First Chapters

The pages through the first three chapters are sequenced: 1 | 2 | 3 | 4 | 5 | 6 

HIGH-VELOCITY LOW-AMPLITUDE THRUST (HVLA)

H igh- V elocity L ow- A mplitude thrust is the grand daddy of manipulation. It is the classical, commonly used maneuver osteopathically coined as “the million dollar roll." It remains popular with both osteopaths and chiropractors and often provides the audible "release" that is so dear to the novice. There are a number of variations, and most joints can be manipulated with it.

The patient remains passive as the clinician dominates. For spinal manipulation, the body is positioned to develop a tension on each side of the joint to be manipulated. It takes a fairly well developed palpatory sense to carefully “take up the slack.” In essence, two “levers” are created by relatively "locking" the joints above and below the anticipated manipulation site so that a rapid thrust will gap it. If the force is not precise, of sufficiently high velocity and unexpected , the patient will have time to reflexly tighten up as the force is exerted. The effect can be more irritating than helpful, especially if performed before the soft tissues have first been adequately prepared. The manipulation's low amplitude is intended to keep the excursion within the joint's normal range of movement so that soft tissues are not injured.

The spinal joints, and many others, move three-dimensionally through flexion-extension, side flexion (right and left) and rotation (right and left). Rotation - especially over-rotation - is the movement into hazard. (That is how my back was injured twice). The range available in any joint at a particular instant is a product of the interactions of those combinations of movements: moving a joint into one direction progressively leaves less range available in the others. By engaging flexion (or extension) and then side bending, little of the potentially troublesome rotation is available before the levers tighten to facilitate the "release."

Concerning the "pop," some patients like it while others can't stand it. In any case, its therapeutic value is uncertain. If no benefit is derived from HVLA, continued attempts can cause problems, and the unscrupulous have been known to injure with it to ‘require" the ongoing need for "treatment.” In good hands, its effectiveness can be dramatic.

I was finishing my specialty training in Physical Medicine and Rehabilitation (PM&R), in 1974, at the University of California at Davis , at The Sacramento Medical Center. Dr. William Fowler headed the department, and he had learned to trust me. I manipulated patients regularly, and the results were often satisfactory, sometimes spectacular, so my activities became well known within the hospital. During the summer, I taught other residents some of the procedures, as well as some acupuncture. (The year before, I had been Co-chairman of Acupuncture Research at USC.)

One of the physical therapists asked me to treat her. She'd been athletic over the weekend, had twisted, and her spine had “glitched.” Her circumstance was one of those sweet pure cases of a single intervertebral segment restriction with no other abnormal findings. The injury was recent, so the soft tissue consequences of inflammation, edema and spasm were still limited. As often happens, her spinal gross range of motion was normal because the spine is like a chain, so the links around a restriction can compensate for a one-level loss. Also, much of the motion in bending at the waist occurs at the hips. (I will have much more to say about the notorious test of bending to touch the fingers to the floor.) To demonstrate individual lumbar segmental movement to the others, I had her side-lie on the exam table facing me. Fully flexing her hips and knees, I placed her forelegs across my abdomen and mildly flexed and extended her spine by rhythmically rocking her knees toward and away from her chest while serially palpating the intervertebral spaces. One segment didn't move at all. I positioned her for the “roll” by fully straightening her lower leg as a stabilizer and then flexing her upper leg until my fingers palpated the beginning of tension at the spinal interspace just below the restriction. Then I palpated the segment just above the restriction while slowly pulling her lower shoulder towards me with the arm reaching for her upside hip, which rotated her upper torso until I palpated the beginning of tension in the segment above. The “levers” on both sides of the restriction were set. Bending close over her to completely control and impart the force, I sensed when the tension was right and delivered a sudden, short thrust through the restriction, producing a satisfying, audible release. Immediate retest confirmed restored segment movement normalcy, and she got off the table pain-free, fully functional and very grateful.

One of the physicians who had observed had been a neurosurgeon before changing his specialty to PM&R. His expression was an interesting combination of “skeptical moralism” as he spoke with a voice consistent with his reserve, “ Kind of intimate wasn't it?” It surprised me, but I responded in an instant. “ You bet it was!” explaining that it was only by her trusting me that she could so completely relax that I was able to be so precise.

Yes, manipulative therapy can be intimate – of the most cherished and professional kind. Manipulation offers the essence of the clinician's greatest privilege - to be so trusted to be able to provide such directed relief - the only such therapy I know that offers the opportunity for instant cure.

FUNCTIONAL TECHNIQUES

The distinction between manipulation and mobilization blurred with the osteopathic advent of what they call Functional Techniques. Instead of thrusting at the passive tissues, they are performed through dynamic realignment by the application of gentle leverage.

MUSCLE ENERGY

Muscle Energy, a powerful technique, was developed by Doctor Fred Mitchell, Sr., an osteopath. It conceptualizes that dysfunction is caused by muscle tone imbalance and is corrected through exploiting the muscle physiology. The patient is precisely positioned. The involved muscles are contracted isometrically: the parts are prevented from moving. Then, the muscles are relaxed and a brief “refractory” phase ensues during which the joint is gently levered towards normalcy.

The manipulation is precise, gentle and slow. It has a number of advantages. When it works well, as it often does, it may provide segmental "training" so the involved muscles has less tendency to return to the former abnormal state. It is ultimately under patient control, and only unusually is it followed by increased pain. There is no thrust so there is little danger of irritating the tissues. Importantly, it is an excellent technique for clinicians to improve their hands-on skills.

The procedure directly addresses the origins of spasm: special fibers interspersed in muscle tissues sense and set the tone for a particular planned task, whether it brushing one's teeth, scratching one's nose in the dark or tensing for a precise leap (as is so beautifully seen in cats) - or lifting a heavy object. So, the physiology is consciously directed yet still acts as a protective reflex which fires whether a threat is real or only perceived to be. Once the alarm goes off, it may persist indefinitely. After a time, the spasm may not be gross, but sufficient muscle fibers remain abnormally tense to painfully restrict normal motion.

The reflex is potent and can be abused. An old "strong man" trick required its intentional "short circuiting." The stunt was to lift the end of a car. The performer would grasp it by its bumper (when cars actually had bumpers), lean back a little while maximally contracting his arm flexors and then suddenly engage his back muscles to thrust his body back. The sudden overload against the tensile strength of the biceps tendon could easily snap it. Tricking someone by inducing them to be convinced an object is very light or very heavy (when the opposite is true) can cause severe harm.

More specifically, for a Muscle Energy manipulation, the patient is carefully placed in a posture so the restricted joint is in its most unrestricted “loose packed” position in all three planes, for which I coined the term The Interbarrier Zone (IBZ). The clinician then assists the patient to perform an isometric contraction (contracting certain muscles while preventing any motion of the involved joints). The effort is held for at least six seconds, during which all the elements of the muscle tend to come into balanced tone.

The final phase of the manipulation occurs when the patient then fully relaxes, and during the anticipated “refractory period” of local quietness, which lasts about four seconds, the muscles that had just been in spasm are stretched back to their normal resting length as the dysfunctional joint is hopefully released to its normal relationship. The maneuver is usually performed three times, with increasing movement against the barrier each time. It is an excellent technique that nicely challenges the clinician.

Vendyl Jones is an archaeologist who is reputedly the namesake for Indiana Jones. He is an extraordinary individual who has devoted his life to the “big dig” for the Temple treasures in Israel . Anthony Carton, a friend of mine, told me that Vendyl would be in Southern California in February 1995 to raise funds for his next excavation later that year, near Qumran , the site where the Dead Sea Scrolls were discovered. I wanted to meet him, but I kept missing him until the day he would leave after lecturing at a small church in Orange County close to Anthony's home. I picked Anthony up on the way. Vendyl and I hit it off. I was sitting across from him at lunch at the Claim Jumper as he was consuming a large plate of ribs when suddenly he became pale and started to sweat. Of course, I was concerned.

“It's just the pain.”

“What pain?”

He told me he had been injured in an auto accident twenty-two years before. He'd had a lot of treatment, but the pain had never gone away, and sometimes it would suddenly increase.

I had no preconceptions about my being able to help him, but he had a few hours before his flight back to Texas , and I asked him if he'd allow me to examine him. He responded that he'd be grateful. Anthony's bed was firm and a perfect workbench.

There were dysfunctions and accommodations all up and down Vendyl's spine with the primary problem about his sacro-iliac joints. I just kept working, almost entirely with Muscle Energy techniques until everything was “back in place” and moving properly. It took about an hour. Vendyl got off the bed and began to move about the room stretching and lifting his legs in all sorts of directions. He wouldn't answer me about his pain. He just smiled and kept doing all sorts of things he hadn't been able to do for years. In fact, for the first time since the accident, his pain was gone. I told him his ligaments were damaged and that the pain would recur. He would need a series of prolotherapy injections (which I will discuss in detail). I showed his secretary, Anita, now his wife, a few maneuvers to use when the pain tended to recur, and that is how I became the physician for the dig November 1995 to February 1996. It was one of the great experiences of my life.

COUNTER STRAIN

CounterStrain, another osteopathic discovery provides profound manipulation through precise motionlessness, which even further expands the manipulation's definition. It appears remarkably simple and is the singular work of Lawrence Jones, D.O. who practices in a small town in Eastern Washington .

Almost four decades ago, he examined a young man who had strained his groin. The pain had been unremitting, and no one had been able to help him. As Dr. Jones told the story, he had worked assiduously but without success, as well. After months of frustration, he said that, at least, he wanted to give the young man some rest by perhaps finding a temporary position of comfort for him. He related that he had spent about twenty-five minutes continuing to readjust pillows about the young man's leg until by trial and error he eventually found a pain free position that had required a precise combination of flexion and rotation of the hip. He was grateful he had, at least, accomplished something and told the young man to just relax and that he would be back. When he returned about twenty minutes later, he found the patient joyously on his feet walking about cured.

To his great credit, Dr. Jones spent the next twenty-five years pursuing the applications of that day's serendipity across the body's entire landscape as he continued to develop his understanding of what had happened. He combined his clinical application to the research of Irvin M. Korr, PhD, a physiologist, who spent his career studying muscle physiology in osteopathic institutions.

Dr. Korr learned that the gamma reflex, the one that sets muscle fiber tone and protects joints (which I briefly discussed above), can fire emergently even if a muscle or a joint has not been overstretched, if its acceleration is unexpected. Then, once the muscle reflexly contracts to attempt to prevent a perceived injury, the “alarm” can persist indefinitely because the muscle fibers persistently remain relatively too short and “overstretched.” Obviously their points of origin and insertion remained the same, so there was no place in their normal functional range for them to find a position of untensed rest. Most movements, especially stretching, tend to further aggravate the condition resulting in an indefinitely painful dysfunction. The technique works by finding a joint position in which the muscle origins and insertions are brought sufficiently close for the involved muscle fibers to relax so the alarm can stop.

A muscle in spasm has a discrete tender and tense spot in it. The patient must remain completely relaxed while the clinician palpates to elicit the tense tenderness and monitor its response as the involved joint is slowly, sensitively, passively moved in the appropriate direction(s) to allow the involved fibers to relax.

While there are guidelines that work most of the time, the principle is the ultimate authority. The technique requires precision, often within a 1-2 ° range. When it is located, there is a sudden diminution of the tenderness under the finger as the tenseness “melts like butter.” While the patient continues to remain completely relaxed , the clinician carefully maintains that exact position for ninety seconds , which is infinity for that reflex. Then slowly the part is passively stretched out, and, if the manipulation is successful, the entire pathologic process aborts as the previously contracted fibers return to their normal resting length.

When I first learned CounterStrain, for more than a year I repeatedly asked one of my instructors if it really worked. Each time, he had only smiled and replied, "Try it." It seemed so simple that I was literally too embarrassed to actually charge for it.

While I was practicing in Phoenix , I treated a young woman whose back was injured in an auto accident. She couldn't afford to lose work, but sitting aggravated her pain. I unsuccessfully tried almost everything I could think of as I continued to insist she needed to be hospitalized for a special type of traction. After several weeks, she tearfully succumbed, but after two days she was still unimproved. Then I remembered I hadn't attempted CounterStrain, asked her to turn over, performed it, whereupon she arose on her elbow and asked me what she was doing in the hospital.

While ice-skating with her children, Melody Shepherd ¹⁰ fell back violently onto the ice with her arms fully extended straight out behind her. She took the full force onto her hands as both elbows violently hyperextended. She came to my office with her arms hanging flail, totally unable to flex her elbows. Every attempt she made was prohibitively painful although I could fully flex them for her painlessly. There were no fractures. I had to splint them straight to diminish her pain. Nothing I tried helped. She had to be fed and dressed and washed by her seven-year-old daughter who also had to care for the other children including an infant. It continued for almost two weeks. Finally, I thought of CounterStrain. Only one treatment to each elbow broke the reflex and almost immediately Melody was functional. Incredibly, within a week she was normal.

Again when practicing in Big Bear Lake , I was having lunch at one of the sandwich houses when Barbara Cunningham ¹¹, the owner, came over to me almost in tears. She held out her hand and told me she'd just inexplicably begun to experience intense pain in it. Her palm was scarred from an old injury that was of uncertain relationship to her complaint. I found an exquisitely tender spot close to her wrist, asked her to sit down with her elbow on the table and her forearm vertical. While continuing to keep some pressure on the tenderness, I fully flexed her wrist and moved it about slowly until the tenderness under my finger disappeared and the tissue tenseness softened. I held it there with one hand on top of hers while I continued eating my soup with the other. When I released it, the pain was gone, and Barbara's hand was fully functional. Her expression was priceless, and the lunch was free. Bad business. Great fun.

MYOFASCIAL RELEASE TECHNIQUE (MFR)

The procedures may be necessary when tissue tenderness, bodily asymmetry from fascial pull and spasm are observed. Not treating them tends to leave a residual whose irritable focus can fire “retrograde” - back down the nerve – and sustain an underlying dysfunction. Untreated, the pain that results from such conditions can persist for life.

MFRs have special value in the treatment of pain from internal scars whether they are realized, or not. The treatment is not benign. It can be as painful as pain can be, but for only a few minutes. As the saying goes, “I hurt so bad I thought I wasn't going to die.” At the same time, the result can be magnificently rewarding.

There are times that an in-depth history is not all that important. Chronic scars into the interior are paths of pain along the entire extent of their adhesions that may be relieved only by palpating into them wherever they go. Sometimes the fingers seem to take on a consciousness of their own as they bond with the tissues and do something of which the intellect may only ask, “Why did you do that?” But sometimes something good happens, and it happened that night.

Sarah had experienced all sorts of abdominal and pelvic problems for many years. She hurt continuously. The area about her umbilicus and lower abdomen was always intensely tender. She couldn't tolerate any pressure on it, and she could only wear loose garments. She had severe chronic constipation, which she often measured in weeks. Her intimate life with her husband was a distant memory. Sarah was gutsy. She worked cleaning houses and would get through her day as she went on with her life, the personification of a lifetime fighting pain and depression.

Our camp had been the location of an old Turkish fort, just outside Mitzpah Jericho, on the road to the Dead Sea . Sarah arrived at my “caravan” at 6:00 p.m. I related what I was about to do. I explained that when tissues tighten and scar, the resultant distortion usually impairs function. I told her how painful MFR can be and that the path of her pain would be my primary guide. The MFR technique I used begins by finding the most tender spot with a fingertip, then increasingly palpating deeply into the abdominal tissues with the finger pads, wherever “it” goes, until the there is no more of “it.”

It can be amazing to watch how the fingertips change direction as they descend as the patient must remain totally committed to relaxed acceptance no matter what, even with only open-mouthed groans from somewhere deep near where the fingers are following, if sound can be uttered at all. I followed the devils down to near her spine, and finally it was over.

When Sarah again relaxed, I treated the full course of the attachments of her large bowel. The procedure has a considerably more distinct end point, the “dissolving” of encountered tissue resistance. While there is usually some discomfort, it is far more easily tolerated than scar treatment. The technique commences in the right lower quadrant where the large bowel begins. The fingers of both my hands, joined in a line, slowly descended at the edge of the abdominal cavity just lateral to the bowel. As soon as I encountered spasm and tenderness, my fingers stopped - and held - and waited - relinquishing nothing. In its own time, the tissues “melted” and I then moved my fingers superiorly adjacent and repeated - up, across, and down. Throughout, each maneuver encountered hard resistance, and finally Sarah's abdomen was soft, and all the tenderness was gone.

Then I examined the movement of her pelvic diaphragm , one of four in the body. In a woman, both the vagina and rectum pass through it. The well-known respiratory diaphragm, of course, is located between the thoracic and abdominal cavities. In contrast to its large movement, the pelvic diaphragm's excursion is relatively small, but it is essential - and palpable.

For health, all the diaphragms need to move synchronously. Especially in the pelvis, lymphatic flow depends on it. Lymph is part of the “extra-vascular, extra-cellular” fluid, which, in fact, is most of the fluid volume of the body. It seeps out of the capillaries, bathes and nourishes the tissues converting it into a “wetlands” and then flows through tributaries back to the main vascular stream, which it reenters in the subclavian vein high in the chest. In Sarah, both sides of the diaphragm weren't moving at all, and the resultant stasis was a major cause of the chronic edema and irritability of her pelvic organs.. Her legs would swell. Her abdomen bloated. Her digestion and her elimination were grossly impaired.

The pelvic diaphragm is palpated with the patient supine and relaxed. To facilitate the placement of the examiner's hand, the hips can initially be flexed to a modified exposed posture. The examiner moves a hand up the inner thigh into the tissues of the buttock. The “sitting bone” (the ischial tuberosity) is palpated, and the hand ascends along its medial border. There is no excuse for a social blunder. The hand is kept reasonably soft. The patient takes a deep breath in, then out. As the respiratory diaphragm ascends, the pelvic diaphragm should ascend, as well, and the clinician's hand advances. If the area remains soft and there is no pain, the advance is progressively repeated a few times. Then the hand waits and “listens” as the patient continues to breathe normally. If the diaphragm is moving properly, a gentle pressure will be felt against the tips of the fingers with each respiratory inspiration (the diaphragm moving down), symmetric with the other side that, of course, is examined separately. But if several cycles pass and no pressure is sensed, it is likely that the diaphragm's movement is impaired.

The pages through the first three chapters are sequenced: 1 | 2 | 3 | 4 | 5 | 6