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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 techniques added! Over 100 photographs of manual therapy in action More than 450 new references A new chapter on neurophysiologic mechanisms in myofascial manipulation

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
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Myofascial
Manipulation

Theory and Clinical Application

Second Edition
Robert I. Cantu, MMSc, PT, MTC Alan J. Grodin, PT, MTC

Group Director Physiotherapy Associates Atlanta, Georgia Adjunct Instructor University of St. Augustine for Health Sciences St. Augustine, Florida

Regional Director Physiotherapy Associates Atlanta, Georgia Adjunct Instructor University of St. Augustine for Health Sciences St. Augustine, Florida

AN ASPEN PUBLICATION® Aspen Publishers, Inc. Gaithersburg, Maryland
2001

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To my Ruth for her years support, expressions it all in confidence, and for helping me

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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. . . .. . .. .... ... ... Mechanical Movement Conclusion 15 19 22 24 PART II-SCIENTIFIC BASIS F OR MYOFASCIAL MANIP ULATION. .. . ... .. .. 27 40 .. . . .. . .. ...... . . ... .. . I-Historical Basis for Myofascial Manipulation. . . . . . .. . .. ... . . ..... .. . and Biomechanics of Muscle Conclusion . .... ... .... Cantu and Alan J Grodin Autonomic Approaches ........ 4 9 15 Modern Times: The Trend toward Mobility and Diagnosis of 2-Modern Theories and Systems of MyofascialManipulation RobertI...... . . .. . . .. .. . . . .. .. . . . 43 47 .. . Histology and Biomechanics of Junctional Zones . .... . 3 Robert I. . Chapter 3-Histology and Biomechanics of Myofascia 25 27 Robert l Cantu and Deborah Cobb and Biomechanics of Connective Tissue .. . . Preface to First Edition . .... .. .. . . .... .. ... .. ... . ... . . .. .. .. . . . . . .. . .. . .. v Copyrighted Material .. . .. ... . . . . ... .... . .. . . . ... .. . .. . . .. . ... Cantu Ancient Times . . .. . ... .. .... . . . . VII IX XI XIII PART (--HISTORICAL DEVELOPMENT AND CURRENT THEORIES OF MYOFASCIAL MANIPULATION . . ...Table of Contents Contributors Preface to Second Edition . .. . ... . . . .. .

of Connective Tissue .. . Index.. . . . ... . .. .. ... . .. . . . 49 Deborah Cobb.. . .... . .. . . . . . . .. . . . . . ... .... .. . .. ... . .. . .. .. .. . .. 94 112 125 Myofasical Pain Syndrome..... . .. .. . . . . . . ... . .. . . .... .. . . .. .. .. .. .. for the Thoracic/Upper Thoracic Spine and .. .. . .. . . . . . . .. . . . . . . .... .. . . . ... ... . . ... . ... ... ......... . .. .. .. Gable Basic Afferent Muscle Tone ..... ... . ... .. . . . . . . . .. ... . . . . . . .. . Application to Conclusion . PART HI-EVALUATION AND TRE AT MEN T OF THE M YOFASCIAL SYSTEM ... .. Soft Tissue Lesion and Mechanical Dysfunction ... . .. . .. . . 161 198 222 246 Techniques for the LumbopelviC/Lower Quarter Area . . Chapter 6-Muscle Pain Jan Dommer/wIt Fibromyalgia . . 65 76 82 86 90 93 Influence on Movement. .... . Cantu and Alan j Grodin Techniques for the Lumbar Spine . .... .... . . . ... . ... ....... .. and Alan j Grodin 49 58 62 Chapter 5-Neuromechanical Aspects of Myofascial Pathology and Manipulation 65 D... . .. 255 Copyrighted Material .... .. ... . .... . ...Atlas Techniques 145 150 153 157 Roberl J... . . . .. . . ... .. . . ..... . . ... . .. . ... ... .... .. .. . . .... .. .. . . . . . . . . . .. . . Chapter 7-Basic Evaluation of the Myofascial 141 143 Robert J.VI MYOFASCIAL MANIPULATION Chapter 4-Histopathology of Myofascia and Physiology of MyofasciaJ Manipulation . .. .. .. . . .. . . .. .. ... .. .. .. . ....... ... . . . . . . ... .. . .. . . ... ... .. . . . . .. .. .. . . . Cantu and Alall j Grodin 144 Postural and Structural Evaluation Active Movement Analysis Examination Chapter 8. Therapeutic Techniques ... Cantu. ... . ... .. Robert J. .. . . . . .. . . . . .. . .. .

PT Physical Therapist Physiotherapy Associates Atlanta.Contributors Deborah Cobb. MS. Gable. Maryland Vice President The International Myofascial Pain Academy Schaffhausen. Georgia Jan Dommerholt. Texas Oil-ector of Rehabilitation Services Pain and Rehabilitation Medicine Bethesda. MPS. Switzerland VII Copyrighted Material . PT Assistant Professor Department of Physical Therapy T he University of Texas Health Science Center at San Antonio San Antonio. PT C layton D. PhD.

and were practical to use in the current arena of managed care. Also. joint mobilization. We respectfully submit the second edition of Myofascial Manipulation for your consideration as a tool to help expand the horizons of our profession. being careful not to add any "fluff" to merely make the book bigger. we have added a number of other "bread and butter" techniques.Preface to Second Edition W hen we published the first edition of iVlyo­ fascial Manipulation in 1992. the first edition relied heavily on basic science principles. we enlisted the help of gifted professionals and content experts. and to re-tool and revise existing mate­ rial in the previous edition. We care­ fully extrapolated and integrated these principles into the principles of management and treat­ ment of soft tissue dysfunction.. optimal result. The chapter on neu­ romechanical aspects of myofascial pathology and manipulation. for example. We believe there are several reasons for the continued interest in this material. we were not fully material. adds a dimen­ sion of understanding we did not offer before. The sav vy clinician knows how to effectively "bounce off" all three aspects of treatment to arrive at the desired. For the second edition. market saturation of therapists. and exercise) as the "pinball triad of manual therapy. Medicare cutbacks. we wanted to strengthen that scientific foundation. to explain the mechanisms of injury and repair. but a great utility tool to be used in conjunction with joint mobi­ lization and exercise. Myo­ fascial Manipulation is not designed to be a aware of the interest and pent-up demand for this materia I. W hat are stiII represented in this edition are the myofascial techniques that the authors have used successfully over the years on a daily basis on literally thousands of patients. we often refer to that triad (soft tissue mobilization. To that end.e. pain of mostly nonmechanical origin) was completely rewritten due to the explosion of research in that area. and this has been a humbling experi­ ence for us. the chapter on muscle pain syndromes (i. and to delineate pain of me­ chanical versus nonmechanical origin. First. Managed care. As we mentioned in the first edition. In our courses. were relatively easy to learn. the book has continued to sell copies. Since 1992. For the second edition. and tlllf erosion have put us in a position where it is no longer IX Copyrighted Material . an underlying philosophy and strategy for the book was to provide good "bread and butter" techniques that were effective on pa­ tients. to add panacea for manual therapy. We went to the litera­ ture." This is because the three aspects of treatment are virtually inseparable and totally integrated in the clinic. Second. The chapter on the histo­ pathology of connective tissue has also been completely updated due to advances in research over the last 8 years. for example.

Our profes­ sional lives and the health and longevity of our profession in general depend on it.J Grodin Copyrighted Material . We hope that this tool wiiJ be useful in helping us aiJ forge ahead to expand our individual and collective horizons. Cantu Alan. Robert /.x MVOFASCIAL MANIPULATION an option for us to be the very best.

Management of certain clini­ cal problems is also discussed. but the way the letters are represented by the individual are. Part III focuses on evaluation and treatment techniques that have repeatedly proved effective in the clinical setting and includes an atlas of therapeutic techniques. while quite innovative. For anyone to say that they were the f irst in history to "invent" certain techniques would be presumptuous. On further reflection." On first reflec­ tion. The second part and purpose of this textbook outlines the scientific basis of myofas­ cial manipulation. were based on a combination of knowledge and clinical experi­ ence he attained throughout his years as a medi­ cal student and as a physician. are not unique.Preface to First Edition In his classic book. The knowledge and experience he gained over the years were molded and integrated in a way that became uniquely his own. incor­ porating both its history and the latest schools of thought. The letters formed in the handwriting. What we attempt to do in this book is to take the most current body of re­ search in myofascia and integrate this cognitive knowledge with psychomotor skill to produce a concrete system of evaluation and treatment acceptable to a profession that is striving for higher professional recognition. The uniqueness comes from the actual process of learning how to write. For the sake of clarity throughout the text. Handwriting is a good analogy for personal style. from years of practicing that handwriting. it is a combination of acquired knowledge and clinical experience that. A physician who has taken voluminous notes throughout school primarily for his or her own benefit wi II have very differ­ ent handwriting from the architect who has to submit drawings with very legible writing. A person's handwriting is a totally unique self-expression. as well as the spelling. Joint Pain. His system became his "hand­ writing. and from the particular function the handwriting serves in the person's life. For us. over the years of treating patients. his ideas and phi­ losophies. The f irst part outlines the evolution of myofascial manipulation. this statement seems a bit contradictory. John Mennell wrote that "no textbook in the field of orthope­ dics can be entirely original. This textbook is divided into three parts that reflect its major purposes. in light of the fact that Mennell was quite an innovator and one of the early advocates of using arthrokinematic rules for joint mobilization. the distinction between joint and soft tissue ma­ XI Copyrighted Material . however. So it is with this book on myofascial manipu­ lation. has evolved into a particular philosophy or system that is unique. As under­ standing of connective tissue has increased." or his style. manual therapy is divided into joint manipu­ lation and soft tissue manipulation.

Joint manipulation has been defined as "the skilled passive movement of a joint." The tissues being hnHiPVPI· are all histologically c1assi­ its restrictive with its most superficial into depth while to the ioints concerned. Soft tissue manipulation is gener­ less concerned with arthrokinematic rules than is joint a majority of the and the interrelations of the joints to the soft tissues.xii MVOfASCIAL MANIPULATION nipulation has become somewhat clouded. Manipulation is not meant to be a panacea or an exhaustive critical review of the but a and into account its relation- and in this can be considered The distinction made or lack of the techniques. Cantu Alan J. Robert J. Grodin or "handwrit­ " will become more distinct as well as more Copyrighted Material . alternate somatic and exercise. These are that we use every mobilization. Our hope is that this information will be into the readers' arsenal of and into their philosophy of treat­ ment. For the purposes of this text. so that each clinician's effective. we have defined as: The forceful pas­ sive movement of the musculofascial elements are not concerned with individual of what we feel integrating them with about clinically.

Acknowledgments The authors thank the following persons for their assistance in the preparation of this volume: To Trevor Roman for shooting the photos in Chapter 8. Paula Gould for her photography in Chapters 6 and 7. PT. XIII Copyrighted Material . Carolyn Law. for her draw­ ings in Chapters 6 and 7. The authors also acknowledge all the pro­ fessors who adopted the first edition for their courses and curriculums-the long-term success of this book is due to your support and votes of confidence. From the First Edition The authors thank the following people for their invaluabJe assistance in the production of this book: Karen Barefield. Thank you. for being the "patient" in Chapters 6 and 7. both from a content and grammatical standpoint. MPT. for her help in editing the manuscript. and Lisa Richardson. and to Debbie Cobb and Brad Fore­ sythe for being the "therapist and patient" in Chapter 8.

PART I Historical Development and Current Theories of Myofascial Manipulation Copyrighted Material .

including spinal pain . This spurred the curios­ ity of researchers in the mid and late-twentieth century. The first period. The science of arthrokinemat­ ics developed. starting with the early twentieth century. and will attempt to explain both the results and the proposed mechanisms of action. the scien­ tific thinking of the day has fashioned the exist­ ing schools of thought in manual medicine. and its scientific basis has only been heavily researched within the last 40 to 50 years. who pushed the study of manual med­ manual therapy affects the biomechanics o/con­ nective tissue. the originality of any current system of manual medicine is gen­ erally found in the underlying philosophy. The advent of the scientific age has yielded a tremendous wealth of scientific infor­ mation . with an emphasis upon myofascial manipulation. but the packaging is new. emphasized position. We treat based on what we know or think we know. which in turn has changed the theory and philosophy of modern manual medicine. not in the techniques themselves. many different systems and supporting theories for the treat­ ment of musculoskeletal pain and dysfunction have come and gone. Throughout history. The purpose of this chapter is to chart briefly the evolution of manual therapy. The tech­ niques may be old. Underlying theories may alter the way the treat­ ment is performed and may vary and modify the technique. They viewed the increased mobil­ ity of the joints as a result of mechanical cbanges icine into a third phase-understanding how 3 Copyrighted Material .CHAPTER 1 Historical Basis for Myofascial Manipulation Robert 1. and throughout history. the phi­ losophy and theory of manual medicine began to emphasize mobility. Today. In the second time period. Restoring mobility to a joint that "was locked" became the focus of manual medicine. The underlying theory and philosophy of any manual therapy system will dictate the sequencing of technique. which begins in ancient history and ends roughly at the close of the nineteenth century. a greater ap­ preciation of current manual therapy will be gained. Cantu Myofascial manipulation is as old as history itself-humans have been performing myofas­ cial manipulation as long as humans have been touching. The evolution and persistence of manual med­ icine throughout the years have been remark­ able. This research has fostered a redefinition of manual medicine and a redefin­ ing of exactly what is being accomplished with manual therapy. was a result of a "luxation or subluxation" of one or more of the joints. Currently. The history of manual medicine can be di­ vided into four basic time periods. As the different historical trends are addressed. Joint pain. and terms such as "accessory movements" appeared. especially since the medical communities often shunned such treatment. The emphasis in the spine was in restoring the position of the verte­ bra to relieve pain.

the present mechanisms of back mechanisms in because of the of back of research in manual and movement reedu­ The science have the same name have not the same effects. obviously dislocated at the shoulder. The physician places the flat of one of his hands on the ky­ phosed portion of the patient's back. the pain is not it is the fourth time it has happened. takes into consideration whether the reduction should natu­ rally be made towards the This method of repositioning is harm­ it will do no harm even if one sits on the hump while extension is applied . However. .I Much of manual medicine can uted to the popularity of work in be attrib­ in his day." Hippocrates is to a kyphosis of the lumbar describes two treatments for this condition conof mechanical traction and extension ex­ ercises. Two relevant "On the Joints. And it is of lordosis is common. The main failed. The next still oily from his last in the He is his and left arm. necessary to rub the shoulder and smoothly.. or in the direction of the head. Each of the different time periods ANCIENT TIMES of manual medicine date back to the time of year 400 Be. The immediate future of manual therapy lies in the combination of pas­ sive manual therapy reeducation or motor and their underlying in the following sections.. or alternately translated "kyphosis. H describes treatment of humpback... The treatment was routine to him ." describe various combinations of manipulations. For rubbing can bind a joint which is too loose and loosen a joint that is too hard. and his other hand Oll the top of the first. .nay there is nothing against one's foot on the hump and succession by bringing upon it [Figure J-ll l(p4J The Entries in early manuscripts include descriptions of both joint manipulation and massage in treat­ ment of a dislocated shoulder. the gladiator had ways to go about it. and movement techniques for is discussed In the treatment of back pain.. around the If the patient is f irst _ a steam bath . The experienced in many ed Iy also in rubbing. prophylaxis. anyway.. The . or in the direc­ tion of the buttocks [Figure I-I]... massage. Copyrighted Material . and traction on a wooden table.. He presses vertically.. and if the maneuver has tient's arm over the chair. a shoulder in the condition described should be rubbed with soft hands moved above aJl but the joint should be not violently but so far as it can be done without chronicity and recurrence of many medicine is beginning to concentrate on neural cation (see Chapter 5 for discussion of neural of motor learning and control will have much to offer in this area. The idea of "reposition­ is an theme in the ancient documented literature on manual medicine. for must be is solved other the pa­ once again... and "On by Leverage.4 MYOFASCIAL MANIPULATION in connective tissues.then he is placed on his stomach on a wooden board [for .

part I. part I. Norske Laegeforening.Historical Basis/or /vIyo/ascial Manipulation 5 Figure I-I The Hippocratic method of traction and manual pressure as described by Galen. Schoitz. Source: Reprinted with permission from E. Manipulation treatment of the spinal column from the medical-historical standpoint. Journal ofthe Norwegian Medical Association (1958.H. Journal ofthe Norwegian Medical Association (1958. Manipulation treatment of the spinal column from the medical-historical standpoint. Copyright © 1958. Copyright © 1958.78:359-372). Norske Lacgcforening. Copyrighted Material .H. Schoitz. Figure 1-2 Method for "repositioning of an outward dislocation" of the spinal column. Source: Reprinted with permission from E.78:359-372).

around his trunk and thighs. and healing takes place when the bones are restored to their original positions." The exogenous causes of dislocation include falls.6 MYOFASCIAL MANIPULATION Claudius Galenus. including 18 commentaries on Hip­ pocrates. Bone setters. Bone setters were known locally. no treat­ ment can be applied. and usually treated "con amore. and pro­ longed work in a greatly bent position. without pay.g. their art was generally passed on from parents to children. If the vertebrae are dislocated and far apart.. face down. If such tension cannot be tolerated. a Greek physi­ cian who I ived in the years AD 129-199. He recognized seven of the cranial nerves. the "bone setters" of England flour­ ished.4 Pare was also instrumental in the de­ velopment of some of the early orthopedic surgi­ cal techniques. The fact that members of the no­ bility sought after bone setters infuriated the traditional medical community. considered "quacks" by tra­ ditional medical practitioners. then pull from top and bottom as hard as pos­ sible. This controversy is exemplified by Wharton Hood. a vagrant peasant woman. For many years. but without violence. the medical community hotly debated the sub­ ject of bone setting. had other primary occupations. differen­ tiated between sensory and motor nerves. among vineyard workers. who was sought out by commoners and nobility alike (Figure 1-3). fasten him to it with bands beneath his armpits. Bone setters derived their name from their basic philosophy that small bones can move out of place. The Hippocratic method had survived. virtually unchanged in technique. Copyrighted Material . Bone Setters From the mid-1600s well into the nineteenth century. with descriptions and illustrations similar to the Hip­ pocratic method. ref­ erences are made to manual medicine. hard blows. or Galen.1 His primary contribution was docu­ mentation of early neurologic investigations. Galen found that the problem was "lo­ calized in the first spinal nerve below the sev­ enth cervical vertebra. Again. who learned the practice of bone setting from one of his patients whom he had treated for a systemic Renaissance The most well-known contributor to manual medicine in the Renaissance period was the French surgeon Ambroise Pare who lived in the 1500S.. One of the most well known bone setters was Sarah Mapp. e. Galen describes one such incident in which a patient developed par­ esthesias and loss of sensation in the third to fifth digits of the hand after falling from a wagon. a good method is to lay the patient on a board. It can be argued that many of the techniques (especially traction and exten­ sion principles) are still being utilized today. with some physicians being shunned for speaking in favor of bone setters.I. and was the first to treat paresthesias and extremity pain by treating the spine. While the advent of the Middle Ages brought a decline in medical advancement. had no formal training. The positional theory was still strong as evidenced in a chapter entitled "Dislo­ cated Spinal Vertebrae. In the work. Much of the emphasis in Galen's work again focused on the "reposition­ ing" of an outward dislocation of the spinal column. a medical doctor in the community. Then you may place your hands on the outcurving part and press the projecting vel'te­ brae.. well into the Middle Ages." that is. with the fundamen­ tal theory being repositioning of the vertebra as in the Hippocratic method. early evidence exists for traction and manipulation into extension. con­ tributed much written material on early manual medicine. an Arabic physician named Avicenna wrote a large work around the year AD 1000 summarizing the med­ ical knowledge of the day."1 and healed the patient by treating the neck. generation after generation.

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. Learn then to imitate what is good and avoid what is bad in the practice of bone setters. part l. Still another surgeon of the day wrote: "The success of certain bone setters is due-in addi­ 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. Norske Laegeforening. Schoitz. there exists some things much stronger and less worthy in prej­ udice and jealousy. and in no respect can he fulfill his duty merely by criticizing quacks for his failures. lIpS) Another physician of the day who defended manual medicine was English surgeon Sir James Paget. and smirched its record of noble endeav­ ors. among other things. Realizing the effectiveness of such treat­ ment in his own practice. His work was effective enough to attract members of the Brit­ ish royal family. if related to anatomical knowledge. the medical community could no longer argue with the success of bone setters . Sarah Mapp (Crazy Sally). If the physician does not know how to fulfill or pursue these needs.78:359-372). who practiced from the late 1800s until Copyright © 1958. actors. and which. frustrated by the arrogant atti­ tudes of most physicians." One of the best-known bone setters. . which have from the be­ ginning of time darkened the pages of surgical history. Source. I obtained information. he was still shunned by the physicians of the day. It is entirely evident that quackery. Fas est ab hoste doceri I opponent. it is more important to consider the fact that their treatment can do some good . Finally. Despite his successful treatments and his willingness to submit his work to the medical community's scrutiny.. Manipulation of the spinal column from the medical-historical standpoint. and politicians. . who was also a respected medical school 1927. . Herbert Barker. and in 1925 the Lancet editorially wrote: "The medical history of the future will have to record that our profession has greatly neglected this Copyrighted Material . it is his duty to study them. vainly attempted to obtain credibility and good standing in the medical community by in­ viting physicians to observe his work and otTer­ ing to perform demonstrations. Reprinted with permission from E. is of the greatest possible value from the prophylactic and therapeutic view­ points. Journal of the Norwegian Medical Association (1958.)I(p6) (It is advisable to learn from one's Figure 1-3 The bone setter.Historical Basis for Myofascial Manipulation 7 professor (1814-1899). Barker wrote: "Strong as the love of service to suffering is among many doctors as a whole. Hood wrote boldly in the journals of the day in favor of bone setting. which sur­ geons do not learn. is an expression of the extent to which the authorized physicians have failed to fulfill their patient's quite reasonable desires or demands. There is little point in presenting a lecture on the injuries which these persons cause. illness."s Eventually.H.

positional release techniques. Taylor maintained that it was God who "asked him to fling in the breeze the banner of osteopathy. abnormal. the treat­ ment scheme included "cures" for all sorts of systemic diseases. ex­ ercising a mechanical pressure on the blood ves­ sels and nerves.. Charles Still." Being a very religious man. Some of the cure-all claims of os­ teopathic practice were being relinquished and were subsequently taken over by chiropractic."7 Thus. Osteopathic Medicine and Chiropractic While controversy was raging over England's bone setters. the Register of Osteopaths in England compiled the Osteo­ pathic Blue Book. and were criticized by skeptics just as in England4 In the mid-1860s.and that by our faulty methods."8 By imposing these limitations. probably influenced by the bone set­ ters of his time. he founded the practice of osteopathic medicine in 1874..21 years after StiII had founded osteo­ pathic medicine.. was helping his father cure native Indians and "simple folks" in the Mid west. osteopathic physicians and osteopathic practice have become more accepted even though the theories are still debated. Three areas in osteo­ pathic medicine that are currently applicable to myofascial manipulation are muscle energy techniques. particularly in the spine. however. But I maintain to have been the first who repositioned dislocated vertebrae by using the spinous process and the transverse process as levers . Dis­ gusted with the traditional practice of medicine. StiII dedicated his f irst textbook to God: "Respectfully dedicated to the Grand Architect and Builder of the Universe.. In 1956. and as a vital ma­ chine of structure and function. son of the founder of osteo­ pathic medicine. A vertebra can become subluxaled. the func­ tion would be adversely affected8 Still main­ tained that the causes of all diseases were "dislo­ caled bones. America's first bone setters were practicing by the mid-1800s in Rhode Island and Connecticut."6 icine continued to evolve into a more scientific and realistic philosophy. osteopathic med­ Copyrighted Material . Andrew Taylor Still. and lym­ phatic vessels). who had attended but never finished medical school. . and strainlcounterstrain techniques9-11 In 1895. If the structure was abnormal. dislocated ligaments or contracted muscles. 2.." I. . A subluxation is apt to affect the struc­ tures that pass through the intervertebral foramen (nerves."7 The original premise of chiropractic can be summed up as the "law of the nerve. Unfortunately. a similar course of controversy was being charted in America during the 1800s and early 1900s. blood vessels. He did. and in part an obstruction of the 'vital juices' through the nerves. David Daniel Palmer founded chiropractic. the rule of the artery and the rule of structure governing function became the cornerstones of osteopathic thought. The fact must be faced that the bone setters have been curing multitudes of cases by movement. a pressure that in part produces ischemia and necrosis.and starting from these fundamental facts to have founded a science that is des­ tined to revolutionize the theory and practice of the healing art7 Dr.8 MVOFASCIAL MANIPULATION important subject. claim to be the founder of a new science. when he lost three of his children to spinal meningitis. Palmer learned his technique through rediscov­ ery of the ancient Hippocratic methods and from osteopathic medicine. which stated in part that "os­ teopathy is a system of therapeutics which lays chief emphasis upon the diagnosis and treat­ ment of structural and mechanical derangements of the body. 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. Fortunately. we are largely responsible for their very existence. would remain healthy as long as it remained structurally normal."7 His basic theory was that the human organism had the innate strength to combat disease.

An adjustment (reposition) of a sublux­ ated vertebra causes the structures pass­ the intervertebral foramen whereby the normal in­ nervation of the organs is become functionally and rehabilitated. 7 so that Iy so that they become function- scientists to describe the facet in the facet joints narrowed the Unfortunately. the innervations of certain parts of the organism or organically sick. As a result thereof.14 Basic science and arthrokinemat­ ics continued to influence and redefine manual and in the late 1940s and and From ancient times to the end of the nine­ teenth The manual medicine had been prac­ of success. so that the conduc­ tion of nerve becomes abbecome 4. sible cause of low-back thritic of sciatic described was further the theory of manual was one of the first as a pos­ He felt that ar­ function can occur at the in the spinal cord with its and autonomic nerves. This influenced severa] others to medicine. The fact that pain could be caused by dysfunction of various or selective soft tis­ sues. and the intervertebral foramen and were a possible cause pothesis was later obscured by the idea of dis­ cogenic pathology as a cause of low-back pain and sciatica. soft tissues. or to disease. the condition he untreatable. Cyriax's work is in the area of of the body's various thoritatively on the subject was father of the late James Cyriax.Historical Basisjor Manipulation 9 3.K. He was of the facet in the evaluation and treatment of back lack of mobi of the facet a causative factor in back of periarticular soft in the development of the philosophy has been partially replaced with the mobility philosophy in explaining the theories of manual medicinc. periarticular connective i s a foundation of soft tissue Copyrighted Material . He is best re­ membered as one of the f irst to as a cause of baek the emergence of basic sci­ became disco­ manipulation in the recognition.16 James advocate of intimate mechanics and the use of appropriate mobiliza­ tion based on those same mechanics. including. S. but not limited to. tissue dysfunction as a causative factor in back theoretical basis of soft tissue manipUlation. R.MODERN TIMES: THE TREND TOWARD MOBILITY AND DIAGNOSIS OF PATHOLOGY In the physician In ential had Mennell was a ticed with all apparcnt high '"'�'CC" fi Manipulation. where the been f irst to publish debated for many years. The work remains of special and differential to this day. James Cyriax classic Textbook of this the first edition of his now Medicine. the subluxation and joints as Mennell's early pain is . a disruption of the a significant factor in the study and philosophy of manual medicine. A Iso in the late 1940s and early 19S0s. One of the and dysfunctions of the extremities. categorization. He is be­ lieved to be the first to coin the term motion" to describe involuntary motions neces­ for proper movement. With traditional closer to age new clinical the value and re­ the advent of the scientific search on the Today. during this time span was on re­ a subluxation for the reduction of and restoration of health. espe­ cially in Great Britain. 17 The lies in the differ­ manual medicine became more common. As a result thereof.

his classic text on extremity mobilization was the first that consistently and comprehensively used arthrokinematic principles to restore func­ tion to joints.10 MYOFASCIAL MANIPULATION manipulation today. There is a normal anatomical range of mechanical play movements in synovial joints. 3. He defined mobilization as "a component of manual therapy referring to any procedure that increases mobility of the soft tis­ sues (soft tissue mobilization) and/or the joints (joint mobilization). Mennell out­ lined the etiological factors that give rise to joint pam: I. Loss of joint play results in a mechanical pathological condition manifested by im­ paired (or lost) function and pain. precise diagnoses can be achieved in disorders of the radio­ translucent moving tissues. disuse. who wrote early on that the treat­ ment of spinal pain involved treatment of the Copyrighted Material . This is joint dysfunction. John Mennell operationally defined the different terms. The healing of a more serious patho­ logical condition in the musculoskeletal system. Intrinsic joint trauma. the connective tissues surrounding the joint are ap­ propriately stretched and normal movement is restored. Another person responsible for bringing ar­ throkinematics into the evaluation and treat­ ment of joint pain was Norwegian physiothera­ pist Freddy Kaltenborn. It is prerequisite to efficient pain free movement. This is joint manipula­ tion. Joint Pain. The recognition of "radiotranslucent moving tissues" as the cause of pain is a cornerstone in the validation of treatment of soft tissue pa­ thology. John. Cyriax was also the first to introduce the concept of "end feel" in the diagnosis of soft tissue lesions. is the method examination moving parts by selective tension. 2. Oddly.19 Thus. and thereby re­ duces pain. In his book. The trend continued with James Mennell's son. which by this time had become confusing. Historically. My only impotiant discovery. Mechanical restoration of joint play by a second party is the logical treatment of joint dysfunction. MenneJl also advocated the following con­ In particular.20 Kaltenborn was the first to ad­ vocate heavily the convex/concave rule for joint mobilization. and others is that restoring the mobility of the joint restores normal function."2o The implication made by Mennell. which is perplexing in light of the extremely systematic evaluation of the soft tissues advocated in extremity dysfunction. 1 have tried to steer ma­ nipulation away from the lay notion of a panacea-the chief factor delay­ ing its acceptance today. Immobilization that includes therapeutic immobilization. and not the disc. by moving joints in selective ways. 2. The extensibility of the surrounding tissues is what ultimately allows for normal ar­ throkinematics in the joint. Influenced by Cyriax. Cyriax sum­ marizes his own philosophy as follows. who was another advocate of the mobility philosophy. IS He argued that there was no reason why the synovial joints of the spine shou Id respond to trauma and/or therapeutic measures any differently from any other synovial joint of the body. of systematic on which the of the whole of this work rests. 1. This is joint play. 3. and aging. the shift toward mobility and soft tissues in the etiology of back pain is quite evident by the mid-twentieth century. Cyriax. A strong proponent of this idea was Stanley Paris. Mennell argued that the principal cause of pain arose from the synovial joints of the back. his views on low-back pain remained strongly and narrowly in the realm of discogenic lesions. even though Cyriax deviated somewhat from his philosophy when evaluating and treat­ ing the spine. cepts in operationally defining manual therapy terminology. By this means.

which occur only in response to outside forces21 Paris developed a comprehensive evaluative system that included. Maitland of Australia. and since all the periarticular tis­ sues affected during manual therapy are con­ nective tissues (soft tissues). Amiel. I. in the J 970s. or to assist in the reduction of a disloca­ tion. and neurophysiolog­ ically. Distrac­ tions are used to unweight the joint sur­ faces. Peripheral Manipulation. or produce neurophysiological ef­ fects. the evaluation of passive segmental mobility of the individual joints of the spine. Th rust manipulation: when a sudden high of connective tissue have helped explain manual therapy's effectiveness. NonthrllSI articulalion: when the joint is either oscillated within the limits of an accessory motion or taken to the end of its accessory range and then oscillated or stretched. necessary for the motion to take place normally. The purpose is either to alter positional relationships. the pain would take care of itself. understanding the biomechanics of connective tissues became par­ amount. Copyrighted Material . Pain follows dysfunc­ tion-pain cannot precede dysfunction. while re­ taining its subluxation theory. Distraction: when two articular surfaces grades I-IV (Figure 1-4). Source: Reprinted with permis­ sion from G. short amplitude motion is deliv­ ered at the pathological limit of an acces­ sory motion. muscular.D. to fire cutaneous. "Dysfunc­ tion is the cause of pain. the chiropractic profession redefined its philosophy to include movement abnormalities. Paris further operationally defined the var­ ious accessory motions of joints in the following manner: (I) Component motions are those mo­ tions occurring in a joint during active motion. Substantial research was performed by Akeson.21 Another recent proponent of the mobility theory is G. 2. Massachusetts. and (2) joint play motions are those motions not under voluntary control. Woburn. Butterworth-Heinemann."J. snap an adhe­ sion. and B representing end-range movement. 3. to relieve pressure on an intra-ar­ ticular structure. 11' IVB - - Figure 1-4 Grades of mobilization with A repre­ senting beginning movement. Maitland. Since restoration of motion is manual therapy's primary goal. Several recent studies have been performed using fluoroscopy to show changes in mobility of spinal facet joints after a thrust manipulation24 The studies are im­ pressive and validate the effectiveness of manual therapy for increasing mobility. Articulations are used mechan­ ically to elongate the connective tissues.21-2J By normalizing mobility and function in the spine. The oscilIations are thought to work by increasing mobility as well as modulating pain through neurophysiological effects. The f indings of this research are discussed in detail in Chapters 3 and 4. and joint receptor mechanisms. © 1981. it states 'something is wrong'. His treat­ ment system includes "graded osci Ilations" of A 11II - III . and others to determine the biomechanical characteristics of normal and immobilized connective tissues. and not of the pain itself. in part .D. The mobility theory so began to dominate the thinking in manual therapy that. He also classified manipula­ tion into three distinct categories. Advances made in the understanding are separated from one another. including adhesions. Others such as Kirkaldy-Willis velocity. Connective Tissue Research The next logical step in the evolution of manual medicine was the emphasis on the his­ tology and biomechanics of connective tissue.Historical Basisfor Myojascial Manipulation II dysfunction. Woo. Pain does not warn of anything. to stretch ajoint capsule. especially myofascial manipulation.

New Engl Swg Soc. MD: National Institute of Neurological and Communi­ cative Disorders and Stroke: 1975. London. Copyrighted Material . IN. 18. On the so-called bone setting. Massage: P rinciples and Technique. the incidence of recurrent spinal pain still bor­ ders on epidemic proportions. Ghorl11ley RK. II. Bethesda. Manipulative treatment of thc column J McM.52:1. Low back pain with special reference to the articular facets.11. 1975. I. University of Indianapolis. Rupture of the intervertebral disc with involvement of the spinal canal.2:210-2 15. Jones L. is in research infancy. Hood W. 11: Osteopathy and chiropractic. Bdhesda. 1924. 4. Strain and Counterstrain. creating a more complete form of treatment. MD: National Institute of Neurological and Coml11uni­ cative Disorders and Stroke. England: Bale and Danielson. Boston. Mixter WJ. 1964:4: 1 09-1 16. Mal1l/w­ lation and A4assage. Brown 1945.) 6. (Taken from bibliography of note & Co. Monograph 15. Cyriax E. In addition. 1958:78:429-438. but also the modulation of cen­ tral nervous system mechanisms. Lomax E. History o/the Development ofl'vledical Manipulative Concepts. Loubcrt PV. and movement therapies help pre­ vent future recurrence. its nature and re­ sults. 15. III: The last 1 00 years.12 MYOFASCIAL MANIPULATION and Falfan have shed light on the degenerative pathologies in the spine. J 9. 9. Mennell J B. Philadelphia: WB Saunders. P hysicalTl'eatment by Movel1lent.I Norweg Med j 958:78:359-372. Paget J. Medical Terminology. 1 4.Therapeutics. The idea of exercise for prevention of low-back pain is widely sanctioned. S1. 1964. 12. 2. A significant addi­ tion to the realm of manual medicine is the idea of movement science. BMf 1867. England: Churchill Ltd: 1949. 499-50 I (Taken from bibliography of note I. MA: Little. the idea that myofascial manipu­ lation can produce not only mechanical and au­ tonomic results. Mennell . Spontaneous release by positioning. CO: American Academy of Osteopathy. 5. Course notes. from Ef-1. The Re­ search Status ofSpinal Manipulative Therapy. 3. Schoitz EH. Monograph 15. Cyriax J. Colorado Springs. JA MA. The Re­ search Status of Spinal Manipulative Therapy. The D. (Taken from bibliography of note 8. 8. Mennell J McM. and have addressed the treatment of such conditions as well as some of the limitations of manual therapy. Krannert Graduate School of Physical Therapy. 1933: 101:1773-1777. 10. FL: Institute Press. The idea that myofascial manipulation can be a form of "sensory-motor education. Augustine.) 1 3. Manipulation treatment of the spinal column !I'om the medical-historical standpoint. Mennell J8. The Science and Art otloint Manipulation. 16. Collected Papers on Mechano.2s-26 of recurrent spinal pain. Barr JS. 1 8 7 1 :336-338. Although manual therapy can be effective in managing spinal problems. Positional Release Techniques. 30-44. Paris SV Foundations ofC/inical Orthope­ dics.) 7. 17. Beard G. Schoitz I. Joint Pain. Lancet. II Jones L. London. Boston. 441 -443.I Non'l'eg Med Assoc.27 Future Considerations Based on the current rate of change. 1981. manual therapy will continue to evolve exponentially into the twenty-first century. 1964:3-4. MA: Little. Schoitz EH. Cases that bone setters cure. Deig D. Integrating alter­ nate somatic therapies such as Feldenkrais and Alexander and the theories of movement science with manual techniques makes sense in light REFERENCES I." helping to establish more efficient movement patterns will also strongly emerge to comple­ ment motor learning theories. 1 99 1. Assoc. Manual technique can correct the dysfunction. and takes the patient an extra step in prevention of recurrence. and conventional exercise can be considered movement science in rudi­ mentary form. Wood E.o. Manipulative Therapy: A Historical Perspec­ tive from Ancient Times to the Modern Era. . Brown & Co. 1934. Manipulative treatment of the spine from a medical-historical point of view. 1958:78:946-950. England: Bailliere Tindall. Vol London. thc mcdical-historical point of view. J Norweg Med Assoc. Textbook of Orthopedic Medicine.

Managing Low Back Pain. 1979. 179:5561. 1987. Oslo. 21 Paris SV The Spine-Etiology and Treatmelll of Dys­ limctioll Including Joint tlfanipulaliol1. Ciin Orllwp. 24. Institute of Graduate Physical Therapy. 25. Farfan HE Mechanical Disorders oJthe Low [Jack. Paris SV Mobilization of the spine. Copyrighted Material . Job s Body. August. NY: Station Hill Press. 27. Phil­ adelphia: Lea & Febigcr. GA. 1988. Kaltenborn F iVlal1ual Thuapyjor ihe EXiremity Joints. 22. COllrse notes. Phys Ther. 1979.1976. New York: Churchill Livingstone. Juhan D. Norway: Olaf Norlis 130khandel. Au­ gustine. St. Kirkaldy-Willis WH. A /Jalldbook/or Bodywork Bar­ rytown. Atlanta.Historical Basis for Myofascia/ Manipulation 13 20. 1983. . Atlanta Craniomandibular Society/Life Chiropractic College Joint Seminar. 59(8)988 995 23. FL. 1987. 1973. 26. Paris SV Spinal manipulative the rapy.

Cantu and Alan J Grodin This chapter provides an overview of some of the alternate somatic therapies considered myo­ fascial in nature. AUTONOMIC APPROACHES The autonomic or reflexive approaches at­ tempt to exert their effect through the skin and superficial connective tissues.2 MacKenzie de­ f ined the autonomic or reflexive component as "that vital process which is concerned in the reception of a stimulus by one organ or tissue and its conduction to another organ. 15 Copyrighted Material ."3 Soft tissue mobilization performed for auto­ nomic effect stimulates sensory receptors in the skin and superficial fascia. These stimuli pass through afferent pathways to the spinal cord and may be channeled through autonomic path ways. Its purpose is neither to give the reader a comprehensive background of each individual system. and movement approaches are those that attempt to change aberrant move­ ment patterns and establish more optimal ones. but also for control of post-surgical nausea or menstrual cramping. producing effects in areas corresponding to der­ matomal zones being mobilized. The systems reviewed repre­ sent th. and move­ ment approaches. the manual therapist should have a basic working knowledge of theories or systems in all three areas. nor to include every system currently being practiced-such an undertaking is a book in itself. Ideally. along with some application tech­ nique from each approach. and have contributed to the development of the authors' personal treatment philosophies. For example. The manual therapist interested in myofascial manipulation should also have a basic working knowledge of the fundamental philosophies behind various systems and theo­ ries in order to become a more educated con­ sumer in the continuing education market. Mechanical ap­ proaches are those that actually attempt me­ chanical changes in the myofascia by direct ap­ plication of force. part of the theory of transcutaneous electrical nerve stim­ ulation (TENS) is direct stimulation of large myelinated ner ve fibers that override noxious stimuli traveling to higher centers of the central nervous system. and to understand the orientation of the respective practitioners. Modern theories and systems are arranged in three categories: autonomic or reflexive ap­ proaches.ose that have influenced the authors the most over the years.1. which on receiving a stimulus produces the effect. So. mechanical approaches. Autonomic approaches are those that exert their therapeutic effect on the autonomic ner vous system. TENS has application not only for pain control.CHAPTER 2 Modern Theories and Systems of Myofascial Manipulation Robert 1.4 The idea of affecting various body areas by stimulating the skin and supelficial connective tissue has been used in areas apart from soft tissue mobilization.

"1 and superficially Over time period of bed amputation would have rest. Dicke refers to certain asof this phenomenon as the "cutivis­ ceral reflex. In sub­ warm flushes and increased sensation. From a treatment the realm of are as fol­ this book. she was able to resume her full duties as a physiotherapist Out of her structed a this pursuit. and shortly thereafter. and improvement continued. Obvi­ ously. is and pro­ three f irst. It can create reactions in distant organs. local blood sUDDlv. She then began other the areas. A Ithough the autonomic etTect cannot be denied. 1920s when Dicke was suffering from a pro­ 3. Subcutaneous connective tissue is ex­ tremely vascularized and can absorb varied quantities of blood as a result of constriction or dilation. the intestine would not be affected from the surface of the skin and the reac­ tion must be "a reflex intestines from the skin" The skin and subcutaneous are highly innervated and are the tissues for the of outside tactile stimuli. Connective Tissue (Bindegwebbsmassage) Connective tissue massage in the 1920s German and Elizabeth Dickel and later expanded by Maria The system was into in rudimentary form in the late of tile 1. and other disturbances. Dicke was in and sacrum. should be exercised by the the extent of autonomic The effects of autonomic technique should not be overemohasized. The CTM system is very Each for example. If the bed rest was unsuccessful in dimin­ been considered as a last resort. she found palpatory inf iltrated area of increased tension of the She found relief by the area with her the low-back tant. an and dermis. notable She tenderness. The effects Dicke outlined that are pertinent to modern manual lows. she also of pain. Most affects the 2-1). with the right side Copyrighted Material .1 The attending physicians prescribed a ishing the bed for a 5-month understandably pain. As she began to palpate her own back. and itself and found Iy the acute patients. and in the area of the iliac crest and opposite it. She stated that she felt "a thickened diminished. Some nomic phenomenon to treatment of dis­ orders unrelated to the neuromusculoskeletal system. times. followed tocol-oriented if performed as Dicke taught. 2.16 MYOFASCIAL MANIPULATION Affecting the autonomic system is an tant cal to more mechani­ especially in acute patients. CTM can also release nerve impulses paths by means of reflexes that are locked into the central nervous system. Within 3 months her symptoms had subsided. how­ border of the greater trochanter and the ilio­ tibial tract. She very stroked these areas. CTM can set general circulation in order. CTM can directly influcnce connective tissue that is locally altered by scars."1 Dicke uses the example of the of a mother's warm hand to alleviate a child's stomachache . clinician in treatment. autonomic techniques are most often used at the beginning and at the end of entry and exit from me­ chanical ever. but more impor­ occurred in the lower ex­ felt itching. which is she gradually con­ treatment method.

with the other hand always in light con­ tact with the patient. Hansen and H.Modern Theories and Systems of Myof cia I Manipulation as J7 . strokes are performed with the middle f inger of the hand. Schliack with permission of Georg Thieme Verlag. Lubrication is never used. 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. and the low back and sacral areas are always treated first. Treatment is never administered without first treating the basic section of the Copyrighted Material . © 1962./ Anterior Root .

HotTa's emphasizes autonomic or reflex­ ive technique as an entry way for other. even for the whole As w ith connective tissue massage. but the strokes can them as reflexive or autonomic. with a "build up" and of the elements. this type of massage. reflex of the deep may skin and bone and hair back may dis­ The patient a cold palpa­ choice also play some of these symptoms. Hoffa states that "the force should be and 'light-handed' so that the as little as possible. Manual therapists often move too quickly into moderate o r gradually CTM offers when other therapeutic properly into the overall treat­ CTM that can patient can be described as seen in the hands and of the chronic intense pain and the type of techthe system. The made without forceful maneuvers that can create Copyrighted Material . rebut behind it as too basic to include in the realm traditional myofascial manipulation can handicap even the most advanced manual therapists. therapists learn these as standard massage tech­ niques in entry-level programs. the skin and sub­ CTM exerts its effect primarily a nipulation (in terms that provides much-needed "lighter" end of the manual technique spectrum. A patient with an most of the may exhibit to feel to the back with of CTM makes it a tonomic nervous system. published in 1900 and later revised by Max Bollm in 1913. What must be remembered about CTM and about all other "systems" is that they are merely and should modify these their to recovery. cutaneous connective tissue. This makes CTM form of myofascial ma­ Hoffa Albert Hoffa's text. The of technique. Often RSD is a hyperactivity cold nervous system that creates cold sweat in the area. CTM allows the nician '8 hands in a very further promoting relaxation and In cases where myofascial restrictions CTM technique provides a good entry into the deeper tissues."5 Hoffa advocates that ment scheme. In a patient who is autonomically (reflex sympathetic dystrophy) type back. and vibration. A technique is not necessarily more effective just because it is more Some may consider these be and to be to be which cat­ more mechanical in nature. Such an acute an RSD­ instead o f the myofascial system. to the affected area. and a nausea response. classical massage techniques such as tapotement. inclines toward the re­ feels t1exive. and eventually trophic including loss. although without tion or treatment. but may lean toward one more than the other. and coccyx. myofascial manipulation systems are neither rellexive nor Hoffa massage mechani­ cal. nausea w ith attempted palpation. since it primarily affects the au­ to grow accustomed to the cl i­ massage should never last more than 15 minutes. more mechanical technique. but sti II be their Some may of advanced manual should and discussed because of in the overall treatment scheme. Moving from superfi­ cial to deep treatment facilitates the in the myofascial tissues.J8 MVOFASCIAL MAN1PULATtON low sacrum. which becomes less forceful with less for tissue microtrauma and exac­ does not need appropriately. Astute clinicians can while The clinician thus allows the body to open itself to treatment. If the clinician the of myofascia too rapidly. With Hoffa massage or the the niques and more spe­ is prepared for tech­ to promote histological can be treatment more difficult.

It glides on it. and may be effective if used at the proper time and in the proper sequence.. but advanced manual therapists continue to use his techniques in their treatment schemes. however. Tapotement. . the elongation of a superficial fascial plane. The hand that follows proceeds likewise. forceful technique is necessary to free up longstanding restrictions. distally to proxi­ mally. One-hand petrissage.. Apply both Hoffa was one of the first clinicians to de­ scribe massage in an actual textbook. is used to correct inefficient posture *Rolfing® is a registered service mark of the Rolf Institute of Structural Integration. slide along at the edge of the muscle with f inger tips to take care of all larger vessels: stroke upward. following the direction of the muscle fibers. With the broad part of the hand. Two-hand petrissa ge. "grip­ ping back and forth. a system created by Ida Rolf." . however. or histological. although many varia­ tions have been introduced. Both hands are held ver­ tically above the part to be treated in a position that is midway between pro­ nation and supination. This manipulation starts peripherally and proceeds centripetally.. or su­ perficial tissue rolling to mobilize adhesions are all mechanical techniques. By lifting the muscle mass from the bone "squeeze it out. stroke using a flat hand.As previously stated. use the ball of the thumb and little fingers to stroke out the muscle­ masses. a few minutes of autonomic technique facilitate the application of mechanical technique." progressing centrip­ etally. changes in the myofascial structures. should always be attempted f irst. The stretching of a hamstring. The gentle. it is a matter of properly going through the "layers" unti I the deeper tis­ sues are accessed. moving back and forth in a zigzag path. instead of picking up the muscle.Bringing them into supination. the abducted fingers are hit against the body with not too much force and with great speed and elasticity. The thumbs are op­ posed to the rest of the fingers. Copyrighted Material ... at times. mechanical techniques should generally be per­ formed after some form of autonomic technique. Place the hand around the part so that the muscle­ masses are caught between the fingers and thumb as in a pair of tongs. forceful mechanical technique is an inferior form of treatment. Some of Hoffa's basic massage strokes are de­ scribed as follows.On flat sur­ faces where this petrissage is not pos­ sible.4 Rolfing® (Structural Integration)* Structural integration. The hand is applied as closely as possible to the part.The fun­ damental strokes of traditional massage are still performed widely today. Principles may be borrowed from any system. Remember that the systems described as fol­ lows are just that: systems-they can be very protocol-oriented. That is not to say that aggres­ sive. and very ordered.Fingers and wrists remain as stiff as possible but the shoulder joint comes into play all the more actively. hands obliquely to the direction of the muscle fibers. and at the same time. The hand that goes first tries to pick the muscle from the bone. Hoffa's massage is considered basic by modern standards. The application of mechanical technique is not nec­ essarily aggressive. Even if the patient is not suffering acute pain.Modern T heories and Systems of Myofascial Manipulation 19 microtrauma or exacerbate painful conditions. . MECHANICAL APPROACHES Mechanical approaches differ from autonomic approaches in that they seek to make mechani­ cal. . Li ght and deep elJleurage.

quickest and most economical method of changing © 1958 Ida P. and balanced move­ ment demanded at a nearby joint. administered independent of specific pa­ thologies... in practice. Upper and lower half of body relation­ ship 10. Rolf with permission of the Rolf Institute of Structural Integration.7 I. tissue and joint will relocate in a more appropriate equilibrium" (Figure 2-3). then to rest of body 8. The treatment principle says that "if tissue is restrained. Rectus abdominis/psoas-for pelvic bal­ ance 6. .9. All behavior is expressed through the musculoskeletal system. Sacrum-weight transfer from head to feet 7. with the body consisting of various blocks. Relationship of head to rest of body-pri­ marily occiput/atlas (OA) relationship. Source: Reprinted from Rolflng: The Integration a/Human Structures (p 33) by 1. A man's emotional state may be seen as the projection of his structural imbalances. © 1977. non­ symptomatic approach to soft tissue manipula­ tion. Two or three advanced sessions can be performed. each emphasizing a particular aspect of pos­ ture. . Base of body/midline (balance left to right) 5. as well as subsequent occasional "tune-up" sessions. Respiration 2. Emotional response is behavior.20 MYOFASCIAL MANIPULATION or to integrate structure. considerations of the physical are inseparable from con­ siderations of the psychological. with all the work performed in the myofas­ ciaI tissues. Rolfing is a standardized.. Balance throughout systemS Rolfing also strives to integrate the structural with the psychological: The technique of Structural Integra­ tion deals primarily with the physical man. The technique involves 10 one-hour sessions. The easiest. is function.The technique involves manual soft tissue manipulation with the goal of balancing the body in the gravitational field (Figure 2-2). Lateral line-front to back (sagittal plane balance) 4. Rolf 1 Figure 2-2 The concept of balancing posture in a gravitational field. Copyrighted Material .. Balance under the body (feet/legs) 3.

The Trager practitioner "uses the hands to communicate a quality of feeling to the nervous system. Trager undertook formal medical training. Source. MD. and this feeling then elicits tissue response within the client. Change in the coarser medium alters the less palpable emotional person and his projections7 Rolfing suggests that a person's psychologi­ cal components are manifested in structure. earning his medical doctorate at the University Autonoma de Guadalajara in Mexico. Eight years later. He opened his private practice in 1959 in Waikiki and."lo The system uses gentle passive motions that empha­ size mobilization techniques. while training as a boxer. It uses the nervous system to make changes. He subsequently left boxing to protect his hands and to pursue the develop­ ment of his system. and exactly to the degree of the physical manifestation.' Reprinted from Rol ng: i f gralion oj Human Structures (p 33) by I. rather than making mechanical changes in the connective tissues themselves. 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.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. The osci Ilations and rocking techniques serve as relaxation techniques that encourage the pa­ tient gradually to relinquish control. Rolf with part in the unconscioLls mind. began teaching his system on an indi­ vidual basis in California. the coarse matter of the physical body is by direct intervention in the body. The approach has no rigid procedures or protocols like some other systems. the active movement part of the treatment serves as a neuromuscular reeducation technique simi­ lar in principle to Feldenkrais' work. and that changing the structure can change the psy­ chological component. *Trager® is a registered service mark of the Trager Institute. Finally. The Trager Institute was formed and there are currently 600 Trager practitioners throughout the world. © 1977."9 Trager began developing his system in his late teens. concentrating on traction and rotation. in the early 1970s. and a system of active movements termed Mentastics(") The intensity of the movements is in the moderate or midrange. with integration of cervical and lumbar traction. The idea is to alter the patient's neurophysiological set and give the patient the tools to maintain the permission of the Rolf Institute of Structural Integra­ tion. Copyrighted Material .

He observed a his mouth. He found he and actively old habits while incorporating subsided. but was coordinated with Copyrighted Material . Matthias Alexander was a orator at the turn of the twentieth a consistent problem in his voice. inhibition of the habit. As time that the "dysfunctional" head other dvsfunctional patterns isolated movement. and other the Alexander prolonged serve himself his head back.22 MYOFASCIAL MANIPULATION II The to alter the neuromuscular set to that ill each human coordination and I discovered that a certain use of the make mechanical but is establish more normal movement patterns. to of rest." where the participant tries to new ones. his improved and his Alexander noticed was not an voice of movement that can teach the entire body to regardless of the activity. and that when I interfered with the employ­ ment of the primary control of my manner. he was ahle to hold his head and neck 111 more efficient posture. like music teachers who suggest that their stu­ dents oractice slow Iv. . and of the MOVEMENT APPROACHES The movement differ from the head and neck in relation to the torso and other parts of the constituted a primary control of the mechanisms as a others in that the patient actively participates in therapy. the clinician guides the a series of movements to and postures. he set up a in his his Since Alexander's recurrent system of mirrors through which he could ob­ torical voice. through aberrant whole . I) Position and motion of the head and neck the cornerstones of the Alexander The student of Alexander learns to activate this primary locus of control in the head and and it functioning during: activi­ ties of daily living. These three stages are what Alexander termed "conscious learning. Both autonomic and mechanical ap­ rely on the clinician to impart the and movement. He studying the relationship a of head and neck posture in relation to voice and from that become 1110re The technique both musicians. are improvements in and body mechanics. and Alexan­ (I) awareness of con­ associated of the standard of my terns and retrain into more efficient movements Alexander F. After repeated practice ses­ sions. . The instructor's approach is usually to the student palpatory as well as verbal feedback as he or she learns new less control and movement patterns. patterns are best learned reinforcement."12 For Alexander. the der goes through three the habit. or to learn to do something right. and with time. his public the dysfunctional oatterns. In the movement ap­ proaches. Awareness of the habit carries great impor­ tance in the Alexander "You are not here to do exercises. but to be able to meet a stimulus that you wrong and learn to deal with it. Many vocal- scious control of the habit. As the student masters new and verbal feedback is Alexander was very experiential the student can independently achieve proper and deliberate in his approach. head in relation to the neck. this was functioning.

"15 Feldenkrais disliked separating the two. Moshe Felden­ krais was a versatile Israeli engineer and physi­ cist who was also athletically active. the patient often may not have the body aware­ ness or the ability to assume it. If a patient ex­ hibits poor posture resulting from myofascial restrictions and movement imbalances. Whether used for treatment of TMJ. the Al­ exander technique aptly appl ies to the evalua­ tion and treatment of temporomandibular joint (TMJ) disorders. Steve Kraus. which he separates only for convenience. then. being aware of the pattern was not enough to change it. espe­ cially if: ". If the clinician addresses mechanical restrictions and emphasizes body awareness. after all. the Alexander technique merges logically with the autonomic and mechanical approaches in help­ ing myofascially dysfunctional patients achieve desired changes. His movement approach is based on the idea that movement abnormalities occur in response to past trauma. allowing the patient to assume optimal posture without undue effort. and the other is for "normal. healthy" people. Simply looking in the mirror to correct an aberrant postural or move­ ment dysfunction was insufficient to change the pattern. with more efficient effort. His approach is designed to help the body reprogram the brain to integrate the whole mind-body entity. The new posture. can increase the patient's original pain. Alexander's concepts have been used and ex­ panded by Mariano Rocobado.Modern Theories and Systems of Myofascial Manipulation 23 had difficulty even recognizing the patterns that were so detrimental to his voice projection. but a persistent knee injury resulting from soccer play led his engineering mind to explore human movement. Some of these principles are integrated into sequencing of overall treatment. rendering one more susceptible to reinjury. neck. Once the dysfunctional pattern was recog­ nized. Feldenkrais The Feldenkrais movement approach seeks to retrain the body away from aberrant movement patterns into more efficient ones. but again. The first is an experiential approach that he terms "Aware­ ness Through Movement. He then used conscious control to "inhibit" the dysfunctional pattern and integrate the new one. Which of us. is not brain damaged in the sense that we allow many areas of our brains to at­ rophy through misuse or nonuse? We can have terrible posture and move­ ment patterns and habits which are distorting and damaging to our bodies and brains-and still be classified as "normal. As is widely known. then to call other people brain damaged simply because their particular "disease?"16 deficiency produces visible effects that we label Copyrighted Material . is able to inhibit the old pattern. The second is a hands-on ap­ proach that he terms "Functional Integration. the patient be­ comes aware of the problem. Developing an awareness of the pattern was the first step. Feldenkrais participated in soccer and judo."J4 in which the patient receives a series of verbal commands designed to weaken old movement patterns and to estab­ lish new ones. since the habit was too well established. head and neck posture and movement affect mandibular position and function. Feldenkrais has two basic approaches. He hypothesized that the brain no longer identified the aberrant patterns of movement as dysfunc­ tional." Who are we. and consciously work toward establishing the new pattern. and establish a negative reinforcement loop. and others in working with head and neck posture in relation to mandibular position. If new posture is emphasized too early in the treatment sequence. the distinction is made that one is for "sick" or "brain damaged" people. inhibition of the movement was neces­ sary. or other spinal dysfunctions. but as normal. mechan­ ical approaches are used to free up the restric­ tions. He began to speak while consciously trying to "turn off " the dysfunc­ tional pattern.

Bohm M. I 10. CONCLUSION Examples of the three types of approaches (autonomic. elongation of the structures be­ comes facilitated. 1983. MacKenzie A Manual of Reflexive 9. Healing Massage Technique. Smilhsol1ian. 2. 1978: 17-22. 3. Ger­ its P rinciples and Technique. Reston. MA. Summer 1986. 15. Malabar. Course notes. 1923:47. Angina Pee/oris. York: Harper del' Massage. 1978. gentle sequences of movement allow for slow. 1972. and working gradually into deeper tissues. Rochester. The Alexander tcchnique--what it is and how it works. Connective Tissue Manipula/ions. 1913. 1941:10. Trager psychophysical integration and rnen­ P Trager psychophysical integration: a n additional J. Whirlpool. 13. When optimal length and mo­ bility are established. as well as postural integration. 12. As with Alexander tech­ nique. Wolff A. Fall 1987: tastics. and then to an emphasis in movement and posture (movement approach) is the key to complete treatment. Witt Therapy of/he Connec/iveTisslIe. The Universal Constam in Living. the sequencing of treatment includes beginning superficially with a manual approach. The progression from a light manual approach (autonomic) to a deep manual approach (mechanical). The Gordon Group. Schliaek I-I. 14th cd. neuromuscular reeduca­ tion is emphasized to prevent recurrence. 1977. 14. Medical Problems of Pelforming Ar/ists. Gordon 1988. Tappan EM. As will be seen in later chapters. Trager M. Roljing: The In/egration of Human Structures. Stuttgart. deliberate changing of abnormal. Once the deeper tissues are accessed and affected. Inc. The Trager Journal. London: Henry Frowde A Study of tool in the treatment of chronic spinal pain and dysfunc­ tion. January 1981. Awareness through Movemen/. Brookline. 5. Rosenfeld A. 4. Myof{lscial Reorganization.24 MYOFASCIAL MANIPULATION The idea that aJ I persons exhibit some ab­ normal movement either from previous trauma or old habit patterns is a cornerstone of the Feldenkrais method. San Francisco: Harper 16. Rosenthal and Hodder and Stroughton. 6. The Trager Journal. Josophy and scheme of treatment. and movement) de­ scribed here merge well with the authors' phi- REFERENCES Dicke E. Teaching the body how to program the brain is Moshe's 'miracle'. 8. Rolf delphia: WB Saunders. Rywerant Y. V T: Healing Arts Press. Mass age : 7. inef­ f icient movement patterns into normal efficient movements. IP. New York: Dutton. Phila­ many: Ferdinand Enke. The Trager approach-psychophysical integra­ tion and mentastics. Feldenkrais M. Copyrighted Material . 1900. Hoffa AJ. Technik EaSlern (lnd Western Methods. mechanical. 1985. Alexander FM. New & Row. Fall 1982 5 . II. FL: Robert E Kreiger Publishing Co. June 1987:53-57. Ebner M.' lishing Co. P. Juhan D. & Row. S Simon Publishers. The Feldel/lentis Method: Teaching by Han­ dling. VA: Reston Pub­ E.

PART II Scientific Basis for Myofascial Manipulation 25 Copyrighted Material .

and fascia.J The importance of these roles to the manual therapist wi 11 be discussed later. Although much of the benchmark HlSTOLOGY AND BIOMECHANlCS OF CONNECTlVE TlSSUE research is from earlier in the century. and connective tissue2 Connective tissue is subclas­ sified into connective tissue proper. joint capsules. microorganisms and contribute to repair after injury. the muscle sheaths. The most important roles of connective tissue are (I) structural. This is es­ sential because the myofascial/connective tissues are those primarily affected by manual therapy treatments. immobilization. Thorough knowledge of myofascial tissue histology and biomechanics will aid the physical therapist in comprehending and assess­ ing the implications of trauma. the surrounding periarticular connective tissue. blood vessel walls. and (2) defensive/ reconstructive.CHAPTER 3 Histology and Biomechanics of Myofascia Robert 1. This information will begin to lay the groundwork for an understanding of how trauma. An appropriate understanding of normal his­ tology and biomechanics of the connective tis­ sues can be found in a review of the scientific I iterature. from a histological stand­ point. bone adipose and cartilage are considered connective tissues. ligaments. immobilization. and remobilization of myofascial tissues. Connective tissue comprises 16 percent of a person's total body weight and stores 23 percent of the body's total water content. but it is the surrounding connective tissues that are affected by the mobilization. cartilage. muscle. and the bed and framework of the inter­ nal organs. tendons. nearby ligaments. When mobilizing a facet joint. A manual physical therapist must have in-depth knowledge of the microscopic and macroscopic structure of the myofascial tissue-connective tissue. nerve. for example. The joint is simply a space built for motion. due to the mechanica I properties. Cantu and Deborah Cobb The foundations of orthopedic physical ther­ apy are based upon the understanding of the anatomy and biomechanics of the soft tissues. the tissue affected by the mobilization technique is the joint capsule.2 Also. it re­ mains accurate and consistent with the more current research. Most of the structures affected by manipula­ tion and mobilization are connective tissues. I Connective tissue forms the base of the skin. Connective tissue proper is further subclassified by orientation and density of fiber 27 Copyrighted Material . nerve sheaths. and remobilization will affect the connective tissues. and bone. periosteum.I. aponeuroses. epithelium. and junctional zones. in that they aid against invading Histology The four basic types of tissue found in the human body are muscle.

Saunders. and mast cells5 Fibroblasts are found in all connective tissues. ground substance. Williams and R. and mobile wandering cells consisting of mac­ rophages. Source: Reprinted from Gray:. Fibroblasts. Copyrighted Material . Warwick with permission ofW. whereas the other cells are found primarily in pathological states. persistent mesenchymal stem cells. and loose irregular (Figure 3-1)4 These tissue types are described in detai I later in this chapter. eosino­ philic leukocytes. 1973. Anatomy. These cells are the primary secre­ tory cells in connective tissue and are respon- Collagen Nerve Adipose cells Elastin Macrophage Pericyte. plasma cells. adipocytes. Capillary Ground Eosinophil Figure Lym phocyte Cell 3-1 A diagrammatic representation of loose connective tissue. and blood vessels. ed 35 (p 32) by P.28 MYOfASCIAL MANIPULATION types. are found in the highest cell numbers.4 The three basic connective tissue types are dense regular. CC. The Cells of Connective Tissue Connective tissue is comprised of cells and extracellular matrix (fibers and ground sub­ stance. nerve. considered the true connective tissue cells.B. showing fibers. Fibroblasts. lymphocytes. dense irregular. These cells can be divided up into a f ixed cell population of fibroblasts. cells. Table 3-1).

Reticulin: delicate meshwork for support of internal organs and glands. Histamine causes vasodilation in neighboring noninjured vessels. inflammatory. Provides medium in which collagen and cells lie. The sig­ nificance of this is still not known5 The disrup­ tion of mast cells also results in the release of histamine. Fibroblasts are nonphago­ cytic. found in lining of arteries. Fibroblasts and fibroblastic activ­ ity are influenced by various factors. Heparin is constantly secreted in small amounts in the blood stream by the mast cells. Also ligamentum flavum and ligamentum nuchae. type IV: basement membranes 2. his­ tamine is bound to heparin. They are mobile and are important defensive cells. and hypersensitivitiesl 5 Mast cells can be hypersensitized by certain antigens introduced into the body. type I: connective tissue proper (loose and dense) b. Components a. mac­ rophages primarily phagocytose damaged cells and damaged macromolecular connective tissue fibers. Fibrocytes. and dietary content. Macrophages and histiocytes: "big eaters" found in traumatic. the fibroblast is converted into the fibrocyte. steroid hormone. [n highly cellular tissues. maintenance of critical interfiber distance.] Macro­ phages may be the signal for vascular regenera­ tion to begin. glycosaminoglycans (GaGs): lubricating effect. Other types of cells. Fibroblasts are adherent to the fibers. Ground substance: viscous gel with high water concentration. Cells A. etc b. damaged tissue. Plasma cells: produce antibodies. present only in infectious conditions. because they appeared "stuffed with granules" (mast is German for well-fed). diffusion of nutrients and waste products b. type III: fetal dermis. D. and foreign matter. provides lubrication between collagen fibers e. The release of histamine is linked to inflammatory reactions. Collagen: very tensile a. proteoglycans: primarily bind water Copyrighted Material . In infectious or inflammatory states.] In mature stable con­ nective tissue. or infectious conditions. including collagen. C. which are formed primarily in loose connective tissue. including prevalent mechanical stresses. I n traumatized states. Fibroblasts: synthesize collagen. Elastin: more elastic. Mast cells: secrete histamine (vaSOdilator) and heparin (anticoagulant). allergies. mechanical barrier against bacteria c. maintains critical interfiber distance. Extracellular Matrix A. elastin. clusive to connective tissue. preventing microadhesions d. type II: hyaline cartilage c. and ground substance. Mast cells. macrophages are capable of phagocytosing bac­ teria or other invading microorganisms. Fibers 1. found in stable mature connective tissue. elastin. Mast cells are responsible for constantly secret­ ing small amounts of the anticoagulant heparin. Macrophages. are found primarily in traumatized or infectious states. E. Within the mast cell granules. mature version of fibroblast. not ex­ I. facilitating 1.Histology and Biomechanics of Myojascia 29 Table 3-1 Histological Makeup of Connective Tissue sible for the synthesis of all components of con­ nective tissue. lining of arteries d. B. decreases with age 2. reticulin. Purpose a. which they lay down. resulting in increased permeability. Clean and debride area of waste and foreign products. Macrophages (which means "big eater") are responsible for phagocytosing waste products. fibroblasts may mix with collagen fibers to become reticular cells. 3. and ground substance. more abundant in early life. B. which is the nonsecretory version of the fibroblast. Mast cells were given their name II. debriding the area in preparation for repair.

Collagen. Lippincott Co. and the reticular tissue of the spleen. Ham and D.W. Copyrighted Material . Figure 3-2).30 MYOFASCIAL MANIPULATION cell production of histamine2 This could be one possibility why individuals with numerous al­ lergies and with diffuse myofascial pain can have an increased histamine response to soft tissue manipulation. The Extracellular Matrix The extracellular matrix of connective tissue comprises all other components of connective tissue except cells (Table 3-1. They are related to the immune system and are responsible for synthesizing an­ tibodies.H. © 1979. and reticulin. the most Figure 3-2 Photomicrograph of loose connective tissue. the cells of the reticuloendothelial system are found in the blood. This widely scattered system consists of phagocytic and im­ munologic cells and associated organs and tis­ sues related to f irst-line defense of the body against invading microorganisms and foreign pat·ticles. With the ex­ ception of the fibroblast and fibrocyte. The matrix is primarily composed of fibers and ground substance.8. elastin. al I other cells found in connective tissue are also related to the reticuloendothelial system. Other connective tissue cells. Plasma cells are somewhat related to mast cells in that they are primarily present in infectious states. The body's connective tissue framework is an integral part of the reticll­ loendothelial system because of the mechanical barrier that connective tissue provides against invading microorganisms. Source: Reprinted from Hislology (p 212) by A. The f iber types consist of col­ lagen. The connective tissue fibers lie ill a bed of ground substance. Cormack with permission of J. and the meninges. This concept is discussed again later in the chapter on myofascial pain syndromes.3 Aside from connective tissue. liver.

substance. The Copyrighted Material . Ground tion and diffusion of nutrients in connective tis­ Iypes: Type II colme and nonsulfated groups . reticuloendothelial of defense helix in the cell to form strands of function of ground substance is to maintain the so-called "critical interf iber distance. It contains a of water and this accounts for the first of its primary functions---di ffusion of nutrients and waste rier A second function of the invading bacteria and part of the the first line organisms. This is the medium in which the cells pro­ Bim. The nonsulfated group. to bind water. The two which is groups of GAGs are the sulfated hyaluronic acts elastin and reticulin are more elastic. The primary substance and water. Water makes up approximately loose and dense connective is found lining the fetal dermis. From the polypeptide procollagen). are linked in series and in to form Initially. the molecules are hydrostatically attracted to through strands the cell membrane into the interstitial spaces. and fibers are embedded. Ground substance has several primary functions. Ground substance con­ tent in connective tissue seems to decrease with age. [V collagen is found in basement mem­ are most The characteris­ 70 percent of the total connective tissue con­ tent. a precursor Strands of in a tropocollagen. Connective tissue f ibers with their ten­ si Ie water suess Collagen is divided into four Type I col is found III is found primal'j Iy In 111 and elasticity are the basis for the with its is the basis for lubrica­ mechanical support." The idea of using nonhor­ tin6. which is another is being sold "to component of ground in alternative medicine help monal will have a of connective tissue to and impact on the and have more elastic characteristics.7 Reticulin is the least tensile of the con­ the delicate meshwork internal organs and glands. A third ground substance is to provide a mechanical bar­ isms.ynthesis of Collagen begins in the fibroblast by the absorption of amino acids into the cell. is a liga­ percentage of elas­ it is found primari Iy the 111 function.astin f ibers are less tensile than has now received Food and Drug Ad­ ministration approval for use in the of human Chondroitin. which has to help restore been used function in the veterinary branes. The lining of arteries contains a high The nuchae of the ment that contains a nective tissue of elastin. Gly­ are a Iso referred to as "acid in the older literature.and Biomechanics of 3] commonly found marily the is very whereas which provides some of the tissue volume. Connective tissue cells. Another important component of connective tissue is hydrophilic. Manual therapy likely I tics of each type are discllssed later.4 acid." Collagen fibers that tC\(1Cptt1pr one another can po­ if a certain distance is not maintained between them. possibly contributing to a decrease in flex­ ibility with aging. EI. lecular unit of In the extracellular space. 3. It is of the inert extracellular matrix that account for the functional charac­ teristics of the di fferent types of connective tissue. In the endoplasmic reticulum of the into polypeptide protocol­ is are linked the amino acids are chains. can maintain the distance between f ibers preventing microadhesions and extensibility. '5 restore the tissue is an idea that is ment of injured or arthritic joints.

Copyrighted Material . Source: Reprinted from Gray ' Ana/amy. Saunders. Warwick with pennission ofWB. The energy re­ quired to break a covalent bond is much greater than the energy required to break a hydrostatic bond.lasts.32 MVOFASCIAL MANIPULATION 1\M Amino acids including proline and lysine collagen fibres 2 Assembly of chain polypeptide and bundles of fibres 7 Aggregation of VV\J\fV\Mrv\M to 3 Hydroxylation proline in and poLypeptide of lysine chain tropocollagen form collagen fibril s V'tJVWVVV\MI\ Passage of tropocollagen to 5 extracellular space 4 AssembLy hyd roxyLate d polypeptide chains into of three carbohydrate Addition of moiety one tropocollagen molecule Figure 3-3 A schematic drawing representing the biosynthesis of collagen by fibrob. the collagen matures and the weak hydro­ static bonds are converted to stronger covalent bonds8 To review briefly. © 1973. Small strands intertwine to form larger strands. This accounts for the increasing strength of collagenous tissue during maturati-on. Eventu­ ally. and so forth (Figure 3-5). Williams and R. The configuration of mature col­ lagen can be likened to the structure of common rope. Covalent bonds are bonds in which the two bonding atoms in the respec­ tive molecules share an electron. ed 35 (p 38) by P. each other and form hydrostatic bonds . hydrostatic bonds are those in which polarized molecules or molecules of different polarities are attracted to and weakly bonded to one another. larger strands intertwine to form even larger strands. Colla­ gen fibrils eventually band together to form col­ lagen fibers.

Kastelic. compression.IF"f:. When a force is applied to connective tissues (mechani­ cal stress).. Tissue strain can be caused by stresses such as a push. Ham and D. but the tissue TROPO­ COLLAGEN (x ray) MICRO FIBRIL (x ray) (EM) SUB FIBRIL (x ray) (EM) FIBRIL (x ray) (EM. i�!:"�II:�I. Gordon and Breach Science Publishers. The multicomposite structure of tendon. are caused by forces acting on these plied along the length of a tissue. however. © 1979. whether to bone or connective tissues. pull.tf.!I'. Adapted with permission from J. Some deformation or change in length can occur. and Bottom showing the proposed quarter stagger arrangement of collagen fibers. SEM) (OM) staining periodicity fibroblasts 1.IO Compression occurs when there is stress ap­ General Characteristics and Definition of Terms All injuries. from the tropocollagen molecule to the collagen fiber. Strain is expressed in de­ formation per unit length. Galeski and E. Baer. In order to prevent and treat these inju­ ries. A. the tissue. Connective Tissue Research (1978. as a result of the : GAP REGION l t OVERLAP REGION stress. or shear. Copyright © 1978. An example of this is in a whiplash Biomechanics of Connective Tissue injury.Histology and Biomechanics o Myo ascia / j 33 'C ' "- - ." Strain is determined by comparing change in length with the normal length. =-. tension. the tissues tend to resist any changes in size or shape. This deformation is called "strain. The posterior and anterior ligaments get tightened or stretched and subjected to ten­ sion stress9. twist. Copyrighted Material ._ tissues. Lippincott Co. the manual therapist must first have a work­ ing knowledge of the basic guiding biomechani­ cal principles that apply to soft tissues.H. The cervical spine is flexed and extended with force.6: 1 1-23). Source. ' : .5nm 10-20nm 50-500nm 50-300u SIZE SCALE Figure 3-5 Architectural hierarchy of dense regular connective tissue. Cormack with permission of lB.. Reprinted from Histology (p 234) by A. Source. or percentage change.5nm 3.W. The latter three are common factors in connec­ tive tissue injury9 Tension is a pulling force along the length of Figure 3-4 Top Electron micrograph showing alter­ nating light and dark regions. SEM) FIBER (EM.

This de­ formation is called "strain.34 MYOFASCIAL MANIPULATION decreases in length and increases in perimeter. The two characteris­ tics combine to give connective tissue its unique qualities. when stress is ap­ plied to a tissue. Copyrighted Material . the permanent change results from breaking in­ termolecular and intramolecular bonds between collagen molecules. If stress continues. as in progressive stretching. As the imposed stress in­ creases further. A graphic representation of this relation­ ship would appear as a stress/strain curve. Ini­ tial change in length requires little force. In other words. or change in length. Some of the change is quickly lost. while some remains. the hydraulic cylinder has been opened and does not close. The viscoelastic model is then simply the vis­ cous and elastic portions of the model combined and arranged in series (Figure 3-10). The early part of the curve. leading to a higher incidence of disc herniation at this Ievel9. deformation occurs. can be temporary or perma­ nent. The viscous (or plastic) component repre­ sents the permanent deformation characteristic of connective tissue. a net change in length is achieved.lo Creep occurs when a load is applied to a tissue over a prolonged period of time. The elastic component has a post-stretch recoil in which all length or extensibility gained during stretch or mobilization is lost over a short period of time (Figure slides over another. A lesser load over a greater period of time will produce a larger amount of Viscoelastic model ofcOl1l1ective tissue. represents the elastic component of connective tissue. The tissue is now permanently deformed. greater amounts of force are required to effect small amounts of change. This allows a gradual elongation of the tissue. This occurs when forces in opposite direction are applied to a tissue. After stretch or mobiliza­ tion. Presumably. In an upright position. As more stress is applied to the tissue. An example of this is L5 sliding forward over S 1. the slack is taken out as the f ibers align themselves in the general direction of the stretch (Figure 3-8). but does not rupture. compression force is put through the intervertebral discs. the spring recoils when tension or force is removed. The two sur­ faces become closer to each other as the sides (annulus f ibrosis) bulge out under tension. part of the length or extensibility gained remains even after a period of time (hydraulic cylinder portion of model). sometimes called the toe region. Connective tissue is some­ times referred to as being viscoelastic in nature. The elastic component is not well understood but is believed to be the slack taken out of the connective tissue f ibers. the curve reaches its peak at the yield point9 3-7). When the stretch is removed. When a stretch is placed on the tissue. There is no post­ mobilization recoil in this component (Figure 3-9). In the model. the f ibers assume their previous orientation and the change in length is lost.lo Shearing occurs when one part of a tissue The elastic component of connective tissue represents the temporary change in length when subjected to stretch (spring portion of model). It contains both a viscous (permanent) deforma­ tion characteristic and an elastic (or temporary) deformation characteristic. the tissue moves into the viscous or plastic range. In the elastic model. and cross links. This point is called the elastic limit. it reaches a point at which the deformation becomes permanent. For example.9. the change in length diminishes. The degree of deformation is more determined by the dura­ tion of force applied to the tissue rather than the amount of force.II-IS This model incorporates a spring (elastic) and a hydraulic cylinder (plastic) linked in series to help depict this deformation quality (Figure 3-6). The combination of viscous and elastic prop­ erties allows for connective tissue to respond by creep and relaxation. After a force is applied to the connective tissue through stretch or mobilization." The strain. This usually represents temporary length changes in the tissue. This concept can be explained further using a simple engineering model. a regular connective tissue has a loose basket weave con­ f iguration of collagen f ibers. f ibers. When the material stretches beyond the elastic range.lo As previously mentioned.

© 1981. (B) Schematic representation of a viscous element in material capable of permanent (plastic) deformation. Source: Reprinted with permission fro m The Physician and Sports Medicine. p. Ground substance matrix Viscous properties -------i� Plastic stretch (8) Hydraulic cylinder model Elastic properties -------l� Elastic stretch (C) Spring model force (D) Tensile force Figure 3-6 (A) The primary and secondary organization of connective tissue in the body. (C) Schematic representation of an elastic element in material capable of recoverable (elastic) deformation. 9. it behaves as if it has both viscous and elastic elements connected in series. No.Histology and Biomechanics o/Myofascia 3S Collagen fibers (A) + Tendons Ligaments Joint capsules Aponeuroses Fascia etc. McGraw-Hili Companies. (D) A simplified model of collagenous tissue. Copyrighted Material . Vol. 12. Connective tissue is a viscoelastic material: When stretched. 58.

With each progressive stretch.lo If force is applied intermittently. Cantu with permission of Forum Medicum Inc. connective tissue is still capable of losing the elongation. but gradually slows as the tissue makes the transi­ tion from elasticity to plasticity. When the stress is re-released. Again. some range is lost due to the elastic com­ ponent. with permission of the Orthopaedic and Sports Sections of the Ameri­ can Physical Therapy Association.. when stretching tight connective tissue. strain. Not all the change in length is lost. Source: Reprinted from Myofas­ cial Manipulation: Theory and Clinical Management (p 4) by A.OOO Figure 3-7 Schematic representation of the visco­ elastic model of elongation-elastic component in which no permanent elongation occurs after applica­ tion of tensile force. pp. with A and B repr esenling elastic stretch and recoil of collagen fibers.1. the curve looks identical. or percent elongation. 1 <'OSrL.CW> manent. In Figure life of collagen is 300 to 500 days in mature 3-11 A. and a portion is also retained. The patient may return a day or two later with a range of motion greater than the original range. again representing the contribution of the elastic por­ tion of connective tissue. the tissue has B \ 1 t Figure 3-8 Diagram showing the weave pattern of collagen. H. is plotted against time for the pur­ poses of illustrating this phenomenon. Initially. warmed tissue held for a sustained period will be more pliable than cold tissue stretched quickly. Copyrighted Material . but starts from the new length achieved after the first stretch (Figure 3-11 B).E some gain in total length that is considered per­ 1'R£ L. Source: Reprinted from Donatelli R. the tissue immediately loses some of the previously attained elongation. If the stress is reapplied to the tissue. 3. representing the con­ tribution of the viscous portion of connective tissue. less elongation is achieved. the initial elongation is very rapid. 67-72. Again. there is a rapid elongation of the tissue. but less than that achieved at the end of the previous treatment. as in progres­ sive stretching. In other words. An elevation in temperature will cause corresponding increases in creep. this phenomenon is consistent with the elastic characteristics of connective tissue.LASTIC MODEL "TENs. however. and some is retained due to the plastic. In stretching a restricted joint capsu Ie. a progressive elongation may be achieved. This phenomenon is seen often in the clinical setting.9. because the tissue was stretched into the viscous or plastic range. Vol. another portion of the change in length is lost.1. Hence. Journal of Orthopaedic and Sports Physical Therapy. . for example. and Owens-Burkhart. As time passes. Effects of Im­ mobilization on Ihe Extensibility ofPeriarlicular Con­ nective Tissue. component. The half­ creep. 1989.36 MYOFASCIAL MANIPULATION A)E. Grodin and R. Although the plastic component represents a permanent elongation.. When the stress is eventually released. a certain increase in range of motion may be achieved during a particular treatment session. or viscous.

Cantu with permission of Forum Med­ icum Inc.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. Grodin and R. 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. Copyrighted Material . © 1989."7 can be applied to connective tissue.16 Over time. it will adaptively shorten as collagen is laid down in the context of the length of the tissues and lack of stresses applied. If the tissue is not stressed for long periods of time. t-I _ ______ _ r > B < nt-'E .J. (B) Repeated elongations of cOllnective tissue (strain) plotted against time. All connective I A <-----i "ME. Source: Reprinted from Myofascial Manipulalion: Theory and Clinical Managemenl (pp 5-6) by A. Wolff's law. New collagen is laid down according to stresses (or lack of stresses) applied to the tissue. nontraumatized conditions. Source: Reprinted from Myofascial Manipulalion: Theory and Clinical Management (p 5) by A.- - -- - ----- )- Figure 3-11 (A) Elongation of connective tissue (strain) plotted against time. new collagen is laid down to replace older collagen. Source: Reprinted from Myofascial lvlanipulation. TheOl)' and Clinical Management (p 5) by AJ. Grodin and R. Cantu with permission of Forum Medicum Inc. F. which states that "bone adapts to the stresses applied. © 1989. Grodin and R. © 1989. Cantu with permission of Forum Medicllm Inc.

Williams and R. small dips or hitches appear in the curve that possibly represent early tissue microfailure.20 Under light mi­ croscopy.e. and the stress-strain curve drops to zero. 17.18 Ligaments have a less consistent parallel arrangement of collagen fibers than does tendon (Figure 3_13). and not very vascular. with further loading. allowing for tension or joint movement. The primary function of tendon is to attach muscle fibers to bone and to transmit forces expended by muscle to the bone with limited elongation. Warwick with permission ofW. Collagen production is thus less haphazard. 17.B. those stresses imparted externally by the clinician in the form of manipulation. Because of the histol­ ologic makeup of these tissues.19 The primary function of ligament is to check excessive motion in joints and to guide joint motion. © 1973. The stress-strain relationship of tendon is similar to that of other connective tissues. Because the spine in this condition cannot withstand the anterior shear forces applied daily.18 The collagen fibers in tendon have. may positively change the metabolic and physical homeostasis of the tissue. and laid down in a quantity and direction more suited to optimal tissue function. applied to connective tissue. Source: Reprinted from Gray s Ana/omy. accounting for the increased healing time required after trauma. When a tendon is stressed. The toe region is generally fol­ lowed by a moderately linear region with a slightly greater slope. been designed in a parallel arrange­ ment to provide the highest unidirectional tensile strength possible. the tissue is not highly metabolic. or by the patient. Specific Characteristics Dense regular connective tissue. ed 35 (p 40) by P. The high propor­ tion of collagen to ground substance and the parallel arrangement of the f ibers accounts for the high tensile strength and limited extensi­ bility of these tissues. they are the least responsive to manual work. more organized. Finally. Copyrighted Material .. the toe region (elastic com­ ponent) of the stress-strain curve is generally smaller due to the parallel arrangement of col­ lagen fibers. 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. This concept is more fully de­ veloped in Chapter 4. or carefully controlled stresses (i. the orientation of the collagen takes on an undulating configuration known as "crimp. with some minor differences. which is indicative of the tendon's greater stiffness. Ligaments and tendons are categorized as dense regular connective tissue.. A clinical example of this phenomenon is the connective tissue band that develops in the patient with spondylolisthe­ sis. Saunders.). facet joints. etc.38 MYOFASCIAL MANIPULATION tissue seeks metabolic homeostasis commen­ surate with the stresses being applied to that particular tissue. in time forming a connective tissue band. the body responds by laying down connective tissue. has a functional as well as a dysfunctional aspect. Normal stresses. Dense parallel arrangement of collagen fibers characterizes dense regular con­ nective tissue (Figure 3-12). Because of the compactness and density of collagen f ibers and the relatively small proportions of ground substance. in the form of exercises).e. With further tensile deformation."21 Figure 3-12 Drawing of dense regular connective tissue. This indicates less realignment of fibers than found in other connective tissues during tension. Wolff's law. therefore. the tissue fails completely. showing the parallel arrangement of collagen fibers. however.17.

showing overall parallel arrangement of fibers. nective tissue is generally characterized by a sparse. but is not limited to. able to resist multidirectional stress Sparse. tendons Characteristics of the Tissue Dense. joint capsules. has many different attachments. The lumbodorsal fascia. Loose irregular connective tissue contains a greater amount of ground substance per unit area than other types of connective tis­ sues. as well as muscle and nerve sheaths. regular connective tissue includes. aponeuroses. until all of the crimp is straightened out and. muscle and nerve sheaths. Source: Reprinteel fr om Loose irreguillr connective tissue. Loose irregular con­ This crimp phenomenon is thought to be respon­ sible for the mildly elastic characteristics ofliga­ ment. loose irregular con­ nective tissue is the most elastic and typically has the greatest potential for change when ma­ nipulated by external forces. The sup­ portive framework of the lymph system and the internal organs is also classified as loose ir­ regular connective tissue. areas of high mechanical stress Loose irregular Superficial fascial sheaths. multidirectional framework of collagen and elastin. The ligament functions biomechanically as a spring. multidirectional arrangement of collagen fibers. [n dense irregular connective tissue. Table 3-2 Classification of Connective Tissue Tissue Type Dense regular Specific Structures Ligaments. Dense ir­ regular connective tissue includes. greater amounts of elastin present Copyrighted Material . subsequently. parallel arrangement of collagen fibers. support sheaths of internal organs Dense. periosteum. multidirectional arrangement of collagen fibers. © 1973. and is pulled in different directions during the spine's normal function. but somewhat less parallel than tenelon. The ultimate biomechanical result is that liga­ ments have somewhat less tensile strength per unit area than tendon. but is not limited to. eel 35 (p 40) by P. Saunders. becomes more tensile when the collagen fibers are actually stressed. The major difference between dense irregular and dense regular connective tissue is the orientation of collagen fibers. the superficial and some deep fascia. proportionally less ground substance Dense irregular Aponeurosis. Loose ir­ Grays Anatomy. but have slightly more yield (Table 3-2). Warwick with permission ofWB. the collagen fibers are aligned multidirectionally in order to withstand multidirectional stresses (Figure 3-14). Williams anel R. Figure 3-13 Drawing of ligamentous tissue.Histology and Biomechanics of Myof ascia 39 Dense irregular connective tissue. and fascial sheaths under high degrees of mechanical stress. dermis of skin. Because of sparse concentrations of col­ lagen in this type of tissue. for example. penos­ teum. joint capsules.

Source: Reprinted from The total number of actual muscle fibers in a muscle is reached sometime before birth. or stri­ ated muscle. As with connective tissue. The striations reflect the functional contracti Ie unit of the muscle called the sarcomere. Human skeletal muscle. Saunders. which is anatomically and histologically similar. A large portion of the myofascial tissues includes muscle tissue. the myofascial tissues account for the majority of tissue being affected by orthopedic manual therapy. Satel­ lite cells.40 MYOFASCIAL MANIPULATION Histology Muscle is histologically categorized into three types: skeletal. cannot compensate for the amount lost during major muscle trauma or degeneration. however. however. This section focuses primarily on skeletal muscle. Skeletal. which in turn will provide a basis for understanding car­ diac and smooth muscle types.B. Likewise. a basic understanding of muscle tissue is also essential for an appropri­ ate empirical understanding of myofascial ma­ nipulation. Increases in diameter are accomplished by the addition of myofilaments in parallel ar­ rangement. The Grays Anatomy. With prolonged disuse. Muscle is also functionally characterized by fiber type based on speed of contraction or relaxation. and remobilization of muscle tissue must be built based on the scientific principles that will be outlined as follows. Actin and myosin fila­ ments are contained in the functional contrac­ tile unit of muscle called the sarcomere. the muscle shortens by losing sarcomeres and decreases in diameter by losing myofilaments. is so named because of its striated or banded appearance under light microscopy. smooth. immobiliza­ tion. Knowledge of trauma. can become activated to produce a limited amount of new muscle fibers. The actin and myosin in­ teract in a ratchet-type manner to shorten the muscle (Figure 3-15). bio­ chemistry and metabolism. Williams and R. The purpose of this sec­ tion is to provide a basic overview of muscle histology and how it relates to connective tissue. Copyrighted Material . the muscle fibers degenerate and the tissue is re­ placed with less metabolically active connective tissue. ed 35 (p 40) by P. The histology and physi­ ology of muscle tissue alone occupies whole chapters in textbooks. 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. showing the multidirectionality as well as high density of collagen f ibers. Mechanism of Growth ill Skeletal Muscle Figure 3-14 Drawing of dense irregular cOlUlective tissue. Much of the knowledge of mammalian skeletal muscle comes from studies of frog skeletal muscle. Cellular alld Histological Organizatiol1 of Skeletal Muscle The contractile proteins of striated muscle are actin and myosin. The number of new fibers that can be produced. Warwick with permission ofW. HISTOLOGY AND BIOMECHANICS OF MUSCLE As previously stated. which are believed to be a persisting version of the prenatal myotubes found inside basement membranes. and in circulation. does have some limited regeneration potential. © 1973. and cardiac.

Warwick with permission ofW. Myo­ filaments are arranged in bundles and are con­ tained in the (Z. ribo­ somes. and glycogen. A. Myofibrils are grouped together into bundles called fasciculi. The distance between two Z bands reflects the length of the sarcomere and will vary depending on the contractile state of the muscle. . R€MM. " M z "\. Loose connective tissue fills the area between myofi­ brils and is called endomysium. which reflect compo­ myofibril. Myofibrils are multinucleated cells that also contain mitochondria. changes depending on the contractile state of the muscle.**:* *. which is the muscle's nents of the sarcomere. Finally.-1 1 1 1 1 "\. Anatomy. .. · . lysosomes. does not change in length during contraction. whereas the I band. . transverse alignment of sarcomeres in adjacent myofi laments gives this tissue the striated ap­ pearance. · 1 1 1 1 1--. . . . which represents myosin molecules. . fasciculi are grouped together to form individual Copyrighted Material . ed 35 (p 479) by P Williams and R. cellular unit.. The striations result from a series of bands Sarcomeres are arranged in series to form cy­ lindrical organelles called myofilaments. Sa. The A band. which represents areas where actin does not overlap myosin.B. A loose con­ nective tissue sheath also surrounds the muscle fasciculus and is called the perimysium. r © 1973.com r 11 Figure 3-lS Diagram showing the organization of skeletal muscle and the mechanism of shortening.*:*:*: **:*:* **: *:* · . Saunders. I bands).Histology and Biomechanics of Myofascia 41 Myosin Ilclin+myosin Actin 4 1 1 1 I 1 1 I 1 1 *. Source: Reprinted f om Gray :\.

© 1973.?f • It i 3-3). Type I fibers are slow t witch fibers that have the slowest contraction times. but have the richest concentration of mitochondria and myoglobin. Within an individual. Williams and R. These connective tissues provide a certain amount of coherence in the muscle while allowing an appropriate degree of mechanical freedom. A high concentration of myoglo­ bin and mitochondria is still present in these C' \\ " IF n�""""'"' ·\/Y(JJIII . or JIm (Table \/\. There is variability in the relative percentages of each type between individuals. Muscle Fiber Types Human muscle is a mixture of Type I and Type II fibers. Figure 3-16 Diagram showing architectural hierar­ chy of muscle tissue.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. I1a.oJibnl I I I I I I I I -tJli) _jsmI. 3-16). ed 3S (p 481) by P. They are also the lowest in glycogen stores. Because of these characteristics.21 Muscles are generally categorized according to the predominant fiber type present throughout the muscle. War­ wick with permission of WB. Source: Reprinted from Gray s Anatomy. lIb. The postural muscles of the body have a predominance of Type I fibers. 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. Saunders. The loose connective tissue sheath that envelops the muscle is called Biomechanics of Muscle T he connective tissues of skeletal muscle have important roles in the optimal function of muscle. there is a correlation be­ t ween muscle function and fiber composition. T he following fiber type classification is cur­ rently the most widely used.22 Fibers are clas­ sified as Type r. Copyrighted Material .42 MYOFASCIAL MANIPULATION muscles (Figure the epimysium. since it most closely approximates the individual muscle fibers. Type JIa fibers (also called fast twitch/ ioxidative or fast red fibers) are intermediate fibers that have a faster contraction time than Type I fibers while remaining moderately fa­ tigue resistant.Ittln -S"iCiiii ��. Type J fibers are the slowest to fatigue.] The endo­ mysium is particularly significant in these roles.

tendon. Type JIb muscle . Histology of Myotendinous Junction The attachment of the muscle is generally through tendon. twitch/glycolytic or fast white fibers) have faster contraction times and rely more on glycolytic pathways for energy metabolism. injury to the junctional zones is quite common. glycolytic metabolism Type 11m Superfast fibers. These musculotendinous junc­ tions are highly specialized areas. Alternately. low content of glycogen. increased numbers of mitochondria. fatigue resistant Faster contraction times than type 1 .24 Numerous recent stress-strain stud­ ies indicate that most tissue failures occur at or near the myotendinous junction25-3o Myofascial restrictions will commonly be found in the areas of the junctional zones due to the frequency of injury to these areas. glycolytic metabolism. First. Finally. are much more susceptible to strain injuries. has been identified in mammalian muscle tissue. and the clinician should be aware of these areas in myofascial evalua­ tion. Type Iia Fast twitch/oxidative (fast red) Moderately high concentrations of myoglobin. T he most common site of those injuries is at the musculoskeletal junction. glycolytic/oxidative (mixed) metabolism less fatigue resistant Fast contraction times. oxidative metabolism Characteristics Slow contraction times. therefore. including human muscle tissue. preliminary to a study of their histopathology and to an empirical understanding of myofascial evaluation and treatment. and joint capsule insertions to bone. increased numbers of mitochondria. Type I!b fibers have a lower concentration of myoglobin and mitochondria and are not fatigue resistant.2! tissues. a superfast fiber. decreased numbers of mitochondria Contains unique myosin configuration.Histology and Biomechanics of Myofascia 43 Table 3-3 Classification of Muscle Fiber Types Fiber Type Type I Functional Classification Slow twitch Functional Metabolic Characteristics High concentrations of myoglobin. those which cross two joints and those working eccentrically. Early studies indicate that although injury can occur in any portion of the myofascial Copyrighted Material . the cell membrane forms a continu­ ous interface between intercellular components HISTOLOGY AND BIOMECHANICS OF JUNCTIONAL ZONES The junctional zones in the myofascial tis­ sues include the myotendinous junction and the ligament. fatigues easily Very fast contraction times Type lib Fast twitch/glycolytic (fast white) High glycogen content. A basic understanding of the histology and biomechanics of junctional zones is. Several histological differences occur in the transitional area between muscle fibers and tendon that give it unique functional character­ istics. The muscle belly attaches to tendon at tlle musculotendinous junction on each side of the belly. termed lIm. high glycogen content. This type of fiber is found primariIy in the jaw muscles and contains a unique myosin that distinguishes it from Types I and 1I fibers23 Muscles with a greater percentage of Type n fibers.

...... Within the cell. --.. ... ... thereby reduc­ ing the stress per unit area on the membrane..••••• . .. Stud­ ies indicate.. muscles with predominantly fast twitch muscle f ibers have an increased folding of the junctional membranes.. . Extracellular components (EX) include tendon collagen fibers junctional plasma membrane (I) and basement membrane (2). -. ....4o. § JEX liN .A.. Biomechanics of the Myotendinous Junction As previously mentioned..-...---.-.. Interestingly.llIIlllQll.-­ " " . however. the decreased extensibility of the ter­ minal sarcomeres also makes the tissue in this area more vulnerable to tearing. ... . M' .. This would create a tensile load at the junction... placing the membrane primarily under shear forces.. . . © 1987... ............-.. ... Finally. believed to be derivatives of actin. This is accomplished architecturally in the following manner...... .. Figure 3-17 Schematic drawing of the structures involved in force transmission between tendon and contractile proteins... " . .. and greater cumulative tensile strength is required to sustain and transmit such forces.. attach from the terminal Z disks of the 2 3 4 5 1 _ v _ _ _ Jv _ v V _ _ _J_ _ _ __ _ J_ __ _ ...42... . .-... .'. Another significant histological characteristic of the myotendinolls junction is decreased sar­ comere length and extensibility42.. .... ..-.. The cell membrane at this junction becomes highly folded or convo­ luted allowing the contractile intercellular com­ ponents to interdigitate with the extracellular components31-38 The folding of the cell mem­ brane increases the surface area... . .:t:!:e...... . Thin myofilaments. the intercellular contractile units must ultimately be coupled with the collagen fibers of the tendon for transfer of forces to take place (Figure 3-17). The (3) separates extracellular (EX) and intracellular (IN) force-transmitting structures..... F' .. " .44 MYOFASCIAL MANIPULATION of muscle fibers and extracellular components of connective tissue....-..... .. a .4J cussed further in Chapter 4. subsarcoJemmal malerial (4)...".......---:: -_-_-_-:::_-_ -:_-_ _-_-_-___-_ . If the folds did not exist.. the junc­ tional membrane would experience vector forces at right angles to the membrane surfaces. Buckwalter with permission of the American Academy of Orthopaedic Surgeons. ..-. Woo and J....41 This also decreases the load per unit area being transmitted from the muscle. the membranous folds increase the potential adhesive area in the musculotendinous junction.... Copyrighted Material ..llllIIlltllUllllIIllllPllll1I .. < ( IIQIIJllllllltlll....-Y. that cell membranes are highly resistant to shear forces that would in­ crease their surface area....... Source: Reprinted from Injury and Repair of the Musculoskeletal SoJi Tissues (p 184) by SL..: .. ... .. The folds hold the membrane at a low angle in re­ lation to the forces coming from the muscle f ibers.. . .. .39 The design of the folds allows for much higher force transmission before tissue rupture. This phenomenon is probably related to the fact that higher forces are developed in fast twitch muscles than in slow twitch muscles.. ... More sig­ nificantly.. .. .. .. as evidenced by the frequency of injury in the experimental models. ..--.... .-.. .... .4J acteristic results in the myotendinous junction first being loaded by terminal sarcomeres and subsequently being fully loaded by the rest of the sarcomeres in the muscle belly... .. thin actin filaments (5) are attached to the cell membrane by dense.•• .

44 These fibers are de­ scribed as originating in the periosteum and per­ forating the underlying bone. where mineral deposits are found around collagen f ibrils. which in turn attaches to bone. which in turn attaches to bone. and the actual attachment site. a basic review of the histology and biomechanics of these junctions is necessary to understand their response to trauma and pathology. Zone 3 consists of mineralized fibrocartilage. the entire bone­ tendon-bone unit. Indirect insertions do not have specifically defined zones as do the direct insertions. The base­ ment membrane is then attached to collagen fibers of the tendon 32-35. The deep f ibers insert into bone or by way of f ibrocarti­ lage.37. The superficial f ibers generally attach to perios­ teum. Zone 2 consists of fibrocartilage. ligaments. and capsule are relatively avascu­ lar compared with the tissue on either side of the zone. The main difference is that the direct inser­ tion has a f ibrocartilaginous transitional zone. rather than in series. these junctions are common sites of injury and remain areas of weakness during loading. zone 4 consists of bone. or capsule. The base­ ment membrane contains type IV collagen and high molecular weight glycoproteins. the connective tissue is transformed into hard tissue (Figures 3-18A and chondroblasts or chondrocytes. the architecture is designed to dissipate tensile forces and minimize stress concentra­ tions.45 6 . as are fibroblasts. The attachment sites undergo more significant strain (elongation) before receiving significant stresses. while the indirect insertions do not. Two types of insertions are iden­ tified in the literature: direct and indirect. These transitional fibers are sometimes referred to as Sharpey's fibers. and joint capsule to bone also vary in their biome­ chanics because of differences in the forces im­ parted by these tissues. but also makes this region more vulnerable.3S As can be seen in Figure 3-l7. ligament. The cells in this region resemble Copyrighted Material . tendon. Direct insertions have four distinct histological zones that represent the transition of the tissues from soft connective tissues to bone. Fi­ nally. indicating that strains in this region are greater than any other region.4 The attachment sites of ligament. The resiliency of the tendon­ bone junction was demonstrated by Noyes and associates49 Several samples of patellar tendon were analyzed to determine stress-strain charac­ teristics of the tendon proper. Obviously. IS No fibrocartilage is seen in indirect insertions. the cell mem­ brane can accommodate shear forces more opti­ mally than tensile forces. This allows for more force dissipation at this region. As with the myotendinous junction. therefore. Connective Tissue InsertiOIt to Bone The insertions of tendons. where the col­ lagen fibrils merge with the f ibrils of the bone matrix. The contracti Ie proteins of the muscle sarcomeres. The connective tissue fibers tend to blend more with the periosteum. whereas the ligament and joint capsule-bone junction will have lesser forces.4 4 Zone I consists of the actual tendon or liga­ ment. and joint capsules to bone vary somewhat in their histo­ logic architecture. Another commonality is that the junctional zones of liga­ ment. Despite their architectural design. have an attachment to the cell mem­ brane. tendon.Histology and Biomechanics of Myofascia 45 myofibri Is to a thickened cell area of the inner cell membrane called the subsarcolemma. The histology of this zone does not differ much from the histology of ordinar y tendon. anchoring the peri­ osteum to underlying bone. 4 A common feature of the two insertional types is the presence of superficial and deep fibers. Within an area of I millimeter. Collagen fibers are found here embedded in the matrix or ground sub­ stance. the tendon­ bone junction will have greater forces because of the forces generated by muscle. As with the other areas examined in this chapter. As previously mentioned. all of the com­ ponents of the myotendinous junction are cou­ pled in a parallel arrangement. The outer portion of the cell membrane is similarly attached to a basement membrane that runs parallel to the cell membrane. B). and the architecture of the myotendinous junction reflects this ef­ ficiency.

uncalcified f ibrocartilage (FC). Benjamin. p. Source: Reprinted with permission from M. © 1986. © J 987. Gomez et aI. 69A.· Reprinted with permission from SL. The Biomechanical and Morphological Changes in the Medial Collateral Ligament of the Rabbit after Immobilization and Remobilization. Cambridge University Press. 1207. Journal ofAnatomy. Vol. The arrow indicates the line of caJcification..46 MYOFASCrAL MANIPULATfON A B Figure 3-18 (A) Direct insertions. pp. of the ligament (B) Femoral insertion of rabbit MCL The deep fibers (L) pass into bone through the fibrocartilage (F). M. E. The four distinct zones seen in the supraspinatus insertion.Y.. 149. Evans. The four zones are tendon (T). )ollrnal qf Bone & Joinl Surgery. Source. and bone (B). The Histology of Tendon Attachments to Bone in Man. J ournal of Bone & Joint Surgery. 89-100. No. Copyrighted Material .J.A. Woo. Figure 6-A. et aI.

Tension studies of human knee ligaments.213: /532-1545. Lehmann JF.48(3). Ritter D. Woo SL-Y. it is essential for our pro­ fession to establish credibility in what we do. Soji Tissue 8. 19.9:384. Barlow Y. The biomechanical and bio­ chemical properties of swine tendons: Long-term effects of exercise on the digital ex tensors. 1984. Tensile strength properties of Scand. F. Frankel VH./ Biomech. A novel myosin present Hcinmann LTD. and reimbursement by insurance com­ panies is decreasing.7:177--183. Histopathology of muscle tears in stretching injuries. MD: Williams & Wilkins./HIstologl'. mation of tendon. 1987.13:521-528. 25. 2. Schliack Therapy o/'the H. Allanta. Garrett WE Jr. 26. Philadelphia: JB 15.480-42. skin and tendon in normal rat. 1967. Trans Orthop Res Soc. McMaster PE.58:A350-A355. Phi ladelphia: WB Saunders. 12. 1986. Yield point. Biophysical 9:57-65./ Bone Joint Surg. New York: 10. 3rd ed (Br). Nachemson AL. McGraw-Hili.1:211. Quedenfcld TC. NY: Sidney Histology. et al. Textbook o. 1976. Biochem. 1968. 17. Copenhaver W M. Hooley CJ. Warren CG.I 1981 . Fielding J W. 11. 1933.GA: Slokesville Pub­ lislling. 1980. H. 1973:32-41. Sports Physical Therapy. Geneser Skeletal System. AIII.57:122-126.2:415-438. where various types of practitioners are competing for patients. 1978. Wolff A. Norris C. 13. Savannah. eds. Tendon and muscle ruptures: Clinical and experimental studies on the causes and 10cMion of subcutaneous ruptures 705-722. Baileys Text­ book ofHistology. Barnes . The viscoelastic defor­ . Crutchfield CA. Warwick R. Scarsdale. Physicion Sports Med. 7. Lippincott: 1979 210-259. The metabolism of collagen from bones. Arch Pilys . et al.53:47-52. 1992.I Physial. ultimate failure. M. Rowlerson A. In: Engel AG. 1993. 16. Ham AW. Gauthier GF Skeletal muscle fiber types. 1976. Cormack DH. 4. Banker BQ. J :255-284. 1984. This understanding will allow the therapist to set realistic goals for manual treatment. 1980. In ury j Musculoskeletal Soji Tissues. Almekinders LC. Acta Orthop 20. 6.I Biomech. faclors in in cat jaw c losin g muscles . Simon Publishers. 22. Willoughby S. Kennedy JC. Burstein AH. Williams PL./ the & Fcbiger. /969./ BOlle. especially in the area of myofascial manipulation. 14. Bunge 1971. Viidik A. 1981. II Sapega AA. et al. GA: American & Academy of Orthopaedic Surgeons Symposium. 5.9:306. Elasticity of soft tissues in simple elonga­ tion. et al. et al. Sports Injuries: Diagnosis' lind Ma nagement . Churchill Livingstone.1:3. . Garrett WE Jr. et al. Oxford: Bullerworlh Br ivIed Bull.40:261-272.5: Mer! Rehahil. 1985.f). range of motion exercise. 1980:56. Gray:5 A nat omy. using rat tail tendon. Slack liver. Nordin 87-110. Spine. Baltimore. Pope B. 21. Buckwalter JA. et al. 1953. The nuchal ligament.698-711. Hawkins RJ. Muscle Res Cell Moti!. Achilles tendon systems in trained and untrained rabbits. Bunge RP. a thorough understanding of basic anatomy and biomechanics is necessary for the manual physi­ cal therapist to be successful in the treatment of the myoJascial tissues. New York: 1986. . 1986. Philadelphia: Lea 18. MR. Almekinders LC. Basic Biom echan i cs S. In this day and age. and Repair of the MB. A.ology.Histology and Biomechanics of Myof ascia 47 CONCLUSION The information covered in this chapter was primarily of a basic science nature. Evans JH. Connect Tissue Res. Copyrighted Material ./. Heat and stretch proce­ dures: An evaluation 24. Changes In COlltractllres. and disruption of the cruciate and tibial collateral ligaments. A ""Ianllat oj Rellexlve Connective Tisslle. 3. et al. Fung YCB. 9. Although somewhat removed from the clinical realm. Art and science must be carefully balanced as the profession forges ahead. Bernhardt D. 1976. 23. Tro n s Orthop Res S oc. REf'ERENCES Dicke E. Cummings G. Woo SL-Y. Pathophysiology of Soft Tissue Repair. Philadelphia: Lea 0. Pathophysiologic response to muscle tears in stretching injuries. Febiger.Ioint Surg. McCrum NG. Neubergcr A. Some mechanical proper­ ties of the third human lumbar inlerlaminar ligament (ligamentum flavum) .

48 MYOFASCIAl MANIPULATION 39 tears in stretching tics of membranes. 1957:24:255-260. biomechanical and medial collateral ligament of the rabbit aftet immobihzaiion and rcmobdization. morphological changes in Bone Joint Surg.9:384. Cell Mali/. I 1-438. dalljuncliol1 in mammalian skeletal 111usck. Am J AI/a/. 1986. Nikalaoll PK. et al.1 0:1--64. . Mair W GP. Garrett WE Jr.. A morphometric analysis of the muscle-tendon junction. Huxley AE 1966. knee joint. Gordon AM. 28. el al. 1960. Milton RL. Alia! Rec. 44.I tendon of the human 34. Bikennan JJ Stresses in cnce ccrlanocllCnnical proper­ Membrane" Transport. Hsi K. Trotter lA. Evans attachments to bone in 47. 588-604. Huxley AF. Macdonald BL. 1968 192-263 41 Lubkin JL The theory of adhesive scarf joints. Misol S. Cell /'. ACla NeuropalllOl. J Physio/. Med Sci 21:506-514. Eisenberg BR. Tidball JG. 30.52:AI-A21 45. Eberhard S. 1987. TenslOn development ill highly stretched vertebrate l11uscle fibers. 43. Computed tomography of hamstring mllscle strains. 1979. The geometry of actin filament membrane associations can modify adhesive strength of the myo­ tendinous junction. 1961. Benjamin M. et 81. J 989. muscle cells: structure and loading.3439-447. al. 1984.2:325-336.184: 143-169. al. 36. Z Zel/fVl'seil insertion: A light and electron microscopic study J Baile Join/ Surg.56:A236-A243. et at The architecture an the biomechanical failure properties of skeletal muscle under passive extension. Harrop TJ. Tendon 1970. o['Adhesive Juil1ls. Structurnl connections of tile muscle-tendon junction. 1984. Nikolaoll PK. Biomechanicsl and histological evaluation of muscle after controlled strain injury. et al. Gamez MA. Noyes FR. J Bone '/oin! Sill'!!. Muscle fiber termination at the tendon in the frog's sartorius: A stereologtcal study. Rubin RM. 171:273-284. 1985. 38. Peachy LD The maximal length for traction in vertebrate striated muscle. 49. Acto Anal. Soc. The fine muscle tendon junction in the rat. Rich FR. of musc!e 40. 42. The ultrastructure of the adult and developing human myotcildinous junction. Tidhall JG. Gelher D. Woo SL-Y. et al. Trotter lA. Daniel TL. Am J SPOl'iS Afed 1988:16:7--12 29.245:315-322. I. Biomechanics of anterior cruciate ligament failure: An analysis of straill-rate sell­ sitivily and mechanisms of failure in primates. Tame F MS. CoopCI' RR.21 :239-252.2 J 3:26-32. 1987. 35. et 31.10Iil. Garrett WE Jr. Mackay B. 48. 156:150-165. 1983. I 974. Microvasculature of the cruciate ligaments and its response to injury: An experimental study in dogs. J Bone Joint Surg. 37. J Appl /c1ec". New Press. Amoczky SP. J COIl­ al. 1 972.69: A 46. et al.61: A1221-A1229. Copyrighted Material . myatcl1­ Pilysiol. Moore DH. Observations Afikrosk Aoal. Alii J Sports Meil. Delucas l L. 1978. 15:9-14.

I The changes may also be af­ fected by the age and fitness level of an indi­ vidual. process with a sequence of recurring stages. redness. In the previous chapter. Because vertebrates lack the ability to regenerate exact duplicates of injured parts. With that groundwork laid. 1-4 This chapter will divide the scar process into four distinct phases: (I) the inflammatory phase. The literature varies as to whether there are three or four distinct phases a wound passes through. and (4) the maturation phase5.8 Whole blood poured directly into a wound will coagulate and temporarily seal off the injured vessels and lymphatic channels. and A Zan J Grodin HISTOPATHOLOGY OF MYOFASCIA The basis of all treatment techniques lies in understanding the basic processes of soft tissue healing. Cantu. resulting in vasodilatation and the appear­ ance of a reddened. a normal prerequisite to heal­ ing. This in turn leads to the cardinal signs of inflam­ mation: heat. With an awareness of the changes that occur in the myofascial tissues under dysfunc­ tional conditions. is the first phase seen after a trauma. This traumatic exudate acts to temporarily seal the wound. swelling. Injury causes chemical and mechani­ cal changes leading to alteration in blood flow. and swollen region.i Prostaglandins. and within one wound itself areas in various phases of heal­ ing may be seen. This phase begins immediately and may last 24 to 48 hours.6 Time tables for the beginning and end of each phase must be understood as general guidelines. hot. Robert I. the normal his­ tology and biomechanics of myofascial tissues were discussed. The inflammatory response to injury is the same regardless of the injuring agent or the location of the injury.CHAPTER 4 Histopathology of Myofascia and Physiology of Myofascial Manipulation Deborah Cobb. formed from cell membrane Pathophysiology of Soft Tissue Repair A wound by its most basic definition is a dis­ ruption of unity. this chapter will now address the histopathology and pathomechanics of those same tissues. (3) the fibroplastic phase. The scar formation process is not a cyclic but a linear 49 Copyrighted Material . and pain. response to injury comes in the form of repair through granulation scar tissue. A review of classic as well as recent literature will be used to provide an understanding of scar formation after trauma as well as how myofascial tissues can be affected by immobilization and remobili­ zation. Histamine is released by the injured tis­ sues. The intuitive aspects of myofascial ma­ nipulation must always be balanced by a solid understanding of tissues and their response to dysfunction. a manual therapist can then set realistic treatment goals and choose the most appropriate treatment techniques to accomplish them. Dif­ ferent tissues heal at different rates.7 Inflammation. (2) the granulation phase.

.lo Heat application at this point may cause increased bleeding in the fragile healing tissues. new collagen is laid down in a disorganized manner in the area of the wound. ice. Vol. Shortly after. joint capsules Figure 4-1 Encouraging favorable healing conditions. remove hematoma . macro­ phages appear to continue the phagocytic pro­ cess and to begin influencing scar production. Gentle manual therapy acute inflammation fibrous repair remodelling and contraction months . Physiotherapy. Proliferation of f ibroblasts and accelerated collagen synthesis now occur. gentle movements . wound closure occurs in 3 to 5 weeks.. etc.9 Its role in recruiting fibroblasts is significantly related to the final amount of scar produced. Vol. Wound closure usually occurs at this stage. As the fibroblasts proliferate. Modalities aimed at de­ creasing inflammation. and appropriate anti-inflammatory medications are of the most value at this point (Figure 4-1). I. Phagocytosis is initiated by short-lived polymorphonuclear leukocytes that first attach to bacteria and then dissolve and digest them. PhYSiotherapy. Evans. muscles.). In tis­ sues with high metabolic activity (muscles. Specific SoflTissue Mobilization in the Trealment of Son Tissue Lesions. elevation. 80. Physiotherapy Canada. Strength of the wound is determined not by the amount of collagen laid down but by the bonding of the collagen filaments or cross­ links (Figure 4-2).8. © 1994. protect weak jOint. 12 Because vascu­ larity remains high during this phase. Immobilization is essential during this phase to permit vascular regrowth and prevent further microhemorrhages and tissue breakdown. Healing cannot pro­ ceed further unless this increased connective tissue vascularity can meet the metabolic de­ mands of the healing tissues. compression. 66.I. wound closure occurs in 5 to 8 days.g. and the time frame varies depending on the vas­ cularity and metabolic rate of the tissue. skin. Hunter... Physiotherapy Canada..I I Rebuilding of tissue begins with the fibro­ plastic phase. The Healing Process at the Cellular Level. I At this point.6 During this phase. are re­ sponsible for pain production.. pp. movement in this area would be disadvantageous and could lead to further tissue and/or clot disruption.2 Phagocytosis then occurs to prevent infection in the wound and prepare the wound for healing. Source: Reprinted with pe rm is s i on from P. ensure joint is stable. 256-259..3 The cross-linking allows for early controlled movement without disruption of the wound. gentle handling of the wound is essential. allow new collagen to feel normal tensions 2 3 4 5 6 7 8 ..50 MYOFASCIAL MANIPULATION phospholipids when cell damage occurs. No. pp. the im­ mature scar sti II has a characteristic pink color­ ing. Controlled movement will cause the fibrils to align lengthwise along the line of stress of the healing structure. and G. The granulation stage is so named because of the appearance of capillary buds that microscopi­ cally look like granules. proper positioning. 15-21. e. Copyrighted Material . No. The granulation phase begins when the mac­ rophages and histiocytes debride the area.. © 1980. In tissues with lower metabolic activity (ligament and tendon). prevent undesirable shortening.

Without controlled stress or mobiliza­ tion during this phase. Dec. Cycle or Fibrosis and Decreasing Mobility in Connective Tissue The fibrotic process is histologically distinct from the scar formation process. Arem and Madden 12 confirmed that a long duration stress during this phase.Histopathology o/Myo/ascia and Physiology oJlvlyoJascia Manipulation 5I Intramolecular Cross-links Collagen filament [ a. Physical Therapy. 1989. 69. (8) Stronger intermolecular cross-links form from one coJiagen filament to another. A Cross-link Amino acid chains Intramolecular Cross-links Collagen filament [ [ '-/"_ __ _ ):__ ""'l W-. The f ibrotic process in connective tissue is a "homogenous" physical change in scar length could be achieved through the application of low load. Source: Reprinted from Hardy.6 The final stage of scar formation is the matu­ ration or remodeling phase. leading to further deposition of collagen5. Copyrighted Material . This stage may last from 3 weeks to 12 months._ _ . No 12. Vol. a. the scar tissue is responsive to manual therapy but the progress will be somewhat slowed. Collagen filament B Figure 4-2 Collagen bonding increases tensile strength: (A) Weak intramolecular cross-links form between amino acid chains within one collagen filament. tensile strength of the scar will not improve and optimal function wiJl be diminished. A reduction in wound size. A. techniques may be appropriate at this time. however. and an increase in the strength of the scar are all characteristic of this phase. Biology of Scar Tissue. collagen must change in order to reach maxi­ mum function. with permission of the American Physical Therapy Association. Soft tissue mobilization designed to break up scar tissue will inflame the wound.13 During this phase. During this time. a realignment of collagen fibers..

shrinking the tissue. With an inflammatory response. which. The collagen begins to be laid down in more haphazard arrangement since ad­ equate stress is not being placed on the tissue. anchor to adjacent collagen fibers and contract. \ . The fibrotic process is generally initiated by the production of an irritant. With increased vascularity and debride­ ment of damaged collagen (from microtrauma). Increased vascularity Increased J \ Increased production of connective tissue (fibrosis) / fibroblastic activity Figure 4-3 Cycle of fibrosis and decreasing mobility. In­ flammatory exudates. The tissue shrinkage results in further dysfunctional movement. are carried away. Chronic irritant Abnormal movement (biomechanics) . in turn. which then starts the process." and does not have clear­ cut stages as does the scar tissue formation pro­ cess. or structural or movement imbalances. fibroblasts are activated to replace lost colla­ gen. The fibrotic process is cyclical in nature. At one point. habit patterns. The low-grade irrita­ tion may be caused by arthrokinematic dysfunc­ tion. along with damaged col­ lagen and other waste products. creates more mechanical stresses and more chronic irritant (Figure 4-3). As long as an ir­ ritant is present. Copyrighted Material . The fibrotic pro­ cess in connective tissue can continue as long as the irritant is present. the joint is not being moved in proper fashion. The myofibroblasts. A rotator cuff irritation. whereas the scar formation process is a linear process that has a distinct end.52 MYOFASCIAL MANIPULATION process involving an entire tissue area or the entire tissue "fabric. Macrophages activated Shrinkage of connective tissue Increased myofibroblastic activity . which contain significant amounts of actin and myosin in the cytoplasm. myofibroblasts appear in similar fashion as in the scar process. and cross-linking with other preexisting col­ lagen fibers begins. overuse. The mechanical irritant produces a low-grade inflammation. oc­ cupational overuse syndromes. poor posture. The increased metabolic activity in the area stimulates the body to increase the area's vascu­ larity. may be caused by a poor tennis service. Since the inflammatory process is gener­ ally painful. poor sleeping postures. and other causes. macrophages are activated to clean and debride the area. for example. possibly trau­ matic exudates from nearby acutely inflamed traumatized tissue or a low-grade irritation/ inflammation of the tissue. the cycle continues.

and do not the orthopedic non traumatized. factors why ap­ in immobile connective tissue is the colJoss in ground showed several significant many of the studies that are discussed in this chapter deal with the response of lization. Most of the currently available research.15 In­ exhibit changes within 4 to [0 connective tis­ to limit mobility. All of these sponses of traumatized and/or scar tissue. This created maIC[. which became more fibrotic. " or a change in the infiltrate's appearance. one of the purposes of the ground substance is to lubricate the area between f ibers. and one being a with no histochemical the primary loss.and S3 Response of Myofascial Tissue to Immobilization knee joint. W hen the criti­ cal interfiber distance is not fibers approximate and cross-linked by newly Also. From a the authors found fibro­ especially in the the amount of infiltrate found. The f irst is that these are animal tion. Trauma does affect the mechanics of the Also tion on the into the scar formation. the results of which should be app! jed to the human and of greater clinical importance. Nontrallmatized Connective Tissue components of lost ground substance were the is subjected to immobilization. the water loss is explained. because coHagen fibers are laid down ac­ to the stresses lack of The collagen then binds adjacent the extensibility of the tissue Several gen is not. The Connective tissue has a characteristic his­ tological and biomechanical response to im­ mobilization. The and water. 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. A the tibia to was connective cells 14. This must be maintained between allow them to microadhesions between fibers. focuses on animal studies in which an area of the body is immobilized for a of timc. the half-life of nontraumatized collagen is 300 to 500 days whereas the half-life of substance is L 7 to 7 days23 25 with immobilization times of less than 12 one-third of the femur to the distal one-third of Copyrighted Material . In studies Woo and primar­ animal studies on immobilized connective tissue animals were immo­ internal fixation for periods from 2 from the proximal avoid the amounts of ground substance are lost. to sues were their associates. The authors re­ a 30 percent to 40 percent loss in both sul­ fated and nonsulfated groups. and the effects of immobiliza­ clinical scenarios are addressed in detail because the response of normal connective tissues to im­ mobilization provides a basis for traumatized conditions. In that has been immobilized has also been trauma­ tized. Since the purpose of the nonsulfated group is to bind water. The animals were then sacrificed at various times of immobilization and the ticular tissues were histochemical fatty and biomechanically. As noted in the chapter. Much of the by Amiel. fiber lubrication is associated the distance that with the maintenance of the so-called critical interfiber distance.)Sc:op adhesions in the recesses and capsular folds. ily knee bilized to 9 weeks. connective tissue to immobi­ address the re­ connective tissue and bio­ is the process of scar tissue. folds the with and recesses.

forming cross-links onto existing collagen f ibers. with per­ mission of the Orthopaedic and Sports Sections of the American Physical Therapy Association. The biomechanicat implication is that fibrofatty macroadhesions and microscopic adhesions in the form of increased collagen cross-linking contributed to the decreased extensibility of the connective tissue. the passive range of motion of the gle­ nohumeral joints was markedly decreased and intraarticular pressure was raised during move­ ments. which looked at rat ankles immobilized for 2 to 6 weeks. Woo and J. 67-72.54 MVOFASCTAL MANIPULATION of synthesis. Vol. Functional and structural changes began to reverse after remobilization and re­ turned to normal limits after 12 weeksY A more recent study. Copyrighted Material . After 12 weeks. Reprinted from Injury and Repair of the Musculoskeletal SoJi Tissues (p 112) by SL. Source: Reprinted from Donatelli. At the end of that time. The capsule showed hyperplasia of the synovial lining and vascular proliferation of the capsular wall.26 Biomechanical analyses indicated that ten times the torque required to move a normal joint was required to move the immobilized joints. Buckwalter with permission of the American Academy of Orthopaedic Surgeons. These cross-links are be­ lieved to be responsible for decreased extensibility in immobilized connective tissue. Effects of Immobilization on the Extensibility of Periarticu­ lar COJlnective Tissue. 3.. Source. Figure 4-5 Electron micrograph of normal ligament (left) and healing scar at 2 weeks (right). found collagen synthesis occurs at the same rate as collagen degradation. R. the rate of collagen degradation exceeds the rate slightly different results. B. This study found that dense connective tissues remodel in such a way that mobility is unaffected after 2 weeks of im- Figure 4-4 Drawing showing the laying down of newly synthesized collagen. however. the amount of torque required to move the immobilized joint was re­ duced to three times that of a normal joint. and net amounts of collagen are lost. After several repetitions.A. 16-21 Schollmeier et at immobilized the forelimbs of 10 beagles for 12 weeks. and Owens-Burkhart.-Y. © 1987. pp. Journal of Orthopaedic and Sports PhySical Therapy.

which limited early mobility.. Journal a/Orthopaedic and Sports Therapy. Langenskiold et al performed a study on im­ mobilized. rather discrete adhesions between folds of tissues were responsible for this. The investigators found that. but the longer the period of immobilization. the curve exhibited intermediate plateaus ( ). Earlier studies implied that cyclic mobilization of the immobilized joints caused rupture of the remodeled tissues. or both. the macroadhe­ sions were ruptured. p. with permission of the Orthopaedic and Sports Sections of the American Physical Therapy Association. and Andrew. healthy rabbits. was able to restore 90% of joint mobility after 3 weeks. following each yield point. the angle of the slope of the curve is unchanged. functional range was regained. The authors found that casting for 5 to 6 weeks significantly de­ creased knee flexion. If joint motion was allowed subse­ quent to the manipulation. with manipulation. C. and partial joint mobility was restored.22 ex­ perimentally immobilized rat knees were remo­ bilized either by high-velocity manipulation. In all ankles casted for 6 weeks. - c \ '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). however. In a study performed by Evans et al. The Effect of Nontraumatic Immobilization on Ankle Dorsiflexion. No. In summary.Histopathology of Myofascia and Physiology of Myojascia Manipulation 55 mobilization but markedly limited after 6 weeks of immobilization28 The authors attribute these changes to dense connective tissue undergoing remodeling between the 2 and 6 week periods. Histologically. did not regain full functional range. Again. followed by small but sudden slipping further into dorsiflexion (*). et aI. Cummings. 23. This supports the idea that rupture of the remodeled tissue that initially limited motion had not oc­ cllrred. The resumption of normal activity.A. produced the same effect. only 28% of knee flexion returned after 10 weeks of re­ conditioning. In Figure 4-6.. suggesting rupture of an adhesion with each slip. When immobiliza­ tion was increased to 7 to 8 weeks. I. Rat knee joints immobilized for more than 30 days..S. by range of motion. although more gradually. 31. after 35 days the joints were histologically indistinguishable. PD. Vol. Range of joint motion. Copyrighted Material . along with freedom of movement. the re­ sults suggest that movement restores the normal histological makeup of connective tissue. however. this results in decreased tissue extensibility due to the inability 75 (j) Q) OJ Q) t :j: 50 0 x . the lower the potential for achieving optimal results. G.29 The study suggests that the longer the period of immobilization. the more difficult it becomes to regain normal tissue structure and mobility. It took as long as 12 months for some of the animals to regain full mobility. The loss of ground substance also allows for signifi­ cant water loss. Source. immobilization of connective tissue generally results in loss of ground sub­ stance with no net collagen loss (with immo­ bilization periods of less than 12 weeks). Reprinted from Reynolds.

Clinicians need to consider changes occurring in the immobilized accordingly. whereas the cast f ixation in the Flowers may have allowed enough movement to prevent tissue can be seen clinically for in the fixation methods of distal radial fractures. hand. but f ibrosis is a homogenous change in the "fabric" Copyrighted Material . and radio-ulnar joints is usually roscopic level. From a rehabilitation standpoint.56 MYOfASCIAL MANIPULATION of the collagen fibers to maintain the critical inand the of microscopic formation cross-links. The implication of this of the previous immobilization studies is that when connective tissues of Jomts are immobilized in the presence of inflammatory joint contractures occur. The other factor in the different results re­ ported in the two studies may be the method of fixation. Scar formation is a localized response. especially less callus formation. with activity limited to a traumatized area. At the mac­ from and of connective present. Scar formation different histo­ some similarities mobilization. methods of fixation may affect tissue changes. Functional range of motion protocols should incorporate sufficient stress to induce connective remodeling to accommodate until full ioint mobility is achieved28 Traumatized Connective Tissue questions have arisen about how traumatized connective tissue response to im­ mobility differs from that of nontraumatized tissue. immobilization causes the forma­ tion of f ibrofatty macroadhesions that become progressively more f ibrotic with increased im­ mobilization times. with however. and result exist. When the fracture is casted. Also. the union is is typically not fully in the wrist and radio-ulnar The clinical patients tation changes as for rehabili­ or surgery and subse­ described. in the connective tissues. Traumatic exudates in­ fi ltrate these and. The studies also indicate that all periarticular connective tissues responded in the same basic fashion. a less than optimal union occurs. The previous studies have dealt with the response of nontraumatized connective tissue to immobilization. Some consider internal fixation of a limb to be a form of im­ quent immobilization will have connective tissue tion of two processes is occurring-scar forma­ tion and f ibrosis. the functional range of motion of the wrist. The range of motion lost 20 minutes. even though the f ixation is located some distance from the tissue studied. even after weeks5. Second.6 Apparently. a catalyst is needed to begin the process of con­ tracture the is traumatic exudate. and cap­ su Ie surrounding fascia all had the same basic response to immobilization. The rigid fixation oflhe previous stud­ no movement. Before weakened cells gentle mid-range movement and excessive forces. Remobilization of the tissues causes a reversal of the immobilization time has not been unreason­ More research is needed on duration and the within the connective tissues. a combina­ Iy much cleaner. usually with the formation of extra callus. If the fracture is fixated with an external f ixator. but after 6 from treatment connective tissues and restored. Scar tissue versus and f ibrosis are two logical processes. Scar formation occurs in areas that sustained direct insult and are in need of Fibrotic changes occur in tissues the scar area that were not directly traumatized but affected chemically by the traumatic exudates. no con­ limb is immobilized without tracture occurs. In a human were casted for a the immobilization within one treatment session of of several weeks and then examined.

Limitation in mobility caused by scar tissue results from the lack of ex­ tenstbil ity of the scar tissue and from the adhe­ sions formed with healthy connective fibrotic of im­ tissue. The purpose of response of muscle tissue to immobilization and to review the various factors in myofascial manipulation. depending on its activity level. This study illus­ trates the principle that muscle tissue will to change in mal lengths. Sarcomeres were 12 hours of recov­ the muscle may be immobiJized in a shortened or lengthened position.". The implication of these studies is that muscles shortened lose sarcomeres at a much slower pace than muscles actively shortened. mobilization (immobilizer or cast) may allow sufficient movement to dampen the effects of immobilization. Being a the immobilized muscle metabolic the histological Im­ ered in the muscles between 48 and 72 hours.. limit motion. since an entire tissue is immobi the potentia I fibrotic Muscle Tissue One of the classic works on muscle response to immobilization was Tabery et aPI In this study. For example. The muscle may be in­ nervated or highly metabolic can this section is to outline or slow twitch or predominantly fast twitch. Limitation in mobility caused results from the lack of the entire tissue. Sciatic nerves The response of muscle tissue to immobiliza­ tion is less simplistic and more multifactorial than the response of connective tissue to immo­ bilization. mobilized muscle that are the most applicable to the muscle fiber diameter. A manipulation under anesthesia may not be as successful in such a case. Muscles immobilized in the lengthened position had no in the characteristics. The muscles im­ a 19% increase in sarcomeres and an overall mobilization. the number of sarcomeres in the muscles returned to normal. By 4 of myofibrils was obser ved and f iber Copyrighted Material .Histopathology and Manipulation 57 of the connective tissue. The animals were immobilized cast. And as fixation methods may a part. cat soleus muscles were im­ mobil ized at various lengths and for various of time. Kauhallen al immobilized the vastis inter­ medius of t3 rabbits in a shortened position for 2 to 28 days. a shoulder may be frozen due to a macroscopic scar adhesion in the folds of the inferior A manipulation under anes­ thesia would tear the scar adhesion and restore A frozen shoulder may also be caused a size 8 in the where the entire capsule shrinks and a sock is The distinction is that homogenous rather than a scar adhesion. length-tension (the analogy here is the size 5 for the to The benefit of the increased mobil­ fabric and the restimulation of the by or sarcomeres in order to keep sarcomeres at were studied. In a follow-up study muscle nprt'. After 3 days of immobilization. From a the muscles immobilized in the shortened posi­ tion had a 40% loss mobilized in the increase in fiber with an over­ position exhibited After 4 weeks of re­ aU decrease in fiber length. a J 5% decline in muscle changes were severe f ibrotic and muscle fiber diameter had de­ creased to 56%. rm vWAU"v. ably because of the connective tissue within and surrounding the muscle. Some of the animals were sacri­ ficed and the muscles were histologically and Biomechanically. can be a contractile a muscle or actively immobilized and/or were stimulated for I either the shortened or lengthened muscles stimulated in the shortened range had a 25% loss of sarcomeres after contraction. the was increased in the mus­ cles immobilized in the shortened position.

In many cases. and the massage lasted 15 minutes. capillary dilation. Kannus et aps found that. those with rheuma­ toid arthritis.33 had decreased to 47% of control of the body. The treated areas were the upper and lower extremities. A good example is the whiplash injury. The terms "myofascial manipula­ tion" or "soft tissue mobilization" are used inter­ changeably with massage. and those with spasmatic paralysis. in which immobilization is caused intrinsically by the cervical and upper thoracic paravertebral muscles. after 3 weeks of immobilization. The effects discussed by these studies include circulatory changes. and metabolism. and (2) a deeper vigorous. kneading. Progressive disorganization of myofibrils with breaking up of Z bands and an increase in the number and size of plasmic lipid vacuoles was seen with increased duration of immobilization. however. cutane­ ous temperature change. the most difficult part of the therapeutic process is deal­ ing with this hypertonicity which is secondary . or as a physiological mechanism (muscle guarding). They also found an increase in the rela­ tive number of muscle fibers with pathological alterations. The subjects re­ ceived (wo types of massage: ( l) a moderate depth stroking and kneading massage described as a modified Hoffa-type massage. as does the prior study. a review of the available literature needs to be explored. PHYSIOLOGY OF MYOFASCIAL MANIPULATION Massage has been used for centuries by vari­ ous cultures around the world. Often. the scapulotho­ racic muscles. the surrounding musculature re­ mains tonically active long after the facet or ligamentous strain has healed. and per­ cussion massage (as practiced in some European schools of physical therapy). Effects of Massage on Blood Flow and Temperature The effects on blood flow in the extremities of 17 adult men and women were analyzed by Wakim36 Groups were subdivided into those with no medical problems.58 MVOFASCIAL MANIPULATION diameter values. past or present. those with flaccid paralysis. immobility may be due to trauma. Significant increases in blood flow and temperature were still apparent in all groups receiving the deep massage when these signs were remeasured at 30 minutes. Immobilization may occur artif icially (external or internal f ixation). Leivo et aP4 also immobilized the vastis in­ termedius of rabbits into the extended position. blood flow changes. In order to understand the effects of myofascial treatments on the body. In the clinical setting. and subjects with spasmatic paralysis. The greatest increase in circulation after deep stroking and kneading massage to the extremities occurred in subjects with flaccid paralysis." causing some of the histological changes mentioned previously. The muscles are then actively "immobilized. theraputic. stimulating. More recent studies. A much milder effect was noted with the more superficial Hoffa-type massage and primarily in the group with paralysis. and the shoulder girdle muscles. The body learns a new recruitment pattern for the surrounding muscles. discuss the effects of massage on collagen and scar healing. patients with rheumatoid ar­ thritis. there was a significant decrease in the mean percent of intramuscular connective tissue. and func­ tional stroking and kneading of the soft tissues Copyrighted Material . The clinical implication of these f indings re­ lates to the types of immobilization that occur in the practice setting. Massage may be described as systematic. Wakim concluded that there was a consistent and significant increase in total blood flow and cutaneous temperature after deep stroking and kneading massage of the extremities in normal subjects. Most studies on the effects of mas­ sage were published before the 1950s and were primarily animal studies. Blood-flow increases diminished markedly after to the original injury. suggests that adverse mechanisms are in effect at the onset of disuse atrophy. and this hypertonic pattern remains long after healing. This study.

Neither deep kneading. massage increases the blood tlow to as when of animal studies to the human The reaction of normal blood vessels to me­ chanical stimuli was microscopically examined by Carrier. The the area being in these studies are similar. EtTects of kneading massage on venous Wolfson. or soft tissue mobilization . Caution should be mechanically Wolfson concluded that massage causes an increase in the blood vessels and allowing them to refill Hoffa massage affected with flaccid the blood flow of ail the in instantaneous microscopic field. Carrier's observations may the results of the studies with Wakim and Wolfson. may well depend on the manner in which the massage is administered. blood flow slowly returned to normal. significant onds. the rate of blood flow with fresh blood. A heavier pressure the underlying capillary for duration.and 59 30 minutes. The I ight stroke or Hoffa massage creates capillary dilation but for too short of a duration to affect blood Yolume. blood or area. an increase in rate of blood flow as well in the vessel walls was noted. In other work of Clark and capil who studied the circulation in the ear of a rabbit fol­ Iy created in the rabbit's ear. W ith mi­ croscopic investigation. The vessel wall the tissue metabolism. was ap­ blood flow were also examined animal models ( after type sured blood flow by cannulation of the femoral vein during anesthesia. Immedi­ cessation of the massage. The massage initially caused a fairly increase in blood flow followed a de­ crease in blood tlow to a rate less than normal. Clark an increased interchange which creates a massage and in both blood flow and skin Hoffa-type massage are used in myofas­ stroked plied to the limbs above and below the knee lowing massage. This decrease in blood flow continued through­ out the administration of the massage. The blood draining out was measured and into the limb at the same rate the blood was being re­ moved. the blood flow and vessel wall affects the vascularization of the of increased the underly­ notion that massage.38 Gross visual observation of skin reaction was made mechanical stimu­ lation of the skin by a blunt instrument. The the area in the of the stroke nor ities resulted in massage of the extrem­ blanched after a latent period of 15 to 20 sec­ lasted for several minutes. allowing observation of the as actual The vessel wall and or followed Following mas­ sagc. pressure resulted of all in the in blood flow of the contralateral unmassaged change in the from increased blood tlow to the part. was evidenced the of leukocytes. W hen vigorous ministered. With on human as well as animal models. Wakim found that the moderate blood flow of effect of studied. Both the vigorous cial manipulation. the result is a of the underlying ture. A harder stimulus resulted in a hyperemic line in the immediate path of the stimulus. Copyrighted Material .39 A permanent window was and Swenson concluded that massage is accom­ of substances between the bloodstream and the tissue cells. Although massage is not defined in Clark and Swenson's study. longer unspecified whereas the deep stimulating massage had the If the moderate depth Hoffa-type massage (non­ is similar to the light stroke pro­ a blunt instrument in Carrier's an immediate reaction is an effect of massage.

Increased na�. A recent study has also examined the benefits of massage on the human virus (HIV) positive popUlation. If capillary dilation occurs. opens up increased circulatory pathways to other regions of the body. of three ( 1°C to Ebner studied the skin found an increase in skin of the massage. gay men (20 HIV+.sal�eo may cause the area to disoose of temperature was examined after back massage. The in nitrogen content. 9 HIV-) received dally mas­ sage for] month. there was no in­ crease in basal fects apply to a crease in basal of oxygen. Clark and Swenson's conclu­ sion agrees with of light and lure of an massage was studied studied 5 to 10 minutes. or effects of massage consists of studies the effects of connective tissue massage distal to the area being treated. 1n the peripheral cutaneous who found an imme­ pressure. a increase in the number of natural men. urine output. Copyrighted Material . resulting in an increased temperature in the area of the massage. in the survey. In tive tissue massage."U'vv' 8 The literature on the retlexlve. increased and increased metabolism to the kilIer cells was noted in the effect on the area the circulation of the part concerned. Cutaneous temperature of the digits was mea­ sured wilh The results indicated that after massage of an extremity. or sodium chloride. the agree on one sage causes capillaries to dilate in the underlying the massage. Further research in this area is 42 ncreased blood massaged have support the notion that massage is indicated in areas where increased tissue circulation and nutrition are desired. especially fol and there was no inorganic increased urine abdominal massage. Connective tissue massage stimulates the circulation to an area of the body that in turn. Efl"ect of on Metabolism can also affect the metabolic prothe vital and bodily waste A review of the literature on Physiological Reflexive (Autonomic) Effects of . there were superficial cutaneous temperature increases in the extremity a related from 15 to 90 minutes. The above metabolic ef­ after connective tissue massage4' Ebner of the foot following 20 minutes of connec­ localized effects have been inconclusive. After the] month of massage. and variable differences. Ebner blood of connec­ that effect on human metabolism was perform Cuthbertson41 Cuthbertson concluded that there was increased output of urine after m assage. Localized in­ may occur. the total net output of urine in a 24-hour oeriod was unchanged. process. The cause for the initial increase in circulation is secondary to the mechanical tension created by the connective tissue massage which stimulates the tissue. increased blood volume and flow occur. Cutaneous following modified Hoffa Martin and associates40 adults and those with rheu­ of massage varied from diate capillary reaction underlying the stimulus Because massage does not influence the basal a likely explanation for the in­ creased urine output is the blood volumes and blood flow fluids during and after massage. With three subiects. massage caused no of the extremities. associated there appears to be an enhancement of the immune system's cytotoxic with massage. The occurred within 3 hours excretion of acid was not consistently altered and supporting tissue and muscle cannot function as separate entities.60 MYOFASCIALMANIPULATION ing the massage. or blood pressure. although rate.

. which was performed on the sacral and lumbar segments of the back. 80.. Chapter 2 fully elaborates on the autonomic effects of myofascial manipulation. The vasodilation increases blood flow to the area treated and to other areas receiv­ ing histamine through the bloodstream. © 1980. Without stress applied through the tissues. The previous chapter dis- Injury 1-----. She concluded that fibrils form almost immediately. The Healing Process at the Cellular Level. The in­ creased permeability of the capillaries and small venules allows for quicker and more complete diffusion of waste products from the tissues to the blood. it produces histamine. No. Volker and Rostovksy (as reported by Ebner) also car­ ried out experiments using connective tissue massage and found a maximum increase in tem­ perature approximately 30 minutes after the mas­ sage ended distal to the area being massaged. I.::. pp. External factors were responsible for assuming an orderly arrangement of these fibrils. Copyrighted Material . the tensile strength will decrease47 Stearns48 observed the effect of movement on the fibroblastic activity in the healing connective tissues. Specific Soft Tissue Mobilization in the Treatment of Soft Tissue Lesions. and Wakim when stimulating massage is performed.'Ii LJ Q:'l! Lag phase __ r!J) Time Figure 4-7 General trend of increase in tensile strength of injured soft tissue during healing process. show in­ creased nitrogen content. Evans. and G. Effects of Massage on Fibroblastic Activity/ Collagen Synthesis during the Healing Process Research has shown that controlled motion of soft tissues influences the healing process. © 1994. Martin et ai. Cyriax and Russe1l49 believe that gentle passive movements of the soft tissues wi II pre­ vent abnormal adherence of the fibrils without affecting their proper healing. Hunter. Vol. The mechanical friction of the massage stroke stimulates the structures within the connective tissue. Physiotherapy Canada. The blood components. follows the f indings of Carrier.44-47 As discussed prior. and sodium chloride. . Source: Reprinted with permission from P. inorganic phosphorus. As the mast cell is stimulated. 15-21. the soft tissues of the body are subjected to both internally and externally generated forces. Physiotherapy Canada.Histopathology of !vf)'ofascia and Physiology of Myofascia Manipulation 61 tive tissue massage. . 256-259. PhYSiotherapy. pp. Physiotherapy.8. No. which is a vasodilator. Vol. primarily the mast cell. 66. when filtered by the kidney and excreted as urine. The manual therapist should use his or her knowledge of the stages of healing to determine when specific massage techniques should be utilized (Figure 4-7). as reported by Cuthbert­ son41 The increased circulation caused by con­ nective tissue massage (stimulating massage) through the reflexive nature of histamine re­ lease. )/ 0'l! -s:-'Ii <::0 .

REFERENCES I. In tile latter stages of healing. Ox ford: Butterworth-Heinmann Ltd. Gentle techniques may be beneficial early on to ensure an orderly arrangement of f ibrils and to prevent adhesions.62 MYOFASCIAL MANIPULATION cussed the soft tissue's inability to withstand stress immediately after injury. 18(5):489-500. Recent re­ search using augmented soft tissue mobilization (ASTM) has proven to be effective during this stage.3:4-8. 1993:21-24. Collage cross- linking adds strength to the wound but can also lead to a decrease in mobility. processes of healing Diagnosis and Treatment for Med. Int J Sports Norris C. 4. CONCLUSION The literature supports the use of myofascial techniques to influence the healing of soft tis­ sues.55 Transverse friction at this point can be gently begun as not to detach the healing fibers. and the tensile strength increases. the value of friction or deep massage before this time is questionable. the wound should be continually tensioned to promote good fiber orientation and scar tissue extensibility. Evans50 found that collagen fibers tend to contract and decrease scar tissue mobility at this point. fibroblasts begin to lay down collagen. As the remodeling phase begins. improve scar extensibility. A good manual therapist must not only under­ stand the histopathology of myofascia and the stages of healing but must remember to use this knowledge when choosing treatment techniques. 57 Fur­ ther studies using longer or more frequent treat­ ment sessions should be done before concluding that massage is ineffective in the treatment of hypertrophic scarring. collagen synthesis equals collagen lysis. 1982. Phys Therapy. the healing process in this animal model was enllanced. Sports Injuries: tIle Physical Therapist.51 As the tissues move into the regeneration phase. The use of deep massage tech­ niques may be appropriate at this time to de­ crease adhesions and break down scar49 One study on friction massage done for 10 minutes a day over 3 months on pediatric burn patients with hypertrophic scarring failed to show any increase in pliability or height of the scar. therefore.53 Carefully applying tension during this phase will help collagen f ibers to align prop­ erly54. Hardy M. deeper techniques may be more appropriate in order to decrease adhesions. 3. An animal model using rat Achilles tendon injuries revealed that ASTM leads to an increase in f ibroblast recruitment and activation as well as an increase in f ibronectin production 52 By increasing f ibroblast activity. 1. ASTM uses speciall y designed instru­ ments to assist the therapist in mobilization of soft tissue fibrosis. 1986. Choosing the appropriate technique at the ap­ propriate time is essential to successful treat­ ment. VanDer 1989. and in­ crease overall mobility of the soft tissues. During this phase. The choice of technique by the physical therapist should be based in part on the stage of healing of the injured tissue. 2.69(12):22-30. important to protect the injured tissues from stress during the early inflammatory stage. Present state of knowledge on in collagen structures. The f ibrin bond holding the wound together can easily be disrupted. Med Sci Sports Exer. The biology of scar formation. It is. The transverse movement is an imitation of the muscle's normal mobility by broadening but not stretching or tearing the heal ing fibers 56 The movement will encourage realignment and lengthening of fibers. Acute soft tissue injuries-A review of the literature. Copyrighted Material . ultimately leading into an increase in the amount of scar tissue formed5o As collagen does not appear in the wound for 4 to 6 days after injury. Kellen Muelen JCH.

Yideman T Osteoar­ 14< thritis of the knee in the rabbit produced by immobiliza­ tion<AclaOrlopScand< 1979. Michclssoll J. metabolism of coJlagen Barnes MR< OrthoSoli Tissue Changes liver.ltttlC\1I$ M. 193 288-295< on metabolic turnover of medial collateral ligament collagen.29:531-538< on healing wounds< of the Cumlllings GS. P. ct aL Structural and functional changes in the canine shoulder cessation of immobilization< Clin Orlho/J< 1 310-315< 28 < Reynolds L Early versus delayed shoulder motion following axillary dissectiofL"lnn Surg< II. et aL The metaholism of mu­ agemenr Continuing Education Seminar< Course NOlcs< Georgia State University () Cummings GS.84(4):1418-1424. changes in the cat's soleus muscle due to immobiliza­ tion at different 1972.50: 30 Flowers KR.nnf'f't!IVP Rehabil. 1998. I SchollmcJcr G. 1986.M8y/June:198-203. 1990< 9< Leibovich SJ. Petilla lVI. Amici D< The connective tissue response to immobility: A study and dermatnn sulfate Or/hop.93:356-362. et aL The effect of nontraumatic immobiJization on ankle dorsi­ flexion. Matthews Jv. Akeson WH. io normal and paralyzed extremities< Arch Phys Med 37< Wolfson K Studies on effect or physical therapeutic on function and structures< JAMA < 193 . Evans 190-197. 12 Shchadi S. JOSPT 1996.23(13):27-33 29< Langenskiold A. 1976. GA: Stokesvillc Publishing. 8< Hetlinga DL Inflammatory response to synovial joint 2nd cd< St Louis: CV Mosby. Amici n Immobility 1980. of macropbages 1-79< WH. Mudd 1 Hypothermia and tourniquet pras Recolls/rllct A. Recovery of skel­ 18 Akeso)l WH.3:289-30 L response< APivllS 1986. Amid D. 1973. CI4 acetate. et aL Experimental immobilization Copyrighted Material . Fukuhara K. Kauhanen S. J Hand C.224:231-244< i 6< Woo S. Michalsson soft tissue injuries-a Sci Sports Exer. et nL Collagen cross-linking alterations in the joint contraetures: Changes in the reducible cross-links in periarticular connective after nine weeks of immobilization. Clill Orlhop< 1983. J 988< In: Orthopedic and Sports Physical Therapy. copolysaccharides in animals: studies on skin Lachman S 5011 Injl/ries in Sports lViedicinc< Oxford: Blackwell Publishing.218: J 3\1-145 rnu­ Studies in skin 1955. bones. Woo SL-Y ct aL The connective tissue to immobillzalion: biochemical changes in periartIcular connective Orlhop. ct aL The connective tisslIe re­ etal 'liter immobilizatIon of rabbjt hind limb< sponse to immobility: an accelerated Exp 1968. Langenskiold I 988. et al < Connective tissue response 18:257-264< to immobility< Arlhritis Rhewll< I 17< WH. [V1. Eroncn 1. 17 95-110 joints: The pathomechanics of joint contracture< Biorhe- Wakim KG< The chondroitin 4 and 6 sulfate in periarticular po.20:93-102< 1962. AmJel D.53:47-52. 24< Schiller S. Pheasant SD< The use of Yidcman T.30: J 35< of massage on the circulatIOn L Akeson WR.and Physiology lvfanipulation 63 5< Cummings GS< Soli COt/fracfures« iV/an1989< and mobilization or rat knee joints. Jozsa L. et al.18(5):489-500 J E. 22. 33< Kauhanen loss with concomitant hypoextensibility< Muscle Nen'e< Leivo I. 11)49. Matthews M. J Applied Physiol. and tendon in normal rat Biochem J Therapy in Con/raelures< Atlanta.42A:737-758< 23< Neuberger A. 13< Kellett J lttcraturc< 1976. and S35 sodium J Bioi Chem. J Bon e Joinl Surg< 19f10.1ammty-March:69-74< A Changes in S-sllifatc different tissue in knee and hip< Acla Orlhop Sea"". Rauhamaki R. Gerber 1981. Duncan M. Sarkar K. Tardieu C. skin. Madden J Effects J Swg Res. Slack 1953.50:465-470< angle curves in the Therapy< digital stiffness.104(11):797-804< Leivo I.212:531-535. Friman C. et aL Stress deprivation effect wound repaie Am J Pafhor I 10< Lotz M. et aL Physiological and structural by plaster casts< Am J Physio/ '"rfYHnPI<1" 15< Videman T.5:1 5-19 20 A PMfS< 1998. Connect 1977. Ross R< 25< Schtllcr S. 96 2020. Michaelsson JE< Abnormal mito­ chondria and sarcoplasmic changes in rabbit skeletal muscle induced by immobilization< 106(12): 1113-1123 35< Kannus 19< Akesol1 WH. PD. Experimental rapid 198 J . ct aL Free mobilization and low­ to high-intensity exercise in immobilization-induced of synovial muscle atrophy. J 956. The metabolism copolysaccharides in labeled acetate< J BioI 26< Amie] D.47:290-298< 3 L Tabery JC. 38< Carrier EB< StudIes on physiology of capillaries: Reac­ tissue of control and immobilized knees of G. of the rabbit knee< 32< Tabery JC. Crutchfield pedic 1983< H. et aL GlycoaminogJy­ metabolism of the medial meniscus< ACla Or/hop 1979. utilizing CI4 glucose.

Philadel­ phia: Blakinston Co: 1950: 13). io/liempy. Massage therapy i s as­ mobilization. Med Sci Sports 43. sociated with enhancement orlhc immune systems cyto­ loxic capacity. Or/hop Res. COllnective Tissue Mali/pula/ions. Phl'SlO/hemp. 66(8):256-259 51 Hunter G. et al.l'. \Vol ff's law in re­ lalion to healing skin. et al.l9(4):347-354 4(1)16-22.fci. The errects of rre­ quency and duration of mohilization Oil tendon healing. London: Tindall and Cassall Ltd.20(3):268 . Melham TJ. 185(5) II 46. Demartino C. Gehlsen G. Tex/book ofOr/i1opedic volume 2. Cyriax. In: AMA Hand­ 49. Woo SLY. The healing process at the cellular lewl. Ganion LR.40(6):80J-804. ]01111/0/ EXeF. fibers Onilop Rei Res. The eITects of collateral hga­ Postacchl!1i F. 1999. Gomez MA. 1940.1. Hayes T. Forrester J. et al. L 4 Davidson CJ. Med Sci Sports 42. Woo SLY. car Am J 39. 165--1 75. Specific soft tissue mobilization in the treat­ ment soft tissue lesions. Horihe S. Connect J980. Novick C. Merlo A. Maynard lA. Increased tension on mCl1ts. book of Phvsical Medicine and Rehabililatioll. 50. Sporl. Studies of the development of connective 57 Patino 0. 1991. in transparent chambers in the Anal. Massage ill hypertro­ phic scar.. Field T. InfluenCe of physical activity on ligaments and tendons. 197(). C. FL: Robert E Kreiger Publishing.80( I)' Med Relwb!l. 1991 I Clill 54. et al. 1 0(9):770-779. Roth GM. 1984. Tiplon CM. Ebnn M. Russell G. Scafidi F. Malabar. Woo SLY. Zederfeldt B. 53. Pemberton R. Rat tendon and functional al. D.. ct al. 1976:84( 1-4):205-217. 271 Copyrighted Material . Evans Cutaneous temperature and patients with P. Martln GM. 1998. 1922:61 and other stimuli. G Cyriax rriction 1982: 47. 1946.64 MYOFASCIAL MANIPULATION tioll of human skin capillaries to Am] Physio/. 1985. Med Sci 45. Akeson WH. el al. ct Chronic ankle pain and fibrosis successfully trcated with a new non-Invasive augmented sort tissue mohilization tech­ nique. Arch Cuthbertson DP. J Trauma. /111] NeUl'O. of the extremities of normal rheumatoid arthritis. Physiology of massage. Pill's­ 40. Mathes RD. Am J :SP0rlS Med. 44. Stearns ML.67:55-97. 1980. Regeneration of rabull tendon maturation of collagen and tenotamy. J 994. Malnofski MJ. 1990.] 48 BIII'I'I Care Rehabil. Physiology and therapeutic value of passive JOlnt range of motion. honson G. Takai S. Sevier TL. 19.

Following the review of the basic science re­ garding neurology and movement control. This section offers explanations for some of the techniques found in Part !If of this volume in terms of cur­ rent understanding of the reviewed neuroscience and neuromechanical aspects of myofascial tis­ sues. One has only to think about their own tendency to stretch on awakening in the morning or after a long trip by airplane or car. for the following account: The verb "stretch" (1:HVW. the author reviews some of the more contemporary f indings regarding (I) the influ­ ence of somatosensory receptors on movement control. in the medical of power of contracting musc/es. muscle contraction has. The noun. the following information summarizes classical and recent understandings of peripheral recep­ As one can surmise from the passage above.CHAPTER 5 Neuromechanical Aspects of Myofascial Pathology and Manipulation Clayton D. K. Therefore." and (3) the interac­ tion of biomechanical properties of myofascial tissues and the nervous system. 65 Copyrighted Material . teino) is the common form and is used by Homer of stretching of a bow. Given that stretching is such an integral part of normal human and vertebrate behavior and the IOO-year history of study of the influence of various sensory mechanisms on movement. of pitch of voice. in Aristoxenus and subsequent musical writers of pitch-key. Borth­ wick.-"to stretch oneself in running. this chapter reviews the basic neurology of myofascial tissues emphasizing the afferent or stimulus perception side of the equation. in Plato and Ae­ schines. 1:0voe. for almost been associated with stretching. In addition. Emeritus Professor of Classics at Edin­ burgh University.fl(p6)] writer Soranus (second century AD) (2) muscle "tone. in Herodotus and Aristophanes of bed and chair cords. is appar­ ently attested in Xenophanes (sixth century BC philosophic poet) of exer­ tion or striving after virtue or courage.(tonos). Walsh cited E. it is necessary to review some neurology that is associated with myofascial tissues. or accent. Gable The mere motion of muscular and/or fascial tissues through stretching feels good to humans and many other vertebrate animals. BASIC AFFERENT NEUROLOGY OF CONNECTIVE TISSUE A detailed presentation of the state of current neuroscience of receptor anatomy and physiol­ ogy is beyond the scope of this book." Aeschylus uses it of straining the voice. To that end. Galen uses it of stretching tendons. there is a science/application section. Even animals such as our pets seem to like stretching. etc. It is used by Aeschylus of stretching flax. etc. 2000 years. reins.

temperature. conduction veloci­ ties and. maximum tension on joint capsule) Mechanical. They include special­ ized neuronal structures and free nerve endings (Table 5-1). They transduce mechani­ cal energy into nerve impulses. and the skin. thermal. Therefore. thermoreceptors. hair-tylotrich Hair-down Primary muscle spindle A A A Au la Secondary muscle spindle A II Golgi tendon organ Au II Joint capsule receptors (Type II) Muscle afferents (III) A II A8 III Muscle afferents (IV) C IV Bare nerve endings A-C Mechanical chemical. which are then transmitted to the central nervous system via their afferent neuron axol1S. All of these receptors influence or are influenced by movement. firing characteristics. or pathol­ ogy. the vas­ cular tree. and thermal stimuli in muscle Tension on a tendon Muscle length. functional andphysiologic effects.e. most importantly of all for a clinician. and chemoreceptors . These receptors fall into four major categories of mechanoreceptors.. chemical. and thermal stimuli in muscle Extremes of joint position (i.66 MVOFASCIAL MANIPULATION tors in skin and the various connective tissues of myofascia. and pain Mechanical. all of these receptors have influence on movement and movement control as well as direct and indirect influences on cardiovascular and respiratory physiology. mostly static Skin: steady indentation Skin: steady indentation Flutter Dynamic change of length Copyrighted Material . They are located throughout the musculoskeletal system. physiology. chemical. they are peripheral sensory receptors Table 5-1 Mechanoreceptors Fiber Size Receptor Type Meissner's corpuscle Pacinian corpuscle and Group A A Location and Information Transduced Skin: touch 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 Hair-guard. thresholds. Also. nociceptors. the next few sections review some of the pe rti nent characteristics and functional implications of Mechanoreceptors Mechanoreceptors are exactly what the name implies. of mechanical events. Each of the various mechanoreceptors listed in Table 5-1 has particular anatomies.

. palms. 533-547.00007-0... Kandel et aI. Three types of mechanoreceptors in muscle and joints signal the station­ ary position of the limb and the speed and direction of limb movement: 111eissner's Corpuscles Meissner's corpuscles are specialized struc­ tures located in glabrous (hairless) skin (e.H. Source: Reprinted with permission from J. Figure 5-1 Receptors in hairy and hairless skin. rapidly adapting receptors have another characteristic. and Jessell's state­ ment in mind that the following review is of­ fered. lips) of mammals. soles of feet."oi� Merkel's ------ii---receptor Meissner's ---+----1{ corpuscle Bare nerve ---41---ending Hair receptor __ is -+--.01 mm) into the skin would result in a single action potential with a subsequent silent period of up to several seconds.k.Neuromechanical Aspects oflvfyofascial Pathology and Manipulation 67 the various receptors. Gardner. Although this behavior would appear to be somewhat dysfunc­ tional. Principles a/Neural Science.. and Jessell state the following. eds. Martin. a single indentation of 70 to 1000 micrometers (0. pp. and (3) receptors located in joint capsules that sense flexion or ex­ tension of the joint. 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. 3rd ed. They are rapidly adapting in their response to mechanical stimuli such as skin indentation (Figure 5-1. and then the receptor will go silent for a period of up to several seconds failing receipt of another mechanical event.) The rapidly adapting characteristic is common to ?everal skin mechanoreceptors. It indicates that a rapidly adapting receptor will respond to a stimulus event with an action potential. In the case of a Meissner's corpuscle.g. receptors in the tendon that sense contracti Ie force or effort exerted by a group of muscle fibers. Copyrighted Material . Martin."2(p443) It is with Gardner. Epidermal-dermal junction ----. They are responsive to repetitive (I) specialized stretch receptors in muscle termed muscle spindle receptors. McGraw-Hili Companies. (2) Golgi tendon organs. © 1991.

the manual practitioner certainly utilizes them in all of his or her practice. Source: Reprinted with permission from J. lated area of skin that can be stimulated and the area that is perceived to be stimulated." " I / I I :::l. Compared with Pacin­ ian corpuscles. " ..H.. Principles ofNeural Science. Copyrighted Material .. .!: o 0 . In an area of skin with small receptive fields.l<: Ul - E c '/ . It does nothing. The impact of Meissner's corpuscles on prac­ titioners of manual therapeutic technique would be difficult to overstate.. © J 991. A receptive field can be thought of as an iso­ 5-2).. with the greatest sensitivity at be­ tween 10 and 100 Hz of stimulus (Figure receptive{teld for Meissner's corpuscles (2-4 mm in diameter). !: . Meissner's corpuscles..68 MYOFASCIAL MANJPULATJON stimuli (at varying frequencies) with repeated action potentials. In particular. eds. even with only a small point stimulated. Other With a rapidly adapting system. the perception of relatively low frequency and low amplitude indentations of the skin is possible. such as sinusoidal indenta­ tions of the skin.. an area with large receptive fields will result in perception of stimulus to a large area. Kandel et aI.. the density of Meissner's corpuscles is higher in glabrous skin of such structures as the hands. Meissner's corpuscles are mechani­ Meissner's corpuscle 1000 .2 This is most beneficial for the therapist in pal­ pation and during treatment. . The second characteristic is related partially to this mechanical coupling but mostly to the fact that the is very small 2 or 3 Hz up to around 300 Hz.cm ::::J o c E{l 100 / 10 10 (50) 100 (300) 1000 Frequency (Hz) Figure 5-2 Sensitivity to skin indentation. <I: . specifically. First.. and so forth. These strands promote the transmission of ad­ equate stimulating force to several surrounding corpuscles for a given pinpoint stimulus area. ..-. this range of stimulus indentation is from 70 to 1000 micrometers. . to explain their superior spatial sensitivity. respond to repetitive stimuli. As previously mentioned. pp. Conversely. There are two other characteristics for which their superior spatial resolution may be account­ able. how­ ever. this range is a relatively slow frequency range. .... stimulus of a small point results in perception of stimulus that is restricted to just that small point. McGraw-Hili Companies. The property of rapid adaptation gives the Meissner's corpuscles excellent temporal resolution in perception of rapid and subtle change. With their excellent spatial resolution and ability to perceive rela­ tively small differences in texture.. at frequency ranges of cally coupled to the surrounding subcutaneous tissues by thin strands of connective tissue. 3rd ed. 533-547.. tissue density.

Their implications for clinical the manual are most I of the corpuscles to be sensitive to stimulus to an awareness of their presence and the know/­ that they. Recall that the receptive field of a Meiss­ ner's corpuscle is from 2 to 4 mm in diameter with excellent localization. ""'''''''''. This synapse or connection of with the Merkel '5 an action potential for the neuron serving the receptor with any mechanical stimulus to its related epithelial Merkel's are but unlike like Ruffini them. as with most any receptor. skin indentation. Merkel's receptors have very small recep­ Copyrighted Material ."0 They are of glabrous (hairless) have unusual receptors in that the appear to synapse with epithelial cells. This further and with but did find He failed to find Pacinian them in the f ibrous periosteum near articular attachments. Hair Receptors Pacinian corpuscles are located in the subcu­ taneous tissue of both hairy and glabrous skin. cells tion. their very sponsive to stimuli a t 1000 Hz. Although the skin is probably the largest organ with the greatest it I is not the of Pacinian location. which makes it re­ from 15 t o adapting quality allows As with other is sensitive to me­ chanical energy. the ref ields of Pacinian that in are so to stimulation of Pacinian cor­ humans were able to localize o r t o the medial half o f the palm. In skin Pacinian fields make them it is extraordinarily sen­ sitive (down to a level of less than I-micrometer which will result in an action Even are very sensitive receptive poor for localiza­ potential from the Pacinian to mechanical energy. do not "turn off" contribute to of their slowly adapting characteristic is of nlllc­ following a stimulus but continue to f ire with a sense and tactiIe sensation. Tylotrich (stiff) hair receptors are sensitive to flutter. A great deal is known about Pacinian cor­ their anatomy and function. consist of a specialized nerve that is surrounded by connective tissue laminae. can be sensitized under conditions Merkel's Receptors 7 Merkel's receptors are ripheral of all the sensory located in the skin.Neuromechanical Aspects V/IJ'nntnovand V1W'''LJUlU'''Uft 69 ications for the Meissner's corpuscles are discussed in a later section of this coneffects and interactions of connective tissue neurophysiology with movement control. and down hair receptors 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. As as found Pacinian corpuscles of various animals3 Gard­ joint corpuscles in the articular or I ported rior and tendon organs.4 Zimny et al re­ i n the ante­ Hair receptors are divided functionally into two based principally on the type to hair are of stimulus to which they respond. They are also found in the superficial layers and other connective tissue Their with the connective tissue is functional in that are stimulated by the displacement of the f ibers surrounding them. They are and they also have very tional f ields. PUcilliull Corpuscles Ruffini Corpuscles Ruffini are found in the subcutane­ ous tissue beneath both hairy and glabrous skin. This connective tissue laminae makes the corpuscle a adapting receptor. One major advantage Since stimulus. In contrast..

(8) A characteristic pause occurs in ongoing discharge when the muscle is caused to contract by stimulation of its alpha motor neuron alone. This sensitivity has been documented at levels as low as the force generated by a twitch contraction of a single motor unit in the triceps surae of a cat (i. © 1951. 113. The reader will recall that the primary endings from dynamic nuclear bag f ibers experience a pause in their f iring during contraction of a muscle. j I i II II j j j j 1111 III j I + .c. (C) If during a comparable contraction a gamma motor neuron to the spindle is also stimulated. Hunt and S. Stimulate gamma motor neuron Contraction t Figure 5--4 During active muscle contractions the ability of the spindles to sense length changes is maintained by activation of gamma motor neurons. pp.W Kuffler. Journal ofPhysiology. Vol." Source: Adapted with permission from c. fa discharge I I I I I I I I II I I Tension / Pull t Weight Stimulate alpha motor neuron ill 1111111111 Contraction t motor neuron la responses is "filled in" .e. 298-315..72 MYOFASCIAL MANIPULATION Sustained stretch of muscle . very few grams of force)9 Another important feature of the GTO is in their combination with muscle spindles.) (A) Sustained tension elicits steady firing of the Ia afferent. The Ia fiber stops firing because the spindle is unloaded by the contraction. the spindle is not unloaded during the contraction and the pause in Ia discharge is "filled in. Stretch Receptor Discharges During Muscle Contraction. sion on the connective tissue in which they are located. j 95 j. Copyrighted Material . The Physiological Society. (Adapted from Hunt and Kuffler.

Consider the following scenario. This Capsule occurred 5 days ago with fairly good resolution of the edema. and length changes being generated by the medial and lateral head of the gastrocnemius. intrafusal fibers are arranged in par­ allel to the extrafusal muscle fibers. the impact of pathology in connective tissue may require some discussion. Implications of Muscle Spindles and Golgi Tendon Organs length that is reflective of the actual change in length. Therefore. Golgi tendon organs are ar­ ranged in series with the extrafusal muscle fibers Copyrighted Material . Assuming a rela­ tively normal foot posture and equal forces. Hence. This results in a mechanical "mis-link" from collagenous cross-bridges and scarring and results in a perceived change in Figure 5-5 Goigi tendon organs.W. 374-382. ]n addition to the mismatch between the two heads of the gastrocnemius relative to the length of the muscles. Unlike them. Muscle spindles measure approximately 4 to 5 mm in length and I mm in diameter. changes in the viscoelastic proper­ ties of the muscle to which it is attached can produce a differential in tension (particularly at the initiation of contraction). the gastrocnemius is active from mid-stance (as a decelerator) until toe-off (as an accelerator). Under the current conditions of a contusion that is in the process of healing but having formed some scar tissue. there is a problem with tension information from the Golgi tendon organs. © 1975. rate of change of length. however. Schoultz. Archives de flaliennes de Biologie Vol. be ap­ proximately equal. Archives de ltaliennes de Biologie.E. a change in the mechanics of a muscle secondary to injury can change the firing patterns of either or both of these proprioceptors. Swett and T. the GTOs are highly active with contraction of a muscle secondary to the tension exerted on them by the muscle. The serial arrangement of the Golgi tendon organs makes them sensitive to tension gener­ ated along the mechanical chain of the muscle. Source: Reprinted with permission from J. With the decreased elasticity of the muscle from the collagenous cross-bridges While the impact of the alpha and gamma motor neuron system is quite well understood conceptually. 1l3. by most practi­ tioners of manual therapeutics. During gait.Neuromechanical Aspe cts of Myofascial Pathology and Manipulation 73 and are approximately I mm in length and 300 to 500 micrometers in diameter. under nonpathologic conditions. the afferent information is different between the 2 heads of the gastrocnemius. With their parallel arrangement. An athlete sustains a contusion to the distal third of the medial head of the gastrocnemius muscle. if not in detail. This differential tension produces another mismatch between the tendinous origin of the medial and lateral heads and even the possibility of differences within the fascicles of the medial head attaching to the Achilles tendon. they are connected to either end of their muscle's attachment by long collagen­ containing fibers. pp. the afferent information is altered because of scarring of the collagenous connections of the intrafusal fibers. the afferent stimuli coming from II---t-Collagen fiber the medial and lateral head of the gastrocnemius would. In the medial head. Mechanical Transduction in the Goigi Tendon Organ: A Hypothesis.

connected to and from connective tissues. the edema would be the sensitivity to effects of increasing Basically. Despite their things in common. thinly myelinated fibers that conduct at 5 to 30 meters per second. I f t h e p a tien t h a d taken anti inflammatory agents. To the Jechanoreceotors of the are numerous and diverse and function. This characteristic is related is reserved of reasoning would serve as a precaution for use of myofascial manipulation on an inflamed muscle.. and cyclooxygenase metabolites (both strongly associated with inflammation and injury) are likely to increase the Contrary to these to produce to contraction. C fibers are unmy­ elinated fibers that carry 0. Group III and IV muscle af­ RECEPTOR INFLUENCE ON MOVEMENT 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. The thermal and mechanical stimuli are transmitted via Ai) fibers and the polymodal stimuli via the C fibers. These three catcan be further classified as to their af­ ferent nerve fibers. ill brief. but no discus­ sion of peripheral is complete without sections explain.76 MYOFASCIAL MANIPULATION tive increased concentrations of bradykinin some attention to nociception and tion. dependll1g on the form of stimulus required. under the assumption that the reader Copyrighted Material . Some of these reflexive ef­ fects will be reviewed in various levels of detail in a later section of this chapter. In the case of an inflammatory process (either acute or there would be that was also in intramuscular e d e ma. considered a sensory mechanical stimulation would be decreased and. the clinician needs to consider these effects during treatment. Given that the muscle receptors is of Group III and IV affected by natu­ of Group III and indomethacin and thrombox­ of the receptors IV afferents to contraction and mechanical proband aspirin. of the nerve whereas sensiti­ Some of zation is a lowering of the stimulus threshold to produce an action the agents are included in Table 5-2. I stimulation (e. a few of the reflexive and order sensory influences on move­ ment and autonomic function. and Meissner's cor­ more vigorous they have two they are all physically mechanical events they all pro­ for the tongue and nose. both of which decrease a muscle's Nociceptors Nerve f ibers that are selectively to tissue are called fall into three or tJ) pOlymodal.5 meter to to stimuli from damage to or that are potentially rally occurring inflammation byproducts and negatively affected by anti-inflammatory drugs. such a line a tendency for a greater increased blood flow in a fibers are at rates from char­ meters per second. to be considered. The are concise. Nociceptors demonstrate two responses to a lame number of chemicals and naturally The chemicals either activate them or tlley are sensitized by them. puscles) whereas others ferents).g. Some are ex­ ceedingly sensitive to mechanical stimuli Merkel's. Activation is manifested an action . it becomes of extreme importance. In addition to their conduction acteristics and the modes of other characteristic to chemoreception. therefore. but in the case of pain.

Connections via scarring or newly formed cross-bridges of collagen to the skin. intermuscular septa. © 1987. 4th Edition. p. The Ia afferent synapses directly on an alpha motor neuron for the same muscle and excites it to the level of an action potential. some attention will be paid to the influence of myo­ fascial pathology on the sensory consequences of movement. 32. Reproduced with permission of has a familiarity with these topics. Source: H. Principles of Neural Sci­ ence. An altera­ tion in the parallel link of the muscle spindle to its tendonous connection can occur with faulty links to other connective tissue outside of the target muscle. movement is that of the muscle stretch reflex (MSR). the influence of pa­ thology in the connective tissue can be consid­ erable on the muscle stretch reflex.L. Muscle Stretch Renex Probably the best understood and most stud­ ied of the influences of peripheral receptors on Copyrighted Material . the stimulus to the primary endings in the form of a sudden lengthening of the muscle is conducted by the Group la af­ ferent. brain stem. Schwartz. Furthermore.Neuromechanical Aspects of Myofascial Pathology and AIanipulation 77 Table 5-2 Chemical or Agent Effect on Nociceptors Chemical or Agent Potassium Serotonin Bradykinin Histamine Prostaglandins Leukotrienes Substance P Damaged cells Platelets Plasma kininogen Mast cells Arachidonic acid-damaged cells (inflammation product) Arachidonic acid-damaged cells Primary afferent Pain. If more in­ formation is desired.22 The following sections emphasize the "sensory consequences of movement upon movement" component of the model in Figure 5-6. During the MSR. Effect on Source Nociceptors Activation Activation Activation Activation Sensitization Sensitization Sensitization the McGraw-Hili Companies. Fields. the following sections follow a scheme of the most familiar of mechanisms moving on to some of the less familiar mechanisms and newer findings. This results in transmission of a motor impulse to the stimulated muscle and contraction of the muscle. such an increase in the sensitivity of the Basics of Motor Control Motor control is considered to be achieved through the hierarchical and sometimes parallel control processes of three different levels. All of this occurs in very short order. and cerebral cortex each have their own independent levels of control and then work together to accomplish control. the reader is referred to Chapters 21-24 and 33-38 of Kandel. Unlike the sections on sensory re­ ceptors. or even bone can occur in connective tissue pathology. Such connections could alter the MSR to either a heightened level or a lowered level of activity depending on the stimulus applied to them. In the case of pathomechanica I cross-bridge forma­ tion. previously known as the deep tendon reflex. The spinal cord. other tendons. requiring only about 40 to 60 milliseconds8 As described previously. In Figure 5-6 the reader can see a relatively simple diagram of the motor system. The MSR is a monosynaptic reflex with input from the primary and secondary endings in the muscle spindle with the major portion of the stimulus coming from the primary endings. and Jessell's classic.

the mechanical stresses would be different on the system resulting in connective tissue remodeling in response to Wolf's Law. Principles o{Neural Science. Each of these has a resting muscle tone. pp. MSR would alter the spinal level mechanisms of muscle tone regulation. Kandel et aI. this example considers the impact of such a pathomechanical situation on the MSR. McGraw-Hili Companies. This example of connective tissue pathology impact on the MSR is just one of many possible scenarios. It has been hypothesized by Janda that these changes would result in an increase of dynamic muscle tone in the agonist muscle. Copyrighted Material . a few of which will be considered in the following section. and vastus intermedius. in the supine position with the lower leg hanging over the end of a treatment mat with the knee in flexion. With this sensory mismatch there will also be a differential MSR response between the three muscles that was not present before the scarring occurred.. 533-547. There are multiple other interactions to be con­ sidered. there wi] I be a sensory mismatch. With the scarring that occurs..78 MYOFASCIAL MANIPULATION Cerebral cortex Motor areas Muscle contraction and Sensory consequences of movement Figure 5-6 Motor system levels of control. eds. If the adhesions have formed in such a way as to differentially affect the rate of change of length in the muscles as they slide together and against each other. however. Consider an example of a patient. rectus femoris. © 1991. there will be adhesions between the vastus lateralis. In like manner. With changes in dynamic muscle tone and subsequent changes in movement patterns. Source: Reprinted with permission from J. 3rd Ed. 3 weeks status post distal third femoral fracture with an intermedullary rod..I-I.

this same mechanism offers great utility for the manual therapist in relaxation of agonist muscle guard­ ing and/or facilitating antagonist retraining during therapeutic exercises. The mechanism of this event is much more complex than the MSR. In like manner. Therefore. interfere with normal motor control and movement patterns. there is a monosynaptic connection of the muscle spindle afferent fibers synapsing with the alpha motor neuron for output. low-threshold cutaneous af­ ferents (e. The most conspicuous of examples for problems with the GTO would be that of tendon­ itis. They are stimulated most at the extreme ranges of motion. have an inhibitory effect on the agonist muscle and a facilitatory effect on the antagonist muscle. and locations in the joints.23 [n addition to the impl ications for fine con­ Joint Receptors As previously described. If the GTO sensitiv­ ity were increased by inflammation byproducts. Golgi tendon organs. an inflam­ mation of the musculotendinous junction would result in interfascicular edema inside the tendon. we restrict our discussion to the Golgi-Mazzoni and the ligamentous free nerve endings because they are the most super­ ficial of the joint receptors and are the most easily stimulated in the practice of myofascial manipulation. In the case of the MSR. In the case of Achilles tendonitis. The receptors for the Golgi tendon organ are specialized nodes on an axon that respond to mechanical deforma­ tion with an action potential. sizes. Merkel's receptors and Pacinian corpuscles). functional charac­ teristics. there are ramifications for patients and their motor Copyrighted Material . resulting in a change in the tension on the braided collagen fibers that surround GTOs. In the case of the posterior trol and control in exploratory behaviors. With greater concentrations of bradykinin and cyclooxygenase metabolites (byproducts of inflammation). Some of the Group Ib inhibitory neurons re­ ceive converging input from Ia afferents from muscle spindles. This edema changes the viscoelastic properties of the musculotendinous junction. when stimulated by a change in tension. it is possible that the sensitivity of the GTO is increased in the same way as the sensitivity of Group III and IV muscle afferents are altered by these agents. the implication for these re­ ceptors' importance when learning to perform manual therapy is obvious. the free nerve endings transmit information to the spinal cord and synapse on Group Ib inhibitory interneurons. Therefore. from a functional viewpoint. Both of these joint receptors are rapidly adapting receptors and are also known to be essentially silent in immobile joints. The outcome regarding muscle tone is the same whether stim­ ulated by tension or other mechanical input. Besides the change in the mechanics of the GTO. the me­ chanical event necessary to fire the GTO does not have to be stretch. The GTOs and the other inputs to the Group lb inhibitory interneurons provide for fine control of exploratory behaviors where the amount of force being generated is critical. The afferent input from the Golgi tendon organ syn­ apses on the Group Ib inhibitory interneurons. joint receptors and excitatory as well as inhibitory input from several descend­ ing pathways. Therefore. All of these combined inhibitory and excitatory inputs have major implications for fine motor control. joint receptors come in a variety of shapes.Neuromechanical Aspects of Myof cia I Pathology and Manipulation as 79 Golgi Tendon Organs control. the surface of a joint capsule in which the receptors are located dic­ tates which muscles are the agonists and which are the antagonists. there is also the ambient change in chemical make-up of the GTO. These interneurons receive input from multiple sources before synapsing themselves with the motor axons of either the agonist or antagonist muscles. For purposes of this discussion.g.. The Golgi-Mazzoni receptors are similar to Golgi tendon organs and exhibit very similar effects on motor control at a reflex level. thereby. it could be direct pressure on the musculotendinous junction. Originally thought to be a protective mechanism to prevent tendon rupture. then the increased GTO firing rates would fur­ ther inhibit the agonist and facilitate the antago­ nist and.

The findings of changes in motor output as a result of manual contact and other stimulus input are well known. failing that. rapid knee extension would result in an inhibitory effect on the quadriceps at the end of range. with the greatest inhibition occurring of the quadriceps. One common technique is that of maintained pressure over the anterior thigh. these f indings offer com­ pelling evidence that in the presence of edema or bleeding following thrust manipulation pro­ cedures. Another example of the inhibitory properties of an abnormal stimulus to joint receptors is provided by Kennedy and colleagues.e. In their classic paper of an effusion Skin Receptors and Position Sense The influence of skin receptors and other mechanoreceptors located in deeper tissues on motor activation levels has been documented for almost 100 years. facilitates motor neuron activity26 These and similar f indings form the foundation for many of the facilitatory and inhibitory handling techniques employed by physical and occupational therapists today.e. Many of these facilitatory and/or inhibitory techniques were originated by clinicians working with neu­ rologic clients. One can only assume that similar findings would be seen in other diarthrodial joints with similar muscular inhibition. to make conserva­ tive recommendations for strenuous activity of the lower extremity. which is inhibitory to the quadriceps after an initial burst of electromyogram (EMG) activity. Another aspect of effects of sensory input from the skin on motor output that is not as well known is that of the contribu­ tion of skin mechanoreceptors to position sense.e. the quadriceps were inhibited. when a local anesthetic was added to the effusion. these findings add even further motivation for the therapist to control joint effusion and. over the TA).. whereas rapid knee flexion would stimulate the joint receptors in the an­ terior capsule and cause inhibition of the ham­ strings at the extreme of knee flexion. however. Psychophysical (i.80 MYOFASCIAL MANIPULATION capsule of the knee. they demonstrated that (60 cc) of the knee would result in 30% to 50% decrement in the electrical activity reflex. operates from a negative assumption. Indeed. however. there would be a reflex inhibition of musculature surrounding that joint or related to that joint neurologically. The work just cited. opposite surface of the muscle) would inhibit the output of motor neu­ rons to the tibialis anterior (TA) whereas the same stimulus presented to the skin on the ven­ tral aspect (i.. such as a slightly caustic agent. behavioral measures of perception) such as those performed by Burgess et al and Matthews failed to demonstrate a sig­ nificant deterioration of kinesthetic sense in . Their findings are consistent with the prior and subsequent I itera­ ture. If such a small joint effu­ sion can inhibit the quadriceps. they were able to show that the receptors in proximity to the joint cavity itself were very important. Such f indings clearly dem­ onstrate that a mechanical stress on the rapidly adapting receptors such as the Pacinian cor­ puscles is (most likely) inhibitory to quadricep motor units. The mechanical stress placed on the joint capsule served to stimu­ late the joint receptors in the same manner as extremes of range of motion would. Although they did not distinguish the particular types of receptors. the inhibition all but disappeared24 CI inically. 1952 that a pinch stimulus to the skin of the dorsal aspect of the hind limb of a cat (i. as measured by the Hoffman in the vastus medialis. response to anesthetizing the skinn The psychophysical findings would lead the clinician to think that skin mechanoreceptors have little if any influence on position sense. then failure to control the effusion could lead to serious injury from inhibition of the surrounding musculature.. Other stimuli of a noxious nature. placed on the leg of a spi­ nalized frog will produce the even more sophis­ ticated movement of attempting to wipe away the stimulating agent25 Hagbarth demonstrated in 1982. Under the conditions of effusion. which confirms that joint receptors are more sensitive to extremes of range. Simple reflexes such as the flexion withdrawal reflex are spinal level systems evoked by stimulation of nociceptors. Burgess et al assumed that because elimination of skin receptors failed to Copyrighted Material .

One misconception that has been from one author to the next is that of the cycle. the data from the CoI­ Iins ct al indicated thaI. In­ 84% of the cells that did not respond to movement also did not stretch. They demonstrated that 84% movement also responded to skin stretch. An experimen­ tal manipulation of the skin on the dorsum of the hand produced a 79% reduction in twitch detection threshold and a 58% reduction in position sense accuracy when compared with controls. These same receptors. In the case of the slowly in the skin. such as that mediated inflammation byproducts and other neuroactive is Polymodal are more is carried on C which conducting fibers. More recent work et al investigated the threshold of of a muscle twitch at the wrist and found it to be attenuated by as much as 60% with volun­ movement of the same ann. In addition. The responses can vary from obvious muscle guarding in the surround­ ing musculature to help decrease movement. as one would expect. Polymodal pain. Cohen et al performed to cell while cell recordings and from the sensory strip of the cortex in monkeys the relative effect of active movement and skin stretch on cortical recorded from cortical cells moving the monkeys' arms into also recorded from the skin of the that to Collins information is obvious. are not Thc implication for cutaneous tor information functioning as position sense of receptors as it reached the mechanics of these toward a target in the left upper quadrant with the situation and the extensibility of to skin most likely because of its continuing nature. On a functional note. This bias pro­ duced a for more phasic of the receptors as the monkey reached toward a upper quadrant target with the left hand. The original hypothesis stated that pain Copyrighted Material . as com­ pared to a tonic the left hand. as cited effects on muscles that are input from that area of skin. as re­ viewed so eloquently and this Walsh. the same cells while of the cell [rol is probably the most obvious in movement control that is stimulation.Pathology and Manipulation 81 the performance of their in the skin had no impact on position sense. some type medial upper arm. I and Simons is based on a misunderstanding of the involved motor re­ flexes. On the other hand. This response may be level or virtually any other level of the nervous system. whether or not contribute to the position sense information is not upon external forces being ap­ plied directly to the skin. The withdrawal reflex seen in even animals is very fast. The initial response to acute pain from mechanical or thermal stimuli is trans­ mitted to the nervous system via Ao f ibers. an adhesion would the subject forces that would when stimulate rapidly adapting in either rapid or extremes have either facilitating or inhibitory of movement.30 The findings from these two studies present fairly evidence that skin mechano­ receptors serve as a source of position sense information. there was a directional bias for skin re­ ceptor firing or lack of firing. to inhibition of a muscle to decrease movement that would increase the pain. or nists for movements normally associated with Nociceptors The influence of on movement and con­ on pe­ flexion and abduction. a constant ab­ normal mechanical stimulus from an adhesion would result in an alteration in the cumulative position sense information even in the absence of motion or extremes of motion. which are rapidly conducting fibers. also has the characteristic of at a of behavioral response. The response to pain of a more polymodal nature. Unfortunately.

cannot occur without an electrical action po­ tential. it is actually more com­ plex than just a contraction. an action po­ tential is not typically discernible via EMG in the case ofl11uscle spasm or even "normal" rest­ ing muscle tone. 75 (pp. then what does cause the increase in muscle tone? This question is actually two-fold. If muscular pain and the apparent increases in muscle tone are not caused by spasm. what does pain have to do with increased muscle tone? Second. they describe muscle tone as consisting of two types of muscle tone. Mense with permission ofW. In it. MUSCLE TONE Muscle tone (taken from the Greek 1:EtVW. Certainly. No. The first level is resting muscle Muscle tone (general tone) Viscoelastic tone (specific tone) / Contractile activity Elastic stiffness /\ Viscoelastic stiffness Contracture (no EMG activity) 11\ Electrogenic spasm (pathologic) Electrogenic contraction (normal) Figure 5-7 Muscle tone. 1-17) by D. Copyrighted Material . First. the timing and intensity of the EMG activity does not correlate with the reported levels of pain. It is relatively easy to identify muscle asymmetries in bulk as well as in muscular activity during movement. as understood from the sliding filament theory. Simons and Mense have offered an ex­ cellent review of muscle tone and its relation to clinical muscle pain.B. Since. what is muscle tone/spasm? The follow­ ing sections explain some of the current thinking regarding these topics. These findings present a contradiction to the practitioner of manual therapy and any acute ob­ server of posture and movement.82 MYOFASCIAL MANIPULATION increased y-motor neuron activity. Electrogenic Muscle Tone Electrogenic tone can be categorized into three levels. Pain. it must entail more than just an electrogenic activation of the actinomyosin complex.G. which would stimulate or increase the sensitivity of the muscle spindle and result in an increased (X-motor neuron activity and muscle contraction. © 1998. Simons and S. Source: Adapted from Understanding and Measurement of Muscle Tone as Related to Clinical Muscle Pain. a typical muscle contraction or level of muscle tone. The major problem with this theory is the fact that muscle pain does not result in increased EMG activity. [teino]) has long been associated with muscular contraction. Since we need a defini­ tion or explanation of muscle tone. as cited previously. Saunders Company. however. The first one is known as electrogenic tone and the second one is viscoelastic tone (Figure 5-7). Furthermore. that section is presented first.

and

83

tone. This muscle tone has historically been ex­ plained as a postural low-level tonic of motor neurons. As explained based on a reported later the Sherrington an explanation inapplicable Brondegeest in 1860. Waller, and explained definition, an Walsh, this was begun by Waller and was

shown to demonstrate localized electrical activ­ ity in the confined area of the point]6 It appears that these taut bands of muscle are the result of the same contracture mechanisms described by physiologists. Other forms of muscle contraction of lar interest to clinicians fall into two The f irst form we know as involuntary where there is unnecessary muscular contraction that limits movcment. The second form could best be described as inefficient use. Most clini­ cians are aware that because of and other causes, patients wi II move in manners that are inefficient. These ineffi­ can have serious con­ sequences. for a marathon runner who gets a blisler over the head of the fifth metatarsal at mile 3 of the race. Such a minor ury has been known to have conse­ quences of a femoral head stress fracture by the end of the marathon. The same such ineffi­ cient use can occur with trigger Lack of Elert et relaxation and Ivanichev points between contractions of th e upper trapezius has been demonstrated failed to relax movements as An muscle tone, which are associated with electri­ cal in the is certainly on (X-motor neuron however, this volume relates more specifically the manipulation of ciaI tissues. Consequently, the next section on
IS

muscle tone with the muscle stretch reflex. Such action potential to be generated in (X-motor neu­ rons. Activation of (X-motor neurons would acti­ vate motor which would be perceptible EMG. All efforts to document resting muscJe tone via EMG have failed.3234 This is not to that some form of contracture is in the muscle. Physiologists tend to define con­ tracture as an of the mus­ cular contractile apparatus in the absence of EMG activity initiated by anterior horn cells. With this there are formed but they have not resulted from an action from the myoneural junction. The second level of spasm. This particular sociated with measurement EMG that muscle31 Voluntary muscular contraction is the third and last level of muscle tone and requires no Before we move on to a more nation of recent findings regarding viscoelastic tone, it useful to discuss in a little more a pain-spasm-pain cycle is spasm. As anyone who has worked on another human or even mammal will attest, and muscular tissue are tion. In this in compressibility of discernible by palpa­ the f indings related to trig­ headache (T-TH) In T-TH it is easy taut bands of muscle. These while often associated with trigger points, do not demonstrate observable EMG activity. The points, have been ideas related to clinical muscle spasm. As we have already an insupportable hypothesis in the sense of an muscle tone of contraction is what Simons and Mense refer to as electro­ is an involuntary contraction that is

demonstrated that muscles with during

for the clinician. Also, an insight into the influ­ ences of various and y-motor neuron activity is useful for under­

very

and will help

the reader to understand some of the very rapid results seen with myofascial

Viscoelastic Muscle Tone
The viscoelastic muscle tone, or tone,

is made up of an elastic component and a vis­ coelastic component. The purely elastic compo­ nent, by requires a force to

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MYOFASCIAL MANIPULATION

produce a deformation of the substance, which in this case is myofascial connective tissue. As we know, the collagen and other structural pro­ teins of myofascial tissue are not the only com­ ponents of connective tissue. These tissues also contain various other proteins in addition to their 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 nonsulfated glycosaminoglycans ( GAGs) and makes version up of about 70% of the extracellular for the matrix. The second component is the sulfated GAGs, which account tissue cohesiveness. Another fluid component of myofascial tissue is actin. Although actin certainly comprises a large complement of muscle itself, it is also abundantly present in noncontractile fluid and serves cell motility and intracellular structure functions. This protein is actually fluid in its purified form and, much like syrup, will form strings when picked up on a glass rod or other stirring device. The GAGs, actin, and myosin all contribute to the viscoelasticity of myofascial tissue. Unlike elasticity, the stiffness of viscoelasticity is veloc­ ity dependent. Also, it is worthy of note that unlike the velocity dependence of spasticity, the relationship between viscoelasticity and ve­ locity of movement is purely mechanical. The mechanical viscoelasticity characteristic and the structural elasticity of the structural pro­ teins combine to make up the specific tone of a muscle that is unrelated to contractile activity. Viscoelasticity of muscle, or viscoelastic tone, affects movement and postural control. The sensation(s) from the musculoskeletal system that prompt mammals to stretch after remaining still are relatively undefined concerning their sensory mechanisms. Concerning posture, there are mechanical properties of muscle (largely unexplored until recently) that tend to support a resting stiffness of muscles in posturally sup­ ported humans that is unrelated to EMG activ­ ity with the exception of occasional corrective bursts of activity. The properties of myofascial

tissues that prompt the stretching behavior and account for maintenance of static balance, how­ ever, have experienced an abundance of study over the past 10 years and a new flurry of activ­ ity during 1998 and 1999. This "new" property is known as

thixotropy.

Thixotropy Defil1ed

Thixotropy [8t1;w (touch) and "po1ITl

(turning

or change)], as a term, is new to many people across the entire spectrum of clinicians who use manual therapeutics. It is not, however, new to physiologists involved in the study of muscle and tissue mechanics. Thixotropy describes a state of stiffness of a fluid that is dependent on the past history of movement. There are a number of common substances that exhibit thixotropy. Tomato catsup is probably the most common. After sitting in the bottle, catsup be­ comes very stiff and difficult to get out of the bottle. With just a little stirring, the stiffness decreases substantially.59 Thixotropy is a

physical property of muscle

and other tissues and not a response to some neu­ rophysiologic event. The mere act of moving a substance with thixotropic properties will result in a reduction of stiffness. The reverse is also true, if a thixotropic substance remains still for a given period of time (variable dependent upon the substance), the substance will become stiffer. In order to measure thixotropy, physiologists have used torque motors with very small torques of approximately 0 .1 Newton.meters (Nm). Under conditions of a sinusoidal motion of the wrist, the amplitude of a motion of the wrist is about 0.02 radians (1.14°). With a movement of the wrist in an amplitude of approximately .075 radians for only three cycles, the amplitude of the passive wrist movement with the same 0.1 Nm of torque increases to about 0.06 radians (3.42°). These amplitudes are very small so as to avoid stirring the muscle; however, it is impor­ tant to note that a brief interruption of as little

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85

as 2.5 seconds returned stiffness to its levels. Also of note is the fact that this which is restorable in as little as 2.5
i-lv.,;:"'",,, IS

Ciinicailmplications ofThixotropy 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 the may offer an explanation for of palpable "muscle spasms" with highly lo­ points have also
{'()tTP''''CI

at most any length with the exception and the amount of inter­ and

position of extreme stretch. As one can tell, the amount of ruption of motion can be very smalL Now that we understand the basic we delve the mechanisms 40

that are found on examination of points. As previously calized electrical ger points. These same has been found in

Possible Mechanisms ofThix:otropy in Muscle have hypothesized that of muscle bell and Lakie have a at mechanisms in muscle. Camp­ that the thixotropic for some of the crossbehavior of relaxed skeletal muscle may be exbridges 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 Campbell and Lakie summarize their tion of thixotropy, which model of undetached saying, "The molecular motors of muscle may be idling rather than switched off when the muscle is relaxed."42(p957) There is another forward Mutungi and that can and other the thixotropy of muscle. This hypothesis put would attribute the viscoelastic of relaxed skeletal muscle to titiD f ila­ ments. Titin filaments are exceptionally structural thick
III

been identified by Simons45 as motor nerve terminals. It is localized electrical tize The is

anatomically with the intramuscular to sensi­

in the area of a trigger agents released may also desta­

bilize the T-tubules enough to result in a calcium concentration within would result in a number of formed between the 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 gel' points. increase the pain and, beneficial to in­ crease the pliability of the muscle around to the "pain-spasm-pain" point should the spasm, with that deep massage of a

attribute to a

even more pain. This does not always occur in as many practitioners can massage can "decrease the spasm." Neurophysioiogicallmpiications of Thixotropy The mechanical of thixotropy have com­ however. thixotropy, as has a profound influ­ and their afferent neu­

which link the a random-coil COl)­

filaments to the Z-lines of muscle. when relaxed and that uncoils with Consequently, titin does not offer a

Titin filaments tend to

been reviewed in the previolls sections. These obviollsly, apply to the plement of fusal f ibers are only part of the As Proske et al have a mechanical ence on muscle rons. the extrafusal fibers. Extra­

very viable

for thixotropy of muscle

but with its increase in tension at extremes of range, it may contribute to the resistance felt in muscle when it is stretched to near its limits of range of motion."'.4ci

These influences are too numerous to

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86

MYOFASCIAL MANIPULATION

review here, but the stretch are search is from muscle

discharge on the history

some of the

movement

or holding
,'pC'pn tAr

spindle afferents and their sensitivity to muscle of movements and/or contraction. In several re­ it has been demonstrated that such as an isometric contraction is increased. The reverse is not a cord mechanisms but the a stimu­ tendon tap) pro­ similar studies an electrophysi­ analog of the tendon tap) have failed to show the same results. Another potential influence of be Dostulated based on the and other connective tissues. the biochemistry and biophysics of the sulfated GAGs have shown them to be responsible for the cohesiveness of conncctive tissue. with this increased cohesiveness comes an increased initial resistance to active or oassive stretch. one would ent discharge from has remained still for a few minutes. Walsh and demonstrated that thixotropy occurs at the human hip, with the amplitude of the resonant frequency of a sinusoidally abducting/adducting hip almost doubling in re­ sponse to a W hether this ent motion of amplitude.46 can bio­ when a conditioning movement or contraction in the shortened Dosition. the afferent is observed in an isometric contraction in the position. This facilitation of the rather a sensitization or this phenomenon duce the with the Hoffman reflex

described by Janda and Feldenkrais. We have reviewed the basic with the and physiology for most of the somatU:5t: of the vestibular system. We have also reviewed some of the in­ teractions of the somatosensory system with the motor system with emphasis on that portion related to the myofascial system. Now that we have f inished the neuromechani­ cal background for myofascial we move into some direct application of this and biophysics.

case may be, of the muscle spindle. Studies of lated muscle stretch reflex APPLICATION TO SPECIFIC THERAPEUTIC TECHNIQUES The following sections are heretofore presented. This form lar technique to which dressed by the to outline takes the is made; technique; a

examples of specific application of the science I) a very brief discussion of the

physical, and neurophysiological properties of

discussion of the pathology/pathomechanics ad­ a pro­ these posed theoretical mechanism,

may influence the somatosensory and (4) proposed mechanisms for altera­ tions in motor control are engendered bv the technique under consideration.

Anterolateral Fascial Elongation The anterolateral fascial elongation
8-96 and

useful to consider as to virtually all of the super-

and associated neuromechanical char­ , described in this book. The as primarily stretches

resistance to initial an increased affer­ very early in the time course of

anterior lateral fascial described later in this the doing so, the number of restrictions at

fascial sheath in a diagonal pat­ is

the movement remains to be tested. Neverthe­ less, if the fluid mechanics of a joint capsule, musculotendinous junction, or direct muscular attachment to bone were changed inflamma­ tion byproducts, then the afferent output from those receptors could certainly be either in­ creased or decreased. Such an event may explain

tern across the anterior surface of the body. In

interface between the skin and the superficial fascia, there may be restrictions secondary to blunt trauma and In the fascia itself and its interface with the

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Neuromechanical Aspects ofJ'vJyofascial Pathology and Manipulation

87

major and the external oblique abdomina Is, the sheath is continuous from the proximal hu­ merus, clavicle, and anterior shoulder down to the contralateral crest of the ilium, thoracolum­ bar fascia, anterior superior iliac spine, inguinal ligament, and the pubis. Restrictions of the superficial fascia of the anterior trunk have mechanical implications for posture and virtually all movements of the trunk and upper and lower extremities. Certainly, there are mechanical restrictions of mobility but given that patients develop such faulty postural habits, the pathomechanical implications for the body as a whole are most likely seated in position sense. Restrictions in the superficial fascia would result in a continuous and abnormal stimulus of the slowly adapting mechanoreceptors in the skin and all the succeeding layers of the superficial fascia. Because the mechanical restriction in the skin and superficial fascia is very similar to that found in the experiment performed by Cohen et ai, some direct postulates are in order. Cohen and colleagues found increased activ­ ity of somatosensory cortical cells representing skin receptive fields in the axilla and the skin of the medial proximal arm associated with par­ allel skin stretching, passive movement, and active movement. They were able to demon­ strate this same highly correlated activity in a va­ riety of tasks including reaction time tasks, hold­ ing tasks, and active movement of the arm. The shortened range of skin produced very little ac­ tivity in tactile receptors of the axilla and upper arm. This is in contrast to movements into shoul­ der tlexion or shoulder flexion with abduction, which increased the activity46 Furthermore, the greater the stretch in either amplitude or move­ ment, the greater the firing rate of phasic (rap­ idly adapting) receptors (e.g., Pacinian corpus­ cles). These findings are completely logical and intuitive when one considers human postural phenomena observed by clinicians. Consider a patient who is 3 to 4 weeks post cholecystectomy via a left upper quadrant incision rather than a laproscopic procedure. A phasic stimulus of skin receptors during erect sitting or right shoulder

flexion would be perceived as a "greater than resting or normal position" burst of activity. In that case, the patient would return to a position that was more in line with resting position. If a mechanical restriction resulted in an abnormal phasic stimulus or tonic stimulus, then the inter­ pretation by the system would be that the patient was in a stretched position when, in fact, the position might be neutral. Consequently, the patient would tend to move into a position that decreases the firing activity of the phasic and/or tonic receptors. This position is then perceived, via the skin receptive f ields, as normal and fur­ ther shortening of the superficial fascia occurs. This faulty receptor activity and the position sense activity it provides soon becomes the basis for postural perception. Historically, the theoretical basis for such be­ havior has been that of pain avoidance. Cer­ tainly pain avoidance behavior is a reasonable and patent argument in the early stages but after several weeks of healing, the pain disappears. What remains is the new position sense refer­ ence from skin and superficial fascia receptors. Another hypothesis concerning the continued behavior of avoiding elongation is that of altera­ tion in motor programs (motor memories) to fit the new and dysfunctional behavior. Considering the amount of practice required to change a very well learned motor program, this is not likely. Consider, for example, attempting to change one's signature. It is possible, but on a practical level, it is not probable secondary to the huge volume (millions of repetitions) of practice re­ quired. It is very likely that this new position sense stimulus from the skin rapidly adapting and slowly adapting receptors function in an inhibitory fashion just like their Golgi tendon organ and Golgi-Mazzoni type joint receptors, by inhibiting muscles which would further stretch these receptors. Such a postulate is based on the findings of numerous investigators of the inhibitory influ­ ences of GTOs and joint receptors on motor output. It is also in agreement with Janda's model of altered muscle function and motor per­ formance resu Iting from "inadequate proprio­

Copyrighted Material

and others as­ structure. and ankle would lead one to conclude that the endings. One major caveat concerning this study is that it was nerformed with standard histologic were noted concerning the area Copyrighted Material . and 8-21). of side bending to Diaphragmatic Techniques for restrictions in the diffi­ progress from a the superficial to middle involve cage. knee. Bogduk and Macintosh discussed the anatomy of the thoracolumbar fascia with its two to the crest of the ilium. This abnormal stimll Ius from normal motions or would result in an abnormally excited or inhibited level of activity for the motor units of the abdominal. Such a cor­ rection would allow the relative levels of excita­ tion and inhibitions to return to levels dictated the normal motor programs as onnosed to proprioceptive signals. Yahia et al found and Vata-Pacini corpuscles (a form of Pacinian were also taken from surgical Yahia's were prepared with im­ munohistochemical staining techniques that tarneural filament protein. it is executed by applying an anterior directed force through the from the border of the iliac crest on to the thoracolum­ bar fascia and the insertion of the erector and quadratus lumborum.49 With the documented presence of Ruffini and Pacinian-like racolumbar fascia. the thoracolumbar fascia would oroduce an ab­ normal afferent stimulus. it is I in the tho­ These stated as and that is that the validly be proprioceptive stimuli. Although directly addressing restrictions in the thoracic is not possible. An assumption that the connective tissue in this structure is no different from that found in the shoulder. it is pos­ fascia of the sible to affect restrictions in the mediastinum the diaphragm and abdomen and diaphragm. Such restrictions can lead to or be the result of multiple postural (Figures and anteriorly while asking the diaphragm and inferior border of the rib cage are 48 They concluded that there were dif­ normal subjects and persons with back pain. As described. This particular tcchnique addresses restriction of the thoraco­ lumbar fascia and the muscular and ligamentous attachments.30 One exception is type of strokc or the skin rolling. address restrictions that are very deep in the thoracic and abdominal cavi­ ties.88 MYOFASCIAL MANIPULATION ceptive " which is probably more cor or mismatched logic described cannot to the Bindegwebsmassage con­ of the thoracolumbar fascia from which surgery. This anatomy makes its mechanics somewhat complicated and allows it to contribute to stabi­ lization of the spine in with the the same sideY the bar fascia. significant back thoracolumbar fascia of ferences in the failed to f ind a w ith chronic of receptors between of mechanoreceptors in the all movements. in a seated restrictions inferior to the anterior rib cage to those that the inferior portion of the rib and and inhale and 8-46). and auadratus lumborum muscula restrictions with the iliac crest release would to cor­ rect this abnormal afferent outflow. In a study however. This is because their goals and physiology are not nected to the evidcnce suoolied by Cohen et aL Iliac Crest Release This technique is useful to a moderately technique as it is 8-20A.

If a restriction occurs between two fascicles or two then the altered mechanics produces a sensory mismatch and inappropriate proprioception from the muscle. The to in in local blood engen­ cardiovascular and with the least emphasis on longitudinal stretchThe the muscle and of individual muscle fascicles on dered by the techniques most likely also extend the outflow from the muscle dies themselves with all the cascade of effects from them. posture in The pathomechanics of slumped and forward-head are fairly well understood. postulated reduction in the inhibitory activity of the GTOs. the a multidirectional mechanical stress a mechanical stimulus to aid in thixotropic resistance to motion. more problems related to such adhesions and benefits related to a transverse muscle the sure caused The pathology of such adhesions of muscle for the ribs and sternum to move infe­ riorly and posteriorly. An increase in tension on these shown to elicit a All of this more especially the GTOs. The manipulation tech­ niques described herein allow for a lengthening of the along its anterior borders with a resultant. This leads to a of the connective tissue in the abdomen and in the thorax. increases in intramuscular pressure have been directly associated with increased afferent action of the III and IV af­ and results in cardiovas­ ferents tures. Copyrighted Material . Second.le and a destabilization of the cell membrane of calcium into the to cause a release This release of calcium will result in the formation of crosswithout benefit of an action potential and increased resistance to stretch. No technique is used. tendency for increased afferent activity from the in intramuscular pres­ them relates to influences of thixotropy and the Group III and I V afferents. tion in lung volume. is relatively simple to perform ef­ more can have a and depending upon the vigor with which it is mechanical effects. inhibitory effect on activity results in a reduc­ of the central tendon of the diaphragm has been the external intercostals and the diaphragm. as lung capac­ ity is diminished by these inhibitory processes. The the have direct effects on the thixotropy of the motion of the muscle would provide This done can have fects or. With length comes a Rufinni endings. Such afferent Transverse Muscle Bend of the Erector Spinae connective tissue in proximity to these struc­ cular and pulmonary changes on a systemic level and an autonomic response of increased blood flow at a local level. The treatment system and the muscle and themselves also III and IV afferents. Over time. Adhesions of such a nature can lead to a local irritation of the musc. the connective tissue would remodel to its new resulting in a new "set" for the normal tension on the tendon. Next. The technique is basically one of bending the muscle as if hose 8-15 and 8-1 can also be modified as in the quadriceps and hamstring technique to include matter what result some muscle rolling and lifting actions. With an increasingly forward-head posture comes a rpnnPf'I'H other muscle fascicles. the tech­ nique would have direct etTects on the Group III with resultant flow and nary effects.VfJ/'nnlflU1J and 89 protracted shoulders. Whi Ie the influence of intermuscular and/or interfascicular adhesions on afferent and effer­ are fairly common among there are other technique. Such a case has been described prein the section on spindles and GTOs.

Wyke B. however. at Neural Jes sell TM. 1990:35-41. Hagen-Torn O. PJ'lncljJles Science. Pearson K. In: W Zenker. Mar t i n JH.Arch Mikros Anol.105:231-254. Afferents from limb skelctalmuscle. 1967. New York: Marcel Dekker. we discussed concepts of thixotropy and their importance in muscle tone. J Appl Physiol. New York: McGraw-Hill. Muscles. R esp onses ofGolgi tendon organs to active contractions of the soleus musc le of the Neurophysiol. Hill JM. of group Sc hwartz. We have endeavored to explain and expound. 6. when they can. Ga rdner E. 9. Anal. Zimny ML. 12. Kaufman MP. 1995:583-617. 2000:7 I 3-736. 5. Later. in an effort to elucidate some of the more recent literature. 2n d ed. 1999. 3 . The Prill/Oly A/jerelll Neuron: A Survey of Recenl Morpho-Funclional Aspecls. In: ER Kandel 11-1 . Nervous outnow from skeletal muscle follow­ . Ho u k J. we have attempted to connect the science directly to the techniques in this volume proceeding from the superficial to the deeper techniques. Mense 75-88. chemical and thermal stim­ ulation in the skeletal muscle of the dog. JA Dempsey. Principles ofNeural Science. JH Schwartz. Von During M. Am J EP. New York: McGraw-Hili. Zimny ML. J Pilysiol. Ent wicklung und Bau del' Sy noviamem­ branen.273:179-194. JesselJ TM. New York: Cambridge Unive rsit y Press. 21 :591-663. Walsh EG. New York: McGraw-Hili. while continuing to use the art of manual therapy to heal and always continue to investigate the explanations for the effects seen. 1988. 2. Zimny M L . J ing chemical noxious stimulation J Pilysio! 1977. Topography and ultrastruc­ ture of group III and IV nerve terminals of cat gas­ trocnemius-soleus muscle. 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. Andres KH. TM Jessell.30:466-481.83:401-419. for the cl inician. 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. eds. the practi­ tioner should use the science for explanation. Finally. 16. the practitioner should remember that many manual techniques appear to have no rational explanation but appear to consistently benefit the patient. Haouzi 1. New York: Plenum.Mechanoreceptors in articular tissues. Thin-fibre receptors re­ ER Kandel. 13. 1988. Mi zumura B a sbaum AI. cds. Am J Anal. Lcwis BK. 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. Consequently. Spaslicily and Rigidily. Schutte M. P. Mechanoreceptors in the human anterio r c ruc i a t e li gament Anal Rec. 4th ed. the relevant issues of mechano­ receptor anatomy and physiology. 17. Henneman E. AI P ack cds. S.1882. eds.1969. Moreover. ogyo[Normalily. 14. JH Mechanorecepto rs in arti cular tissues. 1992. 2000:430-449. we have summarized some of the recent f indings of the influence of skin and joint receptors on position sense and myofascial tone. 182: 16-32.204-209. Kumazawa TN. MP. 4th ed. 2000:472-491 8. 7. Responses III and IV muscle afferents to d i s tensio n of the peripheral vascular bed. N erve terminals associated with the knee WL Neuhu­ joint of the mouse. Anal Rec. Stacey MJ Free nerve endin gs in skeletal muscle of the cat. 15. 1942. REFERENCES I. in: ER Kandel. Spinal renexes. Schwartz. 2 I 4 . 4th ed. eds. Gardner II. TM Jessell.87: 545-553. Hypolonicily. Principles ofNeural Science.90 MYOFASCIAL MANIPULATION CONCLUSION Much of the material presented in the early sections of this chapter may appear to be weighted heavily toward basic science. Ann ROI·ul Coli Surg Eng. Regulalion otBrealhillg. in: . 182: 16-32. Masses and Malian. 4.267: Copyrighted Material . cat.JAllal. 1967. 1977. ber. The neurology of joints. TM Jessell. Furthermore. 1986: . It is highly probable. The Physiol­ 10.41 :25-50. Kaufman Dabezies E. In: K. Gordon spondin g to mechanical. The perception of pain.

1995. JY. New York: Appleton & Lange.44:637-646.68 861-867. kinesthetic information by peripheral sensory reccptors. ' EG. 39. Hill JM. of muscle tone as related to clinical mu scle pain. Bartoo ML. Ranarunga K W. ctal muscle muscle spindles: A review. 40. 21. Prud'homme MJL. 35--48 37. pilot study. J Rheu malo/. Fields HL. QJ Exp Phvsio/. 2. J Musculoskel Pa in .9(2): 164-170. 47.ys/O/. in Clinica/ Nellrophvsi% gy. Campbell KS. . Muscle tension and personality traits in pawith muscle or jOlllt pain: A of group endurance. C1emmesen 33. J Physiol. Mus­ trigger points. Tension due to interaction between the sliding JC Aiexancler I J. The VJSCOUS. Spine. Kalaska Physiol. 1994: contraction by products of arachidonic acid metabolislR I 1576. Elert spots i1l1d control J J Muscu/oske/ci Pain. Ivemeyer ReI' Neurosci. JH cds. 46. Spine.496:827··836. 30. Morgan DL. 44. Linke WA. In: Spmal ami Supraspinal Mechanisflls mo/iolls. The apphcd anatomy thoracolumbar fascia. 25. Simons LS.69: 20 RO llo DM. SpaslieilV New York: Cambridge University Press. Sensitlzarion of group Longhurst JC. 17:425--438. Basma Jian JV New views on Illuscular tone and relax203-205. Schultz HD. Matthews PB. Cohen DAD. Bogduk Back. McGraw-Hili.71: 161-172. Adaptability explain the thixotropIc short-range el astic component of relaxed frog skeletal muscle. 1990. Kaufman MP Cyclo­ oxygenase blockade attenuates the muscle afrerents to slatic contraction. ojlVormalily. 1993. etTect of stimu­ 42. taneOllS electrical activity at sites in rabbit muscle. Proske U. 1995. 1986. Am J Alec! 19R2. Ra l ston Med. Pain. Pickar . Jull GA. Mense S. J 28. 26. Gillard DM. Kennedy Vol. Understanding and measurement Taylor.Nellromechanicct/ and Manipulation 91 Rotto DM. Orr FW. 1991 :533-547. A cross-bndge mechanism 01. The question of tonus in skeletal muscle. Excit atory and inhibitory skin areas for filaments in resting striated muscle.1951. Kaufman MP III muscle afferents to static DiMauro S. Janda V Muscles and motor eontrol 111 low back JF. viscoelastic lld elastic characteristics of resting fast and slow mamma­ lian (rat) muscle fibres. PlVe R Soc GT Observations o n the pathomorphology of the thoracolumbar filscia in chronic mechanical back pain. Am J Phy. 1980:33--43. Hagbarth KE..4 93-121.lG. Prog Houk J. A rnicroscoP1c study. of innate motor patterns and motor control mechanisms. In: ER Kandel. I The Physio/ and RigidUy. Prillciples o /Neura / Science. 32. hip. Cameron T. Hill JM.73:369-377. I innervation of hu man 63(2):195-197. Simon J Signaling of 1982. Kaufman MP Effects of contraction and lactic acid on discharge of group III muscle afferents in cats. 1996. Simons DG. 941·962. ACla Orlh o p Scat/d. Gregory JE. J. Physical Therapy of Ihe York: Churchill Livingstone. JR activity in primate cortex during active arm movements' Correlation with receptive field properties. Bollack Gil. lation. 1993 . Burgess PR. .IO:329-335.41use Res Cell MOli/.3: Ncurophysiol. M. New Ihe Macintosh JE.issoc J 1\1 Sensory thoracolumbar faSCia. Rymer WZ. Simons DG. J Phvsiol 1998. Can J Phvsiol Ph ar macol 1988. Wei Allnl Murungi G. Schwartz. 41. or /l /unl ar} MaIOI' Conlrol alld Loco· o 8. 20(10):116 H 164. Thixotropy in skel­ Ghcz The control of movement. 49. 10531059. I-IJ. Newman N. Rhalmi S. C Franzini-Armstrong. New York: McGraw-Hili. Kazan: Kazan University Press. I I-I Some studics on muscle tone. Eisemann M. 1988. 1987. J Physio/.259H745-H750. Bednar DA. 1968. Tacttie J Neuro­ pam: and l1lilnagemcnl In LT Twomey. J App/ Physi o / 19. Lakie M.510: nexor and extensor notoneurones. Bcrkioblit M8. 50.9:585-<'>38. 27. Dahlqvist SR. vol. Libet B. 1987. 36. cds. TM 23 3 rd cd. Hill DK. Physiol Scali. Am Phys ioi. Hayes KC. Schultz HD. TSlijino S Non-lysosomal In: AG Engel. 1996. An im­ mUlJohistochemical study. Walsh EG. Pain/ullvlusde Hyperlonlls (in Russian).20: 155CH 556. 1984.1994.. Nerve supply of the human knee and its functional importance. Basel: Karger. Belwv Brain Sci. Limits of (ilin extenSJon in single cardiac myofibrils. Altnay B. Walsh of the Goigi tendon organs. 31. Masses alld Molion. 1990. Can !l4ed . 29. Hong CZ. 1996.5: 17 87. Muscles. Copyrighted Material . cds. Simons DG. I-58. Feldman AG. Prevalence of spon­ L1. Y3hia L. Functional properties Neurobio/ 1993:41. 34. Clinical and etiological update on l1lyofas­ cial pain due 10 complex proce ssing. Crago PE. to somatosensory mapping: complex messages require . Clark FJ.199:637--684. 1990. 48.tfyO/ogl" 2nd cd. 1992. Collins OF. Ivanichev GA. W right GW Postural thixotropy at the human cular sense is attenuated when humans 1998: 508:635-643. pi. Pain. Proprioceptors and their contrrburion . ProchazkaA. Hyp% niciIV.66: 430-438.Med.

4 In a recent review. however. Balfour reported "patients as having a large number of nodular tumours and thickenings which were painful to the touch. vary­ ing in size from a small-shot or split-pea to an almond. Physical therapists need to understand the nature of these syndromes. a term introduced in 1942 by Travell and colleagues with the addition of "myofascial" in 1952. Muscle pain syndromes are generally classi­ fied into two distinct categories: fibromyalgia and myofascial pain syndrome. Al­ though there are overlapping characteristics of The author wishes to express gratitude to Christian Grobli. myofasciitis. and from which pains shot to neighbouring parts."2 In 1904. to Mona L. In 1816. Historically. referred to as "muscle hardening" and "myogelosis" appeared in the German literature in 1921 and 193 I re­ spectively3. MSW. if the patient's condition satisfies the set criteria. PT..5-7 The term "fibrositis" was first coined by Gowers in 19048 For many years. Very fre­ quently the thickening takes the form of a strand or cord running through the fascia or subcutane­ ous tissue. Simons postu­ lated that the concept of myogelosis is virtually identical to the concept of trigger points."2 Similar concepts. although based on current evidence fibromyalgia is no longer considered a strict "muscle pain" syndrome. questionable dysfunction. muscular rheumatism. pain from muscles has been described in mUltiple terms. and patients with these conditions are increasingly being referred to physical therapists for evaluation and treat­ ment. and myalgia. rheumatic myositis. It was not until the late 1970s that clinicians attempted to categorize muscle pain conditions into distinct syndromes. Stockman described "chronic rheuma­ tism" as characterized by "fibrous indurations [that are] more defined and circumsclibed. myofascial pain. . and how myofascial manipulation fits into the rehabilita­ tion program. or even half a walnut. Mendelson. for her ongoing support and pa­ tience.CHAPTER 6 Muscle Pain Syndromes Jan Dommerholt Muscle pain syndromes are being diagnosed today using specific criteria. how patients with these syndromes are best rehabilitated. and to David Simons. without an identified histopathological basis. MD. LCSW-C. muscle hardening. 93 Copyrighted Material . for his outstanding contributions to the section on myofascial pain.. persons with fibrositis syndrome were thought to have characteristic tender nodules. including fibrositis. a third category-soft tissue mechanical dysfunction-should be added. To be inclusive. for his critical review of this chapter. a definite diagnosis can be made. or negative diagnostic workups. I Any of these terms has been associated with examinations of patients who had pain of unknown etiology. with specific criteria applying to each9-'2 In theory. rather than a pathology. The distinction is that the clinician is diagnosing a syndrome. myogelo­ sis.

soft tissue mechanical dysfunc­ tion is an acute and local problem usually con­ fined to a particular muscle or tendon. Several other syndromes and clinical entities have been linked to f ibromyalgia in­ cluding headaches.2%.. a renewed interest in defining crite­ ria for diagnosis and classification of fibrositis emerged. Fibro­ myalgia is always widespread and chronic. The purpose of this chapter is to explore the etiology. attention deficit hyperactivity disorder. Myofascial pain syn­ drome can be acute or chronic in nature.. symptomatology.r 51 o I • · 30-39 · 40-49 • =-= • 18-29 50-59 60-69 70-79 80+ I-+. By definition. © 1995.----. and medicall therapeutic management of these common pain syndromes. panic disorder. K. American College of Rlleumatology.15 In a recent study.. yet it is most common in women ages 50 years and above (Figure 6-1 ).4% 90% of women and 0. depression. chronic fatigue syndrome. fa­ Diagnosis Following a 1977 publication of Smythe and Moldofsky.. et aI. Examples of soft tissue mechanical dysfunction include partial or full muscle tears or tendinitis. 19-28. pp. Copyrighted Material . they represent different neuromusculoskeletal conditions.94 MVOFASCIAL MANIPULATION these pain syndromes. FibromyalgiaI Figure 6-1 Prevalence of widespread pain and fibromyalgia. and psychological dis­ tress. Soft tissue mechanical dysfunction has a strict mechanical etiology."24-26 all adults broader neuro-endocrine "dysfunctional spec­ In North Amcrica. The Prevalence and Characteristics of Fibromyalgia in the General Population. Arthritis & Rheumatism. and non­ cardiac chest pain.. Lippincott Williams & Wilkins. whereas f ibromyalgia and myofascial pain can be caused by mechanical dysfunction or neuro-endocrine or metabolic dysfunction. it can be re­ gional or widespread.13-23 Because of its associa­ tion with so many other syndromes. endo­ crine dysfunction involving the hypothalamic­ pituitary-adrenal axis... Fibro­ myalgia is often reported to be a disorder af­ fecting primarily young women. No. of patients are women. 20 I 15 10 . the prevalence of fibromyalgia under children was 1.Widespread Pain . irritable bowel syndrome.27 FIBROMYALGIA Definition Fibromyalgia is a disorder of chronic wide­ spread pain. tigue. it has been suggested that fibromyalgia may be part of a trum syndrome.5% of men). Ross. resulting in the 1990 American Col­ 30 . and to discuss the role of the physi­ cal therapist and physician in the evaluation and treatment of patients with these conditions. . Myo­ fascial pain syndrome is often viewed as a regional pain problem. dyspareunia. 38. Wolfe.. interstitial cystitis. Source: Reprinted with permission from F. restless leg syndrome. f ibromyalgia affects 2% of Seventy to (3. accompanied by tenderness. �. pathophysiology. sleep disturbance.. however.

when the ACR the point count in research protocols. of fibro­ are disthat several contributors to the ACR criteria. symptoms of distur­ and psychological dis­ disturbance. and lacked the did however. group of subto the The ACR criteria have provided researchers below the waist. axial must be present). "they may be useful for sis as well as classification. The tender nine . In addition.. and stiffness were found in more than 75% of fibromyalgia on upper above the scap­ near the medial and muscle criteria are classification criteria established exclusively for clinical and search purposes and not for clinical although the criteria suggested sensitivity. that many clinicians make the primarily based on the tender count in combination with the with a somewhat which has contributed history. and low levels of self-care. irritable bowel syndrome. fatigue. Widespread pain must have been for at least three months. as Other authors. Pain in II out of 18 4 ki tender spots when palpated with approxi­ point sites include the locations Occiput: Low cervical: at the insertions at the anterior aspects of the intertransverse spaces at C5-C7 at the midpoint of the upper border at ula border Second rib: at the second costochon­ dral junctions.. more severe fatigue."28 In 1 be used for clinical 1992 Second World lS Wolfe confirmed that the criteria can As part of the on Myofascial 1I1 Pain and that to the a con­ sensus document on f ibromyalgia was defined strict adherence to the tender declaration.lvfuscle Pain 95 Criteria for the C]assifi­ (ACR that a diagnosis of can be made if a combination of the fol­ criteria is satisfied: .. also the clinical when less then 11 tender of fibromyalgia features (e. were not essential for In clinical symptoms was present in only 56% of patients accuracy of the tender point count. are present at a sutTicient level of The underlying discrete depicts a more is that The number of tender points measure of distress. tion purposes. A represents a continuum of distress rather than a It is noteworthy that the ACR criteria do not include the tress. the combination of the three specificity and The report these typical symptoms. just lateral to the SUifaces Lateral epicondyle: 2 cm distal to the epicon­ dyles Gluteal: in upper outer quadrants of buttocks in anterior fold of muscle Greater trochanter: Knee: posterior to the trochan­ teric at the medial fat pad mal to the line than 11 tender points. fatigue.g. side of the body. The nature of the Copyrighted Material . According as "there are sufficient numbers tender point count may indicate more so­ matic symptoms. defined of force. History 0 f widespread in the left side of the body. (defined as in the above the patients. advocate present.

Source: Reprinted with permission. D. and the specificity of the tender points in relationship to fibromyalgia becomes somewhat question­ able outside the realm of research. © 1989 The McGraw-Hili fibromyalgia concept. 1989. when experts agree that "some loosening of the ACR clas­ sification criteria are necessary for diagnosis in the clinic. 1nc. Diagnostic and Therapeutic Challenges of Fibromyalgia..24(9A):39. Figure 6-2 Fibromya1gia tender points. a focus on tender points is less important than paying attention to the overall psychosocial. and organic aspects of individuals with chronic widespread Copyrighted Material .96 MYOFASCIAL MANIPULATION Insertion of the suboccipital Under the lower sternomastoid muscle muscle Mid upper Near the second costochondral trapezius muscle 2 cm distal to the lateral epicondyle At the prominence of the greater trochanter At the medial fat pad of the knee . Goldenberg. behavioral. Ho.L. 11lustration by La u r a D u p r e y. the ACR criteria.34 Perhaps."D.pital Practices Companies.

From I ization of medical resources.Muscle Pain Syndromes 97 pain35 Jacobs and colleagues did not find a cor­ relation between the tender point count and self­ in Another important is that the diagnosis of fibromyalgia is made of other inclusion. out other."44. but would not be drome.'{' every individual has a strong drive to function in a world of meaning. I they are un­ the case of a person with widespread is conceivable that clinicians and the rehabilitation pro­ A recent phenomenological study re­ vealed that persons with fibromyalgia appeared to seek constant confirmation of their illness.. The researchers concluded that I ifetime diagnoses care settings. a process may be initiated within that individual that serves to gIve new to his or her life.. The were found to be fibromy­ higher rates of may not reveal that a patient started 43 One related to "health care seeking behavior" and not to the fibromyalgia. including a sense of and also to living lessness or a belief that one is disabled. may contribute to the decision to seek medical care for fibromyalgia in There is some of tates a could argue that in such instances fibromyalgia other would not be considered. loss of hope. Because the current treatment modal ities for have not been able to relieve the s ymptoms ad­ with fibrol11yalgia a sense of illness behavior. it was found that the had in these illnesses.45 In other words." sified as having to the "28 a hermeneutic phenomenological . cess. Pf· . Because the ACR criteria were not developed for diagnostic purposes. as having the syn­ it fibromy­ Although this may seem obvious in gia as a complication of These condi­ frequent pain.4649 cific beliefs. they do not consider the potentia lJy and emotional consequences of "a diagnosis of in­ clusion" for patients and their families. are pre­ dictive of the diagnosis of fibromyalgia is "a diagnosis of a subj ect this meeting tbe ACR criteria should always be clas­ may be satisfactory for classification purposes."5] whether a ution the medical system5455 .. it becomes more complicated in clinical diagno­ especially when there is a treatable condition that also features widespread tions include pain hypothyroidism. rather than focus on a treatment outcome. . or actually facili­ McBeth and colleagues established that a high Copyrighted Material . once a person has been given the diagnosis of fibromyalgia.. myoadenylate de­ aminase hypermobility or other rheumatic diseasesF-41 Wolfe maintained that "a person with widespread burns would meet classification criteria for fibromyalgia.. less obvious pain training in identifying myo­ points may conclude that there are no other underlying musculoskeletal causes of widespread rectly with plete taking before the onset of the may resort to the patients with significant psychological problems or with any widespread may be ate intervention for "urln '>" and label a II1cor­ An incom­ patients with who met the criteria but who were not diagnosed as such. which can be described as "an individual's transaction with a situation such that the situation constitutes the individual and the individual constitutes the situation..

Muller and Muller the fulfillment of secondary and toms would further support the cold hands or feet. response following In addition. the Muller and Muller criteria. paresMiiller and of fibromy­ of exclusion. of three autonomic and three functional symp­ bromyaJgia. The medical and thera­ management should focus primarily on the other diagnoses and not resort to patients how to manage their fi­ This was illustrated by Poduri and of exclusion. :spontaneous pain i n three . there are no ob ective laboratory studies that confirm j the diagnosis of fibromvalgia. To overcome some of the clinical limitations of the ACR criteria.32 it may not interest of a patient to be bromyalgia. In of extensive research efforts. the Muller and of tendons or at tendon insertions in at least of the trunk and extremi­ threshold with a visible pressure of out of 24 tender ties for at least three months. Perhaps. Decreased 2 kg/cm' of l in the course 58 In summary. For a cohort of the intermediate and long-term outcomes of f ibro­ in patients seen at least once in specialty clinics concluded that the prog­ was very poor. gas­ trointestinal and should be made only as a cardiac problems.98 MYOFASC1AL MANIPULAT10N tender point count was associated with increased medical care usage in addition to an increased number of physical symptoms. a "diagnosis of inclusion" may be ap­ propriate. the patients were not evaluated for the presence of syndrome. It appears that the same criticism would apply to and required When 11 of 18 tender points must be pain­ Copyrighted Material . and tremor. Functional limitations may include sleep disturbances.. Autonomic symptoms may include sible that clinicians did not consider the other of widespread pain as the ACR cri­ teria were applied. The ACR criteria have been criticized as being arbitrary and at risk for circular reasoning and tautology. but who in fact suffered from drug-related immediate treatment accordingly. ferential diagnosis of or other dif­ and did not receive the most treatment For clinical purposes. even though it may still influence the outcome and conclusions drawn from such re­ search. The ACR criteria were developed 111 including The of fi­ autonomic symptoms. patients with f ibromyalgia continued to demonstrate and functional abnormalities48 clinical it is pos­ ful with 4 kg/cm2 for fulfilling the ACR Muller and iv1i. Although did not examine the results of treat­ ment at these centers. especially in the presence of other musculoskeletal pain for which there are potential solutions42 For classification pur­ poses. orthostatic arrhythmia. excessive mouth.iller required 12 of 24 points to be tender when with a force of 2 _ found that their method when proposed method Muller criteria . the should be made as a all reflect a clinician's attitude that fibromyalgia does not but assures patients of the most treatment." It is not sufficient to several other c Iinica I including and The reliance on a definition 60 met the ACR criteria and who was diagnosed with fibromyalgia.. Muller and Muller devel­ diagnostic criteria for fibromyal­ 57 consensus and the lack of a well-defined concept of patho­ physiology have resulted in critical opposition to the fibromyalgia construct. functional limitations.

tender points usu­ headaches. but also in nonpainful In another sensitivity in fibromyalgia patients was more I. and sensations of numbness or in the hands and feet. for many years. pressure algometry is recommended. further studies are needed to establish the diagnosis of f ibromyalgia.67. It threshold. The result of Clauw explored the utility of skin rolling as a verbal response of the patient and may be more than a tender point count.65. but a means to evaluate immediate and Zohn and and found that skin of the tender Skin rolling does not depend on a at to long-term treatment clinical test for rolling point count. there is no convincing evidence that the peripheral tissues in persons are abnormal. yet cial can evolve into may also have trigger points" do tn"'I>T. and fa- Although the validity and inter-observer and intra-observer reliability of the tender point count have been established in several Fischer commented that 4 and physically fatigued.n and Vecchiet and muscle and observed that three tissues was 66 in all 11 out of 18 cally defined not only over f ibro­ the to the skin and not re­ rather than II tender points out of 18 anatomi­ need to be distinguished from myofascial points.8o Gibson and colleagues demonstrated that persons with cant reduction in heat exhibited a threshold as well. computed netic resonance phy. The altered was not dependent on increased skin sensibi 1ity. Pressure is a standardized method for quantifi­ cation of tenderness and is called pressure pressure that induces also the so­ or discomfort. and should not be ordered unless other clinical would indicate such. Gravenconcluded that the hy­ observed following painful stimuli of a pain-free muscle in fibromyalgia indicates the involvement of central hyperexcit­ knots in muscles that refer pain to a more distant syndrome and myofascial not exist. which are the main characteristic of the myofascial expresses a more pain problem. the nature of skin and its this point. although this was not confirmed by In spite of these findings. the patient typically has complaints of diffuse and widespread pain that not confined to tender tients report report in the morning Almost all pa­ sleep disturbances and unrefreshed anxiety.nr. Tenderness An essential feature of the ACR criteria is a total tender point count of at least II out of 18 anatomically defined are subjected to 4 kg cally.n is not limited to the tender hybut stricted to muscle tissue. it is when these pressure. bouts of abdominal con­ stipation and diarrhea. The ally describes chronic x-rays. Semanti­ that the ACR criteria require defined tender points. in stud­ Other clinical pre­ sentations may include hypersensitivity to cold or heat. and blood studies are normal. or the minimum is not only useful for diagnostic purposes. points are actual contraction Patients with myofascial ger points.' _ tender points.64-66 The do not have an established or points .68 There is no evidence that Copyrighted Material . Persons with fibromyalgia have altered noci­ f'P'r.Muscle Pain 99 Clinical Characteristics Clinically. recurrent frontal-occipi­ tal headaches.

Persons with a tients with fibromyalgia. while several other studies have linked alcoholism in families and sexual and 11 1 abuse to fibromyalgia. 99 It has been described in persons with and even in rheumatoid subjects. The that central sensitization is the final common pathway for the development of abnormal pain perception.IOR In an older no differences were found between per­ sons with fibromyalgia and control subjects in a medicine clinic.""hn".1 Factors state level of flow in the thalamus and caudate also Most studies demonstrated that persons with have more emotional and than persons with other chronic and normal control which led Hudson and Pope to conclude that is an "affective disor­ all are based on rheumatology clinics and may psychological problems based on referral bias. Stages 3 and 4 feature predomi­ nantly delta waves and are referred to as "deep or "slow wave that restorative Moldofsky and col characterized by the so-called " It is during these occursYI. that fibro­ anOlTI­ also patients have an abnormal sleep pattern an intrusion of alpha waves during slow several studies have con­ others failed to duplicate their anomaly was found in patients and was not acquired immune deficiency The alpha-delta of a pain prone be related to posttraumatic stress ences. 1 there is no evidence that there is a a few studies iden­ prone personality" in some pa­ I . 10 prone personality are typically achiev­ ers...92 In 1975..1 were positively correlated with a count32 A pain prone is not to fibromyalgia and is seen disorders. cycles and non-REM divided into four ages of low frequency brain waves referred to as delta waves.105 is insufficient evidence that disturbed sleep pat­ terns are specific for persons with fibromyalgia. I rates of lifetime and current it is not clear how the symptoms are related to the Copyrighted Material ... I I trauma. who lack assertiveness and the ability to "".pi. the use of this term because up unrefreshed and may be debil is absent or has been is not universal..90 In general... As with most symptoms of . In some persons.100-103 Scudds and colleagues did not find any difference for between persons with with m yofascial pain tioned the sensitivity and electroencephalography. I I I with 36% of f ibro­ for fibro­ (AIDS). which in itself is a factor posi­ tively associated with self-reoorted work dis­ 48. Disturbances persons with report but this to Yunus. 3.i. and adverse childhood of were found to suffer from marie stress disorder versus none of the control group. and express unpleasant emotions. any chronic pain state appears to have a negative effect on a person's 104 quality and persons Lue ques­ of alpha among a broad spectrum of Dsychosomatic and Patients with appear a few studies that did not find any evidence of increased depression. fawhereas in others it because of its chronic nature 89 Fatigue may be the result of disturbed sleep.100 MVOFASCIAL MANIPULATION 86 Patients with had a lower cerebral blood which P".n. concluded that affective distress is not but primarily the result of severity.

tions and Wolfe confirmed that persons more Many to these with with f ibromyalgia reported more medical condi­ conditions than persons with rheumatoid ar­ thritis or osteoarthritis. I than four times as to the myalgia. Fassbender and observed that patients with fibro­ had significantly more tender points than patients with f ibromyalgia demonstrated lifetime prevalence rates of mood. Haynes and established that they were SIS. 131 F unctional so­ have certain characteristics Persons from any of often attribute common so­ matic symptoms to the illness."46. 128 Fibro­ " or as Hadler could serve as a rationalization for psychosocial or as can become "a way of stated.121. and a sense of nOIPeleSi.90.122 It is that having a of combined with constant pain.lt Although the report tlon43.1 8. an extenua­ should persons because of pain. the Gulf War syndrome. "if you have to prove you are ill. these the irritable bowel syndrome.130 and Borus included f ibromyalgia in of "functional somatic syn­ a group of characterized and who did not know that had a threefold increase with fibromyal­ work disability. are convinced that have a serious illness that is likely to worsen. chronic whiplash."52 with are not rea Ily "re­ inability to comply Ford also considered of fibromyalgia may pro­ is "just another somatization disorder. or can contribute to Or are both cause or due to increased pain disorders the result of a common underlying Based on recent studies and theo­ and are most likely the result of a commOn underlying abnormality. The is convinced of having a seriolls the a confirmative ness seemed to be important for persons with fibromyalgia. insufficient catecholaminergic or neurotransmission or hyperactivity hormone. Several authors have Hellstrom and col put a label on suffering Having a issues or sponsible for their would upon them. Common symp­ toms are amplified and become the main focus of attention. functional somatic and assume the "sick portrayaI to search for with the demands they themselves and others f ibromya Igia a form of somatization and a "fash­ ionable diagnosis" and r"'(1.ness. If having been is a factor in and if the symptomatology tion of an already difficu.128 This becomes particularly difficult in whether persons with should be a warded disability or A recent further exacerbated by Copyrighted Material . rep­ the side effects of si Iicone and breast implants. somatization disorders than matoid arthritis. poor expectations recovery. may also become factors del)re�5Sl\/e mood disorders.hlp'm" that somatization mechanism."1 27 126 Wolfe and Patients with higher and with rheu­ in work absenteeism after being told the with f ibromyalgia receive disability benefits? of persons with f ibro­ able to as many as 25% have received some form of compensa­ found that persons with f ibromyalgia are more to be divorced com­ etition stress syndrome. the chronic matic in common. you can't get better. vide a means to avoid that pointed out that "to it meaning.Muscle Pain 101 Do patients with fibromyalgia get pnr'p" "F'fl study concluded that having been told that one had f ibromyalgia became one of the work which illustrates the influence of cognitive beliefs on somatic 90 Similarly.

102

MVOFASC1AL MANIPULATION

of the condition as "catastrophic and disabling." Barsky and Borus outlined several other factors relevant for the discussion of fibromyalgia. Health care institutions, medical providers, and advocacy groups have developed professional and financial interests in the diagnosis, as evi­ denced by the increasing number of fibromyal­ gia clinics, Internet Web sites devoted to fibro­ myalgia, and the multiple support groups, which will reinforce the belief that there is no effective treatment (Table 6-1 ).132,133 Many patients with fibromyalgia have ad­ opted other diagnoses and feel that they also have chronic fatigue syndrome or irritable bowel syndrome, a process sometimes referred to as "pathoplasticity," realizing that these additional 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 physician. A rheumatologist may diagnose fi­ bromyalgia, an internist may identify chronic fa­ tigue syndrome, while a gastroenterologist may consider irritable bowel syndrome. In spite of these controversies, patients with fibromyalgia or chronic widespread pain will continue to seek medical help irrespective of physicians' belief s ystemsD6

to be deconditioned, which may account for some of the apparent abnormalities reported metabolites.137,1.18 W hen compared to equally fit healthy subjects, however, persons with fi­ bromyalgia were found to have normal oxygen consumption and normal accumulation of me­ tabolites during exercise,1 39-141 Other studies demonstrated that there was no increased struc­ tural damage with exercise when compared with healthy individuals,142-144 Although the number of subjects was limited, a few studies suggested that persons with fibromyalgia may have a hy­ poresponsiveness of the sympathetic nervous during exercise. 145.146 system and hypothalamus-pituitary-adrenal axis in oxygen consumption and accumulation of

Pathogenesis One of the difficulties of diagnosing and treat­ ing patients with fibromyalgia is the absence of findings in the laboratory and radiologic workup. Much research has been conducted to identify histological and physiological charac­ teristics of fibromyalgia to determine possible etiologies and effective treatment remedies. Fi­ bromyalgia is a complex, multi-factorial dis­ order that has been associated with musculo­ skeletal and neurochemical abnormalities, yet most of these abnormalities are not specific for fibromyalgia. None of the findings have resulted in fibromyalgia-specific laboratory studies or objective diagnostic criteria. Initial studies at­ tempted to identify musculoskeletal abnormali­ ties and signs of inflammation. Altered muscle metabolism, decreased circulation, and struc­ tural damage to muscles have been suggested to explain the widespread muscle pain in patients with fibromyalgia. More recent research has focused on the role of neurotransmitters, the hy­ pothalamus-pituitary-adrenal axis, and various hormones, A brief review of pertinent research follows.

Lack of Exercise
Lack of exercise is another relevant factor in the clinical history and presentation of fibromy­ algia. Most persons with fibromyalgia exercise little and assume that exercise will worsen their condition. Persons with fibromyalgia tend

Table 6-1 Number of Web Sites Found on
www.altavista.com (January 10, 2000)

Number Search Word
Heart disease Arthritis Cancer AIDS Fibromyalgia chat Fibromyalgia

of Sites
249,547 428,885 2,181,318 2,321,925 14,373,294 87,726,785

Musculoskeletal Abl10rmalities
Several studies identified "rubber bands" in single muscle fibers, "moth-eaten" and "ragged

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Muscle Pain

103

a reduced content of high energy and a to to the rate of phosphodiester an abnormal oc­ resonance , which were thought to be related currence of elastic state, or local muscle eaten" fibers are indicative of a change in the distribution of mitochondria or the sarcotubular system; "ragged red" f ibers reflect an accumula­ tion of mitochondria.154 links in persons with of altered collagen tribute to of the extracellular matrix. They hypothesized that these changes may con­ tribute to the lowered pain threshold at tender 155 Others did not f ind any differences between muscles. When healthy control no differences were found in lactate oxygen uptake , and p31 resonance spectroscopy, that patients with f ibromyalgia do not have ab­ normal muscle metabolism.139-142,1 is also no evidence of any strllctura I to muscles of persons with resonance did not reveal any abnormalities of the skeletal muscles of persons with fibromyalgia.160 The structural and func­ tional abnormalities noted in earlier studies appear to be the result of muscle and are not specific for f ibromyalgia.161 Because of the lack of has shifted toward understand the for clinical peripheral and histologi­ research of the central mechanisms it is critical to sciences into cal findings, the focus of There were matched with equally and normal and colleagues identified decreased levels of collagen cross­

trol

163165 Patients with

hip os­

teoarthritis were found 10 have 1.5 to 2 .0 times normal levels of substance with

P, whereas

including diabetic neuropa­

had either below normal or j.5 times normal levels.166-168 Substance P is a neuropeptide in­ volved

in several aspects of the process of noci­
It is released in the dorsal horn of the and and

cord in laminae I, II and V laminae r and II that there is a peripheral tive stimuli; evidence to support a fibers (A ) are but release rotransmitter. activated

C fiber afferent neurons. This seems to suggest
of the nocicep­ mechanism in and terminate as their neu­ at this point, there is no

f ibromyalgia.122.l69 The large diameter sensory in laminae III and IV They do not contain neu­ Dorsal horn neurons are divided

into high-threshold mechanosensitive neurons, low-threshold mechanosensitive neurons, wide­ neurons, and interneurons. All neurons can be sensitized or new synaptic contacts with other neurons. A increase in the excitability neurons may contribute to the pain disorders.171 Under normal high-threshold mechanosensitive neurons are connected with Ao and

C f ibers.

to noxious stimuli, whereas low-threshold mechanosensitive neu­ rons do not mediate pain. Afferent barrage from and muscles can unmask ineffective, or within the dorsal horn synapses the release of sub­

nervous system and the endocrine system. To

stance P, calcitonin-gene related peptides, and glutamate from the primary afferent neuron into the dorsal horn via neurokinin-l that A It1Jury, would then be and There is some evidence

fibers sprout dorsally from laminae III in new synapses with afferent input as nox.ious.17o Be­

Neurochemical Abnormalities Substance P. Several studies have identified
substance P levels to be up to three times higher in the cerebrospinal fluid of persons with with con­

and IV into laminae I and 11 following peripheral tive neurons. Low-threshold

cause substance P can lower the threshold of excitability, there may be an increase

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MYOFASC!AL MA.NIPULATION

in the number of mechanosensitive receptive making fibromyalgia a syndrome of cen­ 4 tral sensitization.172-17 The pain in f ibromyalgia may be related to the action of substance P on neurokinin-l etTector
rp('pntr.r

They

a correlation between pain in fi­

bromyalgia and the plasma concentration of the essential amino acid tryptophan. Tryptophan is the metabolic precursor to serotonin that extracted from in the intestines. decarboxylated to se­ rotonin by neurons in the brain stern raphne nu­ cleus, which is then released in the brain and spinal cord, In with rats, serotonin enhanced the synthesis of substance P in the brain, while it inhibited the release of substance P in the with cord. It is likely that persons have Jow brain tissue levels of

that oromote nociceotion, This does of excitation in of elevated Nerve

however, because the and colleagues reported the

the spinal cord is fairly limited, levels of nerve growth factor in the nal fluid of persons with factor is thought to facilitate the growth of substance P containing neurons and increase the excitability of dorsal horn cells substance P is counteracted can inhibit spinal pathways. SerotOllilt. Serotonin 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 hormone from the the release of mone from the anterior direct influence on the corticosteroid production from adrenocorticol cells. Serotonin increases the production of adenosine monophos­ 179 It is not known whether serotonin de­ f iciencies will result in the perturbations of the hypothalarnic pituitary adrenal axis seen in persons with
IRQ

both serotonin and substance P, and low spinal levels of substance P.186 Although cord levels of serotonin and high spinal cord levels of serotonin have not been reoorted in cerebrospinal fluid of persons with the concentrations of its immediate pre­ cursor product subjects. and its metabolic acetic acid were found 89 Lower serum levels of both tryp­

afferent

muscle input.l76·m The nociceotive activity of

to be lower when compared to normal control tophan and serotonin have been reported, pos­ sibly related to the diversion of tryptophan into levels of kynurenine instead of serotonin and to low serotonin.188,190- 192 The range of serum levels of serotonin in to be toms, dolorimetry.193 seter muscles and may not be tender points, and and colleagues found with fibromyalgia com­ consistently correlated with f ibromyalgia symp­

higher levels of serotonin in the superficial mas­ pared with healthy control subjects. The levels aDDeared to originate in the blood supply, Iy released. 194 Klein the presence of antibodphospholipids, and of the serotonin
14 195-197 ,

1

Multiple

serotonin receptor sites have been identified in the gastrointestinal tract, which may be relevant the relative common occurrence of func­ tional bowel disorders in person with
Ig)

Antibod­

serotonin were also reported in pera condition sometimes 1 98 The inhibition of spinal via descending
""tl""""C

Moldofsky and of its role in the initiation and slow wave sleep and the regulation of pain per­ ception through activity in the thalamus,lg4,lgS

is accomplished primarily via serotonergic and noradrenergic neurons.174,199 Perhaps the wide­

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Muscle Pain Syndromes

105

spread pain in fibromyalgia is the result of a dysfunction of the descending antinociceptive system or of an overactivity of the descending pathways that facilitate nociception.200.201 Hormonal Abnormalities. Because the onset of fibromyalgia is often reported to coincide with physical or emotional stress, it is not sur­ prising that several researchers have focused on possible disturbances of the stress response systems, including the hypothalamic-pituitary­ adrenal axis and the sympathetic nervous system

(Figure 6_3).22.122.202 -205 Fibromyalgia can be considered a "stress-related syndrome.''203 The hypothalamic-pituitary-adrenal axis is the main physiologic response system to stress. Regulation of the hypothalamic-pituitary­ adrenal axis occurs primarily through modu­ lation of corticotropin-releasing hormone, an amino acid peptide that stimulates the secretion of adrenocorticotropic hormone and other hor­ mones. Adrenocorticotropic hormone is an an­ terior pituitary peptide that stimulates the secre­ tion of glucocorticoids and other steroids from

Brain Hypothalamus

CRH

VP

S P
D a

NE

I
c 0 r

ACh

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.

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MYOFASCIAL MANIPULATION

the adrenal cortex. Cortisol is the main form of glucocorticoids released in humans.ISO, cotropin-releasing hormone stimulates adreno­ corticotropic hormone in a diurnal rhythm with a peak before awakening and a decline as the day progresses, The diurnal rhythm of adreno­ corticotropic hormone is reflected in the diur­ nal secretion of cortisopo7 When a stressor is perceived by the brain, corticotropin-releasing hormone is released,180,182,206 The activity of cor­ ticotropin-releasing hormone neurons appears to determine several of the symptoms of fibromy­ algia,122,205 Persons with fibromyalgia displayed a hyperreactive adrenocorticotropic hormone release and a blunted cortisol release in response to exogenous corticotropin-releasing hormone and to endogenous activation by insulin-induced , hypoglycemia.204 The release of adrenocor­ ticotropic hormone by corticotropin-releasing hormone is augmented by arginine vasopressin, another hypothalamic peptide, Based on studies of rats, arginine vasopressin may be instrumen­ ta I in maintaining the activation of the hypo­ thalamic-pituitary-adrenal axis during chronic , stress,19 Different stressors cause different patterns of release of the hypothalamic hor­ mones, Riedel and colleagues observed elevated basal levels of adrenocorticotropic hormone and cortisol in fibromyalgia patients205 Crofford and colleagues and McCain and Tilbe found normal morning levels of cortisol, but elevated evening levels, resulting in a loss of the normal diurnal cortisol fluctuation202,203 Reduced 24-hour uri­ nary free cortisol levels were found as compared with normal subjects and persons with rheuma­ toid arthritis or low back pain, especially in per­ , , 2 2 sons with longstanding fibromyalgia.202,203 081 Crofford and Demitrack speculated that the ap­ parent discrepancy between elevated evening levels of cortisol and reduced 24-hour levels may be attributed to a reduction of the normal frequency of cortisol release,181 with these f indings, Adler and colleagues found normal 24-hour urinary free cortisol levels and normal diurnal patterns of adrenocorticotropic hormone and cortisol22 They found a 30% re­ duction in adrenocorticotropic hormone and epi­

nephrine responses to hypoglycemia, contrast­ ing the findings by Griep and colleagues of an exaggerated adrenocorticotropic hormone responseY,204 Nevertheless, they agreed that f ibromyalgia may be primarily characterized by an impaired hypothalamic-pituitary-adrenal axis,n Another aspect of the hypothalamic-pitu­ itary-adrenal axis was recently investigated by Dessein and colleagues, who looked at the levels of dehydroepiandrosterone sulphate, testoster­ one, cortisol, serotonin, and insulin-like growth factor- l (somatomedin C) and their correlation with health status in persons with fibromyal­ gia.212 Dehydroepiandrosterone sulphate is the metabol ic precursor to estrogen, which was re­ cently shown to be involved in the regulation of enkephalin levels in the superficial dorsal horn, thereby changing the response to nociceptive stimuli.213 During pregnancy, dehydroepiandros­ terone sulphate is involved in the placental pro­ duction of estradiop4 I sulphate levels are a good indicator of adreno­ cortical function and probably more sensitive than cortisol levels.215 Under stress, the secre­ tion of dehydroepiandrosterone sulphate is di­ minished. With aging, there is a suppression of dehydroepiandrosterone sulphate secretion, but not of corticosteroid production2 . ual physical activity was related to lower levels of circulating dehydroepiandrosterone sulphate and insulin-like growth factor-I independently of age and anthropometric measures. elderly women, lower maximal aerobic capacity was associated with lower dehydroepiandros­ terone sulphate concentrations.217 There is also a positive correlation between hours of sleep and serum dehydroepiandrosterone sulphate levels21 8 Dessein and colleagues found that

the levels of dehydroepiandrosterone sulphate and testosterone were significantly reduced in women with fibromyalgia. They speculated that the androgens may protect against f ibromyalgia. There was a positive correlation between dehy­ droepiandrosterone sulphate levels and pain, which disappeared after adjusting for increased weight. Only 14% of the subjects were normal

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Growth hormone is an growth factor-I. 2 An intriguing hypothesis regarding the etiol­ ogy of fibromyalgia was postulated by Yue231 Notwithstanding observations by Ostensen and colleagues describing worsening of symptoms during pregnancy with the last trimester experi­ enced as the worst period. 205 amino acid polypeptide hormone synthesized and secreted by the anterior pituitary. It is se­ creted in females in the corpus luteum.122 Ap­ proximately 70% of growth hormone is se­ creted during slow-wave sleep and the amount of secreted growth hormone correlates with the amount of slow-wave sleep225 It was postulated that the poor sleep patterns of persons with fi­ bromyalgia could disrupt the nocturnal secretion of growth hormone. but plays a role in many other biological processes.219 In Macca­ rio's study.206 26228 2 .224 Norregaard and colleagues did not find any differences in so­ matomedin C levels among persons with fibro- myalgia compared to healthy. [n males. as it is known that physically active individuals have significantly higher somatome­ din C levels than sedentary subjects. which contradicted the findings by Maccario and colleagues in healthy adults. decidua. and placenta and in males in the prostate. the dehydroepiandrosterone-sulphate levels were positively and independently associ­ ated with 24-hour urinary cortisol and insulin­ like growth factor-I levels.I2 S decrease in growth hormone releasing hormone. which is required for the main­ tenance of normal muscle homeostasis. which re­ sulted in the hypothesis that the pathogenesis of fibromyalgia is related to a systemic deficit of relaxin. from which the hormone is secreted mainly in seminal plasma. A fast onset of fibromy­ algia appeared to occur in women following oophorectomies or hysterectomies. serotonin.Muscle Pain Syndromes 107 weight in this study and there was an associa­ tion between a high body-mass index and de­ creased dehydroepiandrosterone sulphate levels. Vue noted that preg­ nant patients with fibromyalgia often experience a remission of their symptoms during pregnancy with a return of symptoms within one or two months following delivery231 J2 2 . which is an­ other reason to include thyroid dysfunction in the differential diagnosis of fibromyalgia. which contains both growth hor­ mone releasing hormone as well as a growth hormone inhibiting hormone.229 They suggested that perhaps the difference in findings was due to selection procedures. or an increase in somatostatinThe somatostatin secretion is promoted by corticotropin-releasing hormone and thyroid hormones.219 Dessein and col­ leagues did not find any significant relationship between the levels of cortisol. Its primary function is to promote linear growth. These findings made Vue search for any agent or hormone that would have an effect on the collagen of connective tissues.ISO. relaxin is thought to promote motility of spermatozoa234 Relaxin has a strong vasodilatory effect and it promotes the genera­ Copyrighted Material .212. In males. Relaxin does not only effect connective tissue extensibility. but sedentary con­ trol subjects. low levels of relaxin appeared to be related to low levels of testosterone. known as soma­ tostatin. and insulin-like growth factor-I and health status as measured by the Fibromyalgia Impact Question­ naire212 Several studies have demonstrated that per­ sons with fibromyalgia may have low levels of growth hormone (somatotropin) and insulin-like .229 3o . Growth hormone stimulates the release of somatomedin C in the liver.223 The secretion of growth hormone is under bidirectional control of the hypothalamus.233 It is involved in the inhibition of uterine contractile activity and it stimulates the growth of the mammary gland. Leal-Cerro and colleagues concluded that the decrease in growth hormone secretion was due to hypothalamic dysfunction. or an inability of the body to utilize relaxin231 He speculated that the increased use of birth control pills at a younger age may lead to relaxin deficiencies. Relaxin is a polypeptide hormone related to insulin and insulin-like growth factors. found that many patients with fibromyalgia re­ sponded positively to injections with botulinum toxin. Relaxin is best known for its role during pregnancy and is known to promote lengthening and softening of pelvic ligaments to facilitate the birth process.

as discussed above. Many chronic prefer to view their pain condition as a medical problem.246 As Turk and Okifuji have assessment with chronic attention to relevant psychosocial. relaxin in the control of sites have been identified in with were classified in one of three blood pressure and the Re­ groups based on their responses to the Multidi­ mensional Pain 1 nventory. Clinicians working with persons with fibromyalgia must be comfortable with different learning stvles and the role of and the and be sible treatment outcome246 Certain others did not treatment to group education. The "interpersonally distressed" copers" demonstrated low Fol­ group was characterized by lems. It is aware of the "5 Ds" of chronic dysfunction. their for their pain and their life situation.108 MYOFASCIAL MANIPULATION tion of nitric which also appears to an important role in muscle pain. hormone. laxin stimulates the release of oxytocin and va­ the release of adrenocorticotropic hormone by laxin was also found to promote the secretion of administration of relaxin in per­ At this point. The "adaptive did that much. possibly because of low levels of distress. and organic factors and an integrated interdisci­ plinary treatment strategy35 The available data suggest that the chology. alsion rate of 24% after two years intervention in community tice. whereas with systems and physical in working with persons with fibromyalgia. treatment can be done in group format.249 It is tant that their are part of the individual interventions. sense of COI1- focuses on the interactions and transactions be­ and their environments. The group was characterized by poor coping and high levels of Re­ Yue specu­ cally pain. and of psy­ of the One therapy offers the best pos­ of learned avoid verbal and nonverbal communications. sopressin.2SI) The approach can lead to significant life interference.2JH37 Of par­ ticular interest is that in exoeriments w ith rats. prolactin and lated that the symptoms. The levels of affective distress and disability. hormone. but not for the "interpersonally distressed" group. It in­ Copyrighted Material . Yue's specula­ by independent the broad spectrum of relaxin deserves further attention. 52 2 All clinicians must recognize the multi-com­ of there or treatment and colleagues re ArtAri pain.248. between acute and chronic pain and the common changes that chronic pain often make. affective perceived perceived interference of pain for the tional" group. uepenue "A""""tc several regions of the brain that are involved secretion of hypothalamic hormones. Systems used in tween is the most popular social work that ary team and develop clear perceptions about role as functional members of the health care team. sons with f ibromyalgia may alleviate many of Management of Fibromyalgia Given the is usually no though of remedy that can offer optimal solutions.245.

including social persuasion. health care others attempt to con­ activities that can persons with to others with have succeeded in for those who their lives and be­ vince patients that they can be more functional previously were thought to be impossible be­ cause of pain or other dilemmas. a especially in under- and each other's contributions. Psychological group interventions may focus on problem-solving techniques.ll It is counterproductive to have the physician or clinical social worker considers the broader context in which into the patients' belief systems and pain is taken are not questioned or lack thereof is essential. Through social persuasion. In any interdisciplinary treatment model.25o Cli­ nicians must move beyond the common Carte­ sian monistic and dualistic treatment based on work from a somatogenic and while the Whereas dif­ ferent disciplines are rl'''nr. alcoholism. the family and society. 121. illness behav­ ior.260-264 Medical Management are tact for the person with for with the appropriate medical d common that patients with f ibromyalgia have already seen the time health care providers by As discussed the first point of con­ and ul­ coming more functional can provide a model who maintain that monitoring their and change their individual situations. it necessary that the various support Copyrighted Material . histories of sexual abuse. mastery and providers and than By feed­ back. patients that their and that their intentions their pain is There is no doubt that components of the overall other team members. should and physical therapy treatand of one discipline should be con- critical from the f irst encounter and throughout the treatment process. posttraumatic stress. Although physical orientation can tial role in physical should an essen­ systems intervention. stress reduction. and so forth.·. Bandura described four techfor altering patients' perception of self­ efficacy. feedback is also important levels of persons with new levels of activity.109 cludes the marital relationship. Patients need to become active participants in men! OA. as well as functional and structural as­ pects. effective and inwhereas 1Il- the overall knowledge psychosocial issues outlined individual sessions may deal with the many depression. It should be obvious that the success­ ful cannot be of persons with without mental health professionals both in group and individual in­ terventions. master new included.thln1 the optimal treatself- 253 and and clinical social workers must be famil­ iar with the and objectives of medicine Each discipline must syn­ Bennett by back loop that exists when stress of chronic chronize its efforts with any of the others. somatization.25o Following is an overview of the role of physi­ cians and physical ment of persons with the context of this in the manage­ The role and will not be levels results in physiologic arousal with sec­ symptoms246 control over of psychologists and clinical social workers is longer stimulation.

for It is and the number of tender points280 Anti-inflam­ matory medications were shown to have little or no effect. 265 Biasi and colleagues reported positive results with tramadol (Ultram)28J . All improvement while Copyrighted Material . In most Clan IS and increase the of the administration of amitriptyline 267-27 Surpris­ affect the sleep anomaly in some patients with f ibro­ myalgia99 The recommended dose is 10-50 mg of amitriptyline and 10-30 mg of cyclobenza­ prine265 The line and strated. There is some evidence that cations may be useful. medi­ can improve like growth factor-I. sulin-like growth factor-l experienced an im­ provement in their overall symptomatology and number of tender had a patients who after nine months of daily growth hormone therapy.276 ibuprofen recommended. and desires and not of the health care assisted in developing their to assume ownership of those of health care providers. and over­ The combination is given in the toward accomplishing them with the support all well-being with a combination of amitripty­ was more effective than either morning to avoid further insomnia54 Others have studied the effect of 5-hydroxytryptamine type 3 receptor antagonists and reoorted that both ondansetron significantly tender Zolpidem tive effect on intensity. but the including tile patients. outcomes is shared by all members of the team. there are some pharmaco­ interventions that appear more effective than others. reported line and fluoxetine of the two drug alone. but no patient remission of symptoms. morning fatigue. After agnosis of information regarding the patients with developing short and Symptomatic and functional be emphasized. the referral to olher therapy alone is as suff icient265 The Based on general principles that apply to the treatment of any patient with chronic pain published research. The selective serotonin reuptake inhibitors may also be of value. The medical management m­ cludes the prescription of medications and in most cascs. but not on pam quality. tation program. The each discipline must support the overall of the patient. rather than a cure of f ibromy­ or a total relief of nain.110 MYOFASCIAL MANIPULATION slow-wave serotonin. agent and is usually and (Xanax) was efficacy of amitripty­ could not be demon­ the physician should and assist provide patients and their families with adequate The goals of Patients who have are more likely and work for approach and for term relief of mild to moderate anxiety or ten­ sioll. The responsibility back to the their significant others. 2 it is probably irrelevant whether the the ACR research criteria. nett and colleagues tested their hypothesis that a role in the hormone to women with with low levels of insulinThey observed that and low levels of in­ ncw medications or combinations of medica­ tions will be used as the understanding of under­ increases54 In an era of evidence-based medi­ the pharmacological management should be based on scientific f indings and subiected to clinical outcome studies.54 66 . in and colleagues pain. although none of the medications used are and none are very effective.

Whenever untrained individuals start to exercise. correlated with less symptoms245 Norregaard and colleagues did not find any improvement in pain. fatigue. however.lowering medica­ tions. although there were no significant dif­ ferences between the two groups at four years of follow-up.283 In clinical practice. When comparing a program emphasizing cardiovascu­ lar training with a flexibility program. several studies have shown that persons with fibromyalgia can participate in regular low-intensity cardiovascular training programs without experiencing an increase in symptoms285-289 The physical therapist must educate patients with fibromyalgia regarding the multiple positive effects of regular exercise on depression. they will experience an initial increase of muscular pain. Strength training should be approached with some cau­ Copyrighted Material . unrealistic because of its high cost. or aerobic capacity in either a progressive exercise program or an aerobic dance program. Will the patient be successful in undertaking a home program? Will the patient be overly zealous in the early aspects of strength or cardiovascular training? A gradual adapta­ tion to a progressive exercise program is usually well tolerated and may include lower or upper body ergometry. the physical therapist should review this with the referring physician and suggest that perhaps the patient may not have fibromyalgia after all. lifestyle. light strength training is appropriate. percent body area involved. and fatigue. partly due to poor compliance291 A common problem with any form of exercise is the lack of consis­ tent long-term compliance. the most important aspect of physical therapy intervention is car­ diovascular training. lifestyle.265 84 . . de­ pression. In addition to education. physical therapists are not trained to rule out medical causes of widespread pain.Muscle Pain Syndromes II I taking growth hormone encountered a worsen­ ing of symptoms over a period of one to three months after stopping treatment223282 . psychological well­ being. many patients diagnosed with fibromyalgia may have other treatable diagnoses as discussed previously. and activity level that need to be considered during the rehabilita­ tion process. not to be confused with the typical pain associated with fibromyalgia. muscle strength. hypomobility.m Although they may perceive that exercise will worsen their condition. and perspectives and resort to living with a chronic incurable disease entity. the appropriate timing and coordinating of vari­ ous aspects of rehabilitation. after being diag­ nosed with fibromyalgia. the patient needs to be convinced that their condition may actually be treatable. was . such as complications of cholesterol. Cerro and colleagues confirmed that the ad­ ministration of growth hormone may reverse some of the symptoms of fibromyalgia224 The widespread use of growth hormone is. levels of serotonin. or hypermobility. general condition. functional status. dehydroepiandrosterone sulphate and insulin­ like growth factor-I levels. overall fitness levels. patients receiving cardiovascular training showed sig­ nificantly improved cardiovascular fitness and improvements in pain threshold scores. Each patient has a distinct personality. Physical Therapy Management When patients are referred to physical therapy with a medical diagnosis of fibromyalgia. many patients modify their expectations. sleep. but not in perceived pain intensity. the physical therapist must examine the patient and determine the appropriate physical therapy di­ agnosis. but they should be able to assess patients for the presence of myofascial trigger points. which may become the main objective during the first few treatment sessions. or myoadenylate deam­ inase deficiency. quality of sleep. including aerobic walking. walking. hypothyroidism. ically. or sleep patterns. 2 myalgia tend to be deconditioned.289 Other studies also suggested that regular exercise. or aquatic physical therapy54 A long with cardiovascular training. In many cases. Again. the symptoms correlate with myofascial trigger points or with altered joint mobility.285 Wigers and col­ leagues compared aerobic exercise with a stress management program and concluded that aero­ bic exercise was the most effective treatment ap­ proach.

Other as well. 297 origin. local tenderness.. or the al­ weight machines are preferred. and Simons as a muscle disorder characterized by the presence of a myo­ fascial trigger point within a taut band. Alexander may be considered the Feldenkrais 1'ai Chi. referral of pain to a distant stricted range of nOl11ena. decreased pain threshold. needle any prospective studies on the effects of intramuscular stimulation on the symptoms of . Travel!. The patient is to stretch before and after workout to maintain tlexibility. Autonomic and autonomic may include and Travell. defined Acupuncture and fective in although the studied yet. and so forth. although a correlation was established differently by different authors or Taxonomy or inflamma­ tiol1."2'19 This modi­ does not CO!1­ other features of the social dysfunction.302 In There are no studies that or joint hyperalgesia. support the use of between functioning. and Simons involved in the gen­ have described trigger pilomotor response. pathogenesi s sitivity of the central nervous system and a functional endocrine system. it may suggest that almost all skeletal muscles of the body. described as muscle pain with or without limitations in mouth opening30 myofascial when there is no obvious of as "chronic con­ ditions that occur in the musculoskeletal lions." analogous to the of the term UWI'C"V"'''.299. that these restrictions are most of likely the resu It of decreased activity levels and not involved in the Muller and col sup­ port for this notion. rather than patho­ logically painful the question emerges whether f ibromvale:ia should still be considered "298 Evell the name for eration of pain. pain is limited to fibrous tissues and muscles.112 MYOFASCIAL MANIPULATION tion. Free small hand are being training cardiovascular it. ' . though there are no scientific studies f ibromyalgia and these somatic Soft tissue restrictions and joint ity should be assessed and corrected when indi­ cated.a.30 Allodynia is defined as "a painful response to a normally f ied including the different stimulus." n." as it meets the criteria for allodynia as defined by the Interna­ tional Association for the Study of Pain.. Copyrighted Material ."HJ4 The most commonly used def inition syndrome is formulatcd by suggests Simons. Because persons with tlbromyalg13 display a generalized. more appropriate name is "complex pain syndrome.. of the syndrome. Trigger points can be present in muscle. MYOFASCIAL PAIN SYNDROME Definition MyofasciaJ syndrome has been defined is defined syndrome of any soft tissue myofascial tion syndrome has become the commonly used term. Russell suggested that f ibromyalgia can be considered "chronic allodynia.

complex regional pain syndrome. nerves and their in­ nervated structures develop "supersensitivity" when the nerves are not functioning properly329 Gunn described that the autonomic phenomena. the criteria have not been subjected to scientific research and lack established re­ liability and validity.Muscle Pain Syndromes 113 fascia. myofascial pain are always secondary to neu­ ropathies. 1 31 . Myofascial pain syndrome should be considered in the differential diagnosis of ra­ diculopathies. who instead deemed all myo­ fascial pain syndrome phenomena the result of secondary hyperalgesia of peripheral neural originJ28 . 3 pain syndrome is often thought of as a regional pain syndrome in contrast to fibromyalgia as a widespread syndrome. carpal tunnel syndrome."7 Although in clinical practice. anginal pain. The concept of primary and secondary myo­ fascial pain syndrome was questioned by Quint­ neT and Cohen. Myofascial pain syndrome can be acute in nature or become a persistent chronic pain problem. Travell. determine the interrater reliabil­ ity of trigger point examination. repeti­ tive strain injuries. especially radiculopathies. Myofascial pain resulting from muscular dysfunction is called pri­ Copyrighted Material . and most other pain syndromes. tension headaches. osteoarthritis. nearly all research has focused on muscle trigger points305 ture. A thorough diagnostic evaluation was recommended to identify the un­ derlying myofascial cause of chronic pain. the term "myogelosis" is commonly used instead of "myofascial trigger point. or as part of post-laminectomy syndromes. the International Myopain So­ ciety established a multidisciplinary committee to design a study model for validation of the diagnostic criteria. the Simons. making myofascial pain syndrome the pre­ ferred diagnosis. During the 1998 Fourth World Congress on Myofascial Pain and Fibro­ myalgia in Italy. and pilomotor changes. that as many as 45% of patients with chronic myofascial pain have generalized pain in three or four quadrants34 5 . joint dysfunction (including craniomandibular dysfunction). the pain and muscle dysfunction are the result of underlying medical pathology. may also meet the ACR criteria for fibromy­ algia. are features of the neuropathy model and not specifically of myofascial trigger points304 . they featured myofascial trigger points within taut bands as the main source of their pain. a complication of certain medical conditions. joint capsule. and determine the sensitivity and specificity with which clas­ sification criteria can distinguish patients with myofascial pain syndrome from healthy control subjects30S and Simons criteria are applied. exist in isolation without involvement of other structures. and Simons criteria appear to be ac­ ceptable. including myocardial infarction or kidney dis­ orders. The committee aims to estab­ lish reliable methods for diagnosis of myofascial pain syndrome. tive. including facet joint inju­ ries. pain syndrome. cluded that primary and secondary myofascial pain were the most commonly missed diagnoses in chronic pain patients. however. and periosteum.3 mary myofascial pain. there is no diagnostic or clinical benefit to the patient in making the distinction between primary and secondary myofascial pain syn­ drome. rather than considering the pain problem to be psycho­ genic in nature32 . Gunn concluded that myofascial pain is the result of functional or structural altera­ tions within the central and peripheral nervous system304 eth's law of denervation. joint or mechanical dysfunction. sudomotor. including vasomotor. or psychologi­ cal dysfunction. or be associated with other muscu­ loskeletal disorders.309 common diagnosis responsible for chronic pain and disability3lO. disc herniations. mi­ graines. ligaments. By apply­ ing Cannon and Rosenblueth's law of dener­ vation.312 are found equally in men and women and are commonly found in children305 13 . whiplash injuries.

Electromyographic demonstration of spontaneous electrical activity characteristic of active loci in the tender nodule of a taut band.330·33J Most patients complain of more global. Myofascial Pain and Dysfunction: The Trigger Point Manual2lE. According to Gerwin and col­ leagues. 2.3]3 Spasms can be defined as electromyographic activity as the result of in­ creased neuromuscular tone of the entire muscle. The interrater reliability of the myofascial trigger point examination has been studied by several authors. Source: Reprinted Copyrighted Material . Visual or tactile identification of local twitch response.G. trigger point. Gerwin and colleagues established that individual features of the trigger point are dif­ ferentially represented in different muscles. A taut band is a localized contracture within the muscle without activation of the motor end­ plate334 The taut band. The presence of a local twitch response. however. 1. following a review of the patient's history. and LS. D. a team of recognized experts could initially not agree. 4. Simons. Exquisite spot tenderness of a nodule in a taut band. identified solely by palpation. which indicates that training is essential for the identification of myofascial trigger points. Confirmatory observations 1. sponse is an indication of the presence of an active trigger point.336 39 . 3.305 The patient's pain pattern and range-of-motion restrictions usually point the clinician to the involved muscles. Imaging of a local twitch response induced by needle penetration of tender nodule. or ob­ served visually or on diagnostic ultrasound. or reproduction of the person's symptomatic pain increased the certainty and specificity of the diagnosis of myofascial pain syndrome332 . did the experts agree. © 1999. Only after developing consensus regarding the criteria. Vol. tiate between myofascial taut bands and general muscle spasms. and Simons and are listed in Table 6_2.G. with permission from Travell. Travell. Painful limit to full stretch range of motion. example. 4. 3. Simons. It is mediated primarily through the spinal cord with­ out supraspinal influence. 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. re­ ferred pain. J. it was only recently established by Gerwin and colleagues for the five major features of the trigger poi'nt332. diffuse pain and are not aware that specific myofascial trigger points may cause their pain. 3 Even in this study.114 MYOFASCIAL MANIPULATION Diagnosis The main criterion for the diagnosis of myo­ fascial pain syndrome is the presence of an active myofascial trigger point.305 The diagnosis of myofascial pain syndrome is made by systematic palpation of taut bands and myofascial trigger points.]30. be felt with the needle during trigger point injection or needling. and an assessment of posture and functional movement patterns. that do not require a verbal response from the patient. Taut band palpable (if muscle is accessible). 2. and local twitch response are objective criteria. The key fea­ tures of the trigger point have been established by Simons. contraction of the taut band that can be recorded electromyographically. Lippincott Williams & Wilkins.335 The patient's body type and specific muscle determine the ease of soliciting a local twitch response. Patient's recognition of current pain complaint by pressure on the tender nodule (identifies an active trigger point). an exquisitely sensitive region in a taut band of skeletal muscle consisting of multiple sensitive trigger loci. the local twitch response was easier Table 6-2 Criteria for Identifying a Myofascial Trigger Point Essential criteria 1. Pain or altered sensation (in the distribution expected from a trigger point in that muscle) on compression of tender nodule.

as most pain syndromes have an autonomic component. systemic. For example. adductors. considering that knee joint motion is accompanied by simultaneous coactivation of the quadriceps and hamstrings muscles. and arthritis. but also appreciate referred pain patterns and the biomechanical implications of taut muscle bands and myofascial trigger points in the quad­ riceps.J47 Copyrighted Material . menis­ cal. even the lateral meniscus through its insertions. vascular effects. Trophic changes may lead to the development of so-called "satel­ lite trigger points" in the area of referred pain305 Gunn considered the trophic changes essential to the diagnosis and treatment of neuropathy304 Autonomic changes are not specific for myofas­ cial pain syndrome. Mechanical dysfunction is one of the main problems of myofascial pain. hamstrings. For ex­ ample.Muscle Pain Syndromes I 15 to obtain and. and kinesiophobia. It can llex and internally rotate the tibia on the femur and pull the posterior horn of the media I menis­ cus posteriorly during flexion of the kneeJ49 Per­ haps. and secretory. a semimembranosis muscle shortened by taut bands and myofascia I trigger points main­ tains the menisci in a relative posterior position The degree of stimulation required to repro­ duce a patient's usual pain determines whether a trigger point is considered active or latentJ40 An active trigger point has a lower pain threshold than a latent trigger point. The semimembranosis muscle reinforces the posteromedial aspect of the knee capsule. pain.304 Physical therapists may use soft tissue mobilization as well to correct mechanical dysfunction. the clinician must determine any mechanical.l2I In patients with acute myofascial pain.345 46 J . and calf muscles34 After establish­ ing the initial diagnosis of myofascial pain syndrome. pi­ lomotor. In chronic cases. tion of the trigger point can produce several autonomic phenomena (i. gluteals and iliotibial band. perhaps. whereas a latent trigger point requires a signif icant amount of mechanical stimulation to reproduce pain. or psychological perpetu­ ating factors that may contribute to the forma­ tion or persistence of myofascial trigger points. Various authors have suggested methods to ob­ jectively quantify the amount of pressure re­ quired to elicit a painful response from a trigger point using algometry or palpometry.344 Muscle weakness without atrophy is often seen with myofascial pain syndrome. soft tissue and joint adhesions can further contribute to restric­ tions in range of motion. inhibition of gamma motoneuron activity. bursitis. Muscle weakness may be due to pain. therefore. and capsular injuries. however. restrictions in range of motion are primarily due to shortening of muscle fibers. and trophic changes). and rule out other pathologica I processes. Major mechanical factors to be considered in the diagnosis and management of myofascial pain syndrome include anatomic variations and poor postures.e. more commonly found in the extensor digitorum communis than in the infraspinatus muscle. or reflex inhibition of anterior horn cell function as a result of painful sensory input. including restric­ tions in range of motion and muscle weak­ ness.. Correcting me­ chanical dysfunction has become the main ob­ jective of Gunn's intramuscular stimulation ap­ proach to myofascial pain syndrome. m The diagnostic process must include the usual differential diagnostic considerations. A trigger point is considered active when normal physiological movements or postures cause pain. It is conceivable that a taut band in the semimembranosis muscle re­ stricts the mobility of the medial and. restrictions in range of motion. changes in skin temperature. in the examination of a patient with knee pain. tendinitis. kinesiopho­ bia. it remains difficult to determine the distinguish­ ing features of active and latent myofascial trig­ ger points J4 U42 It is important to realize that pressure algometry is influenced by nociceptors in the skin and subcutaneous tissuesJ4J Both active and latent myofascial trigger points may cause dysfunction. patellofemoral joint dysfunction. Myofascial trigger points and taut bands may also contribute to further me­ chanical dysfunction. the clinician should consider ligamentous. any me­ chanical discrepancy in either muscle group will affect the resultant joint motion and possibly influence joint stability.

L 16 MYOFASCIAL MANIPULATION even during extension of the knee..362-365 of myofascial tion was not sensitive or imaging studies avail­ syn­ resolu­ to visualize the actual the taut band but allowed stimulation of the the paraspinal muscles at the levels of seg­ in Gunn's footsteps. including L2-3. mechanisms. conditions include Less common yeast infections and Commonly seen folic acid. there Clinical Characteristics patients fuse complain of dif­ confined to one or more regions of the body. as well as the supraspinous and interspinous ligaments. pa- insufficiencies and hypothyroidism. stressful life to have and more tionships than syndromes. Phd Pain trigger point refers restricted to segmental An active is not usually to a distant site. Several researchers established that ger points have a specific electrical discharge characteristic when using needle electromyogIndwelling does not replace manual add any significant value to the clinical tic process358 36J Surface electromyography can be valuable for identifying muscle fatigue. taut bands and are no epidemiologic studies supporting these clinical observations320 Psychological perpetu­ factors may include depression. Some authors have questioned the validity of . which features widesoread Dain. several objective features have been de­ scribed in the scientific literature that further substantiate the existence of myofascial points. The referred or to peripheral nerve distributions. lion. 348 In addition to and dysfunctional muscle fascial trigger Doints. such as arthritis. Where Gunn recommended dry Fischer rec­ of the multifidi researchers to visualize the twitch response of point by insertion of a hypodermic needle. Fischer also promoted treatment of the paraspinal mus­ cles.. and increased irrita- Y. patterns.". and syndrome Patients with myofascial years.. It does or confirm the not demonstrate the electrical activity of myo­ syndrome. J 27 syndrome or its underlying the past few pain associated with a common precur­ sor to myofascial pain syndrome. increase the likelihood of menis­ the local and treatand Gunn advocated mental innervation. may report such as anger. and infections. L4-5304 cal injury. points in the semimembranosis muscle may. Copyrighted Material . hyperrecurrent however. as opposed to f ibromyalgia. and vitamin factors are gout. In some instances. ommended lidocaine iniections into the 304)50 Systemic medical factors that can interfere with recovery from are medical conditions that either affect the muscle energy system or otherwise interfere with muscle metabolism.

the normal. Travell. weight is carried on a knife-edge from the second metatarsal head to the heel. the most common anatomic variations are leg length discrepancy. however. Normally. may not occur. needling of the trigger point.J7S Short upper arms result in pronated shoulders. movement of the involved body region. or muscle stretches33471 J . A distinction must be made between a structural and a functional leg length discrepancy. traumatic.e. 3 in reference zones is described as "deep tissue pain" of a dull and aching nature. small hemipelvis. Leg length discrepancies and pelvic asymmetries may produce muscle imbalances and postural adjustments and result in the devel­ opment of myofascial trigger points. and on the medial Copyrighted Material . yet became a significant factor during the recovery. developmental. By mechanically stimulat­ ing an active trigger point. there is considerable variation in between patients305 07 . making referred pain elicited by stimulation of a tender location a nonspecific finding. hip capsule tightness. and long second metatarsal syndrome305 07 3 . Structural discrepancies are due to true anatomic differences in length of the femur or tibia. short upper arm syndrome. in some individuals with this foot configuration.to IS-second delay. or internal organs). patients may report burning or tingling sensations. It is not unusual that a particular anatomic variation did not cause any dysfunction prior to the event that resulted in the onset of myofascia I pain syn- drome. For example.. Travell. overloading the peroneus longus. as the individual attempts to find a comfortable position when seated. Leg length discrepancies may be due to congeni­ tal. stable tripod sup­ port of the foot created by the first and second metatarsal bones anteriorly. patients may report the reproduction of their pain. Occa­ sionally. In this situation. which is indicative of hypersensitiv­ ity of the nervous system. and Simons. either immedi­ ately or after a 10. and the heel posteri­ orly.306 . which has become one of the differences between Gunn's diagnostic and treatment approach and Simons. whereas functional discrepancies can be caused by hip adductor contractures. the discrepancy may become a critical perpetuating factor for myofascial trig­ ger points in the quadratus lumborum muscle.Muscle Pain Syndromes I 17 Although typical referred pain patterns have been established. The added stress of a motor vehicle accident may exceed the patient's threshold and result in complaints of persistent pain. under the second metatarsal head. Even physiological muscle tone at rest may stimulate an active trig­ ger point. Me­ chanical stimulation can consist of manual pres­ sure. the skin. contractions.J04 According to Simons. skeletal muscle nociceptors require high intensities of stimulation and they do not respond to mod­ erate local pressure.30577 .30 5 J . Another cause of biomechanical stress on muscle that can lead to persistent myofascial trigger points is a long second metatarsal bone. Instead. pecto­ ral muscle shortening. zygopophyseal joints . Gunn maintained that this is due to an already supersensitive peripheral nervous system. such as forward head posture or pressure on the gluteal muscles in sitting. and postural strains. a patient with a sig­ nificant leg length discrepancy may never have had low back pain. J Referred pain is no longer considered a diag­ nostic symptom but can guide a clinician to de­ termine which muscles have active myofascial trigger points (Figures 6­ Anatomic Variations Many persons with myofascial pain syndrome feature anatomic variations that may contribute to myofascial trigger point formation. or by unilateral innominate rotation. however. Gunn no longer considers referred pain an essen­ tial feature of myofascial pain syndrome. and Simons' approach. or pathological changes in one of the osseous I inks of the lower extremity kinetic chain. following a motor vehicle accident. myofascial pain syndrome. it is more common and much easier to elicit over myo­ fascial trigger points340 Normal muscle tissue and other body tissues may also refer pain to dis­ tant regions with mechanical pressure (i. Diagnostic callus formation occurs in these in­ dividuals in the areas of abnormal loading. and abnormal loading of neck and trunk muscles.

. " .. Copyrighted Material . version LOa. : �1LJ ----- l ) Figure 6-4 Referred pain patterns of the gluteus minimus muscle mimic sciatic nerve pain. Williams & Wilkins. J /. Manual Medicine 2.118 M YOFASCIAL MANIPULATION /(( ( '-- ( ( . Source: Reprinted with permission from Mediclip.

aspect of the foot at the great toe and first meta­ tarsal head. version 1. joint hypomobility and hypermobility.320 Although there is still consider­ able controversy regarding the biomechanical implications of poor occlusion on the develop­ ment of myofascial trigger points in the cranio­ mandibular muscles. it is likely that occlusal problems. the formation of myofascial trigger points in adaptively shortened or lengthened muscles. tooth. and facial pain379J80 Posture Abnormal postures can result in muscle im­ balances. contribute to mechanical stress on muscles and their associated pain problems of headaches. Source: Reprinted witll permission from Mediclip.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.. including missing teeth and early con­ tacts.0a. Manual Medicine 2. Williams & Wilkins. Copyrighted Material .

and pinch grips that are either too wide or too narrow." observed degenerative changes of the I-bands. soft chairs or bucket seats that accentuate forward-head posture • • • Table 6-3 Postural Problems Found in 164 Patients with Myofascial Pain Syndrome of the Head and Neck N Body Poor silting/standing posture Forward head tilt Rounded shoulders Poor tongue p os ition Abnormal l o rdosis Scoliosis Occlusion Slide from retruded contact position to intercuspal contact position of 1 mm or greater Unilateral occlusal prematurities in intercuspal contact position Class II. extended reaches beyond the shoulder­ reach envelope. p. © 1989.8 Source: Reprinted with permission from J. including patients with myofascial pain syndrome.384 Awkward postures are common in the workplace and include ex­ cessive wrist flexion and extension. a focal accu­ mulation of glycogen. 19. 94.5% were diagnosed with myofascial pain syn­ drome383 . Skubick and col­ leagues demonstrated that asymmetrical loading of the sternocleidomastoid muscles and cervical paraspinal muscles can result in carpal tunnel syndrome. Forward head posture is the IllOSt common postural deviation in chronic pain patients. 121.7 82. Work tasks with high repetition frequency and static muscle loading may actually decrease the pain pressure threshold and result in allo­ dynia and hyperalgesia. ulnar and radial abduction. Vol.120 MVOFASCIAL MANIPULATION and nerve compression.388-392 leagues reported the onset of myofascial pain syndrome in various occupational groups with monotonous repetitive work382 In a study of pa­ tients with cumulative trauma disorders. Division 2 Class III % 157 139 135 111 76 26 140 96. including a decrease in quantity of mitochon­ 113 96 51 16 68. data entry op­ erators and typists. Myo­ fascial Pain Syndrome: Characteristics and Clinical Epidemiol­ ogy.381 The biomechanical and myofascial aspects of the forward head posture are fully discussed in Chapter 7. industrial workers. Copyrighted Material . thoracic. and a disintegration of the myofibrillar network. 3 78. or lumbar pam • • • Pain or ache on prolonged standing Pain decreased by rest or gentle move­ ments Several studies have shown that occupational groups with constrained work postures and re­ petitive arm movements are at increased risk for developing myofascial pain syndrome3 . Lippincott Williams & Wilkins.0 84. The typical symptoms in this particular scenario (Table 6-3) can include: Intermittent cervical. Gar­ iphianova described pathological changes with biopsy studies of myofascial trigger points. Fricton.1 9. Advances in Pain Research and Therapy.3 15.5 Pathogenesis Musculoskeletal A bllormalilies There is some evidence of histologic changes at the site of myofascial trigger points identifi­ able by light microscopy334 .9 85.5 31. and as­ sembly line workers.R. in addition to capillary damage.3 67. forearm supination and pro­ nation. D ivi sion 1 Class II. • 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 Difficulty sitting for a long period of time. especially in deep.393-395 In 1995.9 58.38 increased risk include musicians.7 46. and Wallraff reported damaged fibril structures in "myogeloses.

" in contrast to the intermit­ tent biphasic spikes of 100 to 600 flV360. pre­ sumably based on their ability to prevent cal­ cium re-uptake40' Electrophysiologic Abnormalities In J 957.402-404 Gunn articulated that the relative increase of acetylcholine release into the muscle may be the result of neural dys­ function. A shortage of adenosine triphosphate can result in local muscle contractures or taut bands. as well as for the release of the actin-myosin complex. associated with a decrease of the avail­ able acetylcholinesterase and the renewed ac­ tivation of acetylcholine receptors throughout the muscle304 tors405. newly formed acetylcholine recep­ Copyrighted Material . which affects the voltage gated sodium channels of the sarco­ plasmic reticulum and increases the intracellular calcium Jevels306. possibly indicating metabolic distress396 Reitinger and colleagues also reported patho­ logic alterations of the mitochondria. Termination of a muscle con­ traction is normally accomplished by pumping calcium back into the sarcoplasmic reticulum against a large concentration gradient. 1 J 6 electrical activity is not mediated through the spine or supraspinal influences.399 shortening of the actin-myosin complex can be caused by a traumatic release of calcium either from the sarcoplasmic reticulum or from a fail­ ure to restore adenosine triphosphate. Energy Crisis Hypothesis Both the local tenderness and taut bands char­ acteristic of myofascial pain s yndrome are pro­ posed to be associated with the "energy crisis hypothesis. as welJ as increased A-bands and decreased I-bands in muscle sarcomeres of myofascial trigger points in the gluteus medius muscle. appeared to confirm the hypoxia com­ ponent of the energy crisis hypothesis.407 Hong proposed that a palpable myofascial trig­ ger point consists of multiple discrete sensible loci. impaired calcium pump. measuring extremely low oxygen levels (5% of normal) within myofascial trigger points. Weeks and Travell published a report that outlined a characteristic electrical activity of a myofascial trigger point358 It was not until 1993 that Hubbard and Berkoff confirmed the presence of specific electromyographic activity in myofascial trigger points of the trapezius muscle. the intracellular cal­ cium concentration stays elevated. however.ickle and colleagues.334 The pathologic alterations of the mitochondria can further contribute to a shortage of adenos­ ine triphosphate. greater than the electromyographic activity in a nontender area of the same muscle. that these spots represent abnormal motor end­ plates407o8 . corded both low amplitude continuous action potentials and intermittent spikes from active myofascial trigger points359 Simons and col­ leagues reported similar action potentials of 10 to 50 flV. they did not describe their definition of a trigger point397 Pongratz and Spath noticed segmental degenera­ tion of muscle fibers with concomitant edema and histiocytic cellular reaction398 ."305 there is decreased circulation and local ischemia in a myofascial trigger point due to sustained sarcomere shortening. Adenosine triphosphate is essential for normal functioning of the calcium pump. The pos­ sible roles of titin and nebulin have not yet been considered in the etiology of myofascial trigger points.J61. associated with an excessive release of acetylcholine.Muscle Pain Syndromes 121 dria. sitized nociceptive nerve endings. and the actin and myosin filaments become continuously ac­ tivated400 Shenoi and Nagler confirmed that an impaired reuptakc of calcium into the sar­ coplasmic reticulum can cause myofascial trig­ ger points. The electrical activity was found to be similar to abnormal endplate potentials. They reported that calcium channel blockers caused myofascial trigger points. 4 .406 Several studies have demonstrated that myo­ fascial trigger points are nearly always located in the region of the motor endplate zone. which they defined as "spontaneous electrical activity. in fact. Studies by Bri. It is not clear whether there are. suggesting that it may be a motor endplate phenomenon.

Hubbard identified a single muscle spindle at the site where the spontaneous electrical activity was recorded. little evidence that the effect of the autonomic nervous system on myofascial trigger points is applied via the muscle spindle. A recent study in mice demonstrated that the administration of botu­ linum toxin resulted in a complete functional repair of the dysfunctional endplates415 Autonomic Contributions Based on the finding that the electromyo­ graphic activity of myofascial trigger points in­ creased as the result of psychological stress. Simons and colleagues refuted this. administration of phentolamine would reduce the electrical activity of the myofascial trigger point.42J Recently. the muscle spindle is exposed to static loading. by demonstrating that the spike potentials are propagated by extrafusal muscle fibers and not by intrafusal fibers. Static stress applied to the muscle spindle Illay lengthen the equatorial part of the intrafusal muscle fibers. the available data are inconclu­ sive.418 As the muscle spindle is auto­ nomically innervated. Hubbard proposed that myofascial trigger points are associated with dysfunctional muscle spindles. Ljung demon­ strated that the extensor carpi brevis muscle is supplied with heterogeneously distributed sym­ pathetic and sensory innervations in relation to small blood vessels424 striated muscles have similar sympathetic nerve distributions. Barker and Saito demonstrated that an autonomic innervation is present to some extra­ fusal muscle fibers. Partanen sup­ ported this notion by expressing that. perhaps these sympathetic fibers can influence the contractibility of muscle fibers or alter the function of the motor endplate. 4 At this point. knowledge from the pain sciences must be considered. Central Sensitization As with f ibromyalgia. likely that the sympathetic influence on muscle receptors has any functional significance under physiological conditions.41 Botulinum toxin is a neurotoxin that blocks the release of acetylcholine from presynaptic cho­ linergic nerve endings. whereas other studies support the role of the sympathetic ner­ vous system. which may resu It in a steady discharge of im­ pulses. The two concepts are not mutually exclusive. however.422 in 1981. es­ pecially under pathological conditions. i n his opinion. due to the constant increased stress within a taut band. however.4ISA'91n an uncontrolled biopsy study. but under patholog­ ical conditions. There is. Hubbard and colleagues proposed that myofas­ cial trigger points are associated with the au­ tonomic nervous system. which supports the hy­ pothesis that the autonomic nervous system is involved in the pathogenesis of myofascial trig­ ger points. the hypothesis that myofascial trigger points are dysfunctional motor endplates. that would still not ex­ plain the formation of myofascial trigger points. known as the static response of the muscle spindle. The mechanism of the interactions between the autonomic nervous system and myofascial trig­ ger points needs further investigations. however. Local tender­ ness of myofascial trigger points is due to pe­ ripheral sensitization of nociceptors as well as Copyrighted Material .4ICr-418 nomena have always been described as part of myofascial pain syndrome305 Several studies have now shown that the administration of the sympathetic blocking agent phentolamine sig­ nificantly reduces the electrical activity of a myofascial trigger point. these sympathetic nerve end­ ings may become sensitized by neuro-active substances released in the vicinity of the end­ plates305 25 4 .42o 21 . the cndplate spikes are indeed action potentials of intrafusal muscle fibers and that the "active spots" are in fact muscle spindles. Direct connections between the sympathetic nervous system and muscle fibers have been established and may be critical for future studies.122 MYOFASCIAL MAN1PULATION points are probably associated with dysfunc­ tional motor endplates3 05 The finding that in­ jections with botulinum toxin are effective in inactivating myofascial trigger points further supports the motor endplate hypothesis4 09. It is conceivable that.

Mense injected a cause one oHhe neuronal branches terminates in would also not explain re­ ferred pain in a distant location. pain may be experienced in point. the panded.368. In f ibromyalgia. The of a rat. 42s The activity of the neuron ing with the receptive f ield was measured an electrode placed in the minutes. This means that ineffective of the time needed to unmask the interneurons a similar process exists for craniomandibular now stimulate the neurons. The would fall short in exmusclc pain be­ the sensation of the skin. in aU three tissues was present not nonpainful ger Afferent With latent the sensory from f ibromyalgia tender points. as the neuronal dykinin in the tibialis anterior muscle. offered evidence of by reeording different conduction velocities in 436.lvluscle Pain 123 neuroplastic horn368 Vecchiet and sensory within the spinal dorsal have described over myofascial ischemia. It appears that Gunn's as several studies have innervating both muscle and from one branch could activate branching falls short in this identified the nociceptive nature of active myo­ 9. afier 15 field no interneurons are located over various segments. After field had ex­ similarities with the effects lying cutaneous and subcutaneous tissues.426. The the onset of referred with substance P and muscles. and rp(. but also in other the cutaneous and subcutaneous tissues66A26. even from the delay of would be the result It is likely that they do not receive input cord.427 joints. of bradykinin to Mense.. static muscle contractions.42742 4 The unmasking processes of interneurons of the dorsal horn arc the pathophysiological basis of the modified convergence projection proposed by Mense. as new or recep­ viscera can result in central sensitization the unmasking of "sleeping" Bendtsen and also noci­ by low-threshold mechanosen­ sitive neurons430 The afferent input from these effective receptors may result in summation in the dorsal horn and the appear­ ance of new input from fields.4.pntr.'< from the conventiona I convergence This mechanism may result in the formation of satellite points in the area of the enfield. Bradyki­ nin levels have been shown to increase during Copyrighted Material .432. whereas sia is the result of both peripheral sensitization 430.66.413 It and dorsal horn is interest­ ing that Gllnn maintained that syndrome is not dependent on to Gllnn. whieh Mense's outside the innervation of the myofascial cord. the pain syndrome are the functional deficiencies oflhe VOllS tive f ields were also identified after injection of mustard oil in the masseter muscle435 Mense emphasized that data from animal re­ search may not be fully applicable to the clinical patient with f ied convergence projection seen in myofascial Another theory t o based on in the viscera. inal After identifying dose of bra­ field oHhe bieeps femoris muscle the other branch antidromically.17 In f ibers excited the neuronal branches have been identified his­ tologically. skin. and inflammation. the effeets on the dorsal horn have They obser ved significant of the pain threshold over active when measured by eleetrica I only in the muscular is in contrast with their not but also in the over­ on fibromyal­ over points. This tender points. McMahon and Wall. of is afferent neurons the modi­ offers a con­ pain ceivable model for the referred pain phenomena system. 30 fascia I points.

and contraindications.44 falls well within the scope of Noninvasive techniques include manual therapy. or muscle energy/hold-relax 305307 Correcting structural and functional discrep­ ancies may include soecific muscle Copyrighted Material . inactivation of the myofascial trigger points is the main short-term goal." which in most physical practice. nate the abnormal biomechanical force patterns to underlying articular mary and secondary d ysfunction of muscles and considered as a single functional unit.124 MYOFASCIAL MANIPULATION branches would not be levels. state laws is described therapy state laws do as physical therapists are the skin. addressing be divided into a or During the trigger points and As with any treatment in one muscle group may eliminate points in muscles that ferred pain area of the treated relaxation training.4. the Therapy Examiners is indeed part of I n clinical and Simons' combination of Gunn's intramuscular stimula­ point therapy appears to be especially effective. Invasive intramuscular stimu­ of a local 'mMrhpt. and resolution of oossible underlying medical disorders that to tbe or maintenance Banks and col­ that autogenic relaxation training reduced the electrical activity of myotascial trigger significantly443 Manual therapy is one of the basic treatment for myofascial pain syndrome. In addition [0 trigger of the treat­ the actual the intratissue and intertissue mobility of the functional unit must be evaluated and treated as well.l9. to decrease activity. Recently. stretch and spray techniques combined with post-iso­ metric relaxation. of electrotherapy tural or mechanical stressors. and to elimi­ the taut bands. The myofas­ cial can and a trainpoint is for the referred pain Q'tnrl"Amp There is evidence that needling trig­ Management of Pain Syndrome The goals of treatment of myofascial pain syndrome are restoration of normal tissue mobil­ by inactivating return to function. although clinical studies have not been com­ pleted.441 Soft tissue mobilization is probably the most im­ manual therapy ment program. indications.. Steroid injections are not recommended for myofascial risks and require Injections can be as they may induce knowledge of anat­ by needling is a form of "mechanical stimulation. The prac­ titioner must evaluate both soft tissue and when indicated. Some not allow dry not allowed to Maryland Board cal tion with Simons. Effective soft tissue techniques include massage therapy sure over the myofascial manipula­ sustained pres­ point. Gunn 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 as one of the mechanisms of physical therapy myopathy365 Invasive techniques are not without omy.44! tbe use control phase. treat to the re­ points. Gunn no pain patterns of Needling the taut band eliminate active near the myotendonal inactivate myofascial or by noninvasive means.J71. It is important to improve the circulation at the site of the myofascial pathological geMerated point.

Facet hypomobility or hypermobility. or de Quervain's disease. or stretch helps to localize the dysfunction to a specific lesion. increasing the risk of myofascial dys­ function. SOFT TISSUE LESION AND MECHANICAL DYSFUNCTION Def inition and Characteristics of Soft Tissue Mechanical Dysfunction Fibromyalgia. In patients with chronic myo­ fascial pain. skeletal. A partial or full tear. patients can correct their postures and muscle imba lances by gently stretching shortened muscles. abnormal postures must be corrected. combined with poor posture. Somatic dysfunction can be defined as impaired or altered function of related components of the somatic system (body framework). functional abdominal breathing305 3 Cer­ tain work tasks or activities of daily living may predispose a patient to chronic musculoskeletal overload. Already during the pain-control phase of the program. There is usually overuse or direct trauma to the tissue that causes inflammation. Considering activity-related aspects of myofascial pain syndrome will enhance treat­ ment outcomes. Looking for reproduction of pain based on palpation. Modifying the workplace or the patient's work habits can be critical. where mechanical pathology exists and can be diagnosed. muscles will not correct muscular imbalances and abnormal posture. Prior to initiating isotonic training and conditioning programs. all represent mechanical dysfunction characterized by soft tissue lesions. afflicts the greater por­ tion of patients with acute pain. mus­ cular or movement imbalances. Paradoxical breathing should be corrected with 32 . may cause adaptive shortening of the auxiliary respi­ ratory muscles. much atten­ tion should be paid to educating the patient re­ garding the etiology. if so. joint mobiliza­ 2 32 . such as the scalenes. muscle contraction. which. Treatment can commence based on evaluative findings and the condition and reactivity of the tissue. for example. restricted chest expansions. Overstretch­ ing must be avoided as this may trigger myofas­ cial trigger points. ar­ Copyrighted Material . and increase pain and dysfunction. with its lack of specific diag­ nostic findings and diffuse pain patterns. strength. Throughout the treatment process. dysfunction. The purpose is to identify and define areas of somatic dysfunction and to localize a lesion site. and paradoxical breathing. psychosocial issues must be as­ sessed and addressed as outlined in the section on fibromyalgia. Patients must learn to modify their behaviors and avoid overloading the mus­ cles without resorting to total inactivity. alter the treatment strategy accordingly. The specific evaluation process for soft tissue mechanical dysfunction requires a systematic ap­ proach. as in a ham­ string tear or "pull. These dys­ functions can be medically diagnosed and eval­ uated for specific pathologies. and self-management. Many patients are aerobically decondi­ tioned. tennis elbow. and restoring basic function. perpetuating factors.Muscle Pain Syndromes 125 neurodynamic mobilizations. and may cause further ag­ gravation of active myofascial trigger points. Once soft tissue mechanical dysfunction becomes more subacute or chronic. endurance. and sacroiliac joint dysfunction. for instance. and breathing patterns. tions. motor control." gastrocnemius tear. the potential cause of myofascial dysfunction may not be addressed adequately. clinicians should consider whether myofascial trigger points have become the main factor and. Correction and prevention of abnormal postures require a comprehensive program to include ex­ ercises to restore normal dynamic vertebral sta­ bilization and mobility. muscle balances. continues to be exposed to certain workplace or other stress factors without modification of the conditions. orthotics. repre­ sents one end of a spectrum of pain severity and complexity and soft tissue mechanical dys­ function represents the other end. are forms of soft tissue mechanical dysfunc­ tion. . or postural re-education3o 3 Patients with chronic myofascial pain syndrome usually present with poor postures and muscle imbalances with both adaptively shortened and lengthened muscles. improv­ ing neural mobility. discogenic pa­ thologies.

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PART III

Evaluation and Treatment of
the Myofascial System

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a postural fulcrum at L4-5. Although other aspects of the biome­ chanical evaluation of the spine may be dis­ cussed when appropriate. a strong statement can be made for dysfunction. an exaggerated lumbar curve reversal on forward bending (with a fulcrum of motion at L4-5). however. the diagnosis is not made based on radiology or physical examination alone. in the absence of any other finding. In the case of discogenic pathology. Segmental hypcr­ mobility and hypomobility in and of themselves are not necessarily dysfunctional. visual. The physician who would diagnose discogenic pathology on the basis of MRI alone would be premature in making the diagnosis."2 A therapist diagnoses dysfunction in the same manner that a physician diagnoses pa­ thology: correlation of f indings. somatic dys­ function can be defined as "impaired or altered function of related components of the somatic system. Connective tissue changes in the absence of other f indings are not dysfunctional. If. and the results should always be correlated with other findings to assess ac­ curately the functional (or dysfunctional) status of the spine and/or extremities. has referred pain in the lower ex tremity. has diminished reflexes. increased erector spinae 143 Copyrighted Material . and move­ ment examinations are correlated to determine dysfunction. Cantu and Alan J Grodin This chapter offers the clinician information and insight into the evaluation of the myofascial sy stem. Somatic dysfunction is a state of altered mechanics. tenderness to palpation at the L4-5 interspace. and electromyograms (EMGs) in order to determine if true discogenic radiculopathy exists. in­ creased or decreased mobility and autonomic changes. For ex­ ample. The physical therapist also diagnoses signifi­ cant dysfunction in the same way. Dysfunction is defined by Dorland's as "a disturbance. If the patient has an m reso­ nance imaging (MRI) with a positive f inding for discogenic lesion . or abnormality of the functioning. physical examina­ tion. se­ lective muscle weakness. Active movement abnormalities alone are not necessarily dysfunctional. the findings together def initively correlate for discogenic pathology. the herniation may not be the cause of the pain and dysfunction.CHAPTER 7 Basic Evaluation of the Myofascial System Robert I. and positive EMG and MRI results. the main focus re­ mains on the myofascial system. When a physi­ cian is looking for pathology in relation to low­ back pain."1 More specifically. the patient is experiencing low-back pain. a patient may have symptoms including localized unilateral low-back pain. palpatory. palpable changes of integrity. for example. If several findings from the evaluation are abnormal. impairment. Myofascial assessment represents on Iy one aspect of the total evaluation. AII findings from the history. however. radiologic findings. the physician uses the history. Postural asymmetry caused by a leg-length discrepancy in itself is not dysfunc­ tional.

pected. Patients morn mg. If the patient may exist rather than a myofascial-type Copyrighted Material . and is usually indicative of 4. syndrome.144 MYOFASCIAL MANIPULATION muscle tone in the lumbar of the L4-5 segment. and increased connective tissue in the area. for the interruption is not as not myofascial be­ cause sharp pain occurs with movement. Treatment can be initiated overall dysfunction.' Most but several ques­ fuse. What medications is the taking? This is extremely important if a myo­ pain syndrome is sw. feeling unrefreshed and fatigued in the at night? pattern. movement The stressed. a of L4-5 with L4-S hypermobility. How is the patient fascial oain is the disturbed the going to sleep and during the night. Does the patient have a or have a tendency toward irrita­ ble bowel syndrome? Many patients with also have well as poorly localized. Tn this theoretical scenario (rarely this clean-cut). What pattern does the pain follow the day? A typical pain in the early morning. What is the quality of the cia I pain is is reporting is easily reproduced. 2. especially in naire and historical clinicians have a standardized routine question­ tions should always be asked when looking for I. report be emphasized when a pain syndrome is suspected. the oain waking the is not due to the patient. How much tive. since few drugs have proven to be even for pain is increased stiffness and HISTORY Cyriax stated that the portance. in­ creased connective tissue in the area as the attempt to stabilize it. 6.4 5. but interrupted. difficulty should be asked as a matter should one of the critical factors in myo­ dull and aching. The aspects of myofascial evaluation consid­ ered in this chapter are the structural evaluation. postural and palpaaddressing this combination of factors that contribute to the normalities alone would have constituted dys­ 3. which pathology block stage 4 choice for restoring normal are amitriptyline (ElaviIR) and (Flexerilf(). movement im­ balance as a result of the hypermobility. and the patient is awakening. Increased aetiv­ will usually aggravate the but the symptoms remain is of great im­ conditions. and protective muscle guarding with altered muscular recruit­ ment none of the above ab­ the combination of abnormalities does. 7. with a at slant and somewhat conthe day. as pain.

to a leg-length discrep­ Figure 7-1 ancy or a pelvic obliquity. since the fascial planes can be restricted over large areas of the body. it is not necessarily a static position5 Posture is dynamic. The entire body should be viewed. requiring muscular forces and creation of connective tissue tensions. and lateral angles to ensure accurate assessment (Figures 7-1 through 7-3). Observation of Posture The patient should be viewed from posterior. and increased muscular activity that may correlate with abnormal structural deviations. Connective tissue Copyrighted Material . anterior. for example. In in­ tegrating the myofascial system into postural evaluation.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. due. connective tissue asymmetry. Muscle asymmetry may be a result of pro­ longed shortening or lengthening of a muscle group. Posture observation directs the clinician's focus Figure 7-2 on a particular area or areas of the system that may be significantly dysfunctional. Looking at the skeletal aspects of posture without considering the dynamic aspects gives a shallow. from the subcranial area down to the feet. the clinician should look for muscle asymmetry. Posture can be defined as balance and mus­ cular coordination and adaptation with minimal expenditure of energy. 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. It is the position the body assumes in preparation for the next movement.

the midcervical facet joints are in the "up and forward position" or forward bent. The anterior cervical spine compensates by lengthening. creating a localized prolifera­ tion of connective tissue. as in a spondylolis­ thesis. asymmetrical. 'vvhich hypolllobility and a shortening of the posterior myofascial structures. Increased muscular activity is usually a precursor to muscle asymmetry and is usually found in more acute cases. the clinician must remember that the human body is. with a tendency toward hypermobility (Figures 7-4. When looking at joint equilibrium in the spine. changing the length-tension relationships. 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. A good example Figure 7-4 Copyrighted Material . This creates COIll­ pression of the facet joints. Postural observations give the clinician some insights into the overall equilibrium of the spine. compression of this nerve can create occipital and frontal headaches. Tn the forward-head posture. and 7-6). by nature's design . and contributing to a weakness in the area. While observing body asymmetry is impor­ tant. consider that a joint can be stable and in optimal functional position only if there is equilibrium between the forces acting on it. leg. In the upper cervical and subcranial area. Figure 7-3 asymmetry may be due to abnormal stresses ap­ plied to an area. 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. There is generally a loss of lordosis in this area. Hand.146 MYOFASCIAL MANIPULATION of myofascial disequilibrium in the spine is the dysfunction caused by the forward-head pos­ ture. Bccause the greater oc­ cipital nerve pierces the subcranial myofascia. 7-5.

The prin­ ciples he put forth include the relationship of "postural" and "phasic" muscles and their cor­ relation to agonist/antagonist muscle groups. The shoulder girdle com­ plex is held in a protracted position with the glenohumeral joint tending to go toward internal rotation. a stretching of posterior structures occurs. a compromise of the Figure 7-5 costoclavicular space. resulting in hy­ permobility and possible strain on the posterior aspect of the disc (Table 7-1). The lumbar spine can be either hyperlordotic or hypolordotic. the myofascial structures are held in a shortened position. the facets are again in a forward bent position.6 has helped tremen­ dously in correlating the effects of myofascial imbalances on postural imbalances. but abnormal. and increasing suscepti­ bility to thoracic outlet-type symptomatology." in the context of Janda's work and for the purposes of this discussion. The terms "postural" and "phasic. 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. In the myofascial context. In the upper thoracic area. hyperactive muscle patterns.Basic Evaluation of the /vlyofascial System 147 In the forward-head posture. Myofascial Aspects The myofascial aspects of the forward head posture correlate well with the mechanical as­ pects. In the anterior chest wall. diaphragmatic breathing is compromised and the accessory muscles of respiration are facilitated. relate more to how the muscle responds to dys­ function. If hypolordotic. the mandible tends to open. whereas a phasic Copyrighted Material . This can lead to eventual degenerative changes in the temporomandibular joint. Because the anterior thorax is held in a shortened position. In histological terms. so the masseters and temporalis are engaged to keep the mouth closed. This leads to new. a postural muscle is one that responds to dysfunction or Figure 7-6 abnormal stress by tightening. leading to a poten­ tially elevated first rib. where the muscles become facilitated and can create dysfunctions such as nocturnal bruxism. The work of Janda2. with the posterior myofascial structures on a stretch.

being by far the most common presentation in the clinic. on the other hand. whereas the ham­ strings tend to tighten on a regular basis. In the agonist/antagonist scheme. In the myofascial scheme. is in an elongated position. which over a period of time Head Posture Forward bending of the midcervical facet joints Backward bending (extension) of the occiput atlas Shortening of suboccipital muscles. subscapularis. and 7-9). strong correlations can be made (Figures 7-7. This relationship places the cervical erector spinae in a shortened posi­ tion. have axially extended posture. The an­ terior musculature. The forward-head posture once again can be used as a clinical example. pectoralis. These agonist! antagonist relationships play a vital role in pos­ tural problem s of the spine. facilitating the dysfunction. This is especially true in the upper cervical spine. while the hamstrings rarely show significant atrophy or weakness. If the knee is injured. the cervical erector spinae are classified as pos­ tural muscles. 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. usually one muscle or set of muscles responds to dysfunction by weakening while the other responds by tightening. resulting in potential impingement of the greater or lesser occipital nerves Imbalance between the sternocleidomastoid. A smaller percentage of patients do.148 MYOFASCIAL MANIPULATION Table 7-1 Postural Sequence for the Forward­ and atrophy. When one superimposes the myofasciaJ elements onto the arthrokincmatics of dysfunctional posture. The quad­ riceps rarely become tight. the levator scapula. An obvious example of this is the quadriceps and hamstrings. 7-8. however. which respond to dysfunction by tightening. and teres major being involved) Increased thoracic kyphosis with decreased lumbar lordosis Increased activity of the accessory respiratory muscles due to poor diaphragmatic breathing and poor expansion of the lower rib cage Elevation of the first rib by increased scalene activity Anterior and posterior restriction of the first rib articulations Tendency toward thoracic outlet symptomatology Cervical imbalance with a tendency toward 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. the quadriceps usually weaken Figure 7-7 Copyrighted Material . which over a period of time permanently shortens the muscle. and the trapezius Imbalance between the anterior cervical musculature (including the suprahyoid and infrahyoid muscles) and posterior cervical extensors Shoulder girdle protraction with internal rotation (the latissimus.

there is an in­ creased kyphosis of the thoracic spine. further facili­ tating the dysfunction. along with the upper trapezius. as does the upper trapezius. which include the abdominals and the gluteus maximus. Once again. antagonistic muscle groups respond in opposite ways to facilitate the same dysfunction. The first. can be correlated to dysfunctional muscle groups. the forward-head posture is further en­ hanced (Table 7-2). ened position. T his places the pectoralis major and minor. the pectoralis major and minor muscles respond to dysfunction by tightening. further compound the problem (Table 7-3). pits the hamstrings and pos­ Copyrighted Material . the anterior of the diaphragm. psoas muscle groups. as well as the straight-line distance between glenohumeral joints. Tables 7-4 and 7-5). in a short­ creates a permanent lengthening. The an­ tagonistic groups. which. excessive lumbar lordosis. with tightening of the posterior struc­ tures (Figure 7-10. facilitates the upper thoracic accessory breathing muscles. in turn. The other scenario. As noted. The Lumbar Spine In the lumbar spine. is de­ creased. In the myofascial system. Thoracic Spine In the forward-head posture. iliacus. The middle and lower trapezius and rhomboid muscles weaken in response to dys­ function. in which there is a loss Figure 7-9 of lumbar lordosis.Basic Evaluation of the Myofascial System 149 Table 7-2 Cervical/Upper Thoracic Agonist! Antagonist Relationships Postural Phasic Upper trapezius Levator scapulae Pectoralis major (upper part) Pectoralis minor Cervical erector spinae Latissimus dorsi Mid/lower trapezius Rhomboids Anterior cervical musculature straight-line distance between the manubrium Figure 7-8 and the umbilicus. and tensor fasciae latae. Corresponding joint dys­ function includes hypomobility of the lumbar segments. two situations commonly exist. The increased lumbar lordosis includes a tight­ ening of the lumbar erector spinae. Because the muscle group responds to dysfunction by weak­ ening. weaken. which further facilitates the thoracic dysfunction.

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 girdle -assist in adduction of scapula Dysfunction Tightens Results of Dysfunction -elevation/adduction of scapula -increased cervical lordosis -restricted a xial extension -limited side bending and rotation of cervical spine -BB and SB of spine Pectoralis major (upper part) -shoulder flexion -horizontal adduction of humerus Pectoralis minor -protraction of scapula -accessory breathing muscle Tightens Tightens -restricted shoulder flexion -restricted horizontal adduction -scapular abduction with outward rotation of inferior angle -winging of inferior border of scapula -increased thoracic kyphosis Rhomboids middle/lower trapezius -adduction of scapula -fixes inferior angle of scapula to thoracic wall Weakness -scapula abduction with outward rotation of inferior angle -winging of inferior border of scapula -increased thoracic kyphosis Cervical erector spinae -extension of cervical spine Tightens -loss of forward bending -loss of axial extension -holds cervical spine in forwardhead posture Anterior cervical musculature -flexion of cervical spine Weakens -weakness in forward bending -loss of axial extension -inability to pull out of forward-head posture terior hip structures against the erector spinae as antagonistic groups. The clinician should consider these myofas­ cial relationships and how they correlate to structure when evaluating posture. The cor­ responding dysfunction is usually joint hyper­ mobility with eventual instability of the lumbar spine (Figure 7-7 and Tables 7-4 and 7-5). These find­ ings may then be correlated to the remainder of the evaluation. leading to progressive weakness. The tightness in the hamstrings and posterior capsule of the hips pulls the spine into forward flexion. This situation is more common in men with early to moderate degen­ erative joint disease of the lumbar spine. ACTIVE MOVEMENT ANALYSIS Evaluation of active movements gives the cli­ nician more valuable information regarding pos­ sible pathology of the spine or extremities that Copyrighted Material . holding the erector spinae in a lengthened posi­ tion.

Looking only segmentally in the lumbar spine can cause the clinician to miss the primary causative dys­ function. Spinal movements Table 7-4 Lumbar/Lumbopelvic Agonist! Antagonist Postural Iliopsoas Tensor fasciae latae Hamstrings Hip adductors Gastrocnemius-soleus Erector spinae Piriformis bending. The patient usually has a flattened lumbar lordosis. then segmentally. regard­ less of the suspected area of pathology. In evaluating active range of motion from a myo­ fascial standpoint. usually a man. The multipJane motions that are useful to observe are: (I) fOJward bending. Restriction of movement in the posterior musculature and fascia of the lower extremity. The pelvic contribution to forward bending is limited be­ cause of tight hips. creating lumbar instability. as are their dysfunctions. This again is especiaUy important when dealing with the myofascial system. and posterior fas­ cial structures in order to balance the contri­ butions of the hip and low back to overall for­ ward bending. As with a standard structural examination. all the cardinal plane movements including forward Phasic Gluteus maximus Quadriceps Gluteus medius Dorsiflexors Abdominals may be correlated with postural findings. The patient. because the fascial planes are more regional. The reason for performing both regional and segmental observations is that many times. Entire spine motion should be observed. with corresponding hypermobility of the lumbar spine. and posterior fascial planes. This is especially true when examining the myofascial system. whereas segmental observation reveal. 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. The area of pathology should then be examined specifi­ cally. The primary dysfunction that needs to be addressed includes the hips. exemplifies regional. Quadrant movements should also be observed because dai Iy movements and result­ ing dysfunctions occur in multiplane dimen­ sions. the clinician should first look regionally.s more specific joint abnormalities. asymptomatic dys­ Figure 7-10 function causing symptomatic dysfunction else­ where. Copyrighted Material . the posterior struc­ tures of the lumbar spine become stretched and hypermobile.Basic Evaluation of the Myofascial System 15l should be observed in total at least once. with the patient being instructed to move segmentally starting in the cervical area and proceeding through the thoracic and lumbar spines. since it is multidirectional. but needs treatment to resolve the symp­ tomatic dysfunction. the loss of lordosis is correlated with regional movement patterns to assess the primary and secondary dysfunctions. exhibits an exaggerated lumbar curve reversal. Regional obser­ vation will usually reveal myofascial abnor­ malities. and rotation should be observed. hamstrings. Over time. hamstrings. side bending. and with active movements . has low-back pain.

the flexibility of the myofascial planes on the contralateral side of the movement. abduction -anterior ilial rotation -knee flexion assistant Tightens -restricted hip extension.152 MYOFASCIAL MANIPULATION Table 7-5 Muscle Agonist/Antagonist Groups of the Lumbopelvic Area and Resulting Dysfunction Response to Muscle Group Iliopsoas Action -hip flexion -assists in external rotation and adduction -backward bending of lumbar spine -anterior ilial rotation Dysfunction Tightens Results of Dysfunction -restricted hip extension -tight anterior capsule -increased lumbar lordosis -decreased posterior rotation of ilium T ensor fasciae latae -hip flexion. side bending. among other things. The f irst combined set of motions follows a very functional movement pattern that usually helps assess. and rotation to the same side. Compressive Testing of the Spine Compressive testing of the spine is usually considered a special test of the spine. adduction -decreased posterior rotation of ilium -contributes to increased lumbar lordosis Gluteus maximus -hip extension -posterior rotation of ilium Weakens -loss of hip extension -decreased posterior rotation of ilium Hip adductors -hip adduction -assist in hip flexion -anterior rotation of ilium Tightens -restricted hip abduction -restricted posterior rotation of ilium Gluteus medius -hip abduction -ant. ER. the anterior fascial planes can be evaluated for restrictions. but should When the same extension quadrant is observed Copyrighted Material . and (2) backward bending. and rota­ tion to the same side. observ­ ing the backward bending quadrant movement from an anterior angle is important. fibers-ER hip Weakens -limited hip abduction -loss of lateral stabilization of hip joint Erector spinae -extension of spine 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. fibers-IR hip -post. Because the di­ aphragm and anterior fascial planes may become restricted in the forward-head posture. from the anterior view. internal rotation. The second combined movement is gen er ally used to assess compressive joint l esion s of the spine on the same side the movement is occurring.

including layer palpation and passive mo­ bility of muscles and fascial mobility. and (3) assess­ ment of passive segmental mobility. The development of tactile skills includes the ability to detect tissue texture abnormalities. subcutaneous fascia. or the tissue Figure 7-ll on the contralateral side? Copyrighted Material . The concept behind compressive testing is to test the amount of "spring" that the spine has when a direct compression is imparted (Figure PALPATORY EXAMINATION Once posture and active movements are as­ sessed. deep fascia. Layer palpation is extremely important. and joint spaces. and offers a clear picture of possible goals and treat­ ment approaches. Palpation of myofascial structures is primarily emphasized here. indi­ cating increased lever arms for the effects of gravity and increased stresses on myofascial structures. muscle sheaths. Layer Palpation Layer palpation is a systematic method of as­ sessing the mobility and condition of the myo­ fascial structures.Basic Evaluafion of the Myofascial System 153 be routinely performed. The palpa­ tory examination reveals yet more information that may be correlated to previous findings. patients with accentuated cur­ vatures will have an increased springiness. (I) palpation of the myo­ fascial structures in the form of layer palpation. but is not necessarily limited to: 7-11). especially since a common error in both assessment and treatment is to delve into the deeper structures without assessing the superfi­ cial structures. A convenient time to perform this test is after active movement test­ ing. 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 clinician may begin to estimate where the significant dysfunctions exist." leading to decreased shock attenuation during normal everyday ac­ tivities. Ballistic or impact exercise such as jog­ ging or aerobic exercise may further accentuate the dysfunction. (2) palpation of joint structures. musculo­ tendinous junctions. starting from the most super­ ficial structures and progressing into the deepest palpable structures. muscle bellies. blood ves­ sels. The clinician should be able to palpate in depth the location of the structures during the palpatory examina­ tion. Postural reeducation after nor­ malization of myofascial tone can help correct this dysfunction. Generally. The tissues that can be palpated include the skin. Is only the skin being palpated or is the subcutaneous fascia also being palpated? Is the muscle sheath being palpated. bone. lig­ aments. How is the tissue at that level different from surrounding tissues at the same level of depth. The palpatory examination includes. The spines of patients with decreased curvatures (axially extended cervical spine along with decreased lordosis in the lumbar spine) will not have enough "spring. tendons.

and the deep periosteal layers of tissue. Reevalu­ ation is taking place before. Once the evaluation is completed. 7-12). and shear. moving perpendicular to the tissue. Shear is movement of the tissues between layers. Table 7-7 Palpatory Exam Elements of Evaluation Superficial examination -Light touch -T issue temperature and moisture -Mobility of superficial fascia -Skin rolling Deep examination -Compression: palpation through layers of tissue perpendicular to the tissue -Shear: movement of tissues between layers perpendicular to tissue -Muscle sheaths -Muscle bellies -Tendons -Myotendinous junction -Joint capsule -Periosteal layer Structures To Palpate -Skin -Superficial connective tissue Copyrighted Material . which is palpation through layers of tissue perpendicular to the tissue.154 MYOFASCIAL MANIPULATION Table 7-6 Descriptive Terms for Layer Palpatory Exam superficial-deep compressible-rigid moist-dry soft-hard hypermobilehypomobile acute-chronic painful-nonpainful circumscribed-diffuse rough-smooth thick-thin as well as the integrity of the tissues may be palpated. the layer pa Ipation format may be categorized into superficial and deep palpation (Tables malities and restrictions are noted in this evalu­ ation. Transverse muscle play is an effective assessment tool for assessing the mobility of a muscle or muscle group within the enveloping fascial sheath. the findings are correlated to define the specific dysfunction and treatment is initiated accordingly. Tissue roiling is an important part of layer palpation. tendons. This concept is elaborated on in Chapter 7-6 and 7-7). The muscle is "bent" in order to assess the transverse flexibility of the muscle. muscle bel­ lies. it gives the clinician information about the extensibility of the subcutaneous connective tissue (Figure 8. the skin and superficial connective tissue are lifted up. tenoperi­ ostial junctions. myotendinous junctions. and after treatment and the treatment is adjusted to ac­ commodate changes being made. during. In tissue rolling. The extensibility of the tissues. Tissue texture abnor­ For practica I purposes. The deep palpatory examination includes compression. The struc­ tures palpable are muscle sheaths. away from the deeper tissues. joint capsules. The su­ perficial palpatory examination includes tissue temperature and moisture and light touch to de­ termine the extensibility and integrity of the superficial connective tissues.

Copyrighted Material . Cantu R.lAMA. Charles C Thomas. Steindler A. 1974 . G ol d en h erg but 2.\ ufSofi Tisslle Lesiuns. cen tral nervolls motor regulation and back programs In: Korr I. . Springfield. 01. Grodin AJ. . C ou rse notes gustine. Cyriax J.Basic Evaluation of the Myofascial System 155 Figure 7-12 I{EFERENCES Dur/ulld:1 IIllIstrated Medical Dietiunm)'. 4. TI/(! Neurubiulogic J'vlech­ aniSIIlS in J'vlanipulative Therapy. 25th ed Phil­ . 5. 257:2782-2803. 3. lextbuuk of Orthopaedic Medicine: Diagno­ ". New York: Pl enu m. Janda V Muscles. SI. Kinesiology. l1. Fibromyalgia syndrome: an emerging controversial condition . 1977:35-37. 1:46. Mvojaseial J'vlan/pulation. FL: Institute of Graduate Physica l . adelphia WB Saunders. 1978:27-42. 6. cd. Lo n don England: Bailliere Tindall. Au­ The ra p y . .

joint mobil ization is a form of soft . many times. whether or not the direc­ tion follows the arthrokinematics of the nearby joint. Myofascial manipulation has undoubtedly been performed since the beginning of time. and has evolved into its present-day variety of formats. Joint re­ strictions occur and are treated in characteristic arthrokinematic fashion.CHAPTER 8 Atlas of Therapeutic Techniques Robert 1. Before discussing individual technique. the operational definition of a joint should be expanded. cer­ tain terms should be defined and treatment con­ cepts and procedures discussed. and therefore. the clinician will modify them to meet the in­ dividual needs of both patient and clinician. may occur in many planes and in many different-and un­ predictabJe---directions. tissue mobilization since the extensibility of the connective tissue surrounding the joint is being changed. The techniques then become personalized. Mobilization technique must be applied following arthrokinematic rules in order to restore extensibility. for example. difficulty may arise in drawing the line between what is soft tissue manipulation and what is joint manipulation. New techniques are born in this way and. in the opinion of the authors. Cantu and Alan J Grodin The following atlas of therapeutic techniques is by no means a comprehensive treatment of all myofascial technique. evolve into specific systems of treatment. MyofasciaJ re­ strictions. is to give the clini­ cian a solid and basic understanding of myo­ fascial technique. For the purpose of clarity in this text. periosteum." The arthrokinematics is the distinguishing factor in separating soft tissue mobilization from joint mobilization. Restrictions of tbe superficial fascia. A joint may be defined as "a space built for motion in which movement is governed by (a) arthrokinematic rules and (b) connective tissue extensibility." then any tissue surrounding the "joint" may be considered 157 Copyrighted Material . on the other hand. then. Joint versus soft tissue manipulation: Some soft tissue. and fascia are all histologically classified as connec­ tive tissue. for the sake of clarity and consistency throughout the chapter. It merely represents a compilation of techniques that. unique to that particular practitioner. and specifically of this chapter. If a joint is operationally defined as "a space bui It for motion. the fol­ lowing concept may be applied: Anything that is not bone is connective tissue. however. The treatment is based on localizing tbe restriction and moving into the direction of restriction. As the techniques are used. are not as predict­ able since they can occur outside the realm of specific joint arthrokinematics. The purpose of the book. When dealing with the joint. capsule. Technically speak­ ing. Myofascial manipulation will continue to evolve into more effective applications as the body of knowledge increases. have consistently proven to be effec­ tive in the clinic. Ligament.

Myofascial manipulation. between scientific scrutiny and clinical intu­ ition. and. At times. Deeper technique is not synonymous with more aggres­ sive technique. The con­ cept is that the shortest distance between any two points is a straight line. Treatment that relies heavily on one while de-emphasizing the other will not be balanced. however. In this way. therefore. without negating the intuitive aspects of the treatment technique. respecting and integrating nearby joint arthrokinematics as much as possible. Treatment that progresses from superficial to deep also allows the patient gradually to grow accustomed to the clinician's hands. and individual joints are more easily isolated. the guidelines discussed below may be helpful in deciding treatment sequenc­ ing for individual patients. autonomic responses. joint mobi­ lization becomes easier. not be as effective. however. this facilitates relaxation and allows for unforced penetration to deeper levels. Joint and myofascial manipulation are "played off" one another-joint mobiliza­ tion inhibits myofascia."There is no doubt that "good hands" and an "intuitive mind" are of great value in manual therapy. Individual joint restric­ tions often have significant myofascial compo­ nents. they may be treated ef­ fectively without potential microtrauma and ex­ acerbation of symptoms. A general scheme of treatment is as follows. and myofascial manipu­ lation facilitates joint manipulation. Copyrighted Material . inhibit surrounding muscu­ lar activity. Releasing myofascial tissues prior to joint mobilization also allows joint mobilization and/or manipulation to be performed with less force application. the techniques locate the restriction and move into the direc­ tion of the restriction. specifically in myofascial manipulation. myofascial manipulation is represented in the most concrete empirical form possible. b. In other words. however. and the shortest distance through a restriction is directly through the restriction. Passive segmental mobility of individual joints may change with regional treatment of myofascia. The general progression of myofas­ cial manipulation considers the following fac­ tors: a. all the techniques described in the text are direct ones. Myojascial manipulation of involved and regional areas associated with local involve­ ment. The danger of losing credibility is higher than in joint manipu­ lation. 2. As the myofascia releases. Direct bejore indirect technique. which are stimulated by joint manipulation. The type III joint mechanoreceptors. Joint mobilization after treatment oj l11yo­ jascia. Supeljicial to deep. joint mobilization and/or manipulation may become necessary to free up the myofascia. For the most part. If the changes cannot be made with direct technique-because of pain. or in search of deeper myo­ fascial restrictions. however. or severity of the restric­ tion-indirect technique may be used. With joint mobilization. Instead of breaking down the doors. the mechanical restriction can more easily and more specifically be treated. If the myofascial component of the restriction is first released. since treatment is based on "what the therapist is feeling. This text rep­ resents myofascial manipulation in a biome­ chanical and kinesiological sense. If the deeper connective tissues are properly accessed. Common sense dic­ tates that application of myofascial technique begins superficially and progresses into depth as changes are made.158 MYOFASCIAL MANIPULATION Herein lies one of the problems with myofas­ cial manipulation: Treatment has a tendency to become subjective and abstract. if the myofascial restriction is unyielding. the clinician allows the body to open the doors for easy and less damaging access into an area. Sequencing of treatment: The sequence in which technique is applied will generally spell the difference between success and failure. generally focuses on larger areas or regions of treatment. The question is: Where in the entire treatment scheme does myofascial manipulation fit? And how does the clinician sequence individual myo­ fascial technique for optimal results? Each pa­ tient is different and each clinician will deter­ mine the sequence of treatment on an individual basis. A balance should exist. the treatment often focuses on individual joints being moved in specific directions. 1.

and a is established. The that "it is easier to slump than to and the poor postural kinetic chain also becomes a force The hands also become more relaxed in the ap­ plication of the becomes more time. A precautionary note is in order at this point.'j' vvhenever i. The use IS and thera­ of and lever and avoids needless body contact. or acts as a the therapist force multiplier.". the pa­ tient cannot effectively assume the new The tires from his or her feedback loop for example. the beginning of the treatment sequence. "all arm. but is to soft tissue mobilization as well. to sit erect. Since physical Alexander2) are ap­ with the con- Important to propriate at this time.Atlas 159 3. Joint and myolascia/ elongation. The alternate somatic movement of myofascial and joint manipulation.'Pl"f'l0l1l7' forced. arms. more efficient pat­ shifting When applying a type of Rather than exists is given at weight shifting allows to access the lower kinetic chain. whether the use The ability to lean over the is prone. Postural instruction. 5. Use can be optimized by utilization of tables. The pillow applied. and since many times the may outsize the the use of body and lever arms is important.\' yet multiplier available to the thera­ and the technique but softer at the same the lever arm. of patient and therapist: To achieve maximal both This concept may seem and therapist should be situated in the most effi­ yet it is often to-day treatment of in the therapist's in the well taken. Using lever arln. The second aspect of in the discussion of generous use of pillows. or supine. the greater and more focused the force becomes. No stretch is ied but for prior to stretch to allow reeducation. Once ex­ is transferred to the this unable to relax fully.. the force multiplication that is Copyrighted Material . the tiplication. the the promotion of new movement tients are terns. the manual lever arms for the force mul­ the risk of injury. the ac­ forces are a between the therapist and the patient. This is es­ important in mobilization. posture is easier and is positively reinforced. With new freedom of movement. siddying. In the lower formed on a 4. exercises and movement ap­ I a mechanical barrier between which aids the biomechanical 1. Some advocate the use of shorter and their point is . with and m. but their effectiveness is limited if the tissue is not of lhe tissue lalion. and move in new. '"Cf" in the manual (distinct from stretching) refers primarily to the where the forces app I ied cordion" and decompress the spine. The of the is all about ill at this time to strengthen. patient and the The patient senses and is tensibility has been improved in the and the joints." is actually rein­ own restrictions. The manual therapist should be care­ ful when lengthening the lever arm..'. The the lever arm. 3. more efficient which is necessary for most the for postural reeducation. Once the restrictions the manual therapist." the use of the lower are removed and the patient new. Neuromuscular myofascial manipulation should always be per­ for greater tissue extensibility. If postural instruction.

Wash hands il1 cold water at er f 8-1). however. If a manual therapist sees 15 patients a day 5 days per week for manual therapy. Manual therapists actually incur treatment. The following are some suggestions for hand care: 1. The fist and elbows are excel­ lent alternatives. If the patient is large-sized. which in turn. End-range maneuvers will only accelerate joint hypermobility problems. do not use the fingers or thumb. W hen gardening or performing any type of work that may be hard on the hands. Adapt for therapist/patient size differences. Protect the hands during off hours. and the desired depth of penetration is not practical. The numbers accumulate dUling the course of a career. use techniques that do not hyperflex aligned with the radius. W henever possible. 3. the cold water may act as a cryotherapy/anti-inflammatory treatment. The thumbs should be aligned with the metacarpals. the therapist should wear gloves. should be If any inflammation occurs during a patient treatment. The hands are very dura­ ble body parts. leading to early arthritic changes. Figure 8-1 Copyrighted Material . Palpate with the fingers. the therapist is laying hands on more than 3700 bodies per year.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. the principles of Wolf's law (good stress/bad stress) all apply. 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. whereas the cold water may slow the process down. treat with the elbows or fist. 4. Practicing correct application of technique and following proper hand-care procedures are essential for en­ suring longevity of the manual therapist's career. Warm water 15 to 20 times per day may have a cumula­ tive inflammatory effect.

The technique is repeated at a deliberate pace. The skin. The technique sug­ gested here offers an entry way into deeper tech­ nique by quieting the autonomic system. going only as deep as the superficial. starting with a deep touch is usually counterproductive. should be only mildly uncomfortabJe. is hypersensitive with a cold clammy feel or touch. moving about an area of the spine as indicated. and the patient is easi Iy nauseated. The amount of lubricant should be just enough to decrease noxious skin friction. The technique is superficial. not to create mechanical changes. Remember. The pisiform is the axis of motion for the technique. the goal of this technique is to quiet the autonomic system. the elbow is moved away from the body. Starting with the elbow close to the body. tonomic technique. during the time when the hands should be getting much-needed rest. and at worst. Use aflubricant. The treatment hand is placed gently on the patient. but not enough to cause slipping of the hand on the body. Hands: Contact will be made with the pads or tips of the last 3 fingers. with the pisi form being the axis of motion for the technique. for example.Atlas afTherapeutic Techniques 161 Figure 8-2 more microtrauma to their hands in the off hours. A certain amount of "traction" on the skin is necessary for appropriate delivery of the technique. Execution: One hand will be placed on the patient to stabilize gently the subcutaneous con­ TECHNIQUES FOR THE LUMBAR SPINE Bindegwebbsmassage-Type Stroke (Figures 8-3 to 8-6)3 Purpose: This technique is a reflexive or au­ nective tissue. bringing the fingers away from the stabilizing hand. the patient. especially in techniques in­ volving longer stroking. Patient position: Prone. perpendicular to the patient. Therapist position: The therapist stands over cant should be used. For a patient Copyrighted Material . Many patients ex­ hibit acute symptoms that mimic a reflex sym­ pathetic dystrophy. subcutaneous connective tissue. 5. it is used when the patient shows signs of being autonomically facilitated or extremely hypersensitive. The technique is generally comfortable. A small amount of lubri­ with such symptoms.

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Atlas o/Therapeutic Techniques 163 Figure 8-5 Figure 8-6 Copyrighted Material .

Care must be exercised with the deeper version of the technique in patients with degenerative joint disease or discogenic lesions. 8-9 and 8-10) Purpose: The purpose of this technique is to elongate the superficial fascia in a medial­ lateral direction. off-center. usually cephalocaudal. Therapist position: The therapist stands over the patient. directly in line with the re­ striction. or in any direction of restriction. whereas any deeper ap­ plication is primarily mechanical. diagonal re­ strictions may occur and should be treated. A gentle distraction is then ap­ plied in the direction of the restriction. Patient position: The prone position is dem­ onstrated here. In the supine position. As with the previous technique. perpendicular to the direction of the restriction. for example. The technique can be performed in the midline. This technique can also be performed on a deeper level to provide an elongation of the spine itself. the application may be superficial as well as deep. but the technique can be per­ formed in any position depending on the loca­ tion of the restriction. Since the subcutaneous connective tissue is multidi­ rectional in the fiber orientation. Hands: Hands are placed in a crossed posi­ tion on the patient. The most superficial application of the technique is autonomic. diagonally. When being performed in the midline with a deeper pressure. usually in the cephalad-caudad direction. a distrac­ tion and elongation of the spine will result. the technique can be used to treat restrictions in the anterior chest or abdomen. Medial-Lateral Fascial Elongation (Figures Purpose: The purpose of this technique is elongation of the superficial connective tissues. Figure 8-7 Copyrighted Material .164 MYOFASCIAL MANIPULATION Long Axis Distraction of Superficial Connective Tissue (Figures Execution: The therapist applies gentle an­ 8-7 and 8-8) terior pressure until the subcutaneous fascial level is reached.

Atlas afTherapeutic Techniques 165 Figure 8-8 Figure 8-9 Copyrighted Material .

Therapist position: The therapist stands di­ agonally over the patient. As with other superficial techniques. and as patient tolerance dictates. The rest of the forearm is merely resting on the patient as the technique is executed. The other elbow is placed in the area of the lumbosacral junction with the forearm and hand resting I ightly on the patient. with the top hand on the treatment table for support and efficiency in application of technique. Lateral elongation pressure is then applied. Some patients Copyrighted Material . taneous fascia are gently lifted in a posterior direction at di fferent levels and areas of the spine. Execution: Assessment: The skin and subcu­ terior pressure with the elbow until the level of superficial subcutaneous fascia is reached . this de­ crease should not be considered dysfunctional. the as­ sessment may be in medial-lateral or diagonal directions because of the multidirectionality of the superficial connective tissue. Execution: The therapist applies gentle an­ mechanical assessment and alteration of restric­ tions in the superficial fascia. Patient position: Prone. Most of the pressure is at the elbow and the proximal one third of the ulna.166 MYOFASCIAL MANIPULATION Figure 8-10 Patient position: Prone. Generally. deeper pressure may be gradually applied to the muscular and periosteal levels. the fascia directly over the spine has much less mobility. As the subcutaneous fascia releases. Therapist position: The therapist stands per­ Tissue Rolling (Figures 8-11 and 8-12) Purpose: The purpose of this technique is pendicular to the patient. and the elbow is allowed to slide laterally and around the body. the tissue is assessed just off the midline of the spine and in a caudal to ce­ phalic direction. Typically.

Atlas afTherapeutic Techniques 167 Figure 8-11 Figure 8-12 Copyrighted Material .

the motion may be stopped and a sustained pressure may be applied. the skin is rolled from caudal to cephalic. and a gentle posterior stretch or oscillation can be applied. but must also cor­ relate the f indings with other components of the evaluation. Using each hand alternately. Therapist position: The therapist is posi­ tioned at the head of the table with one foot in front of the other. the rolling can be stopped. but other directions such as medial to lateral or diagonals can be pursued.168 MYOFASCIAL MANIPULATION will be quite restricted in all planes. Therapeutic application: The skin and su­ perficial subcutaneous connective tissue are gently lifted in a posterior direction with both hands. One can imagine balancing a drop of water on the Ii fted portion of the skin as the roll is applied. The clinician must not only base the clinical j udgment on the su­ perficial fascial assessment. Generally. this may be a general function of body type. the clini­ cian rolls the skin. The patient's head should be as close as possible to the head of the table to allow the therapist to complete the technique through the iliac area. Figure 8-13 Figure 8-14 Copyrighted Material . never releasing the hold on the skin and subcutaneous tissue. The neck also should preferably be in a neutral position and not rotated. Patient position: The patient is positioned prone with the lumbar spine in a neutral posi­ tion. Long Axis Laminar Release (Figures 8-13 and 8-14) Purpose: The first purpose of this technique is elongation and decompression of the spine. The second purpose is the identification of lo­ calized lesions in the medial border of the erec­ tor spinae. When a restriction is encoun­ tered. As these lesions are identified. or may repre­ sent generalized restrictions.

Muscle Play of Erector Spinae (Figures 8-15 and 8-16A. As previously defined. or chronic fibrotic changes. The thumbs are placed in the groove between the erector spinae and the spine. lesions along the groove may be identified. iliac crests. the palms of the hands engage the Figure 8-\5 Copyrighted Material . holding patterns. These lesions are manifested as local increases in muscle tone. muscle play is "the abil­ ity of the muscle to expand and move within its compartment independent of joint movement Execution: Starting in the upper thoracic area and with moderate pressure in the groove between the erector spinae and the spine. and a gentle traction force is ap­ plied. 8) Purpose: This technique mobilizes the fascial sheath or casing surrounding the erector spinae. The technique is best performed with both thumbs on a single side of the spine. After several strokes. A bilateral technique can also be performed but the depth of penetration is somewhat compromised. The movement of the hands may be stopped at any time to apply localized sustained pressure. the thumbs are moved caudally into the lumbar and lumbosacral areas.Atlas a/Therapeutic Techniques 169 Hands: The hands are placed gently over the patient with the fingers and thumbs facing in a caudal direction. one thumb just behind the other. As the lumbosacral junction is reached. The lesions may be results of acute inflammation or may be remnants of older trauma. Note that the thumbs should be aligned so they are in a direct line with the radius. or connective tissue thickenings. reflexive muscle guarding. This alignment allows for the most efficient application of technique and the least amount of biomechanical compromise for the therapist's hands.

the thumbs are placed on the lateral border of the erector spinae. and movement in the localized and general areas is improved. The movement can be lik­ ened to the bending of a garden hose. circulation to the muscle is improved. muscular contraction can occur more efficiently. Patient position: Prone. If one imagines a garden hose being an encasement in which improvement of mobility is desired." Many fascial restrictions occllr in planes perpendicular to or diagonal to the direction of the muscle fibers. By mobilizing the connective tissue sheath surrounding or encasing the muscle or groups of muscle. bending the hose is one way to accomplish this goal. Recall that muscle sheaths are classified as loose connective tissue that has multidirectional fiber orientation.170 MYOFASCIAL MANIPULATION A Figure 8-16 or voluntary muscle contraction. Hands: Hand position for this technique is extremely important. Therapist position: The therapist is standing perpendicular to the patient. For the technique. Once Copyrighted Material .

the top hand remains an­ chored onto the iliac crest. an excellent is usually less noxioLls and more sedative than cross fiber manipulation.Atlas Techniques 171 the thumbs should be positioned so they are in line with the radius of the forearms. the force i s the palms. The of the stroke is lateral to med ial with the thumbs. are placed (MCP). Patient position: Prone. The into the erector of the bottom hand muscle group and slides and f irmly in a cephalic direction. for a moder­ ate traction/distraction of the lumbar area. move to the other side of the table to perform the technique. allowing the patient's body to oscillate primarily in a medial on the too to lateral direction. This rhythm will vary from patient to patient and will also patient's state of relaxation. Once and excursion are attained. This is deep. the index fingers are merely the position of the hand on the erecTo ensure that a executed (as a position away from the toward the body movement a medialto a pOSItiOn of be low to allow for the LIse of the therapist's body Execution: A small amount of lubrication is used. the elbows must move from the power the stroke. the hand or pist must. The portion of the stroke is still delivered through Copyrighted Material . the elbows are held away from the body at the initiation of the stroke (shoulder abduction) and are moved toward the during the stroke If a restriction is identified in a medial to lateral direction. with the "power" of force to maintain the oscillation. so the thumbs are medial border of the erector is changed the The thera­ Bony of the Iliac Crest (Figures 8--18 and 8-]9) Purpose: This then soften the fascia of the is to first at the insertion and quadratus lumbo­ also serves to prepare the evaluate the fascial attachments at the iliac crest. or carpo­ the thumbs in over the The the but now in a medial to lateral direc­ tion. this is for applying moderately is in considerable deep pressure when the discomfort or pain. Different levels of the erector spinae may be treated by simply moving the hands cephalic or sure that the thumbs contact the latera I borders of the erector any other position will quickly produce fatigue. begin to create the force in synchrony with the The primary force retaining a ohhe rest of the is now at the thumbs. metacarpal The index joints. This ensures that forces are distributed throughout the arm and are not localized in the interphalangeal (IP). Hands: The top hand is placed over the iliac crest to "anchor" the pelvis. the thumbs. is performed in a medial-lateral di­ rection of force. In other words. Initially. medial border of the erector "Ironing" of Erector (Figure 8-17) Muscle of the hands are of the Execution: This an oscillatory manner lightly over the lateral body (Figure 8-1 Purpose: The purpose of this technique is to tonal inhibition of the erector muscle group while applying traction to the lumbar unilateral Since longitudinal B). the technique. The bottom hand is crossed over the top hand and placed over the erector muscle mass as close to the lum­ The table should bosacral junction as level quickly or slowly will result in either a logrolling type of motion or a motion that is out of reso­ nance. but utilizes the entire heel of the hand to create a strong but diffuse technique. Therapist position: The therapist stands dithe patient at the of the lumbosacral area. which are the lateral border of the erector spinae.

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lIiac Crest/Lateral Sacral Release (Figures 8-20-A. as close to the midline as possible. and patients with Jow back. For better mechanical advantage. the area of the iliac crests contains connective tissue thickenings from various muscular and fascial attachments. and leg pain can profit from this technique. The lateral border of the sacrum can also be fascially compromised. Patient position: Prone. hip. Execution: In the first part of the technique. Especially patients with diffuse hip and leg pain proximal to the knee can benefit from this tech­ Copyrighted Material . and is vulnerable to myofascial restrictions. As previously discussed. the "power grip" shown in Figure 8-2 is utilized to gain further depth.Atlas afTherapeutic Techniques 173 Figure 8-19 iliac crest surface area for the next series of techniques (i Iiac crest release). B. side bending. A small amount of lubricant should be used to avoid overly frictioning the skin. the therapist scours along the superior border of the iliac crest using the reinforced thumb and PIP joints as the contact on the pa­ tient. and 8-22) Purpose: This technique mobilizes the fascial planes in the area of the iliac crest and the top one third of the ilium and the lateral border of the sacrum. In the second part of the technique. The fingers scour along the superior border of the iliac crest laterally and at moderate depth. Movement restrictions in forward bending. Again starting as medially as pos­ sible. the fingers of both hands are placed directly over the superior border of the iliac crest. the fingers of one hand are placed over the fingers of the hand making contact with the patient. The piriformis attaches close by. and also backward bend­ ing can occur here. The technique starts on the superior border of the iliac crest. 8-21. sacro­ iliac . The posterior portions of the fascial planes create the forward bending restrictions. whereas the anterior portions create backward bending restrictions.

Hands: The optimal hand position for this tive tissue need to be placed in a slackened po­ sition for deeper penetration. Should the connec­ Therapist position: The therapist stands di­ agonally over the patient. or statically with pillows (Figure 8-18). one being below and one being above the middle fingers. This posi­ Copyrighted Material . The lateral sacral release is an excellent technique to use in conjunction with the bilateral sacral release technique shown next.174 MYOFASCIAL MANIPULATION A \ B Figure 8-20 nique. Patient position: Prone. The index fin­ gers are "dummy" fingers. technique is to have the middle fingers approxi­ mating one another (Figure 8-1). the hip may be extended manually by the therapist. approximately perpen­ dicular to the iliac crest.

Atlas a/Therapeutic Techniques 175 Figure 8-21 Figure 8-22 Copyrighted Material .

or at least palpated for restrictions.176 MYOFASCIAL MANIPULATION tion allows for a four-finger contact on the iliac crest or lateral border of the sacrum. When the f ingers are withdrawn posteriorly in preparation for the next stroke. To ensure that contact is being made on the sacrum. This may become necessary before attempting to mobilize the sacrum out of vari­ ous positional faults or movement dysfunctions. The depth of penetration of the stroke is moderate and depends on patient tolerance. they move back on the border of the ilium. and sacrotuberous ligament. To fully mobilize the insertion of the fascia lata. Hands: The hands are brought together so that the thumbs and the index fingers of each hand are making contact with one another. the entire expanse of the ilium should be mobilized. contact with the lateral borders of the sacrum is not being maintained. Bilateral Sacral Release (Figure 8-23) Purpose: The purpose of this technique is to mobilize the connective tissue on tJle sacra I borders. Freeing up the myofascial restrictions often fa­ cilitates mobilization of the sacrum. the fascia lata has its insertion at the ASIS. This area may also be restricted in conjunction with iliac crest restrictions. but contact I or 2 inches distal to the border of the ilium. The clinician should treat this area based on objective f indings in the evaluation and not merely on subjective com­ plaints. Many patients with f ibromyalgia will be extremely sensitive over this area. following the shape of the sacrum. Patient position: Prone. only the distal half of the sacral borders are palpable. Again. until contact is made bilaterally with the patient's buttock. As the force is ap­ plied over the connective tissue of the ilium. whereas many patients will be restricted without expe­ riencing any tenderness. The power for the motion comes from the shoulders and upper body and the stroke is delivered repetitively in an oscil­ latory manner. Execution: The f ingers are placed over the border of the iliac crest and an anterior force is applied through the f ingers. As previously noted. since the entire border of the iliac crest is susceptible and vulnerable to myofascial restrictions. A variation of this technique is to apply the same force. The proximal one half of the sacrum articulates with the ilium and is not palpable. The technique covers the bony surfaces starting just lateral to the anterior superior iliac spine (ASIS) and progressing medially and caudally to the sacrococcygeal junction. the lat­ eral border of the sacrum should be mobilized. The f ingers start just off the sacrum and push onto the lateral surface of the sacrum in a rhythmical fashion. The direction of the technique should be V-shaped. Remember that the sacroiliac joint occupies the cephalic half of the sacrum. The top hand then contacts the bottom hand in the manner described above. A very slight extension of the fingers occurs during the power portion of the stroke. Therapist position: The therapist stands per­ pendicular to the patient. The bottom hand then pal­ pates in a cephalic direction until the inferior lateral angles of the sacrum are palpated. the therapist should approach the sacrum with the bottom hand below the level of the sacrum (distal to the sacrum). lateral border of the iliac crest. except to move to other areas of the iliac crest. Execution: Anatomically. coccyx. lateral borders of the sacrum. If the fingers are only moving cephalically and not spreading. the fingers will slide off the border of the ilium into the connective tissue. In correctly applying the force. Copyrighted Material . The same technique is utilized for the lateral border of the sacrum. A repetitive caudal to cephalic motion is performed following the lateral border of the sacrum. the therapist "detours" onto the lateral aspect of the posterior superior iliac spine (PSIS) and moves caudally toward the inferior-lateral angles of the sacrum. When moving from the ilium to the sacrum on this technique. The crest may and should be mobilized from the most lateral palpable aspect to the most medial palpable aspect. Contact with the patient is never broken during the repetitive application of the tech­ nique. the f ingers do not slide off the ilium into the deeper connective tissues.

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B Figure 8-23

The technique may also be executed unilater­ ally using the same hand position as the iliac crest release described previously (Figure 8-l). The lateral border of the sacrum is located the same way as described above. Once the latera l border is located, contact is made with the fin­ gertips. The fingers are then moved caudal to ce­ phalic, maintaining contact on the lateral border of the sacrum.

Medial-Lateral Pull Away (Figure 8-24) Purpose: The first purpose of this technique is autonomic or reflexive in nature. As with other autonomic techniques, it desensitizes the pa­ tient who is extremely acute and gains entryway to deeper technique. As the patient's condition allows or dictates, deeper pressure is applied until the level of the erector spinae is reached,

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MYOFASCIAL MANIPULATION

Figure 8-24

changing the emphasis of the technique from autonomic to mechanical. The erector spinae is gently being mobilized from a medial to lateral direction.

exerted through the fingertips unti I a moderate to deep pressure is being consistently exerted.

Patient position: Sidelying. The patient's hips
and knees are semiflexed. As discussed earlier, a pillow should always be placed between the patient and the therapist both for biomechanical advantage and for modesty. The patient is moved close to the edge of the table until snug against the pillow.

L3 (Figure 8-25)

Purpose: The purpose of this technique is
to alter the connective tissue in the midlumbar area, and specifically around the L3 area. Since
L3 is generally the apex of the lumbar curve, and

site of hypomobility problems, myofascial prep­ aration of the area is necessary prior to joint mo­ bilization and/or manipulation. Also, the trans­ verse process of L3 is the longest and most easily palpated.

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.

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.

Execution: The stroke begins very gently
at approximately the level of the subcutaneous fascia, and from medial to lateral. Initially, the pressure is evenly distributed throughout the hand. As the patient tolerates, more pressure is

Therapist position: The therapist stands over
the patient with the patient snug against the pillow.

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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.

Purpose: The purpose of this technique is to
prepare the quadratus .Iumborum and the lateral fascial structures of the lumbar spine for elonga­ tion and stretch techniques. The technique in­ volves sustained pressure primarily designed to

Execution: Starting laterally, the transverse
process ofL3 is palpated. Once on the transverse process, the fingers are moved superiorly, pos-

Figure 8-26

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MYOFASCIAL MANIPULATION

...

Figure 8-27

reduce active tonic contractions of the quadratus lumborum, and to prepare for a stretch of the lateral fascial structures. After quadratus tone is diminished, the elongation and stretch tech­ niques are more effective and efficient. Patient position: Sidelying with the hips and knees in approximately 70 degrees of flexion. Therapist position: The therapist stands per­ pendicular over the patient. If a high-low table is available, the table level should be lowered. Hands: The mid forearm of the bottom arm is used in this technique. The forearm is placed in the midlumbar area, in the soft tissue space between the 12th rib and the iliac crest. If the forearm is angled posteriorly, the lateral border of the erector spinae will be contacted. If the forearm is angled anteriorly, the quadratus lum­ borum will be contacted. As an alternate posi­ tion, the web space and MCP joint of the top hand can be placed on the quadratus lumborum as the bottom hand positions to hike the hip.

Execution: The top hand is either placed gently on the patient, or on the treatment table for support. The middle aspect of the forearm (ulnar surface) is wedged into the groove be­ tween the 12th rib and the iliac crest. Light 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 or until it is obvious no change wiII be made. The forearm may be moved forward and back­ ward (the therapist is flexing and extending the shoulder) in a very deliberate "sawing" type of motion. As an alternate technique, the hip is hiked using the bottom hand while the quadratus is accessed with the top hand. The top hand is positioned with the first MCP making contact with the quadratus lumborum. As the quadratus is put on slack, the top hand pushes firmly in a medial direction to access the deeper fibers of the quadratus lumborunl.

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Side Bending Elongation Quadratus Stretch (Figures 8-28,8-29, and 8-30) Purpose: This technique should be used gen­ erally to elongate the posterolateral and antero­ lateral fasciae of the lumbar and thoracic spines and, specifically, to stretch the quadratus lum­ borum. [n unilateral chronic pain conditions, the painful side often retracts , contracts, and gener­ ally shortens. The manifestation of such a condi­ tion can be assessed postura lIy or with active movements. Both the connective tissues as well as contractile tissues may become dysfunctional and exhibit changes consistent with immobiliza­ tion. More specifically, this technique may be used to prepare for correction of lateral shift condi­ tions of more than 3 weeks' duration. As dis­ cussed in Chapter 3, muscle decreases in length by losing sar comeres-the process takes ap­ proximately 3 weeks. Tissue held in a shortened

range for longer than 3 weeks has undergone contractural changes that must be addressed before attempts at shift correction. Finally, this technique may be used to de­ compress compressive lesions such as nerve im­ pingement s yndromes. Aside from backward bending, side bending is the least stressful move­ ment on the disc, followed in increasing order of stress by forward bending and, finally, rotation. In rehabilitation of discogenic lesions, the side bending elongation maneuver decompresses the nerve root and takes the disc into the next most stressful maneuver. Patient position: Sidelying. Therapist position: The therapist stands per­ pendicular over the patient. The top forearm contacts the lateral thorax/rib cage, while the bottom forearm contacts the lateral portion of the ilium. Hands: The fingers contact the medial border of the erector spinae.

Figure 8-28

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with the fingers slightly flexed." The bottom hand is placed initially in the area of the upper lumbar spine in contact with the erector spinae. Patient position: The patient is sidelying in a semifetal position. a gentle hold-relax technique may be performed by asking the patient to gently push the ilium into the therapist's bottom fore­ arm. soft tissue and joint mobilization have a unique relationship in that either the soft tissues or the joint may be contrib­ uting to a hypomobility. but not necessarily short­ ened. The leg movement is executed through the therapist's hip and pelvis. allowing for lengthening of the more cephalic aspect of the quadratus lumbo­ rum. the patient is asked to fully flex the shoulder and hold the top of the treatment table. The top arm con­ tinues to sidebend at approximately 30 degrees off center. as de­ scribed. Note of caution: Discogenic lesions are a strong precaution here. the fin­ gers are moved caudally down the length of the erector spinae while the patient's hip is simul­ taneously being flexed. By rotating in this fashion. Execution: To execute the technique. where the quadratus lumborum has been hypertonic. This technique is often performed before. On the other hand. rib 12 is rotated away from the pelvis. The legs are then lowered off the table. along with the forearm in such a way that the elbow is positioned in a cephalic direction while the fingers are posi­ tioned in a caudal position. the legs are placed off the table and a sidebending force is placed on the pelvis as previously described. [n order to manufacture more length. during. the trunk is rotated to the T l2/L I segment. In this position. The forearms are localizing most of the stretch on the quadratus. The therapist pulls the patient's knee toward Copyrighted Material . Passive segmental mo­ bility of a joint may change dramatically after releasing soft tissue. As discussed earlier. The hands are primarily aiding this movement by gently releasing the erector spinae. In some cases. because the rotation could compromise a discogenic lesion.AlIas o(Therapeulic Techniques 183 Execution: To localize forces in the lumbar area. the hips and knees are bent to 90 degrees and the patient's feet are allowed to hang off the table. Once rotated. To diffuse the forces and provide a more general elongation of the lumbar and thoracic spines. Forward Bending Laminar Release (Figures 8-31 and 8-32) Purpose: The purpose of this technique is to elongate the posterior myofascial tissues of the lumbar spine. it may be necessary to create more length in the quadratus than the previously described technique. Therapist position: The therapist stands per­ pendicular over the patient. The therapist should not continue to rotate. The therapist can apply an elongation of the lateral connective tissue of the lumbar and thoracic spines and even into the connective tissues of the shoulder girdle complex. The forces may be applied through the arm-hand contacts described above. This may be necessary in hyperlor­ dotic postures or in preparation for joint mobil i­ zations. and after joint mobili­ zation to complement specific joint maneuvers. Hands: The top hand is placed over the tho­ racolumbar junction. joint mobilization may have a profound effect on the surrounding myofascial tissues by way of stimu­ lating joint receptors. The top hand is the "stabilizing hand. since the lever arms of the lower extremity are applying considerable forces into the lumbar spine. Care must be taken while lowering the feet off the table not to provoke any symptoms. or a trac­ tion-elongation force may be applied through the palms of the hands as shown in Figure 8-30. Once the feet are off the table. The therapist will stabilize the patient's top knee by placing it in the area of the therapist's anterior hip for control and ease of execution. the f ingers move from medial to lateral on the erector spinae. pressure is exerted in a cephalic direction with the top forearm and in a caudal direction with the bottom forearm. The change in angle of the sidebending provides a more aggressive stretch of the qua­ dratus lumborum. The patient should not be allowed to remain with the legs off the table for more than 30 to 45 seconds. At the same time.

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This motion recruit movement from lower lumbar to upper lumbar areas. Iy strokes the toward the and pace unilaterally with the bottom hand. The hip is first flexed to the level of palpating between the spinous processes for the restriction. Contact is made joint and the tip of the thumb Execution: The therapist instructs the patient to bend forward first at the cervical spine and recruit motion into the thoracic As movement is recruited into the thoracic spine. Simul­ the bottom hand strokes from just distal to the PSIS to the ischial tuberosity and laterally in a the pressure is but the direction. stabilizing the pa­ tient's top knee with the anterior hip. the thumb is held index finger. of for the Hands: For optimal stability and etliciency. Piriformal lesions and well as extensibility problems in the hip. Forward Bending L aminar Release--AII Fours (Figures 8-33. Specificity is sacri­ Longitudinal Posterior Hip Release Purpose: This is an extension of the table should be lowered. but is sometimes lIsed for lesions in the area of the posterior hip.Atlas 185 the chest. Therapist position: The stands at The thera­ or. Once movement the hip to reslacken the tissue at cephalic to the restricted the top hand. Passive intervertebral mobil­ should be assessed prior to an appropriate number of of this technique. Hands: The top hand is placed so that the gently contacts the ASIS. This allows for tissue t o b e both b y the hip tlexion and the caudal pull of the bottom hand. As the patient recruits this move­ ment. The in a caudal has arrived at the coming from hip flexion as of the well as from the caudal Execution: The top hand gently stabilizes the ilium while the patient's hip is gently flexed. One is that the patient than remaining Patient position: Quadruped. forward is extended 51 down to a position almost this time the mo­ are bilization. Therapist position: The therapist is perpendicular to the patient. The top stabilizing hand is brought leveL The bottom hand is brought up to a level then strokes over the erector elongate the posterior son tissues of the lumbar This technique may serve as I f the patient is too the alJ­ some mechani­ to this an alternative to the forward bending laminar for the therapist to manage in ficed somewhat in order to cal advantage. decreasing the lumbar lordosis. The top hand is used as Copyrighted Material . fours position may be used. and Purpose: The purpose of this or thoracic release in is to that level. This allows for bottom hand. The bottom hand is positioned over the buttock with the distal to the SLI. Most of through the remains in contact throughout. If a joint restriction is found. the asks the to start rocking to back on his or her heels. are effectively treated with this Patient position: The lized in the anterior is in the semifetal position with the top knee stabi­ of the therapist. The therapist accomplishes this by in a cephalic direction with his or her pelvis. the PIP of the the previous technique. this may be somewhat localized to prepare the surrounding soft tissues prior to a the restriction. the therapist erector starting from the sacrum and thoracolumbar hand to dictate the movement. allowing for an effective mechanical and a tient. 8-34. jf a high-low the patient's side at a may need to be on a table is direction the length of 2 to 3 segments while the hip is being flexed through a short arc o f movement.

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thoracic. but significant mechanical advantage is gained in performing the technique in a sitting position. the elbows should be directed upward. and a sustained pressure may be applied. and the therapist strokes the erector spinae longitudinally at the level the movement is being recruited . cervical spines.8-38. the thumb-PIP complex of each hand is placed over the erector spinae at the cervicotho­ racic junction in a downward position. Specificity is somewhat sacrificed.Atlas a/Therapeutic Techniques 187 Figure 8-35 Forward Bending Laminar Release-Sitting (Figures 8-36. As with the quadruped technique.8-37. The patient is asked to for­ ward bend segmentally. Patient position: Sitting. Execution: The patient is f irst asked to for­ ward bend segmentally starting from the cervi­ cal spine. and the thumb-PIP should be directed downward. recruiting into the thoracic spine. the patient may be asked to stop the movement at the point of the restriction. and to a certain extent. The same technique may be applied unilater­ ally and with a rotatory component by asking the patient to forward bend diagonally. Therapist position: The therapist stands behind the patient. For opti­ mal mechanical advantage. Hands: The hand placement is as illustrated in Figure 8-2. If a localized restriction is found. The position with the thumb held next to the PIP joint of the index finger is a very stable position and does not compromise the joints of the hand. and finally into the lumbar spine. the patient ac­ tively participates in the technique. Once the patient understands the concept of segmental move­ ment. the technique also allows for working with patients larger than the therapist. facing the patient. The patient Copyrighted Material . and 8-39) Purpose: This technique will elongate the posterior myofascial structures of the lumbar.

The therapist uses one hand to guide the patient's head and neck. generally into a diagonal direction. If a movement restriction and/or myofascial restriction is encountered. Copyrighted Material . This maneuver allows for for­ ward bending. and rotation com­ ponents. side bending. The patient is again asked to move segmentally into the diagonal plane.188 MYOFASCIAL MANIPULATION Figure 8-36 is asked to follow the lateral border of the leg with the arms. and the other hand is used to perform the technique. One hand is used as a guidance hand to dictate the pace and quantity of movement. Contraindications: This technique should not be used with discogenic backs since a loaded spine is being taken into forward bending. and uses the other hand to stroke down the cervical paravertebral muscles. the patient may be asked to stop. The technique may also be applied to the cer­ vical spine. and the therapist may apply a sustained pressure. and the therapist strokes the erector spinae at the level that movement is being recruited.

The top hand is placed over the patient's subclavicular-pectoraJ area. The patient may be apprehen­ sive of rotating the spine to the degree that is re­ quired in the midlumbar manipulation. Therapist position: The therapist stands facing the patient at the level of the lumbar spine. Many times. but also facilitates locking a specific joint of the lumbar spine. The knee of the patient is placed in the anterior por­ tion of the therapist's hip. The lumbar spine is then rotated by pulling the bottom arm of the patient until movement is recruited into the lumbar spine.Atlas a/Therapeutic Techniques 189 Figure 8-38 Figure 8-39 Lumbar Myofascia\ Roll (Figure 8-40) Purpose: This technique is an excellent pre­ paratory technique for a midlumbar roll mobili­ zation or manipulation. a midlum­ bar joint manipulation is difficult to execute because of myofascial restrictions or active muscle guarding. Hands: The fingers of the bottom hand are placed on the medial aspect of the erector spinae. Patient position: Sidelying. while the bottom hand is placed over the midlumbar area. Execution: The lumbar spine is bent forward by flexing the patient's hip and recruiting motion into the lumbar spine. the lumbar spine is rotated from both contact points. Decreas­ ing myofascial restrictions not only allows the patient to relax into rotation. In the therapist position described above. The erector spinae muscles are simulta­ Copyrighted Material .

As relaxation and elongation are achieved. Test procedure: To determine if a lateral shear imbalance exists. This technique should not be confused with the lateral shift correction technique. in a horizontal plane). and will be markedly restricted when sheared in the opposite Copyrighted Material .e. Normalizing this myofascial imbal­ ance is the primary purpose of the technique. which is typically performed on a laterally shifted patient. direction. the therapist stands behind the patient and passively moves the pa­ tient into a lateral shift position. An excellent use of this technique is with a resolving discogenic lesion where the patient has ceased experienc­ ing a lateral shift for a period of time. which may be abnormal and/or asym­ metrical due to past trauma. the patient will usually adopt the posi­ tion of the previous shift quite easily. The technique has application for neuromuscu­ lar retraining at end-stage discogenic rehabilita­ tion. The lumbar spine may be rotated close to end range. The force on the ilium is directly lateral (i. The technique of choice in a lateral shift is the lateral shift correc­ tion technique.. When the patient is tested for lateral shear (passively shifted). while the pressure applied on the upper Lateral Shear (Figures 8-41 and 8-42) Purpose: This technique is performed to nor­ malize the lateral shear forces in the lumbar spine.190 MVOFASCIAL MANIPULATION Figure 8--40 neously stroked diagonally with the fingers as the rotatory force is applied through the top arm. especially when a lateral shift is still present. This is accom­ plished by placing one hand on the ilium and the other hand on the upper trapezius-shoulder girdle area and applying force. but should not be used early in the disco­ genic rehabilitation process. but should not be taken to the limit of motion. the spine may be taken to end range to perform the joint manipulation.

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 Copyrighted Material . the patient is restricted in left lateral shear. ilial movement to the right is trunk motion to the left. the patient is said to be restricted in left lateral shear. The patient then lies prone and the lateral shear is again tested. this time primarily from the pelvis. Remember. The vector on the upper trapezius! shoulder girdle is a combination of lateral force (in the horizontal plane) and compressive force. In the prone position. In standing.Atlas afTherapeutic Techniques 191 trapezius-shoulder girdle is in a 45-degree diag­ onal direction. The next step is determining whether the re­ striction is merely postural or if a true myo­ fascial restriction exists. If the patient's pelvis moves easily to the left and is restricted in movement to the right. If the patient's trunk moves easily to the right and is restricted in movement to the left. If ilial movement to the right is restricted. the direction of the shear is always based on the direction the upper body moves in relation to the lower body. a left lateral shear restriction exists. if the trunk is restricted in movement to the left.

reducing diaphragmatic excursion. the patient is asked to hold his or her position. Also. the pelvis is sheared far­ ther laterally and the process is repeated. Therapist position: The therapist stands per­ pendicular to and over the patient at pelvis level. both in prone and in standing positions. just proximal to the greater trochanter of the hip. The first is a neuromuscular "repassing" to eliminate muscular holding patterns created by old trauma. the condition has become more entrenched and can potentially be more detri­ mental if left unchecked. protracted shoul­ der. and then relax (hold-relax stretch). and 8-46) Purpose: These techniques are designed to free up restrictions in the anterior fascia just caudal to the rib cage. This can lead to increased activity in the secondary accessory breathing muscles. and is usually more easily treated. As the patient relaxes. If a movement restriction exists when standing and remains when prone. Hands: The palm of the hand or a fist may be used to make contact on the ilium.8-44. to see if the technique produced any change.8-45. Patient position: Prone. The second is releasing restric­ tions in the noncontractile elements that became restricted as a result of prolonged dysfunction in the contractile elements. Execution: The restriction is engaged by gently shearing the pelvis laterally. In a for ward-head. the anterior elements col­ lapse . the condition is not as significant. Once resis­ tance is met. Diaphragm (Figures 8-43. Either way. slumped position. for the pa- Figure 8-43 Copyrighted Material . Two things are accomplished ill this tech­ nique. and to mobilize the di­ aphragm. After several repetitions.192 MYOFASCIAL MANfPULATfON prone. treatment is necessary to correct the dysfunction. the lateral shear is retested.

Atlas a/Therapeutic Techniques 193 Figure 8--44 Figure 8-45 Copyrighted Material .

more slack is placed in the superficial connec­ tient to perform postural reeducation techniques successfully and elongate the thoracic area. just lateral to the xiphoid process. with care not to hit the floating ribs. the patient Illay be asked to assume a more erect posture so the therapist can mobilize the rib cage. The second technique bypasses the superficial connective tissue to engage the deeper connec­ tive tissue under the rib cage. ranging from the least ag­ gressive to the most aggressive. Second Position: Side/ying Patient position: The patient is in the sidely­ ing position with the hips and knees flexed to 90 degrees. just lateral to the xiphoid process. In this position. Therapist position: behind the patient. This allows the therapist greater access to the tissues underneath the rib cage. The seated position is biomechanically more advantageous for the therapist. Execution: With the patient more flexed. This allows the fingers of the bottom hand to slide underneath the rib cage (to patient tolerance). The stroke is applied. while the bottom hand is placed at the caudal border of the rib cage. however. Hands: The therapist's top hand is placed over the bottom portion of the rib cage. Care should be taken not to push into the floating ribs while moving laterally with the stroke. The therapist uses the top hand once again to move the con­ nective tissue medially and caudally. and in the connective tissue just caudal to the rib cage. following the border of the rib cage medial to lateral. Three tech­ niques are shown. The bottom hand is placed at the anterior-medial border of tive tissue. The top hand is placed on the Figure 8-46 lower portion of the rib cage. Therapist position: The therapist is either standing at the side of the patient or seated. The therapist stands Copyrighted Material . The first technique actually mobilizes both the connective tissue and the diaphragm. the contracted area of the anterior chest and abdo­ men must be supple and mobile. allowing the bottom hand to slide under 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. First Position: Supine Patient position: The patient lies in the supine position with the knees and hips slightly flexed. As the technique is performed.194 MYOFASCIAL MANIPULATION the rib cage. only a superficial or moderate level of penetration can be achieved. The stroke is again applied in a medial to lateral direction. Third Position: Sifting Patient position: The beginning position for this technique is the slumped sitting posture. the general progression should follow the patient's tolerance level. Hands: The hand position is similar to that described above.

the psoas may be hyper­ tonic in an effort to increase lordosis or to guard a lesion. especially with forward bending. Patient position: The patient lies in the supine position with the hips and knees flexed approxi­ mately 30 to 45 degrees. and the patient is asked to inhale deeply and attempt a more erect pos­ ture. The hands are placed lateral to the umbilicus and the psoas is approached from a 45-degree angle. and if necessary. however. In an axially extended posture (flat Figure 8--4 7 Copyrighted Material . just lat­ eral to the xiphoid process. The patient is leaning into the therapist in a slumped posture. If the muscle does not exhibit enough slack. The rib cage is mobilized anteriorly. Therapist position: The therapist stands at the patient's side. over the therapist's leg. the patient's legs are then placed over the therapist's leg. Psoas (figUl"es 8--47. which is creating mobility problems in the lumbar spine. The therapist may use the leg to change the amount of hip flexion during application of the technique. 8-48. Hands: The f ingertips are used to contact the psoas. the hands firmly grip the rib cage. Both hands slide underneath the rib cage medially. Execution: The stroke is again executed medial to lateral with the patient in the slumped position. and 8-49) Purpose: Mobilization of the psoas muscle is clearly indicated in cases where actual shorten­ ing exists. This should be performed on a high-low table for optimal biomechanical advantage. this technique is bilateral. This puts the muscle in a slackened position. where axial flexion of the lumbar spine is the primary dysfunction producing symptoms. Hands: Whereas the previous techniques are unilateral. the hips may be flexed 90 degrees. At an appropriate time. places one leg on the table.Atlas a/Therapeutic Techniques 195 Therapist position: The tllerapist stands back posture). behind the patient with a pillow between the therapist and the patient.

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Care must be taken to progress slowly into the appropriate depth.Atlas of Therapeutic Techniques 197 Execution: Because of the location of the psoas. and if necessary grasping the lower ex­ tremity to impart hip flexion. The psoas wiII be more rigid than the soft tissue of the abdomen. usually more noxious when the psoas is palpated. Therapist position: Standing over the pa­ tient. Figure 8-50 Copyrighted Material . Only after longitudinal stroking should a cross stroking of the psoas be attempted. the psoas may be more accessible with the patient in a sidelying position. As more depth is achieved through the abdomen. the psoas should be gently stroked longitudinally at first. up to approximately 110 degrees. The therapist may use the thumbs to access and release the psoas. As with the psoas. creating a backward bending dysfunction of the spine. if not enough slack is placed on the tissue. a short­ ening dysfunction of the iliacus can anteriorly rotate the pelvis. especially if the psoas is dysfunctional. Patient position: The patient lies in the supine position with the hip flexed approximately 30 degrees. Even though the iliacus does not have an insertion into the spine. the hip may be flexed by the therapist. In some cases. Because longitudinal stroking of a muscle is generally less noxious than cross stroking. Once the technique is terminated. asking the patient about the relative comfort of the technique. The patient will also report a different sensation. the hands should be gradually removed from the abdomen. a significant depth must be achieved through the abdomen. "landing" on a more rigid structure indicates arrival onto the psoas. Iliacus (Figures 8-50 and 8-51) Purpose: The iliacus muscle can be treated for limited extension of the hip or as an exten­ sion of a psoas release.

posterior hip.198 MYOFASCIAL MANIPULATION Figure 8-51 Hands: The palm of the hand is placed over the anterior superior iliac spine and the fingers are wrapped over the ilium. Hands: The fingers of the top hand will con­ tact the posterior surface of the greater trochan­ ter. Execution: The technique begins with a prox­ imal to distal stroking of the muscle (longitudi­ nal stroking).B and 8-53) Purpose: This technique is designed for • sive work in the piriformis. Application of this technique will generally yield an increase in straight leg raising as well as internal rotation. an anterior pressure is applied with the top hand through the greater trochanter. and hamstrings. The technique is generally performed in the midrange of internal rotation and is gradu­ ally moved toward end range. contacting the an­ terior surface of the ilium. As patient tolerance or muscle response dictates. just proximal to the knee joint. Internal rotation gentle inhibition of the lateral rotators of the hip as well as for the hamstrings. The f ingers are in contact w ith the iliacus at the most accessible portion of the insertion. Patient position: The patient is in the supine position. Execution: A gentle internal rotation motion is begun with the bottom hand. This is an excellent preparatory technique for more exten­ Copyrighted Material . Therapist position: The therapist is either standing or seated at the patient's side. The motion is repeated in an oscillatory fashion at a deliberate speed. further facilitat­ ing the internal rotation motion. the stroke is shifted into a cross stroking of the iliacus (lateral to medial). while the bottom hand gently grasps the leg in the area of the distal femur. TECHNIQUES FOR THE LUMBOPELVIC/LOWER QUARTER AREA Greater Trochanter Rocking (Figures 8-52A. Simultaneously.

Therapist position: The therapist stands at the patient's side at the level of the midfemur. room for the quadriceps to contract. 8-55. The technique has a different "look" com­ pared to the muscle play of the erector spinae because of the size of the quadriceps compared to that of the erector spinae.Atlas a/Therapeutic Techniques 199 A Figure 8-52 and straight leg raising should be reassessed after this technique. Transverse Musele Play of Quadriceps (Figures 8-54. Patient position: Supine or sidelying. 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 Copyrighted Material . The "bend­ ing of the water hose" analogy applies in this case.

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At/as a/Therapeutic Techniques 20 I Figure 8-55 Figure 8-56 Copyrighted Material .

The technique may be performed in a medial to lat­ eral direction by moving to the patient's other side and proceeding to shear the quadriceps in a medial to lateral direction. With the elbow pointing upward. Execution: Firmly grasping the distal aspect of the quadriceps with the bottom hand. the surrounding connec­ tive tissue will more readily respond than the iliotibial band. When the area of the greater trochan­ ter is reached. and (3) the iliotibial band itself. 8-59. depending on whether the anterior or posterior border of the iliotibial band is being treated. just proximal to the knee joint. not to slide over the muscle. the stroke fol­ lows the border of the ITB and the hamstring proximally. the direction of the stroke changes and continues paratrochanterically to encircle the greater trochanter. 8-58A. The technique is designed to move the muscle. both hands may be placed over the quadriceps to engage more surface area. The hand does not slide over the skin.202 MYOFASCIAL MANIPULATION Hands: The bottom hand grasps the quadri­ ceps and femur distally. Treatment of this area becomes important to a variety of problems. and 8-60) Purpose: The iliotibial band is an area com­ monly involved in lower kinetic chain prob­ lems. The elbow should point Iliotibial Band Paratrochanteric Mobilization (Figures 8-57A. this includes superior. The therapist's top hand stabilizes the pa­ tient's leg at the knee joint. The other area this technique addresses is the paratrochanteric area. which is more of a massage tech­ nique. (2) the groove between the iliotibial band and the quadriceps. The technique is generally performed in a lateral to medial direction since more restric­ tions seem to occur in the vastus lateralis. In soft tissue mobilization. The thumb and the PIP of the index finger con­ tact one another and become the point of con­ tact with the patient.B. Hands: The hand position described previ­ ously in Figure 8-2 is used in this technique. the top hand shears the quadriceps from lateral to medial over the femur. and mobilization of the restriction does not depend on arthrokinematics. arthrokinematic rules must be fol­ lowed. however. The thumb and PlP of the bottom hand contact the groove between the iliotibial band (ITB) and the hamstring distally. Many diffuse "referred pain" syn­ dromes in the lower extremity can be traced to iliotibial dysfunctions. and posterior to the greater trochanter. and hip and low-back dysfunction. inferior. Therapist position: The therapist stands at the patient's side at a slight angle to the patient. be exquisitely tender over the area of the ilio­ tibial band and surrounding tissues when other dysfunctions are symptomatic nearby.B. but with the foot on the treatment table. This technique actually addresses three dis­ tinct areas: (I) the connective tissue "groove" between the iliotibial band and the hamstring. The execution of the technique is the same in either position. The main difference between soft tissue mo­ bilization and joint mobilization is that in joint mobilization. Many times the patient wi II up toward the ceiling for the best mechanical advantage in applying the technique. restrictions Illay occur in any plane and at any depth. The connective tissue surrounding the greater trochanter is also often dysfunctional. The technique may also be performed in diagonal planes if a restric­ tion occurs in that plane. the patient is asked to flex and adduct the hip and to hold the position to place the posterior hip in a more stretched position. even if the patient has no conscious awareness of pain in the area. The top hand palm is placed laterally over the vastus lateral is . (2) Anterior border of Copyrighted Material . knee dysfunction. Alternately. The force is applied through the palm of the hand. (2) In a more aggressive form of the technique. anterior. Patient position: (I) Patient lies supine with the hip and knee flexed. Execution: (I) Posterior border of iliotibial band. Because loose irregular connective tissue is the most easily mobilized. The top hand grasps the quadriceps anywhere on the muscle belly where a restric­ tion is identified.

Atlas o/Therapeutic Techniques 203 A Figure 8-57 Copyrighted Material .

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The above techniques may be repeated with the patient holding the leg in hip flexion and adduction to stretch the posterior elements of the hip.Atlas afTherapeutic Techniques 205 Figure 8-59 Figure 8-60 the iliotibial band. and restricted posterior hip connective tissues. Hold-Relax Stretch of Hip (Figure 8-61) Purpose: The purpose of this technique is to stretch the posterior hip capsule and surround­ ing periarticular soft tissues. Both hands may also be used to stroke directly over the [TB. The elbow contacts the ITB and the stroke proceeds from distal to proximal di­ rectly over the ITB and greater trochanter. The therapist's bottom hand stabilizes the patient's leg at the knee joint. again until the greater trochanter is reached. A typical patient presentation is a middle-aged man with a flat­ tened lumbar ordosis. With little pelvic contri­ bution to forward bending. The stroke continues over the anterior border of the greater trochanter. the lumbar spine becomes progressively more hypermobile and symptomatic. Facet as well as disc degeneration may result as a long-term effect. hypermobile lumbar facet l joints. With the elbow pointing upward. encircling the greater trochanter and ending posteriorly. (3) Direct technique over the iliotibial band. The focus of treatment lies in establishing a balance between Copyrighted Material . the stroke follows the border of the ITB proximally. The therapist's bottom hand stabilizes the patient's leg at the knee. and for greater access to the ITB proximally. tight hamstrings. The thumb and PIP of the top hand contact the groove between the iliotibial band and the quadriceps distally.

The leg is grasped with the bottom arm. The patient's leg is placed so it is in contact with the therapist's chest. Patient position: The patient is in the supine position with the hip flexed and adducted. The therapist stabilizes the pelvis at the ASJS with the top hand. A possible explanation is that the anterior capsule may be pinching with the extreme amount of flexion being applied to the hip. or one hand can grasp the patient's leg for added stability.206 MYOFASCJAL MANIPULATION Figure 8--61 the low back and the hip in forward bending. "strapping" the patient to the table. Therapist position: The therapist stands over the patient. Hands: Both hands are grasping the treatment table 011 Execution: With the patient in the therapist's firm grasp. and adducted with a slight externaI rotation component. the patient will complain of anterior hip pain while the tech­ nique is being executed. The addition of ex­ ternal rotation and the increase in adduction will compensate for the loss of flexion and regain the tissue tension lost with the loss of hip flexion. Paratrochanteric mobi­ lization will prepare the tissue for aggressive stretching. either side of the table. Copyrighted Material . facing the patient. The knee should approximate the thera­ pist's axillary or pectoral area. the patient is asked to push the leg into the therapist's chest. The technique of choice to prepare the tissue for this procedure is the paratrochanteric tech­ nique described above. Occasionally. An alternate execution of the technique is to bring the hip out of extreme flexion and to emphasize the technique's adduction com­ ponent. To accomplish greater movement balance." moving the hip into further flexion-adduction. The patient is then asked to release the contraction and the therapist "takes up the slack. the peri­ articular structures of the hip must be mobil ized before movement reeducation can begin.

the hip may be flexed beyond 90 degrees. and 8-65A. the elbow may be used to apply a sustained pressure on the restriction. specific restrictions may be released and flexibility of the hamstrings may be increased prior to stretching. If a specific restriction is identified.Atlas a/Therapeutic Techniques 207 Hamstrings (Figures 8-62. Therapist position: The therapist is seated on the treatment table facing the patient. Longitudinal Stroking Hands: Contact with the patient is made with the "fist" (i. Splay Technique Hands: The hands gently grasp the middle aspect of the lower extremity so the thumbs are Figure 8-62 Copyrighted Material . and rest­ ing over the shoulder of the therapist. If the restriction lies in the proximal hamstring near the ischial tuberosity. The hamstrings may be restricted in a longitudinal direction. By identifying and treating lesions in the appro­ priate plane and position. distal to proximal to the insertion at the ischial tuberosity. The hamstrings are stroked longitu­ dinally.e. The pressure should be sustained for an appropriate period until changes in the restriction are palpable. Patient positioll : Supine with the hip and knee flexed approximately 90 degrees. firm pressure is applied with the fist or elbow to the distal aspect of the hamstrings.B. with the MCP joints of the hand)..B) Purpose: The purpose of these techniques is to mobilize the hamstrings in preparation for aggressive stretching technique. or until it is obvious that no change is going to occur. 8-64. or in a diagonal plane. Execution: With the patient's leg relaxed over the therapist's shoulder. Contact is first made on the distal aspect of the hamstrings. or with the elbow. The stroke should be stopped when the restricted area is reached. 8-63A. medial lateral direction.

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As the distal portion of the hamstrings is reached. Rather." where the injury is in the tenoperiostial junction. Execution: The therapist first performs a straight leg raise until the patient feels a mild hamstring stretch. Patient position: Supine. the thumbs are grasping the muscle bel­ lies and pulling them apart. The thumbs do not slide over the hamstring muscle bellies.AlIas o/Therapeutic Techniques 209 Figure 8-64 in contact with the distal portion of the ham­ strings. Hamstring injuries generally fall into two basic categories: mid belly injuries and proximal inju­ Copyrighted Material . The thumbs approximate one another at the medial aspect of the lower extremity. The patient's leg is placed comfortably on the therapist's shoulder. The proximal injury can some­ times act similar to an "epicondy litis. By isolating a stretch to the proximal hamstring. as the hamstrings are stroked longitudinally from proximal to distal. Proximal injuries can be more serious. and more difficult to treat than mid belly lesions. Execution: Deep pressure is applied medially by the thumbs. with the leg resting on the therapist's shoulder. This technique can be thought of as a specific form of muscle play for the distal hamstrings. The patient is then asked to Stretch of Proximal Hamstring (Figure 8-66) Purpose: The purpose of this technique is to isolate a stretch of the proximal hamstring. This will help to provide a traction force and control the amount of knee flexion. the therapist can more effectively aid in the remod­ eling of the proximal tissues. ries. more recurring. Therapist position: The therapist stands on one leg and places the other leg on the treatment table. the stroke direction changes to medial/lateral. Hands: The therapist places his/her hands around the knee of the patient. splay­ ing or pulling the hamstrings apart.

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. a slight traction force can be placed on the leg while stretching. just distal to the ischial tuberosity. The process is repeated until the stretch is felt closest to the origin at the ischial tuberosity. Hands: The f ingertips or the tips of the thumbs may be used for this technique. At this point. T herapist position: Standing over the patient in a diagonal position. If the stretch is felt in the distal or mid belly of the hamstring. The most stable position of the hands for application of the technique is the four-finger position previ­ ously described in the iliac crest technique. Healing and restoration of proper function may be facilitated with a deep cross­ frictional type of mobilization over this area. the therapist con­ tinues to tlex the hip until the patient again feels the stretch. allowing the knee to flex slightly more.AlIas afTherapeutic Techniques 211 Figure S-66 localize the stretch. Patient position: Prone. The same medial to lateral movement is applied over the ischial Cross-Friction Ischial Tuberosity-Greater Trochanter (Figure 8-67) Purpose: Many hamstring injuries and/or dysfunctions occur at the junctional zone (i. The traction serves to pull slightly more on the origin of the muscle at the ischial tuberosity. Copyrighted Material . To further localize the stretch. The thera­ pist repeats the process. the therapist allows the patient's knee to bend slightly. The fingers are os­ cillated medial to lateral consistent with the concept of cross-friction. The periosteum of the ischial tuberosity may be also damaged or dy sfunctional. the insertion of the hamstrings into the ischial tuberosity). Keep­ ing the slight bend constant.e. The f ingers are then moved proximally onto the ischial tuberosity. and then tlexing the hip further. Execution: The fingers palpate deeply unti I firm pressure is placed on the hamstring inser­ tion and junctional zone. The fingers are placed over the insertion of the ham­ strings. the patient should feel the stretch more proximally because the distal aspect has been slackened and the proxi­ mal aspect has been further stretched.

an osci lIatory motion is per­ formed repetitively in an anterior direction. the lower extremity is grasped with the bottom hand. The hip may be held or positioned in the extended position in order to add tension to the tissue. Both index and ring fingers approximated together provide the stability necessary to perform a technique at this depth. If the therapist chooses to extend the hip manually (as opposed to positioning the hip with pillows). leav­ ing the top hand free to execute the technique. The pressure is exerted through the fingertips. In order to apply tension to the fascial sheath. Patient position: The patient lies in the prone position. but may create hip or lumbar dysfunctions if not exten­ sible. with a slight horizontal component. Since the greater trochanter moves an­ teriorly with hip extension. the Fascial Plane between Ischial Tuberosity and Greater Trochanter (Figures 8-68 and 8-69) Purpose: A fascial plane or connective tissue sheath exists in the area between the ischial tu­ berosity that.212 MYOFASCIAL MANIPULATION Figure 8-67 tuberosity. may limit hip ex­ tension. Therapist position: The therapist stands over the patient in a diagonal position. when restricted. The area is not usually painful and rarely tender. Execution: The direction of force is primarily in a posterior to anterior direction. Copyrighted Material . This technique should be applied ag­ gressively to the point where it is seminoxious to the patient. If the lower extremity is not held by the therapist. Hands: The hand position described in the iliac crest release technique is used. restrictions in this fascial sheath may limit hip extension. As in the iliac crest re­ lease technique. both hands should be used in executing the tech­ llIque.

The thumb is placed in the soft tissue above the lateral aspect of the greater trochanter. As the rotation occurs. the thumb does not move. Patient position: Prone. Execution: Once in position. The superior border of the greater trochanter is palpated by gently internally and externally rotating the leg with the bottom hand. Therapist position: The therapist stands at the patient's side at the level of the hip. Friction of Piriformis Insertion (Figure 8-70) Purpose: This technique helps prepare the piriformis for direct contact on the muscle belly if the piriformis muscle is reactive and cannot tolerate direct pressure. or if direct pressure is not resulting in any palpable changes or changes in symptoms. Hands: The bottom hand grasps the leg at the ankle and bends the knee to 90 degrees. The promi­ nence is the superior border of the greater tro­ chanter. the thumb will come on and off the greater trochanter. A fairly deep pressure is ap­ plied. As the hip is gently internally and externally rotated. the thumb moves distally until arrival at the first bony prominence. thumb of the top hand is placed on the superior border of the greater trochanter. Following the technique. The technique is applied by midrange and pain-free rotation of the hip. but only to patient tolerance. the hip may be stretched into extension as a fol­ low-up technique. The Copyrighted Material . Care must be taken not to take the hip into excessive internal rotation if the piriformis is very reactive.Atlas a/Therapeutic Techniques 213 Figure 8-68 Figure 8-69 hip may be extended by the therapist or posi­ tioned on pillows.

cannot deny the involvement of the piriformis or manifestations of piriformis hypertonicity. and secondari Iy to affect con­ nective tissue. but piriformis involvement related to otber dysfunc­ tions is seen quite often. but the average clini­ cian. The tech­ nique is primarily designed to decrease underly­ ing muscle tone. The clinical reality is that "piri­ formis syndrome" in a pure sense is rare.2 J4 MYOFASCIAL MANIPULATION Figure 8-70 Piriformis Release in Prone (Figures 8-71. The technique is performed in a graded fashion depending on the overall pain and reactivity of the piriformis muscle. 8-72. Figure 8-71 Copyrighted Material . in practice. 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 issue is raised here whether the "pirifor­ mis syndrome" exists or not. Some say that the syndrome does not exist.

Atlas ojTherapeulic Techniques 215 Figure 8-72 Figure 8-73 Copyrighted Material .

even partially.216 MYOFASCIAL MANIPULATION Patient position: Prone. and (3) PIP joints of both (I) Using the palm of the hand. The same principle ap­ pi ies in that as the piriformis releases and as the pain decreases. (2) The same sustained pressure may be applied to the piriformis using the elbow. If the piriformis releases. a gentle oscilla­ tory motion can be performed to inhibit further and mechanically mobilize the piriformis. Figure 8-74 Copyrighted Material . As the piriformis relaxes. If the patient is able to tolerate it. The pressure is gently increased until the level of the piriformis is reached. provided the pressure does not create an increase in tone. Execution: tolerance will increase. The gen­ eral progression of the technique goes through three different hand positions: hand. the therapist applies gentle pressure at mid but­ tock. perpendicular to the patient. (I) palm of the (3) Finally. Therapist position: The therapist stands at the patient's side. Hands: The hand position in the technique will vary depending on the reactivity of the muscle and the tolerance of the patient. (2) elbow. more pressure can be progressively applied. The elbow allows for more localized pressure to be applied. the PIP joints of both hands may be used to apply even more localized pressure. which is the general location of the mid belly of the piriformis. the patient Transverse Muscle Play of Hamstrings (Figures 8-74 and 8-75) Purpose: As described for the quadriceps. hands. A sustained pressure is applied. The leg is gently exter­ nally rotated to put the piriformis on slack. allowing the next varia­ tion of the technique. the concept of transverse muscle play can be used to mobilize the fascial sheath surrounding the hamstrings to provide more space for the hamstrings to contract. more pressure can be applied.

The hand does not slide over the skin. the force may be applied in a poste­ rior to anterior direction. and the technique direc­ tion should be modified to treat the restriction adequately. with major force being appl ied through the palm of the hand. This is an excellent preparatory technique for adductor stretching. The technique may also be performed in a medial to lateral direction if the restriction is present in that direction. Remember. Therapist position: The therapist stands at the patient's side at the level of the mid femur. Therapist position: The therapist stands at the patient's side. Hands: The bottom hand grasps the ham­ strings and femur distally. Execution: Grasping the distal aspect of the hamstrings with the bottom hand. Transverse Muscle Play of Adductor Muscles (Figure 8-76) Purpose: As previously described in concept. Patient position: Prone. The palm of the hand is initially placed over the lateral hamstring. holding the leg with the knee bent at 90 degrees. restrictions can occur in any direction or plane.Atlas a/Therapeutic Techniques 217 Figure 8-75 Patient position: Prone. the technique is designed to mobilize the sur­ rounding fascial sheaths of the adductor mus­ cles. If a restriction is felt in a posterior-anterior direction in the medial hamstring. Both hands may also be used to gain a greater contact surface. again with the palm of the hand. the top hand shears the hamstrings in a lateral to medial direc­ tion. Copyrighted Material . just posterior to the ITB. just proximal to the knee joint. The therapist should approach the patient from the other side of the table so a medial to lateral force may be applied with the palm of the top hand. The top hand grasps the hamstrings anywhere on the muscle belly where a restriction is identified.

depending Transverse Muscle Play of Gastrocnemius­ soleus (Figures 8-77 and 8-78) Purpose: The fascial sheath surrounding the gastrocnemius-soleus muscle group is mobilized in order to increase extensibility and allow for more efficient contraction of the muscle group. Hands: The bottom hand grasps the distal aspect of the gastrocnemius-soleus muscle group just proximal to the Achilles tendon. Patient position: Prone. The hand does not slide over the skin. the technique may be performed medial to lateral. The top hand grasps the gastrocnemius-soleus muscle group at the level of the muscle where the re­ striction is identified. Therapist position: The therapist stands at the level of mid tibia. Execution: The palm of the hand makes con­ tact with the adductor muscles and partially with the medial hamstring. Pressure is applied toward the treatment table to create the bending move­ ment of the adductors. both hands may be used to attain a more optimal "bend" in the muscle. As before.218 MYOFASCIAL MANIPULATION Figure 8-76 Hands: The palm of the top hand is used to apply the transverse pressure on the adductor group. the top hand shears the muscle from lateral to medial with the palm of the hand. Execution: Grasping the distal aspect of the gastrocnemius-soleus muscle group firmly with the bottom hand. or posterior to anterior. Copyrighted Material . As with the other tech­ niques. Longitudinal stretching is also facilitated after application of this technique. SI id­ ing over the skin modifies the technique into a pure massage technique.

Atlas o.fTherapeutic Techniques 219 Figure S-77 Figure S-78 Copyrighted Material .

The success of the treatment often will depend on whether or not the direction of application was properly identified. Therapist position: Standing or sitting at the foot of the table. especially in ath­ letes participating in baJJistic sports (running. Patient position: Supine. Execution: A small amount of lubrication is used.220 MYOFASCIAL MANIPULATION on the direction of the restriction. The thumb then moves proximally. the wedge will either not be as deep. Figure 8-79 Copyrighted Material . These are adhesions that need to be mobilized.). the knee may be bent. Many lower kinetic chain problems. and the foot placed on the table to allow for slightly more slack in the tissues. Hands: The thumb pushes off the border of the tibia. and also continuing to ap­ proximate the tibia. This technique can be used for both anterior and posterior compart­ mental sy ndromes. depend­ ing on the compartment that is affected." The bony clearing techniques are effective in mobilizing the fascia as it adheres to the tibia. or have adhe­ sions that make the wedge nonexistent. Bony Clearing of the Tibia (Figure 8-79) Purpose: The purpose of this technique is to clear fascia from the anterior and posterior compartments as they adhere to the tibia. In compromised areas. since no arthrokine­ matic rules apply. soccer etc. basketball. For the posterior side. continuing to stay in the wedge. The thumb is positioned either anterior or posterior. The thumb drives a wedge between the bone and the approximating soft tissues distally. The clinician should be sensitive to restrictions and follow them with the technique. creating a "wedge" between the bone and the approximating soft tissue. develop fascial adhe­ sions related to "shin splints.

Atlas o{Therapeulic Techniques 221 Lateral Fascial Distraction of the Tibia (Figure 8-80) Purpose: The purpose of this technique is to stretch the posterior compartment fascia that is adhered to the tibia laterally. pulling it away from the tibia. Execution: The therapist puts a medial to lateral pressure on the gastrocnemius-soleus muscle group. that are caused by ex­ cessive ballistic lower kinetic chain activity. This technique can be quite painful if the fascia along the tibial/gastrocnemius border is compromised. Hands: The lateral hand is placed distally and will be used as a counter lever. keeping an eye on patient reaction. The technique starts in the mid belly. As with the tech­ nique above. etc. Patient position: Prone with the knee flexed to 90 degrees and plantarflexed slightly. this technique will be effective in the treatment of lower leg compartment syn­ dromes. shin splints. The therapist carefully attempts to push the muscle laterally into the plastic range. The palm of the medial hand is placed on the mid belly of the gastrocnemius-soleus muscle group as close to the tibia as possible without actually contacting it. Therapist position: Seated on the side of the table at the patient's lower leg. This phenomenon Figure 8-80 Copyrighted Material . depending on the loca­ tion and severity of the restriction. Cross Friction of the Gastrocnemius-soJeus Musculotendinous Junction (Figure 8-81) Purpose: Many patients involved in ballistic type sport activities develop fascial thickening in the musculotendinous junction of the gastroc­ nemius-soleus muscle group. but can move proximal or distal.

222 MYOFASCIAL MANIPULATION Figure 8-8\ may occur with or without muscular shortening. Again. Hands: The hands gently grasp the lower leg so that the f ingers come to rest directly over the musculotendinous junction of the gastrocne­ mius-soleus muscle group. watching for patient response. this is to create slack and allow for access to deeper tis­ sues. the clinician emphasizes both the anterior and posterior structures of the upper thoracic Copyrighted Material . I ni­ tially. This area can be exquisitely tender in active patients participating in ballistic type sporting activities. Therapist position: Seated at the side of the table at the lower leg of the patient. and 8-85) Purpose: The purpose of this technique is elongation of the soft tissue structures of the upper thoracic area (posterior and anterior). 8-84. This technique should be used before attempting postural reeducation techniques. The technique is especially applicable for patients with protracted shoulder girdle complexes and forward-head postures. Patient position: Prone with the knee flexed to 90 degrees and the foot plantarflexed moder­ ately. Execution: The therapist applies firm pres­ sure over the musculotendinous junction with the fingers and applies a firm cross frictional movement across the junction. A stretch can immediately follow the ap­ plication of this technique. The purpose of this technique is to mobilize the musculotendinous junction and the fascia immediately surrounding it. the shoulder girdle and upper tho­ racic spine assume a more relaxed and retracted position. After application of the technique. TECHNIQUES FOR THE THORACIC/UPPER THORACIC SPINE AND UPPER EXTREMITY Lateral Elongation of Upper Thoracic Area (Figures 8-82. Note that the tissue is held in the shortened range. 8-83.

Techniques 223 Figure 8-82 Figure 8-83 Copyrighted Material .A tlas a/Therapeutic.

Three alternate hand placements are described. even though Figure 8-85 contact is maintained through the palm of the Copyrighted Material . Anterior-Posterior Techl1ique Hands: One hand is placed posteriorly. each of which progresses into deeper tissues of the anterior chest. As the technique progresses. with the fingertips just lateral to the ster­ num. 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. The other hand is placed infraclavicu­ lariy. Execution: The primary force of the tech­ nique comes from the fingertips. 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.224 MYOFASCIAL MANIPULATION Figure 8-84 area. more empha­ sis is placed on the anterior structures. at a 45-degree angle to the patient.

The stroke begins medially and pro­ gresses laterally. Unilateral Posterior/Anterior Articulation of First Rib (Figure 8-86) Purpose: This technique is technically a joint mobilization technique. Deep Anterior Technique Therapist position: Standing. The fingertips are just lateral to the sternum. One hand is placed over the other.) the glenohumeral joint. Execution: The stroke begins medially in the intercostal space of the I st and 2nd ribs. Execution: The stroke is applied through the fingertips from medial to lateral.Atlas afTherapeutic Techniques 225 hands. facing the pa­ tietH. Deeper pres­ sure is applied through the hands and f inger­ tips. Once the stroke is completed. The stroke is performed in intercostal space of ribs 2 and 3 (in men in the intercostal space of ribs 3 and 4). but blends in well with the above techniques. The intercostal space is followed finger as shown in Figure Hands: To approximate deeper structures. The depth of penetration is to the intercostal spaces. the hands are quickly placed in the start position again and the stroke is repeated. Rib Splaying: Ribs 1-3 (This aspect of the technique is the most aggressive laterally until no longer palpable (a short distance). Hands: Contact will be made with the thumb and PIP of the index 8-2. both hands are placed anteriorly. again over the infracla­ vicular area. The pressure is placed through each hand and is moderate in depth. as the therapist pulls the hands toward form. especially if rib dysfunc- Figure 8-86 Copyrighted Material .

This bone is the first rib. and the scalenes. T h erapist position: The therapist is seated at the head of the table. although the first rib is being gently articulated. Hands: The bottom hand (which is usually the hand closest to the patient) palpates the pos­ terior aspect of the first rib near the costotrans­ verse junction. First Rib Shoulder Depression Technique (Figure 8-87) Purpose: This technique is largely inhibitory in nature. The rate of oscillation should be 2 to 3 oscillations per second. The clinician then continues caudally and medially until bone is palpated. If the finger is too lateral. With increased myofascial tone in the subclavicular area. Patient position: The patient lies supine with the head flat on the treatment table. joint mechanics in the first rib can easily become dysfunctional. Enough pressure should be applied to create movement in the first rib. which is just lateral to the first sterno­ costal junction. if the finger is too medial. Execution: The clinician applies a moderate oscillatory movement anterior/posterior and posterior/anterior. but to increase mobility. the upper thoracic area. The top hand palpates just lateral to the first sternocostal articulation. the spinous process will be palpated. The clinician may first palpate the sternoclavicular junction with the middle finger and slip the finger just caudal and lateral.226 MVOFASCIAL MANIPULATION tion is present. at a 45-degree angle to the patient. the border of the scapula is palpated. This can be accomplished by first palpating the posterior aspect of the upper trapezius. The purpose of th is technique is not to change the position of the first rib. The rhythm created by the rib and Figure 8-87 Copyrighted Material .

and may spontaneously relax. During execution. (2) with the other hand. Execution: Execution of this technique in­ volves two separate movements occurring si­ multaneously: (I) With the bottom hand. and can indicate to the clinician and patient the degree of inherent relaxation or tension in the upper thoracic area. Patient position: The patient lies supine with spinous process will be palpated. The tissue is then prepared for other techniques at the head of the table at a 45-degree angle to the patient. This bone is the f irst rib. Bilateral Upper Thoracic Release (Figure 8-88) Purpose: The purpose of this technique IS to release the deep paravertebral musculature Figure 8-88 Copyrighted Material . preparing the tissue for deeper or more specific my ofascial work. The two motions occur simultaneously in a slow de­ liberate rhythm (approximately the head flat on the treatment table. the clini­ cian then continues caudally and medially until bone is palpated. and if the finger is too medial. Therapist position: The therapist is seated 2 oscillations per second). and facilitates joint mobilization and manipulation. the shoulder is depressed caudally. the rib is articulated anteriorly. This subtle form of biofeedback releases tone in the upper thoracic area. the patient may become aware of increased tone. If the finger is too lateral. Hands: The hand closest to the patient pal­ pates the posterior aspect of the first rib as de­ scribed in the previous technique. the border of the scapula is palpated. the as necessary. Palpating the posterior aspect of the upper trapezius. tension. The other hand is placed on the superior aspect of the shoulder joint complex.Atlas a/Therapeutic Techniques 227 shoulder articulation provides a form of bio­ feedback for the patient. or holding patterns.

the pectoralis major and minor become restricted and shortened. Execution: The first maneuver is a gentle ce­ phalic-caudal oscillation with moderately deep pressure on the upper thoracic paravertebrals. Hands: The hands slide onto the paraverte­ bral musculature of the upper thoracic spine (to approximately T4). This creates an inability to stand or sit erect without significant effort from the Figure 8-89 Copyrighted Material . While this Jlla y be considered anterior/posterior Jllobilization of the upper thoracic spine. The f ingers make firm contact with the paravertebral musculature. and reduce the potential effect of the technique. Efficiency and ease of ap­ plication of technique are essential for effective technique delivery. Patient position: The patient is supine with the head flat on the table. and 8-91) Pectoralis Major Purpose: In the forward-head posture.228 MYOFASCIAL MANIPULATION of the upper thoracic spine. The first is a moderate depth. the direction of the movement changes from cephalic-caudal to anterior articulations. and the second is a deep anterior/posterior movement. The technique is accomplished in two distinct maneuvers. The clini­ cian should exercise caution in guarding his or her hands. Fatigue will occur quickly and the clinician should proceed to another technique. cephalic-caudal move­ ment. the firm pressure applied through the layers of muscle onto the deep muscle provides adequate force to release deep underlying tone. 8-90. The oscillations should be performed at a rate of approximately 2 per second. since this technique requires max­ imum force through the fingers. Any strain or inefficiency on the clinician's part will be transferred to the patient. In the second ma­ neuver. Therapist position: The therapist is seated at the head of the table directly behind the patient. Pectoralis Major Muscle Play-Pectoralis Minor (Figures 8-89.

Atlas o[Therapeufic Techniques 229 Figure 8-90 Figure 8-91 Copyrighted Material .

The pectoralis muscle is grasped firmly between the thumbs and fingers and is gently lifted or bent away from the thorax. Patient position: The patient is in the supine position. and a gentle "cross-friction type" technique may be performed. The muscle may be difficult to palpate. the muscle is being palpated. Care must be taken because the pectoralis minor area is very tender even if not dysfunctional. and the hands grasp the muscle firmly between the thumbs and f ingers. with hands behind head.230 MYOFASCIAL MANIPULATION patient. Execution: The thumbs are pressed onto the pectoralis minor. minor) to allow for more erect posture. pectoralis major. Hands: The thumbs slide underneath the pec­ toralis major. Execution: The technique can be likened to the garden hose analogy in which a garden hose is being bent. Therapist position: The therapist is standing over the patient at a 45-degree angle to the pa­ tient. Pectoralis Minor Hands: With one hand maintaining the same position as described above. Seated Pectoral Anterior Fascial Stretch (Figures 8-92 and 8-93) Purpose: The purpose of this technique is to stretch the anterior structures (fascia. Patient position: Seated. Figure 8-92 Copyrighted Material . The therapist may place a leg on the table to allow the patient's arm to rest in a relaxed position. the pectorals must have adequate extensibility. Before postural reeducation can occur effectively. The shoulder is flexed 90 to 120 de­ grees. or with elbows straight. The movement can be a sustained movement or an oscillatory movement. but if the ribs are palpable. the thumbs are moved posteriorly until in contact with the pec­ toralis minor.

the patient's arm is pulled posteriorly and superiorly. Unilat­ eral Stretch: The inside hand of the therapist grasps the upper part of the patient's arm. stretching the anterior fascia. Hands: Bilateral Stretch: The hands will grasp the middle part of the upper arm.Atlas afTherapeutic Techniques 23 I Figure 8--93 Therapist position: The therapist is standing behind the patient with either his or her hip or knee stabilizing the thoracic spine and acting as a fulcrum. outside hand on the rib cage is pushed caudally to further engage the anterior superficial fascia. A pillow should be placed between the patient and the therapist. Subscapularis (Figures 8-94 and 8-95) Purpose: The subscapularis is generally not an area reported by the patient to be painful. however. Since the internal rotators are held in a shortened posi­ tion in the forward-head protracted shoulder posture. Copyrighted Material . The area may be signif icantly restricted and extremely tender to palpation. Unilateral Stretch: Using the inside arm and body. acting as barriers to efficient postural reeducation. Execution: Bilateral Stretch: The pressure is applied in a lateral. posterior. and cephalic direction for maximum elongation. The outside hand is place on the midd Ie part of the antero-lateral rib cage. the subscapularis and the surrounding myofascia become restricted. The patient is asked to breathe deeply to increase elongation anteriorly. The Patient position: The patient is in the supine position with the shoulder flexed from 90 to 170 degrees. depending on the restriction and comfort level of the patient.

at the head of the table at a 45-degree angle to the patient. being located on the anterior surface of the lateral border of the scapula. which is in some degree of flexion. As gentle distraction is placed on the arm. The patient's arm is grasped by the therapist close to the therapist's body to provide a slight traction-distraction force. (3) finally. the stroke may be lengthened to include the lateral fascial sheaths between the scapula and the ilium. Execution: (1) The patient's arm. Copyrighted Material . middle. The pressure may be sustained or slow oscillatory in nature. as close to the glenohu­ meral joint as possible. The palm of the hand. or the fingertips may be used in order from least aggressive to most aggressive. the palm strokes caudally and toward the inferior angle of the scapula. specific restrictions. and ring f ingers palpate the anterior surface of the lateral scapula and gentle pressure is applied. is gently distracted. the thumb is used to stroke caudally.232 MYOFASCIAL MANIPULATION Figure 8-94 Figure 8-95 Therapist position: The therapist is standing If fascial restrictions exist. the thumb. The tips of the index. The palm of the other hand is placed on the lateral border of the scapula. (2) In the same position. Hands: The hands may be placed on the pa­ tient in three different ways. The arm is again distracted and the thumb moves caudally over the anterolateral border of the scapula toward the inferior angle. Thumb placement is more spe­ cific. either in the lateral aspect of the subscapularis or in the fas­ cial sheath between the scapula and the thorax. depending on how aggressively the therapist wishes to deliver the technique. may be treated using the f ingertips.

Atlas a/Therapeutic Techniques 233 Anterolateral Fascial Elongation (Figures 8-96 and 8-97) Purpose: The anterior fascial planes are often restricted. a traction force is applied to the superficial fascia. The shoulder should be in as much flexion as possible to allow for maximal stretch of the connective tissues. The direction of the force may be changed. stands The therapist Figure 8-96 Copyrighted Material . Patient position: The patient is in the sidely­ ing position with the spine in Therapist position: behind the patient.) Execution: As the arm is tractioned into flex­ ion. Hands: The entire surface of the hand is placed just below the nipple line. and directed more diagonally toward the contralat­ eral ASIS or into a more cardinal plane direc­ tion toward the ipsilateral ASIS. Anterolateral Fascial Elongation with Rotational Component Purpose: If the myofascia is restricted modified as follows. with the shoulder flexed 120 to 170 degrees. (Note: Male therapists treating female patients should care­ fully drape the patient and should stay well below breast tisslle. first in the direction of the umbiliclls. Hands: In the same position as described above. Therapist position: The therapist stands behind the patient. the above technique may be rotated position. The purpose of this technique is to elongate the superficial fascial sheaths of the anterior thorax. especially in the slumped posture or in various shoulder pathologies. The use of skin lubricants for this technique is discouraged. Patient position: The patient is in the supine position. Execution: The therapist distracts the shoul­ der and simultaneously provides a rotational a 10 a rotational direction. grasping the patient's arm and providing a distraction of the arm.

Alternately. and certain shoulder problems. Patient position: The patient is in the sidely­ ing position with a pillow between patient and therapist. cervical problems. These techniques should routinely be performed on scapulothoracic prob­ lems. The myofascia of the anterior chest. and 8-102) P urpose: This technique is designed to mo­ bilize myofascial restrictions on all three bor­ ders of the scapula. Upper Border Hands: The fingertips of both hands are placed over the upper trapezius muscle medially at the cervicothoracic (CT) junction.234 MYOFASCIAL MANIPULATION Figure 8--97 force on the spine. pillow. The other hand. problems of the upper thoracic and mid­ thoracic spine. and therapist. The patient's arm should be resting comfortably on the pillow. 8-99. between the scapula and the thoracic spinous processes. Execution: The shoulder is slightly retracted to slacken the tissue. 8-100. Therapist position: The therapist stands facing the patient with the pillow pressing against the body. the therapist may be at the head of the table and Copyrighted Material .8-101. Medial Border Hands: The top hand is lightly placed on the Scapular Framing (Figures 8-98. the fingers of the bottom hand stroke from cephalic to caudal along the length of the medial border of the scapula. and abdomen will be effectively stretched in this position. As the shoulder is being retracted. is moved toward the umbilicus or the contralateral ASIS. axilla. shoulder and the bottom hand is placed just off the medial border of the scapula. There should be a "snug" fit between the patient. which is positioned on the anterior myofascia.

Atlas a/Therapeutic Techniques 235 Figure 8-98 Figure 8-99 Copyrighted Material .

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Specific finger pressure may be ap­ plied if trigger points or restrictions are found. from the CIT junction to the glenohumeral joint). the scapula may be mobilized off the thoracic cage. This flexes the shoulder and tightens the myofascia in the lateral border of the scapula.e. LateraL Border ing position but is asked to grasp the top of the treatment table with the hand. Scapular Mobilization (Figures 8-103 and 8-104) P urpose: Once the scapular soft tissues have been prepared from the previously described technique. Pa­ tient position: The patient remains in the sidely­ Copyrighted Material . The technique may continue toward the ilium if fascial restrictions are encountered. Execution: As the patient holds the treatment table.. A gentle stretch is applied with the palms of the hand as the scapula is stroked. Execution: With the bottom hand stabilizing the shoulder. Hands: The palm of the bottom hand is placed over the shoulder joint to stabilize the area. the f inger­ tips stroke the upper border of the scapula and upper trapezius muscle from proximal to distal (i. The palm of the top hand is placed over the lateral border of the scapula. the palm of the top hand strokes the lateral border of the scapula caudally with firm pressure. the palm of the therapist's top hand firmly strokes the lateral border of the scapula caudally. and the patient's arm resting comfortably on the pillow.Atlas afTherapeutic Techniques 237 Figure 8-102 apply a caudal force. 'Execution: With firm pressure. gently stretching the upper trapezius. This allows for more aggressive stretching of the scapulothoracic myofascia. Patient position: The patient is in the sidely ­ ing position with a pillow between the patient and the therapist. ALternate Teclllliquefor LateraL Border.

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to a certain extent the joints. The fingers of the bottom hand slide onto the undersurface of the scapula. into a rotational direction. The fin- Figure 8-105 Copyrighted Material . Therapist position: Standing facing the pa­ tient with a pillow between therapist and pa­ tient.Atlas a/Therapeutic Techniques 239 Therapist position: The therapist stands at of the scapula. This technique is successful with pa­ tients who are larger in size than the therapist. (2) In the alternate technique. resulting in an aggressive stretch of the scapulothoracic myo­ fascia. the patient's side. the scapula and shoulder girdle complex is lifted off the thoracic cage. Execution: (I) Once the fingers of the bottom Thoracic Rotational Laminar Release (Figure 8-105) Purpose: Previous techniques emphasize the scapulothoracic and scapulohumeraI relation­ ships and musculature. Patient position: The patient is in the sidely­ hand have grasped the medial border of the scap­ ula. Hands: The top hand is placed over the ante­ (2) With both hands grasping the medial border rior aspect of the glenohumeral joint. Hands: Two variations of this technique may be pelformed: (I) the top hand grasps the shoul­ der joint anteriorly. and the therapist's shoulder stabi­ lizing anteriorly. This technique pene­ trates to the depth of the paravertebral muscles. ing position similar to the position described above. The shoulder and chest of the therapist contact the patient's shoulder anteriorly for stability. the scapula is lifted off the tho­ racic cage. The top hand also contacts the scapula so the fingers can slide onto the undersurface of the scapula. mobilizing the muscles and. This technique succeeds if the patient is smaller than or equal in size to the therapist. the bottom hand slides under the arm and around the scapula until the fingers can slide onto the scapula's under­ surface.

and medial if the technique is going medial to lateral. Certain proximal humeral fractures cause the binding down of the biceps. Once the tissue is at the end Figure 8-106 Copyrighted Material . Certain low grade peripheral entrapment neuropathies respond well when the biceps is stretched medial to lateral. and this technique will be beneficial for this type of condition as well. biceps in preparation for stretching or strength­ ening. If segmental restrictions are felt as the technique is being performed.240 MYOFASCIAL MANIPULATION gers of the bottom hand are placed in the scapu­ lothoracic area similar to the medial scapular framing described above. Transverse Fascial Stretch of the Biceps (Figure 8-106) Purpose: The purpose of this technique is to increase the medial/lateral mobility of the Execution: The heel of the hand pushes the biceps in a transverse direction (lateral to medial or medial to lateral) until all the "slack" is taken out of the muscle. the fingers of the bottom hand stroke cephalic to caudal with deep pres­ sure. the stroke may be stopped and the restricted segment may be oscillated into rotation. Execution: The primary distinction between this technique and medial scapular framing is in the depth of penetration and the rotational component imparted to the thoracic spine. Patient position: Supine. Hands: The heel of the hand is placed lateral to the muscle if the technique is going lateral to medial. To execute the technique. while the top hand is retracting the shoul­ der complex and rotating the thoracic spine. Therapist position: The therapist will be out­ side the patient's arm if the treatment goes from lateral to medial. The fingers act as a fulcrum of rotation for the thoracic spine. and inside the patient's arm if the technique is applied medial to lateral. This seems to free up the nerves as they pass through just posterior and medial to the biceps.

About the time the patient begins to feel a stretch.A lias of Therapeutic Techniques 241 of the elastic range. If an area is particularly tender. the therapist pushes into the plastic range to get the final stretch. Biceps Stretch (Figure 8-107) Purpose: The purpose of this technique is to apply a focused stretch of the biceps muscle. forearm. it is difficult to tell when the biceps muscle/tendon is in a plastic stretch. just proximal to the wrist. The therapist should ask the patient to tell when a moderate stretch is felt. At the same time the elbow is Forearm "Ironing" (Figure 8-108) Purpose: As previously described for the lumbar erector spinae. Execution: The therapist gently extends the patient's shoulder. While not shown. the arm is released and the stretch may be repeated. Therapist position: The therapist is seated level with the patient's neck or shoulder. After a 5-10 second hold. This technique is effective for a wide array of elbow. The stretch is held 3-5 seconds. or hand dysfunctions. Hands: The top hand is placed over the distal triceps so the fingers and thumb can wrap around the supracondylar space. Figure 8-107 Copyrighted Material . If a less ag­ gressive version of the technique is desired. the "ironing" type tech­ niques are useful to decrease underlying tone and move fluid. The bottom hand is placed on the distal arm. longitudinal stroking is always less painful than cross stroking. wrist. then repeated. a slight traction force is placed on the arm. fully extended and the radioulnar joints are fully pronated. the patient may be placed in the sidelying position to accomplish a lighter version of the stretch. Because of the long lever arm. Patient position: The patient is supine with the shoulder slightly off the table. the technique can be applied to the flexor as well as extensor surfaces of the forearm.

the fingers sl ide prox ima lIy following the wedge created distally. The outside hand is positioned on the distal aspect of the forearm. Lack of a "wedge" or space 8-109) Purpose: Similar to muscle splay of the ham­ string. The pressure is firm. stopping at the elbow. but care must be taken to avoid overuse injury of the thumb. while the index and middle finger find a "wedge" between muscle groups. the therapist wedges in between muscle groups with the index and middle finger (or thumb). but the hand and fingers remain relaxed. the palm of the therapist's hand bears down on the soft tissues and begins to stroke distal to proximal. so the technique feels finn but not painful. Hand position: The inside hand of the thera­ pist gently grasps the wrist and flexes it. Therapist position: The therapist is posi­ tioned at the patient's side. Alternately. their ability to be actively shortened or passively lengthened is enhanced. applying firm pressure. just proximal to the wrist. Execution: Starting distally. the idea is to stroke deeply in the fascial planes separating muscles or muscle groups. The therapist should use some body weight to avoid the technique coming primari Iy from the arm. Patient position: Supine or sitting. Therapist position: The therapist is posi­ tioned lateral to the patient. Hands: One hand flexes the wrist. but the extensor surface may be treated as well. Using a small amount of lubricant. Musc l e Splay ofthe Forearm ( Figure When muscle groups slide more freely on one another. with the wrist slightly flexed (passively).242 MYOFASCIAL MANIPULATION Figure 8-108 Patient position: Supine or seated. Treatment of the flexor surface is shown here. Copyrighted Material . with the forearm on the treatment surface. facing the patient. the thumb can be used. creating greater efficiency of contraction and/or tlex­ ibility. Execution: Using a small amount of lubrica­ tion.

Hands: One hand stabilizes the forearm dis­ tally. and move in the direction of the restriction. Therapist p osition: The therapist stands facing the palm of the patient's hand. The therapist must "think with the hands" to determine where the restrictions are. the flexor mass may be pushed away from or toward the ulna. Patient position: Patient is supine or sitting. Therapist position: The therapist is at the patient's side using the leg to stabilize the pa­ tient's forearm. working longitudinally. Multiple angles can be applied. The therapist should identify and foclls on these areas. This allows the contractile tissues to move more freely in their respective fascial compartments. until the fascial is freed up. For example. the pur­ pose of this technique is to mobilize the fore­ arm musculature in a transverse direction. Palmar Stretch (Figure 8-111) Purpose: The purpose of this technique is to stretch the palmar fascia and the palmar surface of the hand. The brachioradialis may be pushed anterior or poste­ rior. Patient position: Supine.Atlas a/Therapeutic Techniques 243 Figure 8-109 between fibers may indicate fascial adhesions. Copyrighted Material . Transverse Muscle Bending of the Forearm (Figure 8-110) Purpose: Analogous in theor y to previously described muscle bending techniques. The other hand gently grasps the flexor (or extensor) surface of the forearm. The extensor surface can also be moved in either transverse direction. proximal to distal. Execution: The palm of the hand pushes the muscle mass of the forearm firmly in a trans­ verse direction through the elastic range and into the plastic range to encourage permanent deformation of the fascia.

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Execution: The therapist's fingers that are interdigitated. the thumbs can be used to massage the palmar surface of the hand when the stretch is occurring. Hands: The therapist's thenar eminences are placed over the distal forearm and wrist. At the same time. Therapist position: The therapist is facing the palmar surface of the patient's hand. the stretch will also include the wrist flexor muscles. with the middle and ring finger of the therapist in the web space of the patient's hand. Patient position: Supine or sitting. and the thumbs are available for massage during the stretch. Retinacular Stretch (Figure 8-1 ]2) Purpose: Related to the previous technique. the retinacular stretch is designed to open the carpal tunnel in a medial lateral direction. and to increase the extensibility of the retinaculum.Atlas a/Therapeutic Techniques 245 Hands: The hand position is very important in this technique. along with the index fingers. As the therapist's Figure 8-112 Copyrighted Material . If the elbow and wrist are extended. The therapist's fingers are then interdigitated through the patient's fingers. If the elbow is flexed and the wrist is in neutral. A f irm stretch is applied from midline outward to the ulna and radius. the palmar fascia will be localized. Both little fingers of the thera­ pist are placed between the patient's index and middle fingers. Execution: The therapist applies firm pres­ sure into the patient's wrist and distal forearm with the thenar eminences as the fingers apply counter pressure on the dorsal surface of the hand. The therapist's index fingers pull over the patient's hand. open the patient's hand to create a stretch. The fingers are on the dorsal surface of the hand to apply counter pressure.

The concept is that of a dresser drawer that is stuck Figure 8-113 Copyrighted Material . Hands: The fingers are placed over the lower cervical-upper thoracic paravertebral muscles. but to elongate the spine.246 MYOFASCIAL MANIPULATION hands separate. used with superf icial penetration. The idea behind this indirect technique is to take the neck into the di­ rection of restriction. Patient position: The patient lies supine with head flat on the table. As previously def ined. The depth of penetration may gradually be increased with progressive stroking. elongation differs from stJ"etching in that its pur­ pose is not necessarily to lengthen the muscle. Therapist position: The therapist is seated at the head of the treatment table. also has a strong autonomic inhibitive effect. TECHNIQUES FOR THE CERVICAL SPINE Elongation of Paravertebral Muscles (Figure 8-113) Purpose: This is a preparatory technique for other more aggressive myofasciaJ and joint mo­ bil ization techniques. thereby freeing the restric­ tion and allowing greater axial extension. Execution: The technique is executed by lightly stroking the length of the cervical para­ vertebral muscles from upper thoracic to sub­ cranial.) This technique. firm pressure is maintained for maximal stretch. Axial Flexion of the Cervical Spine (Figure 8-114) Purpose: This technique is one of the few described in this text that can be used as either direct or indirect technique. (Recall the analogy of elongating the accordion.

w ith firm pressure being applied at the OA joints bilaterally with the fingertips. This tech­ nique can be divided into two specific compo­ nents. the drawer then becomes free to open. the neck may be axially flexed in the same diagonal plane in an attempt to free lip the restriction. Hands: The palms of the hands cradle the base of the occiput while the fingers contact the lower cervical paravertebral musculature. Execution: The head and neck are brought into a straight axial flexion (moving the head directly toward the ceiling). At this point the technique may be applied more specifically in the area of the OA joint. Therapist position: The therapist is seated at the head of the table. the fingers are moved up a level until they are in contact with the subcranial mus­ culature. With Copyrighted Material . This technique may be used as a direct tech­ nique with the patients who exhibit an axially extended posture. The first is a general axial extension of the cervical spine and the second is specific axial extension at the OA joint. but main­ taining the pressure on the OA joints. The fingers are no longer stroking medial to lateral.Alias o/Therapeutic Techniques 247 Figure 8-114 and cannot be opened. By closing the drawer. While this posture is seen the head flat on the treatment table. The fingers are si­ multaneously stroking the lower cervical para­ vertebra Is in a medial to lateral direction. If a unilateral OA restriction exists. The neck may be axially extended into a diagonal plane to check for unilateral restrictions. The head and neck are again axially flexed. Patient position: The patient is supine with each repetition.

cervicothoracic. Figure 8-115 Copyrighted Material . cervicothoracic. both hands are placed on the paravertebral muscles with the thumbs and PIP of the index finger contacting the patient. If unilateral technique is preferred.248 MYOFASCIAL MANIPULATION less often than the forward-head posture. 8-39. Hands: In the bilateral technique. Supine Purpose: Elongation of the cervical myofas­ cIa. the hands stroke caudally through the midcervical. and 8-115) Silting Purpose: This technique is meant to elongate the cervical paravertebral musculature and to improve cervical forward bending. Therapist position: The therapist is standing behind the patient. the monitoring hand gently guides the patient into a diagonal pattern as the other hand gently strokes unilaterally through the cervical. In the unilateral technique. As the flexion occurs. Patient position: Supine. Patient position: Sitting. tact with the cervical paravertebral muscles. Hands: One hand cradles the head at the oc­ ciput and brings the cervical spine into a for­ ward-bent position. and upper thoracic areas. The other hand makes COI1- Cervical Laminar Release (Figures 8-38. one hand is on the patient's head to monitor the diagonal movement of the patient's head and neck. Execution: The patient is first asked to for­ ward bend the cervical spine segmentally. the technique may be used to move the neck directly into the restriction. and upper thoracic areas. Therapist position: Seated at the head of the table.

Execution: One hand holds the neck statically in the forward-bent position while the other hand strokes gently from approximately midcervical to cervicothoracic junction. Therapist position: Seated at the head of the table. Diagonal Stretch of Cervical Cervicothoracic Myofascia (Figure 8-116) Purpose: This technique stretches the poste­ rior myofascial structures as well as the upper trapezius and levator scapula muscles. The p atient is axially flexing and extending the neck while the occiput is held rigid. Figure 8-116 Copyrighted Material . Hands: One hand cradles and positions the head in a combination of forward bending. as such. The rotation can be to either the same or the opposite side as the for­ ward bending depending on the restriction. and the PIP of the index finger on the other side. other hand is placed firmly on the patient's shoulder. The Manipulation of Subcranial and OA l\1yofascia (Figure 8-117) Purpose: This technique is useful in releas­ ing subcranial myofascia as well as for mobiliz­ ing the OA joints. Patient position: Supine. Patient position: Supine. gentle to moderate pressure is applied caudally on the shoulder while a pressure is applied with the other hand into forward bending. and rotation. and rotation. Execution: With the patient positioned. using the thumb on one side. side bending. The idea behind the technique is stabilization of the occiput and movement of the atlas. may be considered a muscle energy technique. This technique allows patient participation and.ALias o{Therapeulic Techniques 249 bilaterally. side bending.

Masseters-TMJ Decompression (Figure 8-118) P urpose: Prior to any intraoral soft tissue manipulation. Hands: As the patient's head is cradled with one arm and shoulder of the therapist. The patient's head will be cradled by the therapist's arm and shoulder. tempt extraoral soft tissue manipulation in re­ storing mobility of the temporomandibular joint (TMJ). The func­ tional opening may be significantly increased without having to perform intraoral maneuvers. This technique inhibits the masseters. the relaxed mandible will open further and a gentle open­ ing stretch may be applied at the end of the tech­ nique. so the neck is actually moving on the head.250 MYOFASCIAL MANIPULATION Figure 8-117 Therapist position: The therapist may be standing or sitting. the patient is asked gently to axially flex and extend the neck. After several strokes. As the masseters are stroked. the patient is allowed to rest his or her head on the table and the amount of resting axial flexion is reassessed. the clinician should always at­ Copyrighted Material . Execution: With moderate depth of pressure. al­ lowing for a more comfortable and increasingly functional opening of the mandible. middle. the hand f irmly grasps the occiput. The head is not allowed to move. The atlas is allowed to translate anteriorly and posteriorly on a nonmoving occiput. Execution: With the therapist firmly holding the head. the patient is asked to open the mouth in a subtle and relaxed manner as the stroke is being ap­ plied. After several repetitions. Patient position: The patient is supine with the head flat on the treatment table. Hands: The tips of the index. Therapist position: The therapist is seated at the head of the table. the therapist strokes along the length of the l11as­ seters away from the TMJ. The other hand is placed over the hand grasping the occiput as additional reinforcement. and ring f ingers are placed on the masseters just below the temporomandibular joint line.

With the palmar sur­ face of the top hand in full contact over the fron­ talis. This is useful in cases of parieto-occipital headaches or sinus headaches. Hands: One hand gently cradles the occiput. and facial fascias. the technique can be used to inhibit the fronta­ I is muscle or to provide a fascial stretch to the frontal. while the other hand is placed directly over the frontal area of the patient's face. Patient position: Supine. The emphasis of this technique is on the frontal fascial stretch and frontal decompression. a fascial traction is simultaneously applied. nasal. Therapist position: The therapist is seated at the head of the table. Therapist position: Seated at the head of the table. First. The palm of the top hand makes contact with the frontal area. Hands: The bottom gently cradles the base of the occiput. with the ther­ apist's thumb pointing in the direction of the therapist. This tech­ nique is especially indicated for patients with retro-orbital headaches and sinus headaches. Second. the purpose is to stretch the retro-orbital fascia and the fascia around the nasal suture. Patient Position: Supine.Atlas o/Therapeutic Techniques 251 Figure 8-118 Frontal Facial Decompression (Figure 8-119) P urpose: The purpose of this technique i s twofold. Execution: The therapist gives a slight trac­ tion with the bottom hand. the hand position c a n b e used to provide a gentle subcranial traction. Retro-Orbital Decompression (Figure 8-120) Purpose: Related to the previous technique. while the fingers are positioned as follows: The index and ring finger are placed over the left and right orbital Copyrighted Material . and held for 15-30 seconds.

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well away from the eyes. while the fingers apply a fas­ cial traction over the retro-orbital and nasal fas­ ciae. The thumb of the Sternocleidomastoids (Figures 8-121 and 8-122) Purpose: This technique decreases tone of the sternocleidomastoid (SCM) muscles. Figure 8-J2J Copyrighted Material .Atlas afTherapeutic Techniques 253 bones. just inside the eyebrow. SCM may still be exquisitely tender to palpation due to overuse in the erect posture. the other hand is placed on the SCM near the inser­ tion at the mastoid process. Execution: A gentle traction is applied through the occiput with tbe bottom hand. or areas of hypertonicity are encountered. Therapist position: The therapist is seated at the head of the table. Execution: The therapist rotates the patient's neck and adds a slight amount of backward bending of the cer vical spine. The middle finger is placed just over the nasal suture. Care must be taken to make absolutely no contact with the eyes. Patient position: The patient is supine with the head off the edge of the table. The SCM is gently stroked from cephalic to caudal. Even if the muscle is relaxed in the supine position. Hands: One hand is cradling the occiput. gently cradling the patient's head in a very slight backward bent position. while the other hand is positioned with the thumb placed on the cephalic portion of the SCM near the mastoid process. The fascial stretch is applied firmly with the pads of the fingers for 10-20 seconds. tender areas. The palm of the top band places a mild traction over tbe frontal fascia. The SCM may also be cross-stroked at any point along the muscle belly where trigger points.

Rosenthal E. The Alexander technique-What it is and how it works.254 MVOFASCTAL MANIPULATION Figure 8-122 REFERENCES I. New York: Harper & Row. 2. 1978. 1987 (Ju ne ): 53-57. el al. 1972. Medical Problems of Pel/arming Artists. Scars dale. A Manual oJRe/lexive Ther­ apy of the Connective Tisslles. Dietze E. Copyrighted Material . 3. Schliack H. Advances through Movement. NY: Sidney Simon. Feldenkrais M.

history. massage. 28 classi flcation. 8-9 Chondroitin. 31 weave pattern.myofascial pain syndrome. 152-153 Connective tissue. 65-76 biomechanics. 23-24 Axial flexion. 176-177 Bilateral upper thoracic release. myofascial pain syndrome. 30-31 cycle of fibrosis and decreasing mobility. 217-218 Alexander technique. diagonal stretch. 150-153 Adductor muscles. spine. 112 Compression. 30-31 intramolecular cross-links. 58-60 Bone. defined. 220 biosynthesis. 33-39 cells. 122-124 Cervical cervicothoracic myofascia. 241 transverse fascial stretch. cervical spine. 31 Collagen B Back pain. 4 Biceps stretch. 39 collagen. 233-234 Arthrokinematics. 171-173 tibia. 100 Anterolateral fascial elongation. 30-31 255 Copyrighted Material . I 12 Alpha-delta sleep anomaly. 249 Cervical laminar release. 16-18 Bindegwebbsmassage-type stroke. 248 supine. 227-228 Bindegwebbsmassage . 22-23 Allodynia. lumbar spine.neural mechanisms.9 Autonomic nervous system. 30-31 extracellular matrix. 161-163 Biomechanics of connective tissue. 246-248 therapeutic techniques. 248-249 sitting. 51-52 elastin. 27 Bony clearing iliac crest.233-234 with rotational component. transverse muscle play. 50. 36 Complex widespread-pain syndrome. 31-32. 33 connective tissue. 33-34 Compressive testing. 45-46 basic afferent neurology.Index A Active movement analysis. 246-248 Cartilage. Feldenkrais. 3-4 Blood flow. 27 c Central sensitization. 86-88. 122 Awareness through movement. 51 types. 248-249 Cervical spine axial flexion. 246-254 Chiropractic. 240-241 Bilateral sacral release.

characteristics. 192-195 diaphragmatic techniques. 17 Cyriax. 56 loose irregular. Elastin. 30-31 Fibroblast. 29-30 primary organization. 194-195 Distraction. 97-98 exercise. 94-98 diagnosis of exclusion. 194 third position: sitting. 23-24 functional integration. 95 iatrogenic illness behavior. connective tissue. 23-24 Fiber. 102-103 neurochemical abnormalities. 104-105 Cutivisceral reflex. 34 Copyrighted Material . 31 histology. 23-24 awareness through movement. 3--4 immobilization nontraumatized connective tissue. 82-83 Electrogenic spasm. 30-31 fibrosis. 103--108 pathogenesis. connective tissue. 172 muscle play. 98 guidelines. 169-171 transverse muscle bend. cervicothoracic myofascia. 98 diagnosis of inclusion. 211-212 F Facet joint. 143 Dysfunctional spectrum syndrome. 28-29 Fibromyalgia. 53-56 response of myofascial tissue. 28. 41 Feldenkrais. 108-1 12 medical management. 9 Fascial sweater concept. 9-10 D Dense irregular connective tissue. 28. 35 research. 221-222 Cross-friction ischial tuberosity. 94 diagnosis. 28. 94-1 12 clinical characteristics. fibromyalgia. 83 Electromyogram. defined. 30-31 secondary organization. 94-98 criteria. 97. 16. I1-12 reticulin. 107 prevalence. 100-10 I Diagonal stretch. 53-57 scar tissue vs. 105-108 hypothalamic-pituitary-adrenal axis. 102 growth hormone. 30-31 Electrogenic muscle tone. 33 characteristics. 105-106 insulin-like growth factor-I. 21 Fasciculus. 121 Erector spinae ironing. 246 Energy crisis hypothesis. greater trochanter. 107-108 serotonin. 171. II Dysfunction. 249 Diaphragm. James. 34-36 Cross friction. 102 Extracellular matrix. I I 1-112 pregnancy. 40 Dense regular connective tissue architectural hierarchy. 34-38 Creep. 99-102 definition. 28-29 ground substance. 94 psychosocial factors. 143 Elongation. myofascial pain syndrome. paravertebral muscles. 88-89 first position: supine. 194 second position: sidelying. 30-31 fibroblast.256 MYOFASCIAL MANIPULATION fiber. gastrocnemius-soleus musculotendinous junction. 39. 35 types. 94 E Effleurage. 38-39 viscoelastic model. 29 massage. 102-108 pathoplasticity. 19 Elastic limit. 109-1II musculoskeletal abnormality. 89 Exercise. 56-57 traumatized connective tissue. connective tissue. connective tissue. 107 management. 102 physical therapy. 20. 27-39 biomechanics. 16--18 mast cell. 39 macrophage. 30. 38-39 Depression. 100-102 relaxin. 107 hormonal abnormalities.

3 J Golgi tendon organ. 150 Friction.210 longitudinal 207 207-209 160. 53-57 56-57 traumatized connective tissue. 18-19 and one-hand tapotement. 66. 172 fascial plane between. 213. I 03 104 taxonomy. hold relax stretch. 146-149 cervical spine. 252 88. 149 postural sequence. transverse muscle play. 197-198 Iliotibial band 202-205 Immobilization n .'h I. 96. Iliac crest 1-173 release Iliacus. 79 Greater trochanter. 83 Inflammation. 73-74 movement. 221-222 Glycosaminoglycan. pinformis insertion.. 216-2 J 7 Hands.t'm. 148-149 myofascial aspects. 45-46 Joint reeeptor. cross friction. fibromyalgia.214 Frontal facial Functional Functional somatic syndrome. 95. Joint Joint connective tissue insertions. 69 Hairless skm. 3 1 connective tissue. forearm. 99--100 fibrotic process.173-176 G Gastrocnemius-solcLls.J 61 transverse muscle play. 19 two-hand 19 205-206 31 Hypothalamic-pituitary-adrenal axis. fibromyalgia. J 07 11-21 213 198-199. operational 157 H Hair receptor. 149.200 connective tissue nontraumatized connective tissue. 148 thoracic spine. 105-106 19 Hip. 56 muscle tissue.S I-52 First rib shoulder forearm 226-227 splay 207-209. skin. 187-189 Forward-head posture. ischial cross-friction. 57--58 Inefficient movement pattern. Greater trochanter Ground substance components. wound. care and Hoffa massage. I 12 tender points. 53-56 response of scar tissue I'S. 31 Growth hormone. 218-220 Gastrocnemius-soleus musculotendinous junction. 205-206 transverse muscle Forward bending laminar all fours. 79-80 Copyrighted Material . 147-148.Index substance P. 187 sitting.. 49-51 Insulin-like 107 erector Ischial I.7 implications. 101-102 Hold-relax streich. 185-186. 241-242 J Joint. movement. 66. 98 tenderness. tissue.

42-43 Copyrighted Material . massage. 61-62 metabolism. 152 roll. 69-70 Metabolism.258 MYOFASCIAL MANIPULATION Junctional zone biomechanics . 67 hairy skin.155 connective tissue insertions. 190 192 long axis distraction of superficial connective tissue. 4-9 K Kaltenborn. 207 connective tissue. 60 reflexive temperature. 4 M connective tissue. 152 149-150 . 164-166 medial-lateral pull away.68 Mennell James. 9 John. 61-62 fibroblastic activity.165 long axis laminar release. II Motor system control basics. axis laminar release. tibia. 39 19 Long axis distraction of superficial connective tissue. upper thoracic area. therapeutic techniques. 67 thoracolumbar fascia. 58-60 251 Mast cell. 222-225 antenor technique. 66-76 hairless skin. 80-81 Movement reeducation. 29 resonance 143 Muscle architectural hierarchv. 225 Lateral fascial distraction. 79 effects. 66. 61-62 fibroblastic activity. 151.9-11 grades. connective tissue. 61-62 healing collagen synthesis. lumbar spine. 198-222 j oint receptor. 189-190 149-150 stroke. 79-80 81-82 skin receptor. 221 Lateral sacral release.165 hip release. J 73-176 Lateral shear. 249-250 ancient times. 178-179 lateral shear. 67-68 field. lSI. 67-69 characteristics. 10 Merkel's receptor. 66. 161 Lumbar lordosis. 168-169 medial-lateral fascial elongation. 168 169 blood tlow. 177-178 161-198 166-168 techniques. 6 L Lateral elongation. 60-6I Lower quarter area. 45-46 and lumbar Longitudinal Longitudinal Loose Lubricant. 88 Medial-lateral fascial elongation. 28. 77 levels. 198-222 164. 164. lumbar 164-166 Meissner's corpuscle.4346 43-46 ManipUlation OA Manual medicine 249-250 subcranial myofascia. 60 3. 224-225 anterior technique. 185 hamstrings. 161-163 L3. 12 JO renaissance. 78 Movement tendon organ. lumbar 190-192 153154. 42-43 fiber types. 42 biomechanics. bone sellers future trends. 58-60 collagen synthesis.

Muscle tissue. 144 Pectoral.119 system basic evaluation.81-82 Nonthrust manipulation.57-58 :\1uscle tone. 41 biomechanics. I 12-125 anatomic variations. p 68.40 Muscle clinical Muscle type rMI'an.. 76 71 242-243 agent effect 76.69 cycle. 4 Nociceptor. 230 Muscle spindle. 122 central sensitization. 143-155 evaluation.3-12 mechanical movement 58-62 15-1 of pathology. 15-24 J 02 Copyrighted Material .Index 259 classification. 117-119 autonomie nervous system. 82. 121-122 22-124 116-120 Paris. 9-12 19-22 22-24 and abstract treatment [58-159 trend toward paitl 93-94. 93 terms. 66. 93 l\·1uscle erector spinae.J' energy crisis of treatment.83 Palmar stretch. 70-71 components. j 12-113 114-116 abnormalities. 82-86 82-83 viscoelastic.p< posture. clinical defined. 145-150 41 Myofilament. immobilization. 44-46 43-44 historical aspects.65. seated pectoral anterior fascial stretch. 169-171 228-230 minor. 81-82. 42-43 '''n''' r. 83-84 49-58 o autonomic historical basis.85 J 20-121 implications. 124 management. 230-23\ 246 modern theories and systems.118. 77 chemical movement. 85-86 lypes. 153-154 Paravertebra1 10-1 I Pathoplasticity. J J 9-120 referred 116-117. 1 J Muscle stretch reflex. Patient history. 124. 70 N Neural mechanisms.145-150 93-94 structural evaluation.243-245 examination.J 25 85 musculoskeletal 121 4(}42 clinical mechanisms..

in prone. friction. 157 Soft tissue mechanical characteristics. 249-250 and abstract treatment. J 26 93-94. 40-41 Scapular 234-237 lateral border.skin receptor. 125-126 40-4J 16 Seated Serotonin. 245-246 Retro-orbital Rolfing. treatment sequencing.20 19 25 1. See Skeletal muscle 19-21 manipulation. 30 RetinaculaI' stretch. 234 upper border.2J4 Piriformis release. 38.defined.82-83 Reticulin. 10 J -I 02 49-51 152·-153 lateral erector side bending 181-183 transverse muscle 199 202 stretch. 45-46 Tension. Structural Subcranial 207--209 R 209-211 Striated muscle.xlbook 1"II /HwA. 88-89 T 116-117. 3 Position sense. 13. 33 Te. 99-100 Tendon. 8-9 231-232 103-104 159 massage. 9-10 Copyrighted Material . Rib cage. 125 evaluation process. 145-150 fOlward-head. 88-89 107 119-120 meehanism Skin receptor movement. 19-21 balancing posture in Ruffini corpuscle. 125 126 management. 125 defined. 30-3 J Reticuloendothelial s ystem. 88-89 Posture. 58--60 s Sarcomere. Stress/stram curve. J Subluxalion. 237-239 effects.65 influence on movement.119 Reflex Relaxin. defined.34 Skeletal muscle cellular anterior fascial stretch. muscle tone. 230-23J 104-105 Q Soft tissue Somatization disorder.145-147 slumped. Shearing.joint differentiated. myofascial manipulation. 8889 pain . 60-61 Piriformis insertion.69 field.66. 2 Position. connective tissue. 34 34 34 Strelch.252 Substance P.massage.39 connective tissue insertions. inferior border. 80-8 I Soft tissue manipulation. 80-81 pOS! lion sense.34 elastic limit. 80-81 159 Postural reedueation.260 MYOFASCIAL MANIPULATION medial border. " . 234 mobilization. 76-82 Referred 118. 237 Tenderness.\1edicine.

220 lateral fascial distraction. 244 Transverse muscle play adductor muscles. 8 4 muscle clinical mechanisms.84 v 85 Upper thoracic area. lateral anterior 225 techniques. 243. Transverse muscle erector spinae:. 224-225 225 226 inflammation. 82. first rib. 49 favorable fibroplastic granulation maturation or 49 conditions. Thrust Tibia clearing. 50 50 50 phase. 34 y 240-241 lumbar 166-1 defined. n""tprlflri articulation. 85-86 Thoracic rotational laminar release. 149. 239-240 T horacic spine forward-head posture. 150 therapeutic Thoracolumbar fascia. 83-. techniques. 15 Transverse fascial stretch.89 defined. 222-246 222-225 technique. 85 implications. 34-38 Viscoelastic muscle tone. 51 Wound 50.51 II w 222-246 Viscoelastic model. connective tissue. 89 forearm. 217-218 218-220 Yield point. 49-51 Copyrighted Material . 246-254 u Unilateral upper upper thoracic 84-86. 221 Tissue 21-22 Transcutaneous electrical nerve stimulation.Index 261 Therapeutic 157-254 spine.