Manipulation 182
6.1.1 General principles governing technical aspects 182
6.1.2 Extremity joints 187
6.1.3 The spinal column 201
6.3 Exteroceptive stimulation 225
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
6.8 Re-training to correct faulty movement patterns 285
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.
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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.
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| Figure 6.9 |
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.
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| Figure 6.10 |
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.
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| Figure 6.17 |
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).
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| 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.
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| Figure 6.19 |
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.
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| Figure 6.23 |
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.
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| Figure 6.24 |
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.
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| Figure 6.26 |
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.
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| Figure 6.27 |
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.
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.
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| Figure 6.30 |
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.
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| Figure 6.31 |
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.
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| Figure 6.34 |
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).
Using the fingers of his mobilizing hand, the practitioner takes up the slack by applying traction in the region of the transverse process of the lower vertebra, and especially by exerting pressure with his forearm on the patient’s pelvis in the direction of traction, rotation, and kyphosis. The patient is then instructed to offer slight resistance with the pelvis against the practitioner’s mobilizing hand and with the hanging leg against the practitioner’s legs, to breathe in slowly and deeply, to breath-hold, and then to relax. During relaxation the distance between the fingers of the practitioner’s mobilizing hand and the thumb of his other hand will increase as an expression of distraction and kyphosis. The practitioner must wait until relaxation is complete and then, depending on the outcome, he can repeat the procedure or deliver an HVLA thrust using the hand placed on the pelvis. Technically, it is important that the fixing thumb does not exert pressure from above but rather that the interphalangeal joint ‘hooks onto’ the spinous process, something that is readily manageable in kyphosis.
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.
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| Figure 6.37 |
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.
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| Figure 6.39 |
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.
For mobilization into side-bending we use the same technique as for examination (see Figure 4.23) the only difference being that the practitioner’s thumb is not used to palpate mobility at the interspace between two adjacent vertebrae but to fix the lower vertebra in the segment to be treated. Here we utilize the alternating facilitating and inhibitory effect of inhalation and exhalation described by Gaymans (1980); gaze direction can also be used in the even-numbered segments where inhalation has a facilitating effect (see Section 6.1.1).
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.
Mobilization where rotation is restricted: as already discussed in Section 3.4.1, restricted trunk rotation does not result from joint restriction but from increased tension (TrPs) in a shortened muscle chain, namely that comprising the erector spinae, quadratus lumborum, and psoas major on the side opposite to rotation. Consequently, the mobilization technique is not strictly specific. In this situation we use the same technique as for PIR of the erector spinae (see Figure 6.40).
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.
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| Figure 6.41 |
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:
1. Into extension: the patient (supine on the practitioner’s contact hand) is instructed to breathe out slowly. At the same time, while holding the patient’s elbows, the practitioner moves his upper body back over the contact hand, using his thorax to gently increase the pressure via his hand on the patient’s elbows and thorax. This is usually sufficient on its own to make the joint ‘pop’ (alternatively, this may happen after an HVLA thrust has been delivered with the practitioner’s thorax over the contact hand).
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.
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| Figure 6.42 |
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.
Manipulation with HVLA thrust techniques
For the following manipulation technique the patient is supine, with hands crossed to the opposite shoulder and the arm on the restricted side lying uppermost. The practitioner stands beside the treatment table on the side opposite the lesion, takes hold of the uppermost arm, and turns the patient toward him. He then positions the thenar eminence of his other hand beneath the costal angle of the restricted rib (see Figure 6.46 A). Now taking the patient’s other upper arm (i.e. the one that was previously lying underneath), he turns the patient away from him again until the costal angle is resting on his thenar eminence. To do this effectively his thumb must be maximally opposed so that its muscles contract and form a firm contact (see Figure 6.46 B). The practitioner then uses his thorax to exert light pressure on the hand holding the patient’s upper arm until the slack is taken up. Afterward he delivers a vertical HVLA thrust with his thorax in the direction of his thenar eminence (see Figure 6.47).
A simple but harder thrusting technique with the patient prone has a similar effect. The patient’s head is turned to the side of the restricted rib. If this is one of the upper ribs, the patient’s arm on the side being treated hangs down over the edge of the treatment table in order to produce abduction of the shoulder blade. The practitioner stands next to the patient and places the pisiform of his contact hand on the costal angle. The contact hand can be reinforced by grasping it just above the wrist with his other hand. He takes up the slack by exerting light pressure and delivers an HVLA thrust from his trunk via both arms as the patient breathes out (see Figure 6.48). A restricted rib is usually also painful at the sternocostal junction, which is the attachment point for the pectoral muscles. This situation then necessitates relaxation of these muscles (see Section 6.6.4 and Figure 6.109).
A suitable treatment for the lower ribs involves a technique for which the patient sits astride the end of the treatment table, with hands clasped behind the neck. The practitioner stands behind the patient and threads one arm under the patient’s axilla to take hold of the shoulder on the opposite side so as to rotate the patient’s trunk sideways about a vertical axis. With the pisiform or thumb of his other hand, he takes up contact at the costal angle (see Figure 6.49). Using both hands he now rotates the patient until the slack has been taken up. He then delivers an HVLA thrust from his trunk, transmitting it simultaneously to both hands (pulling on the patient’s shoulder with one hand and pressing with the other). This technique produces gapping of the costotransverse joint of the restricted rib.
Manipulation of a painful slipping rib
The patient reports pain in the region of the abdominal cavity during pressure palpation of the inferior costal arch, especially of the tenth rib, between the practitioner’s finger ‘inside’ beneath the costal arch and his thumb on the surface ‘outside.’ Mobilization is performed with the practitioner’s fingers beneath the inferior costal arch and the heel of the hand on the outside surface of the lowest ribs, gently springing ventrally and laterally in a slow rhythm. The technique is always painful but brings immediate relief.
Treatment of the first rib
As we noted for the diagnostic examination, the technique for treating the first rib also differs from that employed for all the others. In terms of function, the first rib forms part of the cervicothoracic junction, and for mobilization we make use of the attachment between it and the scalenes. The practitioner stands behind the seated patient and stabilizes the neck or shoulder from the side. He places his other hand against the side of the patient’s head and instructs the patient to press her head against this hand as he rhythmically intensifies and slackens its pressure (see Figure 6.50). Usually about 20 isometric contractions in a slow rhythm (two per second) will suffice, and this will also mobilize the second rib. This technique is also well suited for self-treatment, with the patient using her own hand to exert rhythmic pressure against isometric resistance from the head.
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| Figure 6.50 |
In another technique the practitioner stands behind the patient who is seated on the treatment table and leans back against him for support. The practitioner can also use his knee to stabilize the side not being treated, while also steadying the patient’s head with one hand on the same side. Using the forefinger of his other hand, he takes up contact over the angle of the first rib from above, close to the patient’s neck (see Figure 6.51). He takes up the slack by exerting light downward pressure and achieves very effective mobilization by rapid shaking; alternatively, he can use the edge of his forefinger to deliver an HVLA thrust in a caudal and slightly ventral direction.
The cervical spine
Traction
Traction is essentially performed using manual and post-isometric techniques, but additionally taking advantage of respiratory synkinesis. In the supine technique, the patient’s head projects over the end of the treatment table while the practitioner simply cradles it in his palms; very little force is required (see Figure 6.52 A). The patient is told to look up toward the forehead and to breathe in deeply. Once the practitioner sees that the sternocleidomastoids are contracting, he instructs the patient to breath-hold and, after a brief pause, to look down toward the chin and breathe out slowly. This automatically ushers in relaxation; he then waits until relaxation is complete before repeating.
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| Figure 6.52 |
A similar procedure is followed with the patient seated. The practitioner stands behind the patient who is sitting on the treatment table. To facilitate relaxation, the patient’s back is supported against the practitioner’s chest. He takes the patient’s head in both hands so that his forearms are resting just in front of the patient’s shoulders, thus ensuring an upright posture. His thumbs are located on the patient’s occiput, with his other fingers placed laterally around the zygomatic bones in as soft a hold as possible (see Figure 6.52 B). After gently taking up the slack with traction, he tells the patient to look up and breathe in deeply. If he senses increased resistance, he tells the patient to breath-hold, look down and then breathe out. He will then feel the patient relax; once this process is complete, the procedure can be repeated.
Relaxation occurs automatically as a result of PIR supplemented by respiratory synkinesis, and for this reason this form of traction appears to be ideal. It acts primarily on the C2/C3 segment. Because it is commonly used for treatment in the acute stage, it is critical that the patient can tolerate the technique well. Consequently, any existing antalgic posture should not be corrected; instead traction with PIR should be performed in the position that best suits the patient. For this reason alone it is preferable to apparatus-based traction techniques. Traction must always be stopped if it proves to be uncomfortable for the patient. In particular, we would not advocate the use of Glisson slings with the patient seated because traction here primarily involves the chin without occipital stabilization (in contrast to the supine position); in such circumstances the patient tenses the flexor muscles of the neck, causing any effect of traction to be lost.
Because patients find it particularly agreeable, we will also describe here a traction technique that is associated with a massage element. For this, the patient is supine with shoulders at the edge of the treatment table. The practitioner sits behind the patient’s head, supporting it on his knees. He places both hands under the patient’s shoulders and then leans back so that both hands slide cranially as far as the patient’s occiput, exerting traction and gentle pressure massage at the same time.
Jirout’s maneuver
A maneuver described by Jirout (2000) has proved particularly effective in acute dysfunction. In such cases it is most usual for rotation to the right in the upper cervical spine to be restricted. The patient is supine with head in a neutral position. The practitioner uses his thumb to exert pressure on the patient’s left shoulder from above while the patient relaxes the shoulder and breathes out. The patient is then told to offer resistance with the shoulder against the practitioner’s thumb while he additionally stimulates the periosteum at the patient’s shoulder with his thumb. After breath-holding, the patient relaxes so that the shoulder moves in a caudal direction. In the considerably rarer cases where rotation is restricted to the left, the above procedure is adopted, but this time the right shoulder is treated. Because the patient’s neck is not touched at all, the technique is invariably well tolerated and it is often possible to begin with this maneuver in acute rotation restrictions of the upper cervical spine.
Mobilization
Side-bending
This can be carried out with the patient seated or supine. The procedure makes use of the phenomenon, described by Gaymans (1980), of alternating fixation and relaxation of neighboring spinal segments. In the even-numbered segments (C0, C2, C4, C6), resistance increases during inhalation and maximal facilitation can therefore be achieved by telling the patient first to look up and breathe in deeply, then to breath-hold and, after a brief latency period, to look down and breathe out (see Figure 4.26). In the lower cervical spine, however, it is preferable to have the neck extended with the patient seated, in which case it is better to tell the patient during the mobilization phase to let go and then to breathe out. In the odd-numbered segments it is sufficient merely to tell the patient to breathe out slowly and then to breathe in slowly. If the patient is supine, then the technique is as described for examination purposes (see Figure 4.29).
The practitioner takes up the slack in the spinal segment to be treated; it will be noted how resistance increases in the initial phase only to decrease abruptly toward the end of the second mobilization phase, at which point the practitioner can still instruct the patient to let go. The most important thing is to wait: if the practitioner commits the cardinal sin of actively forcing side-bending, he will then cancel out the effect of automatic relaxation. This procedure can be repeated two or three times.
Rotation
For post-isometric mobilization the simplest approach is for the practitioner to fix the lower vertebra in the segment between thumb and forefinger, as for examination (see Figure 4.32), and with his other hand on the patient’s chin, to go into rotation as far as the end point (i.e. to take up the slack). He then instructs the patient first to look up and breathe in, then to look down and breathe out, and he will sense how rotation increases during relaxation. Looking first in the opposite direction and then in the direction of mobilization usually produces too much active tension and too little relaxation (Sachse & Berger 1986).
Side-bending mobilization at the cervicothoracic junction
In this case, too, the technique for side-bending mobilization at the cervicothoracic junction is the same as for diagnosis (see Figure 4.30). Throughout the cervicothoracic junction increased resistance is noted during inhalation whereas relaxation/mobilization is seen during exhalation. The practitioner takes up the slack by holding the patient in retroflexion, with side-bending to the side of the restriction and rotation in the opposite direction, and fixes the lower vertebra with the thumb of his other hand. He then instructs the patient to look up and breathe in slowly, to breath-hold, but then to let go and breathe out slowly. Because locking was achieved in retroflexion, etc., if the patient were told to look down, this would cause anteflexion, thus unlocking the cervical spine and locking the cervicothoracic junction.
Technically, it should be emphasized that the fingers over the zygomatic bone have the (sometimes quite difficult) job of holding the patient’s head in retroflexion, side-bending, and rotation to the opposite side, while at the same time the thenar eminence of the same hand fulfils a lateral stabilizing role on the upper vertebra in the restricted segment. During mobilization, the thumb of the practitioner’s other hand is used merely to fix the spinous process of the lower vertebra. As relaxation progresses he will sense how mobility (springing) is restored between his thumb and the thenar eminence of the other hand. Throughout mobilization the patient must be supported in an upright position. Starting from the same end point after taking up the slack, it is also possible to deliver an HVLA thrust; however, this must come from the thumb at the lower vertebra. In the process the practitioner’s other hand fixes the upper vertebra.
It is technically easier (although less comfortable for the practitioner) to carry out this mobilization with the patient side-lying. Here, too, the hold is the same as for diagnosis (see Figure 4.31). The practitioner stands opposite the patient’s head and cradles it between one hand and upper arm, with his elbow resting on the treatment table. Then, without lifting his elbow, he moves it forward on the treatment table and so takes up the slack by moving the patient’s head into side-bending, rotation in the opposite direction, and retroflexion. (The practitioner’s forearm has to adopt this position if his hand keeps hold of the patient’s head and he simply moves his elbow forward.) The heel of the same hand takes up contact at the upper vertebra in the segment to be treated. With the thumb of his other hand he fixes the spinous process of the lower vertebra, using the terminal phalanx of his thumb to ‘hook in’.
Because the practitioner has to bend over the patient for this mobilization technique, his position will be far more comfortable if he supports his knee furthest from the head end on the treatment table. He next instructs the patient to look up to the forehead, breathe in deeply, breath-hold and, after a brief latency period, to let go and breathe out. As the patient exhales, the practitioner will notice how resistance is reduced and how he can advance his elbow further forward without resistance. After taking up the slack, he can deliver an HVLA thrust by pushing his elbow forward rapidly, while the thumb of his other hand firmly holds the spinous process of the lower vertebra.
Rotation at the cervicothoracic junction
The following technique can be used for mobilization: with the patient seated on the treatment table adjusted to a low setting, the practitioner stands behind and takes hold of the patient’s head between his upper arm and forearm, with the patient’s chin in the crook of the elbow. He rotates the patient’s head in the direction of mobilization to take up the slack, with his little finger spanning the vertebral arch and the spinous process of the upper vertebra in the segment to be treated. With the thumb of his other hand he fixes the spinous process of the lower vertebra from the opposite side (see Figure 4.35). The patient is told to look in the opposite direction and breathe in, and to breath-hold while the practitioner offers isometric resistance to the patient’s movement. After a brief latency period, he instructs the patient to look in the direction of mobilization and to breathe out slowly, thus causing mobilization to proceed automatically. Using the same technique, after taking up the slack, he can perform an HVLA thrust as follows: the hand cradling the patient’s head delivers the thrust while his other hand with its thumb against the spinous process fixes the lower vertebra.
Traction HVLA thrust at the upper vertebra in the restricted motion segment
The patient is supine, with head and neck protruding beyond the edge of the treatment table. The practitioner rests the patient’s head on his forearm and cradles the patient’s chin with his fingers. He locates his other hand at the transverse process of the upper vertebra in the restricted motion segment (see Figure 6.53 A). He side-bends the patient’s head just a little toward the side of the contact hand so that it does not slip off from its position. In order to perform longitudinal traction with both hands, he stands to one side level with the patient’s head. However, if the upper partner is the atlas or the occiput, side-bending is not necessary because, in these cases, contact is taken up with the transverse processes of the atlas (which jut out further) or with the mastoid process. The practitioner rotates the patient’s head slightly away from him; however, this rotation should be only minimal so as to avoid locking the segment to be treated. In this position, once the patient is completely relaxed, the practitioner takes up the slack with both hands simultaneously using minimal traction and delivers an HVLA thrust. The critical factor here is that both hands must operate as a single unit. Therefore the thrust must come from the whole trunk. When treating the atlanto-occipital segment, the patient’s head is rotated more to the side so as to lock the atlantoaxial segment (see Figure 6.53 B), and contact is taken up at the mastoid process.
Traction low-velocity thrust applied to the lower cervical spine and the cervicothoracic junction
The patient is seated on the treatment table with hands clasped behind her head and elbows wide apart. The practitioner stands behind the patient and threads his forearms through the triangle formed on each side by the patient’s upper arms and forearms. With the middle fingers of both hands placed over the forefingers to reinforce them, he takes up contact at the spinous process of the upper vertebra in the restricted segment (see Figure 6.54). He now instructs the patient to relax and let her head fall forward as he simultaneously presses with his arms against the patient’s forearms. He takes up the slack by gentle pressure of his fingers forward and upward against the spinous process, followed (in this case!) by a low-velocity thrust as he straightens up and increases the forward and upward pressure with his fingers. It is useful if the patient exerts slight pressure with her arms against the practitioner’s forearms.
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| Figure 6.54 |
This technique is most easily applied to segments C4–C7, and sometimes it is even successful at C3 (where there is increased lordosis). Caudal to C7 the pressure exerted by the fingers is insufficient to be effective. They therefore remain positioned in the lower cervical spine and continue to apply distraction there; however, the practitioner delivers the thrust using the upper part of his breastbone (the manubrium sterni) against the spinous processes of T1–T3. Both techniques are gentle and safe. However, they are not absolutely specific: the thrust is delivered to the upper vertebra in the restricted segment, while the lower vertebra is not fixed. Traction may therefore affect some of the more caudal segments. The practitioner’s fingers in the cervical region also produce some distraction but this should be inconsequential.
Rotation HVLA thrust with the patient seated
The patient is seated on the treatment table adjusted to a low setting and the practitioner takes up a position behind so that he is stabilizing the patient’s back against his chest. Using his mobilizing arm, he takes hold of the patient’s head between upper arm and forearm, so that the patient’s chin and face are in the crook of his elbow (see Figure 6.55). Leaning forward slightly, he spans the upper vertebra with the little finger of his mobilizing hand, while the thumb of his other hand fixes the spinous process of the lower vertebra laterally so as to keep it in a neutral position. The practitioner takes up the slack by carefully rotating the patient’s head while fixing the lower vertebra. He delivers the HVLA thrust with his mobilizing hand, mainly into rotation and traction.
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| Figure 6.55 |
Because the lower vertebra is fixed, this technique is highly specific. If fixation is correct, rotation is only minimal. Throughout manipulation the spinous process of the lower vertebra remains in a neutral position and the cervical spine undergoes kyphosis during traction in a cranial direction. Only if performed in this way is the technique safe and gentle. A similar, primarily mobilizing technique at the cervicothoracic junction has already been described (see Figure 4.34).
The craniocervical junction
Mobilization of the joints at the craniocervical junction is performed using precisely the same techniques as those employed for diagnosis. In this segment (C0/C1), inhalation has a facilitating effect and exhalation an inhibitory effect in all directions.
Anteflexion
After taking up the slack using the technique for examination (see Figure 4.37), the practitioner instructs the patient to look up toward the forehead, breathe in, and then breath-hold; he will clearly sense resistance against anteflexion and will often himself have to resist the patient’s automatic head retroflexion. He then tells the patient to look downward at the chin and to breathe out. Head anteflexion automatically follows. If facilitation is too pronounced on looking up at the forehead, it is sufficient (when repeating the procedure) simply to tell the patient to breathe in. The procedure can be repeated two or three times. This mobilization technique is the gentlest of all and therefore practitioners generally begin with it. The practitioner should check afterward whether the TrPs in the short extensors can still be felt.
Side-bending
Using the technique for examination (see Figure 4.38), the practitioner takes up the slack with the patient’s head rotated and in side-bending. The patient is instructed to look up toward the forehead, breathe in slowly, and then breath-hold. The practitioner will sense increased resistance to side-bending. Afterward he tells the patient to look down toward the chin and breathe out: all resistance to side-bending will spontaneously disappear. The procedure can be repeated two or three times.
Retroflexion
The practitioner takes up the slack with the patient’s head rotated and in retroflexion (see Figure 4.39). As the patient slowly breathes in deeply, resistance to retroflexion is felt to increase. After breath-holding, the patient is told to breathe out slowly and to allow her head to fall back. Toward the end of exhalation all resistance disappears and retroflexion clearly increases spontaneously. The procedure may be repeated once or twice. In this case, looking up to the forehead, that is into retroflexion, would be at odds with the increased resistance to retroflexion during inhalation, while looking downward would be inconsistent with the increase in retroflexion during exhalation.
It is recommended not to rotate the patient’s head more than 60°, especially in the elderly, and it is also helpful simultaneously to lift the patient’s head, which protrudes a long way beyond the end of the treatment table. Because retroflexion increases considerably during exhalation, the practitioner needs to hold the patient’s head quite high up (at the crown) because otherwise his own hand would be an obstacle to retroflexion. Retroflexion must never be actively amplified; usually it increases spontaneously to such an extent that, if anything, the practitioner needs to hold it back. This is therefore the most effective of all mobilization techniques between the atlas and occiput.
Recently we have started to use activation of the deep stabilization system to achieve mobilization. Stabilization in the craniocervical region is enhanced by carrying weights on the head. The following technique successfully exploits this principle: with the patient sitting upright, the practitioner places both hands on the crown of the patient’s head from both sides to exert very light, rapid, shaking pressure in the direction of the long axis of the cervical spine. It is important that the patient sits upright and that care is taken to avoid anteflexion–retroflexion and laterolateral flexion. This technique is ideal for self-treatment (see Figure 6.81 C); it also acts on C1/C2 and possibly on C2/C3.
Side-bending between atlas and axis
The examination technique (see Figure 4.29 A) is used to take up the slack in side-bending between C1/C2 (‘side-nodding’). According to Gaymans’ (1973) rule, C1/C2 is an odd-numbered segment; consequently, resistance to side-bending automatically increases during exhalation. Deep exhalation is followed by slow, deep inhalation. Toward the end of inhalation there is an abrupt reduction in resistance in the restricted segment. Here it is especially important to wait for the precise moment of relaxation. The practitioner should ensure that side-bending is limited to the top part of the cervical spine; the patient’s head here should rotate about an axis that passes through the radix nasi (root of the nose). In terms of joint mechanics, side-bending in the top-most part of the cervical spine produces rotation of the atlas in relation to the axis and, after Jirout’s maneuver, it is the most effective technique for restoring such rotation.
Mobilization techniques utilizing respiratory synkinesis are so effective in the region of the craniocervical junction that relatively more hazardous HVLA thrust techniques are indicated there in exceptional cases only.
6.2. Indirect techniques
This term is used to denote osteopathic techniques that are extremely gentle and yet effective at the same time; and it is these characteristics that justify their inclusion here. Use of the term ‘indirect techniques’ indicates that neither diagnosis nor therapy involves taking up the slack or engaging the barrier.
6.2.1. Johnston’s functional techniques
Functional techniques seek to bring the patient into a position in which good relaxation and pain relief are obtained. Once this objective is successfully achieved, it is found that painfully increased tension gradually dissipates in other positions too.
Functional techniques are based entirely on palpation and therefore it is difficult to capture their essence in writing. I will therefore do my best to help the reader to understand this concept. Palpatory examination may reveal increased tension (spasm) on one side of a lesioned spinal segment in the vicinity of the erector spinae; this appears as an area of prominence and it creates a palpatory illusion suggesting rotation toward the side of the area of prominence (increased tension). If a patient with such findings is now bent forward, backward, and to the side, the practitioner will feel that this increased tension, and hence asymmetry of muscle tone, becomes more apparent following movement in one direction, and more balanced following movement in another direction. In terms of joint mechanics, it should be borne in mind that on side-bending of the spinal column, the joint on the side of lateroflexion moves as it were into extension while that on the opposite side moves as it were into flexion (see Figure 4.5).
Treating the lumbar and thoracic spine
When the lumbar and thoracic spine are being treated, the patient should be seated with both hands clasped behind the neck; with one hand/forearm the practitioner stabilizes the patient, as illustrated in Figure 4.21. With his other hand he palpates with thumb and forefinger in the segment where the tension imbalance between the two sides is greatest, that is where there is a palpatory illusion of rotation. He next establishes whether the tension imbalance diminishes in anteflexion or retroflexion. When this happens the practitioner will experience the palpatory illusion that the spine is ‘de-rotating.’ For example, if tension becomes balanced in retroflexion, then it follows that side-bending toward the side of the spasm will have a beneficial effect; and conversely, if anteflexion restores balanced tension, then side-bending in the opposite direction will alleviate spasm, and this is generally associated with freedom from pain.
In practice, the procedure is as follows: for example, if the practitioner finds that the tension imbalance is reduced in retroflexion, he should move the patient into maximum retroflexion with bending toward the side of the spasm. The patient’s trunk should be supported as effectively as possible so as to enhance relaxation. If tension in fact becomes balanced in this extreme position (wait to see if this happens), the practitioner slowly rocks the patient out of side-bending and maximum retroflexion and back into a neutral position. However, as soon as the tension reappears, he should return the patient to the relief position and make another attempt, taking care to progress slowly in this manner. As a rule, after a few rocking maneuvers back into the neutral position and some anteflexion, the tension will disappear with the result that, after a few repetitions, even full anteflexion and bending to the opposite side are tolerated. The palpating hand will always indicate whether the practitioner has ventured too far, i.e. whether it would be right to go back a step or to proceed further.
The same principle applies if anteflexion brings tension symmetry (‘de-rotation’). In this case the practitioner should work toward achieving a normal balance of tension in anteflexion (see Figure 4.22) and side-bending to the opposite side, and rock the patient carefully back to the neutral position and retroflexion until no further tension imbalance is evident on full retroflexion.
Treating the cervical spine
A similar approach is adopted when treating the cervical spine. As he stands beside the seated patient, the practitioner uses one hand to move the patient’s head into anteflexion, retroflexion, and side-bending; between the thumb and forefinger of the other hand he palpates next to the spinous processes the muscles that lie behind the transverse processes.
The following technique is even more effective: as he stands in front of the patient, the practitioner supports the patient’s forehead on his chest and palpates with both hands either side of the spinous processes (in this way he can use both hands to stabilize the patient’s head and neck). By raising or lowering his own ribcage, he then moves the patient’s head, taking it into anteflexion, retroflexion, and side-bending while simultaneously palpating the paravertebral muscles with his hands.
Once again, the practitioner starts by identifying the side and the segment affected by increased tension and then tests whether this finding is accentuated or diminished in anteflexion or retroflexion. If tension decreases in retroflexion, he moves the cervical spine into retroflexion and side-bending toward the lesioned side, and waits in this position until all tension disappears. Then with gentle rocking movements, he reduces retroflexion and side-bending, always supporting the patient’s head against his chest. He repeatedly returns to the relief position as soon as he notices that increasing anteflexion causes tension to reappear, until finally full anteflexion and bending to the opposite side are well-tolerated. Conversely, if tension is relieved on anteflexion, he performs the treatment the other way round (i.e. anteflexion and side-bending to the opposite side, followed by retroflexion and side-bending to the lesioned side).
This method is extremely gentle and safe and is always most agreeable to the patient. However, it is not easy to illustrate and teach with words alone because it depends entirely on the palpation skills of the practitioner.
6.2.2. Strain and counterstrain
This method has much in common with Johnston’s functional techniques in that it does not engage the barrier and seeks out positions that afford pain relief. The best experiences with strain and counterstrain techniques are obtained in acute lesions where most other traditional methods have failed. Indeed L H Jones, the originator of the strain/counterstrain method, tells how he was called to treat an emergency case involving a patient who was unable to straighten up from flexion because of psoas spasm and could not find any relief position. On examination, however, Jones found that relief could be obtained when the patient was brought into a position of 45° of rotation and 30° of lateral flexion. He then went away to treat another patient. When he returned to his emergency case, he found that the patient was able to straighten up completely.
In his original publication, Jones (1964) explained the rationale for his method, and this corresponds to the situation that is frequently observed in acute lesions: the patient picks up an object lying on the floor, usually bending forward to one side, and then straightens up (too) quickly out of anteflexion–rotation. It is conceivable that during this brisk movement something becomes caught or trapped. If we now help the patient to go back into the original flexed position and exaggerate this a little, then wait in this position before very slowly returning the patient into a neutral position, we give the impinged tissues the opportunity to slip out from their entrapment.
An essential prerequisite is to find the position of relief – information that is frequently volunteered by the patient. However, Jones noted objectively that this process can be used to eliminate the most varied pain points in the muscles, on the thorax close to the midline, and on the abdomen usually more to the left side. Once the patient has been slowly brought into the relief position thus found, it can be exaggerated a little, provided that the patient tolerates this. The patient then remains in this position for 90seconds. Afterward the patient is allowed to return (slowly!) to a neutral position.
As a routine method this technique is time-consuming and cumbersome. However, in a simplified form it is to be highly recommended in emergencies; and sometimes it is the only treatment method that is of help to the patient. It is employed most frequently in acute low-back pain and to treat radicular pain. For this, use is made of the positions (in anteflexion and retroflexion) that the patient adopts when performing McKenzie exercises (see Section 6.5.3). However, in each case, the position must be held for 90seconds. A similar procedure may also be followed in acute cervical myalgia, that is the left-sided rotation and bending into mild flexion that is usually present can be slightly exaggerated and held.
This technique has proved especially useful in instep pain where no movement restriction or TrPs are found and which develops sometimes on pronation and sometimes on supination of the foot. In such cases maximal supination or pronation in the direction of relief is the treatment of choice. On each occasion the position must be held for 90seconds, followed by a slow return to a neutral position.
6.3. Exteroceptive stimulation
(by H Hermach)
6.3.1. Tactile perception and muscle tone
Even though an unborn child in the womb already reacts when its mother’s abdomen is touched, tactile perception can properly be said to develop only after birth. In the very early stages a large part of a baby’s body surface area is in intimate contact with the floor or other support surface. Soon, however, growing babies start to support themselves on their arms and legs and on only limited areas of their trunk, until finally they stand up and support themselves only on the small surface area of the soles of their feet in contact with the ground. In adults, however, it is more common for the caudal end of the trunk to be the main support structure!
Tactile contact over large areas of the body, for example caressing and stroking, has a pleasant and calming feel to the child. However, if the child reacts to stroking by crying, this is a warning sign of unfavorable motor development. It can be a sign of increased tension in impending spasticity.
The size of the support surface of a child or adult will indicate whether muscle tone is increased, normal, or reduced. Starting from the contact area and our ability to use this, we develop the ability to push off from the support surface and return to it. The way in which individuals react to their surroundings in response to contact with their body surface indicates whether they accept this or reject it, how they interpret it, and whether their reactions to environmental stimuli are appropriate or not.
Our skin plays a major role in the processing of information we receive from the world about us; and it is on the basis of this information that we form an image of the space surrounding us and also of our own bodies. Pre-eminently it is our skin and sense of touch that enable us to differentiate between ‘self’ and ‘non-self’ out there. How much room does ‘self’ take up? A disordered or inadequate tactile sense disturbs our orientation in space and our understanding of the position that we occupy in it. And this necessarily has repercussions in the sphere of movement, that is in the locomotor system.
What we feel is closely related to our psyche. What we feel is interpreted, understood, grasped. And this interpretation also shows how we perceive the world, whether as agreeable, friendly and open (so that we open ourselves up to it in turn), or as disagreeable and hostile as we come into contact with it.
If we feel that touch or contact on our skin is agreeable, then contact with the world around us is welcome and we seek it out. Of course, the converse also applies. Hence our sense of inner security and our feelings of insecurity in a spatial sense when moving about are interconnected.
The more precisely we perceive, the better able we are to discriminate. The ability to discriminate precisely bears testimony to precise perception, and our tactile discriminatory skills tell us where we are. Reactions are shaped and behavior develops depending on the quality of our perceptive skills and how we interpret what we perceive.
Our skin’s sensation of touch also has implications for our locomotor system. These implications are so immediate because the sensitivity of our skin is linked to its tension, which in turn is connected with the tension of the subcutaneous connective tissues and of the muscles. Increased skin sensitivity is generally associated with increased tension in all tissues, including the muscles, while reduced sensitivity is linked with hypotonus. However, because sensations in the individual can be widely different, the symptoms can also be different. This explains why the skin may also be tense when sensitivity is reduced. Such a phenomenon may be the consequence of a reaction by the body as a whole to inadequate stimuli (information).
It is therefore extremely important that we are able to intervene at the level of the sense of touch. Our skin has the capacity to learn how to perceive more or less, or even how to perceive better. And we can do this by altering the tension of the skin, subcutaneous tissues, and muscles.
All of the above can be put to good use in the setting of treatment. Appropriate, discriminating sensation goes hand in hand with normal skin and muscle tone. The capacity of a muscle to alter its tension in a discriminating way is an expression of good coordination. Good tactile perception goes hand in hand with well-coordinated movements. If we succeed in the course of treatment in achieving well-balanced tactile perception, then it is no exaggeration to claim that the patient’s movements will then be optimal – coordinated and with good spatial orientation. In order to capitalize on this, we need to learn how properly to examine the tactile sensibility of the skin.
6.3.2. Assessing altered tactile perception
The assessment of tactile perception has much in common with neurological sensibility testing. Our prime assessment tools are our fingers and the dorsal surface of our thumb nail. In the process, we assess how the patient reacts, whether the response is appropriate, and how the patient behaves. We can stroke or scratch, only lightly or even intensively, depending on the part of the body being examined. It is a good idea to begin abruptly so as to provoke a clearly discernible reaction. After a few repetitions, the reaction will change as the skin adapts to the stimulus. Failure of adaptation to materialize is a sign of hypersensitivity.
The response to a stimulus may be merely local or it may also be generalized. A reaction may also be absent. In general, the more intense the general reaction, the less appropriate it will be. Absence of a local reaction is indicative of reduced tactile perception. The reaction may also be appropriate, or it may be exaggerated, as a sign of hypersensitivity. This may manifest itself as ticklishness, and even as pain.
Paradoxical reactions may also be encountered: instead of pulling the sole of the foot away when tickled, the patient may breath-hold and tense the thoracic muscles. Sometimes a patient will develop goose bumps merely at the mention of tickling the soles of the feet.
The most telling signs of a generalized reaction are altered respiration and sweating. These are indicative of instability in the organism as a whole, and the changes in respiration can also affect motor activity. Due consideration must also be given to the patient’s personality and cultural background and to whether current stress might be a factor. There are moments when all of us may react in an exaggerated manner.
6.3.3. Normalizing tactile perception
Sensitivity for tactile stimuli is anything but constant; it alters and adapts rapidly. Sensitivity in response to stroking may also alter in the long term. This means that the skin learns to feel and to discriminate, and as a result the patient learns to interpret.
The effect of a great many massage techniques is also based in part on tactile stimulation, and they can be applied with this in mind, provided that they are gentle and primarily have a surface effect. Brushing is another method that can safely be used in patients with diminished tactile sensitivity. In patients in whom altered tactile perception is expressed as algodynia or hypersensitivity, we must seek to use a technique that is agreeable to the patient or is at least felt to be tolerable. If treatment is felt to be disagreeable, it will provoke a defense reaction that will preclude any successful outcome.
Treatment in patients with altered tactile perception begins in principle with slow and gentle stroking over large areas of the body. Tickling must be avoided. Our hand will provide feedback because it will ‘pick up’ changes in the tension of the skin, subcutaneous tissues, and muscles. As long as the findings improve, we may continue. If this is not the case, then we have failed to understand our task correctly or else the stimulus was too weak. If improvement fails to materialize, we must stop, review the diagnosis and decide whether the stimulus was the correct one. Stroking is generally performed along the long axis of the body, but may also be transverse to the long axis at the buttocks, or diagonal on the abdomen.
If the skin is hypersensitive, we have two options: we can continue stroking through a fine fabric or else the patient can self-stroke for a few minutes each day until the touch of the practitioner’s hand can be tolerated.
If the skin is hyposensitive, we can intensify the stimulus by stroking more quickly, changing pressure and direction, or using a hedgehog ball, brush, or towel. However, we should understand that good tactile perception permits a response to tiny stimuli that can never be achieved with coarse stimuli.
In order to achieve good coordination, a muscle must be able to interact with other muscles as soon as tension changes. Heightened or diminished muscle tonus should not persist anywhere. Each muscle should be capable of relaxing and adapting to modified circumstances. If we have successfully altered muscle tonus using any method, then this means that well-coordinated movement has resulted without the need for special exercises and the correction they bring. If our own experience suggests that we have successfully normalized the tone of the muscles and subcutaneous tissue simply by stroking, then coordination will also improve, along with locomotor system function in every respect.
6.3.4. Altered superficial tactile perception following surgery (due to scarring)
When assessing the tactile perception of the skin, we must also take account of any active scars that may be present. To determine the sensitivity of a scar, we ‘fold’ it a little. If the patient feels pain when we do this, hypersensitivity is present. If sensitivity remains unchanged after stretching and mobilization (see Section 5.2.2), then the pain point is more deep-seated.
It is not sufficient to assess the sensitivity of the scar alone. Surgery may also damage cutaneous nerves, in which case hypesthesia will be present, but sometimes also paradoxical hypersensitivity. In both cases we should attempt to improve sensibility. As long as this is abnormal, then the tone of connective tissues and muscles will remain abnormal, as will their reactions. This tactile perception deficit may be indicative of muscle spasm, which means that the patient has insufficient muscle control. Hypersensitive skin may also be associated with paresthesia and even pain (sometimes referred pain).
Hypersensitivity can be so intense that the patient cannot even bear contact with clothes. This condition is known as ‘clothing sensitivity,’ and the patient may also demonstrate a powerful emotional reaction. In such cases we should perform stroking through a sheet of fabric, or the patient should be encouraged to self-stroke daily until being touched by someone else’s hand becomes tolerable. And even if the sensitivity of the scar has been restored to normal, the patient must repeat the stroking as soon as hypersensitivity returns.
The muscles beneath the active scar are usually hypertonic and painful. These aspects too may also improve as soon as normal cutaneous tactile perception is restored.
Cutaneous tactile perception differs not only from person to person but also depending on body region and age. Infants recognize objects and first touch them with their mouths, and only later with their hands. Soon, however, they also use their feet to feel objects until they stand up and start to toddle. In that phase the foot serves as a support but it is by no means passive: the body reacts to the surface on which its stands to adopt an erect posture.
As is well known, the tongue, mouth, hands (especially the thumbs), and feet are served by large areas of the sensory cerebral cortex. They play a pre-eminent role in tactile perception, and therefore changes in sensibility in those regions result in changes to overall behavior.
The tongue and mouth
The tongue tends to be examined in exceptional cases only. However, it must be examined in young children with behavioral abnormalities: the findings often reveal a restless or, on the contrary, an immobile tongue. Examination is also necessary in cases where the mandible and lips are restless or the patient’s mouth is constantly open. A moistened finger is used for the examination. Where hypersensitivity is present, the tongue will react with a twitching defense movement or else gagging is provoked simply when the tip of the patient’s tongue is touched. In the case of a tongue where there is no reaction, indicative of reduced sensitivity, the tongue, lower jaw, and oral cavity can be stroked with a moistened finger. Adult patients may do this for themselves; for toddlers and children, the parents should be instructed how to do this. It is necessary to proceed with caution owing to the ever-present risk of vomiting.
The hands
It is not easy to assess the sensitivity of the hands. This is probably because the hands themselves are constantly touching objects and working on them. For the examination, the patient is seated in a relaxed position with palms facing upward. In this position, tension of the flexors is the dominant feature. Therefore the fingers are generally in slight flexion. The practitioner should surprise the patient by suddenly scratching one palm. Usually the patient will rapidly jerk the fingers away before returning them to their original position. One sign of hypersensitivity is finger extension, especially if this recurs when the test is repeated. The most effective therapy is stroking or a repetitive activity such as moving the fingers in a bowl of rice, kneading dough, or model-making with Plasticine®. Patients with hypersensitive hands are generally creative but they need to learn to relax their hands.
The feet
An assessment of the sensitivity of the feet should form part of the routine patient examination. The feet play a key role in human upright posture and they are significant for the function of the spinal column. For the examination, the patient should be supine, with legs slightly flexed over a pillow placed behind the knees. Without warning the patient, the practitioner uses his fingernails to simultaneously stroke the soles of both the patient’s feet, from heel to toe in the direction of the big toe. Where tactile perception is normal, the patient will attempt to move away a little from this touch, by slightly increasing knee and hip flexion, dorsiflexing the feet, and flexing the toes a little. It is not uncommon for the observed reaction to be asymmetrical, and this is clinically important. When asked, the patient will also report asymmetric sensitivity.
If the patient does not react at all, this indicates that the foot is not capable of responding appropriately during standing and walking because it is unable to receive information from the terrain. An exaggerated reaction, for example involving the whole body, shows that the foot is not able to adapt to the floor or ground because it is processing the information incorrectly. Therapy consists of stroking and a combination of superficial and proprioceptive stimuli as the practitioner traces numbers and letters on the patient’s soles. Patients can stroke or brush their own soles and walk barefoot on the lawn at home or on a shingle beach.
If the practitioner detects asymmetric sensitivity of the feet, he should also screen for asymmetries in other body regions – lower legs, thighs, abdomen, thorax, arms, and face. In this way it will be possible to identify asymmetry involving the whole body, something that occurs particularly when one side of the body is markedly dominant. Such asymmetry will affect the locomotor system as a whole. The patient then needs to become aware of the ‘forgotten side of the body’ and learn to use it too. Once again, therapy consists of stroking the less sensitive body side (and the patient can also do this independently). However, it is important to establish with certainty whether and when symmetry is restored.
The abdomen
Ticklishness, especially on the abdomen, is also a sign of hypersensitivity. This usually goes hand in hand with increased muscle tension. As a result, coordination, respiration, and spinal function are also disturbed. Ticklishness is linked with nociception and therefore also with TrPs. It is a precursor of pain.
6.3.5. Individual characteristics of perception
The reactions of all patients also need to be assessed in the context of their personality. What appears to be exaggerated may be entirely normal in a highly-strung person. In someone with a very calm temperament, what seems to be normal may already be an indication of hypersensitivity. The practitioner needs to listen to the patient very precisely – the patient’s own words will betray the underlying attitude toward pain – and simultaneously observe the patient’s behavior. Thus, an unusual reaction may ensue following simple skin contact because there is a disturbance at the emotional level, something that may be found in unloved children, even persisting into adulthood.
Differing sensitivity on one side of the body means that the patient has a false perception of body center and hence of the immediate surroundings. Objects seem to some extent less real on the side of diminished sensitivity, explaining why the patient may bump into things more often on that side. This sensitivity imbalance is often associated with emotional lability. As soon as the patient learns to be aware of the whole body and to use the side on which sensitivity was originally diminished, there will be an increase in self-confidence.
Normal sensitivity of the feet is also a prerequisite for good balance and hence for a sense of security. Where such security is absent, the patient will seek to maintain balance through exaggerated activity of other muscle groups, for example in the pelvis and lumbar region, diaphragm, thoracolumbar junction, shoulder girdle, and those involved in mastication. These disturbances of muscle function generate characteristic chain reactions. Individuals with hypersensitive hands are often excessively neat and tidy, with a tendency toward perfectionism.
6.3.6. Self-treatment
Patients can use the following self-treatment techniques to restore a balanced pattern of skin sensitivity:
• Stroking themselves with their fingers.
• Stroking themselves with a towel.
• Rolling a soft rubber ball or tennis ball with their feet.
• Walking on pebbles or hot charcoal.
• Wriggling their fingers in a bowl of rice or peas, etc.
• Lying on a mattress filled with small plastic balls, chestnuts, or other nuts; children may play with balls or chestnuts in a bath containing just a little water.
• Brushing to stimulate the skin.
The prime goal of therapy is to reintegrate the region of diminished or heightened sensitivity into the overall body pattern. There are right-handed people who need to learn how to use their left hand too. Many patients have to re-learn how to walk barefoot or how to roll down a grassy slope (‘roly-poly’ fashion), and others have to be made aware of their thorax.
6.4. Soft-tissue manipulation
As with joints, we examine mechanical function in order to assess elasticity, mobility relative to other structures, and mutual patterns of displacement. The importance of soft tissue is evident from the simple facts that the locomotor system as a whole is embedded in soft-tissue layers, that connective tissue elements are also present in muscles themselves, and that the mutual mobility and displacement of all these structures is made possible by soft tissue. Indeed, motion of the locomotor system proper would not be possible if, starting with the skin, all the aforementioned structures and tissues were not freely mobile or capable of relative shift and stretch. The same applies to the visceral organs, especially in the abdominal cavity. Some of these movements involve quite considerable excursions. Consequently, soft-tissue function needs to be examined diagnostically and treated.
The technique is characteristically uniform for all soft tissue, but differs from most forms of massage in that on each occasion, whether we wish to stretch or shift, we first take up the slack (engage a barrier), and then, without much change in pressure (pull), release occurs after a brief latency period. Release itself may take from a few seconds to half a minute or longer. The practitioner’s role is to sense this. If the release process is cut short prematurely, we will be depriving ourselves of the best possible treatment outcome. During this period of release it may be helpful to slightly modify both the direction and the intensity of pressure (pull). It must never be forceful, and the patient should never feel pain.
If muscles and joints are to move, then the surrounding soft tissue also needs to shift and stretch with them. This capacity for concomitant movement may be disturbed, with adverse repercussions for the locomotor system as a whole.
6.4.1. Skin stretching
As explained in Section 4.3.2, a small area of the skin can be stretched between two fingertips; larger skin areas can be stretched between the practitioner’s thenar eminences or between the ulnar aspects of his palms with hands crossed. Stretching should be performed with a minimum of force, so as to take up the slack. Under normal circumstances a springing resistance will be felt.
If there is a hyperalgesic zone (HAZ), the slack is taken up sooner and there is much less spring. If the skin is then held in this end position, resistance weakens after a brief latency period until the physiological barrier is reached and normal springing is restored (see Figure 6.56). The HAZ is then usually no longer detectable. If the HAZ is the cause of pain, this stretching method is quite as effective as needling, electrostimulation, and similar treatments. Moreover, it is painless and well suited for self-treatment. The effect can even be measured. The method is particularly suitable for small skin areas where a fold cannot be formed, for example between fingers and toes, in radicular syndromes, or in the region of the carpal tunnel if the skin there is taut.
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| Figure 6.56 |
6.4.2. Stretching a connective tissue fold
Folds of soft connective tissue are usually formed between the thumb and forefinger of the practitioner’s two hands; in this way he can produce pull or stretch (but never compression!) and take up the slack. The stretch is held and, after a brief latency period, he will notice that the tissue fold stretches (relaxes) until the physiological barrier is reached (see Figure 6.57). This technique is appropriate for treating HAZs in the subcutaneous tissue and especially for scars with active interference zones (pain points). It is particularly suitable for stretching taut muscles where the connective tissue element is shortened. In the case of large muscles, such as the ischiocrural group, the fold is produced between the palm of one hand and the fingers of the other. This is probably the most effective way of obtaining muscle stretch while avoiding the stretch reflex (‘cross-stretching’).
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| Figure 6.57 |
6.4.3. Sustained application of pressure
In locations where a fold cannot be formed, pressure may be exerted with fingers, thumb, or even the elbow (see Figure 6.58). Here, too, the practitioner takes up the slack using the very minimum of pressure, and after a brief latency period he will notice that the tissue starts to yield and his finger sinks into the deep layers until a new barrier is reached. In the process both the intensity and direction of pressure can be modified slightly. This method is most effective for eliminating TrPs, for example in the erector spinae and the gluteal muscles; it can also be applied by a pincer movement between two fingers, for example in the sternocleidomastoid. The sustained application of pressure is also useful in treating deep, contracted scars where it is impossible to form a skin fold.
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| Figure 6.58 |
6.4.4. Shifting (stretching) the deep fascia
The most important task of soft-tissue manipulation appears to be restoration of the normal mobility of the fascia. Once again, the technique is similar to those described above: after taking up the slack, the practitioner waits until release occurs and the tissue can be shifted in relation to the structure beneath. Many of these techniques were originally elaborated by R Ward (personal communication, 1989). It is worth emphasizing here that restrictions in the mobility of the deep fascia are a sign of a chronic disease stage.
Shifting the deep lumbar fascia caudally
The practitioner takes up a position to one side of the patient, who is prone with feet protruding over the end of the treatment table. He starts by comparing the extent to which the soft tissue can be shifted caudally on both sides. He then instructs the patient to press the toes on the side to be treated against the edge of the table, to stretch out the arm on that side as far as possible with fingers splayed, and to turn the head so as to look toward the side being treated (see Figure 6.59). The practitioner next uses one hand to exert pressure on the gluteal muscles in a caudal direction while his other hand fixes the thoracolumbar area from above. Once the slack has been taken up, he instructs the patient to breathe out (thus increasing resistance to the pressure being exerted caudally), then breath-hold, and breathe in slowly. Inhalation is accompanied by release, caudal shifting of the lumbar fascia, and stretching. The procedure is repeated three or four times. If satisfactory release fails to occur, it can be helpful if the patient gives a cough. After this treatment the shifting qualities of the lumbar fascia on both sides will be symmetrical and the practitioner will notice a blush sign at the treated site. The movement restriction need not necessarily be on the painful side.
Shifting and stretching the dorsal fascia cranially
The practitioner takes up a position to one side of the patient who is prone with feet protruding beyond the end of the treatment table. He starts by comparing the extent to which the soft tissue can be shifted cranially on both sides. He then instructs the patient to press the toes on the side to be treated against the edge of the table, to stretch out the arm on that side as far as possible with fingers splayed, and to turn her head toward the practitioner. With one hand placed at the level of the shoulder blade, the practitioner shifts the soft tissue cranially to take up the slack, while his other hand fixes the soft tissue in the thoracolumbar region using downward pressure toward the treatment table (see Figure 6.60). He next instructs the patient to breathe in deeply, breath-hold, and then breathe out slowly. Release occurs while the patient is breathing out. The procedure is repeated several times. If release is not satisfactory, the situation can be helped by asking the patient to cough.
Stretching the fascia on both sides of the trunk
This technique is indicated where side-bending is restricted due to muscle shortening. For diagnosis and treatment, the practitioner takes up a position behind the patient, who is seated. On the side to be treated, the patient raises her arm above head height and bends it at the elbow. The practitioner takes hold of the elbow with one hand while his other hand fixes the patient’s hip from above. He takes the patient into side-bending over his thigh, which is supported on the treatment table, until the slack has been taken up (see Figure 6.61). He then tells the patient to look up and breathe in deeply, breath-hold, and then look down and breathe out. Stretching occurs after a brief latency period. The procedure is repeated two or three times.
Rotational shifting of the fascia around the thorax
With the patient supine, the practitioner examines and mobilizes the soft tissue around the thorax, particularly on the lateral surface, in a ventromedial direction (see Figure 6.62 A). He palpates for resistance, usually on one side, and makes a comparison with the other side. In the direction in which he feels resistance (a pathological barrier), he takes up the slack during inhalation and senses the release during exhalation. During mobilization, it is helpful for the practitioner to guide the patient’s hand with his own so that the patient can feel the barrier and release first hand, and then continue the (always agreeable) self-treatment at home (see Figure 6.62 B). Clinically, this dysfunction is especially common and significant in the setting of pain in the region of the shoulder and shoulder blade.
In a similar way, in patients experiencing pain in the inguinal region, the shifting qualities of the soft tissue relative to the pubic bone may be reduced. In all such situations, the treatment is fundamentally the same: the practitioner takes up the slack in the direction of increased resistance. This is then held, after which release is obtained and the barrier is restored to normal.
The same also applies for the shifting quality of the buttocks in a caudal-to-cranial direction: the practitioner takes up the slack on the side of increased resistance by exerting pressure in a cranial direction and then, after a brief latency period, release is obtained.
The scalp
In clinical terms, the scalp behaves like a deep fascial layer. Restricted scalp mobility may cause headaches as well as vertigo in conjunction with the cervicocranial and mandibulocranial syndrome. For diagnosis, the practitioner examines the mobility of different scalp areas in different directions in relation to the skull beneath and compares the two sides. Here, too, pathological barriers can be identified: once the slack has been taken up, the typical release phenomenon follows. Examination is generally performed using the pad of a single finger although this may easily slip off the patient’s hair. The practitioner supports the patient’s head with his non-palpating hand.
Fascia at the neck and the extremities
The soft tissue (fascia) at the neck and in the cervicothoracic region can be examined and treated by applying a rotational movement around the long axis of the neck. The practitioner stands behind the seated patient, places one hand round the patient’s neck from behind, and applies a rotational movement to detect increased resistance in one direction (see Figure 6.63). He takes up the slack in that direction and, after a brief latency period, release is obtained as the patient breathes out. Treatment may be applied in the direction of the thumb or of the fingers; treatment in the direction of the thumb is more specific while that in the direction of the fingers covers a larger surface. With his free hand the practitioner fixes the patient’s head.
At the cervicothoracic junction, the same technique can be employed if the patient is extremely slim; in most cases, however, the practitioner will need to take hold of the cervicothoracic junction with both hands and rotate the soft tissue around a vertical axis. Here it is also possible to perform a wringing action with one hand against the other. In each case, the barrier is engaged and then release is obtained.
Treatment of the extremities proceeds in a similar fashion. Soft-tissue rotation about a longitudinal axis can be tested and treated; once the (pathological) barrier has been reached, a wringing movement is performed with both hands in opposite directions. The commonest pathological barriers are detected around the elbow, wrist, knee, and ankle.
Heel pain
In cases of painful calcaneal spur, it may be found that at least in one direction the soft-tissue pad at the heel is less readily shifted than on the other side. As soon as the practitioner detects the pathological barrier, he takes up the slack and then overcomes the resistance to restore normal tissue mobility. Usually it is necessary to apply strong (lateral) pressure in the immediate vicinity of the bone using both thumbs while fixing the heel with the other fingers (see Figure 6.64).
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| Figure 6.64 |
In cases of heel pain around the attachment point of the Achilles tendon, the soft tissue between the tendon and the bones of the lower leg is tender to the touch. In such cases, this tissue must be folded and stretched between the fingers. For this, the patient is prone with the knee flexed. The practitioner stabilizes the patient’s lower leg against his body. He applies pressure with the finger of one hand just above the heel and with the thumb of his other hand a few centimeters further proximally. He then repeats the procedure in the opposite direction (see Figure 6.65). For this, it is necessary to position the thumb flat because there is only minimal space between the Achilles tendon and the tibia. After the slack has been taken up, the fold will stretch during release.
6.4.5. Mutual shifting of metacarpal and metatarsal bones
In radicular syndromes radiating to the fingers (or toes), stretching is not limited only to the skin between the fingers (toes); generally there is also increased resistance (‘bind’) if we try to move one metacarpal (metatarsal) bone against the next, in a dorsopalmar (dorsoplantar) direction. This resistance does not stem from any joint but from the soft tissue between the individual bones. As soon as the practitioner detects increased resistance compared with the other side, he uses a pincer hold (see Figure 6.7) to engage the barrier, and once the slack has been taken up, he waits for release.
The restricted fibular head can be treated in the same way and for the same reasons (see Section 6.1.2, Figure 6.25).
6.4.6. Painful periosteal points
Pathological barriers are also encountered at painful periosteal points, most frequently in the vicinity of attachment points of ligaments and tendons; these barriers are characterized by restriction of subperi-os-te-al tissue on shifting, in at least one direction. It is always necessary to make a comparison with a symmetrical painless area on the non-affected side. Thus, on examination of the epicondyles, it is normally possible to shift the soft tissues easily in all directions; however, when pain is present, shifting is generally restricted in at least one direction. This signals the presence of a pathological barrier, which is indicated by an abrupt end-feel that is devoid of springing. Once the barrier has been engaged, release can be obtained after a brief latency period. After mobilization, the patient experiences relief from pain. Shifting always occurs in a tangential direction and is therefore painless. Pressure is never applied directly to the periosteal point itself (see Figure 6.66).
This technique is also important, for example, in cases where the spinous processes are painful, particularly in the lower lumbar region in hypermobile patients. It is worth emphasizing that the pain point on the spinous process is never precisely in the midline, but always slightly to one side. On the side of painful tenderness, deep pressure ventrally (i.e. parallel to the spinous process) will encounter greater resistance than on the non-painful side. These areas represent painful attachment points of the short intervertebral muscles. Accordingly, the practitioner takes up the slack using downward pressure applied with a fingertip; as the pressure is held, release is obtained.
In the very frequently encountered condition where the spinous process at the axis is tender, the pain point is also located to one side; this is revealed by axis rotation following side-bending of the patient’s head to the non-painful side. In this case it is usual for the mobility of soft tissue to be clearly restricted in a caudal or cranial direction. Therefore the practitioner fixes the patient’s head in side-bending, with his free hand palpates the pain point lateral to the spinous process, and takes up the slack in the direction of the restriction. Release is obtained after a brief latency period. The procedure is repeated and the pain is usually found to have been alleviated.
Another extremely common pain point is at the PSIS, a lateral projection on the iliac crest that runs obliquely in a ventral direction. Soft-tissue mobility in this direction is tested and treated tangentially. A similar procedure may be followed for the pes anserinus and the styloid process of the radius, etc.
6.5. Self-mobilization
A crucial factor contributing to the successful outcome of manual therapy and, in the broader sense, of rehabilitation is the patient’s active cooperation in the therapy. It is in this setting that predominantly passive therapy is transformed into a learning process. Even in the neuromuscular mobilization techniques, the patient’s role is not merely a passive one; however, the patient’s activity unfolds in response to the precise instructions and prompting of the practitioner. The next step on from this emerges with compelling logic: what patients can do in response to the practitioner’s instructions, they should surely be able to learn to do for themselves. And here we have the seamless transition from therapy to rehabilitation. Ultimately, the locomotor system is the organ of active movement, and for that reason alone, normal and painless active movement is the key criterion for treatment success.
It is, of course, nothing new to use our own muscles to stretch and limber up if we are feeling stiff. Engaging in forceful, non-specific movements is frequently problematic and may do more harm than good. Movement restriction is routinely associated with muscle spasm that specifically protects the lesioned motion segments. Forceful movement suddenly applied to those segments is likely only to increase spasm, with the actual end result being that the normal and even the hypermobile segments are mobilized, while the lesioned segments are fixed even more firmly by muscle spasm. Self-mobilization techniques must therefore be gentle and slow (as in passive techniques after the slack has been taken up) and as specific as possible. Precise diagnosis (location) is mandatory, as is careful work to establish the indication for treatment.
6.5.1. Self-mobilization by stretching
It is entirely possible for the patient to stretch an area of skin, and to fold and stretch the subcutaneous tissue, provided that the HAZ is within reach of the hands. It should also be possible for the patient to rotate or wring the deep fascia at the extremities, and around the neck and thorax. The scalp and heel are other areas that are accessible to self-treatment. The same is true for periosteal points. However, self-treatment of the deep fascia on the back is problematic. The literature contains accounts of a wealth of stretching exercises (Anderson, 1980), and good fixation is an absolute prerequisite for these. Two such techniques will now be described.
To stretch the lateral fascia on the trunk, the patient stands with legs apart and one arm raised and flexed behind her neck. With her other hand she takes hold of the raised elbow behind her neck and draws her entire trunk into side-bending to take up the slack (see Figure 6.67). She then looks up and breathes in, causing resistance to side-bending to increase. After breath-holding she looks down, breathes out, and simultaneously increases side-bending by pulling on her elbow. This procedure can be repeated.
A similar technique is also suitable for the cervical region. The seated patient stabilizes herself with one hand holding the edge of the treatment table or a chair to fix her shoulder; with her other hand she reaches over the top of her head and, tilting it slightly forward, draws it sideways to take up the slack (see Figure 6.68). She then looks up, breathes in, and breath-holds for a short time, causing the tension to increase. She then looks down, breathes out, and draws her head further sideways.
6.5.2. Self-mobilization of the sacroiliac joints
Sachse’s technique for self-mobilization
The patient is on all fours close to the edge of the treatment table. One of her knees hangs over the edge of the table, and her instep on that side is hooked over her other leg just above the heel. In this position, if she is properly relaxed, the weight of the overhanging leg with the pelvis brings pressure to bear on the supporting knee and, via the thigh and hip joint, causes the slack to be taken up in the sacroiliac joint on the supported side (see Figure 6.69). The moment the well-relaxed patient senses tension in the region of her sacroiliac joint, she makes a very small downward springing movement with her knee hanging over the edge of the treatment table, moving in a vertical direction, thus amplifying the feeling of tension in the sacroiliac joint when she moves up. This mobilizes the sacroiliac joint on the supported side.
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| Figure 6.69 |
In terms of technique, it is important that the patient lifts only very little so as to avoid trunk rotation.
Self-mobilization in the side-lying position
The patient is side-lying on her non-lesioned side with her underneath leg extended and her uppermost leg flexed approximately at right angles at the hip and knee (which is resting on the padded surface of the treatment table). She now places the heel of her upper hand on her ASIS and exerts light pressure in the direction of mobilization to take up the slack (see Figure 6.70). Self-mobilization is now performed in exactly the same way as if it were being done by the practitioner, that is using rhythmic springing pressure in a ventrocranial direction using minimal force at a rate of about two per second.
Even though this technique appears to be straightforward, it is often difficult to make the precise direction of the hand movement clear to the patient. For anatomical reasons alone it is not possible for her to align her forearm with the direction of springing pressure. It can therefore be helpful if she uses her other hand to reinforce the action of the hand originally placed on the ASIS, and if it is explained to the patient that the direction of springing is in fact along the line of the forearm of the reinforcing hand. It has further been shown that self-mobilization by the patient is only achieved if she contracts her brachial biceps, that is if she flexes the elbow of the arm that is uppermost.
6.5.3. Self-mobilization of the lumbar spine
Self-mobilization of the lower lumbar spine into anteflexion and retroflexion
The patient sits back on her heels with arms stretched forward and supporting herself on her hands resting on her knees. By contracting her gluteal muscles, she raises her pelvis, producing kyphosis of the lower lumbar spine. When she relaxes, her pelvis tilts forward, producing lordosis at the lumbar spine (see Figure 6.71). This exercise (raising the pelvis using the gluteal muscles) is also very helpful as preparatory training for standing correctly.
Self-mobilization of the lumbar spine into retroflexion and side-bending
Fixation is absolutely crucial for this exercise. The patient may either fix the upper vertebra of the motion segment to be treated using the radial edge of the forefingers of both hands; or she may fix the lower vertebra of the motion segment to be treated using the tips of her thumbs. Using the fixation point of her hands as a fulcrum, she then very specifically performs rhythmic repetitive movements into retroflexion or side-bending (see Figure 6.72). Fixation from above (by the forefingers) is indicated if there is hypermobility above the segment to be treated, and from below (by the thumbs) if there is hypermobility below the segment to be treated. Therefore the lumbosacral segment (L5/S1) is always fixed from above, and the thoracolumbar junction is always fixed from below. Forceful movements of large range must be avoided.
Self-mobilization of the lumbar spine (McKenzie techniques)
Techniques elaborated by McKenzie (1981) can be used here in simplified and modified form; these are especially effective in intervertebral disk herniation, irrespective of whether we are dealing merely with low-back pain or with radicular pain. Only the simplest techniques will be described here because, in our opinion, these are the only ones that can be mastered by patients in a self-treatment setting. Of fundamental importance here is the frequency with which the patient needs to exercise: sets of ten repetitions, ten times daily for exercises into extension, and sets of ten repetitions but only five times daily for exercises into flexion.
For the exercise into extension, the patient is prone and raises his trunk with arms straight while moving his pelvis up as little as possible from the treatment table (once his arms are straight, he stops; see Figure 6.73 A). If the pain is acute, he should raise his trunk only as far as is bearable. However, if he is comfortable in the lordotic posture with arms straight, he can intensify the effect by exhaling deeply (synkinetic contraction of the erector spinae muscles during exhalation in lordosis). He can also practice retroflexion in the standing position, as in Figure 6.72 A, the difference being that he fixes his buttocks with the palms of both hands.
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| Figure 6.73 |
For the exercise into flexion, the patient is seated on a chair in such a way that on anteflexion he takes hold of a chair leg with both hands between his own spread legs. Then, by flexing his elbows, he rhythmically and repetitively daws himself down into anteflexion (see Figure 6.73 B).
It is important to take due note of McKenzie’s instructions, especially in the event of radicular syndromes: according to McKenzie, pain during and after the exercise should not project into peripheral regions, that is from the gluteal region distally. However, the patient may continue if the pain is ‘centralized’ from the periphery, that is if it is projected proximally.
6.5.4. Self-mobilization of the thoracic spine and ribs
Retroflexion self-mobilization
The patient is seated upright with arms abducted and flexed at the elbows. Sitting absolutely upright – including her head – she rotates her upper arms dorsally with the help of her forearms, producing extension of the mid-thoracic spine without dorsal flexion of the thoracolumbar segment (see Figure 6.74). In this position, she slowly breathes in and then out as far as she can, thus activating her abdominal muscles and forming a fixed point around the xiphoid process that prevents any retroflexion of the trunk. She can also perform the exercise standing and leaning against a wall, pressing her pubic symphysis forward in the process. At this point, it will be helpful to recall the technique used to mobilize the thoracic spine in the seated position (see Figure 6.38). This may be used for self-treatment but is only indicated if thoracolumbar hyperextension does not occur simultaneously.
Anteflexion self-mobilization on inhalation
The patient sits on her heels and lays her upper body forward over her knees so that her forehead is resting on the padded surface of the treatment table. Her arms are held straight at her sides (see Figure 6.75). In this position, the patient consciously breathes into her back: she will quickly learn how to direct her breathing specifically into the restricted segment. This can first be checked by the practitioner by inspection or palpation and then by the patient using her own fingers.
Self-mobilization of the upper ribs on inhalation
Where there is movement restriction (stiffness) of the upper ribs, the patient sits bending forward and turns her head toward the side to be mobilized, while looking up as far as she is able to (see Figure 6.76). She lets one arm hang down between her knees (which are slightly apart) while the other hangs down at her side. In this position, the upper ribs on the side to which the patient’s head is turned bulge slightly and the slack is taken up. The patient performs mobilization by breathing specifically into those ribs.
Self-mobilization of the thoracic spine in rotation
This technique is identical to the relaxation self-treatment method for the thoracolumbar erector spinae, quadratus lumborum, or psoas major, which are in a chain reaction pattern (see Section 6.6.4).
6.5.5. Self-mobilization of the cervicothoracic junction and first rib
Forward and backward movement of the upper thoracic spine and cervicothoracic junction
The seated patient leans against a chair back in such a way that the lower vertebra of the restricted motion segment to be treated is fixed in a stable position. She then moves her head forward and backward, together with the spinal segment that is above this fulcrum (see Figure 6.77). In this setting, it is important that the movement is not performed like anteflexion or retroflexion but that the patient’s head moves horizontally forward and backward. In terms of mobilization, it is only the backward movement that is important; the forward movement should be only minimal.
Rotation self-mobilization at the cervicothoracic junction (according to Gaymans)
Internal and external rotation of the arms outstretched to the sides has some mobilizing effect on the cervicothoracic junction. This effect is considerably enhanced if the two arms are rotated in opposite directions, that is one from supination into pronation and the other from pronation into supination. However, this alone is not enough. The exercise becomes very effective if the head is also rotated simultaneously, in the same rhythm as the arms and preferably toward the hand that is rotating into pronation (thumb pointing downward). Care must be taken not to lift the shoulders, and for this reason the patient’s arms should not be horizontal but slope down at a slight angle (see Figure 6.78). This technique is performed energetically and is not well tolerated by patients with a flat (hypermobile) upper thoracic spine.
Self-mobilization of the first rib
The technique for self-mobilization of the first rib is identical to the mobilization technique according to Gaymans (1973) (see Figure 6.50). The patient offers isometric resistance with her head against the gentle repetitive lateral pressure delivered rhythmically by her hand at a rate of two pushes per second.
6.5.6. Self-mobilization of the cervical spine
Side-bending self-mobilization
The patient is seated upright. Using her hand on the side toward which she intends to bend as a fulcrum, she reaches over her head to the opposite side and side-bends her head with a minimum of force to take up the slack. She then looks up and breathes in slowly, holds her breath, looks down while breathing out, and relaxes into side-bending. For RI she side-bends actively against repetitive moderate resistance applied by her own hand (see Figure 6.79 and Figure 6.80).
Anteflexion and retroflexion self-mobilization between occiput and atlas
For the atlanto-occipital joints the exercise involves a nodding movement. Standing or sitting upright, the patient turns her head to the side so as to lock the cervical spine. In this position she executes a nodding movement by dropping her head toward her larynx and then lifting it (see Figure 6.81 A and B). As soon as she has engaged the barrier (taken up the slack) in one or other direction, she facilitates an additional brisk nodding movement downward by looking down and exhaling quickly, or upward by looking up and inhaling quickly (through her nose).
PIR of the sternocleidomastoid is also recommended (see Figure 6.96).
The following very effective and simple technique is based on activation of the deep stabilizing muscles of the upper cervical spine: the patient is seated upright and places his two hands from either side on the crown of his head. He then exerts slight but very rapid, centered pressure on his head in the direction of the axis of the cervical spine. Care must be taken to avoid anteflexion–retroflexion and laterolateral flexion: there should be only slight vertical springing (see Figure 6.81 C).
6.5.7. Self-mobilization of the extremity joints
Obviously, the patient can also perform self-mobilization of peripheral joints, especially in the lower extremities, because both hands are free. This possibility has already been alluded to in Sections 6.1.2 and 6.1.3 for some patient categories. Only a few instances will therefore be outlined here.
Self-applied traction of the carpal bones
The patient sits with her legs crossed and fixes her forearm on her thigh. With her free hand she takes hold of one carpal or metacarpal bone (depending on which she wishes to treat) between her thumb and forefinger and performs traction in a distal direction (see Figure 6.82).
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| Figure 6.82 |
Traction of the fingers
Using the little finger of her other hand the patient grasps the distal phalanx of the finger to be treated, while with her thumb and forefinger she takes hold of the first phalanx or the first metacarpal bone. This technique can be used both for traction as well as for mobilization of metacarpophalangeal joints II–V and of the carpometacarpal joint of the thumb.
Self-mobilization of the elbow in a radial direction
The standing patient grasps the edge of the treatment table, with her arm held vertically and stretched in supination so that her thumb lies parallel with the edge of the table. Her other hand grasps her elbow from the ulnar side and produces mobilization there by gentle rhythmic springing or by a fast shaking movement in a radial direction (see Figure 6.83).
Self-applied traction at the shoulder
Traction at the shoulder can also be performed as PIR over the padded back of a chair, provided that the chair back is softly padded and supports the side of the patient’s thorax and not the axilla. Using her non-lesioned hand, the patient takes hold of her other forearm and applies light traction along the longitudinal axis of the arm until the slack is taken up. She then resists her own traction, breathes in slowly, breath-holds, and then relaxes as she breathes out. This procedure can be repeated at least three times.
Self-mobilization of the knee
The patient is seated on a low chair or stool and stabilizes her slightly abducted leg on her foot, which is first in external rotation and then in internal rotation. When the foot is in external rotation, the patient takes hold of her knee with her opposite hand placed medially, takes up the slack using light lateral pressure, and shakes her knee in a lateral direction (see Figure 6.84 A). When her foot is in internal rotation, she takes hold of her knee with her hand on the same side placed laterally. After taking up the slack using pressure directed medially, she performs shaking mobilization in a medial direction (see Figure 6.84 B).
Shaking should never be forceful but should be at a frequency that produces rapid, rhythmic, spontaneous springing of the joint.
6.6. Post-isometric relaxation and reciprocal inhibition
6.6.1. Basic principles
Post-isometric relaxation (PIR) techniques as well as reciprocal inhibition (RI) have already been alluded to in the context of mobilization techniques in Section 6.1. The method forms a connecting link between therapy and rehabilitation: it is simultaneously the specific therapy for muscle spasms, especially of TrPs, but always presupposes activity on the part of the patient. All the techniques presented in this section have been selected because they may also serve as self-treatment methods.
It has already been mentioned that Mitchell et al (1979) use muscle facilitation and inhibition in their muscle energy technique for joint mobilization. Nothing was therefore more logical than to use the method in muscle dysfunctions. However, this is at variance with what Mitchell et al originally wrote: ‘When isometrics are used for joint mobilization, maximal contractions are not desirable since they tighten, or freeze, the joints. Moderate contractions are much more appropriate for joint mobilization … However, when a muscle or its fascia must be stretched, powerful isometric contractions are useful …’
Experience indicates, however, that the use of a minimum of force during isometric contraction is also much more advantageous in the treatment of TrPs. Therefore, as for relaxation, we proceed as follows: the muscle is first stretched only as far as is possible without meeting any resistance. In the (extreme) position thus gained, the patient is instructed to resist with a minimum of force and (in the case of the muscles of the trunk) usually to breathe in. This resistance is held for 5–10seconds, after which the patient is told to let go and breathe out slowly. After a brief wait, the practitioner will sense that the muscle is de-contracting or lengthening, thus allowing a new end position to be reached. This phenomenon can be utilized for as long as the muscle continues to lengthen purely due to the patient’s own relaxation. This phase may last for 10seconds, but also for longer than 30seconds. The process should never be cut short because it is crucial for the therapeutic effect. If relaxation proves to be unsatisfactory after the isometric tension phase, the isometric phase can be prolonged, sometimes to as much as half a minute. However, if good relaxation is achieved at the first attempt, the isometric phase may be shortened. The procedure can be repeated depending on how well the patient relaxes. If relaxation is good, the practitioner will sense how the tension ‘melts away’ so to speak.
It is not possible for the practitioner to relax the patient; this is something that the patient must do. In this process the muscle also stretches (spontaneously). As soon as the muscle is being stretched by the practitioner, it is no longer legitimate to call it relaxation (PIR).
Wherever possible, PIR should be enhanced by methods that utilize inhalation and exhalation, direction of gaze, and gravity for resistance (as advocated by Zbojan (1984)). At this point we would reiterate what has already been said concerning the combination of mobilization techniques. Instructions that determine direction (e.g. of gaze, pressure) should precede breathing instructions, so as to prolong the process. When gravity-induced relaxation is used alone, the contraction and relaxation phases should each last for 20seconds. This approach can be used as self-treatment right from the outset. When combining PIR with inhalation and exhalation, it is important that both inhalation and exhalation should be of sufficient duration, if possible 10seconds or longer. To achieve this it is recommended that once inhalation (and sometimes also exhalation) has ended, the patient should breath-hold to slow the respiratory rhythm.
PIR is routinely combined with RI. For this there are two options: one involves the technique developed by Ivanichev (1997) in which the patient performs a forceful movement of maximal excursion in the direction into which relaxation is intended. In the other option, the patient makes a movement using only a minimum of force against rhythmic repetitive resistance from the practitioner. Maximal forces are also undesirable here because they can easily lead to a ‘duel’ between patient and practitioner in which the practitioner may actually come off worse. Rhythmic repetitive resistance achieves the same inhibiton as one-off maximal resistance.
The effect of treatment can be ascertained not only in the muscle (TrP) treated, but also at its attachment point as well as at the attachment points of ligaments which transmit the tension. Often the discomfort in question will be referred pain, which has a tendency to react favorably. TrPs that are significant for the pathogenesis also give rise to chain reaction patterns (see Section 4.20) involving multiple TrPs and movement restrictions, and hence treatment can have a significant distant effect.
The method is also highly specific: in broad, fan-shaped muscles the forces need to be directed precisely at the muscle bundles that harbor TrPs, and also at the attachment point that belongs with the muscle bundle, for example where the attachment point of the pectoralis muscle to a rib is painful. Hence one common reason for failure is insufficient specificity. This method is inappropriate where there is no increased muscle tension (e.g. at painful hypotonic pain points in the fibromyalgia syndrome). The same naturally applies in situations where the treated TrP itself is a secondary phenomenon and its cause remains untreated.
With regard to the theory underlying this physiologically highly effective method of muscle relaxation, it is suspected that what we are dealing with here is not simple Sherrington-type inhibition. The latency periods are far too long for this. The patient is responding after all to verbal instructions. This is also the case with Kabat inhibition, which is why a simple spinal reflex is hardly worthwhile considering. As described here, the effect of PIR may be due to the fact that:
• when minimal force is used, only those muscle fibers contract that have a low stimulus threshold, as is the case in muscle TrPs
• and consequently, we avoid the stretch reflex, which always comes into play with passive stretching – even of a gentle variety.
It may even happen that the patient experiences some pain during relaxation, even though the range of movement increases during relaxation, for example during PIR in ligament pain. Despite this, the pain disappears once PIR is complete. PIR impressively demonstrates how tension is associated with pain, and relaxation with the absence of pain.
PIR is also comparable with the ‘spray and stretch’ method of Travell (1952) but places greater emphasis solely on relaxation while refusing to accept any stretching (even of a gentle variety). The cold spray evidently causes transient inhibition of the stretch reflex and therefore stretch is not an interfering factor here. Indeed, stretch is by no means an essential component of relaxation, as demonstrated by many techniques that utilize gravity, and in relaxation of the gluteus maximus muscles (see Section 6.6.5). It has been found that stretch need not necessarily occur at all; it serves rather as clinical proof of successful relaxation.
Passive stretching is indicated in situations where the connective tissue element of the muscle is shortened, that is where the muscle sheaths – the connective tissues encasing the muscle bundles and fascia – are involved.
PIR acts on the contractile elements in muscle. This effect has been documented in 351 muscle groups in 244 patients (Lewit & Simons 1984); an immediate analgesic effect was detected in 330 muscle groups, while no effect at all was recorded in 21 patients.
As stated previously, some TrPs do not respond to methods that operate using reflex pathways, and also fail to respond when chain reaction patterns are treated. These would appear to be no longer functionally reversible. In such cases treatment then consists of traumatizing massage or needling in which it is important to ‘hit’ the maximally painful points and, where possible, also to produce a twitch response. Usually these are not just single points, for which reason we do not recommend injecting local anesthetics. With needling it is possible to ascertain with the needle still in situ that the TrP has been eradicated and is no longer painful.
The following sections provide precise descriptions of techniques that can be used to diagnose and treat functionally reversible TrPs in the individual muscles.
6.6.2. Muscles of the head and neck
Masticatory muscles
Increased tension in the masticatory muscles is present if the patient is unable to insert three knuckles between the upper and lower rows of incisors with mouth wide open. Tenderness of the temporomandibular joint (TMJ) is also routinely found on palpation. TrPs in the temporalis can be palpated in the temporal region, those in the masseter through the cheeks, those in the internal pterygoid behind the ramus of the mandible, and those in the external pterygoid inside the mouth above the wisdom teeth. TrPs here are particularly common and intensely painful.
PIR to relax all of these muscles is performed as follows: the patient is supine with her head at the end of the treatment table. The practitioner fixes the patient’s forehead with one hand and places her other hand on the patient’s chin. She takes up the slack by opening the patient’s mouth to a moderate degree (see Figure 6.85). The following respiratory synkinesis is then used: during (slow) exhalation there is an automatic increase in resistance to mouth opening. At this point, however, the patient is told to take a deep breath while energetically opening her mouth wide, as when yawning. The procedure is repeated two or three times. In this instance active mouth opening also provokes RI.
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| Figure 6.85 |
Self-treatment
For self-treatment the patient sits at a table, with one elbow on the table and the same hand supporting her forehead; the fingers of her other hand are resting on her lower incisors (see Figure 6.86). After opening her mouth to take up the slack, she first breathes out; during deep inhalation she then opens her mouth as wide as possible. The hand at her forehead should prevent anteflexion of her head, which would interfere with maximum mouth opening. However, her head should also not tilt backward.
Digastricus
The main antagonists of the masticatory muscles are the muscles at the floor of the mouth, principally the digastricus. Examination is most readily performed by shifting the thyroid cartilage from side to side; resistance is greater on the side where the digastricus is tense. If tension is marked, then deviation of the cartilage to the tense side may even be visible, as may a depression in the floor of the mouth on the tense side and a flattening on the other side.
For PIR the patient should be supine; with one hand placed below the patient’s chin the practitioner should resist mouth opening while the thumb of her other hand is placed laterally against the patient’s hyoid and palpates resistance (see Figure 6.87 A). During the isometric phase the patient opens her mouth against the resistance applied by the practitioner’s hand under her chin, breathes in, breath-holds, and then relaxes and breathes out. In this process the patient’s mouth will close and the practitioner will sense how lateral resistance at the hyoid subsides. It is therefore necessary prior to PIR to palpate the hyoid bone. While she must be able to feel the tension and relaxation, the practitioner must never poke about with her thumb at the hyoid.
Self-treatment
For self-treatment of the digastricus the patient is seated with one elbow supported on a table and her chin cupped in the same hand. The thumb of her other hand lies lateral to the hyoid on the tense side (see Figure 6.87 B). Against the resistance of her chin against her hand, she opens her mouth, breathes in, breath-holds, and then relaxes while breathing out. The procedure is repeated two or three times.
Mylohyoid
If there is increased tension in the mylohyoid muscle at the floor of the mouth, the following self-treatment method is indicated. The patient presses the tip of her tongue against her hard palate, breathes in, and lets her tongue drop back while breathing out.
External pterygoid
For specific treatment of the external pterygoid muscle the patient is supine with her mouth only slightly open. From above, the practitioner places both thumbs on the patient’s chin (see Figure 6.88 A). The patient is then told to push her chin forward and breathe in while the practitioner offers resistance at the chin. She is next instructed to hold her breath, let go and then breathe out.
Self-treatment
For self-treatment the patient places her thumbs on her chin (see Figure 6.88 B). She then pushes her chin against the resistance of her thumbs and breathes in. After holding her breath, she relaxes as she breathes out.
Short extensors of the craniocervical junction
Palpatory examination of these muscles is possible only with the patient supine and her head slightly raised. For treatment, the practitioner stands behind the seated patient and places both thumbs behind the patient’s head below the occiput, with her fingers up over the zygomatic bones. The patient is then told to look up and breathe in deeply as the practitioner resists the (automatic) retroflexion of the head (see Figure 6.89). Afterward the patient is instructed to hold her breath, look down, and breathe out slowly. This must not produce anteflexion of the entire cervical spine but merely a nodding movement. Consequently, the practitioner allows the patient’s supported head and upper body to drop slightly back and down without letting the head fall forward. The procedure is repeated from the newly gained position.
For RI the patient is asked to nod her head forward as the practitioner offers rhythmic repetitive resistance.
Self-treatment
For self-treatment the seated patient stabilizes her occiput from below with her fingers and her zygomatic bones from above with her thumbs. Using both hands she makes a slight nodding movement to take up the slack (see Figure 6.90 A). She then looks up and breathes in, holds her breath, then leans back against the back rest of the chair, looks down, breathes out, and gives a forward nod while doing so (see Figure 6.90 B).
Levator scapulae
The typical TrP lies in the angle between neck and shoulder. Further pain points are located at the superior angle of the shoulder blade and on the lateral surface of the spinous process of the axis.
For treatment, the patient is supine with her head at the top end of the treatment table and the elbow of her flexed arm raised beyond her head. The practitioner exerts pressure on the patient’s shoulder blade by pressing in a caudal direction against the elbow, fixing the elbow in this position with the thigh in order to take up the slack in the levator scapulae. Using both hands the practitioner moves the patient’s head to the opposite side until light resistance is encountered. This is felt sooner on the side of increased tension than on the other side. The practitioner then simultaneously raises the patient’s head a little and turns it to the same side (see Figure 6.91 A). The patient is instructed to look toward the side that is being treated and slowly breathe in, then to hold her breath, let go and breathe out. During the ensuing relaxation the practitioner moves the patient’s head to the opposite side until light resistance is again encountered. The procedure is repeated.
If, as is not infrequently the case, the patient cannot raise her arm as the above technique requires, then the practitioner may employ the method described by Sachse, which can also be used to test for muscle shortening. With the patient supine, the practitioner uses the palm of one hand to draw the patient’s shoulder caudally so as to fix it and positions her fingertips at the attachment of the levator scapulae at the superior angle of the shoulder blade. She places her other hand round the patient’s neck, raises the head into anteflexion, and produces side-bending above C4 to the opposite side until she feels tension at the muscle attachment point (see Figure 6.91 B). The patient is then instructed to look toward the side of the tense muscle and breathe in slowly, hold her breath, then let go and breathe out. The procedure is repeated.
Upper part of the trapezius
Painful TrPs can be readily palpated along the entire length of the upper part of the trapezius. For treatment (and for examination), the patient is supine: the practitioner fixes the patient’s shoulder from above with one hand, while side-bending the head and neck with her other hand to take up the slack (see Figure 6.92). She then instructs the patient to look in the direction of the stabilizing hand and breathe in slowly, then breath-hold, let go and breathe out. During relaxation the practitioner takes the patient’s head further into side-bending until the slack is taken up again, and the procedure is repeated.
For RI the patient exerts pressure with her head toward the side of the tense muscle while the practitioner offers rhythmic repetitive resistance.
Self-treatment
For self-treatment of both the levator scapulae and the upper part of the trapezius, gravity-induced PIR is most effective. The patient sits against a low chair back with both arms hanging down over and behind it, to ensure as upright a posture as possible. In this position she looks up, raises her shoulders, breathes in (see Figure 6.93 A), holds her breath and looks down, lets her arms drop, and breathes out slowly (see Figure 6.93 B). This procedure is repeated several times.
For RI the patient exerts downward pressure with both arms toward the floor.
Scalenes
While tension of the scalenes causes minimal direct pain, it is of great clinical significance. As a rule the scalenes are involved in tension of the other upper fixators of the shoulder girdle; they play a decisive role specifically in the faulty clavicular breathing pattern that is characterized by lifting of the thorax during inhalation. Tension in the scalenes leads to tension in the pectorals with pain points in the region of the sternocostal joints. This is often accompanied by a sensation of tightness that subsides after the scalenes have been treated. In restriction dysfunction of the first rib the scalenes develop reflex tension and this is one contributing cause of the thoracic outlet syndrome (see Section 7.5.2). The site of the typical TrP in the scalenes corresponds to Erb’s point and usually responds to PIR.
Tension in the scalenes causes restriction of retroflexion of the rotated head to the opposite side. If there is marked cervical lordosis, tension of the scalenes may even restrict side-bending of the head, simulating increased tension in the trapezius.
For examination, as for treatment, the practitioner stands behind the seated patient, using her body to support the patient’s shoulder on the side to be examined (treated), and with one hand fixing the upper ribs on the same side. With her other hand she tilts the patient’s head (turned to the opposite side) slightly backward so as to take up the slack (see Figure 6.94). The patient is then told to look up and to the side and to breathe in. As the patient breathes in, the practitioner offers powerful resistance with her hand placed on the patient’s ribs, while her other hand at the side of the patient’s head offers only minimal resistance. As the patient breathes out, she looks to the opposite side and allows her head to drop into retroflexion. Considerable relaxation generally occurs spontaneously with the result that it is rarely necessary to repeat the procedure.
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| Figure 6.94 |
Self-treatment
Self-treatment of the scalenes is possible provided that the faulty clavicular breathing pattern characterized by thoracic lifting is not being treated simultaneously. For this the patient lies on her side, raising her head from the padded cover of the treatment table, and breathes in slowly (see Figure 6.95 A). She then holds her breath, allows her head to sink back (under gravity) to the treatment table while breathing out, and then repeats the exercise (see Figure 6.95 B).
For RI the patient exerts strong pressure with her head against the padded cover.
Sternocleidomastoid
TrPs are almost invariably detected (using a pincer grip) along the course of this muscle in dysfunctions of both the cervical region and the orofacial region; these are associated with pain that is referred to the cranium and face. There is frequently also a pain point at the transverse process of the atlas; painful attachment points may be detected medially at the clavicle and at the mastoid process. The muscle develops TrPs in response to most disturbances involving the head, neck, and even the cervicothoracic region, and it is a good indicator of untreated dysfunctions in this whole territory.
To treat this condition, use is made of gravity-induced PIR and respiratory synkinesis. The patient lies supine, with her head rotated and resting over the edge of the treatment table, so that her chin and mastoid process are (gently) supported by the edge of the table. In this position the patient is told to look up at her forehead and to breathe in slowly and deeply. As she does this the sternocleidomastoid muscle automatically contracts, causing the patient’s head to lift slightly with a side-nod (see Figure 6.96 A). After holding her breath, the patient looks toward her chin and breathes out slowly, causing the sternocleidomastoid to relax and her head to be lowered (see Figure 6.96 B). The act of looking up and down facilitates inhalation and exhalation, and the contraction and relaxation of the sternocleidomastoid occurs in the context of respiratory synkinesis. The patient repeats the exercise several times.
This technique serves not only to relax the sternocleidomastoid muscle. It is also a very effective self-mobilization technique for movement restriction at the atlanto-occipital joint because it encourages side-nodding. In the exceptional cases where respiratory synkinesis is insufficient, the patient may also deliberately raise her head slightly.
6.6.3. Muscles of the upper extremity
Adductor pollicis
The attachment point for this muscle is at the second metacarpal. The TrP in this muscle causes attachment point pain around the che-gu point well known to acupuncturists. Its relaxation is important in the setting of reflex therapy.
For treatment by PIR, the practitioner abducts the patient’s thumb to engage the barrier. The patient is then instructed to adduct her thumb as the practitioner resists with minimal force and to let go after 5–10seconds (see Figure 6.97 A). The procedure is repeated.
This is followed by RI in which either the patient performs maximum abduction herself or the practitioner (or the patient herself) offers rhythmic repetitive resistance to abduction.
Self-treatment
The patient uses her other hand to resist adduction (see Figure 6.97 B).
Radial epicondylopathy
Alongside movement restriction at the elbow, TrPs may be present in the supinator, the forearm extensors, and the biceps and triceps brachii.
The presence of a TrP in the supinator is confirmed by restricted pronation compared with the non-lesioned side. For treatment, the patient should be seated in front of the practitioner or supine. The practitioner places one hand laterally to fix the patient’s elbow, which is flexed at right angles. With her other hand she takes the patient’s forearm at the wrist into pronation to take up the slack (see Figure 6.98 A). She then instructs the patient to resist with minimal force in the direction of supination, holding this for 5–10seconds and then letting go. As the patient breathes out, pronation should increase markedly. The procedure is repeated from the newly gained pronation position.
For RI rhythmic repetitive resistance is offered against pronation performed by the patient.
Self-treatment
The procedure for this is self-evident but care must be taken to ensure that the patient keeps her elbow against her trunk and does not move it forward away from her body (see Figure 6.98 B).
For RI the patient forcefully performs maximal pronation resisted by her other hand.
Finger and hand extensors
TrPs in the finger and hand extensors cause movement restriction, which can be tested very accurately by approximating the patient’s fingertips as far as possible toward the palmar aspect of her forearm, and comparing with the fingers of the other hand (see Figure 6.99 A). This test involves simultaneous flexion of the wrist and fingers. The TrPs can be readily palpated in the forearm. For PIR the practitioner places her thenar eminence or fingers over the back of the patient’s hand and fingertips, so as to approximate them to the forearm; the result can be measured by using the fingers of her other hand. The slack is taken up in this way. The patient next resists the pressure of the practitioner’s hand for 5–10seconds and then lets go. During relaxation there is a measurable increase in flexion.
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| Figure 6.99 |
For RI the patient flexes her fingers while the practitioner offers rhythmic repetitive resistance against flexion.
Self-treatment
Here, too, the procedure for self-treatment is obvious. The main difference is that the patient mainly places her thenar eminence over the fingertips of the hand being treated and uses her fingers to flex the wrist of the treated hand (see Figure 6.99 B).
The patient can also perform RI by rhythmically and repetitively resisting the flexion of the treated hand.
Biceps brachii
When TrPs are present in the biceps brachii it will be found that extension at the elbow is somewhat restricted. Treatment involves gravity-induced PIR. The seated patient supports her extended elbow on one knee, then bends the elbow a little and holds her forearm slightly raised for 20seconds (see Figure 6.100 A). She then allows her forearm to drop back to its original position and relaxes for 20seconds (see Figure 6.100 B). The exercise can be repeated two or three times.
Triceps brachii
When TrPs are present in the biceps brachii they are also routinely found in its antagonist, the triceps brachii. According to Krobot (1994), primary TrPs in the triceps brachii cause axillary pain. They can be palpated in the long head of the triceps close to the axilla and the patient reports pain on extension of the elbow joint under pressure (e.g. when doing press-ups).
Treatment involves gravity-induced PIR. The patient is seated and raises her arm vertically, flexes it at the elbow, and places her hand on the top of her head. She then lifts her forearm a little and holds it there for 20seconds (see Figure 6.101 A). Afterward she lets it fall again to her head and relaxes for 20seconds (see Figure 6.101 B). The exercise can be repeated two or three times.
For RI the patient exerts forceful pressure with her hand on her cranium.
Ulnar epicondylopathy
In this condition TrPs are present in the digital flexor muscles on the ulnar side. For treatment, the patient is seated in front of the practitioner with elbow fully flexed and forearm in supination. The practitioner takes hold of the patient’s dorsiflexed hand from the radial edge and supports the back of the hand with her thumb. The patient’s hand is then taken into dorsiflexion and pronation to take up the slack (see Figure 6.102 A). The patient resists with light pressure toward flexion and supination. After 5–10seconds she relaxes in the direction of pronation and dorsiflexion. The procedure can be repeated two or three times.
For RI the patient exerts pressure toward pronation while the practitioner offers rhythmic repetitive resistance into supination.
Self-treatment
With the hand to be treated in the same position as above, the patient places the fingers of her other hand on the palm of her dorsiflexed hand from the ulnar side, while supporting the back of the hand with her thumb. She takes up the slack into supination and dorsiflexion and then offers isometric resistance in the direction of pronation and flexion (see Figure 6.102 B). After 5–10seconds she relaxes and dorsiflexion and supination are amplified. This exercise is repeated three times.
Supraspinatus
TrPs in the supraspinatus muscle are found in the fossa supraspinata. On abduction against resistance the patient typically feels pain at the greater tubercle. For treatment, the practitioner stands behind the patient and supports her. She brings the patient’s flexed arm medially into adduction in front of her chest, to take up the slack (see Figure 6.103 A). In this position she tells the patient to exert slight counterpressure into abduction while breathing in, and then to relax as she breathes out, causing adduction to increase. The procedure is repeated from the newly gained position. For self-treatment the patient does exactly the same, using her own hand (see Figure 6.103 B).
For RI the patient exerts forceful adduction of her arm resisted by her other hand.
Infraspinatus
The infraspinatus is a common source of shoulder pain. TrPs here are palpated in the fossa infraspinata. External rotation against resistance provokes pain at the attachment point with the greater tubercle. Gravity-induced PIR is used both for treatment and self-treatment. The patient is supine with her arm in abduction over the side of the treatment table and her elbow bent at right angles so that her forearm points toward her hip (i.e. her shoulder is in internal rotation). The effect of gravity causes the muscle slack to be taken up (see Figure 6.104 A). The patient next lifts her forearm about 2cm, holding it in this position for about 20seconds. She then relaxes for at least 20seconds and lets her forearm drop (see Figure 6.104 B). From the newly gained position the procedure is repeated two or three times. The patient can perform this exercise as self-treatment several times a day.
For RI the patient exerts downward pressure with her hand.
Subscapularis
If the subscapularis muscle goes into spasm (contracts), the result is adduction and internal rotation, that is the ‘frozen shoulder’ position. It appears that there is indeed a close relationship between the subscapularis and frozen shoulder, and that TrPs in the subscapularis may accompany frozen shoulder from the outset through all its stages. For diagnosis it is necessary to palpate the TrPs directly. For this, the patient is supine with her arm abducted at about 60°. In this position the practitioner takes hold of the patient’s forearm and exerts light laterocaudal traction along the axis of the patient’s arm. With the fingers of the other hand, the practitioner slips over the edge of teres major and latissimus dorsi deep into the axilla on the ventral aspect of the shoulder blade to palpate the exquisitely tender TrPs of the subscapularis.
Frequently, however, the pain is not consistent with that of frozen shoulder where pain radiates as far as the wrist. The pain may simply be felt in the shoulder, shoulder blade, or thorax; if this pain occurs on the left side, it may also present as cardiac pain or dyspnea with respiratory limitation due to costal restrictions. These conditions are frequently associated with TrPs in the subscapularis. The subscapularis should therefore always be palpated in cases of pain of unknown origin involving the shoulder and thorax.
Here, too, gravity-induced PIR is used for (self-)treatment, with the patient positioned as described for the infraspinatus (see above), the difference here being that her forearm is pointed cranially (see Figure 6.105 A and B). However, it is likely that a patient with a frozen shoulder will not be able to abduct the arm at right angles and that external rotation will also be restricted. In such circumstances the patient should abduct the arm just a little in order for there to be sufficient external rotation for gravity to enhance external rotation still further. It is necessary in such cases for the patient to perform the exercise while side-lying on the painful shoulder (see Figure 6.105 C and D).
For RI the patient exerts active pressure with her forearm into external rotation.
Latissimus dorsi and teres major
These two muscles constitute a functional unit. In combination with the pectoralis major they adduct the arm. On their own they permit retroflexion of the arm. They clearly play an important role in the synkinetic movement of the arms during walking and also probably during trunk rotation. TrPs in these muscles are palpated in the axilla and further down the back. Pain radiates from the shoulder down the ulnar aspect of the arm.
For treatment, gravity-induced PIR is most practical. The patient is side-lying, with her back close to the edge of the treatment table. The arm to be treated is abducted at 135° and flexed at the elbow (see Figure 6.106 A). The patient next takes her arm further into abduction, breathes in slowly, holds her breath, then relaxes while breathing out and lets her arm fall against her head (see Figure 6.106 B). For RI she exerts pressure with her upper arm against her head.
6.6.4. Muscles of the trunk
Pectoralis major
Increased tension (TrPs) of the upper (subclavicular) part of the pectoralis major results in a forward-drawn position of the shoulders. Beneath the clavicle the tendon protrudes on abduction like a ‘false clavicle’ and is tender to palpation. For examination, with the patient supine, the practitioner brings the patient’s arm as far as possible into abduction in order to detect any shortening of the pectoralis major (see Figure 6.107 A).
Gravity-induced PIR is useful for treatment, with the patient in the same position as for examination. She relaxes her arm (which is abducted over the edge of the treatment table) until the slack is taken up. She then raises her arm about 2cm and breathes in slowly, holds her breath, relaxes and breathes out slowly, while her arm sinks down again (see Figure 6.107 B and C). The procedure is repeated two or three times.
For RI the patient exerts forceful pressure with her arm toward the floor.
Where the sternocostal part of the pectoralis major muscle is tense (TrPs), full elevation of the arm is restricted and the tendon in the axilla is taut as well as tender to palpation. For the examination, the patient is supine. Placing her forearm on the patient’s sternum, the practitioner fixes the thorax from above, while with her other hand she brings the patient’s arm into maximum (oblique) elevation without applying any force and identifies any muscle shortening (tension) (see Figure 6.108 A). TrPs can be palpated here by a pincer movement beneath the axilla as the practitioner slips her fingers between the ribs and the flat pectoralis major, while her thumb palpates through the overlying skin, eliciting a twitch response.
Gravity-induced PIR is useful for self-treatment. Like the practitioner previously, the patient performs the same elevation movement with her arm over the edge of the treatment table, then lifts her arm just a very little, breathes in slowly, holds her breath, and then relaxes slowly while breathing out (see Figure 6.108 B and C).
Painful attachment points on the ribs
These pain points are found in the axillary line and often in the vicinity of the sternocostal joints. They are commonly associated with thoracic pain, for which differential diagnosis is essential. The structures in question are attachment points of individual fiber bundles of pectoralis major (in the axillary line, serratus anterior).
For treatment, the patient can be supine or side-lying. The practitioner brings the patient’s arm into abduction, producing contraction of the fiber bundle that is causing the painful pressure point. This tension must be palpated precisely (see Figure 6.109).
Pectoralis minor
Tension (TrPs) of the pectoralis minor manifests itself as a pain point below the clavicle, corresponding to the coracoid process, and as painful attachment points at the ribs. It further produces forward-drawn shoulders and increases thoracic kyphosis; moreover, it can be one contributing cause in the thoracic outlet syndrome (Hong & Simons 1993).
For treatment (relaxation), we use gravity-induced PIR. The patient is supine close to the edge of the treatment table with her arm hanging down over the edge. She raises her shoulder while breathing in slowly (see Figure 6.110 A), holds her breath, and then lets her arm drop while she breathes out and relaxes (see Figure 6.110 B). The procedure is repeated three times.
For RI the patient exerts pressure with her arm toward the floor.
Serratus anterior
In tension of the serratus anterior there are TrPs close to the costal attachment points. For examination, the patient is side-lying, with her underneath leg (i.e. the leg on the treatment table) stretched out while her uppermost leg is bent at the hip to stabilize the side-lying position. The practitioner brings the patient’s upper arm cranially into abduction with retroflexion to engage the barrier. With the thumb of her other hand she simultaneously fixes the painful attachment point at the rib (see Figure 6.111 A). The direction of abduction can be established accurately because, if the patient’s arm is guided correctly, the tension is transmitted precisely to the location of the practitioner’s thumb (pain point). As she breathes in, the patient offers resistance and after holding her breath she relaxes as she breathes out. The procedure can be repeated.
Self-treatment
For self-treatment, gravity-induced PIR is useful. Adopting the same position as for treatment by the practitioner, the patient raises her arm, breathes in, holds her breath, and lets her arm fall again to take up the slack as she breathes out (see Figure 6.111 B and C).
For RI the patient exerts forceful pressure in the direction of extension.
Diaphragm
For palpatory examination of the diaphragm the patient is seated in slight anteflexion and the practitioner stands behind him, supporting his trunk against her own. With the fingers of both hands flexed, she performs palpation beneath the inferior costal arches from below and upward and moves her fingers laterolaterally (see Figure 6.112). If TrPs are present, marked resistance will be felt and the patient will experience some pain.
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| Figure 6.112 |
PIR and RI are regularly effective. The patient breathes in a little, then with mouth closed he pinches his nose and tries to breathe in against isometric resistance. He holds this for 5–10seconds and then breathes out slowly. He is able to last out because he has breathed in a little to start with. For repeats and for subsequent self-treatment the patient learns to perform isometric resistance not by pinching his nose, but by closing his glottis, as when pronouncing the consonant ‘K.’ After two or three repeats the patient performs RI by actively breathing out as far as possible.
The method is so effective that any painful resistance that persists is not a TrP but in all probability is attributable to the gall bladder, spleen, or stomach.
The major clinical significance of these TrPs is that the diaphragm is one of the most important muscles in the deep stabilization system. It is the starting point for extensive chain reaction patterns and for pain that is referred particularly to the thoracic and cervical regions and to the head. Examination of the diaphragm is therefore recommended as a routine procedure. Despite its simplicity and effectiveness, TrP relaxation here is of secondary importance compared with active exercising and strengthening of the deep stabilization system as a whole, which is discussed in Section 6.8.7.
Erector spinae
Increased tension and TrPs are very frequent in all parts of the erector spinae because this muscle often also reacts in response to disturbances in any spinal segment. There is one simple gravity-induced technique that can be used along the entire course of this muscle on both sides. For this, the patient is prone with her head hanging over the end of the treatment table. She raises her head and breathes in (see Figure 6.113 A), then holds her breath and, while breathing out, she relaxes into the starting position (see Figure 6.113 B). If the patient lifts her head only a little, she then contracts and relaxes only the upper parts of the erector spinae; the higher she lifts her head, the further caudally the muscle is contracted. This procedure is repeated.
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| Figure 6.113 |
Thoracic region
Generally, tension is detected predominantly on one side. In such cases it is more specific to treat with a combination of anteflexion, side-bending, and rotation. In the cervicothoracic and thoracic region, the practitioner stands behind the seated patient and fixes the shoulder or costal angle on the painful side with one hand, using the thumb of that hand to fix the muscle paravertebrally just below the TrP. With her other hand she brings the patient’s head into anteflexion, side-bending, and rotation toward the opposite side until she has taken up the slack (see Figure 6.114). Now the patient is instructed to look toward the lesioned side and up, to breathe in deeply (as the practitioner resists the automatic counterpressure), and then to hold her breath, look toward the non-lesioned side, and breathe out. This procedure is repeated.
For RI the patient continues to look toward the non-lesioned side, while the practitioner rotates the patient’s head against resistance toward the restricted side.
Thoracolumbar region
When treating the erector spinae in the lower thoracic and upper lumbar region, the practitioner stands behind the patient, who is seated in slight kyphosis with hands clasped behind her neck. The practitioner threads one arm under the patient’s axilla to reach round to her shoulder on the side to be treated and tells the patient to look toward the non-lesioned side until the slack has been taken up in rotation (see Figure 6.115). She then asks the patient to look toward the lesioned side and to breathe in while she resists the patient’s efforts to turn in this direction. The patient is then instructed to look as far as possible in the direction of the non-lesioned side and to breathe out, which results in an increase in rotation. This procedure is repeated.
For RI the practitioner rhythmically and repetitively resists rotation toward the non-lesioned side.
Lumbar region
Relaxation of the erector spinae in the lower lumbar region is performed using gravity-induced PIR coupled with inhalation and exhalation. Because the position for this technique is identical to that used when mobilizing the lumbar spine into flexion (see Figure 6.35), this technique can also be used for self-mobilization of the lumbar spine into flexion.
The patient is side-lying in kyphosis, her underneath leg flexed at the hip and knee, and her uppermost leg hanging over the edge of the treatment table, bringing her pelvis into a forward-tilted position. She looks up at the ceiling (i.e. she rotates her head and shoulder in the opposite direction from that of the pelvis). In this position the patient relaxes and the weight of her leg hanging down is sufficient to take up the slack of her lumbar erector spinae (i.e. to bring the lumbar spine into anteflexion and rotation). The patient then lifts her hanging leg slightly, breathing in slowly (see Figure 6.116 A), holds her breath, and then relaxes as she breathes out, allowing her leg to fall again (see Figure 6.116 B). This procedure is repeated three times. This technique is also effective in the treatment of pain at the spinous processes, in which case the more painful side must lie uppermost.
Self-treatment
The following technique is effective for self-treatment of the entire erector spinae (apart from the most caudal segment) while seated: with one hand on the top of her head, the patient brings her head and therefore her trunk first into a position of anteflexion, and then into side-bending and rotation so that the peak of the curve is at the level of the painful TrP (which the patient will feel during anteflexion; see Figure 6.117). After taking up the slack, she looks in the opposite direction from rotation, breathes in slowly, and uses the hand placed on her head to resist automatic rotation in the direction of her gaze. She holds her breath and then looks in the direction of mobilization and breathes out, taking her head and trunk into rotation, anteflexion, and side-bending as far as the (new) barrier.
TrPs in the horizontal part of the trapezius
Here the typical pain point is medial to the superior angle of the scapula; it is characterized by a radiating pain pattern, and is encountered especially in radicular syndromes and acute cervicobrachial pain in the upper extremity. For diagnosis, the practitioner takes up the slack in the muscle by bringing the scapula into maximal abduction: to do this she takes the patient’s upper arm as far as possible toward the opposite shoulder, thus causing the muscle to protrude like a taut cord that is painful on snapping palpation.
For treatment, the practitioner stands behind the seated patient and brings the patient’s elbow toward the opposite shoulder to take up the slack (see Figure 6.118 A). She instructs the patient now to give slight counterpressure with the elbow against her hand and to breathe in, hold her breath, and then relax as she breathes out. The patient’s elbow will then come even closer to the opposite shoulder. This procedure is repeated two or three times.
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| Figure 6.118 |
For RI the patient exerts pressure with her hand in the same position against the practitioner’s hand, which rhythmically and repetitively increases springing counterpressure.
Self-treatment
For self-treatment the patient uses her own hand in exactly the same way as the practitioner does above (see Figure 6.118 B). Gravity-induced PIR is especially helpful for self-treatment. The patient is side-lying close to the edge of the treatment table and allows her uppermost arm to hang vertically over the edge. The weight of her hanging arm produces abduction of the shoulder blade and the slack is taken up (see Figure 6.119 A). The patient then raises her hanging arm a little and breathes in, holds her breath, relaxes as she breathes out, and lets her arm drop again (see Figure 6.119 B).
For RI the patient pushes her hand forcefully toward the floor.
Quadratus lumborum
When trunk rotation is restricted, the quadratus lumborum is routinely found to harbor TrPs. These are palpated at the waist. The patient may be prone or supine for comparison of the two sides. However, it can be difficult here to distinguish the quadratus lumborum from the oblique abdominal muscles. For precise palpatory examination it is better if the patient is side-lying. With one hand she holds the top end of the treatment table and lets her uppermost leg hang down over the edge of the table behind her, so as to create as much room as possible for palpation between the iliac crest and the inferior costal arch. Using a pincer hold, the practitioner palpates by forefinger pressure caudally beneath the iliac crest and cranially beneath the inferior costal arch in the direction of the attachment points of the muscle.
Tension in the quadratus lumborum can be treated both by gravity-induced PIR and using respiratory synkinesis. The patient stands with her legs apart and relaxes into side-bending. If she is completely relaxed (her head must also be hanging sideways), looking up and breathing in slowly and deeply will be sufficient to raise her trunk (see Figure 6.120 A). The patient then holds her breath, looks down, relaxes, breathes out slowly, and sinks to a (new) end position (see Figure 6.120 B). This procedure is repeated two or three times.
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| Figure 6.120 |
For RI, after the slack has been taken up, the patient actively pushes her downward-hanging arm toward the floor.
Due to the chain reaction pattern linking the quadratus lumborum with the psoas major and erector spinae muscles, relaxation of the quadratus lumborum normalizes restricted rotation of the trunk.
If this exercise is poorly tolerated, the patient can assume the same side-lying position as for examination, raising the leg while breathing in and letting it fall again beyond the edge of the treatment table while breathing out (see Figure 6.125).
Rectus abdominis
TrPs in the rectus abdominis may give rise to referred pain simulating visceral disease. They may also be associated with pain at the attachment points with the pubic symphysis, xiphoid process, and the adjacent parts of the costal arches. Examination routinely reveals tenderness at the attachment points and it is also possible to diagnose the TrPs using rapid snapping palpation. Clinically, there is frequently a characteristic forward-drawn posture with tension of the neck and back muscles, as well as restriction of retroflexion that the patient experiences as low-back pain.
For treatment (and self-treatment), gravity-induced PIR is most effective: the patient is supine with her buttocks resting at the end of the treatment table and her legs hanging over the edge. She rests the foot of the non-treated side on a low stool, and a pad is inserted under the buttock on the other side to tilt her pelvis slightly to one side. In this position she relaxes her freely hanging leg to take up the slack. She then lifts the knee of that leg a little and breathes in (see Figure 6.121 A); afterward, as she breathes out and relaxes, she lets her leg fall again to a (new) end position (see Figure 6.121 B). This procedure can be repeated twice.
For RI the patient actively presses her hanging foot down toward the floor. If the intention is more to relax the upper part of the rectus abdominis, she should raise her head, hold this for about 20seconds, and then let it sink back to the padded surface of the treatment table. For RI she can then press her head against the padded surface.
This technique is not commonly used because TrPs in the rectus abdominis generally occur secondarily as a result of movement restrictions involving the fibula, the feet, and even the pelvic floor.
6.6.5. Muscles of the hip region
Iliopsoas
Intensely painful TrPs are palpated through the abdominal wall: at the psoas major by parallel pressure from the side against the spinal column; and at the iliacus, parallel to the inguinal ligament, by pressure in the direction of the ilium.
For treatment, we employ gravity-induced PIR. The patient is supine with his buttocks at the end of the treatment table. He flexes his non-lesioned leg at the knee and hip and, with his hands clasped around the tibial tuberosity, he draws the leg up toward his chest, thus fixing the pelvis. He then lifts the knee of his hanging, lesioned leg a few centimeters while breathing in (see Figure 6.122 A), holds his breath, and then lets it fall again as he relaxes and breathes out (see Figure 6.122 B). This procedure is repeated about three times.
For RI the patient exerts pressure in the direction of his hanging foot toward the floor.
Ligament pain (pelvic region)
Where contraction of the ligaments in the pelvic region provokes pain, increased resistance and (on range of motion measurement) restricted adduction are invariably encountered on the side where pain is present. Of course, this resistance cannot derive from the ligaments themselves and therefore can only be of muscular origin.
For treatment, the practitioner flexes the patient’s knee and hip to the point where resistance, and simultaneously the pain response, are greatest on adduction. This technique applies equally for the iliolumbar ligament and for the sacroiliac ligaments. In this position the patient exerts light pressure against the practitioner’s examining hand and holds this for 5–10seconds (see Figure 6.123 A). During the relaxation phase, the practitioner brings the patient’s thigh further into adduction provided that no resistance develops. In the process the patient will generally experience some pain but this is of no significance provided that the patient is still able to relax. This procedure is repeated from the newly gained position.
For RI the patient offers resistance into abduction against the rhythmic repetitive pressure on his thigh.
Self-treatment
For self-treatment, the patient uses the hand on the same side to ensure that hip and knee flexion remain constant while his other hand performs PIR (see Figure 6.123 B). For RI he can also rhythmically and repetitively resist adduction.
Gluteus maximus and levator ani
A tender or painful coccyx is generally attributable to attachment point pain due to increased tension in the caudal part of the gluteus maximus and TrPs in the levator ani.
Treatment consists of PIR of the gluteus maximus and levator ani. For this, the patient is prone, with his heels rotated outward to relax the buttock muscles. Standing by the patient’s legs, the practitioner crosses her hands and places one hand on each buttock. As she exerts light pressure she will feel the increased muscle tension (see Figure 6.124 A). She next tells the patient to clench his buttocks together with minimal force, to maintain this pressure for about ten seconds, and then to let go. During the protracted (!) relaxation phase the practitioner feels her hands going deeper as the tension in the muscles diminishes. This procedure is repeated several times until it seems as if tension is no longer diminishing. The practitioner then checks to establish whether the coccyx is still painful.
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| Figure 6.124 |
Self-treatment
For self-treatment, the patient is supine with his two hands beneath his buttocks and his feet rotated inward; gravity-induced PIR is also used (see Figure 6.124 B). The patient now tenses his gluteals a little and holds this for 20seconds before relaxing for 20seconds. This procedure is repeated three to five times.
A painful coccyx is caused by tendomyopathy of the gluteus maximus and levator ani muscles, and post-isometric muscle relaxation therapy is consistent with the pathogenesis. Only in exceptional cases where there is no increased tension is there an indication for the (standard) therapeutic approach per rectum.
6.6.6. Muscles of the lower extremity
Hip abductors
Tenderness at the greater trochanter is due principally to tension of the hip abductors, primarily the gluteus medius and the tensor fasciae latae. Active abduction is then also frequently painful. However, the same pain points are also found in osteoarthritis of the hip. When TrPs are present in the gluteus medius (palpated using a pincer grip), the inferior margin of the iliac crest is also tender. TrPs in the tensor fasciae latae are palpated just above the greater trochanter and pain points are also found simultaneously along the course of the fascia lata on the lateral aspect of the thigh.
Gravity-induced PIR is used to treat these muscles. The patient is side-lying at the end of the treatment table, with his underneath leg flexed at the knee and hip and his uppermost leg hanging over the end of the table in adduction. The patient lifts his leg horizontally (see Figure 6.125 A), holds for 20seconds, and then relaxes for a further 20seconds (see Figure 6.125 B). This procedure is repeated two or three times. This technique also relaxes the quadratus lumborum at the same time.
For RI the patient exerts forceful pressure with his leg against the padded cover of the treatment table and practices this exercise daily.
It may be helpful to adopt an even more precise procedure here: if the TrPs are located primarily in the gluteus medius, the uppermost leg should perform the exercise in extension. However, if the TrPs are primarily in the tensor fasciae latae, the uppermost leg should be flexed a little at the hip.
Hip adductors
As in osteoarthritis of the hip, Patrick’s sign is positive and the attachment points at the pubic symphysis and pes anserinus are painful, causing the patient also to experience knee pain. TrPs can be palpated in all the muscles belonging to the hip adductor group. The adductors are closely associated with diseases of the hip, they may give rise to pain that is referred to the pelvis, and they are often coupled with TrPs in the pelvic floor.
The position for Patrick’s test is used for examination and to take up the slack: the patient is supine and flexes one leg at the knee and hip so that his heel is touching the medial aspect of his other outstretched leg just below the knee. Gravity-induced PIR is used for treatment. After taking up the slack, the patient raises his knee a little for about 20seconds (see Figure 6.126 A) and then lets it fall again while he relaxes (see Figure 6.126 B). After a further 20seconds, this procedure is repeated two or three times from the newly gained position.
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| Figure 6.126 |
For RI the simplest option is maximal active abduction.
The ischiocrural group of muscles
The basic function of the ischiocrural group of muscles is to fix the pelvis in an upright position. These muscles extend the hip and flex the knee. TrPs can be palpated along the course of these muscles and produce pain in the thigh and at the muscle attachment points, especially at the ischial tuberosity.
For treatment (and self-treatment), the patient is prone with his pelvis at the end of the treatment table so that both legs hang down (his feet may even be resting on the floor). The gravity-induced technique is used for PIR. The patient raises one outstretched leg a little from the floor (see Figure 6.127 A), holds for 20seconds, and then lets it sink back to the floor as he relaxes (see Figure 6.127 B). After a further 20seconds, this procedure is repeated two or three times.
For RI the patient exerts forceful pressure with his foot against the floor.
Rectus femoris
To examine for TrPs, the practitioner uses pincer palpation along the course of the rectus femoris; the diagnosis is usually made by applying the femoral nerve stretch test. Tension in the muscle is therefore generally increased in dysfunction of the L4 segment and in the L4 radicular syndrome.
For treatment and self-treatment, we use gravity-induced PIR. The patient is supine with one leg outstretched so that the lower leg hangs over the edge of the treatment table. Flexing his non-lesioned leg at the hip and knee, he draws it up toward his trunk using his hands, which are clasped round the tibial tuberosity. The patient then extends the knee of the leg to be treated and holds it for 20seconds (see Figure 6.128 A); he next relaxes and allows it to drop back down for 20seconds (see Figure 6.128 B). This procedure is repeated two or three times.
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| Figure 6.128 |
For RI he flexes his knee powerfully in the same position.
Piriformis
The TrP in the piriformis muscle is palpated as painful resistance above and medial to the greater trochanter. Given this location, it is hardly surprising that spontaneous discomfort here causes the patient to complain of ‘hip pain’ and is an obstacle to sleeping on the painful side at night. This TrP is generally linked with dysfunction of the motion segment L4/L5 and with the L5 radicular syndrome.
For treatment, the patient is prone: he flexes his knee at right angles on the side to be treated and allows his lower leg to fall outward. He then turns on to his side so that his lower leg is lying horizontal on the treatment table. The patient now raises his foot and lower leg by about 2cm (see Figure 6.129 A), holds this position for 20seconds, then lets them drop back down to the table surface (see Figure 6.129 B) and relaxes in that position for a further 20seconds. This procedure is repeated three times.
For RI the patient exerts forceful pressure with his lower leg against the padded surface of the treatment table.
Biceps femoris
Pain at the fibular head is the result of TrPs in the biceps femoris. For treatment, the practitioner stands at the foot end of the treatment table on the patient’s non-painful side. The patient is supine. With her right hand the practitioner grasps the patient’s right foot (or with her left hand his left foot), with her thumb at his heel and her little finger at his little toe, so as to rotate his foot inward. She then raises the patient’s stretched leg, bringing it simultaneously into internal rotation and adduction to take up the slack (see Figure 6.130 A). In this position the practitioner tells the patient to exert light pressure with his foot into external rotation against her resistance and to hold this for 5–10seconds. During the subsequent relaxation phase she increases rotation, straight leg raising and adduction. This procedure is repeated two or three times.
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| Figure 6.130 |
Self-treatment
For self-treatment, the patient stands with feet apart: the foot to be treated is rotated inward with its outer edge propped against a table leg, for example. To take up the slack the patient moves a step forward with his free foot and bends his knee, producing an increase in the inward rotation of the foot and in the tension of the ischiocrural muscles (see Figure 6.130 B). He then presses his foot (isometrically) against the table leg and holds this for 5–10seconds. While he relaxes, knee flexion and foot rotation increase. This procedure is repeated two or three times. This technique is awkward, which explains why mobilization of the fibula is generally used in practice.
Foot and toe extensors
Increased tension (TrPs) of the extensor muscles on the ventral aspect of the lower leg manifests itself primarily as fatigue pain. For treatment, the patient is seated. The practitioner sits next to him and places the lower leg to be treated across her thigh. With one hand she fixes his lower leg, and places her other hand dorsally over his forefoot and toes, simultaneously performing plantar flexion of the toes and foot to take up the slack (see Figure 6.131 A). She then tells the patient to resist for 5–10seconds before instructing him to let go until the slack is taken up again. This procedure is repeated two or three times.
For RI the patient offers resistance against rhythmic repetitive extension of the flexed toes.
Self-treatment
For self-treatment, the patient is seated and uses his opposite hand to flex his toes and forefoot (see Figure 6.131 B). The subsequent details are as described for the procedure performed by the practitioner.
Painful Achilles tendon
Pain at the Achilles tendon and at its attachment to the calcaneus is caused by TrPs with increased tension in the soleus muscle. For treatment, the patient lies prone with the knee on the lesioned side flexed. With one hand the practitioner takes hold of the patient’s foot and brings it into dorsiflexion and, depending on whether the tendon is tender on the medial or lateral side, either into pronation or supination to take up the slack on the painful side (see Figure 6.132 A). She then tells the patient to resist using counterpressure of minimum force for about 10seconds. During the subsequent relaxation phase, the patient is instructed to actively enhance dorsiflexion (= RI). This procedure is repeated with the goal of increasing dorsiflexion.
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| Figure 6.132 |
Self-treatment
Gravity-induced PIR is used for self-treatment. The patient stands in front of a table, supporting himself against it on his hands. He steps forward with the foot being treated and flexes his leading leg at the knee until the slack is taken up at the talocrural joint (see Figure 6.132 B). The patient resists with his foot in the direction of plantarflexion for 20seconds, after which he relaxes for a further 20seconds in dorsiflexion. This procedure is repeated three times.
Painful calcaneal spur
A painful calcaneal spur is caused by increased tension (TrPs) in the deep short toe flexors, which have their points of attachment there. For treatment, the patient is prone and flexes the knee of the leg to be treated. The practitioner places one hand round the patient’s heel and with her other hand takes hold of the patient’s forefoot; she next brings the forefoot and toes into dorsiflexion relative to the heel to take up the slack (see Figure 6.133 A). The patient is then told to flex his toes and forefoot relative to his heel, making his foot ‘hollow’; the practitioner offers light resistance to this flexion movement. As far as possible, all plantar flexion must be avoided. During the ensuing relaxation phase there is an increase in the dorsiflexion of the toes and forefoot relative to the heel. This procedure is repeated three times.
RI takes the form of dorsiflexion of the toes, against which the practitioner offers rhythmic repetitive resistance.
In chronic cases, there may be an indication for needling the TrP on the sole of the foot.
Self-treatment
Gravity-induced PIR is used for self-treatment. The patient is standing or seated with his feet on the floor. During the isometric phase he accentuates the arch of the foot by drawing his toes in and he holds this position for 20seconds (see Figure 6.133 B). He then relaxes again for 20seconds (see Figure 6.133 C) and this procedure is repeated three times.
In view of recent experience with the stabilization system of the feet, it seems both simpler and more effective to train automatic toe flexion by forward inclination during standing (see Section 6.8.8 and Figure 6.157).
6.7. Training weak muscles (facilitation)
In general, true paresis is absent in our patients; their muscle weakness is instead the result of inhibition and neglect or disuse. Our task is therefore to teach the patient how to use these neglected muscles correctly again. This goal can be achieved using a variety of facilitation methods, which will be described below. The common feature shared by all these methods is that the patient must become aware of the inhibited muscles. This means that for a certain period the patient must learn consciously to control these muscles until correct function becomes automatic again.
Facilitation implies creating ideal conditions for the weakened muscles. In this setting, posture has an especially important role to play. A bent posture intensifies the activity of the phylogenetically older, predominantly tonic muscles, whereas an upright posture with the extremities in slight abduction and external rotation facilitates the phylogenetically younger, phasic muscles with their tendency to become weak and inhibited. Exteroceptive stimulation in the form of specific judicious stroking also has a part to play here, enabling muscle tone to become balanced on both sides of the body.
6.7.1. Muscles of the trunk
The deep flexors of the neck
These muscles belong to the deep stabilization system and are therefore extremely important. Head anteflexion against resistance can be practiced very simply: the patient is seated at a table, with elbows on the table and chin cupped in both hands. She now pushes against the resistance of her hands. The exercise is effective but not specific for the deep neck flexors.
The following exercise is more specific and highly effective. The seated patient bends backward over the low back of a chair and in that position makes a nodding movement by drawing her chin down to her neck (see Figure 6.134). The exercise is repeated daily. Backward bending serves primarily to inhibit the sternocleidomastoid. The exercise can also be performed supine with the head retroflexed over the end of the treatment table; however, this modified version is very strenuous.
Using a pressure sensor inserted under the neck in the supine position, Jull (2000) discovered that patients following cervical spine injury are unable to exert pressure on the sensor with their neck without sternocleidomastoid contraction. This fact is exploited when exercising the deep neck flexors.
The patient is supine (or standing against a wall) and places two fingers laterally under his cervical spine, while with his other hand he palpates the sternocleidomastoid on the opposite side (see Figure 6.135). He then presses his fingers on his cervical spine and exerts counterpressure with his spine, but only for as long as the sternocleidomastoid does not contract. He then learns to increase the pressure against his own fingers using the deep neck flexors in such a way that the sternocleidomastoid does not contract.
The lower part of the trapezius
This muscle has a key role in the fixation of the shoulder blade. The following exercise should be carried out to facilitate contraction: the patient sits on her heels and bends her upper body and head forward to rest her forehead on the padded surface of the treatment table in front of her. As she does this she may lift her buttocks off her heels. Her hands are on the crown of her head, and her elbows are flexed and resting loosely on the treatment table roughly level with her ears (see Figure 6.136). Throughout the exercise her elbows should not be pressed down on to the padded surface. In this position the medial border of the shoulder blade diverges from the spinal column in a caudal direction. The patient is then told to draw her shoulder blade in a caudal direction, thus bringing the medial border of the shoulder blade parallel with the spinal column. The shoulder blades must not be drawn together in this process. To begin with, it is recommended that the practitioner touches the patient to indicate which muscle she should contract. It can often be helpful if the patient herself uses the thumb of her opposite hand to monitor the contraction of the lower part of the trapezius.
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| Figure 6.136 |
Once the patient has mastered this exercise in the facilitation position, she should learn to perform it in the prone position, with her arms by her sides in internal rotation. Immediately she manages to contract the lower part of the trapezius, the upper part will relax owing to reflex inhibition. Once the patient has mastered the contraction of the lower part of the trapezius in the prone position, she will also be able to do it upright, whether seated or standing. She can always use the thumb of her opposite hand to monitor the contraction of this muscle. This exercise plays a crucial role in good fixation of the shoulder blade.
Serratus anterior
This muscle, which also fixes the shoulder blade from below and is connected to the oblique abdominal muscles, can be tested and exercised using the following method. The patient is on all fours with head held horizontally. Her weight is mainly on her hands, which are in internal rotation so that the fingers are pointing toward each other (see Figure 6.137 A). She then performs a press-up so that her center of gravity is shifted forward and her elbows are pointing outward as she exhales. Her forehead is now pointing at the floor (see Figure 6.137 B). During this movement the contraction of her abdominal ‘muscle corset’ should fix her trunk. Her shoulder blades are kept maximally apart, and the muscles between them must show only eccentric contraction. One very important aspect is the contraction of the upper quadrants of the abdominal muscles because only then will the patient’s back remain as straight as a board. In lordosis the serratus anterior is unable to fix the shoulder blade and a winged scapula is seen (see Figure 6.137 C).
A comparable effect is achieved with the following exercise in which the patient, again on all fours, has a book resting on her occiput. It, too, trains the correct fixation of the shoulder girdle by contraction of the serratus anterior muscles and the lower part of the trapezius (see Figure 6.138). In this instance it is important that the patient supports herself radially on her thenar eminences. At the same time there should be coordinated contraction of the flexors and extensors of the cervical spine. The upper part of the trapezius remains relaxed and the abdominal muscles are contracted. The back and neck should be as straight as a board.
Rectus abdominis
The simplest test for this muscle is for the patient to sit up from the supine position and to lie back down again. In this process her legs remain bent at the hips and knees and her feet should not lift up from the mat. In order to practice coordination even more precisely, the patient may actively contract her knee flexors to press with her heels against an object solidly placed behnd her heels (see Figure 6.139 A). It would be a major error to fix her feet from above (see Figure 6.139 B). If the patient is unable to sit up in this way, and provided that her lumbar erector spinae is not too short, then she may train her abdominal muscles as follows: the patient is seated with legs flexed at the hips and knees, and then lies back slowly with her spine in kyphosis so that her lowest lumbar vertebrae touch the table first, followed in sequence by her other vertebrae up as far as the shoulders (eccentric contraction). The exercise must be stopped the moment the patient’s feet are lifted from the table or if lumbar kyphosis cannot be maintained. Only once the patient has learnt to lie down in this way from the sitting position should she attempt to sit up from the supine position by the same method in reverse.
Nowadays it is more common practice to exercise the deep stabilizers rather than the rectus abdominis.
The deep stabilizers of the lumbar spine and pelvic floor
In principle this group comprises the muscles of the pelvic floor, deep abdominal region, diaphragm, and the multifidus muscles. It is very important to note that the individual muscles form a chain so that the others also react when one is successfully facilitated. For practice, this is of major significance because not all these muscles are equally accessible to therapy; thus Hides (2004) principally advocates exercising the multifidus muscles, with visual feedback provided by ultrasound imaging. While we endeavor to use methods that are more accessible in a clinical setting, we share the view of that Australian physiotherapy team that the function of this system is of major importance and even today it represents uncharted territory.
The simplest way to start is for the patient to draw in his navel (see Figure 6.140). Here it is important for the abdominal wall laterally at the waist and for the lower abdomen to contract simultaneously (or autonomously). This primarily involves the transversus abdominis, but also the obliquus internus abdominis. There is a special reason for this contraction at the waist: it involves eccentric contraction of the abdominal wall coupled with concentric contraction of the diaphragm, unless the two are being exercised separately (see Figure 6.141).
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| Figure 6.140 |
Kolář’s tests, as outlined in Section 4.20.5, can also be used for the purposes of exercise: by raising his head and chest in the prone and/or supine position the patient learns to contract not only his abdominal or back muscles, but also the lateral part of the abdominal wall. The same applies for flexion of the bent legs against resistance, whether supine or sitting upright against gravity. If the patient is performing the exercise alone, it is always possible for him to use his own hands to check what is happening at the waist.
Transversus abdominis
Once the patient has mastered the previous exercises he can perform the following exercise himself, as developed by Wohlfahrt et al (1993). Lying supine, he raises and flexes his legs as if cycling and in so doing exerts pressure on a sensor placed beneath his lumbar spine. Then, instead of the pressure sensor, the patient inserts both hands (palms facing down against the padded table surface) and, by flexing his fingers, exerts pressure against his lumbar spine while simultaneously applying counterpressure against the backs of his hands (see Figure 6.142). To prevent any discomfort, the patient may cover the backs of his hands with a soft material.
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| Figure 6.142 |
This exercise can only be performed correctly if the patient has learnt to contract the lateral part of his abdominal wall and his lower abdomen; otherwise, in this exercise that is targeted specifically at the transversus abdominis, he will make his abdomen protrude.
Coccygeus
The following exercise is designed to help the patient learn both to contract and relax his pelvic floor, particularly the coccygeus muscle. For this it is necessary to distinguish the TrP and its significance here from the TrP in the levator ani that causes attachment point pain at the coccyx. Palpation of the TrP in the coccygeus has been described in Section 4.5.8 (see Figure 4.12).
The exercise begins with the side-lying patient drawing in his navel (the principle is illustrated in Figure 6.140). Once he is able to do this, he places the fingers of one hand flat over his anal region and attempts in a similar manner to draw this in (see Figure 6.143). The practitioner may ask the patient whether he can feel this happening. The problem is that there is no direct means of confirming contraction of the pelvic floor. The patient is therefore instructed to pinch his nose with his other hand and to breathe in against resistance with his mouth closed. The resultant suction will enable the patient to be considerably more aware (perhaps for the very first time) of pelvic floor contraction. In both scenarios it is possible to tell that the patient is actually contracting his pelvic floor. This exercise is repeated two or three times. The practitioner then checks whether palpation of the pelvic floor is still painful and to what extent the usually numerous additional TrPs and restrictions linked with the pelvic floor are still present. If the outcome is satisfactory, the patient can perform the exercise several times daily in the seated position, simultaneously drawing his navel in. He can also do this while at work without anyone noticing. The patient should be instructed always to perform the exercise slowly, otherwise relaxation will fail to materialize.
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| Figure 6.143 |
The exercise also shows that relaxation of the coccygeus takes place in an entirely different manner from relaxation of the levator ani. In the exercise to educate the levator ani and gluteus maximus, the patient clenches his buttocks together and also contracts his sphincter. In the present case, however, the buttocks are relaxed and the patient does the exercise while imagining that he is sucking something in. All this illustrates the two very different functions of the pelvic floor: first, as a component of the deep stabilization system, and second, in connection with sphincteric function.
The ‘cradle’
The patient lies supine, drawing her knees up to her chest and holding them there with her arms clasped. She then lifts her pelvis and brings her lumbar spine into kyphosis by contracting her gluteal muscles (hip extension), causing her arms around her knees to come under tension. At the same time she lifts her head and chest and breathes out, thus producing maximal contraction of her abdominal muscles. By rhythmic pressure of her knees against her clasped arms, she rocks herself up into a sitting position, before rolling on her lumbar kyphosis back to her starting position (see Figure 6.144 A and B). At a later stage she may perform this exercise without the help of her arms, which she holds out in front of her.
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| Figure 6.144 |
The purpose of this exercise is to strengthen and improve coordination between the abdominal and gluteal muscles and to relax the erector spinae.
The ‘pelvic see-saw’
The patient is supine with knees bent and feet placed flat on the treatment table. Breathing calmly and regularly, she brings her lumbar spine into lordosis by contracting her erector spinae (see Figure 6.145 A), and then relaxes the erector spinae while contracting her abdominal and gluteal muscles, thus flattening her lumbar spine against the treatment table.
Once the patient has mastered this phase, another element is added to the exercise. As before, she presses her entire lumbar spine flat against the treatment table without her calm breathing becoming irregular in any way. She then presses her knees together and, in a caudal-to-cranial sequence, raises first her pelvis, then her (kyphosed) lumbar spine, and finally her thoracic spine away from the treatment table while ensuring that her lumbar spine kyphosis is not reduced. Her knees remain pressed together and finally she clenches her buttocks to straighten her pelvis slightly more dorsally. Then in reverse sequence (thoracic spine, lumbar spine, pelvis) she lowers her back down on to the treatment table (see Figure 6.145 B).
The purposes of this exercise are to control pelvic movement, to coordinate the abdominal and buttock muscles, and to strengthen the gluteals in particular.
As a minor modification, and from the same starting position, the patient can press her lumbar spine flat against the treatment table while simultaneously stretching one leg (resting on its heel), but only so far that her lumbar spine does not diminish its pressure against the treatment table. The extent of this stretch will increase with practice.
6.7.2. Muscles of the hip
Gluteus maximus
If this muscle is found to be weak, that is if it is flaccid or displays only minimal activity during hyperextension of the hip (see Figure 4.47), the most effective and simplest facilitation technique is for the patient to lie prone and perform hyperextension with her leg in external rotation. However, if this is insufficient, the patient can consciously contract her buttocks and hold this contraction during hyperextension of the hip in the prone position.
In patients with hyperactive erector spinae and hyperlordosis, lordosis can be reduced by placing a cushion under the patient’s abdomen. She then again consciously contracts her buttock muscles and raises her extended leg very slightly so as not to lordose her lumbar spine or contract her erector spinae. Once she has mastered this she can learn to use both gluteus maximus muscles to reduce pelvic tilt – probably their most important postural function. For this, there is an especially effective exercise that is also used for self-mobilization of the lower lumbar spine (see Figure 6.70).
In the routine activities of daily living the gluteus maximus contracts primarily when a person rises vertically from a squatting or sitting position, that is the individual must not bend forward in the process. This can be practiced if the patient rises vertically from a chair and palpates her gluteus maximus on the side of the weakened buttock muscle.
Gluteus medius
The following method has proved most effective for facilitating the gluteus medius: the patient is side-lying and, because the gluteus medius is weak, she performs ‘false abduction’ chiefly using the tensor fasciae latae and the hip flexors (see Figure 4.48). The practitioner then passively performs maximum abduction correctly, and from that position suddenly and unexpectedly lets go of the patient’s leg. This will cause her gluteus medius to contract automatically. This maneuver is repeated, with the practitioner palpating first how the gluteus medius contracts (and later encouraging the patient to palpate this for herself). This will make the patient aware of her own gluteus medius. Once she has learnt to identify gluteus medius contraction, she can check this with her fingers. Within the space of a few exercises she will learn how to abduct her leg correctly – in the frontal plane – using the simultaneous and coordinated contraction of both the tensor fasciae latae and the gluteus medius.
6.8. Re-training to correct faulty movement patterns
6.8.1. Standing on both feet
An important criterion for standing posture is that it should be stable. Furthermore, the muscle activity required to maintain balance should be as minimal as possible. However, there is always some activity at the level of the feet, and this fact is consistent with the decisive role of the feet in this context. This is no mere coincidence: the major role played by the feet, together with the hands and mouth, is reflected in their extensive representation in the motor region of the cerebral cortex and in the fact that they have the highest density of sensory receptors. This is commensurate with the importance of the feet as stabilizers of upright posture. However, this function is constantly compromised by wearing shoes, which causes a certain degree of sensory deprivation.
First and foremost, therefore, it is necessary to activate the feet. In the ‘Chinese stance’ the patient stands with her legs slightly apart, her feet parallel to each other and knees slightly bent. This position greatly facilitates the activity of the foot flexors, enabling the patient to ‘grip’ the surface on which she is standing. Obviously, this is easier to do without shoes.
The stability of this type of standing can be tested very simply by giving a gentle unexpected push to the patient’s trunk from in front or behind. If she is standing in the conventional way with her feet in external rotation, she is likely to lose her balance. Her stability is greatly enhanced if she stands with legs slightly apart, feet parallel in slight internal rotation and knees bent. This, however, is not the only effect: the pelvis will automatically be in a neutral position, thus greatly improving body statics and posture.
6.8.2. Standing on one leg and walking
Because these are asymmetric functions, asymmetric exercises are used to bring about correction. The ability to stand correctly on one leg is also a prerequisite for a normal gait pattern because walking entails alternate standing on one leg (see Figure 4.77). However, a certain degree of asymmetry is normal, and this is why we distinguish the supporting leg from the free leg. The supporting leg is the one a person puts more weight on when standing at ease. The asymmetry should not be too marked, however. In both standing and walking, it is essential to pay attention to the activity of the feet, and of the toes in particular. In standing, the knee should be bent very slightly and the toes should be pressing against the floor. In walking, the heel strikes the ground first, then the foot rolls on to its lateral edge and its arch should not sink down medially. Pronation does not occur until toe-off; that is toe-off is achieved by the metacarpal bone of the hallux and flexion of all toes.
Understanding and correcting pelvic obliquity
The supine patient is instructed to push one leg and the corresponding side of her pelvis away from her in the direction of its long axis (see Figure 6.146). At the same time she is told to make the opposite movement with her other leg, thus producing pelvic obliquity due to contraction of her non-tense quadratus lumborum. While this is happening, her lumbar spine is firmly fixed against the treatment table by contraction of the abdominal musculature. Her other muscles are relaxed.
Rotation of the hip
The side-lying patient abducts (raises) her extended uppermost leg and (as in the preceding exercise) pushes it away from her. She then performs external and internal rotation of her foot (see Figure 6.147). In the process the position of her pelvis is fixed by her abdominal and buttock muscles.
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| Figure 6.147 |
The purpose of this exercise is to re-educate the hip muscles while the pelvis and lumbar spine are fixed in position.
Flexion and extension of the leg
As for the preceding exercise the patient is side-lying with her uppermost leg slightly raised (abducted) and flexed at the knee. This leg is then flexed at the hip (see Figure 6.148 A) and extended (see Figure 6.148 B).
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| Figure 6.148 |
Her pelvis and lumbar spine are fixed in position. Flexion of all leg joints is accompanied by moderate kyphosis of the lumbar spine via the pelvis. The abdominal muscles and hip flexors are involved in this movement. In the second phase of the exercise, as the leg is extended, all the extensor muscles of the leg contract, and the lumbar spine participates in this movement only by going into moderate lordosis. Correct contraction of the abdominal muscles should prevent hyperlordosis during extension. The exercise can be made easier if the practitioner offers light resistance at the knee against flexion and at the heel against extension.
The purpose of this exercise is to re-educate the hip stabilizers and abdominal muscles, and to re-learn the coordinated movement pattern as in walking where movement is controlled not by the hip but by the lumbar spine. It has proved effective to have the exercise performed side-lying, that is in an exercise position that is ‘unusual’ for the patient.
6.8.3. Sitting
See also Section 4.15.1.
Sitting erect with trunk rotation
The patient is seated on the floor, resting back on her ischial tuberosities. Her knees are parallel and slightly flexed, and her hands are clasped over her occiput (see Figure 6.149 A). The coordinated contraction of her abdominal muscles holds her spinal column erect in a neutral position. In the second phase of the exercise, the patient rotates her trunk from her hips up to and including her head (see Figure 6.149 B). The movement must be performed smoothly from bottom to top and back again. The patient’s spinal column must be kept vertical, avoiding all anteflexion, retroflexion, and side-bending.
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| Figure 6.149 |
This exercise is demanding because the patient’s pelvis is not fixed. Therefore it should be practiced initially with the patient sitting astride a chair or treatment table, thus fixing the pelvis. Good facilitation can be obtained if the patient looks toward the side of rotation and up a little, breathing in during rotation to the side and breathing out as she returns to a neutral position. All this holds true for trunk rotation while standing with legs apart.
Lateral movement of the thorax
The patient is seated on a chair with her feet supported on the floor, and preferably in front of a mirror so that she can correct her position. Her arms are held in abduction at 90°. She then moves her thorax to one side, as if someone were pulling her arm horizontally. If the patient contracts her abdominal wall correctly, her thoracic spine will move sideways without itself curving laterally (see Figure 6.150 A and B). During this sideways movement the patient’s body weight will shift on to one buttock and the leg on the same side. The exercise can be facilitated if the practitioner effects light resistance against the patient’s ribs, first from one side and then from the other.
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| Figure 6.150 |
The purpose of this exercise is for the patient to become aware of how to compensate for scoliotic posture and how to control the oblique and deep abdominal muscles that are so important in this context.
Correction of pelvic tilt while seated
The patient sits on a stool or on her heels facing a mirror. She first intentionally relaxes her abdominal muscles, bringing her lumbar spine into lordosis. She then slowly contracts her abdominal and gluteal muscles to cause lumbar kyphosis. Her shoulders should move as little as possible during this exercise.
The purpose of this exercise is for the patient to achieve ‘dynamic sitting’, something that can be practiced particularly well on an exercise ball.
6.8.4. Anteflexion
It is well-known that a stooped or forward-bent posture can be indicative of underlying pathology. However, anteflexion is an entirely normal function of the locomotor system that should not be avoided but carried out correctly.
Straightening up from anteflexion
The patient is seated on her heels, resting her hands on the floor in front of her knees. As she breathes calmly, her lumbar spine is in kyphosis (see Figure 6.151 A). On coordinated contraction of her abdominal and back muscles and with her pelvis fixed by her gluteals, the patient lifts her hands from the floor and her lumbar spine and thoracic spine straighten up (see Figure 6.151 B).
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| Figure 6.151 |
The purpose of this exercise is to prepare the patient for subsequent exercises.
Anteflexion and retroflexion of the trunk with pelvis upright
Standing erect, the patient contracts her abdominal and gluteal muscles, and begins anteflexion of the head and neck followed by her thoracic and lumbar spine. Her pelvis should remain upright, which means that anteflexion is never extremely pronounced. The patient never touches the floor with her hands, and usually cannot reach further than her knees. From this position she straightens up in reverse sequence (lumbar spine, thoracic spine, head) and continues seamlessly into retroflexion, contracting her gluteal muscles and pushing her pelvis forward. She then straightens up again to her starting position.
The purpose of this exercise is for the patient to learn how to control the position of her pelvis and to master the smooth straightening of her thoracic and lumbar spine.
Lifting an object
In a standing position, the patient places one foot forward, simultaneously bending her trunk and the knee of her forward leg to pick up the object (see Figure 4.72). In this way the load is evenly distributed between leg, pelvis, and trunk. She then straightens her trunk, simultaneously extending her forward leg and righting her pelvis using her gluteal and ischiocrural muscles, while her abdominal and back muscles control the (successive) uncurling of her spinal column. Facilitation of the abdominal muscles can be enhanced by the patient either breathing out against resistance or pressing her outstretched fingers toward the floor. Contraction of the abdominal muscles should be maintained as the patient straightens up and subsequently also during forward-bending, and she can check this using her fingers. She should also keep her trunk as close as possible to her thighs, which in turn prevents leverage. Her body’s center of gravity is over the advanced knee and is supported to some extent.
6.8.5. Lifting the arms
The critical constants here are correct fixation of the shoulder girdle and hence relaxation of the cervical spine.
Lifting the sideways-extended arms
The patient is prone, with arms relaxed and extended sideways and her forehead resting on the exercise mat. Her arms are in internal rotation with palms facing upward (see Figure 6.152 A). Her pelvis is fixed by the abdominal and gluteal musculature. The practitioner brings the patient’s shoulder blade passively into the correct starting position by raising her shoulders and moving her shoulder blades caudally. In this process the patient’s arms go into external rotation and her palms are now flat on the floor. In this position the patient now actively fixes her shoulders. She then raises her forehead slightly and moves her outstretched arms up toward the level of her head, rotating them further externally and lifting them only so far that her forearms are still touching the exercise surface while her shoulders remain higher than her hands (see Figure 6.152 B and C). In this process the lower fixators of her shoulder girdle remain contracted, while the upper fixators are relaxed. This exercise can be performed on one side initially, and later on both sides.
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| Figure 6.152 |
The purposes of this exercise are to enhance coordinated rotation at the shoulder while the upper shoulder blade fixators are relaxed, to achieve coordinated fixation of the trunk, to stretch the pectoralis, and to strengthen the lower shoulder blade fixators.
Raising and lowering the shoulders
The patient is seated erect on a chair, preferably in front of a mirror, with arms hanging down. As forcefully as she can, she fixes her shoulder blades using the lower shoulder blade fixators (see Figure 6.153 A). Now chiefly using the levator scapulae, she lifts her shoulders, leaving the upper part of the trapezius as relaxed as possible while activating the lower part (see Figure 6.153 B). If only one side is being exercised, the patient can check the lower part of the trapezius with her other hand.
The purpose of this exercise is for the patient to learn to feel the relaxation of the upper fixators of the shoulder while consciously contracting the lower fixators.
Lifting the arms above head height
The patient is seated erect on a chair and performs a routine movement, bringing one hand up to her head (e.g. as when combing her hair). It is important that the shoulder blades are fixed properly, the neck muscles are relaxed, and head posture is correct. The levator scapulae and upper part of the trapezius should also remain relaxed (see Figure 6.154 A). The exercise can be performed on one side only, and if done on both sides, the two hands do not need to be lifted equally high.
Head rotation
The patient, who is seated on a chair, is instructed to rotate her head. There should be rotation of the cervical and upper thoracic spine, and the shoulder blades should remain fixed from below, with the upper shoulder blade fixators relaxed (see Section 4.15.1, Figure 4.75). There should be no side-bending and the rotational movement should be around the vertical axis of the body.
The purpose of this exercise is to train properly coordinated head rotation with the upper shoulder blade fixators relaxed.
6.8.6. Carrying loads correctly
For correct load-carrying, the proper fixation of the shoulder blades is just as essential as during lifting of the arms. Here, however, special attention must be paid to relaxing the subclavicular part of the pectoralis major so as to avoid drawing the shoulders forward. The coordinated contraction of the interscapular muscles is also important. Once the patient succeeds in holding her shoulders back behind the body’s gravity line, the upper fixators of the shoulder girdle remain relaxed and the load being carried is not transmitted to the cervical spine (see Figure 4.76). It is no less important to keep the head back, otherwise the shoulders are again drawn forward. It is also necessary to relax the hands when carrying something and not to actively flex the fingers, instead holding a handle by the terminal phalanges, whenever possible. In fact, the terminal phalanges flex automatically thanks to the same mechanism that enables rock-climbers to hold on to the rock face without actively flexing their fingers. This also helps to prevent epicondylopathy.
6.8.7. Breathing
The most serious fault here is clavicular breathing in which the thorax is lifted during inhalation (see Figure 4.78). When this occurs, the tensed scalenes take over the activity of the diaphragm, which means that the deep stabilizers are no longer able to function as they should. In this faulty breathing pattern, not only is the cervical spine constantly overloaded, but the thorax also moves away from the pelvis with every breath taken, causing the diaphragm to tilt and abolishing any fixation of the thorax from below by the abdominal wall. The first step is to restore coordinated activity between the diaphragm and the deep abdominal muscles. As preparation for this it is also helpful to relax the scalenes (see Figure 6.94).
During normal breathing there is eccentric contraction of the transversus abdominis as a result of the concentric contraction of the diaphragm during inhalation, which can be easily palpated at the waist and lateral abdominal wall. To teach this to the patient, the practitioner places his hands with the radial edge of his forefingers at the waist and tells the patient to apply pressure against the fingers at the waist. After a little stimulation with the hands, this will be learned in most cases. However, if this fails to work, the patient should exercise using one of the tests described in Figure 6.140, Figure 6.141, Figure 6.142 and Figure 6.143, which are designed to contract this muscle group.
Once the patient is able to contract the lateral abdominal wall, he is asked to lie supine. The practitioner stands at the head of the treatment table and places both hands over the patient’s lower thorax. As the thorax is usually fixed in an inspiratory position, the practitioner first mobilizes the thorax in a caudal direction during exhalation and then stimulates the lateral abdominal wall with his forefingers (see Figure 6.155). The patient is instructed to breathe out. As he then breathes in, the practitioner uses his hands to prevent the patient’s thorax from moving cranially and simultaneously stimulates the lateral abdominal wall so that the patient feels how to fix his thorax himself using his own muscles. This process helps to coordinate the concentric contraction of the diaphragm and the eccentric contraction of the transversus abdominis in particular. After taking a few breaths, the patient will learn to fix his thorax himself using his abdominal muscles. The practitioner next insists that the patient also contracts his lower abdomen, thus preventing his navel from moving cranially and his abdomen from protruding.
Once the patient is breathing properly in the supine position, he is invited to sit on a chair. He should be erect and not leaning back, stabilizing himself with both legs in slight abduction and feet rotated externally; he can check his position in the mirror. In this position the practitioner starts by placing his hands on the patient’s waist while simultaneously checking the lower abdomen with his fingers. As soon as he notices that the patient is contracting his lateral abdominal wall and lower abdomen, and that his thorax is widening instead of lifting as he breathes in, then the practitioner places the patient’s hands on his waist so that he can feel with the radial edge of his forefingers for himself the contraction of the lateral abdominal wall and palpate with his other fingers his lower abdomen. He can also watch his clavicles in the mirror to check that these are not lifting during inhalation (see Figure 6.156). After a few repeats, the patient will be able to perform the exercise at home in front of the mirror several times a day. After 10–14 days he should attend a follow-up appointment where the main focus will be to establish whether and how he has practiced and what still needs to be corrected. It should also be clarified whether the exercise has helped the patient. Mastery of correct breathing technique is usually associated with restoration of deep stabilizer function.
Actively exercising the deep stabilizers and their function during breathing has the following astounding effect: TrPs and movement restrictions, including chain reaction patterns, are routinely resolved in the same way as after PIR, RI, and manipulation (mobilization). It is impossible to overestimate the importance of the activity and cooperation of the patient here.
6.8.8. The feet
In our earlier discussion of the key regions in the locomotor system, we already emphasized the absolutely crucial role played by the feet. This is reflected in the simple fact that the feet have the highest density of sensory receptors, and is also commensurate with their very significant level of representation in the sensorimotor part of the cerebral cortex. Clinically, this is manifested among other things in the unusually frequent chain reaction patterns that have their origin in the feet. It was clearly stated earlier (see Section 4.20) that the deep stabilizers are the source of the commonest chain reaction patterns, and the same claim can be made emphatically for the feet.
The latest research findings indicate that the feet form a functional unit with the deep stabilizers, as illustrated by the following: the feet play a prominent role in maintaining balance, especially in the sagittal plane. As is well known, when we stand ‘at ease’ our muscles are constantly having to compensate for the oscillations of our body in all directions in order for us to keep our balance. If the feet are functioning well, then the greatest muscle activity occurs in the muscles of the lower legs and feet. It has also been emphasized that one of the characteristics of the deep stabilizers (e.g. the transversus abdominis or the muscles of the pelvic floor) is that we do not generally move them consciously; therefore we have to learn how to control them deliberately. A similar situation occurs with the autochthonous muscles of the foot; it is difficult consciously to accentuate the arch of the foot using the deep plantar flexors or to abduct the hallux.
However, one special characteristic of the feet – something that is not as evident anywhere else in the locomotor system – is their tactile sensitivity and, in this connection, it is possible to use afferent impulses to achieve clinical effects. Although it is repeatedly stressed that the nervous system is an information-processing organ, our knowledge is insufficient to achieve rehabilitation. However, amazing successes in this respect have been recorded with the feet. And here, too, it can be seen especially clearly how sensitivity is linked with changes in muscle tonus (see Section 6.3). This sensitivity of the soles of the feet to exteroceptive stimuli may also be linked to the fact that the feet are shielded by footwear from a host of physiological stimuli and are suffering from constant sensory deprivation.
The following treatment option may therefore be inferred: if we notice during stroking (light scratching) that the patient’s reaction is not symmetrical on both sides and/or the patient informs us that stroking is sensed differently on both soles (and neurological disease has been excluded), we can be satisfied that tonus differences are present in the soles of the feet. If this is the case, then the most effective therapy for TrPs and movement restrictions in the feet and for chain reaction patterns emanating from the feet (most typically on leaning forward) is exteroceptive stimulation of the sole of the foot on the side with the clinical abnormality. The technique that has proved most effective is to trace numbers and letters on the sole and to ask the patient to identify them. Not only is superficial sensitivity addressed but also proprioception, and because the patient focuses attention on deciphering the numbers/letters, the technique is better tolerated in the event of ticklishness.
Functional pes planus (flat foot)
Rehabilitation per se is primarily directed at ‘functional’ pes planus, a condition in which the arch of the foot collapses during the gait cycle, irrespective of whether the foot is normal or flat in purely morphological terms. And here again it has proved useful to exploit afferent impulses. In the gait cycle, after heel-strike, the foot normally rolls first on to its lateral edge, then goes into pronation on toe-off, before completing toe-off in pronation by pushing off with the toes, especially the hallux. Therefore, if pronation occurs prematurely, that is if the foot does not remain on its lateral edge and collapses, then the patient should be instructed when walking to perceive or sense the lateral edge of the foot. If pes planus is not extreme, then the longitudinal arch will momentarily hold far better. The patient then needs to be told constantly to cultivate this ‘awareness’ when walking, regardless of whether barefoot or wearing shoes.
Functional pes planus is also commonly characterized by diminished tonus. As well as exteroceptive stimulation, gentle pressure along the longitudinal axis of the toes has also proved beneficial, that is pressure that is transmitted to the interphalangeal and metacarpophalangeal joints and constitutes a proprioceptive stimulus.
Splay foot
Splay foot is primarily a weakness of the foot and toe flexors in terms of their postural function. Patients are generally able to flex their toes strongly without difficulty but are unable to utilize this in the toe-off phase of the gait cycle. This is indicated by the fact that the toes are unable to perform the test devised by Véle (personal communication). For this, the barefoot patient shifts his body weight forward without lifting his heels from the floor. Normally, this movement automatically produces flexion of the toes, probably as they seek to prevent the person falling forward. Véle has shown that this reaction is absent on the lesioned side in the S1 radicular syndrome. However, it is very much more common for this sign to be positive in functional faulty movement patterns of the foot stabilizers, that is when toe flexion is absent (see Figure 6.157). For rehabilitation, the patient learns to achieve automatic and sufficiently strong toe flexion by rocking back and forth on both feet slowly, and relaxing when rocking back. Recent experience has shown that this rocking technique is the most effective method of mobilization and relaxation for the treatment of restrictions and TrPs in the feet and of chain reaction patterns related to foot dysfunction (e.g. forward-drawn posture). This is true regardless of whether the reaction of the toes on forward rocking is abnormal or entirely normal.
This exercise, together with gait training in which the patient learns awareness of the lateral edge of the foot, eliminates TrPs and movement restrictions in the same way as when exercising the deep stabilizers of the trunk – further evidence that the feet are also a component part of the deep stabilization system.
Where pain due to splay foot is present, it is often the metatarsophalangeal joint of the fourth toe that is worst affected, with pressure from a plantar direction being extremely painful. In these circumstances, counterstrain is often instantaneously effective: for this, the patient applies dorsal pressure on to the transverse arch of the foot at the level of the metatarsal heads, fixes the first and fifth metacarpal bones, and holds this pressure for 90seconds. Padded shoe inserts are also effective, especially when placed under the fourth metatarsophalangeal joint.
Abductor pollicis brevis and hallux valgus
Weakness is often also detected in another postural muscle, the abductor pollicis brevis, especially if hallux valgus is developing. The patient must then learn to abduct the big toe or perform fan-wise abduction of the toes, including the little toe. This, too, is a predominantly postural function, a fact that explains why some time is generally needed before the patient masters it. However, motivation to persist should stem from the experience that active abduction brings immediate relief from the pain of hallux valgus.
Dorsiflexion
The form of weakness most commonly encountered is that involving dorsiflexion of the foot, with the big toe usually being most affected. Among a wide spectrum of possible causes, the commonest is a radicular lesion at L5. In terms of rehabilitation, it is especially effective and simple to utilize the great extent to which the big toe is represented in the sensorimotor cerebral cortex. Rather than advising patients to practice dorsiflexion as assiduously as possible, they should instead be counseled to think of their big toe as often as possible, especially when walking – even when wearing shoes.
6.8.9. The shoulder blade and upper cervical spine
The muscles which stabilize the shoulder blade play a similar role for the upper extremities to that played by the deep stabilizing system of the trunk for the lumbar spine. The most important muscles here are the lower (ascending) part of the trapezius and the caudal part of the serratus anterior. If these muscles are weak, active caudal movement of the shoulder (shoulder blade) with the patient prone does not produce the normal caudal and slightly medial movement of the inferior angle of the shoulder blade; instead the inferior angle of the shoulder blade protrudes like a hook toward the spinal column. This movement can be easily resisted if the practitioner catches the lower angle of the scapular wing between thumb and forefinger. In contrast, the normal movement in a caudal and slightly medial direction cannot be resisted at all.
Training the correct function of the lower fixators of the shoulder blade is described in Section 6.7.1 (see Figure 6.136). The patient learns to palpate the contraction of the lower part of the trapezius, first in the position of facilitation and then sitting. The patient next trains the fixators of the shoulder blade (see Figure 6.137). Immediately after this exercise it frequently happens that there is a marked improvement in TrPs and restrictions in the upper extremity, for example in epicondylar pain and painful shoulder. Current experience indicates that, in painful conditions of the upper extremity, the stabilizing muscles of the shoulder blade play an even greater role than the cervical spine, which itself is stabilized by the shoulder blade.
The extremely labile craniocervical junction is stabilized mainly by the short extensors and the deep flexors. In ancient times, people used to carry heavy loads on their heads, thus improving their posture. While this practice can certainly be recommended even today, it is not readily accepted. Clinical experience has shown that rapid, shaking, vertical pressure in the direction of the axis of the cervical spine with the patient upright engages the deep stabilizing system of the cervical spine and has a strong mobilizing effect on restrictions and relaxes TrPs (see Sections 6.1.3 and 6.5.6 and Figure 6.81 C).
6.8.10. The hands
Probably the most common disorder is cramping of the hands and the hypertonus associated with it. Once again, stroking along the axis of the fingers and metacarpals is indicated here. Helpful self-treatments include wriggling the fingers in a bowl of uncooked rice or peas, or playing/exercising with a soft rubber ball.
For hypertonus of the hands, axial pressure via the fingertips is indicated, placing the interphalangeal and metacarpophalangeal joints under pressure.
6.9. Supports
So far this chapter has been devoted to techniques that restore normal mobility and function; it is beyond the scope of this book to deal with immobilization techniques. However, it will be useful to discuss some simple supports that do not necessarily entail immobilization and can often be acquired by patients themselves.
6.9.1. Cervical collar
A simple cervical collar made of latex foam can be very effective (see Figure 6.158). As soon as the soft material is placed round the neck to form a tube, it is sufficiently firm to support the cervical spine. Such collars are chiefly prescribed to protect patients from jolting and jarring their neck during road and rail journeys. However, wearing a cervical collar should not become a permanent habit.
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| Figure 6.158 |
6.9.2. Inflatable cushion
If they are able to lean against a chair back, hypermobile patients with a tendency to sag into kyphosis when seated should carry an inflatable cushion, fixed by braces or a belt, especially for use during car journeys (see Figure 6.159). The cushion should be only slightly inflated, and should be fitted to provide support at the point where the kyphosis peaks when the patient is sitting relaxed (see Figure 6.160 A). The practitioner can be satisfied as to the correct placement of the cushion if he first supports the patient with his fist as he sits erect and tells him to relax (see Figure 6.160 B).
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| Figure 6.159 |
6.9.3. Pelvic belt (Biedermann and Cyriax)
Use of a pelvic belt is indicated in patients with a ‘loosened’ pelvis, especially after childbirth. This is a leather belt that is 8–10cm wide and has a padded lining on its inner surface. The belt should be worn below the iliac crests and above the greater trochanters (see Figure 6.161). To achieve sufficient tension, it is recommended that the belt be fastened below the pelvis at thigh level and then pulled up over the greater trochanters. It should be worn for at least six weeks, particularly at night but may also be worn through the day.
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| Figure 6.161 |
A pelvic belt may also be prescribed for patients with extensively weakened abdominal muscles in whom rehabilitation is a lost cause. This is not uncommonly the case in obese patients who have undergone multiple surgical procedures and in multiparous women. A key consideration here is that the belt should be worn so that it supports the (overhanging) lower abdomen from below and does not compress the abdomen.
6.10. Local anesthesia
Within the scope of this volume it is not possible to cover the innumerable treatment methods that employ reflex mechanisms. The method that is probably most popular is local anesthesia. As already emphasized in Section 5.3.3, there is no essential difference between the effect of local anesthesia and of dry needling (Frost et al 1980). The critical factor is technique. The needle must touch the point where pain is maximal. It is not enough for the patient to feel pain; this pain must be sufficiently intense for the patient to react involuntarily, and wherever possible, the pain thus provoked should reproduce the patient’s spontaneous pain. Only when the most painful point in the pain zone is touched will needling achieve immediate alleviation (frequently elimination) of pain, affording relief that is just as intense as that of a local anesthetic, a fact that the patient can also corroborate instantly.
The advantage of dry needling is that the position of the needle can be corrected if an analgesic effect is not obtained immediately. If the most painful point is not touched by the needle in local anesthesia, the effect is considerably diminished as soon as the local anesthetic wears off.
If, however, the object is to achieve conduction anesthesia (e.g. of a painful nerve root or a peripheral nerve) or epidural anesthesia is required, then the administration of a local anesthetic is indispensable.
The treatment of TrPs involves the use of methods that employ reflex mechanisms: PIR, RI, minimal pressure, mobilization and/or manipulation of joints and often even of chain reaction patterns arising as a result of treatment of other, often remote TrPs and other dysfunctions. However, there are some TrPs that are not (or no longer) entirely reversible, where needling or traumatic massage are necessary. In such circumstances, however, needling is not so much a form of reflex therapy but more a form of traumatization (microsurgery).
