Therapeutic techniques

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Manipulation 182

6.1.1 General principles governing technical aspects 182
6.1.2 Extremity joints 187
6.1.3 The spinal column 201
6.2 Indirect techniques 223

6.2.1 Johnston’s functional techniques 223
6.2.2 Strain and counterstrain 225
6.3 Exteroceptive stimulation 225

6.3.1 Tactile perception and muscle tone 225
6.3.2 Assessing altered tactile perception 226
6.3.3 Normalizing tactile perception 227
6.3.4 Altered superficial tactile perception following surgery (due to scarring) 227
6.3.5 Individual characteristics of perception 229
6.3.6 Self-treatment 229
6.4 Soft-tissue manipulation 230

6.4.1 Skin stretching 230
6.4.2 Stretching a connective tissue fold 230
6.4.3 Sustained application of pressure 231
6.4.4 Shifting (stretching) the deep fascia 231
6.4.5 Mutual shifting of metacarpal and metatarsal bones 235
6.4.6 Painful periosteal points 236
6.5 Self-mobilization 236

6.5.1 Self-mobilization by stretching 237
6.5.2 Self-mobilization of the sacroiliac joints 238
6.5.3 Self-mobilization of the lumbar spine 238
6.5.4 Self-mobilization of the thoracic spine and ribs 240
6.5.5 Self-mobilization of the cervicothoracic junction and first rib 242
6.5.6 Self-mobilization of the cervical spine 243
6.5.7 Self-mobilization of the extremity joints 245
6.6 Post-isometric relaxation and reciprocal inhibition 246

6.6.1 Basic principles 246
6.6.2 Muscles of the head and neck 248
6.6.3 Muscles of the upper extremity 255
6.6.4 Muscles of the trunk 261
6.6.5 Muscles of the hip region 270
6.6.6 Muscles of the lower extremity 272
6.7 Training weak muscles (facilitation) 279

6.7.1 Muscles of the trunk 279
6.7.2 Muscles of the hip 285
6.8 Re-training to correct faulty movement patterns 285

6.8.1 Standing on both feet 285
6.8.2 Standing on one leg and walking 286
6.8.3 Sitting 287
6.8.4 Anteflexion 289
6.8.6 Carrying loads correctly 292
6.8.7 Breathing 293
6.8.8 The feet 294
6.8.9 The shoulder blade and upper cervical spine 296
6.8.10 The hands 296
6.9 Supports 296

6.9.1 Cervical collar 297
6.9.2 Inflatable cushion 297
6.9.3 Pelvic belt (Biedermann and Cyriax) 297
6.10 Local anesthesia 298
In the preceding chapters we have outlined the diagnosis of locomotor system dysfunctions, their pathogenesis, and the reflex changes they produce. Building on that foundation, we then considered the indications for specific therapeutic methods. However, to describe them all would go beyond the scope of this book. This chapter will confine itself principally to manipulative techniques, including those for soft tissue and especially for muscles, and to rehabilitation in the setting of locomotor system dysfunctions.

6.1. Manipulation

6.1.1. General principles governing technical aspects

The objective of manipulation is to restore normal mobility to joints, including joint play. In this context we distinguish between two types of manipulation: mobilization and high-velocity, low-amplitude (HVLA) thrust techniques.

The positioning of the patient

The patient should lie or sit in such a way as to be relaxed.
The patient’s lying or sitting position should be selected so that the joint to be treated is ideally centered, allowing maximal muscle facilitation and relaxation. The joint that is the object of treatment must be accessible, and one of the articulating bones should be fixed either by the patient’s own position or by the practitioner.
The height of the manipulation table must be adjustable; this is absolutely essential given the large number of techniques in which the patient is seated and the major height variations in patients and practitioners.

The position of the practitioner

The position adopted by the practitioner relative to the patient is in many ways decisive for the technique that is to be used. The practitioner must be in a comfortable and stable position in order to be relaxed at all times. If the practitioner is not relaxed, the patient too will be unable to relax.
When treatment movements are performed correctly, the practitioner’s hand and forearm always form an extension of the direction of motion. However, this in itself is not sufficient to ensure optimally gentle yet effective movement. Movement impulses should emanate from the practitioner’s whole body, with forces usually generated by the feet and legs, as when throwing the discus or putting the shot.
Any practitioner who becomes breathless or perspires during manual therapy is doing it wrongly. It may reasonably be said that during manipulation, especially of the spinal column but also during diagnostic examination, the practitioner’s body forms a harmonious moving unit with the patient’s body, rather like a dancing couple. This harmony between the mover and the moved is the secret of a flowing, gentle and hence elegant technique.

Fixation

When techniques are performed correctly, one of the bones articulating in the joint being manipulated is fixed while the other is mobilized. In extremity joints it is usually the proximal bone that is fixed, that is supported by the body of the practitioner or by the treatment table. For effective fixation the mobilizing force should not act across two joints. In this process the practitioner’s hands are close (but not too close) to the joint so as to avoid any lever action. In the spinal column, fixation is achieved by correct positioning where possible. In the seated position, good fixation of the caudal spinal segment via the pelvis can be obtained if the patient sits astride the treatment table.

The starting position of the joint and the direction of treatment

Treatment of the joint is performed once the slack has been taken up but not in a position in which the joint itself is not overstretched. If it is in an extreme position, the joint will be locked and cannot be treated. This principle must also be adhered to when treating the spinal column. According to Kaltenborn (1989), the direction of movement during gliding mobilization depends on whether the concave joint surface is located on the proximal (fixed) articulating bone or conversely whether the convex joint surface is located proximally and the concave joint surface distally (see Figures 2.7 and 6.1).
In the first instance, gliding of the distal partner occurs in the opposite direction to functional bone movement, whereas in the second case, gliding of the distal partner occurs in the same direction as functional bone movement. Accordingly, in the first case, the convex distal partner is mobilized primarily in the opposite direction to functional bone movement, whereas in the second case, mobilization occurs in the same direction as functional bone movement (see Figure 2.7). For this reason mobilization of the first phalanx relative to the metacarpal head, for example, should be mainly in a palmar direction.

Taking up the slack (engaging the barrier)

Taking up the slack (engaging the barrier) represents the first and crucial phase of manipulation: it is the prelude to release in the context of mobilization and to an HVLA thrust when a thrusting technique is being used.
In peripheral joints we attempt to take up the slack by approaching the limit of joint play, where possible with simultaneous distraction of the joint. In a normal joint this is never a hard or sudden action. A hard end-feel when the limit of joint play is reached is characteristic of a movement restriction. Functional movement in the spinal column cannot always be distinguished from joint play because movements in an individual motion segment cannot be performed actively and therefore resemble joint play to a certain extent.
We know that we have taken up the slack (engaged the barrier) the moment we sense the first slight resistance (indicative of the physiological barrier). This must be performed gently and cautiously, and once the barrier has been engaged we should wait. The commonest reason for error and failure is to misinterpret active resistance by the patient as a sign that we have taken up the slack. This invariably happens if the patient senses pain or feels threatened by a rapid, harsh examination technique.
‘Locking’ is an additional factor in the spinal column, especially when long levers are used (see Section 6.1.3). This term refers to techniques in which all spinal segments are ‘locked’ except the one that is being manipulated.

Manipulation

After the slack has been taken up (the barrier has been engaged), there are two ways to restore normal mobility:

1. Either by a gentle springing movement, but more often simply by waiting, in order to obtain release and thus normalize the barrier.
2. Or, by delivering an HVLA thrust, once the barrier has been engaged and the patient is relaxed.

Simple mobilization

Mobilization can be achieved by gentle rhythmic repetitive springing, or usually just by waiting at the barrier with minimal pressure in the direction of functional movement or joint play.
When simply waiting for the release phenomenon to occur, the practitioner must be able to sense precisely when release has fully run its course, otherwise both practitioner and patient will be ‘robbed’ of success. If the practitioner opts for rhythmic springing at the barrier, care must be taken not to lose the end position, otherwise the springing action can become too coarse and painful. And pressure must never be increased during springing simply because the effect obtained is insufficient. On the contrary, springing will be suppressed if springing back is prevented by increasing the pressure exerted. It appears that the therapeutic effect depends on (spontaneous) springing back to the barrier at the initial end position.
Rhythmic repetitive springing is especially effective in joints that, when restricted, are not directly fixed or moved by muscles. In particular these include the sacroiliac, acromioclavicular, and sternoclavicular joints. To some extent the same also applies in extremity joints where shaking mobilization has proved especially useful. In the spinal column, preference is usually given to the release phenomenon option, although in combination with techniques involving muscular facilitation and inhibition (neuromuscular techniques).

Neuromuscular mobilization techniques

Here we may differentiate between techniques that act on specific individual muscles and others that have an effect on the locomotor system as a whole. A feature common to all of them is that they facilitate, potentiate, and automate the release phenomenon.
Post-isometric relaxation
Wherever possible, post-isometric relaxation (PIR) is supplemented by reciprocal inhibition (RI). According to Mitchell et al (1979), only a minimum of resistance is used here.
After taking up the slack, the practitioner offers resistance for 5–10seconds as the patient exerts minimal pressure in the direction opposite to mobilization, and then the patient is instructed to ‘let go’. After a short latency period, release (i.e. mobilization) occurs and the practitioner then waits for the patient to relax. Starting from the newly gained position, the process is repeated once or twice.
It is important not to interrupt the patient’s relaxation prematurely. The longer relaxation lasts, the better the effect and the fewer repetitions needed. If the patient fails to relax during PIR, the simplest solution is to extend the isometric phase, even for up to 20seconds.
An important improvement was achieved by Zbojan (1984) with his introduction of gravity-induced relaxation: in this technique, where possible, the weight of the head or (part of) an extremity is isometrically raised a little against gravity and then relaxed as gravity takes over. This can be repeated three times. Zbojan recommends holding both the isometric phase and the relaxation phase for 20seconds each. This exercise can be done at home by the patient as a self-treatment method on a daily basis.
Reciprocal inhibition
Wherever possible, PIR may be supplemented with RI: here the patient exerts light pressure in the direction of mobilization while the practitioner applies rhythmic repetitive counterpressure using minimal force. Active rhythmic repetitive movement in the restricted direction against resistance from the practitioner or (following gravity-induced relaxation) as a single powerful movement, also in the restricted direction, achieves RI of the muscles that are restricting movement.
Rhythmic repetitive muscle contraction
In isolated situations, rhythmic repetitive muscle contraction can act to produce mobilization directly, for example rhythmic contraction of the scalenes with their attachment points at the first and second ribs, or of the psoas major at the thoracolumbar junction.
Respiration
(See also Section 4.15.3.) As a rule, inhalation has a facilitating effect and exhalation an inhibitory effect, especially on the muscles of the trunk. Therefore, it is usually appropriate to combine inhalation with isometric resistance and exhalation with relaxation. However, there are important exceptions to this rule: forced exhalation facilitates the abdominal muscles, and maximal exhalation in lordosis facilitates the erector spinae muscles and thus mobilizes the thoracic spine into extension. In kyphosis, in contrast, the thoracic spine is mobilized by inhalation. From gymnastics we are accustomed to associating inhalation with straightening up and exhalation with anteflexion (and with side-bending). Mouth opening is associated with inhalation and mouth closure with exhalation. Where movement in one direction is associated with inhalation, and in the opposite direction with exhalation, this phenomenon is known as respiratory synkinesis. One characteristic of respiratory synkinesis is that it is difficult to perform a particular movement during the respiratory phase that is not associated with it, for example to bend forward while inhaling.
Of particular interest is the mobilizing effect of respiration during side-bending, as noted by Gaymans (1980). During inhalation or exhalation, different spinal segments are facilitated or relaxed in an alternating pattern. Broadly speaking, with the exception of the cervicothoracic junction, the even-numbered segments are inhibited (fixed) during inhalation and relaxed during exhalation, while conversely the odd-numbered segments are inhibited (fixed) during exhalation and relaxed during inhalation.
Other forms of respiratory synkinesis also serve to promote mobilization. During isometric traction, for example, we exploit the fact that neck muscles become tense during inhalation and relax during exhalation, resulting in stretching. During isometric traction of the lumbar spine in lordosis when the patient is prone, tension is increased during exhalation whereas relaxation occurs during inhalation. This happens because the lumbar erector spinae in lordosis contracts during exhalation.
Eye movement (visual synkinesis)
Eye movement facilitates movements of the head and trunk in the direction of gaze and inhibits movements in the opposite direction. While this does not hold for side-bending, looking up facilitates straightening into a neutral position and out of side-bending. Looking up facilitates inhalation and looking down facilitates exhalation – a respiratory synkinesis that should be taken into account for combination with respiratory techniques. However, according to Gaymans (1980), maximal excursion of the eyes has an inhibitory effect.
Zbojan’s use of gravity
Where possible, use can be made of Zbojan’s (1984) gravity-induced technique (see above): during the isometric phase it is sufficient to raise the head or leg a little, hold for 20seconds and then relax for 20seconds.
Combining techniques
It will be self-evident that these methods can be combined to excellent effect. This applies in particular to the combination of PIR, respiratory synkinesis, visual synkinesis, and gravity-induced techniques. As a result the isometric phase (resistance exerted by the patient) and the relaxation phase can be largely automated, thus enabling the practitioner to dispense with repeated instructions to the patient of the type: ‘When you press, use only minimal force’ and ‘Relax completely’.
If rotation to the right is restricted, for example, the practitioner can instruct the patient to look left during the isometric phase and breathe in, and then to look right during the relaxation phase and breathe out. This is especially appropriate when we are dealing with patterns of respiratory synkinesis. For mobilization into side-bending, the practitioner tells the patient to look up during the isometric phase and to look down during the relaxation phase if it is the even-numbered segments (C0, C2, C4) that are involved.
The use of gravity-induced techniques is particularly suitable for combination and for achieving automation. For this, the levers should be arranged so that the force involved is neither too great nor too small. The greater the number of elements, the greater the potential for optimal combinations and for self-treatment, for example self-mobilization of the atlas against the occiput (at the same time also relaxation of the SCM muscle) while supine with the head rotated (see Figure 6.96).
In view of the wide-ranging possibilities, a warning is also appropriate concerning incorrect combinations. Looking up does not work in combination with exhalation and neither does looking down in combination with inhalation. We must also bear in mind that looking up facilitates straightening up (retroflexion) and looking down facilitates forward-bending (anteflexion). For mobilization into side-bending, for the even-numbered segments, it will be useful to proceed in the manner described in the preceding paragraph. For the odd-numbered segments (C1, C3, etc.), exhalation during the isometric phase should not be combined with looking up and inhalation during the relaxation phase should not be combined with looking down. Therefore the combination of respiration with eye movements should be avoided in this case. If visual synkinesis is to be combined with respiratory synkinesis, then the instruction to look in a particular direction must precede the instruction to inhale or exhale. At the cervicothoracic junction and also in the thoracic spine it is essential for the neck to be held in extension during mobilization into side-bending. It is therefore correct during the isometric phase to give the instruction ‘Look up and breathe in’ but not to say ‘Look down’ during the relaxation phase because the patient would then bend forward. Consequently, the instruction in the relaxation phase is ‘Let go and breathe out’.
It is very important for the patient always to breathe in and out as slowly as possible so that both the isometric phase and the relaxation phase are sufficiently long. It is therefore useful, for example, first to say to the patient ‘Look to the right’ and then after a short latency period to add ‘And breathe in slowly’; and also to say ‘Look down’ and after a certain latency period to add ‘Breathe out’. If the patient finds it difficult to breathe in and out slowly, then it is very useful for the patient to breath-hold at the end of inhalation before the instruction is given to breathe out. However, if this also fails to solve the problem, then the patient has a significant faulty breathing pattern (assuming that an organic respiratory disorder is not to blame). Remedial exercises to correct this seriously disordered breathing pattern are then indicated. As a technical note, release may take considerably longer than the process of exhaling slowly. Therefore the best solution is simply to instruct the patient to carry on inhaling and exhaling until release is complete. Once release has started, it will automatically follow its course to the end no matter how the patient continues breathing.
If our combinations are well thought out, the sum total of physiological stimuli involved will considerably enhance the effectiveness of our mobilization techniques, make them less time-consuming and render them largely suitable for self-treatment, which also considerably strengthens the treatment program. PIR can be routinely supplemented with RI, thus allowing a further goal to be realized: taken collectively, all these neuromuscular techniques mean that it is the patient’s own muscles that are increasingly used to achieve mobilization. It will come as no surprise that maximal use of the patient’s own muscles is more ‘physiological’ than the best manipulation techniques delivered by the practitioner.

HVLA thrust techniques

These techniques consist of a high-velocity but non-forceful movement of small amplitude, starting from the end position gained (i.e. after taking up the slack) and going in the direction in which the slack was taken up or mobilization was performed. In the process, a barrier seems to give way, and as a rule we hear the joint ‘pop.’ Immediately afterward we sense a considerable reduction in muscle tone and increased mobility. The following technical conditions must be observed:

• While taking up the slack the practitioner must be able to sense the moment when the patient is completely relaxed.
• The end position is reached (or the barrier is engaged) using a minimum of force.
• The HVLA thrust must start from the end position already gained, that is we must never back off before delivering the thrust. And this is the typical error made by almost every novice because we are used to drawing back our arm before delivering a blow. Here, however, it is a crucial mistake because as we back off (i.e. by releasing the slack that has been taken up), we give the patient time to tense up as a reflex anticipatory reaction. When that happens, manipulation fails or becomes unduly forceful.

If the above conditions are met, HVLA thrust techniques are never forceful because the thrust corresponds to a weight of not more than 1000g. However, there are also situations where high-velocity maneuvers are not even necessary, thus allowing an even gentler approach, as in distraction manipulation in the cervical and cervicothoracic region with the patient seated.

Mierau et al (1988) have shown that HVLA thrust techniques are followed immediately by a state of hypermobility in which the barrier is temporarily overcome. This also explains both the very intensive reflex effect and the presence of a certain degree of risk because the barrier fulfils a protective function. Leaving to one side a small number of incidents that have been widely discussed, it is generally true to say that forceful and frequently repeated HVLA thrusts carry a risk of permanent hypermobility. Figure 6.2 and Figure 6.3 illustrate the different effects achieved with mobilization and HVLA thrust techniques.
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Figure 6.3

Tension curve during joint distraction and the effect of ‘joint cracking’ (adapted from Roston & Wheeler Haines 1947). (A) Tension increase without joint cracking. (B) Sudden ‘give’ at the moment of cracking.

Testing to check the effect

Immediately after treatment, whether this consists of mobilization or manipulation, its effect must be checked by testing (see Section 4.17).

Record keeping

The purpose of keeping records is to ensure detailed documentation of the examination and in particular of any therapeutic interventions so that data are available in case the material later needs to be written up for publication or for an expert legal report. This aspect should not currently pose any difficulties given the general use of computers for data storage.

Follow-up treatment and aftercare

If we discount acute cases where we are in fact administering first aid and where patients should be invited to attend for follow-up within a week, it is generally possible from the case history to offer advice concerning any lifestyle aspects that may require correction. The patient is then given home exercises that can be used either as part of a self-treatment plan or as a basis for a clearly specified course of physiotherapy. The patient should be invited to attend a follow-up appointment within two to three weeks.
Failure to issue such instructions and to set goals is professionally irresponsible and betrays a lack of understanding of rehabilitation. It is always advisable to inform the patient that treatment of any kind may often be followed by a painful reaction lasting for anything from one to three days, after which improvement sets in. If patients are not given such a warning, the inevitable result is that practitioners will be bombarded with telephone calls during the first 24hours about conditions that are ‘worse now than they were before!’

6.1.2. Extremity joints

The techniques used in the manipulation of extremity joints are aimed almost exclusively at restoring joint play. Because examination of joint play is technically identical with the mobilization of these joints, both will be described here simultaneously.

Joints of the upper extremities

Interphalangeal joints

Dorsopalmar shift, distraction, and laterolateral shift are used for mobilization (and examination).
The practitioner fixes the patient’s proximal phalanx between the thumb and forefinger of one hand, supported either against his own body or the treatment table.
Taking the patient’s distal phalanx between the thumb and second finger of the other hand, the practitioner mobilizes the distal phalanx in one of the above directions, always applying distraction at the same time. It is advisable to keep thumb and forefinger at right angles to the direction of movement.

Metacarpophalangeal joints

Because these joints are almost spherical (ellipsoid), joint play is tested in all directions, including rotation and distraction, using a technique similar to that described for the interphalangeal joints.
The practitioner fixes the patient’s metacarpal head between the thumb and forefinger of one hand, supported against his own body or the treatment table, and takes hold of the first phalanx between the thumb and forefinger of the other hand. Here too mobilization is always performed while applying distraction. Only the thumb and forefinger holding the phalanx can be at right angles to the movement only in the dorso-palmar direction. In this case, distraction in a palmar direction is effective; this can be performed as an HVLA thrust using the first phalanx of the forefinger as a fulcrum – and is often administered as first aid following sprains.
The practitioner can also take hold of the first phalanx from above so that the hand and forearm hang down, and then perform distraction by shaking. These last two techniques can also be used in a self-treatment setting (see Figure 6.4).

The carpometacarpal joint of the thumb

The trapezium is first located by palpating the styloid process of the radius. Distal to this there is a groove which corresponds to the scaphoid, which then articulates with the trapezium as the wrist broadens again. Fixing the trapezium between the thumb and forefinger of one hand, the practitioner uses the thumb and forefinger of the other hand to take hold of the first metacarpal bone as close to the carpometacarpal joint as possible.
Here too mobilization can be performed in a dorsopalmar and laterolateral direction, with the practitioner’s thumbs and forefingers positioned at right angles to the direction of movement. For distraction, the terminal phalanx of the patient’s thumb is grasped using the little finger of the practitioner’s mobilizing hand and a pull is exerted via the terminal phalanx.
The following technique is suitable for post-isometric traction and HVLA thrust manipulation: placing his right hand round the ulnar aspect of the wrist of the patient’s supinated right hand, the practitioner takes hold of the metacarpal between the thumb and forefinger of his other hand, so that the proximal phalanx of the forefinger forms a fulcrum close to the carpometacarpal joint dorsally (below), and the thumb, located a little more distally, performs gentle dorsal compression to achieve distraction. The practitioner can amplify this effect further by hooking his little finger round the distal phalanx of the patient’s thumb (see Figure 6.4 A). Once the barrier is engaged, an HVLA thrust is now delivered. The patient can also be instructed to offer slight resistance to distraction, to relax after 5–10seconds and then to repeat this.
Afterward the practitioner takes hold of the patient’s pronated hand from the ulnar aspect using the opposite hand. Using the other hand he then grasps the patient’s first metacarpal so that the radial edge of the proximal phalanx of his forefinger forms a fulcrum close to the carpometacarpal joint on the palmar side (below) and the thumb performs gentle palmar compression to achieve distraction. Once again, this can be amplified by hooking the little finger round the distal phalanx of the patient’s thumb and engaging the barrier (see Figure 6.4 B). An HVLA thrust is now delivered to achieve distraction or again the patient can be instructed to offer slight resistance to distraction, to hold for 5–10seconds and then relax. This technique is then repeated.
Both techniques are eminently suitable for use in self-treatment. An even simpler technique is to take hold of the proximal phalanx of the patient’s thumb from above, to allow the forearm to hang down, and to perform distraction by shaking.

The joints of the wrist

It is important first to find the exact location of the radiocarpal joint and the carpometacarpal joints: when the wrist is dorsiflexed, the skin crease on the dorsal aspect is precisely at the location of the radiocarpal joint, and on palmarflexion the skin crease on the palmar aspect marks the location of the carpometacarpal joints.
If palmar flexion is restricted, the practitioner must examine and mobilize the proximal row of carpal bones relative to the radius in a dorsal direction. With one hand the practitioner takes hold of the patient’s supinated forearm just above the wrist, and supports this on his knee or on the treatment table. With the other hand the practitioner takes hold of the patient’s wrist slightly distal to the radiocarpal joint, takes up the slack dorsally by exerting light pressure, and performs mobilization using rhythmic springing pressure (see Figure 6.5). Self-treatment follows the same principle. It is sufficient for the patient to support her forearm on her thigh; she then uses her other hand to take hold of the hand to be mobilized, and treats it in supination for the radiocarpal and in pronation for the intercarpal joint, first in a palmodorsal and then in a dorsopalmar direction.
If dorsiflexion is restricted, the practitioner must examine and mobilize the distal row of carpal bones relative to the proximal row, in a palmar direction. With one hand the practitioner takes hold of the patient’s pronated forearm just above the wrist and supports this on his knee or on the treatment table. With the other hand the practitioner takes hold of the patient’s hand at the level of the carpometacarpal joints, takes up the slack in a palmar direction by exerting light pressure, and performs mobilization using rhythmic springing pressure (see Figure 6.6). Self-treatment follows the same principle. It is sufficient for the patient to support her forearm on her thigh; she then uses her other hand to take hold of the hand to be mobilized, and treats it in supination for the radiocarpal and in pronation for the intercarpal joint, first in a palmodorsal and then in a dorsopalmar direction.
If radial abduction is restricted, the principle chiefly involves dorsiflexion of the trapezium relative to the scaphoid (see Section 4.10.3). The technique is essentially the same as for restricted dorsiflexion, but with the difference that the mobilizing pressure is directed toward the radius.
In contrast, if ulnar abduction is restricted, then joint play is primarily restricted in the radiocarpal joint (see Section 4.10.3). Consequently, the technique is essentially the same as for restricted palmar flexion, but with the difference that the mobilizing pressure is directed toward the ulna relative to the pisiform bone or the wrist is sprung in a radial direction relative to the forearm.
Where a very specific procedure is required, it is possible to examine and treat joint play between two neighboring carpal bones and also the relevant metacarpal bone. The practitioner fixes one carpal bone between the thumb and forefinger of one hand, while moving the other carpal bone with the thumb and forefinger of the other hand. In technical terms it is crucial to examine using the minimum of force, because even in movement restriction the resistance is so negligible that it will not be recognized at all if the examination is forceful. For mobilization proper it is advantageous to place both forefingers on the palmar aspect and both thumb tips on the dorsal aspect (or vice versa) of adjacent carpal bones before exerting pressure (pincer grip, see Figure 6.7). In conjunction with distraction, this technique is important in carpal tunnel syndrome. The pincer grip can also be performed with the thumb and forefinger of one hand, making this movement a candidate for self-treatment.
The pisiform bone may also be painful and restricted in its movement. Taking it between the thumb and forefinger, this bone can be examined and mobilized very easily in a laterolateral or proximodistal direction.
It is of course important to be able to locate the individual carpal bones. We have already seen how to locate the trapezium when treating the carpometacarpal joint of the thumb. And it is a simple matter to find the pisiform (on the triquetral bone). The capitate forms the most prominent point of the wrist on palmarflexion.
The techniques described here can be used not only for the carpal bones themselves but also for the carpometacarpal and intermetacarpal joints. Technically it is most important to examine using a minimum of force; moreover, the practitioner’s fingers should not be too close together because they might then be pressing on the same bone. Conversely, if they are too far apart, too much mobility will be felt because two joints are being examined.
In addition to the translational (gliding) techniques described, it is also possible to perform a distraction technique that is implemented mainly as an HVLA thrust. This is very effective and entirely innocuous. The practitioner sits in front of (and a little lower than) the patient, who is also seated. He takes hold of the patient’s pronated, downward-hanging hand in the region of the wrist, at the distal articulating partner of the joint where restriction has been found. Both thumbs are placed one on top of the other on the back of the patient’s hand, with both hands encircling the palmar aspect of the patient’s wrist (see Figure 6.8). The slack is taken up by very gentle traction with slight dorsiflexion of the patient’s hand; once the barrier is engaged, an HVLA thrust is delivered along the axis of the patient’s downward-hanging arm but taking care to allow no further dorsiflexion. There are two errors to be avoided at all costs: first, excessive traction while engaging the barrier and then releasing it before the HVLA thrust; and second, further compressive dorsiflexion at the wrist during the HVLA thrust.
Distraction can be performed as mobilization or self-mobilization. Using one hand, which is supported on his knee or on the treatment table, the practitioner takes hold of the patient’s pronated forearm above the wrist. With the other hand he grasps a carpal bone between thumb and bent forefinger and, after taking up the slack, performs springing distraction. The same effect can be achieved with the patient’s arm hanging down: the practitioner takes hold of the carpal bone in the same way and performs a shaking maneuver.
The distal radioulnar joint will be the last wrist joint to be considered. Mobility can be examined between the distal end of the radius and ulna and mobilization can be performed. The technique is broadly similar to that already described for the carpal bones: the practitioner takes hold of the distal end of the radius with one hand and the distal end of the ulna with the other. He then shifts the two bones in opposite (dorsal or palmar) directions to take up the slack and performs springing. For mobilization it is better to use the pincer grip, as for the carpal bones. Examination is clinically important whereas mobilization is less so because the movement restriction is located in the vicinity of the elbow.

The elbow

The elbow actually consists of three joints: the humeroulnar, humeroradial, and proximal radioulnar articulations, with joint play affecting all three. However, treatment is most often directed at epicondylopathies (epicondylar pain). The most important treatment techniques are distraction as well as radial and ulnar springing (lateral gapping), in combination with relaxation of the muscles that insert at the elbow.
Distraction is performed with the patient supine and the arm to be treated flexed at the elbow, with the supinated forearm supported against the shoulder. With one hand the practitioner fixes the patient’s forearm in the crook of the elbow, and with the other hand he fixes the patient’s upper arm by exerting downward pressure toward the padded surface of the treatment table. Using the thumb as a fulcrum, pressure is exerted distally (see Figure 6.9). The practitioner performs traction using the hand on the patient’s forearm while simultaneously enhancing leverage at the elbow by exerting pressure with his shoulder against the patient’s forearm.
For radial and ulnar springing (lateral gapping), the practitioner takes hold of the distal end of the seated or supine patient’s upper arm with one hand and grasps the patient’s wrist with the other hand. With the patient’s forearm supinated, a springing push is exerted at the level of the elbow, either from ulna to radius or from radius to ulna, depending on the direction in which movement is restricted. The patient’s forearm is fixed against the practitioner’s iliac crest (see Figure 6.10). The patient’s elbow must not be fully extended, otherwise the joint will lock. After taking up the slack, which is achieved by slightly rotating the pelvic crest on which the patient’s forearm is fixed, the practitioner gives a push to spring the joint. This maneuver is used primarily for diagnosis and the findings should therefore be compared with those on the contralateral side. When repeated, the maneuver is utilized to achieve mobilization or as an HVLA thrust for manipulation. Most commonly, the practitioner takes up a position to one side of the patient and shakes the patient’s forearm rapidly in a radial or ulnar direction. Lateral springing (shaking) produces distraction of the elbow on the side to which pressure is directed.
The following shaking technique with the patient seated or supine is also gentle and effective. The practitioner sits between the patient’s trunk and slightly abducted arm, takes hold of the forearm proximal to the elbow, and moves it into supination (see Figure 6.11). In this position the arm can be gently and rhythmically shaken into extension. (See also Section 6.5.7.)

The shoulder

Where a typical capsular pattern is encountered at the shoulder, mobilization techniques are virtually useless; in this clinical condition – which is known as ‘frozen shoulder’ – joint play is characteristically normal as long as abduction is still possible to some extent. However, post-isometric traction often relieves pain, evidently due to the presence of good muscle relaxation.
For distraction it is best for the patient to be standing or supine. In the standing option, the practitioner places his corresponding shoulder under the patient’s axilla (i.e. right to right, or left to left), pressing against the patient’s thorax. With one hand he grasps the patient’s wrist and with the other hand takes hold of the slightly abducted arm just above the elbow (see Figure 6.12 A). After taking up the slack using gentle traction, the practitioner performs PIR: he instructs the patient to resist for about 10seconds using minimal force while breathing in and then to relax while breathing out. The technique can be used for self-treatment over the cushioned back of a chair.
If the patient is shorter than the practitioner then it is preferable to perform traction with the patient supine. With the patient’s arm abducted, the practitioner sits in the patient’s axilla, thus fixing the position of the thorax. With one hand he grasps the distal humerus and with the other the wrist of the patient’s pronated arm (see Figure 6.12 B). The slack is taken up by traction on the upper arm; the patient is instructed to offer light resistance, to breathe in slowly and breath-hold, and then to relax while breathing out. In this process, resistance (pressure) should be exerted only against the chest wall and not against the upper arm.
If rotation is free and shoulder abduction only is restricted and/or a painful arc is present, then joint play with the arm abducted will routinely be found to be disturbed. In this context, it is usual nowadays to refer to an impingement syndrome. Joint play is restricted because, in order to achieve abduction, the head of the humerus has to glide caudally in the glenoid cavity. This is also usually the cause of disturbed abduction.
For mobilization the patient is seated with arm abducted. The practitioner places the patient’s elbow on his shoulder so that the upper arm is horizontal. With the radial aspect of one hand he exerts light pressure against the head of the humerus and with the other hand against the glenoid cavity of the shoulder blade in the opposite direction (see Figure 6.13). Once the slack is taken up, mobilization is performed using a springing pressure. In the interplay of both hands the direction of mobilization can be adjusted as desired and the practitioner can also switch hands so that the hand exerting pressure from below is now on the upper arm while the other is on the shoulder blade. Joint play is most frequently restricted in a craniocaudal direction.

The acromioclavicular joint

To mobilize the acromioclavicular joint, with the patient supine, the practitioner gently places his (right) thenar eminence at the lateral end of the patient’s (right) clavicle not too close to the joint and performs dorsoventral springing against the acromion (see Figure 6.14 A). Although fixation of the shoulder blade is guaranteed by the patient’s supine position, it is still recommended that the practitioner fixes the head of the humerus with his other hand.
In technical terms it is important to take up the slack using the very minimum of force and then to deliver a light dorsal push and release the pressure immediately to allow the clavicle to spring back. The practitioner should be able to both feel and even see the rhythmic springing movement. This springing is absent where movement of the acromioclavicular joint is restricted, but after a few mobilizing pushes using minimal force the joint will spring normally. The same effect can be achieved if the practitioner takes hold of the seated patient’s shoulder in both hands from behind and uses both thumbs ventrally to exert lateral pressure on the clavicle.
Craniocaudal springing is an equally important mobilization technique (see Figure 6.14 B). The practitioner stands to one side of the supine patient, fixes the patient’s bent elbow from below with one hand, and places the thenar eminence of the other hand over the lateral end of the clavicle. He takes up the slack by gently pressing both hands toward each other and then mobilizes in the same direction using light alternating pressure from both hands. Here, too, the spontaneous action of springing back as far as the barrier is important for successful mobilization. The worst mistake with this technique is to increase the pressure if springing fails to occur immediately.
Another useful technique is that of distraction performed by shaking. For this, the patient should be seated or (preferably) supine. The practitioner stands to one side of the patient and uses the fingers or thumb of one hand to fix the clavicle close to the acromioclavicular joint; with the other hand he grasps the patient’s abducted upper arm (in slight ventral flexion). Light traction is exerted to take up the slack and the arm is shaken in the given direction: this has the effect of producing traction characterized by rapid rhythm and minimal force (see Figure 6.15).

The sternoclavicular joint and shoulder blade

The clavicle with the shoulder blade moves about an axis that passes through the sternoclavicular joint. Simple movement restriction of this joint without osteoarthritis is relatively rare. The most effective mobilization technique is distraction to spring or gap the joint. For this, the patient should be supine. With hands crossed, the practitioner places one pisiform against the medial end of the clavicle from below, and the other pisiform against the manubrium of the sternum from above. The slack is taken up by slight pressure that pushes the hands apart (see Figure 6.16) and then the joint is sprung into distraction. As with the acromioclavicular joint, mobilization must be performed using a minimum of force and again the spontaneous action of springing back is crucial.
Distraction with leverage can be performed as follows: with the patient supine, the practitioner takes up a position on the side of the restricted joint and fixes the clavicle close to the sternoclavicular joint from below using the thumb of one hand. With the other hand he takes hold of the patient’s forearm and engages the barrier with light traction in a caudal direction, using the fixing thumb as a fulcrum. Mobilization is performed by springing traction from the original end point of the barrier. However, this can be done even more effectively by rapid shaking in the same direction.
The shoulder blade lies flat on the thoracic wall where it is freely mobile. The synovial bursae permit considerable movement and this can be examined and mobilized. With the patient prone, the practitioner grasps the patient’s shoulder and shoulder blade with both hands and performs circling movements of the shoulder blade against the sternum (see Figure 6.17). By pressure on the shoulder blade from above, he mobilizes the ribs simultaneously. In terms of technique, it is important that the movement imparted by the practitioner should come from the trunk so that both hands operate in synchrony, and that the forearm of the mobilizing hand should be vertical to the shoulder blade.
With the patient side-lying, the practitioner can use the finger pads of one hand to lift the inferior angle of the shoulder blade away from the thoracic wall, while using the other hand to deliver a push on the patient’s shoulder in a caudal direction.

Joints of the lower extremities

Metatarsophalangeal joints

The techniques for examining and treating the interphalangeal joints are identical to those described for the fingers (see p. 187).
The most important maneuver for the metatarsophalangeal joints is distraction. The practitioner uses one hand to fix the metatarsal bone at the joint. With some plantar flexion he uses the thumb and flexed forefinger of the other hand to perform distraction, employing the first phalanx of his flexed forefinger as a fulcrum.
A technique that patients find particularly agreeable consists of fan-wise spreading of the metatarsal heads in a dorsal (or more rarely, plantar) direction. For this, the practitioner stands or sits at the foot of the treatment table while the patient sits on the table facing him with knees slightly bent and heels resting on the table. He then takes the patient’s metatarsals in both hands, with thumb and thenar above (on the dorsal aspect) and fingers below (on the plantar aspect). Using his thumbs, he spreads the dorsum of the foot over the fulcrum created by the fingers underneath (see Figure 6.18).

The tarsometatarsal and transverse tarsal joints

The distal row of articulations between the metatarsus and tarsus is known as Lisfranc’s joints (tarsometatarsal joints) and the proximal row of articulations between the tarsal bones is known as Chopart’s joint (transverse tarsal joint). The functional movements possible here are pronation and supination, while joint play primarily takes the form of dorsoplantar mobility. Mobilization and examination are best effected using a dorsal push (Sachse’s method). The practitioner stands at the foot of the treatment table to one side so that he is facing the medial aspect of the foot to be treated. With the more cranial hand he fixes the dorsum of the patient’s foot (above Chopart’s and Lisfranc’s joints). With his other hand supinated and in ulnar abduction, he takes up the slack using light pressure away from the plantar aspect (see Figure 6.19). Mobilization is then performed by springing with the radial edge of the forefinger placed parallel to the joint to be mobilized. The thumb of this hand remains on the dorsum of the patient’s foot.
The most precise technique, however, is to examine and mobilize the joints between individual metatarsal bones as well as the individual tarsometatarsal joints. The technique is the same as that for mobilizing the carpal bones. The patient is supine with the leg slightly bent at the knee and the heel supported on the treatment table. With the thumb and forefinger of one hand the practitioner fixes the proximal tarsal bone: he then examines the play at the joint with the distal articulating bone by performing a dorsoplantar shift between the thumb and forefinger of his other hand. The pincer grip is more appropriate for the purposes of mobilization. The practitioner places both thumbs on the plantar aspect and both forefingers on the dorsal aspect of two adjacent bones (tarsals or tarsal/metatarsus). He takes up the slack by slight pressure first in a dorsal and then in a plantar direction, and then mobilizes the joint by rhythmic springing (see Figure 6.7). For mobilization in the opposite direction, he reverses the position of thumbs and forefingers. While this is a universal technique, the most frequent sites of restriction are the second, third, and fourth tarsometatarsal joints.
For a similarly universal distraction technique, the patient should be prone, with the leg to be treated slightly bent at the knee. The practitioner stands at the foot end of the treatment table and places the fingers of both hands round the patient’s instep and both thumb pads on the plantar aspect of the distal articulating bone in the restricted joint (see Figure 6.20). With both thumbs he exerts pressure in a plantar and distal direction until the slack has been taken up. He then performs dorsoplantar shaking, consistent with the rhythm of the structure (this will be slower in longer feet than in shorter feet). Consequently, it is also slower in the vicinity of Lisfranc’s joints than in Chopart’s joint. Technically, it is important that the treating hand is relaxed so that the practitioner can sense the inherent rhythm of the foot and so as to prevent flexion and extension at the talocrural joint during shaking.

The subtalar and talocalcaneonavicular joints

Here we are concerned with the articulation of the talus with the calcaneus and the navicular, and with the articulation of these bones with the cuboid. In essence, joint play here can be examined (and treated) by assessing the mobility of the calcaneus in all directions relative to the other articulating partners. It is useful to ease the strain on the joint by traction.
The patient is supine with the foot to be treated protruding over the free edge of the treatment table. The practitioner cups one hand round as far as the medial aspect of the patient’s heel while spanning the patient’s instep with his other hand. Applying light traction, he moves the joint in all possible directions: supination, pronation, plantar flexion, and dorsiflexion of the foot (see Figure 6.21).
A very effective distraction technique has been developed for the posterior part of the subtalar joint. The patient is supine with the foot to be treated protruding over the free edge of the table. The practitioner stands at the foot of the table and takes hold of the patient’s lower leg above the ankle for fixation. With his other hand he cups the patient’s heel medially and takes up the slack by exerting light traction in a distal and upward direction (see Figure 6.22). It is now possible to spring the joint distally, deliver an HVLA thrust, or shake the joint rapidly to achieve distraction.

The talocrural joint

The relative anteroposterior mobility of this joint is examined and treated with the patient’s heel on the table and the knee slightly bent. With one hand the practitioner fixes the patient’s foot by grasping its plantar aspect and holding it at right angles to the lower leg. With his other hand he takes hold of the lower leg above the ankle from the front and, after taking up the slack, springs the joint distally (see Figure 6.23). This is followed by rhythmic springing to mobilize the joint.
It can be helpful to perform this mobilization technique using a pincer grip, that is by clasping the patient’s heel in both hands and locating both thumbs on the patient’s tibia above the ankle. The joint is then mobilized by simultaneous rhythmic flexion of the fingers and thumbs, using the forearms to fix the patient’s foot at right angles to the lower leg. Flexion at the knee facilitates mobilization.
Traction manipulation is also very effective. The patient is supine with the leg to be treated protruding over the free edge of the treatment table. The practitioner folds both hands over the patient’s instep with both thumbs flat under the sole to stabilize the foot approximately at right angles to the lower leg (see Figure 6.24). Minimal traction is used to take up the slack and then, from the end position, manipulation is performed with HVLA traction. The most common mistake here is to hold the foot in exaggerated dorsiflexion because that could lock the joint.
An alternative technique is to grasp the forefoot with one hand and the heel with the other, and to perform traction after the slack has been taken up. However, in this case the subtalar joint is also treated.

The tibiofibular joint

Because the fibular head is the attachment point for the biceps femoris muscle, restriction of its movement is clinically important. It is first necessary to assess its mobility against the tibia and to determine the degree of pain present. Here we are concerned not with anteroposterior mobility but with rotation around the tibia. For this, the patient is supine with knee flexed and foot resting on the treatment table. The practitioner sits so as to fix the patient’s toes with his buttocks, and fixes the upper end of the tibia as he mobilizes the fibula against the tibia (see Figure 6.25). With his other mobilizing hand he takes hold of the fibular head between thumb and forefinger, and takes up the slack, first medially and dorsally, and waits for release. Once release in that direction is complete, that is once the normal barrier has been reached, he takes up the slack laterally and ventrally and again waits to obtain release. This technique is far more effective and precise than springing the joint or an HVLA thrust, evidently because it is the soft tissue between the fibula and tibia rather than the joint that plays the crucial role. Technically, it is particularly important that it is in fact the fibular head that is mobilized between the practitioner’s thumb and forefinger (which may be flexed) and not merely the soft tissue.

The knee joint

Using both hands, the practitioner starts examination and treatment by moving the patella on the joint surface with the femur in a laterolateral and craniocaudal direction; this permits detection of any resistance, unevenness, and roughness as he glides the patella over the underlying structures. It is therefore recommended that patellar movement be tested with one hand while light pressure of varying intensity is simultaneously exerted on it from above with the other. In this way, points of resistance and roughness can be sensed, although the patient may also feel some discomfort. The same technique is used to smooth out points of resistance and unevenness. Once this has been done, the patient’s pain will be relieved and the practitioner will sense improved mobility. This technique can also be taught to patients for self-treatment.
The knee joint itself can be treated using distraction techniques. The simplest of these is performed with the patient prone on a mat on the floor. The practitioner stands between the patient’s legs at knee level and fixes the patient’s thigh just above the knee to be treated using his foot, takes hold of the patient’s lower leg with both hands just above the ankle, and bends the patient’s knee at right angles. Mobilizing traction is then exerted along the now vertical axis of the patient’s lower leg (see Figure 6.26). With the treatment table adjusted to a low setting, the practitioner can also fix the patient’s popliteal fossa from above with his knee.
Laterolateral springing is then tested by gapping the joint first medially and then laterally. For medial springing, the practitioner stands alongside the supine patient and, with one hand, takes hold of the patient’s lower leg medially just above the ankle (lifting it slightly off the treatment table). With the heel of his other hand he exerts lateromedial pressure on the knee to take up the slack and test whether the joint springs medially (see Figure 6.27). For lateral springing, the practitioner sits sideways on the treatment table between the patient’s legs, takes hold of the patient’s lower leg with one hand, and tests for lateral springing with the other. Mobilization can also be achieved by rhythmic springing, although currently we prefer using a rapid rhythmic shaking technique during which the joint springs spontaneously. Shaking is also the ideal method for self-treatment (see Section 6.5.7). Technically, it is important to extend the knee but to avoid overextending (locking) it.

The hip joint

Because the hip joint is an almost perfect ball-and-socket joint that allows hardly any shifting movement, only traction techniques are worth considering. Traction may be carried out either along the longitudinal axis of the leg, or in the direction of the femoral neck. The former method is performed with the patient supine and the hip in the neutral position (10° flexion, 10° abduction, and 10° external rotation). In this position the practitioner takes up the slack by gentle traction with both hands above the patient’s ankle. Most commonly this is then followed by:

post-isometric traction. After the slack has been taken up, the patient uses minimal force to resist traction and breathes in slowly, breath-holds, and relaxes while breathing out; the practitioner waits until release is complete. This process can be repeated once or twice. From the end position gained, shaking can also be performed to achieve distraction
traction with HVLA thrust. In this case it is preferable to fix the patient’s position using a strap or stabilizing post placed in the groin area. The practitioner can place a second strap around the patient’s lower leg just above the ankle and around his own waist. He then takes hold of the patient’s leg above the ankle with both hands and applies a minimum of traction to take up the slack with the patient’s hip in the neutral position (see Figure 6.28). From the end position (with the patient relaxed) he then delivers HVLA traction in the same direction, generally producing a tiny thud. The most serious mistake is to apply excessive traction when taking up the slack and then to release this by backing off to deliver the HVLA maneuver. The technique is effective and devoid of risk but is normally not suitable for use in patients with osteoarthritis of the hip.

For traction in the direction of the femoral neck, the patient is supine with flexed knee close to the side edge of the treatment table. The practitioner sits low down near the foot end of the table, looking toward the patient’s head. The patient places the leg (bent at the knee) over the practitioner’s shoulder while the practitioner grasps the patient’s thigh with both hands clasped (or with the forearm) in the groin area and applies caudal and lateral traction, with the patient’s pelvis stabilized against the padded surface at the edge of the table (see Figure 6.29). For post-isometric traction, the patient offers resistance to traction while breathing in by drawing the pelvis up in a cranial direction, a technique that generally has to be carefully taught. In most cases patients have a tendency to flex the hip, which detracts from effectiveness. After 5–10seconds the patient relaxes and breathes out. This process can be repeated two or three times. It is highly effective using the same hold to perform shaking in the same direction of traction. Self-treatment is not really feasible, but once the patient has learnt how to resist while breathing in, and then to relax and wait for release, then any family member or friend can assist on a daily basis by simply placing their hands in the patient’s groin region or round the ankle as the patient offers resistance, breathes in and out, and relaxes.

If it is possible to use shaking techniques for mobilization, these are not only gentle and agreeable, but also particularly effective.

The temporomandibular joint

For this joint, a simple distraction technique can be used. The practitioner stands in front of the patient, whose mouth is open for this technique. He takes hold of the patient’s lower jaw with the fingers of both hands and positions his thumbs (wearing single-finger gloves) as fulcrums on the patient’s molars on both sides, stabilizing his fingers on the patient’s chin. Downward traction is applied with both hands. In this process, whether supine or seated, the patient’s head is stabilized. PIR is then used as the patient offers resistance while breathing out and relaxes while breathing in. Here we are taking advantage of respiratory synkinesis, according to which the masticatory muscles become tense during exhalation and relax during inhalation.
Mobilization can also be performed using laterolateral movements of the jaw. The practitioner stands behind the seated patient whose head is turned so that the painful side is stabilized against the practitioner’s chest and fixed with one hand. Instructing the patient to open the mouth a little (let the chin drop), the practitioner gently ‘cradles’ the patient’s lower jaw between two fingers (see Figure 6.30). Mobilization is achieved by moving the patient’s lower jaw toward the side of the lesion until the slack is taken up. The patient then offers gentle resistance, after which gently springing lateral mobilization is performed during the relaxation phase. Relaxation techniques for the masticatory muscles can also be used for the purpose of mobilization; these are described in detail in Section 6.6.2.

6.1.3. The spinal column

General principles

The general principles set out in Section 6.1.1 also hold true for the spinal column. However, it is not possible in this context to make such a sharp distinction between ‘functional movements’ and ‘joint play.’ Traction along the longitudinal axis of the spinal column and distraction of joints (gapping) clearly utilize joint play for their effect. This applies for rotation holds in the lumbar spine, and for a dorsoventral thrust in the thoracic spine or into the costal angle.
There are several ways of achieving a specific effect. These include fixation of at least one articulating bone wherever practicable (e.g. in an extremity joint). Another way is to apply locking techniques, especially if long levers are used, for example when employing the head in order to manipulate the cervical spine, or the legs and pelvis in order to mobilize the lumbar spine. Locking is achieved when all segments not intended for mobilization are brought into an extreme position and hence ‘locked,’ except for the segment that is the object of mobilization (manipulation). The actual mechanism involved is either apposition of the joint surfaces or maximal tension of ligaments. Even here it should be noted that the slack first has to be taken up with minimal force and that mobilization – and especially HVLA thrust techniques – must be applied with only very little force, otherwise locking will be ineffective. The advantage of long levers is that even tiny forces can be effective; however, these then only have a specific effect if treatment is not unduly forceful.
Locking is achieved mainly by a combination of side-bending and rotation, making use of coupled movements. Lordosis in the lumbar spine means that there is side-bending coupled with rotation to the opposite side; hence locking is achieved by rotation and side-bending in the same direction. In kyphosis, the opposite is the case. In the thoracic spine, there is also rotation and side-bending in the opposite direction and therefore locking involves side-bending and rotation in the same direction. According to Greenman (1984), however, this is not the case on maximal extension. In the cervical spine, there is always side-bending and rotation to the same side, and here we achieve locking by side-bending and rotation to the opposite side.
Obviously, specific treatment can be given using contact holds. For example, a vertebra may be fixed in one direction by exerting lateral pressure on its spinous process, thus preventing rotation to the opposite side. When we exert springing pressure or deliver an HVLA thrust, we are acting in a specific, local manner. There is even a belief among chiropractors that they can achieve the same effect as a rapid hammer blow delivered to a single brick, causing it to fly from its place in the wall without the other bricks changing position at all. Accordingly, the maximum specific effect is achieved with techniques that combine direct contact, leverage, and locking. Here it is vital for locking and contact to be targeted at precisely the same point. It should also be stressed that good fixation with the contact hand is always more reliable than the best locking maneuver.
From this it follows that the stabilizing hand that provides fixation exerts its force in a direction opposed to the direction of the mobilizing hand. However, there are also techniques in which the two hands exert their effect in the same direction. Here the vertebra that is one down from the treated vertebra is fixed by positioning, for example the patient sits astride the treatment table and thus fixes the pelvis and lumbar spine. This type of technique necessarily relies primarily on locking. These techniques are used most frequently in traction holds because they are without risk and less is at stake if they are not applied with pinpoint specificity.
In order to avoid confusion it is important to distinguish between traction along the long axis of the spinal column and distraction of intervertebral joints (gapping). This distinction is clearest in the lumbar region, where traction along the long axis acts primarily on the intervertebral disks, whereas distraction of the joints is produced by rotation. In the cervical spine, on the other hand, traction along the long axis affects both the intervertebral disks and the joints.

The lumbar spine

Traction techniques

Of all the non-specific techniques, traction is the most important. Manual traction has proved particularly effective in radicular syndromes and constitutes first aid in emergency cases.
The patient is prone and provides fixation by holding on to the end of the treatment table. The practitioner grasps both the patient’s legs just above the ankle, and braces himself by placing a foot or knee against the treatment table. The manual technique is performed by applying rhythmic springing traction to both legs and causing the patient’s body to vibrate along its long axis (shaking). For this, the patient must be relaxed, something that can be recognized from the movement of the buttocks and free mobility at the knees and hips. Next it is important to establish the correct rhythm for intermittent traction, in order to localize the effect in the lumbar region. If the rhythm is too slow, the patient’s whole body will move slightly back and forth on the table. By quickening the rhythm the practitioner will find the point at which the patient’s legs and pelvis move at the set rhythm while the lumbar spine remains still, like a nodal point in a standing wave, so that the vibration can be clearly palpated there. It will also be noted that this rhythm, which corresponds to the patient’s inherent rhythm, requires the very minimum of effort.
The force of rhythmic traction can be amplified as desired and an HVLA thrust can be delivered in time with the rhythm that has been set. It follows clearly that this technique can only be performed manually, a fact that is emphasized because every patient will have a different rhythm, depending on how tall they are. Rhythmic traction can be applied not only to both legs but also to one leg (using both hands), depending on what suits the patient better. Technically, it is important to avoid squeezing the patient’s ankles. Rhythmic traction must originate from the practitioner’s entire body and for this reason he should perform it leaning backward. Amplifying the force used and delivering an HVLA thrust are possible options but are not absolutely necessary; the patient should always be consulted during traction to establish what is most appropriate. If the patient expresses misgivings, an attempt should be made to modify the technique and if this does not bring success, traction should be discontinued. Of course, it is an essential prerequisite for this technique that the patient is comfortable lying prone.
However, if the patient has adopted a kyphotic antalgic posture, as is often the case in the acute stage, intermittent traction must be carried out in kyphosis. According to Obererlacher (personal communication), the patient should be supine with knees bent and feet flat on a treatment table adjusted to a low setting or on a floor mattress. The practitioner places one foot on the treatment surface and arranges the patient’s legs so that both popliteal fossae are over his thigh. He can then lever the patient’s lower legs over his thigh, thus lifting the patient’s pelvis from the padded surface with a rocking motion. Once the patient is freely rocking and relaxed (and reports pain relief in the process), the practitioner can rhythmically lever the patient up and down (see Figure 6.31). The mechanism of this traction is similar to that of Perl’s apparatus. Technically, it is important that the practitioner’s thigh is located under the patient’s popliteal fossae and not under the lower legs, otherwise the lever action would be painful.
Another highly effective and gentle technique is post-isometric traction with respiratory synkinesis. The patient is prone with arms alongside the body and the practitioner exerts light craniocaudal pressure on both the patient’s buttocks (see Figure 6.32). As the patient breathes out deeply, increasing resistance will be sensed due to tension of the erector spinae with lordosis of the lumbar spine; inhalation is accompanied by relaxation and kyphosis of the lumbar spine and the buttocks move caudally. The process is repeated from the (new) starting position gained.
In view of the adaptability and simultaneous efficacy of manual traction, apparatus-based traction using special tables appears far less suitable. The one possible exception to this rule is the Perl apparatus. It is absolutely essential that the patient is able to tolerate traction well, and this fact must be established in advance on every occasion.
Mobilization and manipulation
The diagnostic springing test with the patient side-lying (see Figure 4.16) can be used to great advantage for PIR. The side-lying patient, with both hips and knees flexed at right angles, pushes the knees forward with minimal pressure against the practitioner’s thighs. The practitioner fixes the spinous process of the upper vertebra in the treated segment using the fingers of one hand, reinforced by the fingers of the other hand placed over it, and with arms straight. In the process, the patient is instructed to produce a small amount of kyphosis, and to breathe in and then breath-hold, before ‘letting go’ and breathing out. While the patient relaxes, the practitioner will sense the ventral movement (mobilization) of the fixed vertebra into lordosis. As the procedure is repeated, springing is performed during relaxation to confirm that mobilization has occurred. This technique is particularly gentle and this is why most practitioners begin with it.
The most popular technique is probably that of rotation mobilization or manipulation with the patient side-lying in a neutral position, with the leg underneath (i.e. the one resting on the table) very slightly flexed at the knee and hip. The upper leg should be flexed at the hip and knee in such a way that the foot can be stabilized in the popliteal fossa of the leg underneath. The practitioner stands in front of the patient and places one elbow against the patient’s shoulder and one knee against the patient’s knee. It can be helpful if the patient hooks the corresponding arm through the practitioner’s arm at the elbow. With his other forearm the practitioner stabilizes the patient’s pelvis at the greater trochanter while using his fingers to fix the spinous process of the lower vertebra of the segment being treated (see Figure 6.33). With the thumb of the hand coming from the shoulder, the practitioner establishes contact with the spinous process of the upper vertebra in the segment to be treated. Obviously if this is the lumbosacral segment, it is sufficient for the hand passing over the patient’s hip to fix the pelvis alone.
In order to take up the slack, it is best to tell the patient to look in the direction of mobilization (i.e. to rotate to the side). The patient is next instructed to breathe in deeply: this automatically exerts light pressure against the practitioner’s arm. The patient is told to breath-hold and then, as far as possible, to look in the direction of mobilization and breathe out. From the newly gained position, the process is repeated two or three times, waiting for complete relaxation on each occasion. An HVLA thrust can be delivered from the rotation position gained on each occasion.
It can be helpful to supplement the above technique by adding a rhythmic repetitive technique. The patient can be instructed to perform active rhythmic repetitive trunk rotation. As soon as the patient has properly understood the movement emanating from the head and is performing it correctly, the practitioner can let go of the shoulder. He continues to fix the patient’s flexed leg with his thigh and knee, and the pelvis with his forearm. He now fixes the spinous process of the lower vertebra in the treated motion segment using the fingers of both hands placed one over the other (see Figure 6.34). In terms of technique, it is best if the patient uses a minimum of force and tiny excursions to rotate back and forth in the extreme position. Rotation produces gapping of the upper intervertebral joint, and active rotation triggers reciprocal inhibition of the tensed muscles.
One particularly important and gentle technique is mobilization into flexion, first where flexion is restricted but also on the side affected by radicular compression and/or an intervertebral disk lesion, because this technique is associated with widening of the intervertebral canal and spinal canal, and only very minimal rotation takes place but intensive traction occurs.
For this, the patient is side-lying, with the leg underneath slightly flexed and the upper leg hanging over the edge of the table; the weight of this leg causes the pelvis to tilt forward. In this oblique position, the practitioner fixes the patient’s hanging leg with his thighs and the patient’s pelvis with his mobilizing hand. With his other hand he carefully pulls forward the arm underneath on which the patient is lying, so as to increase lumbar kyphosis still further while at the same time taking care not to straighten the patient’s pelvis. Using the arm that is closest to the patient’s head, the practitioner fixes the patient’s shoulder while hooking the patient’s upper arm through his own at the elbow. With the slightly flexed terminal phalanx of the thumb of that hand, he fixes from above the spinous process of the upper vertebra in the segment to be treated. At the same time he tells the patient to look up at the ceiling, thus fixing the head and trunk. It is also helpful if the practitioner stabilizes the patient’s trunk in the kyphotic position using his thorax, and for this the treatment table will have to be adjusted to a high setting (see Figure 6.35).
The same technique can also be used to stretch the frequently shortened thoracolumbar erector spinae, with the practitioner’s thumb fixing a spinous process at the thoracolumbar junction. Isometric resistance offered by the patient is followed not only by relaxation but also by active stretching. Here it is advantageous not only for the practitioner to stabilize the patient with his thorax but also to stretch the patient over his ribcage into kyphosis. This is indeed the most powerful (diagonal) traction technique.
PIR of the lumbar erector spinae can also be used as a self-mobilization technique (see Figure 6.116).
We have limited our descriptions to techniques that treat movement restrictions in anteflexion or retroflexion. Regarding the procedure to be used in cases where side-bending is restricted, it should be recalled that in the lumbar spine (see Figure 4.5) either extension is restricted on the side of the lesion or flexion is restricted on the opposite side. Of course, this does not hold true for the antalgic posture adopted in radicular compression.

The pelvis

The sacroiliac joint

The only pelvic joint that is treated by manipulation is the sacroiliac. Mobilization techniques feature prominently in this setting and should be performed routinely in two (almost) perpendicular planes. In the sagittal plane we are concerned with nutation of the sacrum in relation to the ilium (functional movement), and in the horizontal plane with joint play (gapping the dorsal part of the sacroiliac joint). As there are no muscles between the sacrum and the ilium to move or fix these bones, it is always possible to release functionally reversible movement restrictions using gentle springing mobilization techniques that employ a minimum of force.
For mobilization in the sagittal plane, we first use Stoddard’s crossed-hands position with the patient prone. The practitioner places one pisiform on the posterior superior iliac spine (PSIS) from below, and the other hand on the caudal tip of the sacrum. With his diverging forearms held straight, he exerts light pressure from above on both contact points, pushing them apart simultaneously to restore nutation of the sacrum in relation to the ilium (see Figure 6.36 A). He engages the barrier by first taking the mobility of the skin and subcutaneous soft tissue to its limit until bony contact is achieved (and this should be sufficient).
After a few very gentle springing movements at the restricted joint the practitioner will sense how the two bony structures start to move apart. The commonest mistakes are increasing the pressure (before movement is felt) and not releasing the pressure to allow springing back. Neuromuscular techniques play virtually no role in this context because there are no muscles between the sacrum and ilium. Experience gleaned from chain reaction patterns has modified our thinking inasmuch as indirect connections apparently exist due to the sacrotuberous ligament and the attachment points of the ischiocrural muscles, pelvic floor, and piriformis, etc. As a result, the sacroiliac joint very often no longer requires treatment after the lower extremity, pelvic floor, and piriformis have been treated.
The examination technique with the patient side-lying (see Figure 4.9) is suitable for mobilization in the horizontal plane and it can even be used for an HVLA thrust. The side-lying patient stabilizes the flexed upper leg on the edge of the treatment table. As the practitioner uses his forearm to apply oblique forward and downward pressure on the anterior superior iliac spine (ASIS), he produces gapping of the sacroiliac joint above. From the end position achieved, he can now perform rhythmic springing mobilization or even deliver an HVLA thrust in the same direction. With the thumb of his other (cranial) hand the practitioner can test the mobility of the PSIS in relation to the sacrum. In terms of technique, the pelvis should remain motionless and in particular should not rotate forward. For this technique it is immaterial whether the practitioner stands in front of or behind the patient.
If it is primarily the upper part of the sacroiliac joint that is to be treated to restore nutation, then the patient should lie on the side not being treated, stabilizing the upper knee (or indeed both knees one above the other) flexed on the edge of the treatment table. The practitioner sits below the level of the flexed hips and turns to face the patient’s head (see Figure 6.36 B). With one hand he takes hold of the ASIS and exerts light springing pressure against it in a dorsal direction. With the thumb of his other hand stabilized against the flexed fingers (or with the middle phalanx of his forefinger stabilized over the thumb), he applies counterpressure below the PSIS and takes up the slack. Mobilization is performed by rhythmic springing against the ASIS, and absorbing this synchronously with the thumb (bent forefinger) of the other hand.
If it is the lower end of the sacroiliac joint that is to be treated, the patient should adopt the same position as above; however, the practitioner sits above the level of the patient’s pelvis facing toward the foot end of the treatment table. With one hand he grasps the ASIS and with the ulnar aspect of his other hand he takes up lateral contact with the caudal end of the sacrum (see Figure 6.36 C). Using a rotating, convergent movement of both hands and forearms, the practitioner mobilizes nutation of the sacrum in relation to the ilium. Another option (according to Sachse) is for the practitioner to tilt the ilium dorsally, as for mobilization of the upper part of the sacroiliac joint, and to use the ulnar aspect of his other hand to mobilize the end of the sacrum ventrocaudally to achieve counternutation.
For the HVLA thrust technique described byKubis (1970), which primarily involves the lower part of the sacroiliac joint, the patient lies on the side of the restricted joint, meaning that it is ‘underneath’. Locking of the lumbar spine is performed in rotation up to and including L5 using the rotation hold at the lumbar spine with the leg underneath in extension and the lumbar spine stretched. The practitioner then makes dorsal contact with his pisiform pressing on the caudal tip of the sacrum, and takes up the slack by applying pressure on the sacrum in a dorsoventral direction (see Figure 6.37). He then delivers an HVLA thrust in the same direction. This maneuver primarily produces gapping of the sacroiliac joint ‘underneath’ that is fixed in place by the weight of the pelvis. There are two important technical points to be noted: first, the thrust must be delivered precisely in a dorsoventral direction, and second, there must be no further rotation while the thrust is delivered. This means that the practitioner needs to lean right over the patient so that his forearm delivering the thrust is horizontal. For this, the treatment table must be adjusted to a low setting.
Treatment of what Greenman and Tait call ‘outflare’ and ‘inflare’ (see Section 7.1.8) creates the illusion of true repositioning of an anomaly. On the side where the ASIS is flattened and further away from the umbilicus (outflare), the practitioner should proceed as when testing for ‘ligament pain’ (see Figure 4.13). He grasps the knee of the leg flexed at right angles at the hip and performs adduction until the slack is taken up. He then instructs the patient (as in PIR) to offer resistance for 5–10seconds, to breathe in slowly, to hold the breath, to breathe out again, and to relax into adduction. He waits for relaxation to be completed and then repeats a further two or three times. This is followed by RI in which the patient exerts pressure into adduction against rhythmic repetitive resistance at the knee.
On the opposite side (inflare) the patient adopts the position as for Patrick’s test (see Figure 4.43) and the practitioner exerts light pressure on the abducted knee in order to take up the slack. The patient then offers light resistance into adduction, breathes in slowly, holds the breath, breathes out, and relaxes completely into abduction.This process is repeated two or three times.
RI is performed using active abduction against rhythmic repetitive resistance. After this mobilization technique, the pelvis is routinely symmetrical, and muscle tone in the lower abdomen is balanced, as is internal rotation at the hip joint which is regularly greatly reduced on the side of inflare. The latter may explain the considerable clinical effect.

The coccyx

In the vast majority of cases of a tender coccyx, PIR of the gluteus maximus muscles is the treatment of choice, and this can also be administered as self-treatment (see Section 6.6.5), which is also consistent with the pathogenesis (see Section 7.1.9). However, there are also cases where manipulation per rectum is necessary; even when every effort is made to proceed carefully and gently, this treatment is generally unpleasant for the patient. However, it is a very effective technique, even though the mechanism is still obscure. The articulation of the sacrum with the coccyx is a syndesmosis and not a true joint; consequently, there can be no movement restriction here whatsoever.
For manipulation, the patient is prone with feet rotated inward; alternatively, the treatment can be given with the patient resting on knees and elbows. The practitioner inserts one forefinger into the patient’s rectum and palpates laterally for trigger points (TrPs) in the levator ani. PIR can be used to relax the levator ani. Moving the coccyx permits precise location of the sacrococcygeal syndesmosis. The practitioner then applies (usually painful) pressure with his forefinger (and thumb on the outside) or simply uses his forefinger to exert pressure in a dorsal direction. This is repeated two or three times. It should then be checked whether the tip of the coccyx is still tender.

The thoracic spine

Mobilization
For the thoracic spine there are no ‘pure’ traction techniques such as are used in the lumbar and cervical regions. There is one maneuver that is very popular among lay practitioners and corresponds approximately to traction manipulation. For this, the patient stands or sits with arms folded across the chest. From behind, the practitioner cups the patient’s right elbow with his left hand and left elbow with his right hand and presses the slightly kyphotic patient to his chest to take up the slack. From this position he straightens up and, delivering a thrust to the patient’s elbows, draws the patient upward and at the same time closer to his chest. This unsophisticated technique is quite innocuous unless the patient suffers from osteoporosis.
Because kyphosis with a stiff, rounded back is a particularly common disorder in the thoracic region, mobilization into extension is the technique most frequently called for. In order to make full use of the patient’s own musculature, we do not employ standard PIR but instead utilize the active contraction of the erector spinae muscles during exhalation to achieve mobilization into dorsiflexion. Seated on a stool facing a wall, the patient stabilizes both knees (slightly apart) and with crossed arms against the wall, rests the head on the arms. The practitioner stands behind the patient, and places one hand or just one finger on a spinous process in the stiffened spinal segment to indicate to the patient where attention should be focused (see Figure 6.38). Next, he instructs the patient to relax into extension. When maximum extension has been reached, he tells the patient to press lightly against his fingers and to breathe in deeply and slowly, breath-hold, and then breathe out slowly and completely. While breathing out, the patient should be told to straighten up again and to go into extension at the point where the practitioner’s finger can be felt. If performed correctly with sufficiently deep exhalation, this technique produces powerful contraction of the erector spinae accompanied by an intensive mobilizing effect that the patient experiences as being slightly painful. As soon as the patient has understood and felt this, the technique can then be practiced (and repeated) as self-treatment on a daily basis.
However, this very simple and effective technique has one major drawback: many patients with a kyphotic back have thoracolumbar hyperlordosis or at least hypermobility in that area and are unable to prevent themselves going into hyperlordosis there – something that must be avoided at all costs. Consequently, this technique should only be used in cases where the practitioner is satisfied that the patient is capable of extension, especially in the mid-thoracic part of the spinal column. Extension is frequently also rendered difficult because the erector spinae muscle is less well developed in the mid-thoracic region and most powerfully developed in the thoracolumbar segment. Therefore a more demanding technique is usually preferred, and this is described as a self-treatment method in Section 6.10.4.
If the intention is to treat just one restricted segment, then the procedure is similar to that for examination with the patient side-lying with both hands clasped behind the head. The practitioner stands in front of the patient and with one hand grasps both the patient’s elbows brought together in front of the neck, while using the forefinger of his other hand to stabilize the spinous process of the lower vertebra in the restricted segment. Using his forefinger as a fulcrum, he moves the patient into retroflexion to take up the slack (see Figure 6.39). The patient then uses the elbows to exert light (isometric) pressure against the practitioner’s arm and breathes in. He next instructs the patient to breathe out as fully as possible. As exhalation reaches the maximum, the erector spinae tenses and the thoracic spine is mobilized into extension. Here, too, it is the synkinetic tensing of the erector spinae during maximal (active) exhalation that is utilized for mobilization. This is therefore not a straightforward relaxation phenomenon such as occurs in PIR.
For mobilization into anteflexion, the technique used is the same as that described for examination (see Figure 4.22). To take up the slack, the patient is brought into kyphosis, with the peak of the kyphosis being at the level of the restricted segment. The patient is told to look up and breathe in, to breath-hold, and then to look down and breathe out. During slow exhalation, the patient relaxes and the thoracic spine becomes kyphosed. However, this kyphosis must be controlled so that its peak always remains within the treated segment. This mobilization procedure is repeated two or three times.
Anteflexion restrictions are most common where the upper thoracic spine is flattened and they tend to be associated with tension (TrPs) of the erector spinae, usually on one side. Therefore mobilization can also be achieved by relaxing this muscle. The practitioner stands behind the patient who is seated on the treatment table; with one hand he grasps the patient’s head, placing his palm on the occiput on the side of the lesion (i.e. his left hand is used if the lesion is on the right) (see Figure 6.40). He moves the patient’s head into anteflexion, side-bending, and rotation to the opposite side to take up the slack. Using the thumb of his other hand, he fixes the spinous process of the lower vertebra in the segment to be treated. The patient is then told to look in the opposite direction (toward the side of the restriction) and breathe in, to breath-hold, and then to look in the direction of mobilization and breathe out slowly, during which anteflexion, side-bending, and rotation will be found to increase. This procedure can be repeated two or three times. For specific treatment, it is important to start with anteflexion until the restricted segment is reached (i.e. begins to flex), and only then to move on to head side-bending and rotation.
The practitioner stands behind the seated patient and, placing his hand on the opposite shoulder, bends the patient’s trunk sideways to take up the slack. With his other hand at the level to be treated, he stabilizes the ribs while using his thumb to brace the spinous process of the lower vertebra in the restricted segment. If an even-numbered segment is being treated, he instructs the patient during the isometric phase to look up, breathe in, and hold the breath. It will be noted how resistance to side-bending increases. The patient is then told to relax and breathe out; the practitioner waits until relaxation is complete. In the odd-numbered segments (excluding T1/T2), the patient is simply instructed to breathe in slowly and deeply, to breathe out, and then to breathe in slowly again; the practitioner will sense how resistance increases during exhalation and how relaxation occurs during inhalation. In principle, the patient should avoid looking down during relaxation because this would encourage anteflexion. Mobilization can be repeated two or three times. If counting the segments is too onerous, it is equally reliable to ask the patient to breathe in and out just to see what happens. It will be very apparent whether resistance in the segment in question increases or decreases. However, the difference becomes less clear in the caudal segments because inhalation has a stabilizing effect and the quadratus lumborum becomes tense during inhalation.
Technically, it is critical to wait for the relaxing effect of inhalation on the one hand and of exhalation on the other; relaxation can occur at a relatively late stage during exhalation or inhalation. The practitioner’s stabilizing hand must also provide the patient with good support from the side to allow relaxation to take place; during side-bending the spinous process automatically moves closer to the fixing thumb due to simultaneous rotation of the thoracic spine.
However, if the patient has very broad shoulders and the practitioner has small hands, it is possible to use the technique described in the context of examination (see Figure 4.24). The practitioner stands behind the seated patient on the side into which side-bending is to occur. He tells the patient to raise the upper arm on the opposite (far) side. Taking hold of the upper arm from the front, he uses the thumb of his other hand to fix the spinous process of the lower vertebra in the segment to be treated. With his hand on the patient’s upper arm, the practitioner brings the patient into side-bending and so takes up the slack. Depending on whether the segment is even- or odd-numbered, mobilization is performed in the appropriate way. It must be stressed that during this technique the practitioner needs to lean backward and bend his knees. It is also remarkable that during mobilization into side-bending the vertebrae move closer together on the side in question and thus exert a mobilizing effect on the interposed tubercle of rib.
For mobilization in rotation, the patient sits (with hands clasped behind the neck) in a slightly kyphotic position astride the end of the treatment table. The practitioner stands behind the patient and passes one arm under the patient’s axilla to grasp the opposite shoulder. He places his other hand on the patient’s back to stabilize it. The patient is then told to look at an object in the examination room placed in such a way as to necessitate trunk rotation in that direction, thus taking up the slack. Next the patient is instructed to look in the opposite direction and to breathe in. The practitioner offers isometric resistance in the opposite direction against automatic rotation. After breath-holding, the patient is again told to keep looking in the direction of mobilization and to breathe out. This can be repeated two or three times. RI is then performed by instructing the patient (in the newly gained rotation position) to offer resistance in the opposite direction against repeated pressure.
Because the three muscles mentioned above form a chain, trunk rotation can also be restored by relaxation of the psoas major or quadratus lumborum.

HVLA thrust techniques

First a specific technique for traction manipulation: the practitioner stands behind the seated patient with a firm cushion between his chest and the patient’s back, so that the top edge of the cushion fixes the spinous process of the lower vertebra in the motion segment to be treated. He threads one arm through the patient’s axilla and uses the palm of that hand to stabilize the patient’s head and neck on one side. With his other hand he reaches across the patient’s chest to grasp the patient’s far hand and draw it through the other axilla, at the level of the fixed spinous process (see Figure 6.41). By pulling in a dorsal direction on his arm through the patient’s axilla and on the patient’s hand in the other axilla, he takes up the slack into extension. The practitioner delivers an HVLA thrust as he straightens up, thereby exerting sudden traction. This is the most gentle HVLA thrust technique for treating the thoracic spine.
Manipulation with the patient supine is effective and gentle at the same time. For this, the patient’s hands are clasped behind the neck, with elbows touching in front of the chin. As the practitioner stands beside the treatment table, he grasps both elbows (or forearms below the elbows) using the hand nearer to the patient’s head. He turns the patient toward him a little and lifts (see Figure 6.42). With middle and ring fingers flexed (see Figure 6.43), he places his other hand beneath the transverse processes of the lower vertebra in the restricted segment in such a way that the middle phalanx of his third finger is under the transverse process on the near side and his thenar eminence is under the transverse process on the far side. The spinous processes are accommodated in the groove between the practitioner’s middle finger and thenar eminence. He now rolls the patient over again so that the patient’s back is lying on his prepared contact hand. Using his other hand that is grasping the patient’s elbows, he now brings the patient into kyphosis so that the peak is located over his contact hand, thus taking up the slack. There are now two alternatives for performing manipulation:

2. Into flexion: the patient (again supine on the practitioner’s contact hand) is instructed to breathe in. However, the practitioner uses the patient’s grasped elbows (on which his own thorax is still leaning) to enhance anteflexion. While the patient exhales, the practitioner uses his thorax to deliver an HVLA thrust into flexion toward the stabilizing contact hand underneath.

It may be difficult for the patient with hands clasped behind the neck to bring the elbows into the desired position. In such circumstances the patient’s hands should be ‘semi-clasped’ (i.e. with fingertips only just touching), so enabling the elbows to meet in front of the chin. Another possible difficulty is that the pressure on the middle finger of the contact hand may become painful for the practitioner, especially if he cannot flex the terminal phalanx sufficiently. If that happens, he can insert a thin rubber eraser between the proximal and terminal phalanges of his third finger. If need be, the maneuver can also be performed in such a way that the contact hand (including the wrist) is positioned under the vertebra in question so that the spinous process is located in the carpal tunnel and the transverse processes have contact with the pisiform and thenar eminence. However, it is essential that the thumb is opposed, i.e. touching the little finger.

Contact holds with the patient lying in the prone position are always popular because of their simplicity. No locking technique at all is involved, and no distinction is made between flexion and extension. The HVLA thrust must be directed at the lower vertebra in the restricted motion segment, because only this will result in gapping or distraction of the intervertebral apophyseal joints, which are almost in the frontal plane in the thoracic spine. After the slack has been taken up, the springing technique illustrated in Figure 4.15 can be used and may also be employed for manipulation without an HVLA thrust.
The following technique, which can also be used for mobilization, produces some rotation as well as extension. The practitioner stands to one side of the prone patient with his hands crossed at the level of the motion segment to be treated and places the pisiform of his more cranial hand on the transverse process of the lower vertebra, and the pisiform of his other hand on the transverse process of the upper vertebra (see Figure 6.44). After taking up the slack, the practitioner delivers an HVLA thrust (or performs springing mobilization) from his shoulders with divergent arms held straight while the patient breathes out. Thus the push into extension and rotation is delivered in the direction of the hand on the lower vertebra. In terms of joint mechanics, there is gapping of the articulation on the side toward which rotation is also restricted.
This crossed-hands technique is also suitable for progressive caudal-to-cranial mobilization, described by Terrier (1958) as ‘mobilization massage.’ This begins at the bottom of the thoracic spine and progresses cranially in the rhythm of respiration, from one segment to the next.
There are three important technical aspects here: the practitioner’s arms must be kept straight and yet relaxed; the thrust must be delivered from his upper body through the shoulders; and his hands must be divergent so that the transverse processes of the two vertebrae move apart.

The ribs

Mobilization

A side-lying technique similar to the diagnostic method described by Kubis (1970) (see Figure 4.25) is used for mobilization. After isometric tension, this technique exploits the contraction of the back muscles during maximal exhalation. Standing in front of the side-lying patient, whose upper arm is raised above the head with elbow bent, the practitioner takes hold of the elbow with his hand that is closer to the patient’s head, allowing the patient’s forearm to dangle loosely (see Figure 6.45). Using his other hand with the fingertips held closely together, he fixes the costal angle of the restricted rib. While breathing in slowly, the patient presses the elbow forward against the hand of the practitioner, who offers isometric resistance. During maximal exhalation as the patient relaxes, the practitioner takes the patient’s upper arm into retroflexion while his fingertips form a fulcrum at the restricted rib.
Again, as in diagnosis, although the shoulder blade covers the ribs, it is no obstacle to the fixation of the rib during mobilization. The first rib, however, can be neither diagnosed nor treated with this method, while the second rib can be treated only with difficulty. The ribs to which this technique is most frequently applied are thus the second, third, fourth, fifth, and sixth. It is technically important to raise the patient’s arm vertically to obtain a pure movement of retroflexion and to avoid rotation. However, this is often difficult where shoulder pain is present, and for this reason treatment must start with the shoulder.
Pressure mobilization is recommended for the ribs in cases where the ‘overtake phenomenon’ is detected. The patient is supine and the practitioner stands at the top end of the treatment table, with both thumbs placed on the upper margin of the asymmetric ribs lateral to the sternocostal joint. At the ‘higher’ (restricted) rib he offers resistance while the patient breathes in and delivers a light push in a caudal direction while the patient breathes out. Afterward the position of the two ribs typically evens out and so the overtake phenomenon disappears.
If we find, on comparing the two sides, that one rib is restricted during exhalation, the following technique advocated by Greenman (1979) is indicated: with the patient supine, the practitioner places his thumb laterally on the upper margin of the restricted rib and, with his other hand under the patient’s shoulders, lifts the patient slightly toward him into slight anteflexion to take up the slack. In this position he instructs the patient to breathe out; during exhalation he delivers a push with his thumb in a caudal direction, at the same time lifting the patient’s trunk even higher and bending it to the side. Where several ribs are restricted, the lowest should be mobilized because it acts as an obstacle to its more cranial neighbors during exhalation.
If inhalation is restricted, Greenman makes use of muscle pull. In the region of the upper ribs he uses the pull of the scalenes, for the middle ribs the pectorals, and for the lower ribs the serratus anterior. With the patient supine, the practitioner takes up the slack in the relevant muscles by side-bending of the patient’s head (scalenes), abduction of the arm (pectorals), or maximal elevation of the arm (serratus anterior). During inhalation, the patient offers resistance with the head or upper arm in the starting position described. The practitioner stands on the side opposite to the restricted rib, bends the patient’s head or usually shoulder girdle toward the side he is standing on, and with the same hand, which is now placed under the patient’s shoulders, abducts the upper arm or elevates it as far as it will go. With the thumb of his other hand, the practitioner delivers a push in a cranial direction to the rib while the patient breathes in and resists the practitioner’s hand as it elevates or abducts his arm or side-bends his head. If several ribs are restricted, the uppermost rib should be mobilized because it acts as an obstacle to its more caudal neighbors during inhalation.
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