Key Points

• Many clients avoid activities they love because they fear it will increase their
chronic pain.   

• Techniques that pin, twist, sling, and resist help clients engage with painful movement barriers by introducing novel stimuli that hold the brain’s attention.

Our fitness levels naturally decline after our 20s and nosedive once we hit our 70s. Along the way, we’re drying up, growing stiffer, enduring injuries, and spending less time moving around. 

A saying from orthopedics, “Motion is lotion,” reminds us that muscle and connective tissue shorten and tighten if we don’t regularly move them through their full range. Both exercise and the skilled hands of a manual therapist produce physical movement that lubricates joints and soft tissue.  

Pin, twist, sling, and resist is a fun way to describe several manual techniques that lubricate joints and soft tissue by generating warmth in the tissue and rolling fascial sacs across associated structures. Some of these methods restore capsular flexibility, enhance joint play, and encourage pain-free range of motion. Others stimulate muscle spindles to turn on weak muscles and improve their firing patterns. 

When Clients View Movement as Threatening

While motion’s ability to act like “lotion” for joints and muscles makes pin, twist, sling, and resist techniques useful in any bodywork system, they are uniquely effective for clients who perceive movement as painful and threatening. Many clients avoid activities they love because they fear it will increase their chronic pain. These methods seem to reset faulty pain perception and reduce nervous system hyperactivity. Research demonstrates that in many chronic pain states, pain persists without an objective threat to the body.¹ Instead, pain perception results from faulty brain network interactions that continue long after an injury has resolved.²

No one area of the brain is solely responsible for a person’s experience of pain.³ Instead, the brain generates pain from a complex network of neurons and structures, including the somatosensory, insular, cingulate, and prefrontal cortex; the thalamus; the amygdala; and the brain stem. The structures in this expansive system perform many functions other than pain perception. When necessary, they temporarily come together to produce the sensation of pain.⁴

Most manual therapists know that factors like anger levels, grief, stress, or fear of severe disease can increase someone’s pain experience with or without tissue injury and inflammation.⁵ Conversely, a motivating goal like running a marathon can decrease someone’s pain experience with or without physiological threat.⁶ When we think of pain perception as a dynamic multi-structure system, it is easier to understand clients who continue to feel pain long after an injury has healed. 

While the causes of complex long-term pain without evidence of tissue damage are not fully understood, central sensitization often plays a role.⁷ Central sensitization is a broad term referring to hyperexcitability of the nervous system, including hyperalgesia (increased sensitivity to pain) and allodynia (perception of pain from exposure to nonpainful stimuli). In musculoskeletal conditions, central sensitization results in defensive muscle spasms that lead to muscle imbalances and compensatory issues.  

Techniques that pin, twist, sling, and resist help clients engage with painful movement barriers by introducing novel stimuli that hold the brain’s attention. While other mechanisms underlying the efficacy of these techniques are unclear, they help the brain down-regulate sympathetic nervous system hyperactivity, releasing regions of dysfunction from protective muscle guarding. 

Eight Techniques Clients Enjoy  

Let’s look at eight pin, twist, sling, and resist methods clients almost always enjoy. Incorporate these techniques into your bodywork toolbox to lubricate joints and muscles, reduce unnecessary protective guarding, and encourage clients to move. 

Calf Twist 

With the client prone, stand by the client’s knee and grasp their calf with the hand closest to their foot. Make a soft fist with the other hand and place it on the client’s hamstring muscles. Rhythmically twist their calf by pulling it toward you while you compress the hamstring muscles at the same cadence. Work up and down the length of the hamstring and calf muscles, giving extra attention to areas that feel bound. 

Ankle Twist

With the client prone, stand by the client’s knee and flex that knee to 90 degrees. Grasp the client’s ankle just below the medial malleoli with both hands. With your elbows out, lift their knee off the table and rotate the leg slowly side to side. 

Ankle Sling 

From the ankle twist, move into an ankle sling. The client’s knee is still flexed to 90 degrees. With the hand closest to the client’s foot, grasp their forefoot. Use the other hand to grip the lateral and medial compartments of the client’s leg. With the hand grasping their forefoot, throw the client’s heel away in a rhythmic slinging motion. With the other hand, grip and strum the leg muscles, including the gastrocnemius, peroneus longus, and tibialis anterior.   

Hamstring Pin and Stretch 

With the client prone, stand by the client’s knee and flex it to 90 degrees. Using the soft fist of the other hand, compress and pin the hamstring muscles. Rhythmically pin the hamstrings while you extend the knee with the other hand. Work up and down the hamstrings. 

Hamstring Pin and Twist

From the pin and stretch, move into a pin and twist by flexing the knee and moving the foot toward and away from you with the hand closest to the feet. Flatten the pin hand so that your palm is on the hamstrings. Use your palm to push the hamstring muscles away from you. Work up and down the hamstrings, rolling the fascial bags back and forth. 

Iliosacral Twist and Resist

With the client prone, stand on their left side and reach your right palm across their body to grasp their right anterior superior iliac spine (ASIS) with a soft palm. With your left palm, exert gentle pressure on the client’s left posterior superior iliac spine (PSIS). With both elbows extended, slowly pull on the client’s right ASIS while your left palm resists at the PSIS. Ask the client to inhale and push the right ilium toward the table against your resistance to a count of five. As they exhale, gently pull the right ASIS back to the next rotational barrier while your left palm resists at the PSIS. Ask the client to inhale and push the right ilium toward the table against your resistance to a count of five. Repeat this technique 3–5 times on each side to restore balance. Alternatively, use it to correct an anteriorly-inferiorly rotated ilium. 

Triceps Pull

With the client supine, face the top of the table and stand by their hips. With the hand closest to the massage table, grasp the client’s triceps with your palm. With your other hand, flex the client’s shoulder and elbow to 90 degrees. Ask the client to make a fist with their hand and grasp over their fist. Externally and internally rotate the client’s shoulder rhythmically. As you take their arm into external rotation, twist the triceps by pulling them toward your body while you squeeze. 

Triceps-Biceps Twist 

From the triceps pull, hold the client’s arm, extend their elbow, and tuck their forearm between your rib cage and arm. You are now facing the table. Move your body back so the client’s elbow is extended and grasp the triceps and biceps with both hands. Squeeze and compress these muscles as you twist your hands back and forth to roll the musculofascial bags over one another. As you work, begin to decompress the client’s shoulder by pulling and pushing it back and forth as you twist.  

Break Barriers with These Methods 

In closing, remember that “motion is lotion” and use techniques that pin, twist, sling, and resist to lubricate joints and soft tissue by generating warmth in the tissue and rolling fascial sacs across associated structures. In addition, if you have clients who are afraid of movement, these methods can help them engage painful barriers by introducing novel stimuli that hold the brain’s attention to down-regulate sympathetic nervous system hyperactivity. 

Notes 

1. M. Ploner, C. Sorg, and J. Gross, “Brain Rhythms of Pain,” Trends in Cognitive Sciences 21, no. 2 (February 2017): 100–10, https://doi.org/10.1016/j.tics.2016.12.001. 

2. S. Vanneste, D. De Ridder, “Chronic Pain as a Brain Imbalance Between Pain Input and Pain Suppression,” Brain Communications 3, no. 1 (2021), https://academic.oup.com/braincomms/article/3/1/fcab014/6137834.  

3. V. Legrain et al., “The Pain Matrix Reloaded: A Salience Detection System for the Body,” Progress in Neurobiology 93, no. 1 (January 2011): 111–24, https://pubmed.ncbi.nlm.nih.gov/21040755/.  

4. Katja Wiech, “Deconstructing the Sensation of Pain: The Influence of Cognitive Processes on Pain Perception,” Science 354, no. 6312 (November 2016): 584–7 https://pubmed.ncbi.nlm.nih.gov/27811269/. 

5. D. P. Thompson, D. Antcliff, and S. R. Woby, “Cognitive Factors are Associated with Disability and Pain, but Not Fatigue Among Physiotherapy Attendees with Persistent Pain and Fatigue,” Physiotherapy 106 (March 2020): 94–100, https://pubmed.ncbi.nlm.nih.gov/31000365/. 

6. K. Wiech, “Deconstructing the Sensation of Pain: The Influence of Cognitive Processes on Pain Perception.”  

7. V. Mezhov, E. Guymer, and G. Littlejohn, “Central Sensitivity and Fibromyalgia,” Internal Medicine Journal 51, no. 12 (2021): 1,990–8. https://pubmed.ncbi.nlm.nih.gov/34139045/.