his tec hnique is
indicated to impr ove
motion of the pelv ic
diaphragm and
lymphatic and venous
drainage fr om the
pelv ic v isc era and
pelv ic floor.
T ech niq u e
1. The patient lies

supine with the
hips and k nees
flexed. F ig ure 16.80. Physician and patient
2. The phy sic ian sits pos itioning.
48 of 59 21/08/07 22:13
at the side of the

table opposite the
side of the
dys func tion to be
treated.
3. The phy sic ian
places the thumb
of the hand
closes t to the
table medial to the
isc hial tuber osity
(a r row, F igs.
16.80 and 16.81)
on the
dys func tional F ig ure 16.81. Thumb pos itioning.
side.
4. The phy sic ian
exerts gentle
pressur e c ephalad
(a r row, F ig.
16.81) into the
isc hior ectal fos s a
until r esistance is
met and then
applies a lateral
for ce ( cur ved
arr ow, Fig .
16.82) .
5. The phy sic ian can
F ig ure 16.82. Cephalad lateral force.
attempt to feel a
fluid ebb and flow
with a res ultant
releas e or add a
releas e-enhancing
mec hanism by
ins truc ting the
patient to inhale
and ex hale
deeply .
6. With each
exhalation, the
phy sic ian exerts
inc reas ed
cephalad pres sur e
on the pelvic
diaphr agm until no
fur ther cephalad
and lateral
exc urs ion is
49 of 59 21/08/07 22:13
pos sible.
7. This technique is
repeated on the
opposite s ide of
the pelvis as
needed.
P.4 46
Pel vic Region Ischiorectal Fossa Rel ease, P rone
Indicat ions
T his tec hnique
impr oves motion of the
pelv ic diaphragm and
v enous and lymphatic
drainage fr om the
pelv ic v isc era and
pelv ic floor.
T ech niq u e
1. The patient lies

prone, and the
phy sic ian stands
at the side of the
table facing the F ig ure 16.83. Thumb placement.
head of the table.
2. The phy sic ian
places the thumbs
medial to the
isc hial tuber osities
on eac h side (F ig .
16.83) .
3. Gentle pressure is
exerted cephalad
(a r rows , F ig.
16.84) into the
isc hior ectal fos s a
until r esistance is
met, and then a
F ig ure 16.84. Cephalad for ce.
lateral force
(a r rows , F ig.
16.85) is applied.
4. The patient is
50 of 59 21/08/07 22:13
ins truc ted to

inhale and ex hale
deeply .
attempt to feel a
fluid ebb and flow
with a res ultant
releas e or add a
releas e-enhancing
mec hanism by
ins truc ting the
patient to inhale
and ex hale
deeply .
6. With each F ig ure 16.85. Later al forc e.
exhalation, the
phy sic ian exerts
inc reas ed
cephalad pres sur e
on the pelvic
diaphr agm until no
fur ther cephalad
and lateral
exc urs ion in a
dir ection is
pos sible.
repeated on the
opposite s ide of
the pelvis as
needed.
P.4 47
Lower E xtremi ty REGI ON Pedal P ump (Dalrympl e

Techni que), S upi ne
51 of 59 21/08/07 22:13
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; F ig ure 16.86. Steps 1 to 3, s etup,
Achilles strain, plantarflexion.
gastroc nemius
s train, or other
acute pr ocess
and/or painful
lower ex tremity
c onditions. It
s hould also be
avoided in the
acute
postoper ative
period in s ome
abdominal s urgery
patients .
Physiolo gic Go al
F ig ure 16.87. Step 4, plantar flex ion.
T he goal is to
accentuate
negativ e
intr aabdominal
lymphatic r eturn,
and inc r eas e
endothelial nitrous
oxide, whic h may
offer
anti-inflammatory
benefit (13,14).
T ech niq u e
1. The patient F ig ure 16.88. Step 5, s etup, dor s iflexion.

lies s upine.
2. The phy sic ian
stands at the
52 of 59 21/08/07 22:13
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; F ig ure 16.90. Step 1, phys ician and patient
Achilles strain, pos itioning.
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
F ig ure 16.91. Hand and foot positioning.
T he goal is to
accentuate
negativ e
intr aabdominal
lymphatic r eturn,
and inc r eas e
endothelial nitrous
oxide, whic h may
be of
anti-inflammatory
benefit.
T ech niq u e
53 of 59 21/08/07 22:13
P.4 49
Lower1.EThe
xtremi ty and Pel vic Region Hi p, I ndi rect LAS/BLT,
patient
Supine lies pr one
with the feet
slightly off the
table, and the
Indicatphyionssic ianan d
stands
Physiolo gic at Gotheal
foothnique
T his tec of theis
tabletowith
indicated one
enhance
foot sdrainage
lymphatic lightly and
behind
r elieve venous the
other (inFig
c ongestion . pelvic
the
r egion16.90)
and lower .
extr2.emities
The phy . sic ian F ig ure 16.92. Step 3, c ephalad pr ess ure.
grasps
T ech niq u e the
patient's feet
at the
1. The dis tal lies
patient
metatarwith
supine sal the hip
region
and knee andflex ed
dir ects
on the side a to be F ig ure 16.93. Steps 1 to 3, initiating hand
for ce
treated. placement.
(a r rows
2. The phy,sic F ig.
ian
16.91) to
stands at the side
achiev
of e
the table on the
bilater
side toalbe tr eated.
dor siflexion.
3. The phy sic ian
3. places
At the the
comfor table
cephalad thenar
limit of e on the
eminenc
dor siflexion,
patient's greater
the phy sic ian
trochanter with
begins
the finger a s
rhyected
dir thmic medially
on- and-
and thumb off
cephalad
contour ing
pressur e The F ig ure 16.94. Step 4, posterosuperior
laterally.
(a r rows , force F ig. is v ec tor ed for c e.
initiating
16.92) at one
applied
to two per
anteromedially
sec
(a ond.F ig.
r row,
4. 16.93)
This pr. ess ure
is dirabducted
4. The ected
par alleland
thumb to the
fir st
length
two fingerof thes in an
table
inv ertedandC shape
continued
of the phy sic for ian's
1 to 2 hand
caudal
minutes .
54 of 59 21/08/07 22:13
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 F ig ure 16.95. Step 5, balancing three
and is placed for ces .
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
F ig ure 16.96. Step 6, c ompres sion through
to apply
hip.
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
55 of 59 21/08/07 22:13
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 F ig ure 16.97. Steps 1 to 3, s etup and hand
extended on table. placement.
2. The phy sic ian,
fac ing the head of
the table, sits at
the side to be
treated.
medial hand
reaches ar ound to
the medial as pec t
of the popliteal
fos sa as the
56 of 59 21/08/07 22:13
lateral hand
grasps the later al
aspect of the
popliteal fos sa
(F ig. 16.97).
4. The phy sic ian
palpates for any
fas cial
res tric tions,
inc luding
cephalad, caudad,
medial, and later al
(F ig. 16.98).
5. The phy sic ian
engages the F ig ure 16.98. Step 4, determining barriers .
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).
attempt to feel a
fluid ebb and flow
F ig ure 16.99. Step 5, direct MFR.
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.
repeated on the
opposite s ide as
needed.
57 of 59 21/08/07 22:13
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
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
17
Articulatory and Combined Techniques
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
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

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
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

S tage 1S houl der Extension wi th E lbow Flexed
3 of 39 21/08/07 22:14
1. T he phys ician
s tands facing the
patient.
c ephalad hand
br idges the
s houlder to loc k
out any
and
s c apulothor acic
motion. The
fingers are on the
s pine of the
F igu re 17.1. Stage 1, steps 1 to 5.
s c apula, the
thumb on the
anter ior sur fac e
of the c lav icle.
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 F igu re 17.2. Stage 1, step 6.
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 F igu re 17.3. Stage 1, step 7.
( blac k ar row,
F ig. 17.2)
against the
physician's
4 of 39 21/08/07 22:14
P. 457

S tage 2S houl der Fl exi on with El bow Extended
5 of 39 21/08/07 22:14
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
and
s c apulothor acic
motion. The
F igu re 17.5. Stage 2, steps 1 to 3.
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 F igu re 17.6. Stage 2, step 4.
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) F igu re 17.7. Stage 2, step 5.
against the
physician's
r esis tance ( white
ar row). This
6 of 39 21/08/07 22:14
P. 458

S tage 3Circumducti on with Sl ight Compressi on and El bow
Fl exed
7 of 39 21/08/07 22:14
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) . Fig u re 17.9. Stage 3, s teps 1
5. T here is no specific musc le to 2.
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 17.10. Stage 3, s tep

3.
8 of 39 21/08/07 22:14
P. 459

S tage 4Circumducti on and Tracti on with El bow Extended
9 of 39 21/08/07 22:14
1. T he patient's s houlder is
abduc ted to the edge of the
r estr ictive bar rier with the
elbow ex tended.
2. T he phys ician's caudad
hand grasps the patient's
wr ist and ex erts v ertical
tr action. T he phys ician's
c ephalad hand brac es the
s houlder as in stage 1 (F ig.
17.12).
3. T he patient's arm is moved
through full c lock wis e
c ircumduction with
s y nchronous traction.
Larger and larger
c oncentr ic c irc les are
made, increasing the r ange
of motion ( F ig. 17.13) .
4. T he s ame maneuv er is
r epeated c ounterclock wise F igure 17.12. Stage 4, steps
( F ig. 17.14) . 1 to 2.
5. T here is no specific musc le
energy activ ation for this
s tep; howev er, dur ing
fine- tuning of the
c ircumduction, it may be
feasible to implement it in a
portion of the res tric ted
ar c.
6. T his is repeated for
approximately 15 to 30
s econds in each dir ection,
and c irc umduction is
r eass ess ed.
F igure 17.13. Stage 4, step

3.
10 of 39 21/08/07 22:14
P. 460

S tage 5A—Abduction wi th E lbow Fl exed
11 of 39 21/08/07 22:14
1. T he patient's
s houlder is
abduc ted to
the edge of
the r estric tive
barrier.
2. T he
physician's
c ephalad ar m
is positioned
parallel to the
s urface of the
table.
3. T he patient is
F igu re 17.15. Stage 5A, steps 1 to 3.
instr ucted to
gr asp the
physician's
forearm with
the hand of
the arm being
tr eated (F ig .
17.15).
4. T he patient's
elbow is
moved
towar d the
head,
abduc ting the
s houlder , F igu re 17.16. Stage 5A, steps 4 to 5.
until a motion
barrier is
engaged.
Slight inter nal
r otation may
be added.
5. A slow, gentle
( articulator y,
make and
br eak ) motion
( arrows, F ig .
17.16) is
applied at the
end r ange of
motion. F igu re 17.17. Stage 5A, step 6.
6. Muscle
energy
ac tiv ation:
T he patient is
12 of 39 21/08/07 22:14
P. 461

S tage 5BAdducti on and External Rotation wi th Elbow Flexed
13 of 39 21/08/07 22:14
1. T he patient's
ar m is flex ed
s ufficiently to
allow the
elbow to pas s
in fr ont of the
c hest wall.
2. T he
physician's
forearm is
s till parallel to
the table with
the patient's
wr ist resting
F igu re 17.20. Stage 5B, steps 1 to 3.
against the
forearm.
3. T he patient's
s houlder is
adduc ted to
the edge of
the r estric tive
barrier (F ig .
17.20).
4. A slow, gentle
( articulator y,
make and
br eak ) motion
( arrow, Fig .
17.21) is F igu re 17.21. Stage 5B, step 4.
applied at the
end r ange of
motion.
5. Muscle
energy
ac tiv ation:
T he patient
lifts the elbow
( blac k ar row,
F ig. 17.22)
against the
physician's
r esis tance
( white ar row).
T his F igu re 17.22. Stage 5B, step 5.
c ontr action is
held for 3 to 5
s econds.
6. After a
14 of 39 21/08/07 22:14
P. 462

S tage 6—Internal Rotation wi th Arm Abducted, Hand Behind
Back
15 of 39 21/08/07 22:14
1. T he patient's
s houlder is
abduc ted 45
degrees and
inter nally
r otated
approximately
90 degrees.
T he dors um
of the
patient's hand
is placed in
the s mall of
the back .
F igu re 17.25. Stage 6, s teps 1 to 3.
2. T he
physician's
c ephalad
hand
r einforc es the
anter ior
portion of the
patient's
s houlder .
3. T he patient's
elbow is ver y
gently pulled
forward
( internal
r otation) to F igu re 17.26. Stage 6, s tep 4.
the edge of
the r estric tive
barrier (F ig .
17.25). Do
not push the
elbow
backward, as
this can
dislocate an
unstable
s houlder .
4. A slow, gentle
( articulator y,
make and
br eak ) motion F igu re 17.27. Stage 6, s tep 5.
( arrows, F ig .
17.26) is
applied at the
end r ange of
16 of 39 21/08/07 22:14
P. 463

S tage 7Distraction, S tretchi ng Tissues, and E nhanci ng Flui d
Drainage wi th Arm Extended
17 of 39 21/08/07 22:14
1. T he phys ician
turns and
faces the
head of the
table.
2. T he patient's
s houlder is
abduc ted,
and the
patient's hand
and forearm
ar e plac ed on
the
physician's
F igu re 17.30. Stage 7, s teps 1 to 3.
s houlder
c losest to the
patient.
3. With finger s
inter lac ed,
the
physician's
hands ar e
positioned
just dis tal to
the acromion
pr ocess (F ig .
17.30).
4. T he patient's
s houlder is F igu re 17.31. Stage 7, s tep 4.
s c ooped
infer ior ly
( arrow, Fig .
17.31)
c r eating a
tr ans latory
motion
ac ros s the
infer ior edge
of the glenoid
fossa. T his is
done
r epeatedly in
an
ar tic ulator y F igu re 17.32. Stage 7, s tep 5.
fashion.
5. Alter natively,
the arm may
be pushed
18 of 39 21/08/07 22:14
P. 464
Lower Extrem ity Region Hi p Girdl e: Spencer Technique

S tage 1Hip Flexion
19 of 39 21/08/07 22:14
s upine, and the
physician s tands
at the s ide of the
table next to the
dy sfunctional hip.
2. T he phys ician
flexes the
patient's k nee
and c arr ies the
hip to the
flexion- res tric tiv e
barrier (F ig
17.34).
F igu re 17.34. Stage 1, s teps 1 and 2.
3. A slow, gentle
ar tic ulator y
( make and
br eak ) motion
( arrows, F ig .
17.35) is applied
at the end r ange
of motion.
4. Muscle ener gy
ac tiv ation: The
patient pus hes
( hip extens ion)
the k nee into the
physician's
r esis tance F igu re 17.35. Stage 1, s tep 3.
( arrows, F ig .
17.36). This
c ontr action is
held for 3 to 5
s econds.
5. After a sec ond of
r elax ation, the
hip is c arr ied
farther into the
new r estric tive
barrier (F ig .
17.37).
6. Steps 4 and 5
ar e r epeated
three to fiv e F igu re 17.36. Stage 1, s tep 4.
times , and flex ion
is reass ess ed.
7. Resis tance
against
20 of 39 21/08/07 22:14
P. 465

S tage 2Hip E xtensi on
21 of 39 21/08/07 22:14
1. T he patient's leg is
moved off the s ide
of the table and is
allowed to desc end
towar d the floor until
it meets its
ex tension-r estr ictive
barrier (F ig . 17.39).
2. A slow, gentle
ar tic ulator y (make
and break) motion
( arrows, F ig . 17.40)
is applied at the end
r ange of motion.
F igu re 17.39. Stage 2, s tep 1.
3. Muscle ener gy
ac tiv ation: The
patient is instruc ted
to pull the knee ( hip
flexion) (black
ar row, F ig. 17.41)
into the phy sic ian's
r esis tance ( white
ar row). This
c ontr action is held
for 3 to 5 s econds .
4. After a sec ond of
r elax ation, the hip is
c arried far ther into
the new res tric tiv e F igu re 17.40. Stage 2, s tep 2.
barrier (F ig . 17.42).
5. Steps 3 and 4 are
r epeated thr ee to
five times, and
ex tension is
r eass ess ed.
6. Resis tance against
attempted hip
ex tension
( r eciprocal
inhibition) has been
found to be helpful
in augmenting the
effec t ( Fig . 17.43).
F igu re 17.41. Stage 2, s tep 3.
22 of 39 21/08/07 22:14
P. 466

S tages 3 and 4Circumducti on
23 of 39 21/08/07 22:14
1. T he phys ician
flexes the
patient's hip ( with
k nee flexed)
towar d the flex ion
barrier and adds
s light
c ompr ess ion
( arrow, Fig .
17.44).
2. T he phys ician
c ircumducts
( arrows, F ig .
17.45) the
F igu re 17.44. Stages 3 and 4, s tep 1.
patient's hip
through small and
then enlarging
c ircles (clockwise
and
c ounterc loc k wis e)
for appr oximately
30 seconds while
maintaining
c ompr ess ion.
3. T he phys ician
ex tends the
patient's k nee and
gr asps the foot
and ankle, adding F igu re 17.45. Stages 3 and 4, s tep 2.
moder ate tr action
( arrow, Fig .
17.46).
4. Continuing to hold
tr action, the
physician
c ircumducts the
patient's hip
through small and
then inc reas ingly
large circles
( arrows, F ig .
17.47) both
c lock wis e and
c ounterc loc k wis e F igu re 17.46. Stages 3 and 4, s tep 3.
for appr oximately
15 to 30 sec onds.
24 of 39 21/08/07 22:14
P. 467

S tages 5 and 6I nternal and E xternal Rotati on
25 of 39 21/08/07 22:14
1. T he phys ician
flexes the
patient's hip
and k nee and
inter nally
r otates the
hip to its
barrier.
2. A slow, gentle
( articulator y,
make and
br eak ) motion
( arrows, F ig .
17.48) is
applied at the
end r ange of
motion.
3. Muscle
energy
ac tiv ation:
T he patient is
instr ucted to
push the
k nee
( external
r otation)
( blac k ar row,
F ig. 17.49)
into the F igu re 17.49. Stage 5, s tep 3.
physician's
r esis tance
( white ar row).
T his
c ontr action is
held for 3 to 5
s econds.
After a
s econd of
r elax ation,
the hip is
c arried to the
new
r estr ictive
barrier. F igu re 17.50. Stage 6, s tep 5.
4. Step 3 is
r epeated
three to fiv e
times , and
26 of 39 21/08/07 22:14
P. 468

S tages 7 and 8—Abducti on and Adduction
27 of 39 21/08/07 22:14
1. T he patient
lies supine on
the treatment
table, and the
physician
gently takes
the patient's
s traightened
leg and
abduc ts it to
its r estric tive
barrier.
2. A slow, gentle
ar tic ulator y
( make and
br eak ) motion
( arrows, F ig .
17.52) is
applied at the
end r ange of
motion.
3. Muscle
energy
ac tiv ation:
T he patient is
instr ucted to
pull (b lack
ar row, F ig.
17.53) the F igu re 17.53. Stage 7, s tep 3.
k nee (hip
adduc tion)
into the
physician's
r esis tance
( white ar row).
T his
c ontr action is
held for 3 to 5
s econds.
After a
s econd of
r elax ation,
the hip is
c arried to the F igu re 17.54. Stage 8, s tep 5.
new
r estr ictive
barrier.
4. Step 3 is
28 of 39 21/08/07 22:14
P. 469
Upper Extrem ity Region El bow: Radioulnar Dysfunction,

Long Axi s, P ronati on Dysfunction (Loss of Supination),
Muscl e E nergy, HVLA
29 of 39 21/08/07 22:14
T he long-ax is
dysfunc tions r elate
to a rotational
movement along the
length of the radius
without anterior and
posterior
displac ement. They
are different
dysfunc tions from
the sees aw motions
desc ribed in the
anteroposterior
dysfunc tions, in
whic h the r adial F igu re 17.56. Steps 1 to 3.
head and styloid
proc ess mov e in
opposing direc tions.
1. T he patient is
s eated on the
table, and the
physician
s tands in fr ont
of the patient.
2. T he phys ician
holds the
patient's
dy sfunctional F igu re 17.57. Step 4.
ar m as if
s haking hands
and plac es the
thumb of the
oppos ite hand
anter ior to the
r adial head.
3. T he phys ician
then rotates
the hand into
s upination until
the r estric tive
barrier is
engaged (F ig .
17.56). F igu re 17.58. Steps 7 to 9.
4. T he patient is
instr ucted to
attempt to
pr onate the
30 of 39 21/08/07 22:14
P. 470
Upper Extrem ity Region El bow: Radioulnar Dysfunction,

Long Axi s, S upi nation Dysfuncti on (Loss of Pronation),
Muscl e E nergy, HVLA
31 of 39 21/08/07 22:14
1. T he patient is
s eated on the
table, and the
physician
s tands in fr ont
of the patient.
2. T he phys ician
holds the
patient's
dy sfunctional
ar m as if
s haking hands
and plac es the
thumb of the
oppos ite hand
posterior to the
r adial head
giving s upport.
3. T he phys ician
r otates the
forearm into
pr onation
( arrow, Fig .
17.59) until the
r estr ictive
barrier is
r eached.
4. T he patient is
instr ucted to F igu re 17.60. Step 4.
attempt to
s upinate the
wr ist (blac k
ar row, F ig.
17.60) while
the phys ician
applies an
unyielding
c ounterforc e
( white ar row).
5. After a sec ond
of relax ation,
the patient's
forearm is
taken into F igu re 17.61. Steps 7 to 9.
further
pr onation.
6. Steps 4 and 5
ar e r epeated
32 of 39 21/08/07 22:14
P. 471
P elvi c Regi on Right Anterior Innomi nate Dysfunction: HV LA

wi th Respiratory Assi stance, Leg-Pull Technique
33 of 39 21/08/07 22:14
1. T he patient
lies supine,
and the
physician
s tands at the
foot of the
table.
2. T he phys ician
gr asps the
patient's r ight
ankle and
r aises the
patient's r ight
leg to 45
F igu re 17.62. Steps 1 and 2.
degrees or
more and
applies
tr action on
the s haft of
the leg (w hite
ar row, F ig.
17.62).
3. T his traction
is maintained,
and the
patient is
as ked to tak e
three to fiv e
s low, deep F igu re 17.63. Steps 3 to 4.
br eaths. At
the end of
each
ex halation,
tr action is
increased.
4. At the end of
the last
br eath, the
physician
deliv ers an
impulse
thrus t in the
direc tion of
the trac tion
( arrow, Fig .
17.63).
5. T he phys ician
r eass ess es
34 of 39 21/08/07 22:14
P. 472
Cervi cal Region C2 to C7, Articulatory, Type 2 Moti on
35 of 39 21/08/07 22:14
1. T he patient
lies supine,
and the
physician s its
at head of
table.
2. T he
physician
palpates the
ar tic ular
pr ocesses of
the s egment
to be
ev aluated
F igure 17.64. Steps 1 to 3, translation to
with the pad
r ight.
of the s econd
or third
finger.
3. A
tr ans lational
motion is
introduc ed
fr om left to
r ight (left side
bending) and
then right to
left (right side
bending)
through the
ar tic ular F igure 17.65. Steps 1 to 3, translation to
pr ocesses left.
( F igs. 17.64
an d 17.65).
4. At the limit of
each
tr ans lational
motion, a
r otational
s pringing
may be
applied in the
direc tion fr om
which the
tr ans lation
emanated
( e.g., s ide F igure 17.66. Step 4.
bending left,
r otation left)
36 of 39 21/08/07 22:14
P. 473
Thoracic Region T1 to T4, Articulatory, S i de Bending
37 of 39 21/08/07 22:14
1. T he patient is
s eated, and
the phys ician
either s tands
behind or s its
next to the
patient.
2. T he phys ician
places the
thenar
eminence of
the posterior
hand on the
pr oximal
paras pinal
thoracic
tissues in the
dy sfunctional
ar ea.
3. T he
physician's
other hand
r eaches in
fr ont of the
patient and
c ups the side
of the
patient's head
( F ig. 17.67) . F igu re 17.68. Step 4.
4. As the
physician
adds a gentle
s ide- bending
motion of the
head toward
the
physician's
s ide, the
thoracic hand
applies a
s pringing
force
perpendicular
to the length
of the
v ertebral
c olumn ( Fig .
17.68).
38 of 39 21/08/07 22:14
P. 474
References
1. W ard R ( ed .) . F ou nda ti on s f or Os te opa thi c Me dic i ne . Ph i la del phia : L i pp i nco tt W il l i am s &

W il k i ns , 2 003 .
2. Ki mb erl y P , Fu nk S ( eds. ) . Out l i ne of Os teop ath i c M ani pul ati v e P r oc edu r es: Th e K i m be r ly
M an ual M il l en ni um Ed i ti on. M ar c el i ne, MO : W al sw ort h, 2000 .
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18
Osteopathy in the Cranial Field
O s t e o pa t hy in t he cr a ni a l f i el d ( O CF) as de f i ne d b y t h e E d uc a ti o n al Co u nc i l o n
O s t e o pa t hi c P r i nc i pl e s ( E CO P ) i s a “s y s t e m o f d i ag n os i s a n d t re a t me n t b y a n
o s t e o pa t hi c p r a c t i ti o ne r us i ng th e pr i ma r y r e sp i ra t or y me c ha n is m an d b a la n c ed
mem b r an o us te n s io n f i rs t de s cr i be d by Wi l li a m G a rn e r S u th e rl a nd , DO , a n d i s t h e t it l e
o f t h e r ef e re n c e wor k b y Ha r ol d M a g ou n , S r. ” ( 1) . S u th e r la n d, a s t ud e nt of A . T. S ti l l ,
b eg a n a li f el o n g s tu d y o f t h e c ra n i um an d i t s a n at o my a nd bi o me c h an i c s as t he y
r el a t ed to he a l th an d d i s ea s e. Hi s in t er e s t i n t he cr a n iu m b e ga n af t er he v ie wed a
d is a r ti c ul a te d s k u ll wh e n s t ud y in g in Ki r k s v i ll e , MO ( A me r ic a n S c ho o l o f O s te o pa t hy ) .
A lt h o ug h S u th e r la n d i s t h e n am e m o s t o f t e n a s so c ia t ed wit h t h is f or m o f t e c hn i qu e ,
man y ot h er s t o o k u p h is wor k a n d c o nt i nu e d t h e s tu d y , r es e ar c h, a nd te a ch i n g ( 2, 3 ).
E CO P ha s d e fi n e d t he pr i mar y r e sp i r at o ry me c h an i sm as “ a mod e l p r op o se d b y Wi l li a m
G ar n e r S ut h er l a nd , D O t o de s cr i be t he in t er d e pe n de n t f u nc t io n s a mon g f i ve b od y
c om p o ne n t s as f ol l ow s ” ( 1 ):
1. The i nh e re n t mo ti l it y o f th e b r ai n an d s p in a l c o rd
2. Flu c t ua t io n o f th e c e re b r os p in a l f l ui d
3. Mob i l it y o f t h e i n tr a cr a n ia l a n d i n tr a sp i na l me mbr a ne s
4. A rt i c ul a r mob i l it y o f t h e c r an i al b on e s
5. The i nv o lu n ta r y m o bi l it y of th e s a c ru m b e tw e e n t he il i a ( p el v ic b on e s)
O CF h as al s o b e en ca l le d cr a ni a l o s te o pa t hy ( CO ) ( 1 ), c ra n io s ac r a l t ec h ni q u e ( 4) , a n d
s im p l y c ra n ia l te c hn i qu e . I t i s i mp or t an t t h a t O CF be u se d w i th t he af o re me nt i on e d
p ri n c ip l es . O t h er os t eo p a th i c t ec h n iq u es ca n be us e d o n t h e c ra n i um bu t a r e u s ed wi t h
t he i r s p ec i fi c pr i nc i pl e s f o r t re a t me n t e f f e c t o n s om a t ic dy s fu n c ti o n. Fo r ex a mp l e,
c ou n t er s tr a in , so f t t is s u e, my o fa s c ia l r e le a s e, an d l y mph a ti c t e c hn i qu e s c a n a ll be
u se d in th i s r e gi o n b ut a re no t c l a s s i fi e d a s O CF, CO , or cr a ni o s ac r al te c h ni q ue .
Man y ph y si c ia n s w e re re l u c t a nt to b el i ev e t h a t t he cr a n ia l b o ne s we r e c ap a b le of
mov e men t o r t h a t t he ph y s ic i an co u l d p al p at e mo v em e nt . A n um b er o f s tu d ie s ha v e
s ho wn e v id e nc e of su c h mo ti o n a nd s ug g es t t h a t t he cr a n ia l s u tu r e s may no t
c om p l et e ly os s i f y (1 ) . A si mpl e e x a mp l e t o i l lu s tr a te t ha t t h e s u tu r es al l o w c ra n ia l bo n e
mob i l it y i s t o ha v e o ne s tu d en t f i x a pa r tn e r 's fr o nt o z yg o ma t ic s ut u re s b i l at e ra l ly . Th i s
i s d o ne by pl a c in g o n e t h um b o v er o ne fr o nt o z yg o ma t ic s ut u re an d th e p a d o f t h e
i nd e x f i ng e r o f t h e s am e ha n d o n t h e o pp o si t e f r on t oz y g om a ti c s u t ur e . The n th e
s tu d e nt ge n tl y ro c k s th e z y g om a ti c po r ti o n f r om si d e t o s i de wh i l e t he ot h e r h an d i s
c ra d l in g t h e h e ad . A n a u d ib l e a rt i c ul a r c li c k m a y o c c u r . The op e r at o r, th e pa t ie n t , o r
1 of 48 21/08/07 22:14
b ot h ma y f e el t hi s m o ti o n . We h av e no t s e en a ny ad v er s e e f fe c t s f ro m t h is man e uv e r
a nd t he r ef o re h av e c o nf i d en c e i n a po s it i ve e du c at i on a l o u t c o me .
The r ea s on pa t i en t s r ea c t p o si t iv e l y t o O CF i s n ot co mp le t el y u n d er s to o d, a nd th e
u nd e r ly i ng ca u s e a nd ef f e c t ma y b e a c om b in a t io n o f t h e s t at e d p r in c ip l es . So me o th e r
r ea s o ns ma y i n c lu d e r ef l e x p he n om e n a f ro m c o n ne c ti v e t i s s u e mec h a no r ec e pt o r s
a nd / o r n oc i ce p t or s o r m i c ro s co p ic a nd ma c ro s c op i c f lu i d e x ch a ng e ei t he r p e r ip h er a ll y
( Tr a u be - He r in g - Ma y er os c i ll a ti o ns ) (5 ) o r i n th e c e nt r a l n er v ou s s y s te m. S u th e rl a nd ,
a f t e r p a lp a ti n g m a ny pa t i en t s , fe l t s p ec i fi c t y p es of mot i on s , a n d h e c ou l d n o t a c c o u nt
f or t he s e mot i o ns ba s ed o n mus c le a c t i vi t y u p on re v ie wi ng cr a ni a l a n at o my . Th e re f or e ,
h e b e ga n p o s t u l at i ng an i nh e re n t i n vo l un t ar y me c ha n is m an d e v en t u al l y c am e to th e
t er m pr i ma r y r e sp i ra t or y me c ha n is m (6 ) .
P ri ma ry re s pi r a to r y mec h a ni s m i s f u rt h er de f i ne d t h us :
P. 4 76
P ri ma ry re f er s to in t er n a l t is s ue r es p ir a to r y p r oc e s s .
Res p i ra t or y r e f er s t o t h e p r oc e s s o f i nt e rn a l r e sp i ra t i on (i . e. , th e e x ch a n ge of
r es p i ra t or y g a s es be t we e n t i s s u e c e ll s a n d t h ei r i n te r n al en v ir o n me n t , co n s is t in g
o f t h e f lu i ds b at h in g t h e c e ll s ).
Mec h a ni s m r ef e r s t o t he i nt e rd e pe n d en t m o ve me nt of ti s s ue an d f l u id wi t h a
s pe c i fi c p u rp o s e.
I t i s b e li e ve d th a t a s p e ci f ic pa t t er n o f m o t io n e x is t s a n d i s r e ad i ly ap p a re n t a nd
p al p a bl e i n e a c h p er s on . Th i s mot i o n p at t er n is de t er mi ne d b y a v ar i et y o f fa c to r s b u t
i s t h ou g ht to b e r el a te d to th e b e v el i ng of t he su t ur e s a n d t he a t t a ch men t s o f t h e
d ur a . T h er e fo r e , t o d ia g n os e a n d t r ea t u s in g OC F, t he p hy s ic i an mus t k n ow c ra n ia l
a na t o my (e . g. , at th e p t e ri o n t he b on e s o ve r l ap as fo l l ow s : f ro n t al , p a ri e t al , s p he n o id ,
a nd t em p or a l, i n a lp h ab e t ic a l o rd e r f r om in n e r t o o ut e r t a bl e ).
The i nt e rn a l d u ra l r e fl e c ti o ns of t he fa l x c e re b ri , t h e f a lx ce r e be l li , a n d t h e t en t o ri u m
c er e b el l i a re c ol l ec t iv e l y k no wn a s t h e r ec i p ro c al te n s io n m e mb r a ne . D i s t o r ti o n i n t h e
p os i t io n o r m o t io n o f a n y c r an i al b on e m a y b e t r an s mi t t ed to th e ba s e a nd v au l t
t hr o u gh th i s r e ci p ro c al t en s io n m e mbr a ne . T h e re f or e , r e s t r ic t io n of cr a ni a l b o ne mo t i on
wit h di s to r ti o n o f i t s s y mm e tr i c mo ti o n p at t e rn is te r med cr a ni a l s o ma t ic d y s f un c ti o n .
The b ip h as i c f l uc t ua t io n of mo t io n th a t i s p a lp a te d i n th e c r an i a l b on e s h a s b ee n
r ef e r re d t o a s th e c r an i a l r hy t hm i c i mpu l se ( CR I ). Th e em p ha s is i n O CF is p la c ed on
t he s yn c hr o no u s m o ve men t of th e c r a ni u m wit h th e s a cr u m ( c ra n io s a cr a l mec h a ni s m) .
The mot i on be t wee n t h e c r an i um an d sa c ru m i s be l ie v ed t o b e a s s o c ia t ed wi t h t h e
a t t a c hm e nt s o f th e d u ra l tu b e a t t h e f or a me n ma g nu m a n d t h e s ec o n d s ac r al s eg men t
a t t h e r es p ir a t or y a x is . Th i s i s s o me t im e s c a ll e d t he c or e l i nk . I t fo l lo ws a rh y th mi c
c ad e n ce at 8 t o 1 4 c y cl e s p e r min u t e ( 1, 4 ). Thi s i mpu l s e may be p al p at e d a n yw h er e i n
t he b od y , a nd i t i s u se d no t o n ly i n o s t e op a t hy in th e cr a ni a l f i el d b u t a l so in ba l a nc e d
l ig a men t ou s t e n si o n, or l ig a me n to u s a r ti c ul a r s t ra i n ( B LT / LA S ) t e ch n iq u es . I t s r a te a nd
a mp l i tu d e may v ar y i n c e r ta i n d is e a se pr o ce s s es (e . g. , fe v er ) .
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Cra n i al no men c l at u re is g en e ra l ly r ef e re n ce d to mo t io n oc c ur r in g at th e s p h en o ba s il a r
s ym p h y s i s , or s yn c ho n dr o s is (S B S) . I t is sl i g ht l y c on v e x o n t he s up e ri o r s i de , a n d t h is
c on v e xi t y i s i n cr e as e d d u ri n g f le x i on . T h is c an al s o b e t h ou g ht o f a s t he i nf e ri o r
p or t i on of th e SB S c r ea t i ng an an g l e s o t ha t th i s i nf e r io r -s i de d an g le be c o me s s mal l e r
o r mo re ac u te wit h f l ex i o n o f t he S BS .
I n s p he n ob a si l a r f le x io n , t h e b as i o c c i pu t a n d b a si s ph e n oi d m o ve c ep h al a d wh il e t h e
o c c i p it a l s qu a ma a nd th e wi n gs of t he sp h en o i d mov e m o r e c au d al l y . The s e f l ex i on an d
e x t e n si o n mot i o ns ar e r o t at i on a l a b ou t t r an s v er s e a xe s : o n e a t t h e l ev e l o f t h e
f or a men ma g nu m an d t h e o t he r t h ro u g h t he bo d y o f t h e s p he n oi d ( 6 ) . A ll mi d l in e
u np a i re d c r an i a l b on e s a r e d es c ri b e d a s mov i n g i n f le x i on an d e x t en s io n .
Flexi on and Extension of the Sphenobasilar S ynchondrosi s

Dur i n g f le x io n of th e c r a ni a l b as e (F i g. 18 . 1 ), th e p e t ro u s p or t i on s o f t h e t e mp o ra l
b on e s m o ve ce p h al a d wit h th e S B S. Thi s p r od u c es a f la r i ng ou t wa r d o f t h e t e mp o ra l
s qu a ma c al l ed e x t e rn a l r o ta t io n o f th e t e mp o r al bo n es . Al l p a ir e d b o ne s m o v e i nt o
e x t e r na l r o ta t i on s y n ch r o no u s wit h sp h en o ba s i la r f l ex i o n. In t er n a l r ot a ti o n o f t h e p a ir e d
b on e s i s s y nc h r on o us wi t h s p he n ob a s il a r e x t e n si o n. Th e r ef o re , i t ca n b e s a i d t ha t i n
f le x i on , t h e s k ul l s h or t e ns in th e an t er o po s t er i or di a met e r a nd wid e ns la t e ra l ly . I n
e x t e n si o n ( Fi g . 1 8 .2 ) , t h e s ku l l l e ng t he n s i n t h e a nt e r op o s t e ri o r d i am e te r an d n a rr o ws
l at e r al l y .
B ec a u se of th e li n k b et we en th e c r a ni u m a nd t he sa c ru m, t h e s ac r u m wil l m o v e wit h
t he c ra n iu m. I n S B S f le x i on , t h e s a cr a l b as e mo v es po s t er o su p er i o rl y ( 1 ), a nd in SB S
e x t e n si o n, th e sa c ru m m o v es an t er o i nf e ri o rl y . T h is mo r e r e ce n t c r an i os a cr a l
mec h a ni s m t er mi no l og y h a s c a us e d s o me co n fu s i on be c au s e o f i t s d i f f e re n ce f ro m t h e
p re v i ou s ly us e d n o me n cl a t ur e f o r
P. 4 77
g ro s s s a cr a l mo ti o n. In g ro s s s ac r a l b io mec h a ni c s , a s a cr a l b as e an t er i or mov e me n t
was d es c ri b ed a s f le x io n of th e s a c ru m. How e v er , f l ex i o n i n c ra n i os a cr a l me ch a ni s m
t er mi no l og y i s de f in e d a s t h e s ac r a l b as e m o v in g p o s t e r io r ly . S o me h av e d e c id e d t o
d es c r ib e s a cr a l b a se mo v e me n t s as n od d in g m o t io n s . Th u s , f or war d mo v em e nt o f t he
s ac r a l b as e i s ca l le d n u t at i on , a n d b a c k war d mo v em e nt o f t he sa c r al ba s e i s c a ll e d
c ou n t er n ut a ti o n . No mat t e r whi c h t e rm s o n e c h oo s es (f l e xi o n a nd e x t e ns i on o r n ut a ti o n
a nd c ou n te r nu t a ti o n) , t h e s a cr a l b a se go e s f o rw a rd in g ro s s f le x i on an d i n cr a ni o sa c r al
e x t e n si o n. Th e sa c ra l b a s e mov e s b a c k war d i n gr o s s ex t e ns i on an d cr a ni o sa c r al
f le x i on .
3 of 48 21/08/07 22:14
Figure 18 .1. Fle xio n of th e sp hen oba sil a r synchon d rosis. O,

occipi tal axi s o f ro tation ; S, sp hen oid a l a xis of rotati on.
4 of 48 21/08/07 22:14
Figure 18 .2. Extensi on of the sph eno basi lar synch o ndrosi s. O,
occipi tal axi s o f ro tation ; S, sp hen oid a l a xis of rotati on.
Crani osacral Mechanism

Dy s f u nc t io n al p at t er n s o f c r an i al mot i on ha v e b e en de s c ri b ed as e it h er ph y s io l og i c o r
n ot . Ex a mp l es o f p hy s io l o gi c d y s f u n c t i on s i n c lu d e t or s i on , s i de b en d in g a n d r o ta t io n ,
a nd f ix e d ( fl e x io n a n d e x te n si o n) . Co mpr e s s i o n, ve r ti c a l s tr a in s (s h ea r ), a nd la t er a l
s tr a i ns ar e e x a mp l es of n on p hy s io l o gi c d y s f u n c t i on s . Th ey ma y b e se c on d ar y to he a d
t ra u ma, bi r th t ra u ma , d e n ta l p r oc e d ur e s , in f e ri o r mus c u lo s ke l et a l s t re s s a n d
d y s f u nc t io n , a n d p os t ur a l a b no r ma l i ti e s .
Tor s i on in v ol v e s r ot a ti o n o f t h e S B S a ro u nd a n a nt e ro p o s t e ri o r a x is . T h e s p he n oi d a n d
o c c i p ut ro t at e in op p os i t e d ir e c t i o ns . P a lp a t io n o f a r ig h t t or s i on fe e ls a s i f t he g re a te r
win g of th e s p h en o id on t he ri g ht e le v at e s a n d r ot a te s to th e l e f t whi l e t h e o c c i pi t a l
s qu a ma o n t he r ig h t d ro p s i n to th e ha n ds an d ro t at e s t o t h e r ig h t ( Fig . 1 8 . 3) .
S id e be n di n g/ r o ta t io n i s si d e b en d i ng an d r o t at i on th a t o c cu r s i mul t an e ou s l y a t t he
S BS . Si d e b en d i ng oc c ur s by ro t at i o n a ro u nd t wo ve r ti c a l a xe s , o n e t hr o ug h th e c e nt e r
o f t h e b od y o f th e s p he n o id an d o n e a t t h e f o ra men ma g n um . T h e s p he n oi d a n d t h e
o c c i p ut ro t at e in op p os i t e d ir e c t i o ns ab o ut t he s e a xe s . T h e r ot a t io n c o mp o n en t o f t h e
d y s f u nc t io n o c c ur s a r ou n d a n a n te r o po s te r io r ax i s , bu t th e s p he n o id an d t h e o c ci p ut
r ot a t e i n s am e di r ec t io n . R o ta t io n oc c ur s t o war d t h e s i de of co n v ex i t y (t h e i n fe r io r
s id e ) . Whi l e p a lp a ti n g a le f t s id e be n di n g r o ta t io n , o n e n ot e s t h at th e l e f t h an d f e e ls a
5 of 48 21/08/07 22:14
f ul l n es s a s c o mpa r ed to t he ri g ht h an d ( s id e be n di n g) a nd on e a l s o f ee l s t h at th e l e f t
h an d is be i ng d ra wn c au d a ll y b o th a t t he sp h e no i d a nd o c c i pu t ( r o ta t io n ) ( Fig . 1 8 .4 ) .
S BS c om p re s si o n e i th e r f e el s r o c k h ar d , l ik e a b ow l in g ba l l ( vo i d o f a n y mo ti o n) , o r th e
p hy s i ci a n b eg i n s t o f ee l al l o f t h e d y s f u nc t i on a l s tr a i n p at t er n s t o ge t he r (F i g. 18 . 5 ).
S up e r io r /i n fe r i or ve r ti c a l s tr a in s in v ol v e e i th e r f le x i on at th e sp h en o id a nd ex t en s i on at
t he o c c i pu t ( s u pe r io r ) o r e x te n si o n a t t h e s p he n oi d a n d f l ex i on a t t he oc c i pu t ( i nf e r io r ).
The d y s f un c ti o n i s n a me d by th e p o s it i on of t he ba s is p h en o id . D u r in g p a lp a t io n , a
s up e r io r v e rt i c al sh e ar f ee l s a s i f t h e g re a t er wi n gs o f t he sp h e no i d a re d ra wn t oo f ar
c au d a ll y . I n a n i n fe r io r ve r ti c al s he a r, th e sp h en o id mov e s min i mal l y c au d a d ( Fi g .
1 8. 6 ) .
Figure 18 .3. Rig ht SBS torsio n .
L at e r al s t r ai n in v ol v es r ot a ti o n a r ou n d t wo v er t ic a l a x es , b u t t h e r ot a ti o n o c cu r s i n t h e
s am e di r ec t io n . T h is ca u s es a l at e r al sh e ar i n g f or c e a t t h e S BS . Th e d y s f u n c t i on is
n am e d f o r t he p os i ti o n o f t h e b as i s ph e no i d. Dur i ng pa l p at i on , t h e l a te r al s tr a in s f e e l a s
i f t h e h an d s a r e o n a p a r al l el o gr a m ( Fig . 1 8 . 7) .
6 of 48 21/08/07 22:14
Direct Technique
I n d i re c t c ra n i al os t eo p a th y , t he d y s f un c ti o n i s m o ve d to war d t h e r e s t r ic t i ve ba r ri e r
( bi n d , t en s io n ) . The ph y s ic i an sh o u ld ge n tl y ap p ro a ch t he ba r ri e r a n d mai n t ai n a li g h t
f or c e u n ti l a r el e as e o c c ur s . I f t h e d y s f un c t io n a p pe a r s t o b e mo s t l y a rt i c ul a r, a d i re c t
t ec h n iq u e i s a p pr o pr i at e . T h is te c h ni q ue is c om mon l y u s ed on in f a nt s a n d c h il d re n
b ef o r e f ul l d e v el o pm e nt o f t he cr a n ia l s u tu r e s a nd in v er y s p ec i f ic dy s fu n c ti o ns in
a du l t s ( 4) .
I ndi rect Techni que

I n i n di r ec t c r a ni a l o s t e o pa t hy , t h e d y s f u nc t i on is mo v e d a wa y f r o m t he re s t ri c ti v e
b ar r i er or to wa rd th e e a s e ( fr e ed o m, l oo s e) . Th e p h y s i c ia n a t te mp t s to mo v e t h e
d y s f u nc t io n i n th e d i re c t io n o f f r e ed o m u nt i l a ba l an c e o f t e ns i o n o c c u rs ( ba l an c ed
mem b r an o us te n s io n ) ( 4, 6 ) b e tw e en t he ea s e a n d b in d . Th e CRI is mon i to r ed , an d t h e
i nh e r en t f o rc e s e v en t ua l l y c au s e a sl i gh t i n c re a se
P. 4 78
t ow a r d t he ea s e a n d t he n mo v em e nt b ac k t o t h e o r ig i na l ba l an c e p o si t io n , wh ic h i s a
s ig n of th e r e l ea s e. Th i s t e ch n iq u e i s m o s t a pp r op r ia t e i f t h e k e y d y s f un c t io n i s
s ec o n da r y t o a me mbr a no u s r e s t r ic t i on (4 ) .
7 of 48 21/08/07 22:14
Figure 18 .4. Left SBS side be n din g/rota tion .
E xaggeration
E xa g g er a ti o n me th o d i s p e rf o rm e d wi th th e p h y si c ia n m o v in g t h e d y s f u nc t io n to war d
t he e as e , s im i l ar to in d i re c t , bu t wh e n mee t i ng th e e a s e b ar r ie r an ac t iv a t in g f o rc e is
a dd e d .
8 of 48 21/08/07 22:14
Figure 18 .5. SBS co mpre ssi on.
Disengagement
I n d i se n ga g em e n t , th e p h y si c ia n a t t em p t s to o pe n o r s e p ar a te th e ar t ic u la t i on .
Dep e n di n g o n h o w t he ar t i cu l at i on i s f el t t o be re s tr i c te d , t ra c t io n o r a c om p re s si v e
f or c e m a y b e a d de d .
9 of 48 21/08/07 22:14
Figure 18 .6. SBS in feri or vertica l stra i n. O, occi pital axi s of

rotati on; S, sph eno i dal axis o f rota tio n .
P. 4 79
10 of 48 21/08/07 22:14
Figure 18 .7. SBS la tera l stra i n.
Technique S tyl es
I nherent Force
Use o f t he bo d y 's in h er e n t f or c e t h ro u gh th e pr i ma r y r e sp i ra t or y me c ha n is m is th e
maj o r m e th o d o f O CF. Us i n g t he fl u c tu a ti o n o f t h e c er e b ro s pi n al f lu i d, th e ph y si c ia n
c an a lt e r t he p re s su r e i n o n e a re a or an o th e r a n d c au s e t h is fl u i d t o c ha n g e t he
v ar i o us ba r ri e r s . Th i s i s m o s t ev i d en t i n t h e V - sp r ea d te c hn i qu e (4 ) .
Respi ratory Assistance

A s i n o t he r t e c hn i qu e s , t he us e o f pu l mo n ar y re s pi r at i o n c an fa c i li t at e o s t eo p at h ic
t ec h n iq u e. Th i s r e le a se - e nh a nc i ng mec h an i sm wil l i n cr e a se mo v em e n t s as s oc i a te d w i th
i nh a l at i on an d ex h al a ti o n . For ex a mpl e , i t i s b e li e ve d th a t d ur i n g i nh a la t i on , t h e S B S
t en d s t o m o ve t ow a rd fl e x io n , wit h th e p a ir e d b o ne s m o v in g m o re t ow a rd ex t e rn a l
r ot a t io n . I n e x ha l at i on , th e u n pa i r ed bo n es mov e p r ef e r en t ia l ly t ow a rd ex t e ns i on an d
11 of 48 21/08/07 22:14
t he p ai r ed bo n e s i nt o i n t er n al ro t a ti o n. Th e ph y si c ia n ca n h a ve t he pa t ie n t b r ea t he i n
t he d ir e c t i on p re f er r ed f or it s r e l at e d c ra n i al ef f ec t an d t e ll t he pa t ie n t t o h o ld t he
b re a t h a t f ul l in h al a ti o n o r e x ha l a ti o n. Th i s w i ll en h a nc e a re l e as e .
Distal Acti vati on

I n c e rt a in co n d it i on s , t h e p hy s ic i a n may pr e f er to tr e a t t he pa t i en t 's pr o b le m f r om t he
s ac r a l r eg i on o r e x t r em i t ie s . B y a p pl y in g t e n si o n o n t h e s ac r um , th e p h y s i c ia n c a n
g ui d e t h e mec h a ni s m f ro m be l ow an d ef f ec t t h e m o ve men t of th e S B S . I n a dd i t io n , t he
p hy s i ci a n may h av e t h e p a ti e nt ac t i ve l y a t t e mpt pl a nt a r fl e xi o n o r d o rs i fl e x io n t o g a i n a
p ar t i cu l ar ef f e c t on th e SB S . Dor s i fl e xi o n e n ha n ce s S B S f l ex i on , wh i le pl a n ta r fl e xi o n
e nh a n ce s e x te n s io n ( 4 ).
S til l Point
I n t h is me t ho d , t h e p hy s i ci a n a t t e mpt s t o r e s is t t h e p r im a ry re s p ir a to r y me ch a ni s m
t ha t is be i ng mon i to r ed t hr o ug h t h e C RI . Th i s i s m o s t c om mon l y c a ll e d c om p r es s io n o f
t he f ou r th ve n t ri c le (C V 4 ). Su c ce s s o f t h e CV 4 t ec h ni q u e r el i es o n i nh e re n t f o rc e s . I n
t hi s te c hn i qu e , t h e p hy s i ci a n mon i t or s s e ve r a l c y c l es o f CRI an d th e n p er mi t s
e xh a l at i on mo t i on at th e bo n e b ei n g p a lp a te d (u s ua l ly t he oc c ip i t al sq u am a ) . The n t h e
p hy s i ci a n g en t l y r es i s t s fl e xi o n u n ti l a ce s s at i on of t he ce r eb r a l s pi n al f lu i d f lu c t ua t io n
i s p a lp a te d . Th is is ca l l ed a s ti l l p o in t . Th is po s it i o n i s h el d fo r 1 5 s e c on d s t o a fe w
min u t es , u n ti l th e p h y s i c ia n a p pr e c ia t es a r e tu r n o f t h e CRI . T h i s c an be a pp l ie d t o th e
s ac r u m whe n c o n ta c ti n g t h e h ea d i s co n tr a in d i ca t ed (e . g . , ac u te h ea d t r au ma ) ( 4, 6 ).
I ndi cati ons

1. Hea d a ch e s
2. Mil d to se v er e wh i pl a sh s tr a in an d sp r ai n i n j ur i es
3. V er t i go an d t i n ni t us
4. O ti t i s med i a wi th ef f us i o n a nd se r o us ot i ti s me d ia
5. Tem p o ro man d ib u l ar jo i nt d y s f un c ti o n
6. S in u s it i s
Contraindicati ons
1. A cu t e i n tr a cr a n ia l b l ee d i ng an d h e mor r ha g e
2. I nc r e as e d i nt r a cr a ni a l p r es s ur e
3. A cu t e s k ul l f r a c t u re
4. Cer t a in se i zu r e s t at e s ( r el a ti v e)
12 of 48 21/08/07 22:14

O CF may he l p a nu mbe r o f co n di t io n s . I t s ad v e rs e r e ac t i on s a r e f e w, bu t t h e p h y s i ci a n
s ho u l d b e o n a l er t , a s h e ad a ch e , v e rt i go , t i n ni t us , n a u se a , a nd v om i ti n g c a n o c c u r, a s
c an s om e a u to n o mi c r e la t e d
P. 4 80
e f f e c t s (e . g. , br a dy c ar d i a) . T h es e ar e m o s t l y s e en wh e n s t ud e nt s ar e f i rs t le a rn i ng t he
t ec h n iq u e a nd d o n ot re a l iz e t h e p r es s ur e b e i ng im p ar t e d i nt o t h e ir pa t ie n t 's cr a ni u m.
Thi s is co mmo n , w i th im p r op e r h ol d i ng te c hn i q ue (l o ca t i on an d i n c or r ec t p r e s s u re ) s e e n
a t t i me s a t t h e o c ci p it o mas t oi d s u t ur e . Hea d a ch e s , na u s ea , a n d v o mi t in g , wh il e n o t
c om mo n, ar e s e e n o c c a si o n al l y .
The r e fo r e, th e ph y si c ia n mu s t t ak e ca r e t o c o nt a c t th e pa t ie n t p r op e rl y a n d a p pl y
e no u g h b ut no t to o m u ch p re s su r e f o r t he ap p r op r ia t e a mou n t o f t i me . T h e p h y s i ci a n
s ho u l d a ls o m a k e s ur e t h a t t he pr i mar y r e sp i r at o ry me c h an i sm is p re s en t w h e n
d ec i d in g t o e n d t h e t re a t me n t .
A v a r ia t io n o f th i s t ec h n iq u e i s u s in g a mu l t ip l e- h an d ap p ro a ch . Wh i le on e op e ra t or i s
p al p a ti n g t he c ra n iu m, a n ot h er ca n be on th e sa c ru m o r an o th e r a r ea of th e pa t ie n t' s
b od y . T h is ca n po t en t ia t e t h e e f f e c t o f a t r e at men t .
P. 4 81
Crani al Vault Hold
13 of 48 21/08/07 22:14
Objective s
The ob jective is to assess
the prima ry resp ira tory
mechan ism as it man i fests
itself in the crani u m a nd the
deg ree of participa tion of
each b one in the ge n era l
motion of the crani u m.
Tec hnique

sup ine , a n d the
physician is sea ted at
the he ad o f the tab l e.
2. The ph ysi cian
establ ish e s a fu lcru m
by restin g bo th
forearms o n the tab l e.
3. The ph ysi cian 's han d s
cra dle th e pa tie nt's
hea d, maki ng ful l
pal mar co n tact o n b o th
sid es.
4. The ph ysi cian 's ind e x
fin gers re st on the
gre ate r w i ngs of th e
patien t's sph eno id (A,
Fig. 1 8.8 ).
5. The ph ysi cian 's mid d le
zyg oma tic pro cesses
Figur e 1 8.8 . L a teral vie w of skull with d ots for fi ng
of the pa tien t's
(7).
temporal b one s (B,
Fig. 1 8.8 ).
6. The ph ysi cian 's rin g
mastoi d p roce sse s o f
the pa tie n t's te mpo ral
bon es (C , Fig. 1 8.8 ).
7. The ph ysi cian 's little
14 of 48 21/08/07 22:14
P. 4 82
Fronto-occi pital Hold
Objective s
The ob jective s a re to
assess th e prima ry
respirato ry mech ani sm a s i t
man ife sts itself in the
cra niu m; to a sse ss the
fre edo m o f mo tio n o f th e
cra nia l b a se, especi all y a t
the SBS; a nd to asse ss the
fro nta l b o ne as it rela tes to
the re st o f the CRI.
Tec hnique
Figure 18.11. Ste ps 1 to 5.
sup ine , a n d the
physician is sea ted at
the si de o f the hea d of
the ta ble .
2. The ph ysi cian pl ace s
the ca uda d ha nd
und er the patien t's
occipi tal squ ama wi th
the fo rea rm resting on
the ta ble establ ish i ng
a fulcrum.
3. The ph ysi cian 's Figure 18.12. Ste ps 1 to 5.
cep hal ad h and bridg e s
across th e pa tie nt's
fro nta l b o ne, wi th the
elb ow resting on th e
tab le esta bli shi ng a
ful cru m.
4. The th umb and mi ddl e
fin ger of the
physician 's ceph ala d
han d rest on the
gre ate r w i ngs of th e
patien t's sph eno id (if
15 of 48 21/08/07 22:14
the ha nd spre ad is too Figure 18.13. Ste ps 1 to 5.

sho rt, ap p roxima te the
gre ate r w i ngs).
5. The ph ysi cian ma kes
ful l p alma r contact with
both h and s (Figs .
18.11, 18 .12 and
18.13).
6. The ph ysi cian
pal pates the CRI.
a. Extension /intern al
rotati on: corona l
dia meter n arrows,
antero posteri or
dia meter
increa ses, he igh t
increa ses.
b. Fle xio n/e xternal
rotati on: corona l
dia meter w ide ns,
antero posteri or
dia meter
decrea ses, he igh t
decrea ses.
7. The ph ysi cian no tes
the ampli tude , rate ,
and re gul a rity o f th e
CRI.
8. The ph ysi cian no tes
whi ch bon e s, if any,
have a n a l tered
amp litude , ra te, an d
reg ula rity.
9. The ph ysi cian pa ys
particula r atten tio n to
the SBS, d ete rmi nin g
whe the r th ere is an y
pre ferred motion of the
sph eno id a nd the
occipu t.
16 of 48 21/08/07 22:14
The ph ysi cian ma y i n struct

the pa tie n t to stop
bre ath ing to furthe r
distin gui sh the rhythmi c
sen sation s th at occu rs in
the CR I. The physici an can
also h ave the pa tie n t i nha le
and exhal e fu lly to increa se
the ampli tude of th e CR I,
whi ch can make i t e a sie r to
fee l.
P. 4 83
S acral Hold
Objective
The ob jective is to
cre ate fre e a nd
symmetric motion of
the sa cru m by
pal pation of the CR I.
Tec hnique

sup ine , a n d the
physician is
sea ted at the
sid e o f th e Figure 18.14. Ste ps 1 to 4.
tab le cau d ad to
the sa cru m.
instru cte d to
ben d the far
kne e a nd roll
tow ard th e
physician .
3. The ph ysi cian
sli des th e
17 of 48 21/08/07 22:14
cau dad ha n d
betwee n th e
patien t's leg s
and un der the
sacrum, a n d
the pa tie n t
dro ps his or her
wei ght is on
thi s h and .
4. The ph ysi cian
all ows th e
han d to mo ld to
the sh ape of Figure 18.15. Ste ps 1 to 4.
the sa cru m wi th
the me dia n
sacral cre st
lyi ng betw een
the th ird and
fou rth fi n gers,
the fi nge rtip s
app roxima ting
the ba se a nd
the pa lm
cra dli ng the
ape x (Figs .
18.14 and Figure 18.16. Lumbar an d sa cra l
18.15). con tact.
5. The ph ysi cian
pre sse s th e
elb ow dow n
into the tabl e,
establ ish i ng a
ful cru m.
6. The ph ysi cian
pal pates the
cra nio sacral
mechan ism.
Sph eno basi lar
fle xio n i s
syn chrono u s
with sacra l
cou nte rnu tati on
18 of 48 21/08/07 22:14
(sa cra l b a se
moves
posterior).
Sph eno basi lar
extension is
syn chrono u s
with sacra l
nutati on (sacral
base move s
anteri or).
han d foll o ws
the se moti ons,
encouragi n g
symmetric and
ful l rang e of
sacral mo tion .
8. The ph ysi cian
con tin ues to
fol low an d
encourage
sacral mo tion
until pal p ati on
of a rele a se,
whi ch is
usu all y
accomp ani e d
by a sensa tio n
of soften i ng
and wa rmi n g o f
the sa cra l
tissue s.
9. The ph ysi cian
retests th e
qua nti ty a nd
qua lity o f
sacral mo tion
to assess the
effective n ess of
the te chn i que .
19 of 48 21/08/07 22:14
The ph ysi cian ca n

also u se the
cep hal ad h and ,
either sl i din g i t
und er the patien t's
lumbar are a (Fig.
18.16) la ying th e
forearm a cross b oth
anteri or supe rio r
ili ac spi n es (ASIS).
The ad diti ona l h and
pla cement gives the
physician more
informati o n a bou t
how th e sa cru m
rel ate s to th e
respective areas.
P. 4 84
Decom pressi on of the Occi pital Condyles
Objective s
The ob jective is
to bal ance th e
reciproca l te nsi on
membra ne a t the
hyp ogl ossa l
can al, pe rmittin g
normal ize d
fun cti on o f cran ial
nerve XII.
Tec hnique
1. The pa tie n t Figure 18.17. Ste ps 1 a n d 2 .

lie s supi n e,
and th e
physician is
sea ted at the
20 of 48 21/08/07 22:14
hea d o f th e
tab le with
both
forearms
restin g o n
the ta ble ,
establ ish i ng
a fulcrum.
2. The pa tie n t's
hea d rests
on the
physician 's
pal ms, an d Figure 18.18. Ste ps 1 a n d 2 .
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 Figure 18.19. Ste ps 1 a n d 2 .
cau dad on
the occip u t
as the so ft
tissue an d
C1 wil l
all ow) (Figs.
18.17, 18 .18
and 18 .19 ).
3. The fi nge rs
of both
han ds
ini tia te a
gen tle
cep hal ad
and la tera l
force at the
21 of 48 21/08/07 22:14
base o f th e
occipu t.
4. The fo rce is
mai nta ine d
until a
rel ease i s
fel t.
5. The ra te a nd
amp litude of
the CR I a s it
man ife sts in
the
basioccip i tal
reg ion are
retested to
assess th e
effective n ess
of the
techni que .
P. 4 85
Occi pitoatl antal Decompressi on (8)
Objective s
To tre at
occipi toa tlan tal
somati c d ysfu nction
tha t resu l ts fro m
rotati on o f the
occipu t o n its
antero posteri or
axi s, resu lti ng in
misali gnme nt of the
con dyl es i n the
facets of the atlas.
In gen era l , this Figure 18.20. Ste ps 1 a n d 2 .
techni que sho uld be
22 of 48 21/08/07 22:14
performed after
decomp ression of
the occip i tal
con dyl es.
Tec hnique

sup ine , a n d the
physician is
sea ted at the
hea d o f th e
tab le with bo th
forearms Figure 18.21. Ste ps 1 a n d 2 .
restin g o n th e
tab le,
establ ish i ng a
ful cru m.
2. The ph ysi cian
pla ces th e
pad s o f b o th
mid dle fi n gers
on the
posterior
asp ect of the
cra niu m a n d
sli des th e se Figure 18.22. Ste ps 1 a n d 2 .
fin gers d o wn
the occip u t
until the fin gers
are ag ain st the
posterior
arches of the
atl as (Figs.
18.20, 18 .21
and 18 .22 ).
3. The ph ysi cian
app lie s ca uda d
pre ssu re w ith
both midd l e
fin gers to
sep ara te the
facets fro m the
23 of 48 21/08/07 22:14
con dyl ar p arts.

4. Whi le the
physician
mai nta ins thi s
cau dad
pre ssu re, the
patien t tu cks
the ch in i nto
the ch est,
making su re
NOT to fl e x the
neck (thi s is
the no ddi n g
moveme nt that
occurs at the
occipi toa tlan tal
joi nt).
5. Thi s moti o n
carrie s th e
occipi tal
con dyl es
posteriorl y,
ten ses th e
lig ame nts in
the re gio n , a nd
stretches the
con tra cte d
muscle s i n th e
occipi tal
tri ang le.
6. The ph ysi cian
mai nta ins thi s
positi on w hil e
the pa tie n t
hol ds one or
more d eep
inspirati o ns to
the ir limi t. Thi s
wil l e nha n ce
articu lar
rel ease.
7. The ra te a nd
24 of 48 21/08/07 22:14
amp litude of
the CR I, a s i t
man ife sts in
the
basioccip i tal
reg ion , a re
retested to
assess th e
effective n ess of
the te chn i que .
Occipi toa tlan tal
motion te stin g
can al so b e
assessed for
normal iza tion .
P. 4 86
Compression of the Fourth Ventricl e
Objective s
Tre atment often
sta rts wi th
compre ssi o n o f C V4
for il l p a tie nts. Th e
tre atment aug men ts
the he ali n g
cap abi liti es of the
patien t, rela xes th e
patien t, a nd
imp roves the motion
of the CR I.
Tec hnique Figure 18.24. Ste ps 1 to 3.

sup ine , a n d the
physician is
sea ted at the
25 of 48 21/08/07 22:14
hea d o f th e
tab le with bo th
forearms resting
on the ta b le,
establ ish i ng a
ful cru m.
2. The ph ysi cian
cro sse s o r
interl ace s th e
fin gers o f bo th
han ds, cra dli ng
the pa tie n t's
occipi tal Figure 18.25. Sup eri or view of ha n d
squ ama . posi tio n.
3. The ph ysi cian
pla ces th e
the nar
emi nen ces
posterome d ial
to the pa tien t's
occipi toma sto id
suture s. If the
the nar
emi nen ces are
on the ma stoi d
pro cesses of
the te mpo ral Figure 18.26. Ste ps 1 to 3.
bon es, th e
compre ssi o n
tha t foll o ws wil l
bil ate ral l y
extern all y ro tate
the te mpo ral
bon es, wh i ch
may ca use
extreme
untowa rd
rea cti ons (Figs.
18.23, 18 .24,
18.25 and
18.26).
4. The ph ysi cian
26 of 48 21/08/07 22:14
encourage s
extension of the
patien t's occipu t
by fol low i ng the
occipu t a s it
moves into
extension .
5. The ph ysi cian
resists fl exi on
by hol din g th e
patien t's occipu t
in extensi on
with b ila tera l
med ial fo rces.
Note: The
occipu t i s no t
forced in to
extension .
Rather, i t is
pre ven ted fro m
moving in to
fle xio n. It i s a s i f
the ph ysi cian is
taking up the
sla ck cre a ted by
extension and
hol din g i t th ere .
6. Thi s force is
mai nta ine d un til
the ampli tude of
the CR I
decrea ses, a
sti ll poi n t i s
rea che d, a nd/or
a sense o f
rel ease i s fe lt (a
sen se of
soften ing and
warmth in the
reg ion of the
occipu t).
7. As the CR I
27 of 48 21/08/07 22:14
resume s, the
physician
slo wly re l eases
the fo rce ,
all owi ng the
CRI to un d erg o
new fou nd
excursion .
8. The ra te a nd
amp litude of the
CRI are
retested to
assess th e
effective n ess of
the te chn i que .
28 of 48 21/08/07 22:14
Figure 18 .23. Steps 1 to 3 .
P. 4 87
P. 4 88
I nterparietal S utural Opening (V-S pread)
29 of 48 21/08/07 22:14
Objective
To restore freed om
of moveme n t to the
sag ittal sutu re,
increa sin g th e
dra ina ge o f the
sup eri or sagi tta l
sin us.
Tec hnique

sup ine , a n d
the ph ysi cian Figure 18.27. Ste ps 1 to 3.
is sea ted at the
hea d o f th e
tab le with bo th
forearms
restin g o n
tab le,
establ ish i ng a
ful cru m.
2. The
physician 's
thu mbs are
cro sse d o ver
the pa tie n t's Figure 18.28. Ste ps 1 to 3.
sag ittal sutu re
just a nte rior
and su peri or to
lambda .
3. The re mai n der
of the
physician 's
fin gers re st on
the la tera l
surfaces o f the
patien t's
parietal b one s
(Figs. 18 .27, Figure 18.29. Ste ps 1 to 3.
18.28 and
18.29).
30 of 48 21/08/07 22:14
P. 4 89
S utural Spread (V-Spread, Di rection-of-Fl uid Techni que)
Objective
rel ease a restri cte d
cra nia l su ture (e.g .,
left o cci p ito mastoi d
suture ).
Tec hnique
1. The pa tie n t
lie s supi n e,
and th e
physician is
sea ted at the Figure 18.30. Ste ps 1 to 3.
hea d o f th e
tab le with
both e lbo w s
restin g o n th e
tab le,
establ ish i ng a
ful cru m.
2. The ph ysi cian
pla ces th e
ind ex and
mid dle fi n gers
on the tw o
sid es of the Figure 18.31. Ste ps 1 to 3.
patien t's
restri cte d
suture .
3. The ph ysi cian
pla ces on e or
two fi nge rs o f
the other han d
on the
patien t's
cra niu m a t a
poi nt opp o site
the su ture to
31 of 48 21/08/07 22:14
be rel ease d Figure 18.32. Ste ps 1 to 3.

(Figs. 18 .30,
18.31 and
18.32).
4. With the
lig hte st force
possib le, the
physician
directs a n
imp ulse
tow ard th e
restri cte d
suture wi th
the ha nd
opp osi te the
suture ,
ini tia tin g a
flu id wave .
The ob ject is
not to
physicall y
push flui d
throug h to th e
opp osi te side .
Instea d, the
physician is
usi ng the
flu ctu ati o n o f
the
cerebrosp i nal
flu id to
rel ease th e
restri cti o n.
The ph ysi cian
use s i nte n tio n
to ini tia te this
wave; thi s
method
con tra cts the
few est mu scle
fib ers an d so
app lie s th e
32 of 48 21/08/07 22:14
sli ghtest force.

5. Thi s flui d
wave may
bou nce off th e
restri cte d
suture an d
return to the
ini tia tin g
han d, whi ch
sho uld
receive a n d
red ire ct the
return ed w ave
tow ard th e
restri cte d
suture .
6. Thi s
back-a nd-forth
action ma y be
rep eated for
severa l cycle s
before th e
physician
fee ls the
suture sp read
and th e w a ve
pen etrati n g
the su ture
doe s n ot
return to the
ini tia tin g
han d.
7. The ra te a nd
amp litude of
the CR I a t th at
suture are
retested to
assess th e
effective n ess
of the
techni que .
33 of 48 21/08/07 22:14
P. 4 90
P. 4 91
V enous S inus Drainage (6)
Objective s
The ob jective is
to increa se
intracran i al
ven ous dra ina ge
by affecti ng the
dural memb ran es
tha t comp rise th e
sin use s. Thoraci c
outlet, ce rvi cal ,
and
occipi toa tlan tal
joi nt soma tic Figure 18.33. Tra nsverse si nus.
dysfun cti o ns
sho uld be tre ate d
first to a llo w
dra ina ge from th e
ven ous si n use s.
Tec hnique
1. The pa tie n t
lie s supi n e,
and th e
physician is
sea ted at the
hea d o f th e Figure 18.34. Ste ps 1 a n d 2 .
tab le with
both e lbo w s
restin g o n
the ta ble ,
establ ish i ng
a fulcrum.
2. For
tra nsverse
sin us
dra ina ge the
physician
34 of 48 21/08/07 22:14
pla ces th e
first and
second
fin ger pa d s
of both
han ds
across th e
sup eri or
nuchal li n e
(b l ue lin e ,
Fig. 1 8.3 3 )
(Fig. 18.3 4).
3. Thi s p osi tion Figure 18.35. Con flu ence of si nuse s.
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 Figure 18.36. Ste p 5 .
und er the
fin gers).
4. The
physician
mai nta ins
thi s p ressure
until both
sid es
rel ease.
5. For drain a ge
at the
con flu ence s Figure 18.37. Occipi tal sin us.
of sin use s
the
physician
cra dle s th e
35 of 48 21/08/07 22:14
back o f th e
patien t's
hea d a nd
pla ces th e
mid dle fi n ger
of one ha n d
on the in i on
(b l ue dot,
Fig. 1 8.3 5 )
(Fig. 18.3 6).
6. Ste p 4 is
rep eated
until a Figure 18.38. Ste p 7 .s
soften ing is
fel t.
7. For occip i tal
sin us
dra ina ge the
physician
cra dle s th e
back o f th e
patien t's
hea d a nd
pla ces th e
second to
fou rth Figure 18.39. Sup eri or sagi tta l si nus.
fin gers o f
both h and s
in opp osi tion
alo ng the
mid lin e from
the in ion to
the
sub occipi tal
tissue s (b lue
lin e, Fig.
18.37) (Fig.
18.38).
8. Ste p 4 is Figure 18.40. Ste ps 9 a n d 1 0.
rep eated
until a
soften ing is
36 of 48 21/08/07 22:14
fel t.
9. For drain a ge
of the
sup eri or
sag ittal
sin us, th e
physician
pla ces tw o
cro sse d
thu mbs at
lambda an d
exe rts
opp osi ng Figure 18.41. Metopi c su ture.
forces wi th
each thumb
to diseng a ge
the su ture .
10. Once l oca l
rel ease i s
fel t, the
physician
moves
anteri orl y
and
sup eri orl y
alo ng the Figure 18.42. Ste p 1 1.
sup eri or
sag ittal
suture wi th
the crosse d
thu mb forces
noting
rel eases a t
each
locati on
tow ard
bre gma
(b l ue lin e ,
Fig. 1 8.3 9 )
(Fig. 18.4 0).
11. Once a t
bre gma , th e
37 of 48 21/08/07 22:14
physician
pla ces th e
second to
fou rth
fin gers o f
both h and s
in opp osi tion
alo ng the
mid lin e o n
the fronta l
bon e a t th e
locati on o f
the me top i c
suture (b l ue
lin e, Fig.
18.41) (Fig.
18.42).
12. The
physician
con tin ues
anteri orl y on
the fronta l
bon e,
diseng agi n g
the su ture by
gen tly
sep ara tin g
each fing e r
on opp osi n g
han ds.
13. The ra te a nd
amp litude of
the CR I,
esp eci all y
flu id
flu ctu ati o ns,
are re tested
to assess the
effective n ess
of the
techni que .
38 of 48 21/08/07 22:14
P. 4 92
Unil ateral Tem poral Rocki ng Exampl e: Left Tem poral Bone
i n E xternal or Internal Rotation
Objective
tre at a
dysfun cti o n i n
whi ch the
temporal b one is
hel d i n
extern al/i nte rna l
rotati on.
Tec hnique
1. The pa tie n t
lie s supi n e,
and th e
physician is
sea ted at the
hea d o f th e
tab le with
both
forearms
restin g o n
the ta ble ,
establ ish i ng
a fulcrum.
2. The
physician 's
left h and
cra dle s th e
patien t's
occipu t. Figure 18.43. Ste ps 1 to 5, an ato mic locati o n o f fing e r p lace
3. The
physician 's
rig ht thu mb
and in dex
fin ger gra sp
the
zyg oma tic
39 of 48 21/08/07 22:14
portio n o f th e
patien t's
rig ht
temporal
bon e, thu mb
cep hal ad,
ind ex fin g er
cau dad .
4. The
physician 's
rig ht mid d le
fin ger re sts
on the
extern al
aco ustic
mea tus of the
ear.
5. The
physician 's
rig ht rin g an d
little fi n gers
rest o n th e
inferi or Figure 18.44. Ste ps 1 to 5, fi nge rs o n zygo ma.
portio n o f th e
patien t's
mastoi d
pro cess
(Figs. 18 .43,
18.44 and
18.45).
6. During th e
fle xio n p h ase
of cra nia l
motion , th e
physician 's
rin g a nd l ittle Figure 18.45. Ste ps 1 to 5.
fin gers e xert
med ial
pre ssu re.
Thi s
pre ssu re i s
accomp ani e d
40 of 48 21/08/07 22:14
by cep hal a d
liftin g o f th e
patien t's
zyg oma tic
arch w ith the
physician 's
thu mb and
ind ex
fin gers,
encouragi n g
extern al
rotati on o f
the te mpo ral
bon e.
7. During th e
extension
pha se of
cra nia l
motion , th e
physician 's
fin gers re sist
motion of the
patien t's
temporal
bon e towa rd
intern al
rotati on.
8. An
altern ati ve
method
encourage s
intern al
rotati on a nd
inh ibi ts the
extern al
rotati on.
9. The ra te a nd
amp litude of
the prima ry
respirato ry
mechan ism,
esp eci all y at
41 of 48 21/08/07 22:14
the te mpo ral

bon e, are
retested to
assess th e
effective n ess
of the
techni que .
P. 4 93
Frontal Lift (8)
Objective
The ob jective is
to tre at
dysfun cti o ns of
the fronta l b one s
in rel ati o n to thei r
sutura l o r du ral
con nectio n s (i.e .,
fro nto pari eta l
compre ssi o n,
fro nto nasa l
compre ssi o n).
Tec hnique Figure 18.46. Ste ps 1 to 3, ha nd
pla ceme nt.
1. The pa tie n t
lie s supi n e,
and th e
physician is
sea ted at the
hea d o f th e
tab le with
both
forearms
restin g o n
the ta ble ,
establ ish i ng
42 of 48 21/08/07 22:14
a fulcrum. Figure 18.47. Ste p 4 , co mpressive force.

2. The
physician
pla ces bo th
hyp oth ena r
emi nen ces
on the
latera l
ang les of the
fro nta l b o nes
and th e
the nar
emi nen ces
of both Figure 18.48. Ste p 5 , a n terior gu i ded
han ds force.
anteri or to
the la tera l
asp ects o f
the co ron a l
suture .
3. The
physician
interl ace s
the fi nge rs
abo ve the
metopi c
suture (Fig.
18.46).
4. The
physician 's
the nar an d
hyp oth ena r
emi nen ces
pro vid e a
gen tle
compre ssi ve
force
med ial ly to
diseng age
the fronta ls
fro m the
parietals
43 of 48 21/08/07 22:14
(a rrow s, Fig.
18.47),
intern all y
rotati ng the
fro nta l
bon es.
5. The
physician ,
whi le
mai nta ini n g
thi s medi a l
compre ssi ve
force,
app lie s a
gen tle
anteri or
force eith er
on one si d e
or both a s
nee ded to
diseng age
the su tura l
restri cti o ns
(a rrow s, Fig.
18.48).
6. Thi s p osi tion
is hel d u n til
the
physician
fee ls the
latera l
ang les of the
fro nta l b o nes
move i nto
extern al
rotati on
(expan sio n
und er the
hyp oth ena r
emi nen ces).
7. The
physician
44 of 48 21/08/07 22:14
the n g entl y
rel eases the
hea d.
8. The ra te a nd
amp litude of
the prima ry
respirato ry
mechan ism,
esp eci all y at
the fronta l
bon es, are
retested to
assess th e
effective n ess
of the
techni que .
P. 4 94
P ari etal Li ft (8)
Objective
The ob jective is to tre at
dysfun cti o n o f the
parietal b one s i n
rel ati on to thei r su tural
or dural conn ection s
(i.e., pa rietote mpo ral,
parietofro nta l).
Tec hnique

sup ine , a n d the
physician is Figure 18.49. Ste ps 1 to 3.
sea ted at the he ad
of the ta b le with
both fore a rms
restin g o n th e
45 of 48 21/08/07 22:14
tab le, establ ish ing

a fulcrum.
2. 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.
3. The ph ysi cian
cro sse s th e
thu mbs ju st a bove
the sa gittal suture Figure 18.50. Ste p 4 .
(Fig. 18.4 9). No te:
The th umb s are
NOT to to u ch the
patien t.
4. The ph ysi cian
pre sse s o n e
thu mb aga i nst th e
oth er (arrows, Fig.
18.50) (o n e thumb
pre sse s u p ward
whi le the oth er
resists i t).
5. Pre ssi ng o ne Figure 18.51. Ste p 6 , e xternal ro tati on of
thu mb aga i nst th e pari eta ls.
oth er
app roxima tes the
fin gertip s. This
ind uce s i n ternal
rotati on o f the
parietal b one s a t
the
parietal-squa mou s
suture s.
6. Whi le mai n tai nin g
pre ssu re, the
physician lifts both
han ds cep h ala d
until ful l ness i s
fel t o ver the
46 of 48 21/08/07 22:14
fin gertip s; this

ful lne ss i s
extern al rota tio n
of the pa rietal
bon es (a rrows,
Fig. 1 8.5 1 ).
7. The ph ysi cian
gen tly re l eases
the he ad.
8. The ra te a nd
amp litude of the
pri mary
respirato ry
mechan ism,
esp eci all y at th e
fro nta l b o nes, a re
retested to a sse ss
the effective ness
of the te chni que .
P. 4 95
References
1 . W a rd R ( e d. ) . Fo un d at i on s fo r O s te o p at h ic Me d i ci n e, 2n d ed . P h il a d el p hi a :
2 . A r bu c k le B. Th e Se l ec t ed Wri t in g s o f B e ry l E . Ar b uc k le . Ca mp Hil l , P A : Nat i o na l

O s te o pa t h ic In s ti t u te an d C e r eb r al Pa l s y Fou n da t i on .
3 . W e av e r C . T h e Cr an i al Ve r t eb r ae , J A m O s t e op a t h A s s o c 1 9 36 ; 35 : 32 8 – 33 6 .
4 . G r ee n man P. Pr i n ci p le s o f Ma n ua l M e d ic i ne , 3 r d e d . P hi l a de l ph i a: L ip p in c ot t
5 . N e ls o n K , S e rg u e f f N, Li p i ns k y C, e t a l . Cra n i al rh y th mi c i mp u ls e re l at e d t o t h e
Tr au b e- He ri n g- May e r o s ci l la t i on : C o mp a r in g l a se r Do p pl e r f l ow met r y a n d p al p at i o n.
J Am Os t e op a th As s o c 2 00 1 ;1 0 1 :1 6 3– 1 73 .
47 of 48 21/08/07 22:14
6 . D i Gi o v an n a, E, S ch i ow i t z S . A n O s t e o pa t hi c A p p ro a ch to Dia g no s is a nd
Tr ea t me n t . P hi l ad e l ph i a: Li p p in c ot t W i l li a ms & Wi lk i ns , 2 0 0 5.
7 . M o di f i ed wi t h p e rm i s s i on f ro m A g ur A MR , D a ll e y A F. G ra n t 's At l as o f A na t om y ,
1 1 th ed . Ba l ti mor e : L i pp i nc o t t Wil l ia ms & Wi l ki n s , 2 00 5 .
8 . M a go u n H . O s te o p at h y i n t h e Cra n ia l Fi e ld , 3 r d e d . B oi s e : Nor t hw e s t P ri n ti n g ,
1 9 76 .
48 of 48 21/08/07 22:14
Glossary of Osteopathic Terminology Usage Guide
The Glossary of Osteopathic Terminology is revised twice each year by the Educational Council on Osteopathic Principles, Chairman, John C.
Glover, DO. Forward any comments or suggestions to John Glover, DO, FAAO, Chairman, Department of Osteopathic Manipulative Medicine,
Touro University, California, 1310 Johnson Lane, Vallejo, CA 94592. Office Phone: (707) 638-5245, E-mail: jglover@touro.edu.
The Glossary first appeared in the Journal of the American Osteopathic Association (JAOA 80: 552-567) in April of 1981. The 1995 version of
the Glossary of Osteopathic Terminology was also published in the textbook, Foundations for Osteopathic Medicine, Ward RC (ed.) (1997) pp.
1126-1140: Williams & Wilkins, Baltimore, MD, and in Foundations for Osteopathic Medicine, Ward RC (ed.) (2003) pp. 1229-1253: Williams &
Wilkins, Baltimore, MD. The most current and revised version is available on the AACOM website at www.aacom.org in PDF format. It is also
available on the AOA website at www.osteopathic.org.
The April 2006 glossary review was performed by Andrea Clem, D.O., Lisa DeStefano, D.O., William Devine, D.O., Walter Ehrenfreuchter,
D.O., FAAO, David Essig-Beatty, D.O., Heather Ferrell, D.O., Tom Fotopolis, D.O., Wolfgang Gilliar, D.O., John Glover, D.O., FAAO, Kurt
Heinking, D.O., Jan Hendryx, D.O., Ray Hruby, D.O., FAAO, John Jones, D.O., Robert Kappler, D.O., FAAO, Sean Kerger, D.O., Randy Litman,
D.O., Michael Lockwood, D.O., David Mason, D.O., Evan Nicholas, D.O., Kendi Pim, D.O., Paul Rennie, D.O., FAAO, Mark Sandhouse, D.O.,
Harriet Shaw, D.O., Greg Thompson, D.O., Kevin Treffer, D.O.
Purpose:
The purpose of this osteopathic glossary is to present important and often used words, terms and phrases of the osteopathic profession. It is not
meant to replace a dictionary. The glossary offers the consensus of a large segment of the osteopathic profession and serves to standardize
terminology. The ECOP Glossary Review Committee specifically seeks to include those definitions that are uniquely osteopathic in their origin or
common usage, distinctive in the osteopathic usage of a common word, and/or important in describing OPP/OMT. In the glossary, the term
“osteopathic practitioner” refers to an osteopath, an osteopathic physician or an allopathic physician who has been trained in osteopathic principles,
practices and philosophy. “Methods” are described as being direct, indirect or combined. “Osteopathic manipulative treatment systems” are complete
systems of diagnosis and treatment such as high velocity low amplitude (HVLA), muscle energy and osteopathy in the cranial field. “Techniques”
are those methods used within a treatment system such as lumbar rolls, rib-raising, etc.
This glossary should be useful to the student of osteopathic medicine and helpful to authors and other professionals in understanding and making
proper use of osteopathic vocabulary.
The five models used in discussion of osteopathic patient care are the respiratory-circulatory model, the biomechanical-structural, metabolic-
nutritional, neurological and behavioral-biopsychosocial. For a more complete description of the models and their application to patient care, please
refer to the Educational Council on Osteopathic Principles Core Curriculum, copyright 1987, second edition copyright 2000. Electronic copies are
available from the American Association of Colleges of Osteopathic Medicine.
Definitions are included from:

Dorland’s Medical Dictionary, 29th edition, 2000 Stedman’s Medical Dictionary, 27th edition, 2000
The William & Wilkins Company, Baltimore, MD W.B. Saunders Company, Philadelphia, PA
Foundations for Osteopathic Medicine, 2nd edition, 2003 Rehabilitation Medicine, Principles and Practices, 1st edition, 1988
Ward, Robert, ed. DeLisa, Joel A., ed.
Lippincott Williams & Wilkins, Philadelphia, PA J.B. Lippincott, Philadelphia, PA
Glossary of Osteopathic Terminology

Prepared by the Educational Council on Osteopathic Principles (ECOP) of the American Association of Colleges of Osteopathic Medicine
(AACOM).
Revised July 2006.
©2006 The Educational Council on Osteopathic Principles and the American Association of Colleges of Osteopathic Medicine
A I: indirect treatment OMT: osteopathic manipulative

IND: indirect treatment treatment
abbreviations: types of osteopathic PINS: progressive inhibition of
manipulative treatment. INR: integrated neuromusculoskeletal
release treatment neuromuscular structures
ART: articulatory treatment ST: soft tissue treatment
LAS: ligamentous articular strain
BLT: balanced ligamentous tension treatment VIS: visceral manipulative treatment
treatment ME: muscle energy treatment
CR: osteopathy in the cranial field accessory joint motions: See secondary
MFR: myofascial release treatment joint motion.
CS: counterstrain treatment
NMM-OMM: neuromusculoskeletal accessory movements: Movements used
D: direct treatment medicine to potentiate, accentuate, or
DIR: direct treatment OCF: osteopathy in the cranial compensate for an impairment in a
field/cranial treatment physiologic motion (e.g., the
FPR: facilitated positional release
OMTh: osteopathic manipulative movements needed to move a
treatment
therapy (non-US terminology) paralyzed limb).
HVLA: high velocity/low amplitude
treatment
1
Figure 2. Lumbosacral angle Figure 3. Lumbosacral
Figure 1. Lumbolumbar angle
(S1-horizon) (Ferguson’s angle). lordotic angle.
(L2-L5).
accommodation: A self-reversing and rotation, the left side is the anterior

nonpersistent adaptation. component; usually refers to the less
active motion: See motion, active. prominent transverse process; See also
posterior component.
acute somatic dysfunction: See somatic
dysfunction, acute. anterior compression test: See ASIS
(anterior superior iliac spine)
allopathy: 1. A therapeutic system in compression test.
which a disease is treated by producing
a second condition that is incompatible anterior iliac rotation: See ilium, somatic
with or antagonistic to the first. dysfunction of, anterior (forward)
(Stedman’s) innominate (iliac) rotation.
allopath: A term used to refer those anterior nutation, See nutation.

holding a Doctor of Medicine (MD) anterior rib: See rib somatic dysfunction,
degree, a non-osteopathic medical inhalation rib dysfunction.
degree. ART: See TART.
anatomical barrier: See barrier, (motion articular pillar: 1. Refers to the columnar Figure 4. ASIS compression test
barrier). arrangement of the articular portions of
angle: the cervical vertebrae. 2. Those parts of
the lateral arches of the cervical axis of rib motion: See rib motion, axis.
Ferguson a., See angle, lumbosacral.
vertebrae that contain a superior and ASIS (anterior superior iliac spine)
lumbolumbar lordotic a., an objective inferior articular facet. compression test: 1. A test for
quantification of lumbar lordosis lateralization of somatic dysfunction of
typically determined by measuring the articulation: 1. The place of union or
junction between two or more bones of the sacrum, innominate or pubic
angle between the superior surface of symphysis. 2. Application of a force
the second lumbar vertebra and the the skeleton. 2. The active or passive
process of moving a joint through its through the ASIS into one of the pelvic
inferior surface of the fifth lumbar axes to assess the mechanics of the
vertebra; best measured from a permitted anatomic range of motion.
See also osteopathic manipulative pelvis. See also sacral motion, axis of
standing lateral x-ray film. (Fig. 1) (Fig. 4).
treatment, articulatory treatment (ART)
lumbosacral a., represents the angle of system. axis of sacral motion: See sacral motion,
the lumbosacral junction as measured axis of.
by the inclination of the superior articulatory pop: The sound made when
surface of the first sacral vertebra to cavitation occurs in a joint. See also axoplasmic flow: See axoplasmic
the horizontal (this is actually a sacral cavitation. transport.
angle); usually measured from standing articulatory technique: See also axoplasmic transport: The antegrade
lateral x-ray films; also known as technique. See osteopathic movement of substances from the
Ferguson’s angle. (Fig. 2) manipulative treatment, articulatory nerve cell along the axon toward the
lumbosacral lordotic a., an objective treatment (ART) system. terminals, and the retrograde
quantification of lumbar lordosis asymmetry: Absence of symmetry of movement from the terminals toward
typically determined by measuring the position or motion; dissimilarity in the nerve cell.
angle between the superior surface of corresponding parts or organs on
the second lumbar vertebra and the opposite sides of the body that are B
superior surface of the first sacral normally alike; of particular use when
segment; best measured from a describing position or motion alteration backward bending: Opposite of forward
standing lateral x-ray film. (Fig. 3) resulting from somatic dysfunction. bending. See extension.
anterior component: A positional axis: 1. An imaginary line about which backward bending test: 1. This test
descriptor used to identify the side of motion occurs. 2. The second cervical discriminates between forward and
reference when rotation of a vertebra vertebra. 3. One component of an axis backward sacral torsion/rotation. 2.
has occurred; in a condition of right system. This test discriminates between
2
unilateral sacral flexion and unilateral an audible “pop” in certain forms of
sacral extension. OMT.
backward torsion: See sacrum, somatic cephalad: Toward the head.
dysfunctions of, backward torsions. cephalad pubic dysfunction: See pubic
balanced ligamentous tension bone, somatic dysfunctions of, superior
technique: See osteopathic pubic shear.
manipulative treatment, balanced cerebrospinal fluid, fluctuation of: A
ligamentous tension. See also description of the hypothesized action
osteopathic manipulative treatment, of cerebrospinal fluid with regard to
ligamentous articular strain. the craniosacral mechanism.
barrier (motion barrier): The limit to cervicolumbar reflex: See reflex,
motion; in defining barriers, the cervicolumbar r.
palpatory end-feel characteristics are
useful. (Fig. 5) Chapman reflex: 1. A system of reflex
points that present as predictable
anatomic b., the limit of motion anterior and posterior fascial tissue
imposed by anatomic structure; the texture abnormalities (plaque-like
limit of passive motion. changes or stringiness of the involved
elastic b., the range between the tissues) assumed to be reflections of
physiologic and anatomic barrier of visceral dysfunction or pathology. 2.
motion in which passive ligamentous Originally used by Frank Chapman,
stretching occurs before tissue DO, and described by Charles Owens,
disruption. DO.
pathologic b., a restriction of joint chronic somatic dysfunction: See
motion associated with pathologic somatic dysfunction, chronic.
change of tissues (example: circumduction: 1. The circular movement
osteophytes). See also barrier, of a limb. 2. The rotary movement by
restrictive b. which a structure is made to describe a
physiologic b., the limit of active cone, the apex of the cone being a
motion. fixed point (e.g., the circular movement
restrictive b., a functional limit that of the shoulder).
abnormally diminishes the normal combined technique: See osteopathic
physiologic range. manipulative treatment, combined
batwing deformity: See transitional method.
vertebrae, sacralization. common compensatory pattern: See
bind: Palpable resistance to motion of an fascial patterns, common
articulation or tissue. Synonym: compensatory pattern.
resistance. Antonyms: ease, compensatory fascial patterns: See
compliance, resilience. fascial patterns, common
biomechanics: Mechanical principles compensatory pattern.
applied to the study of biological complete motor asymmetry: Asymmetry
functions; the application of of palpatory responses to all regional
mechanical laws to living structures; motion inputs including rotation,
the study and knowledge of biological translation and active respiration.
function from an application of compliance: 1. The ease with which a
mechanical principles. tissue may be deformed. 2. Direction of
body unity: One of the basic tenets of the ease in motion testing.
osteopathic philosophy; the human Figure 5. Somatic dysfunction in
a single plane: three methods compression: 1. Somatic dysfunction in
being is a dynamic unit of function; which two structures are forced
illustrating the “restrictive barrier”
See also osteopathic philosophy. (the restrainer): AB, anatomic together. 2. A force that approximates
bogginess: A tissue texture abnormality barrier; PB, physiologic barrier; RB, two structures.
characterized principally by a palpable restrictive barrier; SD, somatic
dysfunction (From Foundations for conditioned reflex: See reflex,
sense of sponginess in the tissue, conditioned r.
Osteopathic Medicine, Baltimore,
interpreted as resulting from William & Wilkins, 1997:484.
congestion due to increased fluid contraction: Shortening and/or
content. development of tension in muscle.
bucket handle rib motion: See rib caught in inhalation: See inhalation rib concentric c., contraction of muscle
motion, bucket handle. dysfunction. resulting in approximation of
caught in exhalation: See exhalation rib attachments.
C dysfunction. eccentric c., lengthening of muscle
cavitation: The formation of small vapor during contraction due to an external
caliper rib motion: See rib motion, and gas bubbles within fluid caused by force.
caliper rib motion. local reduction in pressure. This isokinetic c., 1. A concentric
caudad: Toward the tail or inferiorly. phenomenon is believed to produce contraction against resistance in which
the angular change of joint motion is at
3
the same rate. 2. The counterforce is
less than the patient force.
isolytic c., 1. A form of eccentric
contraction designed to break
adhesions using an operator-induced
force to lengthen the muscle. 2. The
counterforce is greater than the patient
force.
isometric c., 1. Change in the tension
of a muscle without approximation of
muscle origin and insertion. 2.
Operator force equal to patient force.
isotonic c., 1. A form of concentric
contraction in which a constant force is
applied. 2. Operator force less than
patient force.
contracted muscle: The physiologic
response to a neuromuscular excitation.
See also contractured muscle.
contracture: A condition of fixed high
resistance to passive stretch of a
muscle, resulting from fibrosis of the
tissues supporting the muscles or the
joints, or from disorders of the muscle
fibers.
Dupuytren c., shortening, thickening
and fibrosis of the palmar fascia,
producing a flexion deformity of a
finger (Dorland’s).
contractured muscle: histological change
substituting non-contractile tissue for
muscle tissue, which prevents the Figure 7. Dermatomal
Figure 6. Dermatomal map map (posterior).
muscle from reaching normal relaxed
(anterior). (Modified from Agur (Modified from Agur AMR,
length. See also contracted muscle. AMR, Grant’s Atlas of Anatomy, 9th Grant’s Atlas of Anatomy, 9th
core link: The connection of the spinal ed. Baltimore Md: Williams & ed. Baltimore Md: Williams
dura mater from the occiput at the Wilkins; 1991:37). & Wilkins; 1991:37).
foramen magnum to the sacrum. It
coordinates the synchronous motion of between the occiput and the sacrum by reversible, resulting when homeostatic
these two structures. the spinal dura mater. 2. A term mechanisms are partially or totally
coined by William G. Sutherland, DO. overwhelmed
coronal plane: See plane, frontal.
See also extension, craniosacral depressed rib: See rib somatic
costal dysfunction: See rib, dysfunction. extension and flexion, craniosacral dysfunction, exhalation rib dysfunction.
counternutation: Posterior movement of flexion.
dermatome: 1. The area of skin supplied
the sacral base around a transverse axis C-SPOMM: Certification Special by cutaneous branches from a single
in relation to the ilia. See also nutation. Proficiency in Osteopathic spinal nerve. (Neighboring dermatomes
counterstrain technique: See osteopathic Manipulative Medicine. Granted by the may overlap.) 2. Cutis plate; the
manipulative treatment, counterstrain. American Osteopathic Association dorsolateral part of an embryonic
through the American Osteopathic somite. (Fig. 6 and Fig. 7)
cranial manipulation: See osteopathic
Board of Special Proficiency in
manipulative treatment, cranial diagnostic palpation: See palpatory
Osteopathic Manipulative Medicine
manipulation. diagnosis.
from 1989 through 1999. See also
cranial rhythmic impulse (CRI): 1. A NMM-OMM. diagonal axis: See sacral, oblique axis,
palpable, rhythmic fluctuation believed diagonal.
creep: The capacity of fascia and other
to be synchronous with the primary
tissue to lengthen when subjected to a direct method (technique): See
respiratory mechanism. 2. Term coined
constant tension load resulting in less osteopathic manipulative treatment,
by John Woods, DO, and Rachel
resistance to a second load application. direct treatment.
Woods, DO.
CV-4: See osteopathic manipulative DO: 1. Doctor of Osteopathy (accredited
cranial technique: See osteopathic
treatment, CV-4. by the American Osteopathic
manipulative treatment, osteopathy in
Association). 2. Doctor of Osteopathic
the cranial field. See also primary
D Medicine (accredited by the American
respiratory mechanism.
Osteopathic Association). 3. Diplomate
craniosacral manipulation: See Dalrymple treatment: See osteopathic in Osteopathy (The first degree granted
osteopathic manipulative treatment, manipulative treatment, pedal pump. by American School of Osteopathy). 4.
osteopathy in the cranial field. Diplomate of Osteopathy, a degree
decompensation: A dysfunctional, granted by some schools of osteopathy
craniosacral mechanism: 1. A term used persistent pattern, in some cases
to refer to the anatomical connection outside the United States.
4
drag: See skin drag. exhalation rib dysfunction: See rib
somatic dysfunction, exhalation rib
dysfunction.
E
exhalation rib restriction: See rib
ease: Relative palpable freedom of motion motion, exhalation rib restriction. See
of an articulation or tissue. Synonyms: also rib somatic dysfunction, inhalation
compliance, resilience. Antonyms: rib dysfunction.
bind, resistance. exhalation strain: See rib somatic
easy normal: See neutral, definition dysfunction, exhalation rib dysfunction.
number 2. extension: 1. Accepted universal term for
-ed: A suffix describing status, position, or backward motion of the spine in a
condition (e.g., extended, flexed, sagittal plane about a transverse axis;
rotated, restricted). in a vertebral unit when the superior
part moves backward. 2. In extremities,
effleurage: Stroking movement used to it is the straightening of a curve or
move fluids. angle (biomechanics). 3. Separation of
elastic deformation: Any recoverable the ends of a curve in a spinal region;
deformation. See also plastic See extension, regional extension.
Figure 9. Regional extension.
deformation. craniosacral extension, motion
elasticity: Ability of a strained body or occurring during the cranial rhythmic
tissue to recover its original shape after impulse when the sphenobasilar
deformation. See also plasticity and symphysis descends and sacral base
viscosity. moves anteriorly. (Fig. 8)
elevated rib: See rib somatic dysfunction,
inhalation rib dysfunction. See also rib
motion, exhalation rib restriction.
end feel: Perceived quality of motion as
an anatomic or physiologic restrictive
barrier is approached.
enthesitis: 1. Traumatic disease occurring
at the insertion of muscles where
recurring concentration of muscle
stress provokes inflammation with a
strong tendency toward fibrosis and
calcification (Stedman’s). 2. In-
flammation of the muscular or
tendinous attachment to bone
(Dorland’s).
ERS: A descriptor of spinal somatic Figure 10. Sacral extension.
dysfunction used to denote a
combination extended (E), rotated (R),
and sidebent (S) vertebral position. Figure 8. Craniosacral their commitment to osteopathic principles
extension. and practice through teaching, writing,
ERS left, somatic dysfunction in which
the vertebral unit is extended, rotated and professional service, performed at
regional extension, historically, the the highest level of professional and
and sidebent left; usually preceded by a
straightening in the sagittal plane of a ethical standards.
designation of the vertebral unit(s)
spinal region; also called Fryette’s
involved (e.g., T5 ERS left or T5 facet asymmetry: Configuration in which
regional extension. (Fig. 9)
ERLSL). the structure, position and/or motion of
sacral extension, posterior movement the facets are not equal bilaterally. See
ERS right, somatic dysfunction in
of the base of the sacrum in relation to also facet symmetry and tropism, facet.
which the vertebral unit is extended,
the ilia. (Fig. 10) See also flexion,
rotated and sidebent right; usually facet symmetry: Configuration in which
sacral flexion.
preceded by a designation of the the structure, position and/or motion of
vertebral unit(s) involved (e.g., C3-5 extrinsic corrective forces: Treatment the facets are equal bilaterally. See also
ERS right or C3-5 ERRSR). forces external to the patient that may facet asymmetry and symmetry.
include operator effort, effect of
exaggeration method: See osteopathic facilitated positional release: See
gravity, mechanical tables, etc. See
manipulative treatment, exaggeration osteopathic manipulative treatment,
also intrinsic corrective forces.
method. facilitated positional release.
exaggeration technique: See osteopathic F facilitated segment: See spinal
manipulative treatment, exaggeration facilitation.
technique. FAAO: 1. Fellow of American Academy facilitation: See spinal facilitation.
exhaled rib: (Archaic) using positional of Osteopathy. 2. This fellowship is an fascial patterns: 1. Systems for
(static) diagnosis. See rib somatic earned post-doctoral degree conferred classifying and recording the preferred
dysfunction, exhalation rib dysfunction. by the American Academy of directions of fascial motion throughout
Osteopathy. Those who earn the the body. 2. Based on the observations
FAAO degree must have demonstrated
5
of J. Gordon Zink, DO, and W. flexion: 1. Accepted universal term for
Neidner, DO. forward motion of the spine, in its
common compensatory pattern
(CCP), the specific finding of
alternating fascial motion preference at
transitional regions of the body
described by Zink and Neidner. (Fig.
11)
Figure 15. Sacral flexion.

Figure 13. Craniosacral
flexion.
flexion left: See sidebending.
f lexion right: See sidebending.
Figure 11. Common compen- flexion tests: Tests for iliosacral or
satory fascial pattern (Zink) sacroiliac somatic dysfunction.
seated flexion test, a screening test
that determines the side of sacroiliac
uncommon compensatory pattern, somatic dysfunction (motion of the
the finding of alternating fascial sacrum on the ilium).
motion preference in the direction
opposite that of the common standing flexion test, a screening test
compensatory pattern described by that determines the side of iliosacral
Zink and Neidner. (Fig. 12) somatic dysfunction (motion of ilium
on the sacrum).
forward bending. Reciprocal of
backward bending. See flexion.
forward torsions: See sacrum, somatic
dysfunctions of, forward torsions.
FRS: A descriptor of spinal somatic
dysfunction used to denote a
Figure 14. Regional flexion. combination flexed (F), rotated (R),
and sidebent (S) vertebral position.
sagittal plane about a transverse axis,
where the superior part moves forward. FRS left, somatic dysfunction in which
2. In the extremities, it is the the vertebral unit is flexed, rotated and
approximation of a curve or angle sidebent left; usually preceded by a
(biomechanics). 3. Approximation of designation of the vertebral unit(s)
the ends of a curve in a spinal region; involved (e.g., T5 FRS left or T5
also called Fryette’s regional flexion. FRLSL).
Figure 12. Uncommon compen- See flexion, regional flexion. FRS right, somatic dysfunction in
satory fascial pattern (Zink). which the vertebral unit is flexed,
craniosacral flexion, motion occurring
during the cranial rhythmic impulse, rotated and sidebent right; usually
uncompensated fascial pattern, the preceded by a designation of the
finding of fascial preferences that do when the sphenobasilar
symphysis ascends and the sacral base vertebral unit(s) involved (e.g., C3-5
not demonstrate alternating patterns of FRS right or C3-5 FRRSR).
findings at transitional regions. moves posteriorly. (Fig. 13)
Because they occur following stress or regional flexion, historically, is the frontal plane: See plane, frontal.
trauma, they tend to be symptomatic. approximation of the ends of a curve in Fryette laws: See laws, Fryette’s. See
fascial release technique: See osteopathic the sagittal plane of the spine; also physiologic motion of the spine.
manipulative treatment, myofascial called Fryette’s regional flexion. (See Fryette principles: See physiologic
release. flexion (Fig. 14). motion of the spine.
fascial unwinding: See osteopathic sacral flexion, anterior movement of Fryette regional extension: See
manipulative treatment, fascial sacral base in relation to the ilia. (Fig. extension, regional extension.
unwinding. 15) See also extension, sacral
extension. Fryette regional flexion: See flexion,
Ferguson angle: See angle, lumbosacral. regional flexion.
6
FSR: A descriptor of spinal somatic guiding: Gentle movement by the ilium: the expansive superior portion of
dysfunction used to denote a operator following the path of least the innominate (hip bone or os coxae).
combination flexed (F), sidebent (S), resistance in the movement of a body indirect method: See osteopathic
and rotated (R) vertebral position. See part within its normal range. manipulative treatment, indirect
FRS. method.
H
functional method: See osteopathic inferior ilium: See innominate, somatic
manipulative treatment, functional dysfunctions of, inferior innominate
habituation: Decreased physiologic
method. shear.
response to repeated stimulation.
functional technique: See osteopathic inferior lateral angle (ILA) of the
hatchet head: See scaphocephaly.
manipulative treatment, functional sacrum: See sacrum, inferior lateral
method. health: Adaptive and optimal attainment angle.
of physical, mental, emotional,
inferior pubis: See pubic bone, somatic
G spiritual and environmental well-being.
dysfunctions of, inferior pubic shear.
hepatic pump: See osteopathic
inferior transverse axis: See sacral
gait: a forward translation of manipulative treatment, hepatic pump.
motion axis, inferior transverse axis.
the body's center of gravity by bipedal high velocity/low amplitude technique
locomotion. (DeLisa) inhalation rib: See rib somatic
(HVLA): See osteopathic
dysfunction, inhalation rib dysfunction.
Galbreath treatment: See osteopathic manipulative treatment, high
manipulative treatment, mandibular velocity/low amplitude technique inhalation rib restriction: See rib
drainage. (HVLA). somatic dysfunction, inhalation rib
dysfunction.
gravitational line: Viewing the patient hip bone: See innominate. See also
from the side, an imaginary line in a innominate, somatic dysfunctions of. inhalation strain: See rib somatic
coronal plane which, in the theoretical dysfunction, inhalation rib dysfunction.
homeostasis: 1. Maintenance of static or
ideal posture, starts slightly anterior to constant conditions in the internal inhibition reflex: 1. In osteopathic usage,
the lateral malleolus, passes across the environment. 2. The level of well- a term that describes the application of
lateral condyle of the knee, the greater being of an individual maintained by steady pressure to soft tissues to effect
trochanter, through the lateral head of internal physiologic harmony that is relaxation and normalize reflex
the humerus at the tip of the shoulder the result of a relatively stable state or activity. 2. Effect on antagonist
to the external auditory meatus; if this equilibrium among the interdependent muscles due to reciprocal inhibition
were a plane through the body, it body functions. when the agonist is stimulated. See
would intersect the middle of the third also law, Sherrington’s. See also
lumbar vertebra and the anterior one homeostatic mechanism: A system of
osteopathic manipulative treatment,
third of the sacrum. It is used to control activated by negative feedback
inhibitory pressure technique.
evaluate the A-P (anterior-posterior) (Dorland’s).
curves of the spine. See also mid- inhibitory pressure technique: See
Hoover technique: See osteopathic
malleolar line. (Fig. 16) osteopathic manipulative treatment,
manipulative treatment, Hoover
inhibitory pressure technique.
technique.
innominate: The os coxae is a large
hysteresis: During the loading and
irregular shaped bone that consists of
unloading of connective tissue, the
three parts: ilium, ischium and pubis,
restoration of the final length of the
which meet at the acetabulum, the cup
tissue occurs at a rate and to an extent
shaped cavity for the head of the femur
less than during deformation (loading).
at the hip (femoroacetabular) joint.
These differences represent energy loss
Also called the innominate bone or
in the connective tissue system. This
pelvic bone. See also hip bone.
difference in viscoelastic behavior (and
energy loss) is known as hysteresis (or innominate rotation: Rotational motion
“stress-strain”). (Foundations, Second of one innominate bone relative to the
Edition, page 1158). sacrum on the inferior transverse axis.
hypertonicity: 1. A condition of excessive innominate, somatic dysfunctions of:
tone of the skeletal muscles. 2. anterior innominate rotation, a
Increased resistance of muscle to somatic dysfunction in which the
passive stretching. anterior superior iliac spine (ASIS) is
anterior and inferior to the contralateral
I landmark. The innominate (os coxae)
moves more freely in an anterior and
ILA: See sacrum, inferior lateral angle of. inferior direction, and is restricted from
ilia: The plural of ilium. See ilium. movement in a posterior and superior
direction. (Fig. 17)
ilial compression test: See ASIS
compression test. downslipped innominate, See inferior
innominate shear.
ilial rocking test: See ASIS compression
test. inferior innominate shear, a somatic
dysfunction in which the anterior
iliosacral motion: Motion of one superior iliac spine (ASIS) and
innominate (ilium) with respect to the posterior superior iliac spines (PSIS)
sacrum. Iliosacral motion is part of are inferior to the contralateral
Figure 16. Gravitational pelvic motion during the gait cycle. landmarks. The innominate (os coxa)
7
Figure 19. Inflared right innominate. Figure 21. Right posterior innominate.
Figure 17. Anterior right innominate. Forced posterior rotation may or may
Forced anterior rotation can also result not result in a superior pubic shear.
in an inferior pubic shear.
Figure 20. Outflare right innominate.
Figure 18. Right inferior innominate Figure 22. Right superior innominate
shear. This also may or may not result innominate (os coxae) moves more shear. This also may or may not
in an inferior pubic shear. freely in a posterior and superior result in a superior pubic shear.
direction, and is restricted from
moves more freely in an inferior movement in an anterior and inferior
direction, and is restricted from direction. (Fig. 21) intrinsic corrective forces: Voluntary or
movement in a superior direction. (Fig. superior innominate shear, a somatic involuntary forces from within the
18) dysfunction in which the anterior patient that assist in the manipulative
inflared innominate, a somatic superior iliac spine (ASIS) and treatment process. See also extrinsic
dysfunction of the innominate (os posterior superior iliac spines (PSIS) corrective forces.
coxae) resulting in medial positioning are superior to the contralateral -ion: A suffix describing a process or
of the anterior superior iliac spine landmarks. The innominate (os coxa) movement (e.g., extension, flexion,
(ASIS). The innominate moves more moves more freely in a superior rotation, restriction).
freely in a medial direction, and is direction, and is restricted from isokinetic exercise: Exercise using a
restricted from movement in a lateral movement in an inferior direction. constant speed of movement of the
direction. (Fig. 19) (Fig. 22) body part.
outflared innominate, a somatic upslipped innominate, See superior isolytic contraction: See contraction,
dysfunction of the innominate (os innominate shear. isolytic c.
coxae) resulting in lateral positioning integrated neuromusculoskeletal
of the anterior superior iliac spine isometric contraction: See contraction,
release: See osteopathic manipulative isometric c.
(ASIS). The innominate moves more treatment, integrated neuromusculo-
freely in a lateral direction, and is skeletal release. isotonic contraction: See contraction,
restricted from movement in a medial isotonic c.
direction. (Fig. 20) intersegmental motion: Designates
J
relative motion taking place between
posterior innominate rotation, a two adjacent vertebral segments or
somatic dysfunction in which the within a vertebral unit that is described Jones technique: See osteopathic
anterior superior iliac spine (ASIS) is as the upper vertebral segment moving manipulative treatment, counterstrain.
posterior and superior to the on the lower.
contralateral landmarks. The
8
junctional region: See transitional and inferior thoracic biomechanics. For normal curvature (normal lordosis).
region. example, if C1 is in a right posterior (Dorland’s). 2. Hollow back or saddle
positional lesion, L5 also moves into a back; an abnormal extension
K right posterior position. In this case, L5 deformity; anteroposterior curvature of
is the " Lovett partner" of C1. The the spine, generally lumbar with the
key lesion: The somatic dysfunction that treatment of L5 helps to stabilize C1 convexity looking anteriorly
maintains a total dysfunction pattern and the skull by changing the lines of (Stedman’s).
including other secondary gravity. (French usage). lordotic: Pertaining to or characterized by
dysfunctions. Sherrington l., 1. Every posterior lordosis.
kinesthesia: The sense by which muscular spinal nerve root supplies a specific lumbarization: See transitional
motion, weight, position, etc., are region of the skin, although fibers from vertebrae, lumbarization.
perceived. adjacent spinal segments may invade
such a region. 2. When a muscle lumbolumbar lordotic angle: See angle,
kinesthetic: Pertaining to kinesthesia. lumbolumbar lordotic.
receives a nerve impulse to contract, its
kinetics: The body of knowledge that antagonist receives, simultaneously, an lumbosacral angle: See angle,
deals with the effects of forces that impulse to relax. (These are only two lumbosacral.
produce or modify body motion. of Sherrington’s contributions to
lumbosacral lordotic angle: See angle,
klapping: Striking the skin with cupped neurophysiology; these are the ones
lumbosacral lordotic.
palms to produce vibrations with the most relevant to osteopathic
intention of loosening material in the principles.) lumbosacral spring test: See spring test.
lumen of hollow tubes or sacs within lymphatic pumps: See osteopathic
Wolff l., every change in form and
the body, particularly the lungs. manipulative treatment, lymphatic
function of a bone, or in its function
kneading: A soft tissue technique that pump. See also osteopathic
alone, is followed by certain definite
utilizes an intermittent force applied manipulative treatment, pedal pump.
changes in its internal architecture, and
perpendicular to the long axis of the See also osteopathic manipulative
secondary alterations in its external
muscle. treatment, thoracic pump.
conformations (Stedman’s, 25th ed.);
kyphoscoliosis: A spinal curve pattern (e.g., bone is laid down along lines of lymphatic treatment: Techniques used to
combining kyphosis and scoliosis. See stress). optimize function of the lymphatic
also kyphosis. See also scoliosis. system. See osteopathic manipulative
lesioned components: See osteopathic
treatment, lymphatic pump. See also
kyphosis: 1. The exaggerated (pathologic) lesion. See somatic dysfunction.
A-P curve of the thoracic spine with lesion (osteopathic): See osteopathic pedal pump. See also osteopathic
concavity anteriorly. 2. Abnormally lesion. manipulative treatment, thoracic pump.
increased convexity in the curvature of
ligamentous:
the thoracic spine as viewed from the
l. articular strain, any somatic M
side (Dorland’s).
dysfunction resulting in abnormal
kyphotic: Pertaining to or characterized mandibular drainage technique: See
ligamentous tension or strain. See also
by kyphosis. osteopathic manipulative treatment,
ligamentous articular strain technique. mandibular drainage technique.
L manipulation: Therapeutic application of
l. articular strain technique, See
osteopathic manipulative treatment, manual force. See also technique. See
lateral flexed vertebral body: See ligamentous articular strain technique. also osteopathic manipulative
sidebent. treatment.
l. strain, motion and/or positional
lateral flexion: Also called lateroflexion. asymmetry associated with elastic manual medicine: The skillful use of the
See sidebending. deformation of connective tissue hands to diagnose and treat structural
(fascia, ligament, membrane). See and functional abnormalities in various
lateral masses (of the atlas): The most
strain and ligamentous articular strain. tissues and organs throughout the body,
bulky and solid parts of the atlas that
including bones, joints, muscles and
support the weight of the head. line of gravity: See gravitational line. other soft tissues as an integral part of
lateroflexion: See sidebending. linkage: See somatic dysfunction, linkage. complete medical care. 1. This term
law: originated from the German Manuelle
liver pump: See osteopathic manipulative
Medizin (manual medicine) and has
Fryette l. of motion, See physiologic treatment, hepatic pump.
been used interchangeably with the
motion of the spine. localization: 1. In manipulative technique, term manipulation. 2. This term is not
Head l., when a painful stimulus is the precise positioning of the patient identical to manual therapy, which has
applied to a body part of low and vector application of forces been used by non-physician
sensitivity (e.g., viscus) that is in close required to produce a desired result. 2. practitioners (e.g. physical therapists).
central connection with a point of The reference of a sensation to a
massage: Therapeutic friction, stroking,
higher sensitivity (e.g., soma), the pain particular locality in the body.
and kneading of the body. See also
is felt at the point of higher sensitivity longitudinal axis: See sacral, sacral osteopathic manipulative treatment,
rather than at the point where the motion axis, longitudinal axis. soft tissue treatment.
stimulus was applied.
lordosis: 1. The anterior convexity in the mechanoreceptor: A receptor excited by
Lovett l., States that there is an curvature of the lumbar and cervical mechanical pressures or distortions,
association between the superior spine as viewed from the side. The such as those responding to touch and
and inferior vertebrae, which are paired term is used to refer to abnormally muscular contractions. (Dorland’s).
two by two. The cervical and superior increased curvature (hollow back,
thoracic biomechanics act in a saddle back, sway back) and to the
synchronous manner with the lumbar
9
membranous articular strain: Any adjustment and the mobilization of inherent m., spontaneous motion of
cranial somatic dysfunction resulting in joints. This model also seeks to address every cell, organ, system and their
abnormal dural membrane tensions. problems in the myofascial connective component units within the body.
membranous balance: The ideal tissues, as well as in the bony and soft m. barrier, See barrier (motion
physiologic state of harmonious tissues to remove restrictive forces and barrier).
equilibrium in the tension of the dura enhance motion. This is accomplished
by the use of a wide range of passive m., motion induced by the
mater of the brain and spinal cord. osteopathic practitioner while the
osteopathic manipulative techniques
mesenteric lift: See osteopathic such as high velocity-low amplitude, patient remains passive or relaxed.
manipulative treatment, mesenteric muscle energy, counterstrain, physiologic m., changes in position of
release technique. myofascial release, ligamentous body structures within the normal
mesenteric release technique: See articular techniques and functional range. See also physiologic motion of
osteopathic manipulative treatment, techniques. the spine.
mesenteric release technique. respiratory-circulatory model, the translatory m., motion of a body part
middle transverse axis: See sacral goal of the respiratory-circulatory along an axis. See also translation.
motion axis, middle transverse axis model is to improve all of the
muscle energy technique: See
(postural). diaphragm restrictions in the body.
Diaphragms are considered to be
mid-heel line: A vertical line used as a muscle energy.
“transverse restrictors” of motion,
reference in standing anteroposterior myofascial release technique: See
venous and lymphatic drainage and
(A-P) x-rays and postural evaluation, osteopathic manipulative treatment,
cerebrospinal fluid. The techniques
passing equidistant between the heels. myofascial release.
used in this model are osteopathy in the
mid-gravitational line: See gravitational cranial field, ligamentous articular myofascial technique: See osteopathic
line. strain, myofascial release and manipulative treatment, myofascial
mid-malleolar line: A vertical line lymphatic pump techniques. technique.
passing through the lateral malleolus, metabolic model, the goal of the myofascial trigger point: See trigger
used as a point of reference in standing metabolic model is to enhance the self- point.
lateral x-rays and postural evaluation. regulatory and self-healing
See also gravitational line. mechanisms, to foster energy myogenic tonus: 1. Tonic contraction of
conservation by balancing the body’s muscle dependent on some property of
mirror-image motion asymmetries: the muscle itself or of its intrinsic
A grouping of primary and secondary energy expenditure and exchange, and
to enhance immune system function, nerve cells. 2. Contraction of a muscle
sites of somatic dysfunction describing caused by intrinsic properties of the
a three-segment complex fundamental endocrine function and organ function.
The osteopathic considerations in this muscle or by its intrinsic innervation
to dysfunction in a mobile system. (Stedman’s).
Each adjacent segment, above and area are not manipulative in nature
below the primary locus, demonstrates except for the use of lymphatic pump myotome: 1. All muscles derived from
opposing asymmetries to that locus. techniques. Nutritional counseling, diet one somite and innervated by one
For example, if the primary locus and exercise advice are the most segmental spinal nerve. 2. That part of
resists rotation right, the segments common approaches to balancing the the somite that develops into skeletal
above and below resist rotation left. body through this model. muscle (Stedman’s).
mobile point: In counterstrain, the final neurologic model, the goal of the
position of treatment at which neurologic model is to attain N
tenderness is no longer elicited by autonomic balance and address neural
palpation of the tender point. reflex activity, remove facilitated neurotrophicity: See neurotrophy.
segments, decrease afferent nerve neurotrophy: The nutrition and
mobile segment: A term in functional signals and relieve pain. The
methods to describe a bony structure maintenance of tissues as regulated by
osteopathic manipulative techniques direct innervation.
with its articular surfaces and adnexal used to influence this area of patient
tissues (neuromuscular and connective) health include counterstrain and neutral: 1. The range of sagittal plane
for segmental motion which affects Chapman reflex points. spinal positioning in which the first
movement, stabilizes position and principle of physiologic motion of the
allows coordinated participation in behavioral model, the goal of this spine applies. See also physiologic
passive movement. model is to improve the biological, motion of the spine. 2. The point of
psychological and social components balance of an articular surface from
mobile system: An osteopathic construct of the health spectrum. This includes
associated with functional methods in which all the motions physiologic to
emotional balancing and compensatory that articulation may take place. (Fig.
which the body as a whole is viewed as mechanisms. Reproductive processes
a centrally integrated system in which 23)
and behavioral adaption are also
all of the individual elements (e.g. included under this model. NMM-OMM: Osteopathic neuromusculo-
mobile segments) have coordinated and skeletal medicine certification is
specific motion characteristics. See motion: 1. A change of position (rotation, granted by the American Osteopathic
also functional methods. and/or translation) with respect to a Association through the American
fixed system; 2. An act or process of a Osteopathic Board of Neuromusculo-
mobile unit: See mobile segment. body changing position in terms of skeletal Medicine. First granted in
models of osteopathic care: Five models direction, course and velocity. 1999.
that articulate how an osteopathic active m., movement produced
practitioner seeks to influence a non-neutral: The range of sagittal plane
voluntarily by the patient. spinal positioning in which the second
patient’s physiological processes.
principle of physiologic motion of the
structural model, the goal of the
structural model is biomechanical
10
standards for osteopaths practicing completed the movements change to
within their countries (International direct forces. 2. A manipulative
usage). 2. Considered by the American sequence involving two or more
Osteopathic Association to be an different osteopathic manipulative
archaic term when applied to graduates treatment systems (e.g., Spencer
of U.S. schools. technique combined with muscle
osteopathic lesion (osteopathic lesion energy technique). 3. A concept
complex): Archaic term used to described by Paul Kimberly, DO.
describe somatic dysfunction. See combined treatment, (archaic). See
somatic dysfunction. osteopathic manipulative treatment,
Osteopathic Manipulative Medicine combined method.
(OMM): The application of compression of the fourth ventricle
osteopathic philosophy, structural (CV-4), a cranial technique in which
diagnosis and use of OMT in the the lateral angles of the occipital
diagnosis and management of the squama are manually approximated
patient. slightly exaggerating the posterior
Osteopathic Manipulative Therapy convexity of the occiput and taking the
(OMTh): the therapeutic application of cranium into sustained extension.
Figure 23. Neutral spinal manually guided forces by an counterstrain (CS), 1. A system of
position. osteopath (non-physician) to improve diagnosis and treatment that considers
physiological function and homeostasis the dysfunction to be a continuing,
that has been altered by somatic inappropriate strain reflex, which is
dysfunction. inhibited by applying a position of mild
spine applies. See also extension. See strain in the direction exactly opposite
Osteopathic Manipulative Treatment
also flexion. See also physiologic to that of the reflex; this is
(OMT): The therapeutic application of
motion of the spine. accomplished by specific directed
manually guided forces by an
normalization: The therapeutic use of osteopathic physician (US Usage) to positioning about the point of
anatomic and physiologic mechanisms improve physiologic function and/or tenderness to achieve the desired
to facilitate the body’s response toward support homeostasis that has been therapeutic response. 2. Australian and
homeostasis and improved health. altered by somatic dysfunction. OMT French use: Jones technique,
employs a variety of techniques (correction spontaneous by position),
NSR: A descriptor of spinal somatic spontaneous release by position. 3.
dysfunction used to denote a including:
Developed by Lawrence Jones, DO.
combination neutral (N), sidebent (S), active method, technique in which the
and rotated (R) vertebral position; person voluntarily performs an cranial treatment (CR), See primary
similar descriptors may involve flexed osteopathic practitioner-directed respiratory mechanism. See osteopathy
(F) and extended (E) position. motion. in the cranial field.
nutation: Nodding forward; anterior articulatory treatment, (archaic). See CV-4, Abbreviation for compression of
movement of the sacral base around a osteopathic manipulative treatment, the fourth ventricle. See osteopathic
transverse axis in relation to the ilia. articulatory treatment system. manipulative treatment, compression of
the fourth ventricle.
articulatory treatment system
O (ART), a low velocity/moderate to Dalrymple treatment, See osteopathic
high amplitude technique where a joint manipulative treatment, pedal pump.
oblique axis: See sacral motion axis, is carried through its full motion with direct method (D/DIR), an
oblique (diagonal). the therapeutic goal of increased range osteopathic treatment strategy by
OMM: See osteopathic manipulative of movement. The activating force is which the restrictive barrier is engaged
medicine. either a repetitive springing motion or and a final activating force is applied to
repetitive concentric movement of the correct somatic dysfunction.
OMTh: See osteopathic manipulative
joint through the restrictive barrier. exaggeration method, an osteopathic
therapy.
balanced ligamentous tension (BLT), treatment strategy by which the
OMT: See osteopathic manipulative
1. According to Sutherland’s model, all dysfunctional component is carried
treatment.
the joints in the body are balanced away from the restrictive barrier and
ONM: See NMM-OMM. ligamentous articular mechanisms. The beyond the range of voluntary motion
OP&P: Osteopathic principles and ligaments provide proprioceptive to a point of palpably increased
practice. See also osteopathic information that guides the muscle tension.
philosophy. response for positioning the joint and exaggeration technique, an indirect
the ligaments themselves guide the procedure that involves carrying the
os coxae: See innominate. motion of the articular components. dysfunctional part away from the
-osis: word element [GR], disease; morbid (Foundations) 2. First described in restrictive barrier, then applying a high
state; abnormal increase. “Osteopathic Technique of William G. velocity/low amplitude force in the
osteopath: 1. A person who has achieved Sutherland”, that was published in the same direction.
the nationally recognized academic and 1949 Year Book of Academy of Applied
Osteopathy. See also ligamentous facilitated oscillatory release
professional standards within her or his technique (FOR), 1. A technique
country to independently practice articular strain.
intended to normalize neuromuscular
diagnosis and treatment based upon the Chapman reflex, See Chapman reflex. function by applying a manual
principles of osteopathic philosophy. combined method, 1. A treatment oscillatory force, which may be
Individual countries establish the strategy where the initial movements combined with any other ligamentous
national academic and professional are indirect; as the technique is
11
or myofascial technique. 2. A indirect method (I/IND), a myofascial release (MFR), a system
refinement of a long-standing use of manipulative technique where the of diagnosis and treatment first
oscillatory force in osteopathic restrictive barrier is disengaged and the described by Andrew Taylor Still and
diagnosis and treatment as published in dysfunctional body part is moved away his early students, which engages
early osteopathic literature. 3. A from the restrictive barrier until tissue continual palpatory feedback to
technique developed by Zachary tension is equal in one or all planes and achieve release of myofascial tissues.
Comeaux, DO. directions. direct MFR, a myofascial tissue
facilitated positional release (FPR), a inhibitory pressure technique, the restrictive barrier is engaged for the
system of indirect myofascial release application of steady pressure to soft myofascial tissues and the tissue is
treatment. The component region of the tissues to reduce reflex activity and loaded with a constant force until
body is placed into a neutral position, produce relaxation. tissue release occurs.
diminishing tissue and joint tension in integrated neuromusculoskeletal indirect MFR, the dysfunctional
all planes, and an activating force release (INR), a treatment system in tissues are guided along the path of
(compression or torsion) is added. 2. A which combined procedures are least resistance until free movement
technique developed by Stanley designed to stretch and reflexly release is achieved.
Schiowitz, DO. patterned soft tissue and joint-related myofascial technique, any technique
fascial release treatment, See restrictions. Both direct and indirect directed at the muscles and fascia. See
osteopathic manipulative treatment, methods are used interactively. also osteopathic manipulative
myofascial release. Jones technique, See osteopathic treatment, myofascial release. See also
fascial unwinding, a manual technique manipulative treatment, counterstrain. osteopathic manipulative treatment,
involving constant feedback to the ligamentous articular strain soft tissue technique.
osteopathic practitioner who is technique (LAS), 1. A manipulative myotension, a system of diagnosis and
passively moving a portion of the technique in which the goal of treatment that uses muscular
patient’s body in response to the treatment is to balance the tension in contractions and relaxations under
sensation of movement. Its forces are opposing ligaments where there is resistance of the osteopathic
localized using the sensations of ease abnormal tension present. 2. A set of practitioner to relax, strengthen or
and bind over wider regions. myofascial release techniques stretch muscles, or mobilize joints.
functional method, an indirect described by Howard Lippincott, DO, Osteopathy in the Cranial Field
treatment approach that involves and Rebecca Lippincott, DO. 3. Title (OCF), 1. A system of diagnosis and
finding the dynamic balance point and of reference work by Conrad Speece, treatment by an osteopathic practitioner
one of the following: applying an DO, and William Thomas Crow, DO. using the primary respiratory
indirect guiding force, holding the liver pump, See hepatic pump mechanism and balanced membranous
position or adding compression to tension. See also primary respiratory
exaggerate position and allow for lymphatic pump, 1. A term used to
describe the impact of intrathoracic mechanism. 2. Refers to the system of
spontaneous readjustment. The diagnosis and treatment first described
osteopathic practitioner guides the pressure changes on lymphatic flow.
This was the name originally given to by William G. Sutherland, DO. 3. Title
manipulative procedure while the of reference work by Harold Magoun,
dysfunctional area is being palpated in the thoracic pump technique before the
more extensive physiologic effects of Sr, DO.
order to obtain a continuous feedback
of the physiologic response to induced the technique were recognized. 2. A passive method, based on techniques
motion. The osteopathic practitioner term coined by C. Earl Miller, DO. in which the patient refrains from
guides the dysfunctional part so as to mandibular drainage technique, soft voluntary muscle contraction.
create a decreasing sense of tissue tissue manipulative technique using pedal pump, a venous and lymphatic
resistance (increased compliance). passively induced jaw motion to effect drainage technique applied through the
Galbreath treatment, See osteopathic increased drainage of middle ear lower extremities; also called the pedal
manipulative treatment, mandibular structures via the eustachian tube and fascial pump or Dalrymple treatment.
drainage. lymphatics. percussion vibrator technique, 1. A
hepatic pump, rhythmic compression mesenteric release technique manipulative technique involving the
applied over the liver for purposes of (mesenteric lift), technique in which specific application of mechanical
increasing blood flow through the liver tension is taken off the attachment of vibratory force to treat somatic
and enhancing bile and lymphatic the root of the mesentery to the dysfunction. 2. An osteopathic
drainage from the liver. posterior body wall. Simultaneously, manipulative technique developed by
the abdominal contents are compressed Robert Fulford, DO.
high velocity/low amplitude to enhance venous and lymphatic
technique (HVLA), An osteopathic positional technique, a direct
drainage from the bowel. segmental technique in which a
technique employing a rapid,
therapeutic force of brief duration that muscle energy, 1. A system of combination of leverage, patient
travels a short distance within the diagnosis and treatment in which the ventilatory movements and a fulcrum
anatomic range of motion of a joint, patient voluntarily moves the body as are used to achieve mobilization of the
and that engages the restrictive barrier specifically directed by the osteopathic dysfunctional segment. May be
in one or more planes of motion to practitioner. This directed patient combined with springing or thrust
elicit release of restriction. Also known action is from a precisely controlled technique.
as thrust technique. position against a defined resistance by progressive inhibition of
the osteopathic practitioner. 2. Refers neuromuscular structures (PINS), 1.
Hoover technique, 1. A form of to a concept first used by Fred L.
functional method. 2. Developed by A system of diagnosis and treatment in
Mitchell, Sr, DO, originally called which the osteopathic practitioner
H.V. Hoover, DO. See also osteopathic muscle energy treatment.
manipulative treatment, functional
technique.
12
locates two related points and high velocity/low amplitude technique an allopathic physician who has been
sequentially applies inhibitory pressure (HVLA). trained in osteopathic principles,
along a series of related points. 2. toggle technique, short lever technique practices and philosophy.
Developed by Dennis Dowling, DO. using compression and shearing forces. osteopathic structural examination: The
range of motion technique, active or traction technique, a procedure of examination of a patient by an
passive movement of a body part to its high or low amplitude in which the osteopathic practitioner with emphasis
physiologic or anatomic limit in any or parts are stretched or separated along a on the neuromusculoskeletal system
all planes of motion. longitudinal axis with continuous or including palpatory diagnosis for
soft tissue (ST), A system of diagnosis intermittent force. somatic dysfunction and
and treatment directed toward tissues viscerosomatic change within the
v-spread, technique using forces context of total patient care. The
other than skeletal or arthrodial transmitted across the diameter of the
elements. examination is concerned with finding
skull to accomplish sutural gapping. somatic dysfunction in all parts of the
soft tissue technique, a direct ventral techniques, See osteopathic body, and is performed with the patient
technique that usually involves lateral manipulative treatment, visceral in multiple positions to provide static
stretching, linear stretching, deep manipulation. and dynamic evaluation.
pressure, traction and/or separation of
muscle origin and insertion while visceral manipulation (VIS), a system osteopathy (osteopathic medicine): A
monitoring tissue response and motion of diagnosis and treatment directed to complete system of medical care with a
changes by palpation. Also called the viscera to improve physiologic philosophy that combines the needs of
myofascial treatment. function. Typically, the viscera are the patient with current practice of
moved toward their fascial attachments medicine, surgery and obstetrics.
Spencer technique, a series of direct to a point of fascial balance. Also Emphasizes the interrelationship
manipulative procedures to prevent or called ventral techniques. between structure and function, and has
decrease soft tissue restrictions about an appreciation of the body’s ability to
the shoulder. See also osteopathic osteopathic musculoskeletal evaluation:
heal itself.
manipulative treatment (OMT), The osteopathic musculoskeletal
articulatory treatment (ART) evaluation provides information
regarding the health of the patient. P
splenic pump technique, rhythmic Utilizing the concepts of body unity,
compression applied over the spleen self-regulation and structure-function palpation: The application of the fingers
for the purpose of enhancing the interrelationships, the osteopathic to the surface of the skin or other
patient’s immune response. See also physician uses data from the tissues, using varying amounts of
osteopathic manipulative treatment musculoskeletal evaluation to assess pressure, to selectively determine the
(OMT), lymphatic pump. the patient’s status and develop a condition of the parts beneath.
spontaneous release by positioning, treatment plan. (AOA House of palpatory diagnosis: A term used by
See osteopathic manipulative Delegates) osteopathic practitioners to denote the
treatment, counterstrain. osteopathic philosophy: a concept of process of palpating the patient to
springing technique, a low velocity/ health care supported by expanding evaluate the structure and function of
moderate amplitude technique where scientific knowledge that embraces the the neuromusculoskeletal and visceral
the restrictive barrier is engaged concept of the unity of the living systems.
repeatedly to produce an increased organism’s structure (anatomy) and palpatory skills: Sensory skills used in
freedom of motion. See also function (physiology). Osteopathic performing palpatory diagnosis and
osteopathic manipulative treatment, philosophy emphasizes the following osteopathic manipulative treatment.
articulatory treatment system. principles: 1. The human being is a
passive method: See osteopathic
Still Technique, 1. Characterized as a dynamic unit of function. 2. The body
manipulative treatment, passive
specific non-repetitive articulatory possesses self-regulatory mechanisms
method.
method that is indirect then direct. 2. that are self-healing in nature. 3.
passive motion: See motion, passive
Attributed to A.T. Still. 3. A term Structure and function are interrelated
motion.
coined by Richard Van Buskirk, DO, at all levels. 4. Rational treatment is
based on these principles. patient cooperation: Voluntary
PhD.
movement by the patient (on
Strain-Counterstrain®, An osteopathic physician: a person with full
instruction from the osteopathic
osteopathic system of diagnosis and unlimited medical practice rights who
practitioner) to assist in the palpatory
indirect treatment in which the has achieved the nationally recognized
diagnosis and treatment process.
patient’s somatic dysfunction, academic and professional standards
within his or her country to practice pedal pump: See osteopathic
diagnosed by (an) associated
diagnosis and treatment based upon the manipulative treatment, pedal pump.
myofascial tenderpoint(s), is treated by
using a passive position, resulting in principles of osteopathic philosophy. pelvic bone: See hip bone.
spontaneous tissue release and at least Individual countries establish the
national academic and professional pelvic declination (pelvic unleveling):
70 percent decrease in tenderness. 2). Pelvic rotation about an anterior-
Developed by Lawrence H. Jones, DO, standards for osteopathic physicians
practicing within their countries. posterior (A-P) axis.
in 1955. See osteopathic treatments,
counterstrain. osteopathic postural examination: The pelvic index (PI): Represents a ratio of
part of the osteopathic musculoskeletal the measurements determined from
thoracic pump, 1. A technique that postural radiograph: One (y) beginning
consists of intermittent compression of examination that focuses on the static
and dynamic responses of the body to from a vertical line originating at the
the thoracic cage. 2. Developed by C. sacral promontory to the intersection
Earl Miller, DO gravity while in the erect position.
with the horizontal line from the
thrust technique (HVLA), See osteopathic practitioner: Refers to an anterior-superior position of the pubic
osteopathic manipulative treatment, osteopath, an osteopathic physician or bone. The second measurement (x) is
13
along this same horizontal line. Normal opposite directions (with rotation III. 1. Initiating motion of a vertebral
values are age-related and increase in occurring toward the convexity). (Fig. segment in any plane of motion will
subjects with sagittal plane postural 25). See somatic dysfunction, type I s.d. modify the movement of that segment
decompensation. Pelvic index (PI) in other planes of motion.
equals x/y. (Fig. 24) 2. Principles I and II of thoracic and
lumbar spinal motion described by
Harrison H. Fryette, DO (1918),
Principle III was described by C.R.
Nelson, DO (1948). See rotation. See
also rotation of vertebra.
plagiocephaly: An asymmetric condition
of the head.
plane: A flat surface determined by the
position of three points in space. Any
of a number of imaginary surfaces
passing through the body and dividing
it into segments. (Fig. 27)
AP plane, See plane, sagittal plane.
Figure 24. Pelvic index (PI). (Modified

from Kuchera WA, Kuchera ML,
Osteopathic Principles in Practice, Figure 25. Physiologic motion of
the thoracic or lumbar spine
Greyden Press, Columbus, OH, 1994:263).
resulting from a neutral spinal
position (Type I motion).
pelvic rotation: Movement of the entire
pelvis in a relatively horizontal plane II. When the thoracic and lumbar spine
about a vertical (longitudinal) axis. are sufficiently forward or backward
pelvic sideshift: Deviation of the pelvis to bent (non-neutral), the coupled motions
the right or left of the central vertical of sidebending and rotation in a single
axis as translation occurs along the vertebral unit occur in the same
horizontal (z) axis. Usually observed in direction. (Fig. 26) See somatic
the standing position. dysfunction, type II, s.d.
pelvic tilt: Pelvic rotation about a

transverse (horizontal) axis (forward or
backward tilt) or about an anterior- Figure 27. Planes of the body.
posterior axis (right or left side tilt).
pelvis: Within the context of structural
diagnosis, the pelvis is made up of the coronal plane (frontal plane), a plane
right and left innominates, (hip bone or passing longitudinally through the
os coxae) the sacrum and coccyx. body from one side to the other, and
percussion vibrator technique: See dividing the body into anterior and
osteopathic manipulative treatment, posterior portions.
percussion vibrator technique. frontal plane, See plane, coronal
pétrissage: Deep kneading or squeezing plane.
action to express swelling. horizontal plane, See plane,
physiologic barrier: See barrier, transverse plane.
physiologic barrier. sagittal plane, a plane passing
physiologic motion: See motion, longitudinally through the body from
physiologic motion. front to back and dividing it into right
physiologic motion of the spine: The and left portions. The median or
three major principles of physiologic midsagittal plane divides the body into
motion are: approximately equal right and left
portions.
I. When the thoracic and lumbar spine
are in a neutral position (easy normal; transverse plane (horizontal plane), a
See neutral Fig. 23), the coupled plane passing horizontally through the
Figure 26. Physiologic motion
motions of sidebending and rotation for body perpendicular to the sagittal and
of the thoracic or lumbar spine frontal planes, dividing the body into
a group of vertebrae are such that resulting from a non-neutral
sidebending and rotation occur in upper and lower portions.
spinal position (Type II motion).
14
plastic deformation: A non-recoverable primary respiratory mechanism: 1. A resulting in lowering of the medial
deformation. See also elastic conceptual model that describes a margin of the foot. See also supination.
deformation. process involving five interactive, prone: Lying face downward (Dorland’s).
plasticity: Ability to retain a shape involuntary functions: (1). The inherent
motility of the brain and spinal cord. psoas syndrome: A painful low back
attained by deformation. See also condition characterized by
elasticity. See also viscosity. (2). Fluctuation of the cerebrospinal
fluid. (3). Mobility of the intracranial hypertonicity of psoas musculature.
positional technique: See osteopathic and intraspinal membranes. (4). The syndrome consists of a
manipulative treatment, positional Articular mobility of the cranial bones. constellation of typically related signs
technique. (5). Mobility of the sacrum between and symptoms:
posterior component: A positional the ilia (pelvic bones) that is typical posture, flexion at the hip and
descriptor used to identify the side of interdependent with the motion at the sidebending of the lumbar spine to the
reference when rotation of a vertebral sphenobasilar synchondrosis. side of the most hypertonic psoas
segment has occurred. In a condition This mechanism refers to the presumed muscle.
of right rotation, the right side is the inherent (primordial) driving typical gait, Trendelenburg gait.
posterior component. It usually refers mechanism of internal respiration as
to a prominent vertebral transverse typical pain pattern, low back pain
opposed to the cycle of diaphragmatic
process. See also anterior component. frequently accompanied by pain on the
respiration (inhalation and exhalation).
lateral aspect of the lower extremity
posterior nutation: See counternutation. It further refers to the innate
extending no lower than the knee.
interconnected movement of every
post-isometric relaxation: Immediately typical associated somatic
tissue and structure of the body.
following an isometric contraction, the dysfunctions, as a long restrictor
Optimal health promotes optimal
neuromuscular apparatus is in a muscle, psoas hypertonicity is
function and the inherent function of
refractory state during which enhanced frequently associated with flexed
this interdependent movement can be
passive stretching may be performed. dysfunctions of the upper lumbars,
negatively altered by trauma, disease
The osteopathic practitioner may take extended dysfunction of L5, and
states or other pathology.
up the myofascial slack during the variable sacral and innominate
relaxed refractory period. 2. This mechanism was first described
dysfunctions. Tender points typically
by William G. Sutherland, DO, and is
postural axis: See sacral motion axis, are found in the ipsilateral iliacus and
thought to affect cellular respiration
postural axis. contralateral piriformis muscles.
and other body processes. In the
postural balance: A condition of optimal original definition, the following pubic bone, somatic dysfunctions of:
distribution of body mass in relation to descriptions were given: anterior pubic shear, a somatic
gravity. dysfunction in which one pubic bone is
primary, because it is directly
postural decompensation: Distribution of concerned with the internal tissue displaced anteriorly with relation to its
body mass away from ideal when respiration of the central nervous normal mate.
postural homeostatic mechanisms are system. inferior pubic shear, a somatic
overwhelmed. It occurs in all cardinal dysfunction in which one pubic bone is
respiratory, because it further
planes, but is classified by the major displaced inferiorly with relation to its
concerns the physiological function of
plane(s) affected. See planes of the normal mate. (Fig. 28)
the interchange of fluids necessary for
body (Fig. 27).
normal metabolism and biochemistry,
coronal plane p. d., causes scoliotic not only of the central nervous system,
changes. but also of all body cells.
horizontal plane p. d., may cause mechanism, because all the constituent
postural changes where part or all of parts work together as a unit carrying
the body rotates to the right or left. out this fundamental physiology. See
When viewed from the right or left also osteopathic manipulative
sides, alignment appears asymmetrical. treatment (OMT), osteopathy in the
sagittal plane p. d., causes kyphotic cranial field
and/or lordotic changes. prime mover: A muscle primarily
postural imbalance: A condition in responsible for causing a specific joint Figure 28. Right inferior pubic shear.
which ideal body mass distribution is action.
not achieved. progressive inhibition of neuromuscular posterior pubic shear, a somatic
posture: Position of the body. The structures (PINS): See osteopathic dysfunction in which one pubic bone is
distribution of body mass in relation to manipulative treatment, Progressive displaced posteriorly with relation to
gravity. Inhibition of Neuromuscular its normal mate.
Structures.
primary machinery of life: The pubic abduction, See pubic gapping.
neuromusculoskeletal system. A term prolotherapy: See sclerotherapy.
pubic adduction, See pubic
used to denote that body parts act pronation: In relation to the anatomical compression.
together to transmit and modify force position, as applied to the hand,
and motion through which man acts out pubic compression (pubic
rotation of the forearm in such a way
his life. This integration is achieved via adduction), a somatic dysfunction in
that the palmar surface turns backward
the central nervous system acting in which the pubic bones are forced
(internal rotation) in relationship to the
response to continued sensory input toward each other at the pubic
anatomical position. Applied to the
from the internal and external symphysis. This dysfunction is
foot: a combination of eversion and
environment. 2. A term coined by I.M. characterized by tenderness to
abduction movements taking place in
Korr, PhD. palpation over the pubic symphysis,
the tarsal and metatarsal joints,
lack of apparent asymmetry, but
15
associated with restricted motion of the reciprocal tension membrane: The functional or arbitrary boundaries. 2.
pelvic ring. (Fig. 29) intracranial and spinal dural membrane Body areas for the diagnosis and
including the falx cerebri, falx coding of somatic dysfunction as
cerebelli, tentorium and spinal dura. defined in the International
red reflex: See reflex, red r. Classification of Diseases (currently
ICD-9 CM) using the codes:
reflex: An involuntary nervous system
response to a sensory input. The sum 739.0 somatic dysfunction, head
total of any particular involuntary 739.1 somatic dysfunction, cervical
activity. See also Chapman reflexes. 739.2 somatic dysfunction, thoracic
739.3 somatic dysfunction, lumbar
cephalogyric reflex, See 739.4 somatic dysfunction, sacrum
oculocephalogyric r. 739.5 somatic dysfunction, pelvis
cervicolumbar r., automatic 739.6 somatic dysfunction, lower
Figure 29. Pubic compression.
contraction of the lumbar paravertebral extremity
muscles in response to contraction of 739.7 somatic dysfunction, upper
pubic gapping (pubic abduction), a postural muscles in the neck. extremity
somatic dysfunction in which the pubic 739.8 somatic dysfunction, rib cage
conditioned r., one that does not occur
bones are pulled away from each other 739.9 somatic dysfunction,
naturally in the organism or system,
at the pubic symphysis. This abdomen/other
but that is developed by regular
dysfunction is frequently seen in See also transitional region.
association of some physiological
women following childbirth. (Fig. 30) regional extension: See extension,
function with a related outside event.
regional extension.
myotatic r., tonic contraction of the
muscles in response to a stretching regional motor inputs: Motion initiated
force, due to stimulation of muscle by an osteopathic practitioner through
receptors (e.g.: deep tendon reflex). body contact and vector input that
produces a specific response at each
oculocephalogyric r., (oculogyric
segment in the mobile system.
reflex, cephalogyric reflex), automatic
movement of the head that leads or resilience: Property of returning to the
Seated flexion test = Bilaterally (+) accompanies movement of the eyes. former shape or size after mechanical
(False negative) distortion. See also elasticity. See also
oculogyric reflex. See
Figure 30. Pubic gapping ( pubic plasticity.
oculocephalogyric r.
abduction) respiratory axis of the sacrum: See
red r., 1. The erythematous
sacral motion axis, superior transverse
superior pubic shear, a somatic biochemical reaction (reactive
axis.
dysfunction in which one pubic bone is hyperemia) of the skin in an area that
has been stimulated mechanically by respiratory cooperation: An osteopathic
displaced superiorly with relation to its
friction. The reflex is greater in degree practitioner-directed inhalation and/or
normal mate. (Fig. 31)
and duration in an area of acute exhalation by the patient to assist the
somatic dysfunction as compared to an manipulative treatment process.
area of chronic somatic dysfunction. It restriction: A resistance or impediment to
is a reflection of the segmentally movement. For joint restriction, See
related sympathicotonia commonly barrier (motion barrier).
observed in the paraspinal area. 2. A
red glow reflected from the fundus of retrolisthesis: Posterior displacement of
the eye when a light is cast upon the one vertebra relative to the one
retina. immediately below.
somatosomatic r., localized somatic rib lesion: (Archaic) See rib somatic
stimuli producing patterns of reflex dysfunction.
Figure 31. Right superior pubic shear. response in segmentally related rib motion:
somatic structures. axis of rib motion, an imaginary line
pubic symphysis, somatic dysfunctions somatovisceral r., localized somatic through the costotransverse and the
of: See pubic bone, somatic stimulation producing patterns of reflex costovertebral articulations of the rib.
dysfunctions of. response in segmentally related anteroposterior rib axis, (Fig. 32) See
pump handle rib motion: See rib motion, visceral structures. also bucket handle rib motion.
pump handle motion. viscerosomatic r., localized visceral bucket handle motion, movement of
stimuli producing patterns of reflex the ribs during respiration such that
R response in segmentally related with inhalation, the lateral aspect of the
somatic structures. rib moves cephalad resulting in an
range of motion technique: See viscerovisceral r., localized visceral increase of transverse diameter of the
osteopathic manipulative treatment, stimuli producing patterns of reflex thorax. This type of rib motion is
range of motion technique. response in segmentally related predominantly found in lower ribs,
reciprocal inhibition: The inhibition of visceral structures. increasing in motion from the upper to
antagonist muscles when the agonist is regenerative injection therapy (RIT): the lower ribs. (Fig. 33) See also rib
stimulated. See also laws, See sclerotherapy. motion, axis of. See also rib motion,
Sherrington’s. pump handle.
region: 1. An anatomical division of the
body defined either by natural, caliper rib motion, Rib motion of ribs
11 and 12 characterized by single joint
16
being held in a position of inhalation
such that motion toward inhalation is
more free and motion toward
exhalation is restricted. Synonyms:
inhaled rib, anterior rib, elevated rib,
ropiness: A tissue texture abnormality

characterized by a cord-like feeling.
See also tissue texture abnormality.
rotation: Motion about an axis.
rotation dysfunction of the sacrum,
See sacrum, somatic dysfunctions of.
rotation of sacrum, movement of the
sacrum about a vertical (y) axis
Figure 34. Pump handle
Figure 32. The functional (usually in relation to the innominate
rib motion.
anterior-posterior rib axis. . bones).
rotation of vertebra, movement about
the anatomical vertical axis (y axis) of
a vertebra; named by the motion of a
midpoint on the anterior-superior
surface of the vertebral body. (Fig. 36)
Figure 33. Bucket handle

rib motion. Figure 35. The functional
transverse rib axis.
motion; analogous to internal and inhalation. See also rib motion,

external rotation. inhalation rib restriction. See also rib
motion, exhalation rib restriction. Figure 36. Rotation of a vertebra
exhalation rib restriction, involves a
rib somatic dysfunction: A somatic (lumbar).
rib or group of ribs that first stops
moving during exhalation. The key rib dysfunction in which movement or
is the bottom rib in the group. See also position of one or several ribs is altered
rib somatic dysfunction, inhalation rib or disrupted. For example, an elevated rule of threes: A method to locate the
dysfunction. rib is one held in a position of approximate position of the transverse
inhalation such that motion toward process (TP) of a thoracic segment by
inhalation rib restriction, involves a inhalation is freer, and motion toward
rib or group of ribs that first stops using the location of the spinous
exhalation is restricted. A depressed rib process (SP) of that same vertebra. The
moving during inhalation. The key rib is one held in a position of exhalation
is the top rib in the group. See also rib relationship is as follows:
such that motion toward exhalation is
somatic dysfunction, exhalation rib freer and there is a restriction in T1 to T3, TP is at the same level as
dysfunction. inhalation. See also rib motion, tip of the SP
pump handle motion, movement of inhalation rib restriction. See also rib T4 to T6, TP is one half vertebral
the ribs during respiration such that motion, exhalation rib restriction. level above the tip of the
with inhalation the anterior aspect of exhalation rib dysfunction, 1. SP
the rib moves cephalad and causes an Somatic dysfunction characterized by a T7 to T9, TP is one full vertebral
increase in the anteroposterior diameter rib being held in a position of level above the tip of the
of the thorax. This type of rib motion is exhalation such that motion toward SP
found predominantly in the upper ribs, exhalation is more free and motion T10, TP is one full vertebral
decreasing in motion from the upper to toward inhalation is restricted. level above the tip of the
the lower ribs. (Fig. 34) See rib Synonyms: inhalation rib restriction SP
motion, axis of. See also rib motion, depressed rib. 2. An anterior rib tender T11, TP is one half vertebral
bucket handle motion. point in counterstrain. See also rib level above the tip of the
transverse rib axis, (Fig. 35) See rib motion, inhalation rib restriction. SP
motion, pump handle rib motion T12, TP is at the same level as
inhalation rib dysfunction, A somatic tip of the SP.
dysfunction characterized by a rib
17
S anterior-posterior (x) axis, axis sacral torsion: 1. A physiologic function
formed at the line of intersection of a occurring in the sacrum during
sagittal and transverse plane. ambulation and forward bending. 2. A
sacral base: 1. In osteopathic palpation, sacral somatic dysfunction around an
the uppermost posterior portion of the inferior transverse axis
(innominate), the hypothetical oblique axis in which a torque occurs
sacrum. 2. The most cephalad portion between the sacrum and innominates.
of the first sacral segment (Gray’s functional axis of sacral motion that
passes from side to side on a line The L5 vertebra rotates in the opposite
Anatomy). direction of the sacrum. 3. If the L5
through the inferior auricular surface
sacral base anterior: See sacrum, of the sacrum and ilia, and represents does not rotate opposite to the sacrum,
somatic dysfunctions of, bilateral the axis for movement of the ilia on the L5 is termed maladapted. 4. Other
sacral flexion. sacrum. 2. A term described by Fred terms for this maladaption include:
Mitchell, Sr, DO. (Fig. 37) rotations about an oblique axis, anterior
sacral base declination (unleveling): or posterior sacrum and a torsion with
With the patient in a standing or seated longitudinal axis, the hypothetical a non-compensated L5 (Archaic use).
position, any deviation of the sacral axis formed at the line of intersection See also sacrum, somatic dysfunctions
base from the horizontal in a coronal of the midsagittal plane and a coronal of.
plane. Generally, the rotation of the plane, See sacral motion axis, vertical
sacrum about an anterior-posterior (y) axis longitudinal. (Fig. 38) sacroiliac motion: Motion of the sacrum
axis. in relationship to the innominate(s)
middle transverse axis (postural), the (ilium/ilia).
sacral base posterior: See sacrum, hypothetical functional axis of sacral
somatic dysfunctions of, bilateral nutation/counternutation in the sacrum, inferior lateral angle (ILA) of:
sacral flexion. standing position, passing horizontally The point on the lateral surface of the
through the anterior aspect of the sacrum where it curves medially to the
sacral base unleveling: See sacral base body of the fifth sacral vertebrae
declination. sacrum at the level of the second sacral
segment. 2. A term described by Fred (Gray’s Anatomy). (Fig. 39, Fig. 40)
sacralization: See transitional vertebrae, Mitchell, Sr, DO. (Fig. 37)
sacralization.
oblique axis (diagonal), a hypothetical
sacral movement axis: any of the functional axis from the superior area
hypothetical axes for motion of the of a sacroiliac articulation to the
sacrum. (Fig. 37, Fig. 38) contralateral inferior sacroiliac
articulation. It is designated as right or
left relevant to its superior point of
origin. 2. A term described by Fred
Mitchell, Sr, DO. (Fig. 38)
postural axis, See sacrum, middle
transverse axis (postural). (Fig. 37)
respiratory axis, See sacrum, superior
transverse axis (respiratory). (Fig. 37)
superior transverse axis
(respiratory), the hypothetical
transverse axis about which the sacrum
moves during the respiratory cycle. It
passes from side to side through the
articular processes posterior to the
Figure 37. Sacral transverse axes point of attachment of the dura at the
(lateral view). level of the second sacral segment.
Involuntary sacral motion occurs as
part of the craniosacral mechanism, Figure 39. Anatomical sacral
and is believed to occur about this axis. divisions.
2. A term described by Fred Mitchell,
Sr, DO. (Fig. 37)
transverse (z) axes, axes formed by
intersection of the coronal and
transverse planes about which
nutation/counternutation occurs. (Fig.
37)
vertical (y) axis (longitudinal), the
axis formed by the intersection of the
sagittal and coronal planes. (Fig. 38)
sacral somatic dysfunction: See sacrum,
somatic dysfunctions of.
sacral sulcus: A depression just medial to
Figure 38. Axes of sacral motion the posterior superior iliac spine (PSIS) Figure 40. Clinical sacral
(posterior view). as a result of the spatial relationship of divisions: sacral sulcus at the base,
the PSIS to the dorsal aspect of the and inferior lateral angles (ILA).
sacrum. (Fig. 39, Fig. 40)
18
sacrum, somatic dysfunctions of: any of backward torsions, 1. A backward
a group of somatic dysfunctions sacral torsion is a physiologic rotation
involving the sacrum. These may be of the sacrum around an oblique axis
the result of restriction of normal such that the side of the sacral base
physiologic motion or trauma to the contralateral to the named axis rotates
sacrum. See also T.A.R.T. posteriorly. L5 rotates in the direction
anterior sacrum, a positional term opposite to the rotation of the sacral
based on the Strachan model referring base. 2. Referred to as non-neutral
to sacral somatic dysfunction in which sacral somatic dysfunctions (Archaic
the sacral base has rotated anterior and use). 3. A term by Fred Mitchell, Sr,
sidebent to the side opposite the DO, that describes the backward
rotation. The upper limb (pole) of the torsion as being non-physiologic in
SI joint has restricted motion and is terms of the walking cycle.
named for the side on which forward bilateral sacral extension (sacral
rotation had occurred. Tissue texture base posterior), 1. A sacral somatic
changes are found at the deep sulcus. dysfunction that involves rotation of Figure 44. Bilateral sacral flexion.
(The motion characteristics of L5 are the sacrum about a middle transverse (Sacral base anterior)
not described.) (Fig. 41) axis such that the sacral base has
moved posteriorly relative to the pelvic
bones. Backward movement of the
sacral base is freer, forward movement
is restricted and both sulci are shallow.
2. The reverse of bilateral sacral
flexion. (Fig 43)
Figure 41. Anterior sacrum left.

Motion of L5 is not described. There
is tissue texture change (t) over the
left sacral base. The superior pole of Figure 45. Left on left sacral
the left sacroiliac joint is affected and torsion. (Left on left forward
the left sacral base will not move torsion)
posteriorly when an anterior test
pressure is applied over the right
lower sacrum. left on left (forward) sacral torsion,
Refers to left rotation torsion around a
Figure 43. Bilateral sacral extension. left oblique axis. (Fig. 45) See also
(Sacral base posterior) sacral torsion.
anterior translated sacrum, a sacral
somatic dysfunction in which the entire left on right (backward) sacral
sacrum has moved anteriorly (forward) bilateral sacral flexion (sacral base torsion, Refers to left rotation around a
between the ilia. Anterior motion is anterior), 1. A sacral somatic right oblique axis. Findings: The left
freer, and the posterior motion is dysfunction that involves rotation of superior sacral sulcus is posterior or
restricted. (Fig. 42) the sacrum about a middle transverse shallow, and the right ILA is anterior
axis such that the sacral base has or deep. There is a positive seated
moved anteriorly between the pelvic flexion test on the left. L5 is non-
bones. Forward movement of the sacral neutral SRRR. Left superior sacral
base is freer, backward movement is sulcus will be restricted when
restricted and both sulci are deep. 2. springing. The lumbosacral spring test
The reverse of bilateral sacral is positive, and the sphinx test is
extension. (Fig 44) positive. (Fig. 46) See sacral torsion.
forward torsions, 1. Forward torsion posterior sacrum, a positional term
is a physiologic rotation of the sacrum based on the Strachan model referring
around an oblique axis such that the to a sacral somatic dysfunction in
side of the sacral base contralateral to which the sacral base has rotated
the named axis glides anteriorly and posterior and sidebent to the side
produces a deep sulcus. L5 rotates in opposite to the rotation. The
the direction opposite to the rotation of dysfunction is named for the side on
the sacral base. 2. Referred to as which the posterior rotation occurs.
neutral sacral somatic dysfunctions The tissue texture changes are found at
(Archaic use) 3. A group of somatic the lower pole on the side of rotation.
dysfunctions described by Fred (Foundations). (The motion
Mitchell, Sr, DO, based on the motion characteristics of L5 are not described.)
Figure 42 Anterior cycle of walking. (Fig. 47)
translated sacrum.
19
Seated flexion test = L (+)
Figure 46. Left on right sacral Figure 49. Right on left backward Figure 51. Right rotated dysfunction
torsion. (Left on right torsion. (Right on left sacral of the sacrum. (Right rotation about a
backward torsion) torsion) vertical axis)
Figure 52. Right unilateral sacral

extension. (Right superior sacral
Figure 47. Posterior sacrum right. shear)
Motion of L5 is not described. There Figure 50. Right on right forward
is tissue texture change (t) over the torsion.
right sacroiliac joint (SI). The inferior
pole of the right SI joint is affected.
During motion testing, there is
shallow, and the left ILA is anterior or
resistance to an anterior/superior test
deep. The seated flexion test is positive
pressure applied over the right lower
on the right. L5 is non-neutral SLRL.
sacrum.
The right superior sacral sulcus is
restricted when springing. The
lumbosacral spring test is positive. The
sphinx test is positive. (Fig. 49) See
sacral torsion.
Figure 53. Right unilateral sacral
posterior translated sacrum, a sacral
flexion. (Right inferior sacral shear)
somatic dysfunction in which the entire
sacrum has moved posteriorly
(backward) between the ilia. Posterior
motion is freer, and anterior motion is to the innominates. (Sometimes
restricted. (Fig. 48) described as a sidebending in one
direction and rotation in the opposite
right on right (forward) torsion, direction. Alternatively described as a
refers to a right rotation about a right unilateral movement along the arc of
oblique axis. (Fig. 50) See sacral the L-shaped curve of the sacroiliac
torsion. joint.) See also sacrum, somatic
rotated dysfunction of the sacrum, a dysfunctions of, unilateral sacral
sacral somatic dysfunction in which the flexion and sacrum, somatic
sacrum has rotated about an axis dysfunctions of, unilateral sacral
Figure 48. Posterior approximating the longitudinal (y) extension.
translated sacrum. axis. Motion is freer in the direction unilateral sacral extension, is a sacral
that rotation has occurred, and is somatic dysfunction described as a
restricted in the opposite direction. superior shear of one side of the
right on left (backward) sacral (Fig. 51) sacrum resulting in a shallow (full) of,
torsion, Refers to right rotation on a sacral sulcus and ipsilateral superior-
left oblique axis. Findings: The right sacral shear, a complex translational anterior inferolateral angle of the
superior sacral sulcus is posterior or motion of the sacrum in its relationship sacrum. (Fig.52) See sacrum, somatic
dysfunctions of, sacral shear.
20
unilateral sacral flexion, is a sacral rootlets of individual spinal nerves. 3. soft tissue technique: See osteopathic
somatic dysfunction described as an A portion of the spinal cord manipulative treatment, soft tissue
inferior shear of one side of the sacrum segmental diagnosis: The final stage of technique.
resulting in a deep sacral sulcus and the spinal somatic examination in somatic dysfunction: Impaired or altered
ipsilateral inferior-posterior infero- which the nature of the somatic function of related components of the
lateral angle of the sacrum. (Fig. 53) problem is detailed at a segmental somatic (body framework) system:
See sacrum, somatic dysfunctions of, level. See also scan. See also screen. skeletal, arthrodial and myofascial
sacral shear. segmental dysfunction: dysfunction in a structures, and their related vascular,
sagittal plane: See plane, sagittal plane. mobile system located at explicit lymphatic, and neural elements.
segmental mobile units. Palpable Somatic dysfunction is treatable using
scan: An intermediate detailed osteopathic manipulative treatment.
examination of specific body regions characteristics of a dysfunctional
segment are those associated with The positional and motion aspects of
that have been identified by findings somatic dysfunction are best described
emerging from the initial examination. somatic dysfunction. (See also STAR,
TART and ART) Responses to regional using at least one of three parameters:
scaphocephaly: Also called scaphoid motor inputs at the dysfunctional 1). The position of a body part as
head or hatchet head, it is a transverse segment support the concepts of determined by palpation and referenced
compression of the cranium with a complete motor asymmetry and mirror- to its adjacent defined structure,
resultant mid-sagittal ridge. image motion asymmetries. 2). The directions in which motion is
freer, and 3). The directions in which
scaphoid head: See also scaphocephaly. segmental mobile unit: A unit of the motion is restricted. See also T.A.R.T.
sclerotherapy: 1. Treatment involving human movement system consisting of See also S.T.A.R.
injection of a proliferant solution at the a bone, with articular surfaces for
movement, as well as the adnexal acute s. d., immediate or short-term
osseous-ligamentous junction. 2.
tissues that create movement, allow impairment or altered function of
Treatment involving injection of
movement and establish position under related components of the somatic
irritating substances into weakened
motor control. (body framework) system.
connective tissue areas such as fascia,
Characterized in early stages by
varicose veins, hemorrhoids, segmental motion: Movement within a vasodilation, edema, tenderness, pain
esophageal varices, or weakened vertebral unit described by and tissue contraction. Diagnosed by
ligaments. The intended body’s displacement of a point at the anterior- history and palpatory assessment of
response to the irritant is fibrous superior aspect of the superior tenderness, asymmetry of motion and
\proliferation with shortening/ vertebral body with respect to the relative position, restriction of motion
strengthening of the tissues injected. segment below. and tissue texture change (T.A.R.T.).
sclerotome: 1. The pattern of innervation sensitization: Hypothetically, a short- See also T.A.R.T.
of structures derived from embryonal lived (minutes or hours) increase in chronic s. d., impairment or altered
mesenchyme (joint capsule, ligament central nervous system (CNS) response function of related components of the
and bone). 2. The area of bone to repeated sensory stimulation that somatic (body framework) system. It is
innervated by a single spinal segment. generally follows habituation. characterized by tenderness, itching,
3. The group of mesenchymal cells
shear: An action or force causing or fibrosis, paresthesias and tissue
emerging from the ventromedial part of
tending to cause two contiguous parts contraction. Identified by T.A.R.T. See
a mesodermal somite and migrating
of an articulation to slide relative to also T.A.R.T.
toward the notochord. Sclerotomal
cells from adjacent somites become each other in a direction parallel to linkage, dysfunctional segmental
merged in inter-somatically located their plane of contact. See also pubic behavior where a single vertebra and
masses that are the primordia of the bone, somatic dysfunctions of. See also an adjacent rib respond to the same
centra of the vertebrae. (Fig. 54) innominates, somatic dysfunctions of, regional motion tests with identical
inferior innominate shear. See also asymmetric behaviors (rather than
sclerotomal pain: Deep, dull achy pain innominates, somatic dysfunction of, opposing behaviors). This suggests
associated with tissues derived from a superior innominate shear. See also visceral reflex inputs.
common sclerotome. (Fig. 54) sacrum, somatic dysfunctions of, sacral
shear. primary s. d., 1. The somatic
scoliosis: 1. Pathological or functional
dysfunction that maintains a total
lateral curvature of the spine. 2. An Sherrington law: See law, Sherrington. pattern of dysfunction. See also key
appreciable lateral deviation in the
sidebending: Movement in a coronal lesion. 2. The initial or first somatic
normally straight vertical line of the
(frontal) plane about an anterior- dysfunction to appear temporally.
spine (Dorland’s. (Fig. 55)
posterior (x) axis. Also called lateral secondary s. d., somatic dysfunction
screen: The initial general somatic flexion, lateroflexion, or flexion right arising either from mechanical or
examination to determine signs of (or left). neurophysiologic response subsequent
somatic dysfunction in various regions
sidebent: The position of any one or to or as a consequence of other
of the body. See also scan.
several vertebral bodies after etiologies.
secondary joint motion: Involuntary or sidebending has occurred. (Fig. 56) type I s. d., 1. A group curve of
passive motion of a joint. Also called See also sidebending. thoracic and/or lumbar vertebrae in
accessory joint motion.
skin drag: Sense of resistance to light which the freedoms of motion are in
segment: 1. A portion of a larger body or traction applied to the skin. Related to neutral with sidebending and rotation
structure set off by natural or arbitrarily the degree of moisture and degree of in opposite directions with maximum
established boundaries, often equated sympathetic nervous system activity. rotation at the apex (rotation occurs
with spinal segment. 2. To describe a toward the convexity of the curve)
single vertebrae or a vertebral segment. soft tissue (ST): See osteopathic
based upon the Principles of Fryette.
corresponding to the sites of origin of manipulative treatment, soft tissue.
(American usage). 2. Second degree
21
Figure 54. Anterior and posterior sclerotomal innervations. (Modified from Foundations for Osteopathic Medicine, Ward
RC—Ed., William & Wilkins; 1997:644).
dysfunction based upon the Laws of

Lovett (French usage).
type II s. d., 1. Thoracic or lumbar
somatic dysfunction of a single
vertebral unit in which the vertebra is
significantly flexed or extended with
sidebending and rotation in the same
direction (rotation occurs into the
concavity of the curve) based upon the
Principles of Fryette (American usage).
2. First degree dysfunction based upon
the Laws of Lovett (French usage).
somatogenic: That which is produced by
activity, reaction and change
originating in the musculoskeletal
Figure 56. Sidebent. system.
somatosomatic reflex: See reflex,
somatosomatic r.
Figure 55. Scoliosis. somatovisceral reflex: See reflex,
somatovisceral r.
22
Figure 57. Extension (SBS).
Figure 59. Right lateral strain
(SBS).
Figure 61. Right torsion (SBS).
Figure 62. Superior

vertical strain (SBS).
Figure 60. Left sidebending/rotation

(SBS).
around parallel transverse axes.
Vertical strains of the SBS are named
basiocciput and basisphenoid are both for the position of the basisphenoid,
inferior in SBS extension with a superior or inferior. (Fig. 62)
Figure 58. Flexion (SBS). decrease in the dorsal convexity spinal facilitation: 1. The maintenance of
between these two bones. (Fig. 57) a pool of neurons (e.g., premotor
spasm: (compare with hypertonicity) a SBS flexion, sphenoid and occiput neurons, motor neurons or
sudden, violent, involuntary have rotated in opposite directions preganglionic sympathetic neurons in
contraction of a muscle or group of around parallel transverse axes; the one or more segments of the spinal
muscles, attended by pain and basiocciput and basisphenoid are both cord) in a state of partial or
interference with function, producing superior in SBS extension with an subthreshold excitation; in this state,
involuntary movement and distortion increase in the dorsal convexity less afferent stimulation is required to
(Dorland’s). between these two bones. (Fig. 58) trigger the discharge of impulses. 2. A
Spencer technique: See osteopathic lateral strain, sphenoid and occiput theory regarding the neurophysio-
manipulative treatment, Spencer have rotated in the same direction logical mechanisms underlying the
technique. around parallel vertical axes. Lateral neuronal activity associated with
sphenobasilar synchondrosis strains of the SBS are named for the somatic dysfunction. 3. Facilitation
(symphysis), somatic dysfunctions of: position of the basisphenoid, right or may be due to sustained increase in
any of a group of somatic dysfunctions left. (Fig. 59) afferent input, aberrant patterns of
involving primarily the inter- afferent input, or changes within the
sidebending-rotation, sphenoid and affected neurons themselves or their
relationship between the basilar portion occiput have rotated in opposite
of the sphenoid (basisphenoid) and the chemical environment. Once
directions around parallel vertical axes established, facilitation can be
basilar portion of the occiput and rotate in the same direction around
(basiocciput). The abbreviation, SBS, sustained by normal central nervous
an A-P axis. SBS sidebending-rotations system (CNS) activity.
is often used in reporting the following are named for the convexity, right or
somatic dysfunctions: left. (Fig. 60) splenic pump technique: See osteopathic
SBS compression, somatic manipulative treatment, splenic pump
torsion, sphenoid and occiput have technique.
dysfunction in which the basisphenoid rotated in opposite directions around an
and basiocciput are held forced anterior-posterior (A-P) axis. SBS spondylo-: Combining form denoting
together significantly limiting SBS torsions are named for the high greater relationship to a vertebra, or to the
motion. wing of the sphenoid, right or left. spinal column (Dorland’s).
SBS extension, sphenoid and occiput (Fig. 61) spondylitis: Inflammation of vertebrae.
have rotated in opposite directions vertical strain, sphenoid and occiput (Dorland’s).
around parallel transverse axes; the have rotated in the same direction
23
spondylolisthesis: Anterior displacement sacrum, somatic dysfunctions of, T
of one vertebra relative to one posterior sacrum.
immediately below (usually L-5 over
Strain-Counterstrain®: See osteopathic tapotement: Striking the belly of a muscle
the body of the sacrum or L-4 over L-
manipulative treatment, counterstrain. with the hypothenar edge of the open
5).
stretching: Separation of the origin and hand in rapid succession in an attempt
spondylolysis: Dissolution of a vertebra, to increase its tone and arterial
insertion of a muscle and/or
aplasia of the vertebral arch, and perfusion.
attachments of fascia and ligaments.
separation at the pars interarticularis;
stringiness: A palpable tissue texture T.A.R.T.: A mnemonic for four
platyspondylia, pre-spondylolisthesis.
abnormality characterized by fine or diagnostic criteria of somatic
spondylosis: 1. Ankylosis of adjacent dysfunction: tissue texture abnormality,
stringlike myofascial structures.
vertebral bodies. 2. Degeneration of the asymmetry, restriction of motion and
intervertebral disk. structural examination: See osteopathic tenderness, any one of which must be
structural examination. present for the diagnosis.
spontaneous release by positioning: See
osteopathic manipulative treatment, subluxation: 1. A partial or incomplete technic: See technique.
counterstrain. dislocation. 2. A term describing an
abnormal anatomical position of a joint technique: Methods, procedures and
sprain: Stretching injuries of ligamentous details of a mechanical process or
which exceeds the normal physiologic
tissue (compare with strain). First surgical operation. (Dorland’s). See
limit, but does not exceed the joint’s
degree: microtrauma; second degree: also osteopathic manipulative
anatomical limit.
partial tear; third degree: complete treatment.
disruption. superior (upslipped) innominate: See
innominate, somatic dysfunctions of, tenderness: 1. Discomfort or pain elicited
springing technique: See osteopathic by the osteopathic practitioner through
superior innominate shear.
manipulative treatment, springing palpation. 2. A state of unusual
technique. See also osteopathic superior pubic shear: See pubic bone, sensitivity to touch or pressure
manipulative treatment, articulatory somatic dysfunctions of. See also (Dorland’s).
treatment system. symphyseal shear. (Fig. 31)
tender points: 1. Small, hypersensitive
sphinx test: See backward bending test. superior transverse axis: See sacral points in the myofascial tissues of the
motion axis, superior transverse axis body that do not have a pattern of pain
spring test: 1. A test used to differentiate
(respiratory) and (z) axis. radiation. These points are a
between backward or forward sacral
torsions/rotations. 2. A test used to supination: 1. Beginning in anatomical manifestation of somatic dysfunction
differentiate bilateral sacral extension position, applied to the hand, the act of and are used as diagnostic criteria and
and bilateral sacral flexion. 3. A test turning the palm forward (anteriorly) for monitoring treatment. 2. A system
used to differentiate unilateral sacral or upward, performed by lateral of diagnosis and treatment originally
extension and unilateral sacral flexion. external rotation of the forearm. 2. described by Lawrence Jones, DO,
Applied to the foot, it generally applies FAAO. See also osteopathic
S.T.A.R.: A mnemonic for four diagnostic manipulative treatment, counterstrain.
to movements (adduction and
criteria of somatic dysfunction:
inversion) resulting in raising of the terminal barrier: See barrier,
sensitivity changes, tissue texture
medial margin of the foot, hence of the physiologic b.
abnormality, asymmetry and alteration
longitudinal arch. A compound motion
of the quality and quantity of range of thoracic aperture (superior): See
of plantar flexion, adduction and
motion. thoracic inlet.
inversion. See also pronation.
static contraction: See contraction, thoracic outlet: 1. The functional thoracic
supine: Lying with the face upward
isometric contraction. inlet consists of T1-4 vertebrae, ribs 1
(Dorland’s).
Still, MD, DO: Andrew Taylor. Founder and 2 plus their costicartilages, and the
symmetry: The similar arrangement in manubrium of the sternum. See fascial
of osteopathy; 1828-1917. First
form and relationships of parts around patterns. 2. The anatomical thoracic
announced the tenets of osteopathy on
a common axis, or on each side of a inlet consists of T1 vertebra, the first
June 22, 1874, established the
plane of the body (Dorland’s). ribs and their costal cartilages, and the
American School of Osteopathy in
1892 at Kirksville, MO. Sutherland fulcrum: A shifting superior end of the manubrium.
suspension fulcrum of the reciprocal thoracic pump: See osteopathic
still point: A term used to identify and
tension membrane located along the manipulative treatment, thoracic pump.
describe the temporary cessation of the
straight sinus at the junction of the falx
rhythmic motion of the primary thrust technique: See osteopathic
cerebri and tentorium cerebelli. See
respiratory mechanism. It may occur manipulative treatment, thrust
also reciprocal tension membrane. See
during osteopathic manipulative technique. See also osteopathic
also osteopathic manipulative
treatment when a point of balanced manipulative treatment, high
treatment, Osteopathy in the Cranial
membranous or ligamentous tension is velocity/low amplitude technique
Field (OCF).
achieved. 2. A term used by William (HVLA).
G. Sutherland, DO. symphyseal shear: The resultant of an
action or force causing or tending to tissue texture abnormality (TTA): A
Still Technique: See osteopathic palpable change in tissues from skin to
cause the two parts of the symphysis to
manipulative treatment, Still periarticular structures that represents
slide relative to each other in a
Technique. any combination of the following
direction parallel to their plane of
strain: 1. Stretching injuries of muscle contact. It is usually found in an signs: vasodilation, edema, flaccidity,
tissue. 2. Distortion with deformation inferior/superior direction but is hypertonicity, contracture, fibrosis, as
of tissue. See also ligamentous strain. occasionally found to be in an well as the following symptoms:
anterior/posterior direction. (Fig. 28, itching, pain, tenderness, paresthesias.
Strachan model: See sacrum, somatic Types of TTA’s include: bogginess,
dysfunctions of, anterior sacrum. See Fig. 31)
thickening, stringiness, ropiness,
24
firmness (hardening), develops characteristic(s) of the treatment, osteopathic manipulative
increased/decreased temperature and adjoining structure or region. techniques: See osteopathic
increased/decreased moisture. lumbarization, a transitional segment manipulative treatment.
toggle technique: See osteopathic in which the first sacral segment Trendelenburg test: The patient, with
manipulative treatment, toggle becomes like an additional lumbar back to the examiner, is told to lift first
technique. vertebra articulating with the second one foot and then the other. The
tonus: The slight continuous contraction sacral segment. position and movements of the gluteal
of muscle, which in skeletal muscles, sacralization, 1. Incomplete separation fold are watched. When standing on
aids in the maintenance of posture and and differentiation of the fifth lumbar the affected limb the gluteal fold on the
in the return of blood to the heart vertebra (L5) such that it takes on sound side falls instead of rising. Seen
(Dorland’s). characteristics of a sacral vertebra. 2. in poliomyelitis, un-united fracture of
When transverse processes of the fifth the femoral neck, coxa vara and
torsion: 1. A motion or state where one congenital dislocations.
end of a part is twisted about a lumbar (L5) are atypically large,
longitudinal axis while the opposite causing pseudoarthrosis with the trigger point (myofascial trigger point):
end is held fast or turned in the sacrum and/or ilia(um), referred to as 1. A small hypersensitive site that,
opposite direction. 2. An unphysiologic batwing deformity, if bilateral. when stimulated, consistently produces
motion pattern about an anteroposterior translation: Motion along an axis. a reflex mechanism that gives rise to
axis of the sphenobasilar referred pain and/or other manifes-
translatory motion: See motion, tations in a consistent reference zone
symphysis/synchondrosis. See also translatory motion.
sphenobasilar synchondrosis that is consistent from person to
(symphysis), somatic dysfunctions of, transverse axis of sacrum: See sacral, person. 2. These points were most
torsion. sacral movement axis, transverse (z) extensively and systematically
axis. (Fig. 37) documented by Janet Travell, MD, and
torsion, sacral: See sacral torsion. See David Simons, MD.
also sacrum, somatic dysfunctions of, transverse process: Projects laterally
sacral torsions. from the region of each pedicle. The trophic: Pertaining to nutrition, especially
pedicle connects the posterior elements in the cellular environment (e.g.,
traction: A linear force acting to draw to the vertebral body. (Fig. 63) trophic function — a nutritional
structures apart. function).
transverse rib axis: See (Fig. 35). See
traction technique: See osteopathic also rib motion, pump handle rib trophicity: 1. A nutritional function or
manipulative treatment, traction motion. (Fig. 34) relation. 2. The natural tendency to
technique. replenish the body stores that have
been depleted.
trophotropic: Concerned with or
pertaining to the natural tendency for
maintenance and/or restoration of
nutritional stores.
-tropic: A word termination denoting
turning toward, changing or tendency
to change.
tropism, facet: Unequal size and/or facing
of the zygapophyseal joints of a
vertebra. See also facet asymmetry.
type I somatic dysfunction: See somatic
dysfunction, type I s.d. See also
physiologic motion of the spine.
Figure 63. The pedicle (B) is the key structure from which other vertebral
parts can be identified. (Ward RC, Ex. Ed., Foundations for Osteopathic Medicine, type II somatic dysfunction: See somatic
Second Edition, Lippincott Williams & Wilkins, Philadelphia, 2003:730. dysfunction, type II s.d. See also
physiologic motion of the spine
transitional region: Areas of the axial Traube-Herring-Mayer wave: An
skeleton where structure changes oscillation that has been measured in U
significantly lead to functional association with blood pressure, heart
changes; transitional areas commonly rate, cardiac contractility, pulmonary uncommon compensatory pattern: See
include the following: blood flow, cerebral blood flow and fascial patterns, uncommon
occipitocervical region (OA), movement of the cerebrospinal fluid, compensatory pattern.
typically the OA-AA-C2 region is and peripheral blood flow including uncompensated fascial pattern: See
described. venous volume and thermal regulation. fascial patterns, uncompensated fascial
cervicothoracic region (CT), typically This whole-body phenomenon, which pattern.
C7-T1. exhibits a rate typically slightly less
than and independent of respiration, V
thoracolumbar region (TL), typically bears a striking resemblance to the
T10-L1. primary respiratory mechanism. v-spread: See osteopathic manipulative
lumbosacral region (LS), typically treatment, v-spread.
L5-S1. Travell trigger point: See trigger point.
velocity: The instantaneous rate of motion
transitional vertebrae: A congenital treatment, active: (archaic). See in a given direction.
anomaly of a vertebra in which it osteopathic manipulative treatment,
active method.
25
ventral technique: See osteopathic viscerovisceral reflex: See reflex,
manipulative treatment, visceral viscerovisceral r.
manipulation. viscosity: 1. A measurement of the rate of
vertebral unit: Two adjacent vertebrae deformation of any material under
with their associated intervertebral load. 2. The capability possessed by a
disk, arthrodial, ligamentous, muscular, solid of yielding continually under
vascular, lymphatic and neural stress. See also elasticity. See also
elements. (Fig. 64) plasticity.
visceral dysfunction: Impaired or altered
mobility or motility of the visceral W
system and related fascial,
neurological, vascular, skeletal and weight-bearing line of L3: See
lymphatic elements. gravitational line. (Fig. 16) vertical
axis: See sacral motion axis, vertical
visceral manipulation: See osteopathic (y) axis (longitudinal).
manipulative treatment, visceral Figure 64. Vertebral unit.
manipulation.
viscerosomatic reflex: See reflex,
viscerosomatic r.
File: D:/Glossary/Glossary of 08-15-2006
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Osteopathic Pri nci ples (P hil osophy)

S tructural Com ponents

S tructure and Function

Myofasci al-Arti cul ar Com ponents

V isceral -Autonomic Components

Order of Exami nati on

Layer-by-Layer Pal pation

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

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

F igu re 2.1. As ymmetr y in sc oliosis . ( Modified with per mis sion fr om

F igu re 2.2. Relating scapular landmar ks to s pinal level. (Modified from

1. The pa tie nt is sea t ed .

Figur e 3.3 . Ste p 3.

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

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

1. The pa tie nt is sea t ed .

Figur e 3.8 . Ste p 3.

Cervical Spin e: Side Bending , Act ive and Passive

1. The pa tie nt is sea t ed .

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

Figure 3 . 14 . S tep 5 , pa ssi ve si de

Figure 3 . 15 . S tep 5 , pa ssi ve si de

Cervical Spin e: Ro tatio n, Active and Passive

1. The pa tie nt is sea t ed .

Figure 3 . 17 . S tep 4 , ac t iv e rotation righ t.

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

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

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

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

1. The pa tie nt is sea t ed .

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

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

1. The pa tie nt is sea t ed .

Figure 3 .27. Step 4.

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

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

1. The pa tie nt is sea t ed .

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

1. The pa tie nt is sea t ed

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

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

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

1. The pa tie nt is sea t ed

1. The pa tie nt st an ds in a ne utral p o si tio n

Lum bar Spine: Side Bend ing, Active

1. The pa tie nt st an ds in a ne utral p o si tio n

1. The pa tie nt st an ds in a ne utral

Figure 3 .45 . Ste p 3,

Figure 3 .46 . Ste p 3,

Norm al Spinal Ra nge s of Motion for Act i ve a nd Pa s sive Test i ng

NORMA L DEGREES O F MOTION– CER VICAL SP INE

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

T1- 3 T4 -8 T8-L 1 T1- 4 T5 -8 T9- 1 2

NORMAL DE GREES OF MOTION–LUM BAR SP INE

Fl ex ion = forw a rd b e nd in g ; Ext en si o n = b ac kw a rd b e nd in g ; R/L , ri g ht a n d le f t.

2. Ca thie A, Ph il ad e lp hi a Col leg e o f Ost eo pa t hy . Fro m Dr. Ca thie ' s PC O M (OP P)

Examinatio n Seq uence

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

Skin Topog raphy and Textu re

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

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

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