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Manual Therapy For The Low Back and Pelvis A Clinical Orthopedic Approach (Original PDF
Manual Therapy For The Low Back and Pelvis A Clinical Orthopedic Approach (Original PDF
ith this text as your guide, you’ll learn how to safely and effec-
tively treat clients who present with a variety of musculoskeletal
conditions of the low back and pelvis. Using clear instructions,
images, and videos, the author leads you step-by-step through a broad
range of tested and proven clinical orthopedic manual therapy assess-
ment and treatment techniques.
To set the foundation for effective treatment, you’ll begin with an
overview of the anatomy and physiology of the low back and pelvis and
the common pathologic conditions seen in these areas. The author then
introduces you to proper assessment. Next, you’ll master the applica-
tion of body mechanics for deep tissue work, as well as a complete set
of treatment techniques, including neural inhibition stretching and joint
mobilization. You’ll build on this knowledge and learn how to safely and
effectively work the anterior abdomen, including the psoas major mus-
cles. Online chapters help you learn how to apply hydrotherapy, posture,
and stretching self-care as an adjunct to client treatment sessions, and
provide self-care exercises to protect yourself from injury.
First Edition
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9 8 7 6 5 4 3 2 1
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted
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with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this
information in a particular situation remains the professional responsibility of the practitioner; the clinical
treatments described and recommended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth
in this text are in accordance with the current recommendations and practice at the time of publication. How-
ever, in view of ongoing research, changes in government regulations, and the constant flow of information
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The author and the Wolters Kluwer Health team would like
to extend our sincere thanks to those who offered feedback
and reviews throughout the development of this book:
Antonella Sena, DC
Chiropractor, Academy of Massage Therapy
Hackensack, NJ
iv
PREFACE
Because my name is the only name on the front cover of this opportunity to see the first draft of a book and compare it
book, the reader could incorrectly assume that I am the only to its final publication knows how invaluable editing and
person responsible for its creation. This is far from the truth. production are. Many thanks to everyone on the Wolters
Many people helped create the book that you are holding. Kluwer Health team who helped to create this book and
This is my opportunity to both directly thank them and to bring it to fruition: Eve Malakoff-Klein, who supervised
acknowledge them to you, the readers. the project; Jonathan Joyce, acquisitions editor; David
Much of the beauty of this book lies in its artwork. I am Orzechowski and Harold Medina who coordinated the
lucky to have worked for many years with an amazing team. production; Linda Francis, who handled development and
Yanik Chauvin is the principal photographer and videogra- manuscript preparation; and Jen Clements, who assisted
pher. His eye for the best angle to portray motion and the with the art.
best lighting to focus the viewer is unsurpassed. He is also Particular thanks are owed to Brett M. Carr, MS, DC,
one of the most enjoyable people to work with! The principal for writing the online chapter on Self-Care for the Therapist
illustrator is Giovanni Rimasti of LightBox Visuals. Under (Chapter 12). His expertise was invaluable and helped to
the extremely competent direction of Jodie Bernard (owner round out and strengthen the content of this book.
of LightBox Visuals), he provided clear and crisply drawn As usual, a special thank you to a former student, now
illustrations that ably convey to the reader both the underly- instructor, William Courtland, who first spurred me to be-
ing anatomy and the motion of the body. And of course, I come a textbook author with the simple words: “You should
was fortunate to have a wonderful group of models: Hyesun write a book.”
Bowman, Vaughn Bowman, Victoria Caligiuri, Simona And, finally, most important of all, thank you to my entire
Cipriani, Emilie Miller, Joseph C. Muscolino, Maryanne family, especially my wife, Simona Cipriani, for all of your
Peterson, Jintina Sundarabhaya, and Kei Tsuruharatani. love, understanding, support, and encouragement. You
Thank you to all for contributing to the beauty of this book! make it all worthwhile!
Editing and production are especially invisible parts of
the creation of a book. But anyone who has ever had the Joseph E. Muscolino
vii
viii
ix
The chapters and materials listed below are located online 12 Self-Care for the Therapist....................................... 414
at thePoint.lww.com/MuscolinoLowBack Introduction 404
Mechanism: Motor Control 415
Part Three: Overview and Performing the Technique 416
Self-Care Stabilization Exercises 419
Self-Care for the Client and Therapist 387
Chapter Summary 425
Case Study 426
11 Self-Care for the Client............................................. 387
Introduction 378
Hydrotherapy 378 Review Questions 427
Stretching 384 Answers to Case Study and Review Questions 439
Postural Advice 398
Chapter Summary 403
Case Study 403
PART ONE
CHAPTER
3112 Anatomy
Multiplane
Chapterand
Stretching
Principles Physiology
Title
ofChapter Review
Blood Collection
Title
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 7. Classify the muscles of the lumbar spine and hip joints into their major
1. Describe the structure of the lumbar spine and pelvis. structural and functional groups.
2. Discuss the importance and implications of the lumbar spinous pro- 8. Explain why knowing the actions of a muscle can facilitate palpating
cesses to assessment and treatment. and stretching it.
3. Discuss the importance and implications of the posterior superior 9. List and describe the structure and function of the ligaments of the
iliac spine (PSIS) and anterior superior iliac spine (ASIS) to assess- lumbar spine and pelvis.
ment and treatment. 10. Explain how ligaments and antagonist muscles are similar in function.
4. Describe the structure and function of the lumbar spinal, sacroiliac, 11. Describe the major precautions and contraindications when working
and hip joints. on the low back and pelvis.
5. Describe the motions of the lumbar spinal, sacroiliac, and hip joints. 12. Define each key term in this chapter.
6. List the attachments and actions of the muscles of the lumbar spine
and pelvis.
KEY TERMS
L1
L1
L2
L3
Right pelvic
bone
L5
Sacrum
Coccyx
Sacrum
Coccyx
Figure 1-1 Posterior view of the lumbar spine and pelvis. The lum-
bar spine is composed of five vertebrae, named L1 to L5 from supe- Figure 1-2 Right lateral view of the lumbar spine. The lumbar
rior to inferior. The pelvis is composed of the two pelvic bones and spine’s curve is described as lordotic, with its concavity facing
the sacrum and coccyx. posteriorly and its convexity facing anteriorly.
Spinous
process
Ilium
Pars interarticularis
Vertebral
Lamina
body
L5 Intervertebral
disc Pubis
Superior articular
process
Laminar
groove
Ischium
Figure 1-3 Right posterolateral view of the lumbar spine. Prominent
bony landmarks are labeled. Figure 1-4 Lateral view of the right pelvic bone. The ilium, ischium,
and pubis have been colored to discern their borders: The ilium is
blue, the ischium is pink, and the pubis is yellow.
Pelvic Girdle
the pelvis. On the posterior side are the posterior superior
The bones of the pelvic girdle are the two pelvic bones and iliac spine (PSIS), posterior inferior iliac spine (PIIS), greater
the sacrum and coccyx (see Fig. 1-1). Each pelvic bone is sciatic notch, ischial tuberosity, ischial spine, and sacral tu-
composed of three bones—the ilium, ischium, and pubis— bercles (Fig. 1-5A). A dimple in the skin of the client can
that fuse together embryologically (Fig. 1-4). The sacrum is usually be seen where the skin falls in on the medial side of
composed of five vertebrae that did not fully form and fused the PSIS (Fig. 1-5B). Locating this dimple is helpful when
together to create a triangular-shaped bone. The triangular- palpating for the PSIS. On the anterior side are the anterior
shaped sacrum is upside down, with the sacral base located superior iliac spine (ASIS), anterior inferior iliac spine (AIIS),
superiorly and the apex located inferiorly. Between the sa- and pubic tubercle (Fig. 1-6). The iliac crest is located later-
crum and iliac portion of the pelvic bone on each side of the ally between the PSIS and ASIS (see Figs. 1-5A and 1-6). The
body is a sacroiliac joint (SIJ). The coccyx, usually considered PSIS and ASIS are easily palpable and important contacts
to be the evolutionary remnant of a tail, is composed of four for stabilization of the pelvis when stretching the client. The
poorly formed vertebral segments that often fuse as a person PSIS and sacral tubercles are also important when perform-
ages. There are a number of important bony landmarks of ing motion palpation assessment of the SIJs of the pelvis,
L5
Sacral base Iliac crest
Posterior superior
iliac spine (PSIS) Sacral tubercle
Posterior inferior
iliac spine (PIIS) Pelvic bone
Sacrum
Sacroiliac joint
Coccyx
Ischial Femur
tuberosity
A B
Figure 1-5 Posterior views of the lumbar spine and pelvis. (A) View of bones and bony landmarks. (B) Dimples
are usually visible immediately medial to the PSISs.
L1
L5 Inferior
Iliac crest articular
process
Sacroiliac
joint Left Disc joint
ASIS
facet joint
AIIS
Sacrum
Pubic tubercle
Superior Right
articular facet joint
process
Femur
Annulus
fibrosus Disc
Nucleus joint
Facet pulposus
joint
Figure 1-6 Anterior view of the lumbar spine and pelvis. The
prominent bones and bony landmarks have been labeled. AIIS,
anterior inferior iliac spine; ASIS, anterior superior iliac spine.
Sagittal plane
Sagittal
Frontal plane
plane
Oblique plane
Transverse
A plane B
Figure 1-8 Plane of the facet joints of the lumbar spine. (A) The plane of the lumbar facets is oriented in the sagit-
tal plane, except for the facet plane of the lumbosacral joint, which is oriented in an oblique plane that is close to
the frontal plane. Right posterolateral oblique view. (B) Review of all three cardinal (major) planes of the body.
([B] Reproduced with permission from Muscolino JE. Advanced Treatment Techniques for the Manual Therapist:
Neck. Baltimore, MD: Lippincott Williams & Wilkins; 2013.)
hence they are also often known as Z joints. Facet joints func- Pelvic Joints
tion to guide motion at that segmental joint level of the spine.
The term segmental joint level refers to a specific joint level of Pelvic joints can be divided into two categories: joints
the spine that includes the disc and facet joints at that level. between the pelvis and adjacent body parts and joints located
For example, the joint between L3 and L4, known as the within the pelvis. The lumbosacral joint is located between
L3-L4 joint, is a segmental level; the L4-L5 joint is another the pelvis and trunk (more specifically, between the sacrum
segmental level. The joint between L5 and the base of the of the pelvis and L5 of the lumbar spine) (see Fig. 1-2), and
sacrum is known as the L5-S1 joint, or simply the lumbosacral the hip joints are located between the pelvis and the thighs
joint. An understanding of the posture of the lumbosacral (more specifically, the femurs of the thighs) (see Fig. 1-6).
joint is extremely important toward understanding pelvic tilt Within the pelvis, there are two SIJs and one symphysis pubis
posture and its effect on the lumbar lordotic curve. joint. Each SIJ is located posteriorly between the sacrum and
The disc joint determines how much vertebral motion is the iliac portion of the pelvic bone on that side (see Figs.
possible at a particular segmental level, and the facet joints 1-5A and 1-6). The symphysis pubis joint is located anteri-
determine the type of motion (i.e., the direction of motion) orly between the two pubic bone portions of the pelvic bones
that can occur there. In the lumbar spine, the plane of the (see Fig. 1-6).
facets is vertically oriented in the sagittal plane. An exception
to this is at the L5-S1 level where the facet plane is oriented
in an oblique plane that is very close to the frontal plane MOTIONS OF THE LUMBAR SPINE AND PELVIS
(Fig. 1-8A). Note: Figure 1-8B is a review of the three cardinal
(major) planes of the body. The three cardinal planes are the Lumbar Spine Motions
sagittal, frontal (also known as coronal), and transverse. Any
plane that is not perfectly sagittal, frontal, or transverse is an The lumbar spine can move axially and nonaxially in all three
oblique plane. cardinal planes (sagittal, frontal, and transverse). The axial
Because of the sagittal plane orientation of the lumbar motions, shown in Figure 1-9, are as follows:
facets, the lumbar spine moves extremely well in flexion
■ Extension and flexion in the sagittal plane
and extension (sagittal plane motions). Because the facets
■ Left lateral flexion and right lateral flexion in the frontal
of the lumbosacral joint are oriented approximately within
plane
the frontal plane, right and left lateral flexion motions occur
■ Right rotation and left rotation in the transverse plane
more freely at that level. It is important to be aware of the
type of motion that each level of the spine allows when The term ipsilateral rotation is used to describe the motion
performing joint mobilization (discussed in Chapter 10). created by a muscle that rotates the trunk to the same side
1 1
4 2 4 2
3 3
A B
Figure 1-10 Circumduction of the trunk at the spinal joints. Circumduction is a series of four joint actions (left
lateral flexion, flexion, right lateral flexion, and extension) carried out one after the other. (A) Joint actions shown
sequentially. (B) Joint actions with the corners “rounded off.”
Pelvic Motions
Pelvic motion can be considered in two ways. The pelvis can
A B move as a unit relative to adjacent body parts. Motion can
also occur within the pelvis; this is called intrapelvic motion.
Motion of the Pelvis as a Unit at the Hip Joint(s)
When the pelvis moves as a unit, it can move relative to both
thighs at the hip joints or relative to one thigh at the hip joint
on that side. These motions are anterior and posterior tilt
in the sagittal plane, depression and elevation in the frontal
plane (depression is also known as lateral tilt; elevation is also
known as hip hiking), and left rotation and right rotation in
C D the transverse plane. It is helpful to understand that motions
of the pelvis at the hip joint are reverse actions of standard
action motions of the thigh at the hip joint. In other words,
the same functional group of muscles that moves the thigh at
the hip joint when the pelvis is stabilized/fixed also moves the
pelvis at the hip joint when the thigh is stabilized/fixed. The
thigh moves at the hip joint when the distal end of the lower
extremity kinematic chain is free to move, in other words,
open chain kinematics; the pelvis tends to move at the hip joint
when the distal end of the lower extremity kinematic chain
is stabilized/fixed, in other words, closed chain kinematics.
E F Specific pelvic reverse actions relative to the same-side thigh
are as follows: pelvic anterior tilt is the reverse action of thigh
Figure 1-11 Nonaxial motions of the lumbar spine. (A, B) An-
flexion, pelvic posterior tilt is the reverse action of thigh ex-
terior glide (protraction) and posterior glide (retraction), respec-
tively; right lateral views. (C, D) Right lateral glide and left lateral tension, pelvic depression is the reverse action of thigh abduc-
glide, respectively; anterior views. (E, F) Superior glide (also known tion, pelvic elevation is the reverse action of thigh adduction,
as distraction or traction) and inferior glide (also known as com- pelvic contralateral rotation is the reverse action of thigh lat-
pression), respectively; anterior views. (Courtesy of Joseph E. Mus- eral rotation, and pelvic ipsilateral rotation is the reverse ac-
colino.) tion of thigh medial rotation (Fig. 1-12 and Table 1-2).
Hip extensor
musculature
Hip flexor
musculature
Flexion of thigh Anterior tilt of pelvis Extension of thigh Posterior tilt of pelvis
A B
Hip abductor
musculature
Hip adductor
musculature
BOX 1.2
Paraspinal
musculature
Anterior
abdominal wall
musculature
Flexion of trunk Posterior tilt of pelvis Extension of trunk Anterior tilt of pelvis
A B
Lateral
flexion
musculature
Trunk rotation
musculature
Even though the pelvis can move at the hip joint(s) and When describing motion of the pelvic bone at the SIJ in
the lumbosacral joint, pelvic motion at the hip joints is the sagittal plane (or near sagittal plane), the terms posterior
functionally more important, both from the standpoint of tilt and anterior tilt are used. In effect, posterior tilt of the
posture and motion. pelvic bone is the reverse action of nutation of the sacrum at
the SIJ, and anterior tilt of the pelvic bone is the reverse ac-
Intrapelvic Motion tion of counternutation of the sacrum at the SIJ. The pelvic
Motion can also occur within the pelvis; this is termed as bone can also be described as moving in the transverse
intrapelvic motion. Intrapelvic motion involves motion of a plane. The term internal (or medial) rotation describes the
pelvic bone relative to the sacrum or motion of the sacrum anterior surface of the pelvic bone orienting medially (in
relative to the pelvic bone at the SIJ located between them effect, toward the opposite side of the body). This motion
(this also involves motion between the pelvic bones at the gaps (opens) the posterior aspect of the SIJ (and approxi-
symphysis pubis joint anteriorly). These motions can be mates [closes] the anterior aspect of the SIJ). The term ex-
named for the sacral motion that occurs or for the motion ternal (or lateral) rotation describes the anterior surface of
of the pelvic bone. the pelvic bone orienting more laterally (toward the same
When describing the sacral motion within the sagit- side of the body). This motion gaps the anterior aspect of
tal plane (or near sagittal plane), the terms nutation and the SIJ (and approximates the posterior aspect of the SIJ)
counternutation are used. When the sacral base drops anteri- (Fig. 1-15). In effect, intrapelvic motion involves one side
orly, it is called nutation; when the sacral base moves in the of the pelvis moving relative to the other side. SIJ motions
posterior direction, it is called counternutation (Fig. 1-14). are small but are very important. An understanding of this
Nutation can also be described as anterior tilt; counternuta- motion is critically important when performing joint mobi-
tion can also be described as posterior tilt. lization technique.
Left pelvic
bone
Sacrum
A B
Longissimus
Spinalis
Semispinalis
Iliocostalis
Latissimus Serratus
dorsi posterior
inferior
Iliocostalis
Iliac crest
Gluteus medius
(deep to fascia) Gluteus medius
Quadratus femoris
Ischial tuberosity
Sciatic nerve
Semitendinosus
Semimembranosus Gracilis
Biceps femoris
Figure 1-16 Posterior view of the musculature of the low back and pelvis region. (A) Superficial view on the left
with an intermediate view on the right. (continued)
Longissimus
Spinalis
Semispinalis
Iliocostalis
Spinalis Multifidus
Longissimus
Iliocostalis Rotatores
Internal abdominal
Quadratus lumborum
oblique
Iliac crest
Gluteus medius (cut)
Gluteus minimus
Piriformis
Superior gemellus
Obturator internus
Inferior gemellus Obturator externus
Quadratus femoris (cut)
Sciatic nerve
Semimembranosus
Gracilis
Biceps femoris
short head
Popliteal artery
and vein Sartorius
Sciatic nerve
B
Figure 1-16 (continued) (B) Deeper set of views.
Serratus posterior
inferior
External
abdominal
oblique
Internal abdominal
oblique
Psoas major
Gluteus medius Iliac crest
Gluteus medius
Sacrum Anterior superior
iliac spine (ASIS)
Piriformis
Tensor fasciae Superior gemellus
latae (TFL) Iliopsoas
Gluteus maximus Obturator internus
Inferior gemellus
Quadratus femoris
Biceps femoris
(short head)
Semimembranosus
Patella
Head of fibula
A B
Figure 1-17 Right lateral views of the musculature of the low back and pelvis region. (A) Superficial view. Deeper
view.
flexion must have a vertical component to their fiber direc- These six major functional groups are not mutually exclu-
tion. Muscles that perform right or left rotation must have a sive. A muscle can be a member of more than one functional
horizontal component to their fiber direction; in fact, it can group. For example, the right external abdominal oblique can
be helpful to view them as partially “wrapping” horizontally flex, right laterally flex, and left (contralaterally) rotate the trunk
around the trunk. Thus, considering the fiber direction of a at the spinal joints. Knowledge of the functional group actions
trunk muscle is important when determining its rotational of musculature is critically important when learning to perform
ability. multiplane stretching, which is presented in Chapter 6.
Rectus abdominis
Diaphragm
External abdominal
External abdominal oblique (cut)
oblique
Internal abdominal
oblique
Iliacus
Gluteus medius
Psoas major Gluteus minimus
Tensor fasciae latae (TFL)
Pectineus Sartorius
Adductor longus
Gracilis
Adductor magnus
Rectus femoris
Gastrocnemius
Tibialis anterior
A Soleus
Figure 1-18 Anterior views of the musculature of the low back and pelvis region. (A) Superficial view
on the right with an intermediate view on the left. (continued)
Diaphragm
Rectus abdominis
Psoas minor
Gluteus medius
Gluteus minimus
Pectineus
Obturator externus
Adductor longus Adductor magnus
Gracilis
Adductor magnus
Adductor brevis
Adductor magnus
Patella
B
Figure 1-18 (continued) (B) Deeper set of views.
Semispinalis
Spinalis
Rotatores
Multifidus
Longissimus
Iliocostalis
Quadratus
lumborum
External abdominal
oblique
Rectus abdominis
Figure 1-26 Lateral view of the right internal abdominal Figure 1-27 Lateral view of the right transversus abdominis.
oblique.
■ The transversus abdominis attaches from the ingui-
■ The internal abdominal oblique attaches from the nal ligament, iliac crest, thoracolumbar fascia, and the
inguinal ligament, iliac crest, and thoracolumbar fascia costal cartilages of ribs 7 through 12 to the abdominal
to the lower three ribs and the abdominal aponeurosis. aponeurosis.
■ The internal abdominal oblique flexes, laterally flexes, ■ The transversus abdominis compresses the abdominal
and ipsilaterally rotates the trunk at the spinal joints. contents.
It also posteriorly tilts and contralaterally rotates the
pelvis and elevates the same-side pelvis at the lumbosa-
cral joint. The internal abdominal oblique also com-
presses the abdominal contents.
Muscles of the Pelvis Posture and motion of the pelvis then have repercussions
on spinal posture and motion (see Chapter 2). See Table 1-2
Similar to learning the muscles of the trunk, it can be helpful for more information on the standard/reverse actions of the
to first look at the functional groups of muscles of the pelvis thigh and pelvis at the hip joint for these muscles. Following
when learning or reviewing them. Before doing that, it is are hip joint muscles of the pelvis.
important to first place muscles of the pelvis into their three Figures 1-30 through 1-39 (in the following Attachments
major categories. They are and Actions boxes) illustrate the individual muscles and
■ Muscles that attach from the pelvis to the trunk and cross muscle groups of the pelvis at the hip joint along with their
the lumbosacral joint specific attachment and action information.
■ Muscles that attach from the pelvis to the thigh/leg and
cross the hip joint
■ Pelvic floor muscles that are located wholly within the pelvis
1.12 ATTACHMENTS AND ACTIONS
Pelvic Muscles that Cross the Lumbosacral Joint and
Attach onto the Trunk Tensor Fasciae Latae
Muscles of the pelvis that cross the lumbosacral joint to
attach onto the trunk were described in the previous section
on “Muscles of the Trunk.” Their reverse action pelvic mo-
tions occur when their superior trunk attachment is fixed,
and the pelvic attachment moves instead. Given that they are
the same trunk muscle groups simply looked at from the per-
spective of their pelvic action, they can also be divided into
the same four quadrants. The anterior muscles posteriorly
tilt the pelvis, the posterior muscles anteriorly tilt the pelvis, Tensor fasciae
the muscles on the right side elevate the right side of the pel- latae (TFL)
vis (and therefore depress the left side of the pelvis), and the
muscles on the left side elevate the left side of the pelvis (and
therefore depress the right side of the pelvis).
As with the discussion of these muscles from the
perspective of the trunk, understanding pelvic rotation mo-
tions by these muscles requires visualizing the horizontal
component to the fiber direction of the muscles. Alternately,
you simply realize that because these are reverse actions, if a
muscle rotates the trunk in one direction, it must rotate the
pelvis in the opposite (reverse) direction. See Table 1-3 for
more information on this.
Pelvic Muscles that Cross the Hip Joint and Attach onto
the Thigh/Leg
Muscles that cross the hip joint are usually thought of with
respect to their open chain motion of the thigh relative to the
pelvis at the hip joint. As such, you can also divide the mus-
culature that moves the thigh at the hip joint into quadrants.
The flexors are located anteriorly, extensors posteriorly, ab- Figure 1-30 Lateral view of the right TFL.
ductors laterally, and adductors medially. Rotation muscu-
lature is not as easily equated with location; however, as a
■ The tensor fasciae latae (TFL) attaches from the ASIS
general rule, lateral rotators are located posteriorly and me-
and anterior iliac crest to the iliotibial band (ITB), one-
dial rotators are located anteriorly. However, looking at these
third of the way down the thigh.
muscles’ open chain actions on the thigh is not as important
■ The TFL flexes, abducts, and medially rotates the thigh
as understanding their closed chain actions on the pelvis.
at the hip joint and anteriorly tilts and depresses the
This is crucially important because the foot is so often on
same-side pelvis at the hip joint.
the ground, causing closed chain kinematic pelvic motion.
Sartorius
Rectus femoris
Figure 1-31 Anterior view of the right rectus femoris of the Figure 1-32 Anterior view of the right sartorius.
quadriceps femoris group.
■ The sartorius attaches from the ASIS to the pes anserine
■ The rectus femoris of the quadriceps femoris group tendon at the proximal anteromedial tibia.
attaches from the AIIS to the patella and then onto the ■ The sartorius flexes, abducts, and laterally rotates the
tibial tuberosity via the patella ligament. thigh at the hip joint and anteriorly tilts the pelvis and
■ The rectus femoris flexes the thigh at the hip joint and depresses the same-side pelvis at the hip joint. It also
anteriorly tilts the pelvis at the hip joint. It also extends flexes the leg (and/or thigh) at the knee joint.
the leg (and/or thigh) at the knee joint.
Iliopsoas
Pectineus
Adductor Adductor
longus brevis
Adductor
magnus
Gracilis
Gluteus maximus
Semimembranosus
Semitendinosus ITB
Biceps femoris
Biceps femoris (long head)
(short head)
Gluteus medius
Gluteus minimus
Figure 1-37 Lateral view of the right gluteus medius. Figure 1-38 Lateral view of the right gluteus minimus.
■ The gluteus medius attaches from the external ilium ■ The gluteus minimus attaches from the external ilium
to the greater trochanter of the femur. to the greater trochanter of the femur (Note: The glu-
■ The entire gluteus medius abducts the thigh at the teus minimus is located deep to the gluteus medius).
hip joint and depresses the same-side pelvis at the hip ■ The entire gluteus minimus abducts the thigh at the
joint. The anterior fibers also flex and medially rotate hip joint and depresses the same-side pelvis at the hip
the thigh and anteriorly tilt and ipsilaterally rotate the joint. The anterior fibers also flex and medially rotate
pelvis at the hip joint; the posterior fibers also extend the thigh and anteriorly tilt and ipsilaterally rotate the
and laterally rotate the thigh and posteriorly tilt and pelvis at the hip joint; the posterior fibers also extend
contralaterally rotate the pelvis at the hip joint. and laterally rotate the thigh and posteriorly tilt and
contralaterally rotate the pelvis at the hip joint.
Piriformis
Quadratus femoris
Figure 1-39 Posterior view of the deep lateral rotator group. All muscles of the group
are drawn on the left side (the obturator externus is not seen). The quadratus femoris has
been cut on the right side to visualize the obturator externus.
■ The deep lateral rotator group attaches from the sacrum to 90 degrees, the deep lateral rotators can horizon-
(piriformis) and the pelvic bone (the rest of the group) tally extend (horizontally abduct) the thigh at the hip
to the (or nearby the) greater trochanter of the femur. joint. Note: If the thigh is first flexed (approximately
■ As a group, the deep lateral rotators laterally rotate 60 degrees or more), the piriformis changes to become
the thigh at the hip joint and contralaterally rotate a medial rotator of the thigh at the hip joint instead of
the pelvis at the hip joint. If the thigh is first flexed a lateral rotator.
Iliacus
Anterior superior
iliac spine (ASIS) Sacrum
Psoas minor
Anterior sacroiliac ligament
Psoas major
Piriformis
Obturator internus Coccygeus
Sartorius Gluteus maximus
Anococcygeal ligament
Iliococcygeus
Pubic symphysis
Pubococcygeus Levator ani
Adductor longus
Puborectalis
Adductor brevis
Gracilis
Adductor magnus
Rectus femoris
Semitendinosus
Semimembranosus
Iliacus
Anterior superior
iliac spine (ASIS) Sacrum
Sacrotuberous ligament
Pubic symphysis
Adductor longus
Adductor brevis
Gracilis
Adductor magnus
Rectus femoris
Semitendinosus
Semimembranosus
Figure 1-40 The muscles of the pelvic floor. (A, B) Medial views of the right side of the pelvis. (A) Superficial.
(B) Deep. (continued)
Pubic symphysis
Levator hiatus
Prerectal fibers
Obturator canal
Puborectalis
Levator ani Pubococcygeus Obturator internus
Iliococcygeus
Tendinous arch
Anterior inferior of levator ani
iliac spine (AIIS)
Coccyx
Sacrum
Pubic symphysis
Obturator canal
Obturator internus
Iliococcygeus
Anterior inferior Anococcygeal ligament
iliac spine (AIIS)
Ischial spine
Piriformis
Coccyx
Sacrum
Figure 1-40 (continued) (C, D) Superior views of the muscles of the female pelvic floor. (C) Superficial. (D) Deep.
Lamina Pedicle
Intervertebral Transverse
foramen Body process
Spinous
Intervertebral Ligamentum
process
disc flavum
Posterior
Anterior
longitudinal
longitudinal
ligament
ligament
Interspinous Ligamentum
ligament flavum Lamina Pedicle
Supraspinous
ligament
A B
Intertransverse
ligament
C
Figure 1-42 Ligaments of the spine. (A) Right lateral view of a sagittal plane cross section through the spine.
(B) Anterior view of a frontal plane section through the pedicles of the spine in which the ligamentum flavum
inside the spinal canal can be seen. (C) Posterior view depicting the intertransverse ligaments. (Courtesy of Joseph
E. Muscolino.)
BOX 1.4
TA Psoas major
Trapezius IAO
Anterior
EAO
layer
Quadratus
lumborum
Middle
Rhomboids layer
Latissimus
dorsi
Erector SP TP
spinae and
Latissimus transversospinalis
dorsi musculature Posterior layer
Thoracolumbar
fascia
ANTERIOR
External
External abdominal Rectus sheath
abdominal oblique (cut) (posterior layer)
oblique RA IAO TA
Internal
abdominal EAO
oblique
Abdominal
aponeurosis
POSTERIOR
RA IAO TA
C D
Thoracolumbar fascia. (A) Posterior view. (B) Transverse plane cross-section view. Abdominal aponeurosis. (C) An-
terior view. (D) Transverse plane cross-section views. Upper figure: upper trunk. Lower figure: lower trunk.
EAO, external abdominal oblique; IAO, internal abdominal oblique; SP, spinous process; TA, transversus
abdominis; TP, transverse process.
Supraspinous Intertransverse
ligament ligament
Iliolumbar
ligaments Iliac crest
Facet joint L5
capsule Posterior
Sacrotuberous sacroiliac
ligament ligaments
Greater sciatic
foramen
Sacrospinous
ligament
Lesser sciatic
foramen
Ischial tuberosity
A
Anterior longitudinal
Intertransverse
ligament
ligament
Iliolumbar L5
ligaments
Anterior
sacroiliac
ligament
Inguinal ligament
Sacrospinous
ligament
Sacrotuberous
ligament
Symphysis
pubis joint
B
Figure 1-43 Ligaments of the pelvis. The SIJ is well stabilized posteriorly and anteri-
orly by ligaments. (A) Posterior view. (B) Anterior view.
AIIS
Ischiofemoral
ligament Pubofemoral Iliofemoral
ligament ligament
Greater trochanter
of femur Pubic
Iliofemoral bone Ischial
ligament tuberosity
Lesser Ischiofemoral
trochanter ligament
Zona orbicularis
Acetabular
Articular cartilage of
labrum
acetabulum
Head of Ligamentum
femur teres (cut)
Transverse acetabular
Capsular ligament
ligaments (cut)
Quadratus
femoris
1.1 THERAPIST TIP
the gluteal region before entering the thigh. Because the sci- CHAPTER SUMMARY
atic nerve is deep to the gluteus maximus muscle, it is not very
superficial and therefore not easily injured with soft tissue This chapter presented a review of the essential anatomy and
work. However, deeper work can translate to the sciatic nerve physiology of the low back and pelvis. The lumbar spine is
and the therapist should be mindful of this, especially when composed of five vertebrae. Landmarks of the lumbar spine
performing deep work on the quadratus femoris muscle. that are particularly important for stretching and joint mo-
bilization techniques are the spinous processes and laminae.
Motions Each lumbar spinal joint level has two paired facet joints and
a disc joint. The lumbar spine moves very well in all ranges
Another caution should be mentioned, even though it does of motion except rotation.
not involve an anatomic structure per se. When treating the Structurally, the musculature of the low back can be
client’s low back, be aware that many clients do not toler- divided into four quadrants: anterior right, anterior left,
ate well any extension beyond anatomic position and/or any posterior right, and posterior left. Functionally, the muscles
extreme or fast rotation motions. This is especially true with of the low back can be divided into six major mover groups:
elderly clients, but it may also be true for middle-aged or flexors, extensors, right and left lateral flexors, and right and
younger clients. The lumbar spine has limited rotation ranges left rotators.
of motion. Further, rotation and extension motions cause Structurally, the muscles of the pelvis can be divided into
the surfaces of the facet joints to approximate each other; if three categories: muscles crossing the lumbosacral joint from
they are injured or irritated in any way, and/or if there are the trunk onto the pelvis, muscles crossing the hip joint from
degenerative joint changes (osteoarthritis), this can result in the lower extremity onto the pelvis, and pelvic floor mus-
pain. For this reason, it is always wise to be aware of this pos- cles. As with the muscles of the trunk, pelvic muscles that
sibility. When stretching or otherwise moving the client, it is cross the hip joint can also be divided into four quadrants:
advisable to increase these ranges of motions gradually over anterior, posterior, lateral, and medial. Functionally, these
the span of several visits if necessary. muscles are usually considered from their open chain action
At the hip joint, caution must be exercised whenever the on the thigh. However, their closed chain action on the pelvis
client’s thigh is moved into flexion combined with adduction is likely more important; certainly, it is with regard to their
and medial rotation. This is especially important for clients effect on the posture of the pelvis and therefore the lumbar
who have had hip replacement surgery. spine.
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 7. Identify the four main ways that a muscle can become hypertonic.
1. Explain why it is important to understand the pathomechanics of a 8. List and describe the two major types of joint dysfunction.
condition. 9. Compare and contrast a sprain and a strain.
2. Describe the presentation, mechanism, and causes of each of the 10. List and describe the different types of pathologic disc.
conditions covered in this chapter. 11. Describe the relationship between tight muscles and a pathologic disc.
3. Describe how the gamma motor system, muscle spindles, muscle 12. Describe the relationship between tight muscles and degenerative
memory, and resting muscle tone work together to create hyper- joint disease.
tonic musculature. 13. Define scoliosis and explain how a scoliotic curve is named.
4. Compare and contrast a globally tight muscle with a myofascial 14. Describe the relationship between excessive anterior tilt and hyperlor-
trigger point. dotic lumbar spine.
5. Describe the difference between the pain-spasm-pain and 15. Describe facet syndrome and explain how it is assessed.
contraction-ischemia cycles. 16. Describe the causes and symptoms of spondylolisthesis.
6. Describe the relationship between adhesions and mobility. 17. Define each key term in this chapter.
KEY TERMS
38
INTRODUCTION are medical specialties for every organ system of the body,
but there is no “muscle doctor.” Even the chiropractic pro-
Proper therapeutic treatment of a client’s low back and pelvis fession usually relegates the importance of tight musculature
depends on an accurate assessment of the client’s condition(s) to a position of lesser importance compared with joint posi-
as well as a clear understanding of the mechanism of the patho- tioning and function. Perhaps the importance of tight mus-
logic condition(s) that the client is experiencing. Therefore, this culature is overlooked because it does not show on x-rays,
chapter offers a brief description of the most common patho- other radiographic imaging, or in laboratory results. For this
logic musculoskeletal conditions that affect these regions. Chap- reason, manual therapists who are highly trained in muscle
ter 3 discusses the procedures used to assess these conditions. palpation assessment skills and soft tissue treatment tech-
When treating a healthy or unhealthy low back and pelvis, niques have the opportunity to step into this niche.
it is most important to understand the mechanism, or physi-
ology, of how these regions function. Normal mechanics of Description of Hypertonic Musculature
the low back and pelvis are addressed in Chapter 1. However,
when a person has a pathologic condition, the mechanics A hypertonic muscle is one that has too much tone; “hyper”
are altered. Each pathologic condition has a unique physi- denotes an excessive amount. Tone refers to tension; in
ologic mechanism, pathophysiology or pathomechanism, that, other words, it is the pulling force of a muscle. The degree
when understood, can guide critical reasoning regarding the of tone that a muscle has varies based on the degree of its
therapeutic tools that should be used. Rather than asking contraction. There are two types of hypertonic musculature:
the learner to apply a memorized “cookbook” routine from a globally tight muscle and a myofascial trigger point (TrP).
one technique or another that may be ineffective or perhaps The first term is used to describe an entire muscle or large
even hurt the client, this chapter will encourage learning how portion of a muscle that is too tight; the second term is used
to choose the technique protocols that will safely and most to describe a small focal area of muscle tightness that can
effectively help the client. refer pain to a distant site.
Spinal
cord
Reflex hammer
Spindle
LMNs
Figure 2-1 Muscle spindle reflex. A reflex hammer is used to strike and cause a quick stretch of the distal tendon
of the quadriceps femoris (knee joint extensor musculature), triggering the muscle spindle reflex. A signal is sent to
the spinal cord via a sensory neuron. In response, a signal is sent from the spinal cord through lower motor neurons
(LMNs) to tell the muscle to contract, causing extension of the leg at the knee joint.
fortably allow, it sends a signal via a sensory neuron into the 3. Adaptive shortening
spinal cord. This sensory neuron then synapses with lower 4. Overstretching
motor neurons (LMNs) that return to the muscle, ordering
In each case, the muscle memory tone set by the gamma
the regular fibers of the muscle to contract (Fig. 2-1). This
motor system and the muscle’s stretch reflex is increased.
is called the muscle spindle reflex, or stretch reflex, and is
Although this chapter addresses each cause separately, when
protective in nature. By tightening the muscle, the stretch
a client presents clinically with tight musculature, the mecha-
is stopped, and the muscle is protected from being over-
nisms of the causes can and often do overlap.
stretched and perhaps torn.
The stretch reflex is usually only thought of as protect- Muscle Overuse
ing a muscle from strong forces such as whiplash accidents.
Overuse of a muscle fatigues it. Overuse also increases its
However, the stretch reflex is also responsible for setting
level of tension. This increases the muscle’s pulling force
resting tone of the musculature. When the gamma motor
on its tendons and bony attachments, irritating these
nervous system directs the spindle fibers within a muscle
structures and causing pain. In response to this pain, the
to contract, they shorten. Then when the person moves, as
nervous system signals the muscle to contract, which cre-
soon as that muscle is stretched even a small amount more
ates increased tightness of the entire muscle. This is a pro-
than the length of its spindles, the stretch reflex will cause
tective mechanism meant to decrease or prevent motion
the muscle’s fibers to contract to the tension level set for the
that might further irritate or injure the musculature and/
spindles. In this manner, the length of a muscle’s fibers, or
or other soft tissues. Muscle tightness causing pain, which
its tone, will match the length and tone set for its spindles.
then triggers further tightness, which then triggers further
The term muscle memory is often used to describe this base-
pain, and so forth, is known as the pain-spasm-pain cycle.
line tone of a muscle. Muscle memory resides in the nervous
Prolonged contraction of a muscle can also result in a dis-
system, not in the muscle itself.
ruption of the blood circulation to the area. Initially, the
Causes of Globally Tight Musculature prolonged contraction interrupts venous return of blood,
causing a buildup of waste products. These waste products
There are a number of causes for globally tight musculature.
are acidic and irritate the muscle tissue, causing increased
Four of the most common causes are as follows:
pain, which then further perpetuates the pain-spasm-pain
1. Overuse cycle. The result is increased reflexive spasm of the muscle
2. Splinting (Fig. 2-2).
Muscle
contraction
Venous congestion;
Pain buildup of waste
products in tissues
A B
have to be counteracted by the postural isometric contrac- and adapt to that posture so it is ready to create tension and
tion of the low back extensor musculature. With excessive movement immediately if needed. One example of this is the
work, postural muscles of the low back will likely fatigue and posture of the hip joint when sitting. Sitting places the hip
tighten. joint into flexion, shortening the hip flexor muscles that cross
the joint anteriorly, attaching from the pelvis to the thigh.
Muscle Splinting This chronic posture of allowing the hip joint to be flexed
Muscles of the low back and pelvis may tighten not only if can result in adaptive shortening of the hip flexor muscu-
the muscles themselves are irritated and overused but also if lature bilaterally. Their tightness will then tend to create an
any other tissues of the region become irritated or injured. excessively anteriorly tilted pelvis because hip flexor mus-
This is especially true of the tissues of the sacroiliac joints and culature’s reverse action is anterior tilt of the pelvis at the
the facet joint capsules and ligaments of the lumbar spine. hip joint (see Anterior Pelvic Tilt and Hyperlordotic Lumbar
This phenomenon is called muscle splinting, and it is a pro- Spine section).
tective mechanism for these fragile and vulnerable tissues.
By tightening, the musculature acts as a splint to the area, Muscle Overstretching
blocking motion and thereby allowing the tissues of the area Another common reason for the low back muscles to tighten
to rest and heal. Therefore, overt traumatic injury or irrita- is overstretching of the musculature. As described previ-
tion to any tissues of the joints of the low back and pelvis can ously, if the low back is stretched too fast or too far, it can
cause the muscles of the region to tighten and splint the area. activate the muscle spindle’s stretch reflex and cause a spasm.
Even though this reflex is protective, the spasming often per-
Adaptive Shortening sists long after the initial event that triggered it, resulting in a
Adaptive shortening occurs when a muscle is held in a short- chronic posture of tight musculature of the region.
ened state for a prolonged time and adapts to that shortened Overstretching a muscle can be caused traumatically,
state by increasing its tone. Adaptive shortening is a protec- as with a fall or other injury. It can also occur when doing
tive mechanism. If a muscle is shortened and slackened, then stretches as part of a health and fitness regimen. This is espe-
when it contracts to move the body, the muscle would be cially true if stretching is done too vigorously when the mus-
unable to generate tension on its attachments until all the cles have not yet warmed up, as often occurs when stretching
slack has been removed. This would not only cause an inef- is done before an exercise routine. For this reason, it is in-
ficient delay in movement but it could also be dangerous in creasingly recommended that stretching be done after exer-
a fight-or-flight scenario. For this reason, the nervous sys- cising, when the muscle tissues are warm. Thus, even though
tem adaptively shortens the muscle by increasing its tone to stretching is a valuable part of a health and fitness regimen,
match the shortened length. The net result is that if a certain when it is performed too aggressively, it can be detrimental
posture is held for a long time, the musculature will shorten to musculoskeletal health. Moderation is the key.
T6
T4–5
A
Iliocostalis thoracis
S4
A
T11 Multifidi and rotatores
B
Iliocostalis thoracis
T10,11
L1 L1
L2
S1
C D
Iliocostalis lumborum Longissimus thoracis
Quadratus lumborum
1
Deep
2
A Superficial B
Figure 2-7 Quadratus lumborum TrPs and their corresponding referral zones. (A) Lateral (superficial) TrPs.
(B) Medial (deep) TrPs. TrP, trigger point. (Reproduced with permission from Travell JG, Simons DG. The Lower
Extremities. Baltimore, MD: Lippincott Williams & Wilkins; 1992. Travell & Simons’ Myofascial Pain and Dysfunc-
tion: The Trigger Point Manual; vol 2.)
A B C
Figure 2-8 Latissimus dorsi TrPs and their corresponding referral zones. (A) Posterolateral view of two most
common TrPs. (B) Upper TrP. (C) Lower TrP. TrP, trigger point. (Reproduced with permission from Simons DG,
Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999. Travell
& Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1.)
A
Rectus abdominis
B
McBurney’s point
Figure 2-12 Tensor fasciae latae TrPs and their corresponding Figure 2-13 Rectus femoris TrP and its corresponding referral
referral zones. TrP, trigger point. (Reproduced with permission zones. TrP, trigger point. (Reproduced with permission from Trav-
from Travell JG, Simons DG. The Lower Extremities. Baltimore, ell JG, Simons DG. The Lower Extremities. Baltimore, MD: Lippin-
MD: Lippincott Williams & Wilkins; 1992. Travell & Simons’ cott Williams & Wilkins; 1992. Travell & Simons’ Myofascial Pain
Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.) and Dysfunction: The Trigger Point Manual; vol 2.)
Figure 2-14 Upper, middle, and lower sartorius TrPs and their corresponding referral zones. TrP, trigger point.
(Reproduced with permission from Travell JG, Simons DG. The Lower Extremities. Baltimore, MD: Lippincott
Williams & Wilkins; 1992. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.)
Figure 2-15 Iliopsoas TrPs and their corresponding referral zones. TrP, trigger point.
(Reproduced with permission from Travell JG, Simons DG. The Lower Extremities. Balti-
more, MD: Williams & Wilkins; 1992. Travell & Simons’ Myofascial Pain and Dysfunction:
The Trigger Point Manual; vol 2.)
Semi-
tendin-
osus
Biceps
Semi-
femoris
membran-
(both heads)
osus
A B
Figure 2-17 Hamstring group TrPs and their corresponding referral zones. TrP, trigger point. (Reproduced
with permission from Travell JG, Simons DG. The Lower Extremities. Baltimore, MD: Lippincott Williams &
Wilkins; 1992. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.)
Gluteus maximus
Trp1
Trp1
Trp2 Trp3
Trp3
Trp2
A B C D
Figure 2-18 Gluteus maximus TrPs and their corresponding referral zones. (A) Upper TrP and its referral
zone. (B) Lower midline TrP and its referral zone. (C) Lower medial TrP and its referral zone. (D) TrPs. TrP,
trigger point. (Reproduced with permission from Travell JG, Simons DG. The Lower Extremities. Baltimore,
MD: Lippincott Williams & Wilkins; 1992. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger
Point Manual; vol 2.)
A B C D
Figure 2-19 Gluteus medius TrPs and their corresponding referral zones. (A) Posterior TrP and its referral
zone. (B) Midline TrP and its referral zone. (C) Anterior TrP and its referral zone. (D) TrPs. TrP, trigger
point. (Reproduced with permission from Travell JG, Simons DG. The Lower Extremities. Baltimore, MD:
Lippincott Williams & Wilkins; 1992. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point
Manual; vol 2.)
A B
Figure 2-20 Gluteus minimus TrPs and their corresponding referral zones. (A) Anterior TrPs. (B) Posterior TrPs.
TrP, trigger point. (Reproduced with permission from Travell JG, Simons DG. The Lower Extremities. Baltimore,
MD: Lippincott Williams & Wilkins; 1992. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point
Manual; vol 2.)
Obturator internus
(oblique front view)
Figure 2-22 Pelvic floor musculature TrPs and their corresponding referral zones.
(A) Coccygeus, levator ani, and sphincter ani. (B) Obturator internus. TrP, trigger
point. (Reproduced with permission from Travell JG, Simons DG. The Lower Ex-
tremities. Baltimore, MD: Lippincott Williams & Wilkins; 1992. Travell & Simons’
Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.)
cause the gamma motor system of the central nervous system joint dysfunction is present, the lack of proper movement
to change its pattern of muscle memory that determines the will either lead to adaptive shortening and tightening of the
tone of that muscle. In contrast, treatment of a TrP is aimed muscles, and/or the pain with attempted motion will cause
directly at causing a local change in the muscle tissue itself, splinting of the adjacent musculature. For this reason, most
increasing blood supply where the TrP is located. musculoskeletal problems involve a combination of tight
However, all hypertonic musculature, whether it is a musculature and joint dysfunction. The benefits of massage
globally tight muscle or a myofascial TrP, can decrease for the musculature are clear, as are the benefits of stretching
motion at the joint that is crossed by that muscle. Once for the musculature and joints and of joint mobilization for
joint motion has been restricted for a prolonged time, the the joints.
functioning of that joint may become impaired. This condi-
tion is known as joint dysfunction and is discussed in the
following section.
BOX 2.3
BOX 2.4
Facets
Meniscoid
body
Facet
joint
(A) A meniscoid body’s normal and healthy relationship to the facet joint. (B) A meniscoid body jammed between
the two facets of the joint. (Adapted with permission from Muscolino JE. Advanced Treatment Techniques for the
Manual Therapist: Neck. Baltimore, MD: Lippincott Williams & Wilkins; 2013.)
Torn ligament
Torn muscle
Figure 2-24 Low back strain and sprain. Attempting to lift a heavy object that is in front of the body places a strong
force on the posterior tissues of the low back. If this force is excessive, a tearing of the low back extensor muscula-
ture, termed a strain, can occur. A tearing of ligament, termed a sprain, can also occur.
Lesser sciatic
foramen
Ischial tuberosity
A
Anterior longitudinal
Intertransverse
ligament
ligament
Iliolumbar L5
ligaments
Anterior
sacroiliac
ligament
Inguinal ligament
Sacrospinous
ligament
Sacrotuberous
ligament
Symphysis
pubis joint
B
transversospinalis musculature (overlying the lumbosacral PATHOLOGIC DISC CONDITIONS AND SCIATICA
joint). Due to the fact that injury to one SIJ often results in
compensation by the other SIJ, it is common for SIJ pain to Pathologic discs of the lumbar spine are extremely common.
switch from one side of the body to the other. Although any pathologic disc is potentially serious, the
degree of symptoms and functional impairment can vary
tremendously. Some pathologic discs require immediate sur-
gery, whereas others cause no problem and may be found,
2.4 TREATMENT CONSIDERATIONS IN BRIEF if at all, only incidentally when magnetic resonance imag-
ing (MRI) or a computed tomography (CT) scan is done for
Sacroiliac Joint Injury and Sprain another reason.
Decreased
IVF IVF
Pinched
Spinal
spinal
nerve
nerve
A B
Figure 2-28 Disc height and the size of the intervertebral foramen. (A) The disc is healthy and there is a normal-
sized intervertebral foramen (IVF) through which the spinal nerve travels. (B) The disc has thinned, resulting
in an IVF that is decreased in size and impingement of the spinal nerve. (Reproduced with permission from
Muscolino JE. Advanced Treatment Techniques for the Manual Therapist: Neck. Baltimore, MD: Lippincott Wil-
liams & Wilkins; 2013.)
and/or altered motor function can occur wherever the motor the spinal nerve within the intervertebral foraminal space
neurons of that spinal nerve end. Sensory symptoms can or the spinal cord within the central spinal canal at that
include tingling, numbness, or pain; motor symptoms can level. Therefore, they are considered to be space-occupying
include twitching, weakness, or flaccid paralysis of the mus- lesions. (Note: DJD, covered later in this chapter, is another
culature. Because the lumbar and sacral spinal nerves inner- common example of a space-occupying lesion that can
vate the lower extremity, these symptoms occur in the pelvic compress spinal nerves). With a bulging disc, the bulging
(gluteal) region, thigh, leg, and/or foot. However, for most annular fibers can compress the neural structures; with a
clients, disc thinning does not usually progress to the point ruptured or sequestered disc, the nucleus pulposus can cre-
that nerve compression with lower extremity referral occurs. ate the compression.
The other major type of pathologic disc condition is a If a pathologic disc compresses nerve roots of the sciatic
weakening of the outer annulus fibrosus that leads to a bulg- nerve, a condition called sciatica can occur. The sciatic nerve
ing or rupture of its fibers. This condition has three major is the largest nerve in the human body. It measures approxi-
types/gradations of severity: mately a quarter inch in diameter and is composed of L3, L4,
L5, S1, and S2 nerve roots. Symptoms of sciatica can be sen-
■ Disc bulge
sory and/or motor because both sensory and motor neurons
■ Disc rupture
are located in the sciatic nerve. Pain and/or motor weakness
■ Sequestered disc
of sciatica can occur in the posterior thigh, or leg, or any-
The mildest form is a disc bulge. In this condition, the annular where in the foot (Fig. 2-30).
fibers weaken and allow the nucleus pulposus to push against The actual determinant of the severity of these conditions
the annulus, causing it to bulge outward (Fig. 2-29A). A disc is the degree of nerve compression that occurs. For this rea-
bulge is considered the mildest form because the annular son, a large disc bulge can be much more problematic than a
fibers are still intact. A disc rupture is considered the next small disc rupture. Sequestered discs are usually the worst be-
degree of severity because the annular fibers have weakened cause the extruded fragment of nucleus pulposus remains in
to the point that the pressure of the nucleus pulposus causes the intervertebral foramen or spinal canal and can continue
them to rupture. In this case, the nucleus pulposus can actu- to compress the spinal nerve or spinal cord, respectively.
ally extrude through the annulus and enter into the interver-
tebral foramen or spinal canal. A disc rupture is also known Mechanism of Pathologic Disc Conditions
as a disc herniation or disc prolapse (Fig. 2-29B). The third Annular bulges and ruptures occur as a result of forces that
and most severe form of this pathologic disc condition is the stress and weaken the annular fibers. These can be micro-
sequestered disc. A sequestered disc is a disc rupture in which traumas or macrotraumas. Microtraumas are small physical
a portion of the nucleus pulposus that extrudes through stresses. One example is the everyday compression that re-
the annular fibers separates from the inner core of nucleus sults from supporting the weight of the trunk, neck, head, and
pulposus (the term “sequester” literally means to set apart or upper extremities. Another example is holding a prolonged
separate) (Fig. 2-29C). It cannot rejoin the disc and is left to posture that stresses the disc, such as maintaining a bent-
float within the intervertebral foramen or spinal canal. over posture of the trunk to work down in front of the body.
The danger with disc bulges, herniations, and seques- Postures in which the trunk is held forward in flexion are
trations is that the disc can push outward and compress especially prevalent and contribute to disc problems. The po-
Annulus
fibrosus
Nucleus
pulposus
Sciatic nerve
Posterior femoral
cutaneous nerve
Common fibular
Medial sural
cutaneous nerve
From sciatic
Superficial fibular nerve
nerve
Tibial nerve
Spinal
cord
Tight Spinal
musculature nerve
B
Figure 2-32 Disc herniation. (A) A posterolateral disc herniation
presses on the spinal nerve as it passes through the intervertebral
foramen. (B) A midline posterior herniation compresses the spinal
(Reproduced with permission from Muscolino JE. Advanced cord in the spinal canal. (Reproduced with permission from Mus-
Treatment Techniques for the Manual Therapist: Neck. Balti- colino JE. Advanced Treatment Techniques for the Manual Thera-
more, MD: Lippincott Williams & Wilkins; 2013.) pist: Neck. Baltimore, MD: Lippincott Williams & Wilkins; 2013.)
BOX 2.5
disc. Unfortunately, the severity of the muscle spasming it- Although local low back pain or spasming may occur,
self may cause pain, and the muscle splinting can increase lumbar pathologic discs often show no local symptoms at
the compression force on the discs, further aggravating the all and present with only lower extremity referral symptoms.
condition by increasing the size of the bulge or rupture. Note Pain, tingling, numbness, or weaknesses that are referred in
that when a disc condition is acute, inflammation can con- the lower extremity should be a red flag that a disc problem
tribute to the neural compression, with the swelling itself may exist. However, this does not mean that all lower ex-
producing symptoms. As the episode passes from the acute tremity referral symptoms come from a lumbar disc bulge
stage to the subacute and chronic stages, symptoms often de- or rupture. Other conditions such as piriformis syndrome
crease because swelling has diminished. (see next section) or meralgia paresthetica (Box 2.6) may also
BOX 2.6
Meralgia Paresthetica
The sciatic nerve is not the only nerve that can be usually tingling or pain, into the anterolateral thigh (see
compressed and cause referral into the lower extremity. accompanying figures). The most common causes of me-
The lateral femoral cutaneous nerve, which exits from ralgia paresthetica are wearing low-rise jeans or a belt too
the pelvis into the anterolateral thigh between the pelvic tightly, being overweight with increased weight carried in
bone and the inguinal ligament, can also be compressed. the anterior abdominal region, and tightness of various
When this occurs, the resulting condition is called meralgia hip flexor muscles, including the iliopsoas, sartorius, and/
paresthetica. or tensor fasciae latae. With the increased rates of obesity
Because the lateral femoral cutaneous nerve is solely in the United States, the incidence of meralgia paresthetica
sensory, this condition results only in altered sensation, will likely increase in the future.
Iliopsoas
Cut edge
of superficial
fascia
Sartorius
Sensory area
of nerve branches
Occasionally affected
sensory area
A B
Meralgia paresthetica. (A) Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve.
(B) Area of sensory symptoms in the anterolateral thigh.
refer symptoms to the lower extremity. Although a reason- gemellus muscle. However, approximately 10% to 20% of
ably accurate assessment can be made with the appropriate the time, part or all of the sciatic nerve either exits through
orthopedic assessment procedures (see Chapter 3), if a lum- the piriformis, or above it, between the piriformis and the
bar disc condition is suspected, the client should be referred gluteus medius (Fig. 2-33). Regardless of the relationship
immediately to a physician for a definitive diagnosis. of the piriformis and sciatic nerve, if the muscle is tight
enough, the nerve may be compressed, resulting in sciatica.
This condition is often said to cause “pseudo sciatica”; how-
ever, this term does not make sense and shows a bias toward
bony or disc impingement on the nerve. If compression of
2.5 TREATMENT CONSIDERATIONS IN BRIEF the sciatic nerve occurs and symptoms of sciatica are ex-
perienced, then regardless of the cause, it can be correctly
Pathologic Disc termed sciatica.
Massage can be extremely beneficial to help decrease Mechanism and Causes of Piriformis Syndrome
muscular spasms associated with a pathologic disc.
Stretching is also helpful, but caution is advised if the cli- The piriformis muscle can become tight due to overuse. The
ent’s trunk is extended or laterally flexed to the side of a piriformis acts as a lateral rotator of the thigh at the hip joint
pathologic disc. It is contraindicated to place the client in as well as a contralateral rotator of the pelvis at the hip joint
any position that causes or increases referral of symptoms (contralateral rotation of the pelvis occurs when planting and
into the lower extremity. Icing may help decrease some of cutting [planting the foot and pivoting to change directions]
the inflammation that accompanies a pathologic disc. For during sports). The piriformis is also functionally important
more details, see Chapter 3. toward stabilizing the sacrum at the sacroiliac joint and sta-
bilizing the hip joint.
PIRIFORMIS SYNDROME
2.6 TREATMENT CONSIDERATIONS IN BRIEF
Piriformis syndrome is a condition in which the piriformis
muscle compresses the sciatic nerve, causing symptoms of
sciatica into the lower extremity (see previous section). Piriformis Syndrome
Because piriformis syndrome is a condition of muscular
Description of Piriformis Syndrome origin, it makes sense that it will respond well to soft tis-
sue manipulation. Moist heat, massage, and stretching are
Normally, the sciatic nerve exits from the internal pelvis into all very beneficial. For more details, see Chapter 3.
the buttocks between the piriformis muscle and the superior
Gluteus
maximus
Gluteus
medius
Piriformis
Superior
gemellus
Quadratus
femoris
Sciatic nerve
A B C
Figure 2-33 Relationship of the sciatic nerve to the piriformis. (A) The usual relationship is for the sciatic nerve
to emerge from the internal pelvis into the gluteal region between the piriformis and the superior gemellus. (B, C)
Sometimes, part or all of the sciatic nerve exits through the piriformis or above the piriformis, between it and the
gluteus medius.
DEGENERATIVE JOINT DISEASE and facet joints of the spine. These bone spurs are easily seen
on radiography, making radiographic analysis (x-ray) the
Degenerative joint disease (DJD) is a disease in which the best and easiest means to assess DJD.
joint surfaces of bones deteriorate. DJD is a normal re- Because DJD occurs as a result of accumulated physical
sponse to the physical forces that are placed on the joints stresses, radiographs of most middle-aged people will re-
as you age. However, if the degree of progression is either veal at least some lumbar spinal DJD. Most of the time, the
more than is typical for the client’s age or impairs function, presence of DJD is an incidental finding, and the condition
it is considered a pathologic disease process. DJD is also causes no symptoms. However, if the condition progresses
known as osteoarthritis (OA); when this condition occurs to the point of functional impairment, a decrease of motion
in the spine, it may also be called spondylosis. Most older can occur at the joint where the DJD is present. This is a
middle-aged and elderly clients who state that they have result of the presence of bone spurs that block full range of
“arthritis” have DJD. motion of the affected joint. Furthermore, if the calcium de-
position creates bone spurs that are large enough to encroach
on the spinal nerve in the intervertebral foramen or on the
spinal cord within the spinal canal, the calcium deposition
2.5 THERAPIST TIP
can cause compression of nervous tissue, resulting in refer-
ral into the lower extremities. When the calcium deposits of
The Terms Degenerative Joint Disease and DJD cause compression of a spinal nerve or the spinal cord,
Osteoarthritis DJD is similar in mechanism to a bulging or ruptured disc
Arthritis literally means “joint inflammation” (“arthr” in that it is a space-occupying lesion that compresses nerve
means joint; “itis” means inflammation). The term tissue.
degenerative joint disease is gradually replacing the term
osteoarthritis because inflammation is rarely involved in Mechanism and Causes of Degenerative Joint
this condition, making the suffix “itis” inappropriate. In-
Disease
flammation is usually present only when the condition has
progressed and is more severe. The mechanism of DJD is a simple wear and tear response
of the cartilage and bony surfaces of a joint resulting from
the physical stress that is placed on the bones at the joint.
Description of Degenerative Joint Disease If the degree of physical stress is more than the joint can
absorb, the articular cartilage begins to degrade, and in so
The beginning stage of DJD involves breakdown of the artic- doing, more stress is transmitted to the subchondral bone.
ular cartilage that covers the joint surfaces of the two bones Excessive stress on the subchondral bone then causes cal-
of the joint. As the condition progresses, calcium is deposited cium to be deposited along the margins of the bones of the
within the bone that underlies the articular cartilage (sub- joint, a physical process known as Wolff’s law. Wolff’s law
chondral bone). In the later stage of DJD, calcium deposi- states that calcium is deposited in response to the physi-
tion begins to occur on the outer surfaces of the bones of the cal stress that is placed on a bone. This process is meant
joints, and bone spurs (also known as osteophytes) protrude to strengthen bone by increasing its calcium mass; how-
at the joint margins (Fig. 2-34). DJD can affect both the disc ever, if the stresses placed on the bone are excessive, ex-
A B
A B
Figure 2-38 Scoliosis as a compensation for unlevel sacral posture.
(A) If the sacrum is unlevel in the frontal plane, the spine would
slant to the side where the sacrum is low. This results in the head,
Figure 2-37 In the lumbar spine, the spinous processes rotate into and therefore the eyes and inner ears being unlevel. (B) As a com-
the concavity of a scoliosis, making the scoliosis less evident during pensation, a scoliotic curve of the spine brings the eyes and inner
visual examination. ears to be level.
Irritated facet
2.7 THERAPIST TIP
Posterior disc
(compressed
Scoliosis and Tight Muscles and irritated)
Muscles are usually tight on both sides of a scoliotic curve.
The muscles are lengthened and tight on the convex side
(often termed “locked long”) and shortened and tight on
the concave side (often termed “locked short”). Although it
is important to work both sides, it is especially important
to work the shortened concave-side muscles with massage
and stretching and to work the lengthened convex-side
muscles with massage and strengthening exercise.
Scoliosis
Moist heat, massage, and stretching can be very beneficial
for clients with scoliosis. When stretching, it is important
that the client focus the stretch so that the lateral flexion
Figure 2-39 A hyperlordotic lumbar spine places greater weight-
component of the stretch is opposite to the concavity of bearing force on the facet joints and the posterior discs.
the curve. In other words, if the concavity is oriented to
the right, the stretch should be into left lateral flexion. For
more details, see Chapter 3. causes immediate low back discomfort or pain. More seri-
ously, because lumbar extension/lordosis decreases the size
of the intervertebral foramina as well as the central spinal
canal, this condition can predispose the client to nerve com-
ANTERIOR PELVIC TILT AND HYPERLORDOTIC pression. Increased compression to the facets and posterior
LUMBAR SPINE disc margins can also further the progression of DJD (see
section on Degenerative Joint Disease earlier in this chapter),
The healthy lumbar spine should have a lordotic curve (also
causing increased bone spurs, which can also further aggra-
known as a lordosis). However, it is very common for the
vate nerve compression.
degree of lumbar extension, described as lordosis, to be
excessive.
15°
30°
45°
A B C
Figure 2-40 Sacral base angle and lumbar lordosis. The sacral base angle is formed by measuring the intersection
of a line drawn along the base of the sacrum and a horizontal line. (A) Normal sacral base angle of 30 degrees and
a healthy lumbar lordosis. (B) An increased sacral base angle results in increased lumbar lordosis. (C) A decreased
sacral base angle results in decreased lumbar lordosis.
Mechanism and Causes of Anterior Pelvic Tilt muscle group (gluteals and hamstrings) and the anterior
and Lumbar Hyperlordosis abdominal wall muscle group do posterior tilt of the pel-
vis (see Chapter 1 for more details on the musculature of
The cause of a hyperlordotic lumbar spine is almost always pelvic tilt). It is very common for hip flexor and low back
an increased anterior tilt posture of the pelvis. The lumbar extensor anterior tilters to be excessively tight and for the
spine sits on the sacrum of the pelvis. If the sacrum tilts anterior abdominal wall and gluteal region posterior tilters
anteriorly within the sagittal plane, the lumbar spine must to be excessively weak. It is often stated that the anterior
compensate by increasing its extension/lordosis to main- tilters are facilitated and the posterior tilters are inhibited in
tain the head upright so that you can see forward and have tone. When viewing this pattern from the side, you see that a
your ears level for balance. The degree of a person’s pelvic cross (“X”) is formed, with one arm of the cross representing
tilt is measured by the sacral base angle. The sacral base the facilitated anterior tilters and the other arm representing
angle is formed by drawing two lines, one horizontal and the inhibited posterior tilters. Because of this crossed pat-
another along the base of the sacrum, and then measuring
the angle formed between them. A sacral base angle of ap-
proximately 30 degrees is usually stated as being ideal. A
greater sacral base angle results in a hyperlordotic lumbar
2.9 TREATMENT CONSIDERATIONS IN BRIEF
spine, and a lesser sacral base angle results in a hypolordotic
lumbar spine (Fig. 2-40). Therefore, the root of a lumbar
hyperlordosis usually rests in the sagittal plane posture of Anterior Pelvic Tilt and Hyperlordotic Lumbar
the pelvis. Treatment must be directed toward remedying Spine
the increased anterior pelvic tilt. Soft tissue work for clients with increased anterior tilt
of the pelvis and the compensatory hyperlordosis of the
Muscles of Pelvic Tilt lumbar spine that follows is extremely valuable. The pri-
mary goal for the manual therapist is to loosen anterior
The tilt posture of the pelvis in the sagittal plane is deter- tilters of the pelvis (hip flexors and low back extensors)
mined by the forces placed on it. Most commonly, these and to have the client strengthen posterior tilters of the
forces result from muscle pulls. Within the sagittal plane, pelvis (anterior abdominal wall and gluteal muscles in the
the hip flexor muscle group and the low back extensor mus- buttocks). For more details, see Chapter 3.
cle group do anterior tilt of the pelvis, and the hip extensor
Irritated facet
Tight upper
Weak deep
trapezius and
neck flexors
levator scapulae
Weak
Tight pectoralis
rhomboids and
musculature
serratus anterior
FACET SYNDROME
As described in its name, facet syndrome is a condition of the
Weak gluteal facet joints of the spine.
Tight hip flexors
muscles
tern, this condition is often described as the lower crossed Mechanism and Causes of Facet Syndrome
syndrome (there is an upper crossed syndrome in the upper
Facet syndrome can occur for a number of reasons. Common
body as well) (Fig. 2-41). among them is excessive time spent in a posture of exten-
Excessive anterior tilt can also be caused or increased by sion or motions into extension because extension transfers
excessive weight carried anteriorly in the abdominal region. weight bearing from the anteriorly located discs to the pos-
Further, if an excessive pelvic anterior tilt and lumbar hy- teriorly located facets (Fig. 2-42). Having an increased an-
perlordotic posture become chronic, ligament laxity/tautness terior pelvic tilt with a compensatory hyperlordotic lumbar
will occur as well as fascial adhesions that resist normaliza- spine (see previous section) is a major predisposing factor
tion of this condition.
Facet Syndrome
Moist heat, massage, and stretching can all be very benefi-
cial for clients with facet syndrome. The primary focus for 0 1 2 3 4
the manual therapist is to counsel the client on decreas-
1.2
ing the causes of the condition, usually excessive postures
and motions into extension. Also important is to relax the
concomitant muscle spasming that usually accompanies
the facet joint irritation. For more details, see Chapter 3.
Decreased
IVF
IVF
Spinal Pinched
nerve spinal
nerve
A B
Figure 2-43 Spondylolisthesis. (A) Healthy posture of L4 on L5. (B) Spondylolisthesis of L4 on L5. Right lateral views.
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 8. Perform and describe the roles in assessment of active range of mo-
1. Explain why it is important to understand the mechanics of a healthy tion (ROM), passive ROM, and manual resistance.
low back and pelvis and the pathomechanics of a pathologic condi- 9. Describe the role of palpation in assessment.
tion when doing assessment. 10. Describe joint play assessment.
2. Explain the difference between a diagnosis and an assessment. 11. List the special assessment tests for a lumbar disc and the special
3. Describe the purpose and role of the health history in assessment. assessment tests for the sacroiliac joint.
4. Describe the principle by which assessment tests work. 12. Describe and perform each of the special assessment tests presented
5. Explain what is meant by a positive result and a negative result for in this chapter.
an assessment procedure. 13. Describe the mechanism underlying each of the special assessment
6. Describe the difference between a sign and a symptom and give an tests presented in this chapter.
example of each. 14. State and be able to perform the assessment procedures for each of
7. Describe the purpose of postural assessment and give an example the conditions presented in this chapter.
of a postural deviation. 15. Define each key term in this chapter.
KEY TERMS
active range of motion Gaenslen’s test passive straight leg raise sign
(active ROM) good posture (passive SLR) slump test
active straight leg raise health history physical assessment special assessment tests
(active SLR) iliac crest compression test examination symptom
ASIS compression test intrathecal pressure piriformis stretch test thigh thrust test
assessment joint play assessment positive test result treatment plan
assessment procedure manual resistance (MR) postural assessment treatment strategy
assessment test assessment posture Valsalva maneuver/test
bad posture motion palpation PSIS compression test Yeoman’s test
cough test Nachlas’ test range of motion (ROM)
diagnosis negative test result assessment
end-feel palpation report of findings
full SLR test passive range of motion sacroiliac joint medley of tests
73
INTRODUCTION
3.1 THERAPIST TIP
To provide proper therapeutic treatment to a client’s low
back and pelvis, it is necessary to perform an accurate Diagnosis and Assessment
assessment of the client’s condition and gain a clear under- Although it is a fine line, there is a distinction between
standing of the mechanism behind the pathologic condition. diagnosis and assessment. With a diagnosis, a physician
This chapter covers the assessment procedures that should be definitively determines the condition that a patient has
performed before treatment can be decided upon. The review and informs the patient of the findings. Assessment, on the
of anatomy and physiology in Chapter 1 and the discussion other hand, is carried out not for the purpose of informing
of pathologic conditions in Chapter 2 form the foundation the client of the condition but to help the therapist deter-
for this chapter. Therefore, both chapters should be read mine which treatment techniques are safe and effective
before starting this chapter. to perform and which treatment techniques to avoid. Of
Assessment usually consists of two main parts: course, if there is any doubt as to the safety and efficacy of
■ Health history. When meeting with a new client, or when treatment, referral of the client to a physician for a defini-
seeing a repeat client who has a new condition, begin tive diagnosis is strongly recommended.
the assessment by obtaining the health history, which
is a written and/or verbal history of the client’s health.
The intention behind the health history and the exami- HEALTH HISTORY
nation is to gain a thorough understanding of the cli-
Think of the health history as a conversation between the
ent’s specific condition(s) so that proper treatment can
therapist and the client. The health history may begin by
be applied.
having the client complete a written questionnaire about the
■ Physical assessment examination. This examination usually
present condition as well as his or her past health history. The
involves several components:
conversation continues with a verbal history in which the cli-
■ Postural assessment
ent answers additional questions regarding his or her health.
■ Range of motion (ROM) assessment
The health history is usually done before the physical
■ Palpation assessment
assessment exam because it helps reveal the problem regions
■ Joint play/mobilization assessment
that need to be assessed during the physical exam. If the his-
■ Special assessment
tory is thorough enough, the signs and symptoms discussed
These assessments are recommended to all therapists during the conversation will often indicate the client’s con-
when assessing a client’s condition, although they need not dition or conditions, allowing the examination to be more
be done in the order shown here. Note: Before performing focused and efficient. During the history, there is no one
joint play/mobilization, be sure to check with local and state required order to the questions asked, however, it may be
licensure/certification regulations for compliance with scope helpful to the individual therapist to develop and follow a
of practice. consistent order when conducting health histories. Such
After gathering all the information from the health his- consistency not only helps keep thoughts organized but also
tory and physical assessment examination, the assessment is increases efficiency when returning later to review a client’s
made, and the appropriate treatment strategy is determined. information. However, it is also important to be flexible with
The next step is to complete a report of findings, in which the questions. The client’s answer to one question will often
client is informed of what was found in the assessment and determine the follow-up questions. Although it is impossible
what treatment is recommended. With the client’s consent, to state every question that should be asked during a health
treatment can begin. history, some of the key questions are listed in Box 3.1.
BOX 3.1
Postural Assessment
Postural assessment is usually the first physical assessment
procedure that is performed. The term posture means A client may assume an infinite number of postures during
position; therefore, in postural assessment, the client’s static the day. Unfortunately, therapists usually perform only stand-
position is evaluated. Before evaluating a client’s posture, it is ing postural assessment, often using a plumb line. (A plumb
important to understand what is meant by good posture and line is a string that has a weight attached to it [“plumb” comes
poor posture. Good posture is defined as a balanced posture from the Latin word for lead] so that the string hangs per-
that is symmetrical and does not place excessive stress on fectly vertical, allowing the therapist to check for symmetry
the tissues of the body (Fig. 3-1A). Bad posture, in contrast, is relative to the vertical line.) Although standing posture may
asymmetrical and/or imbalanced and places excessive physi- be important to evaluate, it is not the only posture that should
cal stress on the tissues of the body (Fig. 3-1B). When evalu- be assessed. In fact, depending on the client’s profession, hob-
ating a client’s posture, look for asymmetries and deviations, bies, and activities, it may not even be pertinent to the client’s
as these will indicate increased stress forces on the tissues of condition. It is important to assess all postures that the client
the body. When a client has a postural deviation, it is impor- assumes. For clients with low back and pelvis problems, sit-
tant to determine why it is occurring and what tissues are ting posture is especially important, such as when sitting at a
stressed as a result of the posture. desk or driving a car. For this reason, it is important to inquire
end-feel of a joint’s ROM. The end-feel of the low back’s joint ists. For example, if the therapist passively moves the client’s
motion occurs at the end of passive ROM and should have a entire low back into right lateral flexion and the motion is
small, healthy bounce or spring to it. An end-feel that is hard decreased, the only information that procedure reveals is that
and unyielding, as if a concrete wall has been reached, usu- decreased motion, or hypomobility, exists in that direction.
ally indicates DJD (arthritic) bone spurs, or perhaps markedly It does not reveal whether every joint of the lumbar spine is
spasmed muscles or adhesions in the soft tissues. hypomobile in that direction, or whether the hypomobility is
The health history and ROM examination, which are present at just one or a few of the segmental joint levels. Joint
usually done before palpation, often give the therapist some play assessment makes it possible to discern this.
advance guidance about where to focus attention when pal- In fact, it is entirely possible for there to be a hypomobile
pating. Palpation often serves to confirm or eliminate the joint level within the lumbar spine in right lateral flexion pas-
clinical impression that the therapist began to form during sive ROM while the entire lumbar spine has a normal degree
the earlier phases of the assessment procedures. of motion. If one segmental level is hypomobile and produces
insufficient movement, another adjacent joint level might
Joint Play/Mobilization Assessment become hypermobile to compensate. This makes it possible
for the gross ROM of the entire lumbar spine to be normal
Joint play assessment is essentially a focused and specific form while lumbar hypomobilities and hypermobilities are pres-
of passive ROM assessment. Instead of moving or stretching ent. Therefore, the only way to determine the health of a spe-
the entire low back or pelvis in a certain direction, the mo- cific segmental joint level is to employ joint play assessment.
tion is directed at one segmental joint level. This is important Joint play assessment is performed similarly to the joint
because it helps narrow down the area where the problem ex- mobilization technique (for a detailed explanation of how to
perform joint mobilization, see Chapter 10). The therapist
pins (fixes/stabilizes) one lumbar vertebra, usually by posi-
tioning the client such that body weight creates the stabiliza-
tion force or by pinning the vertebra with a thumb pad, while
L1 moving the vertebra immediately above (along with the rest
of the spine above that point) relative to the lower vertebra
(Fig. 3-5). This procedure isolates the motion to the segmen-
Pinned spinous L2
tal joint level that is located between these two vertebrae,
process of L2
thereby allowing the therapist to assess specifically that joint
level’s end-feel motion. By performing joint play assessment
at each level of the low back, it is possible to assess specific
hypomobilities and hypermobilities throughout the lumbar
spine and target treatment to those levels. This technique can
also be used to assess the segmental motion of one SIJ of the
pelvis relative to the other. This is accomplished in a similar
manner: one pelvic bone is stabilized and the other pelvic
bone or sacrum is moved relative to it (see Chapter 10). Joint
play assessment is also known as motion palpation.
B C
passively because the same mechanism of pulling long the sion on the tibial nerve portion of the sciatic nerve because
sciatic nerve occurs in either case; however, it is most often the tibial nerve enters the foot by crossing the ankle joint
performed passively. region posteriorly and medially.
SLR test can be augmented to become full SLR test by add-
ing in adduction of the thigh at the hip joint, dorsiflexion Cough Test and Valsalva Maneuver
of the foot at the ankle joint, and eversion of the foot at the Both the cough test and Valsalva maneuver/test are designed
subtalar joint (Fig. 3-6B). The idea behind full SLR test is to increase intrathecal pressure, or pressure on the spinal
that these added joint postures increase the tension on the nerves in the intervertebral foraminal spaces. The mechanics
sciatic nerve. Thigh adduction stretches the entire sciatic are the same as with the SLR tests: Increased compression
nerve around the ischial tuberosity as it crosses the hip joint. on these neural structures can cause referral of symptoms
Dorsiflexion and eversion of the foot increase the stretch ten- into the lower extremity in a client with a space-occupying
A B
lesion. However, whereas the SLR test only increases com- with the SLR tests, local pain in the low back is not a positive
pression to the lumbar spine (and perhaps the lower thoracic sign. A positive sign is the presence of referral symptoms into
spine), the cough test and Valsalva maneuver cause increased the lower extremity (or upper extremity for a cervical spine
compression to be experienced throughout the entire spine. space-occupying lesion).
Therefore, they will also assess a pathologic disc and ad-
vanced DJD of the cervical spine (if the client experiences Slump Test
referral symptoms into the upper extremity).
The cough test is performed by asking the seated (or View the video “Slump Test” online on
standing) client to forcefully cough (Fig. 3-7A). The Valsalva thePoint.lww.com
maneuver is performed by asking the seated client to take in a
deep breath, hold it in, and bear down as if moving the bow-
els (Fig. 3-7B). To preserve client modesty and avoid pos- The slump test places tension on the entire spinal cord
sible embarrassment, avoid eye contact with the client when and peripheral nerves of the upper and lower extremities.
the Valsalva maneuver is being performed. In each case, as Although this test is most effective at assessing a pathologic
condition of the lumbar spine and sciatica, it can also be
useful for assessing a space-occupying lesion in the cervical
spine and thoracic outlet syndrome. (For a detailed descrip-
tion of cervical spine conditions and thoracic outlet syn-
3.7 THERAPIST TIP drome, see Muscolino JE. Advanced Treatment Techniques
for the Manual Therapist: Neck. Baltimore, MD: Lippincott
Valsalva Maneuver Williams & Wilkins; 2013.)
The slump test works by increasing tension on the spinal
Performing the Valsalva maneuver also results in a tem-
cord and spinal nerves by means of a pulling force. If a space-
porary decrease in blood flow to the heart and brain,
occupying lesion is already compressing the nervous system
possibly causing the client to become dizzy and perhaps
structures, then pulling on the nerves by means of the test
even faint. Completing the maneuver also causes a sud-
will likely tether the spinal nerves against this space-occupy-
den increase in blood flow to the heart. This can cause an
ing lesion. Referral of sensory symptoms into the lower ex-
increased strain on the heart and may be risky for clients
tremity is considered a positive result for a space-occupying
who have a weak heart (as from congestive heart failure
lesion of the lumbar spine. (If sensory symptoms refer into
or other advanced cardiac disease). Therefore, it is safer
the upper extremity, the result is positive for a space-occupy-
to perform the Valsalva maneuver with the client seated.
ing lesion of the cervical spine or thoracic outlet syndrome.)
As with the other special tests, local low back (or neck) pain procedure. Thus, for the test result to be considered posi-
does not constitute a positive test result. tive, the client should either experience a reproduction of
The slump test is performed in several sequential steps, the lower or upper extremity symptoms that they have been
each one adding to the tension placed on the spinal cord and experiencing or a high level of pain/discomfort during the
nerves. The motions may be performed actively or passively. procedure.
1. Begin with the client seated, hands clasped behind the Piriformis Stretch Test
back (Fig. 3-8A). (Clasping the hands behind the back
The piriformis stretch test is used to assess piriformis syn-
places tension on the brachial plexus and begins the as-
drome, that is, compression of the sciatic nerve by the
sessment for thoracic outlet syndrome.)
piriformis. As its name implies, the piriformis muscle is
2. Next, ask the client to slump the thoracic and lumbar
stretched, thereby increasing its tautness and its compres-
spine (Fig. 3-8B).
sion on the sciatic nerve. Stretching a muscle is done by
3. Now ask the client to flex the neck and head (Fig. 3-8C).
simply moving the client’s body into the opposite of its
4. You can then add to neck/head flexion by pressing the cli-
joint actions. Two excellent stretches for the piriformis are
ent’s head and neck further into flexion (Fig. 3-8D). These
shown in Figure 3-9. In Figure 3-9A, the client’s thigh is
flexion motions of the spine stretch the spinal cord and
flexed and then horizontally adducted (horizontally flexed)
also add to the tension on the brachial plexus.
because the piriformis is a horizontal abductor (horizon-
5. The client’s knee joint is then fully extended (Fig. 3-8E).
tal extensor) when the thigh is first flexed. In Figure 3-9B,
6. Finally, the foot can be dorsiflexed (Fig. 3-8F). These mo-
the client’s thigh is flexed and laterally rotated because the
tions of the lower extremity add more stretch to the spinal
piriformis is a medial rotator when the thigh is first flexed.
cord and also stretch the sciatic nerve in the lower extrem-
If the client experiences a pulling (stretching) sensation or
ity, thereby assessing a space-occupying lesion of the lum-
pain in the buttock, it is likely due to a tight piriformis but
bar spine (as well as piriformis syndrome).
does not indicate compression of the sciatic nerve, there-
Figure 3-8G illustrates the sum tension of these steps on fore the test is not considered to be positive. For the piri-
the neural structures. Because the slump test places so much formis stretch test to be considered positive, the client must
tension on the spinal cord and nerves, it is common for a experience referral of symptoms distally into the lower ex-
healthy client to feel some pain and discomfort during the tremity (thigh, leg, and/or foot).
A B C
Figure 3-8 The slump test. The slump test is performed in several sequential steps. (A) The client is seated and
clasps the hands behind the back. (B) The client slumps the thoracic and lumbar spine forward into flexion. (C) The
client flexes the neck and head. (continued)
D E
F G
Figure 3-8 (continued) (D) The therapist adds to the neck/head flexion. (E) The client’s knee joint is extended. (F)
The client’s foot is dorsiflexed. (G) This figure shows the biomechanics of the slump test, highlighting the stretch/
tension that is placed on the spinal cord and nerves. (Reproduced with permission from Muscolino JE. Advanced
Treatment Techniques for the Manual Therapist: Neck. Baltimore, MD: Lippincott Williams & Wilkins; 2013.)
A B
Figure 3-9 Stretches for the piriformis. (A) Horizontal adduction of the flexed thigh. (B) Lateral rotation of the
flexed thigh.
Note: The relationship between the piriformis muscle and will occur between the pelvic bones at the SIJs. If either side
sciatic nerve can vary. Usually, the sciatic nerve exits the pel- SIJ is sprained/inflamed, pain will be felt locally at the SIJ
vis inferior to the piriformis. However, some or all of the (Therapist Tip 3.8).
nerve may exit through or above the piriformis. Regardless Most commonly, an SIJ sprain/inflammation will be felt
of the relative relationship between these two structures, a when the thigh is at approximately 30 degrees of flexion. As
tight piriformis can potentially compress the sciatic nerve the thigh is lifted higher than 30 degrees, the sacrum will pos-
and cause piriformis syndrome. teriorly tilt with the pelvic bone, and as the sacrum reaches
the end of its posterior tilt ROM at the lumbosacral joint rel-
Tests for Injured Tissue ative to the L5 vertebra, it will begin to pull L5 into flexion.
Following are assessment tests that are used to assess condi- Once L5 is pulled into flexion to the end of its flexion ROM,
tions caused by injury to soft tissues at a joint such as sprain, L4 will flex. This motion will continue up to the lumbar spine
strain, and irritation/inflammation. Note: Even though SLR as the thigh is moved farther and farther into flexion. If any
tests are forms of active and passive ROM tests and have of these lumbar spinal joints are sprained/inflamed, pain will
therefore already been discussed under the “Range of Motion be felt locally at that level. Generally, the higher the thigh is
and Manual Resistance Assessment” section, they and MR raised when pain occurs, the higher the region of the spine
are discussed again here in their context to other assessment that is assessed.
tests for injured tissue.
Active Straight Leg Raise Test
Passive Straight Leg Raise Active SLR test is performed in a similar manner to passive
Passive SLR test is performed as described earlier in this SLR test except that the client is asked to actively raise the
chapter in the section on special orthopedic assessment tests thigh into flexion at the hip joint by engaging the hip flexor
for space-occupying lesions. The difference is that now the muscles (Fig. 3-10B). This will also cause pelvic and lumbar
intended assessment is for sprains and irritation/inflamma- musculature to engage to stabilize the pelvis and spine as
tion of the SIJ and lumbar spinal joints; the test is considered the thigh is lifted. (Note: It will also cause the psoas major
to be positive if local pain is felt in the SIJ region or lumbar to contract as a mover of the thigh. When contracting, the
spine (referral pain down the lower extremity is not the cri- psoas major will exert tension on its spinal attachments as
terion for a positive test now). Passive SLR test is performed well as the thigh, causing compression and anterior shear of
by the therapist raising the client’s thigh into flexion at the the lumbar spine, which could add to the local low back pain
hip joint while keeping the client’s knee joint fully extended. of active SLR.) The joints are being moved in an identical
It is important that the knee joint remains fully extended manner as when the test was performed passively; therefore,
(hence the name straight leg raise) (Fig. 3-10A). Because the active SLR test will assess sprains and irritations/inflamma-
client is not engaging musculature of the region to create tions of the sacroiliac and lumbar spinal joints just as passive
this motion, the client is passive. Flexing the thigh at the SLR test did. However, because the client is actively contract-
hip joint and keeping the knee joint fully extended places a ing the musculature of the region, active SLR test will also
stretch on the hamstrings. This pulls them taut, creating a assess strains of musculature. Active SLR test is considered to
tension/pulling force on the pelvic bone on that side. There- be an excellent screening test for the region because it will be
fore, as the client’s thigh is lifted into flexion, that side pelvic positive with both sprains (and inflammations) of the joint
bone will be pulled into posterior tilt. Because the other pel- ligaments and capsules, and strains of the musculature of the
vic bone is stabilized on the table and not moving, motion joint.
stop the client from actually moving the joint. Therefore, the
3.8 THERAPIST TIP contraction is isometric (see Fig. 3-3). If the client’s muscu-
lature engages but no joint motion occurs, then the muscu-
Straight Leg Raise and Sacroiliac Joint lature will be stressed and assessed, but the joint ligaments
Assessment and capsule will not. Therefore, MR test assesses for strain of
When performing the SLR test to assess for sprains/ the mover muscles of the joint, but not sprains of the joint.
inflammations and/or strains of the SIJ, although it is typi-
cal to assess the same-side SIJ as the thigh being raised, Nachlas’ and Yeoman’s Tests
the SIJ on the opposite side of the body of the thigh being View the video “Nachlas Orthopedic
raised is also sometimes assessed. The mechanism for Assessment Test for the Sacroiliac Joint”
the SLR test is as follows: If the right thigh is flexed, then online on thePoint.lww.com
the right pelvic bone will move into posterior tilt. Because Nachlas’ test and Yeoman’s test both assess injury to the SIJ,
the left pelvic bone is stabilized on the table, it will not primarily sprain and irritation/inflammation. These two
move. Therefore, motion occurs between the two pelvic tests are similar in that each one introduces a motion/torque
bones. If the right SIJ is mobile, the right pelvic bone will into the SIJ of the prone client; if the joint is injured, this
move relative to the sacrum at the right SIJ. Therefore, motion will stress the tissues and cause pain. Nachlas’ test
motion is introduced into the right SIJ and if it is injured, is performed by passively flexing the client’s knee joint by
pain would occur locally at that joint; therefore, the right bringing the client’s heel toward the same-side buttock
SIJ is assessed. However, if the right SIJ is hypomobile and (Fig. 3-11A). This causes a stretch of the quadriceps femoris
does not move, then when the right thigh is raised and muscles. Specifically, when the rectus femoris of the quadri-
the right pelvic bone posteriorly tilts, the sacrum will be ceps is stretched, it is pulled taut, causing a pulling force to be
“locked” to the right pelvic bone, and they will move as a placed on its attachments. This pulls on the anterior inferior
unit relative to the left pelvic bone. This motion will occur iliac spine (AIIS), causing anterior tilt of the pelvic bone on
at the left SIJ. When this occurs, if the left SIJ is injured, that side. Because that pelvic bone moves and the other pelvic
then pain would be felt at that joint and that joint is as- bone does not because it is stabilized against the table, motion
sessed. Further, even if the right SIJ is mobile and allows is introduced into the SIJs. Usually, Nachlas’ test primarily
motion, as the thigh is lifted higher, there will be a point assesses the same-side SIJ, but as explained in Therapist Tip
where the end of ROM of the right SIJ will be reached 3.8, the opposite-side SIJ can be assessed as well.
and motion will start to occur at the left SIJ, assessing the Yeoman’s test works on a similar principle. It is performed
left-sided SIJ. For these reasons, regardless of which thigh by the therapist using one hand to lift the client’s thigh into
is lifted into flexion, either SIJ could be assessed. Even extension, with the client’s knee joint partially flexed (Fig.
though performing SLR test on one side could assess ei- 3-11B). The client’s rectus femoris, as well as all hip flexor
ther SIJ, it is usual and customary to perform this test on musculature, is stretched, causing a force of anterior tilt on
both sides of the client’s body. the client’s same-side pelvic bone. Because the other pelvic
bone is stabilized against the table, the force is introduced
into the SIJs. The therapist uses the other hand to press down
on the client’s PSIS to both stabilize the pelvic bone on that
3.9 THERAPIST TIP side from lifting off the table and to increase the anterior tilt
motion of that side pelvic bone.
Straight Leg Raise Test and Antagonist Nachlas’ test causes only a mild stress to the SIJs, so it usu-
Musculature ally only shows positive if the SIJ injury is moderate or marked
It is usually stated that passive SLR test assesses only in degree. Yeoman’s test is more forceful and will show positive
sprains, and that active SLR test assesses both sprains and with a mild SIJ injury as well. One limitation to the Nachlas’
strains. However, this is a bit of an oversimplification. test is that because it requires maximal flexion of the client’s
Both passive and active SLR tests also assess for strains knee joint, it cannot be performed if the client has a unhealthy
and spasms of the antagonistic musculature of the joint(s) knee joint on that side that cannot tolerate full flexion.
because both tests require them to stretch to allow the joint
Sacroiliac Joint Medley of Tests
to move (whether the joint moved passively or actively).
The sacroiliac joint medley of tests is a series of five assessment
tests to determine if the SIJ is the causative agent of the client’s
pain. It assesses if the SIJ is sprained and/or irritated/inflamed.
Manual Resistance Test If three or more of the five tests reproduce the client’s pain, the
MR is another test that is used to assess strains of muscula- medley of tests is considered to be positive. The five tests are the
ture. As its name implies, MR test is performed by the thera- PSIS compression test, iliac crest compression test, ASIS com-
pist using his or her hands to add resistance to the client’s pression test, thigh thrust test, and Gaenslen’s test. Each test is
attempted joint motion. The MR must be strong enough to considered to be positive if the client experiences pain at the SIJ.
B
Figure 3-11 Nachlas’ and Yeoman’s tests for the SIJ. (A) Nachlas’
test is performed by bringing the client’s heel to the same-side but-
tock. (B) Yeoman’s test is performed by lifting the client’s thigh
into extension with the knee joint flexed while stabilizing the same-
side pelvic bone from lifting into the air and adding to the anterior B
tilt of the pelvic bone on that side of the body. (Reproduced with
permission from Muscolino JE. Orthopedic assessment of the sac-
roiliac joint. MTJ. Fall 2010: 91–95.)
TREATMENT STRATEGY
Once the health history and physical assessment examina-
tion have been performed, a treatment strategy can be devel-
oped. This involves creating a treatment plan for the client.
Three principle components of a treatment plan must be
determined:
1. Treatment techniques that will be used during the ses-
sions
2. Frequency of sessions
3. Self-care advice that will be given to the client
Treatment Techniques
D
The pathomechanics of the condition will determine the
objectives of care, which in turn will determine the treatment
techniques to be used. Most conditions of the low back and
pelvis involve tight/taut soft tissues (hypertonic musculature
and fascial adhesions), so loosening these tissues is usually
the primary focus of treatment. Most conditions that have
been present for some time also involve joint dysfunction hy-
pomobilities, so joint mobilization should be another focus.
It is essential to address both of these aspects of the condition
if the client’s musculoskeletal health is to improve.
The treatment techniques presented in this book are
designed to address tight muscles and other taut soft tissues
as well as joint dysfunction hypomobilities. These techniques
tend to be most effective if performed after the client’s tissues
E have been warmed up. Choosing which technique to use is
often a matter of both the therapist’s and the client’s personal
Figure 3-12 (continued) (D) Thigh thrust test. (E) Gaenslen’s test.
preferences. The most effective approach is usually to com-
bine multiple techniques within the treatment plan. (Before
employing any new technique in your practice, be sure that it
is within the scope of practice of your profession.)
Thigh thrust test is performed by placing a downward com-
pression force on the client’s knee with the client’s thigh Frequency of Sessions
flexed to 90 degrees (Fig. 3-12D). This test assesses only the
side where the pressure is applied, so it is repeated on the Once the techniques have been chosen, the next step is to
other side of the body. decide the optimal frequency of care. Again, this depends
For Gaenslen’s test, the client needs to be positioned far on the circumstance. If a client is basically healthy and sim-
to the side of the table where the therapist is standing. One ply wants to maintain good health, the frequency might vary
thigh is dropped into extension off the side of the table while from once a week to once a month, depending on the client’s
the client hugs the other thigh into the chest. The therapist lifestyle and health. However, if a client has a musculoskel-
adds downward pressure on the thigh that is off the table, etal condition that needs to be remedied, physical rehabilita-
bringing it farther into extension. This stretches the client’s tion requires a frequency of two to three times per week. This
hip flexors, causing the same-side pelvic bone to anteriorly is common in physical therapy, chiropractic, strength train-
tilt. Having the client hug the other thigh into the chest pos- ing, and sport training, and the same holds true for manual
teriorly tilts and stabilizes the other pelvic bone. The thera- therapy.
pist can add to this stabilization of the other side of the pelvis Each treatment session must build on the previous one if
by pressing against the client’s posterior thigh (Fig. 3-12E). the client is to improve. Performing a treatment physically
The mechanism for Gaenslen’s test is that torque is added changes both the state of the tissues and the neural patterns
into the SIJs by having one pelvic bone anteriorly tilted while for muscle contraction. As time passes after the session, these
the other is posteriorly tilted. Both SIJs are assessed with this changes are gradually lost as the body reverts back to the
test, but the dropped-thigh side is primarily tested. For this pattern of its pathologic condition. If too much time elapses
reason, Gaenslen’s test is usually repeated on the other side between visits, then the client continually regresses back to
of the body. his or her dysfunctional pattern before the successive treat-
Increased speed
of recovery with
Improving health
Improving health
5 more frequent
treatments
4
2 3 4 5
1 1
1 7 14 21 28 35 1 7 14 21 28 35
ment occurs. Therefore, for care to be effective and efficient, therapist’s ability to assist. If instead the client uses that time
treatments should be spaced no more than 2 to 3 days apart to further the objectives of the treatment plan, then recovery
until the desired improvement has been achieved (Fig. 3-13). will proceed more quickly. For more on self-care advice, see
Although this may seem like a strong commitment to ask Chapter 11 (available online at thePoint.lww.com).
of a client, it is the most time-efficient and cost-efficient
approach.
ASSESSMENT AND TREATMENT OF
Self-Care Advice SPECIFIC CONDITIONS
It can be very helpful to involve the client in his or her own Chapter 2 discussed the musculoskeletal conditions of the
treatment plan. Regarding self-care advice, it is extremely low back and pelvis that a manual therapist is most likely
valuable to offer the client suggestions about postures, hy- to encounter. This chapter has introduced and explained
drotherapy (hot and cold), stretching, and strengthening (if how to perform orthopedic assessment tests that are avail-
your scope of practice permits). After all, even if a client sees able to the manual therapist to assess these musculoskeletal
the therapist three times a week for an hour at each session, conditions. Part 2 of this book explains how to perform the
the client is still on his or her own for the other 165 hours of advanced treatment techniques that can be used to treat
the week. If the client is engaging in unhealthy postures and these conditions. The following is a brief overview that links
activities at home and work, this can easily overwhelm the the condition with its corresponding assessment procedure
and its corresponding treatment.
Joint Dysfunction be considered positive, at least three of the five tests should
elicit pain in the SIJ.
Joint dysfunction is assessed with joint play assessment, also Care for a SIJ injury depends on what type of injury is
known as motion palpation. present. SIJ sprains and strains should be treated similarly
If a specific segmental vertebral level is found to be hypo- to lumbar sprains and strains (see preceding section). If no
mobile, then the only effective treatment option is to perform sprain or strain is present and the SIJ is simply irritated/swol-
joint mobilization technique. If a client has a hypermobility, len, then icing and rest are appropriate. Prolonged sitting,
a manual therapist can do little to nothing to directly help particularly prolonged driving, is especially stressful to the
because every treatment tool that a manual therapist employs SIJs and should be eliminated or decreased.
is aimed at increasing, not decreasing, mobility. However, if
the joint hypermobility exists as a compensation for an adja- Pathologic Disc and Sciatica
cent hypomobility, then the hypermobility may be alleviated
if the adjacent hypomobility is mobilized. Note: Strengthen- Assessing a pathologic lumbar disc condition (a disc bulge
ing musculature around a hypermobile joint is helpful. If or rupture) and the resultant pressure on the sciatic nerve
strength training is within your scope of practice/license, (sciatica) can only be done definitively by magnetic reso-
then it should be employed. nance imaging (MRI) or computed tomography (CT) scan.
However, the SLR test, cough test, Valsalva maneuver, and
Lumbar Sprains and Strains slump test may also be used. Although these assessment pro-
cedures are not as accurate as an MRI, they are usually effec-
Assessing a sprain or a strain of the low back can be done by tive at accurately assessing a pathologic disc that is moderate
using active ROM and passive ROM (specifically active and or marked in severity. If a lumbar disc bulge or rupture is
passive SLR tests) as well as MR. The acronym commonly moderate or severe in presentation, it will likely produce a
used to describe the care routine for an acute sprain or strain positive test result for most or all assessment procedures.
is RICE (rest, ice, compression, and elevation). RICE care However, a mild case may produce a negative result for many
should continue as long as inflammation is present in the of the tests and a positive result for others. If there is any
tissues. This may be days, weeks, or even months or more— question about whether a client has a pathologic disc bulge
do not follow a cookbook rule for when to apply ice applica- or rupture, it is advisable to refer the client to a physician for
tion. If inflammation is present, icing is appropriate. a definitive diagnosis.
Care for a chronic sprain is usually geared toward the tight Treating a client with a lumbar disc problem contrain-
muscles that usually occur as a compensation for the exces- dicates doing anything that would increase pressure on the
sive motion. These tight muscles often cause pain and are in disc, thereby increasing the size of the bulge or rupture.
need of treatment. In addition, the best long-term approach Strong compression over the spine should be avoided, and all
that a client can take with a sprain is to strengthen the mus- movements of the client’s lumbar spine should be done with
culature of the region. Stronger musculature can compensate caution. As a rule, anything that increases the referral symp-
for the loss of stability of the stretched ligaments and help toms of the disc lesion is contraindicated. There are opposing
prevent painful muscle spasms. viewpoints on what type of motions are safe and effective for
Care for a chronic strain is geared toward loosening the a client with a lumbar disc injury. Some authorities recom-
muscles if they have become hypertonic and also eliminat- mend flexion motions and avoiding extension (or avoiding
ing or decreasing the formation of further adhesions. For extension with lateral flexion if the disc injury is posterolat-
this reason, once adhesions have mended the strained (torn) eral); others recommend that the client perform extension
muscle tissue, and the tissue’s integrity has returned, it is motions and avoid flexion. The argument for flexion is that
important to begin soft tissue manipulation and stretching it opens up the vertebral and intervertebral foramina. The
to minimize tightness and prevent the formation of further argument for extension is that it removes tension on the pos-
adhesions. If there is any doubt about whether tissue integrity terior annular fibers and pushes the nucleus pulposus anteri-
has returned, consent from a physician should be obtained. orly away from the posterior annular fibers. See Chapter 11
(available online at thePoint.lww.com) for both flexion and
Sacroiliac Joint Injury extension exercises for the lumbar spine.
The primary focus of manual therapy is to loosen the tight
Injury (sprain, strain, or irritation/inflammation) to the SIJ muscles that surround the disc because they can increase
can be assessed with active SLR test, passive SLR test, Nach- compression on the disc, furthering the problem. As a gen-
las’ test, Yeoman’s test, and the sacroiliac medley of tests. eral rule, Western-based Swedish strokes are usually fine as
If either SLR test is used, injury to the SIJ will usually cause long as the pressure is not so great that the vertebral joints are
pain at approximately 30 degrees of thigh flexion. Nachlas’ actually moved, thereby placing stress on the discs. Because
test will usually only show positive if the injury is moderate of the movement involved in stretching and joint mobiliza-
or marked in degree; Yeoman’s test is more sensitive and will tion, these treatment techniques should be avoided or done
usually detect a mild SIJ injury. For the SIJ medley of tests to prudently at or near the level of the disc lesion. Lumbar spine
traction/distraction, if performed prudently, is indicated and the scoliotic spine. Each vertebra within a scoliotic curve is
can be beneficial for relieving disc pressure. laterally flexed and rotated. As a result, the vertebral segment
will usually have decreased ROM in the opposite lateral flex-
Piriformis Syndrome ion direction and also in the opposite rotation direction.
The manual therapist can perform joint mobilization to de-
Piriformis syndrome is best assessed with the piriformis crease these hypomobilities. If the scoliosis is severe and/or
stretch test as well as palpation of the piriformis muscle. very chronic, it is unlikely that joint mobilization will greatly
However, any of the assessment tests for pathologic discs reduce the degree of scoliosis, but it is often very effective at
or other space-occupying lesions may also show positive for decreasing or stopping the progression of the condition.
piriformis syndrome. These tests include SLR, cough test, Perhaps even more important is the role of the manual
Valsalva maneuver, and slump test. therapist in treating the associated spinal musculature.
Treatment for piriformis syndrome is aimed at relaxing Asymmetric muscular pull can contribute to a scoliotic
and loosening the piriformis muscle. Heat, soft tissue manip- curvature by pulling the vertebrae in one direction. There-
ulation, and stretching are all effective means to accomplish fore, the role of the manual therapist is to reduce muscular
this. If the piriformis is tight as a compensation to stabilize hypertonicities that can contribute to the problem. This can
the sacrum when there is an underlying SIJ injury, resolving be done via heat, soft tissue manipulation, and stretching.
the SIJ condition is necessary if any lasting relief of the piri- If strengthening is within the therapist’s scope of practice,
formis is to occur. it should also be done. Although it is beneficial to relax and
stretch as well as strengthen all musculature of a scoliotic
Degenerative Joint Disease curve, as a general rule, musculature in the concavity of the
curve needs to be loosened, and musculature on the convex
Physicians assess DJD by radiograph or other radiologic ex- side of the curve needs to be strengthened.
amination such as MRI or CT scan. Manually, DJD of the
lumbar spine and SIJs is difficult to assess through palpation Anterior Pelvic Tilt and Hyperlordotic
because the bone spurs of DJD are located deep within the Lumbar Spine
client’s tissues. Advanced DJD will impede motion of the af-
fected joints so passive ROM will be decreased and will often Anterior pelvic tilt and hyperlordotic lumbar curvature can
have a hard palpatory end-feel to the motions. be assessed via visual examination. A more definitive diag-
There is nothing that a manual therapist can do to di- nosis of the degree of the condition can be obtained via a
rectly affect the bone spurs of DJD itself. However, manual physician-ordered radiograph.
therapy can play an extremely important role indirectly. The Treatment of this condition is aimed at loosening the
principal cause of DJD is physical stress to the joint, and one anteriorly placed hip flexor musculature as well as the pos-
of the components of the physical stress is the compression teriorly placed low back extensor musculature. This can be
force caused by tight muscles that cross the joint. If manual accomplished by using heat, soft tissue manipulation, and
therapy relaxes tight musculature, less physical stress will be stretching. If strengthening is within the therapist’s scope of
placed on the joint, and that can lead to a decrease or cessa- practice, strengthening of the posterior hip extensor muscu-
tion in the rate at which the condition progresses. Therefore, lature and the anterior abdominal wall musculature should
even though manual therapy cannot reverse the condition, it also be done. Although self-care is important in all condi-
can decrease its progression. tions, it is especially important with dysfunctional postural
If the DJD is advanced and the client has a bone spur that patterns such as excessive anterior tilt. The client should be
is pushing on adjacent tissue, causing inflammation, another counseled regarding proper posture and stretches for the hip
treatment option is the use of cryotherapy (the application flexors and low back extensor muscles.
of ice). If the bone spur is pressing on a spinal nerve, any
positioning/stretching/joint mobilization that increases that Facet Syndrome
nerve compression should be avoided.
Facet syndrome is assessed by asking the client to perform
Scoliosis extension of the lumbar spine; pain located at the spinal
joints indicates facet syndrome.
If scoliosis is severe enough, it can be assessed through vi- Because facet syndrome is often caused by excessive
sual and palpatory examination. However, for a definitive anterior pelvic tilt with resultant increased lumbar lordo-
diagnosis, radiographic examination via an x-ray should be sis, treatment should be directed at improving the client’s
ordered by a physician. posture. This can be best accomplished by applying moist
Treatment of scoliosis by a manual therapist has two ob- heat, soft tissue manipulation, and stretching to the mus-
jectives: one is to work on the spinal joints and the other is to culature of anterior tilt, in other words, the hip flexors and
work the spinal musculature. Joint mobilization can be per- low back extensors. And if strengthening is within the thera-
formed to increase motion of hypomobilities found within pist’s scope of practice, then strengthening of the posterior
tilt musculature, hip extensors, and trunk flexors (anterior extensor muscles (see Chapter 12, available online at the-
abdominal wall) should also be done. Self-care stretches that Point.lww.com).
posteriorly tilt the client’s pelvis and flex the client’s lumbar Because an excessive lumbar lordotic curve, often caused by
spine should also be recommended (see Chapter 11, avail- excessive anterior tilt of the pelvis, exacerbates the slippage of
able online at thePoint.lww.com). Because facet syndrome is an anterolisthesis, remedying this postural condition through
often accompanied by muscular spasming, it is important to hands-on care and self-care advice (see the previous section on
relax this musculature as well. “Anterior Pelvic Tilt and Hyperlordotic Lumbar Spine”) is an
important component of the care of this condition.
Spondylolisthesis
Spondylolisthesis is diagnosed by a physician from lateral CHAPTER SUMMARY
view radiographs. A break in the pars interarticularis and/
or a slippage of one vertebra on the vertebra below indicates There is an adage in the world of medicine that treatment
spondylolisthesis. By far, the most common type of spondy- should never be administered without a diagnosis. Simi-
lolisthesis involves an anterior slippage of the upper vertebra larly, in the world of clinical orthopedic manual therapy,
and is termed an anterolisthesis. Less common, the upper treatment should only be performed if an assessment is first
vertebra slips posteriorly and is termed a posterolisthesis, or made. This chapter covers the orthopedic assessment tests
slips laterally and is termed a laterolisthesis. that manual therapists can perform to assess their clients’
Manual therapy treatment of a spondylolisthesis cannot lower back and pelvic conditions. Of course, there are limits
change the break in the pars interarticularis. Instead, treat- to the ability of these tests to fully and accurately assess every
ment is aimed at reducing any associated muscle spasm and condition. If after performing these assessment tests, there
increasing the stability of the lumbar spine through core is still doubt about the client’s condition, referral should be
stabilization strengthening, if this is within the therapist’s made to a physician for an accurate and thorough diagnosis/
scope of practice. Muscle spasm is best reduced via moist assessment. Once the therapist is armed with an accurate as-
heat, soft tissue manipulation, and stretching. Core stabi- sessment, and therefore a fundamental understanding of the
lization strengthening should be directed toward the an- pathomechanics of the client’s condition, safe and effective
terior abdominal wall musculature as well as the low back treatment can be determined and carried out.
Treatment Techniques
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 8. Explain why it is important to align your core with the stroke and use
1. Describe the mechanism for producing deep tissue pressure. your core and/or lower extremities when performing deep tissue work.
2. Discuss the roles of internally and externally generated forces when 9. Explain why it is important to communicate with the client when doing
doing deep tissue work. deep tissue work.
3. Describe in steps an overview of the usual protocol for performing 10. Describe the possible role of ice when doing deep tissue work.
deep tissue work to the low back and pelvis. 11. Describe the usual breathing protocol for the client during deep tissue
4. Explain why the therapist’s position and the client’s placement on work.
the table are important. 12. Explain how to transition from sustained compression to short
5. Describe the roles of the treatment contact hand and the bracing/ deep stroking massage and long, deep strokes with proper body
support hand. mechanics.
6. Describe the importance of the positioning of the feet when doing 13. Define each key term in this chapter and explain its relationship to
deep tissue work. deep tissue work to the low back and pelvis.
7. Explain the importance of stacking the upper extremity joints when 14. Perform deep tissue work to the client’s low back and pelvis using the
doing deep tissue work. five routines presented in this chapter.
KEY TERMS
95
96 Treatment Techniques
height. When considering the width of a table, two compet- Even more important than table width is table height.
ing concepts are client comfort and therapist body mechan- As a rule, when generating deep pressure, you want the table
ics. The wider a table is, the more comfortable it is for the to be as low as possible so that you can more easily position
larger client. However, a wider table places the client farther your body above the client to take advantage of gravity and
from the therapist and forces the therapist to work much body weight. It is likely that the most common error when
harder to position the core over the client’s body. This often trying to employ efficient body mechanics is that the thera-
results in the therapist having to lean over and compromise pist positions the table too high. This likely happens because
his body mechanics. In effect, having a wide table provides many therapists begin their massage education in school with
comfort for the occasional large client, but the therapist classes that teach light pressure work. Therefore, it is easy to
must struggle with all the rest of the clients. Possible com- work with the table high. Often, the therapist becomes ac-
promises include tables that have sidepieces that can make customed to keeping the table at this height even though
the table wider for the larger client but be removed when deeper pressure techniques are later learned and employed.
working with smaller clients (Fig. A). Other tables have a With the table too high for the techniques now being used,
scoop in the middle that narrows the table width around the therapist struggles to achieve pressure, believing that he is
the low back and pelvis of the client (Fig. B). This allows too weak when the real culprit is a table that is too high. Even
the therapist to place his core closer to the client for efficient though most tables are adjustable in height, it is important to
body mechanics. Another feature that some tables have is choose a table that can go low enough so that the top of the
additional face cradle holes that allow for the face cradle to table is well below the bottom of your knee joint.
be moved to one side, thereby allowing the client to lie closer For any therapist who has a stationary practice in one
to the side of the table (Fig. C). This prevents you from hav- location, it is an extremely wise decision to buy an electric
ing to lean over, thereby reducing stress to your back. It also lift table. This allows easy adjustment of the table height
allows you to get your core in closer to the client, permitting with the touch of a pedal. Adjusting the table height is
more efficient use of your body weight and the engagement not only important between clients of different sizes but
of larger muscles. If your table has these holes, it is wise to it is also important when working on the same client if the
take advantage of them for better body mechanics. client changes position, such as when changing from supine
C continued
98 Treatment Techniques
or prone to side-lying. It is also important when changing table to be very low and others that require the table to be
contacts that are used to work on the client. For example, high. It is logistically impossible to change the table height
work with thumb or finger pads requires a far lower table between each of these stretches. The purchase of an electric
than work with the elbow or forearm. Further, there are lift table is an investment in the quality of your practice as
many stretches for the low back and pelvis that require the well as an investment in your success!
Figure 4-1 Starting position for deep tissue work to the left side of
the low back. Figure 4-2 Thumb pad contact with the other thumb as the brace.
Figure 4-4 Generation of force from the core. When applying pres- Figure 4-5 If the table allows for the prone client to lie close to the
sure into the client, as much of the force as possible should origi- side of the table, it allows for the therapist to more easily position
nate from the core body weight. body weight over the client.
A B
C D
Figure 4-6 Adjust where you stand. When working the lumbosacral region (A) or the lower thoracic region (B), the
therapist stands at the side of the table, adjacent to the region being worked. When working the upper and middle
thoracic region, the therapist stands at the head of the table, between the face cradle and the top of the table (C).
Standing above the face cradle leads to poor body mechanics (D).
To work the upper and middle thoracic region, you need to weight (Fig. 4-6D). Optimally positioning your core requires
choose which side of the client you want to work and stand you to optimally position where you stand.
on that side of the table, between the face cradle and the top
of the table. This allows you to place your core directly over 4.3 Positioning the Feet
the client’s upper thoracic region on that side of the body
(Fig. 4-6C). A common error is for the therapist to stand View the video “Foot Position and Body
above the face cradle at the head end of the table. Standing Mechanics” online on thePoint.lww.com
here only distances you from the client, causing you to lean
over the client to reach the low back; this compromises body Positioning the feet is extremely important because it deter-
mechanics and does not allow for the efficient use of body mines where the core of the body is oriented. If the stroke
A B
is being done across the client’s back or pelvis, then the feet important to place the feet in a sagittal plane stance, with one
should be oriented transversely across the table (Fig. 4-7A). If foot forward and the other foot in back (as seen in Fig. 4-7B).
the stroke is being done up along the client’s pelvis and back, This provides a stable base when working and also allows for a
then the feet should be oriented longitudinally up along the transfer of weight from the rear foot to the front foot if a stroke
length of the table (Fig. 4-7B). In effect, the feet should point is being performed. Also, make sure that the feet are not too far
in the direction of the stroke that is being performed. It is also apart. A wide stance may feel more stable but creates a static
position that makes it difficult to transfer weight from one foot The other way is to begin by again standing next to the
to the other. With a narrower stance, it is easier to shift the table, facing the head end (see Fig. 4-8A). This time, place the
center of weight of the body from one foot to the other as a outer foot in front of the inner foot (Fig. 4-8C). Now adduct
stroke is done. Further, it is better to orient the foot in back the thigh of the inner foot by moving your inner foot away
approximately parallel with the front foot so that the power- from the table, allowing your thigh to rest against the side of
ful sagittal plane musculature of the rear lower extremity is in the table (be sure that there are no hard or sharp projections
line with the stroke and can be used to add to the force of the where you are leaning against the side of the table). This will
stroke. Placing the rear foot transversely is a common error place your trunk over the table, oriented toward the head
and should be avoided because it does not orient the sagittal of the table, in line with your stroke. As with the previous
plane musculature in line with the stroke (Fig. 4-7C). method just described, if any adjustment of the orientation
When working up the client’s back from inferior to su- of the trunk is necessary, this adjustment should be done by
perior, it is important to orient the core of the body so that rotating the pelvis at the hip joints and not by rotating the
it is in line with the stroke, in other words, facing the head spinal joints.
end of the table. It is also important to position the trunk as
close to being over the client’s body as possible. This can be 4.4 Choosing the Treatment Contact
especially challenging if the table is wide. Without climbing
on the table, there are two ways to facilitate this. When working on the low back of the prone client, there
One way is to begin by standing next to the table, facing are many treatment contacts that can be used to contact the
the head end (Fig. 4-8A). Now take the outer foot (the one client. From small to large, these contacts range from fin-
that is farther from the table) and place it behind the inner ger or thumb pad; to palm or ulnar side of the hand, also
foot (the one that is closer to the table). This will naturally known as the “knife-edge” contact; to fist; and to elbow or
lean the thighs against the table and place the pelvis over forearm (Fig. 4-9). The advantage of smaller contacts is that
the table so that your trunk is closer to the middle of the they allow for more precision both when assessing the cli-
table and facing the head of the table in line with your stroke ent’s soft tissues and when working the tissues. The disad-
(Fig. 4-8B). If any adjustment of the orientation of the core vantage is that smaller contacts are less able to deliver deep
of your body is necessary, this adjustment should be done by pressure and are more prone to injury when deeper pressure
rotating the pelvis at the hip joints and not by rotating the is being employed. Larger contacts are less precise for assess-
spinal joints. Note: This position should be avoided if you ment and treatment but can better deliver deeper pressure
have genu valgum of the knee joint in front. without injury.
A B C
Figure 4-8 Positioning the feet to place the core over the client. (A) Begin with both feet parallel to the table. (B) By
placing the “outer foot” behind the “inner foot,” the core naturally positions over the table. (C) Alternately, the core
can be positioned over the table by placing the “outer foot” in front of the “inner foot” and then adducting the thigh
of the inner foot by moving the foot away from the table.
A B
C D
A B
Figure 4-10 Interphalangeal joint of the thumb. (A) Hyperextension of the interphalangeal joint of the
thumb. (B) A brace can be worn to support the thumb’s interphalangeal joint. (Reproduced with permis-
sion from Muscolino JE. Advanced Treatment Techniques for the Manual Therapist: Neck. Baltimore, MD:
Lippincott Williams & Wilkins; 2013.)
When thumbs or fingers are used, it is important to con- in other words, through the carpal region. If the palm
tact the client with the pads and not the tips of your thumb is placed flat on the client and the pressure is exerted
or fingers. Applying pressure with the tips of your thumb through the metacarpals or the fingers, it will usually re-
or fingers will likely feel uncomfortable for the client, es- sult in torque being placed into the wrist joint. Figure
pecially when you are working deep. To best access the 4-11 illustrates this concept. In Figure 4-11A, the wrist
client’s tissues with your fingers, you need to change the joint is shown in extension to emphasize that the contact
angulation of the shoulder, elbow, and wrist joints so that pressure into the client should be at the carpal region.
the pads naturally meet the client’s body. To best access Of course, when actually working on the client, so as not
the client’s tissues with your thumbs, you slightly extend to fatigue the extensors musculature of the forearm, the
the thumbs so the pads naturally meet the client’s body. hand should be relaxed and resting on the client as seen
However, it is important to not extend the thumb too far or in Figure 4-11B.
the joints of the thumb will become unstacked and exces- Working on the prone client with the palm contact usu-
sive torque will be placed through them. A problem that ally requires some bend in the elbow joints so that the wrist
some therapists have is a hyperextendable interphalangeal joints are not excessively extended. When you lean in with
joint of the thumb (Fig. 4-10A). If your thumb is mildly your core to apply pressure into the client, it is extremely
hyperextendable, you may be able to do this work with important that you stabilize your elbow joint and not allow it
your thumb. There are also supports available that can be to bend any further. The purpose of using your core to lean in
worn on the thumb to prevent the interphalangeal joint is to transfer body weight force through your arm, forearm,
from collapsing into hyperextension (Fig. 4-10B). But if and treatment hand contact, and then into the client. If you
your thumb is extremely mobile into hyperextension, you allow your elbow joint to bend further, even a small amount,
may need to employ another contact when doing deep tis- you will lose some or all of that core force (Fig. 4-11C, D).
sue work into the client. This is a common body mechanics error that frustrates many
When using the palm as a contact, it is extremely im- therapists who cannot understand why they are leaning in
portant that the pressure that is exerted into the client is with their core but the client is still not feeling appreciable
exerted through the base of the palm (heel of the hand), pressure.
A B
C D
Figure 4-11 Palm treatment contact. (A) The palm contact is shown with the hand extended at the wrist joint to
illustrate that the pressure should enter the client through the base of the palm. (B) When actually working on a
client with the palm contact, the hand should be relaxed and resting on the client. (C, D) When using core body
weight to press into the client with a palm contact, it is important to not let the elbow joints bend further as pres-
sure is applied.
A B C
D E F
Alternating Contacts
Even perfect body mechanics cannot eliminate all physical
stress to your body when doing massage. Ideal body
mechanics merely minimize the stress. For this reason,
when doing massage, it is wise to alternate which contact
you use during a session. Given the mass of musculature
in the low back and pelvis, it is wise to use larger con-
tacts as much as possible. A good strategy is to begin with
smaller contacts such as thumb or finger pads to assess
and begin treatment of the lumbar region or pelvis and
then switch to a larger contact such as the palm or elbow A
to deliver deeper pressure.
bracing needs to be placed over the carpal region of the con- clearly illustrate that the pressure from the brace hand is
tact hand. Unfortunately, therapists often incorrectly place being exerted directly over the carpal contact on the client.
the brace too far distal on the hand. A common brace for the Of course, when actually working on a client, it is important
palm contact is to use the other palm. When using this brace, to let the hands relax as seen in Figure 4-13B so that the ex-
be sure to place the carpal region of the brace hand directly tensor musculature of the forearms is not fatigued.
over the carpal region of the contact hand. In Figure 4-13A, Another brace for the palm contact that is not used as
both hands are being held in extension at the wrist joint to often but offers a unique advantage over the palm brace is
A B
C D
A B C
Figure 4-14 Bracing the elbow contact. Bracing the elbow treatment contact by holding onto the distal forearm
allows pivoting of the elbow, which can change the angulation of pressure into the client.
the thumb web. Similar to the illustration of the palm brace, arm (Fig. 4-14A). Bracing and pressing down on the ante-
Figure 4-13C illustrates the thumb web brace position with rior elbow region is very effective at adding pressure into the
the hands lifted away from the client so that the exact place- client. Additional pressure can also be exerted when grasp-
ment and pressure can be easily seen; when working on the ing the distal forearm; however, this brace position is espe-
client, be sure to let the hands relax as seen in Figure 4-13D. cially effective at pivoting the forearm at the elbow joint so
The advantage of the thumb web brace is that it allows for an that the angulation of pressure into the client can be varied
easy transition when changing from a full flat palm contact (Fig. 4-14B, C). When working with the forearm contact,
to the knife-edge (ulnar side of hand) contact (see Figs. B and bracing is accomplished by holding onto and pressing down
C in Therapist Tip 4.3). As the forearm supinates to transi- onto the forearm (see Fig. 4-9G).
tion from the full flat palm contact to the knife-edge contact,
the thumb web brace can be easily altered to compensate. 4.6 Stacking the Upper Extremity Joints
This allows for the pressure of the brace to always be directly
over the contact on the client. The palm brace may work well Stacked joints are aligned in a straight line; in other words,
when the contact palm is flat against the client but is difficult the joints are extended as in anatomic position. This al-
to use when the contact transitions to the hypothenar emi- lows for the force from your core to travel through your
nence or the knife-edge. upper extremity and into the client with little or no loss of
When using a closed fist to contact the client, the wrist strength. When working on the prone client’s low back and
joint can be braced and stabilized with the contact hand (see pelvis with the thumb or finger pads as the contact, your
Fig. 4-9E). Even larger and more powerful than the fist con- elbow, wrist, and thumb/finger joints should be stacked (Fig.
tact are the elbow and forearm contacts. Even though the 4-15A, B). When using the fist, the elbow and wrist joints
elbow and forearm contacts are the largest and most effi- should be stacked (Fig. 4-15C). The palm contact can be
cient for producing deep pressure, use of these contacts can problematic because if the elbow joints are fully stacked/ex-
be physically stressful on the shoulder girdle musculature on tended, the wrist joints will be extended to nearly 90 degrees
the contact side because this musculature must function to (Fig. 4-15D). This can increase torque and perhaps lead to
stabilize the shoulder girdle as pressure is exerted into the wrist injury. For this reason, it is advisable to slightly bend
client. Bracing that is done by the other side of the body can the elbow joints to protect the wrist joints (Fig. 4-15E). This
help to relieve the contact-side shoulder girdle musculature will require more muscular effort because the triceps brachii
from having to work so hard. Bracing the elbow contact can musculature will be required to isometrically contract when
be done by pressing down on the anterior surface of the exerting pressure; but triceps effort is preferable to potential
elbow joint (see Fig. 4-9F) or by holding onto the distal fore- wrist injury.
A B C
D E
Figure 4-15 Stacking the upper extremity joints when working on the client (A–C). Upper extremity joints stacked
with the thumb pad, finger pads, and fist treatment contacts, respectively. (D) If the elbow joints are fully extended/
stacked when employing the palm contact, the wrist joints may be excessively torqued and injured. (E) Partially
bending the elbow joints allows the wrist joints to be in a safer posture.
4.7 Aligning Your Core with the Stroke Keeping the elbows in is an important aspect of strong and ef-
ficient body mechanics that allows you to work from the core.
Now that you have positioned the client on the table, adjusted It is not necessary for the elbows to be all the way at the mid-
where and how you are standing, braced your contact, and line of the body, but they should be within the width of your
stacked your joints, it is important to make sure that your core shoulders. If the thumb or finger pads are being used as the
is behind and in line with your stroke. This is accomplished by contact, then the (upper) arms can be placed against the core/
laterally rotating your arms at the glenohumeral joints so that trunk. This will place the elbows just inside (and usually slightly
your elbows are positioned in front of your core (Fig. 4-16A). above) your anterior superior iliac spine (ASIS) (Fig. 4-16B).
A B
Figure 4-16 Place your upper extremities in front of your core. (A) Laterally rotating the arms at the glenohumeral
joints helps to keep your elbows in front of your core. (B) The (upper) arms can be placed against the core for
further support.
Mid-pelvis Middle
Lower
gluteal Lumbosacral thoracic Upper
Lower
Lumbar thoracic thoracic
Figure 4-18 Contours of the client’s back and pelvis regions. The
contours of the posterior surface of the client’s body, and perpen-
dicular lines to these contours illustrating ideal lines of force, have
been drawn.
A B
C D
E F
A B
A B
Figure 4-20 Dropping down into the client with body weight. Core body weight is transferred into the client by
dorsiflexing the ankle joints and flexing the knee and hip joints. (A) Starting position. (B) End position.
A B
extremity in back to push off the floor and into the client.
4.7 THERAPIST TIP Many therapists are excellent at using the plantarflexor
muscles of the ankle joint but neglect to take advantage of
Letting the Shoulder Girdles Rise the large musculature of the knee and hip joints. To use
When the table height is too high, it is common for the these massive muscles, it is important to first assume a
therapist to have to contract musculature to elevate the somewhat crouched position by flexing the knee and hip
shoulder girdles when working on the client. This is con- joints. Then when you push off into the client by plan-
sidered to be poor posture because it stresses the body tarflexing the ankle joint, you simultaneously extend the
by requiring scapular elevation musculature such as the knee joint with the quadriceps femoris musculature and ex-
upper trapezius and levator scapulae to overwork by iso- tend the hip joint with gluteal musculature and hamstrings.
metrically contracting. For this reason, a general rule of To make sure that you do not rise up as you push off, it is
body mechanics is that the shoulder girdles should be re- necessary to simultaneously dorsiflex the ankle joint and
laxed and down. However, there are times when it is fine flex the knee and hip joints of the lower extremity that is in
to have the shoulder girdles elevated. If you are working front. This allows you to push off forward and also slightly
with deep pressure down into the client with the table ad- downward into the client (Fig. 4-21).
equately low, as you press into the client, the client’s body
presses back up into your contacts, causing your shoulder
girdles to passively rise. In these cases, it is less effortful/
stressful for your body to simply let the shoulder girdles 4.8 THERAPIST TIP
rise than to isometrically contract scapular depression
musculature to hold them down. The essence of good pos- Pushing a Box
ture is minimizing stress to the tissues. Having the shoul-
der girdles relaxed and up is less stressful than contracting A common error in body mechanics when pushing off
to hold them down. with the lower extremity in back is for the therapist to rise
up as he pushes off. This is counterproductive to generat-
ing pressure into the client because rising upward would
move the core of your body away from the client. Your
client is in front of you and usually a bit lower. Therefore,
muscles to add to the pressure generated from body weight. it is important to learn to push off with the lower extrem-
When choosing which muscles to contract and use, less effort ity in back and push forward and somewhat downward.
is expended if you work with the larger, stronger proximal To help get the hang of this motion, it can be useful
muscles instead of the smaller distal ones. In ascending order to picture yourself pushing a large box that is on the floor.
of size and strength, the muscles of the upper extremity and When you prepare to push the box, you intuitively crouch
axial body that can be used are the muscles of the thumb/ down and dorsiflex the ankle joint and flex the knee and
fingers, wrist joint, elbow and radioulnar joints, glenohu- hip joints of the lower extremity in back. Then as you push
meral joint, shoulder girdle, and finally the muscles of the the box, you naturally plantarflex the ankle joint and ex-
core, which comprise the trunk and pelvis. Choosing the tend the knee and hip joints in back as you dorsiflex the
larger proximal muscles of your core will decrease fatigue ankle joint and flex the knee and hip joints in front. As
and the possibility of injury. you push the box forward, you would not rise upward.
Rather, you would keep the pelvis more level. Practice
4.11 Pushing Off with the Lower Extremity this when standing; once it feels natural, try to reproduce
this motion when working on a client. If any alteration is
If the surface contour of the client that you are working made, actually drop your pelvis as you push forward so
is oriented somewhat laterally (e.g., the quadratus lumbo- that you push forward and downward into the client.
rum or lateral paraspinal musculature), then you need to
approach the client more horizontally. A horizontal line of
force does not allow for the use of body weight, so mus-
cle contraction is necessary. Less effort is exerted for the 4.12 Engaging the Tissues
same pressure if larger muscles are used. When working
somewhat horizontally, it is wise to take advantage of the Deep tissue work requires that you engage the client’s tissues.
large musculature of the lower extremity. To do this, the This means that you press in until you feel resistance to your
feet should be in a sagittal plane stance, with the rear foot pressure. Once resistance is felt, further pressure then needs
oriented somewhat parallel with the front foot. This allows to be applied for therapeutic deep tissue work to be done.
for the best use of large musculature oriented in the sagit- It is important to stay within your client’s tolerance and to
tal plane. (If the rear foot is turned outward, as therapists increase your pressure slowly. For deep tissue work to be suc-
often do, the sagittal plane musculature will not be in line cessful, however, it is necessary to apply sufficient force for
with the stroke, and power will be lost.) Now use the lower your pressure to translate to the deep tissue layers.
A B
Figure 4-21 Generating pressure into the client by pushing off with the lower extremity in back. (A) Starting posi-
tion. (B) Pushing off involves plantarflexing the ankle joint, extending the knee joint, and extending the hip joint.
A B
Figure 4-22 Transitioning from static compression to a short stroke. (A) Starting position. (B) Movement of the
stroke should originate from the core.
region. This motion should not come from moving your con- keep these strokes short because the farther you reach from
tact (e.g., your thumb or fingers) but must originate from your initial point of contact, the more difficult it is to main-
your core or lower extremities. With stacked joints, this core tain proper body mechanics. Short, deep strokes between 1
motion will translate into motion of your treatment contact and 6 inches in length allow you to preserve optimal body
along the client (Fig. 4-22A, B). However, it is important to mechanics.
A B
Figure 4-23 Body mechanics for a long stroke. (A) Ideal body mechanics at the beginning of a long stroke. (B) If
the feet remain planted in the same position as a long stroke is performed, body mechanics will suffer by the end
of the stroke.
4.15 Transitioning to Long, Deep Strokes right foot to be next to the left foot and then shift your weight
onto the right foot (Fig. 4-24C). You can now reposition your
Good body mechanics are performed by positioning your left foot to be farther in front (Fig. 4-24D). As you continue
body as close to the region being worked as possible. This to gradually move up the client’s back with the stroke, you
allows you to place your core over the area where pressure is repeat this process, again gradually shifting your weight from
being applied so that body weight can be used (Fig. 4-23A). the right (rear) foot onto the left (front) foot. If you perform
However, if ideal body positioning and mechanics are used a very long stroke from the client’s lumbosacral spine to the
to contact the client at one point on her body and then you top of the thoracic spine, this protocol will usually need to be
remain with your feet planted in the same spot as a long done approximately two to three times. This protocol allows
stroke is performed, it is inevitable that your body mechan- your core to always be over the region being worked so that
ics will suffer by the end of the stroke. Your trunk will no you can always take advantage of body weight.
longer be vertical and positioned over the client’s body, you When you reach the top of the client’s trunk, if you want
will not have the ability to efficiently generate strength, and to complete the stroke without an interruption in the appli-
you will be in an imbalanced position that requires isometric cation of deep pressure, you need to make sure that your
contraction by back musculature to keep you from falling core is superior to the client’s trunk (just lateral to the face
(Fig. 4-23B). For these reasons, whenever you want to per- cradle) and you drop/lean backward with your body weight
form a long, deep stroke up the client’s back, it is necessary against the top of the client’s back/shoulder (see Fig. 4-24D).
to move your feet as the stroke is performed. Whereas for the entire length of the stroke, you were leaning
Illustrating this on the client’s left side, you begin the stroke your core body weight forward and down onto the front foot,
with a sagittal stance and your weight balanced over the right at the end, you need to lean your core body weight backward
(rear) foot (Fig. 4-24A). As you gradually move up the client’s and down onto the rear foot. This allows for the stroke to be
back with the stroke, you gradually transfer your weight onto completed without having to reorient your body 180 degrees
your left (front) foot (Fig. 4-24B). You now reposition your around to face the foot end of the table to press onto the top
A B
Weight on
right foot
(in back)
of the client’s back/shoulder. The more you practice grace- sumed, the fascial tissues of the posterior neck will gradually
fully transferring your body weight from foot to foot as you lengthen, resulting in less passive tension force to hold up
move your feet up the table, the smoother you can perform the head and neck. In the long run, this could require greater
one long, deep stroke up the client’s back. work on the part of the extensor musculature of the neck.
A B C
Figure 4-25 Posture of the head and neck. (A) Flexing the head and neck to watch the stroke imbalances the head
anteriorly, requiring isometric contraction of the posterior cervical extensor musculature. (B) Balanced posture of
the head over the vertical trunk. (C) Relaxing the head and neck into flexion when working with the trunk inclined.
ROUTINES
DEEP TISSUE WORK ROUTINES (gluteal region). There is no rule as to where to begin when
working these regions. The order of the five routines pre-
There is more than one way to approach working the low sented here begins at the lumbosacral and lumbar regions,
back and pelvis. You may choose to do spot work based on continues up into the thoracic region, and then concludes
your client’s needs, or you may choose to perform deep work with the gluteal region.
to the entire region as part of your massage that covers more The order of these routines is an excellent approach, but if
of the client’s body. In either case, you must make sure to you like, you can alter the order of the routines. Also, if desired,
always segue into deep tissue work by first working lightly once the five routines have been done, a few longer strokes can
to moderately to prepare the client for the deeper pressure. be done to connect the gluteal, lumbar, and thoracic regions
When performing deep work, remember always to sink (see “15. Transitioning to Long, Deep Strokes”). The five rou-
slowly into the client’s musculature. tines show work to the left side of the low back and pelvis. The
The five routines that follow demonstrate body mechan- right side can be worked in the identical manner by standing on
ics for deep tissue work to the low back and posterior pelvis the other side of the table and reversing the roles of your hands.
Client Communication
The best measure of the appropriateness of the depth of ease and relax, which is especially important when doing
your pressure should always be the response of the cli- deeper work. When asking the client about the pressure,
ent’s tissues to the pressure that you are employing. You you should not simply ask, “How is the pressure?” This
should be able to feel this with the finger pads or other question places your client in the position of having to
treatment contact. In this regard, massage is a two-way criticize your massage, which many clients may not feel
street: You are not only exerting pressure into the client, comfortable doing. As a result, the response is often
you are also constantly monitoring the response of your “Fine,” whether it is or not. A better way to phrase the
client to the pressure. It is also extremely valuable to ver- question is, “Would you like more pressure or less pres-
bally check in with your client about the depth of the pres- sure?” Now you are specifically inviting the client to ask
sure when doing the massage. Even if you feel confident for a change in what you are doing, and the client has to
about the depth of pressure given the response from the go out of the way to say that it is fine as is. This phrasing is
client’s tissues, it is important to communicate directly more likely to elicit an honest and accurate response and
with the client in a way that shows that you are aware of to create a massage that the client enjoys and from which
his or her desires and needs. This can help the client feel at the client benefits.
The following body mechanics for deep tissue work routines ■ Routine 4-4—posterior pelvis—gluteal region
are presented in this chapter: ■ Routine 4-5—lateral pelvis—abductor musculature
■ Routine 4-1—medial low back—paraspinal musculature Note: For each of the five routines, a specific treatment con-
■ Routine 4-2—lateral low back—quadratus lumborum tact and bracing position has been shown. Other options are
■ Routine 4-3—middle and upper back—paraspinal muscu- possible (see Figs. 4-9 and 4-12 through 4-14).
lature
Starting Position:
■ Have the client prone, if possible, positioned to the left
side of the table. Place a bolster under the client’s an-
kles.
■ You are standing at the left side of the table, close to the
client and adjacent to the client’s pelvis (Fig. 4-26A).
Brace/support
side
Figure 4-26A
Figure 4-27A
Further Repetitions:
■ Repeat this stroke in the same location another two to
three times.
■ Now move slightly superiorly to the midlumbar to upper
lumbar region and perform approximately three to four
deep strokes in a similar manner here (Fig. 4-27B). Figure 4-27C
Starting Position:
■ Have the client prone, if possible, positioned to the left
side of the table. Place a bolster under the client’s ankles.
■ You are standing at the left side of the table, close to the
client and adjacent to the client’s lumbar spine, facing
across the client (Fig. 4-28A).
Figure 4-28C
A C
Figure 4-31A
Starting Position:
■ Have the client prone, if possible, positioned to the left
side of the table. Place a bolster under the client’s ankles.
■ You are standing at the left side of the table, close to the
client and adjacent to the client’s pelvis (Fig. 4-32A).
Figure 4-32B
has been reached. The last stroke should begin between When applying deep pressure to the gluteal
the ischial tuberosity and the greater trochanter and region, be aware that the sciatic nerve exits from
should work into the musculature and attachments on the the internal pelvis into the buttock close to the
greater trochanter (Fig. 4-33C). sacrum, usually just inferior to the piriformis. It then runs
■ Beginning back just lateral to the sacrum again, repeat this inferiorly/distally between the ischial tuberosity and the
entire protocol, this time increasing the depth of pressure. greater trochanter.
Figure 4-35A
Further Repetitions:
■ Repeat this stroke in the same location another two to
three times.
■ Now move to the anterolateral pelvis and perform ap-
proximately three to four deep strokes in a similar manner
here (Fig. 4-35B).
■ Now move to the posterolateral pelvis and perform ap-
proximately three to four deep strokes in a similar manner
here (Fig. 4-35C).
■ Beginning back at the middle of the lateral pelvis just dis-
tal/inferior to the iliac crest again, repeat this entire pro-
Figure 4-34B tocol, this time increasing the depth of pressure.
A B
CHAPTER SUMMARY
matter of positioning the core of the body in line with the
This chapter has presented the body mechanics for perform- force of the stroke. With the treatment contact braced, the
ing deep tissue work into the musculature of the client’s low elbow positioned in front of the body, and the upper extrem-
back and pelvis with the least effort possible. When deep ity joints stacked, dropping down with core body weight and/
work is indicated, proper body mechanics not only facilitate or pushing off with the lower extremities translates pressure
effective work for the client but also accomplish it with less through the contact and into the client. In effect, the thera-
physical stress on the therapist’s body. Working deep is a pist can work smart instead of working hard.
CASE STUDY
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 6. Describe the specific caution and contraindication sites of the
1. Explain why assessing and massaging the anterior abdomen is abdomen and proximal thigh.
important. 7. Explain why placing a roll under the client’s knees is beneficial when
2. Describe in steps an overview of the usual protocol for massaging working into the anterior abdominal wall.
the anterior abdomen. 8. Explain how the lateral border of the rectus abdominis can be used as
3. Describe the usual breathing protocol for the client when massag- a landmark for locating other muscles of the abdomen.
ing the abdomen. 9. Define each key term in this chapter and explain its relationship to
4. State the positions in which the client can be placed when working abdominal massage.
the abdominal wall. 10. Perform massage to the abdomen for each of the muscles presented
5. Explain why massaging the anterior abdomen must be performed in this chapter.
with caution.
KEY TERMS
INTRODUCTION wall, it sits against the spine and next to the quadratus lum-
borum and is actually a muscle of the posterior abdominal
The abdomen is the region of the lower trunk that is inferior wall. The diaphragm is also accessed through the anterior
to the thorax (which contains the thoracic vertebrae and rib abdominal wall but is a muscular partition between the
cage) and superior to the pelvis. The lumbar spine is located thoracic and abdominopelvic cavities.
within the abdomen. The abdomen encircles the entire trunk Massage to the anterior abdomen merits a separate chap-
anteriorly, laterally on each side, and posteriorly. What ter in this book because many massage therapists do not
is often referred to as the abdomen in lay terms is actually feel comfortable working therapeutically in this region. The
the anterior abdomen. The anterior wall of the abdomen is musculature of the posterior trunk, primarily composed of
composed of four muscles on each side: the rectus abdomi- the paraspinal musculature, receives most of the attention,
nis (RA), external abdominal oblique, internal abdominal whereas working into the anterior abdominal wall is often
oblique, and the transversus abdominis (TA). Even though glossed over at best. Three reasons may explain this. First,
the psoas major is accessed through the anterior abdominal the anterior abdominal wall muscles are not thick layers of
musculature like the posterior trunk musculature. Second,
the muscles of the anterior abdominal wall are less used
Note: In the Technique and Self-Care chapters of this book (Chapters posturally to support the trunk than are the posterior trunk
4 to 12), green arrows indicate movement, red arrows indicate stabi- muscles, and therefore do not become symptomatic as often.
lization, and black arrows indicate a position that is statically held. Third, the abdomen has a number of sensitive and fragile
134
structures that may cause the therapist to fear venturing into has increased the incidence of anterior abdominal wall tight-
this region. When work is done here, it is often incomplete ness because of the posture in which the trunk is held when
or so light as to not be therapeutic; this is especially true if the doing core strengthening exercises. For this reason, this book
therapist is attempting to access the belly of the psoas major. dedicates an entire chapter to treatment options for working
Although the anterior abdominal wall musculature will into the abdomen and pelvis from the anterior perspective.
rarely necessitate the depth of pressure used when treating
the posterior trunk, it is important to apply enough pressure
to properly engage the tissues and work therapeutically. If
the psoas major abdominal belly is the target muscle being BOX 5.2
worked, deep pressure is needed because the muscle is lo-
cated so deep from the anterior perspective. Strengthening the Anterior Abdominal Wall
This tendency to undertreat the abdomen from the ante-
rior perspective is unfortunate because work in this region is Strengthening the anterior abdominal wall is extremely
often indicated and needed. This is especially true of the psoas important for a number of reasons. The anterior abdomi-
major, a muscle that is crucially important to spinal health. nal wall musculature creates a force of posterior tilt of the
Further, the recent emphasis on core stabilization exercise pelvis, which is important to prevent the tendency toward
excessive anterior tilt due to tight low back extensor and
hip flexor muscles. A strong anterior abdominal wall is
also a part of core stabilization, increasingly understood
BOX 5.1 to be important both to protect the health of the spine
and also to increase the strength of the musculature across
Abdominal Massage Routines the hip joint. When exercises are done to strengthen
the anterior abdominal wall, there is a tendency for the
The following abdominal massage routines are presented
strengthened muscles to become tighter. For this reason,
in this chapter:
strengthening exercises should always be accompanied by
■ Routine 5-1—RA stretching exercises. It is important to pay special atten-
■ Routine 5-2—anterolateral abdominal wall (abdominal tion to assessing the anterior abdominal wall and psoas
obliques and TA) major musculature in clients who do core stabilization
■ Routine 5-3—psoas major proximal (abdominal) belly (e.g., Pilates) work.
■ Routine 5-4—iliacus proximal (pelvic) belly
■ Routine 5-5—iliopsoas distal (femoral) belly/tendon
■ Routine 5-6—diaphragm
OVERVIEW OF TECHNIQUE
Working the anterior abdomen is not difficult if you are
5.1 THERAPIST TIP comfortable with locating the muscles that you will be work-
ing and if you are aware of the precautions that are neces-
Communication with Client sary as a result of the structures located nearby. The best
assurance that your work will be safe and effective is for you
It is important to pay extra attention to communicating
to become as familiar as possible with the anatomy of the
with the client when working the anterior abdominal
region. Therefore, before treating the anterior abdomen, it
region. On a physical level, it can be very sensitive. On
is recommended that you review the anatomy of the region,
an emotional level, clients often hold a lot of emotional
presented in Chapter 1.
tension in this region, especially the psoas major. The
As a quick review for the technique descriptions that
anterior abdominal area may also have special vulner-
follow, the muscles of the abdomen and pelvis that can be
ability for clients who have gastrointestinal problems. For
worked from the anterior perspective can be divided into the
male and female clients, draping the lower abdomen must
following six muscle/muscle group protocols:
be done with modesty given the proximity to the genita-
lia. For female clients, special attention to modesty must 1. Anteromedial abdominal wall (RA)
be paid when draping so that the upper abdomen can be 2. Anterolateral abdominal wall (abdominal obliques
exposed while also keeping the breasts covered. Before and TA)
beginning anterior abdominal work, explain what you 3. Psoas major proximal (abdominal) belly
will be doing and remind the client to let you know if he 4. Iliacus proximal (pelvic) belly
or she feels uncomfortable and wants you to discontinue 5. Iliopsoas distal (femoral) belly/tendon
the treatment. Then, begin the work slowly and carefully, 6. Diaphragm
checking in every few minutes to make sure the client is
The three steps involved in each of the routines for
comfortable.
abdominal massage in this chapter are (1) starting position,
B
Figure 5-4 Performing the technique. (A) Longitudinal strokes on
the right RA with finger pad contact. (B) Cross-fiber strokes across
the right RA. Figure 5-5 An alternate contact to work the RA is the open fist.
PERFORMING THE TECHNIQUE ciable pressure. Be sure to perform at least a few strokes lon-
gitudinally as well as cross fiber with gentle pressure before
When working the anterior abdomen, it is important to keep increasing the pressure.
in mind at all times the guidelines that follow. Each point
addresses a specific aspect of working this region. Under- 5.3 Use Finger Pads
standing and applying these guidelines will aid in safely and
effectively treating the anterior abdomen. Finger pads are an excellent treatment contact for the
anterior abdomen because they are extremely sensitive. As
5.1 Lateral Border of Rectus Abdominis as a rule, the pads of the index, middle, and ring fingers should
Landmark be used (Fig. 5-7).
It is important that the precise borders of the target muscle 5.4 Direction and Number of Strokes
being massaged are located. This requires excellent palpatory
assessment skills. Although this chapter outlines the specific Strokes may be applied longitudinally along the length of the
palpation protocol for each muscle routine, it is worth not- fibers and/or transversely across the direction of the fibers,
ing that locating the lateral border of the RA is especially as there is no one correct or required direction to the strokes
important because it can be used as a landmark for locating used for the muscles of the abdomen. Longitudinal strokes
and working the muscles of the anterolateral abdominal wall tend to work better when working myofascial trigger points,
(the external and internal abdominal obliques and TA) and whereas transverse strokes tend to work better for breaking
the psoas major muscle (Fig. 5-6). up fascial adhesions. Mixing the two is recommended. How-
ever, it is always best to let the client’s needs determine what
5.2 Gradually Increase the Pressure type of strokes you apply.
The number of strokes applied to the target muscle typi-
Because the anterior abdominal wall can be very sensitive, it cally ranges from 3 to 10. As with direction of stroke, it is
is important to warm up the region before using any appre- best to determine the number of strokes based on the client’s
specific needs.
Psoas
major
ROUTINES
ABDOMINAL MASSAGE ROUTINES proximal (pelvic) belly of the iliacus, and then the distal com-
mon belly/tendon of the iliopsoas in the proximal thigh. The
The routines that follow demonstrate soft tissue massage to last routine that is demonstrated is working the diaphragm.
the musculature of the abdomen. We begin with the RA; we In each case, massage of the right side is shown. To massage
then use the RA as a landmark to locate and work first the the left-sided musculature, stand to the left side of the table
external and internal abdominal obliques and the TA muscle and reverse the treatment and support hands. Individual
in the anterolateral abdomen. We then demonstrate how to illustrations and precise attachment and action information
work the proximal (abdominal) belly of the psoas major, the for these muscles are given in Chapter 1.
The RA attaches from the pubic bone inferiorly to the rib cage superiorly. Massage to the right RA
was shown in the “Overview of Technique” section at the beginning of this chapter (see Figs. 5-1
through 5-5). For the left RA, work instead from the left side of the table and reverse treatment
and support hands.
into the space between the sides of the rectus and the depth
of the connected tissue) are Tupler Technique exercises
that target the deepest abdominal muscle, the TA.
The TA is known as the “girdle” of the body. During
pregnancy, a strong TA can support the heavy uterus, min-
imize the diastasis recti, stabilize the lower spine, reduce
back pain, and facilitate labor. Weakness in the TA results
in a protruding abdominal wall, a more pronounced sep-
aration of the recti, lower back instability and pain, and
Figure B (Reprinted with permission from Stillerman E. Prena-
muscular imbalance. Examining the common attachments
tal Massage: A Textbook of Pregnancy, Labor, and Postpartum
of the overlying abdominal muscles (obliques and rectus), Bodywork. St. Louis, MO: Mosby; 2008.)
it can be seen that contracting the TA pulls the linea alba
inward, thereby making the diastasis smaller. Any exercise legs because these motions require contraction of the hip
that puts forward pressure on the weakened connective tis- flexors (i.e., iliopsoas).
sue (i.e., crunches, leg lifts) or that rotates the torso should During pregnancy, psoas balancing can be performed
be avoided until long after the diastasis is healed, if they are through several noninvasive techniques. For instance, cli-
done at all. ent-initiated posterior pelvic tilts shorten the overstretched
iliopsoas. This can also be performed by the massage thera-
Manual Therapy Techniques: pist with the client in a side-lying position: one hand softly
The abdominal massage that is provided during pregnancy covers the client’s sacrum, and the other hand cups her an-
(after client permission) should be light, slow and rhyth- terior superior iliac spine (ASIS). The movement is a gentle
mical, clockwise, and an effleurage stroke performed with stretch with the sacral hand pulling toward the client’s feet
open hands. Care must be taken to avoid further lateral and the ASIS hand pulling in a posterior direction. Hold
pulling on the linea alba. In late pregnancy, however, as the stretch for several seconds and release slowly.
preparation for birth, techniques that release myofascial Positional release shortens the iliopsoas: the client is su-
restrictions in the abdominal area can be provided. Starting pine with her hip and knee joints bent, she is supported by
toward the end of the second trimester, myofascial stretch- bolsters or pillows under her lower extremities and trunk
ing helps maintain pelvic and fascial fluidity and supple- so she is not lying flat on her back, and her cervical spine is
ness for the months that follow. supported (Fig. B). She remains in this position for 15 to
Care must be taken to keep the direction of the stretch 20 minutes.
horizontal (elongating) but lateral to the uterus—never Rocking in a chair also helps to balance the iliopsoas by
on it. A pregnant woman’s rib cage expands 2 to 3 inches affecting proprioception. Another noninvasive technique
anteriorly and laterally, allowing the baby to grow. to balance the iliopsoas comes from Zero Balancing (it is
However, this expansion can create myofascial restrictions also a part of Native American prenatal care.) Lift the su-
and intercostal tightness. These restrictions can be relieved pine client’s lower extremity and place the foot on your
with gentle finger pad myofascial release and appropriate clavicle. Support her lower extremity under her knee to
stretching. This also facilitates diaphragm function and prevent knee joint hyperextension. Your other hand grabs
allows the pregnant client to breathe deeper. slightly above her same-side wrist. Following the client’s
Postural shifting in later pregnancy creates hyperexten- breath, push inward on her foot with your shoulder and
sion, causing stretching of most of the muscles in the front pull her upper extremity toward you as she exhales; release
of the body, and tightness and compression in muscles on the inhalation. Repeat this for a total of three times be-
of the posterior body. This also includes stretching to the fore changing sides. This movement, like rocking, affects
iliopsoas. If the abdominal muscles are weakened, as in the proprioceptors and releases the muscle.
pregnancy and diastasis recti, your client may experience
lower back instability and pain when walking or lifting her Elaine Stillerman, LMT
ROUTINE 5-2: ANTEROLATERAL ABDOMINAL WALL (ABDOMINAL OBLIQUES AND TRANSVERSUS ABDOMINIS)
The three muscles of the anterolateral abdominal wall on Step 1: Locate Target Musculature:
each side are the external abdominal oblique, internal ab- ■ The anterolateral abdominal muscles are located by using
dominal oblique, and the TA. Even though these muscles the RA as a landmark.
are thought of as being anterior, as a group, they attach via ■ Begin by locating the RA as explained in the “Overview of
the thoracolumbar fascia all the way into the transverse pro- Technique” section (see Figs. 5-1 through 5-5), then find
cesses of the lumbar spine (see Fig. 1-16B). Superiorly, they the lateral border of the RA (Fig. 5-11).
attach as far as the 5th rib; inferiorly, they attach onto the ■ Now drop immediately off the lateral border of the RA
pubic bone (Fig. 5-9). (laterally) and you will be on the anterolateral abdominal
wall muscles (see Fig. 5-11).
Starting Position:
■ The client is supine. Step 2: Performing the Technique:
■ You are standing at the right side of the table, facing di- ■ It is important to use the flat surface of the finger pads and
agonally toward the foot end of the table (Fig. 5-10). not the fingertips, which could be uncomfortable for the
■ Your right hand is the treatment hand that contacts the client.
client. ■ Apply mild to moderate pressure, starting over the lateral
■ Your left hand is the support hand that braces the contact rib cage and running inferiorly and medially toward the
hand. RA along the length of the fibers of the external abdominal
■ Note: The treatment and support hands can be reversed. oblique from superolateral to inferomedial (Fig. 5-12A).
A B
Figure 5-9 Anterior view of the muscles of the anterolateral abdominal wall. (A) Superficial view. The external
abdominal oblique is shown on the client’s right side. The internal abdominal oblique is shown on the client’s left
side. (B) Deeper view. The internal abdominal oblique is shown on the client’s right side. The TA is shown on the
client’s left side.
Note: Strokes begin over the rib cage wall because the ex- ■ Now change your orientation to face diagonally toward
ternal abdominal oblique attaches as far superiorly as the the head end of the table and work in the opposite direc-
5th rib. tion, from inferolateral to superomedial (Fig. 5-12B).
■ Repeat this stroke starting slightly more inferiorly each ■ Repeat this stroke until the entire width of the antero-
time until the entire width of the anterolateral abdominal lateral abdominal wall and lower rib cage has been cov-
wall and lower rib cage has been covered. ered.
■ These strokes work longitudinally along the external ■ These strokes work longitudinally along the internal ab-
abdominal oblique and cross fiber over the internal dominal oblique and cross fiber over the external abdomi-
abdominal oblique (and diagonally across the TA). nal oblique (and diagonally across the TA).
■ Now change your orientation to face across the table and ■ Repeat this stroke until the entire width of the anterolateral
work transversely across the anterolateral abdominal wall abdominal wall has been covered.
from lateral to medial (until you reach the lateral border ■ These strokes work cross fiber over the TA (and diago-
of the RA) (Fig. 5-12C). nally across the abdominal obliques).
■ Repeat this stroke until the entire width of the anterolat- ■ Note: It is important to work the entire abdominal wall,
eral abdominal wall has been covered. including the inguinal ligament at the junction with the
■ These strokes work longitudinally along the TA (and di- thigh. The inguinal ligament is actually a thickening and
agonally across the abdominal obliques). folding of the fibrous aponeuroses of the abdominal
■ Now change your orientation to face toward the head end obliques. However, if work is done distal to the inguinal
of the table and work from inferior to superior (until the ligament, caution should be used to avoid compressing
rib cage is reached) (Fig. 5-12D). the femoral artery, vein, and nerve (see Femoral Neuro-
vascular Bundle Precaution on page 154).
Digestive Flow
The strokes described in Routine 5-2 for the anterolateral movement of the bowel contents. This is usually done in
abdominal wall are designed to work longitudinally along three distinct strokes. Begin by working down the descend-
and cross fiber across each of the individual muscles of the ing colon on the client’s left side with superior to inferior,
anterolateral abdominal wall. However, an excellent proto- vertically oriented strokes. Now work across the transverse
col for the anterior abdominal wall, especially if moderate colon from right to left. And then finish by working up the
or deeper pressure is employed, is to work in the physi- ascending colon on the client’s right side with inferior to
ologic direction of the bowel (colon/large intestine). Bowel superior, vertically oriented strokes (Fig. B). This order is
flow travels from the lower right abdomen up the right side followed to first clear the descending colon before promot-
of the abdomen in the ascending colon, across the upper ab- ing movement of contents into it from the transverse colon,
domen in the transverse colon, and then down the left side and the transverse colon is cleared before moving contents
of the abdomen in the descending colon (Fig. A). Pressure into from the ascending colon. In other words, work and
along the bowel and in the direction of the flow may aid in clear distally before working proximally.
Transverse
colon
Descending
colon
Ascending
colon
A B
Side-Lying Position
Routine 5-2 describes the abdominal obliques and TA
muscles as anterolateral. The term anterolateral is used to
emphasize that these muscles are located lateral to the RA,
which is located anteromedially. However, this term can be
misleading because the obliques and TA are not confined to
the anterolateral abdomen; they are also located in the lat-
eral abdominal wall and the posterolateral abdominal wall.
Indeed, the internal abdominal oblique and the TA attach
all the way posteriorly into the transverse processes of the
lumbar spine via their attachment into the thoracolumbar
fascia; therefore, their posterior fibers could be considered
to be low back musculature (see Figs. 1-26 and 1-27). For
this reason, side-lying posture can be an excellent posture
to use when working the entirety of these muscles (see ac-
companying figure).
Large intestine
Umbilicus
ASIS
Appendix
Small intestine
Figure 5-15A
Psoas major
Figure 5-15C
The abdominal aorta is located along the midline of the body, over the anterior
aspect of the bodies of the lumbar vertebrae, medial to the abdominal belly of
the psoas major (see Fig. 1-45A). When sinking into the client’s abdomen to
assess and treat the psoas major, it is important to aim for the anterolateral aspect of
the spine. If the pulse of the aorta is felt, you are too far medial and need to readjust the
direction that you are sinking in to be slightly more lateral. Always feel for the pulse of
the aorta before exerting deep pressure into the psoas major.
Because pressure must be exerted through the abdominal contents to reach the psoas
major, it is important to make sure that the client will be comfortable. If the client has
any type of intestinal condition, has just eaten, or needs to void the bladder, working
into the psoas major can be uncomfortable.
A B
Like the psoas major, the iliacus muscle is also rarely as- Starting Position:
sessed and worked. This is unfortunate because like the psoas ■ The client is supine with one large roll or a number of
major, this muscle often becomes tight due to the principle smaller rolls under the knees. This relaxes the hip flexor
of adaptive shortening (because it is a hip flexor muscle and musculature so that the pelvis can drop into posterior tilt,
so much time is spent seated with the hip joints flexed). The relaxing and slackening the anterior abdominal wall.
iliacus attaches proximally on the internal (medial) surface of ■ You are standing at the right side of the table (Fig. 5-18).
the ilium and distally onto the lesser trochanter of the femur ■ The finger pads of your right hand will be the treatment
(Fig. 5-17). contact, and the finger pads of your left hand will be the
support that braces the right hand treatment contact.
Note: This could be reversed; the left hand could be the
treatment hand and the right hand the support.
Figure 5-18
Iliacus
Step 1: Locate Target Musculature: ■ To confirm that you are on the iliacus, have the client try
■ First, find the ASIS. to gently flex the thigh at the hip joint against the resis-
■ Then drop medial to the ASIS with your finger pads curled tance of gravity (Fig. 5-19C). This will cause the iliacus to
around the ilium (Fig. 5-19A). contract and you will feel it engage. Note: Be sure to ask
for only a very small thigh flexion range of motion; a large
range of motion will engage the anterior abdominal wall
to stabilize the pelvis from anteriorly tilting. If the anterior
abdominal wall engages, it will become difficult to palpate
through it to reach the iliacus.
Figure 5-19A
■ To access and palpate directly on the iliacus, ask the cli- Figure 5-19C
ent to take in a breath; as the client gently exhales, slowly
sink in by curling your finger pads toward the internal
(medial) surface of the ilium (Fig. 5-19B).
5.6 THERAPIST TIP
Ticklish Clients
Many clients are ticklish when the abdominopelvic and
thigh regions are worked. Ticklishness is often a reaction
to feeling that personal space is being invaded. It can be
helpful to ask the ticklish client to place a hand over your
palpating/treatment hand (see figure). This gives the cli-
ent the sense that he or she is in control of this space and
consequently often diminishes sensitivity.
Figure 5-19B
Step 2: Perform the Technique: ■ The iliacus attaches along the entire internal (medial) sur-
■ The iliacus can be worked by performing short longitu- face of the ilium. However, most of it is out of reach and
dinal strokes running vertically along the musculature cannot be accessed. Access as much of this muscle as pos-
with moderate to deep pressure (Fig. 5-20A). Strumming sible by continuing to work the musculature in a similar
transversely across the musculature can also be performed fashion as far superiorly and inferiorly along the ilium as
(Fig. 5-20B). possible and as far medially as possible.
Starting Position: ■ To confirm that you are on the sartorius, ask the client to
■ The client is supine with one large roll or a number of laterally rotate the thigh at the hip joint and then flex it.
smaller rolls under the knees. This relaxes the hip flexor The sartorius will engage, and its contraction can be felt
musculature, allowing better access and deeper work into (Fig. 5-23B).
the iliopsoas.
■ You are standing at the right side of the table (Fig. 5-22).
■ The finger pads of your left hand will be the treatment Sartorius
contact, and the finger pads of your right hand will be the
support that braces the left hand treatment contact. Note:
This could be reversed; the right hand could be the treat-
ment hand and the left hand the support.
Figure 5-23B
■ Once located, drop just off the sartorius medially onto the
Figure 5-22
iliopsoas distal belly/tendon. Strum horizontally across
the belly/tendon and feel for its width. The iliacus fibers
Step 1: Locate Target Musculature: are more lateral within the common belly/tendon, and the
■ First, find the ASIS. Then drop off it immediately distal psoas major fibers are more medial (Fig. 5-23C).
and slightly medially; you should be on the sartorius (Fig.
5-23A).
Iliacus Psoas major
Figure 5-23C
Figure 5-23A
■ You can confirm that you are on the psoas major fibers by
asking the client to perform a gentle, small flexion range
of motion of the trunk at the spinal joints, in other words,
Iliacus Psoas major
a curl-up. Note: This will engage the psoas major fibers but
not the iliacus fibers (Fig. 5-23D).
Iliopsoas
Femoral nerve,
artery, and vein
Figure 5-24C
Most of the diaphragm cannot be reached for soft tissue Starting Position:
work; however, the relatively small part of it that is accessible ■ The client is supine with a large roll under the knees. This
can sometimes greatly help clients who experience shortness relaxes the hip flexor musculature so that the pelvis can
of breath. The diaphragm attaches to the internal surfaces of drop into posterior tilt, relaxing and slackening the ante-
the sternum and lower six ribs circumferentially around the rior abdominal wall.
rib cage as well as to the bodies of L1-L3 (Fig. 5-25). ■ You are standing at the right side of the table (Fig. 5-26).
■ The finger pads of your right hand will be the treatment
contact. If possible, use the finger pads of your left hand as
the support that braces the right hand treatment contact.
Diaphragm
Figure 5-26
Diaphragm
Figure 5-25 The diaphragm.
Figure 5-27A
■ Ask the client to take in a breath; as the client gently ex- Step 2: Perform the Technique:
hales, slowly sink in by curling your finger pads toward ■ The diaphragm can be worked by performing short trans-
the internal surface of the rib cage (Fig. 5-27B). verse strokes across the musculature with moderate to
deep pressure, trapping it against the internal surface of
the rib cage.
■ The diaphragm attaches 360 degrees around the entire
circumference of the internal surface of the lower rib cage
wall (and sternum). Access as much of this muscle as pos-
sible by continuing to work the musculature in a similar
fashion as far anteriorly toward the midline as possible
and then as far posteriorly as possible.
Visceral Massage
Visceral bodywork (visceral massage) refers to working with One of the fundamentals of doing any kind of visceral
restrictions in the organs of the thoracic and abdominal bodywork is knowing the location of visceral structures.
cavities. Jean-Pierre Barral, a French osteopath, developed Barral’s first admonition to Visceral Manipulation stu-
a curriculum called “Visceral Manipulation” that addresses dents is, “Know your anatomy.” Even though there are as
the “mobility” and “motility” of visceral organs and related many variations in the exact location and shape of specific
structures. Mobility refers to the ability of an organ to move organs as there are people, a strong understanding of ana-
relative to the structures around it. Motility refers to the tomic structure is indispensable. The stomach, for exam-
subtle rhythmic motion of an organ that is presumably left ple, probably has the largest amount of variation due to
over from its movement into position during embryonic the effects of genetic, congenital, dietary, and age-related
development. Work done with mobility is easily felt by the influences. It also changes shape and vertical location based
client and can be visibly seen by an observer, whereas mo- simply on how much food is in it. Regardless of these dif-
tility requires a subtle, almost energetic touch. Both inter- ferences, however, it still feels like a stomach. It has a stom-
ventions can have a profound impact on the whole system. ach’s shape, and it has a stomach’s texture. It feels texturally
Barral also works with the cardiovascular structures within very different from a liver or kidney due to the fact that it is
and around the visceral organs, as they are structurally and hollow while the other two organs are very dense.
functionally interwoven. Bruno Chikly, also a French os- It is important to be aware of the way that the “essen-
teopath, works with the lymphatics of the viscera. His cur- tial” organs are protected by compensations in other body
riculum is called “Lymph Drainage Therapy.” continued
systems. If one’s internal temperature drops, for example, between two pieces of wet glass. This effect can also be seen
the autonomic nervous system will direct blood flow away inside the pericardium with the heart and in the peritoneal
from the extremities and toward the internal organs. In cavity with the stomach, liver, most of the small intestine,
other words, the hands and feet will be sacrificed to protect and part of the large intestine. If the slippery quality is di-
the liver, kidneys, lungs, and so forth. Similarly, there can minished by disease or surgical adhesions, there can be
be fascial strain through a visceral organ due to adhesions symptoms such as pain, structural limitation, and organ
or other fascial restrictions within and around the organ. dysfunction. One of the goals of visceral manipulation is to
This strain will be compensated for by “folding” the fascial mobilize the restricted structures so that the normal slip-
web around the restriction in order to minimize its effect pery relationship can be restored.
on the organ. Due to the continuity of the fascial web, this Some of the organs of the abdomen are outside the peri-
means that the whole body’s fascial structure will be lim- toneal cavity. This includes the kidneys, spleen, parts of the
ited in its expression. These limitations may be as small as duodenum and large intestine, and pelvic organs such as
a slight reduction in range of motion of a glenohumeral the bladder, rectum, uterus, and prostate. Because of their
joint or as large as an easily seen and progressively worsen- positions behind and below the peritoneum (retroperito-
ing scoliosis. The musculature will likely be involved as the neal), they have no serous covering. They do, however, still
central nervous system inhibits individual muscles in order need to be able to move within the abdomen the same way
to limit muscle-induced strain on the organs. that muscles need to be able to change shape within the
All of these compensations can affect the fascial web be- arms, legs, and so forth. Also, all organs, slippery or not,
cause of the restrictions they initiate. Symptoms may ap- have ligamentous and fascial relationships to each other,
pear far away from the original problem, making it difficult the sternum, the spine, and the diaphragm as well as their
to know where or how to start dealing with them. Deduc- respective cavities (pleural, etc.). These connections often
ing that a pain in the foot is due to a restriction around require attention the same way that one might address liga-
the spleen is a Holmesian feat. To deal with this difficulty, mentous restrictions within and around a joint. The lungs,
Barral uses a technique called “listening” in which the for instance, have suspensory fascia that connects them to
practitioner feels for areas of restriction, that is, where the the scalenes, cervical spine, and even to the hyoid bone.
body folds around a visceral structure. This allows the prac- Due to these fascial relationships, dysfunction in any of the
titioner to treat visceral causes rather than simply trying structures of the neck can be directly attributable to pleural
to address symptoms. The belief is that only by addressing restrictions.
core issues can those that are the result of compensations Visceral bodywork is necessarily gentle and painless, al-
be truly “cured.” though it may feel strange and uncomfortable at times. Cli-
Although some organs or parts of organs are held within ents generally are not used to having their internal organs
fairly strict fascial boundaries, others can slide around manipulated. It is, however, often profound and long last-
within a lubricated cavity. The lungs, for instance, could ing in its effects. That said, it is imperative that a therapist
not function correctly within the pleural cavity if they were gets appropriate training before performing any visceral
adhered to the lining of the ribs, diaphragm, and medias- bodywork. There are cautions and contraindications to be
tinum, or if the lobes were adhered to each other. To pre- understood and techniques to be learned in order to fully
vent this, a serous (fluid producing) membrane maintains appreciate the value of this underutilized modality.
a steady supply of watery fluid to allow opposing surfaces
to glide easily across each other, similar to what happens Michael Houstle, LMT, Manual Therapist
CHAPTER SUMMARY it can be performed safely and effectively if the therapist under-
stands the anatomy of the abdomen and takes the time to prac-
Working into the anterior abdominal wall musculature, as well tice these techniques. Very deep pressure is rarely appropriate
as accessing the psoas major, iliacus, and diaphragm through here (except perhaps when working the abdominal belly of the
the anterior abdominal wall, can be very powerful and benefi- psoas major), but firm, moderate pressure can be carefully and
cial to the client. However, it is often skipped during treatment safely applied. For therapists who have not routinely worked
sessions by manual therapists. Although massaging this region the anterior abdomen, the information in this chapter will fa-
requires more caution than massaging the posterior low back, cilitate including these techniques in their treatment repertoire.
CASE STUDY
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 8. Describe the roles of the treatment hand and the stabilization
1. Explain why multiplane stretching is so named. hand.
2. Explain why multiplane stretching is effective. 9. Describe the usual breathing protocol for the client during the
3. Compare and contrast static and dynamic stretching. multiplane stretching technique.
4. Explain how multiplane stretching of a muscle can be reasoned out 10. Explain how another muscle can be slackened to make the stretch
instead of memorized. of the target muscle more effective.
5. Describe how to use your core when stretching the client. 11. Define each key term in this chapter and explain its relationship to
6. Explain the mechanism of multiplane stretching by describing the multiplane stretching.
steps employed in it. 12. Perform the multiplane stretching technique for each of the mus-
7. Explain why stretching should never be performed too quickly or cles and muscle groups presented in this chapter.
pushed too far.
KEY TERMS
assisted stretching multi-cardinal plane stretch static stretching “the shortest rope”
classic stretching multijoint stretching stretch reflex treatment hand
creep multiplane stretching stretching unassisted stretching
dynamic stretching muscle spindle reflex stretching hand
functional group of muscles presetting the rotation target muscle
line of tension stabilization hand target tissue
BOX 6.3
Stretching Terms
When a client stretches soft tissues, the stretching may the rest of the client’s body and is called the stabilization
be assisted or unassisted. Unassisted stretching is done hand.
when the client moves her own tissues into a position of The tissue that is to be stretched is termed the target
stretch (Fig. A). Assisted stretching occurs when the thera- tissue. If a muscle is being stretched, it is called the target
pist helps the client to move the body into the position of muscle. Although it is important to stretch all taut soft
stretch (Fig. B). The therapist’s hand that actually moves tissues (and all soft tissues are potentially being stretched
the client into the stretch is called the treatment hand or whenever a stretch is being done), this chapter focuses its
stretching hand. The other hand is often used to stabilize consideration and discussion on stretching of muscles.
A B
Multiplane Stretching erector spinae group is an extensor. Or, the client’s trunk
might be brought into left lateral flexion in the frontal plane
Multiplane stretching involves stretching a client’s target because the right erector spinae group is a right lateral flexor.
muscle not in only one cardinal plane but across two or Although either of these single cardinal plane stretches might
perhaps all three cardinal planes. By involving more than one succeed in stretching the right erector spinae group to some
cardinal plane motion of the target muscle, a more specific degree, a more effective stretch can be accomplished by
and effective stretch can be attained because the target muscle moving the client’s trunk into a combination of flexion in
can be lengthened to its maximum extent. For example, if the sagittal plane and left lateral flexion in the frontal plane
the target muscle is the right erector spinae group, single because this stretches the right erector spinae group across
plane stretching might be accomplished by bringing the cli- both planes.
ent’s trunk into flexion in the sagittal plane because the right A multiplane stretch of the right erector spinae group that
combines the sagittal and frontal plane component actions is
more efficient than either the single plane stretch into flexion
BOX 6.4 by itself or left lateral flexion by itself. However, an even
more effective stretch would be to consider the transverse
Multi-Cardinal Plane Stretching plane component action of the right erector spinae group
as well. The right erector spinae group, being an ipsilateral
It should be noted that stretching the client’s low back rotator, does right rotation of the trunk in the transverse
into two (or all three) cardinal planes is actually motion in plane. Therefore, to maximize the efficiency of the stretch, the
a single plane; it is simply motion within a single oblique client’s trunk should be moved into a combination of flexion,
plane (that has components of multiple cardinal planes). left lateral flexion, and left rotation. Doing the opposite of all
When you say that a stretch is a multiplane stretch, you are three of the right erector spinae group’s component cardinal
really saying that it is a multi-cardinal plane stretch. All mul- plane actions will achieve the maximum stretch.
tiplane stretches presented in this chapter involve motion
across multiple cardinal planes, but motion only within
one oblique plane. For this reason, multiplane stretching
might be better termed multi-cardinal plane stretching. OVERVIEW OF TECHNIQUE
The overview of multiplane stretching technique is straight-
forward. Once you determine what target muscle you want to
6.2 THERAPIST TIP stretch, simply move the client into the joint actions that are
opposite the target muscle’s joint actions—in other words,
What about the Third Cardinal Plane Action? move it into its antagonist actions.
The following is an overview of multiplane stretching
Even when a target muscle can be stretched effectively using the right erector spinae group as the target muscle
within one plane, if its other plane actions are not at least being stretched. This overview describes assisted multiplane
taken into consideration, the effectiveness of the stretch stretching in which the client is stretched with the assistance of
might be compromised. The right erector spinae group will a therapist. However, it is often possible for a client to perform
act as the example again. The right erector spinae group unassisted multiplane stretching without the assistance of a
can often be stretched thoroughly by only considering therapist. For more on unassisted multiplane stretching, see
the sagittal and frontal plane components and stretching Chapter 11 (available online at thePoint.lww.com).
the client into flexion and left lateral flexion. That being
the case, is it truly necessary to add in the transverse plane
component to the stretch as well? Perhaps not. However, Multiplane Stretching of the Right Erector
if you are not at least mindful of the fact that the right Spinae Group
erector spinae group has a transverse plane joint action,
Starting Position:
it might be possible to overlook the rotation of the client’s
■ The client is supine and lying toward the right side of the
trunk and thereby lose the effectiveness of the stretch. For
table. The client flexes both thighs at the hip joints and
example, if you let the client right rotate while stretching
legs at the knee joints.
into flexion and left lateral flexion, the right erector spinae
■ You are standing at the right side of the table.
group will be slackened by the right rotation (because it is
■ Both hands act as treatment hands and are placed on the
a right rotator) and the effectiveness of the stretch will be
client’s distal posterior thighs.
somewhat lost. For this reason, even if you do not intend to
■ No stabilization hand is needed in this protocol. The client’s
stretch the target muscle in all three planes, it is important
body weight acts to stabilize the upper trunk.
at least to consider all three cardinal plane components of
■ Keeping your elbows tucked in front of your body enables
motion/stretch of the target muscle to make sure that you
you to use your core body weight behind your hands when
do not allow it to slacken in one of them.
pressing on the client with your treatment hands (Fig. 6-1).
Figure 6-2 Alternate position to stretch the right erector spinae Figure 6-3 The right erector spinae group is stretched into flexion,
group. left lateral flexion, and left rotation.
BOX 6.5
Reverse Actions
The low back can be stretched two ways. One way is to the upper trunk to stretch the right erector spinae group
stabilize the pelvis and move the upper trunk toward the musculature, you need to perform right rotation of the pel-
stabilized pelvis. The second way is to stabilize the upper vis and lower trunk. (For more on this, see Table 1-3 in
trunk and move the pelvis and lower trunk toward the Chapter 1.)
stabilized upper trunk. Figuring out what actions to
perform to stretch the low back when moving the upper
trunk toward the stabilized pelvis is straightforward. For
example, to stretch the right erector spinae group, because
its actions are extension, right lateral flexion, and right
rotation, you stretch it by moving the client’s upper trunk
into flexion, left lateral flexion, and left rotation. However,
it can be a bit challenging to figure out how to stretch the
low back when moving the pelvis and lower trunk toward
the stabilized upper trunk because you need to create the
reverse actions of the actions you did when moving the
upper trunk. Reverse actions in the sagittal and frontal
planes are the same: namely, flexion and left lateral flex-
ion. However, the transverse plane reverse action is differ-
ent. Whereas you would have performed left rotation of
A B
are done. Recently, advocates of dynamic stretching have ate. For many of the stretching routines presented in this
recommended shorter times to hold the stretch, between 1 chapter, such as the stretch of the LSp erector spinae or hip
and 3 seconds but a greater number of repetitions (between adductor or hamstring groups, the table needs to be low
8 and 10 or more). What works best for one client will likely so that the therapist can use his or her core body weight.
not work best for another. Try both methods and see what For other routines, such as the hip flexor or hip abductor
is most effective for each client. Many therapists like to use groups, the table must be high enough so that the client’s
a combination of the two methods wherein they perform a stretch is not obstructed by his or her foot hitting the floor.
number of shorter-held repetitions and then finish with a Therefore, to be able to perform multiple stretching rou-
longer-held repetition. tines to the LSp and pelvis/hip joint, the therapist must
be able to change the height of the table, and having the
6.7 Lumbar Spine and Rotation client continually get off and back on the table while the
height is adjusted manually is not logistically feasible. For
When performing a multiplane stretch in all three planes of these reasons, an electric lift table is essential for clinical
the LSp, keep in mind that there is not very much rotation orthopedic work.
possible in the LSp. On average, there is only approximately
one degree of rotation possible at each lumbar segmental 6.9 Be Creative
joint level in each direction (see Chapter 1 for ranges of
motion). Therefore, the rotation component of a multiplane There is a science to stretching: Move the client’s body part
stretch for the LSp will be the least important aspect of the into the joint actions that are the opposite of the joint actions
direction of the stretch. of the target muscle. But there is also an art to stretching. It is
important to be creative when stretching the client, altering
6.8 Electric Lift Table the direction of the stretching force based on where you feel
tension in the client’s tissues. Each different line of stretch
When stretching the low back and pelvis/hip joint, that you create will optimally stretch different fibers of the
the value of an electric lift table cannot be overstated. muscles and soft tissues that you are treating. As long as you
Stretching can be much more physically demanding than are not forcing the body into positions that are not within the
soft tissue manipulation, especially if the differential in ranges of motion of the joint being stretched and as long as
size between the therapist and client is large. If the thera- you are mindful of the cautions and contraindications, there
pist is small and/or short or the client is large and/or tall, is no such thing as a bad stretch. Play with the stretching
stretching can be challenging. For good body mechanics, it angles. Feel for the response of the client’s tissues. Be thera-
is extremely important for the table height to be appropri- peutic. Be creative. Have fun.
ROUTINES
Figure 6-7 Posterior view of the erector spinae group. All three
subgroups are shown on the left side; only the iliocostalis is shown
on the right side.
Figure 6-8 shows the transversospinalis group. The transver- Multiplane Stretching of the Right Transversospinalis
sospinalis group is composed of three subgroups: the semi- Group: Stretch #1
spinalis, multifidus, and rotatores. The semispinalis does not ■ The client is supine.
attach into the LSp. Stretching the transversospinalis group ■ You are standing to the side of the client.
is extremely similar to stretching the erector spinae group in ■ Stretch the client’s pelvis and LSp into posterior tilt and
that flexion and opposite-side lateral flexion are performed. flexion, lateral flexion to the opposite (left) side, and ipsi-
The difference is that the transversospinalis musculature does lateral (right) rotation.
contralateral rotation so it is stretched with ipsilateral rotation ■ The client’s upper trunk is stabilized by body weight and
(whereas the erector spinae does ipsilateral rotation so it is contact with the table.
stretched with contralateral rotation). Following are two ■ Therefore, the right transversospinalis group is stretched
methods for stretching the transversospinalis group: The first with posterior tilt and flexion, left lateral flexion, and right
is with the client supine; the second is with the client seated. rotation (left rotation of the pelvis and lower LSp, which
is equivalent to right rotation of the upper spine) (Fig.
As a group, the transversospinalis extends, laterally 6-9A).
flexes, and contralaterally rotates the trunk at the
spinal joints. It also anteriorly tilts and ipsilaterally
rotates the pelvis and elevates the same-side pelvis at the
lumbosacral joint.
Semispinalis
Figure 6-9A
Rotatores
Multifidus
Multiplane Stretching of the Right Transversospinalis ■ Therefore, the right transversospinalis group is stretched
Group: Stretch #2 with flexion, left lateral flexion, and right rotation (Fig.
■ Have the client seated. 6-10A).
■ Stand behind and to the side of the client. ■ Stretch the left transversospinalis group with flexion, right
■ Bring the client’s (upper) thoracolumbar trunk down toward lateral flexion, and left rotation (Fig. 6-10B).
her lower trunk and pelvis.
■ The client’s upper trunk is stretched into flexion,
Whenever stretching the LSp with the client seated,
it is important to have the client’s feet flat on the
opposite-side (left) lateral flexion, and ipsilateral (right)
floor not only for stabilization for the stretch but
rotation. also to prevent the client from possibly falling.
Quadratus
The quadratus lumborum elevates the same- lumborum
side pelvis and anteriorly tilts the pelvis at the
lumbosacral joint and extends and laterally flexes
the trunk at the spinal joints. It also depresses the 12th rib at
the costovertebral joint.
Figure 6-12A
Figure 6-13A
Figure 6-13B
The anterior abdominal wall is composed of four muscles: on the client and lift the client’s upper body into extension.
the rectus abdominis (RA), external abdominal oblique This brings up a number of issues.
(EAO), internal abdominal oblique (IAO), and transversus
1. Professional modesty. Both you and the client must be
abdominis (TA). The muscles of the anterior abdominal wall
comfortable with these boundaries.
are shown in Figure 6-14.
2. Therapist agility. You must be agile enough to be able to
Clients do not often present with an excessively tight ante-
climb onto the table.
rior abdominal wall. However, when they do, it is important
3. Safety. The table must be secure enough to support the
to know how to stretch the region. Stretching the anterior
combined weight of you and the client.
abdominal wall involves having the client prone and moving
her into extension. Whenever the client’s spine is brought The fourth stretch avoids the therapist having to climb
into extension, be sure that this position is comfortable and onto the table; instead, the therapist stands at the head of
healthy for the client’s spine. the table and lifts the client’s upper body into extension. The
Following are five stretching protocols for the anterior fifth stretch demonstrated has the therapist using the client’s
abdominal wall. The first three stretches involve the therapist thigh to bring the client’s lower spine into extension as well
having to climb up onto the table and either hover over or sit as opposite-side lateral flexion and ipsilateral rotation.
External
abdominal Rectus
oblique Internal abdominis
abdominal
oblique Transversus
Internal
abdominis
abdominal
oblique
A B
Figure 6-14 The anterior abdominal wall. (A) Superficial view. The EAO is shown on the client’s right side; the
IAO is shown on the client’s left side. (B) Deeper view. The IAO is shown on the client’s right side; the RA and TA
are shown on the client’s left side.
The TA compresses the abdominal contents. ■ If right rotation in the transverse plane is added to the
extension and right lateral flexion, the stretch becomes
focused on the left-sided IAO (Fig. 6-15C).
Multiplane Stretching of the Anterior Abdominal Wall:
Stretch #1
■ Have the client prone with her hands clasped together on
the back of her head.
■ Climb onto the table and position yourself on the client’s
buttocks (using a cushion between you and the client can
increase both comfort and modesty); grasp the client’s arms.
■ Stretch the client into extension by leaning back with
your body weight (Fig. 6-15A). This stretch is a uniplanar
stretch in the sagittal plane.
Figure 6-15C
Figure 6-15A
■ Now repeat for the other side combining left lateral Caution must be exercised when performing these
flexion with extension. If desired, rotation to the right or stretches for the anterior abdominal wall.
to the left can be combined with the left lateral flexion. ■ Bringing the client’s LSp into extension
Figure 6-15E demonstrates extension with left lateral approximates the facet joints and narrows the
flexion and left rotation. intervertebral foramina and is therefore contraindicated if
the client has facet syndrome or a space-occupying lesion,
such as pathologic disc or a large bone spur.
■ The client’s glenohumeral joints must be healthy enough to
reach behind him or her and have a stretching force placed
through them.
■ Positioning your body weight on the client’s buttocks is
important. If you sit too far superiorly on the pelvis, it can
push it excessively into anterior tilt, increasing the client’s
lumbar lordosis. If you sit too far inferiorly, the pelvis will
not be adequately stabilized.
Figure 6-16A
Figure 6-15F
Multiplane Stretching of the Anterior Abdominal Wall: Multiplane Stretching of the Anterior Abdominal Wall:
Stretch #3 Stretch #4
■ The client is prone with her knee joints flexed to 90 degrees, ■ Have the client prone with her hands placed on the back
and her arms extended behind her. You sit on her feet and of her head.
grasp her arms, and she grasps your arms as you lean back ■ You stand at the head of the table; grasping her elbows, lift
with core body weight (Fig. 6-17A). her upper body into extension.
■ No stabilization hand is used. The client’s pelvis is stabi-
lized by body weight and contact with the table.
■ The client can relax her head and neck into flexion with
gravity if desired (Fig. 6-18A). However, if the client lifts
her head and neck into extension, the tension force of the
stretch into the anterior abdominal wall will be increased
(Fig. 6-18B).
Figure 6-17A
Figure 6-18A
Figure 6-17B
Figure 6-18B
■ This stretch can be transitioned into a multiplane stretch ■ Your right hand is the stabilization hand and holds down
by adding in a component of lateral flexion and/or rota- the client’s upper trunk.
tion (Fig. 6-18C). ■ This protocol stretches the left side anterior abdominal
wall, but because of the left rotation of the pelvis and
lower LSp, it preferentially stretches the left IAO.
■ Now repeat this stretch for the other side (Fig. 6-19B).
Figure 6-18C
Figure 6-19A
Including stretches of the muscles of the hip joint in a book prevent it from moving. If the pelvis is allowed to move, the
on the low back and pelvis is done for two reasons. First, the line of tension of the stretch will move into the LSp, result-
bellies of many of the muscles that cross the hip joint are ing in a loss of the stretch to the hip joint and perhaps an
located in the pelvis. Second, all muscles of the hip joint exert unhealthy torqueing of the LSp.
their pull on the pelvis as well as the thigh. Therefore, if hip Bony landmarks of the pelvic bone are used to stabilize the
joint musculature becomes tight, it can and usually will affect pelvis. Anteriorly, the anterior superior iliac spine (ASIS) is
the posture of the pelvis, which will then affect the posture used; posteriorly, the posterior superior iliac spine (PSIS), or
of the LSp. Therefore, knowing how to stretch the hip joint is perhaps the ischial tuberosity is used; and laterally, the iliac
essential to the health of the low back. crest is used. To broaden and make the stabilization hand
Therapist-assisted stretching of the hip joint can be more comfortable to the client, a cushion should be used.
performed with the client in many positions. Depending Each of the routines presented will start with a uniplanar
on the musculature being stretched, the client will be stretch of an entire functional group of musculature.
prone, supine, or side-lying. As a rule, the client’s thigh Transitioning this stretch to a multiplane stretch will then
will be moved relative to the stabilized pelvis. For this to be be shown, indicating which specific muscles within the
adequately and safely done, the therapist’s stabilization con- functional group are targeted with each additional plane of
tact must firmly, but comfortably, hold down the pelvis and stretch.
A B
continued
An alternative to using your hand or forearm to stabilize (Fig. C, D). The advantage of this method of stabilization is
the client’s pelvis is to use a strap or seat belt that wraps that it frees your upper extremity/hand. The disadvantage is
around the table and holds down the client’s pelvis. Some that it can take a couple of minutes to set up the strap/belt,
type of cushioning is needed to spread out the compression so unless you will be using it for at least a few stretches, it
stabilization force so that it is comfortable for the client might not be worth the time.
C D
Figure 6-20 shows the abductor musculature of the hip joint. Multiplane Stretching of the Right Hip Joint Abductor
The abductors of the hip joint are the gluteus medius and Musculature: Stretch #1
minimus, upper fibers of the gluteus maximus, tensor fas- ■ Have the client side-lying on her left side with her bottom
ciae latae (TFL), and sartorius. Abductors of the hip joint as close to the near (your) side of the table as possible and
cross the hip joint laterally with a vertical direction to their her left shoulder as far to the opposite side of the table as
fibers. Following are two methods for stretching the abduc- possible. This positions the client diagonally on the table
tor group: The first method is with the client side-lying; the so that her right thigh can be dropped off the side of the
second is with the client supine. table into adduction without its path being obstructed by
the table (Fig. 6-21A).
Hip abductors do abduction of the thigh at the hip
joint. They also depress the same-side pelvis at the
hip joint. These actions occur within the frontal
plane. The more anteriorly located hip abductors also flex
the thigh and anteriorly tilt the pelvis at the hip joint in the
sagittal plane and medially rotate the thigh (and ipsilaterally
rotate the pelvis) at the hip joint in the transverse plane. The
more posteriorly located hip abductors also extend the thigh
and posteriorly tilt the pelvis at the hip joint in the sagittal
plane and laterally rotate the thigh (and contralaterally rotate
the pelvis) at the hip joint in the transverse plane.
Figure 6-21A
Gluteus
medius
■ Stand behind the client.
TFL ■ Your right hand is the treatment hand and is placed on the
lateral surface of the client’s distal right thigh.
Gluteus ■ Your left hand is the stabilization hand and is placed on
maximus the client’s iliac crest. It is important to press on the pelvis
in a cephalad/cranial direction; that is, pressing toward
Sartorius
elevation of pelvis on that side (to prevent it from depress-
ing during the stretch).
■ Stretch the client’s right thigh down into adduction off the
side of the table by dropping down with your core body
weight (Fig. 6-21B).
Iliotibial
band
Figure 6-21B
Figure 6-21E
Multiplane Stretching of the Right Hip Joint Abductor ■ If the client is tall and you cannot reach her distal leg, a
Musculature: Stretch #2 towel can be used to extend your reach (Fig. 6-22C).
■ Have the client supine. To stretch the right-sided abduc-
tors, cross the client’s left leg over the right leg.
■ Stand to the left side of the client and grasp the distal
right leg. Placing a small towel/cushion between the dor-
sal surface of your hand and their left leg can add to client
comfort.
■ Stabilize the left side of the client’s pelvis and pull the right
thigh into adduction (Fig. 6-22A).
Figure 6-22C
Figure 6-22A
Figure 6-23 shows the adductor musculature of the hip joint. Multiplane Stretching of the Right Hip Joint Adductor
The muscles of the adductor group are the adductors longus, Musculature: Stretch #1
brevis and magnus, and the pectineus and gracilis. The qua- ■ Have the client supine toward the right side of the table.
dratus femoris and the lower fibers of the gluteus maximus His right hip joint is abducted and laterally rotated at the
also do adduction of the thigh at the hip joint. Adductors of hip joint, his right leg is flexed at the knee joint, and his
the hip joint cross the hip joint medially, below the center right foot is placed on your left ASIS (Fig. 6-24A). (Note:
of the joint. The first stretch of this routine does start with If the client’s adductor musculature is tight, it is likely that
a multiplane stretch; the client’s thigh is both abducted and he will need to also flex the right thigh at the hip joint to
laterally rotated, optimally stretching the muscles of the ad- attain this position.)
ductor group because they do adduction and medial rota-
tion. The degree of flexion or extension can vary to optimally
stretch different aspects of the adductor group. The second
stretch of this routine is performed with the thigh abducted
and laterally rotated, but the knee joint extended so that the
gracilis (which is also a flexor of the knee joint) is preferen-
tially stretched.
Figure 6-24A
■ Stand to the side of the client. Your left hand is the treat-
ment hand and is placed on the medial side of the client’s
right knee. Your left side pelvis (ASIS) is also a treatment
contact and is placed against the client’s right foot.
■ Your right hand is the stabilization hand and is placed on
the client’s left ASIS. Note: A cushion is used to spread out
and soften the contact pressure on the client.
Pectineus
■ First, press downward toward the floor on the client’s
right knee by dropping with your core body weight. This
Adductor motion is horizontal abduction (also known as horizontal
longus
extension) of the thigh at the hip joint and, because of
Adductor the position of the client’s thigh, stretches the more an-
magnus teriorly placed fibers of the adductor group. During this
stretch, the pelvis will tend to rotate to the right, so your
Gracilis stabilization pressure must be oriented toward left rota-
tion (Fig. 6-24B).
Figure 6-24B
■ Now lean in with your pelvis against the client’s foot, fur-
ther stretching the client’s thigh into abduction. Because
of the position of the client’s thigh, this focuses the stretch
to the more posteriorly oriented fibers of the adductor
group. During this stretch, the pelvis will tend to depress Figure 6-24D
on the left side (and elevate on the right side), so your
stabilization pressure must be oriented toward elevation
■ To focus the stretch on the gracilis, you have to also con-
of the left side of the pelvis (Fig. 6-24C).
sider the knee joint because the gracilis crosses this joint,
too. The gracilis is a flexor of the knee joint, so to stretch
the gracilis, the client’s knee joint must be extended as
you abduct and laterally rotate the thigh at the hip joint
(Fig. 6-24E).
Figure 6-24C
Figure 6-24E
■ After performing the appropriate stretches as indicated ■ Your pelvis is the stabilization contact and is placed
for the right side, switch to the left side of the client’s body against the side of the client’s pelvis. Your right hand as-
and perform these stretches there (Fig. 6-24F). sists in stabilization by contacting the client’s opposite
(left) side upper trunk/shoulder girdle. Note: A cushion
can be used to spread out and soften the contact pressure
of your hand’s contact on the client.
■ Now lean forward with your body weight, bringing the
client’s right thigh farther into abduction as you continue
to stabilize his pelvis and trunk (Fig. 6-25).
■ Note: Because the knee joint is extended, this adductor
stretch primarily focuses on the gracilis.
Figure 6-24F
Figure 6-26 shows the flexor musculature of the hip joint. As a functional group, the flexors all flex the thigh at
Flexors of the hip all cross the hip joint anteriorly with a the hip joint and anteriorly tilt the pelvis at the hip
vertical direction to their fibers. The flexors of the hip joint joint. The more laterally located hip flexors (gluteus
are (from lateral to medial) the anterior fibers of the glu- medius and minimus, TFL, and sartorius) also abduct the
teus medius and minimus, TFL, rectus femoris, sartorius, thigh or depress the same-side pelvis at the hip joint. The more
iliacus, psoas major, pectineus, adductor longus and brevis, medially located hip flexors (adductor group muscles) also
and gracilis. Following are six methods for stretching the adduct the thigh and elevate the same-side pelvis at the hip
joint. The sartorius, psoas major, and iliacus can also laterally
hip flexor group. The first two methods are performed with rotate the thigh (and contralaterally rotate the pelvis) at the
the client supine. The next three methods have the client hip joint. The anterior fibers of gluteus medius and minimus,
side-lying, and the last method has the client prone. Each TFL, and adductor group can also medially rotate the thigh
position and method of stretch has unique advantages and (and ipsilaterally rotate the pelvis) at the hip joint.
disadvantages.
Multiplane Stretching of the Right Hip Joint Flexor
Musculature: Stretch #1
■ Have the client supine as far to the right side of the table
as possible.
■ Stand to the right side of the client. Your right hand is
the treatment hand and is initially placed on the posterior
surface of the client’s distal right thigh.
Psoas ■ Your left hand is the stabilization hand and is placed on
major
the client’s left ASIS. Note: A cushion is used to spread out
and soften the contact pressure on the client (Fig. 6-27A).
Iliacus
TFL
Pectineus
Adductor
longus
Gracilis
Rectus
femoris
Sartorius
Figure 6-27A
Figure 6-27B
Figure 6-27C
Multijoint Stretching
This chapter discusses the idea that a target muscle can extending the thigh at the hip joint and flexing the leg at
be optimally stretched if you consider all of the planes of the knee joint, to lengthen the muscle across both joints
its actions to figure out the most effective stretch. Con- (Fig. A). You can also use this information and reasoning
sidering all the planes of a target muscle is called multi- to figure out how to eliminate a muscle from a stretching
plane stretching. However, this concept can be expanded. routine so that other muscles in the functional group are
When a muscle crosses more than one joint, if you want to more efficiently stretched. Use the rectus femoris again as
optimally stretch it, you need to consider its actions across your example. It is often one of the tighter hip flexors and
all the joints that it crosses; this might be called multijoint therefore commonly limits the extension stretch of the hip
stretching. An excellent example is the rectus femoris of joint, preventing other hip flexors from being adequately
the quadriceps femoris group. It crosses and flexes the hip stretched. To slacken and stop the rectus femoris from lim-
joint and also crosses and extends the knee joint. Therefore, iting the stretch, make sure that the client’s knee joint is
to optimally stretch it, you need to consider both joints, extended (Fig. B).
A B
Multiplane Stretching of the Right Hip Joint Flexor ■ The stretch can be focused toward specific muscles in the
Musculature: Stretch #2 hip flexor group by adding in adduction or abduction
Following are the directions for stretching the right-sided hip and/or medial or lateral rotation to the extension (abduc-
flexor group at the end of the table: tion and lateral rotation are shown in Fig. 6-28C).
■ Ask the client to stand facing away from the end of the
table, place his tailbone (coccyx) at the top of the table,
and lean back onto the table to lie supine hugging his left
thigh into his chest.
■ You stand facing the client at the end of the table, placing
your right hand on his distal posterior left thigh to assist
in stabilizing his pelvis and your left hand on his anterior
right thigh.
■ To perform the stretch, gently drop down with body
weight, pushing his right thigh into extension (Fig.
6-28A).
Figure 6-28A
Figure 6-28C
Figure 6-28B
Figure 6-29B
■ If you grasp the client’s leg to move his thigh into exten-
sion, his knee joint will be flexed and his rectus femoris
will be preferentially stretched (Fig. 6-31B). If you can
reach to grasp his thigh instead, then the knee joint can
be held in extension as the stretch is done so that other
flexors of the hip joint will be preferentially stretched (see
Fig. 6-31A).
Figure 6-30
Figure 6-31B
Figure 6-31A
Figure 6-32A
Figure 6-32B
Semimembranosus
Semitendinosus
Biceps femoris
(long head) Biceps femoris
(short head)
Figure 6-34A
■ Using core body weight, gently lean into the client, ■ This stretch can be transitioned to be multiplanar by adding
pressing his right thigh farther into flexion (Fig. 6-34B). in abduction or adduction of the thigh in the frontal plane
Make sure that his right knee joint remains fully extended or medial rotation or lateral rotation in the transverse plane.
(without being hyperextended). ■ Abduction increases the stretch to the more medially located
hamstrings (Fig. 6-34C).
Figure 6-34E
Extensors of the hip joint comprise the hamstrings, gluteal The gluteus maximus extends, laterally rotates,
muscles (gluteus maximus and posterior fibers of the gluteus abducts (upper fibers), and adducts (lower fibers)
medius and minimus), and the adductor magnus. Stretching the thigh at the hip joint. It also posteriorly tilts and
the hamstrings was shown in Routine 6-8. The gluteals and contralaterally rotates the pelvis at the hip joint.
adductor magnus are being given a separate routine because
they do not cross the knee joint, whereas the hamstrings do. The entire gluteus medius and minimus abduct the
Focusing the stretch on the gluteal and adductor magnus thigh at the hip joint and depress the same-side pelvis
at the hip joint. The anterior fibers also flex and
muscles is accomplished by slackening the hamstrings; this
medially rotate the thigh and anteriorly tilt and ipsilaterally
is accomplished by flexing the client’s knee joint. The stretch rotate the pelvis at the hip joint; the posterior fibers also
routine used for the gluteals is often known as the knee-to- extend and laterally rotate the thigh and posteriorly tilt and
chest stretch. Figure 6-35 shows the gluteal muscles and the contralaterally rotate the pelvis at the hip joint.
adductor magnus.
The adductor magnus extends the thigh and
posteriorly tilts the pelvis at the hip joint.
Gluteus medius
Gluteus medius (cut)
Gluteus medius
(deep to fascia) Gluteus minimus
Gluteus maximus
Adductor magnus
A B
Figure 6-35 Posterior view of the gluteal muscles and the adductor magnus. (A) Gluteus maximus and gluteus
medius. (B) Gluteus minimus and adductor magnus.
Figure 6-36C
Figure 6-36A ■ Adduction increases the stretch to the more laterally located
fibers (Fig. 6-36D).
■ Using core body weight, gently lean into the client,
bringing her knee to her chest by pressing her right thigh
farther into flexion (Fig. 6-36B).
Figure 6-36B
■ If medial rotation is added, it increases the stretch to the ■ Note: If knee-to-chest stretch is performed and transitioned
gluteal muscles. into a multiplanar stretch by adding in adduction, lateral
■ If lateral rotation is added, it decreases the stretch to the rotation, or both, it begins to target the deep lateral rotator
gluteal muscles, thereby allowing a better stretch of the group of the hip joint (see Routine 6-10).
adductor magnus. ■ After performing the appropriate stretches as indicated for
■ Frontal and transverse plane components can be combined the right side, switch to the left side of the client’s body and
to focus the stretch more specifically toward certain perform these stretches there. Figure 6-36F demonstrates
fibers. Figure 6-36E demonstrates flexion combined with the initial stretch to the gluteal group performed on the
adduction and medial rotation. This position preferentially client’s left side.
stretches the upper fibers of the gluteus maximus.
Figure 6-36F
The deep lateral rotator group of the hip joint is composed of Stretch #1: Horizontal Adduction
the piriformis, superior and inferior gemelli, obturator inter- ■ Have the client supine toward the left side of the table.
nus and externus, and the quadratus femoris (Fig. 6-37). This ■ Position yourself at the left side of the table.
group is located on the posterior side of the pelvis, crossing ■ Bring the client’s right hip and knee joints into flexion
the hip joint with a horizontal direction to their fibers to at- and then horizontally adduct the right thigh at the hip
tach to the femur. joint and trap the client’s right knee between your trunk
You can generalize and say that the gluteal musculature and right arm, in other words, under your right axillary
runs primarily vertically, and for that reason, it is oriented region.
differently from the fiber direction of the deep lateral rota- ■ No stabilization hand is necessary; the client’s body weight
tors; therefore, a separate stretching routine is presented and contact with the table stabilizes his pelvis.
here. However, they really are not that different; rather, there ■ Using core body weight, gently lean into the client, bring-
is a gradual transition in fiber direction from the gluteals to ing his thigh down and across his chest, farther into hori-
the deep lateral rotators (see the relationship of the posterior zontal adduction (Fig. 6-38A). Be sure that the client’s
fibers of the gluteus medius and the piriformis; Fig. 1-16). pelvis remains stabilized down onto the table.
This is evidenced by the fact that, as mentioned previously, ■ It is beneficial to purposely vary the exact degree of flexion
the knee-to-chest stretch for the gluteals easily transitions versus horizontal adduction of the client’s thigh to catch
into a stretch for the deep lateral rotators (see Fig. 6-36). as many angles as possible between a pure flexion knee-
Following are two routines for stretching the right-sided to-chest stretch and a pure horizontal adduction stretch
deep lateral rotator group using horizontal adduction of the across the client’s body (Fig. 6-38B, C). Each different
thigh and the Figure 4 stretch. angle will preferentially stretch different directions of fi-
bers of the deep lateral rotator group and musculature of
As a group, the deep lateral rotators laterally rotate the posterior buttock in general.
the thigh at the hip joint and contralaterally rotate ■ After performing the appropriate stretches as indicated
the pelvis at the hip joint. If the thigh is first flexed to for the right side, switch to the left side of the client’s body
90 degrees, the deep lateral rotators can horizontally abduct and perform these stretches there (Fig. 6-38D).
(horizontally extend) the thigh at the hip joint. Note: If the
thigh is first flexed (approximately 60 degrees of more), the
piriformis changes to become a medial rotator of the thigh at
the hip joint instead of a lateral rotator.
Piriformis
Quadratus femoris
Figure 6-37 Posterior view of the muscles of the deep lateral rotator group.
A B
Stretch #2: Figure 4 ■ No stabilization hand is necessary; the client’s body weight
■ Have the client supine toward the right side of the table. and contact with the table stabilize his pelvis.
■ Position yourself at the right side of the table. ■ Using core body weight, gently lean forward into the cli-
■ Flex and laterally rotate the client’s right hip joint and ent, pressing equally with both hands and bringing his
flex his right knee joint and place his distal right leg on laterally rotated right thigh farther into flexion, in other
his flexed left thigh. This forms the Figure 4 position for words, down toward his chest (Fig. 6-39B). Be sure that
which the stretch is named. the direction of your pressure is such that the client’s pel-
■ Both of your hands are treatment hands. Place your left vis remains stabilized down onto the table.
hand on the posterior surface of his distal right thigh, and
place your right hand on the posterior surface of his distal
left thigh (Fig. 6-39A).
Figure 6-39B
Figure 6-39A
■ After performing the appropriate stretches as indicated
for the right side, switch to the left side of the client’s body
and perform these stretches there (Fig. 6-39C).
Figure 6-39C
CASE STUDY
FELIX pain in the front of his right hip. Manual resistance to right hip
joint flexion and abduction reproduces the characteristic pain
■ History and Physical Assessment
that he has been experiencing in the front of the right hip. You
A new client, Felix Madison, age 53 years, comes to your perform active and passive straight leg raise, Nachlas’, and
office complaining of pain and stiffness in his right hip and Yeoman’s tests and ask the client to perform the cough test
tightness across his low back. He tells you that he has been and Valsalva maneuver, all of which produce negative results
experiencing pain and stiffness for 3 weeks. Because he is (for a review of assessment procedures, see Chapter 3).
a nurse, his hip and low back pain has made it difficult to Palpatory examination reveals that his hip flexors on
work. He was referred to you by his fitness trainer because the right side are all mildly tight, but his TFL is markedly
the trainer heard that you are skilled at working with low tight and is the source of his anterior hip pain. His adduc-
back problems and stretching techniques. tors and hamstrings are fine. In the low back, his erector
You perform a thorough client history, which reveals spinae musculature is moderately tight, with his right side
that he has had multiple low back sports injuries when he tighter than the left side. The gluteal musculature, deep
was younger and played lacrosse in high school. Since high lateral rotators, and quadratus lumborum muscles bilater-
school, he has had occasional episodes of hip tightness and ally are all within normal limits of tone.
pain as well as low back tightness, but these episodes have At the end of the examination, you ask him to show
never lasted more than a few days. His present episode is you the stretches that he has been doing. He demonstrates
more intense and is not going away. It began during a vaca- single knee-to-chest and double knee-to-chest for his
tion in which he was walking many hours each day. low back and a lunge stretch for his hip flexors as well as
Felix has seen his massage therapist twice now. In the stretches for his hamstrings and quadriceps femoris. You
past, massage has always helped to loosen his hip and low note that when he shows you the lunge stretch, his right
back and eliminate the pain and stiffness, but this time, thigh is abducted as he performs the stretch.
the relief has only been temporary. Felix also has a regular
stretching routine that he does whenever his low back and ■ Think-It-Through Questions:
hip act up. These stretches also usually help, but this time 1. Should you include a multiplane stretching technique in
they have not. At this point, his current episode of stiffness your treatment plan for Felix? Why, or why not?
and pain has not improved, and he is very discouraged. 2. If multiplane stretching would be of value, is it safe to
Postural examination shows that Felix has a mildly exces- use with him? If yes, how do you know?
sive anterior tilt of his pelvis with a concomitantly increased 3. If you do perform multiplane stretching, which specific
lumbar lordosis. Your LSp range of motion assessment shows stretching routines should you do? Why?
that left lateral flexion is decreased by 10 degrees, and flexion
is decreased by 15 degrees. His right hip joint range of motion Answers to these Think-It-Through Questions and the
assessment shows that extension and adduction are decreased Treatment Strategy employed for this client are available
on the right side compared to the left side and also cause mild online at thePoint.lww.com/MuscolinoLowBack
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 5. Explain why the client may perform either an isometric or concentric
1. Explain why contract relax (CR) stretching is also known as proprio- contraction during a CR stretch.
ceptive neuromuscular facilitation stretching and/or postisometric 6. Describe the usual breathing protocol for the client during the CR
relaxation stretching. stretching technique.
2. Describe the mechanism of CR stretching. 7. Explain why stretching should never be performed too fast or too far.
3. Describe in steps an overview of the usual protocol for carrying out 8. Define each key term in this chapter and explain its relationship to
the CR stretching technique. the CR stretching technique.
4. Describe the roles of the treatment hand and the stabilization 9. Perform the CR stretching technique for each of the muscle groups
hand. presented in this chapter.
KEY TERMS
BOX 7.2
Bone
Golgi tendon organ
Sensory neuron
Inhibitory
interneuron
Muscle
)–(
Spinal cord
Alpha LMN
OVERVIEW OF TECHNIQUE
If the GTO reflex is the scientific principle that underlies CR
stretching, then the manner in which it is carried out is its
art. The following is an overview of the CR stretching tech-
nique using the right hamstring muscle group as the target
muscle group being stretched. The following overview of
the CR stretching technique protocol describes assisted CR
stretching in which the client is stretched with the assistance
of a therapist. However, it is often possible for a client to
perform unassisted CR stretching without the assistance of
a therapist. For more on unassisted CR stretching, refer to Figure 7-1 Starting position for CR stretching of the right ham-
Chapter 11 (available online at thePoint.lww.com). string muscle group. Note that the therapist’s elbows are tucked in.
A B
C D
Figure 7-2 (A–D) Alternative starting positions.
■ The fourth position is to actually climb up onto the the table can support the weight of both you and the
table so that you can position your trunk/core directly client (Fig. 7-2D).
in line with the force that the client will be creating.
Using your core in this manner is the most efficient If when stretching the hamstrings, the client’s knee
position for body mechanics. If this position is used, joint flexes, the hamstrings will slacken, and the
it is better to have the client supine toward the middle tension of the stretch will be lost. For this reason, the
of the table instead of the side; this gives you more client’s knee joint must remain extended during the
room to comfortably position your body on the table. entire stretch. However, it is important to not allow or force
Of course, before climbing on the table, be sure that the client’s knee joint to hyperextend.
Figure 7-3 Initial stretch of the client’s right thigh into flexion
at the hip joint by the therapist. Note that the client’s right knee
remains extended.
7.4 THERAPIST TIP
Counting Down
Initial Client Stretch:
While the client is contracting for 5 to 8 seconds, some
■ Gently stretch the client’s target (right hamstring) muscu-
therapists like to encourage the client to keep contract-
lature by moving the client’s thigh into flexion until you
ing by gently repeating something like resist or keep
meet tissue resistance. Note: Make sure that the client’s
contracting. Other therapists like to count down as the
knee joint stays extended.
client contracts. This can be done by asking the client
■ This begins the stretch of the target hamstring muscles
to contract and then gently counting out loud starting
(Fig. 7-3).
with the number of seconds that you want the client
■ Note that your right knee acts as the stabilization contact,
to contract for. For example, you might say contract,
holding down and stabilizing the client’s left thigh. Stabi-
7, 6, 5, 4, 3, 2, 1, relax. Or you may begin with words
lizing the left thigh acts to stabilize the pelvis
to encourage the client’s contraction and then com-
plete the time with the remainder of the countdown,
First Repetition, Step 1: Client Contraction:
such as resist . . . that’s it . . . keep contracting . . . 3, 2,
■ In this position of stretch of the target muscles, ask the
1, relax. The advantage to counting down is that the
client to inhale and then gently isometrically contract the
client knows how long he or she will have to continue
target muscles for approximately 5 to 8 seconds against
contracting.
the resistance of your treatment hands (and/or shoulder).
A B
Figure 7-4 First repetition. (A) Step 1: Isometric contraction of the client’s right hamstring musculature against
the resistance of the therapist. (B) Step 2: After contracting, the client relaxes and is stretched farther into flexion
by the therapist.
A B
Figure 7-5 Second repetition. (A) Step 1: Contraction by the client. (B) Step 2: Further stretch of the client.
A B
Figure 7-6 Third repetition. (A) Step 1: Contraction by the client. (B) Step 2: Further stretch of the client. Note the
increased range of motion attained compared to the first two repetitions.
ROUTINES
CR stretches of the LSp can be performed in two ways. One The following CR stretching routines for the LSp are
way is to stabilize the client’s pelvis and move his or her presented in this chapter:
upper trunk downward toward the pelvis. This method be-
■ Routine 7-1—LSp extensors
gins the stretch of the LSp superiorly, and as the stretching
■ Routine 7-2—LSp flexors
force is increased and the LSp is increasingly moved down-
■ Routine 7-3—LSp right lateral flexors
ward, the stretch moves into the lower LSp. The second way
■ Routine 7-4—LSp left lateral flexors
is to stabilize the client’s upper trunk and move his or her
■ Routine 7-5—LSp right rotators—seated
pelvis and lower LSp upward toward the thoracic trunk. This
■ Routine 7-6 —LSp left rotators—seated
method begins the stretch of the LSp inferiorly, and as the
stretching force is increased and the pelvis and lower spine
are increasingly moved upward, the stretch moves into the
upper LSp. 7.7 THERAPIST TIP
Figure 7-7 shows the functional group of muscles that extend Starting Position:
the LSp. These muscles are located on the posterior side of ■ The client is supine with his hip and knee joints flexed. If
the trunk in the lumbar region. The CR stretching routine you are standing on the right side of the table (as shown in
presented here is essentially the double knee-to-chest stretch Fig. 7-8A), his feet are on your right clavicle. Your left foot
that is presented in Chapter 11 (Self-Care Routine 11-6; is on the floor; your right lower extremity is positioned on
available online at thePoint.lww.com), with the CR stretch- the table to be in line with the force of the stroke.
ing protocol added.
Figure 7-8A
Quadratus
lumborum
Figure 7-7
Figure 7-8B
First Repetition: Client Contraction: ■ Hold this position of stretch for approximately 1 to 3 seconds.
■ With the client in the initial stretch position, ask the cli- ■ Note: To maintain stabilization of the client’s trunk on the
ent to perform a gentle isometric contraction of the target table, be sure to not press the client’s thighs too horizon-
muscles for approximately 5 to 8 seconds (in an attempt tally and parallel with table because this would cause his
to extend the trunk back down toward the table) against trunk to excessively lift from the table, moving the stretch
your resistance (Fig. 7-10A). into the thoracic stretch, thereby losing the stretch in the
lumbar region. It is important to press his thighs some-
what downward toward his chest.
Figure 7-10A
Third Repetition:
■ Beginning from the position of stretch reached at the end
of the second repetition, have the client again contract the
target musculature isometrically for approximately 5 to 8
seconds against your resistance, this time with as much
force as is comfortable for the client.
■ As soon as the client relaxes, gently increase the stretch of
the client’s target musculature by moving the trunk far-
ther into flexion until you meet tissue resistance.
■ If desired, a fourth repetition can be done.
■ Hold the position of stretch of the last repetition for
approximately 10 seconds or more.
Transitioning to Multiplane Contract Relax Stretching: Lumbar Spine Extensor Functional Group
Transitioning the CR stretching protocol for the LSp rotation of the pelvis and lower LSp (equivalent to right
extensor functional group into a multiplane stretch that rotation of the upper LSp) being added into the sagittal
incorporates other planes of motion can be easily done plane lumbar flexion. This increases the stretch to the LSp
by altering the direction of the movement of the client’s extensors that are also left rotators (right-sided transver-
pelvis and LSp. Figure A demonstrates frontal plane LSp sospinalis and left-sided erector spinae musculature). Of
right left lateral flexion being added into the sagittal plane course, both frontal and transverse plane components can
lumbar flexion. This increases the stretch to the left-side be added to the sagittal plane flexion when performing
extensor functional group muscles that also do left lateral a CR multiplane stretch of the LSp extensor functional
flexion. Figure B demonstrates transverse plane left group.
A B
Figure 7-12 shows the functional group of muscles that flex Starting Position:
the LSp. These muscles are often described as muscles of the ■ The client is prone with his hands clasped behind his head.
anterior abdominal wall and are located on the anterior side You are seated on the client’s buttocks and grasping the
of the trunk in the lumbar region. The following CR stretch client’s arms. Note the placement of the cushion for client
involves the therapist climbing onto the table. For more on and therapist modesty and comfort (Fig. 7-13A).
stretching the LSp flexor group, including alternative posi-
tioning, see Routine 6-4.
Figure 7-13A
Rectus
abdominis
Figure 7-13B
Caution must be exercised when performing these First Repetition: Client Contraction:
stretches for the anterior abdominal wall. ■ With the client in the initial stretch position, ask the cli-
■ Bringing the client’s LSp into extension approximates ent to perform a gentle isometric contraction of the target
the facet joints and decreases the size of the muscles for approximately 5 to 8 seconds (in an attempt
intervertebral foramina and is therefore contraindicated if to flex the trunk back down toward the table) against your
the client has facet syndrome or a space-occupying lesion, resistance (Fig. 7-15A).
such as pathologic disc or a large bone spur.
■ The client’s glenohumeral joints must be healthy enough
to reach behind him or her and have a stretching force
placed through them.
■ Positioning your body weight on the client’s buttocks in
this routine is important. If you sit too far superiorly on
the pelvis, it can push it into anterior tilt, increasing the
client’s lumbar lordosis. If you sit too far inferiorly, the
pelvis will not be adequately stabilized.
Figure 7-15A
Figure 7-15B
Figure 7-16B
Third Repetition:
■ Beginning from the position of stretch reached at the end
of the second repetition, have the client again contract the
target musculature isometrically for approximately 5 to 8
seconds against your resistance, this time, with as much
force as is comfortable for the client.
Figure 7-16A ■ As soon as the client relaxes, gently increase the stretch of
the client’s target musculature by moving the trunk far-
ther into extension until you meet tissue resistance.
Second Repetition: Postcontraction Stretch: ■ If desired, a fourth repetition can be done.
■ As soon as the client relaxes, gently increase the stretch of ■ Hold the position of stretch of the last repetition for ap-
the client’s target musculature by moving the trunk far- proximately 10 seconds or more.
ther into extension until you meet tissue resistance (Fig.
7-16B).
■ Hold this position of stretch for approximately 1 to
3 seconds.
Transitioning to Multiplane Contract Relax Stretching: Lumbar Spine Flexor Functional Group
Transitioning the CR stretching protocol for the LSp (ante- left-sided flexor functional group muscles that also do left
rior abdominal wall) flexor functional group into a multi- lateral flexion (left-sided external and internal abdominal
plane stretch that incorporates other planes of motion can obliques). Figure B demonstrates frontal plane right lateral
also be easily done by altering the direction of the move- flexion and transverse plane right rotation being added into
ment of the client’s LSp. Figure A demonstrates frontal the sagittal plane lumbar extension. This focuses the stretch
plane LSp right lateral flexion being added into the sagittal specifically to the left-sided left internal abdominal oblique
plane lumbar extension. This increases the stretch to the muscle (because it does left lateral flexion and left rotation).
A B
Figure 7-17 shows the functional group of muscles that right Starting Position:
laterally flexes the LSp. These muscles are located on the right ■ Have the client side-lying on her left side with her bottom
side of the trunk in the lumbar region. as close to the near (your) side of the table as possible and
her left shoulder as far to the opposite side of the table as
possible. This positions the client diagonally on the table
The Lumbar Spine Right Lateral Flexor Functional Group so that her right thigh can be dropped off the side of the
table into adduction without its path being obstructed by
This functional group comprises the following right- the table.
sided muscles: ■ Stand behind the client.
Erector spinae group ■ Your right hand is the treatment hand and is placed on the
Transversospinalis group lateral surface of the client’s distal right thigh.
■ Your left hand is the stabilization hand and is placed on the
Quadratus lumborum
client’s rib cage. It is important to press on the rib cage in a
Rectus abdominis cephalad/cranial direction. Note placement of a cushion to
External abdominal oblique spread out the stabilization force on the rib cage (Fig. 7-18).
Internal abdominal oblique ■ Bring the client’s right thigh down into adduction off the
Psoas major
side of the table. As the client’s thigh adducts, the client’s
right-side pelvis will drop down into depression, thereby
Psoas minor stretching the right lateral flexor musculature of the trunk.
External
abdominal
oblique
Internal
abdominal
oblique
Psoas
major
Figure 7-17 Note: Not all muscles are seen. Figure 7-18
Figure 7-20A
Figure 7-19
Figure 7-20B
Third Repetition: and pelvis farther into the stretch until you meet tissue
■ Beginning from the position of stretch reached at the end resistance.
of the second repetition, have the client again contract the ■ If desired, a fourth repetition can be done.
target musculature isometrically for approximately 5 to ■ Hold the position of stretch of the last repetition for
8 seconds against your resistance, this time, with as much approximately 10 seconds or more.
force as is comfortable for the client. ■ When the stretching routine is complete, ask the client
■ As soon as the client relaxes, gently increase the stretch to completely relax the thigh as you passively return it to
of the client’s target musculature by moving the thigh the table.
Contract Relax Stretching of the Lumbar Spine Right Lateral Flexors with the Client Seated
It is also possible to perform CR stretching of the LSp right the stabilization hand can be placed on the proximal anterior
lateral flexor musculature with the client seated at the end of surface of the client’s right thigh (Fig. B). In either case, your
the table. For this option, you would be standing to the right stabilization hand contact should be broad in contact so it is
side of the client. Your right hand is the treatment hand and both firm and comfortable for the client; if desired, a cushion
is placed on right side of the client’s trunk. Your left hand is can be used. The advantage of the seated position is that the
the stabilization hand and functions to stabilize the client’s client’s hip joint is not involved with the stretch. The disad-
pelvis. It is placed across the top of the client’s right iliac crest vantage is that it can be challenging to adequately stabilize the
(Fig. A); if it is not possible to grasp the client’s iliac crest, client’s pelvis and to control the motion of the client’s trunk.
A B
External
abdominal
oblique
Internal
abdominal
oblique
Psoas
major
Figure 7-23 shows the functional group of muscles that right Starting Position:
rotate the LSp. These muscles are located both anteriorly and ■ Have the client seated at the right end of the table with
posteriorly and on both the right and left sides of the trunk her arms crossed so that her hands are on the opposite
in the lumbar region. shoulders, but her arms should be adducted at the gle-
nohumeral joints so that her elbows meet at the center of
the body.
The Lumbar Spine Right Rotator Functional Group ■ Stand to the right side of the client.
This functional group comprises the following muscles: ■ Your right hand is the treatment hand and is placed on the
Semispinalis
External Spinalis
abdominal
oblique Longissimus
Multifidus
Internal Iliocostalis
abdominal
oblique
A B
■ Your left hand is the stabilization hand and functions to Initial Client Stretch:
stabilize the client’s pelvis. It is placed across the top of ■ Begin by gently stretching the client’s target (lumbar
the client’s right iliac crest (Fig. 7-24); if it is not possible right rotator) musculature by moving the client’s trunk
to grasp the client’s iliac crest, the stabilization hand can into left rotation until you meet tissue resistance, begin-
be placed on the proximal anterior surface of the client’s ning the stretch of the target lumbar right rotator muscles
right thigh; if desired, a cushion can be used for comfort (Fig. 7-25).
to broaden the stabilization contact as described in Practi-
cal Application Box 7.4.
Figure 7-27B
Third Repetition:
■ Beginning from the position of stretch reached at the end
of the second repetition, have the client again contract the
target musculature isometrically for approximately 5 to
8 seconds against your resistance, this time, with as much
force as is comfortable for the client.
Figure 7-27A ■ As soon as the client relaxes, gently increase the stretch of
the client’s target musculature by moving the trunk far-
ther into left rotation until you meet tissue resistance.
Second Repetition: Postcontraction Stretch: ■ If desired, a fourth repetition can be done.
■ As soon as the client relaxes, gently increase the stretch ■ Hold the position of stretch of the last repetition for
of the client’s target musculature by moving the trunk approximately 10 seconds or more.
farther into left rotation until you meet tissue resistance
(Fig. 7-27B).
■ Hold this position of stretch for approximately 1 to
3 seconds.
Semispinalis
External Spinalis
abdominal
oblique Longissimus
Multifidus
Internal Iliocostalis
abdominal
oblique
A B
As a rule, CR stretches to the muscles of the pelvis that cross The following CR stretching routines for muscles of the
the hip joint are performed by stabilizing the client’s pel- pelvis that cross the hip joint are presented in this chapter:
vis and moving his or her thigh to create the stretch. For
■ Routine 7-7—hip abductors
the stretch to be effective, it is extremely important that the
■ Routine 7-8—hip adductors
pelvis is well stabilized. Otherwise, the stretching force will
■ Routine 7-9—hip flexors
enter the LSp. This will not only dissipate the stretching
■ Routine 7-10—hip extensors: hamstrings
force at the hip joint causing it to lose its effectiveness but it
■ Routine 7-11—hip extensors: gluteals
might also place a torque force into the LSp that can cause
■ Routine 7-12—hip deep lateral rotators
pain or injury.
■ Routine 7-13—hip medial rotators
Figure 7-29 shows the functional group of muscles that eral flexor functional group of the LSp (see Routines 7-3
abduct the right thigh at the hip joint. These muscles are and 7-4). The difference is that the pelvis (instead of the
located on the lateral side of the pelvis and thigh, cross- rib cage) is stabilized when performing this CR stretch
ing the hip joint between them. The CR stretching routine for the hip joint. Following is the CR stretching routine
presented here for the hip abductor functional group is shown for the hip abductor functional group on the right
similar to the CR stretching routine presented for the lat- side of the body.
Sartorius
Iliotibial
band
Figure 7-30
Figure 7-31
Figure 7-32A
Third Repetition:
■ Beginning from the position of stretch reached at the end 7.5 PRACTICAL APPLICATION
of the second repetition, have the client again contract the
target musculature isometrically for approximately 5 to Transitioning to Multiplane Contract Relax
8 seconds against your resistance, this time with as much Stretching: Hip Joint Abductor Functional Group
force as is comfortable for the client. Transitioning the CR stretching protocol for the hip
■ As soon as the client relaxes, gently increase the stretch of joint abductor functional group into a multiplane stretch
the client’s target musculature by moving the thigh farther that incorporates another plane of motion can be done
into adduction until you meet tissue resistance. by altering the position and/or direction of movement
■ If desired, a fourth repetition can be done. of the client’s thigh. The accompanying figure demon-
■ Hold the position of stretch of the last repetition for strates transverse plane lateral rotation added into the
approximately 10 seconds or more. frontal plane adduction of the thigh; this is accomplished
■ When the stretching routine is complete, ask the client by presetting the lateral rotation of the thigh and then
to completely relax the thigh as you passively return it to stretching it down into adduction. This multiplane stretch
the table. focuses the stretch toward the abductor musculature that
also does medial rotation, such as the TFL and anterior
Left-Side Abductor Group: fibers of the gluteus medius and minimus. Differing de-
■ Repeat for the pelvis/hip joint abductor functional group grees of sagittal plane flexion/extension can also be com-
on the left side of the body (Fig. 7-34). bined with the frontal plane stretch into adduction.
Figure 7-34
Figure 7-35 shows the functional group of muscles that adduct Starting Position:
the right thigh at the hip joint. These muscles are located on ■ Have the client supine toward the right side of the table.
the medial side of the pelvis and thigh, crossing the hip joint Her right hip joint is abducted and laterally rotated at
between them. As with all stretches for hip joint musculature, the hip joint, and her right leg is flexed at the knee joint;
it is extremely important that the pelvis is completely stabi- her right foot is placed on your left ASIS (Fig. 7-36).
lized. Following is the CR stretching routine shown for the hip (Note: If the client’s adductor musculature is tight, it is
adductor functional group on the right side of the body. likely that she will need to also flex the right thigh at the
hip joint to attain this position.)
Pectineus
Adductor
longus
Adductor
magnus
Gracilis
Figure 7-36
Figure 7-38A
Figure 7-37A
The client must attempt to isometrically contract
■ Now lean in with your pelvis against the client’s foot, fur- upward against both your resistance and gravity.
ther stretching the client’s thigh into abduction. Because Therefore, it is important to ask for only a gentle
of the position of the client’s thigh, this focuses the stretch contraction on the part of the client. Further,
to the more posteriorly oriented fibers of the adductor because gravity is assisting your stretching force, it is
important that you use extra caution when adding to the
group. During this stretch, the pelvis will tend to depress
force of the postcontraction stretch.
on the left side (and elevate on the right side), so your
stabilization pressure must be oriented toward elevation
of the left side of the pelvis (Fig. 7-37B).
Figure 7-37B
Figure 7-39B
Figure 7-38B
Third Repetition:
Second Repetition: Client Contraction: ■ Beginning from the position of stretch reached at the end
■ Beginning from the position of stretch reached at the end of the second repetition, have the client again contract the
of the first repetition, now have the client contract the target musculature isometrically for approximately 5 to
target musculature isometrically for approximately 5 to 8 seconds, this time, pressing both her thigh against the
8 seconds, this time, gently pressing her foot against the resistance of your hand and her foot against the resistance
resistance of your pelvis (Fig. 7-39A). of your pelvis (Fig. 7-40). The client can isometrically con-
tract with moderate force this time.
■ As soon as the client relaxes, gently increase the stretch of
the client’s target musculature by using your left hand to
move the client’s thigh farther into horizontal abduction
and leaning in with your pelvis to further abduct her thigh
until you meet tissue resistance.
Figure 7-39A
Figure 7-40
Iliacus
Starting Position:
■ Have the client supine as far to the right side of the table
as possible.
■ Stand to the right side of the client.
■ Your right hand is the treatment hand and will be placed
on the anterior surface of the client’s distal right thigh.
Initially, to bring her thigh over and off the side of the
table, your right hand will need to be under (on the poste-
Figure 7-42 Note: Not all muscles are seen. rior side of the thigh).
■ Your left hand is the stabilization hand and is placed on
the client’s left ASIS. Note: A cushion is used to spread out
and soften the contact pressure on the client (Fig. 7-43).
Figure 7-43
Figure 7-44
First Repetition: Client Contraction: The client must attempt to isometrically contract
■ With the client in the initial stretch position, ask the cli- upward against both your resistance and gravity.
ent to perform a gentle isometric contraction of the target Therefore, it is important to ask for only a gentle
muscles for approximately 5 to 8 seconds (in an attempt contraction on the part of the client. This is
to flex the thigh back up toward the table) against your especially true if the client’s thigh is stretched far toward the
resistance (Fig. 7-45A). floor into extension and therefore biomechanically weaker
and less able to contract with much force. Further, because
■ Ask the client to relax.
gravity is assisting your stretching force, it is important that
■ Note that the breathing protocol for every repetition is you use extra caution when adding to the force of the
to have the client either hold the breath or exhale when postcontraction stretch.
contracting against your resistance.
Note: When the stretching routine is completed, be sure to
ask the client to completely relax the thigh as you passively
return it to the table.
Figure 7-45A
Figure 7-45B
Third Repetition:
■ Beginning from the position of stretch reached at the end 7.6 PRACTICAL APPLICATION
of the second repetition, have the client again contract the
target musculature isometrically for approximately 5 to Transitioning to Multiplane Contract Relax
8 seconds against your resistance, again with moderate Stretching: Hip Joint Flexor Functional Group
force if it is comfortable for the client. Transitioning the CR stretching protocol for the hip joint
■ As soon as the client relaxes, gently increase the stretch of flexor functional group into a multiplane stretch that
the client’s target musculature by moving the thigh farther incorporates other planes of motion can be done by al-
into extension until you meet tissue resistance. tering the position and/or direction of movement of the
■ If desired, a fourth repetition can be done. client’s thigh. The accompanying figure demonstrates
■ Hold the position of stretch of the last repetition for frontal plane abduction and transverse plane lateral rota-
approximately 10 seconds or more. tion added into the sagittal plane extension of the thigh.
■ When the stretching routine is complete, ask the client This focuses the stretch toward the flexors that are also
to completely relax the thigh as you passively return it to adductors and medial rotators, such as the pectineus and
the table. adductors longus and brevis. This is accomplished by pre-
setting the abduction and lateral rotation of the thigh and
Left-Side Flexor Group: then stretching it down into extension. This stretch can
■ Repeat for the pelvis/hip joint flexor functional group on also be considered a multijoint stretch if the knee joint
the left side of the body (Fig. 7-47). is involved. If the client’s leg at the knee joint is flexed
while the thigh is extended at the hip joint, multiple joints
are involved, and the stretch is focused toward the rectus
femoris muscle.
Figure 7-47
Contract Relax Stretching of the Hip Flexors at the End of the Table
It is also possible to perform CR stretching of the hip flexor resistance and gravity. This protocol can then be repeated
functional group with the client at the end of the table. Fol- for the client’s left side.
lowing is the protocol for the hip flexor group on the right
side of the body. Ask the client to stand facing away from
the end of the table, place her tailbone (coccyx) at the top
of the table, and lean back onto the table to lie supine, hug-
ging her left thigh into her chest. You stand facing the cli-
ent at the end of the table, placing your right hand on her
distal posterior left thigh to assist in stabilizing her body;
her left foot can be placed on your right clavicle to further
assist stabilization. Your left hand is placed on her distal
anterior right thigh. To perform the stretch, gently drop
down with body weight, pushing her right thigh into exten-
sion. The CR protocol of client isometric contraction and
postcontraction stretch would then be performed from this
position. Similar to the side of table hip flexor stretch, use
caution because the client must contract against both your
View the video “Contract Relax Stretching of the 7.8 PRACTICAL APPLICATION
Hamstring Group” online on thePoint.lww.com
Transitioning to Multiplane Contract Relax
Figure 7-48 shows the hamstring muscles on the right side. Stretching: Hip Joint Extensor—Hamstring Group
They are located in the posterior thigh, crossing from the
Transitioning the CR stretching protocol for the hamstring
pelvis to the proximal leg. The hamstrings are hip extensor
group into a multiplane stretch that incorporates other
muscles because they cross the hip joint posteriorly with a
planes of motion can be done by altering the position and/
vertical orientation to their fibers. However, unlike the glu-
or direction of movement of the client’s thigh. The accom-
teal muscles, which also cross the hip joint posteriorly with
panying figure demonstrates frontal plane adduction and
somewhat of a vertical orientation to their fibers, the ham-
transverse plane lateral rotation added into the sagittal
strings also cross the knee joint posteriorly; therefore, they
plane flexion of the thigh; this is accomplished by presetting
also flex the knee joint. This is important to know when
the lateral rotation of the thigh and then stretching it into
stretching them. CR stretching routine of the hamstring
flexion and adduction. As discussed with other multiplane
group was demonstrated in the “Overview of Technique”
CR stretches, multiplane stretching can involve motion
section, Figures 7-1 through 7-6.
in all three cardinal planes, so both frontal and transverse
plane motion can be added to the sagittal plane flexion of
the thigh. Each cardinal plane component that is involved
The Hamstring Group focuses the stretch toward specific aspects of the hamstring
This group comprises the following muscles: musculature. Note: Whenever stretching the hamstring
Biceps femoris group across the hip joint, whether it is purely into sagit-
tal plane flexion or a multiplane stretch that involves other
Semitendinosus
planes of motion, the knee joint must be kept extension.
Semimembranosus
Semitendinosus
Semimembranosus
Biceps femoris
Figure 7-48
Figure 7-49 shows the functional group of gluteal muscles on Starting Position:
the right side of the body. These muscles are located in the ■ Have the client supine toward the right side of the table
posterior pelvis in the buttock region and cross the hip joint with her right hip and knee joints in flexion.
between the pelvis and thigh. The gluteal muscles are exten- ■ Position yourself at the right side of the table.
sors of the hip joint as are the hamstrings (see Routine 7-10). ■ Both of your hands are treatment hands, grasping the
The difference is that the hamstrings cross the knee joint pos- client’s distal posterior right thigh.
teriorly, whereas the gluteals do not cross the knee joint. So ■ Your right leg/knee is the stabilization contact and is
to most efficiently stretch the gluteals, the knee joint is flexed placed on the client’s left anterior thigh to stabilize her
to slacken and knock the hamstrings out of the stretch. pelvis (Fig. 7-50A).
Following is the CR stretching routine shown for the glu-
teal group on the right side of the body. Note: The gluteus
medius and minimus also have middle and anterior fibers
that are located laterally and anteriorly in the pelvis/thigh
region. These fibers are stretched with Routines 7-7 and 7-9,
respectively. Routine 7-11 presented here stretches the pos-
terior fibers of the gluteal group.
Figure 7-50A
Gluteus maximus
Figure 7-50B
Figure 7-51
Figure 7-52A
Figure 7-52B
Figure 7-53A
Figure 7-53B
Figure 7-55 shows the functional group of deep lateral rota- Starting Position:
tor muscles on the right side of the body. These muscles are ■ Have the client supine toward the left side of the table.
located in the posterior pelvis in the buttock region, deep ■ Position yourself at the left side of the table.
to the gluteus maximus, and cross the hip joint between the ■ Flex the client’s right hip and knee joints into flexion and
pelvis and thigh. Note: The posterior capsular ligament of the then horizontally adduct the right thigh at the hip joint and
hip joint (ischiofemoral ligament) is stretched with medial trap the client’s right knee between your trunk and right
rotation, as are the deep lateral rotator muscles. Therefore, arm, in other words, under your right axillary region.
the stretching protocol presented here for the deep lateral ■ No stabilization hand is necessary; the client’s body weight
rotators is also very effective at stretching and loosening a and contact with the table, as well as the direction that you
taut posterior hip joint capsule. Following is the CR stretch- move her thigh, stabilize her pelvis (Fig. 7-56).
ing routine shown for the deep lateral rotator group on the ■ Using core body weight, gently lean into the client, bring-
right side of the body. ing her thigh down and across her chest, farther into hori-
zontal adduction. Be sure that the client’s pelvis remains
stabilized down onto the table.
The Deep Lateral Rotator Group
This functional group comprises the following muscles:
Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Obturator externus
Quadratus femoris
Figure 7-56
Piriformis
7.10 PRACTICAL APPLICATION
Superior
gemellus Deep Lateral Rotator Stretch and Groin Pain
The direction that you move the client’s thigh during CR
Obturator
internus
stretching of the deep lateral rotator group is extremely
important. If the direction is too horizontal (parallel
Inferior
gemellus
with the table), the client’s pelvis will no longer be sta-
bilized and will lift from the table, causing the stretch to
Quadratus
femoris
travel into the LSp and be lost to the target musculature
of the pelvis. However, if you press the client’s thigh
too downward into their body, it may compress the
anterior hip joint region (groin) and cause discomfort
Figure 7-55 Note: The obturator externus is not seen. or pain for the client. The ideal balance between these
two directions will vary from client to client. If it is not
possible to find an angle that both stabilizes the client’s
pelvis and keeps the client pain-free, then you can use
your hands to grasp the client’s proximal femur and
soft tissue of the proximal thigh and traction the thigh
away from the pelvis (see figure in Practical Application
Box 6.6). This often removes the pinching discomfort/
pain that some clients experience.
Figure 7-57
Figure 7-58A
Figure 7-59B
Figure 7-60
Contract Relax Stretching of the Deep Lateral Rotators Using the “Figure 4” Stretch
It is also possible to perform CR stretching of the deep lat- her pelvis. Using core body weight, gently lean forward into
eral rotator functional group using the Figure 4 stretch (see the client, pressing equally with both hands and bringing
Routine 6-10 in Chapter 6 for more details on this stretch). her laterally rotated right thigh farther into flexion, in other
Following is the protocol for this stretch on the right side words, down toward her chest (Fig. A). Be sure that the
of the body. direction of your pressure is such that the client’s pelvis
Have the client supine toward the right side of the remains stabilized down onto the table.
table and position yourself at the right side of the table. The CR protocol of client isometric contraction and
Alternately, the client can lie at the center of the table, and postcontraction stretch would then be performed from
you can climb onto the table to be centered at the midline this position. When the client contracts, be sure that her
of the client. Flex and laterally rotate the client’s right hip contraction is of the target muscles in the right posterior
joint, flex her right knee joint, and place her distal right leg buttock against the resistance of your left hand; in other
on her flexed left thigh (forming the Figure 4 position for words, she should not be pressing against your right
which the stretch is named). Both of your hands are treat- hand contact that is on her left posterior thigh. If desired,
ment hands: Place your left hand on the posterolateral sur- this protocol can be performed without the involvement
face of her distal right thigh and place your right hand on of the client’s left thigh, in which case, you would place
the posterior surface of her distal left thigh. No stabilization both treatment hands on the client’s right lower extrem-
hand is necessary; the client’s body weight and contact with ity (Fig. B). This protocol can then be repeated for the
the table, as well as the direction that you press, stabilize client’s left side.
A B
Figure 7-62
Initial Client Stretch: Using the client’s leg to create lateral rotation of the
■ Begin by gently stretching the client’s target (hip joint hip joint to stretch the medial rotators means that
medial rotator) musculature by moving the client’s leg force will be placed through his or her knee joint.
medially toward the opposite side of his body until you If the client’s knee joint is unhealthy and this stretch
meet tissue resistance, beginning the stretch of the target causes pain or discomfort, this stretching protocol is
medial rotator muscles (Fig. 7-63). contraindicated.
Figure 7-63
Figure 7-65B
Figure 7-66
CHAPTER SUMMARY allows the therapist to stretch the target muscle farther
afterward.
CR stretching is an advanced stretching technique that can ■ The client usually holds the isometric contraction for 5 to
often provide the key to helping clients with tight muscles 8 seconds; three to four repetitions are typically done.
and fascial adhesions. Although the exact manner in which ■ The client may either hold the breath or exhale when per-
the technique is performed can vary, it is most commonly forming the isometric contraction.
carried out in the following manner:
Essentially, any stretch can be carried out using the CR
■ After the client is prestretched, the client contracts the tar- technique. As with all stretching, CR stretching is most ef-
get muscle isometrically to trigger the GTO reflex, which fective when the client’s tissues have been warmed up first.
CASE STUDY
NATASHA leg raise, cough test, and Valsalva maneuver are all nega-
tive (for a review of assessment procedures, see Chapter
■ History and Physical Assessment
3). Palpation assessment reveals marked spasming of her
A new client, Natasha Rivera, age 24 years, comes to your entire lumbar paraspinal (erector spinae and transverso-
office complaining of low back pain and tightness. She tells spinalis) musculature bilaterally, with the tightness great-
you that she was moving boxes at home the day before, and est on the right side, at the midlumbar region. The tone of
when she bent down to pick up one of the boxes, her low all other trunk and pelvis musculature is within normal
back went into spasm. She indicates that the pain is located limits.
bilaterally in her lumbar region but slightly more intense on
the right side. There is no pain into her lower extremities. ■ Think-It-Through Questions:
On a scale of 0 to 10, she reports that the pain is 4 to 5 when 1. Should an advanced stretching technique such as CR
she is lying down, 6 when she stands, 7 when she sits, and a stretching be included in your treatment plan for Natasha?
9 if she tries to move. The client history reveals no previous If so, why? If not, why not?
incidence of low back pain or trauma in her past. 2. If CR stretching would be of value, is it safe to use with
Because Natasha is so acute, you abbreviate your her? If yes, how do you know? If not, why not?
physical exam and eliminate range of motion assessment 3. If CR stretching is done, which specific stretching rou-
so as to not aggravate her condition. You perform active tines should be done? Why did you choose the ones you
and passive straight leg raise tests as well as cough and did?
Valsalva to rule out a space-occupying lesion and to de-
termine if the injury is a strain or sprain. Active straight Answers to these Think-It-Through Questions and the
leg raise is positive for local lumbar pain bilaterally at ap- Treatment Strategy employed for this client are available
proximately 45 degrees of thigh flexion. Passive straight online at thePoint.lww.com/MuscolinoLowBack
CHAPTER OUTLINE
OBJECTIVES
After completing the chapter, the student should be able to: 5. Describe the added benefits to the AC stretching technique of being
1. Describe the mechanism of agonist contract (AC) stretching. a form of dynamic stretching.
2. Describe in steps an overview of the usual protocol for carrying out 6. Explain why stretching should never be performed too fast or too far.
the AC stretching technique. 7. Define each key term in the chapter and explain its relationship to
3. Describe the roles of the treatment hand and the stabilization hand. the AC stretching technique.
4. Describe the usual breathing protocol for the client during the AC 8. Perform the AC stretching technique for each of the 13 groups of
stretching technique. muscles presented in the chapter.
KEY TERMS
active isolated stretching (AIS) creep reciprocal inhibition (RI) stretching hand
agonist contract (AC) stretching dynamic stretching stabilization hand treatment hand
assisted AC stretching muscle spindle reflex stretch reflex unassisted AC stretching
INTRODUCTION
BOX 8.1
Agonist contract (AC) stretching is another advanced stretch-
ing technique that involves a neurologic reflex to relax the Agonist Contract Routines
target muscle that is to be stretched. Whereas contract relax
(CR) stretching (covered in Chapter 7) has classically been The following AC stretching routines are presented in the
stated as utilizing the neurologic reflex known as the Golgi chapter:
■ Section 1: lumbar spine (LSp) agonist contract routines:
tendon organ reflex, AC stretching utilizes the neurologic
■ Routine 8-1—LSp extensors
reflex known as reciprocal inhibition (RI).
■ Routine 8-2—LSp flexors
■ Routine 8-3—LSp right lateral flexors
■ Routine 8-4—LSp left lateral flexors
■ Routine 8-5—LSp right rotators
■ Routine 8-6—LSp left rotators
■ Section 2: hip joint/pelvis agonist contract routines:
■ Routine 8-7—hip abductors
■ Routine 8-8—hip adductors
■ Routine 8-9—hip flexors
■ Routine 8-10—hip extensors: hamstrings
Note: In the Technique and Self-Care chapters of this book (Chapters 4
to 12), green arrows indicate movement, red arrows indicate stabiliza- ■ Routine 8-11—hip extensors: gluteals
tion, and black arrows indicate a position that is statically held. ■ Routine 8-12—hip deep lateral rotators
■ Routine 8-13—hip medial rotators
264
BOX 8.2
Antagonist
inhibited
Inhibitory Mover
signal stimulated
Facilitatory
signal )–(
)+(
■ As the client begins to flex the right thigh up into the air,
you need to lean in and position yourself to stabilize the
Starting Position: client’s pelvis by placing your right hand on the distal
■ The client is supine and positioned as far to the right side anterior surface of the client’s left thigh (Fig. 8-2). It is
of the table as possible; you are standing at the right side important to make sure that the client’s pelvis is stabi-
of the table (Fig. 8-1). lized before the client reaches the end of thigh flexion;
■ When the client begins the AC protocol, he will flex his
otherwise, the pelvis will move into posterior tilt, and the
right thigh at the hip joint, so it is important to not lean stretch of the right hamstrings will be lessened.
over the table or you might be hit by the movement of the ■ An alternate contact to stabilize the client’s pelvis is to use
client’s thigh. Having said that, it is important to be close your right knee (Fig. 8-3).
so that you can immediately lean in to both stretch the ■ It is also important to lean in quickly so that you can make
client’s thigh and stabilize the client’s pelvis. sure that the client’s right knee joint remains extended
and also to be in position to further stretch the client dur-
Step 1: Client Contraction and Stretch: ing the next step of the routine.
■ Have the client perform active concentric contraction of
■ The client flexing the right thigh begins the stretch of the
the flexors of the right thigh at the hip joint, bringing the target muscles (the hamstrings) and also engages the RI
thigh into flexion as far as is comfortably possible; it is reflex, relaxing the target muscles that are antagonistic to
important that the client maintains his knee joint in full the joint action.
extension. ■ The breathing protocol for this step is to have the client
exhale while actively moving the thigh.
Figure 8-4 Step 2: Further stretch of client. Figure 8-5 Passively return client to starting position.
PERFORMING THE TECHNIQUE nique than the CR technique. Gravity, and therefore client
positioning, is irrelevant with the CR technique because the
When performing AC stretching, it is important to keep the therapist provides the resistance for the client’s contraction,
following guidelines in mind. Each point addresses a specific whereas AC stretching requires the consideration of gravity,
aspect of the AC stretching technique. Understanding and so most AC protocols position the client so that the contrac-
applying these guidelines will aid in more effectively per- tion and motion are up against gravity.
forming AC stretches.
it is still usually necessary to remove the stabilization hand an AC repetition is performed within a time frame of 3 to 5
from its stabilization position to assist the treatment hand in seconds, it is important to begin each successive repetition
supporting and returning the client’s body part back to the immediately at the conclusion of the previous repetition.
starting position (step 3) for the next repetition. This is a point at which time is often wasted. As soon as you
return a client back to the starting position at the end of a
The placement of the treatment and stabilization hands repetition, the client should learn to begin his or her active
often requires your wrist joint to be extended. For the movement immediately for the next repetition without your
health of your wrists, your point of contact through having to repeat the instruction every time.
which pressure is transmitted into the client should be
the heel of your hand (the carpal region). If you direct the
pressure through your palm or fingers, you may hyperextend
and injure your wrist. Given how vulnerable the wrist joint
can be, proper biomechanical positioning of the hand/wrist is 8.6 THERAPIST TIP
crucially important.
Pace Yourself
8.9 Breathing Accomplishing an AC repetition within the recommended
3 to 5 seconds can be difficult for the therapist and/or cli-
The usual breathing protocol for AC stretching is to have the ent who are first learning and practicing the technique.
client exhale while actively moving the body part. A mne- As a result, therapists and clients often feel rushed when
monic device that can help you remember the breathing AC stretching is first introduced. Although AC stretching
protocol is “exhale on exertion” because both begin with the is usually performed at a moderate pace, it should never
letter “e.” Having the client exhale when actively contracting feel rushed to the therapist or the client. Having a sense of
the agonist muscles to create the joint action also works very urgency is likely to cause anxiety and result in the client’s
well logistically when AC stretching is combined with the tightening up, which is counterproductive to effective
CR stretching technique to perform contract relax agonist stretching. As you are first learning the technique, take a
contract (CRAC) stretching (see Chapter 9). little more time if needed to perform each repetition until
The client usually completes the exhalation as the target you have gained a sense of proficiency.
musculature is relaxed and you stretch it; the client then
inhales as you return the client to the starting position for
the next repetition. If the client has already completed the
exhalation while contracting and moving, the client can begin 8.11 Direction of Stretch
the inhalation when relaxing and being further stretched
and then complete the inhalation while being returned to When AC stretching is performed, the client’s motion can
the starting position for the next repetition. What is most be carried out in a cardinal plane or in an oblique plane. The
important is that the client has completed inhaling once three cardinal planes are the sagittal, frontal, and transverse
you return him or her to the starting position in order to be planes. An oblique plane is any plane that is not perfectly
ready to exhale again during the exertion and movement of sagittal, frontal, or transverse; in other words, it has a compo-
the next repetition. If you find that the client has not exhaled nent of two or three cardinal planes (see Fig. 1-8 in Chapter 1
completely when a repetition is finished, perhaps the client is for a review of planes). This chapter presents cardinal plane
inhaling too deeply. The inhalation at the beginning of each AC stretches in the routines, with numerous multiplane/
repetition should not be too deep. oblique AC stretches discussed and demonstrated in Practi-
It often takes a little while for the client to become cal Application boxes.
accustomed to the AC stretching breathing protocol.
However, once the client is comfortable and familiar with 8.12 Electric Lift Table
the breathing protocol, the repetitions proceed smoothly.
As discussed in Chapters 6 and 7, when stretching the low
8.10 Flow of Repetitions back and pelvis/hip joint, the value of an electric lift table for
optimal body mechanics cannot be overstated. Most AC rou-
As mentioned previously, an entire repetition, consisting of tines for the low back and pelvis/hip joint require the table to
client movement, further stretch, and return to the starting be low. If the table was higher for the performance of other
position to be ready to begin the next repetition, should take manual therapy techniques, having an electric lift table so
only 3 to 5 seconds. The means that a set of 10 repetitions can that table height can be easily adjusted for AC stretching is
be accomplished in less than 1 minute. To help ensure that essential for efficient clinical orthopedic work.
ROUTINES
AGONIST CONTRACT ROUTINES joint extensors has already been shown in the “Overview of
Technique” section. For all the other routines, the follow-
The routines that follow demonstrate 13 different applica- ing steps are explained and illustrated: client contraction and
tions of AC stretching to the low back and pelvis/hip joint. stretch, further stretch of client, and passively return client
They are organized according to the functional groups of to starting position. An explanation is then given on how to
muscles being stretched. The routine for the hamstring hip perform further repetitions.
Figure 8-6 shows the functional group of muscles that extend Starting Position:
the LSp. These muscles are located on the posterior side of ■ The client is supine toward the right side of the table with
the trunk in the lumbar region. The AC stretching routine the hip and knee joints flexed. You are standing on the
presented here is essentially the double knee-to-chest stretch right side of the table (Fig. 8-7A).
that is presented in Chapter 11 (Self-Care Routine 11-6;
available online at thePoint.lww.com), with the AC stretch-
ing protocol added.
Figure 8-7A
Iliocostalis
Quadratus
lumborum
Figure 8-6
Figure 8-7B
Step 1: Client Contraction and Stretch: Step 3: Passively Return Client to Starting Position:
■ Begin by asking the client to actively bring her knees ■ Once you have completed step 2, the client remains
toward her chest (move the pelvis into posterior tilt and relaxed as you support and passively bring her trunk and
the LSp into flexion) as far as is comfortable. pelvis back to the starting position.
■ This begins the stretch of the lumbar extensor muscles ■ When you are bringing the trunk and pelvis back down to
(target muscle group) (Fig. 8-8A). the table, it is important that you support the client com-
fortably but securely so that the client feels safe enough
to relax her body weight into your hands, allowing you to
move the client passively (Fig. 8-8C).
Figure 8-8A
Figure 8-8B
A B
Starting Position:
■ The client is prone with her hands clasped behind her
head. You are seated on the client’s buttocks. Note the
placement of the cushion for client and therapist modesty
and comfort (Fig. 8-10).
Rectus
abdominis
Caution must be exercised when performing these Step 2: Further Stretch of Client:
stretches for the anterior abdominal wall. ■ Once the position of stretch at the end of step 1 is reached,
■ Bringing the client’s LSp into extension approximates the client relaxes, and you further stretch the client’s tar-
the facet joints and narrows the intervertebral get flexor musculature by gently pulling up on the client’s
foramina and is therefore contraindicated if the client arms, bringing the trunk farther into extension until you
has facet syndrome or a space-occupying lesion, such as meet tissue resistance (Fig. 8-11B).
pathologic disc or a large bone spur.
■ Hold the position of stretch for 1 to 2 seconds.
■ The client’s glenohumeral joints must be healthy enough
to reach behind him or her and have a pulling force placed
through them.
■ How you position your body weight on the client’s buttocks
is important. If you sit too far superiorly on the pelvis, it
can push it into anterior tilt, increasing the client’s lumbar
lordosis. If you sit too far inferiorly, the pelvis will not be
securely stabilized.
Figure 8-11B
Figure 8-11A
Figure 8-11C
Further Repetitions:
■ Repeat this procedure for each repetition.
■ With each successive repetition, you can add slightly more
pressure to the stretch.
■ At the end of the last repetition (usually 8 to 10 repetitions
are done), you may choose to hold the position of stretch
for a longer period, 5 to 20 seconds or more.
■ Note that the breathing protocol is for the client to exhale
when concentrically contracting.
■ The client continues exhaling as the target musculature is
relaxed and you stretch it, and then inhales as you return
the client to the starting position for the next repetition.
Figure 8-12 shows the functional group of muscles that right Starting Position:
laterally flex the LSp. These muscles are located on the right ■ Have the client seated at the right end of the table with
side of the trunk in the lumbar region. her arms crossed so that her hands are on the opposite
shoulders.
■ Stand to the right side of the client.
The Lumbar Spine Right Lateral Flexor Functional Group ■ Your left hand is the treatment hand and will be placed on
the client’s right upper trunk.
This functional group comprises the following right- ■ Your right hand is the stabilization hand and functions
sided muscles: to stabilize the client’s pelvis. It is placed across the top of
Erector spinae group the client’s right iliac crest or on the anterior surface of the
Transversospinalis group client’s proximal right thigh; if desired, a cushion can be
Quadratus lumborum
used for comfort to broaden the pressure of the stabiliza-
tion contact (Fig. 8-13).
Rectus abdominis
External abdominal oblique
Internal abdominal oblique
Psoas major
Psoas minor
External
abdominal
oblique
Internal
abdominal
oblique
Psoas
major
Figure 8-13
Figure 8-14B
Figure 8-14A
Figure 8-14C
Figure 8-15 shows the functional group of muscles that left laterally flexes the LSp. These muscles
are located on the left side of the trunk in the lumbar region. To use AC stretching to stretch this
functional group of muscles, follow the directions given in Figures 8-13 through 8-14 to stretch
the right lateral flexor group but switch for the left side of the body.
External
abdominal
oblique
Internal
abdominal
oblique
Psoas
major
Semispinalis
External Spinalis
abdominal
oblique Longissimus
Multifidus
Internal Iliocostalis
abdominal
oblique
A B
Figure 8-18A
Figure 8-17
Step 2: Further Stretch of Client: Step 3: Passively Return Client to Starting Position:
■ Once the position of stretch at the end of step 1 is reached, ■ Once you have completed step 2, the client remains
the client relaxes, and you further stretch the client’s tar- relaxed as you support and passively bring her trunk back
get right rotator musculature by gently pushing the client to the starting position (Fig. 8-18C).
farther into left rotation until you meet tissue resistance
(Fig. 8-18B).
■ Hold the position of stretch for 1 to 2 seconds.
Figure 8-18C
Further Repetitions:
Figure 8-18B ■ Repeat this procedure for each repetition.
■ With each successive repetition, you can add slightly more
pressure to the stretch.
■ At the end of the last repetition (usually 8 to 10 repetitions
are done), you may choose to hold the position of stretch
for a longer period, 5 to 20 seconds or more.
■ Note that the breathing protocol is for the client to exhale
when concentrically contracting.
■ The client continues exhaling as the target musculature is
relaxed and you stretch it, and then inhales as you return
the client to the starting position for the next repetition.
Semispinalis
External Spinalis
abdominal
oblique Longissimus
Multifidus
Internal Iliocostalis
abdominal
oblique
A B
A B
Starting Position:
■ Have the client supine toward the left side of the table. Her 8.7 PRACTICAL APPLICATION
right thigh is slightly medially rotated at the hip joint, and
her right leg is extended at the knee joint. Her left thigh is Stabilizing the Pelvis
also slightly medially rotated at the hip joint. One of the biggest challenges to performing AC stretch-
■ Stand to the left side of the client. ing of the musculature of the client’s hip joint is securely
■ Your left hand is the treatment hand and will be placed on stabilizing the client’s pelvis. One extremely efficient way
the lateral side of the client’s right leg. to stabilize the client’s pelvis is to use a strap or seat belt
■ Your right hand is the stabilization hand and functions that is wrapped around the table and on his or her pelvis,
to stabilize the client’s pelvis. It is placed on the client’s with a cushion used to broaden the pressure for client
left thigh; holding the client’s left thigh in medial rotation comfort. See Practical Application Box 6.3.
improves the pelvic stabilization. A cushion can be used
for client comfort (Fig. 8-21).
Step 1: Client Contraction and Stretch:
■ Begin by asking the client to actively adduct and slightly
flex her right thigh across her body as far as is comfortable.
■ This begins the stretch of the right abductor muscles
(target muscle group) (Fig. 8-22A).
Figure 8-21
Figure 8-22A
Step 2: Further Stretch of Client: Step 3: Passively Return Client to Starting Position:
■ Once the position of stretch at the end of step 1 is reached, ■ Once you have completed step 2, the client remains re-
the client relaxes, and you further stretch the client’s tar- laxed as you support and passively bring her thigh back to
get abductor musculature by gently pulling the client the starting position (Fig. 8-22C).
farther into adduction until you meet tissue resistance
(Fig. 8-22B).
■ Hold the position of stretch for 1 to 2 seconds.
Figure 8-22C
Further Repetitions:
■ Repeat this procedure for each repetition.
■ With each successive repetition, you can add slightly more
pressure to the stretch.
■ At the end of the last repetition (usually 8 to 10 repetitions
are done), you may choose to hold the position of stretch
for a longer period, 5 to 20 seconds or more.
■ Note that the breathing protocol is for the client to exhale
when concentrically contracting.
■ The client continues exhaling as the target musculature is
relaxed and you stretch it, and then inhales as you return
the client to the starting position for the next repetition.
■ Note: Because the stretch involves flexion of the thigh an-
teriorly in front of the body, it preferentially stretches the
abductors that are also extensors located posteriorly, such
as posterior fibers of the gluteus medius and minimus and
upper fibers of the gluteus maximus. Medial rotation of
the thigh was added because these abductor and exten-
sor muscles are also lateral rotators. Given the multiple
planes of movement, this stretching routine is a multi-
plane stretch.
Figure 8-23
B C
Starting Position:
■ Have the client supine toward the right side of the table.
■ Stand to the right side of the client (Fig. 8-25).
■ Your right hand is the treatment hand and will be placed
on the medial side of the client’s distal right leg.
■ Your left hand is the stabilization hand and functions to
stabilize the client’s pelvis and other (left) thigh. It will be
placed on the client’s anteromedial left thigh.
Figure 8-25
Figure 8-26B
Figure 8-26C
Further Repetitions:
■ Repeat this procedure for each repetition. 8.9 PRACTICAL APPLICATION
■ With each successive repetition, you can add slightly more
pressure to the stretch. Multiplane Stretching of the Hip Joint Adductors
■ At the end of the last repetition (usually 8 to 10 repetitions The AC stretching protocol for the adductors of the hip
are done), you may choose to hold the position of stretch joint can be transitioned into a multiplane stretch. Fol-
for a longer period, 5 to 20 seconds or more. lowing are AC multiplane stretches of the adductors on
■ Note that the breathing protocol is for the client to exhale the right side: Instead of having the client only abduct his
when concentrically contracting. thigh, ask him to abduct and flex or to abduct and extend;
■ The client continues exhaling as the target musculature is because extension of the thigh is downward with gravity,
relaxed and you stretch it, and then inhales as you return be sure to instruct him to actively create this motion with
the client to the starting position for the next repetition. muscular contraction. Adding thigh flexion would focus
the stretch on the posterior adductor musculature fibers;
Left-Side Adductor Group: adding thigh extension would focus the stretch on the an-
■ Repeat for the pelvis/hip joint adductor functional group terior adductor musculature fibers. Lateral rotation can
on the left side of the body (Fig. 8-27). also be added to increase the stretch for the adductors. If
the knee joint is extended, the gracilis will be maximally
stretched because it is knee joint flexor; if the knee joint is
bent, the gracilis will be knocked out of the stretch, per-
haps allowing other adductor muscles to be maximally
stretched. The accompanying figure shows flexion and
lateral rotation in addition to abduction.
Figure 8-27
Starting Position:
■ Have the client prone toward the right side of the table.
■ Stand to the right side of the client (Fig. 8-29).
■ Your left hand is the treatment hand and will be placed on
the anterior side of the client’s right thigh.
■ Your right hand is the stabilization hand and functions to
stabilize the client’s pelvis. It will be placed on the client’s
right posterior superior iliac spine (PSIS).
Figure 8-29
Step 1: Client Contraction and Stretch: Step 3: Passively Return Client to Starting Position:
■ Begin by asking the client to actively extend his right thigh ■ Once you have completed step 2, the client remains re-
as far as is comfortable. laxed as you support and passively bring his thigh back to
■ This begins the stretch of the right flexor muscles (target the starting position (Fig. 8-30C).
muscle group) (Fig. 8-30A).
Figure 8-30C
Figure 8-30A
Further Repetitions:
Step 2: Further Stretch of Client: ■ Repeat this procedure for each repetition.
■ Once the position of stretch at the end of step 1 is reached, ■ With each successive repetition, you can add slightly more
the client relaxes, and you further stretch the client’s tar- pressure to the stretch.
get flexor musculature by gently pulling the client’s thigh ■ At the end of the last repetition (usually 8 to10 repetitions
farther into extension until you meet tissue resistance are done), you may choose to hold the position of stretch
(Fig. 8-30B). for a longer period, 5 to 20 seconds or more.
■ Hold the position of stretch for 1 to 2 seconds. ■ Note that the breathing protocol is for the client to exhale
when concentrically contracting.
■ The client continues exhaling as the target musculature is
relaxed and you stretch it, and then inhales as you return
the client to the starting position for the next repetition.
Figure 8-30B
Figure 8-31
A B
Biceps femoris
The Hamstring Group
The group comprises the following muscles:
Biceps femoris
Semitendinosus
Semimembranosus
Figure 8-32
■ Have the client flex his right thigh at the hip joint and flex
The Gluteal Group his right leg at the knee joint; his right foot will be flat on
This functional group comprises the following muscles: the table.
Gluteus maximus ■ Your left hand is the treatment hand and will be placed on
the posterior side of the client’s right thigh.
Gluteus medius
■ Your right hand is the stabilization hand and functions to
Gluteus minimus stabilize the client’s pelvis. It will be placed on the anterior
surface of the client’s left thigh.
■ An alternate stabilization contact is to use your right
knee on the anterior surface of the client’s left thigh
(see Fig. 8-3).
Figure 8-35D
Further Repetitions:
■ Repeat this procedure for each repetition.
■ With each successive repetition, you can add slightly more
pressure to the stretch.
■ At the end of the last repetition (usually 8 to 10 repetitions
are done), you may choose to hold the position of stretch
Figure 8-35B for a longer period, 5 to 20 seconds or more.
■ Note that the breathing protocol is for the client to exhale
Step 3: Passively Return Client to Starting Position: when concentrically contracting.
■ Once you have completed step 2, the client remains re- ■ The client continues exhaling as the target musculature is
laxed as you support and passively bring his thigh back to relaxed and you stretch it, and then inhales as you return
the starting position (Fig. 8-35C). the client to the starting position for the next repetition.
■ Note: As discussed in Chapter 6, if the client is asked to
bring the knee up to the chest and over to the opposite
of the body, making this a multiplane stretch, it begins to
resemble the stretch for the deep lateral rotators. Routine
8-12 demonstrates the AC stretching technique for the
deep lateral rotator group.
Figure 8-35C
Starting Position:
■ Have the client prone with her right leg flexed at the knee
joint.
■ Stand to the right side of the table (Fig. 8-38).
■ Your left hand is the treatment hand and will grasp around
the medial side of the client’s distal right leg.
■ Your right hand is the stabilization hand and functions to
stabilize the client’s pelvis. It is placed on the client’s left
PSIS.
Figure 8-38
Figure 8-39A
Figure 8-39B
Figure 8-39C
Figure 8-40
Alternate Agonist Contract Stretch for the Deep Lateral Rotator Group
The deep lateral rotator group can also be stretched with ■ Now ask the client to relax and you increase the stretch
the client lying supine with the hip and knee joints flexed. of the client’s deep lateral rotators by gently pushing her
If the client has an unhealthy knee joint, then her leg knee further toward her opposite shoulder (Fig. B).
should not be used as a lever to create the medial rotation ■ After holding the position for 1 to 2 seconds, passively
force to stretch the deep lateral rotators. Following is an bring the client’s thigh back to the starting position
alternative AC stretch for the deep lateral rotators that does (Fig. C).
not involve the client’s knee joint. This stretch is demon- ■ Repeat for a total of 8 to 10 repetitions.
strated and explained for the client’s right side. ■ Note: It is helpful to purposely change the angle that you
ask the client to bring the thigh up and across her body.
■ Have the client supine with her right hip and knee joints
After bringing the knee toward the opposite shoulder,
flexed and her foot flat on the table. You stand to her
instruct the client to change the angle to be more across
right side.
the body, in other words, less flexion and more horizon-
■ Begin by asking the client to actively bring her right knee
tal adduction. Each different angle within the quadrant
up and across her body toward the opposite shoulder by
between straight up toward the chest and directly hori-
further flexing and horizontally adducting her thigh at
zontally across her body will preferentially stretch differ-
the hip joint (Fig. A). This begins the stretch of the deep
ent fibers of the deep lateral rotator group.
lateral rotators and triggers the RI reflex to inhibit and
relax them.
A B C
Starting Position:
■ Have the client prone with her right leg flexed at the knee
joint.
■ Stand on the (opposite) left side of the table (Fig. 8-42).
■ Your left hand is the treatment hand and will grasp around
the posterior side of the client’s distal right leg.
■ Your right hand is the stabilization hand and functions to
stabilize the client’s pelvis. It will be placed on the client’s
right PSIS.
Figure 8-42
Figure 8-43A
Figure 8-43B
Figure 8-43C
Figure 8-44
A B
Agonist Contract Stretching of Both Functional Groups within a Plane in One Routine
It is not always necessary to perform AC stretching for Starting Position:
only one functional group at a time. In fact, it can be more ■ Have the client supine toward the right side of the table
efficient and beneficial to perform AC stretching for both with her thigh flexed at the hip joint and her leg flexed at
functional muscle groups within a plane—thereby stretch- the knee joint. Stand to the right of the client.
ing two target groups of muscles during the same proce-
dure. To do this, it is necessary that both functional group First Repetition: Client Contraction and Stretch of
actions can be performed with the same client position and Target Muscle Group #1:
that you can position yourself to be able to efficiently partic- ■ Begin by asking the client to actively move the thigh into
ipate in both stretching protocols with regard to your body medial rotation at the hip joint as far as is comfortable
mechanics. An example of this is stretching the client’s (Fig. A).
right hip joint musculature into medial rotation and lateral ■ This begins the stretch of the target lateral rotator mus-
rotation during the same procedure. cles (target muscle group #1).
When stretching the client’s right hip joint into medial
rotation, the lateral rotation group (the first target muscle Further Stretch of Client:
group) is stretched; when stretching the client’s right hip ■ When the position of stretch is reached at the end of the
joint into lateral rotation, the medial rotation group (the first repetition, the client relaxes, and you further stretch
second target muscle group) is stretched. This procedure the client’s target lateral rotator musculature by gently
begins similarly no matter the side to which the rotation moving the client’s thigh farther into medial rotation
stretch begins. The following example is shown on the cli- until you meet tissue resistance (Fig. B).
ent’s right side and is based on starting the stretch for the ■ Hold the position of stretch for 1 to 2 seconds.
lateral rotators. continued
A B
C D
■ Client body weight and contact with the table is usually Further Repetitions:
sufficient to stabilize the client’s pelvis and trunk during ■ All further repetitions are carried out in the same man-
the stretch. ner as the first repetition, except that the starting position
is different. The starting position for the first repetition
Client Contraction and Stretch of Target Muscle Group #2: was neutral anatomic position. However, the starting
■ At this point, instead of bringing the client back to the position for the second and all successive repetitions is
starting position for the next repetition, ask the client to with the client stretched into lateral rotation. Therefore,
actively move the thigh all the way into lateral rotation the client begins the second and all successive repetitions
as far as is comfortable, beginning the stretch of the by moving the thigh from the position of lateral rotation
target medial rotator muscles (target muscle group #2) all the way to medial rotation.
(Fig. C). ■ Note that the breathing protocol is for the client to ex-
hale when concentrically contracting.
Further Stretch of Client: ■ The client completes the exhalation and inhales as the
■ Once this position of stretch is reached, the client re- target musculature is relaxed and you stretch it. Because
laxes, and you further stretch the client’s target medial there is no step in which you return the client to the ini-
rotator musculature by gently moving the client’s thigh tial starting position, the client must also inhale while
farther into lateral rotation until you meet tissue resis- being stretched. For this reason, when performing AC
tance (Fig. D). stretching technique for both functional groups within
■ Hold the position of stretch for 1 to 2 seconds. a plane in one routine, the client’s inhalation should not
■ This completes one repetition in which both groups be too deep.
of hip joint rotation musculature (both target muscle
groups) have been stretched.
CASE STUDY
HYESUN because she has heard that you do effective clinical ortho-
pedic manual therapy.
■ History and Physical Assessment
Your assessment shows that low back flexion is
A new client, Hyesun Alexander, age 42 years, comes to decreased to 5 degrees and that both right and left lat-
your office complaining of low back pain and stiffness. She eral flexions are decreased to 10 degrees. All other ranges
tells you that the symptoms began 1 week ago after she of motion are within normal limits. The results of your
spent a long time standing and bending over, working on assessments are also negative for cough test and Valsalva
a project for work. She says that other than an occasional maneuver (for a review of assessment procedures, see
mild tightness in her low back, she has never experienced Chapter 3). Active straight leg raise causes immediate pain
any low back problems before now. She tried stretching on bilaterally in her lumbar region. Passive straight leg raise
her own, but it only seemed to make the pain worse. After causes no pain but is tight and pulls bilaterally in her lum-
3 days, she saw her medical doctor, who sent her for radi- bar region. Nachlas’ and Yeoman’s tests are negative. Pal-
ography. The radiographs were negative for fracture and pation of Hyesun’s lumbar region reveals extremely tight
dislocation, and she was released with a recommendation paraspinal musculature (erector spinae and transverso-
to use over-the-counter analgesics as needed. She then went spinalis) bilaterally as well as a tight and tender quadra-
to a massage therapist that a friend recommended, but she tus lumborum bilaterally. Gluteal musculature is mildly to
felt that the massage was very light and not effective at re- moderately tight, but when palpating this region, Hyesun
lieving her pain. reports no pain or discomfort.
In addition to strong dull pain with prolonged sitting
(more than 20 minutes) and prolonged standing (more ■ Think-It-Through Questions:
than 30 minutes), she is having difficulty sleeping because 1. Should an advanced stretching technique such as
she cannot find a comfortable position. Her pain level (on a AC stretching be included in your treatment plan for
scale of 0 to 10, in which 0 is no pain and 10 is the worst Hyesun? If so, why? If not, why not?
pain that she can imagine) is 4 when lying down, 5 to 6 2. If AC stretching would be of value, is it safe to use with
with prolonged standing, and 7 to 8 with prolonged sitting, her? If yes, how do you know? If not, why not?
including driving. Bending forward or to either side causes 3. If AC stretching is done, which specific stretching
immediate sharp pain at a level of 9. She normally works routines should be done? Why did you choose the ones
out five times a week, employing a combination of aerobic you did?
training and weights, but has not been able to work out
since the pain began. She points to her lumbar region on Answers to these Think-It-Through Questions and the
both sides of the spine as the source of her pain. She reports Treatment Strategy employed for the client are available
no pain down either lower extremity. She has come to you online at thePoint.lww.com/MuscolinoLowBack
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 5. Explain why stretching should never be performed too fast or
1. Describe the mechanism of contract relax agonist contract (CRAC) too far.
stretching. 6. Define each key term in this chapter and explain its relationship to
2. Describe in steps an overview of the usual protocol for carrying out the CRAC stretching technique.
the CRAC stretching technique. 7. Perform the CRAC stretching technique for each of the functional
3. Describe the roles of the treatment hand and the stabilization hand. groups of muscles of the lumbar spine and pelvis/hip joint.
4. Describe the usual breathing protocol for the client during the CRAC
stretching technique.
KEY TERMS
agonist contract (AC) stretching contract relax (CR) stretching muscle spindle reflex stabilization hand
contract relax agonist contract creep reciprocal inhibition stretching hand
(CRAC) stretching Golgi tendon organ reflex resistance hand treatment hand
INTRODUCTION ther of the two techniques alone, it might prove to be the only
technique that is effective for some difficult cases in which the
Contract relax agonist contract (CRAC) stretching is an advanced client’s target musculature is resistant to relaxing and stretch-
stretching technique that is performed by combining contract ing. In these cases, the extra time spent will be well worth it.
relax (CR) stretching (see Chapter 7) with agonist contract (AC)
stretching (see Chapter 8). CRAC stretching is not difficult for
the therapist to perform once the CR and AC stretching tech- BOX 9.1
niques have each been mastered. It requires only a small ad-
ditional step to synthesize these two techniques into the CRAC Contract Relax Agonist Contract Routines
stretching technique. As the acronym itself indicates, the
therapist simply performs the techniques sequentially, begin- The following CRAC stretching routines are presented in
ning with CR stretching and immediately following with AC the chapter:
stretching. As with any hands-on method, practice is the key to ■ Section 1: lumbar spine (LSp):
a comfortable, smooth, and efficient application. Even though ■ Routine 9-1—LSp extensors
performing CRAC stretching requires more time than does ei- ■ Routine 9-2—LSp right rotators
■ Section 2: hip joint/pelvis:
■ Routine 9-3—hip flexors
■ Routine 9-4—hip extensors: hamstrings (in the
Note: In the Technique and Self-Care chapters of this book (Chapters “Overview of Technique” section)
4 to 12), green arrows indicate movement, red arrows indicate stabi-
■ Routine 9-5—hip deep lateral rotators
lization, and black arrows indicate a position that is statically held.
313
MECHANISM
The proposed mechanism of CRAC stretching is a combina-
tion of the mechanism for CR stretching, which is classically
stated as the Golgi tendon organ reflex, and the mechanism for
AC stretching, which is reciprocal inhibition (RI). Chapter 7’s
Box 7.2 presents the Golgi tendon organ reflex in more detail,
and Chapter 8’s Box 8.2 focuses on RI.
The Golgi tendon organ reflex of CR stretching and the
RI reflex of AC stretching each work to inhibit muscula-
ture from contracting (in other words, to relax it). Both of
these reflexes can be utilized in CRAC stretching to relax
and stretch the target muscle. It stands to reason that if both
of these stretching techniques are employed together when
stretching a client’s target muscle, that muscle’s relaxation
will be increased, allowing for an even greater stretch than Figure 9-1 Starting position for CRAC stretching of the right ham-
would have been possible with either technique alone. string group.
It is important to note that, as with CR and AC stretching,
the therapist’s hand that resists the client’s contraction and
performs the stretch is known as the treatment hand or the Step 1: Client Isometric Contraction:
stretching hand; it is also known as the resistance hand. The ■ Begin by asking the client to gently contract the target
therapist’s other hand is known as the stabilization hand and right hamstring musculature in an attempt to extend the
is used to stabilize the client’s pelvis or trunk. thigh at the hip joint and the leg at the knee joint down
against the table. If you would like, you can place your left
hand under the client’s thigh or leg to monitor that she is
9.1 THERAPIST TIP pressing in the correct manner and direction (Fig. 9-2).
■ The client’s body weight and contact with the table pro-
vides stabilization of the pelvis for this step of the protocol.
Learn the Contract Relax Agonist Contract
■ Have the client hold this isometric contraction for ap-
Stretching Technique before Using It with Clients
proximately 5 to 8 seconds and then ask the client to relax.
CRAC stretching is not difficult to perform, but it does ■ This aspect of the CRAC stretch is the CR protocol, engag-
involve a number of steps and can be confusing at first to ing the Golgi tendon organ reflex to inhibit and relax the
learn and use with clients. For this reason, it is helpful first target right hamstring musculature.
to learn and master working with the CR and AC stretch- ■ Note: It is identical to the CR protocol explained in
ing techniques independently as well as the combined Chapter 7, except that CR stretching usually begins from a
CRAC technique before attempting to learn and apply the position in which the target musculature is first stretched
CRAC stretching technique with clients. (i.e., the thigh is already flexed).
OVERVIEW OF TECHNIQUE
9.2 THERAPIST TIP
View the video “Contract Relax Agonist
Contract Stretching of the Hamstring Group” Communicate with the Client
online on thePoint.lww.com
For clients who have never experienced the CRAC stretch-
The artful performance of CRAC stretching involves a seam-
ing technique, it can be helpful first to give them a brief
less integration of the CR and AC stretching techniques. For
overview of how you will perform the technique. Let the
this reason, it is strongly recommended that Chapters 7 and
client know that he or she will need to press against your
8, which discuss CR and AC stretching individually, be read
resistance in one direction, then move his or her body
and practiced before attempting CRAC stretching.
(thigh, pelvis, and/or low back) in the opposite direction,
The following is an overview of the CRAC stretching tech-
and then relax as you perform the stretch. In addition,
nique using the right hamstring muscle group as the target
inform the client about how long to press against your
muscle group being stretched.
resistance, how many repetitions there will be, and what
the breathing protocol is to be. This will allow the client
Starting Position:
to give you informed verbal consent before beginning the
■ The client is supine and positioned as far to the right side
technique and also will help the client carry out the CRAC
of the table as possible; you are standing at the right side
protocol more easily once you begin.
of the table (Fig. 9-1).
Figure 9-2 Step 1: Isometric contraction of the client’s right ham- Figure 9-4 Step 3: The client relaxes and is stretched further by
string musculature against the resistance of the table. the therapist.
Step 2: Client Concentric Contraction and Stretch: to be in position to further stretch the client during the
■ As soon as the client relaxes, have the client perform next step of the routine.
active concentric contraction of the flexors of the right ■ This step adds in the AC protocol, beginning the stretch of
thigh at the hip joint, bringing the thigh into flexion as far the target right hamstring musculature and engaging the RI
as is comfortably possible; it is important that the client reflex to further inhibit and relax the target musculature.
maintains her knee joint in full extension. ■ Note: This step differs from the usual CR stretching proto-
■ As the client begins to flex her right thigh up into the air, col, in which the client relaxes and the therapist stretches
you need to lean in and position yourself to stabilize the the client’s target musculature by passively moving the cli-
client’s pelvis with your right hand by pressing on the ent’s thigh into flexion.
client’s anterior left thigh (Fig. 9-3A). It is important to
make sure that the client’s pelvis is stabilized before the Step 3: Client Relaxation and Further Stretch:
client reaches the end of her flexion motion; otherwise, ■ Continuing with the AC protocol, once the client has
her pelvis will move into posterior tilt and the stretch of actively moved the thigh into flexion, the client relaxes,
the right hamstrings will not be optimal. An alternate and you now increase the stretch of the client’s target right
position to stabilize the client’s pelvis is to use your right hamstring musculature by gently and passively moving
knee (Fig. 9-3B). the client’s thigh farther into flexion until you meet tissue
■ It is also important to lean in quickly so that you can make resistance (Fig. 9-4).
sure that the client’s knee joint remains extended and also ■ Hold this position of stretch for 1 to 2 seconds.
A B
Figure 9-3 Step 2: Client actively moves into flexion of the right thigh at the hip joint. (A) Stabilization of the
client’s pelvis with the right hand. (B) Alternate stabilization contact: the right knee.
Further Repetitions:
■ Repeat this CRAC protocol for additional repetitions as
needed.
■ The number of repetitions typically performed varies
from 3 to 10.
each repetition will allow for an excellent degree of stretch at 9.9 Hand Placement: Stabilization Hand
the end of the CRAC stretching technique protocol.
The position of your stabilization hand (or other stabilization
9.6 Number of Repetitions contact) is also crucial. Without it, the client’s pelvis and/
or trunk would often move in such a manner as to lose the
The number of repetitions performed for CRAC stretching stretch of the target musculature. As with your treatment
varies. Because CR stretching usually involves 3 to 4 repeti- hand, placement of your stabilization hand should also be
tions and AC stretching usually involves 8 to 10 repetitions, comfortable for the client and offer as broad a contact as pos-
some therapists treat CRAC stretching like an add-on to sible. When performing CRAC stretching of the hamstring
CR stretching and perform 3 to 4 CRAC repetitions. Other group, it is usually necessary to remove the stabilization con-
therapists treat it more like an add-on to AC stretching and tact with each repetition to get out of the way and make room
perform 8 to 10 CRAC repetitions. As with all clinical work, for the client’s thigh to move. However, even when it is not
the response of the client’s tissues is the best guideline for necessary for you to remove the stabilization contact for this
applying the CRAC technique. reason, it is still usually necessary to remove the stabilization
contact from its stabilization position to assist the treatment
9.7 Contraction: Increase Gradually hand in supporting and returning the client’s body part back
to the starting position (step 4) for the next repetition.
The goal for each successive CRAC stretch repetition is
to build on the previous one so that the degree of stretch The placement of the treatment and stabilization
achieved gradually increases. For the CR portion, in which hands often requires your wrist joint to be extended.
For the health of your wrists, your point of contact
the client contracts against your resistance, the strength of through which pressure is transmitted into the client
the client’s contraction can increase gradually from the be- should be the heel of your hand (the carpal region). If you
ginning of the set of repetitions to the end. To accomplish direct the pressure through your palm or fingers, you may
this, instruct the client to press against your resistance gently hyperextend and injure your wrist. Given how vulnerable
during the first repetitions and then gradually increase the the wrist joint can be, proper biomechanical positioning of
strength of his or her contraction in successive repetitions the hand/wrist is crucially important.
until the client is pressing as hard as is comfortably possible
by the last repetitions.
9.10 Breathing
If the client contracts too forcefully or too suddenly,
a pulled or torn muscle is possible. It may be helpful The usual breathing protocol for CRAC stretching is to have
during the final or last few repetitions to tell the the client hold the breath in step 1 when performing isomet-
client, “Contract as hard as you comfortably can ric contraction during the CR phase of the protocol. In step
without hurting yourself.” 2, the client exhales when actively moving into the stretch
at the beginning of the AC phase of the protocol. During for the stretches should be determined by the restrictions
step 3, the client usually continues exhaling as he or she is that you feel when you assess the client’s ranges of motion.
relaxed and you further the stretch. In step 4, the client must
inhale as you passively return the client’s body part back to 9.12 Electric Lift Table
the starting position so that the client is ready to hold his or
her breath for step 1 of the next repetition. As discussed in Chapters 6, 7, and 8, when stretching the low
back and pelvis/hip joint, the value of an electric lift table for
9.11 Direction of Stretch optimal body mechanics cannot be overstated. Most CRAC
routines for the LSp and pelvis/hip joint require the table to
As with CR or AC stretching, when CRAC stretching is per- be low. If the table was higher for the performance of other
formed, the client can carry out the motion in a cardinal manual therapy techniques, having an electric lift table so
plane or in an oblique plane that combines any two or all that table height can be easily adjusted for CRAC stretching
three cardinal planes. The precise directions that you choose is essential for efficient clinical orthopedic work.
ROUTINES
As with CR and AC stretching, CRAC stretches of the LSp The following CRAC stretching routines for the LSp are
can be performed in two ways. One method is to stabilize the presented in this chapter:
client’s pelvis and move his or her upper trunk downward
■ Routine 9-1—LSp extensors
toward the pelvis, thereby stretching the LSp. This method
■ Routine 9-2—LSp right rotators
begins the stretch of the LSp superiorly, and as the stretch-
ing force is increased and the LSp is increasingly moved
downward, the stretch moves into the lower LSp. The sec-
ond method is to stabilize the client’s upper trunk and move 9.7 THERAPIST TIP
his or her pelvis and lower LSp upward toward the thoracic
trunk. This method begins the stretch of the LSp inferiorly, Stretching the Thoracic Spine
and as the stretching force is increased and the pelvis and CRAC stretches that move the upper trunk down toward
lower spine are increasingly moved upward, the stretch the lower trunk and pelvis tend to stretch the thoracic
moves into the upper LSp. spine as well as the LSp. However, any LSp stretch can be
transitioned to also stretch the thoracic spine by altering
either the movement and/or stabilization of the client’s
body so that the line of tension of the stretch enters the
thoracic region.
Figure 9-6 shows the functional group of muscles that extend lower extremity is positioned on the table so that your
the LSp. These muscles are located on the posterior side of core is in line with the force of the stroke.
the trunk in the lumbar region. The CRAC stretching rou- ■ Note: The stretching routine could also be performed from
tine presented here is essentially the double knee-to-chest the other (left) side of the table. Simply reverse the posi-
stretch that is presented in Chapter 11 (Self-Care Routine tioning of your lower extremities.
11-6; available online at thePoint.lww.com), with the CRAC ■ Both of your hands are treatment hands and are placed on
stretching protocol added. the distal posterior surface of the client’s thighs.
■ The client can place his feet on your clavicle as seen in
Figure 9-7.
The Lumbar Spine Extensor Functional Group ■ The client’s upper trunk is stabilized by body weight and
contact with the table as well as the direction that you
This functional group comprises the following muscles
push on his thighs when performing the stretch in step 3).
bilaterally:
Erector spinae group
Transversospinalis group
Quadratus lumborum
Figure 9-7
Semispinalis
Quadratus
lumborum
Figure 9-6
Starting Position:
■ The client is supine toward one side of the table with his
hip and knee joints flexed. You are standing on the right
side of the table. Your left foot is on the floor; your right Figure 9-8A
Figure 9-8C
Figure 9-8B
A B
Semispinalis
External Spinalis
abdominal
oblique Longissimus
Multifidus
Internal Iliocostalis
abdominal
oblique
A B
Starting Position: ■ Your left hand is the stabilization hand and functions to
■ Have the client seated at the right end of the table with stabilize the client’s pelvis. It is placed across the top of
her arms crossed so that her hands are on the opposite the client’s right iliac crest; if it is not possible to grasp the
shoulders, but her arms should be adducted at the gleno- client’s iliac crest, the stabilization hand can be placed on
humeral joints so that her elbows meet at the center of the the proximal anterior surface of the client’s right thigh; if
body. desired, a cushion can be used for comfort to broaden the
■ Stand to the right side of the client. stabilization contact (Fig. 9-10).
■ Your right hand is the treatment hand and is placed on the
client’s elbows.
Figure 9-11B
Figure 9-11D
Further Repetitions:
■ This CRAC protocol can be repeated for a total of 3 to 10
repetitions.
■ Once the final position of stretch is reached at the end
of the last CRAC repetition, many therapists like to hold
this position of stretch for a longer period, often 10 to
20 seconds or more.
Figure 9-11C
Lumbar Spine Left Rotators:
■ Note: To use CRAC stretching to stretch the LSp left
Step 4: Passively Return Client to Starting Position: rotator functional group of muscles, follow the directions
■ Support the client’s trunk as you passively bring the client given in Figures 9-10 through 9-11 to stretch the right
back to the starting position for the next repetition. rotator group but switch for the left side of the body.
■ Use both of your hands to support and move the client’s
body back to starting position (Fig. 9-11D).
As a rule, CRAC stretches to the muscles of the pelvis that For many stretches of the client’s hip joint
cross the hip joint are performed by stabilizing the client’s musculature presented in this book, the leg is shown
pelvis and moving his or her thigh to create the stretch. For as the contact for the therapist’s stretching/treatment
the stretch to be effective, it is extremely important that the hand. Contacting the leg increases the leverage force,
pelvis is securely stabilized. Otherwise, the stretching force making it easier for the therapist to move the client’s thigh
will enter the LSp. This will not only dissipate the stretching to create the stretch. However, if the client’s knee joint is
unhealthy, the contact should be moved from the leg to the
force at the hip joint causing it to lose its effectiveness but thigh itself so that no force is placed through the knee joint.
might also place a torque (rotary force) into the LSp that can This can make the performance of the stretch more
cause pain or injury. logistically challenging, especially if the therapist is small
The following CRAC stretching routines for muscles of and the client is large but is necessary to protect the client’s
the pelvis that cross the hip joint are presented in the chapter: knee from injury.
■ Routine 9-3—hip flexors
■ Routine 9-4—hip extensors: hamstrings (in the “Overview
of Technique” section)
■ Routine 9-5—hip deep lateral rotators
Starting Position:
■ Have the client prone toward the right side of the table.
■ Stand to the right side of the client.
■ Your left hand is the treatment hand and is placed under
(on the anterior surface of) the client’s right thigh.
■ Your right hand is the stabilization hand and functions to
stabilize the client’s pelvis. It is placed on the client’s right
posterior superior iliac spine (PSIS) (Fig. 9-13).
Figure 9-13
Step 1: Client Isometric Contraction: ■ This differs from CR stretching technique, in which the
■ Ask the client to perform a gentle isometric contraction of client would relax, and you would stretch the client’s tar-
the target muscles for approximately 5 to 8 seconds in an get musculature by passively moving the client’s thigh
attempt to flex the thigh at the hip joint down against the into extension.
resistance of the table. Your left hand under the client’s ■ This stage of CRAC stretching begins the AC protocol.
thigh monitors that she is pressing in the correct manner
and direction (Fig. 9-14A). Step 3: Client Relaxation and Further Stretch:
■ Once the client has finished actively moving into exten-
sion, the client relaxes.
■ As soon as the client relaxes, you now increase the stretch
of the client’s target right hip flexor musculature by gently
and passively moving the client’s right thigh farther into
extension until you meet tissue resistance (Fig. 9-14C).
■ Hold the client in this position of stretch for 1 to 2 seconds.
Figure 9-14A
Step 2: Client Concentric Contraction and Stretch: Step 4: Passively Return Client to Starting Position:
■ As soon as the client relaxes, ask her to concentrically ■ Support the client’s trunk as you passively bring the client
contract the extensors of the right thigh at the hip joint back to the starting position for the next repetition.
to actively extend the right thigh as far as is comfortable ■ Use one or both of your hands to support and move the
(Fig. 9-14B). client’s thigh back to starting position (Fig. 9-14D).
Further Repetitions:
■ This CRAC protocol can be repeated for a total of 3 to 10
repetitions.
■ Once the final position of stretch is reached at the end
of the last CRAC repetition, many therapists like to hold
this position of stretch for a longer period, often 10 to 20
seconds or more.
Figure 9-15
A B C
Biceps femoris
The Hamstring Group
This group comprises the following muscles:
Biceps femoris
Semitendinosus
Semimembranosus
Figure 9-16
Figure 9-17 shows the functional group of deep lateral rota- Starting Position:
tor muscles of the hip joint on the right side of the body. ■ Have the client supine toward the right side of the table.
These muscles are located in the posterior pelvis in the but- ■ Position yourself at the right side of the table.
tock region, deep to the gluteus maximus, and cross the hip ■ Flex the client’s right hip and knee joints and place his
joint between the pelvis and thigh. Note: The posterior cap- right foot flat on the table.
sular ligament of the hip joint (ischiofemoral ligament) is ■ Both of your hands will be treatment hands and can be
stretched with medial rotation, as are the deep lateral rotator placed against the lateral surface of the client’s distal right
muscles. Therefore, the stretching protocol presented here thigh (Fig. 9-18).
for the deep lateral rotators is also very effective at stretching ■ No stabilization hand is necessary; the client’s body weight
and loosening a taut posterior hip joint capsule. Following and contact with the table, as well as the direction that you
is the CRAC stretching routine shown for the deep lateral move his thigh, stabilize his pelvis.
rotator group on the right side of the body.
Piriformis
Superior
gemellus
Obturator
internus
Inferior
gemellus
Quadratus
femoris
Figure 9-17 Note: The obturator externus is not seen. Figure 9-18
Step 1: Client Isometric Contraction: Step 2: Client Concentric Contraction and Stretch:
■ Ask the client to perform a gentle isometric contraction of ■ As soon as the client relaxes, ask him to concentrically
the target muscles for approximately 5 to 8 seconds in an contract the horizontal adductors of the right thigh at the
attempt to horizontally abduct the thigh at the hip joint hip joint to actively bring his right thigh up and across
against your resistance (Fig. 9-19A). his body (horizontally adduct) as far as is comfortable
(Fig. 9-19B).
Figure 9-19A
Figure 9-19B
■ Ask the client to relax.
■ This phase of the CRAC stretch is the CR protocol. ■ This differs from CR stretching technique, in which the
■ Please note that the breathing protocol for every repeti- client would relax, and you would stretch the client’s tar-
tion is to have the client hold the breath when contracting get musculature by passively moving the client’s thigh
against your resistance. into horizontal adduction.
■ This stage of CRAC stretching begins the AC protocol.
Step 3: Client Relaxation and Further Stretch: Step 4: Passively Return Client to Starting Position:
■ Once the client has finished actively moving into horizon- ■ Support the client’s thigh as you passively bring the client
tal adduction, the client relaxes. back to the starting position for the next repetition.
■ As soon as the client relaxes, you now increase the stretch ■ Use both of your hands to support and move the client’s
of the client’s target right hip deep lateral rotator mus- thigh back to starting position (Fig. 9-19D). Alternately,
culature by gently and passively moving the client’s right the client’s thigh does not have to be brought all the way
thigh farther into horizontal adduction until you meet tis- back to starting position, but instead, it can be brought
sue resistance (Fig. 9-19C). part way back toward the starting position. What is im-
■ Hold the client in this position of stretch for 1 to 2 seconds. portant is that there is a horizontal adduction range of
motion possible for the client.
Figure 9-19C
Figure 9-19D
Further Repetitions:
■ This CRAC protocol can be repeated for a total of 3 to 10
repetitions.
■ Once the final position of stretch is reached at the end
of the last CRAC repetition, many therapists like to hold
this position of stretch for a longer period, often 10 to 20
seconds or more.
CASE STUDY
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 7. Describe the relationship between joint mobilization and passive
1. Describe the similarity between joint mobilization and stretching. range of motion and joint play.
2. Describe the relationship between joint mobilization and pin and 8. Explain why thrusting should never be done when performing joint
stretch. mobilization.
3. Explain how joint mobilization differs from other forms of 9. State conditions that contraindicate joint mobilization of the sac-
stretching. roiliac and LSp joints.
4. Describe the relationship between joint hypomobilities and hyper- 10. Define each key term in this chapter and explain its relationship to
mobilities. joint mobilization technique.
5. Describe the roles of the treatment hand, stabilization hand, and 11. Perform joint mobilization technique for each of the routines
support hand. presented in this chapter.
6. Describe in steps an overview of the usual protocol for carrying out 12. Describe and perform two methods of joint play distraction
a joint mobilization of the sacroiliac and lumbar spinal (LSp) joints. (traction).
KEY TERMS
active range of motion joint mobilization passive range of motion towel traction
adjustment joint play pin and stretch traction
axial distraction joint release “pocket to pocket” treatment hand
distraction manual traction segmental joint level
hypermobile mobilization grading stabilization hand
hypomobile motion palpation support hand
one or more of its segmental joint levels are restricted and and applied to only one segmental joint level of the low back
in need of stretching/mobilizing. or pelvis. In this sense, joint mobilization can be considered
In this manner, hypomobilities create corresponding hy- a very specific and focused stretching technique.
permobilities. Once formed, hypermobilities enable the per-
sistence of hypomobilities. However, if enough hypomobile
levels are present, their decreased motion might contribute OVERVIEW OF TECHNIQUE
to an overall decrease in gross range of the motion of the
LSp or pelvis. But even this condition can be difficult to re- The following is an overview of joint mobilization technique
solve with standard or advanced stretching, because if you using seated joint mobilization technique for the L2-L3
stretch the client’s low back in an attempt to lengthen and segmental level as the hypomobile joint that needs to be mo-
loosen these hypomobilities, the hypermobilities may “ab- bilized into left lateral flexion. In this example, because the
sorb” the stretch by becoming even more hypermobile. Thus, client has a restriction in left lateral flexion at the L2-L3 joint
this stretch may result in a restoration of gross range of the level, you can assume that the L2 vertebra is not left laterally
motion, even though the underlying hypomobilities are still flexing freely on the L3 vertebra. To resolve this problem, it
present. In cases such as these, which are quite common, all will be necessary to apply a force that moves L2 into left lat-
standard and advanced stretching techniques are usually eral flexion on L3 while L3 remains stable, thereby stretching
ineffective at increasing the flexibility of these hypomobile whatever taut tissues between them are restricting this fron-
joints. In fact, these techniques may actually be detrimen- tal plane motion. This is accomplished by using one hand to
tal because they cause or perpetuate the hypermobile joint stabilize L3 while the other hand moves L2 on L3.
compensations. As with regular stretching, the treatment hand applies the
Joint mobilization is the only treatment technique avail- stretching or mobilization force, and the stabilization hand
able to manual therapists that can address and resolve a seg- prevents the adjacent body part from moving. Placing the
mental joint hypomobility. If, for example, the L3-L4 joint hands in this manner focuses the stretch on the appropriate
is decreased in right lateral flexion, joint mobilization can joint level and keeps it from being lost on other levels of the
apply the localized force needed to address this very specific low back. In this case, the therapist’s right (lower) hand is the
loss of motion at this specific joint level. As with regular stabilization hand that is stabilizing the client’s L3 vertebra.
stretching, the force used in joint mobilization is a tension The therapist’s left (upper) hand is the treatment hand that
force, but instead of producing a line of tension across a large moves the entire upper body and L2 into left lateral flexion
swath of tissue (such as the entire LSp), this force is localized on top of the stabilized L3.
Starting Position:
■ The client is seated, with her hands comfortably crossed to
her opposite shoulders and her arms resting on her chest.
You are standing (or seated) behind the client, slightly to
the left side.
■ Your right hand will be the lower stabilization hand, and
your left hand will be the upper treatment hand.
■ Note that your elbows are tucked in front of your body
as much as possible so that you can use your core body
weight behind your forearms and hands when press-
ing on the client with your treatment and stabilization
hands.
■ Use your left hand to hold across the top of the client’s
shoulders/trunk (Fig. 10-2).
L2 left laterally
L3 flexing on L3
A B C
Figure 10-3 L2-L3 left lateral flexion joint mobilization steps. (A) Step 1, stabilizing L3. (B) Step 2, moving L2 into
left lateral flexion until tissue tension is felt. (C) Step 3, joint mobilization is performed by gently increasing L2’s
left lateral flexion on L3.
Transitioning Seated Lumbar Spine Lateral Flexion Mobilization to Rotation and Extension Mobilizations
The seated LSp lateral flexion mobilization technique bra are stabilized by body weight. Repeat on the other side
can be modified to mobilize the LSp into rotation or ex- of the client for right rotation mobilization, switching the
tension. placement of your hands.
If rotation mobilization is performed, the client’s arms To perform extension mobilization, the client holds
should be crossed so that her hands are on the opposite her arms flexed to 90 degrees at the glenohumeral joint and
shoulders, but her arms should be adducted at the gleno- each hand holds the opposite-side elbow. Stand behind and
humeral joints so that her elbows meet at the center of the to the left side of the client and grasp her forearms with
body. For left rotation, stand behind and to the client’s left your left hand and place your contact over the midline
side and grasp her elbows with your left hand and place the (center) of the SP at the desired level of the LSp (Fig. C).
thumb of your right hand on the left side of the SP at the de- Using both hands, bring the client into extension until the
sired level of the LSp. Rotate the client’s upper body into left end of passive range of motion is reached. To perform the
rotation until the end of passive range of motion is reached. mobilization, both hands act as treatment hands: The left
To perform the mobilization, both hands act as treatment hand gently brings the client’s spine farther into extension
hands: The left hand gently brings the client’s spine farther as your right hand contact pushes the vertebra farther into
into left rotation as the thumb of the right hand pushes the extension (Fig. C). The vertebrae below the contacted ver-
SP farther to the right (when the SP moves to the right, tebra are stabilized by body weight.
the anterior surface of the vertebral body orients to the left; Your contact on the client’s SP can be the middle
therefore, this motion is defined as left rotation) (Figs. A phalanx of your index finger supported by your thumb
and B). The vertebrae that are below the contacted verte- continued
A B C
(Fig. D). Alternately, you can use your fist (Fig. E). This contact and the client’s spine. A folded towel also works
is a stronger contact for the therapist. It is also less pokey well (see Fig. C). Note: This mobilization could have been
because it broadens out the mobilization force across performed with the therapist standing on the other side
several vertebrae; however, for this reason, it is also less of the client using the right hand to support the client’s
precise. With either contact, for client and therapist com- forearms in front and the left hand as the vertebral con-
fort, a small cushion can be placed between the therapist’s tact hand.
D E
Apply the Technique Even If the Spinal Level Joint Mobilization and the Pin-and-Stretch
Cannot Be Discerned Technique
Sometimes, it is difficult to distinguish exactly which ver- Joint mobilization is not only a type of stretching but also
tebral level of the LSp you are on. The most important a form of the pin-and-stretch technique. A pin and stretch
thing is that you apply the joint mobilization technique to is done by pinning, or stabilizing, one point and then
each hypomobile segmental level of the LSp, even if you stretching the soft tissues relative to that pinned point.
cannot name with certainty exactly which segmental joint In the example given in the “Overview of Technique”
you are on at any given time. With continued experience, section, when the stabilization hand stabilizes the third
learning to distinguish and name each segmental level of lumbar vertebra, it is pinning L3. Then, when the trunk
the LSp will become easier. above L3 is moved relative to L3, the tension of the stretch
is directed to the L2-L3 joint level. In effect, the pin-point
accuracy of LSp joint mobilization occurs because one
vertebral level is pinned, directing the stretch specifically
to the joint adjacent to that vertebra. Generally, the lower
vertebra is pinned, and the stretch is applied to the joint
above.
A B C
Figure 10-4 Stabilization hand contacts. (A) Thumb pad. (B) Finger pads. (C) Hypothenar eminence.
A B
C D
Figure 10-7 Using the stabilization hand to treat. (A) The client’s trunk (and specifically the joint to be mobilized)
has been brought to tension. (B) The lower vertebra is stabilized while the upper vertebra is mobilized (moved to
the left) above it. (C) The upper vertebra is stabilized while the lower vertebra is mobilized (moved to the right)
under it. (D) Both hands can administer the joint mobilization force simultaneously. The upper hand moves the
upper vertebra to the left while the lower hand moves the lower vertebra to the right.
It is critical that you study the joint mobilization stabilization hand and then using your treatment hand to
technique carefully and understand it before move the trunk on the fixed vertebra until you reach the end
attempting to use it on your clients. Any technique of passive range of motion. The amount of motion necessary
that has the power to help also has the power to do to reach this point varies depending on the region of the LSp
harm, and joint mobilization is an extremely powerful that is being mobilized. Mobilizing the lower LSp requires
technique. Joint mobilization, when applied inappropriately, more motion on the part of the treatment hand than does
can cause serious harm to the client. Inappropriate
application of joint mobilization technique includes applying mobilizing the upper LSp. Note the difference in the upper
joint mobilization to a condition for which its use is indicated treatment hand’s motion by comparing Figures 10-8A and
but executing the technique incorrectly—for example, 10-8B. Joint mobilization can be performed only when the
performing it too forcefully. It also includes applying joint end of passive range of motion is first reached.
mobilization to a condition for which it is contraindicated, As the treatment hand moves the client through a greater
usually a space-occupying lesion such as a pathologic disc or range of motion, it becomes even more important for the
advanced degenerative joint disease (see Chapter 3 for lower stabilization hand to stabilize the vertebra securely. For
assessment of pathologic conditions). If you have any doubt this reason, it can be more challenging for you to mobilize
about whether it is appropriate to use joint mobilization for a the client’s lower LSp than the client’s upper LSp.
particular client, be sure first to obtain written permission
from the client’s chiropractic or medical physician.
10.7 Degree of Stretch/Mobilization
10.6 Bring the Joint to Tension First The degree of stretch of an LSp joint mobilization is criti-
cally important. Joint mobilization is performed within the
Before you perform the actual stretch of the joint mobiliza- range of motion called joint play. Because the range of mo-
tion, you must first bring the joint that is to be mobilized tion within joint play is so small, the amount of stretch that
to tissue tension at the end of its passive range of motion. you apply during a joint mobilization to the client’s LSp or
This is done by first stabilizing the lower vertebra with your SIJs needs to be extremely small. This motion is barely mea-
A B
Figure 10-8 Bringing the joint to tension. Bringing the joint to tension requires less or more movement of the
client’s trunk depending on the level of joint mobilization. (A) Mobilization of the upper LSp requires less move-
ment of the client’s trunk. (B) Mobilization of the lower LSp requires more movement of the client’s trunk.
Joint Mobilization/Manipulation Grades 10.12 Determining the Need for Joint Mobilization
Some sources define the term joint mobilization more
Determining the need for the stretching techniques pre-
generically to describe all motions of a joint. One
sented in Chapters 6 to 9 is accomplished by assessing the
classification of joint mobilization grading divides joint
low back’s gross passive range of motion in each direction.
motion/mobilization into five grades.
Determining the need for joint mobilization technique is
■ Grade I: slow, small-amplitude movement performed accomplished by assessing the specific joint play range of
at the beginning of a joint’s range of active/passive motion at each segmental joint level. This is done via the as-
motion sessment technique known as motion palpation. Motion pal-
■ Grade II: slow, large-amplitude movement performed pation assessment is performed in the same manner as joint
through the joint’s active range of motion mobilization treatment is. One bone of the client’s joint is
■ Grade III: slow, large-amplitude movement performed stabilized/pinned, and the other bone is moved until tension
to the limit of the joint’s passive range of motion is reached. The motion palpation assessment is then done by
■ Grade IV: slow, small-amplitude movement performed gently introducing a slightly increased motion at that joint
at the limit of a joint’s passive range of motion and into level, feeling for the end-feel of motion in joint play.
resistance (joint play) A healthy joint’s end-feel has a springy bounce to it. An
■ Grade V: fast, small-amplitude movement performed unhealthy hypomobile joint has an end-feel that is restricted
at the limit of a joint’s passive range of motion and into and feels like you are pushing against a hard block. An un-
resistance (joint play) healthy hypermobile joint is excessive in motion and has a
In this grading system, Grade II is the active range of mo- soft doughy/mushy feel to it. If an unhealthy restricted end-
tion that a client can create at a joint. Grade III is a typical feel is found, that joint is in need of mobilization. If a healthy
passive stretch that is performed by a therapist on a client end-feel is present, joint mobilization may be performed at
or a passive self-stretch performed by a client (see Chap- that level to proactively maintain the functional health of the
ters 6 to 9 and Chapter 11, available online at thePoint. joint. However, if a hypermobile joint is assessed, joint mo-
lww.com). Grade IV is joint mobilization as the term is bilization is contraindicated at that level.
used in this text. Grade V is a chiropractic/osteopathic It should be noted that joint mobilization treatment tech-
high-velocity (fast thrust) manipulation that is not within nique is simply an extension of motion palpation assessment
the scope of practice for most manual therapists. technique. They are performed in an identical manner except
that motion palpation is done to assess the motion that is
present, and joint mobilization is done to maintain or in-
crease that motion. When assessing and treating the client’s
tion, once the entire LSp has been mobilized (i.e., all of the low back, it is common to do motion palpation at a joint
hypomobile joints of the LSp have been mobilized), this pro- level and, if it is restricted, to simply add a little more force
cess can now be repeated a second and third time. In other to perform the mobilization. Hence, motion palpation flows
words, instead of performing three to five repetitions at one into joint mobilization.
joint level before moving on, it is more common to perform
one joint mobilization repetition for the entire LSp. Then, if 10.13 Scope of Practice
desired, a second repetition for the entire LSp and/or even a
third repetition for the entire LSp can be done. Most often, Before adding joint mobilization to your practice, it is impor-
two or three repetitions of joint mobilization of the entire tant to be sure that it is within the scope of practice of your
LSp are done. After the LSp has been mobilized in this man- profession. If there is any doubt about the ethical or legal ap-
ner, further joint mobilizations can be repeated at the most plication of joint mobilization within your profession, please
restricted levels as needed. As with all treatment techniques, check with your local, state, or provincial licensing body;
the needs of the client and the response of the tissue are the your certifying body; and/or your professional organization.
ROUTINES
JOINT MOBILIZATION ROUTINES Motion within the spine, both axial and nonaxial, at any
particular segmental joint level is determined by the plane of
As with regular and advanced stretching techniques, joint the facets at that level. This must be taken into account when
mobilizations can be done in axial cardinal plane ranges performing joint mobilization. Generally, the planes of the
of motion. It is also possible to do multiplane joint mobi- lumbar facets are sagittally oriented; therefore, lumbar mo-
lizations by combining two or more of these cardinal plane tion is most free in the sagittal plane, in other words, flexion
motions into an oblique plane motion. Anterior- to poste- and extension. However, the facet plane of the L5-S1 joint is
rior-directed joint mobilization of the LSp into flexion usu- more frontal plane in orientation; therefore, its lateral flexion
ally is not done because it would require contacting and motions would theoretically be freer. When performing joint
pressing on the client’s anterior abdomen, which would be mobilization technique, it is important to palpate and feel
uncomfortable for the client. the facet plane motion at that segmental joint level and work
Additionally, joint mobilizations can be done for nonaxial by mobilizing this plane of motion (see Chapter 1 for more
ranges of motion, including axial distraction, also known as information about the facet joint planes and range of motion
distraction or traction. Nonaxial compression joint mobiliza- of the lumbar and thoracic spine).
tion usually is not performed because it does not stretch any
soft tissue and therefore does not increase mobility, which is
the reason for performing joint mobilization.
View the video “Introduction to Joint Following are seven SIJ mobilization routines:
Mobilization of the Sacroiliac Joint” ■ Routine 10-1—SIJ prone: PSIS compression
online on thePoint.lww.com ■ Routine 10-2—SIJ prone: sacrum compression
SIJ mobilization introduces motion into the SIJ. The motion ■ Routine 10-3—SIJ side-lying: compression
that is introduced can vary depending on which bone is mo- ■ Routine 10-4—SIJ supine: compression
bilized and in what direction. The treatment hand contact ■ Routine 10-5—SIJ supine: single knee to chest
can mobilize the ilium with the sacrum stabilized, or the ■ Routine 10-6—SIJ supine: horizontal adduction
sacrum can be mobilized with the ilium stabilized. Further, ■ Routine 10-7—SIJ side-lying: horizontal adduction
the contact location on the sacrum or ilium can vary, as can
the direction of the mobilization force. Because very little
musculature crosses directly from one bone of the SIJ to the
other, musculature is not the primary target of SIJ mobiliza-
tion. In all cases, the primary soft tissue target of SIJ mobili-
zation is the ligament complex that connects the two bones.
ROUTINE 10-1: SACROILIAC JOINT PRONE: POSTERIOR SUPERIOR ILIAC SPINE COMPRESSION
Figure 10-9C
Figure 10-10B
■ Repeat for the other side SIJ, switching contact and sup-
port hands and which side of the table you are standing on.
■ Repeat these routines as needed with concentration at the
SIJ motions that are restricted.
Figure 10-10A
When contacting the sacral apex, be sure not to contact
■ Hold for only a fraction of a second and then release. the client too inferiorly. If pressure is placed on the coccyx
■ This joint mobilization of the SIJ may then be repeated for instead of the sacrum, a sprain of the sacrococcygeal
a total of two to three times. ligament or fracture of the coccyx could occur.
Similar to prone compression, the SIJ can be mobilized with ■ Hold for only a fraction of a second and then release.
the client side-lying with pressure placed on the client’s iliac ■ This joint mobilization of the SIJ may then be repeated for
crest. Although this pressure will transmit through to both a total of three to five times.
SIJs, the upper SIJ (the one away from the table) is primarily ■ Now repeat the mobilization routine, this time with the
mobilized. For this reason, the routine is usually repeated client lying on the other (left) side (Fig. 10-11B). Repeat
with the client lying on the other side. for a total of two to three times.
The following are the steps to perform side-lying com- ■ Repeat these routines as needed with concentration at the
pression mobilization of the SIJ: SIJ(s) that is/are restricted.
■ The client is side-lying on the right side, and you are
standing at the side of the table, behind the client.
■ Place your left hand on the client’s iliac crest.
■ Support your left hand with the thumb web of your right
hand.
■ The sacrum is stabilized by body weight, so no stabiliza-
tion hand is needed.
■ Gently lean in with body weight, adding compression
force to the iliac crest directly medially (down toward the
table/floor) until you reach tissue tension at the end of
passive range of motion.
■ Now gently stretch the SIJ into its joint play by leaning in
further with body weight, adding a small increased com-
pression force on the iliac crest (Fig. 10-11A). Note: This
mobilization motion causes internal rotation of the ilium
on that side and results in gapping of the posterior aspect
of the SIJ. Figure 10-11B
Figure 10-11A
Figure 10-12
The SIJ can also be mobilized with the client supine by The following are the steps to perform supine single knee
flexing the client’s thigh and bringing the knee up to his to chest mobilization of the right SIJ:
chest. Via femoropelvic rhythm, thigh flexion couples
■ The client is supine, and you are standing at the right side
with posterior tilt of the ilium on that side, so bringing
of the table.
the knee to the chest posteriorly tilts the same-side (ip-
■ Flex the client’s right hip and knee joints. Pressing on
silateral) ilium. Because the pelvis remains on the table,
the posterior surface of the distal thigh, bring the client’s
the other (contralateral) ilium remains stable. When the
knee/thigh toward his chest.
ipsilateral ilium moves into the posterior tilt and the con-
■ For maximal stabilization of the sacrum, place your right
tralateral ilium remains stable, motion is introduced into
knee on the anterior surface of the client’s left thigh. Sta-
the SIJs. This motion will be introduced first into the ipsi-
bilizing his left thigh stabilizes his left ilium, which helps
lateral SIJ. As the ipsilateral ilium continues to posteriorly
to stabilize his sacrum.
tilt and reaches the end range of its motion, the sacrum
■ Gently lean in with body weight, pressing the right thigh
will move with it, and motion will then be introduced
into flexion toward his chest until you reach tissue tension
into the contralateral SIJ. Therefore, supine single knee
at the end of passive range of motion.
to chest routine primarily mobilizes the same-side SIJ but
■ Now gently stretch the right SIJ into its joint play by leaning
can also mobilize the SIJ on the other side of the body. It is
in further with body weight, adding a small increased force
usual to perform this mobilization bilaterally to optimally
on the posterior thigh (Fig. 10-13A). This will involve a very
mobilize both SIJs.
small excursion of posterior tilt of the ilium on that side.
■ Hold for only a fraction of a second and then release. ■ Repeat for the other side SIJ, switching which side of the
■ This joint mobilization of the SIJ may then be repeated for table you are standing on (Fig. 10-13B).
a total of three to five times. ■ Repeat these routines as needed.
Place Client’s Foot on Your Clavicle and Watch the Orientation of the Stretch
An excellent alternative position for the therapist to per- thigh with your knee, and you press horizontally (par-
form supine single knee to chest mobilization is to place allel with the table) in the cephalad (cranial) direction
the client’s foot on your clavicle. Body mechanics wise, this instead of down toward his chest, the client’s pelvis will
allows you to use your core to lean in and press the client’s lift from the table and the mobilization to the SIJ will be
thigh into flexion against the chest. However, this posi- lost because the opposite-side ilium and the sacrum will
tion should not be used if the client’s knee is unhealthy. no longer be stabilized (Fig. B). It is important to also
To further improve body mechanics, position yourself on not compress the client’s thigh too much into his chest
the table so that your core is in line with the client’s lower because the client might experience discomfort or pain in
extremity (Fig. A). Of course, do not climb onto the table the anterior hip joint region (groin). Optimal is to press
if there is any doubt as to the table’s ability to support both as little into his chest as possible (i.e., as much horizon-
your weight and that of the client. tally parallel to the table in the cephalad/cranial direction
It is also important to pay attention to the orienta- as possible) and still keep his pelvis down on the table
tion of the stretching force that you apply to the client’s (see Fig. A). The balance between these two directions
thigh. If you are not stabilizing the client’s opposite-side will vary from client to client.
A B
Similar to the single knee to chest mobilization, the SIJ can ■ Now gently stretch the left SIJ into its joint play by lean-
be mobilized by bringing the client’s thigh into flexion and ing in further with body weight, adding a small increased
then across his body into horizontal adduction. Horizontal force on the posterior thigh, while you simultaneously add
adduction adds a component of internal rotation of the ilium a mobilization force to the PSIS with the finger pads of your
(to the posterior tilt of the ilium created by the thigh flexion), right hand, gapping it away from the sacrum (Fig. 10-14A).
gapping the posterior aspect of the SIJ. Thus far, this routine Note: This mobilization motion causes posterior tilt of the
is identical to the horizontal adduction stretch routine shown ilium; it also causes internal rotation of the ilium on that
in Chapter 6 (see Routine 6-10, stretch #1), which stretches side, resulting in gapping of the posterior aspect of the SIJ.
the lateral rotation musculature of the posterior buttock (and ■ Hold for only a fraction of a second and then release.
also stretches/mobilizes the SIJ). To augment the SIJ mobili-
zation for this routine, you can use your hand to contact and
add mobilization force to the PSIS of the ilium.
The following are the steps to perform supine horizontal
adduction mobilization of the left SIJ:
■ The client is supine, and you are standing at the (opposite)
right side of the table.
■ Flex the client’s left hip and knee joints and then bring the
client’s thigh into horizontal adduction across his body
by trapping the client’s knee between your left arm and
trunk.
■ Curl the finger pads of your right hand around the medial
side of the client’s left PSIS.
■ The sacrum is stabilized by body weight, so no stabiliza-
tion hand is needed.
■ Gently lean in with body weight, pressing the client’s left
thigh into horizontal adduction across his chest (and Figure 10-14A
somewhat down into his chest to prevent the pelvis from
lifting from the table) until you reach tissue tension at the
end of passive range of motion.
■ If the client experiences discomfort/pain at the anterior ■ This joint mobilization of the SIJ may then be repeated for
hip joint region, your hands can be used to traction the a total of three to five times.
anterior proximal thigh away from the pelvis as the mobi- ■ Repeat for the other side SIJ, switching which side of the
lization is performed (Fig. 10-14B). This often relieves the table you are standing on (Fig. 10-14C).
client’s discomfort/pain. However, using the right hand ■ Repeat these routines as needed.
to help traction the thigh means that it cannot be used
to contact the PSIS and augment the mobilization. If the
thigh can be tractioned with just the left hand, then the
right hand can maintain the joint mobilization force on
the PSIS.
Figure 10-14C
Figure 10-14B
Figure 10-15B
Figure 10-15A
Figure 10-15G
Figure 10-15E
Figure 10-15H
Figure 10-15I
Figure 10-15J
■ The opposite side ilium and sacrum are stabilized by body ■ Hold for only a fraction of a second and then release.
weight against the table, so no stabilization hand is needed ■ This joint mobilization of the SIJ may then be repeated for
for this purpose. a total of three to five times.
■ Gently drop down against the client’s left thigh with your ■ Repeat for the other side SIJ, switching contact and stabili-
right thigh and body weight, pressing the client’s left thigh zation hands and which side of the table you are standing
further into horizontal adduction until you reach tissue on (Fig. 10-15O).
tension at the end of passive range of motion (Fig. 10-15M). ■ Repeat these routines as needed.
■ It is important that you leave enough room between
your thigh and the table for the client’s left thigh to Note: An alternative position for the client’s left hand is to
further horizontally adduct down toward the floor. place it on her right hand as seen in Figure 10-15P instead of
■ Now gently stretch the left SIJ into its joint play by leaning draping it over the side of the table as seen in Figure 10-15D.
in further with body weight, adding a small increased force The advantage of this positioning is that it is easier to stabilize
on the thigh, while you simultaneously add a mobilization the client’s upper body. The disadvantage is that it is easier to
force to the left PSIS with the thenar eminence of your torque the client’s spine if you press posteriorly on her hands/
right hand, gapping it away from the sacrum (Fig. 10-15N). trunk.
■ Note: Flexion of the thigh causes posterior tilt of the
If you use this alternative hand positioning, be sure to
ilium; horizontal adduction causes internal rotation of not torque the client’s spine. Torqueing the LSp can
the ilium on that side, causing gapping of the posterior cause injury to the client.
aspect of the SIJ.
Variations of the Sacroiliac Joint Side-Lying Horizontal Adduction Sacroiliac Joint Mobilization
There are variations on how the side-lying mobilization of is done, the direction of the mobilization force can vary de-
the SIJ with horizontal adduction of the client’s thigh can pending on what aspect of the sacrum is contacted. If the
be performed. sacral base is contacted, the thenar eminence of the contact
With the PSIS contact, instead of pressing the client’s hand should be placed on the side of the base that is away
PSIS directly anteriorly, which maximizes the internal from the table to mobilize the SIJ that is on that side of the
rotation of the ilium and gaps the posterior aspect of the client’s body (the one that is away from the table) (Fig. C).
joint, the thenar eminence contact on the PSIS can press The direction of the mobilization stretch is directed ante-
anteriorly and inferiorly to increase the posterior tilt mo- riorly, superiorly, and laterally (this is similar to the prone
tion of the ilium (Fig. A). It is also possible to press an- sacral mobilization seen in Fig. 10-10A in Routine 10-2).
teriorly and superiorly on the PSIS to add anterior tilt to This mobilization will cause anterior tilt (nutation) of the
the gapping of the SIJ (Fig. B). However, if this is done, it sacrum as well as a nonaxial glide of the sacrum relative to
is important to lessen the flexion of the client’s thigh (the the ilium. If the sacral apex is contacted, the direction of the
reason for the thigh flexion was to cause posterior tilt of mobilization stretch would be primarily anterior and infe-
the ilium). rior to create posterior tilt (counternutation) of the sacrum
It is also possible to contact the sacrum instead of the relative to the ilium (Fig. D) (this is similar to the prone
PSIS with the thenar eminence of the contact hand. If this sacral mobilization seen in Fig. 10-10B in Routine 10-2).
A B
C D
Transitioning Side-Lying Horizontal Adduction Mobilization from the Sacroiliac Joint to the Lumbar Spinal Joints
The side-lying horizontal adduction joint mobilization for ilium, the LSp must be contacted. Rotation mobilization is
the SIJ can be easily transitioned to be a mobilization of the performed by contacting the vertebral SP on the side that is
LSp instead. Only two modifications are needed. closer to the table. In other words, if the client is lying on the
The first modification is that the client’s thigh needs to be right side, the right side of the SP is contacted; the mobilization
brought into more flexion so that tension is created in the LSp stretch force is added up against the SP, rotating the SP toward
(Fig. A); joint mobilization can only be done if the joint is first the left, resulting in right rotation of the vertebra (rotation is
brought to tension. Via femoropelvic rhythm, thigh flexion named for the direction that the anterior surface of the body
causes posterior tilt of the ilium on that side, causing tension orients) (Fig. B). For lateral flexion mobilization, contact the
at the SIJ on that side. Increasing thigh flexion causes so much SP/lamina on the side that is away from the table. In other
tension at the SIJ that the sacrum must now move (into poste- words, when the client is lying on the right, the mobilization
rior tilt/counternutation) with the ilium. As the sacrum moves, force is added against the left side SP/lamina and is directed
tension is created at the lumbosacral (L5-S1) joint. If the thigh down toward the table (anteriorly and medially) (Fig. C).
is brought further into flexion, this tension moves up the LSp, As with side-lying SIJ horizontal adduction, side-lying
allowing for effective joint mobilization at these lumbar joints. mobilization for the LSp should then be performed for the
The second modification is the placement of the con- other side, switching contact and support hands and which
tact treatment hand. Instead of contacting the PSIS of the side of the table you are standing on.
LSp mobilization introduces motion into the lumbar verte- 2. Further, the most powerful mobilization for the LSp is
brae. The motion that is introduced can vary depending on side-lying horizontal adduction, which is a variant of the
which lumbar vertebra is mobilized and in what direction. side-lying horizontal adduction mobilization for the SIJ
The most common contact for the mobilization hand is the (Routine 10-7), and transitioning this routine from the
SP because that is the easiest vertebral landmark to locate and SIJ to the LSp was addressed in Practical Application Box
access. However, contact against the lamina or mammillary/ 10.6. Please refer to Routine 10-7 and Practical Applica-
transverse processes is also sometimes done. Because of the tion Box 10.6 for the side-lying horizontal adduction LSp
lordotic curve of the LSp, it can sometimes be challenging to mobilization routine.
contact vertebral landmarks for LSp mobilization. The chal-
Seven LSp mobilization routines are presented in this
lenge is increased if the client has very well developed para-
chapter.
spinal musculature.
Depending on the position of the client, the use of a sta- ■ Routine 10-8—LSp prone: extension compression
bilization hand for LSp mobilization may or may not be ■ Routine 10-9—LSp prone: lateral flexion and rotation
necessary. Often, the client’s body weight provides adequate ■ Routine 10-10—LSp prone: flexion distraction
stabilization. The goal of LSp mobilization is to stretch/mobi- ■ Routine 10-11—LSp seated: mobilizations
lize the facet joint capsules, ligaments, and intrinsic muscles ■ Routine 10-12—LSp side-lying: horizontal adduction
of the region. ■ Routine 10-13—LSp supine: towel traction/distraction
■ Routine 10-14—LSp supine: manual traction/distraction
Notes:
As a rule, lumbar joint mobilizations should not be
1. Seated mobilization routine was shown in the “Overview done at the level of or nearby the level of segmental
of Technique” section and Therapist Tip Box 10.2 that fol- joints that have a space-occupying lesion, such as a
lowed immediately thereafter. For this mobilization, please pathologic disc or bone spur. Further, compression
see Figures 10-2 and 10-3 and Therapist Tip Box 10.2. mobilizations are contraindicated in clients who have
spondylolisthesis or osteoporosis. If there is any doubt as to
the safety of lumbar joint mobilization, consult first with the
client’s chiropractic or medical physician. Joint mobilizations
should never involve any type of fast thrust.
As with prone SIJ compression mobilization, prone com- ■ Now gently stretch the lumbar vertebra into its joint play
pression mobilization of the LSp can also be performed. The by leaning in further with body weight, adding a small
direction of the mobilization force is posterior to anterior increased compression force on the SP. This will involve a
(down toward the table/floor) and mobilizes the lumbar very small excursion of extension of that vertebra relative
vertebra(e) into extension. to the adjacent vertebrae (Fig. 10-16).
The following are the steps to perform prone extension
compression mobilization of the LSp:
■ The client is prone, and you are standing at the left side of
the table.
■ Place your right hand on the client’s LSp, with the SP of
the vertebra you are mobilizing positioned in the inter-
eminential groove of the hand.
■ Support your right hand with the thumb web of your left
hand. Note: The “support” left hand does not just support
the contact hand. It can also function to add to the force of
the mobilization by adding downward pressure through
the contact hand into the client.
■ Body weight stabilizes adjacent vertebrae, so no stabiliza-
tion hand is needed.
■ Gently lean in with body weight, adding compression
force anteriorly until you reach tissue tension at the end
of passive range of motion. Figure 10-16
A B
Routine 10-8 demonstrated posterior to anterior lumbar ■ For rotation mobilization, place the ulnar side (or more
compression mobilization to create extension. An effective specific contact of the pisiform) of your right hand on the
variation on this mobilization routine is to alter the verte- client’s LSp directly lateral to (to the left side of) the SP
bral contact and direction of the stretch mobilization force over the mammillary and transverse processes of the ver-
to introduce lateral flexion and/or rotation of the vertebra tebrae you are mobilizing. Your pressure will be directly
instead of extension. anterior (toward the table/floor) (Fig. 10-17B). This will
Joint mobilization into lateral flexion stretches opposite- create right rotation mobilization of the LSp (the SPs will
sided lateral flexor musculature, especially the smaller, deeper rotate to the left, but the anterior bodies, for which rota-
intrinsic muscles of the joint, and the ligamentous and joint tion is named, will rotate to the right).
capsular tissue on the other side of the joint being mobilized.
Joint mobilization into rotation to one side stretches mus-
culature that causes rotation to the other side as well as liga-
mentous and joint capsular tissue.
The following are the steps to perform prone (left) lateral
flexion and (right) rotation mobilizations to the left side of
the client’s LSp:
■ The client is prone, and you are standing at the left side of
the table.
■ For lateral flexion mobilization, place the ulnar side of
your right hand on the client’s LSp against the left side
of the SP/lamina of the vertebrae you are mobilizing; this
contact can be localized and made more specific by con-
tacting and placing your pressure through the pisiform of
your contact hand. Your pressure will be directed anteri-
orly toward the table/floor as well as laterally toward the
other (right) side of the client’s body (Fig. 10-17A). This Figure 10-17B
will create left lateral flexion mobilization of the LSp.
■ Note: For both mobilizations, because your hand con-
tact is a fairly large and broad, it is usually not possible to
isolate just one segmental vertebral level. Instead, two or
three vertebrae are mobilized together.
■ Support your right contact hand with the thumb web of
your left hand.
■ Body weight stabilizes adjacent vertebrae, so no stabiliza-
tion hand is needed.
■ Gently lean in with body weight, adding compression
force in the appropriate direction until you reach tissue
tension at the end of passive range of motion.
■ Now gently stretch the lumbar vertebra into its joint play
by leaning in further with body weight, adding a small
increased compression force on the vertebrae.
■ Hold for only a fraction of a second and then release.
■ This lumbar vertebral joint mobilization may then be re-
Figure 10-17A peated for a total of three to five times.
■ Once the joint mobilization has been performed at one
level, apply it at all the other levels of the LSp so that all
LSp joints are mobilized.
■ Repeat for the other side, switching contact and support
hands and which side of the table you are standing on.
Figure 10-18A
Figure 10-18B
Routines 10-8 and 10-9 demonstrated how to mobilize the left hand presses inferiorly on the sacral apex, until you
LSp into extension, lateral flexion, and rotation. Mobilizing reach tissue tension at the end of passive range of motion.
the LSp into flexion is more challenging because an effective ■ Now gently stretch the lumbar vertebra into its joint play
contact for the stabilization hand would have to be located by leaning in further with body weight, adding a small
anteriorly on the spine; this is not possible because you can- increased force on the SP, as you slightly increase the force
not easily contact the anterior aspect of the spine through on the apex of the sacrum. This will involve a very small
the anterior abdominal wall. It is also more challenging for excursion of flexion of that vertebra relative to the adja-
the treatment hand contact that creates the mobilization cent vertebrae; it also creates a slight distraction/traction
force to push on a lumbar vertebra in the direction of flex- of the mobilized vertebra (as well as a slight distraction/
ion. For these reasons, it is not possible to create a strong traction of the entire LSp) (Fig. 10-19).
flexion mobilization force. However, for clients whose LSp ■ Hold for only a fraction of a second and then release.
is greatly restricted into flexion, even small flexion mobiliza- ■ This lumbar vertebral joint mobilization may then be re-
tions can be very beneficial. peated for a total of three to five times.
Mobilizing the LSp into flexion can be done with prone ■ Once the joint mobilization has been performed at one
flexion distraction mobilization technique. This mobilization level, apply it at all the other levels of the LSp so that all
is similar to SIJ prone sacrum compression with the mobili- LSp joints are mobilized into flexion and distraction.
zation force applied to the sacral apex, mobilizing it toward ■ Repeat these routines as needed with concentration at the
posterior tilt (counternutation) (see Figure 10-10B). How- lumbar vertebrae that are restricted.
ever, to create a flexion mobilization of the LSp, a lumbar ■ Note: This routine can be performed from the other side
vertebra must also be contacted. This routine is described as of the table instead; simply switch treatment and stabiliza-
flexion distraction because in addition to the flexion, there tion hands.
is also a small element of axial distraction. Axial distraction
is also known as traction and is described in more detail in
Routine 10-13.
The following are the steps to perform prone flexion dis-
traction mobilization of the LSp:
■ The client is prone with a pillow under his abdomen, and
you are standing at the left side of the table.
■ Place your treatment (right) hand on the client’s LSp, with
the SP of the vertebra you are mobilizing positioned in the
intereminential groove of the hand.
■ Place your stabilization (left) hand on the middle of the
apex of the sacrum. Be careful to not contact so far infe-
riorly that you are on the coccyx instead. Pressure on the
coccyx could cause injury to the sacrococcygeal ligament
and/or the coccyx itself.
■ Gently lean in with body weight, pressing in a superior
direction on the lumbar SP with your right hand as your Figure 10-19
Figure 10-20
LSp side-lying horizontal adduction is the most powerful was addressed in Practical Application Box 10.6. Please refer
mobilization for the LSp and is a variant of the side-lying to Routine 10-7 and Practical Application Box 10.6 for this
horizontal adduction mobilization for the SIJ (Routine 10-7). LSp mobilization.
Transitioning from the SIJ to the LSp in side-lying position
Distraction mobilization of the spine, also known as axial dis- ■ You are standing at the foot end of the table, in a sagit-
traction, is usually called traction. In the LSp, it usually in- tal plane stance with your body weight balanced on your
volves an inferior glide of a vertebra relative to the vertebra forward foot (Fig. 10-21B).
that is above it. Distraction lengthens and stretches all of the
tissues that run vertically in the spine at the level(s) of dis-
traction. When performed by hand, it is also called manual
traction. When performed with the aid of a towel, it can be
called towel traction. Towel traction of the LSp is demon-
strated in this routine; manual distraction/traction of the LSp
is shown in Routine 10-14.
The following are the steps to perform distraction/traction
joint mobilization of the LSp using a towel:
■ The client is supine with a towel or king-sized pillowcase
wrapped around the distal legs as seen in Figure 10-21A.
Place the towel over the distal anterior legs. Wrap the two
sides of the towel back under and up through to the me-
dial side of the legs, superior to the part of the towel that
is lying anteriorly across the legs. The ends of the towel are
now draped distally toward the feet.
Figure 10-21B
Figure 10-21A
■ Gently and gradually begin pulling on the towel directly ■ Once tension is reached, perform the mobilization by gen-
inferiorly/distally (parallel with the table) as you slowly tly leaning further back, increasing the traction force. This
shift your weight back onto your rear foot (Fig. 10-21C). will cause a distraction force that tractions the pelvis away
Continue pulling until you feel tissue tension. from the LSp, and sequentially as tension is increased,
tractions each lumbar vertebra inferiorly away from the
vertebra superior to it (Fig. 10-21D).
■ Hold for a second or so and then release.
Figure 10-21C
Figure 10-21D
■ With this distraction technique, the weight of the client’s ■ This mobilization technique can be repeated for a total of
upper body will provide overall stabilization for the rest of three to five times.
the body, but it may not provide sufficient stabilization. If ■ In time, the position of traction stretch can be held for
the client’s body begins to slip on the table, the client can longer, perhaps 5 to 10 seconds or more.
be asked to hold onto the upper table with his hands for ■ To increase the traction tension on one side of the cli-
further stabilization (Fig. 10-21E). Having flannel sheets ent’s back, the client’s legs can be brought to the other
or another similar fabric can help to stabilize the client’s side (Fig. 10-21G). For body mechanics and balance, the
upper body by adding friction to minimize his sliding. therapist’s feet position should be shifted toward more of
a frontal plane stance.
Figure 10-21E
Figure 10-21G
■ Depending on how tight the client is, some of the traction
force might travel farther up the spine to the thoracic and
perhaps even the cervical spine. The tighter the client, the 10.9 PRACTICAL APPLICATION
higher up the spine the traction will be felt. One way to
focus the traction to the LSp is to stabilize the thoracic Towel Distraction/Traction
spine with a strap or seat belt. If this is done, for client Towel traction can be an extremely effective form of LSp
comfort, it is important to place padding between the re- joint mobilization distraction, and most clients enjoy it.
straining belt and the client (Fig. 10-21F). However, choosing the proper towel is important. If the
towel is too thick or too plush, it is difficult to grab the
client’s skin and difficult to hold on to. The optimal towel
is a well-used, somewhat threadbare bath-sized towel (ap-
proximately 40 ⫻ 24 inches [100 ⫻ 60 cm]). A king-sized
flannel pillowcase also works well. But if the fabric of the
towel or pillowcase is too thin, the contact can be too nar-
row and feel uncomfortable to the client.
It is also important to emphasize that the direction
of your pull should be as horizontal and parallel with the
table as possible. Do not lift the client’s feet up as you pull.
Manual traction/distraction joint mobilization of the LSp ■ Gently and gradually begin pulling on the client’s right
can also be effectively performed. In fact, the manual traction thigh as you slowly shift your weight back on the table.
technique routine presented here is generally more effective Press onto the table with your left foot to help stabilize
than towel traction technique placed at the legs (Routine 10- your body as you lean back (Fig. 10-22B). The direction of
13). Because the thigh is used as the lever to pull and traction your pull on the client’s thigh should be as horizontal and
the LSp, the knee joints are spared involvement. However, parallel with the table as possible. Continue pulling until
the hip and SIJs are still involved (see the caution regarding you feel tissue tension.
possible contraindications for this routine if these joints are
unhealthy).
The following are the steps to perform manual distrac-
tion/traction joint mobilization of the LSp using the client’s
right thigh:
■ The client is supine with her left lower extremity straight
on the table, her right hip and knee joints flexed, and her
right foot flat on the table.
■ You are sitting toward the foot end of the table, on the cli-
ent’s right side. Your right (lower) leg and foot are under
the client’s right knee; your left thigh and knee joints are
flexed, and your left foot is placed on the top of the table,
to the right side of the client. The fingers of your hands
are interlaced, and you are grasping the anterior proximal
right thigh of the client (Fig. 10-22A). It is important to
be as proximal on the client’s thigh as possible. Note: The
therapist can choose to either wear or not wear his or her Figure 10-22B
shoes when on the table. If shoes are not worn, be sure to
check that health codes allow this. Also, it can be difficult
■ Once tension is reached, perform the mobilization by gen-
to grab with traction with stocking feet.
tly leaning further back, increasing the traction force. This
will cause a distraction force that tractions the pelvis away
from the LSp and, sequentially as tension is increased,
tractions each lumbar vertebra inferiorly away from the
vertebra superior to it (Fig. 10-22C).
Figure 10-22A
Figure 10-22C
CHAPTER SUMMARY smaller, deeper intrinsic muscles and the ligaments and joint
capsules of the joint being mobilized. As with any stretch-
Joint mobilization is a valuable advanced technique in the ing technique, joint mobilization is usually most effective
therapist’s array of treatment options. In essence, it is a very when performed after the client’s tissues are first warmed
specific form of pin and stretch in which the therapist pins up, whether through massage, heat, or physical activity.
(stabilizes) one vertebra while moving (mobilizing/stretch- Although it is important to practice and hone your skills with
ing) the adjacent vertebra. For clients with segmental hypo- all new treatment techniques before using them with your
mobility (a soft tissue restriction that is limited to one or a clients, because joint mobilization of the LSp is such a power-
few spinal joint levels of the LSp), joint mobilization is often ful technique, particular care needs to be paid to practicing
the only treatment technique that is effective at loosening this technique before incorporating it into your treatment
the taut tissues. It is especially effective for stretching the regimen.
CASE STUDY
ALICIA Your assessment shows that her LSp gross ranges of mo-
tion are all normal, although she describes feeling slightly
■ History and Physical Assessment
stiff when moving into flexion and right lateral flexion.
A new client, Alicia Alexander, age 32 years, comes to your Upon palpation, you find a mild to moderate muscle spas-
office complaining of low back pain and stiffness. She de- ming in the left low back/pelvis region, specifically at the
scribes the pain as a 5 to 7 on a scale of 0 to 10. She tells you left lumbosacral paraspinal muscles, the superomedial fi-
that her condition has been progressing for about a year and bers of the left gluteus maximus, and the left piriformis.
that she believes it is a result of the increased time she has When you ask her to indicate where her pain and tightness
been spent sitting. She first noticed the discomfort late last are located, she points to the medial side of the left PSIS.
year after an 8-hour car ride back from vacation. Since then, Upon joint play/motion palpation of the LSp and SIJs, all
she has had many deadlines at work that require her to spend joints are moving well except that you find a marked hy-
a lot of time seated at the computer; she is a graphic artist. pomobility in her left SIJ. (For a review of assessment pro-
You perform a thorough client history, which reveals cedures, see Chapter 3.)
no trauma. She reports that her discomfort is localized to
the lower left side of her low back. There is no referral into ■ Think-It-Through Questions:
either of the lower extremities. She tells you that she has 1. Should an advanced technique such as joint mobiliza-
seen a massage therapist once a week for the past 4 weeks, tion be included in your treatment plan for Alicia? Why,
with treatment consisting of heat, deep tissue work, as well or why not?
as standard and contract relax stretching, but that the pain 2. Is joint mobilization safe to use with Alicia? If yes, how
and tightness have only improved slightly. She has also do you make that determination?
been walking more, hoping that it would help to loosen her 3. If you do joint mobilization, which specific joint mobi-
low back; it seems to help for a couple of hours but then the lization routines should you use? How and why would
discomfort and pain return. She describes the discomfort/ you choose those particular routines?
pain as a deep dull ache and stiffness.
You perform the passive and active straight leg raise, Answers to these Think-It-Through Questions and the
and you ask her to perform the cough and slump tests and Treatment Strategy employed for this client are available
the Valsalva maneuver, the results of which are all negative. online at thePoint.lww.com/MuscolinoLowBack
CHAPTER
11 Self-Care for the Client
CHAPTER OUTLINE
OBJECTIVES
After completing this chapter, the student should be able to: 8. Explain the importance of stretching for client self-care.
1. Explain the importance of client self-care. 9. Describe to a client how to perform the stretching routines presented
2. Describe the balance scale analogy for client self-care. in this chapter.
3. Describe the indications for and mechanisms of cold, heat, and con- 10. Describe to the client how to incorporate contract relax (CR), agonist
trast hydrotherapy. contract (AC), and contract relax agonist contract (CRAC) stretching
4. Explain the importance of hydrotherapy for client self-care. protocols into self-care stretches.
5. Describe to a client how to perform self-care cold, heat, and con- 11. Explain the importance of posture to client self-care and describe
trast hydrotherapy routines. the most common postures that may be stressful to the low back
6. Describe the advantage to the therapist of using cold hydrotherapy and pelvis that are presented in this chapter and how to avoid
in conjunction with deep tissue work. them.
7. Describe and perform cold hydrotherapy using a CryoCup and ice 12. Define the key terms of this chapter.
pack massage.
KEY TERMS
377
377
PART THREE
INTRODUCTION
11.1 THERAPIST TIP
The goal of all therapists who work clinically is to become
highly skilled, advancing their knowledge base and learning Balance Scale Analogy
as many techniques as possible to help their clients. How- Simple analogies are often extremely helpful when coun-
ever, even the best therapist can have difficulty resolving seling a client regarding the importance of home self-care.
the client’s condition if the client does not become engaged One effective analogy that can be used is to an old-fash-
in the care. Even if a client assertively seeks treatment and ioned balancing scale for measuring weight. With the
comes in three times a week for an hour session each time, balance scale analogy, good health and feeling better are
there are another 165 hours in the week that the client is not represented by one side and occur if the scale is tipped in
in the therapist’s care. If during this time the client is engag- that direction. Bad health and pain/discomfort are rep-
ing in unhealthy postures and activities that aggravate the resented by the other side and continue or worsen if that
problem, it is very difficult for the therapist’s 3 hours of care side tips down (see accompanying figure).
to reverse the problem. For this reason, the self-care a dvice In this analogy, the client can improve if more good
that the therapist gives clients is critically important to the things are done to tip that side down, if fewer bad things
success of the care plan. The three major components of are done so that the other side lightens up and raises (and
c lient self-care are hydrotherapy, stretching, and learning and therefore, the good side tips down), or both. It is important
using proper postures. to explain to the client that your treatments add weight to
the good side but that the client can help his or her healing
with the things he or she does at work and home by adding
BOX 11.1 more good things to the good side and by no longer doing
the bad things that would tip the scale the other way.
Self-Care Routines This chapter presents hydrotherapy and stretching that
the client can perform to tip the scale toward good health.
The following self-care routines are presented in this It also presents information about poor postures that the
chapter: client should avoid so that the client can prevent addi-
■ Hydrotherapy: tional stresses to the low back and pelvis and thereby also
n Routine 11-1—cold hydrotherapy
tip the scale toward the side of good health. It is always
n Routine 11-2—heat hydrotherapy
helpful to point out to clients that the more they do to help
n Routine 11-3—contrast hydrotherapy
themselves, the less you will have to do to help them and
the sooner they will get better.
■ Lumbar spine stretches:
n Routine 11-4—chair low back stretch
n Routine 11-5—knee-to-chest stretch
n Routine 11-6—double knee-to-chest stretch
n Routine 11-7—double knee-to-chest stretch with
Good postures
osture
es
contract relax (CR) protocol Stretching
etchin
ng
Bad postures
“water”). Treating with water is advantageous because water swelling is not always visible on the outside of the client’s
is an excellent medium for conveying temperature. Heated body. Sometimes, the swelling is either mild in degree or is
water can efficiently transfer heat to the client; water in the located in deeper tissue layers. In these cases, if it cannot be
form of ice is excellent at transferring cold. However, the seen, the therapist needs to feel for it by palpating the region
term hydrotherapy is sometimes expanded to include almost gently and carefully. In some cases, the swelling might be so
any form of heat or cold therapy, even if water is not in- deep that it cannot even be palpated. In these cases, it is im-
volved; examples include electric heating pads and chemical portant to listen to how the client describes the discomfort.
gel ice packs. Pain is present in almost every musculoskeletal condition.
Hot and cold hydrotherapy treatments are powerful tools. However, when a client states that an area is tender to the
Although almost every textbook and journal article states touch, swelling is often present. Using cold to decrease swell-
rules and guidelines for the application of hot and cold, it ing can be desirable for a number of reasons:
often seems that they contradict each other. Instead of mem-
■ Swelling causes pressure on sensory nerves, leading to in-
orizing cookbook rules about when and how to use these
creased pain, which can then trigger the pain-spasm-pain
modalities, it is best to simply understand what the underly-
cycle.
ing physiologic mechanism of each one is. Understanding
■ Swelling also draws to the area tissue factors that chemi-
what heat and/or cold does physiologically makes it possible
cally irritate pain endings.
to decide how to best apply them to meet the needs of each
■ The physical presence of the swelling can obstruct move-
specific client.
ment in the region, resulting in decreased range of mo-
tion, allowing muscles to tighten and adhesions to form
Cold Hydrotherapy in the soft tissues.
■ Swelling brings in fibroblasts, cells that form collagen ad-
The use of cold hydrotherapy, also known as cryotherapy, has
hesions. If allowed to remain in an area, these cells will
two major physiologic benefits. Cold numbs sensory recep-
lay down excessive adhesions, further decreasing range of
tors, resulting in the elimination of pain. Cold also causes
motion.
local vasoconstriction, thereby helping to decrease swelling/
■ Excessive swelling can close off local veins, lymph vessels,
inflammation in the region where it is applied.
and arteries, actually resulting in decreased circulation
The first major reason to use cold is that it is an anesthetic
in the area. If venous and lymphatic flow is obstructed,
agent that can decrease pain. This is important because pain
waste products of metabolism are not removed from the
can trigger the pain-spasm-pain cycle. In this cycle, pain trig-
area, resulting in an accumulation in the tissues. These
gers muscular spasming to splint and protect the region from
waste products can then lead to irritation of the local sen-
overuse. This spasming then produces further pain, which
sory nerves, leading to further pain. If arterial flow is ob-
perpetuates the cycle. Therefore, decreasing pain might
structed, oxygen and other nutrients cannot be brought
lessen some of the reflexive muscular spasming. Thus, even
into the area, resulting in ischemia. Ischemia can then
if the use of cold does not directly treat and help improve the
result in the formation of myofascial trigger points as well
underlying mechanism of the client’s condition, the fact that
as inhibit the healing process of injured tissues.
it decreases pain can help to decrease the reflexive muscle
spasming that accompanies almost every musculoskeletal
condition.
Decreasing muscle spasming can then help many other 11.1 PRACTICAL APPLICATION
aspects of musculoskeletal conditions. For example, de-
creased muscle spasming allows for greater joint range of Using Cold for Deep Tissue Work Therapy
motion, thereby allowing for increased movement, which in
Therapists may choose to use cold during a treatment ses-
turn increases local blood circulation and allows for better
sion to numb a region of the client’s body so that they
stretching of the soft tissues. Decreasing muscle spasming in
can work deeper than otherwise would have been pos-
the low back and pelvis also reduces the compression load
sible. If deep tissue work would benefit the client but the
on the joints of the low back, which can be beneficial if the
discomfort/pain would prevent the client from tolerating
client is experiencing a lumbar disc bulge or herniation, a
it, then cold can be applied to the area to make it pos-
facet joint irritation, or a sacroiliac joint condition. And, of
sible. Of course, if the client is now numb in the region
course, muscle spasming itself may cause pain from the ten-
being worked, he or she loses the ability to give feedback
sion of the tight muscles’ pulling force. For all these reasons,
regarding your pressure. For this reason, it is imperative
cold can be used as an anesthetic agent and can be used at
that you judge the depth of your pressure so as not to
any stage of a musculoskeletal problem, whether it is acute
injure the client. If very deep pressure is used, it may be
or chronic.
advisable to also use cold therapy afterward to prevent
The second reason to use cold is to decrease swelling that
swelling in response to the deep work.
might be present in the tissues. It is important to realize that
PART THREE
ROUTINES
A B
The use of a CryoCup. (A) The CryoCup is filled close to the top with water and placed in a freezer to create ice.
(B) The bottom part of the CryoCup is removed and the top part is used as a handle for the ice application.
PART THREE
Heat Hydrotherapy 2. Heat causes local vasodilation, which brings more blood
to the region where it is applied. Arterial blood brings in
The use of heat hydrotherapy has three major physiologic needed nutrients not only for the normal metabolism of
benefits: the cells of the region but also to help heal injured tissues
1. Heat is a central nervous system depressant, which pro- in the region.
motes muscular relaxation. This is heat’s major advantage 3. Heat helps to soften and release the fascial tissues of the
when used as a relaxing agent. If the central nervous sys- body. These include the muscular fascia (endomysia, peri-
tem is relaxed, the baseline contractile tone of the mus- mysia, epimysia, tendons, and aponeuroses) as well as
culature will likely be lessened, resulting in a relaxation the ligaments, ligamentous joint capsules, and other fas-
of tight muscles. This can help improve the health of the cial membranes. Therefore, heat is ideal to apply before
region for all of the reasons already discussed. stretching the client.
Methods and Application of Heat Hydrotherapy preference. Whereas cold therapy poses the danger of frost-
When using heat for self-care, the client has many choices bite to the tissues, heat is generally safer, although there is a
for how to apply it, including a hot shower or bath, hot wet danger of burning the skin if a hot pack or shower is too hot.
towels, microwavable bead packs, or an electric heating pad. It is important to remind the client to monitor the tempera-
If the client owns or has access to a whirlpool, steam room, or ture of whatever heat application method is used. One other
sauna, these are also effective options. Even physical exercise factor that should be considered with heat therapy is that if it
can be used to heat body tissues, especially if the exercise is is applied for too long, it may inflame the area.
aerobic and warms the body, causing sweating. Some of these Regarding frequency of use, the general rule is that if heat
options are easier to manage than others. Microwavable is indicated, then the more often it is performed, the better.
packs and electric heating pads are easy and convenient to When a condition is marked or severe in degree, recommend
use. Both dry and moist electric heating pads serve to warm that the client use heat therapy at least three times a day. As
the tissues, but moist heat is generally superior to dry heat. with cold therapy, when doing multiple heat applications in
A shower is often the preferred method of applying moist 1 day, the guideline is to let the area return to body tempera-
heat to the low back and pelvis (or any region of the body). It ture before repeating the application. As previously stated,
is easy to do, and because the water actually hits the client’s when using heat for tight muscles and/or other soft tissues,
skin, a shower gives a slight stimulating massage in addition stretching should follow.
to applying heat.
As a general rule, heat should not be applied to a swollen
Guidelines for Heat Hydrotherapy area. Because heat produces vasodilation, this would
only cause a further influx of blood, thereby increasing
Unlike cold therapy, whose application time is fairly regi- the swelling. Also, as with cold application, heat must be
mented (apply until numb), heat therapy application time prudently applied with clients who have altered sensation, given
can vary much more. The appropriate length of time for ap- their inability to judge whether the heat is burning the skin. If
plying heat ranges from 5 to 20 minutes, depending on the the client does have altered sensation, ask the client to check the
temperature of the heat application and client comfort and temperature of the heated skin every minute or so.
Contrast Hydrotherapy: Alternating Cold and Heat is called contrast hydrotherapy. Most musculoskeletal condi-
Treatments tions involve a combination of muscular spasming and tissue
swelling. The swelling indicates cold as the treatment of choice,
Even though cold and heat applications may seem to be oppo- and the muscular spasming indicates heat as the treatment of
site treatment approaches, using both is often the most efficient choice. Therefore, any condition that presents with both spas-
hydrotherapy choice. Alternating cold and heat hydrotherapy ming and swelling may benefit from contrast hydrotherapy.
Methods and Application of Contrast Hydrotherapy If both swelling and spasming are present, the ideal treat-
When working with contrast hydrotherapy, any of the methods ment is contrast hydrotherapy. In this case, if the muscle
discussed for cold hydrotherapy and heat hydrotherapy can be spasming is the major factor, the ideal home advice for
used. It is customary to apply the cold therapy first, followed the client is to use ice, followed by moist heat, followed by
by the heat therapy. The cold first numbs the area, interrupting stretching. If swelling is the major factor, the ideal home ad-
the pain-spasm-pain cycle, and causes a vasoconstriction; this vice is to use ice, followed by moist heat, followed by stretch-
is followed by vasodilation caused by the heat. The overall ef- ing, followed by ice again. (Cold is always used until numb;
fect of alternating cold and heat is that of a circulation pump, heat therapy time ranges from 5 to 20 minutes.)
pushing old blood out to remove waste products and drawing
new blood in to bring in nutrients. Ending with heat also results
in relaxation and softening of the tissues, thereby providing the Whenever recommending the application of heat after
perfect springboard to follow with stretching. cold, instruct your clients to be especially careful. If
the cold application has numbed the area, then the
Guidelines for Contrast Hydrotherapy clients might not be aware if they are burning their
skin with the application of heat. It is helpful to have the
As a rule, if only swelling is present, the ideal home care ad- clients also apply the heat to the adjacent skin that was not
vice for the client is to use only cold. If only muscle spasming treated with cold so they can judge if the temperature is too
is present, the ideal home advice is to use only moist heat hot. For example, if a hot shower is the heat application,
followed by stretching. (One amendment to this rule is that instruct them to let the water hit the adjacent skin that has
cold can always be used for its numbing effect.) not had cold therapy applied.
PART THREE
Stretching Protocols
■ Lumbar spine stretches: 11.4 THERAPIST TIP
n Routine 11-4—chair low back stretch
n Routine 11-5—knee-to-chest stretch Limit the Number of Stretches You Recommend
n Routine 11-6—double knee-to-chest stretch
Take care not to overwhelm the client with self-care
n Routine 11-7—double knee-to-chest with CR protocol
stretches and recommendations. Some clients will follow
n Routine 11-8—double knee-to-chest with AC protocol
your advice if you recommend just one or two stretches
n Routine 11-9—double knee-to-chest with CRAC
but will become overwhelmed and do none of them if you
protocol recommend more. When considering how much home
n Routine 11-10—lumbar spine-extension medley
advice to give your clients, assess how engaged and willing
n Routine 11-11—lumbar spine lateral stretch
they are to participate in self-care. It is often a good idea
■ Pelvis/hip joint medley of stretches: to start them off with the most important stretch or two
n Routine 11-12—anterior line (hip flexor) stretches for their condition. If at the next session you find that they
n Routine 11-13—lateral line (hip abductor) stretch were motivated and did what you advised, then you might
n Routine 11-14—medial line (hip adductor) stretch add another stretch or two. Incrementally adding in this
n Routine 11-15—posterior line-vertical (hip extensor/ manner often gives the client time to absorb your advice
hamstring) stretch and become comfortable with the stretches. The skill with
n Routine 11-16—posterior line-horizontal (hip lateral which you educate and encourage your clients influences
rotator/piriformis) stretches their desire to be involved in their own self-care.
CHAPTER 11
Figure 11-1C
Starting Position:
n The client is lying supine.
n The client bends his hip and knee joints on one side and
places his hands on the posterior distal thigh on that
side. Note: It is common to see people grasp the anterior
proximal leg instead; this causes unneeded compres-
sion to the knee joint. Grasping the posterior distal thigh
accomplishes the same stretch to the low back without
compression to the knee joint.
Figure 11-2
CHAPTER 11
n The length of time that this stretch position is held and the
View the video “Knee to Chest and Double Knee
to Chest Stretches” online on thePoint.lww.com number of repetitions performed depend on whether the
stretch is being done statically or dynamically.
n As with the chair low back stretch in which lateral flexion
The double knee-to-chest stretch stretches the posterior gluteal was added, lateral flexion to each side can be added to the
musculature but is primarily aimed at stretching the poste- double knee-to-chest stretch (Fig. 11-3B). The client can
rior extensor musculature of the lumbar spine. By bringing also perform a circumduction motion (Fig. 11-3C). If this
both knees up, the pelvis posteriorly tilts, which decreases the is recommended, be sure to tell the client to perform the
lumbar lordotic curve, stretching the lumbar extensors. As circumduction circles slowly.
the position of the stretch is deepened, the pelvis rolls more
into posterior tilt, leaving the table, and the stretch moves up
the lumbar spine.
Starting Position:
n The client is lying supine.
n The client bends his hip and knee joints on both sides and
places his hands on the posterior distal thighs.
Figure 11-3B
A B
A B
D C
D C
Starting Position:
n The client is lying supine.
n The client bends his hip and knee joints on both sides and
places his hands on the posterior distal thighs.
Figure 11-4A
Figure 11-4C
Further Repetitions:
n Beginning from the position reached at the end of step 3,
the client repeats steps 2 and 3 for a total of three or four
repetitions.
n During the last repetition, the client can hold the position
of stretch attained in step 2 for a longer period of time,
perhaps 10 to 20 seconds or longer.
CHAPTER 11
The client can also perform the double knee-to-chest stretch n This stretch is held usually for 1 to 2 seconds.
using the AC stretching protocol. For more information on n The client usually completes the exhale during this step.
how to perform AC stretching, see Chapter 8. The follow-
ing are the steps for the client to do AC stretching with the
double knee-to-chest stretch.
Starting Position:
n The client is supine (Fig. 11-5A).
Figure 11-5C
Figure 11-5D
Further Repetitions:
Figure 11-5B n Beginning from the starting position, the client re-
peats steps 1 through 3 for a total of approximately 8 to
Step 2: Further Stretch: 10 repetitions.
n The client relaxes and uses the hands to pull the knees n During the last repetition, the client can hold the position
farther in the same direction, increasing the stretch of stretch attained in step 2 for a longer period of time,
(Fig. 11-5C). perhaps 10 to 20 seconds or longer.
PART THREE
ROUTINE 11-9: DOUBLE KNEE-TO-CHEST STRETCH WITH CONTRACT RELAX AGONIST CONTRACT PROTOCOL
Starting Position:
n The client is supine.
n The client bends his hip and knee joints on both sides and
places his hands on the posterior distal thighs (Fig. 11-6A).
Figure 11-6C
Figure 11-6A
Figure 11-6D
Further Repetitions:
Figure 11-6B n Beginning from the starting position with the hands hold-
ing the thighs, the client repeats steps 1 through 4 for a
Step 2: Client Concentric Contraction and Initial Stretch: total of approximately 3 to 10 repetitions.
n The client exhales while actively contracting and bringing n During the last repetition, the client can hold the position
the knees up toward the chest using the musculature of the of stretch attained in step 3 for a longer period, perhaps
anterior abdominal wall and pelvis/hip joint (Fig. 11-6C). 10 to 20 seconds or longer.
CHAPTER 11
Whereas the single knee-to-chest and double knee-to-chest position is to push up on the hands (Fig. 11-7D). The cli-
are flexion stretches of the lumbar spine and pelvis, the lumbar ent should not progress from one position to the next unless
spine-extension medley brings the lumbar spine into exten- he can do so without any increased symptoms. Some clients
sion. Many clients who do not respond to flexion exercises require several days or weeks to progress to the fourth stretch
respond well to extension exercises. Extension exercises are position; other clients are able to perform the fourth stretch
indicated for clients who have pathologic lumbar discs because position on the first day. Progressing through these stretch
the position of extension drives the nucleus pulposus anteri- positions should not be rushed. If the client ever experiences
orly away from the posterior annular fibers, where bulges and an increase in lower extremity referral, instruct the client to
herniations are usually located. However, extension can be discontinue these stretches immediately.
challenging for the client’s spine at first, so it is recommended The first and second stretch positions are simply held
that these exercises are introduced very slowly and carefully. statically; instruct the client to lie in the position for up to 60
The lumbar spine-extension medley is composed of a series seconds. As with other stretches, the third and fourth stretch
of four positions of increasing lumbar spine-extension that positions can be performed statically or dynamically and is
the client performs in the prone position. The first exten- typically performed for approximately 1 minute. Clients have
sion position is to lie prone with a pillow under the anterior the choice of performing approximately three repetitions,
abdominal wall (Fig. 11-7A). The second position is to lie each one held for 10 to 20 seconds (statically), or perhaps
prone without the pillow (Fig. 11-7B). The third position 10 to 20 repetitions, each one held for only 3 seconds or so
is to push up on the forearms (Fig. 11-7C). And the fourth (dynamically).
A B
C D
Figure 11-7
PART THREE
Starting Position:
n The client is standing with the right foot in back and ad-
ducted to the other side of the body. Having a wall or
other stable object nearby for balance is helpful.
Figure 11-8
CHAPTER 11
The anterior line (hip flexor) stretches are important because n If the ankle joint plantarflexion musculature in the right
when hip flexor muscles are tight, they exert their tension by posterior leg (e.g., gastrocnemius and soleus) is tight and
pulling the pelvis into anterior tilt, which then increases the therefore limits the client’s ability to stretch the hip flex-
lordotic curve of the lumbar spine, placing more pressure on ors, then the client can let the right heel leave the floor
the facet joints and narrowing the intervertebral foramina. as seen in Figure 11-9A (this moves the ankle joint into
Tight hip flexors also limit extension of the hip joint, which plantarflexion, thereby slackening these muscles).
can shorten the stride when walking. n The stretching protocol is repeated for the other (left) side
lower extremity.
Starting Position: n The entire stretching protocol is then repeated with the
n The client is standing with the left foot forward and right knee joint in back flexed (Fig. 11-9B) for both the right
foot in back. and left sides. This focuses the stretch to the rectus femoris
of the quadriceps femoris group.
Performing the Stretch: n The length of time that this stretch position is held and the
n The client slowly lunges forward, leaning his weight onto number of repetitions performed depend on whether the
the left foot. This causes the right hip joint to move into stretch is being done statically or dynamically.
extension, stretching the right hip flexors (Fig. 11-9A).
Figure 11-9B
Figure 11-9A
When stretching the hip flexors, the client should
make sure that his or her knee of the foot in front does
not move anterior to his or her foot because this will
cause a shearing force to be placed on the knee joint.
If this occurs, the client should reposition with a wider stance
with his or her front foot farther forward.
PART THREE
Starting Position:
n The client is standing with the right foot in back and ad-
ducted to the other side of the body. Having a wall or
other stable object nearby for balance is helpful.
Figure 11-10
CHAPTER 11
The medial line (hip adductor) stretch is important because Performing the Stretch:
when the adductor muscles are tight, they exert their tension n The client uses his hands to gently push his distal thighs
by pulling the same-side pelvis into elevation, which can then laterally and down. This causes the hip joints to move into
cause a scoliotic curve to compensate. When these muscles abduction, stretching the hip adductors (Fig. 11-11).
are tight, they also limit abduction at the hip joint. Because n The length of time that this stretch position is held and the
most of the adductor muscles also do flexion and medial number of repetitions performed depend on whether the
rotation at the hip joint, when these muscles are tight, they stretch is being done statically or dynamically.
can also limit extension and lateral rotation of the thigh at
the hip joint. Limiting extension can also shorten the stride
when walking.
Starting Position:
n The client is seated with both thighs abducted, knees
flexed, feet together in front of the body, and his hands on
his knees.
Figure 11-11
The posterior line-vertical (hip extensor/hamstring) stretch is im- n The length of time that this stretch position is held and the
portant because when the hamstrings are tight, they exert number of repetitions performed depend on whether the
their tension by pulling the pelvis into posterior tilt, which stretch is being done statically or dynamically.
then decreases the lordotic curve of the lumbar spine. Via a
myofascial continuity with the sacrotuberous ligament, they
also exert their pull onto the sacrum, thereby decreasing
motion of the sacroiliac joint. Tight hip extensors also limit
flexion of the hip joint, which can shorten the stride when
walking.
Starting Position:
n The client is seated with the right lower extremity straight
in front of him and his left thigh flexed and abducted and
his left knee joint flexed.
The posterior line-horizontal (hip lateral rotator/piriformis) n If the client experiences pain in the anterior hip joint re-
stretches are important because when the lateral rotators gion (the groin), advise the client to place a small rolled
are tight, they exert their tension by pulling the pelvis into up towel between his thigh and trunk (Fig. 11-13B).
opposite-side rotation, which can then cause the pelvis to be
torqued. This may likely cause a torque/rotational compen-
sation in the spine. Further, when the piriformis is tight, it
can limit mobility of the sacrum at the sacroiliac joint. Tight
lateral rotators also limit medial rotation of the thigh at the
hip joint. There are two excellent stretching protocols for
the posterior line-horizontal hip lateral rotator stretch. The
first is known as knee-to-opposite-shoulder stretch (named in
contrast to knee-to-chest stretch). The second one is called
the Figure 4 stretch.
Knee-to-Opposite-Shoulder Stretch
Starting Position:
n The client is supine with his right hip and knee joints
flexed.
n His hands are placed on the outside of the distal lateral
right thigh. Figure 11-13B
Figure 4 Stretch
Figure 11-13A Starting Position:
n The client is supine with his right hip joint flexed and lat-
erally rotated and right knee joint flexed. His right ankle
If the client’s knee joint is unhealthy, advise the client
to avoid contacting the (lower) leg and instead be sure is placed on the distal anterior surface of the left thigh (the
to contact the lateral thigh. This avoids compression hip and knee joints of the left lower extremity are flexed
to the knee joint. and the left foot is flat on the table).
n His hands are placed on the posterior distal surface of the
left thigh.
CHAPTER 11
POSTURAL ADVICE the sequelae that follow from tight, spasmed muscles. Fur-
ther, spending prolonged time in trunk flexion will gradu-
In addition to ice, heat, and stretching, it is critical for the ally stretch and lengthen the fascial tissues (thoracolumbar
therapist to give postural advice to clients with low back and fascia, ligaments, joint capsules) on the posterior side. This
pelvis problems. Although many factors can contribute to a will decrease stability of the spine, requiring the musculature
problem in this region, the repeated microtraumas of poor to work even harder. And when the trunk is in flexion, the
posture are often a major factor. Even if poor posture has not lumbar musculature will be lengthened and less able to gen-
caused the client’s condition, it will certainly perpetuate the erate contractile force and therefore less able to stabilize the
problem and impede the healing process. Five of the most spine in the imbalanced flexion posture of bending/leaning
common postures that affect the low back and pelvis are as forward.
follows: It is important to advise the client to avoid this posture as
1. Stoop-bending/leaning-forward posture much as possible, despite the fact that many common tasks
2. Carrying a heavy weight and activities encourage this imbalanced flexion position.
3. Prolonged sitting Examples include bending forward to shovel snow, make a
4. Prolonged standing bed, take care of a child, lift an object, read a book or tablet
5. Bad sleeping posture in the lap, or work in a garden (Fig. 11-14A). Advise the cli-
ent to keep the spine as vertical as possible instead of bend-
Stoop-Bending/Leaning-Forward Posture ing down to perform these and similar tasks. This minimizes
the stress to the client’s extensor musculature. For example,
One of the most common postural problems of the low back when tending to a baby, try to work with the baby on a bed
is stoop bending, in other words, leaning forward into spinal as you kneel; when reading a book/tablet, bring it up to eye
flexion. When you bend forward to work in front of yourself, level; and when gardening, try sitting on the ground and
the center of weight of your trunk is no longer balanced over working directly in front of yourself as much as possible
the pelvis. When this occurs, gravity would cause the trunk (Fig. 11-14B).
to fall into full flexion until you fall down, except for the When you do need to bend down, it is better for the spine
counterforce created by the lumbar extensor muscles. These if you bend with your knees, as well as your hip and ankle
muscles work to maintain this imbalanced posture of flexion joints, and keep your spine straight and vertical (Fig. 11-14C).
through prolonged isometric contraction. Such prolonged The one disadvantage to bending with the knees is that it
contraction will fatigue them, resulting in spasming and all does place more stress on the knee joints.
A B C
Figure 11-14 Bending and working. (A) Stoop bending (leaning forward) while gardening places the center of
weight of the trunk over thin air. This requires contraction of the posterior extensor musculature of the spine to hold
the person in this imbalanced position. (B) Sitting on the ground while gardening allows the spine to remain vertical
so that the center of weight of the trunk is balanced over the pelvis. (C) Bending with the hip, knee, and ankle joints
allows for the spine to remain vertical and therefore the center of weight of the trunk to be balanced over the pelvis.
CHAPTER 11
A B
PART THREE
Prolonged Sitting possible, they get up and walk around for a few minutes. The
specific posture in which a client sits is also very important.
Sitting might be relaxing for the joints of the lower extremity, The client should either sit straight up or lean back against
but it is not for the spinal and sacroiliac joints. When seated, the back of the chair; if the client leans forward, spinal exten-
the trunk is vertical; therefore, these joints are still weight sor musculature must contract to hold the trunk from falling
bearing and under compression of the weight above (Fig. 11- into flexion. It is also important to sit evenly and not lean to
16). In fact, studies have shown that compression forces one side or the other; sitting in a crooked posture will asym-
through the disc joints are greater for sitting than they are for metrically load and physically stress the joints of the spine.
standing if the sitting is done without a lumbar support. As a Further, when armrests are available, they should be used.
result, clients who spend long periods of time sitting, such as Armrests not only support the arms, thereby decreasing
white collar desk workers, often experience lower back pain. work for the shoulder musculature, but also decrease weight
Sitting and driving a car or truck is even worse because every bearing through the spinal joints because the weight of the
time the vehicle hits a bump or a pot hole, the force travels arms is transferred into the armrests instead of through the
up through the person’s spinal joints. For clients whose jobs spinal and sacroiliac joints. If possible, another alternative
require sitting, it is important to recommend that as often as is to sit in a reclining chair. The farther back the chair is
A B
Figure A shows the cross-legged position with adduction; Figure B shows it with abduction.
CHAPTER 11
Prolonged Standing
Similar to prolonged sitting, prolonged standing is also dif- Figure 11-17 When standing on one leg, the center of the weight of
ficult for the spinal and sacroiliac joints because they, in this the body is imbalanced to the other side. This requires the gluteus
position, are weight bearing. It is important to advise the cli- medius on the standing-leg side to contract to stabilize the pelvis.
ent to break up prolonged periods of standing by walking
around or, if possible, lying down. It is also important to ad- row the intervertebral foramina of the spine (Fig. 11-18A).
vise the client to avoid the habit of shifting more weight onto It also causes some muscles to adaptively shorten and will
one leg than the other. Shifting weight to one leg increases most likely overstretch and aggravate others, perhaps initi-
compression forces on the lower extremity joints on that side ating the muscle spindle reflex and causing them to tighten.
of the body. It also requires the gluteus medius on that side If a client insists on sleeping on the stomach, advise him or
to increase its contraction to stabilize the pelvis and trunk. her to place a small pillow under the abdomen to support the
This will further compress and load the hip joint on that side lumbar spine (Fig. 11-18B).
of the body (Fig. 11-17). As compensation, people who stand It is generally better to sleep either on the back or side.
on one leg often laterally flex their trunk to that side. This al- However, if the client sleeps on the side, the “upper” thigh
lows the gluteus medius to relax; however, it asymmetrically can fall into adduction, flexion, and medial rotation toward
loads the spine. the “lower” thigh and bed. This would place a torque on the
pelvis, thereby aggravating the sacroiliac joints and perhaps
Bad Sleeping Posture the joints of the lumbar spine as well (Fig. 11-18C). For this
reason, it is a good idea to place a pillow between the knees
It is critically important to address the posture of the client to support the upper thigh (Fig. 11-18D).
when sleeping. If a client sleeps between 6 and 8 hours per When sleeping on the back, if the hip flexors are tight,
night, then by the time the client reaches the age of 80 years, they can exert their pull on the pelvis, causing it to anteriorly
he or she has spent 20 to 25 years or more sleeping! If a cli- tilt, which would then increase the lumbar lordosis (Fig. 11-
ent’s sleep posture is unhealthy for the low back, it will have 18E). To prevent this, a small roll or pillow can be placed
a profound adverse effect over time. under the knees. This slackens and relaxes the hip flexor
Sleeping on the stomach is simply unhealthy for the musculature, relieving tension on the pelvis and spine. Some
low back (as well as the neck). Stomach sleeping allows the clients also find relief when sleeping on their back by placing
lumbar spine to collapse toward the bed and increase its lor- a small pillow directly under the lumbar spine to support the
dosis. This increases compression on the facet joints and nar- lordotic curve (Fig. 11-18F).
PART THREE
F
Figure 11-18 Sleeping postures. (A) Sleeping on the stomach allows the lumbar curve to collapse into increased
lordosis. (B) Placing a small pillow under the abdomen can support the lumbar curve. (C) Sleeping on the side often
causes the “upper” thigh to fall toward the other thigh and bed, placing a torque into the sacroiliac joint. (D) Placing
a pillow between the thighs supports the upper thigh. (E) When sleeping on the back, tight hip flexor musculature
can anteriorly tilt the pelvis, thereby increasing the lumbar lordosis. (F) Placing a roll under the knees relieves the
tension from the hip flexor musculature.
CHAPTER 11
CHAPTER SUMMARY to client self-care; proper posture is the third. This chapter
presents guidelines for cold, heat, and contrast hydrotherapy;
Developing the client self-care treatment plan should be a presents several effective low back, sacroiliac joint, and hip
collaborative effort between the therapist and the client. The joint stretches for self-care; and describes some of the most
therapist’s role is twofold: to help educate the client about common postures that stress a client’s low back. When the
what they do in their life at home, work, and in their hobbies/ therapist and client work together as a team, not only is the
activities that facilitates healing and to help the client become likelihood of treatment success practically guaranteed but the
aware of what perpetuates problems and impedes progress. client will also improve more quickly and with fewer treat-
Hydrotherapy and stretching are two of the three major keys ment sessions.
CASE STUDY
CHAPTER OUTLINE
Introduction404
Introduction000 Self-Care Stabilization
Ligaments of the Cervical
Exercises
Spine 000
409
The Cervical Spine
Mechanism: Motor Control 000
405 Precautions000
Chapter Summary 425
The Cervical
Overview andSpinal
Performing
Jointsthe Technique 000
406 Chapter
Case Study
summary 000
426
Motion of the Cervical Spine 000 Review Questions 000
Musculature of the Cervical Spine 000
OBJECTIVES
OBJECTIVES
After completing this chapter, the student should be able to: 6. Give examples of destabilizing postures of the body and destabilizing
1. Explain
After why self-care
completing stabilization
this chapter, exercises
the student shouldare
be important
able to: for the 7. surfaces used of
Classify each in the
stabilization
muscles ofexercises.
the neck into its major structural and
therapist the
1. Describe andstructure
client. of the cervical spine. 7. Describe
functionalthe lower crossed syndrome.
groups.
Describethe
2. Discuss theimportance
relationship
andbetween proprioception
implications of the bifidand postural
spinous and 8. 8. Define
Explaineach
whykey term the
knowing in this chapter
actions of a and explain
muscle its relationship
can facilitate palpatingto
stabilization.
transverse processes to palpation and treatment. stabilization
and stretchingexercise.
it.
Describethe
3. Discuss proper posture of the lumbar
importance laminaespine and pelvis.
and articular processes to 9. Perform
9. List andthe stabilization
describe exercises
the structure and presented
function ofinthe
thisligaments
chapter. of the
4. tDescribe
reatment.the two major components of motor control. cervical spine.
5. Describe
4. Explain whythe destabilizing
structure andpostures
function and labile
of the surfaces
cervical spinalarejoints.
used in 10. Explain how ligaments and antagonist muscles are similar in function.
stabilization
5. Describe the exercises.
axial and nonaxial motions of the cervical spine. 11. Describe the major precautions and contraindications when working
6. List the attachments and actions of the muscles of the cervical on the neck.
spine. 12. Define each key term in this chapter
KEY TERMS
KEY TERMS
cervical brace labile surface Pilates side bridge
core lower crossed syndrome powerhouse stabilization strengthening
dead bug track lumbosacral instability prone plank exercises
destabilizing body position lumbopelvic relationship proprioception supine bridging track
destabilizing forces motor control quadruped track The Art of Contrology
destabilizing surface neutral lumbar spine rocker boards wobble boards
extension exercises neutral pelvis sacral base angle
kinesthetic awareness perturbation sensorimotor exercises
BOX 12.3
Lower Syndrome
Lumbar instability is exacerbated by a prolonged sitting
posture. Vladimir Janda of the Czech Republic has de-
scribed the typical pattern of muscular imbalance that
develops as the lower crossed syndrome, which involves
a characteristic postural distortion pattern of rounded
back, slouched posture, and an excessive lumbar lordo-
sis. The term crossed refers to the characteristic cross (X) Tight upper
Weak deep
that describes the relationship between the tight (short- trapezius and
neck flexors
ened and overly facilitated) muscles in front and back levator scapulae
and the weak (lengthened and overly inhibited) muscles
in front and back (see accompanying figure). The word
lower distinguishes this syndrome from the upper crossed
Weak
syndrome that occurs at the cervicothoracic region (also rhomboids and
Tight pectoralis
demonstrated in the accompanying figure). Manual thera- serratus anterior
musculature
pists recognize the lower crossed syndrome as a common
pattern of muscle imbalance in the lower half of the body, Tight low back Weak
with weakness of both the lumbar and pelvic stabilizers as extensors abdominals
well as shortening of other muscles. The weak lumbar sta-
bilizers are the lumbar spine flexors: the rectus abdominis
and internal and external abdominal obliques (and trans-
versus abdominis). The weak pelvic stabilizers are the glu-
teus maximus, medius, and minimus muscles. The tight
muscles are the low back extensors of the lumbar spine Weak gluteal
Tight hip flexors
and the flexors of the hip joint. muscles
OVERVIEW AND PERFORMING THE TECHNIQUE sacrum is the base for the lumbar spine, it is the posture
of the sacrum and therefore the pelvis that determines the
The purpose of low back stabilization exercises is twofold: to
posture of the lumbar spine. Therefore, creating proper
strengthen the stabilization musculature needed for proper
lumbar/lumbosacral spine posture is accomplished by
posture and to train the nervous system to learn and main-
creating proper posture of the pelvis.
tain proper posture while the body performs all of its various
■ There is some debate about what qualifies as ideal neutral
activities. When performing all of the stabilization exercises
posture of the pelvis in the sagittal plane. One way to de-
described in this chapter, it is imperative to keep the lumbo-
scribe neutral pelvic posture is to have the pubic tubercle
sacral spine in proper posture. Posture should be considered
and the anterior superior iliac spine (ASIS) aligned ver-
in all three cardinal planes, but the sagittal plane posture is
tically. So, if you are standing, a line drawn along these
the one that is often most critically important.
bony landmarks would be vertical (Fig. 12-1A), and if
■ Proper sagittal plane posture of the lumbosacral spine you are supine, a line drawn along these bony landmarks
involves keeping the lumbar spine and pelvis (lumbo- would be horizontal (Fig. 12-1B). This method can be
sacral spine) in what is called neutral position, in other problematic because sometimes, it is hard to visualize
words, neutral lumbar spine and neutral pelvis. Because the these landmarks.
CHAPTER 12
A B
Figure 12-1 Determining neutral lumbar spine and pelvis. (A) When standing, a line drawn along the pubic tu-
bercle and ASIS is vertical. (B) When supine, the same line is horizontal.
■ Another way that some sources describe neutral posture in proper posture. For the neck, proper posture entails
is that it is the position that is midway between anterior tucking the chin to prevent hyperextension of the upper
tilt and posterior tilt such that the region is under the least cervical spine and retracting the head and lower cer-
passive strain and the motions are freest. However, if a vical spine to hold/bring the neck over the trunk. For
person’s pelvic posture is chronically excessive in anterior the upper back/shoulder girdle region, proper posture
or posterior tilt, the tissues likely adapt to this excessive entails pinching the shoulder blades back into retrac-
posture, so he or she might feel strain if he or she tries to tion so that the shoulders do not round forward, and
correct/improve the posture. For this reason, this method bringing the upper thoracic spine back into extension
can also be problematic. to prevent the upper back from slumping forward (Fig.
■ If your pelvic tilt is excessive, do not try to suddenly force it 12-2).
into the perfect ideal neutral posture too quickly. I nstead, ■ The goal of each exercise is to learn to maintain these
look to gradually transition from your posture toward the proper postures for a prolonged period. Generally, it is
ideal posture over a period of weeks or months. recommended to work up to holding the posture for 1
■ Note: When performing these exercises, it is imperative minute or more. Performing three repetitions is usually
to also keep the neck, shoulder girdle, and upper back recommended.
PART THREE
BOX 12.4
15°
30°
45°
A B C
BOX 12.5
BOX 12.6
Pelvic Tilts
Pelvic tilts are very simple range of motion exercises for the It can be helpful to place your hand under the small of
pelvis and lumbar spine that can be performed in a seated your low back and feel for your low back to press down
or supine position. They help loosen the low back muscles against your hand.
as well as teach the therapist how the pelvis moves. Pelvic ■ Anterior tilt: Now arch your low back, contracting the
tilts are easier to learn while in the reclining position, so it lumbar extensor paraspinal musculature until the low
is best to begin there. If you have low back pain, this is also back is raised off the floor; the upper back and buttocks
a way to try to increase your pain-free range of motion. should remain on the floor (Fig. B).
■ Repeat for a total of approximately three repetitions.
■ Posterior tilt: Press your low back flat against the floor by ■ If you have a chronically tight low back, the posterior tilt
tightening your abdominal and gluteal muscles (Fig. A). exercise should be emphasized.
A B
ROUTINES
The muscles of the lumbosacral region must be able to proper posture while resisting the force of gravity will build
maintain the low back and pelvis in the proper position for the muscles of this region sufficiently. Thus, the exercises
extended periods of time. This requires endurance, so the that follow can be performed at home, without expensive
exercises included here for lumbosacral stabilization training machines.
only ask you to maintain proper posture of the low back as Performing these strengthening exercises as a part of self-
you oppose the force of gravity acting on the weight of your care can help to prevent problems such as weakness and
body. Movements of the trunk up against gravity and the fatigue of the lumbosacral musculature, as well as poor core
addition of weights are not usually necessary for stabiliza- kinesthetic awareness, which are often associated with low
tion strengthening of the lumbar spine. Simply maintaining back problems.
PART THREE
The prone plank is a well-known stabilization exercise that ■ Hold this posture for 10 seconds and then slowly lower to
strengthens the anterior abdominal wall. Following are two the floor.
variations. The first one is performed by balancing on the ■ Three repetitions are usually performed.
knees and elbows/forearms; this is the less challenging of ■ Build to longer hold times, perhaps 60 seconds or more.
the two variations. Once this variation is mastered, you can ■ Note: If your pelvis begins to dip, then stop.
move on to the second one in which the body is balanced
on the toes and the elbows/forearms. Note: The term plank Second Variation: On Toes:
refers to keeping the body straight like a plank of wood. ■ Lying prone, prop yourself up on your elbows as in the
first variation. Now, with your knee joints extended, rise
First Variation: On Knees: up on your toes and elbows. Your body should be a lmost
■ Lying prone, prop yourself up on your elbows like you are straight as a board, with the rear end raised slightly
reading in bed. (Fig. 12-3B).
■ Bend your knees slightly (flexing the thighs at the knee ■ Hold this posture for 10 seconds and then slowly lower to
joints) and raise your pelvis off the floor. You should now the floor.
be resting only on your elbows and knees, with your hips ■ Three repetitions are usually performed.
and torso suspended between them. Your body should be ■ Build to longer hold times, perhaps 60 seconds or more.
almost straight as a board, with the rear end raised slightly ■ Note: If your pelvis begins to dip, then stop.
(Fig. 12-3A).
A B
Figure 12-3 Prone plank. (A) Variation one: on knees. (B) Variation two: on toes.
CHAPTER 12
The side bridge is similar to the prone plank exercise except, ■ Three repetitions are usually performed.
as its name implies, it is performed in the side-lying position ■ Build to longer hold times, perhaps 60 seconds or more.
instead of prone. The side bridge strengthens the lateral ab- ■ Repeat for the other side.
dominal wall that is closer to the floor. Once performed on ■ Note: If you cannot hold the form and your spine begins
one side, the side bridge exercise should be performed on the to collapse (laterally flex) toward the floor, then stop.
other side. As with the prone plank, there are two variations.
The first one should be mastered before moving on to the Second Variation: On Foot:
second, more challenging variation. Note: The term bridge ■ Position yourself as in the first variation but keep your
refers to raising the body up like a bridge that spans from one knee joints extended. Make sure that your shoulders, hips,
support to the other. knees, and ankles are stacked in a straight line.
■ Raise your pelvis off the floor. Your whole body should
First Variation: On Knee: now be suspended between your elbow and the lateral
■ Lying on your side with your knee joints flexed 90 degrees, edge of your downside foot, with your spine straight
prop yourself up on your elbow, keeping your elbow (Fig. 12-4B).
directly below your shoulder. Make sure that your shoul- ■ Hold this posture for 10 seconds and then slowly lower to
ders, hips, and knees are stacked in a straight line. the floor.
■ Raise your pelvis off the floor so that your spine is straight. ■ Three repetitions are usually performed.
Your whole body should now be suspended between ■ Build to longer hold times, perhaps 60 seconds or more.
your elbow and the lateral side of your downside knee ■ Repeat for the other side.
(Fig. 12-4A). ■ Note: If you cannot hold the form and your spine begins
■ Hold this posture for 10 seconds and then slowly lower to to collapse toward the floor, then stop.
the floor.
A B
Figure 12-4 Side bridge on the left side. (A) Variation one: on knee. (B) Variation two: on foot.
PART THREE
The supine bridging track exercises follow a path (track) that free and comfortable (Fig. 12-5B). If posterior tilt is not
progressively moves from less to more complicated and added, this exercise should be performed in a neutral
challenging exercises. They are a progression of five varia- spine position.
tions performed in the supine position that strengthen the ■ Raise the pelvis straight up off the floor; be sure to main-
posterior abdominal wall (lumbar extensors, e.g., paraspinal tain the posture of the lumbar spine and not arch the back
and quadratus lumborum musculature) and extensors of the (Fig. 12-5C). Many people tend to raise the pelvis too far
hip joint (posterior gluteal musculature and hamstrings). As when bridging, so feel free to limit the height to which you
with other stabilization exercises, each variation should be elevate it.
mastered before progressing to the next. Each variation not ■ Hold this posture for 10 seconds and then slowly lower to
only can be performed in a neutral lumbar spine position but the floor.
may also be performed with a posterior pelvic tilt to avoid ex- ■ Three repetitions are usually performed.
cessive lumbar extension while bridging up. Note: When per- ■ Build to longer hold times, perhaps 60 seconds or more.
forming supine bridges, keep your shoulder girdles r etracted ■ Repeat for the other side.
against the floor; it is also helpful to press your palms down ■ Note: If you cannot hold the form and your spine begins
against the floor. to collapse toward the floor, then stop.
A B
C D
Figure 12-5 Supine bridging track. (A) Starting position. (B) Pelvic posterior tilt added (the arms have been ab-
ducted so that the spine can be seen). (C) Supine bridging by raising pelvis. (D) Bridging with heel raises. (continued)
CHAPTER 12
■ Then the raised heel is slowly lowered to the floor, after ■ As with previous variations, perform this exercise for
which the opposite heel is raised. 10 seconds; three repetitions are usually performed. As
■ The heels are alternately raised and lowered, one at a time. you strengthen, build to longer times for each repetition,
■ Perform this exercise for 10 seconds. perhaps 60 seconds or more.
■ Three repetitions are usually performed.
■ Build to longer times, perhaps 60 seconds or more.
■ The emphasis of this exercise is on the pelvis. During
the foot and ankle movement, the pelvis should remain
immobile/stable.
■ Note: If you find it difficult to stabilize your pelvis dur-
ing this exercise, it can be helpful to place your fingertips
on your ASISs. This gives an additional tactile clue to the
position of your pelvis in space.
The quadruped track is a series of exercises performed on all First Variation: Quadruped Arm Raises:
fours (quadruped) that progressively moves from less to ■ Get onto your hands and knees. Assume the cervical
more complicated and challenging exercises. The exercises brace position and maintain the lumbar spine in neutral
place the spine in a horizontal, non–weight-bearing position, position.
thus limiting weight-bearing loads on the spine. Quadruped- ■ Once the position is stable, elevate one arm into flexion
track exercises are often used as the starting point for cervi- until it is parallel with the floor while maintaining stability
cal stabilization; the term cervical brace is used to describe (Fig. 12-6A).
quadruped exercises performed for cervical stabilization. ■ Hold for 5 to 10 seconds.
However, quadruped-track exercises also actively engage the ■ Repeat with the opposite arm.
anterior abdominal wall and hip extensor musculature. The ■ Perform three repetitions for each side.
focus during these exercises is to maintain neutral posture of ■ As you strengthen, build to longer times for each repeti-
the lumbar spine and pelvis. This involves pulling the umbi- tion, perhaps 60 seconds or more.
licus in and slightly up toward the spine in a simple drawing-
in maneuver (without changing the angle of the bony pelvis Second Variation: Quadruped Leg Raises:
and spine). ■ Assume the quadruped track cervical brace position with
Note: Once the exercises in this position have been mas- the lumbar spine in neutral position.
tered, resistance can be added to increase the stress to the de- ■ Once the position is stable, extend one lower extrem-
sired tissues. Labile surfaces may also be used to increase the ity (thigh at the hip joint and leg at the knee joint) until
proprioceptive input as shown later in this chapter (Routine it is parallel with the floor while maintaining stability
12-11), thus stimulating the sensorimotor system. (Fig. 12-6B).
■ Hold for 5 to 10 seconds.
■ Repeat with the opposite lower extremity.
■ Perform three repetitions for each side.
■ As you strengthen, build to longer times for each repeti-
BOX 12.8 tion, perhaps 60 seconds or more.
A B
The dead bug track is a series of exercises that build lumbo- ■ Now “kick” one leg out by extending it at the knee joint
sacral stability by strengthening the anterior abdominal wall until the lower extremity is straight and pointed toward
muscles. It is named after the appearance of a dead bug, in the ceiling (Fig. 12-7C).
other words, on its back with its legs up in the air. As with ■ Hold this posture for approximately 1 second and then
the other track exercises, it progresses from less to more return the leg to the starting position.
challenging. The initial variation is a statically held position; ■ Repeat this motion with the opposite leg.
further variations increase destabilization forces by adding ■ Continue alternating legs, performing this exercise for
in motions of the extremities as you maintain a stabilized 10 seconds.
position of the lumbar spine and pelvis. Pelvic posterior tilt ■ Three sets of repetitions are usually performed.
is the key aspect of the exercise and should be maintained ■ Build to longer times for each set, perhaps 60 seconds or
throughout the track. more.
■ Note: A more challenging version of this variation is to
First Variation: Dead Bug Position: partially lower (extend) the opposite thigh at the hip joint
■ Lie supine, flattening your back against the floor by poste- as the knee joint is extended, so that the opposite thigh no
riorly tilting your pelvis. longer points toward the ceiling (Fig. 12-7D). The closer
■ Raise (flex) the thighs at the hip joints 90 degrees (until the lower extremity approaches to the floor, the more
they are perpendicular to the ground), with the legs flexed challenging this exercise is for lumbosacral stabilization.
at the knee joints to 90 degrees (parallel to the ground). Remember, what is most important is not the leg motion
■ Now raise (flex) your arms at the glenohumeral joints but the ability to maintain posterior tilt lumbosacral sta-
straight up, so that they are pointing to the ceiling and bilization during the motion. If you cannot maintain pos-
parallel to your thighs (Fig. 12-7A). terior pelvic tilt, lessen the thigh extension of this version
■ Hold this posture for 10 seconds and then slowly lower of the variation.
your arms and legs to the floor. ■ Additional note: As with the second variation with arm
■ Three repetitions are usually performed. movements, this variation can also be made more chal-
■ Build to longer hold times, perhaps 60 seconds or more. lenging by moving the legs simultaneously; in other
words, as you lower one lower extremity, raise the other.
Second Variation: Dead Bug with Arm Movements: Be sure to master the static position before trying simul-
■ Begin the second variation in the position of the first vari- taneous motion of both lower extremities.
ation of the dead bug exercise (see Fig. 12-7A).
■ Now further flex one arm until it is flexed 180 degrees and Fourth Variation: Dead Bug with Arm and Leg
flat on the floor by the side of your head (Fig. 12-7B). Movements:
■ Hold this posture for approximately 1 second and then ■ The fourth dead bug variation is a combination of varia-
return the arm to the starting position. tions 2 and 3 above.
■ Repeat this motion with the opposite arm. ■ Begin in the position of the first variation of the dead bug
■ Continue alternating arms, performing this exercise for exercise (see Fig. 12-7A).
10 seconds. ■ Raise one arm over your head (as in the second variation
■ Three sets of repetitions are usually performed. shown in Fig. 12-7B) while you “kick” the opposite leg (as
■ Build to longer times for each set, perhaps 60 seconds or in the third variation shown in Figs. 12-7C and 12-7D)
more. (Fig. 12-7E).
■ Note: A slightly more challenging version of this variation ■ Hold this posture for approximately 1 second. Then r eturn
is to move the arms simultaneously, in other words, as you both extremities to their starting position.
lower one arm, raise the other. ■ Repeat with the opposite arm and leg.
■ Perform this exercise for 10 seconds.
Third Variation: Dead Bug with Leg Movements: ■ Three sets of repetitions are usually performed.
■ Begin the third variation in the position of the first varia- ■ Build to longer times for each set, perhaps 60 seconds or
tion of the dead bug exercise (see Fig. 12-7A). more.
CHAPTER 12
A B
C D
Figure 12-7 Dead bug track exercises. (A) First variation: dead
bug position. (B) Second variation: dead bug with arm move-
ments. (C, D) Third variation: dead bug with leg (lower e xtremity)
movements. (E) Fourth variation: dead bug with arm and leg
E movements.
PART THREE
Sensorimotor exercises involve maintaining the pelvis and lizing body position can be combined with a destabilizing
lumbar spine (as well as the head and neck) in their proper po- surface, such as standing on one foot while on a rocker or
sition and then introducing destabilizing forces into the body. wobble board, to increase the challenge to the neuromuscu-
This requires the stabilization musculature to work harder lar stabilization pathways.
to maintain stabilization or to restabilize the body, thereby When performing these exercises, one way to increase
strengthening and improving neuromuscular pathways. the challenge of maintaining proper stabilization posture
Destabilizing forces can be introduced in two ways: One is to have an additional destabilizing force introduced—for
method is to stand on one foot, which is a destabilizing body example, have someone gently push you while you are per-
position. The other method is to stand on a labile surface, forming the exercise. This added destabilizing force is called
which is a destabilizing surface because it is movable. Most a perturbation. The level of challenge can be increased as the
people have had the experience of standing on a boat while ability to maintain stability increases.
it is moving. It is more difficult to maintain proper posture The following are examples of lumbar spine sensorimo-
when on a boat because the surface itself is moving. Fortu- tor stabilization exercises. As with the stabilization strength-
nately, it is not necessary to stand on a boat to do sensorimo- ening exercises, these exercises are presented in order from
tor training, although it might be fun. Instead, it is possible to most stable (least challenging) to least stable (most chal-
use tools that provide a moving labile surface, such as rocker lenging). As with all exercise regimens, it is important to
boards and wobble boards. Rocker boards, as their name im- gradually increase the challenge to your body, successfully
plies, rock back and forth with their rocking motion confined mastering the less challenging exercises before attempting
to a single plane of motion. Wobble boards allow for motion the more challenging ones.
(wobbling) in all directions/planes (although the potential Note: As with the stabilization strengthening activities
motion is greatest in the sagittal and frontal planes and least presented in this chapter, it is also important to maintain
in the transverse plane), so they are less stable and therefore proper stabilization of the head, neck, and upper back (see
more challenging than rocker boards. Of course, a destabi- Fig. 12-2).
CHAPTER 12
BOX 12.9
A B
The next most challenging exercise is the double-leg stance ■ As you progress and become more stable, you can increase
on rocker board. the challenge by having perturbations added.
■ If working with clients, it is important to spot them, espe-
■ Stand on both feet (a stabilizing posture) on the platform
cially as they mount and dismount the board and if per-
of a rocker board (a destabilizing surface).
turbations are added.
■ A rocker board is designed to move/rock in one plane. The
unstable surface makes it more challenging to maintain a
stable posture than when performing the single-leg stance Because stabilization exercises, by definition,
on the floor, even though the weight is on both feet. destabilize your posture, there is a danger of falling.
■ Remember that it is critical to maintain proper posture Therefore, it is important to perform these exercises
during the exercise (Fig. 12-9A). in a safe environment, perhaps with a soft couch or
wall nearby that can be used to regain balance if there is a
■ Strive to hold this posture with the board rocking in the
possibility of falling. This is especially true when first stepping
sagittal plane, front and back, for 1 minute. onto (mounting) the board, when stepping off (dismounting)
■ Three repetitions are usually performed. the board, and if perturbations are added. If administering
■ As stability increases, the rocker board can be oriented to or monitoring stabilization exercises with a client, offer
rock/move laterally in the frontal plane, and finally in an assistance or spotting if the client loses balance, especially with
oblique plane (between sagittal and frontal planes). mounting, dismounting, and when perturbations are added.
CHAPTER 12
Perturbations
When performing any sensorimotor stabilization exer- ing muscular contraction. When performing these senso-
cise, it is possible to increase the challenge/difficulty of rimotor exercises for your self-care, if you can enlist the
the exercise by adding a perturbation (small push) to the aid of someone to add perturbations, the proprioceptive
body. The perturbation is usually done at the level of the challenge to your body will be increased. If you are using
pelvis (if a rocker board is being used, the perturbation is these exercises to work with a client, consider adding per-
administered in the plane of the direction of the rocker turbations as the client becomes more advanced in his or
board). The perturbation provokes an increase in stabiliz- her training.
The single-leg stance on rocker board is similar to the ■ Three repetitions are usually performed.
double-leg stance exercise, except the activity is done in a ■ As stability is attained in the sagittal plane, the rocker
single-leg stance position. This may be quite difficult at first. board can be oriented to rock/move laterally in the frontal
plane, and finally in an oblique plane.
■ Stand on one foot (a destabilizing posture) on the rocker
■ As you progress and become more stable, you can increase
board (a destabilizing surface).
the challenge by having perturbations added.
■ Focus on keeping the weight of the foot centered over the
■ If working with clients, it is important to spot them,
rocker board.
especially as they mount and dismount the board and if
■ As with the double-leg stance on the rocker board, strive
perturbations are added.
to hold proper posture, with the board rocking front and
back in the sagittal plane for 1 minute (Fig. 12-9B).
A B
Figure 12-9 Rocker board sensorimotor stabilization exercises. A rocker board is a destabilizing (labile) surface that
can rock in one plane. (A) Double-leg stance on rocker board. (B) Single-leg stance on rocker board. (Reproduced
with permission from Muscolino JE. Advanced Treatment Techniques for the Manual Therapist: Neck. Baltimore,
MD: Lippincott Williams & Wilkins; 2013.)
PART THREE
The double-leg stance on wobble board is similar to the ■ Strive to hold proper posture for 1 minute.
double-leg stance on the rocker board, except that the wob- ■ Three repetitions are usually performed.
ble board is inherently more unstable than the rocker board ■ Perturbations can be added as proficiency is reached.
because it is able to move/wobble in all planes. ■ If working with clients, it is important to spot them,
especially as they mount and dismount the board and if
■ Stand on both feet (a stabilizing posture) on the platform
perturbations are added.
of a wobble board (a destabilizing surface) (Fig. 12-10A).
■ Given how unstable a wobble board is, be especially care-
ful when mounting and dismounting the board.
The single-leg stance on a wobble board is one of the most ■ Work up to holding proper posture for 1 minute.
difficult stabilizing exercises because it involves a destabiliz- ■ Three repetitions are usually performed.
ing posture on a destabilizing surface. As a result, when done ■ As with all sensorimotor exercises, once proficiency is
properly, it can do the most to challenge and improve pro- reached, perturbations can be added.
prioceptive stabilization to the spine. ■ If working with clients, it is important to spot them,
especially as they mount and dismount the board and if
■ Stand on one foot on the wobble board (Fig. 12-10B).
perturbations are added.
■ Given its difficulty, it is especially important to have a wall
nearby when mounting and dismounting the board.
A B
Figure 12-10 Wobble board sensorimotor stabilization exercise. A wobble board is a destabilizing (labile) surface
that can wobble in all planes. (A) Double-leg stance on wobble board. (B) Single-leg stance on wobble board. ([A]
Reproduced with permission from Muscolino JE. Advanced Treatment Techniques for the Manual Therapist: Neck.
Baltimore, MD: Lippincott Williams & Wilkins; 2013.)
CHAPTER 12
Quadruped-track sensorimotor exercises use foam rollers as ■ Note: For proper posture of the rest of the body, tuck the
the labile surface. chin and retract the head and lower neck and push the
interscapular region superiorly toward the ceiling.
■ Begin with two rollers placed parallel to each other, per-
■ Hold this posture for 10 to 20 seconds, gradually working
pendicular to the long axis of the body (Fig. 12-11A). This
up to 1 minute.
challenges balance in the sagittal plane.
■ Three repetitions are usually performed.
■ Place both knees on one roller and both hands on the sec-
■ As stability increases, the foam roller position can be
ond roller.
changed to be parallel to the long axis of the body; this
■ As with most all stabilization exercises, be sure to pull the
challenges posture in the frontal plane (Fig. 12-11B).
umbilicus in and slightly up toward the spine, holding a
■ Once each position is mastered, an external load, such as
slight posture of posterior pelvic tilt.
a textbook, can be added by placing it on your low back.
A B
Figure 12-11 Quadruped-track sensorimotor stabilization exercise. Two foam rollers are used as the destabilizing
(labile) surface. (A) Foam rollers are oriented perpendicular to the long axis of the body. (B) Foam rollers are ori-
ented parallel with the long axis of the body. (Reproduced with permission from Muscolino JE. Advanced Treatment
Techniques for the Manual Therapist: Neck. Baltimore, MD: Lippincott Williams & Wilkins; 2013.)
CHAPTER SUMMARY ing exercises for the musculature. Working with destabiliz-
ing postures and performing these exercises on destabilizing
With manual therapy’s emphasis on stretching and loosening (labile) surfaces provides the challenge to the neuromuscular
tight muscles and other taut soft tissues, it is easy to overlook stabilization pathways that is necessary for this to occur.
the importance of strengthening the musculature for spinal Given the tremendous physicality of manual therapy,
stabilization. However, the best way to support musculoskel- therapists should practice self-care, just as they recommend
etal health is to achieve a balance of loose, flexible soft tissues self-care to their clients. Incorporating spinal stabilization
along with musculature that is strong and able to provide exercises into the self-care regimen is a wise choice. For
stabilization to the joints. A competent lumbosacral spinal therapists who are licensed or certified to recommend and
stabilization regimen incorporates sensorimotor training administer strengthening exercises, weaving these exercises
for the neural proprioceptive system as well as strengthen- into client treatment is also an excellent decision.
PART THREE
CASE STUDY
YOU great deficit, and there is no pain associated with the ranges
of motion. Muscle palpation yields similar results to range
Note: This case study follows a slightly different format of motion assessment. You are generally tight, but there are
than usual. Instead of imagining that a client comes to no glaring trigger points or other areas of hypertonicity.
you, this case study imagines you as the client. Certainly, Further, there is little correlation between the location and
the degree to which the details of this case study match degree of tightness and the presence and degree of your low
your circumstances might vary tremendously. However, back fatigue and discomfort.
this is a fairly common scenario for many therapists and Postural examination shows an excessively anteriorly
given that this is a therapist self-care chapter, it might be tilted pelvis with a corresponding hyperlordotic lumbar
instructive and fun to imagine yourself in the role of the spine. Following up the spine, your thoracic spine is moder-
case study client. ately hyperkyphotic, and your lower cervical spine is mildly
■ History and Physical Assessment hypolordotic with compensatory upper cervical spine hy-
You have been a therapist for many years. When you first perlordosis and forward head carriage (protraction).
began in practice, you felt strong and comfortable doing Evaluating stabilization strength of the lumbar spine,
manual therapy. However, in the past few years, you have Simona asks you to try a number of stabilization exercises
noticed that you fatigue much more easily and feel sore and for the lumbosacral spine such as prone plank, side and
uncomfortable in your low back after working for only a supine bridging, dead bug, and quadruped-track exer-
few hours. Ironically, even though your practice is growing, cises. You are unable to maintain core stability for more
you are finding it increasingly difficult to expend the physi- than 10 to 15 seconds during these exercises without your
cal effort needed to take care of your clients, and you are characteristic low back fatigue and discomfort. During
beginning to have to limit your schedule and even cancel the rocker and wobble board exercises, you do not only
appointments on some of your busier days. Because you exhibit your characteristic fatigue and discomfort but you
notice that the trend is that the problem is getting worse, are also not able to balance for more than a few seconds
not better, you fear that your ability to continue practic- before falling off.
ing might soon be in jeopardy. During your recent yearly Given that you are a manual therapist, Simona also asks
physical with your naturopathic physician, you mentioned you to demonstrate your body mechanics by working on
how you have been feeling. She ordered blood work and someone in her office for a few minutes. She notes that
radiographs of your low back and ruled out any obvious you have a tendency to “muscle” the massage with upper
metabolic disorders. extremity musculature instead of efficiently generating
Not being sure what to do, you consult with a friend of force by working from your core. Simona also notes that
yours, Simona, who is both a massage therapist and a fit- you stand too far from the region of the client that you are
ness trainer. During her verbal history with you, you begin working; as a result, you tend to overly flex/stoop your back
to realize that although you often counsel your clients to to reach the client.
maintain good musculoskeletal health, you are no longer ■ Think-It-Through Questions:
living those ideals. You begin to see yourself as one of your 1. Should you incorporate spinal stabilization exercises in
own clients who does not take care of his or her own body your self-care plan? If so, why? If not, why not?
and instead has prioritized work over health. You rarely 2. If lumbosacral spinal stabilization exercises would be of
get massage yourself, and you stopped going to the gym to value, are they safe for you to perform? If yes, how do
work out quite some time ago. You have also gained weight you know? If not, why not?
in the last couple of years. 3. If you decide that you should perform stabilization
During the physical exam, you show negative for all training, which specific exercise routines should you do,
the low back and sacroiliac joint orthopedic assessment and why?
tests that are administered, including active and passive
straight leg raise, cough test, Valsalva maneuver, Nachlas’
and Yeoman’s tests (for a review of assessment procedures, Answers to these Think-It-Through Questions and the
see Chapter 3). Your low back ranges of motion are mildly Treatment Strategy employed for this client are available
decreased, but there is no one range of motion that shows a online at thePoint.lww.com/MuscolinoLowBack
CHAPTER 1
REVIEW QUESTIONS
2. What is the most palpable bony landmark of the lumbar 4. The facet joints of the lumbar spine are primarily
spine? oriented in the transverse plane.
A. Body
5. The base of the sacrum is its superior surface.
B. Transverse process
C. Spinous process Short Answer:
D. Pedicle 1. What term describes the curve of the lumbar spine?
3. What motion is most limited in the lumbar spine? 2. What nerve is located in the femoral triangle?
A. Rotation
3. The abdominal aorta is located near what muscle?
B. Lateral flexion
C. Extension 4. What term describes the motion of the sacrum wherein
D. Flexion its base drops anteriorly?
4. What pelvic action at the hip joint is the reverse action Matching:
of flexion of the thigh at the hip joint? 1. Between piriformis Multifidus
A. Depression and superior gemellus Iliocostalis
B. Anterior tilt 2. Overlies iliopsoas Sciatic nerve
C. Contralateral rotation 3. Attaches to 12th rib Quadratus lumborum
D. Posterior tilt 4. Largest muscle of the Latissimus dorsi
lumbar spine Femoral nerve
5. Which of the following is a group of the transversospinalis?
5. Low back muscle that
A. Quadratus lumborum
moves the glenohu-
B. Spinalis
meral joint
C. Longissimus
6. Most lateral group of
D. Rotatores
erector spinae
Answers to these Review Questions are available online at
thePoint.lww.com/MuscolinoLowBack
CHAPTER 2
REVIEW QUESTIONS
REVIEW QUESTIONS
430 Body Mechanics for Deep Tissue Work to the Low Back and Posterior Pelvis
REVIEW QUESTIONS
Multiple Choice: 3. You should straddle the corner of the head end of the
1. Which of the following is true regarding treatment contacts? table when working the upper thoracic spine.
A. Smaller contacts allow for more precise assessment.
4. When pushing off with the lower extremities, it is best
B. Smaller contacts allow for more precise treatment.
C. Larger contacts allow for more depth of pressure.
for the rear foot to be oriented perpendicularly to the
D. All of the above
orientation of the front foot.
5. When employing the palm contact and leaning into the
2. When bracing the palm contact, over which aspect of
the treatment contact hand should the brace be placed? client, your elbow joint should bend further as you per-
A. Carpal region
form the stroke.
B. Metacarpals Short Answer:
C. Phalanges 1. At what angle should the direction of force be rela-
D. All of the above tive to the contour of the client’s body that you are
3. When doing soft tissue manipulation, which of the fol-
working?
lowing back postures is the healthiest? 2. To best use your core when doing deep pressure work,
A. Stooped where should you place your elbow?
B. Inclined
3. How can you tell if your core is behind and in line with
C. Vertical
D. All are equally healthy.
your stroke?
4. How can the question “How is the pressure?” be better
4. What technique is increasingly being recommended as
the most effective technique to treat myofascial TrPs? phrased?
A. Ischemic compression Matching:
B. Light static touch 1. Muscle contraction Transitioning to long,
C. Deep stroking massage 2. Upper extremity deep strokes
D. Sustained compression joints in anatomic Core behind stroke
5. Which of the following is true regarding the role of your
position (extended) Stacked
brace hand when doing deep tissue work to the client? 3. Elbow tucked in B
racing/supporting
A. It supports and protects the treatment contact.
4. Thumb pad placed on contact
B. It adds to the pressure of the stroke.
thumb pad I nternal generation
C. It allows for more of the client’s body to be worked.
5. Gravity of force
D. Choices A and B
6. Move your feet E xternal generation
of force
True/False:
1. Biomechanically, to generate force, it is better to use
larger, more proximal muscles compared with smaller,
more distal muscles.
2. Your core should be oriented perpendicularly to the line Answers to these Review Questions are available online at
of force of the stroke. thePoint.lww.com/MuscolinoLowBack
CHAPTER 5
REVIEW QUESTIONS
REVIEW QUESTIONS
REVIEW QUESTIONS
REVIEW QUESTIONS
REVIEW QUESTIONS
REVIEW QUESTIONS
True/False:
1. A joint mobilization never involves a fast thrust.
Answers to these Review Questions are available online at
2. Distraction mobilization is also known as traction. thePoint.lww.com/MuscolinoLowBack.
CHAPTER 11
REVIEW QUESTIONS
2. What are the two reasons for using ice? 4. As a rule, stretching is optimally performed after cold.
A. Decreases pain and causes vasoconstriction
5. Cold can interrupt the pain-spasm-pain cycle.
B. Causes vasoconstriction and loosens fascial tissues
C. Causes vasodilation and promotes relaxation Short Answer:
D. Loosens fascial tissues and causes vasodilation 1. What are the three major keys to client self-care?
3. What are the three reasons for using heat? 2. How does an obese person often compensate posturally
A. Decreases pain, causes vasoconstriction, and loosens for having a large abdomen?
fascial tissues
3. When applying cold, for how long should the client
B. Loosens fascial tissues, promotes muscle relaxation,
place an ice pack on the body?
and causes vasodilation
C. Loosens fascial tissues, promotes muscle relaxation, 4. For how long after an injury should ice be used?
and causes vasoconstriction
Matching:
D. Causes vasodilation, causes vasoconstriction, and
1. Figure 4 stretch S tretches hip flexors
decreases pain
2. Anterior line stretch Stretches hip adductors
4. What is the usual order for contrast hydrotherapy and 3. Chair low back
stretching? stretch Stretches hip abductors
A. Heat, cold, stretching 4. Lateral line stretch S tretches piriformis
B. Stretching, heat, cold 5. Medial line stretch S tretches lumbar
C. Cold, heat, stretching 6. Posterior line- paraspinal muscula-
D. Heat, stretching, cold vertical stretch ture bilaterally
5. Which of the following likely causes tightness of the low S tretches hamstrings
back paraspinal muscles?
A. Sleeping on the stomach
B. Bending forward
C. Carrying a bag on the shoulder Answers to these Review Questions are available online at
D. All the above thePoint.lww.com/MuscolinoLowBack
chapter 12
REVIEW QUESTIONS
439
440 Answers to Case Study and Review Questions
Dan’s tolerance for the Follow-Up: 4. Thumb pad placed on Your decision for which
depth of your pressure, After 3 weeks, Dan reports thumb pad—Bracing/ abdominal muscle to
there is no contrain- to you that his pelvic pain supporting contact massage is clear-cut. The
dication to deep tissue has decreased approxi- 5. Gravity—External gen- right-sided psoas major
massage. mately 80% to 90%, and that eration of force is the only abdominal
he has not experienced any 6. Move your feet—Tran- muscle that is tight and
Treatment: referral pain into the right sitioning to long, deep reproduces her char-
You begin your treatment thigh for a number of days. strokes acteristic pain pattern.
by performing approxi- You continue the same Given the tightness of the
mately 5 to 10 minutes of treatment frequency and iliacus, it is also indicated
gentle-to-moderate depth approach, adding in pin and CHAPTER 5 and appropriate to work
massage to his low back and stretch to the piriformis and it as well. (Note: Because
pelvis bilaterally, employing quadratus femoris. After Case Study: Vera (Massaging Vera’s erector spinae
a combination of effleurage 2 more weeks of care, Dan the Anterior Abdomen) and quadratus lumbo-
and circular friction strokes reports that he is no lon- Think-It-Through Questions rum musculature are also
to warm the tissues and pro- ger experiencing any pelvic 1. Should abdominal mas- tight, it is also indicated
mote circulation. You then pain. You recommend that sage be included in your and appropriate to work
begin to employ broad, long, he return approximately treatment plan for Vera? these muscles.)
stroking massage using once a month for preventa- If so, why? If not, why
your forearm as the contact, tive care. not? Treatment:
with deep pressure into Because Vera’s right- Your treatment plan recom-
the posterior pelvis on the Multiple Choice sided psoas major is tight mends twice-a-week treat-
right side, beginning near 1. d and painful and palpa- ments for the next 3 weeks.
the sacrum and iliac crest 2. a tion of it recreates the After six visits, you will
and successively working 3. c pain that is characteristic reevaluate Vera and deter-
your way laterally (see Rou- 4. c of her problem, the need mine whether further treat-
tine 4-4). You then focus 5. d for massage to the psoas ment is indicated, and if so,
your work to the pirifor- major is clear. Given that what the plan of treatment
mis and quadratus femoris, True/False her right-sided iliacus is will be.
performing approximately 1. True also tight, it is appropri- You begin your treat-
30 to 60 strokes between 0.5 2. False ate to work it as well. ment with Vera prone
and 1 inch in length to the 3. True 2. If abdominal massage and you place a moist heat
TrPs. At the end, you apply 4. False would be of value, is it hydrocollator pack on her
moist heat to the region and 5. False safe to use with her? If low back for 5 to 10 min-
then stretch the deep lateral yes, how do you know? utes as you perform mild to
rotator musculature. You Short Answer Regarding the safety moderate soft tissue mas-
repeat this protocol twice 1. Perpendicular (90 degrees) of massaging the psoas sage to the musculature of
a week for 3 weeks. You 2. In front of your core major (and iliacus), no her thoracic spine, gluteal
recommend that if he is 3. A line drawn from your contraindications are region, and posterior thighs.
sore from the treatment, he belly button should be as prese nt. She reported You then perform approxi-
should apply ice to the re- close to and parallel with that she has no intesti- mately 10 to 15 minutes of
gion for approximately 5 to the line of the forearm nal conditions. Also, all gentle to moderate depth
10 minutes immediately of your treatment hand orthopedic assessment massage to her bilateral
upon returning home after contact. tests of the lumbar spine posterior low back muscula-
the massage. Otherwise, 4. “Would you like more were negative (although ture, with greater emphasis
he should use moist heat pressure or less pressure?” even a positive assess- on the right side, employing
to the right side of his low ment test for disc or a combination of strokes
back and pelvis a few times Matching other space-occupying to warm and loosen the
each day, followed by knee- 1. Muscle contraction— lesion would still not area. You then have her
to-chest and knee-to-oppo- Internal generation of contraindicate massage lie supine with a large roll
site-shoulder stretch (see force to the psoas major). under the knees and place
Chapter 11, available online 2. Upper extremity joints 3. If abdominal massage is a moist heat hydrocolla-
at thePoint.lww.com). You in anatomic position performed, which specific tor pack on her proximal
also discuss proper postures (extended)—Stacked routines should be done? right thigh while you spend
that Dan should use when 3. Elbow tucked in—Core And why did you choose 5 minutes warming and
working at his desk. behind stroke the ones you did? loosening the anterior ab-
dominal wall musculature of the treatment, including Multiple Choice ecause Felix has had
B
bilaterally (Routines 5-1 employing pin and stretch to 1. d massage and has been
and 5-2), again with greater the distal belly/tendon of the 2. a doing stretches for his
emphasis on the right side. right iliopsoas (see Practical 3. d hip and low back, with
For the next 5 minutes, you Application Box 5.6), and 4. b little or no improvement,
work the abdominal belly adding in gentle stretching 5. c a more sophisticated
of the right psoas major to the anterior abdominal stretching technique such
(Routine 5-3), progress- wall and spine by stretch- True/False as multiplane stretch-
ing from mild to moderate ing her into extension (see 1. False ing is indicated. Your
pressure. You then work Chapter 6, Routine 6-4). 2. True reasoning is based on
the right iliacus for a few 3. True your observation that
minutes (Routine 5-4) and Follow-Up: 4. False the stretches he has been
then work the distal belly/ After 3 weeks, Vera reports 5. False doing have not been
tendon of the right ilio- to you that she no longer effective in loosening
psoas (Routine 5-5) in the feels the deep constant Short Answer and lengthening the ten-
proximal anterior thigh for pain that she had been ex- 1. Passive flexion of the sor fasciae latae (TFL) on
5 minutes. You complete periencing. Further, she is thigh at the hip joint the right side. When he
your soft tissue manipula- no longer experiencing the 2. Superolateral to infero- demonstrated the lunge
tion treatment by spending a nterior abdominal wall
medial stretch, by abducting his
approximately 5 minutes on pain, and her low back 3. Sartorius thigh, he is allowing the
her left-sided psoas major does not feel fragile as it 4. Psoas major TFL to slacken in the
proximally and distally. You had before. Prolonged sit- frontal plane (because
also recommend home care ting and quick, unguarded Matching it is an abductor). Fur-
that includes moist heat fol- movements of her low 1. Anteromedial abdominal ther, even though he is
lowed by gentle stretches back are still accompanied muscle—RA performing the double
of her low back and psoas by twinges of pain, but the 2. Anterolateral abdominal knee-to-chest stretch
major/hip flexor group (see intensity has changed from belly—External abdomi- correctly, you feel that
Chapter 11, available online being a sharp twinge to nal oblique its efficiency at stretching
at thePoint.lww.com for being more of a mild, dull 3. Posterior abdominal wall the erector spinae muscu-
more information on home pain. After discussing the muscle—Psoas major lature on each side would
care advice for the client, progress gained, you mutu- proximal belly be improved if he adds
including these stretches). ally decide to continue the 4. Partition between frontal and transverse
After the massage, you frequency of care at two cavities—Diaphragm plane components to the
perform gentle stretching of treatments per week until 5. Underlies femoral neuro- stretch.
her right psoas major (see she is without pain. Once vascular bundle—Iliopsoas 2. If multiplane stretching
Chapter 6, Routine 6-7), that point is reached, she distal belly/tendon would be of value, is it
followed by bilateral single will be weaned from care by 6. Internal surface of pelvic safe to use with him? If
knee-to-chest and then working once a week for 2 bone—Iliacus proximal yes, how do you know?
double knee-to-chest low to 3 weeks. If she remains belly To determine whether
back stretches (see Chapter symptom free, the treat- it is safe to perform any
6, Routines 6-1 and 6-9). ments will then be spaced type of stretching, you
(Note: Negative orthopedic to once every 2 weeks for CHAPTER 6 performed the straight
assessment tests for a patho- two visits, and then once leg raise, Nachlas’, and
logic disc or other space- every 3 to 4 weeks for a few Case Study: Felix (Multi- Yeoman’s tests and asked
occupying lesion indicate visits. Assuming she is still plane Stretching) the client to perform the
that flexion stretching is pain-free at this point, she Think-It-Through Questions cough test and Valsalva
safe to perform.) can either choose to dis- 1. Should you include a mul- maneuver. The nega-
Over the next five treat- continue care and return as tiplane stretching tech- tive results of these tests
ments, you continue your she desires or she can con- nique in your treatment indicate that you can
warm-up as done in the first tinue proactive preventive plan for Felix? Why, or safely use stretching as a
treatment. However, you care for her psoas major why not? treatment tool. In con-
gradually increase the depth and low back by coming in Given that the client’s trast, the results of these
of pressure into the psoas approximately once every range of motion is lim- assessment tests would
major. You also increase 2 to 4 weeks or at what- ited, there is a clear need have been positive if Felix
the intensity of the stretch- ever interval she feels is for you to use stretch- had had a pathologic disc
ing regimen done at the end appropriate. ing as a treatment tool. or advanced degenerative
442 Answers to Case Study and Review Questions
joint disease (osteoarthri- you would also expect performing approximately at home. You also discuss
tis), conditions that might tightness in that muscle 10 minutes of gentle to proper low back postures
contraindicate certain to restrict the opposite moderate depth massage, he can practice when sitting
stretching, depending on actions of extension and again employing a combina- at a desk and when driving
the severity of the condi- adduction. Tightness of tion of effleurage and cross- a car as well as other tips for
tion (for more on these the erector spinae mus- fiber strokes. You then place low back posture.
assessment procedures, culature would cause a moist heating pad on his
see C hapter 3). The fact decreased trunk flexion, anterior right hip while Follow-Up:
that your client history and the fact that the right repeating the same massage At the end of 3 weeks of
revealed no indications erector spinae muscu- procedure for 5 minutes for care, Felix reports that his
of lower e xtremity refer- lature is tighter would his left anterior hip muscu- low back stiffness and his
ral (i.e., no pain, tingling, cause decreased left lat- lature. You then perform right hip pain and stiffness
or numbness) also indi- eral flexion of the trunk. multiplane stretching tech- are gone. Given his history
cates that it is unlikely These restrictions are nique for the right TFL in of episodes, you empha-
that he has a condition consistent with the find- both the supine and prone size how important it is for
that would contraindi- ings of your range of mo- positions (see Routine 6-7, him to continue with his
cate stretching. tion examination. And stretches #1 and #6), with self-care low back and hip
3. If you do perform multi- pain on manual resis- the thigh stretched into stretches, as well as regu-
plane stretching, which tance to right hip flexion extension, adduction, and lar massage and stretching
specific stretching routines and abduction also con- lateral rotation. treatments, even if he is not
should you do? Why? firms that the right TFL The protocol that you fol- symptomatic.
You decide to stretch is the causative agent of low for stretching both the
his right TFL as well as his hip pain. bilateral erector spinae and Multiple Choice
the erector spinae mus- right-sided TFL muscles is 1. a
culature bilaterally with Treatment: to begin with approximately 2. b
more concentration on You begin your treat- 40 seconds of short dynamic 3. d
the right side. The stretch ment with Felix prone and stretches, each repetition 4. c
he has been doing on his perform approximately held for 1 to 3 seconds. You 5. b
own for the right TFL 10 minutes of gentle to then finish with one longer
has not been effective, moderate depth massage static repetition, held for True/False
primarily because it has to his low back, employing approximately 20 seconds. 1. False
not addressed the fron- a combination of effleurage You repeat this protocol for 2. True
tal plane component of and cross-fiber strokes to a total of three sets for each 3. False
the muscle’s actions; in the entire region, with more muscle/muscle group. 4. False
fact, by abducting, he concentration to the right You complete the ses- 5. True
has allowed the muscle side. This helps by warming sion by repeating moderate
to slacken in the fron- the tissues and promoting depth soft tissue massage Short Answer
tal plane. For the erec- local circulation. After the to his right low back for 3 1. Because a multiplane
tor spinae musculature, massage, you apply moist to 5 minutes, followed by stretch actually occurs
you decide to add in the heat to the region for 5 multiplane stretching of within one oblique plane;
frontal and transverse minutes, both to further the right side erector spinae however, it does occur
plane components for a warm the target muscula- group. And then 3 to 5 min- across multiple (two or
more effective stretch. ture and to relax the cli- utes of moderate depth soft three) cardinal planes
For these reasons, mul- ent before beginning the tissue massage to his right 2. Presetting the rotation
tiplane stretching of the stretching. You then per- anterior hip, followed by 3. Elevation of the same-
TFL and erector spinae form multiplane stretch- multiplane stretching of his side (ipsilateral) pelvis
musculature is indicated. ing of the erector spinae right TFL. 4. To avoid placing force
Your decision is based musculature bilaterally You recommend that he through the client’s knee
on the findings of your with flexion, opposite-side receive this massage and joint (especially if the
palpation examination, lateral flexion, and contra- stretching treatment rou- client has an injured/
which revealed tight- lateral rotation of the trunk tine two times a week for unhealthy knee joint)
ness in these muscles, (see Routine 6-1). 3 weeks. Because Felix is
especially the right TFL. You then have Felix turn very motivated and will- Matching
Further, given that two to the supine position and ing to do stretching on his 1. Stretch performed su-
of the TFL’s actions are warm the anterior hip re- own, you show him how to pine at end of table—
flexion and abduction, gion on the right side by do these stretches properly Hip flexors
2. Knee-to-chest stretch— To determine that lumbar spine into flexion both the right lateral flexors
Gluteal muscles stretch ing of any type is indicated. Because the and the left lateral flexors
3. Upper LSp flexed, later- is safe to perform, you paraspinal musculature with her in side-lying posi-
ally flexed to opposite performed active and is tight on both sides, tion (Routines 7-3 and 7-4).
side, and contralaterally passive straight leg raise stretching her lumbar You finish with CR stretch-
rotated—Erector spinae tests and asked the client spine into lateral flexion ing for her lumbar exten-
group to perform the cough test to each side is also indi- sors, this time adding in the
4. Figure 4 stretch—Deep and Valsalva maneuver. cated. In addition, you frontal plane component of
lateral rotators The fact that these test decide to further stretch lateral flexion, first to the
5. Side-lying stretch with results were negative for her low back by also per- right side and then to the
thigh dropped toward referral into the lower ex- forming oblique plane left side.
floor—Hip abductors tremity indicates that you stretches that combine You repeat this proto-
6. Upper LSp flexed, later- can safely use stretching flexion with lateral flex- col 2 days later and then
ally flexed to opposite as a treatment tool. The ion to the right and then 2 days after that, gradually
side, and ipsilaterally ro- results of these assess- flexion with lateral flex- increasing the depth of the
tated—Transversospina- ment tests would have ion to the left. massage and the intensity of
lis group been positive for lower the stretching at each visit.
extremity referral if Na- Treatment: At the first visit, you also
tasha had a pathologic With Natasha prone with discussed with Natasha the
CHAPTER 7 disc or advanced degen- a small roll under her ab- importance of self-care at
erative joint disease (os- domen, you begin your home, recommending that
Case Study: Natasha (Con- teoarthritis), conditions treatment of her low back she avoid sitting as much
tract Relax Stretching) that would contraindi- by placing a moist heating as possible as well as pro-
Think-It-Through Questions cate stretching (for more pad on her lumbar spine for longed standing. You also
1. Should an advanced on these pathologic con- approximately 10 minutes recommend that she per-
stretching technique such ditions, see Chapter 2). while you perform gentle form moist heat followed
as CR stretching be in- The fact that Natasha’s depth massage, employing by double knee-to-chest
cluded in your treatment history revealed no effleurage strokes to her stretching, both into pure
plan for Natasha? If so, lower extremity referral upper back and neck. Your flexion as well as gently
why? If not, why not? (i.e., no pain, tingling, or goal in doing this is to relax adding in the lateral flexion
Given that the client’s numbness) also indicates and calm her before begin- components. You recom-
musculature is spasmed, that it is unlikely that ning work in her lumbar mend that she repeat this
stretching is called for she has a condition that region. You then perform protocol as often as pos-
as a treatment tool. Be- would contraindicate gentle effleurage to her sible, with a minimum of
cause Natasha’s con- stretching. Further, be- lumbar spine and sacroiliac three times a day.
dition is so acute, an cause active straight leg region for 10 to 15 minutes.
advanced stretching raise test was positive for As Natasha relaxes, you Follow-Up:
technique such as con- low back pain and pas- spend an additional 5 min- At the end of the week,
tract relax (CR) stretch- sive straight leg raise test utes increasing the depth of Natasha reports to you that
ing (or agonist contract was negative, you know the massage to be moderate she is pain-free. She can
stretching, covered in that she has a muscular in intensity and adding in now stand, sit, and move
Chapter 8) is indicated. strain/spasm and not a gentle compression strokes. her back freely. You recom-
Advanced stretching ligamentous sprain. With her supine, you mend that she continue to
techniques, by virtue 3. If CR stretching is done, begin stretching her low do moist heat followed by
of adding a neurologic which specific stretching back with gentle single knee- stretching once a day. You
stimulus to relax the routines should be done? to-chest and then double also recommend that she
tight muscles, often Why did you choose the knee-to-chest stretching, schedule sessions once every
work well when regu- ones you did? performed with each repeti- week for the next month for
lar stretching does not. Your decision about tion held for approximately preventative care.
You decide to use CR which stretches to per- 3 to 5 seconds (see Rou-
stretching with her. form is determined by tines 6-1 and 6-9 in Chap- Multiple Choice
2. If CR stretching would be your palpation assess- ter 6). You then perform 1. b
of value, is it safe to use ment. Natasha’s lum- CR stretching technique for 2. a
with her? If yes, how do bar paraspinal extensor the lumbar extensors with 3. b
you know? If not, why musculature is tight, her supine (Routine 7-1) 4. c
not? so stretching Natasha’s and then CR stretching for 5. c
444 Answers to Case Study and Review Questions
active at her job, you spend Short Answer relax (CR), agonist con- history revealed no his-
time discussing proper pos- 1. Extension and adduction tract (AC), or contract tory of lower extremity
tures and movement patterns 2. It begins the stretch of relax agonist contract referral (i.e., no pain,
with her. You also discuss the target musculature, (CRAC) s tretching is tingling, or numbness)
proper postures at home and and it initiates the recip- indicated because of the also indicates that she is
advise her that because she rocal inhibition reflex. added benefit of the neu- unlikely to have a condi-
sleeps on her side, it would 3. Client comfort; it broad- rologic reflexes that are tion that would contrain-
be beneficial to place a pil- ens the pressure of the involved. Given that the dicate stretching.
low between the knees. In stabilization hand force. client has already under- 3. If CRAC stretching is
addition, you recommend 4. The lumbar spine’s lor- gone approximately 1 to done, which specific
that she apply moist heat and dosis will increase. 2 months of massage and stretching routines should
then stretch her low back two stretching with little ben- be done and why did you
or three times a day, demon- Matching efit, you decide to per- choose the ones you did?
strating how she can perform 1. Reflex for AC stretch- form CRAC stretching To help you decide which
unassisted AC stretching for ing—RI because as a combined stretches to perform, you
these muscles. 2. Number of seconds for technique, it is likely to assess the ranges of mo-
an AC stretch repeti- be the most powerful of tion of her lumbar spine
Follow-Up: tion—3 to 5 the advanced stretching in order to determine
At the end of 5 weeks, Hy- 3. Reflex if stretch too far techniques. which ones are decreased.
esun reports that she has re- or too quickly—Muscle 2. If CRAC stretching would In Leslie’s case, flexion,
gained full lumbar range of spindle be of value, is it safe to extension, and bilateral
motion into flexion as well as 4. Hip abductors tight— use with her? If yes, how lateral flexion ranges of
right and left lateral flexion. Stretch the client into do you know? If not, motion are decreased,
You confirm her increased adduction why not? so you decide to devote
ranges of motion with a 5. Number of repetitions To determine whether 20 to 30 minutes of each
follow-up range of motion usually done with AC it is safe to perform any treatment session to car-
assessment at the beginning stretching—8 to 10 type of stretching, you rying out a methodical
of the visit. She also reports 6. Hip adductors tight— perform the active and stretching protocol in
that she can now sleep, Stretch the client into passive straight leg raise which you will not only
stand, and sit comfortably, abduction tests and ask the client to move her low back into
without pain. To minimize perform the cough test cardinal plane ranges of
the chance of remission, and Valsalva maneuver. motion but also perform
you recommend that she CHAPTER 9 The fact that they are neg- some multiplane oblique
return for treatment once a ative for lower extremity plane CRAC stretches
week for the following 3 to Case Study: Leslie (Con- referral shows that you that combine cardinal
4 weeks. At the end of that tract Relax Agonist Con- can safely use stretching plane motions.
time, you recommend that tract Stretching) as a treatment tool. The
she continue to stretch every Think-It-Through Questions results of these assess- Treatment:
day and return for preventa- 1. Should an advanced ment tests would have Given the severity of her
tive care approximately once stretching technique such been positive for referral decreased motion, the
a month thereafter. as CRAC stretching be in- if Leslie had a pathologic long-standing chronicity,
cluded in your treatment disc or advanced de- and the lack of response to
Multiple Choice plan for Leslie? If so, why? generative joint disease stretching at her gym and
1. b If not, why not? (osteoarthritis), condi- massage, you decide on an
2. d The client’s limited range tions that might contra- aggressive 10-week treat-
3. c of motion as well as indicate stretching (for ment plan consisting of
4. a her widespread muscle more on these assess- massage, heat, and CRAC
5. d tightness indicates the ment procedures, see stretching, three times a
need for stretching as a Chapter 3). The presence week for the first 4 weeks,
True/False treatment tool. Because of only mild degenera- twice a week for the next
1. True massage and regular tive joint disease on her 4 weeks, and once a week
2. False stretching have produced radiographs also points for the last 2 weeks. You
3. False minimal results for her, to stretching as being an also instruct her about
4. False you decide that an ad- appropriate treatment proper postures at home
5. True vanced stretching tech- option. In addition, the and work, including that
6. True nique, such as contract fact that Leslie’s verbal she sleep at night either
446 Answers to Case Study and Review Questions
on her back with a pillow approximately once to twice Because Alicia’s lumbar should you use? How and
under her knees or on her a month for preventative spine gross ranges of mo- why would you choose
side with a pillow between care. tion are normal, standard those particular routines?
her knees. You further and advanced stretching Your decisions about
recommend that she per- Multiple Choice techniques are not in- which joint mobiliza-
form self-care stretches 1. d dicated. This is further tions to perform are
after first warming her low 2. b validated by the fact that based on where joint hy-
back by working out, using 3. c she has not responded pomobility was found in
a moist heating pad, or tak- 4. d to the standard and con- Alicia’s low back. During
ing a hot shower. 5. c tract relax stretching joint play/motion palpa-
You begin your treat- treatments that she has tion assessment, the mo-
ment with 5 minutes of heat True/False had so far. Because you tion of all lumbar spine
to her low back and pelvis, 1. False found hypomobility of segmental joints was
followed by 20 minutes of 2. False her left sacroiliac joint found to be normal, as
massage to her entire low 3. False when assessing joint play was motion of the right
back and gluteal region, 4. True range of motion (motion sacroiliac joint. The only
gradually progressing from 5. True palpation), joint mobili- hypomobile joint found
mild to moderate depth of zation is indicated. You was the left sacroiliac.
pressure. Turning her to a Short Answer decide to use joint mobi- Therefore, joint mobili-
supine position, you spend 1. One to 2 seconds (the last lization with her. zation of the left sacro-
approximately 5 minutes repetition is often held 2. Is joint mobilization safe iliac joint is indicated.
working into her psoas longer, perhaps 10 to 20 to use with Alicia? If yes, You decide to perform
major muscles bilaterally, seconds or more) how do you make that de- prone PSIS and sacrum
again beginning with mild 2. The target muscles termination? compression mobiliza-
pressure and progressing to 3. Antagonists to the target To determine that joint tions and supine single
moderate pressure. You re- muscles mobilization is safe to knee to chest mobiliza-
turn her to the prone posi- 4. After the target muscles perform, you performed tion initially and supine
tion and apply an additional have first been warmed up the straight leg raise horizontal adduction and
5 minutes of moist heat to and you asked Alicia to side-lying horizontal ad-
her low back. You then Matching perform the slump test, duction mobilizations in
perform CRAC stretch- 1. Client exhales—AC as- cough test, and the Val- later sessions. Because of
ing to four cardinal plane pect of stretch salva maneuver. The neg- the muscular spasming
functional muscle groups 2. Client holds the breath— ative results of these tests, that is present, you also
(extensors, flexors, and bi- CR aspect of stretch along with the fact that opt for moderate-depth
lateral lateral flexors) of 3. Reflex for CR stretch- Alicia reports no lower massage and heat.
her lumbar spine, followed ing—Golgi tendon organ extremity referral (no
by oblique plane CRAC 4. Reflex for AC stretch- pain, tingling, or numb- Treatment:
stretching that combines ing—RI ness), indicate that you You begin your treatment
lateral flexion and rotation 5. Reflex that occurs if can safely perform joint by performing approxi-
to the extensor and flexor stretched too far or too mobilization as a treat- mately 10 to 15 minutes of
stretches of her lumbar fast—Muscle spindle ment technique. The re- moderate-depth massage
spine. You then perform 6. Reason to hold a stretch sults of these assessment to her lumbopelvic region,
CRAC stretching to the for a longer period— tests would have been with more focus on the left
flexors and deep lateral ro- Creep positive if Alicia had than the right side, employ-
tators of the hip joint. Five had a pathologic disc or ing a combination of effleu-
repetitions are carried out advanced degenerative rage and transverse friction
for each stretch. CHAPTER 10 joint disease (osteoar- strokes to warm the tissues,
thritis), conditions that promote circulation, and
Follow-Up: Case Study: Alicia (Joint would contraindicate decrease the muscular spas-
At the end of 10 weeks’ Mobilization) joint mobilization (for ming. After the massage,
time, Leslie has regained full Think-It-Through Questions more on these assess- you apply moist heat to the
or nearly full lumbar range 1. Should an advanced tech- ment procedures, see region for approximately
of motion in all directions. nique such as joint mobi- Chapter 3). 10 minutes, both to further
You recommend that she lization be included in 3. If you do joint mobiliza- warm the target tissues and
continue to stretch every your treatment plan for tion, which specific joint to relax the client before
day on her own and return Alicia? Why, or why not? mobilization routines beginning the joint mobili-
zations. You then perform that she has been experi- Matching do you know? If not,
prone PSIS and sacrum encing have decreased by 1. Seated LSp extension why not?
compressions and supine approximately 70%. After mobilization—Contact Vaughn does not have
single knee to chest mobili- you discuss with her how midline over SP a sensory neuropathy,
zations for her left sacroiliac well her condition is re- 2. Seated LSp left lateral so hydrotherapy is safe
joint (see Routines 10-1, sponding to treatment, she flexion mobilization— for him. He also has
10-2, and 10-5). decides to continue with Contact left side of SP no contraindications
You perform three rep- treatment at the same fre- 3. Seated LSp right rotation to stretching, such as a
etitions for each of the mo- quency of two times per mobilization—Contact space-occupying lesion
bilizations, and you repeat week for another 4 weeks. right side SP (i.e., pathologic disc or
this protocol twice a week At the end of this time, she 4. Where joint mobilization bone spurs), and the
for the first week. You re- reports feeling 90% to 95% is actually performed— negative results for lower
peat this protocol for the better and decides to de- Joint play extremity referral into
second week, adding in crease care to once a week 5. Prone LSp right rotation the lower extremity with
supine horizontal adduc- until she feels 100%. When mobilization—Contact straight leg raise, cough
tion mobilization (see Rou- she reaches 100% improve- left mammillary/trans- test, and Valsalva ma-
tine 10-6) as Alicia begins to ment, you recommend a verse processes neuver all confirm this.
improve. For the third and gradual weaning of care by 6. Bring to tension at end The absence of lower ex-
fourth weeks, as Alicia con- increasing the interval of of this motion—Passive tremity referral provides
tinues to improve, you also time between visits to be 2, range of motion further confirmation.
add in side-lying horizontal 3, 4, and then 6 weeks. At Further, because he was
adduction mobilization as the 6-week visit, she reports positive to active straight
well (see Routine 10-7), be- that her symptoms have not CHAPTER 11 leg raise (with low back
ginning very gently during come back, so you recom- pain) and negative with
the third week and increas- mend that she return once Case Study: Vaughn (Self- passive straight leg raise,
ing the intensity of this and every 1 to 3 months for Care for the Client) you are confident that
the other mobilizations dur- proactive care consisting of Think-It-Through Questions Vaughn has a muscular
ing the fourth week. massage, heat, stretching, 1. Is home self-care indicated strain, which should re-
You also discuss with and joint mobilization to as a part of your treat- spond well to hydrother-
her proper postures she the lumbar spine and pelvis ment plan for Vaughn? If apy and stretching.
can practice at home and to prevent the recurrence of so, why? If not, why not? 3. If you recommend self-
work, especially regarding segmental joint hypomo- Because Vaughn wants care, what are your spe-
working at the computer, bilities in the region. to be able to leave for his cific recommendations?
and you instruct her to take trip in 4 days, there is And why did you choose
5-minute breaks every half- Multiple Choice little time to resolve his the ones you did?
hour when doing any type of 1. c condition. So, in addi- You recommend con-
desk work, including work- 2. d tion to scheduling three trast hydrotherapy (see
ing at the computer. You 3. a treatment sessions over Routine 11-3) with ice,
also recommend that for the 4. d the next 3 days, the more followed by moist heat,
next month or so, she try to 5. a self-care he does at home and stretching. The initial
decrease how much time she to facilitate healing, the treatment with cold ther-
spends driving; and when True/False better his chances of im- apy is indicated to numb
she must take a longer drive, 1. True proving enough to take the area because his low
to stop every 20 to 30 min- 2. True his business trip and back is so painful. The
utes or so and walk around 3. False enjoy it. You recommend heat therapy that follows
for a few minutes. You also 4. True both contrast hydro- serves to warm and relax
recommend that she apply 5. False therapy and stretching. the muscles, allowing
moist heat to her low back Vaughn’s motivation for him to safely and effec-
and pelvis one to three times Short Answer self-care has been spotty tively stretch his low back
per day, followed by gentle 1. Pin and stretch in the past, but with the and pelvis (because he
to moderate stretching. 2. Motion palpation (joint trip as motivation, you does not have any swell-
play) feel confident that he will ing that is evident, you
Follow-Up: 3. Passive range of motion comply willingly. do not feel that he needs
After 4 weeks, Alicia reports 4. Pocket to pocket 2. If home self-care would to finish with another ice
to you that the feelings of 5. Side-lying horizontal be of value, is it safe to application). Given how
stiffness and deep, dull pain adduction use with him? If yes, how severe his condition is,
448 Answers to Case Study and Review Questions
how little time there is, Treatment: in such a short period of to check in with you when
and how motivated he is Your treatments consist of time, on the last day, you he gets back home.
to improve and go on his soft tissue massage to the finish with 5 minutes of
business trip, you recom- posterior low back for ap- icing to his low back. Multiple Choice
mend that he follow this proximately 15 to 20 min- 1. b
sequence as often as he utes, beginning with mild Follow-Up: 2. a
can, literally every hour pressure and gradually By the end of the third treat- 3. b
or so if possible. working up to moderate ment, Vaughn is feeling ap- 4. c
Specifically, you rec- pressure. You then place proximately 75% better. He 5. d
ommend that he place a heat on the area for an ad- has been doing the contrast
gel ice pack over a paper ditional 5 to 10 minutes. hydrotherapy/stretching be- True/False
towel on the region until Now that his low back has tween five and seven times 1. False
it is numb. Then, he is been somewhat loosened each day. His low back is 2. True
to take a hot shower for and warmed up, you stretch still mildly spasmed but is 3. True
10 to 20 minutes, letting it. You begin by doing gen- much looser than 3 days 4. False
the water beat down on tle static stretches using the before. Although his con- 5. True
his low back. Immedi- single knee to chest and dition is not fully resolved,
ately after the shower, double knee to chest bilat- Vaughn now feels confident Short Answer
he should do a series of erally. Next, you repeat all that he can go on his busi- 1. Hydrotherapy, stretch-
stretches to his low back the stretches with contract ness trip. ing, and posture
and pelvis. relax (CR) stretching pro- You recommend that 2. He or she leans back into
For stretching, you tocol and then agonist con- he continue with the home extension to counterbal-
recommend that he per- tract (AC) protocol. Given self-care, but because he ance the excess weight
form (single) knee to the severity of his condition, is greatly improved, he no anteriorly.
chest (see Routine 11-5) you keep the intensity of the longer needs to do con- 3. Until the area is numb
on each side of the body, CR and AC protocols gentle. trast hydrotherapy with the 4. As long as the region is
but because his right side You then work the hip flexor ice, so he can transition to swollen
is worse than the left, musculature for 5 to 10 min- using only heat followed by
that he perform more utes, gradually transitioning stretching. You also advise Matching
repetitions on the right from light to moderate pres- him to continue with the 1. Figure 4 stretch—
side. He should follow sure. You follow this with a heat and stretching while he Stretches piriformis
this with double knee to stretch for the anterior hip is away and to find a good 2. Anterior line stretch—
chest (see Routine 11-6). flexor musculature and then massage therapist and get a Stretches hip flexors
He can then perform the the knee-to-opposite-shoul- therapeutic massage at least 3. Chair low back stretch—
chair low back stretch der stretch first statically and twice during the week that Stretches lumbar para-
(see Routine 11-4) and then with CR protocol. You he is traveling. You men- spinal musculature
with both positions of purposely vary the angle of tion that hotels often offer bilaterally
lateral flexion, but be- the knee-to-opposite-shoul- massage, and that if they 4. Lateral line stretch—
cause his right side is der stretch between bringing do not, they may be able to Stretches hip abductors
tighter, he should spend the knee straight up toward recommend therapists in
5. Medial line stretch—
more time laterally flex- the chest and bringing the the area. Stretches hip adductors
ing to the left. Because knee directly toward the op- Five days later, Vaughn 6. Posterior line vertical
the musculature of his posite side of the body. With sends you an e-mail from stretch—Stretches ham-
pelvis is somewhat tight, the few minutes you have Europe. He tells you that strings
you also recommend that left, you finish with gentle although the plane ride was
he perform the medley massage to his low back a bit uncomfortable, he im-
of stretches for the hip and pelvis. In each succes- proved rapidly after that. He CHAPTER 12
joint (see Routines 11-12 sive treatment, as Vaughn says that he has continued
through 11-16). Specifi- improves, you gradually in- to do the heat and stretch- Case Study: You (Self-Care
cally, he should focus on crease the depth of pressure ing, gradually lessening the for the Therapist)
the anterior line (hip and the assertiveness of the amount of self-care as he Think-It-Through Questions
flexor) stretches bilater- stretching protocols. Be- improved. He mentions that 1. Should you incorporate
ally and the posterior line cause he has had treatment he also had a couple of ex- spinal stabilization ex-
horizontal (lateral rota- 3 days in a row and the area cellent therapeutic massages ercises in your self-care
tor/piriformis) stretch on might be tender and slightly at his hotel that helped him plan? If so, why? If not,
the right side. swollen from so much work considerably. He promises why not?
Your endurance strength s pinal stabilization exer- (see Routines 12-9 and Pilates method of body
functionality is dimin- cises are safe to perform 12‑10). With each exercise, conditioning as well. You
ished; you know this be- because they require only you begin with one or two commit to 30 private ses-
cause you displayed core contraction of muscu- repetitions of 10 seconds sions with a Pilates in-
lumbosacral musculature lature and/or motion of each and gradually work structor to learn well the
weakness during the sta- the neck and limbs. your way up to three repeti- technique; you then segue
bilization strengthening 3. If you decide that you tions, holding each one for into group classes to lessen
and sensorimotor exer- should perform stabili- 60 seconds or more. the financial cost.
cise routines. Therefore, zation training, which At this point, you will be Because your muscula-
stabilization exercises specific exercise routines ready to start stabilization ture is tight and strength
are clearly called for as should you do, and why? strength training. You begin training often has the ten-
a part of your self-care As a rule, the determina- with prone plank and side dency to increase mus-
program. The fact that tion of which exercises and supine bridging (see cle tone, you also decide
your low back exhibits someone should perform Routines 12-1, 12-2, and to add in stretching as a
not only tightness and is made by considering 12-3) and then gradually part of your routine (see
discomfort/pain but also which muscles are weak begin to mix in quadruped- Chapter 11 for self-care
fatigue also indicates and therefore where track and dead bug exer- stretching exercises for the
the need to strengthen. the functional deficit is cises (see Routines 12-4 and low back). For the same
Further, there was no located. In your case, 12-5). With all the stabi- reasons, you decide to also
clear correlation be- you showed weak for all lization strengthening ex- make time in your schedule
tween muscle tightness major functional groups ercises, you begin with the to receive massage therapy
and your discomfort/ of lumbosacral muscu- least challenging variations by setting up massage with
pain. Given the nature of lature. Therefore, all sta- and gradually work your Teri once a week for the
the demands of manual bilization strengthening way toward the more chal- first month or two and then
therapy for long-stand- exercises are indicated lenging variations, only after once every 2 weeks thereaf-
ing isometric contraction as beneficial. Further, you have mastered the eas- ter. You chose her because
of the core as you work, because you also showed ier ones by reaching three she is excellent at clinical
stabilization strengthen- weak on the proprio- repetitions of 60- second orthopedic work. Her care
ing exercises are particu- ception exercises, the duration or more. consists of moist heat, mas-
larly indicated. Because stabilization sensorimo- In addition, you also sage, stretching, and joint
you have allowed your- tor exercises are also need to pay close attention mobilization. She spends
self to generally get out indicated. to the cervical brace posi- half of each session with
of shape by weakening tion (maintaining proper you, focusing specifically on
and also gaining weight, Treatment: cervicothoracic and shoul- the lumbosacral r egion.
you decide to also begin Given the chronicity of your der girdle postures) during Finally, you purchase an
cardiovascular exercise. condition and the degree of all exercises to improve sta- electric lift table as well as
2. If lumbosacral spinal sta- your weakness, you should bilization of your cervical a good book and DVD on
bilization exercises would begin your stabilization and thoracic spine. biomechanics for manual
be of value, are they safe program gradually. For this You have two options therapists and make a con-
for you to perform? If yes, reason, it is best to begin for incorporating stabili- scious effort to improve
how do you know? If not, with sensorimotor stabiliza- zation training into your your body mechanics when
why not? tion exercises first and then regimen. You can either practicing with your clients.
In your case, spinal sta- work up to strengthening work with a therapist, phy-
bilization exercises are stabilization exercises. You sician, or trainer who is Follow-Up:
safe for you to perform begin your sensorimotor licensed and/or trained to After 6 months, you feel like
because of the negative training with the single-leg recommend and monitor a new person with a new
results of all orthopedic stance (see Routine 12-6). your exercises or you can body. You are now able to
tests that would have You then do double-leg work on your own, imple- work comfortably without
indicated a space-occu- work and then single-leg menting the necessary pain, discomfort, or fatigue.
pying lesion (pathologic work on a rocker board (see exercises into your own You even notice that your
disc or bone spurs) or Routines 12-7 and 12-8). self-care program. Given massage technique has im-
acute condition. In ad- Once you are comfort- your knowledge base, you proved measurably, and
dition, your radiographs able with this work, you decide to begin on your your clients are happier
showed no pathologic can progress to performing own. You also decide to than before and referring
condition. In the absence double- and then single-leg supplement your self-care more friends and family
of these conditions, work on a wobble board program by b eginning the members to you. Realizing
450 Answers to Case Study and Review Questions
that this is not just a short- Multiple Choice Short Answer 4. Destabilizing surface
term fix, that being in shape 1. b 1. Lower crossed syndrome in multiple planes—
is important for your health 2. a 2. Perturbation Wobble board
and a lifelong commitment, 3. b 3. Labile 5. Side bridge—Lateral ab-
and that it is important to 4. d 4. Dead bug dominal wall
live the ideals that you rec- 5. c 6. Supine bridging—
ommend for your clients, Matching Posterior abdominal wall
you dedicate yourself to True/False 1. Destabilizing surface in
continuing your self-care 1. True one plane—Rocker board
program of strength train- 2. False 2. Prone plank—Anterior
ing, stretching, and manual 3. False abdominal wall
therapy as an ongoing part 4. True 3. Destabilizing position—
of your life. 5. True Single-leg stance
INDEX
Page numbers followed by b, f, and t denotes boxes, figures, and tables, respectively. Page numbers in italics denote online chapters.
I-1
hand placement in, 213 Dead bug track, 418, 419f tight muscles versus, 66
increasing contraction in, 212 Deep lateral rotator group, 28, 28f. See also treatment of, 66, 93
indications for, 262, 311 Hip deep lateral rotators Depression, pelvic, 7, 8f, 9, 10f, 11t
initial client stretch in, 210, 210f Deep pressure, 96. See also Deep tissue work Destabilizing body position, 420
knee joint protection in, 251 Deep stroking massage, 117–118, 118f Destabilizing forces, 420
lateral rotation of thigh in, 259 Deep tissue work, 96–133, 96b Destabilizing surface, 420
mechanism of, 206–208 applying pressure in, 99, 99f Diagnosis, 74
multiplane stretching with, 214, 218, 222, 238, art of, 98 Diaphragm, 16f–17f, 22, 22f
247, 249 back posture in, 114, 114f breathing and, 157
overview of technique, 208–211 body weight use in, 112, 113f, 115 massage routine for, 135, 156–157, 156f–157f
pelvis stabilization in, 208 bracing/supporting contact in, 98–99, 99f, Diastasis recti, 140–141, 140f
performing technique in, 212–213 107–109, 107f–109f Disc bulge, 60, 60f
postcontraction stretch in, 210f, 211 case study of, 133 Disc conditions, pathologic, 59–64
presetting the rotation in, 213 client communication in, 122 assessment of, 92–93
resistance in, 212, 213 client positioning for, 99, 99f bulging or rupture of annulus fibrosus fibers,
routines, 207b, 214–261 client’s breathing in, 117 59–60, 60f
gluteals, 250–252, 250f–252f cold for, 379 disc thinning, 59–60, 59f
hamstrings, 208–211, 208f–211f, 249 core alignment with stroke in, 110–112, 111f– major types of, 59–60, 59f, 60f
hip abductors, 234–238, 235f–238f 112f mechanism of, 60–64
hip adductors, 239–242, 239f–242f deep pressure versus, 96 sciatica with, 60, 61f
hip deep lateral rotators, 253–257, 253f–257f depth of, 117 therapist tip on, 62
hip extensors, 249–252, 249f–252f dropping down with core in, 112, 115f tight muscles and, 62
hip flexors, 243–248, 244f–248f engaging client’s tissues in, 116 treatment of, 64, 92–93
hip joint/pelvis, 207b, 234–261 external generation of force in, 96 Disc herniation, 60, 60f
hip medial rotators, 258–261, 258f–261f feet position for, 100–102, 101f–102f Disc joints, 4–5, 4f
lumbar spine, 207b, 214–233 head and neck posture in, 121, 121f functions of, 4
lumbar spine extensors, 214, 215–217, icing to increase depth in, 124 and vertebral motion, 5
215f–217f iliotibial band, 132, 132f Disc prolapse, 60, 60f
lumbar spine flexors, 214, 219–221, internal generation of force in, 96 Disc rupture, 60, 60f
219f–221f larger muscle use in, 112 Disc sequestration, 60, 60f
lumbar spine left lateral flexors, 214, 228 lubricant for, 121 Disc thinning, 59–60, 59f
lumbar spine left rotators–seated, 214, 233 mechanism of, 96 Distraction, lumbar spine, 7, 7f, 371–375, 371f–374f
lumbar spine right lateral flexors, 214, overview of technique, 98–99 DJD. See Degenerative joint disease (DJD)
223–227, 223f–227f performing technique in, 99–121 Double knee-to-chest stretch, 387, 387f
lumbar spine right rotators–seated, 214, perpendicular pressure application in, 112, with agonist contract protocol, 389, 389f
229–232, 230f–232f 112f–113f with contract relax agonist contract protocol,
second repetition in, 211, 211f pinning and stretching piriformis in, 130 390, 390f
slow and easy stretch in, 212 placing contact on client’s musculature in, with contract relax protocol, 388, 388f
starting position for, 208, 208f 98, 98f Double-leg stance on rocker board, 422, 423f
therapist tips on, 208–210, 212–214, 243, 259, pushing off with lower extremity in, 116, 117f Double-leg stance on wobble board, 424, 424f
262 routines, 122–132 Double S-curve, in scoliosis, 66, 66f
third repetition in, 211, 211f lateral low back—quadratus lumborum, Drag, 121
transitioning to thoracic spine in, 214 125–126, 125f Draping, in anterior abdomen massage, 139, 139f
unassisted, 208 lateral pelvis—abductor musculature, 131, Dynamic stretching, 161b, 269, 317
Contralateral muscles, 31, 88 131f–132f
Contralateral rotation, 6 medial low back—paraspinal musculature,
lumbar spine, 6 123–124, 123f–124f EAO. See External abdominal oblique
pelvic, 7, 8f middle and upper back—paraspinal Elbow treatment contact, in deep tissue work, 102,
Contrast hydrotherapy, 383 musculature, 127, 127f–128f 103f, 106, 106f
caution in, 383 posterior pelvis—gluteal region, 128–130, Electric lift table, for stretching, 168, 213, 270, 319
guidelines for, 383 128f–130f Elevation, pelvic, 7, 8f, 9, 10f, 11t
Contrology, The Art of (Pilates), 412b science of, 98 End-feel, 80
Core alignment/use shoulder girdle position in, 116 Erector spinae group, 18, 18f
in agonist contract stretching, 267, 276 stacking upper extremity joints in, 109, 110f actions of, 170
in anterior abdomen massage, 139 standing position for, 99–100, 100f agonist contract stretching of, 272–273,
in contract relax agonist contract stretching, 317 starting position for, 98, 98f 278–280, 282–285
in contract relax stretching, 209, 212 on stretch, 126 alternate position for stretching, 165, 165f
core as powerhouse, 412b strokes and techniques, 96 contract relax agonist contract stretching of,
in deep tissue work, 110–112, 111f, 112, table corner use in, 128 321–326
112f, 115f target musculature in, 98 contract relax stretching of, 215–217, 223–233
in multiplane stretching, 164, 164f, 183, 197 therapist tips on, 96–98, 106–107, 114–117, multiplane contract relax stretching of, 218, 218f
Coronal (frontal) plane, 5, 5f 121–122 multiplane stretching of, 163–166, 164f–166f,
Cough test, 82–83, 83f transition from sustained compression to deep 169b, 170
for pathologic disc conditions, 92 stroking massage in, 117–118, 118f trigger points and referral zones of, 44f
for piriformis syndrome, 93 transitioning to long, deep strokes in, 119–121, Extension. See also Hip extensors; Lumbar spine
Counterirritant theory, 382 120f extensors
Counternutation, 11, 11f treatment contacts in, 102–107, 103f–106f horizontal, of thigh, 9b
CR. See Contract relax (CR) stretching Degenerative joint disease (DJD), 65–66 ligaments and, 31
CRAC. See Contract relax agonist contract assessment of, 93 lumbar spine, 5–7, 6f, 7t
(CRAC) stretching definition of, 65 pelvic, 9t
Creep, 161b, 269, 318 description of, 65, 65f precautions in, 37
Cross-crawl, 416, 417f functional impairment in, 65 trunk muscles, 12
Cross-legged position, 400, 400f mechanism and causes of, 65–66 Extension exercises, 410b, 410f
CryoCup, 381 osteoarthritis, 65 External abdominal oblique, 13f, 15f, 16f, 134
Cryotherapy. See Cold hydrotherapy spondylosis, 65 agonist contract stretching of, 275–285
Curvature, of lumbar spine, 2, 2f therapist tips on, 65, 66 attachments and actions of, 20, 20f, 176
External abdominal oblique (cont.) Gaenslen’s test, 89–90, 90f, 243 Groin pain, in deep lateral rotator stretch, 203,
contract relax agonist contract stretching of, Gamma motor system, 39 203f, 253
324–326 Gastrocnemius, 16f GTO. See Golgi tendon organ (GTO) reflex
contract relax stretching of, 219–233 lateral head of, 13f Gym ball, sensorimotor exercises on, 421b, 421f
massage of, 142–146, 143f, 144f medial head of, 13f
multiplane contract relax stretching of, 222 Gate theory, 382
multiplane stretching of, 175–179 Generation of force Hamstring group, 26, 26f
side-lying position for, 146, 146f external, 96 action of, 195
trigger points and referral zones of, 47f internal, 96 agonist contract stretching of, 265–267,
External generation of force, 96 Genitalia, avoiding contact with, 137 266f–267f, 298
External rotation, pelvic, 11, 12f Glide (translation), of lumbar spine, 6–7, 7f anatomy of, 195, 195f, 249, 249f, 298, 298f,
Globally tight musculature, 39–43 331, 331f
adaptive shortening and, 42 caution in treating, 197, 209
Facet, 3f causes of, 40 contract relax agonist contract stretching of,
Facet joints, 4–5, 4f mechanism of, 39–40 314–316, 314f–316f, 331
capsule of, 34f muscle overstretching and, 42–43 contract relax stretching of, 208–211, 208f–211f,
function of, 5 muscle overuse and, 40–42 249
plane orientation of, 5, 5f muscle splinting and, 42 multiplane contract relax stretching of, 249, 268
and vertebral motion, 5 myofascial trigger points versus, 43–53 multiplane stretching of, 195–197, 195f–197f,
Facet syndrome, 70–71 pain-spasm-pain cycle in, 40, 41f 268
assessment of, 70, 93 poor posture and, 41–42, 42f posterior line-vertical stretching of, 395, 395f
description of, 70 Gluteals/gluteal region sacroiliac joint injury and, 59
mechanism and causes of, 70–71, 70f agonist contract stretching of, 299–300, trigger points and referral zones of, 50f
therapist tip on, 70 299f–300f Hand placement. See Brace hand; Contact hand;
treatment of, 71, 93–94 contract relax stretching of, 250–252, Resistance hand; Stabilization hand;
Fascial adhesions, 41b 250f–252f Stretching hand; Treatment hand
Fascial microtearing, 56 deep tissue work for, 128–130, 128f–130f Head posture, for deep tissue work, 121, 121f
Feet position, for deep tissue work, 100–102, functional group of, 250, 299 Health history, 74, 75b
101f, 102f multiplane stretching of, 198–200, 199f–200f Heat hydrotherapy, 382–383, 383
Femoral artery, 36, 36f and referral symptoms, 36b alternating with cold, 383
Femoral cutaneous nerve, lateral, compression Gluteus maximus, 13f, 29f caution in, 383
of, 63b agonist contract stretching of, 287–294, guidelines for, 383
Femoral nerve, 36, 36f 292–294, 299–300 physiologic benefits of, 382
Femoral neurovascular bundle, 154 attachments and actions of, 26, 26f, 198 stretching after, 382
Femoral triangle, 36, 36f contract relax stretching of, 234–238, 250–252 Heel raises, bridging with, 414–415, 414f
Femoral vein, 36, 36f multiplane stretching of, 182–184, 198–200 Hip abductors
Femoropelvic rhythm, 28b sciatic nerve and, 36–37, 36b, 36f actions of, 182
Femur, 3f, 4f trigger points and referral zones of, 50f agonist contract stretching of, 287–291,
greater trochanter of, 35f Gluteus medius, 13f–14f, 15f, 16f–17f 288f–291f
head of, 35f agonist contract stretching of, 287–291, alternate position for, 290–291, 291f
lesser trochanter of, 35f 295–296, 299–300 anatomy of, 182, 182f, 234, 234f, 287, 287f,
Fibrous adhesions, 41b, 54 attachments and actions of, 27, 27f, 188, 198 292, 292f
in inguinal region, 154 contract relax agonist contract stretching of, caution in treating, 235, 236, 289
Fibular, head of, 15f 328–330 contract relax stretching of, 234–238, 235f–238f
Fibularis longus, 16f contract relax stretching of, 234–238, 243–248, deep tissue work for, 131, 131f–132f
“Figure 4” stretch, 257, 257f, 396–397, 396f–397f 250–252, 258–261 functional group of, 234, 287, 292
Finger treatment contact multiplane stretching of, 182–184, 188–194, lateral line stretching of, 394, 394f
in anterior abdomen massage, 136–137, 137f, 198–200 multiplane contract relax stretching of, 238, 238f
138, 138f trigger points and referral zones of, 51f multiplane stretching of, 182–184, 182f–184f
in deep tissue work, 102, 103f, 104, 107 Gluteus minimus, 14f, 16f–17f Hip adductors
Fist treatment contact agonist contract stretching of, 287–291, action of, 185
in anterior abdomen massage, 137, 137f 295–296, 299–300 agonist contract stretching of, 292–294,
in deep tissue work, 102, 103f, 109, 109f attachments and actions of, 27, 27f, 188, 198 292f–294f
Flexion. See also Hip flexors; Lumbar spine flexors; contract relax agonist contract stretching of, anatomy of, 25, 25f, 239, 239f
Lumbar spine lateral flexors 328–330 caution in treating, 240
horizontal, of thigh, 9b contract relax stretching of, 234–238, 243–248, contract relax stretching of, 239–242, 239f–242f
ligaments and, 31, 31f 250–252, 258–261 functional group of, 239
lumbar spine, 5–7, 6f, 7t multiplane stretching of, 182–184, 188–194, medial line stretching of, 395, 395f
pelvic, 9t 198–200 multiplane stretching of, 185–187, 185f–187f,
precautions in, 37 trigger points and referral zones of, 51f 294
trunk muscles, 12 Golgi tendon organ (GTO) reflex, 206–207, 207b, Hip deep lateral rotators, 28, 28f
Foot raises, bridging with, 415, 415f 208, 314 agonist contract stretching of, 301–304,
Foot raises and kick, bridging with, 415, 415f Good, learning, in client self-care, 378 301f–304f
Forearm treatment contact, in deep tissue work, Good posture, definition of, 76, 76f alternate position for, 304, 304f
102, 103f, 106, 106f Gracilis, 13f–14f, 16f–17f, 29f anatomy of, 201, 201f, 253, 253f, 301, 301f,
Frequency of sessions, 90–91, 91f, 336 agonist contract stretching of, 292–296 332, 332f
Frontal plane, 5, 5f attachments and actions of, 25, 25f, 185 contract relax agonist contract stretching for,
range of motion in, 77 contract relax agonist contract stretching of, 332–335, 332f–335f
Full SLR test, 82, 82f 328–330 contract relax stretching of, 253–257, 253f–257f
Functional group of muscles. See also specific contract relax stretching of, 239–248, 258–261 “figure 4” stretch for, 257, 257f, 396–397,
groups multiplane stretching of, 185–194 396f–397f
definition of, 161 trigger points and referral zones of, 49f functional group of, 253, 301, 332
pelvic, 23 Gravity, in deep tissue work, 112, 115f groin pain with stretch of, 203, 203f, 253
“the shortest rope” in, 162 Greater sciatic foramen, 34f multiplane stretching of, 201–204, 202f–203f
stretching, 161, 162 Greater sciatic notch, 3 posterior line-horizontal stretching of, 396–397,
trunk, 12–15 Greater trochanter of femur, 35f 396f–397f
Hip extensors. See also Hamstring group IAO. See Internal abdominal oblique Ischemic compression, 118
agonist contract stretching of, 298–300, 299f–300f IB. See Iliotibial band Ischial spine, 3, 30f
anatomy of, 198, 198f Ice/icing. See also Cold hydrotherapy Ischial tuberosity, 3, 3f, 13f–14f, 35f
contract relax agonist contract stretching of, 331 application by therapist, 381, 381f Ischiofemoral ligament, 31, 35f
contract relax stretching of, 249–252, 249f–252f RICE protocol, 92, 380 Ischium, 3, 3f
multiplane stretching of, 195–197, 195f–197f Ice pack massage, 381
posterior line-vertical stretching of, 395, 395f Iliac crest, 3, 3f, 4f, 13f, 15f, 17f, 34f
Hip flexors Iliac crest compression test, 89, 89f Janda, Vladimir, 406
action of, 188 Iliac spine. See Anterior inferior iliac spine; Ante- Joint(s). See also specific joints
agonist contract stretching of, 295–296, 295f–296f rior superior iliac spine; Posterior inferior lumbar spinal, 4–5, 4f, 5f
anatomy of, 188, 188f, 243, 243f, 295, 295f, iliac spine; Posterior superior iliac spine pelvic, 5
328, 328f Iliacus, 16f–17f, 29f, 36f Joint dysfunction, 53–55
anterior line stretching of, 393, 393f actions of, 188 assessment of, 92
caution in treating, 194, 244, 245 agonist contract stretching of, 295–296 description of, 53–54
contract relax agonist contract stretching of, contract relax agonist contract stretching of, hypermobility in, 53–54, 338–339
328–330, 328f–330f 328–330 hypomobility in, 53–54, 54f, 55b, 338–339
contract relax stretching of, 243–248, 244f–248f contract relax stretching of, 243–248 joint play (motion palpation) in, 54, 76, 80–81,
at end of table, 248, 248f multiplane stretching of, 188–194 80f, 92
functional group of, 243, 295, 328 proximal belly, massage routine for, 135, mechanism and causes of, 54, 55b
multiplane contract reflex stretching of, 150–152, 150f, 151f, 152f subluxation/misalignment versus, 53b
247, 247f Iliococcygeus, 29f–30f treatment of, 55, 92
multiplane stretching of, 188–194, 188f–189f, Iliocostalis, 13f–14f, 18, 18f Joint mobilization, 337–376
191f–194f, 297, 297f, 330, 330f agonist contract stretching of, 272–273, alternative therapist position in, 357, 357f
Hip hiking, 7 282–284 bringing joint into tension, 340, 340f, 346, 346f
Hip joint(s), 5 contract relax agonist contract stretching of, case study of, 376
agonist contract stretching of, 264b, 287–310 321–326 caution in, 346, 352, 361–362, 373
caution in treating, 181, 327 contract relax stretching of, 215–217, 229–233 client breathing in, 347
concerns/cautions in treating, 181 multiplane stretching of, 170 client positioning in, 358
contract relax agonist contract stretching of, Iliocostalis thoracis, trigger points and referral client’s trunk in, holding, 344
313b, 327–335 zones of, 44f degree of stretch/mobilization in, 346–347
contract relax stretching of, 207b, 234–261 Iliofemoral ligament, 31, 35f force application in, 347
horizontal flexion and extension of thigh at, 9b Iliolumbar ligaments, 31, 34f grades of, 348b
ligaments of, 31, 35f, 200 Iliopsoas, 15f learning technique of, 337, 347
multiplane stretching of, 161b, 180–204, 181b attachments and actions of, 25, 25f length of time of stretch/mobilization in, 347
pelvic motion as unit at, 7, 8f, 9t distal, 135 mechanism of, 338
pelvic muscles crossing, 23 distal belly/tendon, massage routine for, 135, need for, determining, 348
stretching, in client self-care, 378b, 384, 152–155, 152f–155f overview of technique, 339–342
393–397 femoral triangle and, 36 performing technique in, 343–348
Hip medial rotators pinning and stretching, 155, 155f as pin and stretch, 342b
agonist contract stretching of, 305–308, pregnancy of, 141 “pocket to pocket” in, 359
305f–308f trigger points and referral zones of, 48f repetitions in, 341, 347–348
alternate contract stretch for, 308, 308f Iliotibial band (IB), 13f, 15f, 16f routines, 338b, 349–376
contract relax stretching of, 258–261, 258f–261f deep tissue work for, 132, 132f lumbar spine, 338b, 339–342, 365–375
Houstle, Michael, 162 Ilium, 3, 3f lumbar spine, prone, extension compression,
Hydrotherapy, 378–383, 378b Inclined back, 114, 114f 365–366, 365f–366f
cold, 379–380, 380 Inferior articular process, 4f lumbar spine, prone, flexion distraction,
alternating with heat, 383 Inferior gemellus, 13f–14f, 15f 369, 369f
caution in, 380 agonist contract stretching of, 301–304 lumbar spine, prone, lateral flexion and
guidelines for, 380 contract relax agonist contract stretching of, rotation, 367–368, 367f–368f
contrast, 383 332–335 lumbar spine, prone, multiplane, 368
caution in, 383 contract relax stretching of, 253–257 lumbar spine, seated, 370, 370f
guidelines for, 383 multiplane stretching of, 201–204 lumbar spine, seated, lateral flexion, 339–342,
definition of, 378–379 Inguinal ligament, 34f 340f–341f, 370, 370f
heat, 382–383, 383 Internal abdominal oblique, 13f–14f, 15f, 16f, 134 lumbar spine, seated, rotation and extension,
alternating with cold, 383 agonist contract stretching of, 275–285 341–342, 341f–342f
caution in, 383 attachments and actions of, 21, 21f, 176 lumbar spine, side-lying, horizontal
guidelines for, 383 contract relax agonist contract stretching of, adduction, 370
physiologic benefits of, 382 324–326 lumbar spine, supine, manual traction/
stretching after, 382 contract relax stretching of, 219–233 distraction, 374–375, 374f
Hyperlordosis, 2, 68–70 massage of, 142–146, 143f, 144f lumbar spine, supine, towel traction/
assessment of, 93 multiplane contract relax stretching of, 222 distraction, 371–373, 371f–373f
description of, 68, 69f multiplane stretching of, 175–179 sacroiliac joint, 338b, 349–364
mechanism and causes of, 69, 69f side-lying position for, 146, 146f sacroiliac joint, prone, posterior superior
sacral base angle and, 69, 69f trigger points and referral zones of, 47f iliac spine compression, 350–351,
therapist tip on, 68 Internal generation of force, 96 350f–351f
treatment of, 69, 93 Internal rotation, pelvic, 11, 12f sacroiliac joint, prone, sacrum compression,
Hypermobile joint, 53–54, 338–339 Interspinous ligaments, 31, 32f 352, 352f
Hypertonic musculature, 39–53 Intertransverse ligaments, 31, 31f, 32f, 34f sacroiliac joint, side-lying, compression,
assessment of, 91 Intervertebral disc, 3f, 32f 353, 353f
definition of, 39 Intervertebral foramina, 2, 3f, 32f sacroiliac joint, side-lying, horizontal
globally tight musculature, 39–43 Intrapelvic motion, 11, 11f, 12f adduction, 358–364, 358f–364f
joint dysfunction with, 54 Intrathecal pressure, 82–83 sacroiliac joint, side-lying, horizontal
myofascial trigger point, 39, 43, 44f–52f Ipsilateral rotation, 5–7 adduction, transitioning to lumbar
treatment of, 53, 91 lumbar spine, 6 spinal joints, 364, 364f
Hypolordotic curve, 2 pelvic, 7, 8f sacroiliac joint, side-lying, horizontal
Hypomobile joint, 53–54, 54f, 55b, 338–339 Ischemia, 43 adduction, variations, 363, 363f
Joint mobilization (cont.) Longissimus thoracis, trigger points and referral Lumbar spine lateral flexors, right
sacroiliac joint, supine, compression, 354, 354f zones of, 44f agonist contract stretching of, 278–280,
sacroiliac joint, supine, horizontal adduction, Lordotic curve (lordosis), 2, 2f, 68–70, 93, 366 278f–280f
356–357, 356f–357f Lower crossed syndrome, 69–70, 70f, 406 anatomy of, 223, 223f, 278, 278f
sacroiliac joint, supine, single knee to chest, Lower extremity, pushing off, in deep tissue work, contract relax stretching of, 214, 223–227,
354–355, 355f 116, 117f 223f–227f
scope of practice and, 348 Lubricant caution in, 224, 225
skill required for, 337 for deep tissue work, 121 with client seated, 227, 227f
spinous process contact in, 344 for ice pack massage, 381 functional group of, 223, 278
stabilization hand in, 339, 343, 343f Lumbar spinal joints, 4–5, 4f, 5f Lumbar spine rotators
stabilizing lower bone in, 340, 340f Lumbar spine left
starting position for, 340, 340f agonist contract stretching of, 264b, 271–286 agonist contract stretching of, 285, 285f
stretching versus, 338–339 anatomy of, 2, 2f, 3f, 4f anatomy of, 233, 233f, 285, 285f
support hand in, 351 bony landmarks of, 2, 3f, 4f contract relax agonist contract stretching
therapist tips on, 339, 342, 344, 347, 351, 358, contract relax agonist contract stretching of, of, 326
366, 375 313b, 320–326 contract relax stretching of, seated, 214, 233
thrust avoidance in, 347 contract relax stretching of, 207b, 214–233 functional group of, 233, 285
treatment hand in, 339, 344, 344f keeping stretch in, 167, 167f multiplane stretching of, 286, 286f
two-handed technique in, 344, 345f ligaments of, 31, 32f right
underutilization of, 337 lordotic curve of, 2, 2f agonist contract stretching of, 282–284,
without discerning spinal level, 342 motions of, 5–7 283f–284f
Joint play, 338. See also Joint mobilization axial, 5–6, 6f, 7t anatomy of, 229, 229f, 282, 282f, 324, 324f
Joint play assessment, 54, 76, 80–81, 80f, 92 healthy range of, 6, 7t contract relax agonist contract stretching of,
Joint release, 347 nonaxial, 6–7, 7f 324–326, 325f–326f
multiplane stretching of, 161b, 163–179, 167f, contract relax stretching of, seated, 214,
169b 229–232, 230f–232f
Kinesthetic awareness, 405 musculature of (muscles of trunk), 12–15, functional group of, 229, 282, 324
Knee-to-chest stretch, 386, 386f 13f–22f Lumbar spine stretches, in client self-care, 378b,
Knee-to-chest stretch, double, 387, 387f neutral, 406–407, 407f 384–393
Knee-to-opposite-shoulder stretch, 396–397, 396f precautions with, 35–37 chair low back stretch, 385–386, 385f–386f
Knife-edge contact, 102, 103f, 106, 106f rotation of, 168 double knee-to-chest stretch, 387, 387f
traditional strength training of, 410b, 410f double knee-to-chest stretch with agonist
Lumbar spine, joint mobilization routines for, contract protocol, 389, 389f
Labile surfaces, 420 338b, 339–342, 365–375 double knee-to-chest stretch with contract relax
Lamina, 2, 3f, 32f caution in, 373 agonist contract protocol, 390, 390f
Laminar groove, 2, 3f prone, extension compression, 365–366, double knee-to-chest stretch with contract relax
Lateral femoral cutaneous nerve, compression of, 63b 365f–366f protocol, 388, 388f
Lateral line (hip abductor) stretch, 394, 394f prone, flexion distraction, 369, 369f extension medley, 391, 391f
Lateral low back, deep tissue work for, 125–126, 125f prone, lateral flexion and rotation, 367–368, knee-to-chest stretch, 386, 386f
Lateral pelvis, deep tissue work for, 131, 131f–132f 367f–368f lateral stretch, 392, 392f
Lateral rotation, pelvic, 11, 12f prone, multiplane, 368 Lumbopelvic relationship, 412
Laterolisthesis, 71 seated, 370, 370f Lumbosacral joint, 5
Latissimus dorsi, 13f–14f seated, lateral flexion, 339–342, 340f–341f, pelvic motions relative to, 9, 10f, 11t
attachments and actions of, 19, 19f 370, 370f pelvic muscles crossing, 23
trigger points and referral zones of, 45f seated, rotation and extension, 341–342, Lymph Drainage Therapy, 157
Leaning-forward posture, 398, 398f 341f–342f
Leg(s) side-lying, horizontal adduction, 370
crossing of, 400, 400f supine, manual traction/distraction, 374–375, 374f Macrotrauma
pelvic muscles attaching onto, 23 supine, towel traction/distraction, 371–373, in degenerative joint disease, 66
Leg raises 371f–373f in pathologic disc conditions, 60–61
quadruped, 416, 417f Lumbar spine-extension medley, 391, 391f in sacroiliac joint injury, 57
straight. See Straight leg raise tests Lumbar spine extensors in sprains and strains, 56–57
Lengthened active insufficiency, 212 agonist contract stretching of, 272–273, Mamillary process, 3f
Lesser sciatic foramen, 34f 272f–273f Manual resistance (MR) assessment, 78–79, 78f, 88
Lesser trochanter of femur, 35f anatomy of, 215, 215f, 272, 272f, 321, 321f Manual traction, 371, 374–375, 374f
Levator ani, 29f–30f contract relax agonist contract stretching of, Massage with chiropractic treatment, 53
trigger points and referral zones of, 52f 321–322, 321f–322f Mechanism, definition of, 39
Levator hiatus, 30f contract relax stretching of, 214, 215–217, Medial line (hip adductor) stretch, 395, 395f
Lifting, and sprain/strains, 56–57, 56f 215f–217f Medial low back, deep tissue work for, 123–124,
Ligament(s), 31. See also specific ligaments functional group of, 215, 272, 321 123f–124f
function of, 31, 31f multiplane contract relax stretching of, 218, 218f Medial rotation, pelvic, 11, 12f
of hip joint, 31, 35f, 200 multiplane stretching of, 274, 274f, 323, 323f Meniscoid body, 55b
of lumbar spine, 31, 32f Lumbar spine flexors Meralgia paresthetica, 63b
of pelvis, 31, 34f agonist contract stretching of, 275–277, Microtearing, 56
Ligamentum flavum, 31, 32f 275f–277f Microtrauma
Ligamentum teres, 31, 35f anatomy of, 219, 219f, 275, 275f definition of, 60
Line of tension, 161 caution in treating, 276 in degenerative joint disease, 66
Locked long, 68 contract relax stretching of, 214, 219–221, in pathologic disc conditions, 60–61, 62
Locked short, 68 219f–221f in sprains and strains, 57
Longissimus, 13f–14f, 18, 18f, 215f, 229f, 233f functional group of, 219, 275 Middle back, deep tissue work for, 127, 127f, 128f
agonist contract stretching of, 272–273, multiplane contract relax stretching of, 222, 222f Mineral Ice, 381
282–284 multiplane stretching of, 277 Misalignment, 53b
contract relax agonist contract stretching of, Lumbar spine lateral flexors, left Mobilization grading, 348b
321–326 agonist contract stretching of, 281 Motion palpation, 54. See also Joint play assessment
contract relax stretching of, 215–217, 229–233 anatomy of, 228, 228f Motor control, therapist, 405
multiplane stretching of, 170 contract relax stretching of, 214, 228 MR. See Manual resistance assessment
Multi-cardinal plane stretch, 163b. See also resting tone of, 39 piriformis syndrome, 64
Multiplane stretching trunk, 12–15, 12–22, 13f–22f assessment of, 93
Multifidus, 14f attachments and actions of, 18–22, 18f–22f description of, 64, 64f
agonist contract stretching of, 272–273, direction of fibers, 12–15 mechanism of, 64
282–284 erector spinae group of, 18, 18f treatment of, 64, 93
attachments and actions of, 18, 18f functional groups of, 12–15 sacroiliac joint (SIJ) injury, 57–59
contract relax agonist contract stretching of, line of pull, 12 assessment of, 92
321–326 structural groups of, 12 description of, 57, 57f
contract relax stretching of, 215–217, 229–233 transversospinalis group of, 18, 18f and hamstring musculature, 59
multiplane stretching of, 171–172 Muscle knot. See Myofascial trigger points mechanism and causes of, 57, 58f
Multijoint stretching, 190, 190f Muscle memory, 40 muscle splinting in, 57–58, 58f
Multiplane stretching, 160–205 Muscle overstretching symptoms of, 58–59
agonist contract stretching with, 268, 271, 274, and globally tight musculature, 42–43 treatment of, 59, 92
277, 286, 294, 297 and joint dysfunction, 54 scoliosis, 66–68
alternate position for, 165, 165f Muscle overuse, 40–42 assessment of, 93
body mechanics in, 164, 164f, 168, 183, 197 myofascial trigger points in, 43 C-curve in, 66, 66f
case study of, 204 pain-spasm-pain cycle in, 40, 41f definition of, 66
client breathing in, 167 poor posture and, 41–42, 42f description of, 66, 66f, 67f
contract relax agonist contract stretching with, Muscle spindle fibers, 39–40 double S-curve in, 66, 66f
320, 323, 330 Muscle spindle reflex, 40, 40f, 166, 212, 269, 317 idiopathic, 68
contract relax stretching with, 214, 218, 222, Muscle splinting, 42 measurement of curve in, 66, 67f
238, 247, 249 in sacroiliac joint injury, 57–58 mechanism and causes of, 66–68, 67f
creativity in, 168 Musculoskeletal pathologic conditions. See also S-curve in, 66, 66f
definition of, 160 specific conditions therapist tip on, 68
direction of stretch in, 167 anterior pelvic tilt and hyperlordosis, 68–70 tight muscles and, 68
electric lift table for, 168 assessment of, 93 treatment of, 68, 93
length of time, 167–168 description of, 68, 69f spondylolisthesis, 71–72
lumbar rotation in, 168 mechanism and causes of, 69, 69f assessment of, 94
mechanism of, 163 sacral base angle and, 69, 69f definition of, 71
overview of technique, 163–165, 164f, 165f therapist tip on, 68 description of, 71, 71f
pelvis stabilization in, 180–181, 180f–181f treatment of, 69, 93 grading or measurement of, 71–72, 71f
performing technique in, 166–168 degenerative joint disease, 65–66 mechanism or causes of, 71–72
presetting the rotation in, 184 assessment of, 93 roll for supporting patient with, 72
repetitions in, 165, 167–168 definition of, 65 therapist tip on, 72
reverse actions in, 166, 166f description of, 65, 65f treatment of, 72, 94
routines, 161b, 169–204 functional impairment in, 65 sprains and strains, 55–57
anterior abdominal wall, 175–179, 176f–179f mechanism and causes of, 65–66 assessment of, 92
erector spinae group, 163–166, 164f–166f, 170 osteoarthritis, 65 description of, 55–56
gluteals, 198–200, 199f–200f spondylosis, 65 grade I, 56
hamstrings, 195–197, 195f–197f, 268 therapist tips on, 65, 66 grade II, 56
hip abductors, 182–184, 182f–184f tight muscles versus, 66 grade III, 56
hip adductors, 185–187, 185f–187f, 294 treatment of, 66, 93 mechanism and causes of, 56–57, 56f
hip deep lateral rotators, 201–204, 202f–203f facet syndrome, 70–71 microtearing versus, 56
hip extensors, 195–197, 195f–197f assessment of, 70, 93 muscle spasm versus, 56
hip flexors, 188–194, 188f–189f, 191f–194f, description of, 70 severity, 55–56
297, 297f, 330, 330f mechanism and causes of, 70–71, 70f therapist tip on, 56
hip joint/pelvis, 161b, 180–204, 181b therapist tip on, 70 treatment of, 57, 92
lumbar spine, 161b, 163–179, 167f, 169b treatment of, 71, 93–94 therapist tips on, 53, 56, 59, 62, 65–66, 68,
lumbar spine extensors, 274, 274f, 323 hypertonic musculature, 39–53 70, 72
lumbar spine flexors, 277 assessment of, 91 Myofascial trigger points (TrPs), 39, 43
lumbar spine rotators, 286, 286f definition of, 39 causes of, 43
quadratus lumborum, 173–174, 173f–174f globally tight musculature, 39–43 common, of low back and pelvis, 43, 44f–52f
transversospinalis group, 171–172, 171f–172f joint dysfunction with, 54 contraction-ischemia cycle and, 43, 43f
slow and easy stretch in, 166 myofascial trigger point, 39, 43, 44f–52f globally tight musculature versus, 43–53
stabilization hand in, 162b, 167 treatment of, 53, 91 mechanism of, 43
starting position for, 163–164, 164f introduction to, 39, 39b referral zones of, 43, 44f–52f
stretching client in, 164–165, 164f, 165f joint dysfunction, 53–55 treatment of, 118
therapist tips on, 162–164, 169, 184, 197, 200 assessment of, 92
third cardinal plane action in, 163 description of, 53–54
transitioning to thoracic spine in, 169 hypermobility in, 53–54 Nachlas’ test, 88, 89f, 92
treatment hand in, 162b, 166, 166f hypomobility in, 53–54, 54f, 55b Neck posture, for deep tissue work, 121, 121f
Muscle(s). See also specific muscles, conditions, and mechanism and causes of, 54, 55b Negative test result, 76
routines motion palpation in, 54 Nerve(s), precautions with, 35–37, 36f
contralateral (antagonist), 31, 88 subluxation/misalignment versus, 53b Neurovascular structures, 35–37, 36f
globally tight, 39–43 treatment of, 55, 92 Neutral lumbar spine, 406–407, 407f
hypertonic, 39–53 pathologic disc conditions, 59–64 Neutral pelvis, 406–407, 407f
pelvic, 13f–17f, 23–30, 23f–30f assessment of, 92–93 Nonaxial motions, of lumbar spine, 6–7, 7f
adductor group of, 25, 25f bulging or rupture of annulus fibrosus fibers, Nucleus pulposus, 4, 4f
crossing hip joint and attaching onto 59–60, 60f Nutation, 11, 11f
thigh/leg, 23 disc thinning, 59–60, 59f
crossing lumbosacral joint and attaching major types of, 59–60, 59f, 60f
onto trunk, 23 mechanism of, 60–64 OA. See Osteoarthritis
deep lateral rotator group of, 28, 28f sciatica with, 60, 61f Oblique plane, 5, 5f
functional groups of, 23 therapist tip on, 62 Obliques. See External abdominal oblique; Internal
hamstring group of, 26, 26f tight muscles and, 62 abdominal oblique
pelvic floor, 28, 29f–30f treatment of, 64, 92–93 Obturator canal, 30f
Obturator externus, 14f, 17f, 201f motions of, 7–12 Posterior inferior iliac spine (PIIS) compression
agonist contract stretching of, 301–304 intrapelvic, 11, 11f, 12f test, 89, 89f
contract relax agonist contract stretching of, as unit, at hip joint, 7, 8f, 9t Posterior line-horizontal (hip lateral rotator/
332–335 as unit, relative to lumbosacral joint, 9, piriformis) stretches, 396–397, 396f–397f
contract relax stretching of, 253–257 10f, 11t Posterior line-vertical (hip extensor/hamstring)
multiplane stretching of, 201–204 multiplane stretching of, 161b, 180–204, 181b stretch, 395, 395f
Obturator internus, 13f–14f, 15f, 29f–30f, 201f muscles of, 13f–17f, 23–30, 23f–30f Posterior longitudinal ligament, 31, 32f
agonist contract stretching of, 301–304 adductor group of, 25, 25f Posterior pelvic tilt, 7, 8f, 9, 10f, 11, 11t, 12f
contract relax agonist contract stretching of, crossing hip joint and attaching onto Posterior pelvis, deep tissue work for, 128–130,
332–335 thigh/leg, 23 128f–130f
contract relax stretching of, 253–257 crossing lumbosacral joint and attaching Posterior sacroiliac ligaments, 31, 34f
multiplane stretching of, 201–204 onto trunk, 23 Posterior superior iliac spine (PSIS), 3–4, 3f
trigger points and referral zones of, 52f deep lateral rotator group of, 28, 28f compression
Open chain kinematics, 7, 9t, 11t functional groups of, 23 prone, 350–351, 350f–351f
Osteoarthritis (OA), 65. See also Degenerative joint hamstring group of, 26, 26f prone, with thigh extension, 351
disease pelvic floor, 28, 29f–30f Posterolisthesis, 71
Osteopathic adjustment, 347 neutral, 406–407, 407f Postisometric relaxation (PIR) stretching.
Osteophytes. See Bone spur precautions with, 35–37 See Contract relax stretching
Overstretching, muscle stabilization of Postural advice, for client, 378, 398–401
and globally tight musculature, 42–43 in agonist contract stretching, 266, 266f, bad sleeping posture, 401, 402f
and joint dysfunction, 54 267, 288 carrying heavy weight, 399, 399f
Overuse, muscle, 40–42 in contract relax agonist contract stretching, crossing the legs, 400, 400f
myofascial trigger points in, 43 315, 315f for overweight client, 399
pain-spasm-pain cycle in, 40, 41f in contract relax stretching, 208 prolonged sitting, 400–401, 401f
poor posture and, 41–42, 42f in multiplane stretching, 180–181, 180f–181f prolonged standing, 401, 401f
Overweight client, postural advice for, 399 stretching, in client self-care, 378b, 384, stoop-bending/leaning-forward posture,
393–397 398, 398f
Perpendicular pressure, in deep tissue work, 112, Postural assessment, 74, 76–77
Pain-spasm-pain cycle, 40, 41f, 379 112f, 113f Posture
Palm treatment contact, in deep tissue work, 102, Perturbation, 420, 423 back, for deep tissue work, 114, 114f
103f, 104–105, 105f, 107–109, 108f Physical assessment examination, 74, 75–90 bad, definition of, 76, 76f
Palpation, 54, 74, 76, 79–80 joint play, 54, 76, 80–81, 80f cervicothoracic (cervical brace), 407, 408f
Palpation, motion, 54. See also Joint play manual resistance, 78, 78f definition of, 76
assessment negative test result in, 76 good, definition of, 76, 76f
Paraspinal musculature, deep tissue work for, positive test result in, 76 head and neck, for deep tissue work, 121, 121f
123–124, 123f–124f, 127, 127f, 128f sacroiliac joint medley of tests in, 88–90, 89f, and hyperlordosis, 70
Pars interarticularis, 2, 3f 90f, 92 and muscle overuse, 41–42, 42f
Passive range of motion, 77, 77f, 338, 338f signs and symptoms in, 75–76 neutral, 406–407, 407f
Passive SLR test, 81–82, 82f, 86, 87f special tests in, 76, 81–90, 81b pelvic, 9b–11b
Patella, 15f, 16f–17f PIIS. See Posterior inferior iliac spine Powerhouse, core as, 412b
Patellar ligament, 16f Pilates, 412b Precautions, 35–37
Pathologic conditions. See Musculoskeletal Pilates, Joseph, 412b anatomic considerations and, 35–37, 36f
pathologic conditions; specific conditions Pin and stretch motions and, 37
Pathomechanism, definition of, 39 iliopsoas, 155, 155f Pregnancy
Pathophysiology, definition of, 39 joint mobilization as, 342b abdominal massage in, 140–141, 140f, 141f
Pectineus, 16f–17f piriformis, 130 posture in, and muscle overuse, 41–42
agonist contract stretching of, 292–296 Piriformis, 13f–14f, 15f, 17f, 29f–30f Prerectal fibers, 30f
attachments and actions of, 25, 25f, 185 actions of, 201 Presetting the rotation, 184, 213
contract relax agonist contract stretching of, agonist contract stretching of, 301–304 Prone plank, 412, 412f
328–330 contract relax agonist contract stretching of, Prone position, for client, 37
contract relax stretching of, 239–248, 258–261 332–335 Proprioception, 405
femoral triangle and, 36, 36f contract relax stretching of, 253–257 Proprioceptive neuromuscular facilitation (PNF)
multiplane stretching of, 185–187, 188–194 multiplane stretching of, 201–204 stretching. See Contract relax stretching
Pedicle, 32f pinning and stretching, 130 Protraction, lumbar spine, 6–7, 7f
Pelvic bones, 2, 2f, 3, 3f posterior line-horizontal stretching of, 396–397, Pseudo sciatica, 64
Pelvic floor muscles, 28, 29f–30f 396f–397f PSIS. See Posterior superior iliac spine
trigger points and referral zones of, 52f sciatic nerve and, 36–37, 36f, 64, 64f Psoas major, 15f, 16f–17f, 29f
Pelvic girdle, 3–4, 3f, 4f trigger points and referral zones of, 52f actions of, 188
Pelvic joints, 5 Piriformis stretch test, 84–86, 86f, 93 agonist contract stretching of, 275–281,
Pelvic posture, 9b–11b Piriformis syndrome, 64 295–296
Pelvic tilt assessment of, 93 alternate positions for, 149, 149f
anterior, 7, 8f, 9, 10f, 11, 11t, 12f description of, 64, 64f contract relax agonist contract stretching of,
increased, and hyperlordosis, 68–70, 93 mechanism of, 64 328–330
muscles of, 69–70 treatment of, 64, 93 contract relax stretching of, 219–228, 243–248
posterior, 7, 8f, 9, 10f, 11, 11t, 12f PIR stretching. See Contract relax stretching loosening abdominal wall for, 150
pregnancy and, 140–141 Planes, of body, 5, 5f multiplane stretching of, 188–194
Pelvic tilt exercises, for therapist, 411b, 411f range of motion in, 77 precautions in working with, 35–36, 36f
Pelvis stretching in. See Multiplane stretching pregnancy and, 141
agonist contract stretching of, 264b, 287–310 Plank, prone, 412, 412f proximal belly, massage routine for, 135,
anatomy of, 2, 2f, 3–4, 3f, 4f Plantaris, 13f 147–150, 147f–149f
bony landmarks of, 3–4, 4f PNF stretching. See Contract relax stretching Psoas minor, 17f, 22, 22f, 29f
contract relax agonist contract stretching of, “Pocket to pocket,” 359 agonist contract stretching of, 275–280
313b, 327–335 Popliteal artery, 13f–14f contract relax stretching of, 219–221,
contract relax stretching of, 207b, 234–261 Popliteal vein, 13f–14f 223–227
deep tissue work for, 128–131, 128f–132f Positive test result, 76 psoas major, 219f
ligaments of, 31, 34f Posterior inferior iliac spine (PIIS), 3, 3f Pubic bone, 35f
Pubic symphysis, 29f–30f Rocker boards, 420, 422–423, 423f contract relax stretching of, 234–238, 243–248
Pubic tubercle, 3, 4f Roll (bolster) multiplane stretching of, 182–184, 188–194
Pubis, 3, 3f for anterior abdomen massage, 136, 147 trigger points and referral zones of, 48f
Pubococcygeus, 29f–30f for patient with spondylolisthesis, 72 Scar tissue adhesions, 41b
Pubofemoral ligament, 31, 35f ROM. See Range of motion Sciatica, 60, 61f
Puborectalis, 29f–30f Rotation. See also Hip deep lateral rotators; in pathologic disc conditions, 60, 61f
Lumbar spine rotators in piriformis syndrome, 64, 64f
contralateral, 6 pseudo, 64
Quadratus femoris, 13f–14f, 15f ipsilateral, 5–6 Sciatic nerve, 13f–14f, 36–37, 36f
agonist contract stretching of, 292–294, lateral, of thigh, 259 compression of. See Sciatica
301–304 ligaments and, 31 gluteal work and, 36b
contract relax agonist contract stretching of, lumbar spine, 5–7, 6f, 7t precautions with, 36–37
332–335 pelvic, 7, 8f, 9, 9t, 10f, 11, 11t, 12f Scoliosis, 66–68
contract relax stretching of, 239–242, 253–257 precautions in, 37 assessment of, 93
multiplane stretching of, 201–204 presetting, 184, 213 C-curve in, 66, 66f
sciatic nerve and, 36–37, 36f trunk muscles, 12–15 definition of, 66
Quadratus lumborum, 14f Rotatores, 14f description of, 66, 66f, 67f
agonist contract stretching of, 272–273, attachments and actions of, 18, 18f double S-curve in, 66, 66f
278–280 multiplane stretching of, 171–172 idiopathic, 68
attachments and actions of, 19, 19f, 173 trigger points and referral zones of, 44f measurement of curve in, 66, 67f
contract relax agonist contract stretching of, Routines. See specific routines mechanism and causes of, 66–68, 67f
321–322 S-curve in, 66, 66f
contract relax stretching of, 215–217, 223–227 therapist tip on, 68
deep tissue work for, 125–126, 125f Sacral base, 3, 3f tight muscles and, 68
multiplane contract relax stretching of, 218, Sacral base angle, 69, 69f, 409b treatment of, 68, 93
218f Sacral tubercles, 3–4, 3f Scope of practice, 348
multiplane stretching of, 173–174, 173f–174f Sacroiliac joint (SIJ), 3–4, 3f, 4f, 5 S-curve, in scoliosis, 66, 66f
side-lying client position for, 126 ligaments of, 57, 58f Segmental joint hypomobilities, 338–339
trigger points and referral zones of, 45f motion of pelvic bone at, 11, 12f Segmental joint level, 5, 338
Quadruped leg raises, 416, 417f Sacroiliac joint (SIJ) injury, 57–59 Self-care for client. See Client self-care
Quadruped track, 416, 417f assessment of, 92 Self-care for therapist. See Therapist self-care
Quadruped-track sensorimotor exercise, 425, 425f description of, 57, 57f Semimembranosus, 13f–14f, 15f, 29f. See also
and hamstring musculature, 59 Hamstring group
mechanism and causes of, 57, 58f agonist contract stretching of, 298
Range of motion (ROM) medley of tests for, 88–90, 89f, 90f, 92 attachments and actions of, 26, 26f
active, 77, 77f, 338, 338f muscle splinting in, 57–58, 58f contract relax agonist contract stretching of, 331
passive, 77, 77f, 338, 338f Nachlas’ test for, 88, 89f, 92 contract relax stretching of, 249
Range of motion (ROM) assessment, 74, 76, 77–79 straight leg raise test for, 86, 88 multiplane stretching of, 195–197
actual amount (degrees) of ROM in, 77, 78–79 symptoms of, 58–59 Semispinalis, 13f–14f
for hypertonic musculature, 91 treatment of, 59, 92 agonist contract stretching of, 272–273, 282–284
for lumbar sprains and strains, 92 Yeoman’s test for, 88, 89f, 92 attachments and actions of, 18, 18f
pain in, 77–78 Sacroiliac joint (SIJ) mobilization, 338b, 349–364 contract relax agonist contract stretching of,
for scoliosis, 93 alternative therapist position in, 357, 357f 321–326
therapist tip on, 78 caution in, 352, 361–362 contract relax stretching of, 215–217, 229–233
Reciprocal inhibition (RI), 264–265, 265b, 314 “pocket to pocket” in, 359 multiplane stretching of, 171–172
Rectus abdominis, 16f–17f, 134 prone Semitendinosus, 13f, 29f. See also Hamstring group
agonist contract stretching of, 275–280 posterior superior iliac spine compression, agonist contract stretching of, 298
attachments and actions of, 20, 20f, 176 350–351, 350f–351f attachments and actions of, 26, 26f
contract relax stretching of, 219–221, 223–227 sacrum compression, 352, 352f contract relax agonist contract stretching of, 331
lateral border, as landmark, 138, 138f side-lying contract relax stretching of, 249
massage routine for, 135–137, 136f–137f, 140 compression, 353, 353f multiplane stretching of, 195–197
multiplane stretching of, 175–179 horizontal adduction, 358–364, 358f–364f Sensorimotor exercises, for therapist, 405, 405b,
palpating toward public bone attachment of, 137 horizontal adduction, transitioning to 420–425
trigger points and referral zones of, 46f lumbar spinal joints, 364, 364f quadruped-track sensorimotor exercise, 425,
Rectus femoris, 15f, 16f, 29f horizontal adduction, variations, 363, 363f 425f
agonist contract stretching of, 295–296 supine sensorimotor exercises on gym ball, 421b, 421f
attachments and actions of, 24, 24f compression, 354, 354f Sensorimotor exercises, for therapist. See
contract relax agonist contract stretching of, horizontal adduction, 356–357, 356f–357f Stabilization exercises
328–330 placing client’s foot on clavicle in, 355, 355f Sequestered disc, 60, 60f
contract relax stretching of, 243–248 single knee to chest, 354–355, 355f Serratus posterior inferior, 13f, 15f
multiplane stretching of, 188–194 Sacroiliitis, 57 attachments and actions of, 19, 19f
trigger points and referral zones of, 47f Sacrospinous ligament, 31, 34f trigger points and referral zones of, 46f
Referral symptoms, gluteal work and, 36b Sacrotuberous ligament, 13f–14f, 29f, 31, 34f Shortening, adaptive, 42
Referral zones, of myofascial trigger points, 43, Sacrum, 2, 2f, 3, 3f, 4f, 15f, 29f, 30f “Shortest rope,” 162
44f–52f base angle of, 69, 69f, 409b Shoulder girdle position, in deep tissue work, 116
Report of findings, 74 base of, 3, 3f Side bridge, 413, 413f
Resistance hand nutation and counternutation of, 11, 11f Signs, 75–76. See also specific conditions
in contract relax agonist contract stretching, 314 Sacrum compression, 352, 352f SIJ. See Sacroiliac joint
in contract relax stretching, 207–208 Sagittal plane, 5, 5f Single-leg bridges, 415, 415f
Resting tone, 39 range of motion in, 77 Single-leg stance on floor, 422, 422f
Retraction, lumbar spine, 7, 7f Sartorius, 13f–14f, 15f, 16f, 29f Single-leg stance on rocker board, 423, 423f
Reverse actions agonist contract stretching of, 287–291, Single-leg stance on wobble board, 424, 424f
of pelvis, at hip joint, 7, 8f, 9t 295–296 Sitting, prolonged, 400–401, 401f
in stretching, 166, 166f attachments and actions of, 24, 24f, 188 Sleeping posture, bad, 401, 402f
RI. See Reciprocal inhibition contract relax agonist contract stretching of, Sliding filament mechanism, 43
RICE protocol, 92, 380 328–330 SLR. See Straight leg raise tests
Slump test, 83–84, 84f–85f quadruped track, 416, 417f double knee-to-chest stretch with contract
for pathologic disc conditions, 92 quadruped-track sensorimotor exercise, 425, 425f relax protocol, 388, 388f
for piriformis syndrome, 93 sacral base angle in, 409b hip joint/pelvis medley of stretches, 378b,
Soleus, 16f sensorimotor exercises on gym ball, 421b, 421f 393–397
Space-occupying lesion(s), 60 side bridge, 413, 413f knee-to-chest stretch, 386, 386f
Space-occupying lesions tests, 81–86 single-leg stance on floor, 422, 422f lateral line (hip abductor) stretch, 394, 394f
Space-occupying lesion tests single-leg stance on rocker board, 423, 423f lumbar spine-extension medley, 391, 391f
cough, 82–83, 83f single-leg stance on wobble board, 424, 424f lumbar spine lateral stretch, 392, 392f
piriformis stretch, 84–86, 86f stabilization sensorimotor, 405, 405b, 420–425 lumbar spine stretches, 378b, 384–393
slump, 83–84, 84f–85f stabilization strengthening, 405, 405b, 411–419 medial line (hip adductor) stretch, 395, 395f
straight leg raise, 81–82, 82f supine bridging track, 414–415, 414f–415f posterior line-horizontal (hip lateral rotator/
Valsalva maneuver, 82–83, 83f traditional strength training of lumbar spine, piriformis) stretches, 396–397, 396f–397f
Special assessment tests, 76, 81–90, 81b. See also 410b, 410f posterior line-vertical (hip extensor/hamstring)
specific tests Stabilization hand, 162b stretch, 395, 395f
cough test, 82–83, 83f in agonist contract stretching, 265, 269–270 Stretching hand, 162b
for injured tissue, 86–90 in contract relax agonist contract stretching, in agonist contract stretching, 265
manual resistance, 88 314, 318 in contract relax agonist contract stretching,
Nachlas’, 88, 89f in contract relax stretching, 213 314, 318
piriformis stretch, 84–86, 86f in joint mobilization, 339, 343, 343f in contract relax stretching, 207–208, 213
sacroiliac joint medley of, 88–90, 89f, 90f, 92 in multiplane stretching, 167 in multiplane stretching, 166, 166f
slump, 83–84, 84f–85f Stabilization of pelvis Stretch reflex, 40, 40f, 166, 212, 269, 317
for space-occupying lesions, 81–86 in agonist contract stretching, 266, 266f, 267, 288 Stroke–core alignment, in deep tissue work,
straight leg raise, 81–82, 82f, 86–88, 87f in contract relax agonist contract stretching, 110–112, 111f, 112f
Valsalva maneuver/test, 82–83, 83f 315, 315f Structural groups, of trunk muscles, 12
Yeoman’s, 88, 89f in contract relax stretching, 208 Subluxation, 53b
Sphincter ani, trigger points and referral zones in multiplane stretching, 180–181, 180f–181f Superior articular process, 3f, 4f
of, 52f Stacked joints, 109, 110f Superior gemellus, 13f–14f, 15f, 201f
Spinalis, 13f–14f, 18, 18f Standing, prolonged, 401, 401f agonist contract stretching of, 301–304
agonist contract stretching of, 272–273, 282–284 Standing position, for deep tissue work, 99–100, 100f contract relax agonist contract stretching of,
contract relax agonist contract stretching of, Static stretching, 161b 332–335
321–326 Stoop bending, 398, 398f contract relax stretching of, 253–257
contract relax stretching of, 215–217, 229–232 Stooped back, 114, 114f multiplane stretching of, 201–204
multiplane stretching of, 170 Straight leg raise tests sciatic nerve and, 36–37, 36f
Spinal nerve compression, 60 active, 81–82, 82f, 86, 87f Supine bridging track, 414–415, 414f–415f
Spinal nerves, lumbar, 2 and antagonist musculature, 88 Support hand, 98, 351
Spinous process, 2, 3f, 32f full, 82, 82f Supraspinous ligament, 31, 32f, 34f
contact, in joint mobilization, 344 for injured tissue, 86–88, 87f Sustained compression
rotation, in scoliosis, 66, 67f passive, 81–82, 82f, 86, 87f for myofascial trigger points, 118
Spinous process contact, in joint mobilization, 344 for pathologic disc conditions, 92 transitioning from, in deep tissue work,
Splinting, muscle, 42 for piriformis syndrome, 93 117–118, 118f
in sacroiliac joint injury, 57–58, 58f for sacroiliac joint injury, 86, 88, 92 Swayback. See Hyperlordosis
Spondylolisthesis, 71–72 for space-occupying lesions, 81–82, 82f Symphysis pubis joint, 5, 34f
assessment of, 94 therapist tips on, 81, 88 Symptoms, 75–76. See also specific conditions
definition of, 71 Strains. See Sprains and strains
description of, 71, 71f Strengthening, therapist. See Stabilization exercises
grading or measurement of, 71–72, 71f Stretching, 160. See also Agonist contract (AC) Tables
mechanism or causes of, 71–72 stretching; Contract relax agonist contract choosing right, 96–98
roll for supporting patient with, 72 (CRAC) stretching; Contract relax (CR) electric lift, for stretching, 168, 213, 270, 319
therapist tip on, 72 stretching; Multiplane stretching; Pin and using corner of, 128
treatment of, 72, 94 stretch Target muscle, in stretching, 162b
Spondylosis, 65. See also Degenerative joint disease assisted, 162b Target musculature
Sprains and strains, 55–57 classic, 161b in anterior abdomen massage, 136, 137f
assessment of, 92 dynamic, 161b, 269, 317 in deep tissue work, 98
description of, 55–56 functional groups, 161, 162 definition of, 98
grade I, 56 joint mobilization versus, 338–339 Target tissue, in stretching, 162b
grade II, 56 mechanism of, 161–163 Tension, line of, 161
grade III, 56 multijoint, 190, 190f Tensor fasciae latae (TFL), 13f, 15f, 16f
mechanism and causes of, 56–57, 56f “the shortest rope” in, 162 agonist contract stretching of, 287–291, 295–296
microtearing versus, 56 stabilization hand in, 162b, 167 attachments and actions of, 23, 23f, 188
muscle spasm versus, 56 static, 161b contract relax agonist contract stretching of,
severity, 55–56 target muscle in, 162b 328–330
straight leg raise tests for, 86–88, 87f target tissue for, 162b contract relax stretching of, 234–238, 243–248,
therapist tip on, 56 terms in, 162b 258–261
treatment of, 57, 92 therapist tips on, 162, 163 multiplane stretching of, 182–184, 188–194
Stabilization exercises, for therapist, 405–425, 405b treatment hand in, 162b trigger points and referral zones of, 47f
caution in, 422 unassisted, 162b TFL. See Tensor fasciae latae
cervicothoracic (cervical brace) posture in, 407, Stretching, in client self-care, 378, 384–397 Therapist body mechanics. See Body mechanics
408f, 416, 416f limiting number of stretches, 384 Therapist self-care, 404–426
dead bug track, 418, 419f routines, 384–397, 384b case study of, 426
double-leg stance on rocker board, 422, 423f anterior line (hip flexor) stretches, 393, 393f mechanism of, 405
double-leg stance on wobble board, 424, 424f chair low back stretch, 385–386, 385f–386f motor control in, 405
neutral posture in, 406–407, 407f double knee-to-chest stretch, 387, 387f stabilization exercises in, 405–425, 405b
overview and performing technique in, 406–408 double knee-to-chest stretch with agonist caution in, 422
pelvic tilt, 411b, 411f contract protocol, 389, 389f cervicothoracic (cervical brace) posture in,
perturbations in, 420, 423 double knee-to-chest stretch with contract 407, 408f, 416, 416f
prone plank, 412, 412f relax agonist contract protocol, 390, 390f dead bug track, 418, 419f
double-leg stance on rocker board, 422, 423f Traction, lumbar spine, 7, 7f Trunk. See also Lumbar spine; Pelvis
double-leg stance on wobble board, 424, 424f manual, 371, 374–375, 374f circumduction of, 6, 6f
neutral posture in, 406–407, 407f towel, 371–373, 371f–373f muscles of, 12–22, 13f–22f
overview and performing technique in, Translation, of lumbar spine, 6–7, 7f attachments and actions of, 18–22, 18f–22f
406–408 Transverse acetabular ligament, 35f direction of fibers, 12–15
pelvic tilt, 411b, 411f Transverse plane, 5, 5f erector spinae group of, 18, 18f
perturbations in, 420, 423 range of motion in, 77 functional groups of, 12–15
prone plank, 412, 412f Transverse process, 3f, 32f line of pull, 12
quadruped track, 416, 417f Transversospinalis group, 18, 18f structural groups of, 12
quadruped-track sensorimotor exercise, actions of, 171 transversospinalis group of, 18, 18f
425, 425f agonist contract stretching of, 272–273, 278–280, pelvic muscles attaching onto, 23
sacral base angle in, 409b 282–285 Tupler Technique, 141
sensorimotor exercises on gym ball, 421b, 421f contract relax agonist contract stretching of,
side bridge, 413, 413f 321–326
single-leg stance on floor, 422, 422f contract relax stretching of, 215–217, 223–233 Unassisted agonist contract stretching, 265
single-leg stance on rocker board, 423, 423f multiplane contract relax stretching of, 218, 218f Unassisted contract relax stretching, 208
single-leg stance on wobble board, 424, 424f multiplane stretching of, 171–172, 171f–172f Unassisted stretching, 162b
stabilization sensorimotor, 405, 405b, 420–425 Transversospinalis multifidus, trigger points and Upper back, deep tissue work for, 127, 127f, 128f
stabilization strengthening, 404, 405, 405b, referral zones of, 44f Upper extremity joints, stacking, 109, 110f
411–419 Transversus abdominis, 17f, 134
supine bridging track, 414–415, 414f–415f attachments and actions of, 21, 21f, 176
traditional strength training of lumbar spine, massage of, 142–146, 143f, 144f Valsalva maneuver/test, 82–83, 83f
410b, 410f multiplane stretching of, 175–179 for pathologic disc conditions, 92
therapist tip on, 423 pregnancy and, 141 for piriformis syndrome, 93
Therapy tables. See Tables side-lying position for, 146, 146f Vastus lateralis, 13f–14f, 15f
Thigh Treatment contacts. See also Stabilization hand; Vastus muscles, 16f
horizontal flexion and extension of, 9b Treatment hand Vein(s), precautions with, 35–37, 36f
lateral rotation of, 259 in anterior abdomen massage, 136–137, 137f, Vertebrae
pelvic muscles attaching onto, 23 138, 138f of lumbar spine, 2, 2f
reverse actions of, 7, 8f, 9t in deep tissue work, 102–107 of sacrum, 3
Thigh thrust test, 89–90, 90f alternating, 107 Vertebral body, 3f, 32f
Thoracic spine bracing/supporting, 107–109, 107f–109f Vertebral foramina, 2
agonist contract stretching of, 271, 280 gliding, 117–118, 118f Vertical back, 114, 114f
contract relax agonist contract stretching of, 320 knife-edge, 102, 103f, 106, 106f Visceral bodywork, 157–158
contract relax stretching of, 214 transitioning between, 106 Visceral Manipulation, 157
multiplane stretching of, 169 Treatment hand, 162b
Thoracolumbar fascia, 32b–33b in agonist contract stretching, 265, 269
Thrust, avoiding, 347 in contract relax agonist contract stretching, Water therapy. See Hydrotherapy
Thumb treatment contact, in deep tissue work, 314, 318 Weight, carrying, posture in, 399, 399f
102, 103f, 104, 107, 107f in contract relax stretching, 314 Wobble boards, 420, 424, 424f
Tibialis anterior, 16f in joint mobilization, 339, 344, 344f Wolff’s law, 65–66
Tibial nerve, 13f in multiplane stretching, 166, 166f
Ticklish clients, 151 Treatment plan, 90
Tilt. See Pelvic tilt Treatment strategy, 90–91 Yeoman’s test, 88, 89f, 92
Tilt, pelvic, anterior. See Anterior pelvic tilt frequency of sessions in, 90–91, 91f
Tone, muscle self-care advice in, 91
excessive. See Hypertonic musculature treatment techniques in, 90 Zero Balancing, 141
resting, 39 Treatment techniques, 90. See also specific techniques Z joints, 4–5, 4f. See also Facet joints
Topical analgesic balms, 382 Trigger point. See Myofascial trigger points Zona orbicularis, 31, 35f
Towel traction, 371–373, 371f–373f TrP. See Myofascial trigger points Zygapophyseal joints, 4–5, 4f. See also Facet joints