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    Table of Contents

    Principles of Myofascial Release ................................................................................. 3Myofascial Release for Somatic Dysfunctions in the Head Region ........................ 11Temporomandibular J oint MFR ........................................................................................... 12

    Temporalis MFR ..................................................................................................................... 14Suboccipital/Upper Cervical Complex MFR ....................................................................... 16Occipitoatlantal Articulation MFR ........................................................................................ 17

    Myofascial Release for Somatic Dysfunctions in the Cervical Region ................... 18Sub-occipital MFR .................................................................................................................. 19Ligamentum Nuchae MFR .................................................................................................... 20

    Myofascial Release of Somatic Dysfunctions in the Upper Extremities ................ 21Pectoral Lift ............................................................................................................................. 22Shoulder and Arm MFR......................................................................................................... 23Forearm, Elbow and Wrist MFR........................................................................................... 25Hand and Wrist MFR ............................................................................................................. 26

    Myofascial Release for Somatic Dysfunctions in the Thoracic Region .................. 27Thoracolumbar Direct MFR .................................................................................................. 28Thoracic Indirect/Direct MFR................................................................................................ 29Scapular MFR ......................................................................................................................... 30Subscapular MFR .................................................................................................................. 31

    MFR & BLT for Somatic Dysfunctions in the Rib Cage ........................................... 32First Rib MFR/BLT ................................................................................................................. 34Ribs 2-3 MFR/BLT ................................................................................................................. 35Ribs 4-10 MFR/BLT ............................................................................................................... 36Ribs 11-12 MFR/BLT ............................................................................................................. 38

    Myofascial Release of Somatic Dysfunctions in the Lumbar Region ..................... 39

    Regional Lumbar MFR .......................................................................................................... 40Regional Lumbosacral MFR ................................................................................................. 41

    MFR of Somatic Dysfunctions in the Pelvic & Sacral Regions ............................... 42Lumbosacral Compression................................................................................................... 43Sacroiliac Compression ........................................................................................................ 43Lumbosacral Direct Decompression: Supine ................................................................... 44Lumbosacral Indirect Decompression: Supine................................................................. 45Lumbosacral Direct Decompression: Prone ..................................................................... 46Lumbosacral Direct Decompression: Lateral Recumbent.............................................. 47Sacroiliac Direct Decompression: Supine......................................................................... 48Bilateral Sacroiliac Joint Decompression ........................................................................... 49Pelvic Innominate MFR ......................................................................................................... 50

    Myofascial Release for Somatic Dysfunctions in the Lower Extremit ies ............... 51i

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    Lymphatic Techniques ............................................................................................... 62Thoracic Inlet: Direct MFR .................................................................................................... 73Anterior Cervical Fascia Technique .................................................................................... 75Thoracic Diaphragm Techniques......................................................................................... 76

    Seated Thoracic Diaphragm MFR ................................................................................... 76Doming of Diaphragm........................................................................................................ 78

    Pelvic Diaphragm Technique ............................................................................................... 79Pectoral Traction .................................................................................................................... 82Cervical Lymphatic Drainage Techniques.......................................................................... 83Anterior Cervical Effleurage.................................................................................................. 84Liver and Spleen Pumps ....................................................................................................... 85

    Lymphatic Drainage of the Upper Extremities ................................................................... 89Lymphatic Drainage of the Lower Extremities ................................................................... 90Thoracic Pump Technique.................................................................................................... 92Abdominal and Pedal Pumps ............................................................................................... 95

    Lymphatic Technique References ............................................................................. 97

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    Principles of Myofascial Release (MFR)

    Objectives:

    The osteopathic medical student will demonstrate a 70% minimum competency/understanding of the following subject areas on a written and/or practical examination:1. Define fascia.2. Define myofascial release technique.3. Describe the diagnostic and therapeutic process of myofascial release technique.4. Discuss the indications/contra-indications for MFR.5. Describe the proposed mechanism of action of myofascial release technique.6. Correctly demonstrate and perform the following MFR techniques in both a

    practical exam and a clinical scenario.

    Key Words: Direct, indirect myofascial release, fascia, creep, bind, ease, hysteresis,indications, contraindications, GAGs, cross linkage, Wolfs Law, IntegratedNeuromusculoskeletal Release, Hooke Law

    Definition:In Foundations of Osteopathic Medicine, 3rd Edition, Frank Willard, Ph.D. and

    colleagues distinguished fascia as its own body system. In a very deliberate fashion hedefines what fascia is and what it is not:

    Fascia is:o A complete system with blood supply, fluid drainage & innervations

    Thus, fascia comprises the largest organ system in the bodyo Composed of irregularly arranged fibrous elements of varying densityo

    Involved in tissue protection & healing of surrounding systems

    Fascia is not:o Tendonso Ligamentso Aponeuroses

    Fascia is divided into 4 divisions:

    Pannicular Fascia(aka Panniculus)o Outermost layer of fascia derived from somatic mesnchyme & surrounds

    the entire body with the exception of the orifices;o Outer layer is adipose tissueo Inner layer is membranous & adherent, generally, to the outer portion

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    o Surrounds the nervous systemo Includes the dura

    Visceral Fasciao

    Surrounds the body cavities Pleura Pericardium Peritoneum

    Fascia is the connecting element for all body structures, and is continuous, muchlike a sheet of tissue winding through the entire body, composed of superficial, deepand subserous layers (lining the body cavities).

    Myofascial release (MFR) is a passive direct or indirect osteopathic manipulativetechnique in which the physician identifies resistant or tight myofascial tissues in aparticular body region or related to a localized muscle spasm and engages it withcontinuous palpatory feedback to achieve free movement of those tissues and/or otherrelated structures. For the purpose of this manual MFR will be considered, in general,as non-segmental classic MFR.

    Direct MFR: involves engaging a myofascial restrictive barrier loading the tissue withconstant force until the tissue tension release occurs.

    Indirect MFR: involves guiding the dysfunctional tissues along the path of leastresistance until free movement is achieved.

    While Dr. A.T. Still did not specifically describe fascial techniques, his writingsindicate that he identified it as contributing to somatic dysfunction and the perpetuationof disease. Furthermore, his writings indicate that the restoration of fascia to its

    optimum state would have a positive impact on the patients health and well-being.The fascia is the place to look for the cause of disease & the place to consult & beginthe action of remedies in all diseases.

    The fascia of the body is currently being investigated and we are slowly gaininginsight to its properties and its impact on both healthy and diseased states.

    While this manual is focused on classic MFR, the most recent edition ofFoundations of Osteopathic Medicine describes three different models on how topotentially approach and address the fascia. These perspectives are briefly introduced

    here.The first is Dr. Wards approach which is labeled the biomechanical model. He

    emphasizes the muscular- fascial relationships, the bodys mechanics, anatomicalrelationships, the concept of tethering and tight-loose relationships and interdependentneural influences. He is known for using classic MFR and integratedneuromusculoskeletal release (INR) A brief discussion of INR can be found in the

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    thoracic inlet, thoracoabdominal diaphragm, pelvic diaphragm), and the bodyscontinuous maintenance of homeostasis.

    Proposed Mechanism of Action:There are mechanical soft tissue biomechanical principles as well as neuroreflexiveprinciples used to explain the mechanism of action in MFR procedures.

    1) Direct MFR techniques cause continued deformation (creep) in the myofascialtissues by using a combination of traction, compression, and twisting maneuvers.The plastic changes (creep) are associated with the release of bundled energy,and the formation of electronegative charges along the lining of the fascial sheets

    (piezo-electric effect) which stimulates the accumulation of fibroblasts,glycosaminoglycans (GAGs), the formation of free fluid and lubrication betweenthe fascial layers permitting both freedom of movement and release of circulatoryrestriction. The increase in GAGs and fluid content within the connective tissuematrix results in a decrease of connective tissue crosslinks, and increasedcompliance and plasticity of the myofascial tissues.

    2) MFR techniques alter afferent information from proprioceptors in the myofascialtissues that attenuate the efferent limb of the myotatatic reflex (i.e., alpha motor

    neurons and gamma efferents) to effect a change in muscle or myofascialtension.

    Principles of Diagnosis and Therapeutic Process:Diagnosis: Passive range of motion testing for a region, local tissues, or a joint isperformed to identify a restrictive barrier and a position of ease.

    Therapeutic process:

    1) The physician diagnoses a region of somatic dysfunction he/she wishes toengage with MFR.

    2) The physician selects a direct, indirect, or combined approach based on the

    patients clinical presentation and response of the tissues to the procedure.

    a) Indirect MFR: Movement of the patient by a physician into the position of ease

    for all available planes, following any tissue release or fascial unwinding until

    completed and adding if needed:

    Regional compression, distraction, or torsion

    Tissue inhibition or traction

    Respiratory cooperation in the phase that encourages tissue relaxation

    Eye, tongue, jaw, head, or limb movements

    b) Direct MFR: Movement of the patientby the physician into the restriction for

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    3) As the patients soft tissues respond to the sustained force of extrinsic force, thephysician follows the release of the myofascial tissues towards increasingcompliance until no further relaxation is felt.

    4) The physician then retests the treated area for resolution of somatic dysfunction.5) We will include a brief discussion of Integrated Neuromusculoskeletal Release(INR). One will note that there is significant similarity and overlap to what hasbeen defined as classic MFR. INR is defined in the Glossary of OsteopathicTerminology as:a treatment system in which combined procedures are designedto stretch and reflexly release patterned soft tissue & joint related restrictions.This can be further defined as the following:

    Combined procedures: this refers to the utilization of both direct and

    indirect forms of OMT; Additionally, it means that its principles can beapplied and combined with a variety of other types of OMT techniques(MFR, MET, OCF, ART, ST & FPR are all easily be combined with INRprinciples)

    Reflexly Release: this refers to how INR is an active technique throughwhich the patients muscle action (and resultant neurological activity) isable to reset the neural activity in the area being treated

    Patterned soft tissue & joint related restrictions: this refers to howsomatic dysfunction can be patterned into the fascia (soft tissue), themuscles (through their fascial coverings & relations) and the joints(through the peritendineum connection to the periosteum of the bones)

    INR uses Release Enhancing Maneuvers (REMs) which are defined as activepatient movements that engage, stretch and facilitate the release of the

    restrictive barrier through the myofascial continuity of the body. Specific REMsinclude:

    Breath holding

    o The goal is to alter both intrathoracic & intraabdominal pressure using

    costodiaphragmatic, shoulder girdle & lumbopelvic interactions

    Prone & supine simulated swimming & pendulum arm swing maneuvers

    as direct & indirect barriers are released.

    R/L cervical rotation Isometric limb & neck movements against the table, chair

    Patient evoked movement from cranial nerves (eye, tongue, jaw,

    oropharynx)

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    2) A constant input of sensory information through contact with the patients tissues;3) Adaptation to patient response;4) Real-time ongoing response (output) through physician-patient contact;

    5) Awareness of the patients current affective state, and potentially with theaffective state at the time of injury;6) If the operator is treating a joint restriction, note that most joints have both major

    and minor motions.a) Somewhat counter-intuitively, it is often use of minor motion in MFR which

    enables increases in range of major motion to occur. An analogy is thatalthough the major motion of a drawer is anterior/posterior, or in/out, it mostfrequently has its motion restricted if a small amount of lateral displacement is

    present (stuck drawer analogy). If movementaway from the point ofrestriction is employed, then often the motion to the connective tissue systemcan be restored (unjamming the stuck drawer).

    Indications:1) MFR is used to treat somatic dysfunctions involving myofascial, connective, and

    supportive tissues;

    2) It is an excellent technique to use for patients in whom HVLA or muscle energy is

    contraindicated and is also useful in treating patients in whom counterstrain may

    be difficult secondary to their inability to relax;

    3) MFR may be used to address almost all soft tissue or joint restrictions.

    Contraindications:Absolute:

    1) Absence of somatic dysfunction;

    2) Lack of patient consent and cooperation.

    Relative (at the site of treatment):1) Infection, hematoma, or tear in involved muscle;

    2) Fracture, avulsion or dislocation of involved joint;

    3) Severe osteoporosis;

    4) Metastatic disease of bone or soft tissue;

    5) Rheumatologic conditions causing instability of the cervical spine;6) Undiagnosed joint swelling of involved joint;7) Positioning that compromises vasculature;8) Uncooperative or unresponsive patient;9) Open wounds;10) Acute thermal injury;

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    Safety and Efficacy:Indirect MFR is very safe if tolerated by the patient. Direct MFR must be applied

    with caution when immobilization is critical for tissue healing. Ability of MFR proceduresto increase the diameter of the carpal tunnel has been demonstrated and proposed as atreatment approach for patients with carpal tunnel syndrome. Randomized clinical trialsusing OMT typically utilize a variety of techniques, of which MFR is included, but MFROMT alone is seldom studied in RCTs so its true efficacy is unknown. MFR for otherconditions has not been specifically studied but it is believed to be comparable tocounterstrain (indirect MFR), or muscle energy (direct MFR). There are no knownreports of unique complications arising from MFR. There have been anecdotal storiesexchanged amongst practitioners of subcutaneous hemorrhaging after direct myofascial

    release in elderly patients with friable skin who are also taking anticoagulant medication.It is important to assess the patient and observe the response of the tissues to themanual forces applied in order to adjust the MFR procedure accordingly to achieve thedesired effect.

    History:Techniques similar to MFR were first described by Andrew Taylor Still and his early

    students. Principles of direct and indirect soft tissue treatment were organized into a

    system of diagnosis and treatment termed myofascial release by osteopathicphysicians Robert C. Ward 2003, J ohn Goodridge and J ohn Peckham.

    Further Information:1) Important definitions:

    Fascia: A dissectable mass of fibroelastic connective tissue, or otherwisedescribed as a sheet or band of fibrous connective tissue that lies deep to theskin and forms an investment for muscles and various body organs.

    Hysteresis: During loading, followed by unloading of a connective tissue, therestoration of the final length of the connective tissue occurs at a rate andextent less than that during deformation (loading) and represents energy lostin the connective tissue system . This difference in viscoelastic behavior iscalled hysteresis.

    Creep: Connective tissues under a sustained constant load will extend inresponse to that load. An imposed constant load will result in elongation ofthe connective tissue as the rate of deformation remains constant.

    Ease:The direction towards which the connective tissue may be moved moreeasily (looseness of tissue when it is stretched).

    Bind: A palpable restriction to motion, largely created by a tethering effect(tightness of the connective tissue when it is stretched).

    Piezoelectricity: current produced by a substance that transforms mechanicalstress to electrical energy

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    Plastic deformation: A stressed formed or molded tissue preserves its newshape

    Elastic deformation: A stressed formed or molded tissue reverts back to its oldshape

    Viscosity: capability of a solid to continually yield under stress with ameasurable rate of deformation

    Stress: the effect of force normalized over an areaStrain: A change in shape as a result of stressHookes Law: states that stress applied in order to stretch or compression a

    material is proportional to the strain or change in length thus produced aslong as it remains within the elastic property of the material. Once the

    elasticity limit if the material is exceeded, it then enters the plastic region.Now, the material may no longer return to its original length, as it some of itmay have fractured. Nonbiologic material form a linear relationship within thebounds of elasticity while biologic materials generally form a curved line asthey experience hysteresis or a loss in energy as they are stretched.

    2) Physiologic Characteristics of FasciaThe non-fibrous portion of connective tissue is known as the ground

    substance. It is composed of a colloidal suspension with high water content andlong chained linear polymers of repeating disaccharide units known asglycosaminoglycans (GAGS). GAGS are often bound to a protein, and thusare termed proteoglycans. In humans there are different types of GAGS:Keratin sulfate, dermatin sulfate, hyaluronic acid, chondroitin-4 and 6-sulfate,heparin sulfate. The function of GAGS are to bind water, owing to their largehydrophilic capacity. By the uptake of water, it is believed that GAGS maintain acertain critical collagen inter-fiber distance, permitting the free expression of

    normal flexibility of those connective tissues.In studies in the 1970s and 1980s, Woo, Enneking, Amiel and Horowitz

    demonstrated that the fibrocyte expressed GAGS as a function of physiologicbony joint and hence adjacent soft connective tissue movement. In other words,physiologic movement of the body and its connective tissue investments appearto function as a cell signal to stimulate the fibrocyte to produce this GAGmaterial. Saari, et. al. (1991), demonstrated that joint mobilization was capable ofelaborating one type of GAG: hyaluronic acid in a cohort of patients withrheumatoid arthritis. The increased serum levels of GAG corresponded toimproved joint mobility.

    The authors felt that owing to the large hydrophilic capacity of the GAG,excessive accumulation of it may result in interstitial edema and stiffness of jointsafter immobilization while resting at night (over expression of GAG, possiblyresulting in increased H2O uptake and hence joint capsule turgidity may

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    the collagen inter-fiber distance will reach a critical threshold where cross-linkageadhesions (dihydroxylisinonorleucine, hydroxylisinonorleucine andhistidinomerodesmosine) will develop between the collagen fibers. This will resultin impairment of myofascial mobility that will demonstrate itself clinically asstiffness and possibly pain. The pain develops in areas of soft tissuehypomobility, presumably secondary to stimulation of naked free (Type IV/C) and

    possibly light myelinated (Type III/A-) nerves.

    References:Akeson, W.H., Amiel, D., Immobility effects of synovial joints: the pathomechanics of

    joint contracture. Biorheology, 1980: 17: 95-110.

    Akeson, W.H., et. al., Biomechanical and biochemical changes in periarticularconnective tissues during contracture development in the immobilized rat knee,Connective Tissue Research, 2(4): 315-323, 1974.

    Akeson, W.H., et. al., The connective tissue response to immobility, ClinicalOrthopaedics, 51:183-197, 1967.

    Enneking, W., et. al., The intra-articular effects of mobilization on the human knee,Journal of Bone and Joint Surgery, 54(A), 973-985, 1972.

    Friedman HD, Gilliar W, Glassman J , Myofascial and Fascial-Ligamentous Approachesin Osteopathic Manipulative Medicine, San Francisco International ManualMedicine Society, San Francisco, 2000.

    Frost, H.M., A 2003 update of bone physiology and Wolffs law for clinicians, AngleOrthod, 2004 Feb; 74(1):3-15.

    Hayashi, K, Biomechanical studies of the remodeling of knee joint tendons andligaments, J ournal of Biomechanics, 1996 J une 29; (6):707-716.

    Lieber, R.L., Skeletal Muscle Structure, Function and Plasticity, 2ndEd., Lippincott-

    Williams and Wilkins, Philadelphia, 2002.Mense, S., Simons, D.G., et. al., Muscle Pain, Understanding Its Nature, Diagnosis andTreatment, Lippincott-Williams and Wilkins, Philadelphia, 2001.

    Nordin, M., Frankel, V., Basic Biomechanics of the Musculoskeletal System, 3rdEd.,Lippincott, Williams and Wilkins, 2001.

    Saari, H., Konttinen, Y.T., Nordstrom, D., Effect of joint mobilization on serumhyaluronate.Ann Med, 1991; 23 (1): 29-32

    Seffinger M, Hruby R, Evidence-Based Manual Medicine, Saunders Elsevier,

    Philadelphia, 2007.Speece CA, Crow WT, Ligamentous Articular Strain: Osteopathic Maipulative

    Techniques for the Body, Eastland Press, Seattle, 2001.Sucher, B.M., Myofascial release of carpal tunnel syndrome, JAOA, Vol. 92, #1,

    J anuary, 1993, pp. 92-101.Ward 2003, Robert C., D.O., Ed., Foundations for Osteopathic Medicine, 2ndEd.,

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    Myofascial Release for Somatic Dysfunct ions in the Head Region (739.0)

    Introduction

    When many people think of the head they tend to think of treating it usingOsteopathy in the Cranial Field techniques as developed by William Garner Sutherland,D.O., a student of A. T. Still, M.D, D.O. at the American School of Osteopathy inKirksville, MO. However, the head can be treated with myofascial techniques to help

    relieve several complaints, specifically TMJ (temporomandibular joint) pain andheadaches.

    The different muscles and ligaments of the head are all related by the fascia thatbinds them. Within this complex lie the nerves, arteries and veins that supply thesedifferent areas. By treating different areas of the head with myofascial techniques, wemay be able to lessen the effects of TMJ syndrome and headaches by affecting specificmuscles such as the occipitalis and temporalis and ligaments such as the

    stylomandibular and sphenomandibular.

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    Myofascial Release for Somatic Dysfunctions in the Head Region (739.0)

    Temporomandibular Joint MFR

    Possible Objective Findings: R/L/bilateral TMJ myofascial restriction

    How to Diagnose:1. The physician gently grasps the mandible by placing the thumb of each hand on

    the anterior surface of the left and right mandibular rami, the index fingers on theposterior surfaces;

    2. The physician tests the mandibular motion by moving it in an oblique anterior-posterior direction along its axis of motion, paying attention to fascial restrictionsor ease. Translation right to left, and compression and distraction may also beassessed. In testing these motions, the physician is assessing the quality of thefascia and not the full range of motion of the jaw. If a restriction is palpated, thephysician proceeds with the following.

    Set-up: The physician sits at the head of the table with the patient supine.

    Treatment:1. The physician may treat the somatic

    dysfunction indirectly or directly.

    2. To treat indirectly, the physician stacksthe following motions into a position of

    ease or compliance; anterior-posterioron an oblique axis, translation from rightto left, and compression/distraction

    3. To treat directly, the physician stacksthe above planes of motion into aposition of restriction.

    4. The physician may instruct the patientto perform a series of inhalations andexhalations using respiratorycooperation to further engage thefascial planes.

    5 The physician maintains the stacked

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    7. Retest: The physician should use the same method to restest as was used in theinitial assessment of the restriction. Example: increased symmetry andcompliance in the fascial planes of motion.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR component at Step 4:jaw clenching and/or mouth opening [CN5].)

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    Myofascial Release for Somatic Dysfunct ions in the Head Region (739.0)

    Temporalis MFR

    Possible Objective Findings: R/L/bilateral Temporalis myofascial restric tion

    How to Diagnose:1. The patient is asked to open his/her mouth to elongate the jaw elevator muscles.

    2 The physician contacts the temporalis muscles bilaterally by placing his fingertipssuperior to the patients ears, spanning the superior border of the temporalismuscle.

    3. The physician assesses the motion of the temporalis in all directions; anterior-posterior, superior-inferior, and clockwise-counterclockwise. If a restriction ispalpated, the physician proceeds with the following.

    Set-up: The physician sits at the head of the table with the patient supine.

    Treatment:

    1. Treatment is aimed at themore restricted temporalisby first stacking it into theposition of ease (indirect) orinto the position of restriction(direct).

    2. The physician may either A)contact the restrictedtemporalis with one handwhile maintaining a lightcontact on the oppositeparietal to support thehead, or B) the physicianmay contact the temporalis

    with both hands allowingthe patients head to fall tothe opposite side.

    3. The physician may instructthe patient to perform a

    i f i h l ti d

    A

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    5. The physician may sense an unwinding of the fascial planes back to neutral.

    6. Retest: The physician should use the same method to retest as was used in theinitial assessment of the restriction. Example: increased symmetry and

    compliance in the fascial planes of motion.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR component at Step 4:jaw clenching and/or mouth opening [CN5].)

    Note: This is usually a bilateraltechnique where one temporalis isreleased followed by releasing thetemporalis muscle on thecontralateral side of the patientshead.

    B

    Head

    Movement

    B

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    Myofascial Release for Somatic Dysfunct ions in the Head Region (739.0)

    Suboccipital/ Upper Cervical Complex MFR

    Possible Objective Findings: R/L/bilateral Suboccipi tal myofascial restrict ion

    How to Diagnose:1. The physician holds the occiput bilaterally just inferior to the occiput. (Palms

    against the occiput and thumbs just superior to the ears)

    2. With the fingertips contacting the fascia of the suboccipital region, the physicianinduces a slight superior traction. The physician palpates for a sense of ease orrestriction. The physician may also use a small incremented movement in aclockwise-counterclockwise direction to aid him/her in diagnosing this region. If arestriction is palpated, the physician proceeds as follows.

    Set-up: The physician sits at the head of the supine patient.

    Treatment:1. The physician may engage eitherthe position of ease (indirect) orrestriction (direct) with superiortraction or clockwise or counter-clockwise motion.

    2. This form of treatment continues

    until a palpatory sense of warmthand/or softening of the tissues andincreased compliance is reached.

    3. The physician may employrespiratory cooperation in order tofurther engage the fascial planesuntil there is increased compliance

    of the region of the somaticdysfunction.

    4. Retest: The physician should usethe same method to retest as wasused in the initial assessment of the

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    Myofascial Release for Somatic Dysfunct ions in the Head Region (739.0)

    Occipitoatlantal Articulation MFR

    Possible Objective Findings: R/L/bilateral OA restriction

    How to Diagnose:1. With one hand, the physician contacts the posterior tubercle of the atlas, just

    below the occiput, while the opposite hand contacts the vertex of the patientshead.

    2. The fascial motion of the occipitoatlantal articulation is tested while stabilizing the

    vertex of the head.

    3. The motion at the occipitoatlantal joint is tested by gliding the hand on theposterior tubercle of the atlas superior-inferior, clockwise-counter-clockwise, andanterolaterally in both directions. These movements are small in amplitude andpalpated at the level of the fascia under the physicians distal hand. They are notgross movements in the joint. If a restriction is palpated, the physician proceedswith the following.

    Set-up: The physician sits at the head of the table with the patient supine.

    Treatment:1. The physician should stack the fascia

    of the OA into the position of ease(indirect) or restriction (direct) usingthe planes of motion listed above.

    2. The physician should hold thisposition or move deeper into it withrespiratory cooperation until there isa palpatory sense of warmth,softening of the tissues andincreased compliance/flexibility of the

    soft tissues is achieved3. Retest: The physician should use the

    same method to retest as was usedin the initial assessment of therestriction. Example: increased

    t d li i th

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    Myofascial Release for Somatic Dysfunct ions in the Cervical Region (739.1)

    IntroductionThe cervical region is a common site of complaints. In treating the cervical area, it is

    often recommended to begin with the upper thoracic spine and ribs, followed by thesub-occipital region, and then the typical cervical spine. It is important to treat thethoracic spine first because of its sympathetic influence and its critical myofascialattachment. A dynamic treatment modality of whiplash injury, torticollis, and cervicalroot irritation may be more efficacious when cervical myofascial methods are combinedwith other techniques. The goal in the treatment of the cervical spine is to decreasemuscle and fascial tension and allowing the body to return to its optimal function.

    When using cervical myofascial release technique, the physician can be moregeneral by diagnosing and treating several cervical segments at one time, or bydiagnosing and treating a specific segment (i.e. sub-occipital region).

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    Myofascial Release for Somatic Dysfunctions in the Cervical Region (739.1)

    Sub-occipital MFR(See Suboccipital/Upper Cervical Complex MFR for comparison)

    Possible Objective Findings: R/L/bilateral suboccipital myofascial restriction

    How to Diagnose:1. The physicians fingers are flexed and approximated between the occiput and

    spinous process of C2 of the supine patient.

    2. The fingers apply anterior pressure in the sub-occipital region bilaterally using ofthe weight of the patients head onto the fingertips (not by direct pressure fromthe physician).

    3. Gentle gradual superior traction is applied until a restrictive barrier is met.

    Set-up: The patient is supine and the physician is seated at the head of the table.

    Treatment:1. The physician maintains this

    anterior superior tension untilsoftening of the tissue occurs.

    2. Retest: the physician shoulduse the same method to retestas was used in the initialassessment of the restriction.Example: The physician uses

    this sense of increasedcompliance as a form of retest.

    (Optional: Some clinicians have noticedimproved efficacy and effectiveness ofthis technique by instructing the patientto perform the following INR componentsat Step 1: eye movements [CN 3, 4 and6] and tongue thrusts [CN 9].)

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    Myofascial Release for Somatic Dysfunctions in the Cervical Region (739.1)

    Ligamentum Nuchae MFR

    Possible Objective Findings : Ligamentum nuchae myofascial restriction

    How to Diagnose:1. The physician cradles the occiput in the palm of one hand and flexes the cervical

    region slightly to accommodate the movements of the palpating hand.

    2. The palpating hand is placed over the posterior cervical fascia (start position) ofthe treatment region, using thenar/hypothenar eminence on one side and the

    fingertips on the opposite side.

    3. The physician performs motion testing with the palpating hand by moving theposterior cervical fascia superior/inferior, clockwise/counterclockwise,anterolateral arcing on both sides, and by adding compression/distraction. If arestriction is palpated, the physician proceeds as follows.

    Set-up: The patient is supine and the physician is seated at the head of the table.

    Treatment:1. Stacking the above planes of motion,

    the physician places the tissues in thedirection of ease (indirect) or restriction(direct).

    2. The physician may instruct the patient to

    do a series of inhalations or exhalations,using respiratory cooperation to furtherengage the fascial planes either directlyor indirectly until an end point (softening/increased compliance) is reached orunwinding of the fascial planes occurs.

    3. Retest: the physician should use

    the same method to retest as wasused in the initial assessment ofthe restriction. Example: increasedcompliance or improved quality ofmotion within the fascial planeslisted in the diagnosis section

    Movement occurswith the palpating

    hand

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    Myofascial Release of Somatic Dysfunctions in the Upper Extremities (739.7)

    Introduction

    The upper extremity is an important component of the fascial continuity from theocciput, cervical and thoracic regions through the prevertebral fascia and trapezius intothe shoulder axilla and arm. As with other regions of the body, a thoroughunderstanding of the anatomical relationships of the upper extremity is important insuccessfully employing myofascial release technique. With adept use of MFR, thephysician can release muscular, connective tissue, and articular dysfunction of theupper extremities.

    When using myofascial release technique of the upper extremities, the physician canbe more general by diagnosing and treating the entire upper extremity as a unit orhe/she may use this technique to treat a specific region (i.e., shoulder, elbow, wrist,etc.).

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    Myofascial Release of Somatic Dysfunctions in the Upper Extremities (739.7)

    Pectoral Lift (Anterior Axillary Fold Release)

    Possible Objective Findings : R/L/Bilateral Pectoral myofascial restriction

    How to Diagnose:

    1. The physician gently grasps the inferior border of the pectoralis muscles of eachanterior axilla, taking care not to gouge the patient with the fingertips.

    2. With arms fully extended, the physician produces a bilateral superior traction byleaning backwards.

    3. The physician may feel that one side resists the superior traction. This may benoted as a restriction of that region.

    Set-up: The physician stands or sits at the head of the supine patient.

    Treatment:1. While maintaining traction, the

    physician instructs the patient tobreathe deeply. The combinationof traction and respiratory motionwill help to release any restrictionof the pectoralis muscle/anterioraxilla region.

    2. The superior traction is continued

    until the myofascial restrictions arereduced or eliminated.

    3. The physician then gently releasesthe tissue.

    4. The physician retests this region byonce again administering superior

    traction into the anterior axillaregion, noting equal compliance ofboth regions.

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    Myofascial Release of Somatic Dysfunctions in the Upper Extremities (739.7)

    Shoulder and Arm MFR: Prone

    Possible Objective Findings: R/L/BilateralShoulder Internal/External Rotationmyofascial restriction

    Set-up: The patient is prone with his/her arm and shoulder off the table. Thepatient's head should be turned to the most comfortable side. Thephysician sits facing the dysfunctional shoulder.

    Treatment:1. The physician places both hands around the glenohumeral attachments (deltoid

    region) with his/her thumbs distal to the acromioclavicular joint. The fingers ofboth hands wrap around the proximal upper extremity, being sure not tocompromise the brachial plexus and arteries.

    2. The fascia is assessed in multiple directions: distraction/ compression,clockwise/counter-clockwise, superior/inferior, anteroposterior glide.

    3. The physician will then directthe vector of the MFRintervention in a direction ofease (indirect MFR) ordirection of restriction (directMFR) until a palpatory senseof tissue warmth, and/or

    increased compliance/flexibility of the soft tissues isachieved. The physician mayinstruct the patient to do aseries of inhalations andexhalations using respiratorycooperation to further engagethe fascial planes until an end

    point is reached or unwindingof the fascial planes occurs.

    4. Retest: the physician should use the same method to retest as was used in theinitial assessment of the restriction. Example: improved compliance and/orquality of motion in the directions listed in step 2.

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    Myofascial Release of Somatic Dysfunctions in the Upper Extremities (739.7)

    Shoulder and Arm MFR: Supine

    Possible Objective Findings: R/L Shoulder/UE myofascial restriction

    How to Diagnose:Each extremity is assessed by applying flexion/extension, distraction/ compression,internal/external rotation, abduction/ adduction. If a restriction is palpated, thephysician proceeds as follows.

    Set-up: The physician stands at the side of the supine patient or at the head of thetable. The patient's forearm is then grasped proximal to the wrist.

    Treatment:1. The most restricted extremity is taken

    either into its position of ease(indirect) or its position of restriction(direct) using the motions listed above

    under the diagnosis section.2. The physician may use respiratory

    cooperation, instructing the patient toperform a series of inhalations andexhalations to further engage theabove stacked planes of motion.

    3. The physician holds the upperextremities in this position until thetissues release as denoted by anincrease in soft tissue compliance,softening of tissues and/or a palpatorysense of warmth.

    4. Retest: the physician should use the

    same method to retest as was used inthe initial assessment of therestriction. Example: increasedcompliance of improved quality/rangeof motion of the fascial planes in thedirections indicated in the diagnosis.

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    Myofascial Release of Somatic Dysfunctions in the Upper Extremities(739.7)

    Forearm, Elbow and Wrist MFR

    Possible Objective Findings: R/L/Bilateral Wrist/Forearm/Elbow myofascial restrict ion

    How to Diagnose:1. With a light hold on the skin, the physician places his/her hands across the

    forearm or wrist, with the index fingers side by side as depicted below.

    2. To assess for restrictions, deformation is induced against the direct barrier bytwisting the skin and underlying soft tissues in opposite directions. Then the

    twisting forces are reversed.

    Set-up: The patient can be treated in any position (i.e. standing, seated, orsupine). The physician can stand or sit comfortably for easy access to theforearm.

    Treatment:1. This is commonly treated directly. The encountered barrier is held firmly until a

    palpatory release or end point is reached as denoted by increased soft tissue(compliance/flexibility, palpatory warmth, etc.). However, it can also be treatedindirectly.

    2. Retest: the physician should usethe same method to retest as wasused in the initial assessment ofthe restriction. Example:

    increased overall compliance ofthe tissues treated.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR components at Step 1:finger flexion (making a fist)/finger extension, wrist flexion/extension.)

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    Myofascial Release of Somatic Dysfunctions in the Upper Extremities(739.7)

    Hand and Wrist MFR(Flexor Retinaculum/Transverse Carpal Ligament)

    Possible Objective Findings : R/L/Bilateral Hand/Wrist myofascial restriction

    Set-up: The patient may be seated or supine. The physician is seated at the sideof the dysfunction.

    Treatment:1. The physicians hand is introduced

    with the web spaces between thepatients thumb and index finger andthe 4th and 5th digit web spaces.

    2. A midline to lateral stripping motionis applied over the volar surface of thetransverse carpal ligament with thephysicians thumbs, while the

    physicians fingers press upward onthe dorsum of the patients wrist.

    3. While simultaneously applying thestripping motion above, the physiciandorsiflexes the patients wrist tofurther engage a palpable barrier overthe transverse carpal ligament.

    4. The physician continues until apalpable compliance/increasedflexibility and/or tissue softening isachieved.

    5. Retest: the physician should use the

    same method to retest as was used inthe initial assessment of therestriction. Example: increasedcompliance/increased flexibility of thetransverse carpal ligament.

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    Myofascial Release for Somatic Dysfunctions in the Thoracic Region (739.2)

    Introduction

    The thorax is comprised of 12 vertebrae, 12 pairs of ribs, and the sternum. Althoughthe scapulae are more appropriately considered part of the upper extremity, they will beaddressed in this section of the manual as they overlie the posterior portions of thethoracic cage and articulate with the sternum through the clavicle. The thoracic spine isvery closely related to the thoracic cage and essentially works as a single unit.

    The thoracic region has various fascial sheets, including the pericardium and pleura,that can be altered by trauma, chemical alterations, and other pathologic agents

    causing tensions of fascia throughout the body. Direct and indirect myofascial releasetechniques have been developed in order to address these problems.

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    Myofascial Release for Somatic Dysfunctions in the Thoracic Region (739.2)

    Thoracolumbar Direct MFR

    Possible Objective Findings: Lumbar, Sacral or Thoracic myofascial restriction

    Set-up: The physician stands on either side of the prone patient.

    Treatment:1. The physician contacts the

    thoracolumbar junction. One handpoints inferiorly and the other points

    superiorly with the fingers spreadingover the posteroinferiorcostodiaphragmatic region and theupper lumbar region.

    2. The physician gently compresses thethoracolumbar junction by applying ananterior and superior force with the

    hand pointing superiorly, and anterior inferior force with the hand pointing towardthe patients sacrum.

    3. The physician may also add a twisting force by adding a clockwise compressionto the fascial planes with one hand and a counterclockwise compression with theother hand into the direct barrier.

    4. The physician may use respiratory cooperation, instructing the patient to perform

    a series of inhalations and exhalations to further engage the above stackedplanes of motion.

    5. The physician maintains traction by moving his/her arms apart until the tissuesrelax and soften and soft tissue compliance/flexibility increases.

    6. Retest: the physician should use the same method to retest as was used in theinitial assessment of the restriction. Example: increased compliance/flexibility at

    the thoracolumbar junction.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR component at Step 4:internal/external rotation of the lower extremities at the hip joint.)

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    Myofascial Release for Somatic Dysfunctions in the Thoracic Region (739.2)

    Thoracic Indirect/Direct MFR

    Possible Objective Findings: Lumbar, Sacral, Rib or Thoracic myofascialrestriction

    Set-up: The physician stands on either sideof the prone patient.

    Treatment:1. The physician contacts the paraspinal

    musculature with the palms and thenareminences, with the hands pointingsuperiorly.

    2. The physician imparts an anteriorcompression with both hands with enoughforce to contact the layer of fascia desiredand to prevent any slipping across the patients skin.

    3. The physician may add motions in an inferior and superior direction, an antero-lateral arcing motion (a torsional or twisting/clockwise-counterclockwise motion),and a medial and lateral compression to the fascial planes, assessing for anindirect or direct barrier.

    4. Once the physician meets either the indirect or direct barrier, the physician mayemploy the patients respiratory cooperation until the tissues relax and soften or

    there is an increased compliance of flexibility or an unwind occurs.

    5. Retest: the physician should use the same method to retest as was used in theinitial assessment of the restriction.

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    Myofascial Release for Somatic Dysfunctions in the Thoracic Region (739.2)

    Scapular MFR

    Possible Objective Findings: Shoulder, Cervical, Rib &/or Thoracic myofascialrestriction

    How to Diagnose:The fascial layers of the scapula are tested in the following planes: superior/inferior,medial/lateral, clockwise/ counterclockwise. The physician must be sure to not justtest the skin and subcutaneous tissue, but must engage the different fascial layersthat envelope the scapula.

    Set-up: The patient lies lateral recumbent with the side of the dysfunction uptoward the ceiling. The physician stands facing the lateral recumbentpatient.

    Example: Left scapular restriction

    Treatment:

    1. The physician grasps the patientsscapula with the right hand passingunder the patients arm and the left handcontacts the superior/anterior aspect ofthe patients shoulder to stabilize thescapula. The fingers should contact themedial border of the scapula while thethumbs contact the lateral border.

    2. The physician stacks the above fascialplanes of motion either in the position ofease (indirect) or restriction (direct).

    3. The physician may employ respiratory cooperation by using a series ofinhalations and exhalations, further engaging the stacked planes of motion.

    4. The physician maintains this position until an end point is reached or the fascialplanes begin to unwind.

    5. Retest: the physician should use the same method to retest as was used in theinitial assessment of the restriction. Example: increased compliance orimproved quality or range of motion in the planes of motion listed in the diagnosis

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    Myofascial Release for Somatic Dysfunctions in the Thoracic Region (739.2)

    Subscapular Release

    Possible Objective Findings: Shoulder, Cervical, Rib &/or Thoracic myofascialrestriction

    How to Diagnose:The fascial layers of the scapula are tested in the following planes: superior/inferior,medial/lateral, clockwise/ counterclockwise. This technique allows the physician togain more information about the subscapularis muscle as it relates to the scapulaand employs a different position of the sensing hand as shown below. The

    physician must be sure to not just test the skin and subcutaneous tissue, but mustengage the different fascial layers that envelope the scapula.

    Set-up: The physician places the patient lateral recumbent with the side of thedysfunction facing up toward the ceiling. The physician stands facing thepatient.

    Example: Left subscapular restriction

    Treatment:1. The physician places his/her right

    thumb into the posterior axillary foldwith his/her fingers curled around themedial border of the scapula. Thephysicians left hand contacts thesuperior/anterior aspect of the

    patients shoulder to stabilize thescapula.

    2. The physician stacks the myofascialtissue planes in the planes of motionstated above into the position of ease(indirect) or restriction (direct).

    3. The physician may employ respiratory cooperation by using a series ofinhalations and exhalations, further engaging the stacked planes of motion.

    4. The physician follows tissue tension changes until an endpoint (described as asoftening of the soft tissues, a palpatory sense of warmth, increased

    li /fl ibilit f th ti i t d)

    Thumb in

    axilla

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    Myofascial Release & Balanced Ligamentous Tension forSomatic Dysfunctions in the Rib Cage (739.8)

    IntroductionThe muscles of the thoracic cage, like all other muscles in the body, are invested

    with fascia. These muscles function in the actions of the ribs and vertebrae, head andneck control, as well as breathing. Thus, it can be said that fascial restrictions within theribs and thoracic cage may have a profound effect on these functions. As such, it isimportant to understand the fascial relationships between this region and the rest of thebody.

    The subsequent treatment of the ribs described in this manual employs a series oftechniques similar to myofascial release called balanced ligamentous tension. Themyofascial structures along with the joints are positioned so as to balance the tensionamongst the ligaments around a joint to relieve restricted joint motion.

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    Balanced Ligamentous TensionBalanced Ligamentous Tension, or BLT, was described by Dr. William Sutherland as

    an approach to diagnose and treat somatic dysfunction. Ligaments regulate and guidemovement in all articulations. In most joints, they act as checks to the voluntary actions

    of muscles. In normal movements, as the joint changes position, the relationshipbetween the joints ligaments change, but the total tension within the ligamentousarticular mechanism does not. However, the distribution of tension between theligaments may be altered if the joint is affected by injury, inflammation or mechanicalforces. The balance of the ligaments may be distorted or some of the ligamentsthemselves may actually be disrupted.

    If the joint is strained and normal motion is restricted, the position of minimal tension

    within the joint will no longer be at a physiologic neutral. Therefore, in applying BLT, thephysician will attempt to establish a fulcrum in which all the tensions within theligaments are reduced to a minimum. Once this neutral balanced point is achieved,the bodys inherent forces are now free to resolve the strain. These inherent forces arenormal, physiologic movements and forces within the body, including respiration, fluidpressure changes and postural adjustments. The physician must balance all the forceswithin the ligamentous structure of the joint so that a fulcrum is established. Once thefulcrum is created, the inherent forces within the body can work to correct the strain.The physician will eventually sense that the somatic dysfunction has resolved, and thencan retest that area.

    The ribs can be diagnosed and treated with BLT as follows:

    Diagnosis:Inhalation somatic dysfunction (ExhalationRestriction)

    (Treating the most inferior rib in the group somatic dysfunction, or less commonly asingle rib dysfunction in inhalation)

    Exhalation somatic dysfunction(Inhalation Restriction)(Treating the most superior rib in the group exhalation somatic dysfunction or, lesscommonly, a single rib somatic dysfunction in exhalation.)

    Treatment:

    The patient provides the activating force by inhaling completely and holding ituntil forced to exhale for treatment of an inhalation somatic dysfunction(exhalation restriction).

    The patient provides the activating force by exhaling completely and holding ituntil forced to inhale for treatment of an exhalation somatic dysfunction(inhalationrestriction)

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    Myofascial Release & Balanced Ligamentous Tension forSomatic Dysfunctions in the Rib Cage (739.8)

    First Rib MFR/BLT

    Possible Objective Findings: R/L/bilateral 1st rib myofascial restriction

    Set-up: The patient is seated or supine.

    Treatment:1. The physician contacts the

    first rib posteriorly with his orher thumb lateral to thecosto-transverse articulation.Anterior rib contact is madewith a finger of the samehand deep to the medial endof the clavicle in thesupraclavicular fossa.

    2. With the opposite hand, thephysician rotates thepatients head toward oraway from the side of thedysfunctional rib to the pointof ease or restriction. A small amount of flexion, extension, and/or sidebendingmay be similarly induced to enhance the position of ease or restriction,establishing a point of balance at the costovertebral articulation.

    3. The patient holds his/her breath in the appropriate phase of respiration.

    4. Once it is felt that the rib has returned to normal physiologic motion, thephysician will retest by using the same method that was used in the initialassessment. Example: improved range of motion of rib 1 into the prior restrictedphase of respiration.

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    Myofascial Release & Balanced Ligamentous Tension forSomatic Dysfunctions in the Rib Cage (739.8)

    Ribs 2-3 MFR/BLT

    Possible Objective Findings: R/L/bilateral 2nd &/or 3rd rib myofascial restrictions

    Set-up: The patient may be seated or lateral recumbent with the side of thedysfunction toward the ceiling.

    Treatment:1. The physician contacts the affected rib as follows: using the web space, thenar

    eminence and 2nd finger of one hand, the physician grasps the anterior portion ofthe rib adjacent to the costal cartilage. With the other hand, the physiciancontacts the posterior aspect of therib at the rib angle, adjacent to thespine.

    2. The physician applies anteriorpressure to the rib angle to

    disengage the rib and then carriesthe rib head superiorly and laterally.

    3. The physician compresses the ribmedially and slightly superiorly withboth thumbs at the lateral aspect ofthe rib.

    4. The physician balances all three points, the lateral, anterior and posterior ends ofthe rib and then uses the patients appropriate phase of respiration until the ribreturns to normal physiologic motion.

    5. Once it is felt that the rib has returned to normal physiologic motion, thephysician will retest by using the same method that was used in the initialassessment. Example: improved range of motion of rib 2 or 3 into the priorrestricted phase of respiration.

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    Myofascial Release & Balanced Ligamentous Tension forSomatic Dysfunctions in the Rib Cage (739.8)

    Ribs 4-10 MFR/BLT

    Possible Objective Findings: R/L/bilateral 4th 10th myofascial restriction

    Set-up: The patient is seated with the affected side toward the physician.

    Treatment:1. The physician contacts the shaft of the rib with one hand anteriorly and the other

    posteriorly. The middle finger of the anterior hand is placed on the shaft of therib while the middle finger ofthe posterior hand contactsthe rib angle, just lateral tothe costotransversearticulation. The physiciansthumbs contact the lateralaspect of the rib.

    2. The patient is instructed toslightly lean away from andsidebend toward thephysician.

    3. The rib is held firmly toprevent posterior rotation

    while the patient slowlyrotates the oppositeshoulder toward thephysician (toward thedysfunctional side).

    4. The physician is focused onfinding the point of ease or

    restriction of the ligaments,while the patients shoulderis rotating toward the dys-functional costal side.

    sidebend rotate

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    6. The physician may then use respiratory cooperation until there is a sense thatthe rib has returned to its normal physiologic motion.

    7. The physician will then retest using the same method that was used in the initial

    assessment. Example: improved range of motion of the rib.

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    Myofascial Release & Balanced Ligamentous Tension forSomatic Dysfunctions in the Rib Cage (739.8)

    Ribs 11-12 MFR/BLT

    Possible Objective Findings: R/L/bilateral 11th 12th myofascial restriction

    Set-up: The patient is seated and the physician stands at the side of thedysfunctional rib.

    Treatment:

    1. There is no anterior cartilaginousattachment to the sternum, andusually no costotransversearticulation to serve as fulcrums forrotation of the 11th and 12th ribs.

    2. Therefore, the physician mustprovide a stable fulcrum by

    contacting the affected rib justlateral to the adjacent vertebraltransverse process with his/herfinger, with his/her thumb on thelateral aspect of the rib.

    3. The fingers are held very firmly while the patient rotates the opposite shouldertoward the dysfunctional side.

    4. The physician carries the rib anteriorly to disengage it and then draws itsuperiorly and laterally.

    5. The physician maintains balanced traction on the rib until it releases.

    6. Retest: the physician will retest by using the same method that was used in theinitial assessment. Example: improved motion in the phase of respiration in

    which the rib was previously restricted.

    M f i l R l f S ti D f ti i th L b R i (739 3)

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    Myofascial Release of Somatic Dysfunctions in the Lumbar Region (739.3)

    IntroductionLow back pain is one of the most common and costly ailments in our society.

    Osteopathic manipulation has been proven to be efficacious in the treatment of lowback pain with decreased use of medication. Although there are many primary causesof low back pain, the lumbar spine along with the surrounding muscles and fascia arefrequently affected and should be addressed. When treating the lumbar area, it isimportant to keep the anatomy in mind. An optimal myofascial treatment of the lumbararea involves not only the muscles and fascia of the back including the thoracolumbar

    fascia, erector spinae and multifidi. Also, the muscles and fascia on the lateral andanterior side of the lumbar spine including the psoas major and minor, quadratuslumborum, and the right and left crurae of the diaphragm are implicated.

    As with any other myofascial technique, it is very important to continuously sensethe tissues changing under your fingers and follow the release as it occurs.

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    Myofascial Release of Somatic Dysfunctions in the Lumbar Region (739.3)

    Regional Lumbar MFR: Prone

    Possible Objective Findings: L1-5 myofascial restriction

    How to Diagnose:As assessed per structural exam (i.e., TART changes).

    Set-up: The patient lies prone.

    Treatment:1. The physician places his or her

    palms, one on top of the other,over the restricted tissues.

    2. The physician moves the tissuesthrough the range of motion(superiorly and inferiorly,

    laterally then medially, clockwiseand counterclockwise), andholds the tissues in theirdirection of ease/restrictiondepending on whether thephysician is employing indirector direct MFR technique.

    3. The physician may employrespiratory cooperation by usinga series of inhalations andexhalations, further engaging thestacked planes of motion.

    4. The physician follows therelease/unwind until an end point

    is reached (tissues relaxation,cessation of further releases,and/or a sense of softening orincreased soft tissuecompliance/flexibility).

    Myofascial Release of Somatic Dysfunctions in the Lumbar Region (739 3)

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    Myofascial Release of Somatic Dysfunctions in the Lumbar Region (739.3)

    Regional Lumbosacral MFR: Prone

    Possible Objective Findings: Lumbar or Sacral myofascial restrict ion

    Set-up: The patient lies prone.

    Treatment:1. The physician stands at one side of the

    patient facing the patients feet.

    2. The physician places one hand at thelumbosacral junction and one hand over thesuperior lumbar segments.

    3. Using both hands, the physician assessesinferior and superior glide, left and rightrotation, and clockwise and counterclockwisemotion of the desired fascial layer.

    4. After determining the presence of anyasymmetry, the physician may meet eitherthe direct or indirect barrier.

    5. The physician may use the patientsrespiratory assistance to further engage thebarrier until a palpable release occurs as

    denoted by a softening of the tissues,improved soft tissue compliance/flexibility, oran unwinding of the tissues.

    6. Retest: the physician will retest by using the same method that was used in the initialassessment. Example: improved compliance in the different levels of fascia treated.

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    Myofascial Release of Somatic Dysfunctions in thePelvic Region (739.5) & Sacral Region (739.4)

    IntroductionThe pelvic girdle plays an important role in the postural-structural system, the

    respiratory-circulatory system, and the craniosacral system. The pelvis provides thestructural link between the mechanical forces of the lower extremities and the axialskeleton above. Treatment of the fascia and muscular attachments of the innominatesand surrounding joints can have a significant effect on gait. Also, as the sacrum directlysupports the vertebral column, treatment to this area may aid in restoring functional

    symmetry to the entire spine.

    When using myofascial release technique of the pelvis, it is important to address thelumbosacral and sacroiliac joints in addition to the overall mobility of the pelvic girdle.Diagnosis and treatment of the pelvis using MFR is described using varying patientpositions. The treatment position is based on physician and patient comfort.

    The steps to determine whether there is a lumbosacral or sacroiliac somatic

    dysfunction are listed on the next page.

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    Myofascial Release of Somatic Dysfunctions in thePelvic Region (739.5) & Sacral Region (739.4)

    Lumbosacral and Sacroil iac Compressions

    Possible Objective Findings: lumbosacral myofascial compression or SI jointcompressions

    How to Diagnose:Step 1:With the patient supine, the physician places his or her dominant hand

    underneath the sacrum, with the sacral apex resting in the palm, and L-S junction

    at the fingertips (pointing superiorly). The physician observes and palpates forsacral motion. As the patient inhales, the sacral base should move posteriorlyand superiorly. As the patient exhales, the sacral base should move anteriorlyand inferiorly. If the sacrum does not move freely with respiration, either aLumbosacral or Sacroiliac Compression may exist.

    Step 2:To differentiate between these, the physician tests for each separately.

    Lumbosacral CompressionTo test the L-S joint, the physician contacts the sacrum with the dominant hand andplaces his/her other hand under the lower lumbar spine. (See Picture A below.)The physician tests the L-S joint by stabilizing the lumbar spine and by distractingthe sacrum inferiorly. If there is no palpatory resiliency upon L-S distraction, alumbosacral compression exists.

    Sacroil iac Compression

    To test the S-I joint, the physician contacts the sacrum with the dominant hand andplaces the other hand into ipsilateral sacral sulcus, with the fingertips curling aroundthe PSIS. (See Picture B below.) The physician stabilizes the sacrum whileslightly distracting the innominate laterally. If there is no resiliency or give with S-Idistraction, a sacroiliac compression may exist. The physician evaluates, and ifnecessary, repeats on the contralateral side.

    Myofascial Release of Somatic Dysfunctions in the

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    Myofascial Release of Somatic Dysfunctions in thePelvic Region (739.5) & Sacral Region (739.4)

    Lumbosacral Direct Decompression: Supine

    Possible Objective Findings: L5-S1 myofascial compression

    Set-up: The physician sits facing the supine patients head with the dominant hand on thesacrum and the other hand stabilizing the lumbar spine.

    Treatment:1. The lumbar hand provides

    stabilization as the sacral handapplies a slow and gentle inferiorforce.

    2. This is continued until free motionof the sacrum occurs.

    3. Retest: the physician will retest

    by using the same method thatwas used in the initialassessment. Example: resiliencyat the L/S junction.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of this

    technique by instructing the patient to perform the following INR component at Step 1:internal and external rotation of the lower extremity at the hip joint.)

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    Myofascial Release of Somatic Dysfunctions in thePelvic Region (739.5) & Sacral Region (739.4)

    Lumbosacral Indirect Decompression: Supine

    Set-up: The physician sits facing the supine patients head with the dominant hand on thesacrum and the other hand stabilizing the lumbar spine.

    Treatment:1. Positioning as above. The

    physician approximates his/her

    hands, causing compression untilthere is softening of tissues/freemovement. (Note: The patient ispositioned in the supine positionfor purposes of treatment. Thepicture to the right is for handplacement illustration only)

    2. Retest: the physician will retest byusing the same method that wasused in the initial assessment.Example: resiliency at the L/Sjunction.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of this

    technique by instructing the patient to perform the following INR component at Step 1:internal and external rotation of the lower extremity at the hip joint.)

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    Myofascial Release of Somatic Dysfunctions in thePelvic Region (739.5) & Sacral Region (739.4)

    Lumbosacral Direct Decompression: Prone

    Possible Objective Findings: L5-S1 myofascial compression

    How to Diagnose:Facing the patient with the dominant hand on the sacrum and the other hand stabilizing thelumbar spine.

    Set-up: The patient lies prone

    Treatment:1. The physician places one

    hand over the sacrum withhis/her fingers pointinginferiorly. The thenar andhypothenar eminences of that

    hand contact the sacral base.

    2. The physician then contactsthe L5 vertebra with the thenarand hypothenar eminences ofthat hand at the L/S junction.The fingers point superiorly.

    3. Using his/her body weight, thephysician applies anteriorcompression meeting thetissues resistance and then traction between the two hands, moving them apartuntil a release is palpated, denoted by increased soft tissue flexibility/compliance, softening of tissues, increased tissue warmth.

    4. Retest: the physician will retest by using the same method that was used in the

    initial assessment. Example: increased resiliency at the lumbosacral junction.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR component at Step 3:internal and external rotation of the lower extremity at the hip joint )

    Myofascial Release of Somatic Dysfunctions in the

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    Pelvic Region (739.5) & Sacral Region (739.4)

    Lumbosacral Direct Decompression: Lateral Recumbent

    Possible Objective Findings: L5-S1 myofascial compression

    How to Diagnose:The physician places the cephalad hand stabilizing the lumbar spine and the otherhand on the sacrum.

    Set-up: The patient is in the lateral recumbent position with hips and knees flexed.

    The physician stands facing the patient.

    Treatment:1. The physician places the

    thenar eminence of onehand over the L5 vertebra.

    2. The physicians other arm

    is positioned withforearm/elbow contactingthe sacrum.

    3. The physician appliesanterior compressionmeeting the tissuesresistance and then

    traction between the twocontacts, moving themapart until a releaseoccurs. The physicianmay employ respiratory cooperation as needed.

    4. Retest: the physician will retest by using the same method that was used in theinitial assessment. Example: increased resiliency at the lumbosacral junction.

    M f i l R l f S ti D f ti i th

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    Myofascial Release of Somatic Dysfunctions in thePelvic Region (739.5) & Sacral Region (739.4)

    Sacroil iac Direct Decompression: Supine

    Possible Objective Findings: R/L/bilateral SI joint compression

    Set-up: The physician sits facing the supine patient on the side of the compressedSI joint. Hand placement is as described above for sacroiliac diagnosis.

    Treatment:

    1. While stabilizing thesacrum, the physicianapplies a lateral traction toPSIS and innominate

    2. The patient is allowed toeither breathe normally asthe decompression

    continues or the physicianmay employ the patientsrespiratory cooperation toassist the release.

    3. End point is when the iliumappears to pull away fromthe sacrum, and the sacrum moves freely with respiration

    4. This is repeated on the opposite side as needed.

    5. The retest may simply be the sensation of the sacrum moving freely between theilia with resiliency between the bilateral SI joints.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of this

    technique by instructing the patient to perform the following INR component at Step 2:internal and external rotation of the lower extremity at the hip joint.)

    Myofascial Release of Somatic Dysfunctions in thePelvic Region (739 5) & Sacral Region (739 4)

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    Pelvic Region (739.5) & Sacral Region (739.4)

    Bilateral Sacroiliac Joint Decompression with Forearm Pressure : Supine

    Possible Objective Findings: R/L/bilateral SIjoint compression

    Set-up: The physician sits facing thesupine patient. The physician mayask the patient to bend the kneeclosest to the physician and then

    lift his/her hips off the table so thatthe physician may contact thesacrum. The patient may thenrelax in a supine position.

    Treatment:1. The physician places the free forearm

    and hand over the anterior superior iliac

    spines (ASIS) of the patients pelvis.

    2. The physician keeps the hand monitoringthe sacrum soft and relaxed by leaninginto that elbow. With the forearmspanning the ASIS, the physicianassesses for any ease-bind, asymmetryin left and right rotation about a vertical

    axis, and left and right torsion about anoblique axis.

    3. The physician may treat either indirectly ordirectly, engaging that respective barrier.

    4. The physician may ask for the patientsrespiratory cooperation until a palpable release

    occurs as denoted by a softening of the tissues,improved soft tissue compliance and flexibility,or an unwind occurs.

    5. Retest: the physician will retest by using theth d d i th i iti l

    Above two pictures depicting hand

    placement on sacrum. Posterior andlateral views

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    Pelvic Region (739.5) & Sacral Region (739.4)

    Pelvic Innominate MFR

    Possible Objective Findings: R/L/bilateral innominate myofascial restrict ion

    How to Diagnose:1. Alternating pressure toward the table is applied to assess the A-P motion around

    the vertical axis.

    2. Anterior/Posterior Rotation (anterior/ posterior pelvic tilt) of the ilia is assessed

    about a transverse axis in an alternating fashion.

    Set-up: The patient is supine. The physician places his/her hands over theanterior superior iliac spines.

    Treatment:1. With the hands positioned as above,

    the physician stacks the planes of

    motion either into a position of ease(indirect) or restriction (direct.)

    2. The patient is allowed to eitherbreathe normally as thedecompression continues or thephysician may employ the patientsrespiratory cooperation to assist the

    release.

    3. The physician follows therelease/unwind until an end point isreached (tissues relaxation,cessation of further releases, and/ora sense of softening or increasedsoft tissue compliance/flexibility.

    4. Retest: the physician will retest byusing the same method that wasused in the initial assessment.Example: improved compliance of theili d th ti l d t

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    Myofascial Release for Somatic Dysfunctions in the Lower Extremities(739.6)

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    Hip MFR

    Possible Objective Findings: R/L/bilateral hip internally/externally rotated andcompressed or distracted

    How to Diagnose:Using the entire leg as a long lever, the physician assesses the fascial quality ofadduction/abduction, internal/ external rotation, compression/ distraction of the hipregion. If a restriction is noted, the physician proceeds as follows:

    Set-up: The physician stands at the supine patients feet and slightly flexes the hipby holding onto one foot.

    Treatment: Using the motions described:1. The physician either places the lower extremity in a position of ease (indirect) or

    restriction (direct).

    2. The physician may use

    respiratory cooperation.3. The physician waits for the end

    point or for the unwinding of thetissues.

    4. Retest: the physician will retestby using the same method thatwas used in the initialassessment. Example: improvedfascial quality of those motionsdescribed in the abovediagnosis section.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of this

    technique by instructing the patient to perform the following INR component at Step 2:internal and external rotation of the lower extremity at the hip joint by either directmuscular isometric contractions or by reaching to the right or left in an alternatingmanner with the upper extremities, thereby causing rotation from above.)

    Myofascial Release for Somatic Dysfunctions in the Lower Extremities (739.6)

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    yo asc a e ease o So at c ys u ct o s t e o e t e t es ( 39 6)

    Knee MFR

    Possible Objective Findings: R/L/bilateral knee internally/externally rotated andcompressed or distracted

    How to Diagnose:The physician flexes the knee slightly and assesses the fascial quality of motion ofthe following: anterior/ posterior glide, internal/external rotation, compression/distraction. If a restriction is palpated, the physician proceeds as follows.

    Set-up: The patient is supine. The physician stabilizes the supine patients distalthigh with one hand and proximal tibia with the other hand.

    Treatment: Using the motions described:1. The physician either places the lower extremity in a position of ease (indirect) or

    restriction (direct).

    2. The physician may userespiratory cooperation.

    3. The physician follows therelease/unwind until an end pointis reached (tissues relaxation,cessation of further releases,and/or a sense of softening or

    increased soft tissuecompliance/flexibility.

    4. Retest: the physician will retestby using the same method thatwas used in the initialassessment. Example: improved fascial quality of those motions described in theabove diagnosis section.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR component at Step 2:dorsiflexion and plantarflexion of the foot and/or eversion and inversion of the foot )

    Myofascial Release for Somatic Dysfunctions in the Lower Extremities(739.6)

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    Ankle MFR

    Possible Objective Findings: R/L/bilateral ankle inverted/everted andcompressed or distracted and plantar-flexed or dorsif lexed

    How to Diagnose:The physician evaluates the fascial quality of motion of ankle plantar/dorsiflexion,inversion/eversion, compression/ traction. If a restriction is palpated, the physicianproceeds as follows.

    Set-up: The patient is supine. The physician stabilizes the supine patients ankleby holding the distal leg with one hand.

    Treatment: Using the motions described:1. The physician either places the lower extremity in a position of ease (indirect) or

    restriction (direct).

    2. The physician may userespiratory cooperation

    3. The physician follows therelease/unwind until an endpoint is reached (tissuesrelaxation, cessation of furtherreleases, and/or a sense ofsoftening or increased soft

    tissue compliance/flexibility.

    4. Retest: the physician will retestby using the same method thatwas used in the initialassessment. Example: improved fascial quality of those motions described in theabove diagnosis section.

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR component at Step 2:internal and external rotation of the lower extremity at the hip joint.)

    Myofascial Release for Somatic Dysfunctions in the Lower Extremities(739.6)

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    Fibular Release

    Possible Objective Findings: R/L/bilateral anteriorly/posteriorly d isplaced fibularhead

    Set-up: The patient is supine with the physician on the ipsilateral side of thesomatic dysfunction.

    Treatment:

    1. The physicianstabilizes thesupine patients lateral malleoluswith one hand and assessesanterior/ posterior motion of thefibular head with the other hand.

    2. Caution: do not compress thecommon peroneal nerve under

    the fibular head

    3. The physician follows theunwinding in the direction ofease or restriction until an endpoint is reached.

    4. Retest: the physician will retest by using the same method that was used in the

    initial assessment. Example: improved fascial quality of those motions describedin the above diagnosis section.

    Stabilize

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    Talotibial Decompression

    Possible Objective Findings: R/L/bilateral talotib ial compression

    Set-up: The patient lies prone with the physician seated or standing at the side ofthe dysfunction.

    Treatment:1. The physician wraps his/her hands

    about the prone patients ankle. Thephysician flexes the patients knee anddecompresses the talotibial joint.

    2. Retest: the physician will retest by usingthe same method that was used in theinitial assessment: Example: improvedmotion of the talotibial joint.

    (See Speece 2001, pp. 46-47)

    Foot MFR

    Possible Objective Findings: R/L/bilateral foot/feet myofascial restric tion

    How to Diagnose:With the other hand, the physician evaluates the foot for the fascial quality of motionof pronation/ supination, flexion/extension, traction/ compression. If a restriction ispalpated, the physician proceeds as follows.

    Set-up: The patient is supine. The physicianstabilizes the supine patients foot justdistal to the ankle with one hand.

    Treatment: Using the motions described:1. The physician either places the lower

    extremity in a position of ease (indirect) orrestriction (direct).

    2. The physician may use respiratorycooperation

    Stabilize

    (Optional: Some clinicians have noticed improved efficacy and effectiveness of thistechnique by instructing the patient to perform the following INR component at Step 2:fl i d t i f th t )

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    flexion and extension of the toes.)

    References:

    1 Chila A G Foundations of Osteopathic Medicine 3rd Ed Lippincott Williams &

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    1. Chila, A. G., Foundations of Osteopathic Medicine 3rd Ed. Lippincott Williams &

    Wilkins. Philadelphia, PA. (2011).

    2. DeStefano, L., Greenmans Principles of Manual Medicine 4th

    Ed. WoltersKluwer/ Lippincott Williams and Wilkins. Baltimore, MD. (2001).

    3. DiGiovanna, E. L., S. Schiowitz, and D. J . Dowling, Ed. An Osteopathic Approach

    to Diagnosis and Treatment. Lippincott Williams & Wilkins, Philadelphia, PA,

    2005.

    4. Friedman, H.D., Gilliar, W.G., and Glassman, J .H. Myofascial and Fascial-

    Ligamentous Approaches in Osteopathic Manipulative Medicine. San Francisco

    International Manual Medicine Society, San Francisco, CA. (2000).5. Greenman, P. E. Principles of Manual Medicine. Philadelphia, PA, Lippincott

    Williams & Wilkins 2003.

    6. Nicholas A.S. and Nicholas E.A. Atlas of Osteopathic Techniques. Wolters

    Kluwer/ Lippincott Williams and Wilkins, Baltimore, MD. (2008).

    7. Nicholas A.S. and Nicholas E.A. Atlas of Osteopathic Techniques 2nd Ed.

    Wolters Kluwer/ Lippincott Williams and Wilkins, Philadelphia, PA. (2011).

    8. Speece, C.A. Ligamentous Articular Strain: Osteopathic Manipulative

    Techniques for the Body. Eastland Press, Inc., Seattle, Washington. (2001)

    9. Ward, R. C., Ed. Foundations for Osteopathic Medicine. Philadelphia, PA,

    Lippincott Williams & Wilkins 2003.

    Technique Nicholas (1st

    Nicholas (2n

    Chila DeStephano Ward Greenman Friedman Speece DiGiovanna

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    59

    Technique Nicholas (1st

    Ed)Nicholas (2

    n

    Ed)ChilaFOM3

    rdEd

    DeStephanoGreenman4

    thEd

    WardFOM2

    ndEd

    Greenman3rd Ed

    Friedman2000

    Speece2001

    DiGiovanna

    CranialTMJ MFRTemporalis MFRSuboccipital/ UpperC