Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]

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  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]



    Volume II

    The Spinal Columnand the TM - Joint

    Olaf Evjenth & Jern Hamberg


  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    Olaf Evjenth & Jern Hamberg


    Muscle stretching 2000 years ago. Statue from Bangkok.

    Volume liThe Spinal Columnand the Temporo- Mandibular Joint


  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    MUSCLE STRETCHING IN MANUAL THERAPY, A CLINICAL MANUAL, TWO VOLUMESbyOlaf Evjenth, M.S.Lecturer in Manual Therapy,Hans & Olaf Institute ,Oslo , NorwayandJem Hamberg, M.D.Alfta Rehab Center ABAlfta, Sweden

    Original title: Tajning av Muskler , Varfar och Hur?Copyright Alfta Rehab Center Promotion AB , Alfta, SwedenNo part of this publication may be reproduced , stored in retrieval system, or transmitted in anyform or by an y means, electronic, mechanical , photocopying , recording or otherwise, without theprior wlitten permission of the publisher.

    Translated from Swedish by M. Michael BradyPhotos by B am HambergDrawings by Elna Jonsson6th EditionPrinted by Istituto Grafico Silvio Basile, Italy, 2003Distributor: Alfta Rehab Center Promotion AB, Box 94, S-822 22 Alfta, SwedenWebb Site: www.alftarehab.seE-mail: [email protected]

    ISBN 91-85934-03-8

  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]



    Today , one patient in four seeking medical aiddoes so solely with a locomotor system complaint.Many of the remaining three-quarters of allpatients seeking medical aid primarily for otherreasons also complain of stiffness , aches, andpainful movement. The muscular-skeletal dis-orders of patients in th ese two categories comprisethe greatest single cause of sick leave. The personsaffected dominate the group of those who retireea rly on disability pensions. The socio-economicproblems resulting from muscular-skeletal dis-orders are undoubtedly greater and more wide-spread than indicated by any single statistic.

    Years of research and experience in studyingand treating locomotor system maladies havecle arly proven the effectiveness of treatmentthrough relaxation and stretching of shortenedmuscles and other related structures. The techniques involved are basically therapeutic , bu t theymay also be applied in preventative exercise at allleve ls of physical training programs , for persons ofa ll ages.

    Our research has been pragmatically orientedto wards attaining results for a greater number ofpa tients over longer periods of time . Hence wehave not conducted double-blind tests , bu t insteadhave allowed our patients to function as their ownco ntrols. Prolonged dysfunction, which diminishesdramatically after relaxation and stretching treatme nt , is more than ample proof of treatmenteffectiveness , both for the therapist and for thepa tients involved .

    This book is a compendium of therapeutictechniques that we have used to successfully treatpa tients with reduced mobility caused by shortened structures . Treatments for the extremitiesand their associated joints are covered in Volume1. Treatments for the spine and the temporoma ndibular joint are covered in Volume II .A lthough the temporo-mandibular joint is anatomically removed from the spine, it is therapeutica lly recognized as being closely connected to thece rvical spine and therefore is included in VolumeII. Each of the two Volumes is arranged to beus ed as an independent clinical reference.In this Volume II:

    The general principles of manual therapy areo utlined in Part 1, along with a guide to theorganization of the therapy techniques .

    The movement pattern of the spine , includingthe movements involved in locking techniques forthe cervical , thoracic and lumbar spine areco vered in Part 2.

    The therapy techniques are fully described inPart 3, one to a page. Each description consists ofa drawing showing the muscles involved, twophotos showing the starting and final positions ofthe techniqu e, and an explicit text giving posi-tions, grips and procedures.Th e Movement Restriction Tables and Index ofMuscles of Part 4 list the muscles which mayrestrict movement and reference them to pages .

    Th e two volumes of this book are intendedprimarily to be used as ready-reference clinicalmanuals and as texts on muscle stretching inmanual therapy. However, we hope that they willalso provide physiotherapists and medical doctorswith a fresh , comprehensive approach to theentire subject of muscle stretching in manualtherapy. Our underlying goal has been to contribute to improving the quality of the treatment ofmuscular-skeletal disorders, both for patients andfor therapists . We will be pleased if the users ofthis manual find it useful in realizing that goal.Oslo , Norway and Alfta, SwedenAugust 1984Olaf Evjenth and Jern Hamberg


  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]












  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]





  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    1. GENERAL PRINCIPLES OF RELAXATIONAND STRETCHING OF MUSCLES ANDOTHER STRUCTURES1.1. INTRODUCTIONHumans have always been physically active forreasons other than pure necessity. Nonessentialactivities, which now classify physiologically asexercise or stretching, evolved for reasons longforgotten or never recorded. Although dance andritual were obvious progenitors, non-productivephysical activity undoubtedly had utilitarian origins: Its early practitioners felt better aftertretching. Historical confirmation of the originsof exercise and stretching is lacking. But there'sample evidence that stretching, such as thatdepicted by the 2000 year old statue shown in thefro ntispiece of this book , has been practiced sincehe dawn of history.Stretching now divides into therapeutic stretching, the topic of this Manual and self-stretching, asu ed in exercise, athletic training , dance , andertain ritual exercises. The two categories oftretching may supplement each other. Fo r instance, therapists may teach their patients self-tretching to speed recovery, and sports teamsmay employ therapists to treat athletes. Yet therei good reason to differentiate. Controlled, propertretching is beneficial. But uncontrolled stretching of muscles and other structures may damage,uch as through causing instability or pathologicalhypermobility. In most such cases, self-stretchingi involved.

    Unwary athletes and other persons exercisingoften self-stretch with great force at long leverarms, which easily injures. Some competitiveath letic events, such as gymnastics in general andwo men's gymnastics in particular, require extrememovement and therefore frequently injure participants. Other extreme activities, such as groupexercises to music ("jazzexercise" and "aerobicdance" are two) also pose high hazard of stretchmg damage. Some exercises are faulted, but lackof knowledge is the leading underlying cause ofelf-stretching damage. Most people know little ofhe normal ranges of movement of the joints ofheir bodies. The result is that when they stretch,normal structures are often overstretched, whilehor tened structures are seldom adequatelytretched.

    An understanding of why, when and howmuscles or other structures should be stretched isprerequisite to stretching to benefit rather thandegrade body function. The role of the therapist intretching is then not just to understand and treat ,but also to guide and teach patients self-stretchingee references 6 and 7).

    1.2. INDICATIONSEvery patient with symptoms involving the locomotor system, particularly symptoms of painand/or constrained movement, should be examined to assess joint and muscle function. Ifexamination shows joint play to be normal , butreveals shortened muscles or muscle spasm, thentreatment by stretching is indicated. With a viewtowards preventive medicine, all younger childrenshould be examined and, if necessary, treated forany disturbed muscle function before symptomsappear.1.3. CONTRAINDICA TIONSAny dysfunction and/o r pain of suspected pathological origin contraindicates manual therapy.Affected patients should be advised to seekmedical diagnosis, and return to therapy if theirdoctors negate the suspected pathology andrecommend return.1.4. GUIDELINES FOR THE THERAPISTThe only reliable way to become proficient II Idetecting and treating muscle dysfunction isthrough experience gained by thoroughly examining every patient. Unfortunately there are no exactrules for examination. Normal ranges of movement referenced in texts, though typical of largepopulations, are seldom directly applicable inindividual cases and therefore do not alwaysindicate if muscles and/or other structures needstretching. So patient examinations should startwith preliminary biomechanical analyses.

    I f the preliminary analysis identifies shortenedmuscles, then a provisional trial treatment isperformed. If the provisional treatment reducespain and improves the affected movement pattern ,the preliminary analysis is confirmed, and treatment may proceed. The restoration of the muscles' normal pattern of movement, with freedomfrom pain, is the only real measu're by which thetreatment may be judged to have been successful.With experience, examiners can detect particularshortened muscles that constrain movement intheir surrounding structures. Sometimes movement patterns and/or ranges of movements cannotbe fully restored because of irreversible damage orchanges in locomotive structures. Nonetheless,stretching can still be valuable in treatment.

    The starting positions , Fig. a, of the techniquesof Part 3, correspond to positions imposed byshortening, while the final positions, Fig. b,correspond to extent of maximum range ofmovement .


  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    1.5. DYSFUNCTION1.5.1. Causes and MechanismsWhen functioning normally , a muscle has opti-mum circulation and innervation, is able to movefreely, is unimpaired in contracting and relaxing,and has normal elasticity and strength. Allmovements should be free of pain. Musclefunction may depart from this norm in many ways,primarily because muscles are among the mostsusceptible of body structures. They must con-tinually readjust to their use, disuse, or misuse.Muscle shortening frequently results. Stiff orshortened muscles are often activated in move-ments in which they otherwise would not takepart . This overuse in turn leads to injury and/or toexcess inhibition of their antagonists. In general,the shorter the muscle , the more it may inhibit itsantagonists. Therefore , stimulating and streng-thening a muscle's antagonists always aids treat-ment. However , note that the shortened musclebeing treated should always be stretched before itsantagonists are strengthened.Shortened muscles may cause pain from theperiosteum , tendons , or muscle belly , includingreferred pain to other structures or segments. In asynergistic group, no one muscle should be shorterthan the others of the group. A stiff, shortenedmuscle will be subjected to greater stress whencontracted suddenly and forcefully, thus damagingitself and/or its associated tendon . This can beprevented by stretching the relevant muscle ormuscle group.Normal range of movement is determined byseveral structures: skin, subcutaneous tissue , mus-cles , ligaments, joint capsules, joint surfaces, andintraarticular structures. Changes in any of thesestructures alter ranges of movement. Conditionssuch as septic or aseptic inflammations may causerestricted movements when acute, and pathologic-al instability when chronic. The structures mostaffected are the fascia, joint capsules, ligaments,and joint cartilages. An example is the develop-ment of ankylosing spondylarthritis (MorbusBechterew). An initial instability becomes hypo-mobility through degenerative change. Subse-quent development may further restrict move-ment ranges, and occasionally lead to ankylosis. I fa reduced range of movement is caused byshortened muscles, then treatment by stretchingincreases and may restore the range of movementto normal.1.5.2. SymptomsDysfunction due to shortened structures can bedetected by observing one or more of thefollowing changes it may cause:1. Pattern of movement,8

    2. Volume and swelling and/or distention of amuscle,3. Elasticity of a muscle ,4. Range of movement at a joint,5. Joint play (section 1.6.3 , p. 9),6. Quality of the passive stop, end feel (section1.6.3, p. 9); most important.In addition to these indicators, a patient mayexperience fatigue, pain radiating to other musclesand structures, and a feeling of stiffness in theshortened muscle(s). Shortened muscles may alsoirritate and damage peripheral nerves and bloodvessels; examples include sports injuries, and thescalenus, the supinator, the pronator and pirifor-mis syndromes. Poor physical condition, inadequ-ate coordination, or unaccustomed movementoften cause altered circulation and faulty musclemovement patterns. According to VladimirJanda(1) , this leads to constant micro-traumata ,which, in turn, subsequently effects alterations inpatterns of movement with chronic muscle spasm,contractures and pain . In an advanced case, jointfunction is altered and degenerative changes at thejoints result. Stretching of the relevant muscle(s)is one way of preventing this chain of events.

    1.6. MANUAL THERAPY METHODS1.6.1. The Basics of StretchingAll therapy techniques including stretching shouldbe based on thorough examination. Stretchingtechniques differ primarily by the type and degreeof patient involvement in procedures administeredby the therapist. Common to all procedures is abasic, safest sequence of events based on theprinciple that a muscle is most relaxed andtherefore may be maximally stretched immediate-ly after an isometric contraction. According toSherrington(2), the stronger the contraction (with-out pain), the greater the subsequent relaxation.So all procedures start with a static contractionof the shortened muscle(s) . Then the muscles arerelaxed, which makes them more easily stretchedfor a period of a fraction of a second up to 10 or 12seconds in pathological cases. During this period ,the muscles can be safely stretched. Often patientscannot contract from an extreme position , sotreatment procedure cannot begin there. In thesecases, it is best to move back to a position in therange of movement where the patient can easilycontract, and begin the procedure there.Muscles are most amenable to stretching whenthey are warmed up in the physiological sense, bypreliminary exercise rather than by the applicationof passive, external heat. Thus all treatmentshould start with some form of warmup. The bestand most specific warmup exercise is contraction

  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    against resistance. The stronger the contraction,the greater the warmup effect.Unwanted external stimuli , such as noise ordiscomfort, can impair treatment, particularlytreatments requiring combined efforts of patientand therapist. So the patient should always bemade as comfortable as possible. The treatmentsurroundings should be quiet, and other distracting influences should be eliminated whenever

    possible .1.6.2. Therapy ProceduresIn all therapy procedures , the therapist works tocounteract some restriction of movement about ajoint. Three different therapeutic approaches arepossible, depending on whether the patient iscompletely passive, participates by offering resistance , or participates both by offering resistanceand by working with the therapist .1. Patient passive: This technique is used intre ating more serious contractures to producelas ting lengthening of shortened tissue. Thepatient relaxes while the therapis t moves the join tfu rther in the direction of restriction, and thenholds the extreme position as long as necessary,e en up to two minutes or more , to lengthen thehortened structures.2. Patient resists: In this gentle technique , thehe rapist applies moderate force to move a joint asfa r as possible in the direction of restriction. Thehortened structures then press the joint surfacesogether. Then the therapist applies traction at thejoint , and thus tries to separate the joint surfacesa the patient resists. Thereafter , the patient

    relaxes and the therap ist maintains traction as longa necessary, until the j oint surfaces are felt toeparate. The procedure is repeated until movement is appreciably improved.3. Patient resists and aids: This is the recommended technique of this Manual. I t starts as doeshe "Patient resists" technique above, but differshereafter. First , the therapist moves a joint as fara possible in the direction of restriction. Then theherapist holds the position and asks the patient toi ometrically resist it. Patient and therapist shouldresist each other equally, with the patient conrac ting one or all of the muscles which are to betretched; this ensures negligible joint movement.

    The patient then relaxes while the therapist moveshe joint further in the direction of restriction. Theprocess is repeated until improvement is attained.In some cases when the therapist moves. a joint ,he patient either feels pain or fears pain to anextent that blocks relaxation. The therapist canhen apply traction and aid or even offer slightresistance as the patient actively moves the joint inhe direction of restriction. Thus the patienton trois movement and therefore can relax . In allases, the therapist holds the extreme position as

    long as necessary, even up to two minutes ormore , to lengthen the shortened structures .

    1.6.3. Character of Joint MovementIn treating joints , the therapist should continuallyassess the quality and quantity of joint movementand the manner in which movement stops. Theseevaluations then guide the course of furthertherapy. For instance, some joint movementabnormalities may contraindicate stretching therapy.1. Joint PlayJoint play is the gliding and/or separation of jointsurfaces without angular movement about a joint.All joints have a characteristic joint play, withwhich the therapist should be familiar. Normallyjoint play is greatest in the maximally loosepacked position and diminishes to minima at theextremes of the joint range of movement. Thetherapist must always examine a joint for jointplay before using any of the treatment proceduresdescribed above. I f joint play is less than normal,it must be restored to normal before other therapyis begun or continued.2. End FeelThe therapist must be able to sense the extremesof the various possible ranges of movements aboutbody joints, that is, the points at which passivemovement stops (3 ,4). End feel is the sensationimparted to the therapist at these points. Thereare several different types of end feel ; thetherapist must be able to differentiate betweenthem:Normal end feel may be soft, firm or hard:Soft: Soft tissue approximation and/or stretching, such as knee or elbow flexion with normallydeveloped muscles.Firm: Capsule and/or ligament stretching, suchas medial rotation of the humerus or femur .Hard: Bone-to-bone stop, such as elbow extension.Abnormal end feel: Abnormalities may producevarying end feels; six are differentiated:Less-elastic: Such as due to scar tissue orshortened connective tissue.More-elastic: Such as due to increased muscletonus , shortened muscles .Springy block: Internal derangement where therebound is seen and felt, such as due to tornmeniscus." Empty": The patient feels severe pain, such asdue to acute bursitis, extraarticular abscess orneoplasm, and will not permit the movement to gofurther ; no physical stop felt by the therapist.Premature: Occurs before normal stop, such asin rheumatoid arthritis or osteoarthrosis, orcontracted ligaments or capsules.


  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    Extended: Occurs after normal stop, such as incases of instability or hypermobility.1.7. RECOMMENDED THERAPY PROCEDUREThe therapy techniques of Section 3 involve thepatient resisting and aiding, the third of the threeapproaches to procedure described in 1.6.2, p . 9.In these techniques:

    * The therapist moves a patient 's joint(s), in thedirection of restriction, to positions progressivelyapproaching, but never exceeding the normalrange of joint motion, as determined by end feel.* The patient actively participates in the treat-

    ment procedure, alternately resisting or aidingmotion as directed by the therapist.* Successive sequences of isometric contraction ,relaxation and stretching are used to attain thedesired improvement in joint movement range,followed by stimulation of the antagonists. De-scriptions of these treatment phases follow.

    1.7.1. Isometric ContractionFirst, the therapist moves the joint(s) to a positionin the line of movement to less than that whichmight cause pain. It may be possible to start in aposition with the shortened structures relativelystretched. However , it is often necessary to startin a position where the patient can easily resist themovement.

    Then , in this position , the patient is instructedto resist movement by isometrically contractingthe shortened muscle(s). In this phase, thetherapist and the patient apply forces that coun-terbalance so there is no movement in the jointitself. The therapist 's grip and resistance appliedmust be comfortable, painless , and secure for thepatient.

    I f isometric contraction causes the patient nopain, the therapist can readily and rapidly tire themuscle(s) involved by applying sufficient resist-ance (relative to the contracting muscular force)for a few seconds or longer. I f the isometriccontraction is painful for the patient, then thetherapist should decrease resistance and increasethe period of force counterbalance, up to 10 to 30seconds.1. 7 2. RelaxationWhen the therapist feels that the patient hassufficiently contracted the shortened muscle(s),the patient is instructed to relax. As the patientrelaxes, the therapist releases resistance accor-dingly, so as not to cause pain or unwantedmovement(s).1.7 .3. Stretching to Counteract and Reduce Res-trictionAfter the preceding isometric contraction andrelaxation, movement may be improved in fourways:10

    1. The therapist moves the joint in the directionof restriction.2. I f this movement is painful or if the patientfears pain, then the therapist may be morepassive and let the patient actively move atthe joint.3. Pain experienced often may be lessenedconsiderably if the therapist applies gentletraction while the patient actively moves atthe joint.4. Sometimes pain may be further reduced if,in addition to applying gentle traction, thetherapist also simultaneously either:a) aids the patient's movement at the joint,orb) provides gentle resistance while the patientmoves at the joint.

    Once an initial new position is attained, thesequence of contraction, relaxation and stretchingis successively repeated to progressively attain thedesired improvement in movement range. There-after, the antagonist(s) should be stimulated.1. 7 4. Stimulation of AntagonistsThe antagonists to the muscle(s) treated alwaysshould be stimulated immediately after the sequ-ence of treatment to increase movement in thedirection of restriction.

    To stimulate the antagonists, the therapistreverses the direction of force or resistanceapplied , and counteracts movement. To reversethe direction of force applied, the therapist mayeither retain grip or change grip, depending on thetreatment technique involved. Once the therapistis prepared to apply a reverse force , the patient isasked to move in the direction just stretched in thetreatment , and the therapist opposes that move-ment to evaluate the ability and the force withwhich the antagonists contract.

    Inhibition of antagonists can be reducedthrough vigorous stimulation, such as rapid vibrat-ing movements, pinching and shaking/stretchingmuscles, slapping the skin, or traction or com-pression (approximation) of the joint(s).Restricted joint mobility or pain may inhibitand thus lead to weakening of the antagonists.Therefore it may be necessary to strengthen thesemuscles throughout their full range of movement.The muscles should be able to control movementthrough the full range and should also be able tolock the joint in any position in that range.Stimulation of the antagonists is always a vital partof successful treatment.Neurological dysfunction may block or mask apatient's perception of stimuli. In these cases ,stimulation must be confined to localized areas.For instance, in stimulating the finger flexormuscles (antagonists to the finger extensors), the

  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    therapist should apply pressure only to the volarsides of the fingers.1.7.5. Stretching of Other StructuresWhenever successive contraction and relaxationtreatments fail to increase movement at a joint,the joint should be reexamined to ascertain if therestriction is caused by structures other thanmuscle(s), such as by ligaments or joint capsules.I f joint play is noticably diminished or absent, itmay be restored using joint mobilization techniques , such as those described by Kaltenborn(3)and Stoddard(5). However, if joint glide is normalbut movement is restricted, the following procedure may be used. The therapist stretches thehortened structures by applying an optimalintensity force. Intensity is th e combination offorce magnitude and duration of application, withduration being the more important in stretching.Optimal means as small as possible, yet adequatefo r results: a small force for a few seconds to two

    minutes or more.The patient should feel the stretching, possiblyeven as pain, though not to the point of seriousdiscomfort. Elsewhere the treatment should causeno pain. I f the procedure produces no improvement, the force applied may have been ofinsufficient intensity. I f so, stretching should berepeated at greater intensity, preferably for longerperiods of time, and then if necessary, with greaterfo rce.Physiotherapists or doctors may administerthese therapeutic stretching techniques. However ,therapy is more effective if it is supplemented bymore frequent self stretching , preferably daily oreveral times a day. Therefore, patients should be[a ught self stretching (6,7). In general, the morefrequent the stretching, the more moderate theintensity. Less frequent stretching, such as thatdone every other day, may be at greater intensity .1.8 . THERAPY TECHNIQUES - PART 31.8.1. Therapeutic Relation Between the Spine andthe Temporo-Mandibu)ar JointThe commonplace view of the human body places[he head on top of but separate from the back, andanatomical classification separates the jaw from[he spine. Such conceptual lack of connection candeceive. Acrobats thrill circus spectators byhanging in midair from bars clenched in theirteeth , and strongmen stunts often include impressively gigantic humans moving trucks or railroadars by pulling on towropes with their teeth. Thesextraordinary performances underscore that thereactually is a very strong connnection between theja w and the spine.

    Jaw misalignment , habitually clenched teeth, or

    other mastication abnormalities can asymmetrically load and thus lead to dysfunction in thetemporo-mandibular joints. This dysfunction mayresult in referred muscular stress , which, in turn ,can hinder treatment of or even worsen existingdysfunction in the neck. Whenever therapeutictreatment of the cervical spine fails (and there isno underlying neurological or pathological a b n o r - ~mality) , dysfunction in the temporo-mandibularjoints often is the barrier to improvement.Therefore , from a therapeutic viewpoint, thetemporo-mandibular joints are closely connectedto the cervical spine. Thorough therapeutic examination of the cervical spine should alwaysinclude examination of the temporo-mandibularjoints , and vice versa. For these reasons, thetherapies for restrictions at the temporo-mandibular joints are regarded as being part of thetreatments of the spinal column rather than part ofthe treatments of the extremities (Volume I).1.8.2. CaveatIn treating all joints , and particularly in treatingthe cervical spine, the therapist should strive toavoid compression. Compression may hinderdesired movement at the various articulations, canstress nerve tissue, or can otherwise damage thespinal column. Therefore , traction is used in allprocedures as a means of counteracting anycompression which may result from the movementinduced in treatment.

    Therapeutic treatment of the spine and thetemporo-mandibular joints builds on the samegeneral principles as does the correspondingtreatment of the extremeties described in Volume1. However , the nature and function of the spinalcolumn dictate a more cautious approach, whichdemands greater experience and skill on the partof the therapist.In particular, complex spinal movements, involving ventral/dorsal flexion , lateral flexion, androtation , must be made in sequential smallincrements . First ventral/dorsal flexion is increased slightly , then rotation is increased slightly,and finally lateral flexion is increased slightly.Thereafter , the sequence of slight increases ofeach of the three component movements isrepeated successively until the final position isattained. Specifically, a final position should not beapproached through maximum movements. Thatis, the therapist does not maximally ventral/dorsalflex, then maximally rotate, and finally maximallylaterally flex to attain a final position.

    The success of any therapeutic technique used iscontingent upon the cooperation of the patientand upon a careful examination and appropriatetreatment. The therapist must continuously aim ,through practice , to increase the sensitivity of


  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    mind, fingers and hands to "receive signals" fromthe patient. The character of these "s ignals" oftenmakes verbal communication superfluous. Thedevelopment of the requisite skills to "feel" whatlies below the surface and to register the eventsthere , and then to interpret this information alongwith the patient's reactions , may take years ofpractice , even for a skilled and gifted therapist.1.8.3. Key to Therapy TechniquesDetailed descriptions of the techniques used tostretch restricting structures are arranged in fivesections in Part 3: cervical spine, temporomandibular joints , thoracic spine and ribs , lumbarspine and coccyx. Each of these sections startswith a Therapy Guide , the first four of whichcontain two tables. The tables list the possiblerestrictions at the articulation group, the muscleswhich may cause each of the restrictions, thecorresponding techniques (indexed by numberand page) , and the relevant muscle actions.Alternative therapies for any particular restriction are indicated by suffix letters. For instance,there are three specific techniques for increasingventral flexion of the occiput on the atlas listed insection 3.2.2:

    3.2.2.C (see Notes!)Section 3 on thecervical spineSubsection 2 onrestricted ventralflexionSpecific techniques2 for the occiputon the atlaSTechnique C,patient supine

    For uniformity, all technique descriptions aresimilar. In dealing with movements symmetricalwith respect to the mid-sagittal plane where thechoice of right versus left is arbitrary for thetherapist, techniques are explained primarilyassuming a right-handed therapist. In these cases,the therapist may interchange right and left ifmore convenient. In all cases where movementsare asymmetrical with respect to the mid-sagittalplane, the treatment fo.r movement to the right isshown and discussed. The therapist then reads right for left and vice versa in the equivalenttherapy for movement to the patient's left.

    Each therapy is illustrated with a muscledrawing and starting and final position photos.12

    Drawings show directions in all planes.

    in illustrations indicates locking

    X in illustrations indicates points of stabilizationby hands , belts etc. Arrows in illustrations indicatedirections of stretching movements and alsopatient movement in the antagonist muscle stimulation phase. P in texts denotes the patient , Tthe therapist.All instructions are for you, the Therapist, and aredivided into four parts: Starting Position, Grip,Procedure and Stimulation of Antagonists. Whenneeded , Notes clarify or supplement these fourparts.

    The Starting Position instructions consist ofshort statements on how to arrange the patientand yourself to start treatment. They may easilybe remembered if you view them as briefdescriptions of a scene, or as notes you might takeupon first seeing the technique performed byanother therapist. The other three instructions,Grip, Procedure and Stimulation of Antagonistsare direct instructions on how to perform thetreatment.Instructions for the patient also require monitoring by the therapist. For instance, someProcedure instructions require the patient toexhale. You must then ask the patient to exhale,and must check that he/she exhales and does notimmediately inhale again as the treatment isperformed.Note that most stretching should be performedgradually and fully, so as to approach but not gobeyond the normal range of movement.As in anatomy texts, the descriptions of muscleaction of this Manual assume starting in theanatomical position. However , muscle action maychange at an extreme joint position , sometimes tothe opposite of that described . For instance, thesternocleidomastoid muscle in the neck acts as aventral flexor . of the cervical spine when it isventrally flexed, but acts as a dorsal flexor of theupper cervical spine when the cervical spine isdorsally flexed.1.8.4. TerminologyStandard anatomic terminology is used throughout this Manual. However, whenever two or moresynonymous anatomical terms are in acceptedcurrent use, the terms most pertinent to thephysiotherapy situation are used.

    Because manual therapy is concerned withjoints and muscles and related structures, all

  • 7/28/2019 Muscle Stretching in Manual Therapy II - The Extremities[Team Nanban[TPB]


    descriptions of therapy procedures and of muscleactions are in terms of joint movements. Forinstance, the action the rectus capitis dorsalismajor muscle of the neck is described as "dorsallyflexes the occiput on the atlas" while a medicalanatomy text author might prefer "extends head."In summary, the terminology of this Manualmay be viewed as chosen to suit an active situationin which the therapist promotes, directs, or e l i c i t ~motion, as opposed to some surgical or medicalchoices of terms , which may be viewed as morepassive, intended primarily for identification ordescription.1.8.5. Using the Ready Reference FeaturesThe ready reference features of this Manual canbest be explained by example. Assume an adultwhose complaint is that they cannot turn theirhead and look to the rear when backing a car. Therestricted movements involve various degrees ofventral flexion with lateral flexion and rotation tothe same side of the cervical spine. First , Section 3on the Cervical Spine is found either by pagenumber from the Contents or by flipping throughhe pages to find The Cervical Spine at the top ofthe pages involved. Table 3-1 lists the techniques-o r ~ r e a t i n g the restricted movement as part ofectlon 3.3, pp.38-43. All primary and secondary


    restricting muscles are listed in Muscle RestrictionTable 8-1, pp. 142-143 .

    1.9. REFERENCES1. Janda , Vladimir , "Die Bedeutung der muskularen Fehlhaltung als pathogenetischer Faktorvertebrangener StOrungen," Arch. physikal. Therapie, 20 (1968) , 113-116.2. Sherrington , C.S. , "On plastic tonus andproprioceptive reflexes ," Quart. J. Exp. Physiol.,2 (1909) , 109-156.

    3. Kaltenborn , Freddy M., Manual Mobilizationof the Extremity Joints, Vol II , Olaf Norlis Bokhandel, 1988.4. Cyriax , James, Textbook of OrthopedicMedicine, London , Hutchinson, 1969.5. Stoddard , Alan , Manual of OsteopathicTechnique, London, Hutchinson , 1980.6. Gunnari , Hans , and Evjenth, Olaf , Sequence

    Exercise , Oslo , Dreyers Forlag, Norwegian edition 1983 , English edition 1984 (Chapter 7 onself-stretching)7. Evjenth, Olaf and Hamberg, Jern , Autostretching. The Complete Manual of Specific Stretching,Alfta Rehab F6rlag , Alfta, Sweden, 1989.



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    2. THERAPEUTIC VIEW OF THE SPINE2.1. Importance of the Movement Pattern inTherapyThe structure and function of the vertebralcolumn dictate that therapy techniques for thespine differ from therapy techniques for otherjoints in the body in two respects. First, becausethe vertebral column consists of many articulatingsegments , movements are complex and usuallyinvolve several segments. This also means thatrestrictions may be complex. For instance, if asingle segment is restricted , the adjacent segmentsmay assume part of its normal tasks in executingmovement. Thus hypomobility and forced hypermobility may both exist in a relatively shortsection of the spine. Second , because the spinalcord runs along the channel formed by thevertebral column, damage to or excessive movement of the column is potentially hazardous to thecentral nervous system.

    The therapist may exploit the movement pattern of the spine to therapeutic advantage. Forinstance , through controlling movement , segments may be positioned such that they are eithermaximally free or maximally constrained . Exercising such control increases the precision andefficiency of both non-specific and specific treatments.For these reasons, a thorough familiarity with themovement pattern of the spine is prerequisite to alltherapy techniques for the spine.The movement pattern of the spine delineatesthe movements attainable by the unrestricted ,normal spine. It should not and normally cannotbe exceeded without injury. It is described interms of quantity and quality of the variousmovements involved. The quantity of a spinalmovement is described in terms of the basic

    component movements and can be measured indegrees. The quality of a spinal movementdescribes the manner in which it is made . A highquality movement is made throughout its rangewithout pain or obvious mechanical difficulty .Both the quantity and the quality of a spinalmovement and of its basic component movementsare determined by the physiology of the spine andits surrounding structures.2.2. Basic MovementsAlmost all self-propelled human motion is produced and controlled by movements of theappendicular portion of the body. Much of thescience of kinesology is devoted to studies of howthe limbs move in executing various tasks and inpropelling the body. In comparison to the relatively large normal ranges of movements at the jointsof the extremities, the movements of the articulat-14

    ing segments of the vertebral column are small ,and sometimes almost imperceptible. Nonethelessthey are extremely important. And they profoundly affect movements of other parts of thebody, as anyone who has ever tried to walk with a"stiff back" can attest. Movement , howeversubtle, is a vital part of the function of the spine.Therefore , the movements of the spine areprecisely defined:All movements of the spine are referenced to theneutral position in which the spine appears:* As a straight, vertical column in the frontalplane.* As a double S-curved column (post-infancyspine) in the sagittal plane, with normal cervical,thoracic, lumbar and sacral curves.

    And all complex movements are described interms of three constituent component movements.In their most customary order, the componentsare:* Sagittal plane : Ventral or dorsal flexion: Movements changing curvature of the spine in the midsagittal plane.* Frontal (coronal) plane: Lateral flexion: Movements inducing curvature of the spine in thefrontal (coronal) plane , to the right or to the left.* Transverse plane: Rotation about a midline inthe vertebral column, defined when viewed fromabove the head as right (clockwise) or left(counterclockwise) .Theoretically , these three components may beconsidered in any order. But in practice, flexion inthe sagittal plane is always first, because ventral

    Fig . 1. Normal vertebral column in sagittal plane;left lateral view.

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    nd dorsal flexion differ in magnitude throughoutt of the spine and because together they- mprise the greatest range of movement of the"' ine . Thereafter, there are two possible orders.. e order most commonly used in physiotherapya above: ventral/dorsal flexion, followed by ral flexion, followed by rotation. However, ina ting, particularly in treating the cervical spine,ra pists will rotate before laterally flexing. Soorder of ventral/dorsal flexion, followed by- -at ion, followed by lateral flexion is also valid.

    The three basic component movements are no t- lepe ndent, but interact in various ways depend; on where movement occurs in the spine.ause the spine is not a completely symmetrical-I ul ating unit, as is, say, a chain of beads,_ntra l and dorsal flexion may have differing_ -e ts on the two other basic movements, de_ on position in the spine. In the cervical

    ..., n . ventral and dorsal flexion have similart on lateral flexion and on rotation. But inthoracic and lumbar spine, where the position-he articular facets relative to the body of the_r-ebrae differs from that in the cervical verteb. ventral and dorsal flexion have differingt on the two other basic movements. There nces are discussed in the following section.La te ral flexion and rotation interdependughout the spine. Normally, one cannot occur-ho ut the other. The single exception is the- - [ion of the atlas on the axis, which produces


    . negligible lateral flexion at the segment itself.

    ') Normal vertebral column In coronal(frontal) plane; dorsal view.

    However, there is still a degree of movementinterdependence, as rotation of the atlas on theaxis causes lateral flexion of the occiput on theatlas to the opposite side. In general , full lateralflexion is contingent upon rotation .

    The theoretically perfect spine can ventrally ordorsally flex throughout without involving lateralflexion or rotation. However, in almost allpractical situations, apparently pure ventral ordorsal flexion actually involves some lateral flexion and some rotation.2.3. Physiologic MovementIn addition to consisting of three componentmovements, all complex spinal movements arecharacterized by the relative ease with which thephysiology of the vertebral column permits themto be made. In either ventral or dorsal flexion, thenormal, unrestricted spine laterally flexes equallywell to the right and to the left. However, for eachof the four combinations of ventral/dorsal flexionand right/left lateral flexion , there is a differencein the magnitude and the ease with which rightand left rotation may be made. One direction ofrotation is as free as physiologically possible , whilethe other is constrained.

    The same situation arises if rotation is considered (or induced in treatment) before lateralflexion. In ventral/dorsal flexion, the normal,unrestricted spine rotates equally well to the rightand to the left. However, for each of the fourcombinations of ventral/dorsal flexion and right/left rotation, there is a difference in the ease withwhich right and left lateral flexion may be made.One lateral flexion is as free as physiologicallypossible , while the other is constrained. In both ofthese cases, the relative ease of movementdepends on the direction chosen for the last of thethree component movements. So the terms describing ease of movement are referenced to thatlast component movement , and the first twocomponent movements are regarded as attaining aposition:'" A position where a final component movementis maximally free is termed the "physiological" position for movement, which stops with a soft endfeel; i. e. coupled movements.. A position where the Anal component movement is cons trained is termed the "unphysiological"position for movement, which stops with a hard endfeel; i. e. combined movements.

    The range of movement ease, from maximumfreedom in the physiological position for amovement to constraint in the unphysiologicalposition for movement is best illustrated byexamp les in everyday life. Consider, for instance,the normal sequence of movements a sittingperson uses to glanEe to the left, such as to speak


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    to someone in the seat to the left in a theater. Thechin tucks in and the head inclines and rotates tothe left. The sequence of movements involveventral flexion followed by left lateral flexionfollowed by left rotation in the cervical spine. Themovement is accomplished with ease and withoutdiscomfort, as it has been made from the physiolo-gical position for left rotation. Now consider asimilar movement as it is often made by busyoffice workers at their desks. The typical right-handed office worker places the telephone on theleft of his/her desk to leave the right hand free forwriting. When talking on the phone , the head isbent to the left to cradle the telephone receiverbetween the head and the left shoulder, and notesare taken with the right hand , on a pad held stableon the desk with the left hand. Now, if the callrequires some information filed on the worker'sshelf, typically located behind the chair , mostworkers will crane their heads to the right tolocate the desired item, without putting thetelephone receiver down . But head movement tothe right is difficult, because the sequence ofmovements has involved ventral flexion followedby left lateral flexion (which is held) followed byright rotation in the cervical spine . This is theunphysiological position for right rotation. Thefirst two component movements, ventral flexionand lateral flexion to the left , are the same in bothcases, and the position attained by them may evenbe identical. The position is physiological for leftrotation, but unphysiological for right rotation.

    In therapy, the segment( s) treated is /are placedin the physiological position for the movementinvolved. Therapy techniques are most effective ifthe segments not being treated do not move in theprocedure, or "follow" the movement the therap-ist induces in the treated segments . They are thenplaced in an unphysiological position for thatmovement. This use of unphysiological positionsto deliberately constrain movement is termedlocking. Locking is written in italics to indicatethat it does not mean becoming locked, as a doorlocks , but rather considerable constraint to move-ment.


    Fig. 3. Vertebral column in ventral flexion lateralflexion and rotation to the right; dorsalview.

    '- ' .,-Fig . 4. Vertebral column in dorsal flexion , lateralflexion to the right and rotation to the left;dorsal view.

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    Lower thoracic and upper lumbar verte-brae in ventral flexion, lateral flexion androtation to the right (A, above figure) andin dorsal flexion, lateral flexion to theright and rotation to the left (B, belowfigure), both physiological positions formovement involved; dorsal view.




    Lower thoracic and upper lumbar verteb-rae in dorsal flexion and lateral flexion tothe right. Rotation to the left (A, abovefigure) is physiological, while rotate to theright, (B, below figure) is unphysiological;dorsal view.


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    2.4. Physiological and Unphysiological/LockingPositionsThe spine is, so to speak , well designed for itspurpose. The physiological positions are thoseinvolved in natural human movement. Therefore,they differ from the cervical spine to the thoracicand lumbar spines, as suits the differences inneck/head and trunk movements. The physiological and unphysiological positions are listed InTable 2-1 and shown schematically in Fig. 7.

    Table 2-1 Physiological and Unphysiological Positions of the Spine .

    Part of Sp in e Sag itta l Pl ane Flexion Late ral Fl ex ionCe rvica l' Ventral RightVentral Left

    Dorsal RightDorsal Left

    Thorac ic and Ventral Ri ghtLumba r Ventral Left

    Dorsal RightDorsal Le ftNote 1 May include par t of th e upper th oracic spine

    Fig. 7.








    Dorsa l




    Physio lo gica l Unphysiologica l Pos itionRota ti on for Rota ti on toRight Le ft Le ft Ri ghtRight LeftLe ft Ri ghtRi ght Lc ftLe ft Ri ghtRi ght LeftLe ft Right


    Ventr al

    Left Right


    Ventr al

    Left Right


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    The differences in cervical spine behavior andthoracic and lumbar spine behavior are seen mostclearly in the schematic drawing of Fig. 7 . Inventral flexion , the physiological and unphysiolo-gical positions are alike throughout the spine . Butin dorsal flexion , there is a right-to-Ieft reversebetween the cervical spine and the lumbar andthoracic spine, as best suits overall bodybiomechanics. The differences between the behaviors of the cervical spine and the lumbar spineis clearly noticeable in normal body movement.However , the difference between the behaviors ofthe lower cervical spine and th e upper thoracicspine may be less obvious . The transition fromtypical cervical spine behavior to typical thoracicpine behavior is not always abrupt at the C7-Tlegment. It may be gradual. In other words ,ce rvical spine behavior may extend slightlycaudally into the thoracic spine. So in Table 2-1and Fig. 7, Cervical may in some cases beextended to mean Cervical and possibly part of theupper Thoracic.The example of the previous section can beeas ily explained using Fig. 7 . Both the theatergoer and the office worker attain positions of thecervical spine falling into the ventral-left quadrants of the diagrams. The theater-goer's leftrotation is physiological:

    v~L ~ Ro

    Segment(s) in neutral position .o Segment(s) displaced.Fig.7. Schematic representation of the physiolo

    gical and unphysiological positions of spinal segments. Drawings show directions intransverse planes through the spine: ventral and dorsal sagittal-plane flexion , andright and left lateral flexion. Arrows circling displaced spine positions indicatedirections of rotation. Note the right-leftsymmetry of movement in the cervicalspine. The corresponding symmetry in thethoracic and lumbar spines is by sectors inthe above drawings , or mirror symmetricabout a coronal plane. Note 1: May includepart of the upper thoracic spine.

    However , the office worker 's right rotation isunphysiological , or locked (indicated by keyholesymbol in schematic drawing below) :VL4R 8o

    Other everyday movements may be analyzedusing the figure . Consider , for instance , the case ofthe theater-goer whispering to the person in theseat to the right and the office worker trying tofind papers filed on the shelf behind his/her chairwhile talking on the telephone . The theater-goermost likely will bend forward slightly and thenrotate his/he r shoulders to the right to come closerto the next person's ea r to whisper. The sequenceof movements involve ventral flexion followed byright rotation and right lateral flexion. Themovement falls in the ventral-right quadrant ofthe physiological diagram for the thoracic andlumbar spine :

    It is easy , as it has been made from thephysiological position. On the other hand, thestressed office worker, who finds that he/shecannot see the desired item on the shelf behindbecause head rotation to the right is blocked , willoften bend backwards to come closer to the shelf ,and then turn shoulders and the chair back to theright for a better view. The sequence of movements involve dorsal flexion followed by rightrotation and right lateral flexion of the thoracicand lumbar spine. The movement falls in thedorsal-right quadrant of the unphysiologic diagram:

    VL ~ R no

    It is difficult as it has been made from theunphysiological position. The office worker hascompounded the original error, and has strainedto move against locking in the thoracic/lumbarspine as well as locking in the cervical spine.

    Table 2-1 and Fig. 7 may be used to analyzedifficulties due to unintentional locking broughtabout by improper movement. But their majorutility to the therapist is as a reference of lockingpositions used intentionally in various spinaltherapy techniques.


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    2.5. Locking TechniquesLocking in therapy involves intentionally placingsegments in positions to constrain their movement , so adjacent segments may be more effectively treated. Usually cranial/superior segmentsor caudal/inferior segments to the treated segmentare locked. But in some instances , locking may beused both caudal to and cranial to the treatedsegment.The basics of therapeutic locking are easilyderived from Table 2-1 and Pig. 7. Consider , forinstance , a treatment technique to enhance lateralflexion to the left and rotation to the right of asegment of the lower thoracic spine in dorsalflexion , as shown in Pig . 8. The segment itself isplaced in the physiological position , and theadjacent segments are placed in the unphysiological position for rotation to the right. There aretwo options for locking against right rotation:1. Retain dorsal flexion and induce lateralflexion to the right , or2. Induce ventral flexion and retain lateralflexion to the left.

    Por most non-specific treatments and some P ' 8Ig . a.more easily performed specific treatments , one ofthese two locking options is adequate . Because itis usually more convenient to position a patientwith the spine completely in dorsal flexion orcompletely in ventral flexion , the first of the twooptions is the most frequently used. The sagittalplane flexion (ventral/dorsal) in which the treatedsegment is placed is retained caudal to thesegment , because of the convenience of stabilizingPig.8. Typical treatment of lower thoracic spine:Tll-T12 segment in physiological position:Dorsal flexion , lateral flexion to the left ,and rotation to the right.A: Locking retaining dorsal flexionthroughout. Segments caudal to segment

    treated laterally flexed to the right androtated to the left, thus locking for rotationto the right. Segments cranial to segmenttreated retain the lateral flexion to the leftand rotation to the right and therefore donot lock.B: Locking with change of flexion insagittal plane: Segments caudal to segmenttreated positioned as in A : Dorsal flexion,lateral flexion to the right and rotation tothe left, thus locking for rotation to theright. Segments cranial to segment treatedplaced in ventral flexion, lateral flexion androtation to the left, thus locking forrotation to the rifiht. This is double lockin,with segments both caudal to and cranial tothe segment treated locked for rotation to P ' 8 bIg . .the right .


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    he relatively larger mass of the hips. In thexample above, this means that dorsal flexion wille retained caudal to the treated segment.Theoretically, specific treatments , with lockingoth caudal and cranial to the segment treated ,an be conducted by placing the entire vertebralolumn in dorsal flexion and lateral flexion to theright (so it locks) and inducing left lateral flexionin the treated segment. But in practice this ismpo ssible to induce. Therefore , flexion isn g e d in both the frontal and the sagittal planes.In the example above, dorsal flexion is retainedut lateral flexion changes from left to right toock caudal to the segment treated , while lateralxion to the left is retained while sagittal plane_exion changes from dorsal to ventral to lockanial to the segment treated. As illustrated infig. 9, locking both caudal to and cranial to the_ gment treated can be achieved by changing: gi ttal plane flexion either caudal to or cranial to

    : . ~ e segment treated . The choice between these "'0 approaches is largely a matter of convenience. r the therapist and for the patient.

    ::- .:: .9 .Two alternative double locking methods fora typical specific treatment of lower thoracicspine ; segment TIl-T12 in physiologicalposition in dorsal flexion , lateral flexion tothe left and rotation to the right.A: Segments caudal to the segment tre-ated are in ventral flexion , lateral flexionand rotation to the left , and thus lock . forrotation to the right. Segments cranial to ;.thesegment treated are in dorsal flexion, . lateralflexion to the right and rotation to the left,and thus lock for rotation to the right.B: Opposite locking alternative: Seg-ments caudal to the segment treated indorsal flexion , lateral flexion to the right androtation to the left , thus locking for rotationto the right. Segments cranial to ' the segmenttreated are in ventral flexion, .. lateral flexionand rotation to the left, and thus lock forrotation to the right.

    Fig. 9 a.

    Fig. 9 b.


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    Three simple rules for locking may be derivedfrom these examples.1. Locking is always relative: Segments to belocked are themselves physiologically posi-tioned. For instance, in the first option of theexample above , the segments to be lockedcaudal to the treated segment are placed in

    dorsal flexion and lateral flexion to the right.That position involves slight left rotation , andtherefore is physiological for the segmentsthemselves. So for the normal , unrestrictedspine, the position easily attained. But rotationto the right is constrained , which effects thedesired locking. Locking is always relative to aparticular final movement, in this case rotationto the right, from a position attained by normalphysiological movement.2. Locking always involves inflection (changes offlexion): Changes of flexion , either in thesagittal or the frontal planes, or sometimes inboth planes , effect locking. In the first optionof the example above, the flexion change isfrom left to right lateral flexion. In the secondoption, the change is from dorsal to ventralflexion. Inflection is depicted schematically inFig. 10.

    Fig.lO. Schematic representation of inflectionsused in locking. Curves shown are forillustration only , and indicate flexiondeviations from the neutral position of thespine shown in Figures 1 and 2.

    , 0rontal I Rplane \ ~ ) .... \L II,, - C ~agittal , V\plane ,~ ) ,D ,,I

    - '


    - ,, L)I Left ( ) RightIC; II R' -

    - \ D), Dorsal ( ) VentralC: ,.'I\ V ____ treated segments' - - - locked segments

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    3. Only one inflection per locking: The spine is notrubbery; it has an inescapable rigidity (otherwise it could not fulfill its support function). Sotwo changes of flexion from a treated to anadjacent locked segment ar e no t possible. Onecannot , for instance , induce both a changefrom dorsal to ventral flexion and a changefrom left to right lateral flexion for a singlelocking. This is equivalent to requiring that atleast on e of the flexions of the treated segmentbe the same as that of the adjacent lockedsegment. The relationship is shown schematically in Fig . 11. The single exception is the caseof double locking for treatment of the C2-C3segment, where the occiput, atlas an d axis mustbe moved as a unit.

    The simplest inflections to constrain adjacentegment movement involve changes of flexion inhe sagittal plane alone, and are used in treat

    me nts for pure ventral or pure dorsal flexion.In general, inflection in the frontal plane (lateralflex ion) is adequate fo r locking caudal to orra nial to the segment treated in non-specificrea tments. However, for specific treatments ,.ocking both caudal to and cranial to the treated

    :egment, as shown in Figures 8 and 9, is frequentlyu ed.

    Fig. 11. Diagram of inflections and " transmitted"flexions that "g o into" segment treated,with locking both cranial to and caudal tothe segment treated. Case shown is that ofFig.9B.


    ~ O C K I N G CRANIAL Ventral-:-0 TREATED SEGMENT Flexion\/inflection

    /\-:-REATED Dorsal: : : ~ G M E N T Flexion

    1-transmissionI_OCKI G CAUDAL Dorsal- TREATED SEGMENT Flexion

    FRONTAL ROTATIONPLANELeft LeftLateral Flexion RotationItransmission

    ~Left RightLateral Flexion Rotation\/inflection/\Right Left

    Lateral Flexion Rotation23

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    Theoretically, there may be as many as four waysto achieve double locking , with segments cranialto and caudal to the treated segment locked .However, the requirement that the treated segment "receive" flexions from the adjacent lockedsegments limits the number of possible combina-tions for locking.

    For instance, double locking is extremely difficultin the cervical spine itself, except for the C2-C3segment, where the mechanical convenience provided by the occiput , atlas, and axis moving as aunit permits cranial locking . Cervical segmenttreatment is also facilitated by the relativelyexposed positions of the segments which makesdirect manipulation possible . So the advantageoffered by double locking may also be achievedthrough a single cranial/caudal locking. In thiscase , the Therapist can lock caudally to thesegment treated and achieve segment treatmentby holding and moving the cranial vertebraeinvolved. The opposite procedure may also beused: locking cranial to the segment, and holdingand moving the caudal vertebrae involved. Dou-ble locking is possible in the thoracic and lumbarspines.The possible combinations for double locking arelisted in Table 2-2.Table 2-2. Combinations possible for double lockingPart of Spine Segment Treated In Locking Caudal toSegment Treated

    Flexions Rotation Flexions LockedforVentraU Lateral VentraU Lateral rotation toDorsal Dorsal DCervical Ventral Right Right Either Left RightC2-C3 only

    Ventral Left Left E ither Right . LeftDorsal Right Right Either Left RightDorsal Left Left Either Right LeftCervical- Ventral Right Right Dorsal Right Rightthoracic l Ventral Left Left Dorsal Left LeftDorsal Right Left Dorsal Left LeftDorsal Left Right Dorsal Right RightThoracic Ventral Right Right Ventral Left Right& Lumbar " " " Dorsal Right RightVentral Left Left Ventral Right Left

    " " " Dorsal Left LeftDorsal Right Left Dorsal Left Left" " " Ventral Right LeftDorsal Left Right Dorsal Right Right" " " Ventral Left Right

    Locking Cranial toSegment TreatedFlexions Lockedfo rVentraU Lateral rotation toDorsal 2]Either Left RightEither Right LeftEither Left RightEither Right. LeftVentral Left RightVentral Right LeftVentral Right LeftVentral Left RightDorsal Right RightVentral Left RightDorsal Left LeftVentral Right LeftVentral Right LeftDorsal Left LeftVentral Left RightDorsal Right Right

    Note: 1) Usually at the C7-T1 segment; may be in segments caudal to C7-T1 , in cases where cervical behavior extends caudallyinto upper thoracic spine. Therapist must test patient to determine location of cervical-thoracic behavior transition .2] indicates locking for rotation when used in illustrations.24

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    ~ i g . Locking caudal to the segment: ventralflexion , lateral flexion and rotation to theleft; locked for rotation to the right.Locking cranial to the segment: dorsalflexion , lateral flexion to the right androtation to the left ; locked for rotation tothe right.

    A::- _.13 . A:Locking caudal to the segment: dorsalflexion , lateral flexion to the right and

    rotation to the left ; locked for rotation tothe right.Locking cranial to the segment: None:Ventral flexion , lateral flexion , and rota-tion to the right.B: Closeup of A.



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    3. THE CERVICAL SPINE (Occiput on ClIo C7on TJ)3.1. Therapy Guide3.1.1. Mandatory ExaminationRestrictions of the cervical spine of pathologicetiology contraindicate manual therapy; patientsaffected should be referred to relevant medicalspecia lists. Therefore. all patients must be examined prior to and continuously monitoredduring treatment of the cervical spine, least anyexisting pathological condition be worsened, increasing the risk of injury.Prior to treatment: Assure , by test or test report,that De Kleyn's, Hau tand 's and Romberg 's testsare negative. Positive tests contraindicate manualtherapy. Pathological hypermobility in a segmentcontraindicates stretching of that segment.During treatment: Patient dizziness, nausea ,radiating pain , or other severe discomfort duringtreat ment may be signs of vascular spasm, anoma-lous blood vessels, fractures, ruptured ligaments.instability , herniated discs. or other pathologicalconditions that contraindicate manual therapy.The patient should be continuously monitored forthese signs: If they appear, therapy should bestopped immediately.


    3.1.2. Treatment GuidelinesCaution is the watchword in treating the spine.Therefore , in treating any restriction. pelj'orm lhenon-specific techniques first. Perform specific tech-niques only if the non-specific techniques elicit nocontraindications to further therapy.All manual therapy techniques for the cervicalspine involve traction , basically to prevent poten-tially hazardous compression. The therapist applies traction through a firm grip on the patient 'shead. The grip should be adequate for the tractionneeded , and should be positioned to avoiddiscomfort in sensitive areas, such as the ears,nose, eyes, mandible and larnyx . This is mosteasily done if the therapist fixes the patient's headand then moves his/her own body to induce themovement required . Controlled movement of thetherapist 'S body and the patient's head as a unitalso helps prevent unwanted movements.

    The th e rapist may instruct or direct patient ey emovements and respiration to aid therapy . Eyemovements evoke reflex responses. such as " lead-ing " movements of the head. Directing ey emovement then gives the therapist control overpatient head movement. Respiration: Normalbreathing , particularly exhaling, promotes relaxa-tion, while inhaling or holding the breath are oftennaturally evoked when producing muscular force.Therefore, instructing the patient to exhale aids

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    re laxation during stretching, while breathing norma lly promotes relaxation during sustainedtretching (two minutes or more). Inhaling helps-he patient contract against the therapist's resistance , such as during the stimulation of antagonists

    hase of treatment.Lateral flexion and rotation interdepend

    -h roughout the spine. Normally, one cannot occurvi thout the other. The single exception is theota tion of the atlas on the axis , which producesnly negligible lateral flexion at the segment itself.

    However, there is still a degree of movementnte rdependence , as rotation of the atlas on thexis does cause lateral flexion of the occiput on the[las to the opposite side.Of the two mutually dependent movements,ro ta tion is the more crucial. Full lateral flexion isontingent upon rotation. In all procedures in.olving both movements, rotation must be in

    -Teased before lateral flexion is increased. Reversng the sequence by laterally flexing the spine toni ti ate rotation usually causes compression at the-: e t articulations and is therefore potentiallyaza rdous. .

    In cases when the patient's deep, ventral 'flexors-..r inhibited, they should be stimulated. There--- re o treatment should be arranged to prevent:o n traction of the superficial ventral flexors. The:J rapist must monitor patient head position::tro ughout treatment to assure that the superficialntral flexors are not activated when the move

    nt involved is intended to either stretch or=-imulate the deep ventral flexors.\lany of the following therapy techniques for::ea ting the cervical spine may be performed with

    -:1 patient either sitting or lying down. The choice\ een alternative treatment positions depends.., th on comfort and convenience for both the_ tie nt and the therapist. For example, some:' tients may no t be able to tolerate a sittingition when being treated, and therefore must

    treated lying down. Likewise, a smaller- erapist may find treatment of a large patient in a:' o ne or supine position to be far easier than theuivalent treatment of a sitting patient.: . 1.3. Movement Patterns and Lockinglovement patterns and locking are discussed in2, pp. 14-25. The following is a short

    :.Immary review for the cervical spine.First, although the cervical spine and its mobile"gments are anatomically well defined (in the. anial to caudal direction, as starting at the_ iput on Cl and ending with the C7-Tlm e n t ) , the therapeutic definition is not so rigid.::1 many cases, the transition from typical cervical. ine segment behavior to typical thoracic spine

    = m e n t behavior is no t abrupt at the C7-Tl

    segment, but rather more gradual. This meansthat cervical spine behavior may extend caudallyinto the thoracic spine. So therapeutically thecervical spine should always be regarded as thecervical and possibly part of the upper thoracicspzne.

    Segments adjacent to those treated should bestabilized so they do no t follow the movementinduced to effect treatment. Stabilization alwaysrequires inflection , or changes of flexion, either inthe sagittal or the frontal plane. Basic stabilizationof the cervical spine involves changing flexionfrom ventral to dorsal or vice versa. For instance,treatment of a segment in ventral flexion is mosteffective if segments adjacent cranial to or caudalto it are placed in dorsal flexion.

    The movement pattern of the cervical spine issymmetric about the mid-sagittal plane. As shownin Fig. 7 (p . 18), for both ventral and dorsalflexion, lateral flexion and rotation to the sameside are "physiological" movements, while lateralflexion and rotation to opposite sides are " unphysiological." This means that segments to betreated in lateral flexion and/or rotation should beplaced either in right lateral flexion and rightrotation (the convention chosen for the techniqueillustrations of this book) or in left lateral flexionand left rotation. A right-left direction differencebetween lateral flexion and rotation produces the"unphysiological" position used for locking. Lock-ing is a more secure method of stabilization than asingle change of ventral or dorsal flexion. However , it obviously can be used only when thetreatment involves lateral flexion and/or rotation.Double locking , both cranial to and caudal tothe segment treated is possible in the cervicalspine itself only for the C2-C3 segment (seediscussion , p. 24). Otherwise, double locking incervical spine treatments is possible only when the"lower," or caudal lock is effected in the upperthoracic spine.


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    3.1.4. Restrictions, Muscles and TherapiesThe non-specific and specific therapy techniques for treating restrictions of the cervical spine and itssegments are listed in Table 3-1. The actions of the muscles which may cause those restrictions are listedin Table 3-2. The various restrictions possible are listed in Movement Restriction Table 8-1, pp.142-143 .Table 3-1. Restrictions of the Cervical Spine



    3.4 .





    MUSCLES WHICH MAYRESTRICT MOTIONMost on dorsal siderect us capitis dorsalis major &minor , obliquu s capitis superior, splenius cap iti s, semi sp inal is capi tis, trapez iu s

    Ventra l flex ion wilh Most around cervical spi nelateral flexion and rola-tion to same sideVentral flexion with Most around cervical spinelateral flexion and ro ta-tion to opposite sidesDorsal flexion Most on ventral side

    TECHNIQUEITHERAPYnon- specificspec ific, occiput on atlasa tl as on ax isC2 on C3non- specificspec ific, C2 on C3non-specific

    non-specificrectus capitis anterior, longus specific, occiput on atlascapitis , suprahyoidales,infrahyoidales, platysma

    specific, atlas on axisnon-specific, for superficialventral muscles

    Number, Page3.2.1, 303.2.2, 31 -333.2.3, 34-353.2.4, 36 -373.3.1, 38 -403.3.2,4 1-433.4.1,44

    3.5.1 ,4 53.5.2, 46-48

    3.5.3, 49-513.5.4 , 52-53Most on ventral sideplatysma , suprahyoidales,infrahyoidales,suprathyreoidalesinfrathyreoidales I ;longus colli, longus capitis2 non-specific , for deep ventral 3.5.5, 54-57musclesDorsal flexion with later- Most around cervical spineal flexion and rotation 10same sideDorsal flexion with later- Most aro und cervical spineal flexion and rotation 10opposite sides

    non-specificspecific , C2 on C3non- spec ificspec ific, C2 on C3

    Lateral flexion and rota- Most between occiput and specific , occiput on at laslion to opposite sides atlasRotationMUSCLES

    Most around at las and axisSternocleidomastoideusScaleniSubclavius

    spec ific, atl as on axis

    3.6.1, 58-593.6.2, 60 -633.7.1, 64-663.7.2, 67 -713.8.1, 72 -753.9.1,76-773.10.1, 78-803.10 .2&3, 81-833.10.4, 84-85

    Notes: l. With mouth closed. 2. With mouth open.


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    Table 3-2. Actions of muscles which may restrict movement of cervical spine

    IUS capitisdo rsalis major

    IuS capitisdo rsa lis minorliquus capitisupe rior headmfe rior headleni us capitis

    :. lenius cervi cissplnalis cervi cisI os talis cervicis, longissi-- u cervicis, longissimus: .. ilis

    mispinalisapitisez iusdescending partr pinalesrtransversarii

    3lO res-er\'icis- .1.. ifidi__ -u capitis

    .. '1 er io rera lis::gus capitis- _u colli:-rahyo idales--ahyo idales

    '. rna_ nocleidomastoideus

    en us-; rior-ediu

    er io r- a\'i us

    ACTIONUnilateral Action: Dorsal flexes , rotates and laterally flexes the occiput and the atlas tothe same side. Bilateral Action: Dorsal flex the occiput and the atlas.Unilateral Action: Dorsal flexes, rotates and laterally flexes the occiput to the same side.(In ventral flexion , it may laterally flex to the same side and'rotates tothe opposite side).Bilateral Action: Dorsal flex occiput.Dorsal flexes the occiput while rotating to one side and laterally flexing to the oppositeside.Dorsal flexes and rotates the atlas on the axis to the same side.Dorsal flexes and rotates the occiput to the same side.Dorsal flexes, laterally flexes and rotates to the same side.Dorsal flexes, laterally flexes and rotates to th e same side.Dorsal flex, laterally flex and rotate cervical spine to same side .

    Dorsal flexes and slightly rotates the occiput to the opposite side.Elevates the shoulder with the head and neck stabilized. Laterally flexes to one side androtates the head and neck to the opposite side with the shoulder stabilized. Dorsal flexesthe head when acting bilaterally.Dorsal flex the cervical spineUnilateral Action: Lateral ly flexes and rotates the cervical spine to the same side. BilateralAction: Dorsal flex the cervical spine.Unilateral Action: Laterally flexes to one side; rotates to opposite side ; dorsal flexes thecervical spine. Bilateral Action: Dorsal flex , the cervical spine.Dorsal flex, laterally flex and rotate to the opposite side.Ventral flexes the occiput on the atlas .Laterally flexes the occiput to the same side.Ventral flexes, laterally flexes and rotates to the same side.Ventral flexes, laterally flexes and rotates to the same side.Ventral flex while rotating and laterally flexing the occiput on the atlas to the same side(with the mouth closed).

    Unilateral Action: Ventral flexes the cervical spine while laterally flexing and rotating toopposite sides. Bilateral Action: (a) Dorsal flex the occiput on the atlas with the cervicalspine stabilized in the mid-position. (b) Ventral flex the cervical spine with the cervicalspine stabilized in the mid-position and with the occiput and the atlas ventrally flexed. (c)Act as an accessory muscle of respiration with the head and cervical spine stabilized.Unilateral Action: Ventral flexes the cervical spine while laterally flexing and rotating toopposite sides. Bilateral Action: Ventral flex the cervical spine. Act as accessory musclesof respiration when the cervical spine is stabilized.Unilateral Action: Rotates and laterally flexes to the same side. Bilateral Action: Dorsalflex the cervical spine.Depresses and stabilizes the clavicle during movements of the shoulder. Lifts the first ribwhen the shoulder is stabilized .


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    3.2.1. Non-specific technique to In creaseventral flexion.

    Starting Position: P: Supine; hea d and ne ckbeyond end of couch, shoulders and thoraxstabilized with a belt. T: Standing at head ofcouch.Grip : Ts right hand grips p 's occ iput , with wristand forearm suppo rting P's hea d . Ts left handgrip s p 's chin (without press ing on th e larynx).

    Procedure: Using this grip , T applies traction withboth hands, and then maintaining this tr ac tion ,moves his/her body in an upwa rd arc to graduallyand fully ventrally flex P's cervical spine .

    Stimulation of Antagonists: T re tains grip . T th e nasks P to look downwa rd a nd mo ve his/her headfurther in the direction of st retching. T res ists th atmovement to stimula te P's ant agoni sts .


    Fig. 14 a . Starting Position.

    Fig. 14 b . Final Po sition.

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    3.2.2A. Specific technique to increase ventral flexion of th e occiput on th eatlas.P silting.

    tarting Position: P: Sitting; left side of headupported against Ts left shoulder and chest. T:- ta nding facing p' s left side.

    Grip: Ts right index finger and thumb stabilize th e....0 terior arch of P's atlas. P's head is held firmly

    tween Ts left hand an d Ts chest. For comfort ,T left palm cups over P's car, with hand an d1re arm positioned to avoid pressure on P'sandible.

    Procedure: Using this grip, T applies traction, an dn maintaining this traction moves his /he r body:h p's head to gradually an d fully ventrally flexocciput on the atlas. T also uses right hand toh p's atlas in a ventral direction .

    .::-irnulation of Antagonists: T retains grip . T thenP to look downward , tuck chin in , an d move_ J further in the direction of stretching. T_ hts that movement to stimulate P's antagonists.- re: This technique is more easily performed if

    hin is in crook of T 's elbow; see alternative_.::h nique 3.2.2B, p. 32. Treatment accuracy an dT can apply ar e greatest with P supine , see_._C, p. 33.

    Fig. 15 a. Starting Position.

    Fig . 15 b. Final Position.31

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    3.2.2B. Specific technique to increase ven-tral flexion of the occiput on theatlas.P sitting. Alternative grip.

    Starting Position: P: Sitting; left side of headsupported against T's left shoulder and chest. T :Standing facing P's left side .Grip: T's right index finger and thumb stabilize theposterior arch of P's atlas. P's head is held firmlybetween T's left hand and T's chest, chin in thecrook of T' s elbow. For comfort, T's left palmcups over P's ear, with the hand and forearmpositioned to avoid pressure on P's mandible .

    Procedure: Using this grip , T applies traction, andthen maintaining this traction moves his/her bodywith P's head to gradually and fully ventrally flexP's occiput on the atlas . T also uses right hand topush P's atlas in a ventral direction.Stimulation of Antagonists: T retains grip. T thenasks P to look downward, tuck chin in, and movethe head further in the direction of stretching. Tresists that movement to stimulate P's antagonists.


    Fig. 16 a . Starting Position.

    Fig . 16 b. Fina1.Position.

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    3.2.2C. Specific technique to increase ventral flexion of the occiput on theatlas.P supine.

    tarting Position: P: Supine ; head beyond end ofouch with atlas at the edge.T: Standing at head of couch .Grip: T's right hand grips P's occiput with wristnd forearm supporting P 's head. T's right::houlder presses against P's forehead , without. ressing on P's nose or eyes. (If P finds this grip:.lllcomfortable , a small cushion may be placedtween T's right shoulder and P's forehead) . T's

    hand rests, vertical and stable , against the:ouch, firmly and rigidly under P's neck, with the_ terior arch of P's atlas lying against the radial~ p of T' s 2nd metacarpal bone and index-;1ger.

    edure: Using this grip , T applies traction, and., n maintaining this traction , moves his/her body-h P's head to gradually and fully ventrally flex0occiput on the atlas . T also uses right shoulderpush against P's forehead to produce a dorsalof the occipital condyles on the atlas , thus,ing P's atlas ventrally.

    =amulation of Antagonists: T retains grip . T then_ . P to look downward, tuck chin in , and move- head further in the direction of stretching. T- ~ : : i ts that movement to stimulate P 's antagonists .. te: I f P cannot tolerate supine position , treat in01 ting position , see the preceding two therapie s,

    -= _.2A and 3.2.2B, pp. 31 and 32.

    Fig. 17 a. Starting Position.

    Fig. 17 b . Final Position . 33

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    3.2.3A. Specific technique to increase ven-tral flexion of the atlas on the axis.P sitting.

    Starting Position: P: Sitting; left side of headsupported against T's left shoulder and chest. T:Standing facing P's left side.Grip: T's right index finger and thumb stabilize P'saxis. T's left hand grips around the right side of P'shead with the little finger along the posterior archof P's atlas. P's head is held firmly between T's lefthand and T's chest, chin in crook of T's elbow. Forcomfort, T's left palm cups over P's ear, with thehand positioned to avoid pressure on P's man-dible.

    Procedure: Using this grip, T applies traction, and Fig. 18 a. Starting Position.then maintaining this traction, moves his/her bodywith P's head to gradually and fully ventrally flexP's atlas on the axis. T's right hand also pushes P'saxis ventrally and caudally.Stimulation of Antagonists: T retains grip. T thenasks P to look downward , tuck chin in, and movehis/her head further in the direction of stretching.T resists that movement to stimulate P's antagon-ists.Note: The transverse ligament of the atlas may bepathologically weakened. I f so, it must not bestrained by the procedure. T avoids strain bysimultaneously moving P's head dorsally whileventrally flexing, which causes P's occiput andatlas to dorsally glide on the axis. The odontoidprocess ( dens) is then pressed against the anteriorarch of the atlas, which prevents pressure on thetransverse ligament.34

    Fig. 18 b. Final Position.

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    .2.3B. Specific technique to increase ventral flexion of the atlas on the axis.P supine.

    ':::arting Position: P: Supine; head beyond end ofh with the axis at the couch edge. T: Standing. ' J ad of couch.

    'p: T's right index finger and thumb grip P's. -. T's right wrist and forearm support P' s head .- ,: right shoulder presses against P's forehead ,-ho ut pressing on P's nose or eyes . I f P finds this=- uncomfortable, a small cushion may be. __ed between T's right shoulder and P's fore-;:..;. . T's left hand rests , vertical and stable ,= n t the couch , held firmly and rigidly under P's

    - . : ' . stabilizing the spinous process of P's axis_..:...:.n t the radial aspect of T' s 2nd metacarpal-e and index finger. (O r T's left index fingerhumb may grip P's axis).

    d u r e : Using this grip , T applies traction , and- : ma intaining this traction, moves his/her body. p 's head , to gradually and fully ventrally flexlas on the axis. Simultaneously T's right Fig. 19 a. Starting Position.Ide r presses against P's forehead to holderior arch of atlas in contact with the dens ,

    :h prevents stretching of the transverse liga. . of the atlas.u1ation of Antagonists: T retains grip . T then- P to look downward, tuck chin in , and move

    - r head further in the direction of stretching.-_=i t that movement to stimulate P's antagon-

    -. : The transverse ligament of the atl as ma y be- log ically weakened. If so , it mu st not bed by the procedure . T avoids strain by_ -aneously moving p' s head dorsa lly whilelly flexing. which causes p's occiput and-0 do rsally glide on the axis. Th e odonto id.::'_ (de ns) is then pressed aga inst the ante ri or

    - f the atlas. which prevents pressure on ther e ligament. Fig. 19 b. Final Position. 35

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    3.2.4A. Specific technique to increase ven-tral flexion of C2 on C3.P sitting.

    Starting Position: P: Sitting; left side of headsupported against T's left shoulder and chest. T:Standing facing P's left side.Grip: T s right index finger and thumb stabilize thespinous, articular and transverse processes of C3from the dorsal aspect. T's left hand grips aroundthe right side of P's head with the little fing