Technique
Direct or Indirect
Active or Passive
HVLA (thrust)
Direct
Passive
Muscle Energy
Direct and Indirect
Active
Soft Tissue
Direct or Indirect
Passive
Counterstrain
Indirect
Passive
Myofascial
Direct or Indirect
Passive
Lymphatic
Direct
Passive
Cranial Osteopathy
Direct or Indirect
Passive
High velocity-low amplitude (HVLA ), or thrust technique, is a direct technique of mobilization with impulse. Thrust techniques comprise the majority of studies on spinal manipulative therapy (SMT) for low-back pain. Acute pain often responds well to this technique.
Muscle energy is a direct technique that involves moving the patient toward the restrictive barrier. The patient is then instructed to contract the muscle group that moves away from the barrier, while the practitioner resists the movement, performing a series of isometric contractions.
Soft tissue technique is a direct, passive technique that involves rhythmic stretching, deep pressure, and traction to mobilize fluid in the soft tissues, relax hypertonic muscles, and to mobilize the fascial layer of tissue.
Counterstrain is an indirect technique, in which the patient is passively moved away from the restrictive barrier, toward a position without pain. This technique creates a strain in the direction opposite to the reflex that is causing the symptomatic strain. It can be used in all pain conditions, including very acute pain.
Myofascial release technique can be performed in a direct or indirect fashion. In a direct technique, the myofascial barrier is engaged and the tissue is loaded with force until a change occurs. In an indirect technique, the tissues are guided in the direction of ease, until a freedom of motion occurs.
Lymphatic technique promotes circulation of lymphatic fluids, which can be helpful in the presence of infection or acute injury.
Cranial osteopathy involves assessment of the primary respiratory mechanism through the cranial sutures and at the sacrum. This technique is passive, and is performed by applying specific pressures over the sacrum and at the cranio-cervical junction in an effort to impact the flow of cerebrospinal fluid. It can be performed in a direct or indirect fashion.
Specific Applications
Acute Pain
The post-operative lower extremity joint replacement patient is in acute pain in the days to weeks following surgery. The controlled trauma of surgery results in edema, lymphatic stasis, and acute muscle spasm in the surrounding muscles. The osteopathic manipulative treatment plan would include lymphatic techniques to improve drainage of the lower extremity, by first clearing a path proximally, and then working distally to drain the affected limb. Once the lymphatic channels have been opened, pedal pumping would help to mobilize fluid from the extracellular space. Increasing the range of motion around the post-operative joint would be achieved with reducing spasm in the hypertonic muscle groups. Counterstrain technique would be an ideal choice for reducing muscular pain in this patient. These techniques can all be performed at the bed level in the acute or rehabilitation hospita l setting.