Advanced Soft Tissue Techniques

M ET in joint treatment 229 General principles of M ET for rib dysfunction Figure 6. 1 3 Position for M ET treatment of restricted (elevated) 1 st rib on the right. Before using MET on rib restrictions identified in tests such as those outlined above, appropriate my hand'. This 5-7-second effort will activate attention should be given to the attaching muscu­ and isometrically contract the scalenes. lature, for example the scalenes for the upper ribs, and pectorals, latissimus, quadratus lumborum • On releasing the breath, slack is taken out of and others for the lower ribs (see Ch. 5). the soft tissues as all the movements which preceded the contraction are repeated. Additionally, before specific attention is given to rib restrictions, evaluation and appropriate • Two or three repetitions usually results treatment should be given to any thoracic spine in greater rib symmetry and functional dysfunction that may be influencing the function balance. of associated ribs. Attention should also be given to postural and breathing habits that may M ET treatment for restricted 2nd to 1 0th ribs be contributing to thoracic spine and/or rib dysfunction, and appropriate re-education o MET method for elevated ribs (Fig. 6.14) and exercise protocols prescribed (Chaitow et al 2002). • The most inferior of a group of elevated ribs should be identified. M ET treatment for restricted 1 st rib (Fig. 6. 1 3) • The patient is supine and the practitioner stands at the head of the table, slightly to the • The patient is seated. left of the patient's head, with the right hand (for left-side rib dysfunction) supporting the • To treat a right elevated 1st rib, the practitioner's patient's upper thoracic region, forearm left foot is placed on the table and the patient's supporting the neck and head. left arm is 'draped' over the practitioner's flexed knee. • The practitioner's left arm is flexed, with the elbow placed anterior to the patient's shoulder and with the left hand supporting the patient's (side of) head. • The practitioner makes contact with the tubercle of the 1 st rib with the fingers or thumb of his right hand, taking out available soft tissue slack as steady force is applied in an inferior direction. • The practitioner eases his flexed leg to the left and simultaneously uses his left hand to encourage the patient's neck into a side­ flexion and rotation to the right, so unloading scalene tension on that side and encouraging the 1 st rib shaft to move anteriorly and inferiorly. • The contact thumb or fingers on the rib tubercle/shaft take out available slack, and the patient is asked to 'inhale and hold your breath for a few seconds and at the same time gently press your head towards the left against

C HA P TER SIX 230 MET and the treatment of joints • The left hand is placed so that the thenar o MET method for depressed ribs (Fig. 6.15) eminence rests on the superior aspect of the In this protocol various muscles are used costochondral junction of the designated rib, for different depressed rib restrictions (see method close to the mid-clavicular line (for upper ribs; below), based on their attachments. Goodridge & for ribs 7-1 0 the contact would be more lateral, Kuchera ( 1 997) list (and recommend patient closer to the mid-axillary line), directing the positioning to treat) the appropriate muscles as: rib caudally. 1. Rib 1: anterior and middle scalenes. The patient's • The upper thoracic and cervical spine is then eased into flexion, as well as side-flexion ipsilateral arm is flexed, forearm resting on towards the treated side, until motion is forehead, head rotated away from the side to sensed at the site of the rib stabilisation. be treated (towards the left in this example). The patient is instructed to attempt to flex the • If introduction of side-flexion is difficult, the neck and head further, against resistance for patient should be asked to ease the left hand 5-7 seconds. (in this example) towards the feet until motion is noted at the palpated rib. 2. Rib 2: posterior scalene. The patient's ipsilateral • The patient should then be asked to 'inhale arm is flexed, forearm resting on the forehead, fully and hold your breath' (producing an head rotated away from the side to be treated isometric contraction of the intercostals as well (towards the left in this example). The patient as the scalenes) and to attempt to return the is instructed to attempt to move the elbow trunk and head to the table, against the and head anteriorly against resistance for practitioner's firm resistance. 5-7 seconds (see Fig. 6.15). • On release and full exhalation, slack is 3. Ribs 3-5: pectoralis minor. The patient's head removed from the local tissues (with the thenar eminence holding the rib towards is in neutral, the arm flexed and placed its caudad position) as increased flexion and alongside of the head. The patient is asked side-flexion is introduced. to bring the elbow towards the sternum against resistance for 5-7 second�. • This sequence is repeated once or twice only, and usually results in release of the group of 4. Ribs 6-9: serratus anterior. The patient's head is 'elevated' ribs. in neutral, the elbow flexed, the dorsum of Figure 6. 1 4 M ET treatment of elevated rib. the hand resting on the forehead. The patient is asked to bring the hand anteriorly against resistance for 5-7 seconds. 5. Ribs 10-12: latissimus dorsi. The patient is prone; the arm, elbow flexed, lies in abduction between 90° and 130°, depending on localisation of forces to rib being treated. The patient is asked to abduct the arm against resistance (see Fig. 6.16). Method: • The most superior of an identified group of depressed ribs is treated. • The patient is supine and the practitioner stands on the contralateral side, and places his table­ side arm across the patient's trunk, inserting the hand beneath the patient's torso so that he can engage, with fingertips, the superior aspect of the costal angle of the designated rib (the most superior of the group).

M ET in joint treatment 2 3 1 Figure 6. 1 5 M ET treatment of depressed 2nd rib. • The patient's head or arm is placed in the Figure 6. 1 6 MET treatment of depressed 1 1 th a nd/or 1 2th most suitable position so that an isometric ribs. contraction will engage the muscle(s) most likely to influence the key rib (see the list and • After 5-7 seconds, and complete relaxation suggestions above). by the patient, the rib is drawn superiorly towards its new barrier via the finger contact. • The patie.'1t is asked to move the head or arm as appropriate (see list above), against • A repetition of the procedure should then be practitioner resistance, while holding the carried out and the rib reassessed for motion. breath (this produces an isometric contraction of the intercostals), for 5-7 seconds. M ET treatment for elevated 1 1 - 1 2th ri bs (Fig. 6. 1 7) • On complete relaxation the fingers draw the rib inferiorly, to take out available slack, and the • The patient is prone, arms at his side, and the process is repeated at least once more before practitioner stands on the contralateral side to reassessment of rib movement is carried out. the dysfunctional ribs. M ET treatment for depressed 1 1 - 1 2th ribs • For right-side 1 1 th and 1 2th elevated ribs, the (Fig. 6. 1 6) practitioner places the thenar and hypothenar eminences of his cephalad hand on the medial • The patient is prone, and the practitioner stands aspects of the shafts of both the 11 th and 1 2th on the ipsilateral side, facing the patient. ribs (these two ribs usually act in concert in the way they become dysfunctional). • For left-side depressed 1 1 th rib, the patient places his left arm above his head and the • The practitioner's caudad hand grasps the practitioner holds that elbow with his patient's right ASIS. cephalad hand. • The patient is asked to exhale fully, and hold • The practitioner locates the depressed 1 1 th rib this out, and to reach towards the right foot and draws it superiorly to its barrier, with his with the right hand, so introducing side­ finger pads. bending to the right, taking the elevated ribs towards their normal position. • The patient is asked to breathe in and hold the breath, while simultaneously attempting to • At the end of the exhalation the patient is asked bring the elevated and abducted left elbow to bring the ASIS firmly into the practitioner's sideways, back towards the side, against hand ('push your pelvis towards the table'). resistance.

232 C H APTER SIX MET and the treatment ofjoints c:: Figure 6.1 7 M ET treatment of elevated 1 1 th a nd/or 1 2th ribs. • After 5-7 seconds and complete relaxation, Figure 6.1 8 Genera l M ET for release of l ower thorax and the practitioner takes out all slack with his d i a p h ra g m . contact hand and the process is repeated, before retesting. and to 'bear down' slightly (Valsalva manoeuvre). These efforts introduce isometric Q General thoracic cage release using contractions of the diaphragm and intercostal muscles. � M ET (Fig. 6. 1 8) • On release and complete exhalation and • The patient is supine and the practitioner relaxation the diaphragm should be found to stands at waist level facing cephalad, and function more normally, accompanied by a places his hands over the middle and lower relaxation of associated soft tissues and a more thoracic structures, fingers along the rib shafts. symmetrical rotation and side-flexion potential of the previously restricted tissues. • Treating the structure being palpated as a cylinder, the hands test the preference this Assessment and M ET treatment of cylinder has to rotate around its central axis, sacroil iac (51) and i l iosacral ( I S) one way and then the other: restrictions • 'Does the lower thorax rotate with more difficulty to the right or to the left?' In order to usefully apply MET to SI and /or IS (or other pelvic) dysfunction, it is necessary to assess • Once the direction of greatest rotational the implicated joint accurately. This seems to be restriction has been established, the side­ easier said than done . bending one way or the other is evaluated: • 'Does the lower thorax side-flex with more A survey of Australian osteopaths (Peace & Fryer difficulty to the right or to the left?' 2004) evaluated what tests were most commonly used, and whether correlation existed between the • Once these two pieces of information have tests and clinical experience. The results revealed been established, the combined positions of that, amongst the 1 68 responders (representing restriction, so indicated, are introduced. approximately 30% of those surveyed), the commonest assessment tools for the SIJ involved: • By side-bending and rotating towards the tighter directions, the combined directions • Asymmetry of bony landmarks (most commonly PSIS, ASIS and iliac crests) of restriction are engaged, at which time the patient is asked to inhale and hold the breath,

MET in joint treatment 233 • Motion tests (most commonly prone sacral The lead author suggests that form and force springing, standing flexion and ASIS closure assessments (as described below) be compression) carried out before moving on to use of other test procedures, in order to establish that the SIJ is • Pain provocation tests (prone sacral spring, indeed responsible for the individual's symptoms. ASIS compression and SI] spring/ ' thigh In order to understand the concept of form and thrust') . Additionally, piriformis assessment force closure the functional stability of the SI], was reported as being commonly tested for particularly during the gait cycle, is briefly tenderness and tissue texture change. summarised in Box 6.2. Few, if any, of the tests mentioned have been shown Form and force assessment to consistently offer accurate clinical information, and some have been shown to produce positive VQ Supine functional SI assessments (form/ results in asymptomatic individuals (Dreyfuss et force closure) (Vleeming et al 1995, 1996, a1 1994, Meijne & van Neerbos 1 999, Kokmeyer & 1997, Barker et al 2004, Lee 1997, 2000) (Fig. van der Wurff 2002). 6.20A, B) Additionally, factors such as differences in leg • The patient is supine and is instructed to raise length, body type and dimension, and assymetrical one leg. bone structure, as well as the limited experience and skill of the examiner, create questions as to the • If there is evidence of compensatory rotation clinical usefulness of static assessment findings of the pelvis towards the side of the raised leg, (Cibulka & Koldehoff 1999, Levangie 1 999, Lewit during performance of the movement, or if & Rosina 1 999). pain is reported in the SI] during the effort, dysfunction is suggested. It is further suggested that the distinction, initially made by Mitchell et al (1 979) regarding the need Form closure assessment: to differentiate between IS and SI dysfunction, remains clinically useful. • The same leg should then be raised after the practitioner has applied compressive, medially c!J CAUTI O N : Evidence derived from, for directed, force across the pelvis, with a hand • example, the standing flexion test (as on the lateral aspect of each innominate at the described below) might be compromised by level of the ASIS (this augments form closure concurrent shortness in the hamstrings, since this of the SI]) (Fig. 6.20A). will effectively give either: • If this form closure strategy, applied by the • A false positive sign at the contralateral SI] when there is unilateral hamstring shortness. practitioner, enhances the ability to easily raise For example, left hamstring shortness could the leg, this suggests that structural factors prevent left iliac movement during flexion, within the joint may require externally helping to encourage a compensating right enhanced support, such as a trochanter belt. iliac movement during flexion, or Force closure assessment: • False negative signs if there is bilateral hamstring shortness. That is, there may be IS motion • To test for the influence of force closure, the same which is being masked by the restriction placed on the ilia via bilateral hamstring shortness. leg is raised with the patient simultaneously attempting to slightly flex and rotate the trunk The hamstring shortness tests, as described in Ch. towards the side being tested, against the 5, should therefore be carried out before a standing practitioner's resistance, which is applied to flexion test, and if shortness is found these structures the contralateral shoulder (Fig. 6.20B). should be normalised, as far as is possible, prior to the IS flexion tests, described below, being used. • This increases oblique muscular activity and force-closes the ipsilateral SI] (which is being assessed).

CHAPTER SIX 234 MET and the treatment of joints Box 6.2 The sacroiliac joint during gait Tibia lis anticus l i nks via fascia to peroneus longus under the foot, thus completing this elegant sling As the right leg swings forward the right i l i u m rotates mechanism (the 'anatomical stirrup') which both braces backward in relation to the sacrum (Green m a n 1 996). the SU and engages the entire lower l i m b in that S i m u l ta neously, sacrotuberous a n d i nterosseous process. liga mentous tension i ncreases to brace the sacro i l iac Biceps femoris, peroneus longus and tibialis anticus I joint (SU) in preparation for heel strike. together form this long itudi n a l muscle-tendon-fascial Just before heel strike, the i psi latera l ha mstri ngs a re s l i n g , wh ich is loaded to create a n energy store to be activated, thereby tightening the sacro-tuberous l ig ament used during the next part of the gait cycle. (into w h ich they merge) to further sta b i l ise the SU. Vlee m i ng et al ( 1 997) have demonstrated that, As Lee ( 1 997) points out, 'Together, g l uteus maxi mus as the foot a p p roaches heel strike there is a downward and latissi mus dorsi tense the thora columbar fascia and movement of the fibu la, increasing (via biceps femoris) facil itate the force closure mecha nism throug h the SIJ' the tension on the sacrotuberous ligament, while (see fu nctional form and force assessment, in this simu ltaneously tibialis a nticus fires, in order to dorsiflex cha pter). the foot in preparation for heel strike. Latissimus dorsi AB Figure 6. 1 9 A The biceps femoris (BF) i s d i rectly connected to the upper tru n k via the sacrotuberous ligament, the erector spinae a poneurosis (ESA) a n d i l iocosta lis thoracis (IT). B Enlarged view of the l u mbar spine a rea showing the l i n k between biceps femoris (BF) , the l u mbar i ntermuscu lar a poneurosis (LlAl, longissi mus l u mborum (LLl, i l i ocosta lis l u mborum (IL) and m u l tifidus (Mu lt). C Relations between g l uteus maximus (GM), l u m bodorsal fascia (LF) and latisimus dorsi (LD). (Reproduced with perm ission from Vleeming et al 1 999.)