Course Material - Manual Therapy

The Spine: An Osteopathic
Approach
By Laurie Hartman, DO, PhD
Course Materials
The Demonstration
The Spine: an Osteopathic Approach Laurie Hartman, DO,

PhD
Rhythmic Technique:
Kneading
Apply Pressure
Apply Stretch
Hold

PhD
Rhythmic Technique:
Articulation

PhD
Rhythmic Technique:
Traction
Have patient side-lying

PhD
Rhythmic Technique:
Springing
Patient lies on her stomach

PhD
Rhythmic Technique:
Inhibition
Sustained pressure for 20-30 seconds
Muscle changes
Circulation changes

PhD
Rhythmic Technique:
Vibration
Good for congestion

PhD
Rhythmic Technique:
Effleurage
Different from kneading

PhD
Low Velocity Stress Techniques:

Sustained Levers

PhD
Low Velocity Stress Technique:

Sustained Pressure
Find the areas that are tight and apply pressure
until the tissues release

PhD

Sustained Traction
20-30 seconds and tissues release

PhD

Sustained Articulation
Apply stretch and a little movement until the
tissues release

PhD
Thrust Techniques
Conventional Combined Lever Thrust
with Movement
with Minimal Leverage
PhD
Soft tissue Manipulation
Position
Apply Downward pressure and hold
Apply Outward pressure and hold
Change across the hand
Release
Applying pressure using the whole hand provides
more comfort

PhD
Three Basic Postures

(Positioning of the Feet)
1. Front leg well bent, back leg slightly bent
Feet pointing to the top or bottom of table
As thrust is performed the heel of the back leg comes
off the floor.
2. Front leg slightly bent, back leg well bent
Feet pointing at 90 degrees to each other
Better for small practitioners
3. Front and back leg bent
Feet pointing across table

PhD
Soft tissue Manipulation

Side-Lying
For patients who cannot lie on their front
Patient knees are bent, shoulders anterior
Pull hold--- wait-- change

PhD
Soft Tissue Manipulation

of the Neck
Operator positions feet pointing forward towards
the end of the bed
Hold patients head firmly with one hand, the
other hand positioned on the spinous process
Apply pressure upwards hold turn change

PhD
Soft Tissue Manipulation

of the Arm
Position both thumbs on the arm in a
comfortable grip, and turn towards opposite
directions, pull and hold
Work upwards towards the shoulder, gets a
comfortable grip, using one hand, apply
compression to the shoulder, pushing
backwards. With the other hand turn the arm
towards the opposite direction
Apply proper posture
PhD
Propioceptive Manipulation
Fit hand to the shape of the part you are working on
Use compression of operator, tissues and patient
Move your body with the hand as an extension of the part being
worked on
Maintain enough pressure that tactile sensation is overcome
Monitor comfort carefully, apply wide pressure with focused force
Maintain constant slight movement for optimum awareness and
comfort
Proper positioning of the feet provides better pressure

PhD
Propioceptive Manipulation
of the Arm

PhD
Module 1
Soft Tissue and

Articulation Methods
Laurie Hartman, DO, PhD
The Spine: an Osteopathic Approach Laurie Hartman, DO, PhD
Categories of Technique
Designed to assist dialogue and recording.
They are flexible.
Good recording of methods applied can help to
analyze problems.
They are not universal and thus are only a guide
System is designed to state what is actually being applied,
rather than what is perceived to be the effect (British School of
Osteopathy).
Rhythmic Techniques
Mobilizing Methods
Kneading
Springing
Stretching
Inhibition
Articulation
Vibration
Rhythmic traction
Effleurage
Low Velocity Stress Techniques

Sustained
Levers
Pressure
Traction
Articulation
Very low force

Slowly applied methods depending
on patient co-operation in
relaxation.
They are all reactive methods.
They all depend on the guiding
hand being used as a sensitive
instrument rather than as a force
applying tool.
Time - critical component to allow
the tissues to adapt.
4
Thrust Techniques
Can be, high, medium or low velocity
High velocity with low amplitude is the classical method

Combined lever and Thrust (CLT)
Combined Lever and Thrust with Momentum Induced
(CLT-MI)
Minimal Lever Thrust (ML)

Non lever Thrust (NLT)
Non lever Thrust, Momentum Induced (NLT- MI)
5
Optimal Soft Tissue Work
Pressure
6 to 7 seconds
10
Time in seconds
The 4 Cs
Curiosity
This allows us to be able to search for the

best way of aiding natural healing
processes.
Comprehension
This allows us to more fully understand

the various possibilities.
Choreography
This allows us to fit the treatment process

to the patient in the most
comfortable way.
Confidence
The more comfortable you are, the more

relaxed the patient.
This inspires a similar state in the patient.
Problem Words
Traditional in Physical Therapy to say
I always do that or I never do that
Better to be prepared to find the technique

that works best for the patient
Handling Variations
Temperature
Pressure
Speed
Force
Direction
Rhythm
Duration
Comfort
Confidence
Area and size
of hand
Awareness
Tissue dialogue
needs
involvement and
effectiveness
Body Framework & Disease
Perverted or dysfunctional anatomy

Altered responses to stress
Subtle variations from normal patterns
Poor Structural relations
Vulnerability
Emergence of symptoms
Body Framework & Disease

Analysis should lead to the nature &
cause of the problem
This should lead to potential treatment &
choice of techniques
THE
MANIPULATIVE PRESCRIPTION
How do you choose the
appropriate technique?
The bigger the range of procedures,
the more the choices
The Spine: An Osteopathic Approach Laurie Hartman, DO, PhD
What is wrong with the patient?
Neurological Dysfunction
Mechanical Dysfunction
Psychological Dysfunction
Hydraulic Dysfunction
Current Models of Dysfunction

1. Neurological
Afferent - Efferent, Gamma gain changes
2. Mechanical
Apply forces to break the mechanics (locking, spasm)
3. Hydraulic
Fluid impaction, poor lubrication, drainage, circulation
4. Psychological
Emotions, stress, posture problems
Compression
as a Key Component
Compression acts as a secondary lever

Helps minimize the amplitude of the Primary lever
Probably works by tissue creep
Can be applied in different ways and will have
different results
o Compression with one hand is different with
compression with two
Changes in Tissue Response to Strain

1. Creep Deformation
Response to pressure or sustained stretch
2. Plastic Changes
Slow change in ability to bend or stretch
3. Adaptation
Ability to change to meet prolonged demand
Operator Posture
Conscious considered use of Operator Posture
Helps Control
Depth of Force
Direction of Technique
Amplitude of Lever
Power of Procedure
Sensitivity of Hold
Ability to focus the forces to a specific target site
Comfort for Patient and Operator Should Improve

Efficiency, Effectiveness & Balance
Safety & Security
Reduce Fatigue
Primary & Secondary Components

The Primary component is that which is the
executive part of the whole procedure
e.g. Putting the head in rotation
The Secondary components are those that are used

to enhance and reduce the amplitude of the
Primary
e.g. Side bend; apply pressure;extend

Constantly test the primary
Three Basic Postures

1. Feet pointing to top or bottom of table
Front leg well bent, back leg slightly bent
2. Feet pointing at 90 degrees to each other
Front leg slightly bent, back leg well bent
Better for small practitioners
3. Feet pointing across table
Front and back leg bent
Introducing Palpation
Use of palpation:
Locate the dysfunction using tapping
Detect the quality and nature of the dysfunction
Amplify the awareness of the dysfunction
Interpret the findings

Utilize the information constructively to choose the
appropriate technique
Palpation Skills
Essential Abilities are:
A cultivated subjectivity (thinking with your hands)
A palpatory vocabulary
An awareness of tissue behaviour in different states
Normal, patho-physiology, pathology
Consciousness of hyper and hypo-function
o Hyperfunction overworking; late symptoms
o Hypofunction stiff tissues; early symptoms
The capacity to decide relevance

Propioceptive Palpation
Fit hand to the part you are working on
Use compression of operator, tissues and patient,
isometric tension of the arm
Move your body with the hand as an extension of the
part being worked on
Maintain enough pressure that tactile sensation is
overcome (a little movement is better than just static)
Monitor carefully, wide pressure with focused force
Maintain constant slight movement for optimum
awareness and comfort
Response to Demand for Motion

Not Range of Motion
Response to initial demand, from a static position
to what happens when part is recruited
Does it have some ability to move?
Does it fall apart?
What do you feel when you touch it?
Does it Ease or Bind?
Functional Osteopathy
Approach where one decides on Ease or Bind
Most manual therapy works on the bind
Find the bind and hit it
Functional technique works on the opposite
Position the part in its easy position
Apply secondary levers to get to the
point of normalization;
if done right everything releases
Response to Initial Input of Energy

and Motion Demand
EASE
BIND
Ease or Bind
An articular structure in a state of dysfunction will
manifest either ease or bind when asked to allow
initiation of movement
Accumulating the bind directions allows a barrier to be
found that is short of the end of joint range
Accumulating the ease directions allows a functional
release technique to take place
Gentleness
The value of gentleness lies not only in
being more efficient, but in being able
to sense more
Excessive force is not a substitute for
skill.
Diagnosis, Assessment, Evaluation

What is the problem?
Can we do anything for it?
Would anyone or anything else be better?
What is the realistic time scale (prognosis)?
Is our approach justifiable and sensible?
Is a therapeutic trial reasonable?
Diagnosis, Assessment, Evaluation

What is the tissue at fault?
What is the fault in the tissue?
What is the immediate cause?
What are the predisposing factors?
What are the maintaining factors?
Why have the natural homeostatic
mechanisms failed?
Incidence of Symptoms
2 patients with different symptoms
Time Sign Graph
When?
How long?
What happens when you move?
Daily routine and activities
Different approaches
Pathological Sieve
Osteopathic Manipulation
of the Cervical Spine

1
Functional Assessment
Look into the functional assessment of the
patient
Exclude RED FLAGS

Consider YELLOW FLAGS
Listen to the tissues, they know best and
are waiting to be asked.
2
Minimal Leverage Technique
Does not use torsion

Uses small amounts of multiple components
Focused to a specific segment or facet
Uses mid joint range
Subtle gentle positive
Has minimal damage
No pain or discomfort
More difficult to learn
3
Foundation Concepts:
Modifying Factors
Handling
Posture
Positioning
Stance
Anatomical plane
and direction
Compression and
close packing
Applicator
Contact point
Contact point pressure
Onset and arrest
Amplitude
Force and speed
Relaxation
Respiration
Resistance
Primary and secondary levers
4
Foundation Concepts:
Modifying Factors
Primary Lever
Alters the direction of impulse, thrust,
and manipulation
Secondary Levers
Any component, direction or movement used
to reduce the amplitude of the primary

5
Technique Breakdown
Focus (isolate) to the segment

Focus to the joint using compression
Build to the barrier
Create local tissue tension using components

6
Basic Routine to Build Barrier Tension:
Minimal / Short Lever Manipulation

Focus to the segment
Test the Primary Lever Amplitude at the segment
Add some of the 1st chosen Secondary Lever
Retest the Primary Lever Amplitude
Less primary lever amplitude is good
Add some of the 2nd chosen Secondary Lever
Less primary lever amplitude is good
Add some of the 3rd chosen Secondary Lever
A firm, obvious stop point is the barrier
7
Basic Routine to Build Barrier Tension:
Minimal Short Lever Manipulation

Primary Lever: Rotation
Compress
Side bend
(Secondary Levers )
Test the Rotation (Primary Lever)

Side shift
Extend
(Tertiary Levers )

8
Effective Specific Soft Tissue Work

Establish contact sympathetically
Load patient, tissues & operators hand using
proprioception
Initiate application of force
Use dynamic pause to listen for change
Sense change activating
Focus down to target tissue with smaller area of the hand
Follow the open pathway of least resistance
Back away slowly
Release and move on to next area
9
Component Technique
Aim is to create the resistance barrier
Use the best parts of both direct and
indirect technique combined together

10
Creating the Barrier :

Decide on a primary component
Add secondary components as required
Constantly test the primary component
Allow the secondary components to produce
accumulation of resistance
in the primary direction

11
Creating the Barrier :

Search or mobilize as appropriate to the
tissue or structure, maintaining all
secondary components
Thrust requires alignment of the joint
facet in the primary component direction

12
At the Created Barrier, work on
QUANTITY of movement.
Work done at the created or manufactured barrier
will change the tissue behavior at the actual
barrier
QUANTITY: The manufactured barrier is most
usually at a lesser amplitude of motion than the
actual barrier while the secondary levers are in
action
13
Demonstration:
Osteopathic Manipulation of the
Cervical Spine

14
Direction for Rotation

15
Different Holds for the Cervical Spine:
Chin Hold - Into Rotation
Source: Handbook of Osteopathic Technique
Page 174 (21.40)

16
Different Holds for the Cervical Spine:
Cradle Hold Into Sidebending
Page 175 (21.42)17
Cervical Thrust Technique using the

Minimal Lever Approach
1.Choose a Hold
Fix the head comfortably on the proximal interphalangeal joint
of the index finger
2. Perform some Rotation
3. Add some Side-bending
Test the rotation
4. Add some Side-shifting or Side-gliding
Test the rotation
5. Elicit tension using some Extension
Abduction in the fingers adds tension
6. Add the Thrust then release
Make several trial mini-thrusts with slight variations
in angles and balance of components.

18
Cervical Thrust Technique using

the Minimal Lever Approach
Choose a HOLD
Chin hold, Cradle hold, Combination
Get into primary lever position: Rotation
Add some Side bending; Side gliding
Test the rotation
Abduct the hold
Thrust
Release
* Use minimum quantity of movement

19
Cervical Thrust Technique Elements

Primary Levers
Rotation
(Side Bending)
Secondary or Stabilizing Levers

Side Bending / Side Gliding
Compression
Side shifting
Tertiary Elements or Levers

Posterior/Anterior Shifting
Traction
Flexion/extension

20
Manipulation of the
Soft Tissue Scapular Area
Put patient is in a side-lying position
Fix hands in the scapular area
Stretch

21

22

23
Order & Quantity of Components

Varying the order and quantity of the components allows the primary to be
changed according to the needs of the tissues.
Rotation
Sidebending
Compression
Extension
One hand or two?
One first, or both together?

24
Mobilizing Cervico-Thoracic Area -1
Patient puts one hand behind

the head (eg right)
Hook your right arm over the
patients folded arm, rest your
hand on her head
Position your left thumb on the
patients spinous process
Introduce elements to elicit
tension
Rotation
Side-Bending
Flexion-Extension
The Spine: an Osteopathic Approach Laurie

DO, PhD
PageHartman,
149, 20.4
25

Patient rests her arm on your
bended knee
Hook your arm over the
patients arm, rest your hand on
her head
Position your left thumb on
the 1st or 2nd ribs
Apply firm, straight pressure
downwards
156,20.20
26

Using Rotation
Patient is positioned on her
side at the end of the table
Fix your thumb on the
patients spinous process
Position your other arm
bended over the patients head
Introduce Rotation and
Sidebending to separate the
facets
178, 21.51
27
Mobilizing Cervico-Thoracic Area - 4

Using Side-lying Position
Position the patient side-lying,

with both hands clasped over
the head, elbows held together
Position your fingers on the
patients spinous porcess,
the other hand positioned on her
head
Apply Flexion-Extension
Rotation and
Side-bending
Page 150, 20.6

28
Mobilizing the Occipito-Alantal

using Traction
POSITION 1
Positioning one hand under the neck and resting the
other on the head
Produces traction on C1-C5
POSITION 2
Position the hands over either side of the neck, each hand
pushing on opposite directions
one thumb is lower than the other
Produces traction on C6- C7

29
Eliciting Areas of Tension

Use 2 fingers to tap either side of the spinous
process
Listen carefully for areas where there is
tightness/tension
Tapping a normal segment does not elicit
reaction from the patient
Tapping a segment with tension makes the
patient uncomfortable (eg they start to sweat or
complain)

30
Mobilizing Cervico-Thoracic Area

Using Sitting Dog Thrust
Have the patient cross both arms over the chest,
hands positioned over the shoulders
Insert a pillow in between the patients arms
for better facet separation.
Position your hands gripped over the patients elbows
Patients head should drop forward
Gradually pull the patient towards you and apply
Side-bending towards one direction and Rotation
on to the other direction, followed by a thrust.
Position patient side-bendingrotation thrust
Requires 3 sessions.
31
The Thoracic Spine

Email Address: [email protected]

Website:
Book on Osteopathic Techniques: $85

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What Are We Trying to Do?

Manual approaches should be based on prescription
Prescription depends on findings
Flexibility in approach is important
Restriction of mobility or function can often be reversed
Quality of restriction guides the method of choice

A combination of techniques is often necessary
Encouragement rather than force is more acceptable to
the patient and the tissues
Focused forces work best to produce the best result
Recurrent Mid Thoracic Pain

Is this with a chest or cough complaint?
If so, get them investigated by a physician
If not, consider the whole posture as this is often

due to a distorted standing pattern
If this is the case, tell the patient that they cannot
be better until they change their standing pattern.
Local treatment, but fairly quick and gentle
Whole body changes will take time to work
Recurrent Mid Thoracic Pain

Distorted standing pattern may be due to one
legged standing as in a short leg
If this is the case, you will always get a
recurrence unless you can get them standing
properly
Local treatment, but consider their whole
posture
This will take time to get them right
Posture Causing Pain

Check if the patient always stands on one leg
If they do is this habit or is it part of their
compensation to a difference in leg lengths
Flat foot on one side, one knee hyperextends,
one S/I repeatedly posterior, Cervical spine
sidebent towards the leg they stand on.
Have them bring in some photographs of
themselves standing
Posture Causes Pain
The most common cause is one legged standing

Hypermobility is the other cause of discomfort
Degenerative spine can cause this to happen
If so, excess mobilising can make it more
uncomfortable
Educate, then give some help, make sure the
patient knows the situation and what can be
done to ease their discomfort, not cure them
Movement Relieves Pain

If they have some joints that are unstable,
then this will happen

Excess treatment may well make them more
uncomfortable and they will have more pain
Exercises can help, but they need to do these
under a therapist, very few can maintain it
themselves
The main approach is to educate the patient, not
really treat them as it may not help
Discomfort After Not Moving

The most common cause is hypermobility
Check if there is some underlying condition,
eg osteochondrosis, (poor cartilage)
You cannot cure this, but you can make it
better and more manageable
Loose weight, diet, avoid standing still
Clasp hands behind back
Keep rocking from foot to foot
Discomfort After Not Moving

If they have a hypermobile joint, then
mobilisation will not help much, only short term
The main thing is to educate the patient to keep
moving.
Use management and educate the patient to keep
things free by gentle movement
Once they understand the situation, they can then
manage it quite well
Stiff After Sitting

Get them to sit properly, not slumping
Make sure they move around regularly, at least
every 15 minutes
Treatment will help, but it will not last long, so
make sure that they know that
Management, not treatment
Posture helps, but they must know what is good
posture
Stiff After Sitting

Postural education will help them quite a lot
They must sit properly,
not simply slump in a chair
Make sure that they will move regularly to get
up and down from the chair, not simply sit for
hours and then get stiffer and stiffer
Movement will help, not more resting, too
much of this can make them even more stiff
and have more discomfort
Key Elements in Techniques
Operator uses the upper abdomen, not the sternum

Operator uses the Forearm, not the hand
Point feet toward head of table, not across table
Traction with upper lever, while doing
pronation underneath
Do not lose rotation when applying sidebending.
Leg position and head position make a difference
Patient Side-lying
Lumbar Technique
Fix over rib head or T/P
Compress through shoulder,
slightly back and down
Fix on ilium with lower arm
Fix on patients arm with thorax
Focus forces with gentle rocking
Thrust lower lever without
increasing upper, but hold
it firmly.
Thrust for Mid Thoracic Area Sidelying
Page
126 17.29,
17.30DO, PhD
The Spine: an Osteopathic
Approach
Laurie Hartman,
Thrust Mid Thoracic Area Sidelying

Fix over rib head or T/P
Compress through shoulder,
slightly back and down
Fix on ilium with lower arm
Fix on patients arm with thorax
Focus forces with gentle rocking
Thrust lower lever without
increasing upper, but hold
it firmly.
Page
126 17.29,
17.30DO, PhD
The Spine: an Osteopathic
Approach
Laurie Hartman,
Thrust to Mid Rib Articulations

Sidelying Using Lumbar Lever
Page 141 18.21, 18.23

Stretching of the Muscles

Medial to the Shoulder Blade
Patient is prone
Internally rotate the shoulder
to put the maximum stretch on
the muscles
Adduct the shoulder and
stretch the muscles medial to
the scapula
Prone Work Medial to the Scapula

Patient is prone
Pull the shoulder
medially and backwards
Use finger tips under the
scapula to stretch the
muscles

Side lying Stretch of the

Muscles Under the Scapula
Patient is side lying with
shoulder behind them
Work with both hands to
stretch the muscles
under the scapula
Side lying Stretch of the

Muscles Medial to the Scapula
Side Lying Work on the

Scapula Muscles
Patient is side lying
Push down on her shoulder
At the same time pull up on the
muscles superior to the shoulder
You can try moving the body
instead of the hand, or holding
the muscles until they relax
Prone Mobilizing of the Thoracic Spine

Patient lies prone
Folds her hands under her
forehead
Operator lifts the patient
with his upper hand and
rotates her
He fixes the area with his
other hand and uses
extension and local fixing
Sitting Dog Thrust Technique

Have the patient cross both arms over the chest,
hands positioned over the shoulders
Position your hands gripped over the patients

elbows
Patients head should drop forward
Gradually pull the patient towards you and apply

Compression, Side-bending towards one direction
and Rotation on to the other direction, followed by
a thrust.
Variation of
Dog Thrust Technique

Brief Examination of the

Thoracic Spine Using Tapping
Sidelying Work on the

Thoracolumbar Area
Variation of
Thoracolumbar Area
Using flexion
Variation of
Thoracolumbar Area
Lumbar Lever
Variation of
Thoracolumbar Area
Opposite
Supine Dog Technique

Pull down on rib head
Compress gently toward table
on anterior of rib
Have patient lift head
As head lifts, simultaneously
pronate under hand, compress
with upper hand, thrust with
chest against folded arms
Manipulating the
Anterior Muscles of the Shoulder
4 movements to position hold on shoulder
Cradle Hold into Side-Bending
DEMONSTRATION
THORACIC SPINE
Mobilizing Occipito-Alantal
Cradle Hold into Side-Bending

Tilt the head into extension
Do side-bending
Mobilizing/ Thrust
for Cervico-Thoracic Area
Slight rotation
Compression
Sideshifting
Slight sidebending
Pull back on atlas and simultaneously compress
head and twitch head into rotation to separate
facet on concave side
Thrust to 2nd Rib

Pull down on rib head
Compress gently toward table on anterior of rib
Have patient lift head
As head lifts, simultaneously pronate under
hand, compress with upper hand, thrust with
chest against folded arms
Thrust to Middle Ribs

Fix under rib angle with pisiform
Compress through chest
Introduce sidebending and rotation to same side
Maintain rotation and introduce opposite
sidebending at the same time as extension
Have patient extend their head

Thrust up under rib with vertical/upward force
Variations to Head Holds

Traditional Cradle Hold
Combined Chin and Cradle Hold
Chin Hold
Zone of Effectiveness
Cradle hold into side-bending
Junctional Areas
Working on cervical or thoracic area or
joints in between?
Are the ribs in the way?
Fascial attachments make the area strong
Limited flexibility neck vs. thoracic spine
Sensitive areas need care

Occupational and Emotional Stresses
Changes in Stress
Mobilizing Occipito-Alantal and

Atlanto-Axial Facets
40 to 50% rotation
Very slight extension; sideshift
Push and pull to produce
gapping of facet nearer table
and Atlanto-Axial Facets
Rotation
Very slight extension; sideshift
Apply thrust to release the joint
Mobilising/Thrust
Occipito-Altlantal
Sidebend
Extend
Rotate clockwise or counter-clockwise
Soft Tissue Scapular and Shoulder

Area
Osteopathic Approach to the

Lumbar Spine
Skill Assessment:
Technical Competencies
Comprehension
Handling
Effectiveness
Operator Posture
Current Models of Dysfunction

1. Neurological
2. Mechanical
3. Hydraulic
4. Psychological
Handling
Negative
Fast
Rough
Cold
Irritating
Painful
Unsettling
Positive
Slow
Firm
Gentle
Confident
Warm
Caring
Involved
Operator Posture
Conscious considered use of operator posture helps control
Depth of Forces
Direction of Technique
Amplitude of Levers
Power of Procedure
Sensitivity of Hold
Ability to focus the forces to a specific target site
Increase Comfort for Patient and Operator
Should Improve
Efficiency, Effectiveness & Balance
Safety & Security
Reduce Fatigue
Operator Posture
General Rules
Use a wide base

Use operators body
with fixed hands
Use rhythm
Demonstrate control
Thrust Technique
Usually One Leg Forward,
One Back
Thrusting Hand on Side
of Rear Leg
Rear Heel Slightly Raised
Extension of Operators
Spine
Brief Isometric Contraction
of Abdomen
Locking or Focusing
Many types of manipulative procedure use locking where
an attempt is made to remove all mobility from adjacent parts
to allow the force to reach only the target segment.
This can be uncomfortable, traumatic

and potentially unsafe.
With focusing, as little tension as possible is put through
adjacent parts, but, the target segment is at the point of
maximum focus of the forces.
This is usually not uncomfortable

How Can We Focus Without Locking?
Use several components or vectors or elements

Control the part being worked accurately
Direct forces according to anatomical principles
Be highly aware of palpatory cues
Learn how tissues respond to varied forces
Keep an open mind to the varied possibilities!
Components 1
Sidebending
Rotation
100% barrier using 2 components

Components 2
Sidebending
Flexion
Rotation

Components 3
Sidebending
Compression 1
Flexion
Rotation
????
A/P
Compression 1

The Barrier in Technique

Where is the Point of Maximum Resistance?
Direct Action - Engage and Push Barrier
Indirect Action - Work Away From Barrier
Component Technique
In Component Technique
we aim to create the barrier using
the best parts of both
direct and indirect technique
combined together
Creating the Barrier

1. Decide on a primary component
2. Add a secondary components as required

3. Continually test the primary
4. Allow the secondary components to produce
accumulation of resistance in the primary direction
Stretch or mobilize as appropriate to the tissue or structure,
maintaining all secondary components
Adding a thrust requires alignment of the joint facet in the

primary component direction
Mobilization/Articulation
Lumbar Spine Sidelying
Primary vector or lever = flexion
Could be sidebending, rotation,
traction, compression
Secondary or stabilising levers

Add Compression x 4, sidebending
rotation, traction
Absolute Contraindications
Thrust Technique
RECIPES
BONE
Anything that can
weaken bone
NEUROLOGY
Anything that can
damage nerves
Routines and purely

empirical methods
DIAGNOSIS
Lack of working
hypothesis
SYMPTOMS
VASCULAR
Anything that can
damage vessels
Excessive pain or
resistance
Relative Contraindications
Thrust Technique
Pathology
Vertigo
Inflammation
Psychology
Disc Prolapse
Inadequate skill
Degeneration
Hunch/feel
Pregnancy
Pharmacology
Physique
Age
Reasons for Applying a Thrust?

1. To relieve pain
2. To increase range or facility of movement
3. To improve function
4. To increase circulation
5. To affect the neurophysiology
6. To break joint fixation
7. As a short cut
8. To release entrapment
9. Powerful psychological effect
10. Less work than mobilizing and often less painful
Effective Specific High Velocity Thrust

1. Decide on sliding or gapping
2. Take a firm, comfortable grip
3. Introduce some of the primary lever direction
4. Introduce whatever secondary levers help to reduce
the amplitude of the primary
5. Engage the barrier and gently test the quality
6. If the barrier is crisp and firm, apply a very short,
sharp thrust without losing the secondary levers
Which dysfunction to attend to first?

Which one will correct with the least effort?
Which one will unstress the overall structure

the most?
Usually from below upwards.
Usually only one in each area at first.
Establishing Harmony
Make sure the patient is comfortable
Work to make the segment more flexible
As soon as it is, then stop, do not work by time
Monitor results to become more effective
When The Usual Methods Fail

Try to find another method.
Use changes in patient position, or your posture to
make these changes.
Use a different approach to the problem.
Use an altered method of treatment to change the
pattern of the patient.
If you cannot get a result in a normal time, then get

another opinion.
You may be wrong.
DEMONSTRATION
Flex both knees of the patient
Proper operator position.
Position operators elbow putting pressure behind the
mid axillary line of the patient
Fix the middle finger firmly on the lumbar area
Fix the other arm on the sacrum
Apply flexion, if the segment is tight the operator can

change from flexion into rotation or sidebending or
traction
Minimal Lever Approach on

the Lumbar Spine
Position patient comfortably on
the edge of the table; sidelying

Position middle finger on the
lumbar spine
Position other arm on the sacrum
and apply compression
Primary Lever: Rotation
Apply Sidebending/ Flexion
Page 84 (13.43)
Apply tertiary levers as necessary
Apply thrust
Mobilizing the Lumbar Tissues

Assess the part with fingers, locate
restriction
Apply compression with 2 hands
Apply sidebending
Release after 6-7 seconds
Turn patient to the side

Flex both knees
Position fingers on L5 and arm on sacrum
Apply flexion
Apply secondary levers as needed
(sidebending; rotation)
May apply thrust as necessarily if possible/
had been done before
Position patient comfortably sidelying
Apply finger/ fixation on L4
Roll pelvis toward operator; rest on the pelvis
Apply side-bending, compression
Ask patient to take a breathe in
At optimum Moment, increase compressions and
Thrust the joint
Work on the other side
Effective Specific Mobilizing

Using Individual Components
Position patient comfortably on the edge of the table;
sidelying
Position middle finger on the lumbar spine
Position other arm on the sacrum and apply compression,
then roll patient toward the operator
Primary Lever: Flexion/Rotation
Apply secondary and tertiary levers; increase in pressure as
needed to achieve optimum effectivity
Put several components together to focus specifically to
where the finger is positioned to stretch and mobilize
specific tissues
Effective Specific Mobilizing

1. Position patient comfortably
2. Good, firm, but careful contact
3. Introduce some of the primary lever
4. Introduce secondary lever/s to help focus and
amplify the primary
5. Maintain all secondary levers to control the barrier
6. Mobilize by amplifying the primary lever direction,
repeat until change occurs
Effective Specific Soft Tissue Work
Establish contact sympathetically

Load patient, tissues & operators hand using
proprioception
Initiate application of force (stretch hold wait)
Use dynamic pause to listen for change
Sense change activating
Focus down to target tissue with smallest area of hand
Follow opening pathway of least resistance
Back away slowly
Release and move to next area
Operator Stance
Feet pointing to top or bottom of table
Front leg well bent, back leg slightly bent
Feet pointing at 90 degrees to each other
Front leg slightly bent, back leg well bent
Feet pointing across table
Front and back leg bent
Operator Posture
Good use of operator posture can dramatically
change effectiveness
Rear leg keep rear leg internally rotated to bring your
body into the optimum position
Elbows keep elbows as close to sides as possible in most
techniques; 90 degrees
Sides use isometric tension in your own side at moment
of truth to bring you to your elbow of the thrusting hand
Experience
Use knowledge of common patterns to treat the patient
Building Technique with a

Different Subject
Operator Stance
Osteopathic Manipulation of
the Sacro-Iliac
Laurie Hartman,DO, PhD
The Enigma of the Sacro-iliac

So many different theories
So many different diagnostic methods

So many different approaches
So many different techniques

So many varied and disappointing results
Is there a way through the maze?
The Enigma of the Sacro-iliac

Movement
- upward and backward?

- downward and forward?
- inwards?
- outwards?
Where do they go?
Axes of
Movement
Specific
Artcular surface
Varied
Sacro-Iliac joint
Points slightly backwards
and slightly angled
Sacro-Iliac Palpation
Range
Quality
Facility
Direction
Spring and recoil
Is movement from elsewhere?
Sacro-Iliac Palpation
Amplitude
Speed
Recoil
Quality
Consistency
Malleability
Speed of change
Symptoms
Sacro-Iliac Tests
Gossip test
Weight transfer test
Standing rotation test
Levels
One legged standing
Mobility on springing
Character of dysfunction
Gossip Test
Have patient stand and let one knee slump
Do they drop equally both sides?
Is weight bearing on one leg more painful?
How does the lumbar spine side-bend?
Weight Transfer Test

Have patient stand with one leg forward
of the other
Transfer weight from back to front
a few times
How does the pelvis co-operate?
Is the movement even or distorted?
Is there pain on taking the weight?
Standing Rotation Test

Have the patient stand with their back to you
Hold the pelvis and ask them to rotate to
either side, or internally rotate their hips
to block hip movement

Is there pain induced over one sacro-iliac?
Is the movement even?
Do they cheat in the thoraco-lumbar area?
Levels
Posterior Sacro-Iliac Spine

Anterior Sacro-Iliac Spine
Christmas
Iliac crests
Trochanters
Pubic symphysis
Mobility on Springing
Hyper or hypo mobility

Range and quality
Pain on springing
Pain on Spreading and shearing
Relationship of hip mobility
One Legged Standing
Can they lift one leg so knee is opposite hip?

Is there poor balance?
Is there pain on the weightbearing side?
Is there inability to lift the affected side?
Has disturbed proprioception affected the S/I
producing a postural nystagmus?
Character of Dysfunction
Symptoms increase with
Crossing legs
Stair climbing
Turning in bed
Making love
Getting out of a car
Rising from sitting
Prolonged standing
Check for Symmetry
Patient in prone position

Posterior spines
Crests
Inferior spines
Anterior spines
Sacral Squeeze and Release

1. Position hands
2. Compress downwards
3. Squeeze and Release
Page 106,14.31
Lumbo-Sacral Facet Gapping

1. Position hands
2. Compress downwards
3. Push towards head
4. Flex to open facets of
lumbosacral
Page 88, 13.55

Cross Handed Sacro-iliac Thrust/Springing
1. Position hands
2. Apply compression and
torsion
3. Apply thrust/ springing
Page 98, 14.9
Sacro-Iliac Articulation/Mobilization
Page 95, 14.2

Sacro-Iliac Articulation
Page 95, 14.1

Sacro-iliac Thrust
With Patient Assistance
Find plane of joint by springing
Gentle pressure along joint plane
Have patient rotate with one
hand push up
As PSIS hits hand, very small
thrust into joint plane
DO NOT allow lumbar spine to

hyperextend
Page 101,14.18
Releasing Higher Segments Prior to

Focusing on the Sacro-iliac
Focus on the higher segments of the spine
with middle finger and thumb
Locate the site with tension
Release tense spots using cross-handed
springing/thrust
Start from the upper part of the spine
downwards
Applying the Same Techniques on

Sacro-iliac Manipulation on a
Different Type of Patient
Procedure to Normalize the Sacrum

1. Inspect the sacro-iliac
2. Position the hands (one hand on the top of
the sacrum the other above the coccyx)
3. Push downwards then release (note for
springing back of tissues)
Sacro-Iliac Manipulation with Rotation

1. Proper stance
2. Position hands
3. Compress downwards then apply thrust/
rotation
* Apply Control and Torsion
Lumbar Roll with Leg Traction
Page 92
13.64

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What are the different types of techniques discussed?

What are some specific techniques described?

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