High-velocity low-amplitude (HVLA) thrust or impulse techniques

High-velocity low-amplitude (HVLA) procedure is commonly applied in manual therapy/manual medicine as well as OMT. From the perspective of OMT, HVLA is defined as ‘osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction’ (Educational Council on Osteopathic Principles (ECOP) 2009). In that the ‘restrictive barrier’ almost always involves dysfunctional ligaments, instruction in how to perform HVLA is accompanied by a detailed consideration of the fascia, in and around any joint, for which there is an HVLA treatment prospect.

Kappler and Jones (2003, 855) state, ‘As the barrier is engaged, increasing amounts of force are necessary and the distance decreases. The term barrier may be misleading if it is interpreted as a wall or rigid obstacle to be overcome with a push. As the joint reaches the barrier, restraints in the form of tight muscles and fascia serve to inhibit further motion. We are pulling against restraints rather than pushing against some anatomic structure.’

Muscle energy technique

Muscle energy technique is defined as ‘a form of osteopathic manipulative diagnosis and treatment in which the patient’s muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce’ (Educational Council on Osteopathic Principles (ECOP) 2009). Since tendons attach to virtually all muscles, fascia is involved in almost all muscle energy manipulative techniques.

Ehrenfeuchter and Sandhouse (2003, 882) state, ‘He (Fred Mitchell Sr.¹) wrote about the direct method treatments of soft tissues (with attention to fasciae) and the treatment using Neidner’s fascial release² prior to articular correction. Muscle energy technique, he wrote, with its many ramifications, is a most useful tool in preparation of soft tissues. Ligamentous stretching may also be of use before articular correction is attempted’ (Mitchell 1958).

Strain–counterstrain technique

“Also called Counterstrain, the OMT procedure developed in 1955 by Jones (1964) is defined as ‘An osteopathic system of diagnosis and indirect treatment in which the patient’s somatic dysfunction, diagnosed by (an) associated myofascial tenderpoint(s), is treated by using a passive position, resulting in spontaneous tissue release and at least 70 percent decrease in tenderness’ (Educational Council on Osteopathic Principles (ECOP) 2009). Counterstrain technique involves shortening myofascial structures to reduce the nociceptive experience from firm palpation of a tenderpoint.

Glover and Rennie (2003, 1003) state, ‘The location of a specific tender point is constant from one patient to another. This suggests a strong anatomic basis for their location. Different myofascial structures, including tendons, ligaments, and muscle bellies have all been found to contain tender points … another interesting anatomic correlation is the close proximity of tender points in areas where motor points are found. A motor point is the site where the motor nerve pierces the investing fascia and enters the muscle it innervates.’ Without description of the involvement of fascia, counterstrain technique could not be adequately explained

Balanced ligamentous tension and ligamentous articular strain techniques

Developed and first presented by Sutherland in the early 1940s, balanced ligamentous tension (BLT) and ligamentous articular strain (LAS) techniques have fascial elements at the core of musculoskeletal diagnosis and treatment (Lippincott 1949). The basis of balanced ligamentous tension, ‘according to Sutherland’s model, all joints in the body are balanced ligamentous articular mechanisms. The ligaments provide proprioceptive information that guides the muscle response for positioning the joint, and the ligaments themselves guide the motion of the articular components’ (Educational Council on Osteopathic Principles (ECOP) 2009).

Just as a manual medicine/manual therapy practitioners follow fascial planes in directions of ease of motion, the application of BLT focuses on the ligaments and related fascia holding joints in position, placing these structures into a balanced tension position, so that inherent bodily forces and/or respiratory facilitation complete the articular correction. Carreiro (2003, 917) states, ‘The physician must skillfully position the joint so that all forces within the articular mechanism converge on one specific point. This point then becomes the fulcrum around which the shift or change will occur … The more skilled the operator, the more specific the convergence and the less force needed to correct the dysfunction. Very skilled physicians will merely ask the patient to exhale, or will flex the patient’s head to articulate the joint.’

The Lippincott (1949) article describes Sutherland’s techniques that would be termed myofascial release because they were directed toward structures such as diaphragms (respiratory, thoracic inlet and pelvic) that were not specifically articular. The BLT techniques have been elaborated and expanded, based on the work of Rollin Becker, DO and others who carried on the teaching of Sutherland’s techniques, and the term LAS has come into use because of a teaching manual published with that name (Speece et al. 2009).

Myofascial release techniques

As noted above, attention to fascia has been central to osteopathic medicine since the 1890s. Myofascial release (MFR) is ‘a system of diagnosis and treatment first described by Andrew Taylor Still and his early students, which engages continual palpatory feedback to achieve release of myofascial tissues. Direct MFR – a myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with constant force until the tissue release occurs. Indirect MFR – the dysfunctional tissues are guided along the path of least resistance until free movement is achieved’ (Educational Council on Osteopathic Principles (ECOP) 2009).

As this book illustrates, there are a number different schools of thought and teaching on the subject of myofascial technique. Out of the osteopathic tradition, besides BLT and LAS, there are two other sets of techniques directly concerned with fascia, the fascia–ligamentous release – indirect approach (Chila 2003) – and the integrated neuromusculoskeletal release and myofascial release (Ward 2003). A careful reading of Chila (2003) and Ward (2003) reveals that the underlying principles are very similar, but specific hand placements and areas of body contacted are somewhat different. Taken together, the Chila and Ward approaches comprise a comprehensive system of the application of myofascial treatment techniques. In fact, teaching in US osteopathic medical schools draws upon and combines the techniques of BLT and LAS along with integrated neuromusculoskeletal release (INR) and myofascial release (MFR). However, in the present context it is helpful to describe techniques associated with different terminologies because that is how they are identified in texts and teaching as well as in documentation for medical procedure description and coding for reimbursement of healthcare services in the USA.

Osteopathy in the cranial field

Also known as cranial osteopathy, cranial manipulation techniques involve great attention to intracranial dura (Magoun 1966). ‘Osteopathy in the Cranial Field (OCF) – A system of diagnosis and treatment by an osteopathic practitioner using the primary respiratory mechanism and balanced membrane tension … Refers to the system of diagnosis and treatment first described by William G. Sutherland, DO’ (Educational Council on Osteopathic Principles (ECOP) 2009). ‘It has been stated that Sutherland did for the head that which Still did for the rest of the body, which was to delineate an anatomically based understanding of range and vector of motion and physiologic dynamics of cranial bones and intra-cranial structures’ (King 2011a). Structures such as the falx cerebri and diaphragma sellae are contiguous with spinal dura mater, presenting a basis for fascial manipulative techniques that can affect brain centers (King 2007).

While OCF originated in osteopathy, in the context of this book it is important to acknowledge that cranial manipulation has other proponents and perspectives, e.g., craniosacral therapy (Upledger & Vredevoogd 1983) and sacro-occipital technique (SOT) (DeJarnette 1967; Hesse 1991). All cranial manipulation traditions embrace the fascial continuity perspective and its importance in the application of therapy and treatment procedures.