__Manipulative_Therapy__Musculoskeletal_Medicine

Manipulative Therapy Figure 4.65 • Testing elbow extension, forearms aligned and touching. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. precisely in position from above, abduction of 90° is assessed as range A, from 90° to 110° as range B, and beyond this as range C (see Figure 4.68). 4.14.3 The joints of the lower limb Figure 4.66 • Bringing the elbow towards the contralateral The knee shoulder. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. The knee joint is best tested by means of hyperex- tension. This is assessed as range A when the limit of this extension movement is at 0°. Hyperexten- sion of up to 10° is range B, and extension beyond this is assessed as range C (see Figure 4.69). Figure 4.67 • Making both hands meet behind the shoulder. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. 144

Diagnosis of dysfunctions of the locomotor system Chapter 4 variations on that test is followed by the study of more complex movements. We begin with assess- ment of posture (see Section 4.2). Motor stereotypes are the result of conditioned and unconditioned reflexes and/or programs acquired in the course of ontogenesis. Figure 4.68 • Testing the abduction of the glenohumeral 4.15.1 Examination with the joint, with shoulder blade fixed. Evaluation: A, hypomobile to patient sitting normal; B, slight hypermobility; C, marked hypermobility. The hip The patient is examined sitting on a height-adjust- able stool. The examiner notes the position of the To evaluate the hip joint, the most satisfactory feet and the level of the iliac crests, the posture of method is to measure the combination of external the lumbar spine, and the tonus of the abdominal, and internal rotation with the hip flexed at 90°. paravertebral, and gluteal muscles. In correct sit- Combined external and internal rotation of up to ting posture, the feet are flat on the floor and the 90° is assessed as range A, between 90° and 120° as iliac crests level; the lumbar lordosis should be flat- B, and more than 120° as C (see Figure 4.70). tened, and muscles only slightly tensed with the tonus evenly distributed (see Figure 4.71). 4.15 Examination of Anteflexion: stooping and coordinated movements straightening (motor stereotypes) For correct stooping, one leg moves forward in front Examination of individual muscle groups by means of the other and the knee of that leg is bent. At the of simple movements in the muscle test and the same time the trunk bends forward, the movement Figure 4.69 • Testing hyperextension of the knee joint. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. 145

Manipulative Therapy Figure 4.70 • Testing internal and external rotation of the hip joint. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility. Figure 4.71 • Sitting on a stool. (A) Correct posture; (B) and (C) two types of faulty sitting posture. starting with the head, the body then curling up uncurls, lifting first the lumbar spine, then the from caudal to cranial as the abdominal and gluteal more cranial sections of the spine, and finally the muscles contract slightly (see Figure 4.72A). The head (see Figure 4.72A). This action is brought erector spinae contracts initially, but relaxes again about by contraction of the abdominal and gluteal at the point of maximum anteflexion. muscles. As the body straightens up again, the knees The whole of this movement is the result of are extended and at the same time the trunk coordinated activity by the muscles of the gluteal 146

Diagnosis of dysfunctions of the locomotor system Chapter 4 Figure 4.72 • (A) Stooping and (B) lifting an object correctly. Figure 4.73 • (A) Stooping and (B) lifting an object, performed incorrectly. region, abdomen, and back. The knee of the for- raised stiffly like a ramrod, because this acts as a ward leg is positioned under the thorax so that the long lever and places great stress on the lumbosacral center of gravity of the body constantly lies above junction (see Figure 4.73B). Nor must the abdomen this point of support. The trunk must never be be allowed to bulge. 147

Manipulative Therapy Trunk rotation, sitting This test mainly examines the thoracic spine and Figure 4.75 • Head rotation, sitting: (A) correct; (B) faulty shoulder girdle. The patient is seated on a stool, posture. holding a small book in her hands. Correct sitting posture is important. The shoulder girdle should be of the shoulders (see Figure 4.75). If the movement relaxed and posture erect, including the shoulders. is performed correctly, lordosis should not increase The patient is now asked to place the book on a shelf and there should be minimal side-bending. The ster- behind her, at head height (see Figure 4.74). The nocleidomastoid should not be overstrained, and nei- examiner should observe the rotation of the trunk, ther shoulder should be drawn forward or lifted. which should be about a vertical axis, and check for coordinated activity of the back and abdominal mus- cles, fixation of the shoulder blades, and minimal tension in the superior part of the trapezius. If performed properly, the rotation is seen as a fluid movement in which the pelvis and legs do not participate. There is only moderate activity of the abdominal and back muscles, the inferior angles of the scapula do not diverge, and the superior part of the trapezius remains relaxed. Rotation of the head and neck Raising the arms The examiner should begin by observing head pos- When raising the arms, the patient also raises her ture with the patient standing and sitting. The nor- shoulders and shoulder blades. This activates the mal posture is slightly lordotic, but this lordosis upper fixators of the shoulder girdle, in particu- may be absent if the thoracic spine is flat. The angle lar the superior part of the trapezius and the leva- between the mandible and neck should be about 90°. tor scapulae, especially if fixation of the shoulder During head turning, the examiner observes neck blades from below by the inferior part of the trape- rotation and also the cervical muscles and position zius is insufficient (see Figure 6.152). Figure 4.74 • Trunk rotation, with the patient sitting and holding an object in the hand: (A) correct; (B) faulty posture. 148

Diagnosis of dysfunctions of the locomotor system Chapter 4 causing tension in the upper fixators of the shoul- der girdle and muscles of the upper limbs (see Figure 4.76). If a weight is to be carried correctly, the shoulders should be behind the center of grav- ity of the body and the head and neck remain erect. When this is so, the hand carrying the weight is also relaxed. Standing on one leg Figure 4.76 • Carrying weights: (A) correct; (B) faulty The examiner should observe all the joints of the posture, with forward-drawn shoulders and neck. stance leg, the line and center of gravity of the body, the pelvis and iliac crests, the spinal column 4.15.2 Examination with the and muscle tension, especially that of the hip stabi- patient standing erect lizers (the gluteus medius and minimus). Weight carrying In correct posture on one leg, all joints of the stance leg are in the line of gravity; the center of Here the typical fault is a forward-drawn position gravity moves forward as compared with stance on of the head and a drawing forward of the shoulders, two legs, to the second and third metatarsal heads. The iliac crests remain horizontal, the physiological curvatures of the spine remain unchanged, and no scoliosis occurs. The hip stabilizers, in particular the abductors, contract on the side of the stance leg. The flexors and extensors of the lumbar spine (the abdominal and erector spinae muscles) and of the hip should contract evenly, as should the quadratus lumborum (see Figure 4.77A). If the abductors are weak, as is frequently found in patients with faulty posture, the patient raises the iliac crest on the side opposite to the stance leg (see Figure 4.77B). Trendelenburg’s sign, in Figure 4.77 • Standing on one leg. Dorsal view: (A) correct; (B) faulty posture. Lateral view; (C) correct; (D) faulty posture. 149

Manipulative Therapy which the iliac crest is lowered, is mainly found in Respiration can be examined starting with the decompensated hip luxation and extreme muscle patient at rest, supine. In the supine position, weakening. abdominal respiration should predominate. In erect posture, standing or sitting, the abdominal muscles Gait must also perform their postural function during respiration, and this occurs when the thoracic cage In normal gait the steps are even and the weight is widens, beginning from the waist. To find whether placed equally on each leg in turn. Each foot strikes this is happening, the examiner should place his the ground heel first, the entire foot then uncurling hands on the patient’s lower ribs on each side, and along its lateral edge to end in pronation and pro- sense whether his hands are moved apart as the pulsion by the toes. The examiner should note the patient breathes in, or whether they move upward extension of the knees and hips. with no widening of the thorax (lifting of the thorax during inhalation – clavicular breathing – The pelvis sways from side to side, remaining see Figure 4.78). horizontal but rotating about a vertical axis; the excursion is more pronounced in women than in If this faulty breathing pattern is very pronounced, men. The spinal column curves from one side to the thorax may remain permanently in the inhalation the other in waves, the greatest excursion being at position and the lifting of the thorax during inhala- L3; there is some counter-excursion in the thoracic tion may be seen even at rest. In this case the sterno- spine, the point of change occurring at the thoraco- cleidomastoid and scalene muscles and all the upper lumbar junction, which remains vertically above the fixators of the shoulder girdle are found to be taut sacrum. The head should move very little and the arms should swing symmetrically (in right-handed individuals, slightly more on the left than the right). This movement comes from the shoulder, which rotates in the opposite direction to the pelvis. The shoulder blades are fixed against the back by the caudal fixator muscles. The body’s center of grav- ity shifts only slightly, from one side to the other and up and down; that is the person should neither waddle nor rock. Significant asymmetries of gait are also clearly audible, especially if the patient is walking quickly. Certain faults only become observable if the patient walks with eyes closed, on tiptoe, on the heels, or with upstretched arms. If it is possible to examine patients in their typi- cal working position (lifting weights, at the com- puter, at a machine or instrument, etc.), this can provide important insights. 4.15.3 Movement patterns of respiration Although the prime purpose of respiration is the Figure 4.78 • Clavicular and paradoxical breathing: tension exchange of gases, it is the function of the locomo- in the muscles that fix the shoulder girdle from above; deep tor system that underlies it. The muscles involved supraclavicular fossae; the thorax in the inhalation position; in breathing are in their turn extremely important the abdomen is drawn in at inhalation. for the function of the locomotor system, so much so that breathing patterns are considered the most important of all motor stereotypes (see Section 2.9.5). 150

Diagnosis of dysfunctions of the locomotor system Chapter 4 and the supraclavicular fossae are deep. In the most hunched sitting posture, which makes it difficult for severe cases the patient may draw the abdomen in the thoracic cage to expand and so leads to clavicu- during inhalation (paradoxical respiration, see Fig- lar breathing. This kyphotic posture is associated ure 4.78). In these cases clavicular breathing can with a forward-drawn position of the head, which is be evident even when the patient is lying down. In compensated by hyperlordosis of the cervical spine. less severe cases it is only observed when the patient inhales deeply. This lifting of the thorax can also be This close relationship is also shown by holding asymmetrical; the shoulders are each lifted to a dif- the breath during muscular effort (Valsalva maneu- ferent extent and there is often weakness of the infe- ver); the body achieves maximum stability at the rior part of the trapezius on the side that rises more. expense of respiration, as is done, for example, when delivering a tennis serve. Holding the breath Another consequence of the lifting of the thorax is even maintained for the period of a short sprint: is that breathing is performed mainly by the con- the body temporarily reinforces postural function at traction of the scalene muscles and the diaphragm the expense of respiratory function. is not sufficiently activated. The movement of the ventral wall of the thorax may even cause the dia- Inhalation and exhalation have about the same phragm to be cranially angled; if this happens there duration; the patient should be able to extend that will be no co-contraction of the diaphragm together duration considerably, to at least 10 seconds. (Profes- with the abdominal muscles, and therefore no fixa- sional singers should be able to sustain a breath for tion of the thorax to the pelvis. much longer.) A quiet breathing sound is heard, the sound coming from the nose. The nostrils expand As Figure 4.78 also shows, the effect is not only during deep inhalation and narrow during exhalation. to overload the cervical spine, but to lift the thorax away from the pelvis, so that there is no fixation of In the prone position the progress of the res- the lumbar spine. The photograph also shows the piratory wave can be observed traveling up from hypotonus in the region of the waist and lateral the lumbar spine to the upper part of the thoracic abdominal wall (see Section 2.9.5). spine during deep breathing. This wave may be interrupted where there is a restriction. If there is Therefore the tonus of the lateral abdominal a faulty breathing pattern the wave may be com- wall should also be palpated and the patient asked pletely absent. to exert pressure against the examiner’s palpating fingers. The patient often finds this impossible to The close relationship between the locomotor do. According to Koláˇr (2006), the following tests system and breathing means that a faulty breathing can then be performed: pattern, especially clavicular breathing (in which the thorax is lifted during inhalation), is highly • The patient lies supine with knees flexed. pathogenic. It should never be overlooked. Resistance is applied to the knees and the patient asked to flex the knees further against 4.16 Syndromes the resistance; alternatively the patient, sitting erect, is asked to raise both knees against 4.16.1 The lower crossed gravity. The examiner palpates the abdominal syndrome wall laterally at the waist. The lateral abdominal wall contracts (the patient can feel this by In this syndrome there is imbalance of the following touch, and so can provide feedback), but the muscle groups: thorax should not rise as it does so. • Weakness of the gluteus maximus; shortening • The patient lies supine and slowly lifts the head of the hip flexors and tension of the ischiocrural and trunk while the examiner palpates the muscles. medioclavicular line. As the neck is flexed, the • Weakness of the rectus abdominis and abdominal wall begins to contract, and when the shortening of the lumbar and thoracolumbar thorax is lifted, the lateral part of the abdominal part of the erector spinae. wall contracts. The equivalent method with the patient prone is used to examine the extension of the head and shoulders as the muscles at the waist contract. The close relationship between posture and res- piration can be seen not least in the effect of a 151

Manipulative Therapy • Weakness of the gluteus medius, tension of the 4.16.2 The upper crossed tensor fasciae latae, adductors, and quadratus syndrome lumborum. There is imbalance in the following muscle groups: There is also substitution for the weak gluteus max- imus by the ischiocrural and erector spinae mus- • Between the upper and lower fixators of the cles, for the gluteus medius by the tensor fasciae shoulder girdle. latae and quadratus lumborum, and for the rectus abdominis by the hip flexors. • Between the pectorales and the interscapular muscles. Clearly this syndrome renders the curling of the spinal column on lying down from a sitting posi- • Between the deep neck flexors (longus colli, tion impossible. The main visible result of imbal- longus capitis, omohyoid, and thyrohyoid) and ance between the rectus abdominis and the lumbar the neck extensors. There may be shortening erector spinae is lumbar hyperlordosis; if there is of the superior part of the ligamentum nuchae imbalance between the gluteus maximus and hip with fixed lordosis in the upper cervical region. flexors, the hyperlordosis occurs at the lumbosacral junction. The psoas major does not only flex the hip The ascending part of the trapezius is extremely but also brings about lordosis of the lumbar spine important for the fixation of the scapula. Activity (‘psoas paradox’). There is also increased pelvic tilt of this muscle portion can produce reflex relaxa- (see Figure 4.79). tion of the upper fixators. Tension of the pectora- lis muscles leads to increased thoracic kyphosis and forward-drawn shoulders, as well as kyphosis of the lower part and hyperordosis of the upper part of the cervical spine. The correct movement of arched anteflexion from a supine position is only possible if there is coordi- nated activity of the scalenes and deep neck flex- ors. If these are weak and the sternocleidomastoids hyperactive, there is ventral shifting of the head (incoordination). The cause that leads to weakness of the deep neck flexors is often weakness of the deep stabilizers of the lumbar spine. This is because the longus colli has its point of attachment here. 4.16.3 Stratification syndrome (according to Janda) Figure 4.79 • (A) Lumbosacral and (B) lumbar In this syndrome, alternating strata of hyper- hyperlordosis. trophic and weak muscle groups are found: on the dorsal aspect, working in a caudocranial direction, we find fairly slim calves, but hypertrophic ischi- ocrural muscles; hypotrophic, lax gluteal muscles and underdeveloped lumbar erectores spinae, and above these the bulging hypertrophic, thoracolum- bar erectores spinae; above these we find flabby interscapular muscles and hypertrophic, taut upper fixators of the shoulder girdle. On the ventral aspect the inferior part of the abdominal wall bulges, but lateral to the rectus abdominis muscles there is a hollow correspond- ing to the taut obliquus abdominis muscles; lateral to this the abdominal wall may bulge again in the region of the waist (‘pseudohernia’). 152

Diagnosis of dysfunctions of the locomotor system Chapter 4 The significance of the stratification syndrome of joints or sections of the spinal column, and the lies in the alternation of sections marked by con- straight-leg raising test. Side deviation in Hautant’s traction and lax, hypermobile sections. Hypermo- test can also be compared before and after. Even bility in the region of the lumbosacral junction is in radicular syndromes, an increase of strength in especially pathogenic in its effect. weakened muscles may be found on retesting (see Figures 2.12 and 2.13). Routine testing before and Dysfunction of the feet appears to play an after treatment can also be carried out for reflex important part here. Minor variations in balance are changes such as muscle TrPs, HAZs, and mobility normally absorbed by the toes; in fact by the mus- of fasciae, for example following therapies such as cles of the foot and especially the calf. The func- mobilization, needling, PIR, RI, or local anesthesia. tion of the toes is often inhibited by the shoes, and Instrumental methods such as thermography may the muscles of the thighs then take over the task of also be used. managing static balance. Subjective statements by the patient are also val- There is a simple explanation for the fact that uable. Most patients seek treatment because they the interscapular muscles are often found to be are suffering pain, so it matters that they should weak, if we look at developmental kinesiology: in find relief after treatment. The practice of conclud- infants, the development of upright posture takes ing treatment by letting patients palpate their pain place in the form of two lordotic curvatures, and points found during the examination is a helpful is brought about through the activity of the cervi- one; they can palpate them with their own hands cal and thoracolumbar erector spinae muscles. The and confirm for themselves that the symptoms have weak point is at the place where the two meet, at indeed improved or disappeared. T4 or T5. Testing also gives a useful indication as to the 4.17 Retesting most suitable further therapy. The practitioner can test the application of a particular treatment Clinical examination routinely provides a wealth of approach. For example, if we wish to find out data to give us the information we need about dys- whether traction or the treatment of an active functions, and therefore also to compare findings scar is indicated, we can test whether the planned before and after therapy. The effects of such treat- approach brings immediate relief. An immediate ment are often instantaneous, by reflex response. (reflex) result can be useful evidence-based medi- Immediate, post-treatment testing, or retesting, is cine that indicates the effectiveness of a particular therefore a means of feedback, and is indispensable method, although this should not be equated with for all practitioners who want to use solid criteria. therapeutic success. This plays the role of short-term evidence. Yet – with a few exceptions – this kind of instant check 4.18 Dysfunctions and the is simply not possible for other modalities such as course of examination pharmacotherapy, for example. Given the great var- iation in the course of patients’ complaints, there The question to be answered is how to carry out a sys- is great value in this. Nevertheless, however good tematic examination of a patient suffering from dys- the immediate effect, this must not be confused functions. If we wish to draw up the medical report with actual therapeutic success, because patients of a patient with functional disorders as described by are rarely suffering from a single dysfunction; the Brügger (2001), what would this look like? therapeutic effect depends to a great extent on how relevant the lesion is that we have treated. If treat- Having described the various clinical examina- ment of that lesion achieves only a partial effect, tion techniques, the next issue is how to proceed there is no reason why we should not continue by in practice; how to obtain useful results and avoid treating a further lesion and retesting once more. errors as far as is humanly possible. In principle, every abnormal finding at clinical The answer is not simple, as the object of exami- examination can be compared by testing before nation – the locomotor system, including morpho- and after treatment. Where the test involves actual logical changes and dysfunctions – is in fact the measurement, such comparison can be especially concern of many different fields of medicine. The useful; examples include the range of movement locomotor system can in many ways be said to be 153

Manipulative Therapy a reflection of everything that is happening in the affected. Function and dysfunction, on the other body. Some patients present with problems belong- hand, are the result of the interplay of a whole ing to the field of internal medicine; others with chain of different structures which are variously neurological, orthopedic, or rheumatological com- located. plaints. Still others are in the fields of ear, nose, and throat, or gynecology. For some, the main problem • The clinical picture correlates far more with lies in disturbed muscle function, for others, in dis- the functional disturbances than with the turbed joint mobility; yet others may be suffering pathomorphological changes. Consequently, from a great range of reflex changes. pathological processes often do not manifest themselves until they cause dysfunction. To examine each patient from all of these aspects Dysfunctions, on the other hand, can cause very would demand far more time than is practicable, marked clinical symptoms, even in the absence especially given the outpatient nature of most con- of any morphological changes. sultations. The problem is essentially that our focus of interest lies in dysfunctions for which there is no • Thus: pathomorphological changes cause specific, established medical field, since they relate dysfunctions, which manifest themselves in to the locomotor system as a whole. clinical symptoms. 4.19 Adjusting our thinking • Consequently, even pronounced to the functional pathomorphological findings can often exist approach without causing any clinical symptoms, and may even be clinically irrelevant (e.g. disk The examination techniques described in detail so herniation at CT, scoliosis, or spondylolisthesis). far deal with dysfunctions, as do the demanding Concomitant dysfunction, on the other techniques used in treatment. However, they can hand, can be of decisive importance only be used effectively if we have a proper under- clinically. standing of these disturbances of function. Practi- tioners need not only master the techniques but • In such cases, if the pathomorphological changes must adjust their thinking to understand in a func- are assumed to be the key to the disorder, tional way. therapy fails; on the other hand, even if the pathomorphological changes are clinically It is as important – and still more difficult – to adjust relevant, we still may improve the patient’s our thinking to the functional approach as to master condition if we improve function – for example the technical aspect of manual medicine. by rehabilitation. It is, however, necessary to be aware of the limits of what can be achieved. The following points present in general terms the Compensation can occur, so should not be most important differences between the usual, forgotten. pathomorphological understanding and the func- tional approach. • In pathomorphological diagnosis, the aim is to • The first and fundamental task in classification localize the lesion exactly and to identify its nature (principle of localization). and differential diagnosis is to decide whether the particular case is primarily • In diagnosing dysfunction, the aim is to identify pathomorphological or primarily one of the pathogenetic chain of reactions and to assess dysfunction. the interrelationships and relevance of the • Function (physiology) is as real as is morphology individual links (holistic principle). (anatomy). • If a disorder is mainly pathomorpholological, the • In pathological processes, the cause of pain lies task is to localize it and decide what precisely is in the nature of the lesion; in dysfunction, the cause of pain is mainly pathological tension brought about by the dysfunction. • In pathomorphological conditions, if therapy is successful it is continued until healing is achieved. Alternatively a decision may be made to intervene surgically. • If therapy is successful in conditions due to dysfunction, the next step is usually to treat another link in the pathogenetic chain. If the 154

Diagnosis of dysfunctions of the locomotor system Chapter 4 same lesion needs to be treated again, we and such findings are indeed very important. should consider whether there is another link The task is incomparably more difficult when in the chain that is more relevant and requires dealing with dysfunctions. Even in diagnosis, treatment. Change of approach in therapy is the symptom can be the result of a long chain therefore the norm. of various disturbances in various locations, and the relevance of each link can change. In • In pathomorphological conditions, success therapy, if we have treated one link successfully, depends on drug treatment or surgery; success there would be no sense in repeating treatment in dealing with dysfunctions depends on there. If the symptoms continue, we treat the relevance of the particular link in the another link in the chain, and so on. If at the pathogenetic chain we address at that end of the process the clinical symptoms have moment. disappeared, there is no reason to conclude that the treatment of the first link contributed less • When treating dysfunction, the practitioner is to the success. lost – or rather his patient is – if he treats it at • The functional approach is difficult. We may the point where pain is felt. compare function to the ‘software’ and structure to the ‘hardware’ of the system. • Because dysfunctions are by definition reversible, the effect of treatment can be 4.20 Chain reactions of immediate, giving the impression of a miracle dysfunctions and motor cure. This is by no means unusual; at times it is programs even what we would expect. 4.20.1 Function and chain • Modern technology achieves wonders in dealing reactions with pathomorphological lesions, but often fails when it turns to the treatment of dysfunction, In view of the argument presented in the previous where it is at best cumbersome. Clinical skill is section, which emphasizes that dysfunctions nor- decisive in such cases, but is often undervalued mally affect the entire locomotor system, or at least as ‘subjective’ and too little put into practice. the major part of it, we must turn to the question As a result, too much stress is often placed on of how to approach the individual case. Experi- morphological changes, which may in fact be of ence has shown that if on examination we find ‘A’, little relevance. we expect ‘B’, and must then test ‘C.’ What regu- larly occurring patterns or rules can we observe or • The psychological factor is important in all expect? What can we take as our screening guide- disease. In dysfunctions of the locomotor lines in the clinical situation? system, however, psychology is itself a link in the pathogenetic chain, because voluntary motor The first test is based on the premise that these function is the effector of psychological activity. regularly occurring patterns are associated with cer- Here, too, pain is the main symptom, and tain basic functions of the locomotor system. Basic tension and its relaxation play a very important functions or programs relate to the following: role. Practitioners need to decide in each case • Gait, and especially the lower limbs and how relevant the psychological factor is and how amenable it is to treatment. pelvis. • Body statics, and especially the trunk, neck, and • In pathomorphological conditions, the relationship between cause and effect tends to head. be clear. In dysfunctions, what had been the • Respiration, and especially the trunk and neck. cause can often turn into the consequence. • Prehension, and especially the upper limbs and Pain, whatever its origin, will produce changes in movement patterns or stereotypes; these shoulder girdle. in turn cause dysfunction which perpetuates • Eating and speaking, and especially the orofacial pain. Chronic tension and joint restriction cause impaired mobility of the fasciae, and resistance system, head, and neck. in the fasciae in turn becomes the cause of recurring joint restrictions. • When dealing with pathomorphological conditions, it is easy to produce statistics, 155

Manipulative Therapy Table 4.3 Reaction chains of dysfunction Lower limb — gait — swing phase – extension Tension Flexors of toes and foot, soleus, ischiocrural muscles, glutei, piriformis, levator ani, erector spinae Painful points of Calcaneal spur, Achilles tendon, fibular head, ischial tuberosity, coccyx, iliac crest, greater trochanter attachment of femur, spinous processes of L4—S1 Joint dysfunction Small joints of foot, ankle joint, fibular head, sacro-iliac joint, lower lumbar spine, (atlanto-occipital (restrictions) and atlanto-axial joints) Lower limb — gait — stance phase — flexion Tension Extensors of toes and foot, tibialis anterior, hip flexors, hip adductors, recti abdominis, thoracolumbar erector spinae Painful points of Pes anserinus of tibia, patella, lesser trochanter of femur, superior border of pubic symphysis, xiphoid attachment process Joint dysfunction Knee, hip, sacroiliac joint, superior lumbar spine, thoracolumbar junction (atlanto-occipital and (restrictions) atlanto-axial joints) Trunk — body statics Tension in muscle pairs Sternocleidomastoid and: short craniocervical extensors Scalenes + deep neck flexors + digastric and trapezius + levator scapulae + masticatory muscles Iliopsoas + recti abdominis and: erector spinae + quadratus lumborum Painful points of Posterior arch of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior and attachment medial border of scapula, xiphoid process, pubic symphysis, lower ribs, iliac crest Joint dysfunction Atlanto-occipital and atlanto-axial joints, cervicothoracic junction and upper ribs, thoracolumbar (restrictions) junction (trunk rotation), lumbosacral and sacroiliac junction, temporomandibular joint Lifting the thorax during inhalation (clavicular breathing) Tension Superior parts of abdominal muscles, pectoralis, scalene, diaphragm, sternocleidomastoid muscles, short craniocervical extensors, levator scapulae, superior part of trapezius Painful points of Posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal end of attachment clavicle, superior border of scapula, sternocostal joints and upper ribs Joint dysfunction (restrictions) Atlanto-occipital and atlanto-axial joints, cervicothoracic junction, upper ribs, thoracic spine Upper limb — prehension — restricted flexion Tension Extensors of fingers and wrist, thenar eminence, supinator, biceps brachii, triceps brachii, deltoid, supraspinatus, infraspinatus, upper fixators of scapula, interscapular muscles Painful points of Radial styloid process, radial (lateral) epicondyle, attachment of supraspinatus and infraspinatus, attachment attachment of levator scapulae, spinous process of C2 Joint dysfunction Elbow, acromioclavicular joint, middle cervical spine, cervicothoracic junction, upper ribs (restrictions) Upper limb — prehension — restricted extension Tension Flexors of fingers and wrist, pronators, subscapularis, pectoralis, sternocleidomastoid, scalene muscles 156

Diagnosis of dysfunctions of the locomotor system Chapter 4 Table 4.3 (Continued). Painful points of Ulnar (medial) epicondyle, sternal end of clavicle, sternocostal joints, Erb’s point, transverse process attachment of atlas Joint dysfunction Carpal bones, elbow, glenohumeral joint, cervicothoracic junction, atlanto–occipital and atlanto-axial (restrictions) joints Head and neck — eating — speaking Tension Masticatory, digastric, sternocleidomastoid muscles, craniocervical extensors, trapezius, levator scapulae, deep neck flexors, pectoralis muscles Painful points of Hyoid, posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal attachment end of clavicle, superior border of scapula, angle of upper ribs Joint dysfunction (restrictions) Temporomandibular joint, atlanto–occipital and atlanto-axial joints, cervicothoracic junction, upper ribs The chain reactions of dysfunction envisaged here muscles would cause individual motion segments are given in Table 4.3. These do not claim to be to buckle. Therefore, in parallel with the co-con- complete; although these are the chains espe- traction pattern, there developed the system of the cially affected, the disturbance is not limited to deep stabilizers. This includes not only the multi- the details listed. The intention is rather to pro- fidi, but also, ventrally, the abdominal cavity and its vide some means of screening. Our understanding walls: the diaphragm, transversus abdominis, and is further focused and extended by our insight into pelvic floor, sustaining intra-abdominal pressure. The developmental kinesiology. importance of this stabilization function is so great that, in the action of raising the arm, the diaphragm 4.20.2 Chain reactions in the or transversus abdominis contract before the deltoid light of developmental (see Figure 4.80). We even observed a patient who kinesiology was unable to raise her arm if her pelvis was not fixed, on account of paralysis of the deep muscles What is said here follows on from Section 2.5.3, of the back. If her pelvis was fixed, however (in the which describes the development of the co-contrac- sitting position), she was able to carry out the action tion pattern of flexors and extensors, adductors and without difficulty (Lewit & Horácek 2003). abductors, and external and internal rotators. As a prerequisite for human upright posture, antagonists The development discussed so far has been that developed into synergists, a development that can of the postural program, which takes place auto- most clearly be seen at joints such as the knee and matically and is also associated with the optimal individual segments of the spinal column. This pat- positioning (centering) of the limbs. This develop- tern appears yet more fundamental in the craniocau- ment is completed in overall terms in the fourth dal direction, with the formation of muscle chains month of life, but only fully completed at four in the sagittal plane beginning at the feet, connected years of age. As indicated previously in Section 2.6, through their points of attachment and stabilizing in a considerable proportion of children this devel- the spinal column just as a mast is stayed. These opment does not proceed straightforwardly. muscles, as pointed out by Richardson et al. (2004), are long, most of them spanning two or more joints. As soon as children learn movement, their own individual programming of movement patterns This is the more important for the fact that the begins to take shape, in line with their particular spinal column, unlike a mast, is jointed. Panjabi et interests and opportunities. The way this happens al. (1992a) showed that the motion segments are will become clearer if we use an example: playing unstable, and require the activity of the short, deep tennis. On the basis of neurology we would expect muscles of the back to stabilize them. If it were the following: as soon as the player sees the ball, not for these muscles, the contraction of the long the image strikes the retina. From there, the stimu- lus travels to the diencephalon and is transmitted to the occipital lobe, from there to the parietal lobe, and finally to the motor cortex. From here, 157

Manipulative Therapy Figure 4.80 • EMG of the deltoid muscle and diaphragm on raising the arm: contraction of the diaphragm takes place in advance of contraction of the deltoid (modified after Richardson et al 2004). vdi, transdiaphragmatic pressure; Pga, intra-abdominal pressure; Poes, intrathoracic pressure. the neurons of the central nervous system com- postural development.) Then we carefully throw municate with the spinal cord and peripheral neu- the ball to the child, who stands with hands ready rons with the muscles. There is then feedback via to receive it. It takes some time before the child is the posterior horn and the cerebellum. Assuming a actually able to catch the ball, first with both hands, transmission speed of 100 m/s, the ball will be long then with just one. Only now do we give our child a since out of play. tennis racquet for the next stage: learning to hit the ball. What has been happening during those years? The only way to understand this problem is once The brain, that most accomplished computer of all, more by looking at the developmental process: first, has constructed a program, and the moment the we place the ball firmly in the child’s hands. (The eye sees the ball, the program springs into action: child has successfully passed through the stage of 158

Diagnosis of dysfunctions of the locomotor system Chapter 4 the movements of eye, head, trunk, and limbs all The co-activation pattern applies not only within take place automatically. the segment; it also serves to maintain upright posture. From their anchor point at the feet, the This understanding is extremely important muscles and their attachments work together to in determining our practical approach. It clearly maintain upright posture just as a mast is stayed by shows that the program involves the entire sys- the rigging. Dysfunctions often produce TrPs in the tem. If a disturbance appears somewhere along its muscle chains that form these ‘mast stays.’ course, we must reprogram it. It also follows that symptoms, in this case dysfunctions, can appear in TrPs are markers that trace out chain reactions, and many places, and it is our job to discover which is these chain reactions also involve joints and soft the most important dysfunction, the one that is the tissues. key link in the chain reaction. 4.20.3 The pathomechanisms Understanding this development enables us to of chain reactions organize our approach in a rational way and draw up certain rules that describe how this system behaves A further principle can be drawn from developmen- as a whole. A good way to illustrate this ‘holistic’ tal kinesiology: the developmentally older function approach is with reference to the programmed is less susceptible to disturbance, and therefore reaction of supporting oneself, for example with predominates. In pain, exhaustion, aging, and the hand, elbow, or knee, in standing posture. As soon phenomena associated with paresis, the predomi- as we do this there is an instant change in our nating model is that of the newborn. The same posture in every section of our locomotor system. principle follows equally from the disturbances of This reaction must originate from the receptors of movement pattern in the concept developed by these points of support, which are also very impor- Janda (see Table 2.1) and from Brügger’s (1971) tant, according to Vojta & Peters (1992), as points ‘sterno-symphyseal syndrome.’ of stimulation. In both these cases it is possible to speak of a The only way that a programmed function can chain reaction in which the flexors predominate. be directed is by the nervous system, by means of In Janda’s terms these are the ‘primarily postural the musculature. Therefore we must take the mus- muscles’; in terms of current knowledge they are cles as our starting point if we wish to understand the developmentally older muscle groups. Brüg- and analyze the chains of reaction. The function of ger’s (1971) explanation of the round-shouldered the muscles is closely linked with that of the joints: sitting position, however, is not based on muscular the earlier discussion of TrPs made clear that these imbalance, but on the position of the joints: in sit- are linked with movement restrictions; this is mani- ting with thighs adducted, the pelvis tips backward, fested in practical terms in the use of neuromus- and if the arms are folded in front of the chest, it cular techniques of treatment. In this context it becomes impossible to straighten the thorax. This becomes evident that TrPs in fact have the function situation also shows the close relationship between of establishing stability at the cost of mobility. joint function and muscle activity. They are found in antagonists in motion segments A further chain reaction in which the balance or limbs: adductors–abductors; extensors–flexors. In between flexors and extensors is disturbed is the the case of fan-shaped muscles such as the pectoralis forward-drawn posture when standing. On inclin- major, a section of the muscle corresponds to a par- ing forward, all the erector spinae muscles, includ- ticular section of the erector spinae. However, the ing the nuchal muscles, become taut. Proof of this antagonism is not limited to the particular segment: can be found by palpating one’s own neck muscles. if, for example, an extensor is stimulated, this does If patients are found to have tense nuchal mus- not only inhibit its specific antagonist, but also the cles in standing posture, and if restriction of the entire flexor system. As demonstrated by Brügger atlanto-occipital and atlantoaxial joints has been (2001), this effect is especially pronounced when excluded, the following test is decisive: the patient the extensors of the fingers and toes are stimulated, since the density of receptors is particularly great in these locations. As an example, stimulation of the toe extensors can inhibit the activity of the ischiocrural muscles, with consequent weakening in the straight-leg raising test. 159

Manipulative Therapy whose nuchal (and back) muscles are tense when dorsiflexion of the pelvis, described by Silverstolpe standing is asked to sit on a chair; the tension dis- (1989) hence called ‘S’ reflex. appears on sitting excluding the role of the lower limbs. TrPs are generally found in the sternocleido- Working in the cranial direction, the next mus- mastoid and especially the rectus abdominis. There cles are the pectoralis and subscapularis, the upper is often tenderness to pressure of the attachment fixators of the shoulder girdle, scalenes, sternoclei- points on the xiphoid process, inferior costal arch, domastoid, short craniocervical extensors, and the and especially the superior border of the pubic sym- masticatory and digastric muscles. physis, at least on one side. The chain usually contin- ues on down to the ischiocrural muscles, especially Working in the caudal direction, the next mus- the biceps femoris and its insertion at the fibular cles are the hip adductors, the ischiocrural mus- head, and there is generally restriction relative to the cles, and quadriceps femoris; then in particular the fibula. If the chain does not end here, there may be soleus and painful Achilles tendon and the short TrPs in the short toe flexors and short extensors with muscles of the foot. restrictions in Lisfranc’s (tarsometatarsal) joint. The most distal link in the chain is generally the decisive 4.20.5 The role of the diaphragm factor, and in many cases this is in the foot, which also belongs to the deep stabilization system. The diaphragm clearly seems to play a special role because it combines a postural function with that of The pathogenesis of this chain lies in the impor- respiration. This means that disturbance of the deep tant role played by the powerful ischiocrural mus- stabilizers is associated with faulty breathing, or, con- cles in the fixation of the pelvis. If there is a TrP versely, that correct breathing and good stabilization here, the fixation of the pelvis is disturbed and has of the lumbar spine depend on the coordinated con- to be compensated by the rectus abdominis and the traction of the diaphragm and abdominal wall. gluteus maximus. The consequence of this is ten- sion of the rectus abdominis in particular, and this According to Koláˇr (2006), this can be exam- helps cause the forward-drawn posture. Often such ined by means of the following tests: the patient is patients complain of headache and pain in the nape supine or sitting, thorax caudalized in exhalation. of the neck; the cause, however, often lies in the The examiner should fix the thorax in the exhala- region of the patient’s feet. tion position, simultaneously palpating the lateral abdominal wall at the waist. The patient is asked 4.20.4 Causes of chain reactions to exert pressure against the examiner’s palpating fingers. To facilitate this, the patient’s knees should The most frequent cause of chain reactions is dys- be bent and, if the patient is supine, resistance is function of the deep stabilizers. These form a applied to the flexed knees. If the patient is sitting, chain in their own right, as was demonstrated by the only action necessary is for the patient to lift Richardson and coworkers (2004) in their electro- the bent knees slightly; the lateral abdominal wall myographic study of the contraction of the pelvic tenses at that moment. This tension should be floor. The muscles involved are the diaphragm, the maintained during inhalation to prevent clavicular transversus abdominis, the pelvic floor, and the breathing (in which the thorax is lifted during inha- multifidi. TrPs can be palpated directly on the pel- lation) and oblique positioning of the diaphragm. vic floor and diaphragm. In the case of disturbance Contraction of the diaphragm is then concentric, here, the long muscles react with the emergence of and this counters the eccentric contraction of the TrPs in an attempt to compensate for the disturbed transversus abdominis in particular. The examiner stability, a task to which they are little suited. should at the same time ensure that there is con- traction of the muscles of the lower abdomen, and In the trunk region, the longissimus, quadratus to a lesser degree the upper abdomen, so that the lumborum, and psoas major, and sometimes the navel does not move in the cranial direction. rectus abdominis, are the muscles involved. The irritability of the erector spinae is sometimes so If supine, the patient should slowly raise the marked that snapping palpation of a TrP in the tho- head and to a slight degree also the trunk, and the racic portion sometimes produces a twitch reaction examiner should palpate the lower ribs in the medi- in the lumbar portion as well. This causes strong oclavicular line. The raising of the patient’s head activates the abdominal muscles, so that the thorax remains caudalized. Further raising of the thorax 160

Diagnosis of dysfunctions of the locomotor system Chapter 4 causes activation of the lateral abdominal wall, even such cases this test of exteroceptive stimulation is caudad to the navel. However, the abdomen should decisive, meaning that the afferent disturbance is not bulge, either forward or laterally. the most relevant link in the chain. If prone, the patient should be asked to lift the In addition there are shorter chains, which are head and bend upward to create a slight lordosis of of particular local significance. In the case of lateral the back. This should cause the erector spinae mus- (radial) epicondylopathies, these chains consist of cles and lateral abdominal wall to contract. If there TrPs of the extensors of the fingers and wrist, the is insufficiency of the muscles, there will be no con- supinator, the biceps brachii and tripceps brachii, traction of the lateral abdominal wall, and if there all muscles with a point of attachment on the lat- is excessive activity of the thoracolumbar erector eral epicondyle and with a role in prehension. Usu- spinae, the shoulder blades will move craniad. ally, however, these muscles are also linked with chains of dysfunction in the cervical spine. Even 4.20.6 Rotation of the trunk more important is insufficient fixation (stability) of the shoulder blade on the same side. Trunk rotation is another function that is recent in developmental terms. As in the case of the deep The syndrome of the superior thoracic aperture stabilizers, a muscle chain is responsible for this represents a chain of muscular and joint dysfunctions movement. If trunk rotation is restricted, TrPs are in its own right. This chain consists of the cervical found in the thoracolumbar erector spinae, quad- spine, the scalenes, the upper fixators of the shoul- ratus lumborum, and psoas major, usually on the der girdle, the pectoralis minor and subscapularis opposite side to the restricted rotation. Release of muscles, and the uppermost ribs and cervicothoracic one of these three muscles is sufficient to remove junction, as a rule associated with clavicular breath- the TrPs in the other two, whereupon trunk rota- ing and therefore also with the deep stabilizers. tion becomes symmetrical again. This function is so important that, in cases where rotation of the cervi- The soft tissues have for the most part been cal spine is also restricted, the treatment of trunk excluded from the discussion so far for the sake rotation frequently has the effect of normalizing of clarity. However, fasciae that ‘stick,’ especially findings at the cervical spine. around the thorax, the back, and the scalp, can often play a decisive role in the chains. The most pathogenic soft tissue lesions are ‘active scars,’ which will be discussed in Chapter 5. 4.20.7 Unilateral chains of 4.20.8 Analysis of chain dysfunction reactions In very painful conditions such as radicular syn- Chain reactions are not always complete, and some- drome, a unilateral chain pattern tends to be times there may be more than one chain. Diagnosis observed. This involves the sternocleidomastoid, seeks to find the most relevant link in the chain, short craniocervical extensors, trapezius, pectora- since treatment of this key link will often normalize lis muscles, subscapularis, and erector spinae, and the entire chain, enabling therapy to be given in the sometimes the iliacus and quadratus lumborum, most efficient way. Equally importantly, the practi- piriformis, glutei, hip adductors, rectus femoris, tioner needs to know the direction in which to pro- and soleus, down to the TrPs and restrictions of ceed when planning further treatment. What, then, the foot, though it may not include the deep sta- are the criteria to be used in this analysis? bilizers. If this is the case, the disturbance derives from the ‘deep’ short stabilizers of the foot, which • The patient history should give an indication can similarly elude voluntary control; for example as to which symptoms occurred early on and the abductor pollicis brevis. Another very impor- which later, and also which symptoms tend to tant feature here is this: in such unilateral chains, recur and under what circumstances. sensitivity is noticeably asymmetrical, both overall and, in particular, on the soles of the feet. This is • The intensity of a given finding can be important. clearly evident from the involuntary reaction to exteroceptive stimulation of the sole of the foot. In • It is very important to identify whether the part affected is a key region, structure, or function. For example, the problem may affect the feet, 161

Manipulative Therapy the joints of the craniocervical region, structures In the case of these conditions the task is to decide of the deep stabilization system, faulty the significance of the concomitant findings that usu- breathing, or an active scar; this is particularly ally exist in the locomotor system, and to determine important if the symptoms appeared shortly whether they require treatment. This problem covers after trauma or an operation. the whole field of medicine, and so can often only be • Having decided on the treatment, the solved with the collaboration of specialists in the rel- practitioner should of course check the evant branches of medicine. effectiveness of therapy by re-examining the patient immediately afterwards. The second problem is the differential diagno- • Therefore, diagnosis does not end until the first sis of disturbances of the locomotor system and treatment procedure is given. If the expected the spinal column itself. Here the task is to decide effect is not achieved, the practitioner should whether the lesion is a pathomorphological one or a turn to another link in the chain. The first dysfunction, or a combination of both. In that case treatment is often chosen with an eye to there is the further decision as to which disturbance diagnosis, in order to establish the relevance is currently the more relevant. of a particular link in the chain (i.e. that of a particular finding). In the case of active scars, this Errors in diagnosis may arise; in such cases is the normal procedure. If these are found to be inflammatory, metabolic, or neoplastic diseases highly relevant, any other treatment would fail. may be involved. For this reason laboratory tests • Even if the first therapeutic/diagnostic procedure should always be carried out (including blood count proves successful, this does not necessarily mean and erythrocyte sedimentation rate), and X-rays that another might not also be successful. If the requested if there is the least suspicion. Pathological chain reaction runs in one direction, this does processes can often be difficult to diagnose clinically not necessarily mean that it might not run in the in the early stages, so that the practitioner can only opposite direction; these chains are not ‘one-way prescribe pain relief. In cases such as these where it streets’ (Hermach 2007). is not yet possible to arrive at a diagnosis, treatment of dysfunctions using today’s techniques involves no An understanding of chains of dysfunction is more risk than analgesics, which are indeed more fundamental to a holistic approach to their likely to produce undesired side effects. treatment. The regular follow-up examinations given to 4.21 Differential diagnosis patients during therapy mean that the warning comes from the course of the disease; the practitioner 4.21.1 Problems should be alert to warning signs such as repeated relapses, persistent failure of therapeutic measures As has already been mentioned, the locomotor sys- to achieve much effect, and deterioration in the tem reacts to some degree to everything that hap- patient’s condition. However, it would be a mistake pens in the body, and reflects it. As a result, clinical to overestimate the capacity of the test procedures diagnosis is multifaceted and a highly responsible used for these examinations. The practitioner should task. carry out testing directly after treatment to check the immediate effect; but it is wrong to suppose that The problems essentially fall into two fundamen- a favorable finding, indicating success at this immedi- tally different categories. The first concerns condi- ate stage, can be any proof that pathomorphological tions which to varying degrees involve the spinal processes are not present. Even where there is patho- column and locomotor system: headache, vertigo, and morphological disease, dysfunctions can develop and a number of visceral symptoms in which vertebro- feed the symptoms at the moment when we are genic disturbances regularly play a part, such as chest administering therapy. These may include restric- pain, pain in the abdominal cavity, dysmenorrhea, etc. tions and TrPs which it is quite legitimate to treat. This is an appropriate point to describe typi- cal sources of error and how they can be avoided. If, despite repeated treatment and self-treatment, restrictions and identical TrPs repeatedly occur in the same segment, the cause is either internal dis- ease in a location corresponding to that segment, or a correspondingly located tumor or other pathological 162

Diagnosis of dysfunctions of the locomotor system Chapter 4 process in the region of the spinal column. For exam- Case study 2 ple, in a young patient, recurrence of a sacroiliac restriction, if bilateral, suggests sacroiliitis. Recurrent F. M., born 1914. This female patient was an back pain in postmenopausal women, especially if it unskilled worker. From September 1961 she com- occurs following physical stress, suggests osteoporosis. plained of occipital headaches, repeatedly accom- panied by vomiting. She was examined as an 4.21.2 Case studies outpatient at the neurological hospital in November 1961, when cervicocranial headache was diag- Case study 1 nosed. Manipulation was performed and brought instant relief from the pain, lasting about a month. At A. F., carpenter, born 1915. This patient underwent the follow-up examination at the end of December surgery in 1959 for a painful tumor on the left thenar 1961 there was intense pain at the nape of the neck eminence, and for a Dupuytren’s contracture of the and the spinous process of C2 was tender to pres- fourth finger on the left hand. In 1959, he began to sure. This time, manipulation brought no relief; injec- experience pain in the back of the neck, with stiff- tion of procaine at the pain point was then tried, also ness. The pain became increasingly severe and the without success. At the next follow-up examination patient was admitted to a neurological hospital at the in mid February 1962 the patient was holding her beginning of 1961. A contrast study of the spinal col- head in a forced attitude in anteflexion and inclined umn (myelography) yielded no particular findings, and to the left. Passive mobility testing of the head did the patient was therefore referred to us for manual not find any typical restriction, but merely found therapy in May 1961. By the autumn of that year he resistance; overcoming this produced a reaction of had received treatment four times, and each time the nausea. This suggested forced attitude of the head success was only temporary. Despite the absence as a result of increased intracranial pressure. of neurological symptoms, and simply on the basis of the course of the illness, we recommended that Plain film X-ray of the head showed signs of the contrast investigation be repeated. On readmis- increased intracranial pressure at the sella turcica. sion to the neurological hospital in October 1961, the On hospital admission on 21st February 1961, the patient was found to have stiffness of the neck and patient was entirely symptom free and the neurologi- he was holding his head in a fixed position slightly cal findings and electroencephalogram (EEG) were bent forward and permanently rotated to the right. normal. However, pneumoencephalography showed Erb’s point on the right was tender to pressure, as an occipital pressure cone. Only a very small amount were the spinous processes of C2–C4. Mobility of the of the air entered the third ventricle, and showed it to head was restricted in all directions, but especially left be displaced to the left. This finding led the hospital rotation. The one other finding was a static, evidently to perform angiography of the right internal carotid, functional, tremor of the right hand. which revealed a vascularized tumor in the right pari- etal region, located parasagittally and suspected to Pneumomyelography after injection of 30 ml of air be a meningioma. Only after the pneumoencepha- by the lumbar route, with the patient sitting and the lography did the beginnings of papilledema and slight head in maximum anteflexion, showed a well-defined disturbance in the EEG become evident. The patient tumor at C2. Cerebrospinal fluid albuminocytologi- underwent surgery in mid May 1962, and a falx men- cal dissociation was found. Symptoms of a radicular ingioma of the right parietal region was removed. lesion at C8 appeared for the first time following the pneumomyelography. This striking finding led us to In this case an occipital pressure cone initially a diagnosis of neurinoma at C2, partially intradural caused a very ordinary cervicocranial syndrome that and located on the ventral aspect of the cord. The responded well to manipulation. Later came the patient underwent operation and a neurinoma of the development of the forced attitude, and it was impor- spinal root of C2 was removed. The unbearable pain tant for the manual practitioner to distinguish this subsided immediately following the operation. from restriction (the typical hard end-feel is absent). The conclusions to be drawn apply not only A restriction that is not resolved either to other sections of the spinal column but also to spontaneously or in response to treatment, and/or restrictions in the craniocervical region with forced relapses within a short time, suggests visceral attitude of the head in the case of brain tumors with disease in the corresponding segment, or a tumor. an occipital pressure cone; this behaves like an extramedullary tumor. 163

Manipulative Therapy 4.21.3 Common differential to describe or localize the pain at all precisely, and diagnoses there are frequent changes in the patient’s state- ments, it is likely that the pain is (mainly) of psy- Acute pain chological origin. Chronic, relapsing symptoms are not the only Masked depression type to give rise to differential diagnostic deci- sions; acute pain is another. This is especially so if The problem posed by masked depression is an the pain appears following accidents, and manual important one because it can indeed take the out- techniques can also be used to deliver first aid. The ward form of back pain and headache. This is practitioner not only needs to be able to exclude because psychologically caused tension and tense fractures and dislocations, but also torn ligaments posture do actually bring about painful dysfunc- and joint capsules, hematomas, etc. Acute pain at tions, especially in the orofacial system and cervi- the back of the neck, occurring together with severe cal region, and at the coccyx as a result of tension headache, can be the result of subarachnoid hemor- of the gluteal muscles and pelvic floor (levator ani). rhage. Since this is not a joint disturbance but an The diagnosis is hard to establish at the first exami- acute meningeal syndrome, the movement direc- nation; during the course of treatment it is found tion that is restricted is not rotation or side-bending that after a short while the patient complains of but anteflexion of the head. fresh pain, and tension is found at the locations described. This should be a cue to ask targeted Herniated disk questions about whether the patient feels depressed or has experienced sorrow in the past. The most In the case of pain in the lumbar region, perhaps important question to ask is whether the patient the most frequent question that needs to be asked suffers from disturbed sleep; the typical pattern is whether there is disk herniation. This problem of sleep disturbance is for the patient to fall asleep is dealt with in more detail in Sections 7.1.5 and normally, but to wake in the (very) early hours of 7.8.2. the morning and be unable to go back to sleep. A conclusive diagnosis is obtained by test prescription Psychosomatic disorders of mild antidepressive drugs. In patients whose main concern is pain, the practi- Fibromyalgia syndrome tioner very frequently has to decide to what extent psychological factors play a role; every instance of There is an essential distinction to be made between pain is also a psychological experience. Understand- muscle pain that occurs in most cases of back pain ably, medical practitioners base their approach on in the form of TrPs on the one hand, and fibromy- the presence or absence of clinical signs in a con- algia syndrome, which has been much explored in dition that the patient describes as painful. Unfor- the literature. This is a chronic systemic disease tunately, few doctors have the relevant specialist affecting mainly women. The painful muscles are knowledge to diagnose and understand dysfunc- found bilaterally; they are numerous, and not con- tions, which are the most frequent cause of pain. fined to the trunk, but also found on the limbs. The The key is this: if the patient is able to give a pre- pain is accompanied by fatigue, and there is morn- cise description and localization of the pain, and ing stiffness similar to that in rheumatoid arthritis. this information remains consistent on repeated Patients suffer from sleep disturbance, especially of questioning, it is unwise to dismiss it as merely psy- non-REM sleep. The combination of chronic pain, chological. In doubtful cases our guide is the course fatigue, and sleep disturbance is associated with a of the illness, based on observation over time and mood of depression. On palpation, the muscles that knowledge gained of the patient. These enable us to are painful either behave like TrPs or feel hypotonic compare the clinical findings, and the changes that and doughlike. Tenderness in hypotonic muscles is take place in them, with the patient’s own state- a particularly characteristic finding in this disorder. ments. In contrast, if the patient finds it difficult The laboratory findings are not characteristic and the pathogenesis unknown. The cause is thought to 164

Diagnosis of dysfunctions of the locomotor system Chapter 4 lie in a lowering of the pain threshold in the central shows the contours of the joints as ill-defined. In nervous system. Mild antidepressants and carefully the early stages the joint space is widened, but later judged physical exercise are recommended as treat- it may be ossified. On the spinal column, syndesmo- ment. In our experience, there is some benefit in phytes develop and bridge the intervertebral disks, light massage that the patient experiences as pleas- so that in the fully developed stage the anteroposte- ant, administered over fairly long periods of time. rior film shows the spinal column as looking rather The usual analgesics are not very effective. like a stick of bamboo. Typical as these radiological changes are, they may be absent. Diagnosis is espe- Inflammatory conditions cially difficult in female patients, because the dis- ease often follows a milder course which does not Inflammatory conditions also play a role. Rheuma- then lead to stiffness. In males, progressive stiff- toid arthritis is usually not difficult to recognize. ness, gradually extending in the cranial direction, is This does not generally tend to affect the spinal col- the rule. This development can occur largely pain- umn as often as it does the limbs, but this very fact lessly, in which case the impression is given that the makes it important to be aware of inflammatory, disease did not begin until around age 40 or even destructive lesions in the region of the atlas and later. The consequences are particularly severe for axis. For this reason, where vertebrogenic symp- patients in whom the disease develops in the hip toms appear in patients with existing rheumatoid joints. In the early stage it is mainly the palpation arthritis, an X-ray should be performed. findings that are characteristic. This fact makes it difficult to achieve early diagnosis, and calls for Another condition that should particularly be practice. borne in mind is ankylosing spondylitis. This should be considered in cases where the patient’s symp- 4.21.4 Conclusions toms first occurred around the age of 20, from then on taking a progressive course without lasting peri- Perhaps the main point to be made in conclusion ods of remission. Characteristically patients report is that diagnosis of dysfunctions of the locomo- pain at night, which regularly wakes them at the tor system is a new field of clinical medicine, and same time in the very early hours of the morning a difficult one. In differential diagnosis we need to and forces them to get up and move about. The first be aware that in most cases, including structural clinical sign is generally recurrent sacroiliac restric- changes, the earliest clinical manifestation takes tion, often bilateral. The restriction soon extends to the form of disturbed function. Moreover, patients the entire lumbosacral segment, then to rotation of referred for pain due to ‘mere’ disturbed function the trunk, and especially stiffening of the thoracic are usually dealt with as outpatients, who cannot cage, where springing pressure elicits no spring- be examined as thoroughly as those in a hospital ing. Consequently there is clavicular breathing and ward, where the technical facilities available are exaggerated abdominal breathing. also greater. The practitioner in charge of such cases must remain constantly aware of the innumerable Laboratory findings are also important in the pitfalls; nothing is more dangerous than a sense of diagnosis of this condition. One such finding is infallibility. This section on differential diagnosis the HLA-B27 antigen, which suggests a hereditary should also serve as a warning. cause. The radiological findings are also significant; a positive finding in the X-ray of the sacroiliac joints 165

Chapter Five 5 Indications for and principles underlying individual treatment methods Chapter contents The indications for a particular treatment method should be established not only on the basis of 5.1 Manipulation . . . . . . . . . . . . . . . 168 the clinical diagnosis but also following an analy- sis of the pathogenesis so as to identify which 5.1.1 Indications . . . . . . . . . . . . . 168 lesion is most important at a given moment and 5.1.2 Contraindications . . . . . . . . . 169 is therefore likely to be the most effective object 5.1.3 Traction . . . . . . . . . . . . . . . 170 of therapy. Every therapeutic action should there- 5.2 Soft-tissue manipulation . . . . . . . . . 171 fore result from a fresh examination, to keep up to date with the ongoing development of the patient’s 5.2.1 Skin stretching . . . . . . . . . . . 171 condition. 5.2.2 S tretching a soft-tissue fold In this setting it is of the utmost importance to (connective tissue) . . . . . . . . . 171 identify chain reaction patterns of dysfunctions 5.2.3 Application of pressure . . . . . . 171 and to pinpoint the most relevant link in the chain. 5.2.4 Restoration of deep tissue mobility 171 In establishing the indications for a particular treat- 5.2.5 Treatment of (active) scars . . . . . 172 ment, it follows that no therapeutic intervention 5.2.6 Relaxation of muscles . . . . . . . 172 should be applied before examination of the patient 5.3 Reflex therapy . . . . . . . . . . . . . . 172 has been completed and the findings have been meticulously analyzed. 5.3.1 Massage . . . . . . . . . . . . . . 172 5.3.2 Exteroceptive stimulation . . . . . 173 If therapy is determined according to the princi- 5.3.3 Local anesthesia – needling . . . . 173 ples set out here, it is likely to be effective and the 5.3.4 Electrical stimulation . . . . . . . . 174 condition of the patient should be found to have 5.3.5 Acupuncture . . . . . . . . . . . . 174 changed at follow-up examination. If the patient’s 5.3.6 Soft-tissue manipulation condition is unchanged, treatment was not ade- quate and should (generally) not be repeated. versus reflex therapy . . . . . . . . 174 5.4 Remedial exercise . . . . . . . . . . . . 175 Critical assessment of the preceding treatment and ongoing audit and review are essential here. To 5.5 Treatment of faulty statics . . . . . . . . 176 reiterate: this is primarily a question of analyzing the factors contributing to the pathogenesis and not 5.6 Immobilization and supports . . . . . . . 177 simply of conventional clinical diagnosis. This atti- tude rules out an indiscriminate routine approach 5.7 Pharmacotherapy . . . . . . . . . . . . . 178 (e.g. ‘a series of intradermal injections’ or ‘a series of infiltrations’), presupposes critical assessment 5.8 Surgery . . . . . . . . . . . . . . . . . . 178 of any preceding treatment, and thus also enables the treatment program to be corrected in light of 5.9 Lifestyle . . . . . . . . . . . . . . . . . . 178 the results obtained with preceding treatments (evidence-based strategy). 5.10 The course of manipulative treatment . 179 5.11 Conclusions . . . . . . . . . . . . . . . 180

Manipulative Therapy 5.1 Manipulation restrictions can be, and frequently are, the true cause of discomfort. 5.1.1 Indications In ankylosing spondylitis, movement therapy Manipulative treatment is indicated if there is is indicated, and therefore (self-)mobilization tech­ functional movement restriction (a pathological niques are also appropriate; these have to be applied, barrier) of a joint or spinal motion segment, and if however, to those segments that still show some this is considered relevant to the patient’s symp- degree of mobility. toms. In this setting, too, it should be emphasized that the decisive factor is not the clinical condition The reason why manipulation may be regarded as as such or even the clinical diagnosis (headache, diz- safely indicated in all these patient groups is that the ziness, low-back pain), but rather the importance of methods advocated in this book are extremely gen- the movement restriction for the pathogenesis. tle and very effective neuromuscular mobilization techniques. They utilize the inherent muscle forces Once this concept has been fully grasped, defi- of the patient rather than those of the practitioner; nition of the action required in spondylosis, disk indeed the practitioner tends to function more in a herniation, osteoporosis, or ankylosing spondyli- ‘directorial’ capacity, instructing the patient what to tis is a straightforward matter: these conditions in do and frequently allowing the patient to perform themselves do not form the object of manipulative self-treatment. treatment. Nevertheless, if it is felt that movement restriction is a factor in patients with these diag- High-velocity, low-amplitude noses, then the restriction should be treated with thrust techniques a manipulative technique that is appropriate in the given circumstances. After gentle mobilization has been performed, the experienced practitioner will sometimes Given the questionable importance of spondy­ sense that the effect is still not entirely satis- losis for the pathogenesis, it is highly probable that factory; for example, a segment may still not be diagnosis of a movement restriction will be the key completely freed from several neighboring seg- finding. ments or, despite a measure of improvement, an area remains that still requires treatment. Preced- In disk herniation, concomitant movement restri­ ing mobilization ensures that such a segment is ction may often cause the patient’s condition to well-prepared for a high-velocity, low-amplitude deteriorate considerably and in such cases manipu- (HVLA) thrust. Following the work of Mierau lation can be very successful. While it is far from et al (1988) we know that use of HVLA thrust easy to predict a successful outcome, it is always techniques is followed by temporary hypermobil- worth making an attempt with an appropriate ity, and that a very intensive reflex response char- technique. acterized by hypotonus or reduced muscle tone is achieved, which can be beneficial in radicular Scoliosis is certainly not an object for manipu- compression or entrapment syndromes (e.g. car- lation, as in itself the condition does not usually pal tunnel syndrome). HVLA thrust techniques cause pain. If a patient with scoliosis feels pain, and should be delivered with a minimum of force, and movement restrictions are diagnosed, these are far the cracking or popping sound within the joints more likely to be the cause of that pain and should should never be ‘enforced’ by the practitioner. If be treated. Manipulation is indicated if movement the segment has been well prepared for a thrust- restrictions interfere with remedial exercise. ing maneuver, then the technique should succeed with consummate ease. This also applies to the sit- In both osteoporosis and juvenile osteochon­ uation in children who are too young to cooperate; drosis, stiffness (leading to immobility) will cause here it is important to exploit the precise moment the patient’s condition to deteriorate. Adequate when they are relaxed. However, this presupposes gentle mobilization techniques are therefore indi- excellent technical skill. cated to restore mobility. In this connection it is worth quoting Stoddard’s Spondylolisthesis and basilar impression can- (1961) system of recording degrees of joint mobility not be influenced by manipulation, but in clinical (Figure 5.1, Table 5.1). terms they are more often than not symptom-free. Here, too, dysfunctions associated with movement 168

Indications for and principles underlying individual treatment methods Chapter 5 Figure 5.1 • Schematic diagram for recording the tions and contraindications. The situation can now degree of movement restriction (Stoddard’s system). be summarized concisely as follows: there is no real The degree of restrict­ion is indicated in the various contraindication to manipulation and no possibility directions: 1 for side-bending and rotation to the right; that patients will be harmed by it. What is contrain- 2 for retroflexion and rotation to the left. Hypermobility is dicated, however, is poor technique. Nowadays the indicated by the use of an arrow labeled with the number 3 basic approach comprises mobilization with neu- and extending beyond the perimeter of the circle. romuscular techniques that primarily make use of the patient’s inherent muscle forces. This would be 5.1.2 Contraindications like forbidding the patient any spontaneous move- ments. HVLA thrust manipulation is employed to a The major technical advances achieved in the field very limited extent only and the ground is generally of manual medicine in recent years have brought thoroughly prepared beforehand using mobilization about a sea change specifically in the area of indica- techniques. Table 5.1 Stoddard’s classification of joint mobility The following cardinal errors must be avoided: Classification Description • Over-frequent use of HVLA thrust techniques. 0 No mobility, ankylosis, not suitable for • Delivering an HVLA thrust before the patient is manipulative treatment properly relaxed and before the slack has been taken up. 1 Severe movement restriction, only mobilization techniques to be applied • Trying to enforce manipulation of any type against protective muscle spasm or in a direction 2 Slight movement restriction, both that causes pain. mobilization and thrust techniques can be used • Performing cervical manipulation in retroflexion, side-bending, and rotation with traction, 3 Normal mobility, best left alone; however, especially in cases where the patient does not if there is movement restriction in one tolerate this position. direction, a thrust technique in the free direction can be useful (Maigne) • Repeating HVLA thrusts at short intervals (i.e. of less than two weeks); in this context, 4 Hypermobility, all types of manipulative even over-zealous examination of mobility in a treatment should be avoided painful direction may be contraindicated. In the debate surrounding contraindications, repeated reference is made to serious incidents and even fatalities, such as those reported by Dvorák & Ore- lli (1985), Grossiord (1966), Krueger & Okazaki (1980), Lorenz & Vogelsang (1972), and cited in the memorandum issued by the German Association of Manual Medicine (1979). Basing their calculations on the results of a questionnaire sent to members of the Swiss Association of Manual Medicine, Dvorák & Orelli (1985) computed the number of seri- ous complications after manipulation (thrust tech- niques) to be 1:400 000. By far the most important cause of serious complications is undoubtedly injury to the vertebral artery, the wall of which may split longitudinally. Given the low incidence of vertebral artery damage and the rarity of such incidents, more recent publications (up to 2004) have suggested that these findings may be coincidental. Unfortunately, an almost constant feature of the literature cited is a failure to specify the particular technique that was held responsible for the com- plications in question: this is rather like discussing 169

Manipulative Therapy postoperative complications without giving details For obvious reasons, manipulation of any kind of the surgical technique used. One exception, is out of place in hypermobility. While this does however, is the publication by Dvorák & Orelli not mean that no movement restriction should (1985), which includes the following highly charac- be treated in a hypermobile patient, it would be teristic account: better to avoid thrust techniques because tem- porary hypermobility always follows any thrust Case study maneuver. A 35-year-old woman collapsed while attending a Other contraindications include destructive condi­ funeral and suffered from wry neck for three weeks tions of an inflammatory or neoplastic nature. It afterward. Within the space of a few days she is clear that no one would try to treat this type of underwent HVLA thrust manipulation three times, pathology by manipulation; unfortunately, particu- administered by a qualified, experienced chiro- larly in the initial stages of such conditions, diagnos- practor. The patient was supine and manipulation tic error is often unavoidable. The specialist usually consisted of passive rotation, reclination, and side- sees such patients in hospital, at a later stage, when bending of the head. This was followed immedi- the putative diagnosis has already become clearer. ately by a short period of unconsciousness and Nevertheless, with modern-day techniques, these later by tetraplegia. The patient was extubated after patients should come to no more harm than from mechanical ventilation for 36 hours and administra- the administration of analgesics. If, in a case of tion of dexamethasone. After four months the patient diagnosed tumor pathology, coexisting movement was symptom-free apart from slight unsteadiness of restriction is considered harmful to the patient’s gait. HVLA thrust techniques in acute wry neck are condition, there is no reason why such a restriction questionable in themselves, but to use the danger- should not be treated with an appropriate tech- ous combination of ‘rotation, reclination, and side- nique (see Case study 2 in Section 4.21.2). bending’ is to court disaster. Another grave error was to repeat the thrusts in quick succession within the While working at the neurology clinic in Prague- space of a few days because the patient’s condition Vinohrady, I deliberately gave manipulation at the did not show any improvement. In the few instances craniocervical junction to a patient with a decom- where detailed case reports are available, serious pensating acoustic neuroma; he was then able to complications have indeed occurred most frequently be referred to the neurosurgery clinic in a well- when HVLA thrust techniques are repeated within a compensated state. It is regrettable that a vertebral short space of time. artery syndrome is considered to be a contraindi- cation in this setting. Admittedly, treatment must It should be emphasized here that HVLA thrust only ever be given in a direction that is well toler- techniques are inappropriate for painful and severe ated, but there are few disorders where restrictions movement restrictions, even if several adjacent involving the craniocervical junction are more dis- segments are involved simultaneously. In such astrous. cases, HVLA thrusts are not only traumatizing but also ineffective, whereas neuromuscular tech- 5.1.3 Traction niques have proved outstandingly beneficial. For this reason, HVLA thrust techniques hardly ever Traction is essentially a form of mechanotherapy or form the initial component of therapy. The follow- manipulation, but unlike other methods of manipu- ing contraindication may be inferred: if it is a mis- lation it is generally accepted in traditional medicine. take to perform thrust manipulation in the painful Within the framework of manipulative techniques, direction where there is major movement restric- traction of the cervical and lumbar spinal column has tion, then use of this technique is also contraindi- a specific role in radicular compression syndromes cated where pain and gross movement restriction in those spinal regions and in disk herniation. In fact, are present in all directions. In reversible functional traction can also be useful for diagnosis: if it relieves movement restrictions, a distinction is made in any discomfort in the lumbar region, then the diagnosis case between the direction of restriction and the of a herniated disk is corroborated. Traction is also direction of ease; movement restriction in all direc- indicated in acute wry neck and low-back pain. tions does not suggest dysfunction and therefore does not constitute an indication for manipulation. One important point must be emphasized, how- ever: it is essential first to establish in each case 170

Indications for and principles underlying individual treatment methods Chapter 5 whether experimental traction brings the patient (1951). However, it is absolutely painless and may any relief. If no relief ensues, we must first seek also be used by the patient for self-treatment. The to modify the technique so that discomfort is alle- technique can also be applied to very small skin viated, and then desist if traction still fails. One areas, such as the skin fold between fingers or toes, reason for the failure of traction is restriction of where HAZs may develop, especially in radicular movement, either at the craniocervical junction or syndromes radiating to the fingers or toes. HAZs in the lumbar spine. Once this restriction has been are a useful sign of a radicular lesion and their treat- released, traction is often well tolerated, provided ment can be highly effective. that it is implemented gently and with technical skill, preferably by hand. Examination usually starts with a test for skin drag by gently stroking the skin surface with a fin- 5.2 Soft-tissue manipulation gertip. Skin drag in a HAZ is heightened due to increased moisture (sweating) and so permits rapid Soft tissue, in particular the deeper layers including identification of the area where skin stretching the fascia and connective tissue, is intimately con- should be performed. nected with the locomotor system, muscles, and joints. It is the function of soft tissue to be stretch- 5.2.2 Stretching a soft-tissue able while yet able to resist stretch, and to be capa- fold (connective tissue) ble of being shifted while yet able to resist shifting. All this should take place in harmony with the loco- The deeper layers of connective tissue can be folded motor system and may involve considerable ranges and, after the barrier has been engaged, stretched. of movement. This technique is particularly effective for treating short or taut muscles and scars. The fold can be The same also applies for the viscera: there are formed between the fingers or sometimes between no standard measures whatsoever for the degree to the full length of the lateral edges of both hands. which the internal organs may also move. Changes Stretching should never involve compression. Once in soft tissue have usually been considered to be the barrier is engaged, release is obtained spontane- reflex changes, that is secondary changes. This is ously. not always the case, however, particularly in the chronic stage of painful conditions, and in endo- 5.2.3 Application of pressure crine and metabolic disorders. The tissue changes then form what is termed a ‘terrain’ (or constitu- In cases where a tissue fold cannot be formed, the tional factor). application of very light pressure can obtain tissue release. The pressure applied is just sufficient to Clinically, a physiological and a pathological sense the moment of increased resistance when the barrier can be detected in all soft tissue: both barrier is engaged. After a brief latency period, the types of barrier constitute a possible indication for resistance disappears and the practitioner’s finger therapy, enabling disordered function to be cor- spontaneously sinks more deeply into the tissue. rected in precisely the same way as in restricted This method is especially effective for deep-lying joints. If the soft-tissue changes are significant, trigger points (TrPs) and scars, particularly in cases they produce reflex inhibition of the locomo- of painful resistance in the abdominal cavity. tor system; it is then advisable to treat such soft- tissue lesions before performing joint mobilization, 5.2.4 Restoration of deep as the treatment itself may have a considerable tissue mobility mobilizing effect. Where there is a pathological barrier, restriction 5.2.1 Skin stretching of fascial mobility against bone is a characteristic finding, and restoration of normal mobility is indi- This technique is specific for hyperalgesic zones cated. As with fascia, this also applies to the scalp (HAZs). It has an effect similar to that of Kibler’s and its mobility against the underlying bone, to skin-fold rolling test (1958) and of connective tissue massage as advocated by Leube & Dicke 171

Manipulative Therapy the soft-tissue pad at the heel, and to the mobil- injected novocaine into scar tissue and attributed ity of adjacent bones connected mainly by soft tis- the resultant effect to this intervention. However, sue, such as the metacarpal and metatarsal bones simple needling yields the same result. Nevertheless, and the fibular head with the tibia. The situation is therapy using soft-tissue techniques is far more similar with regard to the mobility of subperiosteal precise because it is based on the diagnosis of all tissue in painful periosteal points found especially scar layers. The term ‘instant relief phenomenon’ at the attachments of tendons and ligaments. In emphasizes not only the immediate effect but also most instances these are chronic changes to which the fact that all symptoms disappear with a single the term ‘dystrophic’ may be applied, even though intervention. This is generally over-optimistic; the they may be reversible in functional terms. soft tissue in the vicinity of a scar often requires repeated treatment, and not infrequently the scar is 5.2.5 Treatment of (active) just one of a larger number of factors in the patho- scars genesis. It may itself also be prone to recur. Scars are located chiefly in the soft tissue, involving 5.2.6 Relaxation of muscles all its layers. Where healing is uncomplicated, a scar will be asymptomatic and all the layers involved will Post-isometric relaxation (PIR) is the specific stretch and shift like those in the surrounding tissue. therapy for muscle tension with or without TrPs. However, if healing is not straight forward, but more Here, too, the first step is to take up the slack by frequently for no apparent reason, many years later, lengthening the muscle so as to engage the barrier. a scar may become active in stressful situations and This method, which will be described in detail in may even recurr after successful treatment. Exami- Section 6.6, has a similar effect to the spray and nation will disclose resistance in some or all of the stretch method of Travell & Simons (1999) and is tissue layers penetrated by the scar. Such a scar is effective not only on TrPs in muscle, but also on the termed ‘active.’ Pathological barriers will then be points where tensed muscles attach to the perios- found in all soft-tissue layers, and the patient will teum, and on referred pain in particular. PIR is pain- report pain when these are examined. Because a scar less and is suitable for use in a self-treatment setting. generally passes through several soft-tissue layers, it We routinely combine it with reciprocal inhibition can be a particularly rich source of pathology, caus- (RI) achieved by antagonist stimulation. It should be ing dysfunctions of muscles and joints. emphasized here that the vast majority of TrPs can be treated via reflex mechanisms merely using mini- The process of scar examination begins with mal pressure and generally in the context of chain a test for skin drag, often the most rapid guide as reaction patterns. However, chronic TrPs do exist; to what is happening. However, the diagnosis can these need to be diagnosed and then treated with also be difficult. Following surgery the operative painful needling or with hard ‘traumatizing’ massage. field may (for esthetic reasons) be at some distance from the surface wound. Because surgery is often 5.3 Reflex therapy performed only by laparoscopy or with a laser, it is frequently necessary to rely on findings elicited by This acts on the same structures as soft-tissue deep palpation. The same is true for internal inju- manipulative therapy, but is generally less spe- ries without surface scarring, for example following cific and is consistent with the traditional methods a difficult childbirth. In this setting (compared with employed by physical therapists. the situation in organic disease), palpation of the release phenomenon is of major diagnostic signifi- 5.3.1 Massage cance. Typically, the diagnosis here can be helped by the finding that locomotor symptoms had their This term covers a broad spectrum of techniques onset shortly after surgery or trauma. that have developed from time immemorial; massage can be used to treat soft tissue and even periosteum. Undiagnosed active scars cause problems that From the clinical standpoint, it should be used when keep recurring until they have been treated; how- ever, their treatment can bring surprising successes, described by their discoverer Huneke (1947) as the ‘instant relief phenomenon.’ Huneke himself 172

Indications for and principles underlying individual treatment methods Chapter 5 and where changes are found in the tissue, changes consistent with minor asymmetries in tactile per- that manifest themselves primarily as altered tension. ception. These asymmetries can be corrected by The experienced massage therapist will adapt the stroking. However, the practitioner must be able technique to these changes so as to release tension to sense the reaction during stroking. Stroking (our in the tissues where it is detected, and to bring relief. preference is to trace numbers and letters – prop- Deep massage may be applied to the periosteum, rioception) in asymmetric tactile perception on the but this is painful. There are also some TrPs that do soles of the feet is so effective that it is invariably not respond to reflex methods and that require deep indicated, and is performed on the side that is con- friction, a certain degree of traumatization. sidered abnormal. Bearing this in mind, it would seem that massage 5.3.3 Local anesthesia – is a universal method that is potentially applicable needling in all reflex changes produced by pain (or nocicep- tive stimuli); and indeed that is the case. Massage is Local anesthesia and needling are among the most pleasurable, routinely brings relief and is therefore widely used methods of treating painful lesions. also very popular with patients. Unfortunately, the It may appear unorthodox to deal with these two effect is usually only short-lived, whereas the pro- methods together, and yet it should be recalled that cedure is very time-consuming. At the same time, one does not simply use local anesthetics to relieve some massage techniques can be quite painful. pain for the short period during which the anes- thetic has effect. The popularity of local anesthe- Massage is invariably a purely passive form of sia is due to the fact that its effect far outlasts the treatment, demanding no active involvement what- direct (pharmacological) action of the anesthetic. It soever from the patient. For this reason massage is has further been shown that the effect appears not indicated only as a preparation for other, more spe- to be dependent on the local anesthetic injected. In cific and hence more effective treatment modali- fact, Kibler (1958) used sodium bicarbonate, and ties, and is not the therapy of choice for locomotor Frost et al (1980), in a double-blind study, com- system dysfunction. pared the effect of mepivacaine injections with that of physiological saline injections in the management The term ‘reflex massage’ is also used occasion- of myofascial pain. It was shown that, if anything, ally. It is sufficient to point out that any massage, physiological saline solution was more effective than any palpatory activity, triggers a reflex, depending the local anesthetic. The common denominator in all on the tissue that is being massaged. these methods is, of course, the use of the needle. 5.3.2 Exteroceptive stimulation The effect, however, does appear to depend very much on how precisely the needle touches Although this method does not exploit the bar- the pain point. Needling is most effective when the rier phenomenon, it is nevertheless appropriate for needle is able to reproduce the patient’s spontane- inclusion here because it is a manual method that ously reported pain and its radiation pattern. In the is used in a targeted manner in response to specific case of TrPs, a twitch response should be provoked findings. It is based primarily on stroking, which wherever possible, whether a local anesthetic is is indicated in circumstances characterized by used or not. If the exact spot is successfully located, minor changes in tactile perception. From a purely then analgesia can be produced immediately simply theoretical standpoint, afferent conduction is the with a dry needle (Lewit 1979), both at TrPs and at prerequisite for control by the nervous system. other pain points. Exteroceptive stimulation is one of the few meth- ods to take account of this. It is used not for gross Injection of local anesthetics is, of course, nec- neurological disorders, but merely for dysfunctions essary if the intention is to interrupt conduction in that are comparable to a HAZ. nerve structures, for example in nerve-root infiltra- tion or epidural anesthesia. One special method of These dysfunctions are most clearly evident using local anesthetics is to raise intradermal blebs, on the soles of the feet where an asymmetrical although this technique is advisable only where response to stroking or brushing is often observed administration is within a HAZ. Here, too, it is and patients also confirm that they are aware of the immaterial whether the bleb is produced using a difference. With greater experience it is possible to discern that changes in muscle tone are also 173

Manipulative Therapy local anesthetic, physiological saline, or distilled myself (Lewit 1979) described the ‘needling effect’ water (although the latter is more painful). in 312 pain points in 241 patients. There would seem to be sufficient clinical evidence to support It is interesting that, just as after manipulation the efficacy of this treatment. (so, too, after successful needling or local anesthe- sia), the immediate relief obtained is often suc- There appears to be a growing tendency among ceeded by a painful reaction lasting for a period modern Chinese doctors to select their needle inser- of hours, or one or sometimes two days. It is only tion points not only according to the traditional after this reaction has subsided that the therapeu- ‘meridians,’ but also on the basis of the segmental tic effect proper becomes established. For this rea- anatomy of innervation. Instead of needling, elec- son such treatment should not be repeated before trical stimulation has also been introduced (Chang seven days have elapsed. Repetition is indicated if 1979). Melzack et al (1977) have pointed out impor- improvement has been achieved but there is still tant analogies between the TrPs of Travell & Rinzler some residual pain. (1952) and traditional acupuncture points. Gunn et al (1976) found that of 100 acupuncture loci chosen 5.3.4 Electrical stimulation at random, 70 were motor points in muscles. Other acupuncture loci are attachment points of tendons This category includes a variety of methods that and ligaments; if these are tender, they can be treated ultimately act on the same receptors and therefore by performing PIR on the muscles for which they produce comparable effects. Pain can be allevi- serve as attachment points – for example the fibu- ated by reflex mechanisms in response to electri- lar head (TrP of biceps femoris or by mobilizing the cal impulses, diadynamic current or transcutaneous fibular head), or the che-gu (4 equ L14) acupuncture stimulation and many other similar modalities. point by PIR of the adductor pollicis brevis. They compete successfully with more traditional methods such as poultices, cupping, leeches, etc. Patterns of chain reactions (see Section 4.20) All these methods, especially if they are used rela- help us to understand functional relationships based tively gently, can help to alleviate pain. on physiological principles and thus might pro- vide a rational explanation for the phenomenon of 5.3.5 Acupuncture ‘meridians.’ This discussion of reflex therapies must touch Careful examination often reveals that many briefly on acupuncture, one of the most venerable acupuncture points can be tender at palpation and modalities in this category. Considerable difficulties that increased tension can be felt at these sites. This arise the moment we attempt closer analysis of its is borne out, too, by the measurement of reduced mode of action. According to the orthodox view, electrical skin resistance in the vicinity of acupunc- acupuncture treatment is based on organ diagnoses ture points. and less on principles of pathogenesis, although some modern authors (Bischko (1984), for exam- A rational, scientific attitude to acupuncture ple) concede that acupuncture works primarily in is important because it might enable us to estab- cases of disturbed function rather than in struc- lish the indication more precisely in the context of tural pathology. The choice of acupuncture points is dysfunctions; it would then be possible to identify based on ‘meridians’ and is entirely empirical. From those circumstances where acupuncture might be a theoretical standpoint, the most questionable the treatment of choice. issue surrounds the concept of ‘energies’ that are not at all susceptible to measurement. For scientific 5.3.6 Soft-tissue manipulation analysis, therefore, it will be necessary to examine versus reflex therapy the individual constituent elements that go to make up the system of acupuncture. Soft-tissue manipulation techniques act on the same structures that are the targets for most other One such element is the effect of needling: methods employed in physical (reflex) medicine. this was confirmed as medically effective in an Technically, they are based on the diagnosis and cor- older publication by Travell & Rinzler (1952), and I rection (release) of a pathological barrier and thus form part of the canon of manual therapy. There is one fundamental difference between the human hand and all the other instruments at 174

Indications for and principles underlying individual treatment methods Chapter 5 our disposal: it provides us with information about The first criterion for establishing the indication, the processes unfolding at every stage of therapy namely the diagnosis of faulty movement patterns and offers feedback so that we can continually cor- and muscle imbalance, often presents an insuper- rect or modify our approach. Once the barrier has able problem in the acute stage when pain distorts been engaged and release has been pursued to the all movements and it is impossible to differentiate very end, we can sense how the tension dissipates, between a pain reaction and a faulty movement and we then know that the patient’s pain has sub- pattern. Moreover, the patient is also still unable to sided – at least at the site in question. execute any normal movement patterns. The difference between massage and soft-tissue The second criterion in determining whether manipulation is primarily that massage, with its remedial exercise is indicated is the relevance of relatively rapid rhythmic movements, does not take the faulty movement pattern to the patient’s prob- precise account of the barrier and release phenom- lem. Here the decision can be more difficult, for enon. Despite the rapid movements involved, mas- example, than in the case of a movement restric- sage is far more time-consuming, diagnostic criteria tion or a TrP, because remedial exercise is far more are often lacking, and self-treatment is not really time-consuming and laborious. Muscle imbalances possible. are also common in asymptomatic patients and to embark on a course of remedial exercise in every 5.4 Remedial exercise case would be most unrealistic. Remedial exercise is therefore indicated where we are satisfied that Having discussed the indications for methods that the faulty movement pattern we have diagnosed is are intended to act directly on painful dysfunc- so important that, if left uncorrected, the patient’s tions, we will now turn our attention to methods condition is bound to recur. targeted at the more complex functions. In this setting, remedial exercise has a prominent role to Indeed, specific remedial exercise is indicated play. precisely to prevent these frequent recurrences. Nevertheless, there are cases where the findings Two essentially different types of remedial are so serious that there is no need to wait for exercise should be distinguished. In the first type, recurrences. One criterion is the degree of muscle patients learn to use their own muscles to restore imbalance. In other cases we must consider the cir- joint mobility, to relax their own TrPs and also to cumstances that trigger recurrences: for example treat soft-tissue parts that they can reach them- if they routinely occur when a patient lifts a heavy selves. These techniques will be described systemat- object or bends forward. In such cases we study the ically in conjunction with the corresponding manual patient’s forward-bending movement pattern and therapy techniques. then demonstrate the correct way to bend forward and straighten up again, also while lifting. The same The second type of remedial exercise is intended is true for carrying loads, sitting at the computer, to correct faulty movement patterns (or stereo- etc. However, faulty breathing patterns are the types), which are associated with muscle imbalance most disastrous of all because they are intimately and are frequently the true cause of painful dys- linked with the stability of the spinal column. function. The object of remedial exercise in such cases is to correct a faulty movement pattern that To make remedial exercise as effective as possi- has been diagnosed and is considered relevant to ble, and to make it a routine procedure, it is essen- the patient’s problem. tial to set clear and attainable goals. This means that we should not set out to achieve ‘ideal move- Without this diagnosis of a faulty movement pat- ment patterns,’ but instead we should concentrate tern and subsequent assessment of its relevance in on the fault that is the chief cause of the recurrent terms of the pathogenesis, remedial exercise is sim- problem. When we do this, it is often possible to ply a frustrating waste of time. It should be the role obtain results within a short period, after a few of the physician to make this diagnosis and assess- clear instructions have been given. However, if we ment. The technical aspects are then the domain try to achieve more than this, then remedial exer- of the physiotherapist. A physician who is able to cise therapy may take months. establish the correct indication for remedial exer- cise should also be able to assess the effect that the It is also essential to recognize the limits of what physiotherapist has achieved. is possible. Unlike manipulation or needling, reme- dial exercise demands the active cooperation of the 175

Manipulative Therapy patient. Some movement patterns can be so deeply 5.5 Treatment of faulty ingrained that it is difficult to modify them, espe- statics cially if the patient is no longer young. And the problem of motivation is a hugely important issue. If The diagnosis of faulty statics has been described patients are not really interested in improving their in Section 3.1 and Section 4.2. Contributing causes condition, then any attempt at rehabilitation is a often include muscle imbalance and external influ- waste of time. It cannot be sufficiently emphasized, ences (e.g. ergonomic factors), and faulty statics need however, that the art of the good physiotherapist to be treated accordingly. We will take the opportu- consists not only in technical competence but also nity here to deal with the correction of obliquity. in an ability to motivate patients. The intelligence of the patient also plays a role. Here we would do well Obliquity in the pelvic region and in the lower to recall the remarks made in Section 2.6 concern- part of the lumbar spine can be compensated for ing patients who, from childhood, are incapable of with corrective footwear. Because such footwear forming optimal movement patterns and therefore is beneficial only if it is worn permanently, pre- find it difficult to implement corrections. This group scription of this interventional measure must be also includes individuals gifted with high intelligence approached in a purposeful and responsible manner who are virtually ‘handicapped’ the moment motor if it is to be effective. Considerable thought must skills are called for. be given to ensure that such an intervention is prop- erly indicated. The decision is relatively straightfor- The patient’s general physical condition must ward if obliquity is due to fairly recent trauma, for also be taken into account: cardiac function, circu- example a leg-shortening injury or unilateral com- lation, obesity, generally weakened abdominal mus- pression of the lumbar spine. Unilateral (asymmet- culature after repeated surgery and/or childbirth, ric) flat foot as a further possible indication can be recurrent hernias or decompensating scoliosis in best identified on examination if the patient stands old age – any of these may present insurmountable on the lateral margins of both feet, causing the pel- obstacles from the outset. vis to become horizontal while at the same time the pelvis which deviated to the higher side returns to Despite these limitations, remedial exercise should the mid position. However, because pelvic obliquity constitute the most important modality implemented in most cases gives rise to secondary compensa­ by the physiotherapist for dysfunctions involving the tion during growth, the decision then becomes far locomotor system. The importance and effective- more complex. In such circumstances assessment ness of remedial exercise have increased considerably is impossible without X-ray analysis, as described in now that we have a better understanding of how spe- Section 3.1. Ultimately, however, the decision must cifically to treat the deep stabilization system of the also be taken on clinical grounds. trunk and feet. This is why it is so crucial to devote time primarily to these active methods of rehabilita- Clinically, static pain is a chronic, recurring phe- tion and to a lesser extent to passive procedures such nomenon associated with excessive static loading, as massage, and the many different forms of electro- primarily on standing. therapy. Examination reveals pelvic deviation toward the Finally, there is the question of whether and higher side. When a board of suitable thickness under what circumstances these remedial exer- is placed under the foot of the ‘shorter’ leg, the cise methods can be prescribed for preven­ patient’s pelvis should become horizontal and lat- tive purposes. This is a perfectly reasonable eral deviation should also be reduced. Since X-ray consideration given that, in our modern technically images demonstrate this result much more pre- advanced world, patterns of harm are continu- cisely, the indication for such correction should be ously inflicted on the locomotor system from child- established on the basis of the clinical and X-ray hood. Regrettably, a solution to this problem is findings before and after placing the board under difficult to find, mainly because group therapy is the patient’s foot. not easy to arrange. One possible solution might be to recommend yoga techniques (e.g. breath- It is also important to be guided by the patient’s ing exercises, ‘spinal’ techniques, etc.) or meth- reaction. If a thin insert about 1 cm thick is placed ods utilized in Chinese exercise systems (e.g. under the foot of a normal subject with the instruc- Tai Chi) and certain strategies advocated in back tion to distribute weight equally on both legs schools. 176

Indications for and principles underlying individual treatment methods Chapter 5 without bending the knees, the insert will cause 5.6 Immobilization and considerable discomfort. Where pelvic obliquity is supports present, one of three different responses may be expected: In the acute stage of lesions involving the locomotor system, muscle spasm ensures immobilization. The 1. The patient may find the insert positively same also applies after trauma, when healing makes comfortable. immobilization imperative. However, immobiliza­ tion becomes highly problematic once a condition 2. The patient may feel that the insert makes no threatens to become chronic, and if the objective is difference. full recovery, that is restoration of normal function, then immobilization presents an outright obstacle. 3. The patient may find the insert uncomfortable. For this reason immobilization should only ever be a temporary measure in circumstances where the aim In the first case we can expect the patient to toler- is to restore normal function. Permanent immobili- ate the correction well and instructions should be zation signifies simply that there is no hope of func- given to wear the insert at all times, even in indoor tional recovery. slippers wherever possible. In the second case a degree of adaptation may be necessary and the Unlike immobilization, however, supports need patient should be allowed to become accustomed to not greatly interfere with mobility while protect- the insert gradually. In the third scenario the patient ing the patient against excessive static loading, an should be advised to try wearing the insert for brief important consideration in sedentary occupations. periods; however, if the patient fails to adapt, wear- And it is primarily hypermobile subjects with lax ing the insert should not be rigorously enforced. muscles and ligaments who find it difficult to adapt to excessive static loading, particularly when, as in The type of shoe correction implemented is most modern means of transport, jolting is a com- important in itself. A heel insert fitted inside the pounding factor. shoe is practical, but has the disadvantage that the shoe fits less well. For this reason, it is bet- Automobile drivers and passengers should be ter to lower (shorten) the heel on the shoe of the recommended to use an inflatable cushion to sup- longer leg. However, this is practicable only where port themselves at the point where their kyphosis leg length difference is minimal. Where leg length peaks when they are sitting in a relaxed position. difference is greater than 2 cm, the sole must be Many hypermobile subjects suffering from head- thicker on the shoe of the shorter leg, otherwise the ache should wear a soft supporting collar when foot would be uncomfortable. It is not necessary riding in automobiles or using other means of trans- though to compensate fully for leg-length inequality. port. Elderly, obese patients with weak abdominal musculature, or with scarring and hernias, need a If there is no difference in leg length and the firm lumbar belt. Patients with ligament pain in pelvis is level, but obliquity is detected in the lower the pelvic region require a firm pelvic belt, as pro- lumbar spine, this will have implications during posed by Biedermann (1993) and Cyriax (1978) both standing and sitting. In this instance correc- (see Section 6.9). Most of these supports should tive compensation must also be provided when the be worn primarily under conditions of excessive patient is seated by placing a thin board under one static loading, and the pelvic belt should be worn ischial tuberosity. X-rays will be required to demon- at night. strate the need for such measures. Immobilization should be only as minimal and as The most frequent and most serious fault in sit- brief as necessary. However, in light of the ting is kyphosis due to hypermobility of the lum­ increasing incidence of excessive static loading, bar spine. In such cases a back support should be thoughtfully selected supports can often be prescribed where the kyphosis peaks. If that is not recommended. possible, then it is recommended that the sitting surface should be tilted forward or that the patient should sit in the oriental manner with legs crossed, or on the heels (Japanese fashion), which causes the pelvis to tilt forward. A forward-drawn posture (see Section 4.20.3 and Section 7.1.7) is also very important in this context. 177

Manipulative Therapy 5.7 Pharmacotherapy at tendon and ligament attachments, as well as muscle TrPs, can generally be treated successfully Since the main focus of this book is on dysfunctions using relaxation and soft tissue techniques, and of the locomotor system, it will be understood that by needling and local anesthesia. Corticosteroids pharmacotherapy can be effective only within cer- should be prescribed only if these physiological tain limits. It is hardly likely that a restricted joint, methods have failed. Their administration should an immobile fascia, or faulty motor patterns related be repeated only if they elicit some improvement to breathing or to carrying loads will respond to at the first attempt. However, corticosteroids are pharmacological correction. On the other hand, it is suitable for use where inflammatory changes are clear that disturbed function in itself is not synony- present. mous with disease and pain. It is only with the onset of reflex changes, which are felt to be painful, that 5.8 Surgery the patient will report symptoms. Then it is possi- ble to employ pharmacological means to reduce the If the patient’s clinical condition is due to distur- intensity of the reaction to nociceptive stimulation. bance of function alone, there should be no question Moreover, the pain threshold is a major factor and of surgical intervention. However, disturbed func- this can be influenced by pharmacotherapy. tion may be the consequence of structural changes that necessitate surgery. This scenario is encoun- It is therefore sometimes useful to prescribe tered most commonly in radicular syndromes and medicines that lower the response of the auto- other disorders associated with intervertebral disk nomic nervous system; in particular, non-steroidal lesions. Conservative measures primarily aimed at anti-inflammatory drugs (NSAIDs) are suitable restoring function are frequently successful here. for this purpose. It is important to issue warnings It is therefore not always straightforward to decide concerning the misuse/abuse of all types of analge- when still to adopt a conservative approach or when sics in the setting of chronic pain. Dependence may to intervene surgically (see Section 7.8.2). Spinal develop and it is no coincidence that reduction of canal stenosis may also be a (contributing) cause of the analgesic dose is often the first step taken when radicular compression or even of spinal cord com- patients are admitted to pain clinics. pression. Analgesics are frequently combined with muscle Cauda equina syndrome, a condition character- relaxants, and a great many combination products ized by acute bladder and bowel paralysis and rap- are available. Prescription of these products can be idly progressive muscle weakness, constitutes an beneficial only in cases where general muscle ten- indication for emergency surgery. Instability, for sion has been demonstrated. However, the most example in progressive spondylolisthesis or follow- commonly encountered patient category comprises ing trauma, may also provide an indication for sur- constitutionally hypermobile individuals suffer- gery. Instability due to odontoid abnormality may ing from localized painful muscle tension. In such also be dangerous. It should be noted here that the patients the combination of analgesics and muscle conservative management of instability has become relaxants can serve not only to increase hypermo- far more effective in recent years. bility and poor coordination, but also to complicate specific rehabilitation because fine muscle control 5.9 Lifestyle tends to deteriorate. Lifestyle questions probably play the most impor­ The most rewarding effects of pharmacotherapy tant role of all in the context of treating and pre- are achieved where patients with locomotor pain venting dysfunctions in the locomotor system. and suffering from masked depression are treated Lifestyle issues have been left almost until last with mild antidepressants – a scenario that is not at because they do not constitute a therapeutic all uncommon. method in the true sense of the word, and a sepa- rate chapter has been devoted to this subject (see As a rule, treatment with corticosteroids is Chapter 8). not indicated in locomotor system dysfunctions. Local application of corticosteroids should also only ever be implemented in exceptional cir- cumstances. Pain points on the periosteum and 178

Indications for and principles underlying individual treatment methods Chapter 5 One of the most important tasks facing the rehabilitation plan will be continued or reviewed practitioner during history taking is therefore to and modified. If the findings have definitely discover the potential sources of trouble in the improved and the patient’s home exercise is clear, patient’s daily routine so that warnings can be given then the interval between further follow-up exami- to steer clear of harmful lifestyle habits. Indeed, if nations can be increased. Even if the initial results we succeed in detecting these important clues, we are favorable, patients with a longer history of such should already be able to give very useful advice problems should be followed up for longer – ideally after the first examination. However, if patients for several months – because the natural course of refuse to desist from a clearly harmful lifestyle, dysfunctions tends to be chronic and relapsing. then any therapy offered is destined to fail. If no improvement is reported at the first 5.10 The course of follow-up examination, the first question to ask the manipulative treatment patient must be: Did your condition improve briefly or not at all? The first intervention sometimes The clinical examination provides information produces a very marked but short-lived effect. about the entire locomotor system or, at least, all The follow-up examination may reveal one of two key regions. Only once the examination stage is fundamentally different situations: complete is it possible to consider whether we are faced with a typical chain reaction pattern or with 1. The findings are unchanged. This means that a set of individual disorders of dubious connection. treatment has produced no results or that there has been a rapid recurrence of the In the former, more typical scenario, treat- patient’s condition (which is not much better). ment should be given to the link in the chain that appears to be most relevant. Then all findings must 2. The original findings have been corrected be checked again. Ideally, the chain reaction will no but new factors are now producing similar longer be present and it is then clear what home symptoms. exercise needs to be assigned to the patient: for example, if the key link was in the foot, rehabili- In the latter case the condition may actually be tation will focus on the foot dysfunction. If a sec- regarded as having improved even if the patient ondary finding is diagnosed, for example a painfully does not feel any better. In the cervical region restricted acromioclavicular joint, then this can also in particular, a highly characteristic pattern may be treated. However, if the chosen link turns out develop in which lesions tend to migrate in a caudal to be wide of the mark, then an attempt should be direction until they disappear. made using another link in the chain. And this is by no means uncommon because the first attempt In the former case, however, we must ask our- at treatment is frequently used for diagnostic pur- selves whether the initial analysis was correct and poses; the diagnostic process proper ends with the whether we failed to identify the true cause. Alter- first intervention. It is not unusual for this interven- natively, the underlying condition may be more tion also to be selected on diagnostic grounds so as serious than appeared at first sight and may in fact to confirm the importance of a particular finding – be caused by pathomorphological changes. A fur- something that applies especially with active scars. ther reason may be that patients often perform their home exercise wrongly or skip it altogether, However, if no chain reaction pattern at all is for example, a simple self-mobilization technique detected, then the findings made should be treated, or relaxation of TrPs. and if there is an effective form of self-treatment, then the patient’s home exercise can be assigned. If, despite the failure of treatment, there is a continuing conviction that the original diagnosis was The first follow-up examination about two correct, then the treatment may be repeated once weeks later then assumes special importance. On more. If initial improvement is again promptly fol- that occasion the working hypothesis from the lowed by recurrence, then the underlying cause of first examination will be either verified or found this must be sought. A clinical finding will often be to require revision. Depending on the outcome made in the corresponding segment; in the thoracic of the follow-up examination, the subsequent outlet syndrome this is almost always reflected in clavicular breathing (i.e. lifting of the thorax dur- ing inhalation), with poor stabilization of the trunk, which then needs to be corrected. 179

Manipulative Therapy However, the dysfunctions themselves can also be likely be required when we next see the patient. extremely complicated and multiple chain reaction Our aim is not constantly to promote one particu- patterns may be present, each one competing with lar type of therapy but to normalize function and the others. In such cases rapid results are unlikely hence to relieve the patient’s symptoms. To do and the patient will need to be monitored for a pro- this we select the method that appears to be most longed period. Chronic recurrent conditions such as advantageous. Such a strategy makes it difficult to migraine are routinely associated with dysfunctions determine which method has been most effective: of the locomotor system and tend to improve once manipulation, remedial exercise, or needling of a these dysfunctions are treated. However, they may pain point. It would not be easy to justify the indi- recur after a relatively long interval, and then the cation for further manipulation if movement restric- patient will need to be treated again. tion is no longer present, or for continuing to needle a pain point if this can no longer be detected. It Where manipulation was discussed in a preven- therefore becomes difficult to determine statisti- tive context (see Section 5.4), this should also be cally which method was most successful. understood to include the prevention of recurrence: rehabilitation, which regularly follows on from our If a patient with acute appendicitis is cured and treatment, with patients themselves playing an remains symptom-free after removal of the inflamed ever-increasing role, is truly synonymous with the organ, the surgeon does not have to provide sta- prevention of recurrence. tistical proof that surgery was indicated. If a pain point or TrPs disappear after PIR, RI or needling in 5.11 Conclusions a patient with locomotor system dysfunction, or if a patient has learned how to normalize respiration The ability correctly to establish whether or not a and does not slip back into clavicular breathing (lift- particular therapeutic intervention is indicated is ing the thorax during inhalation), then something the practical result of the pathophysiological think- has been achieved even if other lesions which still ing outlined in the theoretical sections of this book. cause symptoms have yet to be treated. Because the patient’s symptoms are usually the This approach may seem rather unusual and result of many individual factors, the chief task of complex, but it is consistent with the multifacto­ rial the practitioner is to single out on each occasion the nature of locomotor system dysfunction. It also factor that currently appears to be the most impor- precludes a monotonous, routine modus operandi tant and also the most accessible to treatment. In characterized by a propensity for series of injec- this regard the recognition of characteristic chains tions, repeated manipulation of a spinal segment, of dysfunctions has done much to define this proc- or the courses of electrotherapy so beloved of ess more precisely. physiotherapists. The journey is a demanding one, but the effort involved is worthwhile both for the If we are successful at the patient’s initial visit, patient’s well-being and for refining the practitioner’s then a different therapeutic approach will quite skills. 180

Chapter Six 6 Therapeutic techniques Chapter contents 6.5 Self-mobilization . . . . . . . . . . . . . 236 6.1 Manipulation . . . . . . . . . . . . . . . 182 6.5.1 Self-mobilization by stretching . . 237 6.5.2 S elf-mobilization of the 6.1.1 G eneral principles governing technical aspects . . . . . . . . . 182 sacroiliac joints . . . . . . . . . . . 238 6.5.3 S elf-mobilization of the 6.1.2 Extremity joints . . . . . . . . . . . 187 6.1.3 The spinal column . . . . . . . . . 201 lumbar spine . . . . . . . . . . . . 238 6.2 Indirect techniques . . . . . . . . . . . . 223 6.5.4 S elf-mobilization of the thoracic 6.2.1 Johnston’s functional techniques 223 spine and ribs . . . . . . . . . . . 240 6.2.2 Strain and counterstrain . . . . . . 225 6.5.5 S elf-mobilization of the 6.3 Exteroceptive stimulation . . . . . . . . 225 cervicothoracic junction and 6.3.1 T actile perception and first rib . . . . . . . . . . . . . . . 242 muscle tone . . . . . . . . . . . . 225 6.5.6 S elf-mobilization of the cervical spine . . . . . . . . . . . . 243 6.3.2 Assessing altered tactile 6.5.7 Self-mobilization of the perception . . . . . . . . . . . . . 226 extremity joints . . . . . . . . . . . 245 6.6 P ost-isometric relaxation and 6.3.3 Normalizing tactile perception . . 227 reciprocal inhibition . . . . . . . . . . . . 246 6.3.4 A ltered superficial tactile 6.6.1 Basic principles . . . . . . . . . . 246 perception following surgery 6.6.2 Muscles of the head and neck . . 248 (due to scarring) . . . . . . . . . . 227 6.6.3 Muscles of the upper extremity . . 255 6.3.5 Individual characteristics 6.6.4 Muscles of the trunk . . . . . . . . 261 of perception . . . . . . . . . . . . 229 6.6.5 Muscles of the hip region . . . . . 270 6.3.6 Self-treatment . . . . . . . . . . . 229 6.6.6 Muscles of the lower extremity . . 272 6.4 Soft-tissue manipulation . . . . . . . . . 230 6.7 Training weak muscles (facilitation) . . . 279 6.4.1 Skin stretching . . . . . . . . . . . 230 6.7.1 Muscles of the trunk . . . . . . . . 279 6.4.2 Stretching a connective 6.7.2 Muscles of the hip . . . . . . . . . 285 6.8 R e-training to correct faulty tissue fold . . . . . . . . . . . . . . 230 movement patterns . . . . . . . . . . . . 285 6.4.3 S ustained application 6.8.1 Standing on both feet . . . . . . . 285 of pressure . . . . . . . . . . . . . 231 6.8.2 Standing on one leg and walking . 286 6.4.4 S hifting (stretching) the 6.8.3 Sitting . . . . . . . . . . . . . . . . 287 6.8.4 Anteflexion . . . . . . . . . . . . . 289 deep fascia . . . . . . . . . . . . . 231 6.4.5 M utual shifting of metacarpal and metatarsal bones . . . . . . . 235 6.4.6 Painful periosteal points . . . . . . 236

Manipulative Therapy 6.8.5 Lifting the arms . . . . . . . . . . . 290 bones should be fixed either by the patient’s own 6.8.6 Carrying loads correctly . . . . . . 292 position or by the practitioner. 6.8.7 Breathing . . . . . . . . . . . . . . 293 6.8.8 The feet . . . . . . . . . . . . . . . 294 The height of the manipulation table must be 6.8.9 The shoulder blade and upper adjustable; this is absolutely essential given the large number of techniques in which the patient is cervical spine . . . . . . . . . . . . 296 seated and the major height variations in patients 6.8.10 The hands . . . . . . . . . . . . . 296 and practitioners. 6.9 Supports . . . . . . . . . . . . . . . . . 296 The position of the practitioner 6.9.1 Cervical collar . . . . . . . . . . . 297 6.9.2 Inflatable cushion . . . . . . . . . 297 The position adopted by the practitioner relative to 6.9.3 P elvic belt (Biedermann the patient is in many ways decisive for the tech- nique that is to be used. The practitioner must be and Cyriax) . . . . . . . . . . . . . 297 in a comfortable and stable position in order to 6.10 Local anesthesia . . . . . . . . . . . . . 298 be relaxed at all times. If the practitioner is not relaxed, the patient too will be unable to relax. In the preceding chapters we have outlined the diagnosis of locomotor system dysfunctions, their When treatment movements are performed cor- pathogenesis, and the reflex changes they produce. rectly, the practitioner’s hand and forearm always Building on that foundation, we then considered form an extension of the direction of motion. How- the indications for specific therapeutic methods. ever, this in itself is not sufficient to ensure opti- However, to describe them all would go beyond the mally gentle yet effective movement. Movement scope of this book. This chapter will confine itself impulses should emanate from the practitioner’s principally to manipulative techniques, including whole body, with forces usually generated by those for soft tissue and especially for muscles, and the feet and legs, as when throwing the discus or to rehabilitation in the setting of locomotor system putting the shot. dysfunctions. Any practitioner who becomes breathless or per- 6.1 Manipulation spires during manual therapy is doing it wrongly. It may reasonably be said that during manipulation, 6.1.1 General principles especially of the spinal column but also during diag- governing technical nostic examination, the practitioner’s body forms aspects a harmonious moving unit with the patient’s body, rather like a dancing couple. This harmony between The objective of manipulation is to restore normal the mover and the moved is the secret of a flowing, mobility to joints, including joint play. In this con- gentle and hence elegant technique. text we distinguish between two types of manipula- tion: mobilization and high-velocity, low-amplitude Fixation (HVLA) thrust techniques. When techniques are performed correctly, one of The positioning of the patient the bones articulating in the joint being manipulated is fixed while the other is mobilized. In extremity The patient should lie or sit in such a way as to be joints it is usually the proximal bone that is fixed, relaxed. that is supported by the body of the practitioner or by the treatment table. For effective fixation the The patient’s lying or sitting position should be mobilizing force should not act across two joints. In selected so that the joint to be treated is ideally this process the practitioner’s hands are close (but centered, allowing maximal muscle facilitation and not too close) to the joint so as to avoid any lever relaxation. The joint that is the object of treatment action. In the spinal column, fixation is achieved by must be accessible, and one of the articulating correct positioning where possible. In the seated position, good fixation of the caudal spinal segment via the pelvis can be obtained if the patient sits astride the treatment table. 182

Therapeutic techniques Chapter 6 The starting position of the joint is reached is characteristic of a movement restric- and the direction of treatment tion. Functional movement in the spinal column cannot always be distinguished from joint play Treatment of the joint is performed once the slack because movements in an individual motion seg- has been taken up but not in a position in which the ment cannot be performed actively and therefore joint itself is not overstretched. If it is in an extreme resemble joint play to a certain extent. position, the joint will be locked and cannot be treated. This principle must also be adhered to when We know that we have taken up the slack treating the spinal column. According to Kaltenborn (engaged the barrier) the moment we sense the first (1989), the direction of movement during gliding slight resistance (indicative of the physiological bar- mobilization depends on whether the concave joint rier). This must be performed gently and cautiously, surface is located on the proximal (fixed) articulat- and once the barrier has been engaged we should ing bone or conversely whether the convex joint wait. The commonest reason for error and failure is surface is located proximally and the concave joint to misinterpret active resistance by the patient as a surface distally (see Figures 2.7 and 6.1). sign that we have taken up the slack. This invariably happens if the patient senses pain or feels threat- In the first instance, gliding of the distal partner ened by a rapid, harsh examination technique. occurs in the opposite direction to functional bone movement, whereas in the second case, gliding of the ‘Locking’ is an additional factor in the spinal distal partner occurs in the same direction as func- column, especially when long levers are used (see tional bone movement. Accordingly, in the first case, Section 6.1.3). This term refers to techniques in the convex distal partner is mobilized primarily in which all spinal segments are ‘locked’ except the the opposite direction to functional bone movement, one that is being manipulated. whereas in the second case, mobilization occurs in the same direction as functional bone movement Manipulation (see Figure 2.7). For this reason mobilization of the first phalanx relative to the metacarpal head, for After the slack has been taken up (the barrier has example, should be mainly in a palmar direction. been engaged), there are two ways to restore nor- mal mobility: Taking up the slack (engaging the barrier) 1. Either by a gentle springing movement, but more often simply by waiting, in order to Taking up the slack (engaging the barrier) repre- obtain release and thus normalize the barrier. sents the first and crucial phase of manipulation: it is the prelude to release in the context of mobiliza- 2. Or, by delivering an HVLA thrust, once the tion and to an HVLA thrust when a thrusting tech- barrier has been engaged and the patient is nique is being used. relaxed. In peripheral joints we attempt to take up the Simple mobilization slack by approaching the limit of joint play, where possible with simultaneous distraction of the joint. Mobilization can be achieved by gentle rhythmic In a normal joint this is never a hard or sudden repetitive springing, or usually just by waiting at the action. A hard end-feel when the limit of joint play barrier with minimal pressure in the direction of functional movement or joint play. Figure 6.1 • Schematic illustration of directions of joint play. When simply waiting for the release phenom- enon to occur, the practitioner must be able to sense precisely when release has fully run its course, otherwise both practitioner and patient will be ‘robbed’ of success. If the practitioner opts for rhythmic springing at the barrier, care must be taken not to lose the end position, otherwise the springing action can become too coarse and pain- ful. And pressure must never be increased dur- ing springing simply because the effect obtained is insufficient. On the contrary, springing will be 183

Manipulative Therapy suppressed if springing back is prevented by increas- the patient as a self-treatment method on a daily ing the pressure exerted. It appears that the thera- basis. peutic effect depends on (spontaneous) springing back to the barrier at the initial end position. Reciprocal inhibition Wherever possible, PIR may be supplemented Rhythmic repetitive springing is especially effec- with RI: here the patient exerts light pressure in tive in joints that, when restricted, are not directly the direction of mobilization while the practitioner fixed or moved by muscles. In particular these applies rhythmic repetitive counterpressure using include the sacroiliac, acromioclavicular, and ster- minimal force. Active rhythmic repetitive move- noclavicular joints. To some extent the same also ment in the restricted direction against resistance applies in extremity joints where shaking mobi- from the practitioner or (following gravity-induced lization has proved especially useful. In the spinal relaxation) as a single powerful movement, also in column, preference is usually given to the release the restricted direction, achieves RI of the muscles phenomenon option, although in combination with that are restricting movement. techniques involving muscular facilitation and inhi- bition (neuromuscular techniques). Rhythmic repetitive muscle contraction In isolated situations, rhythmic repetitive muscle con- Neuromuscular mobilization techniques traction can act to produce mobilization directly, for example rhythmic contraction of the scalenes with Here we may differentiate between techniques that their attachment points at the first and second ribs, act on specific individual muscles and others that or of the psoas major at the thoracolumbar junction. have an effect on the locomotor system as a whole. A feature common to all of them is that they facilitate, Respiration potentiate, and automate the release phenomenon. (See also Section 4.15.3.) As a rule, inhalation has a facilitating effect and exhalation an inhibi- Post-isometric relaxation tory effect, especially on the muscles of the trunk. Wherever possible, post-isometric relaxation (PIR) Therefore, it is usually appropriate to combine is supplemented by reciprocal inhibition (RI). inhalation with isometric resistance and exhala- According to Mitchell et al (1979), only a minimum tion with relaxation. However, there are important of resistance is used here. exceptions to this rule: forced exhalation facilitates the abdominal muscles, and maximal exhalation in After taking up the slack, the practitioner offers lordosis facilitates the erector spinae muscles and resistance for 5–10 seconds as the patient exerts thus mobilizes the thoracic spine into extension. In minimal pressure in the direction opposite to mobi- kyphosis, in contrast, the thoracic spine is mobilized lization, and then the patient is instructed to ‘let by inhalation. From gymnastics we are accustomed go’. After a short latency period, release (i.e. mobi- to associating inhalation with straightening up and lization) occurs and the practitioner then waits for exhalation with anteflexion (and with side-bend- the patient to relax. Starting from the newly gained ing). Mouth opening is associated with inhalation position, the process is repeated once or twice. and mouth closure with exhalation. Where move- ment in one direction is associated with inhalation, It is important not to interrupt the patient’s and in the opposite direction with exhalation, this relaxation prematurely. The longer relaxation lasts, phenomenon is known as respiratory synkinesis. the better the effect and the fewer repetitions One characteristic of respiratory synkinesis is that it needed. If the patient fails to relax during PIR, the is difficult to perform a particular movement during simplest solution is to extend the isometric phase, the respiratory phase that is not associated with it, even for up to 20 seconds. for example to bend forward while inhaling. An important improvement was achieved by Of particular interest is the mobilizing effect of Zbojan (1984) with his introduction of gravity-in- respiration during side-bending, as noted by Gaymans duced relaxation: in this technique, where possible, (1980). During inhalation or exhalation, different the weight of the head or (part of) an extremity is spinal segments are facilitated or relaxed in an alter- isometrically raised a little against gravity and then nating pattern. Broadly speaking, with the exception relaxed as gravity takes over. This can be repeated of the cervicothoracic junction, the even-numbered three times. Zbojan recommends holding both the isometric phase and the relaxation phase for 20 sec- onds each. This exercise can be done at home by 184

Therapeutic techniques Chapter 6 segments are inhibited (fixed) during inhalation and For mobilization into side-bending, the practitioner relaxed during exhalation, while conversely the odd- tells the patient to look up during the isometric numbered segments are inhibited (fixed) during phase and to look down during the relaxation phase exhalation and relaxed during inhalation. if it is the even-numbered segments (C0, C2, C4) that are involved. Other forms of respiratory synkinesis also serve to promote mobilization. During isometric traction, The use of gravity-induced techniques is particularly for example, we exploit the fact that neck muscles suitable for combination and for achieving automation. become tense during inhalation and relax during For this, the levers should be arranged so that the force exhalation, resulting in stretching. During isometric involved is neither too great nor too small. The greater traction of the lumbar spine in lordosis when the the number of elements, the greater the potential for patient is prone, tension is increased during exha- optimal combinations and for self-treatment, for exam- lation whereas relaxation occurs during inhalation. ple self-mobilization of the atlas against the occiput This happens because the lumbar erector spinae in (at the same time also relaxation of the SCM muscle) lordosis contracts during exhalation. while supine with the head rotated (see Figure 6.96). Eye movement (visual synkinesis) In view of the wide-ranging possibilities, a warn- Eye movement facilitates movements of the head ing is also appropriate concerning incorrect combina- and trunk in the direction of gaze and inhibits tions. Looking up does not work in combination with movements in the opposite direction. While this exhalation and neither does looking down in combi- does not hold for side-bending, looking up facili- nation with inhalation. We must also bear in mind tates straightening into a neutral position and out of that looking up facilitates straightening up (retroflex- side-bending. Looking up facilitates inhalation and ion) and looking down facilitates forward-bending looking down facilitates exhalation – a respiratory (anteflexion). For mobilization into side-bending, synkinesis that should be taken into account for for the even-numbered segments, it will be useful combination with respiratory techniques. However, to proceed in the manner described in the preceding according to Gaymans (1980), maximal excursion paragraph. For the odd-numbered segments (C1, C3, of the eyes has an inhibitory effect. etc.), exhalation during the isometric phase should not be combined with looking up and inhalation dur- Zbojan’s use of gravity ing the relaxation phase should not be combined Where possible, use can be made of Zbojan’s with looking down. Therefore the combination of (1984) gravity-induced technique (see above): dur- respiration with eye movements should be avoided in ing the isometric phase it is sufficient to raise the this case. If visual synkinesis is to be combined with head or leg a little, hold for 20 seconds and then respiratory synkinesis, then the instruction to look in relax for 20 seconds. a particular direction must precede the instruction to inhale or exhale. At the cervicothoracic junction and Combining techniques also in the thoracic spine it is essential for the neck It will be self-evident that these methods can be to be held in extension during mobilization into side- combined to excellent effect. This applies in par- bending. It is therefore correct during the isometric ticular to the combination of PIR, respiratory phase to give the instruction ‘Look up and breathe synkinesis, visual synkinesis, and gravity-induced in’ but not to say ‘Look down’ during the relaxation techniques. As a result the isometric phase (resist- phase because the patient would then bend forward. ance exerted by the patient) and the relaxation Consequently, the instruction in the relaxation phase phase can be largely automated, thus enabling the is ‘Let go and breathe out’. practitioner to dispense with repeated instructions to the patient of the type: ‘When you press, use It is very important for the patient always to only minimal force’ and ‘Relax completely’. breathe in and out as slowly as possible so that both the isometric phase and the relaxation phase are suf- If rotation to the right is restricted, for exam- ficiently long. It is therefore useful, for example, ple, the practitioner can instruct the patient to look first to say to the patient ‘Look to the right’ and left during the isometric phase and breathe in, and then after a short latency period to add ‘And breathe then to look right during the relaxation phase and in slowly’; and also to say ‘Look down’ and after a breathe out. This is especially appropriate when we certain latency period to add ‘Breathe out’. If the are dealing with patterns of respiratory synkinesis. patient finds it difficult to breathe in and out slowly, then it is very useful for the patient to breath-hold at 185

Manipulative Therapy the end of inhalation before the instruction is given (i.e. by releasing the slack that has been taken to breathe out. However, if this also fails to solve up), we give the patient time to tense up as a the problem, then the patient has a significant faulty reflex anticipatory reaction. When that happens, breathing pattern (assuming that an organic respira- manipulation fails or becomes unduly forceful. tory disorder is not to blame). Remedial exercises to correct this seriously disordered breathing pattern If the above conditions are met, HVLA thrust are then indicated. As a technical note, release may techniques are never forceful because the thrust take considerably longer than the process of exhal- corresponds to a weight of not more than 1000 g. ing slowly. Therefore the best solution is simply to However, there are also situations where high- instruct the patient to carry on inhaling and exhaling velocity maneuvers are not even necessary, thus until release is complete. Once release has started, allowing an even gentler approach, as in distraction it will automatically follow its course to the end no manipulation in the cervical and cervicothoracic matter how the patient continues breathing. region with the patient seated. If our combinations are well thought out, the Mierau et al (1988) have shown that HVLA sum total of physiological stimuli involved will con- thrust techniques are followed immediately by a siderably enhance the effectiveness of our mobiliza- state of hypermobility in which the barrier is tem- tion techniques, make them less time-consuming porarily overcome. This also explains both the very and render them largely suitable for self-treatment, intensive reflex effect and the presence of a certain which also considerably strengthens the treatment degree of risk because the barrier fulfils a protec- program. PIR can be routinely supplemented with tive function. Leaving to one side a small number RI, thus allowing a further goal to be realized: taken of incidents that have been widely discussed, it is collectively, all these neuromuscular techniques mean generally true to say that forceful and frequently that it is the patient’s own muscles that are increas- repeated HVLA thrusts carry a risk of permanent ingly used to achieve mobilization. It will come as no hypermobility. Figures 6.2 and 6.3 illustrate the surprise that maximal use of the patient’s own mus- different effects achieved with mobilization and cles is more ‘physiological’ than the best manipula- HVLA thrust techniques. tion techniques delivered by the practitioner. Testing to check the effect HVLA thrust techniques Immediately after treatment, whether this consists These techniques consist of a high-velocity but of mobilization or manipulation, its effect must be non-forceful movement of small amplitude, starting checked by testing (see Section 4.17). from the end position gained (i.e. after taking up the slack) and going in the direction in which the Record keeping slack was taken up or mobilization was performed. In the process, a barrier seems to give way, and as The purpose of keeping records is to ensure a rule we hear the joint ‘pop.’ Immediately after- detailed documentation of the examination and in ward we sense a considerable reduction in muscle particular of any therapeutic interventions so that tone and increased mobility. The following techni- data are available in case the material later needs to cal conditions must be observed: be written up for publication or for an expert legal report. This aspect should not currently pose any • While taking up the slack the practitioner must difficulties given the general use of computers for be able to sense the moment when the patient data storage. is completely relaxed. Follow-up treatment and aftercare • The end position is reached (or the barrier is engaged) using a minimum of force. If we discount acute cases where we are in fact administering first aid and where patients should • The HVLA thrust must start from the end be invited to attend for follow-up within a week, it position already gained, that is we must never is generally possible from the case history to offer back off before delivering the thrust. And this advice concerning any lifestyle aspects that may is the typical error made by almost every novice require correction. The patient is then given home because we are used to drawing back our arm exercises that can be used either as part of a self- before delivering a blow. Here, however, it treatment plan or as a basis for a clearly specified is a crucial mistake because as we back off 186

Therapeutic techniques Chapter 6 Figure 6.3 • Tension curve during joint distraction and the effect of ‘joint cracking’ (adapted from Roston & Wheeler Haines 1947). (A) Tension increase without joint cracking. (B) Sudden ‘give’ at the moment of cracking. 6.1.2 Extremity joints Figure 6.2 • Distraction of the metacarpophalangeal joint The techniques used in the manipulation of extrem- using a force of 8 kg after mobilization (A, B) and after an ity joints are aimed almost exclusively at restor- HVLA thrust (C, D). ing joint play. Because examination of joint play is technically identical with the mobilization of these course of physiotherapy. The patient should be joints, both will be described here simultaneously. invited to attend a follow-up appointment within two to three weeks. Joints of the upper extremities Failure to issue such instructions and to set goals Interphalangeal joints is professionally irresponsible and betrays a lack of understanding of rehabilitation. It is always advisa- Dorsopalmar shift, distraction, and laterolateral ble to inform the patient that treatment of any kind shift are used for mobilization (and examination). may often be followed by a painful reaction lasting for anything from one to three days, after which The practitioner fixes the patient’s proximal improvement sets in. If patients are not given such phalanx between the thumb and forefinger of one a warning, the inevitable result is that practitioners hand, supported either against his own body or the will be bombarded with telephone calls during the treatment table. first 24 hours about conditions that are ‘worse now than they were before!’ Taking the patient’s distal phalanx between the thumb and second finger of the other hand, the practitioner mobilizes the distal phalanx in one of the above directions, always applying distraction at the same time. It is advisable to keep thumb 187

Manipulative Therapy and forefinger at right angles to the direction of uses the thumb and forefinger of the other hand to movement. take hold of the first metacarpal bone as close to the carpometacarpal joint as possible. Metacarpophalangeal joints Here too mobilization can be performed in a dorso- Because these joints are almost spherical (ellipsoid), palmar and laterolateral direction, with the practi- joint play is tested in all directions, including rota- tioner’s thumbs and forefingers positioned at right tion and distraction, using a technique similar to angles to the direction of movement. For distrac- that described for the interphalangeal joints. tion, the terminal phalanx of the patient’s thumb is grasped using the little finger of the practitioner’s The practitioner fixes the patient’s metacarpal mobilizing hand and a pull is exerted via the termi- head between the thumb and forefinger of one hand, nal phalanx. supported against his own body or the treatment table, and takes hold of the first phalanx between The following technique is suitable for post- the thumb and forefinger of the other hand. Here isometric traction and HVLA thrust manipulation: too mobilization is always performed while applying placing his right hand round the ulnar aspect of distraction. Only the thumb and forefinger holding the wrist of the patient’s supinated right hand, the the phalanx can be at right angles to the movement practitioner takes hold of the metacarpal between only in the dorso-palmar direction. In this case, dis- the thumb and forefinger of his other hand, so that traction in a palmar direction is effective; this can the proximal phalanx of the forefinger forms a ful- be performed as an HVLA thrust using the first crum close to the carpometacarpal joint dorsally phalanx of the forefinger as a fulcrum – and is often (below), and the thumb, located a little more dis- administered as first aid following sprains. tally, performs gentle dorsal compression to achieve distraction. The practitioner can amplify this effect The practitioner can also take hold of the first further by hooking his little finger round the distal phalanx from above so that the hand and forearm phalanx of the patient’s thumb (see Figure 6.4A). hang down, and then perform distraction by shak- Once the barrier is engaged, an HVLA thrust is ing. These last two techniques can also be used in a now delivered. The patient can also be instructed to self-treatment setting (see Figure 6.4). offer slight resistance to distraction, to relax after 5–10 seconds and then to repeat this. The carpometacarpal joint of the thumb Afterward the practitioner takes hold of the The trapezium is first located by palpating the sty- patient’s pronated hand from the ulnar aspect using loid process of the radius. Distal to this there is a the opposite hand. Using the other hand he then groove which corresponds to the scaphoid, which grasps the patient’s first metacarpal so that the then articulates with the trapezium as the wrist radial edge of the proximal phalanx of his forefin- broadens again. Fixing the trapezium between the ger forms a fulcrum close to the carpometacarpal thumb and forefinger of one hand, the practitioner joint on the palmar side (below) and the thumb Figure 6.4 • Treatment of the carpometacarpal joint of the thumb (A) into supination with distraction and gentle dorsal compression and (B) into pronation with distraction and gentle palmar compression. 188

Therapeutic techniques Chapter 6 performs gentle palmar compression to achieve dis- for the patient to support her forearm on her thigh; traction. Once again, this can be amplified by hook- she then uses her other hand to take hold of the ing the little finger round the distal phalanx of the hand to be mobilized, and treats it in pronation for patient’s thumb and engaging the barrier (see Figure the radiocarpal joint and in supination for the inter- 6.4B). An HVLA thrust is now delivered to achieve carpal joint, first in a dorsopalmar and then in a distraction or again the patient can be instructed palmo­ dorsal direction. to offer slight resistance to distraction, to hold for 5–10 seconds and then relax. This technique is then If dorsiflexion is restricted, the practitioner must repeated. examine and mobilize the distal row of carpal bones relative to the proximal row, in a palmar direc- Both techniques are eminently suitable for use tion. With one hand the practitioner takes hold of in self-treatment. An even simpler technique is to the patient’s pronated forearm just above the wrist take hold of the proximal phalanx of the patient’s and supports this on his knee or on the treatment thumb from above, to allow the forearm to hang table. With the other hand the practitioner takes down, and to perform distraction by shaking. hold of the patient’s hand at the level of the car- pometacarpal joints, takes up the slack in a palmar The joints of the wrist direction by exerting light pressure, and performs mobilization using rhythmic springing pressure (see It is important first to find the exact location of the Figure 6.6). Self-treatment follows the same prin- radiocarpal joint and the carpometacarpal joints: ciple. It is sufficient for the patient to support her when the wrist is dorsiflexed, the skin crease on forearm on her thigh; she then uses her other hand the dorsal aspect is precisely at the location of the to take hold of the hand to be mobilized, and treats radiocarpal joint, and on palmarflexion the skin it in supination for the radiocarpal and in pronation crease on the palmar aspect marks the location of for the intercarpal joint, first in a palmodorsal and the carpo­metacarpal joints. then in a dorsopalmar direction. If palmar flexion is restricted, the practitioner If radial abduction is restricted, the princi- must examine and mobilize the proximal row of car- ple chiefly involves dorsiflexion of the trapezium pal bones relative to the radius in a dorsal direction. relative to the scaphoid (see Section 4.10.3). The With one hand the practitioner takes hold of the technique is essentially the same as for restricted patient’s supinated forearm just above the wrist, and dorsiflexion, but with the difference that the mobi- supports this on his knee or on the treatment table. lizing pressure is directed toward the radius. With the other hand the practitioner takes hold of the patient’s wrist slightly distal to the radio­carpal In contrast, if ulnar abduction is restricted, then joint, takes up the slack dorsally by exerting light joint play is primarily restricted in the radioc­ arpal pressure, and performs mobilization using rhyth- joint (see Section 4.10.3). Consequently, the tech- mic springing pressure (see Figure 6.5). Self-treat- nique is essentially the same as for restricted palmar ment follows the same principle. It is sufficient flexion, but with the difference that the mobiliz- ing pressure is directed toward the ulna relative to the pisiform bone or the wrist is sprung in a radial direction relative to the forearm. Figure 6.5 • Dorsal shifting of the proximal row of carpal Figure 6.6 • Palmar shifting of the distal row of carpal bones relative to the radius. bones relative to the proximal row. 189

Manipulative Therapy Figure 6.7 • Shifting individual carpal bones against their neighbor: (A) examination; (B) mobilization by pincer grip. Where a very specific procedure is required, it to locate the trapezium when treating the carpo­ is possible to examine and treat joint play between metacarpal joint of the thumb. And it is a simple two neighboring carpal bones and also the relevant matter to find the pisiform (on the triquetral bone). metacarpal bone. The practitioner fixes one car- The capitate forms the most prominent point of the pal bone between the thumb and forefinger of one wrist on palmarflexion. hand, while moving the other carpal bone with the thumb and forefinger of the other hand. In technical The techniques described here can be used not terms it is crucial to examine using the minimum only for the carpal bones themselves but also for of force, because even in movement restriction the the carpometacarpal and intermetacarpal joints. resistance is so negligible that it will not be recog- Technically it is most important to examine using a nized at all if the examination is forceful. For mobi- minimum of force; moreover, the practitioner’s fin- lization proper it is advantageous to place both gers should not be too close together because they forefingers on the palmar aspect and both thumb might then be pressing on the same bone. Con- tips on the dorsal aspect (or vice versa) of adjacent versely, if they are too far apart, too much mobility carpal bones before exerting pressure (pincer grip, will be felt because two joints are being examined. see Figure 6.7). In conjunction with distraction, this technique is important in carpal tunnel syn- In addition to the translational (gliding) tech- drome. The pincer grip can also be performed with niques described, it is also possible to perform a dis- the thumb and forefinger of one hand, making this traction technique that is implemented mainly as movement a candidate for self-treatment. an HVLA thrust. This is very effective and entirely innocuous. The practitioner sits in front of (and a lit- The pisiform bone may also be painful and tle lower than) the patient, who is also seated. He restricted in its movement. Taking it between the takes hold of the patient’s pronated, downward- thumb and forefinger, this bone can be examined hanging hand in the region of the wrist, at the dis- and mobilized very easily in a laterolateral or tal articulating partner of the joint where restriction proximo­distal direction. has been found. Both thumbs are placed one on top of the other on the back of the patient’s hand, It is of course important to be able to locate the with both hands encircling the palmar aspect of the individual carpal bones. We have already seen how patient’s wrist (see Figure 6.8). The slack is taken Figure 6.8 • Traction manipulation of the capitate relative to the lunate: (A) making contact; (B) taking up the slack and delivering the HVLA thrust. 190

Therapeutic techniques Chapter 6 up by very gentle traction with slight dorsiflexion Figure 6.9 • Distraction of the elbow joint. of the patient’s hand; once the barrier is engaged, an HVLA thrust is delivered along the axis of the the other hand he fixes the patient’s upper arm by patient’s downward-hanging arm but taking care to exerting downward pressure toward the padded sur- allow no further dorsiflexion. There are two errors to face of the treatment table. Using the thumb as a be avoided at all costs: first, excessive traction while fulcrum, pressure is exerted distally (see Figure 6.9). engaging the barrier and then releasing it before The practitioner performs traction using the hand on the HVLA thrust; and second, further compressive the patient’s forearm while simultaneously enhanc- dorsi­flexion at the wrist during the HVLA thrust. ing leverage at the elbow by exerting pressure with his shoulder against the patient’s forearm. Distraction can be performed as mobilization or self-mobilization. Using one hand, which is For radial and ulnar springing (lateral gap- supported on his knee or on the treatment table, ping), the practitioner takes hold of the distal end the practitioner takes hold of the patient’s pro- of the seated or supine patient’s upper arm with nated forearm above the wrist. With the other one hand and grasps the patient’s wrist with the hand he grasps a carpal bone between thumb and other hand. With the patient’s forearm supinated, bent forefinger and, after taking up the slack, per- a springing push is exerted at the level of the elbow, forms springing distraction. The same effect can either from ulna to radius or from radius to ulna, be achieved with the patient’s arm hanging down: depending on the direction in which movement is the practitioner takes hold of the carpal bone in the restricted. The patient’s forearm is fixed against same way and performs a shaking maneuver. the practitioner’s iliac crest (see Figure 6.10). The patient’s elbow must not be fully extended, The distal radioulnar joint will be the last wrist joint to be considered. Mobility can be examined between the distal end of the radius and ulna and mobilization can be performed. The technique is broadly similar to that already described for the carpal bones: the practitioner takes hold of the dis- tal end of the radius with one hand and the distal end of the ulna with the other. He then shifts the two bones in opposite (dorsal or palmar) direc- tions to take up the slack and performs springing. For mobilization it is better to use the pincer grip, as for the carpal bones. Examination is clinically important whereas mobilization is less so because the movement restriction is located in the vicinity of the elbow. The elbow Figure 6.10 • Springing the elbow in a radial direction. The elbow actually consists of three joints: the humeroulnar, humeroradial, and proximal radio­ ulnar articulations, with joint play affecting all three. However, treatment is most often directed at epicondylopathies (epicondylar pain). The most important treatment techniques are distraction as well as radial and ulnar springing (lateral gapping), in combination with relaxation of the muscles that insert at the elbow. Distraction is performed with the patient supine and the arm to be treated flexed at the elbow, with the supinated forearm supported against the shoulder. With one hand the practitioner fixes the patient’s forearm in the crook of the elbow, and with 191

Manipulative Therapy the practitioner takes up a position to one side of the patient and shakes the patient’s forearm rap- idly in a radial or ulnar direction. Lateral springing (shaking) produces distraction of the elbow on the side to which pressure is directed. The following shaking technique with the patient seated or supine is also gentle and effective. The practitioner sits between the patient’s trunk and slightly abducted arm, takes hold of the fore- arm proximal to the elbow, and moves it into supi- nation (see Figure 6.11). In this position the arm can be gently and rhythmically shaken into exten- sion. (See also Section 6.5.7.) Figure 6.11 • Shaking mobilization of the elbow joint into The shoulder extension. Where a typical capsular pattern is encountered at otherwise the joint will lock. After taking up the the shoulder, mobilization techniques are virtually slack, which is achieved by slightly rotating the pel- useless; in this clinical condition – which is known vic crest on which the patient’s forearm is fixed, as ‘frozen shoulder’ – joint play is characteristically the practitioner gives a push to spring the joint. normal as long as abduction is still possible to some This maneuver is used primarily for diagnosis and extent. However, post-isometric traction often the findings should therefore be compared with relieves pain, evidently due to the presence of good those on the contralateral side. When repeated, the muscle relaxation. maneuver is utilized to achieve mobilization or as an HVLA thrust for manipulation. Most commonly, For distraction it is best for the patient to be standing or supine. In the standing option, the prac- titioner places his corresponding shoulder under the patient’s axilla (i.e. right to right, or left to left), pressing against the patient’s thorax. With one hand he grasps the patient’s wrist and with the other hand takes hold of the slightly abducted arm just above the elbow (see Figure 6.12A). After taking up the slack using gentle traction, the practitioner Figure 6.12 • (A) Shoulder distraction over the practitioner’s shoulder, in the direction of the long axis of the arm; the patient may sit or stand. (B) Shoulder distraction with the patient supine. 192

Therapeutic techniques Chapter 6 performs PIR: he instructs the patient to resist for Figure 6.13 • Translatory mobilization of the shoulder joint about 10 seconds using minimal force while breath- with the patient seated. ing in and then to relax while breathing out. The technique can be used for self-treatment over the also switch hands so that the hand exerting pres- cushioned back of a chair. sure from below is now on the upper arm while the other is on the shoulder blade. Joint play is most If the patient is shorter than the practitioner frequently restricted in a craniocaudal direction. then it is preferable to perform traction with the patient supine. With the patient’s arm abducted, The acromioclavicular joint the practitioner sits in the patient’s axilla, thus fix- ing the position of the thorax. With one hand he To mobilize the acromioclavicular joint, with the grasps the distal humerus and with the other the patient supine, the practitioner gently places his wrist of the patient’s pronated arm (see Figure (right) thenar eminence at the lateral end of the 6.12B). The slack is taken up by traction on the patient’s (right) clavicle not too close to the joint and upper arm; the patient is instructed to offer light performs dorsoventral springing against the acromion resistance, to breathe in slowly and breath-hold, and (see Figure 6.14A). Although fixation of the shoulder then to relax while breathing out. In this process, blade is guaranteed by the patient’s supine position, resistance (pressure) should be exerted only against it is still recommended that the practitioner fixes the the chest wall and not against the upper arm. head of the humerus with his other hand. If rotation is free and shoulder abduction only is In technical terms it is important to take up the restricted and/or a painful arc is present, then joint slack using the very minimum of force and then to play with the arm abducted will routinely be found deliver a light dorsal push and release the pressure to be disturbed. In this context, it is usual nowadays immediately to allow the clavicle to spring back. The to refer to an impingement syndrome. Joint play is practitioner should be able to both feel and even see restricted because, in order to achieve abduction, the rhythmic springing movement. This springing is the head of the humerus has to glide caudally in the glenoid cavity. This is also usually the cause of dis- turbed abduction. For mobilization the patient is seated with arm abducted. The practitioner places the patient’s elbow on his shoulder so that the upper arm is hori- zontal. With the radial aspect of one hand he exerts light pressure against the head of the humerus and with the other hand against the glenoid cavity of the shoulder blade in the opposite direction (see Figure 6.13). Once the slack is taken up, mobiliza- tion is performed using a springing pressure. In the interplay of both hands the direction of mobilization can be adjusted as desired and the practitioner can Figure 6.14 • Mobilization of the acromioclavicular joint by springing the clavicle relative to the acromion (A) ventrodorsally and (B) craniocaudally. 193

Manipulative Therapy absent where movement of the acromioclavicular The sternoclavicular joint and joint is restricted, but after a few mobilizing pushes shoulder blade using minimal force the joint will spring normally. The same effect can be achieved if the practitioner The clavicle with the shoulder blade moves about takes hold of the seated patient’s shoulder in both an axis that passes through the sternoclavicular hands from behind and uses both thumbs ventrally joint. Simple movement restriction of this joint to exert lateral pressure on the clavicle. without osteoarthritis is relatively rare. The most effective mobilization technique is distraction to Craniocaudal springing is an equally impor- spring or gap the joint. For this, the patient should tant mobilization technique (see Figure 6.14B). be supine. With hands crossed, the practitioner The practitioner stands to one side of the supine places one pisiform against the medial end of the patient, fixes the patient’s bent elbow from below clavicle from below, and the other pisiform against with one hand, and places the thenar eminence of the manubrium of the sternum from above. The the other hand over the lateral end of the clavicle. slack is taken up by slight pressure that pushes the He takes up the slack by gently pressing both hands hands apart (see Figure 6.16) and then the joint is toward each other and then mobilizes in the same sprung into distraction. As with the acromioclavic- direction using light alternating pressure from both ular joint, mobilization must be performed using a hands. Here, too, the spontaneous action of spring- minimum of force and again the spontaneous action ing back as far as the barrier is important for suc- of springing back is crucial. cessful mobilization. The worst mistake with this technique is to increase the pressure if springing Distraction with leverage can be performed as fails to occur immediately. follows: with the patient supine, the practitioner takes up a position on the side of the restricted Another useful technique is that of distraction joint and fixes the clavicle close to the sternoclavic- performed by shaking. For this, the patient should ular joint from below using the thumb of one hand. be seated or (preferably) supine. The practitioner With the other hand he takes hold of the patient’s stands to one side of the patient and uses the fin- forearm and engages the barrier with light traction gers or thumb of one hand to fix the clavicle close in a caudal direction, using the fixing thumb as a to the acromioclavicular joint; with the other hand fulcrum. Mobilization is performed by springing he grasps the patient’s abducted upper arm (in traction from the original end point of the barrier. slight ventral flexion). Light traction is exerted to However, this can be done even more effectively by take up the slack and the arm is shaken in the given rapid shaking in the same direction. direction: this has the effect of producing traction characterized by rapid rhythm and minimal force The shoulder blade lies flat on the thoracic (see Figure 6.15). wall where it is freely mobile. The synovial bur- sae permit considerable movement and this can be examined and mobilized. With the patient prone, the practitioner grasps the patient’s shoulder and shoulder blade with both hands and performs Figure 6.15 • Distraction mobilization of the Figure 6.16 • Mobilization of the sternoclavicular joint with acromioclavicular joint. crossed hands. 194