HANDBOOK OF

OSTEOPATHIC
TECHNIQUE
Third edition

Laurie Hartman oo MRo

Associate Professor of Osteopathic Technique,
British School of Osteopathy

1
m I SPRINGER-SCIENCE+BUSINESS MEDIA, B. v.
First edition 1983 published by NMK Publishers
Second edition 1985 published by Hutchinson
Published in paperback 1990
Reprinted 1992, 1994
Third edition 1997
© 1983, 1985, 1990, 1997 Laurie 5. Hartman
Originally published by Chapman & Hall in 1997

Typeset in 10/12 Palatino by Photoprint, Torquay, Devon

ISBN 978-0-412-62310-3 ISBN 978-1-4899-6868-5 (eBook)

DOI 10.1007/978-1-4899-6868-5

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A catalogue record for this book is available from the British Library

Library of Congress Catalog Card Number: 96--83432

i§ Printed on acid-free text paper, manufactured in accordance with

ANSIINISO Z39.48-1992 (Permanence of Paper).
CONTENTS

Foreword v

Acknowledgements vi

Preface to the third edition vii

1 How to use this book 1

2 Somatic dysfunction 4
3 Diagnosis 7
4 Classification of osteopathic techniques 13
5 Contra-indications and precautions 23
6 Indirect technique 31
7 Modifying factors in technique 39
8 Handling 49
9 Operator posture and stance 51
10 Applied technique 56
11 Principles of locking 62
12 Exercises for developing technical skill 66
13 Techniques for the lumbar area 69
14 Techniques for the sacro-iliac area 94
15 Techniques for the gluteal region and coccyx 108
16 Techniques for the thoraco-lumbar junction area 113
17 Techniques for the thoracic spine 116
18 Techniques for the thoracic cage and ribs 131
19 Techniques for the scapula-thoracic area 143
20 Techniques for the cervico-thoracic junction area 147
21 Techniques for the cervical area 159
22 Techniques for the occipital area 179
iv Contents

23 Techniq ues for the sinuses and tempor o-mand ibular joints 189
24 Techniq ues for the clavicle area 193
25 Techniq ues for the shoulde r area 198
26 Techniq ues for the elbow area 209
27 Techniq ues for the forearm area 218
28 Techniq ues for the wrist and hand 219
29 Techniq ues for the hip area 227

30 Techniq ues for the thigh area 233

31 Techniq ues for the knee area 239

32 Techniq ues for the calf area 250

33 Techniq ues for the foot 253

Recom mended reading 275

Index 277

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FOREWORD

Laurie Hartman has been practising as an osteopath, and teaching osteopathy since 1964. He
first published his Handbook of Osteopathic Technique in 1983, and it has since become accepted
as the leading text in its field. It has been widely read by members not only of the osteopathic
profession, but also many other professions world-wide.
During that time Laurie Hartman has travelled more and more widely to teach, helping
undergraduates and postgraduates to refine existing skills and to widen their technical
repertoires. He continues to be much in demand wherever people wish to learn and practise
manual therapeutic techniques at a high level of skill. Having worked with him frequently
since 1984 I have observed how Laurie's approach has continued to evolve, his enthusiasm for
osteopathy has remained undimmed, and that his desire to help others achieve their full
potential is far from exhausted. Furthermore, he has retained the determination and the
ability to go on learning himself; he is a powerful advocate for osteopathy, and a marvellous
example to those who would practise it.
This new and revised edition of his book is an excellent development of the earlier work,
and an appropriate testimony to one of the leading technicians of his, or any other,
generation. Laurie has included a greater number of techniques, many of them 'specimens'
that he has 'collected' during his worldwide teaching. He has also expanded the text,
incorporating sections on different approaches to technique, their backgrounds and clinical
application. The reworking and augmenting of the photographic contents will greatly assist
the reader in analysing techniques on a step by step basis. The expanded sections on
technique selection, modification and application will enable readers to benefit from Laurie's
huge experience of clinical practice and teaching, and the new format will assist in its use as a
genuine working text from which everyone can learn something.
I am very pleased to have been invited to write this foreword, and have been privileged to
work with someone who is quite simply unique. It is not easy to be a good teacher of
osteopathic technique, and it is particularly difficult to produce a textbook that is genuinely
useful to students of a wide range of backgrounds and levels of skill. Laurie Hartman has for
many years been one of the world's leading technicians and teachers, and this book confirms
his ability as an author.

Clive Standen
Principal
The British School of Osteopathy
ACKNOWLEDGEMENTS

I am indebted to several people who have helped me enormously in the preparation of this
third edition of Handbook of Osteopathic Technique. Firstly, my wife, Susan, who not only
did a great deal of the typing, but made numerous constructive suggestions as to better ways
of expressing many of the ideas. She also modelled for the photographs, which required
much fortitude. The photographs were ably and sympathetically taken by Emmy Anderson.
My friend, colleague, and fellow teacher of osteopathic technique Clive Standen currently the
Principal of the British School of Osteopathy in London helped me a great deal with
constructive criticisms of the text, and Steven Lusty helped model the two-man techniques.
I cannot list all the colleagues who over the years have been inspirational in my work, but
no book of osteopathic technique written in England can be complete without a mention of
one of my chief mentors, the late Clem Middleton. He gave me much encouragement in the
preparation of the first edition in 1983 and was the instigator of the current classifications of
technique and the initial inspiration behind the idea of multiple components.
My publishers Chapman & Hall have been most helpful at every stage, and although it is
invidious to single out any particular individuals, I have had a lot of help and encouragement
from Lisa Fraley, Sally Champion and Rosemary Morris.
My thanks are due also to the many thousands of patients that I have treated since
graduating in 1964 who have helped me develop my skills and be able to transmit them to
others. That is not the reason why they came to an osteopath, but it has been a privilege to be
able to assist in their health care and yet learn at the same time.
PREFACE TO THE THIRD EDITION

The original Handbook of Osteopathic Technique was published in 1983 privately by myself under
the name of NMK Publishers. The NMK represents the first initials of my three children
Nicola, Matthew and Katie. Since that time I have learnt a great deal about the business of
publishing, and I am happy to leave this side of the work in the capable hands of Chapman &
Hall.
Before the first edition was published I had already been lecturing at the British School of
Osteopathy (BSO) since graduating in 1964. I had been teaching internationally since 1970,
and in the years since the first edition, I have been travelling world-wide teaching the art of
manipulative skill as practised by osteopaths trained at the BSO. I have taught at courses of
between 1 and 5 days, and with groups of practitioners and students of osteopathy,
chiropractic, physiotherapy and medicine. During this time there have been many advances
in methods of teaching manipulative skills, and many forms of technical approach have
become more widely integrated into the armamentarium of practitioners. As I have had the
opportunity to work with varied groups, my personal methods have changed and adapted.
In some places there has been a distinct shift in interest towards the many forms of indirect
technique. There are many reasons for this desire to integrate other methods than a traditional
structural approach. Conventional structural manipulation is often seen to be too harsh.
There are increasing fears of litigation. It seems too difficult or too lengthy to acquire the skills.
Other methods genuinely seem to offer advantages in certain cases, or suit certain operator
body types better. Recent times have seen an increasing percentage of female osteopathic
students, and some of the early methods of long and powerful leverages are not very suitable
for the smaller, lighter practitioners.
This book remains mostly dedicated to conventional, traditional structural technique.
Nevertheless, it aims to integrate the thinking behind many of the other methods of approach
to make the structural methods more delicate, gentler, and less uncomfortable for the patient.
Not wishing to be sexist, but only to give clarity and consistency to descriptions, the
operator will always be described as male in the text. Therefore, for he, read she, if
appropriate.
As increasing understanding of the mechanics of manipulative methods emerges, different
categories of technique are better understood. These can be integrated in a more efficient way
into treatment regimens either as separate entities, or as I have tried to do, as modifications or
combinations of existing methods. This is not a new thing; Paul Kimberley DO in the USA
proposed a version of this method of what he called 'combined technique' very many years
ago.
I have renewed all the photographs, but the system of arrow notation remains the same.
The arrows are designed to give some indication of general directions of force only. The text
section has been enlarged to include more detail about methods other than pure structural
technique. Various comments from colleagues and students have led me to include many
more illustrations of soft tissue technique positions and holds.
viii Preface to the third edition
As before, the use of video to illustrate the positions and holds has been found a useful tool,
and video tapes relating to this book with page numbers constantly on screen are available.
I remain open to constructive criticism or comment that will enhance further editions of this
work.

Laurie Hartman
HOW TO USE THIS BOOK 1

This book is divided into two main sections. Body tissues are like a spring in that they will
The first gives a basic understanding of tech- tend to creep away from torsion or stress.
nique, with some mention of many of the Most of the holds illustrated in this book
different approaches available. There is some require the operator to take control, in a
information on using non-structural or indirect comfortable way, to prevent escape from the
technique. Structural technique remains the specifically applied useful tension. This enables
principal method taught and used in most completion of the technique in a position
schools of osteopathy in the UK, and this which, at first, seems to be impossible as the
book remains primarily a work on structural part appears not to be isolated in the more
technique. normal way of conventional manipulation.
The main body of the work is the photo- Once this skill is achieved in 'barrier control'
graphs that are divided by regions of the or 'tension sense', then this uniquely non-
body rather than methods of approach. The traumatic system can be used to its best
arrows on the photographs relate to a general advantage.
direction of the forces rather than an exact There are very few operators who will find
specific path as it is impossible in the static all techniques equally useful in all cases. As
photograph to show a moving procedure. In patients vary, so do operators, and due to
some cases a series of photographs should differences in length of arms, height, strength,
aid clarity, and in others the hands are away weight, and many other factors, some tech-
from the body to show the hold more dearly. niques will not be as good for some as for
It is suggested that the sections relating to others. Nevertheless, with the wide variety
classifications of technique and the modify- of methods available this should not be a
ing factors be read first to avoid problems of problem. The modifying factors again can be
terminology. used to fit each technique specifically to each
The main emphasis in the teaching of patient and operator. The patient's age, general
manipulative technique at the BSO is on the state of health, mental state and degree of
lowest possible use of force, with the max- pain will dearly modify the approach to be
imum of specificity. This skill is not easy to used.
acquire. It can be likened to learning to play a It is not the function of this book to enter
musical instrument. A great deal of practice into aspects of diagnosis and the actual choice
is necessary, many errors will occur, and a of technique for specific conditions but purely
gradual learning curve with many disappoint- to aim at cataloguing a range of approaches
ments along the way is normal. Some of the available. Some tips will be given, however,
positions shown may, initially, not appear to for optimum usage of the techniques shown.
be effective for the purpose intended. It is The actual choice of technique in a given case
only when the use of multiple components must depend on the diagnosis and indica-
in technique is fully understood and used tions and contra-indications specific to that
efficiently that the effectiveness will improve. patient.
2 How to use this book
There is a section devoted specifically to skill well worth acquiring. Many students are
diagnosis that may help to clarify this aspect, surprised at how their tutoris can 'fine tune'
but the reader is directed elsewhere for fuller the position adopted to make it more effective
information. merely by looking at it and making very small
Thrust techniques when poorly applied are adjustments to the position or forces being
potentially dangerous in certain cases and used. Without an observer it has been found
it is suggested that no attempt be made to that the use of a large mirror can be of help
use these without the benefit of personal and the availability of a video camera for
instruction. Those experienced in this par- instant playback is also useful.
ticular category of technique and the ability Those practising manipulative therapies
to perceive joint motion barrier objectives have a unique advantage over many other
may be able to acquire some new useful professions in that it is possible to give
holds from careful study of the photo- subjective feedback from the receiving end of
graphs. techniques and treatment. If the subject
There are specialist texts relating to many merely acts as a silent model, much useful
of the indirect techniques that are not fully information is being lost as to the 'feel' of a
described and pictured in this work and technique from the receiving end. It may
the reader is referred to the bibliography for seem somewhat intimidating to be on the
more complete details on these. receiving end of this sort of comment. Never-
The anatomical terminology used through- theless, students who work together and who
out is standard. The terms relating to flexion trust each other will soon realize the benefit
and extension refer to forward bending and gained in developing the palpatory cues that
backward bending respectively rather than the match the subjective sensations of the patient.
notation used by Fryette relating to embryonic The three students can interchange so that it
curves. Certain vectors of force will be de- is possible to get immediate comment from
scribed which may only require very small people of different morphologies. In this way
amplitude. These are distinctly a minimal it is possible to develop more rapidly an
part of the technique, but in combination understanding of the modifying factors as
with other forces become an essential integral related to different patient body types. It is
part. Some techniques will prove to be also a good idea to work with a variety of
ineffectual if these very small amplitudes of fellow students as the comments will be
the secondary components are not included. subtly different and each will be able to help
They could be termed tertiary rather than the other in slightly different ways. In this
secondary components. manner it should be possible to develop an
If this book is being used for student awareness of the best pressures and forces
learning purposes it may be found that the that are effective and yet cause the least
best effect can be gained by students working amount of discomfort and trauma. This type
in groups of threes. One is the 'patient', one of palpatory awareness is essential if low
the operator, and one a constructively critical force skills are to be cultivated.
observer who can comment on the fine Very few techniques feel right until they
details of positioning and posture. In this have been practised many times until the
way the observer will also be learning how to hold and position is natural and almost
see if a technique is likely to be effective as automatic. The time taken to 'set up' the
the comments from the 'patient' should technique is critical. Many techniques will be
confirm his adjustment and fine tuning. It quite uncomfortable if the position is held for
takes a little practice to become an observer more than a few seconds. Unfortunately, the
capable of 'seeing' good technique, but it is a time necessary to get into the correct position
 How to use this book 3

may invoke so much discomfort that the times just short of a point of tissue tension.
patient may not be able to relax, and then Once this part of the technique is automatic,
more force is necessary to overcome this then move on to the whole procedure rather
increasing resistance. One solution to this is than just the hold and the building of a
to practise getting into the position many barrier sense.
SOMATIC DYSFUNCTION 2

The traditional term osteopathic lesion has responds to manipulation. This definition,
been largely superseded by the term somatic and the follow-on statements relating to it
dysfunction. Although this is not strictly remain relevant today, and form the basis
synonymous, it is in accord with the World of the approach used by most osteopathic
Health Organization International classifica- manipulative practitioners.
tion of diseases. When the original definition of Some schools of thought still relate to
an osteopathic lesion was coined by Andrew dysfunctions by their position of fixation.
Taylor Still the concept of the possibility of a Some are more interested in their inability to
dysfunction in the musculo-skeletal system move in certain directions. Some are more
without the presence of disease was revolu- concerned with the relative hypermobility of
tionary. It has taken many years for the adjacent segments required to compensate
medical profession to accept that it is possible for the restricted areas. The site of maximum
to have altered function in the spine or tenderness and symptoms is often found to
peripheral joints. It has taken even longer to be the relatively hypermobile area and is thus
accept that these dysfunctions can often be notoriously unreliable in diagnosis. Local
treated successfully by manual methods. Many dysfunction, if of recent origin, may be tender
different professions are using manual tech- and sensitive, but quickly subsides to a low
niques in treatment of these conditions, and level of irritability, leaving the compensating
their models of the cause, type of approach areas to become increasingly sensitive. There
necessary and underlying principles vary is, therefore, a time-frame to the tenderness
slightly. and this must be considered in diagnosis and
Osteopathic concepts originally looked on assessment.
joint lesions in relation to positions of dis- It is important to distinguish between a
placement. Techniques were designed to be primary and a secondary dysfunction. Old
corrections or adjustments to this perceived osteopathic terminology described primary
malpositioning. As more understanding of the and secondary lesions in relation to their
physiology, patho-physiology and pathology character and postural relationship. A second-
has developed, so the thinking in relation to ary lesion was one that had undergone certain
the lesion has changed. In 1959 Alan Stoddard, changes in the tissues, making it necessary to
in his Manual of Osteopathic Technique, defined perform two stage corrections. This was not
the condition. 'An osteopathic spinal lesion is only a very complex way of looking at the
a condition of impaired mobility in an inter- problems, but was taught differently by
vertebral joint in which there may or may not different teachers according to their own
be altered positional relations of adjacent personal model of understanding. In attempt-
vertebrae. When altered position is present, ing to simplify matters without totally losing
it is always within the normal range of the basic thinking, the BSO has adopted a
movement of that joint.' He went on to state notation based on what is thought to be a
that although the definition was limited, it logical physiological and anatomical basis.
related specifically to the condition that best A lesion may be primary or secondary. A
 Somatic dysfunction 5
primary dysfunction can be due to trauma, to and overlying them. Joints work best in the
either as a single incident or as a result of a middle of their range, and the reduced move-
series of micro-traumata. If the strains are ment will be accompanied by times when the
due to the presence of some dysfunction else- joints will inevitably meet their ends of range
where in the body, then we have a secondary too easily and strains will develop.
lesion or dysfunction. There is, therefore, a Not all somatic dysfunction states are at end
primary lesion at one or more sites with a of range, but qualitative changes occurring in
palpable dysfunction elsewhere that has been capsules and ligaments tend to make a joint
dependent on the primary for its production. with restricted mobility much more suscept-
Sometimes the primary has resolved naturally ible to mechanical problems. If the demands
or due to the intervention of treatment. If of body mechanics are for flexibility, there
the homeostatic mechanisms are capable of will be a tendency for compensatory hyper-
restoration of normality in the secondary dys- mobility in some areas with its attendant
function, then it will spontaneously correct. symptomatology. Hypermobile joints tend to
If they are not, due to weakness, muscular have a characteristic chronic aching on being
imbalance or habit, what was a secondary
asked to maintain a static position, and are
lesion becomes a self-maintaining entity of likely to have recurrent acute locking episodes
dysfunction in its own right. The secondary
as well. The chronic aching is often due to
dysfunction is really then an adaptation
sustained muscle hypertonia in an attempt
to some intrinsic fault in the structure. An
to stabilize the area. Muscle is not designed
adaptation that cannot fully balance will go
for this sustained contraction and will change
on to become a compensation. Adaptation is
somewhat according to these stresses. Adapt-
a normal physiological response to stress. It
ive changes in the muscles required to main-
is only unsuccessful adaptation processes
tain this state include partial fibrosis and
that lead to the need for compensation.
There is much debate as to what converts changes in the fascial and myofascial tissues
an adaptation to a compensation. Some think to become 'stringy' or 'ropy'. The so-called
that it is due to patterns 'learnt' by muscles. fibrositis and persistent muscular irritability
This can lead to perverted function that need little description.
eventually leads to physiological modifications There is another type of secondary lesion-
that become patho-physiological and eventu- ing that is due to altered neurology from the
ally pathological or at least partly irreversible. presence of perverted viscero-somatic reflexes
This entails the alteration of the material emanating from a dysfunctional or diseased
properties of the collagenous and elastic tissues viscus. The nature of the palpable findings in
that make up the tendons, ligaments, fascia these cases will be somewhat different from
and other soft tissue structures surrounding the simpler mechanical dysfunctions. The
an articular unit. Some of these changes are tissues have a characteristic 'doughy' nature,
not capable of spontaneous resolution once and the palpable joint dysfunction that follows
they .have passed a certain stage. It is before the soft tissue irritability will have a more
this point that manual techniques have the 'springy' nature. If the condition is main-
most use' in restoration of normal function. If tained for long enough, however, there may
muscle or fascia is too short due to compensat- be adaptive changes in the somatic tissues
ory mechanisms, there will be a tendency for that will not restore to normal spontaneously
reduced movement in adjacent joints coming when the primary irritation from the nervous
under the control of these soft tissues. The system has gone. The other characteristic that
bones and joints are only able to function as is different about this type of secondary
well as permitted by the soft tissues attached lesioning is that it tends to have an indurated
6 Somatic dysfunction
feel. Normal mechanical dysfunction tends to system to produce symptoms elsewhere. It is
bulge out with muscle contraction producing often difficult to define what is relevant in the
a palpable swelling of the belly of the muscle. objective findings. Quality of any disturbance
The muscles affected by the secondary dys- is seen to have far greater significance than
function related to a visceral condition are quantity. Imbalance of action around a mov-
often flatter muscles that tend to pull in ing part has to be examined with the part in
rather than bulge out when they contract. It motion. Static examination is an essential
is very easy to miss the presence of this part of testing, but moving analysis using
phenomenon. Any patient who has the mis- active, passive and possibly resisted move-
fortune to have a serious visceral condition, if ments is necessary.
examined before, during and after, will show The aims of treatment can be directed to
evidence of this. It is a finding that may only symptoms, signs, a balance between the two,
become evident in retrospect, but this hind- or simply the restoration of function. It could
sight will enable the experience to be used be directed to helping the patient's structure
to recognize the situation the next time it become more able to adapt itself to the en-
happens. vironment. It is assumed in this respect, that
Asymmetry is the rule when dealing with a structure that is working harmoniously is
the human structure. Nevertheless, asymmetry more efficient and is less likely to be a source
that is dysfunctional is significant as it is often of symptoms. A simple statement to encap-
a source of symptoms or a stressor to the sulate this is that function governs comfort.
DIAGNOSIS 3

The criteria on which a manipulative pre- treatment, a realistic assessment of the likely
scription is based and the choice of technique outcome or prognosis is essential as a safety
to be used are governed by the diagnosis or measure. A prognosis of a good outcome that
pre-treatment assessment. In conventional is not backed up by the results of treatment is
medicine, diagnosis relates to the discovery clearly a wrong prognosis, and although the
of disease and this leads automatically to a chosen path may prove to be the correct one,
choice of treatment methods. The approach the time-scale may be wrong. The next path
to treatment will vary slightly according to is into a decision as to the best choice of
the knowledge, philosophy and system of treatment techniques, and the order in which
the practitioner, but will usually fit in with they are to be carried out. The choice of
established guidelines. Diagnosis in osteo- techniques to be used is governed by the
pathy is similar, in that it relates to the examination findings at the time, and the pre-
discovery of disease in much the same way as treatment assessment at each occasion. There
orthodox medicine, but then should lead the are no absolutes; as with all systems different
practitioner along a choice of several different practitioners will have varied approaches
paths. The first path is the choice whether to according to a multitude of criteria. Choice of
treat or not, and as to whether the case is approach will depend on the understanding
suitable for osteopathic intervention. For a of the requirements of the case, and on the
case to be suitable there must be some evi- ability of the practitioner to carry out the
dence of mechanical dysfunction present that chosen procedure. It would be foolish to
can be changed or improved by physical treat- believe that every practitioner is capable of
ment. If it is not suitable, possibly due to equal skill in each technique. The wise
the presence of serious disease that would practitioner will maximize his strengths, but
be better attended by another discipline, the will constantly be endeavouring to overcome
practitioner must have enough knowledge his weaknesses and add to his strengths.
about the condition to be able to refer the There will be a short-term and long-term
patient to a suitable authority. This would aim to treatment, and it is essential to involve
avoid wasting the patient's time and money on the patient in the diagnosis decision and the
fruitless physical treatment. He must under- reasoning for the approach chosen. Some
stand the contra-indications to treatment, patients only want a 'quick fix' and then get
and have enough knowledge of pathology to back to work without a thought for the long-
be able to make a reasoned judgement as to term situation. Some really want to achieve
possible dangers. His knowledge and com- a longer-lasting result, and are prepared to
petence to decline to treat must be sufficient to perform any necessary exercise routine and
avoid being negligent, yet must be tempered maintenance treatment schedule. They are
by a sense of realism. He must decide whether the 'customer', and have the right to choose.
there are any possible benefits from his If a therapist feels that a chosen way is not to
therapy. his liking, he then has to decide whether to
If a case is deemed suitable for osteopathic obey the patient's wishes or to decline to treat
8 Diagnosis
and pass the patient on to someone else who the treatment and the techniques used in that
is prepared to follow the patient's choice. It is treatment, there must be a choice of methods,
the practitioner's duty to point out the pitfalls frequency, duration and intensity so that the
of any choice, but he must ultimately bow to treatment techniques fit the dysfunction.
the wishes of the patient. In practice most The first requirement of the diagnostic
patients will realize the desire of the practi- process in the mechanical sense is to find the
tioner to help them in the best way, and will tissue causing the symptoms. The next require-
choose the method directed. However, there ment is to assess the fault in that tissue or
is the constant problem of the financial con- tissues. The reason for that breakdown is
straints placed upon any patient required to relevant as are the predisposing and main-
undergo private treatment, and the practi- taining factors. In other words 'why did this
tioner must be realistic in his prescription if it particular person get this particular problem
may entail long-term treatment. at this particular time? Diagnosis in this sense
The diagnostic process, in a medical sense, requires a knowledge of the normal behav-
requires standard clinical methods skills and iour of tissues and the type of symptoms that
understanding of symptoms, signs and the can be produced when they are stressed. It is
normal course of disease processes. In an very important to discover aggravating and
osteopathic sense there is the broader ortho- relieving factors so that the precise tissue or
paedic type of assessment and there is the structure can be discovered. Patho-physiology
osteopathic thinking, based almost entirely is the study of tissues that are dysfunctional,
on applied anatomy. Orthopaedic and neuro- but not yet in a state of true disease. Ultimately
logical testing are essential to discover warn- we are looking for what has been called 'the
ings and precautions and must precede osteo- manipulable lesion'. The three processes of
pathic examination. Once a particular case has history, examination and palpation should
had pathological entities excluded, and has ideally lead to the same conclusions. Separate
been deemed suitable for osteopathic care, operators performing the three parts of the
then the true osteopathic diagnosis will begin. overall assessment should be able to make an
Osteopathic treatment and the techniques independent decision based on their findings
used can be either general as a form of 'tuning' with each method. In practice, naturally, one
the mechanical structures, or specific to a operator is usually responsible for the whole
particular complaint. General treatment is a operation, but attempting to make an assess-
classical osteopathic approach taught at many ment on one aspect only is a very good exercise
schools of osteopathy, and should not be an in thorough analysis.
excuse for lack of diagnosis. It should be per- As an example of this, consider a patient
formed for a specific reason and although it who presents with lower back ache with some
does not depend on specific individual struc- radiation into his right thigh posteriorly as far
tural diagnosis, it must, nevertheless, depend as the knee. He has no sensory phenomena of
on palpatory findings. pins and needles or numbness and has not
Specific or regional treatment is based on a noticed any weakness. He states that it has
history, examination and palpation of the come on for no particular reason but on dose
perceived dysfunction and techniques are questioning he had been rather vigorous in
chosen that have the best chance of restoration cleaning his car the day before. He is right-
of function in a mechanical sense. Some handed. He admits to having had similar dis-
operators have a model of improvement of comfort after ten pin bowling. He is relieved
circulation, some of releasing stiffness and by lying down, although he feels stiff after-
tightness. Some are mainly interested in wards. Walking seems to ease the pain, but if
relief of pain. Whatever the chief reason for he walks for more than 20 minutes, the pain
 Diagnosis 9
starts to increase, particularly if he is carrying to support his weight on his hands placed
anything. He finds the discomfort increases behind him. In supine lying, the passive hip
when he sits for a prolonged period and has rotation on the left is much more limited than
noticed that it is difficult to tie his right the right although the right is the symptomatic
shoelace. He has slight increase of pain when side. Hyperextension in the right knee is much
coughing or sneezing and gets a stab of pain more limited than in the left. Passive move-
if he tries to bend too far. He notices that ment testing of the sacro-iliac joints in this
when he first stands after sitting he is slightly position shows that the left side is much more
sidebent to the left, but that this disappears rigid than the right. In a sidelying position
after a minute or so. His job involves walking passive movement testing shows that the
a lot, but he finds that if he has to stand still, lumbo-sacral segment is very restricted and
he gets a lot of lower back aching. He has had tends to sidebend to the left with ease but not
some lower back discomfort before, but it has to the right. Neurological testing is normal as
always been on the left side and has never are the pulses in the lower extremities.
travelled into the lower extremity. These At first sight this may seem a confusing
episodes are increasing in frequency and jumble of unconnected facts and irrelevant
often disable him for a few days at a time. His findings. However, from all this it is possible
medical history is uneventful, but he has had to make some assumptions and come to a
minor meniscal dysfunction with the right reasoned working hypothesis as to the cause
knee and his left foot seems to be enlarged of the presenting syndrome. This working
slightly. He has noticed that he often catches hypothesis also leads to an understanding of
his left heel in his right trouser turn-up. the case and a strategy for treatment, manage-
After taking the history the patient is asked ment and choice of techniques. If we look at
to undress to his underpants and the examina- the relevance of all these factors, several
tion begins. He is asked to stand and we things become evident. Every one of these
observe his posture and carriage of weight symptoms gives another clue to the overall
from behind, in front and from the side. He diagnosis. His tissues are telling a story; we
appears to be reasonably symmetrical but must decipher and unravel the relevance of
stands with a slight bend in his right leg at each of these factors. The conclusion from the
the knee. When he is asked to stand with the history should accord with the findings on
legs straight he appears to have his left iliac examination and palpation.
crest lower than the right. The waist fold is Some aspects of the pattern of the problem
slightly deeper on the right than the left. His seem to relate to a mild degree of disc
right shoulder is slightly lower than the left. degeneration and subsequent right-sided facet
He has very slight varicose veins evident on syndrome. If we treat the case from this
the left calf. Active movements into flexion
simple viewpoint we are going to have a
show some guarding in the lumbar area and
measure of success with the short-term pat-
he supports his weight on his thighs as he
tern, but the recurrences will have to be dealt
returns from flexion. Sidebending to the left
with as a repeated crisis management. Some
is full, but attempts to sidebend to the right
patients are happy to do this, but if the
cause increase of discomfort. Extension causes
underlying cause of the problem can be
no problems but he is rather stiff. Rotation is
sorted out, they are often much happier.
slightly fuller to the right than the left. If he
The analysis of each finding follows:
is asked to let one knee sag so that he bears
most of his weight on one leg, the right side 1. The nature of the pain is much more
of the pelvis drops far easier than the left. typical of a referred pain syndrome rather
In a sitting position he tends to slump and than a true nerve root pressure.
10 Diagnosis
2. A right-handed person cleaning a car leg side has become an overstretch of the
does a lot of sidebending to the right, soft tissues on the other side.
thus compressing the right side of the 14. The repetitive nature of the previous
spine and possibly causing facet apposi- episodes on the other side and the rapid
tion on the right. resolution, point to simple facet dysfunc-
3. Ten pin bowling involves lifting and tion and joint strains. The transfer of the
quite severe rotation to the left; a back pain to the other side and the tendency
that cannot rotate so well to the left may for it to move more distally indicate
be strained. possible discal irritability.
4. Pain relieved by rest but that feels stiff 15. The meniscal dysfunction in the right
afterwards is typical of discal irritability knee might be unconnected, but could
with subsequent muscle guarding. indicate a tendency to leave that knee in
5. Pain eased by walking that increases with slight flexion when standing, thus pre-
prolonged walking indicates that the spine disposing to knee strains.
does not like sidebending and rotation. 16. The enlargement of the left foot may be
6. The increase of pain with carrying weight incidental, but if he tends to stand with
when walking implicates the disc again. greater weight-bearing on the left leg
7. Prolonged sitting increases irritability in than the right, the foot will spread and
the posterior structures due to the in- enlarge.
creased stretch on the posterior aspect of 17. The catching of the heel of one foot in the
the disc, ligaments and muscles. turn-up of the other leg is sometimes
indicative of a short leg.
8. Difficulty in tying the right shoelace points
to a restriction of right sidebending com- The findings on examination should help in
bined with flexion. the assessment:
9. The cough reflex is indicative of some
1. He tends to stand with more weight on
discal involvement due to the increase of the left leg. This could indicate a short leg
intra-abdominal pressure. on the left and a compensation of weight
10. Pain on bending too far is indicative of transfer to the short leg.
overstretch of the posterior tissues. 2. His increase of waist fold on the right on
11. A symptom of being sidebent on first symmetrical standing indicates a short
standing up after sitting is indicative of leg on the left.
discal irritability or facet joint swelling 3. The lower right shoulder indicates a mild
producing a protective posture. That it left convex lateral scoliosis which is in
subsides after a few moments indicates accord with the short leg theory and
that the inflammatory element is not too compensation to this.
severe. 4. The varicose veins on the left calf only are
12. Pain on prolonged standing and postural indicative of increased weight-bearing on
'nystagmus' can be indicative of poor that side and poorer venous return.
proprioceptive control of muscle and is 5. The guarding in flexion is typical of mild
common in ligamentous overstretch and disc or facet syndrome.
early disc degeneration. 6. The supporting of the weight on the
13. The movement of the pain from one side thighs is typical of a discal irritability and
to the other could be due to many causes; can indicate nuclear movement and antal-
in this case it appears that a simple facet gic protection of the area.
syndrome has been converted to a disc 7. The limited and painful sidebending to
pattern as the compression on the short the right might indicate a facet syndrome,
 Diagnosis 11

or could be due to lateral displacement of slightly flexed for so long that it has been
nuclear material in a disc. predisposed to meniscal dysfunction and lack
8. The stiffness on extension is often due of hyperextension. The lumbo-sacral disc has
to reluctance to compress the posterior stood the onslaught of all this for some time,
elements of the disc and posterior liga- but has now become mildly degenerate, and
ments. there are signs of a mild discal irritability or
9. The easier rotation to the right accords even herniation. The final straw of the car
with the mild scoliosis produced by the washing and severe right sidebending have
left leg standing habit and tendency of jammed the facet of the lumbo-sacral seg-
the spine to rotate away from the side- ment on the right and the disc at that level
bending under prolonged stress. has reacted to the compromised movement
10. The knee drop test, where he is asked to possibility and has become symptomatic.
let the weight drop onto one leg at a time, How can we relate these findings and
is much easier to the left, indicating a conclusions to possible treatment and choice
tendency to stand with greater weight- of techniques? Each different discipline of
bearing on the left, confirming the short practitioner will naturally have varied ideas
leg and distorted posture theory once on how to deal with any particular case.
again. There will be different opinions as to the
11. The need to slump when sitting is indicat- relevance of the findings and even as to their
ive of poor control of postural muscle. existence at all. A physician might be inclined
The need to support the weight on the to deal with this case with rest, mild anti-
hands is indicative of discal irritability. inflammatory medication and advice as to
12. The restricted hip rotation on the left is posture and activity. A surgeon might advise
indicative of increased weight-bearing on the patient to see a physiotherapist for traction
that side, further confirming the one- for the disc and exercises for the muscles. A
sided standing habit. psychologist would be interested in what the
13. The lack of hyperextension of the right stresses are on the patient that have caused
knee is indicative that this knee is often his back to become dysfunctional at this
allowed to flex slightly. This follows the particular time. How would an osteopath
same theory of one-sided standing. deal with it?
14. The rigidity in the left sacro-iliac is further The short-term management would be
confirmation of the one-sided posture similar to the other disciplines as the needs of
producing a riding up and stiffening of the case are for restoration of function, reduc-
the sacro-iliac. tion of pain and reassurance. Assuming that
15. The restriction of the lumbo-sacral joint there were no other contra-indications, the
on passive movement testing accords with patient might be treated as follows.
the mixed facet/disc syndrome. 1. Short-term crisis management of acute
16. The easier sidebending to the left helps pain.
confirm the postural habit and subsequent 2. Mid-term improvement of function for
disc damage. resolution of the presenting syndrome.
3. Long-term treatment and education for
In summary we have a patient who has a
prevention of recurrences.
difference in leg length, his left leg being
shorter than the right. He tends to stand with The short-term crisis management might be
more weight on the left leg than the right and advice to use hot or cold packs or alternation
has had repeated episodes of left-sided facet of these. Gentle soft tissue, cross-fibre knead-
syndrome. His right knee has been kept ing of the area to relax some of the spasm
12 Diagnosis
could be performed with the patient side- pression factor in the facet joints and vertical
lying. This position would be better than adjustment is particularly useful for this.
prone as it would avoid excessive extension Firmer articulation of the left hip and sacro-
that might occur in the prone position. iliac would be used as time progresses to
Supine articulation to both sacro-iliacs might increase mobility there. The lack of extension
follow. If the pain is not too severe, leg tug of the right knee would need to be
high velocity thrust (HVT) to the left sacro- addressed, using accessory movement
iliac to mobilize it and help 'de-stress' the articulation into medial and lateral gapping
right could be useful. Sidelying flexion articu- and traction. Further advice about posture
lation to the lower lumbar area to increase and exercises to stretch the tight left side and
drainage and free movement could be used. possibly strengthen the lumbar erector spi-
It would be helpful to the patient to explain nae might be necessary.
why the injury had occurred and to discuss The long-term approach would be to extend
the possible longer-term management. the treatment interval as the symptoms im-
The mid-term approach would be to try to prove and give natural healing a chance to
restore full function to the lumbo-sacral settle the disc. The posture would be re-
segment with specific HVT directed to the emphasized to ensure that the patient was
facet joints. Minimal lever approaches would standing more symmetrically. An assessment
be used to avoid torsioning the disc. The would need to be made as to whether a heel
HVT would be performed mostly into com- lift was indicated.
pression. Providing the patient could extend So, we can see that a whole lot of seem-
without excessive pain, a vertical adjustment ingly irrelevant and confusing findings can be
would be helpful to reduce pressure on the integrated into an assessment, a diagnosis, a
disc and to gap the facets in traction. One- prognosis and a choice of techniques to be
legged standing habits often lead to a com- used in treatment.
CLASSIFICATION OF OSTEOPATHIC 4
TECHNIQUES

The original classification of osteopathic this statement? This is not to say that we
techniques was evolved at the turn of the should not be trying to rationalize what we
twentieth century and was divided into the are doing. It is only too easy to say that it is
general terms of soft tissue, articulation and an art, and therefore cannot be classified. It
thrust. While these were useful, they were was felt, therefore, that we should make our
limited and caused some problems. They classification for perceived result instead of
were restricted in terms of dialogue between application.
practitioners, or in ability to communicate the The classification being used today is
exact purpose of the technique being per- broadly divided into three main groupings.
formed. Various attempts were made to There is inevitably some overlap, and some
reclassify the different approaches, and in the particular methods are used far less often
early 1970s a team of teachers at the BSO than others. Nevertheless, they are defined
formed a new classification list. Although so that they can be described in a way to
these have been modified slightly since that make communication easier. Education of
time, they remain broadly the same today. students is also much more efficient with a
Other systems of classification exist, but I structured classification, although they quickly
have chosen to keep to the BSO system in realize that no classification covers every
this work. When something is classified, it is eventuality. The three groupings are: (i)
unfortunately limited by that very classifica- rhythmic techniques, (ii) thrust techniques,
tion. Despite this, it is clearly necessary to and (iii) low velocity stress techniques.
have some form of definition of the actual
procedures used so that teaching can be
RHYTHMIC TECHNIQUES
systematized. It must be realized however,
that any classification causes some problems, These are techniques where the use of rhythm
and will not necessarily be in accord with the is fundamental to the procedure. They are
particular approach of an individual practi- repetitive in nature but are not simply the
tioner. same movement repeatedly; they are varied
For these reasons, the classifications that by all the usual modifying factors. All osteo-
have been defined have been designed in an pathic technique is varied according to the
attempt to state what is actually being applied response from the tissues and structures
rather than what is trying to be achieved. In being worked. According to the perception of
conventional medical practice it is relatively the mechanism of a particular technique, so it
easy to define a particular medication, and will vary in rate, rhythm, direction, force,
the dosage. This is far less simple in manual duration and number of repetitions. There
medical systems. If one practitioner says he will also be variations in all the other factors
has performed a particular procedure, who is possible to produce the optimum result in the
to define the efficiency and effectiveness of particular circumstances. In many ways the
14 Classification of osteopathic techniques
control and variables in osteopathic tech- The reader is referred to the section relating
nique are dependent on palpatory awareness to modifying factors and asked to consider
as much as perceptual diagnostic factors. each of these as applied to each technique
Palpatory skill will naturally vary between classification.
different individuals, but the main objective A rhythmic technique is divided into eight
of all forms of manual therapy is to improve categories.
function. Improvement of function is designed
to increase comfort, reduce pain and restore 1. Kneading
2. Stretching
normality to parts of the neuro-musculo-
3. Articulation
skeletal system that are found to be working
4. Effleurage
at less than their optimum efficiency. This
5. Inhibition
will vary according to the demands of the
6. Springing
individual and their environment.
7. Traction
Osteopathy has been variously defined
8. Vibration
over the years, but one definition of Little-
john, a student of A. T. Still, and the founder
of the BSO, was, 'Osteopathy is the science of KNEADING
adjustment.' There are many philosophical Kneading can be defined as a rhythmic squeez-
arguments relating to this statement, but the ing and massaging of muscles and other soft
objective of technique is to allow the optimum tissues to relax them by reducing fluid con-
ability for the body homeostatic mechanisms to gestion and tonic irritability. The mechanism
perform this 'adjustment'. Rhythmic tech- by which this produces a result is open to
niques, by their nature are designed to slowly question. Some say that the effect is one of
re-establish movement, circulatory flow, and reflex balancing. Some think that the result
drainage, and to remove blockages in func- comes from fluid interchange and lymphatic
tion in the somatic structures. drainage. There is also a powerful psycho-
Rhythmic techniques can be used as treat- logical and soporific effect. The technique is
ment by themselves or as preparatory pro- applied in a slow and careful way to produce
cedures for other categories of technique. The the best result. The best rhythm and tempo
choice of when to apply a given technique in for any given case will only be found by
a treatment session naturally depends on the adjusting the common pattern slightly to suit
purpose of the technique and the desired the particular patient. The amount of pressure
effect. Traditionally rhythmic techniques are applied, and the duration of the technique will
used to loosen tissues so that high velocity also vary according to the result obtained.
techniques can be applied more easily. This Many different applicators can be used.
relegates them to a position of secondary The most common way is to use all or part of
procedures, which is unfortunate. They are the heel of the hand or sometimes the pads of
powerful in their own right and should have the fingers. The technique can be a pushing
a much more important role than simply or a pulling, and the hands often work in
padding out a treatment while preparing for opposite directions so that the amplitude of
more spectacular techniques. Suitably applied each is reduced according to the quantity
rhythmic technique can be a whole treatment applied by the other. The direction is usually
in itself, and forms the mainstay of most across the fibres of the muscle, but can be
osteopathic treatment sessions. diagonal or even longitudinal in some cases.
For the sake of reasonable brevity the The most critical element is the finite use of
descriptions of each technique will not repeat- time when the pressure has been applied. If a
edly state the various modifications possible. muscle is simply kneaded repeatedly without
 Rhythmic techniques 15
attention to the duration of pressure, some imum cooperation and relaxation, and the
change will be produced. If the kneading technique is applied just short of pain, but at
force is applied, and then held for a few the border of discomfort to produce the best
seconds, the muscle will be felt to relax and result. The duration of stretch applied will
'melt'. This sensation can be likened to a hot vary in each case according to the response
knife through cold butter. The initial pressure from the tissues, but should be long enough
produces little change, and then the knife to allow change to take place. If stretching is
sinks in and is felt to work its way through applied and released too quickly, a stretch
the butter as it melts ahead of the blade. response will be induced, and an opposite
Kneading should not be painful, but a effect from that desired will take place.
sense of pressure is inevitable. Good handling If a stretch is maintained, there should be a
to produce the best patient cooperation and sense of collapsing tension, and a sense of
relaxation is very important. The operator 'give' from the structures as they relax and
should be aware of any discomfort being lengthen. The direction of stretch is often felt
produced and modify the pressure accord- to change as this takes place and the operator
ingly to be at a balanced point just short of may find the path changing quite a lot at the
pain. The dividing line between discomfort, end of the technique. If this happens, the
pain and effective pressure is often difficult to technique may become a myofascial type of
judge, and constructive comments from a release, but this is quite acceptable and shows
fellow student or practitioner are useful. The an awareness of tissue adaptation during
depth of the pressure should be governed as treatment.
much by body weight as by the force applied Stretching techniques should be released
with the hand. The sense of relaxation is slowly to avoid reactive tension in the tissues
gained by the operator's proprioceptive from the stretch. Rhythm and tempo are also
mechanisms becoming aware of the collapsing variables that need to be constantly adjusted
tension rather than any tactile sensory input. to suit the patient.
The operator should slightly tense his hand
and arm to effectively enhance this proprio-
ARTICULATION
ceptive awareness. Very slight isometric ten-
sion used in this way gives a much better This old osteopathic term has been retained
feedback of tissue response. and relates to the use of repetitive passive
movement, usually employing a lever and
fulcrum. The use of the lever allows the effect
STRETCHING
to be enforced without the application of high
Stretching can be defined as a separation of levels of force. The main difference between
both ends of a muscle or soft tissue structure articulation and simple passive movement is
from each other to lengthen it. The purpose is that the operator should be constantly sens-
to attempt to improve function and allow ing the response from the tissues under his
better mobility in the structures being worked hand. He is then able to measure the require-
as well as the articular structures that they ments and intensity of pressure according to
may limit by their excessive tension. Stretch- what he is feeling.
ing can be applied with a very short lever to Articulation can be performed over a wide
influence specific intra-articular or segmental arc or over a very small amplitude of move-
structures. It can be applied using a long ment according to the requirements of the
lever to influence the extra-articular struc- case. An example of a wide arc would be
tures over a larger area. taking a shoulder from part abduction to full
Good handling is critical to ensure max- abduction. An example of a small amplitude
16 Classification of osteopathic techniques
would be articulation of a lumbar segment may be applied to be counter-irritant. Effleur-
from almost full flexion to its complete range. age can be used as a light introduction to
Many practitioners will add a small empha- gentle kneading techniques that increase in
sis of movement at the end of range. This intensity as the tissues relax and congestion
very small 'bounce' can be a useful way of decreases.
producing more rapid change in tissues as Most osteopaths do not use lubricants
well as allowing a more accurate assessment when performing technique as their use can
of their reactivity. make satisfactory grips difficult. A common
Articulation can be in single directions of exception to this is when effleurage is applied,
movement or use multiple vectors of force. If as some form of skin oil or massage cream
multiple vectors are used, it is easier to can help prevent soreness and may make the
approach a motion barrier which is not at the technique easier to perform. Several propriet-
end of true range and is, therefore, more ary types are available with a variety of
under operator control. Working at this claimed therapeutic properties. If it is desired
manufactured barrier would seem to be to have a light lubricant effect, a fine talcum
inefficient, but will be found to produce the powder may suffice.
fastest change in mobility of the 'actual'
barrier when subsequently tested. The move-
INHIBITION
ment does not produce the same discomfort
as capsular stretch, but will, nevertheless, Inhibition is the one exception to the rule of
influence joint receptor mechanisms in a very stating what is being applied instead of
efficient way. The chief governing factor in stating the perceived effect of a technique. The
this type of articulation is good operator term is retained as it is an historical osteopathic
control. This can only come from a firm yet classification. In practice it consists of pressure
comfortable grip that takes command of the applied for fairly long periods. The pressure is
part in such a way as to promote confidence. slowly applied and maintained for up to a
Although the vectors of force can be de- minute or so and then slowly released. It is
scribed individually, they are best applied in usually applied over a small area or point.
a combined way to absorb the free play and The rhythm is always slow and needs a
slack in the tissues. This prevents the natural constant feedback from tissue response and
tendency of the tissues to escape from the reaction. It is applied with increasing pres-
induced tension state. sure as the patient exhales, and is maintained
until suitable change is perceived. An example
would be pressure with the pad of the thumb
EFFLEURAGE
over the lower attachment of the levator
Effleurage has been borrowed from the arma- scapulae in a case of acute torticollis.
mentarium of the massage practitioner. There Considering recent research, inhibition may
are several situations when a rhythmically have its effect on tissue fluid interchange
applied movement of light force and slow rate rather than by balancing the afferent and
is necessary. It is usually used on the super- efferent outflow as was previously thought.
ficial tissues to produce a 'drainage' effect on This does not negate the benefit of the tech-
lymphatic channels. In traditional massage, nique, but simply explains in a different way
the central area is cleared first to make room for what we can feel with our hands.
the fluid, and then the effleurage is applied Excessive pressure will have the opposite
from peripheral to central. It is often used over effect in that irritation can be produced.
areas where congestion is greatest to produce Clearly this is undesirable and good palpatory
a circulatory response to aid decongestion. It awareness should avoid this problem.
 Thrust techniques 17
If 'stimulation' as distinct from irritation is being tractioned again. The effect will be one
desired, a faster oscillation will be required, of drainage and circulatory interchange as
but active contraction techniques are probably well as opening of intervertebral foraminae to
more valuable than manual procedures. attempt to release nerve root pressure.
Manual rhythmic traction is unlikely to be
SPRINGING as strong as mechanical traction, but will be
much more easy to control as the operator
Springing refers to repetitive graduated has a constant feedback from the structures.
pressure over a bony point. It is sometimes Some operators use straps to assist in these
combined with very short leverages. Spring- techniques, and some find mechanical traction
ing is usually slowly applied and released apparatus beneficial if more sustained traction
using the proprioceptive response from the is necessary. Many modem mechanical trac-
applicator and the operator's arm to sense the tion tables have an intermittent setting de-
optimum pressure. It can be used as a diagnos- signed to mimic the manual rhythmic traction.
tic procedure over spinous processes to assess The main advantages of the mechanical
their reactivity, tenderness and resistance. traction table are that it is possible to use
The direction of force in springing is often more power than can be applied by hand and
into accessory ranges of movement. A given that the table does not tire as does a human
joint may be maintained in a certain position operator.
by operator control, and then springing is
applied in another direction to improve
quality of movement. It is usually applied VIBRATION
against the resistance of the table so that Some practitioners use manual vibration
operator body weight can be employed more techniques over hollow organs or sinuses in
easily. It is usually performed from a point an attempt to increase drainage and enhance
approaching end-of-range up to end-of-range circulatory flow. Vibration is difficult to sus-
rather than through a long amplitude. Spring- tain for long periods, but when used, is
ing is, in effect, very short lever articulation. usually applied at a fairly fast rate for several
short intervals in a treatment session. Con-
TRACTION siderable muscle control of the operator's
arms is required, and the oscillation is per-
Rhythmic traction is manually applied traction formed by rapid alteration of muscle tension
performed to a point or area with some release or by fast light tapping.
and repeated several times. When applied to a
point, the operator attempts to block adjacent
THRUST TECHNIQUES
joints from movement, and then using a
suitable grip, tries to separate the target joint Thrust techniques can be defined as tech-
surfaces with the traction. When applied to niques using a single application of force
an area, a comfortable grip is gained, and using high velocity and low amplitude. The
then the traction is applied until the area objective of the technique is to direct forces to
is felt to be affected. The amplitude is an a specific point, area or structure. It is not
important element as the traction must reach usually necessary to perform thrust tech-
the target tissue or area. Rhythmic traction of niques at the end of a range of movement. By
this sort is usually applied from a point of combining many components, a barrier is
some stretch to a further point rather than formed which is at a cumulative end-of-range
from no stretch to full stretch. The tissues are rather than at an anatomical end of range. If
only partly released from the stretch before sufficient speed can be attained, the inertia of
18 Classification of osteopathic techniques
the tissues can form enough resistance to analysis and decision of lesion correction
permit efficient thrust procedures. They will direction will be found to give the same path
reach a target tissue or structure without of optimum barrier sense achieved with far
reaching the end of range of the joint. This is less effort by the methods described here.
much less potentially traumatic and uncom- The palpatory cues of barrier sense are less
fortable, and allows a chance to use this likely to give the operator a wrong message
category of technique in a wider range of than a conceptional model of lesion correction
patients. It is accepted that not all practitioners analysis. This means that traditional descrip-
can achieve this ideal of ultra rapid acceleration tions of a rotation lesion or a sidebending
and very controlled braking force. Inevitably lesion are becoming less common in schools
some thrust techniques will be of a lower or adopting this principle. There may be a
intermediate velocity, but the aim of minimal description of a segment that is reluctant to
amplitude remains consistent. A force short rotate or sidebend, but this information can
of adequate joint separation is not going to be be immediately introduced into the choice of
traumatic; an excessive force or amplitude is vectors of force most likely to break fixation.
potentially dangerous. If an accurate palpatory assessment is not
Thrust techniques are usually performed possible in a static or dynamic examination,
parallel or at right angles to the plane of the the patient can be placed in a thrust position,
joint and in a direction designed to break and the vectors and components adjusted to
joint fixation in the most efficient way. The find the optimum barrier. The resistance to
barrier to motion in a well-positioned thrust particular movement pathways will then
technique has a characteristic feel of potential become more evident as much of the joint
or dynamic tension. It is necessary to balance play will have been absorbed, and the best
all the available components of a particular
path can be chosen. This places greater
thrust technique to achieve the 'best' barrier,
emphasis on good operator control and
which is not necessarily the maximum barrier.
balance of available components, and is not
Original osteopathic thinking was tradition-
an excuse for poorly applied technique skill.
ally designed to 'reverse' the path of a lesion.
If anything, it requires greater skill, as the
Diagnosis was concerned with discovering
decision about the best pathway to produce
the pathway of the lesion, and thus the
correct path of 'correction'. Although this is the release will change slightly as the patient
an attractive concept it has become accepted is moved into the technique position.
that many cases do not require this type of Neither is this an excuse for merely 'pop-
analysis. A simple breaking of fixation in the ping' joints. The purpose of any technique is
direction of optimum barrier is sufficient to improvement or restoration of normal func-
improve range and quality, and positional tion, not simply the completion of the tech-
correction is often unnecessary and excessively nique. Re-assessment of function, range and
complex. Attempts to classify fixations by quality is the critical element.
directions of lesion can be extremely limiting, Traditional 'manipulation' is performed at
particularly for students whose palpatory the end-of-range, and then by the application
awareness is not able to perceive the fine of overpressure beyond the point of control
differences. There are certainly some cases of the patient. Well-controlled osteopathic
where specific directions play a part, but thrust technique is not usually performed in
these are relatively rare, and results are just this way. The act of inducing multiple com-
as good if this element is largely ignored. ponents produces a point of useful tension
This approach angers some traditionalists. It that is short of the end of anatomical range.
is interesting, however, that their detailed The thrust is performed in a chosen direction
 Thrust techniques 19
while the secondary components are main- performed coincident with a pull on the
tained by operator control to make the barrier wrists.
available. The same amplitude of the primary
In many techniques it may be difficult to
lever applied without the secondary compo-
separate the exact principles, and this is not a
nents would not be effective. It is, therefore,
problem if everything is going according to
the understanding and control of these second-
plan. If, however, the technique is not pro-
ary components which make this osteopathic
ducing the desired result, analysis according
approach different from manipulation as it is
to basic principles may reveal the reason and,
usually defined.
therefore, possibly the solution.
Current classification divides thrust tech-
niques into five broad headings.
COMBINED LEVER AND THRUST USING
1. Combined lever and thrust MOMENTUM
2. Combined lever and thrust using momentum
This category of thrust technique is, in reality,
3. Minimal lever and thrust
a subdivision of the previous one described
4. Non lever and thrust
above. The momentum component is intro-
5. Non lever and thrust using momentum
duced for several reasons. Some patients may
find the position for a combined lever and
COMBINED LEVER AND THRUST thrust technique can be threatening and
uncomfortable and the use of momentum
This variation uses a thrust applied at or near
helps to avoid this. Some operators find that
the dysfunction or lesion, with or without
it is difficult to accelerate sufficiently rapidly
application of exaggeration of the leverage.
from a static position to achieve enough
As an alternative a thrust could be applied at
controlled power to cause facet gapping.
or near the extremity of a lever remote from
Momentum will aid these cases as it is much
the lesion. A static fulcrum may be created by
easier to overcome the inertia of the tissues if
pressure or fixation at or near the lesion. A
a gentle oscillatory movement is used in the
combination approach is also possible. As an
primary lever direction. Care must be taken
example of these different types consider:
to avoid the natural tendency to use momen-
1. Thrust at the lesion point. A typical cervical tum in more than one parameter of lever
thrust technique using sidebending to one direction. If this is allowed, it is far too easy to
side and rotation to the other. This could be take the part into a compound lever position
performed in a variety of patient positions: which is beyond that desired. The momentum
supine, sidelying or sitting. must be used in the accumulation of optimum
2. Thrust at the extremity of a lever arm. An lever position and not used to emphasize
example of this might be a supine mid- several levers at once.
thoracic thrust where the operator's hand Momentum can be used while the part is
is placed under the patient's body and the held in a near optimum position by rolling
thrust is applied to the arms crossed in a the body back and forth. This allows the fine
variety of ways over the chest. tuning to take place on the move, and the
3. Combination thrust at a lesion point and final sense of best barrier can be palpated
at the extremity of a lever arm. An ex- more easily. An example of this might be a
ample of this variation would be a sitting typical lumbar roll type of thrust manipulation.
mid-thoracic, knee in the back technique. The patient is positioned for the thrust, and
It would be performed with the operator's then gently rocked back and forth while
hands clasped around the patient's wrists, maintaining the lever components almost con-
and a simultaneous push with the knee is sistent. This is not an increase and decrease of
20 Classification of osteopathic techniques
levers, more a rolling of the body while the tially less traumatic. It is necessary to be
levers are held. At the optimum point in the aware of the various components available
rolling, the lower component can be rotated and to apply them systematically while test-
toward the operator in the usual way more ing the primary lever direction to sense the
easily as the body is already moving in this accumulation of compound barrier. If the
direction. primary lever is not felt to accumulate to a
The use of momentum also enables in- suitable barrier, more components can be
creased force to be applied when absolutely introduced, or slightly greater amplitude
necessary. The barrier can be accumulated in introduced to those already in use. The
the usual way, and the momentum introduced primary lever should then be felt to become
as an increase of acceleration in the chosen firmer and the resistance more crisp and
direction. This often proves to be of greater available to the thrusting hand. Although
efficiency for small operators, particularly this can be thought of in terms of minimal
when working on large patients. Naturally, lever, it is rather maximal number of levers,
due consideration must be paid to precautions but minimal quantity of each. It is important
against applying an excessive leverage in such to leave some free play available so that the
a case. various components can be balanced against
Although thrust technique is normally per- each other in the best combination for the
formed in straight lines, there are no straight patient, the operator and the technique.
lines in the body, and momentum inevitably Acquisition of skill in this category of
induces some curving aspect to the force. thrust technique is well worth the consider-
This may help to find the optimum direction able effort required. Results are often faster,
for any given thrust. with less discomfort during and after treat-
ment, and tissue reactions and possible trauma
are considerably reduced. Thrust technique
MINIMAL LEVER AND THRUST
that gaps facet joints without straining sur-
Minimal lever and thrust can be further rounding tissues is much more comfortable,
divided into two broad subdivisions. There is and in the presence of local tissue shortening
the true minimal lever and thrust where the may be the only way that they can be
part is positioned in as little lever position as reached. To be effective, treatment consists of
is possible, and an extremely rapid thrust is a combination of approaches, not only thrust
performed. This is designed to break fixation techniques, and suitable mobilizing using
before other tissues deform under the pressure other categories of technique will be necess-
and requires very rapid application and ary to get a good and lasting result. Using
braking by the operator. This type of thrust this type of thrust technique it is also possible
method is probably the most difficult to to manipulate many cases where conventional
perform, and many operators find it difficult full lever techniques might be impossible. An
to acquire the particular skill necessary to example might be a case where there is a disc
make this method effective. prolapse. If full rotatory thrust is applied
There is also the more common method of there is considerable danger of further im-
minimal lever and thrust which employs pinging a nerve root, or of allowing further
multiple components in an attempt to limit extrusion of disc material. Minimal lever
the amplitude of each. The more components technique might allow the facet joints to be
used, the less range will be necessary and the gapped as the disc is not torsioned anywhere
final thrust position can become closer to the near as much as in full lever techniques.
midline. This is desirable because it is far Releasing the facets might be a useful way
more comfortable, and should become poten- of helping to promote faster healing. Caution
 Low velocity stress techniques 21
is clearly necessary, as although the tech- cranio-sacral technique may be more accept-
nique may then be possible, is it a desirable able.
procedure? The BSO classifications embrace all these
methods under the broad heading of low
velocity stress technique. The four sub-
NON LEVER AND THRUST
divisions of these techniques are:
Non lever and thrust technique is a type of
1. Using sustained leverage
thrust where the operator applies a force to a
2. Using sustained traction
bony point aiming to break fixation in a facet
3. Using sustained pressure
or joint structure. Some preliminary com-
4. Using sustained articulation
pression may substitute for the use of levers,
and high speed is often necessary to over- The common factor is the maintenance of a
come the resistance of the facet before the sustained position, pressure or movement and
force is dissipated through other tissues. This the waiting for a response from the tissues.
type of approach is more commonly used by They are all slowly applied using sense of
chiropractors, but many osteopaths find it of optimum relaxation and change for the better
use in some cases. An example might be a in tissue function. They are reactive tech-
prone thoracic thrust technique where the niques rather than direct action techniques
operator uses the hands applied to opposite and the reader is referred to the section
sides of the same or adjacent vertebrae. The relating to indirect technique for fuller details.
thrust is made directly toward the table or
into a sidebending or rotation direction USING SUSTAINED LEVERAGE
according to the needs of the case.
An example of a low velocity stress technique
using sustained leverage might be a gently
NON LEVER AND THRUST USING held combined lever and thrust position where
MOMENTUM the operator waits for a sense of tissue release
and collapsing of barrier. Sometimes the
A thrust using non lever forces and usi:ag
barrier will be felt to ease in one direction, and
momentum recognizes that some operators
further barriers can be addressed in slightly
find momentum aids the discovery of the
different directions. This can be likened to
optimum sense of barrier in their patient. The
peeling away the layers of the dysfunction.
technique is the same as any other non lever
Examples from the categories of indirect
thrust, except that oscillatory momentum
techniques might be functional technique or
is induced in the direction of the final thrust.
some types of muscle energy technique.
At the optimum moment, the thrust can
be applied as an emphasis of one of these
oscillations. USING SUSTAINED TRACTION
An example of low velocity stress technique
using sustained traction might be a 'disengage-
LOW VELOCITY STRESS TECHNIQUES
ment' of a capsulitis in an acute shoulder. A
The term low velocity stress technique may firm traction might well irritate the tissues,
be unfamiliar to many practitioners. The terms but using a careful hold and maintaining a
muscle energy technique, functional tech- very light traction until tissue release is felt
nique, strain and counter-strain technique, might be more appropriate.
myofascial technique, harmonic technique, Examples from the categories of indirect
specific adjusting technique, gentle therapeutic technique might be some of the holds used in
manipulation, neuro-muscular technique and myofascial technique.
22 Classification of osteopathic techniques
USING SUSTAINED PRESSURE Examples from the categories of indirect
An example of low velocity stress technique technique might be some of the holds used in
using sustained pressure might be pressure strain and counter-strain technique.
applied over a muscle and fascial area until a
sense of release is perceived. Although this USING SUSTAINED ARTICULATION
overlaps with inhibition from the section relat- Low velocity stress technique using sustained
ing to rhythmic technique, there are subtle articulation is really a conglomerate of the
differences. Pressure is usually lighter than previous subcategories and might include
that used in inhibition, and the force can be many of the cranio-sacral techniques. Some
directed at bony structure instead of purely functional techniques also fall into this head-
soft tissue structures. ing, as does harmonic technique.
CONTRA-INDICATIONS AND 5
PRECAUTIONS

All systems of medical treatment have contra- even be identified on a conscious level. It can
indications to their use, or the timing and become a very reliable method of deciding to
dosage of their use. There is more than one stop and re-consider in a given case. This
way of looking at contra-indications to osteo- must be in addition to reasoning and normal
pathic technique and treatment. Although caution, but must not become a substitute. It
there are some deficiencies in the system, this is far better to be too cautious and to be
book will continue using the notation of the wrong, than to be not cautious enough, and
description of absolute and relative contra- be wrong! Hindsight gives 20/20 vision, but
indications. It provides some useful guidelines this is no comfort to a patient hurt or, worse,
that are not too difficult to follow. permanently or even fatally damaged. Until
Some authorities feel that the manipulative this sixth sense has been developed over a
prescription must be guided only by which considerable passage of time, some rules are
type of manipulative technique is suitable advisable.
and possible for the case. The idea is that no Absolute contra-indications relate to situ-
case is beyond the aid of osteopathic treat- ations where certain techniques should not be
ment. The choice of technique will be made used. It would be rare, however, for no
with due consideration for all the factors treatment at all to be possible. Relative contra-
presenting. Procedures will be used which indications relate to certain cases that require
cannot be expected to produce any damage, special caution for an identified reason as to
whatever the condition. In this way, treat- the choice of technique. As experience grows,
ment of even a terminally ill patient can be some techniques previously considered un-
undertaken. If there is any small benefit wise may become possible with suitable
gained, even for a very short time, this can be precautions for the case.
justified. I have some sympathy for this type Thrust techniques are virtually outside the
of thinking, but feel that it is inappropriate active control of the patient and joints may be
for a student to be expected to work in this taken to their limit of anatomical movement
way. For this reason the considerations of where ligaments and capsules are put at risk of
absolute and relative contra-indications remain damage. This means that contra-indications to
in use. thrust technique will generally be more specific
As in all skills it is possible to develop a than for other types of technique. However,
sixth sense for warnings and precautions. If strong articulation, springing, or very firm soft
an experienced operator puts his hands on a tissue kneading are powerful in their own right
patient, there will often be an immediate and also require caution. Adhesions around
awareness of a disturbed tissue state when joint structures are often stronger than the
there is any reason for caution. This sixth sense normal tissues and force applied may damage
is a combination of learning and experience. normal tissues before adhesions are broken.
Many hidden cues are being used that cannot In the presence of adhesions, force is
24 Contra-indications and precautions
often increased in an attempt to break them reduced. In my view it is dangerous to place
down and the risk factor increases proportion- absolute reliance on this. In some cases,
ately. Generally, the shortest amplitude poss- particularly when using violent techniques,
ible consistent with the production of the this may be true. Traction, in its many guises,
desired result is to be encouraged. Even is a valid and useful method of treatment, but
the highest velocity, if combined with ultra- to use it to render safe an otherwise unsafe
short amplitude can be made relatively safe. procedure seems an inadvisable approach.
Naturally, this is a skill-dependent factor that Excessive reliance on any absolute rule such
requires time to develop and not every as this is responsible for a rigid approach
practitioner is going to be able to acquire this with no possibility of variation for different
skill. circumstances. The osteopathic approach is
The increasing use of the category of to make constant subtle changes according to
minimal leverage technique helps to reduce the needs of the tissues at the time they are
risk and many cases previously incapable of being worked.
being thrust can be treated in this way.
Caution is still necessary, however, as forces
ABSOLUTE CONTRA-INDICATIONS
generated can still damage vulnerable tissues.
A decision must be made as to whether a Situations where a particular technique is
given case is treatable at all and if it is, which absolutely contra-indicated include those in
techniques are most likely to help deal with which there is the possibility of tissue damage
the presenting problem. If a case is deemed if the technique is performed. It is better to
to be untreatable using any category of tech- think of tissues rather than conditions, as there
nique, suitable consideration must be given may be conditions that are unknown and that
to methods of referral and the patient must are, therefore, not diagnosed. If tissues are
be informed why this decision is being made. the main consideration, applied anatomy and
If this is not done, there is a danger of them physiology are the guiding factors.
going to another manipulator who may not As an example of this, consider a patient
recognize the contra-indication, treat the who complains of increasing back pain the
patient and cause them damage. longer he is upright. He gets some relief
A case which is not going to be helped by when lying down, but is much worse when
treatment is contra-indicated, not because carrying any weight. He has increased pain
harm will be done, but because no good can when descending in an elevator as it draws to
be done. In the presence of a seemingly a stop and finds that even lifting an arm out
'hopeless' case where many other therapies in front of him causes back pain. This pattern
have been used, there may be a case for some of symptoms is typical of a weight-bearing
'trial' treatment. It is a good idea to make a structure giving pain on increased loading.
'contract' with the patient to try a few The two main weight-bearing structures in
treatments and if there is no good result, to the lower lumbar spine are the discs and the
review and reconsider. There is then less of a vertebral bodies. Disc disease is not in itself a
problem about treating apparently hopeless contra-indication to treatment, but will alter
cases. the choice of technique. Vertebral body
There is a school of thought that feels that damage is clearly a condition where treat-
the use of high levels of traction can render ment must be withheld until a clear diagnosis
all manipulative procedures 'safe'. They feel has been established. If there is bony weak-
that as joint surfaces are separated and ness due to a secondary cancerous deposit,
foraminae opened, the chance of nerve or any technique putting forces through that seg-
blood vessel damage and impingement is ment would be unwise. Many other scenarios
 Absolute contra-indications 25

could be described to illustrate tissue analysis this is a sign of impaired circulation in the
but applied anatomy and knowledge of tissue vertebra-basilar system.
behaviour in health and disease is the key.
The most dangerous conditions are those
that could weaken structures and so could 3. DE KLEJN'S TEST
possibly lead to a fatality or at best a severe Have the patient lie supine with the neck in
injury. The greatest liability to this possibility maximum extension. Slowly increase the
is in the upper cervical region where inherent extension and add sidebending and rotation
weakness in the vertebral ligamentous sup-
to see if there is an increase of symptoms as
porting structures may lead to nerve or vessel
described in the extension test.
damage if unsuitable forces are applied. The
vertebra-basilar system is particularly vulner-
able to damage if excessive torsion is used. 4. FLEXION TEST
The results of this could be catastrophic and
some tests exist to assess the possibility of If extreme cervical flexion produces symptoms
potential trauma. No tests are an absolute of paraesthesia, particularly in the lower limbs,
safety screen, but may help to eliminate the the possibility of a cervical bar must be con-
most obvious cases from having ill-advised sidered. A spondylotic bar can occur in
techniques and treatment. There is no excuse patients of a generally younger age group
for insufficient diagnostic care and lack of than may be expected. This simple test is a
precautions that could amount effectively to useful diagnostic screen for this condition.
negligence. Every precaution that is neces- Clearly any vigorous cervical manipulation
sary must be taken before undertaking any would be unwise in the presence of this
treatment to vulnerable areas. symptom.
The tests most often quoted as useful Absolute contra-indications would include
screening in the upper cervical spine follow: any case where there is evidence of severe
nerve or cord compression. Where there are
1. EXTENSION TEST cauda equina signs or evidence of neuro-
praxia, further investigation is essential.
Have the patient seated and slowly bring his Lack of diagnosis, or even of a reasonable
head and neck into extension. Then side bend working hypothesis, is also an absolute
and rotate it to one side and then the other.
contra-indication. It is very easy to fall into
Any evidence of nystagmus, dizziness or dys-
the trap of treating by recipes without even
arthria should cause the operator to abandon
thinking about the possible implications of
all attempts at thrust techniques and should
the techniques chosen and treatment in
lead to an investigation of the reasons for the
symptoms. These are classical symptoms of general. As the human body is so ready to
postural hypotension which is indicative of accept the benefit of manual treatment, many
compromised vertebra-basilar circulation. practitioners are tempted to take the easy
path of treating first and diagnosing after-
wards, if at all. Most times they will get away
2. HAUTANT'S TEST with it, but eventually hidden pathology or
Have the patient seated and ask him to anomaly will catch them out. Some sort of
stretch both arms out in front at shoulder working system is seen to be essential to
height. Have him close his eyes and then avoid this tendency.
extend the neck and sidebend and rotate it to Extreme pain or resistance should be
either side. If one arm sinks and pronates, another warning that must be heeded. There
26 Contra-indications and precautions
must be a re-evaluation of the signs and ADVERSE REACTIONS
symptoms if this is met. It should never be
Adverse reactions to treatment could be due
necessary to force against pain or resistance.
to a hypersensitive patient, an undiscovered
Find another way, or another day. The few
pathological state or excessive force or dosage
occasions when manipulative therapy has
in the previous treatment. An excessively
been responsible for injury are mostly those
emphasized history and histrionic reactions
where the practitioner has continued in the
may be purely due to fear and distress or low
presence of substantial resistance from the
pain threshold. Any of these mean that
patient. The patient's tissues know best and if
choice of technique must be modified accord-
they are giving a message, take notice of it.
ingly. If suitable care is taken to grade the
The less the experience of the operator, the
treatment from the lightest possible forces
greater the need to consider the absolute
and only increase force according to the
contra-indications in the light of pain or needs of the case, then the chance of adverse
resistance. With increasing experience it may reaction and over-treatment is minimal.
be possible to allow some of the absolute Despite the most meticulous care, a severe
category to move toward the relative contra- reaction to treatment in general, or particular
indication category. techniques, can occasionally occur. There are
many ways of reducing the effects of adverse
RELATIVE CONTRA-INDICATIONS reactions. Some practitioners advise rest and
heat. Some advise analgesics or anti-
Under this heading could be included a inflammatory medications. Some will apply
complete list of pathologies that may affect gentle effleurage techniques and yet others
bone, disc, ligament, etc. Any patient who has will carefully repeat the treatment plan
a pathological condition may also, incidentally, previously applied. My personal approach is
have mechanical dysfunction in the musculo- to examine the patient thoroughly using
skeletal system. As long as the object of the examination procedures which are basically
technique is to deal with the mechanical treatment manoeuvres and try to find the
disorder and suitable care is taken to protect reason for the reaction. If there is an area of
the patient's welfare, contra-indications m~y inflammation and congestion, then apply
be considered relative in that case. The mam gentle techniques from the indirect categories
reason for grading osteopathic techniques to settle the situation down. I generally then
into their various different varieties and ask the patient to report in a couple of days
different modifications is that it should be by telephone or in person. The mere fact of
possible to make a prescription of a particular making contact and discussing the situation
approach to technique that would suit a given seems to defuse the situation and restore the
patient. A combined leverage and thrust tech- patient's confidence.
nique using a long leverage in an 80-year-old
with a stiff neck would clearly be unwise.
This does not mean that a very light and DOSAGE AND TIMING
delicate minimal leverage thrust technique or Dosage and timing is important in considering
muscle energy technique could not be carried relative contra-indications. A severe reaction
out in such a case. may settle in a day or so to a situation of a
Relating the technique to the physique, considerable improvement in signs and
age, general health and state of the tissues at symptoms. If the same patient were to be
the time is part of the diagnostic process. It seen during that phase of soreness from
should form part of the pre-technique assess- treatment, the practitioner might have wrongly
ment in each case. assumed that he had approached the earlier
 Relative contra-indications 27

treatment wrongly. For this reason, daily menced. Over-zealous attempts to force a
treatment is generally to be discouraged. If joint to become fully functional in this situ-
the operator is prepared to perform only ation will often lead to extreme reactions.
minimal treatment on each occasion and is Inflammation due to ankylosing spondylitis
ready to accept the possibility of an accumu- or Reiter's disease is a situation where excess-
lating adverse reaction, then this may be ive active treatment is best avoided. Gentle
acceptable. There may be reasons of urgency settling techniques can be of use to reduce
due to impending travel, sporting event or the irritability enough so more powerful
important life event that make daily treat- procedures can be used later. The timing and
ment essential. From experience, I would say selection of when to treat can only be gained
that absolute specificity is necessary in these by thought, consideration and experience.
cases. Short, purposeful treatment, aimed at
one specific target tissue on each visit, seems
to produce the best result without excessive ILLNESS
reaction. Although the original purpose of osteopathic
treatment was for the treatment of systemic
DISCS disease through the medium of the musculo-
skeletal system, osteopathic medicine of this
The vexed question of whether to manipulate type is not as widely used as osteopathic
in the presence of evidence of disc herniation
treatment for mechanical dysfunction syn-
or prolapse will be the subject of discussion
dromes. This may not be the choice of work
as long as manual therapy is in use. The use
for many practitioners, but is governed by
of magnetic resonance imaging (MRI) has
self-selection of patients. Cases where there
shown that many cases with disc disease
is evidence of systemic disease can be treated
have been manipulated with great success.
either as a complement to conventional med-
Had the MRI been performed earlier and a
ical care, or as an alternative. If a patient is
decision taken not to manipulate, the patient
unwell systemically and is seeking treatment
may not have had such a good result! Once
again each case is individual and all factors for the systemic disorder there will be a
must be considered in coming to a conclusion difference in approach from the same patient
about the best approach. In the author's experi- asking for treatment for a mechanical dis-
ence, providing there are no signs of extreme order. A patient who has influenza, for
nerve pressure, either before treatment, or example, may not get much help from treat-
when applying the technique positions slowly, ment for their low back condition as their
then disc prolapse is a sign for caution, not muscles and connective tissues may not be
abandonment. Powerful rotatory techniques able to take the benefit of the treatment. The
in the presence of radiological evidence of general illness will be making the system
large osteophytes are best avoided for fear of weak and normal mechanical treatment will
nerve impingement. Forced flexion tech- often be wasted. It will tire the patient and
niques are unwise where there is evidence of the tissues will often be reactive and ultra-
disc prolapse in the lumbar spine as increase sensitive. This would then be a reasonable
of prolapse can occur. contra-indication to treatment at that time.
Some diabetics may find their insulin balance
disturbed by osteopathic treatment. Provid-
INFLAMMATION
ing they are warned to keep a close check on
A joint that is acutely inflamed is best left to their glucose levels, this should not be a
rest for a while until treatment is com- problem.
28 Contra-indications and precautions
PREGNANCY treatment. If the symptoms are directly refer-
During pregnancy, any technique that might able to the spondylolisthesis and there are cord
jeopardize the health of the mother or develop- signs, then osteopathic techniques directed to
ing infant must be avoided. The chief danger, the segment are best avoided as there is the
of producing a spontaneous abortion, occurs possibility of causing further damage. How-
in the first trimester. The possibility of pro- ever, many cases have the condition as an
ducing a miscarriage with properly applied artefact that has no bearing on the tissues
osteopathic care is so slight as to be almost causing the symptoms. Its existence then
discounted; nevertheless, in a patient with a does not preclude the use of carefully applied
history of spontaneous abortion care is essen- technique. Techniques that are specific and
tial. Statistically, the highest incidence of are applied to adjacent segments may well
miscarriage is in the 12th and 16th weeks of reduce stress on the unstable segment and
pregnancy. These are times when treatment can be very useful in the overall manage-
is best withheld in such a case. This is not ment of the case. Mobilization of an unstable
because it could cause a miscarriage, but spondylolisthesis is unwise and if it is due
more because there is the possibility of being to a recent trauma, there is some evidence
accused of producing it. Treatment during that complete immobilization can produce
the later stages of pregnancy will necessitate healing of this stress fracture condition. A con-
techniques modified somewhat from normal genital defect will not respond to temporary
methods. Hormonal relaxation in tissues immobilization.
makes most osteopathic procedures easier to
complete and light techniques can be most LIGAMENTOUS LAXITY
effective. With sufficient care a patient can be
treated right through her pregnancy, and in There are several situations when ligaments
certain cases osteopathic care has even been may be excessively lax. Inflammatory dis-
given during parturition itself with benefit. orders such as rheumatoid arthritis not only
The BSO has an expectant mothers clinic that affect peripheral joints. The ligamentous
undertakes extensive work on pregnant apparatus supporting the dens of the axis
women with excellent results. against the atlas can become disrupted. Any
excessive force in this area could be disastrous
ARTERIAL CALCIFICATION in these cases. Long-term use of systemic
steroids can produce osteoporosis, but can also
Calcification of the abdominal aorta is not in have a disorganizing effect on ligamentous
itself a total contra-indication to treatment
structures, particularly in the upper cervical
but clearly must dictate choice of technique: spine. Therefore, once again the possibility of
Caution is essential and extreme rotatory
ligamentous laxity in the upper cervical
techniques best avoided. In general, patients
column is present. It is impossible to state
with this condition will be of an age where what is a 'safe' dose, but any patient taking
this type of technique is unwise anyway. more than 10 mg daily over a period of more
Calcification of the aorta in a younger patient than 6 months should be treated with cau-
may be due to extreme hypertension and this tion. Anticoagulants have been incriminated
must be taken into consideration in the in producing ligamentous weakening due to
choice of technique. breaking down the fibrin matrix of the con-
nective tissue. This seems to target the upper
SPONDYLOLISIS AND SPONDYLOLISTHESIS cervical ligaments again, so any vigorous
The existence of spondylolisis or spondylo- techniques in this area must be tempered by
listhesis is not in itself a reason to withhold extreme caution. Any patient who is taking
 Relative contra-indications 29
anticoagulants is going to be somewhat more responses to pain and may become deficient
susceptible to micro-trauma, bleeding and in some of the B vitamins, for example.
slower healing in tissues, so the category of Heavy smoking has been shown to reduce
technique chosen must be of the lowest spinal circulation to the extent that some
invasiveness. Patients do not take these practitioners have insisted that patients do
drugs unless they have quite serious under- not smoke for 2 hours before or after treat-
lying pathological conditions and it is neces- ment. They feel that much of the benefit of
sary to evaluate the overall approach to treatment will be lost if the patient does
treatment with great care. smoke in this time. They also feel that
bringing the subject to the patient's notice in
such a graphic way can help trigger a thought
MEDICATION
process in those who want to stop to help
Several perfectly normal, valid medications them along the path. Every practitioner will
that patients may be taking can change the have to consider whether their conscience
effects of manual treatment. I have already allows them to work in this rather moralistic
mentioned the effects of systemic steroids and way; nevertheless, the ill-effects of smoking
anticoagulants in the section on ligamentous on spinal health are becoming more evident
laxity, but other substances must be con- as further research takes place.
sidered. Analgesics clearly modify the re-
sponse to pain and although they cannot SCOLIOSIS
obliterate it, they can reduce it to a point
where patient feedback is inaccurate. Due Mild degrees of scoliosis are common but
consideration must be made for this effect. extreme scoliosis requires modified techniques.
Antidepressants will modify pain response If an organic scoliosis is reasonably stable, it
and some patients will have apparently would be unwise to attempt to 'correct' it.
strange reactions to physical treatment when Vertebral bodies will have changed shape and
they are taking them. Any patient who is there will often be calcification of ligaments
taking powerful medication of any kind and fascial attachments. There will often be
should be questioned as to the reason for the osteophytic outgrowths and severe torsional
prescription. If they are unsure of the reason, techniques may cause problems of nerve im-
the practitioner should investigate the actions pingement. Vigorous techniques are generally
of, side-effects of and reactions to the sub- not indicated.
stances so that he can be aware of the medical
aspects of the case. There may be good SPONDYLOSIS AND SPONDYLARTHROSIS
reasons as to why the medical attendant has The presence of these common ageing pro-
not given much information. Probably the cesses are not reasons to withhold treatment,
most important medication that a patient but the thoughtful operator will naturally
may be taking is the one with which the modify approaches according to the degree of
therapist is not familiar. It should be standard degeneration. Some categories of technique
procedure to investigate every medication will be perfectly acceptable and others not.
that patients have prescribed so that import- Expect the worst reaction, and then if you are
ant precautions can be identified. In a very wrong it will not be too disastrous.
short space of time the common drugs will be
understood and memorized. It is also wise to
know the effects of the common recreational MALIGNANCY
drugs, alcohol and tobacco. Patients taking In any patient who has had a past history of
large amounts of alcohol will have different malignancy, the most thorough and searching
30 Contra-indications and precautions
examination should be carried out. It is obvious thing and as this has not produced
essential to have an accurate diagnosis of the the result, the patient has moved on to
tissue causing symptoms. If the tissue symp- someone else. Every practitioner wants to
tom is of a mechanical nature, then there is give the patient a good result; if drawn in to a
no reason why treatment cannot be carried situation where the patient is very importunate
out. Symptoms that might originate from for treatment, it can be very difficult to resist.
secondary malignancies may well appear to Several treatments later, if there is no result,
respond in the short term to physical treat- it can be very difficult to extricate oneself
ment, but the benefit will only be temporary from the situation unless a 'contract' has been
and is probably due to circulatory and psycho- established in the first place. This is the type
logical factors. of case where it is wise to establish an agree-
ment to a re-examination after a predetermined
number of treatments. If the desired changes
VERTIGO
have not taken place, it is best to avoid
Some types of vertigo can be helped substan- further treatment until further investigations
tially by physical treatment, particularly to or a second opinion have been sought.
the neck and upper thoracic area. Some types
can be aggravated. Meniere's disease and
FEEL
postural hypotension can be irritated by over-
vigorous and rapid techniques. Both may If something just does not feel right, then this
well be helped, however, by appropriate is a good reason to perform more thorough
techniques for the situation. Both cases may investigation or examination. The sixth sense
prefer to be treated sitting up rather than of this combination of learned facts, experi-
fully recumbent. ence and temporarily forgotten aspects can
be very reliable. If something just feels wrong,
stop and reconsider. If signs and symptoms do
PSYCHOLOGY
not match, this is the time to think again.
Psychological dependence on physical treat- There may be hidden pathology or anomaly.
ment is not uncommon and providing the There may be psychological factors, or the
operator has assured himself that the patient patient may be overemphasizing their problem
does have a true physical cause for his for some other reason. It is clearly necessary to
symptoms, then treatment can be valid. It find out more accurately what is going on.
must be said, nevertheless, that this type of
patient becomes an expert in emphasizing The whole subject of contra-indications is
minor physical disturbances. The less experi- dependent on accurate assessment of the
enced practitioner may well find themselves cause and nature of the presenting condition.
treating such a patient who has been the If an accurate diagnosis has been made, the
rounds of others. Any patient who has seen contra-indications should be obvious. Slow,
several other practitioners should be looked deliberate technique while getting feedback
on with extreme caution. It is easy to assume from the tissues is probably the guide that
that the other practitioner has missed some- most practitioners rely on. It is not a finite
thing obvious. They may have done, but it is science, but rather an application of science,
far more likely that they have done the art and reasoning.
INDIRECT TECHNIQUE 6

Although the teaching at most osteopathic quarters it has been due to the ever increas-
training establishments world-wide has been ing fears of litigation when 'manipulation' is
predominantly structural in approach, there performed and an articular sound is heard.
is a considerable interest, and validity, in This can lead to accusations of possible harm
many of the more newly developed methods. and wrong results. That a well-constructed
Indirect methods are generally less invasive in treatment based on good technique using
application, although they may be no less structural methods should not be painful or
effective in action. They require just as long to traumatic is clearly not considered by indi-
perfect as direct methods, but give the viduals who use powerful and uncomfortable
student or practitioner who is not experi- methods. There may be many reasons why
enced in direct technique an ability to treat practitioners continue to use such approaches.
the patient immediately in a generally safe They may not have been trained sufficiently
and comfortable way. in gentle and effective technique, or have not
Indirect methods should not be an excuse been able to acquire the skills adequately.
for inefficiency in technique. They should be They may feel that firm force is an essential
a supplement and complement to primary requirement, or that it is what the patient
methods, and add a dimension to treatment expects. In my view, excessively high force is
that cannot be gained as easily with structural generally a sign of weakness in approach.
approaches. There are some cases that will Force conceals weakness. This is not to say
only respond to some of the indirect tech- that force is not necessary, but simply to state
niques, but these are rare, and conventional that the minimum force capable of producing
structural technique remains the mainstay of the required result should be the aim of the
osteopathic practice for most practitioners. thinking, caring practitioner.
Increasingly, as knowledge of these meth- The various categories of indirect tech-
ods spreads, they are being integrated with the nique therefore have many uses and possible
more common structural methods as adjuncts, advantages. In this section the description of
as supplements, or as a substitute in some situ- these methods is not designed to be a full
ations. Most experienced practitioners un- exposition, but simply an introduction. Experi-
consciously use a combination of approaches. enced practitioners of these various methods
No single method has all the answers to may be somewhat irritated by my attempts to
all mechanical dysfunction problems in the simplify and abbreviate the systems, but this
neuro-musculo-skeletal system. simplification is the whole purpose of this
The reasons for the development of in- section. The reader is referred to the biblio-
direct technique are interesting and varied graphy for more details of literature relating
according to location. In some countries it has to each of the various types of technique and
been due to a backlash against the powerful treatment. There are many other methods in
manipulative methods in common usage, and use, and this list is not as comprehensive as
is seen to be more holistic and cooperative some might like; however, I have tried to
rather than being confrontational. In some include the main methods in wide use by
32 Indirect technique
osteopathic practitioners. Although no method With the combination of these principles, and
'belongs' to any system, some approaches are a range of holds and techniques, the cranio-
more commonly practised by other manual sacral system and dysfunctions in movement
therapists such as chiropractors and physio- patterns can be addressed. The head is held
therapists. I have tried to remain essentially in a variety of predetermined holds, and the
osteopathic and to try to reflect the main practitioner 'tunes in' to the cranial rhythmic
methods in use in Great Britain rather than impulse (CRI). This rhythmic impulse is de-
that in world-wide. From my travels and ob- scribed as being an ebb and flow of approx-
servation elsewhere, I suspect that the British imately 10-12 cycles per minute. He may find
situation closely resembles most other coun- disturbed movement or flow. If this is the
tries. There may be regional and national case he can apply gentle forces to stimulate
differences that are due largely to the lack of the potency of the system and the fluid drive
availability of technique teachers. to perform any correction deemed necessary.
I have tried not to be judgemental in my The sacrum can similarly be treated with
comments, but only to speak as a structural holds that allow it to float on the fluid drive
osteopath who has eclectically incorporated and free itself, guided by the practitioner.
many other methods into my armamentarium The dural attachments to the sacrum can be
as I have found them useful. There are some freed to allow better function at the upper
methods that I rarely use, but I may incorpor- end of the system in the cranium. As time has
ate some of their principles, if not the tech- passed, the concept has been developed to
niques themselves. The various methods are make it applicable to most structures of the
listed alphabetically. body via the CRI. The impulse is best located
in the cranium, but can be felt to a greater or
CRANIO-SACRAL TECHNIQUE lesser extent all over the body. Treatment
using this principle can be applied to many
Cranio-sacral technique was first described structures remote from the head. For this
by William Gamer Sutherland DO. He was a reason, many practitioners now like to refer
student of Andrew Taylor Still, so clearly got
to treatment of the involuntary mechanism,
some of his knowledge from the fountainhead
rather than cranial osteopathy.
of osteopathy. He postulated the possibility of
Although cranio-sacral techniques were at
movement between the cranial sutures and
one time the exclusive province of osteo-
bones and that they could become dysfunc-
paths, they are now (like most techniques)
tional. He put forward the idea that these dys-
being used increasingly by other manual
functions were amenable to manual manipu-
therapists. However, the fuller implications
lative methods. The technique rapidly grew to
of cranial work with whole body health seem
include some basic concepts. These were:
only to have been considered in detail by
1. The existence of an inherent motility of the osteopaths. Osteopaths using cranio-sacral
central nervous system. techniques often treat many conditions other
2. An inherent motility and pulsatile nature than local head symptoms and many good
of the cerebro-spinal fluid. results are produced. There is substantial
3. The existence of reciprocal tension mem- interest, and increasing evidence of the par-
branes, namely the meninges, particularly ticular benefits in neonates and small children,
the falx cerebelli and the tentorium. although the techniques can be used with
4. The mobility of the cranial bones around efficacy in all age groups. Of all the systems
articular axes. of indirect technique, cranio-sacral methods
5. The mobility of the sacrum between the are probably the one approach used by some
ilia. practitioners as an exclusive treatment tech-
 Gentle therapeutic manipulation 33
nique. This shows the effective nature of the tion considering more up-to-date thinking,
approach. If it did not produce good results, the validity and effectiveness of the method
they would not be able to sustain a private is not in doubt.
practice with its sole usage. Holds have been developed for treatment
of most articular structures. Although the
principles of moving away from a barrier are
FUNCTIONAL TECHNIQUE
opposite to conventional structural technique,
Functional technique was evolved by Bowles they can be integrated with other treatment
and Hoover, DOs in the USA in the first half techniques very easily to form a combined
of the twentieth century. It has been extens- system. The system is guided purely by
ively developed by Professor William Johnson palpatory feedback from the tissues and is,
DO, in Michigan. It is a system of osteopathic therefore, dependent on good palpatory skill.
technique based on the premise that segmental Conventional manipulative skill gives the
dysfunction is palpable as an increasing resist- practitioner the ability to perceive accumulat-
ance to motion demand in certain directions in ing barriers. Functional technique requires
a lesioned segment. This has been called the the skill to palpate disintegrating barriers.
bind sensation. Any dysfunction will have This may take some conversion of thinking
certain pathways of 'ease', where resistance and awareness, but most can acquire it fairly
to movement is felt to progressively collapse. quickly with suitable instruction.
The 'bind' states can be treated by finding
a pathway of least resistance in the segment.
GENTLE THERAPEUTIC MANIPULATION
If all directions and pathways of 'ease' can
be found this should allow 'quietening' of Gentle therapeutic manipulation (GTM) is a
proprioceptive feedback and 're-setting' of system of active patient movement guided by
Gamma gain in tendon and joint receptors. the practitioner in specific directions and in
The dysfunction can be detected by a specific order. The active movement of the
variety of methods including palpatory aware- patient is monitored by gentle pressure in
ness of limitation of movement quality rather particular directions over the dysfunctional
than range of motion. He then assesses the area by the operators' fingertips. It was first
responses to find which ones bind, and which demonstrated in Great Britain by John Spence
ones ease. Whereas conventional manipulation DO, in 1994. The system originated in New
challenges barriers to 'break' them down, Zealand, and like many of these indirect
functional technique eases the segment into a approaches, evolved from a combination of
multiple movement pathway of accumulating other methods.
ease. This aims to aid relaxation of the adnexial Immediate change in perceived muscle
tissues and produce more harmonious mobil- tension and fascial irritability is apparent
ity. It is based on the concept that afferent after successful treatment using this method.
feedback to the spinal cord is disturbed in a Relatively little is known of this method in
dysfunctional segment. The proprioceptive Europe so far, but interest is growing as
mechanisms are maintaining this disturbance, results are seen. It is commonly combined
and by passing the segment into a pathway of with specific advice as to ice packs and
ease, the afferents will quieten. This should specific exercise as a follow-up to treatment.
lead to a reduction of efferent firing. The sum Although it employs hardly any applied
effect of this is to cause a new setting of the force, there may be tissue reaction due to the
afferent to efferent balance, and a more changes produced. The rationale is thought
harmonious movement pattern. Although to be of joint and tissue release by way of
the physiological explanation is open to ques- guided pathways of active movement pro-
34 Indirect technique
ducing a return to more normal harmonious natural recoil to return the thigh to neutral,
patterns. would be a typical harmonic technique. The
range of movement might change only
HARMONIC TECHNIQUE slightly, but the quality of movement should
improve markedly if the correct harmonic has
Harmonic technique is a system of approach been found. There will also be circulatory
that uses a harmonic pressure against differ- changes stimulated by better relaxation and
ent areas of the body, and allows a natural fluid interchange.
recoil to take place. It is a re-discovery of The technique is not merely an oscillation
some of osteopathy's oldest methods. The back and forth. There are certain directions
early pioneers of osteopathic technique used that are essential for the system to produce the
harmonic oscillating movement as part of
best results, and amplitude is also important.
their treatment. It became less used as time
There are several possible explanations for
went by and more linear methods became
the effect of harmonic technique. There are
popular. Although most schools of osteopathy
evidently neurological, hydraulic, mechanical
taught some form of rhythmic technique, it
was not generally taught as a system in itself. and psychological reasons why it works.
E. Lederman DO re-discovered, classified and
re-introduced harmonic methods, and has ex- MUSCLE ENERGY TECHNIQUE
tensively researched the physiological effects
of this, and other methods of manipulative Muscle energy technique (MET) was first
approach. described by Fred Mitchell Sr. DO, in Michi-
The patient allows the part being worked gan USA in 1958, and was developed extens-
to be pushed, pulled or moved in a specific ively by his son Fred Mitchell Jr. Much further
direction, and the natural recoil and rebound development has taken place under Ed Stiles
of the tissues return it to neutral. This action DO, also of Michigan. It is a system of
is repeated in a harmonic fashion until an therapeutic approach that relies on diagnosis
oscillation is taking place where the operator of a mechanical dysfunction, and treatment
is acting as a catalyst. The best balanced with active patient resistance in certain direc-
harmonic rhythm is when the effort on the tions against the resistance applied by the
behalf of the practitioner becomes least. The operator. The barrier to joint motion or
operator starts the oscillation and changes muscle function is found and the operator
speed until this dynamic balance is found.
holds the part against this barrier. He then
The rate of oscillation will vary according to
gets the patient to push either away or
which part of the body is being worked and
toward the barrier depending on the required
length of the lever. The technique is con-
result and effect. After a few seconds, the
tinued until a sense of relaxation is perceived
in the area being worked. Holds have been patient is instructed to relax, and the barrier
developed for most body areas, and the tech- should have been found to have moved. The
nique can be used as a treatment in itself, or new motion barrier is found, and the activity
as a preliminary to other categories of tech- repeated several times. The mechanism is
nique if desired. It is seen as most useful perceived to be a re-balancing of the afferent
where the rhythmic pattern of movement of a to efferent feedback from the spinal cord.
part has been lost. An example might be as in There are four main methods of approach:
a severe arthrosis of the hip. Conventional isotonic; isometric; isokinetic; isolytic.
stretching will clearly make some change, but Isotonic muscle energy technique is where
a gentle rolling of the thigh, allowing the the operator resists the patient's active muscle
 Myofascial technique 35

contraction and allows slight movement in MYOFASCIAL TECHNIQUE

the direction of muscle contraction to main-
Myofascial technique has developed relatively
tain the muscle in the same tension. The 're- recently as a conglomerate of several different
training' of muscle is perceived to change the approaches. It has some similarity in approach
tone and body awareness of the muscle so to some of the cranio-sacral approaches.
that it can learn a new pattern of useful However, it can be applied to all areas of the
contraction. body as it works on the muscle to fascia and
Isometric muscle energy technique is where fascia to bone and viscera interface. It may
the operator resists the patient's active muscle use some of the principles of muscle energy
contraction and does not allow movement. technique in that resistance is utilized. It uses
This causes the muscle to remain at the same perception of fascial plane tension in diagnosis
length throughout. This is used to either and treatment procedures. There are various
strengthen the muscle, or to allow the practi- common methods of application.
tioner to use the reflex relaxation after con- The technique is often applied by the
traction to apply a stretch. It will also produce operator finding an area of perceived dys-
a reflex relaxation in the antagonist muscle function and gently guiding it toward more
which can then be stretched more easily. harmonious working with adjacent areas.
Isokinetic muscle energy technique is The pressure will vary, and the time taken
where the operator resists contraction of a will depend on the speed of release perceived
muscle or group of muscles in the patient and by the operator's palpating hand. This is
allows a gradual lengthening of the muscle generally a very slow and gentle method that
during the resistance. This is perceived to act is perceived as relating to the neurological
as a re-education to the muscle to normal control of the muscle and fascial attachments.
movement and contraction patterns. This concept relies on accurate feedback from
Isolytic muscle energy technique is where the fascia and muscle state as to the optimum
the operator resists the contraction of a relaxation phase of the area. Control of the
phase of breathing is also emphasized.
muscle or group of muscles in the patient and
Some myofascial technique approaches use
overcomes the resistance to 'breakdown' the
quite strong stretch along the fascial planes
muscle. The patient must resist with enough
with either single or multiple, slowly applied
effort to cause the muscle to contract, but at
stretches. Some approaches use diagonal
the same time must allow the operator to
transfascial stretches. One of the chief critical
overcome the resistance to the effort. The elements of myo-fascial technique success is
effect of this is for the muscle or muscle the use of sufficient time in the hold position
group being affected to lengthen under the to allow adequate fluid interchange and soft
stretch while it is contracting. This is de- tissue 'creep' to take place. Muscles are
signed to have the effect of breaking down essentially fluid in life, and as fluid is non-
resistance to movement caused by muscle compressible, some of the action is probably
protection and allowing greater freedom of produced by sustained pressure allowing
function. fluid to change its position within the fascial
Each one is designed to have a different tubes.
action on muscle and can be performed against The two models of approach may seem at
or with a barrier. Although this concept may variance, but like many other approaches will
now be found wanting physiologically, results depend on many factors as to their applicabil-
of recent research show that the method is in ity in any given case. As in most systems of
wide-spread and effective use. approach, practitioners usually polarize to a
36 Indirect technique
particular method. Some may find one method who was a chiropractor and osteopath. He
easier; some may prefer the rationale of one combined the current thinking of the two
method; some may feel one is more effective. professions at the time to introduce a system
of osteopathic manipulative methods that
used chiropractic thinking on malpositioning
NEURO-MUSCULAR TECHNIQUE
and replacement. The technique is mostly a
Neuro-muscular technique was developed by thrust approach using extremely rapid yet
Stanley Lieff DO and Boris Chaitow DO, gentle force that is often performed just short
English osteopaths. It employs a system of of a facet gapping. It is designed to replace or
progressively searching sliding pressure retrace the pathway of lesioning position,
designed to find dysfunctional areas and then and relies on specific positional diagnosis and
treats them with varied directions of deeper specific directions of adjustment. The system
pressures. It attempts to 'normalize' these was little known or taught for some years
areas by allowing improved circulation and until being re-introduced to osteopathic
're-setting' of the neural control of tendons education by Tom Dummer DO at the Euro-
and muscles. Its main action is on connective pean School of Osteopathy in Maidstone. It is
tissues, fascia and muscle attachments. In the now being carried on by some of his pupils.
spinal area the practitioner uses thumb pres-
sure on the para-vertebral gutters, directly
STRAIN AND COUNTER-STRAIN
over the facet joints and using the fingers as a
fulcrum, oscillates over each level until the Strain and counter-strain technique was first
lesion is detected. He then sometimes uses described by Lawrence Jones DO in 1981. He
a lubricant such as a massage oil to apply put forward the notion that many somatic
mostly longitudinal pressure repeatedly over dysfunction syndromes are accompanied by
the segment in question and one or two specific trigger points. These points are often
adjacent segments. very remote from the lesion and may not
Neuro-muscular technique can also be accord with conventional anatomical think-
applied along the whole length of the spine, ing, but are consistent and have a characteris-
concentrating on areas of dysfunction with tic sensitivity and tenderness The technique
firmer pressure. It is also sometimes used on consists of locating the trigger point relevant
the abdomen and limbs. There is a complete to the particular dysfunction and then posi-
system of approach that has been docu- tioning the patient in such a way as to cause
mented to apply it to a wide range of the trigger point to become painless. The
conditions. Although this technique is not as position is then held for some 90 seconds and
widely used now as it was in the first half of the patient is then slowly returned to a
the twentieth century, it has a certain follow- normal posture. If the technique has been
ing. It is now not taught in many osteopathic successful, the trigger point will have disap-
schools. There are some similarities with Rolf- peared, or at least substantially reduced. The
ing and some other deep massage tech- holding of the position will often be accompa-
niques. Practitioners using this method feel nied by a sense of release, heat and freedom.
that it can produce longer-lasting results than Testing the articular lesion should also show
some of the articular-directed techniques. a return of function in terms of mobility.
The technique can be applied to any area
where the trigger point has been identified,
SPECIFIC ADJUSTING TECHNIQUE
and even if it is not used as a sole method,
Specific adjusting technique was evolved forms a good preparation to further structural
mostly by the late Parnell Bradbury DO DC techniques. It may seem somewhat non-
 Visceral technique 37

dynamic as the position held for 90 seconds movement. The practitioner applies a hold to
is not in any way rhythmic, but nevertheless the viscera with or against the axis or axes.
it is often successful in releasing specific He very gently tests the range and quality of
fixations. There have been some attempts to movement in all available planes. If necessary,
shorten the time, and although these are not he then applies a 'corrective' force against a
in accord with the origins of the technique, perceived barrier, or applies an 'ease' direction
they are more acceptable to some practi- of combined pathways to allow greater free-
tioners. To allow the shortening of the time it dom of movement and release of excessive
is necessary to perform the hold with some- tethering. Barral has stated that the force
what more pressure or emphasis. applied need rarely exceed 300 grams.
The thinking behind the reasons for the Visceral technique has become very widely
existence of the trigger point and its precise used in the continent of Europe, and is now
location may vary with different practi- being taught in the United Kingdom at
tioners. The perception is that the lesion is undergraduate and post-graduate level. The
due to an aberrant pathway of movement work has been developed and documented
and is maintained by muscle spasm. The part well by several authorities, but Jean Pierre
must be taken back through the lesion Barral from France and Stephen Sandler from
pathway until an antalgic position is found. the UK need special mention here for their
The part is maintained in this position for 90 logical descriptive texts and descriptions of
seconds, which is long enough for the pro- the techniques. Many schools now integrate
prioceptive feedback from the Gamma gain the teaching of visceral techniques with all
mechanisms to quieten down. The proprio- the other approaches to the body that will
ceptors then re-set, and the spasm reduces, have an influence on the visceral systems.
allowing normal articular patterns of move- This is a logical development from looking at
ment to be restored. visceral technique in isolation.
The part has thus been taken back to the An interesting development in the field of
position in which the lesion occurred and visceral technique has been the study of the
allowed to recover slowly, guided by the relationships between the organs and their
operator pressure and control. supporting tissue as well as the adjacent
somatic structures. Grays Anatomy and other
standard textbooks refer to the folds in the
VISCERAL TECHNIQUE
peritoneum that connect organs as peritoneal
The origination of visceral technique is un- ligaments. These so-called ligaments, such as
clear, although Barra! in France is often the gastro-colic ligament, provide potential
credited with first describing it. It is a form of for organ restriction if they are thickened or
functional technique as applied directly to the fibrosed, thus potentiating the eventual dys-
viscera and their fascial attachments. It has function of the organ. Visceral technique
many similarities to cranio-sacral technique, taught at the British School of Osteopathy
in that the barrier sense is used in easing involves diagnosing and treating these visceral
perceived dysfunctions with extremely gentle restrictions. Their manipulation involves hold-
forces guided by the operator's listening ing and release techniques as well as guiding
hand. The hand is at one and the same time a and functional techniques which make use
diagnostic instrument and a therapeutic tool. of the fact that as structures they contain
The resistance to motion or function is muscular elements as well as collagenous
sought, and the appropriate technique used fibres. It is hoped that, by restoring a normal
to normalize the lack of function. All viscera functional relationship between the organs
are perceived to have one or several axes of and their neighbouring structures (both
38 Indirect technique
visceral and somatic), one can move away techniques are necessarily brief, they should
from dysfunction towards better health. This help to give a taste of the various methods.
concept of working on viscera that are dys- This may give the reader sufficient interest
functional as opposed to pathological has to permit further study to be undertaken. To
been found to be both safe and efficacious. this end the recommended reading list should
Although these descriptions of indirect be of some use.
MODIFYING FACTORS IN TECHNIQUE 7

Any psychomotor skill can be varied by 4. Plane or direction of force.

several modifying factors. From the sporting 5. Force or quantity of effort.
world let us use a tennis shot as an example. 6. Onset or the point at which the useful
The direction of the feet, the bend of the part of the technique begins.
knees, the size of the racquet and the twist of 7. Arrest or the method and point of end of
the wrist are modifying factors. They will be a technique.
determining the success or failure of the 8. Compression or the use of dose-packing
stroke. If the player directs his feet across the in a technique.
direction of the ball trajectory rather than in 9. Primary and secondary levers or the
the same direction, the stroke will have more identification of the principal direction of
power. If the knees are slightly bent, the force, and the vectors that help stabilize
recoil of the strike against the ball will direct the part to make the primary lever more
the force into the ball, and not into the efficient.
player, thus increasing the potential power of 10. Respiration or the phase of breathing
the stroke. It can be seen, therefore, that any when the force of the technique is to be
of the modifying factors will interconnect applied.
with the others to make up the composite 11. Resistance or awareness of accumulating
whole that we might call a tennis stroke. The barrier sense.
principle of understanding the modifying 12. Contact point pressure or local close-
factors and using them to the advantage of packing of tissues and pushing aside of
the activity is without question, although unwanted structures.
some are clearly more important than others. 13. Hunch or the ability to develop a sixth
If we relate this to osteopathic technique, sense that something needs or does not
several important factors come to mind. need a particular approach.
Posture and handling have been separated
and warrant complete sections to themselves SPEED OR VELOCITY
as they are so critical, but the others are only
The speed at which a force is to be applied for
slightly lower in the scale of relevance.
a given technique will be dictated by the type
A list of the factors that most people vary
of technique. A rhythmic technique will have
when modifying a technique follows. There
a slower speed than a thrust, but will be
are several others that will come to mind with
repeated several times whereas a thrust is
a little thought. The exercise of doing this will
usually only performed once at a given site.
be of some benefit as the effort of identifying
There must be some determination of whether
them often reveals vital factors not previously
the speed is the same throughout the tech-
considered.
nique, or if there is an acceleration and
1. Speed or velocity. subsequent deceleration, and the rate and
2. Duration or length of time. amplitude of these changes. It can be seen
3. Amplitude or distance travelled. immediately, therefore, that other modifying
40 Modifying factors in technique
factors of onset, arrest and amplitude are Effective technique needs less time to per-
immediately varied by the consideration of form but the duration of a particular treat-
speed. A useful rule about speed is that ment session itself is not really a function of
rhythmic technique should be performed technique but is another matter completely.
slowly enough for tissue change to be pal- Every osteopath seems to have his idea of the
pated during the procedure. Suitable changes duration of treatment necessary to produce
can then be made to find the optimum path the appropriate amount of change in the
for tissue response. Thrust technique is usually tissues and the condition. I have known
performed at as high a velocity as possible. variations between 5 and 60 minutes for a
Once the tension has been accumulated in treatment session. My feeling is that there are
the target tissues minimum effort is then different needs to every case, but due to the
dissipated into other tissues, and the max- constraints of most practitioners' appoint-
imum effect of the technique is applied to the ment systems, this is not a very practical
desired site. The critical thing about use of statement. Experience should allow most
speed is that it should always be under the practitioners gradually to reduce the time
tight control of the operator. Do not use needed to work on each case in an effective
the patient's tissues as the brake to the force. way. There will naturally be an optimum for
The control must be directed by the operator each practitioner and his set-up of consulting
using his muscles as a brake. This requires rooms and changing areas, etc. Patients seem
close-packing of the tissues and a thorough to want a long treatment giving good value
understanding of the vectors necessary for for money and the maximum involvement,
the successful completion of the technique. but they do not like a long waiting list! The
two are not usually mutually compatible.
DURATION
AMPLITUDE
The duration of application of force in a given
The amplitude, or distance travelled by the
technique will vary again according to the
applicator, is governed by some of the other
type of the technique and the response from
modifying factors. In a rhythmic technique
the tissues. A rhythmic technique will be
the amplitude will tend to be fairly long
repeated several times until a sense of change
unless it is a springing technique when the
has taken place. It is easier to over-treat than
oscillation is very short. In a thrust technique
to under-treat. Many students, and some
the amplitude must be very closely controlled
practitioners, feel that they want to give the
to give the technique as short an amplitude
patient the maximum benefit and will work
as possible consistent with the successful
for too long in a given way on a part of the
completion of the procedure. High velocity,
body. Too much is possibly worse than too
short amplitude remains the mainstay of
little. A technique performed for too short a
manipulative thrust techniques. As composite
time may not produce much benefit, but it is
levers accumulate at a point the sense of
unlikely to make the situation worse. How-
resistance should cause the amplitude to
ever, a technique performed for too long may
reduce until the forces are focused accurately.
well make a pain syndrome more uncomfor-
This sense of resistance or barrier is critical to
table by fatiguing the tissues.
manipulative technique.
A sustained release technique will be held
until a sense of release occurs. A thrust
technique may be primed several times, but PLANE
the actual technique will only take as long as The plane of force in a technique will be
is necessary to perform the thrust itself. governed by the purpose of the technique
 Force 41

and the direction of the tissues being worked FORCE

on. In a cross-fibre kneading technique, the
Force is a variable that again integrates with
plane will be across the muscle. In a stretch-
all the others to make a technique specific,
ing technique, the plane will be along the
successful and accurate. High force should
muscle ligament or fascia concerned. In a not be used as a substitute for accuracy. The
thrust technique the plane will either be aim should be to use as little force as possible
across the joint to gap it, or along the joint to that will achieve the desired effect. Generally
produce a sliding force. It can be seen, it is better to generate force by good control of
therefore, that an accurate knowledge of the levers and components than to apply high
anatomy of the part is essential, as is a good levels of force to make up for inefficient tech-
sense of accumulating resistance to applied nique. The higher the force, the greater the
forces. chance of injury and the greater the control
Unfortunately, anatomical variations are necessary.
the rule not the exception, and although When higher force techniques are necess-
certain principal directions are going to be ary, it is essential to keep the target tissue in
accurate within certain limits, there may be mind so that the force is directed accurately
considerable variation from the expected and specifically rather than allowing forces to
planes in many cases. There are no straight dissipate in the surrounding tissues. A suit-
lines anywhere in the body, and all forces able analogy is the difference between a shot-
should have a slightly curving vector so that gun and a rifle. The power of the shotgun will
they are more likely to reach the correct plane have a major effect at close range, but at any
for the technique in question. An analogy distance it will dissipate and the effect of the
might be to attempt to drop a small pebble force will be minimal at any given point. The
into a funnel. The ideal would be to drop it rifle, however, will be ineffective in hitting
straight down the centre. However, it would anything except the object in the direct line of
be more normal to drop it in and see it rattle fire, but will be extremely powerful in its
around until it finds its own way down the effect on that object.
centre by running around in ever-decreasing The part of the hand applying the force,
circles until it drops. Technique is often the length of the lever, the amplitude and the
performed by applying forces in a particular sharpness of the arrest will all modify the
direction and then making many small actual force applied. Re-duplication of force
adjustments until the optimum direction can will have an interesting effect according to
be found. If the force is applied without these the maintained pressure after the initial force.
minor adjustments, the quantity will often If a force is applied and removed the natural
need to be very high. The correct plane has recoil of the tissues will allow deformation
not been accessed and force is being used to to take place at the target site and in the
overcome the resistance rather than accuracy. surrounding tissues or structures. If there is a
This is unwise, uncomfortable and poten- dysfunction, with fixation and hypertonus,
tially dangerous. the fixed point may not release as the other
The plane of a given technique may change tissues are relatively more compliant and can
as the forces are applied and tissues deform absorb the applied force of a technique.
in front of the applicator. This is not uncom- However, if a force is applied, released and
mon, and it is necessary to allow for this then re-applied immediately afterwards and
possibility and not be too rigid in approach so held, the effect will be quite different. The
that the variation can take place guided by force will go into the tissues, and recoil out
the tissues. but will meet the fixed part of the operator's
42 Modifying factors in technique
hand or arm. Having met this resistance the and a small applicator would be used. There-
force will not be able to dissipate, and will fore, within the handhold that uses the
recoil back into the tissues. If the operator whole of the palm and fingers to produce
holds this position for a few seconds there contact, there might be an area of the hand,
will be an induced oscillation of force within such as the pisiform, that performs the
the structures that may allow release to take cardinal part of the technique. If a larger area
place. of contact is required, such as in a kneading
It is difficult to find an analogy for this technique applied to a muscle group, the
phenomenon, but imagine a ball bouncing
whole hand would be applied, and less
and then your hand placed directly in the
emphasis placed on focusing to a small part
trajectory of the ball. If the ball hits your hand
of the hand. Even in this case, there might be
before the whole of its energy has been lost, it
the need to focus with the heel of the hand at
will speed up its bounce. It will also usually
the culmination of the technique so that the
escape to one side as the energy has to find
an outlet. Using this in technique is a little part of the muscle needing the pressure could
different. The patient is positioned in such a be worked more efficiently.
way that the only direction the tissues can go
is against the hand and the force is, therefore,
ONSET
thrown directly back to the target site. This
type of technique is often used by chiro- The onset, or point at which the effective part
practors in classical 'toggle-recoil' thrusts. of the technique is to be applied, is naturally
The principles can be equally well used a subdivision of many of the other modifying
by osteopathic practitioners although chiro- factors. If the onset of the effective part of the
practors often use specifically designed tables technique is made too early, the force will be
with 'drop' sections to enhance the effect. dissipated before the technique has had a
Force is also modified partly by the size of chance to reach the target tissue. This effect
the applicator. Assume that the palm of the can be used purposely to minimize the stress
hand is used to transmit a force, and is, let us on the tissues, but if it used without realizing
say, 4 inches across and 4 inches long. that is happening, naturally the benefit of the
Assume also that the force applied is of 16 technique will be reduced. If the onset of the
pounds pressure. Simple arithmetic will
technique is delayed until towards the end of
reveal that there will be an applied force of 1
a movement stroke, the power will inevitably
pound per square inch. However, if the area
increase as there will be much less room for
of the applicator is reduced to 2 square
the tissues to deform ahead of the hand.
inches, by the operator gripping in such a
way that only a small part of the hand is Most categories of technique can have their
performing the effective part of the tech- effect enhanced or reduced by small variations
nique, the force will have increased to 8 of the onset of the effective part of the
pounds per square inch. Despite using the procedure. The difficult thing is sensing at
same quantity of overall force, the effect will what point to start the critical part of the
be some 8 times as powerful, and directed technique.
much more specifically to a point or area. Consider for a moment a classical lumbar
Naturally, there will be times when a small roll thrust procedure. A thrust early on in an
area of contact is preferable, and others when oscillating movement of the patient will have
a much larger area of contact would be more a far weaker effect than one performed at the
appropriate. A thrust technique using very end of a rotatory oscillation. A large patient
high specificity might require great specificity might need the thrust applied much later in
 Compression 43

the technique than a small and frail one. but the vehicle to reach this result is only
However, excessive attempts to control this slightly less important.
variable can lead to lack of confidence, and
there can be a tendency to become fixed and
COMPRESSION
unable to move at all. The variation of onset
is happening whether on a conscious level or The term compression needs some explana-
not; it is merely necessary to become aware of tion. Compression is not the opposite of trac-
it so that it can be varied slightly when tion. Indeed, it can be combined with traction
necessary. within the same technique. Compression can
be applied in several different directions,
either separately or in combination. The direc-
ARREST
tion most often used is a compression into a
The point at which a technique finishes can be 'close-packed' position. The act of applying
referred to as the arrest. This can be graduated, compression has several interesting effects. If
as in a soft tissue technique, or sharp, as in a compression is considered simply as another
thrust technique. There can be a sudden vector of leverage and force it can be brought
release of tension, a slow release of the into perspective. In the same way that adding
accumulated tension, or a re-duplication of components to a composite lever will reduce
force as previously described. Each one will the quantity of each component, compres-
have a varied effect and must be considered sion can act to reduce lever amplitude. If you
with all other variables. The method of arrest apply any technique in the usual way and
and release from tension also needs to be then add a compression between your hands,
considered. If the arrest is slow and then the the patient's tissues, and yours, will meet a
applicator is rapidly removed from the con- point of resistance. This resistance, or barrier,
tact point, there will be a different effect from will be that much earlier than if the compres-
that produced if the applicator is removed sion was not used. Let us consider some
slowly. Even if this effect is psychological, it examples.
is still relevant to consider it. If a technique is Apply a cross-fibre kneading technique to
arrested just short of the release of tension, the lumbar erector spinae with a patient
and then re-applied, there will be another prone as you normally would. Try adding a
difference in the rate and quantity of the compression force into the table, and a
distortion of the tissues that will inevitably compression of your chest and arm muscles
affect fluid interchange. by a small isometric contraction before the
Although these may seem minor factors, stroke lateral from the spine. You should find
they can make the difference between a that the stroke is of a smaller amplitude as
successful technique, and one that is only you have absorbed some of the slack with
partly successful. The rate of change in a target this 'pre-loading' of the tissues. This will
tissue is of importance in dosage of treatment have several effects. Firstly, the amplitude
and will influence the overall result. Many will be less; secondly, the force can be
operators hardly pause to consider how they reduced according to how much compression
finish a given technique. However, even a is applied; thirdly, the sense of release in the
little thought given to this variable may allow tissues should be easier to feel. The cues
a smoother integration of one technique into should become much crisper. As another
another. The choreography of treatment will example, consider a lumbar roll type of thrust
be that much smoother and a situation where manipulation. Position the patient in the
the patient can relax will be much easier to normal way and then, instead of increasing
produce. Naturally, the result is the objective, the rotation at the moment of thrust, intro-
44 Modifying factors in technique
duce a compression force toward the table safety. I would go so far as to say that com-
and toward yourself. The patient is, there- pression is far more useful as it allows a
fore, sandwiched firmly between your pelvis substantial reduction of force and amplitude.
and the table. If you now apply the rotary I feel that the traction rule has many potential
force, you should find that the range or pitfalls. By separating joint surfaces and
amplitude of the movement has been sub- putting surrounding ligaments on tension,
stantially reduced. Take this further, and start there is definitely a safety component intro-
the technique with even less rotation and it duced, but amplitude generally needs to be
should still be possible to attain a satisfactory greater, and the discomfort of this negates
lever position to focus to the target joint with- the benefits. Any attempt to 'protect' discs
out the common discomfort induced around and other structures using this method is
the patient's ribs and shoulder. laudable, but prone to a possible false sense
It can be seen that compression works, but of security. To some extent this rule developed
what is the mechanism? There is no definitive out of the belief that all joint dysfunction
answer to this question, but there are several syndromes were due to small disc fragments,
possible explanations. The effect of com- and that traction helped to replace these. MRI
pression may be due to squeezing the fluid and more sophisticated diagnostic methods
within fascial tubes: the fluid is naturally have found this belief wanting, and the use
non-compressible and will, therefore, become of traction in manipulative procedures for
relatively solid. There will, therefore, be a this reason has been slowly superseded.
reduction of range of movement as the relative There is no doubt that traction has its uses,
mass of the part increases. This possibility but it is not a panacea.
relates to the hydraulic effects of fluid pres-
sures and tensions. The effect may be due to
PRIMARY AND SECONDARY LEVERS
the compression acting as a stabilizing of the
part. This may be due to an increase of The primary lever can be identified as the
muscle tension that is produced in a similar principal or executive vector of force within a
way to the effect of strapping an unstable particular technique. The secondary levers,
joint. It has been shown that strapping a joint or components of the composite lever, are
acts by increasing the resting tone of the area, stabilizing and enhancing vectors that allow
and by 'switching on' the proprioceptors that the greatest efficiency in the primary lever
have ceased to function at their optimum. direction. The primary lever in a thrust tech-
There may be effects due to the elimination nique is usually in a sliding or a gapping
of fascial slide that, therefore, focuses the direction in relation to the joint surfaces in
forces to the articular structures in a more question. Sliding forces generally need less
efficient way. There may be effects due to the force than gapping, and are preferable when
squeezing having a psychological action by possible. Although the inclinations of facet
the patient becoming aware of operator planes conform broadly to certain pre-defined
control and, therefore, having a greater directions, there will often be some variation.
ability to relax and cooperate. There are The direction of a primary lever is deter-
several other possible explanations that make mined partly by a knowledge of the anatomy,
sense. Not having a logical one, I am, but ultimately by palpatory awareness. The
nevertheless, happy to recommend the conti- greater the number of secondary levers, the
nuation of the method, as it is so effective, less is the required contribution of each one,
comfortable and useful. and the nearer to the midline the part can be
Some authorities insist that all manipulative while the technique is performed. Clearly the
techniques be applied in traction to increase nearer to the midline, the less the distortion
 Primary and secondary levers 45

and stress on the tissues, and the greater the one below. The normal method of locking is
comfort. With greater comfort, the patient is to induce some sidebending to the affected
better able to relax, and there is less likeli- side and to rotate to the other side. This so-
hood of trauma in treatment and adverse called physiological locking obeys Fryette's
reaction afterwards. laws and adds specificity to the technique.
To illustrate primary and secondary levers I Using the principles just outlined you could
will again use some examples. Flex your wrist add several other secondary levers to minim-
until it can go no further without discomfort. ize the amplitude of the rotation. The ones
Become aware of the quality of resistance most commonly used in this case would be
from the tissues to this minor stress. Use the sideshifting, compression and anterior shift-
other hand to push the hand further into ing. The total of all the vectors would reach a
flexion, and become aware of the immediate 100% locking position, allowing the facet to
increase of normal resistance and strain. be freed in the desired direction. However,
Return the wrist to the resting position, and the quantity of each could be reduced as the
put it into a degree of ulnar deviation. While number is increased. All thrust technique
maintaining this ulnar deviation, add flexion requires a little free play so that the optimum
until resistance is felt. It will be noticed that plane can be found. The accumulating barrier
the point of resistance in flexion is at a lesser will be felt at an earlier point than without the
point than before, and that the quality of the secondary levers, and the potential for a
resistance is different in feel from that successful technique will be enhanced. To an
induced before. Now try gripping around the outside observer, the manipulative position
wrist and hand with the other hand and re- would not seem effective as the neck is not
peating the exercise. This adds a compression torsioned as in the common method of only
vector to the overall leverage. The feel of the two or three vectors. The operator would also
composite lever will be quite different on a need to be in much more control than normal
subjective level in the wrist being levered, as as the tissues would tend to escape from the
well as in the hand doing the levering. This induced tension. Body tissues are like a
simple example illustrates the use of a com- spring, and if allowed freedom to take their
posite lever with a primary force of flexion, own path, will usually take the easiest
and secondary levers of ulnar deviation and direction. This easy path is one that allows
compression. The quality of the resistance the minimum distortion and the maximum
felt will not only be different, but will be less ability to dissipate force over a large area. If
uncomfortable than a simple flexion. Addition- the technique is applied without the opti-
ally, if you were to use it as an articulation mum tension it is unlikely to succeed, but it is
movement repeated several times, even also extremely unlikely to cause pain or
though the joints are not being taken to their distress.
normal articular limit, there would be an In every technique there will be an execut-
increase of range produced. This effect can be ive or primary lever, and there will be
used freely in treatment and makes technique secondary or stabilizing levers or compon-
very much less uncomfortable. With practice, ents of the composite lever. Some complex
specificity improves also, as the variables techniques may even have what might be
allow the desired structure or tissue to be termed tertiary levers that come into play
targeted accurately. only rarely if suitable barrier sense cannot
Another example might be a classical thrust be achieved. Even though I have avoided
technique in the cervical spine. The primary terminology relating to lesion positioning,
lever is usually rotation in an attempt to slide the decision about a primary lever can be
one facet on the affected side forward on the taken on this basis if desired. The system of
46 Modifying factors in technique
identification of lever vectors is usable in both flexible subjects whose tissues may be able to
approaches. dissipate the force before it reaches the target
Even an operator who has no knowledge of site. However, even in a flexible subject, at
this positional thinking will inevitably be the end of exhalation the tissues are at the
using it, as the optimum position for any point of minimum ability to release further,
technique is made up of several different so technique performed at that point can be
forces. Once the consideration of primary extremely specific. If technique is performed
and secondary levers has been identified, it on largely inflexible subjects who happen to
should be possible to return to a technique be at the end of an exhalation phase, there
that is not working and identify what is will be much more possibility of trauma and
missing. Like all the other modifying factors, discomfort. This will particularly be the case
lever identification must be integrated with when working on the thoracic spine and rib
all other aspects to make it fully useful. cage.

RESPIRATION RESISTANCE

The active use of respiration in technique is The resistance to a manipulative procedure

not new, but the identification of the different should come from the target tissue or struc-
phases of breathing that can be integrated in ture. There should not be more than the
technique to personalize each procedure to minimum resistance from other structures
the patient may be. Naturally, it is not neces- surrounding it. Indeed, the zone of effective
sary to perform every technique at a specific resistance to the force should be as small as
phase of respiration. It would be far too easy to possible to ensure that the forces reach the
confuse and upset the patient with constant desired structure in the most efficient way. If
instructions about when to breathe! Never- progressively accumulating forces are applied
theless, there are times when the active use in a general, coarse way, there is the distinct
of breathing can be useful. Many practi- possibility of straining surrounding struc-
tioners ask their patient to take a deep breath tures. The other possibility is of the force
and then to breathe out just before a thrust being dissipated in the other structures and
technique is to be performed. This is designed not having the desired effect on the part in
to produce the optimum state of relaxation in question. Adhesions around a dysfunctional
the tissues and the patient. This is sometimes segment will often be stronger than the
useful, but if this is the only use of breathing, surrounding normal tissues, and forces
many other possibilities are being ignored. applied will distort the normal tissues and
Exhalation certainly can produce relaxation, not affect the dysfunction unless the forces
but in very flexible subjects this in itself can are accurately localized. Imagine two pieces
be a problem. Patients who are generally of wood joined by a strong glue joint.
hypermobile and have a fixed area needing Attempts to separate them with force might
techniques applied, might be better addressed just as likely break the wood as the glue joint.
when they are inhaling, to produce a sense of If, however, the glue joint itself were to be
focusing in the tissues by firming them up. struck with a hammer, there is a good chance
During inhalation the normal physiological that it would separate without as much
curves of the spine are slightly flattened, and damage to the rest of the wood, the max-
this fact can be used in technique. imum resistance to the force having been
During exhalation there will be more recoil formed exactly at the joint itself.
and give in the tissues and this may prove to It is difficult to acquire the skill necessary
be a disadvantage. This is particularly true in to be able to sense the optimum state of
 Hunch 47
resistance in a joint or other structure while The total force would be similar, but the
maintaining the other structures in a state of initial pressure of standing on it would bring
minimum tension. It is not difficult to sense the structure nearer to a breaking point
an increasing barrier by being aware of excess without so much impact. Naturally, the use
tissue distortion and strain. This is very of contact point pressure can be excessive as
different from an accurately applied force well as insufficient, but like most of the other
using controlled forces to a target seg- modifying factors, can be decreased as well
ment within a zone of minimum induced as increased as necessary.
tension. Generally the closer the applicator
can be applied to the structure being worked HUNCH
on, the better. The optimum resistance de-
pends on the best accumulation of forces Some will say that the use of hunch or sixth
controlled by using several of the modifying sense should have no place in a scientific
factors in combination. The best sense of activity like osteopathic technique or treat-
resistance is very dependent on the next ment. All activities that require skill or know-
modifying factor described, contact point ledge, and rely on variable factors, are liable to
pressure. so many variations that sixth sense is in-
evitably used. Rather than denying this, it
seems to make more sense to use it construc-
CONTACT POINT PRESSURE tively. This does not mean that one should
rely purely on feelings and not use reasoning
The amount of pressure with the applicator,
and logic. It is normal for this sixth sense to
and the method of application of that pres-
develop, and one can use it constructively
sure, are other critical variables. It is almost
providing it is backed up by some reasoning.
impossible to produce the best resistance in a
When an experienced practitioner is asked
joint or structure unless enough pressure has why he is doing something in a particular
been used to remove the slack from the way, the answer is often, 'because it feels like
overlying structures. This pressure must be it needs it'. If we analyse this statement it is
very carefully applied if it is not to become possible to see that there is a combination
painful, and the part of the hand or other of learning, forgotten experiences, conscious
structure used must be considered carefully. comparisons and previous mistakes and suc-
The method of application as well as the total cesses. Experience can be defined as the ability
quantity is also important, and depending on to recognize common patterns. The recog-
the type of the technique, the pressure rarely nition is one thing; being able to act in an
remains static, but increases and decreases as appropriate way is another. Hunch is really
the technique progresses. All techniques have all of these. It is necessary to guard against
a beginning and an end, and the point of onset the trap of the 'always, never' syndrome,
and arrest has already been discussed, but where the two words are used as an excuse
variations in pressure will influence the other for not thinking something through thor-
factors to a large extent as well. As an oughly. If a practitioner finds himself saying,
analogy, visualize attempting to break a piece 'I always ... ', he may not be flexible enough
of wood laid across two bricks. If the force to allow the essential variations that allow the
were to be applied from a distance, consider- technique and the treatment to vary subtly to
able impact might be necessary. If, however, suit the particular case. The same is true of 'I
you were to stand on the wood and simply never . . .' Providing this is used for contra-
bounce up and down, there would be a good indications, I have no argument with it; if it is
chance that it would break under the strain. used in other situations too often, it shows
48 Modifying factors in technique
a rigidity of mind that cannot fit with good aware of them or not. By bringing them to a
manipulative skill that is tailored to the level of analysis and conscious thought, it
individual patient. should be possible to use them constructively
It can be seen, therefore, that the modifying to tailor a given technique to the particular
factors are being used whether an operator is patient.
HANDLING 8

The term handling refers to more than just ticular technique. Subsequently the operator
the placement of the operator's hands on the makes one specific part of the hand the
surface of the patient's body. The term should executive applicator of force to be applied for
encompass all aspects of tissue sympathy from that technique within the overall hand con-
the initial contact right through to the very tact. This type of consideration seems to be
last touch of any treatment or technique. needlessly detailed and complex. However,
The initial touch in any given technique close attention to this aspect can improve
should be smooth, gentle yet firm and impart patient compliance, relaxation and ultimately
confidence to the patient. Consideration must success in any given technique or treatment.
be given to the 'choreography' of the treatment Handling not only refers to the use of the
session so that one move can be smoothly hands but must include all other parts of the
integrated with the next, in an apparently operator's body, particularly those coming
seamless way. An aspect often not sufficiently into contact with the patient. For example,
considered is the initial application of the where the patient's head is cradled in the
hand. If the whole hand is applied in one hands of the operator, it is important to
action this may be uncomfortable and threaten- ensure that the patient's ears and eyes are not
ing to the patient. It is often better to apply being obstructed by part of the operator's
first the fingertips, then the palm and lastly clothing or arms. When patients are sitting,
the heel of the hand. Depending on the part most of the movement of their body is often
being worked, it may be more appropriate to performed by pressure from the operator's
use the ulnar part of the hand subsequently body rather than the hands. In this way the
spreading to the palm, heel and then fingers communication of the required position or
last of all. The time for this gradual intro- movement is transmitted efficiently without
duction of touch will vary with different excessive pressure on a possible painful site.
operators but the thoughtful operator will A simple rule relating to efficiency in
use comments from a fellow student or handling is for the operator to examine care-
practitioner to judge the optimum in a variety fully the position of his elbows. In most tech-
of situations. An average for most operators niques, at the culmination of the procedure
is about 3 seconds from initial touch to full the elbows should be as close to his body as is
contact. This may seem rather a long time but practicable. To check on this element it is a
feedback will reveal that it is about right. good idea to assume a variety of technique
The amount of pressure in any situation positions and then see if it is possible to
will also vary. Within reason, the firmer the modify the hand and elbow positions for
contact, the more confidence the patient will greater comfort and effectiveness. Comments
have and, therefore, the better they will be able from a cooperative fellow student will prove
to relax. However, the chief guiding factor in valuable in this respect.
this contact point pressure is how much of the Clearly it is important to avoid discomfort
hand is in use. Again, a rule is to apply as produced by the pulling of hair, excessive
much of the hand as possible within the par- skin drag and digging in of wristwatches,
50 Handling
rings or long fingernails. Operator's long hair by one practitioner over another. Although
should be suitably tied back, and front- each practitioner will develop their style of
fastening clinic coats avoided. It should not approach, some adjustments can be made;
be necessary to mention that breath smelling there is no better way of discovering useful
of alcohol, garlic or cigarettes, and fingers modifications than giving treatment to a
stained and smelling of nicotine are unpro- colleague who is empowered to make con-
fessional and, therefore, not acceptable. structive criticism of the handling used. It
In many techniques it may be necessary for could be very intimidating to have one's work
the operator's body to be in dose proximity to scrutinized in this way, but if the purpose is
the patient. If this is likely to cause potential for self-improvement it is very worthwhile.
embarrassment due to the part of the body Even the finest sports personalities in the
being used, then a suitably interposed pillow world have their coaches whose job it is to
or rolled towel may come in useful. Female make such minor adjustments in method
operators will, no doubt, be especially aware to improve performance. We are naturally
of the need to avoid embarrassing breast interested in the result, but the comfort,
contact with the patient and may choose efficiency and effectiveness of the methods
other techniques when necessary to over- are open to substantial variation and without
come this problem. Patients may feel extremely constructive comment we are unlikely to
vulnerable if they are aware of contact with the know how to adjust them.
operator's genital area. This must be avoided. Care should also be taken in the use of
Belts with large buckles can dig into the equipment. If a hydraulic table is used, find
patient as can other items of jewellery such as the best way of elevating and lowering it to
necklaces and name badges and it is as well avoid excessive jarring. Avoid banging into
to remember this in clinical practice. the table when walking from one side to the
The power of touch should not be under- other and move pillows with due considera-
estimated, and in emotionally unstable patients tion for patient comfort to avoid the head
can produce strong reactions and responses. being jerked to one side.
In such cases it is essential to be sympathetic The term handling also relates to all aspects
and yet firm and reassuring in such a way as of patient care including the operator-patient
to show care without excessive involvement. relationship. It is not suggested that excessive
It is very easy for the caring practitioner to fall formality is necessary, but that a truly pro-
into the trap of palliative stroking that may fessional relationship will help the patient to
give this type of patient a false impression. develop trust. Patient education about the
However, neither is it acceptable to be heavy- nature and purpose of different aspects of
handed in an attempt to avoid seeming treatment is a useful part of practitionership.
excessively sympathetic. It is not practical to give exact descriptions of
From the point of view of patient satisfac- each manoeuvre. However, involving the
tion, some practitioners will be able to build patient in the treatment process by way of
and maintain a practice far faster than others. information and discussion is dearly a way of
Some of this may be due to subliminal helping them to understand what is happen-
awareness by the patient of superior handling ing, and is likely to avoid misunderstandings.
OPERATOR POSTURE AND STANCE 9

Factors relevant to operator posture are: reasons for them have been considered, it
weight in relation to gravity; the contact with takes a little practice to make each one a
the floor or table; the position of his head; natural flowing part of the technique. This
and all other aspects of weight distribution effort will be amply rewarded in less long-term
consistent with the ability to transmit forces effort, strain, and possible physical problems
in the best way for each technique. The term for the operator, as well as increasing the
stance relates more to the position of the effectiveness of each technique for the patient.
operator in relation to the table, and the All techniques employ forces applied to
proximity to the patient. Although the two the body of the patient. These forces can be
are to some extent interdependent, there are extremely delicate and light, or can progress
differences. For example, an operator can be to quite high forces when necessary for a
in a good posture from the point of view of specific objective. Clearly the lighter the force
balance and ability to control the amount of applied, the less the potential trauma to the
weight he is to carry, but be in a totally tissues being worked, but if heavier forces are
inappropriate placing for the technique to necessary, they must be very carefully con-
work well. He might have his feet pointing in trolled to avoid excessive discomfort. After
such a direction that when he applies the
all, the main purpose of manipulative treat-
culmination of the technique, the force dissi-
ment is an attempt to relieve pain, not cause
pates away from the intended path. He is
more!
then not in sufficient contact to control the
If we analyse operator posture from the
target area as his foot position prevents him
feet up there are many simple things that can
directing the force in the desired direction.
If one operator tries to copy the posture of
alter the way techniques are applied. If the
another exactly, purely by imitation, he is feet are placed parallel, any forces applied to
unlikely to make every procedure a success. the patient will require the operator to push
The morphology of each practitioner is in- with an equal and opposite force to avoid the
evitably different. It is clearly essential to tendency of his body to be pushed away from
learn to control the operator's body with the the plinth. If the feet are in an inefficient
forces he is to apply. This will lead to good position it may be necessary to stand further
control of the aspects of the forces needed in from the plinth, and then be in a poorer
treatment of the patient for maximum benefit balance position. This will require an increase
and minimum effort in technique. of muscle tension in his body that immediately
The patient-operator interface, that consti- takes away some of the control of the tech-
tutes the use of the operator's weight, nique. The simple expedient of having one
balance, and grip or hold, must be efficient if foot slightly ahead of the other means that it
it is to be effective. There are many elements is easier to generate forces that have more
of this particular modifying factor in tech- control and balance than if the feet are
nique that can be adjusted by some simple parallel.
but subtle changes. Once the ideas and the To make one foot the front foot and the
52 Operator posture and stance
other the rear does not necessarily require the bent. If one knee is kept straight, movement
operator to step back with one or forward of the operator must pivot around that straight
with the other. All that is necessary is to knee, and this will artificially limit the ability to
swivel slightly on the balls of the feet so that perform the technique. Slightly bent knees
the feet are pointing either to one of the top also permit movement in the antero-posterior
or bottom corners of the table depending on plane and up and down movement as well,
the direction necessary for the technique. In thus allowing a far greater flexibility of ap-
very few techniques will the feet be pointing proach. Sometimes, however, it will be found
straight across the table. that one knee straightens at the end of a
If the reader will look carefully at some of given technique. This gives the ability to firm
the pictures later in this book he will find that up the technique at the last moment, and can
in most cases there is a front foot and a rear often be a useful inclusion.
foot. Further study will reveal that in most In a similar way most techniques are per-
cases, if a rhythmic technique is being used, formed better if at least one of the operator's
the weight is being used to transfer the force hips is somewhat flexed. Any technique that
to the patient through the hand on the same requires the hips to be extended will inevitably
side as the front foot. However, if the be extending the operator's back. Although
technique is a thrust technique, then the there may be times when this is necessary,
weight is being transferred to the patient excessive extension repeated too often can be
through the hand on the same side as the rear just as much of a problem as excessively
foot. This is not an absolute rule, but it repeated flexion. The use of a front and a rear
applies with very few exceptions. Further leg allows one hip to be flexed while the other
study will reveal that the operator is some- may be extended. This inevitably puts the
times not in contact with the table at all. At operator's spine in a twisted posture which,
other times he has shortened the lever by when excessive, can be problematical. Never-
leaning with some part or parts of his lower theless, some twist means that the technique
extremities against the table edge. Shortening can be performed with the operator in a
the lever by leaning on the edge of the table is firmer position to allow better transmission of
far more common in rhythmic techniques forces.
than in thrust techniques. The operator's own lower back is best held
In most thrust techniques it is easier to in as near neutral position as possible, and if
accelerate rapidly and then form the sharp it is necessary to bend over the patient, then
braking action necessary to produce the short the flexion usually comes from the hips while
amplitude movement if the heel of the rear keeping the lower back straight. To avoid
foot is elevated slightly off the floor just strain the small amount of twist already
before the thrust is applied. The subsequent mentioned must not be allowed to become an
contact of the heel with the floor forms a excessive torsional movement to end-of-range.
trigger for the completion of the thrust when Single techniques such as thrust techniques
the operator drops onto it. In most tech- should be less of a strain to perform than
niques the feet should be tending to point in rhythmic techniques that may need to go on
approximately the same direction. If they are for some time, but the possibility for over-
substantially different in direction there is the strain of the operator is always present. A
tendency to lock the operator's posture as the single application technique performed many
technique progresses and only to be able to times in a week can become a repetitive strain
move in a downwards direction. if inefficient methods become a habit. If the
Most techniques are easier to perform with lumbar spine is held in a neutral lordosis
some flow if the operator's knees are slightly directly over the centre of gravity between
 Operator posture and stance 53
the feet, then the position is likely to be the maintain the position. This does not mean
most efficient in the majority of cases. that the operator must look up at the ceiling,
The operator's middle back is best held in a but that he must be aware of the need to keep
neutral position without excessive strain into his head as high as is reasonably practicable.
either flexion or extension. Some degree of Simply keeping the neck long is often enough.
torsion is possible as the muscles are capable This simple aspect is enough to control almost
of controlling articular stress, and this has the the whole of the spinal posture of the operator.
effect of firming up the technique. It should The operator's elbows are an important
be noted that with the mid back the operator's part of many techniques. Most procedures
own ribs play an important part in many are performed better, and with a greater
techniques. If the operator is in firm contact degree of accuracy, if the operator pulls his
with the patient's body, a slight twist in his elbows as close to his sides as is feasible. This
back will bring the side of the operator's rib need not be taken to extremes, but if any
cage in contact more than the springy part of technique is not working as intended, a
the sternum. This also allows the operator's simple adjustment of posture of elbows is
arms greater freedom to move as the one foot often all that is needed to 'fine tune' it to a
forward posture can tend to separate them better efficiency. Elbow position is a simple
slightly from his body. thing to consider in this regard. Even in
The operator's upper thoracic area is placed techniques where it is impossible to bring the
under considerable risk of mechanical stress elbows close to the sides, a small isometric
as the arms are being used all the time. The pull downwards and inwards of the operator's
mechanical leverage of arms is transmitted to arms will have a beneficial effect of firming up
the rest of the body through the shoulders the hold, and increasing the proprioceptive
and upper thoracic area. For this reason, it is awareness of the operator. The slack of the
clearly important to always keep the shoulders operator's own joint play is also reduced if
and upper thoracic area as relaxed as possible. this small 'setting' of the arms is undertaken.
A good rule is that if the operator can see his The hands of the operator will be applied
shoulders from the position he is in to per- to the patient but overstrain can be avoided
form the technique, they are probably too high by minimizing flexion or extension of the
for maximum efficiency. A small amount of wrist. When techniques require the use of the
isometric tension in the operator's latissimus thumb for pressure, this is best applied in as
dorsi muscles will ensure that the shoulders little abduction as possible. Some isometric
are pulled down far enough so that he has a setting of the hand will allow the 'switching
better chance of increasing the compactness on' of the joint proprioceptors in the hands
of his body. This will allow transmission of and arms which will enhance the palpatory
the force to the patient in the most efficient awareness of the operator considerably. This
way. Isometric tension and breath-holding also has the effect of slightly protecting the
must be used with caution to avoid locking hands from overstrain by giving a sense
the operator's rib cage excessively. of graduated resistance to all forces being
It is perfectly understandable to want to applied. It is sometimes easy to fall into a
see what one is doing in technique, but the habit of ulnar deviation and allowing the
head is a heavy object. If the operator allows ligaments on the radial side to be repeatedly
his head to incline forward excessively, in- stressed. Although this may not produce a
creased strain is being caused to the upper true hypermobility, there is some indication
thoracic area. The weight of the head is being that it may produce discomfort if frequently
placed in front of the centre of gravity line repeated.
and greater muscular effort is required to Female operators may have problems, in
54 Operator posture and stance
some techniques, with the proximity of their exhalation as the operator's rib articulations
breasts to the patient. If the operator is are in a vulnerable position to strain.
required to place their chest against the Breathing also changes posture; on in-
patient, which may be a source of embarrass- halation the spine lengthens and straightens
ment or difficulty, then a pillow or suitable pad slightly, and the reverse happens on exhala-
can be interposed. Similarly operators of both tion. It is easier to transmit a sense of relaxation
sexes will want to avoid excessive proximity of to the patient if the operator is relaxing himself.
their groin area to the patient. The trust built A controlled outward breath will often help to
up between practitioner and patient can easily produce an optimum sense of tissue relaxation
be destroyed if these simple common sense in the patient. If the operator asks the patient
aspects are not considered. It is easy to forget to breathe out at the same time, this shows
that most patients are going to be somewhat how another modifying factor of patient
apprehensive or nervous about treatment. respiration can be combined with operator
They may already feel vulnerable by being posture and breathing to good effect.
partly clothed, and a thoughtless operator who The ideal test of whether a posture is
does not realize the implication of his proxim- balanced for any given technique is to attempt
ity to the patient is at risk of problems in this to perform the manoeuvre without a patient.
regard. Tension sense, or barrier sense, is This may seem very artificial, but it demon-
acquired not only through the hands of the strates balance, control of the operator's body,
operator. In many cases the friction with the and the ability to perform the technique with-
patient through the operator's own chest out excessively leaning on the patient. Also,
transmits as much feel for the best time to the understanding of how much tension the
apply a thrust as does the feeling through the operator needs to put into his hands is often
hands. One is looking for interpretation of the poorly considered. If the hand is merely applied
subtle difference between tissue stress, and to the surface of the body and pressure is in-
tissue potential for activation of force when a creased until mild discomfort is felt by the
technique is applied. The subtle cues that come patient, there will be a completely different
from a joint placed in a position of 'potential' sensation than if the operator puts his own
are felt through the accumulation of forces hand and arm into a slight degree of isometric
sensed by the whole body of the operator. tension and then repeats the same exercise.
The phase within the breathing cycle of the This type of dynamic tension in the operator
operator when techniques are to be per- must be practised to acquire the correct level
formed is sometimes of importance. Some for each technique. Some techniques require
operators tend to hold their breath and strain quite firm isometric tension in the operator,
against the fixed abdomen and thorax by this others very light. An example relating to other
temporary Valsava manoeuvre. This has the activities that may make this more easily under-
effect of firming up the technique, but also stood, is to imagine threading a needle. Excess-
has the undesirable effect of raising the ive tension in the hands would make this a
operator's blood pressure. This is clearly best very difficult exercise, but insufficient tension
avoided. There are times when this explosive would make it equally difficult, but in a differ-
force of breath-holding is useful, but it should ent way. Another example would be pushing a
not be used too frequently. Some operators drawing pin into a resistant surface. This would
tend to breathe out when performing thrust clearly require a different type of tension and
techniques to help speed up the move. control to the threading of a needle with cotton.
Although this can be useful, and avoids the The ability to take the grip in a firm but
tendency to hold the breath, it is better not to comfortable way, promoting confidence in
perform the technique at the extreme of the patient, and yet not causing unnecessary
 Operator posture and stance 55
discomfort, is not easy to acquire, but with In any activity requiring psychomotor skill,
a helpful fellow student can be suitably the expert makes things look very easy. This
developed. If any posture is causing excessive is true in sporting or other activity such as
fatigue for any reason the cause must be manipulative technique. The reason that it
found. Performing a technique once in isola- looks so easy is that the practitioner has
tion is not how treatment is carried out in learned to avoid the things that make it look
practice. Treating many patients in a day difficult! Most of these aspects are related to
requires the operator to master the business the way forces are transmitted or developed.
of minimizing strain on his structure if he is Good control of posture and, therefore, the
to be able to carry on the work without injury practitioner himself is one of the key ways that
and excessive fatigue. this can be done in osteopathic technique.
APPLIED TECHNIQUE 10

There is a blurred dividing line between what POSITIONING

is technique and what is treatment, and the
Positioning or moving the patient on the
term applied technique relates to fitting
table must be performed slowly and purpose-
the chosen technique to the patient and the
fully, particularly if they are in acute pain. It
situation that has presented. There are several
may be necessary to perform a whole treat-
factors that need to be considered in addition
ment with the patient in one position, and
to the modifying factors already identified.
this can try the ingenuity of even the most
Some of the previously mentioned modifying
inventive practitioner. If it is necessary to
factors also need amplifying:
move the patient, it is often better to guide
1. Handling the movement, after describing what is re-
2. Positioning quired, rather than try to do all the work
3. Posture yourself. Acute pain is best controlled by the
4. Weight-taking patient initiating the motion rather than the
5. Operator relaxation therapist. Once they have started to move,
6. Holds then operator assistance is useful. In this way
7. Apparatus they do not feel so threatened by being
8. Approach moved into a painful position and can be
9. Planning much more in control of their pain. Most
10. Difficult situations techniques can be performed in a variety of
11. Response to reactions positions. It makes sense to find the most
12. Category of technique comfortable for patient and operator provid-
13. Interval between treatments ing this does not require the acute patient to
14. Advice and aftercare move excessively. It is possible to reduce
operator fatigue by alternating, say, sidelying
with prone lying in subsequent patients. In
HANDLING this way you can use your pushing muscles
In addition to the factors identified in the in one patient, and your pulling muscles in
section devoted to handling, is the need to the next. Alternating in this way can be a
consider the transition of hold from one useful method of being inventive and adding
technique to another. It is not sufficient to variety to the day. It will often allow the
have good handling in a technique if the discovery of different and useful ways of
transition phase involves a rough and irritat- performing a particular treatment in different
ing approach. Patients in acute pain, in par- types of case.
ticular, need sympathetic handling, precision
and care to avoid further unnecessary pain.
POSTURE
Patients who are nervous or embarrassed need
extra care, and judicious use of gowns or other I have already commented extensively on
suitable covering should be considered. posture but will reiterate here the critical
 Apparatus 57

factors of safety for patient and operator, and movement that can become almost balletic
effectiveness in technique by the use of and apparently choreographed if practised
efficient posture. Many operators have suf- efficiently.
fered injury from strains in treating patients.
Much of this could have been avoided by
HOLDS
more care over posture. Good posture allows
the operator to reduce strain on his own The hand placement or hold for a given tech-
structure, and to reduce the possibility of nique can be varied in several different ways.
excessive force being applied unwittingly to The thoughtful operator should not grip ex-
the patient. cessively with the fingertips. It may be difficult
Small and light operators of both sexes be- to avoid excessive tension in the grip when
come extremely efficient at utilizing leverage performing a new hold for the first few times.
rather than weight when performing tech- The balance between a firm and positive
nique. When learning technique it is a good hold, and one that is painful, uncomfortable
idea to have some instruction from a small or irritating, is very delicate. It is a good idea
operator to help to acquire this skill. Virtually to constantly re-evaluate the approach to any
every operator will meet a patient one day particular technique; the method that has
who is much larger than normal. It is only become most comfortable by frequent usage
then that the problems that the small operators may not be the most effective for the purpose
have daily, become evident. Strength is really intended. Most operators restrict themselves
no substitute for skill. to a relatively limited range of techniques,
and can have great difficulty when called
upon to perform them in a different way.
WEIGHT-TAKING
This is avoided if variety is added as a regular
It is clearly wise to reduce to the absolute feature.
minimum any techniques that involve taking
the patient's weight. On some occasions
APPARATUS
there is no other way, but if the table can be
made to do some of the work, physical stress It is useful to experiment with different types
can be minimized. Avoid breath-holding if it of apparatus such as stools, pillows, pads
is necessary to lift a patient. Learn from the and plinth types, etc. A height-adjustable
weight-lifters who exhale when lifting. Obey plinth is extremely useful to allow the patient
the advice you give the patients about keep- to be at the optimum height so that different
ing a straight back when lifting! areas can be worked without excessive bend-
ing or stretching. In a multi-practitioner setting
an adjustable plinth or table is essential. A
OPERATOR RELAXATION
rising head-piece is useful, but failing this
It is important to be aware of the necessity to pillows of various sizes can be a substitute.
relax when performing osteopathic technique Any plinth that is height-adjustable should
and treatment. A state of tension not only have the minimum free play in the adjust-
transmits itself to the patient and their tissues, ment mechanism to allow forces to be trans-
but reduces the appreciation of palpation, mitted to the patient and not the hydraulics
leverage, pressure, stretch and other sensory of the table. If the table is too springy the
perception. Fatigue is also increased if the force used in technique will need to be harder
operator is tense during treatment. This is and sharper to overcome the bounce of the
not an excuse for sloppy technique, but mechanism. If the only table available is a
rather a reason for smooth and controlled fixed height one, it is better to be too low than
58 Applied technique
too high. It is far easier to lose height by rather than being targeted to the desired
spreading the legs than to stand on tiptoe tissue. However firm or soft the table padding,
and be off-balance. However, a table that is most patients prefer having a pillow under the
too low will be very tiring to work on. Pillows abdomen when lying prone. This avoids ex-
of different sizes and density are necessary, cessive pressure on ribs, breasts and genitals.
partly to prop the patient up when lying in It also allows the lumbar spine to be taken out
different positions, and partly to act as fulcra of excess lordosis. Excessive lordosis can
for some techniques. produce pain if pressure is applied to the
There are advantages and disadvantages in lumbar area. The padding of the plinth
different widths of table. Patients generally should extend over the sides so that the
feel more comfortable on a wider table, but as patient does not have discomfort on the inside
they automatically tend to lie in the middle of of the arms when lying prone with the arms
the table, they may be so far away that many over the edges. Many techniques require the
techniques can place a strain on the operator. operator to lean against the side of the table. If
Table width can be 18-28 inches (46-71 it is padded this will be more comfortable.
centimetres). The narrow table will tend to be For hygiene, the plinth is now generally
unstable, and will produce unease in elderly covered with a plastic material, whereas cloth
patients who may be fearful of falling. The was often used in the past. Cloth will harbour
widest will be preferred by patients but, in skin debris and dust and is not really suit-
addition to the problem stated above, it will able, although it does have the advantage
be impossible to place the patient astride for that towels or paper covers do not slide on it
sitting techniques. If the patient is sitting as they do on plastic and vinyl. If the patient
across the table with the backs of the knees is asked to lie directly on the plastic it will be
resting on the edge, they will still be a long sticky and unpleasant, so some covering is
way from the operator. Sitting techniques usually placed over it. Towelling is ideal, but
will require the operator to reach a long way will tend to slide. Fitted elasticated covers
to apply any hold, and that can place his own avoid this, as will those with string ties under
back at risk. All tables are a compromise. One the table, although they are rather fiddly to
way to get around this problem is to have a tighten and tie when the cover is changed.
table that tapers from about a third of the way Paper cover sheets are hygienic and look good
from the head end to a narrow foot end. This when fresh, but are expensive and create a
means that astride techniques are possible at disposal problem. They also look awful when
the foot end, and that sitting across tech- rucked up and creased and torn after the
niques can be performed toward the foot patient has turned over a few times. Pillows
end. When the patient is lying down they will should be covered with a suitable paper
have the impression that the table is wide, as towel or serviette.
the part they can see is wider than the rest. Some female patients wear large bras with
The padding should be dense enough to multiple fixings. It may be preferable to ask
prevent the combined weight of the patient them to remove these, and, for the sake of
and the pressure of the technique from propriety, to provide a rear-fastening surgical
'bottoming out' the foam. This is of particular type of gown.
importance in prone techniques where the Most practitioners wear a clean clinic coat of
costo-chondral junctions are at risk of damage their preferred style. Although some operators
if the table padding is too firm. If the padding choose to work in less formal clothes, there is
is too soft, it will be difficult to absorb enough some evidence that many patients prefer their
of the spring when treating, and some of the practitioner to be dressed like a practitioner.
effort of technique will be lost in the padding They find it easier to relate to them and
 Difficult situations 59
develop a relationship based on trust and for the patient who may be in great distress
understanding. There are a few practitioners when performing rotational movements. It is
who choose to wear a suit and tie, and often better to work toward a part that is in
although this may be acceptable for a hospital acute pain rather than go straight to it. Never-
consultant, it is not really practical for a theless, a thorough palpatory investigation of
therapist who is required to get into some the site of discomfort is reassuring for the
contorted positions on occasions! It is clearly patient and can give clues about the types of
better to avoid the use of excessive jewellery techniques most likely to influence the affected
that can catch on the patient or their hair. tissues. Insufficient force to achieve the re-
quired result can be remedied by a re-duplica-
tion of the technique using a graduated
APPROACH
approach until the result is obtained. Much
The operator should cultivate an unhurried, experience is required to judge just the right
calm, reassuring approach to the patient. degree of force in any particular case, and it is
This is particularly important with new better to be ineffectual than dangerous. An
patients, the very nervous, the elderly and ineffective technique can be repeated and
small children. Excessive formality should be altered until it is effective; a dangerous one
avoided, but an over-friendly approach could may be disastrous. It is unwise to persevere
be misinterpreted as flippancy or suggestive- with any technique, particularly a thrust
ness and this must be guarded against. The technique, in the presence of extreme pain or
operator must appear to be calm and in resistance. Similarly, if a patient is unable to
control even when highly pressurized by the relax, there may be hidden pathology or
telephone, late patients and his own prob- anomaly.
lems. Lack of confidence is sensed by the
patient very quickly and is taken as a sign of
DIFFICULT SITUATIONS
weakness. However, if the patient is taken
into the confidence of the operator and in- There are numerous difficult situations that
volved in the decision process, they often can occur in practice, and it is not my
appreciate this immensely. intention here to consider any except those
related to technique. Patients can be very
importunate of time and energy and encour-
PLANNING
age a practitioner to perform procedures he
It is not a good idea to give casual, off the may consider unwise. It is better to politely
cuff, unplanned treatment. It is very common decline than to perform a technique one is
to be pressurized into fitting someone in to an uneasy about and then have problems due to
already full schedule for 'just a quick look'. reactions or injury. It is naturally important
Some practitioners seem able to do this with to avoid medico-legal complications, and in
no problems, but many will be prone to make this respect the best rule is that of informed
mistakes and errors of judgement. consent. It is not possible or desirable for the
Empirical treatment will tend to have very patient to be informed of every single pro-
mixed results. It is better to have a specific cedure that is to be applied and its percentage
objective in mind based on a diagnosis and risk factor. However, the overall likelihood of
backed up by some idea of prognosis. The success, and a broad outline of what is going
thoughtful operator should be considering to be done, and the tacit permission to per-
the immediate and longer-term objectives of form the treatment techniques is a necessary
the techniques that are being used. A planned preliminary to treatment. In cases where a
treatment avoids unnecessary re-positioning practitioner has been accused of wrongful
60 Applied technique
treatment, a very common factor is lack of reaction. Providing a thorough examination
communication and information. The General has been performed, and no sinister cause for
Council & Register of Osteopaths has gone so the reaction can be found, a gentler repeat of
far as having a consent form available so that the same procedures can often reverse the
patients can put in writing their agreement effect of the reaction and provide relief from
to treatment in what might be considered symptoms. Most patients will accept an
sensitive areas of the body. These aspects of adverse reaction if they are forewarned, but
treatment must be considered more and more may not believe it is normal if they are told
in the light of litigation experienced by after the event.
practitioners in the USA. Cases that may
seem frivolous matters to Europeans are
CATEGORY OF TECHNIQUE
sometimes fodder for legal actions.
Choice of the best category of technique to
use and the order of technique usage is based
RESPONSE TO REACTIONS
upon the requirements of the case and the
Some discomfort after treatment is common. duration of the problem. The least invasive
If this is excessive it might be termed a approach is naturally the best, but if satisfact-
reaction to treatment or technique. The degree ory results are not being obtained subjectively
of invasiveness in the chosen technique will and objectively, that is the time that most
clearly have some influence on the frequency practitioners will increase the intensity of
of reactions, but some patients will have method. However, simply using firmer meth-
severe reactions however careful the approach. ods in the absence of a good result is not
A feedback from the patient as to reactions necessarily wise. A good rule would be to use
will give considerable guidance as to the the gentlest procedure likely to give the
advisability of continuing treatment or the desired result considering all factors in the
need to make a re-assessment. Reactions out case. As has been stated elsewhere, the effect
of proportion to those expected should always of a technique may be out of proportion to the
give cause for re-evaluation. Like any other application of force. Some amazing results
medicine, manipulative treatment has to be have been obtained with the gentlest of
given in the correct dosage. An overdose can approaches when a patient has already been
cause adverse reactions, whereas under- treated unsuccessfully by other practitioners
treatment may be unable to produce the using violent methods.
desired symptomatic and objective changes. It
is, nevertheless, a far more common mistake to
INTERVALS BETWEEN TREATMENT
over-treat than to under-treat. If in doubt,
hold back. The interval between treatments is often
Due to the muscle 'memory' phenomenon critical. The decision as to the spacing of treat-
it is often necessary to repeat a given pro- ment is only arrived at by a consideration of all
cedure on subsequent occasions. It is unwise the relevant factors relating to the chronicity,
to attempt miracle treatments in one session. acuteness, urgency and practical factors of
Making allowances for variations in fitness, distance, etc. If a patient reports benefit out
resilience, sensitivity, and state of general of all proportion to the techniques used, it is
health, different patients will react differently generally better to suspend treatment for a
on various occasions. An accurate record of while as it is possible to reverse the situation.
treatment and techniques performed is not Even though it may mean sending the patient
only a legal requirement; it is wise as it gives away with no treatment and possibly no fee,
possible clues to the cause of any adverse this is preferable to causing a return of the
 Advice and aftercare 61
symptoms by treating them just because they ADVICE AND AFTERCARE
have an appointment. Many conditions are
Most patients ask for exercises. Most patients,
uncomfortable after treatment, then feel
however, do not do the exercises prescribed!
much better, and then slowly worsen as
normal life patterns take over. If treatment is Providing they are really motivated to do
undertaken in the 'good' phase it is far too them, carefully designed exercises of a stretch-
easy to stir up problems. The best timing is ing or strengthening nature make sense. Many
probably just as the symptoms are starting to patients find that exercise rather than exer-
recur. Naturally this does not always fit in cises is preferable. They may be persuaded to
with appointment schedules, but a reason- walk, swim, do yoga or dance rather than
able compromise can be found. perform specific exercises. Some will assidu-
Maintenance treatment at extended intervals ously follow instructions. Some will over-
of several months has been found to reduce work themselves in an attempt to get a
the frequency, intensity and duration of quicker result, and some will do nothing and
acute mechanical dysfunction attacks. Many feel guilty about it. Each case must be judged
practitioners undertake this sort of work, on its merits.
although some feel that it is not getting fully Patients are generally very keen to have
to the bottom of any particular syndrome. advice as to prevention of recurrences and
Being realistic, occupational, postural and quicker results in treatment, so long as it does
degenerative states mean that it is not always not involve them in any effort! Many practi-
possible to fully correct any dysfunction, and tioners are not aware of the respect the
some maintenance makes sense. The patient patient has for their advice, and it must be
must be involved in the decision to under- carefully given so as not to cause unnecessary
take this type of approach. If the patient is distress by their being unable to carry out
symptom free on a maintenance visit, it that advice. Unwise advice to change job, for
would be unwise to perform forceful tech- example, might cause loss of respect for the
niques as symptoms could be caused. How- operator who gives it as it may be completely
ever, some say that this is the best time to be impractical. Advice given with the best in-
doing firmer work as the patients' tissues are tentions and consideration for the patient's
unlikely to be so reactive. The decision must welfare is fine, so long as it is tempered with
be individual to each case and each operator. realism.
PRINCIPLES OF LOCKING 11

All techniques that work by focusing forces to overpressure. This will often be very uncom-
a specific joint need some method of produc- fortable for the patient. If held for more than
ing that specificity. The usual method is to a few seconds, the discomfort will cause the
combine levers in such a way as to produce a barrier to increase and there can be a sense of
locking or focusing. This means that other over-locking. An absolute point where the
adjacent structures are excluded from being forces come together needs to be found. If
the target for the forces and are, therefore, to this can be done without actually applying
some extent, protected. Excessive attempts the full necessary leverage until the last
to 'protect' them, however, are just as likely to possible moment, the patient will feel more
harm, from 'over-locking' which can produce relaxed and better able to cooperate with the
discomfort and potential trauma. procedure. This can only be done if the
How is locking produced? The usual operator is aware of the feel of the tissues as
method in the spine is to induce some torsion the barrier accumulates, but just short of full
with a combination of sidebending to one tension. This allows him to tease the tension
side and rotation to the other. This so-called point several times from slightly different
'physiological locking' is in accord with angles until the optimum can be found. If
Fryette's laws, and is the mainstay of manipu- the same exercise were to be performed at the
lative work utilizing thrust techniques. There absolute point of full tension and locking, the
are several other ways that a combination of discomfort would probably be unacceptable.
levers can be produced to focus forces. Com- If the accumulation of tension was to 80-
pression, in combination with much smaller 90%, the comfort level would be acceptable.
quantities of the other levers, can be effective, The last 10-20% or so can be added for as
as can the use of accelerating rhythm and short a duration as possible to finish the
oscillation. technique. The skill necessary to work in this
Methods of producing this focusing have way requires the ability to palpate a pathway
traditionally been taught using the terms of resistance rather than an absolute position.
'physiological locking' and 'ligamentous lock- This ability is well worth developing.
ing'. The difference between these two meth- Some authorities insist on the need to lock
ods is that physiological locking implies facet 'down to' or 'up to' a point or segment. The
apposition and ligamentous locking implies intersegmental changes taking place in this
progressive tissue tension. In practice both of sort of application of forces are somewhat
these methods are used in combination. A complex. The situation is also governed by
thoughtful operator will use the combination normal variations in anatomy and physio-
of several complex leverages to position the logical function of the part. Also relevant are
part in an optimum placing so that only a the distortions of anomaly and pathological
slight emphasis of leverage will achieve a processes. These will produce distorted pat-
focus at the desired point. terns and altered quality of movements,
Locking need not consist of a steady 'wind particularly at the ends-of-range.
up' to a point and then the application of The physiological movements of the spine
 Principles of locking 63
are such that most manipulative techniques any particular operator builds up the levers to
require composite levers to achieve the stabil- a given technique will vary slightly from
ization necessary to localize force. Most tech- patient to patient. There will be a number of
niques can be performed with a variety of other variable factors such as table height,
levers, and quantities of those levers. As an patient positioning on the table and different
example, consider a technique where 30° of ability with either hand. Nevertheless, the
flexion is combined with 60° of rotation and principles obey certain ground rules. Any
20° of sidebending. If the flexion is applied particular area of the spine can be manipulated
first, there will be a tendency to use more using thrust techniques in a whole variety of
than the desired 30°. The technique will still positions and ways. There are certain direc-
work, but it will be found that the other 1tions that will be most effective, least trauma-
levers have been decreased by the same tic, and most comfortable for operator and
amount as the flexion has been increased. patient. A useful guide is that locking can be
Conversely, if the rotation is put in first, it produced most effectively when consciously
tends to become an executive part of the using movements least available in the parti-
technique as the mind is focused on main- cular segment or area. Conversely, the
taining the rotation as the other levers are greater the available range, the more the
applied. These interesting phenomena can be variety of locking procedures that will have
used to advantage by playing with the order broadly similar efficiency.
as well as the quantity of the different As an example, consider the mid cervical
components until the optimum application is spine. This area has a wide range of flexibility
found. Experienced operators usually apply in most directions in a normal subject, and so
any given leverage as a composite movement it will usually be possible to position in most
and are constantly varying the quantities of combinations of leverages. However, the
all the directions as the tissues yield or lower cervical spine has less range of move-
otherwise in each direction. Locking does not ment due to the variation in facet angles and
then become full leverage and overpressure. other factors. The range of extension particu-
It achieves the desirable situation of being as larly is limited, and therefore manipulation
near a neutral point as possible until the using extension will produce a locking with
critical time when the technique is finalized much less amplitude of leverage than flexion.
as an arc of movement. In the upper cervical spine, the movement
The term locking is actually a misnomer. least available is sidebending, and therefore
Nothing is actually locked; rather the forces sidebending will produce the quickest and
are concentrated more at one point than any most efficient locking without using large
other. Extreme movement in any direction ranges of movement. Naturally, if too much
followed by overpressure can stretch, deform sidebending is used, over-locking and pain
and possibly damage tissues, particularly if would result just as easily as if any other
combined with high applications of force. lever were applied excessively.
Use of locking helps to focus the localization Having identified this principle it is possible
without any lever reaching its maximum to evaluate the particular directions that this
range, although the primary, or executive, theory will support in each area. Naturally
lever is taken further than all the others. The each case must be considered on its merits,
commonest method in the spine is to use with regard to other factors such as age,
sidebending to one side, and rotation to the condition, size, etc:
other. The addition of small quantities of
flexion or extension, compression or traction, 1. Upper cervical - emphasize sidebending,
etc., will further aid the localization. The way although the neck as a whole can be in
64 Principles of locking
flexion or extension. Excessive extension you are still performing left rotation at a
in the upper cervical area is undesirable asspinal level. This may seem self-evident, but
there is the potential for stress on the if considered carefully can alter the approach
vertebra-basilar structures. to a particular technique and possibly make it
2. Mid cervical - all positions are possible, effective where it may not be otherwise. The
therefore use a balance between them all, focusing of forces to a specific point in a
but generally emphasize rotation as it is comfortable way for the patient and the
least uncomfortable. operator is the essence of skill in manipulative
3. Lower cervical- use extension in addition technique. If a particular combination of
leverages is applied in a steadily progressive
to main leverage of rotation. Flexion is also
effective, but needs a greater range than way to a point of full tension, not only will
extension. the patient be uncomfortable, but the operator
4. Upper thoracic - most ranges are limited is unlikely to be in an optimum position to
so use whichever combination is most complete the technique efficiently. However,
effective in the particular case; extension if the build-up of the accumulating tension is
combined with a primary lever of rotation sensed, and the absolute point of maximum
is usually the choice. tension is 'teased', it should be possible to
5. Mid thoracic - depending on the degree accelerate through to the thrust position
of kyphosis, usually extension combined more efficiently. This means that the point
with sidebending. can be approached from several different
6. Thoraco-lumbar - extension produces angles, and allowed to increase and decrease
quickest locking, although extreme flexion to find the best balance of all the components.
is effective, if more uncomfortable. This 'playing' with the joint is not a vague
7. Mid lumbar - as this is a generally free- searching, but is a purposeful, considered
moving area, a neutral position emphasiz- variation of all the components and direc-
ing rotation produces best effects. tions of force. There should be a constant
8. Lower lumbar - as the facet angles are so search for the optimum in a position of least
prone to variation, and the lumbo-sacral strain on the tissues.
angle varies so much, it is difficult to make In the peripheral joints similar methods
any useful rules. However, sidebending can be used, but this time the focusing is best
applied first, followed by the rotation performed by using compression as a focus-
ing force. Compression acts as a limiter of
element using flexion in the lordotic spine,
and extension in the flat spine will usuallyamplitude and can be useful to bring effective
be effective. barrier sense nearer to the midline, thus avoid-
ing painful torsional leverages. The other
Any general principles are open to comment consideration that is particularly effective in
and criticism, but the analysis behind these the peripheral skeleton is the use of induced
ideas should allow the development of per- levers by taking both hands in opposite
sonal approaches and individual development. directions. Consider the force necessary to
When applying locking forces there are wring the water out of a sodden cloth if one
some other considerations that need clarify- hand was to remain still while the other did all
ing. Stand with feet parallel and turn the the work. Consider how the force could be
upper body to the left. You are performing reduced by both hands working in opposite
left rotation in the spine. Now stand with the directions. Some schools of thought in the
upper body fixed and perform a swivelling of manipulative field insist that one hand be
the feet and pelvis to the right. Despite the fixed, while the other does all the work.
fact that the body is being turned to the right, Although this seems to make sense, the effort,
 Principles of locking 65

discomfort and strain is much more than if ing and gradually refine the methods being
both hands share the work. used by introducing these principles a little at
It does take quite a lot of time and practice a time. It is very easy to fall back on methods,
to make this effective in finding this pathway which although effective, are uncomfortable,
of optimum potential without the guidance of procedural and require higher force, effort
full tension. The time taken to acquire this and strain for patient and operator. To quote
skill is well worthwhile in that it can produce a cliche, 'If you keep looking back, you will
quicker results, less adverse reactions to end up going there.' There are no absolutes
treatment, and better patient satisfaction. in osteopathic approaches; the infinite variety
If this method seems intangible at first, carry of possible composite levers allows most
on using full leverages as with traditional train- situations to be catered for.
EXERCISES FOR DEVELOPING 12
TECHNICAL SKILL

Any psychomotor skill can be improved and if they are physically able. As experience and
developed by suitable practice. It is not pos- practice develops, they gradually improve
sible to practise every technique or method their skill to a certain level dependent on the
sufficiently to become skilled enough so that amount of time and effort used. If a student is
the process is automatic without a consider- going to be an osteopath, their whole life's
able quantity of time and effort. However, work is going to be concerned with perform-
there are some exercises or drills that may ing osteopathic treatment. It would seem to
help to shorten the learning time for students make sense therefore to practise the skills
and I have included a few here. It is un- until they are efficient. For many reasons
fortunate that it is extremely difficult to find some are unwilling to do this. Although life
activities that are similar to the skills needed places many demands on our time, without
for osteopathic technique. There are many sufficient practice it is fair to say that a
things that can be done to improve mechanical student is unlikely to become an efficient
handling skills for dealing with inanimate technician. The practice must, nevertheless,
objects. These do little in helping the student
be of the correct methods. Bad habits, par-
to appreciate the subtle differences in tissue
ticularly regarding posture, can be very
states that exist in patients. We are dealing
difficult to correct later.
with living structures in real people and the
The best sports are going to be those that
psychology, age, weight, size and nature of
the student enjoys and will, therefore, partici-
the problem all subtly alter the approach and
forces necessary. With this in mind it must be pate in regularly. Racquet sports help in
said that the best exercise is constant practice coordination, but dance and contact sports
with a willing fellow student who is em- are probably better for posture, balance and
powered to give constructive feedback as to the psychomotor development necessary for
handling, comfort and effectiveness. osteopathic technique. Physical strength is
Not all exercises or drills will be of equal not a requirement for an osteopath. How-
benefit to all individuals. We all have our ever, a reasonable level of stamina and fitness
own personal model of learning and some is useful. A high proportion of students who
systems of skill development will feel more become good technicians have done some
natural than others. Osteopathic skills can be training in martial arts. It seems that the
divided into palpatory skill and technique discipline, fitness and body awareness have
skill although one is not really possible without many uses in their subsequent osteopathic
the other. career. Team games seem to have less to offer
From a general viewpoint, anything that in terms of the future needs of an osteopath,
improves hand and eye coordination should but that is not to say that they do not have
be useful. Most people, at some time in their their use in general fitness.
life, undertake sport of some sort or another Here are a few specific exercises:
 Exercises for developing technical skill 67

1. Face a partner and take up a posture with and sense of tissue resistance. Alternate
one leg forward of the other. Place a foot- legs.
ball between one of your outstretched 5. Acquire some bubble wrap as used in
hands and that of your partner so that it protective packing. Place it on a table and
is sandwiched between you. Take turns use your heel of hand or pisiform to burst
in pushing and pulling. If you coordinate one bubble at a time. Draw an ink line
with your partner, the football will remain around one bubble and try to burst the
between your hands. If you do not co- bubble within the line and no others.
ordinate, you will drop it. Responding to Examine your hand and see if you have a
the subtle cues of your partner's move- neat ink circle around your pisiform or
ments will help develop coordination only an arc of a circle. Progress to doing
and response to motion. It will also help the same thing on your thigh so that
in developing the feel for 'setting' the there is normal tissue underneath the
hand in slight isometric tension which is bubbles and not the firmness of the table.
necessary in many techniques. Reverse Progress to performing the same task on
hands. a partner's back to see how little force
2. Pull a toilet roll gently until the tissue is you can apply and yet still achieve the
taut. Apply a sharp tug, aiming the force objective. This will develop skill and
at the perforations of the sheet. Avoid accuracy in minimum force technique.
simply unravelling the roll. Practise mov- 6. Have a partner place a single hair under-
ing the force to the next row of perfora- neath a single page of a smooth tele-
tions while missing the nearer one. This phone book without you knowing where
drill improves the ability to sense tension it is. Use light pressure and scanning of
and to direct force beyond one point to the surface with your fingers to locate the
another. hair. See if you can do the same with the
3. Stand facing a partner and place one leg in heel of the hand. Try with eyes shut or
front of the other. Extend one arm slightly open and standing or sitting to see which
and place the back of the hand against the is your personal best method. When you
back of your partner's similarly extended become adept at this, have your partner
hand. Decide who is to be the mover and place the hair under several pages of the
who is to be the follower. Take turns in book rather than just one. See how deep
moving the hand at different rates, and in you can still feel it. This improves palpat-
different planes and directions. The fol- ory perception and trains you in which
lower must try to remain in contact at all part of the hand is best to use in palpation.
times. This is similar to exercise 1, but uses 7. Perform a similar exercise to 6, but use a
direct contact rather than via the football. coin instead of a hair. Have your partner
Alternate hand and leg positions. place the coin at varied depths and try to
4. Stand facing a partner with one leg in judge the depth. Have him vary the size
front of the other. Grip each others' of the coin and try to estimate the size
wrists and gently assume a rhythm of by palpation. This palpatory exercise is
push and pull. Attempt to pull or push similar to the previous one but it develops
your partner from his firm stance, but be different aspects of your skill in estimat-
aware that he is doing the same with ing size and bulk.
you. Force will not work; you must use 8. Perform the magician's trick of snatching
balance and transmission of energy and the tablecloth from under cutlery or crock-
rapid change of direction to be effective. ery. Use unbreakable crockery at first!
This will improve balance, coordination Once you have acquired the skill to pull
68 Exercises for developing technical skill
away the tablecloth without disrupting movement as if you are a mirror. Gradu-
the articles on the table, try the same ally make the movements more complex
exercise sitting, or with varied leg and see if you can follow his mime. This
positions. Try it bent over or straight to will improve your ability to learn tech-
find the optimum posture necessary for nique by watching and copying.
the sharp pulling action. This exercise 13. Sit at a table with your forearms hori-
should improve your fast movement and zontal. Relax and then try to contract your
acceleration skills. brachio-radialis muscle alone on one side.
9. Play 'red hands' with a partner. Have You may find that this is difficult, but
your partner extend his hands in front with practice it should be possible to
with palms facing down. Place your isolate this one muscle alone. When you
hands, palms upward, lightly under his have achieved this, move on to specifically
so that they are just touching. Keep very contracting part of your forearm extensor
slight movements going and try to extract group. To do this, lift one finger and
your hands fast enough to gently slap the watch and feel the muscle contract. Try
back of your partner's hands before he
different fingers. Progress to contracting
has had a chance to snatch them away. If
specific parts of the muscle group with-
you manage to slap him, you repeat the
out moving the fingers. Try to contract
move until he manages to anticipate your
your biceps muscle without visibly con-
movement and snatch his hands away so
that you slap the air. When this happens, tracting brachio-radialis. These exercises
you reverse roles. Try not to snatch the give you the ability to use your muscles
hands away at every move; wait until in a controlled fashion. This is a very
the slapper is committed. This improves useful facility when performing thrust
response to motion and reaction time, techniques that require accurate use of de-
but will give sore hands if continued for fined parts of your structure for specificity.
too long! With a little ingenuity it should be possible to
10. Have a partner suspend a crisp banknote
develop most daily activities into suitable
between finger and thumb. Place your
practice for some aspects of technique skill.
finger and thumb on either side of it near
When vacuuming, swivel from foot to foot to
the bottom, without touching. Have him
practise weight transfer necessary in many
drop the note and try to catch it before it
passes through your hand. As you im- articulation techniques. When washing a car
prove, gradually widen the gap between try different directions of circling the hands
your finger and thumb and raise your to find the variety possible in addition to the
hand nearer the top so that there is less most natural directions. Try placing a few
time to react. This is another exercise in pieces of fruit or vegetables in a bag and
response to motion and improves your identifying each one by feel. Trace the out-
ability to move only at the right speed lines of the bones of your own wrist; see how
when necessary. much pressure is comfortable and how you
11. Learn to juggle with suitable juggling can deflect the tendons out of the way to get
balls. This teaches you to relax and yet to the deeper structures.
remain alert and responsive to moving Until it is possible to develop some form
objects. This is extremely good for co- of thrust meter or pressure-sensing device
ordination and hand-eye reactions. to objectively measure forces and directions,
12. Have your partner mime a simple move- these simple drills should help in a small way
ment. Stand in front of him and copy this to aid understanding, palpation and skill.
TECHNIQUES FOR THE LUMBAR AREA 13

Accurate and efficient techniques for the occur. General mobilizing can be extremely
lumbar area are extremely important. The helpful, but the nature of release achieved
highest percentage of patients presenting to with a well-timed, accurate and specific
osteopathic practitioners are suffering with thrust can be not only a short cut, but the
low back pain, and techniques for the lumbar only way to get full restoration of function.
spine will probably be used more often than Although size of operator should not be a
any others. The practical difficulties for a critical factor, it must be said that in some
small operator in reaching a facet joint no cases a larger operator will have a distinct
bigger than the thumb nail, in the back of advantage. The use of excessive force rather
a patient weighing anything up to around than accuracy, however, conceals a weakness
200 pounds, can be considerable. The sheer in approach.
depth of the joints, the difficulty of controlling Cases of possible disc injury require particu-
the area in many subjects, and the common
lar care to avoid worsening the situation. An
complicating factor of an underlying acute
educated, aware practitioner should be con-
or chronic disc lesion add to the problems.
versant with neurological symptoms and
For treatment to be more specific, accurate
signs. Extreme antalgic posture is present for
mechanical diagnosis is essential. There is,
a reason and consideration should be given
therefore, a requirement for techniques
designed to be efficient and feasible for the to that reason before attempts to 'correct' the
operator to perform without undue stress on posture are made. Many pathological states
his own structure. in the body can manifest as low back pain
It can be a problem to localize a force to a and the reader is referred to literature on
segment or segments while attempting to pathology and diagnostic screening as an
'protect' adjacent areas that may be hyper- essential prerequisite to treatment in this
mobile. It is often difficult to manipulate a area. A patient should be fully investigated
specific segment, but in some cases unless when they are clearly ill, have lost weight for
this is achieved, the relief from a particular no apparent reason, or have intractable pain
pain and dysfunction syndrome will not that does not subside on rest.
70 Techniques for the lumbar area

--

13.1 • Kneading soft tissues lumbar area prone 13.2 • Kneading soft tissues lumbar area prone
The operator is working on the muscles on the side Perform the technique with the near hand while the
furthest from him. The near hand is holding back on other stabilizes. There is no particular advantage in
the area to apply a small compressive force toward which hand is used. However, it may be easier to
the table and to prevent rotation of the spine and to reach right down to the sacral attachments of the
sense the best resistance from the tissues. Push erector spinae using the caudal hand rather than
with the active hand into the muscle belly until a the cephalic one, as in technique photograph 13.1 .
sense of resistance is felt, and then maintain this Tips: Least useful in cases where lying prone
position for a few moments until a sense of may be a problem. Extra considerations: Try
activation is felt. There should be a sense of asking the patient to turn the head to one and then
'melting' as the muscles relax, and then you can the other side to assess which produces the most
follow this sense until the muscle is gently but fully useful tension. Combining phases of breathing with
eased. The direction of the pathway may be in a the technique may be useful. The pillow is optional
curve, and it is important to allow the tissues to increase patient comfort if necessary. Most
sufficient time to guide the force direction rather patients find that a pillow underneath the abdomen
than to impose on them. The pressure is then is preferred when prone lying.
slowly released until the cycle can be repeated on
an adjacent area. The whole cycle can take up to
about six or seven seconds. Most operators will not
use such a long cycle, but paradoxically it is often
found that the slower one works, the quicker and
more effective the results.
Tips: Least useful in cases where prone lying is a
problem and in acute cases where there may be a
tendency for the muscles to go into a greater
spasm when the patient subsequently moves.
Extra considerations: Note that a pillow is placed
under the patient's abdomen to reduce excessive
hyperextension of the lumbar spine.
 Techniques for the lumbar area 71

13.3 • Kneading soft tissues lumbar area side-

lying The patient has the knees and hips flexed to
increase stability on the table. Stabilize the patient's
body with your cephalic hand and apply the
kneading force to the muscles nearest the table.
Tips: Most useful in cases where prone lying may 13.5 • Articulation into sideshifting lumbar area
be a problem. Least useful in large patients where prone Grip the transverse processes of the vertebra
the reach for the operator may be too great. Extra concerned with the pads, not the tips, of the fingers
considerations: In acute cases this may be the and thumb and use a direct sideshifting force from
only way to work on the lumbar muscles as pr~ne side to side. The oscillation can be quite firm when
lying may be impossible due to spasm. Try vaned used carefully, and this will act as a useful test as
angles of hip and knee flexion. Try working on the well as a mobilizing force. As the hands are applied
muscles by pulling up instead of pushing down. Try to adjacent vertebrae, differences in mobility. ~an
performing the same procedure when standing easily be felt, and this hold can be used to mob1hze,
behind the patient. or other techniques can be applied to deal w1th the
restriction in movement.
Tips: This is a movement of the whole of the
patient's body around the vertebra, and needs
quite a long amplitude to be effective. Least useful
in cases of antalgic sidebent posture as this move-
ment will cause pain when working against the curve.

13.4 ~ Stretching superficial fascia lumbar area

prone Gather skin and superficial fascia over
upper lumbar area, and then apply a lifting fo~ce so
that a gapping is produced. In some cases th1s can
be made into a thrust, and the fascia will separate
with a vacuum gapping sound.
Tips: Most useful in cases of tightness in the
superficial fascia which can be a factor in mainte~­
ance of pain syndromes. Least useful where the sk1n
is very tender.
72 Techniques for the lumbar area

13.6 • Harmonic technique lumbar area prone

Fix the sacrum in some traction towards the
patient's feet and fix the thoraco-lumbar area
towards the head. The harmonic technique is
performed by a rhythmic oscillation of the patient's
whole body in a caudal and cephalic direction. See
earlier section relating to harmonic technique. 13.7 • Sacral springing and traction prone Flex
Tips: The range of mobility available in a longitudi- the sacrum as far as is comfortable, and fix the
nal plane is going to be smaller than in a rotary thoraco-lumbar area with the other hand. Aid the
plane, but is, nevertheless, often useful in re- flexion of the sacrum with the elbow of the one
establishing rhythm and mobility. Least useful in hand by pressing the other hand into the table.
cases where prone lying is a problem. Extra Tips: Try adding various amounts of rotary
considerations: It is also possible to perform movement of the pelvis or the body as a preliminary
rotary harmonic technique if the tension is main- before the sacral flexion. This can enable forces to
tained between the hands, and the whole body be directed to either side of the lumbo-sacral joint
oscillated into rotation. The pillow under the rather than simply flexing the sacrum. Most useful
abdomen often makes the position more comfortable in cases of very tight lumbar fascia where this
for the patient. position removes some of the soft tissue tension
and allows the force to reach the facet joints. Least
useful in cases where prone lying is a problem.

13.8 ~ Harmonic technique pelvis and lumbar

spine supine Take up any slack in the tissues of
the pelvis by pressing firmly into the table with both
hands. Perform the oscillation with alternating
pressure towards the table with the heel of each
hand on the anterior superior spines. This induces
a rotatory movement in the lumbar spine. See
earlier section relating to harmonic technique.
Tips: Try using varied amounts of traction as an
additional movement. Most useful in fairly small
patients where the stretch to reach is not too far.
Least useful in large patients, or for small operators
where the reach is a problem.
 Techniques for the lumbar area 73

13.9 £. Harmonic technique lumbar spine and

pelvis prone Apply pressure above the crests of
the ilia and a variable traction force towards the
patient's feet. A harmonic oscillation is induced into
rotation, sidebending and traction. See earlier
section relating to harmonic technique.
Tips: Least useful where prone lying would be a
problem.

13.11 £. Functional technique typical hold The

operator is controlling all possible vectors of patient
movement while monitoring the sense of ease and
bind at a particular segment. The controlling hand
is directing the body towards accumulating ease at
the target segment. See earlier section relating to
functional technique.

13.10 ~ Traction supine Fix the patient's legs

against your chest and push gently downwards so
that the feet are fixed to the table. Lean back to
produce a traction force in the lumbar spine. This
hold can also be used in a harmonic fashion.
Tips: Most useful where a gentle traction force is
required. Extra considerations: Try varying the
angles of hip and knee flexion to focus the force to
different areas.
74 Techniques for the lumbar area

13.13 .& Articulation into reinforced flexion Pull

the sacrum directly toward you while bracing the
ribs towards the table. The upper hand fixes above
the target segment while you pull the sacrum into
flexion.
Tips: Try varied amounts of compression of the
thighs toward the table and adding elements of
sidebending or rotation to the flexion, to focus on
3.12 .& Articulation into flexion sidelying Flex particular parts of the segment. Most useful where
the patient's hips until a sense of gapping is felt at a strong localized force is required. Least useful
the target segment. Rock from foot to foot and turn where the patient is very large and the reach
this diagnostic procedure into an articulation with around them would be too great.
an increase of pressure with either hand to localize
the force.
Tips: Most useful in almost all cases of lumbar
vertebral dysfunction. Least useful in extremely
large patients or in the presence of any disorder
preventing hip flexion. Extra considerations: Try
using one hand to pull the pelvis into more flexion
or the other hand to hold back above the target
vertebra or both.

13.14 ..,. Articulation into flexion supine Sit on

the table and hold over one or more spinous or
transverse processes. Flex the hips with the other
hand. Hold the patient's legs against your chest so
that as you rock back and forth, the force causes a
flexion movement of the lumbar area.
Tips: Least useful if there is any hip disorder
preventing flexion. Extra considerations: Try using
varied degrees of sidebending or rotation at the
same time to enhance localization.
 Techniques for the lumbar area 75

13.15 .A Articulation supine Stand at the side of

the table and fix over one or more of the spinous or
transverse processes. Cross the patient's thighs
and apply a flexion and sidebending force as you
lean forward. This hold makes it easy to introduce
some element of sidebending to the primary
movement of flexion. 13.17 .A Articulation into sidebending sidelying
Tips: Least useful in any patient with hip mobility Compress toward yourself, and down into the
restriction. Most useful in very flexible subjects table. Sidebend the pelvis away from the table with
where the position automatically absorbs some of the caudal hand as the other hand pushes down on
the excess movement. Extra considerations: Try the spinous processes.
using a fisted hand to form a stronger fulcrum in Tips: Most useful where very localized articulation
suitable cases. is necessary, and in cases where a firm lever
through the hips may be undesirable.

13.16 ..,... Articulation supine (alternative view) The

hold is as in photograph 13.15, but shows hand
placement from the other side.
76 Techniques for the lumbar area

13.19 _. Articulation into extension sidelying

Fix the patient's knees against your thigh, and fix
the patient's feet to the table with your caudal
hand. Pull against the lumbar area to produce a
direct force into extension.
Tips: Least useful in very stiff subjects who
would be very difficult to move with this hold as it
would require great strength in the pulling hand to
13.18 _. Articulation into extension sidelying
overcome the stiffness. Extra considerations: As
Fix the patient's shoulder girdle to the table with a
extension is elicited from above, try asking the
compressive force and apply a direct posterior to
patient to extend the head and upper back to
anterior force over the lumbar spine.
enhance the action of the technique.
Tips: Most useful where a very localized force is
required. Least useful in large subjects where a
small operator may find it difficult to develop
sufficient leverage. Extra considerations: Try
varying the initial patient position on the table to
find the optimum in each case.

13.20 ..,.. Articulation into extension supine Pull

upward on the transverse processes on both sides.
The patient has interlaced the hands behind her
head to enhance the extension force.
Tips: Most useful in small subjects and children,
and when directing the force into the upper lumbar
area. Extra considerations: Try extending and
then adding an oscillatory rotation force as an
additional vector.
 Techniques for the lumbar area 77
13.21 <1111 Articulation into extension sidelying
Overlap the hands and pull directly on the area to
introduce extension. The patient's knees are
directly fixed by your thigh to form a counter-force.
Keep the patient's hips at 90°.
Tips: Most useful where a fairly strong force is
desired. Extra considerations: Try introducing an
element of sidebending or rotation to assist the
primary movement.

13.22 .& Articulation into extension sitting Take 13.23 .& Articulation into extension sitting Apply
up the slack of the area with crossed hands and as thumb pressure to the paravertebral area of the
the patient is rocked back and forth an extension segment to be mobilized. The patient is asked to
force is produced. By placing the cephalic hand on hold the edge of the table and then you can push
either side of the area, a rotation or sidebending against the area rhythmically to introduce the
force can also be introduced. The patient is astride extension force. The natural recoil of the tissues will
the table to stabilize the pelvis. bring the spine back to neutral.
Tips: Least useful in elderly patients or those Tips: Least useful in cases where astride sit-
where the astride position may be a problem. Extra ting can be a problem. Extra considerations:
considerations: Try asking the patient to move the Try staggering the thumbs on either side of the
hands further forward to change the angle of spine to introduce a rotation element to the
approach to the area. movement.
78 Techniques for the lumbar area
13.24 ..,.. Articulation into sidebending sidelying
Push down with one hand on the legs while pulling
up on the spinous processes to induce sidebend-
ing. Increase the angle of hip flexion to direct the
force to higher segments as desired.
Tips: Least useful in patients who have any hip
disorder as this position may be a problem. Where
the table has a hard edge the pressure may be
uncomfortable for the thigh on the table. Extra
considerations: Try introducing an element of
extension to the technique to change the effect of
the pure sidebending if necessary.

13.25 _. Articulation into flexion/side bending 13.26 _. Articulation into sidebending sidelying
sidelying Pull up with one hand on the spinous Lift the patient's feet until tension is felt to
processes while the patient's pelvis is sandwiched accumulate under the other hand which pushes
between your body and arm and lean away from toward the table to produce sidebending.
the spinal hand to produce sidebending. Varied Tips: Most useful where a strong generalized
degrees of flexion are applied by rocking against force is required. Least useful in the presence of
the patient's knees. any hip joint dysfunction. Extra considerations:
Tips: Most useful where very localized articulation Try varied degrees of hip flexion.
is desired.
 Techniques for the lumbar area 79
13.27 ..,.. Articulation into sidebending sidelying
Take the patient's feet in the crook of your arm and
fix against the upper thigh with your wrist. Your
other hand pushes against the spinous processes
toward the table. Varied degrees of flexion of the
hips are applied to focus the forces to the segment
desired.
Tips: Least useful in the presence of any hip
disorder. Most useful where a very strong stretch is
desired.

13.28 .& Articulation into sidebending sidelying

The patient is sidelying in a neutral position of slight
hip flexion and you can push on the rib cage toward
her head, on the pelvis toward her feet and on her
spine toward yourself. The articulation movement
is either a fixation with one hand and a pulling with 13.29 .& Articulation into sidebending prone
the other or a movement of both. Varied degrees of Apply the fingers to the side of the spinous
rotation or flexion can be introduced as part of the processes and push away from yourself to produce
overall leverage. a sidebending and rotation force. This is most
Tips: Most useful where any hip disorder applicable in the upper lumbar area.
prevents use of the hip as a lever and where strong Tips: Least useful where the patient may find the
localized forces are required. Extra considerations: prone position a problem. Extra considerations:
A high compressive force toward the table helps to Try placing the patient in some sidebending before
focus the technique. the initiation of the technique.
80 Techniques for the lumbar area
13.30 ..,.. Articulation into sidebending sidelying
The patient is lying in a neutral position with hips
only slightly flexed. Apply a compressive force to
the pelvis with your body and caudal hand to
produce sidebending away from the table. With the
other hand apply a downward force toward the
table to localize the sidebending.
Tips: Most useful where a localized force is
required and it is necessary to avoid using the hips
in the leverage. Extra considerations: Try using
varied amounts of compression through either arm
and rotation to enhance the sidebending force.

13.32 .& Generalized articulation into rotation

supine Apply a force with your lower hand through
13.31 .& Generalized rotation mobilization the patient's hip using your wrist as a fulcrum. Use
supine Pull the flexed hip of the patient toward the other hand to hold the patient's folded arms
you while holding the thorax of the patient toward away from you.
the table and away from you. This will produce a Tips: Least useful where specific localization is
rotational mobilization focused primarily in the required. Extra considerations: Try placing the
thoraco-lumbar region. Varying the angle of hip patient in some sidebending before the onset of the
flexion will change the localization to some extent. technique to enhance the effect.
Tips: Least useful where specific localization is
required.
 Techniques for the lumbar area 81

13.33, 13.34 and 13.35 Thrust sidelying, building

of upper lever component. There are many ways of
introducing the upper component to the lumbar roll
position for applying a thrust. Each has its ad-
vantages and disadvantages. Individuals will have to
experiment to find their own preferred method.
Photograph 13.33 shows the operator clasping the
patient's forearm under his arm. While pushing the
other shoulder toward the table he is pulling the lower
scapula out of the way. The pull can be either into
pure rotation or sidebending either way according to
the direction he takes the arm. In photograph 13.34
the patient's arms are folded and the operator is
lifting on the lower elbow while holding down on the
upper shoulder. It is less easy to introduce a
sidebending component with this hold. In photo-
graph 13.35 the operator is sliding the lower scapula
forward while holding down on the upper shoulder.
This hold allows sidebending to either side to be
introduced if necessary and does not involve any
strain on the patient's shoulder.
 13.36 ..,.. Thrust using lumbar roll sidelying rear
view The operator is applying a classical com-
bined lever and thrust technique. This rear view
shows operator posture and how both feet are
pointing to the head of the table with the rear heel
just off the floor. Note that the weight is applied to
the patient's pelvis with the thrusting hand. The
other arm is only lightly fixing on the lateral aspect
of the thorax and NOT the anterior aspect of the
shoulder. The patient's body is rolled toward the
operator who is, therefore, only slightly flexed and
is able to apply the rotary force of the technique
simply by a flexing of his knees.

13.37 .& Thrust using minimal leverage side-

lying The patient is positioned in a balanced side-
lying position and a very small element of rotation has
been introduced from above. Apply the hand to the
patient's shoulder to produce a compressive force
toward the table and your other arm is then flexed to
90° and held close to your side. Gather some skin
from your forearm and the patient's buttock by
gripping the buttock with the forearm and pulling it
into you before applying the downward compression
force. The force is applied as a combination of (a)
compression to the table, (b) localized compression
over the segment, (c) rotation of the pelvis by you
flexing your knees and (d) a sidebending of the pelvis
away from the shoulder. In minimal leverage thrust 13.38 .& Thrust, upper hand hold, combined
the amplitude is very short and the velocity is high. leverage and thrust, sidelying The operator has
Tips: Most useful where it is desired to produce placed the patient in position for the thrust, and this
facet separation with minimal distortion of the spinal photograph shows the rotation of the upper lever.
area or torsion through the rib cage. Extra consider- Note that the patient's upper shoulder is behind
ations: The final vectors of force direction will be the lower one, but only by a small amount. The
slightly different in each subject. Although the operator's head is vertically over the lumbar spine
directions given will apply in most cases, it must be although the abducted arm is going to apply the
remembered that an increase of one force direction thrust. A compression force is applied to the
will automatically reduce the quantity necessary for shoulder with only enough backward pressure to
others. The order in which they are applied may also act as an equal and opposite force to the thrusting
be changed to suit the circumstances. Considerable hand. It does NOT enter into the thrust other than
experimentation will be necessary to find the opti- as a stabilizer.
mum for each operator's particular skill, the patient's
morphology and the facet orientation. This depends
to a large extent on palpatory awareness.
 Techniques for the lumbar area 83
13.39 <IIIII Thrust, lower hand hold, combined
leverage and thrust, sidelying Roll the patient's
body toward you and apply the heel of your hand to
the ilium so that it is possible to produce a rotation
and extension force as necessary. Your pelvis and
side must be applied to the patient's thigh, and you
must fix the patient's thigh to the table with your
thigh.
Tips: Most useful for larger operators, and where
an extension force is needed. This hold can also be
used for a direct sacral thrust. Extra considerations:
Some of the thrust force comes from a downward
movement of the operator's body along with the
hand force.

13.40 .& Thrust using minimal leverage, alternat- 13.41 .& Thrust into flexion using combined
ive shoulder hold Apply a downward pressure lever and thrust sidelying The initial patient
through the pelvis, after gathering some tissue positioning involves using some flexion and after-
under the applied forearm to induce compression wards you apply a compressive, rotary and flexion
and some rotation. Place your hand in direct force to the pelvis. Note that the patient's lower leg
contact with the vertebra at the apex of the force. is off the edge of the table and that you must be
Your other arm compresses the patient's thorax square to the table rather than in the usual position
through the shoulder toward the table. The final of facing toward the opposite top corner. The
thrust direction is a combination of compression, combined effect of this is to produce a flexion
rotation and some sidebending as necessary. gapping force that may be very useful in hyper-
Tips: More useful in larger patients where it may extended patients.
be too far to reach up to the axilla with the Tips: The final flexion is the gapping force and
stabilizing hand. Less useful for operators with long sufficient free play must be left to allow this to
arms, who may find it difficult to apply the hand to operate.
the spine at the same time as the usually applied
part of the forearm to the ilium. This action will
cause hyperflexion of the elbow and if repeated
many times will make the risk of injury to it
extremely high!
84 Techniques for the lumbar area
13.42 <1111 Thrust into rotation combined lever
and thrust sidelying The hold used here is specific
for the lumbo-sacral and L4/5 levels. The difference
in this hold is that your lower hand is not in contact
with the patient. The upper hand is threaded through
and is palpating the relevant spinal level. The upper
hand is used to apply a compression force at the
target segment. If the lower hand were to be in
contact with the spine the thrusting elbow would
become excessively flexed and liable to injury.
Tips: The optimum plane for the thrust will be
easier to find if the patient, as a whole, is rolled
gently back and forth on the table within the thrust
position. This does not mean that the levers alter at
all, but that a momentum force is being used in
rolling while keeping the levers the same. It is also
easier to apply the thrust from a dynamic rather
than a static position.

and thrust sidelying This view shows the lower

arm hold used in photograph 13.42. The medial
aspect of the elbow is applied to the small plateau
on the lateral aspect of the ilium between gluteus
maximus and gluteus medius. The soft tissues
have been gathered first and the forearm muscles 13.44 A Thrust into rotation combined lever
have been rolled to form a cushion between your and thrust sidelying This view shows the upper
ulna and the patient's pelvis. arm hold used in photograph 13.42. Notice that the
Tips: It is worth spending some time experiment- operator is standing fairly upright and that his arm
ing to find the most comfortable way of applying pressure is not on the shoulder but rather the
the lower hand hold. It is often useful to apply the antero-lateral aspect of the thorax. He is using ulnar
arm, and then, keeping contact with the patient, deviation of the wrist to bring the ulnar border of the
adduct it so that your forearm muscles are rolled hand against the lower ribs. To avoid the force
between your ulna and the patient. Avoid using the dissipating when the thrust is applied, ensure your
back of the ulna or the point of the elbow. The shoulders are pulled down by active contraction of
forearm will be at approximately 60° to the long axis your latissimus dorsi muscles on both sides. A useful
of the table. If it is at 90° this is likely to be very rule is that if you can see your shoulders, except out
uncomfortable for the patient. of the corner of your eyes, they are too high.
 Techniques for the lumbar area 85

13.45 A Thrust into rotation combined lever

and thrust sidelying The hold shown here is for a
pure rotary thrust where the operator is focusing
the forces and then will simply flex his knees to
introduce the rotation. This direction of force is
most useful in patients who have very sagittal lower
lumbar facet planes.
Tips: The optimum plane and timing for the
thrust will be found if the patient's body is kept
slowly rolling back and forth. 13.4 7 A Thrust into rotation combined lever
and thrust sidelying Hold directly on the spinous
process of L4 or L5 to help make the force specific.
Apply the thrusting arm to produce a direct
compression and rotation force through a very
small amplitude.
Tips: The stabilizing hand is not applied to the
anterior of the thorax in this case but more to the
lateral side of the ribs as the force should not reach
much above the segment concerned. Most useful
where excessive rotation of the thoracic spine is
best avoided.

13.46 A Thrust into sidebending combined lever

and thrust The normal position of the patient's legs
for HVT (high velocity thrust) techniques is reversed
in that the upper leg is straight. This will introduce a
sidebending toward the table and you can apply
forces to emphasize this fact. The final thrust uses
rotation and flexion or extension as necessary but will
be primarily into rotation.
Tips: Most useful in cases where the sidebend-
ing force is desired to open an inter-vertebral
foramen and possibly decompress a nerve root.
86 Techniques for the lumbar area

13.48 A Thrust into extension combined lever 13.49 A Thrust using combined lever and
and thrust sidelying Pull the lumbar spine into thrust with patient assistance Focus forces in
extension with your stabilizing hand and then while the usual way to the lumbo-sacral facet and then
maintaining this vector perform the thrust into ask the patient to turn her head to look over her
rotation and compression, avoiding flexion. If it is shoulder. This will often cause the barrier sense in
desired to gap the facet nearer the table, this is the joint to be enhanced which may aid the thrust.
possible with the following vectors. Extension is Tips: Most useful in patients who are very flexible
maintained and a sidebending force is applied where it is difficult to produce an accurate focus. It
away from the table and then a compression thrust is also a useful distraction for patients who find it
is used. very difficult to relax. Extra considerations: Try
Tips: Most useful in patients who have very tight asking the patient to look toward the table - this
fascia, as their superficial posterior tissues will will have the effect of slackening the levers.
come on tension too early in flexion and prevent the
technique reaching the facet joints. Paradoxically
this is also effective in some very flexible patients
where extension will produce an easier localization
than flexion. This is because they automatically fall
into extension and, rather than trying to fight this,
the extension can be used as one of the compo-
nents of the technique. The ability to gap the lower
facet is very useful where there is nerve root
impingement, as rotation, with the patient lying with
the painful side uppermost, may be impossible.

13.50 <1111 Thrust combined lever and thrust side-

lying Fix behind the patient's knee and against the
upper shoulder and apply a rotary force to the
lumbar spine. The patient's body is rocked back
and forth until a sense of focusing of forces is
produced. The thrust is applied with a short
amplitude, high velocity force toward the floor with
the knee hand. Although this hold can be a very
generalized manipulation, some operators find it is
possible to be very specific to a particular segment.
The tendency, however, may be for any relatively
hypermobile segments to gap leaving the restricted
ones unaffected.
 Techniques for the lumbar area 87

13.51 .A. Thrust into sidebending combined

lever and thrust sidelying Place a pillow under 13.53 .A. Thrust using sciatic stretch sidelying
the patient's side which will produce sidebending This hold uses similar principles to photograph
toward the table. Accumulate the forces at the 13.52 except that you hook your leg around the
target segment and apply the final thrust directly patient's foot. At the time of thrust you can
into sidebending by pulling up on the spinous straighten your leg to increase the traction compo-
process with the fixing hand and thrusting toward nent through the patient's leg. This clearly has
the feet with the other. disadvantages, as you are standing on one leg, but
Tips: Most useful where there may be nerve root is sometimes a useful technique. It is often possible
pressure or foramina! encroachment and it is to produce a force specific to the sacro-iliac with
desired to open the foramen during the technique. this hold.
Some treatment tables have moveable sections
capable of producing the initial positioning rather
than needing to use a pillow.

13.54 .A. Thrust into flexion using minimal lever

and thrust sidelying Compress the lateral wall of
the thorax into the table with the stabilizing hand.
Apply a compressive force directly over the sacrum
with the other and then the thrust is performed as a
short, sharp flick into flexion of the sacrum to
13.52 .A. Thrust using sciatic stretch sidelying specifically gap the lumbo-sacral facets.
Sandwich the patient's leg between your thighs and Tips: Most useful in cases of acute spasm where
after accumulating tension at the facet joint flex the any torsion is best avoided. Extra considerations:
thigh until sciatic stretch begins. Apply the thrust into This is an extremely difficult technique to perform
rotation while maintaining the sciatic stretch. This can effectively. However, it is well worth the effort of
be useful in cases of long-term sciatica where it may practising it, as it is then possible to manipulate
be possible to break some adhesions around the cases where most other techniques would be too
nerve root. Great care must be taken not to over- painful due to the leverages necessary.
stretch the nerve and traumatize it. Some adhesions
will be stronger than the normal tissues, and if this is
the case, damage can occur if excess force is used.
88 Techniques for the lumbar area

---

13.55 .A. Thrust lumbo-sacral facets prone Apply

a three-phase force to the sacrum. The first phase
is pressure toward the table. Maintain the pressure
and apply the second phase that carries the whole
sacrum toward the head. The third phase is to flex
the sacrum until resistance is felt and then sharply
apply a small force into further flexion while
maintaining the other vectors.
Tips: Most useful where specific lumbo-sacral
gapping is required without spinal torsion. Least
useful in patients where prone lying is a problem for
any reason. Try adding a sidebending or rotation
vector to direct the forces more specifically to one
side or the other.

13.56 ...,.. Thrust lumbo-sacral supine Hold the

pelvis firmly down onto your hand, cupping the
sacrum, and apply a traction force to the sacrum
until some sense of resistance is achieved. Flex the
distal interphalangeal joints of your sacral hand to
pull effectively toward the feet with the fingers.
Then use a short, sharp tug on the sacrum to
specifically gap the lumbo-sacral facets.
Tips: Most useful in heavy or pregnant patients
where torsional manipulation would be a problem.
Extra considerations: Try varying the hip flexion
and initial sidebending position of the patient as
well as the phase of respiration.
 Techniques for the lumbar area 89

13.57 ~ (see facing page, top right) Thrust into

rotation combined lever and thrust sitting The
patient sits astride the table to help stabilize the
pelvis and places her folded arms over the operator's
padded shoulder. Keep the patient's head vertically
over her pelvis throughout. Introduce sidebending of
the spine away from you and then, while maintain-
ing this, rotate the spine until tension accumulates
under your hand applied to the spinous processes.
You and the patient turn as a unit and the thrust is
performed during this turn by the spinal hand
accelerating slightly into rotation.
Tips: Most useful in large heavy patients where
their weight in compression on the spine assists
the technique. Least useful where the sitting astride
position may be a problem. Extra considerations:
Try varying the compressive force forward toward
you to minimize the rotation element. Do not lose
the sidebending when applying the rotation or the
focus of tension will be lost, and strain can occur at
the sacro-iliac joints.

13.59 .& Thrust into rotation combined lever and

thrust standing Fix the sacrum with your hip on the
forward leg and rotate the patient to that side with
your hand interlaced between the patient's clasped
hands. Your other hand holds back on the ilium and
then you sidebend the patient toward your fixing
13.58 .& Thrust into rotation combined lever hand. When tension accumulates, sharply increase
and thrust sitting This shows an alternative hold the pull with both hands.
for the same technique as photograph 13.57. It Tips: Most useful in flexible subjects where the
may be more useful in large subjects where you slight pull of psoas in this position will help limit
may prefer to avoid taking the weight through your spinal movement and aid focusing the forces. This
shoulder. This technique may be useful where no technique may be useful where no treatment table
treatment table is available as it can be performed is available.
on a chair with the patient sitting astride the chair.
Tips: Keep the patient's head vertically over the
sacrum throughout the technique.
90 Techniques for the lumbar area
13.60 ..,.. Vertical adjustment position standing
This shows the most common hold used where the
operator is cupping his hands to clasp the patient's
folded arms by the elbows. Note that one foot of
the operator is in front of the other and that
although he is flexed from the hips his spine is
relatively straight.

13.61 ..,.. Vertical adjustment standing The hold

shown in photograph 13.60 is applied and the
patient is lifted so that your sacrum fits into her
lumbar spine. Maintain firm compression of the
patient's back against yours. You rise onto your
toes and the adjustment is performed by dropping
to your heels and firming your grip at the same
moment. Your knees should never fully extend.
Tips: Ensure that the patient can extend her
lumbar spine before performing this technique or it
is likely to produce a lot of pain, as she will be in
quite a considerable amount of extension at
completion. Most useful where there is a vertical
compressive component to any dysfunction such
as disc herniation or overriding of facets. It is also
useful in heavy patients where some element of
traction can be very beneficial. This technique can
often undo fixations that rotary techniques will
leave partly unresolved and is usually best applied
after rotary techniques. Least useful when the
operator is shorter than the patient unless he
stands on a suitable platform or step. Extra
considerations: It is important that the operator
pulls firmly through the elbows toward himself to
add a compressive element. This helps to limit
upper lumbar movement and increases friction so
that the lifting force is less of a strain. The move-
ment in the technique is synonymous with shaking
the feathers down in a pillow. This technique would
appear to be quite a strain on the operator but if
performed properly the weight is taken mostly on
his sacrum. There is not necessarily a big vertical
compressive force on the operator's spine. With
practice small amounts of sidebending and rotation
can be used to focus the forces to particular
locations within the lumbar spine.
 Techniques for the lumbar area 91

13.63 A Adjustive traction supine Clasp above

the patient's wrists and apply a steady pull until
force is felt to accumulate at the lumbo-sacral joint.
13.62 A Vertical adjustment sitting Lift the torso This is confirmed by watching the pelvis tilt. Keep
of the patient through the folded arms, possibly using the arms at approximately 30° from the horizontal.
a pillow in the lumbar lordosis as a fulcrum. The Apply a short, sharp tug through the patient's arms
adjustive force is a short sharp lift at the end of the without releasing any of the tension produced.
accumulation of tension. There are several other Tips: Most useful in very tall subjects where a
hand holds for this procedure that may be tried. standing adjustment may be difficult. Least useful
You could have the patient clasp the hands behind in the presence of any shoulder dysfunction that
her neck. The patient could grip opposite shoulders, may be irritated by the traction force. It is essential
or she could be clasped around the lower thorax. to pre-load with the initial traction or the force will
Tips: Most useful in small, light patients and be dissipated before it reaches the lumbo-sacral.
where a narrow table is available so that the
operator can bring the patient close to him. Extra
considerations: Small elements of sidebending
and rotation can be introduced by pulling differen-
tially on the elbows or by the patient crossing the
ankles or knees.
92 Techniques for the lumbar area

13.64 A. Thrust sidelying using second operator Apply forces in the normal way to focus to a
particular joint. The second operator applies a slowly increasing traction force through the ankle until you
tell him to stop. You will be able to do this as you should feel an enhancement of localization during this
traction component. The thrust can then be performed while the traction is maintained.
Tips: Most useful in very flexible subjects where it is difficult to accumulate tension unaided. This is also
a useful method where there is some nerve root impingement as the traction may allow a rotary force to
reach the facet while the foramen is being opened slightly. Extra considerations: The second operator,
with a minimum of practice, will also be able to feel tension accumulating as the levers are applied.

13.65 A. Thrust sidelying using second operator This technique uses exactly the same principles as
those in photograph 13.64, except the second operator is applying traction to the neck until the required
tension is felt by the first operator.
Tips: With a third operator this technique can be combined with the previous technique in photograph
13.64 if even more traction is required.
 Techniques for the lumbar area 93
13.66 ~ Thrust sidelying two operator technique
The patient is in a semi-Simms position and the first
operator has lifted the patient's flexed knees while
pushing toward the floor with the heel of his hand
applied to the spinous processes. The second
operator rests his thorax on the patient's scapula
and while applying traction through the patient's
wrist, is fixing under the spinous processes with his
other hand. The forces are accumulated by the
contra-rotation of the upper part of the patient's
body toward the table and the lower part away. The
thrust is performed by the second operator fixing
while the first operator presses down on the
spinous processes and sharply lifts the patient's
knees toward the ceiling. Varied angles of hip
flexion in the patient will direct the force higher or
lower in the lumbar spine. It is critical to keep the
patient's hips flexed throughout or the tension is
very easily lost.
Tips: See photograph 13.67 for clarification of
hand positions. Most useful where conventional
rotary techniques are ineffective as this technique
works on the principle of backward rotation of the
lower component that will sometimes break fixation
in a way not previously achieved. Least useful in
very heavy patients where the strain on the
operator lifting the legs may be too great. Extra
considerations: This technique needs some prac-
tice to achieve appropriate coordination between
operators.

13.67 .&. Thrust sidelying two operator technique The rear view shown here of photograph 13.66
clarifies the hand hold and patient position.
TECHNIQUES FOR THE SACRO-ILIAC 14
AREA

There are probably more differences of opinion principles of treatment, therefore, are those
amongst osteopaths as to how to deal with of spinal joints.
dysfunction of the sacro-iliac articulations than The sacro-iliac, or to be more accurate the
for any other area of the body. There are ilio-sacral articulations have a very limited
multiple theories of movement directions and range of mobility. However, that mobility is
type of lesioning. I have attempted to sim- often very easily induced, and therefore it is
plify the issue into the two main types of extremely easy to 'overlock' when trying to
lesioning positions of anterior and posterior produce a specific force. Then, as no move-
rotation. This is not to say that other types of ment can be felt, even more force is used and
dysfunction do not occur, but to say that they pain, trauma and ineffective technique is the
seem to be fairly rare. Treating the sacro-iliac result. The sacro-iliac articulations respond
joint as a rotary articulation will deal with the far better to delicate, careful applications of
vast proportion of joint problems of a mechan- force in very specific directions.
ical nature without excessive complication Special precautions include the elimination
and therefore uncertainty. It is possible for of pathological states in the bones them-
the sacrum itself to become distorted, as in selves, and the possibility of inflammatory
life it is a somewhat flexible structure. It can disorders. If the sacro-iliac dysfunction is
produce apparent sacro-iliac dysfunction recurrent the possibility of it being part
which is, in fact, due to sacral torsion. Some of a postural compensation must be con-
techniques for addressing this problem are sidered. Excessive recurrence and a sense of
included in this section. Others are more precariousness should alert the practitioner
appropriate when considered with the lum- to the possibility of hypermobility. This,
bar spine, as the sacrum can sometimes be nevertheless, may manifest as recurrent lock-
classed as a vertebral, midline structure. The ing.
 Techniques for the sacro-iliac area 95

14.1 .& Articulation of sacro-iliac further side 14.2 .& Sacro-iliac articulation nearer side prone
prone Find the approximate angle of the joint Operator applies gentle pressure along perceived
plane using your cephalic hand, and apply gentle plane of joint with cephalic hand and then performs
pressure. The other hand takes the leg through a a circumduction movement with other hand con-
circumduction movement until a sense of potential trolling leg. As sense of tension accumulates in
for mobility is perceived through the applied hand. sacro-iliac joint, firmer pressure is applied to ilium
At this point of stressing the joint, a pressure along along joint plane to mobilize joint. The arc of
the line of joint movement is applied. The arc of movement within the circumduction where the joint
movement in the circumducting leg when a sense play will be felt varies slightly with different patients.
of resistance from the sacro-iliac is reached will Tips: Most useful in larger patients where reach-
vary slightly from person to person. It is sometimes ing across may be a problem when working on the
difficult to isolate the sacro-iliac movement from other side. Least useful if the table is not adjust-
hip movement in this hold. able, and it is not possible to get the angle of the
Tips: Most useful in patients who are not too articulating arm vertical. Not comfortable in acute
acute and can lie prone. Least useful in acute patients where lying prone is a problem, or in the
cases, or in the presence of any lumbar disc presence of lumbar disc lesions where extension
syndrome where the position may be a problem. May may be painful. Extra considerations: Use of a
be difficult in very large patients to reach across this pillow under the abdomen will often make the
far for small operators. Extra considerations: It is correct joint plane accessible.
very easy to apply too much pressure with the
cephalic hand, feel nothing, and therefore, press 14.3 <IIIII Sacro-iliac articulation anteriorly side-
even harder. If a sense of movement cannot be felt, lying The patient is put into some rotation of the
change angle or reduce pressure; do not increase spine, and the upper leg flexed to a comfortable
force. Use of a pillow under the abdomen can aid position. The operator firmly grasps the ilium
comfort and finding the best angle for the joint. between his own forearm, abdomen and other
hand. A rocking back and forward along the plane
of the joint can be applied. Sufficient rotation must
be applied to obliterate most of the lumbar move-
ment, as otherwise the rocking action will simply
produce flexion and extension of the lumbar area.
Tips: Most useful in patients who cannot lie
prone such as pregnant women, and acute lumbar
pain syndromes. Least useful in very flexible subject
where the lumbar movement tends to absorb the
forces. Extra considerations: Harmonic technique
can be performed in this position if the upper part
of the body is made to oscillate, and if the ilium is
held very firmly, an anterior gapping can be applied
if the operator flexes his own knees and holds the
pelvis in the same plane. This hold can also be
used for lumbar sidebending and several other
directions of articulation with a little thought.
96 Techniques for the sacro-iliac area

14.5 .&. Sacro-iliac articulation and springing

prone This illustration directly follows on from the
14.4 .&. Sacro-iliac springing prone This is as previous one. The springing hand has gradually
much a testing hold as it is a treatment technique. changed direction until the plane of the joint has
The operator is palpating in the sulcus of the sacro- been sensed, and the combined sense of proprio-
iliac joint on the opposite side, and the other hand ceptive awareness with the springing hand and
is applying a force vertically towards the table. If tactile sensing with the other hand allows the
movement is felt in the sacro-iliac it must be optimum direction of movement to be used. If the
hypermobile, as the plane of the joint is far more best direction for joint play cannot be sensed, use
medial to lateral than vertical. Rotary movement of less force not more as the applied weight of the
the lumbar spine is sensed with this pressure also, hands may have obliterated the free play, and more
and if excessive gives a clue as to possible cause pressure will only rotate the lumbar spine and not
of dysfunction states. have any more effect on the sacro-iliac joint.
Tips: The pressure must be applied carefully Tips: Gradually moving the shoulder of the
over the posterior superior iliac spine as otherwise springing hand through a circle will allow the
only soft tissue mobility will be sensed. Least useful optimum direction of force to be assessed. A pillow
in acute subjects where lying prone is a problem. under the abdomen may help to reduce the lumbar
Extra considerations: This hold develops into the lordosis, and make the sacro-iliac joint more
next one illustrated as a means of sensing from accessible. Least useful in acute lumbar pain
where movement is being induced. syndromes where lying prone may be a problem.

14.6 ~ Harmonic technique pelvis supine

Operator cups anterior superior iliac spines in the
palms of both hands and initiates an oscillatory
movement into rotation of the pelvis. This can be
diagnostic as well as therapeutic, as differences in
rotary capability of the pelvis on the lumbar spine
can be sensed.
Tips: A pillow behind the knee may change the
angle of the pelvis and make movement easier.
Least useful in cases of sacro-iliac hypermobility as
this pressure may induce pain in the joint con-
cerned. This is in itself diagnostic.
 Techniques for the sacro-iliac area 97

14.8 • Sacro-iliac thrust into anterior direction

supine The optimum direction of the joint is found
and then a downward pressure is applied with
some internal rotation of the hip to put the hip
capsule on some tension. The knee will be approxi-
mately over the midline of the body in most cases.
14.7 • Sacro-iliacarticulationsupine Thefingers Small adjustments of flexion and extension of the
of the palpating hand are placed so that the tips are hip will be necessary to find the optimum, and then
in the sulcus of the joint and while gentle downward a short sharp downward force is applied to direct
pressure is applied toward the table the knee is the ilium into an anterior rotation direction. At first
taken through a circular movement to mobilize the this may seem to be doing the opposite of what is
joint. intended, but it should be remembered that the
Tips: Excessive pressure toward the table should sacro-iliac joint is superior to the hip, and therefore
be avoided as this will obliterate joint movement. when a pressure is applied towards the table, the
Within the arc of circumduction of the knee, a point ilium will be rotated forward, not backward. If,
of resistance will be felt and this can be empha- however, the hip is taken further into flexion, the
sized with increased downward pressure at that ilium will be rotated backward.
time to optimize the mobilizing force. Most useful Tips: Very accurate joint plane sense is required
where patient cannot lie prone for any reason. Least for this technique, and it may be necessary to feel
useful in the presence of osteoarthrosis in the hip this with fingers in the sulcus of the joint first, and
or knee. then remove the hand and apply it to the knee. Most
useful in simple uncomplicated sacro-iliac dysfunc-
tion in fairly stiff subjects where the force will not be
dissipated into the lumbar spine. Least useful in
cases where there is osteo-arthrosis of the hip and
this pressure will be uncomfortable or impossible.
Extra considerations: May be repeated several
times as a springing rather than a specific thrust if
correct barrier sense cannot be found.
98 Techniques for the sacro-iliac area
14.9 <IIIII Sacro-iliac thrust and articulation anter-
iorly prone The plane of the joint has been found
with the caudal hand and while maintaining this
direction of force, the operator applies the other
hand to the sacrum near to the other sacro-iliac
joint. The sacral hand becomes a fixing hand, and
the sacro-iliac can be mobilized with springing into
an anterior direction. If a crisp barrier is sensed, a
thrust can be applied, but, owing to the small range
of movement of the joint, this will be a very short
amplitude.
Tips: The sacral hand can be placed in such a
way to tip the sacrum into flexion, rotation or
sidebending to optimize the tension at the sacro-
iliac joint. Different phases of breathing can be
used as felt appropriate. If the thrust is applied
when the patient is holding a full breath in, the
pelvis will become firmer, and the thrust may be
easier. In a very tight subject, exhalation may be
more useful. Most useful in uncomplicated sub-
acute or chronic cases. Least useful in acute cases
or where the patient may find lying prone a
problem.

14.10 • Thrust sacro-iliac anteriorly prone The medial aspect of the elbow is applied over the
posterior superior iliac spine and along the crest of the ilium. The other hand levers against the table and
the other thigh, to produce an anterior rotation movement of the ilium. Adjustments will be necessary of
the adduction and extension of the thigh to produce the optimum tension in the joint. At the point of
accumulation of forces, the thrust is applied along the crest of the ilium.
Tips: Most useful in small patients, and where there is no problem lying prone. Least useful in acute
cases where the prone position may be a problem. Extra considerations: Care must be taken not to
hyperextend the lumbar spine and thus cause pain. In this respect keeping the anterior of the pelvis on the
table is a help. If the correct tension sense does not accumulate, reduce tension rather than increase it, as
it is very easy to over-lock. Different phases of respiration may help to produce the best barrier.
 Techniques for the sacro-iliac area 99

14.12 • Thrust sacro-iliac anteriorly prone

thrusting hand is applied behind the posterior
superior iliac spine, and the fingers of the other hand
interlock with the thrusting hand so that the leg can
be lifted until tension is felt to accumulate. Adduction
of the leg will help the build-up of tension.
Tips: Most useful in patients who are fairly tight as
14.11 • Thrust sacro-iliac anteriorly prone Pres- tension will accumulate more easily. Least useful
sure is applied to the posterior superior iliac spine where there is any hip dysfunction or where exten-
of the opposite ilium in the direction of the joint. The sion of the lumbar spine is going to be a problem.
other hand lifts the thigh into extension and some Extra considerations: If the operator is small, the
adduction of the hip until tension accumulates at position may be difficult, as the leg-lifting hand is
the sacro-iliac. Varied rotation of the hip will aid the drawing the operator toward the feet of the patient,
build-up of tension. The thrust is applied with the and thus reducing the force available at the sacro-
hand on the ilium, not the lifting hand. iliac. Use of a pillow under the abdomen can be
Tips: Most useful in chronic cases where fixation useful to avoid hyperextension of the lumbar spine.
is liable to be more crisp and, therefore, more easy
to release. Least useful in acute cases where lying 14.13 ..,.. ThrusUarticulation sacro-iliac anteriorly
prone may be a problem or where the patient is supine The patient has firmly clasped the other
very heavy, making lifting of the leg a problem. thigh into flexion to lock the lumbar spine. The
Extra considerations: Keep the pelvis firmly operator has fixed the patient's leg between his
applied to the table as otherwise hyperextension thighs and is assisting the patient in holding the
of the lumbar spine can occur. A pillow under other leg in flexion. He applies a downward force to
the abdomen may assist patient comfort. Different the knee so that the sacro-iliac is torsioned forward
phases of breathing will often assist in accumulation on the sacrum. If tension is sufficient, a thrust can
of optimum tension. be applied toward the table.
Tips: Most useful in young and fairly fit patients
as the position can be rather extreme. The position
of extreme flexion of the other hip puts the lumbar
spine in a flexed position which can help to obliterate
movement which may be useful. Least useful if there
is any hip disorder. Extra considerations: A useful
fulcrum can be made if the patient is capable of
lying with the sacrum on the edge of the table. This
position is also a differential test of lumbar and
sacro-iliac dysfunction. If pain is reproduced in this
position, as the lumbar spine is not involved in the
movement, it can be reasonably assumed that the
sacro-iliac is the source of the symptoms. If pain
gets much worse as the patient releases the other
knee, there is a good chance that it is movement of
the lumbar spine which is implicated in the pain
syndrome.
100 Techniques for the sacro-iliac area
14.14 .,.. ThrusVarticulation sacro-iliac anteriorly
sidelying This position is fundamentally the same
as photograph 14.13 except that the leg has been
flexed at the knee. The movement is now much
stronger as the quadriceps is put on tension earlier.
Tips: Varying the flexion of the knee can focus
the tension more efficiently. Extra considerations:
The same implications of the testing nature of this
position apply as for photograph 13.15.

14.15 ..,.. Thrust using leg tug sacro-iliac anter-

iorly supine The hand hold is shown before being
applied to the foot. Note that one hand is supinated
and the other pronated. The thumb of the pronated
hand is interposed between the third and fourth
fingers of the other hand. This has the advantage
that as the operator leans back, without actively
gripping, the hold becomes tighter automatically.
Tips: Experimentation will reveal which is the
most comfortable way to interlock the hands.

14.16 ..,.. Thrust anteriorly sacro-iliac using leg

tug supine The hold shown in photograph 14.15 is
applied and the lower extremity is taken into some
flexion to clear the other leg as adduction is applied.
Apply adduction and internal rotation of the hip until
the fascia lata and hip capsule, respectively, are on
tension. A preliminary traction force is used until
tension is felt to accumulate in the sacro-iliac and
then without releasing the tension a sharp longitudi-
nal tug completes the thrust.
Tips: Least useful where there is any knee or hip
dysfunction or in very lax subjects where the force
will be dissipated. Extra considerations: Greater
efficiency is sometimes achieved if the patient is
asked to hold their breath or to cough coincident
with the thrust. Try bracing the patient's other leg
on the table against the operator's thigh.
 Techniques for the sacro-iliac area 101

14.17 _. Harmonic technique for sacro-iliac This technique shows longitudinal harmonic technique to
the pelvis and particularly the sacro-iliac.
Tips: Refer to earlier section relating to harmonic technique.

14.18 _. Thrust sacro-iliac anteriorly prone Operator focuses forces applied to posterior superior iliac
spine along the plane of the joint and fixes pelvis to the table. Patient performs a one-handed push up and
as tension accumulates at the joint, operator applies a very short amplitude thrust.
Tips: Most useful in very mobile subjects where the use of active muscle contraction in the patient helps
reduce spinal mobility. Extra considerations: Try adjusting initial sidebending to find the optimum tension.
102 Techniques for the sacro-iliac area

14.19 .A. Thrust to sacro-iliac anteriorly sidelying 14.20 .A. Thrust to sacro-iliac anteriorly sidelying
This is a modified lumbar roll position. The cephalic shown on skeleton This photograph may clarify
hand of the operator is pushing towards himself on the hand position of photograph 14.19.
the posterior superior iliac spine of the ilium on the
table. The other hand is applying a rotary force on
the pelvis so that the lower sacro-iliac is gapped.
Firm compression with both hands is necessary to
focus the forces at the target joint. Excessive
rotation of the spine must be avoided.
Tips: Most useful where there is a disc syndrome
making rotation to the other side difficult. Least
useful in very large subjects where it may not be
possible to achieve sufficient compressive force.
Extra considerations: With compression main-
tained, roll the pelvis forward and backward to find
the optimum barrier sense.

14.21 ..,. Thrust to sacro-iliac anteriorly sitting

The operator's knee pushes firmly forwards against
the posterior superior iliac spine. The patient is
flexed slightly and rotated down until tension
accumulates at the operator's knee. The thrust is a
combination of a slight increase of rotation of the
patient's body and a forward movement of the
knee against the ilium.
Tips: This is a very long lever technique and
rarely used; however, there may be some cases
where it can be a method of choice, particularly
those where it is desired to have the spine vertical,
thereby slightly driving the sacrum down between
the ilia.
 Techniques for the sacro-iliac area 103

14.22 .& Thrust to sacro-iliac anteriorly part 14.23 .& Thrust sacro-iliac anteriorly part stand-
standing Patient lies across the table keeping the ing The patient lies across the table which has
other foot on the floor. The operator applies the been lifted to the height of the patient's pelvis. She
heel of his thrusting hand to the posterior superior flexes her knees slightly so that the anterior
iliac spine and his knee in the popliteal space of the superior iliac spines support her weight. Pressure is
l:exed knee. He pushes down with his knee while applied along the plane of the joint with one hand
pulling up with the hand holding the ankle until and the other stabilizes the sacrum. The thrust is
tension accumulates at the sacro-iliac. The thrust is applied forwards on the posterior superior iliac
mostly a force with his hand but the knee and other spine to break fixation of the sacro-iliac furthest
hand assist slightly. from the operator.
Tips: This will be a rarely used manoeuvre but Tips: Most useful where it is necessary to avoid
was taught by Andrew Taylor Still. Most useful torsion of the lumbar spine. Least useful where the
where lumbar torsion is to be avoided. Least use- patient is elderly and the position may be difficult to
ful where there is any knee dysfunction. Extra attain. Extra considerations: The sacrum-stabilizing
considerations: The barrier sense will accumulate hand can hold the bone in a variety of directions. It
more easily, in most cases, if the patient holds the will be necessary to experiment to find the optimum
breath for the thrust. direction which focuses the forces at the sacro-iliac.
It will usually be easier to accumulate tension if the
patient holds the breath for the thrust.
104 Techniques for the sacro-iliac area

14.24 • Thrust sacro-iliac posteriorly supine

This photograph shows the hand hold and patient
positioning for this technique. The palm of the
cephalic hand will be applied with the anterior
superior iliac spine. The other hand will be placed
under the ischial tuberosity and the flexed knee and
hip are positioned across the operator's abdomen.
 Techniques for the sacro-iliac area 105
14.25 <1111 (see facing page, top right) Thrust/
articulation sacro-iliac posteriorly supine The
hold shown in the previous photograph is applied
and the operator is pushing the thigh into abduc-
tion with his elbow. The thrust is performed as a
combination of pushing back with one hand,
pulling up with the other and a bending of the knees
to further abduct and flex the hip. This will drive the
ilium back on the sacrum.
Tips: Most useful in patients with a fairly rigid
lumbar spine where the force will focus more easily
in the sacro-iliac. Least useful in the presence of
any hip dysfunction. Extra considerations: Barrier
sense may accumulate more easily if the patient
holds the breath at the time of the thrust.

14.26 <1111 (see facing page) Thrust position sacro-

iliac posteriorly supine The patient is positioned
into sufficient initial sidebending so that when the
operator applies the other components, the side-
bending may reduce, but will not be completely lost.
14.28 _. Thrust sacro-iliac posteriorly sitting The
14.27 <1111 (see facing page) Thrust sacro-iliac patient has folded her arms and the operator has
posteriorly supine The so-called 'Chicago' tech- rotated her whole torso down to the sacrum. He
nique has been applied with the operator's cephalic holds back on the ilium with index finger and
hand maintaining sidebending and producing a thumb. He applies a rotary force away from the
rotation of the patient's torso towards him. His other ilium with the other hand and as tension accumu-
hand holds the ilium against the table, and as tension lates he thrusts backwards on the ilium. Side-
accumulates in the sacro-iliac a short amplitude bending toward the thrust side is maintained at all
thrust is applied to the anterior superior iliac spine. times to help focus the forces as otherwise they will
Tips: Initial positioning of the patient is critical dissipate through the lumbar spine.
with this technique. The sidebending must not be Tips: Most useful in tight subjects who have no
lost or the force will dissipate higher in the spine. major spinal dysfunction. Least useful in very tall
The direction of force applied to the ilium will subjects where it will be difficult to control the
govern whether the technique focuses at the sacro- levers. Extra considerations: It may sometimes
iliac or the lumbo-sacral. If the thrust is applied with aid the technique if the patient sits astride the table.
the cephalic hand, it will tend to focus forces on the
thoraco-lumbar junction. It may be necessary to
experiment to find the optimum. Most operators
find that tension accumulates best if the patient's
leg on the operator's side is crossed over the other
one, but sometimes the opposite is true.
Tips: Least useful for small operators working on
large patients where it may be impossible to reach
sufficiently well to accumulate the correct tension.
106 Techniques for the sacro-iliac area
14.29 ..,.. Thrust/articulation sacro-iliac poster-
iorly prone The operator has abducted and flexed
the patient's hip and knee and the tibia is resting on
his own flexed thighs. He fixes the whole lower
extremity between his forearm and abdomen and
cups the anterior superior iliac spine in the palm of
his thrusting hand. The wrist of his other hand has
applied pressure behind the ischial tuberosity and
the two hands together pull the ilium back-
wards. The thrust is applied with a combination of
operator's hands and body.
Tips: Least useful where the patient may find
prone lying a problem. Extra considerations: It is
important to hold the ilium and pelvis against the
table as abduction is applied to the hip, as other-
wise rotation occurs into the lumbar spine and the
force will not accumulate at the sacro-iliac.

14.30 • Thrust sacro-iliac posteriorly sidelying

This is a modified lumbar roll position. The operator
has applied only a small amount of rotation to the
thorax and lumbar spine but has substituted 14.31 • Thrust to sacrum prone This shows a
compression toward the table, through the shoulder. recoil technique where the operator has applied a
The thrusting forearm is placed behind the ilium slight compressive force to the sacrum toward the
and the elbow pushes the ischial tuberosity to- table and then squeezes the sacrum between both
wards himself to rotate the ilium backwards. The hands to slightly buckle it. The technique is
thrust is applied with a compression force from the performed with the release of tension allowing the
operator's body at the same time as an adduction natural recoil of the bone to act as the mobilizing
and external rotation of his arm applied to the ilium. force. This may need to be repeated two or three
Tips: Excessive rotation of the lumbar spine will times.
dissipate the force up to the thoraco-lumbar Tips: Most useful where despite ilia-sacral gap-
junction; hence the use of compression. A gentle ping, some dysfunction remains which may be due
oscillatory rolling of the whole patient will enhance to intra-sacral distortion. Extra considerations: It
the ability to find the optimum thrust plane. Least may be found that compressing the sacrum more
useful in very flexible subjects where the thrust will on one side than the other will produce a more
merely produce lumbar flexion. specific result.
 Techniques for the sacro-iliac area 107
14.32 ..,.. Thrust to sacrum sidelying This is a
modified lumbar roll position. The operator has
applied compression to the pelvis and the thorax to
reduce the range of rotation necessary to reach the
sacrum. The thrust is a combination of an increased
compressive force on the ilium with the operator's
chest at the same time as the heel of his hand
drives the sacrum forwards.
Tips: Most useful where torsion of the sacrum
rather than the ilium is the prime element in the
dysfunction. Least useful in very flexible or very
large subjects. Extra considerations: The direc-
tion of the sacral thrust can vary according to the
optimum sense of barrier accumulation.

14.33 • Thrust to symphysis pubis supine This 14.34 • Muscle energy technique symphysis
is a combined technique where the operator holds pubis supine See earlier section on principles of
the patient's knees apart as she attempts to draw muscle energy technique.
them together. The patient does not use full power Tips: Vary the angle of hip flexion and knee
but allows him to gradually work the knees further flexion to achieve the optimum. This hold only
apart until tension accumulates at the joint. He allows an isometric muscle energy technique as the
applies a short amplitude thrust into abduction of patient presses against the operator's flexed hand
the thighs while the patient maintains muscle tone. and elbow between the knees.
Tips: Vary the range of hip flexion and knee
flexion to find the optimum. Ensure the amplitude
of the thrust is very short. Least useful when the
patient is very strong and the operator is small.
TECHNIQUES FOR THE GLUTEAL 15
REGION AND COCCYX

As the glutei are such strong muscles and are taken with the treatment here so that no
in close proximity to the sciatic nerve they accusations of improper handling can occur.
may play an important role in production and Informing the patient of the purpose or a
maintenance of sciatic pain syndromes. Hyper- particular procedure should eliminate this
tonic glutei can affect posture and prevent problem.
normal mechanical relationship of the hips to The coccyx is commonly a site of pain
the rest of the body. There may be a tendency although many cases are due to referred pain
for the hips to rotate outwards and thus upset from the lumbar spine. It is, however, possible
locomotion, sitting and standing postures. to have a dysfunctional junction between the
Lumbar origin pain syndromes will often sacrum and the coccyx. There are techniques
present as tense painful areas in the glutei, that approach the joint through the rectum,
piriformis and gamelli, and work on these can but external techniques are generally pre-
be helpful in treatment of such cases. ferred by patients and operators alike!
Particular caution is rarely necessary in Particular precautions include the possibility
working on the glutei except that a Ewing's of fracture if there has been direct trauma,
tumour in the bone or the ilium itself can and rare cases of referred pain from the
present as gluteal pain. Due to the sensitive rectum in the presence of a space-occupying
nature of the area, particular care needs to be lesion.
 Techniques for the gluteal region and coccyx 109

15.1 .&. Kneading prone Use your thumb to apply 15.2 .&. Kneading prone Apply a kneading force
cross-fibre kneading to the ischial tuberosity and to the glutei, gamelli and piriformis on the opposite
lower part of gluteus maximus. The other hand side of the patient. The other hand monitors the
applies a counter-force, partly to limit the forces to stretch produced, and spreads the effect of the
a specific part of the muscles, and partly to reduce hold to reduce any discomfort.
the discomfort of direct pressure. Tips: Least useful where prone lying may be a
Tips: Most useful in cases of ischial tuberosity problem. Exquisite tender areas will often be found
bursitis, muscle strains and residual sciatica. Least in the glutei in lumbar dysfunction syndromes, and
useful where prone lying might be a problem. Extra although these are often due to referred pain, they
considerations: The pillow under the abdomen is can be maintaining factors. Recovery can be
for patient comfort. Try using varied degrees of enhanced if these muscles are relaxed to allow
abduction in the thigh, or a pillow under the tibia to freer pelvic movement. Extra considerations: The
flex the knee and reduce stretch on the posterior pillow under the abdomen will usually aid patient
thigh muscles. comfort. Try abducting the leg by varied amounts
to find the optimum.
110 Techniques for the gluteal region and coccyx
15.3 Kneading prone Work on the lower part
<111111

of the glutei and the piriformis while holding back

on the belly of the muscle with the other hand, to
localize the force. The lateral muscles of the thigh
can also be addressed in this position.
Tips: Most useful in cases of residual sciatica
where there is a muscular component as a main-
taining factor. Least useful where prone lying may
be a problem. Extra considerations: The pillow
under the abdomen will usually aid patient comfort.
Try varying the abduction of the thigh to find the
optimum for the technique.

15.4 'f Inhibition prone Apply a direct pressure

over the piriformis with your thumb. Maintain a
steady pressure and internally rotate the hip until
tension is felt. Inhibition implies a steady pressure,
usually while a lever is applied, and a finite time
must elapse until a sense of release is attained.
Tips: Most useful in cases of persistent piriformis
tension as in some sciaticas. Least useful where
prone lying is a problem. Extra considerations:
Try varying the hip abduction in the
initial set-up for the technique. This
may be a very uncomfortable pro-
cedure, but within about 10-15
seconds the muscle will be felt to
relax, often accompanied by an
immediate relief of symptoms.

15.5 Inhibition prone Carefully

<111111

apply the tip of your elbow to the

piriformis while maintaining the in-
ternal rotation of the hip with the
other hand applied to the ankle.
Tips: Most useful in cases of
severe, long-term spasm of pirifor-
mis. It is also the method of choice
when the operator's thumbs are not
strong enough. Least useful where
prone lying may be a problem. Extra
considerations: The pillow under the
abdomen is to increase patient com-
fort. This is clearly a powerful tech-
nique, and needs sympathetic care in
handling to avoid excessive pain;
however, it can be extremely useful.
 Techniques for the gluteal region and coccyx 111

15.7 A Articulation of sacro-coccygeal joint prone

Abduct and internally rotate the hip carefully, as
this is potentially a very strong hold. Hold back on
the coccyx with your thumb. The technique can be
performed as a force with either hand, or both
simultaneously.
Tips: Least useful where prone lying is a
problem. Extra considerations: Try asking the
patient to temporarily hold the breath to assist in
firming up the pelvic floor.
15.6 A Inhibition prone Apply a double thumb
pressure to the piriformis with the pads of the
thumbs overlaid. This has the advantage over the
elbow hold of being a little more gentle, yet very
specific.
Tips: Most useful in cases of sciatic nerve
irritation where the piriformis is involved, and
inhibition alone is required, without stretch. The
previous holds for working on piriformis use some
longitudinal stretch. Least useful where prone lying
is a problem.

15.8 ..,.. Articulation of sacro-coccygeal joint prone

Internally rotate the hip with varied degrees of knee
flexion as suitable for the case. Hold back on the
coccyx with the other thumb. The technique is
performed with either a pressure on the coccyx, a
circumduction of the leg, or both simultaneously.
Tips: Least useful where prone lying is a prob-
lem. This hold is more suitable than the one in
photograph 15.7 if a gentler procedure is required
as it avoids stressing the hip.
112 Techniques for the gluteal region and coccyx

15.10 .A. Articulation of sacro-coccygeal joint

prone Hold the coccyx toward yourself while
internally rotating the opposite leg.
Tips: Most useful where one hip has a dysfunction
15.9 .A. Articulation of sacro-coccygeal joint prone making it unusable as a lever, so the contralateral
Spring alternately on the sacrum and the coccyx. side is used. Least useful where prone lying may be a
Different lateral pressures can be introduced if problem or where the reach may be too great for a
required to find the optimum barrier for the small operator. Extra considerations: Try using
articulation. varied degrees of hip abduction to amplify the
Tips: Most useful where it is desired to avoid technique.
using the hip as a lever. Least useful where the
prone lying position may be a problem. Extra
considerations: To make the technique more
effective try using patient breath-holding to drive
the pelvic floor down and firm up the area.
TECHNIQUES FOR THE THORACO- 16
LUMBAR JUNCTION AREA

When referring to the thoraco-lumbar region static deposits from these sites must always
we are encompassing the area from about the be considered in history, examination and
tenth thoracic to the second lumbar vertebrae, diagnosis.
not just the twelfth thoracic to first lumbar Excessive torsion of this area in treatment
articulations. The term refers to an area rather can produce nausea. Poor application of tech-
than a specific segment. nique and excessive leverage into rotation can
Like all the junctional areas of the spine, lead to sacro-iliac joint strain. Careful con-
there are differences from adjacent areas. As sideration of appropriate modifying factors,
the curves are changing and the stability of and greater use of compression rather than
one area meets the relative mobility of the rotation can help to avoid this problem.
other, difficulties occur. From a technique Techniques for the area can be difficult in
and treatment viewpoint the presence of the extremely mobile young subjects, as it is not
autonomic outflow to the coeliac plexus, and easy to isolate the area, but high force should
the diaphragmatic attachments, further com- not be used instead of skill.
plicate this area. Osteochondrosis is extremely The area can be considered as part of the
common and often causes the characteristic lumbar spine, the thoracic spine, or an area in
flexion deformity, premature arthrosis, and its own right. It should be possible to employ
stiffening which make the application and techniques that reach the area without ex-
choice of technique difficult. As the prostate cessive force, but owing to the length of the
and uterus drain through their veins into levers necessary, suitable protection of adjac-
this area, the possibility of secondary meta- ent areas is important.
114 Techniques for the thoraco-lumbar junction area

16.2 _. Articulation prone Stand below the

patient's pelvis and pull up against the anterior
superior iliac spine. Fix with the other hand over the
transverse processes at the thoraco-lumbar area. If
a suitable barrier accumulates, this can be made
into a rotation and extension thrust although to
avoid pain the amplitude must be kept very small.
Tips: Try placing the patient in some sidebend-
ing first which will have the effect of making the
technique reach the deeper or more superficial
tissues according to the direction of the sidebend-
ing. Try asking the patient to turn her head to one
16.1 _. Articulation into sidebending sitting The
side or the other. Try having her arms by her sides,
patient sits across the table at one end with one
under her shoulders, under her forehead or over the
arm over the operator's shoulder. Apply a side-
sides of the table. Each change will make a
bending force by pulling with one hand while giving
difference to the technique. Try applying the
a counter-force with the other. Rock from your front
technique at varied phases of breathing.
to your back foot to produce the desired move-
ment.
Tips: Control of the compression through the
fixing hand on the patient's shoulder is critical in
this hold. Note that the patient's head remains over
her pelvis. The spine is being buckled specifically at
the thoraco-lumbar area.

16.3 ..,.. Articulation prone Lift the thigh just above

the knee of the prone patient. Fix with the other
hand over the transverse processes of the thoraco-
lumbar area. Adduct the thigh and extend it. Force
will be transmitted through to the upper lumbar
area. The pull on psoas is very powerful and in
most subjects it will direct forces to the area
without excessively stressing the lumbar area.
Tips: Least useful in very heavy subjects where
lifting the leg would be a problem. Most useful
where strong articulation is necessary.
 Techniques for the thoraco-lumbar junction area 115
16.4 ~ Thrust prone The patient lies prone in a
'sphinx' position. Clasp her ankles between thumb
and index finger and index and middle finger of the
pronated hand. Apply the other hand over the
spinal level desired and initiate a rocking motion of
the patient from end to end of the table. As you are
rocking, increase the traction force with both hands
until tension is felt to accumulate under the spinal
hand. Apply a small thrust against the spinous
process into extension, or against a transverse
process into rotation.
Tips: Try asking the patient to stagger her
elbows slightly which will introduce a preliminary
sidebending or rotation to the area. It may be
necessary to have the patient drop her feet over the
end of the table if they are uncomfortable. Try using
varied phases of respiration to find the optimum
barrier.

16.5 .A. Thrust sidelying The patient is placed 16.6 .A. Thrust sidelying The patient is sidelying
sidelying with her lower arm behind the thorax. in a classical lumbar roll position. Apply the levers
Push backwards against the anterior aspect of the in the usual way for the thrust with some small
pelvis to stabilize it. Push the spine backwards variations. Use a substantial element of compres-
from below to introduce rotation. Pull forward sion through the pelvis toward the table. Use a
against the transverse processes of the vertebrae compressive force through the shoulder toward the
above with the other hand and use the forearm to table and slightly toward the patient's head. The
stabilize the scapula. Rock the whole patient into a thrusting hand is pushing into compression against
small amplitude of rotation to find the optimum the lamina of the vertebral segment desired. As the
point of tension and then apply the thrust with the forces accumulate, the thrust is applied with the
upper hand while maintaining the lever position lower hand pulling the vertebra and the pelvis
with the lower. toward you as a unit. This ensures that the force is
Tips: This technique requires quite firm com- not dissipated in rotation of the lumbar spine. This
pression with both hands into the table as well as is primarily a compression thrust with a small local
into rotation. It is critical not to release the fixation rotary force at the contact point at the moment of
produced by the lower hand at the moment of the full compression.
thrust as the focus is liable to be lost. Try varied
phases of breathing.
TECHNIQUES FOR THE THORACIC 17
SPINE

The term 'thoracic' will be used in preference The autonomic chain is very close to the
to the term dorsal, which has now been largely thoracic spine and this means that applying
superseded. If the reader is accustomed to any physical therapy can produce undesired
'dorsal', he will need to make a mental trans- or unexpected autonomic changes in the body.
lation at each reference. The thoracic spinal These may include sweating, sense of cold-
area is more accessible than the lumbar in ness, fatigue, yawning and breathing and
that the embryological curve is maintained. digestive changes. While adverse reactions of
The facet joints are liable to be involved in this sort are usually temporary, and not too
mechanical dysfunction syndromes as they alarming, it is best to be aware of this
are in apposition during normal posture, not possibility so that the practitioner can advise
just in flexion of the spine. Despite the the patient accordingly.
torsional nature of movement in the thoracic Prognostic factors for a poor result include
area, disc lesions are much less common than the patient with very 'stringy' muscle tissue
in the other areas. However, when they do in the area. This awareness can allow the
occur, they produce equally serious problems. practitioner to be more accurate in prognosis
The flexible nature of the thoracic area in early on in a treatment series. 'Stringy'
rotation means that it is often necessary to muscle has undergone some partial fibrotic
use a large element of 'contra-rotation' to changes, which are by their very nature only
produce locking in manipulative technique. partly reversible. This is not uncommon in
This in itself, if excessive or poorly controlled, the thoracic area and it should direct treat-
will be painful and result in over-locking. ment to the cause of the dysfunction, rather
There can be a tendency to apply more than just the painful area.
leverage when suitable resistance is difficult to It is often useful to consider phases of
feel, which leads to even more discomfort. breathing when performing technique in the
Special precautions for the area must thoracic area. Most thrust technique is easier
include the possibility of bony weakness such if performed as the patient exhales. There are
as osteoporosis and secondary deposits. times when this is not the case. If it is
There is potential for damage in cases of necessary to stabilize a very mobile subject,
advanced osteoarthrosis with ligamentous asking them to hold the breath may be of
stiffening, particularly if excessive force is more help. Experimentation is necessary to
used. find the best method for each patient.
 Techniques for the thoracic spine 117
17.1 .,.. Harmonic technique prone Use your
upper hand to fix or focus the harmonic rocking
of the pelvis induced by your lower hand. The
amplitude of the harmonic movement will increase
depending how far up the thoracic spine you fix as
the lever lengthens. See earlier section relating to
harmonic technique.
Tips: Although this is a therapeutic procedure, it
performs a useful diagnostic test that will rapidly
find areas of diminished flexibility.

17.3 T Articulation in sidebending and exten-

sion sitting The patient rests her folded arms on
the operator's shoulder and upper arm and he is
reaching around to clasp the paravertebral regions
on each side. Rock into sidebending and, therefore,
induce sidebending in the patient. Pull your hands
toward yourself against the fulcrum of the shoulder
and induce extension into the patient's spine.
Tips: Try adding rotation to either side before or
after the other movements to help focus them.
Extra considerations: Fix the patient's knees,
padded if necessary, against you.

17.2 .,.. Articulation into rotation sitting Fix against

the spinous process at a chosen level and rotate
the rest of the body back against this level by
pulling the shoulder backwards. The natural recoil
of the body will take it forward again so that you
can move up or down to the next segment and
repeat the exercise.
Tips: This can be a diagnostic exercise or a mild
therapeutic technique.
118 Techniques for the thoracic spine

17.4 • Articulation into sidebending sitting Sit

or stand close to the patient's side and hook your
abducted arm over her shoulder. Apply your thumb
or thenar eminence against the spinous process
and buckle the body into sidebending while using
your thumb as a fulcrum.
Tips: Most useful in fairly stiff subjects where only
small movement is required. Extra considerations:
Try using circumduction movement of the upper
body around the thumb to induce other ranges of
movement.

17.5 • (top right) Articulation into sidebending

sitting The patient sits with hands clasped behind
the neck. Clasp the far shoulder of the patient. Hold
her near shoulder firmly against your chest and
keeping her head directly above her pelvis, buckle
the spine over your thumb or thenar eminence
applied to a spinous process. Firm compression of
the patient against the operator is necessary and the
movement comes from a slight flexing of the knees.
Tips: Try adding other ranges of movement to
the sidebending to help focus it. Try circumduction.

17.6 ~ Articulation into sidebending sitting The

patient sits with folded arms. Lift the further elbow
while pressing down on the near shoulder with your
axilla. Buckle the spine around your thumb or thenar
eminence applied to the near side of a spinous
process. It is necessary to have firm compression of
the patient into the operator and the sidebending
movement occurs as you flex your knees.
Tips: Most useful where it would be difficult for
the patient to clasp hands behind the neck.
 Techniques for the thoracic spine 119
17.7 <1111 Articulation into rotation sitting The
patient folds her arms and the operator reaches
either across the folded arms, or through them, to
clasp the further shoulder. Compress the patient
into your chest and apply a thumb or thenar
eminence to one or more spinous processes.
Induce a small amount of sidebending away from
yourself and rotate the patient's and your body
together to focus the force at the contact point.
Tips: Try circumduction instead of simple rotation
to address different parts of the dysfunction.

17.8 T (bottom left) Articulation into rotation

sitting The patient clasps her hands behind the
neck. Reach around to clasp her far shoulder and
apply your thumb or thenar eminence to one or more
spinous processes. Compress the patient into your-
self and induce rotation down to your applied thumb
by twisting your body and the patient's as a unit.
Tips: The thumb applied to the spinous process
can be on the nearside to push further rotation or
on the far side to block rotation below that point.
Extra considerations: If the patient is very flexible,
an astride sitting position may be more efficient as
it limits thoraco-lumbar mobility with the legs
abducted in this way.

17.9 T Articulation into extension upper thoracic

area sitting The patient folds her arms and rests
them on the operator's upper chest. Thread your
forearms through her folded arms and using your
hands as a fulcrum lever the spine into extension.
Tips: Try making this into a circumduction
movement. Brace the operator's thighs against the
patient's knees- padded, if necessary.
120 Techniques for the thoracic spine

17.1 0 £. Articulation into flexion sitting The 17.11 £. Traction and sidebending articulation
patient folds her arms and drops her head forward sitting The operator threads his arms under the
onto the operator's chest. Fix the top of her head patient's arms. Lift under the patient's mastoid pro-
with your chin and apply a lateral compression force, cesses with the heels of your hands. The lift also takes
to the thorax, through your wrists and forearms. Pull place through the axillae. Lean the patient against
up under the angles of a chosen pair of ribs while your chest and while maintaining the lift, introduce
bending your knees to induce a localized flexion. circumduction to reach the mid thoracic area.
Tips: Try inducing some sidebending movement Tips: Most useful in smaller patients and children
or circumduction. Fix the patient's knees against as the lift can prove hard work if applied to larger
the operator's thighs, if necessary. adults.
 Techniques for the thoracic spine 121
17.14 ..,.. Articulation into extension prone The
patient lies prone with her arms folded under the
forehead. Lift the folded arms, head and thoracic
spine into extension while counter-fixing with your
other hand.
Tips: Least useful where the patient is very large as
considerable effort would be required to perform this
technique. Extra considerations: Try introducing
sidebending or rotation to help focus the forces.

17.12 ..,.. (see facing page, bottom left) Articulation

into rotation prone The patient lies prone with her
arms folded under the forehead. Fix a thoracic
spinous process toward yourself and with your
other hand under the patient's folded arms intro-
duce rotation down to the fixing hand. Note that the
patient is not being lifted as the operator's upper
hand acts as a fulcrum and rests on the table.
Tips: Most useful where it is desired to limit
rotation down to a specific segment as the thumb
will act as a block to movement below this point.
Extra considerations: Try adding different com-
bined forces of sidebending or extension to the
rotation.
17.15 • Springing prone Apply a classical 'push
17.13 ..,.. (see facing page, bottom right) Articu- and pull' technique by bracing several spinous
lation into extension prone The patient lies prone processes with the heel of one hand to rotate them
with her arms folded under the forehead. Lift the away from yourself. Brace several adjacent ones
folded arms, head and thoracic spine into exten- above to produce a rotation force between the
sion while counter-fixing with your other hand. hands. Naturally, the technique can be used with
Tips: Least useful where the patient is very large as the hands reversed .
considerable effort would be required to perform this Tips: Try fixing with one hand and mobilizing
technique. Extra considerations: Try introducing with the other and vary the patient's head rotation
sidebending or rotation to help focus the forces. to find the optimum.
122 Techniques for the thoracic spine
17.16 <IIIII Articulation into rotation prone The
operator is working specifically on one segment,
taking hold of it as if it were a wing nut. Push toward
the table to absorb the spring. Apply the thumb and
index finger on opposite sides of adjacent spinous
processes. They introduce the rotary force as you
pronate your forearm.
Tips: Least useful where the spine is very tender.
The force needed to make this technique effective
would be too great in cases of severe restriction.

17.17 T (bottom left) Springing postero-anterior

prone The patient is lying prone, in this case with
her hands folded under her head. Stand at the head
of the table and use the pads of your thumbs to
spring the chosen level directly anteriorly. Press
with the thumbs over the laminae of the vertebrae,
not the spinous processes as they can tend to be
sensitive.
Tips: Most useful where specific segmental dys-
function is present. Extra considerations: Try spring-
ing on one side only, or staggering the thumbs to
work on adjacent segments. Try having the patient's
arms by her side or over the edge of the table.

17.18 T Thrust starting position supine The

patient grasps opposite shoulders without crossing
her forearms. The operator has rolled the patient
toward himself and is sliding his hand under the
spine. He is using a flat hand, but can apply a variety
of possible holds to the target segment. Note that the
patient's head is left on the pillow and that she is only
rolled far enough to allow the hand to be slipped
underneath. This has become known as the dog
technique after Fryette saw this being done badly
and commented, 'I wouldn't do that to a dog!' If he
had seen it done well, he would not have made that
comment, but the name has stuck since then!
 Techniques for the thoracic spine 123

17.19 .& Thrust to mid thoracic spine supine

The hold shown in photograph 17.18 is adopted
and the patient is rolled over onto the hand. Test for
free play in the primary lever direction of traction.
Focus all other components of flexion, rotation
away from yourself, sidebending toward yourself
and slight compression and sideshifting away. If
this seems excessively complex, you should simply
concentrate on bringing your elbows in toward your 17.20 .& Thrust to mid thoracic spine supine The
sides; this will automatically produce the correct patient is only crossing one arm over her chest. The
components. The underneath hand performs a small operator is using a pad between his chest and the
pronation and traction toward the pelvis to help
patient's elbow. His upper hand is applied to the
tighten up the levers. At the point of barrier accumu-
pad to direct the force more accurately. It is usually
lation, emphasize the pronation of the lower hand
and apply the thrust through your upper hand and possible to reach from about the third to the tenth
chest into traction pushing her elbows toward her thoracic level with this hold.
shoulders. It is usually possible to reach from about Tips: Most useful for the patient with a shoulder
the third to the tenth thoracic vertebra with this hold. dysfunction as the painful shoulder can be left out
Tips: This is not a flexion thrust. It is not a com- of the hold. All other factors are as the details in
pression thrust. The use of all the secondary levers is photograph 17.19.
designed purely to help minimize the amplitude of the
primary lever of traction. Extra considerations: Many
varieties of hand hold underneath are possible. A flat
hand pronated slightly is most comfortable for the
patient. The hand can be applied with the fingers
loosely clasped. It can be applied using a fist so that
the spinous processes fit into the space between
flexed fingers and thenar eminence. The underneath
hand is as much a part of the technique as the upper
hand. If the hold causes pain to the operator in the
lower hand, try pushing the hand firmly into the thor-
acic spine, rather than simply resting it on the table.
Leave a small space between the back of the hand
and the table so that the wrist is as much part of the
fulcrum as the hand. Try using varied quantities of
patient head rotation to help focus the technique.
Generally rotation away from the operator will tighten
the levers.
124 Techniques for the thoracic spine
17.21 <Ill( Thrust mid thoracic area supine The
patient clasps her hands behind her neck. Lift her
upper body with your upper hand and slip your
lower hand under the patient to apply it to the
target vertebra. Flex the patient down to the
segment and while holding her steady, apply a
thrust with your thorax to the patient's elbows. In
this variation of the basic technique it is difficult to
reach much above the fifth thoracic level in most
subjects.
Tips: This is a mobile technique and it is not
usually possible to stay in the thrust position for
more than a few moments. It is much more difficult
to use varied secondary levers with this hold and it
tends to become a flexion and compression thrust.
As the secondary levers are not used to any great
extent, this can become a rather forceful variation.
It is more difficult to be specific with this technique
and, therefore, it can become a technique for
gapping several facets at once. This means that a
restricted segment in the midst of a mobile area
may not be mobilized effectively.

17.22 and 17.23 _. Thrust upper thoracic area supine The patient clasps her hands behind her neck.
The operator makes a loose fist and slips it under the patient to fit the spinous processes into the palm.
Flex the patient's elbows and apply all the usual components. The thrust is performed into traction and
some compression when the levers have focused.
Tips: Most useful for upper thoracic area from second to fifth levels.
 Techniques for the thoracic spine 125

17.24 and 17.25 • Thrust mid thoracic supine

single arm lever The operator is using one or
other arm of the patient, crossed over the chest. It
is perfectly possible to make the technique work
with one arm only, but this will be a little more
difficult. All the usual components are available
although more compression will probably be re-
quired.
Tips: Most useful in cases where any problem
with one shoulder or the other makes the normal
hold impossible.

17.26 and 17.27 ~ Thrust mid thoracic area

from same side The patient crosses her chest
with her arms in the usual way avoiding crossing
the forearms. Roll the patient away from you to
slide your hand under the spine from the nearside.
Roll the patient onto your hand and apply your
forearm to her folded arms. (Note that the com-
pleted hold is shown from the other side for clarity.)
Test for free play in the primary lever direction of
traction while adding the secondary components to
bring the target joint to the optimum thrust focus.
Tips: Most useful in very large subjects where it
may be impossible to reach all the way around.
This hold can also be used for costo-vertebral and
costo-transverse joints. It is also a useful method
when an operator, for any reason, finds use of one
particular hand a problem, as it means that the
same hand can be used from both sides, whereas
with t he conventional hold he would need to
change hands to reach the other side.
126 Techniques for the thoracic spine

17.29 • Thrust mid thoracic area sidelying The

17.28 • Thrust using crossed hands mid thora- operator is using his lower arm to stabilize
cic area prone The patient lies prone with her the pelvis in this modified lumbar roll position. The
arms over the sides of the table to spread the upper, or fixing, hand is maintaining a downward
scapulae. Apply your crossed hands to opposite pressure to produce a compression force. The
sides of the spine. The far hand is slightly supinated actual thrust is applied with a direct compression
to bring the pisiform into contact with a transverse force into the table and against the transverse
process. The near hand is pronated to bring the process of the level desired.
hypothenar eminence into contact with a trans- Tips: Most useful in cases where compressive
verse process of the same or adjacent vertebra. forces on the chest might be undesirable for
The thrust is applied after the slack has been taken any reason. Extra considerations: Although this
out of the tissues with a downward pressure and a position might seem difficult, or even impossible for
small element of sidebending. the purpose intended, it needs remarkably little
Tips: Most useful in fairly flexible subjects. Extra practice to be made into an efficient technique. The
considerations: Try changing the hands to make control of the two very long levers is critical. Careful
the far hand push toward the head and the near study of the photograph will reveal the compres-
one push toward the feet. It may be necessary to sive and torsional forces being applied. Try varying
change the applicator to use the thenar eminences the phase of breathing to find the optimum tension.
for some operators. The thrust is usually co-
incident with exhalation to avoid rib damage. Try
varying the patient's head rotation to find the
optimum.
 Techniques for the thoracic spine 127

17.31 .& Thrust mid thoracic area sitting The

patient clasps round her chest gripping opposite
shoulders. She has not crossed her forearms. Pull
in toward yourself on her elbows using a pad, if
17.30 .& Thrust mid thoracic area sidelying, necessary, as a fulcrum between your chest and
shown on skeleton The hold shown in photograph the desired level of the patient's spine. You need to
17.29 is applied here to the skeleton for clarity. Note pull in on the elbows to produce a compression
that the lower hand is applied to the transverse while engaging the barrier in a traction, flexion,
processes and the ribs. The lower elbow is applied sidebending and opposite rotation direction. The
to the lateral aspect of the pelvis. The upper hand is thrust is an accentuation of the primary lever of
pushing the shoulder back slightly, but mostly traction. Extra considerations: Lateral compres-
down into the table. sion is available simply by the operator bringing
his elbows toward his sides. If the elbows are
staggered slightly one above the other, an auto-
matic sideshift will be introduced. Note that the
patient is sitting astride the table in this illustration.
This is not an essential part of the technique but
may help fix the pelvis in a very mobile subject. Try
varying the phase of breathing to find the optimum.
128 Techniques for the thoracic spine

17.32 .& Thrust mid thoracic area sitting {taking 17.33 .& Thrust mid thoracic area sitting The
up the hand hold) The operator is clasping the operator has taken up the hold in the way shown in
patient's wrists. Ask her to interlace her hands photograph 17.32. Place a pad if necessary between
behind her neck. Taking up the hold in this way your chest and the patient's spine. Pull her into
avoids having to thread your hands through her flexion down to the segment desired, compress
elbows, and makes the grip much easier to access. toward your chest and induce some sidebending and
opposite rotation. The thrust is applied with a
combination of a lift of your body from the knees, and
an increase of compression of the patient against
your chest. The forces are produced by pulling in on
her arms at the same time as the lift.
Tips: Least useful where a shoulder problem
might make the hold painful or difficult. Try a lateral
compression of the chest in mobile subjects to
absorb the free play in the thorax. Try making the
thrust after a circumduction of the patient's body
so that the technique becomes a movable pro-
cedure rather than just a lifting exercise. Extra
considerations: Note that the patient is astride the
table in this illustration. This is not essential to the
technique. Nevertheless, in mobile subjects the
astride position will help to absorb excessive free
play in the lumbar spine. Note that the patient's
elbows remain pointing forward; if they are allowed
to splay to the side the patient's shoulders may be
strained. Try varying the phase of breathing to find
the optimum tension for the thrust.
 Techniques for the thoracic spine 129

17.35 .& Thrust mid thoracic area sitting

patient's arms across chest The patient clasps
17.34 .& Thrust mid thoracic area sitting, knee opposite shoulders without crossing her forearms.
fulcrum The patient is sitting with hands clasped Grip her elbows and pull her into your chest over a
behind her neck. Thread your hands through the
suitable pad, if necessary, applied to the desired
arms and grip the patient's wrists to pull her into
spinal level. Apply a lateral compressive force to
flexion down to the level desired. Apply your
absorb the free play in the thorax. Stagger your
padded knee to the spinous or transverse process.
arms slightly to produce a small component of
The thrust is performed with a small lifting force
sideshift as you squeeze the thorax. The patient
through the patient's arms, against a very small
leans back against you and you flex her spine until
increase of pressure with your knee.
the barrier accumulates. The thrust is performed
Tips: Note that the patient's elbows remain with a small increase of the compression coincid-
pointing to the front; they are not allowed to splay
ing with a lift directly into traction. Small vectors of
out as this can strain the shoulders. This is a very
sidebending and rotation can be introduced as
powerful technique, and if performed with excess-
necessary.
ive force could very easily become traumatic. Try Tips: Try varying the phase of breathing to find
varying the phase of breathing to find the optimum
the optimum barrier. Note that in this photograph
tension for the thrust.
the patient is sitting across the table. If the table is
very wide, this will mean that she is too far from the
operator to make the technique efficient. Either a
narrower table would be necessary or she could sit
astride the table. Another alternative might be to
use a stool.
130 Techniques for the thoracic spine

17.36 .& Thrust mid thoracic area standing The

patient clasps opposite shoulders without crossing 17.37 .& Thrust mid thoracic area standing,
her arms. Pull her into your chest with a suitable hands clasped behind neck The patient clasps
pad interposed if necessary. Grip her elbows and her hands behind her neck. Pull her against your
pull her into compression, some sidebending and chest with a suitable pad interposed if necessary.
opposite rotation. Flex down to the segment Warn her that she is to be pulled off balance. Apply
desired and then lean her back against you as you a compression, sidebending and opposite rotation
drop your weight onto your back leg. The patient force while pulling her into flexion down to the
has been told what to expect. At the optimum segment desired. At the point of optimum tension,
tension, apply a small increase of compression at perform the thrust with a small shrug of your
the same time as a small lift by shrugging your shoulders.
shoulders. Tips: Note that the patient's elbows remain
Tips: At all times the patient remains in some pointing to the front. If they are allowed to splay,
flexion. This is not so much a lifting force as a there is a possibility of straining her shoulders.
resistance to dropping of the segments above the
fulcrum. The primary lever is a traction force.
TECHNIQUES FOR THE THORACIC 18
CAGE AND RIBS

The ribs and thorax present certain of their considered simply in respect of good function
own particular problems from the point of or lack of it. The choice of technique is by the
view of efficient performance of technique. quality and quantity of the dysfunction found
These problems mainly relate to the variations rather than by any pre-conceived notion of
in shape of the thoracic curve in different indi- specific functional movement possibilities.
viduals and the need to modify approaches Although this does not accord with traditional
accordingly. There are several pathological thinking when working on ribs, it is no less
conditions that need particular care. Although effective in actual practice, and considerably
this is not the place to be detailing all these, the simpler to apply.
reader is encouraged to think in particular Due to the springy nature of the ribs in
about osteochondrosis, osteoporosis, scoliosis, normal subjects, it is usually necessary to
and myeloma. All these are examples of the absorb some of that spring in performing
type of conditions where special considera- techniques. This is done by using several
tion as to type of approach is needed as there vectors of force of compression in more than
will be deficiency of bone strength. one direction. This can be either along or
The rib articulations are rarely dysfunctional across a particular rib so that the amplitude of
by themselves, and it has been stated that in a force applied need not be too great. Torsion
a given case, the thoracic spine should with this method of approach is less neces-
receive attention first and subsequently the sary, and discomfort is reduced with these
ribs. If rib articulations are addressed first, carefully applied compressions.
they may be disturbed again when any The control of rhythm is clearly necessary,
thoracic spinal technique is performed there- particularly in rhythmic techniques that have
by rendering the rib work ineffective. to be repeated several times. Phases of breath-
Although there are usually twelve pairs of ing also need to be taken into consideration.
ribs, they vary progressively from above Many techniques require either exhalation to
down, in shape and movement possibility; induce relaxation or, alternatively, inhalation
technique will inevitably vary according to the to create a firming up of the part and im-
area being worked. The techniques, therefore, proving the access to the optimum motion
are divided broadly into those applicable on barrier.
the lower, middle and upper ribs. Naturally The choice of position to perform the
these demarcations are artificial, and there technique, such as supine, sidelying, etc., is
will be some overlap. going to be governed by the most comfortable
Technique classifications have often referred position for the patient at the time, and the
to the nature of movement of ribs. They de- position most effective for the requirements
marcate the 'bucket-handle' type of movement of the treatment and technique being given.
from the 'pump-handle' type. This classifica- As a rule, sidelying is more comfortable than
tion is not used here as rib dysfunction is supine, and supine is more comfortable than
132 Techniques for the thoracic cage and ribs
prone. Sitting is better where larger move- and articulation will be more useful. Thrust
ments are necessary, but this requires more techniques have a particular use when there
cooperation from the patient and control by has been a traumatic onset to a particular
the operator. It is preferable to avoid the syndrome. They play a smaller part in more
necessity of changing the patient's position chronic conditions, except at the outset, to
excessively during treatment and the relative break fixation and pave the way for more
size of operator and patient may also deter- rhythmic approaches later. Care should
mine the optimum position in which most always be taken of the aesthetic nature of the
techniques can be performed. procedure being used. This is particularly
Because of the deep nature of the intercostal true when working on female patients so as
muscles, direct soft tissue work is less effective not to put pressure on breast tissue which
here than in some regions, and stretching could be embarrassing and possibly painful.
 Techniques for the thoracic cage and ribs 133

18.1 • Articulation of mid ribs supine Hold the 18.2 • Articulation of upper ribs Stand at the
patient's arm in extension, and use internal rotation head of the table with the patient's arm extended
to put the shoulder capsule on tension. Apply the and internally rotated. Apply a force through the
applicator thumb and thenar eminence to the shoulder and ribs by rotating your body. Keep the
costal interspaces. Rock from one foot to the other patient's arm held firmly into your side so that the
and apply a careful pressure to the lower of a pair rotation movement causes rib articulation forces to
of ribs so it is possible to increase their spacing and develop.
mobility. This hold can be used from twelfth to third Tips: Most useful where the first three or four ribs
rib. are involved in a dysfunction syndrome. Least
Tips: Most useful in kyphotic patients where the useful where there is any shoulder problem making
ribs will be in close apposition. Least useful in the arm movement difficult in this plane. Extra
large-breasted women where it may be impossible considerations: With tension maintained try using
to get to the ribs without intruding on the breasts. a harmonic oscillation in this position.
Extra considerations: It may be useful to use
different phases of respiration.

18.3 ~ Articulation of lower ribs Apply a slight

compressive force to the thoracic cage and use the
thumbs to carefully hold the ribs being worked
towards the pelvis while you rhythmically lean
back. The patient here is holding a towel between
her hands as the stretch round the operator to
clasp her hands may be too great.
Tips: Least useful in patients where shoulder
movement of this amplitude may be a problem.
Extra considerations: Try using a harmonic oscil-
lation in this position.
134 Techniques for the thoracic cage and ribs

18.4 • Articulation of mid ribs Apply a slight 18.5 • Articulation of lower ribs The patient
lateral compression force to the upper thorax to links her hands behind her head and then you apply
limit movement there, then, with the back of the a resistive force to her elbow. You can lift the lower
hands resting on the table, apply an anterior force ribs by twisting your own body with relatively fixed
to the shafts of the ribs. At the same time apply a arms.
traction by leaning back and, thereby, produce a Tips: Most useful where there is a need to
stretch from the patient's linked hands. elevate and spread the lower ribs strongly. Least
Tips: Most useful in kyphotic patients where rib useful where the shoulder cannot be used in this
'spreading' is an important element of treatment. range of movement. Extra considerations: Try
Least useful where the shoulders cannot adopt the using varied phases of respiration.
position. Extra considerations: Try using different
phases of respiration.

18.6 ~ Articulation of mid ribs With the patient's

hands linked behind her neck you apply a lifting
and spreading movement to the mid ribs on the
opposite side. This is particularly effective in
patients who have a very flexed thoracic spine, for
example from age, osteoporosis or osteochondrosis.
It will only be effective as far as the sixth or seventh
rib, as the scapula intervenes.
Tips: Least useful in large subjects where the
reach may be too great for smaller operators. Extra
considerations: Try using varied phases of respira-
tion and varied amounts of preliminary sidebending
of the patient's body.
 Techniques for the thoracic cage and ribs 135

18.7 .A. Articulation of mid and upper ribs This hold uses initial patient positioning as the opposite leg
is flexed at the hip and adducted to produce some rotation of the pelvis toward the operator. The arm is
placed under the side of the patient. Apply the thenar eminence to the angle of the rib. With the other
hand, hold down the shoulder and pronate the applicator forearm to apply the mobilizing force. Stabilize
the patient's folded arms with a traction force applied with your own chest if required.
Tips: Most useful in very tight subjects where the springing force developed in this way will help
mobilize the individual joints effectively. Least useful if the rib heads are very tender to pressure. Extra
considerations: Try using varied phases of respiration and head rotation to optimize the tension.

18.8 .A. Articulation of mid to lower ribs The applicator here is the border of index finger and second
metacarpal. They apply an extension and separating force, while the patient's shoulder is held down with
the other hand and the elbow of your applicator hand rotates the patient's pelvis towards you.
Tips: Most useful where a strong mobilizing force is required. Least useful where rotation in the thorax
may be a problem. Extra considerations: Try using different phases of respiration and varying the patient's
initial position to help localize the force.
136 Techniques for the thoracic cage and ribs

18.9 • 'Stretching' mid ribs sitting Hold down 18.10 • Articulation of mid to lower ribs sitting
on the rib being worked while straightening your This hold can be used where there is a scoliosis, as
knees and sidebending the patient with your other the ribs can be worked on the convexity. It requires
hand. Apply rib stretching or articulation. Note that a firm compression between the bodies of the
the patient's head is kept in the midline above the operator and the patient, and whilst the hands are
pelvis so that the maximum stretch can be applied held relatively fixed the oscillation of body move-
to the rib. If the patient's body is taken out of the ment will perform the articulation. Extra considera-
midline there will tend to be more of a compressive tions: Try using varied phases of respiration and
force on the other side. This will be uncomfortable different amounts of active flexion and extension in
and tend to dissipate the forces into other tissues the patient.
than the area intended.
Tips: Least useful in very flexible subjects where
it would be difficult to localize the force. Extra
considerations: Try using different phases of
respiration and try circumducting the patient's
body around the fixed applicator hand as an
alternative approach.
 Techniques for the thoracic cage and ribs 137
18.11 <IIIII Articulation of upper ribs sitting Apply
the hand to the costo-chondral junction and keep it
relatively fixed while you abduct and externally rotate
the shoulder to a comfortable limit. Then, hold the
shoulder and perform the articulatory force by press-
ing forwards against the scapula to induce a force
localized to the rib. Sometimes a slight increase of
traction through the arm assists the technique. Extra
considerations: Try using varied phases of respiration.

18.12 • (bottom left) Articulation of costo-

chondral joints Hold back on the sternum and
apply a traction, external rotation and abduction
force to the shoulder. Then lean forward against the
patient's scapula to produce a gapping force. Lower
down the rib cage, more initial rotation needs to be
induced in the patient's body to establish localization.
Tips: Least useful in cases where shoulder
dysfunction would cause pain in this position.
Extra considerations: Try using different phases
of respiration.

18.13 • Articulation of mid to lower ribs Side-

bend the patient over your padded knee and com-
press her firmly against your side. The mid ribs will
require more extension of the patient's body than
the lower.
Tips: Least useful if the patient is very large and
the operator very small. Extra considerations : Try
using varied phases of respiration .
138 Techniques for the thoracic cage and ribs
18.14 ~ Articulation of mid ribs sidelying Use
your upper hand to apply a posterior to anterior
force while your elbow maintains the patient's
shoulder in extension, abduction and external
rotation. This transmits the force to just below your
fingertips where the other hand applies a slight
compressive force and holds down on the rib
towards the pelvis. It is possible to reach up to
about the fourth or fifth rib except in very mobile
subjects, where the scapula gets in the way.
Extra considerations: Try using varied phases
of respiration.

18.15 A Articulation of mid to lower ribs sidelying Apply a downward force through both forearms on
the lateral border of the scapula and the pelvis. Use a small component of postero-anterior force and then,
while maintaining these, separate your hands slightly to produce the required direction of force.
Extra considerations: This position can be used for harmonic technique where the focus is made with
the hands and then the whole patient's body rocked around them . Try using varied phases of respiration.
 Techniques for the thoracic cage and ribs 139

18.16 • Articulation of mid ribs prone Extend

and abduct the shoulder and then, while the rib is
held toward the pelvis with the fingertips and
thumb, further abduct the shoulder to reach the
fixation point so that articulation can be performed. 18.17 • Thrust first rib prone Sidebend the
Tips: Least useful in patients where prone lying is neck toward the rib and rotate it away. Produce a
a problem and where there is shoulder dysfunction. component of sideshifting with the stabilizing hand.
Extra considerations: Try using varied phases of Form an apex by pressure of your metacarpo-
respiration. phalangeal joint as close to the head of the rib as
possible. When you have taken up the slack, the
direction of force will be approximately toward the
opposite axilla. The hand holding the head is a
stabilizer in this technique and does not enter into
the thrust. As the technique is mostly used on ribs
that have been fixated relatively superiorly by the
pull of the scaleni, it is normally performed as the
patient exhales.
Tips: Most useful where a treatment table head-
piece can drop below horizontal to take the whole
neck into some flexion. Least useful where the
patient is over the age of 40, where neck extension
and rotation may be limited. Extra considerations:
Avoid this technique where there is a brachial nerve
compression syndrome on the same side, as it may
aggravate nerve root pressure.
140 Techniques for the thoracic cage and ribs

18.19 • Thrust first, second or third rib supine

Use the hand hold shown in the photograph. Apply
your hand to the head of the rib, keeping it in some
pronation so that the thenar eminence is applied to
the angle of the rib. Apply the other hand just lateral
to the costo-chondral junction, and use your thorax
to push downwards on the folded arms and toward
the head, to produce traction and some com-
pression. As the patient lifts her head from the
pillow, barrier sense will accumulate on the thenar
eminence. It is then necessary to make a small
increase of pressure toward the table with the
18.18 • Thrust hand position first, second and
upper hand, and a further sharp pronation with the
third rib
table hand to complete the thrust.
Tips: Most useful in very tight subjects where neck
levers are best avoided. Extra considerations: If
excessive pressure is applied to the rib head too
early, the patient will be unable to lift the head. Try
using varied phases of respiration .

18.20 <1111 Thrust mid ribs sitting Pull the patient's

body into extension and apply a localized force
using your thumb directed to the angle of a rib.
Sidebend the spine over that thumb and then rotate
it away to produce locking of the spinal column.
Then apply a short amplitude thrust in an upward
and forward direction which will break fixation in
the costo-vertebral or costo-transverse articulations,
depending on the amount of preliminary rotation.
More rotation directs the force laterally to the
costo-transverse articulation.
Tips: Least useful in very flexible subjects where it
is difficult to produce localization. This technique
may be impossible in large patients as the reach for
the operator may be too great. Extra considera-
tions: The patient may be more comfortable with a
pillow between her arms and the operator's shoulder.
Try using different phases of respiration.
 Techniqu es for the thoracic cage and ribs 141

18.21 • Thrust starting position for mid ribs

sitting Apply the hypothenar eminence to the angle
of the rib and stretch the other arm across the
thorax to compress the ribs slightly from front to
18.23 • Thrust for middle ribs sitting This shows
back. This compression of the chest makes the
essentially the same technique as photograph
thrust point more accessible. Then rotate your and
18.22 but an alternative hand hold across the
the patient's body, pushing the rib forward. At the
thorax has been taken and the patient is sitting
last moment introduce a sidebending toward the
across the table rather than astride.
rib with enough extension to focus the forces. The
Tips: This hand hold may be better as it avoids
extension is produced partly by pressure on the rib
the breast area in female patients.
angle, and partly by asking the patient to extend
her head and neck. Most techniques do not require
a specific order of components. However, in this
hold it is far too easy to over-lock if the balance
between the components is wrong. If the order
described is used there is a greater probability of
balance between comfort and effectiveness.

18.22 <1111 Thrust for mid ribs The operator has

applied the rotation away from the rib and the side
bending down to it until the forces accumulate as in
photograph 18.21 . The patient then extends her
head. Apply a compressive force between the two
hands and perform the thrust with the pisiform
vertically on the angle of the rib. If the thrust force is
more anterior than vertical, pain will be induced and
the technique will be less effective.
Tips: Least useful where the operator is smaller

I
than the patient and where the reach around may
be a problem. Extra considerations: This is one of
the few thrust techniques where generally it is
better not to apply very much in the way of soft
tissue procedures first. It is often difficult to
accumulate useful tension if the structures have
been previously relaxed . Try using varied phases of
respiration . (The sitting astride position shown here
is not an essential part of the technique.)
 18.24 <1111 Thrust for mid ribs sidelying This is a
modified lumbar roll position with hand applied
directly over the costo-transverse articulation on
the side of the thorax closest to the table. Use the
other hand to compress the pectoral girdle directly
toward the table and prevent forward rotation of
the body. Apply the force with the whole of the
thrusting arm and hand and use a direct compres-
sive force anteriorly and slightly superiorly to
produce gapping of the joint.
Tips: Most useful in tight subjects as their
stiffness helps to produce a localization more
easily. Least useful where the operator is small and
it may be difficult to apply sufficient compressive
force for localization. Extra considerations: Try
different phases of respiration.

18.26 A Thrust to lower ribs sidelying shown

on skeleton A modified lumbar roll position has
been applied and the finger tips of the thrusting
hand have been directed toward the table. This will
reduce spinal movement. A force is applied then
18.25 A Thrust to mid ribs sidelying shown on toward the operator to gap the rib articulations
skeleton The exact positions of the fingers of the while the other hand holds back on the spinous
thrusting hand in the previous illustration are seen processes. The critical element in this technique is
more clearly here. Although this may seem a rather the control of compressive force to focus the forces
unusual way of reaching the mid ribs, it is particu- accurately.
larly useful where excess torsion would be a Tips: Most useful where torsion of the whole
problem. The controlled compressive force allows thorax is best avoided as compression substitutes
the target rib to be reached. If a pure rotation force for rotation. Least useful in the presence of lumbar
were to be used instead of the compression, the or sacro-iliac dysfunction as some stress inevitably
whole lumbar spine would be at risk of strain. occurs at these regions.
TECHNIQUES FOR THE SCAPULO- 19
THORACIC AREA

The soft tissue articulation of the scapula- separated from the thoracic wall to allow
thoracic junction is frequently involved in ten- the operator's fingers or hand access to the
sion states and postural control of the pectoral muscles. Very tight fascial states will make this
girdle. Fibrotic muscle bands are frequently difficult, but these patients are the subjects
found under the scapula, and these can limit most likely to benefit from such approaches.
mobility and be a source of symptoms in There are few special precautions when
themselves. Restricted mobility of the scapula working on this area except to be aware of the
can put undue strain on the shoulder joint forces being put through the shoulder joint.
itself. In cases of shoulder dysfunction this can It is necessary to avoid excessive stress on
make the difference between comfort, reason- the gleno-humeral joint in the process of
able usage, and mechanical problems. reaching the scapula-thoracic junction. Deep
From a practical viewpoint the difficulties emotional tension often manifests here, and
lie mostly in finding ways to access the area release of the muscles can produce emotional
underneath the scapula. Techniques must be release, so the thinking practitioner should
used which allow the scapula to be partly be prepared for this possibility.
144 Techniques for the scapula-thoracic area
19.1 ..,.. Kneading of soft tissues on superior and
medial part of scapula-thoracic junction side-
lying Fix the scapula slightly down toward the
table with the stabilizing hand while the other
applies kneading to the horizontal fibres of trapezius,
and the rhomboids. As these muscles are involved
in respiration, it may be best to use the exhalation
phase of breathing to enhance the relaxation
response.
Extra considerations: Try holding the muscles
on tension and moving the whole body against the
tension in very tight subjects rather than moving
the muscles against the body.

0 0

19.2 • Kneading and stretching rhomboids and 19.3 • Articulation of scapula-thoracic junction
subscapularis sidelying Push the patient's shoulder sidelying Fix the scapula and shoulder between
and upper arm toward the table with your thorax your thorax and finger tips and rhythmically roll the
and arm to wing the scapula. Then push the finger patient's upper body into rotation. This will have
tips up into the space formed so that they can work the effect of mobilizing the scapula on the thorax.
directly on the muscles. Kneading can be per- Extra considerations: Try taking the whole
formed directly or the whole scapula can be lifted scapula superiorly and inferiorly.
while being held against your chest to perform
stretching. If you sidebend your body it is possible
to work the upper or lower parts of the area.
Extra considerations: Can be used as an
inhibition technique with sustained pressure.
 Techniques for the scapula-thoracic area 145

.\

19.4 _. Articulation of scapulo-thoracic junction 19.5 _. Kneading and articulation of scapulo-

sidelying This slightly complex hold will reach the thoracic junction prone Abduct the patient's arm
scapula-thoracic junction in a number of ways to an appropriate point and rotate it as necessary
depending on the pressures used. Press against with your lateral hand. You can reach the deep
the lateral border of the scapula with your lower interscapular muscles and pull the scapula into
arm while moving your body in a circle. This will different degrees of rotary movement.
produce a completely different effect than if you Tips: Least useful where prone lying is a problem
compress your upper arm hand against the lower for any reason. Extra considerations: Try chang-
arm elbow and then perform rotary movements. ing the patient's head position to vary the tension
With some experimentation of different directions on the scapular muscles.
of pressure of the arms, hands and body it is
possible to vary this technique in many subtle ways
and, therefore, its effect on the tissues.
Tips: Most useful where stretch rather than
kneading is the preferred method. Least useful
where there is shoulder dysfunction making this
position difficult for the patient.
146 Techniques for the scapula-thoracic area
19.6 <IIIII Kneading scapular muscles prone Pull
the shoulder toward you and backwards to wing
the scapula and apply the thumb of the other hand
to work on the muscles that have been taken off
tension.
Tips: Most useful in very tight subjects and
where it is required to work on the posterior
thoracic wall. Least useful where prone lying may
be a problem and where operator thumb strength
may be insufficient for the technique.

19.8 ~ Kneading and friction of scapula-thoracic

junction prone Perform the work with fingertips
applied to the soft tissues. This allows a wider
spread of pressure that may be less uncomfortable
than thumb pressure. Some operators will find this
easier to perform if their thumbs are too mobile for
the other holds.

19.7 <IIIII Kneading and articulation scapula prone

Place the patient's arm in strong internal rotation
and pull the shoulder toward you and backwards to
make the subscapular muscles more accessible.
The thumb is performing the kneading work.
Tips: As photograph 19.6.
TECHNIQUES FOR THE CERVICO- 20
THORACIC JUNCTION AREA

The cervico-thoracic, or cervico-dorsal, region get adequate relaxation in the area should alert
can be a source of more frustration in the practitioner to this possibility. As a pre-
attempting to achieve successful technique cursor to incipient cardiac infarction there
results than almost any other area. There are can also be a characteristic feel to this area,
many reasons for this. The area is junctional presumably due to aberrant viscera-somatic
which means that there will be a change in reflex patterns. This manifests as an increas-
orientation of anatomical curves. There is a ing state of tension with a 'sheet like' nature
mobile area of the neck meeting a less mobile in that there is no specific point of tension.
area of the thoracic spine and ribs. There are There is, rather, a generalized state that
emotional factors which manifest in the area partly resolves with manual treatment only
relating to stress and tension. The use of the to recur very rapidly. This is difficult to
arms puts mechanical strains on the area, describe, but once it has been felt, will never
requiring it to be stable, and this very stability be forgotten. This muscular state disappears
means that the range of movement of the almost immediately after a myocardial infarc-
joints is somewhat limited. This can lead to a tion, presumably due to the changes in the
greater susceptibility to mechanical strain in reflex patterns. There may be other factors in
these joints if they are taken out of their operation here such as changes in life-style,
normal range in an uncontrolled fashion. the shock to the system, and many others,
Particular care should be taken with regard but it is, nevertheless, quite characteristic.
to the possibility of pathological conditions in Some of the techniques are modified ver-
the area affecting bone strength, such as sions of cervical holds, some modified thoracic
secondary deposits from primary carcinoma ones, and some are specific to the area itself.
in the lung and thyroid. Severe brachial nerve There is no inherent benefit in any one over
entrapment syndromes require particular another, except there may be times when it is
caution if the neck is going to be used as a necessary to avoid the neck or the thorax for
lever. The presence of extreme hypertension some reason. It is, therefore, necessary to
can manifest as a very hypertonic state in the have a range of techniques available to affect
muscles of the cervico-thoracic area. Inability to the area by a variety of means.
148 Techniques for the cervico-thoracic junction area

r.
20.1 _. Kneading sidelying The patient is side-
lying nearer you than the back of the table. Fix the
upper scapula with your forearm and hand and
apply the kneading to the trapezius and rhomboids
towards the spine with the thenar eminence.
Tips: More useful for patients who might find 20.2 _. Kneading prone The patient is prone
prone lying a problem. Better for tight-muscled with her arms over the sides of the table and her
subjects where the action of pushing the muscles face in a breathing hole in the table if available.
toward the spine may be easier than pulling away Fix the nearer side of the spine with the lower hand
using the more traditional methods. into a slight rotation toward you. Use the thenar
eminence of the kneading hand to push against the
muscles on the opposite side toward the table and
away from the spine.
Tips: Try using the expiration phase of breathing
to give the best relaxation effect.
 Techniques for the cervico-thoracic junction area 149

20.4 • Articulation sitting Stand behind the

20.3 • Kneading prone The patient is prone with seated patient and have her place one hand behind
her face in a breathing hole in the table if available. her neck. Fix with your thumb against a spinous
Her arms are over the sides of the table. Fix the process directed toward her other axilla so that the
spine with the upper hand to prevent too much thumb forms a fulcrum for a sidebending move-
rolling of the spine into rotation and apply the ment. Reach under her flexed arm with your arm
kneading with the other hand. Take up some skin and fix against the side of her head. Keep the
slack and use the thumb or thenar eminence to vertex in the midline and introduce the sidebending
perform the kneading to trapezius and rhomboids. movement with both hands simultaneously.
Tips: Least useful if the operator has any prob- Tips: Try circumducting the patient's body
lem of thumb instability. around the fixed vertebra to make a stronger and
more variable force. Avoid continuing this move-
ment for a long duration as there will be a tendency
for ulnar nerve irritation from your arm pressure
under her flexed arm.
150 Techniques for the cervico-thoracic junction area
20.5 ~ Articulation sidelying The patient clasps
her hands behind her neck in the sidelying position.
Fix on the spinous process of the target vertebra
with the fingers of one hand. Clamp the patient's
flexed arms between the side of your thigh, hand
and forearm. Introduce flexion and extension with
small amounts of any other movements by making
a small rotation movement of your body.
Tips: Least useful where there is any shoulder
condition which may make this position difficult for
the patient. Try using only one arm flexed and
gripping the neck rather than both.

20.7 ~ Articulation sidelying Fix the patient's

flexed arms between your body and abducted
upper arm. Grip around her hands with your upper
hand so that the movements of flexion, extension
and small amounts of rotation and sidebending can
be introduced. Fix the spinous process of the
target vertebra with the other hand to act as a
counter-force to the movement induced.
Tips: Least useful in nervous patients as this
position is somewhat claustrophobic. Not very
useful if there is any shoulder condition which may
make the position difficult to attain. Try using only
one flexed arm instead of two. Most useful where it
is desired to block out cervical movement.

20.6 ~ Articulation sidelying Fix the under-surface

of the patient's flexed upper arms against your side
and hold her elbows. Use a firm grip on the spinous
process of the target vertebra with the other hand.
Introduce flexion and extension by rocking your body
into rotation, thereby carrying her arms back and forth.
Tips: Least useful where the patient has any
condition of her shoulders making the flexed position
difficult. Try using one flexed arm only. Most useful
where it is desired to eliminate neck movement from
the equation as her hands will help do this.
 Techniques for the cervico-thoracic junction area 151

20.8 £. Articulation sidelying Flex both of the 20.9 £. Articulation sidelying Flex the patient's
patient's arms to pull the scapulae apart. Support neck and grip as far down as possible with the
her head and mid neck with your upper hand. Use upper hand to avoid neck strain. Use the fingers of
the fingertips of the other hand to push against the the other hand to pull the spinous processes
spinous processes of the area to introduce against the movement of the upper hand. Most
a sidebending articulation with some possible movement directions are possible with this hold.
rotation. Lift the head using the tips of the fingers Tips: The fixing hand protects the neck and
under the neck to limit the movement to the lower allows reasonable localization of the articulation.
cervical and upper thoracic area. Avoid crowding the patient's face with your upper
Tips: The lower down the neck you fix with the arm or chest.
upper hand, the more localized the force becomes,
and the more the upper neck is protected from
strain. Avoid having your upper arm biceps against
the patient's eyes; rather, fix against the forehead.
Use some downward compression through the
upper scapula to stabilize the body. Least useful
where there may be any neck instability, as
however much protection is introduced, there will
be some strain induced.
152 Techniques for the cervico-thoracic junction area

'
20.1 0 A Articulation sitting The patient sits 20.11 A Articulation sitting The patient sits
across the table at one end. Stand at the end of the across the table at one end. Stand at the end of the
table and reach around her clasped hands to hold table and reach around her clasped hands to hold
her far shoulder and pull her against you. Use the her far shoulder and pull her against you. Use the
thumb of the rear hand to pull the spinous process heel of the rear hand to push the spinous process
of the target vertebra toward you. Keep the head in of the target vertebra toward you. Keep the head in
the midline and rock the patient into sidebending, the midline and rock the patient into sidebending
making this vertebra a focus and fulcrum for the making the vertebra a focus and fulcrum for the
movement. movement.
Tips: Firm compression toward you will allow Tips: Firm compression toward you will allow the
induction of movement to be produced by a induction of movement by a rocking back of your
rocking back of your body. Try introducing circum- body. Try introducing circumduction movements
duction movements as well as simple sidebending. as well as simple sidebending. Least useful if the
Least useful if the operator has an unstable thumb. movement needs to be very specific to only one
In this case try substituting a thenar hold. segment as this pushing movement will inevitably
involve several vertebrae.
 Techniques for the cervico-thoracic junction area 153

r..,. _.,,
.. '

20.13 • Thrust prone Stand at the side of the

20.12 • Thrust prone Sidebend the neck and table with the prone patient's head in rotation away
head of the prone patient at the same time as you from you. Fix the scapula with your lower hand and
induce a slight rotation to the other side. Fix as low gently fix the head into rotation and a small amount
down on the neck as possible with the head hand of sidebending. Apply the heel of the thrusting hand
to avoid excessive neck strain. Apply a compres- against the side of the spinous process of the
sion force against the transverse process of the target vertebra toward the patient's axilla. Balance
target vertebra toward the table and axilla with the the forces so that the head hand does not move
thrusting hand. Gently rock the head on the chin to when the thrust is applied with the spinal hand to
find the optimum barrier accumulation under the gap the facet on the far side of the patient's spine.
thrusting hand. At the point of optimum barrier, Tips: The direction of thrust governs which side
apply a very short amplitude thrust to the trans- will be gapped. If the force is toward the axilla, the
verse process to gap the joint on the same side. other side will gap as the facets on the nearside are
Tips: Least useful for patients who find the prone in apposition. If the force is predominantly into the
position a problem. Least useful for most patients table, there will be a tendency for the same side to
over 45 years of age, as normal degenerative gap. Avoid this position in patients over about 45
changes in the neck will make the lever uncomfort- years of age as the strain on the neck may be
able. If a table with a dropping head leaf is unacceptable. Avoid the tendency to introduce
available, it is possible to perform this technique on excessive extension as this can be traumatic and,
a wider range of patients as the slightly flexed moreover, renders the technique less effective.
position will remove some of the strain. Avoid Move the thrusting hand more laterally onto the
pulling the head harder when the thrust is per- angle of the rib to make this into a rib gapping
formed as this is often painful. Try varied balance technique.
between rotation and sidebending to find the best
mix of effectiveness and comfort. Try moving the
thrusting hand laterally to the angle of the rib to
make this into a rib gapping technique.
154 Techniques for the cervico-thoracic junction area

20.14 • Thrust prone Stand at the head and 20.15 • Thrust prone (shown on skeleton) The
slightly to one corner of the table with the patient's technique shown in photograph 20.14 is demon-
head turned away from you. Carefully fix the neck strated here on the skeleton to show the position of
as low down as you can reach with the upper hand. the hands more accurately.
Fix the spinous process of C7 with the thumb of
this hand to limit movement to the upper thoracic
area. Apply the thenar eminence of the thrusting
hand to the transverse process of the target
vertebra, pushing it toward the axilla. Stabilize the
rotation with the head hand, and increase the
pressure with the thrusting hand until a suitable
barrier accumulates. Apply the thrust with the lower
hand only to gap the facet on the thrusting side.
Tips: Apply the thrust to the angle of the rib to
make this into a rib gapping technique. Avoid this
position in patients over about 45 years of age as
the neck extension may be uncomfortable. It is
possible to perform this at a more advanced age if
a drop leaf table is available.
 Techniques for the cervico-thoracic junction area 155

20.16 .& Thrust prone Stand at the side of the 20.17 .& Thrust prone Fix the scapula with the
prone patient and apply the hypothenar eminences forearm and the head into rotation away from you
of both hands to opposite sides of the spine at with the lower hand. Introduce a very small element
adjacent segmental levels. Apply some pressure of extension and sidebending with the head hand.
onto the transverse processes to induce some Push against the spinous process of the target
compression and sidebending. Rotate your body to vertebra with the thumb of the thrusting hand into
emphasize this movement and vary the pressure sidebending and slight compression into sideshift-
with the hands to introduce some rotation to the ing. The thrust is applied into sidebending with the
movement until a suitable barrier is found. The thrusting hand while maintaining the head position
thrust can be applied with one hand, the other with the other hand. This will gap the facet on the
hand, or both. far side. If the force is directed more toward the
Tips: Try reversing the hand position to find the table with the thrusting thumb, it will tend to gap
optimum for each case. As each vertebra has the facet on the nearside.
multiple joints, every change in angle or pressure Tips: Least useful where the operator has prob-
will vary which will be the target joint. A sidebend- lems with thumb stability. The fixation of the
ing thrust rather than a compression thrust will be scapula and head gives some protection to the neck
more comfortable, and less potentially traumatic in providing they are held steady during the thrust.
cases of possible rib fragility.
156 Techniques for the cervico-thoracic junction area

20.18 .& Thrust prone Rest the patient's head on

her chin and gently support it with one hand avoiding
throat pressure. Cup one spinous process with the
area between the thenar and hypothenar eminences
of the other hand and apply a pressure toward the
sternum. Carefully oscillate between the hands until a
suitable barrier accumulates under the thrusting 20.20 .& Thrust sitting This hold is substantially
hand. The thrust is a very short amplitude force while similar to photograph 20.19 except that the patient
maintaining the head steady. Avoid excessive neck has placed her arm over a suitable pad on the
extension that can become traumatic. operator's knee to act as a fulcrum. It is easier to
Tips: This is a technique that is potentially induce sideshifting with this hold, and some
dangerous, and must only be used with great care patients feel more stable and secure. It is, however,
in suitable subjects. more difficult for the operator to balance the forces
as he is standing on one leg.

20.19 ~ Thrust sitting Stand behind and slightly to

one side of the seated patient. Apply the thumb
against the side of a spinous process of the target
vertebra to induce sidebending and rotation. Support
the patient by pulling her against your abdomen with
the hand, and introduce slight rotation by pulling
back against the clavicle. Flex your other arm and
apply the inside of the forearm against the side of the
head and face to produce a direct sideshifting force.
Form a fulcrum of the vertebra and thumb while per-
forming slight circumduction to the body to accumu-
late the best thrust barrier. When the tension is opti-
mum, apply the thrust with the thumb toward the op-
posite axilla while the neck is fixed by the other hand.
Tips: Least useful for operators who might have
instability in the thumb. Try using the thenar or
hypothenar eminence instead. Vary the flexion and
extension of the head, and try antero-posterior
shifting to aid the focus of forces. If the thrust is
applied against the spinous process toward the
opposite axilla, it will gap the facet on the opposite
side. If the thrust is applied more in a forward
direction it will tend to gap the facet on the same
side. In this case there will need to be a vector of
downward pressure introduced as well.
 Techniques for the cervico-thoracic junction area 157

20.21, 20.22, 20.23 and 20.24 Thrust sitting This hold is very specific for the C7 to T1 joints. The
sequence of photographs shows the order of application of the hold. Have the patient place one hand
behind her neck and reach under the other arm with your thrusting hand. When you have reached as far as
possible, flex your elbow to bring the heel of your hand against the fingertips of the patient that are flexed
over the lower neck. Maintain some pressure there, and reach around her chest to grasp her wrist with
your other hand. Apply some sidebending toward your thrusting hand, and rotate slightly away from this
hand by pulling on the wrist. Pull the patient firmly against your chest to produce a direct antero-posterior
compression. This will better help focus the other vectors of force. Apply the thrust vertically through the
patient's fingers to gap the facet on the same side. (Note the astride position is shown for clarity only; it is
not an essential part of the technique.)
Tips: This is a complex technique, and several things can cause it to fail. The thrust must be vertical not
anterior. The pull on the wrist must be quite firm to maintain the sidebending. Some extension is
necessary, but too much will block the technique.
158 Techniques for the cervico-thoracic junction area
20.25, 20.26 and 20.27 Thrust sidelying Fix
against the side of the spinous process with the
thumb, heel of the hand or thenar eminence
according to your preference. Lift the head into
sidebending away from the table. Abduct the arm
holding the head so that the patient's face is not
obstructed and so it is possible to reach down to
support the neck with the ulnar border of the hand.
Introduce some sideshifting away from the table as
well as a slight anterior shift of the neck. Fix against
the upper scapula with your chest. Accumulate the
barrier with a combination of sideshifting and
sidebending away from the table, slight rotation
toward the table, and compression against the
shoulder. Apply the thrust with the chosen appli-
cator to produce a rotation and sidebending of the
target vertebra.
Tips: Note that the direction of the thrust can be
varied to gap the lower or upper facet. Force
directed toward the table will tend to gap the lower
one, while force toward yourself will tend to gap the
upper one. The lower down the neck you grip, the
more the neck protection, and the less uncomfort-
able for the patient. The selection of applicator is
dependent on operator thumb strength and ability
to focus with the other parts of the hand.
TECHNIQUES FOR THE CERVICAL 21
AREA

The cervical spine poses several problems for nique slow, deliberate, and non-threatening
the manipulative practitioner. Patients are than in the neck.
often nervous of having their neck handled. Discomfort and pain will often occur if not
This is either through natural fear of damage enough care is taken to keep the head sub-
to the area from its apparent fragility, or stantially in the midline. Most of the thrust
due to having had a previous bad experi- techniques require the vertex to remain
ence. Some operators are also afraid of almost central and the neck to be pushed or
harming the patient with techniques in the buckled into sidebending and sideshifting
neck and unconsciously transmit this to to achieve locking and localization. It may
the patient. The patient then finds relaxation apparently be easier to produce an effective
impossible, thus perpetuating the vicious barrier if the head is taken out of the midline,
circle. but pain, distress and overstretch are the
There are clearly particular reasons for common undesirable results.
extreme caution in the neck, and it is wise to Some patients feel threatened if they can-
use as gentle technique as is possible consist- not see the practitioner, and in these cases
ent with a good result. Particular care should techniques should be performed from the
be taken in cases of hypertension, postural side or front of the patient. Some patients
hypotension and vestibular origin dizziness. intensely dislike chin hold techniques, and in
Each of these conditions can be irritated by these cases cradle hold methods are prefer-
excessive force or rapid movement. If a able. The use of rhythm is essential to pro-
particular position irritates a brachial syn- duce a dynamic state of relaxation, and it is
drome, it should also be stopped immediately. also easier to accelerate in thrust technique
Nowhere is it more important to make tech- from a slightly moving pathway.
 160 Techniques for the cervical area

21.2 .6. Kneading of soft tissues supine This

operator viewpoint photograph shows the hold
illustrated in photograph 21 .1. Note that even though
the head has been sidebent, the vertex remains in the
midline. This avoids excessive facet compression on
one side, and overstretch on the other.
21.1 .6. Kneading of soft tissues supine Stand
at the side of the patient and stabilize the head with
the upper hand. Pull up on the posterior and lateral
tissues with the pads and fingertips of the active
hand. Depending which fingers are used, the lower,
mid or upper parts of the neck muscles are
kneaded .
Tips: Try adding a sidebending movement with
the head hand to emphasize the effect. Try not to
slide over the skin excessively as this can be
uncomfortable.

21 .3 ~ Kneading of soft tissues supine This

photograph is of a similar procedure to that shown
in photograph 21 .1. However, it can be seen that
by changing the hand hold slightly, you can pull
into a combined extension and rotation at the same
time as the kneading . This will have the effect of
making the technique much stronger.
Tips: Try extending the neck with the kneading
hand or fixing with this hand and extending with the
other. Try using both hands together.
 Techniques for the cervical area 161
21.4 ..,.. Kneading of soft tissues supine Fix the
head into the pillow with one hand applied to the
forehead. Apply the fingertips of the kneading hand
parallel to the spinous processes. Push the fingers
upwards into the neck and pull laterally while
maintaining this upward push. The effect of this is
to stretch the muscle tissue away from the spine
while the neck remains static.
Tips: Use the back of the hand on the pillow as a
fulcrum . Extra considerations: Try rolling the head
slightly to enhance the effect of the kneading force.

21.5 • Kneading of soft tissues supine Fix the 21 .6 • Kneading of soft tissues prone Stand to
head into the pillow with the stabilizing hand. Use the side of the table and stabilize the head with the
the fingers and thumb of the kneading hand to work upper hand. Apply the kneading hand to the tissues
on the posterior tissues of the neck on both sides at on the other side of the neck and pull toward
once. yourself.
Tips: With both fingers and thumb applied under- Tips: This is not very comfortable for the patient
neath it is easier to combine an articulation force at unless a table with a breathing hole is used as
the same time rather than when just using the fingers. excessive extension can result if insufficient care is
Extra considerations: Try adding a traction force. taken.
162 Techniques for the cervical area

21.9 _. Kneading of soft tissues sidelying Stand

21 .7 _. Kneading of lower soft tissues prone in front of the patient and stabilize the head with the
Stand at the side of the table and stabilize the head upper hand. Use the heel of the kneading hand to
with the upper hand. Use the heel of the kneading work on the lateral and posterior tissues uppermost
hand to push the trapezius and lower posterior to push them toward the spine.
cervical muscles toward the table. Tips: Most useful in subjects with very tight
Tips: This is not very comfortable for the patient fascial states as working toward the spine is often
unless a table with a breathing hole is used as easier than working away. Try reaching round to
excessive extension can result. the lower side and pulling up with the fingertips to
work on the tissues nearer the table.

21.8 _. Kneading of lateral soft tissues side- 21.1 0 _. Kneading of soft tissues sidelying
lying Stand at the head of the table and stabilize Stand at the corner of the table slightly behind the
the patient's head with the front hand. Use the patient and stabilize the head with the upper hand.
thumb and thenar eminence of the kneading hand Use the thumb and thenar eminence of the lower
to work on the tissues on the side of the neck to hand to work on the soft tissues of the neck.
produce the kneading force. Tips: Try using a rotation force at the same time
Tips: This hold allows the anterior tissues to be with the head hand to emphasize the effect of the
worked as well as the lateral ones. Try varying the force applied with the kneading hand.
rotation of the head with the stabilizing hand to
direct the effect of the technique to different layers
and parts of the muscles.
 Techniques for the cervical area 163
21.11 <1111 Kneading of soft tissues sitting The
patient sits with her legs over the side of the table.
Stand in front of her and stabilize her head on your
chest; use a suitable pad if necessary. Reach round
her neck and use the fingertips to pull the soft tissues
away from the spine on both sides simultaneously.
Tips: Try adding a sidebending movement at the
same time to aid the muscle stretch effect.

21 .12 T Kneading of soft tissues sitting The

patient sits with her legs over the side of the table
and her head is stabilized against your chest,
suitably padded if necessary. Control her head with
one hand and use the fingertips of the other to
knead the soft tissues on the lateral and posterior 21 .13 T Kneading of anterior tissues supine
parts of the neck. Stand at the head of the table and fix the head into
Tips: This hold allows movements to be com- the pillow with one hand. Reach carefully round the
bined with the kneading as the head hand can anterior part of the neck to the scaleni muscle
control the directions more easily than if two hands group and push toward the table with the thumb
are performing the kneading. and thenar eminence. When the barrier has been
engaged, keep the thumb still and roll the head
away with the other hand to bow the muscles over
the thumb.
Tips: If kneading is applied directly to the
scaleni, it is extremely uncomfortable. Working on
the muscles using this method allows quite strong
stretch with far fewer problems.
164 Techniques for the cervical area

21.14 • Kneading of anterior tissues supine 21 .15 • Kneading of anterior soft tissues
Stand to the side of the table and stabilize the head supine Stand at the side of the patient and
on the pillow with the upper hand. Use the heel of stabilize the head with the upper hand. Reach
the lower hand to push carefully into the scaleni round the throat with the lower hand and pull the
until resistance is felt. Hold the muscles on this tissues toward the midline. When a small amount of
slight tension and roll the head away to bow the tension has been achieved, push the head away to
muscles over the thenar eminence. focus the forces in the throat and anterior tissues.
Tips: As the scaleni are so sensitive to pressure, Tips: A direct stretch and kneading on these
this allows quite strong stretch and kneading effect tissues can be very uncomfortable so this tech-
by using a lever rather than pressure. nique allows them to be worked with far less
discomfort.

21.16 ~ Stretching of lateral tissues supine

Stand to the side of the patient and cup the
shoulder in the lower hand. Hook the upper hand
around the occiput with the thenar eminence
resting against the mandible. Stabilize the shoulder
and rotate the head away from the shoulder until
tension is felt to accumulate in the lateral tissues.
Tips: Try varied degrees of rotation to reach
different depths of tissues. Try varied degrees of
sidebending, either before or after the rotation to
alter the tissue to be affected. Try reaching down
the neck with the head hand to fix around the
transverse process of a mid or even lower cervical
segment. This will focus the force below the fingers
to emphasize the stretch in the lower neck instead
of the whole neck. Try varied directions of pressure
on the shoulder, toward the table or toward the
axilla for example. Try changing the order of
application with each hand. Every minor change in
order, amplitude or direction will vary the technique
and only by experimenting in this way can you find
the optimum for each case.
Techniques for the cervical area 165
166 Techniques for the cervical area
21.17 <1111 (see previous page, top left) Stretching
of lateral tissues supine Stand at the head of the
table and cup the occiput and upper neck in one
hand. Fix on the distal part of the shoulder with the
other hand. Apply a sidebending to the neck while
rotating it away from the shoulder until a stretch is

*
felt to accumulate in the tissues.
Tips: Try varied degrees of sideshift with the
head hand to focus the forces at the area desired.
See tips for photograph 21.16, as the same para-
meters apply.

21.18 <1111 (see previous page, top right) Stretching

of lateral posterior tissues supine Stand slightly
to the side of the head of the table and support the
head in the palm of the upper hand. Fix the tip of
the shoulder with the other hand. Apply the stretch
with the head hand pulling into a combination of
flexion, sidebending and rotation until the tension is
felt to accumulate in the area desired. Note that the
head hand has pushed up into the neck in this view
to focus the force more specifically to the lower
neck.
Tips: See tips for photograph 21.16 as the same
variations apply in this hold.

21.19 <1111 (see previous page, bottom left) Stretch-

ing of posterior tissues supine (hand hold) Cross
your forearms with the palms facing the floor. When
they are placed under the head and the hands are 21.21 • Functional technique or strain and
against the shoulders it will be possible to lever counter-strain hold supine The patient lies with
downwards with the hands, and upward with the the head over the end of the table. Support the
forearms to push the head into flexion. This will, head in your palms with the fingertips of both
therefore, stretch the posterior tissues. hands contacting the articular pillars of the relevant
segment. With this hold it is possible to introduce
21.20 <1111 (see previous page, bottom right) Stretch- all possible movement parameters of the neck to
ing of posterior tissues supine The hand hold find the optimum pathway of ease for the functional
shown in photograph 21.19 is applied. Induce the technique. See earlier section relating to functional
flexion movement by shrugging your shoulders, or techniques.
by slightly straightening your arms.
Tips: Try sidebending your body to produce a
rotation of the patient's head which will tend to
focus the force on one side more than the other.
Try changing which arm is on top to see which
reaches the target structure and tissue best in each
case.
 Techniques for the cervical area 167
21.22 ~ Articulation into sideshifting, sidelying
Stand in front of the patient and stabilize the head

-
into the pillow with the upper hand. Reach around
the articular pillars with the lower hand and pull
directly up toward the ceiling to induce a sideshift-
ing movement. Focus the forces by emphasizing
most of the lifting force with one finger while
maintaining some pressure with the other fingers to
reduce discomfort.
Tips: This hold allows an accurate test of
individual segmental mobility as well as being a
useful treatment technique. Restricted mobility will
manifest as a distinct lack of sideshift capability.

21 .23 ~ Articulation into sidebending supine The

patient's head rests on the pillow. Push with the
pads of the fingers of one hand over the transverse
processes while pushing the head with the other
hand in the same direction. Note that it is important
to keep the vertex substantially in the central plane
so that you do not induce excessive strain on the
other side.
Tips: Least useful where the transverse pro-
cesses are very tender for any reason. In this case,
use the pads of the fingers and prise the head over
them. This will be much less uncomfortable than
pushing into the neck with the fingertips. Extra
considerations: Paradoxically the operator per-
forms rotation of his body to perform sidebending
of the patient's neck.

21.24 ~ Articulation into extension supine Leave

the head resting on the pillow and prise up toward
the ceiling behind the articular pillars to induce
extension. The backs of the hands remain on the
pillow to act as a fulcrum for the movement.
Tips: Least useful in cases where extension
movement may be a problem, such as postural
hypotension or brachial neuritis syndromes.
168 Techniques for the cervical area
21.25 <1111 Articulation into flexion supine Lift the
head with the palms of the hands and rest it on your
upper abdomen or lower chest. Pull up against the
desired level with the pads of the fingers to induce
flexion. Use a small straightening of the knees to
aid the movement which will also help avoid
excessive fatigue in the hands.
Tips: Note that the elbows remain close to the
sides throughout so that the movement is per-
formed by the operator's body, not the arms.

21.26 • Articulation into localized extension 21.27 • Articulation into rotation supine Leave
supine Leave the head on the pillow and use the the head on the pillow and stand slightly to the side
forearm as a fulcrum. Prise the target level up with of the table. Rotate the head to the same side.
the pads of the fingers into localized extension. Keep the vertex in the midline so that a pure
Tips: Avoid pressing too far laterally as the tips of rotation can be made. Support the head with one
the transverse processes are usually very tender. hand and allow it to slide under the head as the
Extra considerations: Try adding sidebending to other hand pulls behind the transverse processes
the extension movement to localize it even more into rotation. Note that the index finger is applied at
specifically. a target level to focus the force principally to one
point.
Tips: Try standing in varied positions to find the
best personal method, at the end of the table,
to one side or the other. Extra considerations:
Paradoxically the operator performs sidebending of
his body to produce rotation in the patient's neck.
 Techniques for the cervical area 169
21.28 ..,.. Articulation into rotation supine Keep
the head on the pillow and turn it to one side,
allowing the underneath hand to slide under the
head. Apply the other hand to the temporal and
maxilla area of the upper side and pull into rotation .
Tips: It is easy to introduce different elements of
sidebending along with rotation in this hold. Try rotat-
ing and then adding sidebending, or sidebending and
later adding the rotation. The sum of the movement is
similar, but the effect is completely different accord-
ing to which tissue is put on tension first.

21.30 A Springing into extension prone The

patient lies prone, preferably with the face in a
breathing hole in the table. Apply your pads of
21 .29 A Articulation into sidebending supine thumbs directly over the posterior aspect of the
For this alternative hold sit at the head of the table transverse processes of the target segment. Apply
and use the fingertips of one hand to act as a a direct posterior to anterior springing movement to
fulcrum for the sidebending. Push with the other produce localized extension.
hand against the parietal area on the other side to Tips: Least useful where the patient may have a
induce the sidebending. problem with prone lying. Least useful in cases
Tips: The sitting posture forms a useful variation where extension is best avoided due to any
for the operator who might find standing tiring, circulatory insufficiency causing potential obstruc-
inconvenient or impossible. tion of vertebral arteries.
170 Techniques for the cervical area

21.32 • Traction unilaterally supine Sit at the

21.31 • Traction supine This operator viewpoint head of the table and fix the head to the pillow with
photograph shows the hands applied to perform the wrist, forearm and lateral border of the hand.
traction. The underneath hand has carefully gripped Slip the other hand under the head and hook the
round the occiput with the head resting on the fingers under the occiput or around the spinous
palm. The other hand is gripping around the chin process of a vertebra. Maintain the pressure with
and the heel of the hand is applied to the mandible. both hands and pull gently in the long axis of the
The wrist and forearm of the chin hand push slightly spine.
toward the opposite side to induce a slight side- Tips: Note that some rotation and slight side-
shift. The occiput hand is introducing a variable bending has been introduced to focus the move-
quantity of sideshifting depending on the target ment to a specific area on the lower side.
segment. More sideshifting will drive the force
lower in the neck. The wrist of the chin hand
balances the pressure of the other hand. Once
the sideshift is applied, the traction force can
be brou~ht into play. Remarkably little range of
tract1on IS available if the sideshift is maintained
which makes it very specific to a small number of
segments.
Techniques for the cervical area 171
172 Techniques for the cervical area
21.33 <IIIII (see previous page, top left) Traction and
sidebending articulation combined Stand at the
head of the table and fix the head against your upper
abdomen. Apply a slight lifting force with the index
fingers to produce a small anterior shifting move-
ment. Keep the arms fairly rigid and pivot your body
into sidebending from side to side while leaning back
slightly. The sum effect is to produce a sidebending
and traction force that will vary in level according to
how far down the neck you fix with the hands.
Tips: This can be rather hard work, but is capable
of producing rapid changes in mobility, making it an
extremely useful technique. Most useful in cases of
brachial neuritis where the sidebending force will be
introduced primarily in one direction to open the
foramen on the convexity.
21.34 <IIIII (see previous page, bottom left) Thrust
using cradle hold supine (hand position) Stand
21.37 A. Thrust using cradle hold into sidebend-
slightly to the corner of the table on the side that the
ing, supine Stand at the head of the table slightly
thrust is to be applied. Supinate the tower hand and
pronate the upper one so that they form a mirror to the corner behind the head. Take up the hold
image of each other. Note that the fingers are slightly with the underneath hand supinated to support the
splayed to spread the force over a larger area. Note head. Apply the thrusting hand with the arm close
also that the elbows remain fairly close to the to your body and the lateral aspect of the middle
operator's sides. interphalangeal joint of the index finger slightly
behind and to the side of the transverse process of
21.35 <IIIII (see previous page, top right) Thrust into the target segment. Keep gently testing the primary
rotation, cradle hold supine Use the hand position lever of sidebending while adding all the other
shown in photograph 21 .34 and turn the head gently available components until a sense of barrier
into the primary lever direction of rotation. There is accumulates. When the optimum barrier has been
unlikely to be a sense of barrier with this small found, maintain the secondary components and
amount of rotation, so add other components either apply a low amplitude thrust with the index finger
individually or in combination to accumulate the most directed toward the opposite shoulder.
effective potential barrier. You need to constantly test The secondary components most often useful in
the primary lever direction while adding the other this technique are contra-rotation, sideshifting,
components until the optimum barrier is sensed. Firm compression of the head between the hands, slight
contact point pressure is important as it helps to extension and localized pressure over the contact
further reduce the other components. Maintain all the
point with the finger. It is important that the
secondary levers of sidebending, sideshifting, com-
underneath hand does not allow the head to move
pression, anterior shifting and slight extension and
away from the barrier when the thrust is performed,
apply the thrust into a small amplitude of rotation.
as otherwise excessive torsion can result.
Tips: Note that the elbows are close to the sides,
Tips: Most useful in cases of brachial neuritis on
and the technique will be more efficient if you stand
as upright as possible so that the arms move with the the side to which the neck is being rotated as the
body. This technique is designed to slide the facet on foramina on that side will be opened by this thrust.
the same side as the thrust is applied. This thrust is designed to gap the facet on the
opposite side to the thrusting hand.
21.36 <IIIII (see previous page, bottom right) Thrust
into rotation, cradle hold supine This operator
viewpoint photograph shows the underneath hand
acting in compression against the thrusting hand.
The vertex is maintained in the midline. Note that the
wrist of the thrusting hand is in a neutral position. At
the end of the thrust the hands accentuate their
positions of supination and pronation respectively. This
should slide the facet on the same side as the thrust.
 Techniques for the cervical area 173

---

21.39 • Thrust using cradle hold into sidebend-

ing This illustration is of the sidebending thrust
applied to a lower cervical segment. The hold is
taken up in the usual way, but instead of applying
more levers, the head is being compressed
between the hands so that the effect of the
sidebending force is amplified. Note that the
thrusting forearm is almost horizontal so that the
neck is not being forced into a painful direction,
and that the thumb is applied to the mandible to
21.38 • Thrust using cradle hold into sidebend- help block out upper cervical movement. This is
ing, supine This operator viewpoint photograph designed to gap the facet on the opposite side to
shows the hold described in photograph 21.37. the thrusting hand.
Note the buckling of the neck over the operator's
thrusting hand and that the vertex is almost in the
midline. The hands are applying a compression
toward each other to minimize the quantities of the
other secondary levers. This should gap the facet
on the opposite side to the thrust hand.
174 Techniques for the cervical area

21.40 .A Thrust into rotation using chin hold

Stand at the head of the table, slightly at the corner
behind the head. Gently rotate the head to one side
and slide the chin hand under the side of the head
to take up the hold. Take a small step to the back 21 .41 .A Thrust using chin hold into rotation,
corner of the table and slide the thrusting hand into supine This operator viewpoint photograph shows
place with the metacarpo-phalangeal joint of the the hold illustrated in photograph 21.40. Note the
index finger applied behind the articular process. midline position of the head, and the straight
Keep testing the primary lever direction of rotation position of the wrist of the thrusting arm. Note the
while adding the contra-sidebending and other position of the supporting forearm under the head
components until a suitable barrier has been is in front of the patient's ear. This technique is
accumulated. Thrust with the hand behind the head designed to slide forward the facet on the side
while stabilizing the head and chin with the other being thrust.
hand. Note that the thrusting hand wrist should be
in line with the forearm, and both elbows close to
the sides. Note also that the forearm of the
thrusting arm is almost horizontal. The most useful
secondary components to focus this technique are
compression between the hands, slight sideshifting
in the opposite direction to the sidebending, and a
slight anterior shift of the whole assembly. This is
designed to slide the facet on the same side as the
thrusting hand.
 Techniques for the cervical area 175
21.42 ~ Thrust using chin hold into sidebend-
ing This photograph shows the hold applied to a
lower cervical segment from a different viewing
angle. Take up the hold in the way previously
described. Apply the lateral border of part of the
index finger or metacarpal to the posterior part of
the transverse process of the segment. Buckle the
neck over the thrusting hand so that the sidebend-
ing and sideshifting occur at the same time.
Introduce a small amount of controlled rotation
with the other hand, and then balance all the
secondary components against the primary lever of
sidebending. At the optimum moment apply the
thrust with one hand while maintaining the head
position with the other. Note that the thrusting
forearm is almost horizontal and that the vertex
remains in the midline. This is designed to gap the
facet on the opposite side to the thrust hand.

21.43 • Thrust using chin hold into rotation of

atlanto-axial joint Take up the chin hold in the
manner previously described fixing behind the
transverse process of the atlas with the thrusting
hand. As the principal movement possible of this
joint is rotation, only slight sidebending will be
required. Introduce a very small extension to take
the posterior tissues off tension, and apply the
thrust in pure rotation through a small amplitude to
gap the facet on the same side.
Tips: Most regions of the body can be treated in
any order, but if it is necessary to thrust the atlanto- 21.44 • Thrust using chin hold into rotation or
axial joint, it is often found to be best left to the last sidebending This photograph is to show the
manipulation of a treatment session. This is not an ab- overall posture usually adopted for these types of
solute rule, but has sound reasoning. This joint is very techniques. Note that although the operator is bent
susceptible to becoming hypermobile and therefore from the waist, he has not flexed his spine. Note
suffering recurrent lesioning. If it is manipulated first, that the leg on the thrusting side is behind the other
it is liable to be stressed when any other thrusts are so that the operator's body is brought into the
done in the area, thereby irritating it further. thrust. Note that the forearm of the thrusting hand
is horizontal and that the patient's head has been
left on the pillow.
176 Techniques for the cervical area

21.45 • Thrust using pulling hold supine Stand 21.46 • Thrust into rotation prone Stand to the
to the side of the table and grip around the side of the prone patient and stabilize the head with
transverse process of the target segment with the the upper hand. Use the thrusting hand as a
middle phalange of the index or middle finger of the fulcrum to sidebend the neck. Maintain the head in
thrusting hand. Balance the forces with the other the midline and carefully push the lateral side of the
hand applied to the side of the forehead closest to index finger into the neck against the posterior
you. Introduce part of the primary lever of rotation aspect of the articular process of the target
and slowly oscillate in the primary lever direction segment. The primary lever of rotation is going to
while adding the secondary levers until a satis- be a force directed in the line of the forearm as
factory barrier accumulates. Maintain the secondary shown. Maintain the position with the stabilizing
levers, and apply the thrust with a short sharp hand and apply the thrust behind the articular
pulling action with the thrusting hand into rotation. process through a very small amplitude.
Tips: Some operators find that pulling tech- Tips: Note that there is a tendency to introduce
niques are easier for them than pushing ones. This extension, and that this is potentially dangerous
technique is most useful in these cases. It is also and must be avoided. Although a sidebending
useful where the operator has a problem in using thrust could be applied with this hold, it is even
one particular hand for any reason. The left side of more likely to produce an unwanted hyperextension.
the neck is usually thrust with the left hand of the If a table with a breathing hole is being used, either
operator, but with this technique the right hand is plug it up for this technique, or have the patient
thrusting the left side of the patient's neck. move slightly to one side so that the chin can act
as a pivot directly on the table. Least useful for
patients over 40 years of age.
 Techniques for the cervical area 177

21.47 A Thrust into rotation sitting Have the

patient sit across the table toward one end.
Stabilize the head with the front hand, and apply
the pads of the fingers behind the articular process
of the target segment with the other. Introduce
sidebending toward the thrusting hand, and
rotation away. Keep testing the primary lever of
rotation while adding the secondary components of
the composite lever until a suitable barrier accumu-
lates. Maintain the secondary levers and apply a
short sharp thrust into rotation with the hand
applied to the neck.
Tips: This is a rather difficult technique to control
as the neck tends to try to escape from the tension
induced unless it is very carefully managed. Many
operators may find it difficult to generate the
sharpness needed to break facet fixation with this
hold. It is, nevertheless, useful as some patients will
not relax well in a supine position, and may find this
hold more comfortable.
178 Techniques for the cervical area
21.48 <IIIII (see previous page, top right) Thrust
into rotation sitting (hand hold) The hand reach-
ing in front of the patient is supinated, and either
the index or the middle finger is flexed to make it
more prominent and ready to apply behind the
articular process. The other hand is spread slightly
and is applied to the nearside of the head to act as
a stabilizer for the thrusting hand. Note that the
operator's elbows are close to his sides.
21 .50 ..,... Thrust into rotation sitting (hand hold)
The patient sits across the table near the end.
Stand at the end of the table and reach around the
neck with the front hand so that the lateral border
of the hand can pull forward on the far side articular
process. Place the thumb of the pronated posterior
hand on the far side of the spinous process of the
next lower vertebra. Maintain a small amount of
sidebending away from you by firm pressure
against the side of the spinous process. The thrust
will be applied with both hands. One is pulling
forward from behind the articular process, and the
other pushing the spinous process toward you .
This will produce a contra-rotation force between
the adjacent vertebrae.
21.49 <IIIII (see previous page, bottom right) Thrust
into rotation sitting The hold described in photo-
graph 21.48 is applied. Rotate the head using both
hands until it is approximately in mid rotation.
Apply some sidebending to the opposite side.
Maintain the rotation and opposite sidebending
and circumduct the patient's body through a small
arc keeping the vertex directly over the sacrum.
When tension accumulates in the target segment,
apply the thrust with a short sharp pulling action
with the front hand while aiding it with the other.
Note that firm compression between the hands is a
critical part of this technique.
Tips: It sometimes helps to ask the patient to
exhale just before the thrust to produce an opti-
mum state of relaxation. Another useful relaxation
aid is to ask the patient to let the shoulders drop; as
they do this, there will be an interval of 2 or 3
seconds when the thrust is more easily performed.
21.51 ..,... (bottom right) Thrust into rotation sitting
Take up the hold with the grip described in photo-
graph 21.50. Produce a buckling into sidebending
at the target segment, and pull back slightly on the
clavicle with the posterior hand while prising the
spinous process toward yourself. The secondary
components of sideshifting, antero-posterior shift-
ing and compression are balanced. At the optimum
barrier, the thrust is applied by a stabilizing force
with the posterior hand and a rotation force with the
anterior hand .
TECHNIQUES FOR THE OCCIPITAL 22
AREA

The occipital and upper cervical regions are mistakenly applied to counteract the lack of
areas where extreme caution is necessary in ability to focus accurately. Maximum safety is
preliminary assessment before techniques are paramount and too much force jeopardizes
applied. Care is required in all areas, but in this. If a given technique is not working, try
the occipital region this is even more critical. reducing levers and forces rather than
There is the possibility of damage to the increasing them. It may seem paradoxical,
vertebra-basilar system if instability is present. but this often works much better. It is often
Precautions need be undertaken before per- necessary to make many subtle changes in
forming any thrust technique that is in any direction or plane to find the optimum for
way liable to put the area under mechanical each technique. Every patient will differ, and
stress. As in the rest of the neck, the patient changes in table height, operator position in
is often fearful of manipulation, and as light a relation to the patient, and quantities of the
force as will achieve the required result is varied components of a composite lever vary.
essential. It is often difficult for students to Many cases will respond well to general
achieve the required acceleration and subse- mobilizing and articulation. Some, however,
quent braking force necessary in thrust tech- will only achieve full and lasting relief from
nique in this area, and there is no substitute treatment when a specific thrust is successfully
for practice and practical experience. performed to fully liberate a facet fixation.
The reader is referred specifically to the Although specific positions of lesion fixation
section on contra-indications. However, suffice are often described, the techniques shown here
it to say that anything that can compromise the are simply designed to break fixation. If posi-
integrity of the ligamentous structures of the tional correction is deemed necessary, the
area requires extreme caution in the choice fixation is dealt with first, and then the joint is
of technique. Some will say that all thrust coaxed into the direction required afterwards
technique should be avoided in the area if with articulatory technique.
there is so much potential danger. However, If a barrier does not seem to accumulate in
this would be to deny the possibility of aid in one direction, another is sought. This re-
many cases where almost nothing else will moves some of the fear of many students
work as well. that they may be performing the technique in
Occipital thrust techniques performed with- the 'wrong' direction. If this does not satisfy
out excessive force require a well-developed the purist in relation to lesion directions, then
barrier sense. The angles through which any several of the techniques shown can be
given technique will succeed are very small. applied in a 'correction' direction if required.
Slightly too much leverage will block the I have included the details of these under the
techniques and more force is then often 'Extra considerations' headings.
180 Techniques for the occipital area

22.1 • Articulation into flexion supine Push the 22.2 • Articulation supine (hand hold) Form a
head into flexion with your thumbs on the mandible pivot with the pad of thumb and index or middle
while you pull under the occiput with your finger- finger. Rest the back of the hand on the pillow.
tips. Apply the other hand to the forehead of the patient
Tips: Try adding traction to the movement. Try to be able to tip the head into all the directions that
adding sidebending to the movement. Ensure the the technique allows.
patient has time to breathe between repetitions as
the flexed position may obstruct the ability to
breathe.
 Techniques for the occipital area 181
22.3 ~ Articulation into extension supine Apply
the hand hold shown in photograph 22.2 and tip
the head into extension with the forehead hand
while pivoting it over the occiput hand. Once the
head is in extension it can be rolled into sidebend-
ing to either side to focus the force to each condyle
of the occiput.

22.4 T (bottom left) Articulation into flexion supine

This operator viewpoint photograph shows the hold
from photograph 22.3 in use for flexion. Note that
the pillow is retained, partly to allow it to be used as
a fulcrum, and partly as most patients seem to
prefer the security and familiarity of a pillow.
Tips: Allow the patient time to breathe between
pressures as the trachea can be obstructed in
extreme passive flexion!

22.5 T (bottom right) Articulation into extension

supine In this operator viewpoint photograph the
head is pushed up with the lower hand while
tipping it into extension with the frontal hand. Note
that this is an extension focused to the occiput
rather than an extension of the whole neck.
Tips: Try alternating this movement with flexion
and sidebending to focus forces to one specific
condyle of the occiput. Try varying the spacing of
the lower hand to find the optimum for efficiency
and comfort.
182 Techniques for the occipital area

22.7 A Traction to occiput supine Apply the

hand hold shown in photograph 22.6. Lower your
elbows over the end of the table to form a fulcrum,
and fix your hooked fingers under the occiput. As
you lower your elbows, the traction force accumu-
lates automatically. Although this would not seem
to be very powerful, it does reach very specifically
to the occiput and can be very useful if localized
traction is desired.

22.6 A Traction to occiput (hand hold) The

operator has his fingers close together and is
hooking them so that they can pull cephalically
under the occiput into localized traction. The backs
of the forearms will be applied to the pillow with the
elbows over the end of the table. This will allow him
to produce traction partly by pulling, and partly by
levering his forearms against the end of the table.
 Techniques for the occipital area 183

22.8 • Thrust to occipito-atlantal joint sitting body. As the head is in contact with your chest this
(hand hold) This hold is used for a specific thrust bowing action will form a sidebending action of the
technique to be applied to the occipito-atlantal joint neck so that the atlas is driven slightly toward you.
on the far side from the operator. The upper hand You must simultaneously supinate your upper
will be applied around the frontal bone, temporal forearm. The patient's body is now in sidebending
bone and maxilla of the patient. The lower hand is away from you, and you can rock into circumduc-
to be applied with the index or middle finger placed tion from your ankles. As the barrier accumulates,
gently in front of the transverse process of the increase the compression of the head toward you,
atlas. The palm will be cupping the occipital bone. and momentarily grip the atlas firmly as you adduct
both arms. The cumulative effect of this is to
22.9 ..,.. (top right) Thrust to occipito-atlantal produce a rotation of the head toward you, and of
joint sitting The hold illustrated in photograph the atlas away.
22.8 has been applied. Stand to the side and Tips: Most useful in cases where it is best to
slightly behind the seated patient. Fix the frontal avoid excess rotation of the head on the neck. This
bone with your biceps avoiding the eyes. The technique works with the head in any degree
forearm of the upper arm lies around the temporal of rotation so it is hardly necessary to torsion the
bone and the inside of the elbow is in contact with neck at all. It is probably the safest of the thrust
the maxilla. The technique will not work effectively techniques that can be applied to this joint. Least
if the hand of the upper arm is in contact with the useful if the atlas is extremely sensitive to touch
patient. The grip is only performed with the medial as the pressure may be unacceptable. Extra
aspect of the forearm. Your lower hand grips gently considerations: Ensure that firm compression of
around the anterior aspect of the transverse the head into your body is maintained throughout.
process of the atlas with the pad of the index or Only pull back on the transverse process of the
middle finger. Pull carefully backwards on the atlas atlas for as short a time as possible to avoid excess
while performing a bowing movement with your discomfort.
184 Techniques for the occipital area
22.10 ...,. Thrust to occipito-atlantal joint sitting
{rear view) The technique described in photo-
graph 22.9 is set up. Note that the patient is
sidebent toward the operator at the pelvis, and
away at the neck. Note the supinated upper arm
that is maintaining the compression. Note that the
upper arm hand is not in contact with the patient.
Note that the patient's head is in a position of
almost no rotation but a contra-rotation force is,
nevertheless, being applied to the occipito-atlantal
joint.
 Techniques for the occipital area 185
22.11 ~ Thrust using minimal leverage to gap
occipito-atlantal joint supine This technique is
designed to gap the occipito-atlantal joint on the
side where the thrust is applied. It is a minimal
leverage technique as the neck is not taken to full
rotation, but merely placed in an available position
so that the contact point is available for the thrust.
Some small quantities of levers are used, but the
emphasis is mostly on carefully applied compres-
sion, and high velocity with very short amplitude. -
Keep the vertex of the head in the midline and take
up the chin hold with one hand. Keep the head
resting on the forearm applied anterior to the ear.
Ensure that the head is against your upper arm and
thorax so that it is firmly controlled, cradled and
supported. Place the applicator, the first metacarpo-
phalangeal joint of your thrusting hand, on the
posterior aspect of the arch of the atlas. Keep the
vertex midline and press firmly into the atlas to take
up the slack in the soft tissues. Apply the thrust
with a rapid force toward the patient's opposite eye
and a simultaneous force of the other forearm
against the side of the head.
The total of these forces should keep the head
still while the atlas is driven forwards underneath
the occiput. This is not a torsional force of the head
on the neck, but a force of the atlas under the
occiput to break fixation on the side of the thrusting
hand. If excessive head movement is allowed, the
occipito-atlantal joint on the other side will be
0
strained, with a sidebending force. There will also
be a tendency to strain the atlanto-axial joint into
excess rotation. Note: this is an extremely difficult
technique to perform well as there is no sense of
accumulating barrier. The control of acceleration
and braking and accurate directions of force are
the governing factors. If it is performed as de-
scribed here there is little chance of trauma but if
torsion is added instead of the method described it
is then no longer a minimal lever technique and
tissue stress is more likely.
Tips: Most useful where torsion is best avoided
and fixation is not too severe. Least useful if the
operator is not able to develop the skill to apply the
necessary ultra-high velocity, and the strict control
of the braking force. Extra considerations: Try
asking the patient to look over the shoulder of the
side to which the head is being rotated. This will
increase the effect of the small amount of levers
applied as the eye torsion tenses the cervical
musculature. Conversely, try asking the patient to
turn the eyes to the other side if the tension
accumulates too fast as this will have the effect of
reducing neck tension.
186 Techniques for the occipital area
22.12 ~ (see previous page, bottom right) Thrust
atlanto-axial joint cradle hold supine As the main
movement of the atlanto-axial joint is into rotation,
thrust techniques normally used are rotatory types.
This technique is designed to break fixation on the
side of the thrusting hand. Apply the proximal
metacarpo-phalangeal joint of the thrusting hand
behind the arch of the atlas. Support the head in
the palm of the underneath hand and apply a
compression force toward the thrusting hand to
absorb the slack into compression to avoid excess
torsion. Keep the vertex in the midline and gently
rotate the head to about 50% of its available range.
Apply a small amount of sidebending opposite to
the rotation and a very small extension of the head
on the neck to take the posterior tissues off
tension. This will make room for the applicator to
reach the atlas. Slowly increase the compression
while gently oscillating the head into rotation until a
sense of barrier accumulates under the thrusting
hand. Apply a short amplitude and high velocity
force to the atlas to break fixation in a forward or
rotation direction of the atlas on the axis.
Tips: Most useful in older necks as the compres-
sion force helps to minimize the torsion necessary.
Least useful if the operator is not able to develop 22.13 ..l Thrust to occipito-atlantal joint supine
the speed necessary to break fixation in this type of This hold is useful if a traction component is found
technique. Extra considerations: This hold makes to be necessary to gap the joint. It is also useful if a
several variations of the technique available. It is sidebending component is necessary. Pronate the
possible to thrust into sidebending to gap the other arm of the thrusting hand and apply it behind the
side of the occipito-atlantal joint. It is possible to occiput on one side of the head. Rotate the head to
thrust on the occiput itself to gap the occipito- the other side and fix the head against your chest
atlantal joint on the same side. It is possible to and the pillow with the underneath hand. Rotate
thrust on the posterior aspect of the atlas while the head to about 50% of the neck range and apply
holding the head still to gap the occipito-atlantal a traction force with the underneath hand. Com-
joint of the same side. press the head between the hands and push firmly
up into the occiput with the pisiform of the thrusting
hand. Apply very slight extension and sidebending
toward the thrusting hand to take the tissues off
tension and allow the thrusting hand to reach the
target tissues. Perform the thrust as a traction with
the underneath hand and a rapid adduction with
the pisiform.
Tips: Most useful in cases where there is a
sidebending component in the lesion complex.
Least useful where operator arm strength may not
be sufficient or where the patient may have an
extremely large head. Extra considerations: A
sidebending, rotation or traction force can be used
according to which gives the optimum barrier.
 Techniques for the occipital area 187
22.14 ~ Thrust to occipito-atlantal joint supine
This technique is useful for breaking fixation in a
sidebending or rotation direction. Leave the head
on the pillow and take a small step to the corner of
the table. Slip your upper hand under the occiput
so that the fingertips just curl under the base of the
skull. Pull gently upwards under the occiput on the
lower side as you apply the other hand to the
maxilla and mandible on the upper side. Use a
small compression between the hands to hold the
head firmly, but avoid excessive pressure on the
mandible as otherwise the temporo-mandibular
joint can be strained. Tip the head into very slight
extension to take the posterior tissues off tension,
but not enough to reach the end of range of
movement in the occipito-atlantal joints.
Increase the rotation to about 50% of full range
and then balance all the components together until
tension accumulates on the occipital condyle
nearer the table. Apply a short amplitude thrust into
sidebending with the maxilla hand while tugging
upwards with the occiput hand. Note that this
thrust can also become a rotation thrust with the
maxilla hand around the fixed axis of the under-
neath hand. This will have the effect of gapping the
upper condyle rather than the lower as in the
sidebending thrust.
Tips: Most useful in cases of sidebending re-
striction. Least useful in patients who have a very
mobile mid cervical spine as the force will too easily
dissipate there and not accumulate at the occipito-
atlantal joint. Extra considerations: Try using this
position as a firm articulation procedure, but do not
carry it on for very long as the forces generated are
very strong and will provoke discomfort.

22.15 ~ Thrust to occipito-atlantal joint 'fly-

wheel' technique (hand hold) This technique is a
complex one where both hands work in opposition
to hold the axis and rotate the occiput on it. The
axis hand is to be placed with the thumb gently
applied in front of the transverse process and the
reinforced middle finger posterior to the transverse
process on the other side. The chin hand will be
rotating the head to one side as the atlas is held to
the other. Even though momentum is used, the
head should not reach full rotation even at the end
of the technique. It is the effect of the one hand
pulling back on the atlas as the head is rotated
which causes the joint to gap, not full rotation of the
head on the neck.
188 Techniques for the occipital area

22.16 .& Thrust to occipito-atlantal joint 'fly-

wheel' technique Stand to one corner at the head
of the table. Take up the chin hold with one hand
while using the other to take a hold on the atlas. The
atlas hand is applied with the thumb placed just
in front of the transverse process. The reinforced
middle finger is placed on the other side just behind
the transverse process of the atlas. As you drop the
elbow of the atlas hand toward the table while pulling
carefully back on the transverse process you will
rotate the atlas slightly back toward the neutral
position. As you rotate the head toward the pillow,
you will tend to carry the atlas with the head. Make a
few gentle rotation movements with both hands
moving in the same direction of movement of the
chin toward the pillow. At the optimum moment
accelerate the chin hand to rotate the head sharply
toward the pillow. At the same time grip for as short a
time as possible on the atlas to hold it from joining
the head rotation. Release the atlas immediately the
technique is completed as the transverse process is
usually very tender to pressure.
Tips: Most useful in fairly flexible necks where the
mobility makes normal locking techniques difficult.
Least useful in stiff necks with degenerative changes
as the torsional forces, however carefully applied,
can be potentially problematical. Extra considera-
tions: Try tipping the head into very slight extension
to take the posterior tissues off tension and make the
atlas more accessible. At the moment of thrust try
pushing the head into the pillow to add a compres-
sion component that may help in localization.
TECHNIQUES FOR THE SINUSES AND 23
TEMPORO-MANDIBULAR JOINTS

The nasal sinuses are a common site of backtracking into the skull and brain must
congestion, infection and inflammation and always be borne in mind.
osteopathic intervention using vibration and The temporo-mandibular joints are a site of
frictional techniques can play a part in treat- symptoms and dysfunction in some patients,
ment in some cases. Rarely will these be a and can be somewhat improved in their
complete answer, and other methods from function by osteopathic intervention. Hyper-
hot or cold packs through to antibiotics are all mobility is clearly not going to respond well
appropriate in certain cases. The osteopathic to mobilizing techniques; however, when
input can, however, add a dimension to that hypermobility is due to over-stress pro-
treatment which may not have been con- duced by the opposite side being too tight,
sidered by other practitioners. Some appar- suitable mobilization of the restricted side can
ently simple manoeuvres can have a very be useful. The dental surgeon has a role in
profound effect on drainage, and produce assessing the occlusion of the teeth and
benefit out of all proportion to the time and making any suitable adjustments here, but
effort used. Some of these techniques can gentle stretching of over-tight muscles and
also be taught to the patient for their own use capsule can be valuable.
if appropriate. There are few special precautions here
Special precautions are mostly those relat- except to consider the indications as much as
ing to the possibility of spreading infection the contra-indications, and to be aware that
when the mask' area of the face is being poor results in treatment are often due to the
worked. The lack of valves in the veins wrong choice of treatment as much as the
draining the face, and the chance of infection wrong choice of technique.
190 Techniques for the sinuses and temporo-mandibular joints

23.1 A Friction or vibration frontal sinus supine 23.2 A Friction or vibration over nasal bones
Direct friction over the emission of the supra-orbital supine The nasal bones can be gently squeezed
nerve as it emits from the ridge of the frontal bone and massaged in this hold where the operator is
is being used here. The operator's fingers are steadying the head with one hand and applying the
directly applied to the notch, and either circular technique with the other.
friction or vibration can be performed. Tips: Most useful in conjunction with other
Tips: Most useful in conjunction with other sinus friction and vibration techniques. Extra
friction and vibration points and particularly when considerations: Start gently and gradually in-
the frontal sinus is involved. Least useful where crease pressure and perform the technique for
acute sinusitis makes the friction points too tender. short periods during the treatment session, repeat-
Extra considerations: Start slowly and super- ing this several times.
ficially and gradually work deeper, repeating the
technique intermittently during treatment rather
than keeping up the contact for a long period.
Techniques for the sinuses and temporo-mandibular joints 191
23.3 .,... Friction and vibration maxillary sinus
supine The operator is sitting at the head of the
table and has applied the tips of middle fingers to
the maxilla so that direct pressure can be used over
the emission of the nerve. Vibration can be applied
over the maxillary sinus in this position also. The
patient's head is stabilized by the heels of the
operator's hands.
Tips: Most useful where maxillary sinus is involved.
Least useful where acute sinusitis makes pressure
extremely uncomfortable. Extra considerations:
Start gently and gradually increase pressure, per-
form technique for short periods and return several
times during treatment session.
23.4 ~ (bottom left) Springing temporo-mandibular
joint supine While sitting at the head of the table,
the operator is holding back on the temporal bone
with one hand and applying a repetitive force along
the ramus of the jaw with the other. It is possible to
make small adjustments to the angle of that force
so that the articulation can be stressed in different
ways according to the restriction of motion
encountered. It is necessary for the patient to let
the jaw sag to make the joint accessible; when the
masseter is tense, the technique will not produce
any effect.
Tips: Most useful in cases of unilateral temporo-
mandibular joint dysfunction and intra-articular disc
derangements. Least useful in cases of bruxism
where it is more important to work on the muscles
and occlusion than the joint. Extra considerations:
While under stretch try antero-posterior move-
ments and lateral movements to find the optimum.

23.5 ~ (see next page, bottom left) Articulation

temporo-mandibular joints supine From the head
of the table the operator can gently grip both sides
of the mandible between fingers and thumbs and
apply a direct distraction force to the joints on one
or both sides. It is necessary for the patient to relax
the jaw so as to take the muscles off tension to
make this effective. The whole mandible can also
be taken into a forwards or backwards direction as
required, and if the patient slowly opens and closes
the jaw while the distraction force is applied,
adjustment of the 'tracking' during this action can
be brought to their attention as this often is an
essential part of any treatment to these joints.
Tips: Most useful in cases of mal-occlusion and
bilateral joint dysfunction where the traction com-
ponent is helpful. Least useful where muscle tissue
is very tight and prevents effective traction. Extra
considerations: Extreme tenderness at the angle
of the jaw can be an indication of occipita-atlanta
dysfunction.
192 Techniques for the sinuses and temporo-mandibular joints
23.6 ..,.. Traction and articulation temporo-
mandibular joint supine The operator is holding
directly over the joint and palpating for sense of
tension as the other hand pulls on the mandible to
distract the joint in a variety of directions as
necessary. It is also possible to hold over the articular
disc, and sensing when the joint is on optimum
tension, apply a force directly over it which may give
an opportunity for the disc to relocate if it is mal-
aligned in the joint. As in most temporo-mandibular
joint techniques it is necessary for the patient to relax
the jaw muscles during these procedures.
Tips: Most useful where muscle stretch is
needed and intra-articular disc dysfunction exists.
Extra considerations: Add antero-posterior and
lateral movements for optimum tension.
23.7 T Traction temporo-mandibular joint supine
A suitable wooden rod is interposed between the
teeth as far back as possible to form a fulcrum, and
the operator is carefully closing the jaw as distally
as possible. This causes a direct traction force to
be generated in the temporo-mandibular articula-
tion on the side of the fulcrum. Traction can be a
useful force as it is an accessory movement to the
joint and can thus produce mechanical changes
that primary movement under the control of the
patient's own muscles cannot achieve.
Tips: Most useful where muscle stretch rather
than articular work is required and where patient
has own teeth. Least useful with dentures. Extra
considerations: Pad wooden rod if necessary and
vary the thickness to find the optimum tension.
TECHNIQUES FOR THE CLAVICLE 24
AREA

The clavicle is mentioned often in early osteo- pectoral girdle that may have diminished if
pathic literature, yet relatively little attention the clavicle is not working properly.
seems to have been given to it in modem Precautions are minimal, except that hyper-
times. Although the nomenclature given to mobility of the joints can occur, and then tech-
lesion positions was attractive, and gave speci- niques applied will be irrelevant and indeed
fic directions of force to be applied to reverse may worsen the situation. Some techniques
the positions, it also limited thinking into use the arm as a lever, but possible shoulder
certain directions only. Some specific directions conditions may need protection, or alternative
of fixation are common, but modem thinking is techniques sought in these cases.
much more directed toward function, and The clavicle acts as a prop to join the arm to
techniques designed in such a way that they the body and to protect the vessels and nerves
can restore perceived deficits of function. underneath it. It is essentially a stable unit, but
The clavicle can be thought of in isolation, when the stability is lost, disproportionate
or as a structure influenced by trauma, posture symptoms and dysfunction of the arm may
and occupational disorders. It can be con- occur. This in tum can make restoration of
sidered as a bone with a pair of joints attaching function of the clavicle an important part of
it to the sternum and the scapula. Whatever any syndrome affecting the upper thoracic or
the type of thinking, the main object of shoulder area. Many 'difficult' upper thoracic
osteopathic technique is to restore normal cases will respond well if clavicular dysfunc-
mobility where it has been lost. This aims tion is attended to as a major part of the
to re-introduce integrity of function to the treatment approach.
194 Techniques for the clavicle area

24.1 _. Articulation of clavicle sidelying Stabilize

the scapula with your body and while you hold the
clavicle down circumduct the shoulder. Varied
degrees of abduction will influence the sterno- 24.3 _. Articulation of clavicle supine Hold the
clavicular or acromio-clavicular joints or simply patient's wrist and forearm firmly against you so
place the main emphasis on the shaft of the bone. that as your hand applied to the clavicle fixes
Tips: Most useful when the muscles attaching toward the table, a small straightening of your
superiorly to the clavicle are involved. Least useful knees will perform the articulation. The opposite
when the use of the shoulder as a lever would be a can be applied if you gently lift the clavicle with
problem. Extra considerations: Try using different your fingertips and apply a downward pressure
phases of respiration. through the patient's arm.
Extra considerations: Try using varied angles of
rotation of the shoulder.

24.2 <1111 Articulation of sterno-clavicular joint sit-

ting Stabilize the scapula with your body and hold
down on the medial end of the clavicle. Abduct the
patient's arm and extend and externally rotate it to
apply a pull along the length of the clavicle. Due to
the shape of the joint, the most common dysfunc-
tion is a riding upwards and medially of the sternal
end of the clavicle. In a true subluxation, this
technique may produce a realignment of the joint
but it will not last, as the capsule and ligaments will
have been disrupted, probably permanently.
Tips: Most useful where for any reason the
recumbent patient position is a problem. Least useful
in very mobile subjects where it would be difficult to
achieve a localization. Extra considerations: Try
using different phases of respiration.
 Techniques for the clavicle area 195

24.4 A Thrust to acromio-clavicular joint supine Fixation in the acromio-clavicular joint is most usual
on the anterior aspect and can be addressed well with this technique. To avoid excessive tension on the
brachial plexus when the tug is applied, the patient's head is sidebent and rotated to the same side. Pull
steadily on the distal part of the forearm and above the elbow with the other hand. Make small
circumduction movements and vary the angles of flexion and abduction of the shoulder until tension is felt
to accumulate in the acromio-clavicular joint. Apply the thrust without releasing the previously applied
tension as otherwise a whipping action will occur which makes the technique ineffective.
Tips: Least useful when gleno-humeral dysfunction is present.

24.5 ~ Thrust to a cromio-clavicular joint sitting

The final position for this technique is shown here.
The operator has applied an external rotation,
flexion and traction to the patient's shoulder while
firmly holding back on the clavicle so that forces
accumulate at the acromio-clavicular joint. As a
preliminary the patient's arm is taken from a
position with the back of her hand facing forwards
at, or behind her waist and then thrust out sharply
forwards while supinating her forearm. This puts a
gapping force on the acromio-clavicular joint.
Tips: Least useful in very flexible subjects as the
force will tend to dissipate. Extra considerations:
Try using different phases of respiration and varying
the flexion angle of the shoulder.
196 Techniques for the clavicle area

24.6 • Thrust to acromio-clavicular joint supine Start with the patient's arm by the side and firmly fix
the distal third of the clavicle with the pad of your thumb. Bring the patient's arm into elevation and rotate it
gently until tension accumulates at the acromio-clavicular joint. An articulatory force can be used, or if
tension is suitable, a small thrust can aid in breaking fixation in the joint. Care must be taken to apply the
thumb to the plateau on the top of the clavicle to keep the discomfort of the pressure to a minimum.
Tips: Least useful where there is gleno-humeral dysfunction making this range of movement impossible.
Extra considerations: Try sandwiching the patient's wrist between your hand and forearm and then
moving your whole body and arms together.

24.7 ..,.. Articulation of sterno-clavicular joint sit-

ting Hold tension with both hands in opposite
directions and fix the patient's scapula with your
thorax, then twist into rotation both ways to
produce a mobilizing force on the sterno-clavicular
articulation and first rib anteriorly.
 Techniques for the clavicle area 197
24.8 ..,.. Thrust to sterno-clavicular joint supine
Use crossed hands to put a longitudinal force
through the shoulder and, therefore, the clavicle
while holding back against the sternum with the
ulnar border of the sternal hand. When tension
accumulates, the sternal hand maintains the pres-
sure and the pisiform pushes toward the table and
along the clavicle by means of the hand deviating
into an ulnar direction. It may be necessary to
rotate the patient's head to one side or the other to
optimize the accumulation of tension in the joint.
Extra considerations: Try varying the range
of abduction and adduction in the shoulder to
optimize the tension.
TECHNIQUES FOR THE SHOULDER 25
AREA

Patients often present in osteopathic practice potentially strong, and excess force could
with dysfunctions and disorders of the gleno- possibly compromise bone strength. In prac-
humeral articulation and the shoulder area tice the amount of force used should never be
generally. The shoulder can be described as enough to cause bone damage even in a
a structure that is slung from the occiput, diseased state. However, it may not always
and tethered to the pelvis, so, like all other be realized how much leverage is being
areas of the body, cannot be considered in applied. From the point of view of indica-
isolation. The joint itself can manifest mech- tions, accurate diagnosis of the cause of any
anical derangement as well as pathological particular syndrome is not always easy. Pain
conditions, particularly those involving the due to inflammatory disorders and secondary
capsule and the surrounding muscles and protection of hypermobility may not be
tendons. responsive to physical treatment and much
Special precautions that must be considered wasted time, discomfort and expense can be
when working on the shoulder with manual avoided by recognizing this. As the joint is a
techniques include the possibility of bone- ball and socket, thrust techniques directly
weakening conditions such as osteoporosis, applied to the shoulder do not play a large
as some of the levers used will be long and part in the treatment of dysfunctions.
 Techniques for the shoulder area 199

25.1 .A. Kneading shoulder muscles supine This

is an operator view of the technique. It shows the 25.2 .A. Kneading upper arm muscles supine
hands applied with the use of a 'wringing' action to This operator's viewpoint photograph shows cross-
the soft tissues to work either the anterior, superior or fibre kneading being applied to the triceps. If the
even the posterior aspects of the joint. Varying hands were changed over, the biceps and brachialis
degrees of abduction, compression and rotation can could be worked in the same way. Similar work on
be used to aim the forces to the tissue or area the muscles can be performed with the arm in a
desired. The technique can be applied with the neutral position. In the position shown the muscles
medial hand while the other one remains still, or the and fascia are on some tension that can allow more
medial hand can remain still while the operator's efficient combined technique with stretch as well
body and other hand move in varied directions as cross-fibre work.
together. There are many more variations of this hold Tips: Most useful in cases where the belly of the
than would appear at first glance, and a little experi- upper arm muscles rather than the tendons is the
mentation will reveal some interesting changes in target. Least useful in cases of articular dysfunction
target tissue with only small adjustments of hold where the muscles may be less important. Extra
and pressures. considerations: Varying the degree of abduction
Tips: Most useful in cases where shoulder dys- or adduction will change the initial tension on the
function permits a reasonable degree of abduction. muscles to make the technique a combined knead-
Least useful in acute capsular conditions where ing and stretch procedure.
abduction beyond a small range is impossible. Extra
considerations: As with all techniques that are
designed to work on soft tissues, the duration of the
hold is an important element. A finite quantity of time
of several seconds with the tissues under slight sus-
tained pressure is necessary to produce a significant
change. Simply stretching and immediately releasing
the tissues will produce a less efficient result as fluid
interchange will not have had time to take place.
200 Techniques for the shoulder area

25.3 A. Kneading shoulder prone The posterior 25.4 A. Articulation of shoulder sitting Induce
parts of the shoulder and muscles are more access- antero-posterior and supero-inferior movement in
ible in this position. Control the arm with your hand this position. The long head of the biceps is
so that you can vary the angle at which the available for friction in cases of tendonitis, as is the
shoulder is held to reach the particular tissue rotator cuff tendon behind the shoulder that you
desired. can work with your thumb.
Tips: Most useful where the posterior muscles Tips: Most useful in any patient who finds a
and the scapula are involved. Least useful where recumbent position difficult. Least useful where
the patient finds prone lying a problem for any shoulder movement of any amplitude must be
reason. Extra considerations: Varying the position introduced to make the technique reach the target
of head rotation can change the effect of the tissue. Extra considerations: Introduce a traction
technique. component with the patient holding a small weight
as the technique is being performed.
 Techniques for the shoulder area 201

25.5 • Harmonic technique hold for shoulder

supine Clasp the patient's hand between your
hands and induce a harmonic oscillation into a
pendulum-like movement of the arm into abduc- 25.6 _. Traction of shoulder supine Fix the
tion, adduction and internal and external rotation. patient's arm between your upper arm and hand
Flexion or extension can be introduced as well, or while you apply the other hand behind the head of
combinations of several components are possible. the humerus. Lean back and allow the fingertips to
An appropriate rhythm for this technique would fall into the space produced by the traction. These
be slightly different in each subject but would fingers monitor the force necessary and can add a
vary between fifty and a hundred oscillations per small tugging motion to the joint.
minute. The correct rhythm is determined by find- Tips: Most useful in mild inflammatory disorders
ing the rate that can be maintained with least effort where this gentle oscillation allows circulatory
by the operator. Interchange. Least useful in cases of specific
Tips: Refer to earlier section specifically relating individual muscle disorders where this technique is
to harmonic technique. non-specific. Extra considerations: Try varying
the angle of rotation of the arm and the abduction
and flexion angles as well for optimum effect.
202 Techniques for the shoulder area
25.7 ..,.. Traction of shoulder sidelying Fix the
patient's forearm between your flexed wrist and
biceps and keep the elbow well flexed so that as
you lean back, the forearm and upper arm is carried
into traction. Apply the other hand just below the
acromium to produce a traction and distraction
force at the shoulder. Varied degrees of abduction
and rotation and flexion, extension can be induced
to maximize the effectiveness and reach different
parts of the capsule.
Tips: Most useful where rotation in traction is
indicated rather than pure rotation. Least useful
where there is any dysfunction in the elbow or
wrist. Extra considerations: Try applying the
traction with alternating hands.

25.8 T (bottom left) Articulation of shoulder

sitting The sitting position allows you to treat the
shoulder by your body movement while the
shoulder is held still rather than the shoulder being
moved on the body. Fix the scapula to your
sternum and rotate or sidebend yourself, thereby
influencing different parts of the shoulder joint
complex. You must maintain a firm grip so that you
and the patient move as a unit.
Tips: Most useful where the long muscles affecting
the shoulder inferiorly are involved. Least useful in
very mobile subjects. Extra considerations: Take
care to avoid the patient's trachea.
 Techniques for the shoulder area 203

25.1 0 £. Traction to shoulder sitting Place your

interlocked fingers just below the acromium and
apply a traction and distraction force. While this
force is maintained take the shoulder through a
variety of movements while the body is torqued into 25.11 £. Traction and articulation to shoulder
the opposite directions. This will have the effect of prone Clasp the patient's forearm between your
influencing the shoulder directly and the long thighs and grip the shoulder between your hands.
muscles acting on it. Rest the back of your fingers on the table and while
Tips: Most useful where for any reason the you hold the shoulder firmly in position straighten
recumbent position may be a problem and where your knees to produce the traction. You can move
good abduction range is possible. Least useful in the hands into a variety of directions.
very flexible subjects where spinal movement will Tips: Most useful where accessory movements
absorb the levers. Extra considerations: An initial of antero-posterior and supero-inferior movement
force applied diagonally toward the opposite hip are required. Least useful where lying prone for any
first, before the traction, is useful. reason is a problem. Extra considerations: An
adjustable table is essential to allow the patient to
be lowered so that the arm is horizontal.
25.9 <IIIII (see facing page, bottom right) Traction
and articulation to shoulder sidelying Place your
interlocked fingers just under the acromium and
apply a force toward the axilla so that you produce
a distraction and traction to the joint. Some
variation of angles of rotation can be introduced to
affect different parts of the capsule.
Tips: Most useful where it is necessary to avoid
putting forces through the elbow or wrist. Extra
considerations: Firm pressure toward the table is
an essential component.
204 Techniques for the shoulder area

0
 Techniques for the shoulder area 205
25.12 ~ (see facing page, top left) Articulation
of shoulder supine Hold the acromion and the
clavicle into the table and pull them slightly
caudally while your other hand elevates the arm
until resistance is felt. Different degrees of rotation
and more or less abduction can be introduced to
focus to particular parts of the joint.
Tips: Most useful where it is desired to isolate
the clavicle from shoulder movement. Least useful
in very kyphotic subjects as this range of move-
ment can be very limited as the anterior tissues will
be rather shortened.

25.13 ~ (see facing page, bottom left) Articulation

of shoulder into external rotation sidelying Use
your cephalic forearm to act as a fulcrum while that
hand fixes the acromion and clavicle, and palpates
the shoulder joint. The other hand introduces
external rotation with varying degrees of flexion
while your body assists the movement. The greater
the degree of flexion in the shoulder the stronger
this articulation will be.
Tips: Most useful where a strong mobilizing
force is required. Least useful where there is any
suspicion of lack of bone strength as this is a long
lever on the humerus. Extra considerations: Try
holding the joint on tension and rocking the whole
body backward and forward into rotation.

25.14 ~ (see facing page, top right) Articulation 25.16 _. Articulation into external rotation of
into external rotation of shoulder sidelying In shoulder supine This very strong long lever articula-
this hold, both of your hands are applied to the tion needs great care, but with your caudal hand
shoulder and your caudal elbow induces the rotary you apply a postero-anterior force so that the
movement. This has the advantage that com-
shoulder can be externally rotated. The other hand
pressive force can be applied more firmly to the is used rhythmically, to increase range of motion.
shoulder. This limits the range of motion from Tips: Most useful where a strong lever is
the joint itself which will therefore have a greater required. Least useful where there is any fear of
influence on the soft tissues. lack of bone strength. Extra considerations: Vary
Tips: As photograph 25.13. the angle of shoulder abduction to find the optimum.
25.15 ~ (see facing page, bottom right) Articula-
tion into external rotation of shoulder sidelying Fix
the lateral border of the scapula with your caudal
hand and use your cephalic hand to hold the
scapula firmly against the posterior wall of the
thorax. Apply the external rotation force with your
upper abdomen pressing down on the patient's
elbow.
Tips: As photographs 25.13 and 25.14 but most
useful in very flexible subjects to avoid scapula-
thoracic movement and focus into the shoulder
itself.
206 Techniques for the shoulder area

25.17 • Articulation into external rotation and 25.18 • Traction and external rotation articula-
traction prone Face the head of the table and use tion to shoulder supine Face the head of the
your elbow to fix the scapula with your hand firmly table and apply traction by placing your hand in
applied in the cubital fossa. The other hand applies the cubital fossa while the other hand applies the
a force toward the patient's head, thereby levering external rotation force.
the head of the humerus away from the glenoid. Tips: Most useful as the scapula is held by the
Varied ranges of extension and abduction and table and strong traction and external rotation can
external rotation can be introduced. be applied. Least useful where the biceps tendons
Tips: Least useful in patients where lying prone is are sensitive as pressure on them will be a
a problem for any reason. problem. Extra considerations: Vary the angle of
abduction and flexion to find the optimum.
 Techniques for the shoulder area 207

25.19 .A Articulation into internal rotation of

shoulder sidelying From in front of the patient you
fix the shoulder with your cephalic hand while the
caudal hand applies the internal rotation force.
Tips: Most useful where a strong force is
required. Least useful in cases of severe movement
restriction as the position will be difficult to attain.
Extra considerations: Try applying a traction force
at the same time.

25.20 .A (top right) Articulation into internal

rotation of shoulder sidelying Abduct the shoulder
just sufficiently so that the patient's wrist is fixed
behind the lower ribs. The internal rotation force will
be much stronger in this position. The cephalic
hand can either hold back on the scapula and
clavicle or assist the rotary movement by pulling on
the head of the humerus.
Tips: As photograph 25.19.

25.21 ..,. Articulation into internal rotation ofthe

shoulder sidelying Fix the scapula from behind
with your torso and introduce the rotary movement
by holding firmly with your cephalic hand while
carefully pushing your caudal hand anteriorly.
Tips: Most useful where the scapula tends to
wing excessively. Least useful in cases of severe
movement restriction where the position may be
difficult to attain. Extra considerations: Try using
traction in addition to rotation.
208 Techniques for the shoulder area

25.22 _. (top left) Articulation into internal rota-

tion of shoulder prone In this operator viewpoint
photograph you face the foot of the table and while
fixing the scapula with your elbow, you apply a trac-
tion force through the patient's cubital fossa. Your
other hand carefully raises the patient's hand toward
the ceiling while maintaining pressure on the distal end
of the forearm toward the table to induce traction.
Tips: Least useful where the patient may find
prone lying a problem for any reason.
25.23 ..,.. Articulation into internal rotation and
traction of shoulder supine In this operator view-
point photograph you face the foot of the table and
fix the shoulder to the table with your elbow while the
hand in the cubital fossa acts as a fulcrum for the other
hand. Push, at the same time, toward the table for the
traction and toward the floor for the internal rotation.
Tips: Most useful where a strong force is
required. Least useful where there is any elbow
dysfunction. Extra considerations: Vary the angles
of abduction and flexion for optimum results.
25.24 _. (top right) Articulation of shoulder supine
Fix the lateral border of the scapula with one hand
while firmly gripping the lower end of the humerus
with the other hand which can induce rotation
movements, elevation and traction as required. The
fixation of the scapula causes the movement to be
localized to the shoulder joint itself rather than the
scapulo-thoracic articulation and naturally less range
of motion will be achieved.
Tips: Most useful where there are adhesions in
the inferior aspect of the capsule. Least useful in
acute cases where this much abduction would be a
problem.
TECHNIQUES FOR THE ELBOW AREA 26

Mechanical dysfunctions in the joints of the together. Often individual joint dysfunction
elbow are not uncommon. Their importance will not be corrected until a suitable balance is
in painful syndromes and disturbances of obtained between all the relevant joints and
usage varies, but is often a factor that can be soft tissues. The fascial state is also important
addressed by osteopathic treatment. From a as poor circulation, healing and myofascial
mechanical viewpoint the elbow poses various tone may be part of the equation.
problems. There are rather small but import- Special precautions need to be considered
ant ranges of accessory movement and it is to exclude the possibility of myositis ossificans,
necessary to use these in treatment tech- which sometimes affects the brachialis muscle
niques. They may be difficult to control. in the presence of a haematoma after trauma.
Other problems are posed by the fact that the The ulnar nerve is vulnerable to damage on
joints will tend to escape from corrective the medial side of the ulna. An ulnar neuritis
forces if the grip is not firm enough. How- takes a very long time to heal when traumatic-
ever, an excessively firm grip will produce ally induced. It would be very hard to do this
pain and even more resistance. A balance be- in treatment, but an existing condition could
tween force, direction and amplitude is critical. be irritated by injudicious technique. It is
The joint complex must be considered as a essential to avoid excessive force, particularly
whole; the elbow, radio-humeral articulation, into extension as there is a possibility of
and distal articulation at the wrist all work damage to the floor of the olecranon fossa.
210 Techniques for the elbow area
26.1 ~ Kneading of lateral tissues supine Clasp
the arm between your body and forearm and knead
the extensor muscles on the lateral side of the
arm. The hands share the pressure in opposite
directions to reduce the amplitude of movement
necessary in each.
Tips: Try varying the angle of shoulder abduction
and rotation; this will change the initial tension in
the muscles before they are kneaded. If there is
extreme tenderness, try holding the muscles on
some tension and moving the arm back and forth
rather than the muscles themselves.

26.2 T (bottom left) Kneading of medial and

anterior tissues supine Fix the patient's forearm
to your side with your forearm and then apply a
kneading and stretching to the medial compart-
ment muscles with both thumbs. It is possible to
reach deep into the cubital fossa with this hold.
Tips: Take care to protect the brachialis and
brachial artery from excessive pressure.
26.3 T (bottom right) Kneading of lateral com-
partment muscles supine Sit on the edge of the
table. Put some tension on the muscles with the
proximal hand and then, while maintaining this
pressure, pronate the forearm with your other hand
to generate the kneading force.
Tips: Try varying the angle of elbow flexion and
adding components of traction or circumduction
to the hold. As an alternative, the operator can
perform this technique standing.
 Techniques for the elbow area 211
26.4 ~ Stretching of medial compartment supine
Fix the arm to the table with your proximal hand and
apply some compression to the medial side of the
elbow. Apply a stretching force with the other hand
by pulling the forearm into your side. Keep your arms
against your sides and rotate away from the table.
Tips: Try varying the pronation and supination
during the technique to reach different parts of the
muscles.

26.5 T (bottom left) Stretching of intra-osseous

membrane supine Grip the forearm between your
hands and apply opposite movements with each
hand of traction and compression as well as
antero-posterior shearing.
Tips: Try varying the angle of flexion before
applying the other levers.

26.6 T (bottom right) Traction supine Fix in the

ante-cubital fossa with your pronated proximal
hand and grip the forearm with the other. Com-
press the forearm against your abdomen and turn
away from the table to pivot round the fixing hand
to apply traction.
Tips: Most useful where there has been a
longitudinal compression force injury and it is
necessary to disengage the joints.

0
212 Techniques for the elbow area

26.7 • Traction to ulna supine Fix the upper 26.8 • Traction to radius supine Fix the upper
arm to the table with the pronated proximal hand. arm to the table with your pronated hand and reach
Grip the ulna with the other hand and compress the around the forearm with the distal hand to grip the
forearm against your abdomen. Pivot around your radius. Apply traction and mobilize in pronation and
fixing hand to apply a specific traction to the ulna. supination.
Tips: Try adding a small circumduction force to Tips: Most useful in cases of 'tennis elbow'
the traction. where there tends to be an element of compression
in the radio-humeral joint. Least useful where the
forearm is very large and it would be difficult to
reach around the ulna to the radius.
 Techniques for the elbow area 213

26.11 _. Thrust to radio-humeral joint supine The patient is lying supine but slightly turned toward the
affected arm. Apply your hands to the slightly flexed arm. Contact the shafts of the radius and ulna and the
upper part of the humerus. Compress with both hands toward the table and apply a gentle rocking force
from side to side until tension accumulates in the radio-humeral joint. The thrust is applied without
releasing this preliminary tension by dropping some weight onto both hands.
Tips: If preferred, use crossed arms to apply the hold.
214 Techniques for the elbow area
26.9 and 26.10 <1111 (see previous page, top left and
top right) Thrust to radio-humeral joint supine
Fix the patient's forearm to your side and clasp
around the slightly flexed elbow, applying the web
of your thumb to the medial aspect of the joint.
Compress the elbow between your hands and
circumduct through a small range to find the
optimum point of tension. The tip of the index finger
of either hand palpates for this tension and applies
a local compression to the radio-humeral joint. The
thrust is performed with an increase of compres-
sion between the hands, an increase of fixing of the
arm to your side and a short, sharp rotation of your
body away from the table.
Tips: Note the angle of the thrusting arm is not
directly across the joint but is directed slightly
anteriorly, as the radio-humeral joint is anterior to
the humero-ulnar joint. This technique may require
several priming forces of gradually increasing
amplitude until the optimum tension accumulates.

26.12 and 26.13 Thrust to radio-humeral joint supine These operator viewpoint photographs show a
complex technique for gapping the radio-humeral joint. Sit on the edge of the table and place the internally
rotated arm across your lower thigh. Fix the medial epicondyle against your thigh and hold back on the distal
end of the humerus. Your other hand grips the distal end of the radius and applies a force directly toward the
floor. Vary the pronation and supination until tension is felt to accumulate. The thrust is performed by an
accentuation of all three forces, the operator's thigh and upper and lower hand simultaneously.
Tips: Try placing the fifth finger in the palm of the patient's hand to allow better control of the pronation and
supination. This also allows control of the flexion and extension of the wrist to help focus the forces in the
elbow. If a stronger effect is needed, instead of using more force, try introducing ulnar deviation of the wrist
with the distal hand. If an even stronger effect is needed, place the patient's thumb in the palm of their hand to
place the extensor muscles on stretch, and then apply ulnar deviation. Note: The internal rotation of the arm is
essential if this is not to become an extension thrust. It is often very difficult to maintain this internal rotation.
Ensure that the medial and lateral epicondyles are vertical before performing the technique.
 Techniques for the elbow area 215

26.14 and 26.15 Thrust to radial head supine Place your thumb behind the radial head and hold the
distal end of the forearm against your abdomen. Maintain slight flexion of the elbow throughout the whole
technique. Sharply pronate the forearm, flex the wrist and extend the elbow to slap the forearm against
your abdomen. This 'Mills procedure' is often performed with hyperextension, which is not only painful,
but can be potentially dangerous as the proximal end of the ulna can be driven through the floor of the
cubital fossa. Hyperextension also means that the force will be unlikely to reach the radial head so the
technique will be ineffective for the purpose intended!
Tips: Try compressing the radial head between thumb and fingers of the proximal hand to help localize
the levers.
216 Techniques for the elbow area

26.16 _. Thrust to humero-ulnar joint into adduc- 26.17 _. Thrust to humero-ulnar joint into adduc-
tion supine This operator viewpoint photograph tion supine Stand outside the slightly flexed arm
shows the patient's forearm gripped firmly against and pull with your proximal hand on the medial
the operator's abdomen. His hands are gripping aspect of the ulna. Push the distal end of the
around the elbow and the metacarpo-phalangeal forearm in the opposite direction to produce a force
joint of the index finger is applied to the medial designed to reduce the carrying angle.
aspect of the ulna. While gripping firmly against the Tips: Try adding varied amounts of wrist devi-
barrier of joint resistance he rotates his body away ation to help focus the technique. This hold can be
from the table to apply the thrust. The direction of used to perform the opposite function of increasing
force is from medial to lateral to reach the humero- the carrying angle where necessary, by reversing
ulnar joint, not the radio-humeral joint which would the hand directions.
require a more anterior force. A few degrees of
flexion must be maintained throughout the tech-
nique.
Tips: This technique would be used where there
is an increased carrying angle or a perception of an
inability for the head of the ulna to locate in the
fossa on full extension.
 Techniques for the elbow area 217

26.18 • Thrust to humero-ulnar joint into adduc- 26.19 • Thrust for 'pulled' radius supine Shake
tion supine Fix the forearm against your side and hands with the patient and fix behind the elbow
grip firmly around the elbow with both hands. Apply with your other hand. Apply a small compression
the metacarpo-phalangeal joint of your index finger force between the hands and gently pronate and
of the proximal hand to the lateral aspect of the supinate the elbow until the radial head is felt to
upper end of the ulna. Maintain slight flexion in the relocate within the annular ligament.
elbow and apply the thrust with your proximal hand Tips: This technique should only be necessary in
and a small rotation of your body. children and any suspicion of a 'pulled' radius in an
adult should alert the operator to the possibility of a
fracture or dislocation. Dislocations of the ulna
must NEVER be reduced using pronation and
supination as there is a danger of the coronoid
process damaging the brachial artery!
TECHNIQUES FOR THE FOREARM 27
AREA

The forearm transmits torque between the tional cross-fibre massage has a part to play in
elbow and hand by way of the fascia, bones specific soft tissue states of adhesions and
and muscles. Bones in life are somewhat local irritability. This can be of particular use
malleable, and torque on these tissues can over the medial or lateral epicondyles of the
cause mechanical problems. The state of the humerus in states of 'golfer elbow' and
fascia that encloses the muscles and vessels is 'tennis elbow', respectively.
particularly important here, and myofascial Rehabilitation of post fracture cases can
techniques are extremely useful in contribut- also often be helped by direct work on the
ing to improvement in function. Tension muscles and fascia of the forearm. Particular
states in the muscles of the forearm can have care should be applied where there is a true
an adverse influence on wrist and elbow neuritis as this can be aggravated by physical
function and may be maintaining factors in treatment applied over the nerve itself. No
dysfunction at those sites. technique holds have been illustrated for this
Muscle energy techniques are useful here section as the principles are similar to those
and are based on anatomical knowledge of in the upper arm or the calf holds shown in
muscle planes and attachments. Deep fric- the relevant sections.
TECHNIQUES FOR THE WRIST AND 28
HAND

The wrist is an extremely delicate structure Special precautions need be considered in

that requires mobility and yet stability. Some- relation to the true cause of symptoms. In
times this balance goes wrong, and then many cases there is hypermobility, and al-
osteopathic intervention is appropriate. Tech- though this will manifest as subjective stiff-
niques can be general or specific, and although ness, accurate motion testing should reveal
general techniques can often be effective in the real nature of the problem. Undiagnosed
restoration of function, specific manipulative fracture of the scaphoid, for example, is
skill is sometimes essential. Some apparently well documented in books on fractures and
pathological conditions can be influenced by traumatology and should never be overlooked.
osteopathic treatment such as carpal tunnel Inflammatory disorders such as rheumatoid
syndrome, and osteopathic management in- arthritis need special care, and although
cluding direct work on the wrist and hand gentle short treatment can be helpful, excess-
can be valuable. ive mobilization is not wise.
220 Techniques for the wrist and hand
28.1 ~ General mobilization The patient is lying
supine and the operator is performing alternating
ulnar and radial deviation with his hands, gripping
around the wrist. This will produce a shearing force
that will reach many of the carpal articulations.
Tips: Try fixing with one hand and moving the
other or using both hands. This hold can be applied
to the palmar or dorsal surface of the wrist.
28.2 T (bottom left) Shearing of carpal rows The
operator is standing by the side of the supine patient
and is introducing a direct dorsal and palmar force
with the wrist maintained in a neutral position.
Tips: Try moving both hands distally to focus on
the inter-carpal articulations rather than the true
wrist joint. Try squeezing or spreading the patient's
hand with the distal operator's hand or applying
traction between the operator's two hands.
28.3 T (bottom right) Kneading thenar eminence
In this operator viewpoint photograph, the lateral
border of the hand is being held stable while the
operator's thumb is applying kneading to the thenar
eminence.
Tips: Use care and a gradual introduction of
force as these muscles are often extremely ten-
der initially. Try adding circumduction articulation
simultaneously.
 Techniques for the wrist and hand 221
28.4 ..,. Stretching palmar surface In this operator
viewpoint photograph the hand is being stretched
laterally between the operator's hands.
Tips: Most useful in cases of carpal tunnel syn-
drome where shortening of the flexor retinaculum
may be a maintaining factor. Extra considerations:
Try inducing an ulnar and radial deviation of the
operator's hands when tension has been applied to
reach different parts of the flexor structures.
28.5 T (bottom left) Stretching proximal part
palmar surface The operator is gripping over the
ham mate and scaphoid to produce a strong stretch
on the flexor retinaculum.
Tips: Most useful in cases of carpal tunnel syn-
drome. Extra considerations: Try sustained stretch
for several seconds and then adding a diagonal
torsion to reach the proximal and distal parts of the
retinaculum.
28.6 T (bottom right) Stretching palmar surface
This operator's viewpoint photograph shows the
hand held against the operator's abdomen and his
hands applying a diagonal stretch to the ulnar
border of the patient's hand.
Tips: Most useful in carpal tunnel syndrome and
Dupetrens contracture if slowly applied and main-
tained for several seconds.
222 Techniques for the wrist and hand
28.7 <1111 General mobilization The operator is inter-
locking fingers with the patient and then while his
other hand stabilizes the forearm he introduces a
variety of forces to the wrist and hand.
Tips: Try each range of possible movement in-
cluding combinations, not forgetting traction and
compression.
28.8 T (bottom left) Specific articulation carpo-
metarcarpal joints This operator viewpoint photo-
graph shows the distal hand pulling on a meta-
carpal bone while the proximal hand fixes on the
appropriate part of the wrist to introduce a traction
articulation. Other vectors can be used, such as
rotation, circumduction and abduction/adduction,
as the restriction demands.
Tips: Most useful in cases of carpo-metacarpal
dysfunction rather than the actual wrist itself.
28.9 T (bottom right) Specific articulation carpo-
metarcarpal joints This operator viewpoint photo-
graph shows the patient's pronated hand being
fixed against the table while the operator's distal
hand grips one of the metacarpals. Traction, with or
without other ranges of movement, can be intro-
duced.
Tips: Most useful in impaction injuries where the
metacarpal may be driven into the related carpal
bone.
 Techniques for the wrist and hand 223

0 /
()
224 Techniques for the wrist and hand
28.1 0 <Ill (see previous page, top left) Articulation
carpo-metarcarpal joints lateral border The oper-
ator clasps the wrist of the supine patient to his
abdomen by turning his back to the table. He holds
firmly on the relevant metacarpal and carpal bone
and then turns his body to produce the traction and
mobilizing effect. Many different vectors of force
can be introduced while the traction is applied, to
effectively address the restriction of movement.

28.11 <Ill (see previous page, bottom left) Circum-

duction articulation/thrust The operator is very
firmly clasping the patient's hand between the
heels of his hands. He applies a circumduction
motion and, within the movement, an arc of
effective resistance will be felt. If this is a soft
resistance, increased pressure between his hands
may create a suitable thrust barrier, where he can
perform a short, sharp force against the restriction.
Tips: Try varying the part of the applicator
performing the compression, thus directing the
force to different parts of the wrist (see photograph
28.12). Extra considerations: This technique
requires fairly high compression force that must be
varied to reduce operator strain and patient dis-
comfort.

28.12 <Ill (see previous page, top right) Circum-

duction articulation/thrust See description for
photograph 28.11 , but note that in this hold the 28.14 ._ Thrust mid carpus supinated This oper-
operator is applying the force with his hypothenar ator viewpoint photograph shows the patient's hand
eminences to the proximal part of the patient's supine and the operator is applying a direct force
wrist. He is also in a different arc of the circumduc- between the scaphoid and the hammate to open
tion cycle. out the wrist curve, The other hand is reinforcing.
He slowly twists his applied hand until tension
28.13 <lll(see previous page, bottom right) Thrust accumulates in the wrist and then a very small
mid carpus pronated This operator viewpoint amplitude thrust is introduced. Note: for clarity, this
photograph shows the patient's hand pronated and illustration shows the initial contact; at the point of
the operator is pressing firmly with his pisiform thrust the fingers will be in the same direction as
directly over a chosen articulation. His other hand those of the patient.
is reinforcing the pressure and he maintains this
pressure while slightly deviating the thrusting hand
into ulnar or radial deviation to find the optimum
tension. Without releasing the tension a very small
amplitude thrust is applied.
Tips: Most useful where it is necessary to reduce
the angle of the curve of the wrist and stretch the
anterior structures while specifically manipulating
any restricted joint.
 Techniques for the wrist and hand 225
28.15 ~ Thrust specific articulations dorsal
surface This operator viewpoint photograph shows
the patient's pronated hand held between the
operator's hands. He crosses his thumbs over the
dysfunctional articulation on the dorsum of the
wrist. He circumducts the wrist while introducing
small changes in ulnar and radial deviation and if
tension accumulates efficiently he can apply a very
short amplitude thrust with the thumbs.
Tips: This can be a very uncomfortable tech-
nique unless the amplitude is kept extremely small.
Try making the thrust more of an increase of
compression rather than dorsi-flexion.

28.16 T (bottom left) Thrust metacarpo-phalangeal

joints This operator viewpoint photograph shows
the operator is fixing and pulling back the meta-
carpal while applying a traction and flexion force to
the phalange.
Tips: Least useful in inflammatory disorders such
as rheumatoid arthritis.
28.17 T (bottom right) Thrust interphalangeal
joints This operator viewpoint photograph shows
the patient's pronated hand gripped at the wrist.
The operator's finger and thumb of the other hand
are applying a medial and lateral gapping force to
the interphalangeal joint.
Tips: Keep the interphalangeal joint slightly
flexed to reduce strain on the capsule and to take
the lateral ligaments off tension. This technique
may require several priming movements until the
tension accumulates efficiently.
226 Techniques for the wrist and hand

28.18 _. Thrust interphalangeal joint of thumb 28.19 _. Thrust/articulation interphalangeal joints

This operator viewpoint photograph shows the This operator viewpoint photograph shows an
index finger of the thrusting hand is applied on the articulatory force into direct medial and lateral
flexor surface of the distal phalange while the gliding being performed. If a thrust is necessary a
thumb is on the dorsal surface. The other hand is small component of flexion will be required to
holding back on the base of the patient's thumb. produce the optimum barrier sense in the joint.
The thrust is applied as a short, sharp flexion and Tips: Least useful in inflammatory disorders
traction movement to the distal phalange while the where the joint structure may be weakened. Extra
other hand applies a small opposite force. considerations: Several priming movements are
Tips: Not all interphalangeal joints can be often necessary before applying a thrust to these
gapped due to their inherent joint configuration and joints.
excessive attempts to do so are unwise.
TECHNIQUES FOR THE HIP AREA 29

The hip joint can be a source and site of therefore, a possibility of inducing a strain of
symptoms in itself although in most cases the knee in the process. Harmonic techniques
pain originating in the hip will be referred are particularly useful here in re-establishing
along the third lumbar nerve root down the normal movement patterns.
medial side of the thigh to the knee. Hip Precautions relate particularly to the pos-
disease, whether of an acute or chronic nature, sibility of undiagnosed fracture of the neck of
can produce a characteristic discomfort deep in the femur, which even though still allowing
the groin, but not usually where the patient the patient to have movement, shows on X-
perceives the hip to be. Restoration of even ray as severe damage. Unexpected hip frac-
a small part of lost mobility can be very ture in an inappropriate age group can be due
successful in relieving many of the symptoms to a secondary deposit from a cancerous
of hip disorders, even if the progress of the growth elsewhere, and clearly the indications
degenerative state has not been changed at for osteopathic treatment must be carefully
all. Technical problems occur mostly due to considered. The full implications of the pos-
the deep nature of the joint, and the need to sible ill-effects of treatment on possible dis-
use quite long levers to reach it. There is, eased bone are considerable.
228 Techniques for the hip area

29.1 _. Harmonic technique into rotation supine Roll the lower extremity harmonically into rotation as
a unit. See earlier section referring to harmonic technique.
Tips: Most useful in cases where there is considerable stiffness and loss of 'dynamism' in the limb.
Extra considerations: Try using varied degrees of preliminary abduction to produce the most useful
angle of the hip.

29.2 _. Harmonic technique pelvic hold supine Choose whether to fix on the pelvis and roll the leg, or
fix on the leg and rock the pelvis. This hold will allow the peri-articular tissues of the hip to be reached. See
earlier section relating to harmonic technique.
Tips: Harmonic technique is rarely going to be a complete treatment by itself, but is often a useful
preliminary to other procedures to loosen the tissues.
 Techniques for the hip area 229

29.3 • Harmonic technique both legs supine Roll both legs into rotation and apply alternating
traction and abduction/adduction as required. See earlier section relating to harmonic technique.
Tips: This hold is useful in cases of bilateral dysfunction. Alternating traction and compression will also
address a lumbar dysfunction that is restricting sidebending.

29.4 ~ Articulation into internal rotation supine

Interlock your arms and hold over the knee to avoid
straining it. Apply a rhythmic internal rotation
movement to the hip as you vary the range of
flexion and abduction/adduction according to the
needs of the case.
Tips: Most useful where strong mobilizing is
required. Least useful in cases of extreme move-
ment limitation as the position may not be attain-
able. This hold may be unacceptable in cases of
severe knee disorders as the strain may be
excessive.
230 Techniques for the hip area
29.5 <1111 Articulation into internal rotation supine
Grip around the knee and you can partly protect the
knee joint while you apply an internal rotation force
to the hip.
Tips: Most useful where the knee joint may
require some protection. Least useful where strong
mobilizing is necessary as the lever is not very
powerful. Extra considerations: Try using varied
angles of flexion or abduction/adduction as
necessary to reach the part of the hip capsule
desired.

29.6 T (bottom left) Articulation into abduction

and adduction sidelying Fix firmly above the
greater trochanter to limit the movement to the hip
joint and prevent movement into the lumbar spine.
Hold the lower medial side of the thigh with the
other hand to produce the abduction force. Varied
degrees of flexion, extension and rotation can be
introduced as required.
Tips: This position can also be used for muscle
energy technique holds. To reduce any discomfort
in this technique try varying the angle of flexion of
the lower leg in the initial set-up of the technique.
This will allow the lever to change the effect on the
pelvis and lumbar spine.
29.7 T (bottom right) Articulation in external rota-
tion and abduction sidelying This hold is similar
to that in photograph 29.6 except that you can hold
further round the thigh and it is easier to introduce
the strong external rotation possible with this
technique.
 Techniques for the hip area 231

29.8 A Traction to hip supine Pull laterally against 29.9 A Traction sidelying Use a pillow over your
the padded upper, inner thigh at the same time as anterior thigh to act as a fulcrum over which you
you create a fulcrum with your chest against the place the patient's upper thigh. Fix down toward
lateral aspect of the knee. The sum of these two the table with the cephalic hand, and push toward
forces will be to produce a true traction force that the table with the caudal hand to produce a true
will tend to separate the head of the femur from the traction effect on the hip. Note that the other leg
acetabulum. has been flexed well out of the way.
Tips: Most useful in cases of degenerative hip Tips: Most useful in cases of degenerative
disease where traction can allow greater circulatory disease where fairly strong traction may be
interchange. The actual stretch on muscles is very needed. Extra considerations: Extension move-
small, but this technique can produce considerable ment may be a problem in many cases of hip
symptomatic improvement. Extra considerations: degeneration so that some flexion may be necess-
Try varying the angle of flexion of the hip to find the ary to make the technique feasible.
optimum for the case.

29.1 0 A Traction and distraction supine Fold your arms and interlace your forearm under the patient's
knee. The traction is produced simply by leaning back.
Tips: Most useful in cases of severe degenerative disease as the knee and hip are in considerable flexion,
reducing the strain on them, but still allowing the effect to reach the hip. Extra considerations: Try varying the
abduction and flexion range to find the optimum.
232 Techniques for the hip area

29.11 • Low velocity stress into internal rotation 29.12 • Low velocity stress technique into
technique supine Place the patient's foot lateral external rotation supine Place the foot of the
to the other knee. Hold the hip into firm internal affected side on the thigh of the other leg. Hold
rotation for several seconds until a sense of 'give' is down on the knee with the hip well abducted, while
felt. This can be a multiple stage technique, as fixing on the other side of the pelvis to prevent
there may be more than one sense of release as lumbar rotation . After a few seconds there should
different parts of the dysfunction release. be a sense of release in the hip. This may be a
Tips: Most useful in almost all cases of hip multiple stage technique. Release may be only
dysfunction providing the patient can achieve the partial if it is not repeated in slightly varied angles.
position; if not, place the foot medial rather than Tips: Most useful in almost all cases of hip joint
lateral to the other knee. This will , however, reduce dysfunction as stress techniques do not put undue
the lever somewhat. Extra considerations: Try strain on the articulation, but allow it to adopt its
also varying the angle of hip flexion to find the own path of free movement. Extra considerations:
optimum . If the position is impossible due to severe limitation
of movement, try placing the foot medial to the
other knee. Try varied degrees of hip flexion to find
the optimum for the case .
TECHNIQUES FOR THE THIGH AREA 30

The thigh contains some of the strongest Special precautions include the obvious
muscles in the body and can be very influen- one of the necessity to work sometimes in
tial in postural problems. It is also the site of sensitive areas near the groin, but with
many sports injuries, and although not a very suitable choice of technique position, and
common presenting site of symptoms in most care in handling, this should not present
osteopathic practices, may well be involved too much of a problem. There is also the
in hip, knee and lower back problems. chance of interfering with an organizing
Although it is possible to work on most of the haematoma, and the possibility of myositis
muscles with conventional structural stretch- ossificans, particularly in gracillis and to a
ing and cross-fibre techniques, muscle energy lesser extent in the quadriceps, must be con-
and inhibitory pressure are often useful here. sidered.
234 Techniques for the thigh area

30.2 • Stretching lateral aspect of thigh side-

lying As it is impossible to adduct the thigh more
than a small amount to stretch the lateral tissues,
direct stretch with pressure is sometimes the only
30.1 • Kneading anterior thigh supine From
way to get to these tissues. Here the operator has
the opposite or same side of the table the operator
adducted the patient's thigh as much as possible,
can apply a cross-fibre kneading to the quadriceps
and then while holding back on the superior part, is
by concentrating either on the hand pushing away
applying a longitudinal stretch with the other hand.
from himself, the hand pulling towards himself or a
As the ilio-tibial band is largely non-extensible, very
bit of both according to the needs of the tissue: The
little stretch can be produced, and this procedure
more the work is shared by both hands, the less
can be very uncomfortable. This is one of the
the amplitude of movement with each hand, and
few osteopathic techniques where the use of a
therefore the less discomfort for the patient.
lubricant oil or cream may make the technique
Tips: Most useful where the muscles are not very
more effective.
well developed as it is possible to get into the belly
Tips: Most useful in severe cases of osteo-
of the muscle well. Least useful with large strong
arthrosis of the hip where it is not possible to
muscles and very tight fascia. Extra considerations:
mobilize the hip directly. Least useful when there
Deep and slow produces the best result as the
are fibrous bands in the fascia lata which are very
muscle has time to relax, and fluid interchange
tender. Extra considerations: Change the angle of
takes place.
the hip flexion to find the optimum in each case.
 Techniques for the thigh area 235
30.3 ..,... Kneading lateral and anterior muscles
of thigh From behind the patient the operator has
grasped the muscles on the lateral side of the thigh
and, while applying a pushing force with the
thumbs, is pulling with the fingers to produce a
cross-fibre kneading to the area. There are many
variations of hand hold that can be used here.
Tips: Most useful where the patient can take
direct kneading on the muscles and where the
fascia is mobile enough to accept stretch in this
way. Least useful where the patient has any
problems with the other side making sidelying
difficult. Extra considerations: Vary the angle of
the hip for optimum tension, fix hands and use
body movement rather than hand movement alone.

30.4 .& Kneading medial or posterior muscles

of thigh supine With the patient's knee and hip
flexed and firmly held against the operator's 30.5 .& Kneading thigh supine Here the operator
abdomen, a cross-fibre kneading action is being has fixed the anterior part of the thigh to himself,
performed. The more the work is shared by both and is holding the patient's foot into the table at
hands, the less the discomfort of the movement, varied angles of flexion of the knee to optimize the
and the deeper the technique can be applied to technique. The other hand is applying the cross-
produce a better and quicker result. With the hip fibre kneading to the adductor muscles. In this
and knee flexed, the muscles are off tension and position it is possible to reach well up to the origin
therefore easier to work in most cases. of the muscles.
Tips: Most useful in cases where the patient Tips: Most useful where there are tight bands in
cannot extend the hip fully. Least useful when the the adductor muscles, particularly close to the
patient is very ticklish. Extra considerations: It pubis. Least useful when the patient may feel
may be necessary to experiment to find whether it threatened by this position. Extra considerations:
is better in a particular case to fix with one hand Sometimes the kneading hand can be held still and
and move with the other or to work both hands. the operator and his other hand moved against it.
236 Techniques for the thigh area

30.6 • Kneading thigh sidelying The operator 30.7 • Kneading thigh medial aspect sidelying
is in front of the patient and is working on the The operator is standing behind the patient and
medial aspect of the leg on the table. Both hands using the fingertips to work deep into the muscles.
are working in opposite directions to minimize the It is possible to get behind the quadriceps in this
amplitude of force in each. In this position the position, and right up to the adductor muscle
upper thigh 'protects' the groin area and it is origins to the pubis as the patient's other thigh
possible to reach very high up into the origins of the 'protects' the groin area.
muscles; this also allows the pubic ramus to be Tips: Most useful where it is necessary to reach
reached without excessive embarrassment to the deep into the muscles. Least useful where the muscles
patient. are extremely tender. Extra considerations: Find
Tips: Most useful where it is necessary to apply which works best in each case, either pushing or
the technique high in the adductors. Least useful pulling.
where the patient has difficulty sidelying. Extra
considerations: Changes in the angle of flexion of
the knee and hip can make it possible to reach
different parts of the muscles.
 Techniques for the thigh area 237

30.9 A Kneading thigh prone This position en-

ables the operator to work on the posterior and
lateral aspect of the thigh on the opposite side from
30.8 A Kneading thigh prone The operator is where he is standing. As usual with this sort of
standing on the same side as the leg being worked technique, the hands are performing opposite
on. The medial and posterior aspects of the thigh actions so that the work is shared and this reduces
can be reached in this position. According to the the amplitude of the forces and the distortion of the
needs of the case and the preference of the operator tissues accordingly.
this can be made into a pulling technique or a Tips: Most useful in smaller patients where leaning
pushing technique as desired. As in all such across the table is not too much of a stretch. Least
techniques, the more the work is shared between useful in large subjects or where the patient finds
the hands, the less amplitude need be applied with lying prone difficult. Extra considerations: Vary the
each one as the conjoint effort produces the result. angle of flexion at the knee and abduction at the hip
Tips: Most useful where muscles are fairly slack as for best results.
it is possible to work deeply into them. Least useful
where muscles are extremely tight, as the technique
will be very uncomfortable. Extra considerations:
Vary the angle of knee flexion if necessary, with a
pillow.
238 Techniques for the thigh area
30.1 0 <IIIII Muscle energy posterior thigh The
lower extremity is taken to a point of tension in the
posterior muscles and held there. The patient is
asked to push the leg against the shoulder for
about six seconds, and then after relaxing, a new
motion barrier is found at a greater angle of flexion
of the hip. After a few seconds this is repeated,
usually three times to achieve a state of enhanced
stretch of the muscles and a new barrier to motion
at a greater range of joint motion. As with all muscle
energy procedures, the resistance need not be
more than about 25% of muscle force.
Tips: Most useful in chronic contracture where
direct work on the muscle may be too uncomfort-
able. Least useful in acute muscle strains as it may
be too painful. Extra considerations: See the
earlier section on principles of muscle energy
technique.

30.11 .&. Muscle energy technique thigh supine The operator is holding the patient's foot against the
table and the patient is asked to push against the hand either into flexion of the knee or extension as
necessary for the case. The other hand is stabilizing the knee. As in most muscle energy techniques, the
force applied by the patient is about 25% of muscle action, and the position is held for about 6 seconds,
repeated usually three times with short rest periods between.
Tips: Most useful in small, light subjects where the operator can resist easily. Least useful in large
or strong subjects where it may be difficult to keep a true isometric contraction controlled. Extra
considerations: See earlier section on muscle energy technique.
TECHNIQUES FOR THE KNEE AREA 31

The knee is both a simple and a very complex of mechanical dysfunction manifesting as
joint. Osteopathic thinking embraces the apparent malpositioning.
concept of mechanical dysfunction with or Precautions include the need to avoid
without positional displacement. The bones excessive force and pain, as in all other areas,
making up the joint can be working in one of but also include the need to avoid excessive
several different disturbed positions. This is pressure over any varicose veins. Some knee
not so much a positional finding as a lack syndromes are manifestations of hyper-
of function in various possible directions. mobility masked by muscle protection. If this
Techniques are designed to restore function is the case, mobilizing techniques are not
generally, or to mobilize in a particular direc- indicated, so careful assessment should pre-
tion to restore normal relationships. Function cede treatment. If a knee is degenerative it will
is seen to be more necessary than symmetry generally tend to have lost some of its normal
and position. Nevertheless, in some cases, hyperextension, and excessive attempts to
directions of force are chosen for specific restore this are doomed to failure and will only
reasons. These usually relate to perceptions provoke more pain and problems.
240 Techniques for the knee area
31.1 and 31.2 ..,.. Harmonic technique into cir-
cumduction sitting The patient sits with her leg
over the side of the table. Hold the superior aspect
of the tibia with one hand and rock the leg from side
to side with the other. At the same time circumduct
the foot to induce a rhythmic oscillation in the knee.
See earlier section relating to harmonic technique.
Tips: Most useful in cases where rhythm and
spring has been lost in normal knee movement.
Harmonic technique is particularly useful as a
preliminary procedure to structural mobilizing to
loosen the tissues and help re-establish circulatory
function. Extra considerations: Light patient resist-
ance can be introduced into this movement as a
'muscle re-training' procedure.
 Techniques for the knee area 241
31.3 and 31.4 <1111 Harmonic technique into flexion
and extension sitting The patient sits with her
legs over the side of the table. Instruct her to resist
your movements with a light pressure only. Rock
the leg forward and back to flex and extend the
knee. Vary the start and finish point so that the
flexion and extension movement will be through a
larger and smaller arc. This has the effect of 're-
training' the proprioceptive feedback from the joint.
See earlier section relating to harmonic technique.

31 .5 T Articulation patella-femoral joint supine

This hold allows mobilization of the patella through
all possible ranges. The accessory ranges of diagonal
movement in particular can be addressed as
release of these often improves overall function.
Tips: Most useful in the majority of cases of knee
dysfunction as the patella-femoral joint may be
involved and can often be a neglected element. To
avoid discomfort, preliminary work on the sur-
rounding soft tissues is helpful to release the area
prior to this technique.

0
242 Techniques for the knee area
31.6 ..,.. Articulation flexion supine Flex the knee
over your hand placed in the popliteal space. Use
your other hand to monitor the tissue tension to
avoid excessive strain. Hold the leg firmly between
your forearm and body. Circumduction movements
can be added so that the flexion becomes one part
of the arc of movement.
Tips: Avoid excessive flexion in the presence of
any effusion unless it is very slight.
31 .8 T Articulation extension supine Grip the
knee firmly and hold it against the table while your
other hand braces the foot and lifts the heel. This
hold has the advantage over the one shown in
photograph 31.7, in that the gastrocnemius is placed
on some tension and will be stretched if desired.
Tips: Try varying the amount of dorsiflexion in
the foot to assess at what point the limitation of
extension manifests. The earlier this occurs, the
more the gastrocnemius will be involved in the lack
of extension.

31.7 ..,.. Articulation extension supine Grip the

knee firmly and hold it against the table while your
other hand lifts the lower end of the tibia.
Tips: Many knee dysfunctions manifest as a lack
of hyperextension, particularly internal derange-
ments. This movement is as much an assessment of
successful restoration of function as it is a treatment.
 Techniques for the knee area 243
31.9 <IIIII Traction supine Hold back on the femur
with your fully pronated hand avoiding the patella.
The other hand applies the traction and can vary
rotation, abduction and adduction of the tibia as
necessary.
Tips: Many internal derangements of the knee
seem to have some sort of internal entrapment
involved. Traction can be very helpful in these
instances.

31.11 T Articulation rotation and flexion supine

Hold directly over the joint line with your upper hand
and introduce internal and external rotation with
varied degrees of flexion with the other.
Tips: Most useful in cases of meniscal dysfunc-
tion where there is often a limitation of full flexion
and rotation combined, at one specific point in
the range of movement. Extra considerations: In
many cases of meniscal dysfunction it is useful to
break fixation in flexion before trying to re-establish
full extension.

31.10 <IIIII Traction prone Fix the femur into the

table. Lift the leg, from above the ankle, with the
other hand while introducing different ranges of
flexion and rotation. This can be applied to the
near or far leg. It has the advantage over supine
methods in that it can be performed in flexion and
can be made into a circumduction movement at the
hip to be more rhythmic.
244 Techniques for the knee area

31.12 _. Thrust meniscus supine Fix the femur 31.13 _. Thrust medial meniscus supine Firmly
between your hand, the table and the lateral aspect clasp the ankle between your body and forearm.
of your thigh. You can then circumduct the tibia to Grip around the leg just below the knee and
alternately apply medial and lateral gapping to the introduce a circumduction movement. Within this
knee. This forms a very efficient articulation tech- circumduction there will be a point of tension. This
nique and if the fixing hand presses directly over point usually occurs with a combination of abduc-
the joint line, a firm abduction and extension force tion and external rotation of the t ibia. At this point
can often allow a medial meniscus fixation to be apply a force combining further abduction, external
released. If the lateral meniscus is the target, rotation and extension. It is more of a flick than a
adduction combined with extension is necessary. thrust.
Tips: As the hand pressure increases over the Tips: Visualize a piece of string with a weight
joint the available ranges of abduction and adduc- attached tied around the knee and hanging down
tion will reduce to a specific small arc. Within this on the lateral side. Try to flick the weighted string
arc will be found the appropriate barrier to apply over to the medial side sharply. This gives an image
the final very short amplitude force. of the direction and type of force necessary.
 Techniques for the knee area 245
31.14, 31.15 and 31.16 Thrust to medial meniscus
supine This series of photographs shows the
sequence of moves normally used in this tech-
nique. Flex and externally rotate the knee to break
fixation in the medial meniscus. Gently repeat this a
few times until nearly full flexion is attained.
Maintaining the external rotation and some abduc-
tion of the knee, extend it until the position shown
in photograph 15. At this point the final part of the
technique takes over which is an extension, trac-
tion and internal rotation movement. At the end of
the technique it is important to hold the knee firmly
into extension, to avoid reflex muscle contraction
into flexion that may dislodge the meniscus again.
Tips: Least useful where there is a suspected
tear in the meniscus and the extension movement
would be very painful. Extra considerations: It
may take several attempts to produce sufficient
flexion to unlock the joint. It may be very uncomfort-
able at the position shown in photograph 31.15
where the patient loses active control of the joint. It
is important to pass through this point fairly quickly.
246 Techniques for the knee area

31.18 • Thrust lateral shift of tibia supine Fix

the patient's leg between your crossed thiahs.
Apply your staggered hands to the medial aspect
31.17 • Thrust for lateral shift of tibia supine
of the femur and the lateral aspect of the tibia with
Internally rotate the patient's thigh slightly and
firm compression. Circumduct the knee using both
place your infra-patella tendon against the small
~ands and as the point of tension builds, sharply
plateau on the antero-lateral part of the tibia. Your
mcrease the pressure with both hands while
upper hand is placed under the knee maintaining a
straightening your knees to produce a traction
small amount of flexion and holding the femur over
effect.
the medial condyle. The lower hand clasps the
Tips: As this position is inherently unstable for
heel. Focus the forces by pulling the femur toward
the operator it may help to lean against the side of
the fulcrum of your applied knee while circumduct-
the table. Keep the patient's knee slightly flexed
ing the ankle and tibia. The thrust is a combination
throughout.
of a small push with the knee and a pull toward you
with both hands.
_Tips: Because the operator is pivoting on the
m1ddle part of his tibia against the side of the table
it is important to adjust the patient's positio~
accordingly. If the patient's leg is not externally
rotated sufficiently, painful pressure occurs on the
head of the fibula. Have the patient close enough to
the ~dge of the table so that your tibia can be nearly
vert1cal at the start of the technique.
 Techniques for the knee area 247
31.19 ..,.. Thrust for medial shift of tibia supine
Fix the patient's leg between your crossed thighs.
Apply your staggered hands to the medial aspect
of the tibia and the lateral aspect of the femur. Use
firm compression and circumduct your hands until
tension accumulates and then apply the thrust with
both hands at the same time as straightening your
knees to produce the traction.
Tips: Maintain a small amount of flexion to
prevent the patient's knee from locking.

31.20 • Thrust for medial shift of tibia and lateral meniscus Fix the abducted leg between your body
and forearm and grip the knee firmly just below the joint. Maintain a small amount of flexion and firm
compression and apply a rapid circumduction and lateral gapping force by rotating your body away from
the table. A direct lateral force will tend to correct the tibial shift whereas an abduction force will reach the
lateral meniscus.
Tips: Visualize a piece of string with a weight attached tied around the knee, with the weight hanging
down medially. The movement of this technique is to flick the weight from the medial side over to the
lateral side.
248 Techniques for the knee area
31.21 ..,.. Thrust for lateral shift of tibia and medial
meniscus Place the leg between your body and
forearm and clasp the knee firmly between your
hands. Use several small oscillating movements to
prime the joint and then apply a small rotation of
your body toward the table to open the medial side
of the joint. This can be a circumduction movement
or a medial gapping movement.
Tips: This technique can be suitable for correcting
an internal rotation restriction of the tibia if the tibia is
held firmly with both hands and externally rotated at
the same time as the gapping force is applied.
31 .23 ~ Thrust for internal rotation fixation of
tibia Firmly clasp the upper end of the tibia
between your hands and hold the lower end
between your forearm and body. Adduct the thigh
to produce a torsional force into external rotation of
the knee. Apply a small extension force to break
fixation into an external rotation direction.

31.22 ..,.. Thrust for external rotation fixation of

tibia Grasp the tibia firmly between your hands and
against your body with your forearm. Abduct the
thigh and flex the knee slightly and then apply an
internal rotation force by using your grip and by
sidebending your body toward the table. A small
final extension force may be necessary.
Tips: Use the weight of a more abducted thigh as
a resistance to the internal rotation force.
 Techniques for the knee area 249
31 .24 ..,.. Thrust superior tibio-fibula joint supine
Place the metacarpo-phalangeal joint of your index
finger behind the fibular head. Adduct the thigh and
externally rotate and flex the leg until you feel the
fibular head gripping your hand. Apply a small
flexion force to the leg while prising the fibular head
toward you.
Tips: Least useful in the presence of degenerative
disease in the knee that may make extreme flexion
painful. Extra considerations: Try varying the
distal hold to grip under the foot if preferred.
31 .26 T (Thrust superior tibio-fibular joint side-
lying Dorsiflex the foot slightly with your thigh
while holding the inferior end of the fibula back.
Your other hand applies a compression and for-
ward movement to the upper end of the fibula. The
thrust is applied to the upper end while the lower
part is held stable or the lower lever is slightly
increased.
Tips: Least useful where the operator may find
the thrust with the abducted arm difficult.

31.25 ..,.. Thrust superior tibio-fibular joint side-

lying Stand behind the patient and apply a forward
force against the head of the fibula of the flexed
knee. Hold back on the distal end of the fibula with
varied degrees of dorsiflexion of the foot to find the
optimum tension. Hold the foot firmly and then
apply the thrust against the fibular head.
Tips: Most useful where full flexion of the knee
may be a problem.
TECHNIQUES FOR THE CALF AREA 32

The calf area is often involved in conditions It is performed with the knee extended to
of dysfunction in the foot and the knee. reach the gastrocnemius, and flexed to take
Conditions of the calf muscles themselves the gastrocnemius off stretch and make it
such as muscle tears and direct trauma easier to reach the deeper muscles. Calf
sometimes need addressing. Contracture due muscles are closely concerned with posture,
to postural conditions and occupational dis- which means that there may be only partly
orders can also occur. reversible contracture and fibrosis present.
Particular care should be taken in phlebitis Techniques should usually be slow and deep
or varicose vein cases where there is the to produce the best result. Control of rhythm
possibility of thrombosis, haemorrhage and is also important. There may be remote
haematoma formation. If a clot is present, causes of calf muscle hypertonicity, such as
there is a distinct possibility of it being shifted nerve root pressure in the lumbar spine or
and subsequently lodging in heart, lung or circulatory deficit in the arterial supply. Initial
brain with potentially disastrous results. attention to these extraneous causes should
Technique to be used on the soft tissues be considered to get the best result from any
can be cross-fibre, stretching or muscle energy. later work on the calf.
 Techniques for the calf area 251
32.1 <1111 Kneading of lateral calf supine Sit on the
end of the table, stabilizing the patient's foot by rest-
ing your thigh on it. Hold the ankle to prevent move-
ment of the leg. Apply deep cross-fibre kneading to
the calf muscles with the pads and tips of the fingers.
Tips: Most useful where it is necessary to reach
the lateral muscles of the calf. Extra considerations:
Try varying the angle of knee flexion and rotation.
32.3 T Kneading of medial part of calf supine
Sit on the table stabilizing the patient's foot with your
thigh. Hold against the knee with your stabilizing
hand. The medial aspect of the calf is available to the
fingertips of the kneading hand.
Tips: Most useful when working on the musculo-
tendinous junctions deep in the calf. Try varying the
angles of knee flexion and rotation to achieve the
optimum for the technique.

32.2 <1111 Kneading of lateral calf supine Sit at

the end of the table. Stabilize the patient's foot with
your thigh. Fix the knee with one hand and knead
the muscles around the fibular head with the other.
Tips: Most useful when it is necessary to stabilize
the knee when working on the upper part of the calf.
Extra considerations: Try varying the angles of
flexion and rotation of the knee to vary the tension on
the muscles before the technique is applied.
252 Techniques for the calf area

32.5 _. Kneading of calf prone Support the tibia

on a small pillow and then apply a cross-fibre
kneading to the calf muscles with both hands
working in opposite directions.
32.4 _. Kneading and stretching calf prone Tips: Try using varied sizes of pillow or no pillow
Stretch the muscles by applying a dorsiflexion at all, if it is desired to make the principal effect on
force to the foot. Use a pulling or pushing force on the gastrocnemius.
the bellies of the muscles with the other hand.
Tips: Most useful where it is necessary to get
very deep into the muscle tissue. Try circumducting
the knee to reach different parts of the muscle. Try
changing the order of the stretch and kneading to
produce the best combination of comfort and
effectiveness.

32.6 ~ Kneading of calf sidelying Stand behind

the patient and apply opposite forces with both
hands, using the thumbs to knead the muscles of
the calf.
Tips: In this hold it is possible to work the whole
length of the calf of either leg with the thumbs. If
use of the fingertips is preferred to use of the
thumbs, work from the other side of the table.
TECHNIQUES FOR THE FOOT 33

Some osteopaths neglect foot technique in some cases, relative hypomobility in one part
patient care as they find the techniques of the foot will cause relative hypermobility
difficult to master, and sometimes uncomfort- in another. This is where very specific treat-
able on the hands. Many cases of foot dysfunc- ment to the hypomobile section will help to
tion receive benefit from general mobilization 'unload' the excessively mobile articulations.
and some practitioners are happy to use such Hypomobility also seems to have reflex effects
methods rather than specific techniques. in maintenance of hypermobility in adjacent
However, specific techniques can often be a areas. If a hypomobile joint is satisfactorily
short cut to good results, and save not only mobilized, there is often an immediate restora-
time and effort, but can produce a better and tion of ligamentous tone in adjacent, pre-
longer-lasting relief from mechanical dys- viously diagnosed, hypermobile joints. This
function problems. The foot is the foundation is too rapid to be simply a balancing of
of posture, and to neglect it is to leave out a mechanics, and seems to be due to fascial
very important part of patient care. Clearly a tension alteration and some proprioceptive
poor foundation is not going to help in feedback mechanism.
resolution of mechanics in other parts of the Most positions used traditionally for thrust
body if a practitioner is trying to restore good techniques are perfectly suitable for articula-
function. There are also local problems of tion procedures. This is not mentioned each
pain and disturbed mechanics in the foot that time in the descriptions appended to the
can often be suitably addressed by osteo- photographs to avoid repetition. Where a
pathic treatment. technique is declared a thrust, a repetitive
As in all areas of the body, particular care articulation is usually performed as a prelimin-
must be taken in cases of potential bone ary, and if tension accumulates to a suitable
weakness as techniques may induce quite sense of barrier, the thrust can be performed. If
strong effects on bone. However, the chance it does not, repeated articulation may deal
of damage is quite small, as the stresses used with the dysfunction adequately. A suitable
are liable to be less than those in normal thrust barrier has a potential for the short
locomotion. Infection, cellulitis and inflam- amplitude movement that implies a quite
matory disorders are common in the foot, characteristic 'crispness'. Without this the
and will need careful pre-treatment assess- thrust is not liable to succeed as a specific
ment. By its very nature osteopathic treat- technique and is best avoided, as the tissues
ment is designed to increase mobility. Many may become traumatized. A successful short
cases of disturbed foot mechanics are due to amplitude thrust performed well is rarely
excess mobility or hypermobility and, there- traumatic in the foot. An unsuccessful one may
fore, further mobilization may be unwise. In be uncomfortable, although rarely damaging.
254 Techniques for the foot
33.1 ..,.. Kneading of sole supine Stabilize the
foot with the cephalic hand and use your thumb to
work on the soft tissues of the sole.
Tips: Many patients are ticklish and the grip
should be firm but not painful. Kneading is more
likely to be of benefit than stretching, as a normal
standing posture stretches the tissues more than
any technique is able to do. Try varied degrees of
plantar flexion to reach different layers of tissue.
33.3 T Thrust to tibio-talar joint supine Cup the
calcaneum and pull the foot into a neutral point
between plantar and dorsiflexion. Push the tibia with
the cephalic hand toward the table and allow the
natural recoil of the tissues to cause it to spring back.
The plane of the joint is not directly antero-posterior
and it will be necessary to slightly internally rotate the
hip to produce the optimum resistance for a thrust. If
there is a barrier, several priming movements will be
necessary before the thrust can be executed.
Tips: Most useful where the patient mentions the
symptom that they are unable to achieve comfort in
the ankle in any position and feels that the joint needs
to 'crack'. Extra considerations: When a satisfactory
thrust is attained with this technique, the amplitude of
movement within the thrust will often be greater than
expected and possibly alarming to the practitioner!

33.2 ..,.. Articulation to distal tibio-fibular joint

supine Stand at the foot of the table and grasp the
tibia and fibula between the index finger and thumb
of each hand. Introduce antero-posterior and slight
supero-inferior movements.
Tips: Most useful in cases where fibular mobility is
particularly relevant, that is most ankle dysfunctions
and some knee conditions. Extra considerations:
Try dorsi-flexing the foot with the operator's thigh
to produce the optimum tension in the joints.
 Techniques for the foot 255
33.4 <1111 Thrust to tibio-talar joint supine Fix the
calcaneum with your crossed thumbs, and grip
firmly around the front of the ankle. This produces a
dorsiflexion component and an antero-posterior
component. As you lower the foot toward the table
increase the firmness of the grip. You can then
amplify the hold to apply a force in an antero-
posterior direction to the tibia to separate the joint.
Tips: Least useful where the operator may have
any weakness in the thumbs. It is also difficult in
large feet to maintain the dorsiflexion necessary
and to grip around the foot at the same time. Extra
considerations: The thrust is performed by the
operator adducting his arms at the same moment
as the grip tightens.

33.5 • Thrust to tibio-talar joint prone Apply 33.6 • Thrust to tibio-talar joint prone Stand to
some pre-tension to the joint by gripping around the side of the prone patient facing toward the foot
the anterior aspect of the ankle while pulling of the table. Grip round the front of the ankle as you
forward on the calcaneum. Maintain a degree of push forward with your crossed thumbs behind the
dorsiflexion of the foot with your forearm and when calcaneum. Rock the patient's leg forward and
the forces accumulate, execute a sharp adduction back. When tension accumulates emphasize the
of your arms to cause a gapping at the joint. simultaneous pull and push to gap the joint.
Tips: Least useful for smaller operators, and for Tips: The thumbs can also vary the dorsiflexion
those where the necessary strength may be a to focus the technique more accurately.
problem. Extra considerations: Try circumducting
the leg in the build-up to the technique, so that the
perception of continuous tension for the patient is
not too uncomfortable.
256 Techniques for the foot
33.7 <IIIII Thrust to tibio-talar joint prone Put the
patient's foot over the end of the table and fix the
tibia with your cephalic hand while taking up
the slack with the other hand pushing down on
the calcaneum. You can vary the dorsiflexion to
achieve the optimum tension and then apply the
thrust toward the floor.
Tips: Most useful for small operators as this
technique relies on application of weight rather than
use of levers and force. Extra considerations: Try
using the operator's inner thigh to produce the
relevant amount of dorsiflexion.

33.8 A Traction to tibio-talar joint supine Brace your elbow against your flexed knee on the table
under the patient's flexed knee. Use your lower forearm as a fixed lever while your upper hand pulls the
foot into dorsiflexion and drives it straight down over the edge of the table. The larger the space between
your elbow and the patient's knee the stronger the lever will be to open the tibio-talar articulation.
Tips: Try gently mobilizing the foot in circumduction while it is under traction.
 Techniques for the foot 257

33.9 A Traction to tibio-talar joint supine Brace your elbow against the back of the patient's flexed
thigh. Cup the calcaneum in the same hand and fix the talus and the rest of the foot with the other hand.
Traction is produced by maintaining these holds and simply leaning back. The push of the patient's flexing
thigh against your elbow performs the technique.
Tips: Least useful where the operator's arm is very short and the patient's leg is very long. Extra
considerations: Try abducting the hip further as necessary or placing a pad between elbow and thigh.

33.1 0, 33.11 and 33.12 .,.. (see also next page,

top left and bottom left) Articulation to sub-talar
joints supine This series shows the overlapping
fingers hand hold in the shape of a letter 'W'; then
the hands applied to the foot can produce inver-
sion, eversion and circumduction to influence the
sub-talar joints. The operator viewpoint photo-
graphs show the pressure being applied with one
thenar eminence and the opposite hypothenar
eminence. This is then reversed to gap the medial
and lateral sides of the joint respectively.
Tips: Try varying the angle of dorsiflexion using
the operator's abdomen against the sole of the
foot. Extra considerations: This hold requires a
firmer grip than may be apparent; it also requires a
good control of rhythm.
258 Techniques for the foot

33.13 A Articulation to sub-talar joints prone

Brace the foot against your lower chest. Fix the
fingers of both hands over the medial side of the
foot while gripping firmly under the lateral maleolus.
Rock forward over the foot to put tension on the
medial aspect of the joint. Then rotate your body to
alternate the stress applied to the anterior and
posterior parts of the joint.
Tips: Least useful for the smaller operator who
may find the reach a problem. Extra considerations:
A firm grip is necessary if this technique is to be
effective.
 Techniques for the foot 259
33.14 <1111 Articulation to sub-talar joint sidelying
The patient lies on the affected side and the
operator fixes the dorsiflexed foot against his inner
thigh. Hold it firmly against the table with the fixing
hand and rock the calcaneum into inversion and
eversion. Dysfunctional areas of the sub-talar joint
are reached by varying the angles of movement.
Tips: This technique will only gap the medial
aspect of the joint. Extra considerations: If the
pressure on the table is uncomfortable, try inter-
posing a pillow between foot and table.

33.15 T (bottom left) Articulation to sub-talar

joint sidelying In this operator viewpoint photo-
graph the patient is lying on the unaffected side
and the operator is gripping medially on the distal
part of the calcaneum. Place your thumbs just under
the lateral maleolus. Maintain a firm grip and lean
forward until tension is felt to build in the joint. The
medial side of the joint is being stretched.
Tips: Try varying the angle of dorsiflexion to
reach different surfaces of the joint.

33.16 ~ (see next page, top left) Thrust to sub-

talar joint sidelying The patient lies on the affec-
ted side with the knee flexed. Fix the foot into
dorsiflexion to stabilize the ankle. Fix the calca-
neum to the table, and with your other hand invert
the foot by fixing on the navicula and pushing up
along the long axis of the tibia. Tension should
accumulate in the sub-talar joint. Rock the foot
between the hands until the optimum barrier is
sensed. Maintain the pressure and thrust the whole
foot toward the table thereby applying a gapping
force to the target joint.
Tips: If the tension is correct the foot will rock
back and forth like a saucer rocking from edge
to edge. According to whether the anterior or
posterior of the joint is dysfunctional, the tension
will be felt better with the proximal or the distal
hand. Extra considerations: If this position is very
painful, try working from the lateral side of the foot
as in next technique illustration.
260 Techniques for the foot
33.17 and 33.18 T Thrust to sub-talar joint side-
lying The patient lies on the unaffected side. Pull
the medial side of the dorsiflexed foot into inversion
with your distal hand. Maintain pressure toward the
table with your other hand cupping the lateral
maleolus. The calcaneum is, therefore, a fulcrum.
This has the effect of putting a stress on the sub-
talar joint on the medial aspect of the foot. Vary the
degree of abduction with your distal hand until a
suitable barrier is felt, and then apply a thrust with
your proximal hand to gap the joint.
Tips: This may be useful when the opposite
sidelying position is a problem. Note that the
second photograph shows the distal hand in the
final position. The wrist is now straight and the foot
inverted and abducted. Firm compression is
necessary if the force is not to be dissipated in the
tissues generally. The sub-talar joint is extremely
strong, and if the compression is not firm enough,
the technique will be ineffective.
 Techniques for the foot 261
33.19 and 33.20 ~ Articulation mid tarsus supine
These operator viewpoint photographs show a hold
for applying general mobilization to the mid foot.
The thumbs are aligned along the shafts of one or
more of the metatarsals. A torsional force is
introduced to direct the articulation forces to the
joint to be mobilized.
Tips: Try varying the spacing between the
thumbs or making them more proximal or distal to
reach different parts of the foot.

33.21, 33.22, 33.23 and 33.24 ~ (see next page)

Articulation mid tarsus supine This series of
photographs show the so-called 'figure of eight'
technique in its various phases. Take the foot
through an imaginary figure of eight, in a variety of
planes, either vertically, horizontally or diagonally.
Tension accumulates at the cross-over in the
middle or at the outer edges of the figure as
directions change. Visualize the eight as having a
somewhat flat top and bottom.
Tips: Most useful in almost all cases of dysfunc-
tion causing restricted mobility in the foot. Extra
considerations: Quite firm compression is usually
necessary to the metatarsal heads by the operator's
lower abdomen to help focus the technique.
262 Techniques for the foot
 Techniques for the foot 263

33.25 • Articulation mid tarsus and fore foot 33.26 • Thrust to mid tarsus supine Fix over
supine The hands grasp firmly around the medial the target joint with the centre of your interlocked
and lateral aspects of the foot. The foot is dorsi- hands. Apply some traction to put the area on
flexed to stabilize the ankle. One hand can stabilize tension . Then spread the foot with the thumbs to
while the other mobilizes, or they can both drive the allow some space for the bone you wish to
metatarsals up in the centre of the foot by fingertip manipulate. The mid tarsal bones are somewhat
pressure. At the same time the heels of the hands wedge shaped and need a space to 'fall into'. The
drive down the borders of the foot. thrust is performed with a short tug in the long axis
Tips: Try introducing twisting forces to direct the of the tibia.
levers to different parts of the foot. With traction Tips: Try using slight variations of abduction and
and firm moulding of the foot it is possible to reach adduction while accumulating the optimum forces.
most of the mid foot articulations.
264 Techniques fo r the foot

33.27 A Thrust to middle or lateral cuneiform 33.28 A Thrust to middle and lateral cuneiforms
supine Shake hands with the foot, that is right supine This technique uses a similar principle to
hand to right foot, or left to left. Maintain the foot in the one shown in photograph 33.27. The difference
a neutral position between dorsiflexion and plantar- is that the operator is using a reinforced pisiform
flexion by levering up with the back of your hand on while a pad is performing the dorsiflexion resistance.
the table. The other hand applies a firm pressure Tips: Most useful where the operator may not
down on the cuneiform using your pisiform as the be able to develop the force sufficiently with the
applicator. Ensure that the tendons are pushed to single-handed grip. The disadvantage is that part
one side to avoid excess discomfort. Balance the of the control of the inversion, eversion and traction
tension between the hands and adjust the inver- is lost.
sion, eversion, traction and abduction components
with the underneath hand. The upper hand main-
tains the firm pressure, and at the optimum
moment apply a thrust force to the cuneiform
towards the heel.
Tips: Try varying the knee flexion to find the
optimum sense of tension in the foot. It generally
helps to have the foot closer to the side of the table
than the hip so that the leg does not fall into
external rotation .
 Techniques for the foot 265

33.29, 33.30 and 33.31 Thrust to middle or

lateral cuneiform supine These three sequence
photographs show the foot pulled into dorsiflexion
to lock the ankle. The upper hand then fixes the
tibia to the table. The thrusting hand is then very
rapidly pronated, and before the foot can drop into
plantarflexion, it applies a force to the cuneiform
with the thenar eminence. Note: This requires very
fast movement by the operator to reach the
cuneiform before the foot drops. Very few operators
can achieve the amount of speed necessary, but if
it can be developed, this is an extremely effective
technique. If the thrust is performed on the
cuneiform after the foot has dropped into plantar-
flexion, it may be very uncomfortable on the tissues
on the front of the ankle.
266 Techniques for the foot
33.32 and 33.33 <1111 Articulation of medial border
prone The foot is grasped with the target joint
between the index finger of one hand and the fifth
finger of the other. Fix the lateral border of the foot
into your chest. Apply a dorsiflexion force with your
distal hand, while holding a plantarflexion force
with the other. Then reverse the movement.
Tips: Try using abduction or adduction, as well
as traction, to amplify the primary levers. Extra
considerations: If a suitable barrier accumulates,
this hold can develop sufficient tension to perform
a thrust.

33.34 • Articulation of lateral border Sit on the

table and rest the patient's foot on your thigh. Fix
the ankle with the inside of your wrist and clasp
around the lateral border of the foot with the same
hand. The other hand reaches under the foot and
pulls the fourth and fifth metatarsals into plantar-
flexion. The direction of forces of both hands can
be reversed to produce the articulating force.
Tips: The sitting position cradling the foot can be
quite a useful one for general mobilization as an
_ _..;;,_________ alternative to standing.
 Techniques for the foot 267

33.35 and 33.36 .A Thrust to medial border

Dorsiflex the foot to stabilize the ankle and fix the
foot into the table with the stabilizing hand. Place
the index finger of the stabilizing hand under either
the talus, navicula or cuneiform according to which
joint is being mobilized. Apply a buckling force
toward the table with the thrusting hand and a
combination of plantarflexion, eversion and abduc-
tion to focus at the target joint.
Tips: Several priming movements are often neces-
sary to produce the optimum potential for the thrust.
268 Techniques for the foot

33.39 • Articulation of medial border Sit on the 33.40 • Articulation of lateral border Sit and
table so that you can apply a very specific force to stabilize the calcaneum or cuboid with the proximal
articulate the joints. The hand applied to the sole hand. The distal hand articulates either the cuboid,
pushes the forefoot into dorsiflexion and varied or the fourth and fifth metatarsals on the cuboid.
degrees of inversion, eversion, abduction and Form a fulcrum with the thumbs under the foot or
adduction while the other hand fixes specifically, the fingertips on the dorsum.
proximal to the target joint. Tips: Try introducing traction and direct dorsal to
Tips: Although this hold does not allow a very plantar movement.
powerful articulation it can be extremely specific.
The sitting position can be a useful variation for the
operator.

33.37 and 33.38 ~ (see previous page, top right

and bottom right) Thrust to medial border Stabilize
the foot against the table holding the hind foot in
dorsiflexion to lock the ankle. Supinate the other
hand and pull the medial border of the foot into
plantarflexion, abduction and eversion. Reverse the
direction of forces and then, when a suitable
tension is developed, execute the thrust with both
hands. The stabilizing hand fixes on either the talus,
navicula or cuneiform according to the target joint.
Tips: It may be easier to develop the eversion
required with this hold than with some others, as
the heel of the thrusting hand can be used.
 Techniques for the foot 269
33.41 ..,.. Articulation of mid tarsus supine Sit
on the table and reach around the foot with both
hands to fix the target joint between the clasping
fingers and thumbs. Traction, circumduction, inver-
sion , eversion, abduction and adduction are poss-
ible in this hold. Although this is not a very strong
hold it is highly specific and can have a useful
influence to re-introduce mobility in these other-
wise inaccessible joints.

33.43 T Articulation of lateral border supine

Form a fulcrum either under the foot with the thumb
or on the dorsum with the fingertips of the proximal
hand. Apply traction, compression, abduction,
adduction or circumduction to the third, fourth or
fifth metatarsals with the distal hand. This will
articulate the lateral cuneiform, cuboid and some of
the mid tarsal joints.
Tips: Least useful with large feet as the reach
may be a problem.

33.42 ..,.. Articulation of cuboid supine Sit and

clasp either the calcaneum or the cuboid to apply
traction and adduction with different degrees of
dorsiflexion and plantarflexion. Fix the foot against
your abdomen to help block movement in the rest
of the foot.
Tips: Most useful in very mobile feet where it
may be difficult to isolate the cuboid.
270 Techniques for the foot

33.44 and 33.45 Thrust to cuboid supine Pull up on the fourth and fifth metatarsals with your fingertips.
Apply the pad of the other thumb under the medial border of the cuboid. The thumb becomes a fulcrum
over which you can plantarflex, invert and slightly adduct the foot. As tension accumulates you can
amplify these components and add a compression force toward the table. The thumb forming the fulcrum
should remain in as little abduction as possible to avoid straining it. Although the thumb applies a slight
increase of force the thrust comes principally from the other hand. At the end of the thrust both elbows
should be close to the operator's sides.
Tips: Least useful where operator thumb strength may be suspect. The technique could be modified so
that the thenar or hypothenar eminences could be substituted. Extra considerations: If it proves impossible
to build a suitable barrier, try lifting the whole leg off the table then bring it down sharply and, as the heel hits
the table, execute the thrust. The momentum component may allow the barrier to be accessed more
effectively.
 Techniques for the foot 271
33.46 ..,.. Thrust to cuboid prone Pull the foot
into dorsiflexion with the distal hand and fix the
other thumb toward the table on the medial border
of the cuboid. Keep the arm close to the side, shrug
the shoulder of the distal hand to produce an
inversion of the lateral border of the foot with the
heel of your hand.
Tips: Least useful where thumb strength is a
problem but try substituting the thenar or hypo-
thenar eminences. Extra considerations: Try cir-
cumducting the operator's body and the patient's
lower extremity until the optimum thrust point is
sensed.

33.4 7 T (bottom left) Thrust to cuboid prone

Cross the thumbs under the cuboid and dorsiflex
the foot. Maintain the thumb pressure and plantar-
flex, invert and adduct the foot with some com-
pression. This hold can be applied to most of the
mid tarsal joints by changing the position of the
crossed thumbs.
Tips: Ensure the ankle is maintained in dorsiflexion
throughout as otherwise the force will dissipate
through the ankle joint and the mid tarsal joints will
tend to lock in plantarflexion.

33.48 and 33.49 ~ (see next page, top left and

bottom left) Thrust to cuboid prone leg over
side Cross the thumbs and apply them under the
cuboid. Overlap the fingers on the dorsum of the
foot and push with both thenar eminences against
the sole to maintain dorsiflexion at the ankle. Keep
dorsiflexion constant, and flex and extend the
patient's hip and knee. Maintain the tibia in an
almost horizontal position and push the leg away
and allow it to recoil. Midway through one of these
recoil movements drive the thumbs against the
cuboid while the fingers produce inversion, adduc-
tion and compression.
Tips: Least useful in patients who may find the
position a problem. Extra considerations: The co-
ordination necessary for this technique is rather
difficult. Note that it is applied as the tibia comes
towards the operator, not away. If it is applied as
the tibia moves away it becomes an undesirable
plantarflexion thrust. It is possible to perform this
thrust in simple plantarflexion but there are several
disadvantages in this; greater force will be re-
quired, it will not be as specific, and the ankle will
come under some strain.
272 Techniques for the foot

33.50 • Articulation to metatarso-phalangeal

joint of hallux supine Sit and rest the foot across
your thigh. Fix the foot, particularly the first
metatarsal, with your proximal hand and apply a
traction and circumduction force to the first
metatarso-phalangeal joint.
Tips: By gripping the distal end of the first
metatarsal rather than the phalange the traction
force will reach into the medial border of the foot.
 Techniques for the foot 273

33.51 .& Traction to hallux supine Grip the first 33.52 .& Thrust to metatarso-phalangeal joints
toe between your flexed fingers and hold back on supine Fix on the body of the foot and apply a
the rest of the foot. This hold permits the use of traction, then plantarflexion force to the toe. Small
traction, circumduction and rotation. amounts of circumduction and rotation help localize
Tips: This grip allows a more comfortable hold the force.
than a simple clasping of the toe with finger and Tips: Try using the finger under the toe as a
thumb. fulcrum rather than just using traction or flexion.
RECOMMENDED READING

Bogduk, N. et al. (1985) Theoretical pathology of Johnson, W.L., Robertson, J.A. and Stiles, E.G.
acute locked back: a base for manipulative (1969) Finding a common denominator for the
therapy. Manual Medicine, 1, 78-82. variety of manipulative techniques. Yearbook of
Bourdillon, J.F. (1982) Spinal Manipulation, 3rd edn, the Academy of Applied Osteopathy, American
Appleton-Century-Crofts, East Norwalk, CT. Academy of Osteopathy, Carmel, CA, pp. 5-15.
Bowles, C.H. (1956) A functional orientation for Jones, L.H. (1981) Strain and Counterstrain, American
technique I, Yearbook, New England Academy of Academy of Osteopathy, Colorado Springs, CO.
Applied Osteopathy, Academy of Applied Kimberley, P.E. (1976) Formulating a prescrip-
Osteopathy, pp. 107-14. tion for osteopathic manipulative treatment.
Bowles, C.H. (1956) A functional orientation for Journal of the American Osteopathic Association, 75,
technique II, Yearbook, New England Academy 486--99.
of Applied Osteopathy, Academy of Applied Kimberley, P.E. (1980) Outline of Osteopathic Manipu-
Osteopathy, pp. 107-14. lative Procedures, 2nd edn, Kirksville College of
Bowles, C.H. (1957) A functional orientation for Osteopathic Medicine, Kirksville, MO.
technique III, Yearbook, New England Academy Korr, I.M. (1976) Proprioceptors and somatic
of Applied Osteopathy, Academy of Applied dysfunction. Journal of the American Osteopathic
Osteopathy, pp. 53-5. Association, 74, 638-49.
Bowles, C.H. (1981) Functional Technique, a Korr, I.M. (ed.) (1978) The Neurologic Mechanisms in
modern perspective. Journal of the American Manipulative Therapy. Plenum, New York.
Osteopathic Association, 80, 326--31. Lederman, E. (1992) Harmonic Technique. British
Chaitow, L. (1988) Soft Tissue Manipulation, Osteopathic Journal, IX, 11-13.
Thorsens, Wellingborough, Northants. Lederman, E. (in press) Physiological Basis of
Chaitow, L. (1980) Neuro-muscular Technique, Manual Therapy, Churchill Livingstone.
Thorsens, Wellingborough, Northants. Lewit, K. (1986) Postisometric relaxation in combina-
Chaitow, L. (1993) Palpatory Literacy, Thorsens, tion with other methods of muscular fascilitation
Wellingborough, Northants. and inhibition. Manual Medicine, 2, 101-4.
Fryette, H.H. (1954) Principles of Osteopathic Littlejohn, J.M. Fundamentals of Osteopathic Tech-
Technique, American Academy of Osteopathy, nique, Wernham J, Maidstone School of Osteo-
Carmel, CA. pathy.
Greenman, P.E. (1989) Principles of Manual Medicine, Magoun, H.I. (1966) Osteopathy in the Cranial
Williams & Wilkins, London. Field, 2nd edn, Journal Printing Co., Kirksville,
Grieve, G.P. (1981) Common Vertebral Joint MO.
Problems, Churchill Livingstone, Edinburgh. Maitland, G.D. (1980) Vertebral Manipulation, 4th
Grieve, G.P. (1990) Contra-indications to Spinal edn, Butterworths, Stoneham, MA.
Manipulation and Allied Treatments. British Middleton, H.C. (1970) Osteopathic Technique.
Osteopathic Journal, IV, 23-4. British Osteopathic Journal, 4(4), 21-6.
Haas, M. (1990) Physics of spinal manipulation. Mitchell, F.L. Jr, Moran, P.S. and Pruzzo, N.A.
Journal of Manipulative and Physical Therapeutics, (1979) An Evaluation and Treatment Manual of
13, 204-6; 253-6; 305-8; 378-83. Osteopathic Muscle Energy Procedures. Mitchell,
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tion of Motor Function, Osteopathic Supplies, niques, Philadelphia College of Osteopathic
Hereford. Medicine, Philadelphia.
276 Recommended reading
Rahlmann, J.F. (1987) Mechanisms of interverte- ance. American Journal of Physical Medicine, 63 (5),
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177-8. sacral Therapy. Eastland Press, Chicago.
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2nd edn, Osteopathic Supplies, Hereford. nique Procedures, 2nd edn, American Academy of
Stoddard, A. (1993) Manual of Osteopathic Practice, Osteopathy, Colorado Springs, CO.
3rd edn, Osteopathic Supplies, Hereford. Wernham, J. (1989) The Art and Science of
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INDEX

Abortion 28 Cerebro-spinal fluid 32 Dizziness 25, 159

Acceleration 20, 52, 179, 185 Cervical bar 25 Dosage 26, 43
Accessory movements 12, 17 Chaitow, B. 36 Drainage 16, 17
Adaptation 5 Chiropractic 21, 32, 36, 42 lymphatic 14, 16
Adhesions 23, 46 Choreography 43, 49 Drugs
Adjustments 4 Clinical methods 7 recreational 29
Alcohol, see Medication Close packing 40, 43 Dummer, T. 36
Amplitude, see Technique, Coach 50 Duration, see Technique, modifying
modifying factors Compensation 5, 10 factors
Anatomy Components Dysarthria 25
applied 7, 24 multiple 1, 18, 19, 20
Ankylosing spondylitis 27 secondary 2, 19
Elbow
Anomaly 25, 30 tertiary 2
golfer 218
Applicator 14, 43 Compression 43, 62
tennis 218
Arrest, see Technique, modifying see also Technique, modifying
Equipment 50
factors factors
pads 57
Arthrosis Contact point 43
pillows 57
hip 97, 234 Contract 24, 30
plinths 57
osteo 34, 113, 116 Contra-indications, see Technique
stools 57
Arteries Control 1, 41
Examination 8, 9
calcification 28 Cord compression 25, 28
Exercises 61
see also Vertebro-basilar arteries Counter-irritant 16
Ewing's tumour 108
Articular Corrections 4
Experience 47
limit 45 Cranial rhythmic impulse (CRI) 32
Extension test 25
sound 31
Assessment 4, 7, 8 Damage
pre-technique 26 blood vessel 24, 25 Facet
Asymmetry 6 nerve 24, 25 angles 63
De Klejn' s test 25 lower 86
Barra!, J.P. 37 Diabetes 27 orientation 82
Barrier 1, 18, 43 Diagnosis 1, 4, 7, 8 overriding 90
collapsing 21 aggravating factors 8 syndrome 9, 10
compound 20 applied anatomy 8 Feedback 2
sense 1, 54, 64 examination 8, 9 Feel 30
Bind-ease 33 history 8, 9 Fibrosis 5
Bowles 33 maintaining factors 8 Fibrositis 5
Bradbury, P. 36 manipulative prescription 7 Fine-tuning 2
Braking 52, 179, 185 palpation 8 Flexion test 25
British School of Osteopathy ix, 1, patho-physiology 8 Fluid exchange 14
28, 37 predisposing factors 8 Force
Bruxism 191 relieving factors 8 conceals weakness 31
symptoms 8 re-duplication 42
Capsule 5 Disc 24, 27 see also Technique, modifying
shoulder 21, 200 degeneration 9, 10 factors
Cardiac infarction 147 disease 43 Fracture
Carpal tunnel syndrome 219, 220 herniation 27, 90 femur 227
Cauda equina 25 irritability 10 scaphoid 21
Cellulitis 253 lesion 69, 113, 116 stress 289
Central nervous system 32 prolapse 20, 29 Free play 20, 45
see also Nerve syndrome 95, 102 Fryette 2, 45, 62, 122
278 Index
Function 6, 18 Littlejohn, J.M. 14 Myeloma 131
restoration 69 Locking Myositis ossificans 210, 233
Function governs comfort 6 acute 5
ligamentous 62 Negligence 7, 25
Gapping 19, 44 localization 63 Nerve
General Council & Register of physiological 45, 62 afferent 16, 33
Osteopaths (GCRO) 60 principles 62 autonomic 113, 116
Grays Anatomy 37 recurrent 94 efferent 16, 33
wind-up 62 gamma receptors 33
Hand impingement 20, 29, 86, 92
active 70 root pressure 9, 17, 27, 86, 139
Magnetic resonance imaging
Handling 49 signs 67, 147, 159, 167, 172
(MRI) 27
breast contact 50 ulnar neuritis 210, 218
Malignancy 29
comfort 49 Neuro-musculo-skeletal system
secondary deposits 24, 30, 113,
effectiveness 49 13, 14, 31
116, 147, 227
genital area 50 Neuropraxia 25
Management 9
pressure 49 Neutral point 63
crisis 9
Hautant' s test 25 Nystagmus 25
Manipulable lesion 8
Heel lifts 12
Manipulation 18 Observer 2
Hold 3
Manipulative prescription 7, 23 Onset, see Technique, modifying
Homeostasis 14
Martial arts 67 factors
Hoover 33
Massage 16 Operator
Hypermobility 4, 5, 46, 69, 94, 96,
oil 16, 36 breasts 54
190, 191, 194, 199, 219, 253
Mechanical dysfunction 7 breathing 54
Hypertension 28, 147, 160, 240
Mechanics control 18
Hypertonia 5
homeostatic 4 differences 2
Medication 29 dynamic tension 54
Illness 27
alcohol 29, 49 effort 51
Indications
antibiotics 28 elbows 49, 53
Infection 253
analgesics 26 fatigue 56
Inflammation 27
anti-coagulants 28 front foot 52
foot 253
anti-depressants 29 grip 57
Influenza 27
anti-inflammatory 11, 26 groin 54
Informed consent 59
steroids 28 hands 53, 54
Insulin balance 27
Inter-vertebral foramen 18, 85 tobacco 29, 49 head 53
Involuntary mechanism 32 Medico-legal complications 59-60 hips 52
Meniere's disease 30 injury 56
Johnson, W.J. 33 Middleton, H.C. vm isometric tension 43, 53, 54
Joint Mills procedure 215 knees 52
fixation 18, 20 Mitchell, F. Jr and Sr 34 lower back 52
play 18 Modifying factors, see Technique mid back 53
popping 18 Momentum 19, 21 palpatory awareness 53
separation 18 Motion demand 33 posture 12, 51
Jones, L. 36 Motion barrier 1 proprioceptive awareness 53
see also Barrier psycho-motor skill 55
Kimberley, P. ix Movement rear foot 52
Knee active 9 relaxation 57
internal derangements 239 axis 37 repetitive strain 52
passive 9 second 92
Lederman, E. 34 pathways 18 strain 55
Levers quality 6, 33 third 92
composite 63 Muscle upper back 53
see also Technique, modifying fibrosis 116 Oscillation 34
factors guarding 10 Osteochondritis, see
Lieff, S. 36 memory 60 Osteochondrosis
Ligaments 5 postural 11 Osteochondrosis 113, 131, 134
calcification 29 pulling 56 Osteopathic lesion 3, 4, 5
laxity 28 pushing 56 positioning 45
Litigation ix, 31, 60 spasm 71 see also Somatic dysfunction
 Index 279
Osteopathic medicine 27 Reiter's disease 27 Student ix, 1, 13, 23, 49, 67
Osteoporosis 28, 113, 131, 134, Resistance Surgeon 11
199 effective 46 Sutherland, W.G. 32
Osteophytes 27 Rheumatoid arthritis 28, 219, Symptoms 6, 7, 9
Overpressure 18 225
Ribs Tapping 17
Pain 25 bucket handle 131 Target
acute 56, 59, 95, 96 pump handle 131
recurrences 61 joint 17
Rolfing 36 tissue 39, 41, 42
referred 9 Rolling 20
Palpation Technique
palpatory assessment 18 applied 56
Sacro-iliac advice 56
palpatory awareness 2, 13, 16,
rotation 94 apparatus 57
18, 33, 44
torsion 94 approach 59
palpatory feedback 33
Sandler, S.L. 37 category 60
palpatory findings 8
Sciatic Nerve clinic coat 58
palpatory investigation 59
adhesions 87 difficult situations 59
palpatory perception 67
pain syndromes 108 gown 58
pal pa tory skill 13, 33
sciatica 87, 110 handling 56
Paraesthesia 25
Pathology 7, 25, 67 stretch 87 holds 57
Scoliosis hygiene 58
Patho-physiology 4, 5, 8
Pathway organic 10, 29, 131, 136 intervals 60
of ease 33 Screening 69 operator relaxation 57
of resistance 62 Semi-Simms position 93 planning 59
Peritoneum 37 Short leg 10 positioning 56
Physiological curves 46 Signs 6, 7, 26 posture 56
Physiotherapist 11, 32 Sinusitis 191 reactions 59
Plane, see Technique, modifying Sixth sense 47 weight taking 57
factors Skill classification 1, 13
Positioning 2 exercises 66 combined ix
Postural hypotension 25, 30, 159, palpatory 14, 67 components 1
167 psycho-motor 39, 66 secondary 2
Postural nystagmus 10 technique 64, 67 tertiary 2
Posture 2 Sliding 44 contra-indications 1, 7, 23
antalgic 10, 31, 69, 71 Smoking 29, 50 absolute 23, 24
compensation 94 Somatic dysfunction 4 relative 23, 26
Practitionership 50 adaptation 4 cranial 21, 32
Pregnancy 28, 88, 95 adjustments 4 dog 122
Pre-loading 43 compensation 5 effectiveness 57, 151
Prescription 26 correction 4, 18 functional 33
Prognosis 7, 12 patho-physiology 5 gentle therapeutic manipulation
Proprioceptive feedback 15, 17, 37 primary lesion 4 33
Psychology 11, 30 secondary lesion 4 harmonic 21, 35
tenderness 4 indirect ix, 1, 31
Range Space occupying lesion 108 levers
anatomical 18 Speed, see Technique, modifying composite 63, 65
Reactions 20, 26, 60 factors primary 20, 44
Recipes 25 Spence, J. 33 secondary 44
Reciprocal tension membranes 32 Spondylarthrosis 29 tertiary 46
Recurrences 61 Spondylolisis 28 low velocity stress
Re-evaluation 25, 60 Spondylolisthesis 28 sustained articulation 21
Referral 24 Spondylosis 29 sustained leverage 21
Reflexes Sports injuries 233 sustained pressure 22
afferent-efferent 33 Stance 52 sustained traction 22
balancing 14 Stiles, E. 34 modifying factors 1, 2, 39
cough 10 Still, A.T. 4, 14, 32 amplitude 1, 17, 40, 43
relaxation 35 Stimulation 17 arrest 43
viscero-somatic 5, 147 Stoddard, A. 4 compression 43
see also Nerve Stressor 6 contact point pressure 47
280 Index
Technique, modifying factors contd thrust 1, 13, 17 daily 27
duration 40 combined lever and thrust 19 empirical 59
force 2, 41 combined lever and thrust exercises 7
hunch 47 with momentum 19 general 8, 61
onset 42 minimal leverage and thrust interval 12, 60
plane 40 20 long-term 7, 11
momentum 19 non-leverage thrust 21 maintenance 7, 61
muscle energy 34 non-leverage thrust with mid-term 11
isokinetic 34 momentum 21 osteopathic 7, 8
isometric 35 visceral 37 specific 7
isolytic 35 Tension 1, 2, 19 trial 24
isotonic 35 isometric 67 Trigger points 36
myo-fascial 35 minimum 47
neuro-muscular 36 optimum 45 Valsalva manoeuvre 54
resistance 2, 46 useful 70 Veins
respiration 46 Testing
haematoma 239
rhythmic 13 knee drop 11
haemorrhage 239
articulation 13, 15 neurological 8, 9
phlebitis 239
effleurage 16 orthopaedic 8
thrombosis 239
inhibition 16 Thrust trigger 52
varicose 9, 240
kneading 14 Tissues 24 Velocity 17
springing 17 sympathy 91 Vertebral body 24
stretching 15 Tobacco, see Medication
Vertebra-basilar arteries 25, 64,
traction 17 Toggle-recoil 42
179
vibration 17 Torticollis 16 Vertical adjustment 12
set-up 2 Traction 23, 43, 44
Vertigo 30
soft tissue ix, 1, 13 adjustive 91
Video ix
specific adjusting 35, 36 mechanical 17
speed 39 Treatment
strain and counterstrain 35, 36 aims 7 Working hypothesis 9, 25
structural ix, 1 crisis management 11 World Health Organisation 4