Definition and Goals

The International Federation of Manual Medicine defines manipulation as “the use of the hands in the patient management process using instructions and maneuvers to maintain maximal, painless movement of the musculo­skeletal system in postural balance.” The goal of manipulation or manual medicine is to help maintain optimal body mechanics and to improve motion in restricted areas. Enhancing maximal, pain-free movement in a balanced posture and optimizing function are major goals. These goals are accomplished by treatments that attempt to restore the mechanical function of a joint and normalize altered reflex patterns, as evidenced by optimal range of motion, body symmetry, and tissue texture. The indications for successful use of manual medicine techniques are determined by structural evaluation before and after treatment.

Manual medicine can involve manipulation of spinal and peripheral joints as well as myofascial tissues (muscles and fascia). The most fundamental use of manual medicine is to relieve motion restriction and improve motion asymmetry. Improved motion and flexibility are helpful in restoring optimal muscle function and ease of motion. This restoration of function is often accompanied by a decrease in pain, which is often the end point most noticeable to the patient. The ultimate goal of manipulation is to improve the function and well-being of the patient. Examples of this include reduction of pain, improved ambulatory ability, and improved efficiency of biomechanical motion. There are physiologic objectives, such as decreasing nociceptive input, decreasing gamma gain, enhancing lymphatic return, and improving circulation to the tissues. Sometimes therapy is directed at reduction of afferent (nociceptive) input to the spinal cord. Endorphin release increases pain threshold and reduces pain severity.

Manual medicine continues to be widely practiced and is in high demand by patients. It is estimated that 12 to 17.6 million Americans receive manipulations each year, with a high degree of patient satisfaction. Providers who perform manual medicine include physicians from osteopathic medical schools (D.O.), who have this training as part of their core curriculum, and also include allopathic physicians (M.D.) who have obtained additional training in manipulation. Chiropractic providers are taught manual medicine as their primary form of treatment and typically provide this as their only or most primary service to patients. Indeed, in 2002, 7.4% of the population used chiropractic care. Physical therapists can also receive training in some manual therapy techniques and provide this service to patients.

Overview of Various Types of Manual Medicine

Barrier Concept

Central to the application of manual medicine techniques is the barrier concept. This concept recognizes limitation of motion of a normal joint in which asymmetric motion is present. Motion is relatively free in one direction, with loss of some motion in the other direction. Motion loss occurs within the normal range of motion for that joint ( Figure 16-1 ).

A model of somatic dysfunction. The first three panels depict production of somatic dysfunction from a mechanical cause. The last three panels depict treatment positions with thrust technique, isometric muscle energy technique, and indirect balancing. A, A normal joint is positioned in the center, with free motion available in either direction. The shaded area at either end depicts the end of permitted motion. The outside line is termed the anatomic barrier. If joint motion goes beyond this point, structural damage will occur. The Glossary of Osteopathic Terminology describes the anatomic barrier as the end point of passive motion and the physiologic barrier as the end point of active motion. B, This panel, injury, shows a force moving the center of the joint to the right. C, The third panel, somatic dysfunction , shows the effect of the injury. The neutral point is now positioned to the right. The muscle on the right is contracted and shortened; the muscle on the left is stretched (strained). Motion to the right is freer; motion to the left exhibits bind or restriction. This is asymmetric motion, which is typical of spinal somatic dysfunction. There is restriction of motion to the left so that the range of motion is impaired. The end point of this restriction of motion to the left is termed the restrictive barrier . Think of the barrier as a series of restrainers that are preventing motion to the left, as contrasted to a brick wall preventing motion. The short, tight muscle on the right prevents full motion to the left. The last three panels show treatment position. D, Thrust technique (impulse, high velocity, and low amplitude) is a direct technique. The barrier is engaged by moving the joint to the left. The final corrective force is a practitioner force. E, Direct isometric muscle energy technique looks very similar on the panel. The barrier is engaged by moving the joint to the left. The physician holds and asks the patient to contract against the holding force. The shortened, contracted muscle is the one that is contracting. F, Indirect balancing involves moving the joint to the right, away from the restrictive barrier. The tension should be balanced on both sides. Final corrective force is a release by inherent forces.

The barrier concept implies that something is preventing a full range of motion of a joint. The term pathologic barrier was initially used to describe that point where normal motion is limited. The current term used is restrictive barrier , which means that no organic pathology can be seen under the microscope; these are functional restrictions. The motion restriction associated with this somatic dysfunction occurs within the normal range of motion of the joint. The new neutral position has shifted in the direction of less restricted motion. This gives rise to positional asymmetry, which leads to physical diagnosis. The lay terms “out” and “out of place” are often used to describe this positional asymmetry. Manipulation is designed to restore normal motion. Manipulation does not put the joint back in place. If a joint is dislocated, this is not somatic dysfunction. Dislocation involves movement beyond the anatomic barrier and outside the normal range of motion and involves associated tissue damage.

Historical Perspective and Practitioners

Manual medicine has regained popularity over the past 30 to 40 years, but its practice dates back to the time of Hippocrates (460-377 bc ) and Galen (131-202 ad ). Many other physicians (e.g., Sydenham, Hahnemann, Boerhaave, and Shultes) deviated from the traditional disease-oriented form of medicine during the sixteenth and seventeenth centuries, but manual medicine fell out of favor until the nineteenth century. The pioneers of manual medicine at that time included the “bonesetters” of England: Richard Hutton, Wharton Hood, and Sir Herbert Baker.

Manual medicine today is most closely linked to the pioneers of the late nineteenth century, including Andrew Taylor Still, the founder of osteopathic medicine in 1874, and Daniel David Palmer, the founder of chiropractic medicine in 1895.

Still’s philosophy stressed wellness and wholeness of the body. Osteopathic principles describe the body as a unit that possesses self-healing mechanisms, and that structure and function are interrelated. All of these principles are incorporated into practice. Manual medicine was and is an integral part of this treatment. Today, graduates of one of the 30 colleges of osteopathic medicine, awarded a Doctor of Osteopathy, or D.O., have all had these tenets and training in manual medicine as part of their training curriculum.

Chiropractic philosophy describes a fundamental relationship between the spine and health and its mediation by the nervous system. Mechanical impairments of the spine are thought to impair health, and the correction of these subluxations can bring about improvements in health. There are currently 18 chiropractic colleges in the United States graduating Doctors of Chiropractic Medicine.

“Traditional” medical professionals have also shown interest in manual medicine. Mennell and his son John M. Mennell espoused the use of joint manipulation within the British medical community. Beginning in the 1940s James Cyriax, a British orthopedic surgeon, published several works related to manipulation, incorporating massage, traction, and injections. The use of manual techniques for examination purposes by Janet G. Travell, M.D., has been widely accepted. Today, the Fédération Internationale de Médecine Manuelle represents manual medicine practitioners throughout the world.

Normal and Abnormal Coupled Spinal Motion

Motion of the spine follows principles of spinal motion often attributed to Harrison H. Fryette. Flexion (forward bending) and extension (backward bending) are sagittal plane motions and are not coupled. However, rotation and side bending are coupled. The amount of pure rotation or pure side bending of spinal joints is limited and varies depending on the site within the spine. Rotation and side bending occur together in normal spinal joints. Fryette stated that when there is an absence of marked flexion or extension (termed neutral ) and side bending is introduced, a group of vertebrae rotate into the produced convexity, with maximum rotation at the apex. Rotation and side bending occur to opposite sides when compared with the original starting position. This is sometimes referred to as neutral mechanics or type 1 dysfunction. Nonneutral, or type 2, mechanics involve a component of flexion or extension with rotation and side bending to the same side. This is usually single-segment motion, although several segments may be involved. The cervical spine (C2 to C7) exhibits rotation and side bending to the same side whether flexed, neutral, or extended.

Some atypical joints (occiput, atlas, and sacrum) do not have an intervertebral disk. Their motion patterns are dictated by anatomy. The major motions of the occiput are flexion and extension. Rotation and side bending occur to opposite sides because of the anatomic construction of the joint. The major motion of the atlas is rotation. The atlas rotates around the dens (odontoid process). Half the rotation of the cervical spine occurs at the atlas. Flexion and extension occur but are not involved in motion restriction of the atlas. The atlas does not side bend as it rotates. Actually, both sides of the atlas translate inferiorly during rotation, but side bending does not occur. Trauma can produce atypical motion patterns.

Nomenclature

Physiologic Rationale for Manual Therapies

Indications and Goals of Treatment

Somatic dysfunction is the indication for manual medicine and is diagnosed by palpatory examination. If manual medicine is being considered as a treatment option, there are several questions. Are there signs of a musculoskeletal component to the patient’s complaint? Does the somatic dysfunction found in the patient rationally seem to be contributing to the patient’s complaint? If the answer to these questions is “yes,” then manual medicine may be considered as a potential treatment.

Somatic dysfunction can coexist with “orthopedic disease” (e.g., osteoarthritis or disk disease). Manual medicine treatment helps the somatic dysfunction and helps the patient, but the underlying orthopedic disease process will remain. Other confounding factors are causes for the somatic dysfunction. The patient might have an anatomic short leg, which will continue to maintain sacroiliac and low back dysfunction. Certain activities might be too stressful for the musculoskeletal system. In a controlled study of low back pain, it is impossible to control for these confounding factors. Despite these factors, manual medicine may still be an appropriate option in conservative treatment before more aggressive measures are taken.

Examination and Diagnosis

An examination is a process of data gathering. Subjective data can be obtained by taking a history. On taking a history from a patient, Dr. Max Gutensohn stated, “I always had a feeling that if I could talk to patients long enough, they would tell me what was wrong with them.” Pain, discomfort, or functional loss is a frequent complaint. Additional information such as predisposing factors, patient motivation, postural issues, and stresses can all be elicited from a good history.

Physical examination includes acquiring a sufficient physical examination database to enable appropriate diagnosis and treatment. The musculoskeletal examination goes beyond the standard examination of looking for problems in a system (Video 16-1 ). The practitioner should look for clues about the health status and function of the patient. Is there a somatic component to the patient’s problem? The musculoskeletal screening examination looks at gait, posture, and symmetry or asymmetry. This is ordinarily done with the patient standing. A standardized 12-step biomechanical screening examination may be done, or the screening examination may be nonstandard, with a systematic approach used to evaluate all body regions. This examination can be integrated into a comprehensive physical examination.

A standardized examination is ordinarily used by students, whereas experienced physicians often raise questions, and the examination is tailored to finding answers to the questions. For efficiency the patient should be examined in multiple positions: standing, seated, supine, and prone. To conserve time and enhance efficiency, all tests should be completed with the patient in one position before moving the patient to the next position. The mnemonic for a musculoskeletal examination is TART: T , tenderness or sensitivity; A , asymmetry (look); R , restriction of motion (move); T , tissue texture abnormality (feel). The diagnosis of somatic dysfunction is based on a palpatory examination with TART.

Palpation for Tissue Texture Abnormality

Tissue texture abnormality is palpable evidence of physiologic dysfunction. The approach to palpation is to compare right versus left and above versus below. When evaluating a single area without comparing with adjacent areas, it is difficult to come to a meaningful conclusion. Description of dysfunctional areas is done relative to these adjacent areas. Palpation is done in layers, projecting your sense of touch to the depth required.

Acute tissue texture change can be described and remembered by thinking of acute inflammation and the four cardinal signs: red, puffy, painful or tender, and warm. With acute tissue texture changes, sweating is increased and the skin is usually moist (increased sympathetic tone). Chronic tissue texture abnormality is associated with thin, dry, atrophic skin that is cool. The palpatory quality is firm or fibrotic. Motion testing reveals motion loss.

Paraspinal viscerosomatic reflexes have palpatory qualities that are characteristic and give the experienced clinician clues that these changes may be as a result of visceral disturbances. The maximum intensity of the findings is reported to be at the costotransverse and rib angle areas. The greatest number of findings is in the skin and subcutaneous tissue.

Palpating for tissue texture abnormalities can be an accurate and efficient method of identifying problem areas, as well as their acuity, in the musculoskeletal system that require further examination.

Motion Testing

There are multiple methods for motion testing. Because manipulative treatment has as its immediate objective the improvement of motion, motion testing skills and treatment skills become intertwined with the motion testing being used for ongoing diagnosis throughout the treatment.

Types of motion testing include the following:

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  Observation of active motion.

  
  
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  Palpation of active motion with palpating fingers over the facet area.

  
  
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  Rib motion, which is often tested by palpating motion as the patient inhales and exhales.

  
  
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  Active hand/passive hand, which is motion testing in which one hand does the moving and the other hand assesses motion (e.g., moving the head and neck while palpating in the upper thoracic spine).

  
  
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  Direct passive motion testing in which the physician’s hands provide the force and also monitor response to this force. Terms to describe the “feel” might be ease and bind or freedom and resistance ( Figure 16-2 ).

  
  

  
  

  
  

  

  
  

  
  

  Motion testing or articulatory treatment of the thoracic spine. The patient is seated, and the practitioner stands behind the patient with the arm draped over the patient’s shoulder girdles. This enables the practitioner to comfortably induce forces from above that can be used for diagnosis and treatment. These forces include rotation, side bending, lateral translation, and flexion-extension. The opposite hand is placed on the opposite side of the spine to monitor motion for diagnosis. Articulatory treatment can occur with the same hand position but with forces combined from both hands or arms.

  
  

The muscle energy type of motion testing looks for the most posterior transverse process. Place the palpating fingers on the transverse process area of both sides of the segment to be tested. Instruct the patient to flex and extend. For example, assume T3 is extended, rotated, and side bent right. When T3 is flexed (this is the barrier), the muscle on the right side “balls up” under the palpating finger, and the right transverse process becomes more posterior. When T3 is extended, the findings on either side are decreased. The concept demonstrated is that positional asymmetry is increased when the barrier is engaged.

Using the same example of T3 extended, rotated, and side bent right, flex T3 by flexing the head and neck. Attempt to rotate right and left. Left rotation will be very restricted. Extend T3 and again rotate. Left rotation will be much freer. This confirms that the barrier is flexion, and the dysfunction is extended.

Segmental motion testing can also be induced with pressure through the hands without relying on patient movement for diagnosis ( Figure 16-3 ).

Segmental motion testing. The practitioner’s hands are positioned with the thumbs overlying the transverse processes on either side of the segment in question. Alternating pressure on the thumbs induces rotation at the segment while side bending can be induced with medial pressure directed from the hand itself. Flexion and extension preference is tested separately.

There are other approaches to diagnosis, but they share the evaluation of relative motion differences in one of the cardinal planes. The choice of technique for motion testing varies depending on the physician’s preference, the body type of the practitioner and the patient, as well as the physical layout of the treatment area.

Assessment of Fascia

Fascia has unique features that include the formation of sheets with multidirectional fibers giving it tensile strength, and sheets with nonlinear motion that allow for shortening and elongating, thus accounting for its flexibility and pliability. By contrast, there is little or no motion in scar tissue. Fascia is three-dimensional and can form sleeves to compartmentalize, act as cables, or form diaphragms. All these properties must be considered when assessing fascia.

Assessment of fascia starts with placement of the hands to perceive the combined vector force in the tissue. Hand placement varies depending on the area to be assessed and treated. Assessment of an extremity would start with hand placement proximal and distal to the area. An example of this would be the assessment of the forearm. One hand grasps the patient’s hand and the other hand grasps the proximal forearm near the elbow.

In the assessment of a three-dimensional region, such as the chest cage, the hands will start with one anterior and the other posterior on the thorax. The hands should be placed in such a manner that they are 180 degrees to one another. Assessment of a large area, such as the thoracolumbar fascia, might begin with the hands placed in the same direction, on either side of the spine, adjacent to each other.

Once the hands are placed, the fascia must be “entered” by adding tension to the area to engage the viscoelastic property of fascia. The viscoelastic property allows fascia to deform. With tension in place, the practitioner can now “read” the tissue and simultaneously assess and treat. The practitioner can move the fascia to a tightened position by combining multiple motion vectors (clockwise-counterclockwise rotation, anterior-posterior motion, cephalad-caudad motion, pronation-supination) as in a direct release, or follow the combined vector to a point of balance as in an indirect release. Examination of the fascia and myofascial structures may include looking for special “points” or “triggers.” These include counterstrain tender points, the myofascial triggers of Simon and Travell, and acupuncture points.

Types of Technique

Direct Techniques

Soft Tissue Technique.

The purpose of soft tissue technique is to relax muscles and fascia. There are an infinite number of modifications of soft tissue technique. Usually they involve lateral force to stretch the muscle, direct longitudinal stretching, or careful kneading. Sensitive hands and experience are necessary to assess the response of the tissues to the treatment. Apply forces slowly and release slowly. Do not allow tissues to snap back quickly or spasm might occur. Do not allow your fingers to slide over the skin. Avoid excess force per unit area; instead, spread the forces out. Avoid direct pressure over bony prominences. Soft tissue technique can be the primary approach. It can be used to prepare an area for specific mobilization. It can be used to facilitate movement of fluids. It can reduce or modify pain. This is similar to massage, but there is a different end point of the treatment. The focus here is on moving tissue rather than relaxing muscles.

Articulatory Treatment.

This procedure moves a joint back and forth repeatedly to increase freedom of range of motion. Articulatory treatment may be classified as a low-velocity, high-amplitude approach. Sometimes articulatory treatment is a form of soft tissue treatment in which the only way to access deep muscles is to move origin and insertion (see Figure 16-2 ). Articulatory treatment is very useful for stiff joints and for older patients. It might be the only form of treatment applicable for some patients. There are many modifications to articulatory technique.

Mobilization with Impulse (Thrust; High Velocity, Low Amplitude).

Thrust technique is often considered synonymous with manipulation. In Europe, thrust techniques are reserved for the physician, whereas other techniques are termed mobilization . Thrust techniques are applicable for restriction of motion in joints. Thrust technique is often the quickest form of addressing restriction of joint motion. An audible pop can occur with application of the technique. The noise has no effect on treatment outcome. To assess the effectiveness of treatment, reevaluation is required.

A diagnosis of motion restriction is essential before application of thrust technique, and this diagnosis should incorporate the three planes of motion: flexion-extension, rotation, and side bending. The first principle of thrust technique is to engage the barrier. With an accurate diagnosis, engaging the barrier is specific. The barrier must feel solid, not rubbery. A thrust should not be applied if the barrier does not feel solid. Instead of addressing the restriction of motion of the joint, the force is dissipated by muscles and fascia. The thrust must be low amplitude, meaning a very short distance. The thrust should be high velocity ( Figures 16-4 to 16-6 ). There is no place for high-velocity, high-amplitude technique.

Supine treatment of thoracic somatic dysfunction. There are multiple variations of this technique, sometimes referred to as the “Kirksville krunch.” It can be modified to treat type 1 and type 2 dysfunctions, as well as ribs. The technique pictured involves T5 flexed, rotated, and side bent to the left. The practitioner stands on the right side of the patient. The patient’s arms are folded across the chest (position can vary with technique). The practitioner’s fulcrum hand is placed posteriorly over the T6 left side (segment below, side opposite) ( A ). The patient’s torso is rolled back and the patient’s body is moved adjusting side bending and flexion-extension to localize force over fulcrum hand ( B ). The patient is flexed to the segment, and extension is created at the fulcrum as the corrective high-velocity, low-amplitude force is applied.

Treatment of lumbar somatic dysfunction. There are many variations of technique for treating the lumbar region with the patient on their side. This technique shown is for an L2 dysfunction that is flexed, rotated, and side bent to the left. The posterior transverse process from diagnosis is placed down (left side down). The patient’s torso is perpendicular to the table. The patient’s hips and knees are flexed with the upper leg flexed more. Extension at L2 is obtained from above by torso movement. Side bending is maintained by stretching out the right side. Rotation from below is obtained by pushing the shoulder posteriorly. The final corrective force on the iliac crest emphasizes side bending toward the patient’s head; rotation is automatic with the force.

Treatment of cervical spine C2 to C7. In this example, the diagnosis is C4 flexed, rotated, and side bent left. The lateral mass of C4 is contacted with the index finger. An extension break at C4-C5 keeps forces localized at the segment to be treated. Rotation to the left is performed to lock out the rotation component. The corrective force is a side bending into the barrier.

The tissues should be prepared for thrusting technique with soft tissue treatment often used as a precursor to thrust technique. If the tissues are not properly prepared, it is more difficult to engage the barrier and more force must be used. The dissipation of excess force can cause iatrogenic problems. The patient must be relaxed. There is no substitute for skilled hands that allow the patient to relax. Often the thrust is given during exhalation because the tissues are more relaxed at this time. The final activating force is operator force.

Muscle Energy: Direct Isometric Types.

Muscle energy technique was introduced by Fred Mitchell, Sr. Muscle energy technique involves the patient voluntarily moving the body as specifically directed by the practitioner. This directed patient action is from a precisely controlled position against a defined resistance by the practitioner. The initial classification of muscle energy techniques was based on whether the force was equal (isometric), greater (isotonic), or less (isolytic) than the patient force. Most muscle energy techniques used by physicians are direct isometric techniques. This technique has been used extensively by therapists and is often referred to as contract relax technique.

Muscle energy technique requires a specific diagnosis incorporating all three planes of motion (Video 16-2 ). The first step is moving the dysfunctional component into the restrictive barrier. Fred Mitchell Jr. emphasizes that the practitioner moves the dysfunctional component to the “feather edge” of the barrier. The practitioner holds this position and instructs the patient to contract against the holding force. The patient controls the amount of force, so injury is not likely. Additionally, the manner in which the practitioner holds the patient position suggests the amount of force. A heavy-handed vice grip will suggest more force than a lighter touch. The muscle contraction is held for 3 to 5 seconds. Then there is a period of relaxation, sometimes termed postisometric relaxation . The practitioner then reengages a new barrier, and the process is repeated several times. If there is no further increase in the range of motion, it is time to stop. Three repetitions are the usual number, followed by reassessment.

Most direct isometric muscle energy techniques involve the patient actively contracting the shortened (sometimes referred to as the “sick”) muscle. The usual mistakes in using muscle energy technique are failure to properly engage the barrier, application of too much force, or not allowing enough time for postisometric relaxation. Although engaging the barrier involves three planes of motion, the patient contraction may be in one, two, or three planes. Often the patient contraction will be a flexion or extension. In muscle energy technique, the final activating force is a patient muscle contraction ( Figure 16-7 ).

Treatment of thoracic spine with seated, direct muscle energy technique. In this example, the diagnosis is T5 to T8 flexed, rotated right, side bent to the left. The patient is asked to place right hand behind neck and grasp right elbow with left hand and maintain this arm position. The practitioner then reaches in front of the patient to grasp the patient’s right arm to allow for movement to engage the dysfunctional barrier, and in this case it is slight extension of the trunk, rotation to the left, and side bending to the right. The practitioner’s right hand then monitors motion to ensure localization to proper segments and provide some counter force. The activating force is an isometric contraction from the patient.

Direct Myofascial Release.

The goal of myofascial technique is to identify tissue restriction and to remove the restriction. This requires sensing arms and hands. Direct myofascial technique involves loading the myofascial tissues (stretch), holding the tissues in position, and waiting for release. Release is by inherent forces. When collagen is stretched, the viscoelastic properties of collagen allow the tissues to slowly stretch. The term creep is applied to this phenomenon. When release occurs, there is additional lengthening of the tissues without an increase of force being applied. This phenomenon takes several seconds. This release might be likened to an ice cube melting. The release is perceived by the practitioner treating the patient. Reevaluation of the patient reveals a decrease of the restriction being treated, with increased freedom of range of motion ( Figure 16-8 ).

Direct myofascial/indirect treatment for rib. In this example, the diagnosis is right rib 8 exhalation preference. The hand position approximates the length of the rib. Slight pressure is placed anteriorly and posteriorly on the rib to free the rib. For a direct myofascial technique, the rib is taken into the restrictive barrier with slight consistent pressure until release is felt. In an indirect technique, the rib is positioned in the position of ease away from the restrictive barrier exaggerating the exhalation preference.

Indirect Techniques

Strain-Counterstrain.

Counterstrain is a type of manipulative treatment that uses spontaneous release by positioning, and uses tender points serving as a monitor to achieve the proper position. Lawrence Jones, D.O., developed this method of treatment (Video 16-3 ). Counterstrain is classified as an indirect technique. The objective is to relieve painful dysfunction through a reduction of inappropriate afferent proprioception activity. Referring to Figure 16-1 , the shortened muscle remains shortened because of inappropriate proprioceptive activity. Tender points are located in the muscle belly, tendon (usually at or near the bony attachment of the tendon), or dermatome of the shortened muscle. Treatment position further shortens the short muscle, as a “counterstrain” is applied to the originally strained muscle on the other side. The neurophysiologic mechanism is based on the fact that shortening the muscle quiets the muscle and breaks into the inappropriate strain reflex.

Tender points are related to specific dysfunctions. The practitioner must know where to look for these specific points. For example, if the patient has a dysfunction at L3 that is flexed, rotated, and side bent left, an anterior lumbar tender point is located in the abdominal wall in the vicinity of the anterior inferior iliac spine. The use of counterstrain requires a structural evaluation and assessment for tender points. Tender points are tissue areas that are tender to palpation. They are sometimes described as “pealike” areas of tension. The common denominator is the tissue change and tenderness.

Treatment involves identifying the tender point, maintaining a palpating finger on the tender point, and placing the patient in a position so that tenderness in this point is eliminated or reduced significantly. This position is in a pain-free direction of ease. Also, the position places the patient in the original position of injury. Counterstrain is not a form of acupressure. The monitoring finger continues to palpate and assess the point, but pressure is not applied. The amount of time that the treatment position is held is 90 seconds, 120 seconds for ribs. It is essential that the patient be slowly returned from the treatment position to the starting point. The patient should remain passive during the entire process. After return, the tender point is reassessed. If the physician’s palpating finger stays on the tender point, and tenderness is now absent, both practitioner and patient know that a change was made ( Figure 16-9 ).

Counterstrain for iliacus tender point. The patient is in supine position. The tender point is palpated in the anterior pelvis deep in iliac fossa (see inset). Treatment is achieved by flexion of the legs and bilateral hip rotation until tenderness is decreased by more than 80% while tension in the tender point is continuously monitored. The position is then held for 90 seconds or until palpable release. The practitioner then slowly removes the patient from the treatment position and rechecks tenderness for resolution.

Counterstrain is a very gentle technique with an extremely low risk of injury. However, patients can become very sore after counterstrain treatment. It is appropriate to caution patients that they might become sore after treatment. Sometimes analgesics are used to treat the soreness. Patients are often advised to drink plenty of water to maintain adequate hydration. Counterstrain can be used to treat tenderness that remains after other manual treatments have addressed motion restriction. These techniques are also often a good starting point for those learning manual medicine techniques.

Indirect Balancing.

There are multiple names to describe types of indirect technique. These names include functional technique and balanced ligamentous tension. The common denominator in all these technique types is that they are indirect, in that the dysfunction is positioned in a direction of freer motion away from the restrictive barrier. The positioning involves achieving a balance of tension on all sides of the dysfunction. The functional technique of Johnston involves balancing tension in the three translations (front-back, side to side, up-down) and respiration. The more perfect this balance, the quicker the release. Release is by inherent forces.

Indirect balance techniques are difficult for some practitioners and much easier for others. With counterstrain, a tender point helps in finding the proper treatment position. Achieving the proper treatment position with other forms of indirect technique can be a challenge. However, when release occurs, this is very apparent to the treating clinician because there is a decrease of overall tension surrounding the dysfunction.

Some forms of indirect technique use various methods to facilitate a release. Facilitated positional release, developed by DiGiovanna, Schiowitz, and Downing, is an indirect technique that uses a facilitating force (compression, distraction, or torque) to speed the release. DiGiovanna was once asked about the difference between counterstrain and facilitated positional release. She thought for a moment and replied, “About 85 seconds!”

Combined technique or a combined approach is often used with indirect technique. As release is occurring, the original barrier is softening, and the dysfunction is moved into the restrictive barrier. Combined technique means that one starts with indirect technique and finishes with direct technique. Still technique, based on the surviving evidence of how A.T. Still approached manual therapy, has been described by several sources and is a type of combined technique. It involves positioning a joint into the position of ease (indirect), then inducing a light force of compression or traction into the joint. This is followed by then using this force to carry the tissue through its range of motion and through the restrictive barrier ( Figure 16-10 ).

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