Class Notes 6

Class Notes 6
Tuina 1 Class Notes 6
Today we will talk about what are usually described as "manipulations," in which we attempt to improve the function of different joints of the body by traction or rotation of those joints. Manipulations are on the border between Tuina (a form of bodywork) and Zheng Gu (bonesetting). When we perform manipulations, keep in mind that we are primarily encouraging the SOFT TISSUE to lengthen to accommodate our manipulations; we are NOT forcibly trying to reset the bones. While resetting may occur as a result of our manipulations, this is not our chief aim.

REAL INJURY can result from attempting to forcibly perform any manipulation. Furthermore, manipulations designed to improve the function of a given joint CAN RESULT IN A WORSENING OF THE CONDITION if they are performed without proper sensitivity (forcibly). So keep the proper spirit when doing these techniques!!!

Usually, manipulations are performed at or near the end of a treatment. You want the tissues of the body to be as soft as possible, so that they can be more or less receptive to the manipulation. You may place manipulations at the very end, or before percussive techniques.

(NOTE: when we learn the routine, we may place certain manipulations at different points in the routine just for logistical purposes. It is inconvenient, after all, to work on the patient in prone position, then supine position, then have the patient get back into prone position to do manipulations. GENERALLY, however, for ANY GIVEN SECTION of the body, we will do all of our other softening techniques, and then perform a manipulation appropriate for that part of the body, in that particular posture.)

When you perform manipulations, you need to be aware of the natural movements of the joint you are working on. The elbows and knees, for example, are hinge joints, and can basically only open and close. Any techniques on them should only encourage opening and closing, NOT TWISTING. If you perform a manipulation on a joint that is not proper to the movement dimensions of that joint, then you are essentially injuring that joint (arguably, you would be doing joint-LOCKING, or even joint-BREAKING).

[Let me amend this: while the elbows and knees are hinge joints, the soft tissue surrounding them may allow and be capable of more dimensions of movement. Note that, with the elbow bent, you can still pronate and supinate the hand; this illustrates a “twisting” motion across a hinge joint.]

In addition to the above, you need to be able to FEEL the borders of a patient's range of motion. A good place to practice is the shoulder. Shoulders are ball and socket joints, and they generally have a wide (spherical) range of motion. With a patient seated, cradle the wrist of the patient's arm with one hand (between your thumb and index finger- tiger's mouth) and place your other hand on the patient's shoulder. First of all, as you extend the patient's arm out, try to feel the weight of the arm. Can you tell if it is relaxed or not? Experiment. Ask the patient to tense up, and see what that feels like. Then ask the patient to relax, and feel the difference.

[This is crucial for these manipulation techniques. Nothing obstructs these techniques more than a patient “superimposing” their volitional movements over your manipulations. Manipulations, in general, are intended to be passive. Note that there are situations in which you would want the patient to actively participate and move a part of the body while you are working on it. We may go over these situations later.]

Now, attempt to take the patient's arm through circles. Start off with very small circles, and gradually, gradually get larger and larger. Eventually, you may begin to reach the borders of the range of motion. You will "feel" it as a kind of resistance, like rubber bands holding back your motion. The sooner you can feel this without "going through it," the better. You may also be able to tell that you are reaching this border by observing your patient's reactions; s/he may tense up as you reach the border. HOWEVER, this is an unreliable marker, as a lot of patients try to mask their reactions (particularly men). Learn to read, through feeling, where the borders are.

So there are three general categories of techniques that I class under Manipulations: Shaking/Trembling (DIFFERENT FROM VIBRATING!), Rectifying/Pulling (basically, it can be thought of as Tractioning), and Rotating.

SHAKING/TREMBLING: This technique is only applicable on the limbs (arms and legs). You grasp the wrist or ankle with both hands, lift the limb slightly (off the table, with the legs, or about level with the shoulder with the arms), FEEL whether or not the limb is relaxed or not, and then, with repeated up and down motions, you SHAKE/TREMBLE the limb. Start off with small and gentle shakes, and gradually build up to larger shakes. DO NOT MAKE YOUR SHAKES TOO LARGE, particularly if the patient has some kind of injury in that limb; it could exacerbate the condition!

Throughout this technique, try to develop the feeling of passing waves through a jumprope.

Different forms include: single arm (usually in seated position), single leg (prone, or side-lying), both legs.

[Note: Just as it is difficult to pass a wave through a rope that is TOO slack, so too is it difficult to pass a wave through a limb that is so slack that it is bent/folded. Gently extend the limb prior to performing shaking/trembling.]

FLEXING/EXTENDING or FOLDING/UNFOLDING joints: This category comes from Maria Mercati's book. It is used for knees and elbows, the hinge joints of our body. All this involves is flexing and extending these joints. Sometimes you can use a fist in the joint, and fold the joint around it like a "nutcracker."

[As stated previously: the elbows and knees are hinge joints, but it is possible to perform other motions with them (or rather, through them) besides opening and closing. To be precise, these motions do not directly involve the hinge joints, but involve the soft tissue either proximal to or distal to the hinge joint. Let’s take the elbow:

Say you have the patient keep their upper arm next to the body, as though it were glued to it. Have the patient bend their elbow 90 degrees. Now, while keeping the upper arm next to the body, you can use the lower arm like a lever, and “turn” the arm in or out. This can also be performed with the upper arm at other angles, like 45 degrees out from the body, or 90 degrees out from the body. This type of motion actually involves what is called “internal or external rotation of the humerus,” and is actually a test for the flexibility and integrity of the rotator cuff muscles in the shoulder (and not the elbow).

Here’s another example. Again, start from the same position as above. Lock the patient’s elbow by gently wrapping your hand around it. Then, have the patient turn their hand palm up and palm down. These motions involve the muscles of the forearm, and are called “supination and pronation.”

Similar exercises can be performed around the knee (although the foot cannot really do the “supination and pronation” motions cleanly).]

ROTATION (YAO): This category involves taking joints through circular range of motions. In the experiment above, we basically did a Rotation technique for the shoulder. It is also possible to do Rotations on the wrist joint, or the hip joint (usually this is done with the patient in supine position), or the ankle joint. Variations for the hip joints include: single straight leg, double straight leg, single leg with the leg folded in towards the chest, both legs bent and together.

Note: Rotation is not performed on the neck. It's not that the neck is incapable of such motions, but it is not necessary for you to control them.

RECTIFYING/PULLING: This is basically traction, although for some reason, depending on the direction and the part of the body you are working on, it can resemble Rotating.

On the limbs, this is relatively simple; you are always pulling OUT from the body. A simple example of pulling is "snapping the fingers."

Note: this is a gentle PULL, NOT A YANK!!! It should feel as though you are pulling a heavy boat into dock with a rope. You don't jerk on the rope, rather, you feel the rope's full length, and THEN using your own body weight, you just allow your "influence" to transfer through the rope.

A slight modification involves combining a pulling motion with a pushing motion. If you want to focus on, say, the wrist joint, then you can use one hand to "push" proximal to the wrist while the other hand "pulls" the patient's hand (distal to the wrist). This "opens" the joint. You can do the same thing for the elbow.

Pulling/Pushing need not only be longitudinal/lengthwise. For example, you can turn the head to one side, "pulling" the head to one side with one hand while the other hand "pushes" on the shoulder.

One of the most critical areas to apply Pushing/Pulling is the back. The back moves in a variety of ways. It can, of course, flex and extend (bend forwards and backwards). Flexion can be "assisted" with the patient in supine position, reaching for his/her toes, while the practitioner (sometimes) works on the back. There are Thai versions of this, but they require the practitioner to "stand on the table." Overall, flexion can best be practiced on the patient in supine or standing positions (there are also side-lying options).

Extension, on the other hand, involves bending backwards (or, alternatively, "opening up the front"). Such exercises involve pulling up or back on corners of the back. The four corners of the back are the shoulders and the hips. If you decide to use the shoulder levers via the arms (particularly the wrists), then you need to be sure that the shoulders are flexible enough to accommodate your pulls (it is often the case that patients cannot extend their arms behind them). If they cannot accommodate your pulls at the wrist, then you may have to directly use the shoulders, which can involve a lot more work on your part. Again, there are a variety of Thai stretches that can provide assistance in this regard, notably the Cobra stretch variations, but they do require a bit of "balancing". There are also variations that can be done in the sitting position.

The back can also side-bend. The side can be worked on in the side-lying position, and it is possible to do some manipulations that open up the side (mostly via a cross pushing motion on the two levers, the rib cage and the pelvis). More extension side-bending can be accomplished in the sitting position, as the table isn't in the way: an elegant (if somewhat ambitious) Thai version is available for this.

The back can twist/rotate. This is by far the most complicated movement of the back. There are versions of twisting the back that can be approximated in both the prone and supine positions. If you think of the back as a rectangle, you are trying to "twist" the rectangle by either "folding back" individual corners, or having opposite corners move in opposite directions. For example, if the patient is prone, you can accomplish some degree of rotation and twist by "lifting" one shoulder (preferably as you "push" into the rhomboids). Or, if the patient is in side-lying position, you can have the top shoulder go "forwards," and the bottom leg go "backwards", and vice versa.

It is also, of course, possible to accomplish a twisting motion in a sitting position. There are varieties of this that can be accomplished in both Thai and Tuina formats.

DEMONSTRATED TECHNIQUES:
NECK: Seated Position, Prayer Hands, Flexion, Extension, Sidebending, Rotation

Supine Position, Cradle/Bridge Hands, Lifting with Slight Traction

Supine Position, Cradle/Bridge Hands under Occiput, Circles

Supine Position, Cross Hands Under Neck, Flexion

Supine Position, One Hand Cradles Occiput, Other Hand placed on Opposite Shoulder, Turning Stretch

SHOULDER TO WRIST:
Seated, Stand to one side and behind patient, Place one hand on top of shoulder (holding points like LI 15), Other hand grasps wrist. Pull at wrist, “Push” (anchor) at shoulder. Accomplish this mainly by turning your whole body slightly rather than by actually using your arms to “pull” or “push.”

In same position, try Shaking, first with very little waves, and then gradually larger and larger, and then Rotating, first with very little circles, and then gradually larger and larger. PAY ATTENTION TO PATIENT’S END RANGE OF MOTION.

*More advanced: Stand to one side of the patient. Step one leg up onto the working surface, such that your knee, if possible, goes into patient’s armpit. One hand goes on patient’s shoulder. The patient’s arm goes BEHIND your back, and you grasp the wrist with your hand. To accomplish traction, you slightly “push” up with your knee, and “pull” primarily by turning your body away from the patient (not by actually “pulling” with your hand).

*Other variations: Opening the Armpit, Finding Wings (using one hand to open front of shoulder while the other Presses in the space under shoulder blade), Water Pump.

Swimming/Brushing Back Hair: Seated, Stand to one side of patient, Support Patient’s Right forearm with your Left forearm (patient’s wrist at your tiger’s mouth), take Patient’s arm through swimming motion or brushing back hair motion to test internal/external rotation at humerus.

Supine. Stand at head of patient, Pull one arm up, Shake (either vertical or horizontal), Rotate. Alternatively, you can try both arms simultaneously.

Supine. Stand at side of patient, Pull one arm, Shake (either vertical or horizontal), Rotate.

ELBOW and WRIST: Pulling/Traction at the elbow and wrist can be accomplished by PULLING below the joint and PUSHING (or rather anchoring) above the joint.

The Elbow can be opened and closed via the Nutcracker technique.

The Wrist can also be flexed and extended, and go through rotation. There is also a technique called Water Faucet which helps with supination and pronation.