76350065 1 Jeffrey Maitland Spinal Manipulation Made Simple

"Meeting the plasticity of the body with a flexible and gentle somatic response" As somatic therapists our goal is not to make clients measure up to some external standard that we impose on them by means of somatic ideals and formulistic protocols, but to try to discover the limitations that stand in the way of them becoming who they are—and then to release

their

fixations

in

the

right

order.

— f r o m the text

In Spacious Body: Explorations in Somatic Ontology, Jeffrey Maitland e x p l o r e d the philosophical implications of Rolfing, interrogating different kinds of will and showing h o w p e o p l e can b e g i n to understand their c o r e fixations a n d c o n f l i c t e d o r i e n t a t i o n s a n d m o v e t o creative t r a n s f o r m a t i o n s . His m o v i n g descriptions o f healing s h o w e d h o w a n e w u n d e r s t a n d i n g o f h o w the h u m a n b o d y works can create a transformation of the spirit. In this new m o r e physiological b o o k , Maitiand stays with the myofascial release techniques invented by Rolfing, b u t focuses the reader's attention o n the p r o b l e m o f j o i n t fixations w h i c h u n d e r l i e m a n y soft-tissue pain syndromes. His attention is especially on h o w to ease back pain and bring the b o d y into a m o r e comfortable alignment, because back pain is a major c o m p l a i n t dealt with by c h i r o p r a c t o r s , Rolfers, massage therapists, a n d physical therapists. Maitland shows h o w to elegandy release j o i n t fixations in the spine, sacrum, pelvis, and ribcage by using subtle soft-tissue techniques, rather than the high-velocity low-amplitude thrusting techniques that " p o p " the j o i n t s . This gentler kind of individualized Rolfing w o r k is t h o r o u g h l y d e s c r i b e d within an e x p l a n a t i o n of b i o m e c h a n i c s , a i d e d by drawings and p h o t o g r a p h s which d e p i c t t e c h n i q u e s and anatomy. Jeffrey Maitland, Ph.D., is a philosophical counselor and advanced Rolfer. He is a senior instructor and Director of A c a d e m i c Affairs at the International Rolf Institute. Spacious Body: Explorations in Somatic Ontology was published by North Atlantic Books in 1 9 9 5 . He lives and practices in Scottsdale, Arizona.

Health/Somatics North Atlantic Books Berkeley, California www.northatlanticbooks.com

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Spinal Manipulation Made Simple

Spinal Manipulation Made Simple A Manual of Soft Tissue Techniques

Jeffrey Maitland Photographs by Kelley Kirkpatrick

N o r t h Atlantic B o o k s Berkeley, California

Copyright © 2001 by Jeffrey Maitland. Photographs © 2001 by Kelley Kirkpatrick. All rights reserved. No portion of this book, except for brief review, may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the written permission of the publisher. For information contact North Atlantic Books. Published by North Atlantic Books P.O. Box 12327 Berkeley, California 94712 Cover photograph by Brandy Wilkins Cover and book design by Paula Morrison Printed in the United States of America Spinal Manipulation Made Simple is sponsored by the Society for the Study of Native Arts and Sciences, a nonprofit educational corporation whose goals are to develop an educational and crosscultural perspective linking various scientific, social, and artistic fields; to nurture a holistic view of arts, sciences, humanities, and healing; and to publish and distribute literature on the relationship of mind, body, and nature. ISBN-13: 978-1-55643-352-8 Library of Congress Cataloging-in-Publication Data Maitland, Jeffrey, 1943Spinal manipulation made simple : a manual of soft tissue techniques / by Jeffrey Maitland. p. cm. ISBN 1-55643-352-2 (trade paper : alk. paper) 1. Spinal adjustment—Handbooks, manuals, etc. 2. Manipulation (Therapeutics)—Handbooks, manuals, etc. I. Title. RZ265.S64 M35 2000 615.8'2— dc21 00-041133 6 7 8 9 1 0 DATA 11 10 09 08 07

ACKNOWLEDGMENTS

Spinal Manipulation Made Simple answers a q u e s t i o n that m a n y s o m a t i c manual therapists have p o n d e r e d : Is it possible to release spinal fixations without resorting to high-velocity, l o w - a m p l i t u d e thrusting t e c h n i q u e s e m p l o y e d by osteopaths and chiropractors? This b o o k delineates my very straightforward a n d simple technical solution to this p r o b l e m . But simple solutions often have c o m p l e x histories that result f r o m the c o n f l u e n c e of many disparate influences. T h e r e are so many p e o p l e that have h e l p e d me find my way that I w o u l d be disrespectful and remiss if I d i d n ' t try to thank s o m e o f t h e m . With respect to somatic therapy, the m o s t i m p o r t a n t i n f l u e n c e on the evolution of my a p p r o a c h c o m e s f r o m the m a n y p e o p l e at the R o l f Institute w h o l a b o r e d in the service of teaching me the t h e o r y a n d art of the Rolfing® m e t h o d of Structural Integration and h o w to teach it. I am espe1

cially i n d e b t e d to the teaching a n d gifts of senior teachers Jan Sultan a n d Michael Salveson a n d I want to a c k n o w l e d g e their untiring d e d i c a t i o n to the education of Rolfers. T h e i r i n f l u e n c e can be f o u n d in various places t h r o u g h o u t this b o o k . I am also v e r y grateful f o r what I l e a r n e d f r o m E m m e t t Hutchins a n d Peter M e l c h i o r w h e n they were still m e m b e r s o f the Rolf Institute. My understanding of the functional side of somatic therapy has benefitted greatly f r o m the work of the m o v e m e n t teachers at the Rolf Institute, especially f r o m the following p e o p l e : H u b e r t G o d a r d , J a n e Harrington, M e g a n James, Vivian Jaye, Gael O h l g r e n , a n d H e a t h e r W i n g . I also want to acknowledge J o h n (Nottingham, physical therapist, researcher, and R o l f e r n o t o n l y f o r his s u p p o r t , generosity o f heart, a n d sparkling intellect, but also for his sensational research on holistic manual and m o v e m e n t therapy. I feel privileged to have w o r k e d with h i m and to have b e e n able to publish two articles with h i m . His research is n o t only elegant, b u t s o m e of the best on holistic manual therapy.

SPINAL MANIPULATION MADE SIMPLE I have greatly benefitted, b o t h professionally and personally, f r o m the wonderful work of osteopathy. I owe a special debt of gratitude to the guida n c e a n d generosity of my friend a n d m e n t o r , the late Dr. Walter Wirth, D . O . His brilliant w o r k a n d teaching c h a n g e d n o t only my body, but the d i r e c t i o n of my w o r k as a somatic practitioner. I am also grateful for the i n t r o d u c t i o n to the mysteries of the c r a n i u m a n d i n d i r e c t t o u c h that I received f r o m Dr. J o h n Upledger, D . O . early in my development as a Rolfer. I feel especially fortunate to have b e e n able to train with the U p l e d g e r Institute and Didier Prat, D . O . in the revolutionary Visceral Manipulation d e v e l o p e d by Jean-Pierre Barral, D . O . Many thanks to Dr. Marilyn Wells, D . O . a n d the o t h e r A r i z o n a osteopaths with w h o m I have had the great pleasure to associate. I have learned m o r e than I can say from a great n u m b e r of b o o k s on osteopathy, but I particularly appreciate the work of Phillip Greenman, D.O. I also want to thank Dr. J o s e p h D e B r i u n , D.C. a n d Dr. L . J o n P o r m a n , D.C. f o r their e x c e l l e n t w o r k o n m y j o i n t s a n d f o r i n t r o d u c i n g m e t o the principles and practice of Dynamic Chiropractic. Although I do n o t employ c h i r o p r a c t i c t e c h n i q u e in my p r a c t i c e , I have f o u n d their a p p r o a c h to m o t i o n testing a n d u n d e r s t a n d i n g spinal fixation invaluable. I am by instinct a n d training a p h i l o s o p h e r a b o v e all else. Philosophy has m a n y faces, b u t the o n e I am m o s t attracted to c o n c e r n s the nature o f b e i n g . A n o t h e r i m p o r t a n t aspect o f p h i l o s o p h y consists i n e x p o s i n g and e x a m i n i n g the veracity of the presuppositions that i n f o r m o u r every a t t e m p t t o u n d e r s t a n d the nature o f reality. T h i s a s p e c t has l e d s o m e thinkers to d u b p h i l o s o p h y "the q u e e n of the sciences." A l t h o u g h it may n o t be immediately o b v i o u s , these two c o n c e r n s are at work in the backg r o u n d of this manual. To all the p h i l o s o p h e r s w h o have c o n t r i b u t e d so m u c h to my growth over the years I give heartfelt thanks. O n e of the greatest practical p h i l o s o p h e r s with w h o m I have had the g o o d f o r t u n e to study is my Z e n teacher. I c a u g h t my first glimpse of h o w the b o d y speaks to an o p e n heart while c u d d l i n g my infant daughters. But this truth a b o u t the activity of b e i n g d i d n o t really b l o s s o m until it was simultaneously articulated and manifested by my Roshi. His influence c o n tinues to alter the c o u r s e of my life a n d work. Even the O x f o r d English Dictionary c a n n o t supply e n o u g h w o r d s to express the d e p t h of my gratitude to h i m . I r e m e m b e r asking h i m , " H o w do y o u heal p e o p l e ? " With a

ACKNOWLEDGMENTS spacious imperturbability that s h o w e d no hesitation, he said, " A h h , y o u must b e c o m e o n e with t h e m ! " His simple answer p o r t e n d s a great d e p t h . Today, twenty years later, I think I am just b e g i n n i n g to grasp the w i s d o m he demonstrated. I h o p e s o m e small part of his p r o f o u n d teachings has also f o u n d its way into this b o o k . I want to thank Kelley Kirkpatrick f o r h e r w o n d e r f u l p h o t o g r a p h s that so clearly demonstrate my t e c h n i q u e s . H e r skill, p a t i e n c e , a n d aesthetic sensitivity are a gift. Also m a n y thanks go to David R o b i n s o n , Rolfer, w h o generously agreed t o b e the m o d e l . Finally, I want to give thanks to my pain f o r leading me to a n e w a n d better life. But m o s t of all, I want to give my d e e p e s t b o w of gratitude to my detractors. F r o m t h e m I have l e a r n e d the impossible.

Note 1. Rolfing® is a service mark of the R o l f Institute of Structural Integration.

ILLUSTRATIONS

Permission to use their illustrations was granted from the following publications: The illustrations of the spine in forward and backward bending and the dysfunctional vertebrae (Figures 2.1, 2.2, and 2.3) come from Greenman, Phillip E. The Principles of Manual Medicine, second edition. Baltimore, Maryland: Williams and Wilkins, 1996, figures 5.24 and 5.25 on p. 61 and figure 6.1 on p. 67. The illustration of rib tender points (Figure 9.5) comes from DiGiovanna, Eileen L. and Schiowitz, Stanley. An Osteopathic Approach to Diagnosis and Treatment. New York, New York: Williams and Wilkins, 1991, figures 17.7 and 17.10 on pp. 261-262. The following illustrations come from Kapandji, I. A The Physiology of the Joints, Vol Three. New York, New York: Churchill Livingstone, 1974. Figure 4.2 is 34 on p. 193. Figure 7.14 and 10.11 are 8, 9, and 10 on p. 61. Figure 7.13 is 2 on p. 11. Figure 8.1 is 11 and 12 on p.63. Figurel0.3 is 11 and 12 on p. 63. Figure 10.7 is 75 p.233. Figure 10.10 is 6 on p. 59 and 8, 9, 10 on p. 61. The photograph in Figure 8.3 displaying an posteriorly tilted and anteriorly shifted pelvis comes from Kendall, Florence Peterson and McCreary, Elizabeth Kendall. Muscles: Testing and Function, Third edition. Baltimore, Maryland: Williams and Wilkins, 1983, p. 284. The illustration of the of the Ideal Body (Figure 10.8) comes from Kendall, Florence Peterson and McCreary, Elizabeth Kendall. Muscles: Testing and Function, Third edition. Baltimore: (Williams and Wilkins), 1983, p. 280. The illustration of the rib/vertebral complex (Figure 9.1) comes from Schultz, R. Louis and Feitis, Rosemary. The Endless Web. Berkeley, California: North Adantic Books, 1996, figure 9.1 is 8.5 on p. 30. The illustration of the possible positions of the sciatic nerve in relation to the piriformis muscle (Figure 10.4) comes from Ward, Robert, ed. Foundations for Osteopathic Medicine. Baltimore, Maryland: Williams and Wilkins, 1997, figure 10.4 is 49.6 p. 606. The illustration of the ideal spine (Figure 10.9) comes from Rolf, Ida P. Rolfing: The Integration of Human Structures. Santa Monica: Dennis-Landman Publishers, 1977, figure 10.9 is 13.3 on p. 209.

CONTENTS

Introduction Chapter 1: O u r Fine Spine: T h e B a c k b o n e of Structural Integrity

xi 1

Chapter 2: Primates in T r o u b l e Or where d o e s y o u r back go w h e n it g o e s out?

13

Chapter 3: Finding and Fixing the Fixations

27

Chapter 4: T h e N e c k

35

Chapter 5: M o t i o n Testing the Cervical Spine

51

Chapter 6: T h e Atlas a n d O c c i p u t

61

Chapter 7: T h e Sacrum

71

Chapter 8: T h e Pelvis

95

Chapter 9: T h e Ribs

113

Chapter 10: O d d s a n d Ends

129

Bibliography

157

Index

161

INTRODUCTION

T

HIS B O O K G R E W O U T O F M Y B A C K P A I N A N D M Y D E E P A P P R E C I A T I O N F O R

the somatic manual therapists w h o allowed me to heal a n d find a n e w

life. I r e m e m b e r all t o o well the day my back "went o u t " f o r the first time. I was 27 years o l d , fresh o u t of graduate s c h o o l , and into my s e c o n d semester of teaching p h i l o s o p h y at P u r d u e University. Feeling the n e e d to get into better shape, I had b e g u n a rather thoughtless p r o g r a m of exercise.

A few days later, I awoke to a nasty pain in my lower b a c k c o n f i n e d to an area about the size of a 50-cent piece. By n o o n I c o u l d n ' t stand up straight. I was p i t c h e d forward at a 45-degree angle and f o r c e d to lean on a b r o o m h a n d l e t o m o v e a b o u t . M y wife arrived h o m e f r o m r u n n i n g e r r a n d s t o find m e i n this d e p l o r a b l e c o n d i t i o n . She d r o v e m e t o the l o c a l e m e r g e n c y r o o m w h e r e I was p r o d d e d a n d p o k e d , a n d then sent h o m e with muscle relaxants. T h e muscle relaxants were useless; their only effect was to turn me into a s t u p o r o u s version of the local village idiot. W h e n the effects w o r e off, I immediately flushed my m e d i c a t i o n s d o w n the toilet. That day m a r k e d the b e g i n n i n g of a seven-year search f o r relief. At first I tried the c o n v e n t i o n a l m e d i c a l a p p r o a c h . On the first visit to my doctor, an o r t h o p e d i c surgeon, I was i n f o r m e d I had back pain because h u m a n beings were n o t d e s i g n e d to stand upright. " W h a t a bizarre theory!" I thought. " D o e s he think that I w o u l d n o t have d e v e l o p e d back pain if I had spent my life crawling a r o u n d on my hands a n d knees? Obviously we are n o t d e s i g n e d f o r that way of getting a b o u t either." I k n e w better than t o express m y o b j e c t i o n s t o his t h e o r y b e c a u s e h e , like t o o m a n y o t h e r authoritarian practitioners, m a d e up s p e c i o u s explanations at the d r o p of a hat. Besides, I was in pain, a n d at that m o m e n t in my life he was my only h o p e . I certainly d i d n ' t want h i m angry with m e . He t h e n sent me to a physical therapist w h o gave me a set of useless exercises. Over time xi

SPINAL MANIPULATION MADE SIMPLE my pain subsided a n d I b e g a n j o g g i n g in the naive belief that I was h e l p ing my back problem. O v e r the n e x t few years my back regularly "went out." W h e n the pain was at its worst, I m a d e another a p p o i n t m e n t with my doctor. Even though I h a d n o p a i n radiating d o w n e i t h e r leg, h e i n f o r m e d m e , without the b e n e f i t o f X-rays o r any o t h e r k i n d o f i m a g e s o f m y b a c k , that I h a d a b u l g i n g disk, a n d said, "You know, if I have to see y o u t o o often, we are g o i n g to have to do surgery." His ultimatum was c o m p e l l i n g and I drew the only c o n c l u s i o n I c o u l d — I w o u l d never go to see h i m again. "Surely," I t h o u g h t , " s o m e b o d y must understand h o w backs work, why they get in trouble, a n d h o w they can be h e l p e d . " A friend r e c o m m e n d e d that I go to a c h i r o p r a c t o r w h o had h e l p e d her. I m a d e an a p p o i n t m e n t . His secretary a p p l i e d ultrasound to my low back and then he "adjusted" it. He sold me a back brace and after a few weeks of his treatment, my pain b e g a n to subside. I w o u l d make an a p p o i n t m e n t every time my back flared u p . Unfortunately, even t h o u g h my c h i r o p r a c t o r c o u l d ease my pain, he c o u l d never k e e p me that way. After many treatments my n e c k also b e g a n to cause me trouble a n d every session I had to r e m i n d h i m to "adjust" my n e c k . I c o n t i n u e d to j o g a n d my pain c o n t i n u e d to get worse. A n u m b e r of years later I a l l o w e d a n o t h e r c h i r o p r a c t o r to strap me o n t o a table that l o o k e d like it h a d b e e n built in the last century. As he tightened the straps I felt vaguely uneasy a n d had a m o m e n t a r y vision of myself as a victim of the Crusades. As he slowly t u r n e d the crank, I was tortuously a n d painfully stretched. I c o u l d barely stand afterwards and I s o o n d e v e l o p e d a h o r r i b l e case of sciatica. If y o u have never e x p e r i e n c e d this pain, y o u never want to. It is like having the world's worst t o o t h a c h e in y o u r butt and legs. So I knew I h a d to find a n o t h e r way. W h i l e I was o n sabbatical f r o m P u r d u e , o n the r e c o m m e n d a t i o n o f f r i e n d s I m a d e an a p p o i n t m e n t with a very talented Rolfer. To make a l o n g process short, after thirty five or so sessions with a n u m b e r of o t h e r Rolfers a n d with the a d d i t i o n a l h e l p of a gifted o s t e o p a t h , I was finally freed of my b a c k pain. I subsequently b e c a m e a R o l f e r a n d then a Rolfing teacher. As my u n d e r s t a n d i n g a n d ability as a Rolfer grew, my frustration with certain aspects of the traditional a p p r o a c h to Rolfing also grew. O l d style R o l f i n g was often t o o painful a n d m u c h t o o general to p r o p e r l y handle

xii

INTRODUCTION local areas of immobility a n d pain. B e f o r e b e c o m i n g a Rolfer, I h a d b e e n practicing Z e n meditation intensely f o r a n u m b e r of years a n d h a d s o m e what unintentionally d e v e l o p e d the ability to feel e n e r g y in a n d a r o u n d my clients' b o d i e s . Unfortunately the heavy pressure I was taught to use when applying the techniques of Rolfing m a d e it impossible f o r me to feel the subde energy c o n n e c t i o n s t h r o u g h o u t the body. For a n u m b e r of years I e x p e r i m e n t e d with trying to find a gentler a p p r o a c h that w o u l d n o t sacrifice the p r o f o u n d structural changes f o r w h i c h Rolfing is k n o w n . I b u m bled along until I finally learned h o w to feel the energies of the b o d y while still applying the heavy pressure often required by Rolfing. My c o n f i d e n c e grew as I realized that I was able to apply a full range of pressures, f r o m very light to very heavy, w i t h o u t causing u n n e c e s s a r y d i s c o m f o r t to the client or sacrificing the goals of Rolfing. T h e s e e x p l o r a t i o n s also allowed m e t o penetrate m o r e d e e p l y i n t o and t h r o u g h the b o d y ' s tangled webs of fascial and energetic c o n f u s i o n . My clients were happy because I was getting better results without causing unnecessary discomfort. Many r e p o r t e d that their e x p e r i e n c e of massage was actually m o r e u n c o m f o r t a b l e than the way I R o l f e d . I was feeling better a b o u t my w o r k because I was also able to be very specific without losing sight of the whole. Unfortunately, I did n o t remain c o n t e n t for long. As if some universal principle were being worked out in my life that n o b o d y had i n f o r m e d me a b o u t , the better a Rolfer I b e c a m e , the m o r e difficult my client's p r o b l e m s b e c a m e . While I was training to b e c o m e a teacher of advanced Rolfing I learned that two senior teachers, Jan Sultan a n d M i c h a e l Salveson, were already in the process of trying to solve m a n y of the same p r o b l e m s that I h a d b e e n struggling with. I was able to build on their insights a n d my investigations revealed that many of the traditional R o l f i n g t e c h n i q u e s were all t o o often incapable of releasing facet restrictions in the spine a n d o t h e r joints of the body. As Rolfing instructors, we had no interest in teaching the high-velocity, low-amplitude thrusting techniques p i o n e e r e d by osteopaths and later a d o p t e d by chiropractors. Since R o l f i n g is a f o r m of m y o fascial m a n i p u l a t i o n a n d e d u c a t i o n , w e w a n t e d o u r t e c h n i q u e s t o l o o k and feel like a variation of o u r already established a p p r o a c h to soft-tissue m a n i p u l a t i o n . C r u d e l y stated, high-velocity t e c h n i q u e s are d e s i g n e d to " p o p " j o i n t f i x a t i o n s free, b u t they l o o k a n d feel n o t h i n g like Rolfing. xiii

SPINAL MANIPULATION MADE SIMPLE We h a d e x p l o r e d o t h e r soft-tissue t e c h n i q u e s similar to ours, b u t s o o n realized that they were incapable of p r o d u c i n g the global structural changes of Rolfing. We also d i s c o v e r e d that m a n y of the p o p u l a r i z e d myofascialrelease t e c h n i q u e s that were m i s a p p r o p r i a t e d f r o m osteopathy a n d Rolfi n g t e n d e d to merely " u n w i n d " the tissue a r o u n d the j o i n t without ever releasing the actual fixation. O u r goal was to find m e t h o d s of mobilizing j o i n t fixations that were consistent with the way Rolfing works with soft tissue, but we had no interest in importing techniques f r o m other disciplines. After studying h o w j o i n t s w o r k a n d b e c o m e restricted, I e x p e r i m e n t e d with a n d finally m a n a g e d to d e v e l o p a range of soft-tissue techniques that effectively release j o i n t fixation without resorting to high-velocity thrusting techniques or any other techniques d e v e l o p e d in other systems of manual therapy. T h e s e soft-tissue t e c h n i q u e s , c o u p l e d with an understanding of h o w the spine gets in a n d o u t of trouble c o m p r i s e the c o n t e n t of this book. Like s o m a n y o t h e r p e o p l e struggling t o o v e r c o m e debilitating back pain, I was w o r k e d on by m a n y different practitioners f r o m many differe n t s c h o o l s of therapy. I n o t i c e d that a few were astonishingly m o r e effective than others a n d that they all h a d similar qualities a n d abilities that were missing in the average therapist. Y o u will often hear the average practitioner boast that his t e c h n i q u e or a p p r o a c h is so m u c h better than all the others b e c a u s e he d o i n g s o m e t h i n g remarkably and uniquely differe n t f r o m e v e r y o n e else. But my e x p e r i e n c e as a patient a n d teacher of m a n u a l therapy l e d me to just the o p p o s i t e c o n c l u s i o n : what makes f o r a really g o o d practitioner is n o t what is different about his or her approach, b u t what he or she shares in c o m m o n with all great practitioners in every discipline. In the e n d there is nothing unique about being unique, because the p o w e r is n o t in what is u n i q u e , b u t in what is c o m m o n . T h e s e qualities are fairly easy to state, b u t n o t so easy to teach. All of the gifted practitioners w h o w o r k e d with me e x h i b i t e d an u n c a n n y perceptual vitality a n d sensitivity that allowed t h e m to see and feel the details of my p r o b l e m s with an exquisite specificity and mastery of technique that never lost sight of my w h o l e p e r s o n . T h e y were capable of releasing local areas of dysfunction in a way that benefitted my entire body. T h e y released my symptoms without ever getting caught in the trap of chasing them and they w e r e always able to track h o w their l o c a l m a n i p u l a t i o n s c a s c a d e d

xiv

INTRODUCTION t h r o u g h o u t my w h o l e body. As a result, they almost always k n e w w h e r e to work next and they rarely drove p r o b l e m s to o t h e r areas of my body. Since my b o d y was constantly c h a n g i n g a n d i m p r o v i n g u n d e r their care, they rarely repeated the same session. But most importandy, because they c o u l d k e e p the w h o l e of me in view a n d affect the w h o l e as they addressed local areas of my body, their w o r k often p r o d u c e d far-reaching a n d long-lasting changes. All of these practitioners were also w e l l - e d u c a t e d a n d well-versed in their disciplines. T h e y h a d a t h o r o u g h a n d detailed k n o w l e d g e that they continually e x p a n d e d t h r o u g h further study a n d research. Part of what m a d e them masters of their arts was their daunting k n o w l e d g e , their c o m mitment to always learning m o r e , a n d a most remarkable mastery of technique. But there was another, m o r e elusive, factor that contributed to their mastery—their way of being. At least for the duration of each session, they lived their art with a clarity, compassion, and openness quite b e y o n d everyday life. I felt that my b e i n g and pain were seen and u n d e r s t o o d . I was n o t treated like a s p e c i m e n with a p r o b l e m w h o was in n e e d of s o m e sort of outside intervention that f o r c e d me to measure up to s o m e objective standard o f normality. T h e i r u n c a n n y p e r c e p t i o n , exquisite discrimination, and sense o f t o u c h were n o t r o o t e d i n any sort o f objective, j u d g m e n t a l separation f r o m m e , b u t in a d e e p l y felt participatory u n d e r s t a n d i n g free of conflict, grandiosity, and self-importance. T h e y never tried to c o n v i n c e me that they knew what was best f o r me or that only they h a d the answer to my p r o b l e m s . If I d i d n ' t r e s p o n d to their treatment as they e x p e c t e d , they d i d n ' t make me feel like it was my fault and were always willing to try another approach or refer me to o t h e r practitioners. Unlike so many practitioners w h o only chased symptoms while paying lip service to a holistic a p p r o a c h , they were truly holistic practitioners. This way o f b e i n g , n o t the m e r e a c c u m u l a t i o n o f t e c h n i q u e s , i s b o t h the source of all healing and the limitless heart of life itself. W o r k i n g this way is n o t a matter of g o i n g into an altered state, b u t of returning to o u r senses, to o u r native c o n d i t i o n free of the contaminations a n d conflicts of self and culture. O n c e we are freed f r o m o u r conflicts, we see a n d feel the world differently, a n d we no l o n g e r stand apart f r o m what we sense. We live and perceive o u r world with a participatory sensorial affinity that g e n tly embraces and is e m b r a c e d by b o t h s o m a and nature. T h e r e is a w i s d o m

XV

SPINAL MANIPULATION MADE SIMPLE and spacious clarity that arises f r o m resting in o u r primordial unconflicted s t a t e — w i t h o u t it a therapist is b u t a m e r e technician; b u t with it amazing things are possible. F o r this w i s d o m to evolve i n t o a healing ability, however, it must also be c o u p l e d with the right kind of rationality and objective knowledge that is t h e n fully i n t e g r a t e d i n t o the s o m a t i c i n t e l l i g e n c e of the t h e r a p i s t — k n o w l e d g e a n d w i s d o m must go h a n d in h a n d . To paraphrase Kant: wisd o m without k n o w l e d g e is blind and k n o w l e d g e without wisdom is empty. Since I have already discussed the nature of transformation in my b o o k Spacious Body, I will n o t dwell on this way of b e i n g h e r e , I only m e n t i o n it b e c a u s e it is so i m m e n s e l y i m p o r t a n t . Every p r a c t i t i o n e r has p r o b a b l y e x p e r i e n c e d m o m e n t s o f this s p a c i o u s o p e n n e s s , i n w h i c h every interv e n t i o n p r o d u c e s almost magical a n d effortless results. It is, after all, the heart of all healing. T h r o u g h its cultivation the healer heals herself and b e c o m e s effortlessly m o r e effective in healing others. W h i l e no less i m p o r t a n t than articulating the healer's way of b e i n g , this b o o k is n o t so ambitious. It is rather a practical manual of techniques f o r treating the spine. It offers all m a n u a l therapists s o m e of the knowle d g e a n d specificity of t e c h n i q u e that is r e q u i r e d to treat a n u m b e r of d i f f e r e n t kinds of s o m a t i c dysfunctions that they see every day in their practices. However, k n o w l e d g e and specificity of t e c h n i q u e , is n o t the be-all and end-all of therapy. It is o n e thing to k n o w h o w to apply techniques and it is quite a n o t h e r to k n o w w h e n and in what o r d e r to apply them. Beyond the m e r e application of t e c h n i q u e there are the three fundamental questions of therapy: "What do I do first, What do I do next, and W h e n am I finished?" Answering these questions to the benefit of o u r clients is crucial f o r any holistic a p p r o a c h . However, as important as understanding these considerations is to the d e v e l o p m e n t of every practitioner, this b o o k is also n o t a treatise on the clinical decision process, b u t a manual of techniques. T h e mastery of t e c h n i q u e is i m p o r t a n t f o r m a n y obvious reasons, n o t the least of w h i c h is the b e n e f i t it p r o v i d e s f o r o u r clients. But there is a n o t h e r b e n e f i t f o r the p r a c t i t i o n e r w h o puts the time a n d effort i n t o learning h o w to effectively apply technique: this mastery is o n e of the n e c essary stepping stones f o r cultivating the healer's way of being. Just as practicing scales can be p r e p a r a t o r y f o r the inspired p e r f o r m a n c e of music,

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INTRODUCTION s o t o o can p r a c t i c i n g t e c h n i q u e s b e c o m e part o f the cultivation o f the healer's way of b e i n g . No matter what f o r m of manual therapy you were trained in, and regardless of w h e t h e r y o u w o r k with a corrective or holistic a p p r o a c h , y o u will find these techniques deceptively simple to apply a n d yet highly effective in dealing with m o s t f o r m s of b a c k pain. T h e t e c h n i q u e s all arose f r o m my frustration with my inability to resolve the m o r e difficult b a c k p r o b lems that I was seeing in my practice. After I c r e a t e d these t e c h n i q u e s I tested them in my practice, classes, and in collaboration with my colleagues, Jan Sultan and Michael Salveson, at the R o l f Institute. Understanding this b o o k requires a working k n o w l e d g e of the anatomy of the muscular a n d skeletal systems. I discuss a n a t o m y w h e r e it is relevant, but in the simplest of terms. My goal is to give y o u the skills y o u n e e d t o evaluate a n d i m m e d i a t e l y treat y o u r patients. T h e r e are m a n y w o n derful b o o k s available that go into c o n s i d e r a b l e detail r e g a r d i n g manual therapy and I see no n e e d to repeat what has already b e e n said well. T h e texts I have f o u n d m o s t useful are i n c l u d e d in the bibliography.

xvii

CHAPTER

1

Our Fine Spine: The Backbone of Structural Integrity F Y O U R BACK HAS EVER " G O N E O U T , " T H E EASE W I T H W H I C H Y O U G O

about your life goes right out the window with it. A n d you are n o t a l o n e — at least 80 million A m e r i c a n s are in the same fix. Many m a k e the mistake of thinking that w h e n their pain disappears their p r o b l e m also g o e s away. But e x p e r i e n c e d clinicians k n o w that this b e l i e f is based on an illusion. We c o u l d term the confusion of the experience of pain with the p r o b l e m causing the pain the "fallacy of misplaced h o p e . " A facet restriction can exist at a subclinical level, showing no obvious signs of pain, and then suddenly rear its painful c o u n t e n a n c e at the most i n o p p o r t u n e times. Y o u arise from a chair to greet a friend and suddenly there's that stabbing pain i n y o u r back again. Back pain can c o m e a n d g o , b u t the p r o b l e m almost always remains. A n d if left untreated, it often gets worse as time a n d gravity take their unforgiving toll on o u r b o d i e s . W h o l e disciplines a n d theories o f manual therapy have b e e n created based on the idea that the spine is the most important and sometimes the only area of the b o d y that n e e d s to be treated. As naive as that view is, it i s certainly n o t h a r d t o a p p r e c i a t e its a p p e a l . Y o u d o n ' t n e e d a l o t o f research to understand that if y o u c a n n o t treat spinal dysfunctions, y o u are incapable of h e l p i n g m a n y p e o p l e . If y o u are a holistic practitioner trying t o p r o v i d e h i g h e r a n d h i g h e r levels o f o r g a n i z a t i o n a n d b a l a n c e for y o u r clients a n d y o u c a n n o t release p e o p l e f r o m their spinal dysfunctions, then y o u r grandest n o t i o n s of what can be achieved f o r t h e m will 1

SPINAL MANIPULATION MADE SIMPLE n o t b e realized. T h e r e i s n o d o u b t a b o u t it: u n d e r s t a n d i n g a n d successfully treating the spine is important to every somatic practitioner, no matter what y o u r p o i n t of view. In o r d e r to be effective w h e n y o u a t t e m p t to release a painful j o i n t , y o u n e e d to k n o w h o w the j o i n t works w h e n it's n o r m a l and h o w it works w h e n it's in t r o u b l e — a n d h o w to tell the d i f f e r e n c e . In o r d e r to experie n c e what we are g o i n g to be discussing b e f o r e y o u read a lot of theory, h e r e is a simple exercise y o u can do with y o u r o w n spine. Stand u p a n d p l a c e y o u r t h u m b s o n y o u r s p i n e o v e r the transverse processes ( T P ) of L4 or L5. D o n ' t w o r r y t o o m u c h at this p o i n t about h o w a c c u r a t e y o u are. Just use y o u r t h u m b s t o m a k e y o u r best guess. N o w s i d e b e n d ( o r laterally flex) to y o u r left. W h e n y o u s i d e b e n d to the left, the left side of y o u r lumbar spine will be c o n c a v e and the right will be c o n vex (Figure 1.1). Notice what happens u n d e r your thumbs. As you sidebend to y o u r left, y o u r right t h u m b is f o r c e d posteriorly a bit while y o u r left t h u m b sinks anteriorly a little. N o w s i d e b e n d the o t h e r way a n d n o t i c e that just the o p p o s i t e o c c u r s : y o u r left t h u m b is p u s h e d a little posteriorly a n d y o u r right t h u m b sinks anteriorly. W h a t y o u are feeling is y o u r vertebra rotate as y o u s i d e b e n d . T h e c o n v e n t i o n f o r d e s c r i b i n g rotation is to d e s c r i b e the d i r e c t i o n in w h i c h the a n t e r i o r f a c e o f the v e r t e b r a turns. S o while standing o r sitting, i f y o u s i d e b e n d right, y o u r vertebra will rotate left, and if y o u sidebend left, your vertebra will rotate right. S i d e b e n d i n g is difficult to feel at first and n o t s o m e t h i n g y o u n e e d to be c o n c e r n e d with at this p o i n t . But rotation is easy to palpate. As y o u will s o o n see, by k n o w i n g the direction in which a vertebra is rotated y o u can gather lots of the necessary i n f o r m a t i o n f o r dealing with a painful back. If y o u have a history of b a c k trouble, y o u may n o t i c e that the vertebral m o v e m e n t y o u are m o n i t o r i n g with y o u r thumbs is n o t exactly the same as y o u s i d e b e n d f r o m side to side. This discovery may be no surprise to y o u — i t p r o b a b l y means y o u have a facet restriction that is inhibiting norm a l m o t i o n t h r o u g h the area y o u are p a l p a t i n g . I f o n e o f the facets i s restricted, y o u will feel the vertebra rotate m o r e as y o u s i d e b e n d o n e way a n d less as y o u s i d e b e n d the other. If y o u feel rotation m o r e in o n e direction than the o t h e r a n d y o u haven't h a d a history of back trouble, d o n ' t panic. Perhaps y o u haven't p l a c e d fingers in quite the right area or maybe

2

OUR FINE SPINE: THE BACKBONE OF STRUCTURAL INTEGRITY

Figure 1.1

Figure 1.2

y o u are having trouble clearly differentiating b e t w e e n what the vertebra is d o i n g and h o w the soft tissues are r e s p o n d i n g . In s o m e p e o p l e the t o n e of the musculature a l o n g the sides of the spine is n o t the same a n d as a result each side responds differently to s i d e b e n d i n g . Of c o u r s e , it c o u l d m e a n that y o u do have s o m e sort of facet restriction that hasn't r e a c h e d y o u r awareness t h r o u g h the attention-getting m e d i u m of pain. But again d o n ' t panic, we will learn h o w to deal with these p r o b l e m s a little later. What you have learned so far is that sidebending and rotation are always c o u p l e d . W h a t y o u are a b o u t to feel n e x t is that they are n o t always c o u p l e d the same way in the thoracic a n d l u m b a r spines. Stand up again a n d place y o u r thumbs on either L4 or L5. If y o u have a history of b a c k pain and y o u r b a c k is presently in t r o u b l e y o u may n o t want to try this n e x t exercise. But if y o u are g a m e , first b e n d way f o r w a r d a n d then s i d e b e n d to the left (Figure 1.2). As y o u s i d e b e n d left y o u will n o t i c e that the left transverse process pushes y o u r t h u m b a little posteriorly and on the right transverse process y o u r o t h e r t h u m b sinks anteriorly a bit. W h a t y o u are feeling can be d e s c r i b e d by saying that as y o u s i d e b e n d left in f o r w a r d b e n d i n g y o u r vertebra rotates left. N o w , while y o u are still in the f o r w a r d 3

SPINAL MANIPULATION MADE SIMPLE b e n t position, sidebend right and you will notice that your vertebra rotates right. Next, straighten up and then back b e n d . In the back-bent position, s i d e b e n d right and left, a n d n o t i c e that y o u r vertebra behaves the same way as it d i d in the forward b e n t position: as y o u s i d e b e n d left, your vertebra rotates left a n d as y o u s i d e b e n d right y o u r vertebra rotates right. Standing or sitting with the spine comfortably straight is called the neutral position In neutral position the facets do n o t e n g a g e w h e n you sideb e n d . I n the n o n - n e u t r a l p o s i t i o n s o f f o r w a r d b e n d i n g a n d backward b e n d i n g the facets of the thoracic a n d l u m b a r spines do get e n g a g e d and their relationship alters the way the vertebrae rotate. What you have learned t h r o u g h d i r e c t p a l p a t o r y e x p e r i e n c e are two i m p o r t a n t facts a b o u t the thoracic a n d l u m b a r spines: 1) in neutral position, s i d e b e n d i n g and rotation are always oppositely c o u p l e d a n d 2) in the non-neutral positions of forward a n d backward b e n d i n g , s i d e b e n d i n g and rotation are always c o u p l e d to the same side. So in neutral p o s i t i o n w h e n y o u right s i d e b e n d , y o u r vertebra rotates left and w h e n y o u left sidebend, your vertebra rotates right. In the non-neutral positions, w h e n y o u s i d e b e n d right, y o u r vertebra rotates right a n d w h e n y o u s i d e b e n d left, y o u r vertebra rotates left. W h e n s i d e b e n d i n g a n d rotation are c o u p l e d to o p p o s i t e sides it is called T y p e I m o t i o n a n d w h e n they are c o u p l e d to the same sides it is called Type II m o t i o n . This classification of spinal m o t i o n into Type I and Type II is a d e s c r i p t i o n of n o r m a l m o t i o n . Dysfunction arises only if there is s o m e sort o f restriction o r facet f i x a t i o n involved. A n i m p o r t a n t p o i n t t o r e m e m b e r i s that s i d e b e n d i n g a n d rotation always h a p p e n t o g e t h e r a l o n g the spine. A vertebra or g r o u p of vertebrae can n e v e r rotate w i t h o u t also s i d e b e n d i n g a n d never s i d e b e n d without also rotating. Interestingly, the l u m b a r spine can s i d e b e n d m o r e than it can rotate a n d the thoracic spine can rotate m o r e than it can s i d e b e n d . T h e cervical spine behaves differendy f r o m the lumbar and thoracic spines in o n e very important respect: regardless of whether you forward or backward b e n d , the m o t i o n of C 2 - C 7 is always Type II. T h e n e c k is different e n o u g h f r o m the thoracic and lumbar spines that it deserves its own chapter. So f o r the r e m a i n d e r of this c h a p t e r and t h r o u g h the next c o u p l e of chapters we will be discussing only the thoracic a n d lumbar spines. Since we will be using rotation as o u r starting p o i n t f o r d e t e r m i n i n g and treating facet dysfunction, let's e x p l o r e palpating vertebral rotation

4

OUR FINE SPINE: THE BACKBONE OF STRUCTURAL INTEGRITY a bit m o r e . If y o u are a soft-tissue practitioner a n d y o u h a v e n ' t assessed vertebral rotation b e f o r e , y o u r highly d e v e l o p e d palpatory skills f o r assessing soft tissue strain and tightness may mislead y o u in y o u r first attempts to feel b o n e . If y o u are like m a n y soft-tissue practitioners I have taught, when y o u try to get a sense of the tissue b e n e a t h y o u r fingers, y o u often gently niggle i t — y o u p o k e a bit h e r e a n d p r o d a bit t h e r e — o f t e n y o u m o v e y o u r fingers up a n d d o w n , back a n d forth, a n d in small circles. But w h e n y o u feel f o r b o n e , y o u must resist the temptation to palpate in this way. Instead, y o u s h o u l d apply gentle b u t firm a n d constant pressure as you let your fingers sink into the tissue until they c o m e to an obvious stopping p o i n t where they can sink no further. W h e n they can sink no further and y o u feel a hard s t o p p i n g p o i n t , y o u have r e a c h e d b o n e . T h i s h a r d stopping p o i n t feels different than tight or strained soft tissue. I m a g i n e that a v e r t e b r a y o u are p a l p a t i n g is right r o t a t e d . As y o u r thumbs sink t h r o u g h the tissue a n d c o m e to rest on the b o n y surface of the vertebra, y o u will n o t i c e that y o u r right t h u m b stops sinking into the tissue b e f o r e the left t h u m b d o e s . To say it differently, y o u will n o t i c e that y o u r right t h u m b has c o m e to rest on a b o n y b u m p that is a little m o r e p o s t e r i o r a n d p r o m i n e n t than w h e r e the left t h u m b l a n d e d . Y o u r left t h u m b in contrast seems to have sunk into a littie indentation and is h e n c e a little m o r e anterior than the right t h u m b . If y o u niggle the tissue as y o u are letting y o u r thumbs sink toward the vertebra, y o u can easily get c o n fused a b o u t what y o u are feeling. Ask o n e o f y o u r friends o r clients t o v o l u n t e e r his b a c k a n d sit c o m fortably straight in the neutral position. K e e p y o u r t h u m b s in the same horizontal plane facing e a c h other, e a c h j u s t slightly lateral to the spinous processes of the vertebra y o u are palpating. Make sure that the palmer surfaces o f y o u r t h u m b s c o v e r the transverse p r o c e s s e s . K e e p i n g y o u r thumbs in this horizontal position, run t h e m up a n d d o w n y o u r friend's thoracic spine until y o u find a vertebra with o n e transverse process that is obviously m o r e posterior or p r o m i n e n t than the others (Figures 1.3 and 1.4, p a g e 6 ) . D o n ' t w o r r y a b o u t t h o s e v e r t e b r a e that y o u are n o t sure a b o u t — i g n o r e t h e m f o r n o w a n d o n l y l o o k f o r the m o s t o b v i o u s o n e s . O n c e y o u find a transverse process that is obviously m o r e p r o m i n e n t or posterior on o n e side, y o u have f o u n d a rotated vertebra. T h e vertebra is rotated to the side w h e r e y o u feel the p r o m i n e n t transverse process. T h e 5

SPINAL MANIPULATION MADE SIMPLE

Figure 1.3

Figure 1.4

6

OUR FINE SPINE: THE BACKBONE OF STRUCTURAL INTEGRITY easy way to r e m e m b e r h o w to designate rotation is to r e m e m b e r that the side of the bump is the side of the rotation. If y o u feel the b u m p on the left (with an indentation on the r i g h t ) , the vertebra is left-rotated. If y o u feel the b u m p on the right (with an indentation on the left), the vertebra is rightrotated. T o b e m o r e p r e c i s e i n y o u r d e s c r i p t i o n , y o u s h o u l d f o l l o w the c o n vention and designate the rotation y o u feel in r e f e r e n c e to the n e x t vertebra just b e l o w it. This c o n v e n t i o n makes g o o d sense b e c a u s e what y o u are ultimately interested in u n d e r s t a n d i n g is j o i n t fixation a n d y o u cann o t have a j o i n t , let a l o n e a fixated o n e , without two c o n t i g u o u s b o n e s . So if you find that T7 is right-rotated, y o u w o u l d say that T7 is rotated right on T8. You can say it any reasonable way y o u want to, of course, a n d there are many different conventions for designating rotation. But I have a d o p t e d the conventions of the osteopaths, because they constantly scrutinize their language for consistency and accuracy. I should m e n t i o n that even t h o u g h I use descriptive c o n v e n t i o n s derived f r o m osteopathy, I do n o t discuss or b o r r o w their t e c h n i q u e s f o r this b o o k . Unless o t h e r w i s e n o t e d , all the techniques y o u will learn in this b o o k were my o w n creation a n d are softtissue techniques, n o t high-velocity, low-amplitude osseous manipulations. E x p e r i m e n t with feeling f o r rotation with a lot of different backs a n d always begin with the most obvious rotations along the thoracic spine first. On the w h o l e it is m u c h easier to feel rotations of the thoracic spine in a sitting position than it is to feel t h e m in the lumbar spine. A b o v e all, d o n ' t fret a b o u t the vertebrae w h o s e rotational patterns are n o t clear to y o u r fingers. As y o u gain c o n f i d e n c e in f e e l i n g f o r the o b v i o u s cases, in time y o u will also gain sensitivity in feeling f o r the less o b v i o u s o n e s . After y o u gain s o m e c o n f i d e n c e with the thoracic spine, try feeling f o r rotations in the lumbar spine. First feel f o r rotation in the sitting position. T h e n ask y o u r volunteer to lie p r o n e on y o u r treatment table and feel the same areas in this position. In the sitting position the erectors are working to maintain an upright posture a n d since many p e o p l e ' s back muscles are o v e r d e v e l o p e d , y o u will find that it is o f t e n difficult to feel t h r o u g h these muscles to the b o n e b e n e a t h . In the p r o n e position y o u will find it is m u c h easier to feel the transverse processes t h r o u g h the b a c k muscles. I n o r d e r t o better d e t e r m i n e w h i c h vertebrae y o u are palpating y o u n e e d a few landmarks f r o m which to take your bearings. If y o u trace a h o r 7

SPINAL MANIPULATION MADE SIMPLE izontal line across from

Iliac crests at level of L4 Sacral base

the crest of the ilium to the spine, y o u r fingers will l a n d the s p i n o u s p r o c e s s o f L 4 (Figure 1.5). F r o m t h e r e y o u can c o u n t down o n e spinous process to find L5 or up to d e t e r m i n e L 3 , L 2 , and L I . To

find Tl

place

y o u r fingers o n y o u r

Figure 1.5

best guess to locate C6 a n d ask y o u r v o l u n t e e r to b e n d his h e a d a n d n e c k backward. If y o u are on C6 as y o u r v o l u n t e e r b e n d s , it will slide obviously anteriorly. If you are on C7 it will n o t m o v e in this way at all. If y o u d o n ' t have a volunteer as y o u read this, y o u can try it on yourself. O n c e y o u have l o c a t e d C6 y o u can easily c o u n t d o w n spinous processes to find T l , T 2 , and so forth. This test f o r anterior sliding of C6 with b a c k b e n d i n g works quite well most of the time f o r m o s t p e o p l e . But be f o r e w a r n e d : on o c c a s i o n y o u will find a p e r s o n w h o s e c e r v i c o t h o r a c i c j u n c t i o n is fixated in a way that makes this test useless. A n o t h e r useful landmark f o r finding y o u r way through the spine is the inferior tip of the scapula. If y o u trace a horizontal line f r o m the inferior tip to the spine, y o u r fingers will m o s t likely land a r o u n d T 8 .

A Simple Indirect Technique

N

OW T H A T Y O U HAVE SOME EXPERIENCE PALPATING ROTATION, WE CAN

build on y o u r k n o w l e d g e by practicing a simple, indirect t e c h n i q u e

f o r derotating vertebrae. This t e c h n i q u e was discovered by a n u m b e r of therapists i n d e p e n d e n t l y o f e a c h o t h e r . Ask y o u r v o l u n t e e r t o sit c o m fortably. Find the m o s t obviously rotated vertebra in his thoracic spine. F o r the p u r p o s e of this discussion, let's assume that y o u find that T4 is right rotated on T 5 . W h a t y o u will feel is y o u r right t h u m b resting on the b u m p (the p r o m i n e n t , posterior transverse process o f T 4 ) and y o u r left

8

OUR FINE SPINE: THE BACKBONE OF STRUCTURAL INTEGRITY

Figure 1.6 t h u m b resting in an indentation (the anterior transverse process of T 4 ) . To begin the technique, use your left t h u m b to apply a c o u p l e of p o u n d s of gentle b u t firm pressure to the left transverse p r o c e s s ( T P ) with the intention of m a k i n g it sink m o r e anteriorly (Figure 1.6). If y o u are n o t used to this sort of t e c h n i q u e , the idea of p u s h i n g the anterior TP m o r e anteriorly may seem counter-intuitive a n d a bit o d d . Y o u m i g h t be thinking that it w o u l d make m o r e mechanical sense to push the right posterior TP anteriorly as a way to derotate it. But b o d i e s are n o t machines a n d they have p r o f o u n d l y interesting ways of r e s p o n d i n g to intelligent pressure that will m a k e y o u r life as a somatic p r a c t i t i o n e r easier than y o u m i g h t imagine. This is called an indirect t e c h n i q u e b e c a u s e it d o e s n o t directly f o r c e c h a n g e on the spine the way high-velocity, low-amplitude thrusting techniques d o . Indirect techniques b e g i n by p u s h i n g a dysfunctional segm e n t further into its dysfunction a n d letting it w i n d its way b a c k to w h e r e a n o r m a l p o s i t i o n is. D o n ' t w o r r y a b o u t why this t e c h n i q u e works. Just enjoy h o w y o u r volunteer's b o d y r e s p o n d s to p u s h i n g the left anterior TP m o r e anteriorly.

9

SPINAL MANIPULATION MADE SIMPLE W h e n y o u apply y o u r pressure to the left TP of T 4 , imagine that y o u are pushing a boat away f r o m a d o c k . If y o u push t o o quickly and t o o hard, y o u will e x p e r i e n c e resistance. But if y o u push in a slow, gentle, firm way, the b o a t will almost effortlessly drift away f r o m the d o c k . As y o u first push anteriorly on the left TP, n o t h i n g h a p p e n s f o r a few s e c o n d s . But n o t i c e that as y o u k e e p the pressure u p , y o u r left t h u m b b e g i n s to sink a little m o r e anteriorly as y o u r right t h u m b b e g i n s to m o v e a little m o r e posteriorly. Y o u are actually feeling T4 go further into right rotation. You may even feel it go i n t o s i d e b e n d i n g . Maintain the i m a g e of p u s h i n g a b o a t away f r o m a d o c k in the back of y o u r m i n d , and k e e p the pressure u p , but d o n ' t f o r c e the issue; just push a n d c o n t i n u e to follow this m o t i o n until it stops. B e f o r e it stops the vertebra may rotate a n d s i d e b e n d in o d d and u n p r e d i c t a b l e ways. D o n ' t w o r r y a b o u t it or q u e s t i o n it, j u s t f o l l o w the m o t i o n until it stops. At that p o i n t , T4 will have m o v e d as far it can go into right rotation. T h e r e will be a pause, s o m e t i m e s a c c o m p a n i e d by the feeling of a little pulsation u n d e r y o u r thumbs. Just wait a n d s o o n y o u will feel the impulse of the vertebra to start derotating as if it were m o v i n g into left rotation. Y o u may feel it s i d e b e n d and rotate left, then right, and in o t h e r o d d and u n p r e d i c t a b l e ways b e f o r e it finally stops, b u t stay with it. It will stop moving w h e n it is d e r o t a t e d and w h e n it stops y o u will also feel a softening of the tissues u n d e r y o u r t h u m b s . If y o u wait a little l o n g e r y o u may also feel the spine l e n g t h e n i n g a b o v e a n d / o r b e l o w y o u r t h u m b s , a s i f the b o d y were organizing itself a l o n g vertical lines in response to the release of the vertebra. W h e n y o u feel the tissue softening a n d sense the b o d y organizi n g itself a l o n g the sagittal p l a n e y o u are finished. If y o u d o n ' t feel the b o d y o r g a n i z i n g itself a l o n g this l i n e , d o n ' t w o r r y a b o u t i t — a s l o n g a s y o u r thumbs remain in contact with the body, it will organize itself a r o u n d the release w h e t h e r y o u feel it or n o t . Just wait f o r the softening and then wait j u s t a bit l o n g e r afterward. If y o u use this t e c h n i q u e with the e x p e c tation of feeling that y o u can sense h o w the b o d y organizes itself a r o u n d the vertical release, in time y o u will actually sense this o r t h o t r o p i c effect. B e i n g able to feel h o w the b o d y organizes or fails to organize itself in relation to y o u r intervention is a very useful skill to learn a n d it will allow y o u to tell immediately what o t h e r areas b o d y require intervention. Interestingly, n o t only d o e s the b o d y o r g a n i z e itself a r o u n d the sagittal plane,

10

OUR FINE SPINE: THE BACKBONE OF STRUCTURAL INTEGRITY it also organizes itself simultaneously a r o u n d the transverse a n d c o r o n a l planes. K n o w i n g h o w to feel f o r the p r e s e n c e or a b s e n c e of this o r t h o g o nal relationship tells y o u w h e n y o u are finished with y o u r t e c h n i q u e a n d where to go next. T h e simple t e c h n i q u e y o u have just l e a r n e d will o p e n m a n y interesting doorways for y o u if y o u just k e e p practicing it and feeling f o r as m u c h information as y o u can. But this indirect t e c h n i q u e , like so m a n y indirect techniques ( o r so-called " u n w i n d i n g t e c h n i q u e s " ) , is n o t always effective. You will n o t i c e that s o m e t i m e s y o u will achieve easy a n d amazing results with it and at o t h e r times the p r o b l e m y o u t h o u g h t y o u had taken care of reasserts itself within a matter of m i n u t e s or h o u r s . T h e d r a w b a c k with most u n w i n d i n g techniques is that they often do n o t address o n e of the most i m p o r t a n t aspects of a painful b a c k — t h e u n d e r l y i n g facet restriction. Most indirect t e c h n i q u e s t e n d to u n w i n d the tissues a n d vertebra a r o u n d the j o i n t fixation. Since the j o i n t fixation has n o t b e e n resolved, the p r o b l e m quickly returns. To deal with the facet restriction, y o u first n e e d to understand h o w facet fixations w o r k a n d then y o u n e e d a soft-tissue technique that challenges the j o i n t fixation. This is what y o u will learn in the next two chapters.

II

CHAPTER

2

Primates in Trouble, or where does your back go when it goes out? O W MANY TIMES HAVE Y O U H E A R D T H I S SURPRISED C O M M E N T FROM

a client? ' Y o u know, I was just b e n d i n g over to p i c k up s o m e t h i n g , w h e n all of a s u d d e n I felt s o m e t h i n g slip in my lower b a c k a n d the next thing I k n o w I'm on my knees in terrible p a i n ! " T h e r e are m a n y levels to, a n d c o m p e t i n g e x p l a n a t i o n s for, h o w the spine b e c o m e s c o m p r o m i s e d . T h e i m p o r t a n t p o i n t is that facets n o t only get e n g a g e d in forward b e n d i n g and s i d e b e n d i n g , they s o m e t i m e s escalate an already strained r e l a t i o n s h i p i n t o a b a d m a r r i a g e a n d r e m a i n severely f i x a t e d . W h e n w e f o r w a r d b e n d o r b a c k b e n d a n d t h e n twist ( s i d e b e n d ) , w e p u t o u r l o w backs a t risk. I f y o u w e r e t o e x a m i n e y o u r client's u n h a p p y marriage w h e n he is in the neutral position (sitting or standing c o m f o r t a b l y straight), y o u w o u l d discover that o n e o r m o r e o f his lumbar vertebra is stuck so that it is s i d e b e n t a n d rotated to the same side. In neutral position, thoracic and l u m b a r vertebrae are n o t s u p p o s e d to act this way. So if y o u find a vertebra in neutral p o s i t i o n that is stuck rotated and sidebent to the same side, y o u are p r o b a b l y l o o k i n g at a person in pain. At this p o i n t y o u may be thinking, "Wait a m i n u t e , if, as y o u say, it is m u c h easier to feel rotation than sidebending, h o w can y o u k n o w whether a vertebra is rotated to the same or o p p o s i t e side of the s i d e b e n d i n g ? " T h e answer is simple: every time y o u find a vertebra in neutral position that is stuck sidebent a n d rotated to the same side, v o u have d i s c o v e r e d 13

SPINAL MANIPULATION MADE SIMPLE restricted facets. Because the facets are restricted, there is loss of n o r m a l m o t i o n in the area. If facets are fixed, the vertebra will n o t be able to m o v e normally in back b e n d i n g a n d forward b e n d i n g . T h e restricted facets will act as fixed pivot points that will f o r c e the vertebra to m o v e in characteristically errant ways as y o u r client b e n d s f o r w a r d a n d backward. By feeli n g h o w the vertebra rotates a r o u n d this fixed pivot p o i n t in forward and b a c k b e n d i n g y o u will b e able t o d e t e r m i n e precisely w h i c h facets are restricted a n d h o w they are restricted. O n c e y o u k n o w this, treating t h e m is easy a n d obvious. But b e f o r e we c o n s i d e r the facet-restriction test, let's deal with a very i m p o r t a n t clinical question: w h e r e d o e s y o u r b a c k g o w h e n i t g o e s out? This is o n e of those o d d questions like " W h e r e d o e s y o u r lap go when you stand u p ? " or " W h e r e d o e s fire go w h e n it goes out?" that seems as though it s h o u l d have an answer, b u t d o e s n ' t . T h e s e sorts of questions d o n ' t have answers n o t because they are t o o difficult for anyone to answer, but because they are c o n f u s e d questions. I stated the q u e s t i o n this way to m a k e an i m p o r t a n t p o i n t a b o u t the nature of spinal dysfunction. Somatic therapists and non-therapists alike t e n d to describe b a c k pain by saying, ' Y o u r back is out." But this expression is imprecise a n d even quite misleading. T h e critical p o i n t is n o t that a client's b a c k "went o u t , " as if its n e w position were the primary p r o b l e m , b u t that there are facet restrictions and loss of function associated with the client's pain. T r e a t m e n t consists n o t of putting it b a c k where it b e l o n g s , b u t in releasing the restricted facets in o r d e r to restore function. W h e r e the vertebra goes after y o u release it f r o m its facet restrictions is sometimes quite different f o r e a c h p e r s o n . A l o n g the same lines, if y o u were able to get the vertebra to " g o back to where it belongs" (derotate it) and you didn't release the restricted facets, the person's b a c k w o u l d still be dysfunctional a n d it w o u l d n o t be l o n g until the pain returned. If y o u have b e e n experi m e n t i n g with the simple indirect t e c h n i q u e i n t r o d u c e d in the last chapter, y o u already k n o w that it is n o t always effective. N o w y o u k n o w why. S o m e vertebral dysfunctions also have very little to do with the position of the vertebrae. For e x a m p l e , often the facets on b o t h sides of the spine can be restricted, but the vertebra shows no obvious palpatable signs o f b e i n g " o u t o f p l a c e " (rotated a n d s i d e b e n t ) . W h e n b o t h sides are restricted, y o u r client will have pain a n d loss of m o t i o n in the area. Again,

14

PRIMATES IN TROUBLE, OR WHERE DOES YOUR BACK GO WHEN IT GOES OUT? the treatment goal is to release the facet restrictions so that y o u can restore p r o p e r f u n c t i o n i n g , n o t r e p o s i t i o n vertebrae. M a n y times y o u will f i n d vertebrae that are rotated and still perfectly functional b e c a u s e no facet or myofascial restrictions are interfering with m o t i o n in the area. Given the unique structure of that person in relation to h o w his b o d y has adapted to gravity and the stresses of life, his vertebrae p r o b a b l y can only be right where they are. T h e y are n o t likely to be functional in any o t h e r position. If y o u had the p o w e r to f o r c e his vertebrae into s o m e version of the ideal position, y o u w o u l d probably just create pain f o r h i m . In o r d e r to m o r e clearly understand the role of j o i n t manipulation and the role of positioning b o d y structure a n d segments, it is very helpful to preview the words of physiologist I.M. Korr. Discussing the n o n - s e g m e n t e d " s y m p h o n i e s " of m o t o r activity that are orchestrated a n d c a r r i e d o u t by the spinal c o r d and h i g h e r centers, he says: T h e important point is that these patterns of activity involve neurons up and d o w n the spinal c o r d , e a c h b e i n g called i n t o play a c c o r d i n g to the pattern required at the m o m e n t — n o t a c c o r d ing to where the n e u r o n is l o c a t e d in the c o r d b u t a c c o r d i n g to what structure it innervates. W h e r e it "lives" segmentally is of no importance . . . This presents us with an interesting p a r a d o x : the n o r m a l patterns of activity mediated by the spinal c o r d are completely n o n segmental in nature . . . yet the spinal c o r d is obviously segmented and the physician is very m u c h c o n c e r n e d with segmental relationships

Nevertheless, in n o r m a l life s e g m e n t a l relation-

ships d o n o t appear. T h e reason f o r this p a r a d o x may b e best c o n v e y e d b y [ a n ] illustrative simile. Consider a beautifully executed parade of skilled marching m e n , where the many ranks and c o l u m n s are seen as patterned activity of the w h o l e parade. We do n o t see individual ranks a n d certainly n o t individual m a r c h e r s , we see p a t t e r n e d motion. But let something go wrong, let o n e of the marchers lose step and his rank immediately b e c o m e s c o n s p i c u o u s . T h e o t h e r marchers cannot compensate in a c o o r d i n a t e d m a n n e r and s o o n the ranks on either side are thrown into c o n f u s i o n a n d then we 15

SPINAL MANIPULATION MADE SIMPLE do see segmental relationship. It is something like this that causes segmental relationships in the spine to e m e r g e into v i e w . . . . A s e g m e n t "in view" is a s e g m e n t in trouble H o w shall we r e c o n c i l e this p a r a d o x ? First by realizing that the thing that is s e g m e n t e d is the a r m o r that houses and p r o tects the c o r d

In n o r m a l life the segmentation is n o t of the

spinal c o r d itself; the segmentation is in the assembling of the nerve fibers into " c a b l e s " — r o o t s and n e r v e s — t h a t can pass o u t to the tissues innervated. What is segmented is ingress and egress, n o t the function of the c o r d itself.

1

W e can see even m o r e clearly f r o m Dr. Korr's w o n d e r f u l e x a m p l e o f the m a r c h e r s h o w spinal m a n i p u l a t i o n is n o t a simple matter of reposit i o n i n g o r p u t t i n g b o n e s " b a c k i n t o p l a c e . " T h e ultimate aim o f spinal m a n i p u l a t i o n i s the r e c o v e r y o f n o r m a l p a t t e r n e d m o t i o n , n o t the creation of an ideal position f o r the segments. By implication, the aim is also n o t the creation of a spine that measures up to s o m e ideal pattern. W h e n a vertebral s e g m e n t or a g r o u p of vertebrae b e c o m e "segments in view," to use Dr. Korr's phrase, we perceive a loss of patterned m o t i o n througho u t the s p i n e . Part of what we see are breaks or fixations in the overall continuity of structure and m o v e m e n t . We see loss of continuity and appropriate m o t i o n . T h e "segments in view" often show up as fixations in the myofascial, ligamentous, and articular systems. These fixations create varyi n g d e g r e e s of local immobility, w h i c h in turn inhibit n o r m a l integrated m o v e m e n t t h r o u g h o u t the w h o l e body. With this new understanding, let's reconsider those p e o p l e whose backs "went o u t " w h e n they b e n t over. All of t h e m were well on their way to having b a c k p r o b l e m s b e f o r e they first e x p e r i e n c e d back pain. T h i n k of what h a p p e n s w h e n y o u p u t water o n the stove t o b o i l . Y o u turn u p the heat a n d the water gets h o t t e r a n d hotter. S u d d e n l y it passes a certain temperature threshold a n d boils. If the water were c o n s c i o u s , the first time it was b r o u g h t to a b o i l it m i g h t say, ' Y o u k n o w it was really weird, I was just h a n g i n g o u t on the stove f e e l i n g the heat w h e n all of s u d d e n I b e g a n to b o i l ! " A n a l o g o u s l y y o u r clients' backs were "heating u p " t o " g o o u t . " Myofascial, l i g a m e n t o u s , a n d facet restrictions were already present; there were larger overall patterns of i m b a l a n c e in their b o d i e s ; their legs

16

PRIMATES IN TROUBLE, OR WHERE DOES YOUR BACK GO WHEN IT GOES OUT? probably were n o t p r o v i d i n g adequate s u p p o r t ; there were dysfunctional adaptations to o l d injuries and to gravity; and vertebrae were slighdy m o r e toward a T y p e II p o s i t i o n than was g o o d f o r t h e m . T h e n the fatal day arrived when your client passed his critical threshold by b e n d i n g over a n d slightly twisting ( s i d e b e n d i n g ) to p i c k s o m e t h i n g u p . D u r i n g this m o v e m e n t , his vertebra slipped a little t o o quickly and a little t o o far past what was n o r m a l f o r a Type II position. T h e nervous system registered the danger and sent the muscles into a fearful spasm thereby l o c k i n g the vertebra into a Type II position and creating facet restrictions. T h e r e are o t h e r ways y o u can l o c k up y o u r back, of c o u r s e , b u t this simple case is useful b e c a u s e i t allows u s t o u n d e r s t a n d h o w facets b e c o m e restricted. T h e i m p o r t a n t p o i n t is that f a c e t fixations create a m o t i o n restriction that adversely affects the way the rest of the spine behaves in walking and o t h e r forms of m o v e m e n t . A n d over time it can facilitate o t h e r facet restrictions. I f y o u r spine has n o facet restrictions, w h e n y o u f o r w a r d b e n d , y o u r facets slide o p e n i n a n a c c o r d i o n - l i k e fashion a n d w h e n y o u b a c k b e n d they slide closed. As you forward b e n d , each vertebra in relation to the o n e inferior to it slides slightly superiorly and anteriorly. W h e n y o u b a c k b e n d the opposite occurs: each vertebra slides slightly inferiorly a n d posteriorly. Now, if facets are restricted, they will act as a fixed p o i n t a r o u n d w h i c h the vertebra will b e f o r c e d t o rotate w h e n y o u f o r w a r d a n d b a c k b e n d . T h e side on which the facets are restricted remains fixed d u r i n g f o r w a r d and backward b e n d i n g , while the o t h e r side appears to rotate and d e r o tate. To say it differently, o n e side of the vertebra remains a f i x e d pivot point a r o u n d which the o t h e r side moves anteriorly a n d posteriorly in forward and backward b e n d i n g , respectively. Figures 2.1 a n d 2.2, page 18, show rather clearly the effects of f o r w a r d b e n d i n g and backward b e n d i n g on the behavior of the facets. During back b e n d i n g the facets slide toward a closed position and during forward b e n d ing they slide toward an o p e n position. Figure 2.3 shows a dysfunctional vertebra. W h a t y o u are l o o k i n g at are two v e r t e b r a e in neutral p o s i t i o n . T h e s u p e r i o r v e r t e b r a is stuck right rotated and right sidebent. Notice h o w the facets on the left have slid o p e n and the facets on the right have slid closed. Since we are l o o k i n g at a Type II dysfunction, o n e side must be restricted. Either the left facets are fixed o p e n (in flexion or forward b e n d i n g ) or the right facets are fixed c l o s e d 17

SPINAL MANIPULATION MADE SIMPLE

Figure 2.1

Figure 2.2

Figure 2.3

(in e x t e n s i o n or backward b e n d i n g ) . But w h i c h facets are fixed? R e m e m b e r that restricted facets create a fixed pivot point around which the vertebra is f o r c e d to rotate in f o r w a r d a n d backward b e n d i n g . So if y o u were t o p l a c e y o u r t h u m b s o n the transverse processes o f the superior vertebra and feel f o r h o w it rotates a n d derotates during forward and b a c k w a r d b e n d i n g , y o u c o u l d d e t e r m i n e w h i c h facets w e r e f i x e d . Y o u w o u l d k n o w w h e t h e r the left facets w e r e f i x e d o p e n o r the right facets w e r e f i x e d c l o s e d . A n d o n c e y o u k n e w w h i c h a n d h o w the facets were restricted, y o u c o u l d simply a n d easily release t h e m . But b e f o r e y o u learn h o w to apply the test, let's e x p l o r e a t e c h n i q u e f o r releasing facet restrictions first. For many somatic therapists, learning a simple facet release t e c h n i q u e that d o e s n ' t require precise k n o w l e d g e of w h i c h facet is fixed is the best way to d e e p e n their palpatory and c o n ceptual u n d e r s t a n d i n g of h o w to apply the test. Many hands-on therapists find that if they can get this understanding into their hands first, they have an easier time getting it into their heads. T h e t e c h n i q u e y o u are a b o u t to learn is a kind of shotgun a p p r o a c h to a m o r e specific way to address facet restrictions. F r o m the clinical s t a n d p o i n t , this a p p r o a c h is less efficient than the o n e y o u will use o n c e y o u k n o w h o w to apply the test. But f r o m the learning standpoint this a p p r o a c h is a far m o r e effective teaching techn i q u e . Y o u will also be h a p p y to k n o w that it is, f o r the m o s t part, as effective as the m o r e efficient a p p r o a c h .

18

PRIMATES IN TROUBLE, OR WHERE DOES YOUR BACK GO WHEN IT GOES OUT? W h e n y o u find a rotated vertebra, j u s t p r e t e n d that it is a Type II fixation. It may turn o u t , of c o u r s e , that the rotated vertebra y o u p i c k e d is n o t dysfunctional at all. If it isn't stuck rotated a n d sidebent to the same side w h e n in the neutral position a n d y o u apply this s h o t g u n a p p r o a c h , the worst thing that will h a p p e n is that you will have wasted your time (and your client's). Since rotated vertebrae with restricted facets are m o r e c o m m o n than flowers in the Spring, the best thing that will h a p p e n is that y o u will actually p u t y o u r f i n g e r o n the s o u r c e o f y o u r client's p a i n a n d b y applying this t e c h n i q u e release h e r f r o m h e r misery. If the rotated vertebra y o u pick is sidebent and rotated to the same side in the neutral p o s i t i o n , it will have restricted facets a n d it will be a dysfunctional Type II. A n d this is always true: either the facets are fixed closed on the side of the p r o m i n e n t or posterior TP (the same side to w h i c h it is rotated) or they are fixed o p e n o p p o s i t e to the side of the p r o m i n e n t TP ( o p p o s i t e to the side to w h i c h it is r o t a t e d ) . T h e t e c h n i q u e f o r releasing fixed o p e n or fixed c l o s e d facets is simple. Since you d o n ' t k n o w which facets are restricted, y o u simply treat b o t h sides as if they were fixed. Let's say that y o u f o u n d T3 is right rotated on T 4 . If the p r o b l e m is with the right facets, it is because they are fixed closed and c a n n o t o p e n in forward b e n d i n g . If the p r o b l e m is with the left facets, they are fixed o p e n and c a n n o t close in back b e n d i n g . Pick the right facets first. If y o u r client is sitting, ask h i m to curl over i n t o a f o r w a r d b e n t position. Put a knuckle or e l b o w in the right spinal g r o o v e on the p r e s u m e d fixed closed facets (Figures 2.4 a n d 2.5, p a g e 2 0 ) . Slowly a n d firmly apply 5 to 10 p o u n d s of c o n t i n u o u s pressure to the facets a n d let y o u r k n u c k l e or e l b o w sink to w h e r e it can go no further. Wait until y o u feel the tissue soften a n d give way u n d e r y o u r p r e s s u r e . ( S e e i f y o u c a n also f e e l the o r t h o t r o p i c effect as the b o d y l e n g t h e n s a n d o r g a n i z e s itself a l o n g the sagittal plane after the facets release.) T h e n return y o u r client to a n e u tral sitting position. Put y o u r k n u c k l e or e l b o w in the left spinal g r o o v e on the facets that are p r e s u m e d fixed o p e n . Instruct y o u r client to b a c k b e n d while y o u slowly a n d firmly apply 5 to 10 p o u n d s of pressure (Figure 2.6, page 2 1 ) . Let y o u r knuckle or e l b o w sink to w h e r e it can sink no further and wait until y o u feel the tissue soften a n d give way u n d e r y o u r pressure. (Again, see if y o u c a n f e e l the o r t h o t r o p i c e f f e c t as the b o d y l e n g t h e n s a n d o r g a n i z e s itself a l o n g the sagittal p l a n e after the facets 19

SPINAL MANIPULATION MADE SIMPLE

Figure 2.4

Figure 2.5

20

PRIMATES IN TROUBLE, OR WHERE DOES YOUR BACK GO WHEN IT GOES OUT?

Figure 2.6

release.) After y o u have a p p l i e d this t e c h n i q u e to b o t h sides, c h e c k T3 to make sure that it is no l o n g e r rotated. W h e t h e r y o u are releasing fixed c l o s e d or fixed o p e n facets, as l o n g as y o u k e e p the pressure up (just waiting f o r the softening, the sense of the tissue giving way, a n d the spine l e n g t h e n i n g a n d o r g a n i z i n g itself a l o n g the sagittal plane) it is e n o u g h to release the facets. W i t h time a n d practice you may begin to feel the facets actually close or o p e n , but it is n o t n e c essary f o r y o u to feel the facets release f o r the t e c h n i q u e to work. As y o u learn to feel the facets release, y o u will also b e g i n to feel a corollary p h e n o m e n o n , namely that n o t m u c h h a p p e n s u n d e r y o u r fingers w h e n y o u apply pressure to unrestricted facets. In time y o u want to be able to feel the facets release, the tissue soften, a n d the b o d y l e n g t h e n and organize itself a l o n g the sagittal plane. A l t h o u g h tenderness or pain is n o t always the best evaluative tool, y o u will often find that the soft tissues associated with the problematic facets is t e n d e r or painful w h e n y o u apply pressure. Practice this s h o t g u n t e c h n i q u e on the t h o r a c i c v e r t e b r a e first with y o u r client in a sitting p o s i t i o n . T h e n practice it with the l u m b a r verte21

SPINAL MANIPULATION MADE SIMPLE

Figure 2.7

Figure 2.8

22

PRIMATES IN TROUBLE, OR WHERE DOES YOUR BACK GO WHEN IT GOES OUT? brae. Until y o u are m o r e c o n f i d e n t in y o u r ability to feel rotation in the lumbar vertebrae, always c h e c k what y o u f e e l in t h e sitting p o s i t i o n against w h a t y o u f e e l i n t h e p r o n e p o s i t i o n . O n c e y o u are sure that a l u m b a r vertebra is rotated, y o u can use t h e sitting p o s i t i o n t o release facet restrictions in m u c h the same way y o u l e a r n e d to release the t h o racic vertebrae. Y o u can also release lumbar facet restrictions with y o u r client p r o n e . S u p p o s e y o u f i n d that L5 is left rotated. Begin with the assumption that the right facets are fixed o p e n . Figure 2.9

Instruct y o u r client to raise himself up on his elbows a n d to rest in that

position. T h e n apply pressure to the right side of the spinal g r o o v e w h e r e the p r e s u m e d fixed o p e n facets are a n d wait f o r t h e m to release (Figure 2.7). T h e n d o u b l e over a pillow a n d place it u n d e r y o u r client's a b d o m e n so that the lumbar spine is appropriately flexed. A p p l y pressure to the left side w h e r e the p r e s u m e d f i x e d c l o s e d facets are a n d wait f o r t h e m t o release (Figures 2.8 a n d 2 . 9 ) . T h e side-lying position is also a very effective way to release facet restrictions in b o t h l u m b a r a n d thoracic vertebrae. To release p r e s u m e d fixedclosed facets, instruct y o u r client to lie in a tight fetal position on the side of his b o d y o p p o s i t e the c l o s e d facets. A p p l y pressure with y o u r k n u c k l e or elbow to the facets and wait f o r t h e m to release (Figures 2.10, 2.11, and 2.12, pages 24 a n d 2 5 ) . Ask h i m to roll o v e r on his o t h e r side a n d b a c k b e n d as y o u apply pressure to the p r e s u m e d f i x e d o p e n facets a n d wait for t h e m to release (Figure 2.12). It will m a k e y o u r life as a m a n u a l therapist j u s t a little easier if y o u u n d e r s t a n d s o m e t h i n g a b o u t h o w the t h o r a c i c facets o f the s p i n e are arranged: parallel to the c o r o n a l plane. Y o u can use this a r r a n g e m e n t to your advantage. W h e n y o u are releasing c l o s e d thoracic facets y o u will be 23

SPINAL MANIPULATION MADE SIMPLE

Figure 2.10

Figure 2.11 slightly m o r e effective a n d efficient if y o u apply pressure in a c e p h a l a d direction. With o p e n - f i x e d thoracic facets, the t e c h n i q u e will work just a litde bit better if y o u apply pressure in a caudad direction. T h e lumbar and cervical facets are clearly n o t a r r a n g e d in the same way as the thoracic facets, so the direction in which y o u apply pressure is n o t as important. As you practice this technique y o u will quickly understand why it is m o r e

24

PRIMATES IN TROUBLE, OR WHERE DOES YOUR BACK GO WHEN IT GOES OUT? effective than the indirect technique introd u c e d i n the last chapter. T h e p r o b l e m with the i n d i r e c t t e c h n i q u e is that it d o e s n ' t address the fixed facets, whereas this new technique actually challenges the facet restrictions. If the facets are f i x e d closed the technique requires that you put y o u r client in a forward-bent position to e n c o u r a g e the facets t o o p e n while y o u release the tissues r e s p o n s i b l e f o r the restriction. In the same way, w h e n the facets are f i x e d o p e n , b a c k b e n d i n g e n courages the facets to close as y o u release the restricting tissues. T h e indirect technique is probably only successful when the Figure 2.12

restrictions are n o t very severe. Generally speaking, if you want to release a j o i n t anywhere in the body, it is almost always m o r e

effective to use a technique that challenges the restricted facets rather than a technique that simply unwinds tissue a r o u n d the fixation. K e e p practicing this shotgun a p p r o a c h until y o u gain c o n f i d e n c e with feeling rotation a n d releasing facet restrictions. In the n e x t chapter, y o u will learn h o w to apply the test so y o u d o n ' t waste time trying to release what is n o t restricted.

Note 1. Korr, I.M. "Vulnerability of the Segmental N e r v o u s System to Somatic Insults" in The Physiological Basis of Osteopathic Medicine, G e o r g e W. N o r t h u p ed., (New York, 1 9 8 2 ) , p p 5 6 - 5 7 . Emphasis a d d e d .

25

CHAPTER

3

Finding and Fixing the Fixations HENEVER YOU ARE LOOKING AT A VERTEBRA T H A T IS ROTATED

and sidebent to the same side (Type I I ) , w h e t h e r it is dysfunctional or n o r m a l , the facets on the side with the p r o m i n e n t TP (the side to which it is rotated) are always c l o s e d a n d the o p p o s i t e facets are o p e n . If all is n o r m a l a n d no facets are restricted, n o r m a l m o t i o n is p o s s i b l e t h r o u g h the area. If the situation is d y s f u n c t i o n a l , t h e r e are restricted facets a n d an o b v i o u s loss of m o t i o n . So w h e n y o u find a rotation, you n e e d a way to d e t e r m i n e which facets are restricted so y o u d o n ' t waste time trying to release facets that are n o t restricted. If y o u find restricted facets in the l u m b a r or thoracic spine, then they are either fixed o p e n o r f i x e d c l o s e d . A g a i n , y o u n e e d a way t o d e t e r m i n e w h e t h e r the o p e n facets are fixed or the c l o s e d facets are fixed to avoid wasting time. T h e cervical facets are unlike the thoracic a n d l u m b a r facets in that o n e side can be fixed o p e n while the o t h e r is fixed closed. If C3 is right-rotated and right sidebent on C4, it is possible for the right facets to be fixed closed and the left facets to be fixed o p e n . But this kind of bilateral fixation d o e s n o t o c c u r in the thoracic a n d l u m b a r facets. For n o w we are only g o i n g to deal with the l u m b a r a n d thoracic facets. In the n e x t c h a p t e r we will e x a m i n e the cervical facets. T h e test f o r d e t e r m i n i n g which thoracic or lumbar facets are restricted and h o w they are restricted is fairly easy to p e r f o r m , b u t s o m e w h a t c o m plicated to explain, although there is a very simple way to r e m e m b e r the 27

SPINAL MANIPULATION MADE SIMPLE i m p o r t a n t i n f o r m a t i o n y o u can gather f r o m it. W i t h y o u r client in a sitting position, find the m o s t obviously rotated t h o r a c i c v e r t e b r a . Say y o u f i n d that T 3 i s right r o t a t e d o n T 4 a n d let's assume that the left facets are the restricted o n e s . Since they are fixed o p e n , in a position of flexion or forward b e n d i n g , when y o u r client b e n d s f o r w a r d the left TP r e m a i n s stationary, f i x e d slightly anteriorly. M e a n while, y o u r right t h u m b will follow the right TP as it moves anteriorly during forward b e n d i n g . T h e right TP moves anteriorly during forward b e n d i n g , b e c a u s e that is what it d o e s normally. But because the left side is already fixed anteriorly, the right TP is f o r c e d to pivot a r o u n d the o p e n f i x e d left f a c e t as y o u r c l i e n t b e n d s f o r w a r d . As a result, the right side appears to derotate. To say it differently, w h e n y o u r client forward b e n d s , the b u m p on the right seems to disappear and the indentation on the left stays where it is (Figure 3.1). W h e n y o u r client returns to neutral position, the b u m p on the right reappears. If y o u r client n o w back bends, the b u m p on the right will a p p e a r to get m o r e e x t r e m e a n d the vertebra will m o v e m o r e into right rotation (Figure 3.2). As y o u r client back b e n d s the fixed pivot p o i n t created by left facets keeps the left TP fixed anteriorly. Since b a c k b e n d i n g forces the right side to m o v e m o r e posteriorly in c o m p a r i s o n to the fixed indentation on the left, the right TP appears to m o v e further i n t o right rotation. N o w let's imagine the o p p o s i t e situation in which the right side is fixed closed, as if the right facets were backward b e n t ( o r e x t e n d e d ) . As a result, the right TP will be fixed posteriorly. W h e n y o u r client b a c k b e n d s , y o u r t h u m b s feel the vertebra derotate a n d the b u m p seems to go away. Why? Because the right TP is already fixed posteriorly a n d the left TP is f o r c e d to pivot a r o u n d the fixed right facets a n d m o v e posteriorly as y o u r client b a c k b e n d s . Since the left side is free to m o v e posteriorly a n d the right side is fixed posteriorly already, back b e n d i n g removes the indentation as the left T P m o v e s p o s t e r i o r l y t o m a t c h the right TP. W h e n y o u r client returns to neutral, the b u m p on the right returns. If y o u r client n o w forward b e n d s , the b u m p seems t o b e c o m e m o r e e x t r e m e . Since the right facets are fixed closed, the right TP is fixed posteriorly. Since the left facets are free, as y o u r client f o r w a r d b e n d s they allow the left TP to m o v e anteriorly in c o m p a r i s o n to the right TP w h i c h is fixed posteriorly. T h e difference between the two TP's is n o w m o r e extreme and your thumbs seem

28

FINDING AND FIXING THE FIXATIONS

Figure 3.1

Figure 3.2 29

SPINAL MANIPULATION MADE SIMPLE to sense that the vertebra has m o v e d into a m o r e extreme right rotation. T h e p r e c e d i n g p r o c e d u r e is the basis of the test f o r d e t e r m i n i n g rotation a n d s i d e b e n d i n g , a n d identifying w h i c h facets are restricted. But let me caution y o u a b o u t a very i m p o r t a n t p o i n t : if y o u are like most o t h e r practitioners w h o are n e w to this test, y o u will p r o b a b l y try to think y o u r way t h r o u g h what h a p p e n s each time y o u p e r f o r m the test. As y o u r client f o r w a r d a n d backward b e n d s , y o u will be t e m p t e d to describe to yourself what y o u are f e e l i n g , similar to the way I j u s t d e s c r i b e d it. D o n ' t do it, because there is an easy way to r e m e m b e r the i n f o r m a t i o n f o r identifying which facet to release. Describing to yourself a c o m p l i c a t e d p h e n o m e n o n (that also d e m a n d s that y o u d e d u c e the side o n w h i c h the facets are restricted f r o m the way a vertebra rotates a n d derotates d u r i n g forward and backward b e n d i n g as y o u r e m e m b e r that it is sidebent and rotated to the same side) while simultaneously trying to feel what is happening under y o u r thumbs f o r the first time in y o u r life is 100 times m o r e difficult than trying to follow this awkward sentence I am writing trying to describe what y o u s h o u l d n ' t attempt. W h a t y o u n e e d is a simple rule that will allow y o u to identify a n d treat the facet fixation with palpatory ease and very little conceptual thought. First y o u d e t e r m i n e rotation in neutral position. K e e p your thumbs on the TP's of the rotated vertebra, forward and backward b e n d your client, and feel a n d watch what h a p p e n s u n d e r y o u r thumbs. L o o k for the position (whether in forward or backward b e n d i n g ) where the b u m p (the posterior or p r o m i n e n t TP of the rotated vertebra) disappears. S o m e p e o p l e object to saying the b u m p disappears and like to say that the vertebra appears to derotate. This is a matter of taste, so use whatever description works best. But r e m e m b e r this important point: the position where the bump disappears (or the vertebra appears to derotate) is the position in which the facets are restricted. If the b u m p disappears in forward b e n d i n g , the facets are fixed in the forward b e n t position, which means the facets are fixed o p e n (flexion fixed). If the b u m p disappears in back b e n d i n g , the facets are fixed in the back b e n t position, which means the facets are fixed closed (extension fixed). T h e r e is o n e m o r e i m p o r t a n t r e m i n d e r : if the b u m p , or posterior TP, disappears in forward b e n d i n g , the fixed-open facets are on the opposite side of the rotation, or posterior TP. If the b u m p disappears in back b e n d ing, the fixed-closed facets are on the same side of the rotation. In o t h e r

30

FINDING AND FIXING THE FIXATIONS words, if a vertebra in neutral position is rotated and sidebent to the same side (Type II dysfunction), it has a facet restriction and the facets are either fixed o p e n or fixed closed. If they are fixed closed, the fixed facets are on the same side as the rotation, or p o s t e r i o r TP. If they are fixed o p e n , the fixed facets are on the o p p o s i t e side of the rotation, or p r o m i n e n t TP. So h e r e are two very simple rules that will allow y o u to k e e p y o u r sanity as y o u practice this test:

In backward bending if the prominent TP disappears, the facets on the side of the rotation are fixed closed. In forward bending if the prominent TP disappears, the facets on the side opposite to the rotation are fixed open. Y o u can reformulate these rules any way y o u want, b u t k e e p a c o p y of t h e m where y o u can easily see t h e m as y o u practice p e r f o r m i n g the test. Again, d o n ' t try to think t h r o u g h the l o g i c of this test as y o u p e r f o r m it. Learn h o w to apply the test a n d get the i n f o r m a t i o n y o u n e e d by using these rules first. In time, if it is i m p o r t a n t to y o u to be able to state the logic of the test to yourself or to others, y o u can practice d o i n g it. For now, use this easy m e t h o d to d e t e r m i n e w h e t h e r the facets are restricted a n d whether they are fixed o p e n or c l o s e d so that y o u can directly a n d effortlessly release t h e m . T h e t e c h n i q u e s f o r releasing facet restrictions are the same as t h o s e you learned in the last chapter. Since y o u n o w have a q u i c k way to determ i n e whether y o u are dealing with fixed o p e n o r f i x e d c l o s e d facets, y o u only n e e d to apply the t e c h n i q u e to the side with the facet restriction. So if the facets are fixed o p e n , apply the t e c h n i q u e in any of the b a c k b e n d ing positions (sitting, p r o n e , or sidelying). If the facets are fixed c l o s e d , apply the t e c h n i q u e in any of the f o r w a r d b e n d i n g positions. Previously I m e n t i o n e d that facets can be bilaterally fixed o p e n or closed. These fixations are n o t as easy to find t h r o u g h palpation because they do n o t show up as rotated a n d sidebent. Test f o r t h e m by putting y o u r client in the sitting position. Find the suspected vertebrae a n d p u t a finger or t h u m b on the spinous process of the superior vertebra a n d p u t the finger or t h u m b of the o t h e r h a n d on the spinous process immediately inferior, and instruct y o u r client to b e n d forward a n d backward (Figures 3.3 a n d 31

SPINAL MANIPULATION MADE SIMPLE

Figure 3.3

Figure 3.4

32

FINDING AND FIXING THE FIXATIONS

Figure 3.6

Figure 3.5

3.4). If your thumbs m o v e away f r o m each o t h e r in forward b e n d i n g , b u t do n o t approximate in backward b e n d i n g , the facets are bilaterally fixed o p e n . If your thumbs approximate in backward b e n d i n g , but do n o t m o v e apart in forward b e n d i n g , the facets are bilaterally fixed closed. Releasing either is quite simple. A g a i n with y o u r client in the sitting p o s i t i o n , p l a c e the k n u c k l e o f y o u r right f o r e f i n g e r i n the right spinal g r o o v e and the knuckle of y o u r left f o r e f i n g e r in the left spinal g r o o v e . If the facets are bilaterally fixed o p e n , ask y o u r client to back b e n d over y o u r knuckles as y o u apply pressure to b o t h sides a n d wait f o r the release (Figure 3.5). If the facets are bilaterally fixed c l o s e d , ask y o u r client to f o r ward b e n d , apply pressure to b o t h facets, and wait f o r the release (Figure 3.6). Y o u can apply these techniques in the p r o n e or sidelying positions if you wish, b u t f o r obvious reasons y o u will p r o b a b l y find the sitting position the easiest a n d m o s t efficient. As you practice the test for unilateral facet restrictions, y o u will find vertebrae that are obviously rotated, b u t do n o t r e s p o n d to forward and backward b e n d i n g by appearing to rotate and derotate. Y o u will p r o b a b l y also notice that these vertebrae often g r o u p themselves together into a curva33

SPINAL MANIPULATION MADE SIMPLE ture. W h a t y o u are l o o k i n g at are T y p e I g r o u p fixations. W h e n y o u forward a n d backward b e n d clients with g r o u p fixations, the rotated vertebrae stay in their rotated position all the way through the process of forward a n d backward b e n d i n g . If, as is often the case, they are a part of a r o t o scoliosis (Figure 3.7), their positions are fixed because of larger myofascial restrictions and because the shape of the vertebrae has b e e n altered as part of the curvature. Type I dysfunctions tend n o t to be restricted at the facet level by the small muscles and the ligaments like Type II dysfunctions are. Y o u s h o u l d be aware that within a Type I curvature y o u can find individual dysfunctional Type II vertebrae. As y o u might imagine, they are a little hard to find. Suppose your client's thoracic vertebrae are all right sidebent a n d left rotated, e x c e p t f o r o n e . T h a t o n e vertebra c o u l d b e left rotated a n d left sidebent or right rotated and right sidebent. If it is rotated right a n d sidebent right it will be nearly impossible to differentiate it f r o m the o t h e r vertebrae that are also right rotated by feel alone. If it is left rotated and left sidebent, since it is also shaped in the Type I pattern, it will still be very difficult to differentiate. You can find it if you apply the f o r w a r d / b a c k ward b e n d i n g test. But realize that it is also part of the curvature, so d o n ' t expect it to appear to derotate all the way. S i n c e o n e of the facets is r e stricted, it will appear to rotate and

Crossover

d e r o t a t e to s o m e d e g r e e . A n d it is that d e g r e e of rotating and derotating y o u have to get a feel f o r if y o u

Apex

want to locate Type II dysfunctions in the midst of Type I patterns.

Crossover

In any case, if y o u find s o m e vertebrae in thoracic or l u m b a r spine

Apex

that d o n o t c h a n g e h o w they are rotated in forward and backward b e n d i n g , they are T y p e I fixations.

Crossover

T h e y r e q u i r e a slightly m o r e c o m p l i c a t e d t e c h n i q u e than what y o u h a v e l e a r n e d s o far a n d y o u will learn these t e c h n i q u e s in C h a p t e r Ten.

Figure 3.7

34

CHAPTER

4

The Neck N H I S M O N U M E N T A L W O R K , The Interpretation of Dreams, F R E U D S A I D T H A T

the royal r o a d to the u n c o n s c i o u s is t h r o u g h d r e a m interpretation. His brilliant c o l l e a g u e , W i l h e l m R e i c h , said that the royal r o a d is t h r o u g h understanding the body. Well, after m a n y years of w o r k i n g with p e o p l e in various kinds of distress, I have c o m e to see that they are b o t h w r o n g — it's the n e c k ! Of course, my claim is an exaggeration. But like all such exaggerations it contains s o m e d e g r e e of truth. T h e cervical vertebrae s u p p o r t a rather large and heavy e g g s h a p e d thing that is constantly m o v i n g a b o u t , sticking a fleshy p r o t u b e r a n c e called a n o s e i n t o situations that o f t e n d o n ' t c o n c e r n it. O u r e m o t i o n s often b e g i n their j o u r n e y toward expression in o u r bellies and wind their way t h r o u g h o u r n e c k — o n e o f the m a j o r thoro u g h f a r e s t h r o u g h w h i c h they eventually g e t e x p r e s s e d . If we suppress o u r e m o t i o n s , we often do it by tightening the c o m p l i c a t e d musculature of the neck. If we do this over a l o n g e n o u g h p e r i o d of time, we can lose a g o o d deal of o u r flexibility and create a rather painful b o t t l e n e c k . A l s o , since the cervical spine is n o t e m b e d d e d as securely in bony, myofascial, m e m b r a n o u s structures as the thoracic and l u m b a r spines, it can m o v e in many interesting and c o m p l i c a t e d w a y s — a n d as a result get into trouble m o r e easily. Since the n e c k is so highly flexible, it is better able to adapt to imbalances in the rest of the b o d y than o t h e r parts of the spine. Try standing up and sidebending to the right. Notice h o w your shoulder

35

SPINAL MANIPULATION MADE SIMPLE girdle a n d n e c k r e s p o n d . Y o u w o u l d actually be m o r e c o m f o r t a b l e if your n e c k f o l l o w e d the s i d e b e n d i n g . But because of y o u r righting reflexes y o u instinctively l o o k a h e a d with y o u r eyes r o u g h l y horizontal to the g r o u n d p l a n e . N o t i c e h o w y o u r n e c k loses s o m e of its flexibility as y o u attempt to k e e p y o u r h e a d on straight while s i d e b e n d i n g . In a less exaggerated, b u t no less i m p o r t a n t way, o u r necks are always adjusting to imbalances everyw h e r e in o u r b o d i e s . Since n o n e of us have perfectly b a l a n c e d b o d i e s , to s o m e e x t e n t we have all lost s o m e d e g r e e of mobility and adaptability in the cervical r e g i o n . B e c a u s e of this loss of adaptability, y o u will almost always find p r o b l e m s with p e o p l e ' s necks, even those w h o do n o t c o m e to y o u c o m p l a i n i n g a b o u t their necks. Y o u will find restrictions in the necks of y o u n g p e o p l e and see the effects of unresolved restrictions in the severely restricted necks of o l d e r clients. T h e implication of these observations is significant: m u c h of the time it will be difficult to adequately treat n e c k p r o b l e m s unless y o u u n d e r s t a n d a n d m a n a g e the imbalances a n d c o m pensatory patterns in the w h o l e body. A l t h o u g h this situation is especially true f o r the n e c k , it also applies to the entire body. Any time y o u consider manipulating a local restriction, do y o u r best to also understand h o w it is related to all the o t h e r areas of c o m p e n s a t i o n a n d strain t h r o u g h o u t the body. If y o u r client's b o d y c a n n o t adapt to or support the release of a local fixation, then either the local area will revert to its dysfunctional state or strain will be driven e l s e w h e r e — o r b o t h . A l t h o u g h necks are very c o m p l i c a t e d , describing their m o t i o n is easy. With the e x c e p t i o n of C I , all m o t i o n of the cervical spine is always Type II. W h e n y o u s i d e b e n d a n d rotate y o u r n e c k , w h e t h e r y o u forward o r back b e n d , and whether there are facet restrictions or not, sidebending and rotation are always c o u p l e d to the same side. This fact makes your life as a therapist a litde easier. Unlike the rest of the spine, o n c e you know how a cervical vertebra is rotated y o u automatically k n o w it must be sidebent to the same side. F r o m the previous chapters y o u also k n o w that the facets on the side to which the vertebra is rotated are closed and that the facets on the o p p o site side are o p e n . Y o u c o u l d use the f o r w a r d / b a c k w a r d b e n d i n g test you learned in the last chapter to d e t e r m i n e which facets are restricted, but if y o u try it y o u will realize rather quickly that it is n o t easily applied to the n e c k and that a different test w o u l d be useful. It turns o u t that there is a rather elegant m o t i o n test f o r d e t e r m i n i n g facet restrictions, but we will

36

THE NECK save it f o r the next chapter. In this c h a p t e r y o u will learn s o m e easy techniques that do n o t require k n o w i n g w h i c h facets are fixed. T h e rationale f o r this a p p r o a c h is b a s e d on e x p e r i e n c e a n d is the s a m e as the o n e I explained in Chapter T w o : on average, somatic practitioners tend to learn t h e o r y and t e c h n i q u e m o r e easily a n d quickly w h e n they can g e t their hands to understand first.

Indirect Cervical Techniques

T

HE FIRST T W O TECHNIQUES WE ARE G O I N G TO L O O K AT ARE SIMPLE

indirect techniques that do n o t c h a l l e n g e facet restrictions. T h e y are

similar to the first t e c h n i q u e y o u l e a r n e d f o r derotating l u m b a r a n d t h o racic vertebrae in Chapter O n e . Even t h o u g h these indirect t e c h n i q u e s are n o t as consistently effective as the t e c h n i q u e s that c h a l l e n g e the restricted facets, they can be effective on m a n y o c c a s i o n s a n d they are fun to practice. But m o r e importantly they can assist y o u r learning in two very useful ways: practicing t h e m will give y o u e x p e r i e n c e in f e e l i n g i n t o a n d through the body, a n d they will also teach y o u r h a n d s and m i n d the clear difference between addressing the myofascial level and the articular level. In o r d e r to d e t e r m i n e w h e t h e r to apply these indirect t e c h n i q u e s the only piece of information you n e e d to know is whether a vertebra is rotated.

With your client supine, place the tips of y o u r i n d e x fingers t o u c h i n g each o t h e r o n o n e o f the s p i n o u s processes o f the cervical s p i n e . M a k e sure that y o u r fingers are on the same horizontal plane a n d that they are perp e n d i c u l a r to the sagittal p l a n e . T h e n slowly pull y o u r fingers laterally apart a l o n g the horizontal plane. A l m o s t immediately y o u will feel y o u r fingertips sink into the spinal g r o o v e . If the vertebra is right rotated, y o u will feel that y o u r right finger is a little posterior a n d y o u r left finger is a little anterior. T h e b u m p is on the right and the indentation is on the left. Test all of the cervical vertebrae in this way until y o u find o n e that is obviously rotated. A n d again, d o n ' t fret a b o u t the o n e s that are n o t clear. For now, just find the o n e s that are obviously rotated. If y o u are n o t familiar with locating cervical vertebrae, h e r e is a simple m e t h o d f o r f i n d i n g y o u r way. L o c a t e the i n f e r i o r tip of the mastoid process and let y o u r finger sink f r o m there medially i n t o the e d g e of the cervical spine. Your finger will land on the articular pillar a n d transverse 37

SPINAL MANIPULATION MADE SIMPLE

Figure 4.1

process of C2. T h e cervical vertebrae are spaced about a finger-width apart f r o m e a c h other. F r o m C 2 , m o v e d o w n o n e f i n g e r - w i d t h and place y o u r first finger on the right articular pillar of C3. T h e n let y o u r o t h e r fingers fall in line u n d e r y o u r i n d e x finger on e a c h successive vertebrae. You n o w have y o u r m i d d l e f i n g e r o n C4, y o u r ring f i n g e r o n C 5 , and y o u r pinky o n C 6 (Figure 4 . 1 ) . Figure 4.2 is a illustration of a typical cervical vertebra. T h e anterior a n d posterior tubercles in this particular vertebra constitute its transverse processes. In o t h e r cervical vertebrae, the transverse process is c o m p o s e d o f only o n e p r o m i n e n c e . O n c e y o u realize h o w close the articular pillars are to the tubercles, or transverse processes, y o u can appreciate h o w your fingertips, in m a n y cases, are b i g e n o u g h to cover b o t h at o n c e . T h e articular pillars are also k n o w n as the articular processes. If y o u l o o k at h o w the cervical vertebrae line u p o v e r o n e another, y o u can easily see h o w these articular processes f u n c t i o n as s u p p o r t i n g pillars. Let's go back to y o u r client's n e c k a n d find the most obviously rotated cervical vertebra so that y o u can practice the first indirect t e c h n i q u e f o r

38

THE NECK

Facet Body Anterior tubercle Posterior tubercle

Facet

Spinous process

Articular pillar

Figure 4.2 derotating it. Let's assume y o u d i s c o v e r that C3 is right r o t a t e d on C 4 . Place the tips of y o u r thumbs on the TP's of C3 a n d let y o u r forefingers sink into the spinal g r o o v e at the level of C3 (Figures 4.3 a n d 4.4, p a g e 4 0 ) . Gently b u t firmly s q u e e z e C3 b e t w e e n y o u r fingers t o g e t h e r in the following way: press the tips of y o u r thumbs toward each o t h e r in a medial direction as y o u squeeze your forefingers into the spinal g r o o v e in an anterior and slightly superior direction. Wait a n d y o u will feel the m a r v e l o u s response of y o u r client's b o d y to y o u r t o u c h as it begins to c o r r e c t itself. Y o u will probably first feel C3 m o v e further i n t o right rotation a n d right s i d e b e n d i n g a n d t h e n c h a n g e d i r e c t i o n a n d possibly m o v e toward left rotation and left s i d e b e n d i n g , perhaps m o v i n g in u n p r e d i c t a b l e a n d surprising ways before it setdes and releases. D o n ' t try to anticipate its m o t i o n , just follow the d a n c e . W h e n it releases y o u will feel the associated tissues soften and the n e c k o r g a n i z e itself a l o n g the sagittal p l a n e . If the t e c h n i q u e was successful y o u r client will r e p o r t that his pain is either g o n e or lessened a n d y o u will n o t i c e that C3 is no l o n g e r right rotated. Practice this t e c h n i q u e f o r a while until y o u try the n e x t o n e . 39

SPINAL MANIPULATION MADE SIMPLE

Figure 4.3

Figure 4.4

40

THE NECK T h e s e c o n d indirect t e c h n i q u e is n o t only simple, b u t rather elegant. It was created by my friend a n d c o l l e a g u e , Jan Sultan, w h o j o k i n g l y a n d appropriately calls it "Dial-a-Neck." Y o u may f i n d this t e c h n i q u e a little m o r e effective than the previous o n e because it involves larger m o v e m e n t s of the h e a d and n e c k w h i c h may, in turn, have m o r e of an effect on the facet restrictions. Grasp the T P ' s o f C 3 b e t w e e n the t h u m b a n d m i d d l e f i n g e r o f y o u r right h a n d (Figures 4.5, 4.6, a n d 4.7). W i t h y o u r left h a n d grasp the t o p of y o u r client's h e a d a n d rotate it to the right so that its rotation, a c c o r d ing to your best guess, matches the rotation of C3. N o w wait f o r a m o m e n t and you will e x p e r i e n c e a remarkable d e v e l o p m e n t — C 3 and y o u r client's head will b o t h b e g i n to m o v e further i n t o right rotation. Just f o l l o w this m o t i o n until the h e a d and n e c k rotate no further a n d wait. In a few seco n d s y o u may feel a slight pulsation u n d e r y o u r fingers (it d o e s n ' t really matter whether y o u feel this pulsation or n o t ; b u t since m a n y therapists do feel it, it is worth m e n t i o n i n g ) . Continue to wait for a few m o r e m o m e n t s and y o u will feel an impulse in y o u r client's n e c k a n d h e a d to c o m e o u t

Figure 4.5 41

SPINAL MANIPULATION MADE SIMPLE

Figure 4.6

Figure 4.7

42

THE NECK of its extreme rotation. Again, just follow the directions in w h i c h the h e a d and n e c k want to m o v e . T h e y may rotate to the left a n d then b a c k to the right as they s i d e b e n d , f o r w a r d a n d b a c k w a r d b e n d , this way a n d that. D o n ' t impose your notions of what is possible or what y o u think they should d o , j u s t f o l l o w the d a n c e . Eventually, the h e a d a n d n e c k will c e a s e all s i d e b e n d i n g and rotating, and setde in a straight line. Wait f o r the tissues to soften u n d e r y o u r fingers a n d f o r the o r t h o t r o p i c effect as the n e c k lengthens and organizes itself a l o n g the sagittal axis. Palpate C3 a n d see if it derotated. If the technique was successful, C3 will no l o n g e r be rotated, the tissues will feel m o r e relaxed, a n d y o u r client will r e p o r t that his pain is lessened or c o m p l e t e l y g o n e . Y o u may have n o t i c e d that my favorite expression f o r h o w to r e s p o n d to the b o d y as it finds n o r m a l is "Just f o l l o w the d a n c e . " T h e refined aesthetic sensibilities of s o m e Italian students that I o n c e taught in R o m e l e d them to coin the phrase, ' T h e D a n c e of the Tissues " t o describe this astonishing ability of the b o d y to f i n d its way b a c k h o m e w h e n given p e r m i s sion. With a little practice a n d p a t i e n c e e v e r y o n e can learn to p e r c e i v e this d a n c e . All it requires is that y o u let go of y o u r t e n d e n c y to anticipate and c o m m e n t on the process that is u n f o l d i n g u n d e r y o u r h a n d s a n d let what is h a p p e n i n g u n f o l d in its o w n way. Resist the temptation to step o u t of the flow of lived-experience a n d reflect on what is h a p p e n i n g . Reflectively thinking a b o u t e x p e r i e n c e certainly has a place in life, b u t n o t w h e n y o u are applying these t e c h n i q u e s . Athletes s o m e t i m e s refer to this pre-reflective way of b e i n g a n d d o i n g as the " Z o n e . " If a basketball player were to think to himself as he was a b o u t to score the w i n n i n g p o i n t in the last s e c o n d s of the g a m e , " O h , this is great I am a b o u t to s c o r e two b i g o n e s , " he p r o b a b l y w o u l d n ' t . If, d u r i n g an inspired p e r f o r m a n c e , a great c o n c e r t musician were to continually c o m m e n t to herself, "I am playing this beautifully, Mozart w o u l d be so impressed!" h e r inspiration w o u l d s o o n b e c o m e a fleeting m e m o r y . In the same way, if y o u reflect on the process or c o m m e n t to yourself in elation, skepticism, or self-doubt, y o u will just as surely lose y o u r ability to f o l l o w the d a n c e of the tissues. All t o o often w h e n therapists first attempt to f o l l o w the d a n c e of the tissues they a d o p t all sorts of silent, self-defeating m o n o l o g u e s a n d attitudes that instantly h i n d e r their ability to feel the obvious. Since they are often n o t p r e p a r e d f o r the e x p e r i e n c e o f the b o d y m o v i n g u n d e r its o w n 43

SPINAL MANIPULATION MADE SIMPLE d i r e c t i o n i n d e p e n d e n t l y o f their o r the client's c o n s c i o u s c o n t r o l , they d o u b t what they are feeling. S o m e t i m e s their skepticism gets in their way a n d they think, " O h , this c a n ' t be h a p p e n i n g ! " a n d s u d d e n l y what they were feeling disappears u n d e r their hands. At other times their own astonishment brings the d a n c e to a c o m p l e t e standstill. Before they even touch the b o d y , s o m e therapists assume that they are n o t sensitive e n o u g h to feel such m o v e m e n t s a n d just as surely as they let their feelings of inadeq u a c y take over, they lose their innate ability to f o l l o w the d a n c e of the tissues. However, y o u can learn to p u t all such n o t i o n s aside a n d just let yourself feel what the b o d y wants to d o . T h e most c o m m o n mistake that b e g i n n i n g followers of the dance make is to anticipate what the b o d y wants to do as it transitions f r o m o n e position to a n o t h e r . At first they f i n d themselves f o l l o w i n g the d a n c e quite well as the b o d y c o n t i n u e s to rotate a n d s i d e b e n d in o n e direction. But at the very m o m e n t the b o d y stops m o v i n g in the direction they are following a n d b e g i n s to shift in a n o t h e r direction, they immediately w o n d e r what is h a p p e n i n g , a l t h o u g h m o r e than likely they will n o t even f o r m a c o m p l e t e t h o u g h t a b o u t it. Either the m o m e n t a r y cessation of m o v e m e n t in a clear d i r e c t i o n or a slow b u t o b v i o u s c h a n g e of d i r e c t i o n c o m p e l s t h e m to instinctively w o n d e r a b o u t what is g o i n g o n . It is m u c h like what happens when you see m o v e m e n t from the c o r n e r of your e y e — y o u instinctively a n d inquisitively turn to see what the m o v e m e n t is. A l t h o u g h no w o r d s may b e s p o k e n , y o u r o r i e n t a t i o n a n d c o m p o r t m e n t say "What's that?" It d o e s n ' t really matter what therapists say or d o n ' t say to themselves w h e n the b o d y c h a n g e s directions d u r i n g treatment. W h a t matters is that they step o u t of the flow of lived-experience and lose track of the d a n c e . If y o u are n o t pre-reflectively there to f o l l o w the b o d y ' s lead, y o u are no l o n g e r able to r e c o g n i z e its pattern of strain—there is no l o n g e r anything f o r y o u to f o l l o w a n d so y o u stop m o v i n g . Since it takes two to tango, the b o d y also stops m o v i n g . If this h a p p e n s to y o u d u r i n g the transitions, all that y o u n e e d to do is simply stop thinking a b o u t what y o u are feeling. Let g o o f y o u r surprise, p u z z l e m e n t , o r wordless "What's that?" and just feel again h o w the b o d y slow d a n c e s toward its o w n c o r r e c t i o n . L e a r n i n g to w o r k this way is an exercise in learning h o w n o t to think, h o w n o t t o worry, a n d h o w t o b e h a p p y with what is. T h e m o r e y o u learn

44

THE NECK to live in this place of no-thinking, the h a p p i e r y o u will b e c o m e . E x p l o r e this o p e n way of n o t reflectively thinking a b o u t what is o c c u r r i n g , because it is a gateway into the healer's way of b e i n g that I briefly m e n t i o n e d in the i n t r o d u c t i o n . E x p l o r e this s p a c i o u s way o f b e i n g w h e n y o u are n o t working with clients and y o u can transform your life. Explore it while working with y o u r clients a n d their b o d i e s will reveal m o r e a n d m o r e of what they n e e d f r o m y o u . I n time y o u will b e less a n d less c o n c e r n e d a b o u t i m p o s i n g your will and presuppositions on y o u r clients, or the world, a n d things will u n f o l d with an i m p e c c a b l e clarity. Like most indirect techniques of this nature Dial-a-Neck will sometimes p r o d u c e w o n d e r f u l and astounding results and at o t h e r times it will s e e m like a waste of effort. N o w you know w h y — i t ' s because these techniques do n o t direcdy challenge j o i n t fixations. Since we are a p p r o a c h i n g all j o i n t fixations in this b o o k f r o m the soft-tissue perspective, we n e e d a way to chall e n g e the j o i n t fixation without resorting to high-velocity, low-amplitude thrusting techniques, and that is what the next technique will accomplish.

A Joint Challenging Technique

T

HIS J O I N T - C H A L L E N G I N G T E C H N I Q U E IS VERY LIKE T H E S H O T G U N

t e c h n i q u e y o u l e a r n e d in Chapter T w o to release facet restrictions in

the thoracic and l u m b a r sections of the spine. A l t h o u g h there are a n u m -

b e r o f small d i f f e r e n c e s , let m e d e s c r i b e the t e c h n i q u e simply, w i t h o u t m e n t i o n i n g these differences so y o u k n o w y o u are in familiar territory. It works just as y o u might expect: y o u locate the rotated vertebra and assume that it is fixed c l o s e d on the side to w h i c h it is rotated a n d fixed o p e n on the opposite side, put pressure on the fixed-closed facets in forward b e n d ing and wait f o r the release, a n d p u t pressure on the f i x e d - o p e n facets in backward b e n d i n g a n d wait f o r the release. Y o u will be h a p p y to learn that this s h o t g u n t e c h n i q u e d o e s n o t waste as m u c h time w h e n a p p l i e d to the cervical spine. In the thoracic or l u m bar spines, the facets are either fixed o p e n or fixed c l o s e d . So every time you apply this shotgun a p p r o a c h to a lumbar or thoracic vertebra, y o u are always addressing o n e side t o o many. But the cervical spine is different. Very often y o u will find that the facets on b o t h sides are fixed. It is very c o m m o n to find a cervical vertebra that is bilaterally restricted with facets 45

SPINAL MANIPULATION MADE SIMPLE that are f i x e d c l o s e d o n o n e side a n d f i x e d o p e n o n the o t h e r side. Your efficiency, t h e r e f o r e , g o e s up s o m e w h a t w h e n y o u use this t e c h n i q u e for the n e c k . T h e r e are s o m e important differences between the vertebra of the neck a n d the rest of the spine that y o u n e e d to understand. O n e of these diff e r e n c e s is reason f o r c a u t i o n . T h e r e are two vertebral arteries that run a l o n g a n d inside the cervical vertebrae and irritating or cutting them off, especially in o l d e r clients, can be very d a n g e r o u s . T h e vertebral arteries are especially at risk at C 6 , C 7 , a n d at the occiptioatlantal j u n c t i o n . Even if y o u r arteries are n o r m a l , w h e n y o u rotate y o u r n e c k they can narrow as m u c h a s 9 0 % o n the side o p p o s i t e the r o t a t i o n . F o r w a r d b e n d i n g and s i d e b e n d i n g the n e c k will n o t put these arteries at risk, but back b e n d i n g will greatly exaggerate what h a p p e n s in rotation. Back b e n d i n g a client's n e c k while applying a high-velocity, low-amplitude thrusting t e c h n i q u e , f o r e x a m p l e , is a very d a n g e r o u s a p p r o a c h . Be careful. W h e n y o u are attempting to release o p e n fixed cervical facets, even using the soft-tissue t e c h n i q u e s taught in this b o o k , y o u must m o d i f y t h e m and n o t put your clients's n e c k very far i n t o extension. If y o u p u t y o u r client into back b e n d i n g a n d rotation by mistake and she c o m p l a i n s of dizziness or y o u notice that her eyes begin to m o v e involuntarily in a rhythmic b a c k a n d forth pattern ( k n o w n as nystagmus) take h e r o u t of e x t e n s i o n immediately a n d suggest that she see her doctor. If y o u have any d o u b t s a b o u t the integrity of a client's vertebral arteries, there is a simple test y o u can apply. Put y o u r client in a sitting position with h e r spine c o m f o r t a b l y straight. Ask h e r to back b e n d h e r h e a d and then turn h e r h e a d to the right a n d to the left. Watch f o r the appearance of nystagmus or dizziness. Since the n e c k is c a p a b l e of m o r e m o t i o n than the rest of the spine, y o u can i n t r o d u c e s i d e b e n d i n g a n d rotation as a way to further challenge facet restrictions. In fact, y o u should use sidebending and rotation in place of i n t r o d u c i n g significant extension as y o u manipulate o p e n fixed facets. I n the case o f closed-fixed facets, y o u can apply e x t r e m e f o r w a r d b e n d i n g without w o r r y w h e n y o u apply s i d e b e n d i n g a n d rotation. N o t i c e also h o w the facets are arranged in the cervical spine. N o t only are they are almost parallel to the transverse p l a n e , the facets are accessible to y o u r fingers in three places: in the spinal g r o o v e , at the lateral

46

THE NECK e d g e s w h e r e the articular pillars a n d transverse p r o c e s s e s are, a n d j u s t slighdy anterior and medial to the articular pillars and transverse processes. Having a n u m b e r of places w h e r e the facets are accessible to y o u r fingers makes the application of this t e c h n i q u e just a little bit easier, because y o u can adjust the application of pressure to allow f o r h o w the b o d y is best able to release. So let's take a m o r e careful l o o k at this t e c h n i q u e . For the p u r p o s e s of illustration, assume again that C3 is right rotated on C4. Either the right facets are fixed c l o s e d or the left facets are fixed o p e n — o r b o t h sides are fixed. Since C3 is right rotated, you know that it also must be right sidebent. If it is right sidebent, it will be restricted in left s i d e b e n d i n g a n d rotation, which means that it can easily s i d e b e n d a n d rotate right, b u t c a n n o t sideb e n d and rotate left. Y o u n e e d to k n o w the direction in w h i c h C3 c a n n o t s i d e b e n d and rotate in o r d e r to c h a l l e n g e the facets. Release the right facets first. Cradle the b a c k of y o u r client's h e a d in y o u r left h a n d a n d lift it o f f the table. L e a n y o u r e l b o w on the table so that y o u can c o m f o r t a b l y s u p p o r t y o u r client's h e a d . T h e n left s i d e b e n d and left rotate y o u r client's h e a d a n d n e c k as far as they will c o m f o r t a b l y g o . Forward b e n d i n g and sidebending b o t h challenge the p r e s u m e d fixedclosed right facets. T h e n put your i n d e x or m i d d l e finger on the p r e s u m e d fixed c l o s e d facets in the right spinal g r o o v e or on the articular pillars, as shown in Figure 4.8, p a g e 48. As y o u k e e p y o u r client's h e a d in its lefts i d e b e n t p o s i t i o n , let y o u r f i n g e r sink i n t o the spinal g r o o v e a n d wait. W h e n the facets release, y o u will n o t i c e the usual indicators: softening of the tissue and a sense of the n e c k l e n g t h e n i n g a l o n g the sagittal p l a n e . But y o u will also feel s o m e t h i n g else. R e m e m b e r that C3 is n o t able to sidebend and rotate left because of the p r e s u m e d right-fixed facets. W h e n the facets release, you will also feel your client's head and neck left sidebend and rotate just a little further. If these are the only facets restricted in the neck, then the left s i d e b e n d i n g a n d rotation will be very obvious. N o w let's release the p r e s u m e d fixed-open facets on the left. A g a i n , cradle the back of y o u r client's h e a d in y o u r right h a n d , lift it u p , a n d rest your e l b o w on the table. Put y o u r left i n d e x or m i d d l e finger on the fixed o p e n facets by placing y o u r left finger in the left spinal g r o o v e or between the articular pillars as s h o w n in Figures 4.9 a n d 4.10, p a g e 49. To m a k e things easier f o r yourself, allow y o u r client's h e a d to rest on the w e b b i n g 47

SPINAL MANIPULATION MADE SIMPLE

Figure 4.8 between the t h u m b a n d forefinger of y o u r left h a n d . Push ever so slightly in an anterior d i r e c t i o n to give just the suggestion of back b e n d i n g . With y o u r right h a n d , s i d e b e n d a n d rotate y o u r client's h e a d and n e c k to the left as far as they will c o m f o r t a b l y go a n d wait. W h e n the facets release, y o u will feel the tissues soften, the sense of l e n g t h e n i n g a l o n g the sagittal plane, and y o u r client's h e a d and n e c k turning further into left sidebending a n d rotation. It is a g o o d idea to e x p e r i m e n t with a n d m o d i f y this t e c h n i q u e a bit. Try different p l a c e m e n t s of y o u r left i n d e x finger. See h o w the technique works for you when you put your index finger in the spinal groove, between the TP's of C3 a n d C 4 , or j u s t slightly in front of and between the TP's of C3 a n d C4 as y o u s i d e b e n d a n d rotate y o u r client's h e a d and n e c k to the left. A l s o , y o u d o n ' t have to wait passively f o r the facets to release. Experi m e n t with gently twisting a n d j i g g l i n g y o u r client's h e a d in the direction o f left s i d e b e n d i n g a s y o u apply pressure either o n the o p e n o r c l o s e d facets. Y o u can also very effectively c o m b i n e the direct and indirect app r o a c h e s . By twisting a n d then j i g g l i n g y o u r client's h e a d and n e c k in the

48

THE NECK

Figure 4.9

Figure 4.10 49

SPINAL MANIPULATION MADE SIMPLE d i r e c t i o n i t c a n n o t s i d e b e n d a n d rotate, y o u are c h a l l e n g i n g the facet restriction by p e r f o r m i n g a direct t e c h n i q u e . But if y o u then wait for your client's b o d y t o r e s p o n d t o y o u r direct c h a l l e n g e and f o l l o w the d a n c e o f the tissues y o u are a p p r o a c h i n g the fixation indirectly. Try j i g g l i n g and rotating while waiting f o r the d a n c e , and then m o r e j i g g l i n g and rotating a n d again waiting f o r the d a n c e , a n d so on until y o u secure a satisfactory release. D o n ' t be surprised if y o u have to p e r f o r m the t e c h n i q u e a c o u ple of times to c o m p l e t e l y release the fixation. This j o i n t - c h a l l e n g i n g t e c h n i q u e can also be used with a n e w m o t i o n test f o r d e t e r m i n i n g w h i c h facets are fixed a n d h o w they are fixed. That y o u will learn in the n e x t chapter. T h e test will allow y o u to be m o r e effic i e n t in y o u r a p p r o a c h a n d p r o v i d e an i m p o r t a n t indicator of facet fixation. R e m e m b e r that fixation is m o r e i m p o r t a n t than position. C h e c k i n g f o r rotation b e f o r e and after the application of a t e c h n i q u e is n o t a perfecdy reliable indicator of dysfunction or its release. A vertebra may appear to have derotated and yet n o t have b e e n completely released f r o m its facet restriction. Y o u should also realize that a vertebra can appear to be slightly rotated a n d n o t actually have any facet restrictions. T h e m o t i o n testing that y o u are a b o u t to learn will give y o u a very clear way to know, without relying on palpating rotation, w h e t h e r y o u have discovered cervical facet restrictions a n d w h e t h e r y o u were successful in releasing t h e m .

50

CHAPTER

5

Motion Testing the Cervical Spine HE MOTION TEST DEVELOPED BY OSTEOPATHS FOR DETERMINING

facet restrictions in the cervical spine is called the Translation Test. Translation in this context refers to m o t i o n i n d u c e d along a straight or c u r v e d plane. T h e test is simple and quite elegant: y o u forward b e n d and backward b e n d y o u r client's h e a d a n d n e c k a n d then push e a c h vertebra f r o m right to left and f r o m left to right a l o n g a horizontal p l a n e . If y o u find that the vertebra m o v e s f r o m right to left b u t n o t f r o m left to right, y o u have discovered a facet restriction. W h e n y o u h o l d y o u r client's n e c k i n forward b e n d i n g while y o u translate the vertebra, y o u are testing to see if the facets can o p e n . If there are no facet restrictions, the facets will o p e n in forward b e n d i n g a n d y o u will be able to translate the vertebra f r o m left to right a n d right to left. H o w ever, if y o u find that y o u can translate f r o m right to left, b u t n o t f r o m left to right in forward b e n d i n g , y o u have discovered fixed c l o s e d facets that will n o t p e r m i t translatory m o t i o n . Likewise, w h e n y o u p u t y o u r client's n e c k in a back b e n d i n g position and translate, y o u are testing f o r whether the facets can close. If y o u find that y o u c a n n o t translate f r o m right to left with y o u r client's n e c k in backward b e n d i n g , then y o u have d i s c o v e r e d fixed o p e n facets that will n o t p e r m i t translatory m o t i o n . T h e absence o f translatory m o t i o n indicates the l o c a t i o n o f the facet restriction. In the forward b e n d i n g position, loss of m o t i o n indicates fixedclosed facets and in the backward b e n d i n g position, loss of m o t i o n indi51

SPINAL MANIPULATION MADE SIMPLE cates fixed-open facets. In the forward b e n d i n g position the facet restriction is on the side o p p o s i t e the m o t i o n restriction a n d in the backward b e n d i n g position the facet restriction is on the same side as the m o t i o n restriction. This may s o u n d o d d , or even paradoxical at first, but it makes perfectly g o o d sense o n c e y o u u n d e r s t a n d the l o g i c o f the test and the Type II biomechanics of C 2 - C 7 . D o n ' t c o n c e r n yourself with the logic of the test just yet or with h o w to d e t e r m i n e on which side the facet restriction is. We will get to these important aspects of the test s o o n e n o u g h . B e f o r e we d o , there is an important distinction to k e e p in m i n d . N o t understanding or hearing this simple distinction at the outset has b e e n e n o u g h to drive s o m e rather intelligent and n o r m a l therapists a r o u n d the b e n d . T h e distinction is between a facet restriction a n d a motion restriction. A facet restriction is the cause of the m o t i o n restriction. If you c a n n o t translate a c e r v i c a l v e r t e b r a in o n e d i r e c t i o n , the cause of this lack of m o t i o n is a facet restriction. After y o u apply this test y o u then use the disc o v e r y of the m o t i o n restriction to d e d u c e w h e r e the facet restriction is. Unlike what y o u l e a r n e d in the forward a n d backward b e n d i n g tests for the t h o r a c i c a n d l u m b a r spines, y o u will b e d e d u c i n g facet restrictions f r o m m o t i o n restrictions in the cervical spine, n o t f r o m the h o w the vertebra appears to derotate. R e m e m b e r this distinction and that you are taki n g y o u r r e f e r e n c e p o i n t f r o m m o t i o n restriction, n o t f r o m rotation. In o r d e r to understand what translation is a n d h o w it works, practice it with y o u r client's h e a d lying c o m f o r t a b l y on the treatment table, maki n g sure that his n e c k is relatively straight. Admittedly, this position is n o t very useful f o r getting the i n f o r m a t i o n y o u n e e d f o r d e t e r m i n i n g facet restrictions. Y o u must use translation in the f o r w a r d a n d b a c k b e n d i n g positions to get that i n f o r m a t i o n . However, we are practicing translation this way first so that y o u can understand h o w it works without the a d d e d effort o f m a i n t a i n i n g y o u r client's h e a d a n d n e c k i n forward and backward b e n d i n g . Let's start by translating C3 with y o u r client's h e a d and n e c k lying c o m fortably straight on the table. Find C3 a n d place y o u r i n d e x and m i d d l e fingers on each TR Use y o u r palms and thenar e m i n e n c e s to stabilize and h o l d the u p p e r part of the cervical spine and the h e a d . I n t r o d u c e translation by m o v i n g y o u r fingers and hands (as a w h o l e , as if their were no

52

MOTION TESTING THE CERVICAL SPINE j o i n t s i n y o u r h a n d s ) f r o m left t o r i g h t a n d f r o m right to left a l o n g the h o r i z o n tal plane (Figure 5.1). Be certain that y o u are i n t r o d u c i n g m o t i o n o n l y a l o n g the horizontal p l a n e — b e very careful n o t t o actually s i d e b e n d y o u r client's n e c k . T h e n e c k a n d C3 will automatically s i d e b e n d as a result of m o v i n g it a l o n g t h e h o r i zontal. If y o u inadvertently s i d e b e n d y o u r client while y o u are attempting to translate C 3 , y o u will n o t get a clear reading. Feel w h a t h a p p e n s u n d e r y o u r f i n g e r s . D o e s C3 m o v e better left to right or right t o left? I f y o u are n o t sure c h e c k C 2 t h r o u g h C7 until y o u find a vertebra that clearly d o e s n o t m o v e a s easily i n o n e Figure 5.1

direction as it d o e s the other. D o n ' t worry yet a b o u t h o w to interpret y o u r findings.

Y o u may actually find s o m e vertebrae that d o n ' t translate at all. I g n o r e these cases until y o u find a vertebra that obviously translates o n e way a n d n o t the other. Just make sure y o u are translating correctly a n d n o t inadvertently i n t r o d u c i n g s i d e b e n d i n g into y o u r m o t i o n . D o y o u n o t i c e h o w translation a l o n e is sufficient to create s i d e b e n d i n g ? O n c e y o u are c o m f o r t a b l e with translating C 2 - C 7 , try translating C3 in the forward b e n d i n g position. P r o p y o u r elbows on the table. Cradle and stabilize y o u r client's h e a d and cervical vertebrae a b o v e C3 with y o u r palms a n d thenar e m i n e n c e s a n d lift the h e a d o f f the table (Figure 5.2, page 5 4 ) . It is very i m p o r t a n t that y o u p r o p up y o u r elbows so that y o u are n o t e x e r t i n g a l o t of u n n e c e s s a r y effort trying to h o l d y o u r client's h e a d still. Many clients have a difficult time relinquishing c o n t r o l of their necks to your hands, so the m o r e stable and secure they feel in y o u r hands, the m o r e they can give up c o n t r o l . If y o u c a n n o t comfortably m a n a g e this position f o r yourself, y o u m i g h t try using a face cradle f o r y o u r table that will allow y o u r client's h e a d to rest easily on it in the f o r w a r d a n d backward b e n d i n g positions (Figure 5.3). In any case, put y o u r client's n e c k in flexion by lifting it o f f the table. 53

SPINAL MANIPULATION MADE SIMPLE

Figure 5.2

Figure 5.3

54

MOTION TESTING THE CERVICAL SPINE

Stabilize t h e h e a d a n d C 1 - C 2 with y o u r palms and thenar eminences, and then translate C3 along the horizontal plane from right to left a n d t h e n f r o m left to right. D o e s it translate better o n e way than another? If so, you have discovered a m o t i o n restriction that will allow y o u to d e d u c e the side on w h i c h the facets are fixed c l o s e d . If C3 translates f r o m right to left, b u t n o t f r o m left to right, the m o t i o n restriction is on the left. D o n ' t c o n c e r n yourself right n o w with h o w t o d e d u c e the side with the f i x e d - c l o s e d facets f r o m the discovery of m o t i o n restriction, just feel the restriction. If C3 translates both ways, go l o o k i n g f o r a vertebra that d o e s n ' t . N o w try translating i n the b a c k w a r d Figure 5.4

b e n d i n g position. To achieve an easy extension of the neck, simply slide the lateral e d g e

of y o u r forefinger u n d e r the n e c k and gently push it in an anterior direction while y o u simultaneously a n d gently push y o u r client's h e a d in an inferior position. Stabilize the head and C 1 - C 2 with your palms and thenar eminences, and translate C3 first o n e way and then the o t h e r (Figure 5.4). If y o u find that C3 translates o n e way better than another, y o u have disc o v e r e d a m o t i o n restriction that will allow y o u to d e d u c e the side on which the facets are fixed o p e n . If C3 translates f r o m left to right, b u t n o t f r o m right to left, the m o t i o n restriction is on the right. Again, d o n ' t c o n c e r n y o u r s e l f at this p o i n t with l e a r n i n g w h i c h side is f i x e d o p e n , j u s t learn to feel f o r the m o t i o n restriction. If y o u d o n ' t find a m o t i o n restriction at C3 on C4, then test other cervical vertebrae until y o u find a m o t i o n restriction. Practice translation on all the cervical vertebrae with the e x c e p t i o n of C I : in forward and backward b e n d i n g until y o u are fairly c o n f i d e n t that you can locate each individual vertebra and feel its free or restricted motion. After practicing on a n u m b e r of different clients, y o u will be a m a z e d at the p r o f o u n d differences between necks. S o m e necks seem to be very flexible, with supple soft tissues, a n d yet still s h o w facet restrictions. O t h e r 55

SPINAL MANIPULATION MADE SIMPLE necks s e e m to be tight a n d rigid at every level. Of c o u r s e , y o u will find those necks that s e e m at first as t h o u g h they s h o u l d be fixated at every level, b u t are relatively free of facet restrictions. W h a t e x p e r i e n c e teaches y o u is that everyone is different and that the feeling of a restriction in o n e p e r s o n may b e u n r e s t r i c t e d m o t i o n f o r a n o t h e r . Ultimately, n o matter what part of the b o d y y o u are evaluating, y o u must learn to feel what c o n stitutes a restriction f o r e a c h individual p e r s o n . N o w that y o u have s o m e familiarity with translation, let's l o o k a little m o r e closely at the m o t i o n test a n d the i n f o r m a t i o n y o u can glean f r o m it. Translation automatically i n t r o d u c e s s i d e b e n d i n g a n d rotation to the same side. Since s i d e b e n d i n g and rotation are always c o u p l e d to the same side in the n e c k (with the e x c e p t i o n of C I ) , if y o u k n o w which direction a vertebra c a n n o t sidebend, y o u also k n o w the way it cannot rotate. Regardless o f w h e t h e r y o u translate y o u r client's n e c k i n f o r w a r d o r backward b e n d i n g , if C3 can translate f r o m the right to the left, b u t n o t f r o m the left to the right, y o u immediately k n o w that the vertebra is right sidebent a n d right r o t a t e d , with f i x e d facets s o m e w h e r e that are p r e v e n t i n g left s i d e b e n d i n g a n d left rotation. Figuring o u t w h i c h facets are restricted is quite simple. Suppose in forward b e n d i n g y o u can translate C3 f r o m right to left, b u t n o t f r o m left to right. T h e discovery of a m o t i o n restriction on the left means that C3 is right sidebent a n d right rotated on C4 a n d that C3 c a n n o t left s i d e b e n d a n d left rotate. Since y o u are testing in forward b e n d i n g , y o u also k n o w that y o u have d i s c o v e r e d fixed c l o s e d facets. So since C3 has facets that are fixed c l o s e d and C3 is right sidebent and right rotated, then you know the fixed c l o s e d facets must be on the right. S u p p o s e y o u test a n o t h e r client's n e c k in back b e n d i n g and y o u find the same m o t i o n restriction. In back b e n d i n g you discover a m o t i o n restriction on the left: C3 translates easily f r o m right to left but, n o t f r o m left to right. This discovery tells y o u that C3 is right sidebent and right rotated a n d c a n n o t left s i d e b e n d a n d left rotate. Since y o u are testing in b a c k b e n d i n g , y o u k n o w that y o u have discovered fixed o p e n facets. Since C3 is right s i d e b e n t a n d right rotated on C4 a n d the facets are fixed o p e n , y o u k n o w that the fixed o p e n facets must be on the left. T w o simple rules immediately e m e r g e f r o m this exercise: 1) w h e n y o u translate in forward b e n d i n g and m e e t a m o t i o n restriction, the facets are

56

MOTION TESTING THE CERVICAL SPINE fixed c l o s e d on the side o p p o s i t e to the m o t i o n restriction, a n d 2) w h e n y o u translate in b a c k b e n d i n g a n d m e e t a m o t i o n restriction, the facets are fixed o p e n on the same side as the m o t i o n restriction. D o n ' t let y o u r m e m o r y o f the forward a n d backward b e n d i n g tests f o r the thoracic a n d l u m b a r spines c o n f u s e y o u r u n d e r s t a n d i n g of the translation test. R e m e m b e r that f o r the cervical spine y o u are d e d u c i n g w h e r e the facet restriction is f r o m d e t e r m i n i n g w h e r e the m o t i o n restriction is. Y o u are n o t d e d u c i n g the l o c a t i o n of the facet restriction f r o m h o w the vertebra appears to derotate, as y o u did in the thoracic and lumbar spines. T h e reference p o i n t y o u are using to d e d u c e the facet restriction in the cervical s p i n e , is m o t i o n restriction, n o t r o t a t i o n . F o r the t h o r a c i c a n d l u m b a r spines, y o u d e d u c e that the fixed-closed facets are on the same side as the rotation and that the fixed-open facets are on the o p p o s i t e side o f the rotation. I n the cervical s p i n e , y o u d e d u c e that the f i x e d - c l o s e d facets are on the side opposite to the m o t i o n restriction a n d that the fixed o p e n facets are on the same side as the m o t i o n restriction. W i t h cervical translation, the r e f e r e n c e p o i n t — t h e side to w h i c h the facet fixation is either o p p o s i t e or the s a m e — i s reversed in relation to the f o r w a r d a n d backward b e n d i n g test f o r the thoracic a n d l u m b a r spines. W h y d o e s it w o r k this way? Let's stick with the same e x a m p l e . If there are no fixed-closed facets, then w h e n y o u forward b e n d y o u r client's n e c k all the facets will o p e n and when you translate you will n o t m e e t any m o t i o n restriction. W h e n y o u translate i n f o r w a r d b e n d i n g a n d m e e t a m o t i o n restriction, the cause is fixed closed facets. In o u r e x a m p l e translation tells y o u that C3 is right s i d e b e n t a n d right rotated on C4 a n d that the right facets are fixed closed. W h e n y o u translate right to left the left facets must be free to o p e n to allow that m o t i o n to o c c u r . S i n c e the left facets are i n d e e d free to o p e n , y o u are able to translate right to left. But w h e n y o u try to translate left to right the situation changes. Translating left to right can o n l y h a p p e n i f the right facets c a n o p e n . But since they are f i x e d closed, they c a n n o t o p e n a n d will n o t p e r m i t left-to-right translation. Y o u feel the m o t i o n restriction on the left, b e c a u s e the right facets will n o t o p e n , and are f i x e d c l o s e d . Y o u d o n o t feel the m o t i o n restriction o n the right because the left facets are able to o p e n as y o u translate right to left. W h e n y o u b a c k b e n d y o u r client's n e c k , i f t h e r e are n o f i x e d - o p e n facets, all the cervical facets will close a n d y o u will n o t m e e t any m o t i o n 57

SPINAL MANIPULATION MADE SIMPLE restrictions w h e n y o u translate. If y o u m e e t a m o t i o n restriction while translating in b a c k b e n d i n g , the cause is f i x e d o p e n facets. Translation tells y o u that C3 is right sidebent and right rotated on C4 and that the left facets are fixed o p e n . In back b e n d i n g , w h e n y o u translate f r o m right to left, the right facets must be capable of closing f o r that m o t i o n to occur. Since the right facets are free a n d able to c l o s e , y o u can easily translate f r o m right to left. In o r d e r f o r y o u to be able to translate C3 f r o m left to right, the left facets must be capable of closing. But since they are fixed o p e n , they c a n n o t close, a n d h e n c e y o u c a n n o t translate C3 f r o m left to right. Y o u feel the m o t i o n restriction on the left, because the left facets will n o t c l o s e , b e c a u s e they are f i x e d o p e n . Y o u d o n o t feel the m o t i o n restriction on the right, because the right facets are able to close to permit translation f r o m right to left. After translating the necks of a n u m b e r of p e o p l e , y o u may n o t i c e a rather c o m m o n o c c u r r e n c e , i n w h i c h y o u m e e t a m o t i o n restriction o n the same side in b o t h forward and backward b e n d i n g . For e x a m p l e , supp o s e y o u f i n d that y o u can translate C 4 f r o m left t o right b u t n o t f r o m right to left in b o t h forward and backward b e n d i n g . W h e n y o u discover a case like this w h e r e the m o t i o n restriction is on the right in b o t h forward a n d backward b e n d i n g , it m e a n s that the facets on b o t h sides are fixed. T h e left facets are fixed c l o s e d a n d the right facets are fixed o p e n . If y o u d e t e c t a m o t i o n restriction on the left in b o t h f o r w a r d a n d back b e n d i n g , it m e a n s that the right facets are fixed c l o s e d and the left facets are f i x e d o p e n . Y o u will also e n c o u n t e r necks that exhibit m o t i o n restriction on b o t h sides in b o t h forward a n d backward b e n d i n g . Bilateral m o t i o n restriction can be the result of arthritis or s o m e t h i n g simple, like rigid tight muscles a n d fasciae. In the latter case, y o u must release these myofascial restrictions first. W h e n y o u are first learning h o w to m o t i o n test the neck for facet restrictions, do n o t c o n f u s e yourself by trying to elucidate the logic of the test. Just learn to feel f o r m o t i o n restrictions and use the simple rules provided to d e d u c e the facet restriction. Unlike the forward and backward b e n d i n g tests f o r the thoracics a n d lumbars, cervical translation involves n o t only s i d e b e n d i n g , rotation, forward b e n d i n g , and backward b e n d i n g , but also left a n d right translation. Trying to understand the results of the test

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MOTION TESTING THE CERVICAL SPINE while attempting to r e m e m b e r all these c o n d i t i o n s can b e c o m e very c o m plicated. So h e r e are the simple rules f o r C 2 - C 7 :

If translation reveals a motion restriction in backward bending, then the facets are fixed open on the same side as the motion restriction. If translation reveals a motion restriction in forward bending, then the facets are fixed closed on the side opposite to the motion restriction. As with the o t h e r rules p r o v i d e d , y o u can r e f o r m u l a t e these any way that suits y o u r understanding. If y o u m e m o r i z e these rules or k e e p a c o p y where y o u can see t h e m , y o u will save yourself a lot of grief as y o u w o r k with y o u r clients. If y o u are like m o s t therapists, y o u do n o t want to try to think y o u r way t h r o u g h the l o g i c of these tests while y o u are a p p l y i n g t h e m — y o u just want to apply the tests so that y o u can quickly d e t e r m i n e which facets are fixed. If y o u have b e e n practicing the s h o t g u n t e c h n i q u e s f r o m C h a p t e r 3 that c h a l l e n g e cervical facet restrictions, then y o u already k n o w h o w to release them. T h e translation test gives you the a d d e d ability to locate m o r e precisely w h e r e a n d h o w the facet is restricted. T h e translation test has another great advantage. As previously n o t e d , if y o u r only way of k n o w i n g whether a cervical facet restriction has b e e n released is the a p p e a r a n c e of d e r o t a t i o n , then y o u do n o t have a fully reliable indicator. Translation gives y o u a far m o r e accurate way to d e t e r m i n e whether the facet has b e e n released than c h e c k i n g f o r derotation. As y o u practice these techniques, allow yourself the f r e e d o m to let the client's b o d y tell y o u h o w it wants to release itself. W h e n y o u rotate a n d s i d e b e n d the h e a d a n d n e c k to c h a l l e n g e a facet restriction, s o m e t i m e s the b o d y wants to rotate and sidebend to the opposite side before it releases. Be p r e p a r e d to follow the d a n c e of the tissues, even if it m e a n s f o l l o w i n g the b o d y into seemingly o d d positions. Learn to easily shift f r o m direct to indirect techniques and back again as the b o d y d e m a n d s . W h e n y o u b e g i n with challenging a facet restriction, wait to see h o w the b o d y r e s p o n d s to y o u r invitation. T h e h e a d a n d n e c k may want to rotate a n d s i d e b e n d to the side o p p o s i t e to h o w y o u are h o l d i n g t h e m . T h e y may want to go into flexion and then extension as they s i d e b e n d a n d rotate this way a n d that until they finally release. Or the facets may simply go directly into a release 59

SPINAL MANIPULATION MADE SIMPLE in the direction y o u are e n c o u r a g i n g it to g o . Always c h e c k the results of y o u r work. After y o u have a p p l i e d a techn i q u e , translate the cervical vertebra again to make sure y o u released the facet restriction completely. D o n ' t be surprised if y o u have to apply the t e c h n i q u e a few times b e f o r e the facets release to y o u r satisfaction. Unlike the t e c h n i q u e s y o u l e a r n e d f o r releasing the rest of the spine, the cervical vertebrae s o m e t i m e s require a few applications of the t e c h n i q u e until the facets release. In the n e x t c h a p t e r y o u will learn h o w to release atlas-on-axis restrictions a n d occiput-on-atlas restrictions.

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CHAPTER

6

The Atlas and Occiput O C O M P L E T E Y O U R U N D E R S T A N D I N G O F T H E NECK Y O U NEED T O K N O W

h o w to release atlas on axis (AA) restrictions a n d o c c i p u t on atlas ( O A ) restrictions. T h e t e c h n i q u e s are similar t o w h a t y o u have already learned and are very easy to apply. Ninety p e r c e n t of n o r m a l atias m o t i o n on the axis is rotation. T h e r e is some sidebending, but from a clinical standpoint it is n o t important e n o u g h to w o r r y about. W h e n the atlas gets in t r o u b l e , it is d u e to restricted rotation. Y o u can d e t e r m i n e w h e t h e r C I i s r o t a t e d o n C 2 b y p a l p a t i n g f o r whether o n e TP is anterior a n d the o t h e r is posterior, b u t in m a n y necks CI rotation is sometimes difficult to feel. Besides, sometimes the atlas can be slightly rotated and show no restricted facets. In general, the m o s t reliable way to d e t e r m i n e dysfunction is by using a simple m o t i o n test. Begin with y o u r client in a s u p i n e p o s i t i o n on y o u r treatment table. Grasp his h e a d with b o t h h a n d s a n d flex the cervical s p i n e so that the h e a d is lifted up a b o u t 45 degrees. Positioning the cervical spine in this way locks C 2 - C 7 and forces the atlas to rotate with the o c c i p u t . Maintain the cervical spine in this position a n d rotate y o u r client's h e a d to the left and then to the right (Figures 6.1 and 6.2, page 6 2 ) . If CI is n o t restricted on C 2 , then y o u will be able to easily a n d obviously rotate his h e a d freely to each side. If the atlas rotation is restricted, y o u will be able to rotate his h e a d easily in o n e d i r e c t i o n , b u t n o t as far in the o t h e r . So if his h e a d rotates to the right a n d n o t as well to the left, CI is r i g h t r o t a t e d a n d 61

SPINAL MANIPULATION MADE SIMPLE

Figure 6.1

Figure 6.2

62

THE ATLAS AND OCCIPUT restricted in left rotation. If his h e a d rotates better to the left than the right, then the atlas is left rotated a n d restricted in right rotation. Releasing the atlas is easy: k e e p y o u r client's h e a d in 45 d e g r e e s flexion and rotate it in the direction it is restricted. If the test shows y o u that the atlas is left rotated, turn his h e a d to the right as far as it can c o m f o r t ably g o . Place y o u r right i n d e x a n d / o r m i d d l e fingers o n the p o s t e r i o r arch of the adas close to the posterior surface of the right transverse process (Figure 6.3, page 64) and let the full weight of his h e a d rest on y o u r fingers (Figure 6.4). Make sure y o u d o n o t place y o u r f i n g e r s o n the tip o f the right transverse process of the atlas. N o t only will this t e c h n i q u e n o t work with this finger p l a c e m e n t , it will also create unnecessary pain f o r y o u r client. Just let his weight rest on y o u r fingers while y o u wait f o r the release. Y o u will feel all the familiar indications of release as his h e a d an atlas b e g i n to slowly rotate m o r e a n d m o r e to the right. Y o u can either wait for the tissues to release or e n c o u r a g e the release by gently turning a n d / o r j i g g l i n g his h e a d to the right. Retest to m a k e sure y o u have c o m pletely released the rotation restriction. It may take m o r e than o n e application of this t e c h n i q u e to c o m p l e t e l y release the atlas. Restrictions o f the o c c i p u t o n the atlas are very c o m m o n a n d i f n o t released these restrictions will c o m e back to haunt you. T h e m o s t sterling and p r o f o u n d releases o f the C 1 - C 7 o f t e n will n o t relieve y o u r client's pain if you do n o t address the influence of the o c c i p u t . S o m e t i m e s an OA restriction is e n o u g h to reestablish an AA restriction e v e n after the AA restriction has b e e n r e l e a s e d . A n d o v e r time t h o s e restrictions c a n b e r e s p o n s i b l e f o r o t h e r restrictions s h o w i n g u p t h r o u g h o u t y o u r client's spine. W h e t h e r n o r m a l o r a b n o r m a l , i n b o t h forward o r backward b e n d i n g , all m o d o n of the o c c i p u t on the atlas is Type I. T h e r e are no discs between the o c c i p u t and the atlas, and the j o i n t s do n o t o p e n and close in forward and backward b e n d i n g the way they do in the rest of the spine. Rather the c o n v e x condyles o f the o c c i p u t glide posteriorly o n the s u p e r i o r c o n c a v e facets of the atlas when you forward b e n d and glide anteriorly on the adas when you backward b e n d . W h e n y o u s i d e b e n d t o the right, f o r e x a m p l e , the right c o n d y l e will slide inferiorly on a facet of the atlas a n d the left condyle will slide superiorly. If y o u find an OA restriction, y o u can say that the o c c i p u t is fixed in extension ( o r backward b e n d i n g ) or in flexion ( o r 63

SPINAL MANIPULATION MADE SIMPLE

Figure 6.3

Figure 6.4

64

THE ATLAS AND OCCIPUT forward b e n d i n g ) . Since the c o n d y l e s d o n o t o p e n a n d close i n f o r w a r d and backward b e n d i n g , y o u c a n n o t say that they are fixed c l o s e d or fixed open. You can reliably test f o r restrictions of the o c c i p u t on the atlas by using the lateral translation test. If y o u m e e t a restriction while translating in forward b e n d i n g , it m e a n s that the occipital c o n d y l e c a n n o t glide p o s t e riorly because it is fixed anteriorly, in e x t e n s i o n , or back b e n d i n g . If y o u m e e t a m o t i o n restriction while translating in backward b e n d i n g it m e a n s that the occipital c o n d y l e c a n n o t glide anteriorly because it is fixed p o s teriorly, in flexion, or forward b e n d i n g . You can easily and quickly release OA restrictions by using a t e c h n i q u e that is almost the same as the o n e you learned f o r releasing the atlas. T h e only difference between the two techniques is where y o u place your fingers. To locate the restriction, translate y o u r client's h e a d f r o m right to left and f r o m left t o right i n b o t h f l e x i o n a n d e x t e n s i o n . S u p p o s e y o u f i n d that y o u can translate y o u r client's o c c i p u t f r o m left to right b u t n o t f r o m right to left in forward b e n d i n g . Since translation i n t r o d u c e s s i d e b e n d ing and y o u are testing in forward b e n d i n g , finding a m o t i o n restriction on the right means that his o c c i p u t is left s i d e b e n t a n d right rotated a n d f i x e d i n e x t e n s i o n , o r backward b e n d i n g . T o release this b a c k - b e n d i n g restriction, k e e p his h e a d a n d n e c k in the f o r w a r d - b e n d i n g p o s i t i o n to challenge the facet restriction. S i d e b e n d a n d rotate h i m in the d i r e c t i o n he c a n n o t s i d e b e n d , w h i c h in this case is to the right. Place y o u r right i n d e x and m i d d l e f i n g e r s o n the base o f the o c c i p u t near the right o c c i p ital c o n d l y e and let the full weight of his h e a d rest on y o u r fingers (Figure 6.5, page 6 6 ) . Again, either just wait f o r the release or e n c o u r a g e the release b y gently t u r n i n g , s i d e b e n d i n g a n d / o r j i g g l i n g his h e a d t o the right. You will feel the tissues soften while his h e a d slowly s i d e b e n d s a n d turns right. Retest to make sure y o u released the restriction completely. T h e test and t e c h n i q u e are basically the same in the backward b e n d ing p o s i t i o n . Backward b e n d y o u r client's h e a d a n d n e c k a n d translate the o c c i p u t b o t h ways. If his h e a d translates easily f r o m right to left b u t n o t f r o m left to right, then y o u k n o w that the o c c i p u t is right s i d e b e n t , left rotated, and fixed in flexion or forward b e n d i n g . To release this forward-bending restriction, k e e p his h e a d in a back b e n d i n g position a n d s i d e b e n d a n d turn it to the left while resting the base of the o c c i p u t — 65

SPINAL MANIPULATION MADE SIMPLE

Figure 6.5

n e a r the left occipital c o n d y l e — o n y o u r left i n d e x a n d m i d d l e fingers. Again, just wait f o r the release or e n c o u r a g e the release by gently turning a n d / o r j i g g l i n g the h e a d m o r e to the left. Y o u will feel the tissues soften as his h e a d s i d e b e n d s a n d turns left. Be sure to retest y o u r results a n d d o n ' t b e surprised i f i t takes m o r e than o n e a p p l i c a t i o n t o adequately release O A restrictions. D e s c r i b i n g the b i o m e c h a n i c s o f O A restrictions can b e c o m p l i c a t e d , but testing f o r and releasing them, as y o u have discovered, is fairly straightforward. If translation reveals a m o d o n restriction in forward or backward b e n d i n g , y o u s i d e b e n d a n d turn the h e a d in the direction it w o n ' t translate, which is the direction in which it c a n n o t s i d e b e n d . K e e p the head in either f o r w a r d o r backward b e n d i n g , d e p e n d i n g o n which position y o u find the m o t i o n restriction, a n d apply pressure a c c o r d i n g l y — t h a t ' s all there is to it. Y o u may be t e m p t e d to formulate a rule f o r yourself like the following: when y o u translate the o c c i p u t on the atlas in forward and backward b e n d ing the side on which y o u m e e t the m o t i o n restriction is the side on which the facet restriction is f o u n d . T h e t e c h n i q u e actually works as if this rule

66

THE ATLAS AND OCCIPUT were correct, b u t it's not. W h e n y o u m e e t a m o t i o n restriction in forward b e n d i n g the facet restriction is on the side o p p o s i t e the m o t i o n restriction. In backward b e n d i n g the facet restriction is on the same side as the m o t i o n restriction. In backward b e n d i n g it makes g o o d clinical sense to both turn y o u r client's h e a d in the direction of the m o t i o n restriction a n d apply y o u r pressure to the side of the m o t i o n restriction. But in forward b e n d i n g , since the facet restriction is on the side o p p o s i t e the m o t i o n restriction, although it makes g o o d sense to turn y o u r client's h e a d in the direction of the m o t i o n restriction, it d o e s n ' t s e e m sensible to apply y o u r pressure to the side of the m o t i o n restriction. Y o u w o u l d think it w o u l d be m o r e effective to apply y o u r pressure to the side o p p o s i t e the m o t i o n restriction. Interestingly, the t e c h n i q u e works quite well in forward b e n d ing, but I d o n ' t k n o w exactly why it d o e s . I c o u l d speculate a b o u t why and h o w it works, b u t I am n o t sure that w o u l d further y o u r technical skills. Instead let's l o o k at why the rule is n o t c o r r e c t a n d try to c o m e up with a rule that reflects the specifics of what is actually g o i n g on a n d that will allow y o u to be m o r e specific in h o w y o u apply the t e c h n i q u e . W h e n y o u b a c k b e n d a n d translate the o c c i p u t o n the atlas, y o u are testing f o r whether the occipital condyles can glide anteriorly. If y o u find a m o t i o n restriction it m e a n s that o n e of c o n d y l e s is f i x e d posteriorly. W h e n you forward b e n d and translate the o c c i p u t , y o u are trying to determ i n e whether the condyles can glide posteriorly. Finding a m o t i o n restriction indicates that o n e of the c o n d y l e s is fixed anteriorly. To f o r m u l a t e the c o r r e c t rule we n e e d to k n o w h o w to d e d u c e the fixed c o n d y l e f r o m a m o t i o n restriction. S u p p o s e y o u translate y o u r client's o c c i p u t in b a c k b e n d i n g a n d disc o v e r that it can translate f r o m left to right, b u t n o t f r o m right to left. Since y o u k n o w that the o c c i p u t always s i d e b e n d s a n d rotates to o p p o s i t e sides, the discovery of this m o t i o n restriction tells y o u that the o c c i p u t is left sidebent and right rotated. In back b e n d i n g , since translation tests f o r the ability of the condyles to glide anteriorly, if y o u m e e t a m o t i o n restriction you also k n o w that o n e of the c o n d y l e s is fixed in flexion or forward b e n d i n g . If it is fixed in flexion or forward b e n d i n g , then it is fixed p o s teriorly. Y o u n o w have all the i n f o r m a t i o n y o u n e e d to figure o u t the side on which the condyle is fixed. If the o c c i p u t is right rotated, then the right side of the o c c i p u t is p o s t e r i o r a n d the left side is anterior. If it is fixed 67

SPINAL MANIPULATION MADE SIMPLE posteriorly a n d right rotated, the posterior fixation must be on the right. W h y d o e s it w o r k this way? In b a c k b e n d i n g , translation of the o c c i p u t r e q u i r e s that the o c c i p i t a l c o n d y l e s g l i d e anteriorly. W h e n y o u m e e t a m o t i o n restriction translating right to left it means that the right c o n d y l e is fixed posteriorly a n d will n o t p e r m i t anterior glide. Y o u can translate the o t h e r way, f r o m left to right, because the left c o n d y l e is n o t fixed and will p e r m i t anterior glide. Since the right c o n d y l e is fixed posteriorly, left s i d e b e n t , a n d right r o t a t e d , w h e n y o u translate f r o m left t o right, the occiput sidebends left and rotates right. As a result, the left occipital condyle glides anteriorly a n d s i d e b e n d s left, while the right side of the o c c i p u t slides posteriorly, in the direction it is already rotated and posteriorly fixed. So when y o u translate the occiput in back bending, you will feel the motion restriction on the same side as the facet restriction. N o w s u p p o s e y o u translate y o u r client's o c c i p u t i n f o r w a r d b e n d i n g a n d m e e t a m o t i o n restriction g o i n g f r o m right to left, but n o t f r o m left to right. T h e facet restriction is on the left, the side opposite to the m o t i o n restriction. But h o w d o y o u g e t t o this c o n c l u s i o n ? Finding the m o t i o n restriction on the right tells y o u that the o c c i p u t is left s i d e b e n t , right rotated, and that o n e of the condyles is fixed anteriorly because it is unable to glide posteriorly. O n c e y o u k n o w that the o c c i p u t is right rotated and o n e c o n d y l e is fixed anteriorly, y o u k n o w that the anteriorly fixed condyle has to be on the left. If the o c c i p u t is right rotated, it is posterior on the right a n d anterior on the left. Since translation revealed that a c o n d y l e is fixed anteriorly, y o u k n o w that the fixation must be on the left. Y o u can p r o b a b l y figure o u t yourself why it works this way in forward b e n d i n g , b u t let's go t h r o u g h the l o g i c of it. In o r d e r f o r the o c c i p u t to translate b o t h ways, the condyles must be capable of gliding anteriorly. In the a b o v e e x a m p l e , the m o t i o n restriction i s o n the right. T h e o c c i p u t can translate f r o m left to right b e c a u s e it is c a p a b l e of s i d e b e n d i n g left while the left c o n d y l e glides anteriorly. As the left c o n d y l e glides anteriorly the occiput rotates right. Since the right condyle is already right rotated a n d posterior, it can glide in that direction. But in o r d e r f o r y o u to translate the o c c i p u t f r o m right to left, the left c o n d y l e must be capable of gliding posteriorly. Since the left c o n d y l e is fixed anteriorly, it will n o t permit translation a n d y o u will feel the m o t i o n restriction on the right. Y o u can use the "as if r u l e " a n d simply turn y o u r client's h e a d in the

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THE ATLAS AND OCCIPUT direction of the m o t i o n restriction a n d apply pressure to that side in b o t h forward and backward b e n d i n g to very effectively release the gliding fixations of the occipital condyles. Or y o u can be m o r e specific in y o u r techn i q u e n o w that y o u k n o w w h e r e the gliding fixations are to be f o u n d in flexion and extension. T h e rules are: in forward b e n d i n g the anteriorly fixed condyle is on the side opposite to the m o t i o n restriction and in backward b e n d i n g the p o s t e r i o r l y fixed c o n d y l e is on the s a m e side as the m o t i o n restriction. If y o u find a m o t i o n restriction in backward b e n d i n g , j u s t apply the technique outlined above. If you find a m o t i o n restriction in forward b e n d ing y o u can vary y o u r t e c h n i q u e to directly address the posteriorly fixed c o n d y l e . S u p p o s e y o u find a m o t i o n restriction in forward b e n d i n g while translating f r o m left to right b u t n o t f r o m right to left. T h e right c o n d y l e is fixed anteriorly and the o c c i p u t c a n n o t s i d e b e n d to the left. H o l d y o u r client's h e a d in f o r w a r d b e n d i n g , a n d s i d e b e n d a n d rotate it to the left with y o u r left h a n d . Place y o u r right i n d e x a n d / o r m i d d l e f i n g e r s near the right anteriorly fixed c o n d y l e a n d apply pressure in a p o s t e r i o r superior direction as if y o u were trying to pry the right c o n d y l e f r o m its anteriorly fixed position (Figure 6.6, p a g e 7 0 ) . Or try laying the radial e d g e of y o u r left i n d e x finger a l o n g the base of the o c c i p u t a n d place the tip of your right t h u m b into the area near the right anteriorly fixed c o n d y l e . Apply pressure with y o u r t h u m b in a posterior superior d i r e c t i o n as y o u s i d e b e n d a n d rotate y o u r client's h e a d to the left (Figure 6 . 7 ) . Y o u are c h a l l e n g i n g the facet restriction by t u r n i n g y o u r client's h e a d left a n d applying pressure with y o u r right fingers or t h u m b . T u r n i n g y o u r client's head left e n c o u r a g e s left s i d e b e n d i n g a n d right rotation a n d h e n c e p o s terior glide. Meanwhile, the fingers or t h u m b of y o u r right h a n d are clearing the restrictions so that p o s t e r i o r glide can actually o c c u r . As always, just wait f o r the release, or e n c o u r a g e it a little by gently turning a n d / o r j i g g l i n g the h e a d m o r e to the left. D o n ' t f o r g e t to f o l l o w the d a n c e a n d always c h e c k y o u r results by retesting. In the next chapter we will turn o u r attention to the o t h e r e n d of the spine and l o o k at the b i o m e c h a n i c s of the sacrum and h o w to release it f r o m its restrictions.

69

SPINAL MANIPULATION MADE SIMPLE

Figure 6.6

Figure 6.7

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CHAPTER

7

The Sacrum HE SACROILIAC J O I N T IS INFAMOUS IN ITS R E P U T A T I O N FOR CAUSING

pain to featherless bipeds. Given the e n o r m o u s a m o u n t of discomfort and pain that is associated with this joint, it is very curious that the w o r d " s a c r u m " means "the sacred b o n e . " T h e sacroiliac (SI) j o i n t is f o r m e d by the articulation of the pelvis a n d the sacrum. Dysfunction of this j o i n t can result f r o m h o w the pelvis impacts on the s a c r u m or h o w the s a c r u m impacts on the pelvis. If the pelvis is responsible f o r a fixed SI j o i n t , then it is called a iliosacral dysfunction. If the sacrum is responsible, then it is called a sacroiliac dysfunction. In this c h a p t e r y o u will learn h o w to r e c o g n i z e a n d m a n i p u l a t e sacroiliac dysfunctions a n d in the n e x t y o u will learn a b o u t h o w to deal with iliosacral dysfunctions. A c c o r d i n g to s o m e experts the sacrum is capable of 14 different types o f m o t i o n . D e s c r i b i n g all o f these m o t i o n s can b e very interesting, b u t s o m e w h a t tedious unless y o u j u s t h a p p e n to love such activities. My a p proach in this chapter is to provide a series of quick and easy ways to release the sacrum without first l o a d i n g y o u d o w n with c o m p l i c a t e d b i o m e c h a n ical explanations. We will start o u r e x p l o r a t i o n of the s a c r u m with o n l y the simplest of b i o m e c h a n i c a l descriptions so that y o u can b e g i n practicing techniques f o r releasing the sacrum right away. After y o u r h a n d s are familiar with h o w the sacrum works, y o u will learn a m o r e t h o r o u g h app r o a c h to the b i o m e c h a n i c s . 71

SPINAL MANIPULATION MADE SIMPLE

Sacral Motion

W

H E N Y O U F O R W A R D B E N D , Y O U R SACRAL BASE MOVES IN A POSTERIOR

a n d slighdy s u p e r i o r d i r e c d o n . W h e n y o u b a c k b e n d y o u r sacral

base m o v e s in the o p p o s i t e direction, anteriorly and inferiorly. This anterior and posterior m o v e m e n t of the sacrum occurs a l o n g a transverse axis that runs t h r o u g h S2. T h e anterior a n d posterior m o v e m e n t of the sacral base is called nutation and counternutation, but I will use the simpler designations of anterior nutation a n d p o s t e r i o r nutation w h e n referring to this m o t i o n . T h e w o r d "nutation" m e a n s " n o d d i n g . " To find the sacral base on y o u r client, first locate the spinous process of L 4 . Begin with y o u r client seated in neutral position. With o n e of y o u r fingers trace an imaginary horizontal line f r o m the crest of the ilium to the spine. T h e s p i n o u s process y o u r finger lands on b e l o n g s to L4 (Fig-

u r e 7.1). C o u n t d o w n t o the s p i n o u s p r o c e s s o f L 5 a n d then o n e m o r e n o t c h to the sacral base. Or find the sacral base by finding the sacral sulcus (Figure 7.2). T h e sacral sulcus are vertical grooves that y o u r thumbs will sink i n t o if y o u roll t h e m just medially o f f the posterior superior iliac spines (PSIS). Place y o u r right t h u m b on the right sacral base or sulcus a n d y o u r left t h u m b on the left sacral base or sulcus. Ask y o u r client to forward and backward b e n d while you m o n i t o r h o w the sacral base nutates posteriorly in forward b e n d i n g a n d anteriorly in backward b e n d i n g .

Iliac crests at level of L4 Sacral sulcus

Sacral base Median sacral crest

PSIS Inferior lateral angle Ischial tuberosity

Figure 7.1

72

THE SACRUM

Figure 7.2

Figure 7.3 73

SPINAL MANIPULATION MADE SIMPLE It is useful to be able to feel sacral m o t i o n in a n u m b e r of positions so y o u can d o u b l e c h e c k y o u r results. So ask y o u r client to lay in a p r o n e position on y o u r treatment table. Again place y o u r thumbs on the sacral base. Ask y o u r client to raise himself up and p r o p himself on his elbows as illustrated in Figure 7.3, p a g e 73, while y o u feel f o r w h e t h e r the sacral base moves anteriorly. Ask y o u r client to lie back d o w n and to then tilt his pelvis posteriorly. This action will a c c o m p l i s h the same results as forward b e n d ing. Since m o s t p e o p l e do n o t understand what tilting their pelvis posteriorly means, y o u m i g h t suggest that he turn his pelvis u n d e r as if to slowly thrust his p u b i c area forward toward the surface of the table. As he tilts his pelvis posteriorly, feel for whether the sacral base nutates posteriorly. If you do n o t feel the sacral base nutate either posteriorly or anteriorly, y o u have discovered a bilateral sacral fixation. Either the sacral base is fixed in bilateral posterior nutation or bilateral anterior nutation. Sacrums are also capable of s i d e b e n d i n g and rotating. If there are no j o i n t fixations, then this is what y o u r sacrum d o e s in walking as you shift y o u r weight f r o m o n e leg to the other. Most experts agree that the sacrum only exhibits Type I m o t i o n and that sidebending and rotadon are c o u p l e d to o p p o s i t e sides. S i d e b e n d i n g and rotation of the sacrum are also called torsion. Rotation and torsion of the sacrum are n a m e d the same as rotadon of the vertebrae. If the right sacral base is posterior, then the sacrum is right rotated or right torsioned (and left sidebent). If the left sacral base is posterior, then the sacrum is left rotated or left torsioned (and right sidebent). It is m o r e accurate b u t also m o r e c o m p l i c a t e d to d e s c r i b e rotation and s i d e b e n d i n g in terms of torsion but let's leave these complexifies for later. If the sacral base is right rotated in neutral position then it is probably dysfunctional a n d h e n c e the j o i n t is fixed in s o m e way. Either the right sacral base is fixed in posterior nutation or the left sacral base in fixed in anterior nutation, b u t h o w do y o u d e t e r m i n e which side is the fixed side? Forward and backward b e n d your client and watch h o w each side behaves. W h e n y o u r client f o r w a r d a n d backward b e n d s , if the rotation of his sacrum appears to go away in forward b e n d i n g and gets worse in backward b e n d i n g , then y o u k n o w that the right side of his sacrum is fixed posteriorly. T h e right side of the sacrum b e c o m e s a fixed p o i n t a r o u n d which the sacrum is f o r c e d to turn in forward and backward bending. Since his sacral base is fixed posteriorly, it c a n n o t m o v e anteriorly in backward b e n d i n g .

74

THE SACRUM So in backward b e n d i n g his right sacral base stays w h e r e it is, posteriorly fixed, while his left sacral base moves further in an anterior direction thereby making it appear that the sacral rotation has w o r s e n e d . In forward b e n d ing his right sacral base again stays w h e r e it is, while his left sacral base moves posteriorly, making it appear that the rotation has disappeared. What happens if y o u r client's sacrum is right rotated, left sidebent, and the left sacral base is fixed anteriorly? His left sacral base in this case will be the fixed pivot p o i n t a r o u n d w h i c h his s a c r u m turns in f o r w a r d a n d backward b e n d i n g . W h e n y o u r client f o r w a r d b e n d s , his left sacral base stays fixed anteriorly a n d his right sacral base m o v e s further in a p o s t e rior direction and as a result the rotation seems to worsen. W h e n y o u back b e n d y o u r client, again his left sacral base r e m a i n s fixed in its a n t e r i o r position, but this time his right sacral base moves in an anterior direction, making it s e e m like the rotation disappears. Thus, when y o u find a rotated sacrum, y o u can create a simple rule f o r d e t e r m i n i n g which side is fixed. If sacral rotation b e c o m e s m o r e e x t r e m e in back b e n d i n g , then the side to which the sacrum is rotated is fixed p o s teriorly. If sacral rotation seems to disappear in b a c k b e n d i n g , then the side o p p o s i t e to the rotation is fixed anteriorly. Y o u can state the rule differently if y o u wish. I c h o o s e to state the rule solely in terms of back b e n d ing because so often my evaluation of sacral dysfunction takes place with my client in a p r o n e position on my treatment table. Rather than asking the client to get o f f the table a n d sit on the e x a m i n a t i o n stool, it is usually m u c h m o r e c o n v e n i e n t a n d easier to read sacral rotation with h i m in the p r o n e position. For the sake of practice, however, y o u s h o u l d learn to test the sacrum in b o t h the p r o n e a n d seated positions. In any case, there are always a n u m b e r of ways to state these rules. H e r e is a n o t h e r possibility y o u m i g h t prefer: if the rotation disappears in b a c k b e n d i n g , then the sacrum is fixed anteriorly on the side o p p o s i t e its rotation, and if the rotation disappears in forward b e n d i n g , then the sacrum is fixed posteriorly on the side to w h i c h it is rotated.

Techniques F PALPATION REVEALS T H A T T H E S A C R U M IS R O T A T E D , Y O U CAN USE A

simple indirect technique to derotate it. Recall the first indirect technique 75

SPINAL MANIPULATION MADE SIMPLE that y o u l e a r n e d in C h a p t e r O n e to derotate vertebrae: it can be applied in the same way to the sacrum. With your client in either a seated or p r o n e p o s i t i o n , place y o u r thumbs on e a c h side of the sacral base. If his sacrum is left rotated, the left sacral base will be posterior and the right sacral base will be anterior. Push the sacrum further into rotation by increasing the pressure of y o u r right t h u m b , wait, f o l l o w the d a n c e , and let the sacrum derotate itself. As y o u already know, this sort of indirect t e c h n i q u e d o e s n o t challenge the facet restriction. As a result, it tends to be a less effective way to release fixations. B e f o r e y o u can c h a l l e n g e a j o i n t fixation, y o u must k n o w the l o c a t i o n of the fixation a n d w h e t h e r it is fixed anteriorly or posteriorly. Do this by using the forward and backward b e n d i n g test in o r d e r to determ i n e w h e t h e r o n e side is fixed anteriorly or posteriorly. If the sacrum is right rotated a n d fixed posteriorly on the right, back b e n d y o u r client to e n c o u r a g e the right side of his sacrum to m o v e anteriorly a n d apply several p o u n d s of pressure to his right sacral base in an anterior a n d slightly inferior d i r e c t i o n . Wait f o r the d a n c e of the tissues a n d f o r the release. Y o u can apply this t e c h n i q u e with y o u r client in a seated position (Figure 7.3), o r with y o u r client p r o n e p r o p p e d u p , and resting on his elbows as a way to back b e n d a n d c h a l l e n g e the posteriorly fixed side (Figure 7.4). If his sacrum is right rotated a n d fixed anteriorly on the left, forward b e n d y o u r client to e n c o u r a g e the left side of the sacrum to m o v e posteriorly. Apply several p o u n d s of pressure to his left base in an inferior direction with your t h u m b . With your other t h u m b , push the right base, or push further d o w n on the right side, in an anterior direction, as if y o u were trying to lever the left side free by pushing on the right. Wait for the d a n c e a n d the release. Y o u can use this t e c h n i q u e with y o u r client in a seated position (Figure 7.5, page 78) or p r o n e . In the p r o n e position place a d o u b l e d - u p p i l l o w u n d e r y o u r client's a b d o m e n t o f o r w a r d b e n d and chall e n g e the anteriorly fixed side and then apply y o u r pressure (Figure 7.6). If y o u r evaluation of the sacrum reveals that it is bilaterally fixed in posterior nutation, then b a c k b e n d y o u r client to challenge the bilateral fixation a n d equally apply several p o u n d s of pressure with y o u r thumbs to e a c h side of his sacral base (Figure 7.7). A p p l y y o u r pressure in an anterior a n d slightly inferior direction and wait f o r the d a n c e and the release.

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Y o u can of c o u r s e use this t e c h n i q u e with y o u r client in either a seated or p r o n e position. If the sacrum is bilaterally fixed in anterior nutation, forward b e n d y o u r client to c h a l l e n g e the bilateral fixation and equally apply several p o u n d s of pressure to b o t h sides of his sacral base in an inferior d i r e c t i o n (Figure 7.8, p a g e 7 9 ) . Wait f o r the d a n c e a n d f o r the release. A g a i n y o u c a n apply this t e c h n i q u e in either the seated or p r o n e position. If y o u elect to release a s a c r u m f i x e d in bilateral a n t e r i o r n u t a t i o n , use a d o u b l e d - u p p i l l o w u n d e r your client's a b d o m e n to enFigure 7.3

c o u r a g e p o s t e r i o r nutation.

Figure 7.4 77

SPINAL MANIPULATION MADE SIMPLE

Figures 7.5

Figure 7.6

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Figures 7.7

Figure 7.8 79

SPINAL MANIPULATION MADE SIMPLE

LR RSB Left torsion (or rotation) on Right axis

RR LSB Right torsion (or rotation) on Right axis

Figure 7.9

Figure 7.10

Sacral Torsion O U N O W HAVE E N O U G H I N F O R M A T I O N A N D T E C H N I Q U E S T O RELEASE

I

m o s t sacral dysfunctions. T h e r e is a n o t h e r kind of sacral dysfunction

that involves a sacral shear, b u t b e f o r e we e x p l o r e this, let's e x p a n d o u r u n d e r s t a n d i n g of sacral torsion. To s o m e d e g r e e y o u already k n o w what sacral torsion is, because I introduced it as rotation and sidebending. Introd u c i n g torsion as a n o t h e r way to talk a b o u t sacral rotation and sidebendi n g will n o t require learning any new techniques. T h e techniques remain the s a m e — o n l y the language changes. Y o u m i g h t be t e m p t e d to skip this discussion, b u t I r e c o m m e n d that y o u persist because it will h e l p y o u to b e c o m e a m o r e effective therapist. S i d e b e n d i n g a n d r o t a t i o n o f the s a c r u m are c a l l e d " t o r s i o n " w h i c h o c c u r s a r o u n d either right or left o b l i q u e axis. T h e c o n v e n t i o n states that the left o b l i q u e axis runs f r o m the superior aspect of the left articulation of the sacrum on the ilium to the right inferior aspect of the sacrum where it articulates with the right ilium a n d the right o b l i q u e axis runs f r o m the superior aspect of the right articulation of the sacrum on the ilium to the left inferior aspect of the sacrum w h e r e it articulates with the left ilium. T h e right a n d left o b l i q u e axes a n d varieties of torsion are shown in Figures 7.9, 7.10, 7.11, a n d 7.12. N o t i c e that each of the f o u r kinds of tor-

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Posterior nutatioji

Anterior nutation

LR RSB Left torsion (or rotation) on Left axis

RR LSB Right torsion (or rotation) on Left axis

Figure 7.12

Figure 7.11

sion s h o w n is d e s c r i b e d in terms of the o b l i q u e axis on w h i c h it is torsioned and as well as in terms of rotation a n d s i d e b e n d i n g . So, f o r e x a m p l e , Figure 7.12 shows a s a c r u m in left t o r s i o n on the left o b l i q u e axis which is also designated as LR and RSB (left rotated and right s i d e b e n t ) . Y o u can correctly say that the s a c r u m is left rotated on the left o b l i q u e axis or left torsioned on the left axis. P r o p e r b o d y m o v e m e n t while walking is i n f l u e n c e d by ability of the sacrum to torsion left on the left axis a n d right on the right axis. Since most walking is a c c o m p l i s h e d with y o u r spine relatively u p r i g h t a n d vertical, f o r the p u r p o s e s of illustration we will assume that y o u r spine a n d sacrum are in neutral while y o u walk. Y o u m i g h t want to stand and slowly do what is a b o u t to be d e s c r i b e d h e r e so y o u can get a sense of what h a p pens with y o u r b o d y in n o r m a l walking. As y o u r right leg m o v e s f r o m h e e l strike to toe off, y o u r b o d y weight begins to m o v e over y o u r right leg, causing y o u r pelvis to shift laterally to the right. As the m o v e m e n t c o n t i n u e s toward t o e off, y o u r right pelvic i n n o m i n a t e b o n e b e g i n s to rotate anteriorly while y o u r left i n n o m i n a t e begins to rotate posteriorly. As y o u r right i n n o m i n a t e rotates anteriorly, y o u r sacrum m o v e s into right torsion on the right o b l i q u e axis (i.e., right rotates and left sidebends b e c a u s e the left sacral base m o v e s in anterior 81

SPINAL MANIPULATION MADE SIMPLE

nutation). Your lumbar spine sidebends right and rotates left, y o u r thoracic spine sidebends left and rotates right, and y o u r cervical spine sidebends right and rotates right. As the left leg m o v e s f r o m weight bearing to toe off, the left i n n o m i n a t e , the sacrum, lumbars, and thoracics torsion, rotate, and sidebend in an opposite manner. Notice in Figure 7.13 h o w this same c o m p l e x pattern of pelvic shift, sacral torsion, spinal s i d e b e n d i n g , a n d rotation is i n t r o d u c e d as the weight of the b o d y shifts to rest on the left leg. Walking and standing with y o u r weight over o n e l e g i n t r o d u c e s a n d requires this k i n d o f curvature f o r normal movement. T h e way o u r axial c o m p l e x alternately undulates in s i d e b e n d i n g a n d rotation as we walk is very interesting a n d very i m p o r t a n t to o u r well-being. Its m o v e m e n t is Figure 7.13

reminiscent of the vermicular u n d u l a t i o n of a snake as it slithers through the grass. T h e big difference, of course,

is that o u r snake-like spine has b e e n u p - e n d e d and given two legs on which to walk. Can y o u i m a g i n e h o w a snake w o u l d be f o r c e d to m o v e through its w o r l d if we were to snap a n u m b e r of very tight r u b b e r b a n d s a r o u n d its b o d y ? T h e resulting dis-ease w o u l d spread t h r o u g h its entire b u t limited e x p e r i e n c e a n d b o d y . In an a n a l o g o u s , b u t m o r e c o m p l i c a t e d way, j o i n t fixations anywhere along o u r spine act like the r u b b e r bands a r o u n d the snake's body. So if at the level of the sacroiliac j o i n t we e x p e r i e n c e any fixation, w h e t h e r it is d u e to pelvis on s a c r u m or s a c r u m on pelvis dysfunctions, it can eventually cause trouble t h r o u g h o u t o u r b o d i e s . So far I have only d e s c r i b e d neutral sacral t o r s i o n s — R on R or L on L torsions. W h e n y o u f o r w a r d b e n d a n d s i d e b e n d y o u i n t r o d u c e n o n - n e u tral m e c h a n i c s i n t o y o u r sacroiliac j o i n t a n d y o u create what are called b a c k w a r d or p o s t e r i o r t o r s i o n s . T a k e a l o o k at the d i a g r a m s (Figures 7 . 9 - 7 . 1 2 ) a n d y o u will see that in backward or p o s t e r i o r sacral torsions the s a c r u m either torsions ( o r rotates) right on the left axis or torsions ( o r rotates) left on the right axis. N o t i c e that w h e n the sacrum torsions R on L the right sacral base m o v e s posteriorly a n d w h e n the sacrum torsions L on R the left sacral base m o v e s posteriorly. N o w j u s t as the sacrum can torsion normally in these f o u r ways, it can

82

THE SACRUM also g e t stuck in any o n e of these ways. So if y o u f i n d a rotated s a c r u m when y o u r client is in neutral position, either seated or p r o n e , y o u can be pretty sure y o u are l o o k i n g at a dysfunctional sacrum. In the n e x t c h a p ter on the pelvis y o u will learn a n o t h e r test to d e t e r m i n e sacral dysfunction. It is called the sitting flexion test. But f o r the time b e i n g use rotation as y o u r guide. T h e n use the forward and back b e n d i n g tests to d e t e r m i n e whether o n e side is fixed anteriorly or posteriorly. If y o u discover that the sacral base is fixed anteriorly, it is dysfunctional a n d y o u have d i s c o v e r e d what is called an anterior sacral torsion. If the sacral base is fixed p o s t e riorly, it is called a posterior sacral torsion. L o o k o n c e again at the drawings of sacral torsion a n d n o t i c e that there are f o u r ways the sacrum can b e c o m e dysfunctional in torsion: 1) if the sacrum is t o r s i o n e d left on the left o b l i q u e axis (L on L) a n d the right sacral base is fixed anteriorly, 2) if the sacrum is torsioned right on the right o b l i q u e axis (R on R) and the left base is fixed anteriorly, 3) if the sacral base is t o r s i o n e d right on the left o b l i q u e axis (R on L) and the right sacral base is fixed posteriorly, and 4) if the sacral base is t o r s i o n e d left on the right o b l i q u e axis (L on R) and the left sacral base is posteriorly fixed.

Sacral Shear

T

HERE IS ONE LAST TYPE OF SACRAL DYSFUNCTION T H A T Y O U S H O U L D

k n o w a b o u t , called sacral shear. Shear o c c u r s w h e n two surfaces in

contact with each o t h e r slide on each o t h e r in a direction parallel to their plane of contact. Imagine putting two pieces of glass t o g e t h e r w h o s e sur-

faces are wet and pushing t h e m so that they slide on each other. Y o u have just created a shear. Sacral shear is m u c h less c o m m o n than torsion a n d its origin, as you probably guessed, is usually traumatic. Sometimes a sacral shear can result f r o m a long-standing l u m b a r lordosis or a rotoscoliosis in which the l u m b a r spine curves in o d d a n d u n e x p e c t e d ways. If y o u palpate only the sacral base, y o u c a n n o t distinguish shear f r o m torsion. You might be surprised to know, however, that the techniques y o u just l e a r n e d f o r releasing dysfunctional sacral torsions will also, by a n d large, release sacral shears, w h e t h e r y o u correctly distinguish t h e m f r o m torsions o r not. S o even i f y o u d o n o t k n o w the d i f f e r e n c e b e t w e e n shear and torsion, y o u c o u l d u n k n o w i n g l y release a sacral shear, thinking y o u 83

SPINAL MANIPULATION MADE SIMPLE

Figure 7.14

are releasing t o r s i o n . F o r the m o s t part, the very same t e c h n i q u e s y o u l e a r n e d to release torsion will also release shear. Since these techniques d o d o u b l e duty f o r t o r s i o n a n d shear, y o u c o u l d skip this discussion o f sacral shear a n d still do a lot of g o o d f o r y o u r clients. But there are s o m e i m p o r t a n t subtleties that can s o m e t i m e s m a k e a stunning d i f f e r e n c e in y o u r effectiveness in dealing with sacral dysfunctions. I will discuss o n e of these subtleties a little later, b e c a u s e it reveals why the m e r e mechanical application of t e c h n i q u e is n o t as effective as i n f o r m e d t o u c h . Figure 7.14 shows quite clearly h o w the facet of the sacrum fits into a facet on the innominate. T h e facets are shaped like a fat " L " or " C . " Notice h o w the wide variations in the shape a n d c o n t o u r of these facets are c o r related to types of spinal curvature. T h e s e drawings dramatically d e m o n strate that any attempt to reposition the sacrum is limited by these inherent shapes a n d u n d e r s c o r e s o n c e again the clinical priority of releasing j o i n t restrictions o v e r a t t e m p t i n g t o r e p o s i t i o n b o n y s e g m e n t s a c c o r d i n g t o s o m e external ideal. W h e n the sacrum is fixed in a shear the sacral base slips anteriorly or posteriorly a r o u n d a transverse axis on the facet of the innominate. W h e n

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y o u first palpate the sacral base in a

Transverse axis

s a c r u m that has g o t t e n stuck i n shear, y o u will think y o u are feeling r o t a t i o n , b e c a u s e o n e side o f the sacral base will be posterior a n d the o t h e r anterior. So y o u n e e d another r e f e r e n c e p o i n t o n the s a c r u m t o differentiate shear f r o m torsion. In o r d e r to distinguish the two, y o u palpate the right a n d left sides Left ILA

of the inferior lateral angle (ILA) of

Right ILA

the sacrum. Y o u can find the p o s t e rior aspect of the ILA by locating the

Sacral hiatus

sacral hiatus. Find the sacral hiatus

Figure 7.15

b y running o n e o f your f i n g e r s d o w n the c e n t e r of the s a c r u m a l o n g the

spinous processes until y o u r finger lands in the indentation of the sacral hiatus. F r o m the sacral hiatus m o v e y o u r thumbs laterally a b o u t o n e half to three quarters of an i n c h and y o u will land on the p o s t e r i o r ILA. T h e posterior ILA is the transverse process of S5 (Figure 7.15). Let y o u r thumbs slip inferiorly just ever so slightly so that they are resting on the inferior aspect of the ILA a n d use this aspect of the ILA as y o u r r e f e r e n c e p o i n t . Let's imagine that y o u find a sacrum in w h i c h the right base is posterior and the left is anterior. If the sacrum is t o r s i o n e d , the ILA's will foll o w the p a t t e r n o f the t o r s i o n a n d also b e p o s t e r i o r o n the r i g h t a n d anterior on the left. But if the sacrum is fixed in anterior shear, then the left sacral base will be anterior a n d the left ILA will be m o r e inferior a n d posterior than the right ILA. T h e left ILA also will be m o r e inferior than it is posterior. So in o r d e r to distinguish b e t w e e n shear a n d torsion, y o u should always palpate n o t just the sacral base, b u t also the ILA's. If the left sacral base is anterior a n d the left ILA is anterior a n d the right ILA is p o s terior, then y o u are l o o k i n g at a torsion. If the left sacral base is anterior and the left ILA is m o r e inferior a n d p o s t e r i o r than the right I L A ( a n d m o r e inferior than p o s t e r i o r ) , then y o u are l o o k i n g at a sacral shear. Anterior sacral shear is m u c h m o r e c o m m o n than posterior sacral shear. S o m e think that posterior sacral shear may be no m o r e than j u s t a t h e o 85

SPINAL MANIPULATION MADE SIMPLE

retical possibility, b u t I have f o u n d t h e m and k n o w they exist. So for examp l e , in a right p o s t e r i o r shear of the sacral base, the right sacral base is posterior a n d the left sacral base is anterior. T h e right ILA is m o r e superior a n d anterior than the left ILA a n d the right ILA will be m o r e superior than it is anterior. A sacrum fixed in anterior shear is called a unilateral sacral flexion or a unilateral anteriorly nutated s a c r u m , a n d a s a c r u m fixed in posterior s h e a r is c a l l e d a unilateral sacral e x t e n s i o n or a unilateral posteriorly nutated sacrum. But I p r e f e r to call these two fixations anterior and p o s terior shear of the sacral base. This way of n a m i n g shear is a bit clearer, I believe, in that it designates the fixation in the description and therefore immediately tells y o u w h e r e y o u n e e d to w o r k to facilitate a release. Y o u can call it what y o u will, of c o u r s e , b u t the critical question f o r y o u as the therapist is to d e t e r m i n e w h e t h e r the sacral base is f i x e d in anterior or p o s t e r i o r shear. First y o u palpate the sacral base. If y o u find that o n e side is posterior a n d the o t h e r is anterior, in o r d e r to differentiate shear and torsion y o u then palpate the I I A ' s . If palpation of the ILA's reveals shear, y o u r n e x t step is to d e t e r m i n e w h e t h e r the anterior base or the posterior base is the fixed side. Testing f o r w h e t h e r the sacral base is fixed in anterior or p o s terior shear is the same as testing f o r w h e t h e r the sacral base is f i x e d in Anterior shear

anterior or p o s t e r i o r sacral torsion. You forward and back b e n d your client and watch h o w the sacral base behaves. Let's l o o k at anterior sacral shear first (Figure 7.16). If the left sacral base is fixed in anterior sacral shear, the left sacral base will be anterior a n d the right sacral base will be posterior. T h e left ILA will be m o r e inferior a n d posterior than the right ILA, a n d the left I L A will b e m o r e

Left ILA inferior/ posterior

inferior than it is posterior. Put y o u r t h u m b s o n e a c h side o f the sacral

Figure 7.16

86

Right ILA superior/ anterior

THE SACRUM

base a n d watch what h a p p e n s in f o r w a r d a n d backward b e n d i n g . Since the left side is fixed in anterior shear, it will b e c o m e a fixed pivot p o i n t a r o u n d which the right sacral base will be f o r c e d to m o v e in f o r w a r d a n d backward bending. W h e n y o u forward b e n d your client her left sacral base will stay fixed anteriorly and the right sacral base will m o v e in a m o r e p o s terior direction making the difference between the two sides m o r e extreme. W h e n y o u backward b e n d y o u r client h e r left anterior base remains fixed anteriorly and h e r right sacral base m o v e s in a m o r e anterior d i r e c t i o n , making the difference b e t w e e n the two sides disappear. Let's l o o k at what h a p p e n s if y o u r client's right sacral base is fixed in posterior shear (Figure 7.17). Palpation will reveal that h e r left sacral base is anterior a n d her right sacral base is posterior. It will also s h o w that the right ILA is m o r e superior a n d anterior than the left ILA, a n d the right ILA is m o r e superior than it is anterior. In f o r w a r d a n d backward b e n d ing her right sacral base b e c o m e s the fixed pivot p o i n t a r o u n d w h i c h h e r left sacral base is f o r c e d to m o v e . W h e n y o u backward b e n d y o u r client, her right sacral base will stay in its posteriorly fixed position a n d h e r left sacral base will m o v e m o r e in an anterior d i r e c t i o n . As a result, the diff e r e n c e between h e r two sides will b e c o m e m o r e e x t r e m e . W h e n y o u forward b e n d y o u r client h e r right sacral base maintains its posteriorly fixed p o s i t i o n a n d h e r left sacral b a s e m o v e s in a m o r e posterior position, m a k i n g the d i f f e r e n c e b e t w e e n the two sides disappear. The forward and back bending test reveals w h e t h e r the sacral base is f i x e d anteriorly or posteriorly in exactly the s a m e way f o r b o t h torsion a n d shear. T h e r e f o r e , y o u can use the s a m e r u l e s w e f o r m u l a t e d for torsion to help y o u figure out Left ILA inferior/ posterior

Right ILA superior/ anterior

whether the sacral base is fixed anteriorly or posteriorly in sacral shear. T h u s , f o r e x a m p l e , if the p o s t e r i o r sacral base remains posterior while the a n t e r i o r side m o v e s anteriorly

Figure 7.17 87

SPINAL MANIPULATION MADE SIMPLE d u r i n g b a c k b e n d i n g , then the posterior side is fixed in posterior shear. If the anterior sacral base remains anterior while the posterior side moves anteriorly d u r i n g back b e n d i n g , then the anterior side is fixed in anterior shear.

The Rum pel stilts kin Effect F Y O U DO N O T PALPATE T H E ILA's, Y O U HAVE NO WAY TO D I S T I N G U I S H

b e t w e e n shear a n d torsion. T h e same is true if y o u only use the forward and backward b e n d i n g tests. Forward and backward b e n d i n g can only test f o r w h i c h side is fixed anteriorly or p o s t e r i o r l y — i t c a n n o t tell y o u all by itself w h e t h e r the anterior or posterior fixation it reveals g o e s with a torsion or a shear. Y o u must palpate the ILA's to d e t e r m i n e the difference. Interestingly e n o u g h the very same t e c h n i q u e s y o u l e a r n e d f o r releasing an anteriorly or posteriorly fixed sacral base in a torsion will also release an anteriorly or posteriorly fixed sacral base associated with shear. T h e u p s h o t of this discussion is a bit peculiar. If y o u o n l y palpate the sacral base a n d use the f o r w a r d a n d backward b e n d i n g tests without palpating the ILA's, and if y o u only use the j o i n t challenging techniques y o u learned f o r releasing sacral torsions, y o u will also be able to release sacral shear without b e i n g aware that it even exists. In practical terms, since the technique is pretty m u c h the same in b o t h cases, it might seem as though knowi n g h o w to differentiate shear f r o m torsion is unnecessary. S o y o u m i g h t b e w o n d e r i n g why b o t h e r l e a r n i n g h o w t o distinguish b e t w e e n shear a n d torsion in the first place? O n e answer is that a therapist s h o u l d j u s t k n o w these things. A n o t h e r answer is that o n c e y o u k n o w what these differences are y o u can a d d variations to y o u r techniques that will make t h e m m o r e effective in releasing shear. T h e last answer is harder to understand, b u t is probably the most significant. Knowing what y o u are releasing in a client's b o d y adds to y o u r clarity of p u r p o s e a n d actually makes y o u a m o r e effective therapist. If y o u k n o w what it is that n e e d s to c h a n g e , then the t e c h n i q u e s y o u apply will be m o r e effective than if y o u d o n ' t k n o w precisely what y o u are releasing. T h i s characteristic o f the somatic m a n u a l arts r e m i n d e d my wife of the psychotherapeutic setting w h e r e , metaphorically, y o u must n a m e y o u r d e m o n s if y o u want to get rid of t h e m . She calls this p h e n o m e n o n , " T h e Rumpelstiltskin Effect."

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THE SACRUM As strange as it may s o u n d , I am c o n v i n c e d that y o u r r e c o g n i t i o n of the fixation is m o r e than j u s t an intellectual a c c o m p l i s h m e n t that h a p p e n s to a c c o m p a n y y o u r a p p l i c a t i o n of a t e c h n i q u e — i t is actually an important part of the t e c h n i q u e itself. B e f o r e I knew h o w to tell the diff e r e n c e b e t w e e n shear a n d torsion, I h a d d e v e l o p e d the t e c h n i q u e s d e scribed in this chapter for releasing torsion. During the time I was reading about and trying to understand shear, I was working with a client w h o had what I believed was a posterior torsion in w h i c h the right base was p o s t e riorly fixed. For a n u m b e r of sessions I had applied my t e c h n i q u e f o r p o s terior torsion. I was able to give him s o m e relief from his pain, but I couldn't get rid of all of it. My client told me at the b e g i n n i n g a n d e n d of every session that even t h o u g h the o t h e r pains a r o u n d his low back area had g o n e away, the pain in his butt never went away. T h e pain he was c o m p l a i n i n g a b o u t was in close proximity to the right ILA. I n o w realize that it is c o m m o n for clients with sacral shear p r o b l e m s to c o m p l a i n of pain in the area of o n e of their ILA's, especially in weight bearing situations. W h e n I finally g o t clear about h o w to tell the difference between shear a n d torsion, I palpated my client's ILA's and discovered that he had a right posterior sacral shear. A d d i n g this r e c o g n i t i o n — t h a t his sacrum was actually in posterior shear, n o t posterior t o r s i o n — t o the very same t e c h n i q u e I had used w h e n I believed his sacrum was posteriorly t o r s i o n e d fully released his sacrum for the first time. A n d f o r the first time the pain in the right side of his buttocks disappeared. This e x a m p l e is n o t an isolated case. My e x p e r i e n c e a n d the e x p e r i e n c e of my friends and colleagues has shown us o v e r a n d over again that knowing and n a m i n g what y o u are working on is an essential part of effective therapy. I have a l o t of ideas a b o u t why this is so a n d c o u l d lay o u t what I think is a rather interesting t h e o r y a b o u t what is h a p p e n i n g . But it w o u l d require a rather lengthy philosophical discussion that w o u l d take us well b e y o n d the s c o p e of this manual. If y o u r u n d e r s t a n d i n g is stimulated by poetry, y o u m i g h t appreciate h o w a line f r o m the great p o e t , Stefan G e o r g e , explains h o w p r o f o u n d l y o u r lives can be i n f l u e n c e d by n o t knowing the n a m e o f s o m e t h i n g : " W h e r e the n a m e breaks off, n o thing may b e . " In any case, my observation is very easy to test a n d w o u l d m a k e f o r an interesting study in somatic manual therapy. Find 20 e x p e r i e n c e d thera89

SPINAL MANIPULATION MADE SIMPLE

pists a n d 20 patients with sacral shear. T e a c h 10 therapists h o w to r e c o g nize a n d treat f o r sacral torsion only, teach the o t h e r 10 therapists h o w to treat a n d r e c o g n i z e the d i f f e r e n c e b e t w e e n shear and torsion, and make sure b o t h g r o u p s of therapists learn the same t e c h n i q u e f o r releasing an anterior a n d p o s t e r i o r sacral base. T h e n turn t h e m l o o s e on the patients a n d see what h a p p e n s . T h e most important c o n c l u s i o n f o r y o u as a therapist to draw f r o m this discussion is that the clearer y o u are a b o u t what y o u are w o r k i n g on the m o r e effective y o u will b e c o m e . In terms of the techniques y o u learn from this b o o k , y o u will find that the simple indirect a n d shotgun techniques are less effective f o r the reasons already given earlier, b u t also b e c a u s e they d o n ' t d e m a n d the same level of k n o w l e d g e as the t e c h n i q u e s that are specific to the j o i n t fixation. I i n t r o d u c e d these simple techniques first as a p e d a g o g i c a l device. T h e i r simplicity is d e s i g n e d to give y o u a kind of palpatory understanding that prepares the way and makes it easier understanding the m o r e c o m p l i c a t e d b i o m e c h a n i c a l descriptions. If a therapist is m o r e i n c l i n e d to use these simple indirect and shotgun techniques, it usually means that he d o e s n ' t fully grasp the biomechanical descriptions a n d h o w t o m o r e precisely locate the j o i n t f i x a t i o n . T h e b i o m e c h a n i c a l descriptions are important to y o u r grasp of your client's p r o b l e m . If a therapist d o e s n ' t have this u n d e r s t a n d i n g , he w o n ' t fully grasp the p r o b l e m in his client's body. As a result he w o n ' t have the same clarity of p u r p o s e as the therapist w h o is oriented toward the specifics of the j o i n t fixation—and without this clarity of p u r p o s e , his application of technique will be less effective. If a therapist knows h o w to locate the j o i n t fixation, she will c h o o s e the t e c h n i q u e that specifically addresses the p r o b l e m , because the other m e t h o d is inefficient and time consuming. But the exper i e n c e d therapist also picks the m o r e specific a p p r o a c h because at s o m e level she understands the Rumpelstiltskin effect and h o w powerful clarity of p u r p o s e is f o r effective therapy. This understanding also constitutes part of what I d e s c r i b e d in the i n t r o d u c t i o n as the healer's way of being.

Variations on Technique EFORE W E C O N C L U D E T H I S C H A P T E R O N T H E S A C R U M , I W A N T T O PRESENT

s o m e variations on the t e c h n i q u e s that y o u l e a r n e d f o r anterior and

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THE SACRUM posterior torsion that make t h e m m o r e specific to anterior a n d p o s t e r i o r shear. T h e idea is to help you b e c o m e m o r e specific and h e n c e m o r e effective in y o u r a p p r o a c h to anterior a n d p o s t e r i o r shear. Y o u may want to refer to the drawings of the sacrum in anterior and posterior shear ( 7 . 1 6 7.17) as y o u read t h r o u g h these variations Recall the technique f o r manipulating a torsioned sacrum with an anteriorly f i x e d sacral base. Y o u f o r w a r d b e n d y o u r client, p u t y o u r t h u m b s on each side of the sacral base, apply pressure in an inferior d i r e c t i o n to the anteriorly fixed base, wait f o r the d a n c e of the tissues, a n d then the release. R e m e m b e r that y o u can further a d d to y o u r effectiveness if y o u also a d d s o m e pressure in an i n f e r i o r / a n t e r i o r d i r e c t i o n to the o p p o s i t e sacral base or in an anterior direction to the o p p o s i t e ILA as a way to lever the anteriorly fixed base in a posterior direction. N o w for the sake of c o m p a r i s o n let's say y o u find a sacral shear in which the left sacral base is fixed anteriorly. Y o u can use pretty m u c h the same t e c h n i q u e : ask y o u r client to forward b e n d a n d apply pressure in an inferior direction to the left sacral base (Figure 7.18). Y o u can also apply s o m e

Figure 7.18 91

SPINAL MANIPULATION MADE SIMPLE

Figure

7.19

anterior pressure to the right sacral base to lever the anterior fixed side in a p o s t e r i o r d i r e c t i o n . But make sure y o u d o n ' t use the o t h e r variation f o r anterior torsion in w h i c h y o u apply anterior pressure to the right ILA. It works f o r left anterior torsion b e c a u s e the right ILA is p o s i t i o n e d posteriorly. But it w o n ' t w o r k f o r left anterior shear, because the right ILA is p o s i t i o n e d superiorly a n d anteriorly. Instead, y o u c o u l d a d d to y o u r effectiveness by applying pressure to the right ILA in an inferior direction, as in Figure 7.19, where the client is lying on a d o u b l e d - u p pillow. Or you c o u l d a d d to y o u r effectiveness by w o r k i n g with the left ILA. Since the left ILA is p o s i t i o n e d inferiorly a n d posteriorly, y o u can facilitate the release of the left sacral base by applying pressure to the left ILA in a superior and a n t e r i o r d i r e c t i o n . S o , f o r e x a m p l e , with y o u r client in a f o r w a r d b e n t position (in Figure 7.20 the client is again lying on a d o u b l e d - u p p i l l o w ) , y o u can p u t o n e t h u m b on the left sacral base a n d the o t h e r on the left ILA. W i t h y o u r t h u m b s p o s i t i o n e d in this way y o u can r o c k the left side of the s a c r u m o u t of its anterior fixation. Alternately push inferiorly on the left sacral base, a n d superiorly a n d anteriorly on the left ILA. R o c k

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THE SACRUM

the left side of the s a c r u m in this way in a c o n t i n u o u s easy m o t i o n , stop, and then apply appropriate pressure to either the left base or the left I L A a n d wait f o r the d a n c e a n d release. Recall h o w y o u m a n i p ulate a t o r s i o n e d s a c r u m with

a posteriorly fixed

sacral base. Y o u b a c k b e n d y o u r client, apply pressure in an anterior d i r e c t i o n to the posteriorly f i x e d base, wait f o r the d a n c e , a n d then the release. For c o m p a r i s o n , let's s u p p o s e y o u find a sacrum fixed in right

Figure 7.20

posterior shear. Y o u can o f c o u r s e use the s a m e t e c h -

n i q u e for posterior shear that y o u used f o r p o s t e r i o r torsion. Or y o u can further your effectiveness by a d d i n g s o m e pressure to the right ILA. Since the right ILA is positioned superiorly and anteriorly, y o u c o u l d push superiorly on the right ILA while y o u c o u l d push anteriorly on the right p o s teriorly fixed sacral base (Figure 7.21, page 9 4 ) . Or y o u can put o n e t h u m b on the right posteriorly fixed sacral base a n d the h e e l of y o u r o t h e r h a n d on the left ILA. Since the left ILA is p o s i t i o n e d superiorly a n d posteriorly, y o u c o u l d push anteriorly a n d inferiorly on the left ILA while y o u push anteriorly on the right sacral base (Figure 7.22). O n c e y o u have a clear u n d e r s t a n d i n g of the type of fixation y o u are dealing with a n d the ways the s a c r u m c a n b e p o s i t i o n e d , t h e n y o u can make up y o u r o w n t e c h n i q u e s and variations. In this chapter y o u l e a r n e d h o w to r e c o g n i z e a n d manipulate sacroiliac dysfunctions that were caused by eight different sacral fixations. In the next y o u will learn h o w to r e c o g n i z e and release fixations that are created by the pelvis. 93

SPINAL MANIPULATION MADE SIMPLE

Figure

7.21

Figure

7.22

94

CHAPTER

8

The Pelvis H E SACRUM A N D T H E PELVIS A R E S O CLOSELY T I E D T O G E T H E R T H A T

w h e n they exist freely in their natural state of c o o p e r a t i v e i n d e p e n d e n c e life can b e grand. But w h e n o n e o r the o t h e r interferes with n o r m a l m o t i o n , pain a n d misery can d e s c e n d quickly, like a black c l o u d c a p a b l e o f o b s c u r i n g even the best o f o u r s h i n i n g m o m e n t s . Y o u already know the ways the sacrum can create painful p r o b l e m s in this area. T h e influence of the pelvis on the sacroiliac (SI) j o i n t can be just as p r o b lematic. Knowing h o w to recognize and treat the many dysfunctions caused by the pelvis is extremely i m p o r t a n t if y o u want to be able to resolve y o u r client's low back pain. If you do a great j o b of releasing your client's sacrum, but do n o t take care of its interaction with the pelvis, m u c h of y o u r w o r k will be in vain. If y o u do n o t release iliosacral (pelvis on sacrum) fixations, it will n o t be l o n g b e f o r e most, if n o t all, of y o u r client's pain returns. Like every area of the b o d y y o u d e c i d e to study, the pelvic area is very c o m p l i c a t e d a n d i n t e r c o n n e c t e d to the rest of the body. In this c h a p t e r y o u will be learning primarily a b o u t j o i n t dysfunction, b u t y o u also want t o a p p r e c i a t e the i n t i m a t e c o n n e c t i o n s that exist b e t w e e n t h e pelvis, sacrum, spine, and the rest of the body. W h e n y o u study Figure 8.1, p a g e 96, showing the iliosacral and sacroiliac ligaments, y o u can clearly see h o w tightly c o n n e c t e d the pelvis, sacrum, L4, a n d L5 are. W h e n e v e r y o u w o r k on any of these structures, r e m e m b e r h o w they are c o n n e c t e d and be certain that y o u have released all the associated restrictions. As y o u are a b o u t 95

SPINAL MANIPULATION MADE SIMPLE

1 Superior band of the iliolumbar ligament 2 Inferior band of the iliolumbar ligament 3 3 & 4 Intermediate plane of the sacroiliac 4

5

ligaments 6 Anterior plane of the sacroiliac ligaments

6

1

7

2

8&9 Anterior sacroiliac ligament

8 9

7 Sacrotuburous ligament 7 6 Sacrospinous ligament 6

Figure 8.1

to learn, the pelvis can cause p r o b l e m s in three ways. Any o n e or c o m b i nation of these patterns of pelvic dysfunction will also strain the ligaments a n d create further dysfunction in the low back and sacrum. Be aware that the i l i o l u m b a r , s a c r o s p i n o u s , a n d s a c r o t u b e r o u s ligam e n t s are t h r e e very i m p o r t a n t l i g a m e n t s in this area. A l o n g with the pelvic rotaters (especially the piriformis) and the psoas, they must be capable of adapting to your manipulations in order to create l o n g lasting change f o r y o u r clients. Y o u probably already have y o u r favorite ways of releasing these muscles a n d ligaments. Make sure y o u address t h e m either b e f o r e or after releasing all sacroiliac or iliosacral fixations. L i g a m e n t o u s structures are clearly i m p o r t a n t f o r p r o p e r j o i n t f u n c tion, b u t so is overall b o d y structure and posture. T h e alignment of y o u r b o d y in gravity can p r o f o u n d l y affect h o w y o u r pelvis is p o s i t i o n e d and this in turn can d e t e r m i n e h o w well y o u r j o i n t s f u n c t i o n . T h e drawings in Figure 8.2 represent f o u r ways the pelvis can be positioned with respect to the entire body. " Tilt" refers to the anterior or posterior torsioning of the entire pelvis a r o u n d a transverse axis that runs t h r o u g h the inferior a s p e c t o f the sacroiliac j o i n t . "Shift" refers t o the a n t e r i o r o r p o s t e r i o r

96

THE PELVIS

Figure 8.2

Posterior Tilt Posterior Tilt Anterior Tilt Anterior Tilt Posterior Shift Anterior Shift Anterior Shift Posterior Shift TILT occurs as an anterior or posterior torsioning of the entire pelvis around a transverse axis that runs through the inferior aspect of the sacroiliac joint. S H I R occurs as an anterior or posterior translation of the entire pelvis along the transverse plane.

translation o f the entire pelvis a l o n g the transverse p l a n e . T h e c u r v e d arrows represent tilt and the straight arrows indicate shift. T h e difference b e t w e e n tilt a n d shift was first r e c o g n i z e d by Jan Sultan a n d is part of a brilliant typology he d e v e l o p e d f o r identifying c o m m o n structural types and their associated myofascial strain a n d gait patterns. His u n d e r s t a n d ing of tilt/shift was further refined by Swiss Rolfer, Dr. Hans Flury. Many myofascial structures c o n t r i b u t e to these overall patterns. F o r e x a m p l e , a posteriorly tilted pelvis is often tied to tight, short hamstrings while an anteriorly tilted pelvis is often tied to tight, short quadriceps. These postural issues are also often associated with typical sacral dysfunctions. W h e n the sacrum gets stuck bilaterally in posterior nutation it often drags the lumbars with it, especially L4 and L5. As it turns out, a p e r s o n w h o s e pelvis inclines toward posterior tilt will m o r e likely show bilateral posterior nutation fixations of the sacrum than a p e r s o n with an anterior pelvis. N o t recognizing the difference between tilt a n d shift has mislead many 97

SPINAL MANIPULATION MADE SIMPLE

therapists in their evaluations of clients' overall alignment. W h e n a client's pelvis is p o s t e r i o r l y tilted, b u t shows an a n t e r i o r shift well b e y o n d the mid-sagittal axis, it is c o m m o n to misread this pattern as a lordosis or a swayback. As the pelvis shifts anteriorly, the thorax shifts posteriorly givi n g the p e r s o n the a p p e a r a n c e of falling backward. But if y o u l o o k carefully, y o u will often see a l u m b a r spine that is actually lacking an appropriate lordosis. T h e illusion of a swayback is created by an anterior shift of the pelvis. Figure 8.3 is f r o m Kendall and McCreary's Muscles: Testing and Function a n d is a clear case of an anteriorly shifted pelvis 1

with a posterior tilt. N o t i c e that this person's lumbar spine is actually rather flat and displays very little lordotic curve. A l t h o u g h this e x a m p l e is n o t e x t r e m e , clearly Kendall and M c C r e a r y are misled by the anterior shift of a posteriorly tilted pelvis a n d wrongly describe this p e r s o n as having a swayback p o s t u r e . T h i s pattern of the a n t e r i o r shift of a posteriorly tilted pelvis can b e slight f o r o n e p e r s o n a n d very e x t r e m e in another, b u t in most cases y o u will see that the l o r d o t i c c u r v e is lacking to s o m e d e g r e e . A l t h o u g h dealing with these many a n d varied postural issues is well b e y o n d the s c o p e of this m a n u a l , s o m e discussion is helpful. It serves to r e m i n d y o u of the of i m p o r tance of always trying to understand h o w local fixations are Figure 8.3

intimately related to w h o l e b o d y structure a n d gravity. In a very real sense, y o u can never work on any local area of the b o d y without b e i n g in contact with the whole b o d y and

its c o m p l i c a t e d network of c o m p e n s a t i o n s . If a local c h a n g e is i n t r o d u c e d i n t o a b o d y without taking a c c o u n t of its network of c o m p e n s a t i o n s and p o s t u r a l habits, t h e n typically the b o d y will n o t be able to sustain the c h a n g e . If it c a n n o t adapt above or s u p p o r t the c h a n g e below, then either the b o d y will return to its original dysfunction or d e v e l o p strain and dysfunction elsewhere—or both.

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Testing and Palpating for Iliosacral Dysfunction E T ' S LEAVE T H E S E L A R G E R ISSUES A N D T U R N O U R A T T E N T I O N T O T H E

specifics of h o w the pelvis creates j o i n t fixations. T h e three ways the pelvis can create dysfunction are t o r s i o n , flare, a n d shear. First y o u will learn what these patterns are and then you will learn h o w to test and release them. You have already encountered pelvic torsion in the last chapter where I d e s c r i b e d the vermicular u n d u l a t i o n of the spine d u r i n g walking. Y o u may recall h o w n o r m a l walking requires that each i n n o m i n a t e rotate ( o r torsion) anteriorly and posteriorly in response to h o w each leg moves f r o m heel strike to toe off. Torsion of the i n n o m i n a t e s o c c u r s a r o u n d a transverse axis that runs t h r o u g h the inferior aspect of the sacroiliac j o i n t . Just as it is possible for the innominates to torsion normally, it is also possible for o n e of t h e m to get stuck in either anterior or posterior torsion. Flare of the i n n o m i n a t e can o c c u r as either out-flare or in-flare. W h e n out-flared, the ilium rotates laterally, or away f r o m the mid-sagittal axis as the ischial tuberosity rotates medially, or toward the mid-sagittal axis. Inflare behaves in the o p p o s i t e fashion: the ilium rotates medially toward the mid-sagittal axis and the tuberosity rotates away f r o m the mid-sagittal axis. Shear is a just a bit m o r e c o m p l i c a t e d , because it can o c c u r in two distinct ways, either as a n t e r i o r / p o s t e r i o r shear or s u p e r i o r / i n f e r i o r shear. In s u p e r i o r / i n f e r i o r shear, also k n o w n as up-slip a n d down-slip, o n e of the innominates either slips upward on the sacrum in relation to the o t h e r i n n o m i n a t e or it slips downward. In a n t e r i o r / p o s t e r i o r ( A / P ) shear, o n e of the innominates either slips anteriorly in relation to the o t h e r i n n o m inates or it slips posteriorly. Y o u c o u l d reasonably call A / P shear anterior and posterior slip. Y o u are p r o b a b l y w o n d e r i n g h o w y o u d e t e r m i n e w h e t h e r a c l i e n t is manifesting o n e of these iliosacral fixations a n d , if she is, h o w y o u tell whether the i n n o m i n a t e is fixed anteriorly or posteriorly or inferiorly or superiorly. As y o u m i g h t have guessed, the osteopaths have created s o m e rather simple tests to h e l p y o u answer these questions. T h e first test f o r d e t e r m i n i n g iliosacral d y s f u n c t i o n is the s t a n d i n g flexion test. To p e r f o r m it y o u n e e d to place y o u r thumbs on the inferior 99

SPINAL MANIPULATION MADE SIMPLE

Iliac crests at level of L4

Sacral sulcus

Sacral base Median sacral crest

Inferior slope of PSIS

Inferior lateral angle

Ischial tuberosity

Figure 8.4

slopes of the p o s t e r i o r s u p e r i o r iliac spines (PSIS), illustrated in Figure 8.4. Y o u can find the PSIS by l o o k i n g f o r the d i m p l e s most p e o p l e have in this area, l o c a t e d a b o u t two inches lateral to the lumbosacral j u n c t i o n . By p l a c i n g the pads of y o u r thumbs over t h e m y o u will find the most p o s terior aspect of the PSIS. Drag y o u r thumbs in an inferior direction until y o u find the inferior slopes of the PSIS. Y o u will k n o w y o u are there when y o u feel y o u r thumbs just b e g i n to slide off the inferior aspect of the PSIS. With y o u r client standing, place the pads of y o u r thumbs on the inferior s l o p e of the PSIS a n d ask h i m to b e n d forward as far as he c o m f o r t ably c a n . W a t c h what h a p p e n s to y o u r t h u m b s . If there is an iliosacral fixation, o n e of y o u r t h u m b s will ride up in a superior direction and the o t h e r o n e will stay w h e r e it is. T h e side on w h i c h the t h u m b rides up is the fixed side. Figure 8.5 shows the restriction on the right side. This test works quite well, unless the hamstrings or the quadratus l u m b o r u m are asymmetrically tight. If the hamstrings are tight on the side o p p o s i t e to w h e r e y o u r t h u m b rides u p , or if the quadratus l u m b o r u m is tight on the same side as w h e r e y o u r t h u m b rides u p , the superior m o v e m e n t of y o u r t h u m b will n o t be a true indicator. T h e standing flexion test will n o t tell y o u w h e t h e r o n e i n n o m i n a t e is

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THE PELVIS

Figure 8.5

Figure 8.6

in-flared o r out-flared, w h e t h e r o n e i n n o m i n a t e i s u p - s l i p p e d o r d o w n slipped, whether o n e is anteriorly slipped or posteriorly slipped, or whether o n e is posteriorly torsioned or anteriorly torsioned. T h e tests will only tell y o u the side on which the i n n o m i n a t e is fixed on the sacrum. In o r d e r to tell what kind of iliosacral fixation y o u are l o o k i n g at y o u must palpate a n u m b e r of o t h e r areas on the pelvis, a t e c h n i q u e that will be d e s c r i b e d shortly. For now, j u s t practice the standing flexion test a n d n o t i c e what h a p p e n s to y o u r thumbs. N o w that y o u have l e a r n e d h o w to use this test to d e t e r m i n e iliosacral dysfunction, y o u can use the sitting version of it to h e l p y o u d e t e r m i n e unilateral sacroiliac fixations. Ask y o u r client to assume a seated position, o n c e again place the pads of your thumbs on the inferior slope of the PSIS, and ask him to forward b e n d as far as he c o m f o r t a b l y can. If o n e of y o u r thumbs rides superiorly, as it d o e s in Figure 8.6, y o u have d i s c o v e r e d a sacroiliac fixation. Like the standing flexion test, the sitting flexion test only tells y o u on w h i c h the side the sacral fixation exists, it d o e s n ' t tell whether it is fixed in anterior/posterior torsion or anterior/posterior shear. 101

SPINAL MANIPULATION MADE SIMPLE

T h e sitting flexion test effectively r e m o v e s the i n f l u e n c e o f y o u r client's legs and pelvis on the sacrum and theref o r e allows y o u t o d e t e r m i n e w h e t h e r sacroiliac fixations are present. In c o n trast, the standing flexion test adds the influence of the pelvis and legs, and lets y o u d e t e r m i n e w h e t h e r iliosacral f i x a tions are p r e s e n t . If y o u r t h u m b rides up in b o t h the sitting and standing flexi o n tests, t h e n y o u have d i s c o v e r e d a s a c r o i l i a c a n d iliosacral d y s f u n c t i o n . K n o w i n g h o w to use these tests is h e l p ful to sorting o u t what kind of fixations are present. Often you may be working with clients w h o s e low back p r o b l e m s create t o o Figure 8.7

m u c h p a i n w h e n they try t o f o r w a r d b e n d f r o m a standing position. In these

cases, a n d as a way to d o u b l e c h e c k y o u r results, the so-called stork test is also very useful. Ask y o u r client to stand facing a wall so he can stabilize himself while p e r f o r m i n g the test. Put the pad of your right t h u m b on the posterior aspect of his right PSIS and y o u r left t h u m b at the same level on the m e d i a n sacral crest, which is basically the mid-line of the sacrum. Ask y o u r client to raise his k n e e to at least 90 d e g r e e s a n d watch what y o u r right t h u m b d o e s (Figure 8.7). If there is no iliosacral fixation, y o u r right t h u m b will r i d e inferiorly as he raises his l e g a n d y o u r left t h u m b will remain where it is. If there is a fixation, then y o u r right t h u m b will remain w h e r e it is a n d n o t m o v e inferiorly. Test the o t h e r side in the same way. Place y o u r left t h u m b on the p o s t e r i o r aspect of his left PSIS a n d y o u r right t h u m b at the same level on the m e d i a l sacral crest, ask h i m to raise his k n e e to at least 90 d e g r e e s , a n d watch h o w y o u r left t h u m b responds. If it d o e s n ' t m o v e inferiorly, y o u have discovered an iliosacral fixation. If either the standing flexion or the stork test reveals an iliosacral fixation, the n e x t part of y o u r evaluation requires y o u to figure o u t by means of palpation w h e t h e r y o u are dealing with flare, shear, torsion, or a cora-

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bination of s o m e or all of t h e m . Let's take a simplified l o o k at an e x a m ple. Suppose you find an iliosacral fixation on the right by using the standing flexion test, and you palpate the innominates to discover that the right i n n o m i n a t e seems out-flared a n d the left seems in-flared. If y o u had palpated the i n n o m i n a t e s without having p e r f o r m e d the standing f l e x i o n test, it w o u l d be very difficult f o r y o u to be able to say w h e t h e r the right i n n o m i n a t e was out-flared or the left i n n o m i n a t e was in-flared. But since y o u p e r f o r m e d the standing flexion test a n d it revealed that the fixation was o n the right, y o u c a n c o n c l u d e that the right i n n o m i n a t e m u s t b e fixed in an out-flared position. So h e r e is h o w it works: first y o u d e t e r m i n e the side on which the fixation is present; then y o u palpate to d e t e r m i n e whether the iliosacral fixation is an in-flare or out-flare, an anterior or p o s terior shear, an up-slip or down-slip, an anterior or p o s t e r i o r torsion, or some combination.

Palpating for In-flare/Out-flare Let's l o o k m o r e carefully a t w h e r e a n d h o w y o u palpate f o r e a c h o f these c o n d i t i o n s . We will b e g i n with palpating f o r in-flare a n d out-flare. Find the anterior superior iliac spine (ASIS) (Figure 8.8) with y o u r client in a supine position. T h e easiest way to do this is to first place y o u r palms over the ASIS to locate it a n d n o t i c e h o w the shape of this area feels to y o u r t o u c h . T h e n p l a c e the p a d s o f y o u r thumbs on the medial infer i o r e d g e o f e a c h ASIS. N e x t draw an imaginary line d o w n the center of your client's b o d y to r e p r e s e n t the mid-sagittal axis. On most p e o p l e the navel is on this c e n t e r line. T h e n c o m p a r e

Inferior s l o p e of ASIS

h o w far each t h u m b is f r o m this center line. If the t h u m b on the right ASIS s e e m s c l o s e r t o the m i d l i n e than the left, t h e n y o u

Left pube

are p r o b a b l y l o o k i n g at an u n i lateral in-flare or out-flare. If the standing flexion test or the stork

Figure 8.8 103

Ischial tuberosity

SPINAL MANIPULATION MADE SIMPLE test reveals a fixation on the right, then y o u have d i s c o v e r e d a right inflare. If the tests show that the fixation is on the left, then y o u have f o u n d a left out-flare.

Palpating for Up-slip/Down-slip (Superior/Inferior Shear) Shear is most often the result of trauma and although down-slips do occur, they are very rare. W h e n o n e d o e s o c c u r it is usually c o r r e c t e d by walking. So if y o u r palpation reveals o n e i n n o m i n a t e that seems inferior and o n e that seems superior, y o u can pretty m u c h be assured that you are looki n g at up-slip. B e g i n y o u r palpation s e q u e n c e with y o u r client in a p r o n e position. Be sure that y o u r thumbs are always p l a c e d on exactly the same level. Place the pads o f y o u r t h u m b s o n e a c h o f the ischial tuberosities and c o m p a r e their relative positions to o n e another. D o e s o n e seem superior a n d the o t h e r inferior? If so, a n d the standing flexion and stork tests s h o w a fixation on the same side as the superior tuberosity, then you have p r o b a b l y discovered an up-slip. T h e position of the tuberosities is a fairly reliable indicator, b u t y o u can b e m i s l e d u n d e r certain circumstances. Sometimes what appears to be an up-slip is the result of curvature in which the l u m b a r s p i n e s i d e b e n d s to the same side as the a p p a r e n t up-slip. A T y p e I g r o u p curvature with a right s i d e b e n d i n g , f o r e x a m p l e , will make the right i n n o m i n a t e s e e m m o r e superior than the left. N e x t palpate the PSIS's f o r their relative s u p e r i o r / i n f e r i o r positions and then roll y o u r client over and palpate the ASIS's. If the ASIS and PSIS o f o n e o f the i n n o m i n a t e s are b o t h superior, then y o u are probably l o o k i n g at an up-slip. Ask y o u r client to return to a p r o n e position and c h e c k the s a c r o t u b e r o u s ligaments. To find these ligaments, place y o u r thumbs b e t w e e n the a p e x of the s a c r u m a n d the ischial tuberosities. T h e sacrot u b e r o u s ligament will be lax on the same side as the up-slip a n d tight on the same side as the down-slip. Ask y o u r client to turn over again and in a s u p i n e p o s i t i o n palpate the s u p e r i o r e d g e s of the p u b e s to see if they s e e m s u p e r i o r a n d i n f e r i o r with respect to e a c h other. Lastly c h e c k the inguinal ligaments f o r t e n d e r n e s s . T h e inguinal l i g a m e n t will likely be t e n d e r on the same side as shear: if it's a right up-slip, it will be tender on the right, a n d if it's a left down-slip, t e n d e r on the left. Be aware that tenderness is a less reliable i n d i c a t o r than position. If the standing flexion a n d stork tests reveal a fixation on the right and all palpatory indicators

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THE PELVIS show the right side superior in relation to the left, y o u have d i s c o v e r e d a right up-slip.

Palpating for Anterior/Posterior Shear With y o u r client in a supine p o s i t i o n p l a c e the p a d s of y o u r t h u m b s on the most anterior aspect of each p u b e and evaluate for whether o n e seems anterior a n d the o t h e r posterior. If the standing f l e x i o n a n d stork tests reveals a fixation on the right and the right p u b e is anterior, then the right innominate is fixed in anterior shear. If the tests reveal the fixation on the left, then the left i n n o m i n a t e is fixed in posterior shear.

Palpating for Anterior/Posterior Torsion I left torsion f o r last because of all the f o r m s of dysfunction we have discussed, it is usually the least likely type of pelvic dysfunction. S o , I suggest that in your palpation s e q u e n c e y o u also save torsion f o r last. If y o u find a shear or flare fixation c o r r e c t t h e m first b e f o r e y o u even palpate f o r torsion. A l m o s t everybody's i n n o m i n a t e s torsion in the same way. T h e n o r mal a n d e x p e c t e d pattern y o u will see o v e r a n d o v e r again is the right i n n o m i n a t e t o r s i o n e d anteriorly a n d the left posteriorly. If y o u find the o p p o s i t e situation y o u may be l o o k i n g at trauma, or a s o c c e r player w h o kicks with his left foot. If the standing flexion test and the stork tests reveal an iliosacral fixation and y o u palpate torsion first y o u will predictably find the right i n n o m i n a t e t o r s i o n e d anteriorly a n d the left posteriorly. M o r e than likely the torsion is n o r m a l a n d the fixation the test revealed is d u e to shear or flare. So y o u r best b e t is to palpate f o r shear a n d flare first, c o r r e c t what y o u find, a n d p e r f o r m the standing flexion a n d stork tests to c h e c k y o u r results. If the fixation is no l o n g e r present, there is no n e e d to b o t h e r yourself with palpating f o r torsion. If the fixation persists after correcting shear and flare, then c o r r e c t f o r torsion. But if y o u palpate f o r torsion b e f o r e you paipate f o r flare or shear, y o u may be mislead into c o r recting a torsion fixation w h e n n o n e is present. Palpate f o r t o r s i o n with y o u r client in a s u p i n e p o s i t i o n . Place y o u r thumbs on the ASIS's and c o m p a r e their relative positions to o n e another. D o e s o n e i n n o m i n a t e s e e m t o r s i o n e d anteriorly a n d the o t h e r posteriorly? Let's assume that either y o u have already released flare or shear dysfunctions or n o n e are present. If the standing flexion and stork tests show 105

SPINAL MANIPULATION MADE SIMPLE a fixation on the right a n d the right i n n o m i n a t e is t o r s i o n e d anteriorly, then the right i n n o m i n a t e is fixed in anterior torsion. If y o u discover the fixation on the left a n d the left i n n o m i n a t e is t o r s i o n e d posteriorly, then the left i n n o m i n a t e is fixed in posterior torsion. I have never w o r k e d with a client w h o s h o w e d all three iliosacral fixations at o n c e , b u t I believe it is possible. O f t e n , however, y o u will find a c o m b i n a t i o n o f two o f these f i x a t i o n s . D e p e n d i n g o n the uniqueness o f e a c h client's body, s o m e t i m e s it is very easy to palpate these patterns and o t h e r times it is m o r e difficult. D o n ' t be d i s c o u r a g e d if at first y o u are n o t quite sure what pattern y o u l o o k i n g at. If y o u are n o t certain, c o r r e c t f o r what y o u think the p r o b l e m is a n d retest. T h e t e c h n i q u e s d e s c r i b e d in this b o o k f o r releasing iliosacral fixations are gentle e n o u g h that they will n o t cause h a r m i f y o u misread the p o s i t i o n o f the i n n o m i n a t e a n d c o r rect f o r a p r o b l e m that is n o t present. If the standing flexion a n d stork tests s h o w a fixation a n d y o u are u n c l e a r f r o m palpation whether y o u are l o o k i n g at shear or flare, c o r r e c t f o r b o t h on the side on which the fixation shows u p . For instance, c o r r e c t f o r shear a n d then retest and, If the test is negative y o u k n o w the p r o b l e m was shear. If the test is still positive, c o r r e c t f o r flare a n d retest again. Always palpate b e f o r e and after m a n i p ulation so that y o u learn to see and feel subtle but important differences. A n d in time y o u will learn to see a n d feel m o r e and m o r e subtle patterns.

Techniques for Pelvis-on-Sacrum Dysfunctions

A

L L O F T H E T E C H N I Q U E S Y O U ARE A B O U T T O LEARN W O R K BEST I F Y O U

free up all the associated soft tissues a n d ligaments in this area. For

e x a m p l e , be sure that the hamstrings, gluteals, rotators, psoas, quadratus

l u m b o r u m , e r r e c t o r s , a n d ligaments are b a l a n c e d a n d free e n o u g h f o r y o u r client's pelvis to a c c e p t pelvic manipulations.

Out-flare Put y o u r client in a supine position. On the out-flared side bring o n e of y o u r client's knees up ( f o o t flat on the table). Sit on the same side of the table as the out-flare. Place the fingers of o n e h a n d on the medial surface of the ischial tuberosity a n d the h e e l of the o t h e r h a n d on the ilium with fingers w r a p p e d a r o u n d the ASIS (Figures 8.9 and 8.10). Gently but firmly

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Figure 8.9

Figure 8.10 107

SPINAL MANIPULATION MADE SIMPLE

traction the tuberosity laterally while p u s h i n g the ilium medially a n d wait. Either the i n n o m i n a t e will release its restriction by g o i n g t h r o u g h a d a n c e or by moving directly to its normal position. This technique was created by Jan Sultan.

In-flare Place y o u r client in a supine position a n d stand on the o p p o s i t e side of the table f r o m the in-flare. A s s h o w n i n Figure 8.11, reach across to the k n e e o f the in-flared side. B e n d the k n e e , h o o k y o u r a r m u n d e r n e a t h , lift, a n d b r i n g it across the midline as y o u pull Figure 8.11

it in a superior direction. As y o u h o l d the knee in this position, pull it toward y o u ever so slightly to stabilize the

tuberosity. Put the h e e l of y o u r o t h e r h a n d j u s t m e d i a l to the ASIS and gently b u t firmly push the ilium laterally a n d wait. Either the i n n o m i n a t e will go t h r o u g h its d a n c e a n d release or it will m o v e directly to its n o r m a l position.

Up-slip With y o u r client lying on the side o p p o s i t e the up-slip, use the leg of the up-slipped side as a handle to guide the innominate. Using the direct techn i q u e y o u gently b u t firmly pull the leg inferiorly a n d wait for the i n n o m inate to glide into its normal position (Figure 8.12). T h e indirect technique requires a few m o r e steps. Use the f e m u r to gently b u t firmly a n d slowly push the i n n o m i n a t e superiorly a n d h e n c e further into its up-slip. Wait. Y o u will feel the i n n o m i n a t e m o v e further into the up-slip. N e x t y o u may feel a pulsation a n d then an impulse in the client's b o d y f o r the i n n o m i nate t o m o v e inferiorly. W h e n y o u f e e l the i m p u l s e t o m o v e inferiorly, e n c o u r a g e that m o v e m e n t by slowly a n d gently pulling the leg inferiorly at a s p e e d that matches the s p e e d with w h i c h the client's b o d y releases. If

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Figure 8.12

at first y o u are u n a b l e to feel the impulse of the b o d y to m o v e inferiorly, d o n ' t w o r r y a b o u t it. P e r f o r m the t e c h n i q u e as d i r e c t e d : use the f e m u r to push the i n n o m i n a t e further into its up-slip, a n d simply h o l d it in that position f o r a b o u t 5 to 10 s e c o n d s , a n d then traction the l e g a n d pelvis inferiorly. T h e s e two m e t h o d s f o r releasing an up-slip were also created by Jan Sultan.

Down-slip Simply reverse the direct and indirect up-slip t e c h n i q u e . Y o u can use y o u r client's leg t o directly push the pelvis superiorly. O r y o u c a n pull y o u r client's leg inferiorly to increase the down-slip a n d wait f o r the i m p u l s e to release superiorly.

Anterior Shear With y o u r client p r o n e , stand on the same side of the table as the anterior shear. Place the fingers of o n e h a n d on the anterior p u b e a n d place the f o r e a r m o f y o u r o t h e r a r m o n the o p p o s i t e i n n o m i n a t e . W i t h y o u r f o r e a r m , stabilize the pelvis while y o u gently b u t firmly push the anterior 109

SPINAL MANIPULATION MADE SIMPLE p u b e in a p o s t e r i o r d i r e c t i o n (Figure 8.13) a n d wait. Either the i n n o m i n a t e will d a n c e to its release or it will m o v e directly to its n o r m a l position.

Posterior Shear W i t h y o u r c l i e n t p r o n e , stand o n the opposite side of the posterior shear. Use the same h a n d a n d f o r e a r m p l a c e m e n t as d e s c r i b e d f o r the anterior shear, but this time use y o u r fingers to stabilize the p u b e while you use your forearm to gently b u t firmly push the o p p o s i t e i n n o m inate (with the p o s t e r i o r p u b e ) in an a n t e r i o r d i r e c t i o n . Wait. Either the inn o m i n a t e will release its restriction by Figure 8.13

d a n c i n g this way and that or by m o v i n g directly to its n o r m a l position.

Anterior Torsion W i t h y o u r c l i e n t s u p i n e , stand o n the s a m e side as the a n t e r i o r t o r s i o n a n d place the heel o f o n e h a n d o n the ASIS o f the anteriorly t o r s i o n e d i n n o m i n a t e (Figure 8 . 1 4 ) . Bring the f e m u r p e r p e n dicular to the table with the k n e e b e n t a n d lean a little of y o u r b o d y weight on the k n e e . With y o u r o t h e r h a n d , gently b u t f i r m l y apply pressure o n the ASIS in the d i r e c t i o n of posterior torsion as y o u use y o u r b o d y weight t o m o v e the f e m u r t o e n c o u r a g e the p o s t e r i o r tors i o n i n g o f the i n n o m i n a t e a n d wait. Either the i n n o m i n a t e will go t h r o u g h its d a n c e or it will m o v e directly to its n o r m a l position.

Figure 8.14

110

THE PELVIS

Figure 8.15

Posterior Torsion With your client p r o n e , stand on the side with the posterior torsion. Place o n e hand u n d e r the f e m u r just above the knee of the posteriorly torsioned i n n o m i n a t e a n d the o t h e r h a n d o n the p o s t e r i o r aspect o f the i n n o m i nate itself. Lift the f e m u r slightly o f f the table a n d place y o u r k n e e u n d e r it so y o u d o n ' t have to h o l d the leg up as y o u p e r f o r m the t e c h n i q u e (Figure 8 . 1 5 ) . Gently b u t firmly apply pressure to the i n n o m i n a t e with the o t h e r h a n d in the d i r e c t i o n of an a n t e r i o r torsion a n d wait. Either the i n n o m i n a t e will release its restriction by u n w i n d i n g or by m o v i n g directly to its n o r m a l position. As a general rule, r e m e m b e r that these iliosacral techniques, as well as all the o t h e r techniques discussed in this b o o k , work best if y o u prepare the myofascial and ligamentous tissues associated with the fixations y o u are attempting to release. Preparing the tissues means that y o u release the associated strain patterns and bring e n o u g h balance to the appropriate areas of your client's b o d y so that he is able to adapt to y o u r manipulations. It 111

SPINAL MANIPULATION MADE SIMPLE also helps if y o u are able to address the alignment of the whole b o d y along with its m a n y patterns of c o m p e n s a t i o n . As a s o m a t i c p r a c t i t i o n e r y o u already have y o u r favorite ways of releasing a n d b a l a n c i n g these tissues, a n d y o u r t e c h n i q u e s are certainly a useful adjunct to the techniques y o u learn f r o m this b o o k . However, even if y o u do n o t h i n g to p r e p a r e the tissues or address patterns of c o m p e n s a t i o n , the t e c h n i q u e s taught in this b o o k are still p o w e r f u l e n o u g h to get g o o d results all by themselves.

Note 1. Kendall, F l o r e n c e Peterson a n d McCreary, Elizabeth Kendall. Muscles: Testing and Function. T h i r d e d i t i o n , B a l t i m o r e : (Williams a n d W i l k i n s ) , 1983.

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CHAPTER

9

The Ribs N T H E L A S T C H A P T E R Y O U L E A R N E D H O W T H E PELVIS C O N T R I B U T E S T O

back pain. In this chapter y o u will learn h o w the ribs c o n t r i b u t e to a n d h e l p perpetuate b a c k pain. T h e organization of the thorax, as well as its myofascial, ligamentous, a n d articular fixations, can p r o f o u n d l y affect the organization, integrity, a n d f u n c t i o n i n g of the w h o l e body. If y o u c o n sider only the j o i n t s of the thorax, there are 150 articulations, a n d m o s t ribs can be involved in 6 articulations a l o n e . Just by f r e e i n g a myriad of thoracic restrictions, w h i c h m i g h t i n c l u d e rib fixations in the ribs, stern u m , clavicles, the l i g a m e n t s a n d fascia f r o m w h i c h the l u n g s are susp e n d e d , a n d so o n , it is s o m e t i m e s possible to release n e c k a n d low b a c k facet restrictions w i t h o u t ever e v e n w o r k i n g o n the n e c k o r l o w e r b a c k themselves. In this chapter, however, we will limit o u r discussion to the ribs only. O n c e y o u learn h o w to r e c o g n i z e a n d release rib dysfunctions, y o u will be surprised a n d pleased at h o w this k n o w l e d g e will c o n t r i b u t e greatly to your ability to release many facet restrictions in the thoracic and cervical spines.

The Influence of the Ribs

S

INCE T H E RIBS A R T I C U L A T E W I T H T H E SPINE I N VERY SPECIFIC WAYS,

they play a significant role in spinal dysfunction. Rib 1 articulates with

Tl and ribs 11 and 12 articulate with T i l and T 1 2 respectively. Ribs 1 , 1 1 , 113

SPINAL MANIPULATION MADE SIMPLE and 12 articulate with the spine by means of unifacets, whereas ribs 2 - 1 0 articulate by m e a n s of demifacets. All the ribs, with the e x c e p t i o n of 11 and 12, articulate in the front of the thorax by means of strong cartilagin o u s attachments and this cartilage in turn also articulates with the stern u m . L o o k at the front of the thorax and y o u will see that there are really two attachments, called the c o s t o c h o n d r a l and sternochondral j u n c t i o n s , that are associated with most of these ribs. T h e costochondral j u n c t i o n acts like a j o i n t a n d is f o r m e d by the insertion of the c o n c a v e e n d of the rib into a c o n e - s h a p e d p i e c e of cartilage. T h e s t e r n o c h o n d r a l articulation is f o r m e d by the costal cartilage inserting into the triangular notches of the sternum, in which are f o u n d small synovial joints. M o t i o n occurs at b o t h of these articulations a n d releasing a rib requires addressing the c o s t o c h o n d r a l j u n c t i o n and sometimes the sternochondral articulations as well. T h e c o m p l e x relation between the ribs and vertebrae illustrated in Figure 9.1 shows why dysfunctional rib torsions usually result f r o m vertebral rotations and Type II dysfunctions in the thoracic spine. T h e ribs that c o n n e c t to the s p i n e by m e a n s of d e m i f a c e t s articulate with two vertebrae.

Costal facet of transverse process

Inferior costal articular facet Superior costal articular facet

Figure 9.1

114

THE RIBS Let's l o o k at the fifth rib as an e x a m p l e . R i b 5 attaches to the i n f e r i o r costal facet of T 4 , the superior costal facet of T 5 , a n d the costal facet of the transverse process of T 5 . If T4 rotates right on T 5 , T4 pulls the s u p e rior aspect of the rib with it, while the inferior aspect of the rib, w h i c h is attached to T 5 , remains u n a f f e c t e d by the rotation. T h e right rotation of T4 will thus cause the right fifth rib to torsion externally a n d the left fifth rib to torsion internally. Ribs that articulate by m e a n s of d e m i f a c e t s have two c o s t o v e r t e b r a l c o n n e c t i o n s a n d o n e costotransverse c o n n e c t i o n . T h e floating ribs, 1 1 and 12, which attach by m e a n s of a unifacet do n o t have a costotranverse articulation. Even t h o u g h they do n o t attach to the front of the rib cage itself, they do have interesting c o n n e c t i o n s to the muscles of the p o s t e rior a b d o m i n a l wall. T h e s e c o n n e c t i o n s are important, because w h e n the articulations of ribs 11 or 12 are fixed, they are a c c o m p a n i e d by myofascial strain patterns in the a b d o m i n a l muscles. As my c o l l e a g u e a n d friend Jan Sultan discovered, these strain patterns are often in the f o r m of a vortex and they must also be released if y o u want to successfully release these ribs as well. T h e ribs even have a t o u g h little ligament that attaches to the annulus of the intervertebral disk. All of these c o n n e c t i o n s m e a n that a rib in trouble can often cause m o r e pain than a dysfunctional vertebra and learning h o w to release rib fixations will c o n t r i b u t e greatly to y o u r skills. D u e to the intimate relationships between ribs and spine, y o u can often release rib dysfunctions simply by releasing the vertebral dysfunctions. So the best strategy is to release Type II fixations first. But m a n y times releasing the dysfunctional thoracic vertebra will n o t be e n o u g h to release the rib. So always test and retest b o t h vertebral and rib fixations to make sure y o u r manipulations are successful. Just r e m e m b e r that releasing Type II fixations will sometimes release the rib a n d s o m e t i m e s n o t . Be aware that it also works the other way—Type II fixations will not always remain released until the rib fixations are released. If y o u successfully release a dysfunctional thoracic vertebra, y o u r client will p r o b a b l y immediately r e p o r t f e e l i n g better. But if y o u d o n ' t release the associated rib fixation, y o u can e x p e c t to hear h o w the pain r e t u r n e d within a few h o u r s or days. S o m e t i m e s this r e p o r t m e a n s that the u n r e solved rib fixation was e n o u g h to make the facet restriction reassert itself. 115

SPINAL MANIPULATION MADE SIMPLE A n d o t h e r times it m e a n s that y o u r client is still in pain b e c a u s e of the u n r e s o l v e d rib fixations, even t h o u g h y o u r release of the vertebral dysf u n c t i o n was c o m p l e t e l y successful. Ribs are very i m p o r t a n t in p e r p e t u ating back and n e c k pain. Many cervical fixations are held and maintained by u p p e r rib fixations. I have seen t o o m a n y clients w h o received treatm e n t s f r o m therapists w h o k n e w h o w t o release vertebral dysfunctions, b u t d i d n o t k n o w h o w to release rib fixations. T h e result of only releasing the thoracic vertebrae is that often the rib fixations worsen a n d the client ends up with m o r e pain than b e f o r e she started treatment. So always c h e c k f o r a n d release rib fixations. Y o u r clients will love y o u f o r it.

Finding the Fixed Ribs

R

IBS C A N G E T I N T O T R O U B L E I N A N U M B E R O F W A Y S . T H E Y C A N T O R S I O N

internally or externally, they can sublux anteriorly or posteriorly, the

first rib can slip superiorly, a n d they can b e c o m e distorted a n d dysfunctional t h r o u g h trauma. We will e x p l o r e h o w to understand a n d treat torsion, subluxation, a n d first rib dysfunction. T h e technique for releasing the ribs is very simple and straightforward.

All y o u n e e d to k n o w is h o w to locate the fixed rib. T h e r e are two simple ways to locate a fixed rib that do n o t require y o u to k n o w whether the rib is torsioned or subluxed. O n c e y o u locate the fixed rib, applying the techn i q u e will tell y o u h o w the rib is p o s i t i o n e d as y o u f o l l o w h o w it dances toward its r e l e a s e — e v a l u a t i o n and treatment m e r g e t o g e t h e r as o n e and the same process. N o t i c e that there are two grooves associated with the spine. T h e spinal g r o o v e is b e t w e e n the spinous a n d transverse processes of the spine. A n o t h e r groove is f o r m e d where the ribs articulate with the spine at the costotransverse j u n c t i o n . Illustrated by the drawing in Figure 9.2, this articulation is r o u g h l y at the lateral b o r d e r s of the errectors. To find this rib g r o o v e , place the p a d of y o u r t h u m b on the spinous process, and drag your t h u m b laterally. A l m o s t immediately y o u will feel y o u r t h u m b sink into the spinal g r o o v e . C o n t i n u e to drag y o u r t h u m b laterally over the transverse process until y o u feel it o n c e again fall i n t o an i n d e n t a t i o n or g r o o v e . This seco n d g r o o v e is the costotransverse g r o o v e and y o u will n o t i c e that it is n o t as d e e p as the spinal g r o o v e . Practice finding the costotransverse g r o o v e

116

THE RIBS

b e c a u s e the two tests that y o u will learn f o r d e t e r m i n ing rib fixations require y o u to p l a c e y o u r fingers h e r e . Although the costotransverse g r o o v e is the b e s t p l a c e to

Rib angle

feel for rib fixations, it is n o t as useful if y o u are trying to palpate f o r t o r s i o n o r s u b luxation. Before y o u learn the two methods for determining rib fixation, let's first look at how to palpate for torsion and

Costotransverse groove

Spinal groove

Figure 9.2

subluxation. A l t h o u g h it is n o t altogether necessary, it helps if y o u can l o o k at a skeleton while practicing rib palpation. T h e first thing to n o t i c e is that the superior b o r d e r s of ribs are n o t as easy to feel as the inferior b o r d e r s . T h e shape and position of these b o r d e r s is such that the s u p e r i o r b o r d e r feels less distinct than the inferior border. So d o n ' t let this feature of h o w the ribs are shaped mislead y o u into thinking y o u are palpating internal torsion. To d e t e r m i n e torsion, palpate the superior and inferior b o r d e r s of the suspected rib at about the rib angle. If the rib is externally torsioned, then y o u will find two telltale signs: the s u p e r i o r b o r d e r will be m o r e p r o m i n e n t a n d the i n f e r i o r less p r o m i n e n t than n o r m a l , a n d the intercostal space above the rib will be wider a n d the intercostal space b e l o w the rib will be narrower than n o r m a l . Internal torsion displays j u s t the o p p o s i t e features. T h e inferior b o r d e r of the suspected rib will be m o r e p r o m i n e n t and the superior b o r d e r will be less p r o m i n e n t than n o r m a l , and the intercostal space b e l o w the rib will be wider a n d the intercostal space a b o v e the rib will be narrower than usual. T o d e t e r m i n e subluxation, palpate the h e a d o f the s u s p e c t e d rib o n the front of the rib cage at the c o s t o c h o n d r a l j u n c t i o n a n d the rib angles on the posterior side of the rib c a g e . T h e n c o m p a r e the suspected rib to the rib on the o t h e r side. Is the p o s t e r i o r rib angle of the suspected rib m o r e a n t e r i o r / p o s t e r i o r ? Is the rib h e a d m o r e a n t e r i o r / p o s t e r i o r than 117

SPINAL MANIPULATION MADE SIMPLE the rib on the o t h e r side at the c o s t o c h o n d r a l j u n c t i o n ? If the rib angle a n d the rib h e a d at the c o s t o c h o n d r a l j u n c t i o n are b o t h m o r e anterior in c o m p a r i s o n to the rib on the o t h e r side, then the suspected rib is p r o b a bly anteriorly s u b l u x e d . If the rib a n g l e a n d the rib h e a d at the c o s t o c h o n d r a l j u n c t i o n are b o t h m o r e posterior than the rib on the o t h e r side, then the suspected rib is p r o b a b l y posteriorly s u b l u x e d . Palpating ribs f o r torsion a n d subluxation can be difficult, especially on clients w h o s e b a c k musculature is highly d e v e l o p e d . To increase y o u r palpatory skills it is best f o r y o u to practice feeling these rib patterns. But fortunately, y o u really d o n ' t have to go t h r o u g h the a b o v e process of palp a t i o n to find a fixed rib a n d free it. Y o u can simply p u t y o u r t h u m b in the costotransverse g r o o v e on the suspected rib and m o t i o n test it. Use the so-called "spring test" to motion-test ribs. Put y o u r t h u m b on the suspected rib where it articulates with the costotransverse process and with firm pressure quickly push anteriorly a n d j u s t as quickly release the pressure. Do this a c o u p l e of times in rapid succession so that y o u can feel w h e t h e r the rib springs or not. If y o u c a n n o t feel the rib spring, it is p r o b ably fixed. Spring test a n u m b e r of ribs until y o u can feel the clear difference between a fixed rib that has no spring to it and a free rib that easily springs with pressure. A n o t h e r way to m o t i o n test for rib fixations is through a kind of assisted spring test. Place y o u r client in a sitting position and ask h i m to put each h a n d on his o p p o s i t e s h o u l d e r so that his arms are crossed. Stand b e h i n d y o u r client a n d h o l d up his crossed arms at his elbows with o n e of y o u r hands. Make sure that y o u r client gives you the full weight of his arms and is n o t unconsciously trying to help you h o l d his arms u p . Place your thumb in the area of the suspected rib a n d then s m o o t h l y b u t rapidly raise and lower y o u r client's arms. As y o u raise his arms, push y o u r t h u m b anteriorly a n d then let the pressure o f f as y o u lower his arms (Figures 9.3 and 9 . 4 ) . If either or b o t h the costotransverse or costovertebral joints are fixed, y o u r t h u m b will n o t sink in an anterior direction as y o u raise y o u r client's arms. If y o u r t h u m b d o e s n ' t sink anteriorly as y o u raise your client's arms, y o u have d i s c o v e r e d a fixed rib. B o t h of these tests will give y o u all the information y o u n e e d to release rib fixations, b u t the assisted spring test is a little m o r e reliable a n d accurate, especially if y o u are n e w to palpating f o r rib fixations. N o t i c e that

118

»

THE RIBS

Figure 9.3

Figure 9.4

these tests only tell y o u w h i c h ribs are fixed b u t they do n o t also tell y o u whether the ribs are fixed in anterior or posterior subluxation or in external or internal torsion. Fortunately y o u d o n ' t really n e e d to m a k e these kinds of discriminations in o r d e r to use the t e c h n i q u e f o r releasing ribs. Y o u only n e e d to k n o w w h e r e the fixation is l o c a t e d . By the way, as a m e t h o d to increase evaluation skills, y o u s h o u l d also k n o w that rib fixations are usually a c c o m p a n i e d by characteristic t e n d e r points in the soft tissues, illustrated in Figure 9.5, p a g e 120. N o t i c e that a n u m b e r o f these t e n d e r points are a l o n g the e d g e o f the scapula. W h e n clients have fixed ribs, it is quite c o m m o n f o r t h e m to tell y o u that they are experiencing pain at the e d g e of their scapula. However, d o n ' t be misl e d b y w h e r e y o u r clients tell y o u t o l o o k f o r painful spots. M o r e o f t e n than n o t the pain they feel in the area of the r h o m b o i d s is s e c o n d a r y to and a result of the rib fixation. If y o u release the r h o m b o i d s a n d do n o t release the o f f e n d i n g rib, y o u r client's pain will return very shortly. H o w ever, after y o u release the rib, releasing the myofasciae a l o n g the should e r blade will s u p p o r t y o u r release of the rib. 119

SPINAL MANIPULATION MADE SIMPLE

Rib tenderpoints

Figure 9.5

A n o t h e r way to locate fixations is to run y o u r thumbs or fingers d o w n the costotransverse g r o o v e o n o n e side o f the spine and then the other, a n d n o t i c e if y o u feel s o m e t h i n g that makes y o u want to investigate. Do this w i t h o u t any p r e c o n c e p t i o n s a n d y o u will be surprised by h o w often y o u r fingers will land on a rib fixation. Y o u can do the same thing in the spinal g r o o v e if y o u want to practice a quick way to find vertebral facet fixations. O n c e y o u gain c o n f i d e n c e in y o u r ability to feel for fixations in this way, y o u c a n search o u t dysfunctions in the same way anywhere in y o u r client's body. This m e t h o d of locating p r o b l e m s in your clients is quite elegant a n d s o m e t h i n g y o u can easily practice every time y o u treat them. As y o u may r e m e m b e r , the first rib behaves a little differently than ribs 2 - 1 0 . W h e n the first rib b e c o m e s dysfunctional it tends to get fixed in a superior position. W h e n it is in trouble y o u will also find that the scalenes will be hypertonic on the same side as the fixed rib and that there will be m a r k e d tenderness in the area of the superior aspect of the first rib near where it articulates with T l . Have y o u ever had the e x p e r i e n c e of d o i n g a great j o b of releasing your client's cervical pain only to have him report that his n e c k still h u r t s — a n d that it especially hurts when he turns his head to o n e side where he feels the pain shooting along the right superior edge of his traps? Such a report is usually an indication that the right first rib is fixed.

120

THE RIBS T h e r e are two ways of testing f o r whether the first rib is in trouble. T h e first m e t h o d is just a n o t h e r variation of the spring test. With y o u r client in a sitting position, place the p a d of y o u r t h u m b over w h e r e the first rib articulates with Tl and spring test downwardly in a c a u d a d direction. If it d o e s n ' t spring it is p r o b a b l y fixed. A n o t h e r way to test the first rib is to p u t y o u r client in a sitting p o s i t i o n a n d p l a c e the fingers of e a c h h a n d over the first ribs, with y o u r forefingers very close to the spinal articulation a n d ask y o u r client to take a d e e p b r e a t h . If o n e of the first ribs is fixed it will n o t m o v e with the inhalation.

Rib Techniques

B

EFORE Y O U R E L E A S E A N Y R I B F I X A T I O N S , B E C E R T A I N T H A T T H E S O F T

tissues o f the t h o r a c i c r e g i o n are a d e q u a t e l y p r e p a r e d , e s p e c i a l l y

a r o u n d the costotransverse, costovertebral, c o s t o c h o n d r a l , a n d s t e r n o c h o n d r a l regions. First release all T y p e II facet fixations in the t h o r a c i c spine. All o f the f o l l o w i n g t e c h n i q u e s f o r releasing ribs are d o n e with the client in a sitting position. For dysfunctions of ribs 2 - 1 0 , place the finger o r t h u m b o f o n e h a n d o n the costotransverse articulation a n d a f i n g e r o f the o t h e r h a n d on the c o s t o c h o n d r a l articulation of the dysfunctional rib (Figures 9.6, 9.7, a n d 9.8, pages 1 2 2 - 1 2 3 ) . Slowly, b u t with g e n t l e , firm pressure push y o u r fingers toward each other. As y o u apply pressure, ask

your client to sidebend his b o d y to the same side as the fixed rib. H o l d and wait. Follow the d a n c e of the rib as it unwinds, releases its restrictions, a n d the tissue softens. C o n t i n u e to h o l d a n d wait until y o u feel the b o d y organize itself as m u c h as it can a r o u n d vertical a n d h o r i z o n t a l planes. Y o u may r e m e m b e r f r o m earlier chapters that there are two stages to the final release of a j o i n t fixation. First y o u will feel the s o f t e n i n g of the tissues and then, if y o u waitjust a little longer, y o u may feel the o r t h o t r o p i c effect as y o u r client's b o d y organizes itself a r o u n d the sagittal, transverse, a n d c o r o n a l planes. For m o s t somatic practitioners feeling the b o d y o r g a n i z e itself a r o u n d vertical lines is the easiest. So d o n ' t w o r r y a b o u t n o t feeling all of these planes c o m e in d u r i n g the release. Just practice f e e l i n g what you can and in time you will feel even m o r e . These planes intersect at right angles and as a short h a n d way to talk a b o u t h o w the b o d y organizes itself

121

SPINAL MANIPULATION MADE SIMPLE

Figure 9.6

Figure

9.7

122

THE RIBS

a r o u n d these planes, I refer to it as o r t h o g o n a l organization. Let's s u p p o s e the rib y o u are attempting to release is stuck in external torsion. As the rib g o e s t h r o u g h its d a n c e , y o u will n o t i c e it o f t e n m o v e s further i n t o external torsion b e f o r e it releases. T h e rib will m o v e in m a n y o d d ways, b u t eventually it will m o v e further i n t o external tors i o n . W h e n the rib c o m p l e t e s this m o v e m e n t it will then m o v e o u t of external torsion toward a m o r e n o r mal position. Tracking this rib m o tion and taking n o t e of its positions while y o u are attempting to release Figure 9.8

it is the way y o u d e t e r m i n e h o w the rib is stuck. W h e n the rib finally comes

to rest in what is n o r m a l position in relation to the rest of the body, it will stop m o v i n g . Y o u will t h e n feel the tissue soften a n d the characteristic attempt of the b o d y to organize orthotropically and o r t h o g o n a l l y a r o u n d the release. For dysfunctions of the 11th a n d 12th ribs, place the t h u m b or finger of o n e h a n d as close as possible to the costovertebral articulation a n d the forefinger and t h u m b of the o t h e r h a n d a l o n g the length of the rib as it wraps its way a r o u n d the body, as shown in Figures 9.9 a n d 9.10, page 124. Slowly apply gentle b u t firm pressure to the costovertebral j u n c t i o n a n d sidebend your client to the side on which the rib is fixed. Follow the d a n c e and wait f o r the rib to release a n d f o r the b o d y to o r g a n i z e orthogonally. D o n ' t forget that there are fascial vortices in the posterior a b d o m i n a l wall that are often associated with restrictions in the 11th a n d 12th ribs, a n d that these myofascial strain patterns must also be released f o r this techn i q u e to be fully effective. To release these associated fascial vortices, ask y o u r client to lie supine. If any vortices are present, they will be f o u n d medial to the tips of the 11th and 12th ribs roughly in the area of the external a b d o m i n a l o b l i q u e , trans123

SPINAL MANIPULATION MADE SIMPLE

Figure

9.9

Figure

9.10

124

THE RIBS versus, a n d rectus a b d o m i n u s . To search f o r these vortices, gently push the pad of your t h u m b or forefinger and m i d d l e finger into various places in the area just d e s c r i b e d and wait to see if y o u r fingers are drawn d o w n and into the tissue in a spiraling fashion, as shown in Figures 9.11, 9.12, and 9.13. If this h a p p e n s y o u have d i s c o v e r e d a fascial vortex. Place the forefingers, o r the forefingers a n d m i d d l e f i n g e r s , o f b o t h h a n d s i n the area of the vortex a n d gently sink i n t o the tissue waiting f o r the b o d y ' s response. M o r e often than n o t y o u r fingers will gently follow the tissue by spiraling d e e p e r i n t o the vortex. W h e n y o u r e a c h the e n d o f the spiraling, y o u will feel a softening of the tissue a n d an i m p u l s e f o r the v o r t e x to unwind itself up a n d o u t of its spiral. Let this h a p p e n . S o m e t i m e s y o u r fingers just spiral d o w n into the tissue and the b o d y will simply release the strain without spiraling back out. Either way the release h a p p e n s , y o u will know the technique is finished when y o u feel the tissues soften and release along a vertical line. Like all releases, the b o d y will try to o r g a n i z e itself orthogonally, but feeling the o t h e r planes while releasing fascial vortices is sometimes a little difficult.

Figure 9.11 125

SPINAL MANIPULATION MADE SIMPLE

Figure

9.12

Figure

9.13

126

THE RIBS

Figure 9.14

Figure 9.15

If y o u m o t i o n test and find a restricted first rib, m o r e than likely it will be fixed superiorly. Let's s u p p o s e y o u find the restriction in the right first rib. With y o u r client in a sitting position, snuggle the e d g e of y o u r ulna (the part that is closest to y o u r o l e c r a n o n ) o n t o your client's first rib where it attaches to Tl at the costotransverse j u n c t i o n . Ask y o u r client to d r o p his head as far forward as is c o m f o r t a b l e and to remain in this position while he slowly turns his head to the left. As he turns left, let y o u r e l b o w sink further into the j o i n t space (Figure 9 . 1 4 ) . T h e n ask h i m to b r i n g his h e a d back to center and very slowly turn to the right, all the while k e e p i n g his head in the forward b e n t position (Figure 9.15). As he slowly turns right, continue to apply gentle but firm pressure in a caudad direction to the rib head. Wait f o r the rib to go through its unwinding, release its restriction, and f o r the tissues to soften. C o n t i n u e with the pressure until the b o d y organizes itself o r t h o g o n a l l y as m u c h as it c a n . T h e n be sure to release scalenes on the ipsilateral side. This chapter on the ribs really brings this manual on spinal manipulation to a close. In the next and last chapter I will discuss a few o d d s and ends that will clarify s o m e important points and suggest a few o t h e r techniques. 127

CHAPTER

10

Odds and Ends

T

HE BODY IS N O T A SOFT MACHINE OR A C O M P L E X T H I N G M A D E OF

parts. It is a seamless unified living w h o l e capable of adapting to an e v e r - c h a n g i n g internal a n d e x t e r n a l e n v i r o n m e n t . W h a t w e are

t e m p t e d to call "parts" of the b o d y are really n o t parts at a l l — o u r b o d i e s

are n o t c o b b l e d t o g e t h e r f r o m p r e - s h a p e d parts the way m a c h i n e s are. Any attempt to take apart a b o d y the way y o u might disassemble a m a c h i n e into its parts only results in a heap of lifeless pieces that c a n n o t be reassemb l e d as a body. So we speak t o o loosely w h e n we refer to the liver or brain or the f o o t as a part of the body. W h e n e v e r we refer to s o m e aspect of the living body, such as the h a n d or the heart, we are really r e f e r r i n g to an aspect or expression of the w h o l e . An organ is n o t in the b o d y in the same way a c a r b u r e t o r is in a car. Conceptually, we can distinguish these different aspects of the w h o l e , but no o n e of these aspects is functionally separate f r o m the w h o l e . What we call organs and other anatomical structures are in reality organized, unified relationships related to the living whole which is also a living, organized, unified relationship. Every unified relationship is c o m p o s e d of other unified relationships and every relationship is an integral aspect of other relationships. T h e connections, c o m m u n i c a t i o n networks, and forces between bodily relationships are themselves unified relationships and the way they all function together is a unified relationship. What we are tempted to call parts are n o t only unified relationships, but also organized wholes. 129

SPINAL MANIPULATION MADE SIMPLE T h e s e o r g a n i z e d w h o l e s exist in relationship to o t h e r o r g a n i z e d wholes a n d overlap as networks of c o m m u n i c a t i o n a n d c o n n e c t i o n that are all expressions of a deliquescent, b u t exquisitely and hierarchically organized w h o l e . S o m e u n i f i e d r e l a t i o n s h i p s , like the h e a r t a n d b r a i n , are m o r e i m p o r t a n t to the survival of the w h o l e than others. But since the b o d y is n o t c o m p o s e d of parts, there is n o t h i n g m o r e fundamental to the makeup a n d organization of the w h o l e than the w h o l e itself. Since the b o d y is an i r r e d u c i b l e c o m p l e x i t y a n d n o t c o b b l e d t o g e t h e r f r o m pre-shaped parts, every detail of the w h o l e is an expression of the unified, seamless o r g a n ization o f the w h o l e . T h e shape o f every b o n e i n y o u r body, f o r e x a m p l e , is a matchless manifestation of y o u r u n i q u e m o r p h o l o g y . All living organisms are self-organizing a n d we h u m a n s are the most highly plastic of all. O r g a n i s m s persist o v e r time b e c a u s e they are c o n stantly i n the p r o c e s s o f f o r m i n g a n d r e - f o r m i n g their b o u n d a r i e s i n response to their ever-changing e n v i r o n m e n t s . Living beings are able to accomplish this remarkable feat in the face of persistent internal and external c h a n g e b e c a u s e their o r d e r a n d organization is self-maintained and self-contained. An o r g a n i s m is like a fountain of water w h o s e constituent materials are b e i n g rapidly r e p l a c e d , while variations in the f o r m remain the same o v e r time. But unlike a fountain w h e r e the f o r m is maintained b y o u t s i d e f o r c e s , o r g a n i s m s have the i n h e r e n t p o w e r t o maintain a n d adapt their f o r m to their e n v i r o n m e n t . Maintaining, adapting, and evolving bodily f o r m in an ever-changing environment are part of what it means to be alive. H o w well o u r b o d i e s a c c o m p l i s h these amazing feats are also an i m p o r t a n t part of what d e t e r m i n e s o u r level of health, happiness, and sense o f well-being a n d f r e e d o m . T h e s e characteristics result in a b o d y that is also highly adaptive and plastic. If a p e r s o n is i n j u r e d , say in an a u t o m o b i l e a c c i d e n t , h e r b o d y often d e v e l o p s patterns of c o m p e n s a t i o n in relation to the original pattern of injury. T h e a u t o m o b i l e a c c i d e n t d o e s n o t just cause a local p r o b l e m with s o m e "part" of the body, it also creates global patterns of strain that in turn affect the o r g a n i z a t i o n a n d f u n c t i o n i n g of the entire b o d y a n d its relation to gravity. T h e o r i g i n a l p a t t e r n o f injury m o r e o f t e n than n o t i s laid d o w n o n o t h e r previous injuries a n d postural imbalances. A l o n g with the resulting p a t t e r n s o f c o m p e n s a t i o n i n r e l a t i o n t o gravity, these i m b a l a n c e s a n d

130

ODDS AND ENDS injury patterns result in a complicated loss of inherent plasticity and adaptability throughout the entire body. Over time, further losses in m o v e m e n t , plasticity, and adaptability will appear as the b o d y struggles with gravity in its daily activities. If these c o m p l i c a t e d patterns of strain a n d c o m p e n s a tion are n o t released, a n d perhaps m o r e importantly, n o t released in the p r o p e r order, the b o d y will n o t be able to r e s p o n d p r o p e r l y to interventions d e s i g n e d to release the original injury site or any o t h e r area of dysfunction. Treating the b o d y as an assemblage of dysfunctional parts a n d releasing the parts s y m p t o m by s y m p t o m is the m o s t c o m m o n way that somatic practitioners a p p r o a c h therapy. This m e t h o d o l o g y can be called the " c o r r e c t i v e a p p r o a c h . " It certainly has its p l a c e in the t h e r a p e u t i c arena, b u t it is usually less effective than the "holistic a p p r o a c h " w h i c h requires understanding the i n t e r c o n n e c t e d living w h o l e in which all these local dysfunctions are e m b o d i e d . T h e h u m a n b o d y is a m a z i n g in its i n t e r c o n n e c t e d , i r r e d u c i b l e c o m plexity a n d equally a s t o u n d i n g in its seamless simplicity. T h e m o r e we understand a b o u t the unified, systematic, i n t e r c o n n e c t e d nature o f o u r b o d i e s a n d h o w the w h o l e p e r s o n r e s p o n d s t o injury and i n t e r v e n t i o n , the better o u r therapy b e c o m e s . This realization m e a n s that as m u c h as possible we must k e e p e x p a n d i n g o u r u n d e r s t a n d i n g of, a n d o u r ability to feel, this unified living w h o l e that we are. It also m e a n s that if we want o u r manipulations to be l o n g lasting, we must e x p a n d o u r u n d e r s t a n d i n g so that we can work holistically rather than just correctively. T h e holistic a p p r o a c h to somatic therapy aims n o t o n l y to r e m e d i a t e s y m p t o m s , b u t also to e n h a n c e the w h o l e p e r s o n . Effective holistic somatic therapy d e m a n d s that the practitioner n o t only be able to perceive the w h o l e , b u t to also track the effects of her local manipulations on the w h o l e . So in a sense, even t h o u g h this b o o k is a b o u t spinal m a n i p u l a t i o n , it should also be a b o u t the w h o l e body. But such a goal is t o o vast f o r a m a n ual of technique. In order to make this b o o k manageable, I have approached therapeutic intervention f r o m the corrective perspective. Unfortunately, since the corrective a p p r o a c h tends to understand the client as a c o l l e c tion of symptoms, it is almost always just a little t o o shortsighted. Since so many local areas of dysfunction are tied to, a n d h e l d , by m o r e global patterns of strain, the holistic perspective is r e q u i r e d to gain s o m e u n d e r standing of these whole b o d y connections. That is why I mention the holistic 131

SPINAL MANIPULATION MADE SIMPLE perspective n o w a n d also why I have taken s o m e limited excursions into o t h e r areas of the body. Like all therapists, y o u want y o u r clients to e x p e r i e n c e long-lasting relief as a result of y o u r spinal manipulations. T h e s e digressions will h e l p y o u to u n d e r s t a n d a n d treat s o m e of the m o r e significant c o m p e n s a t i o n s and fixations that contribute to your client's b o d y maintaining its d y s f u n c t i o n s — b u t obviously n o t all of them. T h e i n h e r e n t difficulties with the corrective a p p r o a c h to therapy can only be o v e r c o m e with a m o r e complete discussion of the holistic approach. Such a discussion w o u l d have to show that the corrective approach is based on a mechanical understanding of the b o d y that sees it as a c o m p l e x thing m a d e of parts. It w o u l d also have to articulate a p r o p e r p h i l o s o p h y and s c i e n c e of living w h o l e s that w o u l d f o r m the biological f o u n d a t i o n f o r a holistic m e d i c a l system. It w o u l d also i n c l u d e understanding and treating the w h o l e body, n o t just the spine. T h u s , we w o u l d also have to e x p l o r e h o w to treat the c r a n i u m , the extremities, a n d the o r g a n s , the c e l o m i c sacs, and the m a n y energetic d i m e n s i o n s , n e u r o l o g i c a l and psychological dysfunctions, a n d s o o n . Even assuming that we had all this k n o w l e d g e and were able to effectively treat all these different aspects of the w h o l e person, it w o u l d still n o t be e n o u g h . On what basis do we take all of the information gathered from o u r evaluation a n d prioritize all the relevant techniques into a treatment strategy that takes a c c o u n t of h o w o u r client's w h o l e b o d y can adapt to a n d s u p p o r t o u r interventions? H o w w e answer the three f u n d a m e n t a l questions of therapy is critical: W h a t do I do first, W h a t do I do next, and W h e n am I finished? After we have fully evaluated o u r client's kinds a n d levels of dysfunction, we n e e d a way to create a treatment strategy that is based on s o m e thing other than simply following already d e t e r m i n e d formulistic protocols or j u s t treating the p r o b l e m s s y m p t o m by s y m p t o m . Treating clients by following a treatment recipe is a useful way to learn in the beginning stages of b e c o m i n g a s o m a t i c practitioner, b u t this m e t h o d is n o t fully a p p r o priate f o r m o s t clients a n d it is n o t a p p r o p r i a t e f o r us as we c o n t i n u e to mature as therapists. In o r d e r to learn h o w to treat o u r clients in all their individuality, w i t h o u t the b e n e f i t of formulistic p r o t o c o l s , we must also k n o w h o w t o e n g a g e i n a p r i n c i p l e - c e n t e r e d clinical d e c i s i o n - m a k i n g process. So a c o m p l e t e discussion of holistic somatic therapy w o u l d also

132

ODDS AND ENDS require a lengthy investigation into the principles of intervention: what a principle is, h o w principles are different f r o m strategies, h o w principles function in formulating treatment strategies, a n d j u s t exactly what these principles are. All of these important topics are obviously b e y o n d the s c o p e of a m a n ual on soft-tissue t e c h n i q u e s . But m e n t i o n i n g t h e m illuminates the full scope of somatic therapy and discussing t h e m keeps us h u m b l e by r e m i n d ing us h o w m u c h we have to learn. Since we have to start s o m e w h e r e , and this b o o k marks a way to b e g i n , let's return to a m o r e m a n a g e a b l e task. This c h a p t e r of the b o o k will be d e v o t e d to a few details that I purposely left f o r the e n d . U n d e r s t a n d i n g them will contribute further to y o u r ability to manipulate the spine. S o m e of these details c o n c e r n the issue of adaptability—in this discussion y o u will learn what can appropriately be called preparatory t e c h n i q u e s . But I also want to give y o u a few simple ways to a p p r o a c h spinal curvature. Y o u may r e m e m b e r that I briefly talked a b o u t curvature w h e n I i n t r o d u c e d what are called T y p e I g r o u p curves toward the e n d of C h a p t e r T h r e e . We will l o o k at adaptability issues first a n d then take a b r i e f tour of spinal curvature.

Adaptability

A

S I S U G G E S T E D A B O V E , F O R M U L A T I N G A T R E A T M E N T S T R A T E G Y T H A T IS

n o t d e p e n d e n t on formulistic p r o t o c o l s or treating y o u r clients symp-

t o m by s y m p t o m requires a clinical-decision m a k i n g process that is based

on the principles of intervention. I f o r m u l a t e d a principle-centered d e c i sion-making process in c o l l a b o r a t i o n with my c o l l e a g u e a n d f r i e n d , Jan Sultan. O n e of the principles is called the "Adaptability Principle." I have discussed the rationale b e h i n d this principle a n u m b e r of times t h r o u g h out this b o o k . T h e idea b e h i n d it is simple and quite obvious: if your client's b o d y i s n o t capable o f adapting t o o r a c c e p t i n g y o u r i n t e r v e n t i o n , t h e n either his b o d y will return to its dysfunctional state or y o u r m a n i p u l a t i o n will drive strain to o t h e r areas of his b o d y — o r b o t h . This is very often the u n w e l c o m e c o n s e q u e n c e o f treating s y m p t o m b y s y m p t o m . But e x p e r i e n c e d holistic therapists understand what happens w h e n they do n o t p r o p erly prepare a client's b o d y to adapt to the effects of their manipulations. 133

SPINAL MANIPULATION MADE SIMPLE Y o u r c l i e n t c o m p l a i n s that his pain r e t u r n e d a l m o s t i m m e d i a t e l y after y o u r treatment, or that his pain is n o w worse, or has spread to o t h e r areas of his body. Of course, there c o u l d be o t h e r explanations for why this happ e n s , b u t failure to p r e p a r e the client's b o d y is certainly o n e of the m o r e c o m m o n reasons. Techniques f o r preparing y o u r client's b o d y so that it can adapt to your interventions can vary f r o m simply relaxing the appropriate tissues around a vertebra b e f o r e y o u release its facet restriction to making sure that the b o d y as a w h o l e can adapt to y o u r manipulations above and support them below. S o m e t i m e s p s y c h o l o g i c a l issues interfere with y o u r intervention. It is n o t at all u n c o m m o n to treat clients w h o have b e e n sexually and physically abused. For s o m e of these clients every attempt y o u make to m a n i p ulate the pelvis a n d l o w b a c k is m e t with u n c o n s c i o u s resistance. T h e s e u n f o r t u n a t e clients c a n n o t adapt to y o u r intervention because they are n o t p s y c h o l o g i c a l l y p r e p a r e d t o deal with the m e m o r i e s a n d e m o t i o n s that m i g h t result if they were to allow c h a n g e s in their b o d i e s . A n o t h e r very important principle of intervention is the "Support Princ i p l e . " It is actually a specific application of the adaptability principle and also derived f r o m the p i o n e e r i n g work of Dr. Ida P. Rolf. It says that o r d e r is a f u n c t i o n of available s u p p o r t in gravity. A g a i n , the rationale b e h i n d this principle is simple and obvious: if y o u r client's b o d y is n o t able to supp o r t the c h a n g e s y o u i n t r o d u c e , then either it will revert to its p r i o r dysfunctional state or y o u will drive strain e l s e w h e r e — o r b o t h . If y o u d e c i d e to release a n u m b e r of fixations in the pelvic and lumbar region, for example, and your client's legs are n o t u n d e r him properly supporting the pelvis a n d the rest of his b o d y , then the ability of y o u r client to h o l d o n t o the results of y o u r treatment will be limited. I m a g i n e h o w y o u m i g h t p r o c e e d if y o u r evaluation revealed that y o u r client c o u l d neither adapt above o r below, o r s u p p o r t y o u r interventions. Y o u w o u l d have to create a treatment strategy that addressed all of h e r specific adaptability a n d s u p p o r t issues. In a situation like this, it is usually best to b e g i n by addressing the m o s t important adaptability issues first a n d the s u p p o r t issues last. T h e reason f o r this particular a p p r o a c h rests on the observation that w o r k on the feet a n d legs tends to release upward through the body. If y o u r client's b o d y c a n n o t adapt above to this upwardly rising wave of release that almost always results f r o m w o r k i n g on feet and

134

ODDS AND ENDS legs, then y o u r manipulations c o u l d cause s o m e nasty p r o b l e m s in y o u r client's thorax, n e c k , a n d h e a d . O n l y after these adaptability a n d s u p p o r t issues have b e e n h a n d l e d should y o u b e g i n working to release the myofascial and j o i n t fixations in the pelvic r e g i o n . A s y o u p r o b a b l y realized, there are o t h e r p r i n c i p l e s o f i n t e r v e n t i o n and other considerations a b o u t h o w to evaluate the structural, functional, and energetic aspects of the w h o l e p e r s o n that are important to this holistic decision-making process. I m e n t i o n only the s u p p o r t a n d adaptability principles because they are o b v i o u s a n d can be used to give y o u an idea of h o w p r i n c i p l e - c e n t e r e d d e c i s i o n m a k i n g works a n d a sense of h o w a holistic somatic practitioner operates a c c o r d i n g to principles. In this c h a p t e r we will limit o u r discussion to issues of local adaptability. Discussing the m o r e g l o b a l c o m p e n s a t i o n s a n d strain patterns that manifest in a p e r s o n ' s structural, f u n c t i o n a l , e m o t i o n a l , a n d e n e r g e t i c ways of b e i n g w o u l d require another b o o k on h o w to evaluate these global patterns, as well as a c o m p l e t e discussion of the p r i n c i p l e s of i n t e r v e n tion. To k e e p things simple we will o n l y discuss those local areas of the b o d y that are directly relevant to releasing the j o i n t fixations we have discussed in this b o o k .

What to Prepare

T

HIS SECTION DESCRIBES MANY OF T H E LOCAL AREAS OF MYOFASCIAL

and ligamentous dysfunction that are c o m m o n l y associated with j o i n t

fixations. As a general r u l e , y o u s h o u l d c o n s i d e r releasing these associated areas first b e f o r e d e a l i n g with the s p e c i f i c j o i n t f i x a t i o n . Y o u c a n release the tissues after y o u release the j o i n t fixation, b u t it is usually easier on y o u a n d on y o u r client if y o u release the relevant tissues first. As I m e n t i o n e d previously, all the t e c h n i q u e s I discuss in this b o o k will w o r k quite well if you do n o t attempt to release these associated soft tissue restrictions. But y o u definitely will be m u c h m o r e effective if y o u release these myofascial a n d ligamentous restrictions first. This discussion is n o t m e a n t to be exhaustive, it contains only the most important a r e a s — the o n e s y o u s h o u l d always be sure n o t to o v e r l o o k . Also I will n o t devote m u c h discussion to the techniques to use to release these areas, because there are many ways to accomplish the desired results 135

SPINAL MANIPULATION MADE SIMPLE and m o s t readers of this b o o k already k n o w many of them. Besides, there are m a n y classes and workshops on soft tissue techniques readily available to somatic practitioners in b o t h the U n i t e d States a n d E u r o p e . T h e m o s t i m p o r t a n t r e c o m m e n d a t i o n I want to make is to find ways to release soft-tissue restrictions that do n o t cause u n n e c e s s a r y pain to your clients. W h e n it c o m e s to treating the h u m a n body, m o r e is n o t always better. T o o m a n y soft tissue practitioners apply way t o o m u c h pressure to the b o d y and willfully push their way through the tissues. This willful application of elbows a n d knuckles n o t only causes unnecessary pain and tissue d a m a g e , it also interferes with your ability to feel the orthotropic effect. A p p l y i n g the " n o pain, no gain" p h i l o s o p h y is n o t the most effective app r o a c h , a n d can o f t e n be abusive. Use what y o u have l e a r n e d f r o m this b o o k w h e n y o u a p p r o a c h the release o f myofasciae a n d ligaments, and d o n ' t f o r c e y o u r way t h r o u g h the tissue. L e t y o u r client's b o d y tell y o u what it wants a n d h o w it wants to release. If y o u respect the way the b o d y wants to release a n d find its way to its o w n i n h e r e n t order, y o u can apply heavy pressure a n d n o t w o r r y a b o u t causing unnecessary pain. Sink into the tissue a n d wait f o r the d a n c e . Your clients will be m u c h happier if you do a n d y o u r results will also be better. Dr. Rolf, the c r e a t o r a n d f o u n d e r of R o l f i n g , taught a s h o t g u n techn i q u e that is s o m e t i m e s useful f o r releasing the musculature of the back, b u t it also has its dangers. Since this t e c h n i q u e has gained a lot of p o p u larity a m o n g m a n y o t h e r somatic practitioners, I want to make sure you k n o w w h e n to use it a n d w h e n n o t to. T h e t e c h n i q u e works this way: p l a c e y o u r client in a sitting position a n d l e a n y o u r r i g h t e l b o w o n his right u p p e r b a c k a t a b o u t the cervicothoracic j u n c t i o n over the spinal g r o o v e and transverse processes. D o n ' t use the p o i n t of y o u r elbow, use the flatter aspectjust superior to the o l e c r a n o n . Let y o u r e l b o w sink into the tissue by letting y o u r weight do most of the work. Ask y o u r client to slowly b e n d forward (Figure 10.1). As he d o e s so, k e e p y o u r pressure up a n d slide y o u r e l b o w d o w n his back at a rate that k e e p s up with the rate at w h i c h the tissue releases. Be sure to slide your elbow all the way d o w n and through the tissue around the sacroiliac j o i n t (Figure 1 0 . 2 ) . Ask y o u r client to sit up a n d repeat the process on the left side. Y o u can run y o u r e l b o w d o w n y o u r client's back a c o u p l e of times on each side. As a matter of course you may even release s o m e closed

136

ODDS AND ENDS

Figure 10.1

Figure 10.2

fixed facets. But as y o u also p r o b a b l y realized, this t e c h n i q u e wall have no effect on all the o p e n - f i x e d facets. This technique is a very useful shotgun a p p r o a c h f o r releasing the back musculature. But be careful with it. If y o u r client has severe b a c k p a i n , degenerative j o i n t disease, a n d / o r disc p r o b l e m s , d o n ' t use this technique, because y o u can actually make h e r b a c k pain m u c h m u c h worse. I f y o u r client has disc p r o b l e m s y o u may even cause the disc to herniate further. A n y time y o u release sacroiliac, iliosacral, o r l u m b a r facet f i x a t i o n s , c h e c k the hamstrings, the gluteals, the pelvic rotators, the a d d u c t o r s , the quadratus l u m b o r u m , the psoas, the myofasciae o f the l u m b a r a n d t h o racolumbar regions, and the pelvic ligaments. Normalize those areas where y o u find strain, tightness, a n d imbalances f r o m side to side. Figure 10.3, p a g e 138, shows the c o m p l e x l i g a m e n t o u s structure of this area. W h e n releasing the sacrum, be sure to pay special attention to the sacrotuberous ( 7 ) , sacrospinous ( 6 ) , sacroiliac ( 5 ) , a n d the piriformis (Figure 1 0 . 4 ) . W h e n y o u are releasing the sacrum, L 5 , a n d L4 also be certain y o u c h e c k 137

SPINAL MANIPULATION MADE SIMPLE

1

2 3

85%

4

5

10%

6 7

1 2

2-3%

8

1%

7 6

Figure 10.3

Figure 10.4

the i l i o l u m b a r ligaments (1 a n d 2 ) . If y o u r client is c o m p l a i n i n g of sciatic pain, y o u want to be sure to evaluate L 4 , L 5 , the sacrum, the ligaments previously m e n t i o n e d , a n d especially the piriformis muscle. It is usually n o t e n o u g h to release the c o m pression o n the sciatic n e r v e a t L 4 o n L 5 , b e c a u s e L 5 , the s a c r u m , the ligaments, a n d the pelvic rotators, especially the piriformis, are often part of the p r o b l e m . T h e drawings in Figure 10.4 present f o u r different ways the sciatic n e r v e can thread its way a r o u n d or t h r o u g h the piriformis and the p e r c e n t a g e of time e a c h shows up in the h u m a n p o p u l a t i o n . It also dramatically illustrates why sciatic pain can be maintained by a dysfunctional piriformis muscle l o n g after the c o m p r e s s i o n on the nerve r o o t has b e e n alleviated. So always c h e c k the piriformis muscle when you are releasi n g the s a c r u m or dealing with sciatic pain. T h e hamstrings a l m o s t always c o n t r i b u t e to m a i n t a i n i n g strain and fixation t h r o u g h the l u m b a r a n d pelvic regions. T i m e a n d again I have w a t c h e d a s a c r u m d e r o t a t e as I released the hamstrings. W h e n y o u see l u m b a r s i d e b e n d i n g , m o r e than likely y o u will also see b o t h a tight and

138

ODDS AND ENDS short psoas a n d quadratus l u m b o r u m on the side to w h i c h the s p i n e is sidebending. T h i n k of the l u m b a r spine as a tent p o l e a n d the psoas muscles as guy wires. Every l u m b a r vertebrae is attached to the psoas a n d if o n e of these guy wires is pulling m o r e than the o t h e r it is sure to u n b a l ance the spine. Even if y o u j u s t find the c o m m o n dysfunctional pattern where L4 a n d L5 are sidebent a n d rotated to the same side, y o u s h o u l d treat the psoas and the quadratus l u m b o r u m on the side to which L4 and L5 are sidebent. You s h o u l d also pay attention to the a d d u c t o r s , especially w h e r e they attach at the pelvic ramus. Manipulating dysfunctionally s h o r t e n e d a d d u c tors will gready contribute to y o u r attempt to release the sacrum and l u m bars. Since the a d d u c t o r s a n d the psoas are intimately c o n n e c t e d in this area, if y o u release the adductors y o u s h o u l d also release the psoas. A n d then make sure that the l u m b a r a n d t h o r a c o l u m b a r myofasciae will permit the full release of this area. It is very c o m m o n to find myofascial strain and tightness in the t h o r a c o l u m b a r r e g i o n of clients w h o have had a history of low back pain. Even if y o u have p r e p a r e d all the associated tissues properly, and d o n e a great j o b of releasing all the fixations in the sacrum, lumbars, and pelvis, s o m e t i m e s y o u r client c o m p l a i n s that he still has j u s t a little bit of pain and stiffness either in the center of his sacrum or a r o u n d the SI joints a n d ILA's. If this h a p p e n s , y o u p r o b a b l y n e e d to be m o r e specific in h o w y o u release the associated myofasciae a n d ligaments. Ask y o u r client to sit on y o u r treatment b e n c h and forward b e n d as far o v e r as he is c o m f o r t a b l e . Use the knuckles of b o t h hands to apply 20 to 30 p o u n d s of pressure to the area a r o u n d the right side of the lumbosacral j u n c t i o n . Sink into the tissues and wait f o r t h e m to r e s p o n d (Figure 10.5, p a g e 1 4 0 ) . W h e n y o u feel the tissues begin to soften, slide inferiorly a l o n g the right SI j o i n t with y o u r left knuckle on the m e d i a l side of the SI j o i n t a n d the right k n u c k l e on the lateral side of the SI j o i n t . Slide t h r o u g h this area at a s p e e d that m a t c h e s t i s s u e s ' release, t h e n d o the o t h e r side. I f y o u r c l i e n t i s c o m plaining of lingering pain in the c e n t e r of the s a c r u m , place the k n u c k les of each hand close together, apply the same a m o u n t of pressure starting at the lumbosacral j u n c t i o n , sink into the tissues, wait f o r t h e m to soften, and slide inferiorly a l o n g the b o d y of the sacrum. This t e c h n i q u e can be s o m e w h a t i n t e n s e f o r the c l i e n t ( m e a n i n g i t m a y h u r t ) , b u t i t i s v e r y 139

SPINAL MANIPULATION MADE SIMPLE

effective f o r releasing this last bit of strain. Apply the technique a c o u p l e of times in a way that your client can tolerate a n d h e s h o u l d feel i m m e diate relief. W h e n e v e r y o u release fixations at o n e e n d of the spine, be sure you attend to the o t h e r e n d and release whatever

fixations

you

find.

A

c h a n g e i n the l u m b a r s c a n create c h a n g e in the c e r v i c a l s a n d visa versa. So it is always a g o o d idea to m a k e sure that b o t h e n d s o f the spine are happy and free b e f o r e you send y o u r clients h o m e . B e f o r e y o u release facet restrictions in the neck, use whatever techFigure 10.5

niques y o u know to ease and release the muscles and fascial sheets along

the back a n d sides of the n e c k and the tissues a r o u n d the O A . Figure 10.6 shows a useful shotgun technique you may want to try. Pick up your client's h e a d a n d rest the b a c k of his h e a d in the c r o o k of y o u r right h a n d (the part f o r m e d b y w e b b i n g o f y o u r t h u m b a n d f o r e f i n g e r ) . With the i n d e x a n d / o r m i d d l e fingers of y o u r left h a n d , apply pressure and sink into the tissue of the left spinal g r o o v e a r o u n d the atlas. W h e n y o u feel the tissue soften, slide inferiorly with the fingers of y o u r right h a n d to a b o u t Tl and T 2 . Reverse y o u r hands and treat the right cervical spinal g r o o v e the same way. Besides releasing the posterior myofasciae, this t e c h n i q u e will often release s o m e of the less severe fixed-closed facets. Of course it w o n ' t release the fixed-open facets, b u t because it d o e s double-duty in releasing soft tissues a n d extension restrictions, it saves y o u time and energy. W h e n e v e r y o u work in the n e c k area be sure that y o u always attend to the suboccipital muscles. This r e g i o n is almost always involved with dysf u n c t i o n a l patterns in the n e c k . In Figure 10.7, n o t i c e h o w all of these suboccipital muscles, with the e x c e p t i o n of the obliquus capitus inferior (3) ( a n d the interspinous muscles), attach to the base of the o c c i p u t . T h e

140

ODDS AND ENDS

Figure 10.6

2 4

3

3

5

2

Rectus capitus posterior minor

4

Obliquus capitus superior

l

Rectus capitus posterior major

Obliquus capitus inferior

Interspinous m u s c l e s

Figure 10.7

rectus capitus posterior m a j o r (1) attaches to the spinous process of C2 and the o c c i p u t , the rectus capitus posterior m i n o r (2) attaches to CI and the o c c i p u t , the o b l i q u u s capitus superior (4) attaches to the transverse 141

SPINAL MANIPULATION MADE SIMPLE

process of CI and the occiput, and the obliquus capitus inferior (3) attaches to C2 a n d the transverse process of C I . N e w dissection p r o c e d u r e s have revealed the existence of a previously u n k n o w n muscle and ligament c o m p l e x that e x t e n d s f r o m the suboccipital muscles to the dura mater that s u r r o u n d s the brain. W h e n y o u p u t this newly u n d e r s t o o d c o n n e c t i o n to the cranial dura t o g e t h e r with what h a p p e n s w h e n the suboccipital muscles get tight a n d short in response to stress or facet restrictions, then you easily u n d e r s t a n d why these muscles can be the s o u r c e of a real pain in the n e c k — a n d s o m e really nasty h e a d a c h e s . So always m a k e sure this entire r e g i o n is soft a n d at ease b e f o r e y o u e n d y o u r treatment. B e f o r e y o u release ribs, it is very helpful to ease the back musculature a n d the tissues a l o n g the sides a n d the f r o n t of the rib c a g e , especially a r o u n d the s t e r n u m , a n d the c o s t o c h o n d r a l a n d stern o c h o n d r a l j u n c t i o n s . Pay special attention to the intercostal muscles, especially a b o v e a n d b e l o w the fixed ribs y o u plan to treat, a n d m a k e sure they are at ease. As I m e n t i o n e d in C h a p t e r N i n e , the r h o m b o i d s are always involved in rib restrictions, but y o u should also pay attention to the levator scapulae and serratus posterior superior muscles.

Curvature T r e a t i n g curvatures in the h u m a n b o d y is a very c o m plicated affair. Curvature is i n h e r e n t to o u r b o d i e s a n d a l o n g with curvature c o m e s asymmetry. Many schools of manual and m o v e m e n t therapy l o o k u p o n all bodily curvature and asymmetry as dysfunctional a n d try their best to i n t e r v e n e a n d c h a n g e these patterns. Many of these s c h o o l s a d h e r e t o s o m e n o t i o n o f a n "Ideal B o d y " that they use as a s t a n d a r d against w h i c h to evaluate their clients' b o d i e s . A g o o d e x a m p l e of the t h e o r y of the ideally aligned b o d y and its use in evaluating dysfunction is described by Kendall and McCreary. Pictured in Figure 10.8, the ideal 1

b o d y is d e f i n e d by d r o p p i n g a p l u m b line t h r o u g h the

142

Figure 10.8

ODDS AND ENDS center of gravity of the b o d y (i.e., slightly anterior to the first or s e c o n d sacral s e g m e n t ) . If the centers of gravity of the o t h e r segments fall a l o n g this p l u m b line, it is c o n s i d e r e d properly aligned. A c c o r d i n g to this view, the line of gravity should fall t h r o u g h the m i d d l e of the ear l o b e , t h r o u g h the middle of the a c r o m i o n process, through the greater trochanter, slighdy anterior to the axis of the k n e e j o i n t , a n d slightly anterior to the lateral m a l l e o l u s . T h i s c o n c e p t o f the ideal b o d y has i n f l u e n c e d m a n y practitioners, w h o o f t e n i n a p p r o p r i a t e l y evaluate a n d treat their patients in terms of h o w well they measure up to this external ideal. Unfortunately this c o n c e p t i o n rests on the gratuitous assumption that the h u m a n b o d y is equally d e n s e t h r o u g h o u t . Since it is n o t , it c a n n o t be lined up the way y o u m i g h t align a pile of blocks. Like Dr. R o l f and many o t h e r theorists, Kendall and M c C r e a r y assume that the closer b o d i e s match this ideal, the better they f u n c t i o n . This view has s o m e truth to it, b u t w h e n a p p l i e d indiscriminately to every patient, d y s f u n c t i o n c a n result. C o n s i d e r a few o b v i o u s e x a m p l e s . A p r e g n a n t w o m a n or an overweight patient with a large " p o t belly" w o u l d be aligned in a most peculiar way if any attempt were m a d e to b a l a n c e t h e m a r o u n d the line of gravity. C o n s i d e r patients with u p p e r n e u r o n p r o b l e m s like cerebral palsy. In many of these patients, any attempt to align their heads on t o p of their b o d i e s , as this ideal r e c o m m e n d s , will often result in tonal overflow to the extremities, possible increase in non-functional reflex patterns o f m o v e m e n t , a n d loss o f c o n t r o l . We s h o u l d n ' t automatically assume that clients are manifesting s o m e sort of dysfunction solely because their b o d i e s do n o t measure up to this external ideal of g o o d posture. A n y attempt to c o m p l e t e l y rid the b o d y of curvature and asymmetry is a h o p e l e s s enterprise. If such an impossible goal c o u l d be realized, it w o u l d p r o b a b l y cause the u t m o s t distress a n d pain to the p o o r p e r s o n w h o received this well-intentioned therapy. As you might well imagine, most theorists w h o believe that there is standard that all b o d i e s should measure up to also believe in an "Ideal Spine." Figure 10.9, page 144, shows Dr. R o l f s view of what this ideal spine s h o u l d l o o k like. But w h e n y o u c o m p a r e h e r view to what actually exists, y o u see there is quite a disparity. T h e f o r m a n d curvature of any given spine is a u n i q u e expression of the m o r p h o l o g y and f u n c t i o n i n g of the entire body. If y o u l o o k carefully at the great differences b e t w e e n y o u r clients' spines, 143

SPINAL MANIPULATION MADE SIMPLE

y o u will realize that any attempt to manipulate t h e m to m a t c h the shape of the ideal spine is an impossible goal. Do y o u r e m e m b e r Figure 10.10? It a c c o m p a n i e d the discussion of the shape of the facets of the i n n o m i n a t e and sacrum in Chapter Seven. Notice h o w clearly it shows the r e l a t i o n s h i p b e t w e e n the facets a n d the s h a p e o f the sacrum. T h e impossibility of ever manipulating the sacrum of spine A in Figure 10.10 toward a position like spine B's is all t o o obvious. T h e r e is no way to c h a n g e the position of a s a c r u m with that s h a p e , b e c a u s e the shape of the facets w o u l d never permit it. R e m e m b e r , the shape of any given b o n e is an expression of the u n i q u e m o r p h o l o g y of the entire body. If y o u c a n n o t get the sacrum into this idealized position, you will never get the spine there either. I have seen t o o m a n y dysfunctional spines that l o o k just like the ideal spine and many very functional spines l o o k like spine A. So we c a n n o t automatically c o n c l u d e that

Figure 10.9

A

c

8

Figure

10.10

144

B

ODDS AND ENDS just because a client's spine or b o d y d o e s n ' t measure up to an ideal that it is dysfunctional a n d in n e e d of m a n i p u l a t i o n . In fact, m a n y times the attempt to make a client's b o d y c o n f o r m to an ideal either has no effect or, worse, actually creates further dysfunction. Somatic practitioners in every discipline have b e e n taught to evaluate clients by comparing their bodies to some conscious or unconscious somatic ideal. T o o often, c o n t o u r , position, curvature, a n d asymmetry are used as the o n l y i n d i c a t o r s o f s o m a t i c d y s f u n c t i o n a n d d i s o r d e r . O n c e w e see t h r o u g h the limitations o f evaluating o u r clients against these s o m a t i c ideals, we will see the o d d c o n t o u r s a n d the o d d p o s i t i o n i n g of segments, curvatures, and asymmetries that show up in every b o d y in an entirely different light. All of these o d d patterns must be evaluated in terms of the u n i q u e limitations a n d possibilities f o r e a c h b o d y a n d e a c h b o d y type. Rejecting the n o t i o n s of an ideal b o d y a n d ideal positions f o r individual segments d o e s n o t u n d e r m i n e o u r ability to evaluate o u r clients' b o d i e s . T h e r e are recognizable patterns of dysfunction that show up in every b o d y type, as well as c o m m o n patterns of asymmetry that s h o w up in various types of bodies, and there are asymmetries u n i q u e to the individual client. S o m e of these patterns are associated with dysfunction a n d s o m e are n o t . W h e n patterns that are associated with structural, functional, a n d e n e r getic fixations are properly m a n a g e d in a c c o r d a n c e with individual needs, overall function can b e restored a n d e n h a n c e d . So w h e n y o u see o d d l y p o s i t i o n e d segments, curvature, a n d asymmetries, what do y o u do a b o u t them? My suggestion is that y o u view an o d d l y positioned segment or curvature as no m o r e than a clue to possible somatic dysfunction or disorder, n o t the certainty of it. So always l o o k f o r loss of function in the f o r m of fixations first (myofascial, articular, energetic, e t c ) . Unless a c c o m p a n i e d b y s o m e level o f fixation, asymmetries a n d c u r v a tures may n o t be even clinically significant. Asymmetries, oddly positioned segments, curvatures, and o d d c o n t o u r s d o n o t always d e m a n d intervention. W h e n they do d e m a n d attention and manipulation, it is usually u n d e r the following c o n d i t i o n s : 1) w h e n they are a c c o m p a n i e d by a fixation or fixations (at the structural, functional, a n d / o r e n e r g e t i c levels), 2) w h e n they c o n t r i b u t e to a d y s f u n c t i o n or f i x a t i o n , or 3) w h e n m a n i p u l a t i n g them will clearly e n h a n c e the overall f u n c t i o n i n g of the w h o l e . So o u r j o b is to always try to u n d e r s t a n d a n d r e c o g n i z e the c o m m o n 145

SPINAL MANIPULATION MADE SIMPLE patterns o f d y s f u n c t i o n w i t h o u t l o s i n g sight o f the u n i q u e n e s s o f e a c h individual client a n d h o w h e r o r g a n i s m is o r g a n i z e d as a w h o l e . For each individual, the appropriate position of structures is d e t e r m i n e d by a p p r o priate f u n c t i o n . If a s e g m e n t seems to be in an o d d p o s i t i o n , b u t works the way it is s u p p o s e d to, d o n ' t mess with it. T h e same is true f o r all local a n d global asymmetries. A p e r c e i v e d asymmetry may be dysfunctional in o n e b o d y a n d entirely f u n c t i o n a l a n d n o r m a l i n a n o t h e r . A p p r o p r i a t e f u n c t i o n is d e t e r m i n e d by u n d e r s t a n d i n g what is possible in relation to e a c h individual's u n i q u e patterns o f c h a n g i n g a n d u n c h a n g i n g limitations. In turn, these limitations must be seen in terms of h o w well the person has adapted to gravity and his or her environment. Position can never be abstracted f r o m what is functionally appropriate f o r each individual in relation to gravity a n d the e n v i r o n m e n t . So what is n o r m a l , then? Etymologically, "normal" is rooted in the idea of measuring up to a n o r m , m o d e l , or pattern, like a carpenter's square. This m e a n i n g is the o n e m o s t often associated with somatic idealism. But " n o r m a l " also carries another meaning. It can m e a n "natural" in the sense of " b e i n g in a c c o r d a n c e with the i n h e r e n t nature of a p e r s o n or a thing." This m e a n i n g is at w o r k w h e n we say that a p e r s o n is a natural-born artist o r healer. W h e n I use the w o r d " n o r m a l " I m e a n it in this s e c o n d sense as b e i n g natural o r i n h e r e n t t o the b e i n g o f the w h o l e p e r s o n . T h i s c o n c e p t o f " n o r m a l " is clearly quite different in s c o p e and implication f r o m the idea of m e a s u r i n g up to a n o r m , statistical average, or standard that is external to the b o d y . T e m p l a t e s a n d n o r m s m a k e sense w h e n y o u r aim is to mass p r o d u c e m a c h i n e s a n d o t h e r non-living p r o d u c t s . Templates a n d n o r m s are important in the d e v e l o p m e n t of quality controls. But o u r b o d ies are n o t m a c h i n e s or p r o d u c t s , a n d it makes little sense to claim that all h u m a n b o d i e s f u n c t i o n best w h e n they measure up to s o m e external standard or statistical average. " N o r m a l " in the sense in w h i c h I use it, refers to what is appropriate a n d optimal f o r each individual p e r s o n . It c a n n o t be d e t e r m i n e d without a careful case-by-case examination of what is possible for each person, given the fixations a n d limitations i n h e r e n t to his or her body. N o r m a l is also n o t a static state that we can attain permanently. Living organisms are selforganizing, self-regulating wholes characterized by the continual o n g o i n g

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attempt to balance, organize, e n h a n c e , a n d h a r m o n i z e their lives. Given the t r e m e n d o u s plasticity and resulting diversity that actually exist a m o n g humans, clearly there c a n n o t be o n e ideal way f o r every b o d y or every segm e n t of the body. O u r world and lives are always in flux, and, whether o u r b o d i e s m a i n t a i n severe fixations o r n o t , w e are always striving t o w a r d b e c o m i n g m o r e fully ourselves. S o m e o f o u r limitations are t i m e - b o u n d and c h a n g e a b l e a n d s o m e are n o t . W h a t is n o t c h a n g e a b l e in the present may be changeable in the future. W h a t is c h a n g e a b l e f o r o n e p e r s o n may n o t be f o r a n o t h e r . N o r m a l i t y is an a c h i e v e m e n t that is w o n again a n d again in the course of o u r lives. As a somatic therapist y o u are always up against three limitations: y o u r own limitations as a therapist, the limitations of the therapeutic discipline that y o u l e a r n e d , and the limitations of y o u r client. S o m e of these limitations c a n n o t b e o v e r c o m e . Most f o r m s o f manual therapy will n o t c u r e cancer, for e x a m p l e . But m a n y of these limitations can be o v e r c o m e . For instance, y o u can always learn m o r e a n d i m p r o v e y o u r skills. W h a t o f t e n appear to be severe limitations in y o u r clients can c h a n g e over time a n d what was i n c a p a b l e of c h a n g i n g yesterday may c h a n g e t o m o r r o w . So we must learn to r e c o g n i z e a n d respect what we can c h a n g e today, what we can change in the future, and what we cannot change at a l l — a n d of course, h o w to tell the d i f f e r e n c e . As somatic therapists o u r g o a l is n o t to m a k e clients measure up to s o m e external standard that we i m p o s e on t h e m by means of somatic ideals and formulistic p r o t o c o l s , b u t to try to discover the limitations that stand in the way of t h e m b e c o m i n g w h o they are a n d then to release their fixations in the right order. Normality is n o t a matter of measuring up to an ideal f o r m or way of f u n c t i o n i n g , b u t a matter of uncovering what is natural or inherent in the being of the whole. Somatic therapy is, therefore, best practiced as a process of discovery, n o t as an act o f i m p o s i n g p r e d e t e r m i n e d standards o n o u r clients b y m e a n s o f f o r mulistic p r o t o c o l s . Let's return to the m o r e practical issues at h a n d and l o o k at h o w to deal with curvature. As I m e n t i o n e d earlier, curvature is a c o m p l i c a t e d affair. As y o u know, the spine has a n u m b e r of curves in the a n t e r i o r / p o s t e r i o r dimension. These are the lumbar lordosis, the thoracic kyphosis, a n d the cervical lordosis. T h e s e A / P curves can b e shallow o r d e e p , d e p e n d i n g o n the structure of each p e r s o n . A n d like all curvature, understanding t h e m 147

SPINAL MANIPULATION MADE SIMPLE

r e q u i r e s u n d e r s t a n d i n g the structure of the w h o l e body.

Crossover

We are n o t g o i n g to discuss h o w to manipulate these A / P curves, but

Apex

rather only Type I curves where there is an appreciable lateral deviation from the sagittal axis. T h e draw-

Crossover

i n g in F i g u r e 10.11 is a s c h e m a t i c representation of a scoliosis that displays h o w s i d e b e n d i n g and rotation

Apex

are c o u p l e d to opposite sides. T h e r e are f o u r p l a c e s i n the s p i n e w h e r e

Crossover

the curve might cross over and b e n d in the opposite direction. These typical transition p o i n t s are the l u m b o s a c r a l , the t h o r a c o l u m b a r , the

Figure

10.11

c e r v i c o t h o r a c i c , a n d atlantocciptal j u n c t i o n s . T h r e e o f these transitional j u n c t i o n s are displayed schematically in the drawing. Y o u can almost always c o u n t on these crossover points b e i n g the site of myofascial strain a n d tightness. T h e r e are many differe n t kinds of laterally deviated curvatures a n d no two are the same. But they all involve c o m p l i c a t e d twisting patterns that go t h r o u g h the entire b o d y f r o m the c r a n i u m to the feet a n d they all involve varying degrees of characteristic c h a n g e s in the shape of the b o n e s . Figure 10.12 shows the d i r e c t i o n of the scoliosis a n d its effect on the shape of a vertebra. N o t i c e , f o r e x a m p l e , h o w the shape of the facets a n d the spinal canal have b e e n m o d i f i e d by the twisting forces of the curvature. Since the shape of the vertebrae and other b o n e s of the b o d y sometimes have b e e n so profoundly m o d i f i e d by the scoliosis, your ability to affect curvature will be constrained by these b o n y c h a n g e s . Y o u s h o u l d always r e m e m b e r that a scoliosis is really a curvature that twists a n d spirals t h r o u g h o u t the w h o l e b o d y at every l e v e l — i t is n o t j u s t a c u r v a t u r e of the s p i n e . A n y a t t e m p t to m a n i p u l a t e the spine without addressing h o w the entire b o d y is involved in the curvature is almost always h o p e l e s s . B e f o r e y o u can e x p e c t any significant and lasting c h a n g e , y o u must make sure the c r a n i u m , the pelvis, the extremities, a n d the ribs are

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able t o a d a p t t o any u n w i n d i n g o f the c u r v a t u r e y o u m i g h t m a n a g e . Facets

Many times a curvature will w i n d its way d o w n m o r e i n t o o n e l e g than the o t h e r a n d r e l e a s i n g the c o m p e n s a t o r y patterns in that l e g c a n s o m e t i m e s significantly c h a n g e the curvature. Treating a scoliosis requires being able to p e r c e i v e the w h o l e with all its compensatory patterns and b e i n g

Figure 10.12

a b l e t o track t h e e f f e c t o f y o u r manipulations on the w h o l e . This is

a b i g a n d c o m p l i c a t e d j o b . A scoliosis is a m u l t i d i m e n s i o n a l shape that d o e s n o t r e s p o n d to a two-dimensional treatment a p p r o a c h . If y o u h a d a magic wand that p e r m i t t e d y o u to o n l y affect the spine by f o r c i n g the Sshaped curvature straight (the way that surgically implanting H a r r i n g t o n rods d o e s , f o r e x a m p l e ) , y o u w o u l d alter the s i d e b e n d i n g without significantly c h a n g i n g the rotational f o r c e a n d , as a result, send a mess of spirals a n d c o m p e n s a t o r y strain patterns t h r o u g h o u t the entire b o d y . T h e holistic a p p r o a c h is really the best m e t h o d f o r treating a scoliosis, because it is based on seeing a n d treating the w h o l e . T h e corrective a p p r o a c h is almost always less than satisfactory. A holistic a p p r o a c h s o m e t i m e s p r o duces amazing results, especially when the curvature is n o t t o o p r o n o u n c e d and has n o t dramatically spun its way d o w n i n t o the legs or up i n t o the cranium. In s o m e clients y o u may see an actual lessening of the curve and in o t h e r cases no significant c h a n g e at all. W h a t y o u can reasonably h o p e f o r is a general l e n g t h e n i n g of the b o d y a n d the spine, a n d greater freed o m and mobility t h r o u g h o u t y o u r client's body. L e n g t h e n i n g the b o d y and the spine gives the scoliosis a softer a n d less c o m p r e s s e d a p p e a r a n c e .

Technique for Type I Group Curvatures

T

HE TECHNIQUE FOR TREATING T Y P E I CURVATURES WAS CREATED BY MY

c o l l e a g u e , Jim Asher, an a d v a n c e d R o l f i n g Instructor. If y o u k e e p all

the above considerations in m i n d , y o u may find his a p p r o a c h very useful. 149

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Y o u can certainly attempt to apply the t e c h n i q u e without addressing the w h o l e body, p r o v i d e d y o u make sure b o t h ends of the spine are relatively free and at ease, that y o u have released iliosacral, sacroiliac, and all spinal facet ( i n c l u d i n g the O A ) a n d rib restrictions. If y o u release these areas first, y o u will n o t cause any h a r m to y o u r client if y o u do n o t address the rest of the b o d y — y o u may even see s o m e surprising results. S o m e g r o u p curvatures are easy to see a n d others are quite difficult. If y o u are n o t quite sure w h i c h way the spine is sidebent, ask y o u client to stand or sit and s i d e b e n d to the right a n d then to the left. If y o u r client can s i d e b e n d m o r e easily to the right than the left, y o u will n o t i c e that in right sidebending the curve is clear and p r o n o u n c e d while in left sidebending the spinal curvature is n o t as p r o n o u n c e d . Y o u will also notice that in r i g h t s i d e b e n d i n g the v e r t e b r a e will rotate m o r e than they d o i n left s i d e b e n d i n g . C h e c k each curve in the spine the same way and n o t e where the a p e x of e a c h c u r v e is on the c o n v e x side. In preparation f o r u n d e r s t a n d i n g this t e c h n i q u e , also n o t i c e h o w on the c o n v e x side of the c u r v e the errectors are pulled toward, and p a c k e d in c l o s e t o , the s p i n e in a way that s e e m s to d i m i n i s h the d e p t h of the spinal g r o o v e . On the c o n c a v e side the errectors are pulled away f r o m the spine a n d s e e m to be lying flat across the ribs. Let's assume y o u r client has a curvature like the o n e previously illustrated. His lumbar spine is right sidebent and left rotated and his thoracic spine is left sidebent and right rotated. For ease of understanding we will start on the thoracic spine. Place y o u r client in a side-lying position on his left side with his left a r m b e h i n d h i m , as shown in Figure 10.13. This position c h a l l e n g e s the existing s i d e b e n d i n g a n d rotational pattern. Place y o u r fingers (Figure 1 0 . 1 4 ) , e l b o w (Figure 10.15, page 1 5 2 ) , or knuckles in the right spinal g r o o v e a l o n g the convexity of the curvature. Sink into the spinal g r o o v e , wait f o r the tissues to soften, and then push in a lateral direction away f r o m the spine. Your effort should be partly directed toward freeing the tissue f r o m b e i n g p a c k e d in t o o close to the spinal g r o o v e . If y o u start at the b o t t o m of the convexity, push laterally as y o u m o v e superiorly. If y o u start at the t o p of the convexity, push laterally as y o u m o v e inferiorly. Be sure to p u t s o m e extra effort into the a p e x of the curve. T h e n ask y o u r c l i e n t t o roll o v e r o n t o his o t h e r side. But d o n ' t ask h i m to lay with his a r m b e h i n d his back. Place y o u r e l b o w (Figure 10.16),

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ODDS AND ENDS

Figure 10.13

Figure 10.14

151

SPINAL MANIPULATION MADE SIMPLE

Figure

10.15

fingers, or knuckles (Figure 10.17) on the lateral b o r d e r s of the erectors a l o n g the concavity of the curvature. Sink i n t o the tissue as if y o u were trying to g e t u n d e r the erectors, wait f o r the softening, and then push in a m e d i a l d i r e c t i o n toward the spine. Since these tissues are pulled wide and away f r o m the spine, y o u r effort is directed at easing them toward the spine. T h e t e c h n i q u e f o r treating the l u m b a r curvature is exactly the same. T h e only d i f f e r e n c e is h o w y o u position y o u r client's legs to challenge his right sidebending, left rotational pattern. Use the side-lying position again a n d instruct y o u r client to lay on his right side with his right k n e e slightly b e n t . In o r d e r to c h a l l e n g e the curvature a bit m o r e , ask h i m to place his left leg in front of his b o d y a n d b e n d his k n e e to 90 d e g r e e s as shown in Figure 10.18, p a g e 154. W o r k in the left spinal g r o o v e a l o n g the length of the convexity of the curvature. A g a i n , apply pressure laterally, as if y o u were trying to release the tissues away f r o m the spinal g r o o v e and put a little m o r e e f f o r t i n t o the a p e x o f the c u r v e (Figure 1 0 . 1 9 ) . T u r n y o u r c l i e n t o v e r on his left side, b u t this time m a k e sure he k e e p s his knees

152

ODDS AND ENDS

Figure 10.16

Figure 10.17 153

SPINAL MANIPULATION MADE SIMPLE

Figure

10.19

154

ODDS AND ENDS

Figure 10.20

t o g e t h e r a n d slightly b e n t . A p p l y pressure to the lateral b o r d e r s of the errectors toward the spine a l o n g the length of the concavity of the c u r v e (Figure 10.20). E x p e r i m e n t with this t e c h n i q u e , b e c a u s e on o c c a s i o n it may p r o d u c e surprising results. S o m e t i m e s y o u will see an actual r e d u c t i o n or lengthe n i n g of the curvature. Many times y o u will see a g e n e r a l i m p r o v e m e n t in range of m o t i o n t h r o u g h o u t the entire spine, b u t s o m e t i m e s y o u will see no obvious change at all. Always try to see the whole p e r s o n with w h o m y o u are working and track the effects of y o u r local manipulations on the w h o l e , m a k i n g sure y o u r client can adapt to y o u r interventions. R e m e m b e r that this b o o k is just an introduction to the spine and I have left out s o m e discussion of the o d d things spines d o . For e x a m p l e , the cervical vertebrae have a b a d habit of side slipping in s o m e clients. Also, many p e o p l e ' s spines have vertebrae that have slipped j u s t a little bit t o o p o s t e rior. T h e y are n o t full b l o w n e x a m p l e s of what is called a retrolisthesis, but they are just posterior e n o u g h to cause s o m e loss of m o t i o n t h r o u g h the entire s p i n e . I have also d i s c o v e r e d that the facets c a n be f i x e d in 155

SPINAL MANIPULATION MADE SIMPLE

planes o t h e r than the o n e s p r e s e n t e d in this b o o k . Unfortunately, delineating the tests and techniques f o r addressing these fixations w o u l d make this b o o k unnecessarily complicated. As y o u probably suspected, n o t everyb o d y is in full a g r e e m e n t that the spine works in the ways this b o o k d e scribes. This is no surprise, b u t if y o u use the i n f o r m a t i o n and techniques p r e s e n t e d h e r e , they will serve y o u well. A b o v e all else, d o n ' t forget to do everything y o u can to i m p r o v e y o u r understanding, y o u r technical skills, a n d y o u r ability t o see a n d feel y o u r way i n t o the simple c o m p l e x i t y o f what we h u m a n s truly are in relation to all of this to w h i c h we are neither identical n o r separate. G o o d luck! It has b e e n a pleasure writing this b o o k f o r y o u .

Note 1. Kendall, F l o r e n c e Peterson a n d McCreary, Elizabeth Kendall. Muscles: Testing and Function. T h i r d e d i t i o n , B a l t i m o r e : (Williams a n d W i l k i n s ) , 1983.

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BIBLIOGRAPHY

Basmajian, J o h n V. a n d Rich Nyberg, editors. Rational Manual Therapies, Baltimore: Williams and Wilkins, 1993. B o n d , Mary. Balancing your Body: A Self-Help Approach to Rolfing Movement, Rochester, V e r m o n t : H e a l i n g Arts Press, 1993. Bortoft, Henri. The Wholeness of Nature: Goethe's Way toward a Science of Conscious Participation in Nature, H u d s o n , New York: Lindisfarne Press, 1996. Cailliet, R e n e . Low Back Syndrome, Edition 4. Philadelphia, Pennsylvania: F.A. Davis C o m p a n y , 1988. Scoliosis: Diagnosis a n d M a n a g e m e n t , Philadelphia: F.A. Davis C o m pany, 1975. C h u r c h l a n d , Patricia Smith. Neurophilosophy: Toward a Unified Science of the Mind/Brain, C a m b r i d g e , Massachusetts: T h e M I T press,1990. C o t t i n g h a m , J o h n T. "Effect of Soft Tissue M o b i l i z a t i o n on Pelvic Inclin a t i o n A n g l e , L u m b a r L o r d o s i s , a n d Parasympathtic T o n e : I m p l i c a tions for Treatment of Disabilities Associated with L u m b a r Degenerative J o i n t Disease." P a p e r p r e s e n t e d o n M a r c h 19, 1992, t o the N a t i o n a l Center of Medical Rehabilitation Research of the National Institute of Child Health and H u m a n Development, Bethesda, Maryland. Reprinted in Rolf Lines, Spring,1992, pp 4 2 - 4 5 . . Healing Through Touch: A History and Review of the Physiological Evidence. Boulder, C o l o r a d o : R o l f Institute, 1985. . with Jeffrey Maitland. "Integrating Manual a n d M o v e m e n t T h e r apy with Philosophical Counseling for Treatment of a Patient with Amyo t r o p h i c Lateral Sclerosis: A Case Study that E x p l o r e s the Principles of Holistic Intervention," in Alternative Therapies in Health and Medicine, Vol. 6, N o . 2, 2000, p. 128, p p . 1 2 0 - 1 2 7 . . with Steven W. Porges and K. R i c h m o n d . "Shifts in Pelvic Inclination A n g l e and Parasympathic T o n e P r o d u c e d By Rolfing Soft Tissue 157

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Manipulation," in Physical Therapy Vol.68, 1988, p p . 1364-1370. . with Steven W. Porges and T. Lyon. "Soft Tissue Mobilization (Rolfing pelvic lift) and Associated Changes in Parasympathetic T o n e in T w o A g e G r o u p s , " in Physical Therapy, Vol. 68, 1988, p p . 3 5 2 - 3 5 6 . . with Jeffrey Maitland. "A Three-Paradigm Treatment M o d e l Using Soft Tissue Mobilization and G u i d e d Movement-Awareness Techniques f o r a Patient with C h r o n i c L o w Back Pain: A Case Study," in Journal of Orthopedic Sports Physical Therapy, Vol. 26, N o . 3, 1997, p p . 1 5 5 - 1 6 7 . D i G i o v a n n a , E i l e e n L. a n d Stanley S c h i o w i t z , e d i t o r s . An Osteopathic Approach to Diagnosis and Treatment, Philadelphia, Pennsylvania: J.B. Lipp e n c o t t C o m p a n y , 1991. Flury, Hans. Die Neue Leichtigkeit des Kbrpers: Grundlagen der normalen Bewegung Ubungen and SelbsthilfefurAlltag and Freizeit, M i i n c h e n : Deutscher T a s c h e n b u c h Verlag, 1995. . Notes on Structural Integration, a j o u r n a l series on Structural Integ r a t i o n f r o m 1986 to the present. P u b l i s h e d in Switzerland b u t also available f r o m the R o l f Institute. G r e e n m a n , Phillip E. Principles of Manual Medicine, second edition, Baltim o r e , Maryland: Williams a n d Wilkins, 1996. H a m m e r , Warren I. Functional Soft Tissue Examination and Treatment by Manual Methods, Gaithersburg, Maryland: A s p e n Publishers, 1991. Kapandji, LA. The Physiology of the Joints, Volumes I, 2,and 3, N e w York, New York: Churchill Livingstone, 1974. Kendall, Florence Peterson and Elizabeth Kendall McCreary. Muscles: Testing and Function, third edition, Baltimore, Maryland: Williams and Wilkins, 1983. Langebartel, David A., illustrated by R o b e r t H. Ulrich, Jr. The Anatomical Primer: An Embryological Explanation of Human

Gross Morphology, Balti-

m o r e : University Park Press, 1977. Maitland, Jeffrey. " A n O n t o l o g y o f A p p r e c i a t i o n : Kant's Aesthetics a n d the P r o b l e m of Metaphysics," Journal of the British Society for Phenomenology,Vo\. 13, N o . 1,January 1982, p p . 4 5 - 6 8 . . A P h e n o m e n o l o g y of Fascia, " i n Somatics, Vol. Ill, N o . 1, A u t u m n 1980, p p . 1 5 - 2 1 . . "Creative P e r f o r m a n c e : T h e Art of Life," in Research in Phenomenology, Vol. X, 1980, p p . 2 7 8 - 3 0 3 .

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Rolf, Ida R Ida Rolf Talks About Rolfing and Physical Reality. Edited by Rosem a r y Feitis. N e w York, N e w York: H a r p e r a n d Row, 1978. . R o l f i n g : T h e Integration of H u m a n Structures. N e w York, N e w York: H a r p e r a n d Row, 1977. R o s e , Steven. Lifelines: Biology, Freedom, Determinism, L o n d o n : P e n g u i n B o o k s , 1997. Schultz, L o u i s R. a n d R o s e m a r y Feitis. The Endless Web: Fascial Anatomy and Physical Reality, Berkeley: N o r t h Atlantic B o o k s , 1996. Schwind, Peter. Alles in Lot: Korperliches and Seelisches Gleichwicht durch Rolfing. M u n c h e n : G o l d m a n Verlag, 1985. Shafer, R.C. with L . J . Faye. Motion Palpation and Chiropractic Technique— Principles of Dynamic Chiropractic, H u n t i n g t o n B e a c h , California: T h e M o t i o n Palpation Institute, 1989. Steiner, Rudolf. Goethean Science, Spring Valley, N e w York: M e r c u r y Press, 1988. Sultan, Jan H. "Toward a Structural L o g i c , " in Notes on Structural Integration, P u b l i s h e d a n d e d i t e d by H a n s Flury, 1986, p p . 1 2 - 1 6 . Available f r o m the R o l f Institute. Ward, R o b e r t C, executive editor. Foundations for Osteopathic Medicine, Balt i m o r e , Maryland: Williams a n d Wilkins, 1997.

160

INDEX

A AA (atlas on atlas) restrictions, 61, 63 Adaptability, 1 3 3 - 1 3 5 Adductors, 139 Anterior nutation, 72 Anterior superior iliac spine (ASIS), 1 0 3 - 1 0 6 , 108, 1 1 0 Articular pillars/processes, 38 A s h e r j i m , 149 Atlantocciptal junction, 148 Atlas, 61, 63. See also AA restrictions; OA restrictions B Back. See also Spine "goes out," 14, 1 6 - 1 7 pain vs. problems, 1 6 - 1 7 releasing musculature of, 1 3 6 - 1 3 7 Backward bending cervical spine and, 46, 5 1 - 5 2 , 59 lumbar and thoracic spine and, 17, 30-31 OA restrictions and, 6 5 - 6 9 sacrum and, 74—75 Bilateral fixations cervical, 27, 4 5 - 4 6 lumbar and thoracic, 31, 33 sacral, 7 6 - 7 7 C C2-C7 finding, 8, 38 Type II biomechanics of, 52 Cervical spine. See also Neck arrangement of facets in, 24, 4 6 - 4 7

backward bending and, 46, 5 1 - 5 2 , 59 bilateral fixations in, 4 5 - 4 6 finding rotated vertebrae in, 3 8 - 3 9 forward bending and, 5 1 - 5 2 indirect techniques for, 3 7 - 4 5 joint-challenging technique for, 45-50 locating vertebrae, 3 7 - 3 8 motion of, 4, 36 motion testing, 5 1 - 6 0 sidebending and, 3 5 - 3 6 , 56 vertebral arteries and, 46 Cervicothoracic junction, 148 Corrective approach, 1 3 1 - 1 3 2 Costochondral junction, 114, 142 Costotransverse groove, 1 1 6 - 1 1 7 Counternutation, 72 Curvature, 1 4 2 - 1 5 5 as clues, 145 "ideal body," 1 4 2 - 1 4 5 Type I, 148, 1 4 9 - 1 5 5 D Dance of the tissues, 4 3 - 4 4 Demifacets, 1 1 4 , 1 1 5 Dial-a-Neck technique, 4 1 - 4 5 Down-slip, 99, 1 0 4 - 1 0 5 , 1 0 8 - 1 0 9 F Facet restrictions. See also Techniques backward bending and, 17 bilateral fixations, 27, 31, 33, 4 5 - 4 6 discovery of, 1 3 - 1 4 forward bending and, 17 motion restrictions vs., 52

161

SPINAL MANIPULATION MADE SIMPLE sidebending and, 2 - 3 test for, in cervical spine, 5 1 - 6 0 test for, in lumbar and thoracic spine, 2 7 - 3 1 Flare, 99, 1 0 3 - 1 0 4 , 106, 108 Flury, Hans, 97 Forward bending cervical spine and, 5 1 - 5 2 lumbar and thoracic spine and, 17, 30-31 OA restrictions and, 6 5 - 6 9 sacrum and, 72, 7 4 - 7 5

K Kendall, Florence, 143 Korr, I.M., 1 5 - 1 6 Kyphosis, 147 L L4, finding, 8 Levator scapulae, 142 Ligamentous structures, 9 5 - 9 6 , 136 Lordosis, 83, 98, 1 4 7 Lumbar spine arrangement of facets in, 24 psoas a n d , 1 3 9 rotation and, 4, 7 shotgun technique and, 21, 23 test for finding facet restrictions in, 27-31 Type I fixations in, 34 Lumbosacral junction, 148

G Gait patterns, 97 H Hamstrings, 97, 138 Holistic approach, 1 3 1 - 1 3 2 I "Ideal body," 1 4 2 - 1 4 5 ILA. See Inferior lateral angle Iliolumbar ligament, 96 Iliosacral dysfunction, 71, 95. See also Pelvis flare, 99, 1 0 3 - 1 0 4 , 106, 108 shear, 99, 1 0 4 - 1 0 5 , 1 0 8 - 1 1 0 techniques for, 1 0 6 - 1 1 2 testing and palpating for, 9 9 - 1 0 6 torsion, 99, 1 0 5 - 1 0 6 , 1 1 0 - 1 1 1 Iliosacral ligament, 95 Indirect techniques for cervical spine, 3 7 - 4 5 drawback of, 1 1 , 25 for lumbar and thoracic spine, 8 - 1 1 nature of, 9 sacral, 7 5 - 7 6 Inferior lateral angle (ILA), 8 5 - 8 9 , 139 In-flare, 99, 1 0 3 - 1 0 4 , 108 Innominates, 84, 99 Interspinous muscles, 140

M McCreary, Elizabeth, 143 Motion restrictions cervical spine and, 5 6 - 5 9 facet restrictions vs., 52 OA restrictions and, 65, 69 Myofasciae, 135, 136, 139 N Neck. See also Cervical spine AA (atlas on atlas) restrictions, 61, 63 emotions and, 35 imbalances and, 3 5 - 3 6 OA (occiput on atlas) restrictions, 63, 6 5 - 6 9 ribs and, 1 1 6 sidebending and, 46 suboccipital muscles and, 1 4 0 - 1 4 2 Neutral position, 4 "Normal," definition of, 1 4 6 - 1 4 7 Nutation, 72 Nystagmus, 46

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INDEX

O OA (occiput on atlas) restrictions, 63, 65-69 Obliquus capitus inferior, 140, 142 Obliquus capitus superior, 141 Occiput, 63, 1 4 0 - 1 4 2 . See also OA restrictions Organisms, 130 Organs, 129

techniques for, 1 2 1 - 1 2 7 tender points and, 1 1 9 - 1 2 0 torsion of, 1 1 7 - 1 1 8 , 123 Rolf, Ida P., 134, 136, 1 4 3 Rotoscoliosis, 34, 83 Rumpelstiltskin effect, 8 8 - 9 0 S Sacral base, 72 Sacral sulcus, 72 Sacroiliac dysfunction, 71. See also Sacrum

Out-flare, 99, 1 0 3 - 1 0 4 , 106, 108 P Pelvis, 9 5 - 9 8 . See also Iliosacral dysfunction Piriformis, 96, 138 Posterior nutation, 72 Posterior superior iliac spine (PSIS), 1 0 0 - 1 0 2 , 104 Preparation techniques, 134, 1 3 5 - 1 4 2 Pre-reflection, 4 3 - 4 5 Psoas, 96, 139 Q Quadratus lumborum, 139 Quadriceps, 97 R Rectus capitus posterior major, 141 Rectus capitus posterior minor, 141 Retrolisthesis, 155 Rhomboids, 142 Ribs, 1 1 3 - 1 2 7 articulating with spine, 1 1 3 - 1 1 4 dysfunctional thoracic vertebrae and, 1 1 5 - 1 1 6 , 121 11th and 12th, 123 findingfixed,116-121 f i r s t , 1 2 0 - 1 2 1 , 127 floating, 115 influence of, 1 1 3 - 1 1 6 motion-testing, 1 1 8 - 1 1 9 preparation for, 142 subluxation of, 1 1 7 - 1 1 8

palpating for, 72, 7 4 - 7 5 shear, 8 3 - 9 3 techniques for, 7 5 - 7 7 , 9 0 - 9 3 torsion, 74, 8 0 - 8 3 Sacroiliac joint, 71, 95, 139. See also Pelvis; Sacrum Sacroiliac ligament, 95 Sacrospinous ligament, 96 Sacrotuberous ligament, 96 Sacrum, 7 1 - 7 5 . See also Sacroiliac dysfunction Scapula, pain at edge of, 1 1 9 Sciatic pain, 138 Scoliosis, 1 4 8 - 1 4 9 Serratus posterior superior, 142 Shear pelvic, 99, 1 0 4 - 1 0 5 , 1 0 8 - 1 1 0 sacral, 8 3 - 8 8 Shift, 9 6 - 9 8 Shotgun techniques cervical, 4 5 - 5 0 lumbar and thoracic, 1 8 - 2 5 preparation, 1 3 6 - 1 3 7 , 1 4 0 Sidebending cervical spine and, 35—36, 56 lumbar and thoracic spine and, 2 - 4 sacrum and, 74, 8 0 - 8 2 Sitting flexion test, 1 0 1 - 1 0 2 Skepticism, 4 3 - 4 4 Spinal groove, 1 1 6

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Spine. See also Cervical spine; Curvature; Lumbar spine; Thoracic spine classification of motion of, 4 explanations for compromise of, 13 "ideal," 15, 16, 1 4 3 - 1 4 5 importance of treating, 1 - 2 landmarks, 7 - 8 neutral position of, 4 ribs articulating with, 1 1 3 - 1 1 4 segmentation and, 1 5 - 1 6 Spring test, 1 1 8 - 1 1 9 Standing flexion test, 9 9 - 1 0 2 Sternochondral junction, 114, 142 Stork test, 102 Suboccipital muscles, 1 4 0 - 1 4 2 Sultan, Jan, 41, 97, 1 1 5 , 133 Support Principle, 134 Swayback, 98 T Tl finding, 8 first rib articulating with, 1 2 0 - 1 2 1 T8, finding, 8 Techniques for AA restrictions, 63 cervical, indirect, 3 7 - 4 5 cervical, joint-challenging, 4 5 - 5 0 Dial-a-Neck, 4 1 - 4 5 iliosacral, 1 0 6 - 1 1 2 lumbar and thoracic, direct, 31, 33 lumbar and thoracic, indirect, 8 - 1 1 , 25 lumbar and thoracic, shotgun approach, 1 8 - 2 5 for OA restrictions, 6 5 - 6 9 preparation, 134, 1 3 5 - 1 4 2 rib, 1 2 1 - 1 2 7 sacroiliac, 7 5 - 7 7 , 9 0 - 9 3 for Type I curvatures, 1 4 9 - 1 5 5 Thoracic spine arrangement of facets in, 2 3 - 2 4 rotation and, 4, 7

shotgun technique and, 21 test for finding facet restrictions in, 27-31 Type I dysfunction in, 34 Type II dysfunction in, 114, 115, 121 Thoracolumbar junction, 148 Tilt, 9 6 - 9 9 Torsion pelvic, 99, 1 0 5 - 1 0 6 , 1 1 0 - 1 1 1 rib, 1 1 7 - 1 1 8 , 123 sacral, 74, 8 0 - 8 3 Translation Test, 5 1 - 6 0 Tranverse processes, 5, 7, 38 Treatment strategy, creating, 132, 133 Type I dysfunctions, 34, 148, 1 4 9 - 1 5 5 Type II dysfunctions, 17, 19, 27, 31, 114, 115,121 Type I motion, 4, 63, 74 Type II motion, 4, 36 U Unified relationships, 1 2 9 - 1 3 0 Unilateral sacral extension, 86 Unilateral sacral flexion, 86 Unwinding techniques. See Indirect techniques Up-slip, 99, 1 0 4 - 1 0 5 , 1 0 8 - 1 0 9 V Vertebrae. See also Spine derotating, 8 - 1 1 designating rotation of, 7 landmarks, 7 - 8 palpating, 2 - 5 , 7 sidebending and, 2 - 4 tranverse process and, 5, 7 Type II motion and, 27 W Walking, 8 1 - 8 2 , 99

164