OMM Techniques: MSIIFall Semester

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OMM TechniquesMSII-Fall Semester
Re-organized from Arnold Cuencas powerpoint
study guides and OMM lectures Final
Practical Fall, 2003
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Disclaimer

• This is a STUDY AID, not a STUDY REPLACEMENT and
  should be used with discretion. The user is
  responsible for knowing all material presented in
  the classroom

Note There are some pictures missing
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Stuff for Midterm Practical, fall 2003

• Articulatory
• Counterstrain
• HVLA
• Lymphatics
• Muscle Energy
• Myofascial Release
• Soft Tissue
• Still Technique

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ARTICULATORY TECHNIQUES

• What is the technique?
• Direct
• Passive
• Engages the Barrier
• Low Velocity, High Amplitude
• Why do you to the technique?
• Gap the joints and separate the facets
• Increase range of motion
• Prepare the patient for HVLA
• Decrease tissue tension
• Enhance lymphatic flow

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CERVICAL ARTICULATORY TECHNIQUES Flexion

• Pt. Supine
• Dr. facing Pt.
• Place one hand on Pt.s shoulder
• Place other hand cradling the occiput
• Lift the head until full flexion is obtained
• Repeat smoothly in a rhythmic fashion, each time
  increasing range of motion
• RE-TEST range of motion

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CERVICAL ARTICULATORY TECHNIQUES Extension

• Pt. Supine
• Dr. facing Pt.
• Place one hand under Pt.s neck and use thumb and
  forefinger as fulcrum by pressing them against
  articular pillars of a vertebra
• Grasp Pt.s chin with other hand and lift fulcrum
  and chin to extend the neck
• Use smooth, rhythmic motion several times, on
  each vertebrae
• RE-TEST range of motion

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CERVICAL ARTICULATORY TECHNIQUES Rotation

• Pt. Supine
• Dr. facing Pt.
• Grasp the chin with one hand and the occiput with
  the other
• Rotate the head to one side and engage the
  barrier, then return partway towards neutral
• Repeat several times, each time increasing range
  of motion (slow and rhythmic)
• RE-TEST range of motion

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CERVICAL ARTICULATORY TECHNIQUES Sidebending

• Pt. Supine
• Dr. at head of table
• Place one hand on shoulder, using other hand to
  cradle the occiput
• Firmly sidebend neck towards opposite shoulder
• Engage the barrier and repeat several times using
  a slow, rhythmic motion
• RE-TEST

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ARTICULATORY TECHNIQUESRIBS (Anterior)

• Dr. stands on side of SUPINE Pt.
• Grasp wrist with cephalad hand
• Stabilize anterior ribs with caudad hand (for
  females, have them cover their breasts)
• Use ulnar border and little finger, thumb and
  thenar eminence, or group the fingertips in a row
• Stretch arm upwards into flexion to point where
  elbow is straight and behind head
• Use respiratory cooperation as Pt. Inhales, flex
  
• During exhalation, return partly back to neutral
• This stretches pectoralis minor (ribs 3-5) and
  serratus anterior (ribs 6-10) to pull towards
  pump handle inhalation
• Repeat several times
• RE-TEST

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ARTICULATORY TECHNIQUESRIBS (Posterior)

• Dr. stands at head of table with Pt. PRONE
• Grasp the Pt.s arm just proximal to elbow
• Stabilize each rib in sequence with thumb and
  thenar eminence at the rib angle
• Stretch arm into full abduction
• Use respiratory cooperation as Pt. inhales,
  abduct
• During exhalation, return partly back to neutral
• This stretches primarily serratus anterior (ribs
  1-9) toward bucket handle inhalation
• Repeat several times
• RE-TEST

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ARTICULATORY TECHNIQUESRIBS (Lateral)

• Dr. faces lateral recumbent Pt.
• Dr. grasps Pt.s elbow which is flexed
• Stabilize each rib in the mid-axillary line with
  thumb and thenar eminence
• Stretch shoulder into full abduction
• Use respiratory cooperation as before
• This stretches primarily serratus anterior (ribs
  1-9) toward bucket handle inhalation
• Repeat several times
• Repeat other side
• RE-TEST

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ARTICULATORY TECHNIQUESRIBS (Elevation)

• Dr. stands to side of SUPINE Pt.
• Dr. lifts arm into full abduction so that wrist
  is held firmly in cephalad axilla
• Place one hand under Pt.s scapula
• Press tips of fingers anteriorly against angles
  of Pt.s ribs, and caudal
• Simultaneously stretch Pt.s arm superiorly and
  laterally
• This stretches primarily serratus anterior (ribs
  1-9) into bucket handle inhalation
• Repeat several times
• Repeat on other side
• RE-TEST

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ARTICULATORY TECHNIQUESRIBS (Seated)

• Pt. seated, Dr. in front of patient
• Pt. crosses arms on Dr.s chest (or shoulders)
  with head resting on his/her arms
• Dr. places fingerpads on posterior rib angles
• Pull anteriorly and laterally to draw rib angles
  lateral
• At the same time, extend the spine and lift the
  arms (elbows) to flex the arms at the shoulders
• This articulates ribs toward pump handle
  inspiration
• Add respiratory cooperation to exaggerate range
  of motion of the ribs
• Repeat until ribs move easily

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Spencer Technique

• An articulatory technique for the shoulder
  developed by Charles Spencer, DO
• Allows for evaluation of shoulder ROM
• Useful in monitoring changes in shoulder
  dysfunction with tx
• Indications adhesive capsulitis, bursitis,
  tenosynovitis patients with decreased shoulder
  motion and pain

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Spencer Technique
Extension
Circumduction/ Compression
Flexion
Circumduction/ Traction
Adduction, External Rotation
Abduction, Internal Rotation
Flexion, Internal Rotation, Abduction
Tissue Stretch, Fluid Pump
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Patient positioning and Tx Technique

• Patient lateral recumbent with affected shoulder
  up
• Patients back perpendicular to table
• Place pillow under patients head for support
• Adjust degree of force with respect to patients
  pain threshold

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Stage 1Extension

• Stabilize shoulder
• Extend
• 8-10 repetitions
• ME component

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Stage 2 Flexion

• Stabilize shoulder
• Flex
• 8-10 repetitions
• ME component

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Stage 3 Circumduction with Compression

• Stabilize shoulder
• Flex and abduct to 90
• Add compression
• Circumduct clockwise and counterclockwise 8-10
  times
• Gradually increase diameter of concentric circles

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Stage 4 Circumduction with Traction

• Stabilize shoulder
• Extend elbow and abduct to 90
• Add traction
• Circumduct clockwise and counterclockwise 8-10
  times
• Gradually increase diameter of concentric circles

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Stage 5a Addn, Horizontal Flexion,Extl Rotn

• Stabilize shoulder place patients hand on your
  cephalad hand
• Push patients elbow toward the table with caudad
  hand
• 8-10 repetitions
• ME component

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Step 5b Abduction,Internal Rotation

• Stabilize shoulder place patients hand on your
  cephalad hand
• Push patients elbow toward his head with caudad
  hand
• 8-10 repetitions
• ME component

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Stage 6 Internal Rotation, Abduction, Flexion

• Stabilize shoulder
• Place patients hand in his lumbosacral region
• Pull patients elbow anterior and medial
• 8-10 repetitions
• ME component

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Stage 7 Fluid pump and Tissue Stretch

• Place patients extended arm on your shoulder
• Grasp patients humeral head with your
  interlocking fingers
• Maintain traction on the arm while gently moving
  humeral head to scoop out glenoid cavity

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Articulatory Supine Shoulder

• Shoulder flexion restriction (0-180 degrees)
• Stand at head of table, grasp arm to be treated
  at wrist with one hand, and just proximal to the
  elbow with the other hand.
• Gently treat by rhythmically moving the extremity
  within an arc of motion that causes some pain
  (should be less than 4 out of a 0-10 scale by
  patient report). As pain decreases with
  repetitive motion, increase the ROM towards the
  restrictive barrier
• Shoulder extension restriction (0-40-60 degrees)
• Stand or sit beside patient on restricted side.
  Place one hand on ant. Shoulder for stabilization
  and with other hand, grasp patients wrist.
  Gently treat by rhythmically moving extremity
  within an arc of motion that confronts the
  barrier /or causes some pain. (lt4 on 0-10
  scale). Repetitive articulations should cause
  pain to decrease, allowing increase of ROM to a
  new motion barrier. Treat until as much ROM as
  possible is restored.

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Articulatory Wrist/Hand

• Patient is seated. Operator stands in front of
  patient. Use one hand to grasp patients distal
  forearm just proximal to wrist. Use other hand to
  grasp patients hand just distal to wrist.
• Use increasing arcs of affected ROM to restore
  mobility to wrist and hand area.

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Counterstrain

• What is it?
• Passive, positional technique that utilizes
  tender points
• Places a segment (spinal or other) in a position
  of comfort
• Technique treats the somatic dyfunction, NOT THE
  TENDER POINT
• Why do it?
• Shortens involved muscles and connective tissue
• It arrests inappropriate nociceptive and
  proprioceptive activity that maintains the
  somatic dysfunction
• Inhibition of inappropriate strain reflex

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Anterior Cervical Counterstrain
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Anterior Cervical Counterstrain
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Posterior Cervical Counterstrain
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Summary of Posterior Cervical Points
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Anterior Counterstrain Points
iliac crest, in mid-axillary line, supero-medial
surface of ilium
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AT 3-4 Cuff em AT 9-11 Invade em
AT 1-2 Youre under arrest AT 5-8 Stuff em
AT 12- Rotate knees/ankles toward you
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Post. Thoracic CS PointsESARA

• Pt. prone with arms hanging over sides of table
  (1,2,3..hug a tree)
• Dr. supports Pt.s head by cupping point of chin
  in hand
• Dr. applies force straight posterior, bringing
  neck into extension
• Dr. monitors greatest tenderness very close to,
  or on midline, of spinous process of
  corresponding vertebral level
• Dr. fine tunes position to point of least
  tenderness by Extending, Side bending Away,
  Rotating Away the head (ESARA)
• Hold for 90 seconds
• Slowly bring back to neutral
• Retest

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1, 2, 3 Hug A Tree
4, 5, 6 Arms Like Sticks
7, 8, 9 Use A Pillow By This Time
10, 11, 12 Rotate The Pelv
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Anterior RibsCounterStrain (2min)
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Posterior RibsCounterstrain (2min)
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Anterior LumbarCounterStrain
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Posterior lumbarCounterstrain
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Anterior PelvisCounterstrain

• Adductor
• Iliacus
• Inguinal Ligament

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Adductor (ADD)

• In the adductor muscle near its origin on the
  pubic bone.
• Can be very tender.

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Adductor (ADD)

• Patient supine.
• Physician on opposite side of tender point.
• Slight flexion of the hip with marked adduction
  of the thigh and slight rotation

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Iliacus (IL)

• Located over the lower quadrant of the iliac
  fossa.
• 4 cm medial and slightly inferior to the ASIS

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Iliacus (IL)

• Patient supine.
• Physician on same side as tender point.
• Hips and knees flexed.
• Marked external rotation of thigh and ABduction
• Yoga or frog position.

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Inguinal Ligament (InL)

• Lateral border of the pubic bone, close to the
  medial attachment of the inguinal ligament.

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Inguinal Ligament (InL)

• Patient supine.
• Physician on same side of tender point.
• Hips and knees flexed 90o onto physicians thigh.
• Cross leg on opposite side of tender point over
  the other leg.
• Internally rotate thigh on affected side by
  pulling foot laterally.

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Posterior Pelviscounterstrain

• Gemelli
• Midpole Sacroiliac
• Piriformis

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Gemelli (GEM)

• 4 cm caudad to the posterior medial surface of
  the greater trochanter.

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Gemelli (GEM)

• Physician stands on the opposite side of
  dysfunction.
• Patient prone.
• Knee flexed to 90 degrees.
• Thigh extended, externally rotated and adducted.

Use pillow on same side
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Midpole sacroiliac MPSI

• Middle of the gluteus maxiums
• Inferior to the lower edge of the PSIS, approx.
  9cm
• slightly lateral

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Midpole sacroiliac MPSI

• Pt Prone
• Abd thigh
• Fine tune with Flex/Ext

Coccydynia
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Piriformis (PIR)

• Midway between the greater trochanter and the
  ILA., in the belly of the piriformis m.
• Press medially.

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Piriformis (PIR)

• Patient prone with hip suspended over the side of
  the table.
• Hip flexed to 90-135 degrees with hip abduction
  and external rotation.

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Upper Extremity Shoulder

• Supraspinatus (SUP)
• Belly of supraspinatus m.
• Tx Pt. supine, F. humerus to 45, abduct to 45,
  EROT to 45
• Teres minor (TMI)
• lat. Border of scapula at the origin of teres
  minor m.
• Tx Pt. supine. Marked EROT of humerus, with
  slight F abdn, as needed
• Long head biceps (LH)
• In bicipital groove of humerus
• Tx Pt. Supine. Supinate pts forearm, then F.
  humerus with palmar aspect of wrist placed on
  forehead, I/EROT as needed.

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Upper Extremity Elbow/wrist

• Radial head (RAD)
• Anterolat surface of head of radius
• tx supine, fully E. pts arm/wrist, add
  supination of forearm with addn and abdn as
  needed.
• Flexion thumb and wrist (CMI)
• Lat. Surface of prox 1st Metacarpal
• Tx fully F. pts wrist, E. thumb toward elbow,
  add wrist addn or abdn as needed.
• Neutral wrist (WRI)
• Multiple points at distal wrist crease, at carpal
  bones
• Tx F. pts wrist with deviation of wrist toward
  tenderpoint, and add pronation/supination as
  needed.

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HVLA

• What is it?
• Passive, Direct, High Velocity/Low Amplitude
  technique
• Engages the barrier
• Why do it?
• Increase range of movement
• Restore normal joint receptor activity
• Decrease muscle spasm and hypertonicity
• Stretch connective tissue

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HVLA OA

• ? EXAMPLE SRRL
• SOFT TISSUE FIRST!!
• R hand cups chin, palm on zygoma
• L MP or PIP of index finger on bony calvarium of
  occiput
• Add a mild extension component limited to OA
• Rotate head to R
• Sidebend head to L and step slightly to the L of
  patient
• Approach the barrier
• Pt. inhales and at end point of exhalation, apply
  impulse toward R eye
• RETEST

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HVLA AA

• ? EXAMPLE RL
• SOFT TISSUE FIRST!!
• Same hand positions as previous slide BUT R hand
  cups chin with palm OR forearm (for stability) on
  zygoma
• Rotate Pt.s head to R and approach barrier
• Pt. inhales and at end point of exhalation, apply
  rotatory impulse at AA joint
• RETEST

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HVLA Typical Cervicals (Sidebending Focus)
(C2-C7)

• ? EXAMPLE C3 F SR RR
• SOFT TISSUE FIRST!!
• Same hand positions as before
• Flex patient down to C3/C4 joint space
• Add a mild extension component limited to C3
• Rotate head to R
• Sidebend head to L and step slightly to the L of
  patient
• Approach the barrier
• Pt. inhales and at end point of exhalation, apply
  impulse horizontally at C3 (towards opposite
  shoulder
• RETEST

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HVLA Typical Cervicals (Rotational Focus)
(C2-C7)

• ? EXAMPLE C3 F SL RL
• SOFT TISSUE FIRST!!
• Same hand positions as before, BUT
• Rotate AWAY and sidebend TOWARD restriction
• Apply thrust toward opposite eye

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HVLA Kirksville KrunchExtension Restriction

• Dr. stands on side of supine Pt. facing Pt.s
  head
• Cross Pt.s arms over chest w/ hands over outside
  portion of each shoulder and arm on Pt.s
  opposite side superior to the other
• Using cephalad hand, grasp Pt.s opposite elbow
  to rotate Pt. toward you
• Using caudad hand, in a bilateral fulcrum hand
  position, contact skin 1 superior to flexed
  vertebra and pull skin inferiorly
• Support Pt.s head and neck while gently flexing
  Pt. to engage barrier
• Pt. inhales and at end of exhalation, apply
  short, quick thrust straight down toward floor by
  dropping weight
• RE-TEST

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HVLA Kirksville KrunchFlexion Restriction

• Same positioning as Kirksville Krunch Flexion
  Restriction EXCEPT
• Apply thrust 45 degrees cephalad from the A-P axis

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HVLA Texas TwistType I Dysfunction

• Dr. stands on side of prone Pt.s posterior
  transverse process
• Pt.s head is turned away from Dr.
• Contact skin superior to posterior TP with
  hypothenar eminence with CEPHALAD hand and pull
  skin caudad until hand contacts TP
• Contact skin just inferior to opposite TP of
  segment BELOW dysfunctional joint space with
  thenar eminence of CAUDAD hand and draw skin up
  until hand contacts the TP
• Have Pt. inhale then exhale, to localize forces
  with some rotation
• Apply HVLA thrust through wrists and elbows held
  rigid as Pt. reaches maximum end-exhalation
• RE-TEST

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HVLA Texas TwistType II Dysfunction

• Same as Type I except reverse hand placement and
  direction of rotation localization

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HVLA RIBS

• ?Why do it with respects to Inhalation somatic
  dysfunction of rib 1?
• Due to anatomical relationships, the
  dysfunctional first rib has been implicated in
  several clinical syndromes, including
• Vascular compression
• Venous compression
• Lymphatic compression
• Nervous compression

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HVLA RIBS

• ?AS A RULE Diagnose and treat corresponding
  thoracic vertebral segment 1st BEFORE treating
  dysfunctional rib

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HVLA RIB 1 (CROSS-ARM)Inhalation Somatic
Dysfunction(Ribs up)

• ? EXAMPLE Dysfunctional LEFT 1st rib
• SOFT TISSUE FIRST
• Pt. prone, Dr. at head of patient
• Pt.s head resting on chin Dr. places Pt.s chin
  toward side OPPOSITE (R) to dysfunctional rib and
  rotates head (with his/her Right hand) so it
  faces TOWARD dysfunction (L)
• Dr. places (L) thenar eminance on posterior
  aspect of Pt.s dysfunctional (L) rib (you should
  be crossing forearms at this point)

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HVLA RIB 1 (CROSS-ARM)-ContinuedInhalation
Somatic Dysfunction(Ribs up)

• Pt. inhales and during exhalation, Dr. takes up
  tissue slack
• At end point of EXHALATION, Dr. applies obliquely
  anterior, caudal, and lateral impulse against
  dysfunctional rib
• RETEST
• Note this technique is very effective for the
  upper two ribs

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HVLA TYPICAL RIBS (2-10)Inhalation Exhalation
Somatic Dysfunction

• SOFT TISSUE FIRST!!
• Pt. supine, Dr. stands to side OPPOSITE
  dysfunctional rib
• Pt.s arms crossed with OPPOSITE arm superior,
  elbows meeting in the middle
• Dr. places thenar eminence against rib angle
• Ribs UP BELOW inferior border pressing CEPHALAD
• Ribs DOWN ABOVE superior border pressing CAUDAD

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HVLA TYPICAL RIBS (2-10)-ContinuedInhalation
Exhalation Somatic Dysfunction

• Dr. places epigastrium over Pt.s elbows
• Dr. rolls patient BEYOND MIDLINE
• Pt. inhales and Dr. follows patient down during
  exhalation to restrictive barrier using his/her
  weight
• At exhalation end point, Dr. applies thrust
  through elbows to dysfunctional rib

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HVLA Lumbar Roll

• Positioning is same as Muscle Energy Lumbar
  Lateral Recumbent
• Instruct Pt. to fold arms across their chest or
  side, or have Pt. clasp their forearms together
• Slip cephalad hand beneath Pt.s left arm and
  contact Pt.s anterior axilla (pectoral area) w/
  your forearm
• Place caudad forearm on Pt.s left buttock across
  SI area, while your hand grasps spinous process
  of dysfunctional vertebra
• While maintaining localization, roll the Pt. as a
  unit toward you
• Have Pt. Inhale/exhale and at end-exhalation,
  thrust in a rotatory motion anteriorly (toward
  the ground) with forearm
• RE-TEST

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HVLA UEPosterior Radial Head

• Pt is seated. Operator stands in front of pt. Use
  one hand to grasp patients proximal forearm with
  index finger overlying the posterior aspect of
  radial head. Use other hand to maintain stability
  of the proximal forearm. Control patients distal
  forearm, wrist, hand b/n operators elbow and
  chest wall. Engage barrier or extension,
  supination, and slight adduction. Introduce
  slight HVLA thrust at posterior radial head,
  thrusting in an ant. lat. Direction. Retest
  motion of radial head.

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LYMPHATIC TECHNIQUES

• What is it?
• Passive, direct techniques (except for myofascial
  indirect release techniques)
• Order of releasing the central lymphatic system
• 1. Thoracic inlet release
• 2. Thoracic diaphragm release (indirect
  myofascial)
• 3. Pelvic diaphragm release (indirect myofascial)
• 4. Release peripheral lymphatic system
• 5. Thoracic pump
• Why do it?
• Re-establish maximum lymphatic fluid flow
• Increase removal of toxic products of metabolism
  and increase circulation of healing elements

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LYMPHATIC TECHNIQUESAnterior Cervical Traction

• ? This works on anterior cervical fascia and SCM
  (Treat one side at a time!)
• Dr. sits at head of supine Pt.
• Pt.s head is slightly flexed with a pillow or
  manually
• Dr. places thumb along anterior margin and
  2nd-5th digits along posterior margin of SCM
• Starting in lower portion of SCM and anterior
  cervical fascia, gently lift anteriorly and
  laterally until relaxation is noted
• Move superiorly to middle portion, then to
  superior portion
• Repeat 3X
• RE-TEST
• Take care NOT to put pressure on the carotid
  bodies causing a vasovagal response!

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LYMPHATIC TECHNIQUESCervical Lymph Drainage

• ? This works on jugular lymphatic chains
• Dr. sits at head of supine Pt.
• Pt. has head rotated away from side being treated
  with slight flexion via a pillow or manually
• Dr. places pad of thumb on anterior margin of SCM
  in inferior portion of neck
• Apply slow steady firm strokes along SCM margin
  to clavicle
• Repeat in middle portion
• Repeat in superior portion
• Repeat sequence 3X
• RE-TEST

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MYOFASCIAL RELEASE for lymphatic
drainageThoracic Inlet Release

• ? This works on scalene muscles and continuations
  of cervical fascia in thorax (Sibsonfascia)
• ? DIRECT technique
• Pt. supine w/ arm abducted at 90 degrees to body
• Dr. sits to same side of abducted arm facing
  Pt.s head
• Support Pt.s elbow on knee with the cephalad
  hand supporting Pt.s wrist and caudal fingers
  placed on superior aspect of supraclavicular
  fossa
• Apply downward pressure to Pt.s wrist as caudal
  fingers wrap around clavicle applying gentle
  anterior pressure
• Move Pt.s wrist in arc back toward shoulder w/
  caudal hand following rotation of clavicle
  posteriorly until tension develops
• Hold this until some relaxation is noted
• Repeat arc enabling fingers to wrap around
  clavicle further
• Repeat 2-3X
• RE-TEST

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MYOFASCIAL RELEASE for Lymphatic
DrainageThoracic Diaphragm Release

• ? INDIRECT technique
• Pt. Is seated
• Dr. stands behind Pt. and passes hands around
  thoracic cage (under arms of Pt.) and gently, but
  firmly, introduces fingertips, 5th finger-edge
  and hypothenar eminence, underneath costal margin
• Test for diaphragmatic restriction by passively
  rotating thorax gently to left and right until
  you feel tissue tension in ONE cycle
• Rotate diaphragm in direction if ease and follow
  tissue unwinding until it settles down into a
  free, rhythmic, vertical respiratory motion
• RE-TEST

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MYOFASCIAL RELEASE for lymphatic drainagePelvic
Diaphragm ReleaseInhalation Somatic Dysfunction
(Direct)

• DIRECT method
• Pt. is supine
• Dr. sits at side of pelvis to be treated, facing
  Pt.s head
• Flex Pt.s knee and hip and introduce index
  middle fingers medial to ischial tuberosity (the
  ischiorectal fossa)
• Instruct Pt. to inhale and during exhalation,
  press fingertips superiorly
• Maintain this position, ask Pt. to inhale and
  during exhalation, continue to follow and press
  fingers more superiorly
• Repeat several cycles
• RE-TEST

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MYOFASCIAL RELEASE for lymphatic Drainage Pelvic
Diaphragm ReleaseInhalation Somatic Dysfunction
(Indirect)

• INDIRECT method
• Same hand positions but
• Ask Pt. to inhale to limit and maintain
  inhalation until FORCED to exhale
• At moment of forced exhalation or just before,
  the pelvic diaphragm asscends
• Repeat several cycles
• RE-TEST

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MYOFASCIAL RELEASE for lymphatic drainage Pelvic
Diaphragm ReleaseExhalation Somatic Dysfunction
(Indirect)

• INDIRECT method
• Same hand positions but
• Ask pt. to inhale then exhale to the limit until
  FORCED to inhale
• At moment of forced inhalation or just before,
  the pelvic diaphragm descends
• Repeat several cycles
• RE-TEST

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LYMPHATIC TECHNIQUESLiver/Spleen Pump

• For Liver Dr. stands on right side of supine
  Pt., beside lower thorax and facing the head
• Pass left hand underneath lower ribs and right
  hand on abdominal wall immediately below the
  costal margin
• Ask Pt. To take in deep breath and identify
  border of liver with tips of fingers of right
  hand
• As exhalation occurs, fingers penetrate over
  liver and underneath thoracic cage
• Deep breath again, and during exhalation, apply a
  vibratory motion of right hand on liver
• Repeat 3-4X
• RE-TEST
• For spleen, treat other side

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LYMPHATIC TECHNIQUESLymphatic Drainage of
Upper Extremities

• Dr. stands to side of supine Pt.
• Tuck Pt.s hand into axilla and hold it there
• Take hold of upper arm close to shoulder and with
  hand on either side of limb, apply a rotatory
  wringing motion
• Move a hands width closer to elbow and repeat
  wringing motion
• Continue wringing proximal to distalwhen you get
  to elbow, repeat process 3-4X until adequate
  drainage is achieved
• Go to forearm and place thumbs on ventral surface
  between flexor and extensor muscle masses and
  rest of digits around other side
• Gently squeeze muscle masses simultaneously, then
  relax
• Repeat 3-5X moving proximal to distal
• RE-TEST

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LYMPHATIC TECHNIQUESLymphatic Drainage of
Lower Extremities

• With Pt. supine, sit on table facing Pt. with leg
  balanced on shoulder
• Flex Pt.s hip and knee to right angles
• Place palmar surface of both hands on opposing
  sides of leg and perform wringing motion
• As tissue changes take place, move distally down
  thigh towards knee, one hands width at a time
• Repeat sequence 3-5X
• Go to lower leg and place hands on either side w/
  thumbs pressing deeply b/w two gastrocnemius
  heads
• Rock body backward during each squeezing motion
• Work progressively toward foot and repeat 3-5X
• RE-TEST

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LYMPHATIC TECHNIQUESThoracic Pump Technique

• Dr. stands at head of supine Pt.
• Place hands on thoracic wall w/ thenar eminence
  of each hand just distal to respective clavicle,
  fingers spreading over chest wall
• Induce rhythmic pumping action by alternating
  pressure and release with hands

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MUSCLE ENERGY

• What is it?
• Active, direct technique
• Applied unyielding force by physician
• Isometric contraction by patient in all 3 planes
• Joints are positioned at the restrictive barrier
• Why do it?
• Decrease muscle tightness
• Decrease muscle hypertonicity

86
Muscle Energy Upper Trap and SCM

• SCM flex head moderately, go to restricted
  barrier (SB away, Rotate Toward). Isometric
  Contraction, Hold 3-5 seconds.
• Inhale, Exhale, Final Stretch, Retest.
• Trap Flex head slightly, same as above.

87
MUSCLE ENERGY AA

• Flex neck to lock out cervicals
• Introduce rotation towards leading edge of
  restrictive barrier
• Place hand on patients cheek and have Pt.
  perform isometric contraction towards neutral for
  3-5 seconds
• Ask Pt. to stop, then take up slack in tissues by
  repositioning toward leading edge of new
  restrictive barrier
• Repeat 3-5X
• RE-TEST

88
MUSCLE ENERGY OA

• Dr. positions Pt.s head into restrictive
  barriers
• Repeat isometric contractions as described in
  Muscle Energy AA
• RE-TEST

89
MUSCLE ENERGY TYPICAL CERVICALS

• Dr. supports head with one hand on posterior
  lateral surface opposite side of restriction
• Other hand placed w/ MP joint and index finger
  held against articular pillar of restricted
  vertebral segment as a fulcrum
• Position neck against barrier at that segment
  level and rotation in same direction around the
  fulcrum
• Perform isometric contractions as described in
  Muscle Energy AA
• RE-TEST

90
MUSCLE ENERGYThoracic Type I Group Dysfunction

• Dr. stands behind/beside seated Pt.
• Dr. is on opposite side where sidebending will be
  induced
• Place your shoulder underneath Pt.s axilla and
  grasp Pt.s opposite shoulder
• Have Pt. rest hands inside your elbow w/ arms
  hanging in relaxed manner
• Palpate posterior transverse process of
  dysfunctional vertebra
• Sidebend Pt. by lifting your shoulder and rotate
  Pt. towards you while applying pressure on
  posterior transverse process
• Perform isometric contractions and reposition
• RE-TEST

91
MUSCLE ENERGYThoracic Type II Group Dysfunction

• Dr. stands behind/beside seated Pt.
• Place axilla on shoulder where sidebending will
  be induced (towards restriction) and grasp
  opposite shoulder
• Have Pt. Rest hands inside your elbow w/ arms
  hanging in relaxed manner
• Position Pt. toward leading edge of restriction
• Perform isometric contractions and repositioning
• RE-TEST

92
MUSCLE ENERGY RIB 1INHALATION SOMATIC
DYSFUNCTION(RIBS UP)

• Dr. at head of patient
• Patient SUPINE
• Place and localize thumb in supraclavicular fossa
  on rib of dysfunction
• Flex head up with opposite hand
• Pt. Exhales holds 3 sec and Dr. follows rib down
• Dr. adjusts to new restrictive barrier
• Repeat 3-5X

93
MUSCLE ENERGY RIBS 2-5INHALATION SOMATIC
DYSFUNCTION(RIBS UP)

• Same position of Dr. and Pt. as previous slide
• Localize dysfunctional rib with fulcrum of MP/PIP
  joint
• Flex head up with opposite hand
• Pt. Exhales holds 3 sec and Dr. follows rib down
• Dr. adjusts to new restrictive barrier
• Repeat 3-5X
• Final Stretch

94
MUSCLE ENERGY RIBS 6-10INHALATION SOMATIC
DYSFUNCTION(RIBS UP)

• Same hand positions as previous BUT have the
  patient reach for his/her knee on side of
  dysfunction

95
MUSCLE ENERGY RIB 1 EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• ? This technique is utilizing the scalenes
• Pt. SUPINE
• Pt. Places forearm (same side of rib dysfunction)
  on his/her forehead
• Dr. stands on OPPOSITE side of dysfunction
• Dr. grasps dysfunctional rib POSTERIORLY at rib
  angle

96
MUSCLE ENERGY RIB 1 (continued)EXHALATION
SOMATIC DYSFUNCTION(RIBS DOWN)

• Dr. holds down patients forearm
• Pt. INHALES, HOLDS BREATH (2-3 seconds), and
  FLEXES head while Dr. provides counterforce on
  forearm
• After exhalation, Dr. adjusts to new restrictive
  barrier
• Repeat 3-5X
• Final Stretch

97
MUSCLE ENERGY RIB 2EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Same hand positions as previous BUT patient turns
  head AWAY from side of lesion 30 degrees, then
  lifts head toward ceiling

98
MUSCLE ENERGY RIBS 3-5EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Same positions of Dr. and patient as previous
  BUT
• Pt. has forearm (lesion side) flexed up beside
  lesion
• Dr. places hand on Pt.s elbow of forearm
• Pt. lifts elbow of affected side toward OPPOSITE
  ASIS (diagonally)

99
MUSCLE ENERGY RIBS 6-10EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Same positions of Dr. and patient as previous
  BUT
• Pt. has arm (lesion side) straight out at 90
  degrees from body
• Dr. places hand on Pt.s elbow
• Pt. pushes elbow of affected side directly
  lateral pull your arm straight down to your
  side

100
MUSCLE ENERGY RIBS 10-12EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Pt. prone, positioned CONVEX on the side of the
  lesion
• Abduct Pt. Arm on lesion side
• Dr. stands to side of patient (facing towards
  Pt.s head) OPPOSITE of lesion
• Dr. places hamate of cephalic hand on medial part
  of dysfunctional rib
• Dr. grasps ASIS on lesion side with caudal hand

101
MUSCLE ENERGY RIBS 10-12 (continued)EXHALATION
SOMATIC DYSFUNCTION(RIBS DOWN)

• Dr. lifts ASIS off table and with cephalic hand
  pushes anterior, lateral, and superiorly on
  dysfunctional rib
• Pt. INHALES, holds breath 3 sec. and pushes ASIS
  down against Dr.s unyielding force
• After exhalation, Dr. adjusts to new restrictive
  barrier
• Repeat 3X
• Final Stretch
• Retest

102
MUSCLE ENERGYLumbar Type I and II Group
Dysfunction

• Same positioning as Thoracic Muscle Energy except
  hand is place on posterior transverse processes
  of lumbar region

103
MUSCLE ENERGY LATERAL RECUMBENT

• Pt. lies on side of posterior transverse process
• While monitoring lesion with cephalad hand, Dr.
  flexes Pt.s knees until motion is achieved at
  restricted joint
• Pt.s bottom leg is straightened with foot of top
  leg cupped in popliteal fossa of bottom leg
• Dr. changes hands to monitor with caudad hand
• Pt. grasps Dr.s cephalad elbow with arm laying
  on table, while Dr. hold onto Pt.s arm with
  his/her hand
• Type I pull arm caudad
• Type II pull arm cephalad

104
MUSCLE ENERGY LATERAL RECUMBENT

• To treat rotational component, place cephalad
  hand on Pt.s upper shoulder and have Pt. Perform
  isometric contractionsreposition
• To treat sidebending component, flex Pt.s
  bottoms leg until it is even w/ top legthen
• Type I bring Pt.s ankles down off table until
  barrier is engaged. Have Pt. lift feet toward
  ceiling with isometric contractions and
  reposition
• Type II lift Pt.s ankles to ceiling until
  barrier is engaged. Have Pt. push feet toward
  floor with isometric contractions and reposition
• RE-TEST

105
MUSCLE ENERGY Hamstring tightness

• ? Tight hamstrings may affect Standing Flexion
  Test
• Pt. supine, Dr. standing next to leg to be
  treated facing Pt.s head
• Dr. flexes Pt.s hip and knee fully with hands on
  Pts ankles while flexed, knee is extended to
  its limit
• Pt. flexes knee 3-5 sec. against unyielding force
  by Dr.
• Dr. extends knee to new barrier, repeat 3-5X
• Retest

106
MUSCLE ENERGY Pubic Disengagement Part A B

• Knees TOGETHER
• Pt. supine, hips flexed 90 degrees, feet on
  table, knees together
• Dr. wraps arms around Pt.s knees
• Pt. spreads knees against unyielding force by Dr.
  3-5 sec.
• Repeat 2-3X
• Knees APART
• Pt. in same position, but knees APART
• Dr. places forearm between Pt. knees
• Pt. brings knees together against unyielding
  force by Dr.
• Repeat 2-3X

107
MUSCLE ENERGY Anterior Innominate Rotation

• Pt. supine, Dr. on same side as dysfunction
• Dr. flexes Pt.s hip and knee toward abdomen to
  restriction barrier
• Dr. braces flexed knee against caudad shoulder
• Dr. places cephalad hand on rotated ASIS and
  caudad hand on ischial tuberosity
• Dr. pushes posteriosuperiorly on ASIS and pulls
  ischial tuberosity inferiorly and anteriorly
• Pt. pushes against unyielding force by Dr. for
  3-5 sec.
• After Pt. relaxes, Dr. engages new restrictive
  barrier
• Repeat 3-5X

Note hand should be on Pt. ASIS, NOT on knee
108
MUSCLE ENERGY Posterior Innominate Rotation

• Pt. supine, Dr. stands on same side as
  dysfunction
• Dr. drops Pt.s affected leg off table to
  restriction barrier
• Dr. places one hand on affected anterior thigh,
  other hand on opposite ASIS
• Pt. raises thigh toward ceiling against Dr.s
  unyielding force 3-5 sec.
• Pt. relaxes Dr. engages new restrictive barrier
• Repeat 3-5X

109
MUSCLE ENERGY OUTWARD ILIAL FLARE

• Pt. supine, Dr. stands on SAME side as
  dysfunction (e.g. on the R)
• Dr. flexes Pt.s leg at knee 90 degrees with one
  hand (R), lateral traction of posterior ilium
  with the other hand (L)
• Dr. adducts knee to barrier and patient abducts
  against unyielding force
• Repeat 3-5X

110
MUSCLE ENERGY INWARD ILIAL FLARE

• Pt. supine, Dr. stands on OPPOSITE side of
  dysfunction
• Dr. positions affected leg in the sartorius
  muscle position
• Dr. places cephalad (L) hand on Pt.s ASIS on
  unaffected side
• Dr. places caudad (R) hand on Pts knee of
  affected leg and moves knee laterally to barrier
• Pt. adducts against unyielding force
• Repeat 3-5X

111
TREATMENT FOR UP-SLIPPED INNOMINATE

• ? Direct action technique against the barrier
• Pt. supine, Dr. stands at Pt.s feet facing
  patient
• Dr. grabs ankle of affected leg and applies
  caudad traction, gently ab/adducting leg to
  determine most relaxed position for 30-60 sec.
• Short thrust IF NECESSARY

112
TREATMENT FOR DOWN-SLIPPED INNOMINATE

• Pt. lies on side OPPOSITE side of dysfunction
• Dr. places one hand on inferior aspect of pubes
  other hand on ischial tuberosity of affected side
• Pt. Inhales and during EXHALATION, Dr. exerts
  cephalad force
• Short thrust IF NECESSARY or jump up and down on
  dysfunctional leg

113
MUSCLE ENERGY FORWARD SACRAL TORSION

• ? L/L
• Pt. lies on side of involved axis (L)
• Dr. rotates Pt.s shoulders to face toward table
  (L)
• Pt. drops R arm off table
• Dr. flexes Pt.s knees and hips off table to
  localize
• Pt. inhales and during EXHALATION reaches toward
  for the floor (R arm)
• Repeat 3-5X

• Dr. now applies unyielding force to patients
  ankles towards the floor while stabilizing Pt.
  with other hand
• Pt. Lifts ankles toward ceiling against
  unyielding force 3-5 sec.
• Pt. relaxes and Dr. engages new barrier
• Repeat 3-5X
• RETEST (Note Patient can do both actions
  simultaneously)

Part II
Part I
114
MUSCLE ENERGY BACKWARD SACRAL TORSION

• ? EXAMPLE L/R
• Pt. lies on side of involved axis (R)
• Dr. extends Pt.s leg and flexes thigh off table,
  placing one hand on Pt.s knee
• Dr. places other hand on Pt.s shoulder and
  rotates Pt.s trunk to L down to L5
• Pt. raises upper leg toward ceiling against
  unyielding force
• Repeat 3-5X

115
MUSCLE ENERGY UNILATERAL SACRAL FLEXION

• ? EXAMPLE Unilateral LEFT sacrum flexed
• Pt. prone, Dr. stands on affected (L) side and
  monitors L sacral sulcus
• Dr. abducts Pt.s L leg to area of maximum
  relaxation of SI joint
• Dr. springs L ILA with his/her R hand to find
  angle with greatest spring places palm of hand
  at angle
• During Pt. INHALATION, Dr. induces CEPHALAD and
  ANTERIOR force to L ILA
• Repeat 3-5X

116
MUSCLE ENERGY UNILATERAL SACRAL EXTENSION

• ? EXAMPLE Unilateral RIGHT sacrum extension
• Pt. prone, Dr. stands on affected (R) side and
  monitors R sacral sulcus
• Dr. abducts Pt.s R leg to area of maximum
  relaxation of SI joint
• Dr. springs R sacral base with his/her L hand to
  find angle with greatest spring places palm of
  hand at angle
• During Pt. EXHALATION, Dr. induces CAUDAD and
  ANTERIOR force to R Sacral Base
• Repeat 3-5X

117
MUSCLE ENERGY BILATERAL SACRAL FLEXION

• Pt. supine, Dr. stands to side
• Dr. abducts BOTH legs to area of maximum
  relaxation of BOTH SI joints
• Dr. springs over BOTH ILAs to find angle with
  greatest spring at the sulcus
• During Pt. INHALATION, Dr. induces a CEPHALAD and
  ANTERIOR force over the ILAs
• Repeat 3-5X

118
MUSCLE ENERGY BILATERAL SACRAL EXTENSION

• Pt. supine, Dr. stands to side
• Dr. abducts BOTH legs to area of maximum
  relaxation of BOTH SI joints
• Dr. springs sacral base to find angle with
  greatest spring at the ILAs
• During Pt. EXHALATION, Dr. induces a CAUDAD and
  ANTERIOR force over the sacral base
• Repeat 3-5X

119
Muscle Energy Superior Clavicle

• Stand on side of dysfunction, facing supine pts
  head. Monitor medial end of superior clavicle
  with one hand. Position arm in approx. 45
  abduction below the level of the table. The
  shoulder will be in EROT with forearm in
  supination. Grasp wrist with other hand, gently
  press downward until a mild resistance is felt.
• Have patient raise arm toward ceiling while
  resisting movt. Repeat 3-5 times, but one
  contraction/relaxation cycle may be sufficient if
  repositioning occurs. Goal is to utilize
  pectoralis major or subclavius muscle to directly
  pull clavicle inferior. No final stretch is
  necessary.

120
Muscle Energy Inferior Clavicle

• Use SCM to elevate the medial end of inferior
  clavicle.
• Pt. is supine. Stand at head of table. Palpate
  dysfunctional sternoclavicular joint to monitor
  clavicular motion. First have pt partially flex,
  then rotate head 30-45 away from side of
  dysfunction. Place other hand on pts forehead.
  Perform muscle energy by resisting further
  flexion and additional rotation to opposite side.
  No further stretch is needed.

121
Muscle Energy Shoulder/ glenohumeral and AC
joint, seated

• EROT Pt. is seated, (operator stands behind
  patient) abduct arm, externally rotate shoulder
  of affected side to barrier by grasping the elbow
  and distal arm with one hand (to stabilize
  shoulder), and grasping the raised wrist and
  distal forearm with other hand. Have pt. IROT
  humerus ag. Your unyielding counterforce 3-5
  times (3-5 s), End with a stretch.
• IROT Pt. is seated, (operator stands behind
  patient) abduct arm, IROT shoulder to barrier by
  stabilizing shoulder, reaching under the arm to
  grasp the dorsum of the wrist with your other
  hand. Have pt. EROT humerus ag. Your unyielding
  counterforce 3-5x (3-5s). End with stretch.

122
Muscle Energy Shoulder, Glenohumeral AC joint,
Supine

• Shoulder flexion restriction (0-180)
• Stand at head of table, gasp arm to be treated at
  wrist, and just prox. To the elbow. Gently
  confront flexion barrier, treat with muscle
  energy. Repeat on other side IF needed.
• Shoulder extension restriction (0 to 40-60)
• Stand/sit beside patient on restricted side.
  Place one hand on ant. Shoulder for
  stabilization, with other hand grasp pts wrist.
  Gently confront extension barrier, treat with
  Muscle Energy

123
Muscle Energy Shoulder, Supine

• Abduction restriction (0-180)
• Stand next to shoulder of fully abducted arm.
  Place on hand on elbow, other hand grasps
  patients wrist. Gently confront abduction
  barrier, treat with Muscle Energy (ME).
• Horiz. Adduction restriction (0-45)
• Grasp pts elbow on restricted side with one
  hand, and opposite shoulder with other hand for
  stabilization. Have patient take a deep breath,
  and exhale fully. As pt. completes exhalation,
  treat with ME. Repeat on other side if needed.
• Horiz. Abduction restriction (0-45)
• Take extremity into restrictive barrier, treat
  with muscle energy.

124
Muscle Energy Shoulder, Supine

• External Rotation Restriction (0-90)
• Have patient abduct shoulder to 90, flex elbow
  to 90, EROT to restrictive barrier, gently treat
  with ME.
• Internal Rotation Restriction (0-90)
• Have pt. abduct shoulder to 90, flex elbow to
  90, IROT shoulder to restriction, treat with ME.

125
Muscle Energy Seated Radial head

• For supination restriction (0-90)
• Stabilize affected elbow medially and palpate
  radial head. Grasp wrist with your other hand,
  and supinate the forearm to the barrier. Have
  patient pronate his forearm, using muscle energy
  principles 3-5 times.
• For Pronation Restriction (0-90)
• Stabilize affected elbow medially, palpate for
  radial head. Grasp wrist with other hand and
  pronate the forearm to barrier. Have patient
  supinate using muscle energy principles 3-5 times.

126
Muscle Energy Humeroulnar

• Elbow flexion restriction (0-135)
• Stabilize patients elbow with one hand, grasp
  dorsum of wrist and flex elbow, confront barrier,
  treat with muscle energy.
• Elbow extension restriction (0-5)
• Hold extremity at elbow and wrist, and passively
  move into full extension, maintain hand
  positioning so elbow is in full extension against
  restrictive barrier. Repeat on other side if
  needed.

127
Muscle Energy Wrist

• Flexion restriction (0-80)
• Stabilize forearm by grasping elbow, while other
  hand grasps dorsum of pts wrist with thumb and
  fingers on opposite sides. Gently move wrist into
  flexion, confront barrier, treat with muscle
  energy.
• Extension restriction (0-70)
• Extend patients wrist, stabilizing forearm with
  one hand placed under patients elbow. Place palm
  of your other hand against the patients palm,
  confront barrier, treat with muscle energy.

128
MYOFASCIAL RELEASE

• What is it?
• Either a Direct or Indirect technique
• Direct
• Load and Hold
• Engaging the restrictive barrier and is loaded
  until free movement is achieved
• Indirect
• Dysfunctional soft connective tissues are guided
  along a pathway of least palpatory resistance
  until free movement is achieved
• Why do it?
• Release fascial tension and restore function to a
  somatic dysfunction
• Increase arterial, venous, and lymphatic
  circulation

129
Myofascial Release Cervical Segmental (indirect)
130
CERVICAL MYOFASCIAL RELEASELigamentum Nuchae
Regional Technique

• ? INDIRECT technique
• ? Useful to balance regions covering greater than
  2-3 segments
• Example F SR RR C4-C7
• Pt. Supine, Dr. at head of table
• Dr. cradles Pt.s occiput in palm of one hand
  (fingertips in suboccipital region) and flexes
  neck to C4-C5
• Dr.s other hand grasps C4-C7 fascia overlying
  articular pillers
• Dr. applies gentle traction superiorly w/
  cephalad hand
• Motion test in all 3 planes
• Move tissue in direction of ease and follow
  tissues as they unwind
• Wait at least 90 seconds or until tissue is no
  longer changing
• Re-check range of motion

131
CERVICAL MYOFASCIAL RELEASESuboccipital Release

• ? DIRECT technique
• Pt. Supine
• Dr. seated at head of table
• Dr. contacts suboccipital soft tissue between the
  occiput and spinous process of C2 with fingers
• Dr. applies deep pressure bilaterally by the use
  of patients head onto fingertips
• Dr. uses a GRADUAL traction until a resistance
  barrier is met
• Hold until palpable stretch and relaxation is
  achieved

132
Other MFR you are responsible for

• Thoracic
• General- prone or supine
• Thoracic Diaphragm Release (direct/indirect)
• Scapular Release (direct or indirect)
• Subscapular Release (direct or indirect)
• Ribs
• Myofascial release Ribs 2-12 (indirect)
• Pelvis
• L-S Decompression, supine, prone or lat recumb
  (direct)
• Sacroiliac Decompression (Direct)

133
Myofascial Release Ribs 4-10

• Ribs 4-10
• Same side as patient, facing patient,
• Pt. raises shoulder, ab arm to allow access
• Use middle finger of one hand, place post. On
  rib angle, lat costotransverse articulation
• Middle finger of other hand ant on shaft of rib
• Thumbs lateral on shaft
• Allow pt to drop elbow, relax.
• Pt. slightly leans away, sidebends toward
  physician
• Hold rib firmly to prevent post. Rotn, while pt.
  slowly rotates op. shoulder toward physician
• Find point of ease, ask pt. to
• inhale, hold breath (Inhaln somatic dysfunction)
• Exhale, hold it (exhaln somatic dysfunction)
• Rib is held securely, until pt. is forced to
  exhale/inhale.
• Retest, repeat

134
Myofascial Release Ribs 2-3, 11-12

• Ribs 2-3
• Same as 4-10, except, thumb of hand contacting
  rib posteriorly contacts lat. Border of scapula
• Ribs 11-12
• Fingers placed on rib just lat to adj vertebral
  transverse process, hold firmly while pt rotates
  op. shoulder toward physician. Hand holding shaft
  of rib and ant. Extension exerts anteromedial
  force while pt. turns.
• Rib is brought to point of lig. relaxation., use
  respiratory cooperation.
• Retest!

135
Myofascial Release Lumbar, Regional, prone
(indirect)

• Find area of greatest resistance in tissues by
  gently springing the spine and lumbar tissues.
  Place palms, one on top of the other, over
  restricted tissues. Move tissue under your hands
  thru its ROM. (cephalad, caudad, rt/lft, right
  rotn, Left rotn), and hold tissues in their
  direction of ease with gentle force.
• Hold tissues in this position, slightly resisting
  and following changes in the tissues as they
  release under your hands, always maintaining same
  force
• Continue until endpoint is reached (softening
  of the tissues, normal positioning of tissues,
  warmth, end of unwinding)
• Retest tissues for symmetry of mobility.

136
Lumbosacral Decompression

• Positioning/ normal lumbosacral motion
• Supine
• 1 hand beneath sacrum, 3 middle fingers across
  L-S junction, little finger/thumb across SI
  joint.
• 2 hand under lower lumbar spine, lumbar spinous
  processes either held in palm with fingers
  slightly flexed or at finger tips.
• Ask pt. to inhale. (sacral base should move post.
  And sup. As lumbar spine straightens and
  diaphragm and viscera descend. Sacrum should
  actually move after lumbar spine moves)
• As pt. exhales, lumbar spine should regain
  lordosis.
• Technique
• If sacral motion in inhaln occurs with lumbar
  spine, or has poor amplitude, L-S compression is
  present. Lumbar hand provides stabilization, pt
  is asked to inhale and exhale.
• As sacral base moves antero-inf. The physician
  applies a caudad force through sacral hand. (slow
  and gentle)
• Pt inhales and breathes normally, but
  decompression force is continued.
• As direct decompression continues, sacrum will
  move indept from lumbar spine during respn
• Endpoint- when sacrum appears to demonstrate
  palpatory warming, softening, or oscillatory
  motion.

137
L-S decompression Prone and lat. recumbent

• Prone
• Stand to side of pt., cephalad hand placed on
  pts sacrum, fingers point caudally. Caudad hand
  crosses over with base of palm contacting spinous
  process of L5, fingers pointing cephalad.
• Push in opp. Directions, with decompression
  occurring as you apply traction b/n hands
• Resp. cooperation can be added- have pt. exhale
  and hold the breath as long as possible
• Lat-Recumb
• Knees and hips flexed, Physican stands facing pt.
  Cephalad hand contacts spinous process L5, Caudad
  arm positioned with maximal forearm/elbow contact
  ag. Pts sacrum. Decompression occurs as you
  apply traction b/n 2 contacts.

138
Sacroiliac Direct Decompression

• Indications
• Somatic SI dysfunction
• Positive Standing/or seated flexion test
• Decreased amplitude of sacral motion on palpation
  during respirn
• Sacral and SI strain patterns on palpation
• Part of tx with pelvic diaphragm
• Part of tx for pelvic visceral disturbance
• Technique
• Supine, arms at sides, head on pillow
• Physician- seated with dominant hand contacting
  pts sacrum (as with L-S compression)
• Other hand- sacral sulcus, curling around PSIS,
  fingertips apply lat. Traction
• Pt. is allowed to breathe normally as
  decompression continues.
• Endpoint- reached when ilium appears to pull
  away from sacrum, sacrum moves freely with
  respiration
• If any specific sacral strain patterns or abnml
  movements noted, use indirect principles
• Repeat on other side
• Retest

139
Myofascial Release UEAnterior Axillary Fold
Release (Pectoral Lift)

• Direct technique Stand at head of supine pt.
  Grasp anterior axillary fold (pectoralis major m
  clavipectoral fascia) with your flexed fingers.
• With extended elbows, lean backwards, gently
  pulling cephalad, maintaining traction at 90
  against the pectoralis mm until release occurs
  the muscles will soften and lengthen.

140
Myofascial Release UE Arm/Shoulder Release, Prone

• Arm shoulder off the table, feet also off the
  end of the table to minimize pelvis and lumbar
  myofascial tension. Turn pts head to most
  comfortable side. Pts hands and arms are placed
  comfortably on either side of table or on table
  beside hips. If hands are over sides of table, be
  sure to note asymmetrical scapulocostal effects.
  Sit facing dysfunctional shoulder. Maintain
  control and localization of forces being applied
  by holding the affected arm b/n knees. Place both
  hands firmly around glenohumeral attachments
  immed. Lat. To AC jt. Fingers of one hand firmly
  contact pectoralis major attachts anteriorly,
  hwile other hand contact teres/infraspinatus
  attachments posteriolry. Assess
  tightness/looseness by 3-D stressing the system
  using distraction, compression, twist and shear.
  Apply direct and firm stressing against tightness
  (approx 5-15 lbs of lad are common before initial
  release begins) Pay attention to restriction
  close to scapula. Give pt. home exercises.

141
Myofascial Release UE Arm/Shoulder Release,
Supine

• Pt. lies supine, with heels on table, arms
  comfortably at sides. Stand at head of table,
  have supine pt. raise arms cephalad with palms
  towards ceiling. With palms upward, grasp pts
  wrist, securely controlling pts thenar emine