Atlas of Osteopathic Techniques 2ed

A"'Iuimi.mr Ediion: CharlO)' Mitchell & Sus= Rby" .. l'roduc, M_~ Catherine NOrultI Marlu~''W Ma~ Joy Fir.her-William, Hndor M"""P'" A1ici. I_eben Manufaaurint Ma~ !.Urgi< Orucb

n..~ Torry M.Uon Comf"', iIM: SPi Global

Se=nd Edition

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The autho ... , editors, and publisher 1=" eRnod every ellort to ens= tIl21 drug .. lection and do_ .. t forth in this ten "'" in . ccordance with tb< =t rKommend.otions and practice . t the time of publication. H~r, in view of ongoing ..... uch, change. in JO'fl1lD1ent ~tions, and tb< conllt2nt IIow of informatio" reJotintt to drug therapy and drug ",. ctions, tb< reader is urgM to checl; the p"chge ir=rt for each drug for any change in indications and dosage and for added warnings and prec. utions. This is particuI.orly important when tb< recommended agent is new or ~eotly emplOj'M drug.

Some dru{IlI and medical devices prH

1ledi:3tian I'n!faoo !II !he First E6bon w I'n!faa! 1D!he Second &hlJon ..

~""''''IS to !he First EdilJon lO ALb", .. ! .... , .. ,lSto!heSecondEditoan lOii

PART 1 OSTEOPATHIC PRINCIPLES IN DIAGNOSIS

Chlpter 1 I'Ti nc ipk!s of !he OstBOPBtNc Exaomination Chapter 2 OSl9Op8thoc: StatH: ~usculosk&letal &ilmirliltion Chlpterl S~na l Regional Range of Motion . Chapt .. 4 Osteopathic: Layer.bo,o.laya, Palpation . Chlpt .. 5 Inler~ Motion Teiti~

PART 2 OSTEOPATHIC MANIPULATIVE TECHNInUES

CtI'pI" , Pronc,~ of Osteopodut ~pulatove TedriquBs .. _., SolI TISS\JIt Tec:Inques CtlIpI" Myofu;oeI fIeIee,s. Tadnques _., !:wIllOW., JecMiques

--" Musde &.gy Tadnques

a..,.: .. n H9'-\4aIo;I!y. Low-~ TedwolQU8$ n..,..12 fd18l8d I'oSItO'IIf I1eIesw Tedri;p.on CbIpIIfU Tadnques 01 Still ChIpIlf 14 a.. it8CI UgamerolllUl T6'ISIOI1 8IId ~t .... Altia.t. StJain Ti!CIniqu!s .. a.lpllf15 Visceral Techroques a.lpllf l6 L"fI'1INtIC Tedwooqun a.lpt., n ArloculalOly 8IId Coobiioed Tedwooqun . Chlpt.,11 Ost8Opllhy in !he Crln&el field

IlIhx ill

1

. . 3 6 ..

~ ~

73

15

"

'" '"

....... .

'" '" .. .. ,

'" m

'" 530

'"

"

Chapllr 3 fofward 1Io!ndinIj ..... _ genIIing

(Rmln ..... f.o,

long ~ (Log lqth) SacroiI'" J

Trapelius, _tory PreSSiJl., ~"" Upper Thoracic""!11 ShooIder Block, Late Upper f'DIe l5 ~igI1lit.m Sacroilio< ~igI1'it.m Rare Out Pl.1; Pl4 Lat""" GMoos Medius . Piriformi . Sacral lentlei' Points PSI Biiatol.' . PSl; PS3: PS4 Mid~ne . PS5 Biiatol. ' . l!Jwor El:trernity lentlei'_ T"""", F ...". Lalae Late

AcrnrniocIaW:ular """'t, ~: RigIlt ~tioo [)ytfoootion [Restrict,," Abdt.:atioo .. J:I3

ArIomiocloW:ular -Oiot, ~: RigI1t IIlIernal llotiltion DysfIn:Iioo [Restrict,," Eo:tema i llotationi Post I>ometric Rela>:ation. . . 324

ArIMli:laW:ular -Oint, ~: RigI1t ExtemaIllatation [)yW'Ictioo [Restrict,," Intemaillatatiool Post Isoole1ric Rela>:ation. . 325

Po:Iteriol Radiaillea.l, Pronation DysfL01C:tion' Post Isometric Rela>:ation. . 326

Anterior Radial f\ead, S~ioo DysflW'ictioo' Post Isoole1ric Rela>:ation. . . 327

WriOl [RadiocItr)l;lII MJucticM'I/\J Inar [)eviation. Post Isoole1ric relaxation . . 328

WriOl [Radioca!)lall AtWction,IlI;lO,,1 Deviatioo, Post Isometric Rela>:ation. . . 329

Wriot [Radiocarpall Flelion DysItn1ioo, Post _" Relaxatioo. . m WriOl [Radi:at"". . 334 Ti ... : External Rotation ,,"ttl MtetOfl\!!di;! I Glide

Post Isometric Rela>:ation. . 33S Ti ... : IntemalRotation ,,"ttl Posterolatet.1 Glide

Post Isoole1ric Rela>:atiorL .. 336 Ti ... : Internal Rotation ,,"ttll'tl:at"". . 337 T~ibular Joif1t Ilyofunction OiagMsis ~ TMJ

DysfuIc!ioo Jaw Deviation 1Il1ho ~ Post Isoole1ric Relaliltion. . . 338

Hypertmi< MwcIe:I of Mootica1ion Restricted.ltN:ilt"". . . 339

Hypertmi< MwcIe:I of MoOlicalion Restticterl Jaw/ Moottl Closing Post 1_" Relaxatioo. . . . 340

Chapter 11 Occ:ipitoatlarltal [m-I, OAI [)ytflW'ictiorls,

~: 01\ FIE", N-SlRR.. ..345 Atlonto;uial [CI -2, AAl ti,'orur.:tion, xI"r~", CI ill .. 346 f:l -7Ilysf1n:!icJm, ExarnpIo: C4 FSlRl. Shart-l....,,-,

Ratat_ ~s . . . 347 f:l -7Ilysf1n:!icJm, ExarnpIo: CS ESRIlR, Lang-leYer

Ratat_ ~s . . . 348 f:l -71lysf1n:!icJm. ExarnpIo: CS NSlRL Stlart-lel'er

Tec:hrtiqlIe. Side-BeMing EmpM.is . . . 348 TI-12, Nartraillysfln:!icJm, ExarnpIo: T5 NSIlIIL Stipne .. JS() TI-12 -Re""'- [)ys1ooctiMs. ~:T4FSU!l ~ne .. JS2 TI -12 -Ext""""'- [Iysf\Ilct""" ~~: T'J ESRRR Supil'le . . . 354 TH Extefdioo ti,'oflW'ictiorls. EtompIe: T4, ERRSR, ~

[Combined Lang ..... Stlart llMJrl . . . . 3SIi THI Dysf...-.c:tioo!. Eal . 3115 Elw.., Ettemiorl DysflW'ictiorllPrmimal ow.., Ulnal . 386 Elw.., Radial f\ead, Sl.fIirIatioo Ilyofunction . . 387 Elw.., Radial f\ead, Pr.,..,t"" [Iysf\Ilct"" . 388 Elw.., LIIMr Ab:Ioctiaf1_ Mod"" GI~, ~ RigI1t

EI------.ruea ... Carrying ~ ,,"ttl lJi.tallJr>a l

xx USTQFTECH NlnUES

Rijlt-Sided Trapez'" Musfoootion. Pwterio< E....-.non: ~at""l

ModeI , SoftllSSlJeEffec:t. ..410 Left ~ Rib. InIIItlation tiv>flW'lCliM . . . 411 LI5 [)yofoootiMs, ~:l3 NSlRR. ..412 LI5 [)yofoootiMs, ~:l4fSRRR . ..413

~SidOO Erector SpiMe MuocIe Hyportrnicity .. (14 ~ Pnsterior Imominat. [)yofL.OlC:lioo . . . (15 ~ Mttt"" Imlrninate [)ysfln:tion, . . . 416

Chapter 13 Occipitoatlarrtal{CIl-I. OAI [)ysfoootiM, ~:

I)) ESRRL. Seauoo . . . 410 Atlantoaltial{C1-211ly>f1.nction. ~: CI AL ~ .. 421 (;1-7 [)ys1In:tioo. ~: VI ESRRft. Supi"" .. 4Z2 TI and T2 [)ysfIJ:lctiom. ~: TI EffiSR. Seated .. 423 T1 andT2 [)y>IIn:tiMs. ~:T2 fRLSL.~. ..424 T1-12 [)ys1ooction:I. ~~ 1> NSlRR, Seated . . . 425 flr:It Rib [)yofl.OlC:lion. ~: RitjII. Poster"",

EIevat!!O rnt Rib (HorI'siIogic. Hof'tes!Ii~ . . . 426 fj"t 01 Stocrod Rill. ~~ Left. flr:It Rib Ethalation

[)ys1In:tioo. Seat"" .. 421 fj"t Rib. Efascial Release. Direct Of lMirec:t.

Se''''". Steering 'MleeI Tec:IYIique . . 5C2 Thor",,, Inlet and Ou!let: M)l>fascial Relea". Direc!, Supine. . 5C3

MiI IerThoracic{t~IIIJill. .504 Miller Thoracic {l~llIJill. ~ Respiration. . 5Ili Thor",,, {l\'l'lllflaticl~, Side Mod ificat iM . 500 Thor",ic {ll"'flll;lticl~, Atelec:ta,i. Mod ifica! iM . 5(]7 PfJct0r31 Traction: PfJct0r3 l ~ Major. PfJct0r3 l ~ Mi"", ......

.v.terio< Deltoill. . . 500 Rill RIIiling: B

Mesefltert _ .... Ascending Colon . . ..51 4 Mo1entert _ , Destend~CoIon. ..516 rre...:ra l Release, Oirec! OIln:Iitoc! .. 518 r.tarian Clart Dr......... .519

l";'OrectaI fossa1lo""".~. ..520 1";'0rectaI fossa 1Io1ease. Prone . 521

~I ~{DaI!jiO Muodes .. 527 Posterior A>: il larv KMd. Soft TIssue _!ion. Sup;ne

{e.g., RiqI!. PooteriOl Alillaly FoIdI-. ..5:18

Chapter 11 Shoolder Girlie, s;.enoer Tedv'Iiqo.>e. . . 532 Shoolder Girlie, ~ T~ Stage l--SOOoider

&ter!1ioowi!"EI __ . ..533 Shoolder GiIe Stage ~""

and T!atI",,,,ith EI_ Ett!ll'ldeO .. 5J6 Shoolder Gir"", :;p.oc.. Tedv'Iiqo.>e Stage 5A----AbdIo:!ioo

wi!" E_ Flexed. . . 537 $MuIderG irId . . 560 Sacral fk>Id. 501 IlecoonfwwlM of tt.e lb:ipiIaI Coo:IyIeo . . . 502 Occip;1M11M!a1 D

xviii LlSTOFTECll*lrion 0pI\rIctIonIj _ _ _ _ 261 PtoIJIis Mil" M.oIo:Ie. _ _ _ 26l RiJlt Rib 1. 4, til 5, EINIatj"" ~tiMutdI Cuo1~~ MoM_ Atlii::WticJl __ m FtMl GIIlIlifog 01 tht Pubic Symptoyo j. \A.bWtteOl Pubic IIMMI'

Muoda Cuo1trae1ion IdotiiIi>eo Aniih.",. -. s.mw til DYonit OysI\n::tiCrl: I'Dst _itPthQlion ___ JJ2

Forw.d ,ontiGft AIxd 0l11li CloI"", ...... ~ (JlllII CuonboIed AIctopi ..... 114 .. 1ioo,..,_ Cutelioo, MoIIiIiOII ~ _ _ ___ :Jll

Forw.d lontiGft AbtU. ft9tI CloIicp .... is 1Ai1W on Pi(fCI: CuontoirtoIcI RtcipoOC&l _lion 1116 Muocit CoItrticJl

Mobil i~ AtlitulatiJIol1lll CloIique .... ~ IRog/lt "" lII

CuontoirtoIcIIIecipocoIIYoibilion n ~ CIInIr1iM ~~_ _DI

Bod;-.Ilonion..t.boolt. fI9lI CloIquo""'. ~ on II9ttt-~ l\Ki .. " ..... 1.4 .. 1ioo,.-.d _ CllnlrIlOticwo ModiOII~_ _ _____ 310

o..Mew '" IN Slcrallonoion 0pf\rII0n ______ 31Z lI'tilllllrll APed s..cnn on tilt IJ!It. Rt_, .t.ssist 31. Lnl.otlilll bUInded s.m..n on tht IJ!It. """"'"101'\' ASsjjI __ 315 I>IatoIaIt!' FIe..;ed Skr\In. ResfWator; Aais\ __ 31B

Bj1a!e

OSTEOPATHIC PRINCIPLES (PHILOSOPHY) -rn., primary goal of the Educational Council on Osteopathic Principle. (ECOP) of the American Asso-ciation cfCelle"". ofOsleopathic Medicine i'lo evalu-ate the mo,t current knowledgmtly studying the moot current u"nds in oOleopathk principles and practi",". as well ao the basic science dal>lba.e, thi. commime produces a gl""ary of osteopathic u.rminology that is the [angus&" standard for teaching this .ubject. II was originally c"'Rled to develop a .ingle, unified osteo-pathic terminology to ~ used in all American osteo-pathic medical schools. One of the ""asons Nichola. S. Nichola., DO, FAAO, published In. original Au"" of O", and its passiv~ limit is

d~.cri~d as the a .. arom!.: bam" (1). This barrier mar ~ the most important to und~rstand, a. m"",ment ~yond this point can disrupt the tissues and may ...,sult in .ubluntion or di.location. Ou~opathic techniqu~. mould n"""r involve movt:m~nt pa.t!hi. barri~r.

Th~ phy

4 PART' I OSTEOPATllIC PRINCIPLES IN DIAGNOS IS

pbylioloP: batrim; may IN: demonslJ'ated ( 1). The resmctM barrier, 1M major aspect of the ovenoll dys-functional paUtttl, can IN: diminated Of minimiu.t with osteopathic (ron io _ablo: ulintl ost motion;' frftr; and ) U\

(e.g., HVIA). Articular dy.fimctions, on !he other hand, ....., best treated with an articular technique, such as HVLA, and myofascial ttl"""" wollld ~ less appropriate.

VISCERAL-AUTONOMIC COMPONENTS Some dy.fimctions may directly aff~ct an area (~.g., small intestines with adhesions), while other dr"functions may

~ mo,.., rdIexively important (i.e., cardiac arrhythmia-somatovisceral rdIex). Somatic dysfunction may cau.., ",actions within !he autonomic nervous sy.tem and ",slllt in many clinic:ol p",sent:ations, or visceral disorden present with a number of somatic components (3).

ORDER OF EXAMINATION The order of the osteopathic phy.ical examination ill

~st based on the patient'. history and cIinic:ol p",senta-tion. In general, it ill best to ~gin the e=ination br performing the step. that have the least impact on the patient phy.icaUy and that I~ad to th~ l~ast tissue ,..,ac-tivity and least secondary "'flex stimlllation.

General Observation It i. ,..,commended that the phy.ician ~gins with

gen~ral oboerVlltion of the static postutt and th~n the dynamic postlltt (gait and r~gionaI ROM ). F or saf~ty, it ill ~st to ~gin by observing function and ROM with activ~ "'gional motion testing. After e=ining the patient in this mann~r, the ph}'Sician may decide to oboerve the patient'. limits by passive ROM testing. The passive ranges shollld typically ~ slightly guater than thos~ elicited during acti,'e motion assessment. After id~ntifYi:ng any asymmetries or abnormalities at this point, it is ",,,,,onable to proceed to the palpatory examination.

layer-by-layer Palpation The palpatory examination ill aI.o best started by oboerv-ing the area of inte",st for any vasomotor, dermatoIogic, or d"""Iopm~ntal abnormalities. The examination may then proceed to temperat"'" evaluation. The physician may now make contact with th~ patient following a la}'

The osteopathic structurnl examination h.as both S!>ltic and dynamic components. The physician will normally lise static examination a. a method to diocern obvi-OilS structural asymmetries of ",seolls and myofascial origin and el

CHAPTER Z I OSTEOPATlHC STATIC MUSCUlOSKElETAlEXAMI~TION 7

FIGURE 2.1 . Asymmetry in scol iosis.IModified from Nettina SM. The lipp incott Manual of NUrsing Practice, 7th ed. Baltimo re, MD: lippincott Wi lliams & Wilkins, 2001, with pennission.)

Vllltebnt prominoI"" C7 opirou. pro:;:

8 PART 1 1 OSTEOPATlHC PRINCIPlfS IN OIAGNOS IS

Scapula, anterior view

,

FIGURE Z.4. Imponant landmar'


HN::I(~)

-

-FIGURE z.6. landmarks to help determine hooizontallevelness. (Reprinted from Premakur K. Anatomy and Physiology, 2nd ad. Baltimore, MO: lipp incott Williams & Wilkins, 2004, with permission.)


Body planes

Sagittal

Medial

lateral

Directionallerms

_Ox (cephalad)

InlerK.>< (caudad)

_ _ "'"01enor

AGURE 2.7. Planes of the body and directional terms. The coronal plane is assoc ia1ed with b01h the ventra l lanteriorl and dorsal (posteriorI aspects.IReprin1ed from Clay JH, Pounds OM. Basic Clinical Massage Therapy. Integrating Anatomy and Treatment, 2nd ed. Baltimore, MO: l ipp incott Williams & Wilkins, 2008, with permission.1

CHAPTER Z I OSTEOPATlHC STATIC MUSCUlOSKElETAlEXAMI~TION "

On examination note: Midgravitationall ine lateral body line Position of feet

Pronation Supination levelness of tibial tuberosities

levelness of patellae Anterk)r superior iliac spines

level? Anteroposterior: rotational prominence

Prominence of hips Iliac crests, levelness Ful lness over iliac crest Relation of forearms to iliac crests

One longer Anteroposterior relation Nearness to body

Prominence of costal arches Thoracic symmetry or asymmetry ProminerlC6 of sternal angle Position of shoulders

level or unlevel Anteroposterior relations

ProminerlCe of sternal end of clavicle ProminerlCe of sternocleidomastoid muscles Direction of symphysis menti Symmetry of face (any scolios is capitis) Nasal deviation Angles of mouth level of eyes level of supracil iary arches (eyebrows) Head positi on relative to shoulders and body

FIGURE 2.8. Anterior view po ints of reference. IModified from Premakur K. Anatomy and Phys iology, 2nd ed. Ba~imore, MO: Lippincott Williams /I, Wilkins, 2004, with permission.)

12 PART t 1 OSTEOPATlHC PRINCIPlfS IN OIAGNOS IS

On examination note: Midgravitationalline Achilles tendon: straight , curved? Position of feet Relation of spine to midline (curves, etc.) Prominence of sacrospinal is muscle mass Symmetry of calves Symmetry of thighs (including any folds) Symmetry of buttocks lateral body lines levelness of greater trochanters Prominence of posterior superior iliac spines levelness of posterior superior iliac spines levelness of iliac crasts (supine, prone, sitting,

standing) Fullness over iliac crests Prominence of scapula Position of scapula and its parts levelness and relation of fingertips to body Arms (relations) levelness of shoulder Neck-shoulder angles levelofeartobes level of mastoid processes Position of body relative to a straight vertical line

through the midspinalline Posterior cerv~1 muscle mass (more prominent,

equal, etc.) Head position: lateral inclination

FIGURE 2.9. Posterior view points of reference. (Modified from Pre makur K. Anatomy and Physio logy, 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 21114, with pennission.)


~f---a

b On examination nole: Lateral midgravitationalline

a External auditory canal b Lateral head of the humerus c Third lumbar vertebra d Anterior third of the sacrum

c Greater trochanter of the femur f lateral condyle of the knee

d 9 lateral malleolus Anterior and posterior body line Feet: degree of arching or flatness

Knees: degree of flexion or extension Spinal curves: increase, decreased, or normal

Cervical lordosis: posterior concavity Thoracic kyphosis: posterior convexity Lumbar lordosis: posterior concavity Sacrum, lumbosacral angle

Arms: position relative to body f Abdomen: prominence or flatness

Sternal angle Thorax: prominence or flatness Head: relation to shoulder and body

--g

FIGURE 2.1D. Lateral villW points of reference and midgravity line. (Modified with permission of the AACOM. Copyright 1983-2Offi. All rights reserved.)

R"gional motion t ... 1ing

Forward Bending and Backward Bending (Flexion and Extension), Active

1. Th~ patient is !luted.

2. Th~ phy.ician stands at th~ .ide of th~ patient. 3. The physician palpates rru, C7-Tl SpinoUll process

interspace (Fig. 3.1) or the SpinOUll procesoes (Figs. 3.2 and 13).

4. The patient is instructed to bend the head and neck forward to the functional and pain-me limitation of motion (Fig. 3.4).

S. The dogree of forward bmding (flexion) is noted. NCnI!Ul/o ... ",,,,,,l brnding of w uroi

16 PART I 1 OSTEOPATlHC PRINCIPlfS IN OIAGNOS IS

Forward Bending and Backward Bending (Flexion and Extension), Passive

1. The patient is ..,ated.

2. The phy.ician stands at th~ side of th~ patient. 3. Th~ phy.idan palpates the C7-Tl spinous pro-

cess interspace (fig. 3.6) or the spinous processes (figs. 3.7 . nd 111.

4. The phy.ician b"nd. the patient's head and neck forward while monitoring C7 and Tl and otops when motion is detected stTl (fig.3.9).

S. The deg",e of forward b"nding (flexion) i. note

Side Bending, Active and Passive

1. Th~ patient is .uted.

2. Th~ phy.ician stands at th~ .ide of the patient.

3. The phy.idan palpates the tran.veroe proc~es of C7andTl lFig.3.11J.

4 . The pati~nt is instructed to side bend the head and neck to the right to the functional and pain-free limitation of motion (Fig. 1U). This i. repeatm to the left (Fig. 3.13).

s. The phy.ician side bend. the patient'. head and neck to the right while monitoring C7 and Tl and stops when motion i. det:ted at Tl (Fig. 114). This is reJl"ated to the left (Fig. 3.151.

6. The degree of both active and passive side bending i. noted. Normal nlding '" ,~ ~al


Rotation. Active and Passive

1. The patient is ..,ated.

2. The phy.ician stands at th~ .ide of th~ patient.

3. Th~ phy.ician palpates the tran."",""" proc~es of C7andTI (Fig. ! .16) .

4. The patient is in.tructed to rotate the head to the right to the functional and pain-frtt limita-tion of motion (Fig. 117). Thi. i. ,..,,,,,ated to the left (Fig. 3.U ).

5. The phy.ician rotates th" patient'. head to the right while monitoring C7 and Tl and .top. when motion is detected at TI (Fig. 119). Thi. i. rt:p

T14 Side Bending. Passive

1. Th~ patient is outed.

2. Th~ phy.ician stands behind th~ patient . 3. The phy.idan'. left index finger or thumb may

palpate the trans""rse proceo.es of T4 and T5 or the interspa"" between them to monitor motion. Th~ webbing betw"en the physician's right index f1n&"r and thumb is placed on the patient', right .houlder closest to midline at th" levd of Tl (Fig.3.21 1.

4. A gentle springing force is dittcred toward th~ ""r-tebral body ofT4 until the phy.idan fed. motion ofT4 on T5."Ibis is done by Cttating a """tor with the fo",arm that is di",ctly in line with the ""rtebral body ofT 4 (Fig. 3.22)."Ibis is repeated to the oppo-site side (fillS. Uland 124).

S. The degl""e of pa"ive side bending on each side is noted. NO'I"mal titk ~ for T/-4 is 5 10 25 Mgreu.

CHAPTER ! I SPINAlREGlQNAlRANGECFMOTION 19

FIGURE3.21. Stap].

AGURE3.Z2. Stap 4, sida heading right.

AQURE 3.23. Stap 4.

AGURE3.24. Stap 4, side bending laft


T5-8 Side Bending, Passive

I. The patient is seated.

2. Th~ phJl'ician stands bdlind the patient.

3. The phJl'ician'. left hand palpates the transv,"rse processes ofTS and TI or the inte,.,pace b,,""'en them to monitor motion. The webbing b"twttn the physician'. index fingtt and thumb is placed on the patient', right shoulder halfWay b,,""'en th~ hase of the patient's neck and the acromion proces. (Fig.3.251.

4. A ""nile springing force is directed toward. the ""r~ tebral body ofTS until the phJl'ician feds motion ofTS on TI. This is done by Cttating a ""ctor with the fo",arm that is directly in line ,,1th the ""rtebral body ofTS (Fig. 3.21i). This i, repeated to the oppo-site side (Figs. 3.21 and 3.28).

5. The degt""e of pa .. i"" side b"nding on eacb side i, noted. NU1l n& bending for TS-8 iJ /Q f(} 1() ikg..u

T912 Side Bending. Passive

I. The patient is ""ated.

2. The physician stands bdlind the patient.

3. The ph}"ician'slefthandmay palpate the tran."' .... procnsn ofTI2 and Ll or the intel"Space b

22 PART 1 1 OSTEOPATlHC PRINCIPlfS IN OIAGNOSIS

T9-12 Rotation, Active

1. The patient i eated with the artnll cros.ed so that the elbows rnai

T912 Rotation. Passive

1. The patient io ..,ate2. The physician stands at the oide of the patient and palpates the patient'. tran.verse proce ..,s of T I2 and LI, which are u!led to monitor roilltion (Fig.3.lll .

3. Th test passi"" right rotation, the physician's right hand is pLaced on the patient'. dbows or oppos-ing left shoulder. The physician rotates the patient toward the right while monitoring motion at TI2-L1 (Fig. 3.361. TIti. i. repeated to the opposite 'ide lFig. 3.37) .

4. The degree of aeti"" and pllS.i"" roilltion i. noted. Nornt


Forward Bending and Backward Bending (Flexion and Extension), Active

1. The patient stands in a neutral pooition with f~t a .houlder width apart.

2. The physician .tands to the side of the patient so as to view the patient in a sagittal p lane (Fig. USI .

1. The patient i. instructed to bttId forward and attempt to touch the toes without bending the kneeo to the functional and pain-me limitation of motion (Fig. 3.391.

4. The degue of active forward bttIding (flexion) is noted. Illorm

Side Bending, Active

1. The patient stand. in a neutral pooition with feet a shoulder width aport.

2. The phyoician OIands bdlind the patient so as to view the patient in a coronal plane (Fig. 3.41 1.

3. The patient i. instnlcted to reach down with the right hand toward the knee to the functional and pain-free limitation of motion (Rg. 3..42). 'Ilti. i. repeated to the opposite side (Rg.3.43J.

4. The degru of actm side bmding is noted. N{JfflI;l/ tiM bnuii~g;'" W I .. mba,


Side Bending, Passive, with Active Hip Drop Test

1. The patient stands in a neutral pooition with f~t a .houlder width apart.

2. The phyoidan 'Lands behind the patient 110 "" to view the patient in a coronal plane. The physi-cian',

CHAPTER! I SPINAlREGIONAlRANGECFMOTION 27

Normal Spinal Ranga. of Motion for Active end PassiYe Tastinll

Guidll to Evaluation of Angu. CatIIie, D.O. (21 Reyised PCDM (31 Parmanem Impairment (AMAI (If

NORMAL DEGREES Of MOnOM--CERVlCAL SPINE FLEXION 50 ., 45-90

EXTENSION 60 45 45-90 SlOE BENDING AIL 45 ....., 30-45

ROTATION R/l OJ ., 70-90 NORMAL OEGREES Of MOnON-THORACIC SPINE

T1-3 , .. T8-L1 T1~ TH TIl-12 FLEXION 45 EXTENSION 0

I I I ROTATIOti..!!&. 31) ., 70-90

NORMAL DEGREES Of MOTION-lUMBAR SPINE FLEXION so. 70-9\1

EXTENSION 25 30-45 SlOE BENDING AIL 25 25 25-30

ROTATION R/l Aerion . 10"""..0 bending: Extension . b.ckwa..o bending: R/!. . right and left. 1. Re~""'d with permission from Cocd,iarella l. Andersson G (eds). Guides to the Evaluation of Permanent Impairment.

5th ed. New Vorl

EXAMINATION SEQUENCE 1. O"'ervation 2. ThmP"!'lI= 3. Skin topography and textutt 4. Fa.cia 5. Muscle 6. Thndon 7. Ugament 8. Erythema friction rub

OBSERVATION Prior to touching the patient, the phyoician should visualize the aua to be aamined for evidence of trauma, infection, anomalie., g.o a,ymmetrie., skin lesions, andlor anatomic variation . The patient should t." positioned comfortably 00 thaI the most complete e:mmination can be performed. At this point, the pri-mary inlercot i, in chang .. a .. ocialM with somatic dyofunction and any autonomic related effects. The physician should visually ins!",C! the ""'3 for due. that somatic dysfunction may be pre.ent (e.g., h~remia, abnormal bair patterns, nevi, follicular erup-t;ono) (Fig . '-1).

TEMPERATURE nmpua= is evaluated by using the velar a'pect ofm" wrist or the dorsal hypothenar eminence of the hand.-rn., physicion does chi. by placing the wrist. or hands a rew inches above the g",g 10 be tesu.d and using both handll to evaluate the paravertebral area. bilaterally and simul-taneollSly (Fig 42!. Chan~s in heat distribution may be palpated para.pinally a. secondary efI.cts of metabolic

28

FIGURE 4.1. Visual obselVation of patient

processes, trauma, and 80 on (acute inflammatory vef-SIlS chronic fibrotic effects). Heat radiation may also be palpated in other area. of the body (e.g., extttmities, abdomen). If unable to determine the thermal .tatu. of the region in que.tion, the physician may at this point make slight physical contact with the appropriate area of the palpating hand.

SKIN TOPOGRAPHY AND TEXTURE A ""'Y light touch will be llSed. G

AGURE 4~ A aod B: Evaluatioo for thermal asymmetry.

Skin topography and t""t\ltt are evaluated for in=aseFASCIA The physician adds enough pres.lItt to m""" the skin with the hand to ~valu.ate the fascia. This preo.\Itt will cause slight reddening of the nail bed. The physician moves the hand vLIGAMENTS Ugaments must ~ cO!1llid=d when r


ERYTHEMA FRICTION RUB The final step is to perform the erythema friction rub, in which the pads of the physician's second and third digil'O att placed just paraspinaUy and then in two to th",e quid .trokes att drawn down the spine cephalad to caudad. Pallor or reddening is evalu.ated p

CHAPTER 4 I OSTEOPAT11IC LAI'ER-8Y-LAI'ER PALPATION 31

FIGURE U . A. Bilateral percussion using whipp ing motion of wristlfingers. B. Contact sensing tissue texture changes in tension.

levrl {Fig. 4-SA . nd BJ. For ~:mmpl~, th~ physician will start p~rcussing bilat~rally at T ] and with ~ach p"rcus-sion d~scmd inferiorly on~ oegm~nt at a time, even-tually ",aching the LS level. If p"rcusoion r~als tluIt one side fe~ls harder or mo", deru~, the physician can mov" to that side and tap with the fingers of one hand to deterrnin" the ~nent of this chan"" (Le.,T2-7 on th~

]~ft) (Fig. 4.7A ond BI. If the ti ue's t~= i. difficult to

distinguish, or if the phyoician p",fel"S, listening to the pitch of the round the p"r


THORACIC REGION CROSSSECTION

T_ Jl'Iojor m. --,if-

LUMBAR REGION CROSSSECTION

Oua:I8maI oblique m - -ir Inlomal oblique m

TfBn$\lflrSalio fascia

REFERENCE I. Johnston ~ FriedlD2n H D. Function2l M othods: A Mao_

ual for Polp atory SI:ill Development in Ost..,pathic Enmi_ nation ond M:uripulation of Motor Function. Indi2n:opoli. , IN: American Acockmy of Osteopathy, 1994.

\-__ --:::-_ Erector opinaoI m.

Int~ental motion leiting i. classicaUy describW. as an evaluation ohpinal articulatory (fa"'t) motion. In this chapter, it is also considettd as a technique to dicit any motion at a joint (articulation), whether spinal, pdvic, costal, or extrtmity. ~nding on the joint, the motions evaluated may include flexion and enension; rotation; side bending and rotation coupling; translational motions anteriorly, pooteriOl"Iy, or laterally; separation 01" approxi-mation of joint surface.; and to ... ional movnnents.

In .pinal motion testing, the physician attempts to di=rn the th~a", morkm and the ",lation ~"ttn side bmding and rotation (coupling). The phyoician can determine the coupling statu. and whether the articu-lar .omatic dysfunction is e>:h.ibiting a ~ I (oppooite

AllURE 5.1. Type 1 spinal coupled pattern.

side) or ~ 2 (same side) pattern (Figs. 5.1 . ad 5.2). In the thoracic or lumbar "'gion, if the dyofunctional pat-tern i. found to ~ ~ I, the =m.ination i. complete, as the segment has a neutral ",Iation with the coupling. If the dyofunction exhibits a ~ 2 coupling pattern, the pbysician must typically continue the =m.ination to determine whether a flexion or enen.ion component is as.ociated with the coupled motions of the dysfunction. In the cervical spine, these coupling ",lations follow a difl"e",nt set of biomechanical ruI .. from those of the thoracic and lumbar "'gions. In the cervical spine, flex-ion, extension, and neutral components may be found with ~ 1 or 2 coupling; 01" in the case ofCI-2 motion,

th~ may be no coupling at all.

AllURE 5.2. Type 2 spinal coupled pattern.

33


Some phy.icians p"'fer to .tarl with the flexion and exlension porlion of the e>

~ LUMBAR INTERSEGMENTAL MOYlON TESTlNG

L1 to L5-S1 Rotation, Short-Lever Method. Prone (l4 Example)

1. Th~ patient lies prone on the treatment table with the bead in neutral (if a face hole is present) or rotated to the more comfortable side.~, W titk '" wl&h 'M Mad is roU1ud will t>=;wly ;"""'''"''' 1M ro~ tffta ro Ma! titk.

2. Th~ phyoician stands at either side of the table and palpates the IA transverse processes (level of the iliac crest) with the pads of the thumb. (Figs. 5.3 n d 5.4!.

3. The physician ahemat~ly presses on the left and right trans",rse processes ofIA with firm ventr:ally dittcted impulses to evaluate for ease (rr.,edom) of left and right rotation (Figs. 5.5 and 5.&!.

4. If the right trans",,= p~ rn"""s anteriorly (in"1!l"d) (UJhiu ,,"rI"I)W) rno,"" easily and the left transverse proce .. is resistant, the segment is rotat-ing left more fruly (rotated left) (Fig. 5.J).

S. If the left mtn.""rse procCllS m""". anteriorly (wiriu arl"l)W) mo,"" easily and the right transverse process is ,",,';:stant, the segment is rotating right rno,"" ft~1y (rotated right) (Fig. 5 . ).

6. The left trans""rse process of U in this example may present rno,"" prominently (posteriorly) on static (Iayer-by-laytt) palpation in a rotated left dysfunction.

7. The physician p


WMBAR INTERSEGMENTAL MonON TESTING

L1 to l5-S1 Side Bending. Translational Short-lever Method, Prone lL4 Example)

1. The patient lies prone on the lUatment table with the bead in neutral (if a face hole is p",sent) or rotated to the more comfortable oide.

2. The phY"ician'. thumb. rest on the posterolateral a.pect of the tranwu.e proce .. es (Figs. 5.9 . nd 5.IOf.

3. The physician introduces an alternating translatory glide, left and right, 10 evaluate for ease of left and righl side ~nding.

4. If the thumb translate. the segment mo", easily from left to righI, the segment has its eaoe in left side bending and i. termed sitU ben, kft (Figs. 5.11 . nd 5.l2f.

5. If the thumb translates the ..,gment more easily from right to left, the ""&ment has it> ease in right side ~nding and i. termed sitU ben, righ' (Figs. 5.13 . nd5.14f.

6. The ph)"ician perform. th= steP'" at each ..,gment of the lumbar spine and documents the side-~nd.ing freedom of movement.

FIGURE 5.14. Step 5, side bending right on patient

AGURE 5.9. Step 2, hand position on skelelon.

AGURE 5.10. Step 2, hand position on patient.

AGURE 5.11. Step 4, side bending left on skeleton.

AGURE 5.12. Step 4, side bending left on patient.

AGURE 5.13. Slep 5, side bending right on skeleton.

CHAPTER 5 I INTERSEGMENTAL MOnON TESTING 37

~ WMBAIIINTERSEGMENTAL MOTION TESTING

L1 to L5S1 Type 2, Extension (Sphinx Position) and flexion

1. After det~rmining that th~ rotational and sid~h


WMBAR INTERSEGMENTAL MonON TESTING

L1 to l5-S1 Passive Flexion and Extension. Lateral Recumbent Position

1. The patient lies in the lateral r

5. Th~ physician sl",,1y fl~,..,s and ~=nds th~ pati~nt'. hip. with th~ caudad hand and thigh whil~ th~ c~phalad hand consllln!ly monitors m" spinous processes to d~termin~ th~ relative fuedom oflum-bar flexion and exten.ion ofL5 on SI (fillS. 5.22 ... d 5.23).

6. Th~ physician .... ses.~. th~ ability of th~ upp


L1 to l5-S1 Passive Side Bending, Lateral Recumbent Position (l5-S1 Example)

1. The physician fle"es the patient'. hips to approxi-mately 90 degree. and gmt/y m~. the patient', low"r enremiti.,. slightly off the edge of the table (Fig. 5.241.

2. The physician slowly lie"". and ""tends the patient'. hip" until 1.5 is neutral rdath.., to S l.

3. The nn~r pad. of the physician" cephalad hand palpate the left and right tran,,,,,...., p=sses of 1.5 (Fig. 525) or the internpa"" bem..,en their Tran.""...., pI"OC"'"se .

4. The physician's caudad hand slowly rai,es the patient', feet and anltleo upward as the cephalad hand monitol'S the apprOltimation of the Tran.""...., proallseo on the .ide to which the feet a,.., raised (or the separation of the trans",,"e p=s..,. on the .ide to which the patient i.lying) (Fig. 5.26).

S. The physician then low= the patient's feet and ankleo while the ""Phalad hand monitors the approlrimation of the trans",,"e proc.,.seo on the side to ","hich the feet att I"",..,,..,d (or the separation of the Tran"..,...., proceoseo on the side "PP""ite to which the patient i. lying) (Fig. 5.21) .

6. The physician asses..,. the ability of the upper of the two .egmentt (1.'5) to side bend left and .ide bend right. In this test, side bending occurs on the .ide to which the feet and ankles att moved.

7. The pbysidan puform. th"'" Olep" at each .egmen-tal level of th" lumbar 'pine.

g. The physician will document the findings in the progress note according to the position or frttdom of movement didted.

FIGURE 5.24. Step! .

FIGURE 5.25. Step 3, palpation of 1.5 transverse processes.

FIGURE 5.27. Step 5, side bending left.


~ WMBAIIINTERSEGMENTAL MOTION TESTING

L1-5 (Also T1-12}-Prone. Spring Test Type 2, Flexion and Extension

1. After determining that the rotational and side-b.nding components """ coupled in a type 2 pattern (same--oide pattern of ea..,), the physician'. thumb and inde" fll18"r of one hand a,.., placed immedi-ately parupinal and betwun the spinous p=sset of the dysfunctional ""rtebral unit (uPP'C'r and lower .egments) of the prone patient, or the pbysician may u.., the thumb. placed bilaterally b.tween the .pinous processes of the dysfunctional "'rtebral unit (upper and lowu segmenLs) (Fig. 5.28A ond 81.

2. The physician imparts a quick, springing impulse that is ""ctore


THORACIC II'lTERSEGMENTAL MOTION TESTING

T1-4 Passive Flexion, Extension, Side Bending, and Rotation, Seated, Long-Lever Method

1. The patient i. ,eated with the phyoici.an .t.anding behind the patient.

2. The physician control. the patient'. head with one hand and palpates the .pinou. proce .. es ofT! and T 2 with the index and third finger of the other hand.

3. The physician .lowly moves the patient'. head for-,,1lCd and backward while con'tantly monitoring the ability of the upper of the segments to move in the respecti"" direction tested (Rgs. 5.30 and 5.311.

4. The physician, while controlling the patient', head, palpates the left tram",,"e proce .. e. ofT ! and 1'2 and moves the p.atient', head to the left .houlder, asse"ing the ability of the leftT! trans",,= proces, to approximate the left 1'2 transverse proces . Thi. elicits left 'ide bending (Rg. 5.321. Thi, i, repeated on the right to elicit right side bending (Rg. 5.331.

AGURE 5.JO. S1ep 3, fll!xion,spttens ion-spinous process approximate.

AGURE 5.n Step 4, side bending right

5. While monitoring the left tran.vene proce.~, the physician olowly ro"'te. the patient's head to the left. This e .... luates left ro"'tion; it i en.ed by a .imultaneous posterior mo","ment of the trans","roe process on that .Jde (Rg. 5.34). Thi. is repeated on the right to elicit right ro",tion (Rg. 5.35).

6. The physician performs these step;l at each oegmen-tallevelT2-3, TI-4,andT4-5.

7. The physician wiU document the findingo in the progreso note according to the pooition or freedom of motion elicited.

CHAPTER 5 I INTERSEGMENTAL MOTION TESTIN I

AGURE 5.34. Step 5, rotatian left.

AGURE 5.35. Step 5, rotatian right.


THORACIC INTERSEGMENTAl MOllON TESTING

T1-4 Side Bending, Lateral Recumbent Position (long lever)

1. The patient lie. in the lateral ""cumbmt position with the bad dose to the side of the table.

2. The physician .its in front of the patient at the side of the table, facing the patient'. head.

3. The physician pla","s the f"'8"r pads of the cau-dad hand over the transverse process", of the dysfunctional segment or the interspa"," Mrw"en them while the cephalad hand ""ach", under the patient', head and carefully lifts it off the table (Fig. 5.361.

4. The physician 8"ntly lifts the patient's head while monitoring the involvro .egment'. = pro-ces""s or the interspace MtWttn them. Side Mnd-ing is introduced on the side to which the head is m"""d. Thi. presents a. a sense of approximation of the tran.ve= proces.es on the upward side and separation of the transverse p=''''' on the 0ppo-site .ide (table .ide) (Fig. 5.311.

s. The physician ",verses the m"""ment hy 8"ntly lowering the head toward the tahle (Fig. 5.311 while monitoring the approximation of the tran.ve= pro-c",se. on the low"r side (table side) and/or .epara-tion on the opposite side. Again, W silk f(} ~h ,~

~ad >II""'" jj W titk 011 ~h titk 1muJi"l{ aU ...

6. The phY"idan ""p"ats this sequence throughout the T 14 "'gion to determine side-bmding pref=nce or ease of motion and then documento the findings in the prog...,.s note.

, ,-

FIGURE 5.36. Step 3.

, --

FIGURE 5.31. Step 4, side bending right

, -

FIGURE 5.38. Step 5, side bending left.


THORACIC INTERSEGMENTAl MOTION TESTING

T1-12 Passive Flexion and Extension. Translatory Method. Seated IT6-7 Example)

1. Th~ pati~nt is .~ated "'ith th~ physician .tanding b.hind and to th~ sid~.

2. Th~ phyoician plac~. th~ thllmb and inda fin-ger of on~ hand b.~en th~ .pinous proc .. s .. of T6 and T7, or th~ index and third f1l1&"r palpat~

!h~ spinous proc~sses of T6 and T7, tt.pectivrly (Fig. 5.391.

3. Th~ pati~nt'. arms au crossed, ant~riorly, in a V-formation. Th~ physician'. right arm and hand au plac~d und~r th~ pati~nt's cros""d elbow. whil~

I~ft hand ",mains on th~ T6-7 int~rnpace (Fig. 5.4111. 4. Th~ phyoician innructs th~ patient to compl~tely

",In forward, ,...ting th~ fo",h~ad on th~ forearm as th~ left hand monitorn flexion oIT6 onT7 (sq>a-ration of th~ spino"" process .. ). Th~ pati~nt m""t b. compl~tely ttlaxed and not guarding (Fig. 5.41 ).

5. Th~ phyoician'. posterior hand gently pllohes or glid~s th~ .pinous proceos or int~rnpac~ ant~riorly a. th~ other hand lifts th~ patient's ~lbows slightly to evalllat~ extension ofT6 on T7. This i. noted hy th~ approximation of th~ 'pinOIl' proc~.""s (Fig. 5.42). The patient mll.t b. compl~tely ",Iaxed and not guarding. Car~ mllst tahn to avoid hyp~""'t~nsion.

6. Step. 4 and 5 ..,.., p"rform~d at ~ach thoracic s~gm~ntall""",l.

7. Th~ phyoician will docum~nt th~ finding> in th~ progreso not .. according to th~ po.ition or freedom of motion ~licit~d.

f

AGURE5.39. Step 2.

, ,

AGURU.4G. Step 3.

AGURE 5.41. Step 4, flexion-spinous processes separate.

AGURE!i.42. Step 5, elrtensionspinous processes approximate.

46 PART t 1 OSTEOPATlHC PRINCIPlfS IN OIAGNOSIS

-THORACIC IN'T"ERSEGMENTAL MOTION TESTING I

11-12 Translatory Method (Passive Side Bending), Seated

1. The patient i. seated and the physician .tand. behind and to the side.

2. The physician place. the left thumb and indu fIn-ger betw~n the .pinou. processeo of T6 and T7 (Rg. 5.43). A1temativdy, the physician's left thumb and index fln&"r palpate the SpinOUll pr",,"s. ofT6.

3. The physician ...,ache. acroo. the front of the patient'. chest with the right arm and place. the right hand on the patient'. left shoulder with the physician'. right ax::illa =ting on the pa.tient'. right shoulder IRg. 5.44).

4. The physician'. right a>:::illa applies a downward force on the pa.tient'. right shoulder as the left hand simultaneously glide. or pu.hes the T 6-7 interspace to the patient'. left. Thi. causes a left tran.latory effect that produce. right .ide bending ofT6 on T7 (Rg. 5.45).

s. The physician'. right hand applies a down""rd force on the patient'. left shoulder as the left hand simultaneously glides the T6-7 interspace to the patient', right. This produces left .ide bending of T6 0nT7 (Fig. 5.46).

6. These oteps are performed to evaluate right and left side bending at each thoracic segmental level.

7. The physician wiU document the findingll in the progress note according to the position or freedom of motion elicited.

AGURE 5.43. Step 2.

AGURE 5.44. Step 3.

AGURE 5.45. Step 4, trans latory side bending right

AGURE 5.46. Step 5, trans latory side bending left.

-


THORACIC INTERSEGMENTAL MOTION TESTING

T1-12 Prone Short-Lever Method. Passive Rotation. Side Bending (Example TIl

1. Th~ patknt lies prone with the head in neutral. If this is not possible, the patient should turn the head to the mo,"" oomfortable oide. Note any chal18" below.

2. The phyoidan '!and. at either side of the table and palpates the T7 tran.vene process with the pad. of the thumbs or index fingen.

3. The phyoician alternately presses on the left and right trans",""", proceo.e. ofT7 , evaluating for eaoe ofmovnnent.

4. If the right trans",,,,,, process moves anteriorly (inward) mo,"" easily, the .egment is rotating left mo,"" [""ely and vice ",rsa (Figs. 5.47 and 5.48).

s. In the otep 4 scenario, the left transvene process may be palpated mOtt prominently (posteriorly) on layer-by-lay,,, palpation.

6. Next, with the thumbs palpating o",r the mo.t lateral aspect of the tran.",,..., processes, an alter-nating translatory glide to the left and right i. intro-duced to test .ide bending.

7. If the thumb translates the "'gment mOtt easily ftom left to right, left side bending is occurring and vice ",rsa (Figs. 5.49 and 5.50).

8. These steps a,"" performed to evaluate right and left rotation and .ide bending at each .egmentallevel (T1-2, T2-3, T3-4, and '" on to TIl-12).

9. The physician will document these findings in the prog=' note according to the position or the frttdom of motion palpated.

AGURE 5.47. Step 4, rotation left.

FIGURE 5.48. Step 4, rotation right.

--

FIGURE 5.49. Step 7, .ide bending left.

FIGURE 5.511.. Step 7, .ide bending right.


THORACIC INTERSEGMENTAl MOllON TESTING

TH-12 long-lever Method, Passive Flexion and Extension, lateral Recumbent

1. The patient lies in the lateral ucumbmt position with the h ips and knees flext2. The physician stands on the side of the table facing the front of the patient and controls the patient'. knees at the tibial ruberosity with the caudad hand.

3. The physician's cephlllad hand palpates the spinous processes oIT12 and Ll or their interspace with the ind"", and/or long fU18"r (Fig. 5.51 1.

4. The phyoician slowly flexes the hips by bringing the knees to the chest as the physician'. cephalad hand monitors the .eparation of the spinous proces.e. (flexion) (Fig. 5.52.1.

S. The phyoician then extends the hips by bringing the knees away from the chest as the cephalad hand monitors the approximation of the spinous pro-ces..,. (extension) (Fig. 5.531.

6. These sttps are performed to evaluate flexion and ene11llion at each thoracic ..,gmentallevrl.

7. The physician will document the findings in the prog:ress note according to the position or frttdom of motion elicited.

AGURE 5.51 . Step 3, spinous processes of T12-U.

,

AGURE 5.52. Step 4, flexi on.

AGURE 5.53. Step 5, extension.


THORACIC INTERSEGMENTAL MOTION TESTING

TB12 Long-Lever Method, Passive Side Bending, Lateral Recumbent

1. Th~ patient lies in the lateral recumbent position with the h ips and kne,," flexed (fetal pooition).

2. The physician stands on the side of the table facing the front of the patient and controls the patient'. knee. at the tibial ruberosity with the caudad hand.

3. Th~ phy.ician mo.,". the patient'. lower legll off the edg

50 PART I I OSTEOPATlHC PIHNCIPlES IN OIAGNOS IS

Costal Mechanics

In rapiraUoD,!he slernum and ribs ffiO\Oe in. simulane-0 ... and combined ""nan IIw

Angle of Inclination of the Axes of Rib 1 and Rib 6 The costotrans",,...., articulations combine with the costovertebral articulations at uch "'rtebral levd to de",lop angles through which axis of rotation a rib may m"",. Thus, the rib m= within !hi. s!",cific axis of rotation, and the angle change. from .upenor to infe-rior ribs. The angle, a. it rdates to the anteroposterior planes and the lateral body line, determines wbether the rib motion produced through normal ...,spiration is gttatest at the anterior middavicular line or the lat-eral davicular-mid.a>:::illary line. Ribs 1 to 10 have some .tI=d motion parameters in each of the "".,. of rota-tion. However, the motion pattern of the up!"'r ribo is ...,lateCHAPTER 5 I INTERSEGMENTAL MOnON TESTING 51

. . . . ..

. . . . .

. . . . ..

.

. ..

'. .' .-.. .

. ..

. . .

. . . . . ..

. . ..

FIGURE 5.60. Rib l: most frontal in plane, allowing a more purely "pump handle" rib excurs ion.

...

FIGURE 5.61. Rib 6: less frontal plane, allowing for greater ability to move in a "bucket handle" type motion than can rib I .


Costal Mechanics (Continued)

Pump Handle Rib Motion The term. pump Iwndk rih moti::is that permit' the opposite end to mo~ through .pace IRg. 5.62.1.

Bucket Handle Rib Motion The term /JudI" Iwndk rib """""' describes the move-ment of a rib that can be best compared to the movement of the handle of a bucket as it i. lifted up and off the rim of the bucket and then laid down on the same .ide. The motion is produced by both end. of the handle being fixed at a rotational axi, permining only the a",a between the two point, to move through 'pace IRg. 5.63).

AGURE 5.62. Pump handle lib motion. (From Clay JH, Pounds OM. Bas ic Clinica l Massage Therapy: Integrating AnalClrny and Treatment Baltimore, MO: Lippincott Wi lliams & Wilkins, 2003, with permission.)

AGURE 5.63. Bucket handle rib motion. (From Clay JH, Pounds OM. Basic Cl inical Massage Therapy: Integrating Anatomy and Treatment Ba~imore, MD: Lippincott Wil liams & Wilkins, 2003, with permiss ion.)

Upper Ribs 1 and 2, Supine Method

1. Th~ patient lies .upine, and the physician .its or .tand. at the head of the table. (Or the patient may .it.)

2. Th~ pbysician palpates the f .... t rim at their infra-cIavicular position at the nemoclavicular articula-tion (the .upraclavicular position can also be used) (Fig. 5.64).

3. The pbysician monitors th~ ,..,Iative .uperior (cephalad) and inferior (caudad) ,..,lation of the pair and, on the .ymptomatic side, determines whether that rib i. prominent or not and positioned superi-orly or inferiorly.

4. The patient is instructed to inhale and ahale deeply through the mouth as the physician monitors the ability of the pair off .... t rim to move superiorly and inferiorly.

5. If th~ rib on the symptomatic side is statically cephalad and on inhalation has lV"ater cephalad (on erllalation, Ie .. caudad) mov.ment, it ill classi-lied as an inhalation rib dyifunaion (Fig. 5.&5).

6. If the rib on the symptomatic side ill st>ltically caudad and on inhalation has les. cephalad (on ~lation, gttater caudad) movement, it is classified as an .. xhaltuUm rib dyifuru:tion (Fig. 5.&&).

7. The physician next palpate. the .econd rim approx-imately one fmgtt". br


First Rib. Elevated. Seated Method

1. The patient is .eated, and the physician .tamb behind the patient.

2. The physician palpates the pmterolateral .ru.rt of each first rib immediately lateral to the ooototrans-v=e articulation (Fig. 5.68). No"" The trapezius bor-ders may ha~ to be pulled pmteriorly (Fi g. 5.691.

J. With firm pres'Utt of the thumbo or fing

Upper Ribs 3 to 6, Supine Method

1. Th~ patient lies ,upine, and the phyoician stands on one .ide of the patient.

2. Th~ phyoician'. thumbs palpate the third ribs biLat-erally at their cootochondral articulatiol1ll for pump handle motion and at the midaxillary line with the econd or third fingertip" for bucket handle motion (Fig. 5.n l.

3. The pbyoicilln monitors the "'lati"" cq>halad or caudad rrlation of the pair and, on the symptom-atic side, determines whether that rib is m",.., or less prominent or .uperiorly or inferiorly positioned.

4. The patient is instructed to inhale and exhale deeply through the mouth a. the phyoician moni-to,", the "'lati"" cephalad and caudad movements of each rib with the palpating thumhi and fingertips (Fig. 5.731.

5. If the rib on th~ symptomatic side is statically m",.., cephalad and on inhalation has greater cephalad movement (on el


Lower Ribs 7 to 10, Supine Method

1. The patient i. supine and the physician stands on one .ide of the patient.

2. The physician's thumhs palpate the s",,,nth ribs bilaterally at their costochondral articulations for pump handle motion and at the midaxillary line with the s:ond or third fingertips for bucket handle motion (Figs. 5.76 . nd 5.771 .

3. The physician monito ... the rrla~ cephalad or caudad rdation of the pair and determines on the .ymptomatic side whether that rib i. more or Ie .. prominent or superiorly or inferiorly positioned.

4. The patient is instructed to inhale and exhale deeply through the mouth as the physician monitors the rnati", cephalad and caudad mo,,,ments of each rih with the palpating thumbs and fingertip'.

5. If the rib on the symptomatic .ide is statically more ceph.alad and on inhalation has greater cephalad movement (on exhalation, les. caudad move-ment), it is termed an inh.>]

Floating Ribs 11 and 12, Prone Method

1. The patient lies prone, and the physician stands on either .ide of the patient.

2. The physician" thumb and thenar eminence pal-pate the shaft of each II th rib (Figs. 5.10 . nd 5.111 .

3. The patient i, instructed to inhale and erllale deeply through the mouth.

4. The physician notes any a.ymmetric motion at each ,".

S. If, on the .ymptomatic .ide, the patient's rib m= m"", postmorly and inferiorly with inhalation and lest anteriorly and .uperiorly with erllalation than ito mate, it is classified as an illhlll(JlWn rib (dysfunction) (Fig. 5.12.1.

6. If, on the .ymptomatic .ide, the patient'. rib m= m"", anteriorly and ,up


Ribs 3 to 6 Physiologic and Nonphysiologic Restrictions, Prone, Short Lever Method

1. The patient lie upine and the physician stands at the side of the table.

2. U.ing the thum'" and the inde>: fing

S. Nat, the physician imparto a &"ntle impul.., from a lateral to medial dittction to evaluate for a later:al tr:iln.lation of the rib. Resistance to the impul.., reveal. a lateral tr:iln.lation (Fig. 5.11&1.

6 . The patient i. then pooitioned in the prone pooi-tion, and the physician ,tand. at the .ide of the table.

7. Using the thumb. and the index fin&"rs of each hand, the physician anempt. to contour them over the ribs (bilaterally) to ~ evaluated.

8. The contact should ~ ~twttn the angle of the rib and the mida>:::illary line.

9. The pbysician then imparts a &"nlle imp~ from a posterior to an anterior dittction to evaluate for posterior tr:iln.lation of the rib. Resi.tance to the impul.., =al. a posterior translation (1'"'11. 5.111.

10. In the a~ st"P" the frttdom or ea.e of motion determines the ~ of dy.function, but the resis-tance is generally the easiest to palpate. Therefore, the categorization of rib dysfunction would ~ named oppo.ite the restriction.


AGURE 5.11&. Step 5, Iateral to medial impulse.

AGURE 5.11. Step 9, posterior to anterior impulse.


CERVICAL INTERSEGMENTAL MDTION TESTING

Occipitoatlantal Articulation (Occiput-C1), Type I Coupling Motion

1. The patient lie. supine on the lttatment table.

2. The phy.ician sits at the head of the table.

3. The physician'. index or third frn~r pad palpate. the tran.""...., p~seo of C] (Fig. 5.881 .

4. The phy.ician gently moveo the patient'. head for-",1U"d and back, cattful not to bring the segmento below the occiput into this motion (Fig. 5.191 .

FIGURE 5.88. Step 3, Cl transversa process.

FIGURE 5.19 A. Slep 4, flexio n.

,

FIGURE 5.19 e . Step 4, extension.

5. The physician gently move. the head off the table and to the table in a forward-and-back trarulatory movement, again c"",ful not to induce mm"ment of the inferior cervical ..,gments (Fig. 5.901.

6. Th evaluate oide bending and rotation, the physi-cian minimally tran.une. the patient'. occiput alter-nately to the left and right OVtt CI (atlas) without inducing any movement of C 1-7 (Fig . 5.91 . nd 5.921.

1. Theoe .t


Atlantoaxial Articulation (C1-2), Rotation

1. The patient lies supine, and the physician sit. at the hoa2. The physician palpates the uan.veroe proc~es of the atlas (C l) with the pads of the index fing

CHAPTEflS j lNTERSEGM ENTAlMOTIONTESTING 63

CERVICAL INTfRSEGMENTAL MOTION TESTING

Atlantoaxial (C12). Supine. with Fieldon Alternative

L Th~ patin\( liet . upine on !he trelunenl tlbl~. 2. Th~ physiciAn sill I I !he head of !he 1Ib[j: . 1. Th~ physician r.!O"'ly Oaes (forward bendl) th~

pari


C2-7 Articulations. Short-Lever Translatory Effect. Type II Motion

1. The patient lies supine on the treatment table, and the physician sits at the head of the table.

2. The physician palpates the articular proces""s of the segment to be evaluated with the pads of the index or third fing


I CERVICAL INTERSEGMENTAL MOTION TESTING

C2-7 Articulations. Long-Lever Method. Type II Motion (e.g . OSRRR or SLRL)

1. Cervical inu.....,gmental motion may be evaluau.d by long-l"""'r method. !\io,," the head in an ear-to-ohoulder, arclike mOvm1ent to the 1""",1 of the dyofunctional ..,gment for ito side-bending ability IRg. 5.11141.

2. At the end of the limit of oide bending, a slight rota-tion io added to the d;",ction of the . ide bending (Rg. 5.1051.

3. With the head in neutral for C2, flexion i. increased approrimately 5 to 7 deg"''''' for each descending ..,gment to be evaluated. The articlliar processes are positioned in side bending/rotation to the right and then the left llntil their limit ill elicited (Rgs. 5.1116 . l1li 5.1D1).

4 . Sin", C2-7 side bend and rotate to the .ame side ",gardless of the .agittal plane, the physician must also assess fle>:::ion and extension motion p",ference or which position (flexion, extension, or neutral) improves the asymmetry at each ..,gmental levd (C2-7).

s. The physician will document the f",dings in the progreso note by ",cording the position of medom of motion elicited in all t:tu..e plane. (F, E, or N---if there is no preferen", for fle>:::ion or extension prd'-erence, SRRR or SLRL).

AGURE 5.105. Step 2, rotation added.

FIGURE 5. ID1. Step 3, sidebend ingjrotation left.


Pelvis on Sacrum (lliosacral), Anteroposterior Rotation, Supine, Long Lever !Leg Length)

1. The patient lie upine on the lttatment table.

2. The physician .tand. at the side of the table at the patient'. hip.

3. The physician palpates the patient'. anterior .u!",-rior iliac .pine. (ASIS.) and medial malleoli and notes the ",lation of the pair (ctphalad or caudad, .ymmetric or asymmetric panern) (R g. 5.1081.

4. The physician inotructo the patient to flex the hip and knee on one sid~. The physician'. hands then control the patient'. knee and ankle (Rg. 5.1091.

5. The pbysician llIkes the patient's hip through a range of motion .tarting with 130 d~grtts of flexion and prog""ses through :ternal rotation and finally :t

Sacroiliac Joint and Pelvic Dysfunctions, Pelvic (e,g" Innominate Rotation, Shear, Inflare-Outflarel, Standing Flexion Test

1. Th~ pati~nt Oland. erect with th~ fttt a shoulder width apart,

2, Th~ pbysician .t.ands or knttls bobind th~ pati~nt "ith th~ ~yeo at th~ l~vd of th~ patient's posterior .uperior iliac spin~. (PSISs),

3, Th~ pbysician's thumb. ar~ placW. on th~ inf~rior ""p"ct ofth~ pati~nt'. PSIS. Maintain firm PWlS",," on th~ PSISs, fWl skin or f""dal drag, to follow bony landmark motion (Fi g. 5.1121.

4 . Th~ patient i. instruct~d to activ~ly forward bond and try to toucb th~ toes within a pain-frtt r:ang~ (Fig. 5.1131.

5, n., t~st i. positi"" on th~ sid~ wb~tt th~ thumb (PSIS) moveo rno", c~pbal3d at th~ end rnng~ of motion (Fig. 5.114). A positi"" standing fko:::ion t~st

id~ntifi~. th~ sid~ on whicb th~ ... croiliac joint is dysfunctional, not th~ specific t}"P" of dysfunction. A positi"" W1ult indicat~s that an iliosacral dysfunc-tion ~Ivi. on sacrum) may bo p",sent. This i. u.u-ally compaud to th~ W1ults of th~ ""ated flexion teot to ruI~ out sacroiliac dysfunction ( ... crum on p"lvio). Regardless of th~ typ" of dysfunction, th~ probI~m i. at th~ sacroiliac joint.

6, Thi. i. a preoumptiv


Sacroiliac Joint and Pelvic Dysfunctions. Pelvic (Innominate) or Sacral. Seated Flexion Test

1. The patient i ..,ated on a .tool or treatment table with both f~t flat on the floor a shoulder width

.-. 2. The physician .tands or kn~ls behind the patient

with the e}'

Sacroiliac Joint Motion, Pelvis on Sacrum (liiosacral Dysfunction), Anteroposterior Rotation Prone, long lever

1. Th~ patient lie. prone on the treatment table.

2. The physician stands to one side of the patient at level of the hip.

3. The pbysician places the cephalad hand ovu the p>ltient'. sacroiliac joint with the finger pads of the index and third digits contacting the .aerum and PSIS; or the index frnS"r contacts the PSIS while the thumb contacts the sacrum (Fig.5.11Ij. Ifpalpat-ing the opposite sacroiliac joint, the finger pads will contact the landmark on the other side.

4. The pbysicians other hand grasps the patient', fully enended (straight) lower leg at the 1"",1 of the tibial tuberosity (Fig. 5.1191.

5. The pbysician S"ntly lifts the extended leg and then slowly and minimally lowers it while palpating the movement of the PSIS a. it relates to the


Sacroiliac Joint Motion, Pelvis on Sacrum (liiosacral Dysfunction), Inflare-Outflare Prone, Long Lever

1. The patient lie. prone on the ~atment table.

2. The physician stands to one side of the patient at the l~l of the hlp.

3. The physician places the cephalad-oriente

Sacroiliac Joint Motion. General Restriction, Prone, Short Lever

1. Th~ patient lie. prone on the treatment table.

2. The physician stands to one side of the patient at the level of the hip.

3. Th~ physician pla","s the thenar eminence. over the p>ltient'. PSISs (Fig. 5.1271.

4. The physician alternately introduces a mild to mod-erate impuhe through the PSIS. with the thenar eminenceo (Fig. 5.1211.

S. The pbysiciannoteo the quality (end feel) and quan-tity of motion on each side.

6. This is a positive teot that will determine which sac-roiliac joint is most restricted but will not determine the nature of the dysfunction.

7. The pbysician will document the findings in the progreso note according to the position or freedom of motion elicited.

CHAPTER 5 I INTERSEGMENTAL MOnON TESTI NG 71

FIGURE 5.121. Step 4, prone short leverwim a~ernati ng menar impulse.

72 PART t 1 OSTEOPATlHC PRINCIPlfS IN OIAGNOS IS

Sacroiliac Joint Motion, General Restriction or Anteroposterior Rotation, Supine, Short lever

1. The patient lie. '''pine on the treatment table.

2. The physician sl>ln

O.t~opathic manipulative techniqu~. (OMT.) """ num~rou . Som~ techniqu~. have been known by mo", than on~ nam~, many n~w t~chniques nave h

76 PART 1 1 OSTEOPATlHC MANIPULATIVE TECHNIQUES

N,: anatomic bam. PI> ph)'sioIogoic barrio>r Rb: rsstricIiv1I barrisr

AGUAE U Two restrictive barriers (Rb) asymmetri cal~ restricted.

paired ran&" (Fig. 6.6); or, they may ~rlIibit Wltriction within a normal ph)"iologic rangr PI> pI>ysioIogOc barr;'" Ab: rsstricIiv1I barrio>r

AGURE 6.3. Two restrictive b!rners (Rb) symmetri cal~ restricted.

Ab: aoatrniysioIogOc barrio>r AGURE&.4. Symmetrica l hypemlObil1ry.

which ha"" ;""en duplicat~d by others (~.g., White and Panjabi, coupled motions) (I).

Paraphrasing C.R Nelson (",f>os,:, principl~ of motion ;,. considerepI>ysioIogOc barTio< AGURE 6.!i. Asymmetrical hypennobil 1ry.

CHAPTE R Ii I PR INCIPLES Of OSTEOPArnlC MANIPULAnVETECHNlllUES 77

Ab: onatomi:; barrier Pb: physiologic barri&r

HPb:~ ~barri&r

AGURE&.6. Unilateral hvpermability (HPbl, making ~ appear as if there is an asymmetry with a restrictive barrier to the

oppos~e pa ired range, wtlich is actually the phys iologic barrier (PBI.

SOMATIC OYSFUNCTION A tated earlier, .omatic dyofunction io the diagnos-tic criterion that caU. for OMT. The various qualities elicited on the physical elmmin.ation of a patient may lead the phyoidan to understand that the nature of a dyo-function in one region is different from that of another dyofunction in a different region . Thuo, the phyoidan may chome to use one technique for one dy-ofunction and another technique for the other. Ifa patient exhibits regional motion disturbance but intersegmental motion is normal, a technique orienteAb: onatomi:; barrier Pb: physiologic barri&r Rb: r8$lr'dMo banier

HPb:~ physiologic banier

AGURE 6.1. Unilateral hypermobil ity (HPbl in one motion, while it. pa ired motion has a restrictive barrier (Rbi between neutral and tim phys iologic barrier (Pbl.

of the anatomy may not be indicated. Or a patient m ight present for neck ache that on elmmin.ation altibits para-vertebral muscle hypertonicity and general tenderneo. but no specific tender points. Thio patient may benefit from a mrofasdal technique but not counterntrain, all no counterntrain tender pain" are present.

Some patients exhibit somatic components of vis-ceral disealle, and the u.:.atment of this component may have only a limited effect, whereas a patient with a primary somatic dysfunction and a secondary visceral component mar ttact well (somatically and viscerally) to a specific OM T. Other factors in the presentation of somatic dysfunction may change the thought process in de>"rloping the u.:.atment p lan. Other visceral and auto-nomic effects, lymphatic congestion, and 8'''''' eCONTRAINOICATIONS Contraindication> to OMT have changed dramati-cally during our years of clinical p",ctice because of the development of new andlor modified techniques and better undentanding of disealle processes. The abil-ity to perform OMT in a range of e>, ouch all fra


mo.t prominent manif~"ation . 11ti. atla. p",.enlO 12 OMT sections. Each ..,ction ha. an explanatory prtfac~ for th~ 'pecific t~chniqu~ and th~ principles of ilO U!l~ and application. Th~ p""';ously '!>Ited a",as of dysfunc-tion (articular, myofascial, visceral, vascular, lymphatic, and so on) that can M con,id=d during selection of

th~ ~atm~nt plan may alf~ct th~ decision to U!l~ a spe-cific techniqu~ at on~ dysfunctional 1"",,1 or anoth~r,

d~p"nding on the physical findings (Le., HVl.A \'USus muscle energy versus facili!>lted positional ",lea.., ver-sus myofascial ",l~ase or a combination). Thill will M discussed further and more sp"cifically in ~ach of the technique ..,roons.

The OMT p,-.,scription is similar to that of the pharmacologic prescription: The typ

TECHNIQUE PRINCIPLES Soft tillSU~ technique i. defineThe forces should ~ dittcted deeply enough to engage the tissue being mated, but at the same time, the matment should be mildly to moderately intro-du""d and comfortably ac","pled by the patient. The only exception 10 this rule i. the inltihiwry PTt",.rt: style, in which the physician may choose 10 use a constant, deeply introduced force ="..;n vary with the specillc art3 being treated beca""" of normal anatomic changts from region to region.

TECHNIQUE STYLES Parallel Traction In parallel traction, the myofascial stru= bring treated is contacted at its origin and insution, and the treatment fo= is dittcted parallel to the musculotendinous axis, causing an """rail in=ase in length of the stru=. "Ibis may be done by directing a force with the hand that is prorimal to the origin, the hand that i. proxim.al to the insertion, or both hand s moving opposite each other at the same ti1ne. Each of these will cause a ",Iati"" inc",g"" in length of the myofasdal tissue being treated.

Parpendicular Traction (HKneading H) In perp


INDICATIDNS I . U.e a. part of the musculo.kelMaI !ICf~ning exami-

nation to quicldy identify regions of =tricted motion, tis.ue texture changes, and .ensitivity.

2. Reduce muscle hypertonicity, mu""le tension, f",,-d.al tension, and muscle tpalm.

3. Stretch and increase elasticity ohhortened, inelas-tic, andlor fibrotic myofa""ial structtJres to improve regional and/or intersegmental ranges of motion.

4. ImPfOV" circulation to the specific "'gion being treated by local pbysical and thermodynamic effects or by ref]a phenomena to imPfOV" circulation in .a distal area (e.g., through somatic-somatic or ooma-tovisceral reflexes).

5. Inc",sse venous and lymphatic drainage to decrease local andlor distal s"",Uing and edema and poten-tially imPfOV" the ~l immune =ponse. This will Improve local tissue nutrition , os:ygen-a tion , and removal of m e taboUc wa stes.

6. Stimulate the stretch reflex in hypotonic muscles. ,. Promote patient ",laxation. 8. Reduce patient guardi~g during implementlltion of

other osteopathic manipulati"" techniqu.,. or addi-tional medical treatment.

9. Potentiate the effect of other ""teopathic techniques. 10. Improve the phY'ician-patient rrl.ationship, as this

technique typically imparts a pleasant .en.ation [0 the patient.

CDNTRAINDICATIDNS Relative Contraindications Use with caution, as common medical sense is the rule. For enmple, in an elderly osteoporotic patient, the soft tissue J>rotU pres"''''' technique may be contraindi-cated over the thoracocostal and pelvic ttgions, but the kun-ai """'mbem methods can be more safely applied. AI.o, contact and stretching over .an acutely strained or sprained myof""cial, ligamentous, or capsular struc-ture may e""cerbate the condition. Therd'o"" in these situations, caution .hould prevail, and the soft tissue technique may be withheld until tissue disruption and inflammation have stabilized.

Other p",cautions in the use of soft tissue technique:

1. Acute sprain or strain 2. Fract"'" or dislocation 3. Neurologic or va""u1ar compromise

4. Osteoporoois and ""teop=ia 5. M.align.ancy. Most =trictions are for treatment in

the affected area of malignancy;h"""'ver, care should be taken in other distal areas dopending on the type of malignancy andlor lymphatic involvement.

6. Infection (e.g., osteomyelitis), contagiom skin dis-eas.,., painful rash.,. or ahoc.,.,.,., acute fa.ditis, and any other conditions that would preclude skin contact

,. Organomegaly secondary to infection, obstruction, or neopl.asm

8. Undiagno.ed visceral pathology/pain

Absolute Contraindications None, as the phY'idan may work proximal to the problem above or below the affected are.a and may alter the patient'. position or technique to achieve some beneficialef fect.

GENERAL CONSIDERATIONS AND RULES I. The patient should be comfortable and rel.axed. 2. The phY'ician should be in a position of comfort

.0 as to minimize energy apenditure and whenever pOllsible should me body weight instead of upper enremity strength and energy.

3. lniti.ally, foree. mu.t be of low intemity and applied slowly and rhythmically. As heat develops and the tissues begin to react, the pressure may be increa.ed if clinically indicated and w"ll tolerated; however, the cadence should ",main slowly rhyth-mical.

4. The applied forces should alwaY' be comfortable and not cau"" pain. A comfortable and pleasant experience is the intended effect.

5. Never direct fore.,. directly into bone, and limit pres."", into the muscle belly.

6. As this is not a ma a&" or friction technique, never rub or irritate the patient's .kin by the friction of your hands. The phY'idan's hand should carry the .kin with it and not slide across it when applying the directed force.

7. Determine how you would like to employ the foree: a . By pushing or pulling perpendicular to cause

traction to the long a>:::is of the mmculotendinous

.=-b. By applying traction in a parallel direction to the long a>:::is, incre""ing the distan'" berw.:.en the origin and the insertion of the mmcle fibe ..

Traction, Supine

1. Th~ patient lies supine on the treatment table.

2. Th~ physician sits or 'tands at the head of the table.

3. Th~ physician's on~ hand &"ntly cradles the occiput be~en the thumb and index finger. The phy.i-cian', other hand lie. across the patient's fo",head or grasps under the chin (Figs. 1.1 and 1.21. (Use caution in patients with temporomandibular joint [TMll dysfunctions.)

4. The phy.ician exerts cepbalad traction with both hands with th~ head and neck in a neutral to slightly fle""d pooition to avoid extension. The =dling band mlllll not oquuze the occiput, or the occipito-mastoid suture will he compreo.ed IRg. 1.3).

5. This tractional force is applied and released dOldy. It may be increased in amplitude as per patient tolerance.

6. "Ibis technique may also be performed using sus-tained traction.

7. This technique may be performed for 2 to ~ minutes to aebi""", the desired dfects. It may be especially belpful in patients with de&"nerativ.: di";: disease.

8. In patients withTM] dysfunction, it may be modified by placing one hand on the forehead instead of the mandible (Fig. 1.4).

9. Tissue tension is ",evaluated to assess the effective-ness of the technique.

CHAPTER l I SOFTTISSUETECH NIIlUES 81

I

AGURE 7.1. Step 3, skeleton.

FIGURE 1.2. Step 3, patie nt.

AGURE 7.3. Step 4.

FIGURE 1.4. Step 8.


Forward Bending (Forearm Fulcrum), Supine

1. The patient lies supine on the tttatment table.

2. The phy.ician is ..,ate3. The phy.ician S"ntly flexes the patient'. neck with one hand while sliding the other hand palm down under the patient's neck and opposite shoulder (Fig. 1.5).

4. The physician gently rotates the patient'. head along the phy.ician's fOttarrn toward the dbow, produc-ing a unilateral sttttch of the cervical para",rtebral muscula= (Fig. 1.6) .

s. Thi. sttttch ClIn ~ ",peate6. This procedUtt is =r..,d to treat the opposite side of the patient's ned, or the phy.ician's hand that WlIS on the table can ~ lifted onto the patient's shoulder (Fig. 1.1), and steps 4 and S can ~ ~ated in the opposite di",ction (Fig. 1.' ).

7. Tis.ue tension is r~valuate

Forward Bending (Bilateral Fulcrum), Supine

1. The patient lie. oupine on the Ittatment table.

2. The pby.ician i. oeate3. The physician'. arm.att ernsoed under the patient'. head and the phy.ician'. band. a", pla""d palm down on the patient', anterior shoulder ttgion (Fig. 7.9).

4. The physician'. fottarms gently flex the patient', neck, producing a longitudinal sltttch of the cervi-cal paraVtttebral musculatutt (Fig. 7.10).

S. Thi. technique maybe performed in agentle, rhyth-mic fashion or in a .ustained manner.

6. Ti ue tension i. ruvaluated to asses. the effective--ness of the technique.

CHAPTER l I SOFTTISSUETECHNIIlUES 83

FIGURE 7.9. Step 3.

AGURE7.1D. Step4.


Contralateral Traction, Supine

I. The patient lies supine on the tttatment table.

2. Th~ pbysician stands at the side of the table oppo-site the sid~ to ~ tttated.

3. The physician'. caudad hand ,..,aches 0= and around the neck to touch with the pads of the fingel"S the patient'. cervical paraVtttebrai muscularu,.., on the side opposit~ the physician (Fig. 1.11 ).

4. The physician'. ceph.alad h.and lies on the patien!"s fo,..,h.ad to stabilize the head (Fig. 1.121.

5. Kuping the caudad arm straight, the physician gen-tly draws the para""rtebral muscles ventrally (whi'" arl'OW, Fig. 1.13), producing minimal extension of the cervical'pine.

6. This technique may ~ performed in a gentle, rhythmic, and kneading fashion or in a sustained manner.

7. Tissue tension is ,..,,,,,a1uated to assess the effective-ness of the technique.

AGURE 1.11. Step 3.

AGURE 1.12. Step 4.

AGURE 1.13. Step 5.

Cradling with Traction, Supine

1. Th~ patient lies supine on the treatment table.

2. Th~ phy.ician silll at the head of the table.

3. The pbysician's tinge ... "'" placed under the patient'. neck bilaterally, with th~ flngertips lateral to the cervical spinous processes and the finger pads touching the paravertebral musculature overlying the articular pilla ... (Fig. 1.141.

4. The phyoician exerts a gentle to mode"'te force, ventrally to engage the .oft tissues and cephalad to produce a longitudinal tractional effect (stretcb) {Figs. 1.15 . nd 1.161.

S. This traction on the cervical musculature is slowly releaoM.

6. The phy.ician's hands are r~itioned to contact different levels of the cervical spine, and otep. 4 and 5 "'" performed to .tretch various portions of the cervical paravertebral musculature.

7. This technique may be performed in a gentle rhythmic and kneading fashion or in a oust.ained

-~ 8. Tissue tension is reevaluated to ..... es. the effective-

ness of the technique.






Suboccipital Release, Supine

I. The patient lies supine on the Ittatment table.

2. Th~ phJl'ician sits at the head of the table.

3. The phJl'ician'. finger pads ..,.., placW. palm up booneath the patient'. suboccipital "'gion, in contact with the trapezius and its immediate underlying muscularu", (fig. 1.11).

4. The physician .lowly and gently applie. P"'''''''' upward into the tis.ues for a few seconds and then releases the pres'''''' (fip. 1.11 . nd 1.19).

S. Tbl. press"", may boo ",applied and "'leased .lowly and rhythmically until tissue texture chang

Rotation. Supine

1. Th~ patient lie. supine on the treatment table.

2. Th~ phy.ician silll at the head of the table. 3. The phy.idan'. cupped harub (palmar aspect) are

placed to each side of the patient'. temporoman-dibular r"&ion, making sur~ to not compress over the enernsl acoustic meatus (Fig. 1.201.

4. The phy.ician g:::ially rotates the patient'. head to the left to the restrictive barrier at its passive tolerable elastic limit and holds this posi-tion for 3 to ~ second. (Fig. 1.21 1.

5. The phy.idan then slowly rotates the head to the right restricti"" barrier at its passi"" tolerabl~ eI.alltic limit and holds this position for 3 to 5 second. (Fig. 1.22.1.

6. Thill i. rt:peated to each side until "'lease of tissue tension and/or improvement of range of motion.




-

FIGURE 7.22.. Step 5.


Supine. Forefingers Cradling

1. The patient lie. supine on the lttatment table.

2. The physician .its or .lands at the head of the table.

3. The physician'. hands cradle the temporal ...,gion. (avoiding p..., lItt O\"r the ears) with the fing

Thumb Rest. Supine

1. Th~ patient liell supine on the treatment table with or without a pillow under the head.

2. The physician sits or st>mds at the head of the table.

3. The thumb and fordinger of one of the phy.i-dan, bands cup the posterior cervical atta palm up (Fig. J.26I.

4. The physician'. other hand i. p laced over the tem-poral and frontal regions of the patient"s head and gently bring:o the bead into slight backward bending (extension) and rotation against the thumb (Figs. J.n .. d J.2I).

s. The motion is vuy .light.

6. Thn.ion (pres.Utt) is relaxed slowly and reapplied slowly.

7. The pressUtt rnay be reversed to the other side.

g. Tissue ten.ion is reevaluated to as.ess the dfect:i,e-nellS of the technique.

CHAPTER l I SOFTTISSUETECH NIIlUES 89

AGURE 7.26. Step 3.

AGURE7Z1. Step 4.

AGURE 7.21. Step 4.

!III PART 1 1 OSTEOPATlHC MANIPULATIVE TECHNIQUES

Coupling with Shoulder Block. Supine

1. The patienl lies supine on the treatmenl lable and the physician stands or s;\'O al the head of the IlIble.

2. The pbysician places one hand on lOp of the patient'. acromioclavicular joinl on the side 10 be treated (Rg. J.29).

3. The pbysician'. other hand crosses the midline 10 control the patient'. head from thai same .ide and gently pushes the head t""'ard the opposile .ide (Rg. 1.30I.

4. The physician moves the head unlil m~ting the reotrictive barrier al its pa ive tolerable elastic limit and holds this position for 3 10 5 seconds and then slowly ",lur11ll the head to neutral.

S. This i. "'p"aled rhythmically and ""ntly until me""e of tiosue ie11llion andlor improv"menl in I"lU18" of motion.

6. The physician'. hands may be """,roed and the pro-ce ~Ied on the opposile .ide.


FIGURE 7.30. A. Steps 3 and 4, anteriDr head cDntrDI.

FIGURE 7.30. B. Steps 3 and 4, a~ernate, pDsterior head control.

Lateral Traction, Seated (e.g., Left Cervical Paravertebral Muscle Hypertonicity, Fascial Inelasticity, and Others)

1. Th~ patient is "uted on the m.atment table.

2. Th~ pbysician .tand. behind and to the right .ide of the patient with th~ patient =ting comfortably again.t the physician'. che.t.

3. Th~ physician'. right cupped nand and foreann g", passed under the patient'. chin so a. to gently touch the patient'. left p"riauricular region (Fig. 1.31 ).

4. The phyoidan" left nand is placed on top of the patient'. left .houlder at the superior Imp"";u, and .upraclavicular "'gion (Fig. 1.32).

5. The physician, right hand gently rotates the patient'" bead to the right and exert" a gentle cephalad trac-tion while the left hand maintain. a gentle caudad counterforce on the left shoulder (Fig. 1.33).

6. lbi. technique may be performed in a gentle , rhyth-mic fashion or in a .ustained manner.

7. If indicated, the technique may be rt:VersW. to m.at the opposite "ide.

S. Thome tension i. fUVlIluated to asses. the ~ffectivene of the technique.

CHAPTER 1 I SOFTTISSUETECHNIIlUES 91

AGURE 1.31. Step 3.

AGUREl.32. Step4.

AGUREl.33. Step 5.


Sitting Traction (e,g" Using Right Knee)

1. The patient is ""ated on the m.atment table.

2, The phY"ician stands ~hind and to the ld't of the patient.

3, The phY"idan" right foot i, placed on the table with the right knu and hip flexed.

4, The physician'. right elbow is placed on the patient'. right thigh.

5. The phY"ician'. right hand cradle. the occiput with the thumb and index fU1~r while the left hand hold. the patient's fOrt:head (Figs. 7.34 . nd 7.351.

6. The phyoidan .lowly ~levatet the right thigh and knee by lifting the heel of the right foot (planlM-flexing foot), thereby producing ",rvieal trnction (Fig. 7.361.

7. n., traction is ",lea""d when the phJl'idan slowly rerum, the right heel to its original position (Fig. 7.37).

8. This technique may be performed in a ~ntle, rhyth-mic fashion or in a ou,tllined manner.

9. Tis,ue tension is ,..,evaluated to a .. ess the dfecri,~ net. of the tN:hnique .

AGURE 7.34. Step 5.

AGURE 7.35. Step 5, a~ernativa hand position.

AGUREJ.J6. Step 6.

-.=-----.

AGURE 7Z1. Step 7.

Head and Chest Position. Seated

1. Th~ patient is outed on the m.atment table.

2. Th~ pbysician .tands facing the patient with one leg in front of the other for balance.

3. Th~ patient'. frontal bone (fordlead) i. placed again.t the ph,.ician's infraclavicular fossa or .ternum (Fig. 1.311.

4. The padll of the physician's nn~,.. contact the medial aspect of the cervical pa!>lVerlebral millCU-larure overlying the articular pillars lFig. 1.391 .

S. The ph}.ician l~an. backward, drawing the patient toward the physician. 'Ibi. causes the pbysician'. hand. to engage the !IOfr tissue., exerting a gmtJe ventral force with concomitant cephalad trac-tion. This produces a longirudinal tractional effect (.m.tch) (Fig. 1.40).

6. 'Ibi. technique may be p"rformed in a gentle, rhythmic, and kneading fashion or in a sustained manner.

7. Tissue tension is ,..,evaluated to aosess th~ effective-ness of the techniql1e.


AGURE 7.311. Step 3.

-'

AGURE 7.39. Step 4.

RGURE 7.4(1. Step 5.


Prone Pressure

\\ l. The patient i, prone, prne!':ilbly with the head

rumed toward the pbysician. (If the table hat a face hole, the head may be kept in neutr:al.)

2. The physician stands at the side of the table oppo-oite the 'ide to be treated. FIGURE 7.41 . Step 3.

3. The pbysician placet the thumb and thenar emi-nence of one hand on the medial a.pt of the patient'. tho!':ilcic paravertebral musculatur

Prone Pressure with Two Hands (Catwalk)

1. Th~ patient is pron~ on th~ treatment table, p",fer-ably with the head rumed toward the physician. (If the table has a face hole, the head may be kept in neutral).

2. Th~ physician stand. at the side of th~ table, oppo- ite the .id~ to be t",ated.

3. Th~ physician's hands are placed palm down .id~ by .ide on the medial aspect of the patient'. tho-racic paravert~bral musculat"'" """rlying the trarul-veTOe proc ... es on the .ide opposite the physician (Rg. 1.44I .

4. The physician adds enough downward pres."", to engage the underlying fascia and musculature with the caudal hand (R,. 1.451.

S. The physician add. lateral P"'''''''', taking the myo-fascial structure. to their comfortable ela.tic limit (Rg. 1.46I .

6. This force is held for .everal oecond. and then slowly "'lea.w..

7. A. th~ press"", is being "'lea.w. with the caudal hand, the physician'. cephalad hand begin. to add a downward lateral force (Rg. 1.41) .

S. The combination of downward and lateral forces and the "'lease of thl. P"'''''''' is alternately applied between the two hand .

9. The downward and lateral pres.u", directed by each hand should be rhythmically applied for several second .

10. T i .. ue tension i. ",evaluated to a ..... the dfec~ ness of the technique.


FIGURE1A4. Slep3 .


FIGURE 1.46.. Step 5.

AGUREU1. Step7.


Prone Pressure with Counterpressure

1. The patient lies prone on the u"atment table, pref-erably with the head turned toward the physician. (If the table has a face hole, the h~ad may ~ kept in n~utt'lil.)

2. The phyoician stands at either side of the table.

3. The physician place. the thumb and thenar ern;-nen~ of the caudad hand on the medial as~ of the patient's thoracic paravertehral musculatlltt overly-ing the transv,,= proces..,s on the side opposite the phyoician with the f"'8"'"' pointing cephalad.

4. The physician places the hypothenarerninence of the cephalad hand on the medial asp"ct of the patient's para""rtehral muo;culature O\"rlying the thoracic trans,,,r.., proces..,s, ipsilateral to the side on which the physician is standing, with the fingers pointing caudad (Figs. 1.48 and 1.49).

5. The phy'Sician e:rerts a I>"nde force with both hands, '''''trally to engal>" the soft tissues and then in the dirt:cr:ion the finger'S of each hand a,.., pointing, cre-ating a separation and distt'liction effect (Fig. 1.50).

6. The degtte of ventral f

Atlas of Osteopathic Techniques 2ed

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