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Full text of "Atlas of Osteopathic Techniques"

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P. C.O.M. LIBRARY 



ATLAS 

OF 

OSTEOPATHIC 

TECHNIQUES 



ATLAS 

OF 

OSTEOPATHIC 

TECHNIQUES 



N. S. Nicholas, B.S., D.O., F.A.A.O. 



y/S^S 



m wo 



OSTEOPATHIC MEDICINE 



Osteopathic Medicine is a complete and comprehensive system 
of medical practice which recognizes that the neuro-musculoskeletal 
system is of major importance to human life and includes as its 
basis the inter-relationships between this major system and the 
body's internal environment. 

The Osteopathic Physician incorporates evaluation and treat- 
ment of the musculoskeletal system as a basis for his approach to 
health and disease. This is not to the exclusion of the diagnostic 
and therapeutic modalities incorporated by other scientific ap- 
proaches to the healing arts. 

It should be made clear that the Osteopathic Profession main- 
tains its own schools of education, its own system of hospitals, and 
produces large numbers of General Practitioners in addition to 
training specialists in all fields. 



© COPYRIGHT 1974 BY 

NICHOLAS S. NICHOLAS, B.S., DO., F.A.A.O. 

AND 

PHILADELPHIA COLLEGE OF 

OSTEOPATHIC MEDICINE 

ALL RIGHTS RESERVED 

SECOND EDITION, 1 980 



PREFACE 



This textbook of osteopathic techniques has been compiled 
with photographic depictions and descriptive narratives to 
better illustrate myofascial and osteopathic manipulative 
procedures that have been used successfully in the pro- 
fession for many years. We are not attempting to teach 
osteopathic principles nor their application for various 
conditions, but merely to demonstrate the most widely 
employed techniques, primarily for use in student teaching 
and for reference. 



APPRECIATION 



I wish to express my sincere thanks and appreciation to the 
following for their help and cooperation in the preparation of the 
material in the compilation of this atlas of osteopathic manipulative 
techniques: 



Faculty 

David Heilig, D.O., F.A.A.O. 

Robert W. England, D.O., F.A.A.O. 

Alexander Nicholas, D.O. 

Jerome Sulman, D.O. 

Marvin E. Blumberg, D.O., F.A.A.O. 

Galen D. Young, D.O. 

John Sheetz, D.O., M.Sc.(Ost.) F.O.C.O. 



Students 
Thomas Falone 
Michael Saltzburg 
Ronald Kludo 
Douglas Gilbert 
Anthony J. Silvagni, 
Pharm.D., M.Sc. 



Department of Educational Communications 

Donald Hulmes — Graphics 
G. Walter Webb— Photography 



This volume is respectfully dedicated 

to 

my dear wife, Marika 

and to 

my three sons 

Alexander, Evan, and George 



CONTENTS 



Section 
Section 
Section 
Section 
Section 
Section 
Section 
Section 
Section 



I — Cervical Myofascial Techniques 

II — Thoracic Myofascial Techniques 

III — Lumbar Myofascial and Traction Techniques 

IV — Cervical Manipulative Techniques 

V — Thoracic Manipulative Techniques 

VI — Rib Manipulative Techniques 

VII — Lumbar Manipulative Techniques 

VIM — Innominate and Sacral Manipulative Techniques 



IX 



-1. 
2. 
3. 



Section 
Section 



Section XII 



Section 
Section 



Acromio-Clavicular Manipulative Techniques 
Sterno-Clavicular Manipulative Techniques 
Shoulder Techniques 

a. Spencer Techniques 

b. Three Stage Traction Technique 

c. Glenoid Techniques 

X — Wrist and Intercarpal Manipulative Techniques 

Radio — Ulnar Manipulative Techniques 
XI — Knee Techniques 

1. Posterior Tibial Techniques 

2. Posterior Fibular Techniques 

3. Anterior Medial Displacement of the 
Medial Meniscus 

Ankle and Foot Techniques 

1. Ankle Techniques 

2. Talo-Tibial and Talo-calcaneal Techniques 

3. Springing of Tarsal Joints 

4. Metatarso-Phalangeal 

5. Spring Action Technique 
XIII — Lymphatic Drainage 

XIV — 1. Mandibular Drainage 

2. Auricular Drainage 

3. Anterior Cervical Drainage 



8-11 
11-17 
18-21 
22-25 
26-34 
35-37 
38-40 
41-47 
48-49 

50 
51-56 
51-53 
54-55 

56 

57 
51-59 
60-61 

60 

60 

61 
62-66 

62 

63 
63-64 

65 

66 
67-69 

70 

70 

71 



CERVICAL MYOFASCIAL TECHNIQUES 



Patient Supine — Head is rotated to the left; 
physician at the right side of table; the thenar 
eminence of the left hand is placed just below 
the mastoid process of the left side. A gentle 
springing pressure is exerted downward over 
the temporal bone by the right hand in order to 
"stretch" the tissues. 

This, of course, can be done in the same 
manner to the opposite side by reversing the 
procedure. 




Cupping Chin and Occiput — The patient is in 
the supine position; the right hand cups the 
chin; the left hand the occiput, with the thumbs 
in a natural position. There is gradual cephalad 
traction produced through both hands, then the 
atlanto-occipital, atlanto-axial, and the rest of 
the upper cervical segments are put through 
their range of motion springing where tension 
appears with the release being gradual. You 
may then bring the head up free from the end of 
the table so that backward bending into the mid 
and lower cervical areas can be added. 




Forearm Fulcrum— Patient is supine, the right 
forearm is placed under the cervical column 
perpendicular to the axis of the body with the 
hand resting on the table just below the 
patient's head. The patient's head is now rolled 
across the physician's right forearm using the 
left hand of the physician to direct the head. 
This is done very gently for the forearm is 
considerably less sensitive to pressure than the 
hands. The procedure is reversed to work the 
opposite side. 




CERVICAL MYOFASCIAL TECHNIQUES 




Bilateral Forearm Fulcrum for Forward Bend- 
ing — Patient supine — the physician reinforces 
the fulcrum arm with the other forearm forming 
a V-shaped cradle for the patient's occiput and 
slowly increases the pressure in forward bending. 




Head-Chest Position — The patient is sitting on 
a table or stool with the physician facing the 
patient. The patient's frontal bone is placed 
against the physician's chest and the physician's 
hands or index fingers reinforce each other in 
the posterior cervical area. The patient is then 
drawn toward the physician and a slight 
exaggeration of movement is produced forward 
and upward with a springing motion. 
Modification: Patient's head is turned to the 
side and side-bending is produced. Excellent 
geriatric technique. 




Sitting Traction — The patient is sitting with the 
physician standing behind and to the left side of 
the patient. The physician's right foot is placed 
on the stool behind the patient and the 
physician's right elbow is placed on his right 
thigh. Now the right hand sustains the occiput 
with the thumb and forefinger and the left hand 
sustains the forehead. Traction is produced by 
gently elevating the right thigh and knee by 
lifting the heel of the right foot. Traction is 
released by slowly returning the right heel to its 
original position. 



CERVICAL MYOFASCIAL TECHNIQUES 



Lateral Traction — The patient is sitting on a 
stool, with the physician behind and to the right 
side of the patient. The physician passes his 
right hand around the front of the patient's face 
resting on the patient's mandible. The physi- 
cian's fingers are back toward the occiput, 
drawing the patient's head over to the physi- 
cian's chest. The physician's left hand is placed 
on the patient's left shoulder. Gentle traction is 
applied to the head in an upward direction with 
countertraction downward on the shoulder. 
Procedure may be reversed. 




Counter-Lateral Traction Technique — The 
physician stands at the side and head of the 
table with the patient lying supine on the table. 
The physician places one hand on the frontal 
bone of the patient, the other hand on the lateral 
aspect of the cervical spine along the articular 
facets. Now while applying pressure on the 
frontal bone away from the physician, the other 
hand stretches the musculature of the cervical 
area toward the physician. This procedure may 
be reversed. 




Supine Thumb Rest — The patient is supine 
and may or may not use a small pillow. The 
physician is standing or sitting at the head of 
the table. The thumb and forefinger of the 
physician's left hand cups the posterior cervical 
area, with the palm toward the occiput. The 
physician's right hand is over the temporal and 
frontal regions and brings the head into a slight 
backward bending with rotation against the 
thumb. The motion is very slight. Tension (pres- 
sure) is relaxed slowly and reapplied slowly. 
Procedure may be reversed. 




10 



CERVICAL MYOFASCIAL TECHNIQUES 





Supine Forefingers Cradling — The patient is 
supine. The physician is standing or sitting at 
the head of the table. The physician's hands 
cradle the temporal regions (avoiding pressure 
over the ears) and the fingers are allowed to 
find the tissues about the articular column. The 
patient's head is slightly backward bent, then 
sidebent and rotated from side to side bringing 
alternate pressures behind the articular column 
with the fingertips. 




Cradling with Traction — (Lower cervical) — A 
modification of the above technique. The 
patient's head is allowed to rest free on a pillow, 
the palms of the physician's hands cradle the 
temporal regions avoiding pressure over the 
ears. The physician's fingers are close to the 
cervical spines and bring anterior pressure 
bilaterally with slight traction through the arms 
of the physician. 



11 



THORACIC MYOFASCIAL TECHNIQUES 



Prone Pressure — The patient is prone. The 
physician is at side of table and facing patient. 
The thumb and thenar eminence of one hand is 
reinforced by the palm of the other hand. The 
physician's hands are placed on the far side of 
the patient's spine between the spinous and 
transverse processes. The pressure is down- 
ward and outward, continuous or intermittent. 




Prone Pressure with Counterpressure — This is 
similar to the one above except one hand 
(thenar eminence) exerts pressure downward 
and cephalad, while the other hand applies 
counterpressure so that there is locking of the 
thoracic vertebrae, hence any motion is 
imparted to the ribs. The hands are straddling 
the spinous processes. 




Thumb Pressure — The patient is prone. The 
physician is at the head of the table facing the 
patient. The physician's hands are placed with 
the thumbs close to the spinous processes and 
fingers outstretched laterally. Pressure and 
kneading are done with the thumbs. This can be 
combined with respiratory movements. 




12 



THORACIC MYOFASCIAL TECHNIQUES 




Lateral Recumbent with Shoulder Block— Jr\e 
patient is in the right lateral recumbent position, 
with the physician facing the patient at the side 
of the table. The physician's right forearm is 
slipped under the patient's upper left arm and 
his fingertips find the area supero-lateral to the 
spinous processes. The physician's left hand 
restrains the shoulder as the fingertips of the 
right hand are pulled toward the physician. This 
procedure may be reversed. 




i 



Lateral Recumbent under the Shoulder — The 
position is the same as the above technique 
except that the physician's left hand slips under 
the patient's left upper arm and assumes a 
position alongside the right hand. The patient's 
shoulder will automatically be restrained by the 
physician's left forearm. This procedure may be 
reversed. 




Interscapular (Far Side) Technique — The 
patient is in the right lateral recumbent position. 
The physician is facing the patient at the side of 
the table. The physician's arms reach across 
the patient and the thumbs are placed in the 
rhomboids of the patient's right side. Pressure 
and kneading is done with the thumbs and is 
continuous or intermittent. This procedure may 
be reversed. 



13 



THORACIC MYOFASCIAL TECHNIQUES 



Side Leverage Technique — The patient is 
lying on his right side, his left arm straight down 
along his side. The physician is sitting on the 
edge of the table, the physician's right arm 
locking the patient's left arm. The physician's 
thumb is placed over the spinous process of the 
lower of the two in lesion. Patient's head is 
cupped with the physician's left hand and 
brought gently upwards with sidebending and 
forward bending. Backward bending can also 
be employed with the side bending. This 
procedure may be reversed. 




r -5S»- 



Under-Over Technique and Modification — The 
patient is sitting with his arms crossed in front of 
his chest and his thumbs hooked in each of his 
ante-cubital fossae. The physician is standing 
facing the patient. The physician's hands are 
placed under the patient's forearms and over 
his shoulders with the physician's fingers con- 
tacting the tissues over the transverse 
processes of the thoracic vertebrae. The 
patient is drawn toward the physician and 
springing is accomplished by an upward 
leverage on the forearms and a downward 
pressure exerted through the fingertips. 



Prone Elbow Support for Upper Thoracic — The 
patient is prone and his elbows are perpen- 
dicular to his body. His hands are crossed or his 
forearms are placed straight ahead in a parallel 
position depending on the degree of flexion of 
his head. The physician stands to the left side of 
the table facing the patient. The patient's upper 
thoracics are fixed with the physician's right 
hand, (either thumb, thenar eminence, or palm) 
just below the area of involvement. The physi- 
cian's left hand is placed over the occiput 
forward bending the cervical region and then 
gently springs downward. 




14 



THORACIC MYOFASCIAL TECHNIQUES 





Prone Elbow Support with Calf Hold (Mid and 
Lower Thoracic) — The patient's position is the 
same as the Prone Elbow Support tor Upper 
Thoracic. Now the physician moves to a posi- 
tion next to the patient's left thigh. The physi- 
cian's right hand holds the patient's left calf. His 
left hand straddles the spinous processes 
anterior to the affected thoracics with his 
fingers in a cephalad direction. Springing is 
forward and upward with the left hand. 




Patient Sitting — Rib Raising with Extension 
(Backward Bending)— The patient's hands are 
clasped behind his neck. The physician sup- 
ports the patient's elbows with one hand while 
his other hand straddles the spinous processes. 
The physician elevates the patient's elbows as 
backward bending pressure is exerted forward 
and upward with his dorsal hand. With the 
physician's hand lateral to the spine, specific 
rib areas can be reached. 



15 



THORACIC MYOFASCIAL TECHNIQUES 



Thoracic Traction Stretch Technique — The 
patient is sitting with his hands clasped behind 
his neck. The physician stands behind the 
patient with his arms under the patient's axillae 
and his hands grasping the patient's wrists or 
reinforcing the patient's hands. The physician's 
arms and hands simply maintain this position, 
while the patient s entire trunk is backward bent 
and/or rotated or sidebent. 




Sitting Elbow Support Technique — The pa- 
tient is seated on a stool facing the table. He 
then bends forward placing his elbows on the 
treatment table to support his trunk. The physi- 
cian is standing to the right side maintaining 
forward bending of the head with his right hand, 
while springing downward in the thoracic area 
with his left hand. 




Straddle-Backward Bending Technique — The 
patient straddles the table with his arms 
extended and placed forward so that his hands 
grasp the sides of the table. Backward bending 
of the patient's trunk is attained by pressure of 
the physcian's hand straddling the patient's 
spine. 



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- 



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16 



THORACIC MYOFASCIAL TECHNIQUES 





Supine-Extension Technique (Table or Bed) — 
The patient is supine and the physician is to one 
side. The physician's fingers are placed with 
the palms up under the near side of and as 
close as possible to the thoracic spinous 
processes. The pads of the fingers elevate as 
the forearms or elbows are used as a fulcrum. 
Continuous or intermittent pressure is used. 



17 



LUMBAR MYOFASCIAL TECHNIQUES 



Supine Flexion — The patient is supine with his 
thighs drawn up and flexed on his abdomen and 
his legs flexed on his thighs. The physician 
stands on either side and places one hand on 
the patient's chest for stability. The other hand 
grasps the patient's knees and springs 
downward through the thighs. The position of 
the thighs may be altered to produce 
sidebending or rotation. 




Supine with Leverage — The patient is supine 
with thighs drawn up and feet on the table. The 
physician stands on the right side of the patient. 
The patient's knees are grasped by the physi- 
cian's right hand and pulled toward the physi- 
cian so that the left hand can reach across the 
patient and under the opposite side. As the left 
hand applies pressure lateral to the lumbar 
spinous processes the knees are pushed with 
the right hand toward the opposite side. This 
procedure may be reversed by having the 
physician on the other side of the table and 
reversing hands. 



T»T 




Prone Pressure over Sacrum — Intermittent 
sacral pressure with hands reinforcing each 
other over the sacrum. 




18 



LUMBAR MYOFASCIAL TECHNIQUES 




Prone Pressure with Counter-Leverage — The 
patient is prone. The physician is to the left and 
exerts a deep pressure with his left hand in the 
right lumbar area on the right paravertebral 
musculature. His right hand is placed under the 
right anterior superior iliac spine pulling with 
counter-leverage. A counter-springing motion 
is also used with this technique. The procedure 
is changed to use on the patient's left lumbar 
area. 




— ^ 



Prone Pressure with Crossed Hands over 
Lumbars and Sacrum — The left hand crosses 
and maintains a pressure downward and 
caudad on the sacral promontory. The 
physician's right hand straddles the lumbar 
spinous processes and pressure is applied 
downward and cephalad. 




Prone Scissors Techniques — The patient is 
prone. The right lower limb remains extended 
as it is brought across the popliteal space of the 
left lower limb. The physician stands on the left 
side of the patient and with his right hand 
maintains the position of the lower limbs while 
the left hand prpduces a springing motion 
downward toward the table and laterally in the 
lumbar and pelvic areas. This also can be 
reversed by having physician on the other side 
of the table 

Modification of the Prone Scissors Technique — 
Same as preceding, except the physician's right 
hand is placed between the patient's knees to 
maintain scissors. 



19 



LUMBAR MYOFASCIAL TECHNIQUES 



Sitting Lumbar Technique — The patient is sit- 
ting astride the table near one end, his arms are 
extended and placed forward so that the hands 
grasp the side of the table and the back is held 
in a slight forward inclination. The physician 
holds one hand against the lumbar vertebrae 
and produces a forward springing motion 
increasing the backward bending (extension) in 
the lumbar area. 




Modification of Sitting Lumbar Technique with 
Belt Traction — Same as above, but the physi- 
cian's free hand draws back gently on the 
patients belt or a towel placed around the 
patient's abdomen. 




Lumbar Downward Springing Technique with 
Straddle — The patient is sitting astride the end 
of the treatment table with his left hand behind his 
neck and his right hand on his left elbow. The 
physician is to the right side of the patient 
reaching under the patient's right upper arm 
with his right hand grasping the patient's left 
upper arm. The patient's weight is allowed to 
drop forward on the physician's right arm. There 
is now a left forward rotation and elevation with 
the physician's right arm and a downward 
springing motion with the left hand to the lumbar 
area. This technique can be reversed and per- 
formed from the other side. 




20 



LUMBAR MYOFASCIAL TECHNIQUES 



-^^ 




Supine Bed Extension — The patient is supine 
and the physician may be on either side of the 
patient. The physician's fingers are placed with 
the palms up under the near side of and as 
close as possible to the lumbar spinous 
processes. The pads of the fingers elevate as 
the forearms or elbows are used as a fulcrum. 
Continuous or intermittent pressure is used. 




Prone Bilateral Pressure Technique — The 
patient is prone. The physician stands on either 
side of the patient. His hands are placed with 
the thumbs close to the lumbar spinous proc- 
esses and fingers outstretched laterally. Deep 
pressure and kneading are done with the 
thumbs. 




Lateral Recumbent Technique — The patient is 
in a right lateral recumbent position with his 
knees flexed above the level of the abdomen. 
The physician's fingers hook over the proximal 
transverse processes or in the soft tissues of 
the proximal paravertebral area. The physician's 
fingers pull toward him while counterpressure is 
applied by the physician's thigh or thighs 
against the patient's knees. This procedure is 
changed for the right lumbar area. 



21 



CERVICAL MANIPULATIVE TECHNIQUES 



Occipto-Atlantal Techniques — 1st Method — 
The patient is supine and the physician is at the 
head of the table. If the occiput is anterior on 
the left and/or posterior on the right, the 
physician places his thumb and index finger of 
his left hand posterior to the arch of the atlas, 
with his thumb on the left side and the index 
finger on the right side. These fingers support 
the cervJcal area in slight backward bending. 
The right hand is placed on the forehead and 
using this hand the cervical area is sidebent to 
the left and rotated to the right. The corrective 
force is delivered with the right hand, which 
exaggerates the rotation, sidebending against 
the thumb which acts as a fulcrum. Care is 
taken to avoid excessive deep pressure over 
the vertebral artery. 




Occipito-Atlantal Techniques — 2nd Method — 
The patient is supine and the physician is at the 
side of the head of the table. If the occiput is 
posterior on the left, the physician's right hand 
cups the chin and rotates the head to the right 
and with a slight sidebend to the left. Now the 
physician applies pressure to the occiput with 
the hypothenar eminence of the left hand. 
When complete "locking" is attained, a force 
with the left hypothenar eminence is made on a 
line through to the right orbit, which causes a 
gapping between occiput and atlas. The 
procedure is changed if the lesion is on the 
right. 



\ 




Occipito-Atlantal Technique — 3rd Method — 
The patient is supine and the physician is at the 
side of the head of the table. If the lesion is on 
the right, the physician cups the patient's chin 
in his left hand with the patient's head resting 
on the physician's forearm. Now he rotates the 
chin away from the side of the lesion and side- 
bends toward the side of the lesion with a slight 
amount of backward bending. The index finger 
of the physician's right hand is placed postero- 
lateral to the occiput. The thrust is delivered 
with the index finger in the direction of the 
opposite orbit. 



f 




22 



CERVICAL MANIPULATIVE TECHNIQUES 



r 




Atlanto-Axial Technique — 1st Method — The 
patient is supine and the physician is at the side 
of the head of the table. If the lesion is on the 
right, the physician cups the patient's chin in his 
left hand with the patient's head resting on the 
physician's forearm. The physician's right index 
finger is postero-lateral to the posterior arch of 
the atlas and the thumb of the same hand is on 
the ramus of the mandible. The cervical column 
otherwise is in a neutral position. The corrective 
force is rotational. This procedure is changed if 
the lesion is on the left. 




Atlanto-Axial Technique — 2nd Method — The 
patient is supine and the physician is at the side 
of the head of the table. If the lesion is on the 
right, the cervical area is rotated to the left, with 
the temporal bone resting on the palm of the left 
hand. The physician's right hand is placed on 
the ramus of the mandible with the fingers 
extending downward toward the chin. This hand 
is used to suddenly increase the left rotation by 
pressing downward toward the table on the 
ramus of the mandible. The cervical column is 
otherwise kept in a neutral position. This proce- 
dure is changed if the lesion is on the left. 




Cervical Technique (3rd to 7th Cervicals 
Inclusive) — 1st Method — The patient is 
supine and the physician is at the side of the 
head of the table. If the lesion is on the right, the 
physician's left hand cups the chin and rotates 
the cervical area to the left and sidebends to the 
right. The index finger of the right hand is 
placed postero-laterally to the articular process 
of the upper of the two in lesion. After 'locking' 
rotation, there is sidebending with slight 
backward bending with the left hand the thrust 
being given with the right index finger in an arc 
conforming to the plane of the facets at that 
point. This procedure is changed if the lesion is 
on the left. 



23 



CERVICAL MANIPULATIVE TECHNIQUES 



Cervical Technique (3rd to 7th Cervicals 
Inclusive) — 2nd Method — The lesion is on the 
right. The patient is supine and the physician 
stands at the side and head of the table with his 
left hand under the patient's left temporal bone. 
With his left hand the physician rotates the 
patient's head away from the side of the lesion 
and sidebends it towards the side of the lesion. 
The index finger of the right hand is postero- 
lateral to the articular process of the upper of 
the two in lesion. The patient's head may be 
flexed or extended depending on the cervical 
curve, and then a corrective thrust is made with 
the index finger in an arc conforming to the 
plane of the facets at that point. The left hand 
under the left temporal bone acts entirely as a 
control or counterforce since it merely holds the 
position. The procedure is changed if the lesion 
is on the left. 




Lower Cervical Technique Variation — When 
the lesion is located in the lower cervical area, 
the physician may use the hypothenar 
eminence for the thrust. 




24 



CERVICAL MANIPULATIVE TECHNIQUES 






>> 




A. "Indirect Technique" — Cervical Technique 
Variations — The lesion is on the right — The 
patient is supine and the physician is at the 
head and side ot the table. The index finger of 
the right hand is placed at the articular pillar of 
the lower vertebra of the two in lesion. The 
index finger of the left hand is placed on the 
articular pillar of the upper vertebra of the two in 
lesion. Now the cervical column is rotated to the 
left and sidebent to the right and when "rotation 
locking" is accomplished, the rotation is 
increased by the left hand. The procedure is 
changed if the lesion is on the left. 




B. Method II — The lesion is on the right — 
Same as above: The emphasis must be made 
that in the "indirect" technique only a holding 
force is applied by the finger on the lower of the 
two in lesion. 



25 



THORACIC MANIPULATIVE TECHNIQUES 



Upper Thoracic Technique — Supine — 1st 
Method — The lesion is on the left. The patient 
Is in the supine position, and the physician 
stands at the right side of the patient. The 
physician crosses the patient's arms, instruct- 
ing the patient to grasp the opposite shoulders 
with his hands. The physician then places his 
right hand under the lower of the two vertebrae 
in lesion. The patient's elbows are then placed 
in the physician's abdomen, just under the 
costal arch. 

a. Backward bending: 

The physician's left hand is placed 
posterior to occiput and the patient's head 
is forward bent toward the operator. Slight 
pressure is then applied through the 
operator's abdomen toward the upper of 
the two vertebrae as the patient's head is 
allowed to drop back. 

b. Forward bending: 

The head is raised as before, but the fulcrum 
of the right hand is placed posterior to the 
upper of the two lesioned vertebrae. As 
you apply slight pressure toward the lower 
of the two vertebrae, the head is brought 
into further forward bending. 





26 



THORACIC MANIPULATIVE TECHNIQUES 




Upper Thoracic Technique — 2nd Method — The 
lesion is on the left. The patient is in a right 
lateral recumbent position and the physician is 
sitting on the table facing the patient. The 
physician's left hand is placed under the occiput, 
and his right thumb contacts the spinous 
process of the lower of the two in lesion, 
pressing downward toward the table. The 
physician sidebends upward and forward bends 
the cervical column and rotates the face toward 
and away from him testing resistance. After 
selecting the point of least resistance, the 
thrust is made in the form of an upward thrust lift 
with the left hand while maintaining the down- 
ward pressure with the right thumb on the 
spinous process. The procedure is changed if 
the lesion is on the right. 




Upper Thoracic — Sitting and Arms Crossed — 
The patient is sitting on the table or on a stool. 
The physician stands behind the patient and 
crosses the patient's arms, grasping the elbows 
and pulling them laterally as far as possible to 
separate the scapulae. The physician places 
his foot on the table and his knee with, or with- 
out, a pillow, behind the lower of the two in 
lesion. The thrust is made in a forward direction 
while drawing the patient backward with the 
arms. 



27 



THORACIC MANIPULATIVE TECHNIQUES 



Upper Thoracic Technique — Sitting — 

Converging forces — The lesion is on the left. 
The patient is sitting. The physician stands 
behind the patient and places his right foot on 
the table. The patient's right arm is draped over 
the physician's right thigh with the physician's 
leg close to the patient's body. The physician's 
right hand is placed on the top of the patient's 
head with the forearm against the right side of 
the face. The physician sidebends the patient's 
head to the left and rotates it away from (or 
towards, if the resistance is too great), the side 
in lesion. The thumb of the physician's left hand 
contacts the transverse process of the lesioned 
vertebra and the thumb thrust is given in a 
forward and downward direction. This proce- 
dure is changed if the lesion is on the right. This 
method may also be used in rib manipulative 
techniques for the upper three ribs. 





Upper Thoracic Technique with Knee under 
Patient — The patient is supine. The physician is 
at the head of the table with one knee flexed on 
the table and the patient's upper thoracic area 
resting on the physician's thigh. The patient's 
hands are clasped behind his neck with the 
elbows outward. The physician passes his 
hands under the patient's forearms and encircles 
the patient's ribs with the tips of the fingers over 
the rib angles. The physician's arms press 
downward on the patient's shoulders while his 
hands and fingers lift upwards 




28 



THORACIC MANIPULATIVE TECHNIQUES 




Upper Thoracic — Prone with Pillows under 
Chest — 2 Positions — A. This technique is 
used mostly in patients who have hypermobility 
and locking is difficult when the primary force is 
against the transverse process of the lower 
lesioned vertebrae. The patient is prone with 
his face turned so that his cheek rests on the 
table. The physician stands to the side of the 
table towards which the occiput is directed. The 
physician's cephalad hand cups the patient's 
chin with his forearm resting on the patient's 
face, producing an extreme rotation. Use cau- 
tion in this maneuver. The physician's thenar 
eminence of the other hand delivers a thrust 
against the proximal side of the spinous 
process. 




B. This technique is the same as above except 
it is used for individuals who have a relatively 
flat thoracic area. Use enough pillows under the 
upper chest wall in order to increase the 
kyphosis of the patient's upper thoracic area. 
The physician is at the head of the table with the 
patient's head rotated to the side of the lesion 
and sidebent away from the side of the lesion. 
The physician's thenar eminence is placed 
against the transverse process of the lower of 
the two in lesion while the other hand thrusts 
the head in an exaggerated sidebent position. 
This may be modified by moving out to the 
angle of the ribs to become a 'rib' technique. 



29 



THORACIC MANIPULATIVE TECHNIQUES 



Mid-Thoracic Technique — Supine — 1st Method — 
The lesion is on the left. The patient is supine 
with his arms crossed over his chest with each 
hand grasping the opposite shoulder The 
physician stands on the right side of the table 
facing the patient. Using his left hand, the 
physician rolls the patient toward him by lifting 
the patient's shoulder far enough to place his 
right thenar eminence under the lower of the 
two lesioned vertebrae. He then places the 
patient's elbows in his axilla and delivers a 
thrust in a downward (toward the table) and 
slightly cephalad direction. This force is directed 
toward the upper of the two vertebrae in lesion 
to produce backward bending. This procedure 
is changed if the lesion is on the right. See also 
upper thoracic technique page 26. 





30 



THORACIC MANIPULATIVE TECHNIQUES 




*^*F 





Mid-Thoracic — Supine with Cervical Leverage — 
2nd Method — The lesion is on the right. The 
patient is supine with his arms crossed over his 
chest, with each hand grasping the opposite 
shoulder. The physician stands on the left side 
of the table, and rolls the patient towards him by 
lifting the patient's shoulder. The physician 
then passes his right hand under the patient's 
occiput to support the patient's head and to 
sidebend the thoracic column down to the 
lesioned area. The physician's left thenar 
eminence is placed under the lower of the two 
lesioned vertebrae. The patient is then returned 
to a supine position and his elbows are placed 
in the physician's axilla. The thrust is through 
the upper of the two in lesion. This procedure is 
changed if the lesion is on the left. 



31 



THORACIC MANIPULATIVE TECHNIQUES 



Mid and Lower Thoracic Techniques — Supine 
— 3rd Method — The lesion is on the left. The 
physician stands on the right side of the table. 
The patient is supine with his hands clasped 
behind his neck. The physician rolls the patient 
towards him by lifting the patient's shoulder and 
then places his right thenar eminence under the 
lower of the two vertebrae in lesion. The patient 
is returned to a supine position and his elbows 
are placed in the physician's axilla with the phy- 
sician's left hand and forearm on the patient's 
elbows to increase the kyphosis of the thoracic 
spine. The corrective thrust is directed toward 
the upper of the two in lesion which is above the 
hand fulcrum. The procedure is changed if the 
lesion is on the right. 




Mid and Lower Thoracic — Sitting and Back- 
ward Bending — The patient is sitting with the 
physician in back of him. The patient's hands 
are placed flat on his back, one over the other 
so as to contact the lower of the two lesioned 
vertebrae. The physician passes his hands 
under the patient's arms, reaches around and 
clasps his hands across the patient's chest. The 
physician's sternum or abdomen contacts the 
patient's hands. The physician then draws 
backward with his arms and simultaneously 
thrusts forward with sternum or abdomen. 




V.-. •* ^%"3&* 



32 



THORACIC MANIPULATIVE TECHNIQUES 




Mid and Lower Thoracic — Sitting with Side- 
bending and Rotation — The patient sits with 
his hands clasped behind his neck and his 
elbows forward. The physician is in back of the 
patient and reaches across with his right arm 
under the patient's upper arm and grasps the 
patient's left upper arm and draws him in rota- 
tion. The physician's left arm reaches around in 
front with his forearm on the patient's thigh and 
his hand grasping the table between the patient's 
legs. This anchors the patient's pelvis while the 
physician produces extreme rotation and then 
back into 45 degrees backward bending. (This 
is a non-specific technique.) 




Mid and Lower Thoracic — Prone Technique 
for Sidebendmg Lesions — The patient is prone 
with a pillow placed under his abdomen. The 
physician stands on the side of the high 
transverse process. The physician places the 
hypothenar eminence of the hand with the 
fingers pointing caudad on the high transverse 
process. The thenar eminence of the hand with 
the fingers pointing cephalad is placed on the 
low transverse process. The patient is 
instructed to breathe deeply and as he starts to 
exhale a thrust is delivered with both hands 
simultaneously in the direction in which the 
fingers are pointing. 




Mid and Lower Thoracic Technique — Prone 
with Elbows Resting on Table — The patient is 
prone and resting on his elbows with his arms 
vertical and each hand grasping the opposite 
forearm. The physician is at the side of the 
table, pressing down on the occiput and pro- 
ducing a forward bending of the cervical spine. 
The other hand straddles the spinous process 
of the lower of the two vertebrae in lesion with 
the fingers pointing toward the pelvis. The 
pressure on the occiput is maintained while a 
thrust is made with the other hand. 



33 



THORACIC MANIPULATIVE TECHNIQUES 



* 1 ' > 



Mid and Lower Thoracic Technique — Sitting 
or Standing with Backward Bending Thrust — 
The patient is sitting or standing with his hands 
clasped behind his neck. The physician passes 
his forearms under the patient's arms and 
grasps the patient's wrists. The physician's 
sternum (or a pillow) is placed posterior to the 
lower ot the two vertebrae in lesion. The patient 
is instructed to breathe deeply and on exhala- 
tion, the physician delivers a thrust in a forward 
direction with his sternum against the pillow 
while pulling backwards on the patient's arms. 




Mid and Lower Thoracic Technique — Sitting 
with Patient Facing Physician — The patient is 
sitting. The physician faces the patient and 
crosses the patient's arms placing the patient's 
elbows in his supraclavicular area. The physi- 
cian turns the patient's face away from him and 
reaches around both sides of the patient con- 
tacting the transverse processes of the lower of 
the two vertebrae in lesion. The physician steps 
backward drawing the patient toward him, plac- 
ing the spine in backward bending and thrusts 
by pulling the patient toward him with both 
hands simultaneously. 




34 



RIB MANIPULATIVE TECHNIQUES 




First Rib Technique — Supine — 1st Method — 
The lesion is on the left. The patient is supine 
and the physician is at the patient's head. The 
physician places his right hand on the patient's 
head and forward bends and rotates the cervi- 
cal spine away from the side of the lesion and 
sidebends the cervical spine towards the side of 
the lesion. The index finger of the left hand is on 
the upper surface of the first rib close to the 
cervical column. The thrust is given in a down- 
ward slightly medial direction with the index 
finger. The procedure is changed if the lesion is 
on the right. 





First Rib Technique — Supine — 2nd Method — 
The lesion is on the left. The patient is supine 
and the physician stands on the right side of the 
table. The physician's left hand grasps the 
patient's right upper arm, lifting the patient's 
shoulders high enough to allow him to pass his 
right arm under the patient so that the fingers of 
that hand can be placed over the left first rib. 
The physician then allows the patient to rest on 
his right arm. The physician's left hand is placed 
on the patient's right cervical area, with the 
fingers extending backward under the occiput. 
The thumb of the left hand is in front of the ear 
extending upward toward the temporal area. 
With his left hand the physician produces a 
slight flexion (forward bending), left sidebend- 
ing and right rotation until he feels confident 
that he has locked the cervical spine down to 
the area in lesion. The thrust is delivered by a 
sudden pull by the right hand applied to the first 
rib along the axis of the forearm upon which the 
patient is resting. The procedure is changed if 
the lesion is on the right. 



35 



RIB MANIPULATIVE TECHNIQUES 



Upper Rib Technique (Second through Fourth 
Ribs) — Prone — The lesion is on the right. The 
patient is prone and the physician is at the head 
of the table. A pillow is placed under the 
patient's chest so that his chin and mandible 
may act as a fulcrum. The physician then places 
his left hand on the patient's right temporal area 
and rotates the occiput away from the side 
lesioned (right rotation). This rotation is con- 
tinued until the patient's right shoulder is seen 
to begin to rise from the table. The physician's 
right hand is placed on the angle of the rib in 
lesion and a thrust in a downward direction is 
delivered with the right hand. The procedure is 
changed if the lesion is on the left. Note: these 
prone techniques are not advised for 1st rib 
dysfunctions and are contraindicated in 
presence of extensive or painful cervical 
involvement. 




Fifth Through Twelfth Ribs — Supine — For 
these rib lesions, the supine thoracic technique 
as previously taught can efficiently be used by 
moving your fulcrum lateral to the thoracic 
transverse process or the angle of the rib in 
lesion. The corrective thrust is then given in a 
direction through the vertebra to-which the rib is 
attached. This causes a-separational stress at 
the costo-transverse articulation and a gliding 
motion of the costo-vertebral articulation. 





36 



RIB MANIPULATIVE TECHNIQUES 




Floating Rib Technique — Prone — The lesion 
is on the right. The patient is prone with his legs 
flexed and knees together. The phsyician 
stands at the patient's left side and using his 
right hand draws the patient's ankles towards 
himself. The physician presses downward 
towards the table with the left hand on the 
lesioned rib. This tension is maintained while 
the patient inhales and exhales several times, 
quickly and forcibly. The procedure is changed 
if the lesion is on the left. 




Floating Rib Technique — Lateral Recumbent — 
The patient is in a lateral recumbent position 
with the lesioned rib away from the table. The 
physician is in front of the patient, flexing the 
patient's thighs and legs 90 degrees and draw- 
ing the patient toward him so that the legs can 
be dropped off the side of the table. The physi- 
cian then presses downward on the legs while 
drawing the lesioned rib toward him with the 
opposite hand. Again the patient breathes 
quickly and deeply several times. In these 
techniques no thrust is employed, because the 
correction is accomplished by breathing, and 
with the tension applied as described above. 



37 



LUMBAR MANIPULATIVE TECHNIQUES 



Sitting with Patient Straddling the Table— 1st 
Method — The patient is sitting near the end of 
the table, straddling it and facing towards the 
center of the table. The physician is standing in 
back of the patient. The patient clasps his 
hands in the back of his neck with his elbows 
directed forward. The physician passes his right 
forearm under the patient's right upper arm 
grasping the patient's left upper arm with his 
right hand. The physician's left hand is placed 
posterior to the right transverse process of the 
lower of the two in lesion. With the right hand, 
the physician forward bends the patient's spine, 
rotating it to the right, and carrying it into back- 
ward bending while maintaining pressure in a 
forward direction with the left hand. 





Variation — The physician places his left thenar 
eminence on the right side of the spinous 
process of the upper of the two in lesion main- 
taining a pressure with this hand in a crosswise 
or lateral direction to the left. With the right 
hand, the physician produces a forward bend- 
ing rotation and then carries it into backward 
bending. In this case, the backward bending is 
not as complete as in the former method and 
the inertia below the lesion acts as a counter- 
force. 





Sitting with Patient Straddling Table — 2nd 
Method — The patient has his arms crossed 
with his hands resting on his shoulders. The 
physician stands behind the patient on the side 
of the convexity in such a position that he can 
press downward on the shoulder nearest him 
(convex side) while he pushes against the 
spinous process in the lumbar area with the 
other hand. The pressure is applied to the con- 
vex side in a crosswise direction. 




38 



LUMBAR MANIPULATIVE TECHNIQUES 




Scoliosis Technique — The patient is in a 
lateral recumbent position with the convexity of 
the scoliosis toward the table. The physician 
stands in front of the patient and fixes the 
patient's legs on his thighs and the patient's 
thighs on his abdomen. The legs are dropped 
over the side of the table and allowed to hang. 
The physician presses downward on the legs 
while lifting the lumbar column with the opposite 
hand. This is a springing type motion and tends 
to reduce the curvature. 




Lumbar Mobilization in the Presence of Scoli- 
osis and Sidebending Lesions — The patient is 
in the lateral recumbent position with the con- 
vexity of the lumbar curve away from the table. 
The physician locks down to and including the 
upper of the two vertebrae in lesion by drawing 
forward on the lower shoulder. The patient's 
uppermost leg is dropped off in front of the 
table. The physician stands in front of the 
patient and places his elbow against the upper 
shoulder, grasping the patient's elbow with his 
hand in a manner such that he can push down- 
ward on the arm while he thrusts in a cephalad 
direction with the opposite hand against the 
crest, trochanter, and tuberosity of the ischium. 




Lumbar Modification — The lesion is on the 
right. The patient is prone and the physician 
stands at the side of the table opposite the 
lesion. The patient's right leg (on the side of the 
lesion) is flexed 90 degrees and is drawn over 
the opposite proximal popliteal space. Pressure 
is applied to the right ankle, producing rotation 
from below upward. The left thenar eminence is 
placed on the transverse process of the upper 
of the two in lesion. The physician's thrust is 
delivered with this hand in a downward, lateral- 
ward direction. The procedure is reversed if the 
lesion is on the left. 

Modification A — Both of the patient's legs are 
flexed 90 degrees and drawn to the opposite 
side of lesion and then the same technigue is 
used. 



39 



LUMBAR MANIPULATIVE TECHNIQUES 



Hip Joint — The patient is in a supine position. 
The physician flexes the patient's leg on his 
thigh and then the patient's thigh against his 
abdomen. The flexed leg is then adducted until 
the knee is over the opposite anterior iliac 
spine. The physician stands at the side of the 
flexed leg facing the table and places his 
clasped hands over the knee and delivers a 
thrust downward towards the table along the 
axis of the femur. 




Symphysis Pubis — The patient is in a supine 
position. His lower limbs are partly flexed with 
his feet resting on the table and his knees 
approximated. The patient is now instructed to 
open and separate the knees against the physi- 
cian's carefully regulated resistance. This is 
repeated several times, gradually increasing 
the tension. The reverse resistance can also be 
employed. The patient contracting his abductor 
muscles and bringing his knees together 
against the operators resistance. 



5wir 





40 



INNOMINATE AND SACRAL TECHNIQUES 





Posterior Iliac (Innominate) (Anterior Sacral) — 
The lesion is on the left. The patient is in the 
right lateral recumbent position with the physi- 
cian facing the patient. The physician places 
the index finger of his right hand on the left 
posterior superior spine of the ilium. With his 
left hand he then grasps the patient's right 
lower arm and draws the shoulder forward lock- 
ing down to and including the lumbo-sacral 
articulation. The physician then places his left 
hand on the patient's uppermost shoulder. The 
right leg of the patient is kept extended and the 
left foot of the patient is placed in the right 
popliteal area. Maintaining the locking with his 
left hand on the uppermost shoulder, the physi- 
cian may direct a corrective thrust with either 
the hypothenar eminence or with the left fore- 
arm in a downward-forward direction high on 
the crest of the ilium towards the umbilicus. The 
procedure is changed if the lesion is on the right. 





Anterior Iliac (Innominate) (Posterior Sacral — 
The lesion is on the left. The patient is in the 
right lateral recumbent position with the physi- 
cian facing the patient. The physician places 
the index finger of his right hand on the left 
posterior superior iliac spine. With his left hand 
he then grasps the patient's right lower arm 
drawing the shoulder forward and locking down 
to and including the lumbo-sacral articulation. 
The physician then places his left hand on the 
patient's uppermost shoulder. The right leg is 
kept in a flexed position on the table and the left 
leg is dropped over the side of the table and 
allowed to assume its own position without any 
assistance from the physician. The patient's 
foot must not be in contact with the floor. Main- 
taining the locking with his left hand on the 
patient's shoulder, the physician places his 
right forearm on the ischial spine and delivers a 
corrective thrust through the femur in a 
downward-forward direction towards the table 
and the physician. The procedure is changed if 
the lesion is on the right. 



41 



INNOMINATE AND SACRAL TECHNIQUES 



Posterior Iliac (Innominate) Anterior Sacral) — 
The lesion is on the right. The patient is prone. 
The physician uses four pillows, two under the 
patient's thighs and the other two under the 
abdomen, to keep the pelvis free of the table 
The physician stands to the left side of the 
patient. One hand is placed (reinforced by the 
other) over the right posterior superior iliac 
spine. The correction is made by a downward 
springing pressure. The procedure is changed if 
the lesion is on the left. 




Anterior Iliac (Innominate) (Posterior Sacral)— 
Same position as above except that the pres- 
sure is applied to the left side of the posterior 
surface of the sacrum but medial to the left 
posterior surface of the iliac spine. This proce- 
dure is changed if the lesion is on the left. 



Posterior Iliac (Innominate) (Anterior Sacral) — 
The same position as the preceeding except 
that the thigh is adducted and internally rotated 
while forcibly extending the leg. 




r*& 





***-- 



Qk 



-::■... 



42 



INNOMINATE AND SACRAL TECHNIQUES 




Anterior Iliac (Innominate) (Posterior Sacral) — 
The lesion is on the left. The patient is supine. 
The physician is to the left side of the patient. 
He grasps the patient's left leg at the ankle with 
his left hand, and places his right hand over the 
left patella. Now the physician flexes the 
patient's leg and thigh. Corrective procedure is 
made with abduction and external rotation of 
the thigh, while forcibly extending the leg. The 
right leg is used if the lesion is on the right. 



*-.' .'}-. ■ KsiLI3lf*tu 




Posterior Iliac (Innominate) (Anterior Sacral) — 
The patient is supine. The lesion is on the right. 
The physician flexes both legs and thighs, plac- 
ing the patient's knees in his right axilla. The 
other hand is placed under the posterior 
superior iliac spine on the right side. The physi- 
cian rolls over the patient so that the weight of 
the pelvis and legs rests on the fulcrum. The 
physician presses downward on the patient's 
knees. The procedure is changed if the lesion is 
on the left. 



Anterior Iliac (Innominate) (Posterior Sacral) — 
Same as above, except that the fulcrum is 
placed under the left side of the base of the 
sacrum but medial to the left posterior superior 
iliac spine. The procedure is changed if the 
lesion is on the left. 



43 



INNOMINATE AND SACRAL TECHNIQUES 



ST 



Post Iliac (Innominate) (Anterior Sacral) — The 
lesion is on the left side. The patient is supine 
with the left leg and thigh flexed at right angles. 
The patient is moved over so that the left ilium 
(innominate) is free of the edge of the table. The 
physician clasps both his hands over the 
patient's left knee. The physician makes a 
corrective thrust downward towards the table 
on a line with the left femur. The procedure is 
changed if the lesion is on the right. 



Modification — Anterior Iliac (Innominate) (Pos- 
terior Sacral) — The same position as the pre- 
ceding except that the left knee is pressed over 
until it is above the right anterior superior iliac 
spine before the corrective thrust is made. The 
procedure is changed if the lesion is on the right. 

Post Iliac (Innominate) (Anterior Sacral) — The 
lesion is on the left. The patient is prone with 
the physician standing on the right side. The 
patient's left leg is drawn over to the right. The 
physician places his left leg between the 
patient's knees. The physician now places his 
left hand, reinforced by his right hand, over the 
left posterior superior iliac spine. The corrective 
thrust is in a downward direction toward the 
table. A springing type correction may be used 
in this position. The procedure is changed if the 
lesion is on the right. 



\ 




Modification — Anterior Iliac (Innominate) (Pos- 
terior Sacral) — The same position as the pre- 
ceding except that the hands are placed over 
the left side of the base of the sacrum but 
medial to the right posterior superior iliac spine. 
The procedure is changed if the lesion is on the 
right. 




44 



INNOMINATE AND SACRAL TECHNIQUES 




E^ 



J * #M v 




Posterior Iliac (Innominate) (Anterior Sacral)— 
Lesion is on the left side. The patient is in the 
right lateral recumbent position, with the right 
arm dropped back and off the side of the table 
(Sim's Position), with the physician standing 
behind the patient's pelvis. The physician 
places his right hand in such a position that he 
can exert a forward pressure against the 
posterior superior iliac spine of the lesioned 
side. The patient's legs and thighs are flexed at 
right angles. The physician grasps the left knee, 
producing in order named: flexion, abduction, 
and finally extension. 



Modification — Anterior Iliac (Innominate) 
(Posterior Sacral)— Same as above, except 
that the physician's right hand is placed 
posterior to the left side of the base of the 
sacrum. 



45 



NNOMINATE AND SACRAL TECHNIQUES 



Posterior Iliac (Innominate) (Anterior Sacral)— 
Lesion is on the left. The patient is in the right 
lateral recumbent position with the right arm 
dropped back and off the table (Sim's Position), 
with the physician standing behind the patient's 
pelvis. The physician's left forearm is passed 
under the thigh with the left hand resting on the 
anterior superior iliac spine. The right thenar 
eminence of the physician is placed posterior to 
the posterior superior iliac spine. Now the thigh 
is elevated slowly, testing for the point at which 
relaxation occurs, this being about 12 to 15 
inches. This elevation is maintained while the 
thigh is carried into extension meanwhile press- 
ing forward with the thenar eminence of the 
right hand of the physician. 




Modification— Anterior Iliac (Innominate) (Pos- 
terior Sacral) — Same as above except the 
physician's right hand is placed posterior to the 
left side of the base of the sacrum. 




46 



INNOMINATE AND SACRAL TECHNIQUES 






1 




Posterior Iliac (Innominate) (Anterior Sacral) — 
The patient is supine with the physician stand- 
ing at the foot of the table. The physician grasps 
the ankle on the lesioned side with both hands. 
The foot is now elevated about six inches above 
the table. The physician applies traction and 
instructs the patient to breathe deeply several 
times. The corrective force is a sudden traction- 
like pull as the patient begins to exhale after a 
full inspiration. 



M&mm 
WW 

p. 



£zy 



/ 




Modification — Anterior Iliac (Innominate) (Pos- 
terior Sacral) — Same as above except that the 
foot is held about 18 to 20 inches above the 
table. 



47 



AC R O M I 0-C L A V I C U LAR MANIPULATIVE TECHNIQUES 



Test for Motion — The patient is sitting with arms 
relaxed and elbows flexed. The physician's' 
right hand grasps the patient's right elbow and 
lifts upward on the arm while palpating the 
articulation with the" opposite hand. The proce- 
dure is reversed for the testing the left acromio- 
clavicular articulation. 



Elevated Clavicle — The lesion is on the left. 
The patient is sitting and the physician is stand- 
ing behind the patient. The physician places his 
right index finger over the middle or lateral third 
of the left clavicle and presses downward. The 
physician's left hand grasps the patient's left 
proximal forearm drawing the arm backward 
into circumduction and finishing with the arm 
across the patient's chest. This maneuver lifts 
the scapula up to the clavicle. The procedure is 
changed if the lesion is on the right 





48 



ACRO M I O-CLA VI CU LAR MANIPULATIVE TECHNIQUES 




Depressed Clavicle — The lesion is on the left. 
The position is same as the preceding tech- 
nique with the patient sitting and the physician 
standing behind the patient. The physician's 
right index finger presses downward on the 
medial third of the left clavicle and on the left 
scapula. Circumduction begins from an anterior 
position, lifting the clavicle up to the scapula. 



49 



ST E R N 0-C LA VI CU L AR MANIPULATIVE TECHNIQUES 



Elevated Clavicle at the Sterno-Clavicular Joint 
— The lesion is on the left. The patient is sitting 
with the physician standing behind the patient. 
The physician's left hand grasps the patient's 
left forearm, and with his right hand reaching 
across the front of the patient he presses 
downward on the left sternal end of the clavicle 
with his right thumb. Now from an anterior 
position he begins circumduction with his left 
hand, thus causing the sternal end of the 
clavicle to go downward. The procedure is 
changed if the lesion is on the right. 



The last 2 techniques are interchangeable. 






50 



SHOULDER TECHNIQUES 



Spencer Techniques — with Variances 
A. Position 

1. The Spencer Technique is done with the 
patient lying on his side with the injured 
shoulder up. 

2. The patient's back should be approxi- 
mately perpendicular to the table and 
with the under elbow forward. If the elbow 
next to the table is behind or under the 
patient, the patient's position is angled 
too far forward. 

3. The pillow should be in proper height in 
relation to the patient's lower shoulder 
width, so that the head is supported com- 
fortably without too much drag on the 
neck and shoulder muscles. 

4. The lower knee is drawn up to provide a 
firm anchorage for the hips and lower 
extremities. 




B. Approach 

1. The patient must be approached accord- 
ing to the tenderness and discomfort 
present. He should not however be 
handled so gently that he is constantly 
fearful of slipping from the physician's 
hands without warning. 

C. Treatment — First Stage 

1. The physician stands in front of the 
patient with the hand nearest the 
patient's feet grasping the wrist and 
lower forearm of the arm to be treated. 

2. The other hand of the physician is placed 
on top of the patient's shoulder to anchor 
the shoulder girdle and localize the 
stretching influence on the shoulder joint. 
(If this is not done, the shoulder girdle will 
ride all over the upper ribs, and there will 
be little or no influence on the shoulder 
girdle.) 

3. The patient's arm is then moved back 
and forth in a horizontal plane with the 
elbow rather sharply flexed. The back- 
ward motion of the elbow is carried to the 
extreme limit permitted by the capsule of 
the shoulder. 

4. The amount of firmness manifested in 
the stretch will vary with the severity of 
the injury and the condition of the tissues. 

5. In all of these moves, only gentle pres- 
sure is used. 

6. Each move is repeated 8 to 10 times for 
the first 2 or 3 treatments to determine 
the ability of the tissues to react. If the 
results warrant it, the effort involved can 
be stepped up and the physician can be 
sure that the patient will not be frightened 
away by unnecessary painful reactions to 
the early treatments. 



51 



SHOULDER TECHNIQUES 



Second Stage 

1. The patients arm is fully extended. 

2. The wrist Is firmly grasped by the corres- 
ponding hand of the physician and the 
patient's arm is carried horizontally in a 
forward arc to the point where the arm is in 
a line with the body and covers the ear in a 
patient with a normal range of motion. In 
the patient with an abnormal range of 
motion the arm is carried in the upward 
swing as far as possible with reasonable 
comfort. 

3. The physician should remember to keep 
comfortably balanced on his feet and to 
carry the patient's arm with an easy 
smooth rhythmic swing of the body 

4. Working the patients arm like a pump 
handle will not accomplish any beneficial 
results. 




Third Stage 

1. The patient's elbow is flexed and pointed 
upward with the arm at a right angle to the 
patient's body. 

2. The physician's other hand, on the side of 
the patient's head, firmly holds the 
shoulder down on the ribs while the elbow 
is slowly rotated in small concentric circles 
clockwise and counter-clockwise. The 
concentricities of the circles are increased 
to the maximum tolerance of the patient. 
(The maximum circle that the capsule will 
permit.) 

Fourth Stage 

1. Extending the elbow and grasping the 
patient's wrist, the physician holds down 
the shoulder with his free hand and moves 
the patient's arm in the same progressive 
concentric circles, clockwise and counter- 
clockwise to the maximum as above. 
When the fully extended arm is being 
carried in a complete circle, the best 
results are obtained by always 
maintaining even positive extension or 
traction 

2. In an injured shoulder, the hand does not 
describe a perfect circle. 

3. Sometimes, owing to adhesions, the 
upper segment of the circle is flat. 
However, by the use of careful, steady 
pressure through this portion of the swing, 
these adhesions are gradually and usually 
overcome. 

4. These last two steps must be taken with 
extreme care and with due regard to the 
advantage which the physician has in his 
leverage. 





52 



SHOULDER TECHNIQUES 




f 








The fifth and sixth stages must not be used until 
the patient's reactions have been tested by the 
other four procedures, and the physician is sure 
that the patient's progress has reached the 
point where the patient will be benefited by 
them. 

Fifth Stage 

1. The physician's hand closest to the 
patient's head is placed on top of the 
patient's shoulder. 

2. The patient's elbow is flexed and the 
patient's hand rests just in front of the 
physician's elbow on the forearm. 

3. Now with a gentle upward pressure exerted 
on the patient's elbow, the physician 
swings it towards the patient's head, 
balancing his weight from one foot to the 
other in order to get an easy rhythmic 
swing backward and forward. 

Sixth Stage 

1 . The patient's hand is placed just in back of 
the lower ribs, close to the lumbo-sacral 
junction and just far enough to prevent it 
from sliding forward when pressure is 
applied to the elbow. The elbow is flexed 
and pointing directly upward. 

2. The physician's hand closest to the 
patient's head, holds the shoulder while 
the physician's other hand is used to draw 
the patient's elbow forward and downward 
with a gentle and firm motion. 

3. The elbow is allowed to return to the start- 
ing point and then the movements are 
repeated. 

Seventh Stage 

1. This stage may start and end the treat- 
ment. 

2. The patient's elbow is extended so that 
the physician can slide his shoulder (the 
one toward the patient's feet) under the 
patient's hand, thus supporting the injured 
arm. Now both hands grasp the deltoid 
area side by side and with a gentle up and 
down pumping motion and with traction of 
the arm, the physician's hands are 
alternately grasped firmly and then 
relaxed on the soft tissue around the 
patient's shoulder. The patient's arm is 
simultaneously raised and lowered by the 
motion of the physician's body. 

In all of these procedures, the physician should 
cultivate the easiest standing postion with the 
feet comfortably spaced to allow an easy shift of 
weight from one foot to the other. This produces 
a smoother rhythmic swing to the manipulation, 
and automatically avoids the sharp, quick 
movements which give little therapeutic benefit 
and may produce unnecessary discomfort for 
the patient. 



53 



SHOULDER TECHNIQUES 



Three Stage Traction — Shoulder Girdle 
The three stages are described for a patient 
with a left shoulder somatic dysfunction. The 
procedures are changed for a patient with a 
right shoulder lesion. 

Stage I — The patient is supine with the physi- 
cian seated on a stool at the head of the table. 
The physician's left index finger is placed in the 
posterior axillary fold and the right index finger 
is placed in the anterior axillary fold, with the 
physician's right forearm resting across the 
upper portion of the patient's chest wall. With 
both index fingers, the physician now applies 
traction in a cephalad direction in an alternating 
traction and release manner for a total time of 
approximately 30 seconds. 



r" 





Stage II — Maintaining the same position as in 
stage I, the physician asks the patient to reach 
across the chest wall with his right hand and to 
grasp his left arm just above the left elbow. The 
patient then applies a lifting force to his left arm 
so as to offer resistance as the physician is 
applying traction at about a 60 degree vector 
force downward with both index fingers in a 
traction and release manner as described in 
stage I. 



jMP**' 




54 



SHOULDER TECHNIQUES 









Stage III— The patient is maintained in the 
same position as stage II. The physician now 
applies steady traction in a cephalad direction 
with both index fingers as the patient raises the 
arm gradually off the table and simultaneously 
pronates and supinates the hand and arm. This 
stage is also performed for approximately 30 
seconds. 



55 



SHOULDER TECHNIQUES 



Glenoid Labrum Technique — Normalizing 
Technique, Right Shoulder Involvement — The 
patient is prone with the right arm hanging over 
the side of the table. If fingers are touching the 
floor, elevate the patient by placing as many 
small pillows under the chest as are needed to 
allow the fingers to be about 2-3 inches above 
the floor. The physician encircles the head of 
the humerus with both hands, his thumbs rest- 
ing on the upper edge of the humerus and the 
fingers encircling its posterior aspect The 
physician rocks the head of the humerus back- 
wards and forwards, and then rotates the head 
of the humerus clockwise and counter-clockwise. 
The physician now draws the head of the 
humerus downward and applies a figure eight 
motion in an anterior and posterior direction. 




56 



RADIO ULNAR AND WRIST TECHNIQUES 




Wrist Joint — The patient is seated and the 
physician faces the patient grasping the patient's 
hand in his two hands with his fingers under the 
palm of the hand on the medial and lateral 
sides. The phsyician's thumbs extend over the 
dorsum of the hand coming to rest on the distal 
end of the radius and ulna. Mobilization is 
accomplished by circumduction and carrying 
the wrist into forceful dorsi-flexion while 
pressing firmly downward with the thumbs. 




Intercarpal Articulation — The patient is seated. 
The physician stands facing the patient and 
grasps the patient's hand in his two hands with 
his fingers under the palm of the hand on the 
medial and lateral sides. The physician's thumbs 
are now placed on the patient's row of carpal 
bones. Mobilization is accomplished by 
circumduction and carrying the wrist into forceful 
dorsiflexion while pressing firmly downward 
with the thumbs. 



57 



RADIO ULNAR AND WRIST TECHNIQUES 



^1 W 



Test for Motion — Part A — A radio-ulnar lesion 
will interfere with supination of the hand. The 
patient is instructed to approximate the elbows 
with the forearms parallel to each other, and the 
hands in full supination in front of the chest. The 
patient then extends the arms as far forward as 
he can, keeping the elbows as close together as 
possible. If a radio-ulnar lesion is present, the 
hand on that arm will tend to pronate. 



Test for Motion — Part B — Grasp the patient's 
hand as though you were going to shake hands. 
Place the thumb of the other hand posterior to 
the head of the radius and pronate and supinate 
the hand. Free motion in rotation should be felt 
at the radial head if it is not lesioned. 



Corrective Technique — With the patient sitting, 
maintain the position as described above in Test 
for Motion Part B. The physician now places the 
patient's forearm into extension with the hand in 
supination while pressing forward on the head of 
the radius with the thumb. The physician then 
places the wrist of the lesioned arm under his 
axilla, pressing it firmly against his body. Without 
removing the thumb from the head of the radius, 
the physician's hands encircle the patient's 
elbow with his thumbs uppermost. The fingers 
of one hand reinforce the other hand posterior 
to the head of the radius. Moderately carry the 
elbow into extension with thumb pressure 
maintained over the head of the radius and 
producing some traction on the arm with the 
physician's axilla. 




58 



RADIO ULNAR AND WRIST TECHNIQUES 




Variation — The patient is supine with his 
involved arm over the side of the table. The wrist 
of the lesioned arm is placed between and 
slightly above the slightly flexed physician's 
knees. The physician's hands encircle the 
patient's elbow with his thumb uppermost. The 
fingers of one hand reinforce the other hand 
posterior to the head of the radius. The correc- 
tion is accomplished by a sudden upward lift 
with both hands thus exerting a pressure 
posterior to the head of the radius while at the 
same instant, traction is applied by the physi- 
cian straightening his knees. 




Variation — Lesion of the Right Elbow — The 
patient is sitting. The physician places the wrist 
of the lesioned arm under his axilla pressing it 
firmly against his body. The physician's hands 
encircle the patient's elbow with his thumbs 
uppermost and the index finger of the left hand 
posterior to the head of the patient's radius. The 
physician now carries the elbow gently into ex- 
tension, while producing a traction on the arm 
using his axilla. The procedure is changed if the 
lesion is on the left elbow. 



59 



KNEE MANIPULATIVE TECHNIQUES 



Posterior Displacement of the Tibia in Relation 
to the Femur — A. The lesion is at the right tibia. 
The physician has the patient prone with his 
right lower extremity hanging over the side of 
the table or perhaps both extremities hanging 
over the table so that the pelvis is held firmly on 
the table. The right knee is bent to a right angle 
The physician grasps the patient's right ankle 
with his left hand and uses his right hand to 
steady the patient's pelvis. The physician 
bends his right knee and places it behind the 
proximal end of the patient's right calf and then 
with his knee applies a thrust towards the floor 
This automatically makes the tibia move for- 
ward on the femur, since the femur is secured 
by the pelvis fixed on the table, and the tibia 
being held in a position of 90 degrees flexion 
The procedure is changed if the lesion is on the 
left. 

B. The lesion is at the left tibia. The physician 
has the patient prone on the table and has the 
patient lift his left lower leg to about 90 degrees 
flexion. The physician encircles the proximal 
end of the patient's left calf and places the 
dorsum of the patient's left foot over his right 
shoulder. Now as the physician applies a force 
parallel to the table against the posterior aspect 
of the left tibia, he simultaneously lifts up the 
dorsum of the foot so that the foot goes into 
plantar flexion. The procedure is changed if the 
lesion is on the right. 

Posterior Fibular Lesions — 2nd Method — The 
lesion is on the left. The physician has the 
patient lying prone on the table which allows for 
greater relaxation of the biceps femoris muscle 
because it is not flexed. The physician stands 
on the right side of the table and places his right 
hypothenar eminence behind the left knee. He 
then simultaneously applies pressure with his 
right index finger against the left fibular head 
while his left hand externally rotates the left foot 
and pushes the lower leg downward towards 
the thigh. The procedure is changed if the 
lesion is on the right. 

Posterior Fibular Lesions — 1 st Method — The 
lesion is on the right. The patient is supine. This 
procedure involves three different maneuvers 
which are continued until point release is 
achieved. The first maneuver is extreme flexion 
of the right knee against the wedge of the left 
hand. Secondly, the wedge is applied with 
increasing firmness to the fibular head. For the 
third maneuver the physician's right hand 
rotates the tibia extremely to bring the fibula 
which is being forced anteriorly by the wedge. 
The procedure is changed for lesions on the 
left. 




60 



KNEE MANIPULATIVE TECHNIQUES 




Antero-Medial Displacement of the Left Medial 
Meniscus — The patient lies supine on the 
treatment table. The left thigh and knee joint are 
flexed by placing the left lower leg and ankle in 
the physician's left axilla. This position is main- 
tained by the patient's leg being held between 
the physician's thoracic cage and his left upper 
arm. The physician's left thumb is placed over 
the antero-medial aspect of the joint space 
where the displacement has occurred. The rest 
of the fingers of the left hand circle the posterior 
aspect of the tibia (the fingers should be distal 
to the joint space). The physician's right hand is 
placed at the lateral aspect of the left knee joint 
just distal to the joint space. The positions as 
described are maintained as the physician 
starts the forces in motion which causes an 
antero-medial gapping of the left knee joint 
space. Finally, the physician's left thumb exerts 
pressure at the gapped joint space while down- 
ward traction is applied and the antero-medial 
displacement of the medial meniscus is cor- 
rected. The procedure is changed if the lesion is 
on the right. 



61 



ANKLE AND FOOT TECHNIQUES 



Ankle Joint — The patient is supine and the 
physician stands at the foot of the table. The 
physician interfaces his fingers over the dorsum 
of the foot, just distal to the ankle joint. The 
physician's thumbs are under the sole of the 
foot. The separation is in a longitudinal direc- 
tion and is accomplished by a mild traction 
followed by a sudden pull. 




Ankle Joint — Second Method — The patient is 
supine and the physician is at the side of the 
table. The physician flexes the patient's leg on 
the patient's thigh and the thigh on the 
abdomen. The patient's knee is directed 
enough laterally so that the physician can insert 
his elbow into the popliteal space. It is this hand 
that is placed across the back of the patient's 
heel with the thumb under the medial malleolus 
and fingers under the lateral malleolus. The 
opposite hand contacts the dorsum of the foot 
just below the ankle joint with the thumb on the 
medial side and the fingers laterally placed. As 
the thigh is forcibly flexed on the abdomen, 
pressure is brought to bear in a downward 
direction by keeping the wrist stiff. As this trac- 
tion on the ankle increases, the opposite hand 
also presses in a downward direction, prevent- 
ing dorsiflexion of the foot. While maintaining 
this traction, the ankle joint is put through its 
range of motion, at which time, a correction may 
be accomplished. 




-j*ee£aMt;Ms • •■ivi-S'., 



62 



ANKLE AND FOOT TECHNIQUES 




Talo-Tibial and Talo-Calcaneal Artculation — 
The patient sits on a table or chair with his knee 
at the end of the table. The physician grasps the 
heel with one hand, while the other hand grasps 
the dorsum of the foot, well back toward the 
ankle. Traction is exerted downward to take all 
the slack from the articulation. The articulation 
is then put through its normal range of motion, 
at which time, a correction may be accomplished. 




General Springing of the Tarsal Joints, Left 
Foot — The physician grasps the patient's foot 
with his left hand and places his fingers across 
the dorsum of the ankle joint and his thumb 
underneath the sustentaculum tali. His right 
hand grasps the forepart of the foot with his 
fingers over the dorsum of the toes and his 
thenar eminence against the ball of the foot. 
The physician uses his left hand to produce a 
rotary motion in a counter-clockwise direction. 
The procedure is changed for the right foot. 



63 



ANKLE AND FOOT TECHNIQUES 



Technique to Produce Motion at the Outer 
Tarsal Joints, Left Foot — The patient is sitting. 
The physician's left hand grasps the patient's 
left foot with his fingers across the dorsum and 
his thumb on the plantar surface. The right hand 
grasps the lateral aspect of the foot with the 
3rd, 4th, and 5th fingers curled undernearth the 
cuboid bone and the thenar eminence placed 
on the dorsal surface of the outer two meta- 
tarsal shafts. The physician inverts the patient's 
foot slightly and makes a thrust upward and 
outward with the fingers of the right hand, and 
downward and inward with the thenar eminence 
of the same hand. The procedure is changed for 
the right foot. 




Technique to Produce Motion at the Inner 
Tarsal Joints, Left Foot — The left thumb is 
placed across the plantar surface of the foot so 
that the webbing between the fingers and thumb is 
held firmly against the inner aspect of the 1st 
cuneifrom bone with the fingers across the 
dorsum of the foot. The right hand is placed 
over the dorsum of the metatarsal shafts with 
the thenar eminence on the two medial 
metatarsal shafts. The left hand is carried up 
and laterally as the right hand is carried down 
and medially. The procedure is changed for the 
right foot. 




64 



ANKLE AND FOOT TECHNIQUES 




Metatarso-Phalangeal Joint Motion, Left Foot 
— Grasp the foot with the left hand so that the 
thumb is placed under the metatarsal head of 
the toe to be corrected. The finger and thumb of 
the right hand grasps the toe and exerts traction 
and flexion, removing all slack in the joint. A 
slight increase in traction and flexion with a 
slight upward thrust on the metatarsal head with 
the thumb of the left hand will produce motion, 
This procedure should never be used on the 
great toe. The procedure is changed for the 
right foot. 




Correction of Tarsal Displacements — The 
patient stands with his back to the physician 
and flexes his lower right limb. The physician's 
thumb (either hand) is placed on the plantar 
surface of the bone to be corrected and is 
reinforced by the other thumb. The fingers of 
the lateral hand encircle the dorsum of the foot 
with the index finger along the bases of the 
metatarsals. The fingers of the medial hand 
reinforce those of the lateral hand. With a firm 
grip, but relaxed wrists and arms, a slight 
snapping motion is produced in a manner of 
cracking a whip, thrusting the foot forward 
maintaining a fulcrum with the thumbs. The 
direction of force depends on the angle of the 
joint to be corrected. For the cuboid bone, the 
thrust is made at a 45 degree angle laterally. 
For the internal cuneiforms and navicular, the 
thrust is made directly forward. 



65 



ANKLE AND FOOT TECHNIQUES 



Spring Action Technique, Left Foot — The 
patient is sitting or lying supine. The physician 
places the thenar eminence of his right hand on 
the lateral aspect of the cuboid bone, the 
fingers curling around the heel. The fingers of 
the left hand are placed on the dorsum of the 
transverse arch with the thumb on the plantar 
surface, so that the webbing between the thumb 
and first finger presses against the inner aspect 
of the navicular and the first cuneiform bones. 
The physician exerts pressure medially with his 
right hand against the cuboid bone and the 
base of the 5th metatarsal while a lateral motion 
is made with the right hand. You may repeat this 
squeezing motion several times. The procedure 
is changed for the right foot. 





66 



LYMPHATIC DRAINAGE 




Classical Maneuvers — The patient is supine 
with his knees flexed, feet on the table, and 
head rotated to one side. The physician is at the 
head of the table with his hands spread over the 
upper thorax, fingers directed outward and the 
heels of his hands below the clavicles. (Modifi- 
cations: The palms may be above the breasts, 
cupping the breasts, or the fingers may be 
pointed inward between the breasts.) A soft 
foam rubber pillow may be placed over the 
upper chest before applying pressure with the 
palms of the hands. The physician's arms are 
maintained in as full extension as possible. The 
pressure is equally distributed over the entire 
surface of both hands and is applied downward 
and caudally in a rhythmic manner as explained 
below. 



Modification — Same position except one hand 
is over the sternum. Same rhythmic pressure. 




Modifications of Rhythms— A. A slight pressure 
is maintained constantly after the patient com- 
pletely exhales. The pressure is then exag- 
gerated for short intervals, regardless of the 
respiratory movement. The patient should 
remain in a relaxed state (100-120 vibrations 
per minute for 3-5 minutes). 

B. The pressure is applied after complete 
exhalation and relaxed with inhalation. The 
patient increases his respiratory rate to 18-24 
cycles per minute. 




\^^A> 



Modification I — The patient is supine and the 
physician is on the right side of the patient. The 
patient's right arm is extended and abducted by 
the physician's left arm. The physician's right 
hand is placed over the lateral and anterior 
chest wall with his fingers upward and toward 
the sternum. There is traction applied to the 
patient's right arm by the physician's left hand 
during inhalation. A gentle pressure is applied 
to the patient's chest by the physician's right 
hand during exhalation. The patient increases 
his respiratory rate to 18-24 cycles per minute. 



67 



LYMPHATIC DRAINAGE 



Modification II — The patient is supine. The 
physician is at the head of the table. The physi- 
cian's left hand grasps the patient's left wrist, 
extending and then abducting the upper arm. 
The physician's right hand, with the heel just 
below the clavicle (left), applies gentle pressure 
during exhalation. The left hand applies traction 
during inhalation. The patient maintains a res- 
piratory rate of 18 to 24 cycles per minute. 




Modification III — The patient is supine and the 
physician is at the head of the table. The 
patient's hands are extended above his head 
and clasped behind the thighs of the physician. 
The physician's hands are placed as before on 
the patient's chest just below the clavicle. 
Pressure is then applied downward and caudad 
during exhalation. During inhalation, traction is 
produced throughout the patient's arms by the 
physician leaning back against the patient's 
hands. 





68 



LYMPHATIC DRAINAGE 




Modification IV — Doming the Diaphragm — 
The patient is supine, and the physician is to 
one side facing the patient cephalad. The 
hands are placed symmetrically with the fingers 
outspread over the lower three of four ribs. The 
thumbs are placed under the ribs at about the 
junction of the eighth and ninth costal cartilages. 
The thumbs produce a bilateral upward and 
lateral pressure simultaneously with forced 
exhalation. 



69 



MANDIBULAR DRAINAGE 



Mandibular Drainage — (Galbraith's Technique) 
(Left Side Drainage) — The patient is supine 
and his head rotated to the right. The physician 
stands on the patient's right and places his left 
forearm under the patient's head and his left 
hand on the left shoulder of the patient. The 
physician's right hand is placed with his fingers 
at the tempero-mandibular joint and the thenar 
eminence along the ramus of the mandible. 
With the patient's mouth open, the physician 
produces a downward, anterior and medial 
traction on the patient's mandible. This is done 
intermittently and very slowly. The procedure is 
changed for right mandibular drainage. There 
are other variations to this technique also 





AURICULAR DRAINAGE 



Auricular Drainage — The patient is placed in a 
supine position as described above with the 
head again rotated toward the physician. The 
physician's fingers (2nd and 3rd) are placed on 
each side of the ear and a clockwise and 
counter-clockwise motion are used at this area. 




70 



ANTERIOR CERVICULAR DRAINAGE 




Anterior Cervical Drainage (Left Side) — The 
patient is in a supine position. The physician 
stands at the patient's right side and places his 
right hand gently on the patient's left anterior 
cervical musculature. The physician's left hand 
steadies the head while it also adds slight left 
sidebending. The fingers of the right hand 
remain flat and exert gentle pressure caudad 
without sliding over the skin. When the skin 
begins to stretch, pressure is released and 
reapplied without moving the fingers. This can 
be done 3-5 movements per second. The proce- 
dure is changed for right side drainage. 



Modification: The physician may clench all but 
his index finger and use only that finger to 
promote drainage. This is particularly useful in 
small patients. 



71 



P. C.O.M. LIBRARY 



PHILADELPHIA COLLEGE OF OSTEOPATHIC MEDICINE 



3 2243 00024 8615