Manipulative Body Mechanics Therapy: II

THE JOURNAL OF THE AMERICAN OSTEOPATHIC ASSOCIATION

Manipulative body mechanics therapy: II. Upper dorsal lesion complex

I. WILLARD JOHNSON, D.O.,° Minneapolis, panying upper dorsal intervertebral lesion will be Minnesota referred to as the "upper dorsal lesion complex." In children the presence of the upper dorsal lesion complex is the rule rather than the exception. Symptoms of pain are not often present during the The primary lesion in the upper dorsal region is a early years, but usually develop in one form or slip of the costovertebral joint. As with the sacro- another in later life. Somatovisceral reflexes origi- iliac joint, the lesion apparently involves a trau- nating in the area produce changes in autonomic matically produced abnormal relationship of the function ( visceral and circulatory) which are of articular surfaces which locks the joint against particular importance because of the segmental normal free motion. association of the upper dorsal region with vital Costovertebral maladjustment is typically en- functions. countered as a group lesion, involving the first and second dorsal costovertebral joints and producing a Symptoms characteristic pattern of abnormal mechanics in the upper dorsal region. The lesion is apparently pre- Symptoms commonly associated with the upper disposed by the normally restricted movement be- dorsal lesion complex include: tween the ribs and vertebrae in this area. 1. Pain and tension in the upper border of the Costovertebral maladjustment is intimately associ- trapezius muscle, extending from the suboccipital ated with varying degrees of muscle spasm, inflam- or mastoid regions down the side of the neck to the mation, fibrositis, and arthritis involving the inter- point of the shoulder. vertebral structures of the upper dorsal area. The 2. Pain and tension in the upper dorsal, cervical, lesion is identified by sensitiveness to pressure, and suboccipital regions, from mild tension to the stiffness upon applying springing pressure over the acute stiff neck. area, and frequently by a marked "hardness" pal- 3. Headache, from the occasional tension head- pated across the upper two or three dorsal trans- ache to the severe migraine. (While there are many verse processes and ribs. The chronic nature of the precipitating causes of headaches, costovertebral lesion, in most instances, suggests injury sustained maladjustment is found to be the usual primary, or at an early age. The pathologic changes develop predisposing, cause.) through succeeding years because of strain resulting 4. Symptoms commonly referred to by the patient from the costovertebral maladjustment and from as "sinus trouble" ( suboccipital and supraorbital the gradually developing restricted mobility in the tension and headache, eye strain, nasal congestion, area. In a spinal area in which movement is re- and postnasal discharge ). Dental pain may be stricted, inability to conform to normal function of greatly aggravated by costovertebral strain. the spine in body activity produces irritation and 5. Shoulder pain (referred pain, bursitis, brachial strain in the affected area. neuritis). Costovertebral maladjustment and the accom- 6. Numbness and tingling, rheumatic aches and pains, and arthritis in the fingers, hands, and arms. Part I, on the sacroiliac joints, appeared in the June issue of TUE JOURNAL. 7. Vertigo, usually in certain positions or on per- °Address, 2723 E. 38th St. forming certain movements.

JOURNAL A.O.A., VOL. 60, JULY 1961 887 111111111111111111111111111111111111111111111111111,1111111111111111111111111111111111111111111110111111111111111111111111111111111111111111111111. develop gradually as a result of the strain caused by the slip and from the accompanying abnormal In children the presence of an mechanics. It is also noted that the pain or discomfort may disappear with no change in the upper dorsal lesion complex is the mechanical situation, and then reappear later. It is therefore important that treatment be given on rule rather than the exception. the basis of establishing mechanical normalcy rather than on the basis of symptom response. Symptoms of pain are not often Diagnosis of the present during the early years, but slipped costovertebral joint

usually develop in one form or The diagnosis of slipped costovertebral joints is based on mechanical asymmetry, and upon tension another in later life and sensitiveness of irritated musculature. The following mechanical changes from normal sym- metry are noted: "111111111111111111111111111111111111111111111111111111111111111111.11111111111111111111111111111111111111111111111111111111111111111111111111111111a 1. With the patient sitting or standing, head and dorsal spine in forward flexion, the first ribs are 8. Ocular disturbances (refraction changes, er- palpated ( through intervening soft tissue struc- ratic visual disturbances). tures) from above downward, and somewhat medi- 9. Ringing or buzzing in the ears. ally, close to the base of the neck. The rib is ele- 10. Tension in the muscles of the throat (sensa- vated on one side (usually the left) and depressed tion of a "lump" in the throat). on the other. 11. Habit spasms, particularly in children. 2. The second ribs are palpated from above down- 12. Nervous tension and fatigue. ward, deeply, at a point about halfway between the These symptoms may be present singly or in any point of the shoulder and the base of the neck, and combination, and with recovery following treat- between the clavicle and the upper border of the ment a recurrence of the lesion may result in the trapezius muscle. The second rib is elevated on the same or a different combination of symptoms. same side and depressed on the other. In cases of migraine headache or epileptiform 3. There is a fullness or prominence over the attacks the upper dorsal lesion complex is usually transverse processes and ribs on the side upon found to be the determining etiologic factor. Occa- which the ribs are elevated, which reflects rotation sionally clinical experience suggests an additional of the upper dorsal vertebra toward this side. causative factor in the form of nerve damage which 4. Rotation of the upper dorsal vertebra carries sensitizes the patient to symptoms. It seems proba- the ribs forward on the side of the depressed ribs ble in these cases that the original injury occurred and backward on the other. With the patient in a at birth and involved minor nerve damage. dorsal position, the second and third ribs are In sprains and fractures involving the upper ex- prominent and sensitive and offer greater resistance tremities in which, for no apparent reason, pain to springing pressure on the side upon which they and swelling persist or arthritis develops, the cause are carried forward (usually the right). is usually to be found in circulatory interference The strain produced by slipped first and second resulting from costovertebral maladjustment and dorsal costovertebral joints results in palpatory find- strain. ings based upon soft tissue changes as follows: The failure of normal spontaneous recovery in 1. There is marked sensitiveness to pressure upon "whiplash" injuries is found to be caused by costo- palpating the ribs from above downward. vertebral maladjustment. The situation is frequently 2. The upper border of the trapezius muscle is complicated by the fact that the injury is super- tense and sensitive on the side upon which the ribs imposed upon existing upper dorsal strain in which are elevated. secondary arthritis has developed, and the injury 3. There is tension and sensitiveness in the mus- results in an acute flare-up of the previously chronic, cles over the costotransverse articulations and the and perhaps subsymptomatic, process. angles of the ribs. Somatovisceral reflexes originating in the upper While the costovertebral joints are usually slipped dorsal lesion complex are found to be a most im- with the bodies of the ribs elevated on the left side portant etiologic factor in thyroid hyperfunction, and depressed on the right, the reverse is occa- arterial hypertension, and gastrointestinal dysfunc- sionally encountered and must not be overlooked. tion. The importance of the upper dorsal lesion in coronary heart disease is becoming increasingly Costovertebral lesion mechanics apparent. As with the sacroiliac joint, a costovertebral slip In the study of upper dorsal costovertebral me- is seldom accompanied by symptoms of pain and chanics it is significant to note that the first ribs are discomfort at the time of its occurrence. Symptoms attached rigidly to the manubritun sterni (syn-

880 ehondroses ), so that the first ribs and manubrium move as a single unit. Upon complete inspiration there is slight elevation of the first ribs with corre- sponding movement at the costovertebral joints ("pump-handle" motion). The second ribs attach directly at the junction of the manubrium with the sternum, but the articulations are diarthrodial in type and permit slight motion. The second ribs thus move with the first ribs upon complete inspiration, and in addition perform restricted movement about an anteroposterior axis in which the bodies of the ribs are elevated ("bucket-bail" motion ). The relative rigidity of the first and second rib mechanism is conducive to slight maladjustment and locking of the costovertebral joints. The lesions occur with elevation of the bodies of the ribs on one side and depression of the bodies of the ribs on the other, and the vertebrae are rotated toward the side upon which the ribs are elevated. Since for the most part the upper two ribs do not normally Fig. I perform this "bucket-bail" type of motion, costovertebral slips occur, in which the head of the rib apparently slips downward in relation to the verte- point of his chin resting on a small pillow (pref- bra on the side upon which the rib is elevated and erably foam rubber). The head is in complete upward on the other. This movement of the rib extension. The arm on the side to be treated rests occurs around an axis which passes through the on the table at the patient's side. The operator stands costotransverse joint and the sternal attachment at the side of the joint to be treated (the side of of the rib. The lesions are produced by strained the depressed rib). or sudden movements or by strained positions of 2. The operator localizes firm counterforce with the head or shoulders. the hypothenar eminence of one hand over the end The above interpretation of the costotransverse of the first and second dorsal transverse processes and capitular mechanics involved in a costovertebral ( over the costotransverse joints), directing the force slip is based upon clinical observation of the effects ventrally and cephalad. of various manipulative procedures. Manipulative 3. The head is rotated toward the opposite side technic designed according to this mechanism is ( the occiput moves away from the operator) to effective in correcting the lesions. Methods which the end of the range of relaxed motion, the move- are counter to the mechanism are usually unsuccess- ment pivoting on the chin. The head rests in this ful and, if applied after the lesions have been cor- position. rected, will usually cause the lesions to recur. 4. The operator bends forward to contact the The mechanical defects encountered in the upper localizing hand with his lower ribs on the same dorsal and lumbopelvic regions are found to con- side. form to a definite pattern with remarkable consist- 5. The heel of the free hand is placed high on the ency. Costovertebral slips typically occur with the patient's forehead, just anterior to the templar ribs elevated on the left side and depressed on the region; the elbow is held well out from the trunk right, and with rotation of the upper dorsal verte- and in contact with the table; and the fingers brae toward the left. The sacroiliac joints are slipped extend back over the top of the occiput. most frequently in such a way that, with the patient 6. The head is now carried sharply in extension standing in forward flexion, the pelvis and lumbar and rotation toward the opposite side, against spine are rotated backward on the right, and the counterforce maintained over the transverse proc- right innominate appears to be rotated backward esses in a ventral and cephalad direction. The and the left forward. Differences in leg length movement is one of high speed and low excursion, complicate but do not materially change this followed by quick release. picture. The primary force is extension with rotation applied as a locking mechanism. The rotation lock- Treatment of the ing is introduced by the position of the heel of the slipped costovertebral joint hand on the anterolateral aspect of the occiput. The manipulation forces the body of the verte- On the side upon which the first and/or second bra upward ( extension in relation to the head of ribs are depressed (usually the right), treatment of the rib), the movement pivoting at the costotrans- the costovertebral slip (head of the rib slipped up- verse joint (the point at which counterforce is ward in relation to the body of the vertebra) is localized). carried out as follows (Fig. 1): The maneuver is usually effective in correcting 1. The patient lies in a ventral position with the slips of both the first and second costovertebral

JOURNAL A.O.A., VOL. 60, JULY 1961 889 head of the rib, the movement pivoting at the costotransverse joint. Visualization of costovertebral mechanisms is facilitated with a vertebral segment at hand. The maneuver is usually effective in correcting slips of both first and second costovertebral joints at the same time. Both maneuvers are carried out with the operator bending forward in contact with the localizing hand, to assure that they are performed without a counterthrust over the transverse processes, and to protect the operator against slipping his own costovertebral joints as the movement is applied. Patient relaxation is essential to successful application of the technics. The patient may be instructed to "let the head and shoulders drop down on the table." He may further be instructed to "take a Fig. 2 breath and then let it out," and the thrust is applied at the end of expiration. If relaxation is not secured joints at the same time. It is noted that the first the head may be rotated from side to side in a dorsal transverse process is at the level of the relaxed rhythmic manner; when relaxation is sensed seventh cervical spinous process ( vertebra pro- the thrust is applied without breaking the rhythm minens ), and the second and third dorsal transverse of the rocking movement. In the difficult case, the processes are at the level of the first and second patient may simply be required to relax. Relaxation dorsal spinous processes, respectively. is not a negative act, but a positive accomplishment On the side upon which the first and/or second requiring a voluntary effort. ribs are elevated (usually the left), treatment of If the maneuvers are not successful it is usually the costovertebral slip (head of the rib slipped because of inadequate rotation locking, or because downward in relation to the body of the vertebra) the patient is not relaxed. If the treatment is not is performed as follows (Fig. 2): successful there is a sensation of the force "bounc- 1. The patient lies in a ventral position with the ing back" rather than "going through." point of his chin resting on a small pillow. The Following successful treatment of the costo- arm on the side to be treated is dropped down off vertebral joints, any maneuver which involves the table. The operator stands at the side of the lateral flexion toward the side upon which the ribs joint to be treated (the side of the elevated rib). were elevated will usually cause the costovertebral 2. The operator localizes firm counterforce with slips to recur. Since treatment on the side of the the hypothenar eminence over the ends of the first depressed ribs may involve a degree of lateral and second dorsal transverse processes (over the flexion toward the side of the elevated ribs, treat- costotransverse joints), directing the force ventrally, ment is carried out first on the side of the depressed caudad, and somewhat laterally. ribs and then on the side of the elevated ribs. 3. The head is rotated toward the opposite side With the patient in a dorsal position, treatment (occiput moves away from the operator) to the end of slipped costovertebral joints is performed as of the range of relaxed motion, the movement pivot- follows (Fig. 3): ing on the chin. The head rests in this position. 1. The patient lies in a dorsal position with his 4. The operator bends forward to contact the localizing hand with his lower ribs on the same Fig. 3 side. 5. The heel of the free hand contacts the occiput just above the ear. 6. The head is now carried sharply in lateral flexion, rotation, and extension toward the opposite side, against counterforce maintained over the transverse processes in a ventral, caudad, and somewhat lateral direction. The movement is one of high speed and low excursion, followed by quick release. Rotation of the head is accented as a locking mechanism as the lateral flexion thrust is applied. The rotation is introduced by the position of the heel of the hand well back on the side of the occiput (above the ear). The manipulation forces the body of the vertebra downward (lateral flexion) in relation to the

890 arms folded across his chest. The operator stands at 1111111111111111111111111111111111111111111111111111iiimiimill111111111111111111.11111111111111111111111111111111111111111111111111111111111. the head of the table. 2. The operator places one hand beneath the Since the basic causes of disease occiput and raises the patient's head in flexion. may be studied in each patient, and 3. With the other hand flexed and the thumb flexed over the forefinger, force is localized with useful conclusions arrived at the knuckle of the thumb at the end of the transverse process (beneath the costotransverse joint). long before symptoms develop, it The head is then brought back down on the table. 4. The operator steps forward with one foot (on becomes possible to institute the side to be treated), bends forward, and braces the elbow on this side against his thigh. therapy long before a specific 5. The operator contacts the patient's upper fore- disease syndrome appears head with his chest, thus holding the patient's head between his chest and the hand beneath the occi- ...11111111:1011:111111,1111.1111111111111111111111111111111111111,111111111111111111111111111111111111111111111111111111111111111111111111111111111, put. 6. Pressure is applied with the localizing thumb attempt. Whether or not "popping" occurs thus has (elbow braced against the thigh) in a ventral and no significance with regard to whether or not a medial direction to the point of moderate tension. manipulation has been successful. The result of This is accompanied by slight lateral flexion of the treatment must be determined by careful examina- head toward the side being treated. tion. 7. A sharp rotation and extension movement of the head is now applied by thrusting straight across with the heel of the hand on the posterior occiput, Diagnosis following treatment and at the same time a thrust is applied in a ventral The effectiveness of the manipulations is checked and somewhat medial direction with the localizing by the change toward normal in the mechanical thumb. asymmetry, and by the release of muscle tensions The maneuver is performed in the same manner and decreased sensitiveness. The examination must on both sides. The method is mechanically accurate be carefully performed. The general pattern of the on the side of the depressed ribs, and is usually mechanics of the upper back has usually been successful on the side of the elevated ribs through established over a period of years; while correction forcing movement in the slipped joints. of the primary costal maladjustments improves the This technic is particularly useful in bedside over-all picture, the original pattern may still be treatment, and in the treatment of children. In more or less in evidence and must not confuse the performing the manipulation on children counter- diagnosis. The immediate release of muscular ten- force is applied with the pad of the thumb, hand sions and disappearance of acute sensitiveness upon open, and the thumb held close to the hand for correction of rib maladjustments are dramatic. support. With the patient sitting or standing, the first and Careful attention to detail in the application of second ribs are palpated carefully from above the costovertebral technics is essential. downward. If the manipulative procedure has been The reduction of slipped costovertebral joints is successful, a symmetrical relationship is noted. If accomplished more easily following treatment of asymmetry persists, the side upon which treatment upper dorsal muscle spasm and fibrosis ( see later ). was unsuccessful is indicated by acute sensitiveness The pathologic effects of costovertebral malad- to pressure upon palpating the ribs from above justment and strain develop through the stages of downward, and by the muscle spasm, acute sensi- muscle spasm, inflammation, fibrositis, and sec- tiveness, and "hardness" over the angles of the ribs. ondary arthritis. Occasionally a subacute arthritic Upon release of the rib locking, the acute sensitive- process is activated by the trauma of a corrective ness and tension disappear almost immediately. Ex- manipulation and by the mechanical change, result- amination of the ribs and of the costovertebral areas ing in an acute flare-up of inflammation and pain. may be carried out both from in back and from in Heat, rest, and gentle manipulation are helpful in front of the patient. Accuracy is developed by ex- this situation. If the costovertebral slips recur they perience in before-and-after diagnosis. must be corrected with as little trauma as possible. The fullness, or prominence, over the transverse Active arthritis in the upper dorsal region may be processes and angles of the ribs on the side upon suspected in cases in which fibrositis is well de- which the ribs are elevated disappears or is notably veloped, and stiffness, "hardness," and sensitiveness diminished with reduction of the costovertebral to pressure are marked. lesions. While the reduction of costovertebral slips is Diagnostic accuracy will be found to depend to ordinarily accompanied by some degree of joint a great extent upon the degree of success with "popping," reduction may occur with no audible which the therapeutic technics are applied. Since evidence of joint movement, particularly at a second both sacroiliac and costovertebral strain are present

JOURNAL A.O.A., VOL. 60, JULY 1961 891 tend to maintain the abnormal vertebral and costal relationships produced by slipped costovertebral joints. The stiffness in the area and the mechanical defect predispose to recurring slips of the joints, and the strain which is inherent in an area of restricted mobility is found to be an important factor in producing the symptoms which are characteristic of the upper dorsal lesion complex. Treatment of fibrosis and degenerative changes in the upper and middle dorsal areas is performed as follows (Fig. 4): 1. The patient lies in a dorsal position. The operator stands at the side to be treated. 2. A sponge rubber ball 3 inches in diameter is placed beneath the transverse processes on the near side. 3. The arm on the side under which the ball is Fig. 4 placed is brought to approximately a vertical position, elbow extended and hand closed. ( The arm should be at slightly less than a right angle with in most individuals, it is necessary that a normal the trunk.) condition of the joints be produced by treatment 4. The other hand is placed back of the head, in order to establish a comparison by which the and the head is raised in complete flexion. existence, characteristics, and significance of the 5. The patient is now instructed to "swing the abnormal can be identified. extended arm back as far as he can." This movement is repeated in rhythmic fashion several times, The upper dorsal intervertebral lesion and the patient is then instructed to "rock backward over the ball as the arm swings back." The Costovertebral maladjustment is intimately associ- backward movement of the arm and trunk must ated with muscle spasm, fibrositis, and degenerative end with a relaxed "whip" effect to impose a hyper- changes involving the intervertebral structures of extension thrust at the point of ball contact. The the upper dorsal area. Upon palpation the para- head is maintained in complete flexion as the move- vertebral muscles feel tense and "ropy," and are ment is performed. The movement is repeated five sensitive to pressure; the area feels hard and non- or six times. resilient according to the extent of the fibrosis and The maneuver is performed in the same manner degenerative changes. In cases in which fibrositis on both sides, and treatment is applied through the is well advanced, a marked "hardness" is palpated upper and middle dorsal areas as indicated. across the upper two or three dorsal transverse In the presence of shoulder pain of such intensity processes and ribs, and there is usually a degree that the patient cannot bring the arm back, the of increased flexion in the area (kyphotic defect). manipulation may be performed with the hands Secondary arthritis is often well developed in these clasped high on the posterior occiput. The head cases and must be given due consideration in treat- is flexed on the chest, and the patient rocks forward ment. and backward over the ball. In the lower upper dorsal segments and in the The maneuver exerts a powerful torsion-exten- middorsal region, a "hyperextension" area is fre- sion effect between the vertebrae, which forcibly quently encountered, in which the spinous processes stretches the deep muscles and ligaments and the are depressed and approximated each to the other. intervertebral fibrocartilages, breaking down fibrosis The spinous process, or processes, at the center and restoring mobility, and thus enabling regenera- of the extended area are acutely sensitive to pres- tion of the structures toward normal. As the fibrosis sure, reflecting the acute strain and inflammation is overcome sensitiveness at the point of ball con- caused by restricted mobility. The lesion, as above, tact disappears. Muscle tension and "hardness" in involves fibrositis and degenerative changes affect- the upper dorsal area disappear, flexibility improves, ing the deep muscles and ligaments and the inter- the residual mechanical defect is diminished or vertebral fibrocartilages. The spinous processes are removed, and stability of the costovertebral joints best palpated with the patient in the dorsal position (resistance to recurring slips) is increased. and the head raised in flexion. The reduction of slipped costovertebral joints is In view of the development early in life of the accomplished more easily following treatment by upper dorsal lesion complex and of sacroiliac mal- this method. adjustment and strain, the common presence of It is noted that performance of the manipulation degenerative changes in the intervertebral disks in with the head resting on the table instead of with the young adult is given a basis in long-continued the head held in a fully flexed position will usually trauma. cause costovertebral slips to recur. Upper dorsal fibrositis and degenerative changes It is often desirable to have the patient use this

892 technic at home. The maneuver is performed on flexed wrist, and placing the hand on the opposite the floor in the manner described. The patient may side of the face. The forearm contacts the point of roll on the ball in adjusting it from one position the shoulder. to another. The lacquered finish may be removed 3. Counterforce is localized with the other hand from the ball to prevent it from slipping upward. over the transverse processes on the opposite side It is noted that the effects of strain upon the of the spine, or against the spinous processes on articular structures develop differently in the upper the near side. dorsal and in the lower lumbar and upper cervical 4. Rotation and lateral flexion of the head and areas. The normally restricted mobility of the upper upper spine are now alternately applied and re- dorsal area strongly favors the development of leased in a springing manner, pulling on the face, restricting fibrosis, whereas the free mobility of chin, and shoulder and pushing with the localizing the lower lumbar and upper cervical areas, and hand. The level of the localizing pressure may be the extensive functional requirement in these areas varied to include the upper and middle dorsal areas. in weight-bearing, favor acute inflammation and muscle spasm and tend to prevent the develop- Recurring slips of the costovertebral joints ment of fibrosis. Restricted mobility, "hardness," and nonresilience are thus prominent in the upper As with the sacroiliac joints, stability of the upper dorsal region, and are not often encountered to an dorsal costovertebral joints increases gradually as important degree in the lower lumbar and upper mechanical normalcy in the upper dorsal area is cervical regions. restored. Since slips of the costovertebral joints are seldom Treatment of the lesion mechanism accompanied by identifying symptoms at the time of their occurrence, it is usually difficult to deter- The mechanism of costovertebral maladjustment mine the exact manner in which the lesions were involves depression of the ribs on one side and produced. While the lesions may result from trau- elevation of the ribs on the other, with slight matic movements of the head or shoulders, certain lateral flexion and rotation of the vertebrae toward positions habitually assumed have been identified, the side of the elevated ribs. Upper dorsal fibrosis which are found to be of greater importance than and degenerative changes tend to maintain this direct trauma in causing recurrences of the lesions. mechanical defect. Following reduction of the The following positions are found to cause costo- costovertebral slips this lesion mechanism may be vertebral joints to slip: reversed, and stretching treatment applied to the 1. Lying on the side, the arm on the underside soft tissue structures, by a method which applies held more or less straight out from the shoulder, lateral flexion and rotation of the vertebrae toward and the upper shoulder rolled forward to a posi- the side of the depressed ribs, as follows (Fig. 5): tion of tension. In this position the hand may be 1. The patient is seated on a chair, sitting up beneath the head or pillow or around the neck, straight with head up and arms hanging loosely. or the forearm may be extended straight out. The operator stands at the side upon which the 2. Lying on the side with the arm on the under- ribs were depressed (usually the right). side extending upward and the head resting thereon. 2. The operator passes one hand in front of the 3. Lying on the side with the arm on the under- patient's chin, cradling the chin in the angle of his side extending straight downward, and the trunk rolled forward onto the arm. 4. Lying on the back or side with the head

Fig. 5 propped up toward a vertical position. This position is usually assumed in reading while lying down. 5. Lying in the ventral position with the head turned sharply sideways. 6. Straining to reach in any direction. Regarding positions one, two, and three the patient may be instructed, "When lying on the side keep the arms down, and do not let the upper shoulder roll forward." Since both the sacroiliac and costovertebral joints are readily slipped while lying in the ventral position, sleeping in this position should be discour- aged. Reduction of recurring slips of the costovertebral joints may frequently be accomplished without the assistance of an operator, by the following maneuvers: The depressed rib technic (right side), is as follows:

JOURNAL A.O.A., VOL. 60, JULY 1961 893 Fig. 6 Fig. 7

1. The maneuver is performed in the standing den manner to produce a sharp thrust at the point position. at which force is localized with the fingers. The 2. Using the third and fourth fingers of the left corrective force is developed mainly by the move- hand (little finger flexed on the hand) firm pressure ment of the shoulder. An attempt is made to local- is applied over the right first and second costo- ize the lateral flexion movement of the head at transverse joints in a forward and downward direc- the point at which force is localized with the tion. The pressure must be firm, and localized fingers. It is noted that the movement of the head accurately over the costotransverse joints (over the is in the same direction in both technics. ends of the transverse processes). The location of The technics are mechanically accurate. Practice the first dorsal transverse process at the level of is required in order to achieve the synchronization the seventh cervical spinous process must be kept of movement necessary to successful performance in mind. of the maneuvers. Diagnosis in self-treatment is 3. The head is extended slightly and tilted toward based upon symptoms, and upon examination of the left side (Fig. 6). the rib areas in front of a mirror. 4. A quick movement of the right shoulder and head is now performed, in which the shoulder is Manipulative body mechanics therapy: elevated sharply and the head is thrown in right lateral flexion and rotation toward the left (posterior summary occiput moves toward the point of the right shoul- The essential basic lesions which produce strain der). The movement of the shoulder is reinforced and irritation in body mechanics are slipped sacro- by bringing the arm up sharply in abduction, flex- iliac joints, slipped upper dorsal costovertebral ing the elbow (Fig. 7). joints, fibrosis which restricts mobility of the upper The elevated rib technic ( left side) is as follows: dorsal spinal segments, and body imbalance (main- 1. The maneuver is performed in the standing ly unequal leg length). Effective treatment of these position. basic lesions is for the most part clinically adequate 2. Using the third and fourth fingers of the right in body mechanics therapy. With removal of basic hand, firm pressure is applied over the left first lesions secondary muscle spasm and inflammation and second costotransverse joints in a forward and resolve spontaneously. Secondary fibrositis and ar- downward direction. thritis may require direct manipulative treatment to 3. The left shoulder is elevated, the elbow is improve mobility of the involved joints, and to im- flexed somewhat, and the head is extended slightly prove circulation. and tilted toward the left side. The position is maintained in a relaxed manner ( Fig. 8). The manipulative treatment of reflex spinal lesions is a separate field of application of manipu- 4. A sudden movement is then performed, in lative science. which the left hand and shoulder thrust sharply downward, and the head is thrown in right lateral An approach to therapy flexion and rotation toward the left (posterior occiput moves toward the point of the right shoulder) Man may be defined as a mechanically and chem- (Fig. 9). ically functioning organism, reacting to his environ74 The maneuvers are performed in a relaxed, sud- ment according to. his intellectual and emotional

894 Fig. 8 Fig. 9 capacities, and subject to inherent characteristics sents is considered for the benefit of whatever of function and to the external influences of his specific therapy may be available for that par- environment. The basic causes of disease may thus ticular disease. be outlined as: (1) mechanical stress, (2) nutritional Since the basic causes of disease may be studied excess or deficiency (chemical imbalance), (3) emo- in each patient, and useful conclusions arrived at tional trauma, (4) unhygienic habits of living, (5) long before symptoms develop, it becomes possible inherent predispositions to disease, and (6) external to institute therapy long before a specific disease injury. syndrome, with well developed pathologic changes, The osteopathic concept of medicine, which at- appears. Therapy is thus oriented to health main- taches greatest importance to treatment of the tenance rather than to the treatment of disease. patient rather than of the disease, approaches diag- This approach to therapy becomes practical to nosis from the point of view of determining pri- a very great extent because of the major importance marily what is wrong with the patient that he has of mechanical stress as a cause of disease, and the disease, and then directs treatment toward because of the possibility of the control of me- removal of these underlying causes. The disease chanical stress through manipulative body mechan- entity which classification of his symptoms repre- ics therapy.

JOURNAL A.O.A., VOL. 60, JULY 1961 895