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Abstract
In the osteopathic literature, manipulative techniques are classified as either direct or indirect. Direct technique passively mobilizes articular and myofascial tissues against an opposing restrictive barrier, whereas indirect manipulation moves these same tissues away from the motion barrier into tissue "ease." Direct technique is suited for low reactive tissues characterized as stiff and tight, whereas indirect technique is indicated when there is reflex muscle splinting associated with somatic and/or neurologic pain. In this article, direct and indirect forms of manipulation are combined into one technique and referred to as Position-Assisted Combination Technique (PACT). The theory and clinical application of PACT is described and illustrated for common Type-II impairments (FRS, ERS) with major motion loss present in the thoracic and lumbar spine. The integration of other forms of spinal manual therapy into PACT, including muscle energy technique, non-thrust mobilization/manipulation, and high-velocity/low-amplitude thrust is described in detail.