__Manipulative_Therapy__Musculoskeletal_Medicine

Therapeutic techniques Chapter 6 Figure 6.18 • Fan-wise spreading of the metatarsals. Figure 6.17 • Mobilization of the shoulder blade A technique that patients find particularly against the thoracic wall (also useful for mobilizing the agreeable consists of fan-wise spreading of the upper ribs). metatarsal heads in a dorsal (or more rarely, plantar) direction. For this, the practitioner stands circling movements of the shoulder blade against or sits at the foot of the treatment table while the the sternum (see Figure 6.17). By pressure on the patient sits on the table facing him with knees shoulder blade from above, he mobilizes the ribs slightly bent and heels resting on the table. He simultaneously. In terms of technique, it is impor- then takes the patient’s metatarsals in both hands, tant that the movement imparted by the practi- with thumb and thenar above (on the dorsal tioner should come from the trunk so that both aspect) and fingers below (on the plantar aspect). hands operate in synchrony, and that the forearm Using his thumbs, he spreads the dorsum of the of the mobilizing hand should be vertical to the foot over the fulcrum created by the fingers under- shoulder blade. neath (see Figure 6.18). With the patient side-lying, the practitioner can The tarsometatarsal and transverse use the finger pads of one hand to lift the inferior tarsal joints angle of the shoulder blade away from the thoracic wall, while using the other hand to deliver a push The distal row of articulations between the meta- on the patient’s shoulder in a caudal direction. tarsus and tarsus is known as Lisfranc’s joints (tarsometatarsal joints) and the proximal row of Joints of the lower extremities articulations between the tarsal bones is known as Chopart’s joint (transverse tarsal joint). The func- Metatarsophalangeal joints tional movements possible here are pronation and supination, while joint play primarily takes the The techniques for examining and treating the inter- form of dorsoplantar mobility. Mobilization and phalangeal joints are identical to those described for examination are best effected using a dorsal push the fingers (see p. 187). (Sachse’s method). The practitioner stands at the foot of the treatment table to one side so that he is The most important maneuver for the metatar- facing the medial aspect of the foot to be treated. sophalangeal joints is distraction. The practitioner With the more cranial hand he fixes the dorsum of uses one hand to fix the metatarsal bone at the the patient’s foot (above Chopart’s and Lisfranc’s joint. With some plantar flexion he uses the thumb joints). With his other hand supinated and in ulnar and flexed forefinger of the other hand to perform abduction, he takes up the slack using light pressure distraction, employing the first phalanx of his flexed forefinger as a fulcrum. 195

Manipulative Therapy Figure 6.20 • Mobilization (manipulation) of the tarsal and tarsometatarsal joints by rhythmic shaking; an HVLA thrust may also be used. Figure 6.19 • Mobilization of Lisfranc’s and Chopart’s For a similarly universal distraction technique, joints by moving the distal articulating bones dorsally. the patient should be prone, with the leg to be treated slightly bent at the knee. The practitioner away from the plantar aspect (see Figure 6.19). stands at the foot end of the treatment table and Mobilization is then performed by springing with places the fingers of both hands round the patient’s the radial edge of the forefinger placed parallel to instep and both thumb pads on the plantar aspect the joint to be mobilized. The thumb of this hand of the distal articulating bone in the restricted joint remains on the dorsum of the patient’s foot. (see Figure 6.20). With both thumbs he exerts pressure in a plantar and distal direction until the The most precise technique, however, is to slack has been taken up. He then performs dorso- examine and mobilize the joints between individual plantar shaking, consistent with the rhythm of the metatarsal bones as well as the individual tarsometa- structure (this will be slower in longer feet than in tarsal joints. The technique is the same as that for shorter feet). Consequently, it is also slower in the mobilizing the carpal bones. The patient is supine vicinity of Lisfranc’s joints than in Chopart’s joint. with the leg slightly bent at the knee and the heel Technically, it is important that the treating hand is supported on the treatment table. With the thumb relaxed so that the practitioner can sense the inher- and forefinger of one hand the practitioner fixes the ent rhythm of the foot and so as to prevent flexion proximal tarsal bone: he then examines the play at and extension at the talocrural joint during shaking. the joint with the distal articulating bone by per- forming a dorsoplantar shift between the thumb The subtalar and talocalcaneonavicular and forefinger of his other hand. The pincer grip joints is more appropriate for the purposes of mobiliza- tion. The practitioner places both thumbs on the Here we are concerned with the articulation of the plantar aspect and both forefingers on the dorsal talus with the calcaneus and the navicular, and with aspect of two adjacent bones (tarsals or tarsal/met- the articulation of these bones with the cuboid. atarsus). He takes up the slack by slight pressure In essence, joint play here can be examined (and first in a dorsal and then in a plantar direction, and treated) by assessing the mobility of the calcaneus then mobilizes the joint by rhythmic springing (see in all directions relative to the other articulating Figure 6.7). For mobilization in the opposite direc- partners. It is useful to ease the strain on the joint tion, he reverses the position of thumbs and forefin- by traction. gers. While this is a universal technique, the most frequent sites of restriction are the second, third, The patient is supine with the foot to be and fourth tarsometatarsal joints. treated protruding over the free edge of the treat- ment table. The practitioner cups one hand round as far as the medial aspect of the patient’s heel while spanning the patient’s instep with his other 196

Therapeutic techniques Chapter 6 Figure 6.21 • Mobilization of the calcaneus against the talus and navicular by applying traction (A) medially and (B) laterally. hand. Applying light traction, he moves the joint in all possible directions: supination, pronation, plantar flexion, and dorsiflexion of the foot (see Figure 6.21). A very effective distraction technique has been developed for the posterior part of the subt­alar joint. The patient is supine with the foot to be treated protruding over the free edge of the table. The practitioner stands at the foot of the table and takes hold of the patient’s lower leg above the ankle for fixation. With his other hand he cups the patient’s heel medially and takes up the slack by exerting light traction in a distal and upward direc- tion (see Figure 6.22). It is now possible to spring the joint distally, deliver an HVLA thrust, or shake the joint rapidly to achieve distraction. The talocrural joint Figure 6.22 • Gapping the subtalar joint by pulling on the heel. The relative anteroposterior mobility of this joint is Figure 6.23 • Examination and mobilization of the talocrural examined and treated with the patient’s heel on the joint by springing the lower leg against the stabilized foot. table and the knee slightly bent. With one hand the practitioner fixes the patient’s foot by grasping its plantar aspect and holding it at right angles to the lower leg. With his other hand he takes hold of the lower leg above the ankle from the front and, after taking up the slack, springs the joint distally (see Figure 6.23). This is followed by rhythmic spring- ing to mobilize the joint. It can be helpful to perform this mobilization technique using a pincer grip, that is by clasping the patient’s heel in both hands and locating both thumbs on the patient’s tibia above the ankle. The joint is then mobilized by simultaneous rhyth- mic flexion of the fingers and thumbs, using the 197

Manipulative Therapy Figure 6.24 • Traction manipulation of the ankle joint. forearms to fix the patient’s foot at right angles to Figure 6.25 • Mobilization of the fibular head against the the lower leg. Flexion at the knee facilitates mobi- tibia. lization. fibula against the tibia (see Figure 6.25). With his Traction manipulation is also very effective. The other mobilizing hand he takes hold of the fibular patient is supine with the leg to be treated protrud- head between thumb and forefinger, and takes up ing over the free edge of the treatment table. The the slack, first medially and dorsally, and waits for practitioner folds both hands over the patient’s release. Once release in that direction is complete, instep with both thumbs flat under the sole to sta- that is once the normal barrier has been reached, he bilize the foot approximately at right angles to the takes up the slack laterally and ventrally and again lower leg (see Figure 6.24). Minimal traction is waits to obtain release. This technique is far more used to take up the slack and then, from the end effective and precise than springing the joint or an position, manipulation is performed with HVLA HVLA thrust, evidently because it is the soft tissue traction. The most common mistake here is to hold between the fibula and tibia rather than the joint the foot in exaggerated dorsiflexion because that that plays the crucial role. Technically, it is particu- could lock the joint. larly important that it is in fact the fibular head that is mobilized between the practitioner’s thumb and An alternative technique is to grasp the forefoot forefinger (which may be flexed) and not merely with one hand and the heel with the other, and the soft tissue. to perform traction after the slack has been taken up. However, in this case the subtalar joint is also treated. The tibiofibular joint The knee joint Because the fibular head is the attachment point Using both hands, the practitioner starts examina- for the biceps femoris muscle, restriction of its tion and treatment by moving the patella on the movement is clinically important. It is first neces- joint surface with the femur in a laterolateral and sary to assess its mobility against the tibia and to craniocaudal direction; this permits detection of determine the degree of pain present. Here we any resistance, unevenness, and roughness as he are concerned not with anteroposterior mobility glides the patella over the underlying structures. It but with rotation around the tibia. For this, the is therefore recommended that patellar movement patient is supine with knee flexed and foot rest- be tested with one hand while light pressure of var- ing on the treatment table. The practitioner sits so ying intensity is simultaneously exerted on it from as to fix the patient’s toes with his buttocks, and above with the other. In this way, points of resist- fixes the upper end of the tibia as he mobilizes the ance and roughness can be sensed, although the 198

Therapeutic techniques Chapter 6 Figure 6.27 • Lateral springing (gapping) of the knee joint. Figure 6.26 • Distraction of the knee with the patient Mobilization can also be achieved by rhythmic prone. springing, although currently we prefer using a rapid rhythmic shaking technique during which patient may also feel some discomfort. The same the joint springs spontaneously. Shaking is also the technique is used to smooth out points of resist- ideal method for self-treatment (see Section 6.5.7). ance and unevenness. Once this has been done, the Technically, it is important to extend the knee but patient’s pain will be relieved and the practitioner to avoid overextending (locking) it. will sense improved mobility. This technique can also be taught to patients for self-treatment. The hip joint The knee joint itself can be treated using distrac- Because the hip joint is an almost perfect ball- tion techniques. The simplest of these is performed and-socket joint that allows hardly any shifting with the patient prone on a mat on the floor. The movement, only traction techniques are worth con- practitioner stands between the patient’s legs at sidering. Traction may be carried out either along knee level and fixes the patient’s thigh just above the longitudinal axis of the leg, or in the direction the knee to be treated using his foot, takes hold of of the femoral neck. The former method is per- the patient’s lower leg with both hands just above formed with the patient supine and the hip in the the ankle, and bends the patient’s knee at right neutral position (10° flexion, 10° abduction, and angles. Mobilizing traction is then exerted along 10° external rotation). In this position the prac- the now vertical axis of the patient’s lower leg (see titioner takes up the slack by gentle traction with Figure 6.26). With the treatment table adjusted both hands above the patient’s ankle. Most com- to a low setting, the practitioner can also fix the monly this is then followed by: patient’s popliteal fossa from above with his knee. • post-isometric traction. After the slack has Laterolateral springing is then tested by gap- been taken up, the patient uses minimal force ping the joint first medially and then laterally. For to resist traction and breathes in slowly, breath- medial springing, the practitioner stands alongside holds, and relaxes while breathing out; the the supine patient and, with one hand, takes hold of practitioner waits until release is complete. This the patient’s lower leg medially just above the ankle process can be repeated once or twice. From (lifting it slightly off the treatment table). With the end position gained, shaking can also be the heel of his other hand he exerts laterom­ edial performed to achieve distraction pressure on the knee to take up the slack and test • traction with HVLA thrust. In this case it is whether the joint springs medially (see Figure 6.27). preferable to fix the patient’s position using For lateral springing, the practitioner sits side- a strap or stabilizing post placed in the groin ways on the treatment table between the patient’s area. The practitioner can place a second strap legs, takes hold of the patient’s lower leg with one around the patient’s lower leg just above the hand, and tests for lateral springing with the other. 199

Manipulative Therapy Figure 6.29 • Traction of the hip joint along the axis of the femoral neck, over the edge of the table. Figure 6.28 • Traction of the hip joint along the long axis of down near the foot end of the table, looking toward the leg: (A) stabilizing the patient with one strap; (B) applying the patient’s head. The patient places the leg (bent the second strap. at the knee) over the practitioner’s shoulder while the practitioner grasps the patient’s thigh with both ankle and around his own waist. He then takes hands clasped (or with the forearm) in the groin hold of the patient’s leg above the ankle with area and applies caudal and lateral traction, with the both hands and applies a minimum of traction patient’s pelvis stabilized against the padded surface to take up the slack with the patient’s hip in at the edge of the table (see Figure 6.29). For post- the neutral position (see Figure 6.28). From isometric traction, the patient offers resistance to the end position (with the patient relaxed) traction while breathing in by drawing the pelvis up he then delivers HVLA traction in the same in a cranial direction, a technique that generally has direction, generally producing a tiny thud. to be carefully taught. In most cases patients have a The most serious mistake is to apply excessive tendency to flex the hip, which detracts from effec- traction when taking up the slack and then to tiveness. After 5–10 seconds the patient relaxes and release this by backing off to deliver the HVLA breathes out. This process can be repeated two or maneuver. The technique is effective and devoid three times. It is highly effective using the same hold of risk but is normally not suitable for use in to perform shaking in the same direction of trac- patients with osteoarthritis of the hip. tion. Self-treatment is not really feasible, but once For traction in the direction of the femoral neck, the the patient has learnt how to resist while breathing patient is supine with flexed knee close to the side in, and then to relax and wait for release, then any edge of the treatment table. The practitioner sits low family member or friend can assist on a daily basis by simply placing their hands in the patient’s groin region or round the ankle as the patient offers resist- ance, breathes in and out, and relaxes. If it is possible to use shaking techniques for mobilization, these are not only gentle and agreeable, but also particularly effective. 200

Therapeutic techniques Chapter 6 The temporomandibular joint mobilization is performed during the relaxation phase. Relaxation techniques for the masticatory For this joint, a simple distraction technique can muscles can also be used for the purpose of mobili- be used. The practitioner stands in front of the zation; these are described in detail in Section 6.6.2. patient, whose mouth is open for this technique. He takes hold of the patient’s lower jaw with the 6.1.3 The spinal column fingers of both hands and positions his thumbs (wearing single-finger gloves) as fulcrums on the General principles patient’s molars on both sides, stabilizing his fingers on the patient’s chin. Downward traction is applied The general principles set out in Section 6.1.1 also with both hands. In this process, whether supine or hold true for the spinal column. However, it is not seated, the patient’s head is stabilized. PIR is then possible in this context to make such a sharp distinc- used as the patient offers resistance while breathing tion between ‘functional movements’ and ‘joint play.’ out and relaxes while breathing in. Here we are tak- Traction along the longitudinal axis of the spinal col- ing advantage of respiratory synkinesis, according to umn and distraction of joints (gapping) clearly utilize which the masticatory muscles become tense dur- joint play for their effect. This applies for rotation ing exhalation and relax during inhalation. holds in the lumbar spine, and for a dorsoventral thrust in the thoracic spine or into the costal angle. Mobilization can also be performed using lat- erolateral movements of the jaw. The practitioner There are several ways of achieving a spe- stands behind the seated patient whose head is cific effect. These include fixation of at least one turned so that the painful side is stabilized against articulating bone wherever practicable (e.g. in an the practitioner’s chest and fixed with one hand. extremity joint). Another way is to apply lock- Instructing the patient to open the mouth a little ing techniques, especially if long levers are used, (let the chin drop), the practitioner gently ‘cradles’ for example when employing the head in order to the patient’s lower jaw between two fingers (see manipulate the cervical spine, or the legs and pel- Figure 6.30). Mobilization is achieved by moving vis in order to mobilize the lumbar spine. Locking is the patient’s lower jaw toward the side of the lesion achieved when all segments not intended for mobi- until the slack is taken up. The patient then offers lization are brought into an extreme position and gentle resistance, after which gently springing lateral hence ‘locked,’ except for the segment that is the object of mobilization (manipulation). The actual Figure 6.30 • Mobilization of the temporomandibular joint. mechanism involved is either apposition of the joint surfaces or maximal tension of ligaments. Even here it should be noted that the slack first has to be taken up with minimal force and that mobilization – and especially HVLA thrust techniques – must be applied with only very little force, otherwise lock- ing will be ineffective. The advantage of long levers is that even tiny forces can be effective; however, these then only have a specific effect if treatment is not unduly forceful. Locking is achieved mainly by a combination of side-bending and rotation, making use of coupled movements. Lordosis in the lumbar spine means that there is side-bending coupled with rotation to the opposite side; hence locking is achieved by rotation and side-bending in the same direction. In kyphosis, the opposite is the case. In the thoracic spine, there is also rotation and side-bending in the opposite direction and therefore locking involves side-bending and rotation in the same direction. According to Greenman (1984), however, this is 201

Manipulative Therapy not the case on maximal extension. In the cervical particularly effective in radicular syndromes and spine, there is always side-bending and rotation to constitutes first aid in emergency cases. the same side, and here we achieve locking by side- bending and rotation to the opposite side. The patient is prone and provides fixation by holding on to the end of the treatment table. The Obviously, specific treatment can be given using practitioner grasps both the patient’s legs just above contact holds. For example, a vertebra may be the ankle, and braces himself by placing a foot or fixed in one direction by exerting lateral pressure knee against the treatment table. The manual tech- on its spinous process, thus preventing rotation to nique is performed by applying rhythmic spring- the opposite side. When we exert springing pres- ing traction to both legs and causing the patient’s sure or deliver an HVLA thrust, we are acting in a body to vibrate along its long axis (shaking). For specific, local manner. There is even a belief among this, the patient must be relaxed, something that chiropractors that they can achieve the same effect can be recognized from the movement of the but- as a rapid hammer blow delivered to a single brick, tocks and free mobility at the knees and hips. Next causing it to fly from its place in the wall without it is important to establish the correct rhythm for the other bricks changing position at all. Accord- intermittent traction, in order to localize the effect ingly, the maximum specific effect is achieved with in the lumbar region. If the rhythm is too slow, techniques that combine direct contact, leverage, the patient’s whole body will move slightly back and locking. Here it is vital for locking and contact and forth on the table. By quickening the rhythm to be targeted at precisely the same point. It should the practitioner will find the point at which the also be stressed that good fixation with the contact patient’s legs and pelvis move at the set rhythm hand is always more reliable than the best locking while the lumbar spine remains still, like a nodal maneuver. point in a standing wave, so that the vibration can be clearly palpated there. It will also be noted that From this it follows that the stabilizing hand this rhythm, which corresponds to the patient’s that provides fixation exerts its force in a direction inherent rhythm, requires the very minimum of opposed to the direction of the mobilizing hand. effort. However, there are also techniques in which the two hands exert their effect in the same direction. Here The force of rhythmic traction can be amplified the vertebra that is one down from the treated ver- as desired and an HVLA thrust can be delivered in tebra is fixed by positioning, for example the patient time with the rhythm that has been set. It follows sits astride the treatment table and thus fixes the clearly that this technique can only be performed pelvis and lumbar spine. This type of technique nec- manually, a fact that is emphasized because every essarily relies primarily on locking. These techniques patient will have a different rhythm, depending on are used most frequently in traction holds because how tall they are. Rhythmic traction can be applied they are without risk and less is at stake if they are not only to both legs but also to one leg (using both not applied with pinpoint specificity. hands), depending on what suits the patient better. Technically, it is important to avoid squeezing the In order to avoid confusion it is important to patient’s ankles. Rhythmic traction must originate distinguish between traction along the long axis of from the practitioner’s entire body and for this rea- the spinal column and distraction of intervertebral son he should perform it leaning backward. Ampli- joints (gapping). This distinction is clearest in the fying the force used and delivering an HVLA thrust lumbar region, where traction along the long axis are possible options but are not absolutely neces- acts primarily on the intervertebral disks, whereas sary; the patient should always be consulted during distraction of the joints is produced by rotation. In traction to establish what is most appropriate. If the the cervical spine, on the other hand, traction along patient expresses misgivings, an attempt should be the long axis affects both the intervertebral disks made to modify the technique and if this does not and the joints. bring success, traction should be discontinued. Of course, it is an essential prerequisite for this tech- The lumbar spine nique that the patient is comfortable lying prone. Traction techniques However, if the patient has adopted a kyphotic antalgic posture, as is often the case in the acute Of all the non-specific techniques, traction is stage, intermittent traction must be carried out the most important. Manual traction has proved in kyphosis. According to Obererlacher (personal 202

Therapeutic techniques Chapter 6 Figure 6.32 • Post-isometric traction of the lumbar spine during exhalation and inhalation. Figure 6.31 • Traction of the lumbar spine in kyphosis. In view of the adaptability and simultaneous efficacy of manual traction, apparatus-based trac- communication), the patient should be supine tion using special tables appears far less suitable. with knees bent and feet flat on a treatment table The one possible exception to this rule is the Perl adjusted to a low setting or on a floor mattress. apparatus. It is absolutely essential that the patient The practitioner places one foot on the treatment is able to tolerate traction well, and this fact must surface and arranges the patient’s legs so that both be established in advance on every occasion. popliteal fossae are over his thigh. He can then lever the patient’s lower legs over his thigh, thus lifting Mobilization and manipulation the patient’s pelvis from the padded surface with a The diagnostic springing test with the patient side- rocking motion. Once the patient is freely rocking lying (see Figure 4.16) can be used to great advan- and relaxed (and reports pain relief in the process), tage for PIR. The side-lying patient, with both hips the practitioner can rhythmically lever the patient and knees flexed at right angles, pushes the knees up and down (see Figure 6.31). The mechanism of forward with minimal pressure against the practi- this traction is similar to that of Perl’s apparatus. tioner’s thighs. The practitioner fixes the spinous Technically, it is important that the practitioner’s process of the upper vertebra in the treated seg- thigh is located under the patient’s popliteal fossae ment using the fingers of one hand, reinforced by and not under the lower legs, otherwise the lever the fingers of the other hand placed over it, and action would be painful. with arms straight. In the process, the patient is instructed to produce a small amount of kypho- Another highly effective and gentle technique is sis, and to breathe in and then breath-hold, before post-isometric traction with respiratory syn­kinesis. ‘letting go’ and breathing out. While the patient The patient is prone with arms alongside the body relaxes, the practitioner will sense the ventral and the practitioner exerts light craniocaudal pres- movement (mobilization) of the fixed vertebra into sure on both the patient’s buttocks (see Figure lordosis. As the procedure is repeated, springing is 6.32). As the patient breathes out deeply, increasing performed during relaxation to confirm that mobi- resistance will be sensed due to tension of the erec- lization has occurred. This technique is particularly tor spinae with lordosis of the lumbar spine; inhala- gentle and this is why most practitioners begin tion is accompanied by relaxation and kyphosis of with it. the lumbar spine and the buttocks move caudally. The process is repeated from the (new) starting The most popular technique is probably that of position gained. rotation mobilization or manipulation with the patient side-lying in a neutral position, with the leg underneath (i.e. the one resting on the table) very 203

Manipulative Therapy slightly flexed at the knee and hip. The upper leg (i.e. to rotate to the side). The patient is next should be flexed at the hip and knee in such a way instructed to breathe in deeply: this automatically that the foot can be stabilized in the popliteal fossa exerts light pressure against the practitioner’s arm. of the leg underneath. The practitioner stands in The patient is told to breath-hold and then, as far front of the patient and places one elbow against the as possible, to look in the direction of mobilization patient’s shoulder and one knee against the patient’s and breathe out. From the newly gained position, knee. It can be helpful if the patient hooks the cor- the process is repeated two or three times, wait- responding arm through the practitioner’s arm at the ing for complete relaxation on each occasion. An elbow. With his other forearm the practitioner sta- HVLA thrust can be delivered from the rotation bilizes the patient’s pelvis at the greater trochanter position gained on each occasion. while using his fingers to fix the spinous process of the lower vertebra of the segment being treated (see It can be helpful to supplement the above tech- Figure 6.33). With the thumb of the hand coming nique by adding a rhythmic repetitive technique. from the shoulder, the practitioner establishes con- The patient can be instructed to perform active tact with the spinous process of the upper vertebra rhythmic repetitive trunk rotation. As soon as the in the segment to be treated. Obviously if this is the patient has properly understood the movement lumbosacral segment, it is sufficient for the hand emanating from the head and is performing it cor- passing over the patient’s hip to fix the pelvis alone. rectly, the practitioner can let go of the shoulder. He continues to fix the patient’s flexed leg with In order to take up the slack, it is best to tell his thigh and knee, and the pelvis with his fore- the patient to look in the direction of mobilization arm. He now fixes the spinous process of the lower Figure 6.33 • (A) Rotation mobilization or (HVLA thrust) manipulation of the lumbar spine and (B) close-up of the segment to be treated. 204

Therapeutic techniques Chapter 6 Figure 6.34 • Active rhythmic repetitive rotation mobilization of the lumbar spine (Gaymans’ technique). vertebra in the treated motion segment using the above the spinous process of the upper vertebra fingers of both hands placed one over the other in the segment to be treated. At the same time (see Figure 6.34). In terms of technique, it is best he tells the patient to look up at the ceiling, thus if the patient uses a minimum of force and tiny fixing the head and trunk. It is also helpful if the excursions to rotate back and forth in the extreme practitioner stabilizes the patient’s trunk in the position. Rotation produces gapping of the upper kyphotic position using his thorax, and for this the intervertebral joint, and active rotation triggers treatment table will have to be adjusted to a high reciprocal inhibition of the tensed muscles. setting (see Figure 6.35). One particularly important and gentle technique Using the fingers of his mobilizing hand, the is mobilization into flexion, first where flexion is practitioner takes up the slack by applying traction restricted but also on the side affected by radi­cular in the region of the transverse process of the lower compression and/or an intervertebral disk lesion, vertebra, and especially by exerting pressure with because this technique is associated with widen- his forearm on the patient’s pelvis in the direction ing of the intervertebral canal and spinal canal, and of traction, rotation, and kyphosis. The patient is only very minimal rotation takes place but intensive then instructed to offer slight resistance with the traction occurs. pelvis against the practitioner’s mobilizing hand and For this, the patient is side-lying, with the leg Figure 6.35 • Mobilization and manipulation of the lumbar underneath slightly flexed and the upper leg hang- spine in kyphosis into flexion. ing over the edge of the table; the weight of this leg causes the pelvis to tilt forward. In this oblique position, the practitioner fixes the patient’s hang- ing leg with his thighs and the patient’s pelvis with his mobilizing hand. With his other hand he carefully pulls forward the arm underneath on which the patient is lying, so as to increase lum- bar kyphosis still further while at the same time taking care not to straighten the patient’s pelvis. Using the arm that is closest to the patient’s head, the practitioner fixes the patient’s shoulder while hooking the patient’s upper arm through his own at the elbow. With the slightly flexed terminal phalanx of the thumb of that hand, he fixes from 205

Manipulative Therapy with the hanging leg against the practitioner’s legs, reversible movement restrictions using gentle to breathe in slowly and deeply, to breath-hold, springing mobilization techniques that employ a and then to relax. During relaxation the distance minimum of force. between the fingers of the practitioner’s mobilizing hand and the thumb of his other hand will increase For mobilization in the sagittal plane, we first as an expression of distraction and kyphosis. The use Stoddard’s crossed-hands position with the practitioner must wait until relaxation is complete patient prone. The practitioner places one pisiform and then, depending on the outcome, he can repeat on the posterior superior iliac spine (PSIS) from the procedure or deliver an HVLA thrust using the below, and the other hand on the caudal tip of the hand placed on the pelvis. Technically, it is impor- sacrum. With his diverging forearms held straight, tant that the fixing thumb does not exert pressure he exerts light pressure from above on both con- from above but rather that the interphalangeal joint tact points, pushing them apart simultaneously to ‘hooks onto’ the spinous process, something that is restore nutation of the sacrum in relation to the readily manageable in kyphosis. ilium (see Figure 6.36A). He engages the barrier by first taking the mobility of the skin and sub­ The same technique can also be used to stretch cutaneous soft tissue to its limit until bony contact the frequently shortened thoracolumbar erec- is achieved (and this should be sufficient). tor spinae, with the practitioner’s thumb fixing a spinous process at the thoracolumbar junction. Iso- After a few very gentle springing movements metric resistance offered by the patient is followed at the restricted joint the practitioner will sense not only by relaxation but also by active stretching. how the two bony structures start to move apart. Here it is advantageous not only for the practitioner The commonest mistakes are increasing the pres- to stabilize the patient with his thorax but also to sure (before movement is felt) and not releasing stretch the patient over his ribcage into kyphosis. the pressure to allow springing back. Neuromus- This is indeed the most powerful (diagonal) trac- cular techniques play virtually no role in this con- tion technique. text because there are no muscles between the sacrum and ilium. Experience gleaned from chain PIR of the lumbar erector spinae can also be used reaction patterns has modified our thinking inas- as a self-mobilization technique (see Figure 6.116). much as indirect connections apparently exist due to the sacrotuberous ligament and the attachment We have limited our descriptions to techniques points of the ischiocrural muscles, pelvic floor, and that treat movement restrictions in anteflexion or piriformis, etc. As a result, the sacroiliac joint very retroflexion. Regarding the procedure to be used in often no longer requires treatment after the lower cases where side-bending is restricted, it should be extremity, pelvic floor, and piriformis have been recalled that in the lumbar spine (see Figure 4.5) treated. either extension is restricted on the side of the lesion or flexion is restricted on the opposite side. The examination technique with the patient Of course, this does not hold true for the antalgic side-lying (see Figure 4.9) is suitable for mobili- posture adopted in radicular compression. zation in the horizontal plane and it can even be used for an HVLA thrust. The side-lying patient The pelvis stabilizes the flexed upper leg on the edge of the treatment table. As the practitioner uses his fore- The sacroiliac joint arm to apply oblique forward and downward pres- sure on the anterior superior iliac spine (ASIS), he The only pelvic joint that is treated by manipula- produces gapping of the sacroiliac joint above. From tion is the sacroiliac. Mobilization techniques the end position achieved, he can now perform feature prominently in this setting and should be rhythmic springing mobilization or even deliver performed routinely in two (almost) perpendicu- an HVLA thrust in the same direction. With the lar planes. In the sagittal plane we are concerned thumb of his other (cranial) hand the practitioner with nutation of the sacrum in relation to the ilium can test the mobility of the PSIS in relation to the (functional movement), and in the horizontal plane sacrum. In terms of technique, the pelvis should with joint play (gapping the dorsal part of the sac- remain motionless and in particular should not roiliac joint). As there are no muscles between rotate forward. For this technique it is immate- the sacrum and the ilium to move or fix these rial whether the practitioner stands in front of or bones, it is always possible to release functionally behind the patient. 206

Therapeutic techniques Chapter 6 Figure 6.36 • (A) Examination and mobilization of the sacroiliac joint, with crossed hands. (B) Springing mobilization of the upper part of the sacroiliac joint. (C) Springing mobilization of the lower part of the sacroiliac joint. If it is primarily the upper part of the sacroiliac the middle phalanx of his forefinger stabilized over joint that is to be treated to restore nutation, then the thumb), he applies counterpressure below the the patient should lie on the side not being treated, PSIS and takes up the slack. Mobilization is per- stabilizing the upper knee (or indeed both knees one formed by rhythmic springing against the ASIS, and above the other) flexed on the edge of the treat- absorbing this synchronously with the thumb (bent ment table. The practitioner sits below the level of forefinger) of the other hand. the flexed hips and turns to face the patient’s head (see Figure 6.36B). With one hand he takes hold of If it is the lower end of the sacroiliac joint that the ASIS and exerts light springing pressure against is to be treated, the patient should adopt the same it in a dorsal direction. With the thumb of his other position as above; however, the practitioner sits hand stabilized against the flexed fingers (or with above the level of the patient’s pelvis facing toward the foot end of the treatment table. With one hand 207

Manipulative Therapy he grasps the ASIS and with the ulnar aspect of his illusion of true repositioning of an anomaly. On other hand he takes up lateral contact with the cau- the side where the ASIS is flattened and further dal end of the sacrum (see Figure 6.36C). Using a away from the umbilicus (outflare), the practi- rotating, convergent movement of both hands and tioner should proceed as when testing for ‘ligament forearms, the practitioner mobilizes nutation of pain’ (see Figure 4.13). He grasps the knee of the the sacrum in relation to the ilium. Another option leg flexed at right angles at the hip and performs (according to Sachse) is for the practitioner to tilt adduction until the slack is taken up. He then the ilium dorsally, as for mobilization of the upper instructs the patient (as in PIR) to offer resistance part of the sacroiliac joint, and to use the ulnar for 5–10 seconds, to breathe in slowly, to hold the aspect of his other hand to mobilize the end of the breath, to breathe out again, and to relax into adduc- sacrum ventrocaudally to achieve counternutation. tion. He waits for relaxation to be completed and then repeats a further two or three times. This is For the HVLA thrust technique described by followed by RI in which the patient exerts pressure Kubis (1970), which primarily involves the lower into adduction against rhythmic repetitive resistance part of the sacroiliac joint, the patient lies on the at the knee. side of the restricted joint, meaning that it is ‘under- neath’. Locking of the lumbar spine is performed in On the opposite side (inflare) the patient adopts rotation up to and including L5 using the rotation the position as for Patrick’s test (see Figure 4.43) hold at the lumbar spine with the leg underneath in and the practitioner exerts light pressure on the extension and the lumbar spine stretched. The prac- abducted knee in order to take up the slack. The titioner then makes dorsal contact with his pisiform patient then offers light resistance into adduction, pressing on the caudal tip of the sacrum, and takes breathes in slowly, holds the breath, breathes out, up the slack by applying pressure on the sacrum in and relaxes completely into abduction.This process a dorsoventral direction (see Figure 6.37). He then is repeated two or three times. delivers an HVLA thrust in the same direction. This maneuver primarily produces gapping of the sacro- RI is performed using active abduction against iliac joint ‘underneath’ that is fixed in place by the rhythmic repetitive resistance. After this mobiliza- weight of the pelvis. There are two important tech- tion technique, the pelvis is routinely symmetrical, nical points to be noted: first, the thrust must be and muscle tone in the lower abdomen is balanced, delivered precisely in a dorsoventral direction, and as is internal rotation at the hip joint which is reg- second, there must be no further rotation while the ularly greatly reduced on the side of inflare. The thrust is delivered. This means that the practitioner latter may explain the considerable clinical effect. needs to lean right over the patient so that his fore- arm delivering the thrust is horizontal. For this, the The coccyx treatment table must be adjusted to a low setting. In the vast majority of cases of a tender coccyx, Treatment of what Greenman and Tait call ‘out- PIR of the gluteus maximus muscles is the treat- flare’ and ‘inflare’ (see Section 7.1.8) creates the ment of choice, and this can also be administered Figure 6.37 • HVLA thrust manipulation of the sacroiliac joint (after Kubis) with contact at the tip of the sacrum. 208

Therapeutic techniques Chapter 6 as self-treatment (see Section 6.6.5), which is also both knees (slightly apart) and with crossed arms consistent with the pathogenesis (see Section against the wall, rests the head on the arms. The 7.1.9). However, there are also cases where manip- practitioner stands behind the patient, and places ulation per rectum is necessary; even when every one hand or just one finger on a spinous process effort is made to proceed carefully and gently, this in the stiffened spinal segment to indicate to the treatment is generally unpleasant for the patient. patient where attention should be focused (see However, it is a very effective technique, even Figure 6.38). Next, he instructs the patient to relax though the mechanism is still obscure. The articula- into extension. When maximum extension has been tion of the sacrum with the coccyx is a syndesmosis reached, he tells the patient to press lightly against and not a true joint; consequently, there can be no his fingers and to breathe in deeply and slowly, movement restriction here whatsoever. breath-hold, and then breathe out slowly and com- pletely. While breathing out, the patient should be For manipulation, the patient is prone with told to straighten up again and to go into extension feet rotated inward; alternatively, the treatment at the point where the practitioner’s finger can be can be given with the patient resting on knees and felt. If performed correctly with sufficiently deep elbows. The practitioner inserts one forefinger into the patient’s rectum and palpates laterally for trig- ger points (TrPs) in the levator ani. PIR can be used to relax the levator ani. Moving the coccyx permits precise location of the sacrococcygeal syndesmo- sis. The practitioner then applies (usually painful) pressure with his forefinger (and thumb on the out- side) or simply uses his forefinger to exert pressure in a dorsal direction. This is repeated two or three times. It should then be checked whether the tip of the coccyx is still tender. The thoracic spine Figure 6.38 • Mobilization of the thoracic spine into extension during exhalation, patient seated. Mobilization For the thoracic spine there are no ‘pure’ traction techniques such as are used in the lumbar and cer- vical regions. There is one maneuver that is very popular among lay practitioners and corresponds approximately to traction manipulation. For this, the patient stands or sits with arms folded across the chest. From behind, the practitioner cups the patient’s right elbow with his left hand and left elbow with his right hand and presses the slightly kyphotic patient to his chest to take up the slack. From this position he straightens up and, delivering a thrust to the patient’s elbows, draws the patient upward and at the same time closer to his chest. This unsophisticated technique is quite innocuous unless the patient suffers from osteoporosis. Because kyphosis with a stiff, rounded back is a particularly common disorder in the thoracic region, mobilization into extension is the technique most frequently called for. In order to make full use of the patient’s own musculature, we do not employ standard PIR but instead utilize the active contraction of the erector spinae muscles during exhalation to achieve mobilization into dorsiflexion. Seated on a stool facing a wall, the patient stabilizes 209

Manipulative Therapy exhalation, this technique produces powerful con- Figure 6.39 • Mobilization of the thoracic spine into traction of the erector spinae accompanied by an extension during exhalation, patient side-lying. intensive mobilizing effect that the patient expe- riences as being slightly painful. As soon as the the thoracic spine becomes kyphosed. However, this patient has understood and felt this, the technique kyphosis must be controlled so that its peak always can then be practiced (and repeated) as self-treat- remains within the treated segment. This mobiliza- ment on a daily basis. tion procedure is repeated two or three times. However, this very simple and effective tech- Anteflexion restrictions are most common where nique has one major drawback: many patients with the upper thoracic spine is flattened and they tend a kyphotic back have thoracolumbar hyperlordosis or to be associated with tension (TrPs) of the erector at least hypermobility in that area and are unable to spinae, usually on one side. Therefore mobiliza- prevent themselves going into hyperlordosis there – tion can also be achieved by relaxing this muscle. something that must be avoided at all costs. Conse- The practitioner stands behind the patient who is quently, this technique should only be used in cases seated on the treatment table; with one hand he where the practitioner is satisfied that the patient is grasps the patient’s head, placing his palm on the capable of extension, especially in the mid-thoracic occiput on the side of the lesion (i.e. his left hand is part of the spinal column. Extension is frequently also used if the lesion is on the right) (see Figure 6.40). rendered difficult because the erector spinae mus- He moves the patient’s head into anteflexion, side- cle is less well developed in the mid-thoracic region bending, and rotation to the opposite side to take and most powerfully developed in the thoraco­lumbar up the slack. Using the thumb of his other hand, he segment. Therefore a more demanding technique fixes the spinous process of the lower vertebra in is usually preferred, and this is described as a self- the segment to be treated. The patient is then told t­reatment method in Section 6.10.4. to look in the opposite direction (toward the side of the restriction) and breathe in, to breath-hold, If the intention is to treat just one restricted and then to look in the direction of mobilization segment, then the procedure is similar to that for and breathe out slowly, during which anteflexion, examination with the patient side-lying with both side-bending, and rotation will be found to increase. hands clasped behind the head. The practitioner This procedure can be repeated two or three times. stands in front of the patient and with one hand For specific treatment, it is important to start with grasps both the patient’s elbows brought together in anteflexion until the restricted segment is reached front of the neck, while using the forefinger of his (i.e. begins to flex), and only then to move on to other hand to stabilize the spinous process of the head side-bending and rotation. lower vertebra in the restricted segment. Using his forefinger as a fulcrum, he moves the patient into For mobilization into side-bending we use the retroflexion to take up the slack (see Figure 6.39). same technique as for examination (see Figure 4.23) The patient then uses the elbows to exert light (iso- metric) pressure against the practitioner’s arm and breathes in. He next instructs the patient to breathe out as fully as possible. As exhalation reaches the maximum, the erector spinae tenses and the tho- racic spine is mobilized into extension. Here, too, it is the synkinetic tensing of the erector spinae dur- ing maximal (active) exhalation that is utilized for mobilization. This is therefore not a straightforward relaxation phenomenon such as occurs in PIR. For mobilization into anteflexion, the technique used is the same as that described for examina- tion (see Figure 4.22). To take up the slack, the patient is brought into kyphosis, with the peak of the kyphosis being at the level of the restricted seg- ment. The patient is told to look up and breathe in, to breath-hold, and then to look down and breathe out. During slow exhalation, the patient relaxes and 210

Therapeutic techniques Chapter 6 Figure 6.40 • Unilateral mobilization of the thoracic spine until relaxation is complete. In the odd-numbered into anteflexion–rotation; the spinous process is fixed with segments (excluding T1/T2), the patient is sim- the thumb. ply instructed to breathe in slowly and deeply, to breathe out, and then to breathe in slowly again; the only difference being that the practitioner’s the practitioner will sense how resistance increases thumb is not used to palpate mobility at the inter- during exhalation and how relaxation occurs dur- space between two adjacent vertebrae but to fix the ing inhalation. In principle, the patient should avoid lower vertebra in the segment to be treated. Here looking down during relaxation because this would we utilize the alternating facilitating and inhibitory encourage anteflexion. Mobilization can be repeated effect of inhalation and exhalation described by two or three times. If counting the segments is too Gaymans (1980); gaze direction can also be used in onerous, it is equally reliable to ask the patient to the even-numbered segments where inhalation has breathe in and out just to see what happens. It will a facilitating effect (see Section 6.1.1). be very apparent whether resistance in the seg- ment in question increases or decreases. However, The practitioner stands behind the seated the difference becomes less clear in the caudal seg- patient and, placing his hand on the opposite shoul- ments because inhalation has a stabilizing effect der, bends the patient’s trunk sideways to take up and the quadratus lumborum becomes tense during the slack. With his other hand at the level to be inhalation. treated, he stabilizes the ribs while using his thumb to brace the spinous process of the lower vertebra Technically, it is critical to wait for the relaxing in the restricted segment. If an even-numbered effect of inhalation on the one hand and of exha- segment is being treated, he instructs the patient lation on the other; relaxation can occur at a rela- during the isometric phase to look up, breathe in, tively late stage during exhalation or inhalation. and hold the breath. It will be noted how resist- The practitioner’s stabilizing hand must also pro- ance to side-bending increases. The patient is then vide the patient with good support from the side to told to relax and breathe out; the practitioner waits allow relaxation to take place; during side-bending the spinous process automatically moves closer to the fixing thumb due to simultaneous rotation of the thoracic spine. However, if the patient has very broad shoul- ders and the practitioner has small hands, it is pos- sible to use the technique described in the context of examination (see Figure 4.24). The practitioner stands behind the seated patient on the side into which side-bending is to occur. He tells the patient to raise the upper arm on the opposite (far) side. Taking hold of the upper arm from the front, he uses the thumb of his other hand to fix the spinous process of the lower vertebra in the segment to be treated. With his hand on the patient’s upper arm, the practitioner brings the patient into side-bending and so takes up the slack. Depending on whether the segment is even- or odd-numbered, mobiliza- tion is performed in the appropriate way. It must be stressed that during this technique the practitioner needs to lean backward and bend his knees. It is also remarkable that during mobilization into side- bending the vertebrae move closer together on the side in question and thus exert a mobilizing effect on the interposed tubercle of rib. Mobilization where rotation is restricted: as already discussed in Section 3.4.1, restricted trunk rotation does not result from joint restriction but 211

Manipulative Therapy from increased tension (TrPs) in a shortened muscle Figure 6.41 • Traction thrust technique applied to the chain, namely that comprising the erector spinae, thoracic spine, using a cushion, with patient seated. quadratus lumborum, and psoas major on the side opposite to rotation. Consequently, the mobiliza- Manipulation with the patient supine is effec- tion technique is not strictly specific. In this situ- tive and gentle at the same time. For this, the ation we use the same technique as for PIR of the patient’s hands are clasped behind the neck, with erector spinae (see Figure 6.40). elbows touching in front of the chin. As the practi- tioner stands beside the treatment table, he grasps For mobilization in rotation, the patient sits both elbows (or forearms below the elbows) using (with hands clasped behind the neck) in a slightly the hand nearer to the patient’s head. He turns the kyphotic position astride the end of the treatment patient toward him a little and lifts (see Figure 6.42). table. The practitioner stands behind the patient With middle and ring fingers flexed (see Figure 6.43), and passes one arm under the patient’s axilla to he places his other hand beneath the transverse proc- grasp the opposite shoulder. He places his other esses of the lower vertebra in the restricted segment hand on the patient’s back to stabilize it. The in such a way that the middle phalanx of his third patient is then told to look at an object in the exam- finger is under the transverse process on the near ination room placed in such a way as to necessitate side and his thenar eminence is under the trans- trunk rotation in that direction, thus taking up the verse process on the far side. The spinous processes slack. Next the patient is instructed to look in the are accommodated in the groove between the prac- opposite direction and to breathe in. The practi- titioner’s middle finger and thenar eminence. He tioner offers isometric resistance in the opposite now rolls the patient over again so that the patient’s direction against automatic rotation. After breath- back is lying on his prepared contact hand. Using his holding, the patient is again told to keep looking in other hand that is grasping the patient’s elbows, he the direction of mobilization and to breathe out. now brings the patient into kyphosis so that the peak This can be repeated two or three times. RI is then is located over his contact hand, thus taking up the performed by instructing the patient (in the newly slack. There are now two alternatives for performing gained rotation position) to offer resistance in the manipulation: opposite direction against repeated pressure. 1. Into extension: the patient (supine on the Because the three muscles mentioned above form practitioner’s contact hand) is instructed to a chain, trunk rotation can also be restored by relax- ation of the psoas major or quadratus lumborum. HVLA thrust techniques First a specific technique for traction manipulation: the practitioner stands behind the seated patient with a firm cushion between his chest and the patient’s back, so that the top edge of the cushion fixes the spinous process of the lower vertebra in the motion segment to be treated. He threads one arm through the patient’s axilla and uses the palm of that hand to stabilize the patient’s head and neck on one side. With his other hand he reaches across the patient’s chest to grasp the patient’s far hand and draw it through the other axilla, at the level of the fixed spinous process (see Figure 6.41). By pulling in a dorsal direction on his arm through the patient’s axilla and on the patient’s hand in the other axilla, he takes up the slack into exten- sion. The practitioner delivers an HVLA thrust as he straightens up, thereby exerting sudden traction. This is the most gentle HVLA thrust technique for treating the thoracic spine. 212

Therapeutic techniques Chapter 6 Figure 6.42 • Manipulation of the thoracic spine. this may happen after an HVLA thrust has been delivered with the practitioner’s thorax Figure 6.43 • Position of the practitioner’s contact hand over the contact hand). during manipulation of the thoracic spine. 2. Into flexion: the patient (again supine on the breathe out slowly. At the same time, while practitioner’s contact hand) is instructed to holding the patient’s elbows, the practitioner breathe in. However, the practitioner uses the moves his upper body back over the contact patient’s grasped elbows (on which his own hand, using his thorax to gently increase the thorax is still leaning) to enhance anteflexion. pressure via his hand on the patient’s elbows While the patient exhales, the practitioner and thorax. This is usually sufficient on its uses his thorax to deliver an HVLA thrust own to make the joint ‘pop’ (alternatively, into flexion toward the stabilizing contact hand underneath. It may be difficult for the patient with hands clasped behind the neck to bring the elbows into the desired position. In such circumstances the patient’s hands should be ‘semi-clasped’ (i.e. with fingertips only just touching), so enabling the elbows to meet in front of the chin. Another pos- sible difficulty is that the pressure on the middle finger of the contact hand may become painful for the practitioner, especially if he cannot flex the ter- minal phalanx sufficiently. If that happens, he can insert a thin rubber eraser between the proximal and terminal phalanges of his third finger. If need be, the maneuver can also be performed in such a way that the contact hand (including the wrist) is positioned under the vertebra in question so that the spinous process is located in the carpal tunnel and the transverse processes have contact with the pisiform and thenar eminence. However, it is essen- tial that the thumb is opposed, i.e. touching the lit- tle finger. Contact holds with the patient lying in the prone position are always popular because of their sim- plicity. No locking technique at all is involved, and no distinction is made between flexion and exten- sion. The HVLA thrust must be directed at the lower vertebra in the restricted motion segment, because only this will result in gapping or distrac- tion of the intervertebral apophyseal joints, which are almost in the frontal plane in the thoracic spine. After the slack has been taken up, the springing technique illustrated in in Figure 4.15 can be used and may also be employed for manipulation with- out an HVLA thrust. The following technique, which can also be used for mobilization, produces some rotation as well as extension. The practitioner stands to one side of the prone patient with his hands crossed at the level of the motion segment to be treated and places the pisiform of his more cranial hand on the 213

Manipulative Therapy Figure 6.44 • Treatment of the thoracic spine with hands Figure 6.45 • Mobilization of the ribs in dorsiflexion during crossed. maximal exhalation. transverse process of the lower vertebra, and the this technique exploits the contraction of the back pisiform of his other hand on the transverse process muscles during maximal exhalation. Standing in of the upper vertebra (see Figure 6.44). After tak- front of the side-lying patient, whose upper arm is ing up the slack, the practitioner delivers an HVLA raised above the head with elbow bent, the practi- thrust (or performs springing mobilization) from tioner takes hold of the elbow with his hand that is his shoulders with divergent arms held straight closer to the patient’s head, allowing the patient’s while the patient breathes out. Thus the push into forearm to dangle loosely (see Figure 6.45). Using extension and rotation is delivered in the direction his other hand with the fingertips held closely of the hand on the lower vertebra. In terms of joint together, he fixes the costal angle of the restricted mechanics, there is gapping of the articulation on rib. While breathing in slowly, the patient presses the side toward which rotation is also restricted. the elbow forward against the hand of the practi- tioner, who offers isometric resistance. During This crossed-hands technique is also suitable for maximal exhalation as the patient relaxes, the prac- progressive caudal-to-cranial mobilization, described titioner takes the patient’s upper arm into retro- by Terrier (1958) as ‘mobilization massage.’ This flexion while his fingertips form a fulcrum at the begins at the bottom of the thoracic spine and restricted rib. progresses cranially in the rhythm of respiration, from one segment to the next. Again, as in diagnosis, although the shoulder blade covers the ribs, it is no obstacle to the fixation There are three important technical aspects here: of the rib during mobilization. The first rib, how- the practitioner’s arms must be kept straight and ever, can be neither diagnosed nor treated with this yet relaxed; the thrust must be delivered from his method, while the second rib can be treated only upper body through the shoulders; and his hands with difficulty. The ribs to which this technique is must be divergent so that the transverse processes most frequently applied are thus the second, third, of the two vertebrae move apart. fourth, fifth, and sixth. It is technically important to raise the patient’s arm vertically to obtain a pure The ribs movement of retroflexion and to avoid rotation. However, this is often difficult where shoulder pain Mobilization is present, and for this reason treatment must start with the shoulder. A side-lying technique similar to the diagnostic method described by Kubis (1970) (see Figure 4.25) is used for mobilization. After isometric tension, 214

Therapeutic techniques Chapter 6 Pressure mobilization is recommended for the up the slack in the relevant muscles by side-bending ribs in cases where the ‘overtake phenomenon’ is of the patient’s head (scalenes), abduction of the detected. The patient is supine and the practitioner arm (pectorals), or maximal elevation of the arm stands at the top end of the treatment table, with (serratus anterior). During inhalation, the patient both thumbs placed on the upper margin of the offers resistance with the head or upper arm in the asymmetric ribs lateral to the sternocostal joint. starting position described. The practitioner stands At the ‘higher’ (restricted) rib he offers resist- on the side opposite to the restricted rib, bends ance while the patient breathes in and delivers a the patient’s head or usually shoulder girdle toward light push in a caudal direction while the patient the side he is standing on, and with the same hand, breathes out. Afterward the position of the two ribs which is now placed under the patient’s shoulders, typically evens out and so the overtake phenome- abducts the upper arm or elevates it as far as it will non disappears. go. With the thumb of his other hand, the practi- tioner delivers a push in a cranial direction to the If we find, on comparing the two sides, that one rib while the patient breathes in and resists the rib is restricted during exhalation, the following practitioner’s hand as it elevates or abducts his arm technique advocated by Greenman (1979) is indi- or side-bends his head. If several ribs are restricted, cated: with the patient supine, the practitioner the uppermost rib should be mobilized because it places his thumb laterally on the upper margin of acts as an obstacle to its more caudal neighbors dur- the restricted rib and, with his other hand under the ing inhalation. patient’s shoulders, lifts the patient slightly toward him into slight anteflexion to take up the slack. In Manipulation with HVLA thrust this position he instructs the patient to breathe out; techniques during exhalation he delivers a push with his thumb in a caudal direction, at the same time lifting the For the following manipulation technique the patient’s trunk even higher and bending it to the patient is supine, with hands crossed to the oppo- side. Where several ribs are restricted, the lowest site shoulder and the arm on the restricted side should be mobilized because it acts as an obstacle lying uppermost. The practitioner stands beside to its more cranial neighbors during exhalation. the treatment table on the side opposite the lesion, takes hold of the uppermost arm, and turns the If inhalation is restricted, Greenman makes use patient toward him. He then positions the thenar of muscle pull. In the region of the upper ribs he eminence of his other hand beneath the costal uses the pull of the scalenes, for the middle ribs the angle of the restricted rib (see Figure 6.46A). Now pectorals, and for the lower ribs the serratus ante- rior. With the patient supine, the practitioner takes Figure 6.46 • (A) Preparatory phase for rib manipulation as the practitioner turns the patient to face him and places his thenar eminence underneath the costal angle. (B) Position of the practitioner’s hands during manipulation, showing full opposition of the thumb. 215

Manipulative Therapy Figure 6.47 • Delivering the thrust through the patient’s Figure 6.48 • HVLA thrust manipulation of the ribs, with upper arm vertically toward the thenar eminence placed the patient prone. under the costal angle. of the treatment table, with hands clasped behind the neck. The practitioner stands behind the patient taking the patient’s other upper arm (i.e. the one and threads one arm under the patient’s axilla to that was previously lying underneath), he turns the take hold of the shoulder on the opposite side so patient away from him again until the costal angle as to rotate the patient’s trunk sideways about is resting on his thenar eminence. To do this effec- a vertical axis. With the pisiform or thumb of his tively his thumb must be maximally opposed so other hand, he takes up contact at the costal angle that its muscles contract and form a firm contact (see Figure 6.49). Using both hands he now rotates (see Figure 6.46B). The practitioner then uses his the patient until the slack has been taken up. thorax to exert light pressure on the hand holding the patient’s upper arm until the slack is taken up. Figure 6.49 • Manipulation of the lower ribs using trunk Afterward he delivers a vertical HVLA thrust with rotation and pressure at the costal angle in the same his thorax in the direction of his thenar eminence direction. (see Figure 6.47). A simple but harder thrusting technique with the patient prone has a similar effect. The patient’s head is turned to the side of the restricted rib. If this is one of the upper ribs, the patient’s arm on the side being treated hangs down over the edge of the treatment table in order to produce abduction of the shoulder blade. The practitioner stands next to the patient and places the pisiform of his contact hand on the costal angle. The contact hand can be reinforced by grasping it just above the wrist with his other hand. He takes up the slack by exerting light pressure and delivers an HVLA thrust from his trunk via both arms as the patient breathes out (see Figure 6.48). A restricted rib is usually also painful at the sternocostal junction, which is the attach- ment point for the pectoral muscles. This situation then necessitates relaxation of these muscles (see Section 6.6.4 and Figure 6.109). A suitable treatment for the lower ribs involves a technique for which the patient sits astride the end 216

Therapeutic techniques Chapter 6 He then delivers an HVLA thrust from his trunk, transmitting it simultaneously to both hands (pull- ing on the patient’s shoulder with one hand and pressing with the other). This technique pro- duces gapping of the costotransverse joint of the restricted rib. Manipulation of a painful slipping rib Figure 6.50 • Repetitive mobilization of the first and second ribs by isometric rhythmic contraction of the The patient reports pain in the region of the abdom- scalenes. inal cavity during pressure palpation of the inferior costal arch, especially of the tenth rib, between the practitioner’s finger ‘inside’ beneath the costal arch and his thumb on the surface ‘outside.’ Mobilization is performed with the practitioner’s fingers beneath the inferior costal arch and the heel of the hand on the outside surface of the lowest ribs, gently spring- ing ventrally and laterally in a slow rhythm. The technique is always painful but brings immediate relief. Treatment of the first rib Figure 6.51 • Manipulation (shaking) of the first rib from above. As we noted for the diagnostic examination, the technique for treating the first rib also differs from rapid shaking; alternatively, he can use the edge of that employed for all the others. In terms of func- his forefinger to deliver an HVLA thrust in a caudal tion, the first rib forms part of the cervicothoracic and slightly ventral direction. junction, and for mobilization we make use of the attachment between it and the scalenes. The prac- titioner stands behind the seated patient and stabi- lizes the neck or shoulder from the side. He places his other hand against the side of the patient’s head and instructs the patient to press her head against this hand as he rhythmically intensifies and slack- ens its pressure (see Figure 6.50). Usually about 20 isometric contractions in a slow rhythm (two per second) will suffice, and this will also mobilize the second rib. This technique is also well suited for self-treatment, with the patient using her own hand to exert rhythmic pressure against isometric resist- ance from the head. In another technique the practitioner stands behind the patient who is seated on the treatment table and leans back against him for support. The practitioner can also use his knee to stabilize the side not being treated, while also steadying the patient’s head with one hand on the same side. Using the forefinger of his other hand, he takes up contact over the angle of the first rib from above, close to the patient’s neck (see Figure 6.51). He takes up the slack by exerting light downward pres- sure and achieves very effective mobilization by 217

Manipulative Therapy The cervical spine ushers in relaxation; he then waits until relaxation is complete before repeating. Traction A similar procedure is followed with the patient Traction is essentially performed using manual and seated. The practitioner stands behind the patient post-isometric techniques, but additionally taking who is sitting on the treatment table. To facilitate advantage of respiratory synkinesis. In the supine relaxation, the patient’s back is supported against technique, the patient’s head projects over the end the practitioner’s chest. He takes the patient’s head of the treatment table while the practitioner simply in both hands so that his forearms are resting just cradles it in his palms; very little force is required in front of the patient’s shoulders, thus ensuring (see Figure 6.52A). The patient is told to look up an upright posture. His thumbs are located on the toward the forehead and to breathe in deeply. Once patient’s occiput, with his other fingers placed later- the practitioner sees that the sternocleidomastoids ally around the zygomatic bones in as soft a hold as are contracting, he instructs the patient to breath- possible (see Figure 6.52B). After gently taking up hold and, after a brief pause, to look down toward the slack with traction, he tells the patient to look the chin and breathe out slowly. This automatically up and breathe in deeply. If he senses increased resistance, he tells the patient to breath-hold, look down and then breathe out. He will then feel the patient relax; once this process is complete, the procedure can be repeated. Relaxation occurs automatically as a result of PIR supplemented by respiratory synkinesis, and for this reason this form of traction appears to be ideal. It acts primarily on the C2/C3 segment. Because it is com- monly used for treatment in the acute stage, it is crit- ical that the patient can tolerate the technique well. Consequently, any existing antalgic posture should not be corrected; instead traction with PIR should be per- formed in the position that best suits the patient. For this reason alone it is preferable to apparatus-based traction techniques. Traction must always be stopped if it proves to be uncomfortable for the patient. In particular, we would not advocate the use of Glisson slings with the patient seated because traction here primarily involves the chin without occipital stabiliza- tion (in contrast to the supine position); in such cir- cumstances the patient tenses the flexor muscles of the neck, causing any effect of traction to be lost. Because patients find it particularly agreeable, we will also describe here a traction technique that is associated with a massage element. For this, the patient is supine with shoulders at the edge of the treatment table. The practitioner sits behind the patient’s head, supporting it on his knees. He places both hands under the patient’s shoulders and then leans back so that both hands slide cranially as far as the patient’s occiput, exerting traction and gentle pressure massage at the same time. Figure 6.52 • Traction of the cervical spine (A) with the Jirout’s maneuver patient supine and (B) with the patient seated. A maneuver described by Jirout (2000) has proved particularly effective in acute dysfunction. In such 218

Therapeutic techniques Chapter 6 cases it is most usual for rotation to the right in the Rotation upper cervical spine to be restricted. The patient is supine with head in a neutral position. The prac- For post-isometric mobilization the simplest titioner uses his thumb to exert pressure on the approach is for the practitioner to fix the lower patient’s left shoulder from above while the patient vertebra in the segment between thumb and fore- relaxes the shoulder and breathes out. The patient finger, as for examination (see Figure 4.32), and is then told to offer resistance with the shoulder with his other hand on the patient’s chin, to go against the practitioner’s thumb while he addi- into rotation as far as the end point (i.e. to take tionally stimulates the periosteum at the patient’s up the slack). He then instructs the patient first shoulder with his thumb. After breath-holding, the to look up and breathe in, then to look down patient relaxes so that the shoulder moves in a cau- and breathe out, and he will sense how rotation dal direction. In the considerably rarer cases where increases during relaxation. Looking first in the rotation is restricted to the left, the above proce- opposite direction and then in the direction of dure is adopted, but this time the right shoulder is mobilization usually produces too much active treated. Because the patient’s neck is not touched tension and too little relaxation (Sachse & Berger at all, the technique is invariably well tolerated and 1986). it is often possible to begin with this maneuver in acute rotation restrictions of the upper cervical Side-bending mobilization at the spine. cervicot­horacic junction Mobilization In this case, too, the technique for side-bending mobilization at the cervicothoracic junction is the Side-bending same as for diagnosis (see Figure 4.30). Through- out the cervicothoracic junction increased resist- This can be carried out with the patient seated or ance is noted during inhalation whereas relaxation/ supine. The procedure makes use of the phenom- mobilization is seen during exhalation. The practi- enon, described by Gaymans (1980), of alternat- tioner takes up the slack by holding the patient in ing fixation and relaxation of neighboring spinal retroflexion, with side-bending to the side of the segments. In the even-numbered segments (C0, restriction and rotation in the opposite direction, C2, C4, C6), resistance increases during inhalation and fixes the lower vertebra with the thumb of his and maximal facilitation can therefore be achieved other hand. He then instructs the patient to look by telling the patient first to look up and breathe up and breathe in slowly, to breath-hold, but then in deeply, then to breath-hold and, after a brief to let go and breathe out slowly. Because locking latency period, to look down and breathe out (see was achieved in retroflexion, etc., if the patient Figure 4.26). In the lower cervical spine, however, were told to look down, this would cause anteflex- it is preferable to have the neck extended with the ion, thus unlocking the cervical spine and locking patient seated, in which case it is better to tell the the cervicothoracic junction. patient during the mobilization phase to let go and then to breathe out. In the odd-numbered segments Technically, it should be emphasized that the fin- it is sufficient merely to tell the patient to breathe gers over the zygomatic bone have the (sometimes out slowly and then to breathe in slowly. If the quite difficult) job of holding the patient’s head patient is supine, then the technique is as described in retroflexion, side-bending, and rotation to the for examination purposes (see Figure 4.29). opposite side, while at the same time the thenar eminence of the same hand fulfils a lateral stabi- The practitioner takes up the slack in the spinal lizing role on the upper vertebra in the restricted segment to be treated; it will be noted how resist- segment. During mobilization, the thumb of the ance increases in the initial phase only to decrease practitioner’s other hand is used merely to fix the abruptly toward the end of the second mobiliza- spinous process of the lower vertebra. As relaxation tion phase, at which point the practitioner can still progresses he will sense how mobility (springing) instruct the patient to let go. The most important is restored between his thumb and the thenar emi- thing is to wait: if the practitioner commits the nence of the other hand. Throughout mobilization card­inal sin of actively forcing side-bending, he will the patient must be supported in an upright posi- then cancel out the effect of automatic relaxation. tion. Starting from the same end point after taking This procedure can be repeated two or three times. up the slack, it is also possible to deliver an HVLA thrust; however, this must come from the thumb at 219

Manipulative Therapy the lower vertebra. In the process the practitioner’s movement. After a brief latency period, he instructs other hand fixes the upper vertebra. the patient to look in the direction of mobilization and to breathe out slowly, thus causing mobilization It is technically easier (although less comfortable to proceed automatically. Using the same technique, for the practitioner) to carry out this mobilization after taking up the slack, he can perform an HVLA with the patient side-lying. Here, too, the hold is thrust as follows: the hand cradling the patient’s the same as for diagnosis (see Figure 4.31). The head delivers the thrust while his other hand with practitioner stands opposite the patient’s head and its thumb against the spinous process fixes the lower cradles it between one hand and upper arm, with vertebra. his elbow resting on the treatment table. Then, without lifting his elbow, he moves it forward on Traction HVLA thrust at the upper the treatment table and so takes up the slack by vertebra in the restricted motion moving the patient’s head into side-bending, rota- segment tion in the opposite direction, and retroflexion. (The practitioner’s forearm has to adopt this posi- The patient is supine, with head and neck protrud- tion if his hand keeps hold of the patient’s head and ing beyond the edge of the treatment table. The he simply moves his elbow forward.) The heel of practitioner rests the patient’s head on his forearm the same hand takes up contact at the upper verte- and cradles the patient’s chin with his fingers. He bra in the segment to be treated. With the thumb locates his other hand at the transverse process of of his other hand he fixes the spinous process of the the upper vertebra in the restricted motion segment lower vertebra, using the terminal phalanx of his (see Figure 6.53A). He side-bends the patient’s thumb to ‘hook in’. head just a little toward the side of the contact hand so that it does not slip off from its position. Because the practitioner has to bend over the In order to perform longitudinal traction with both patient for this mobilization technique, his posi- hands, he stands to one side level with the patient’s tion will be far more comfortable if he supports his head. However, if the upper partner is the atlas or knee furthest from the head end on the treatment the occiput, side-bending is not necessary because, table. He next instructs the patient to look up to in these cases, contact is taken up with the trans- the forehead, breathe in deeply, breath-hold and, verse processes of the atlas (which jut out fur- after a brief latency period, to let go and breathe ther) or with the mastoid process. The practitioner out. As the patient exhales, the practitioner will rotates the patient’s head slightly away from him; notice how resistance is reduced and how he can however, this rotation should be only minimal so as advance his elbow further forward without resist- to avoid locking the segment to be treated. In this ance. After taking up the slack, he can deliver an position, once the patient is completely relaxed, HVLA thrust by pushing his elbow forward rapidly, the practitioner takes up the slack with both hands while the thumb of his other hand firmly holds the simultaneously using minimal traction and deliv- spinous process of the lower vertebra. ers an HVLA thrust. The critical factor here is that both hands must operate as a single unit. Therefore Rotation at the cervicothoracic junction the thrust must come from the whole trunk. When The following technique can be used for mobiliza- treating the atlanto-occipital segment, the patient’s tion: with the patient seated on the treatment table head is rotated more to the side so as to lock the adjusted to a low setting, the practitioner stands atlantoaxial segment (see Figure 6.53B), and con- behind and takes hold of the patient’s head between tact is taken up at the mastoid process. his upper arm and forearm, with the patient’s chin in the crook of the elbow. He rotates the patient’s Traction low-velocity thrust applied head in the direction of mobilization to take up the to the lower cervical spine and the slack, with his little finger spanning the vertebral cervicothoracic junction arch and the spinous process of the upper vertebra in the segment to be treated. With the thumb of his The patient is seated on the treatment table with other hand he fixes the spinous process of the lower hands clasped behind her head and elbows wide vertebra from the opposite side (see Figure 4.35). apart. The practitioner stands behind the patient The patient is told to look in the opposite direction and threads his forearms through the triangle and breathe in, and to breath-hold while the prac- titioner offers isometric resistance to the patient’s 220

Therapeutic techniques Chapter 6 Figure 6.54 • (A) Traction manipulation of the lower cervical spine and cervicothoracic junction; (B) finger position. Figure 6.53 • Traction manipulation of the cervical spine fingers forward and upward against the spinous with contact (A) at the transverse process of the upper process, followed (in this case!) by a low-velocity vertebra in the segment to be treated, or (B) at the mastoid thrust as he straightens up and increases the for- process. ward and upward pressure with his fingers. It is useful if the patient exerts slight pressure with her formed on each side by the patient’s upper arms arms against the practitioner’s forearms. and forearms. With the middle fingers of both hands placed over the forefingers to reinforce This technique is most easily applied to segments them, he takes up contact at the spinous process of C4–C7, and sometimes it is even successful at C3 the upper vertebra in the restricted segment (see (where there is increased lordosis). Caudal to C7 Figure 6.54). He now instructs the patient to relax the pressure exerted by the fingers is insufficient and let her head fall forward as he simultaneously to be effective. They therefore remain positioned presses with his arms against the patient’s forearms. in the lower cervical spine and continue to apply He takes up the slack by gentle pressure of his distraction there; however, the practitioner deliv- ers the thrust using the upper part of his breast- bone (the manubrium sterni) against the spinous processes of T1–T3. Both techniques are gentle and safe. However, they are not absolutely specific: 221

Manipulative Therapy the thrust is delivered to the upper vertebra in the Because the lower vertebra is fixed, this tech- restricted segment, while the lower vertebra is not nique is highly specific. If fixation is correct, rota- fixed. Traction may therefore affect some of the tion is only minimal. Throughout manipulation the more caudal segments. The practitioner’s fingers spinous process of the lower vertebra remains in a in the cervical region also produce some distraction neutral position and the cervical spine undergoes but this should be inconsequential. kyphosis during traction in a cranial direction. Only if performed in this way is the technique safe and Rotation HVLA thrust with the gentle. A similar, primarily mobilizing technique patient seated at the cervicothoracic junction has already been described (see Figure 4.34). The patient is seated on the treatment table adjusted to a low setting and the practitioner takes The craniocervical junction up a position behind so that he is stabilizing the patient’s back against his chest. Using his mobilizing Mobilization of the joints at the craniocervical junc- arm, he takes hold of the patient’s head between tion is performed using precisely the same tech- upper arm and forearm, so that the patient’s chin niques as those employed for diagnosis. In this and face are in the crook of his elbow (see Figure segment (C0/C1), inhalation has a facilitating effect 6.55). Leaning forward slightly, he spans the upper and exhalation an inhibitory effect in all directions. vertebra with the little finger of his mobilizing hand, while the thumb of his other hand fixes the Anteflexion spinous process of the lower vertebra laterally so as to keep it in a neutral position. The practitioner After taking up the slack using the technique for takes up the slack by carefully rotating the patient’s examination (see Figure 4.37), the practitioner head while fixing the lower vertebra. He delivers instructs the patient to look up toward the fore- the HVLA thrust with his mobilizing hand, mainly head, breathe in, and then breath-hold; he will into rotation and traction. clearly sense resistance against anteflexion and will often himself have to resist the patient’s automatic head retroflexion. He then tells the patient to look downward at the chin and to breathe out. Head anteflexion automatically follows. If facilitation is too pronounced on looking up at the forehead, it is sufficient (when repeating the procedure) simply to tell the patient to breathe in. The procedure can be repeated two or three times. This mobilization technique is the gentlest of all and therefore prac- titioners generally begin with it. The practitioner should check afterward whether the TrPs in the short extensors can still be felt. Figure 6.55 • Rotation HVLA thrust of the cervical spine Side-bending with the patient seated, under traction, in kyphosis. Using the technique for examination (see Figure 4.38), the practitioner takes up the slack with the patient’s head rotated and in side-bending. The patient is instructed to look up toward the fore- head, breathe in slowly, and then breath-hold. The practitioner will sense increased resistance to side- bending. Afterward he tells the patient to look down toward the chin and breathe out: all resist- ance to side-bending will spontaneously disap- pear. The procedure can be repeated two or three times. 222

Therapeutic techniques Chapter 6 Retroflexion is followed by slow, deep inhalation. Toward the end of inhalation there is an abrupt reduction in The practitioner takes up the slack with the patient’s resistance in the restricted segment. Here it is espe- head rotated and in retroflexion (see Figure 4.39). cially important to wait for the precise moment of As the patient slowly breathes in deeply, resistance relaxation. The practitioner should ensure that side- to retroflexion is felt to increase. After breath-hold- bending is limited to the top part of the cervical ing, the patient is told to breathe out slowly and spine; the patient’s head here should rotate about to allow her head to fall back. Toward the end of an axis that passes through the radix nasi (root of exhalation all resistance disappears and retroflexion the nose). In terms of joint mechanics, side-bending clearly increases spontaneously. The procedure may in the top-most part of the cervical spine produces be repeated once or twice. In this case, looking up rotation of the atlas in relation to the axis and, after to the forehead, that is into retroflexion, would be Jirout’s maneuver, it is the most effective technique at odds with the increased resistance to retroflexion for restoring such rotation. during inhalation, while looking downward would be inconsistent with the increase in retroflexion during Mobilization techniques utilizing respiratory exhalation. synkinesis are so effective in the region of the craniocervical junction that relatively more It is recommended not to rotate the patient’s hazardous HVLA thrust techniques are indicated head more than 60°, especially in the elderly, and there in exceptional cases only. it is also helpful simultaneously to lift the patient’s head, which protrudes a long way beyond the 6.2 Indirect techniques end of the treatment table. Because retroflex- ion increases considerably during exhalation, the This term is used to denote osteopathic techniques practitioner needs to hold the patient’s head quite that are extremely gentle and yet effective at the high up (at the crown) because otherwise his own same time; and it is these characteristics that justify hand would be an obstacle to retroflexion. Retro- their inclusion here. Use of the term ‘indirect tech- flexion must never be actively amplified; usually niques’ indicates that neither diagnosis nor therapy it increases spontaneously to such an extent that, involves taking up the slack or engaging the barrier. if anything, the practitioner needs to hold it back. This is therefore the most effective of all mobiliza- 6.2.1 Johnston’s functional tion techniques between the atlas and occiput. techniques Recently we have started to use activation of the Functional techniques seek to bring the patient into deep stabilization system to achieve mobilization. a position in which good relaxation and pain relief Stabilization in the craniocervical region is enhanced are obtained. Once this objective is successfully by carrying weights on the head. The following achieved, it is found that painfully increased ten- technique successfully exploits this principle: with sion gradually dissipates in other positions too. the patient sitting upright, the practitioner places both hands on the crown of the patient’s head from Functional techniques are based entirely on pal- both sides to exert very light, rapid, shaking pres- pation and therefore it is difficult to capture their sure in the direction of the long axis of the cervical essence in writing. I will therefore do my best to spine. It is important that the patient sits upright help the reader to understand this concept. Pal- and that care is taken to avoid anteflexion–retro- patory examination may reveal increased tension flexion and laterolateral flexion. This technique is (spasm) on one side of a lesioned spinal segment ideal for self-treatment (see Figure 6.81C); it also in the vicinity of the erector spinae; this appears acts on C1/C2 and possibly on C2/C3. as an area of prominence and it creates a palpatory illusion suggesting rotation toward the side of the Side-bending between atlas and axis area of prominence (increased tension). If a patient The examination technique (see Figure 4.29A) is used to take up the slack in side-bending between C1/C2 (‘side-nodding’). According to Gaymans’ (1973) rule, C1/C2 is an odd-numbered segment; consequently, resistance to side-bending automati- cally increases during exhalation. Deep exhalation 223

Manipulative Therapy with such findings is now bent forward, backward, few repetitions, even full anteflexion and bending and to the side, the practitioner will feel that this to the opposite side are tolerated. The palpating increased tension, and hence asymmetry of mus- hand will always indicate whether the practitioner cle tone, becomes more apparent following move- has ventured too far, i.e. whether it would be right ment in one direction, and more balanced following to go back a step or to proceed further. movement in another direction. In terms of joint mechanics, it should be borne in mind that on side- The same principle applies if anteflexion brings bending of the spinal column, the joint on the side tension symmetry (‘de-rotation’). In this case the of lateroflexion moves as it were into extension practitioner should work toward achieving a normal while that on the opposite side moves as it were balance of tension in anteflexion (see Figure 4.22) into flexion (see Figure 4.5). and side-bending to the opposite side, and rock the patient carefully back to the neutral position and Treating the lumbar and retroflexion until no further tension imbalance is thoracic spine evident on full retroflexion. When the lumbar and thoracic spine are being Treating the cervical spine treated, the patient should be seated with both hands clasped behind the neck; with one hand/ A similar approach is adopted when treating the forearm the practitioner stabilizes the patient, as cervical spine. As he stands beside the seated illustrated in Figure 4.21. With his other hand he patient, the practitioner uses one hand to move the palpates with thumb and forefinger in the segment patient’s head into anteflexion, retroflexion, and where the tension imbalance between the two sides side-bending; between the thumb and forefinger is greatest, that is where there is a palpatory illusion of the other hand he palpates next to the spinous of rotation. He next establishes whether the tension processes the muscles that lie behind the transverse imbalance diminishes in anteflexion or retroflexion. processes. When this happens the practitioner will experience the palpatory illusion that the spine is ‘de-rotating.’ The following technique is even more effective: For example, if tension becomes balanced in retro­ as he stands in front of the patient, the practitioner flexion, then it follows that side-bending toward supports the patient’s forehead on his chest and the side of the spasm will have a beneficial effect; palpates with both hands either side of the spinous and conversely, if anteflexion restores balanced ten- processes (in this way he can use both hands to sion, then side-bending in the opposite direction stabilize the patient’s head and neck). By raising will alleviate spasm, and this is generally associated or lowering his own ribcage, he then moves the with freedom from pain. patient’s head, taking it into anteflexion, retroflex- ion, and side-bending while simultaneously palpat- In practice, the procedure is as follows: for ing the paravertebral muscles with his hands. example, if the practitioner finds that the tension imbalance is reduced in retroflexion, he should Once again, the practitioner starts by identify- move the patient into maximum retroflexion with ing the side and the segment affected by increased bending toward the side of the spasm. The patient’s tension and then tests whether this finding is accen- trunk should be supported as effectively as pos- tuated or diminished in anteflexion or retroflexion. sible so as to enhance relaxation. If tension in fact If tension decreases in retroflexion, he moves the becomes balanced in this extreme position (wait to cervical spine into retroflexion and side-bending see if this happens), the practitioner slowly rocks toward the lesioned side, and waits in this posi- the patient out of side-bending and maximum ret- tion until all tension disappears. Then with gentle roflexion and back into a neutral position. However, rocking movements, he reduces retroflexion and as soon as the tension reappears, he should return side-bending, always supporting the patient’s head the patient to the relief position and make another against his chest. He repeatedly returns to the relief attempt, taking care to progress slowly in this man- position as soon as he notices that increasing ante- ner. As a rule, after a few rocking maneuvers back flexion causes tension to reappear, until finally full into the neutral position and some anteflexion, the anteflexion and bending to the opposite side are tension will disappear with the result that, after a well-tolerated. Conversely, if tension is relieved on anteflexion, he performs the treatment the other way round (i.e. anteflexion and side-bending to the 224

Therapeutic techniques Chapter 6 opposite side, followed by retroflexion and side- this position for 90 seconds. Afterward the patient bending to the lesioned side). is allowed to return (slowly!) to a neutral position. This method is extremely gentle and safe and is As a routine method this technique is time- always most agreeable to the patient. However, it consuming and cumbersome. However, in a sim- is not easy to illustrate and teach with words alone plified form it is to be highly recommended in because it depends entirely on the palpation skills emergencies; and sometimes it is the only treat- of the practitioner. ment method that is of help to the patient. It is employed most frequently in acute low-back pain 6.2.2 Strain and counterstrain and to treat radicular pain. For this, use is made of the positions (in anteflexion and retroflexion) that This method has much in common with Johnston’s the patient adopts when performing McKenzie functional techniques in that it does not engage exercises (see Section 6.5.3). However, in each the barrier and seeks out positions that afford pain case, the position must be held for 90 seconds. A relief. The best experiences with strain and counter­ similar procedure may also be followed in acute strain techniques are obtained in acute lesions where cervical myalgia, that is the left-sided rotation and most other traditional methods have failed. Indeed bending into mild flexion that is usually present can L H Jones, the originator of the strain/counter- be slightly exaggerated and held. strain method, tells how he was called to treat an emergency case involving a patient who was un­able This technique has proved especially useful in to straighten up from flexion because of psoas instep pain where no movement restriction or TrPs spasm and could not find any relief position. On are found and which develops sometimes on pro- examination, however, Jones found that relief could nation and sometimes on supination of the foot. be obtained when the patient was brought into a In such cases maximal supination or pronation in position of 45° of rotation and 30° of lateral flexion. the direction of relief is the treatment of choice. He then went away to treat another patient. When On each occasion the position must be held for he returned to his emergency case, he found that 90 seconds, followed by a slow return to a neutral the patient was able to straighten up completely. position. In his original publication, Jones (1964) 6.3 Exteroceptive stimulation explained the rationale for his method, and this corresponds to the situation that is frequently (by H Hermach) observed in acute lesions: the patient picks up an object lying on the floor, usually bending forward to 6.3.1 Tactile perception and one side, and then straightens up (too) quickly out muscle tone of anteflexion–rotation. It is conceivable that dur- ing this brisk movement something becomes caught Even though an unborn child in the womb already or trapped. If we now help the patient to go back reacts when its mother’s abdomen is touched, tac- into the original flexed position and exaggerate tile perception can properly be said to develop only this a little, then wait in this position before very after birth. In the very early stages a large part of a slowly returning the patient into a neutral position, baby’s body surface area is in intimate contact with we give the impinged tissues the opportunity to slip the floor or other support surface. Soon, however, out from their entrapment. growing babies start to support themselves on their arms and legs and on only limited areas of their An essential prerequisite is to find the position trunk, until finally they stand up and support them- of relief – information that is frequently volun- selves only on the small surface area of the soles teered by the patient. However, Jones noted objec- of their feet in contact with the ground. In adults, tively that this process can be used to eliminate the however, it is more common for the caudal end of most varied pain points in the muscles, on the tho- the trunk to be the main support structure! rax close to the midline, and on the abdomen usu- ally more to the left side. Once the patient has been Tactile contact over large areas of the body, for slowly brought into the relief position thus found, example caressing and stroking, has a pleasant and it can be exaggerated a little, provided that the patient tolerates this. The patient then remains in 225

Manipulative Therapy calming feel to the child. However, if the child with the tension of the subcutaneous connective reacts to stroking by crying, this is a warning sign of tissues and of the muscles. Increased skin sensitiv- unfavorable motor development. It can be a sign of ity is generally associated with increased tension increased tension in impending spasticity. in all tissues, including the muscles, while reduced sensitivity is linked with hypotonus. However, The size of the support surface of a child or adult because sensations in the individual can be widely will indicate whether muscle tone is increased, nor- different, the symptoms can also be different. This mal, or reduced. Starting from the contact area explains why the skin may also be tense when sen- and our ability to use this, we develop the ability sitivity is reduced. Such a phenomenon may be the to push off from the support surface and return consequence of a reaction by the body as a whole to to it. The way in which individuals react to their inadequate stimuli (information). surroundings in response to contact with their body surface indicates whether they accept this or It is therefore extremely important that we are reject it, how they interpret it, and whether their able to intervene at the level of the sense of touch. reactions to environmental stimuli are appropriate Our skin has the capacity to learn how to perceive or not. more or less, or even how to perceive better. And we can do this by altering the tension of the skin, Our skin plays a major role in the processing subcutaneous tissues, and muscles. of information we receive from the world about us; and it is on the basis of this information that All of the above can be put to good use in the we form an image of the space surrounding us and setting of treatment. Appropriate, discriminating also of our own bodies. Pre-eminently it is our skin sensation goes hand in hand with normal skin and and sense of touch that enable us to differenti- muscle tone. The capacity of a muscle to alter its ate between ‘self ’ and ‘non-self ’ out there. How tension in a discriminating way is an expression of much room does ‘self ’ take up? A disordered or good coordination. Good tactile perception goes inadequate tactile sense disturbs our orientation in hand in hand with well-coordinated movements. If space and our understanding of the position that we we succeed in the course of treatment in achieving occupy in it. And this necessarily has repercussions well-balanced tactile perception, then it is no exag- in the sphere of movement, that is in the locomotor geration to claim that the patient’s movements will system. then be optimal – coordinated and with good spa- tial orientation. In order to capitalize on this, we What we feel is closely related to our psyche. need to learn how properly to examine the tactile What we feel is interpreted, understood, grasped. sensibility of the skin. And this interpretation also shows how we perceive the world, whether as agreeable, friendly and open 6.3.2 Assessing altered tactile (so that we open ourselves up to it in turn), or as perception disagreeable and hostile as we come into contact with it. The assessment of tactile perception has much in common with neurological sensibility testing. Our If we feel that touch or contact on our skin is prime assessment tools are our fingers and the dor- agreeable, then contact with the world around us is sal surface of our thumb nail. In the process, we welcome and we seek it out. Of course, the con- assess how the patient reacts, whether the response verse also applies. Hence our sense of inner secu- is appropriate, and how the patient behaves. We can rity and our feelings of insecurity in a spatial sense stroke or scratch, only lightly or even intensively, when moving about are interconnected. depending on the part of the body being examined. It is a good idea to begin abruptly so as to provoke a The more precisely we perceive, the better able clearly discernible reaction. After a few repetitions, we are to discriminate. The ability to discriminate the reaction will change as the skin adapts to the precisely bears testimony to precise perception, stimulus. Failure of adaptation to materialize is a and our tactile discriminatory skills tell us where sign of hypersensitivity. we are. Reactions are shaped and behavior develops depending on the quality of our perceptive skills The response to a stimulus may be merely local and how we interpret what we perceive. or it may also be generalized. A reaction may also be absent. In general, the more intense the general Our skin’s sensation of touch also has implica- tions for our locomotor system. These implications are so immediate because the sensitivity of our skin is linked to its tension, which in turn is connected 226

Therapeutic techniques Chapter 6 reaction, the less appropriate it will be. Absence of a task correctly or else the stimulus was too weak. local reaction is indicative of reduced tactile percep- If improvement fails to materialize, we must stop, tion. The reaction may also be appropriate, or it may review the diagnosis and decide whether the stimu- be exaggerated, as a sign of hypersensitivity. This lus was the correct one. Stroking is generally per- may manifest itself as ticklishness, and even as pain. formed along the long axis of the body, but may also be transverse to the long axis at the buttocks, Paradoxical reactions may also be encountered: or diagonal on the abdomen. instead of pulling the sole of the foot away when tickled, the patient may breath-hold and tense the If the skin is hypersensitive, we have two thoracic muscles. Sometimes a patient will develop options: we can continue stroking through a fine goose bumps merely at the mention of tickling the fabric or else the patient can self-stroke for a few soles of the feet. minutes each day until the touch of the practition- er’s hand can be tolerated. The most telling signs of a generalized reaction are altered respiration and sweating. These are If the skin is hyposensitive, we can intensify the indicative of instability in the organism as a whole, stimulus by stroking more quickly, changing pres- and the changes in respiration can also affect motor sure and direction, or using a hedgehog ball, brush, activity. Due consideration must also be given to or towel. However, we should understand that good the patient’s personality and cultural background tactile perception permits a response to tiny stimuli and to whether current stress might be a factor. that can never be achieved with coarse stimuli. There are moments when all of us may react in an exaggerated manner. In order to achieve good coordination, a muscle must be able to interact with other muscles as soon 6.3.3 Normalizing tactile as tension changes. Heightened or diminished mus- perception cle tonus should not persist anywhere. Each muscle should be capable of relaxing and adapting to modi- Sensitivity for tactile stimuli is anything but con- fied circumstances. If we have successfully altered stant; it alters and adapts rapidly. Sensitivity in muscle tonus using any method, then this means response to stroking may also alter in the long that well-coordinated movement has resulted with- term. This means that the skin learns to feel and out the need for special exercises and the correc- to discriminate, and as a result the patient learns to tion they bring. If our own experience suggests that interpret. we have successfully normalized the tone of the muscles and subcutaneous tissue simply by strok- The effect of a great many massage techniques ing, then coordination will also improve, along with is also based in part on tactile stimulation, and locomotor system function in every respect. they can be applied with this in mind, provided that they are gentle and primarily have a surface 6.3.4 Altered superficial tactile effect. Brushing is another method that can safely perception following be used in patients with diminished tactile sensi- surgery (due to scarring) tivity. In patients in whom altered tactile percep- tion is expressed as algodynia or hypersensitivity, When assessing the tactile perception of the skin, we must seek to use a technique that is agreeable we must also take account of any active scars to the patient or is at least felt to be tolerable. If that may be present. To determine the sensitivity treatment is felt to be disagreeable, it will provoke of a scar, we ‘fold’ it a little. If the patient feels a defense reaction that will preclude any successful pain when we do this, hypersensitivity is present. outcome. If sensitivity remains unchanged after stretching and mobilization (see Section 5.2.2), then the pain Treatment in patients with altered tactile percep- point is more deep-seated. tion begins in principle with slow and gentle strok- ing over large areas of the body. Tickling must be It is not sufficient to assess the sensitivity of the avoided. Our hand will provide feedback because scar alone. Surgery may also damage cutaneous it will ‘pick up’ changes in the tension of the skin, nerves, in which case hypesthesia will be present, subcutaneous tissues, and muscles. As long as the but sometimes also paradoxical hypersensitivity. In findings improve, we may continue. If this is not both cases we should attempt to improve sensibility. the case, then we have failed to understand our 227

Manipulative Therapy As long as this is abnormal, then the tone of con- no reaction, indicative of reduced sensitivity, the nective tissues and muscles will remain abnormal, tongue, lower jaw, and oral cavity can be stroked as will their reactions. This tactile perception defi- with a moistened finger. Adult patients may do cit may be indicative of muscle spasm, which means this for themselves; for toddlers and children, the that the patient has insufficient muscle control. parents should be instructed how to do this. It is Hypersensitive skin may also be associated with par- necessary to proceed with caution owing to the esthesia and even pain (sometimes referred pain). ever-present risk of vomiting. Hypersensitivity can be so intense that the The hands patient cannot even bear contact with clothes. This condition is known as ‘clothing sensitivity,’ and the It is not easy to assess the sensitivity of the hands. patient may also demonstrate a powerful emotional This is probably because the hands themselves reaction. In such cases we should perform stroking are constantly touching objects and working on through a sheet of fabric, or the patient should be them. For the examination, the patient is seated encouraged to self-stroke daily until being touched in a relaxed position with palms facing upward. In by someone else’s hand becomes tolerable. And this position, tension of the flexors is the domi- even if the sensitivity of the scar has been restored nant feature. Therefore the fingers are generally in to normal, the patient must repeat the stroking as slight flexion. The practitioner should surprise the soon as hypersensitivity returns. patient by suddenly scratching one palm. Usually the patient will rapidly jerk the fingers away before The muscles beneath the active scar are usually returning them to their original position. One sign hypertonic and painful. These aspects too may also of hypersensitivity is finger extension, especially improve as soon as normal cutaneous tactile percep- if this recurs when the test is repeated. The most tion is restored. effective therapy is stroking or a repetitive activ- ity such as moving the fingers in a bowl of rice, Cutaneous tactile perception differs not only kneading dough, or model-making with Plasticine®. from person to person but also depending on body Patients with hypersensitive hands are generally region and age. Infants recognize objects and first creative but they need to learn to relax their hands. touch them with their mouths, and only later with their hands. Soon, however, they also use their feet The feet to feel objects until they stand up and start to tod- dle. In that phase the foot serves as a support but it An assessment of the sensitivity of the feet should is by no means passive: the body reacts to the sur- form part of the routine patient examination. The face on which its stands to adopt an erect posture. feet play a key role in human upright posture and they are significant for the function of the spinal As is well known, the tongue, mouth, hands column. For the examination, the patient should be (especially the thumbs), and feet are served by supine, with legs slightly flexed over a pillow placed large areas of the sensory cerebral cortex. They play behind the knees. Without warning the patient, the a pre-eminent role in tactile perception, and there- practitioner uses his fingernails to simultaneously fore changes in sensibility in those regions result in stroke the soles of both the patient’s feet, from heel changes to overall behavior. to toe in the direction of the big toe. Where tac- tile perception is normal, the patient will attempt The tongue and mouth to move away a little from this touch, by slightly increasing knee and hip flexion, dorsiflexing the The tongue tends to be examined in exceptional feet, and flexing the toes a little. It is not uncom- cases only. However, it must be examined in young mon for the observed reaction to be asymmetrical, children with behavioral abnormalities: the findings and this is clinically important. When asked, the often reveal a restless or, on the contrary, an immo- patient will also report asymmetric sensitivity. bile tongue. Examination is also necessary in cases where the mandible and lips are restless or the If the patient does not react at all, this indicates patient’s mouth is constantly open. A moistened that the foot is not capable of responding appro- finger is used for the examination. Where hyper- priately during standing and walking because it is sensitivity is present, the tongue will react with a twitching defense movement or else gagging is pro- voked simply when the tip of the patient’s tongue is touched. In the case of a tongue where there is 228

Therapeutic techniques Chapter 6 unable to receive information from the terrain. An may be found in unloved children, even persisting exaggerated reaction, for example involving the into adulthood. whole body, shows that the foot is not able to adapt to the floor or ground because it is processing the Differing sensitivity on one side of the body information incorrectly. Therapy consists of strok- means that the patient has a false perception of ing and a combination of superficial and propriocep- body center and hence of the immediate surround- tive stimuli as the practitioner traces numbers and ings. Objects seem to some extent less real on the letters on the patient’s soles. Patients can stroke side of diminished sensitivity, explaining why the or brush their own soles and walk barefoot on the patient may bump into things more often on that lawn at home or on a shingle beach. side. This sensitivity imbalance is often associ- ated with emotional lability. As soon as the patient If the practitioner detects asymmetric sensitivity learns to be aware of the whole body and to use the of the feet, he should also screen for asymmetries side on which sensitivity was originally diminished, in other body regions – lower legs, thighs, abdomen, there will be an increase in self-confidence. thorax, arms, and face. In this way it will be poss­ ible to identify asymmetry involving the whole body, Normal sensitivity of the feet is also a prerequi­ something that occurs particularly when one side si­te for good balance and hence for a sense of secu- of the body is markedly dominant. Such asymme- rity. Where such security is absent, the patient try will affect the locomotor system as a whole. The will seek to maintain balance through exaggerated patient then needs to become aware of the ‘forgot- activity of other muscle groups, for example in the ten side of the body’ and learn to use it too. Once pelvis and lumbar region, diaphragm, thoracolum- again, therapy consists of stroking the less sensitive bar junction, shoulder girdle, and those involved in body side (and the patient can also do this indepen­ mastication. These disturbances of muscle function dently). However, it is important to establish with generate characteristic chain reactions. Individuals certainty whether and when symmetry is restored. with hypersensitive hands are often excessively neat and tidy, with a tendency toward perfectionism. The abdomen 6.3.6 Self-treatment Ticklishness, especially on the abdomen, is also a Patients can use the following self-treatment tech- sign of hypersensitivity. This usually goes hand in niques to restore a balanced pattern of skin sensi- hand with increased muscle tension. As a result, tivity: coordination, respiration, and spinal function are also disturbed. Ticklishness is linked with nocicep- • Stroking themselves with their fingers. tion and therefore also with TrPs. It is a precursor of pain. • Stroking themselves with a towel. 6.3.5 Individual characteristics • Rolling a soft rubber ball or tennis ball with of perception their feet. The reactions of all patients also need to be assessed • Walking on pebbles or hot charcoal. in the context of their personality. What appears to be exaggerated may be entirely normal in a highly- • Wriggling their fingers in a bowl of rice or strung person. In someone with a very calm temper­ peas, etc. ament, what seems to be normal may already be an indication of hypersensitivity. The practitioner • Lying on a mattress filled with small plastic needs to listen to the patient very precisely – the balls, chestnuts, or other nuts; children may play patient’s own words will betray the underlying atti- with balls or chestnuts in a bath containing just tude toward pain – and simultaneously observe the a little water. patient’s behavior. Thus, an unusual reaction may ensue following simple skin contact because there is • Brushing to stimulate the skin. a disturbance at the emotional level, something that The prime goal of therapy is to reintegrate the region of diminished or heightened sensitivity into the overall body pattern. There are right-handed people who need to learn how to use their left hand too. Many patients have to re-learn how to walk barefoot or how to roll down a grassy slope (‘roly- poly’ fashion), and others have to be made aware of their thorax. 229

Manipulative Therapy 6.4 Soft-tissue manipulation As with joints, we examine mechanical function in Figure 6.56 • Skin stretching. order to assess elasticity, mobility relative to other structures, and mutual patterns of displacement. er’s thenar eminences or between the ulnar aspects The importance of soft tissue is evident from the of his palms with hands crossed. Stretching should simple facts that the locomotor system as a whole be performed with a minimum of force, so as to is embedded in soft-tissue layers, that connective take up the slack. Under normal circumstances a tissue elements are also present in muscles them- springing resistance will be felt. selves, and that the mutual mobility and displace- ment of all these structures is made possible by If there is a hyperalgesic zone (HAZ), the slack soft tissue. Indeed, motion of the locomotor sys- is taken up sooner and there is much less spring. If tem proper would not be possible if, starting with the skin is then held in this end position, resistance the skin, all the aforementioned structures and tis- weakens after a brief latency period until the phys- sues were not freely mobile or capable of relative iological barrier is reached and normal springing is shift and stretch. The same applies to the visceral restored (see Figure 6.56). The HAZ is then usu- organs, especially in the abdominal cavity. Some of ally no longer detectable. If the HAZ is the cause these movements involve quite considerable excur- of pain, this stretching method is quite as effective sions. Consequently, soft-tissue function needs to as needling, electrostimulation, and similar treat- be examined diagnostically and treated. ments. Moreover, it is painless and well suited for self-treatment. The effect can even be measured. The technique is characteristically uniform for The method is particularly suitable for small skin all soft tissue, but differs from most forms of mas- areas where a fold cannot be formed, for example sage in that on each occasion, whether we wish to between fingers and toes, in radicular syndromes, stretch or shift, we first take up the slack (engage or in the region of the carpal tunnel if the skin a barrier), and then, without much change in pres- there is taut. sure (pull), release occurs after a brief latency period. Release itself may take from a few seconds 6.4.2 Stretching a connective to half a minute or longer. The practitioner’s role is tissue fold to sense this. If the release process is cut short pre- maturely, we will be depriving ourselves of the best Folds of soft connective tissue are usually formed possible treatment outcome. During this period of between the thumb and forefinger of the practi- release it may be helpful to slightly modify both tioner’s two hands; in this way he can produce pull the direction and the intensity of pressure (pull). or stretch (but never compression!) and take up the It must never be forceful, and the patient should never feel pain. If muscles and joints are to move, then the surrounding soft tissue also needs to shift and stretch with them. This capacity for concomitant movement may be disturbed, with adverse repercussions for the locomotor system as a whole. 6.4.1 Skin stretching As explained in Section 4.3.2, a small area of the skin can be stretched between two fingertips; larger skin areas can be stretched between the practition- 230

Therapeutic techniques Chapter 6 Figure 6.57 • Stretching a connective tissue fold. slack. The stretch is held and, after a brief latency Figure 6.58 • Applying sustained pressure. period, he will notice that the tissue fold stretches (relaxes) until the physiological barrier is reached 6.4.4 Shifting (stretching) the (see Figure 6.57). This technique is appropriate for deep fascia treating HAZs in the subcutaneous tissue and espe- cially for scars with active interference zones (pain The most important task of soft-tissue manipulation points). It is particularly suitable for stretching taut appears to be restoration of the normal mobility of muscles where the connective tissue element is the fascia. Once again, the technique is similar to shortened. In the case of large muscles, such as the those described above: after taking up the slack, the ischiocrural group, the fold is produced between practitioner waits until release occurs and the tissue the palm of one hand and the fingers of the other. can be shifted in relation to the structure beneath. This is probably the most effective way of obtain- Many of these techniques were originally elabo- ing muscle stretch while avoiding the stretch reflex rated by R Ward (personal communication, 1989). (‘cross-stretching’). It is worth emphasizing here that restrictions in the mobility of the deep fascia are a sign of a chronic 6.4.3 Sustained application disease stage. of pressure In locations where a fold cannot be formed, pres- Shifting the deep lumbar sure may be exerted with fingers, thumb, or even fascia caudally the elbow (see Figure 6.58). Here, too, the practi- tioner takes up the slack using the very minimum The practitioner takes up a position to one side of pressure, and after a brief latency period he of the patient, who is prone with feet protrud- will notice that the tissue starts to yield and his ing over the end of the treatment table. He starts finger sinks into the deep layers until a new bar- by comparing the extent to which the soft tissue rier is reached. In the process both the intensity can be shifted caudally on both sides. He then and direction of pressure can be modified slightly. instructs the patient to press the toes on the side This method is most effective for eliminating to be treated against the edge of the table, to TrPs, for example in the erector spinae and the stretch out the arm on that side as far as possible gluteal muscles; it can also be applied by a pin- with fingers splayed, and to turn the head so as cer movement between two fingers, for example to look toward the side being treated (see Fig- in the sternocleidomastoid. The sustained appli- ure 6.59). The practitioner next uses one hand to cation of pressure is also useful in treating deep, exert pressure on the gluteal muscles in a caudal contracted scars where it is impossible to form a direction while his other hand fixes the thoraco- skin fold. 231

Manipulative Therapy Figure 6.59 • Shifting and stretching the deep lumbar fascia caudally. lumbar area from above. Once the slack has been his other hand fixes the soft tissue in the thora- taken up, he instructs the patient to breathe out columbar region using downward pressure toward (thus increasing resistance to the pressure being the treatment table (see Figure 6.60). He next exerted caudally), then breath-hold, and breathe instructs the patient to breathe in deeply, breath- in slowly. Inhalation is accompanied by release, hold, and then breathe out slowly. Release occurs caudal shifting of the lumbar fascia, and stretch- while the patient is breathing out. The procedure ing. The procedure is repeated three or four times. is repeated several times. If release is not satis- If satisfactory release fails to occur, it can be help- factory, the situation can be helped by asking the ful if the patient gives a cough. After this treat- patient to cough. ment the shifting qualities of the lumbar fascia on both sides will be symmetrical and the practi- Stretching the fascia on both sides tioner will notice a blush sign at the treated site. of the trunk The movement restriction need not necessarily be on the painful side. Shifting and stretching the dorsal This technique is indicated where side-bending is fascia cranially restricted due to muscle shortening. For diagnosis and treatment, the practitioner takes up a position The practitioner takes up a position to one side behind the patient, who is seated. On the side to of the patient who is prone with feet protruding be treated, the patient raises her arm above head beyond the end of the treatment table. He starts height and bends it at the elbow. The practitioner by comparing the extent to which the soft tissue takes hold of the elbow with one hand while his can be shifted cranially on both sides. He then other hand fixes the patient’s hip from above. He instructs the patient to press the toes on the side to takes the patient into side-bending over his thigh, be treated against the edge of the table, to stretch which is supported on the treatment table, until out the arm on that side as far as possible with the slack has been taken up (see Figure 6.61). fingers splayed, and to turn her head toward the He then tells the patient to look up and breathe practitioner. With one hand placed at the level in deeply, breath-hold, and then look down and of the shoulder blade, the practitioner shifts the breathe out. Stretching occurs after a brief latency soft tissue cranially to take up the slack, while period. The procedure is repeated two or three times. 232

Therapeutic techniques Chapter 6 Figure 6.60 • Shifting and stretching the dorsal fascia cranially. Figure 6.61 • Stretching the lateral fascia (muscles) of resistance, usually on one side, and makes a com- the trunk. parison with the other side. In the direction in which he feels resistance (a pathological barrier), he Rotational shifting of the fascia takes up the slack during inhalation and senses the around the thorax release during exhalation. During mobilization, it is helpful for the practitioner to guide the patient’s hand with his own so that the patient can feel the barrier and release first hand, and then continue the (always agreeable) self-treatment at home (see Figure 6.62B). Clinically, this dysfunction is espe- cially common and significant in the setting of pain in the region of the shoulder and shoulder blade. In a similar way, in patients experiencing pain in the inguinal region, the shifting qualities of the soft tissue relative to the pubic bone may be reduced. In all such situations, the treatment is fundamen- tally the same: the practitioner takes up the slack in the direction of increased resistance. This is then held, after which release is obtained and the barrier is restored to normal. The same also applies for the shifting quality of the buttocks in a caudal-to-cranial direction: the practitioner takes up the slack on the side of increased resistance by exerting pressure in a cra- nial direction and then, after a brief latency period, release is obtained. The scalp With the patient supine, the practitioner examines In clinical terms, the scalp behaves like a deep and mobilizes the soft tissue around the thorax, fascial layer. Restricted scalp mobility may cause particularly on the lateral surface, in a ventrom­ edial headaches as well as vertigo in conjunction with direction (see Figure 6.62A). He palpates for the cervicocranial and mandibulocranial syndrome. 233

Manipulative Therapy applying a rotational movement around the long axis of the neck. The practitioner stands behind the seated patient, places one hand round the patient’s neck from behind, and applies a rotational move- ment to detect increased resistance in one direc- tion (see Figure 6.63). He takes up the slack in that direction and, after a brief latency period, release is obtained as the patient breathes out. Treatment may be applied in the direction of the thumb or of the fingers; treatment in the direction of the thumb is more specific while that in the direction of the fingers covers a larger surface. With his free hand the practitioner fixes the patient’s head. At the cervicothoracic junction, the same tech- nique can be employed if the patient is extremely slim; in most cases, however, the practitioner will need to take hold of the cervicothoracic junction with both hands and rotate the soft tissue around a vertical axis. Here it is also possible to perform a wringing action with one hand against the other. In each case, the barrier is engaged and then release is obtained. Treatment of the extremities proceeds in a similar fashion. Soft-tissue rotation about a lon- gitudinal axis can be tested and treated; once the (pathological) barrier has been reached, a wringing Figure 6.62 • Shifting the fascia laterally around the thorax: (A) performed by the practitioner; and (B) performed as self- treatment. For diagnosis, the practitioner examines the mobil- ity of different scalp areas in different directions in relation to the skull beneath and compares the two sides. Here, too, pathological barriers can be identi- fied: once the slack has been taken up, the typical release phenomenon follows. Examination is gen- erally performed using the pad of a single finger although this may easily slip off the patient’s hair. The practitioner supports the patient’s head with his non-palpating hand. Fascia at the neck and the extremities The soft tissue (fascia) at the neck and in the cervico- Figure 6.63 • Rotational movement of the soft tissue thoracic region can be examined and treated by (fascia) at the neck. 234

Therapeutic techniques Chapter 6 movement is performed with both hands in oppo- site directions. The commonest pathological barri- ers are detected around the elbow, wrist, knee, and ankle. Heel pain In cases of painful calcaneal spur, it may be found Figure 6.65 • Folding and stretching the soft tissue between that at least in one direction the soft-tissue pad at the Achilles tendon and the tibia (A) laterally and (B) medially. the heel is less readily shifted than on the other side. As soon as the practitioner detects the path- 6.4.5 Mutual shifting of ological barrier, he takes up the slack and then metacarpal and overcomes the resistance to restore normal tissue metatarsal bones mobility. Usually it is necessary to apply strong (lat- eral) pressure in the immediate vicinity of the bone using both thumbs while fixing the heel with the other fingers (see Figure 6.64). In cases of heel pain around the attachment point of the Achilles tendon, the soft tissue between the tendon and the bones of the lower leg is tender to the touch. In such cases, this tissue must be folded and stretched between the fingers. For this, the patient is prone with the knee flexed. The practitioner stabilizes the patient’s lower leg against his body. He applies pressure with the fin- ger of one hand just above the heel and with the thumb of his other hand a few centimeters further proximally. He then repeats the procedure in the opposite direction (see Figure 6.65). For this, it is necessary to position the thumb flat because there is only minimal space between the Achilles tendon and the tibia. After the slack has been taken up, the fold will stretch during release. Figure 6.64 • Shifting the soft-tissue pad at the calcaneus. In radicular syndromes radiating to the fingers (or toes), stretching is not limited only to the skin between the fingers (toes); generally there is also increased resistance (‘bind’) if we try to move one metacarpal (metatarsal) bone against the next, in a dorsopalmar (dorsoplantar) direction. This resist- ance does not stem from any joint but from the soft tissue between the individual bones. As soon as the practitioner detects increased resistance compared with the other side, he uses a pincer hold (see Figure 6.7) to engage the barrier, and once the slack has been taken up, he waits for release. 235

Manipulative Therapy The restricted fibular head can be treated in the represent painful attachment points of the short same way and for the same reasons (see Section intervertebral muscles. Accordingly, the practitioner 6.1.2, Figure 6.25). takes up the slack using downward pressure applied with a fingertip; as the pressure is held, release is 6.4.6 Painful periosteal points obtained. Pathological barriers are also encountered at painful In the very frequently encountered condition periosteal points, most frequently in the vicinity of where the spinous process at the axis is tender, attachment points of ligaments and tendons; these the pain point is also located to one side; this is barriers are characterized by restriction of subperios­ revealed by axis rotation following side-bending of t­eal tissue on shifting, in at least one direction. It is the patient’s head to the non-painful side. In this always necessary to make a comparison with a sym- case it is usual for the mobility of soft tissue to be metrical painless area on the non-affected side. Thus, clearly restricted in a caudal or cranial direction. on examination of the epicondyles, it is normally Therefore the practitioner fixes the patient’s head possible to shift the soft tissues easily in all direc- in side-bending, with his free hand palpates the tions; however, when pain is present, shifting is gen- pain point lateral to the spinous process, and takes erally restricted in at least one direction. This signals up the slack in the direction of the restriction. the presence of a pathological barrier, which is indi- Release is obtained after a brief latency period. The cated by an abrupt end-feel that is devoid of spring- procedure is repeated and the pain is usually found ing. Once the barrier has been engaged, release can to have been alleviated. be obtained after a brief latency period. After mobi- lization, the patient experiences relief from pain. Another extremely common pain point is at the Shifting always occurs in a tangential direction and is PSIS, a lateral projection on the iliac crest that runs therefore painless. Pressure is never applied directly obliquely in a ventral direction. Soft-tissue mobility to the periosteal point itself (see Figure 6.66). in this direction is tested and treated tangentially. A similar procedure may be followed for the pes This technique is also important, for example, in anserinus and the styloid process of the radius, etc. cases where the spinous processes are painful, par- ticularly in the lower lumbar region in hypermobile 6.5 Self-mobilization patients. It is worth emphasizing that the pain point on the spinous process is never precisely in the mid- A crucial factor contributing to the successful out- line, but always slightly to one side. On the side of come of manual therapy and, in the broader sense, painful tenderness, deep pressure ventrally (i.e. par- of rehabilitation is the patient’s active coopera- allel to the spinous process) will encounter greater tion in the therapy. It is in this setting that pre- resistance than on the non-painful side. These areas dominantly passive therapy is transformed into a learning process. Even in the neuromuscular mobili- Figure 6.66 • Shifting the subperiosteal soft tissue at zation techniques, the patient’s role is not merely a painful periosteal points. passive one; however, the patient’s activity unfolds in response to the precise instructions and prompt- ing of the practitioner. The next step on from this emerges with compelling logic: what patients can do in response to the practitioner’s instructions, they should surely be able to learn to do for themselves. And here we have the seamless transition from therapy to rehabilitation. Ultimately, the locomo- tor system is the organ of active movement, and for that reason alone, normal and painless active move- ment is the key criterion for treatment success. It is, of course, nothing new to use our own muscles to stretch and limber up if we are feeling stiff. Engaging in forceful, non-specific movements is frequently problematic and may do more harm 236

Therapeutic techniques Chapter 6 than good. Movement restriction is routinely asso- ciated with muscle spasm that specifically protects the lesioned motion segments. Forceful movement suddenly applied to those segments is likely only to increase spasm, with the actual end result being that the normal and even the hypermobile segments are mobilized, while the lesioned segments are fixed even more firmly by muscle spasm. Self-mobiliza- tion techniques must therefore be gentle and slow (as in passive techniques after the slack has been taken up) and as specific as possible. Precise diag- nosis (location) is mandatory, as is careful work to establish the indication for treatment. 6.5.1 Self-mobilization by stretching It is entirely possible for the patient to stretch an Figure 6.67 • Stretching the lateral fascia and muscles of area of skin, and to fold and stretch the subcutane- the trunk. ous tissue, provided that the HAZ is within reach of Figure 6.68 • Stretching the lateral soft tissue of the neck, the hands. It should also be possible for the patient including the trapezius. to rotate or wring the deep fascia at the extremi- ties, and around the neck and thorax. The scalp and heel are other areas that are accessible to self-treat- ment. The same is true for periosteal points. How- ever, self-treatment of the deep fascia on the back is problematic. The literature contains accounts of a wealth of stretching exercises (Anderson, 1980), and good fixation is an absolute prerequisite for these. Two such techniques will now be described. To stretch the lateral fascia on the trunk, the patient stands with legs apart and one arm raised and flexed behind her neck. With her other hand she takes hold of the raised elbow behind her neck and draws her entire trunk into side-bending to take up the slack (see Figure 6.67). She then looks up and breathes in, causing resistance to side-bending to increase. After breath-holding she looks down, breathes out, and simultaneously increases side- bending by pulling on her elbow. This procedure can be repeated. A similar technique is also suitable for the cervi- cal region. The seated patient stabilizes herself with one hand holding the edge of the treatment table or a chair to fix her shoulder; with her other hand she reaches over the top of her head and, tilting it slightly forward, draws it sideways to take up the slack (see Figure 6.68). She then looks up, breathes in, and breath-holds for a short time, causing the tension to increase. She then looks down, breathes out, and draws her head further sideways. 237

Manipulative Therapy 6.5.2 Self-mobilization of the sacroiliac joints Sachse’s technique for self-mobilization The patient is on all fours close to the edge of the Figure 6.70 • Self-mobilization of the sacroiliac joint in the treatment table. One of her knees hangs over the side-lying position. edge of the table, and her instep on that side is hooked over her other leg just above the heel. In of the treatment table). She now places the heel of this position, if she is properly relaxed, the weight her upper hand on her ASIS and exerts light pres- of the overhanging leg with the pelvis brings pres- sure in the direction of mobilization to take up the sure to bear on the supporting knee and, via the slack (see Figure 6.70). Self-mobilization is now per- thigh and hip joint, causes the slack to be taken up formed in exactly the same way as if it were being in the sacroiliac joint on the supported side (see done by the practitioner, that is using rhythmic Figure 6.69). The moment the well-relaxed patient springing pressure in a ventrocranial direction using senses tension in the region of her sacroiliac joint, minimal force at a rate of about two per second. she makes a very small downward springing move- ment with her knee hanging over the edge of the Even though this technique appears to be treatment table, moving in a vertical direction, thus straightforward, it is often difficult to make the amplifying the feeling of tension in the sacroiliac precise direction of the hand movement clear to joint when she moves up. This mobilizes the sacro- the patient. For anatomical reasons alone it is not iliac joint on the supported side. possible for her to align her forearm with the direc- tion of springing pressure. It can therefore be help- In terms of technique, it is important that the ful if she uses her other hand to reinforce the action patient lifts only very little so as to avoid trunk of the hand originally placed on the ASIS, and if rotation. it is explained to the patient that the direction of springing is in fact along the line of the forearm of Self-mobilization in the the reinforcing hand. It has further been shown that side-lying position self-mobilization by the patient is only achieved if she contracts her brachial biceps, that is if she The patient is side-lying on her non-lesioned side flexes the elbow of the arm that is uppermost. with her underneath leg extended and her upper- most leg flexed approximately at right angles at the hip and knee (which is resting on the padded surface 6.5.3 Self-mobilization of the lumbar spine Figure 6.69 • Self-mobilization of the sacroiliac joint on the Self-mobilization of the lower lumbar side of the supported knee (Sachse’s method). spine into anteflexion and retroflexion The patient sits back on her heels with arms stretched forward and supporting herself on her hands resting on her knees. By contracting her gluteal muscles, she raises her pelvis, producing 238

Therapeutic techniques Chapter 6 the motion segment to be treated using the radial edge of the forefingers of both hands; or she may fix the lower vertebra of the motion segment to be treated using the tips of her thumbs. Using the fixation point of her hands as a fulcrum, she then very specifically performs rhythmic repetitive movements into retroflexion or side-bending (see Figure 6.72). Fixation from above (by the forefin- gers) is indicated if there is hypermobility above the segment to be treated, and from below (by the thumbs) if there is hypermobility below the seg- ment to be treated. Therefore the lumbosacral segment (L5/S1) is always fixed from above, and the thoracolumbar junction is always fixed from below. Forceful movements of large range must be avoided. Self-mobilization of the lumbar spine (McKenzie techniques) Figure 6.71 • Self-mobilization of the lumbar spine: Techniques elaborated by McKenzie (1981) can be (A) anteflexion; (B) retroflexion. used here in simplified and modified form; these are especially effective in intervertebral disk her- kyphosis of the lower lumbar spine. When she niation, irrespective of whether we are dealing relaxes, her pelvis tilts forward, producing lordosis merely with low-back pain or with radicular pain. at the lumbar spine (see Figure 6.71). This exer- Only the simplest techniques will be described cise (raising the pelvis using the gluteal muscles) is here because, in our opinion, these are the only also very helpful as preparatory training for stand- ones that can be mastered by patients in a self- ing correctly. treatment setting. Of fundamental importance here is the frequency with which the patient needs Self-mobilization of the lumbar to exercise: sets of ten repetitions, ten times daily spine into retroflexion and for exercises into extension, and sets of ten rep- side-bending etitions but only five times daily for exercises into flexion. Fixation is absolutely crucial for this exercise. The patient may either fix the upper vertebra of For the exercise into extension, the patient is prone and raises his trunk with arms straight while moving his pelvis up as little as possi- ble from the treatment table (once his arms are straight, he stops; see Figure 6.73A). If the pain is acute, he should raise his trunk only as far as is bearable. However, if he is comfortable in the lor- dotic posture with arms straight, he can intensify the effect by exhaling deeply (synkinetic contrac- tion of the erector spinae muscles during exhala- tion in lordosis). He can also practice retroflexion in the standing position, as in Figure 6.72A, the difference being that he fixes his buttocks with the palms of both hands. For the exercise into flexion, the patient is seated on a chair in such a way that on anteflexion he takes hold of a chair leg with both hands between 239

Manipulative Therapy Figure 6.72 • Self-mobilization of the lumbar spine, with fixation from above (A) into retroflexion and (B) into side-bending; and with fixation from below (C) into retroflexion and (D) into side-bending. his own spread legs. Then, by flexing his elbows, he 6.5.4 Self-mobilization of the rhythmically and repetitively daws himself down thoracic spine and ribs into anteflexion (see Figure 6.73B). Retroflexion self-mobilization It is important to take due note of McKenzie’s instructions, especially in the event of radicular The patient is seated upright with arms abducted syndromes: according to McKenzie, pain during and and flexed at the elbows. Sitting absolutely upright after the exercise should not project into periph- – including her head – she rotates her upper arms eral regions, that is from the gluteal region distally. dorsally with the help of her forearms, produc- However, the patient may continue if the pain is ing extension of the mid-thoracic spine without ‘centralized’ from the periphery, that is if it is pro- jected proximally. 240

Therapeutic techniques Chapter 6 Figure 6.74 • Retroflexion self-mobilization of the thoracic spine. Figure 6.73 • Self-mobilization of the lumbar spine (McKenzie technique): (A) into extension and (B) into flexion. dorsal flexion of the thoracolumbar segment (see Figure 6.75 • Anteflexion self-mobilization of the thoracic Figure 6.74). In this position, she slowly breathes in spine on inhalation, with the patient sitting on her heels and and then out as far as she can, thus activating her in maximum anteflexion. abdominal muscles and forming a fixed point around the xiphoid process that prevents any retroflexion of is resting on the padded surface of the treatment the trunk. She can also perform the exercise stand- table. Her arms are held straight at her sides (see ing and leaning against a wall, pressing her pubic Figure 6.75). In this position, the patient con- symphysis forward in the process. At this point, it sciously breathes into her back: she will quickly will be helpful to recall the technique used to mobi- learn how to direct her breathing specifically into lize the thoracic spine in the seated position (see the restricted segment. This can first be checked by Figure 6.38). This may be used for self-treatment the practitioner by inspection or palpation and then but is only indicated if thoracolumbar hyperexten- by the patient using her own fingers. sion does not occur simultaneously. Self-mobilization of the upper ribs Anteflexion self-mobilization on inhalation on inhalation Where there is movement restriction (stiffness) of The patient sits on her heels and lays her upper the upper ribs, the patient sits bending forward and body forward over her knees so that her forehead turns her head toward the side to be mobilized, while 241

Manipulative Therapy backward, together with the spinal segment that is above this fulcrum (see Figure 6.77). In this set- ting, it is important that the movement is not per- formed like anteflexion or retroflexion but that the patient’s head moves horizontally forward and backward. In terms of mobilization, it is only the backward movement that is important; the forward movement should be only minimal. Figure 6.76 • Self-mobilization of the upper ribs on inhalation with head rotated. looking up as far as she is able to (see Figure 6.76). She lets one arm hang down between her knees (which are slightly apart) while the other hangs down at her side. In this position, the upper ribs on the side to which the patient’s head is turned bulge slightly and the slack is taken up. The patient performs mobi- lization by breathing specifically into those ribs. Self-mobilization of the thoracic spine in rotation This technique is identical to the relaxation self- treatment method for the thoracolumbar erector spinae, quadratus lumborum, or psoas major, which are in a chain reaction pattern (see Section 6.6.4). 6.5.5 Self-mobilization of the cervicothoracic junction and first rib Forward and backward movement of the upper thoracic spine and cervicothoracic junction The seated patient leans against a chair back in Figure 6.77 • Self-mobilization of the upper thoracic spine such a way that the lower vertebra of the restricted and cervicothoracic junction by (A) forward and (B) backward motion segment to be treated is fixed in a stable movement of the head, with the back supported at the lower position. She then moves her head forward and vertebra of the segment to be treated. 242

Therapeutic techniques Chapter 6 Rotation self-mobilization at the Self-mobilization of the first rib cervicothoracic junction (according to Gaymans) The technique for self-mobilization of the first rib is identical to the mobilization technique accord- Internal and external rotation of the arms out- ing to Gaymans (1973) (see Figure 6.50). The stretched to the sides has some mobilizing effect patient offers isometric resistance with her head on the cervicothoracic junction. This effect is con- against the gentle repetitive lateral pressure deliv- siderably enhanced if the two arms are rotated in ered rhythmically by her hand at a rate of two opposite directions, that is one from supination pushes per second. into pronation and the other from pronation into supination. However, this alone is not enough. The 6.5.6 Self-mobilization of the exercise becomes very effective if the head is also cervical spine rotated simultaneously, in the same rhythm as the arms and preferably toward the hand that is rotat- Side-bending self-mobilization ing into pronation (thumb pointing downward). Care must be taken not to lift the shoulders, and The patient is seated upright. Using her hand on for this reason the patient’s arms should not be the side toward which she intends to bend as a horizontal but slope down at a slight angle (see fulcrum, she reaches over her head to the opposite Figure 6.78). This technique is performed energeti- side and side-bends her head with a minimum of cally and is not well tolerated by patients with a flat force to take up the slack. She then looks up and (hypermobile) upper thoracic spine. breathes in slowly, holds her breath, looks down while breathing out, and relaxes into side-bending. For RI she side-bends actively against repetitive Figure 6.78 • Rotation self-mobilization at the Figure 6.79 • The patient sits upright and bends her cervicothoracic junction, by a combination of arm rotation in head with her left hand to the right over her right hand as opposite directions and head rotation in the direction of the a fulcrum. She first looks up and breathes in, breath-holds, pronated forearm. then looks down and relaxes into side-flexion. 243

Manipulative Therapy Figure 6.80 • The patient side-bends actively against repetitive moderate resistance by her hand. moderate resistance applied by her own hand (see Figures 6.79 and 6.80). Anteflexion and retroflexion self-mobilization between occiput and atlas For the atlanto-occipital joints the exercise involves Figure 6.81 • Self-mobilization of the craniocervical a nodding movement. Standing or sitting upright, junction with head rotated to the side using a nodding the patient turns her head to the side so as to lock movement (A) into anteflexion and (B) into retroflexion. the cervical spine. In this position she executes a (C) Self-mobilization by slight but fast shaking pressure of nodding movement by dropping her head toward both hands with the arms abducted in the direction of the her larynx and then lifting it (see Figure 6.81A and axis of the cervical spine. B). As soon as she has engaged the barrier (taken up the slack) in one or other direction, she facilitates an additional brisk nodding movement downward by looking down and exhaling quickly, or upward by looking up and inhaling quickly (through her nose). PIR of the sternocleidomastoid is also recom- mended (see Figure 6.96). The following very effective and simple tech- nique is based on activation of the deep stabilizing muscles of the upper cervical spine: the patient is seated upright and places her two hands from either side on the crown of her head. She then exerts slight but very rapid, centered pressure on her head in the direction of the axis of the cervical spine. Care must be taken to avoid anteflexion– retroflexion and laterolateral flexion: there should be only slight vertical springing (see Figure 6.81C). 244