Facilitated Positional Release and Beyond

Sydney, AustraliaJuly 2019

Dennis J. Dowling, D.O., F.A.A.O.

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Registrations and Payment: Contact: Dr Terry VardyEmail:  tv8000@isotechnology.net

Cost this year is $1250.00 per registration. This may be paid by direct debit to: Bank: NABName: NEUROMUSCULAR ENGINEERING & TECHNOLOGYBSB: 082-738ACCOUNT NO: 67-526-9577 Cheque to Neuromuscular Technology, PO BOX 375, TWEED HEADS. NSW 2485

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Facilitated Positional Release and Beyond

Dennis J. Dowling, D.O., F.A.A.O.

Program: Day 108:00 – 9:00 Overview

1. Dr. Schiowitz and the development of FPR2. Theory of FPR 3. Introduction to philosophy and principle.4. Relationship to other Still techniques

9:00 – 10:00 Cervical1. Review of Cervical Anatomy and Function2. Integration of Intersegmental and Rotoscoliosis Cervical Diagnosis3. Rapid diagnosis of the cervical region

10:00 – 10:15 Break10:15 – 12:00

4. Efficient application of FPR to the cervical region.5. Discussion of Indications and Contraindications6. FPR for Cervical Extension and flexion dysfunctions.

12:00 – 13:00 Lunch13:00 – 14:30

7. O-A somatic dysfunction.8. AA somatic dysfunction9. Muscle specific treatment

a. Trapeziusb. Sternocleidomastoidc. Spleniid. Sub-occipital musclese. Scalenesf. Strap muscles

14:30 – 14:45 Break14:45 – 15:30

10.When does treatment determine the diagnosis?11.Treatment for the patient with chronic restriction of gross motion of the cervical

region.12.Key Dysfunction13.Integration of FPR with other OMT Treatment modalities14.The difficult to treat acute cervical dysfunction 15.Discussion and case application in the cervical region.

15:30 – 16:30 Thoracic1. Review of Thoracic Spinal and Regional Anatomy and Function2. Rapid diagnosis of the thoracic region

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3. Integration of Rapid Diagnosis with Intersegmental and Rotoscoliosis Testing4. Discussion of Indications and Contraindications5. Treatment of Group Curve – Seated6. Treatment of compound scoliosis - Seated7. Specific treatment to mobilize the last vertebra of upper curve and first vertebra of

lower curve.16:30 – 16:45 Break16:45 – 18:00

8. Treatment of the localized thoracic flexion single dysfunction.a. Seatedb. Sidelying

9. Treatment of the localized thoracic extension or flexion single dysfunctiona. Seatedb. Pronec. Sidelying

10.Rapid relaxation of the thoracic superficial muscles a. Seatedb. Pronec. Sidelying

11.Integration with other OMT modalities12.When does treatment determine the diagnosis?13.Problem solving for the Thoracic region with FPR

18:00 Dinner

Day 208:00 – 10:00 Ribs

1. Review of Thoracic Cage/Rib Anatomy and Function2. Rapid Diagnosis of the first rib3. Rapid Diagnosis of Typical Ribs4. Integration with other Rib Diagnosis approaches5. Discussion of Indications and Contraindications6. Utilization of the patient’s upper extremity for the mobilization of first rib

dysfunctions.a. Seatedb. Supinec. Sidelying

10:00 – 10:15 Break10:15 – 12:00

7. Treatment of anterior rib dysfunction a. Seatedb. Supine

8. Treatment of lateral rib dysfunctionsa. Seated

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b. Supinec. Sidelying

9. Treatment of posterior rib dysfunctionsa. Seatedb. Pronec. Sidelying

10.Discussion and case application to the rib regions11.Integration with other OMT modalities12.When does treatment determine the diagnosis?

12:00 – 13:00 Lunch13:00 – 15:00 Lumbar

1. Review of Lumbar Anatomy and Function2. Rapid diagnosis of the Lumbar region3. FPR as applied with the patient to the lumbar region4. Discussion of Indications and Contraindications5. Treatment of soft tissue dysfunctions.

a. Paravertebral Musclesb. Quadratus Lumborum

6. Treatment of flexion dysfunction.a. Proneb. Supinec. Sidelying

7. Treatment of extension dysfunction a. Proneb. Sidelying

8. Lumbar Discogenic Treatmenta. “Traditional”b. “Multi-lever” approach

9. Integration with other OMT modalities10.Discussion and case application to the lumbar region.

15:00 – 15:15 Break15:15 – 18:00 Sacrum & Pelvis

1. Review of Sacrum and Pelvic Anatomy2. Discussion of Indications and Contraindications3. Principles utilized to differentiate and treat sacroiliac and iliosacral dysfunctions.4. Rapid Diagnosis of sacroiliac restriction of motion5. Integration with other Sacral Diagnostic methods6. Treatment of restriction of motion, S-I articulation, patient in prone position,

a. Straight leverb. Bent lever

7. Functional long or short leg as related to anterior rotation dysfunction and posterior rotation dysfunction of the ilium on the sacrum.

8. Technique to treat anteriorly rotated ilio-sacral restriction

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9. Technique to treat posteriorly rotated ilio-sacral rotation.10.Inflare and out-flare treatment11.Technique to treat Pubic region

a. Adducted pubic dysfunctionb. Abducted pubic dysfunctionc. Pelvic floor dysfunction

12.Diagnosis and treatment of dysfunctions found of the piriformis muscle, glutei muscles, and tensor fascia lata.

13.Integration with other OMT Modalities14.Discussion and case application to the sacrum and pelvic region.

Day 308:00 – 10:00 Upper Extremities

1. Review of Upper Extremity Anatomy and Function2. Rapid Diagnosis of the Shoulder3. Rapid Diagnosis of Elbow4. Rapid Diagnosis of the Wrist and Hand5. Integration with other OMT approaches6. Discussion of Indications and Contraindications7. FPR for the Shoulder

a. Facilitated Positional Release for the Claviclei. Addressing

1. Sternoclavicular joint2. Acromioclavicular joint3. Suprahumeral pseudojoint4. (first rib – clavicle – manubrium pseudojoint)

ii. Shoulder – Rib – Cervical – Thoracic Inlet considerationsb. Supine Treatment of the Shoulder

i. Glenohumeral jointii. Scapulothoracic pseudojoint

iii. Muscular components1. Rotator cuff2. Scapulothoracic

8. FPR for the Elbowa. Radiohumeralb. Radioulnarc. Humeroulnard. Musclese. Ligaments

i. Medical collateralii. Lateral collateral

iii. Annular9. Wrist and hand

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a. Proximal carpal row with radius and ulnarb. Intercarpal c. Carpal- metacarpald. Metacarpale. Phalanges

10.Two- and three-joint simulateous treatment of the muscles and joints11.Discussion and case application to the upper extremity

10:00-10:15 Break10:15 – 12:00 Lower Extremities

1. Review of Lower Extremity Anatomy and Function2. Rapid Diagnosis of the Hip3. Rapid Diagnosis of Knee4. Rapid Diagnosis of the Foot and Ankle5. Integration with other OMT approaches6. Discussion of Indications and Contraindications7. FPR for the Hip

a. Supine Treatment of the Hipi. Joint

ii. Muscular components1. Adductors2. Flexors3. Gluteal4. Abductors

a. Iliotibial bandb. Tensor fascia lata

b. Integration with FPR of the Pelvis8. FPR for the Knee

a. Patellab. Fibular-tibialc. Femoral-tibial

i. Ligaments1. Anterior cruciate2. Posterior cruciate3. Medial collateral4. Lateral collateral

d. Musclesi. Quadriceps

ii. Hamstringsiii. Gastrocnemius

9. Ankle and foota. Talocrural jointb. Subtalar jointc. Metatarsals

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d. Tarsals e. Phalanges

10.Integration with other OMT Modalities11.Discussion and case application to the lower extremity12.Recap and questions

Objectives:Participants will:

1. Learn the application of osteopathic principles to apply concepts of structure and function to diagnosis

2. Review traditional diagnostic methods and integrate with rapid diagnosis of specific dysfunctions and regional problems

3. Demonstrate treatment of patients in sitting, prone, supine and sidelying positions utilizing Facilitated Positional Release and adaptations.

4. Review indications and contraindications.5. Review Clinical application of Facilitated Positional Release.

BACKGROUND:

Stanley Schiowitz, D.O., F.A.A.O. was an innovator with over sixty years experience in the application of osteopathic philosophy, principles and practices. Facilitated Positional Release (FPR) was but one of his legacies, and as a modality, it employs aspects that make for quick diagnosis and treatment of somatic dysfunction with very efficacious results. Dr. Schiowitz did not limit himself just to FPR but extended clinical application to make certain that somatic dysfunctions were found and fixed in rapid fashion. This six-hour course is designed only for experienced osteopathic physicians with some basic

knowledge of the application of FPR who want to go beyond the basic level and expand their knowledge to difficult clinical scenarios. It will include elements of FPR and beyond that so as to make the course participant more efficient in time and results as well as integration with other aspects of osteopathic manipulative medicine.

In the 1980s, Dr.Schiowitz, was an associate dean and chairman of the Department of Osteopathic Principles and Practices (OPP) at the New York College of Osteopathic Medicine. His clinic practice on campus gave the undergraduate OPP fellows a great opportunity to practice osteopathic manipulation under the supervision of an experienced practitioner. Time after time, they would describe the same experience: Dr. Schiowitz would enter the treatment room after each had treated a patient, they would describe some finding or restriction that was recalcitrant to treatment, Dr. Schiowitz would perform some quick maneuver that was unfamiliar to them, the patient would be improved, and Dr. Schiowitz would quickly exit to go see other patients. As they exchanged observations on what they experienced and mimicked some of his treatments, the group found that they were able to successfully perform them. Whenever possible, Dr. Schiowitz taught them one-on-one or in small groups. It appeared that he had a cohesive approach for treatment that was, as of that time, nameless, without explanation, and outside of the typical OPP curriculum. In order to record the description in the “Progress” section of the SOAP note, the OPP fellows would use the letters “IO” (“Instant Osteopathy”) as an abbreviation. Because of his busy practice and

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time limitations, Dr. Schiowitz sought out and adapted methods of treatment that were rapid and effective and based upon anatomical and physiological principles. Some of his students have remarked that he had to develop a quick approach to treatment since he couldn’t stay in one place for ninety seconds. He admitted that he may have seen some practitioners using some similar elements or methods addressing very specific diagnoses but not in a globally designed system. By 1990, Dr. Schiowitz had formulated the treatment to the extent that it was published in the JAOA1 and taught at national meetings. The OPP fellows and some faculty members became his earliest table trainers at some of these sessions.

Facilitated positional release (FPR) is primarily an indirect method of treatment as has been published. Actually, as practiced by Dr. Schiowitz and those whom he has directly taught, FPR is a mixed indirect followed by direct treatment. The physician initially places the region or somatic dysfunction into a position between flexion and extension to approach the neutral position as defined by Fryette12. An activating force, compression, traction, “jiggling” or torsion, is then applied to facilitate an immediate release of tissue tension, joint motion restriction, or both. This is followed by placing the region into its directions of dysfunction for a few seconds and then repositioned, if desired, in the barrier directions followed by re-diagnosis. This latter aspect, the positioning into the barriers, brings FPR into greater resemblance with the Still Technique3. The goals of treatment are to decrease muscle hypertonicity that maintains somatic dysfunction whether by affecting larger regional groups or by modifying smaller more intrinsic deep muscles, which are involved in joint immobility.

FPR as a technique is easily applied, effective and time-efficient. Often, patients report immediate relief of tension and/or tenderness and restoration of function. Because treatment of specific dysfunctions is accomplished in seconds, repeat application can be attempted or other methods of treatment can be subsequently applied.

THEORY Korr4 wrote that the immobility of a lesioned segment was initiated or maintained by

increased gain in gamma motor neuron activity of the muscles of that segment. The gamma motor neurons specifically innervate the intrinsic muscles, the muscle spindle apparatus that act as sensors for overall muscle tonicity. When a gamma motor neuron stimulates a muscle spindle, such as a nuclear bag fiber, the fiber shortens in length and the stretch receptor, either annulospiral or flower spray, becomes more sensitive to stretch than it was previously. Even if the overall extrinsic muscle is in a rest position, the length-sensing nerve fibers of the muscle spindles may be sending signals back to the spinal cord which in turn stimulate alpha motor neuron fibers innervating the same muscles. In effect, the muscle may remain in tension even in a so-called neutral position and may worsen with further stretching. Bailey5 proposed that this high gain-set of the muscle spindle results in changes of the soft tissues that are characteristic of somatic dysfunction. Because of these aspects, FPR is an indirect form of osteopathic manipulation in which the patient remains passive throughout treatment.

Carew’s6 discussion of the feedback mechanism of the muscle spindle stretch reflex indicated that compressing muscles into more than the neutral position results in an inverse spindle output. The afferent excitatory input to the spinal cord through the Group Ia and II fibers is eliminated. This results in a “quieting” of the gamma motor gain to the spindle, reduction of the stretch stimuli and resultant elimination of the reflex activation of the alpha motorneuron. The tension and hypertonicity of the extrafusal muscle fibers is reset.

Specific diagnosis in three planes is required for accurate treatment with FPR when addressing articular difficulties and noting tissue tension resistances are important in muscular, fascial, and ligamentous dysfunctions. The primary step in the application of facilitated positional release is the placement of the region of somatic dysfunction into its neutral position. This unloads the joints and may also affect both proprioceptive and nocioceptive elements. When addressing extremities, the joint should not be in a closed-pack position. The dysfunction can then respond

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more easily and rapidly to the applied therapeutic position, motion, and force. For the spine, the articular facets are placed into an idling position between the flexed and extended extremes. A facilitating force, typically compression and/or torsion, is applied and maintained throughout the treatment. When necessary, traction and oscillatory motion may be necessary. Generally, initial soft tissue relaxation is noted at this time. Using the tri-planar diagnosis, further positioning of the somatic dysfunction is applied into all of the directions of relative freedom. Further easing of the dysfunction occurs at this point. This position is held for approximately 5 seconds after which the region is restored to neutral. In practice, Dr. Schiowitz often followed neutral by bringing the dysfunction into the barrier directions and then returned the region again to neutral. The dysfunction is then reassessed. The tension that was noted in the area is most typically is gone or at least reduced. Joint motion symmetry increases after treatment with the facilitated positional release modality if the etiology or maintenance of the dysfunction is due to muscular hypertonicity. If the asymmetry of joint motion is caused by other factors, such as arthritic or other degenerative changes, congenital malformation, meniscoid or synovial entrapment or ligamentous damage, the joint may remain restricted. Other modalities of osteopathic manipulation or repeated treatment with facilitated positional release may be necessary to complete treatment of the dysfunction.

DIAGNOSISThe diagnostic methods used to determine somatic dysfunction can vary. The use of FPR

treatment procedures does not require special diagnostic tests unique to FPR. However, diagnosis is a prerequisite to treatment. Mennell7 has described a method of skin rolling. Mitchell8 and others have used the coupled motion of vertebrae as described by Fryette to conduct rotoscoliosis testing while Johnston9 incorporates a method of scanning and screening to progressively narrow the findings to specific diagnoses.

Schiowitz utilizes a very rapid method of diagnosis that incorporates the introduction of small motions to test all cardinal planes of motion. The appreciated palpatory response indicating relative freedom and resistance results in a specific diagnosis. For superficial muscular diagnosis, the physician places the pads of his fingers on the area of dysfunction and determines elements of Sensitivity, Tissue Texture Changes, Asymmetry, and Restriction of Motion (S-T-A-R)10.This can be accomplished in seconds and the FPR treatment applied. For specific segmental dysfunction, the physician introduces motion in all three planes by alternating forces in opposite directions. In the spine, the pads of the fingers apply anterior force to create rotation both to the left and to the right. When pressure is placed on the right transverse process, it creates a slight left rotation. Segmental dysfunctions will have directions of relative ease and restriction with the direction of restriction demonstrating greater resistance to the applied pressure and the freedom allowing less.

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Lateral motion, or sidebending in the spine, is tested by applying pressure to deviate one transverse process into a more cephalad direction and the opposite side simultaneously into the caudad direction. Relative ease and restriction to the forces are noted and the opposite directions are tested.

Sagittal planar motions of flexion and extension require observation of the resistance to anterior deviation of one vertebra with the next lower one. The pads of the fingers are pressed anteriorly on the superior surfaces of the upper vertebra’s transverse processes for flexion and on the inferior surfaces for extension.

The combination of all findings results in a tri-planar diagnosis of segmental dysfunction. For the extremities, similar methods are utilized to determine flexion-extension, abduction-adduction, and rotation. The directions of ease will be the ones that will be introduced immediately after placing the joint into neutral and adding the facilitating force.

Using a combination of methods can further increase the accuracy of the diagnosis and therefore the treatment.

TREATMENTFacilitated positional release treatment can be used to address at abnormal superficial tissue texture as well as influence the deep intrinsic muscles involved in segmental joint mobility. When it is a clear diagnostic differentiation as to which is primarily involved in the somatic dysfunction, the superficial soft tissue changes should be initially treated. If the dysfunction persists after this treatment, FPR should then be directed towards treatment of the deeper muscular component involved in the specific joint motion restriction. Facilitated Positional Release is primarily an indirect technique that requires the patient to remain passive. However, sometimes the patient can assist initially into attaining a neutral position, the physician braces the patient, and then the patient

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relaxes. The technique can be adapted to treat the patient in a supine, prone, sidelying, or upright position.

Tissue Texture Change Treatment1. The physician monitors the region to be treated2. The antero-posterior spinal curve of the treatment area is flattened. This position places that

region of the spine into an idling position, which shortens and softens associated muscle. A palpatory softening is customarily noted immediately. The lordoses of the lumbar and cervical regions are slightly flexed while the thoracic spine is extended. When treating the patient in the supine or prone positions, pillows can be used to attain approximation of neutral

3. A facilitating force is applied. This may be compression, torsion, or a combination of the two. At times, traction may be used with or without torsion.

4. The physician places the patient (patient's musculature) into a relaxed position. This usually requires approximating the origins and insertions by further compression and/or torsion. Additional softening is often noted.

5. The position is held for 3-5 seconds and then all facilitating forces are released. 6. The patient's condition is re-evaluated. In some cases, passive stretch can be introduced.

Intervertebral Motion Restriction TreatmentThe same basic procedures are used to address intervertebral motion restrictions, with the additional requirement that the physician place the vertebra into a position that allows freedom of motion in all planes. For the Cervical spine, the patient can be treated in the seated position but more frequently in the supine position. The Thoracic and Lumbar regions are typically treated in the seated or prone positions but the techniques can be adapted for sidelying positions.

1. The dysfunction is monitored continuously.2. The lordosis or kyphosis is flattened3. A facilitating force, either compression, torsion, or a combination is applied specifically to

the monitored dysfunction. Often, regional tension decreases immediately.4. The directions of the somatic dysfunction are added just to the level of the dysfunction.

Further relaxation is noted. The sequencing can be varied depending on the skill and experience of the physician. In fact, motion into all directions can be applied simultaneously rather than in a stepwise fashion. Some clinicians have even found the treatment effective by placing the dysfunction into neutral, applying the directions of relative freedom, and then adding the facilitating force.

4. The position is held for 3-5 seconds, the facilitating forces are released, and the region is returned to neutral.

5. The dysfunction is re-evaluated. When appropriate, movement can be introduced into the barrier directions.

Other Joint Motion Restriction TreatmentJoints in other regions of the body also experience motion restrictions, with the additional requirement that the physician place the joint into a position that is at neither extreme of motion and that allows freedom of motion in all planes. It cannot be in a closed pack position. For the extremities, the patient can be treated in the seated position but more frequently in the supine position. In some cases, prone positions may be preferable but the techniques can be adapted for sidelying positions.

1. The dysfunction is monitored continuously.2. The joint is brought into a relative neutral position3. A facilitating force, either compression, torsion, or a combination is applied specifically to

the monitored dysfunction. Often, regional tension decreases immediately.

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4. The directions of the somatic dysfunction are added just to the level of the dysfunction. Further relaxation is noted. The sequencing can be varied depending on the skill and experience of the physician. In fact, motion into all directions can be applied simultaneously rather than in a stepwise fashion. Some clinicians have even found the treatment effective by placing the dysfunction into neutral, applying the directions of relative freedom, and then adding the facilitating force.

4. The position is held for 3-5 seconds, the facilitating forces are released, and the region is returned to neutral.

5. The dysfunction is re-evaluated. When appropriate, movement can be introduced into the barrier directions.

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CERVICALSoft Tissue TreatmentFINDINGSPosterior cervical muscle hypertonicity (soft tissue texture abnormalities).PATIENT POSITION - Supine on the table; the patient's head is beyond the end of the table, resting on a pillow on the physician's lap

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PROCEDURE1. The patient is supine and the physician sits at the head of the table.2. The physician cradles the patient's neck in the palm of his hand utilizing the hand that is on

the opposite side of the dysfunctional region. When treating the right side, the left hand is used. The pad of the index or other finger acts as both monitoring finger and fulcrum, on the contralateral muscular spasm.

3. The physician’s other hand is placed on the top of the patient's head. This hand then straightens the patient's cervical lordosis by slightly forward bending the neck.

4. Using the hand that is on the top of the patient’s head, the physician applies a compressive facilitating force to the neck, through the patient's head and sufficient enough to be appreciated and to create a relaxation of the tissue noted at the monitored location.

5. Maintaining the compressive force, extension is introduced to the neck to the level of the monitoring finger. This should cause a further relaxation of the tissue being treated.

6. Side-bending and rotation, usually toward the side of the tense tissues, are added to the point that the tissues continue to soften.

7. The position is maintained for 3-5 seconds before returning the neck slowly to a neutral position.

8. The tissue being treated is re-evaluated. A mild stretch can be applied into the barrier directions can be added while monitoring the tissue tension.

Note: If tissue changes are found anteriorly, flexion instead is usually required. Some muscles, such as the sternocleidomastoid, have sidebending and rotation components in opposite directions.

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Knowledge of anatomy determines the direction that muscles must be placed into their individual shortened positions as determined by palpation and tissue response. Careful localization of the component motions of forward/backward bending, side-bending/rotation, and compression to the area of tissue texture change will result in faster and more efficient results.

Cervical Segmental Somatic DysfunctionFINDINGSC3 ESLRL (Fig. 64.2 FOM2) and C7 FSLRL

PATIENT POSITIONSupine, with the patient's head beyond the end of the table, resting on a pillow on the physician's lap .PROCEDURE

1. The physician sits at the head of the table.2. The physician cradles the patient's neck in the palm of his hand. When treating the left side,

the right hand is used. The pad of a finger monitors posterior to the left articular pillar of C3.

3. The physician’s other hand is placed on the top of the patient's head. This hand then introduces straightening the patient's cervical lordosis by slightly flexing the neck down to the level of the monitoring finger on C3. This is the neutral component.

4. The physician’s hand on the top of the patient's head adds a compressive force directed through the head to the neck until noted at the monitored level.

5. The physician adds slight extension to the neck through the level of the monitored C3 while maintaining the compression.

6. The relative freedoms of motion of the somatic dysfunction is added by sidebendingC3 to the left by introducing a translatory force to the right through your monitoring finger.7. Rotation of the head and neck only through the level of C3 is added. This places C3 into all

three planes of freedom of motion.8. This position is held for 3-5 seconds and then the physician slowly returns the neck to

neutral.9. The C3 motion freedoms and restrictions are re-evaluated. Improved range of motion into the

barrier directions can be applied.Note: If the diagnosis is flexion rather than extension (C7 FSLRL), step 5 is replaced by adding flexion through the level of C7 rather than adding extension. Similarly, if the diagnosis is one of right side-bending and right rotation, the appropriate adjustments should be made to engage these relative freedoms.This procedure to dysfunctions of the suboccipital area can be specifically applied to the occipito-atlantoid articulation. The flexion or extension component can be localized by introducing a nodding motion to the skull. Any further flexion or extension of the cervical spine is non-specific. The typical and restrictive motions of the occipito-atlantoid joint involves sidebending and rotation in opposite in opposite directions. The appropriate directions of relative freedom should be used.

O-A Dysfunction. (Example ESLRR)FINDINGSOA ESLRR PATIENT POSITIONSupine, with the patient's head beyond the end of the table, resting on a pillow on the physician's lap

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The usual FPR technique is as follows:1. The patient is in the supine position2. The physician is seated at the head of the table.3. The physician places his right hand under the patient’s occiput4. The index or middle finger of that hand reaches to the left across the occiput and just

posterior to the right mastoid process (below the occipitomastoid suture). The patient’s occiput rests on the physician’s right hand.

5. The physician grasps the patient’s skull with the left hand and flexes the occiput upon the atlas until motion is felt at the monitoring finger. This is a very small motion. If the diagnosis is flexion, then flexion is utilized instead.

6. The physician now creates a mild compressive force with the left hand until it is felt by the monitoring finger.

7. While maintaining the compression, the physician adds extension of the occiput upon the atlas. This is a very small motion.

8. Maintaining this position, the physician creates a translatory force left to right, with his right monitoring finger. This creates the left sidebending but also automatically right coupled rotation of the OA joint. desired in order to obtain the three planes of motion needed to complete the treatment. A release of the sidebending restriction and normalization of the O-A relationship may be noted at this point.

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9. If the O-A dysfunction remains resistant to treatment, the physician may continue the treatment as follows: Maintaining his right index finger under the occiput and medial and posterior to the patient’s right mastoid; the physician places the thumb of f the right hand medial to the patient’s right mastoid and just below the edge of the occiput.

10. Maintaining the compression the physician now exaggerates the left sidebending motion of the occiput upon the atlas by increasing the left to right translator motion

11. A small amplitude repetitive oscillatory motion is added12. Maintaining the left sidebending the physician uses his right monitoring finger and thumb to

apply a traction force on the occiput in a left, cephalad direction. 13. While maintaining the traction, the physician creates a circular motion, left to right and then

adds right sidebending motion over the right thumb. 14. The physician releases the traction and places the occiput into compression and right lateral flexion on the atlas.

15. A small amplitude repetitive oscillatory motion is added thatexaggerates the right sidebending through the thumb

16. The traction is released and the right thumb applies a translatory force, right to left through the OA joint.

17. Tractionis again applied backwards and to the right. 18. While maintaining traction a circular motion right to left and then left to right is introduced

into the occiput on the atlas 19. All of these steps can be be repeated until the joint motion is normalized.20. The region is reassessed.

Multilevel treatment1. The patient is supine with the head against the physician’s abdomen or chest. A pillow can

be placed between the two surfaces.2. The physician is initially seated but may come to a standing or crouched position during

treatment.3. The physician can monitor at singular levels using a single finger or thum of each hand

placed at a dysfunction level or multiple fingers of each hand at several levels.4. The palms of the hands cradle the head at either the occipital or temporal regions of the

head on both sides.5. The head and neck are placed into a neutral position.6. The physician introduces a compressive force from the abdomen or chest through the

patient’s head to the monitoring finger or fingers.7. Motion in all three planes can be introduced by translating one side to the opposite side

creating sidebending to the dysfunctional side.8. Simultaneously, the physician can add a slight rotation towards the dysfunctional side.9. Flexion or extension can be added, depending on the diagnosis.10. Traction can then be introduced to the dysfunctional level(s)11. Movement can then be introduced into all of the barrier directions into the sidebending,

rotation and flexion/extension components.12. Additionally, compression-traction, sidebending, rotation and flexion/extension can be

applied in an oscillatory fashion in a helical pattern.13. The patient is brought back to neutral and the dysfunctions are reassessed.

Cervical Muscle Hypertonicity. FINDINGSSpasmed Right Trapezius - posterior aspect of the patient’s neckPATIENT POSITIONSupine, with the patient's head beyond the end of the table, resting on a pillow on the physician's lap

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:1. The patient is seated but place on a chair or a lowered treatment table. 2. The physician stands behind the patient and bends slightly forward to position the lateral

aspect of the patient’s right shoulder into his right axilla.3. The physician wraps his right arm around the front of the patient and grasps the patient’s left

shoulder. If the physician’s arm is too short, grasp the patient’s left lateral chest as high up to the axilla as possible. In this manner the physician locks the patient’s shoulders and chest in order to lessen the creation of extraneous body motions as he proceeds with applying the treatment. NOTE; it is important that you show the patient that you are protecting them from any extrinsic motions that may be created that may cause additional pain in the neck .

4. The physician places his left hand, gently, on the top of the patient’s head, and then spreads the fingers of his left hand on the head so that his thumb extends slightly down and posteriorly on the patient’s head and his middle and ring fingers are on the right side and slightly pointed down on the patient’s head.

5. The physicians palm is now used to press gently down on the skull create a mild compressive force. NOTE: motion must be in a straight line downwards so as to avoid creating any other motions.

6. The compressive force is maintained and the physician creates a right side bending and extension force on the skull by pressing his middle and ring fingers on the right side of the skull and his thumb against the posterior aspect of the skull. This creates a very mild amount of extension as well as a translatory motion of the skull right to left, which allows a mild right sidebending motion to develop. These maneuvers should not cause any additional pain. As the physician feels the muscles relax (give slightly) he increases the amount of compression that is applied in both areas by his fingers to increase the extension and translatory motions created. This will normalize the muscle(s) involved. This should be done slowly as you feel a release of the muscle(s) involved. Occasionally you may feel that rotation to the same side should be added. This is done by turning the skull in the direction of the side bending being created. When done properly, you will not see any motion of the head or neck and the patient will not feel that motion has been created.

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THORACICThoracic Spine, SeatedFINDINGST6 FSLRL.PATIENT POSITIONThe patient is seated on the end of the table.

.PROCEDURE1. The physician stands behind and to the side of the dysfunction to be treated (In the T6 FSLRL

somatic dysfunction as in the current case, this is to the left of the patient).2. The physician monitors at the left T6 transverse process with his right hand. The palm of the

hand can be used to support the region during the next step.3. Although FPR is a passive technique, attaining a neutral position in the seated position

requires patient cooperation. The patient is asked to sit up as straight as possible and push his or her chest forward. This will straighten the thoracic kyphosis and add to the initial neutral component.

4. The physician places his left axilla over the patient's left shoulder. This should be as close to the cervico-thoracic junction as is possible. The physician's forearm is placed across the patient’s chest and his left hand should grasp the patient's right shoulder.

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5. The physician adds a downward compressive force through his left axilla onto the patient’s left shoulder. This both adds the facilitating force and introduces a localized left side-bending down through to the level of the monitoring finger at T6.

6. Flexion to the level of T6 is added by pulling forward on both of the patient's shoulders while maintaining the side-bending.

7. The physician rotates the patient's thoracic spine to the left down through the level of T6 by pulling the right shoulder forward.

8. The position is held for 3-5 seconds, and then the patient is slowly returned to a neutral position.

9. The somatic dysfunction is reassessed. Improved range of motion into the barrier directions can be applied.

Note: If the diagnosis is extension rather than flexion (T6 ESLRL), the flexion in step 6 is replaced adding extension instead through the level of T6. This is accomplished by the physician pulling the shoulders backward. Similarly, if the diagnosis is side-bending and rotation is to the right, the appropriate adjustments into the relative freedoms of the somatic dysfunction are made. If the somatic dysfunction is a neutral group curve, neither flexion nor extension is used. The physician stands on the side of the curve concavity, the sidebending side) and monitors at the apex of the curve. Adjustments are applied in order that the side-bending and rotation are achieved in the opposite directions.

Alternative Thoracic Spine (Extension dysfunctions), ProneFINDINGST6 ESLRL.PATIENT POSITION

The patient is prone, with pillows beneath the abdomen and head. This creates a flattening of the thoracic kyphosis. The patient's arms are placed at his sides..

PROCEDURE1. The physician stands at the side of the table opposite to the somatic dysfunction. For T6 E

SLRL, the physician stands at the right side of the patient.2. The physician palpates and monitors the T6 posterior left transverse process with the fingers

of his right hand.

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3. The physician's left hand grasps the patient's left shoulder. The patient's entire shoulder should be held with your fingers placed on the superior and lateral portion of the shoulder.

4. The patient's left shoulder is compressed medially toward the spine (this flattens the spine in the antero-posterior plane), and then toward the patient's feet (this compressive force creates left side-bending). The combination of forces creates a force vector that is parallel to the patient's thoracic spine.

5. Some extension of the spine is created through the level of T6 by maintaining traction on the shoulder as the patient's shoulder is lifted from the table, until motion can be palpated at the level of the monitoring fingers.

6. To create greater extension, the physician stands up straighter, pulling the patient's shoulder further posteriorly. This also creates some additional left rotation down through the level of T6.

7. This position is held for 3-5 seconds, and then the patient's shoulder and thoracic region are slowly returned to the neutral position.

8. The T6 somatic dysfunction is then re-evaluated.Note: If the diagnosis is a flexion somatic dysfunction, facilitated positional release is more

easily accomplished with the patient in the seated position as described previously.

Treatment of an”S” or “C” shaped scoliosis of the thoracolumbar spine:

S” or “C” shaped scoliosis of the thoracolumbar spineFINDINGST1-9 NSLRR and T10-L5 NSRRL T1-L5 NSLRR.PATIENT POSITIONThe patient is seated on the end of the table.

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1. Structural scoliosis may be resistant to treatment of any kind.2. However, regions above and below are usually compensatory and more amenable to

treatment.3. Functional scoliosis may respond to a greater degree4. The causes of the scoliosis should be determined and treated to expect and more sustained

treatment effect.5. The purpose of treatment is to increase the motion, relieve pain snd discomfort, and reduce

the amount of scoliosis present and/or prevent it from worsening.6. The physician monitors at the transitional (middle) section of the “S” shaped curve or at the

apex on the convexity side of the “C” shaped curve.7. The patient is seated8. The physician is standing behind the patient.9. The physician places the thumb and forefinger of one hand on either side of the spinous

process of the vertebral dysfunction complex to be addressed.10. The physician places his other arm over the patient’s shoulder and anterior to the patient’s

chest wall and grasps the opposite shoulder.11. The patient is instructed to sit straight. This flattens the thoracic kyphosis.12. The physician’s hand on the spinal region maintains the flattened position.13. The physician’s other arm places a downward force that creates sidebending of the patient’s

thoracic spine into the concavity down until noted at the monitoring-stabilizing fingers. This is maintained for 3-5 seconds.

14. The physician repeats the procedure but now introduces side bending to the patient’s opposite side by leaning on the patient’s opposite shoulder to move the patient into the convexity. These are repeated several times.

15. The physician can subsequently instruct the patient to take a deep breath - this creates a mild extension of the spine. To exaggerate this further, the physician simultaneously raises the patient slightly in cephalic and extension directions to the level of the monitoring-stabilizing fingers. This typically challenges the restriction. A further exaggeration of this extension motion can be introduced by the physician pushing the involved vertebra forward.

16. The physician then creates a circular motion of the involved vertebra on the next one s above and below. Rotation, sidebending, and flexion/extension are applied in combinations to both mimic the dysfunction preference of the vertebra and the barriers. These can be along helical axes.

17. These circular motions are repeated as necessary two or more times.This can also be applied to the next lower and upper vertebrae. Other individual vertebrae that

constitute the scoliosis of the spine can be treated in a similar fashion.

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FIRST RIBFINDINGSFirst rib elevated on left.PATIENT POSITIONThe patient is Supine

.

PROCEDURE1. The physician stands on the side of the elevated rib. In the current example, this is to the left

of the patient. The physician faces toward the head of the table.2. The physician places the monitoring finger of the hand that is closer to the patient (left hand

for an elevated left first rib) over the posterior portion of the elevated first rib. The finger serves primarily as a monitoring component. The physician’s forearm serves as a fulcrum for some of the subsequent steps.

3. The physician’s other (right) hand, grasps the patient's left elbow. The shoulder is flexed to approximately 90 degrees and abducted slightly (10-20 degrees) from the vertical. This should be adjusted until the tissues soften maximally

4. A compressive force is introduced through the patient’s left elbow directed toward the monitoring finger

5. Slight further flexion of the patient’s shoulder is introduced by the physician deviating the patient’s elbow more cephalad. This causes the patient’s forearm to abut the physician’s

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forearm and introduces some internal rotation into the shoulder. The absolute position should be determined by the relaxation of the monitored rib soft tissue.

6. The position is held for 3-5 seconds.7. While maintaining the compressive force and the internal rotation, the physician adducts and

further internally rotates the patient’s upper arm. To complete the treatment, the physician circumducts the patient’s arm through a curving motion and back into a neutral position alongside his torso.

8. The first is re-evaluated.

STERNOCLAVICULAR/ACROMIOCLAVICULAR DYSFUNCTIONSShoulder restrictions – Left anteriorly rotated clavicle with the lateral clavicle anterior and inferior PATIENT POSITIONThe patient is seated

1.

The physician stands behind the patient. The patient should sit as far backwards on the table as far as possible so that his back is leaning against the physician’s chest.

2. To treat a dysfunction of the left sternoclavicular and acromioclavicular articulation, which is displaced in the anterior-inferior direction at its lateral aspect, the physician places his left

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forearm in the patient’s left axillary region and grasps the patient’s lateral clavicle just medially to the acromioclavicular joint.

3. The physician uses his left forearm that is positioned high up into the patient’s axilla,to pull the patient’s left arm into a lateral direction, creating a traction movement. This is maintained until motion is noted at the sternoclaviculer articulation.

4. The physician uses one or more fingers of his right hand on the inferior aspect and the thumb of that hand on the superior aspect of the left sternoclavicular articulation.

5. The physician directs the patient to take a deep breath and then exhale.6. While maintaining the lateral traction, the physician now moves his right forearm in a

slightly inferior direction and then in a lateral and forward direction during the patient’s full exhalation, until he feels motion at the articulation. At the same time, the physician’s hand on the medial aspect of the clavicle pulls that region superiorly and slightly posteriorly.

7. The patient is instructed to inhale deeply following the exhalation8. Simultaneously, the physician pulls the lateral aspect of the clavicle superiorly, posteriorly

and medially. The medial aspect of the sternoclavicular is simultaneously brought inferiorly, anteriorly, and laterally.

9. If the diagnosis involves Left posteriorly rotated clavicle with the lateral clavicle posterior and superior, the sequencing would be reversed (The physician directs the patient to take a deep breath and hold it. While maintaining the medial traction, the physician now moves his right forearm in a slightly superior direction and then in a medial and posterior direction during the patient’s full inhalation, until motion is noted at the articulation. At the same time, the physician’s hand on the medial aspect of the clavicle pulls that region inferiorly and slightly anteriorly. The patient is instructed to exhale deeply following the inhalation. Simultaneously, the physician pulls the lateral aspect of the clavicle inferiorly, anteriorly and laterally. The medial aspect of the sternoclavicular is simultaneously brought superiorly, posteriorly, and medirally).

10. The region is reassessed.

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FPR RIBS - SEATED FINDINGSSoft tissue and/or dysfunctions of the ribs.PATIENT POSITIONThe patient is seated

1. The physician’s axilla rests on patient’s shoulder on dysfunctional side2. The physician’s same hand grasps the patient's elbow on the dysfunctional side and abducts

the patient’s humerus 3. The physician's opposite hand monitors the involved rib anteriorly, axillary, or posteriorly 4. The physician has the patient straighten(sit up straight).5. The physician puts a facilitating force downwards through the patient’s shoulder to involved

rib(s)6. The physician determines the tissue response as well as any persistent tenderness.7. Modifications can be made as follows:

1) Inhalation Bucket or pump handle dysfunction a) Patient inhales b) Sidebend patient away &/or backwardsc) Rotate forwards if tissue relaxes (External intercostals) or rotate backwards if tissue

relaxes (Internal intercostals)d) Hold for five seconds

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e) Reverse directions with exhalation to challenge barriers2) Exhalation Bucket or pump handle dysfunction

a) Patient exhalesb) Sidebend patient towards & or forwardsc) Rotate forwards if tissue relaxes (External intercostals) or rotate backwards if tissue

relaxes (Internal intercostals)d) Hold for five secondse) Reverse directions with inhalation to challenge barriers

8. The physician determines the tissue response as well as any persistent tenderness.9. The position is maintained for five seconds, repositioned and reassessed:

FPR RIBS & THORACIC - SIDELYING FINDINGSSoft tissue and/or dysfunctions of the thoracic and ribs.PATIENT POSITIONThe patient is sidelying with the side to be treated up

1. The physician stands facing the patient at approximately the thoracic region.2. The physician’s forearms rest on the pelvis and axillary areas of the patient on the

dysfunctional side3. The physician rests his weight downwards onto the patient 4. The physician then approximates his hands to create approximation of either the adjacent

ribs or transverse processes5. The physician can introduce rotational movements at these levels either in the same

direction and then into opposite directions in an oscillatory fashion according to the tissue response.

6. The region is reassessed

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LUMBARSoft Tissue TreatmentFINDINGSHypertonic right paravertebral lumbar muscles.POSITIONThe patient is prone, close to the right edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis

.

PROCEDURE1. The physician stands on the same side of the patient as the region to

be treated and faces towards the patient. In the current diagnosis, the physician stands to the patient’s right side.

2. The physician monitors the region of maximum paravertebral muscle spasm with fingers of the hand that is closer to the patient’s head. In the current diagnosis, the physician monitors with his right hand.

3. The physician places the (right) knee that is closer to the patient’s head on the table next to the patient's pelvis.

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The opposite leg is further adducted and crossed at the ankle

Patient’s lower half is sidebent towards the side to be treated

Patient prone with pillow beneath abdomen

3

2

1

4. The physician uses his non-monitoring (left) hand to grasp the patient's (left) knee that is on the opposite side and pulls the patient's legs toward the dysfunctional side creating (right) lumbar side-bending until motion and/or softening is noted at the monitoring finger.

5. The physician can maintain or remove his knee that was placed on the table6. The physician crosses the patient’s legs at the ankles by placing the opposite (left) ankle over

the near (right) ankle.7. The physician’s non-monitoring (left) hand then reaches around the laterally, anteriorly, and

then medially the patient’s (left) thigh of the leg that is opposite to the lumbar paravertebral muscle spasm. The physician’s palm is on the patient’s anterior and medial (left) thigh.

8. The physician lifts the patient’s (left) leg upwards away from the table and slightly towards the physician. This should be done by the physician standing upright with his arm straight, using postural rather than arm muscles. When the (left) leg is pulled toward the dysfunctional side, it creates adduction and external rotation while at the same time extending the lumbar region and inducing a relative rotation of the upper trunk toward the right. A relaxation of the monitored muscular tissue should be noted.

9. The position is held for 3-5 seconds and then the patient is slowly returned to the initial position.

10. The tissue is re-evaluated..Extension Somatic DysfunctionFINDINGSL3 ESLRL.POSITIONThe patient is prone, close to the left edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis

.PROCEDURE

1. The physician stands on the same side (left) as the somatic dysfunction and faces the head of the table.

2. The physician monitors the posterior transverse process (left) with a finger of the (right) hand tat is closer to the patient.

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THE LUMBAR VERTEBRA OF THE

SOMATIC DYSFUNCTION RELATIVELY

ROTATES TOWARD THE SAME SIDE

3. The physician places a small pillow or soft bolster between the patient's (left) thigh on the side to be treated and the table. This will provide a fulcrum for the treatment while protecting the patient’s thigh from pressure from the table's edge.

4. The physician uses his (left) hand that is further from the table to abduct the patient’s (right) leg that is on the treatment side. This creates (left) lumbar side-bending toward the relative freedom. Often, the physician will need to stand between the table and the patient's abducted leg.

5. The physician then grasps the patient's (left) lower leg or ankle on the dysfunctional side until motion is noted at the monitoring site. Internal rotation is introduced until motion is noted at the monitoring hand. This creates rotation of the pelvis and lumbar elements below the dysfunction and results in relative rotation of the dysfunctional vertebra towards its freedom.

6. The physician pushes the patient's abducted leg toward the floor (hip flexion) until motion is noted at the monitoring finger. With the thigh pillow acting as a fulcrum, this induces lumbar extension (the pelvis is lifted and the patient’s torso remains on the table and regional extension is created).

7. The position is held for 3-5 seconds until there is a sudden release of the somatic dysfunction and then the patient is slowly returned to the initial position.

8. The L3 somatic dysfunction is re-evaluated.

Flexion Somatic DysfunctionFINDINGSL4 FSLRL.POSITIONThe patient is prone, close to the left edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis (Fig. 64.8).

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PROCEDURE1. The physician sits on a rolling stool at the (left) side of table of the dysfunction, with the

physician’s thighs parallel to the table, at the level of the patient's pelvis, facing the patient's head.

2. The physician monitors the posterior transverse process (left) with a finger of the (right) hand that is closer to the patient.

3. The patient’s (left) leg on the side of the dysfunction is flexed at the knee and hip. The patient’s lower leg comes to rest between the physician’s knees, to the point where the physician notes localized motion at his monitoring finger.

4. The physician uses his non-monitoring (left) hand to grasp the patient’s (left) knee, adducting it toward and under the edge of the table until motion is felt at the monitoring finger. The patient’s knee will be held and supported by the non-monitoring hand during the rest of the technique. This induces left rotation, as internal rotation of the leg causes pelvic rotation to the contralateral side, and relative lumbar rotation toward the posterior transverse process.

5. The physician abducts the patient’s (left) lower leg by shifting his own body and rotating his outermost shoulder anteriorly and toward the table until motion is noted at the monitoring finger In the current diagnosis, this induces left side-bending.

6. The position is held for 3-5 seconds until there is a sudden release of the somatic dysfunction and then the patient is slowly returned to the initial position.

7. The L4 somatic dysfunction is re-evaluated.

Discogenic Pain Syndrome TreatmentFINDINGSLeft lumbar disk herniation or bulge with left radiculitis.POSITION

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THE ADDUCTION CAUSES INTERNAL ROTATION WHICH LOCKS THE

FEMORAL HEAD INTO THE ACETABULUM OF

THE PELVIS

THE LUMBAR VERTEBRA OF THE

SOMATIC DYSFUNCTION RELATIVELY

ROTATES TOWARD THE SAME SIDE

The patient is prone, close to the left edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis (Fig. 64.9 FOM2)

PROCEDURE1. The physician sits on a rolling stool at the (left) side of table of the dysfunction, with the

physician’s thighs parallel to the table, at the level of the patient's pelvis, facing the patient's head.

2. The physician monitors the posterior transverse process (left) of the level to be treated (L4-L5) with a finger of the (right) hand that is closer to the patient.

3. The physician uses his non-monitoring(left) hand to grasp the patient’s (left) knee and flex the patient's (left) hip and knee on the involved side.

4. The physician places the patient’s upper leg across his anterior thighs. This creates abduction and external rotation. The patient’s lower leg is lateral to the physician’s thighs and the physician grasps the patient’s (left) ankle.

5. The physician localizes motion to the involved segment by moving the upper patient's leg in a cephalad direction. It is easiest to do this by rolling the stool closer to the head of the table.

6. The physician raises his outer (left) knee by lifting his heel off the floor. The physician pushes the lateral part of his (left) knee into the popliteal fossa of the patient's (left) knee. This creates a traction force that can be modified, as the physician further raises and moves his knee laterally, until motion is palpated at his monitoring finger. The physician’s knee is now at the medial surface of the popliteal fossa of the patient’s knee and the medial surface of the knee and acts as a fulcrum for the rest of the technique.

7. The physician uses his non-monitoring (left) hand to push the patient’s (left) lower leg toward the floor until motion is palpated at his monitoring finger. There may be a slight amount of tension noted at the monitored location. Often, the patient will state that the symptoms are reduced while in this position.

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THE PHYSICIAN PUSHES THE

PATIENT’S FOOT TOWARDS THE

FLOOR

THE PHYSICIAN RAISES HIS OUTER

KNEE AND PUTS LATERAL

PRESSUREON THE PATIENT’S

POSTERIOR KNEE

8. The position is held for 3-5 seconds until there is a sudden release of the somatic dysfunction and then the patient is slowly returned to the initial position.

9. The lumbar region is re-evaluated.

FPR LUMBAR- SIDELYING FINDINGSSoft tissue and/or dysfunctions of the lumbar.PATIENT POSITIONThe patient is sidelying with the side to be treated up

1. The physician stands facing the patient at approximately the lumbar region.2. The physician’s forearms rest on the pelvis and shoulder areas of the patient on the

dysfunctional side3. The physician rests his weight downwards onto the patient 4. The physician then approximates his hands to create approximation of either the adjacent

lumbar soft tissue or transverse processes5. The physician can introduce rotational movements at these levels either in the same

direction and then into opposite directions in an oscillatory fashion according to the tissue response.

6. The physician can further exaggerate the compression by grasping the patient’s wrist or elbow on the dysfunction side with the hand of the arm that rests on the patient’s pelvis. This pulls the region into further shortening and extension (compressing the latissimus dorsi, quadrates lumborum, and paravertebral muscles)

7. A challenge to the dysfunctional components can be introduced by separating the pelvis and the shoulder and placing the region into the barriers.

8. The region is reassessed

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SACRUM & PELVIS

DIAGNOSIS RIGHT ANTERIOR PELVIC ROTATIONFINDINGS – RIGHT + STANDING FLEXION TEST RIGHT ASIS LOW – RIGHT PSIS HIGH The patient is supine

1. The physician stands facing the patient alongside the patient on the side of the dysfunction.2. The Physician places his cephalad hand on inferior ASIS of the pelvis to be treated3. The physician flexes the patient’s leg at the hip and knee 4. The patient’s leg is externally rotated5. The physician places his other (more distal) hand on the patient’s anterior-medial knee of

the same side 6. The patient is instructed to slide that foot down along the opposite leg 7. The physician simultaneously resists with both the hand on the ASIS and the hand on the

knee (can be repeated) 8. The region is reassessed

DIAGNOSIS RIGHT POSTERIOR PELVIC ROTATIONFINDINGS – RIGHT + STANDING FLEXION TEST RIGHT ASIS HIGH – RIGHT PSIS LOW The patient is supine

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1. The physician stands facing the patient alongside the patient on the side of the dysfunction.2. The Physician places his cephalad hand under the patient’s ischium on the dysfunctional

side and the physician’s fingers grasp the ischial tuberosity3. The physician flexes the patient’s leg at the hip and knee 4. The patient’s leg is externally rotated5. The physician places his other (more distal) hand on the patient’s anterior-medial knee of

the same side 6. The patient is instructed to slide that foot down along the opposite leg 7. The physician simultaneously resists with both the hand on the ischial tuberosity and the

hand on the knee (can be repeated) 8. The region is reassessed

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SACRUM

DIAGNOSIS LEFT SACRAL RESTRICTIONFINDINGS – LEFT + SEATED FLEXION TEST LEFT SACRAL RESTRICTIONThe patient is prone

1. The physician stands facing the patient alongside the patient on the side of the dysfunction.2. The Physician places his cephalad hand thenar and hypothenar region is on the ILA of the

sacrum on the same side as the dysfunction. The index &/or the pads of the index and middle fingers are medial to the PSIS on the same side The patient’s leg is externally rotated

3. The Physician's other hand grasps the patient’s lower leg above the ankle on the same side

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4. The Physician's cephalad hand maintains pressure on the sacrum with a slight anterior and cephalad force.

5. The Physician's hand on the patient’s lower leg introduces slight abduction of the hip by deviating the leg laterally and external rotation of the hip until motion is felt by the hand on the sacrum.

6. Slight compression is introduced up to the pelvis and sacrum.

7. The Physician's cephalad hand maintains pressure on the sacrum with a slight anterior and cephalad force.

8. The Physician's hand on the patient’s lower leg introduces internal rotation of the hip until motion is felt by the hand on the sacrum. Traction is introduced.

9. The Patient is instructed to inhale deeply.10. The physician increases the cephalad pressure on the ILA and can even introduce a slight

cephalad/anterior thrust.11. The patient exhales 12. The dysfunction is reassessed

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ALTERNATIVE SUPINE SACRAL TECHNIQUEDIAGNOSIS RIGHT SACRAL RESTRICTIONFINDINGS – RIGHT + SEATED FLEXION TEST RIGHT SACRAL RESTRICTIONThe patient is prone

38

1. The physician stands facing the patient alongside the patient on the side of the dysfunction.2. The Physician's thenar and hypothenar areas of his cephalad hand is placed on the patient’s

sacrum medial to the PSIS on the same side but lateral to the sacral crest.3. With his other hand, the physician flexes the patient’s knee of the leg on the same side to

approximately 90 degrees

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4. The physician maintains pressure on the dorsal sacrum with a slight pressure towards the opposite side.

5. The physician’s hand that is on the sacrum pushes the sacrum transversely away while the hand holding the patient’s foot deviates the leg towards the physician creating leg and hip internal rotation (inflare)while maintaining pressure on the sacrum

6. This gaps the posterior component of the sacroiliac joint.

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7. The physician’s hand on the patient’s sacrum then pulls the sacrum laterally transversely towards the physician while simultaneously pushing the patient’s foot away

8. By pushing the patient’s leg away, the physician creates external rotation while maintaining pressure

9. This gaps the anterior component of the sacroiliac joint.10. The physician’s hand that is on the sacrum pushes the sacrum transversely away while the

hand holding the patient’s foot deviates the leg towards the physician creating leg and hip internal rotation(inflare)while maintaining pressure on the sacrum

11. This gaps the posterior component of the sacroiliac joint.12. This procedure can be repeated several times by alternating internal and external rotation of

the of the hip while pushing or pulling the sacrum in opposite directions 13. The region is reassessed.

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SIDE-EFFECTS AND CONTRAINDICATIONS

There are few contraindications and most are relative in nature in the clinical application of Facilitated Positional Release. If the patient is not able to tolerate the positioning or experiences discomfort, either alternative positioning of the region or alternative techniques should be used. FPR to the cervical region approximates a Spurling maneuver and if the patient experiences radicular pain, then re-positioning or traction may be used. Lumbar techniques may put torsion into knees or hips that have degenerative changes or prosthetics. Performing Lumbar discogenic treatment would be contraindicated with a patient who has had a hip replacement as the external rotation and torque forces nay possibly disarticulate the joint. The same can be said for the use of the first rib technique with patients with shoulder pathology. The compression and twisting involved with the treatment may exacerbate conditions where there are new or chronic shoulder dislocations or separations. Any recent history trauma of any region should raise suspicion of fracture or dislocation. Compression, even the relatively small forces used in FPR, may make a stable fracture unstable. Accurate diagnosis and integration of clinical knowledge should direct the use of any intervention with osteopathic manipulation. Caution but not contradiction should be used in case of osteoporosis, malignancy, rheumatological disorders, congenital malformations, stenosis, or other clinical diseases.

Generally, patients experience relief and few side-effects when treated with Facilitated Positional Release. As with any other treatment, there may be transient fatigue, soreness, or stiffness due primarily to restoration of circulation to previously dysfunctional tissue and release of muscular waste products. In rare cases, the patient experiences these discomforts on subsequent treatments.

CONCLUSION

Facilitated Positional Release is an easily, non-traumatic, and efficient technique. When it is properly performed, the patient often reports immediate relief of point tenderness and restoration of function. If complete normalization is not achieved, it can be repeated, or other methods of treatment can be applied immediately. This can mean treatments lasting a few minutes that can be easily incorporated into a busy clinical, non-manipulative specialist practice. Although primarily axial procedures have been described in this chapter, it is possible to use facilitated positional release for other regions of articular and soft tissue dysfunction.

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Dr. Schiowitz quotes compiled by Barbara Polstein, D.O.

.“It is important to learn efficiency in time and effort. “

“Any mechanical dysfunction in the body can effect any other part of the body and therefore can effect any system of the body (and visa versa). When treating a patient, never treat them for a diagnosed medical condition. Treat the musculoskeletal change, and if the patient feels better then you are both lucky. Maybe it will help, maybe it won’t.”

“When talking about restriction in motion, somatic dysfunction, “osteopathic lesion”, the great majority of limitation is created in the accessory (slide) motion of an articulation/segment.”

(At a different time, DR. Schiowitz preferred the term coupled motion to describe when treating extremities.)

(discussion re concept of translation, accessory motion and coupled motion. “…accessory and coupled motion are not the same . Don’t think of it as I have a flexion lesion, think of it as a translation problem. If you think that way, then you’ll know what to do. Go with the flow but remember what your motion is and go with that.”)

“Real segmental motion is very small.”

“Don’t play with it, it is either gone or it isn’t”

Learned from Moe Levy, D.O. (his mentor):1. Always do a complete H&P2. Always do a rudimentary structural exam3. Always use OMT whenever you can.

“When practicing Osteopathy, you want to treat the hard stuff and the hard stuff doesn’t have a name. Just treat what you find.”

Re somatic dysfunction… “there is no such thing as pure anything.”

“I don’t treat the way I teach, I get down to smaller and smaller motions.”

“You have to treat all the garbage because you don’t know what’s holding what.”

“Treat what you find, try to avoid naming it because the bad ones (somatic dysfunction) have no name.”

“Nature is smarter than we are, give it what it needs.”

As long as you the doctor knows what the hell you are treating and the knows it, you can go home at night and sleep.”

“The simpler you make it, the easier your life will be.”

“Can motion be introduced, that is what is important.”

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“When you put a spinal segment into neutral it opens the facets and the articulation moves freely.”

When treating…”the key is the angle of the vector force.”

“You have motion you’re through. The name of the game is motion. “

when treating muscles…”the muscles will tell you which way to go.”

“ I don’t treat the parasympathetic nervous system, I don’t treat disease, I treat a mechanical defect. I see everything that way. I come up with mechanical answers.”

“Manual medicine treats the musculoskeletal system. If I can’t treat it, what the hell am I doing here?”

I don’t treat herniated discs of the lumbar spine. I do treat (essentially) lateral stenosis. I don’t want you to say; “oh he taught me to pop a disc back,” no I didn’t.”

“Learn the position, you can move the world.”

“Do you have a standardized way to look at a patient-no, should you have one-no.”

…”we only think we talk the same language, we don’t”

When dealing with patients,..“In the patients mind the important factor is their chief complaint not what you think about”…

“Success is when a student can apply what you teach them and improve it.”

“You learn how to make accommodations. I remember making house calls. If the patient was on the floor (ie with acute LBP…my insert)I’d lay on the floor with them and treat them.”

“Visually is easier than feeling, if you know how to look. The trouble is we were never trained to look.”

“My major complaint with DOs is even if they’re looking, they don’t know what the hell they are looking at.”

“This kind of nonsense is doable.”

“Basically, manual medicine treats only one thing, the musculoskeletal system. The purpose is to restore motion.”

“Someday, someone will explain to me what the hell I am doing.”

“All curves are related.”

“If compression doesn’t work, try traction. If it doesn’t work going to the right, go to the left. Simple philosophy.”

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re localized flattening of an upper thoracic segment…”it is stuck in translator slide. There is no other technique to help that, therefore treat it.”

REFERENCES

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1 Schiowitz, S. Facilitated positional release, JAOA, 1990:901: 145-155

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