In this article I will be using the words and ideas of pioneers of osteopathic medicine who devised and refined Functional Technique to describe exercises which will ensure that you have the beginnings of the concept at your fingertips.
Functional technique is gentle, absolutely safe, attractive intellectually and deserving of the devotion it requires to perfect its use – from all therapists and practitioners who wish to offer their patients the best in bodywork.
Its one and only drawback is the level of concentration it demands and the mental fatigue it produces because of this.
What is functional technique
The term ‘functional technique’ grew out of a series of study sessions held in the New England Academy of Applied Osteopathy in the 1950s under the general heading of ‘a functional approach to specific osteopathic manipulative problems’.
In functional work palpation for ‘a position of ease’ involves a subjective appreciation of tissue as it is brought through positioning towards ‘ease’, to a state of ‘dynamic neutral’, rather than relying on a report by the patient as to reduction in pain as positioning is pursued, as is the case in Strain/ Counterstrain.
Theoretically (and usually in practice) the palpated position of maximum ease (reduced tone) in the distressed tissues should correspond with the position which would have been found were pain being used as a guide.
Bowles gives an example: “A patient has an acute low back and walks with a list. A structural diagnosis is made and the fingertips palpate the most distressed tissues, within the area of most distress. The operator begins tentative positioning of the patient, preferably sitting. The fingertips pick up a slight change toward a dynamic neutral response, a little is gained, a little, not much, but a little. A little, but enough so the original segment is no longer the most distressed area within the area of general distress. The fingers then move to what is now the most acute segment. As much feeling of ‘dynamic neutral’ (ease) is obtained here as possible. Being temporarily satisfied with slight improvements here and there, this procedure continues until no more improvement is detectable. That is the time to stop. Using tissue response to guide the treatment the operator has step by step eased the lesioning and corrected the structural imbalance to the extent that the patient is on the way to recovery.”1
Hoover summarises the key elements of Functional Technique2
- Diagnosis of function involves passive evaluation as the part being palpated responds to physiological demands for activity made by the operator or the patient.
- Functional diagnosis determines the presence or absence of normal activity of a part which is required to respond to normal movement demands. If the participating part has free and ‘easy’ motion it is normal, if it has restricted or ‘binding’ motion it is dysfunctional.
- The degree of ease and/or bind present in a dysfunctional site when motion is demanded is a fair guide to the severity of the dysfunction.
- The most severe areas of dysfunction are the ones to treat initially.
- The directions of motion which induce ease in the dysfunctional sites indicate precisely the most desirable pathways of movement.
- Use of these guidelines automatically precludes undesirable manipulative methods since bind would result from any movement towards directions of stress.
- Treatment using these methods is seldom if ever painful and is well received by patients.
- Functional methods are suitable for application to the very ill, the extremely acute and the most chronic situations.
Functional Technique Exercises
The exercises which are described are variously derived from the work of Johnston3,5 , Stiles4, Greenman6 , Hoover7, and Bowles1
These experts are definite in their instructions to those attempting to learn to use palpating contacts in ways which will allow the application of functional methods.
- The palpating contact (‘listening hand’) must not move.
- It must not initiate any movement.
- Its presence in contact with the area under assessment/ treatment is simply to derive information from the tissue beneath the skin.
- It needs to be tuned into whatever action is taking place beneath the contact and must temporarily ignore all other sensations such as “superficial tissue texture, skin temperature, skin tension, thickening or doughiness of deep tissues, muscle and fascial tensions, relative positions of bones and range of motion..”
- All these signs should be assessed and evaluated and recorded separately from the functional evaluation which should be focused single-mindedly on tissue response to motion. “It is the deep segmental tissues, the ones that support and position the bones of a segment, and their reaction to normal motion demands that are at the heart of functional technique specificity.” (Bowles)
Bowles’ Summary of Functional Methods.
In summary, whatever region, joint or muscle is being evaluated by the listening/palpating hand the following results might occur:
a/ The motive hand (which guides the patients movement) makes a series of motion demands (within normal range) which includes all possible variations. If the response noted in the tissues by the listening hand is ease in all directions then the tissues are functioning normally.
b/ The motive hand makes a series of motion demands which includes all possible variations, however some of the directions of movement produce bind when the demand is within normal physiological ranges. The tissues are responding dysfunctionally.
“Therapy is monitored by the listening hand and fine-tuned information as to what to do next is then fed back to the motive hand. Motion demands are selected which give an increasing response of ease and compliance under the quietly palpating fingers.”
The results can be startling, “Once the ease response is elicited it tends to be self-maintaining in response to all normal motion demands. In short,somatic dysfunctions are no longer dysfunctions. there has been a spontaneous release of the holding pattern.”
Stiles and Johnston’s Sensitivity Exercise #1
1A.: The time allocation for this exercise is 3 minutes.
Pair up with another person and have them sit as you stand behind them resting your palms and fingers over their upper trapezius muscle, between the base of the neck and shoulder. The object is to evaluate what happens under your hands as your partner takes a deep inhalation. This is not a comparison between inhalation and exhalation, but is meant to help you assess how the areas being palpated respond to inhalation – do they stay easy, or do they bind ? You should specifically not try to define the underlying structures or their status in terms of tone or fibrosity, simply assess the impact, if any, of inhalation on the tissues.
- Do the tissues resist, restrict, bind or do they stay relaxed on inhalation ?
- Compare what is happening under one hand with what is happening under the other during inhalation.
- Reverse the roles and have your partner assess you in the same manner to see which hand palpates the area of greatest bind on your inhalation.
1B.: Time suggested 5 to 7 minutes.
- Go back to the starting position where you are palpating your original partner who is
seated with you standing behind.
- The objective this time is to map the various areas of ‘restriction’ or bind in the thorax, anterior and posterior, as your partner inhales.
- In this exercise try not only to identify areas of bind but assign what you find into ‘large’ (several segments) and ‘small’ (single segment) categories.
- To commence place a hand, mainly fingers, on (say) the upper left upper thoracic area over the scapula, and have them inhale deeply several times, first with your partner seated comfortably hands on lap, and then with the arms folded on the chest (exposing more the costovertebral articulation).
- After several breathes with your hand in one position resite it a little lower, or more medially or laterally as appropriate, until the entire back has been ‘mapped’ in this way.
- Remember that you are not comparing how the tissues ‘feel’ on inhalation as compared with exhalation, but how different regions compare (in terms of ease and bind) with each other in response to inhalation.
- Map the entire back and front of the thorax in this way – for location of bind and for ‘size’
- Go back to any ‘large’ areas of bind and within them see whether you can identify any ‘small’ areas, using the same simple contact and inhalation as the motion component.
- Individual spinal segments can also be mapped by sequentially assessing them one at a time as they respond to inhalations.
- Switch so that your partner now has the opportunity to assess you.
- As you sit having your thorax assessed take the opportunity to ask yourself how you would normally handle the information you have uncovered in your ‘patient’.
- Would you try in some way to mobilise what appears to be restricted ?
- If so how ?
- Would your therapeutic focus be on the large areas of restriction or the small ones?
- Would you work on areas distant from or adjacent to the restricted areas?
- Would you try to achieve a release of the perceived restriction by trying to move it mechanically towards and through its resistance barrier, or would you rather be inclined to try to achieve release by some indirect approach, moving away from the restriction barrier ?
- Or do you try a variety of approaches, mixing and matching until the region under attention is free or improved ?
- Would you try in some way to mobilise what appears to be restricted ?
There are no correct or incorrect answers to these questions, however perhaps you can see that there exist methods which do not impose a solution but allow one to emerge.
1C.: The time allocation for this exercise is 5 to 7 minutes
Go back to the original ‘doctor/patient’ setting, with your partner seated, arms folded on the chest, and you standing behind with your listening hand/fingertips placed on the upper left thorax, on or around the scapula area.
- Your motive hand is placed at the cervico-dorsal junction so that it can indicate to your partner your request that s/he move forward of the midline not into flexion but in a manner which carries the head and upper torso anteriorly.
- The movement will be found to be more easily accomplished if your partner has arms folded as suggested as above.
- The repetitive movement forwards, into the position described, and back to neutral, is initiated by the motive hand, while the listening hand evaluates the changes created by this.
- The comparison which is being evaluated is of one palpated area with another in response to this normal motion demand.
As Stiles and his colleagues state it, “It is not anterior direction of motion compared with posterior direction, but rather a testing of motion into the anterior compartment only, comparing one area with the ones below and the ones above, and so on.”
- Your listening hand is asking the tissues whether they respond easily or with resistance to the motion demanded of the trunk. In this way try to identify those areas, large and small, which bind as the movement forward is carried out.
- Compare these areas with those identified when the breathing assessment was used.
The patterns elicited in 1C involve movement initiated by yourself, whereas the information derived from 1A and 1B involved intrinsic motion, initiated by exaggerated respiration.
Stiles and his colleagues have in these simple exercises taken us through the initial stages of palpatory literacy in relation to how tissues respond to motion, self-initiated or externally induced.
Hoover poses a number of questions in the following exercises (‘experiments’ he calls them) the answers to which should always be ‘yes’. If your answers are indeed positive at the completion of the exercise then you are probably sensitive enough in palpatory skills to be able to effectively utilise functional technique.
Hoover’s Thoracic Exercise
Suggested time for this exercise is 5 to 7 minutes.
- Stand behind your seated partner whose arms are folded on their chest. Having previously assessed by palpation, observation and examination the thoracic or lumbar spine of your partner, lightly place your listening hand on those segments which are most restricted or in which the tissues are most hypertonic.
- Do nothing as your hand ‘tunes’ in to the tissues. Make no assessments as to structural status. Wait for at least 15 seconds. Hoover says “The longer you wait the less structure you feel. The longer you keep the receiving fingers still, the more ready you are to pick up the first signals of segment response when you proceed to induce a movement demand.”
- With your other hand and by voice guide the patient into flexion and then extension. The motive hand should apply very light touch, just a suggestion in which direction you want movement to take place. The listening hand does nothing but wait to feel the functional response of ease and bind as the spinal segments move into flexion and then extension.
- A wave-like movement should be noted as the segment being palpated is involved in the gross motion demanded of the spine. A change in the tissue tension under palpation should be noted as the various phases of the movement are carried out. Can you feel this?
- Practice the assessment at various segmental levels and try to feel the different status of the palpated tissues during the phases of the process, as bind starts, becomes more intense, eases somewhat and then becomes very easy before a hint of bind reappears and then becomes intense again.
Decide where the maximum bind is felt and where maximum ease occurs. These are the key pieces of information required for functional technique as you assiduously avoid bind and home in on ease. Can you feel this?
- Try also to distinguish between the bind which is a normal physiological response to an area coming towards the end of its normal range of movement, and of the bind which is a response to dysfunctional restriction.
Can you feel this?
A series of similar execises (5 to 7 minutes for each exercise is suggested) can then be introduced in which you assess the response with your listening hand to side bending and/or rotation in one direction or another.
Different Responses
Hoover describes variations in what might be felt as the response of the tissues is palpated during these various positional demands.
- Dynamic Neutral: This response to motion is an indication of normal physiological activity. there is minimal signalling during a wide range of motions in all directions. Hoover states it in the following way, “This is the pure and unadulterated unlesioned (i.e.not dysfunctional) segment, exhibiting a wide range of easy motion demand-response transaction.”
- Borderline Response: This is an area or segment which gives some signals of some bind fairly early in a few of the normal motion demands. The degree of bind will be minimal and much of the time ease, or dynamic neutral, will be noted. Hoover states that ‘ most segments act a bit like this’, they are neither fully ‘well’ nor ‘sick’.
- The Dysfunctional Response: This is where bind is noted almost at the outset of almost all motion demands, with little indication of dynamic neutral. Hoover suggests that, “Try all directions of motion carefully. try as hard as you can to find a motion demand that doesn’t increase bind, but on the contrary,a actually decreases bind and introduces a little ease. this is possible. This is an important characteristic of the lesion [dysfunction].”
Indeed he states that the more severe the restriction the easier it will be to find one or more slight motion demands which produce a sense of ease, dynamic neutral, because the contrast between ease and bind will be so marked.
Hoover’s Summary
Three major ingredients are required for performing this Functional exercise successfully according to Hoover.
- A focused attention to the process of motion demand and motion response, while whatever is being noted is categorised, as ‘normal’, ‘slightly dysfunctional’, ‘frankly or severely dysfunctional’ and so on.
- A constant evaluation of the changes in the palpated response to motion in terms of ease and bind, with awareness that this represents increased and decreased levels of signalling and tissue response.
- An awareness that in order to thoroughly evaluate tissue responses all possible variations in motion demand are required, which calls for a structured sequence of movement demands. Hoover suggests that these be verbalised (silently).
“Mentally set up a goal of finding ease, induce tentative motion demands until the response of ease and increasing ease is felt, verbalise the motion-demand which gives the response of ease in terms of flexion, extension, sidebending and rotation. Practice this experiment until real skills are developed. You are learning to find the particular ease-response to which the dysfunction is limited.”
References
1. Bowles C A functional orientation for technic Academy of Applied Osteopathy Year Book part 1:177-191 1955 & part 2:107-114 1956 & part 3:53-58 1957
2. Hoover H V Functional technique Academy of Applied Osteopathy Yearbook 1957 pp142-146
3. Johnston W Strategy of a functional approach in acute knee problems American Academy of Applied Osteopathy Yearbook 1964 pp168-1744
4. Johnston W Robertson A Stiles E Finding a common denominator American Academy of Applied Osteopathy Yearbook 1969 pp5-15
5. Johnston W Segmental Definition Parts 1 & 2 J American Osteopathic Association January 1988 and February 1988
6. Greenman P Principles of Manual Medicine Williams and Wilkins 1989
7. Hoover H V A method for teaching Functional Technic American Academy of Applied Osteopathy 1969 pp147-150