SOFT TISSUE PERFORMING A PASSIVE LATERAL FLEXION ASSESSMENT

1. Support head in palms and create a pivot point with finger- tips at postero-lateral margin of the facet joint at the level of the required assessment. 2. Move all structures above the formed pivot into lateral flex- ion to R1. Take up any ‘gentle slack’ to a position we will call R1+.

3. Apply overpressure 1, 2, 5% to evaluate ROM and end feel. An assessment of reduced ROM with a firm end feel which yields under slight overpressure may indicate restriction caused by soft tissue which can be treated successfully with the protocol to be outlined. Note also that a common limitation to segmen- tal movement are changes in the joint itself eg. loss of disc height and bone changes due to age and certain disease processes eg. osteoporosis. End feel on passive assessment will reveal a hard bony block, which may contraindicate specific joint techniques, however direct soft tissue treatment may be very useful to maintain soft tissue health.

Then re-assess in 10o FLEXION – further tensioning means a

possibility of already shortened tissue. If it is worse it confirms that dysfunction is on the RIGHT – not opening. If the ROM is the same, soft tissue dysfunction is NOT on the RIGHT.

Re-assess LEFT lateral flexion in 10o EXTENSION. Further

compressing possible if there is already thickened tissue on the left. If WORSE it confirms dysfunction on the LEFT - not closing. Now you know which side to direct your soft tissue treatment to. This assessment system is applicable to cervical joints C2/3 to C6/7.

SEGMENTAL TREATMENT – AN IDEAL SOFT

TISSUE TREATMENT PROTOCOL ■ Assess movement (covered above) ■ Identify dysfunctional segments (covered above) ■ Identify dysfunctional tissue ■ Apply direct soft tissue treatment ■ Apply muscle energy technique ■ Reassess movement

Identify dysfunctional tissue Palpate while taking the joint through the restricted range. The dysfunctional tissue will come into your palpation as the first structure to develop tension, this will be called the 'target tissue'.

Apply direct soft tissue treatment Treat identified target tissue with: ■ Transverse/longitudinal gliding, progress treatment with simultaneous, slow, small amplitude passive segmental lateral flexion movements

■ Digital ischaemic pressure in position of ideal tension ■ Rapid transverse movement (‘Bowen’ type treatment) across target tissue

■ Myofascial tension technique, progress treatment with passive segmental movement, for example, lateral flexion or rotation.

Apply muscle energy technique The components of muscle energy technique are:

www.sportex.net

Figure 3: Passive lateral flexion

4. Assess all levels. Evaluate passive ROM on both the left and the right.

1. Accurate assessment 2. Position to motion barrier (R1, to be conservative, R1+, to be more aggressive) 3. Practitioner provides unyielding counter-force 4. Patient contracts affected muscles by attempting to move back to the neutral position (direct method) with the correct procedure, that is correct force/direction/duration ■ Force: 10–20% ■ Direction: toward the neutral, central point ■ Duration: 6-8 seconds 5. Have the patient relax, wait for a full breath inhalation and exhalation 6. Reposition to new barrier

Repeat steps 4 to 6, three times then reassess passive movement

There are two variations of this method which are particularly useful in the cervical spine.

1. Perform the ‘contraction (attempting to move back to the neutral position) and relaxation cycle’ three times then reposition to new barrier once. This method is useful in more irritable patients. 2. Perform the above variation however, during the contraction phase, alternate between the direct method (attempting to move back to the neutral position against your resistance) once, then the indirect method (attempting to move away from the neutral position against your resistance) once. Perform this cycle three times then reposition to new barrier once. This is useful in stiffer joints not responding to the above techniques.

There are specific variations of how to apply muscle energy technique to each of the three cervical regions (C0/1, C1/2 and C2/3 to 6/7) which will expanded in the live presentation at the sportEX 2007 Conference.

PATIENT SELF-MOBILISING EXERCISES The exercises reinforce and maintain the range of motion gains made through the treatment.

19