Osteopathic Manipulative Medicine: A Functional Approach to Pain

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18 Osteopathic Manipulative Medicine

A Functional Approach to Pain

Stevan Walkowski, DO, Robert Baker, DO

“Nature applies to you the switch of pain when her mandates are disregarded, and when you feel the smarting of her switch, do not pour drugs into your stomachs, but let a skillful engineer adjust your human machine, so that every part works with Nature’s requirements.”¹

The practice of osteopathic medicine is the practice of a complete system of medicine with deep historical and philosophical underpinnings. As osteopathic physicians, we are given the unique opportunity to use all means available to help our patients, from technological testing to surgical procedures and pharmaceuticals. Additionally, we are given the tools to affect the body’s physiology through manipulative therapies. We are taught from our first days in medical school how to use our hands to diagnose and treat dysfunction within the musculoskeletal system whether it is expressed as structural problems or more systemic problems. By restoring function to the tissue, we are restoring health, and because pain is a symptom of dysfunction within the organism, we have the opportunity to provide relief from suffering. Osteopathic manipulative medicine has an application in all specialties of medicine—from family practice to cardiothoracic surgery—because musculoskeletal pain and visceral distress exhibit somatic dysfunction and are amenable to osteopathic treatment.

This chapter is designed to be an introduction to the practice of osteopathic manipulative medicine. Although it is possible to read about diagnosis and treatment principles and begin to apply them in your practice, the study of this body of knowledge is best accomplished through application and direction within a formal course of study. The intention of this chapter is to provide an overview of the history, principles, and examples of common diagnosis and treatments in osteopathic manipulative medicine. Further resources will be introduced later in the chapter for the reader to explore and expand on the knowledge and information described here.

History of Osteopathy

Osteopathy has had a rich and varied history. One of the unique aspects of this profession is the importance of understanding its roots and the relationship of its roots to the present day practice of osteopathic medicine. It is only through understanding the totality of osteopathic medicine can one begin to appreciate fully the impact of osteopathic manipulative medicine. The heroes and founders of the osteopathic profession are unique and they bear witness to the tenacity of a belief in a style of practice different from the “medicine of the day.”

Truly an American practice of medicine, osteopathy began on June 22, 1874 in Kansas when Andrew Taylor Still, MD “flung to the breeze the banner of osteopathy”¹ and “like an explorer trimmed [his] sail…”.¹ A.T. Still was born in 1828 in Jonesboro, Virginia, but he grew up in Missouri as the son of a Methodist minister. Many stories surround the early years of Dr. Still, but little historical evidence is documented. As a Methodist minister, his father was a “circuit rider,” a preacher who would travel out to the edges of the frontier, settle his family, and provide religious service to the pioneers of that day. Although he would also do some missionary work to the indigenous people, conversion was rarely successful. Young Andrew was known to have spoken with the Native Americans around his father’s settlement and was said to have learned about the practice of herbal medicine from them. He was also known to have taken some skeletal remains from the burial grounds and with them began his study of anatomy. As he grew older and the debate around slave states and free states grew, he was a noted abolitionist and later joined the Kansas militia as sides were taken in the early days of the Civil War.

Following his tour of duty in the Kansas militia, he returned home and began the study of medicine as it was practiced in the late 1800s. Practices such as bleeding, administration of purgatives and cathartics, including arsenic and mercury, were common and considered standard of care at that time. This “heroic medicine” was mainly directed at suppressing symptoms and was practiced prior to the advent of the microbial orientation of disease or the understanding of much of the pathophysiology that we take for granted today. He became an accomplished physician by apprenticeship as was the custom and was awarded the title of Medical Doctor. An important event occurred in 1864 when a meningitis outbreak took the lives of three of Still’s children. This devastated Andrew and he “blamed the gross ignorance of the medical profession for the deaths of his children.”² This tragedy created an alarming sense of helplessness in Andrew and from then on he was determined to find better methods of healing.²

After a prolonged episode of depression and fasting, along with meditation and prayer, he came to the realization that the human form was a perfect reflection of the divinity that created it with the further realization that all of the natural elements of healing were present in the human body, and needed a physician only to release them. He reasoned that any being so created would have contained within it all of the substances it needs to heal itself and that the mechanical structure of the body must have a significant impact on its function. As Still’s most prominent quote said “To find health should be the object of the doctor. Anyone can find disease.”³ It was also the object of the physician to understand every aspect of human anatomy because it is only through understanding of anatomy that an accurate assessment of the healthy functioning of the body could be ascertained. This new science, Dr. Still called “osteopathy”, because it was the study of the relationship that the osseous structure and its interrelationships had on health. He advocated abandoning all use of drugs in favor of dietary, spiritual, and mechanical functional treatment.

During the late 1880s, word of Dr. Still’s successes was traveling far, and with it the desire by many patients to be seen. The local train station in Kirksville at the time had to increase the number of stops into Kirksville because of so many patients flocking there in hope of relief.

Because of this growing success, A.T. Still began to attract the attention of other physicians who wanted to learn this skill that seemed to be healing those who were previously found to be beyond repair. In 1892, he started the American School of Osteopathy in Kirksville, Missouri, and began teaching the first class of 17 students, of which notably three were women. The major system of study was anatomic dissection and the study of manual therapies designed to improve the overall functioning of the human body, allowing it to move toward its natural state of health. One of these first 17 students was Arthur Hildreth, a friend of the Still family, who went on to great success and eventually wrote a book about his great teacher. In the book he says of Dr. Still: “I wish it were in my power to describe in a simple, practical way some of his most outstanding technics. Not only the methods he used but also his own individual way of explaining what he did,” also, “Dr. Still’s technique was marvelous, often beyond our comprehension. He seemed to do everything so easily we wondered how he could accomplish so much.”⁴ This same Dr. Hildreth was the pioneer who led the charge in many states to gain practice rights for this new method of healing called ”osteopathy”.

Osteopathy has suffered minor setbacks in its history since the time of Dr. Still, but also many successes. There are now 25 schools of osteopathic medicine and the total number of DOs (doctors of osteopathy) totals more than 61,000. There are 18 specialty boards and the practice of medicine is unrestricted in each of the fifty states in the United States. Osteopathy is a recognized form of medicine in 44 countries world-wide with unlimited practice rights and recognized in another 8 countries with practices limited to osteopathic manipulative medicine. At present, the practice of osteopathic manipulative medicine is both a specialty practice and considered an integral part of any other specialty in osteopathic medicine. Osteopathic manipulative medicine is taught at all of the osteopathic medical schools in the first 2 years and is reinforced in the clinical third and fourth years. The American Osteopathic Association has listed it as the first Core Competency requirement in all osteopathic residency programs, and it is the intent of the AOA to ensure that the practice of osteopathic manipulative medicine be integrated into all residency training programs and all clinical practices of osteopathic medicine. Although it is part of a complete system of medicine and is applicable for both musculoskeletal problems and internal systemic dysfunctional issues, this chapter will largely deal with the use of manipulative medicine in pain.

Principles of Osteopathic Medicine

Osteopathic medicine is the only system of medicine that has clearly established principles guiding its practice. The principles, as distilled from the writings of A.T. Still, M.D., include (1) the body is a unit; (2) structure and function are interrelated; (3) the body has the innate ability to heal itself; (4) rational practice of medicine must take these principles into account. These tenets of osteopathy are easily developed to encompass a holistic treatment paradigm that characterizes osteopathy in the 21st century.

That the body should be considered as a unified whole as opposed to a summation of its parts is central to the first tenet. Additionally, one must consider the individual as an extension of his entire environment: social, family, environmental, nutritional, psychospiritual. It must be recognized that each aspect of his existence plays as significant role in the maintenance of his health and must be addressed if health is to be restored and maintained.

The interrelationship between structure and function seems central to the practice of osteopathic manipulative medicine in particular. More significantly, perhaps, is the realization that the structure of the body and its function are intrinsically, reciprocally, and inextricably connected; that one cannot be altered without affecting the other and that the health of the organism could easily be affected by limitations in its function.

Understanding that the body has the innate ability for self-healing is common knowledge today as we understand many examples of the homeostatic mechanisms that are present in many regulatory functions that the body possesses. This tenet implies, however, that the natural and innate state of the body is health, that the organism will instinctively move toward health, and that left unimpeded and supported, will continue its movement toward health throughout its lifetime. This concept is in significant opposition to the common method of pharmaceutical healing wherein all ills are seen as a result of the excess of something and what is most needed is medication that is designed to suppress whatever has invaded the organism or spun out of control. This tenet of self-healing supports the notion that by providing the right environment, structure, and milieu, the body will naturally take that information and use it instinctually in its eternal movement toward health.

Although this concept may have been medical heresy in 1874, none of these tenets seems far-fetched, even in today’s scientific environment and to say that rational treatment of disease requires an adherence to the aforementioned tenets follows easily. However, if one is to consider the veracity of these principles, then it is incumbent on all physicians to consider, at each turn, with each diagnostic and treatment choice, what among the range of possible options holds the most benefit, with the lowest risk, and honors the principles described earlier. What are the limits of all available treatments and which is the one with the most promise of being resonant with the health of the individual and, at the same time, which treatment holds the lowest risk?

Diagnostic Principles

Because osteopathic manipulative treatment is aimed at restoration of function, the diagnosis of dysfunction within the somatic system is a crucial starting point. As Dr. Still’s writing was ripe with concepts and barren with practice, the clarification and development of these topics is ongoing within the osteopathic profession.

The primary structural diagnosis in osteopathic manipulative medicine is “somatic dysfunction.” This is defined by the AOA glossary of terms as “impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements.”⁵ This broad definition is important for two reasons: (1) it creates a definitive concept around a palpatory experience and (2) it extends the scope of dysfunction to a zone greater than that of the neuromusculoskeletal system, that of the visceral and cellular functioning of the human organism.

This diagnosis is based on palpatory findings within the musculoskeletal system. The classic acronym for establishing a diagnosis of somatic dysfunction is STAR, which stands for sensitivity, tissue texture change, asymmetry of palpatory landmarks, and restriction of motion. Sensitivity may be identified as the patient’s experience of nociception to palpation, that is, tenderness, although sensitivity could be identified as hypalgesia, dysesthesia, or paresthesia. Tissue texture change is the appreciation of a palpatory difference of resilience of the examined tissue when compared to the surrounding area or an area of mirror image tissue; zones superior, inferior, or contralateral to those examined. Descriptors such as “boggy”, “ropy”, “banded” are commonly used to document alterations from the patient’s individual baseline reference. Asymmetry of palpatory landmarks is easily appreciated by the beginner at shoulder heights, iliac crest heights, or relative lengths of the lower extremities at the medial malleoli. Less obvious are discrepancies between the heights of the occipital condyles, anterior and posterior superior iliac spines, or pubic tubercles. More difficult to appreciate are prominences of rib angles, transverse processes of the vertebral segments, and the relative depths of the sacral sulci. Restriction of motion is the final examination criteria for the diagnosis of somatic dysfunction. This restriction of motion is generally very small and limited to one segment or joint but can extend to surrounding segments. Through the process of segmental definition, a practitioner evaluates a patient with greater and greater tissue specificity until a segmental diagnosis such as T3 flexed, rotated right, and side-bent right is determined. These diagnoses are based upon the normal motions of the regions being examined and are named according to their respective motions of ease rather than restriction. Therefore, in the example, examination would have found the third thoracic vertebrae was relatively restricted in its motion of extension, rotation to the left, and side-bending left when compared to the segments T2 and T4.

Diagnostic Process

In addition to conventional medical diagnostic procedures, palpatory examination leading to segmental diagnosis of somatic dysfunction is essential to the practice of osteopathic manipulative medicine. Typically, the process of coming to a diagnosis usually involves some measure of palpatory screen, scan, and finally, segmental definition. Screening is the process of palpation and movement designed to answer the question, “Is there a problem?” Scanning answers the question, “Where is the problem?” and segmental definition answers the question, “What is the problem?”⁶

The screening structural examination is a rapid assessment of tissue texture and motion asymmetries throughout the body, evaluating the differences in tissue texture and motion in the major regions of the body: head, cervical, thoracic, ribs, lumbar, sacropelvis, upper extremities, and lower extremities. This is accomplished by broad-based palpation using an open, flat hand to assess tissue tension in two of each of these regions and determine if there is a differential tension at any of them. For instance, screening examination of the lumbar spine consists of a flat hand placement over the upper lumbar region and lower lumbar region. If there is a difference in tension between those two regions, that difference is noted. Similarly, palpation of the upper extremity checks the tension bilaterally in the upper (humeral) arm and separately at the lower (radio-ulnar) arm. Regional motion is assessed by testing for the relative extent of passive (practitioner-directed) motion capacity in two planes and noting the presence of asymmetry. For example, the cervical spine is tested by slowly rotating the head on the cervical spine passively to the right and left and noting differences in the endpoint of motion. If the spine is capable of rotating more to the left than the right, that difference is noted. Typically, two separate motions are used to screen any region just as two areas are palpated in any region. Again, in the cervical spine, rotation and side-bending are typically tested. A presence of asymmetry in tissue tension and motion in any of the regions is considered prima facie evidence of somatic dysfunction and demands a scanning evaluation.

The scanning examination is one that narrows the finding of somatic dysfunction to a segment, rib, or joint. This is accomplished by a more focused palpation over the region assessing changes in tissue texture that are more specific to the region involved. For instance in the thoracic spine, palpation along the zone of the transverse processes, segment by segment, will help to identify the segment that is dysfunctional, usually by noting a firmness of the surrounding tissue as compared to the segmental transverse process above and below it. This finding is then confirmed through motion testing by initiating passive side-bending or rotation in the thoracic spine and then observing the tissue response to that motion and comparing that response to motion in the segments above and below it. For example, after screening the thoracic spine and finding it to be dysfunctional, a scan is performed and the 5th thoracic segment displays increased tissue tension at the region of the transverse process when compared to the transverse processes above and below it. With the patient’s arms crossed (to eliminate unconscious external stabilization), the trunk is side-bent to the left and an assessment of ease or bind at the 5th thoracic segment is identified as compared to the segments above and below. If restriction to motion is identified with left side-bending, there will be ease to right side-bending of the thoracic spine. Typically, a restriction to motion is more easily appreciated on palpation, but conventionally, the segment is always described in its direction of ease; therefore, the 5th thoracic segment with restriction to side-bending to the left is described as “side-bent right.” The choice of side-bending as a test is completely arbitrary here and passive rotation could just as easily have been demonstrated. The findings of segmental tissue texture change and motion asymmetry determine a positive scan and the next step, segmental definition, must be accomplished if any treatment is to be considered (Fig. 18-1).

Figure 18-1 Scanning the thoracic region. This figure demonstrates the position for determining segmental response to regional rotation of the thoracic spine.

Segmental definition is the process of finely tuning one’s scan and focusing palpation and motion testing to account for all possible motion characteristics that occur at the particular segment or joint. To continue our example of the 5th thoracic vertebrae, we identified that motion ease is palpated in lateral side-bending to the right.³ Additionally, we must further check rotation right and left, flexion and extension, anterior or posterior translation, cephalad or caudad translation, or ease in response to the respiratory cycle of inhalation or exhalation. Again, this testing is done passively with the operator moving the patient in all of the aforementioned planes of motion with a palpating hand checking for tissue response to that movement. This provides the most accurate and detailed type of definition for a vertebral segment. Segmental definition of joints of the extremities is a natural extension of the scan for that region. Because motion restriction is detected asymmetrically in the extremities, that motion is more definitively described according to the major motions, but also the minor or secondary motions, such as glide and translation. While these secondary motions are significant in the vertebral column, these subtler motions in the extremities often hold the key to defining dysfunction and, hence, treating it.

This style of diagnosing somatic dysfunction is but one method of approach to this problem. It is a simple, yet comprehensive approach to the entire body. There are as many approaches to defining somatic dysfunction as there are practitioners of osteopathic manipulative medicine, but they each contain some portion of the steps elucidated herein. What is simple is not always easy. Palpating for these tissue texture changes and motion characteristics seems simple when described, but the psychomotor skill of applying these techniques is extremely difficult to begin to appreciate and takes many years to master. As in many other aspects of medicine, the learning process continues until death. Osteopathy has the unique attribute of revealing itself through its patients to the practitioner, if he or she approaches it with open eyes, an open heart, and thinking fingers. My patients teach me every day, and new clues to a greater appreciation of osteopathy are revealed to me, unexpectedly, enriching my experience and my ability to help them.

Treatment

Osteopathic manipulative treatment is divided into two main types: direct and indirect. Direct techniques are those in which an operator moves a segment or joint in a direction toward its barrier to motion and uses an internal or externally applied force to create movement through that barrier to restore normal motion and function. Examples of direct treatment include: muscle energy technique, high-velocity low amplitude technique, and direct myofascial release technique. Conversely, an indirect treatment moves a segment in a direction away from its barrier and allows for a spontaneous correction or release to restore normal motion and function. Examples of indirect treatment include: strain counterstrain technique, functional methods technique, and indirect myofascial release technique.

Inherent in these descriptions is the barrier concept. This much debated concept is a direct result of palpatory experience in segmental definition (Fig. 18-2). One model of the barrier concept states that there exists within any segment or joint, a neutral zone in which all of the forces that normally impinge on that segment or joint are equal and balanced. There is a zone around that neutral area that represents the entirety of the normal range of motion that segment or joint possesses. Any motion that segment or joint performs is met with increasing resistance as it approaches its endpoint of motion or barrier. Some definitions of the barrier include distinctions of motion that describe the barrier to passive motion versus the barrier to active motion, or the barrier that exists between the endpoint of passive motion and the barrier that occurs at the limitation of bony resistance of the skeleton. Another important part of the barrier concept is that of a pathologic neutral. When a joint or segment is functioning fully, its neutral position of rest is balanced within its endpoints of motion. When one of the functional endpoints of motion or barriers have been changed through dysfunction, then a new balance point is established that is still neutral in relation to its total potential of function. That change in the neutral is palpable in structural diagnosis as somatic dysfunction. The restriction to motion in one or more planes of motion creates palpatory findings that are commensurate with the definitions of dysfunction.

Figure 18-2 Somatic dysfunction in a single plane: three methods illustrating the “restrictive barrier” (the restrainer): AB, Anatomic barrier; PB, Physiologic barrier; RB, Restrictive barrier; SD, Somatic dysfunction.

As an example of direct technique, in the case of T5 flexed, rotated right and side-bent right, by definition, it is named for its positions of ease of motion. Conversely, this means that its directions of restriction are extension, rotation left, and side-bending left. In a direct technique, the segment is moved into its directions of restriction and an activating force is applied to move it through that barrier. An indirect technique is applied by moving the segment into its direction of ease of motion and the intrinsic physiologic forces are used to allow for a release of the dysfunction. In both cases, following treatment, the segment is rechecked to ensure that a change to a more functional state has been achieved.

Muscle Energy Treatment: Lumbar

Muscle energy treatment was developed by Fred Mitchell, Sr., DO, as a way to approach problems directly without high-velocity, low-amplitude thrusting.⁷ This is a direct technique in which the operator moves the dysfunctional segment toward its restrictive barrier and then stabilizes it while the patient applies an isometric contraction away from the barrier. This contraction is held for 3 to 5 seconds and the patient is instructed to discontinue the contraction. At that point, the operator readjusts the position of the segment to accommodate for the muscle relaxation and lengthening that has occurred, and moves the segment into a new barrier. This sequence is repeated until maximum improvement in the segmental findings is achieved. The advantage of this technique is that the force that is applied is generated by the patient and monitored by the physician. Dr. Fred Mitchell, Jr, DO, who wrote extensively about his father’s technique, explained that the anatomy in a patient’s own (body) was more precisely and intimately known to the patient’s muscles than they could be to any examiner. For this reason he said, his father chose to use the energy of the patient’s muscles instead of his own for the corrective forces.⁷ This alleviates the danger or unnecessarily overzealous application of an externally applied force. Difficulties with this procedure usually surround the localization of force by the practitioner, lack of stabilization against the isometric contraction on the part of the physician, and too great a force applied by the patient. The force applied need only be great enough to engage the tissues at the level of the localized, treated segment. Too great a force can become too diffuse and difficult to localize around the segment, it may also be too strong to oppose by the physician. The treated segment must be stabilized in its position against the barrier and if that stabilization is compromised because the physician is trembling against the force of the patient, it will be impossible to maintain a stable position at the barrier. Muscle energy technique, when properly applied, should not look like a wrestling match.

The lumbar spine is identified as the lower five vertebrae resting on the sacrum. These are large vertebrae with no rib attachments. Primary motions at these segments include flexion, extension, side-bending, and rotation. The intervertebral discs support the vertebrae, providing both a cushion for shock absorption and a stable, yet flexible interface between the segments, allowing for movement. The remainder of the vertebrae include a pedicle and spinous process creating the spinal canal; transverse processes bilaterally and articular processes above and below the transverse process that create functional joints with the spinal segments superior and inferior to it. These processes form the zygapophyseal or facet joints, true synovial joints in the lumbar spine. Between the pedicles of each of the vertebral segments course the peripheral spinal nerve roots.⁸

Pain in the lumbar spine is common and multifactorial.⁹ It is beyond the scope of this chapter to discuss all of the possible causes of back pain; more importantly, there is much speculation about the true etiologies of any of these types of pain. Common pathologies occurring in the lumbar spine that can easily affect the function of the region include: osteoarthritis, herniated nucleus pulposus, inflammatory arthropathy, spondylolisthesis, spondylosis, and ligamentous strain. Although each of these problems has its unique presentation, they each have the capacity to express themselves as a functional limitation of that region, exhibiting signs of somatic dysfunction. Disruption of the normal integrity of the musculoligamentous structures of the axial spine in any location can result in muscular hypertonicity. Because this hypertonicity is usually asymmetrical and is generally restrictive in motion of the spine, diagnosis of tissue texture differences and resultant motion asymmetry is quickly identified. Important in the diagnosis of somatic dysfunction at any location is the appreciation of the anatomic and subsequent physiologic influences any dysfunction can have at local, adjacent regions or distal regions, whether by myofascial continuity or neural irritability.

Important influences that extend from lumbar dysfunction include regional influences. Lumbar dysfunction with its requisite biomechanical changes can affect segments locally adjacent. Because of the physiologic differences between the regions of the axial spine, dysfunction in the lumbar region can influence the appearance of dysfunction in the thoracic spine and sacropelvis and vice versa. As a result of normal physiologic relationships within the viscera and their relationship to the lumbar region anatomically, functions of those viscera can be affected, especially the viscera of the lower pelvis including the large intestine, sigmoid colon, rectum, and pelvic organs. Although this is partly due to the direct effect that a change in normal biomechanics can have on involuntary motions such as those associated with respiration, some of the effect is due to a reflex influence of the somatic system on the autonomic nervous system in the levels of the spine that are affected. In this case, T12 to L2 are most closely associated with the sympathetic cell bodies that provide autonomic influence to the colon below splenic flexure and other pelvic organs. In this way, osteopathic manipulative medicine extends beyond the realm of musculoskeletal pain management and becomes part of a complete system of medicine in which its application begins to influence the visceral function and ultimately the metabolic health of the organism.¹⁰ At this point the encompassing definition of “somatic dysfunction” becomes actualized in its application of treatment.

Beginning with muscle energy treatment of the lumbar spine, let us assume that the practitioner has previously performed a structural screening examination, scanning examination, and obtained a segmental definition of L4 flexed, rotated, and side-bent to the right. According to the previous discussion this implies ease in the direction of diagnosis and restriction in the opposite directions. Therefore, its motions are restricted at L4 in extension, rotation, and side-bending to the left. Any manner of positioning designed to activate that segment at its points of restriction is appropriate, but for the purpose of this description of treatment, the seated position will be used. Because the nature of this treatment is to provide resistance against the patient’s activating force in an isometric contraction, it is important to consider how one will stabilize the body of the patient while monitoring tissue changes at the dysfunctional segment. Proper body mechanics and choice of positioning allows for the use of as many core trunk muscles of the physician for stabilization and fewer of the muscles of the appendicular skeleton that tend to be shorter and quicker to fatigue. In this case, the patient is seated on the table and the physician is standing behind her on the side of her side-bending restriction. The height of the table or chair is selected to maximize the physician’s ability to apply an adequate counterforce in side-bending by bringing his axilla as close to the superior aspect of his patient’s shoulder on the side of side-bending restriction. The opposite hand is used to palpate the tissue at the dysfunctional segment and monitor for specific localization of forces into that segmental region.

The physician grasps the opposite shoulder by placing his arm across the anterior cervical thoracic junction of the patient and holds the patient snugly. He moves the patient’s trunk passively until the position of restriction is palpated at the previously identified segmental level, which in this case means rotating her trunk to the left and side-bending to the left with lumbar extension until the force of these motions is palpated at L4. The accuracy of the localization of these forces is crucial to the effective application of these techniques (Fig. 18-3). Too little motion and the forces will be localized superior to the segmental region, too much motion and the forces will be directed at a level inferior to the dysfunctional segment. When localization is achieved, the patient is asked to attempt to side-bend and rotate away from the position that she has been put into by the physician. In this case, the patient is directed to, “gently turn to the right.” Generally, only one direction of motion is necessary to activate the force sufficiently to achieve an effect at the dysfunctional segment. Because of normal spinal mechanics, motion in one of the cardinal directions of the spine will affect motion in all the other planes where motion is engaged, so by asking the patient only to rotate, side-bending and flexion are normally engaged. The force of the isometric contraction must be palpated at the level of the dysfunctional segment. The localized isometric contraction is held for 3 to 5 seconds and then the patient is asked to stop turning, or to relax. A moment is given to appreciate the relaxation in the tissues and then the segment is moved into its next restrictive barrier, in this case, slightly further rotated left, side-bent left, and extended. This sequence is repeated as many times as it is needed to effect maximal change, but generally this occurs within five repetitions. At that point, the patient is slowly and gently returned to physiologic neutral, and the dysfunctional segment is checked again for improvement in tissue texture and motion.