Basic_Clinical_Manipulation.pdf

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Clinical Manipulation

Donald Lee McCabe

D O , F A C F P , F A P M

Freeland Medical Center,

Freeland, Washington, USA

The Parthenon Publishing Group

International Publishers in Medicine; Science & Technology

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PO Box 1564, Pearl River, New York 10965, USA Published in the UK by

The Parthenon Publishing Group Limited Casterton Hall, Carnforth,

Lanes. LA6 2LA, England

McCabe, Donald Lee, 1 9 2 5

-The handbook of basic clinical manipulation /Donald Lee McCabe. p. cm.

Includes bibliographical references and index. ISBN: 1-85070-670-0

1. Manipulation—Handbooks, manuals, etc. I. Title.

[DNLM: 1. Manipulation, Orthopedic—handbooks. 2. Osteopathic Medicine. WB 39 M478h 1995]

RM724.M38 1995 615.8'2-dc20 D N L M / D L C

for Library of Congress 95-23661

British Library Cataloguing in Publication Data McCabe, Donald Lee

Handbook of Basic Clinical Manipulation. I. Title

616.0754

ISBN 1-85070-670-0 First published 1996

No part of this book may be reproduced in any form without permission from the publishers except for the quotation of brief passages for the purposes of review Typesetting by H&H Graphics, Blackburn

Printed and bound by J.W. Arrowsmith Ltd., Bristol

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List of illustrations

All illustrations are by the author

Figure 3.1 Use of fingers and hands in palpation Figure 3.2 The sacrospinalis muscle group Figure 3.3 Dorsal sacrospinalis

Figure 3.4 Spinal reflexes for somatic and visceral responses Figure 4.1 Gross structural alterations

Figure 4.2 Crosses mark the axial stress areas Figure 4.3 Leg length check

Figure 4.4 Checking the 45° angle of the feet; patient supine on the table Figure 4.5 Arm lengths

Figure 4.6 Prone testing for acetabular and sacroiliac motion (posterior left sacroiliac lesion)

Figure 5.1 Manipulating hands

Figure 5.2 Rib-springing/stretching Figure 6.1 Cranial bones

Figure 6.2 Cranial motion

Figure 6.3 Craniosacral motion in inhalation (flexion) Figure 6.4 Craniosacral motion in exhalation (extension) Figure 6.5 The tempomandibular joint

Figure 6.6 The tempomandibular joint capsule and ligaments Figure 6.7 The posterior cranial hold

Figure 6.8 The anterior cranial hold

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Figure 6.9 Cranial suture opening Figure 6.10 Occipital pump

Figure 6.11 Temporal rotation

Figure 6.12 Temporal respiratory pump Figure 6.13 Sphenoid ethmoid sinus drainage Figure 6.14 Variation of vomer ethmoid drainage Figure 6.15 Sphenoid ethmoid vomer drainage Figure 6.16 Opening the nasal fossa

Figure 6.17 Anterior tempomandibular joint technique Figure 6.18 Buccal posterior technique

Figure 7.1 Neck with anatomical landmarks Figure 7.2 Superficial muscles under the platysma Figure 7.3 Cervical and brachial nerve plexes Figure 7.4 Deep anterior cervical muscles Figure 7.5 Superficial posterior neck muscles Figure 7.6 Transverse muscle schematic at C-6 Figure 7.7 Suboccipital cervical structures Figure 7.8 Deep posterior cervical long muscles Figure 7.9 The atlas vertebra

Figure 7.10 The axis vertebra

Figure 7.11 Superior view of the atlas showing the odontoid process C-2 held forward by the transverse ligament

Figure 7.12 A cervical vertebra from the C-3 to C-7 section Figure 7.13 Rotation

Figure 7.14 Rotation and extension

Figure 7.15 Cruciate ligamentous complex: sagittal view Figure 7.16 Cruciate ligamentous complex: coronal view Figure 7.17 Atlanto-axial testing

Figure 7.18 Alar testing

Figure 7.19 Alar and accessory testing Figure 7.20 Vertebral artery testing

Figure 7.21 Approach to cervical soft tissue palpation Figure 7.22 Palpation of an articular lesion (1)

Figure 7.23 Palpation of an articular lesion (2) Figure 7.24 Chin-occiput traction

Figure 7.25 Cervical rotation

Figure 7.26 Forearm fulcrum traction Figure 7.27 Lateral traction

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Figure 7.28 Counter-lateral traction 72 Figure 7.29 Suboccipital traction 73

Figure 7.30 Side-slipping 73 Figure 7.31 Counter-pressure springing 73

Figure 7.32 Supine platysma stretch 74

Figure 7.33 Sitting variation 74 Figure 7.34 M E T cervical technique 74

Figure 7.35 Occipito-atlantal technique (1) 75 Figure 7.36 Occipito-atlantal technique (2) 75 Figure 7.37 Occipito-atlantal technique (3) 76

Figure 7.38 Ligamentous technique 76 Figure 7.39 Atlanto-axial technique 76 Figure 7.40 Cervical rotation technique 77 Figure 7.41 Illustration of the hold on the transverse 77

processes of C-2

Figure 7.42 C-l/C-2 technique 77 Figure 7.43 Ligamentous technique 78 Figure 7.44 C-3 to C-7 technique 78 Figure 7.45 Ligamentous technique 78 Figure 7.46 Rotation-side-bending lesion technique 79

Figure 7.47 Flexion lesion technique 79 Figure 8.1 Thoracic skeletal structures 82 Figure 8.2 The 1st, 4th, 5th and 12th thoracic vertebrae 83

Figure 8.3 Thoracic vertebrae with ligaments 84 Figure 8.4 Rib articulations with vertebra and sternum 85

Figure 8.5 Ribs showing respiratory excursion 85 Figure 8.6 Sternoclavicular joint and first rib with 85

ligamentous attachments and disc

Figure 8.7 Anterior thoracic muscles: pectoralis major 86 and minor, subclavius and serratus anterior

Figure 8.8 Posterior thoracic muscles 87 Fiqure 8.9 Superficial dorsal muscles 88 Figure 8.10 Deep thoracic sacrospinalis muscles

Figure 8.11 Thoracic ganglionic sympathetic nerves Figure 8.12 Thoracic segmental sympathetic reflex nerves Figure 8.13 Dorsal soft tissue manipulation

Figure 8.14 Lateral recumbent myofascial technique Figure 8.15 Prone counter-stretch technique

Figure 8.16 Lateral side-bending thoracic testing

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Figure 8.17 Prone upper dorsal vertebral testing Figure 8.18 Upper dorsal vertebral testing with the

patient sitting Figure 8.19 Supine dorsal testing

Figure 8.20 Prone dorsal technique using lower extremity Figure 8.21 Supine dorsal vertebral flexion technique Figure 8.22 Supine dorsal vertebral technique with the

elbows approximated

Figure 8.23 Dorsal vertebral correction with patient sitting or standing

Figure 8.24 Anterior rib testing Figure 8.25 Prone posterior rib testing Figure 8.26 Anterior rib technique Figure 8.27 First rib sitting technique

Figure 8.28 First posterior rib correction with the patient supine

Figure 8.29 Alternative first rib technique Figure 8.30 Alternative first rib technique Figure 8.31 Supine posterior rib technique Figure 8.32 Supine floating rib technique Figure 8.33 Rib springing

Figure 8.34 Standard lymphatic pump Figure 8.35 Lateral lymphatic pump Figure 8.36 Liver pump

Figure 8.37 Liver decongestion variation

Figure 9.1 Muscular attachments of the shoulder girdle Figure 9.2 Ligamentous attachments of clavicle to sternum,

first rib and scapula (anterior view)

Figure 9.3 Testing and correction of the sternoclavicular joint

Figure 9.4 Sternoclavicular joint testing using the shoulder action

Figure 9.5 Spreading and stretching action on the clavicles Figure 9.6 Elevated clavicle technique

Figure 9.7 Depressed lateral clavicle technique

Figure 9.8 Scapula showing anterior (A) and posterior (B) muscle attachments

Figure 9.9 Scapular soft tissue manipulation of the dorsum Figure 9.10 Scapular soft tissue variation

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Figure 9.11 Glenohumeral and acromioclavicular ligaments Figure 9.12 Rotator cuff muscles: (A) superior view; (B)

posterolateral view

Figure 9.13 Muscle actions of the shoulder Figure 9.14 Prone testing of the shoulder joint Figure 9.15 Sitting or standing shoulder technique Figure 9.16 Lateral recumbent shoulder technique Figure 9.17 Supine shoulder technique

Figure 9.18 Spencer shoulder technique Figure 9.19 Elbow joint and ligaments Figure 9.20 Arm muscles

Figure 9.21 The volar or anterior muscles of the elbow and forearm. (A) Superficial muscles; (B) deep muscles

Figure 9.22 Posterior muscles of the forearm.

(A) Superficial muscles; (B) deep muscles Figure 9.23 Proximal radio-ulnar joint testing

Figure 9.24 Trigger proximal radio-ulnar joint technique Figure 9.25 Proximal radio-ulnar technique with two hands

encircling the joint

Figure 9.26 Variation of proximal radio-ulnar technique Figure 9.27 'Hanging the radius' technique

Figure 9.28 Carpal (wrist) bones and ligaments Figure 9.29 Carpal tunnel and median nerve Figure 9.30 Still's wrist technique

Figure 9.31 Carpal technique

Figure 9.32 Adductor pollicis brevis trigger point Figure 10.1 Abdominal cavity with associated muscles Figure 10.2 Scheme of abdominal regions

Figure 10.3 Visceral structures in the abdomen Figure 10.4 Lumbar vertebra

Figure 10.5 Lumbar vertebral right rotation showing iliolumbar and posterior sacroiliac ligaments Figure 10.6 Gravity forces in the lumbar and sacral regions Figure 10.7 Lumbar ligament testing

Figure 10.8 Sectional scheme of the lumbar torso muscles at L-3

Figure 10.9 Iliolumbar psoas spasm complex

Figure 10.10 Pelvic girdle with ligaments. (A) Anterior view; (B) posterior view 121 121 122 123 124 124 125 126 127 128 129 130 131 131 132 132 133 133 134 135 135 135 138 139 139 140 142 142 143 143 144 144

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Figure 10.11 Testing sacroiliac joint motion and ligaments Figure 10.12 Pubic lesion testing

Figure 10.13 Minor pelvis showing coccygeal ligaments Figure 10.14 Lateral myofascial technique

Figure 10.15 Iliolumbar stretching

Figure 10.16 Lumbar stretch with leg leverage Figure 10.17 Lateral lumbar side-bending stretch Figure 10.18 Checking lumbar motion

Figure 10.19 Sitting, twisting and side-bending Figure 10.20 Supine flexion

Figure 10.21 Prone counter-pressure technique Figure 10.22 Prone scissor technique

Figure 10.23 Sacral rocking

Figure 10.24 Lateral lumbar vertebral technique using thigh Figure 10.25 Lateral 'lumbar roll' sacroiliac technique Figure 10.26 Lateral sacroiliac technique for a posterior lesion Figure 10.27 Prone sacroiliac technique

Figure 10.28 Lateral sacroiliac technique for an anterior lesion Figure 10.29 Supine posterior sacroiliac technique with

the knees flexed

Figure 10.30 Supine posterior sacroiliac traction with thrust Figure 10.31 Flexed abducted thigh sacroiliac technique Figure 10.32 Anterior sacroiliac adducted thigh technique Figure 10.33 Pubic lesion, method A

Figure 10.34 Pubic lesion, method B Figure 10.35 Coccyx technique

Figure 10.36 A visceral or omentum lifting technique Figure 11.1 Adductor muscle complex

Figure 11.2 Hip joint ligaments Figure 11.3 Anterior hip muscles Figure 11.4 Posterior hip muscles

Figure 11.5 Deep posterior hip joint muscles Figure 11.6 External rotation testing: sign of four Figure 11.7 Internal rotation testing

Figure 11.8 Knee ligaments

Figure 11.9 Posterior knee muscles

Figure 11.10 Knee ligament testing in the sitting position Figure 11.11 Knee ligament testing in the supine position Figure 11.12 Tibio-femoral technique

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Figure 11.13 Supine proximal tibiofibular technique Figure 11.14 Prone proximal tibiofibular technique Figure 11.15 Meniscus technique

Figure 11.16 Anteromedial meniscus lesion correction Figure 11.17 Coronal section of ankle joint

Figure 11.18 Lateral ankle ligaments Figure 11.19 Medial ankle ligaments Figure 11.20 Fibular ligaments of ankle

Figure 11.21 Testing posterior tibial displacement Figure 11.22 Testing anterior tibial displacement Figure 11.23 Ankle traction technique

Figure 11.24 Talotibial and talocalcaneal technique Figure 11.25 Anteromedial talocalcaneal lesion treatment Figure 11.26 Transverse arch of the foot

Figure 11.27 Longitudinal arch, lateral view Figure 11.28 Longitudinal arch, plantar view Figure 11.29 Spring ligament

Figure 11.30 Foot stirrup Figure 11.31 Long arches

Figure 11.32 Walking weight-bearing sequence Figure 11.33 Tarsal testing

Figure 11.34 Releasing joint pressure Figure 11.35 Talocalcaneal testing

Figure 11.36 Plantar vectors for thrust correction Figure 11.37 Correction of cuboid tarsal lesion Figure 11.38 Supine cuboid thrust

Figure 11.39 Metatarsophalangeal release Figure 11.40 Spring action technique

Figure 12.1 Superficial cervical fascia with platysma

Figure 12.2 External deep cervical fascia, transverse section Figure 12.3 Lumbodorsal fascia, transverse section

Figure 12.4 Anterior cervical fascia release Figure 12.5 Thoracic outlet/inlet technique Figure 12.6 Anterior chest release

Figure 12.7 Upper chest release Figure 12.8 Thoracosternal release Figure 12.9 Lower anterior rib release Figure 12.10 Rib release technique Fiqure 12.11 Rhomboid-scapula release

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Figure 12.12 Respiratory diaphragm lift

Figure 12.13 External arcuate ligament release Figure 12.14 Lumbodorsal fascia

Figure 12.15 Torso twisting-stretching lumbodorsal fascia technique

Figure 12.16 Iliolumbar stretch, method 2

Figure 12.17 Iliolumbar stretch and release, method 3 Figure 12.18 Lumbosacral fascial release

Figure 12.19 Pelvic diaphragm lift technique

Figure 12.20 Upper extremity fascia with cross-sections Figure 12.21 Shoulder release

Figure 12.22 Upper extremity fascial twisting technique Figure 12.23 Thenar trigger point

Figure 12.24 Lower extremity fascia with cross-sections Figure 12.25 Modified lower extremity twisting

Figure 13.1 Neck with hands only

Figure 13.2 Neck manipulation using an aid to create pressure

Figure 13.3 Cervicodorsal and interscapular/shoulder pain technique

Figure 13.4 Chest-shoulder stretch

Figure 13.5 Dorsal recumbent leg-thigh flexion Figure 13.6 Lateral recumbent twist

Figure 13.7 Dorsal recumbent leg raise Figure 13.8 Flexing the plantar muscles

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Foreword

The use of the hands to bring about changes in patients is no doubt as old as civilization itself, perhaps older. The practice can be found throughout the world and in all cultures and has been a part of medicine from ancient to modern times. There have been various theoretical constructs and models presented to account for the empirical results obtained by multiple types of practitioners. As with most things, multiple educational systems have evolved and are evolving to contribute to this body of knowledge.

In general, there have been few books produced on manual medicine, as manipulation has come be known, in comparison to other branches of the healing arts. Perhaps even more books have been written to decry the lack of 'scientific evidence' for manipulation than have been written in its defense. The osteopathic community has been somewhat remiss in producing books to fulfill this need. As early as 1927, Leon Page, DO stated: 'There has been no new book on the fundamental principles of osteopathic practice in recent years'. Dr McCabe has done his part to change the situation.

In many ways, Dr McCabe has returned to the roots of osteopathic writing in the production of this book. From the start of the profession in 1892 until the period of the Second World War, the body of osteopathic literature was, in general, produced by the people actually performing the techniques. This resulted in a lack of systematic

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terminology which continues to the present. Each writer chose descriptive terms which they felt were appropriate to the explanations of their techniques. For perhaps the last 50 years, and especially during the last 30, there has been a movement within the osteopathic profession to codify the language and the treatments described. During this period, many of the books produced have been written by the teachers of technique in the various osteopathic institutions, rather than the practitioners of the art. The book contains elements of both camps.

Dr McCabe has produced a book which will be of interest to a broad range of practitioners within and outside the osteopathic profession because of its readable and practical approach to manual medicine. While it is written by a generalist for generalists it will find a place on the bookshelves of specialists as well as any practitioners who perform manual treatment in their practice. Allopathic, chiropractic, naturopathic, as well as other physicians and physical therapists, should find this book useful because of its simple, straightforward approach.

The book is not intended to be the final word on all aspects of manual medicine but to provide lifelong learners an opportunity to expand their knowledge base with the principles necessary to develop and utilize procedures of their own that benefit the patients in their practice.

Loren H. Rex, DO

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In almost all c a s e s , patients c o m e to a physician b e c a u s e t h e y a r e suffering and they are s e e k i n g relief from pain and discomfort. T h e particular diagnosis is generally of s e c o n d a r y importance at t h e t i m e . Even w h e n there is a specific diagnosis, however, c o m m o n s e n s e a n d years of e x p e r i e n c e tell me that - e x c e p t in such c a s e s as injury due to accident - it is a rare patient who h a s an organ with an isolated disease in some limited s e n s e . In reality, every d i s e a s e affects t h e whole person.

It is my b e l i e f that treatment of most patients' c o m p l a i n t s should not be limited to just treating a specific c a t e g o r i c a l d i s e a s e . Instead, it is n e c e s s a r y to treat the w h o l e person. Every d i s e a s e p r o c e s s is set in motion by (and in turn s e t s in m o t i o n ) a v a r i e t y of p h y s i c a l , c h e m i c a l and psychological events. T h i s is w h y d i s e a s e p r o c e s s e s affect the whole body, and why, therefore, just treating a particular disease area for symptomatic relief most often l e a v e s s o m e t h i n g to be desired.

A ' h o l i s t i c ' p i c t u r e of d i s e a s e c a n s e e m a bit o v e r w h e l m i n g ; however, i t a c t u a l l y b r i n g s e n o r m o u s h o p e a n d p r o m i s e t o t h e physician's role (by 'physician' I m e a n not only a trained doctor, but a n y p e r s o n a c t i n g o n b e h a l f o f a n o t h e r i n a h e a l i n g r o l e , a n d especially, perhaps, t h e patient who wishes to a s s u m e responsibility

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for his or h e r own well-being). This holistic approach m e a n s that every d i s e a s e must h a v e an observable physical manifestation, a departure from the status of health, w h i c h c a n be s e e n as a w a y to 'get a h a n d l e ' on a p a r t i c u l a r i l l n e s s . T h i s structural c o m p o n e n t of t h e d i s e a s e p r o c e s s is significant, and I b e l i e v e it should be addressed as a vital part of treatment. Manipulation is a manual method of dealinq with

adverse structural conditions that reflect less visible components of disease.

Patients appreciate physicians who s e e t h e m as people, not j u s t a c o l l e c t i o n o f s y m p t o m s r e p r e s e n t i n g a p a r t i c u l a r d i s e a s e . T h e 'traditional' view tends to treat specific d i s e a s e s without regard for t h e w h o l e person. This approach may be prudent in the practice of c e r t a i n s p e c i a l t y a r e a s , but not only is that narrower p e r s p e c t i v e unnecessary, it fails to m a k e use of a wide range of treatment methods and tools. Applying the principles of manipulation often provides a n e w and e a s y a c c e s s to t h e treatment of d i s e a s e and the restoration of w e l l - b e i n g .

T h e purpose of this text is twofold. First, it is to help e n c o u r a g e the integration of manipulation into the g e n e r a l practice of m e d i c i n e and s e c o n d , t o p r o v i d e a h e l p f u l m a n u a l for a n y o n e i n t e r e s t e d i n u n d e r s t a n d i n g t h e b a s i c s involved in t h e u s e of m a n i p u l a t i o n in improving the total ' w e l l n e s s ' of the organism - physiologically and psychologically.

T h i s b o o k specifically addresses the treatment of altered structural c o m p o n e n t s that reflect d i s e a s e p r o c e s s e s and describes methods for relieving symptoms, signs and underlying disease.

M A N I P U L A T I O N : A N A N C I E N T A R T / N E W S C I E N C E

M a n i p u l a t i o n refers to certain m a n u a l procedures for both detecting and interpreting irregularities in the body structure and then applying s p e c i f i c m a n u a l m a n e u v e r s to r e s t o r e a m o r e b a l a n c e d p h y s i c a l structure. T h e improved structure e n h a n c e s the b o d y ' s efforts in re-establishing health.

Historically, the use of manipulation to alleviate pain and suffering is not new. T h e r e are references to its use dating b a c k 4 0 0 0 years in I n d o - C h i n a ; however, in America, it was only in the last century that b o d y structure w a s c o n s i d e r e d to be an important c o m p o n e n t of

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disease in general. In the late 1800s, a Mid-west physician, Dr Andrew Taylor Still, b e g a n to note a correlation b e t w e e n his findings of altered structure in his patients and the v a l u e of treating t h e s e c h a n g e s to help patients r e c o v e r from illness. Dr S t i l l o r g a n i z e d a structural system for d i a g n o s i n g and treating diseases, b a s e d on manipulation. O u t o f h i s w o r k g r e w t h e o s t e o p a t h i c p h i l o s o p h y a n d t h e first osteopathic m e d i c a l school

Dr Still g a v e the initial impetus for this n e w form of t r e a t m e n t a n d the use of manipulation was elaborated by some of his followers. O n e of Dr Still's students, G e o r g e Palmer, split off from the t h e n A m e r i c a n S c h o o l of O s t e o p a t h y (now the Kirksville C o l l e g e of O s t e o p a t h i c M e d i c i n e and Surgery) before c o m p l e t i n g his m e d i c a l e d u c a t i o n to found a school promoting a specific manipulation w h i c h he c a l l e d chiropractics.

T h e u s e of manipulation, with its related structural considerations, has m a d e osteopathic m e d i c i n e and surgery distinct from t h e m a i n stream of allopathic m e d i c i n e . O s t e o p a t h i c m e d i c i n e ' s e m p h a s i s is on treating the body, or host, m a n u a l l y to provoke or to initiate t h e patient's own response to body stresses, w h i c h m a y be in part due to structural d e r a n g e m e n t . In contrast, traditional (allopathic) m e d i c i n e has focused on and addressed t h e d i s e a s e process, a t t e m p t i n g to specifically treat symptomatic factors, principally with m e d i c a t i o n . T h e allopathic m e d i c i n a l approach h a s b e e n to treat t h e d i s e a s e ; t h e osteopathic approach, in contrast, is to treat the p e r s o n holistically with e m p h a s i s on structural c o n s i d e r a t i o n s . T h i s holistic position includes h y g i e n e in the most c o m p r e h e n s i v e s e n s e . Both allopathic a n d o s t e o p a t h i c p h i l o s o p h y h a v e m e r i t ; t h e y a r e n o t m u t u a l l y exclusive.

M e d i c a l subjects a r e usually d i s c u s s e d a n d written about with reference to a specific d i s e a s e ; m e d i c a l p r a c t i c e s a r e c a t e g o r i z e d under various recognized specialties. It is no wonder, therefore, that subscribed treatments tend to be specific to the descriptive d i s e a s e without consideration of the entire person. In this light, from t h e perspective of allopathic medicine, manipulation has b e e n considered and presented specifically, as a thing unto itself, not as an e n t i r e system to be used in the context of total patient c a r e . T h i s is in sharp contrast to t h e original c o n c e p t of manipulation, w h i c h w a s to focus attention on t h e structural reflection of d i s e a s e in both d i a g n o s i s a n d treatment.

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T h e position subscribed to h e r e i n is that manipulation is applied in order to facilitate the host r e s p o n s e to disease, by addressing the structural deviations that o c c u r in various diseases as s e e n in g e n e r a l practice, in order to e n h a n c e t h e b i o m e c h a n i c a l and b i o c h e m i c a l host r e s p o n s e s for o p t i m a l h e a l i n g . M a n i p u l a t i o n m a y s e r v e a s a preventative m e a s u r e , s i n c e structural c h a n g e s (lesions) m a y take p l a c e prior to overt or manifest d i s e a s e .

H O M E O S T A S I S : L I F E I N B A L A N C E

A l l d i s e a s e r e f l e c t s s t r u c t u r a l , b i o c h e m i c a l a n d p s y c h o l o g i c a l i m b a l a n c e w i t h i n t h e body. S c h e m a t i c a l l y , t h e e q u i l i b r i u m o f h o m e o s t a s i s , the state of health, is m a i n t a i n e d by a proper b a l a n c e b e t w e e n t h e s e descriptive a r e a s . D i s e a s e is a reflection of a body's i m b a l a n c e of t h e s e areas, with o n e or more of t h e s e areas put under stress. W h e n this occurs, the most dominant area of d e c o m p e n s a t i o n will g e n e r a l l y be prominent as the primary area of stress with the o t h e r two a r e a s s u p p l e m e n t i n g t h e i m b a l a n c e . I f t h i s t h e o r y i s a c c e p t a b l e , it s u g g e s t s that treatment may very well be only n e e d e d t o a d d r e s s t h e p r i m a r y d e c o m p e n s a t i o n (the d i s e a s e ) s i n c e t h e s e c o n d a r y r e a c t i o n s would a p p e a r t o b e s e l f - c o r r e c t i n g o n c e t h e primary d i s e a s e system is corrected; however, s o m e t i m e s this does not h a p p e n . In such c a s e s , addressing the structural dysfunction may m a k e t h e difference in t h e host's r e s p o n s e to m e d i c i n a l or other treatment.

By improving structure with manipulation, body functions improve, c i r c u l a t i o n i m p r o v e s , n e u r o v a s c u l a r t o n e i m p r o v e s , a n d o r g a n functioning improves, such as is s e e n in the i m m u n e response. It is understandable that patients usually feel better and more comfortable after manipulation.

Structural alterations h a v e pervasive and specific effects on the b o d y ' s functioning. T h e s e are not simply limited to the m u s c u l o -s k e l e t a l ti-s-sue. O t h e r ti-s-sue-s are affected, too, -such a-s arterie-s, vein-s, lymphatics, and glandular and n e u r o l o g i c a l tissues.

Clearly, a b o n e fracture is a primary structural disease, but there a r e a l s o b i o c h e m i c a l a n d p s y c h o l o g i c a l c h a n g e s . S i m i l a r l y , i n p n e u m o n i a , w h i c h i s p r i m a r i l y a b a c t e r i a l - b i o c h e m i c a l i l l n e s s , structural c h a n g e s occur, such as b i o m e c h a n i c a l restrictions of the t h o r a c i c myofascial contractures (i.e. costal or rib musculature and

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respiratory d i a p h r a g m ) and p u l m o n a r y c o n g e s t i o n , w h i c h affect cardiopulmonary function m e c h a n i c a l l y and biochemically.

B i o c h e m i c a l c h a n g e s result not only from structural alterations but also from m e t a b o l i c alterations. D i s e a s e of o n e system c a n c a u s e regressive psychological c h a n g e s , for instance, resulting in a patient's l o s s o f i n d i v i d u a l i n d e p e n d e n c e a n d i n h i s b e c o m i n g a u t o -intoxicated.

Osteopathic manipulation, presented herein, can affect the b a l a n c e of the structural c o m p o n e n t of the h u m a n a n a t o m y in s u c h a w a y as to t r i g g e r a host r e s p o n s e , reflectively a n d a s s o c i a t i v e l y , with a s u b s e q u e n t r e - b a l a n c i n g o f b i o c h e m i c a l a n d p s y c h o l o g i c a l components. Thus, the patient has an opportunity to e x p e r i e n c e o n c e more the full-life restoration of body, mind and spirit.

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WHAT IS A 'LESION'?

S o m e patients ask me, 'What's c a u s i n g my pain? Do I h a v e a b o n e out of p l a c e ? Did I pull a m u s c l e ? ' Perhaps p e o p l e get t h e i d e a that there is simply a b o n e out of p l a c e b e c a u s e t h e r e is g e n e r a l l y s o m e s k e l e t a l o r b o n e / j o i n t c o r r e c t i o n o r a d j u s t m e n t n e c e s s a r y i n t h e treatment of lesions by manipulation, but to s a y , simply, that a b o n e is 'out' limits our understanding of what a lesion is. For a b o n e or joint malfunction to occur, there must be c o n c o m i t a n t alterations in all associated structures, including ligaments, fascia, m u s c l e s a n d neurocirculatory structures. A useful a n a l o g y is that if o n e p i e c e in a c l o c k m e c h a n i s m g o e s wrong, it affects t h e entire function of t h e t i m e p i e c e .

Physiologically, all healthy tissue must be free to m o v e within t h e r a n g e s intended by nature. Any restriction in t h e n o r m a l or optimal motion is pathological, and the d e g r e e of restriction d e t e r m i n e s t h e extent of d i s e a s e . In short, life is motion. D e a t h is t h e e p i t o m e of restricted motion. W h e n parts of t h e body a r e immobilized for too long, there c a n be atrophy or tissue degradation.

E v e n in m e d i c a l circles, w h e n the term 'lesion' is used, r e f e r e n c e to articular elements is generally inferred. However, this is too limiting

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and m a y be misleading for a fuller therapeutic understanding. For a m o r e t h o r o u g h u n d e r s t a n d i n g , it is n e c e s s a r y to t h i n k of all t h e s t r u c t u r e s a s b e i n g i n a n i n t e r - r e l a t e d c o m p l e x . T h u s , a m o r e c o m p r e h e n s i v e understanding of t h e c o n c e p t of lesions must include c o n s i d e r a t i o n s of all a s s o c i a t e d a n a t o m i c a l structures affected by structural d e c o m p e n s a t i o n .

A c c c o r d i n g to D o r l a n d ' s The American Illustrated Medical

Dictionary, a lesion is any pathological or traumatic discontinuity of

tissue or loss of function of a part. Simply put, a lesion is an alteration of structure from the norm.

T h e American Osteopathic Association defines a lesion as a somatic dysfunction. In o s t e o p a t h i c m e d i c i n e , an a r t i c u l a r l e s i o n is any alteration in t h e a n a t o m i c a l or p h y s i o l o g i c a l relationships of t h e articular (musculoskeletal) structures, resulting in local and/or remote functional d i s t u r b a n c e . An o s t e o p a t h i c l e s i o n is a n y p a t h o l o g i c a l variation from the normal in the position of soft tissue support and m o b i l i t y o f o n e o r m o r e s k e l e t a l s t r u c t u r e s w h i c h o r i g i n a t e s o r registers signs and/or symptomatology or pathology; however, some lesions are non-symptomatic.

T h e s e d e f i n i t i o n s i n c o r p o r a t e c o n s i d e r a t i o n o f a b n o r m a l interosseous (bone-to-bone) relationships, with either restricted or e x c e s s i v e motion, a b n o r m a l soft tissues (lymphatics, blood vessels, nerves, fascia, muscle, ligaments), as well as both peri-articular and remote tissues. It should be noted, too, that some lesions are non-symptomatic to the patient, i.e. not apparent to the patient.

WHAT C A U S E S A L E S I O N ?

A n y o n e c a n e x p e r i e n c e a lesion at a n y time in life, but, in general, t i m e t a k e s its toll. In a world fraught with s t r e s s e s from gravity, t e c h n o l o g y and accident, the breakdown of all systems is a fact of life. S o m e c a u s e s of lesions are:

(1) F a t i g u e : c a u s e s i n c r e a s e d irritability of myofascial soft tissues. (2) Psychic tension: aberrant psychic e n e r g y shunted to an organ;

t h e p s y c h o s o m a t i c factor of c a t h e c t i n g psychic e n e r g y to body structures such as m u s c l e s or the gut.

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(4) Direct force: t r a u m a or injury, direct or indirect.

(5) Reflex: a viscero-somatic effect, such as kidney infection c a u s i n g b a c k pain.

(6) I n f e c t i o n : viral o r o t h e r b a c t e r i o l o g i c a l f a c t o r s w i t h t o x i n s causing irritability or pain in m u s c l e s and n e r v e s .

(7) T h e r m a l : cold draughts, dampness, hot dry conditions. (8) E x a g g e r a t i o n of motion: e x e r c i s e or work.

(9) Toxic c h e m i c a l s : smoke, a l l e r g e n s , alcohol, c l e a n i n g liquids, DDT, etc.

Other factors that modify physiological m o v e m e n t s a n d affect t h e s e v e r i t y o f l e s i o n s a r e : g r a v i t y ; a r t i c u l a r f a c e t s a n d j o i n t configurations; bony shapes; and soft tissue limits of fascia, l i g a m e n t s and m u s c l e s .

Lesions may be either primary or secondary. T h e y c a n manifest t h e m s e l v e s a c u t e l y , s u b - a c u t e l y o r c h r o n i c a l l y a n d m a y o c c u r insidiously a n d quietly. A n e x a m p l e o f t h e first m i g h t b e a c u t e torticollis (wry neck) from sitting in a cold draught. Another condition is an acute lower b a c k pain from getting out of b e d or b e n d i n g over to pick something up. T h e latter may manifest itself by j u s t gradually f e e l i n g b e l o w p a r o r b y finding p r o g r e s s i v e l i m i t a t i o n i n s o m e movements where the pain is not obviously c a u s e d by an overt injury.

S t r u c t u r a l l e s i o n s , i.e. altered t i s s u e structure, a r e m a n i f e s t e d particularly in overt disease, but lesions also occur in covert conditions and may be a precursor condition for the inception of overt d i s e a s e . Thus, the identification of structural lesions contributes materially to understanding pathological processes, so h e l p i n g in the prevention and active treatment of d i s e a s e .

A structural lesion (osteopathic) is any structural perversion that produces or maintains functional c h a n g e s from the norm, reflecting disorder somatically, viscerally, neurally, vascularly, glandularly and psychologically. To better understand the i m p o r t a n c e of structure in h e a l t h a n d d i s e a s e , i t m u s t b e a p p r e c i a t e d t h a t ' o s t e o ' (as i n osteopathy) refers to structure, not simply to b o n e . T h e somatic or body effects of structural lesions are demonstrated in motor, sensory a n d v i s c e r a l c h a n g e s , t h e l a t t e r h a v i n g b e e n d o c u m e n t e d i n postmortem tissue e x a m i n a t i o n s .

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T h e perception a n d appreciation of specific lesions c o m e s through p a l p a t i o n ( t h e m a n u a l p r a c t i c e o f d i a g n o s t i c o s t e o p a t h i c m a n i p u l a t i o n ) . Lesions c a n b e d e t e c t e d by:

(1) A l t e r e d s k e l e t a l s t r u c t u r e w i t h a l t e r a t i o n o f j o i n t m o t i o n . M u s c u l o s k e l e t a l lesions involve different kinds of joints. T h e r e are t h r e e types of j o i n t s :

(a) Fibrous j o i n t s : contiguous fibrous tissue, little motion, e.g. c r a n i a l calvarium sutures, distal fibulo-tibial joint;

(b) Cartilaginous joints: hyaline cartilage or fibrocartilage disc, l e a s t m o t i o n , e . g . s y m p h y s i s p u b i s , s p h e n o b a s i l a r synchondrosis; and

(c) Synovial joints: connective tissue capsule, most motion, e.g. elbow, k n e e , shoulder.

(2) Altered soft tissues:

(a) M u s c l e : m a y be palpated as fibrous, ropey, boggy, jelly-like, rubbery;

(b) F a s c i a : m a y be hypertonic (tight) or hypotonic (loose); (c) Vascular: c o n g e s t e d , nodular, with a thrill; and

(d) V i s c e r a : swollen, rigid, ptosed.

S T R U C T U R E G O V E R N S F U N C T I O N

N o r m a l function is d e p e n d e n t on normal structure. W h e n h u m a n structure is altered by stress, w h e t h e r due to physical, c h e m i c a l or p s y c h o l o g i c a l factors, t h e r e is usually acutely i n c r e a s e d irritability a n d e d e m a of soft tissues, w h i c h is a sign and/or symptom (if pain is present) of t h e somatic c o m p o n e n t of active or incipient d i s e a s e .

W h e n a structural lesion is chronic, t h e surrounding myofascial soft tissues m a y be found to be fibrous and more rigid than normal a n d t h e pain or s o r e n e s s noted is not usually as great as w h e n the lesion is a c u t e .

For a c o m p r e h e n s i v e u n d e r s t a n d i n g of t h e pervasive effects of lesions, attention should be paid to the inter-relationships of body s y s t e m s or parts, particularly t h e nervous system. T h e autonomic nervous system reflects the interdependency of various parts of the

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body: consider the viscero-somatic, visceral, a n d somatico-somatic reflexes. Alterations in structure effect s o m a t i c o - v i s c e r a l reflexes, causing visceral functional c h a n g e s that in time lead to organic structural c h a n g e s . As examples, consider the w a y in w h i c h lower b a c k lesions alter bowel function, or cervical lesions c a u s e h e a d a c h e s or b r o n c h i a l p r o b l e m s . D u e to t h e c o n t i n u i t y of m u s c l e s a n d fascia, structural c h a n g e s to the lower b a c k c a n effect structural c h a n g e s up the central axis, causing lesions in the cervico-occipital area.

To b e t t e r a p p r e c i a t e structural l e s i o n s , a p e r s o n m u s t l e a r n to p e r c e i v e v a r i a t i o n s i n t i s s u e t e x t u r e s b y p a l p a t i o n . T h i s i s a c c o m p l i s h e d b y t h e r e p e a t e d p r a c t i c e o f p a l p a t i n g t i s s u e s . A practitioner must touch and feel the tissues or he or s h e will certainly not develop discretion a n d a p p r e c i a t i o n of t h e a n a t o m i c a l t i s s u e c h a n g e s that o c c u r as a result of d i s e a s e . Information g a i n e d by palpation expands a physician's understanding of the disease process. For example, w h e n there is a sore throat or upper respiratory infection, s i m p l y o b s e r v i n g t h e p e r s o n ' s o r o p h a r y n x l i m i t s a p h y s i c i a n ' s understanding of the disease considerably as compared to a physician who also palpates t h e n e c k and underlying soft t i s s u e s a n d finds c o n g e s t i o n with a d e n o p a t h y and m y o f a s c i a l c o n t r a c t u r e s . Also, a physician who just looks at a leg does not g a i n as m u c h information a s o n e who feels a n d p a l p a t e s t h e l e g for e v i d e n c e o f v a s c u l a r insufficiency, inflammation or the extent of e d e m a , or w h e t h e r t h e e d e m a is hydrophilic or lipophilic.

Lesions exhibit asymmetry of form and function, altered r a n g e of motion and tissue deviation from the optimal p h y s i o l o g i c a l texture. Textural c h a n g e s m a y be felt, from a slight b o g g i n e s s to a c o a r s e fibrousness in myofascial tissues as c o m p a r e d to t h e n o r m a l texture of relaxed forearm muscles, or in t h e c a s e of articular lesions t h e r e may b e ligamentous c o n g e s t i v e c h a n g e s altering the n o r m a l texture. It is helpful to compare the homologous or contralateral tissues, w h i c h may be t a k e n as the norm, such as in testing a l e s i o n e d shoulder and comparing it with the opposite shoulder.

S t r u c t u r a l c h a n g e s a r e e i t h e r t h e result of a c t i v e d i s e a s e or a condition leading to a further d i s e a s e p r o c e s s or both. M a n y l e s i o n s are covert a n d a r e not a p p r e c i a t e d u n l e s s r e v e a l e d b y p a l p a t o r y testing, although some structural lesions are overtly called to attention by pain or discomfort w h i c h is noted by patients and called to t h e e x a m i n e r ' s attention.

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T h e role of structure in t h e t r e a t m e n t of s o m e d i s e a s e s h a s b e e n a c c e p t e d i n part b y a l l o p a t h i c m e d i c i n e b y t h e i n c o r p o r a t i o n o f p h y s i c a l m e d i c i n e i n t o p r a c t i c e ; however, t h e a l l o p a t h i c u s e o f manipulation is not with t h e sophisticated theoretical view as already e x p r e s s e d . S t r u c t u r a l t r e a t m e n t w i t h m a n i p u l a t i o n i s g e n e r a l l y a c c e p t e d i n s o m e lower b a c k a n d n e c k problems, but even h e r e the incorporation of manipulation into t h e total m e d i c a l program is often l a c k i n g . T h o s e conditions w h i c h are treated with manipulation are g e n e r a l l y a c c e p t e d as primary structural problems; however, there are diseases with considerable structural c h a n g e that are not generally s e e n a s i n v o l v i n g s t r u c t u r a l p r o b l e m s , s u c h a s p n e u m o n i a , hypertension or gastroenteritis. However, the structural c h a n g e s play an important part in t h e d i s e a s e p r o c e s s and in the host response to treatment. T h e s e m e d i c a l diseases also respond well to manipulation. It must be b o r n e in mind that, as with any treatment modality or prescription, t h e treatment does not always yield the desired or usual host r e s p o n s e . T h e r e a r e s o m e p e r s o n s w h o respond very well to manipulative treatment; on the other hand, t h e r e are a few patients who do not respond well to manipulation, t h e y are usually persons who do not like b e i n g t o u c h e d .

T h e most frequent c a u s e of patients s e e k i n g m e d i c a l help is pain. After manipulation is judiciously applied for the correction of lesions, patients usually e x p e r i e n c e a feeling of relief from pain to some degree and/or have a feeling of well-being, s o m e i m m e d i a t e l y and others several hours later. T h i s effect m a y last from a day or more to a few w e e k s d e p e n d i n g o n t h e p a t i e n t ' s condition. I n the manipulative t r e a t m e n t of s o m e conditions, t h e r e are dramatically good results w h i c h take a patient from crippling pain to freedom of motion and p a i n l e s s n e s s . Undoubtedly this feature h a s materially contributed to patients s e e k i n g manipulative therapy. To those of us who have an understanding of the underlying principles of manipulation, it c o m e s as no surprise w h e n patients respond dramatically. S o m e t i m e s we forget j u s t h o w g o o d a p e r s o n feels after m a n i p u l a t i o n , so it is r e c o m m e n d e d t h a t p e r s o n s w h o p r a c t i s e m a n i p u l a t i o n a l s o e x p e r i e n c e m a n i p u l a t i o n from t i m e to time. W h a t is n e c e s s a r y in a d d r e s s i n g the treatment of a structural lesion is that it is considered as part of t h e total treatment program for the patient. T h e treatment m a y involve only the u s e of manipulation, or t h e r e m a y also be a n e e d t o u s e s u p p o r t i n g m e d i c a t i o n , s u c h a s a n o d y n e s , a n t i -inflamatory agents, m u s c l e relaxants, etc.

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T h e purpose of this text is to facilitate a holistic program for t h e c o n c u r r e n t u t i l i z a t i o n o f b i o p h y s i c a l ( s t r u c t u r a l ) , b i o c h e m i c a l (medicines) and psychological modalities in t h e treatment of patients with various disorders by g e n e r a l practitioners.

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Before therapeutic manipulation c a n be used, tissue discretion a n d appreciation are needed, and this appreciation c o m e s with i n c r e a s i n g e x p e r i e n c e in palpating body structures. T h e ten fingers of t h e h a n d s are unsurpassed for diagnostic and m a n u a l treatments. H a n d s m a y disclose information about a patient that c a n be g a i n e d in no other way. T h e information is u n i q u e . Observation, auscultation, radiology, myography or t h e r m o g r a p h y a l o n e c a n n o t give the information that palpation may give. T h e r e is no other m e a n s apart from various X-ray techniques of assessing certain structures other than by palpation. T h e use of palpation r e q u i r e s tactile p e r c e p t i v e sensitivity of t h e hands, a i d e d b y o b s e r v a t i o n . With t h e d e v e l o p m e n t o f t h e v e r y i m p o r t a n t s e n s e o f t o u c h , a n e w a p p r e c i a t i o n i s g a i n e d o f t h e importance of structure in the detection of l e s i o n s for diagnosis a n d treatment. T h e use of palpation is applicable to all tissues: skin, fascia, muscle, skeletal, vascular and visceral.

J u s t as the a v e r a g e person c a n n o t m a k e s e n s e out of braille until he or she h a s b e e n taught the m e a n i n g of t h e dots a n d h a s h a d r e p e a t e d p r a c t i s e i n f e e l i n g t h e s m a l l , r a i s e d dots, s o i t i s i n a p p r e c i a t i n g t h e v a l u e o f a l t e r e d s t r u c t u r e b y p a l p a t i o n . A n experienced carpenter c a n tell what kind of wood he is using j u s t by using his s e n s e of t o u c h on t h e w o o d . An e x p e r i e n c e d t a i l o r or

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d r e s s m a k e r c a n tell what the fabric is, w h e t h e r it is linen, cotton, silk or w o o l simply by his or h e r s e n s e of touch. Likewise, b e c o m i n g proficient in palpation requires repeated and focused use of the tactile s e n s e . To b e c o m e well-versed in t h e talent of manipulation, repeated use of the tactile s e n s e is n e e d e d to appreciate the quality of structure a n d t h e l e v e l o f vitality o f t i s s u e s i n h e a l t h a n d d i s e a s e . W h e n p a l p a t i n g or actively manipulating, t h e operator should maintain tactile discrimination of the affected area as m u c h as possible so as to appreciate tissue c h a n g e s . T h e experienced palpator perceives with his hands what the novice has yet to learn.

T h e proper use of palpation is essential for successful manipulation. T h e practitioner's hands must be n i m b l e and sensitive in order to be sufficiently receptive to p e r c e i v e tissue c o n s i s t e n c y or texture in the neutral or normal state through the r a n g e of motion. For instance, w h e n the n e c k is cradled with both hands, the fingers are used to feel and explore t h e various levels of structure from the skin right down to the bony anatomy - the cervical spine. T h e practitioner notes t h e d e g r e e of joint flexibility or restriction while gaining appreciation o f t h e t e x t u r e , t o n e a n d t e m p e r a t u r e o f t h e m u s c l e s , fascia and lymphatics. Attention is paid to areas of congestion (which are tender or painful on palpation) in t h e soft and/or bony structures. W h e n a m u s c l e is involved in a lesion, the tendinous a t t a c h m e n t s are at least c o n g e s t e d , if not painful to s o m e d e g r e e .

In palpatory e v a l u a t i o n of structures, t h e texture, consistency, r e s i l i e n c e , t e m p e r a t u r e and motion should be d e t e r m i n e d . Is the structure freely moveable, rigid, fibrous, tender or painful, etc.? It is one thing to touch tissue, but it is more important to s e n s e the quality. It is important to visualize the anatomy under inspection, palpation or manipulation.

Performing a c c u r a t e tissue appreciation during palpation requires the development of sensitivity and dexterity of the fingers and hands. In g e n e r a l , 'tissue s e n s e ' is best appreciated with the pads of the thumb, i n d e x or middle fingers; finger tips are not as sensitive as the pads (Figure 3 . 1 ) .

Discriminating tactile palpation m a y discern the following tissue c h a n g e s :

(1) Superficial palpation:

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Figure 3.1 Use of fingers and hands in palpation

(b) Superficial m u s c l e and fascia tension: normal, l a x or t e n s e ; and

(c) Temperature: warm, hot, cool or normal. (2) D e e p palpation:

(a) M u s c l e and fascia tone: resistant (firm or t e n s e ) , ropiness, fibrous, heavy or i n c r e a s e d density, e d e m a t o u s or normal. (b) Structural c h a n g e s :

(i) Interrelationships: flexion, rotation, fixation; a n d (ii) T i s s u e set: motion or t h e l a c k of it in v i s c e r a l organs

(congestion, swelling, t e n d e r n e s s ) , b o n e s , l i g a m e n t s a n d t e n d o n s ( m a l a l i g n m e n t , e d e m a , r e s i l i e n c y , mushiness, swellings, etc.).

In addition to static examination, any thorough structural examination must include testing of a n a t o m i c a l motion. A b n o r m a l a n a t o m i c a l motion and a l i g n m e n t of tissues are direct signs and symptoms of altered function with or without pain. Generally, with musculoskeletal lesions, there is m u s c l e h y p e r e s t h e s i a (abnormal sensitivity to p a i n and touch); this may be particularly n o t i c e a b l e at t h e origins a n d insertions of muscles (the tendons) and over the associated j o i n t areas

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Figure 3.2 The sacrospinalis muscle group

rectus capitis posterior minor rectus capitis posterior major obliquus capitis superior obliquus capitis inferior

semispinalis dorsi semispinalis capitis longissimus capitis semispinalis corncis iliocostalis cervicis longissimus cervicis iliocostalis dorsi longissimus dorsi spinalis dorsi multifidus quadratus lumerum

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w h e n palpated. S o m e conditions m a y be palpated as h a v i n g laxity of tissues, such as in unstable k n e e or lower b a c k sacro-iliac conditions. A good p l a c e to practise palpation is on t h e b a c k (dorsum) of the chest; h e r e lies t h e l a r g e s a c r o s p i n a l i s m u s c u l a r m a s s , t h e l a r g e muscular bundles running parallel to t h e spine. T h e sacrospinalis m u s c l e b u n d l e s e x t e n d from t h e l u m b o s a c r a l a p o n e u r o s i s , a r e attached to the spines of t h e lumbar and sacral vertebrae, lateral and posterior iliac crest, and the sacroiliac l i g a m e n t s a n d e x t e n d upwards to the occiput and mastoid p r o c e s s e s . T h e sacrospinalis is illustrated on the left in F i g u r e 3 . 2 : on the right are t h e d e e p e r m u s c l e s lying underneath. T h e dorsal part of sacrospinalis (Figure 3.3) is c o m p o s e d of the:

(1) Iliocostalis dorsi m u s c l e (laterally);

(2) Longissimus dorsi m u s c l e (intermediately); and (3) Spinalis dorsi m u s c l e (medially).

T h e spinalis dorsi m u s c l e lies next to the spine. T h e iliocostalis dorsi lies over the tips of the vertebral transverse p r o c e s s e s a n d a n g l e s of the ribs. T h e longissimus dorsi lies in b e t w e e n . T h i s is an e x c e l l e n t area in w h i c h to develop t h e ability to discriminate b e t w e e n n o r m a l t i s s u e a n d t h e v a r i o u s a l t e r e d t i s s u e t e x t u r e s m o s t c o m m o n l y encountered.

A s t a n d a r d o f n o r m a l m u s c l e t e n s i o n m a y b e e s t a b l i s h e d b y palpation of the relaxed m u s c l e s of t h e upper and lower e x t r e m i t i e s

(arms and legs) while t h e person is lying relaxed.

spinalis dorsi

longissimus dorsi iliocostalis

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S T R U C T U R A L C O N S I D E R A T I O N S

S o m e structural lesions may be noted by merely observing the patient 'grossly', that is, by visual observation. For i n s t a n c e , the patient may not be a b l e to stand or sit erect, m a y w a l k abnormally or may not be b i l a t e r a l l y s y m m e t r i c a l , with a b n o r m a l c u r v a t u r e s . T h e n o r m a l postural set or motion may be altered. In gross postural c h a n g e s there a r e obvious structural c h a n g e s for w h i c h there may be compensatory structural c h a n g e s , as is s e e n in pelvic i m b a l a n c e (see C h a p t e r 4, F i g u r e 4 . 1 ) .

W h a t m a y be far less obvious are t h o s e structural lesions w h e r e t h e gross a n a t o m y is not outwardly marked by t h e s e c h a n g e s , for e x a m p l e , l e s i o n s i n v o l v e d w i t h h y p e r t e n s i o n , l o w e r a n d u p p e r r e s p i r a t o r y d i s e a s e o r v i s c e r a l d i s e a s e s . V i s c e r a l d i s e a s e c a u s e s m u s c u l o s k e l e t a l s t r u c t u r a l d y s f u n c t i o n , s u c h a s i s s e e n i n t h e restrictive dorsal m u s c u l o s k e l e t a l lesions that o c c u r with gastritis, peptic ulcers or gastroenteritis.

N o r m a l structure and proper function are intimately related. As a result, a primary lesion in one area will produce deleterious secondary effects i n c o n t i g u o u s a n d c o n t i n u o u s a r e a s o f t h e a n a t o m y . For e x a m p l e , a patient c o m p l a i n i n g of arm or shoulder pain from bursitis or tendonitis has, at least, structural dysfunction of the shoulder girdle o n t h e i p s i l a t e r a l ( s a m e ) s i d e . H o w e v e r , m o s t often t h e r e a r e associated c h a n g e s in the central axis, i.e. cervical, dorsal and lumbar areas of the spine. Further, there may be restrictions in the proximal radio-ulnar j o i n t at the elbow.

A good rule-of-thumb is to e x a m i n e both the proximal (closer to the c e n t r a l axis) and distal (further from the central axis) joints in the j o i n t a r e a c o m p l a i n e d of by a patient.

E X A M I N A T I O N A N D EVALUATION

All t h e a r e a s of a n a t o m i c a l dysfunction should be e x a m i n e d and e v a l u a t e d by palpation before manipulation is given to facilitate the p a t i e n t ' s host r e s p o n s e to structural stress. It must be r e m e m b e r e d that stress underlies all disease, w h e t h e r b i o c h e m i c a l , b i o m e c h a n i c a l or p s y c h o l o g i c a l , and that t h e s e factors are mutually d e p e n d e n t on e a c h other. Treating the structural c o m p o n e n t of d i s e a s e will r e d u c e t h e total stress on t h e patient, w h i c h in turn reduces, to s o m e degree, the stress in all other a r e a s .

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In performing examination and evaluation, a n y limits or barriers to normal motion are noted. M o t i o n is tested with both active and passive m o v e m e n t s ; in t h e former, t h e patient m a k e s t h e motion, w h e r e a s i n t h e latter t h e e x a m i n e r m a k e s t h e m o t i o n s w h i l e t h e patient is relaxed. Sometimes w h e n active motion is restricted, passive motion is not restricted. Palpatory e x a m i n a t i o n and evaluation of a joint area by the testing of motion and identification of a n y restriction allows for corrective manipulation.

In the course of an examination, patients frequently c o m p l a i n of pain in a particular area. In an a c c u r a t e evaluation, it is helpful to know the spinal level from w h i c h t h e n e r v e e n n e r v a t i o n derives. E x a m p l e s of nerve ennervation are illustrated in Table 3 . 1 .

T h e m a s s e t e r m u s c l e is e n n e r v a t e d by t h e first c e r v i c a l ( O - C - l ) nerve root, respiratory function is ennervated from tne second cervical

T A B L E 3.1 S P I N A L N E R V E F U N C T I O N S

Nerve root Level Reduced reflex Area of reduced power

O/C-l C-2 C-4 C-5 C-6 C-7 C-8 L-2 L-3,4 L-4 L-4,5 L-5, S-l S-l S-2,3 C-2 C-4,5 C-5,6 C-6,7 C-7, T-l L-2 L-4 L-4 L-5 S-l S-l S-2,3 masseter biceps biceps brachioradialis triceps triceps patellar knee Achilles none ankle plantar reflex anovisceral and genital masseter respiratory

deltoid and upper pectoral shoulder biceps wrist extensors triceps intrinsics of hand patella knee extension,

anterolateral thigh and calf medial muscles dorsiflexion of lateral calf

and great toe

plantar flexion, lateral foot, back of calf (gastrocnemius)

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(C-2) n e r v e root, a n t e r o l a t e r a l k n e e e x t e n s i o n and t h i g h and calf m u s c l e s are e n n e r v a t e d from lumbar n e r v e roots at L-3,4 (figure 3 . 4 ) . T h e p a t e l l a r reflex is e n n e r v a t e d from the L-2 n e r v e root and the A c h i l l e s reflex from t h e L-4 n e r v e root.

C e r v i c a l spondylolethesis, a p l a s i a (lack of d e v e l o p m e n t ) of the v e r t e b r a l arch, i s usually a t C 5 - 6 o r C 6 - 7 , and m a y p r e s e n t with e x t r e m i t y w e a k n e s s a n d m u s c u l a r atrophy o r w i t h e r i n g . L u m b a r Figure 3.4 Spinal reflexes for somatic and visceral responses. O = occiput; C = cervical (neck); D or T = dorsum or thoracic; L = lumbar (lower back); S = sacral

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spondylolethesis, a developmental defect of t h e vertebra allowing forward slippage, usually involves L-5 and S-1 or L-4 and L - 5 . Lumbar intervertebral disc d i s e a s e m a y c a u s e peripheral p a i n and w e a k n e s s . Previously, the importance of somatico-somatic, somatico-visceral, and visceral-somatic reflexes w e r e m e n t i o n e d as giving a rationale and understanding to the structural aspects of osteopathic philosophy and the i m p o r t a n c e of structure w a s e m p h a s i z e d in the t r e a t m e n t of disease with the u s e of manipulation. During manipulation t h e r e is stimulation of the somatic tissue w h i c h s e n d s impulses to the c e n t r a l nervous system in the spine, w h i c h in turn emits i m p u l s e s to somatic or visceral tissues of the s a m e s e g m e n t and/or to s e g m e n t s above and below that level.

RADIOLOGY IN S T R U C T U R A L EVALUATION

X-ray studies can be valuable in examination and evaluation b e c a u s e they may reveal structural abnormalities w h i c h c a n n o t be d i s c e r n e d by palpation in structural analysis. In g e n e r a l , lower b a c k problems should have postural X-ray studies (the person stands with feet about 10 i n c h e s (25 cm) apart for sagittal and coronal films). Lumbar films will not only rule out s u c h things a spondylolethesis and c o n g e n i t a l defects, but will also give information on the effect of gravity on the spine, for example, w h e t h e r there is a true a n a t o m i c a l short leg, the status of the sacral b a s e p l a n e and other important information s u c h as d e g e n e r a t i v e vertebral and disc c h a n g e s .

Another area for X-ray documentation is the c e r v i c a l spine, w h e r e X - r a y films will d i s c l o s e t h e curvature of t h e s p i n e and w h e t h e r degenerative diseases of the spine are present. In c e r v i c a l inertial injuries, studies of the upper two cervical s e g m e n t s are important for evaluation in order to d e t e r m i n e if t h e r e is c r u c i a t e l i g a m e n t or tectoral d a m a g e or m u s c u l a r splinting; this is shown by malposition of the odontoid process of C-2 and an altered c e r v i c a l spine curve.

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ANALYSIS

For a physical examination to be c o m p l e t e a structural analysis is necessary. Amongst the gross observations that c a n be made, the first group are weight-bearing (Figure 4.1). T h e patient's gait, posture, and stance should be observed. Is there a limp, a wide gait, erect posture, etc.? Are the extremities equal in rotation and length? T h e front and b a c k should be checked and the symmetry or asymmetry of shoulders, pelvis and set of the head observed. From the front it should be noted whether the head is held in the normal neutral position, and whether the shoulder or pelvic girdles are symmetrical by comparing the heights of the scapular acromioclavicular joint levels and the symmetry and comparative levels of the iliac crests, femoral trochanters and the anterior superior iliac spines. From the b a c k it should be noted whether the pelvic base plane is level or not, whether there is a scoliosis or asymmetrical vertebral/paravertebral muscular tension and development, whether the shoulder girdle is symmetrical with equal scapulae and whether or not there is any scoliosis, lordosis or kyphosis (Figure 4 . 2 ) . Observations should be made of how the patient sits down, how he sits and the posture.

T h e non-weight b e a r i n g observations i n c l u d e the following: (1) H a v e the patient lie supine and o b s e r v e how this is d o n e . A

person with moderate to severe b a c k pain will lie down from a lateral approach.

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(2) C h e c k t h e l e g l e n g t h s (Figure 4.3) b y c o m p a r i n g the m e d i a l m a l l e o l l i o f t h e a n k l e s , t h e a n t e r i o r s u p e r i o r i l i a c s p i n e s o r nodules, and for pubic tubercle alignment. A posterior sacroiliac rotation c a u s e s a functional shortening of that extremity. (3) O b s e r v e the e x t e r n a l rotation of t h e lower extremities. Is e a c h

foot at a 4 5 ° a n g l e from the midline, i.e the normal relaxed pose (Figure 4 . 4 ) ? C h e c k the a c e t a b u l a r motion in e a c h hip joint for e x t e r n a l rotation by using the 'sign of 4' m a n e u v e r by flexing the t h i g h and k n e e , t h e n abducting the k n e e : internal rotation is c h e c k e d by adduction of the flexed k n e e .

Figure 4.1 Gross structural

alterations

Figure 4.2 Crosses mark the axial

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(4) C h e c k the anterior lumbar ligaments by deep palpation through

the relaxed a b d o m e n (patient's k n e e s flexed with feet resting on the table) and c h e c k the viscera, costal a r c h and ribs.

(5) Compare the arm lengths by approxi-m a t i n g t h e t h u approxi-m b s i n t h e approxi-m i d l i n e with the extremities extended (Figure 4 . 5 ) . Anterior shoulder girdle rotation c a u s e s e x t e n s i o n o f t h e i p s i l a t e r a l upper extremity.

(6) C h e c k the n e c k motion and cervical soft and b o n y tissues. With lesions, t h e r e is t e n d e r n e s s or p a i n at t h e t e n d o n a t t a c h m e n t s t o t h e b o n y structure.

(7) With the patient prone, c h e c k the hip rotation externally and internally by flexing both lower extremities at the k n e e and abducting and adducting the extremities (Figure 4 . 6 ) . Do both s i d e s a n d c h e c k t h e s a c r o i l i a c landmarks.

Figure 4.3 Leg length check Figure 4.4 Checking the 45° angle

of the feet; patient supine on the table

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(8) In all areas, c h e c k for l i g a m e n t o u s t e n s i o n and restrictions of m o t i o n . C o m p a r e b i l a t e r a l l y t h e soft t i s s u e m a s s e s o f t h e sacrospinalis in all areas, the lumbodorsal transition, the set of the s c a p u l a e , the curvature of the spine and t h e tension of the lumbar ligaments. Using springing intermittent lumbar pressure on e a c h l u m b a r spine and interspinous ligament, progressively c h e c k t h e l u m b a r l i g a m e n t o u s t o n e a n d integrity. U s i n g t h e index and second finger, exert downward pressure on the lumbar s p i n e at e a c h level to d e t e r m i n e l i g a m e n t o u s tone, and using t h e fingers c h e c k for soft tissue e d e m a . In disc disease, lumbar pressure or percussion on the spine may evoke radicular pain s u c h as sciatica and/or deep vertebral pain. C h e c k the sacroiliac l i g a m e n t s w h i l e b e a r i n g d o w n w i t h p r e s s u r e t o e l i c i t t h e underlying l i g a m e n t o u s tone and w h e t h e r or not there is soft tissue e d e m a . C h e c k for sacral motion by rocking the sacrum. R e m e m b e r that in testing joint motion, the motion created is not l a r g e .

Figure 4.6 Prone testing for acetabular and sacroiliac motion (posterior left

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T h e purpose of therapeutic manipulation is the m a n u a l h a n d l i n g of the patient's anatomy to bring about an improvement in structural relationships, with an improvement in physiological functioning, both b i o c h e m i c a l l y as well as b i o m e c h a n i c a l l y . S t r u c t u r a l dysfunction involves defective and/or restricted motion. In health, all tissues h a v e motion: in d i s e a s e motion is restricted. S u c c e s s f u l m a n i p u l a t i o n at least reduces restriction of motion, pain and discomfort, and at b e s t establishes normal motion.

Manipulation directly affects the structural relationships of b o n e s , ligaments, fascia and striated muscles. Active soft tissue manipulation affects fascia and muscles, w h e r e a s t h e skeletal t e c h n i q u e s directly affect the joints and ligaments. M u s c l e s attach by origin and insertion to two b o n e s by e x t e n d i n g a c r o s s a j o i n t a r e a . W h e n a m u s c l e c o n t r a c t s , t h e o r i g i n t e n d s t o b e s t a t i o n a r y s o t h a t t h e m u s c l e contracting action is towards the origin attachment.

Corrective manipulation m a y be done with: direct force a g a i n s t t h e resistance; indirect force away from the restriction; or by exaggeration of the resistance.

Activating forces may be extrinsic, intrinsic, or both. Extrinsic force may be applied in a n u m b e r of ways, s u c h as: