OMT for the Lumbar, Spine and Sacrum

INTENSIVE UPDATE AUGUST 24 - 26, 2018 & BOARD REVIEW Loews Chicago O’Hare Hotel Rosemont, IL

INNOVATIVE • COMPREHENSIVE • HANDS-ON

Breakout Session 2: OMT for the Lumbar, Spine and Sacrum

Harald Lausen, DO, FACOFP Elias Ptak, DO

The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians.

The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content.

8/13/2018

Intensive Board Review: OMT Breakout Session Rosemont, IL August 2018

Lumbar, Innominate, Sacrum Diagnosis and Treatment Review

Elias J. Ptak, D.O. Harald Lausen, D.O., M.A. Associate Professor in Professor of Family & Osteopathic Manipulative Community Medicine Medicine Southern Illinois Touro University-Nevada University Medicine College of Osteopathic Medicine

Lumbar Anatomy and Landmarks

L4 is approximately at the level of the iliac You can find this landmark With this approach you crest with the patient standing, can then contact the seated or prone transverse processes

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Lumbar Anatomy and Landmarks

• By identifying L4’s spinous process you T12 can then effectively L1 count up to find the L2 specific segment of L3 interest as well as the L4 thoracolumbar L5 junction/lower thoracic segments

Lumbar Somatic Dysfunction Diagnosis

L R

In this image the RIGHT L4 transverse In this image the LEFT L4 transverse process is posterior, indicating L4 to be process is posterior, indicating L4 to be rotated RIGHT rotated LEFT

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“Fryette” Mechanics

• Type I • Type II Motion/Somatic Motion/Somatic Dysfunction (Non-neutral) Dysfunction (Neutral) • Non-neutral somatic dysfunctions of the thoracic • Neutral somatic or lumbar spine (either dysfunctions of the flexed or extended) occur at thoracic or lumbar a single vertebral unit: spine: sidebending sidebending and rotation and rotation in a occur in the same directions group occur in opposite directions. • When treating group dysfunctions the APEX of the group is the focus of the treatment

Something to consider…

• “If your treatment involves an active correction, thrust, or HVLA, you are to set the patient into the proper position only and verbalize the mechanism and direction of your correction. You are not to complete the active correction. Performing an active correction, thrust or HVLA is grounds for immediate failure of the entire exam.” -AOBFP website

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Muscle Energy: Lumbar FRS- L4 FRLSL

• The patient is seated and you stand or sit behind the patient. • With the left hand, monitor the interspinous region between L4 and L5 and the transverse processes of L4. • Bring the patient’s upper trunk into extension, right side bending, and right rotation to the L4 segment.

Muscle Energy: Lumbar FRS- L4 FRLSL cont.

• The patient performs an isometric contraction attempting to side bend to the left against your counterforce for 3-5 seconds. • The patient then relaxes and slack is “taken-up” until the next restrictive barriers are engaged. • This contraction, relaxation, and barrier re- engagement cycle is repeated up to 3 times until adequate improvement in motion is obtained.

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Lumbar Soft Tissue: Prone Traction

• Stand at the side of your prone patient. • One hand is placed over the sacrum with the fingers directed caudal, the other hand is placed over the lumbosacral junction with fingers directed cephalad • Exert a mild anterior force (inhibitory pressure) with each hand in opposing directions. (superior and inferior) This force can be sustained or intermittent to accomplish decompression of LS junction or paraspinal muscle softening • You may place the cephalad hand on one side of the spinous processes, with similar action and can capitalize on the respiratory cycle to aid this process.

Lumbar Soft Tissue: Thoracic (and/or Lumbar) Prone or Lateral Recumbent Pressure

• Stand at the side of the prone patient • On the opposite side of the area to be treated, place the thumb and thenar eminence of each hand on the paravertebral muscles lateral to the spinous processes. • Exert an anterolateral pressure on the soft tissues, directed laterally away from the spine, bowstringing the musculature. • Maintain the pressure as a sustained inhibitory pressure, or use it in an intermittent fashion to soften hypertonic musculature. • Repeat as necessary at various levels. • This can also be conducted on the lateral recumbent patient.

Modified Lumbar Soft Tissue Lateral Recumbent

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Lumbar Soft Tissue: Prone Pressure with Counter Leverage • Stand at the side of your prone patient. • Contact the lumbar paravertebral muscles on the contralateral side of the spine with the heel of your cephalad hand. • Contact the ASIS with your caudal hand, inducing a posterior force. • Apply an anterior and lateral force, to stretch the lumbar paravertebral tissues bowstringing the musculature • Allow the ASIS to return to the table, while maintaining and gently increasing the resistance of your cephalad hand further stretching the paravertebral muscles. • Repeat as necessary at additional levels to reduce hypertonic lumbar musculature.

Sympathetic Viscerosomatic Reflexes

• T1-5 Heart • T10-L2 Genitourinary Tract • T2-7 Lungs • T10-L1 Kidneys and upper ureter • L1-2 Lower ureter • T2-9 Upper GI Tract • T11-L2 Bladder • T2-8 Esophagus • T10-11 Testes/Ovaries • T5-9 Stomach and Duodenum • T10-L2 Uterus & Cervix • T11-L2 Penis/anterior vaginal wall & • T8-L2 Mid and Lower GI Clitoris Tract • L1-2 Prostate • T9-11 Small Intestine through ascending colon • T8-L2 Transverse colon Parasympathetic viscerosomatic reflexes: through rectum • Sacral plexus (S2-4) • T10-L2 Vasomotor to • Lower ureter and bladder • Uterus, prostate and genitalia Lower Extremities • Distal 1/3 of transverse colon, descending colon, sigmoid colon, and rectum

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Lumbar High Velocity, Low Amplitude: Initial Positioning • Regardless of the diagnosis; Extended, Flexed or Neutral…the patient is positioned so that they are lying on the side that they are side-bent toward. Examples:

• L1 ERSL : the patient is lying on the left side

• L3 FRSR : the patient is lying on the right side

• L1-3 NSLRR : the patient is lying on the left side

L2-FRS left 1. The patient lies on the LEFT side • THIS IS THE SAME SIDE THE PATIENT IS SIDEBENT TOWARD 2. The shoulders and pelvis are perpendicular to the table. 3. The physician monitors the interspinous space between L2 and L3 4. The physician induces extension at this interspinous space from below using the lower extremities 5. The monitoring hands are switched and the physician induces extension at this interspinous space from above using the shoulders/torso.

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L2-FRS left cont.

6. The patient is asked to straighten the bottom (left) leg and the foot of the top leg (right) is placed in the popliteal fossa. 7. The patient’s left arm is used to pull the left shoulder anteriorly inducing RIGHT rotation of the Rotation torso down to the dysfunctional segment 8. The physician then grasps the elbow of the left upper extremity and pulls cephalad to induce right side bending from above the apex of the dysfunction. At this point the patient is positioned into the extension, right rotation, and right Side bending side bending restrictions of L2 on L3.

L2-FRS left cont.

Now, with the patients right foot in the left popliteal fossa and positioned to engage the restrictions in extension, right rotation, and right side bending the physician can provide a High Velocity-Low Amplitude thrust to correct the restrictions.

8. The physician places his /her right forearm on the anterior aspect of the patient’s right chest/shoulder . 9. The physician places his/her left forearm on the inferior aspect of the patients right iliac crest inducing an anterior and superior movement localized to the dysfunctional segment. 10. A high velocity low amplitude force is induced with the left forearm in an anterior/superior direction while maintaining a static counterforce on the right shoulder/chest.

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L2 ERS left 1. The patient lies on the LEFT side • THIS IS THE SAME SIDE THE PATIENT IS SIDEBENT TOWARD 2. The shoulders and pelvis are perpendicular to the table. 3. The physician monitors the You can use a interspinous space between L2 pillow under the patient’s head to and L3 carry him further 4. The physician induces flexion at into flexion this interspinous space from below using the lower extremities 5. The monitoring hands are switched and the physician induces flexion at this 6. The patient is asked to straighten the interspinous space from above bottom (left) leg and the foot of the top using the shoulders/torso. leg (right) is placed in the popliteal fossa.

L2 ERS left cont.

7. The patient’s left arm is used to pull the left shoulder anteriorly inducing RIGHT rotation of the torso down to the dysfunctional segment; L2 on L3

Rotation

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L2 ERS left cont.

8. The physician then grasps the elbow of the left upper extremity and pulls cephalad to induce right side bending from above the apex of the dysfunction.

At this point the patient is positioned into the flexion, right rotation, and right side bending restrictions of L2 on L3. Side bending

L2 ERS left cont.

Now, with the patients right foot in the left popliteal fossa and positioned to engage the restrictions in flexion, right rotation, and right side bending the physician can provide a High Velocity-Low Amplitude thrust to correct the restrictions.

9. The physician places his /her right forearm on the anterior aspect of the patient’s right chest/shoulder. 10. The physician places his/her left forearm on the inferior aspect of the patients right iliac crest inducing an anterior and superior movement localized to the dysfunctional segment. 11. A high velocity low amplitude force is induced with the left forearm in an anterior/superior direction while maintaining a static counterforce on the right shoulder/chest.

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L1-3 N RRIGHTSLEFT

1. Patient begins in the left lateral recumbent position • THIS IS THE SAME SIDE THEY ARE SIDE BENT TOWARD

2. While monitoring the interspinous space the physician flexes the knees and hips until motion is palpated below the apex of the dysfunctional segments- the patient is to remain neutral at the apex 3. The patient is then asked to straighten the bottom leg (left) and the Right foot is placed into the popliteal fossa.

Counterstrain: Steps in Treatment

1. Evaluate tender points 5. Re-evaluate pain level 2. Ask the patient to rate for at least a 2/3 the pain 1-10 improvement 3. Choose the most 6. Hold position for 90 tender in a group sec (ribs 120 sec) 4. Position the patient for 7. Return to resting treatment position 8. Re-evaluate pain level

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Anterior Lumbar Counterstrain

AL1

AL3 AL2

AL4

AL5

Anterior Lumbar Counterstrain: AL3 & AL4 Counterstrain point location The anterior L3 point is at the lateral portion of the AIIS while the anterior L4 point is at the inferior portion of the AIIS. Both points are treated similarly.

Treatment position Flexion of the hips and lumbar spine to either the L3 or L4 level (depending on which tender point is being treated) with trunk rotation toward (pelvic rotation away) from the tender side and side bending away by pulling the feet away from the tender point side. From Counterstrain and Exercise: An Integrated Approach, 3rd ed., RennieMatrix®

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Posterior Lumbar Counterstrain

Left side: Right side: PL1-5 PL1-5

Posterior Counterstrain: PL1-5

Counterstrain point location At the inferolateral side of the deviated spinous process. This signifies vertebral rotation of this segment to the opposite direction.

Treatment position Extend the lower trunk on the ipsilateral side of the deviated spinous process by lifting the pelvis in a posterior direction. This creates extension and relative rotation of the upper

From Counterstrain and Exercise: An Integrated trunk away from the tender Approach, 3rd ed., RennieMatrix® point side.

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Posterior Pelvic Landmarks

PSIS PSIS Sacral base *Posterior Sacroiliac superior iliac joint spine (PSIS)*

ILA ILA *Inferior lateral angle (ILA)*

Ischial tuberosities

Anterior Pelvic Landmarks

*Anterior superior iliac spine (ASIS)*

ASIS ASIS

Pubic rami

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Physiologic Somatic Dysfunctions: Innominate Rotations

ASIS PSIS

Anterior Innominate Rotation: Posterior Innominate Rotation: This will result in a relatively This will result in a relatively longer leg on the same side shorter leg on the same side

Non-Physiologic Somatic Dysfunctions: Innominate Shears

PSIS ASIS

ASIS PSIS

Superior Innominate Shear Inferior Innominate Shear

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ME for Anterior Innominate Rotation

Steps: 1. Patient is supine with the physician standing on the opposite side of the dysfunction with the hip and knee flexed. 2. With his upper hand, the physician flexes, externally rotates, and abducts patient’s right leg, which loose packs the right sacroiliac joint 3. With his lower hand, the physician places the heel of the hand on the ischial tuberosity and exerts a cephalad and lateral force on the ischial tuberosity while the physician resists extension of the leg by the patient for 3 to 5 reps. Slack is taken up between the contraction intervals then the innominate is reassessed.

Physician Force Blue, Patient Force Red

ME for Posterior Innominate Rotation Steps: 1. The physician stands on the side of dysfunction and brings the supine patient’s SI joint to the edge of the table. 2. The patient’s leg is placed between the physician’s knees while the pelvis is supported with a hand placed over the contralateral innominate. Tip: Variations in leg placement are possible as long as the patient’s leg is comfortable. 3. Physician’s other hand applies a force to the floor which attempts to pull the ipsilateral innominate toward anterior rotation. 4. The physician resists as the patient flexes the hip for 3 to 5 reps. Slack is taken up between the contraction intervals then the innominate is reassessed.

Physician Force Blue, Patient Force Red

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ME for Superior Innominate Shear Steps: 1. Patient is supine with the feet off the end of the table. 2. Physician places his thigh against the contralateral foot (non- dysfunctional side) to stabilize the pelvis and then holds the patient’s other leg (dysfunctional side) just above the ankle. 3. The leg is abducted to about 10-15° to loose-pack the SIJ and the hip is internally rotated to close-pack the hip joint. 4. The physician pulls on the leg while the patient performs a series of about three to four inhalation and exhalation efforts. 5. During the last exhalation effort the patient is asked to cough while simultaneously the leg is pulled in a caudal direction. 6. Assess that proper release was obtained.

Physician Force Blue

ME for Inferior Innominate Shear Steps: 1. Patient is prone with the physician standing on the same side as the dysfunction. 2. The patient’s foot is placed onto the physician’s thigh and then the patient’s knee is stabilized with one hand while the other hand is placed on the patient’s ipsilateral ischial tuberosity. 3. The leg is abducted to about 10-15° to loose-pack the SIJ, then a cephalad force is placed on the ipsilateral ischial tuberosity by the physician while the patient performs a series of deep inhalation and exhalation efforts. 4. Additionally, the patient attempts to straighten the ipsilateral arm (that is holding onto the table leg) which results in a caudal force through the trunk. 5. Assess that a proper release was obtained.

Physician Force Blue, Patient Force Red

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ME for Superior or Inferior Pubic Shear Steps: 1. Patient is supine with the hips and knees flexed and feet together and flat on the table. 2. Physician first holds the patient’s knees together and resists as the patient attempts to abduct both knees for one rep of 3 to 5 seconds. 3. The physician then holds (or places the forearm between) the patient’s knees and resists as the patient attempts to adduct both knees for one rep of 3 to 5 seconds or until a release is felt at the pubic symphysis. Note: During this step, a "pop" sound may occur. The noise is completely benign. 4. Assess that proper release was obtained.

Patient Abducts Patient Adducts Knees Knees

Physician Force Blue, Patient Force Red

Sacroiliac Joint BLT

• Physician sits on the same side as the SI somatic dysfunction • The posterior hand contacts the posterior aspect of the sacrum, as close to the SI joint as possible • The more proximal part of the fingers of this hand also contact the medial aspect of the PSIS • The other hand is placed on the ASIS. The ASIS will be your handle on the innominate (hip) bone

• With the posterior hand place a slight anterior force on the sacral sulcus with your finger pads and a lateral force on the PSIS with the more proximal portion of the fingers to disengage the SI joint

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Sacroiliac Joint BLT cont.

• Inflare: the anterior hand moves medially (the posterior hand does not move)

• Outflare: the anterior hand moves laterally (the posterior hand does not move)

Sacroiliac Joint BLT cont. • Posterior rotation: the • Anterior rotation: the anterior hand moves anterior hand moves superior and the posterior inferior and the posterior hand moves inferior. hand moves superior.

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Sacroiliac Joint BLT cont. • Superior shear: the • Inferior shear: the anterior and posterior anterior and posterior hands both move hands both move superiorly. inferiorly.

Physician Force Blue

Sacroiliac Joint BLT cont. • While maintaining the disengagement with the slight anterior and lateral force from your posterior hand, move the innominate to create balance at he sacroiliac ligaments (in anterior/posterior rotation, inflare/outflare and superior/inferior shear).

• Remember, these are minor motions. • Establish a point of balanced ligamentous tension, hold until a release is felt and then retest.

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Pelvic Counterstrain

High Ilium

Lateral Piriformis Trochanter

Gluteus Medius Coccygeus Iliacus

Piriformis Counterstrain Point

• Tender point location • Treatment position • Found half way along a line • Marked flexion of the hip with between the top of the greater abduction and fine-tuning with either trochanter and a point internal or external rotation. between the PSIS and the coccyx. Flex Abd Extrn or intrn

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Iliacus Counterstrain Point

• Tender point location • Treatment position • 1/3 distance from the ASIS • Marked bilateral flexion and to the midline of the external rotation of the hips with abdomen pressing deep in a the knees flexed. postero-lateral direction toward the iliacus. FLEXternal rot.

Sacral Evaluation and Treatment

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Sacral Anatomical Landmarks Sacral Sulcus: A depression (an area) just medial to the PSIS as a result of the spatial relationship of the PSIS to the dorsal aspect of the sacrum. (FOM Glossary) Sacral Base: 1. In osteopathic palpation, the uppermost posterior portion of the sacrum. (FOM Glossary) 2. The most cephalad portion of the first sacral segment. (Gray’s Anatomy) Inferior Lateral Angle (ILA): The point on the lateral surface of the sacrum where it curves medially to the body of the fifth sacral vertebrae. (Gray’s Anatomy)

Sacral Sulcus Sacral Base area

ILA ILA Anterior or Posterior area ILA Superior or Inferior

Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010

Muscle Energy: Bilateral Sacral Flexion ME Type: Respiratory Assistance 1. With patient prone, abduct both legs 15 degrees to loose-pack both SI joints. 2. Internally rotate both legs to gap the posterior aspect of both SI joints (this will allow the sacrum to move posterior). 3. Heel of the hand presses anterior-superior on the (posterior/inferior) sacral apex at the midline, encouraging inhalation while resisting exhalation as the patient takes deep breaths. This will help bring the sacral base posteriorly.

4. Repeat for 3-5 cycles then retest. L5

D D

Physician Force Blue P/I P/I

(–) Seated flexion test Bilat. Deep Sacral Sulci Bilat. Posterior/Inferior ILA (–) Lumbosacral Spring Test (+) ILA Spring Test

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Muscle Energy: Bilateral Sacral Extension ME Type: Respiratory Assistance 1. With patient prone, abduct both legs 15 degrees to loose-pack both SI joints. 2. Externally rotate both legs to gap the anterior aspect of both SI joints (this will allow the sacrum to move anteriorly). 3. The patient is asked to come up on his elbows to achieve the Prone-Prop position. This forces the sacral base anteriorly into its restriction. 4. Heel of the hand presses anterior-inferior on the (shallow) sacral base at the midline, encouraging exhalation while resisting inhalation as the patient takes deep breaths. This will help bring the sacral base anteriorly. L5

5. Repeat for 3-5 cycles then retest. S S

Physician Force Blue A/S A/S

(–) Seated flexion test B/L Shallow Sacral Sulci B/L Anterior/Superior ILA (+) Lumbosacral Spring Test DeStefano LA, Greenman’s principles of manual medicine, 4th ed, 2011 (–) ILA Spring Test

Muscle Energy: Right Unilateral Sacral Extension ME Type: Respiratory Assistance 1. Patient prone with physician standing on the same side as the Right Unilateral Sacral Extension. 2. One hand monitors the deep right sacral base (in the right sacral sulcus). 3. Abduct the right leg 15 degrees to loose-pack the SI joint. 4. Externally rotate the right leg to gap the anterior aspect of the right SI joint (this will allow the sacrum to move anteriorly).

Monitoring right sacral base Abduct leg Externally rotate leg

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Muscle Energy: Right Unilateral Sacral Extension cont. 5. The patient is asked to come up on his elbows to achieve the Prone-Prop position. This forces the sacral base anteriorly into its restriction. 6. Heel of the right hand presses anterior-inferior on the right (shallow) sacral base, encouraging exhalation while resisting inhalation as the patient takes deep breaths. 7. Fingers of the left hand monitor the right ILA. 8. Repeat for 3-5 cycles then retest. L5 S +SeFT

A/S

(+) Right seated flexion test Right Shallow Sacral Sulcus Right Anterior/Superior ILA (+) Lumbosacral Spring Test (–) ILA Spring Test Force applied to right sacral base Force applied to right sacral base (+) Backward Bending Test

ME: Forward Sacral Torsion (Physiologic)

ME Type: Post-Isometric Relaxation and Joint Mobilization using Muscle Force 1. Patient prone with physician standing on patient’s right for a Left on Left Torsion (opposite the oblique axis side.) 2. Flex knees to 90 degrees then roll the patient onto the left hip introducing the modified sims position. (left oblique axis down on the table) This introduces left rotation of the lumbar spine. The TORSO is relatively PRONE 3. While monitoring the right sacral base, flex the hips (to around 90o) until the right sacral base begins to move posteriorly.

Flex legs Roll onto left side Flex Thigh

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ME: Forward Sacral Torsion (Physiologic) cont.

4. Continue monitoring the right sacral base while the left hand introduces left trunk sidebending by pushing the patient’s feet to the floor. Tip: Use your leg as a fulcrum against the patient’s lower leg for comfort. 5. Resist as the patient lifts his feet towards the ceiling. 6. Repeat for 3-5 cycles then retest.

Push feet to floor Patient lifts Physician uses feet to ceiling leg as a fulcrum

ME: Backward Sacral Torsion (Non-Physiologic) ME Type: Post-Isometric Relaxation and Joint Mobilization using Muscle Force 1. Patient lies in the lateral recumbent position with the oblique axis down. For a R on L Torsion shown below, patient is on his left side because of the left oblique axis. 2. While monitoring the right L5 transverse process with the left hand, pull the patient’s left arm anteriorly introducing right rotation of the lumbar spine until L5 first rotates to the right. The TORSO is relatively SUPINE 3. Now use the left hand to extend both legs while monitoring the right sacral base with the right hand until the base first moves anteriorly.

Anteriorly pull arm Extend legs

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ME: Forward Sacral Torsion (Physiologic) cont.

Push feet to floor Patient lifts Physician uses feet to ceiling leg as a fulcrum

MFR- Prone Lumbosacral Release • Assess the thoracolumbar myofascial tissues in the following planes: o Rotation (Left/Right, often the hands are moving in opposite directions) o Side Bending (Clockwise/Counterclockwise, often the hands are moving in opposite directions) o Flexion/Extension (superior/inferior movement of hands) • Hold tissues in all planes of ease (indirect) or restriction (direct)- this may match what is being done on the sacrum

Rotation Rotation Sidebending Sidebending Flexion Extension Right Left Left Right

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MFR- Prone Lumbosacral Release

• Flexion/Extension (superior/inferior movement of the hands)

Physician Force Blue Physician Force Blue

Extension: Neutral Flexion: The hands move The hands move together. apart.

MFR- Prone Lumbosacral Release

• Rotation: Hands move in opposite directions left and right, rotation is named relative to the movement of the torso(cephalad hand) Physician Force Blue Physician Force Blue

Rotation Left Neutral Rotation Right

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MFR- Prone Lumbosacral Release

• Sidebending: The hands can move in opposite directions, clockwise and counterclockwise, if so, it is named for the side of the concavity. If the hands move in the same direction it is named for the cephalad hand

Physician Force Blue Physician Force Blue Sidebending Neutral Sidebending Right Left

MFR- Prone Lumbosacral Release

• After assessment of each of the planes of motion, hold the tissues in all planes of ease (indirect) or restriction (direct) until release is palpated. • Respiratory assistance as an activating force can be utilized. ✓ Have patient hold breath in position of ease if performing indirect or position which tightens the restriction if performing direct. • This can be done with a single plane of motion at a time or multiple based on patient tolerance and practitioner skill level.

• In this image; • If this were indirect treatment the diagnosis would be: flexion, right rotation and left sidebending • If this were direct, it would be the opposite

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Sacral Rock

1. The patient is prone, and the physician stands at the side of the patient

2. Place the 1. 3. Place the caudal cephalic (operating) hand (palpating) hand on top of the on the sacral cephalic hand base with the with the fingers fingers pointing pointing toward toward the the opposite coccyx. direction.

2. 3.

Sacral Rock cont.

4. Neutral 6. Then gently 5. Gently move the move the sacrum sacrum into extension flexion (counter- (nutation) nutation)

5. Flexion 6. Extension

While palpating, determine where the greatest restriction is in each phase of motion.

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Sacral Rock cont.

7. Gently spring against the barrier in each direction alternately, repeating several times in a slow rocking motion.

8. Respiratory assistance can be used additionally. Inhalation will enhance counternutation (extension) and exhalation will enhance nutation (flexion). This would then combine articulatory and muscle energy principles.