Copyrighted Material
The =#=1
Guide to Myo/ascial Manipulation - Fully Updated and Expanded Second Edition!
Myl!fascial Manipulation: Theory and Clinical Application, Second Edition Hailed as a landmark professional resource, the first edition of Myl!fascial
Manipulation: Theory and Clinical Application was the first book to combine historical analysis, scientific theory, and evaluative and therapeutic techniques in a single, easy-to-use volume. Now this ground-breaking clinical reference has been thoroughly revised and expanded to include even more in-depth coverage... •
Complete catalog of muscle painlmyofascial pain syndromes
•
Step-by-step evaluation guide for the myofascial system
•
Comprehensive atlas of techniques for myofascial manipulation-with 30 new
•
Over 100 photographs of manual therapy in action
•
More than 450 new references
•
A new chapter on neurophysiologic mechanisms in myofascial manipulation
techniques added!
An ideal handbook for practitioners, instructors, and students of manual therapy, the book's step-by-step guidelines and clear photographic illustrations help readers gain a scientific understanding of and the clinical skill necessary to practice myofascial manipulation.
ABOUT THE AUTHORS Robert I. Cantu, MMSc, PT, MTC, is Group Director and continuing education instructor at Physiotherapy Associates in Atlanta, Georgia. He is also Assistant Professor at the University of St. Augustine for Health Sciences, where he has taught in the area of myofasciaI manipulation for the last 12 years.
AlanJ. Grodin, PT, MTC, co-author, is Regional Director for Physiotherapy Associates in Atlanta, Georgia and is also an instructor at the University of St. Augustine, where he has taught in the area of myofascial manipulation for the last 18 years.
ISBN 0-8342-1779-1
90000
Aspen Publishers, Inc. 200 Orchard Ridge Drive Gaithersburg, MD 20878 www.aspenpublishers.com Copyrighted Material
Myofascial
Manipulation
Theory and Clinical Application
Second Edition Alan J. Grodin, PT, MTC
Robert I. Cantu, MMSc, PT, MTC
Group Director
Regional Director
Physiotherapy Associates
Physiotherapy Associates
Atlanta, Georgia
Atlanta, Georgia
Adjunct Instructor
Adjunct Instructor
University of St. Augustine for
University of St. Augustine for
Health Sciences
Health Sciences
St. Augustine, Florida
St. Augustine, Florida
N
AN ASPEN PUBLICATION® Aspen Publishers, Inc. Gaithersburg, Maryland 2001
Copyrighted Material
To my Ruth for her years
support, expressions
and for helping me
confidence,
it all in
and to my son Samuel zeal for Ii fe, and spnng In my
To my wi
and my children Evan, Seth, for
. support and
of my personal and professional 1
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U!P0.lD U!tJJSU.ltJJS ItJlfJv I1IUV:J "!J VP!JV pUV !tJV.ISj fo MOUltJUl Uj
Table of Contents
Contributors
VII
Preface to Second Edition ....
IX
Preface to First Edition ..........
XI
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XIII
PART (--HISTORICAL DEVELOPMENT AND CURRENT THEORIES OF MYOFASCIAL MANIPULATION ................................... I-Historical Basis for Myofascial Manipulation... .. .... .... . ...........
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Robert I. Cantu Ancient Times
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Modern Times: The Trend toward Mobility and Diagnosis of
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2-Modern Theories and Systems of MyofascialManipulation
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RobertI. Cantu and Alan J Grodin Autonomic Approaches ....
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Mechanical
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Movement
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Conclusion
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PART II-SCIENTIFIC BASIS F OR MYOFASCIAL MANIP ULATION......... .. .
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Chapter 3-Histology and Biomechanics of Myofascia
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Robert l Cantu and Deborah Cobb and Biomechanics of Connective Tissue ........ and Biomechanics of Muscle
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Histology and Biomechanics of Junctional Zones Conclusion
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MYOFASCIAL MANIPULATION
Chapter 4-Histopathology of Myofascia and Physiology of MyofasciaJ Manipulation .........................................
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Deborah Cobb, Robert J. Cantu, and Alan j Grodin 49 58 62 65
Chapter 5-Neuromechanical Aspects of Myofascial Pathology and Manipulation
D. Gable Basic Afferent
of Connective Tissue ...................................
Influence on Movement.. Muscle Tone .........
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Therapeutic Techniques
Application to Conclusion
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Chapter 6-Muscle Pain
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PART HI-EVALUATION AND TRE AT MEN T OF THE M YOFASCIAL SYSTEM ...
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Chapter 7-Basic Evaluation of the Myofascial
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Robert J. Cantu and Alall j Grodin 144 145
Postural and Structural Evaluation Active Movement Analysis
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Examination
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Chapter 8- Atlas
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Techniques
Roberl J. Cantu and Alan j Grodin Techniques for the Lumbar Spine ...
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Techniques for the LumbopelviC/Lower Quarter Area ...............
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for the Thoracic/Upper Thoracic Spine and
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Index.............. . ......................................................
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255
Contributors
Deborah Cobb, MS, PT
C layton D. Gable, PhD, PT
Physical Therapist
Assistant Professor
Physiotherapy Associates
Department of Physical Therapy
Atlanta, Georgia
T he University of Texas Health Science Center
Jan Dommerholt, MPS, PT
San Antonio, Texas
at San Antonio Oil-ector of Rehabilitation Services Pain and Rehabilitation Medicine Bethesda, Maryland Vice President The International Myofascial Pain Academy Schaffhausen, Switzerland
VII
Copyrighted Material
Preface to Second Edition
W hen we published the first edition of iVlyo
material, and to re-tool and revise existing mate
fascial Manipulation in 1992, we were not fully
rial in the previous edition. The chapter on neu
aware of the interest and pent-up demand for this
romechanical aspects of myofascial pathology
materia I. Since 1992, the book has continued to
and manipulation, for example, adds a dimen
sell copies, and this has been a humbling experi
sion of understanding we did not offer before.
ence for us. We believe there are several reasons
Also, the chapter on muscle pain syndromes
for the continued interest in this material.
(i.e., pain of mostly nonmechanical origin) was
First, an underlying philosophy and strategy
completely rewritten due to the explosion of
for the book was to provide good "bread and
research in that area. The chapter on the histo
butter" techniques that were effective on pa
pathology of connective tissue has also been
tients, were relatively easy to learn, and were
completely updated due to advances in research
practical to use in the current arena of managed
over the last 8 years.
care. For the second edition, we have added a
As we mentioned in the first edition, Myo
number of other "bread and butter" techniques,
fascial Manipulation is not designed to be a
being careful not to add any "fluff" to merely
panacea for manual therapy, but a great utility
make the book bigger. W hat are stiII represented
tool to be used in conjunction with joint mobi
in this edition are the myofascial techniques
lization and exercise. In our courses, we often
that the authors have used successfully over the
refer to that triad (soft tissue mobilization, joint
years on a daily basis on literally thousands of
mobilization, and exercise) as the "pinball triad
patients.
of manual therapy." This is because the three
Second, the first edition relied heavily on
aspects of treatment are virtually inseparable
basic science principles. We went to the litera
and totally integrated in the clinic. The sav vy
ture, for example, to explain the mechanisms of
clinician knows how to effectively "bounce off"
injury and repair, and to delineate pain of me
all three aspects of treatment to arrive at the
chanical versus nonmechanical origin. We care
desired, optimal result.
fully extrapolated and integrated these principles
We respectfully submit the second edition of
into the principles of management and treat
Myofascial Manipulation for your consideration
ment of soft tissue dysfunction. For the second
as a tool to help expand the horizons of our
edition, we wanted to strengthen that scientific
profession. Managed care, Medicare cutbacks,
foundation. To that end, we enlisted the help of
market saturation of therapists, and tlllf erosion
gifted professionals and content experts, to add
have put us in a position where it is no longer
IX
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x
MVOFASCIAL MANIPULATION
an option for us to be the very best. Our profes
ahead to expand our individual and collective
sional lives and the health and longevity of our
horizons.
profession in general depend on it. We hope that
Robert /. Cantu
this tool wiiJ be useful in helping us aiJ forge
Alan.J Grodin
Copyrighted Material
Preface to First Edition
In his classic book, Joint Pain, John Mennell
So it is with this book on myofascial manipu
wrote that "no textbook in the field of orthope
lation. For us, it is a combination of acquired
dics can be entirely original." On first reflec
knowledge and clinical experience that, over
tion, this statement seems a bit contradictory,
the years of treating patients, has evolved into a
in light of the fact that Mennell was quite an
particular philosophy or system that is unique.
innovator and one of the early advocates of using
For anyone to say that they were the f irst in
arthrokinematic rules for joint mobilization. On
history to "invent" certain techniques would be
further reflection, however, his ideas and phi
presumptuous. What we attempt to do in this
losophies, while quite innovative, were based on
book is to take the most current body of re
a combination of knowledge and clinical experi
search in myofascia and integrate this cognitive
ence he attained throughout his years as a medi
knowledge with psychomotor skill to produce
cal student and as a physician. The knowledge
a concrete system of evaluation and treatment
and experience he gained over the years were
acceptable to a profession that is striving for
molded and integrated in a way that became
higher professional recognition. This textbook is divided into three parts that
uniquely his own. His system became his "hand writing," or his style.
reflect its major purposes. The f irst part outlines
Handwriting is a good analogy for personal
the evolution of myofascial manipulation, incor
style. A person's handwriting is a totally unique
porating both its history and the latest schools
self-expression. The uniqueness comes from the
of thought. The second part and purpose of this
actual process of learning how to write, from
textbook outlines the scientific basis of myofas
years of practicing that handwriting, and from
cial manipulation. Management of certain clini
the particular function the handwriting serves
cal problems is also discussed. Part III focuses
in the person's life. A physician who has taken
on evaluation and treatment techniques that have
voluminous notes throughout school primarily
repeatedly proved effective in the clinical setting
for his or her own benefit wi II have very differ
and includes an atlas of therapeutic techniques.
ent handwriting from the architect who has to
For the sake of clarity throughout the text,
submit drawings with very legible writing. The
manual therapy is divided into joint manipu
letters formed in the handwriting, as well as the
lation and soft tissue manipulation. As under
spelling, are not unique, but the way the letters
standing of connective tissue has increased, the
are represented by the individual are.
distinction between joint and soft tissue ma
XI
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xii
MVOfASCIAL MANIPULATION
its restrictive
nipulation has become somewhat clouded. Joint manipulation has been defined as "the skilled
with its most superficial
passive movement of a joint." The tissues being
into depth while
to the ioints concerned.
hnHiPVPI· are all histologically c1assi
and in this
Manipulation is not meant to be a
can be considered
panacea or an exhaustive critical review of the but
The distinction made or lack of the less concerned with arthrokinematic rules
that we use every
and exercise. Our hope is that this information will be
are not concerned with individual
into the readers' arsenal of and into their philosophy of treat
ment, so that each clinician's
interrelations of the joints to the soft tissues. For the purposes of this text, we have defined
integrating them with
mobilization, alternate somatic
a majority of the and the
of what we feel
a
about clinically. These are
techniques. Soft tissue manipulation is gener than is joint
and
into account its relation-
or
"handwrit
" will become more distinct as well as more effective.
as: The forceful pas
Robert J. Cantu
sive movement of the musculofascial elements
Alan J. Grodin
Copyrighted Material
Acknowledgments The authors thank the following persons for
The authors also acknowledge all the pro
their assistance in the preparation of this volume:
fessors who adopted the first edition for their
To Trevor Roman for shooting the photos in
courses and curriculums-the long-term success
Chapter 8, and to Debbie Cobb and Brad Fore
of this book is due to your support and votes of
sythe for being the "therapist and patient" in
confidence. Thank you.
Chapter 8.
From the First Edition The authors thank the following people for
MPT, for her help in editing the manuscript,
their invaluabJe assistance in the production of
both from a content and grammatical standpoint;
this book: Karen Barefield, PT, for her draw
and Lisa Richardson, for being the "patient" in
ings in Chapters 6 and 7; Paula Gould for her
Chapters 6 and 7.
photography in Chapters 6 and 7; Carolyn Law,
XIII
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PART I
Historical Development
and Current Theories
of Myofascial Manipulation
Copyrighted Material
CHAPTER 1
Historical Basis for
Myofascial Manipulation
Robert 1. Cantu
Myofascial manipulation is as old as history
The evolution and persistence of manual med
itself-humans have been performing myofas
icine throughout the years have been remark
cial manipulation as long as humans have been
able, especially since the medical communities
touching. Throughout history, many different
often shunned such treatment, and its scientific
systems and supporting theories for the treat
basis has only been heavily researched within
ment of musculoskeletal pain and dysfunction
the last 40 to 50 years. This research has fostered
have come and gone. Today, the originality of
a redefinition of manual medicine and a redefin
any current system of manual medicine is gen
ing of exactly what is being accomplished with
erally found in the underlying philosophy, not
manual therapy.
in the techniques themselves. The underlying
The history of manual medicine can be di
theory and philosophy of any manual therapy
vided into four basic time periods. The first
system will dictate the sequencing of technique,
period, which begins in ancient history and ends
and will attempt to explain both the results and
roughly at the close of the nineteenth century,
the proposed mechanisms of action. The tech
emphasized position. Joint pain, including spinal
niques may be old, but the packaging is new.
pain , was a result of a "luxation or subluxation"
Underlying theories may alter the way the treat
of one or more of the joints. The emphasis in the
ment is performed and may vary and modify the
spine was in restoring the position of the verte
technique. The advent of the scientific age has
bra to relieve pain. In the second time period,
yielded a tremendous wealth of scientific infor
starting with the early twentieth century, the phi
mation , which in turn has changed the theory
losophy and theory of manual medicine began
and philosophy of modern manual medicine.
to emphasize
mobility.
Restoring mobility to
a joint that "was locked" became the focus of
Currently, and throughout history, the scien tific thinking of the day has fashioned the exist
manual medicine. The science of arthrokinemat
ing schools of thought in manual medicine. We
ics developed, and terms such as "accessory
treat based on what we know or think we know.
movements" appeared. This spurred the curios
The purpose of this chapter is to chart briefly the
ity of researchers in the mid and late-twentieth
evolution of manual therapy, with an emphasis
century, who pushed the study of manual med
upon myofascial manipulation. As the different
icine into a third phase-understanding how
preciation of current manual therapy will be
manual therapy affects the biomechanics o/con nective tissue. They viewed the increased mobil
gained.
ity of the joints as a result of mechanical cbanges
historical trends are addressed, a greater ap
3
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4
MYOFASCIAL MANIPULATION
because of the
in connective tissues.
chronicity and recurrence of many the present
have the same name have not the same
of back
effects. For rubbing can bind a joint
of research in manual
which is too loose and loosen a joint
medicine is beginning to concentrate on neural
that is too hard. However, a shoulder
mechanisms of back
and movement reedu
in the condition described should be
cation (see Chapter 5 for discussion of neural
rubbed with soft hands
The science
mechanisms in
above aJl
but the joint should be
of motor learning and control will have much
moved
to offer in this area. The immediate future of
as it can be done without
not violently but so far
manual therapy lies in the combination of pas sive manual therapy
and movement
reeducation or motor
techniques for
prophylaxis. Each of the different time periods is discussed
and their underlying in the following sections.
In the treatment of back pain, H describes treatment of humpback, or alternately translated "kyphosis." Hippocrates is to a kyphosis of the lumbar describes two treatments for this condition conof mechanical traction and extension ex
ANCIENT TIMES
ercises. of manual medicine date
back to the time of year 400 Be. Two relevant "On the Joints,
the patient is f irst
If
_
a steam bath ...then he is placed on
around the
his stomach on a wooden board [for
and "On
..
The physician places the
flat of one of his hands on the ky
by Leverage," describe various combinations of manipulations, massage, and traction on a
phosed portion of the patient's back,
wooden table.I Much of
and his other hand
work in
manual medicine can
be attrib
uted to the popularity of
Oll
the top of the
first.. .. He presses vertically, or in the
in his day.
direction of the head, or in the direc
Entries in early manuscripts include descriptions
tion of the buttocks [Figure I-I]. The .. takes into consideration
of both joint manipulation and massage in treat
whether the reduction should natu
ment of a dislocated shoulder.
rally be made
The next
towards the
still oily from his last in the
He is
This method of repositioning is harm
his
it will do no harm even if
left arm, obviously dislocated at the shoulder; the pain is not
one sits on the hump while extension is
and
applied ...nay there is nothing against
it is the fourth time it has happened,
one's foot on the hump and
anyway. The treatment was routine to him .... The main
succession by bringing
is solved
upon it [Figure J-ll l(p4J
once again; and if the maneuver has failed, the gladiator had
other
The
the pa
ways to go about it,
tient's arm over the chair. .. And it is necessary to rub the shoulder and smoothly. The
must be
of lordosis is common. The idea of "reposition is
experienced in many ed Iy also in rubbing; for
an
theme in the ancient
documented literature on manual medicine.
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Historical Basis/or /vIyo/ascial Manipulation
5
Figure I-I The Hippocratic method of traction and manual pressure as described by Galen. Source: Reprinted with permission from E.H. Schoitz, Manipulation treatment of the spinal column from the medical-historical standpoint, part I, Journal ofthe Norwegian Medical Association (1958;78:359-372), Copyright © 1958, Norske Laegeforening.
Figure 1-2 Method for "repositioning of an outward dislocation" of the spinal column. Source: Reprinted with permission from E.H. Schoitz, Manipulation treatment of the spinal column from the medical-historical standpoint, part I, Journal ofthe Norwegian Medical Association (1958;78:359-372), Copyright © 1958, Norske Lacgcforening.
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6
MYOFASCIAL MANIPULATION
Claudius Galenus, or Galen, a Greek physi
e.g. among vineyard workers.... If the
cian who I ived in the years AD 129-199, con
vertebrae are dislocated and far apart,
tributed much written material on early manual
a good method is to lay the patient
medicine, including 18 commentaries on Hip
on a board, face down, fasten him
pocrates.1 His primary contribution was docu
to it with bands beneath his armpits,
mentation of early neurologic investigations. He
around his trunk and thighs, then pull
recognized seven of the cranial nerves, differen
from top and bottom as hard as pos
tiated between sensory and motor nerves, and
sible, but without violence. If such
was the first to treat paresthesias and extremity
tension cannot be tolerated, no treat
pain by treating the spine. Galen describes one
ment can be applied. Then you may
such incident in which a patient developed par
place your hands on the outcurving
esthesias and loss of sensation in the third to
part and press the projecting vel'te
fifth digits of the hand after falling from a
brae.
wagon. Galen found that the problem was "lo
Again, early evidence exists for traction and
calized in the first spinal nerve below the sev
manipulation into extension, with the fundamen
enth cervical vertebra,"1 and healed the patient
tal theory being repositioning of the vertebra as
by treating the neck. Much of the emphasis in
in the Hippocratic method.
Galen's work again focused on the "reposition ing" of an outward dislocation of the spinal column.
Bone Setters
While the advent of the Middle Ages brought a decline in medical advancement, an Arabic
From the mid-1600s well into the nineteenth
physician named Avicenna wrote a large work
century, the "bone setters" of England flour
around the year AD 1000 summarizing the med
ished. Bone setters, considered "quacks" by tra
ical knowledge of the day. In the work, ref
ditional medical practitioners, had no formal
erences are made to manual medicine, with
training; their art was generally passed on from
descriptions and illustrations similar to the Hip
parents to children, generation after generation.
pocratic method. The Hippocratic method had
Bone setters were known locally, had other
survived, virtually unchanged in technique, well
primary occupations, and usually treated "con
into the Middle Ages. It can be argued that many
amore," that is, without pay.
of the techniques (especially traction and exten sion principles) are still being utilized today.
Bone setters derived their name from their basic philosophy that small bones can move out of place, and healing takes place when the bones are restored to their original positions.
Renaissance
One of the most well known bone setters was
The most well-known contributor to manual medicine in the Renaissance period was the French surgeon Ambroise Pare who lived in the 1500S.I,4 Pare was also instrumental in the de velopment of some of the early orthopedic surgi cal techniques. The positional theory was still strong as evidenced in a chapter entitled "Dislo cated Spinal Vertebrae."
Sarah Mapp, a vagrant peasant woman, who was sought out by commoners and nobility alike (Figure 1-3). The fact that members of the no bility sought after bone setters infuriated the traditional medical community. For many years, the medical community hotly debated the sub ject of bone setting, with some physicians being shunned for speaking in favor of bone setters. This controversy is exemplified by Wharton
The exogenous causes of dislocation
Hood, a medical doctor in the community, who
include falls, hard blows, and pro
learned the practice of bone setting from one of
longed work in a greatly bent position,
his patients whom he had treated for a systemic
Copyrighted Material
Historical Basis for Myofascial Manipulation
professor
7
(1814-1899). In a lecture to his stu
dents and later in an editorial to one of the medi cal journals he wrote: Few of you will enter into practice today without having a so-called bone setter as a competitor. There is little point in presenting a lecture on the injuries which these persons cause; it is more important to consider the fact that their treatment can do some good . . . . Learn then to imitate what is good and avoid what is bad in the practice of bone setters. Fas est ab hoste doceri I (It is advisable to learn from one's
Figure 1-3 The bone setter, Sarah Mapp (Crazy
opponent.)I(p6)
Sally). Source. Reprinted with permission from E.H.
Still another surgeon of the day wrote: "The
Schoitz, Manipulation of the spinal column from the
success of certain bone setters is due-in addi
medical-historical standpoint, part l. Journal of the Norwegian Medical Association (1958;78:359-372),
Copyright © 1958, Norske Laegeforening.
tion to their skill-to the lack of practice and ignorance with which the practicing physician is equipped as concerns injuries to and diseases of the joints." One of the best-known bone setters, Herbert Barker, who practiced from the late 1800s until
illness. Realizing the effectiveness of such treat
1927, vainly attempted to obtain credibility and
ment in his own practice, Hood wrote boldly in
good standing in the medical community by in
the journals of the day in favor of bone setting. I obtained information, which sur geons do not learn, and which, if related to anatomical knowledge, is of the greatest possible value from the prophylactic and therapeutic view points..
It is entirely evident that
quackery, among other things, is an expression of the extent to which the authorized physicians have failed to fulfill their patient's quite reasonable desires or demands. If the physician does not know how to fulfill or pursue these needs, it is his duty to study them, and in no respect can he fulfill his duty merely by criticizing quacks for his failures. lIpS) Another physician of the day who defended
viting physicians to observe his work and otTer ing to perform demonstrations. His work was effective enough to attract members of the Brit ish royal family, actors, and politicians. Despite his successful treatments and his willingness to submit his work to the medical community's scrutiny, he was still shunned by the physicians of the day. Finally, frustrated by the arrogant atti tudes of most physicians, Barker wrote: "Strong as the love of service to suffering is among many doctors as a whole, there exists some things much stronger and less worthy in prej udice and jealousy, which have from the be ginning of time darkened the pages of surgical history, and smirched its record of noble endeav ors."s Eventually, the medical community could no longer argue with the success of bone setters , and in
1925 the Lancet editorially wrote: "The
manual medicine was English surgeon Sir James
medical history of the future will have to record
Paget, who was also a respected medical school
that our profession has greatly neglected this
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8
MVOFASCIAL MANIPULATION
important subject.... The fact must be faced that
icine continued to evolve into a more scientific
the bone setters have been curing multitudes
and realistic philosophy. In 1956, the Register
of cases by movement. ..and that by our faulty
of Osteopaths in England compiled the Osteo
methods, we are largely responsible for their
pathic Blue Book, which stated in part that "os
very existence."6
teopathy is a system of therapeutics which lays chief emphasis upon the diagnosis and treat
Osteopathic Medicine and Chiropractic While controversy was raging over England's
ment of structural and mechanical derangements of the body."8 By imposing these limitations, osteopathic physicians and osteopathic practice
bone setters; a similar course of controversy was
have become more accepted even though the
being charted in America during the 1800s and
theories are still debated. Three areas in osteo
early 1900s. America's first bone setters were
pathic medicine that are currently applicable
practicing by the mid-1800s in Rhode Island and
to myofascial manipulation are muscle energy
Connecticut, and were criticized by skeptics just
techniques, positional release techniques, and
as in England4
strainlcounterstrain techniques9-11
In the mid-1860s, Andrew Taylor Still, who
In 1895,21 years after StiII had founded osteo
had attended but never finished medical school,
pathic medicine, David Daniel Palmer founded
was helping his father cure native Indians and
chiropractic. Some of the cure-all claims of os
"simple folks" in the Mid west, when he lost
teopathic practice were being relinquished and
three of his children to spinal meningitis. Dis
were subsequently taken over by chiropractic.
gusted with the traditional practice of medicine,
Palmer learned his technique through rediscov
he founded the practice of osteopathic medicine
ery of the ancient Hippocratic methods and from
in 1874, probably influenced by the bone set
osteopathic medicine. He did, however, claim to
ters of his time. Taylor maintained that it was
be the founder of a new science.
God who "asked him to fling in the breeze the
But I maintain to have been the first
banner of osteopathy." Being a very religious
who repositioned dislocated vertebrae
man, StiII dedicated his f irst textbook to God:
by using the spinous process and
"Respectfully dedicated to the Grand Architect
the transverse process as levers . ..and
and Builder of the Universe."7 His basic theory
starting from these fundamental facts
was that the human organism had the innate
to have founded a science that is des
strength to combat disease, and as a vital ma
tined to revolutionize the theory and
chine of structure and function, would remain healthy as long as it remained
practice of the healing art7
structurally
normal. If the structure was abnormal, the func tion would be adversely affected8 Still main tained that the causes of all diseases were "dislo caled bones, abnormal, dislocated ligaments or contracted muscles, particularly in the spine, ex ercising a mechanical pressure on the blood ves sels and nerves, a pressure that in part produces ischemia and necrosis, and in part an obstruction of the 'vital juices' through the nerves."7 Thus,
Dr. Charles Still, son of the founder of osteo pathic medicine, maintained that Palmer had acquired his skills from a certain student at the Kirksville Osteopathic School and wrote that: "Chiropractic is the malignant tumor on the body of osteopathy."7 The original premise of chiropractic can be summed up as the "law of the nerve."
the rule of the artery and the rule of structure
I. A vertebra can become subluxaled.
governing function became the cornerstones of
2. A subluxation is apt to affect the struc
osteopathic thought. Unfortunately, the treat
tures that pass through the intervertebral
ment scheme included "cures" for all sorts of
foramen (nerves, blood vessels, and lym
systemic diseases. Fortunately, osteopathic med
phatic vessels).
Copyrighted Material
Historical Basisjor
3. As a result thereof, a disruption of the
function can occur at the
Manipulation
a significant factor in the study and philosophy of manual medicine. This influenced severa]
in the spinal cord with its
further the theory of manual
others to
and autonomic nerves, so that the conduc
medicine. R.K.
tion of nerve
scientists to describe the facet
becomes
4. As a result thereof, the innervations of certain parts of the organism
ab-
so that they become functionor organically sick, or
9
become
to disease.
was one of the first
sible cause of low-back thritic
as a pos He felt that ar
in the facet joints narrowed the
intervertebral foramen and were a possible cause of sciatic
Unfortunately, the condition he untreatable, and the
described was
S. An adjustment (reposition) of a sublux
pothesis was later obscured by the idea of dis
ated vertebra causes the structures pass
cogenic pathology as a cause of low-back pain
the intervertebral foramen
and sciatica.14 Basic science and arthrokinemat
whereby the normal in
ics continued to influence and redefine manual
nervation of the organs is
and in the late 1940s and
so that
become functionally and
Iy
rehabilitated. 7 and manual medicine had been prac
ticed with all apparcnt high The
of success.
during this time span was on re a subluxation for the reduction of and restoration of health. With traditional closer to
Mennell was a
advocate of intimate
mechanics and the use of appropriate mobiliza tion based on those same mechanics. He is be lieved to be the first to coin the term motion" to describe involuntary motions neces for proper movement. He was
the value
the advent of the scientific age
new clinical
and re
Today, the subluxation
search on the
philosophy has been partially replaced with the
fi
Manipulation.16 James
From ancient times to the end of the nine teenth
'"'�'CC"
of the facet in the evaluation and treatment of back and
lack of mobi
joints as
of the facet
a causative factor in back
mobility philosophy in explaining the theories
Mennell's early
of manual medicinc.
tissue dysfunction as a causative factor in back in the development of the
pain is ,MODERN TIMES: THE TREND TOWARD
theoretical basis of soft tissue manipUlation. A Iso in the late 1940s and early 19S0s, James
MOBILITY AND DIAGNOSIS OF
the first edition of his now
Cyriax
PATHOLOGY
classic Textbook In the
physician
In
manual medicine became more common, espe cially in Great Britain, where the been f irst
of periarticular soft
had
debated for many years. One of the
of this
lies in the differ
ential and dysfunctions of the extremities. The work remains of special
to publish
Medicine. 17 The
to this day. Cyriax's work is in the area of
thoritatively on the subject was
manipulation in the recognition, categorization,
father of the late James Cyriax. He is best re
and differential
membered as one of the f irst to
disco
soft tissues. The fact that pain could be caused
the emergence of basic sci
sues, including, but not limited to, periarticular
as a cause of baek
of the body's various
by dysfunction of various or selective soft tis became
connective
Copyrighted Material
i s a foundation of soft tissue
MYOFASCIAL MANIPULATION
10
manipulation today. Cyriax was also the first
3. The healing of a more serious patho
to introduce the concept of "end feel" in the
logical condition in the musculoskeletal
diagnosis of soft tissue lesions. Cyriax sum
system.
marizes his own philosophy as follows. MenneJl also advocated the following con In particular, 1 have tried to steer ma
cepts in operationally defining manual therapy
nipulation away from the lay notion
terminology.
of a panacea-the chief factor delay ing its acceptance today. My only
1. There is a normal anatomical range of
on which the
mechanical play movements in synovial
whole of this work rests, is the method
joints. It is prerequisite to efficient pain
impotiant discovery, of
systematic
examination
of
free movement. This is joint play.
the
moving parts by selective tension. By
2. Loss of joint play results in a mechanical
this means, precise diagnoses can be
pathological condition manifested by im
achieved in disorders of the radio
paired (or lost) function and pain. This is
translucent moving tissues.
joint dysfunction. 3. Mechanical restoration of joint play by
a
The recognition of "radiotranslucent moving
second party is the logical treatment of
tissues" as the cause of pain is a cornerstone
joint dysfunction. This is joint manipula
in the validation of treatment of soft tissue pa
tion.19
thology, even though Cyriax deviated somewhat from his philosophy when evaluating and treat
Thus, by moving joints in selective ways, the
ing the spine. Oddly, his views on low-back pain
connective tissues surrounding the joint are ap
remained strongly and narrowly in the realm of
propriately stretched and normal movement is
discogenic lesions, which is perplexing in light
restored. The extensibility of the surrounding
of the extremely systematic evaluation of the
tissues is what ultimately allows for normal ar
soft tissues advocated in extremity dysfunction.
throkinematics in the joint.
Historically, the shift toward mobility and
Another person responsible for bringing ar
soft tissues in the etiology of back pain is quite
throkinematics into the evaluation and treat
evident by the mid-twentieth century. The trend
ment of joint pain was Norwegian physiothera
continued with James Mennell's son, John, who
pist Freddy Kaltenborn. Influenced by Cyriax,
was another advocate of the mobility philosophy.
his classic text on extremity mobilization was
John Mennell operationally defined the different
the first that consistently and comprehensively
terms, which by this time had become confusing.
used arthrokinematic principles to restore func
In his book, Joint Pain, Mennell argued that the
tion to joints.20 Kaltenborn was the first to ad
principal cause of pain arose from the synovial
vocate heavily the convex/concave rule for joint
joints of the back, and not the disc. IS He argued
mobilization. He defined mobilization as "a
that there was no reason why the synovial joints
component of manual therapy referring to any
of the spine shou Id respond to trauma and/or
procedure that increases mobility of the soft tis
therapeutic measures any differently from any
sues (soft tissue mobilization) and/or the joints (joint mobilization)."2o
other synovial joint of the body. Mennell out
The implication made by Mennell, Cyriax,
lined the etiological factors that give rise to joint pam:
and others is that restoring the mobility of the joint restores normal function, and thereby re
I. Intrinsic joint trauma.
duces pain. A strong proponent of this idea was
2. Immobilization that includes therapeutic immobilization, disuse, and aging.
Stanley Paris, who wrote early on that the treat ment of spinal pain involved treatment of the
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Historical Basisfor Myojascial Manipulation
II
dysfunction, and not of the pain itself. "Dysfunc
grades I-IV (Figure
tion is the cause of pain. Pain follows dysfunc
thought to work by increasing mobility as well
1-4).
The oscilIations are
tion-pain cannot precede dysfunction. Pain
as modulating pain through neurophysiological
does not warn of anything, it states 'something is wrong'."J.21-2J By normalizing mobility and
effects.
function in the spine, the pain would take care of
thinking in manual therapy that, in the J 970s, the
itself. Paris further operationally defined the var
chiropractic profession redefined its philosophy
ious accessory motions of joints in the following
to include movement abnormalities, while re
The mobility theory so began to dominate the
manner: (I) Component motions are those mo
taining its subluxation theory. Several recent
tions occurring in a joint during active motion,
studies have been performed using fluoroscopy
necessary for the motion to take place normally;
to show changes in mobility of spinal facet joints
and (2) joint play motions are those motions not
after a thrust manipulation24 The studies are im
under voluntary control, which occur only in
pressive and validate the effectiveness of manual
response to outside forces21
therapy for increasing mobility.
Paris developed a comprehensive evaluative system that included, in part , the evaluation of passive segmental mobility of the individual
Connective Tissue Research
The next logical step in the evolution of
joints of the spine. He also classified manipula tion into three distinct categories.
manual medicine was the emphasis on the his tology and biomechanics of connective tissue.
I. Distraction: when two articular surfaces
Since restoration of motion is manual therapy's
are separated from one another. Distrac
primary goal, and since all the periarticular tis
tions are used to unweight the joint sur
sues affected during manual therapy are con
faces, to relieve pressure on an intra-ar
nective tissues (soft tissues), understanding the
ticular structure, to stretch ajoint capsule,
biomechanics of connective tissues became par
or to assist in the reduction of a disloca
amount. Substantial research was performed by
tion.
Akeson, Amiel, Woo, and others to determine
2. NonthrllSI articulalion: when the joint is
the biomechanical characteristics of normal and
either oscillated within the limits of an
immobilized connective tissues. The f indings of
accessory motion or taken to the end of
this research are discussed in detail in Chapters
its accessory range and then oscillated or
3 and 4. Advances made in the understanding
stretched. Articulations are used mechan
of connective tissue have helped explain manual
ically to elongate the connective tissues,
therapy's effectiveness, especially myofascial
including adhesions, and neurophysiolog
manipulation. Others such as Kirkaldy-Willis
ically, to fire cutaneous, muscular, and joint receptor mechanisms. 3. Th rust manipulation: when a sudden high
velocity, short amplitude motion is deliv
III
ered at the pathological limit of an acces sory motion. The purpose is either to alter positional relationships, snap an adhe sion, or produce neurophysiological ef fects.21
A
11-
II
-
, 11-
-
'
-
IVB
Figure 1-4 Grades of mobilization with A repre senting beginning movement, and
B representing
end-range movement. Source: Reprinted with permis
Another recent proponent of the mobility
sion from G.D. Maitland, Peripheral Manipulation,
theory is G.D. Maitland of Australia. His treat
Woburn, Massachusetts, Butterworth-Heinemann, ©
ment system includes "graded osci Ilations" of
1981.
Copyrighted Material
12
MYOFASCIAL MANIPULATION
and Falfan have shed light on the degenerative
of recurrent spinal pain, and takes the patient
pathologies in the spine, and have addressed the
an extra step in prevention of recurrence. The
treatment of such conditions as well as some of the limitations of manual therapy.2s-26
idea of exercise for prevention of low-back pain is widely sanctioned, and conventional exercise can be considered movement science in rudi mentary form. Manual technique can correct the
Future Considerations
dysfunction, and movement therapies help pre
Based on the current rate of change, manual therapy will continue to evolve exponentially
vent future recurrence, creating a more complete form of treatment.
into the twenty-first century. A significant addi
In addition, the idea that myofascial manipu
tion to the realm of manual medicine is the idea
lation can produce not only mechanical and au
of movement science. Although manual therapy
tonomic results, but also the modulation of cen
can be effective in managing spinal problems,
tral nervous system mechanisms, is in research
the incidence of recurrent spinal pain still bor
infancy. The idea that myofascial manipulation
ders on epidemic proportions. Integrating alter
can be a form of "sensory-motor education,"
nate somatic therapies such as Feldenkrais and
helping to establish more efficient movement
Alexander and the theories of movement science
patterns will also strongly emerge to comple
with manual techniques makes sense in light
ment motor learning theories.27
REFERENCES I. Schoitz EH. Manipulation treatment of the spinal column !I'om the medical-historical standpoint. Assoc.
.I
10. Jones L. Spontaneous release by positioning. The D.o.
Norweg Med
j 958:78:359-372.
1964:4: 1 09-1 16. II
CO: American Academy of Osteopathy; 1981.
2. Beard G, Wood E. Massage: P rinciples and Technique. Philadelphia: WB Saunders; 1964:3-4.
12. Cyriax E. Collected Papers on Mechano- Therapeutics. London, England: Bale and Danielson; 1924. (Taken
3. Loubcrt PV, Paris SV Foundations ofC/inical Orthope
from bibliography of note 8.)
dics. S1. Augustine, FL: Institute Press; 30-44. 4. Lomax E. Manipulative Therapy: A Historical Perspec
1 3. Ghorl11ley RK. Low back pain with special reference to the articular facets. JA MA. 1933: 101:1773-1777.
tive from Ancient Times to the Modern Era. The Re search Status of Spinal Manipulative Therapy. Bethesda, MD: National Institute of Neurological and Communi
1 4. Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. New Engl Swg
cative Disorders and Stroke: 1975. Monograph 15.
Soc. 1934;2:210-2 15.
5. Hood W. On the so-called bone setting, its nature and re sults. Lancet. 1 8 7 1 :336-338, 441 -443, 499-50 I (Taken
15. Mennell J B. P hysicalTl'eatment by Movel1lent, Mal1l/w lation and A4assage. Boston, MA: Little, Brown
from bibliography of note I.)
I.)
16. Mennell J8. The Science and Art otloint Manipulation. 17. Cyriax J. Textbook of Orthopedic Medicine. Vol
a medical-historical point of view, 11: Osteopathy and chiropractic.
.I Non'l'eg
Co;
London, England: Churchill Ltd: 1949;52:1,11.
7. Schoitz EH. Manipulative treatment of the spine from
8. Schoitz
&
1945.
6. Paget J. Cases that bone setters cure. BMf 1867. (Taken from bibliography of note
Jones L. Strain and Counterstrain. Colorado Springs,
Med Assoc. 1958:78:429-438.
Ef-1. Manipulative treatment of thc column
18. Mennell
from
thc mcdical-historical point of view. III: The last 1 00 years. J Norweg Med Assoc. 1958:78:946-950.
I,
II.
London, England: Bailliere Tindall.
& Co; J 9.
J
McM. Joint Pain. Boston, MA: Little, Brown
1964.
Mennell
J McM.
History o/the Development ofl'vledical
Manipulative Concepts; Medical Terminology. The Re
9. Deig D. Positional Release Techniques. 1 99 1. Course
search Status ofSpinal Manipulative Therapy. Bdhesda,
notes. Krannert Graduate School of Physical Therapy,
MD: National Institute of Neurological and Coml11uni
University of Indianapolis, IN.
cative Disorders and Stroke; 1975. Monograph 15.
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Historical Basis for Myofascia/ Manipulation
20. Kaltenborn F iVlal1ual Thuapyjor ihe EXiremity Joints. Oslo, Norway: Olaf Norlis 130khandel; .1976.
21
Paris SV The Spine-Etiology and Treatmelll of Dys limctioll Including Joint tlfanipulaliol1. 1979. COllrse notes. Institute of Graduate Physical Therapy, St. Au
gustine, FL.
22. Paris SV Mobilization of the spine. Phys Ther. 1979; 59(8)988 995
13
24. Atlanta Craniomandibular Society/Life Chiropractic College Joint Seminar; August. 1987; Atlanta, GA.
25. Farfan HE Mechanical Disorders oJthe Low [Jack. Phil
adelphia: Lea
& Febigcr; 1973.
26. Kirkaldy-Willis WH. Managing Low Back Pain. New York: Churchill Livingstone; 1988.
27. Juhan D. Job s Body. A /Jalldbook/or Bodywork Bar rytown, NY: Station Hill Press; 1987.
23. Paris SV Spinal manipulative the rapy. Ciin Orllwp. 1983; 179:5561.
Copyrighted Material
CHAPTER 2
Modern Theories and Systems of
Myofascial Manipulation
Robert 1. Cantu and Alan J Grodin
This chapter provides an overview of some of
three areas, along with some application tech nique from each approach.
the alternate somatic therapies considered myo fascial in nature. Its purpose is neither to give the reader a comprehensive background of each
AUTONOMIC APPROACHES
individual system, nor to include every system currently being practiced-such an undertaking
The autonomic or reflexive approaches at
is a book in itself. The systems reviewed repre
tempt to exert their effect through the skin and
sent th.ose that have influenced the authors the
superficial connective tissues.1,2 MacKenzie de
most over the years, and have contributed to the
f ined the autonomic or reflexive component as
development of the authors' personal treatment
"that vital process which is concerned in the
philosophies. The manual therapist interested
reception of a stimulus by one organ or tissue
in myofascial manipulation should also have a
and its conduction to another organ,
basic working knowledge of the fundamental
on receiving a stimulus produces the effect."3
which
philosophies behind various systems and theo
Soft tissue mobilization performed for auto
ries in order to become a more educated con
nomic effect stimulates sensory receptors in the
sumer in the continuing education market, and
skin and superficial fascia. These stimuli pass
to understand the orientation of the respective
through afferent pathways to the spinal cord and
practitioners.
may be channeled through autonomic path ways,
Modern theories and systems are arranged
producing effects in areas corresponding to der matomal zones being mobilized.4
in three categories: autonomic or reflexive ap proaches, mechanical approaches, and move
The idea of affecting various body areas by
ment approaches. Autonomic approaches are
stimulating the skin and supelficial connective
those that exert their therapeutic effect on the
tissue has been used in areas apart from soft
Mechanical ap
tissue mobilization. For example, part of the
proaches are those that actually attempt me
theory of transcutaneous electrical nerve stim
chanical changes in the myofascia by direct ap
ulation (TENS) is direct stimulation of large
autonomic ner vous system.
plication of force, and movement approaches
myelinated ner ve fibers that override noxious
are those that attempt to change aberrant move
stimuli traveling to higher centers of the central
ment patterns and establish more optimal ones.
nervous system. So, TENS has application not
Ideally, the manual therapist should have a basic
only for pain control, but also for control of
working knowledge of theories or systems in all
post-surgical nausea or menstrual cramping.
15
Copyrighted Material
16
MYOFASCIAL MANIPULATION
Affecting the autonomic system is an tant
to more
cal
warm flushes and increased sensation. She then
mechani
especially in acute patients. In sub
began
the
itself and found areas,
other
the
Iy
acute patients, autonomic techniques are most
border of the greater trochanter and the ilio
often used at the beginning and at the end of
tibial tract. She very
entry and exit from me
and
stroked these areas, and improvement continued.
The effects of autonomic
Within 3 months her symptoms had subsided,
technique should not be overemohasized, how
and shortly thereafter, she was able to resume
ever, Some
her full duties as a physiotherapist
chanical
nomic phenomenon to
Out of her
treatment of dis
orders unrelated to the neuromusculoskeletal
she gradually con
structed a
treatment method, From
system, A Ithough the autonomic etTect cannot
this pursuit, she also
be denied,
of
should be exercised by the the extent of autonomic
clinician in treatment.
a treatment the realm of
pain, which is
this book, The effects Dicke outlined that are pertinent to modern manual
are as fol
lows,
Connective Tissue
1, CTM can directly influcnce connective
(Bindegwebbsmassage)
tissue that is locally altered by scars, local blood sUDDlv, and other
Connective tissue massage in the 1920s
disturbances.
German
Elizabeth Dickel and later expanded by Maria The system was
2. CTM can set general circulation in order. Subcutaneous connective tissue is ex
and
tremely
in rudimentary form in the late
into
1920s when Dicke was suffering from a pro of tile
vascularized and
can
absorb
varied quantities of blood as a result of constriction or dilation,
3. CTM can also release nerve impulses paths by means of reflexes that are locked into the central nervous system. It can create reactions in
The attending physicians prescribed a
distant organs. Dicke refers to certain as-
period of bed
of this phenomenon as the "cutivis
rest. If the bed rest was unsuccessful in dimin ishing the
ceral reflex,"1 Dicke uses the example of
amputation would have
the
been considered as a last resort. Dicke was in bed for a 5-month
ously, the intestine would not be affected
understandably
from the surface of the skin and the reac
pain. As she began to palpate her own back, she tenderness,
found
tion must be "a reflex
and
She found relief by
She
are the
and dermis,"1 Over time
diminished, but more impor
tissues for the
of outside tactile stimuli.
and superficially
the area with her tant, notable
are highly innervated and
and opposite it, an
increased tension of the
The CTM system is very
and pro
tocol-oriented if performed as Dicke taught. for example, is
occurred in the lower ex
Each
felt itching, followed
times, with the right side
Copyrighted Material
2-1),1
The skin and subcutaneous
and sacrum, She stated that she felt "a thickened inf iltrated area of
affects the
intestines from the skin"
in the area of the iliac crest
palpatory
the low-back
of a mother's warm hand
to alleviate a child's stomachache , Obvi
three f irst. Most
Modern Theories and Systems of Myofascia I Manipulation
./
J7
Anterior Root
. Myotome
Dermatome
Pancreas (EnterotomeF
Figure 2-1 An example of the cutivisceral reflex as described by Dicke. Source: Reprinted from Segmenla/e Innervation by K. Hansen and H. Schliack with permission of Georg Thieme Verlag, © 1962.
strokes are performed with the middle f inger of
and the low back and sacral areas are always
the hand, with the other hand always in light con
treated first. Treatment is never administered
tact with the patient. Lubrication is never used,
without first treating the basic section of the
Copyrighted Material
J8
MVOFASCIAL MAN1PULATtON
low
sacrum, and coccyx, with a "build up"
to the affected area. What must be remembered about CTM and about all other "systems" is that Astute clinicians can
they are merely
of the
elements.
The clinician thus allows the body to open itself to treatment, which becomes less forceful with less
for tissue microtrauma and exac
while
and should modify these their
and
does not need
to recovery.
CTM exerts its effect
the skin and sub
appropriately.
cutaneous connective tissue. This makes CTM form of myofascial ma
primarily a
Hoffa
nipulation (in terms Albert Hoffa's text, published in 1900 and later
that provides much-needed "lighter" end of the manual technique spectrum.
revised by Max Bollm in 1913,
Manual therapists often move too quickly into
classical massage techniques such as
instead o f
moderate o r CTM offers when
tapotement, and vibration. therapists learn these as standard massage tech
the myofascial system.
gradually
other therapeutic
niques in entry-level programs, but
properly into the overall treat
sti II be
ment scheme. In a patient who is autonomically CTM that can
the type of tech-
their
in the overall treatment scheme.
Some may
an RSD
this type of massage, re-
it as too basic to include in the realm
the system. Such an acute
patient can be described as
should
and discussed because of
of advanced manual
but
behind
(reflex sympathetic dystrophy) type back. Often
traditional myofascial manipulation
seen in the hands and
can handicap even the most advanced manual
RSD is a hyperactivity
nervous system that creates
of the
cold
chronic intense pain and
therapists. A technique is not necessarily more effective just because it is more Some may consider these
cold sweat in the area, nausea w ith attempted palpation, and eventually trophic including
skin and bone and hair
loss. A patient with an
be
and
may exhibit
to
feel to the back with
cal, but may lean toward one more than the other.
palpa
Hoffa massage
allows the
also
to grow accustomed to the cl i
nician '8 hands in a very
and 'light-handed' so that the as little
feels
as possible."5 Hoffa advocates that
massage should never last more than 15 minutes, even for the whole As w ith connective tissue massage, HotTa's emphasizes
further promoting relaxation and
autonomic or reflex
myofascial restrictions
ive technique as an entry way for other, more
CTM technique provides a good entry into
mechanical technique. With Hoffa massage or
In cases where
the deeper tissues. If the clinician the
inclines toward the re
t1exive. Hoffa states that "the force should be
choice
of technique, since it primarily affects the au tonomic nervous system. CTM
mechani
rellexive nor
a cold
tion or treatment, and a nausea response. The of CTM makes it a
which cat
myofascial manipulation systems are neither
The patient
most of the
to be
them as reflexive or autonomic.
back may dis
play some of these symptoms, although without
to be
more mechanical in nature, but the strokes can
of the deep
the niques
may
and more spe
the
of myofascia too rapidly, reflex
is prepared for tech to promote histological can be
treatment more difficult. Moving from superfi
in the myofascial tissues. The
cial to deep treatment facilitates the
made without forceful maneuvers that can create
Copyrighted Material
Modern T heories and Systems of Myofascial Manipulation
19
microtrauma or exacerbate painful conditions.
Hoffa was one of the first clinicians to de
Some of Hoffa's basic massage strokes are de
scribe massage in an actual textbook.The fun damental strokes of traditional massage are still
scribed as follows. Li ght and deep elJleurage. The hand is applied as closely as possible to the part. It glides on it, distally to proxi mally.... With the broad part of the hand, use the ball of the thumb and
performed widely today, although many varia tions have been introduced. Hoffa's massage is considered basic by modern standards, but advanced manual therapists continue to use his techniques in their treatment schemes.
little fingers to stroke out the muscle masses, and at the same time, slide along at the edge of the muscle with f inger tips to take care of all larger vessels: stroke upward.
MECHANICAL APPROACHES Mechanical approaches differ from autonomic approaches in that they seek to make mechani cal, or histological, changes in the myofascial
One-hand petrissage. Place the hand
structures. The stretching of a hamstring, the
around the part so that the muscle
elongation of a superficial fascial plane, or su
masses are caught between the fingers
perficial tissue rolling to mobilize adhesions are
and thumb as in a pair of tongs. By
all mechanical techniques.As previously stated,
lifting the muscle mass from the bone
mechanical techniques should generally be per
"squeeze it out," progressing centrip
formed after some form of autonomic technique. Even if the patient is not suffering acute pain,
etally. Two-hand
petrissa ge.
Apply
both
hands obliquely to the direction of the muscle fibers. The thumbs are op posed to the rest of the fingers. This manipulation starts peripherally and proceeds centripetally, following the direction of the muscle fibers. The hand that goes first tries to pick the muscle from the bone, moving back and forth in a zigzag path. The hand that follows proceeds likewise, "grip ping back and forth." ...On flat sur faces where this petrissage is not pos sible, . . . stroke using a flat hand, instead of picking up the muscle. Tapotement. Both hands are held ver
a few minutes of autonomic technique facilitate the application of mechanical technique. The application of mechanical technique is not nec essarily aggressive; it is a matter of properly going through the "layers" unti I the deeper tis sues are accessed. That is not to say that aggres sive, forceful mechanical technique is an inferior form of treatment; at times, forceful technique is necessary to free up longstanding restrictions. The gentle, however, should always be attempted f irst. Remember that the systems described as fol lows are just that: systems-they can be very protocol-oriented, and very ordered. Principles may be borrowed from any system, however, and may be effective if used at the proper time and in the proper sequence.
tically above the part to be treated in a position that is midway between pro nation and supination.Bringing them
Rolfing® (Structural Integration)*
into supination, the abducted fingers
Structural integration, a system created by
are hit against the body with not too
Ida Rolf, is used to correct inefficient posture
much force and with great speed and elasticity.Fingers and wrists remain as stiff as possible but the shoulder joint comes into play all the more actively.4
*Rolfing® is a registered service mark of the Rolf Institute of Structural Integration.
Copyrighted Material
MYOFASCIAL MANIPULATION
20
or to integrate structure.The technique involves manual soft tissue manipulation with the goal
5. Rectus abdominis/psoas-for pelvic bal ance
of balancing the body in the gravitational field
6. Sacrum-weight transfer from head to feet
(Figure 2-2). Rolfing is a standardized, non
7. Relationship of head to rest of body-pri
symptomatic approach to soft tissue manipula
marily occiput/atlas (OA) relationship,
tion, administered independent of specific pa
then to rest of body
8,9. Upper and lower half of body relation
thologies. The technique involves 10 one-hour sessions, each emphasizing a particular aspect of pos
ship 10. Balance throughout systemS
ture, with all the work performed in the myofas ciaI tissues. Two or three advanced sessions can be performed, as well as subsequent occasional "tune-up" sessions. The treatment principle says that "if tissue is restrained, and balanced move ment demanded at a nearby joint, tissue and joint will relocate in a more appropriate equilibrium" (Figure 2-3).7
Rolfing also strives to integrate the structural with the psychological: The technique of Structural Integra tion deals primarily with the physical man; in practice, considerations of the physical are inseparable from con siderations of the psychological. ... Emotional response is behavior, is
I. Respiration 2. Balance under the body (feet/legs) 3. Lateral line-front to back (sagittal plane balance) 4. Base of body/midline (balance left to right)
function. All behavior is expressed through the musculoskeletal system. ... A man's emotional state may be seen as the projection of his structural imbalances. The easiest, quickest and most economical method of changing
© 1958 Ida P. Rolf
1
Figure 2-2 The concept of balancing posture in a gravitational field, with the body consisting of various blocks.
Source:
Reprinted from
Rolflng: The Integration a/Human Structures
Rolf Institute of Structural Integration. © 1977.
Copyrighted Material
(p 33) by 1. Rolf with permission of the
Modern Theories and Systems o/Myofascial Manipulation
21
Tragering is a mechanical soft tissue and neu rophysiological reeducation approach developed graduaJly over the last 50 years by Milton Trager, MD. The approach has no rigid procedures or protocols like some other systems. It uses the nervous system to make changes, rather than making mechanical changes in the connective tissues themselves. The Trager practitioner "uses the hands to communicate a quality of feeling to the nervous system, and this feeling then elicits tissue response within the client."9 Trager began developing his system in his late teens, while training as a boxer. He subsequently left boxing to protect his hands and to pursue the develop ment of his system. Eight years later, Trager undertook formal medical training, earning his medical doctorate at the University Autonoma de Guadalajara in Mexico. He opened his private practice in 1959 in Waikiki and, in the early 1970s, began teaching his system on an indi vidual basis in California. The Trager Institute was formed and there are currently 600 Trager practitioners throughout the world. Tragering is directed toward the unconscious mind of the patient: "for every physical non yielding condition there is a psychic counter Figure 2-3 The fascial sweater concept showing that a fascial restriction In one area will strain areas away from the restriction and cause abnormal movement patterns. Source.' Reprinted from Rolfing:
part in the unconscioLls mind, and exactly to the degree of the physical manifestation."lo The system uses gentle passive motions that empha size mobilization techniques, concentrating on
gralion oj Human Structures (p 33) by I. Rolf with
traction and rotation, and a system of active
permission of the Rolf Institute of Structural Integra
movements termed Mentastics(") The intensity of
tion. © 1977.
the movements is in the moderate or midrange, with integration of cervical and lumbar traction. The osci Ilations and rocking techniques serve
the coarse matter of the physical body is by direct intervention in the body. Change in the coarser medium alters the less palpable emotional person and his projections7 Rolfing suggests that a person's psychologi
as relaxation techniques that encourage the pa tient gradually to relinquish control. Finally, the active movement part of the treatment serves as a neuromuscular reeducation technique simi lar in principle to Feldenkrais' work. The idea is to alter the patient's neurophysiological set and give the patient the tools to maintain the
cal components are manifested in structure, and that changing the structure can change the psy chological component.
*Trager® is a registered service mark of the Trager Institute.
Copyrighted Material
22
MYOFASCIAL MANIPULATION
II
that ill each human
The
make mechanical to alter the neuromuscular set to
but is
coordination and
establish more normal movement patterns.
I discovered that a certain use of the
head in relation to the neck, and of the MOVEMENT APPROACHES The movement
head and neck in relation to the torso and other parts of the
differ from the
constituted a primary control of the
others in that the patient actively participates
mechanisms
in therapy. Both autonomic and mechanical ap rely on the clinician to impart the
a series of movements to
whole .
.
.
and that
ment of the primary control of my
and movement. In the movement ap
associated
manner, this was
through
proaches, the clinician guides the
as a
when I interfered with the employ
of the standard of my
aberrant
functioning. I)
terns and retrain into more efficient movements
Position and motion of the head and neck
and postures.
the cornerstones of the Alexander The student of Alexander learns to
Alexander
activate this primary locus of control in the head
F. Matthias Alexander was a
and
a consistent problem in
of head and neck posture in relation to voice and from that
it functioning during: activi
The instructor's approach is usually to
studying the relationship
his voice. He
and
ties of daily living.
orator at the turn of the twentieth
a
the student palpatory as well as verbal feedback and movement
as he or she learns new
patterns. As the student masters new and verbal feedback is
of movement that can teach the entire body to
less
become 1110re
the student can independently achieve proper
regardless of the activity. are improvements in
The technique
and body mechanics. Many vocal-
both
Alexander was very experiential
and deliberate in his approach, like music teachers who suggest that their stu
musicians, and other to
the Alexander
control
dents oractice slow Iv. patterns are best learned
Since Alexander's recurrent prolonged
reinforcement.
system of mirrors through which he could ob in his
serve himself
der goes through three the habit;
his
where the participant
sions, he was ahle to hold his head and neck
tries to
111
new ones.
more efficient posture, and with time, his improved and his
subsided. As time
inhibition of the habit; and
con
what Alexander termed "conscious learning,"
his mouth. After repeated practice ses
voice
Alexan (I) awareness of
scious control of the habit. These three stages are
torical voice. He observed a his head back,
the
of rest, he set up a
and actively
old habits while incorporating
Awareness of the habit carries great impor
Alexander noticed
tance in the Alexander
"You are not
was not an
here to do exercises, or to learn to do something
isolated movement, but was coordinated with
right, but to be able to meet a stimulus that
that the "dysfunctional" head other dvsfunctional patterns
you wrong and learn to deal with it."12 For Alexander, his public the dysfunctional oatterns. He found he
Copyrighted Material
Modern Theories and Systems of Myofascial Manipulation
23
had difficulty even recognizing the patterns that
autonomic and mechanical approaches in help
were so detrimental to his voice projection, He
ing myofascially dysfunctional patients achieve
hypothesized that the brain no longer identified
desired changes.
the aberrant patterns of movement as dysfunc tional, but as normal. Simply looking in the
Feldenkrais
mirror to correct an aberrant postural or move ment dysfunction was insufficient to change the
The Feldenkrais movement approach seeks to
pattern, Developing an awareness of the pattern
retrain the body away from aberrant movement
was the first step,
patterns into more efficient ones, Moshe Felden
Once the dysfunctional pattern was recog
krais was a versatile Israeli engineer and physi
nized, inhibition of the movement was neces
cist who was also athletically active, Feldenkrais
sary, but again, being aware of the pattern was
participated in soccer and judo, but a persistent
not enough to change it, since the habit was
knee injury resulting from soccer play led his
too well established, He began to speak while
engineering mind to explore human movement.
consciously trying to "turn off " the dysfunc
His movement approach is based on the idea that
tional pattern. He then used conscious control to
movement abnormalities occur in response to
"inhibit" the dysfunctional pattern and integrate
past trauma, rendering one more susceptible to
the new one,
reinjury, His approach is designed to help the
Some of these principles are integrated into sequencing of overall treatment. If a patient ex
body reprogram the brain to integrate the whole mind-body entity.
hibits poor posture resulting from myofascial
Feldenkrais has two basic approaches, which
restrictions and movement imbalances, mechan
he separates only for convenience. The first is
ical approaches are used to free up the restric
an experiential approach that he terms "Aware
tions, allowing the patient to assume optimal
ness Through Movement,"J4 in which the patient
posture without undue effort, If new posture is
receives a series of verbal commands designed
emphasized too early in the treatment sequence,
to weaken old movement patterns and to estab
the patient often may not have the body aware
lish new ones. The second is a hands-on ap
ness or the ability to assume it. The new posture,
proach that he terms "Functional Integration,"15
then, can increase the patient's original pain,
Feldenkrais disliked separating the two, espe
and establish a negative reinforcement loop, If
cially if:
the clinician addresses mechanical restrictions and emphasizes body awareness, the patient be
". the distinction is made that one is
comes aware of the problem, is able to inhibit
for "sick" or "brain damaged" people,
the old pattern, and consciously work toward
and the other is for "normal, healthy"
establishing the new pattern, with more efficient
people, Which of us, after all, is not
effort.
brain damaged in the sense that we
Alexander's concepts have been used and ex
allow many areas of our brains to at
panded by Mariano Rocobado, Steve Kraus, and
rophy through misuse or nonuse? We
others in working with head and neck posture
can have terrible posture and move
in relation to mandibular position, As is widely
ment patterns and habits which are
known, head and neck posture and movement
distorting and damaging to our bodies
affect mandibular position and function; the Al
and brains-and still be classified as
exander technique aptly appl ies to the evalua
"normal." Who are we, then to call
tion and treatment of temporomandibular joint
other people brain damaged simply
(TMJ) disorders. Whether used for treatment
because their particular
of TMJ, neck, or other spinal dysfunctions, the
produces visible effects that we label
Alexander technique merges logically with the
"disease?"16
Copyrighted Material
deficiency
24
MYOFASCIAL MANIPULATION
The idea that aJ I persons exhibit some ab
Josophy and scheme of treatment. As will be seen
normal movement either from previous trauma
in later chapters, the sequencing of treatment
or old habit patterns is a cornerstone of the
includes beginning superficially with a manual
Feldenkrais method. As with Alexander tech
approach, and working gradually into deeper
nique, gentle sequences of movement allow for
tissues. Once the deeper tissues are accessed
slow, deliberate changing of abnormal, inef
and affected, elongation of the structures be
f icient movement patterns into normal efficient
comes facilitated. When optimal length and mo
movements.
bility are established, neuromuscular reeduca
CONCLUSION
as postural integration. The progression from
tion is emphasized to prevent recurrence, as well a light manual approach (autonomic) to a deep Examples of the three types of approaches
manual approach (mechanical), and then to an
(autonomic, mechanical, and movement) de
emphasis in movement and posture (movement
scribed here merge well with the authors' phi-
approach) is the key to complete treatment.
REFERENCES Dicke E, Schliaek I-I, Wolff A.
A Manual of Reflexive
S Simon Publishers; 1978. FL: Robert E Kreiger Publishing Co, Inc; 1985.
J. Angina Pee/oris. London: Henry Frowde
and Hodder and Stroughton; 1923:47. 4. Tappan EM. Healing Massage Technique.' lishing Co; 1978: 17-22.
its P rinciples and Technique. Phila
delphia: WB Saunders; 1913.
E. The Alexander tcchnique--what it is and
how it works. Medical Problems of Pelforming Ar/ists. 13. Alexander FM. The Universal Constam in Living. New
IP. Roljing: The In/egration of Human Structures. P. Myof{lscial Reorganization. Course notes.
1988. The Gordon Group, Brookline, MA.
Copyrighted Material
Awareness through Movemen/. New & Row; 1972.
14. Feldenkrais M. York: Harper
Rochester, V T: Healing Arts Press; 1977. 8. Gordon
12. Rosenthal
York: Dutton; 1941:10.
many: Ferdinand Enke; 1900.
7. Rolf
P Trager psychophysical integration: a n additional
tool in the treatment of chronic spinal pain and dysfunc
June 1987:53-57.
del' Massage. 14th cd. Stuttgart, Ger
6. Bohm M. Mass age :
tastics. The Trager Journal. Fall 1982 5 . II. Witt
tion. Whirlpool. Summer 1986.
A Study of
EaSlern (lnd Western Methods. Reston, VA: Reston Pub 5. Hoffa AJ. Technik
I
10. Trager M. Trager psychophysical integration and rnen
2. Ebner M. Connective Tissue Manipula/ions. Malabar, 3. MacKenzie
9. Juhan D. The Trager approach-psychophysical integra tion and mentastics. The Trager Journal. Fall 1987:
Therapy of/he Connec/iveTisslIe.
15. Rywerant Y. The Feldel/lentis Method: Teaching by Han dling. San Francisco: Harper
& Row; 1983.
16. Rosenfeld A. Teaching the body how to program the brain is Moshe's 'miracle'. Smilhsol1ian. January 1981.
PART II
Scientific Basis for
Myofascial Manipulation
25
Copyrighted Material
CHAPTER 3
Histology and Biomechanics of Myofascia Robert 1. Cantu and Deborah Cobb
The foundations of orthopedic physical ther
microorganisms and contribute to repair after
apy are based upon the understanding of the
injury.J The importance of these roles to the
anatomy and biomechanics of the soft tissues.
manual therapist wi 11 be discussed later.
A manual physical therapist must have in-depth
Most of the structures affected by manipula
knowledge of the microscopic and macroscopic
tion and mobilization are connective tissues.
structure of the myofascial tissue-connective
When mobilizing a facet joint, for example, the
tissue, muscle, and junctional zones. This is es
tissue affected by the mobilization technique is
sential because the myofascial/connective tissues
the joint capsule, the surrounding periarticular
are those primarily affected by manual therapy
connective tissue, nearby ligaments, and fascia.
treatments. Thorough knowledge of myofascial
The joint is simply a space built for motion, but
tissue histology and biomechanics will aid the
it is the surrounding connective tissues that are
physical therapist in comprehending and assess
affected by the mobilization.
ing the implications of trauma, immobilization,
An appropriate understanding of normal his tology and biomechanics of the connective tis
and remobilization of myofascial tissues.
sues can be found in a review of the scientific I iterature. Although much of the benchmark
HlSTOLOGY AND BIOMECHANlCS OF
research is from earlier in the century, it re
CONNECTlVE TlSSUE
mains accurate and consistent with the more
Connective tissue comprises 16 percent of a
current research. This information will begin to
person's total body weight and stores 23 percent
lay the groundwork for an understanding of how
of the body's total water content. I Connective
trauma, immobilization, and remobilization will
tissue forms the base of the skin, the muscle
affect the connective tissues.
sheaths, nerve sheaths, tendons, ligaments, joint capsules, periosteum, aponeuroses, blood vessel
Histology
walls, and the bed and framework of the inter nal organs.I.2 Also, from a histological stand
The four basic types of tissue found in the
point, bone adipose and cartilage are considered
human body are muscle, nerve, epithelium, and
connective tissues. The most important roles
connective tissue2 Connective tissue is subclas
of connective tissue are (I) structural, due to
sified into connective tissue proper, cartilage,
the mechanica I properties; and (2) defensive/
and bone. Connective tissue proper is further
reconstructive, in that they aid against invading
subclassified by orientation and density of fiber
27
Copyrighted Material
MYOfASCIAL MANIPULATION
28
types.4 The three basic connective tissue types
and mobile wandering cells consisting of mac
are dense regular, dense irregular, and loose
rophages, lymphocytes, plasma cells, eosino
irregular (Figure 3-1)4 These tissue types are
philic leukocytes, and mast cells5 Fibroblasts
described in detai I later in this chapter.
are found in all connective tissues, whereas the
The Cells of Connective Tissue
states.
other cells are found primarily in pathological
Connective tissue is comprised of cells and extracellular matrix (fibers and ground sub
Fibroblasts. Fibroblasts, considered the true
stance; Table 3-1). These cells can be divided
connective tissue cells, are found in the highest
up into a f ixed cell population of fibroblasts,
cell numbers. These cells are the primary secre
adipocytes, persistent mesenchymal stem cells,
tory cells in connective tissue and are respon-
Collagen
Nerve
Adipose cells
Elastin
Macrophage
Pericyte, Capillary
Ground Eosinophil Figure
Lym phocyte
Cell
3-1 A diagrammatic representation of loose connective tissue, showing fibers, cells, ground substance,
nerve, and blood vessels. Source: Reprinted from Gray:, Anatomy, ed 35 (p 32) by P. Williams and R. Warwick
with permission ofW.B. Saunders, CC; 1973.
Copyrighted Material
Histology and Biomechanics of Myojascia
29
Table 3-1 Histological Makeup of Connective
sible for the synthesis of all components of con
Tissue
nective tissue, including collagen, elastin, and ground substance. Fibroblasts are adherent to the
I.
fibers, which they lay down. [n highly cellular
Cells A. Fibroblasts: synthesize collagen, elastin, reticulin, and ground substance.
B. Fibrocytes; mature version of fibroblast, found in stable mature connective tissue. C. Macrophages and histiocytes: "big eaters" found in traumatic, inflammatory, or
tissues, fibroblasts may mix with collagen fibers to become reticular cells.] In mature stable con nective tissue, the fibroblast is converted into the fibrocyte, which is the nonsecretory version of the fibroblast. Fibroblasts and fibroblastic activ ity are influenced by various factors, including
infectious conditions. Clean and debride
prevalent mechanical stresses, steroid hormone,
area of waste and foreign products.
and dietary content. Fibroblasts are nonphago
D. Mast cells: secrete histamine (vaSOdilator) and heparin (anticoagulant). E. Plasma cells: produce antibodies; present only in infectious conditions.
II. Extracellular Matrix A. Fibers
1. Collagen: very tensile a. type I: connective tissue proper (loose and dense) b. type II: hyaline cartilage c.
type III: fetal dermis, lining of arteries
d. type IV: basement membranes
2. Elastin: more elastic, found in lining of arteries. Also ligamentum flavum and ligamentum nuchae.
3. Reticulin: delicate meshwork for support of internal organs and glands.
B. Ground substance: viscous gel with high water concentration. Provides medium in
cytic. Macrophages. Other types of cells, not ex
clusive to connective tissue, are found primarily in traumatized or infectious states. Macrophages (which means "big eater") are responsible for phagocytosing waste products, damaged tissue, and foreign matter. I n traumatized states, mac rophages primarily phagocytose damaged cells and damaged macromolecular connective tissue fibers, debriding the area in preparation for repair.
In infectious or inflammatory states,
macrophages are capable of phagocytosing bac teria or other invading microorganisms.] Macro phages may be the signal for vascular regenera tion to begin. Mast cells. Mast cells were given their name
because they appeared "stuffed with granules"
which collagen and cells lie.
(mast is German for well-fed). They are mobile
1. Purpose
and are important defensive cells, which are
a. diffusion of nutrients and waste products b. mechanical barrier against bacteria c. maintains critical interfiber distance, preventing microadhesions d. provides lubrication between collagen fibers e. more abundant in early life; decreases with age
2. Components a. glycosaminoglycans (GaGs):
b.
formed primarily in loose connective tissue. Mast cells are responsible for constantly secret ing small amounts of the anticoagulant heparin. Heparin is constantly secreted in small amounts in the blood stream by the mast cells. The sig nificance of this is still not known5 The disrup tion of mast cells also results in the release of histamine. Within the mast cell granules, his tamine is bound to heparin. Histamine causes vasodilation in neighboring noninjured vessels, resulting in increased permeability. The release
lubricating effect, maintenance of
of histamine is linked to inflammatory reactions,
critical interfiber distance, etc
allergies, and hypersensitivitiesl5 -
proteoglycans: primarily bind water
Mast cells can be hypersensitized by certain antigens introduced into the body, facilitating
Copyrighted Material
30
MYOFASCIAL MANIPULATION
cell production of histamine2 This could be one
sues related to f irst-line defense of the body
possibility why individuals with numerous al
against invading microorganisms and foreign
lergies and with diffuse myofascial pain can
pat·ticles.3 Aside from connective tissue, the cells
have an increased histamine response to soft
of the reticuloendothelial system are found in
tissue manipulation. This concept is discussed
the blood, and the reticular tissue of the spleen,
again later in the chapter on myofascial pain
liver, and the meninges. The body's connective
syndromes. Plasma cells are somewhat related
tissue framework is an integral part of the reticll
to mast cells in that they are primarily present in
loendothelial system because of the mechanical
infectious states. They are related to the immune
barrier that connective tissue provides against
system and are responsible for synthesizing an
invading microorganisms.
tibodies.
The Extracellular Matrix
Other connective tissue cells. With the ex
The extracellular matrix of connective tissue
ception of the fibroblast and fibrocyte, al I other
comprises all other components of connective
cells found in connective tissue are also related
tissue except cells (Table 3-1; Figure 3-2).
to the reticuloendothelial system. This widely
The matrix is primarily composed of fibers and
scattered system consists of phagocytic and im
ground substance. The f iber types consist of col
munologic cells and associated organs and tis
lagen, elastin, and reticulin. Collagen, the most
Figure 3-2 Photomicrograph of loose connective tissue. The connective tissue fibers lie ill a bed of ground substance. Source: Reprinted from Hislology (p 212) by A.W. Ham and D.H. Cormack with permission of J.8. Lippincott Co, © 1979.
Copyrighted Material
and Biomechanics of
commonly found
is very
whereas
elastin and reticulin are more elastic. It is
which provides some of the tissue maintain the distance
volume, can
of the inert extracellular
marily the
3]
between f ibers preventing microadhesions and
matrix that account for the functional charac
extensibility. Ground substance con
teristics of the di fferent types of connective
tent in connective tissue seems to decrease with
tissue. Connective tissue f ibers with their ten and elasticity are the basis for the
si Ie
mechanical support. Ground water
with its
age, possibly contributing to a decrease in flex ibility with aging. The primary
substance
is the basis for lubrica
and water. Gly
tion and diffusion of nutrients in connective tis
are a Iso referred to as "acid
suess
in the older literature.
Collagen is divided into four Type I col
Iypes:
is found primal'j Iy
loose and dense connective is found III
is found lining the fetal dermis;
branes, Manual therapy
70 percent of the total connective tissue con tent. 3.4
are most The characteris
I
acid, which has to help restore
tics of each type are discllssed later.
ministration approval for use in the
and have more elastic characteristics. The lining
of human
of arteries contains a high
of elastin,
component of ground
is a liga
in alternative medicine
nuchae of the
percentage of elas
ment that contains a
tin6,7 Reticulin is the least tensile of the con it is found primari Iy
nective tissue
the
the delicate meshwork
111
'5
Another important component of connective
substance. This is the
hydrophilic,
help
Chondroitin, which is another is being sold "to
function." The idea of using nonhor of connective tissue to
monal
restore the tissue is an idea that is will have a
and
impact on the
ment of injured or arthritic joints,
internal organs and glands. tissue is
been used
function in the veterinary
has now received Food and Drug Ad
EI.astin f ibers are less tensile than
The
acts
hyaluronic
which is
to bind water. Water makes up approximately
me
[V collagen is found in basement mem likely
groups of GAGs are the sulfated
and nonsulfated groups . The nonsulfated group,
111
Type II col-
In
The two
Bim,ynthesis of Collagen
medium in which the cells
begins in the fibroblast
and fibers are embedded, Ground substance has
by the absorption of amino acids into the cell.
several primary functions. It contains a
pro
of water and this accounts for the first of its primary functions---di ffusion of nutrients
In the
procollagen), a precursor
ground substance is to provide a mechanical bar rier
invading bacteria and
isms. Connective tissue cells, reticuloendothelial of defense
in a the first line
lecular unit of
through
the cell membrane into the interstitial spaces, In the extracellular space,
so-called "critical interf iber distance." Collagen
are linked in series and in Initially, the
if a certain distance
is not maintained between them. The
strands
to form
one another can po tC\(1Cptt1pr
is
helix in the cell to form strands of
tropocollagen.
function of ground substance is to maintain the fibers that
protocol are linked
Strands of
part of the
organisms. A third
into polypeptide
chains. From the polypeptide
A second function of the
and waste
endoplasmic reticulum of the
the amino acids are
molecules are hydrostatically attracted to
Copyrighted Material
32
MVOFASCIAL MANIPULATION
1\M
Amino acids including proline and
collagen
2
fibres
Assembly
lysine
of
polypeptide
chain
and bundles of fibres
7
Aggregation
form
VV\J\fV\Mrv\M
of
tropocollagen
to
collagen fibril s
3
Hydroxylation proline in
and
of lysine
poLypeptide
chain
V'tJVWVVV\MI\ Passage of tropocollagen
to 5
extracellular
Addition
of
carbohydrate
space
4
AssembLy
of
three
hyd roxyLate d polypeptide chains into
moiety
one
tropocollagen molecule
Figure 3-3 A schematic drawing representing the biosynthesis of collagen by fibrob.lasts, Source: Reprinted from Gray ' Ana/amy, ed 35 (p 38) by P. Williams and R, Warwick with pennission ofWB, Saunders, © 1973,
each other and form hydrostatic bonds , Eventu
quired to break a covalent bond is much greater
ally, the collagen matures and the weak hydro
than the energy required to break a hydrostatic
static bonds are converted to stronger covalent
bond, This accounts for the increasing strength
bonds8
of collagenous tissue during maturati-on, Colla
To review briefly, hydrostatic bonds are those
gen fibrils eventually band together to form col
in which polarized molecules or molecules of
lagen fibers. The configuration of mature col
different polarities are attracted to and weakly
lagen can be likened to the structure of common
bonded to one another, Covalent bonds are bonds
rope. Small strands intertwine to form larger
in which the two bonding atoms in the respec
strands; larger strands intertwine to form even
tive molecules share an electron. The energy re
larger strands, and so forth (Figure 3-5),
Copyrighted Material
Histology and Biomechanics o/ Myojascia
'C
'
-
"-
i�!:"�II:�I;;tf;!I'. =--
.
..
.IF"f:;_
:
'
33
tissues. In order to prevent and treat these inju ries, the manual therapist must first have a work ing knowledge of the basic guiding biomechani cal principles that apply to soft tissues. When a force is applied to connective tissues (mechani
:
cal stress), the tissues tend to resist any changes in size or shape. Some deformation or change
GAP
REGION
l t OVERLAP
in length can occur, however, as a result of the REGION
Figure 3-4 Top Electron micrograph showing alter
nating light and dark regions, and Bottom showing
the proposed quarter stagger arrangement of collagen
stress. This deformation is called "strain." Strain is determined by comparing change in length with the normal length. Strain is expressed in de formation per unit length, or percentage change. Tissue strain can be caused by stresses such as a
fibers. Source. Reprinted from Histology (p 234) by
push, pull, twist, tension, compression, or shear.
A.W. Ham and D.H. Cormack with permission of lB.
The latter three are common factors in connec
Lippincott Co, © 1979.
tive tissue injury9 Tension is a pulling force along the length of
the tissue. An example of this is in a whiplash Biomechanics of Connective Tissue
injury. The cervical spine is flexed and extended
General Characteristics and Definition of Terms
get tightened or stretched and subjected to ten
with force. The posterior and anterior ligaments sion stress9.IO
All injuries, whether to bone or connective
Compression occurs when there is stress ap
tissues, are caused by forces acting on these
plied along the length of a tissue, but the tissue
TROPO COLLAGEN
MICRO FIBRIL
SUB FIBRIL
FIBRIL
FIBER
(x ray) (EM)
(x ray) (EM)
(x ray) (EM, SEM)
(EM, SEM) (OM)
(x ray)
staining
periodicity fibroblasts
1.5nm
3.5nm
10-20nm
50-500nm
50-300u
SIZE SCALE Figure 3-5 Architectural hierarchy of dense regular connective tissue, from the tropocollagen molecule to the
collagen fiber. Source. Adapted with permission from J. Kastelic, A. Galeski and E. Baer, The multicomposite structure of tendon, Connective Tissue Research (1978;6: 1 1-23), Copyright © 1978, Gordon and Breach Science Publishers.
Copyrighted Material
34
MYOFASCIAL MANIPULATION
decreases in length and increases in perimeter.
The elastic component of connective tissue
In an upright position, compression force is put
represents the temporary change in length when
through the intervertebral discs. The two sur
subjected to stretch (spring portion of model).
faces become closer to each other as the sides (annulus f ibrosis) bulge out under tension.9,lo
The elastic component has a post-stretch recoil
Shearing occurs when one part of a tissue
in which all length or extensibility gained during stretch or mobilization is lost over a short period
slides over another. This occurs when forces in
of time (Figure
opposite direction are applied to a tissue. An
spring recoils when tension or force is removed.
example of this is L5 sliding forward over S 1,
The elastic component is not well understood
3-7). In the elastic model, the
leading to a higher incidence of disc herniation
but is believed to be the slack taken out of the
at this Ievel9,lo
connective tissue f ibers. For example, a regular
As previously mentioned, when stress is ap
connective tissue has a loose basket weave con
plied to a tissue, deformation occurs. This de
f iguration of collagen f ibers. When a stretch is
formation is called "strain." The strain, or
placed on the tissue, the slack is taken out as the
change in length, can be temporary or perma
f ibers align themselves in the general direction
nent. A graphic representation of this relation
of the stretch (Figure
ship would appear as a stress/strain curve. Ini
is removed, the f ibers assume their previous
tial change in length requires little force. As
orientation and the change in length is lost.
3-8). When the stretch
more stress is applied to the tissue, the change
The viscous (or plastic) component repre
in length diminishes. In other words, greater
sents the permanent deformation characteristic
amounts of force are required to effect small
of connective tissue. After stretch or mobiliza
amounts of change. The early part of the curve,
tion, part of the length or extensibility gained
sometimes called the toe region, represents the
remains even after a period of time (hydraulic
elastic component of connective tissue. This
cylinder portion of model). There is no post
usually represents temporary length changes in
mobilization recoil in this component (Figure
the tissue. When the material stretches beyond
3-9). In the model, the hydraulic cylinder has
the elastic range, it reaches a point at which the
been opened and does not close. Presumably,
deformation becomes permanent. This point is
the permanent change results from breaking in
called the elastic limit. If stress continues, the
termolecular and intramolecular bonds between
tissue moves into the viscous or plastic range.
collagen molecules, f ibers, and cross links.
The tissue is now permanently deformed, but
The viscoelastic model is then simply the vis
does not rupture. As the imposed stress in
cous and elastic portions of the model combined
creases further, the curve reaches its peak at the
and arranged in series (Figure
yield point9
force is applied to the connective tissue through
3-10). After a
stretch or mobilization, a net change in length
Viscoelastic model ofcOl1l1ective tissue. This concept can be explained further using a simple
is achieved. Some of the change is quickly lost, while some remains.
engineering model. Connective tissue is some
The combination of viscous and elastic prop
times referred to as being viscoelastic in nature.
erties allows for connective tissue to respond by
It contains both a viscous (permanent) deforma
creep and relaxation.lo Creep occurs when a load
tion characteristic and an elastic (or temporary)
is applied to a tissue over a prolonged period of
deformation characteristic. The two characteris
time, as in progressive stretching. This allows
tics combine to give connective tissue its unique
a gradual elongation of the tissue. The degree
qualities.II-IS This model incorporates a spring
of deformation is more determined by the dura
(elastic) and a hydraulic cylinder (plastic) linked
tion of force applied to the tissue rather than the
in series to help depict this deformation quality
amount of force. A lesser load over a greater
(Figure
period of time will produce a larger amount of
3-6).
Copyrighted Material
Histology and Biomechanics o/Myofascia
Collagen
(A)
Tendons
fibers
Ligaments
+
Joint capsules
Ground
Aponeuroses
substance
Fascia
matrix
etc.
Viscous properties
3S
-------i�
Plastic stretch
(8)
Hydraulic cylinder model
Elastic properties -------l� Elastic stretch
(C)
force
Spring model
Tensile
(D)
force
Figure 3-6 (A) The primary and secondary organization of connective tissue in the body. (B) Schematic representation of a viscous element in material capable of permanent (plastic) deformation. (C) Schematic representation of an elastic element in material capable of recoverable (elastic) deformation. (D) A simplified model of collagenous tissue. Connective tissue is a viscoelastic material: When stretched, it behaves as if it has both viscous and elastic elements connected in series. Source: Reprinted with permission fro m The Physician
and Sports Medicine, Vol. 9, No. 12, p. 58, © 1981, McGraw-Hili Companies.
Copyrighted Material
36
MYOFASCIAL MANIPULATION
A)E.LASTIC
some gain in total length that is considered per
MODEL
1'R£ L.OOO
"TENs.1..E
1
<'OSrL.CW>
manent. This phenomenon is seen often in the clinical setting. In stretching a restricted joint capsu Ie, for example, a certain increase in range of motion may be achieved during a particular
Figure 3-7 Schematic representation of the visco elastic model of elongation-elastic component in which no permanent elongation occurs after applica
treatment session. The patient may return a day or two later with a range of motion greater than the original range, but less than that achieved
tion of tensile force. Source: Reprinted from Myofas
at the end of the previous treatment. In other
cial Manipulation: Theory and Clinical Management
words, some range is lost due to the elastic com
(p 4) by A.1. Grodin and R. Cantu with permission of
ponent, and some is retained due to the plastic,
Forum Medicum Inc, ; 1989.
or viscous, component. Although the plastic component represents a permanent elongation, connective tissue is still capable of losing the elongation. The half
creep. An elevation in temperature will cause
life of collagen is
300 to 500 days in mature
corresponding increases in creep. Hence, when stretching tight connective tissue, warmed tissue held for a sustained period will be more pliable than cold tissue stretched quickly.9,lo If force is applied intermittently, as in progres sive stretching, a progressive elongation may be achieved. In Figure
3-11 A, strain, or percent
elongation, is plotted against time for the pur poses of illustrating this phenomenon. Initially, there is a rapid elongation of the tissue, again
\
representing the contribution of the elastic por
1
tion of connective tissue. As time passes, less elongation is achieved, representing the con tribution of the viscous portion of connective tissue. When the stress is eventually released, the tissue immediately loses some of the previously attained elongation. Again, this phenomenon is consistent with the elastic characteristics of connective tissue. Not all the change in length is lost, however, because the tissue was stretched into the viscous or plastic range. If the stress is reapplied to the tissue, the curve looks identical, but starts from the new length achieved after the first stretch (Figure 3-11 B). Again, the initial elongation is very rapid, but gradually slows as the tissue makes the transi tion from elasticity to plasticity. When the stress is re-released, another portion of the change in
B
t Figure 3-8 Diagram showing the weave pattern of collagen, with A and B repr esenling elastic stretch and recoil of collagen fibers. Source: Reprinted from Donatelli R. and Owens-Burkhart, H., Effects of Im mobilization on Ihe Extensibility ofPeriarlicular Con nective Tissue, Journal of Orthopaedic and Sports Physical Therapy, Vol. 3, pp. 67-72, with permission
length is lost, and a portion is also retained.
of the Orthopaedic and Sports Sections of the Ameri
With each progressive stretch, the tissue has
can Physical Therapy Association.
Copyrighted Material
Histology and Biomechanics of Myofascia
37
Figure 3-9 Schematic representation of the viscoelastic
model
of elongation-plastic
component in which deformation remains after the application of tensile force. Source: Reprinted
from
Myofascial lvlanipulation.
TheOl)' and Clinical Management (p 5) by
AJ. Grodin and R. Cantu with permission of Forum Medicllm Inc, © 1989.
Figure 3-10 Schematic representation of the viscoelastic model of elongation-some elon gation is lost and some is retained after the ap plication of tensile force. Source: Reprinted from Myofascial Manipulalion: Theory and Clinical Management (p 5) by A.J. Grodin
and R. Cantu with permission of Forum Med icum Inc, © 1989.
nontraumatized conditions.16 Over time, new
will adaptively shorten as collagen is laid down
collagen is laid down to replace older collagen.
in the context of the length of the tissues and
New collagen is laid down according to stresses
lack of stresses applied. Wolff's law, which states
(or lack of stresses) applied to the tissue. If the
that "bone adapts to the stresses applied,"7 can
tissue is not stressed for long periods of time, it
be applied to connective tissue. All connective
r
I A
<-----i "ME. t-I
_ ______ _
>
B
<
nt-'E
-
,-
-
--
)-
-----
Figure 3-11 (A) Elongation of connective tissue (strain) plotted against time. (B) Repeated elongations of cOllnective tissue (strain) plotted against time. Source: Reprinted from Myofascial Manipulalion: Theory and Clinical Managemenl (pp 5-6) by A. F. Grodin and R. Cantu with permission of Forum Medicum Inc, © 1989.
Copyrighted Material
38
MYOFASCIAL MANIPULATION
tissue seeks metabolic homeostasis commen surate with the stresses being applied to that particular tissue. Wolff's law, however, applied to connective tissue, has a functional as well as a dysfunctional aspect. Abnormal stresses chroni cally applied to connective tissues may change the tissue resulting in dysfunction in the tissues and the adjacent structures supported by that tissue (i.e., facet joints, etc.). A clinical example of this phenomenon is the connective tissue band that develops in the patient with spondylolisthe sis. Because the spine in this condition cannot withstand the anterior shear forces applied daily, the body responds by laying down connective tissue, in time forming a connective tissue band.
Figure 3-12 Drawing of dense regular connective tissue, showing the parallel arrangement of collagen
Normal stresses, or carefully controlled stresses
fibers. Source: Reprinted from Gray s Ana/omy, ed 35
(i.e., those stresses imparted externally by the
(p 40) by P. Williams and R. Warwick with permission
clinician in the form of manipulation, or by the
ofW.B. Saunders, © 1973.
patient, in the form of exercises), may positively change the metabolic and physical homeostasis of the tissue. Collagen production is thus less
ment. 17,18 The collagen fibers in tendon have,
haphazard, more organized, and laid down in a
therefore, been designed in a parallel arrange
quantity and direction more suited to optimal
ment to provide the highest unidirectional tensile
tissue function. This concept is more fully de
strength possible. The stress-strain relationship
veloped in Chapter 4.
of tendon is similar to that of other connective tissues, with some minor differences. When a
Specific Characteristics
tendon is stressed, the toe region (elastic com
Dense regular connective tissue. Ligaments
ponent) of the stress-strain curve is generally
and tendons are categorized as dense regular
smaller due to the parallel arrangement of col
connective tissue. Dense parallel arrangement of
lagen fibers. This indicates less realignment of
collagen fibers characterizes dense regular con
fibers than found in other connective tissues
nective tissue (Figure 3-12). The high propor
during tension. The toe region is generally fol
tion of collagen to ground substance and the
lowed by a moderately linear region with a
parallel arrangement of the f ibers accounts for
slightly greater slope, which is indicative of the
the high tensile strength and limited extensi
tendon's greater stiffness. With further tensile
bility of these tissues. Because of the histol
deformation, small dips or hitches appear in
ologic makeup of these tissues, they are the
the curve that possibly represent early tissue
least responsive to manual work. Because of
microfailure. Finally, with further loading, the
the compactness and density of collagen f ibers
tissue fails completely, and the stress-strain curve drops to zero. 17.19
and the relatively small proportions of ground substance, the tissue is not highly metabolic, and
The primary function of ligament is to check
not very vascular, accounting for the increased
excessive motion in joints and to guide joint motion.17,18 Ligaments have a less consistent
healing time required after trauma. The primary function of tendon is to attach
parallel arrangement of collagen fibers than
muscle fibers to bone and to transmit forces
does tendon (Figure 3_13).20 Under light mi
expended by muscle to the bone with limited
croscopy, the orientation of the collagen takes on
elongation, allowing for tension or joint move-
an undulating configuration known as "crimp."21
Copyrighted Material
Histology and Biomechanics of Myofascia
39
Dense irregular connective tissue. Dense ir
regular connective tissue includes, but is not limited to, joint capsules, aponeuroses, penos teum, and fascial sheaths under high degrees of mechanical stress. The major difference between dense irregular and dense regular connective tissue is the orientation of collagen fibers. [n dense irregular connective tissue, the collagen fibers are aligned multidirectionally in order to withstand multidirectional stresses (Figure 3-14). The lumbodorsal fascia, for example, has many different attachments, and is pulled in different directions during the spine's normal function. Figure 3-13 Drawing of ligamentous tissue, showing overall parallel arrangement of fibers, but somewhat
Loose irreguillr connective tissue. Loose ir
less parallel than tenelon. Source: Reprinteel fr om
regular connective tissue includes, but is not
Grays Anatomy, eel 35 (p 40) by P. Williams anel R.
limited to, the superficial and some deep fascia,
Warwick with permission ofWB. Saunders, © 1973.
as well as muscle and nerve sheaths. The sup portive framework of the lymph system and the internal organs is also classified as loose ir regular connective tissue. Loose irregular con
This crimp phenomenon is thought to be respon
nective tissue is generally characterized by a
sible for the mildly elastic characteristics ofliga
sparse, multidirectional framework of collagen
ment. The ligament functions biomechanically
and elastin. Loose irregular connective tissue
as a spring, until all of the crimp is straightened
contains a greater amount of ground substance
out and, subsequently, becomes more tensile
per unit area than other types of connective tis
when the collagen fibers are actually stressed.
sues. Because of sparse concentrations of col
The ultimate biomechanical result is that liga
lagen in this type of tissue, loose irregular con
ments have somewhat less tensile strength per
nective tissue is the most elastic and typically
unit area than tendon, but have slightly more
has the greatest potential for change when ma
yield (Table 3-2).
nipulated by external forces.
Table 3-2 Classification of Connective Tissue Tissue Type Dense regular
Specific Structures
Characteristics of the Tissue Dense, parallel arrangement of collagen
Ligaments, tendons
fibers; proportionally less ground substance Dense irregular
Loose irregular
Aponeurosis, periosteum, joint
Dense, multidirectional arrangement
capsules, dermis of skin, areas
of collagen fibers; able to resist
of high mechanical stress
multidirectional stress
Superficial fascial sheaths, muscle
Sparse, multidirectional arrangement of
and nerve sheaths, support
collagen fibers; greater amounts of
sheaths of internal organs
elastin present
Copyrighted Material
40
MYOFASCIAL MANIPULATION
Histology Muscle is histologically categorized into three types: skeletal, smooth, and cardiac. This section focuses primarily on skeletal muscle, which in turn will provide a basis for understanding car diac and smooth muscle types. Skeletal, or stri ated muscle, is so named because of its striated or banded appearance under light microscopy. The striations reflect the functional contracti Ie unit of the muscle called the sarcomere. Muscle is also functionally characterized by fiber type based on speed of contraction or relaxation, bio chemistry and metabolism, and in circulation. Mechanism of Growth ill Skeletal Muscle Figure 3-14 Drawing of dense irregular cOlUlective tissue, showing the multidirectionality as well as high density of collagen f ibers. Source: Reprinted from
Grays Anatomy, ed 35 (p 40) by P. Williams and R. Warwick with permission ofW.B. Saunders, © 1973.
The total number of actual muscle fibers in a muscle is reached sometime before birth. Lon gitudinal growth in a muscle is accomplished in early years by an increase in the length of the individual sarcomeres and by addition of sarco meres. Increases in diameter are accomplished by the addition of myofilaments in parallel ar rangement. Likewise, the muscle shortens by
HISTOLOGY AND BIOMECHANICS OF MUSCLE
losing sarcomeres and decreases in diameter by losing myofilaments. With prolonged disuse, the muscle fibers degenerate and the tissue is re
As previously stated, the myofascial tissues
placed with less metabolically active connective
account for the majority of tissue being affected
tissue. Human skeletal muscle, however, does
by orthopedic manual therapy. A large portion of
have some limited regeneration potential. Satel
the myofascial tissues includes muscle tissue. As
lite cells, which are believed to be a persisting
with connective tissue, a basic understanding of
version of the prenatal myotubes found inside
muscle tissue is also essential for an appropri
basement membranes, can become activated to
ate empirical understanding of myofascial ma
produce a limited amount of new muscle fibers.
nipulation. Knowledge of trauma, immobiliza
The number of new fibers that can be produced,
tion, and remobilization of muscle tissue must be
however, cannot compensate for the amount lost
built based on the scientific principles that will
during major muscle trauma or degeneration.
be outlined as follows. The histology and physi ology of muscle tissue alone occupies whole chapters in textbooks. The purpose of this sec
Cellular alld Histological Organizatiol1 of Skeletal Muscle
tion is to provide a basic overview of muscle
The contractile proteins of striated muscle
histology and how it relates to connective tissue.
are actin and myosin. The actin and myosin in
Much of the knowledge of mammalian skeletal
teract in a ratchet-type manner to shorten the
muscle comes from studies of frog skeletal
muscle (Figure 3-15). Actin and myosin fila
muscle, which is anatomically and histologically
ments are contained in the functional contrac
similar.
tile unit of muscle called the sarcomere. The
Copyrighted Material
Histology and Biomechanics of Myofascia
Myosin
Ilclin+myosin
4 1 1 1 I 1
41
Actin
*:*
*.**:* *.*:*:*: **:*:* **:
·
.
. .
. .
. .
·
·
. .
1 1 1 1 1--...-1 1 1 1 1
1 I 1 1
"\. "\.
" M
R€MM.
z
Sa,com r 11
Figure 3-lS Diagram showing the organization of skeletal muscle and the mechanism of shortening. Source: Reprinted from Gray :\. Anatomy, ed 35 (p 479) by P Williams and R. Warwick with permission ofW.B. Saunders,
© 1973.
transverse alignment of sarcomeres in adjacent
Sarcomeres are arranged in series to form cy
myofi laments gives this tissue the striated ap
lindrical organelles called myofilaments. Myo
pearance. The striations result from a series of
filaments are arranged in bundles and are con
bands
(Z,
A, I bands), which reflect compo
nents of the sarcomere. The distance between
tained in the
myofibril,
which is the muscle's
cellular unit. Myofibrils are multinucleated cells
two Z bands reflects the length of the sarcomere
that also contain mitochondria, lysosomes, ribo
and will vary depending on the contractile state
somes, and glycogen. Myofibrils are grouped
of the muscle. The A band, which represents
together into bundles called
myosin molecules, does not change in length
connective tissue fills the area between myofi
fasciculi.
Loose
during contraction, whereas the I band, which
brils and is called endomysium. A loose con
represents areas where actin does not overlap
nective tissue sheath also surrounds the muscle
myosin, changes depending on the contractile
fasciculus and is called the perimysium. Finally,
state of the muscle.
fasciculi are grouped together to form individual
Copyrighted Material
42
MYOFASCIAL MANIPULATION
muscles (Figure
3-16).
The loose connective
tissue sheath that envelops the muscle is called the epimysium.
Biomechanics of Muscle T he connective tissues of skeletal muscle have important roles in the optimal function of muscle. These connective tissues provide a certain amount of coherence in the muscle while allowing an appropriate degree of mechanical
I I I I I I I I
freedom. The connective tissue layers also serve to carry the blood supply to the tissue and ramify to form a rich capilIary network in the muscle fiber.21 They also allow the penetration of nerves along with this blood supply to allow for dif fusion of nutrients and ions as necessary for muscular metabolism and excitation.] The endo mysium is particularly significant in these roles, since it most closely approximates the individual
It
muscle fibers. Muscle Fiber Types
-tJli) _jsmI?;f
Human muscle is a mixture of Type I and \/\,oJibnl
Type II fibers. There is variability in the relative percentages of each type between individuals. Within an individual, there is a correlation be t ween muscle function and fiber composition.21 Muscles are generally categorized according to the predominant fiber type present throughout the muscle. T he following fiber type classification is cur rently the most widely used.22 Fibers are clas sified as Type r, I1a, lIb, or JIm (Table
3-3).
Type I fibers are slow t witch fibers that have the slowest contraction times. They are also the
C'
•
IF"
\\
i
n�""""'"'
-S"iCiiii ·\/Y(JJIII
lowest in glycogen stores, but have the richest concentration of mitochondria and myoglobin. Because of these characteristics, Type J fibers are the slowest to fatigue. The postural muscles of the body have a predominance of Type I
��, .Ittln
fibers. Type JIa fibers (also called fast twitch/ ioxidative or fast red fibers) are intermediate fibers that have a faster contraction time than
Figure 3-16 Diagram showing architectural hierar
Type I fibers while remaining moderately fa
chy of muscle tissue. Source: Reprinted from Gray s
tigue resistant. A high concentration of myoglo
Anatomy, ed 3S (p 481) by P. Williams and R. War
bin and mitochondria is still present in these
wick with permission of WB. Saunders, © 1973.
Copyrighted Material
Histology and Biomechanics of Myofascia
43
Table 3-3 Classification of Muscle Fiber Types Fiber
Functional
Type
Classification
Type I
Slow twitch
Functional Metabolic Characteristics High concentrations of myoglobin,
Characteristics Slow contraction
increased numbers of
times, fatigue
mitochondria, low content of
resistant
glycogen, oxidative metabolism Type Iia
Fast twitch/oxidative (fast red)
Moderately high concentrations of
Faster contraction
myoglobin, increased numbers of
times than type 1
mitochondria, glycolytic/oxidative
less fatigue resistant
,
(mixed) metabolism Type lib
Fast twitch/glycolytic (fast white)
High glycogen content, glycolytic metabolism, decreased numbers
Fast contraction times, fatigues easily
of mitochondria Type 11m
Superfast
Contains unique myosin configuration, high glycogen
Very fast contraction times
content, glycolytic metabolism
fibers. Type JIb muscl. e
tissues, injury to the junctional zones is quite
twitch/glycolytic or fast white fibers) have faster
common.24 Numerous recent stress-strain stud
contraction times and rely more on glycolytic
ies indicate that most tissue failures occur at or
pathways for energy metabolism. Alternately,
near the myotendinous junction25-3o Myofascial
Type I!b fibers have a lower concentration of
restrictions will commonly be found in the areas
myoglobin and mitochondria and are not fatigue
of the junctional zones due to the frequency of
resistant. Finally, a superfast fiber, termed lIm,
injury to these areas, and the clinician should
has been identified in mammalian muscle tissue,
be aware of these areas in myofascial evalua
including human muscle tissue. This type of
tion. A basic understanding of the histology and
fiber is found primariIy in the jaw muscles and
biomechanics of junctional zones is, therefore,
contains a unique myosin that distinguishes it
preliminary to a study of their histopathology
from Types I and 1I fibers23 Muscles with a
and to an empirical understanding of myofascial
greater percentage of Type n fibers, those which
evaluation and treatment.
cross two joints and those working eccentrically, are much more susceptible to strain injuries. T he most common site of those injuries is at the musculoskeletal junction.2!
Histology of Myotendinous Junction
The attachment of the muscle is generally through tendon. The muscle belly attaches to
HISTOLOGY AND BIOMECHANICS OF JUNCTIONAL ZONES
tendon at tlle musculotendinous junction on each side of the belly. These musculotendinous junc tions are highly specialized areas.
The junctional zones in the myofascial tis
Several histological differences occur in the
sues include the myotendinous junction and the
transitional area between muscle fibers and
ligament, tendon, and joint capsule insertions
tendon that give it unique functional character
to bone. Early studies indicate that although
istics. First, the cell membrane forms a continu
injury can occur in any portion of the myofascial
ous interface between intercellular components
Copyrighted Material
44
MYOFASCIAL MANIPULATION
of muscle fibers and extracellular components
are developed in fast twitch muscles than in slow
of connective tissue. The cell membrane at
twitch muscles, and greater cumulative tensile
this junction becomes highly folded or convo
strength is required to sustain and transmit such
luted allowing the contractile intercellular com
forces.
ponents to interdigitate with the extracellular
Another significant histological characteristic
components31-38 The folding of the cell mem
of the myotendinolls junction is decreased sar
brane increases the surface area, thereby reduc
comere length and extensibility42,4J
ing the stress per unit area on the membrane. The
acteristic results in the myotendinous junction
folds hold the membrane at a low angle in re
first being loaded by terminal sarcomeres and
lation to the forces coming from the muscle
subsequently being fully loaded by the rest of
f ibers, placing the membrane primarily under
the sarcomeres in the muscle belly. More sig
shear forces. If the folds did not exist, the junc
nificantly, the decreased extensibility of the ter
tional membrane would experience vector forces
minal sarcomeres also makes the tissue in this
at right angles to the membrane surfaces. This
area more vulnerable to tearing, as evidenced
would create a tensile load at the junction. Stud
by the frequency of injury in the experimental
ies indicate, however, that cell membranes are
models.42,4J
highly resistant to shear forces that would in
cussed further in Chapter 4.
crease their surface area.39 The design of the folds allows for much higher force transmission before tissue rupture.
Biomechanics of the Myotendinous Junction
Finally, the membranous folds increase the
As previously mentioned, the intercellular
potential adhesive area in the musculotendinous
contractile units must ultimately be coupled with
junction.4o,41 This also decreases the load per
the collagen fibers of the tendon for transfer
unit area being transmitted from the muscle.
of forces to take place (Figure 3-17). This is
Interestingly, muscles with predominantly fast
accomplished architecturally in the following
twitch muscle f ibers have an increased folding
manner.
of the junctional membranes. This phenomenon
Thin myofilaments, believed to be derivatives
is probably related to the fact that higher forces
of actin, attach from the terminal Z disks of the
1
2 3 4
5
IIQIIJllllllltlll,llIIlllQll,llllIIlltllUllllIIllllPllll1I ..,
v _ _ _ Jv _ v V _ _ _J_ _ _ __ _ J_ __ _ - - --- - -.: - - ---:: -_-_-_-:::_-_-:_-_..._-_-_-___-_ . -..."... --,- -- -,- - -,- - -,- - -,-- -,---,- " " , , " , , " , , F' , , , < (
_
................................................................................................................................ . . . . . . . . . . . . .. , .a ' ..M':t:!:e•• •••••
.
.
.
.
.
§
,
JEX liN ,
Figure 3-17 Schematic drawing of the structures involved in force transmission between tendon and contractile
(I) and basement membrane (2). The (3) separates extracellular (EX) and intracellular (IN) force-transmitting structures.
proteins. Extracellular components (EX) include tendon collagen fibers junctional plasma membrane
Within the cell, thin actin filaments (5) are attached to the cell membrane by dense, subsarcoJemmal malerial (4). Source: Reprinted from Injury and Repair of the Musculoskeletal SoJi Tissues (p 184) by SL.-Y. Woo and J.A. Buckwalter with permission of the American Academy of Orthopaedic Surgeons, © 1987.
Copyrighted Material
Histology and Biomechanics of Myofascia
myofibri Is to a thickened cell area of the inner
45
chondroblasts or chondrocytes. Zone 3 consists
cell membrane called the subsarcolemma. The
of mineralized fibrocartilage, where mineral
contracti Ie proteins of the muscle sarcomeres,
deposits are found around collagen f ibrils. Fi
therefore, have an attachment to the cell mem
nally, zone 4 consists of bone, where the col
brane. The outer portion of the cell membrane is
lagen fibrils merge with the f ibrils of the bone
similarly attached to a basement membrane that
matrix.
runs parallel to the cell membrane. The base
Indirect insertions do not have specifically
ment membrane contains type IV collagen and
defined zones as do the direct insertions. The
high molecular weight glycoproteins. The base
connective tissue fibers tend to blend more with
ment membrane is then attached to collagen fibers of the tendon 32-35,37.3S
These transitional fibers are sometimes referred
As can be seen in Figure 3-l7, all of the com
to as Sharpey's fibers.44 These fibers are de
the periosteum, which in turn attaches to bone.
ponents of the myotendinous junction are cou
scribed as originating in the periosteum and per
pled in a parallel arrangement, rather than in
forating the underlying bone, anchoring the peri
series. As previously mentioned, the cell mem
osteum to underlying bone. IS No fibrocartilage
brane can accommodate shear forces more opti
is seen in indirect insertions.45,46
mally than tensile forces, and the architecture
A common feature of the two insertional types
of the myotendinous junction reflects this ef
is the presence of superficial and deep fibers.
ficiency.
The superficial f ibers generally attach to perios
Connective Tissue InsertiOIt to Bone
f ibers insert into bone or by way of f ibrocarti
teum, which in turn attaches to bone. The deep
The insertions of tendons, ligaments, and joint
lage. The main difference is that the direct inser
capsules to bone vary somewhat in their histo
tion has a f ibrocartilaginous transitional zone,
logic architecture. As with the myotendinous
while the indirect insertions do not. Another
junction, the architecture is designed to dissipate
commonality is that the junctional zones of liga
tensile forces and minimize stress concentra
ment, tendon, and capsule are relatively avascu
tions. Despite their architectural design, these
lar compared with the tissue on either side of the
junctions are common sites of injury and remain
zone.4
areas of weakness during loading. As with the
The attachment sites of ligament, tendon, and
other areas examined in this chapter, a basic
joint capsule to bone also vary in their biome
review of the histology and biomechanics of
chanics because of differences in the forces im
these junctions is necessary to understand their
parted by these tissues. Obviously, the tendon
response to trauma and pathology. Within an area of I millimeter, the connective
bone junction will have greater forces because of the forces generated by muscle, whereas the
tissue is transformed into hard tissue (Figures
ligament and joint capsule-bone junction will
3-18A and
have lesser forces. The resiliency of the tendon
B). Two types of insertions are iden
tified in the literature: direct and indirect. Direct
bone junction was demonstrated by Noyes and
insertions have four distinct histological zones
associates49 Several samples of patellar tendon
that represent the transition of the tissues from
were analyzed to determine stress-strain charac
soft connective tissues to bone.4 4
teristics of the tendon proper, the entire bone
Zone I consists of the actual tendon or liga
tendon-bone unit, and the actual attachment site.
ment. The histology of this zone does not differ
The attachment sites undergo more significant
much from the histology of ordinar y tendon,
strain (elongation) before receiving significant
ligament, or capsule. Collagen fibers are found
stresses, indicating that strains in this region are
here embedded in the matrix or ground sub
greater than any other region. This allows for
stance, as are fibroblasts. Zone 2 consists of
more force dissipation at this region, but also
fibrocartilage. The cells in this region resemble
makes this region more vulnerable.
Copyrighted Material
46
MYOFASCrAL MANIPULATfON
A
B
Figure 3-18 (A) Direct insertions. The four distinct zones seen in the supraspinatus insertion. The four zones are tendon (T), uncalcified f ibrocartilage (FC), and bone (B). Source: Reprinted with permission from M. Benjamin, E.J. Evans, et aI., The Histology of Tendon Attachments to Bone in Man, Journal ofAnatomy, No. 149, pp. 89-100, © 1986, Cambridge University Press. of the ligament
(L)
(B)
Femoral insertion of rabbit MCL The deep fibers
pass into bone through the fibrocartilage (F). The arrow indicates the line of caJcification.
Source.· Reprinted with permission from SL- Y. Woo, M.A. Gomez et aI., The Biomechanical and Morphological Changes in the Medial Collateral Ligament of the Rabbit after Immobilization and Remobilization, )ollrnal qf Bone & Joinl Surgery, Figure 6-A, Vol. 69A, p. 1207, © J 987, J ournal of Bone & Joint Surgery.
Copyrighted Material
Histology and Biomechanics of Myofascia
47
will allow the therapist to set realistic goals for
CONCLUSION
manual treatment. In this day and age, where The information covered in this chapter was
various types of practitioners are competing for
primarily of a basic science nature. Although
patients, and reimbursement by insurance com
somewhat removed from the clinical realm, a
panies is decreasing, it is essential for our pro
thorough understanding of basic anatomy and
fession to establish credibility in what we do. Art
biomechanics is necessary for the manual physi
and science must be carefully balanced as the
cal therapist to be successful in the treatment
profession forges ahead, especially in the area of
of the myoJascial tissues. This understanding
myofascial manipulation.
REf'ERENCES H, Wolff A. A ""Ianllat oj Rellexlve Connective Tisslle. Scarsdale, NY: Sidney
Dicke E, Schliack Therapy o/'the
S. Simon Publishers; 1978. 2.
Ham AW, Cormack DH.
liver,
H. The metabolism of collagen from bones, skin and tendon in normal rat. Biochem./.
1953;53:47-52.
Gray:5 A nat omy. 3rd ed (Br).
Phi ladelphia: WB Saunders; 1973:32-41,480-42.
17. Frankel VH, Nordin
M.
Basic Biom echan i cs
Skeletal System. Philadelphia: Lea
MB. Baileys Text book ofHistology. Baltimore, MD: Williams & Wilkins;
4. Copenhaver W M, Bunge RP, Bunge 1971. 5. Geneser
Hooley CJ, McCrum NG, et al. The viscoelastic defor .I Biomech. 1980;13:521-528.
mation of tendon.
16. Neubergcr A, Slack
Histology. Philadelphia: JB
Lippincott: 1979 210-259. 3. Warwick R, Williams PL.
15.
0./ the & Fcbiger; 1980:56,
87-110. 18. Woo SL-Y, Buckwalter JA. Injury
and Repair
of the
Musculoskeletal Soji Tissues. Savannah, GA: American
F.
Textbook o./HIstologl'. Philadelphia: Lea
&
Febiger; 1986.
Academy of Orthopaedic Surgeons Symposium; 1987. 19. Viidik A. Tensile strength properties of
6. Fielding J W, Burstein AH, et al. The nuchal ligament.
Achilles tendon
systems in trained and untrained rabbits. Acta Orthop Scand. /969;40:261-272.
Spine. 1976;1:3.
7. Nachemson AL, Evans JH. Some mechanical proper
20. Kennedy JC, Hawkins RJ, et al. Tension studies of
ties of the third human lumbar inlerlaminar ligament
human knee ligaments. Yield point, ultimate failure, and
./ Biomech. 1968;1:211.
(ligamentum flavum)
8. Cummings G, Crutchfield CA, Barnes
Changes In
MR.
disruption of the cruciate and tibial collateral ligaments.
Soji Tissue
COlltractllres. Allanta,GA: Slokesville Pub
9. Norris C. Sports Injuries: Diagnosis' lind Ma nagement .
Hcinmann LTD; 1993.
10. Bernhardt D. Sports Physical Therapy. Sapega AA, Quedenfcld TC. Biophysical
McGraw-Hili;
1986; J :255-284. 23. Rowlerson A, Pope B, et al. A novel myosin present
faclors in
range of motion exercise. Physicion Sports Med. 1981, 9:57-65.
in cat jaw c losin g muscles . .I
Muscle Res Cell Moti!.
1981 ;2:415-438. 24. McMaster PE. Tendon and muscle ruptures: Clinical
12. Warren CG, Lehmann JF, et al. Heat and stretch proce dures: An evaluation
Br ivIed Bull. 1992;48(3),698-711.
22. Gauthier GF Skeletal muscle fiber types. In: Engel AG, Banker BQ, eds. A;f),ology. New York:
New York:
Churchill Livingstone; 1986.
II
21. Barlow Y, Willoughby S. Pathophysiology of Soft Tissue Repair.
lislling; 1985. Oxford: Bullerworlh
./ BOlle.Ioint Surg. 1976;58:A350-A355.
using rat tail tendon.
Arch Pilys
Mer! Rehahil. 1976;57:122-126.
13. Woo SL-Y, Ritter D, et al. The biomechanical and bio
and experimental studies on the causes and 10cMion of subcutaneous ruptures
.
./ Bone
Joint Surg. 1933; 11.5:
705-722. 25. Almekinders LC, Garrett WE Jr, et al. Pathophysiologic
chemical properties of swine tendons: Long-term effects
response to muscle tears in stretching injuries. Tro n s
of exercise on the digital ex tensors. Connect Tissue Res.
Orthop Res S oc. 1984;9:384.
1980;7:177--183. 14. Fung YCB. Elasticity of soft tissues in simple elonga tion. AIII.I Physial. 1967;213: /532-1545.
26. Almekinders LC, Garrett WE Jr, et al. Histopathology of muscle tears in stretching injuries. Trans Orthop Res Soc. 1984;9:306.
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48
MYOFASCIAl MANIPULATION
ccrlanocllCnnical proper
39 tears in stretching
Membrane" Transport,
tics of membranes,
Soc, 1984;9:384,
1978;10:1--64.
28, Garrett WE Jr, Nikalaoll PK, et at The
of musc!e
40, Bikennan JJ Stresses in o['Adhesive Juil1ls, New
architecture an the biomechanical failure properties of
cnce
skeletal muscle under passive extension, Am J SPOl'iS
1968 192-263
Afed 1988:16:7--12
Press;
41 Lubkin JL The theory of adhesive scarf joints, J Appl
29, Nikolaoll PK, Macdonald BL, et al. Biomechanicsl and histological evaluation of muscle after controlled strain injury. Alii J Sports Meil, 1987; 15:9-14,
/c1ec". 1957:24:255-260, 42, Gordon AM, Huxley AE
al. TenslOn development
ill highly stretched vertebrate l11uscle fibers, J Physio/.
30, Garrett WE Jr, Rich FR, et al. Computed tomography of hamstring mllscle strains, Med Sci
J 989;
21:506-514,
1966;184: 143-169, 43, Huxley AF, Peachy LD The maximal length for traction in vertebrate striated muscle, J
I, Gelher D, Moore DH, et al. Observations Afikrosk Aoal, 1960;2:325-336,
COIl
1961;
156:150-165.
myatcl1
dalljuncliol1 in mammalian skeletal 111usck, Z Zel/fVl'seil
Pilysiol.
44, CoopCI' RR, Misol S, Tendon
insertion: A
light and electron microscopic study J Baile Join/ Surg,
Mackay B, Harrop TJ, et al. The fine
1970;52:AI-A21
muscle tendon junction in the rat.
45. Woo SL-Y, Gamez MA, el al.
588-604,
morphological changes in
Tidhall JG, Daniel TL.
biomechanical and
medial collateral ligament
of the rabbit aftet immobihzaiion and rcmobdization, .I Bone Joint Surg. 1987;69: A
muscle cells: structure and loading,
1986;245:315-322,
46, Benjamin M, Evans
34. Eisenberg BR, Milton RL. Muscle fiber termination at the tendon in the frog's sartorius: A stereologtcal study. Am J AI/a/. 1984; 171:273-284,
tendon
attachments to bone in 47,
of the human knee joint. Acto Anal,
35, Tidball JG. The geometry of actin filament membrane associations can modify adhesive strength of the myo tendinous junction. Cell Mali/. 1983;3439-447. 36, Trotter lA, Hsi K, et 81. A morphometric analysis of the muscle-tendon junction, Alia! Rec. 1985;2 J 3:26-32, 37, Mair W GP. Tame F MS, The ultrastructure of the adult
48, Amoczky SP, Rubin RM,
al. Microvasculature of
the cruciate ligaments and its response to injury: An experimental study in dogs, J Bone '/oin! Sill'!!,. 1979;61: A1221-A1229. 49, Noyes FR, Delucas l L,
al. Biomechanics of anterior
cruciate ligament failure: An analysis of straill-rate sell
and developing human myotcildinous junction, ACla
sitivily and mechanisms of failure in primates, J Bone
NeuropalllOl. 1 972;21 :239-252,
Joint Surg, I 974;56:A236-A243,
38. Trotter lA, Eberhard S, et 31. Structurnl connections of tile muscle-tendon junction, Cell /';10Iil, I
1-438,
Copyrighted Material
CHAPTER 4
Histopathology of Myofascia and Physiology of Myofascial Manipulation Deborah Cobb, Robert I. Cantu, and A Zan J Grodin
HISTOPATHOLOGY OF MYOFASCIA
process with a sequence of recurring stages. The literature varies as to whether there are three or
The basis of all treatment techniques lies in
four distinct phases a wound passes through. 1-4
understanding the basic processes of soft tissue
This chapter will divide the scar process into
healing. In the previous chapter, the normal his
four distinct phases:
tology and biomechanics of myofascial tissues
(2) the granulation phase; (3) the fibroplastic
(I) the inflammatory phase;
were discussed. With that groundwork laid, this
phase; and (4) the maturation phase5,6 Time
chapter will now address the histopathology and
tables for the beginning and end of each phase
pathomechanics of those same tissues. A review
must be understood as general guidelines. Dif
of classic as well as recent literature will be used
ferent tissues heal at different rates, and within
to provide an understanding of scar formation
one wound itself areas in various phases of heal
after trauma as well as how myofascial tissues
ing may be seen. I The changes may also be af
can be affected by immobilization and remobili
fected by the age and fitness level of an indi
zation. With an awareness of the changes that
vidual.7
Inflammation,
occur in the myofascial tissues under dysfunc
a normal prerequisite to heal
tional conditions, a manual therapist can then
ing, is the first phase seen after a trauma. This
set realistic treatment goals and choose the most
phase begins immediately and may last 24 to
appropriate treatment techniques to accomplish
48 hours. Injury causes chemical and mechani
them. The intuitive aspects of myofascial ma
cal changes leading to alteration in blood flow.
nipulation must always be balanced by a solid
This in turn leads to the cardinal signs of inflam
understanding of tissues and their response to
mation: heat, redness, swelling, and pain. The
dysfunction.
inflammatory response to injury is the same
Pathophysiology of Soft Tissue Repair
of the injury.8 Whole blood poured directly into
regardless of the injuring agent or the location
A
a wound will coagulate and temporarily seal off
wound by its most basic definition is a dis
the injured vessels and lymphatic channels. This
ruption of unity. Because vertebrates lack the
traumatic exudate acts to temporarily seal the
ability to regenerate exact duplicates of injured
wound. Histamine is released by the injured tis
parts, response to injury comes in the form of
sues; resulting in vasodilatation and the appear
repair through granulation scar tissue. The scar
ance of a reddened, hot, and swollen region.i
formation process is not a cyclic but a linear
Prostaglandins, formed from cell membrane
49
Copyrighted Material
50
MYOFASCIAL MANIPULATION
phospholipids when cell damage occurs, are re
and tissue breakdown.I,lo Heat application at
sponsible for pain production.2 Phagocytosis
this point may cause increased bleeding in the fragile healing tissues.I I
then occurs to prevent infection in the wound and prepare the wound for healing. Phagocytosis
Rebuilding of tissue begins with the fibro
is initiated by short-lived polymorphonuclear
plastic phase. Proliferation of f ibroblasts and
leukocytes that first attach to bacteria and then
accelerated collagen synthesis now occur. As
dissolve and digest them. Shortly after, macro
the fibroblasts proliferate, new collagen is laid
phages appear to continue the phagocytic pro
down in a disorganized manner in the area of the
cess and to begin influencing scar production.9
wound. Strength of the wound is determined
Its role in recruiting fibroblasts is significantly
not by the amount of collagen laid down but by
related to the final amount of scar produced. I
the bonding of the collagen filaments or cross
At this point, movement in this area would be
links (Figure
disadvantageous and could lead to further tissue
early controlled movement without disruption
and/or clot disruption. Modalities aimed at de
of the wound. Controlled movement will cause
4-2),3 The cross-linking allows for
creasing inflammation, proper positioning, and
the fibrils to align lengthwise along the line of
appropriate anti-inflammatory medications are
stress of the healing structure. 12 Because vascu
of the most value at this point (Figure 4-1).
larity remains high during this phase, the im
The granulation phase begins when the mac
mature scar sti II has a characteristic pink color
rophages and histiocytes debride the area. The
ing. Wound closure usually occurs at this stage,
granulation stage is so named because of the
and the time frame varies depending on the vas
appearance of capillary buds that microscopi
cularity and metabolic rate of the tissue. In tis
cally look like granules. Healing cannot pro
sues with high metabolic activity (muscles, skin,
ceed further unless this increased connective
etc.), wound closure occurs in 5 to 8 days. In
tissue vascularity can meet the metabolic de
tissues with lower metabolic activity (ligament
mands of the healing tissues. Immobilization is
and tendon), wound closure occurs in 3 to 5
essential during this phase to permit vascular
weeks.6 During this phase, gentle handling of
regrowth and prevent further microhemorrhages
the wound is essential. Gentle manual therapy
acute inflammation fibrous repair remodelling and contraction
months
2
3
4
... ice, compression, elevation, gentle movements
5
6
7
8
... protect weak jOint, ensure joint is stable, remove hematoma
... allow new collagen to feel normal tensions
... prevent undesirable shortening, e.g., muscles, joint capsules
Figure 4-1 Encouraging favorable healing conditions. Source: Reprinted with pe rm is s i on from P. Evans, The Healing Process at the Cellular Level, PhYSiotherapy, Vol. 66, No.8, pp. 256-259, © 1980, Physiotherapy Canada, and G. Hunter, Specific SoflTissue Mobilization in the Trealment of Son Tissue Lesions, Physiotherapy, Vol. 80, No. I, pp. 15-21, © 1994, Physiotherapy Canada.
Copyrighted Material
Histopathology o/Myo/ascia and Physiology oJlvlyoJascia Manipulation
5I
Intramolecular Cross-links
Collagen filament
[
a,
a,
Amino acid chains
Cross-link
A
Intramolecular Cross-links
Collagen filament
Collagen filament
[
'-/"_
__ _
):__ ""'l
W--__,
[
B Figure 4-2 Collagen bonding increases tensile strength: (A) Weak intramolecular cross-links form between amino acid chains within one collagen filament. (8) Stronger intermolecular cross-links form from one coJiagen filament to another. Source: Reprinted from Hardy, A., Biology of Scar Tissue, Physical Therapy, Dec. 1989, Vol. 69, No 12, with permission of the American Physical Therapy Association.
techniques may be appropriate at this time. Soft
long duration stress during this phase. During
tissue mobilization designed to break up scar
this time, the scar tissue is responsive to manual
tissue will inflame the wound, leading to further
therapy but the progress will be somewhat
deposition of collagen5,6
slowed. Without controlled stress or mobiliza
The final stage of scar formation is the matu
tion during this phase, however, tensile strength
ration or remodeling phase. This stage may last
of the scar will not improve and optimal function
from 3 weeks to 12 months.13 During this phase,
wiJl be diminished.
collagen must change in order to reach maxi mum function. A reduction in wound size, a realignment of collagen fibers, and an increase in the strength of the scar are all characteristic
Cycle or Fibrosis and Decreasing Mobility in Connective Tissue
of this phase. Arem and Madden 12 confirmed
The fibrotic process is histologically distinct
physical change in scar length could be
from the scar formation process. The f ibrotic
achieved through the application of low load,
process in connective tissue is a "homogenous"
that
a
Copyrighted Material
52
MYOFASCIAL MANIPULATION
process involving an entire tissue area or the
flammatory exudates, along with damaged col
entire tissue "fabric," and does not have clear
lagen and other waste products, are carried away.
cut stages as does the scar tissue formation pro
The increased metabolic activity in the area
cess. The fibrotic process is cyclical in nature,
stimulates the body to increase the area's vascu
whereas the scar formation process is a linear
larity. With increased vascularity and debride
process that has a distinct end. The fibrotic pro
ment of damaged collagen (from microtrauma),
cess in connective tissue can continue as long as
fibroblasts are activated to replace lost colla gen. Since the inflammatory process is gener
the irritant is present. The fibrotic process is generally initiated
ally painful, the joint is not being moved in
by the production of an irritant, possibly trau
proper fashion. The collagen begins to be laid
matic exudates from nearby acutely inflamed
down in more haphazard arrangement since ad
traumatized tissue or a low-grade irritation/
equate stress is not being placed on the tissue,
inflammation of the tissue. The low-grade irrita
and cross-linking with other preexisting col
tion may be caused by arthrokinematic dysfunc
lagen fibers begins. At one point, myofibroblasts
tion, poor posture, overuse, habit patterns, or
appear in similar fashion as in the scar process.
structural or movement imbalances. A rotator
The myofibroblasts, which contain significant
cuff irritation, for example, may be caused by a
amounts of actin and myosin in the cytoplasm,
poor tennis service, poor sleeping postures, oc
anchor to adjacent collagen fibers and contract,
cupational overuse syndromes, and other causes.
shrinking the tissue. The tissue shrinkage results
The mechanical irritant produces a low-grade
in further dysfunctional movement, which, in
inflammation, which then starts the process.
turn, creates more mechanical stresses and more
With an inflammatory response, macrophages
chronic irritant (Figure
are activated to clean and debride the area. In
ritant is present, the cycle continues.
4-3). As long as an ir
Chronic irritant
,
Macrophages activated
Abnormal movement (biomechanics)
, \ ,
\
Increased vascularity
Shrinkage of connective tissue
J
Increased myofibroblastic
Increased
activity
fibroblastic activity
Increased production of connective tissue (fibrosis)
Figure 4-3 Cycle of fibrosis and decreasing mobility.
Copyrighted Material
/
S3
and
Response of Myofascial Tissue to
knee joint. The animals were then sacrificed at
Immobilization
various times of immobilization and the
Connective tissue has a characteristic his tological and biomechanical response to im mobilization. Most of the currently available focuses on animal studies in
research,
which an area of the body is immobilized for a of timc, after which the connective tissue is histologically and biomechanically Several factors must be considered before ap the results of these studies to the rehabilitative population. The f irst is that these the results of which should be
are animal
app! jed to the tion.
human
and of greater clinical importance,
many of the studies that are discussed in this chapter deal with the response of
address the re
sponses of traumatized and/or scar tissue. In the
connective tissue
orthopedic
that has been immobilized has also been trauma and bio
tized. Trauma does affect the mechanics of the Also
into the
is the process of
scar formation, and the effects of immobiliza tion on the
scar tissue. All of these
clinical scenarios are addressed in detail because the response of normal connective tissues to im mobilization provides a basis for
the authors found fibro fatty
especially in the
and recesses. The
exhibit changes within 4 to [0
a change in the infiltrate's appearance, which became more fibrotic. This created maIC[;)Sc:op adhesions in the recesses and capsular folds. and
to
one being a
the primary
Joss in ground loss. The
with no
components of lost ground substance were the and water. The authors re a 30 percent to 40 percent loss in both sul fated and nonsulfated groups. Since the purpose of the nonsulfated group is to bind water, the water loss is explained. chapter, one of the
As noted in the
purposes of the ground substance is to lubricate the area between f ibers.
fiber lubrication is associated
with the maintenance of the so-called critical interfiber distance. This
the distance that
must be maintained between allow them to the col-
Also, because coHagen fibers are laid down ac to the stresses
connective tis
by Amiel,
lack of
ap
in immobile connective tissue is The collagen then binds adjacent
animal studies on immobilized connective tissue
the extensibility of the tissue
Woo and
In studies
primar
animals were immo internal fixation for periods from 2
to 9 weeks. A
histochemical
showed several significant
14.15 In
to limit mobility. Much of the
ily knee
with
cross-linked by newly
connective cells
immobilization,
bilized
the
amount of infiltrate found,
fibers approximate and
is subjected to
their associates.
folds
the
cal interfiber distance is not
Nontrallmatized Connective Tissue
were
and biomechanically. From a
microadhesions between fibers. W hen the criti
traumatized conditions.
sues
histochemical
" or
non traumatized, connective tissue to immobi lization, and do not
ticular tissues were
Several
factors
why
amounts of ground substance are lost, gen is not.
the half-life of nontraumatized
one-third of the femur to the distal one-third of
collagen is 300 to 500 days whereas the half-life of substance is L 7 to 7 days23 25
the tibia to
with immobilization times of less than 12
was
from the proximal avoid
the
Copyrighted Material
54
MVOFASCTAL MANIPULATION
of synthesis, and net amounts of collagen are lost.26 Biomechanical analyses indicated that ten times the torque required to move a normal joint was required to move the immobilized joints. After several repetitions, the amount of torque required to move the immobilized joint was re duced to three times that of a normal joint. The biomechanicat implication is that fibrofatty macroadhesions and microscopic adhesions in the form of increased collagen cross-linking
Figure 4-4 Drawing showing the laying down of
contributed to the decreased extensibility of the connective tissue. 16-21
newly synthesized collagen, forming cross-links onto
Schollmeier et at immobilized the forelimbs
existing collagen f ibers. These cross-links are be
of 10 beagles for 12 weeks. At the end of that
lieved to be responsible for decreased extensibility
time, the passive range of motion of the gle
in immobilized connective tissue. Source: Reprinted
nohumeral joints was markedly decreased and
from Donatelli, R. and Owens-Burkhart, B., Effects
intraarticular pressure was raised during move
of Immobilization on the Extensibility of Periarticu lar COJlnective Tissue, Journal of Orthopaedic and Sports PhySical Therapy, Vol. 3, pp. 67-72, with per mission of the Orthopaedic and Sports Sections of the American Physical Therapy Association.
ments. The capsule showed hyperplasia of the synovial lining and vascular proliferation of the capsular wall. Functional and structural changes began to reverse after remobilization and re turned to normal limits after 12 weeksY A more recent study, which looked at rat ankles immobilized for 2 to 6 weeks, found
collagen synthesis occurs at the same rate as
slightly different results. This study found that
collagen degradation. After 12 weeks, however,
dense connective tissues remodel in such a way
the rate of collagen degradation exceeds the rate
that mobility is unaffected after 2 weeks of im-
Figure 4-5 Electron micrograph of normal ligament (left) and healing scar at 2 weeks (right). Source. Reprinted from Injury and Repair of the Musculoskeletal SoJi Tissues (p 112) by SL.-Y. Woo and J.A. Buckwalter with permission of the American Academy of Orthopaedic Surgeons, © 1987.
Copyrighted Material
Histopathology of Myofascia and Physiology of Myojascia Manipulation
55
mobilization but markedly limited after 6 weeks
In a study performed by Evans et al,22 ex
of immobilization28 The authors attribute these
perimentally immobilized rat knees were remo
changes to dense connective tissue undergoing
bilized either by high-velocity manipulation,
remodeling between the 2 and 6 week periods.
by range of motion, or both. The investigators
Earlier studies implied that cyclic mobilization
found that, with manipulation, the macroadhe
of the immobilized joints caused rupture of the
sions were ruptured, and partial joint mobility
remodeled tissues, which limited early mobility.
was restored. If joint motion was allowed subse
In Figure 4-6, following each yield point, the
quent to the manipulation, functional range was
angle of the slope of the curve is unchanged. This
regained.
supports the idea that rupture of the remodeled
Range of joint motion, along with freedom of
tissue that initially limited motion had not oc
movement, produced the same effect, although
cllrred; rather discrete adhesions between folds
more gradually; after 35 days the joints were
of tissues were responsible for this.
histologically indistinguishable. Rat knee joints immobilized for more than 30 days, however, did
Langenskiold et al performed a study on im mobilized, healthy rabbits. The authors found
not regain full functional range. Again, the re
that casting for 5 to 6 weeks significantly de
sults suggest that movement restores the normal
creased knee flexion. The resumption of normal
histological makeup of connective tissue, but the
activity, however, was able to restore 90% of
longer the period of immobilization, the lower
joint mobility after 3 weeks. When immobiliza
the potential for achieving optimal results.
tion was increased to 7 to 8 weeks, only 28%
In summary, immobilization of connective
of knee flexion returned after 10 weeks of re
tissue generally results in loss of ground sub
conditioning. It took as long as 12 months for
stance with no net collagen loss (with immo
some of the animals to regain full mobility.29
bilization periods of less than 12 weeks). The
The study suggests that the longer the period of
loss of ground substance also allows for signifi
immobilization, the more difficult it becomes to
cant water loss. Histologically, this results in
regain normal tissue structure and mobility.
decreased tissue extensibility due to the inability
t :j:
75 (j) Q)
OJ Q)
\
50
c
0 x . -
'iI
25
0 0 0 0
20
40
Loading Time (seconds) Figure 4-6 Diagrammatic representation of the qualitative difference in pattern of dorsiflexion between limbs casted for six weeks (n and all other limbs (t). In all ankles casted for 6 weeks, the curve exhibited intermediate plateaus ( ), followed by small but sudden slipping further into dorsiflexion (*), suggesting rupture of an adhesion with each slip. Source. Reprinted from Reynolds, C.A., Cummings, G.S., and Andrew, PD. et aI., The Effect of Nontraumatic Immobilization on Ankle Dorsiflexion, Journal a/Orthopaedic and Sports Therapy, Vol.
23, No. I, p. 31, with permission of the Orthopaedic and Sports Sections of the American Physical Therapy Association.
Copyrighted Material
56
MYOfASCIAL MANIPULATION
of the collagen fibers to maintain the critical inand the of microscopic
from
of connective
and
limb is immobilized without
formation
cross-links, At the mac
present, no con
roscopic level, immobilization causes the forma
tracture occurs, even after weeks5,6 Apparently,
tion of f ibrofatty macroadhesions that become
a catalyst is needed to begin the process of con
progressively more f ibrotic with increased im
tracture
mobilization times, The studies also indicate that
methods of fixation may affect tissue changes,
the
is traumatic exudate. Also,
all periarticular connective tissues responded
The other factor in the different results re
and cap
ported in the two studies may be the method of
su Ie surrounding fascia all had the same basic
fixation, The rigid fixation oflhe previous stud
in the same basic fashion,
response to immobilization, Remobilization of
no movement, whereas
the tissues causes a reversal of
the cast f ixation in the Flowers
the immobilization time has not been unreason
allowed enough movement to prevent tissue
More research is needed on duration and
within the
may have
can be seen clinically for
in the fixation methods of distal
connective tissues. Clinicians need to consider
radial fractures, When the fracture is casted, a
the
less than optimal union occurs, usually with the
changes occurring in the immobilized
connective tissues and
formation of extra callus, From a rehabilitation
accordingly. Before
standpoint, the functional range of motion of
weakened cells
the wrist, hand, and radio-ulnar joints is usually from
gentle mid-range movement and excessive forces; but after 6
treatment
protocols should incorporate sufficient stress to induce connective remodeling to accommodate until full ioint mobility is
restored. If the fracture is fixated with an external Iy much cleaner, with
f ixator, the union is
less callus formation. Functional range of motion is typically not fully
however, especially
in the wrist and radio-ulnar The clinical
achieved28
patients
Traumatized Connective Tissue
for rehabili or surgery and subse
tation
questions have arisen about how
quent immobilization will have connective tissue
traumatized connective tissue response to im
changes as
mobility differs from that of nontraumatized
tion of two processes is occurring-scar forma
described. Second, a combina
tissue. The previous studies have dealt with the
tion and f ibrosis. Scar formation occurs in areas
response of nontraumatized connective tissue to
that sustained direct insult and are in need of Fibrotic changes occur
immobilization. Some consider internal fixation form of im
of a limb to be a
in tissues
the scar area that were not
mobilization, even though the f ixation is located
directly traumatized but affected chemically by
some distance from the tissue studied, In a
the traumatic exudates. Traumatic exudates in
human were casted for a
of several weeks
and then examined. The range of motion lost
fi ltrate these and, in the connective tissues,
the immobilization within one treatment session of
Scar tissue versus
Scar formation
20 minutes. The implication of this
and f ibrosis are two
of the previous immobilization studies is that
logical processes,
when connective tissues of
exist. Scar formation is a localized response,
Jomts are
different histo some similarities
immobilized in the presence of inflammatory
with activity limited to a traumatized area, but
joint contractures occur, and result
f ibrosis is a homogenous change in the "fabric"
Copyrighted Material
Histopathology
and
of the connective tissue. Limitation in mobility
Manipulation
57
One of the classic works on muscle response
caused by scar tissue results from the lack of ex
to immobilization was
tenstbil ity of the scar tissue and from the adhe
aPI In this study, cat soleus muscles were im
sions formed with
mobil ized at various lengths and for various
healthy connective
tissue. Limitation in mobility caused
fibrotic of
results from the lack of
Tabery et
of time. The animals were immobilized cast. Some of the animals were sacri and
ficed and the muscles were
the entire tissue. And as fixation methods may
im
a part.
Biomechanically, the
histologically
was increased in the mus
mobilization (immobilizer or cast) may allow sufficient movement to dampen the effects of
cles immobilized in the shortened position,
immobilization,
ably because of the connective tissue
For example, a shoulder may be frozen due
within and surrounding the muscle, Muscles
to a macroscopic scar adhesion in the folds of
immobilized in the lengthened position had no
the inferior
A manipulation under anes
thesia would tear the scar adhesion and restore A frozen shoulder may also be caused where the entire capsule shrinks
a
length-tension
in the characteristics. From a
the muscles immobilized in the shortened posi with an over
tion had a 40% loss
and a
aU decrease in fiber length. The muscles im
The distinction is that homogenous
a 19% increase in sarcomeres and an overall
(the analogy here is the size 5 size 8 in the
rather than a
scar
adhesion, limit motion, A manipulation under anesthesia may not be as successful in such a for the
case, since an entire tissue is immobi
The benefit of the increased mobil the potentia I
position exhibited
mobilized in the
sock is
to
fabric and the restimulation of the
After 4 weeks of re
increase in fiber
mobilization, the number of sarcomeres in the muscles returned to normal. This study illus trates the principle that muscle tissue will to change in
by
mal lengths. In a follow-up study
fibrotic
muscle
Muscle Tissue
or
sarcomeres in order to keep sarcomeres at nprt'.. rm
vWAU"v,",
were studied.
The response of muscle tissue to immobiliza
Sciatic nerves
were stimulated for I
tion is less simplistic and more multifactorial
either the shortened or lengthened
than the response of connective tissue to immo
muscles stimulated in the shortened range had
bilization,
a 25% loss of sarcomeres after
can be
a contractile
a muscle
or actively immobilized and/or
contraction. Sarcomeres were
12 hours of
recov
the muscle may be immobiJized in a shortened
ered in the muscles between 48 and 72 hours,
or lengthened position. The muscle may be in
The implication of these studies is that muscles
nervated or
slow
or
twitch or predominantly fast twitch. Being a highly metabolic
the immobilized muscle
can
metabolic the histological
response of muscle tissue to immobilization and to review the various factors in
Im
mobilized muscle that are the most applicable to myofascial manipulation,
Kauhallen
al immobilized the vastis inter
medius of t3 rabbits in a shortened position for
depending on its activity level. The purpose of this section is to outline
shortened lose sarcomeres at a much slower pace than muscles actively shortened.
2 to 28 days, After 3 days of immobilization,
a J 5% decline in muscle
the muscle fiber diameter.
changes were
and muscle fiber diameter had de creased to 56%. By 4
severe f ibrotic
of myofibrils was obser ved and f iber
Copyrighted Material
58
MVOFASCIAL MANIPULATION
diameter
had decreased to 47% of control
values.33
of the body. The terms "myofascial manipula tion" or "soft tissue mobilization" are used inter
Leivo et aP4 also immobilized the vastis in
changeably with massage. In order to understand
termedius of rabbits into the extended position.
the effects of myofascial treatments on the body,
Progressive disorganization of myofibrils with
a review of the available literature needs to be
breaking up of Z bands and an increase in the
explored. Most studies on the effects of mas
number and size of plasmic lipid vacuoles was
sage were published before the 1950s and were
seen with increased duration of immobilization.
primarily animal studies. The effects discussed
This study, as does the prior study, suggests that
by these studies include circulatory changes,
adverse mechanisms are in effect at the onset of
blood flow changes, capillary dilation, cutane
disuse atrophy.
ous temperature change, and metabolism. More
Kannus et aps found that, after 3 weeks of immobilization, there was a significant decrease
recent studies, however, discuss the effects of massage on collagen and scar healing.
in the mean percent of intramuscular connective tissue. They also found an increase in the rela tive number of muscle fibers with pathological
Effects of Massage on Blood Flow and Temperature
alterations. The clinical implication of these f indings re
The effects on blood flow in the extremities
lates to the types of immobilization that occur in
of 17 adult men and women were analyzed by
the practice setting. Immobilization may occur
Wakim36 Groups were subdivided into those
artif icially (external or internal f ixation), or as
with no medical problems, those with rheuma
a physiological mechanism (muscle guarding).
toid arthritis, those with flaccid paralysis, and
In the clinical setting, immobility may be due
those with spasmatic paralysis. The subjects re
to trauma, past or present. A good example is
ceived (wo types of massage: ( l) a moderate
the whiplash injury, in which immobilization is
depth stroking and kneading massage described
(2) a
caused intrinsically by the cervical and upper
as a modified Hoffa-type massage, and
thoracic paravertebral muscles, the scapulotho
deeper vigorous, stimulating, kneading, and per
racic muscles, and the shoulder girdle muscles.
cussion massage (as practiced in some European
In many cases, the surrounding musculature re
schools of physical therapy). The treated areas
mains tonically active long after the facet or
were the upper and lower extremities, and the
ligamentous strain has healed. The body learns
massage lasted 15 minutes.
a new recruitment pattern for the surrounding
Wakim concluded that there was a consistent
muscles, and this hypertonic pattern remains
and significant increase in total blood flow
long after healing. The muscles are then actively
and cutaneous temperature after deep stroking
"immobilized," causing some of the histological
and kneading massage of the extremities in
changes mentioned previously. Often, the most
normal subjects, patients with rheumatoid ar
difficult part of the therapeutic process is deal
thritis, and subjects with spasmatic paralysis.
ing with this hypertonicity which is secondary
A much milder effect was noted with the more
to the original injury.
superficial Hoffa-type massage and primarily in
,
the group with paralysis. The greatest increase PHYSIOLOGY OF MYOFASCIAL MANIPULATION
in circulation after deep stroking and kneading massage to the extremities occurred in subjects with flaccid paralysis. Significant increases in
Massage has been used for centuries by vari
blood flow and temperature were still apparent
ous cultures around the world. Massage may
in all groups receiving the deep massage when
be described as systematic, theraputic, and func
these signs were remeasured at 30 minutes.
tional stroking and kneading of the soft tissues
Blood-flow increases diminished markedly after
Copyrighted Material
59
and
30 minutes. Neither deep
nor
kneading,
massage of the extrem
ities resulted in
the area in the onds. The
significant
in blood flow of the contralateral unmassaged
of the stroke
blanched after a latent period of 15 to 20 sec lasted for several minutes.
A harder stimulus resulted in a hyperemic line in the immediate path of the stimulus. W ith mi croscopic investigation, in instantaneous
change in the from increased blood tlow to the part,
pressure resulted of all
may well depend on the manner in which the
the underlying capillary for
massage is administered. Wakim found that the
duration.
moderate
Hoffa massage affected
the
with flaccid
blood flow of
longer unspecified
Carrier's observations may the results of the studies
whereas the deep stimulating massage had the
with
Wakim and Wolfson.
If the moderate depth Hoffa-type massage (non
the blood flow of ail
effect of
in the
microscopic field. A heavier pressure
is similar to the light stroke pro
studied.
a blunt instrument in Carrier's
EtTects of
kneading massage on venous Wolfson,
blood flow were also examined
an immediate
reaction is
an effect of massage. The I ight stroke or Hoffa
was ap
massage creates capillary dilation but for too
plied to the limbs above and below the knee
short of a duration to affect blood Yolume, blood
animal models ( after
stroked
or type
area. W hen vigorous
sured blood flow by cannulation of the femoral
ministered, the result is a
vein during anesthesia. The blood draining out
of the underlying
was measured and
limb at the same rate the blood was being re increase in blood flow followed
a de
crease in blood tlow to a rate less than normal.
Hoffa-type massage are used in myofas cial manipulation. In other
This decrease in blood flow continued through
work of Clark and
out the administration of the massage. Immedi
capil
cessation of the massage, blood Wolfson
massage and
ture. Both the vigorous
moved. The massage initially caused a fairly
flow slowly returned to normal.
which creates a
in both blood flow and skin
into the
who studied the
circulation in the ear of a rabbit fol
lowing massage.39 A permanent window was Iy created in the rabbit's ear, allowing
concluded that massage causes an increase in
observation of the
the rate of blood flow
sagc, an increase in rate of blood flow as well
mechanically
the blood vessels and allowing them to refill
as actual
with fresh blood.
The vessel wall
The
massage increases the blood tlow to as
in the vessel walls was noted. was evidenced
on human
as well as animal models. Caution should be
the
of leukocytes. Clark
and
in these studies are similar.
the area being
Following mas
and Swenson concluded that massage is accom or followed
an increased interchange
of substances between the bloodstream and the tissue cells. The vessel wall
when of animal studies to the human
the tissue metabolism.
The reaction of normal blood vessels to me
Although massage is not defined in Clark
chanical stimuli was microscopically examined
and Swenson's study, the
by Carrier.38 Gross visual observation of skin
blood flow and vessel wall
reaction was made
notion that massage, or soft tissue mobilization ,
mechanical stimu
lation of the skin by a blunt instrument. With
affects the vascularization of the
Copyrighted Material
of increased the underly
60
MYOFASCIALMANIPULATION
ing the massage. Clark and Swenson's conclu sion agrees with
Because massage does not influence the basal
who found an imme
diate capillary reaction underlying the stimulus pressure. Cutaneous
of light and
following modified Hoffa
lure of an massage was studied
a likely explanation for the in creased urine output is the
the area
blood volumes and blood flow
na�;sal�eo may cause the area to disoose of
Martin and associates40 adults and those with rheu
studied
effect on
the circulation of the part concerned, Increased
fluids during and after massage, urine output.
of massage varied from 5 to 10 minutes.
A recent study has also examined the benefits
Cutaneous temperature of the digits was mea The results indicated
sured wilh
that after massage of an extremity, there were
of massage on the human virus (HIV) positive popUlation. gay men (20 HIV+, 9 HIV-) received dally mas
superficial cutaneous temperature increases in
sage for] month. After the] month of massage,
the extremity
a
from 15 to 90 minutes. 1n the peripheral cutaneous
a related
increase in the number of natural there appears to be an enhancement of the
temperature was examined after back massage. With three subiects. massage caused no
men,
kilIer cells was noted in the immune system's cytotoxic
associated
with massage. Further research in this area is 42
of the extremities. and variable differences. the agree on one
increased
ncreased blood
sage causes capillaries to dilate in the
and increased metabolism to the
underlying the massage. If capillary dilation
massaged have
occurs, increased blood volume and flow occur,
support the notion that massage is
resulting in an increased temperature in the area
indicated in areas where increased tissue circulation and nutrition are desired.
of the massage.
on Metabolism
Efl"ect of
Physiological Reflexive (Autonomic) Effects of
can also affect the metabolic prothe vital
and bodily waste
A review of the literature on
,"U'vv' 8
The literature on the retlexlve, or effects of massage consists of studies
effect on human metabolism was perform
the effects of connective tissue massage distal
Cuthbertson41 Cuthbertson concluded that there
to the area being treated. In
was increased output of urine after m assage,
tive tissue massage, Ebner
especially fol
blood
abdominal massage. The
excretion of acid was not consistently altered and there was no
in nitrogen content,
of connec that
and supporting tissue and muscle
cannot function as separate entities. Connective tissue massage stimulates the circulation to an
inorganic
or sodium chloride. The
area of the body that in turn,
increased urine
occurred within 3 hours
increased circulatory pathways to other regions
of the massage; the total net output of urine
of the body. The cause for the initial increase
in a 24-hour oeriod was unchanged. in the survey, there was no in crease in basal
in circulation is secondary to the mechanical tension created by the connective tissue massage
of oxygen,
which
crease in basal
process. Localized in may occur, although
stimulates the tissue.
Ebner studied the skin
rate, or blood pressure. The above metabolic ef fects apply to a
opens up
of three
after connective tissue massage4' Ebner found an increase in skin
localized effects have been inconclusive.
Copyrighted Material
( 1°C to
of the foot following 20 minutes of connec
Histopathology of !vf)'ofascia and Physiology of Myofascia Manipulation
61
tive tissue massage, which was performed on the
performed. Chapter 2 fully elaborates on the
sacral and lumbar segments of the back. Volker
autonomic effects of myofascial manipulation.
and Rostovksy (as reported by Ebner) also car ried out experiments using connective tissue
Effects of Massage on Fibroblastic Activity/
massage and found a maximum increase in tem
Collagen Synthesis during the Healing
perature approximately 30 minutes after the mas
Process
sage ended distal to the area being massaged. The mechanical friction of the massage stroke
Research has shown that controlled motion of
stimulates the structures within the connective
soft tissues influences the healing process.44-47
tissue, primarily the mast cell. As the mast cell
As discussed prior, the soft tissues of the body
is stimulated, it produces histamine, which is
are subjected to both internally and externally
a vasodilator. The vasodilation increases blood
generated forces. Without stress applied through
flow to the area treated and to other areas receiv
the tissues, the tensile strength will decrease47
ing histamine through the bloodstream. The in
Stearns48 observed the effect of movement on
creased permeability of the capillaries and small
the fibroblastic activity in the healing connective
venules allows for quicker and more complete
tissues. She concluded that fibrils form almost
diffusion of waste products from the tissues to
immediately. External factors were responsible
the blood. The blood components, when filtered
for assuming an orderly arrangement of these
by the kidney and excreted as urine, show in
fibrils. Cyriax and Russe1l49 believe that gentle
creased nitrogen content, inorganic phosphorus,
passive movements of the soft tissues wi II pre
and sodium chloride, as reported by Cuthbert
vent abnormal adherence of the fibrils without
son41 The increased circulation caused by con
affecting their proper healing.
nective tissue massage (stimulating massage)
The manual therapist should use his or her
through the reflexive nature of histamine re
knowledge of the stages of healing to determine
lease, follows the f indings of Carrier, Martin
when specific massage techniques should be
et ai, and Wakim when stimulating massage is
utilized (Figure
4-7). The previous chapter dis-
Injury 1-----,
)/
0'l! -s:-'Ii <::0 . .,::, ,,'Ii
r!J)
LJ Q:'l! Lag phase __
Time Figure 4-7 General trend of increase in tensile strength of injured soft tissue during healing process. Source: Reprinted with permission from P. Evans, The Healing Process at the Cellular Level, PhYSiotherapy, Vol. 66,
No.8, pp. 256-259, © 1980, Physiotherapy Canada, and G. Hunter, Specific Soft Tissue Mobilization in the Treatment of Soft Tissue Lesions, Physiotherapy, Vol. 80, No. I, pp. 15-21, © 1994, Physiotherapy Canada.
Copyrighted Material
62
MYOFASCIAL MANIPULATION
cussed the soft tissue's inability to withstand
linking adds strength to the wound but can also
stress immediately after injury. It is, therefore,
lead to a decrease in mobility. During this phase,
important to protect the injured tissues from
the wound should be continually tensioned to
stress during the early inflammatory stage. The
promote good fiber orientation and scar tissue
f ibrin bond holding the wound together can
extensibility. The use of deep massage tech
easily be disrupted, ultimately leading into an
niques may be appropriate at this time to de
increase in the amount of scar tissue formed5o
crease adhesions and break down scar49 One
As collagen does not appear in the wound for
study on friction massage done for 10 minutes
4 to 6 days after injury, the value of friction or
a day over 3 months on pediatric burn patients
deep massage before this time is questionable.51
with hypertrophic scarring failed to show any
As the tissues move into the regeneration
increase in pliability or height of the scar. 57 Fur
phase, fibroblasts begin to lay down collagen,
ther studies using longer or more frequent treat
and the tensile strength increases. Recent re
ment sessions should be done before concluding
search using augmented soft tissue mobilization
that massage is ineffective in the treatment of
(ASTM) has proven to be effective during this
hypertrophic scarring.
stage. ASTM uses speciall y designed instru ments to assist the therapist in mobilization of
CONCLUSION
soft tissue fibrosis. An animal model using rat Achilles tendon injuries revealed that ASTM
The literature supports the use of myofascial
leads to an increase in f ibroblast recruitment and
techniques to influence the healing of soft tis
activation as well as an increase in f ibronectin
sues. The choice of technique by the physical
production 52 By increasing f ibroblast activity,
therapist should be based in part on the stage of
the healing process in this animal model was
healing of the injured tissue. Gentle techniques
enllanced.53 Carefully applying tension during
may be beneficial early on to ensure an orderly
this phase will help collagen f ibers to align prop
arrangement of f ibrils and to prevent adhesions.
erly54,55 Transverse friction at this point can
In tile latter stages of healing, deeper techniques
be gently begun as not to detach the healing
may be more appropriate in order to decrease
fibers. The transverse movement is an imitation
adhesions, improve scar extensibility, and in
of the muscle's normal mobility by broadening
crease overall mobility of the soft tissues. A
but not stretching or tearing the heal ing fibers 56
good manual therapist must not only under
The movement will encourage realignment and
stand the histopathology of myofascia and the
lengthening of fibers.
stages of healing but must remember to use this
As the remodeling phase begins, collagen
knowledge when choosing treatment techniques.
synthesis equals collagen lysis. Evans50 found
Choosing the appropriate technique at the ap
that collagen fibers tend to contract and decrease
propriate time is essential to successful treat
scar tissue mobility at this point. Collage cross-
ment.
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collagen. Clill Orlhop< 1983; I SchollmcJcr G, Sarkar K, Fukuhara K, ct aL Structural and functional changes in the canine shoulder cessation of immobilization< Clin Orlho/J< 1 310-315<
PD, et aL The
Cumlllings GS,
28 < Reynolds
effect of nontraumatic immobiJization on ankle dorsi 29< Langenskiold A, Michalsson
WH, Woo SL-Y ct aL The connective tissue to immobillzalion: biochemical changes in of the rabbit knee<
tion
14<
30 Flowers KR, Pheasant SD< The use of
Therapy<
I 988;1ammty-March:69-74< C, et aL Physiological and structural
tion at different
by plaster casts< Am J Physio/
1972;224:231-244<
32< Tabery JC, Tardieu C. Experimental rapid
'"rfYHnPI<1"
loss with concomitant hypoextensibility< Muscle Nen'e< 33< Kauhanen
18 Akeso)l WH, Amid D, ct aL The connective tisslIe re
response<
1968;3:289-30 L
Leivo I, Petilla lVI,
Recovery of skel
'liter immobilizatIon of rabbjt hind limb<
etal
APivllS 1986;104(11):797-804<
Leivo I, Kauhanen S, Michaelsson JE< Abnormal mito
19< Akesol1 WH, AmJel D, et nL Collagen cross-linking
chondria and sarcoplasmic changes in rabbit skeletal
alterations in the joint contraetures: Changes in the
muscle induced by immobilization<
reducible cross-links in periarticular connective
106(12): 1113-1123
after nine weeks of immobilization. Connect
35< Kannus
A PMfS< 1998;
P, Jozsa L, ct aL Free mobilization and low
to high-intensity exercise in immobilization-induced
1977;5:15-19
Akeson WH, Amici n Immobility
of synovial
joints: The pathomechanics of joint contracture< Biorhe1980; 17 95-110
to immobility: A study and dermatnn sulfate
muscle atrophy. J Applied Physiol. 1998;84(4):1418-1424.
Wakim KG< The
L Akeson WR, Amici D< The connective tissue response chondroitin 4 and 6 sulfate in periarticular po,nnf'f't!IVP
of massage on the circulatIOn
io normal and paralyzed extremities< Arch Phys Med Rehabil. 11)49;30: J 35<
37< Wolfson K Studies on effect or physical therapeutic on function and structures< JAMA < 193 ;
tissue of control and immobilized knees of 22. Evans
angle
digital stiffness. J Hand
198 J ;M8y/June:198-203.
Orlhop. 1973;93:356-362.
sponse to immobility: an accelerated
J E, Yideman T Osteoar
changes in the cat's soleus muscle due to immobiliza
i 6< Woo S, Matthews Jv, et al < Connective tissue response 18:257-264< to immobility< Arlhritis Rhewll< I
Or/hop.
rnu
WH, et aL Stress deprivation effect
3 L Tabery JC,
knee and hip< Acla Orlhop Sea"". 1976;47:290-298<
Exp
Studies in skin
curves in the
15< Videman T, Michclssoll J, Rauhamaki R, Langenskiold
periartIcular connective
copolysaccharides in
thritis of the knee in the rabbit produced by immobiliza
Yidcman T, Eroncn 1, Friman C, et aL GlycoaminogJy
17<
J 956;218: J 3\1-145
flexion. JOSPT 1996;23(13):27-33
soft tissue injuries-a
lttcraturc<
J Bioi Chem.
studies on skin
on metabolic turnover of medial collateral ligament
1-79<
10< Lotz M, Duncan M, Gerber
animals:
in
25< Schtllcr S, Matthews M, et al. The metabolism
26< Amie] D,
of macropbages
wound repaie Am J Pafhor I
20
and mobilization or rat knee joints. J Bon e Joinl Surg< 23< Neuberger A, Slack
Barnes MR< Ortho-
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lvfanipulation
96 2020.
190-197.
G, et aL Experimental immobilization
38< Carrier EB< StudIes on physiology of capillaries: Reac
Copyrighted Material
64
MYOFASCIAL MANIPULATION
and other stimuli.
tioll of human skin capillaries to
in transparent chambers in the
Am] Physio/. 1922:61
39. Pemberton R. Physiology of massage. In: AMA Hand
Am J
49. Cyriax.1, Russell G. Tex/book ofOr/i1opedic
book of Phvsical Medicine and Rehabililatioll. Philadel phia: Blakinston Co: 1950: 13).
40. Martln GM, Roth GM,
car
Anal. 1940;67:55-97. volume 2. London: Tindall and Cassall Ltd; 1990.
P.
50. Evans Cutaneous temperature
of the extremities of normal
and patients with
rheumatoid arthritis. Arch
Med
Relwb!l. 1946;
The healing process at the cellular lewl. Pill's
io/liempy. 1980; 66(8):256-259 51 Hunter G. Specific soft tissue mobilization in the treat soft tissue lesions. Phl'SlO/hemp,l'. J 994;80( I)'
ment
L 4
Cuthbertson DP.
Davidson CJ, Ganion LR, Gehlsen G, et al. Rat tendon and functional
42. honson G, Field T, Scafidi F,
al. Massage therapy i s as
mobilization. Med Sci Sports
sociated with enhancement orlhc immune systems cyto loxic capacity. /111] NeUl'O.fci. 1976:84( 1-4):205-217.
19. 53. Melham TJ, Sevier TL, Malnofski MJ, ct
43. Ebnn M. COllnective Tissue Mali/pula/ions. Malabar, FL: Robert E Kreiger Publishing; 1985.
non-Invasive augmented sort tissue mohilization tech nique. Med Sci Sports
44. Takai S, Woo SLY, Horihe S, et al. The errects of rre quency and duration of mohilization Oil tendon healing. ]01111/0/
I
Or/hop Res. 1991
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therapeutic value of passive JOlnt range of motion.
Sporl,.
Clill
Increased tension on mCl1ts.
tendon maturation of collagen and D,
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The eITects of
Connect
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J980;
collateral hga
Am J :SP0rlS Med. 1991.l9(4):347-354
G Cyriax rriction
47. Forrester J, Zederfeldt B, Hayes T, et al. \Vol ff's law in re lalion to healing skin. J Trauma. 197(); 1 0(9):770-779.
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165--1 75.
Postacchl!1i F, Demartino C. Regeneration of rabull
Onilop Rei Res. 1984; 185(5) II 46. Gomez MA, Woo SLY,
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C, Akeson WH, Woo SLY, et al. Physiology and
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Chronic
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1982:
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Copyrighted Material
phic scar.]
BIII'I'I Care Rehabil. 1999;20(3):268 .. 271
CHAPTER 5
Neuromechanical Aspects of Myofascial Pathology and Manipulation Clayton D. Gable
The mere motion of muscular and/or fascial
Given that stretching is such an integral part
tissues through stretching feels good to humans
of normal human and vertebrate behavior and
and many other vertebrate animals. One has only
the IOO-year history of study of the influence
to think about their own tendency to stretch on
of various sensory mechanisms on movement,
awakening in the morning or after a long trip by
it is necessary to review some neurology that
airplane or car. Even animals such as our pets
is associated with myofascial tissues. To that
K. Borth
end, this chapter reviews the basic neurology
wick, Emeritus Professor of Classics at Edin
of myofascial tissues emphasizing the afferent
seem to like stretching. Walsh cited E.
burgh University, for the following account: The verb "stretch"
or stimulus perception side of the equation. In addition, the author reviews some of the more
(1:HVW, teino) is the
contemporary f indings regarding (I) the influ
common form and is used by Homer
ence of somatosensory receptors on movement
of stretching of a bow, reins, etc.-"to
control,
stretch oneself in running." Aeschylus
(2) muscle "tone," and (3) the interac
tion of biomechanical properties of myofascial
uses it of straining the voice. Galen
tissues and the nervous system.
uses it of stretching tendons, etc.
Following the review of the basic science re garding neurology and movement control, there
The noun, 1:0voe- (tonos), is appar
is a science/application section. This section
ently attested in Xenophanes (sixth
offers explanations for some of the techniques
century BC philosophic poet) of exer
found in Part !If of this volume in terms of cur
tion or striving after virtue or courage.
rent understanding of the reviewed neuroscience
It is used by Aeschylus of stretching
and neuromechanical aspects of myofascial tis
flax; in Herodotus and Aristophanes of
sues.
bed and chair cords, in Plato and Ae schines, of pitch of voice, or accent; in
BASIC AFFERENT NEUROLOGY OF CONNECTIVE TISSUE
Aristoxenus and subsequent musical writers of pitch-key; in the medical writer Soranus (second century AD)
A detailed presentation of the state of current
of power of contracting musc/es.fl(p6)]
neuroscience of receptor anatomy and physiol
As one can surmise from the passage above,
ogy is beyond the scope of this book. Therefore,
2000 years,
the following information summarizes classical
muscle contraction has, for almost been associated with stretching.
and recent understandings of peripheral recep
65
Copyrighted Material
66
MVOFASCIAL MANIPULATION
tors in skin and the various connective tissues of
of mechanical events. They transduce mechani
myofascia. These receptors fall into four major
cal energy into nerve impulses, which are then
categories of mechanoreceptors, nociceptors,
transmitted to the central nervous system via
thermoreceptors, and chemoreceptors . All of
their afferent neuron axol1S. They are located
these receptors influence or are influenced by
throughout the musculoskeletal system, the vas
movement, temperature, physiology, or pathol
cular tree, and the skin. They include special
ogy. Also, all of these receptors have influence
ized neuronal structures and free nerve endings
on movement and movement control as well as
(Table 5-1). Each of the various mechanoreceptors listed
direct and indirect influences on cardiovascular
in Table 5-1 has particular anatomies, firing
and respiratory physiology.
characteristics, thresholds, conduction veloci ties and, most importantly of all for a clinician,
Mechanoreceptors
functional andphysiologic effects. Therefore, the
Mechanoreceptors are exactly what the name
next few sections review some of the pe rti nent
implies; they are peripheral sensory receptors
characteristics and functional implications of
Table 5-1 Mechanoreceptors Fiber Size Receptor Type
Location and Information Transduced
and Group
Meissner's corpuscle
A
Skin: touch
Pacinian corpuscle
A
Skin: flutter Fibrous connective tissue: compressive stimuli
Ruffini's corpuscle
A
Skin: steady indentation Fibrous connective tissue: tension on structures such as ligaments
Merkel's receptor
A
Skin: steady indentation
Hair-guard, hair-tylotrich
A
Skin: steady indentation
Hair-down
A
Flutter
Primary muscle spindle
Au
Dynamic change of length
la Secondary muscle spindle
A
Muscle length, mostly static
II Golgi tendon organ
Au
Tension on a tendon
II Joint capsule receptors (Type II) Muscle afferents (III)
A II A8
Extremes of joint position (i.e., maximum tension on joint capsule) Mechanical, chemical, and thermal stimuli in muscle
III Muscle afferents (IV)
C
Mechanical, chemical, and thermal stimuli in muscle
IV Bare nerve endings
A-C
Mechanical chemical, thermal, and pain
Copyrighted Material
Neuromechanical Aspects oflvfyofascial Pathology and Manipulation
the various receptors. It is important to note that even those receptors listed in Table 5-1 as being primarily located in the skin contribute to pro prioception and kinesthesia. Gardner, Martin, and Jessell state the following.
Meissner's corpuscles are specialized struc tures located in glabrous (hairless) skin (e.g., palms, soles of feet, lips) of mammals. They are stimuli such as skin indentation (Figure 5-1.) The rapidly adapting characteristic is common
muscle and joints signal the station
to ?everal skin mechanoreceptors. It indicates
ary position of the limb and the speed
that a rapidly adapting receptor will respond to
(I)
a stimulus event with an action potential, and
specialized stretch receptors in muscle
then the receptor will go silent for a period of
termed muscle spindle receptors; (2)
up to several seconds failing receipt of another
Golgi tendon organs, receptors in the
mechanical event.
tendon that sense contracti Ie force or
In the case of a Meissner's corpuscle, a
effort exerted by a group of muscle fibers; and
111eissner's Corpuscles
rapidly adapting in their response to mechanical
Three types of mechanoreceptors in
and direction of limb movement:
67
single indentation of 70 to 1000 micrometers
(3) receptors located in
(0.00007-0.01 mm) into the skin would result in
joint capsules that sense flexion or ex
a single action potential with a subsequent silent
tension of the joint."2(p443)
period of up to several seconds. Although this
It is with Gardner, Martin, and Jessell's state
behavior would appear to be somewhat dysfunc
ment in mind that the following review is of
tional, rapidly adapting receptors have another
fered.
characteristic. They are responsive to repetitive
Epidermal-dermal junction ----,k;"oi� Merkel's ------ii---receptor Meissner's ---+----1{ corpuscle
is
Bare nerve ---41---ending Hair receptor
-+--,
__
Figure 5-1 Receptors in hairy and hairless skin.
Principles a/Neural Science,
Source:
Reprinted with permission from J.H. Kandel et aI., eds.,
3rd ed., pp. 533-547, © 1991, McGraw-Hili Companies.
Copyrighted Material
68
MYOFASCIAL MANJPULATJON
stimuli (at varying frequencies) with repeated
cally coupled to the surrounding subcutaneous
action potentials.
tissues by thin strands of connective tissue.
Meissner's corpuscles, specifically, respond
These strands promote the transmission of ad
to repetitive stimuli, such as sinusoidal indenta
equate stimulating force to several surrounding
tions of the skin, at frequency ranges of
2
or 3
corpuscles for a given pinpoint stimulus area.
Hz up to around 300 Hz. Compared with Pacin
The second characteristic is related partially to
ian corpuscles, this range is a relatively slow
this mechanical coupling but mostly to the fact
frequency range. As previously mentioned, this
that the
range of stimulus indentation is from 70 to 1000
is very small
micrometers, with the greatest sensitivity at be
receptive{teld for Meissner's corpuscles (2-4 mm in diameter). A receptive field can be thought of as an iso
5-2).
lated area of skin that can be stimulated and the
tween 10 and 100 Hz of stimulus (Figure
With a rapidly adapting system, the perception
area that is perceived to be stimulated. In an area
of relatively low frequency and low amplitude
of skin with small receptive fields, stimulus of a
indentations of the skin is possible. In particular,
small point results in perception of stimulus that
the density of Meissner's corpuscles is higher in
is restricted to just that small point. Conversely,
glabrous skin of such structures as the hands.2
an area with large receptive fields will result in
This is most beneficial for the therapist in pal
perception of stimulus to a large area, even with
pation and during treatment. The property of
only a small point stimulated.
rapid adaptation gives the Meissner's corpuscles
The impact of Meissner's corpuscles on prac
excellent temporal resolution in perception of
titioners of manual therapeutic technique would
rapid and subtle change. It does nothing, how
be difficult to overstate. With their excellent
ever, to explain their superior spatial sensitivity.
spatial resolution and ability to perceive rela
There are two other characteristics for which
tively small differences in texture, tissue density,
their superior spatial resolution may be account
and so forth, the manual practitioner certainly
able. First, Meissner's corpuscles are mechani
utilizes them in all of his or her practice. Other
Meissner's corpuscle 1000 .
!:
..l<: Ul -
,
E
:::l.
o 0 - .cm ::::J o c E{l c
'/
100
,
,
I
/
" .... .....
.... - --
."
/
I I
"
10
10
(50)
100
(300)
1000
Frequency (Hz) Figure 5-2 Sensitivity to skin indentation.
Principles ofNeural Science,
Source:
Reprinted with permission from J.H. Kandel et aI., eds.,
3rd ed., pp. 533-547, © J 991, McGraw-Hili Companies.
Copyrighted Material
V/IJ'nntnovand
Neuromechanical Aspects
ications for the Meissner's corpuscles are discussed in a later section of this
con-
effects and interactions of connective tissue neurophysiology with movement control.
Ruffini Corpuscles
Ruffini
and other connective
Pacinian corpuscles are located in the subcu taneous tissue of both hairy and glabrous skin.
Their
tissue
with the connective tissue is functional in that are stimulated by the displacement of the
Although the skin is probably the largest organ it
f ibers surrounding them, They are
of Pacinian
is not the
location. As
as
found Pacinian corpuscles
I
are found in the subcutane
ous tissue beneath both hairy and glabrous skin. They are also found in the superficial layers
PUcilliull Corpuscles
with the greatest
of various animals3 Gard joint
further and with
He failed to find Pacinian corpuscles in the articular
and they also have very
f ields. One major advantage
of their slowly adapting characteristic is of nlllc tional
Since
attachments.4 Zimny et al re i n the ante
rior and
sense and tactiIe sensation.
Hair receptors are divided functionally into
tendon organs. their anatomy and function. that
consist of a specialized nerve
is surrounded by connective tissue laminae. This connective tissue laminae makes the corpuscle adapting receptor, which makes it re
sponsive to stimuli a t
from 15 t o adapting quality allows
1000 Hz. This
the corpuscles to be sensitive to is sensitive to me chanical energy. In
it is extraordinarily sen
sitive (down to a level of less than I-micrometer skin
which will result in an action
potential from the Pacinian
Even are very sensitive
Pacinian
to mechanical energy, their very
receptive
poor for localiza
fields make them
tion. Recall that the receptive field of a Meiss ner's corpuscle is from 2 to 4 mm in diameter with excellent localization. In contrast, the ref ields of Pacinian
to
(stiff) hair receptors are
skin indentation, and down hair receptors are sensitive to flutter.
hair
are
specialized nerve endings incorporated in the connective tissue at the base of a follicle and are very sensitive to mechanical deformation of the hair. Their implications for clinical
of
are most I
the manual
to an awareness of their presence and the know/ that they, as with most any receptor, can be
As with other
stimulus
based principally on the type
of stimulus to which they respond. Tylotrich
A great deal is known about Pacinian cor
that in
Hair Receptors
two
a
contribute to
stimulus,
but did find
ported
do not "turn off"
following a stimulus but continue to f ire with a
them in the f ibrous periosteum near articular or I
69
V1W'''LJUlU'''Uft
are so
o r t o the medial half o f the palm.
7
Merkel's Receptors
Merkel's receptors are ripheral of all the sensory located in the skin.
They are
of glabrous (hairless)
have unusual receptors in that the
""''''''''',,"0
appear to synapse with epithelial cells.
This synapse or connection of
cells
with the Merkel '5 an action potential for the neuron serving the receptor with any mechanical stimulus to its
stimulation of Pacinian cor humans were able to localize
sensitized under conditions
related epithelial
to
Merkel's
like Ruffini
are but unlike
them, Merkel's receptors have very small recep
Copyrighted Material
72
MYOFASCIAL MANIPULATION
Sustained stretch
,
of muscle
fa discharge
I I I I I I I I II I I
Tension
/
t
Pull Weight
Stimulate alpha motor neuron
ill
1111111111
t
Contraction
la responses is "filled in"
motor neuron
+
,
,
j I i II II j j j j 1111 III j I
Stimulate gamma motor neuron
t
Contraction
Figure 5--4 During active muscle contractions the ability of the spindles to sense length changes is maintained by activation of gamma motor neurons. (Adapted from Hunt and Kuffler,
j 95 j.)
(A) Sustained tension elicits
steady firing of the Ia afferent. (8) A characteristic pause occurs in ongoing discharge when the muscle is caused to contract by stimulation of its alpha motor neuron alone. The Ia fiber stops firing because the spindle is unloaded by the contraction.
(C)
If during a comparable contraction a gamma motor neuron to the spindle is
also stimulated, the spindle is not unloaded during the contraction and the pause in Ia discharge is "filled in."
Source:
Adapted with permission from c.c. Hunt and S.W Kuffler, Stretch Receptor Discharges During Muscle
Contraction,
Journal ofPhysiology, Vol.
113, pp. 298-315, © 1951, The Physiological Society.
sion on the connective tissue in which they are
Another important feature of the GTO is in
located. This sensitivity has been documented at
their combination with muscle spindles. The
levels as low as the force generated by a twitch
reader will recall that the primary endings from
contraction of a single motor unit in the triceps
dynamic nuclear bag f ibers experience a pause
surae of a cat (i.e., very few grams of force)9
in their f iring during contraction of a muscle.
Copyrighted Material
Neuromechanical Aspe cts of Myofascial Pathology and Manipulation
73
and are approximately I mm in length and 300 to 500 micrometers in diameter. Hence, a change in the mechanics of a muscle secondary to injury can change the firing patterns of either or both of these proprioceptors. Consider the following scenario. An athlete sustains a contusion to the distal third of the medial head of the gastrocnemius muscle. This Capsule
occurred 5 days ago with fairly good resolution of the edema. During gait, the gastrocnemius is active from mid-stance (as a decelerator) until toe-off (as an accelerator). Assuming a rela tively normal foot posture and equal forces, rate of change of length, and length changes being generated by the medial and lateral head of the gastrocnemius, the afferent stimuli coming from II---t-Collagen fiber
the medial and lateral head of the gastrocnemius would, under nonpathologic conditions, be ap proximately equal. Under the current conditions of a contusion that is in the process of healing
Figure 5-5 Goigi tendon organs. Source: Reprinted with permission from J.E. Swett and T.W. Schoultz, Mechanical Transduction in the Goigi Tendon Organ:
but having formed some scar tissue, however, the afferent information is different between the 2 heads of the gastrocnemius. In the medial
A Hypothesis, Archives de flaliennes de Biologie Vol.
head, the afferent information is altered because
1l3, pp. 374-382, © 1975, Archives de ltaliennes de
of scarring of the collagenous connections of
Biologie.
the intrafusal fibers. This results in a mechanical "mis-link" from collagenous cross-bridges and scarring and results in a perceived change in
Unlike them, the GTOs are highly active with
length that is reflective of the actual change
contraction of a muscle secondary to the tension
in length. ]n addition to the mismatch between
exerted on them by the muscle.
the two heads of the gastrocnemius relative to the length of the muscles, there is a problem
Implications of Muscle Spindles and
with tension information from the Golgi tendon
Golgi Tendon Organs
organs.
While the impact of the alpha and gamma
The serial arrangement of the Golgi tendon
motor neuron system is quite well understood
organs makes them sensitive to tension gener
conceptually, if not in detail, by most practi
ated along the mechanical chain of the muscle.
tioners of manual therapeutics, the impact of
Therefore, changes in the viscoelastic proper
pathology in connective tissue may require some
ties of the muscle to which it is attached can
discussion. intrafusal fibers are arranged in par
produce a differential in tension (particularly at
allel to the extrafusal muscle fibers. Muscle
the initiation of contraction). This differential
spindles measure approximately 4 to 5 mm in
tension produces another mismatch between the
length and I mm in diameter. With their parallel
tendinous origin of the medial and lateral heads
arrangement, they are connected to either end
and even the possibility of differences within
of their muscle's attachment by long collagen
the fascicles of the medial head attaching to the
containing fibers. Golgi tendon organs are ar
Achilles tendon. With the decreased elasticity of
ranged in series with the extrafusal muscle fibers
the muscle from the collagenous cross-bridges
Copyrighted Material
MYOFASCIAL MANIPULATION
76
tive
some attention to nociception and
increased concentrations of bradykinin
and cyclooxygenase metabolites (both strongly
tion.
associated with inflammation and injury) are of Group III and
likely to increase the
IV afferents to contraction and mechanical probContrary to these
Nociceptors Nerve f ibers that are selectively
indomethacin
and aspirin, both of which decrease a muscle's to produce
to
stimuli from damage to or that are potentially to tissue are called
and thrombox
fall into three
of the receptors
or tJ) pOlymodal, dependll1g on
to contraction. of Group III and IV
Given that the
the form of stimulus required. These three cat-
affected by natu
can be further classified as to their af
rally occurring inflammation byproducts and
ferent nerve fibers. The thermal and mechanical
negatively affected by anti-inflammatory drugs,
stimuli are transmitted via Ai) fibers and the
muscle receptors is
the clinician needs to consider these effects
polymodal stimuli via the C fibers.
during treatment. In the case of an inflammatory
thinly myelinated fibers that conduct at 5 to 30 meters per second. C fibers are unmy
there would be
process (either acute or
a tendency for a greater increased blood flow in a that was also
elinated fibers that carry 0.5 meter to
I f t h e p a tien t h a d taken
anti
the sensitivity to
inflammatory agents,
characteristic
other
to be considered. This characteristic is related
effects of increasing
therefore, the
char
acteristics and the modes of
mechanical stimulation would be decreased and, edema would be
at rates from
meters per second.
In addition to their conduction
in intramuscular e d e ma.
fibers are
is
to chemoreception. considered a sensory
Basically, such a line
of reasoning would serve as a precaution for use
reserved
for the tongue and nose, but in the case of pain,
of myofascial manipulation on an inflamed
it becomes of extreme importance. Nociceptors
muscle.
demonstrate two responses to a lame number the
To
Jechanoreceotors of the
of chemicals and naturally The chemicals either activate them or tlley are
are numerous and diverse and function. Some are ex
sensitized by them. Activation is manifested
.
ceedingly sensitive to mechanical stimuli
an action
Merkel's,
zation is a lowering of the stimulus threshold
and Meissner's cor
puscles) whereas others
more vigorous
to produce an action
things in common. connected to and from connective tissues.
Some of
the agents are included in Table 5-2. I
stimulation (e.g., Group III and IV muscle af ferents). Despite their
of the nerve whereas sensiti
they have two they are all physically
RECEPTOR INFLUENCE ON
mechanical events
MOVEMENT
they all pro
vide afferent information to the central nervous system that then exhibits reflexive effects in the Some of those reflexive effects are directly motoric in nature and others are more autonomic in nature. Some of these reflexive ef
sections explain, ill brief, a few of the reflexive
fects will be reviewed in various levels of detail
and
in a later section of this chapter, but no discus
ment and autonomic function. The
sion of peripheral
is complete without
Copyrighted Material
order sensory influences on move
are concise, under the assumption that the reader
Neuromechanical Aspects of Myofascial Pathology and AIanipulation
77
Table 5-2 Chemical or Agent Effect on Nociceptors Chemical or
Effect on
Agent
Nociceptors
Source
Potassium
Damaged cells
Serotonin
Platelets
Activation
Bradykinin
Plasma kininogen
Activation
Histamine
Mast cells
Activation
Prostaglandins
Arachidonic acid-damaged cells (inflammation product)
Sensitization
Leukotrienes
Arachidonic acid-damaged cells
Sensitization
Substance P
Primary afferent
Sensitization
Source: H.L. Fields.
Pain, p. 32.
Activation
© 1987. Reproduced with permission of
has a familiarity with these topics. If more in
the McGraw-Hili Companies.
movement is that of the muscle stretch reflex
formation is desired, the reader is referred to
(MSR), previously known as the deep tendon
Chapters 21-24 and 33-38 of Kandel, Schwartz,
reflex. The MSR is a monosynaptic reflex with
and Jessell's classic, Principles of Neural Sci
input from the primary and secondary endings
ence, 4th Edition.
in the muscle spindle with the major portion of the stimulus coming from the primary endings. During the MSR, the stimulus to the primary
Basics of Motor Control
endings in the form of a sudden lengthening
Motor control is considered to be achieved
of the muscle is conducted by the Group la af
through the hierarchical and sometimes parallel
ferent. The Ia afferent synapses directly on an
control processes of three different levels. The
alpha motor neuron for the same muscle and
spinal cord, brain stem, and cerebral cortex each
excites it to the level of an action potential. This
have their own independent levels of control and
results in transmission of a motor impulse to
then work together to accomplish control. In
the stimulated muscle and contraction of the
Figure 5-6 the reader can see a relatively simple
muscle. All of this occurs in very short order,
diagram of the motor system.22 The following
requiring only about 40 to 60 milliseconds8
sections emphasize the "sensory consequences
As described previously, the influence of pa
of movement upon movement" component of
thology in the connective tissue can be consid
the model in Figure 5-6. Furthermore, some
erable on the muscle stretch reflex. An altera
attention will be paid to the influence of myo
tion in the parallel link of the muscle spindle to
fascial pathology on the sensory consequences
its tendonous connection can occur with faulty
of movement. Unlike the sections on sensory re
links to other connective tissue outside of the
ceptors, the following sections follow a scheme
target muscle. Connections via scarring or newly
of the most familiar of mechanisms moving on
formed cross-bridges of collagen to the skin,
to some of the less familiar mechanisms and
intermuscular septa, other tendons, or even bone
newer findings.
can occur in connective tissue pathology. Such connections could alter the MSR to either a heightened level or a lowered level of activity
Muscle Stretch Renex
depending on the stimulus applied to them. In
Probably the best understood and most stud
the case of pathomechanica I cross-bridge forma
ied of the influences of peripheral receptors on
tion, such an increase in the sensitivity of the
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78
MYOFASCIAL MANIPULATION
Cerebral cortex Motor areas
Muscle contraction and
Sensory consequences of movement
Figure 5-6 Motor system levels of control. Source: Reprinted with permission from J.I-I. Kandel et aI., eds.,
Principles o{Neural Science, 3rd Ed., pp. 533-547, © 1991, McGraw-Hili Companies.
MSR would alter the spinal level mechanisms of
intermedius. Each of these has a resting muscle
muscle tone regulation. It has been hypothesized
tone. If the adhesions have formed in such a
by Janda that these changes would result in an
way as to differentially affect the rate of change
increase of dynamic muscle tone in the agonist
of length in the muscles as they slide together
muscle. With changes in dynamic muscle tone
and against each other, however, there wi] I be a
and subsequent changes in movement patterns,
sensory mismatch. With this sensory mismatch
the mechanical stresses would be different on the
there will also be a differential MSR response
system resulting in connective tissue remodeling
between the three muscles that was not present
in response to Wolf's Law.
before the scarring occurred. This example of
Consider an example of a patient, 3 weeks
connective tissue pathology impact on the MSR
status post distal third femoral fracture with an
is just one of many possible scenarios. In like
intermedullary rod, in the supine position with
manner, this example considers the impact of
the lower leg hanging over the end of a treatment
such a pathomechanical situation on the MSR.
mat with the knee in flexion. With the scarring
There are multiple other interactions to be con
that occurs, there will be adhesions between
sidered, a few of which will be considered in the
the vastus lateralis, rectus femoris, and vastus
following section.
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Neuromechanical Aspects of Myofas cia I Pathology and Manipulation
79
control. The most conspicuous of examples for
Golgi Tendon Organs
problems with the GTO would be that of tendon Golgi tendon organs, when stimulated by a
itis. In the case of Achilles tendonitis, an inflam
change in tension, have an inhibitory effect on
mation of the musculotendinous junction would
the agonist muscle and a facilitatory effect on the
result in interfascicular edema inside the tendon.
antagonist muscle. The mechanism of this event
This edema changes the viscoelastic properties
is much more complex than the MSR. In the case
of the musculotendinous junction, resulting in
of the MSR, there is a monosynaptic connection
a change in the tension on the braided collagen
of the muscle spindle afferent fibers synapsing
fibers that surround GTOs. Besides the change
with the alpha motor neuron for output. The
in the mechanics of the GTO, there is also the
afferent input from the Golgi tendon organ syn
ambient change in chemical make-up of the
apses on the Group Ib inhibitory interneurons.
GTO. With greater concentrations of bradykinin
These interneurons receive input from multiple
and cyclooxygenase metabolites (byproducts of
sources before synapsing themselves with the
inflammation), it is possible that the sensitivity
motor axons of either the agonist or antagonist
of the GTO is increased in the same way as the
muscles. Originally thought to be a protective
sensitivity of Group III and IV muscle afferents
mechanism to prevent tendon rupture, this same
are altered by these agents. If the GTO sensitiv
mechanism offers great utility for the manual
ity were increased by inflammation byproducts,
therapist in relaxation of agonist muscle guard
then the increased GTO firing rates would fur
ing and/or facilitating antagonist
ther inhibit the agonist and facilitate the antago
retraining
during therapeutic exercises. The receptors for
nist and, thereby, interfere with normal motor
the Golgi tendon organ are specialized nodes on
control and movement patterns.
an axon that respond to mechanical deforma tion with an action potential. Therefore, the me chanical event necessary to fire the GTO does
Joint Receptors
not have to be stretch; it could be direct pressure
As previously described, joint receptors come
on the musculotendinous junction. The outcome
in a variety of shapes, sizes, functional charac
regarding muscle tone is the same whether stim
teristics, and locations in the joints. For purposes
ulated by tension or other mechanical input.
of this discussion, we restrict our discussion
Some of the Group Ib inhibitory neurons re
to the Golgi-Mazzoni and the ligamentous free
ceive converging input from Ia afferents from
nerve endings because they are the most super
muscle spindles, low-threshold cutaneous af
ficial of the joint receptors and are the most
ferents (e.g., Merkel's receptors and Pacinian
easily stimulated in the practice of myofascial
corpuscles), joint receptors and excitatory as
manipulation. The Golgi-Mazzoni receptors are
well as inhibitory input from several descend
similar to Golgi tendon organs and exhibit very
ing pathways. All of these combined inhibitory
similar effects on motor control at a reflex level.
and excitatory inputs have major implications
In like manner, the free nerve endings transmit
for fine motor control. The GTOs and the other
information to the spinal cord and synapse on
inputs to the Group lb inhibitory interneurons
Group Ib inhibitory interneurons. Both of these
provide for fine control of exploratory behaviors
joint receptors are rapidly adapting receptors
where the amount of force being generated is
and are also known to be essentially silent in
critical. Therefore, the implication for these re
immobile joints. They are stimulated most at
ceptors' importance when learning to perform
the extreme ranges of motion. Therefore, from
manual therapy is obvious.23
a functional viewpoint, the surface of a joint
[n addition to the impl ications for fine con
capsule in which the receptors are located dic
trol and control in exploratory behaviors, there
tates which muscles are the agonists and which
are ramifications for patients and their motor
are the antagonists. In the case of the posterior
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80
MYOFASCIAL MANIPULATION
capsule of the knee, rapid knee extension would
Skin Receptors and Position Sense
result in an inhibitory effect on the quadriceps at the end of range, whereas rapid knee flexion
The influence of skin receptors and other
would stimulate the joint receptors in the an
mechanoreceptors located in deeper tissues on
terior capsule and cause inhibition of the ham
motor activation levels has been documented
strings at the extreme of knee flexion.
for almost
100 years. Simple reflexes such as
Another example of the inhibitory properties
the flexion withdrawal reflex are spinal level
of an abnormal stimulus to joint receptors is
systems evoked by stimulation of nociceptors.
provided by Kennedy and colleagues. In their
Other stimuli of a noxious nature, such as a
1982, they demonstrated that
slightly caustic agent, placed on the leg of a spi
(60 cc) of the knee would result in 30% to 50% decrement in the electrical activity
nalized frog will produce the even more sophis
of the quadriceps, as measured by the Hoffman
the stimulating agent25
classic paper of an effusion
reflex, with the greatest inhibition occurring in the vastus medialis. Although they did not
ticated movement of attempting to wipe away Hagbarth demonstrated in
1952 that a pinch
stimulus to the skin of the dorsal aspect of the
distinguish the particular types of receptors, they
hind limb of a cat (i.e., opposite surface of the
were able to show that the receptors in proximity
muscle) would inhibit the output of motor neu
to the joint cavity itself were very important.
rons to the tibialis anterior (TA) whereas the
Under the conditions of effusion, the quadriceps
same stimulus presented to the skin on the ven
were inhibited; however, when a local anesthetic
tral aspect (i.e., over the TA), facilitates motor
was added to the effusion, the inhibition all but
neuron activity26 These and similar f indings
disappeared24 CI inically, these findings add even
form the foundation for many of the facilitatory
further motivation for the therapist to control
and inhibitory handling techniques employed by
joint effusion and, failing that, to make conserva
physical and occupational therapists today. Many
tive recommendations for strenuous activity of
of these facilitatory and/or inhibitory techniques
the lower extremity. If such a small joint effu
were originated by clinicians working with neu
sion can inhibit the quadriceps, then failure to
rologic clients. One common technique is that
control the effusion could lead to serious injury
of maintained pressure over the anterior thigh,
from inhibition of the surrounding musculature.
which is inhibitory to the quadriceps after an
One can only assume that similar findings would
initial burst of electromyogram
(EMG) activity.
be seen in other diarthrodial joints with similar
The findings of changes in motor output as
muscular inhibition. Such f indings clearly dem
a result of manual contact and other stimulus
onstrate that a mechanical stress on the rapidly
input are well known. Another aspect of effects
adapting receptors such as the Pacinian cor
of sensory input from the skin on motor output
puscles is (most likely) inhibitory to quadricep
that is not as well known is that of the contribu
motor units. Indeed, these f indings offer com
tion of skin mechanoreceptors to position sense.
pelling evidence that in the presence of edema
Psychophysical (i.e., behavioral measures of
or bleeding following thrust manipulation pro
perception) such as those performed by Burgess
cedures, there would be a reflex inhibition of
et al and Matthews failed to demonstrate a sig
musculature surrounding that joint or related
nificant deterioration of kinesthetic sense in response to anesthetizing the skinn.
to that joint neurologically. Their findings are consistent with the prior and subsequent I itera
The psychophysical findings would lead the
ture, which confirms that joint receptors are more
clinician to think that skin mechanoreceptors
sensitive to extremes of range. The mechanical
have little if any influence on position sense.
stress placed on the joint capsule served to stimu
The work just cited, however, operates from a
late the joint receptors in the same manner as
negative assumption. Burgess et al assumed that
extremes of range of motion would.
because elimination of skin receptors failed to
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Pathology and Manipulation
the performance of their
81
information is obvious. In the case of the slowly
in the skin had no impact
in the skin, a constant ab
Collins
normal mechanical stimulus from an adhesion
et al investigated the threshold of
would result in an alteration in the cumulative
of a muscle twitch at the wrist and found it to
position sense information even in the absence
be attenuated by as much as 60% with volun
of motion or extremes of motion. On the other
on position sense. More recent work
movement of the same ann, An experimen
forces that would
hand, an adhesion would
stimulate rapidly adapting
the skin on the
tal manipulation of
when
dorsum of the hand produced a 79% reduction in
the subject
twitch detection threshold and a 58% reduction
of movement. These same receptors, as cited
in either rapid or extremes have either facilitating or inhibitory
in position sense accuracy when compared with
effects on muscles that are
controls. Cohen et al performed
cell recordings
from the sensory strip of the cortex in monkeys to
active movement and skin stretch on cortical recorded from cortical cells
while
moving the monkeys' arms into
flexion and abduction,
also recorded from the skin of the
the same cells while
input from that area of skin.
and
the relative effect of
cell
Nociceptors
The influence of
that
to
on movement and con
[rol is probably the most obvious on
in movement control that is
pe
stimulation. The initial response to acute
medial upper arm. They demonstrated that 84% of the cell
or
nists for movements normally associated with
pain from mechanical or thermal stimuli is trans
movement also responded to skin stretch. In
mitted to the nervous system via Ao f ibers,
84% of the cells that did not respond to
which are
movement also did not
The withdrawal reflex seen in even
to skin
stretch,30
rapidly conducting fibers,
animals is very fast. The response to pain of a
The findings from these two studies present evidence that skin mechano
fairly
more polymodal nature, such as that mediated inflammation byproducts and other neuroactive is
receptors serve as a source of position sense information, In addition, whether or not contribute to the position sense information is not
upon external forces being ap
plied directly to the skin.
are
which
conducting fibers. Polymodal pain,
most likely because of its continuing nature, some type
also has the characteristic of
On a functional note, the data from the CoI Iins ct al
more is carried on C
Polymodal
indicated thaI, as one would
of behavioral response. This response may be at a
level or virtually any other level
expect, there was a directional bias for skin re
of the nervous system. The responses can vary
ceptor firing or lack of firing. This bias pro
from obvious muscle guarding in the surround
for more phasic
duced a
of the
ing musculature to help decrease movement, to
receptors as the monkey reached toward a
inhibition of a muscle to decrease movement
upper quadrant target with the left hand, as com
that would increase the pain.
pared to a tonic
of receptors as it reached
toward a target in the left upper quadrant with the left hand.
One misconception that has been from one author to the next is that of the
the mechanics of
the situation and the extensibility of
these
are not Thc implication for cutaneous tor information functioning as position sense
cycle. Unfortunately, as re viewed so eloquently and
this
Walsh, I and Simons is based on
a misunderstanding of the involved motor re flexes, The original hypothesis stated that pain
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82
MYOFASCIAL MANIPULATION
increased y-motor neuron activity, which would
MUSCLE TONE
stimulate or increase the sensitivity of the muscle
Muscle tone (taken from the Greek 1:EtVW,
spindle and result in an increased (X-motor
[teino]) has long been associated with muscular
neuron activity and muscle contraction. The
contraction; however, it is actually more com
major problem with this theory is the fact that
plex than just a contraction. Certainly, a typical
muscle pain does not result in increased EMG
muscle contraction or level of muscle tone, as
activity. Furthermore, the timing and intensity
understood from the sliding filament theory,
of the EMG activity does not correlate with the
cannot occur without an electrical action po
reported levels of pain.
tential. Since, as cited previously, an action po
These findings present a contradiction to the
tential is not typically discernible via EMG in
practitioner of manual therapy and any acute ob
the case ofl11uscle spasm or even "normal" rest
server of posture and movement. It is relatively
ing muscle tone, it must entail more than just
easy to identify muscle asymmetries in bulk as
an electrogenic activation of the actinomyosin
well as in muscular activity during movement.
complex. Simons and Mense have offered an ex
If muscular pain and the apparent increases in
cellent review of muscle tone and its relation to
muscle tone are not caused by spasm, then what
clinical muscle pain. In it, they describe muscle
does cause the increase in muscle tone? This
tone as consisting of two types of muscle tone.
question is actually two-fold. First, what does
The first one is known as electrogenic tone and
pain have to do with increased muscle tone?
the second one is viscoelastic tone (Figure 5-7).
Second, what is muscle tone/spasm? The follow ing sections explain some of the current thinking
Electrogenic Muscle Tone
regarding these topics. Since we need a defini tion or explanation of muscle tone, that section
Electrogenic tone can be categorized into
is presented first.
three levels. The first level is resting muscle
Muscle tone (general tone)
/
Viscoelastic tone (specific tone)
/\
Elastic stiffness
Viscoelastic stiffness
Contractile activity
11\
Contracture (no EMG activity)
Electrogenic spasm (pathologic)
Electrogenic contraction (normal)
Figure 5-7 Muscle tone. Source: Adapted from Understanding and Measurement of Muscle Tone as Related to Clinical Muscle Pain, Pain, No. 75 (pp. 1-17) by D.G. Simons and S. Mense with permission ofW.B. Saunders Company, © 1998.
Copyrighted Material
and
83
tone. This muscle tone has historically been ex
shown to demonstrate localized electrical activ
plained as a postural low-level tonic
ity in the confined area of the
of motor neurons. As explained
Walsh, this
It appears that these taut bands of muscle are
was begun by Waller and was
the result of the same contracture mechanisms
based on a
described by physiologists.
inapplicable Brondegeest in 1860. Waller, and
reported
explained
later the Sherrington
Other forms of muscle contraction of lar interest to clinicians fall into two
muscle tone with the muscle stretch reflex. Such an explanation
point]6
The f irst form we know as involuntary
an
where there is unnecessary muscular contraction
action potential to be generated in (X-motor neu
that limits movcment. The second form could
rons. Activation of (X-motor neurons would acti
best be described as inefficient use. Most clini
vate motor
cians are aware that because of
definition,
which would be perceptible
EMG. All efforts to document resting muscJe
and other causes, patients wi II move
tone via EMG have failed.3234 This is not to
in manners that are inefficient. These ineffi
that some form of contracture is
can have serious con
in the muscle. Physiologists tend to define con of the mus
tracture as an
a marathon
for
sequences.
runner who gets a blisler over the head of the
cular contractile apparatus in the absence of
fifth metatarsal at mile 3 of the race. Such a
EMG activity initiated by anterior horn cells.
minor
there are
With this
formed but they have not resulted from an action from the myoneural junction. The second level of
muscle tone
is what Simons and Mense refer to as electro spasm. This particular
ury has been known to have conse
quences of a femoral head stress fracture by
of contraction
the end of the marathon. The same such ineffi cient use can occur with relaxation
Lack of
trigger
between contractions of th e upper trapezius has been demonstrated
Elert et
is an involuntary contraction that is
demonstrated that muscles with
sociated with measurement EMG
failed to relax
that muscle31 Voluntary muscular contraction
movements as
is the third and last level of muscle tone and requires no
points
during
An muscle tone, which are associated with electri cal
Before we move on to a more nation of recent findings regarding viscoelastic tone, it
and Ivanichev
useful to discuss in a little more
ideas related to clinical muscle spasm. As we have already
in the
ences of various
spasm. As anyone who has worked
however, this volume relates more specifically the manipulation of ciaI tissues. Consequently, the next section on
on another human or even mammal will attest, and muscular tissue are tion. In this
in compressibility of discernible by palpa
on (X-motor neuron
and y-motor neuron activity is useful for under
a pain-spasm-pain cycle is
an insupportable hypothesis in the sense of an
is certainly
for the clinician. Also, an insight into the influ
IS
very
and will help
the reader to understand some of the very rapid results seen with myofascial
the f indings related to trig headache (T-TH)
Viscoelastic Muscle Tone
In T-TH it is easy taut bands of muscle. These
The viscoelastic muscle tone, or
tone,
while often associated with trigger points, do
is made up of an elastic component and a vis
not demonstrate observable EMG activity. The
coelastic component. The purely elastic compo
points,
have been
nent, by
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requires a
force to
84
MYOFASCIAL MANIPULATION
produce a deformation of the substance, which
tissues that prompt the stretching behavior and
in this case is myofascial connective tissue. As
account for maintenance of static balance, how
we know, the collagen and other structural pro
ever, have experienced an abundance of study
teins of myofascial tissue are not the only com
over the past 10 years and a new flurry of activ
ponents of connective tissue. These tissues also
ity during 1998 and 1999. This "new" property
contain various other proteins in addition to their
is known as
thixotropy.
obvious structural systems. These other sub stances are primarily in fluid form and have varying degrees of viscosity or "fluid stiffness." The primary component of noncontractile fluid component is water, which is retained by the
Thixotropy Defil1ed
nonsulfated glycosaminoglycans ( GAGs) and makes
up
about
70%
of
the
Thixotropy [8t1;w (touch) and "po1ITl
(turning
extracellular
or change)], as a term, is new to many people
matrix. The second component is the sulfated
across the entire spectrum of clinicians who use
the
manual therapeutics. It is not, however, new to
tissue cohesiveness. Another fluid component
physiologists involved in the study of muscle
of myofascial tissue is actin. Although actin
and tissue mechanics. Thixotropy describes a
version
of
GAGs,
which
account
for
of
state of stiffness of a fluid that is dependent
muscle itself, it is also abundantly present in
on the past history of movement. There are
certainly comprises
a large
complement
noncontractile fluid and serves cell motility and
a number of common substances that exhibit
intracellular structure functions. This protein is
thixotropy. Tomato catsup is probably the most
actually fluid in its purified form and, much like
common. After sitting in the bottle, catsup be
syrup, will form strings when picked up on a
comes very stiff and difficult to get out of the
glass rod or other stirring device.
bottle. With just a little stirring, the stiffness
The GAGs, actin, and myosin all contribute to
decreases substantially.59 Thixotropy is a
the viscoelasticity of myofascial tissue. Unlike elasticity, the stiffness of viscoelasticity is veloc
physical property of muscle
and other tissues and not a response to some neu
ity dependent. Also, it is worthy of note that
rophysiologic event. The mere act of moving a
unlike the velocity dependence of spasticity,
substance with thixotropic properties will result
the relationship between viscoelasticity and ve
in a reduction of stiffness. The reverse is also
locity of movement is purely mechanical. The
true, if a thixotropic substance remains still
mechanical viscoelasticity characteristic and
for a given period of time (variable dependent
the structural elasticity of the structural pro
upon the substance), the substance will become
teins combine to make up the specific tone of a
stiffer.
muscle that is unrelated to contractile activity. Viscoelasticity of muscle, or viscoelastic tone,
In order to measure thixotropy, physiologists have used torque motors with very small torques
affects movement and postural control. The
of
sensation(s) from the musculoskeletal system
Under conditions of a sinusoidal motion of the
approximately
0 .1
Newton.meters
(Nm).
that prompt mammals to stretch after remaining
wrist, the amplitude of a motion of the wrist is
still are relatively undefined concerning their
about 0.02 radians (1.14°). With a movement of
sensory mechanisms. Concerning posture, there
the wrist in an amplitude of approximately .075
are mechanical properties of muscle (largely
radians for only three cycles, the amplitude of
unexplored until recently) that tend to support
the passive wrist movement with the same 0.1
a resting stiffness of muscles in posturally sup
Nm of torque increases to about 0.06 radians
ported humans that is unrelated to EMG activ
(3.42°). These amplitudes are very small so as to
ity with the exception of occasional corrective
avoid stirring the muscle; however, it is impor
bursts of activity. The properties of myofascial
tant to note that a brief interruption of as little
Copyrighted Material
and
as 2.5 seconds returned stiffness to its
Ciinicailmplications ofThixotropy
levels. Also of note is the fact that this which is restorable in as little as 2.5 i-lv.,;:"'",,,
IS
at most any length with the exception
position of extreme stretch. As one can tell, the amount of
and the amount of inter
ruption of motion can be very smalL Now that and
we understand the basic
Considering the ranges of motion used in measurement of thixotropy, it is questionable whether thixotropy has any tion to clinical practice. This author proposes that
may offer an explanation for
the
of palpable "muscle spasms"
that are found on examination of
the mechanisms 40
we delve
85
calized electrical
Possible Mechanisms ofThix:otropy in Muscle have hypothesized that at
of muscle
mechanisms in muscle. Camp that the thixotropic
behavior of relaxed skeletal muscle may be exa
for some of the cross-
bridges to connect even in the absence of an action potentiaL As described by Hill, the early stage of the tension response to movement ap pears to be dependent on the duration of the rest
(no
and the
release tension, which occurs later in the move ment and is linked to the stretch velocity 41
points have also
been identified by Simons45 as
attribute to a
model of undetached saying, "The molecular motors of muscle may be idling rather than switched off when the muscle is relaxed."42(p957)
motor nerve terminals. It is localized electrical tize
that can
There is another forward
Mutungi and
bilize the T-tubules enough to result in a calcium concentration within would result in a
ments. Titin filaments are exceptionally which link the
filaments to the Z-lines of muscle.
thick
Titin filaments tend to
ponin, which would increase the stiffness thixotropy). Such an increase in would decrease the pliability of muscle in the muscle tissue. This is feasible to explain the ence of deep massage
beneficial to in
crease the pliability of the muscle around to the "pain-spasm-pain"
gel' points.
deep massage of a
point should
a random-coil COl)
Consequently, titin does not offer a for thixotropy of muscle
but with its increase in tension at extremes of
the spasm, with
even more pain. This does not always occur in that
as many practitioners can massage can "decrease the spasm." Neurophysioiogicallmpiications of Thixotropy The mechanical
of thixotropy have
been reviewed in the previolls sections. These obviollsly, apply to the
when relaxed and that uncoils with very viable
number of
formed between the
would attribute the viscoelastic
III
to sensi
agents released may also desta
The
and other
of relaxed skeletal muscle to titiD f ila structural
is
in the area of a trigger
increase the pain and,
the thixotropy of muscle. This hypothesis put
{'()tTP''''CI
anatomically with the intramuscular
Campbell and Lakie summarize their tion of thixotropy, which
highly lo
has been found in
ger points. These same
bell and Lakie have
with
points. As previously
plement of
com
the extrafusal fibers. Extra
fusal f ibers are only part of the As Proske et al have
however. thixotropy, as
range, it may contribute to the resistance felt in
a mechanical
has a profound influ
muscle when it is stretched to near its limits of
ence on muscle
and their afferent neu
range of motion."'.4ci
rons.
These influences are too numerous to
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86
MYOFASCIAL MANIPULATION
review here, but the
some of the
discharge
stretch are
on the
or holding
We have reviewed the basic
history
of movements and/or contraction. In several re search
movement
described by Janda and Feldenkrais.
spindle afferents and their sensitivity to muscle
,'pC'pn tAr
and physiology for most of the somatU:5t:
it has been demonstrated that
of the vestibular
with the
when a conditioning movement or contraction
system. We have also reviewed some of the in
such as an isometric contraction
teractions of the somatosensory system with the
is
in the shortened Dosition. the afferent
motor
from muscle
is increased. The reverse
on that portion related to the myofascial system.
is observed in an isometric contraction in the
Now that we have f inished the neuromechani
position. This facilitation of the
is not a cord mechanisms but
rather a sensitization or
system with
emphasis
cal background for myofascial we move into some direct application of this and biophysics.
the
case may be, of the muscle spindle. Studies of this phenomenon
a
stimu
lated muscle stretch reflex
tendon tap) pro
duce the
APPLICATION TO SPECIFIC THERAPEUTIC TECHNIQUES
similar studies
with the Hoffman reflex
to outline
The following sections are
an electrophysi
analog of the tendon tap) have failed to
examples of specific application of the science heretofore presented. This
show the same results. Another potential influence of
can
be Dostulated based on the
bio
physical, and neurophysiological properties of and other connective tissues.
form
lar technique to which
technique;
posed theoretical mechanism,
GAGs have shown them to be responsible for the cohesiveness of conncctive tissue.
is made;
a
discussion of the pathology/pathomechanics ad dressed by the
the biochemistry and biophysics of the sulfated
takes the
I) a very brief discussion of the
a pro these
may influence the somatosensory
with
and (4) proposed mechanisms for altera
this increased cohesiveness comes an increased
tions in motor control are engendered bv the
initial resistance to active or oassive stretch.
technique under consideration.
one would ent discharge from has remained still for a few minutes. Walsh and
Anterolateral Fascial Elongation
demonstrated that thixotropy
The anterolateral fascial elongation
occurs at the human hip, with the amplitude
8-96 and
of the resonant frequency of a sinusoidally
and associated neuromechanical char
abducting/adducting hip almost doubling in re sponse to a W hether this ent
motion of
useful to consider as to virtually all of the superdescribed in this book. The
,
amplitude.46
resistance to initial
anterior lateral fascial
as
an increased affer
described later in this
primarily stretches
very early in the time course of
the movement remains to be tested. Neverthe
the
fascial sheath in a diagonal pat
tern across the anterior surface of the body. In
less, if the fluid mechanics of a joint capsule,
doing so, the
musculotendinous junction, or direct muscular
number of restrictions at
is
inflamma
interface between the skin and the superficial
tion byproducts, then the afferent output from
fascia, there may be restrictions secondary to
attachment to bone were changed
those receptors could certainly be either in
blunt trauma and
creased or decreased. Such an event may explain
fascia itself and its interface with the
Copyrighted Material
In the
Neuromechanical Aspects ofJ'vJyofascial Pathology and Manipulation
87
major and the external oblique abdomina Is, the
flexion would be perceived as a "greater than
sheath is continuous from the proximal hu
resting or normal position" burst of activity. In
merus, clavicle, and anterior shoulder down to
that case, the patient would return to a position
the contralateral crest of the ilium, thoracolum
that was more in line with resting position. If a
bar fascia, anterior superior iliac spine, inguinal
mechanical restriction resulted in an abnormal
ligament, and the pubis.
phasic stimulus or tonic stimulus, then the inter
Restrictions of the superficial fascia of the
pretation by the system would be that the patient
anterior trunk have mechanical implications for
was in a stretched position when, in fact, the
posture and virtually all movements of the trunk
position might be neutral. Consequently, the
and upper and lower extremities. Certainly, there
patient would tend to move into a position that
are mechanical restrictions of mobility but given
decreases the firing activity of the phasic and/or
that patients develop such faulty postural habits,
tonic receptors. This position is then perceived,
the pathomechanical implications for the body as
via the skin receptive f ields, as normal and fur
a whole are most likely seated in position sense.
ther shortening of the superficial fascia occurs.
Restrictions in the superficial fascia would result
This faulty receptor activity and the position
in a continuous and abnormal stimulus of the
sense activity it provides soon becomes the basis
slowly adapting mechanoreceptors in the skin
for postural perception.
and all the succeeding layers of the superficial
Historically, the theoretical basis for such be
fascia. Because the mechanical restriction in the
havior has been that of pain avoidance. Cer
skin and superficial fascia is very similar to that
tainly pain avoidance behavior is a reasonable
found in the experiment performed by Cohen et
and patent argument in the early stages but after
ai, some direct postulates are in order.
several weeks of healing, the pain disappears.
Cohen and colleagues found increased activ ity of somatosensory cortical cells representing
What remains is the new position sense refer ence from skin and superficial fascia receptors.
skin receptive fields in the axilla and the skin
Another hypothesis concerning the continued
of the medial proximal arm associated with par
behavior of avoiding elongation is that of altera
allel skin stretching, passive movement, and
tion in motor programs (motor memories) to fit
active movement. They were able to demon
the new and dysfunctional behavior. Considering
strate this same highly correlated activity in a va
the amount of practice required to change a very
riety of tasks including reaction time tasks, hold
well learned motor program, this is not likely.
ing tasks, and active movement of the arm. The
Consider, for example, attempting to change
shortened range of skin produced very little ac
one's signature. It is possible, but on a practical
tivity in tactile receptors of the axilla and upper
level, it is not probable secondary to the huge
arm. This is in contrast to movements into shoul
volume (millions of repetitions) of practice re
der tlexion or shoulder flexion with abduction,
quired. It is very likely that this new position
which increased the activity46 Furthermore, the
sense stimulus from the skin rapidly adapting
greater the stretch in either amplitude or move
and slowly adapting receptors function in an
ment, the greater the firing rate of phasic (rap
inhibitory fashion just like their Golgi tendon
idly adapting) receptors (e.g., Pacinian corpus
organ and Golgi-Mazzoni type joint receptors,
cles).
by
These findings are completely logical and
inhibiting muscles
which
would further
stretch these receptors.
intuitive when one considers human postural
Such a postulate is based on the findings of
phenomena observed by clinicians. Consider a
numerous investigators of the inhibitory influ
patient who is 3 to 4 weeks post cholecystectomy
ences of GTOs and joint receptors on motor
via a left upper quadrant incision rather than a
output. It is also in agreement with Janda's
laproscopic procedure. A phasic stimulus of skin
model of altered muscle function and motor per
receptors during erect sitting or right shoulder
formance resu Iting from "inadequate proprio
Copyrighted Material
88
MYOFASCIAL MANIPULATION
" which is probably more cor
ceptive
of the thoracolumbar fascia from which
or mismatched
stated as
surgery. Yahia et al found
proprioceptive stimuli,30 One exception is and that is that the
and Vata-Pacini corpuscles (a
logic described cannot
validly be
were also taken from surgical
type of strokc or the skin rolling. This is because their goals and physiology are not
con
These
form of Pacinian
to the Bindegwebsmassage
were prepared with im
Yahia's
munohistochemical staining techniques that tar-
nected to the evidcnce suoolied by Cohen et aL
neural filament protein.49 With the documented presence of Ruffini and Pacinian-like
Iliac Crest Release
in the tho
racolumbar fascia. it is I
This technique is useful to
as it is
the thoracolumbar fascia would oroduce an ab
technique
8-20A,
normal afferent stimulus. This abnormal stimll
a moderately
and 8-21). As described, it is executed by
Ius from normal motions or
would
applying an anterior directed force through the
result in an abnormally excited or inhibited level
from the border of the iliac crest
of activity for the motor units of the abdominal, and auadratus lumborum muscula
on to the thoracolum bar fascia and the insertion of the
restrictions with the
erector
and quadratus lumborum, This particular tcchnique addresses restriction of the thoraco
iliac crest release
would
to cor
rect this abnormal afferent outflow, Such a cor
lumbar fascia and the muscular and ligamentous
rection would allow the relative levels of excita
attachments. Bogduk and Macintosh discussed
tion and inhibitions to return to levels dictated
the anatomy of the thoracolumbar fascia with its
the normal motor programs as onnosed to
to the crest of the ilium.
two
proprioceptive signals.
This anatomy makes its mechanics somewhat complicated and allows it to contribute to stabi lization of the spine in
all movements,
Diaphragmatic Techniques
of side bending to
with the the same sideY
restrictions in the
for
diaphragm and inferior border of the rib cage are the
bar fascia. An assumption that the connective
diffi progress from a
tissue in this structure is no different from that
the superficial to middle
found in the shoulder, knee. and ankle would
inferior to the anterior rib cage to those that
lead one to conclude that the
involve
the inferior portion of the rib
cage, in a seated endings, and others as
and inhale
failed to f ind a
(Figures
and 8-46),
of mechanoreceptors in the
address restrictions that are
w ith chronic
very deep in the thoracic and abdominal cavi
48 They concluded that there were dif
ties. Although directly addressing restrictions
significant
thoracolumbar fascia of back
and
and anteriorly while asking the
structure. In a study however,
restrictions
ferences in the
of receptors between
normal subjects and persons with back pain.
in the thoracic
One major caveat concerning this study is that it was nerformed with standard histologic were noted concerning the area
is not possible, it is pos
sible to affect restrictions in the mediastinum the diaphragm and
fascia of the
abdomen and diaphragm, Such restrictions can lead to or be the result of multiple postural
Copyrighted Material
VfJ/'nnlflU1J
protracted shoulders, posture in
and
89
other muscle fascicles. If a restriction occurs then the
between two fascicles or two
The pathomechanics of slumped
and
altered mechanics produces a sensory
forward-head are fairly well understood. With
mismatch and inappropriate proprioception from
an increasingly forward-head posture comes a
the muscle. Such a case has been described pre-
rpnnPf'I'H
for the ribs and sternum to move infe
riorly and posteriorly. This leads to a
in the section on
of muscle
spindles and GTOs.
of the connective tissue in the abdomen and
Whi Ie the influence of intermuscular and/or
length comes a
interfascicular adhesions on afferent and effer
in the thorax. With
tendency for increased afferent activity from the Rufinni endings, An increase in tension more especially the GTOs,
on these
are fairly common among
related to a transverse muscle
of the central tendon of the diaphragm has been shown to elicit a
there are other
problems related to such adhesions and benefits
inhibitory effect on
the external intercostals and the diaphragm.
the sure caused
activity results in a reduc
All of this
technique.
The pathology of such adhesions
more
in intramuscular pres them relates to influences of
thixotropy and the Group III and I V afferents.
tion in lung volume. Over time, as lung capac
Adhesions of such a nature can lead to a local
ity is diminished by these inhibitory processes,
irritation of the musc.le and a destabilization of
the connective tissue would remodel to its new
the cell membrane
resulting in a new "set" for the normal tension on the tendon. The manipulation tech along its anterior borders with
a resultant, postulated reduction in the inhibitory
This release of
calcium will result in the formation of cross-
niques described herein allow for a lengthening of the
to cause a release
of calcium into the
without benefit of an action potential resistance to stretch.
and increased
Second, increases in intramuscular pressure have been directly associated with increased afferent
activity of the GTOs.
action
of the
III and IV af and
ferents
Transverse Muscle Bend of the Erector
connective tissue in proximity to these struc
Spinae
tures. Such afferent
results in cardiovas
is relatively simple to perform
cular and pulmonary changes on a systemic level
and depending upon the vigor with which it is
and an autonomic response of increased blood
done can have
flow at a local level.
This
fects or,
ef more
can have
themselves also
The treatment
mechanical effects. The technique is basically
have direct effects on the thixotropy of the
one of bending the muscle as if
system and the
a
8-15 and 8-1
hose
muscle
can also be modified as in the quadriceps and hamstring technique to include
III and IV afferents. The
motion of the muscle would provide the
a mechanical stimulus to aid in
and
thixotropic resistance to motion. Next, the tech
some muscle rolling and lifting actions. No
nique would have direct etTects on the Group III
matter what result
technique is used, the
a multidirectional mechanical stress
with the least emphasis on longitudinal stretch-
in local blood
with resultant
cardiovascular and
flow and nary effects. The
in
engen
dered by the techniques most likely also extend The
to the
the outflow from the muscle
dies themselves with all the cascade of effects
muscle and of individual muscle fascicles on
from them.
Copyrighted Material
90
MYOFASCIAL
MANIPULATION
position sense and myofascial tone. Later, in
CONCLUSION Much of the material presented in the early sections
of this chapter may appear to be
weighted heavily toward basic science. It is highly probable, however, that a significant part of benefit derived from the techniques is neuro physiological in origin due to the rapidity of their effects and the relatively longer period of time required for remodeling. A number of these techniques can be viewed as methods to prepare the patient to be able to function in a manner that will lead to more functional remodeling of collagen. We have endeavored to explain and expound, for the cl inician, the relevant issues of mechano receptor anatomy and physiology. Moreover, we have summarized some of the recent f indings of the influence of skin and joint receptors on
an effort to elucidate some of the more recent literature, we discussed concepts of thixotropy and their importance in muscle tone. Finally, we have attempted to connect the science directly to the techniques in this volume proceeding from the superficial to the deeper techniques. The practitioner is encouraged to apply the science and neurophysiology where valid but to be cautious in extending their explanation too far afield from the intent of the science. Furthermore, the practitioner should remember that many manual techniques appear to have no rational explanation but appear to consistently benefit the patient. Consequently, the practi tioner should use the science for explanation, when they can, while continuing to use the art of manual therapy to heal and always continue to investigate the explanations for the effects seen.
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Copyrighted Material
CHAPTER 6
Muscle Pain Syndromes Jan Dommerholt
Muscle pain syndromes are being diagnosed
an almond, or even half a walnut. ... Very fre
today using specific criteria, and patients with
quently the thickening takes the form of a strand
these conditions are increasingly being referred
or cord running through the fascia or subcutane
to physical therapists for evaluation and treat
ous tissue."2 Similar concepts, referred to as
ment. Physical therapists need to understand the
"muscle hardening" and "myogelosis" appeared
nature of these syndromes, how patients with
in the German literature in 1921 and 193 I re
these syndromes are best rehabilitated, and how
spectively3,4 In a recent review, Simons postu
myofascial manipulation fits into the rehabilita
lated that the concept of myogelosis is virtually
tion program. Historically, pain from muscles
identical to the concept of trigger points, a term
has been described in mUltiple terms, including
introduced in 1942 by Travell and colleagues
fibrositis, myofasciitis, muscular rheumatism,
with the addition of "myofascial" in 1952.5-7
rheumatic myositis, muscle hardening, myogelo
The term "fibrositis" was first coined by Gowers
sis, myofascial pain, and myalgia. I Any of these
in 19048 For many years, persons with fibrositis
terms has been associated with examinations
syndrome were thought to have characteristic
of patients who had pain of unknown etiology,
tender nodules, however, without an identified
questionable dysfunction, or negative diagnostic
histopathological basis. It was not until the late
workups. In 1816, Balfour reported "patients as
1970s that clinicians attempted to categorize
having a large number of nodular tumours and
muscle pain conditions into distinct syndromes,
thickenings which were painful to the touch, and
with specific criteria applying to each9-'2 In
from which pains shot to neighbouring parts."2
theory, if the patient's condition satisfies the set
In 1904, Stockman described "chronic rheuma
criteria, a definite diagnosis can be made. The
tism" as characterized by "fibrous indurations
distinction is that the clinician is diagnosing a
[that are] more defined and circumsclibed, vary
syndrome, rather than a pathology.
ing in size from a small-shot or split-pea to
Muscle pain syndromes are generally classi fied into two distinct categories: fibromyalgia and myofascial pain syndrome, although based
The author wishes to express gratitude to Christian
on current evidence fibromyalgia is no longer
Grobli, PT, for his outstanding contributions to the
considered a strict "muscle pain" syndrome.
section on myofascial pain; to Mona L. Mendelson, MSW, LCSW-C, for her ongoing support and pa
To be inclusive, a third category-soft tissue
tience; and to David Simons, MD, for his critical
mechanical dysfunction-should be added. Al
review of this chapter.
though there are overlapping characteristics of
93
Copyrighted Material
94
MVOFASCIAL MANIPULATION
these pain syndromes, they represent different
tigue, sleep disturbance, and psychological dis
neuromusculoskeletal conditions. Soft tissue
tress.
mechanical dysfunction has a strict mechanical
entities have been linked to f ibromyalgia in
Several other syndromes and clinical
etiology, whereas f ibromyalgia and myofascial
cluding headaches, irritable bowel syndrome,
pain can be caused by mechanical dysfunction
chronic fatigue syndrome, interstitial cystitis,
or neuro-endocrine or metabolic dysfunction.
depression, panic disorder, dyspareunia, endo
Examples of soft tissue mechanical dysfunction
crine dysfunction involving the hypothalamic
include partial or full muscle tears or tendinitis.
pituitary-adrenal axis, restless leg syndrome,
By definition, soft tissue mechanical dysfunc tion is an acute and local problem usually con
attention deficit hyperactivity disorder, and non cardiac chest pain.13-23 Because of its associa
fined to a particular muscle or tendon. Myo
tion with so many other syndromes, it has been
fascial pain syndrome is often viewed as a
suggested that fibromyalgia may be part of a
regional pain problem; however, it can be re gional or widespread.
broader neuro-endocrine "dysfunctional spec
trum syndrome."24-26
Myofascial pain syn
In North Amcrica, f ibromyalgia affects 2% of
drome can be acute or chronic in nature. Fibro
(3.4% 90%
myalgia is always widespread and chronic. The
all adults
purpose of this chapter is to explore the etiology,
Seventy to
of women and
0.5%
of men).
of patients are women. Fibro
symptomatology, pathophysiology, and medicall
myalgia is often reported to be a disorder af
therapeutic management of these common pain
fecting primarily young women, yet it is most
50
years and above
syndromes, and to discuss the role of the physi
common in women ages
cal therapist and physician in the evaluation and
(Figure 6-1 ).15 In a recent study, the prevalence
treatment of patients with these conditions.
of fibromyalgia under children was
1.2%.27
Diagnosis
FIBROMYALGIA
Following a
Definition
1977 publication
of Smythe and
Moldofsky, a renewed interest in defining crite
Fibromyalgia is a disorder of chronic wide
ria for diagnosis and classification of fibrositis
spread pain, accompanied by tenderness, fa
emerged, resulting in the
1990
American Col
30 ,,----, -
20 I
.
�.
..r
15 10
51 o
I
·
•
·
18-29
30-39
40-49
• =-=
•
50-59
60-69
70-79
80+
I-+- Widespread Pain ....... FibromyalgiaI Figure
6-1
Prevalence of widespread pain and fibromyalgia. Source: Reprinted with permission from F. Wolfe,
K. Ross, et aI., The Prevalence and Characteristics of Fibromyalgia in the General Population, Arthritis & Rheumatism, No. 38, pp. 19-28, © 1995, American College of Rlleumatology, Lippincott Williams & Wilkins.
Copyrighted Material
95
lvfuscle Pain
Criteria for the C]assifi
the combination of the three
patients;
symptoms was present in only 56% of patients
(ACR
and lacked the
that a diagnosis of can be made if a combination of the fol criteria is satisfied:
however, (defined as
in the left side of the body,
In clinical
that many clinicians make the
above the
primarily based on the tender
below the waist. In addition, axial
count in combination with the
must be present). Widespread pain must for at least three months.
have been
were not essential for
tion purposes.
in the
.. Pain in II out of 18
The report
these typical symptoms;
did
.. History 0 f widespread side of the body,
specificity and
accuracy of the tender point count.
history.
The ACR criteria have provided researchers group of sub-
with a somewhat
defined
to the
which has contributed
tender spots when palpated with approxi 4 ki
of force. The tender
point sites include the
nine
locations
criteria are classification criteria established exclusively for clinical and
Occiput:
at the
muscle
search purposes and not for clinical although the criteria suggested
insertions Low cervical:
the intertransverse spaces
sis as well as classification."28 In 1
at C5-C7
and
at the midpoint of the
be used for clinical
upper border
1992 Second World
at
lS
As part of the on Myofascial
Pain and
above the scap
Wolfe
confirmed that the criteria can
a con
1I1
near the medial
sensus document on f ibromyalgia was defined
border
that
at the second costochon
point count in research protocols. According
dral junctions, just lateral
to the
ula Second rib:
sensitivity, "they may be useful for
at the anterior aspects of
to the
strict adherence to the tender declaration, when the ACR the
on upper
SUifaces Lateral epicondyle: 2 cm distal to the epicon Gluteal:
than 11 tender points.
several contributors to the ACR criteria, also
in upper outer quadrants of
advocate
of fibro are
muscle
present, as
posterior to the trochan
of fibromyalgia features (e.g., fatigue,
dis-
irritable bowel syndrome,
that
teric Knee:
the clinical when less then 11 tender
buttocks in anterior fold of Greater trochanter:
Other authors,
dyles
as "there are sufficient numbers
at the medial fat pad
are present at a sutTicient level of
mal to the
The underlying
line
is that
represents a continuum of distress rather than a It is noteworthy that the ACR criteria do not include the
symptoms of
distur
and psychological dis tress.
disturbance, fatigue, and stiffness
were found in more than 75% of fibromyalgia
discrete depicts a more
The number of tender points measure of distress. A
tender point count may indicate more so matic symptoms, more severe fatigue, and low levels of self-care.
Copyrighted Material
The
nature of the
96
MYOFASCIAL MANIPULATION
Insertion of the suboccipital Under the
muscle
lower sternomastoid muscle
Mid upper trapezius muscle
Near the
second costochondral
2 cm distal
to the lateral
epicondyle
At the prominence of the greater
At the
trochanter
,,
medial fat pad of the knee
Figure 6-2 Fibromya1gia tender points. Source: Reprinted with permission. D.L. Goldenberg. Diagnostic and Therapeutic Challenges of Fibromyalgia, Ho;pital Practices
1989;24(9A):39. © 1989
The McGraw-Hili
Companies, 1nc. 11lustration by La u r a D u p r e y.
fibromyalgia concept, the ACR criteria, and the
sification criteria are necessary for diagnosis in
specificity of the tender points in relationship
the clinic."D.34 Perhaps, a focus on tender points
to fibromyalgia becomes somewhat question
is less important than paying attention to the
able outside the realm of research, when experts
overall psychosocial, behavioral, and organic
agree that "some loosening of the ACR clas
aspects of individuals with chronic widespread
Copyrighted Material
Muscle Pain Syndromes
97
pain35 Jacobs and colleagues did not find a cor
a hermeneutic phenomenological
relation between the tender point count and self
every individual has a strong drive to function
in
.... Pf· .... ,'{'
in a world of meaning, which can be described as "an individual's transaction with a situation
Another important is that the diagnosis of fibromyalgia is made "28
of other
such that the situation constitutes the individual and the individual constitutes the situation,"44,45
the diagnosis of fibromyalgia is "a diagnosis of
In other words, once a person has been given
inclusion."
the diagnosis of fibromyalgia, a process may
to the
a subj ect
meeting tbe ACR criteria should always be clas this
sified as having
be initiated within that individual that serves to to his or her life. Because the
gIve new
may be satisfactory for classification purposes,
current treatment modal ities for
it becomes more complicated in clinical diagno
have not been able to relieve the s ymptoms ad
especially when there is a treatable condition that also features widespread tions include
with fibrol11yalgia a sense of
These condi
pain
illness behavior.4649
gia as a complication of
cific
hypothyroidism, myoadenylate de aminase
or
hypermobility
beliefs, including a sense of
lessness or a belief that one is disabled, are pre dictive of
and
other rheumatic diseasesF-41 Wolfe maintained frequent pain, loss of hope,
as having the syn
but would not be drome.
rather than focus on a treatment outcome.
Although this may seem obvious in
the case of a person with widespread
it fibromy
is conceivable that clinicians
out other, less obvious pain and
to living
also
that "a person with widespread burns would meet classification criteria for fibromyalgia,
they are un
the rehabilitation pro cess.
I
A recent phenomenological study re
vealed that persons with fibromyalgia appeared to seek constant confirmation of their illness.
training in identifying myo points may conclude that there are no other underlying musculoskeletal causes of widespread
and label a
plete
II1cor
patients
An incom
rectly with
with
who met the criteria
may not reveal that a patient started
but who were not diagnosed as such, it was found that the
taking before the onset of the
fibromy higher rates of
had
illnesses. The
may resort to the patients with significant psychological
were found to be
in these
43 One
related to "health care seeking behavior" and not
could argue that in such instances fibromyalgia
to the fibromyalgia. The researchers concluded
problems or with any widespread
that
may be ate intervention for "urln '>"
other
care for fibromyalgia in
would not be considered.
Because the ACR criteria were not developed
There is some of
for diagnostic purposes, they do not consider the potentia lJy
diagnoses
I ifetime
may contribute to the decision to seek medical
and
care settings."5] whether
a uti-
I ization of medical resources, or actually facili
emotional consequences of "a diagnosis of in
tates a
clusion" for patients and their families. From
McBeth and colleagues established that a high
Copyrighted Material
on the medical system545 , 5
MYOFASC1AL MANIPULAT10N
98
tender point count was associated with increased
ful with 4 kg/cm2 for fulfilling the ACR
medical care usage in addition to an increased
Muller and iv1i.iller required 12 of 24 points to
number of physical symptoms.32
be tender when
with a force of 2
_
found that their method
it may not interest of a patient to be when
bromyalgia, especially in the presence of other musculoskeletal pain
for which there
are potential solutions42 For classification pur
proposed method
poses, a "diagnosis of inclusion" may be ap
cohort
in the course
of tendons or at tendon insertions in at least
outcome and conclusions drawn from such re a
In summary, the Muller and
.. :spontaneous pain i n
propriate, even though it may still influence the search. For
58
Muller criteria
three
of the
of the trunk and extremi
ties for at least three months.
intermediate and long-term outcomes of f ibro
.. Decreased
in patients seen at least once in specialty
threshold with a visible
response following
clinics concluded that the prog
2 kg/cm' of l
was very poor. Although
pressure of
out of 24 tender
In addition, Muller and Muller
did not examine the results of treat ment at these centers, patients with f ibromyalgia
the fulfillment of secondary
continued to demonstrate
autonomic symptoms, functional limitations,
clinical it is pos
and functional abnormalities48
sible that clinicians did not consider the other of widespread pain as the ACR cri teria were applied. Perhaps, the patients were not evaluated for the presence of or other dif
syndrome, ferential
including The
and
of three autonomic and three functional symp of fi
toms would further support the
bromyaJgia. Autonomic symptoms may include cold hands or feet,
mouth,
excessive
orthostatic
and did not receive the most
arrhythmia, and tremor. Functional
treatment For clinical purposes, the
limitations may include sleep disturbances, gas
diagnosis of
should be made as a
trointestinal
cardiac problems, pares-
and
of exclusion." It is not sufficient to
Miiller and
all
of fibromy of
should be made only as a reflect a clinician's attitude that fibromyalgia does not
exclusion.
but assures patients of the most
In
of extensive research efforts, there
treatment. The medical and thera
are no obj ective laboratory studies that confirm
management should focus primarily on
the diagnosis of fibromvalgia. The ACR criteria
the other diagnoses and not resort to
were developed 111
patients how to manage their fi This was illustrated by Poduri and
several other c Iinica I including
and
60
met the ACR criteria and who was
The reliance on a definition
diagnosed with fibromyalgia, but who in fact
the lack of a well-defined concept of patho
suffered from drug-related
and required
physiology have resulted in critical opposition
To overcome some of the clinical limitations
have been criticized as being arbitrary and at
immediate treatment accordingly.
to the fibromyalgia construct. The ACR criteria
of the ACR criteria, Muller and Muller devel diagnostic criteria for fibromyal 57
consensus and
When 11 of 18 tender points must be pain
risk for circular reasoning and tautology.
It
appears that the same criticism would apply to the Muller and Muller criteria.
Copyrighted Material
99
Muscle Pain
Although the validity and inter-observer and
Clinical Characteristics Clinically, the patient typically has complaints of diffuse and widespread pain that not confined to tender tients report report
Almost all pa
intra-observer reliability of the tender point count have been established in several Fischer commented that 4
sleep disturbances and in the morning
unrefreshed
and physically fatigued.
anxiety, in stud Other clinical pre
sentations may include hypersensitivity to cold bouts of abdominal
or heat,
con
stipation and diarrhea, recurrent frontal-occipi tal headaches, and sensations of numbness or usu
in the hands and feet. The ally describes chronic
headaches, and fa-
for many years. The result of x-rays, computed
pressure algometry is recommended. Pressure is a standardized method for quantifi the so
cation of tenderness and is called pressure
threshold, or the minimum
pressure that induces
or discomfort.
also
a means to evaluate immediate and
long-term treatment
Zohn and
Clauw explored the utility of skin rolling as a clinical test for
and found that skin
rolling
netic resonance phy, and blood studies are normal, and should not be ordered unless other clinical
of the tender
point count.
Skin rolling does not depend on a
verbal response of the patient and may be more than a tender point count;
would indicate such.
It
is not only useful for diagnostic purposes, but
at
this point, further studies are needed to establish the nature of skin
Tenderness
and its
to
the diagnosis of f ibromyalgia.
An essential feature of the ACR criteria is a total tender point count of at least II out of 18 anatomically defined
when these
are subjected to 4 kg
pressure. Semanti that the ACR criteria require
cally, it is
11 out of 18
defined tender points,
Persons with fibromyalgia have altered noci f'P'r,nr.n
tender points, but also in nonpainful 66
need to be distinguished from myofascial
In another
the
sensitivity in fibromyalgia patients was
points, which are the main characteristic of the I.n
in all
not only over f ibro
three tissues was
tender points
myofascial
Vecchiet and
muscle and observed that
rather than II tender points out of 18 anatomi cally defined
and
more
to the skin and not re
hy-
stricted to muscle tissue. The altered
but
expresses a more
was not dependent on increased skin sensibi 1ity.65.8o Gibson and colleagues demonstrated that
pain problem.64-66 The
persons with
is not limited to the tender
do not have an established
exhibited a
cant reduction in heat
or
threshold as well,
although this was not confirmed by
points .
points are actual contraction
In spite of these findings, there is no convincing
knots in muscles that refer pain to a more distant
evidence that the peripheral tissues in persons
Patients with myofascial
may also have
ger points, yet can evolve into
Graven-
concluded that the hy
trigger points" do
not exist.67.68 There is no evidence that cial
are abnormal.
syndrome and myofascial tn"'I>T,' _
observed following painful stimuli of a pain-free muscle in fibromyalgia indicates the involvement of central hyperexcit
Copyrighted Material
100
MVOFASCIAL MANIPULATION
Patients with
had a lower
state level of
cerebral blood
86
flow in the thalamus and caudate also
P",""hn",n,.,i,,1 Factors
Most studies demonstrated that persons with
which
have more emotional and
that central sensitization is the
than persons with other chronic
final common pathway for the development of abnormal pain perception,
and normal control which led Hudson and Pope to conclude that
Disturbances
persons
disor
is an "affective with
report
to Yunus, the use of this term because
but this
up unrefreshed and
is not universal. In some persons, famay be debil
all are based on
whereas in others it
rheumatology clinics and may
because of its
psychological problems based
is absent or has been
chronic nature 89 Fatigue may be the result of
on referral bias,
disturbed sleep, which in itself is a factor posi
concluded that affective distress is not
tively associated with self-reoorted work dis 48,90 In general,
also
but primarily the result of severity.IOR In an older
cycles
no
differences were found between per
and non-REM
sons with fibromyalgia and control subjects in a medicine clinic, 1
divided into four
there is no evidence that there is a
ages of low frequency brain waves referred to as delta waves, Stages 3 and 4 feature predomi
a few studies iden
nantly delta waves and are referred to as "deep
prone personality" in some pa Persons with a tients with fibromyalgia, 1I 0,
or "slow wave
" It is during these
that restorative
occursYI,92 In 1975,
prone personality are typically
achiev
that fibro
ers, who lack assertiveness and the ability to
patients have an abnormal sleep pattern
"",,,pi,,,, and express unpleasant emotions, The
Moldofsky and col
anOlTI
characterized by the so-called
an intrusion of alpha waves during slow several studies have con others failed to duplicate their
of a pain prone be related to posttraumatic stress ences, I I
trauma, and adverse childhood
The alpha-delta
anomaly was found in
36% of f ibro for fibro
patients and was not
99 It has been described in persons with (AIDS),
acquired immune deficiency
between persons with
group, while several other studies have linked alcoholism in families and sexual and abuse to fibromyalgia,113-11 were positively correlated with a
with m yofascial pain tioned the sensitivity and
count32 A pain prone
quality and persons
104
with
marie stress disorder versus none of the control
and even in rheumatoid subjects,100-103 Scudds and colleagues did not find any difference for
of were found to suffer from
to fibromyalgia and is seen
is not
among a broad spectrum of Dsychosomatic and disorders, I I
Lue ques
I
appear
Patients with
of alpha
rates of lifetime and current
electroencephalography,105
a few studies that did not find
is insufficient evidence that disturbed sleep pat
I
terns are specific for persons with fibromyalgia;
any evidence of increased depression,
any chronic pain state appears to have a negative
As with most symptoms of
effect on a person's
not clear how the symptoms are related to the
Copyrighted Material
,
it is
101
Muscle Pain
Do patients with fibromyalgia get pnr'p" "F'fl
study concluded that having been told that one had f ibromyalgia became one of the
because of pain, or can contribute to
cause or
the influence of cognitive beliefs on somatic 90 Similarly, Haynes and
disorders the result of a common underlying Based on recent studies and theo are most likely
and
the result of a commOn underlying abnormality, insufficient catecholaminergic or neurotransmission or hyperactivity hormone.1 8,121.122 It is that having a
of
combined with constant pain, poor expectations recovery, and a sense of nOIPeleSi;ness, may also become
established that
del)re�5Sl\/e mood disorders, Fassbender and observed that patients with fibro
in work absenteeism after being told the If having been
SIS.
work disability,
and if the symptomatology
an extenua
tion of an already difficu,lt
should persons
with f ibromyalgia receive disability benefits? of persons with f ibro
Although the report
able to
as many as
25% have received some form of compensa tlon43,90,130 and Borus included f ibromyalgia in
Patients with
of "functional somatic syn
higher
characterized
a group of
and
lifetime prevalence rates of mood,
and
with rheu
somatization disorders than matoid arthritis. I
with fibromyal
is a factor in
had significantly more tender points f ibromyalgia demonstrated
who did not know that had a threefold increase
they were
factors
than patients with
which illustrates
work Or are both
due to increased pain
126 Wolfe and
found that persons with f ibromyalgia are more than four times as
to be divorced com
to the
syndrome, rep etition stress
the side effects of si Iicone
breast implants, the Gulf War syndrome, chronic
myalgia.
whiplash, the chronic
is "just another somatization disorder."1 27 pointed out that "to
Hellstrom and col
it meaning."52
put a label on suffering Having a
of fibromyalgia may pro with
vide a means to avoid issues or
and
the irritable bowel syndrome. 131 F unctional so
that
Several authors have
have certain characteristics
matic in common.
from any of
Persons
often attribute common so
these
matic symptoms to the illness, Common symp toms are amplified and become the main focus
are not rea Ily "re
of attention,
are convinced that
have
inability to comply
a serious illness that is likely to worsen, The
with the demands they themselves and others
is convinced of having a seriolls
sponsible for their would
upon them.
f ibromya Igia a form of somatization and a "fash ionable diagnosis" and
that somatization
could serve as a rationalization for psychosocial r"'(1,hlp'm"
or as
mechanism, 128 Fibro
can become "a way of
" or as Hadler
stated, "if you have to prove you are ill, you
a confirmative ness seemed to be important for persons with fibromyalgia,
Wolfe confirmed that persons
with f ibromyalgia reported more medical condi tions and
more
to these
conditions than persons with rheumatoid ar
can't get better."46,128 This becomes particularly
thritis or osteoarthritis,
difficult in
functional somatic
whether persons with
to search for
the
Ford also considered
should be a warded disability or A recent
Many
further exacerbated by and
Copyrighted Material
with
assume the "sick portrayaI
102
MVOFASC1AL MANIPULATION
of the condition as "catastrophic and disabling."
to be deconditioned, which may account for
Barsky and Borus outlined several other factors
some of the apparent abnormalities reported
relevant for the discussion of fibromyalgia. Health care institutions, medical providers, and
in oxygen consumption and accumulation of
metabolites.137,1.18 W hen compared to equally
advocacy groups have developed professional
fit healthy subjects, however, persons with fi
and financial interests in the diagnosis, as evi
bromyalgia were found to have normal oxygen
denced by the increasing number of fibromyal
consumption and normal accumulation of me tabolites during exercise,1 39-141 Other studies
gia clinics, Internet Web sites devoted to fibro myalgia, and the multiple support groups, which
demonstrated that there was no increased struc
will reinforce the belief that there is no effective treatment (Table 6-1 ).132,133
tural damage with exercise when compared with healthy individuals,142-144 Although the number
Many patients with fibromyalgia have ad
of subjects was limited, a few studies suggested
opted other diagnoses and feel that they also
that persons with fibromyalgia may have a hy
have chronic fatigue syndrome or irritable bowel
poresponsiveness of the sympathetic nervous
syndrome, a process sometimes referred to as
system and hypothalamus-pituitary-adrenal axis
"pathoplasticity," realizing that these additional
during exercise. 145.146
syndromes may have etiologic similarities to f ibromyalgia.134,135 The diagnosis given to a pa tient may in fact depend on the specialty of the
Pathogenesis
physician. A rheumatologist may diagnose fi
One of the difficulties of diagnosing and treat
bromyalgia, an internist may identify chronic fa
ing patients with fibromyalgia is the absence
tigue syndrome, while a gastroenterologist may
of findings in the laboratory and radiologic
consider irritable bowel syndrome. In spite of
workup. Much research has been conducted to
these controversies, patients with fibromyalgia
identify histological and physiological charac
or chronic widespread pain will continue to seek
teristics of fibromyalgia to determine possible
medical help irrespective of physicians' belief
etiologies and effective treatment remedies. Fi
s ystemsD6
bromyalgia is a complex, multi-factorial dis order that has been associated with musculo
Lack of Exercise
skeletal and neurochemical abnormalities, yet
Lack of exercise is another relevant factor in
most of these abnormalities are not specific for
the clinical history and presentation of fibromy
fibromyalgia. None of the findings have resulted
algia. Most persons with fibromyalgia exercise
in fibromyalgia-specific laboratory studies or
little and assume that exercise will worsen
objective diagnostic criteria. Initial studies at
their condition. Persons with fibromyalgia tend
tempted to identify musculoskeletal abnormali ties and signs of inflammation. Altered muscle metabolism, decreased circulation, and struc
Table 6-1 Number of Web Sites Found on www.altavista.com (January 10, 2000)
tural damage to muscles have been suggested to explain the widespread muscle pain in patients with fibromyalgia. More recent research has
Search Word Heart disease
Number
focused on the role of neurotransmitters, the hy
of Sites
pothalamus-pituitary-adrenal axis, and various
249,547
Arthritis
428,885
Cancer
2,181,318
AIDS
2,321,925
hormones, A brief review of pertinent research follows.
Musculoskeletal Abl10rmalities
Fibromyalgia chat
14,373,294
Several studies identified "rubber bands" in
Fibromyalgia
87,726,785
single muscle fibers, "moth-eaten" and "ragged
Copyrighted Material
Muscle Pain
a reduced content of high energy and a
rate of phosphodiester
resonance , which were thought to be related an abnormal oc
to the
to
103
163165 Patients with
trol
hip os
teoarthritis were found 10 have 1.5 to 2 .0 times normal levels of substance
P, whereas
including diabetic neuropa
with
had either below normal or j.5 times normal
currence of elastic state, or local muscle
levels.166-168 Substance P is a neuropeptide in
eaten" fibers are indicative of a change in the
volved
distribution of mitochondria or the sarcotubular
It is released in the dorsal horn of the cord in laminae I, II and V
system; "ragged red" f ibers reflect an accumula and colleagues
tion of mitochondria.154
in several aspects of the process of noci
laminae r and II
and
activated
and
identified decreased levels of collagen cross
C fiber afferent neurons. This seems to suggest
links in persons with
that there is a peripheral
of altered collagen
tive stimuli; of the extracellular matrix.
tribute to
of the nocicep
at this point, there is no mechanism in
evidence to support a
They hypothesized that these changes may con
f ibromyalgia.122.l69 The large diameter sensory
tribute to the lowered pain threshold at tender
fibers (A ) are
155 Others did not f ind any muscles.
but release
and normal
differences between
rotransmitter.
When
were matched with equally
and terminate
in laminae III and IV They do not contain neu as their neu
Dorsal horn neurons are divided
healthy control
into high-threshold mechanosensitive neurons,
no differences were found in lactate
low-threshold mechanosensitive neurons, wide neurons, and interneurons. All
oxygen uptake , and p31 neurons can be
resonance spectroscopy, that patients with f ibromyalgia do not have ab normal muscle metabolism.139-142,1
There
increase in the excitability
is also no evidence of any strllctura I
neurons
to muscles of persons with
may contribute to the did not reveal any
resonance
sensitized or
new synaptic contacts with other neurons. A
abnormalities of the skeletal muscles of persons
pain disorders.171 Under normal high-threshold mechanosensitive neurons are
with fibromyalgia.160 The structural and func
connected with Ao and
C f ibers.
to noxious stimuli,
tional abnormalities noted in earlier studies appear to be the result of muscle
whereas low-threshold mechanosensitive neu
and are not specific for f ibromyalgia.161 Because
rons do not mediate pain. Afferent barrage from
of the lack of
and muscles can unmask
peripheral and histologi
ineffective, or
research
cal findings, the focus of has shifted toward
of the central
within the dorsal horn
synapses the release of sub
nervous system and the endocrine system. To
stance P, calcitonin-gene related peptides, and
understand the
mechanisms
glutamate from the primary afferent neuron into
for
it is critical to sciences into
that A
clinical
and
the dorsal horn via neurokinin-l
There is some evidence
fibers sprout dorsally from laminae III
and IV into laminae I and 11 following peripheral
Neurochemical Abnormalities
It1Jury,
Substance P. Several studies have identified
in new synapses with
tive neurons. Low-threshold
afferent input as nox.ious.17o Be
substance P levels to be up to three times
would then be
higher in the cerebrospinal fluid of persons
cause substance P can lower the threshold of
con
excitability, there may be an increase
with
with
Copyrighted Material
104
MYOFASC!AL MA.NIPULATION
in the number of mechanosensitive receptive
They
making fibromyalgia a syndrome of cen 4 tral sensitization.172-17
bromyalgia and the plasma concentration of the
The pain in f ibromyalgia may be related to the action of substance P on neurokinin-l etTector rp('pntr.r
a correlation between pain in fi
essential amino acid tryptophan. Tryptophan is the metabolic precursor to serotonin that extracted from
in the intestines.
that oromote nociceotion, This does
decarboxylated to se
of excitation in
cleus, which is then released in the brain and
rotonin by neurons in the brain stern raphne nu however, because the
the spinal cord is fairly limited,
with rats, serotonin
spinal cord, In
and colleagues reported the
of elevated
levels of nerve growth factor in the nal fluid of persons with
brain, while it inhibited the release of substance Nerve
factor is thought to facilitate the growth of substance P containing neurons and increase the excitability of dorsal horn cells
enhanced the synthesis of substance P in the
afferent
muscle input.l76·m The nociceotive activity of
cord. It is likely that persons
P in the with
have Jow brain tissue levels of
both serotonin and substance P, and low spinal cord levels of serotonin and high spinal cord
levels of substance P.186 Although
substance P is counteracted
levels of serotonin have not been reoorted in
can inhibit spinal
cerebrospinal fluid of persons with the concentrations of its immediate pre
pathways. SerotOllilt. Serotonin
and its metabolic
cursor
is a neurotransmitter involved in the organiza
sleep,
neuroendocrine rhythms, and pain
178 It is one of the neurotransmitters
for regulation of the function of the hypothalamic pituitary adrenal axis. Serotonin can influence the release of
product
acetic acid were found
to be lower when compared to normal control subjects.
89 Lower serum levels of both tryp
tophan and serotonin have been reported, pos sibly related to the diversion of tryptophan into kynurenine instead of serotonin and to low serotonin.188,190- 192 The range
levels of
of serum levels of serotonin in
hormone from the
to be
the release of mone from the anterior
and may not be
consistently correlated with f ibromyalgia symp tender points, and
direct influence on the corticosteroid production
toms,
from adrenocorticol cells. Serotonin increases
dolorimetry.193
the production of adenosine monophos 179 It is not known whether serotonin de
seter muscles
f iciencies will result in the perturbations of
pared with healthy control subjects. The
the hypothalarnic pituitary adrenal axis seen
levels aDDeared to originate in the blood supply,
IRQ
1
and colleagues found
higher levels of serotonin in the superficial mas with fibromyalgia com
Multiple
Iy released. 194 Klein
serotonin receptor sites have been identified in
the presence of antibod-
in persons with
phospholipids, and
the gastrointestinal tract, which may be relevant
of the serotonin
the relative common occurrence of func
14 195-197 ,
tional bowel disorders in person with Ig)
Antibod
serotonin were also reported in pera condition sometimes 1 98 The inhibition
Moldofsky and
via descending
of its role in the initiation and
of spinal
slow wave sleep and the regulation of pain per ception through activity in the thalamus,lg4,lgS
is accomplished primarily via serotonergic and
""tl""""C
noradrenergic neurons.174,199 Perhaps the wide
Copyrighted Material
Muscle Pain Syndromes
105
(Figure 6_3).22.122.202 -205 Fibromyalgia can be
spread pain in fibromyalgia is the result of a dysfunction of the descending antinociceptive
considered a "stress-related syndrome.''203 The
system or of an overactivity of the descending
hypothalamic-pituitary-adrenal axis is the main
pathways that facilitate nociception.200.201
physiologic response system to stress. Regulation of the hypothalamic-pituitary
Hormonal Abnormalities. Because the onset
adrenal axis occurs primarily through modu
of fibromyalgia is often reported to coincide
lation of corticotropin-releasing hormone, an
with physical or emotional stress, it is not sur
amino acid peptide that stimulates the secretion
prising that several researchers have focused
of adrenocorticotropic hormone and other hor
on possible disturbances of the stress response
mones. Adrenocorticotropic hormone is an an
systems, including the hypothalamic-pituitary
terior pituitary peptide that stimulates the secre
adrenal axis and the sympathetic nervous system
tion of glucocorticoids and other steroids from
Brain Hypothalamus
VP
CRH
S P D
NE
a
I c 0
ACh
r
ry
d NE
ACh
Adrenal cortex
Cortisol
Liver
Sornatomedin C Figure 6-3 The hypothalamic-pituitary-adrenal axis pertinent for the etiology of fibromyalgia. Note: CRH, corticotropin-releasing hormone; YP, vasopressin; SS, somatostatin; GHRH, growth hormone releasing hor mone; GH, growth hormone; ACTI-!, adrenocorticotropic hormone; NE, norepinephrine; ACh, acetylcholine;
EPr, epinephrine.
Copyrighted Material
106
MYOFASCIAL MANIPULATION
the adrenal cortex. Cortisol is the main form of
nephrine responses to hypoglycemia, contrast
glucocorticoids released in humans.ISO,
ing the findings by Griep and colleagues of
cotropin-releasing hormone stimulates adreno
an exaggerated adrenocorticotropic hormone
corticotropic hormone in a diurnal rhythm with
responseY,204 Nevertheless, they agreed that
a peak before awakening and a decline as the
f ibromyalgia may be primarily characterized
day progresses, The diurnal rhythm of adreno
by an impaired hypothalamic-pituitary-adrenal
corticotropic hormone is reflected in the diur
axis,n
nal secretion of cortisopo7 When a stressor is
Another aspect of the hypothalamic-pitu
perceived by the brain, corticotropin-releasing hormone is released,180,182,206 The activity of cor
itary-adrenal axis was recently investigated by Dessein and colleagues, who looked at the levels
ticotropin-releasing hormone neurons appears to
of dehydroepiandrosterone sulphate, testoster
determine several of the symptoms of fibromy
one, cortisol, serotonin, and insulin-like growth
algia,122,205 Persons with fibromyalgia displayed
factor- l (somatomedin C) and their correlation
a hyperreactive adrenocorticotropic hormone
with health status in persons with fibromyal
release and a blunted cortisol release in response
gia.212 Dehydroepiandrosterone sulphate is the
to exogenous corticotropin-releasing hormone
metabol ic precursor to estrogen, which was re
and to endogenous activation by insulin-induced hypoglycemia.204, The release of adrenocor
cently shown to be involved in the regulation of enkephalin levels in the superficial dorsal horn,
ticotropic hormone by corticotropin-releasing
thereby changing the response to nociceptive
hormone is augmented by arginine vasopressin,
stimuli.213 During pregnancy, dehydroepiandros
another hypothalamic peptide, Based on studies
terone sulphate is involved in the placental pro
of rats, arginine vasopressin may be instrumen
duction of estradiop4 I
ta I in maintaining the activation of the hypo
sulphate levels are a good indicator of adreno
thalamic-pituitary-adrenal axis during chronic stress,19, Different stressors cause different
than cortisol levels.215 Under stress, the secre
patterns of release of the hypothalamic hor
tion of dehydroepiandrosterone sulphate is di
cortical function and probably more sensitive
mones, Riedel and colleagues observed elevated
minished. With aging, there is a suppression of
basal levels of adrenocorticotropic hormone and
dehydroepiandrosterone sulphate secretion, but
cortisol in fibromyalgia patients205 Crofford and
not of corticosteroid production2.
colleagues and McCain and Tilbe found normal
ual physical activity was related to lower levels
morning levels of cortisol, but elevated evening
of circulating dehydroepiandrosterone sulphate
levels, resulting in a loss of the normal diurnal
and insulin-like growth factor-I independently
cortisol fluctuation202,203 Reduced 24-hour uri
of age and anthropometric measures.
nary free cortisol levels were found as compared
elderly women, lower maximal aerobic capacity
with normal subjects and persons with rheuma
was associated with lower dehydroepiandros
toid arthritis or low back pain, especially in per sons with longstanding fibromyalgia.202,203,208,21
terone sulphate concentrations.217 There is also a positive correlation between hours of sleep
Crofford and Demitrack speculated that the ap
and
parent discrepancy between elevated evening
serum dehydroepiandrosterone sulphate levels21 8 Dessein and colleagues found that
levels of cortisol and reduced 24-hour levels
the levels of dehydroepiandrosterone sulphate
may be attributed to a reduction of the normal
and testosterone were significantly reduced in
frequency of cortisol release,181
women with fibromyalgia. They speculated that
with these f indings, Adler and colleagues found
the androgens may protect against f ibromyalgia.
normal 24-hour urinary free cortisol levels and
There was a positive correlation between dehy
normal diurnal patterns of adrenocorticotropic
droepiandrosterone sulphate levels and pain,
hormone and cortisol22 They found a 30% re
which disappeared after adjusting for increased
duction in adrenocorticotropic hormone and epi
weight. Only 14% of the subjects were normal
Copyrighted Material
Muscle Pain Syndromes
107
weight in this study and there was an associa
myalgia compared to healthy, but sedentary con
tion between a high body-mass index and de
trol subjects.229 They suggested that perhaps
creased dehydroepiandrosterone sulphate levels,
the difference in findings was due to selection
which contradicted the findings by Maccario
procedures, as it is known that physically active
and colleagues in healthy adults.212,219 In Macca
individuals have significantly higher somatome
rio's study, the dehydroepiandrosterone-sulphate
din C levels than sedentary subjects.229,23o
levels were positively and independently associ
An intriguing hypothesis regarding the etiol ogy of fibromyalgia was postulated by Yue231
ated with 24-hour urinary cortisol and insulin like growth factor-I levels.219 Dessein and col
Notwithstanding observations by Ostensen and
leagues did not find any significant relationship
colleagues describing worsening of symptoms
between the levels of cortisol, serotonin, and
during pregnancy with the last trimester experi
insulin-like growth factor-I and health status as
enced as the worst period, Vue noted that preg
measured by the Fibromyalgia Impact Question
nant patients with fibromyalgia often experience
naire212
a remission of their symptoms during pregnancy
Several studies have demonstrated that per
with a return of symptoms within one or two
sons with fibromyalgia may have low levels of
months following delivery2312, J2
growth hormone (somatotropin) and insulin-like Growth hormone is an growth factor-I. 205.
found that many patients with fibromyalgia re
amino acid polypeptide hormone synthesized
toxin. These findings made Vue search for any
and secreted by the anterior pituitary. Its primary
agent or hormone that would have an effect on
sponded positively to injections with botulinum
function is to promote linear growth. Growth
the collagen of connective tissues, which re
hormone stimulates the release of somatomedin
sulted in the hypothesis that the pathogenesis
C in the liver, which is required for the main
of fibromyalgia is related to a systemic deficit
tenance of normal muscle homeostasis.122 Ap
of relaxin, or an inability of the body to utilize
proximately 70% of growth hormone is se
relaxin231 He speculated that the increased use
creted during slow-wave sleep and the amount
of birth control pills at a younger age may lead
of secreted growth hormone correlates with the amount of slow-wave sleep225 It was postulated
to relaxin deficiencies. A fast onset of fibromy
that the poor sleep patterns of persons with fi
oophorectomies or hysterectomies. [n males,
bromyalgia could disrupt the nocturnal secretion
low levels of relaxin appeared to be related to
of growth hormone.223 The secretion of growth
low levels of testosterone.
algia appeared to occur in women following
hormone is under bidirectional control of the
Relaxin is a polypeptide hormone related to
hypothalamus, which contains both growth hor
insulin and insulin-like growth factors. It is se
mone releasing hormone as well as a growth
creted in females in the corpus luteum, decidua,
hormone inhibiting hormone, known as soma
and placenta and in males in the prostate, from
tostatin.ISO,I2 S
which the hormone is secreted mainly in seminal
decrease in growth hormone releasing hormone,
plasma. Relaxin is best known for its role during
or an increase in somatostatinThe somatostatin
pregnancy and is known to promote lengthening
secretion is promoted by corticotropin-releasing
and softening of pelvic ligaments to facilitate
hormone and thyroid hormones, which is an
the birth process. Relaxin does not only effect
other reason to include thyroid dysfunction in the differential diagnosis of fibromyalgia.2062, 262- 28
many other biological processes.233 It is involved
Leal-Cerro and colleagues concluded that the
in the inhibition of uterine contractile activity
connective tissue extensibility, but plays a role in
decrease in growth hormone secretion was due
and it stimulates the growth of the mammary
to hypothalamic dysfunction.224 Norregaard and colleagues did not find any differences in so
gland. In males, relaxin is thought to promote motility of spermatozoa234 Relaxin has a strong
matomedin C levels among persons with fibro-
vasodilatory effect and it promotes the genera
Copyrighted Material
108
MYOFASCIAL MANIPULATION
tion of nitric
which also appears to
an important role in muscle pain.2JH37 Of par ticular interest is that in exoeriments w ith rats, sites have been identified in
relaxin
several regions of the brain that are involved secretion of hypothalamic hormones.
groups based on their responses to the Multidi mensional Pain 1 nventory. The
Re
group was characterized by poor coping and high
laxin stimulates the release of oxytocin and va sopressin,
as discussed above,
levels of
the release of adrenocorticotropic hormone by Re
hormone.
laxin was also found to promote the secretion of prolactin and lated that
hormone.
were classified in one of three
with
blood pressure and the
in the control of
The "interpersonally distressed"
group was characterized by lems. The
copers" demonstrated low
levels of affective distress and disability.
administration of relaxin in per
cally perceived
sons with f ibromyalgia may alleviate many of
pain, affective
the symptoms.
perceived interference of pain for the
At this point, Yue's specula
tional" group, but not for the "interpersonally
by independent the broad spectrum of relaxin
that much, possibly because of low levels of distress.252 All clinicians must recognize the multi-com
Management of Fibromyalgia
of there
of
is usually no
or treatment
remedy that can offer optimal solutions, although
and colleagues re ArtAri
pain. between acute and chronic pain and the common
changes that
chronic pain often make, It is
sion rate of 24% after two years
aware of the "5 Ds" of chronic
intervention in community tice.245,246 As Turk and Okifuji have
dysfunction. uepenue "A""""tc
of learned
with chronic
assessment
did
distressed" group. The "adaptive
deserves further attention.
Given the
Fol
Yue specu
avoid
attention to relevant psychosocial,
verbal and nonverbal
and organic factors and an integrated interdisci
communications. Many chronic
plinary treatment strategy35 The available data
prefer to view their pain condition as a medical
suggest that the chology, and
of
psy
therapy offers the best pos
problem,
their
for
their pain and their life situation. Clinicians
of the
working with persons with fibromyalgia must be
treatment can be done in group format, whereas
comfortable with different learning stvles and
others
the role of
sible treatment outcome246 Certain individual interventions.
One
and the and be
did not treatment to group education.248.249 It is tant that
with systems
are part of the
and physical
ary team and develop clear perceptions about their
role as functional members
in working with persons with fibromyalgia. Systems
of the health care team.2SI) The approach can lead to significant
used in
life interference, sense of COI1-
is the most popular social work
that
focuses on the interactions and transactions be tween
Copyrighted Material
and their environments. It in
109
cludes the marital relationship, the family and
and
society, as well as functional and structural as
nicians must move beyond the common Carte
pects.
Although physical
should
systems intervention, a orientation can
an essen
especially in under-
tial role in physical
each other's contributions.25o Cli
sian monistic and dualistic treatment based on
and
It is counterproductive to have the physician while the
work from a somatogenic
the broader context in which
or clinical social worker considers
into the patients' belief systems patients that their
There is no doubt that
Whereas dif ferent disciplines are
or lack thereof is essential.
and pain is taken
and that their intentions
are not questioned
their pain
rl'''nr.ll
treat-
components of the overall
of one discipline should be conand
other team members.
is
critical from the f irst encounter and throughout
should
the treatment process. Patients need to become the optimal treat-
active participants in men!
OA,·,thln1
and physical therapy
253
and clinical social workers must be famil
Bennett
self-
by
iar with the
and objectives of medicine Each discipline must syn
and
chronize its efforts with any of the others.25o
back loop that exists when stress of chronic levels results in physiologic arousal with sec symptoms246
Following is an overview of the role of physi cians and physical
in the manage
ment of persons with
control over
The role
of psychologists and clinical social workers is and will not be
the context of this longer
included. It should be obvious that the success
stimulation.
Bandura described four tech-
for altering patients' perception of self efficacy, including social persuasion, mastery and
ful
of persons with without mental health
cannot be
professionals both in group and individual in
feed
terventions. Psychological group interventions
back. Through social persuasion, health care
may focus on problem-solving techniques, stress
providers and
reduction,
others attempt to con
vince patients that they can be more functional than
activities that
By
previously were thought to be impossible be cause of pain or other dilemmas, master new
psychosocial
1Il-
histories of sexual
abuse, alcoholism, illness behav ior, somatization, posttraumatic stress, and so forth, 121,260-264
their lives and be
Medical Management are
change their individual situations. levels of
outlined
who
who maintain that
feedback is also important
issues
depression,
persons with
coming more functional can provide a model for those
and inwhereas
individual sessions may deal with the many
can
to others with have succeeded in
effective
the overall knowledge
monitoring their
the first point of con
tact for the person with
and
and ul
for
persons with
with the appropriate medical d
new levels of activity.
common that patients with f ibromyalgia have
In any interdisciplinary treatment model, it
already seen
necessary that the various
the time
support
Copyrighted Material
health care providers by As discussed
MYOFASCIAL MANIPULATION
110
slow-wave
and increase the
of
serotonin.54.266 it
the administration of amitriptyline 267-27 Surpris
is probably irrelevant whether the
affect the sleep
the ACR research criteria. After the physician should
agnosis of
in some patients with f ibro
anomaly
provide patients and their families with adequate
myalgia99 The recommended dose is 10-50 mg
information regarding the
of amitriptyline and 10-30 mg of cyclobenza
and assist
patients with developing short and
could not be demon
line and
be emphasized, rather than a cure of f ibromy The goals of
or a total relief of nain.
efficacy of amitripty
prine265 The
Symptomatic and functional
strated.276 (Xanax) was
and
ibuprofen recommended.
agent and is usually
and desires and not of the health care
Patients who have
term relief of mild to moderate anxiety or ten
are more likely
sioll. The selective serotonin reuptake inhibitors
assisted in developing their to assume ownership of those
and work
toward accomplishing them with the support of health care providers. The
for
and colleagues
may also be of value. reported
in
pain, and over
all well-being with a combination of amitripty
each discipline must support the overall
line and fluoxetine
of the patient. The
approach
of the two
was more effective than either
and
drug alone.
is given in the
responsibility back to the their significant others, but the
for
The combination
morning to avoid further insomnia54 Others have
outcomes is shared by all members of the team,
studied the effect of 5-hydroxytryptamine type
including tile patients.
3 receptor antagonists and reoorted that both
In most Clan
ondansetron significantly
IS
tation program. The medical management m
tender
cludes the prescription of medications and in
Zolpidem
most cascs, the referral to olher therapy alone is
as
suff icient265 The
general principles that apply to the treatment of
tive effect on
but not on pam
intensity,
quality, morning fatigue,
and the number of tender points280 Anti-inflam
Based on
matory medications were shown to have little
published research, there are some pharmaco
or no effect.265 Biasi and colleagues reported
any patient with chronic pain
interventions that appear more effective than others, although none of the medications used are
positive results with tramadol (Ultram)2 . 8J nett and colleagues tested their hypothesis that a role in the
for
and none are very effective.
It is with low levels of insulin-
ncw medications or combinations of medica
hormone to
tions will be used as the understanding of under
like growth factor-I.
They observed that and low levels of in
women with increases54 In an era of evidence-based medi
sulin-like growth factor-l experienced an im
the pharmacological management should
provement in their overall symptomatology and
be based on scientific f indings and subiected to
number of tender
clinical outcome studies.
daily growth hormone therapy, but no patient
There is some evidence that cations may be useful.
medi can improve
had a patients who
Copyrighted Material
after nine months of
remission of symptoms. All improvement while
Muscle Pain Syndromes
taking growth hormone encountered a worsen
II I
educate patients with fibromyalgia regarding the
ing of symptoms over a period of one to three
multiple positive effects of regular exercise on
months after stopping treatment2. 232, 82
depression, quality of sleep, levels of serotonin,
Cerro and colleagues confirmed that the ad
dehydroepiandrosterone sulphate and insulin
ministration of growth hormone may reverse
like growth factor-I levels, psychological well
some of the symptoms of fibromyalgia224 The
being, overall fitness levels, and fatigue. When
widespread use of growth hormone is, however,
comparing a program emphasizing cardiovascu
unrealistic because of its high cost.
lar training with a flexibility program, patients receiving cardiovascular training showed sig
Physical Therapy Management
nificantly improved cardiovascular fitness and
When patients are referred to physical therapy
improvements in pain threshold scores, but not
with a medical diagnosis of fibromyalgia, the
in perceived pain intensity, percent body area
physical therapist must examine the patient and
involved, or sleep patterns.285 Wigers and col
determine the appropriate physical therapy di
leagues compared aerobic exercise with a stress
agnosis.283 In clinical practice, many patients
management program and concluded that aero
diagnosed with fibromyalgia may have other
bic exercise was the most effective treatment ap
treatable diagnoses as discussed previously.
proach, although there were no significant dif
ically, physical therapists are not trained to rule
ferences between the two groups at four years of
out medical causes of widespread pain, such as
follow-up.289 Other studies also suggested that
complications of cholesterol- lowering medica
regular exercise, including aerobic walking, was
tions, hypothyroidism, or myoadenylate deam
correlated with less symptoms245.
inase deficiency, but they should be able to
and colleagues did not find any improvement
Norregaard
assess patients for the presence of myofascial
in pain, fatigue, general condition, sleep, de
trigger points, hypomobility, or hypermobility.
pression, functional status, muscle strength, or
the symptoms correlate with myofascial trigger
aerobic capacity in either a progressive exercise
points or with altered joint mobility, the physical
program or an aerobic dance program, partly
therapist should review this with the referring
due to poor compliance291 A common problem
physician and suggest that perhaps the patient
with any form of exercise is the lack of consis
may not have fibromyalgia after all. In many
tent long-term compliance. Whenever untrained
cases, the patient needs to be convinced that
individuals start to exercise, they will experience
their condition may actually be treatable, which
an initial increase of muscular pain, not to be
may become the main objective during the first
confused with the typical pain associated with
few treatment sessions. Again, after being diag
fibromyalgia.
nosed with fibromyalgia, many patients modify
the appropriate timing and coordinating of vari
their expectations, lifestyle, and perspectives
ous aspects of rehabilitation. Each patient has a
and resort to living with a chronic incurable
distinct personality, lifestyle, and activity level
disease entity.
that need to be considered during the rehabilita
In addition to education, the most important
tion process. Will the patient be successful in
aspect of physical therapy intervention is car
undertaking a home program? Will the patient
diovascular training.265,284
be overly zealous in the early aspects of strength
myalgia tend to be deconditioned.m Although
or cardiovascular training? A gradual adapta
they may perceive that exercise will worsen
tion to a progressive exercise program is usually
their condition, several studies have shown that
well tolerated and may include lower or upper
persons with fibromyalgia can participate in
body ergometry, walking, or aquatic physical
regular
training
therapy54 A long with cardiovascular training,
programs without experiencing an increase in symptoms285-289 The physical therapist must
training should be approached with some cau
low-intensity
cardiovascular
light strength training is appropriate. Strength
Copyrighted Material
MYOFASCIAL MANIPULATION
112
Because persons with tlbromyalg13 display a
tion. Free small hand
generalized, decreased pain threshold, Russell
are being
weight machines are preferred.
training
suggested that f ibromyalgia can be considered
to stretch before and after workout to maintain
criteria for allodynia as defined by the Interna tional Association for the Study of Pain.299,30
cardiovascular
may be considered
tlexibility. Other as well,
the Feldenkrais
Alexander
1'ai Chi, or
allodynia," as it meets the
"chronic
it. The patient is
Allodynia is defined as "a painful response to
the
a normally
al
f ied
stimulus."2'19 This modi does not CO!1
though there are no scientific studies
other features of the
f ibromyalgia and these somatic
social dysfunction, and so forth.
Soft tissue restrictions and joint ity should be assessed and corrected when indi cated,
that these restrictions are most
likely the resu It of decreased activity levels and not involved in the
UWI'C"V"''',
hyperalgesia,
including the different
of the syndrome,
more appropriate name is "complex pain syndrome," analogous to the of the term
of
Muller and col sup port for this notion. support the use of
There are no studies that or joint
lions, although a correlation was established between
MYOFASCIAL PAIN SYNDROME Definition
functioning, defined
MyofasciaJ
syndrome has been defined
differently by different authors or
Acupuncture and
is defined
fective in although the
syndrome of any soft tissue
studied yet.
origin.302 In
needle
tion syndrome has become the commonly used any prospective studies
on the effects of intramuscular stimulation on the symptoms of ..a," n;,, ' ; 297
myofascial
term, described as muscle pain with or without limitations in mouth opening30 myofascial
as "chronic
con
ditions that occur in the musculoskeletal when there is no obvious
Taxonomy
syndrome is formulatcd by
of pathogenesi s
or inflamma
tiol1."HJ4 The most commonly used def inition suggests
Simons, Travel!, and Simons as a muscle
sitivity of the central nervous system and a
disorder characterized by the presence of a myo
functional endocrine system, rather than patho
fascial trigger point within a taut band, local
logically painful
the question emerges
whether f ibromvale:ia should still be considered "298 Evell the name
tenderness, referral of pain to a distant stricted range of nOl11ena.
and autonomic
Autonomic
for
may include
pilomotor response,
and
Travell, and Simons involved in the gen eration of pain.
have described
trigger
it may suggest that
almost all skeletal muscles of the body.
pain is limited to fibrous tissues and muscles.
Trigger points can be present in muscle,
Copyrighted Material
Muscle Pain Syndromes
113
fascia, ligaments, joint capsule, and periosteum;
including myocardial infarction or kidney dis
however, nearly all research has focused on
orders. Myofascial pain syndrome should be
muscle trigger points305
considered in the differential diagnosis of ra
ture, the term "myogelosis" is commonly used
diculopathies, anginal pain, joint dysfunction
instead of "myofascial trigger point."7
(including craniomandibular dysfunction), mi
Although in clinical practice, the Simons,
graines, tension headaches, complex regional
Travell, and Simons criteria appear to be ac
pain syndrome, carpal tunnel syndrome, repeti
ceptable, the criteria have not been subjected
tive strain injuries, whiplash injuries, and most Myofascial pain
to scientific research and lack established re
other pain syndromes.3
liability and validity. During the 1998 Fourth
resulting from muscular dysfunction is called pri
World Congress on Myofascial Pain and Fibro
mary myofascial pain.
myalgia in Italy, the International Myopain So
pain syndrome, the pain and muscle dysfunction
ciety established a multidisciplinary committee
are the result of underlying medical pathology,
to design a study model for validation of the
joint or mechanical dysfunction, or psychologi
diagnostic criteria. The committee aims to estab
cal dysfunction.
lish reliable methods for diagnosis of myofascial
cluded that primary and secondary myofascial
pain syndrome, determine the interrater reliabil
pain were the most commonly missed diagnoses
ity of trigger point examination, and determine
in chronic pain patients. A thorough diagnostic
the sensitivity and specificity with which clas
evaluation was recommended to identify the un
sification criteria can distinguish patients with
derlying myofascial cause of chronic pain, rather
myofascial pain syndrome from healthy control
than considering the pain problem to be psycho
subjects30S
genic in nature3 . 2
and Simons criteria are applied.
tive, there is no diagnostic or clinical benefit
Myofascial pain syndrome can be acute in
to the patient in making the distinction between
nature or become a persistent chronic pain
primary and secondary myofascial pain syn
problem.309
drome.
common diagnosis responsible for chronic pain and disability3lO- 312
fascial pain syndrome was questioned by Quint
The concept of primary and secondary myo
are found equally in men and women and are
neT and Cohen, who instead deemed all myo
commonly found in children305,313
fascial pain syndrome phenomena the result
pain syndrome is often thought of as a regional
of secondary hyperalgesia of peripheral neural
pain syndrome in contrast to fibromyalgia as a
originJ . 28
widespread syndrome.
myofascial pain are always secondary to neu
that as many as 45% of patients with chronic
ropathies, especially radiculopathies. By apply
myofascial pain have generalized pain in three
ing Cannon and Rosenblueth's law of dener
or four quadrants3 . 4 1 3 . 5 1
vation, Gunn concluded that myofascial pain
may also meet the ACR criteria for fibromy
is the result of functional or structural altera
algia, they featured myofascial trigger points
tions within the central and peripheral nervous
within taut bands as the main source of their
system304
pain, making myofascial pain syndrome the pre
eth's law of denervation, nerves and their in
ferred diagnosis.
nervated structures develop "supersensitivity"
exist in isolation without involvement of other
when the nerves are not functioning properly329
structures, or be associated with other muscu
Gunn described that the autonomic phenomena,
loskeletal disorders, including facet joint inju
including vasomotor, sudomotor, and pilomotor
ries, disc herniations, osteoarthritis, or as part
changes, are features of the neuropathy model
of post-laminectomy syndromes.
and
a complication of certain medical conditions,
points3 . 04
not
specifically
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of
myofascial
trigger
114
MYOFASCIAL MANIPULATION
posture and functional movement patterns.305
Diagnosis The main criterion for the diagnosis of myo fascial pain syndrome is the presence of an active myofascial trigger point, an exquisitely sensitive region in a taut band of skeletal muscle consisting of multiple sensitive trigger loci.330·33J Most patients complain of more global, diffuse pain and are not aware that specific myofascial trigger points may cause their pain. The key fea tures of the trigger point have been established by Simons, Travell, and Simons and are listed in Table 6_2.305 The diagnosis of myofascial pain syndrome is made by systematic palpation of taut bands and myofascial trigger points, following a review of the patient's history, and an assessment of
The patient's pain pattern and range-of-motion restrictions usually point the clinician to the involved muscles. According to Gerwin and col leagues, the minimum criteria that must be satis fied in order to distinguish a myofascial trigger point from any other tender area in muscle are a taut band and a tender point in that taut band. The presence of a local twitch response, re ferred pain, or reproduction of the person's symptomatic pain increased the certainty and specificity of the diagnosis of myofascial pain syndrome3. 32 tiate between myofascial taut bands and general muscle spasms.3]3
Spasms can be defined as
electromyographic activity as the result of in creased neuromuscular tone of the entire muscle. A taut band is a localized contracture within the muscle without activation of the motor end
Table 6-2 Criteria for Identifying a Myofascial
plate334 The taut band, trigger point, and local
Trigger Point
twitch response are objective criteria, identified
Essential criteria
response from the patient.
solely by palpation, that do not require a verbal
1. Taut band palpable (if muscle is accessible).
2.
Exquisite spot tenderness of a nodule in a taut band.
3. Patient's recognition of current pain
4.
sponse is an indication of the presence of an active trigger point. contraction of the taut band that can be recorded electromyographically, be felt with the needle during trigger point injection or needling, or ob
complaint by pressure on the tender
served visually or on diagnostic ultrasound. It is
nodule (identifies an active trigger point).
mediated primarily through the spinal cord with
Painful limit to full stretch range of motion.
out supraspinal influence.]30,335 The patient's body type and specific muscle determine the
Confirmatory observations
ease of soliciting a local twitch response.
1. Visual or tactile identification of local twitch 2. Imaging of a local twitch response induced 3.
several authors; however, it was only recently
by needle penetration of tender nodule.
established by Gerwin and colleagues for the
Pain or altered sensation (in the distribution
five major features of the trigger poi'nt3. 32.3363- 39
expected from a trigger point in that muscle) on compression of tender nodule.
4.
The interrater reliability of the myofascial trigger point examination has been studied by
response.
Electromyographic demonstration of spontaneous electrical activity characteristic of active loci in the tender nodule of a taut band.
Source: Reprinted
Even in this study, a team of recognized experts could initially not agree. Only after developing consensus regarding the criteria, did the experts agree, which indicates that training is essential for
the
identification
of myofascial trigger
points. Gerwin and colleagues established that
D.G. Simons, J.G. Myofascial Pain and Dysfunction: The Trigger Point Manual2lE, Vol. 1, Lippincott Williams & Wilkins, © 1999. with permission from
Travell, and LS. Simons,
Copyrighted Material
individual features of the trigger point are dif ferentially represented in different muscles. example, the local twitch response was easier
Muscle Pain Syndromes
I 15
to obtain and, therefore, more commonly found
The diagnostic process must include the usual
in the extensor digitorum communis than in the
differential diagnostic considerations, and rule
infraspinatus muscle.
m
out other pathologica I processes. For example, in
The degree of stimulation required to repro
the examination of a patient with knee pain, the
duce a patient's usual pain determines whether a
clinician should consider ligamentous, menis
trigger point is considered active or latentJ40 An
cal, and capsular injuries, patellofemoral joint
active trigger point has a lower pain threshold
dysfunction, bursitis, tendinitis, and arthritis,
than a latent trigger point. A trigger point is
but also appreciate referred pain patterns and
considered active when normal physiological
the biomechanical implications of taut muscle
movements or postures cause pain, whereas a
bands and myofascial trigger points in the quad
latent trigger point requires a signif icant amount
riceps, hamstrings, gluteals and iliotibial band,
of mechanical stimulation to reproduce pain.
adductors, and calf muscles34 After establish
Various authors have suggested methods to ob
ing the initial diagnosis of myofascial pain
jectively quantify the amount of pressure re
syndrome, the clinician must determine any
quired to elicit a painful response from a trigger
mechanical, systemic, or psychological perpetu
point using algometry or palpometry; however,
ating factors that may contribute to the forma
it remains difficult to determine the distinguish
tion or persistence of myofascial trigger points.
ing features of active and latent myofascial trig ger points
J4 U42
It is important to realize that
Major mechanical factors to be considered in the diagnosis and management of myofascial
pressure algometry is influenced by nociceptors
pain syndrome include anatomic variations and
in the skin and subcutaneous tissuesJ4J
poor postures. Myofascial trigger points and
Both active and latent myofascial trigger points may cause dysfunction, including restric
taut bands may also contribute to further me chanical dysfunction.
tions in range of motion and muscle weak
Mechanical dysfunction is one of the main
ness.l2I In patients with acute myofascial pain,
problems of myofascial pain. Correcting me
restrictions in range of motion are primarily
chanical dysfunction has become the main ob
due to shortening of muscle fibers, pain, and
jective of Gunn's intramuscular stimulation ap
kinesiophobia. In chronic cases, soft tissue and
proach to myofascial pain syndrome.304 Physical
joint adhesions can further contribute to restric
therapists may use soft tissue mobilization as
tions in range of motion.344 Muscle weakness
well to correct mechanical dysfunction. For ex
without atrophy is often seen with myofascial
ample, considering that knee joint motion is
pain syndrome. Muscle weakness may be due to
accompanied by simultaneous coactivation of
pain, restrictions in range of motion, kinesiopho
the quadriceps and hamstrings muscles, any me
bia, inhibition of gamma motoneuron activity,
chanical discrepancy in either muscle group will
or reflex inhibition of anterior horn cell function
affect the resultant joint motion and possibly
as a result of painful sensory input.345J , 46
influence joint stability. It is conceivable that
tion of the trigger point can produce several
a taut band in the semimembranosis muscle re
autonomic phenomena (i.e., vascular effects,
stricts the mobility of the medial and, perhaps,
changes in skin temperature, and secretory, pi
even the lateral meniscus through its insertions.
lomotor, and trophic changes). Trophic changes
The semimembranosis muscle reinforces the
may lead to the development of so-called "satel
posteromedial aspect of the knee capsule. It can
lite trigger points" in the area of referred pain305
llex and internally rotate the tibia on the femur
Gunn considered the trophic changes essential
and pull the posterior horn of the media I menis
to the diagnosis and treatment of neuropathy304
cus posteriorly during flexion of the kneeJ49 Per
Autonomic changes are not specific for myofas
haps, a semimembranosis muscle shortened by
cial pain syndrome, as most pain syndromes
taut bands and myofascia I trigger points main
have an autonomic component.J47
tains the menisci in a relative posterior position
Copyrighted Material
L 16
MYOFASCIAL MANIPULATION
and dysfunctional muscle
even during extension of the knee. points in the semimembranosis muscle increase the likelihood of menis
may,
cal injury. 348 In addition to
fascial trigger Doints.
or confirm the
syndrome.362-365
the local and treat-
Gunn advocated
or imaging studies avail of myofascial
the paraspinal muscles at the levels of seg mental innervation, including L2-3, L4-5304
patterns. It does
not demonstrate the electrical activity of myo
syn resolu
and
in Gunn's footsteps, Fischer
tion
was not sensitive
to
but allowed
also promoted treatment of the paraspinal mus
visualize the actual
cles, as well as the supraspinous and interspinous
researchers to visualize the twitch response of
ligaments.
the taut band
Where Gunn recommended dry
of the multifidi
Fischer rec
ommended lidocaine iniections into the 304)50
stimulation of the
point by insertion of a hypodermic needle.
Clinical Characteristics
Systemic medical factors that can interfere patients
with recovery from
complain of dif
are medical conditions that either affect the
fuse
muscle energy system or otherwise interfere
body, as opposed to f ibromyalgia, which
with muscle metabolism.
features widesoread Dain. In some instances. pa-
conditions include
Commonly seen
confined to one or more regions of the
folic acid, and vitamin
insufficiencies and hypothyroidism. factors are gout, hyper-
Less common
and infections,
recurrent
yeast infections and
however, there
lion, taut bands and
are no epidemiologic studies supporting these clinical observations320 Psychological perpetu factors may include depression, stressful life
anger, and
Patients with myofascial
syndrome
to have and more tionships than syndromes, such as arthritis. Some authors have questioned the validity of
mechanisms. J 27.
syndrome or its underlying the past few
years, several objective features have been de
a common precur sor to myofascial pain syndrome. pain
scribed in the scientific literature that further substantiate the existence of myofascial
associated with
points. Several researchers established that
may report such as
fatigue, and increased irrita-
ger points have a specific electrical discharge characteristic when using needle electromyogIndwelling
Y,,",.. Phd
does not replace manual
Pain
An active
add any significant value to the clinical tic process358 36J Surface electromyography can
trigger point refers
usually to a distant site. The referred is not
be valuable for identifying muscle
Copyrighted Material
restricted to
segmental
or to peripheral nerve distributions.
Muscle Pain Syndromes
Although typical referred pain patterns have
I 17
drome, yet became a significant factor during
been established, there is considerable variation
the recovery. For example, a patient with a sig
in between patients305,307
nificant leg length discrepancy may never have
in
reference
zones
is
described
as
"deep
had low back pain; however, following a motor
tissue pain" of a dull and aching nature. Occa
vehicle accident, the discrepancy may become
sionally, patients may report burning or tingling
a critical perpetuating factor for myofascial trig
sensations.30 5J,
ger points in the quadratus lumborum muscle.
By mechanically stimulat
ing an active trigger point, patients may report
Gunn maintained that this is due to an already
the reproduction of their pain, either immedi
supersensitive peripheral nervous system. The
ately or after a 10- to IS-second delay. Me
added stress of a motor vehicle accident may
chanical stimulation can consist of manual pres
exceed the patient's threshold and result in
sure, needling of the trigger point, movement of
complaints of persistent pain.J04 According to
the involved body region, and postural strains,
Simons, Travell, and Simons, the most common
such as forward head posture or pressure on the
anatomic variations are leg length discrepancy,
gluteal muscles in sitting. Even physiological
small hemipelvis, short upper arm syndrome,
muscle tone at rest may stimulate an active trig
and long second metatarsal syndrome3053, 07
ger point, which is indicative of hypersensitiv
Leg length discrepancies may be due to congeni
ity of the nervous system. Normally, skeletal
tal, developmental, traumatic, or pathological
muscle nociceptors require high intensities of
changes in one of the osseous I inks of the lower
stimulation and they do not respond to mod
extremity kinetic chain. A distinction must be
erate local pressure, contractions, or muscle
made between a structural and a functional leg
stretches334J.71
length discrepancy. Structural discrepancies are
myofascial pain syndrome; however, it is more
due to true anatomic differences in length of the
common and much easier to elicit over myo
femur or tibia, whereas functional discrepancies
fascial trigger points340 Normal muscle tissue
can be caused by hip adductor contractures, hip
and other body tissues may also refer pain to dis
capsule tightness, or by unilateral innominate
tant regions with mechanical pressure (i.e., the
rotation. Leg length discrepancies and pelvic
skin, zygopophyseal joints , or internal organs),
asymmetries may produce muscle imbalances
making referred pain elicited by stimulation of a
and postural adjustments and result in the devel
tender location a nonspecific finding.306,
opment of myofascial trigger points.J7S Short
Gunn no longer considers referred pain an essen
upper arms result in pronated shoulders, pecto
tial feature of myofascial pain syndrome, which
ral muscle shortening, and abnormal loading
has become one of the differences between
of neck and trunk muscles, as the individual
Gunn's diagnostic and treatment approach and
attempts to find a comfortable position when
Simons, Travell, and Simons' approach.305.J77
seated. Another cause of biomechanical stress
Referred pain is no longer considered a diag
on muscle that can lead to persistent myofascial
nostic symptom but can guide a clinician to de
trigger points is a long second metatarsal bone.
termine which muscles have active myofascial
In this situation, the normal, stable tripod sup
trigger points (Figures 6
port of the foot created by the first and second metatarsal bones anteriorly, and the heel posteri
Anatomic Variations
orly, may not occur. Instead, in some individuals
Many persons with myofascial pain syndrome
with this foot configuration, weight is carried
feature anatomic variations that may contribute
on a knife-edge from the second metatarsal head
to myofascial trigger point formation. It is not
to the heel, overloading the peroneus longus.
unusual that a particular anatomic variation did
Diagnostic callus formation occurs in these in
not cause any dysfunction prior to the event
dividuals in the areas of abnormal loading, under
that resulted in the onset of myofascia I pain syn-
the second metatarsal head, and on the medial
Copyrighted Material
118
M YOFASCIAL MANIPULATION
/(( (
( (
'--
J /.
.
"
. ..
: �1LJ
-----
l
)
Figure 6-4 Referred pain patterns of the gluteus minimus muscle mimic sciatic nerve pain. Source: Reprinted with permission from Mediclip, Manual Medicine 2, version LOa, Williams & Wilkins.
Copyrighted Material
A1uscle Pain Syndromes
119
v v
v V'
(S\ v
v v v
Figure 6-5 Referred pain patterns from trigger points in the infraspinatus muscle mimic a C6 racliculopathy. Source: Reprinted witll permission from Mediclip. Manual Medicine 2, version 1.0a., Williams & Wilkins.
aspect of the foot at the great toe and first meta tarsal head.320 Although there is still consider able controversy regarding the biomechanical implications of poor occlusion on the develop
and their associated pain problems of headaches, tooth, and facial pain379J80 Posture
ment of myofascial trigger points in the cranio
Abnormal postures can result in muscle im
mandibular muscles, it is likely that occlusal
balances, the formation of myofascial trigger
problems, including missing teeth and early con
points in adaptively shortened or lengthened
tacts, contribute to mechanical stress on muscles
muscles, joint hypomobility and hypermobility,
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120
MVOFASCIAL MANIPULATION
and nerve compression. Forward head posture is
•
Pain or ache on prolonged standing
the IllOSt common postural deviation in chronic
•
Pain decreased by rest or gentle move ments
pain patients, including patients with myofascial pain syndrome. 3 78,381 The biomechanical and myofascial aspects of the forward head posture are fully discussed in Chapter 7. The typical symptoms in this particular scenario (Table 6-3) can include:
•
Intermittent cervical, thoracic, or lumbar Unilateral or bilateral headaches and facial pam
•
Myofascial trigger points in multiple muscle sites
•
Upper extremity referred pain or paresthe sia in the absence of neurological f indings
•
petitive arm movements are at increased risk for developing myofascial pain syndrome3. Work tasks with high repetition frequency and
pam •
Several studies have shown that occupational groups with constrained work postures and re
Difficulty sitting for a long period of time, especially in deep, soft chairs or bucket seats that accentuate forward-head posture
static muscle loading may actually decrease the pain pressure threshold and result in allo dynia and hyperalgesia.384 Awkward postures are common in the workplace and include ex cessive wrist flexion and extension, ulnar and radial abduction, forearm supination and pro nation, extended reaches beyond the shoulder reach envelope, and pinch grips that are either too wide or too narrow.
Skubick and col
leagues demonstrated that asymmetrical loading of the sternocleidomastoid muscles and cervical paraspinal muscles can result in carpal tunnel syndrome,38 increased risk include musicians, data entry op erators and typists, industrial workers, and as
Table 6-3 Postural Problems Found in 164 Patients with Myofascial Pain Syndrome of the Head and Neck
sembly line workers.388-392 leagues reported the onset of myofascial pain syndrome in various occupational groups with
N
%
Body
monotonous repetitive work382 In a study of pa tients with cumulative trauma disorders, 94,5% were
Poor silting/standing posture
157
96.0
Forward head tilt
139
84.7
Rounded shoulders
135
82.3
Poor tongue p os ition
111
67.7
Abnormal l o rdosis
76
46.3
Scoliosis
26
15.9
140
85.5
diagnosed
with myofascial pain
syn
drome3, 83
Pathogenesis Musculoskeletal A bllormalilies There is some evidence of histologic changes
Occlusion Slide from retruded contact position to intercuspal contact
at the site of myofascial trigger points identifi able by light microscopy3. 34
position of 1 mm or greater
113
68,9
Class II, D ivi sion 1
96
58,5
Class II, Division 2
51
31.1
Class III
16
9.8
Unilateral occlusal prematurities in intercuspal contact position
Source: Reprinted with permission from J,R, Fricton, Myo fascial Pain Syndrome: Characteristics and Clinical Epidemiol ogy, Advances in Pain Research and Therapy, © 1989, Lippincott Williams & Wilkins,
Vol.
19,
p,
121,
and Wallraff reported damaged fibril structures in "myogeloses." observed degenerative changes of the I-bands, in addition to capillary damage, a focal accu mulation of glycogen, and a disintegration of the myofibrillar network,393-395 In 1995, Gar iphianova described pathological changes with biopsy studies of myofascial trigger points, including a decrease in quantity of mitochon
Copyrighted Material
Muscle Pain Syndromes
121
dria, possibly indicating metabolic distress396
blockers caused myofascial trigger points, pre
Reitinger and colleagues also reported patho
sumably based on their ability to prevent cal
logic alterations of the mitochondria, as welJ
cium re-uptake40'
as increased A-bands and decreased I-bands in muscle sarcomeres of myofascial trigger points in the gluteus medius muscle; however, they did
Electrophysiologic Abnormalities In J 957, Weeks and Travell published a report
not describe their definition of a trigger point397
that outlined a characteristic electrical activity
Pongratz and Spath noticed segmental degenera
of a myofascial trigger point358 It was not until
tion of muscle fibers with concomitant edema
1993 that Hubbard and Berkoff confirmed the
and histiocytic cellular reaction3. 98
presence of specific electromyographic activity in myofascial trigger points of the trapezius
Energy Crisis Hypothesis
muscle.
Both the local tenderness and taut bands char acteristic of myofascial pain s yndrome are pro
greater than the electromyographic activity in a nontender area of the same muscle.
posed to be associated with the "energy crisis
corded both low amplitude continuous action
hypothesis."305
potentials and intermittent spikes from active
there is decreased circulation and local ischemia
myofascial trigger points359 Simons and col
in a myofascial trigger point due to sustained
leagues reported similar action potentials of 10
sarcomere shortening. Studies by Bri.ickle and
to 50 flV, which they defined as "spontaneous
colleagues, measuring extremely low oxygen
electrical activity," in contrast to the intermit
levels (5% of normal) within myofascial trigger
tent biphasic spikes of 100 to 600 flV360,J61
points, appeared to confirm the hypoxia com
electrical activity is not mediated through the
ponent of the energy crisis hypothesis.399
spine or supraspinal influences, suggesting that
shortening of the actin-myosin complex can be
it may be a motor endplate phenomenon. The
caused by a traumatic release of calcium either
electrical activity was found to be similar to
from the sarcoplasmic reticulum or from a fail
abnormal endplate potentials, associated with an
ure to restore adenosine triphosphate. The pos
excessive release of acetylcholine, which affects
sible roles of titin and nebulin have not yet been
the voltage gated sodium channels of the sarco
considered in the etiology of myofascial trigger
plasmic reticulum and increases the intracellular
points. Adenosine triphosphate is essential for
calcium Jevels306.402-404 Gunn articulated that
normal functioning of the calcium pump, as well
the relative increase of acetylcholine release
as for the release of the actin-myosin complex.
into the muscle may be the result of neural dys
A shortage of adenosine triphosphate can result
function, associated with a decrease of the avail
in local muscle contractures or taut bands.334
able acetylcholinesterase and the renewed ac
The pathologic alterations of the mitochondria
tivation of acetylcholine receptors throughout
can further contribute to a shortage of adenos
the muscle304
ine triphosphate. Termination of a muscle con
are, in fact, newly formed acetylcholine recep
traction is normally accomplished by pumping
tors405,406
calcium back into the sarcoplasmic reticulum
It is not clear whether there
Several studies have demonstrated that myo
against a large concentration gradient.
fascial trigger points are nearly always located
impaired calcium pump, the intracellular cal
in the region of the motor endplate zone.J61,407
cium concentration stays elevated, and the actin
Hong proposed that a palpable myofascial trig
and myosin filaments become continuously ac
ger point consists of multiple discrete sensible
tivated400
Shenoi and Nagler confirmed that
loci.
an impaired reuptakc of calcium into the sar
sitized nociceptive nerve endings.
coplasmic reticulum can cause myofascial trig
that these spots represent abnormal motor end
ger points. They reported that calcium channel
plates4. 07 4.o8
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122
MYOFASCIAL MAN1PULATION
points are probably associated with dysfunc
vous system. The two concepts are not mutually
tional motor endplates3 05 The finding that in
exclusive. There is, however, little evidence that
jections with botulinum toxin are effective in
the effect of the autonomic nervous system
inactivating myofascial trigger points further supports the motor endplate hypothesis4 09- 41
on myofascial trigger points is applied via the muscle spindle. It is conceivable that, due to
Botulinum toxin is a neurotoxin that blocks the
the constant increased stress within a taut band,
release of acetylcholine from presynaptic cho
the muscle spindle is exposed to static loading,
linergic nerve endings. A recent study in mice
which may resu It in a steady discharge of im
demonstrated that the administration of botu
pulses, known as the static response of the
linum toxin resulted in a complete functional
muscle spindle.
repair of the dysfunctional endplates415
administration of phentolamine would reduce the electrical activity of the myofascial trigger
Autonomic Contributions
point. Static stress applied to the muscle spindle
Based on the finding that the electromyo
Illay lengthen the equatorial part of the intrafusal
graphic activity of myofascial trigger points in
muscle fibers; however, that would still not ex
creased as the result of psychological stress,
plain the formation of myofascial trigger points.
Hubbard and colleagues proposed that myofas
The mechanism of the interactions between the
cial trigger points are associated with the au
autonomic nervous system and myofascial trig
tonomic nervous system.4ICr-418
ger points needs further investigations. Direct
nomena have always been described as part of
connections between the sympathetic nervous
myofascial pain syndrome305 Several studies
system and muscle fibers have been established
have now shown that the administration of the
and may be critical for future studies.422
sympathetic blocking agent phentolamine sig
in 1981, Barker and Saito demonstrated that an
nificantly reduces the electrical activity of a
autonomic innervation is present to some extra
myofascial trigger point, which supports the hy
fusal muscle fibers.42J Recently, Ljung demon
pothesis that the autonomic nervous system is
strated that the extensor carpi brevis muscle is
involved in the pathogenesis of myofascial trig
supplied with heterogeneously distributed sym
ger points.4ISA'91n an uncontrolled biopsy study,
pathetic and sensory innervations in relation
Hubbard identified a single muscle spindle at
to small blood vessels424
the site where the spontaneous electrical activity
striated muscles have similar sympathetic nerve
was recorded.418 As the muscle spindle is auto
distributions, perhaps these sympathetic fibers
nomically innervated, Hubbard proposed that
can influence the contractibility of muscle fibers
myofascial trigger points are associated with
or alter the function of the motor endplate, es
dysfunctional muscle spindles. Partanen sup
pecially under pathological conditions.
ported this notion by expressing that, i n his
likely that the sympathetic influence on muscle
opinion, the cndplate spikes are indeed action
receptors has any functional significance under
potentials of intrafusal muscle fibers and that
physiological conditions, but under patholog
the "active spots" are in fact muscle spindles.
ical conditions, these sympathetic nerve end
Simons and colleagues refuted this, however,
ings may become sensitized by neuro-active
by demonstrating that the spike potentials are
substances released in the vicinity of the end
propagated by extrafusal muscle fibers and not
plates3054 , 25
by intrafusal fibers.42o.421 At this point, the available data are inconclu
Central Sensitization
sive.
As with f ibromyalgia, knowledge from the
the hypothesis that myofascial trigger points are
pain sciences must be considered. Local tender
dysfunctional motor endplates, whereas other
ness of myofascial trigger points is due to pe
studies support the role of the sympathetic ner
ripheral sensitization of nociceptors as well as
Copyrighted Material
123
lvluscle Pain
neuroplastic
within the spinal dorsal have described
horn368 Vecchiet and sensory
over myofascial
They obser ved significant
on the dorsal horn have
similarities with the effects
when measured by eleetrica I
not
but also in the over
lying cutaneous and subcutaneous tissues. This is in contrast with their
to Mense, the effeets
of bradykinin
points. 42s The activity of the neuron
of the pain threshold over active only in the muscular
ischemia, static muscle contractions, and inflammation.
on fibromyal
tender points. In f ibromyalgia,
ing with the receptive f ield was measured an electrode placed in the minutes, the
cord. After field had ex
panded; afier 15 field no
in aU three tissues was present not
over
f ibromyalgia tender points, but also in other
interneurons are located over various segments,
nonpainful
pain may be experienced in
ger
With latent
outside the
innervation of the myofascial
the sensory
the cutaneous and subcutaneous tissues66A26.427
point, whieh
Afferent
from the conventiona I convergence
from
joints. skin, and
Mense's
viscera can result in central sensitization
This mechanism may result in the formation
the unmasking of "sleeping"
of satellite
rp(,pntr.,'<
points in the area of the en-
noci
also
Bendtsen and
by low-threshold mechanosen sitive neurons430 The afferent input from these effective receptors may result in
the onset of referred
would be the result
of the time needed to unmask the interneurons with substance P and
summation in the dorsal horn and the appear
It is likely that
a similar process exists for craniomandibular
ance of new
fields. This means that
muscles, even
input from
ineffective
from the
now stimulate the neurons.
delay of
field. The
they do not receive input recep
cord, as new or
tive f ields were also identified after injection of mustard oil in the masseter muscle435 whereas
Mense emphasized that data from animal re search may not be fully applicable to the clinical
sia is the result of both peripheral sensitization 430.432,413 It and dorsal horn is interest
patient with
ing that Gllnn maintained that
f ied convergence projection
pain
syndrome is not dependent on
ceivable model for the referred pain phenomena seen in myofascial
to Gllnn, the
Another theory t o
pain syndrome are the functional deficiencies oflhe VOllS
based on
system. It appears that Gunn's
falls short in this
the modi offers a con
afferent neurons
innervating both muscle and
in the
as several studies have
is
of
viscera.
from one branch could activate
identified the nociceptive nature of active myo 9, 30 fascia I points.66.368.426,42742 4
the other branch antidromically. McMahon and
The unmasking processes of interneurons of the dorsal horn arc the pathophysiological basis
by reeording different conduction velocities in 436.4.17 In f ibers excited
of the modified convergence projection
the neuronal branches have been identified his
proposed by Mense.
tologically. The
inal
After identifying
field oHhe bieeps femoris muscle
of a rat, Mense injected a
dose of bra
Wall. offered evidence of
branching
would fall short in ex-
the sensation of
musclc pain be
cause one oHhe neuronal branches terminates in would also not explain re
dykinin in the tibialis anterior muscle. Bradyki
the skin. The
nin levels have been shown to increase during
ferred pain in a distant location, as the neuronal
Copyrighted Material
124
MYOFASCIAL MANIPULATION
not be
branches would
levels. Gunn no pain patterns of Needling the taut band
Management of
eliminate active
Pain Syndrome
The goals of treatment of myofascial pain
near the myotendonal
syndrome are restoration of normal tissue mobil
inactivate myofascial
trigger points and
by inactivating return to function.
can
addressing be divided into a
and a train-
or
or by noninvasive means. The myofas cial
As with any treatment
point is
for the
referred pain Q'tnrl"Amp There is evidence that needling trig
in one muscle group may eliminate
During the
control phase, inactivation of the myofascial
points in muscles that
to the re points.44!
trigger points is the main short-term goal. It
ferred pain area of the treated
is important to improve the circulation at the
Noninvasive techniques include manual therapy,
site of the myofascial pathological
point, to decrease activity, and to elimi
tbe use
relaxation training, of electrotherapy
nate the abnormal biomechanical force patterns
tural or mechanical stressors, and resolution
geMerated
of oossible underlying medical disorders that
the taut bands. Invasive
to tbe
intramuscular stimu
or maintenance
of a local 'mMrhpt;
Banks and col that autogenic
Steroid injections are not recommended for as they may induce
myofascial
relaxation training reduced the electrical activity of myotascial trigger
myopathy365 Invasive techniques are not without knowledge of anat
risks and require
for myofascial pain syndrome. The prac
omy, indications, and contraindications.4.l9,44
titioner must evaluate
Injections can
both soft tissue and
be
by
significantly443
Manual therapy is one of the basic treatment when indicated, treat
falls well within the scope of needling is
to underlying articular
a form of "mechanical stimulation," which in
mary and secondary
most physical
d ysfunction of muscles and
state laws is described
as one of the mechanisms of physical therapy
considered as a single functional unit.J71;,441 Soft
practice. Some
tissue mobilization is probably the most im
not allow dry not allowed to Maryland Board
therapy state laws do the skin. Recently, the
trigger
the intratissue and
intertissue mobility of the functional unit must be evaluated and treated as well. Effective soft
I n clinical
combination of Gunn's intramuscular stimula tion with Simons,
the actual
ment program. In addition [0
Therapy Examiners is indeed part of
cal
of the treat
manual therapy
as physical therapists are
tissue techniques include massage therapy
and Simons'
manipula sustained pres
point therapy appears to be especially effective,
sure over the myofascial
although clinical studies have not been com
and spray techniques combined with post-iso
pleted. Gunn
metric relaxation, or muscle energy/hold-relax 305307
correcting the biome
chanical aspects of taut bands by needling the taut bands in muscles combined with needling of paraspinal muscles at the same segmental
point, stretch
Correcting structural and functional discrep ancies may include soecific muscle
Copyrighted Material
Muscle Pain Syndromes
125
on fibromyalgia. Patients must learn to modify
neurodynamic mobilizations, joint mobiliza 2 3 , 3 2 tions, orthotics, or postural re-education3o
their behaviors and avoid overloading the mus
Patients with chronic myofascial pain syndrome
cles without resorting to total inactivity.
usually present with poor postures and muscle imbalances with both adaptively shortened and lengthened muscles. muscles will not correct muscular imbalances and abnormal posture, and may cause further ag gravation of active myofascial trigger points, and increase pain and dysfunction. Overstretch
SOFT TISSUE LESION AND MECHANICAL DYSFUNCTION Def inition and Characteristics of Soft Tissue Mechanical Dysfunction
ing must be avoided as this may trigger myofas
Fibromyalgia, with its lack of specific diag
cial trigger points. Prior to initiating isotonic
nostic findings and diffuse pain patterns, repre
training and conditioning programs, abnormal
sents one end of a spectrum of pain severity
postures must be corrected. Already during the
and complexity and soft tissue mechanical dys
pain-control phase of the program, patients can
function represents the other end.
correct their postures and muscle imba lances
dysfunction, where mechanical pathology exists
by gently stretching shortened muscles, improv
and can be diagnosed, afflicts the greater por
ing neural mobility, and restoring basic function.
tion of patients with acute pain. There is usually
Correction and prevention of abnormal postures
overuse or direct trauma to the tissue that causes
require a comprehensive program to include ex
inflammation. A partial or full tear, as in a ham
ercises to restore normal dynamic vertebral sta
string tear or "pull," gastrocnemius tear, tennis
bilization and mobility, motor control, muscle
elbow, or de Quervain's disease, for example,
balances, strength, endurance, and breathing
are forms of soft tissue mechanical dysfunc
patterns. Many patients are aerobically decondi
tion. Facet hypomobility or hypermobility, mus
tioned, which, combined with poor posture, may
cular or movement imbalances, discogenic pa
cause adaptive shortening of the auxiliary respi
thologies, and sacroiliac joint dysfunction, for
ratory muscles, such as the scalenes, restricted
instance, all represent mechanical dysfunction
chest expansions, and paradoxical breathing.
characterized by soft tissue lesions. These dys
Paradoxical breathing should be corrected with
functions can be medically diagnosed and eval
, 3 2 , functional abdominal breathing3053
uated for specific pathologies. Treatment can
Cer
tain work tasks or activities of daily living may
commence based on evaluative findings and the
predispose a patient to chronic musculoskeletal
condition and reactivity of the tissue. Once soft
overload, increasing the risk of myofascial dys
tissue mechanical dysfunction becomes more
function. Considering activity-related aspects
subacute or chronic, clinicians should consider
of myofascial pain syndrome will enhance treat
whether myofascial trigger points have become
ment outcomes. Modifying the workplace or the
the main factor and, if so, alter the treatment
patient's work habits can be critical.
strategy accordingly.
continues to be exposed to certain workplace
The specific evaluation process for soft tissue
or other stress factors without modification of
mechanical dysfunction requires a systematic ap
the conditions, the potential cause of myofascial
proach. Looking for reproduction of pain based
dysfunction may not be addressed adequately.
on palpation, muscle contraction, or stretch helps
Throughout the treatment process, much atten
to localize the dysfunction to a specific lesion.
tion should be paid to educating the patient re
The purpose is to identify and define areas of
garding the etiology, perpetuating factors, and
somatic dysfunction and to localize a lesion site.
self-management. In patients with chronic myo
Somatic dysfunction can be defined as impaired
fascial pain, psychosocial issues must be as
or altered function of related components of the
sessed and addressed as outlined in the section
somatic system (body framework), skeletal, ar
Copyrighted Material
126
MY OFASCIAL MANIPULATION
throdial, and myofascial structures. The criteria
observations and palpation, utilizing both
for dysfunction consist of:
active and passive testing.
•
Structural or functional asymmetry of re lated parts of the musculoskeletal system,
Management of Soft Tissue Mechanical
ascertained by observation and palpation. •
•
Dysfunction
Tissue texture abnormality of the musculo skeletal system soft tissues (skin, fascia,
The clinical history will usually offer sub
muscle, ligament, or joint capsule) ascer
stantial clues to causes of the dysfunction, such
tained by observation and palpation.
as trauma, overuse, or lifestyle, among others.
Range-of-motion abnormality of a joint,
The evaluation will reveal specific findings
several joints, or regions of the musculo
that will allow for systematic development of
skeletal system (either restricted or hy
treatment plans specific to the particular pathol
permobile, qualitative changes in range of
ogy or dysfunction. Treatment is usually much
motion such as cogwheel movement, hesi
shorter term, and the prognosis for recovery is
tations, and compensations) ascertained by
the best of the three categories described.
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PART III
Evaluation and Treatment of
the Myofascial System
141
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CHAPTER 7
Basic Evaluation of the Myofascial System Robert I. Cantu and Alan J Grodin
for discogenic lesion , in the absence of any
This chapter offers the clinician information and insight into the evaluation of the myofascial
other finding, the herniation may not be the
sy stem. Although other aspects of the biome
cause of the pain and dysfunction. The physician
chanical evaluation of the spine may be dis
who would diagnose discogenic pathology on
cussed when appropriate, the main focus re
the basis of MRI alone would be premature in
mains on the myofascial system. Myofascial
making the diagnosis. If, however, the patient is
assessment represents on Iy one aspect of the
experiencing low-back pain, has referred pain in
total evaluation, and the results should always
the lower ex tremity, has diminished reflexes, se
be correlated with other findings to assess ac
lective muscle weakness, and positive EMG and
curately the functional (or dysfunctional) status
MRI results, the findings together def initively
of the spine and/or extremities.
correlate for discogenic pathology.
Dysfunction is defined by Dorland's as "a
The physical therapist also diagnoses signifi
disturbance, impairment, or abnormality of the
cant dysfunction in the same way. AII findings
functioning."1 More specifically, somatic dys
from the history, visual, palpatory, and move
function can be defined as "impaired or altered
ment examinations are correlated to determine
function of related components of the somatic
dysfunction. Postural asymmetry caused by a
system. Somatic dysfunction is a state of altered
leg-length discrepancy in itself is not dysfunc
mechanics, palpable changes of integrity, in
tional. Active movement abnormalities alone are
creased or decreased mobility and autonomic
not necessarily dysfunctional. Segmental hypcr
changes."2 A therapist diagnoses dysfunction in
mobility and hypomobility in and of themselves
the same manner that a physician diagnoses pa
are not necessarily dysfunctional. Connective
thology: correlation of f indings. When a physi
tissue changes in the absence of other f indings
cian is looking for pathology in relation to low
are not dysfunctional. If several findings from
back pain, the diagnosis is not made based on
the evaluation are abnormal, however, a strong
radiology or physical examination alone. In the
statement can be made for dysfunction. For ex
case of discogenic pathology, for example, the
ample, a patient may have symptoms including
physician uses the history, physical examina
localized unilateral low-back pain, a postural
tion, radiologic findings, and electromyograms
fulcrum at L4-5, an exaggerated lumbar curve
(EMGs) in order to determine if true discogenic
reversal on forward bending (with a fulcrum
radiculopathy exists. If the patient has an m reso
of motion at L4-5), tenderness to palpation at
nance imaging (MRI) with a positive f inding
the L4-5 interspace, increased erector spinae
143
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MYOFASCIAL MANIPULATION
144
muscle tone in the lumbar
3.
the oain waking the is not due to
of the L4-5 segment, and increased connective
the patient, but
tissue in the area. Tn this theoretical scenario (rarely this clean-cut), a
of L4-5
with L4-S hypermobility, movement im balance as a result of the hypermobility, in creased connective tissue in the area as the attempt to stabilize it, and protective
interrupted, and the patient is awakening, for the
interruption is not as
and is usually indicative of not myofascial
muscle guarding with altered muscular recruit ment
none of the above ab
be
cause sharp pain occurs with movement,
4. How much
normalities alone would have constituted dys the combination of abnormalities does. Treatment can be initiated
addressing this
combination of factors that contribute to the overall dysfunction.
tive.4
The aspects of myofascial evaluation consid ered in this chapter are the
postural and
5. What pattern does the pain follow the day? A typical
for
pain is increased stiffness and
palpa-
structural evaluation, movement
pain in the early morning, with a The
and
at
somewhat con-
stressed. slant
the day. Increased aetiv
will usually aggravate the
HISTORY
but the symptoms remain
Cyriax stated that the
is of great im conditions.' Most
portance, especially in
clinicians have a standardized routine question naire and historical
but several
fuse.
6. What medications is the
taking?
This is extremely important if a myo
ques
pain syndrome is sw;pected.
tions should always be asked when looking for
since few drugs have proven to be even
I. What is the quality of the cia I pain is
dull and aching, as
block stage 4
well as poorly localized. If the patient
choice for restoring normal
is reporting
are amitriptyline (ElaviIR) and
is easily reproduced,
pain, which pathology
may exist rather than a myofascial-type
or have a tendency toward irrita
syndrome. 2. How is the patient
at night?
one of the critical factors in myo fascial oain is the disturbed the
ble bowel syndrome? Many patients with also have
pattern. difficulty
going to sleep and during the night. Patients
(Flexerilf(). 7. Does the patient have a
should be asked as a matter report
should
feeling unrefreshed and fatigued in the
be emphasized when a
morn mg.
pain syndrome is suspected.
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Basic Evaluation o/the Myofascial System
145
POSTURAL AND STRUCTURAL EVALUATION The first part of any objective evaluation for somatic dysfunction consists of observing pos ture. Posture can be defined as balance and mus cular coordination and adaptation with minimal expenditure of energy. It is the position the body assumes in preparation for the next movement; it is not necessarily a static position5 Posture is dynamic, requiring muscular forces and creation of connective tissue tensions. Looking at the skeletal aspects of posture without considering the dynamic aspects gives a shallow, incomplete picture of the postural influences of dysfunction. Body posture may give preliminary clues to the location of a movement disturbance or to an area where stress may occur due to overuse or trauma. Posture observation directs the clinician's focus
Figure 7-2
on a particular area or areas of the system that may be significantly dysfunctional.
Observation of Posture The patient should be viewed from posterior, anterior, and lateral angles to ensure accurate assessment (Figures 7-1 through 7-3). In in tegrating the myofascial system into postural evaluation, the clinician should look for muscle asymmetry, connective tissue asymmetry, and increased muscular activity that may correlate with abnormal structural deviations. The entire body should be viewed, from the subcranial area down to the feet, since the fascial planes can be restricted over large areas of the body. Muscle asymmetry may be a result of pro longed shortening or lengthening of a muscle group, due, for example, to a leg-length discrep Figure 7-1
ancy or a pelvic obliquity. Connective tissue
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146
MYOFASCIAL MANIPULATION
of myofascial disequilibrium in the spine is the dysfunction caused by the forward-head pos ture. Tn the forward-head posture, the midcervical facet joints are in the "up and forward position" or forward bent. There is generally a loss of lordosis in this area, with a tendency toward hypermobility (Figures 7-4, 7-5, and 7-6). In the upper cervical and subcranial area, the facet joints are in the "down and back" position or backward bent in order to compensate for the forward bending in the lower cervical spine and to keep the eyes in horizontal. This creates COIll pression of the facet joints, 'vvhich hypolllobility and a shortening of the posterior myofascial structures. Bccause the greater oc cipital nerve pierces the subcranial myofascia, compression of this nerve can create occipital and frontal headaches. The anterior cervical spine compensates by lengthening, changing the length-tension relationships, and contributing to a weakness in the area. Figure 7-3
asymmetry may be due to abnormal stresses ap plied to an area, creating a localized prolifera tion of connective tissue, as in a spondylolis thesis. Increased muscular activity is usually a precursor to muscle asymmetry and is usually found in more acute cases. While observing body asymmetry is impor tant, the clinician must remember that the human body is, by nature's design , asymmetrical. Hand, leg, and eye dominance possibly contributes to myofascial and structural asymmetry. The crit ical factor in determining whether or not the asymmetry is significant is its correlation to other relevant evaluative findings. Postural observations give the clinician some insights into the overall equilibrium of the spine. When looking at joint equilibrium in the spine, consider that a joint can be stable and in optimal functional position only if there is equilibrium between the forces acting on it. A good example
Copyrighted Material
Figure 7-4
Basic Evaluation of the /vlyofascial System
147
In the forward-head posture, the mandible tends to open, so the masseters and temporalis are engaged to keep the mouth closed. This leads to new, but abnormal, hyperactive muscle patterns, where the muscles become facilitated and can create dysfunctions such as nocturnal bruxism. This can lead to eventual degenerative changes in the temporomandibular joint. In the upper thoracic area, the facets are again in a forward bent position, with the posterior myofascial structures on a stretch. In the anterior chest wall, the myofascial structures are held in a shortened position. The shoulder girdle com plex is held in a protracted position with the glenohumeral joint tending to go toward internal rotation. Because the anterior thorax is held in a shortened position, diaphragmatic breathing is compromised and the accessory muscles of respiration are facilitated, leading to a poten tially elevated first rib, a compromise of the Figure 7-5
costoclavicular space, and increasing suscepti bility to thoracic outlet-type symptomatology. The lumbar spine can be either hyperlordotic or hypolordotic. If hypolordotic, a stretching of posterior structures occurs, resulting in hy permobility and possible strain on the posterior aspect of the disc (Table 7-1). Myofascial Aspects The myofascial aspects of the forward head posture correlate well with the mechanical as pects. The work of Janda2.6 has helped tremen dously in correlating the effects of myofascial imbalances on postural imbalances. The prin ciples he put forth include the relationship of "postural" and "phasic" muscles and their cor relation to agonist/antagonist muscle groups. In histological terms, postural and phasic muscles are differentiated by oxidative capacity and abil ity to generate large or small amounts of force for short or long periods of time. The terms "postural" and "phasic," in the context of Janda's work and for the purposes of this discussion, relate more to how the muscle responds to dys function. In the myofascial context, a postural muscle is one that responds to dysfunction or
Figure 7-6
abnormal stress by tightening, whereas a phasic
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148
MYOFASCIAL MANIPULATION
Table 7-1 Postural Sequence for the Forward
Head Posture
and atrophy, while the hamstrings rarely show significant atrophy or weakness. These agonist! antagonist relationships play a vital role in pos
Forward bending of the midcervical facet joints Backward bending (extension) of the occiput atlas Shortening of suboccipital muscles, resulting in potential impingement of the greater or lesser occipital nerves Imbalance between the sternocleidomastoid,
tural problem s of the spine. The forward-head posture once again can be used as a clinical example, being by far the most common presentation in the clinic. A smaller percentage of patients do, however, have axially extended posture. When one superimposes the
the levator scapula, and the trapezius
myofasciaJ elements onto the arthrokincmatics
Imbalance between the anterior cervical
of dysfunctional posture, strong correlations can
musculature (including the suprahyoid and infrahyoid muscles) and posterior cervical extensors Shoulder girdle protraction with internal rotation (the latissimus, subscapularis, pectoralis, and teres major being involved) Increased thoracic kyphosis with decreased lumbar lordosis Increased activity of the accessory respiratory muscles due to poor diaphragmatic breathing
be made (Figures 7-7, 7-8, and 7-9). Cervical Spine In the forward-head posture, the cervical lor dosis is increased and the straight-line distance between the occiput and the cervicothoracic junction is decreased. This relationship places the cervical erector spinae in a shortened posi tion, which over a period of time permanently
and poor expansion of the lower rib cage
shortens the muscle. This is especially true in the
Elevation of the first rib by increased scalene
upper cervical spine. In the myofascial scheme, the cervical erector spinae are classified as pos
activity Anterior and posterior restriction of the first rib articulations
tural muscles, which respond to dysfunction by tightening, facilitating the dysfunction. The an
Tendency toward thoracic outlet
terior musculature, on the other hand, is in an
symptomatology Cervical imbalance with a tendency toward
elongated position, which over a period of time
degenerative joint disease from C5 through C7 Muscular imbalance leading to abnormal muscle firing (some muscles become facilitated with trigger points) Joints and soft tissues maintained in shortened range lead to restriction of joint capsules and loss of proprioception
muscle is one that responds to dysfunction by weakening. In the agonist/antagonist scheme, usually one muscle or set of muscles responds to dysfunction by weakening while the other responds by tightening. An obvious example of this is the quadriceps and hamstrings. The quad riceps rarely become tight, whereas the ham strings tend to tighten on a regular basis. If the knee is injured, the quadriceps usually weaken
Copyrighted Material
Figure 7-7
Basic Evaluation of the Myofascial System
149
Table 7-2 Cervical/Upper Thoracic Agonist! Antagonist Relationships Postural
Upper trapezius
Phasic
Latissimus dorsi
Levator scapulae Pectoralis major
Mid/lower trapezius
(upper part) Pectoralis minor
Rhomboids
Cervical erector
Anterior cervical
spinae
musculature
straight-line distance between the manubrium and the umbilicus, as well as the straight-line
Figure 7-8
distance between glenohumeral joints, is de creased. T his places the pectoralis major and minor, along with the upper trapezius, in a short creates a permanent lengthening. Because the
ened position. In the myofascial system, the
muscle group responds to dysfunction by weak
pectoralis major and minor muscles respond to
ening, the forward-head posture is further en
dysfunction by tightening, as does the upper
hanced (Table 7-2).
trapezius. The middle and lower trapezius and rhomboid muscles weaken in response to dys
Thoracic Spine
function, which further facilitates the thoracic
In the forward-head posture, there is an in creased kyphosis of the thoracic spine. The
dysfunction. Once again, antagonistic muscle groups respond in opposite ways to facilitate the same dysfunction. As noted, the anterior of the diaphragm, which, in turn, facilitates the upper thoracic accessory breathing muscles, further compound the problem (Table 7-3).
Lumbar Spine In the lumbar spine, two situations commonly exist. The first, excessive lumbar lordosis, can be correlated to dysfunctional muscle groups. The increased lumbar lordosis includes a tight ening of the lumbar erector spinae, psoas muscle groups, iliacus, and tensor fasciae latae. The an tagonistic groups, which include the abdominals and the gluteus maximus, weaken, further facili tating the dysfunction. Corresponding joint dys function includes hypomobility of the lumbar segments, with tightening of the posterior struc tures (Figure 7-10, Tables 7-4 and 7-5). The other scenario, in which there is a loss Figure 7-9
of lumbar lordosis, pits the hamstrings and pos
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150
MYOFASCIAL MANIPULATION
Table 7-3 Muscle Agonist/Antagonist Groups of the Cervicothoracic Area with Resulting Dysfunctions
Response to Muscle Group Upper trapezius levator scapulae
Action -elevation of shoulder
Dysfunction Tightens
-restricted a xial extension
of scapula
-limited side bending and rotation of
-BB and SB of spine
(upper part)
-elevation/adduction of scapula -increased cervical lordosis
girdle -assist in adduction
Pectoralis major
Results of Dysfunction
-shoulder flexion
cervical spine Tightens
-horizontal adduction
-restricted shoulder flexion -restricted horizontal adduction
of humerus Pectoralis minor
-protraction of
Tightens
scapula
-scapular abduction with outward rotation of inferior angle
-accessory breathing
-winging of inferior border of
muscle
scapula -increased thoracic kyphosis
Rhomboids middle/lower trapezius
-adduction of scapula
Weakness
-fixes inferior angle of
-scapula abduction with outward rotation of inferior angle
scapula to thoracic
-winging of inferior border of
wall
scapula -increased thoracic kyphosis
Cervical erector spinae
-extension of cervical
Tightens
spine
-loss of forward bending -loss of axial extension -holds cervical spine in forwardhead posture
Anterior cervical musculature
-flexion of cervical
Weakens
-weakness in forward bending -loss of axial extension
spine
-inability to pull out of forward-head posture
terior hip structures against the erector spinae
The clinician should consider these myofas
as antagonistic groups. This situation is more
cial relationships and how they correlate to
common in men with early to moderate degen
structure when evaluating posture. These find
erative joint disease of the lumbar spine. The
ings may then be correlated to the remainder of
tightness in the hamstrings and posterior capsule
the evaluation.
of the hips pulls the spine into forward flexion, holding the erector spinae in a lengthened posi tion, leading to progressive weakness. The cor
ACTIVE MOVEMENT ANALYSIS
responding dysfunction is usually joint hyper
Evaluation of active movements gives the cli
mobility with eventual instability of the lumbar
nician more valuable information regarding pos
spine (Figure 7-7 and Tables 7-4 and 7-5).
sible pathology of the spine or extremities that
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Basic Evaluation of the Myofascial System
15l
should be observed in total at least once, regard less of the suspected area of pathology. The area of pathology should then be examined specifi cally. The reason for performing both regional and segmental observations is that many times, dysfunction that is symptomatic in one area of the body can be caused by a primary dysfunction in another area of the body that is not symptom atic, but needs treatment to resolve the symp tomatic dysfunction. This is especially true when examining the myofascial system, because the fascial planes are more regional, as are their dysfunctions. Restriction of movement in the posterior musculature and fascia of the lower extremity, with corresponding hypermobility of the lumbar spine, exemplifies regional, asymptomatic dys function causing symptomatic dysfunction else
Figure 7-10
where. The patient, usually a man, has low-back pain, and with active movements , exhibits an exaggerated lumbar curve reversal. The pelvic may be correlated with postural findings. In evaluating active range of motion from a myo fascial standpoint, the clinician should first look regionally, then segmentally. Regional obser vation will usually reveal myofascial abnor malities, whereas segmental observation reveal.s more specific joint abnormalities. Entire spine motion should be observed, with the patient being instructed to move segmentally starting in the cervical area and proceeding through the thoracic and lumbar spines. Spinal movements
contribution to forward bending is limited be cause of tight hips, hamstrings, and posterior fascial planes. Over time, the posterior struc tures of the lumbar spine become stretched and hypermobile, creating lumbar instability. The primary dysfunction that needs to be addressed includes the hips, hamstrings, and posterior fas cial structures in order to balance the contri butions of the hip and low back to overall for ward bending. The patient usually has a flattened lumbar lordosis; the loss of lordosis is correlated with regional movement patterns to assess the primary and secondary dysfunctions. Looking only segmentally in the lumbar spine can cause the clinician to miss the primary causative dys
Table 7-4 Lumbar/Lumbopelvic Agonist! Antagonist
Postural Iliopsoas
function. As with a standard structural examination, all the cardinal plane movements including forward
Phasic Gluteus maximus
Tensor fasciae latae Hamstrings
Quadriceps
Hip adductors
Gluteus medius
bending, side bending, and rotation should be observed. Quadrant movements should also be observed because dai Iy movements and result ing dysfunctions occur in multiplane dimen sions. This again is especiaUy important when
Gastrocnemius-soleus
Dorsiflexors
dealing with the myofascial system, since it is
Erector spinae
Abdominals
multidirectional. The multipJane motions that
Piriformis
are useful to observe are: (I) fOJward bending,
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MYOFASCIAL MANIPULATION
Table 7-5 Muscle Agonist/Antagonist Groups of the Lumbopelvic Area and Resulting Dysfunction Response to Muscle Group Iliopsoas
Dysfunction
Action
Tightens
-hip flexion
Results of Dysfunction -restricted hip extension -tight anterior capsule
-assists in external rotation and
-increased lumbar lordosis
adduction
-decreased posterior rotation of
-backward bending
ilium
of lumbar spine -anterior ilial rotation Tensor fasciae latae
-hip flexion, internal
Tightens
rotation, abduction
-restricted hip extension, ER, adduction
-anterior ilial rotation
-decreased posterior rotation of
-knee flexion
ilium
assistant
-contributes to increased lumbar lordosis
Gluteus maximus
-hip extension
Weakens
-posterior rotation of ilium Hip adductors
-loss of hip extension -decreased posterior rotation of ilium
-hip adduction
Tightens
-restricted hip abduction -restricted posterior rotation of ilium
-assist in hip flexion -anterior rotation of ilium Gluteus medius
-hip abduction
Weakens
-ant. fibers-IR hip
-loss of lateral stabilization of hip
-post. fibers-ER hip Erector spinae
-extension of spine
-limited hip abduction joint
Tightens
-increased lumbar lordosis -pelvis tilted anteriorly
Abdominals
-flexion of spine
Weakens
-tendency for pelviS to tilt anteriorly -tendency toward increased lumbar lordosis
side bending, and rotation to the same side; and
from the anterior view, the anterior fascial planes
(2) backward bending, side bending, and rota
can be evaluated for restrictions. Because the di
tion to the same side. The f irst combined set
aphragm and anterior fascial planes may become
of motions follows a very functional movement
restricted in the forward-head posture, observ
pattern that usually helps assess, among other
ing the backward bending quadrant movement
things, the flexibility of the myofascial planes
from an anterior angle is important.
on the contralateral side of the movement. The second combined movement is gen er ally used to assess compressive joint l esion s of the spine
Compressive Testing of the Spine
on the same side the movement is occurring.
Compressive testing of the spine is usually
When the same extension quadrant is observed
considered a special test of the spine, but should
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Basic Evaluafion of the Myofascial System
be routinely performed. A convenient time to
153
PALPATORY EXAMINATION
perform this test is after active movement test ing. The concept behind compressive testing is
Once posture and active movements are as
to test the amount of "spring" that the spine has
sessed, the clinician may begin to estimate where
when a direct compression is imparted (Figure
the significant dysfunctions exist. The palpa
7-11). Generally, patients with accentuated cur
tory examination reveals yet more information
vatures will have an increased springiness, indi
that may be correlated to previous findings, and
cating increased lever arms for the effects of
offers a clear picture of possible goals and treat
gravity and increased stresses on myofascial
ment approaches.
structures. The spines of patients with decreased
The palpatory examination includes, but is not palpation of the myo
curvatures (axially extended cervical spine along
necessarily limited to:
with decreased lordosis in the lumbar spine) will
fascial structures in the form of layer palpation,
(I)
(3) assess
not have enough "spring," leading to decreased
(2) palpation of joint structures, and
shock attenuation during normal everyday ac
ment of passive segmental mobility. Palpation of
tivities. Ballistic or impact exercise such as jog
myofascial structures is primarily emphasized
ging or aerobic exercise may further accentuate
here, including layer palpation and passive mo
the dysfunction. Postural reeducation after nor
bility of muscles and fascial mobility.
malization of myofascial tone can help correct this dysfunction.
Layer Palpation Layer palpation is a systematic method of as sessing the mobility and condition of the myo fascial structures, starting from the most super ficial structures and progressing into the deepest palpable structures. Layer palpation is extremely important, especially since a common error in both assessment and treatment is to delve into the deeper structures without assessing the superfi cial structures. The tissues that can be palpated include the skin, subcutaneous fascia, blood ves sels, muscle sheaths, muscle bellies, musculo tendinous junctions, tendons, deep fascia, lig aments, bone, and joint spaces. The clinician should be able to palpate in depth the location of the structures during the palpatory examina tion. Is only the skin being palpated or is the subcutaneous fascia also being palpated? Is the muscle sheath being palpated, or has the muscle belly been penetrated? Is the clinician palpating the musculotendinous junction or the tendon itself? Perfecting layer palpation requires devel opment of tactile as well as visual senses. The development of tactile skills includes the ability to detect tissue texture abnormalities. How is the tissue at that level different from surrounding tissues at the same level of depth, or the tissue
Figure 7-ll
on the contralateral side?
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MYOFASCIAL MANIPULATION
Table 7-6 Descriptive Terms for Layer Palpatory
as well as the integrity of the tissues may be
Exam
palpated. The deep palpatory examination includes
superficial-deep
acute-chronic
compressible-rigid
painful-nonpainful
moist-dry
circumscribed-diffuse
soft-hard
rough-smooth
hypermobile-
thick-thin
hypomobile
compression, which is palpation through layers of tissue perpendicular to the tissue, and shear. Shear is movement of the tissues between layers, moving perpendicular to the tissue. The struc tures palpable are muscle sheaths, muscle bel lies, tendons, myotendinous junctions, tenoperi ostial junctions, joint capsules, and the deep periosteal layers of tissue. Tissue texture abnor
For practica I purposes, the layer pa Ipation
malities and restrictions are noted in this evalu
format may be categorized into superficial and
ation. Transverse muscle play is an effective
deep palpation (Tables
assessment tool for assessing the mobility of a
7-6 and 7-7). The su
perficial palpatory examination includes tissue
muscle or muscle group within the enveloping
temperature and moisture and light touch to de
fascial sheath. The muscle is "bent" in order to
termine the extensibility and integrity of the
assess the transverse flexibility of the muscle.
superficial connective tissues. Tissue roiling is
This concept is elaborated on in Chapter
8.
Once the evaluation is completed, the findings
an important part of layer palpation; it gives the clinician information about the extensibility
are correlated to define the specific dysfunction
of the subcutaneous connective tissue (Figure
and treatment is initiated accordingly. Reevalu
7-12). In tissue rolling, the skin and superficial
ation is taking place before, during, and after
connective tissue are lifted up, away from the
treatment and the treatment is adjusted to ac
deeper tissues. The extensibility of the tissues,
commodate changes being made.
Table 7-7 Palpatory Exam Elements of Evaluation Superficial examination
Structures To Palpate
-Light touch
-Skin
-T issue temperature and moisture
-Superficial connective tissue
-Mobility of superficial fascia -Skin rolling Deep examination
-Compression: palpation through
-Muscle sheaths
layers of tissue perpendicular to
-Muscle bellies
the tissue
-Tendons
-Shear: movement of tissues
-Myotendinous junction
between layers perpendicular to
-Joint capsule
tissue
-Periosteal layer
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Basic Evaluation of the Myofascial System
155
Figure 7-12
I{EFERENCES Dur/ulld:1 IIllIstrated Medical Dietiunm)', 25th ed Phil .
adelphia
WB Saunders; 1974 .
Cantu R. Mvojaseial J'vlan/pulation. SI. Au The ra p y ; C ou rse notes
2. Grodin AJ,
gustine, FL: Institute of Graduate Physica l .
3. Cyriax J. lextbuuk of Orthopaedic Medicine: Diagno ".\ ufSofi Tisslle Lesiuns. Lo n don England: Bailliere Tindall; 1:46. ,
4. Steindler A. Kinesiology. Springfield, l1. Charles C Thomas; 1977:35-37. 5. G ol d en h erg but
01. Fibromyalgia syndrome: an emerging controversial condition . .lAMA. 257:2782-2803.
6. Janda V Muscles, cen tral nervolls motor regulation and back programs In: Korr I, cd. TI/(! Neurubiulogic J'vlech aniSIIlS in J'vlanipulative Therapy. New York: Pl enu m; .
1978:27-42.
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CHAPTER 8
Atlas of Therapeutic Techniques Robert 1. Cantu and Alan J Grodin
The following atlas of therapeutic techniques
soft tissue. Ligament, capsule, periosteum, and
is by no means a comprehensive treatment of
fascia are all histologically classified as connec
all myofascial technique. It merely represents a
tive tissue. When dealing with the joint, the fol
compilation of techniques that, in the opinion of
lowing concept may be applied: Anything that is
the authors, have consistently proven to be effec
not bone is connective tissue. Technically speak
tive in the clinic. The purpose of the book, and
ing, then, joint mobil ization is a form of soft
specifically of this chapter, is to give the clini
. tissue mobilization since the extensibility of the
cian a solid and basic understanding of myo
connective tissue surrounding the joint is being
fascial technique. As the techniques are used,
changed.
the clinician will modify them to meet the in
For the purpose of clarity in this text, however,
dividual needs of both patient and clinician.
the operational definition of a joint should be
The techniques then become personalized, and
expanded. A joint may be defined as "a space
therefore, unique to that particular practitioner.
built for motion in which movement is governed
New techniques are born in this way and, many
by (a) arthrokinematic rules and (b) connective
times, evolve into specific systems of treatment.
tissue extensibility." The arthrokinematics is the
Myofascial manipulation has undoubtedly been
distinguishing factor in separating soft tissue
performed since the beginning of time, and has
mobilization from joint mobilization. Joint re
evolved into its present-day variety of formats.
strictions occur and are treated in characteristic
Myofascial manipulation will continue to evolve
arthrokinematic fashion. Mobilization technique
into more effective applications as the body of
must be applied following arthrokinematic rules
knowledge increases.
in order to restore extensibility. MyofasciaJ re
Before discussing individual technique, cer
strictions, on the other hand, are not as predict
tain terms should be defined and treatment con
able since they can occur outside the realm of
cepts and procedures discussed, for the sake of
specific joint arthrokinematics. Restrictions of
clarity and consistency throughout the chapter.
tbe superficial fascia, for example, may occur
Joint versus soft tissue manipulation: Some
in many planes and in many different-and un
difficulty may arise in drawing the line between
predictabJe---directions. The treatment is based
what is soft tissue manipulation and what is
on localizing tbe restriction and moving into the
joint manipulation. If a joint is operationally
direction of restriction, whether or not the direc
defined as "a space bui It for motion," then any
tion follows the arthrokinematics of the nearby
tissue surrounding the "joint" may be considered
joint.
157
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158
MYOFASCIAL MANIPULATION
Herein lies one of the problems with myofas
of the restriction is first released, the mechanical
cial manipulation: Treatment has a tendency to
restriction can more easily and more specifically
become subjective and abstract. The danger of
be treated. The general progression of myofas
losing credibility is higher than in joint manipu
cial manipulation considers the following fac
lation, since treatment is based on "what the
tors:
therapist is feeling."There is no doubt that "good
a. Direct bejore indirect technique. For the
hands" and an "intuitive mind" are of great value
most part, all the techniques described in the text
in manual therapy, specifically in myofascial
are direct ones. In other words, the techniques
manipulation. A balance should exist, however,
locate the restriction and move into the direc
between scientific scrutiny and clinical intu
tion of the restriction. If the changes cannot be
ition. Treatment that relies heavily on one while
made with direct technique-because of pain,
de-emphasizing the other will not be balanced,
autonomic responses, or severity of the restric
and, therefore, not be as effective. This text rep
tion-indirect technique may be used. The con
resents myofascial manipulation in a biome
cept is that the shortest distance between any
chanical and kinesiological sense, respecting
two points is a straight line, and the shortest
and integrating nearby joint arthrokinematics
distance through a restriction is directly through
as much as possible. In this way, myofascial
the restriction.
manipulation is represented in the most concrete
b. Supeljicial to deep. Common sense dic
empirical form possible, without negating the
tates that application of myofascial technique
intuitive aspects of the treatment technique.
begins superficially and progresses into depth as
Sequencing of treatment: The sequence in
changes are made, or in search of deeper myo
which technique is applied will generally spell
fascial restrictions. Treatment that progresses
the difference between success and failure.
from superficial to deep also allows the patient
The question is: Where in the entire treatment
gradually to grow accustomed to the clinician's
scheme does myofascial manipulation fit? And
hands; this facilitates relaxation and allows for
how does the clinician sequence individual myo
unforced penetration to deeper levels. Deeper
fascial technique for optimal results? Each pa
technique is not synonymous with more aggres
tient is different and each clinician will deter
sive technique. If the deeper connective tissues
mine the sequence of treatment on an individual
are properly accessed, they may be treated ef
basis; however, the guidelines discussed below
fectively without potential microtrauma and ex
may be helpful in deciding treatment sequenc
acerbation of symptoms. Instead of breaking
ing for individual patients. A general scheme of
down the doors, the clinician allows the body to open the doors for easy and less damaging
treatment is as follows. 1. Myojascial manipulation of involved and
access into an area.
regional areas associated with local involve
2. Joint mobilization after treatment oj l11yo
With joint mobilization, the treatment
jascia. As the myofascia releases, joint mobi
often focuses on individual joints being moved
lization becomes easier, and individual joints
in specific directions. Myofascial manipulation,
are more easily isolated. At times, however, if
ment.
however, generally focuses on larger areas or
the myofascial restriction is unyielding, joint
regions of treatment. Individual joint restric
mobilization and/or manipulation may become
tions often have significant myofascial compo
necessary to free up the myofascia. The type III
nents. Passive segmental mobility of individual
joint mechanoreceptors, which are stimulated by
joints may change with regional treatment of
joint manipulation, inhibit surrounding muscu
myofascia. Releasing myofascial tissues prior to
lar activity. Joint and myofascial manipulation
joint mobilization also allows joint mobilization
are "played off" one another-joint mobiliza
and/or manipulation to be performed with less
tion inhibits myofascia, and myofascial manipu
force application. If the myofascial component
lation facilitates joint manipulation.
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Atlas
3. Joint and myolascia/ elongation. Once ex m,,',", '"Cf"
tensibility has been improved in the
in the manual
and is
unable to relax fully. The second aspect of
with (distinct from stretching) refers primarily to the the ac
where the forces app I ied ied but
in the discussion of generous use of pillows, patient and the
cordion" and decompress the spine. No stretch is
The patient senses
is transferred to the this
and
and the joints,
159
forces are
applied. In the lower
a
for
between the
myofascial manipulation should always be per prior to stretch to allow
formed on a
therapist and the patient. The pillow
for greater tissue extensibility. 4. Neuromuscular
of
which aids the biomechanical
and avoids needless body contact.
reeducation,
exercises and movement ap I
and thera
a mechanical barrier between
Alexander2) are ap
propriate at this time. The alternate somatic movement
use
1. The
and lever
arms. Since physical
IS
Important to
the manual therapist, and since many times the may outsize the
with the con-
of myofascial and joint manipulation, but
the use of body
and lever arms is important. Use can be optimized by utilization of
their effectiveness is limited if the tissue is not of lhe tissue
tables, or
the therapist
The ability to lean over the lalion, the
force multiplier, whether the
acts as a
the promotion of new movement tients are
is prone, siddying, or supine.
at this time to
The
strengthen, and move in new, more efficient pat terns.
use
of the
"all arm," the use of the lower
Rather than
the
exists
a
to access the lower kinetic chain.
5. Postural instruction. Once the restrictions
new, more efficient
ill
weight shifting allows
type of
are removed and the patient
is all about
shifting When applying
kinetic chain also becomes a force
for postural reeducation. If postural instruction,
The hands also become more relaxed in the ap
which is necessary for most
plication of the
is given at
the beginning of the treatment sequence, the pa
becomes more
tient cannot effectively assume the new
time.
The
tires from
his or her
3. Using lever arln,'j' vvhenever
feedback loop
own restrictions, and a is established. The that "it is easier to slump than to and the poor postural
for example,
the lever arm, the greater and
to sit erect,"
more focused the force becomes, This is es important in
is actually rein
precautionary note is in order at this point. The
of patient and therapist: To
the lever arm, the tiplication, the
both
and therapist should be situated in the most effi This concept may seem in the
mobilization, but is
to soft tissue mobilization as well. A
posture is easier and is positively reinforced.
yet it is often
i,,\' yet
multiplier available to the thera
forced. With new freedom of movement,
achieve maximal
and the technique but softer at the same
manual
the force mul
the risk of injury. Some advocate the use of shorter
lever arms for
and their point is
well taken. The manual therapist should be care
to-day treatment of
ful when lengthening the lever arm,
in the therapist's
the force multiplication that is
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,'Pl"f'l0l1l7'
160
M YOFASCIAL MANIPULATION
Care and protection of hands: The hands are the primary treatment modality for the manual therapist and do not come with a replacement guarantee. If a manual therapist sees 15 patients a day 5 days per week for manual therapy, the therapist is laying hands on more than 3700 bodies per year. The numbers accumulate dUling the course of a career. The hands are very dura ble body parts; however, the principles of Wolf's law (good stress/bad stress) all apply. Practicing correct application of technique and following proper hand-care procedures are essential for en suring longevity of the manual therapist's career. The following are some suggestions for hand care: 1. W henever possible, use techniques that do not hyperflex
8-1). End-range maneuvers will only accelerate joint hypermobility problems, leading to early arthritic changes. The thumbs should be aligned with the metacarpals, which in turn, should be
aligned with the radius. The thumb and proximal interphalangeal joint (PIP) of the index finger can be used together to form a very stable con tact surface (Figure 8-2). 2. Adapt for therapist/patient size differences.
If the patient is large-sized, and the desired depth of penetration is not practical, do not use the fingers or thumb. The fist and elbows are excel lent alternatives. Palpate with the fingers; treat with the elbows or fist. 3. Wash hands il1 cold water aft er treatment.
If any inflammation occurs during a patient treatment, the cold water may act as a cryotherapy/anti-inflammatory treatment. Warm water 15 to 20 times per day may have a cumula tive inflammatory effect, whereas the cold water may slow the process down. 4. Protect the hands during off hours. W hen gardening or performing any type of work that may be hard on the hands, the therapist should wear gloves. Manual therapists actually incur
Figure 8-1
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Atlas afTherapeutic Techniques
161
Figure 8-2
more microtrauma to their hands in the off
with such symptoms, starting with a deep touch
hours, during the time when the hands should be
is usually counterproductive. The technique sug
getting much-needed rest.
gested here offers an entry way into deeper tech
5. Use aflubricant. A small amount of lubri
nique by quieting the autonomic system.
cant should be used, especially in techniques in
Patient position: Prone.
volving longer stroking. The amount of lubricant
Therapist position: The therapist stands over
should be just enough to decrease noxious skin
the patient, perpendicular to the patient.
friction, but not enough to cause slipping of the
Hands: Contact will be made with the pads
hand on the body. A certain amount of "traction"
or tips of the last 3 fingers. The pisiform is the
on the skin is necessary for appropriate delivery
axis of motion for the technique. Execution: One hand will be placed on the
of the technique.
patient to stabilize gently the subcutaneous con nective tissue. The treatment hand is placed
TECHNIQUES FOR THE LUMBAR
gently on the patient, with the pisi form being
SPINE
the axis of motion for the technique. Starting with the elbow close to the body, the elbow is
Bindegwebbsmassage-Type Stroke (Figures
moved away from the body, bringing the fingers
8-3 to 8-6)3
away from the stabilizing hand. The technique is
Purpose: This technique is a reflexive or au
repeated at a deliberate pace, moving about an
tonomic technique; it is used when the patient
area of the spine as indicated. The technique is
shows signs of being autonomically facilitated
superficial, going only as deep as the superficial,
or extremely hypersensitive. Many patients ex
subcutaneous connective tissue. The technique
hibit acute symptoms that mimic a reflex sym
is generally comfortable, and at worst, should
pathetic dystrophy. The skin, for example, is
be only mildly uncomfortabJe. Remember, the
hypersensitive with a cold clammy feel or touch,
goal of this technique is to quiet the autonomic
and the patient is easi Iy nauseated. For a patient
system, not to create mechanical changes.
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(';91
Atlas o/Therapeutic Techniques
Figure 8-5
Figure 8-6
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163
164
MYOFASCIAL MANIPULATION
Execution: The therapist applies gentle an
Long Axis Distraction of Superficial Connective Tissue (Figures
8-7
and
8-8)
Purpose: The purpose of this technique is elongation of the superficial connective tissues, usually in the cephalad-caudad direction. Since the subcutaneous connective tissue is multidi rectional in the fiber orientation, diagonal re strictions may occur and should be treated. This technique can also be performed on a deeper level to provide an elongation of the spine itself. Patient position: The prone position is dem onstrated here, but the technique can be per formed in any position depending on the loca tion of the restriction. In the supine position,
terior pressure until the subcutaneous fascial level is reached. A gentle distraction is then ap plied in the direction of the restriction, usually cephalocaudal. The technique can be performed in the midline, off-center, diagonally, or in any direction of restriction. When being performed in the midline with a deeper pressure, a distrac tion and elongation of the spine will result. Care must be exercised with the deeper version of the technique in patients with degenerative joint disease or discogenic lesions. Medial-Lateral Fascial Elongation (Figures
8-9
for example, the technique can be used to treat
and 8-10)
Purpose: The purpose of this technique is
restrictions in the anterior chest or abdomen. Therapist position: The therapist stands over
to elongate the superficial fascia in a medial
the patient, perpendicular to the direction of the
lateral direction. As with the previous technique,
restriction.
the application may be superficial as well as
Hands: Hands are placed in a crossed posi
deep. The most superficial application of the
tion on the patient, directly in line with the re
technique is autonomic, whereas any deeper ap
striction.
plication is primarily mechanical.
Figure 8-7
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Atlas afTherapeutic Techniques
Figure 8-8
Figure 8-9
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165
166
MYOFASCIAL MANIPULATION
Figure 8-10
Patient position: Prone.
Tissue Rolling (Figures 8-11 and 8-12)
Therapist position: The therapist stands per
pendicular to the patient, with the top hand on
Purpose: The purpose of this technique is
the treatment table for support and efficiency
mechanical assessment and alteration of restric
in application of technique. The other elbow is
tions in the superficial fascia.
placed in the area of the lumbosacral junction
Patient position: Prone.
with the forearm and hand resting I ightly on the
Therapist position: The therapist stands di
patient.
agonally over the patient.
Execution: The therapist applies gentle an
Execution: Assessment: The skin and subcu
terior pressure with the elbow until the level
taneous fascia are gently lifted in a posterior
of superficial subcutaneous fascia is reached .
direction at di fferent levels and areas of the
Lateral elongation pressure is then applied, and
spine. Generally, the tissue is assessed just off
the elbow is allowed to slide laterally and around
the midline of the spine and in a caudal to ce
the body. Most of the pressure is at the elbow
phalic direction. Typically, the fascia directly
and the proximal one third of the ulna. The rest
over the spine has much less mobility; this de
of the forearm is merely resting on the patient as
crease should not be considered dysfunctional.
the technique is executed. As the subcutaneous
As with other superficial techniques, the as
fascia releases, and as patient tolerance dictates,
sessment may be in medial-lateral or diagonal
deeper pressure may be gradually applied to the
directions because of the multidirectionality of
muscular and periosteal levels.
the superficial connective tissue. Some patients
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Atlas afTherapeutic Techniques
Figure 8-11
Figure 8-12
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167
168
MYOFASCIAL MANIPULATION
will be quite restricted in all planes; this may be
Long Axis Laminar Release (Figures 8-13
a general function of body type, or may repre
and 8-14)
sent generalized restrictions. The clinician must not only base the clinical j udgment on the su
Purpose: The first purpose of this technique
perficial fascial assessment, but must also cor
is elongation and decompression of the spine.
relate the f indings with other components of the
The second purpose is the identification of lo calized lesions in the medial border of the erec
evaluation. Therapeutic application: The skin and su perficial
subcutaneous connective tissue are
gently lifted in a posterior direction with both
tor spinae. As these lesions are identified, the motion may be stopped and a sustained pressure may be applied.
hands. Using each hand alternately, the clini
Patient position: The patient is positioned
cian rolls the skin, never releasing the hold on
prone with the lumbar spine in a neutral posi
the skin and subcutaneous tissue. Generally, the
tion. The neck also should preferably be in a
skin is rolled from caudal to cephalic, but other
neutral position and not rotated. The patient's
directions such as medial to lateral or diagonals
head should be as close as possible to the head
can be pursued. One can imagine balancing a
of the table to allow the therapist to complete the
drop of water on the Ii fted portion of the skin as
technique through the iliac area.
the roll is applied. When a restriction is encoun
Therapist position: The therapist is posi
tered, the rolling can be stopped, and a gentle
tioned at the head of the table with one foot in
posterior stretch or oscillation can be applied.
front of the other.
Figure 8-13
Figure 8-14
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Atlas a/Therapeutic Techniques
Hands: The hands are placed gently over the
169
iliac crests, and a gentle traction force is ap
patient with the fingers and thumbs facing in
plied. After several strokes, lesions along the
a caudal direction. The thumbs are placed in
groove may be identified. These lesions are
the groove between the erector spinae and the
manifested as local increases in muscle tone,
spine. The technique is best performed with both
reflexive muscle guarding, or connective tissue
thumbs on a single side of the spine, one thumb
thickenings. The lesions may be results of acute
just behind the other. A bilateral technique can
inflammation or may be remnants of older
also be performed but the depth of penetration is
trauma, holding patterns, or chronic fibrotic
somewhat compromised. Note that the thumbs
changes. The movement of the hands may be
should be aligned so they are in a direct line with
stopped at any time to apply localized sustained
the radius. This alignment allows for the most
pressure.
efficient application of technique and the least amount of biomechanical compromise for the therapist's hands.
Execution: Starting in the upper thoracic
Muscle Play of Erector Spinae (Figures 8-15 and 8-16A, 8)
area and with moderate pressure in the groove
Purpose: This technique mobilizes the fascial
between the erector spinae and the spine, the
sheath or casing surrounding the erector spinae.
thumbs are moved caudally into the lumbar and
As previously defined, muscle play is "the abil
lumbosacral areas. As the lumbosacral junction
ity of the muscle to expand and move within
is reached, the palms of the hands engage the
its compartment independent of joint movement
Figure 8-\5
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170
MYOFASCIAL MANIPULATION
A
Figure 8-16
or voluntary muscle contraction." Many fascial
Patient position: Prone. Therapist position: The therapist is standing
restrictions occllr in planes perpendicular to or diagonal to the direction of the muscle fibers.
perpendicular to the patient.
Recall that muscle sheaths are classified as loose
Hands: Hand position for this technique is
connective tissue that has multidirectional fiber
extremely important. The movement can be lik
orientation. By mobilizing the connective tissue
ened to the bending of a garden hose. If one
sheath surrounding or encasing the muscle or
imagines a garden hose being an encasement
groups of muscle, muscular contraction can
in which improvement of mobility is desired,
occur more efficiently, circulation to the muscle
bending the hose is one way to accomplish this
is improved, and movement in the localized and
goal. For the technique, the thumbs are placed
general areas is improved.
on the lateral border of the erector spinae. Once
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Atlas
the thumbs should be positioned so they are in line with the radius of the forearms. This
Techniques
171
but now in a medial to lateral direc
the
tion. Different levels of the erector spinae may
ensures that forces are distributed throughout the
be treated by simply moving the hands cephalic
arm and are not localized in the interphalangeal
or
(MCP), or carpo
(IP), metacarpal
joints.
the thumbs in
any other position will quickly produce fatigue. are placed
The index
over the
medial border of the erector
The
lightly over the lateral
of the hands are
body (Figure 8-1
of the
sure that the thumbs contact the
latera I borders of the erector
an oscillatory manner
(Figure 8-17) Purpose: The purpose of this technique is to tonal inhibition of the erector
B).
is performed in
Execution: This
a medial-lateral di
muscle group while applying traction to the lumbar
the palms, allowing the patient's body primarily in a medial
sedative than cross fiber manipulation, this is an excellent
for applying moderately
to lateral direction. This rhythm will vary from
deep pressure when the
patient to patient and will also
discomfort or pain.
patient's
on the
state of relaxation.
too
quickly or slowly will result in either a logrolling and excursion
are attained, the thumbs, which are
Patient position: Prone.
force in synchrony with the
ohhe rest of the
The primary force
is now at the thumbs, with the
retaining a
of force to maintain the oscillation. The "power"
level
the patient at the of the lumbosacral area.
Hands: The top hand is placed over the iliac
the lateral border of the erector spinae, begin to create the
is in considerable
Therapist position: The therapist stands di-
type of motion or a motion that is out of reso nance. Once
unilateral
Since longitudinal
is usually less noxioLls and more
rection of force. Initially, the force i s to oscillate
Muscle
"Ironing" of Erector
crest to "anchor" the pelvis. The bottom hand is crossed over the top hand and placed over the erector
muscle mass as close to the lum
bosacral junction as
The table should
be low to allow for the LIse of the therapist's body
of the stroke is lateral to med ial
with the thumbs; the index fingers are merely the position of the hand on the erecmovement
To ensure that a executed (as
Execution: A small amount of lubrication is used. The
a medialto a pOSItiOn
the power
toward the body
muscle group and slides
and f irmly in a cephalic direction. This
the elbows must move from a position away from the
of the bottom hand
into the erector
is deep, but utilizes the entire heel of the hand to create a strong but diffuse technique.
of
the technique, the top hand remains an
the stroke. In other words, the elbows are held
chored onto the iliac crest,
away from the body at the initiation of the stroke
ate traction/distraction of the lumbar area.
for a moder
(shoulder abduction) and are moved toward the during the stroke If a restriction is identified in a medial to lateral direction, the hand or
medial border of the erector pist must,
is changed
so the thumbs are
the The thera
move to the other side of
the table to perform the technique. The
Bony
of the Iliac Crest (Figures
8--18 and 8-]9) Purpose: This
is
to first
evaluate the fascial attachments at the iliac crest, then soften the fascia of the
at the insertion and quadratus lumbo
also serves to prepare the
portion of the stroke is still delivered through
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Atlas afTherapeutic Techniques
173
Figure 8-19
iliac crest surface area for the next series of techniques (i Iiac crest release).
lIiac Crest/Lateral Sacral Release (Figures 8-20-A, B, 8-21, and 8-22)
Patient position: Prone. Execution: In the first part of the technique,
Purpose: This technique mobilizes the fascial
the fingers of both hands are placed directly over
planes in the area of the iliac crest and the top
the superior border of the iliac crest. For better
one third of the ilium and the lateral border of
mechanical advantage, the fingers of one hand
the sacrum. As previously discussed, the area
are placed over the fingers of the hand making
of the iliac crests contains connective tissue
contact with the patient. The technique starts on
thickenings from various muscular and fascial
the superior border of the iliac crest, as close to
attachments, and is vulnerable to myofascial
the midline as possible. The fingers scour along
restrictions. Movement restrictions in forward
the superior border of the iliac crest laterally and
bending, side bending, and also backward bend
at moderate depth. A small amount of lubricant
ing can occur here. The posterior portions of
should be used to avoid overly frictioning the
the fascial planes create the forward bending
skin.
restrictions, whereas the anterior portions create
In the second part of the technique, the "power
backward bending restrictions.
grip" shown in Figure 8-2 is utilized to gain
The lateral border of the sacrum can also be
further depth. Again starting as medially as pos
fascially compromised. The piriformis attaches
sible, the therapist scours along the superior
close by, and patients with Jow back, hip, sacro
border of the iliac crest using the reinforced
iliac , and leg pain can profit from this technique.
thumb and PIP joints as the contact on the pa
Especially patients with diffuse hip and leg pain
tient.
proximal to the knee can benefit from this tech
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174
MYOFASCIAL MANIPULATION
A
\ B Figure 8-20
nique. The lateral sacral release is an excellent
Therapist position: The therapist stands di
technique to use in conjunction with the bilateral
agonally over the patient, approximately perpen
sacral release technique shown next.
dicular to the iliac crest.
Patient position: Prone. Should the connec
Hands: The optimal hand position for this
tive tissue need to be placed in a slackened po
technique is to have the middle fingers approxi
sition for deeper penetration, the hip may be
mating one another (Figure 8-1). The index fin
extended manually by the therapist, or statically
gers are "dummy" fingers, one being below and
with pillows (Figure 8-18).
one being above the middle fingers. This posi
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Atlas a/Therapeutic Techniques
Figure 8-21
Figure 8-22
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175
176
MYOFASCIAL MANIPULATION
tion allows for a four-finger contact on the iliac
The technique covers the bony surfaces starting
crest or lateral border of the sacrum.
just lateral to the anterior superior iliac spine
Execution: The f ingers are placed over the border of the iliac crest and an anterior force
(ASIS) and progressing medially and caudally to the sacrococcygeal junction.
is applied through the f ingers. A very slight extension of the fingers occurs during the power portion of the stroke. The power for the motion
Bilateral Sacral Release (Figure
8-23)
comes from the shoulders and upper body and
Purpose: The purpose of this technique is
the stroke is delivered repetitively in an oscil
to mobilize the connective tissue on tJle sacra I
latory manner. In correctly applying the force,
borders. This may become necessary before
the fingers will slide off the border of the ilium
attempting to mobilize the sacrum out of vari
into the connective tissue. When the f ingers are
ous positional faults or movement dysfunctions.
withdrawn posteriorly in preparation for the next
Freeing up the myofascial restrictions often fa
stroke, they move back on the border of the
cilitates mobilization of the sacrum. This area
ilium. Contact with the patient is never broken
may also be restricted in conjunction with iliac
during the repetitive application of the tech
crest restrictions. As previously noted, the fascia
nique, except to move to other areas of the iliac
lata has its insertion at the ASIS, lateral border
crest. The crest may and should be mobilized
of the iliac crest, lateral borders of the sacrum,
from the most lateral palpable aspect to the most
coccyx, and sacrotuberous ligament. To fully
medial palpable aspect, since the entire border
mobilize the insertion of the fascia lata, the lat
of the iliac crest is susceptible and vulnerable to
eral border of the sacrum should be mobilized.
myofascial restrictions. The depth of penetration
Patient position: Prone.
of the stroke is moderate and depends on patient
Therapist position: The therapist stands per
tolerance. Many patients with f ibromyalgia will
pendicular to the patient.
be extremely sensitive over this area, whereas
Hands: The hands are brought together so
many patients will be restricted without expe
that the thumbs and the index fingers of each
riencing any tenderness. The clinician should
hand are making contact with one another.
treat this area based on objective f indings in the
Execution: Anatomically, only the distal half
evaluation and not merely on subjective com
of the sacral borders are palpable. The proximal
plaints. A variation of this technique is to apply
one half of the sacrum articulates with the ilium
the same force, but contact I or 2 inches distal
and is not palpable. To ensure that contact is
to the border of the ilium. As the force is ap
being made on the sacrum, the therapist should
plied over the connective tissue of the ilium, the
approach the sacrum with the bottom hand
f ingers do not slide off the ilium into the deeper
below the level of the sacrum (distal to the
connective tissues. Again, the entire expanse
sacrum), until contact is made bilaterally with
of the ilium should be mobilized, or at least
the patient's buttock. The bottom hand then pal
palpated for restrictions.
pates in a cephalic direction until the inferior
The same technique is utilized for the lateral
lateral angles of the sacrum are palpated. The
border of the sacrum. The f ingers start just off
top hand then contacts the bottom hand in the
the sacrum and push onto the lateral surface of
manner described above. A repetitive caudal
the sacrum in a rhythmical fashion. Remember
to cephalic motion is performed following the
that the sacroiliac joint occupies the cephalic
lateral border of the sacrum. The direction of
half of the sacrum. When moving from the ilium
the technique should be V-shaped, following
to the sacrum on this technique, the therapist
the shape of the sacrum. If the fingers are only
"detours" onto the lateral aspect of the posterior
moving cephalically and not spreading, contact
superior iliac spine (PSIS) and moves caudally
with the lateral borders of the sacrum is not
toward the inferior-lateral angles of the sacrum.
being maintained.
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Atlas a/Therapeutic Techniques
177
B Figure 8-23
The technique may also be executed unilater
Medial-Lateral Pull Away (Figure 8-24)
ally using the same hand position as the iliac crest release described previously (Figure 8-l).
Purpose: The first purpose of this technique
The lateral border of the sacrum is located the
is autonomic or reflexive in nature. As with other
same way as described above. Once the latera l
autonomic techniques, it desensitizes the pa
border is located, contact is made with the fin
tient who is extremely acute and gains entryway
gertips. The fingers are then moved caudal to ce
to deeper technique. As the patient's condition
phalic, maintaining contact on the lateral border
allows or dictates, deeper pressure is applied
of the sacrum.
until the level of the erector spinae is reached,
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178
MYOFASCIAL MANIPULATION
Figure 8-24
changing the emphasis of the technique from
exerted through the fingertips unti I a moderate
autonomic to mechanical. The erector spinae is
to deep pressure is being consistently exerted.
gently being mobilized from a medial to lateral direction.
Patient position: Sidelying. The patient's hips
L3 (Figure 8-25)
and knees are semiflexed. As discussed earlier,
Purpose: The purpose of this technique is
a pillow should always be placed between the
to alter the connective tissue in the midlumbar
patient and the therapist both for biomechanical
area, and specifically around the L3 area. Since
advantage and for modesty. The patient is moved
L3 is generally the apex of the lumbar curve, and
close to the edge of the table until snug against
site of hypomobility problems, myofascial prep
the pillow.
aration of the area is necessary prior to joint mo
Therapist position: The therapist stands over the patient snug against the pillow.
Hands: The hands are placed gently over the patient with the fingertips resting over the medial border of the lumbar erector spinae.
Execution: The stroke begins very gently at approximately the level of the subcutaneous
bilization and/or manipulation. Also, the trans verse process of L3 is the longest and most easily palpated.
Patient position: Side lying. The patient is positioned with the hips and knees in a semi flexed position, and a pillow is placed between the therapist and the patient.
fascia, and from medial to lateral. Initially, the
Therapist position: The therapist stands over
pressure is evenly distributed throughout the
the patient with the patient snug against the
hand. As the patient tolerates, more pressure is
pillow.
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Atlas a/Therapeutic Techniques
179
teriorly, inferiorly, and anteriorly to contact the connective tissue surrounding the L3 transverse process. Once off the transverse process, firm pressure, depending on patient tolerance, is ap plied with an oscillatory motion. Passive segmental mobility may be tested in any plane just before and just after the technique is applied. Because soft tissue and joint mobi lization are often used together, and because joint restrictions may often be due to soft tissue restrictions, passive segmental mobility may be altered with this or any other myofascial tech nique. Figure 8-25
Quadratus Lateral Erector Spinae Release (Figures 8-26 and 8-27) Hands: The middle fingertips are used for this technique.
Execution: Starting laterally, the transverse
Purpose: The purpose of this technique is to prepare the quadratus .Iumborum and the lateral fascial structures of the lumbar spine for elonga
process ofL3 is palpated. Once on the transverse
tion and stretch techniques. The technique in
process, the fingers are moved superiorly, pos-
volves sustained pressure primarily designed to
Figure 8-26
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180
MYOFASCIAL MANIPULATION
...
Figure 8-27
reduce active tonic contractions of the quadratus
Execution: The top hand is either placed
lumborum, and to prepare for a stretch of the
gently on the patient, or on the treatment table
lateral fascial structures. After quadratus tone
for support. The middle aspect of the forearm
is diminished, the elongation and stretch tech
(ulnar surface) is wedged into the groove be
niques are more effective and efficient.
tween the 12th rib and the iliac crest. Light
Patient position: Sidelying with the hips and knees in approximately 70 degrees of flexion. Therapist position: The therapist stands per
to moderate pressure is placed down onto the muscle groups and sustained for a period of time until a release of muscular tone is achieved
pendicular over the patient. If a high-low table is
or until it is obvious no change wiII be made.
available, the table level should be lowered.
The forearm may be moved forward and back
Hands: The mid forearm of the bottom arm
ward (the therapist is flexing and extending the
is used in this technique. The forearm is placed
shoulder) in a very deliberate "sawing" type of
in the midlumbar area, in the soft tissue space
motion.
between the 12th rib and the iliac crest. If the
As an alternate technique, the hip is hiked
forearm is angled posteriorly, the lateral border
using the bottom hand while the quadratus is
of the erector spinae will be contacted. If the
accessed with the top hand. The top hand is
forearm is angled anteriorly, the quadratus lum
positioned with the first MCP making contact
borum will be contacted. As an alternate posi
with the quadratus lumborum. As the quadratus
tion, the web space and MCP joint of the top
is put on slack, the top hand pushes firmly in a
hand can be placed on the quadratus lumborum
medial direction to access the deeper fibers of
as the bottom hand positions to hike the hip.
the quadratus lumborunl.
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Atlas oj'Therapeutic Techniques
181
range for longer than 3 weeks has undergone
Side Bending Elongation Quadratus Stretch
contractural changes that must be addressed
(Figures 8-28,8-29, and 8-30)
before attempts at shift correction. Purpose: This technique should be used gen
Finally, this technique may be used to de
erally to elongate the posterolateral and antero
compress compressive lesions such as nerve im
lateral fasciae of the lumbar and thoracic spines
pingement s yndromes. Aside from backward
and, specifically, to stretch the quadratus lum
bending, side bending is the least stressful move
borum. [n unilateral chronic pain conditions, the
ment on the disc, followed in increasing order of
painful side often retracts , contracts, and gener
stress by forward bending and, finally, rotation.
ally shortens. The manifestation of such a condi
In rehabilitation of discogenic lesions, the side
tion can be assessed postura lIy or with active
bending elongation maneuver decompresses the
movements. Both the connective tissues as well
nerve root and takes the disc into the next most
as contractile tissues may become dysfunctional
stressful maneuver.
and exhibit changes consistent with immobiliza
Patient position: Sidelying.
tion.
Therapist position: The therapist stands per
More specifically, this technique may be used
pendicular over the patient. The top forearm
to prepare for correction of lateral shift condi
contacts the lateral thorax/rib cage, while the
tions of more than 3 weeks' duration. As dis
bottom forearm contacts the lateral portion of
cussed in Chapter 3, muscle decreases in length
the ilium.
by losing sar comeres-the process takes ap proximately 3 weeks. Tissue held in a shortened
Hands: The fingers contact the medial border of the erector spinae.
Figure 8-28
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Execution: To localize forces in the lumbar
o(Therapeulic Techniques
183
off center. The therapist should not continue to
area, the hips and knees are bent to 90 degrees
rotate. The change in angle of the sidebending
and the patient's feet are allowed to hang off the
provides a more aggressive stretch of the qua
table. Care must be taken while lowering the feet
dratus lumborum. Note of caution: Discogenic
off the table not to provoke any symptoms. Once
lesions are a strong precaution here, because the
the feet are off the table, pressure is exerted in
rotation could compromise a discogenic lesion.
a cephalic direction with the top forearm and in a caudal direction with the bottom forearm. At the same time, the f ingers move from medial to lateral on the erector spinae. The forearms are
Forward Bending Laminar Release (Figures 8-31 and 8-32)
localizing most of the stretch on the quadratus.
Purpose: The purpose of this technique is to
The hands are primarily aiding this movement
elongate the posterior myofascial tissues of the
by gently releasing the erector spinae.
lumbar spine. This may be necessary in hyperlor
In this position, a gentle hold-relax technique
dotic postures or in preparation for joint mobil i
may be performed by asking the patient to gently
zations. As discussed earlier, soft tissue and joint
push the ilium into the therapist's bottom fore
mobilization have a unique relationship in that
arm. The patient should not be allowed to remain
either the soft tissues or the joint may be contrib
with the legs off the table for more than 30 to
uting to a hypomobility. Passive segmental mo may change dramatically after
45 seconds, since the lever arms of the lower
bility of a
extremity are applying considerable forces into
releasing soft tissue. On the other hand, joint
the lumbar spine.
mobilization may have a profound effect on the
joint
To diffuse the forces and provide a more
surrounding myofascial tissues by way of stimu
general elongation of the lumbar and thoracic
lating joint receptors. This technique is often
spines, the patient is asked to fully flex the
performed before, during, and after joint mobili
shoulder and hold the top of the treatment table.
zation to complement specific joint maneuvers.
The legs are then lowered off the table, as de scribed. The forces may be applied through the
Patient position: The patient is sidelying in a semifetal position.
arm-hand contacts described above, or a trac
Therapist position: The therapist stands per
tion-elongation force may be applied through the
pendicular over the patient. The therapist will
palms of the hands as shown in Figure 8-30. The
stabilize the patient's top knee by placing it in
therapist can apply an elongation of the lateral
the area of the therapist's anterior hip for control
connective tissue of the lumbar and thoracic
and ease of execution.
spines and even into the connective tissues of the shoulder girdle complex. In some cases, where the quadratus lumborum
Hands: The top hand is placed over the tho racolumbar junction, along with the forearm in such a way that the elbow is positioned in
has been hypertonic, but not necessarily short
a cephalic direction while the fingers are posi
ened, it may be necessary to create more length
tioned in a caudal position. The top hand is the
in the quadratus than the previously described
"stabilizing hand." The bottom hand is placed
technique. [n order to manufacture more length,
initially in the area of the upper lumbar spine in
the trunk is rotated to the T l2/L I segment. By
contact with the erector spinae, with the fingers
rotating in this fashion, rib 12 is rotated away
slightly flexed.
from the pelvis, allowing for lengthening of the
Execution: To execute the technique, the fin
more cephalic aspect of the quadratus lumbo
gers are moved caudally down the length of the
rum. Once rotated, the legs are placed off the
erector spinae while the patient's hip is simul
table and a sidebending force is placed on the
taneously being flexed. The leg movement is
pelvis as previously described. The top arm con
executed through the therapist's
tinues to sidebend at approximately 30 degrees
The therapist pulls the patient's knee toward
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hip
and pelvis.
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185
Atlas
the chest, decreasing the lumbar lordosis. This
Execution: The top hand gently stabilizes the
coming from hip flexion as
ilium while the patient's hip is gently flexed.
allows for
of the
well as from the caudal
The therapist accomplishes this by
bottom hand.
in a
cephalic direction with his or her pelvis. Simul joint restriction is found, this
the bottom hand strokes from just
may be somewhat localized to prepare
distal to the PSIS to the ischial tuberosity and
If a
the surrounding soft tissues prior to a
mo
direction. Most of
laterally in a
bilization. The hip is first flexed to the level of
the pressure is
the restriction.
but the
are
this time the
through the
remains in contact throughout.
palpating between the spinous processes for the restriction. Once movement
forward
Forward Bending L aminar Release--AII
the hip
has arrived at the is extended 51
Fours (Figures 8-33, 8-34, and
to reslacken the tissue at
that level. The top stabilizing hand is brought down to a position
Purpose: The purpose of this
cephalic to the restricted
is to
elongate the posterior son tissues of the lumbar
leveL The bottom hand is brought up to a level
or thoracic
almost
an alternative to the forward bending laminar
the top hand. The
then strokes over the erector
This technique may serve as
release in
in a caudal
I f the patient is too
direction the length of 2 to 3 segments while
for the therapist to manage in
the hip is being flexed through a short arc o f
fours position may be used. Specificity is sacri
movement. This allows for tissue t o b e
ficed somewhat in order to
both b y the hip tlexion and
cal advantage. One
the caudal pull of
some mechani to this
is that the patient
the bottom hand. Passive intervertebral mobil should be assessed prior to an appropriate
than remaining
of this technique.
number of
the alJ
Patient position: Quadruped. stands at
Therapist position: The the patient's side at a
Longitudinal Posterior Hip Release
may need to be on a
is an extension of
Purpose: This
The thera
table is
or, jf a high-low
the table should be lowered.
Hands: For optimal stability and etliciency,
the previous technique, but is sometimes lIsed
the thumb is held
for lesions in the area of the posterior
the PIP
hip. Piriformal lesions and
index finger. Contact is made
well as extensibility problems in the
joint and the tip of the thumb Execution: The therapist instructs the patient
hip, are effectively treated with this Patient position: The
is
in
to bend forward first at the cervical spine and recruit motion into the thoracic
the semifetal position with the top knee stabi lized in the anterior
of the
of the therapist.
As movement is recruited into the thoracic spine, the
Therapist position: The therapist is
to start rocking
asks the
perpendicular to the patient, stabilizing the pa
back on his or her heels. This motion
tient's top knee with the anterior hip, allowing
recruit movement from lower lumbar to upper
for an effective mechanical
lumbar areas. As the patient recruits this move
and a
for the
of
tient.
ment, the therapist erector
Hands: The top hand is placed so that the gently contacts the ASIS. The bottom hand is positioned over the buttock with the
to
Iy strokes the
unilaterally with the bottom hand,
starting from the sacrum and thoracolumbar
hand to dictate the movement.
distal to the SLI.
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toward the
The top hand is used as and pace
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187
Figure 8-35
Forward Bending Laminar Release-Sitting
Execution: The patient is f irst asked to for
(Figures 8-36,8-37,8-38, and 8-39)
ward bend segmentally starting from the cervi
Purpose: This technique will elongate the
finally into the lumbar spine. Once the patient
posterior myofascial structures of the lumbar,
understands the concept of segmental move
cal spine, recruiting into the thoracic spine, and
thoracic, and to a certain extent, cervical spines.
ment, the thumb-PIP complex of each hand is
As with the quadruped technique, the patient ac
placed over the erector spinae at the cervicotho
tively participates in the technique; the technique
racic junction in a downward position. For opti
also allows for working with patients larger than
mal mechanical advantage, the elbows should be
the therapist. Specificity is somewhat sacrificed,
directed upward, and the thumb-PIP should be
but significant mechanical advantage is gained in
directed downward. The patient is asked to for ward bend segmentally, and the therapist strokes
performing the technique in a sitting position. Patient position: Sitting. Therapist position:
The
the erector spinae longitudinally at the level therapist
stands
the movement is being recruited . If a localized
Hands: The hand placement is as illustrated
stop the movement at the point of the restriction,
behind the patient, facing the patient.
restriction is found, the patient may be asked to
in Figure 8-2. The position with the thumb held
and a sustained pressure may be applied.
next to the PIP joint of the index finger is a very
The same technique may be applied unilater
stable position and does not compromise the
ally and with a rotatory component by asking the
joints of the hand.
patient to forward bend diagonally. The patient
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MYOFASCIAL MANIPULATION
Figure 8-36
is asked to follow the lateral border of the leg with the arms. This maneuver allows for for ward bending, side bending, and rotation com ponents. One hand is used as a guidance hand to dictate the pace and quantity of movement, and the other hand is used to perform the technique. The patient is again asked to move segmentally into the diagonal plane, and the therapist strokes the erector spinae at the level that movement is being recruited. If a movement restriction and/or myofascial restriction is encountered, the patient may be asked to stop, and the therapist may apply a sustained pressure. The technique may also be applied to the cer vical spine. The therapist uses one hand to guide the patient's head and neck, generally into a diagonal direction, and uses the other hand to stroke down the cervical paravertebral muscles. Contraindications: This technique should not be used with discogenic backs since a loaded spine is being taken into forward bending.
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Figure 8-38
Figure 8-39
Lumbar Myofascia\ Roll (Figure 8-40)
spine. The top hand is placed over the patient's subclavicular-pectoraJ area, while the bottom
Purpose: This technique is an excellent pre
hand is placed over the midlumbar area. The
paratory technique for a midlumbar roll mobili
knee of the patient is placed in the anterior por
zation or manipulation. Many times, a midlum
tion of the therapist's hip.
bar joint manipulation is difficult to execute
Hands: The fingers of the bottom hand are
because of myofascial restrictions or active
placed on the medial aspect of the erector
muscle guarding. The patient may be apprehen
spinae.
sive of rotating the spine to the degree that is re
Execution: The lumbar spine is bent forward
quired in the midlumbar manipulation. Decreas
by flexing the patient's hip and recruiting motion
ing myofascial restrictions not only allows the
into the lumbar spine. The lumbar spine is then
patient to relax into rotation, but also facilitates
rotated by pulling the bottom arm of the patient
locking a specific joint of the lumbar spine.
until movement is recruited into the lumbar
Patient position: Sidelying. stands
the lumbar spine is rotated from both contact
facing the patient at the level of the lumbar
points. The erector spinae muscles are simulta
Therapist position:
The
spine. In the therapist position described above, therapist
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MVOFASCIAL MANIPULATION
Figure 8--40
neously stroked diagonally with the fingers as
direction. Normalizing this myofascial imbal
the rotatory force is applied through the top
ance is the primary purpose of the technique.
arm. The lumbar spine may be rotated close
This technique should not be confused with
to end range, but should not be taken to the
the lateral shift correction technique, which is
limit of motion. As relaxation and elongation are
typically performed on a laterally shifted patient.
achieved, the spine may be taken to end range to
The technique has application for neuromuscu
perform the joint manipulation.
lar retraining at end-stage discogenic rehabilita tion, but should not be used early in the disco
Lateral Shear (Figures 8-41 and 8-42) Purpose: This technique is performed to nor malize the lateral shear forces in the lumbar
genic rehabilitation process, especially when a lateral shift is still present. The technique of choice in a lateral shift is the lateral shift correc tion technique.
spine, which may be abnormal and/or asym
Test procedure: To determine if a lateral
metrical due to past trauma. An excellent use
shear imbalance exists, the therapist stands
of this technique is with a resolving discogenic
behind the patient and passively moves the pa
lesion where the patient has ceased experienc
tient into a lateral shift position. This is accom
ing a lateral shift for a period of time. When
plished by placing one hand on the ilium and
the patient is tested for lateral shear (passively
the other hand on the upper trapezius-shoulder
shifted), the patient will usually adopt the posi
girdle area and applying force. The force on
tion of the previous shift quite easily, and will be
the ilium is directly lateral (i.e., in a horizontal
markedly restricted when sheared in the opposite
plane), while the pressure applied on the upper
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trapezius-shoulder girdle is in a 45-degree diag onal direction. The vector on the upper trapezius! shoulder girdle is a combination of lateral force (in the horizontal plane) and compressive force. If the patient's trunk moves easily to the right and is restricted in movement to the left, the patient is restricted in left lateral shear. The next step is determining whether the re striction is merely postural or if a true myo fascial restriction exists. The patient then lies prone and the lateral shear is again tested, this time primarily from the pelvis. If the patient's pelvis moves easily to the left and is restricted in movement to the right, the patient is said to be restricted in left lateral shear. Remember, the direction of the shear is always based on the direction the upper body moves in relation to the lower body. In standing, if the trunk is restricted in movement to the left, a left lateral shear restriction exists. In the prone position, ilial movement to the right is trunk motion to the left. If ilial movement to the right is restricted, the restriction is still in left lateral shift. If a movement restriction exists when the pa Figure 8-4 1
tient stands but normalizes when the patient is
Figure 8-42
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MYOFASCIAL MANfPULATfON
prone, the condition is not as significant, and
both in prone and in standing positions, to see if
is usually more easily treated. If a movement
the technique produced any change.
restriction exists when standing and remains
Two things are accomplished ill this tech
when prone, the condition has become more
nique. The first is a neuromuscular "repassing"
entrenched and can potentially be more detri
to eliminate muscular holding patterns created
mental if left unchecked. Either way, treatment
by old trauma. The second is releasing restric
is necessary to correct the dysfunction.
tions in the noncontractile elements that became
Patient position: Prone.
restricted as a result of prolonged dysfunction in
Therapist position: The therapist stands per
the contractile elements.
pendicular to and over the patient at pelvis level. Hands: The palm of the hand or a fist may be
Diaphragm (Figures 8-43,8-44,8-45, and 8-46)
used to make contact on the ilium, just proximal to the greater trochanter of the hip.
Purpose: These techniques are designed to
Execution: The restriction is engaged by
free up restrictions in the anterior fascia just
gently shearing the pelvis laterally. Once resis
caudal to the rib cage, and to mobilize the di
tance is met, the patient is asked to hold his or
aphragm. In a for ward-head, protracted shoul
her position, and then relax (hold-relax stretch).
der, slumped position, the anterior elements col
As the patient relaxes, the pelvis is sheared far
lapse , reducing diaphragmatic excursion. This
ther laterally and the process is repeated. After
can lead to increased activity in the secondary
several repetitions, the lateral shear is retested,
accessory breathing muscles. Also, for the pa-
Figure 8-43
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Figure 8--44
Figure 8-45
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MYOFASCIAL MANIPULATION
the rib cage, just lateral to the xiphoid process, and in the connective tissue just caudal to the rib cage. Execution: The top hand gently pushes the connective tissue in a caudal direction in order to slacken the tissue just caudal to the rib cage. This allows the fingers of the bottom hand to slide underneath the rib cage (to patient tolerance). The stroke is applied, following the border of the rib cage medial to lateral. Care should be taken not to push into the floating ribs while moving laterally with the stroke. In this position, only a superficial or moderate level of penetration can be achieved. Second Position: Side/ying Patient position: The patient is in the sidely ing position with the hips and knees flexed to 90 degrees. Therapist position:
The
therapist
stands
behind the patient. Hands: The hand position is similar to that described above. The top hand is placed on the lower portion of the rib cage, while the bottom
Figure 8-46
hand is placed at the caudal border of the rib cage, just lateral to the xiphoid process. Execution: With the patient more flexed, more slack is placed in the superficial connec tient to perform postural reeducation techniques
tive tissue. The first technique actually mobilizes
successfully and elongate the thoracic area, the
both the connective tissue and the diaphragm.
contracted area of the anterior chest and abdo
The second technique bypasses the superficial
men must be supple and mobile. Three tech
connective tissue to engage the deeper connec
niques are shown, ranging from the least ag
tive tissue under the rib cage. The therapist
gressive to the most aggressive; the general
uses the top hand once again to move the con
progression should follow the patient's tolerance
nective tissue medially and caudally, allowing
level.
the bottom hand to slide under the rib cage. The
First Position: Supine
direction, with care not to hit the floating ribs.
stroke is again applied in a medial to lateral
Patient position: The patient lies in the supine position with the knees and hips slightly flexed.
Third Position: Sifting
Therapist position: The therapist is either
Patient position: The beginning position for
standing at the side of the patient or seated.
this technique is the slumped sitting posture.
The seated position is biomechanically more
This allows the therapist greater access to the
advantageous for the therapist.
tissues underneath the rib cage. As the technique
Hands: The therapist's top hand is placed over
is performed, however, the patient Illay be asked
the bottom portion of the rib cage. The bottom
to assume a more erect posture so the therapist
hand is placed at the anterior-medial border of
can mobilize the rib cage.
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stands
back posture), however, the psoas may be hyper
behind the patient with a pillow between the
tonic in an effort to increase lordosis or to guard
Therapist position:
The tllerapist
therapist and the patient. The patient is leaning
a lesion, where axial flexion of the lumbar spine
into the therapist in a slumped posture.
is the primary dysfunction producing symptoms.
Hands: Whereas the previous techniques are
Patient position: The patient lies in the supine
unilateral, this technique is bilateral. Both hands
position with the hips and knees flexed approxi
slide underneath the rib cage medially, just lat
mately 30 to 45 degrees. This puts the muscle
eral to the xiphoid process.
in a slackened position. If the muscle does not
Execution: The stroke is again executed
exhibit enough slack, the hips may be flexed
medial to lateral with the patient in the slumped
90 degrees, over the therapist's leg. This should
position. At an appropriate time, the hands
be performed on a high-low table for optimal
firmly grip the rib cage, and the patient is asked
biomechanical advantage.
to inhale deeply and attempt a more erect pos ture. The rib cage is mobilized anteriorly.
Therapist position: The therapist stands at the patient's side, and if necessary, places one leg on the table; the patient's legs are then placed
Psoas (figUl"es 8--47, 8-48, and 8-49) Purpose: Mobilization of the psoas muscle is
over the therapist's leg. The therapist may use the leg to change the amount of hip flexion during application of the technique.
clearly indicated in cases where actual shorten
Hands: The f ingertips are used to contact
ing exists, which is creating mobility problems
the psoas. The hands are placed lateral to the
in the lumbar spine, especially with forward
umbilicus and the psoas is approached from a
bending. In an axially extended posture (flat
45-degree angle.
Figure 8--4 7
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Execution: Because of the location of the psoas, a significant depth must be achieved
197
patient in a sidelying position. The therapist may use the thumbs to access and release the psoas.
through the abdomen. Care must be taken to progress slowly into the appropriate depth, asking the patient about the relative comfort
Iliacus (Figures 8-50 and 8-51)
of the technique. As more depth is achieved through the abdomen, "landing" on a more rigid
Purpose: The iliacus muscle can be treated
structure indicates arrival onto the psoas. The
for limited extension of the hip or as an exten
psoas wiII be more rigid than the soft tissue
sion of a psoas release. Even though the iliacus
of the abdomen. The patient will also report a
does not have an insertion into the spine, a short
different sensation, usually more noxious when
ening dysfunction of the iliacus can anteriorly
the psoas is palpated, especially if the psoas is
rotate the pelvis, creating a backward bending
dysfunctional.
dysfunction of the spine.
Because longitudinal stroking of a muscle is
Patient position: The patient lies in the supine
generally less noxious than cross stroking, the
position with the hip flexed approximately 30
psoas should be gently stroked longitudinally at
degrees. As with the psoas, if not enough slack
first. Only after longitudinal stroking should a
is placed on the tissue, the hip may be flexed by
cross stroking of the psoas be attempted. Once
the therapist, up to approximately 110 degrees.
the technique is terminated, the hands should be
Therapist position: Standing over the pa
gradually removed from the abdomen. In some
tient, and if necessary grasping the lower ex
cases, the psoas may be more accessible with the
tremity to impart hip flexion.
Figure 8-50
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MYOFASCIAL MANIPULATION
Figure 8-51
sive work in the piriformis, posterior hip, and
Hands: The palm of the hand is placed over the anterior superior iliac spine and the fingers
•
hamstrings. Application of this technique will
are wrapped over the ilium, contacting the an
generally yield an increase in straight leg raising
terior surface of the ilium. The f ingers are in
as well as internal rotation.
contact w ith the iliacus at the most accessible
Patient position: The patient is in the supine position.
portion of the insertion. Execution: The technique begins with a prox imal to distal stroking of the muscle (longitudi
Therapist position: The therapist is either standing or seated at the patient's side.
nal stroking). As patient tolerance or muscle
Hands: The fingers of the top hand will con
response dictates, the stroke is shifted into a
tact the posterior surface of the greater trochan
cross stroking of the iliacus (lateral to medial).
ter, while the bottom hand gently grasps the leg
TECHNIQUES FOR THE
the knee joint.
in the area of the distal femur, just proximal to LUMBOPELVIC/LOWER QUARTER AREA
Execution: A gentle internal rotation motion is begun with the bottom hand. Simultaneously,
Greater Trochanter Rocking (Figures 8-52A,B and 8-53)
an anterior pressure is applied with the top hand through the greater trochanter, further facilitat ing the internal rotation motion. The motion is
technique is designed for
repeated in an oscillatory fashion at a deliberate
gentle inhibition of the lateral rotators of the
speed. The technique is generally performed in
Purpose:
This
hip as well as for the hamstrings. This is an
the midrange of internal rotation and is gradu
excellent preparatory technique for more exten
ally moved toward end range. Internal rotation
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A
Figure 8-52
and straight leg raising should be reassessed
room for the quadriceps to contract. The "bend
after this technique.
ing of the water hose" analogy applies in this case. The technique has a different "look" com
Transverse Musele Play of Quadriceps (Figures 8-54, 8-55, and 8-56) Purpose: The concept of muscle play is ap pI ied to the quadriceps muscle where the sur rounding fasciae are mobilized to provide more
pared to the muscle play of the erector spinae because of the size of the quadriceps compared to that of the erector spinae. Patient position: Supine or sidelying. Therapist position: The therapist stands at the patient's side at the level of the midfemur.
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Figure 8-55
Figure 8-56
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MYOFASCIAL MANIPULATION
Hands: The bottom hand grasps the quadri
be exquisitely tender over the area of the ilio
ceps and femur distally, just proximal to the
tibial band and surrounding tissues when other
knee joint. The top hand grasps the quadriceps
dysfunctions are symptomatic nearby.
anywhere on the muscle belly where a restric
This technique actually addresses three dis
tion is identified. The top hand palm is placed
tinct areas:
laterally over the vastus lateral is . Alternately,
between the iliotibial band and the hamstring,
(I) the connective tissue "groove"
both hands may be placed over the quadriceps to
(2) the groove between the iliotibial band and
engage more surface area.
the quadriceps, and
(3) the iliotibial band itself.
Execution: Firmly grasping the distal aspect
Because loose irregular connective tissue is the
of the quadriceps with the bottom hand, the
most easily mobilized, the surrounding connec
top hand shears the quadriceps from lateral to
tive tissue will more readily respond than the
medial over the femur. The force is applied
iliotibial band.
through the palm of the hand. The hand does not
The other area this technique addresses is
slide over the skin, however. The technique is
the paratrochanteric area. The connective tissue
designed to move the muscle, not to slide over
surrounding the greater trochanter is also often
the muscle, which is more of a massage tech
dysfunctional; this includes superior, inferior,
nique. The technique is generally performed in
anterior, and posterior to the greater trochanter.
a lateral to medial direction since more restric
Patient position: (I) Patient lies supine with
tions seem to occur in the vastus lateralis. The
the hip and knee flexed, but with the foot on the
technique may be performed in a medial to lat
treatment table. (2) In a more aggressive form
eral direction by moving to the patient's other
of the technique, the patient is asked to flex and
side and proceeding to shear the quadriceps in
adduct the hip and to hold the position to place
a medial to lateral direction. The technique may
the posterior hip in a more stretched position.
also be performed in diagonal planes if a restric
The execution of the technique is the same in
tion occurs in that plane.
either position.
The main difference between soft tissue mo
Therapist position: The therapist stands at
bilization and joint mobilization is that in joint
the patient's side at a slight angle to the patient,
mobilization, arthrokinematic rules must be fol
depending on whether the anterior or posterior
lowed. In soft tissue mobilization, restrictions
border of the iliotibial band is being treated.
Illay occur in any plane and at any depth, and
Hands: The hand position described previ
mobilization of the restriction does not depend
ously in Figure 8-2 is used in this technique. The thumb and the PIP of the index finger con
on arthrokinematics.
tact one another and become the point of con tact with the patient. The elbow should point Iliotibial Band Paratrochanteric Mobilization (Figures 8-57A,B; 8-58A,B;
up toward the ceiling for the best mechanical advantage in applying the technique. Execution:
8-59, and 8-60)
(I) Posterior border of iliotibial
band. The therapist's top hand stabilizes the pa Purpose: The iliotibial band is an area com
tient's leg at the knee joint. The thumb and PlP of
monly involved in lower kinetic chain prob
the bottom hand contact the groove between the
lems, knee dysfunction, and hip and low-back
iliotibial band (ITB) and the hamstring distally.
dysfunction. Many diffuse "referred pain" syn
With the elbow pointing upward, the stroke fol
dromes in the lower extremity can be traced to
lows the border of the ITB and the hamstring
iliotibial dysfunctions. Treatment of this area
proximally. When the area of the greater trochan
becomes important to a variety of problems,
ter is reached, the direction of the stroke changes
even if the patient has no conscious awareness
and continues paratrochanterically to encircle
of pain in the area. Many times the patient wi II
the greater trochanter. (2) Anterior border of
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Figure 8-57
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Figure 8-59
205
Figure 8-60
the iliotibial band. The therapist's bottom hand
and adduction to stretch the posterior elements
stabilizes the patient's leg at the knee joint.
of the hip, and for greater access to the ITB
The thumb and PIP of the top hand contact
proximally.
the groove between the iliotibial band and the quadriceps distally. With the elbow pointing upward, the stroke follows the border of the ITB
Hold-Relax Stretch of Hip (Figure 8-61)
proximally, again until the greater trochanter is
Purpose: The purpose of this technique is to
reached. The stroke continues over the anterior
stretch the posterior hip capsule and surround
border of the greater trochanter, encircling the
ing periarticular soft tissues. A typical patient
greater trochanter and ending posteriorly. (3)
presentation is a middle-aged man with a flat
Direct technique over the iliotibial band. The
tened lumbarl ordosis, hypermobile lumbar facet
therapist's bottom hand stabilizes the patient's
joints, tight hamstrings, and restricted posterior
leg at the knee. The elbow contacts the ITB and
hip connective tissues. With little pelvic contri
the stroke proceeds from distal to proximal di
bution to forward bending, the lumbar spine
rectly over the ITB and greater trochanter. Both
becomes progressively more hypermobile and
hands may also be used to stroke directly over
symptomatic. Facet as well as disc degeneration
the [TB. The above techniques may be repeated
may result as a long-term effect. The focus of
with the patient holding the leg in hip flexion
treatment lies in establishing a balance between
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Figure 8--61
the low back and the hip in forward bending. To
Execution: With the patient in the therapist's
accomplish greater movement balance, the peri
firm grasp, the patient is asked to push the leg
articular structures of the hip must be mobil ized
into the therapist's chest. The patient is then
before movement reeducation can begin.
asked to release the contraction and the therapist
The technique of choice to prepare the tissue
"takes up the slack," moving the hip into further
for this procedure is the paratrochanteric tech
flexion-adduction. Occasionally, the patient will
nique described above. Paratrochanteric mobi
complain of anterior hip pain while the tech
lization will prepare the tissue for aggressive
nique is being executed. A possible explanation
stretching.
is that the anterior capsule may be pinching with
Patient position: The patient is in the supine position with the hip flexed and adducted.
the extreme amount of flexion being applied to the hip. An alternate execution of the technique
Therapist position: The therapist stands over
is to bring the hip out of extreme flexion and
the patient, facing the patient. The patient's leg
to emphasize the technique's adduction com
is placed so it is in contact with the therapist's
ponent. The therapist stabilizes the pelvis at
chest. The knee should approximate the thera
the ASJS with the top hand. The leg is grasped with the bottom arm, and adducted with a slight
pist's axillary or pectoral area. Hands: Both hands are grasping the treatment
externaI rotation component. The addition of ex
either side of the table, "strapping" the
ternal rotation and the increase in adduction will
patient to the table, or one hand can grasp the
compensate for the loss of flexion and regain the
patient's leg for added stability.
tissue tension lost with the loss of hip flexion.
table
011
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Hamstrings (Figures 8-62, 8-63A,B; 8-64,
207
or with the elbow. Contact is first made on the
and 8-65A,B)
distal aspect of the hamstrings.
Purpose: The purpose of these techniques is
the therapist's shoulder, firm pressure is applied
Execution: With the patient's leg relaxed over to mobilize the hamstrings in preparation for
with the fist or elbow to the distal aspect of the
aggressive stretching technique. The hamstrings
hamstrings. The hamstrings are stroked longitu
may be restricted in a longitudinal direction,
dinally, distal to proximal to the insertion at the
medial lateral direction, or in a diagonal plane.
ischial tuberosity. If the restriction lies in the
By identifying and treating lesions in the appro
proximal hamstring near the ischial tuberosity,
priate plane and position, specific restrictions
the hip may be flexed beyond 90 degrees.
may be released and flexibility of the hamstrings may be increased prior to stretching.
If a specific restriction is identified, the elbow may be used to apply a sustained pressure on the
Patient positioll : Supine with the hip and
restriction. The stroke should be stopped when
knee flexed approximately 90 degrees, and rest
the restricted area is reached. The pressure should
ing over the shoulder of the therapist. Therapist position: The therapist is seated
be sustained for an appropriate period until changes in the restriction are palpable, or until it
on the treatment table facing the patient.
is obvious that no change is going to occur.
Longitudinal Stroking
Splay Technique
Hands: Contact with the patient is made with
Hands: The hands gently grasp the middle
the "fist" (i.e., with the MCP joints of the hand),
aspect of the lower extremity so the thumbs are
Figure 8-62
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Figure 8-64
in contact with the distal portion of the ham
ries. Proximal injuries can be more serious, more
strings. The thumbs approximate one another at
recurring, and more difficult to treat than mid
the medial aspect of the lower extremity. Execution: Deep pressure is applied medially
belly lesions. The proximal injury can some times act similar to an "epicondy litis," where
by the thumbs, as the hamstrings are stroked
the injury is in the tenoperiostial junction. By
longitudinally from proximal to distal. As the
isolating a stretch to the proximal hamstring, the
distal portion of the hamstrings is reached, the
therapist can more effectively aid in the remod
stroke direction changes to medial/lateral, splay
eling of the proximal tissues.
ing or pulling the hamstrings apart. The thumbs do not slide over the hamstring muscle bellies.
Patient position: Supine, with the leg resting on the therapist's shoulder.
Rather, the thumbs are grasping the muscle bel
Therapist position: The therapist stands on
lies and pulling them apart. This technique can
one leg and places the other leg on the treatment
be thought of as a specific form of muscle play
table. The patient's leg is placed comfortably on
for the distal hamstrings.
the therapist's shoulder. Hands: The therapist places his/her hands
Stretch of Proximal Hamstring (Figure 8-66) Purpose: The purpose of this technique is
around the knee of the patient. This will help to provide a traction force and control the amount of knee flexion.
to isolate a stretch of the proximal hamstring.
Execution: The therapist first performs a
Hamstring injuries generally fall into two basic
straight leg raise until the patient feels a mild
categories: mid belly injuries and proximal inju
hamstring stretch. The patient is then asked to
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Figure S-66
localize the stretch. If the stretch is felt in the
the insertion of the hamstrings into the ischial
distal or mid belly of the hamstring, the therapist
tuberosity). Healing and restoration of proper
allows the patient's knee to bend slightly. Keep
function may be facilitated with a deep cross
ing the slight bend constant, the therapist con
frictional type of mobilization over this area.
tinues to tlex the hip until the patient again
Patient position: Prone.
feels the stretch. At this point, the patient should
T herapist position: Standing over the patient
feel the stretch more proximally because the
in a diagonal position.
distal aspect has been slackened and the proxi
Hands: The f ingertips or the tips of the
mal aspect has been further stretched. The thera
thumbs may be used for this technique. The most
pist repeats the process, allowing the knee to flex
stable position of the hands for application of
slightly more, and then tlexing the hip further.
the technique is the four-finger position previ
The process is repeated until the stretch is felt
ously described in the iliac crest technique. The
closest to the origin at the ischial tuberosity. To
fingers are placed over the insertion of the ham
further localize the stretch, a slight traction force
strings, just distal to the ischial tuberosity.
can be placed on the leg while stretching. The
Execution: The fingers palpate deeply unti I
traction serves to pull slightly more on the origin
firm pressure is placed on the hamstring inser
of the muscle at the ischial tuberosity.
tion and junctional zone. The fingers are os cillated medial to lateral consistent with the
Cross-Friction Ischial Tuberosity-Greater Trochanter (Figure 8-67)
concept of cross-friction. The f ingers are then moved proximally onto the ischial tuberosity. The periosteum of the ischial tuberosity may be
Many hamstring injuries and/or
also damaged or dy sfunctional. The same medial
dysfunctions occur at the junctional zone (i.e.,
to lateral movement is applied over the ischial
Purpose:
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Figure 8-67
tuberosity. This technique should be applied ag
Therapist position: The therapist stands over
gressively to the point where it is seminoxious
the patient in a diagonal position. If the therapist
to the patient.
chooses to extend the hip manually (as opposed to positioning the hip with pillows), the lower extremity is grasped with the bottom hand, leav
Fascial Plane between Ischial Tuberosity and
ing the top hand free to execute the technique. If
Greater Trochanter (Figures 8-68 and
the lower extremity is not held by the therapist,
8-69)
both hands should be used in executing the tech llIque.
Purpose: A fascial plane or connective tissue sheath exists in the area between the ischial tu
Hands: The hand position described in the
berosity that, when restricted, may limit hip ex
iliac crest release technique is used. Both index
tension. Since the greater trochanter moves an
and ring fingers approximated together provide
teriorly with hip extension, restrictions in this
the stability necessary to perform a technique at
fascial sheath may limit hip extension. The area
this depth. The pressure is exerted through the
is not usually painful and rarely tender, but may
fingertips.
create hip or lumbar dysfunctions if not exten
Execution: The direction of force is primarily in a posterior to anterior direction, with a slight
sible. Patient position: The patient lies in the prone
horizontal component. As in the iliac crest re
position. The hip may be held or positioned in
lease technique, an osci lIatory motion is per
the extended position in order to add tension to
formed repetitively in an anterior direction. In
the tissue.
order to apply tension to the fascial sheath, the
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213
Figure 8-68
Figure 8-69
hip may be extended by the therapist or posi
thumb of the top hand is placed on the superior
tioned on pillows. Following the technique, the
border of the greater trochanter. The superior
hip may be stretched into extension as a fol
border of the greater trochanter is palpated by
low-up technique.
gently internally and externally rotating the leg with the bottom hand. The thumb is placed in the soft tissue above the lateral aspect of the greater
Friction of Piriformis Insertion (Figure
trochanter. As the hip is gently internally and
8-70)
externally rotated, the thumb moves distally until
Purpose: This technique helps prepare the
arrival at the first bony prominence. The promi
piriformis for direct contact on the muscle belly
nence is the superior border of the greater tro
if the piriformis muscle is reactive and cannot
chanter.
tolerate direct pressure, or if direct pressure is
Execution: Once in position, the thumb does
not resulting in any palpable changes or changes
not move. The technique is applied by midrange and pain-free rotation of the hip. As the rotation
in symptoms. Patient position: Prone.
occurs, the thumb will come on and off the
Therapist position: The therapist stands at
greater trochanter. A fairly deep pressure is ap
the patient's side at the level of the hip.
plied, but only to patient tolerance. Care must be
Hands: The bottom hand grasps the leg at the ankle and bends the knee to 90 degrees. The
taken not to take the hip into excessive internal rotation if the piriformis is very reactive.
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MYOFASCIAL MANIPULATION
Figure 8-70
Piriformis Release in Prone (Figures 8-71, 8-72, and 8-73) Purpose: This technique is used in cases where the dysfunction lies in a hypertonic mus cular state of the piriformis rather than in a connective tissue dysfunctional state. The tech nique is primarily designed to decrease underly ing muscle tone, and secondari Iy to affect con nective tissue. The technique is performed in a graded fashion depending on the overall pain and reactivity of the piriformis muscle. The issue is raised here whether the "pirifor mis syndrome" exists or not. Some say that the syndrome does not exist, but the average clini cian, in practice, cannot deny the involvement of the piriformis or manifestations of piriformis hypertonicity. The clinical reality is that "piri formis syndrome" in a pure sense is rare, but piriformis involvement related to otber dysfunc tions is seen quite often.
Figure 8-71
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Figure 8-72
Figure 8-73
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MYOFASCIAL MANIPULATION
Patient position: Prone.
tolerance will increase, allowing the next varia
Therapist position: The therapist stands at
tion of the technique. (2) The same sustained
the patient's side, perpendicular to the patient.
pressure may be applied to the piriformis using
Hands: The hand position in the technique
the elbow. The elbow allows for more localized
will vary depending on the reactivity of the
pressure to be applied. The same principle ap
muscle and the tolerance of the patient. The gen
pi ies in that as the piriformis releases and as the
eral progression of the technique goes through
pain decreases, more pressure can be applied.
three different hand positions:
(I) palm of the
(3) Finally, the PIP joints of both hands may be
(2) elbow, and (3) PIP joints of both
used to apply even more localized pressure. If
hand, hands.
Execution:
the patient is able to tolerate it, a gentle oscilla
(I) Using the palm of the hand,
the therapist applies gentle pressure at mid but
tory motion can be performed to inhibit further and mechanically mobilize the piriformis.
tock, which is the general location of the mid belly of the piriformis. The leg is gently exter nally rotated to put the piriformis on slack. The pressure is gently increased until the level of the
Transverse Muscle Play of Hamstrings (Figures 8-74 and 8-75)
piriformis is reached. A sustained pressure is
Purpose: As described for the quadriceps,
applied, provided the pressure does not create
the concept of transverse muscle play can be
an increase in tone. As the piriformis relaxes,
used to mobilize the fascial sheath surrounding
more pressure can be progressively applied. If
the hamstrings to provide more space for the
the piriformis releases, even partially, the patient
hamstrings to contract.
Figure 8-74
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217
Figure 8-75
with the palm of the top hand. If a restriction is
Patient position: Prone. Therapist position: The therapist stands at the patient's side at the level of the mid femur.
felt in a posterior-anterior direction in the medial hamstring, the force may be applied in a poste
Hands: The bottom hand grasps the ham
rior to anterior direction, again with the palm of
strings and femur distally, just proximal to the
the hand. Remember, restrictions can occur in
knee joint. The top hand grasps the hamstrings
any direction or plane, and the technique direc
anywhere on the muscle belly where a restriction
tion should be modified to treat the restriction
is identified. The palm of the hand is initially
adequately.
placed over the lateral hamstring, just posterior to the ITB. Both hands may also be used to gain a greater contact surface. Execution: Grasping the distal aspect of the
Transverse Muscle Play of Adductor Muscles (Figure 8-76)
hamstrings with the bottom hand, the top hand
Purpose: As previously described in concept,
shears the hamstrings in a lateral to medial direc
the technique is designed to mobilize the sur
tion, with major force being appl ied through the
rounding fascial sheaths of the adductor mus
palm of the hand. The hand does not slide over
cles. This is an excellent preparatory technique
the skin. The technique may also be performed
for adductor stretching.
in a medial to lateral direction if the restriction
Patient position: Prone.
is present in that direction. The therapist should
Therapist position: The therapist stands at
approach the patient from the other side of the
the patient's side, holding the leg with the knee
table so a medial to lateral force may be applied
bent at 90 degrees.
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MYOFASCIAL MANIPULATION
Figure 8-76
Therapist position: The therapist stands at
Hands: The palm of the top hand is used to apply the transverse pressure on the adductor
the level of mid tibia.
group.
Hands: The bottom hand grasps the distal
Execution: The palm of the hand makes con
aspect of the gastrocnemius-soleus muscle group
tact with the adductor muscles and partially with
just proximal to the Achilles tendon. The top
the medial hamstring. Pressure is applied toward
hand grasps the gastrocnemius-soleus muscle
the treatment table to create the bending move
group at the level of the muscle where the re
ment of the adductors.
striction is identified. As before, both hands may be used to attain a more optimal "bend" in the muscle.
Transverse Muscle Play of Gastrocnemius
Execution: Grasping the distal aspect of the
soleus (Figures 8-77 and 8-78)
gastrocnemius-soleus muscle group firmly with
Purpose: The fascial sheath surrounding the
the bottom hand, the top hand shears the muscle
gastrocnemius-soleus muscle group is mobilized
from lateral to medial with the palm of the
in order to increase extensibility and allow for
hand. The hand does not slide over the skin. SI id
more efficient contraction of the muscle group.
ing over the skin modifies the technique into a
Longitudinal stretching is also facilitated after
pure massage technique. As with the other tech
application of this technique.
niques, the technique may be performed medial
Patient position: Prone.
to lateral, or posterior to anterior, depending
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Figure S-77
Figure S-78
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220
MYOFASCIAL MANIPULATION
on the direction of the restriction. The clinician
Patient position: Supine.
should be sensitive to restrictions and follow them with the technique, since no arthrokine
Therapist position: Standing or sitting at the foot of the table.
matic rules apply. The success of the treatment
Hands: The thumb pushes off the border of
often will depend on whether or not the direction
the tibia, creating a "wedge" between the bone
of application was properly identified.
and the approximating soft tissue. The thumb is positioned either anterior or posterior, depend
Bony Clearing of the Tibia (Figure 8-79)
ing on the compartment that is affected. Execution: A small amount of lubrication is
Purpose: The purpose of this technique is
used. The thumb drives a wedge between the
to clear fascia from the anterior and posterior
bone and the approximating soft tissues distally.
compartments as they adhere to the tibia. Many
The thumb then moves proximally, continuing
lower kinetic chain problems, especially in ath
to stay in the wedge, and also continuing to ap
letes participating in baJJistic sports (running,
proximate the tibia. In compromised areas, the
basketball, soccer etc.), develop fascial adhe
wedge will either not be as deep, or have adhe
sions related to "shin splints." The bony clearing
sions that make the wedge nonexistent. These
techniques are effective in mobilizing the fascia
are adhesions that need to be mobilized.
as it adheres to the tibia. This technique can
For the posterior side, the knee may be bent,
be used for both anterior and posterior compart
and the foot placed on the table to allow for
mental sy ndromes.
slightly more slack in the tissues.
Figure 8-79
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Lateral Fascial Distraction of the Tibia
221
Execution: The therapist puts a medial to
(Figure 8-80)
lateral pressure on the gastrocnemius-soleus
Purpose: The purpose of this technique is to stretch the posterior compartment fascia that is adhered to the tibia laterally. As with the tech nique above, this technique will be effective in the treatment of lower leg compartment syn dromes, shin splints, etc. that are caused by ex cessive ballistic lower kinetic chain activity. Patient position: Prone with the knee flexed to 90 degrees and plantarflexed slightly.
muscle group, pulling it away from the tibia. The technique starts in the mid belly, but can move proximal or distal, depending on the loca tion and severity of the restriction. The therapist carefully attempts to push the muscle laterally into the plastic range, keeping an eye on patient reaction. This technique can be quite painful if the fascia along the tibial/gastrocnemius border is compromised.
Therapist position: Seated on the side of the table at the patient's lower leg. Hands: The lateral hand is placed distally and will be used as a counter lever. The palm
Cross Friction of the Gastrocnemius-soJeus Musculotendinous Junction (Figure 8-81)
of the medial hand is placed on the mid belly
Purpose: Many patients involved in ballistic
of the gastrocnemius-soleus muscle group as
type sport activities develop fascial thickening
close to the tibia as possible without actually
in the musculotendinous junction of the gastroc
contacting it.
nemius-soleus muscle group. This phenomenon
Figure 8-80
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222
MYOFASCIAL MANIPULATION
Figure 8-8\
may occur with or without muscular shortening.
sues. A stretch can immediately follow the ap
The purpose of this technique is to mobilize
plication of this technique.
the musculotendinous junction and the fascia immediately surrounding it. Patient position: Prone with the knee flexed
TECHNIQUES FOR THE THORACIC/UPPER THORACIC SPINE
to 90 degrees and the foot plantarflexed moder
AND UPPER EXTREMITY
ately. Therapist position: Seated at the side of the table at the lower leg of the patient.
Lateral Elongation of Upper Thoracic Area (Figures 8-82, 8-83, 8-84, and 8-85)
Hands: The hands gently grasp the lower leg so that the f ingers come to rest directly over
Purpose: The purpose of this technique is
the musculotendinous junction of the gastrocne
elongation of the soft tissue structures of the
mius-soleus muscle group.
upper thoracic area (posterior and anterior). The
Execution: The therapist applies firm pres
technique is especially applicable for patients
sure over the musculotendinous junction with
with protracted shoulder girdle complexes and
the fingers and applies a firm cross frictional
forward-head postures. After application of the
movement across the junction, watching for
technique, the shoulder girdle and upper tho
patient response. This area can be exquisitely
racic spine assume a more relaxed and retracted
tender in active patients participating in ballistic
position. This technique should be used before
type sporting activities. Note that the tissue is
attempting postural reeducation techniques. I ni
held in the shortened range. Again, this is to
tially, the clinician emphasizes both the anterior
create slack and allow for access to deeper tis
and posterior structures of the upper thoracic
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A tlas a/Therapeutic; Techniques
Figure 8-82
Figure 8-83
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224
MYOFASCIAL MANIPULATION
Figure 8-84
area. As the technique progresses, more empha sis is placed on the anterior structures. Three alternate hand placements are described, each of which progresses into deeper tissues of the anterior chest. Patient position: The patient is supine with
the head lying flat on the treatment table. Therapist position: The therapist is seated
at the head of the table, at a 45-degree angle to the patient. Anterior-Posterior Techl1ique Hands: One hand is placed posteriorly, so
that the fingertips are just lateral to the spinous processes of the upper thoracic spine. The hand should be resting superior to the spine of the scapula. The other hand is placed infraclavicu lariy, with the fingertips just lateral to the ster num. Execution: The primary force of the tech
nique comes from the fingertips, even though Figure 8-85
contact is maintained through the palm of the
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Atlas afTherapeutic Techniques
hands. The stroke begins medially and pro
form. The depth of penetration is to
gresses laterally, as the therapist pulls the hands
the intercostal spaces.)
toward
the glenohumeral joint.
Once the stroke
is completed, the hands are quickly placed in the start position again and the stroke is repeated. The pressure is placed through each hand and is moderate in depth.
225
Therapist position: Standing, facing the pa tietH. Hands: Contact will be made with the thumb and PIP of the index
finger
as shown
in Figure
8-2. Execution: The stroke begins medially in the
Deep Anterior Technique
Hands: To approximate deeper structures, both hands are placed anteriorly. One hand is placed over the other, again over the infracla vicular area. The fingertips are just lateral to the sternum.
intercostal space of the I st and 2nd ribs. The intercostal space is followed
laterally until no
longer palpable (a short distance). The stroke is performed in intercostal space of ribs 2 and 3 (in men in the intercostal space of ribs 3 and
4).
Execution: The stroke is applied through the fingertips from medial to lateral. Deeper pres sure is applied through the hands and f inger tips.
Unilateral Posterior/Anterior Articulation of First Rib (Figure 8-86) Purpose: This technique is technically a joint
Rib Splaying: Ribs 1-3 (This aspect of
mobilization technique, but blends in well with
the technique is the most aggressive
the above techniques, especially if rib dysfunc-
Figure 8-86
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MVOFASCIAL MANIPULATION
tion is present. With increased myofascial tone
too medial, the spinous process will be palpated.
in the subclavicular area, the upper thoracic area,
The top hand palpates just lateral to the first
and the scalenes, joint mechanics in the first rib
sternocostal articulation. The clinician may first
can easily become dysfunctional. The purpose
palpate the sternoclavicular junction with the
of th is technique is not to change the position of
middle finger and slip the finger just caudal and
the first rib, but to increase mobility.
lateral, which is just lateral to the first sterno
Patient position: The patient lies supine with
costal junction.
the head flat on the treatment table.
Execution: The clinician applies a moderate
T h erapist position: The therapist is seated
oscillatory
movement
anterior/posterior
and
posterior/anterior. Enough pressure should be
at the head of the table, at a 45-degree angle to
applied to create movement in the first rib. The
the patient.
rate of oscillation should be 2 to 3 oscillations
Hands: The bottom hand (which is usually
per second.
the hand closest to the patient) palpates the pos terior aspect of the first rib near the costotrans verse junction. This can be accomplished by
First Rib Shoulder Depression Technique
first palpating the posterior aspect of the upper
(Figure 8-87)
trapezius. The clinician then continues caudally and medially until bone is palpated. This bone
Purpose: This technique is largely inhibitory
is the first rib. If the finger is too lateral, the
in nature, although the first rib is being gently
border of the scapula is palpated; if the finger is
articulated. The rhythm created by the rib and
Figure 8-87
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Atlas a/Therapeutic Techniques
227
shoulder articulation provides a form of bio
spinous process will be palpated. The other hand
feedback for the patient, and can indicate to
is placed on the superior aspect of the shoulder
the clinician and patient the degree of inherent
joint complex.
relaxation or tension in the upper thoracic area.
Execution: Execution of this technique in
This subtle form of biofeedback releases tone in
volves two separate movements occurring si
the upper thoracic area, preparing the tissue for
multaneously: (I) With the bottom hand, the
deeper or more specific my ofascial work, and
rib is articulated anteriorly;
facilitates joint mobilization and manipulation.
hand, the shoulder is depressed caudally. The
Patient position: The patient lies supine with
the head flat on the treatment table. Therapist position: The therapist is seated
(2) with the other
two motions occur simultaneously in a slow de liberate rhythm (approximately
2 oscillations
per second). During execution, the patient may
at the head of the table at a 45-degree angle to
become aware of increased tone, tension, or
the patient.
holding patterns, and may spontaneously relax.
Hands: The hand closest to the patient pal
pates the posterior aspect of the first rib as de
The tissue is then prepared for other techniques
as necessary.
scribed in the previous technique. Palpating the posterior aspect of the upper trapezius, the clini cian then continues caudally and medially until bone is palpated. This bone is the f irst rib. If the
Bilateral Upper Thoracic Release (Figure 8-88)
finger is too lateral, the border of the scapula
Purpose: The purpose of this technique
is palpated, and if the finger is too medial, the
to release the deep paravertebral musculature
Figure 8-88
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MYOFASCIAL MANIPULATION
of the upper thoracic spine. The technique is
firm pressure applied through the layers of
accomplished in two distinct maneuvers. The
muscle onto the deep muscle provides adequate
first is a moderate depth, cephalic-caudal move
force to release deep underlying tone. The clini
ment, and the second is a deep anterior/posterior
cian should exercise caution in guarding his or
movement.
her hands, since this technique requires max
Patient position: The patient is supine with
imum force through the fingers. Fatigue will occur quickly and the clinician should proceed
the head flat on the table. Therapist position: The therapist is seated at
to another technique. Efficiency and ease of ap
the head of the table directly behind the patient.
plication of technique are essential for effective
Hands: The hands slide onto the paraverte
technique delivery. Any strain or inefficiency
bral musculature of the upper thoracic spine
on the clinician's part will be transferred to the
(to approximately T4). The f ingers make firm
patient, and reduce the potential effect of the
contact with the paravertebral musculature.
technique.
Execution: The first maneuver is a gentle ce phalic-caudal oscillation with moderately deep pressure on the upper thoracic paravertebrals. The oscillations should be performed at a rate of approximately 2 per second. In the second ma
Pectoralis Major Muscle Play-Pectoralis Minor (Figures 8-89, 8-90, and 8-91) Pectoralis Major
neuver, the direction of the movement changes
Purpose: In the forward-head posture, the
from cephalic-caudal to anterior articulations.
pectoralis major and minor become restricted
While this Jlla y be considered anterior/posterior
and shortened. This creates an inability to stand
Jllobilization of the upper thoracic spine, the
or sit erect without significant effort from the
Figure 8-89
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Figure 8-90
Figure 8-91
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MYOFASCIAL MANIPULATION
patient. Before postural reeducation can occur effectively, the pectorals must have adequate extensibility. Patient position: The patient is in the supine position. The shoulder is flexed 90 to 120 de grees. Therapist position: The therapist is standing over the patient at a 45-degree angle to the pa tient. The therapist may place a leg on the table to allow the patient's arm to rest in a relaxed position. Hands: The thumbs slide underneath the pec toralis major, and the hands grasp the muscle firmly between the thumbs and f ingers. Execution: The technique can be likened to the garden hose analogy in which a garden hose
Pectoralis Minor Hands: With one hand maintaining the same position as described above, the thumbs are moved posteriorly until in contact with the pec toralis minor. The muscle may be difficult to palpate, but if the ribs are palpable, the muscle is being palpated. Execution: The thumbs are pressed onto the pectoralis minor, and a gentle "cross-friction type" technique may be performed. Care must be taken because the pectoralis minor area is very tender even if not dysfunctional. Seated Pectoral Anterior Fascial Stretch (Figures 8-92 and 8-93)
is being bent. The pectoralis muscle is grasped
Purpose: The purpose of this technique is to
firmly between the thumbs and fingers and is
stretch the anterior structures (fascia, pectoralis
gently lifted or bent away from the thorax. The
major, minor) to allow for more erect posture.
movement can be a sustained movement or an oscillatory movement.
Patient position: Seated, with hands behind head, or with elbows straight.
Figure 8-92
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23 I
Figure 8--93
Therapist position: The therapist is standing
outside hand on the rib cage is pushed caudally
behind the patient with either his or her hip or
to further engage the anterior superficial fascia.
knee stabilizing the thoracic spine and acting as a fulcrum. A pillow should be placed between the patient and the therapist.
Subscapularis (Figures 8-94 and 8-95)
Hands: Bilateral Stretch: The hands will grasp the middle part of the upper arm. Unilat
Purpose: The subscapularis is generally not
eral Stretch: The inside hand of the therapist
an area reported by the patient to be painful.
grasps the upper part of the patient's arm. The
The area may be signif icantly restricted and
outside hand is place on the midd Ie part of the
extremely tender to palpation, however. Since
antero-lateral rib cage.
the internal rotators are held in a shortened posi
Execution: Bilateral Stretch: The pressure
tion in the forward-head protracted shoulder
is applied in a lateral, posterior, and cephalic
posture, the subscapularis and the surrounding
direction for maximum elongation. The patient
myofascia become restricted, acting as barriers
is asked to breathe deeply to increase elongation
to efficient postural reeducation.
anteriorly. Unilateral Stretch: Using the inside arm and
Patient position: The patient is in the supine position with the shoulder flexed from 90 to
body, the patient's arm is pulled posteriorly and
170 degrees, depending on the restriction and
superiorly, stretching the anterior fascia. The
comfort level of the patient.
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MYOFASCIAL MANIPULATION
Figure 8-94
Figure 8-95
Therapist position: The therapist is standing
If fascial restrictions exist, the stroke may be
at the head of the table at a 45-degree angle to
lengthened to include the lateral fascial sheaths
the patient. The patient's arm is grasped by the
between the scapula and the ilium.
therapist close to the therapist's body to provide a slight traction-distraction force.
(2) In the same position, the thumb is used to stroke caudally. Thumb placement is more spe
Hands: The hands may be placed on the pa
cific, being located on the anterior surface of the
tient in three different ways, depending on how
lateral border of the scapula. The arm is again
aggressively the therapist wishes to deliver the
distracted and the thumb moves caudally over
technique. The palm of the hand, the thumb, or
the anterolateral border of the scapula toward
the fingertips may be used in order from least
the inferior angle.
aggressive to most aggressive.
(3) finally, specific restrictions, either in the
(1) The patient's arm, which is in
lateral aspect of the subscapularis or in the fas
some degree of flexion, is gently distracted. The
cial sheath between the scapula and the thorax,
Execution:
palm of the other hand is placed on the lateral
may be treated using the f ingertips. The tips
border of the scapula, as close to the glenohu
of the index, middle, and ring f ingers palpate
meral joint as possible. As gentle distraction is
the anterior surface of the lateral scapula and
placed on the arm, the palm strokes caudally
gentle pressure is applied. The pressure may be
and toward the inferior angle of the scapula.
sustained or slow oscillatory in nature.
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Anterolateral Fascial Elongation (Figures
The direction of the force may be changed, and directed more diagonally toward the contralat
8-96 and 8-97)
eral ASIS or into a more cardinal plane direc Purpose: The anterior fascial planes are often
tion toward the ipsilateral ASIS. The shoulder
restricted, especially in the slumped posture or
should be in as much flexion as possible to allow
in various shoulder pathologies. The purpose
for maximal stretch of the connective tissues.
of this technique is to elongate the superficial
The use of skin lubricants for this technique is
fascial sheaths of the anterior thorax.
discouraged.
Patient position: The patient is in the supine position, with the shoulder flexed 120 to 170 degrees. Therapist position:
The
therapist
stands
Anterolateral Fascial Elongation with Rotational Component Purpose: If the myofascia is restricted
10
a
behind the patient, grasping the patient's arm
rotational direction, the above technique may be
and providing a distraction of the arm.
modified as follows.
Hands: The entire surface of the hand is placed just below the nipple line. (Note: Male therapists treating female patients should care fully drape the patient and should stay well below breast tisslle.) Execution: As the arm is tractioned into flex
Patient position: The patient is in the sidely ing position with the spine in Therapist position:
a
rotated position.
The therapist
stands
behind the patient. Hands: In the same position as described above.
ion, a traction force is applied to the superficial
Execution: The therapist distracts the shoul
fascia, first in the direction of the umbiliclls.
der and simultaneously provides a rotational
Figure 8-96
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MYOFASCIAL MANIPULATION
Figure 8--97
force on the spine. The other hand, which is positioned on the anterior myofascia, is moved
Therapist position:
The therapist stands
facing the patient with the pillow pressing
toward the umbilicus or the contralateral ASIS.
against the body. There should be a "snug" fit
The myofascia of the anterior chest, axilla, and
between the patient, pillow, and therapist.
abdomen will be effectively stretched in this position.
Medial Border
Hands: The top hand is lightly placed on the Scapular Framing (Figures 8-98, 8-99, 8-100,8-101, and 8-102)
shoulder and the bottom hand is placed just off the medial border of the scapula, between the scapula and the thoracic spinous processes.
P urpose: This technique is designed to mo
Execution: The shoulder is slightly retracted
bilize myofascial restrictions on all three bor
to slacken the tissue. As the shoulder is being
ders of the scapula. These techniques should
retracted, the fingers of the bottom hand stroke
routinely be performed on scapulothoracic prob
from cephalic to caudal along the length of the
lems, problems of the upper thoracic and mid
medial border of the scapula.
thoracic spine, cervical problems, and certain shoulder problems.
Upper Border
Patient position: The patient is in the sidely
Hands: The fingertips of both hands are
ing position with a pillow between patient and
placed over the upper trapezius muscle medially
therapist. The patient's arm should be resting
at the cervicothoracic (CT) junction. Alternately,
comfortably on the pillow.
the therapist may be at the head of the table and
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Figure 8-98
Figure 8-99
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Atlas afTherapeutic Techniques
237
Figure 8-102
apply a caudal force, gently stretching the upper trapezius. 'Execution: With firm pressure, the f inger tips stroke the upper border of the scapula and upper trapezius muscle from proximal to distal (i.e., from the CIT junction to the glenohumeral joint). A gentle stretch is applied with the palms of the hand as the scapula is stroked.
ing position but is asked to grasp the top of the treatment table with the hand. This flexes the shoulder and tightens the myofascia in the lateral border of the scapula. Execution: As the patient holds the treatment table, the palm of the therapist's top hand firmly strokes the lateral border of the scapula caudally. The technique may continue toward the ilium if fascial restrictions are encountered.
LateraL Border
Hands: The palm of the bottom hand is placed over the shoulder joint to stabilize the area. The palm of the top hand is placed over the lateral border of the scapula.
Scapular Mobilization (Figures 8-103 and 8-104) P urpose: Once the scapular soft tissues have been prepared from the previously described
Execution: With the bottom hand stabilizing
technique, the scapula may be mobilized off the
the shoulder, the palm of the top hand strokes the
thoracic cage. This allows for more aggressive
lateral border of the scapula caudally with firm
stretching of the scapulothoracic myofascia.
pressure. Specific finger pressure may be ap plied if trigger points or restrictions are found. ALternate Teclllliquefor LateraL Border. Pa
tient position: The patient remains in the sidely
Patient position: The patient is in the sidely ing position with a pillow between the patient and the therapist, and the patient's arm resting comfortably on the pillow.
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Therapist position: The therapist stands at
the patient's side. Hands: Two variations of this technique may
be pelformed: (I) the top hand grasps the shoul
239
of the scapula, and the therapist's shoulder stabi lizing anteriorly, the scapula is lifted off the tho racic cage. This technique is successful with pa tients who are larger in size than the therapist.
der joint anteriorly. The fingers of the bottom hand slide onto the undersurface of the scapula.
(2) In the alternate technique, the bottom hand slides under the arm and around the scapula until
Thoracic Rotational Laminar Release (Figure
8-105)
the fingers can slide onto the scapula's under
Purpose: Previous techniques emphasize the
surface. The top hand also contacts the scapula
scapulothoracic and scapulohumeraI relation
so the fingers can slide onto the undersurface
ships and musculature. This technique pene
of the scapula. The shoulder and chest of the
trates to the depth of the paravertebral muscles,
therapist contact the patient's shoulder anteriorly
mobilizing the muscles and, to a certain extent
for stability.
the joints, into a rotational direction.
Execution: (I) Once the fingers of the bottom
Patient position: The patient is in the sidely
hand have grasped the medial border of the scap
ing position similar to the position described
ula, the scapula and shoulder girdle complex
above.
is lifted off the thoracic cage, resulting in an
Therapist position: Standing facing the pa
aggressive stretch of the scapulothoracic myo
tient with a pillow between therapist and pa
fascia. This technique succeeds if the patient is
tient.
smaller than or equal in size to the therapist.
Hands: The top hand is placed over the ante
(2) With both hands grasping the medial border
rior aspect of the glenohumeral joint. The fin-
Figure 8-105
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240
MYOFASCIAL MANIPULATION
gers of the bottom hand are placed in the scapu
biceps in preparation for stretching or strength
lothoracic area similar to the medial scapular
ening. Certain low grade peripheral entrapment
framing described above.
neuropathies respond well when the biceps is
Execution: The primary distinction between
stretched medial to lateral. This seems to free up
this technique and medial scapular framing is
the nerves as they pass through just posterior and
in the depth of penetration and the rotational
medial to the biceps. Certain proximal humeral
component imparted to the thoracic spine. To
fractures cause the binding down of the biceps,
execute the technique, the fingers of the bottom
and this technique will be beneficial for this type
hand stroke cephalic to caudal with deep pres
of condition as well.
der complex and rotating the thoracic spine.
Patient position: Supine. Therapist position: The therapist will be out
sure, while the top hand is retracting the shoul The fingers act as a fulcrum of rotation for the
side the patient's arm if the treatment goes from
thoracic spine. If segmental restrictions are felt
lateral to medial, and inside the patient's arm if
as the technique is being performed, the stroke
the technique is applied medial to lateral.
may be stopped and the restricted segment may
Hands: The heel of the hand is placed lateral to the muscle if the technique is going lateral
be oscillated into rotation.
to medial, and medial if the technique is going
Transverse Fascial Stretch of the Biceps (Figure 8-106)
medial to lateral.
Execution: The heel of the hand pushes the biceps in a transverse direction (lateral to medial
Purpose: The purpose of this technique is
or medial to lateral) until all the "slack" is taken
to increase the medial/lateral mobility of the
out of the muscle. Once the tissue is at the end
Figure 8-106
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A lias of Therapeutic Techniques
241
of the elastic range, the therapist pushes into the
fully extended and the radioulnar joints are fully
plastic range to get the final stretch. The stretch
pronated. About the time the patient begins to
is held 3-5 seconds, then repeated.
feel a stretch, a slight traction force is placed on the arm. The therapist should ask the patient
Biceps Stretch (Figure 8-107) Purpose: The purpose of this technique is to apply a focused stretch of the biceps muscle. Patient position: The patient is supine with
to tell when a moderate stretch is felt. Because of the long lever arm, it is difficult to tell when the biceps muscle/tendon is in a plastic stretch. After a 5-10 second hold, the arm is released and the stretch may be repeated.
the shoulder slightly off the table. If a less ag gressive version of the technique is desired, the patient may be placed in the sidelying position to accomplish a lighter version of the stretch. Therapist position: The therapist is seated level with the patient's neck or shoulder.
Forearm "Ironing" (Figure 8-108) Purpose: As previously described for the lumbar erector spinae, the "ironing" type tech niques are useful to decrease underlying tone
Hands: The top hand is placed over the
and move fluid. If an area is particularly tender,
distal triceps so the fingers and thumb can wrap
longitudinal stroking is always less painful than
around the supracondylar space. The bottom
cross stroking. This technique is effective for
hand is placed on the distal arm, just proximal
a wide array of elbow, forearm, wrist, or hand
to the wrist.
dysfunctions. While not shown, the technique
Execution: The therapist gently extends the patient's shoulder. At the same time the elbow is
can be applied to the flexor as well as extensor surfaces of the forearm.
Figure 8-107
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242
MYOFASCIAL MANIPULATION
Figure 8-108
Patient position: Supine or seated, with the
When muscle groups slide more freely on one another, their ability to be actively shortened
wrist slightly flexed (passively). Therapist position: The therapist is posi tioned at the patient's side.
or passively lengthened is enhanced, creating greater efficiency of contraction and/or tlex
Hand position: The inside hand of the thera
ibility. Treatment of the flexor surface is shown
pist gently grasps the wrist and flexes it. The
here, but the extensor surface may be treated as
outside hand is positioned on the distal aspect of
well. Patient position: Supine or sitting, with the
the forearm, just proximal to the wrist. Execution: Using a small amount of lubrica
forearm on the treatment surface.
tion, the palm of the therapist's hand bears down on the soft tissues and begins to stroke distal to
Therapist position: The therapist is posi tioned lateral to the patient, facing the patient.
proximal, stopping at the elbow. The pressure is
Hands: One hand flexes the wrist, while the
firm, but the hand and fingers remain relaxed,
index and middle finger find a "wedge" between
so the technique feels finn but not painful. The
muscle groups. Alternately, the thumb can be
therapist should use some body weight to avoid
used, but care must be taken to avoid overuse
the technique coming primari Iy from the arm.
injury of the thumb.
Musc l e Splay ofthe Forearm ( Figure
wedges in between muscle groups with the index
Execution:
8-109)
Purpose: Similar to muscle splay of the ham
Starting distally,
the therapist
and middle finger (or thumb), applying firm pressure. Using a small amount of lubricant, the
string, the idea is to stroke deeply in the fascial
fingers sl ide prox ima lIy following the wedge
planes separating muscles or muscle groups.
created distally. Lack of a "wedge" or space
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Atlas a/Therapeutic Techniques
243
Figure 8-109
between fibers may indicate fascial adhesions.
Execution: The palm of the hand pushes the
The therapist should identify and foclls on these
muscle mass of the forearm firmly in a trans
areas, working longitudinally, proximal to distal,
verse direction through the elastic range and
until the fascial is freed up.
into the plastic range to encourage permanent deformation of the fascia. Multiple angles can
Transverse Muscle Bending of the Forearm (Figure 8-110)
be applied. For example, the flexor mass may be pushed away from or toward the ulna. The brachioradialis may be pushed anterior or poste
Purpose: Analogous in theor y to previously described muscle bending techniques, the pur pose of this technique is to mobilize the fore arm musculature in a transverse direction. This allows the contractile tissues to move more freely in their respective fascial compartments. Patient position: Supine.
rior. The extensor surface can also be moved in either transverse direction. The therapist must "think with the hands" to determine where the restrictions are, and move in the direction of the restriction.
Palmar Stretch (Figure 8-111)
Therapist position: The therapist is at the
Purpose: The purpose of this technique is to
patient's side using the leg to stabilize the pa
stretch the palmar fascia and the palmar surface
tient's forearm.
of the hand.
Hands: One hand stabilizes the forearm dis tally. The other hand gently grasps the flexor (or extensor) surface of the forearm.
Patient position: Patient is supine or sitting. Therapist p osition:
The
therapist stands
facing the palm of the patient's hand.
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Hands: The hand position is very important
245
Retinacular Stretch (Figure 8-1 ]2)
in this technique. Both little fingers of the thera pist are placed between the patient's index and
Purpose: Related to the previous technique,
middle fingers. The therapist's fingers are then
the retinacular stretch is designed to open the
interdigitated through the patient's fingers, with
carpal tunnel in a medial lateral direction, and to
the middle and ring finger of the therapist in the
increase the extensibility of the retinaculum.
web space of the patient's hand. The therapist's
Patient position: Supine or sitting.
index fingers pull over the patient's hand, and
Therapist position: The therapist is facing
the thumbs are available for massage during the
the palmar surface of the patient's hand. Hands: The therapist's thenar eminences are
stretch. Execution: The therapist's fingers that are
placed over the distal forearm and wrist. The
interdigitated, along with the index fingers, open
fingers are on the dorsal surface of the hand to
the patient's hand to create a stretch. At the same
apply counter pressure.
time, the thumbs can be used to massage the
Execution: The therapist applies firm pres
palmar surface of the hand when the stretch is
sure into the patient's wrist and distal forearm
occurring. If the elbow is flexed and the wrist is
with the thenar eminences as the fingers apply
in neutral, the palmar fascia will be localized. If
counter pressure on the dorsal surface of the
the elbow and wrist are extended, the stretch will
hand. A f irm stretch is applied from midline
also include the wrist flexor muscles.
outward to the ulna and radius. As the therapist's
Figure 8-112
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246
MYOFASCIAL MANIPULATION
Therapist position: The therapist is seated at
hands separate, firm pressure is maintained for
the head of the treatment table.
maximal stretch.
Hands: The fingers are placed over the lower TECHNIQUES FOR THE CERVICAL SPINE
cervical-upper thoracic paravertebral muscles. Execution: The technique is executed by lightly stroking the length of the cervical para
Elongation of Paravertebral Muscles (Figure 8-113)
vertebral muscles from upper thoracic to sub cranial. The depth of penetration may gradually be increased with progressive stroking.
Purpose: This is a preparatory technique for other more aggressive myofasciaJ and joint mo bil ization techniques. As previously def ined,
Axial Flexion of the Cervical Spine (Figure 8-114)
elongation differs from stJ"etching in that its pur pose is not necessarily to lengthen the muscle,
Purpose: This technique is one of the few
but to elongate the spine. (Recall the analogy of
described in this text that can be used as either
elongating the accordion.) This technique, used
direct or indirect technique. The idea behind this
with superf icial penetration, also has a strong
indirect technique is to take the neck into the di
autonomic inhibitive effect.
rection of restriction, thereby freeing the restric
Patient position: The patient lies supine with head flat on the table.
tion and allowing greater axial extension. The concept is that of a dresser drawer that is stuck
Figure 8-113
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Alias o/Therapeutic Techniques
247
Figure 8-114
and cannot be opened. By closing the drawer,
each repetition, the fingers are moved up a level
the drawer then becomes free to open. This tech
until they are in contact with the subcranial mus
nique can be divided into two specific compo
culature.
nents. The first is a general axial extension of the
At this point the technique may be applied
cervical spine and the second is specific axial
more specifically in the area of the OA joint.
extension at the OA joint.
The head and neck are again axially flexed, w ith
Patient position: The patient is supine with
the head flat on the treatment table. Therapist position: The therapist is seated at
the head of the table.
firm pressure being applied at the OA joints bilaterally with the fingertips. The fingers are no longer stroking medial to lateral, but main taining the pressure on the OA joints. The neck
Hands: The palms of the hands cradle the
may be axially extended into a diagonal plane to
base of the occiput while the fingers contact the
check for unilateral restrictions. If a unilateral
lower cervical paravertebral musculature. Execution: The head and neck are brought
into a straight axial flexion (moving the head
OA restriction exists, the neck may be axially flexed in the same diagonal plane in an attempt to free lip the restriction.
directly toward the ceiling). The fingers are si
This technique may be used as a direct tech
multaneously stroking the lower cervical para
nique with the patients who exhibit an axially
vertebra Is in a medial to lateral direction. With
extended posture. While this posture is seen
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248
MYOFASCIAL MANIPULATION
less often than the forward-head posture, the
Execution: The patient is first asked to for
technique may be used to move the neck directly
ward bend the cervical spine segmentally. As
into the restriction.
the flexion occurs, the hands stroke caudally through the midcervical, cervicothoracic, and
Cervical Laminar Release (Figures 8-38, 8-39, and 8-115)
upper thoracic areas. If unilateral technique is preferred, the monitoring hand gently guides the patient into a diagonal pattern as the other hand
Silting
gently strokes unilaterally through the cervical,
Purpose: This technique is meant to elongate the cervical paravertebral musculature and to improve cervical forward bending. Patient position: Sitting.
cervicothoracic, and upper thoracic areas. Supine Purpose: Elongation of the cervical myofas
Therapist position: The therapist is standing
cIa. Patient position: Supine.
behind the patient. Hands: In the bilateral technique, both hands are placed on the paravertebral muscles with the
Therapist position: Seated at the head of the table.
thumbs and PIP of the index finger contacting
Hands: One hand cradles the head at the oc
the patient. In the unilateral technique, one hand
ciput and brings the cervical spine into a for
is on the patient's head to monitor the diagonal
ward-bent position. The other hand makes
movement of the patient's head and neck.
tact with the cervical paravertebral muscles,
Figure 8-115
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ALias o{Therapeulic Techniques
249
bilaterally, using the thumb on one side, and the
other hand is placed firmly on the patient's
PIP of the index finger on the other side.
shoulder.
Execution: One hand holds the neck statically
Execution: With the patient positioned, gentle
in the forward-bent position while the other hand
to moderate pressure is applied caudally on the
strokes gently from approximately midcervical
shoulder while a pressure is applied with the
to cervicothoracic junction.
other hand into forward bending, side bending, and rotation.
Diagonal Stretch of Cervical Cervicothoracic Manipulation of Subcranial and OA
Myofascia (Figure 8-116) Purpose: This technique stretches the poste rior myofascial structures as well as the upper
l\1yofascia (Figure 8-117) Purpose: This technique is useful in releas ing subcranial myofascia as well as for mobiliz
trapezius and levator scapula muscles. Patient position: Supine.
ing the OA joints. This technique allows patient
Therapist position: Seated at the head of the
participation and, as such, may be considered
table.
a muscle energy technique. The idea behind
Hands: One hand cradles and positions the
the technique is stabilization of the occiput and
head in a combination of forward bending, side
movement of the atlas. The p atient is axially
bending, and rotation. The rotation can be to
flexing and extending the neck while the occiput
either the same or the opposite side as the for
is held rigid.
ward bending depending on the restriction. The
Patient position: Supine.
Figure 8-116
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250
MYOFASCIAL MANIPULATION
Figure 8-117
Therapist position: The therapist may be
tempt extraoral soft tissue manipulation in re
standing or sitting. The patient's head will be
storing mobility of the temporomandibular joint
cradled by the therapist's arm and shoulder.
(TMJ). This technique inhibits the masseters, al
Hands: As the patient's head is cradled with
lowing for a more comfortable and increasingly
one arm and shoulder of the therapist, the hand
functional opening of the mandible. The func
f irmly grasps the occiput. The other hand is
tional opening may be significantly increased
placed over the hand grasping the occiput as
without having to perform intraoral maneuvers.
additional reinforcement.
Patient position: The patient is supine with
Execution: With the therapist firmly holding the head, the patient is asked gently to axially flex and extend the neck. The head is not allowed
the head flat on the treatment table.
Therapist position: The therapist is seated at the head of the table.
to move, so the neck is actually moving on the
Hands: The tips of the index, middle, and ring
head. The atlas is allowed to translate anteriorly
f ingers are placed on the masseters just below
and posteriorly on a nonmoving occiput. After
the temporomandibular joint line.
several repetitions, the patient is allowed to rest
Execution: With moderate depth of pressure,
his or her head on the table and the amount of
the therapist strokes along the length of the l11as seters away from the TMJ. After several strokes,
resting axial flexion is reassessed.
the patient is asked to open the mouth in a subtle
Masseters-TMJ Decompression (Figure 8-118)
and relaxed manner as the stroke is being ap plied. As the masseters are stroked, the relaxed mandible will open further and a gentle open
P urpose: Prior to any intraoral soft tissue manipulation, the clinician should always at
ing stretch may be applied at the end of the tech nique.
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Atlas o/Therapeutic Techniques
251
Figure 8-118
Frontal Facial Decompression (Figure 8-119)
talis, a fascial traction is simultaneously applied, and held for 15-30 seconds, The emphasis of
P urpose: The purpose of this technique i s twofold, First, the hand position c a n b e used
this technique is on the frontal fascial stretch and frontal decompression,
to provide a gentle subcranial traction, Second, the technique can be used to inhibit the fronta I is muscle or to provide a fascial stretch to the
Retro-Orbital Decompression (Figure 8-120)
frontal, nasal, and facial fascias, This is useful in cases of parieto-occipital headaches or sinus
Purpose: Related to the previous technique,
headaches,
the purpose is to stretch the retro-orbital fascia
Patient Position: Supine,
and the fascia around the nasal suture. This tech
Therapist position: The therapist is seated at
nique is especially indicated for patients with
the head of the table,
retro-orbital headaches and sinus headaches,
Hands: One hand gently cradles the occiput,
Patient position: Supine.
while the other hand is placed directly over the
Therapist position: Seated at the head of the table.
frontal area of the patient's face, with the ther apist's thumb pointing in the direction of the therapist.
Hands: The bottom gently cradles the base of the occiput. The palm of the top hand makes
Execution: The therapist gives a slight trac
contact with the frontal area, while the fingers
tion with the bottom hand, With the palmar sur
are positioned as follows: The index and ring
face of the top hand in full contact over the fron
finger are placed over the left and right orbital
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Atlas afTherapeutic Techniques
253
bones, just inside the eyebrow, well away from
SCM may still be exquisitely tender to palpation
the eyes. The middle finger is placed just over
due to overuse in the erect posture. Patient position: The patient is supine with
the nasal suture. Execution:
A
gentle
traction
is
applied
the head off the edge of the table.
through the occiput with tbe bottom hand. The
Therapist position: The therapist is seated at
palm of the top band places a mild traction over
the head of the table, gently cradling the patient's
tbe frontal fascia, while the fingers apply a fas
head in a very slight backward bent position.
cial traction over the retro-orbital and nasal fas
Hands: One hand is cradling the occiput,
ciae. Care must be taken to make absolutely
while the other hand is positioned with the
no contact with the eyes. The fascial stretch is
thumb placed on the cephalic portion of the
applied firmly with the pads of the fingers for
SCM near the mastoid process. Execution: The therapist rotates the patient's
10-20 seconds.
neck and adds a slight amount of backward bending of the cer vical spine. The thumb of the other hand is placed on the SCM near the inser
Sternocleidomastoids (Figures 8-121 and
tion at the mastoid process. The SCM is gently
8-122)
stroked from cephalic to caudal. The SCM may Purpose: This technique decreases tone of
also be cross-stroked at any point along the
the sternocleidomastoid (SCM) muscles. Even if
muscle belly where trigger points, tender areas,
the muscle is relaxed in the supine position, the
or areas of hypertonicity are encountered.
Figure 8-J2J
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MVOFASCTAL MANIPULATION
Figure 8-122
REFERENCES I. Feldenkrais M. Advances through Movement. New York: Harper
& Row, 1972.
2. Rosenthal E. The Alexander technique-What it is and how it works. Medical Problems of Pel/arming Artists, 1987 (Ju ne ): 53-57.
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3. Dietze E, Schliack H, el al. A Manual oJRe/lexive Ther apy of the Connective Tisslles. Scars dale, NY: Sidney Simon, 1978.
Index
A
c
Active movement analysis, 150-153
Cartilage, 27
Adductor muscles, transverse muscle play, 217-218
Central sensitization,myofascial pain syndrome,
Alexander technique, 22-23
122-124
Allodynia, I 12
Cervical cervicothoracic myofascia, diagonal stretch,
Alpha-delta sleep anomaly, 100
249
Anterolateral fascial elongation, 86-88,233-234
Cervical laminar release, 248-249
with rotational component, 233-234
sitting, 248
Arthrokinematics,9
supine, 248-249
Autonomic nervous system, myofascial pain
Cervical spine
syndrome, 122
axial flexion, 246-248
Awareness through movement, Feldenkrais, 23-24
therapeutic techniques, 246-254 Chiropractic, history, 8-9
Axial flexion, cervical spine, 246-248
Chondroitin, 31 Collagen
B
biosynthesis, 31-32, 33 connective tissue, 30-31
Back pain,neural mechanisms, 4
intramolecular cross-links, 50, 51
Biceps
types, 31
stretch, 241
weave pattern, 36
transverse fascial stretch, 240-241
Complex widespread-pain syndrome, 112
Bilateral sacral release, 176-177
Compression, defined, 33-34
Bilateral upper thoracic release, 227-228
Compressive testing, spine, 152-153
Bindegwebbsmassage , 16-18
Connective tissue, 45-46
Bindegwebbsmassage-type stroke, lumbar spine,
basic afferent neurology, 65-76
161-163
biomechanics, 33-39
Biomechanics of connective tissue, 3-4
cells, 28
Blood flow, massage, 58-60
classi flcation, 39
Bone, 27
collagen, 30-31
Bony clearing
cycle of fibrosis and decreasing mobility, 51-52
iliac crest, 171-173
elastin, 30-31
tibia, 220
extracellular matrix, 30-31
255
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256
MYOFASCIAL MANIPULATION
fiber, 30-31
Elastin, connective tissue, 30-31
fibroblast, 28-29
Electrogenic muscle tone, 82-83
ground substance, 30, 31
Electrogenic spasm, 83
histology, 27-39
Electromyogram, 143 Elongation, paravertebral muscles, 246
biomechanics, 3--4 immobilization
Energy crisis hypothesis, myofascial pain syndrome,
nontraumatized connective tissue, 53-56 response of myofascial tissue, 53-57 scar tissue
vs.
121
Erector spinae ironing, 171, 172
fibrosis, 56-57
traumatized connective tissue, 56
muscle play, 169-171
loose irregular, 39
transverse muscle bend, 89
macrophage, 28, 29
Exercise, fibromyalgia, 102
massage, 16--18
Extracellular matrix, connective tissue, 30-31
mast cell, 28, 29-30 primary organization, 35
F
research, I1-12 reticulin, 30-31 secondary organization, 35
Facet joint, 9
types, 28, 38-39
Fascial sweater concept, 20, 21
viscoelastic model, 34-38
Fasciculus, 41
Creep, 34-36
Feldenkrais, 23-24
Cross friction, gastrocnemius-soleus
awareness through movement, 23-24
musculotendinous junction, 221-222 Cross-friction ischial tuberosity, greater trochanter,
functional integration, 23-24 Fiber, connective tissue, 30-31 Fibroblast, connective tissue, 28-29
211-212
Cutivisceral reflex, 16, 17
Fibromyalgia, 94-1 12
Cyriax, James, 9-10
clinical characteristics, 99-102 definition, 94 diagnosis, 94-98
D
criteria, 94-98
Dense irregular connective tissue, characteristics, 39, 40
diagnosis of exclusion, 98 diagnosis of inclusion, 97, 98 guidelines, 95
Dense regular connective tissue
iatrogenic illness behavior, 97-98
architectural hierarchy, 33
exercise, 102
characteristics, 38-39
growth hormone, 107
Depression, 100-10 I Diagonal stretch, cervicothoracic myofascia, 249 Diaphragm, 192-195
hormonal abnormalities, 105-108 hypothalamic-pituitary-adrenal axis, 105-106 insulin-like growth factor-I, 107
diaphragmatic techniques, 88-89
management, 108-1 12
first position: supine, 194
medical management, 109-1II
second position: sidelying, 194
musculoskeletal abnormality, 102-103
third position: sitting, 194-195
neurochemical abnormalities, 103--108
Distraction, II
pathogenesis, 102-108
Dysfunction, defined, 143
pathoplasticity, 102
Dysfunctional spectrum syndrome, 94
physical therapy, I I 1-112 pregnancy, 107
E
prevalence, 94 psychosocial factors, 100-102
Effleurage, 19
relaxin, 107-108
Elastic limit, 34
serotonin, 104-105
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Index
substance P, I 03 104
207-209,210
taxonomy, I 12
longitudinal
tender points, 95, 96, 98
splay
tenderness, 99--100
207 207-209
transverse muscle play, 216-2 J 7 160- J 61
fibrotic process,S I-52
Hands, care and
First rib
Hip, hold relax stretch, 205-206
shoulder
226-227
Hoffa massage, 18-19 and
forearm
19
one-hand tapotement, 19 two-hand
transverse muscle
19
Hold-relax streich,
Forward bending laminar
205-206
31
all fours, 185-186, 187
Hypothalamic-pituitary-adrenal axis, fibromyalgia,
sitting, 187-189
105-106
Forward-head posture, 146-149 cervical spine, 148-149 myofascial aspects, 147-148, 149 postural sequence, 148 thoracic spine, 149, 150
Iliac crest
Friction, pinformis insertion, 213,214
I, 252
Frontal facial
1-173 release
88,173-176
Functional
Iliacus, 197-198
Functional somatic syndrome, 101-102
Iliotibial band
n ,,- t'm,'h
202-205
Immobilization
G
connective tissue
nontraumatized connective tissue, 53-56
Gastrocnemius-solcLls, transverse muscle play, 218-220
Gastrocnemius-soleus musculotendinous junction, cross friction, 221-222
response of
tissue, 53-57
scar tissue
56-57
I'S,
traumatized connective tissue, 56
muscle tissue, 57--58
Glycosaminoglycan, 3 J
Inefficient movement pattern, 83
Golgi tendon organ, 66,7
Inflammation, wound, 49-51
implications, 73-74
Insulin-like
107
movement, 79
Greater trochanter, ischial
cross-friction,
I, 172
erector
11-21
fascial plane between,
213
Greater trochanter
198-199,200
forearm, 241-242
Ischial
Ground substance
components, 3 1
connective tissue,
31
J
Growth hormone, fibromyalgia, J 07
Joint, operational
H
Joint
157
connective tissue insertions, 45-46
Joint Hair receptor, 66, 69
Hairless skm, skin,
Joint reeeptor, movement, 79-80
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258
MYOFASCIAL MANIPULATION
ManipUlation
Junctional zone
OA
biomechanics ,4346
249-250
subcranial myofascia, 249-250
43-46
Manual medicine ancient times. 4-9
K
bone sellers future trends, 12
JO
Kaltenborn,
renaissance, 6
L
blood tlow, 58-60
collagen synthesis, 61-62
Lateral elongation, upper thoracic area, 222-225 antenor
technique, 224-225
healing
collagen synthesis, 61-62
anterior technique, 225 Lateral fascial distraction, tibia, 221
fibroblastic activity, 61-62
Lateral sacral release, J 73-176 Lateral shear, lumbar
fibroblastic activity, 61-62
metabolism, 60 reflexive
190-192
153154,155
251
connective tissue insertions, 45-46
Mast cell, connective tissue,
19
and
66-76
Long axis distraction of superficial connective tissue, 164,165
lumbar
hairless skin, 67
axis laminar release, lumbar spine, 168 169 Longitudinal
hip release, 185
Longitudinal
hamstrings, 207
Loose
hairy skin, 67
thoracolumbar fascia, 88
Medial-lateral fascial elongation, lumbar 164-166
connective tissue, 39
Lower quarter area, therapeutic techniques, 198-222
Meissner's corpuscle, 66, 67-69 characteristics, 67-68
Lubricant, 161 Lumbar lordosis,
151, 152
field,68
149-150 , lSI, 152
Mennell
roll, 189-190
James, 9 John, 10
149-150 stroke, 161-163 L3, 178-179
Merkel's receptor, 66, 69-70 Metabolism, massage, 60
lateral shear, 190 192
3,9-11 grades, II
long axis distraction of superficial connective tissue, 164,165
Motor system control
long axis laminar release, 168-169
basics. 77
medial-lateral fascial elongation, 164-166 medial-lateral pull away, 177-178
levels. 78 Movement
161-198
tendon organ, 79
166-168
j oint receptor, 79-80 techniques, 198-222
81-82 skin receptor, 80-81 Movement reeducation, 4
M
Muscle architectural hierarchv, 42
connective tissue, 28, 29 resonance
effects, 60-6I
temperature, 58-60
143
biomechanics, 42-43
fiber types, 42-43
Copyrighted Material
Index
energy crisis
classification, 42-43 '''n'''
r,J'
4(}42
121
of treatment, 124 management, 124- J 25 85
clinical
musculoskeletal
J 20-121
mechanisms,85 implications, 85-86 lypes,40
posture, J J 9-120
Muscle
116-117,118,119
referred
clinical
system
Muscle
basic evaluation, 143-155
type
evaluation,145-150 93-94
rMI'an,.,p<
structural evaluation, 145-150
historical aspects, 93
41
terms, 93
Myofilament, 41
l\·1uscle erector spinae, 169-171
biomechanics, 44-46
228-230
43-44
minor, 230 Muscle spindle, 66, 70-71 components, 70
N Neural mechanisms, 4 Nociceptor, 76 71
agent effect 76. 77
242-243 Muscle stretch reflex,
chemical movement,81-82
Muscle tissue, immobilization,57-58
Nonthrust manipulation, 1 J
:\1uscle tone,65, 82-86 82-83
viscoelastic, 82, 83-84
o 49-58
autonomic
15-1
of pathology, 9-12
historical basis,3-12
mechanical
19-22
p
modern theories and systems, 15-24
movement
68,69
22-24
cycle, 81-82,83
58-62
and abstract treatment
Palmar stretch,243-245
[58-159
examination, 153-154
trend toward
Paravertebra1 93-94, I 12-125
paitl
Paris,
246 10-1 I
anatomic variations, 117-119
Pathoplasticity,
autonomie nervous system, 122
Patient history, 144
central sensitization,
Pectoral, seated pectoral anterior fascial stretch,
clinical
22-124 116-120
230-23\
defined, j 12-113 114-116 abnormalities, 121-122
Copyrighted Material
J 02
259
MYOFASCIAL MANIPULATION
260
medial border, 234
upper border, 234
mobilization, 237-239
effects,massage,
60-61
Seated
anterior fascial stretch. 230-23J
Serotonin,
Piriformis insertion, friction, 13,2J4
16
Piriformis release, in prone, 2
104-105
Shearing,defined,34
Skeletal muscle
Position, 3
cellular
Position sense,skin receptor, 80-81
159
Postural reedueation, 88-89
meehanism
40-4J
Skin receptor
Posture, 145-150
fOlward-head, 8889
movement, 80-81
119-120
pain
pOS! lion sense, 80-8 I
,145-147
Soft tissue manipulation,joint
slumped, 88-89
differentiated, 157
107
Soft tissue mechanical
93-94, 125-126
characteristics, 125
defined, 125
evaluation process, 125 126
management, J 26
49-51
Soft tissue
Q
Somatization disorder, 10 J -I 02
152·-153
lateral erector
207--209
side bending
stretch,
Stress/stram curve,34
181-183
transverse muscle
199 202
elastic limit, 34
34 34
R Strelch,65 influence on movement, 76-82
Referred
209-211
116-117,
118,119
Striated muscle. See Skeletal muscle
Reflex
Structural
19-21
Relaxin,
Subcranial
manipulation, 249-250
muscle tone,82-83
and abstract treatment, myofascial
manipulation, treatment sequencing, J
Reticulin, connective tissue, 30-3 J
Subluxalion, 8-9
Reticuloendothelial s ystem, 30
RetinaculaI' stretch, 245-246
Retro-orbital
231-232
25 1,252
103-104
Substance P,
Rib cage, inferior border, 88-89
T
Rolfing, 19-21
balancing posture in
field,20
19
Ruffini corpuscle,66,69
massage, 58--60
Tenderness, 99-100
s
Tendon, 38,39
connective tissue insertions, 45-46
Sarcomere, 40-41
Scapular
Tension, defined, 33
234-237
lateral border, 237
Te.xlbook
Copyrighted Material
1"II /HwA; " ,\1edicine, 9-10
159
Index
Therapeutic
261
157-254
spine, 246-254
u Unilateral
articulation, first rib,
n""tprlflri
225 226
upper
techniques, 222-246
upper thoracic 84-86,89
222-225
Upper thoracic area, lateral
technique, 224-225
anterior
defined, 8 4
225
muscle
techniques,
85
clinical mechanisms, 85
implications, 85-86
v
Thoracic rotational laminar release, 239-240
T horacic spine forward-head posture, 149, 150
222-246
therapeutic
Viscoelastic model, connective tissue, 34-38
Viscoelastic muscle tone, 82, 83-,84
Thoracolumbar fascia, Thrust
w
II
Tibia
clearing, 220
Wound 50,51
lateral fascial distraction, 221
166-1
lumbar
Tissue 21-22
defined, 49
favorable
Transcutaneous electrical nerve stimulation, 15
Transverse fascial stretch,
240-241
conditions, 50
fibroplastic
50
granulation
50
inflammation. 49-51
Transverse muscle
maturation or
erector spinae:, 89
phase, 51
49
forearm, 243, 244
Transverse muscle play
y
adductor muscles, 217-218
218-220
Yield point, 34
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